key: cord-333285-0s6dnm9i authors: noonan, devon; simmons, leigh ann title: navigating nonessential research trials during covid19: the push we needed for using digital technology to increase access for rural participants? date: 2020-04-13 journal: j rural health doi: 10.1111/jrh.12446 sha: doc_id: 333285 cord_uid: 0s6dnm9i nan it is well known that rural populations experience significant health disparities, especially in rates of common chronic diseases (eg, heart disease, diabetes, cancer) and associated health behaviors (eg, diet, physical activity, tobacco, and other substance use). these disparities are in part due to rural residents' lack of access to, knowledge about, and participation in clinical trials. 1, 2 thus, despite increased need for effective disease management and health promotion strategies, rural residents are frequently underrepresented in these clinical trials. there are a number of reasons why rural residents are frequently absent in clinical trials. first, most clinical trial research is conducted by large academic medical centers, which tend not to be located in rural areas. this lack of proximity to research sites contributes to some of the disparity in rural access to clinical trials. 3 second, some rural areas experience systemic barriers to remote clinical trial implementation, such as limited access to internetenabled mobile devices and requisite bandwidth capacity. 4 third, rural areas often have poor health care infrastructure to support clinical trials, such as lack of electronic health records, high turnover of primary providers, few to no specialty providers, and hospital closures. 5, 6 added to these barriers are the issues of research mistrust, lack of local provider buy-in to participate in clinical trials, and lack of awareness of potential benefits of clinical research. 5, 7 lastly, many trials that were designed for ongoing, in-person monitoring or biospecimen collection are not as easily translated to a remote status. 8 despite these challenges, covid-19 may be the impetus investigators need to retool their research not only for continuity of data collection, but also for the very real benefit of being able to enroll hard-to-reach populations like rural residents. the strategies employed and validated now may be the beginning of ongoing efforts to ensure that clinical trials are more accessible to rural residents. to achieve this aim, there are several key components to address. first, it is becoming clearer every day that with thoughtful use of digital technology, study activities can be implemented remotely. for example, the authors are currently working on 2 nih-funded (r01ca242593, r01nr017659) behavioral clinical trials that employ text-based protocols with interim assessments that can be completed virtually. when nonessential research activities restart, investigators need to carefully reconsider simply returning to the status quo of solely traditional in-person approaches and develop strategies for implementing protocols, including sample collection, remotely. second, covid-19 has demonstrated that when the need exists, telehealth is an effective care delivery tool that can be disseminated quickly and easily. telephonic and videoconference clinical care approaches can be leveraged and adapted to increase access to research trials for rural populations. third, the infrastructural challenges should be addressed through increased academic-private-public partnerships. for example, universities could collaborate with satellite internet cooperatives to increase access to rural broadband that would support a wide range of public health and clinical care initiatives beyond clinical trial research that would benefit rural areas. or, state departments of heath could replicate the partnership that the california department of education initiated with google to distribute mobile hotspots to areas without broadband access so that k-12 education could continue amid school closures associated with shelter-inplace orders. likewise, as academic medical centers establish accountable care organizations, they can share resources with rural partners for electronic records, care pathways, and care delivery, all of which will enhance clinical trial implementation. these partnerships and investments also will help to build trust within rural communities, and they may help to bridge the gap between local providers and researchers. lastly, researchers should focus on innovative ways to collect biospecimens remotely and push for the adoption of more decentralized clinical trials. 9 as technologies improve, this will undoubtedly be an area with significant capacity to change the way clinical trials are conducted. the covid-19 pandemic has necessarily prompted immense creativity in addressing health care and research challenges. while we will at some point return to a "pre-covid-19 existence," the creativity generated from this period can and should be harnessed to continue to consider ways to reach rural and other populations who are underrepresented in research. remote access to clinical trials has many potential benefits for rural populations, including expanding representation of people of color, native and indigenous peoples, and those living in poverty, housing and food insecurity, and with other limited resources. researchers who were able to move to remote study activities during this time period should be encouraged to assess the "unintended benefits" of remote clinical trial study activities, rather than simply revert to traditional, in-person strategies. in fact, researchers who have moved to remote clinical trial delivery mid-study should report on comparative analyses of recruitment, adherence, accessibility, participant sociodemographics, and outcomes for remote and inperson delivery so that future researchers can learn from and adapt these strategies for future research. as a collective, researchers should continue to support the development of strategies, infrastructure, and innovations necessary to support remote participation in clinical trials so that remote access for clinical trials transitions from serving as a short-term solution to becoming a mainstay necessity in all trials whenever possible. establishing remote access to clinical trials will serve to not only decrease rural clinical trial disparities, but also to promote rural health equity into the next decade and beyond. geographic distribution and survival outcomes for rural patients with cancer treated in clinical trials review strategies to recruit and retain rural patient participating self-management behavioral trials barriers to recruitment of rural patients in cancer clinical trials a conceptual framework for barriers to the recruitment and retention of rural cvd participants in behavior intervention trials clinical trial recruitment in rural south carolina: a comparison of investigators' perceptions and potential participant eligibility. rural and remote health barriers to medical research participation as perceived by clinical trial investigators: communicating with rural and african american communities recruitment and participation in clinical trials: socio-demographic, rural/urban, and health care access predictors. cancer detection and prevention incorporating site-less clinical trials into drug development: a framework for action legal, regulatory, and practical issues to consider when adopting decentralized clinical trials: recommendations from the clinical trials transformation initiative key: cord-324607-rpwccvqi authors: rojek, amanda m; moran, james; horby, peter w title: core minimal datasets to advance clinical research for priority epidemic diseases date: 2020-02-15 journal: clin infect dis doi: 10.1093/cid/ciz760 sha: doc_id: 324607 cord_uid: rpwccvqi the ebola virus disease outbreak in west africa has prompted significant progress in responding to the clinical needs of patients affected by emerging infectious disease outbreaks. among the noteworthy successes of vaccine trials, and the commendable efforts to implement clinical treatment trials during ebola outbreaks, we should also focus on strengthening the collection and curation of epidemiological and observational data that can improve the conception and design of clinical research. during the currently ongoing ebola virus disease (evd) outbreak in the democratic republic of congo, a clinical trial of potential treatments has commenced. this is a significant step toward improving outcomes for patients with the disease. ebola virus disease constitutes but one of the priority diseases that the world health organization (who), in their blueprint for action to prevent epidemics, suggests poses a severe public health risk and for which there are insufficient countermeasures [1] . the purpose of this priority list is to identify high-threat pathogens for which there is a need to prioritize and advance the development of diagnostics, vaccines, and therapeutics. any diagnostics, drugs, or vaccines that are developed as a result of this and other initiatives, such as the coalition for epidemic preparedness innovation, will need to be fully evaluated in diagnostic evaluation studies or phase ii and iii clinical trials. however, due to the very nature of the epidemic-prone infectious diseases that appear in the who list of priority diseases, evaluation in clinical studies is challenging, not least because the epidemiology is unpredictable but also because the pathogenesis and natural history of many of these diseases are not well defined. for example, during the influenza a(h1n1)pdm09 pandemic, case fatality rate (cfr) estimates varied widely from 0 to 13 500 per 100 000 laboratory-confirmed infections, with a heterogeneity of 99.97% (using i 2 estimate) [2] . a therapeutic trial designed with patient survival as a primary outcome measure would have grossly misjudged the required sample size if the trial was designed using the wrong cfr. therapeutic trials for the prevention of congenital zika syndrome will be hindered by the absence of consistently used criteria to define the outcome of congenital malformations [3] . for middle east respiratory syndrome coronavirus, a lack of systematic biological sampling means that disease pathophysiology and factors associated with more severe disease and viral clearance (a commonly used secondary outcome measure) are not well understood [4] . the need for well-defined core minimal datasets for emerging infectious diseases is not a new observation. a decade ago sheila bird and jeremy farrar [5] noted the need to define a core minimal dataset for human cases of avian influenza a/h5n1, yet there remains no systematic examination of the completeness of the core data needed to design and conduct trials for highpriority pathogens. table 1 identifies some key domains that could contribute to a core minimal dataset that informs clinical trial design for each priority pathogen. the benefit of this approach, when complemented by scoring or assessment of the available information, is that it allows for initial bench-marking and triaging of unmet data needs in order to prioritize further data gathering activities. importantly, a harmonized data collection initiative can also prospectively embed data-sharing agreements into data-collection protocols. this will allow valuable clinical information to be readily available to stakeholders, while identifying and protecting the interests of those collecting data in regions where outbreaks occur. accumulation and curation of the data will depend on a variety of sources and methodology types, but it is critical that high-quality clinical data are highlighted as an integral component. often lost to competing priorities for clinicians during outbreaks, standardized data collection regarding the presentation and natural history of disease, biomarkers of disease severity, and response to supportive care can be sporadic or missing. while these data have their most important benefits in improving patient management (through better recognition of disease complications and informing supportive care) and public health control, patient-based data are also used to determine key parameters for clinical trials, such as the inclusion criteria, the nature and rate of clinically relevant outcomes, and potential confounders. we suggest that adoption of clinical case registries (such as those used for rare cancers) provides a feasible option to produce standardized clinical data that have multiple clinical, public health, and research benefits [6] . compared with expensive and lengthy countermeasure development pipelines, improving the scale, relevance, and quality of observational data is likely to be an efficient and cost-effective strategy to improve global preparedness against epidemic and pandemic infections. disclaimer. the funders had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. temporal and geographical profile of previous outbreaks this is required for logistical planning, to ensure that local teams are sufficiently trained in research practices (such as good clinical practice) and trial-specific equipment is available. an agreed-upon case definition clinical characteristics of the disease are used to define enrollment criteria. analysis of strength of evidence for factors associated with increased disease severity or fatality stratification (or other statistical adjustment) on the basis of severity is often required when interpreting the clinical trial outcome. best available descriptions of the type and rate of clinical outcomes clinical outcomes will function as a trial outcome measures. understanding the natural course of illness will also help differentiate disease course from adverse events from treatment. assessment of confidence in estimates of clinical outcomes heterogeneity in patient outcomes between or within outbreaks creates uncertainty for power calculations and will affect selection of a statistical design for a trial. spurious heterogeneity may occur due to random error in small cohorts, or represent ascertainment, lead-time, measurement, or follow-up bias. real heterogeneity can occur due to improvements in care over an outbreak, pathogen evolution, or changes in host susceptibility and vulnerability but should be adjusted for. analysis of known or suspected covariates of outcome highlights possible confounders that will alter outcome independently of treatment and that will require adjustment if unequally distributed between treatment and control arms. the mean time from onset of symptoms to outcome allows for an estimation of the feasibility and logistics of medical intervention. agreed-upon standards of care for patient treatment determines if there is standardized supportive therapy to be adopted in all arms of a trial. this is especially important for multicenter research the performance characteristics of the favored diagnostic method determines whether a trial will be performed on an itt basis or following laboratory confirmation. mean time for laboratory diagnosis determines whether a trial will be performed on an itt basis or following laboratory confirmation. community priorities and expectations for trials determines the priorities of affected communities in terms of access to trials, acceptable methodology, and acceptability of treatments or vaccines. abbreviation: itt, intention-to-treat. annual review of diseases prioritized under the research and development blueprint informal consultation case fatality risk of influenza a (h1n1pdm09): a systematic review clinical trials of therapeutics for the prevention of congenital zika virus disease: challenges and potential solutions development of medical countermeasures to middle east respiratory syndrome coronavirus minimum dataset needed for confirmed human h5n1 cases a systematic review and meta-analysis of patient data from the west africa (2013-16) ebola virus disease epidemic key: cord-266730-mio282vy authors: li, long‐quan; huang, tian; wang, yong‐qing; wang, zheng‐ping; liang, yuan; huang, tao‐bi; zhang, hui‐yun; sun, weiming; wang, yuping title: covid‐19 patients' clinical characteristics, discharge rate, and fatality rate of meta‐analysis date: 2020-03-23 journal: j med virol doi: 10.1002/jmv.25757 sha: doc_id: 266730 cord_uid: mio282vy the aim of this study was to analyze the clinical data, discharge rate, and fatality rate of covid‐19 patients for clinical help. the clinical data of covid‐19 patients from december 2019 to february 2020 were retrieved from four databases. we statistically analyzed the clinical symptoms and laboratory results of covid‐19 patients and explained the discharge rate and fatality rate with a single‐arm meta‐analysis. the available data of 1994 patients in 10 literatures were included in our study. the main clinical symptoms of covid‐19 patients were fever (88.5%), cough (68.6%), myalgia or fatigue (35.8%), expectoration (28.2%), and dyspnea (21.9%). minor symptoms include headache or dizziness (12.1%), diarrhea (4.8%), nausea and vomiting (3.9%). the results of the laboratory showed that the lymphocytopenia (64.5%), increase of c‐reactive protein (44.3%), increase of lactic dehydrogenase (28.3%), and leukocytopenia (29.4%) were more common. the results of single‐arm meta‐analysis showed that the male took a larger percentage in the gender distribution of covid‐19 patients 60% (95% ci [0.54, 0.65]), the discharge rate of covid‐19 patients was 52% (95% ci [0.34,0.70]), and the fatality rate was 5% (95% ci [0.01,0.11]). data extraction and the evaluation of literature quality were conducted independently by two investigators (l.q.l. and t.h.). microsoft excel database was used to record all available information, including baseline details, clinic data, discharge rate, and fatality rate. any disagreement was resolved by another investigator (y.q.w.). the minors (table 1) 7 was used to assess bias risk. microsoft excel was used to analyze the clinical symptoms and laboratory results. single-arm meta-analysis was performed using stata 15.0 software. heterogeneity among studies was tested using the cochran chi-square test and i 2 , when i 2 < 50%, a fixedeffects model was used, while when i 2 > 50%, a random-effects model was selected. if there was statistical heterogeneity among the results, a further sensitivity analysis was conducted to determine the source of heterogeneity. after the significant clinical heterogeneity was excluded, the randomized effects model was used for meta-analysis. funnel plot and egger test were used to detect the publication bias. p < .05 was considered as statistically significant (two-sided). guan wj 2 2 2 2 2 0 0 0 10 chang d 2 2 2 2 2 1 2 0 13 huang cl 2 2 2 2 2 1 2 0 13 wang dw 2 2 2 2 2 1 2 0 13 liq 2 2 2 2 2 0 0 0 10 chen ns 2 2 2 2 2 1 1 0 12 wang zw 2 2 2 2 2 1 2 0 13 liuk 2 2 2 2 2 0 0 0 10 chen l 2 2 2 2 2 1 2 0 13 zhang mq 2 2 2 2 2 0 0 0 10 note: ① a clearly stated aim; ② inclusion of consecutive patients; ③ prospective collection of data; ④ endpoints appropriate to the aim of the study; ⑤ unbiased assessment of the study endpoint; ⑥ follow-up period appropriate to the aim of the study; ⑦ loss to followup less than 5%; ⑧ prospective calculation of the study size. the items are scored 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate). the global ideal score being 16 for noncomparative studies. study ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ score a total of nine studies were included. [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] the results of the randomized effects model meta-analysis showed that in the sex distribution of this disease men accounted for 60% (95% ci [0.54,0.65]) of covid-19 patients (figure 2a) , which was higher than women. the sensitivity analysis (supporting information materials) showed that there was no study that greatly interfered with the results of this meta-analysis, suggesting that the study was stable. a funnel plot was drawn to test the publication bias ( figure 2b ). publication bias test results: egger's test (p = .312 > .1) indicated that there was no publication bias. a total of eight studies were included, [8] [9] [10] [11] [13] [14] [15] [16] with 1560 cases. the results of the random effects model meta-analysis showed that the fatality rate of the covid-19 patients was 5% (95% ci 15, 27 found that the fatality rate of patients with viral pneumonia increased when they had a basic disease and mixed bacterial infection, which was consistent with the results of our study. owing to the lack of awareness of the virus in the early stage of this disease, inadequate medical protection, and treatment measures, the high infectivity of the virus led to a dramatic increase in the number of patients, which reflects a lack of medical resources. as a result, the patient discharge rate is relatively low. recently, it was reported that remdesivir clinical effect is visible, clinical iii trials are ongoing in the domestic, and survivors plasma treatment for heavy, severe cases has shown definite curative effect. 6 we should believe that these treatments will significantly reduce the mortality of such patients soon. limited by the number and quality of included studies, more extensive and large-scale studies are required to identify the clinical features of the disease. national health commission of the people's republic of china main website a novel coronavirus from patients with pneumonia in china a pneumonia outbreak 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susceptibility to severe acute respiratory syndrome coronavirus infection sexual dimorphism in innate immunity sars and other coronaviruses as causes of pneumonia from sars to mers, thrusting coronaviruses into the spotlight clinical features of three avian influenza h7n9 virus-infected patients in shanghai how to cite this article covid-19 patients' clinical characteristics, discharge rate, and fatality rate of meta-analysis the authors declare that there are no conflict of interests. sw-m: methodology; zh-y: validation; ly: formal analysis; ht-b:investigation; wz-p: data curation; ll-q, ht, and wy-q: original draft preparation; wy-p: writing review and editing. http://orcid.org/0000-0002-6373-2263 key: cord-332078-vl309ss7 authors: cipollaro, lucio; giordano, lorenzo; padulo, johnny; oliva, francesco; maffulli, nicola title: musculoskeletal symptoms in sars-cov-2 (covid-19) patients date: 2020-05-18 journal: j orthop surg res doi: 10.1186/s13018-020-01702-w sha: doc_id: 332078 cord_uid: vl309ss7 nan symptoms at onset is influenced by socio-geographical factors [64] . the most common symptoms in patients with mild to moderate clinical presentation of the condition are fever, fatigue, and dry cough, followed by other symptoms including headache, nasal congestion, sore throat, myalgia, and arthralgia [65, 66] . the evidence on the central role of inflammation during covid-19 infection underlines the need to block this inflammatory cascade [30, [60] [61] [62] [67] [68] [69] [70] . the presence of musculoskeletal symptoms is worrying: there is a high rate of use, especially in the middle age and elderly population, of nsaids. the fact that patients therefore report musculoskeletal symptoms is even more worrying because it may imply that the inflammatory reactions overcome the antiinflammatory effect of such drugs. clinical features have to be analyzed deeply, especially considering the new evidences on covid-19. musculoskeletal symptoms should be married with laboratory findings, such as inflammatory and infectionrelated parameters (interleukin-6, procalcitonin, creactive protein). understandably, the involvement of the musculoskeletal system has not been deeply investigated during this pandemic, but synovial and muscle biopsy, and joint fluid analysis, for example, should clarify how extensive the attack of the virus on the whole of the human body is. until now, no report has been published on the presence of covid-19 in the skeletal muscles, joint, or bones. the musculoskeletal symptoms are only anecdotally attributed to indirect effects, mainly arising from inflammatory and/or immune response, but other mechanisms can be hypothesized, such as direct damage by the virus on the endothelium or peripheral nerves. these findings could help to plan specific rehabilitation protocols in covid-19 patients. as a new infectious disease, it is particularly important to underline the clinical features of covid-19, especially in the early stage of the illness, to help clinicians to individuate and isolate patients earlier, and then minimize its diffusion. from the onset of the symptoms and to the most severe stages of covid-19 disease, musculoskeletal symptoms, including myalgia, arthralgia, and fatigue, are a nearly constant presence. it is still unclear how the effects of covid-19 on the musculoskeletal system are mediated. a systematic review of covid-19 epidemiology based on current evidence clinical characteristics of coronavirus disease 2019 (covid-19) in china: a systematic review and meta-analysis clinical value of immune-inflammatory parameters to assess the severity of coronavirus disease 2019 symptom pathogenesis during acute influenza: interleukin-6 and other cytokine responses rheumatologists' perspective on coronavirus disease 19 (covid-19) and potential therapeutic targets investigation of three clusters of covid-19 in singapore: implications for surveillance and response measures clinical characteristics of older 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key: cord-327738-i400ynjp authors: milner, ross; donington, jessica; matthews, jeffrey; posner, mitchell; turaga, kiran; angelos, peter title: is it ethically appropriate to continue surgical clinical trials during the covid-19 pandemic? edited by dr sarr date: 2020-04-27 journal: surgery doi: 10.1016/j.surg.2020.04.024 sha: doc_id: 327738 cord_uid: i400ynjp covid-19 has greatly impacted surgical care and decision-making. the status of surgical clinical trials during this pandemic has not been addressed. we provide a framework and recommendations for the management of patients involved in surgical clinical trials. the covid-19 pandemic has greatly impacted both clinical care and its underlying ethical basis, shifting from the traditional patient-centered approach to a public health strategy. 1 as surgeons, we have been challenged to balance the risk of proceeding with planned operations ith the cncerns to the patient and to the health care system against the risk of delay. for the first time in the united states, we have found it necessary to consider the availability of appropriate hospital resources, the potential for increased adverse outcomes in occult covid-19-positive patients, and limitations in pre-operative testing, as well as potential health dangers posed not onoy to the patients but also to hospital staff including the entire operating room staff-nurses, anesthesiologists, physicians, etc. at the university of chicago, we introduced a scoring system to assist in the ethical triage of medically-necessary, timesensitive (ments) procedures given that the imperative to halt all "elective" surgery does not adequately capture the nature or define the types of non-emergency procedures that may still need to proceed. 2 we have found this approach to be particularly useful with respect to the constantly changing pressures on peri-operative resources (anesthesiologists, nursing, personal protective equipment, blood, ventilators) and hospital inpatient capacity otherwise diverted to dedicated covid units and icus during different phases of the pandemic. the timing of surgery for cancer patients has been particularly thorny, and a number of groups have proposed thoughtful frameworks for these clinical decisions. 3, 4, 5 so far unaddressed during this pandemic has been the status of surgical clinical trials. specifically, is it ethically appropriate to continue enrollment and treatment of patients in clinical trials that include surgical intervention? if we continue such clinical trials, are we putting patients at greater risk of covid19-related complications? could the pandemic inappropriately skew the results? if we expedite and prioritize surgical treatment for those patients who are part of a trial, are we unduly pressuring them to participate (a form of coercion)? in contrast,, is it ethical to suspend future enrollment or active participation if it would potentially deny patients the benefit of novel therapeutic interventions or improved outcomes associated with the clinical trial? although the ethical debates might apply across a broad range of clinical studies during the pandemic, we sought to focus specifically on surgical trials. we discuss here the ethics of clinical trial care within the surgical specialties and the the pros and cons of participation in clinical trial during the covid-19 pandemic, with a specific focus on surgical oncology and vascular surgery. the clinical trial portfolio is the core of any comprehensive cancer center. oncologic therapeutic clinical trials offer patients access to exciting new treatments. these trials are designed typically to answer specific questions regarding treatment and outcomes and not the timing of surgical procedures or the frequency of visits and invasive procedures (at least not as primary objectives). the current need for social distancing and limitations of health care resources has shifted priorities appropriately, but completely halting clinical trials would hinder dramatically the delopment of novel treatment sand leave patients currently enrolled in these trials without access to potentially life-saving medications. the cancer therapy evaluation program (ctep) at the national cancer institute (nci) recognizes these issues and encourage sponsors, investigators, and institutional review boards to revise existing policies and procedures to mitigate risk and to protect trial participants while keeping clinical trials open. this program includes steps to alter the informed consent process, study visits and procedures, data collection, and the reporting of adverse eventz. for example, local treating physicians can perform a majority of study-related activities and administer all medications except investigational agents. 6 the issues related to surgery in a clinical trial during the covid pandemic are more challenging. many of the proedyres ypically cannot be performed by the surgeon at the local hospital, have strict time constraints dictated by inclusion/exclusion criteria in the trial protocol, and carry the potential to place an undue strain on limited inpatient resources and the health care workforce. futhermore, cancer patients undergoing complex surgical procedures are inherently immunosuppressed and are at risk for superinfection by the covid-19 virusn and the associated increase in morbidity and mortality. therapeutic clinical trials that involve oprative intervention tend to focus on locally advanced tumors and often involve induction therapies (chemotherapy, radiation therapy or both) that increase the potential for post-induction fibrosis, which may increase the technical difficulty of an operative procedure and prolong the postoperative hospital stay due to peri-operative complications. in the end, the decision to proceed with a planned cancer resection for a patient enrolled in a clinical trial is highly dependent on the institution's phase in the pandemic and availability of peri-operative resources. the decision to proceed with an operationthat is governed by stict time-dependent guidelines is often somewhat arbitrary and that time interval can likely be prolonged without adversely affecting the there are cities and hospitals where only urgent surgery is possible and others where resources still allow for high priority, oncologic resections. at the university of chicago, we have attempted to maintain patients already enrolled in clinical trials, butwehave curtailed new enrollment dramatically due to the uncertainty of available resources and have focused our research efforts on covid-centric issues. only low risk trials with novel agents and unique therapies remain open to enrollment, but, as expected, accrual has slowed tremendously. trials that include surgery do not fall into this category. surgical trials typically require multiple different therapies on rigid time schedules and are not deemed prudent in our current environment. it is unclear how these decisions will impact cancer care for individual patients and the advancement of our science, but in a time of limited resources, we do not want to embark on a treatment strategy that we cannot potentially safely complete. but, it is not lost on us that clinical cancer trials that do or do not involve surgery are invaluable in defining new treatment paradigms that lead to improved outcomes for cancer patients, and it is known that just by participating in a clinical trial, derivative benefits in patient outcomes are the rule. therefore, striking the correct balance between these two conflicting concepts is the essence of the ethical dilemma we are facing. the majority of clinical trials in vascular surgery involve the use of medical devices or a surgical procedure to treat peripheral artery disease, carotid artery disease, or aortic aneurysms/dissections. at the university of chicago, we participate in a number of such trials. many of these large, multiinstitutional device trials are sponsored by industry. in light of the covid-19 pandemic, all vascular clinical trials have been halted. one of the large device trials that was scheduled to start in march has delayed its start during the covid-19 pandemic due to the need to eliminate "elective" cases for the well-being of individual health care systems. the decision on the part of industry to suspend such clinical trials has been met largely with support from vascular surgeons. what is the ethical basis for supporting this decision even though it means that some patients are not getting the latest and potentially more effective devices to treat their vascular disease? the care and focus of linical trials in vascular surgery are both resource-intensive and time-sensitive. using our current framework of ments procedure prioritization, we have focused attention on patient care issues related to critical limb ischemia, symptomatic carotid artery disease, and symptomatic or ruptured aortic aneurysms. as such, vascular surgeons should not utilize scarce operating room time or clinic time to investigate novel devices with unknown outcomes. it is our belief that this same prohibition on vascular clinical trials should also apply to fda-approved devices that are being investigated under a registry designation. by halting the nenrollment of patients into such trials, we relieve the pressure placed on surgeons to enroll patients in a clinical trial that could negatively impact the timely care of other patients whose needed procedures have greater medical urgency. most importantly, we believe that in the present environment, surgeons should provide care that is the best known "standard of care" and that can provide the most benefit to our patients and minimize the impact on our hospital and health care systems with unknown outcomes from devices. finally, patients should not feel pressured to participate in clinical trials in the hope that by enrolling they may be given an advantage to have surgery sooner. the covid-19 pandemic has created both clinical and ethical dilemmas for surgeons. we believe that continuing surgical clinical trials at the present time poses unique ethical concerns. before continuing to enroll patients in surgical trials, we believe that surgeons must carefully consider the type of trial, the institutional status with respect to scarce resources, and the potential risk/benefit ratio to patients and health care workers involved. we have decreasedour clinical trial efforts mzarkedly during the pandemic to minimize patient coercion and to maximize the use and avialablity of patient care resources for evidence-based procedures. . surgeons, ethics, and covid-19: early lessons learned medically-necessary, time-sensitive procedures: a scoring system to ethically and efficiently manage resource scarcity and provider risk during the covid-19 pandemic management of cancer surgery cases during the covid-19 pandemic: considerations a multidisciplinary team approach for triage of elective cancer surgery at the massachusetts general hospital during the novel coronavirus covid-19 outbreak are we harming cancer patients by delaying their cancer surgery during the covid-19 pandemic? preserving clinical trial integrity during the coronavirus pandemic safety considerations in the laboratory testing of specimens suspected or known to contain the severe acute respiratory syndrome coronavirus 2 (sars-cov-2). lab medicine cancer patients in sars-cov-2 infection: a nationwide analysis in china covid-19 has greatly impacted surgical care and decision-making. the status of surgical clinical trials during this pandemic has not been addressed. we provide a framework and recommendations for the management of patients involved in surgical clinical trials key: cord-300325-f3eomugb authors: ferguson, nadia c.; quinn, nicholas j.; khalique, saira; sinnett, mark; eisen, lewis; goriacko, pavel title: clinical pharmacists: an invaluable part of the coronavirus disease 2019 frontline response date: 2020-10-15 journal: crit care explor doi: 10.1097/cce.0000000000000243 sha: doc_id: 300325 cord_uid: f3eomugb although coronavirus disease 2019 was first identified in december 2019, it rapidly spread and became a global pandemic. the number of patients infected with the novel coronavirus (severe acute respiratory syndrome coronavirus 2) rose rapidly in new york state, placing great stress on healthcare systems. the traditional roles and practices of healthcare providers were dramatically redefined to meet the demand to care for the large number of ill patients. while literature reports on the experiences of many frontline staff, there is a scarcity of reports on the role of clinical pharmacists during this crisis. we report the role of critical care clinical pharmacists at a large academic medical center in new york city during this pandemic. effective crisis management required clinical pharmacists to employ a wide array of skills and knowledge. areas included clinical expertise, education, data analysis, health informatics infrastructure, and inventory management in times of surging medication use and manufacturer shortages. clinical pharmacists fulfilled an essential service during the coronavirus pandemic by working to ensure the best possible outcomes for the patients they served on the frontline. t he 2020 pandemic currently plaguing the world, was first identified in wuhan, china, in december 2019 (1) . in early 2020, the world health organization named the virus severe acute respiratory syndrome coronavirus 2 based on its identification and genetic composition (2). the coronavirus disease was later named coronavirus disease 2019 (covid19) and has spread globally within 4 months of its identification (3, 4) . public containment and medical management from every healthcare worker, including physicians, nurses, respiratory therapists, pharmacists, ancillary services, and even administrators and government, has been necessary to decelerate the disease's impact. scientific literature and media outlets constantly highlight the work of nurses and doctors on the frontline, but this article will specifically focus on the role of the clinical pharmacist during the coronavirus pandemic emphasizing the extraordinary work done to ensure safe effective therapy was provided to optimize health outcomes in hospitalized patients (5) (6) (7) (8) . with post-graduate education and training in direct patient care areas and specialty certification, clinical pharmacists are equipped to work alongside physicians and other healthcare professionals to coordinate care (9) . in recognition of this, the society of critical care medicine (sccm) strongly recommends that an entire team, including pharmacists, should be available for all critically ill patients to provide direct care (10) . as of march, the united states became the epicenter of covid-19. new york state became the epicenter of the epicenter according to government officials, with the first case on march 1, 2020 (11) (12) (13) . by the end of the week, 636 cases were identified per day, rising to 5,987 cases per day by march 30, 2020. this was an exponential increase to the peak of 6,160 by april 6, 2020, causing peak new hospitalizations of 1,724 reported to the state, requiring governor cuomo to ask new york hospitals on march 16, 2020, to increase capacity 50% with a goal increase of 100% to accommodate new hospitalizations (12, 13). operating rooms and post-anesthesia care units and all areas with telemonitoring were converted to icus, requiring critical care pharmacists to create standardized list of medications, rapid response kits, and advanced cardiovascular life support medication trays for emergencies (fig. 1) . since the bronx, in particular, had the highest per capita rate of any borough with 2,513 cases per 100,000 people totaling 36,969 cases by april 30, 2020, medication administrations for norepinephrine, vasopressin, fentanyl, and propofol were obtained from medication administration record data for the iv infusion dosage forms of these agents. potassium and phosphate binder numbers were obtained from medication administration record data for sevelamer, calcium acetate, patiromer, sodium zirconium cyclosilicate, and sodium polystyrene sulfonate. there was a remarkable surge in resource utilization at our urban multicenter academic medical facility located in the bronx and lower westchester (fig. 2) . the immediate effect of this unprecedented surge was a looming shortage of first-line medications for the treatment of covid-19-related complications. the crisis placed an enormous amount of stress on the entire medication supply chain: health system pharmacies, distributors, and manufacturers could not keep up with this rapid increase in demand for medications such as sedatives, analgesics, vasopressors, and electrolyte modifiers for patients with acute kidney injury (fig. 2) . in response, clinical pharmacists established daily teleconferences to keep abreast of the data on medication utilization and shortages, as well as to address the clinical implications of depleting first-line treatments for covid-19 patients. they tailored existing business intelligence data reporting tools (sap business objects) linked to medication order and administration data in a replicate electronic medical record database (epic caboodle) to analyze medication surge trends daily to provide crucial dialogue between clinicians and buyers. clinical pharmacists met with operational directors daily to review these data and project the inventory requirements for the upcoming weeks. likewise, the prompt shortage detection helped pharmacy leadership communicate directly with manufacturers, requesting direct supply rather than waiting for wholesaler delivery (14) . in cases where adequate supply could not be obtained in a timely manner, clinical pharmacists used the established communication channels with their clinical teams to implement preemptive shortage management strategies that avoided therapeutic interruptions, optimized patient care, and mitigated stress for other frontline staff. examples of these strategies included the use of hydromorphone as first-line analgosedation in select patient populations to avoid depletion of fentanyl supply or using succinylcholine as our preferred paralytic for rapid sequence intubation (in the absence of contraindications) to avoid running out of vecuronium or rocuronium stock. to ensure rapid system-wide implementation of strategies such as the use of alternative analgosedation for an entire unit, clinical pharmacists established direct email communication chains with the chair of the medicine and critical care departments, who included these recommendations in their daily briefings to hospitalists and advanced practice practitioners in those areas. in addition to the shortages, the lack of proven treatments for covid-19 resulted in a wide array of experimental therapies being tested in covid-19 patients. unfortunately, no medication was food and drug administration (fda) approved or clinically safe and effective against covid-19 in the early period of the pandemic. drugs that potentially decrease viral uptake and replication like lopinavir/ritonavir, chloroquine, and hydroxychloroquine were readily available, but supply was depleted within 2 weeks, so clinical pharmacists restricted these medications by adding them to the antimicrobial stewardship designation, which mandated infectious disease specialist consult and approval. additionally, immunomodulators like tocilizumab, anakinra, and baricitinib were extremely difficult to acquire, so clinical pharmacists reviewed baseline laboratories like c-reactive protein and ferritin in patients with persistent fevers to determine patients who would benefit, then directed the primary team to critical care, immunology, or rheumatology services for final approval. investigational drug therapies with preliminary data, such as remdesivir, sarilumab, and leronlimab, were only available to patients through clinical trials, compassionate use, and expanded access programs (15, 16) . multidisciplinary efforts involved clinical pharmacists screening and educating providers regarding the feasibility and accessibility to assure safe and effective use of investigational drugs. these pharmacists met with investigational drug services, monitored adverse events, and served as coinvestigators on clinical trials such as nct04343651, nct04347239, nct04280705, and nct04315298 (17) (18) (19) (20) . this influx of new therapies required clinical pharmacists to work with the information technology department to rapidly create and link appropriate records in the computerized physician order entry system (epic), admixture preparations system (doseedge), automated dispensing cabinets (pyxis), and the smart infusion pumps (alaris). pharmacists also identified patients who were not candidates for clinical trials. if the patients were eligible to receive study drugs through compassionate use and expanded access programs, they completed emergency investigational new drug applications from the fda, obtained the drug from the pharmaceutical company, and gained approval from the local investigational review board (21) . in addition to investigational agents for covid-19, many protocols for critically ill patients were rapidly implemented in the face of uncertain evidence, with minimal opportunity for lengthy contemplation or risk-benefit deliberation. thromboprophylaxis was one such topic of uncertainty, especially in the critically ill, where the risk of bleeding and clotting was the highest throughout the health system. literature out of china regarding abnormal laboratory variables in covid-19 patients left clinicians perplexed (22) . clinical pharmacists' review of the protocols prompted multidisciplinary discussions on the risks versus benefits of employing various agents and regimens for thromboprophylaxis, or therapeutic anticoagulation strategies with little supportive evidence. in such cases where medications were used off-label without quality evidence supporting or refuting their use, pharmacists' extensive training in clinical pharmacology proved invaluable in guiding rational decision making. pharmacists used their clinical expertise to review retrospective data, case reports, expert opinions, drug interactions, adverse reactions, and contraindications to formulate potential dosing of these investigational drugs or approved drugs prescribed offlabel. as a result, a pharmacist-led multidisciplinary team created an anticoagulation protocol for covid-19 patients, which maximized evidence-based use of pharmacotherapy, and at the same time, provided guidance for safe use of anticoagulants for clinicians wishing to take on a more aggressive anticoagulation approach for their patients. finally, with the inflow of patients exceeding traditional icu bed capacity, many intubated patients needed to be cared for outside of a traditional icu setting by clinicians without primary critical care specialization. a critical step to ensure patient safety was implementing sedation guidelines to aid clinicians with treating ventilated patients in these nontraditional areas (23) . this task proved extremely challenging due to looming medication shortages. opioid analgesics and benzodiazepines were chosen as the backbone of analgesia and sedation ensuring physician familiarity and relative low risk of hemodynamic compromise. the first line of those were fentanyl and midazolam, considering safety and ease of use, however, overuse would invariably lead to severe shortage (23) . pharmacists led education regarding bolus use and the addition of enteral agents to preserve iv agents for more acute situations. they also emphasized boluses prior to increasing continuous sedation to avoid unnecessary over-sedation and waste, drug accumulation, and future tolerance and withdrawal in addition to other relevant side effects (24, 25) . for chronic cases where patients were unable to wean off opioid or benzodiazepine infusions, the addition of enteral or even transdermal agents were considered to safely transfer patients to lower acuity units or floors (26) . without the luxury of time, adequate medication supplies, or storage space, aggressive efforts emphasized using oral therapy. methadone, chlordiazepoxide, lorazepam, and quetiapine were chosen to reduce opioid and sedative requirements while simultaneously keeping patients sedated at their target richmond agitation-sedation scale score, and potentially decreasing the occurrence of delirium (27, 28) . the most important aspects of this protocol were to make it adaptable, understandable, and efficient. a simplified flow chart was distributed to hospitalists (fig. 3) . additionally, clinical pharmacists created protocols with two to three alternative pathways to account for the inevitable shortages of preferred medications. information was then disseminated-throughout the medical center with the assistance of pulmonary specialists, who recorded a detailed lecture and were often consulted for ventilator management, hospitalist-led daily briefings with their peers, and daily emails with a department of medicine intranet link to the resources. in conclusion, clinical pharmacists played an invaluable and often unrecognized role in managing the health system's response to the covid-19 pandemic. the work of clinical pharmacists to manage and mitigate drug shortages allowed clinicians to continue to provide the highest level of care throughout the health system. the education and acquisition assistance in off-label, investigational, and compassionate use medications expedited therapy in the most critical cases. the skills and knowledge of clinical pharmacists allowed for rapid development and dissemination of critical drug information. importantly, algorithm development prevented medication therapy errors by clinicians practicing in unfamiliar settings. the pandemic response was a multidisciplinary effort in which clinical pharmacists not only worked tirelessly behind the scene but alongside their colleagues on the front line at the epicenter of the covid-19 pandemic. incorporating a clinical pharmacist in the preparations and management of any crisis is a crucial step in preparing for future disasters, epidemics, or pandemics such as covid-19. importantly, sccm likewise recommends clinical pharmacists' placement into the staffing models for expansion of icu services (10). this work was performed at einstein division, montefiore medical center, the university for hospital for albert einstein college of medicine, bronx, ny. the authors have disclosed that they do not have any potential conflicts of interest. for information regarding this article, e-mail: nafergus@montefiore.org severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and coronavirus disease-2019 (covid-19): the epidemic and the challenges centers for disease control and prevention: mmwr: presymptomatic transmission of sars-cov-2 singapore division of viral diseases how doctors and nurses manage coronavirus grief fair allocation of scarce medical resources in the time of covid-19 executive summary: pharmacists as frontline responders for covid-19 patient care pharmacists' readiness to deal with the coronavirus pandemic: assessing awareness and perception of roles american college of clinical pharmacy: standards of practice for clinical pharmacists society of critical care medicine: united states resource availability for covid-19 world health organization: rolling updates on coronavirus disease (covid-19). 2020. available at nyc health: covid-19 data. 2020. available at regulatory affairs professional society: fda reports shortage of sedation drug used for putting covid-19 patients on ventilators gilead sciences: gilead sciences update on the company's ongoing response to covid-19 medication safety in clinical trials: role of the pharmacist in optimizing practice, collaboration, and education to reduce errors cytodyn: a phase 2, randomized, double blind, placebo controlled study to evaluate the efficacy and safety of leronlimab for mild to moderate coronavirus disease 2019 (covid-19) adaptive design study to evaluate the efficacy and safety of leronlimab for patients with severe or critical coronavirus disease 2019 (covid-19) regeneron: an adaptive phase 2/3, randomized, double-blind, placebo-controlled study assessing efficacy and safety of sarilumab for hospitalized patients with covid-19 food and drug administration: emergency investigational new drug applications. 2020. available at abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia executive summary: clinical practice guidelines for the prevention and management of pain, agitation/ sedation, delirium, immobility, and sleep disruption in adult patients in the icu a protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial the use of continuous i.v. sedation is associated with prolongation of mechanical ventilation factors predisposing to coma and delirium: fentanyl and midazolam exposure; cyp3a5, abcb1, and abcg2 genetic polymorphisms; and inflammatory factors opioid tolerance in critical illness replacement of fentanyl infusion by enteral methadone decreases the weaning time from mechanical ventilation: a randomized controlled trial critical care explorations www.ccejournal.org key: cord-344705-co0nk7pt authors: eichler, hans‐georg; cavaleri, marco; enzmann, harald; scotti, francesca; sepodes, bruno; sweeney, fergus; vamvakas, spiros; rasi, guido title: clinical trials for covid‐19: can we better use the short window of opportunity? date: 2020-05-14 journal: clin pharmacol ther doi: 10.1002/cpt.1891 sha: doc_id: 344705 cord_uid: co0nk7pt the scientific community has risen to the covid‐19 challenge, coming up with an impressive list of candidate drugs and vaccines targeting an array of pharmacological and immunological mechanisms. yet, generating clinical evidence of efficacy and safety of these candidate treatments may be frustrated by the absence of comprehensive trial coordination mechanisms. many small stand‐alone trials and observational studies of single‐agent interventions are currently running or in planning; many of these will likely not deliver robust results that could support regulatory and patient‐level treatment decisions. we here discuss actions that all stakeholders in the clinical trial ecosystem need to take to ensure that the window of opportunity during this pandemic will not shut, both for patients in need of treatment and for researchers to conduct decision‐relevant clinical trials. absence of comprehensive trial coordination mechanisms. many small stand-alone trials and observational studies of single-agent interventions are currently running or in planning; many of these will likely not deliver robust results that could support regulatory and patient-level treatment decisions. we here discuss actions that all stakeholders in the clinical trial ecosystem need to take to ensure that the window of opportunity during this pandemic will not shut, both for patients in need of treatment and for researchers to conduct decision-relevant clinical trials. this article is protected by copyright. all rights reserved the scientific community has risen to the covid-19 challenge. research funding bodies, academic and clinical centres, life science companies, and regulatory agencies are bending over backwards to enable the rapid development and authorisation of anti-covid-19 treatments. the result is an impressive and growing list of candidate drugs and vaccines targeting an array of pharmacological and immunological mechanisms 1 . experience teaches that most candidate treatments will fail but with so many shots at goal there is reason for cautious optimism that at least a handful may succeed. so far, so good. yet, one bottleneck may frustrate many useful efforts. in the absence of comprehensive trial coordination mechanisms, stand-alone trials and observational studies of single-agent interventions are mushrooming. we 2 and others 3 4 have drawn attention to this development in the global covid-19 clinical trials landscape which we consider unfortunate, for the reasons outlined below. a recent search of the european eudract database 5 (date of search 2020/05/12) shows no less than 268 interventional trials being planned or running in the eu alone; at least 173 of these have already started. of note, 216 clinical trial applications were submitted by non-commercial sponsors, versus 52 by commercial ones. most trials are mono-country trials, 9 trials are conducted in 2 different eu-member states while one trial involves 11 eu-member states. forty-six trials involve less than 50 subjects, 121 trials include between 100 and 500 subjects, and 36 trials plan to enrol more than a thousand subjects. even early on during the pandemic, the question has rightly been asked "do we need 300 trials? is that a good use of resources?" 3 . as of 2020/05/06, well over 2,000 interventional and non-interventional trials have been registered world-wide 6 . aside from the important resource issue and the ethical issue of having to enrol so many patients in small, individual control groups, we raise another obvious concern: can these trials possibly deliver? we recall that the worst outcome of a clinical trial is not a negative result. while clear-cut negative results may dash hopes of a cure (and professional aspirations) they are useful in showing us what treatments not to expose patients to and what lines of research to abandon early on. the real worry is trials that leave us as much in the dark as we were before the trial was conducted. consider a series of compassionate use applications of remdesivir for patients with severe covid-19. the conclusion from observing 61 patients treated was "measurement of efficacy will require ongoing randomized, placebocontrolled trials of remdesivir therapy." 7 . could we have gleaned more useful information from the fate of those same 61 patients by including them in a well-coordinated multi-arm trial? it is easy to detect large treatment effects but tricky to demonstrate the relatively small effect sizes we will likely see with single-agent treatment approaches for covid-19 (with the possible exception of this article is protected by copyright. all rights reserved vaccines) 4 . for example, a 200-patient randomized controlled trial of lopinavir plus ritonavir showed no benefit beyond standard care 8 but beneficial effects in subgroups cannot be excluded. the authors concluded that "future trials in patients with severe illness may help to confirm or exclude the possibility of a treatment benefit" 8 . for every week that trials don't deliver, more and more patients are exposed to the wrong treatments, which well-designed and rapidly run clinical trials could have taken off the table, making space to pursue, other, and ultimately more meaningful, therapeutic options. we acknowledge the difficulties of running larger, coordinated multicentre trials in an extremely challenging environment, especially in the early days of the pandemic. however, as drug regulators, we ask: how many of the ongoing trials will be able to support robust regulatory (and individual treatment) decisions? even under ideal clinical trial settings, a substantial fraction of trials in epidemiologically stable diseases like diabetes or depression fail; one of the most frequent reasons for failure is lack of patient enrolment 9 . covid-19 is characterized by a highly dynamic epidemiology in all global regions. shown that despite compressed development plans no study for therapeutics and vaccines could be completed as initially planned due to the waning epidemic, and only one prematurely terminated clinical study gave sufficient results to be used for vaccine authorization. similarly, with zika virus, vaccines were ready for large clinical testing when the virus was disappearing making it impossible to generate clinical evidence. while covid-19 is different from ebola, in that it affects essentially all global regions, we are still concerned that a high fraction of trials starting in a confined geography at the peak of this pandemic will not be able to enrol patients up to their pre-established sample size. to make matters even more complex, it is improbable that a single drug will be enough to control and improve the most severe forms of covid-19, given its systemic pathophysiology. successful treatment regimens will likely need to address: treatment of the viral infection itself, to reduce and eliminate the viral load; prevention and treatment of the development of the severe acute respiratory distress syndrome and of hyperinflammation and cytokine storm; and additional pathophysiologic components of the severe disease such as blood coagulation activation/ thrombosis. we agree with gaborit et al 4 that investigators should join their efforts in proposing studies of combined approaches through multifactorial this article is protected by copyright. all rights reserved designs. large platform trials offer the possibility to compare multiple treatments and approaches within a trial and across trials especially when they share standard disease classifications and outcome measures. such large studies afford an opportunity to agree on clear and consistent definitions and categorization of disease stages, viral infection and respiratory distress, clear consistent endpoints and standard approaches for the measurement of these. yet, even platform trials may not provide the sole answer because even very large platform trials will not be able to test every plausible permutation for mixed antiviral and anti-inflammatory interventions. in addition, platform trials come with their own weaknesses such as (frequently) a lack of blinding, and the fact that, in a pandemic situation, controls become historical as disease management improves, requiring more sophisticated analyses. ideally, platform trials must be preceded by well designed (placebo) controlled phase ii trials that will quickly read out and would be the ideal partner to platform trials to define the next intervention to add. however, this requires proper co-ordination between these phase ii and iii type trials. an additional dimension of complexity is the planning of study populations: while studies may be initiated and performed more rapidly when focused on well-defined homogenous populations, the overall development strategy must aim for representativeness and include the elderly, pregnant women and younger participants in their numbers. fortunately, there are attempts underway to address the issue of uncoordinated clinical research. platform trials have been established by a range of public and private institutions; they aim to bundle the clinical assessment of treatments across clinical scenarios, ranging from community-level prophylaxis to critical disease treatment in icu settings. for example, who has now taken steps to provide greater coordination through its solidarity trial 10 though the need to establish sponsorship in each jurisdiction caused some hurdles. the "eravscorona" action plan, launched by the european commission, aims to "[extend and support] large eu wide clinical trials for clinical management of coronavirus patients" by providing rapid, dedicated funding and infrastructure 11 . such initiatives are welcome but will only deliver if the clinical research community comes onboard. why has this not happened to a larger extent and what are the possible reasons behind the fragmented trial landscape, globally and in the eu? there remain substantial organisational and bureaucratic obstacles to rapid research coordination in all regions 12 . in the eu specifically, and with few exceptions (e.g. imi funded combacte clinical trial network), there is a limited culture of large networks that go beyond national borders. as the crisis unfolded, the focus has been on using national resources for setting up this article is protected by copyright. all rights reserved protocols at national level, with limited ambition of expanding to a larger context despite the obvious benefits. moreover, our eudract database search shows a predominant role for non-commercial, largely academic clinical trial sponsors. this is not surprising; in the context of epidemics, academic groups, public health authorities, and funding bodies generally step up in their contribution to the crisis including design and conduction of clinical trials. historically, a high proportion of clinical trials run by academia or public health bodies are run in a single member state, often based around single institutions, resulting in many smaller trials and/or trials constrained by national boundaries from achieving larger, more rapid recruitment. this is seen also in the case of covid-19 clinical trials of antivirals. by contrast, vaccine development is largely driven by commercial sponsors. vaccines are still in early stages of development, but we expect them to be tested mostly in multi-member state trials. first, we reiterate our call 2 on academic researchers and companies alike, to first consider if their planned trial or development plan could become part of a broader platform trial, as discussed above. second, we call on ethics committees to consider in their assessment of clinical trial protocols whether a given stand-alone trial for covid-19 can be assumed to meet the ethical requirement that "medical research involving human subjects may only be conducted if the importance of the objective outweighs the risks and burdens to the research subjects." 13 . is this condition met by a small, (underpowered) standalone trial, perhaps with a high probability of failure due to lack of enrolment? or could the objective be better met by redirecting the energy to one of the larger ongoing trials? third, we highlight the importance for developers of covid-19 treatments, academic or industry alike, to seek interactions with drug regulators early on in their research. the goal of successful development of any repurposed or de novo treatment is to obtain regulatory authorization for its use. this is to provide reassurance to prescribers and patients of independent assessment of the data and of a favourable benefit-risk balance. our query of the eudract database (see above) shows that most covid-19 trials, at least in the eu, are proposed and run by academic group, ngos or public health authorities that are not always used to interact with regulators and may perceive regulatory authorization as less relevant compared to patient care. to strengthen the dialogue between such organizations and regulators, the european medicines agency (ema) has established the covid-19 ema pandemic task force (covid-etf) in charge of a dedicated this article is protected by copyright. all rights reserved pathway and procedures to enable covid-19 drug and vaccine developers to obtain regulatory input on their development plans and clinical trial protocols in a rapid, unbureaucratic fashion, no fees payable. we invite researchers in the field to avail themselves of this opportunity. fourth, we need to support and bring together the well-established public or private consortia such as the coalition for epidemic preparedness innovations (cepi), or the european clinical research infrastructure network (ecrin) 14 , to ramp up their activities and take on a wider role in the management of trials. ema is currently liaising with such groups to rapidly explore how their activities could facilitate regulatory acceptability of trial results. in the course of formal or informal scientific advice interactions, ema can also guide drug developers towards existing trial collaborations. a key goal is to establish entities that can be the single lead sponsor for large platform trials. this might be one per trial or one overall for multiple trials. it might be a single entity, or an entity composed via joint sponsorship between several (national) research bodies. there is a framework for such joint sponsorship in ec guidance on clinical trials 15 . fifth, infrastructure to support clinical trial conduct needs to be established. at a first level it could make a strong contribution by managing clinical trial applications to competent authorities and ethics committees, dealing with administrative challenges such as insurance/indemnity requirements, linking investigators and networks to clinical trials, and organisation of logistics of supplies to sites. it could go on to broader trial management/sponsor activities such as balancing trial participation across sites and protocols to improve recruitment, minimise interprotocol competition, matching protocol demands with site capabilities, running randomisation schemes, monitoring, data management and analysis and reporting of trials. organisations such as ecrin are well placed to carry out such activities if given the collective buy-in and resource needed. sixth, we ask umbrella patient organizations, like the european patients forum, and learned societies to bring to bear their considerable influence to support trial coordination efforts. last, regulatory flexibility needs to be exercised in the face of these challenges, in order to keep the process moving despite the practical and infrastructural difficulties that lockdown imposes to enable the rapid pace of development required. eu regulators, like those in north america and elsewhere, have issued guidance on adapting clinical trial and good clinical practice processes to the challenges of the pandemic environment with its social distancing and high demands on front line health care staff and facilities. this guidance enables clinical trials, and especially those for covid-19 treatments, but also other this article is protected by copyright. all rights reserved important therapies, to be carried out and to ensure their ethical conduct and scientific validity 16 17 . the aim is to avoid the perfect becoming the enemy of the good and avoid attention being given to minor aspects that would cause unnecessary delays. covid-19 trials are an international concern and the best knowledge is that shared quickly and effectively at global level. to ensure international cooperation, workshops of regulators, hosted by the international coalition of medicines regulatory authorities (icmra), have been convening experts from dozens of medicines regulatory authorities worldwide and the world health organization (who). these workshops helped share expertise, streamline and standardise requirements, and focus on what is essential to the process of development and authorisation of vaccines and therapeutics 18 . the needs and interest of lowand middle-income countries and their patients need to be incorporated and clinical trial designs to include some which can also be run in resource constrained environments. ideally, in a pandemic situation, we would hope to see a group taking an overall look at the entire clinical trial endeavour, to assess all trials and determine if a certain type of trial is needed or if redundant trials are being conducted. in the eu, there is no single group conducting such review, though the ema's covid-etf, the eu clinical trial facilitation group 19 plan 11 have a number of actions aiming to achieve this kind of high-level assessment. given the amount of human suffering, there is an ethical imperative for the scientific community to make full use of the learning opportunity provided by each successive pandemic or epidemic. with this pandemic, we were slow to apply the lessons from ebola (and other waves) to covid-19 trials. now is the time to ensure that the window of opportunity will not shut, both for patients in need of treatment and for researchers to conduct clinical trials that deliver. a call to pool eu research resources into large-scale, multi-centre, multi-arm clinical trials against covid-19 flooded by the torrent: the covid-19 drug pipeline plea for multitargeted interventions for severe covid-19 international clinical trials registry platform (ictrp) compassionate use of remdesivir for patients with severe covid-19 a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 factors associated with clinical trials that fail and opportunities for improving the likelihood of success: a review european commission (ec) website: first eravscorona action plan wma) website: wma declaration of helsinki -ethical principles for medical research involving human subjects eudralex vol 10 -guidance documents applying to clinical trials questions & answers -paragraphs 50 and 51 guidance to sponsors on how to manage clinical trials during the covid-19 pandemic points to consider on implications of coronavirus disease 4 (covid-19) on methodological aspects of ongoing clinical 5 trials ema website: international regulators pledge collective support to combat covid-19 pandemic clinical trials facilitation and coordination group (ctfg) key: cord-277528-t0tglg0a authors: tay, yi xiang; sng, li hoon; chow, hwei chuin; zainuldin, muhammad rahizan title: clinical placements for undergraduate diagnostic radiography students amidst the covid-19 pandemic in singapore: preparation, challenges and strategies for safe resumption date: 2020-08-18 journal: j med imaging radiat sci doi: 10.1016/j.jmir.2020.08.012 sha: doc_id: 277528 cord_uid: t0tglg0a abstract introduction the covid-19 pandemic resulted in the suspension of clinical training for undergraduate radiography students in singapore. coordinated preparation plans and strategies between the university and hospitals were needed to safely resume clinical placements within national and hospitals’ risk control measures against covid-19 transmission. methods singapore institute of technology (sit) and the radiology department of singapore general hospital (sgh) had collaborated to meet requirements for safe resumption of clinical placements. sit prepared students by emphasising compliance to all risk measures, addressing concerns of risk transmission, meeting learning objectives, and reassessing infection control competencies. in tandem, sgh prepared an orientation program and used technology for open communication among faculty, clinical educators and students which included monitoring of well-being and rapid dissemination of updates. of note, sgh reorganised operating procedures and physical spaces to meet national standards of safe physical distancing, restricted movement between treatment areas and teams, and rosters to remain committed to the supervision and education of students. results clinical placements resumed 3 months following suspension. clinical educators faced the challenge of the need for balance between increasing clinical load and student supervision. a solution was frequent engagement and support by faculty, with educators and students via video conferencing platforms. students’ well-being was frequently checked. there was less variation in cases which simulation training made up for some of the learning objectives. conclusion adaptation and commitment to continue active and quality clinical education while ensuring students' safety were vital during a pandemic. clinical training within stringent precautionary measures may shape the era of the new norm. redefined strategy and priorities to mitigate the crisis. 54 'circuit breaker' measures 56 it is important to put into context how sit and sgh prepared the students for the 57 challenges and designed strategies for safe resumption of clinical placements. like many 58 parts of the world when the world health organisation (who) classified the covid-19 virus 59 outbreak as a pandemic on march 11th, 2020 (15), singapore went into a 'partial lockdown', 60 which was termed as 'circuit breaker' on april 7 th , 2020 (16). 61 national circuit breaker measures included mandatory wearing of masks at all times 62 in public spaces, banning the gathering of people from different households, practising social 63 distancing of one metre and registering entry at community places for contact tracing (16) (17) . 64 in hcis, new precautionary measures, such as segregation of healthcare workers by teams 65 or by physical boundaries (7) , movement restriction between teams or hcis restricting 66 contact between personnel (1819) , twice-daily temperature recording and safe physical 67 distancing (where possible) (7) , were added to existing good hygiene practices, such as 68 hand washing and the use of protective personal equipment (ppe) (7) . 69 on 16 th march 2020, the moh began an online dialogue session with hcis and sit 70 on a feasibility plan to resume healthcare students' clinical placement progressively. 71 following a few iterations, a plan was finalised. it included priority placements for final and 72 penultimate year students to ensure graduation would not be affected and no-go areas that 73 were considered high risks of covid-19 transmission (7), such as emergency departments 74 and covid-19 designated wards. moh and hcis needed the assurance that students 75 would strictly adhere to the national and hcis' risk control measures. safe resumption had 76 also seemed possible, contingent on the availability of on-site clinical educators (ces). 77 preparations from sit 78 j o u r n a l p r e -p r o o f the assurance of strict compliance to national and hcis' risk control measures came 79 in the form of a clinical practice information package for submission to moh. this 80 communique was developed for all sit health and social science (hss) students in 81 preparation for their clinical placement resumption and had all elements of risk control 82 measures for students' compliance. a pre-clinical briefing was also conducted to reinforce 83 the importance of risk control measures in place, allay students' concerns and address any 84 gaps in understanding of the need for strict compliance. a survey was conducted to obtain 85 an overview of year 2 and 3 radiography students' concerns to resume clinical placement 86 during dorscon orange, using a web-based platform (qualtrics, provo, ut). a total of 87 forty-five year 3 students (81.8%) and 46 year 2 students (82.1%) had completed the survey. 88 as a requirement to meet moh's and hci's protocols for infection control measures 89 including the use of ppe at workplace, sit embarked on a refresher training course to build 90 on radiography students' competency in these areas. onsite face-to-face 'refresher' session 91 was not possible due to campus closure in the pandemic state, and hence, was converted to 92 an online session. students performed the infection control procedures guided by training 93 material and a competency checklist. performance was recorded and submitted to sit's 94 infection control team for assessment of the competencies. all year 2 and 3 radiography 95 students successfully obtained the competency. 96 challenges faced by sit and redefining strategy 97 the survey findings revealed that half of year 3 and year 2 students (51% and 54% 98 respectively) had concerns about resuming clinical placement amidst the current covid-19 99 situation. the concerns were similar between the two cohorts, with the risk of contracting the 100 virus as the top concern. students feared contracting the virus at clinical placements and 101 during travels on public transport between placement site and home and passing it on to 102 their family members. the clinical coordinators reassured the students that they would not 103 be placed in high risk areas, and there was no evidence to suggest that a healthcare worker based on their home address. written logs of radiographic examinations signed-off by the 107 supervising radiographer were used as patient log sheet records for contact tracing. this 108 was simultaneously used as evidence in the form of a portfolio to support the completion of 109 competencies. sit worked with sgh on the surveillance of students' health by sharing a 110 weekly report of temperature monitoring. 111 the second concern was on the potential problem in meeting the learning objectives 112 due to the limited number and types of cases encountered. the lower caseload for students 113 was further exacerbated by the removal of high-risk areas as placement sites. in order to 114 support students and address their concerns, faculty supervisors used video-conferencing 115 platforms for students to check in on their progression at midway and end of placements and 116 provided pastoral care. however, in this covid-19 pandemic, it was clear that ensuring 117 placements for all students was a challenge as hcis had introduced new temporary rules to 118 limit placement capacity. working with limited placement options, sit redesigned the 119 structure of clinical placement by halving the duration of each placement to allow splitting of 120 the cohort into two groups with students taking turns at placements. despite the reduction, 121 students could still fulfil ahpc's registration requirement of 1200 clinical hours. simulation in 122 skills-based labs at philips medical asia pacific centre, singapore, replaced the reduced 123 duration of placements to ensure meeting learning objectives. in addition, academic modules 124 were repositioned in the curriculum to fill in the 3-month suspension of clinical placements. 125 sit faced another challenge when allocating students to sites. where work was 126 performed in smaller rooms, such as an x-ray examination room, hcis allowed only one 127 student to adhere to the safe physical distancing measure. sit was also cognisant of the 128 reduced manpower at sgh and other hcis due to temporal segregation of covid-19 129 designated wards from the other wards (7) , which meant the ces (usually the more 130 experienced ones) at these wards could not supervise students. it was also possible that a 131 ce could be burdened by increased workload as a result of rising cases of transmission in 132 j o u r n a l p r e -p r o o f the community and the urgent need for a quick turnaround (19) . the clinical coordinators 133 worked with each hci partner to recalibrate the ce-to-student ratio. at many sites, the ratio 134 reduced from 1:2 or 1:3 to a ratio of 1:1. the division of the cohort into two groups helped in 135 making the ratio of 1:1 feasible. 136 to meet compliance of precautionary measures in the 'circuit breaker' period, 138 preparations to resume placements at sgh leveraged in the use of technology, reorganising 139 training areas and orientation programme. to prioritise students' safety while on placement, student rosters were planned to 161 avoid assignment to areas deemed high-risk such as emergency department, intensive care 162 unit/high dependency and covid-19 designated wards. they were also not allowed to work 163 with dedicated scanners for isolation and high-risk cases, such as the mobile radiography small group size also facilitated safe physical distancing and prevented overcrowding. 173 measures had also been put in place to ensure safe distancing at the different social 174 spots within the hospital campus such as food outlets and staff rest areas. students were 175 reminded to practice social distancing, even at mealtimes. in short, mealtime socialising and 176 team building were prohibited during this period (21) . 177 an orientation programme serves as an important element to welcome students to 178 the department. in this period of uncertainty and potential fear, the orientation programme 179 when a radiographer was reported in the press to have contracted the virus while 196 working at a satellite facility (22), there was concern on the volatility of students' emotions -197 fear, panic, stress, and/or anxiety (10) . to allay their concerns, messages were sent through 198 the chat group to reassure students that the clinical environment was still safe and that their 199 health had been of utmost priority. in this time of crisis, ce could help to support students in since the covid-19 crisis began, temperature recording has been seen as a liability 202 by many staff. there were instances that students had forgotten to perform and record their 203 temperature on their rest day. to mitigate this, students were required to send text 204 messages indicating their temperature and time of submission to s3 through the whatsapp 205 chatgroup. a team leader was appointed from the group of students to ensure temperature 206 recording compliance. faculty supervisors were also kept in the loop for surveillance 207 as the situation was constantly evolving, whatsapp was also used to manage rapid 209 sharing of accurate and critical updates, such as daily covid-19 instructions issued by the 210 hospital disease outbreak taskforce. to minimise the impact of information overload and 211 misinformation, summaries were curated to highlight essential points relevant to their clinical 212 placement during their orientation. 213 the reduction in the number of cases across the department and manpower crunch 214 carried the risk of reduced clinical exposure and practice. there was a need to ensure 215 learning outcomes and progression were not compromised. this was mitigated through 216 broad, but essential learning outcomes written by sit. furthermore, the student's learning 217 contract related to the placement area was developed in collaboration with the ce to 218 encourage student-centric learning. this allowed understanding of expectations and ensured 219 that no students were missing out on learning (23). using the learning contract, the ce 220 engaged students regularly to discuss learning progress. while the students were excluded 221 from handling patients with covid-19, ces continued to create learning opportunities for 222 them by sharing the department's policies and procedures on the management of covid-19 223 patients. this included an overview of the pre-procedure room and patient preparation, 224 scanning techniques and infection control prevention and practices through case-based 225 with a smaller educator-to-student ratio, more manpower was needed to supervise 227 students. while it was stressful to divide the work between managing patients and students, 228 it was important that educators understood the importance of clinical education. throughout 229 the clinical placement, there were increased support, feedback and assistance provided to 230 the students from both stakeholders (faculty and ce) than in pre-covid situation. 231 the widespread of covid-19 presented a massive test on the global healthcare and 233 education system with the initial suspension of clinical training of undergraduate radiography 234 students and the uncertainty surrounding the epidemiologic data of . 235 however, it was critical to resume clinical placements for a timely graduation, thereby 236 producing safe and competent diagnostic radiographers to meet manpower shortage (25). it 237 was also vital for safe resumption of clinical placements. the paper had described the 238 preparatory steps taken by the university and hci to integrate and increase the awareness 239 of precautionary measures as part of training and the strategies to overcome implementation 240 challenges without compromising essential learning outcomes. 241 maintaining students' psychological well-being was key to a positive clinical learning 242 experience. our survey finding that infection risk was the biggest concern among students at 243 clinical placements highlighted the need for strategies such as frequent check-ins on their 244 mental health and emotional well-being. sustaining mental health in the midst of an 245 extremely disrupted curriculum was also raised in a perspective paper (10) . similarly, high 246 stress levels were also found in radiology education (26). our strategy in using whatsapp shown to be a valuable approach for technical skills training, patient communication, 267 managing complex cases and increasing confidence and motivation in students (31-32). in 268 addition, the use of virtual platforms for teaching and learning during covid-19 could be a 269 potential approach to augment learning outcomes (11). however, there were no prior plans 270 in place on using virtual technology to maintain the education of singapore student 271 radiographers during an outbreak. this serves as a timely reminder for us to exploit 272 technology-enhanced learning in the clinical setting in the future. 273 although the local radiography students may be limited by the availability of 274 alternative technology-enhanced learning experiences compared to other allied healthcare 275 professionals (28), ce can still contribute to a meaningful student learning experience by 276 being positive role models themselves (2). building a positive educator-student relationship 277 may be challenging within the covid-19 situation as ce may experience additional burden 278 and stress with increasing workload and smaller teams. this was highlighted as sgh's 279 challenge in managing smaller ce-student ratio where more manpower was needed for 280 student supervision and assessment. while it might be arguable that students may benefit 281 from a 1:1 ratio model where ce could focus solely on the student, a paired-student model 282 j o u r n a l p r e -p r o o f would provide peer-assisted learning (33) . however, there has been no clear advantages 283 between the ce-student ratio models (33) , hence the strategy to develop a strong belief 284 among ce in the value of clinical education was more important than standardising ratio 285 models. a partnership between sgh ce and sit with close communication was key to 286 support ce in ensuring that students had met all expectations and competencies for entry 287 level clinical practice (34). embracing students as members of covid-19 teams would help 288 build a positive relationship (35). 289 the first batch of penultimate senior year students had recently completed a 290 placement during the 'circuit breaker' period. a survey is ongoing to measure how successful 291 the preparation and strategies implemented had been in terms of providing fulfilling learning 292 experience amidst the restrictions imposed onto the clinical placements. 293 despite the uncertain covid-19 situation, clinical placements are essential 295 components for graduation and therefore, safe resumption of undergraduate diagnostic 296 radiography clinical placements was needed. sit's strategies to assure sgh and other hcis 297 include raising students' awareness to mandatory adherence to strict national and hci's 298 regulations by creating an information package, a pre-clinical briefing and a survey to 299 address any concerns. sit also conducted an infection control and ppe use refresher 300 training and ensured close communication with ces in the allocation and supervision of 301 students. sgh emphasised on a more comprehensive orientation package to students on 302 protocols for risk control measures within sgh, including team and temporal segregation 303 and even lunch etiquette in line with safe distancing. sit and sgh have collaborated in 304 many aspects of clinical placements, namely managing students' well-being, meeting 305 learning outcomes and adhering to national and hcis' risk control measures through the use 306 of whatsapp, open communication among students, educators and faculty, and continuous 307 sit support for ce. all strategies were planned with learning outcomes in mind. where 308 learning outcomes might not be achieved in covid-stricken placements, these were 309 clinical radiography education across 344 how do the attitudes of therapeutic radiographers affect 347 students' learning during practice placement investigation of three clusters of covid-19 in singapore: implications for 352 surveillance and response measures. the lancet singapore ministry of health health and social sciences operational strategies to prevent 368 covid-19 spread in radiology: experience from a singapore radiology department 369 after sars joint statement on planned placements for 371 ahp, nursing and midwifery students during covid-19 medical student education in the time of covid-19 important guidance for medical 390 students on clinical rotations during the coronavirus (covid-19) outbreak 395 coordinated responses of academic medical centres to pandemics: sustaining 396 medical education during covid-19 circuit breaker to minimise further spread of 405 covid-19 stricter safe distancing measures to prevent 409 further spread of covid-19 cases updated guidance on the movement of 414 healthcare workers, patients and visitors in healthcare institutions at dorscon 415 orange dealing with covid-19: initial perspectives of a small radiology 422 department touch me not: safe distancing in radiology during coronavirus disease 431 2019 (covid-19) covid-19 cases; 4 cases there currently unlinked. the straits times perceived benefits of the use of learning contracts to guide clinical 439 education in respiratory care students covid-19's staggering impact on global education. 441 world economic forum experience critical global issues that require attention and action current problems in diagnostic radiology the impact of covid-19 454 epidemic declaration on psychological consequences: a study on active weibo users guidance on participation 457 in clinical education experiences in physical therapy education considerations for covid-19 462 preparedness and response in u.s. schools of nursing mediated learning in the workplace: student perspectives on 467 knowledge resources is there a role for simulation based education within conventional 470 diagnostic radiography? a literature review motivation of student radiographers in learning situations based 474 on role-play simulation: a multicentric approach involving trainers and 475 students radiographers' and students' experiences of undergraduate 479 radiotherapy practice placement in the united kingdom we signed up for this!" -student and 487 trainee responses to the covid-19 pandemic key: cord-280431-tuzdng4h authors: alinier, guillaume title: 5 basing a nonclinician's career upon simulation the personal experience of a physicist date: 2008-12-31 journal: clinical simulation doi: 10.1016/b978-012372531-8.50013-3 sha: doc_id: 280431 cord_uid: tuzdng4h publisher summary this chapter concerns the breed of people who start by selecting a nonclinician path and eventually work in clinical simulation. their new role requires their grasping a wide range of clinical and educational concepts and skills that should already be second nature to their new colleagues who are trained as an educator, a clinician, or health care professional. there are many different opportunities and responsibilities in the domain of clinical simulation, and nonclinicians could occupy almost any one of them. this ranges from educationalist, communication or team dynamic expert, technician, or technical manager, center coordinator, administrator, to operations manager. the background of potential simulation center employees will be an important asset in their new role as it could give them a different perspective, additional skills, and innovative ideas that complement those of their clinical colleagues. in today's society, workers are very mobile and do not stay in the same company or even in the same field during their entire professional career. this is not only true for the general unskilled or unqualified workforce but also applies more frequently to trained graduates and highly skilled and specialized professionals. nowadays, an employer sees a degree more as a learning passport than as a field-specific qualification. it is clearly expected that employers will look for specific attributes in prospective candidates, but it also appears that they believe in the transferability of skills of their new recruits. a qualification is seen as someone's ability to learn about a subject, hence it is expected that with the right attributes or aptitude and motivation, one can also acquire the relevant knowledge and skills required to adapt effectively to a different field. this chapter is about the breed of people who start by selecting a nonclinician path and eventually work in clinical simulation. their new role requires their grasping a wide range of clinical and educational concepts and skills that should already be second nature to their new colleagues who are trained as an educator, a clinician, or health care professional. there are many different opportunities and responsibilities in the domain of clinical simulation, and nonclinicians could occupy almost any one of them. this ranges from educationalist, communication or team dynamic expert, technician, or technical manager, center coordinator, administrator, to operations manager. the background of potential simulation center employees will be an important asset in their new role as it could give them a different perspective, additional skills, and innovative ideas that complement those of their clinical colleagues. simulation is currently a very exciting field where today's veritable explosion of global simulation activity has come from decades of isolated pioneering efforts. some of these simulation explorers started developing and testing methods, and technology eventually succeeded in making commercial training products, along with a generalized teaching approach that could be more widely available and affordable [1] . the triggers for this rapid growth have not only been recent technological developments in terms of personal computer power, but primarily clinical educators believing in the potential of simulation training approaches to help others effectively acquire life-saving skills in a safe and controlled environment. as the appellation "simulation" indicates, everything can and should not be real to allow control of the scenario (patient and environment). the key is determining how much reality copyright © 2008 by elsevier inc. all rights of reproduction in any form reserved 53 is needed, and how to produce it. fortunately, the realism of most clinical items and settings can be very high, given that most are actual clinical equipment and clinical settings. however, quite often, because of the procedures to be carried out and for ethical, consent, and safety reasons, one of the principal simulated components has to be the patient. for scenarios including invasive procedures, part or the entire patient is substituted by a mannequin, and in the latter case, under computer direction. in other words, it is a machine or nonbiological system designed by a team of engineers to reproduce the physical aspects, as well as the pharmacological and biological behaviors of a human being. although great discoveries have been made in medicine in general, creating a machine that simulates a whole human being is a particularly challenging task that might never be realized. fortunately, education is characterized by the instructor illuminating a small fraction of all reality as a way to attract the students' attention toward one or two learning objects to the exclusion of all else. this intentional focus and isolation upon a very small segment of reality is the essential basis for simulation's success, since all that is needed to be created is that which is illuminated. we often make the analogy between simulation in the aviation industry and in health care, with the aviation being ahead of health care by decades. technically, this is not a very fair comparison as the simulated atmosphere (the patient equivalent) is readily available for testing and has no will of its own while the simulated aircraft (the clinical devices and tools equivalent) has well-defined components that do not change at the whim of frequent equipment purchasing decisions. even if it is very costly, it is evident that building a device that will simulate the functions of an aircraft strictly obeying the laws of physics is less challenging than building a life-like patient. socially, this gap is an indictment on the insufficient interest in creating data and using evidence to drive both clinical care and clinical education. today's flight simulators can be very realistic. sitting in the cockpit, one could feel as though you were inside a real airplane as it moves through the air. the technology is now even available to the general public in fun parks as rides which can provoke adrenaline rushes. one key difference between flight and clinical simulation is the perceived return on financial investment. the business linkage between the payers for flight simulation (investment) is very close to the payers for flight (customers). in contrast, the payers for clinical education (investment) are very far from the payers for health care (insurance?) and the payers for the lack of health care (all of us). thus, the amount of resources expended upon developing and implementing both the technology and the acceptance of flight simulation is orders of magnitude greater than that expended upon clinical simulation. even with unlimited finances today, we would not be able to build a patient simulator that really feels and looks like a real patient on which one could connect any type of medical monitoring equipment, provide invasive or noninvasive treatment and expect the entire range of possible human responses. however, such a tour de force is totally unnecessary, since today's clinical care, to say nothing of clinical education, never sees nor treats the entirety of any one patient. just as we have very large selection of different types of automobiles and trucks to meet differing needs, we will develop and employ a large selection of different clinical simulation devices, each optimized for particular uses. a simulation center is a versatile environment in the sense that every aspect of a clinical simulation program is evolving. it needs to follow not only the developments in terms of medical practices across an ever-growing number of disciplines that adopt simulation, but also the development of the simulation technology itself. there is a permanent challenge to stay on top of it all, whether it is the adoption of new resuscitation protocols, hospital policies, new roles of health care practitioners, the release of revolutionary pieces of medical equipment, or even the social and political context. scenarios and debriefing provided to participants constantly need to be improved just as their clinical competencies need to be improved. because of recent natural and unnatural catastrophes such as floods, epidemics, and chemical, biological, radioactive, and nuclear terror threats, there has been unprecedented efforts in developing large-scale simulation training programs to review protocols and prepare emergency services and hospitals [2] [3] [4] [5] . the consequences after the use of weapons of mass destruction, for example, on our populations would be even more catastrophic if our emergency services have not had the chance to prepare themselves through simulation exercises. my interests and technical mindset have encouraged me to study physics at university, both in france and great britain. during and after my master studies in applied physics, i started working for two sister companies primarily specializing in underwater acoustics research and in the design and installation of fish deterrence systems. although i thoroughly enjoyed the scientific research challenges and the technicality of the work, i felt the need to apply my skills and knowledge in a different area where it could directly benefit people. i did not want to carry on working in isolation or always with the same people (as nice as they are), but instead was in search of doing something where i could more directly see the effect of my efforts and meet more people. in 2000, i decided to look for a position in medical physics, but instead i found myself attracted by a university research job in biomedical engineering and clinical education. it consisted on coordinating projects toward the development of a low-cost interactive patient simulator for the training of preregistration nursing and paramedic students. this project was funded by the british heart foundation, with the goal of creating a low-cost patient simulator with which real medical pieces of monitoring equipment could be used (blood pressure cuffs, ecg monitors, pulse oxymeters), which at the time was not available in any low-price commercially available simulator. at first, this seemed an intriguing yet interesting project as i had never heard of patient simulators nor knew anything about the training of health care professionals. once engaged to take on this job, for 3 years i strived to come up to speed with the overall concepts and the current developments in the field of health care simulation. very rapidly, the enthusiasm of the pioneers working in this area fully made sense to me. learning about the patient simulator developments throughout the world, i realized a fair amount of work had already been carried out and employed in high-fidelity patient simulators. it was often overlapping with projects in which the department in which i was now working was engaged through the work of some of their biomedical engineering students. in parallel, i was made aware of the imminent arrival on the market of the intermediate-fidelity patient simulators with similar features. not intending to reinvent the wheel, and coincidently with the student recruitment difficulties in biomedical engineering, our project's aims or objectives were significantly reduced. within a couple of years, the university's biomedical engineering teaching program was stopped, which unfortunately almost put an end to our technical developments in patient simulation. at the same time, i assumed responsibility for the development of the university of hertfordshire's intensive care and emergency simulation center concentrating primarily on delivering simulation-based training to nursing and paramedical students and evaluating the teaching effectiveness of this approach [6] . the center was initiated and inaugurated by my line managers in 1998, but was not very actively used as a simulation center as no one was in charge of the center on a day-to-day basis. despite this shift in my focus, i believed that remaining active on the engineering development side of patient simulators was still important for me in order not to lose the skills i had previously acquired through my academic qualification and prior work experience. to that effect, alongside the day job in the faculty of health and human sciences, i have always tried to pursue my research efforts in technically challenging projects [7] to further enhance current patient simulators. to this end, i supervise the regular visits of physics research students from the french university where i graduated in 1997. an interesting advantage as a technically minded person is to be able to understand how the patient simulator operates at the overall scale and at the subcomponent scale; that is, from the philosophy inherent to its intended use, to the computer interface to the microswitches and pneumatic valves inside the mannequin. it proves particularly useful to rapidly troubleshoot problems with the patient simulators or pieces of medical equipment and quickly identify solutions. there is also certainly a greater awareness in terms of the technology that can be used to further enhance the simulation center, and make it a better learning environment. this includes, for example, choosing appropriate audio and visual equipment to link the observation room or simply providing advice to colleagues regarding the best tool to use to teach a particular skill, concept, or attitude. education or pedagogy is a major aspect of anyone working in the control room or on the simulation platform of a simulation center. very early on, after starting my research job in simulation, i started studying for a postgraduate certificate in teaching and learning in higher education. it has recently become a compulsory qualification for new uk university lecturers. i felt it could be another very valuable asset to become a faculty in a simulation center. this gave me some underpinning knowledge of the theories of learning, teaching, and assessment that i could relate to in my simulation teaching practice, especially during debriefing, or through the examination sessions organized as part of my research on the effectiveness of simulation training [8] . at the end of my 3-year research contract, i was offered a lectureship to carry on operating the hertfordshire's intensive care and emergency simulation center as the center coordinator and take on responsibilities for a broader range of activities such as producing short courses and taking on consultancy work. as the only permanent member of staff of the center, i have a very varied role including scheduling, cleaning and maintaining the patient simulators, controlling them during the simulation sessions, and training other faculty how to facilitate simulation sessions. the latter has even been validated by the university's postgraduate medical school as an optional module counting for one-sixth of a master of health and medical education [9] . this is probably one of the first "simulation faculty training course" attracting academic credits. training as a physicist, i had never thought i could ever be involved in teaching or in facilitating learning with such diverse groups of health care trainees and professionals, but simulation opened up these opportunities to me. hence, i strongly believe that there is a place in simulation centers for physicists who want a career change. i find working in the simulation center very fulfilling and i would not discourage anyone with a nonclinical background trying their chance in health care simulation. engineers and scientists have rarely been renowned for their outstanding communication skills, and i believe that it is an aspect of extreme importance in the field of health care simulation education. it is very relevant and applicable to different aspects of a job in a simulation center, whether it involves interaction with participants, colleagues, and especially the media. whether you are a faculty or a technical manager, communication should always work both ways. if you are a faculty, you need to work closely with other faculty and actors to make the scenarios work and execute smoothly. good communication skills will help you in this teamwork activity. another important part of any simulation is the actual debriefing where, after having listened to the participants discussing their experience, you need to be able to appropriately debrief them. good communication skills will be an asset to clearly and effectively transmit your teaching points and tips. similarly, if you intend to become a technician or technical manager, you might have to brief fellow educators about particular features of your simulation room, the audio/visual system, or the patient simulator, and similarly, you will continuously take in their suggestions and requests to improve aspects of the environment or the simulator itself to further their teaching objectives. i believe that poor communication skills could hinder your career progression in this field. although one might think that if you have a technical role, you are not very exposed to coming into contact with participants because you can hide in the control room most of the time; accepting this limited role will doom you into never ever extending beyond being a technician. in reality, even if you only have to deal with small numbers of participants at a time, you will certainly be involved in their briefing about the simulation environment, the patient simulator, and maybe the debriefing of scenarios. your interaction with participants can significantly contribute to the learning success of the simulation session. alongside your colleagues, you need to be able to make participants feel at ease in this unfamiliar environment to them, and not being a good communicator will not help you or them in this aspect. similarly, you can greatly contribute to the success of your center's simulation programs by effectively communicating with other educators to refine scenarios provided to your participants, develop the simulation environment and new props. as an engineer or scientist working in a simulated health care environment places, you are in an ideal position to think "outside the box" and make new ones. it might help you seeing things from a different angle in comparison to your clinical colleagues. this is particularly true and useful when it comes to building simulation props and tricks. not possessing the physiological knowledge might be an advantage and help you being more innovative and creative. at times, for the development of a simulation component, it is useful to only understand what someone is expecting to see from the outside rather than the full underlying physiological principles. during scenarios, you might have new ideas for future developments that will enhance the simulation experience of the participants. hence, at any time, it is always useful to take notes before you forget. integration of new capabilities required for one new scenario often opens up opportunities for the creation of others. eventually, exposure to a broader range of scenarios can be very enriching for participants, and helps prevent fatigue and boredom in the educators. similarly, working collaboratively with clinical colleagues will be something to explore. you might be able to use your skills and technical knowledge to further develop their ideas and improve aspects of the simulation training experience of participants. the reality of a nonclinician working in a simulation is that you have all chances to become an overall expert of simulation-based training as you will be involved in all aspects of operation of your center. many people with an engineering background are currently employed by hospitals or universities as "simulation center coordinators" or even "simulation center managers." taking on educational training might even enable you to become a member of the faculty team. the more you want to participate in clinical education, the more you will be able to do so through simulation, but only to the extent that you are willing to learn how to be useful. as we have seen through this chapter, the simulation arena is a versatile environment that offers interesting opportunities to nonclinicians. the brief overview of a physicist's journey in a university simulation center provides a concrete example. the advice provided to engineers and scientists is probably also valid to other professionals wishing to work in the field of health care simulation. the society in europe for simulation applied to medicine, sesam http://www.sesam.ws meeting other people in the field was an eye opener. because it is europe-based, there are many participants from the uk with the same problems and in the same situation (institutional/economical/social climate). the international meeting on simulation in healthcare, imsh http://ssih.org/ much broader in terms of audience and experiences, largerscale centers, but also valuable things to learn from. a simulation user website with a lot of useful information: http://www.patientsimulation.co.uk an open forum of simulation users. pages with tips and tricks to simply modify simulators, share scenarios. thank you neal for your great work at maintaining the pages up-to-date! a brief history of the development of mannequin simulators for clinical education and training, quality and safety in health care the use of simulation in planning the transportation of patients to hospitals following a disaster using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome a multidisciplinary approach to teach responses to weapons of mass destruction and terrorism using combined simulation modalities simulationbased training of medical teams to manage chemical warfare casualties effectiveness of intermediate-fidelity simulation training technology in undergraduate nursing education 12-lead ecg training: the way forward nursing students' and lecturers' perspectives of osce incorporating simulation accredited university module for clinical simulation facilitators at the university of hertfordshire key: cord-299082-s8bm40vy authors: wang, yueying; wang, zhaojia; tse, gary; zhang, lin; wan, elaine y.; guo, yutao; lip, gregory y. h.; li, guangping; lu, zhibing; liu, tong title: cardiac arrhythmias in patients with covid‐19 date: 2020-07-26 journal: j arrhythm doi: 10.1002/joa3.12405 sha: doc_id: 299082 cord_uid: s8bm40vy the emergence of coronavirus disease 2019 (covid‐19), caused by the severe acute respiratory syndrome coronavirus 2 (sars‐cov‐2) has become a major global public health concern. although sars‐cov‐2 causes primarily respiratory problems, concurrent cardiac injury cannot be ignored since it may be an independent predictor for adverse outcomes. cardiac arrhythmias are often observed in patients with covid‐19, especially in severe cases, and more likely contribute to the high risk of adverse outcomes. arrhythmias should be regarded as one of the main complications of covid‐19. mechanistically, a number of ion channels can be adversely affected in covid‐19, leading to alterations in cardiac conduction and/or repolarization properties, as well as calcium handling, which can predispose to cardiac arrhythmogenesis. in addition, several antimicrobials that are currently used as potential therapeutic agents for covid‐19, such as chloroquine, hydroxychloroquine and azithromycin, have uncertain benefit, and yet may induce electrocardiographic qt prolongation with potential ventricular pro‐arrhythmic effects. continuous electrocardiogram monitoring, accurate and prompt recognition of arrhythmias are important. the present review focuses on cardiac arrhythmias in patients with covid‐19, its underlying mechanisms, and proposed preventive and therapeutic strategies. severity and fatal outcomes. [4] [5] [6] [7] a variety of pro-inflammatory mediators play a key role in the pathophysiology of cardiac complications in covid19 . previous work has identified that ards (20%), arrhythmias (17%), shock (9%), and acute cardiac injury (7%) are common compilations in covid-19. 1 therefore, a better understanding of cardiovascular effects in sars-cov-2 infection is essential to mitigate poor prognosis in patients with covid19 . the aim of this study is to conduct a comprehensive review of published studies on the electrophysiological effects of covid-19. this is followed by a discussion on the underlying mechanisms, with proposals of preventative and therapeutic strategies for treating cardiac arrhythmias in covid-19 patients. the clinical course of sars-cov-2 infection is mostly characterized by respiratory tract symptoms, including fever, cough, pharyngodynia, fatigue, and complications related to pneumonia, such as acute respiratory distress syndrome and shock. nevertheless, a brief case reported by inciardi et al 8 several studies have proved that sars-cov-2 infection can induce cardiac injury. previous studies defined cardiac injury as the serum levels of cardiac biomarkers (eg, troponin i) were above the 99th percentile upper reference limit. 1, 2, 9 huang et al 2 first reported a 12% (5/41) incidence of acute cardiac injury in patients with covid-19. a series of subsequently published studies confirmed the previous findings, the incidence of cardiac injury ranged from 7.2% to 28%. 1, 2, 6, 7, 10, 11 moreover, the incidence of myocardial injury was higher in severe and critical cases, which ranged from 22% to 44%, 1, 2, 9, 12 compared to an incidence of approximately 2% to 4% 1, 2 in less severe cases. death cases (28% to 89%) had a conspicuously higher risk of cardiac damage than survivors (1% to 15%). 5, 6, 9, 10, [12] [13] [14] [15] several investigators have reported cardiac function and structural abnormalities in patients with sars-cov-2 infection, including acute heart failure (hf), 3,10,16 takotsubo syndrome, 17 ,18 viral myocarditis, 19 and acute myocardial infarction. 10 full-genome sequencing and phylogenic analysis indicated that sars-cov-2 has features typical of the coronavirus family and distinct classified in the beta-coronavirus, belongs to the same genus as human severe acute respiratory syndrome coronavirus (sars-cov) and middle east respiratory syndrome coronavirus (mers-cov). in patients with sars, tachycardia was the most common ecg abnormalities but usually self-limiting, the incidence ranged from 72% 22 ; bradycardia was relatively less common, ranged from 2% to 15%. [22] [23] [24] st-t changes and cardiac arrhythmias such as branch block, atrial fibrillation (af), premature beats, qt interval prolongation, or even sudden cardiac death (scd) were also seen in sars patients. 22 had arrhythmia, 14 in addition, cardiac arrhythmias were independently associated with an increased risk of in-hospital death (11.5%, vs 5.6% among those without arrhythmia; odds ratio, 1.95; 95% ci, 1.33-2.86). 31 thus, arrhythmia should be regarded as one of the main complications of covid-19, and proactive arrhythmia monitoring and management is needed. covid-19 patients have relatively increased fast heart rates (hr) ranging from 80 to 88 beats per minute (bpm) in sinus rhythm. 1, 5, 20, 32 hr in patients treated in the icu was faster than whom admitted in the general ward. 1 nonsurvivors showed significantly faster baseline heart rates on admission compared to survivors. 10 another study documented heart rate in 17 covid-19 patients, and tachycardia was found in three patients (17.6%), one of those was a severe case, and two were critical cases. 33 among them, atrial fibrillation in 12 patients, atrial flutter in 6 patients, and atrial tachycardia in 1 patient. 34 atrial tachyarrhythmias were common among patients with covid-19 who required admission to an intensive care unit and were often followed by hemodynamic deterioration. in short, we have to pay attention to the tachycardias in the severe and critical covid-19 patients. in addition to exacerbating the previous cardiomyopathy and conduction disorders, inducing arrhythmia events, sars-cov-2 may also induce electrophysiological abnormalities in patients with no previous history of heart disease under a variety of mechanisms. our recent work reported that the incidence of cardiac arrhythmias in covid-19 patients ranged from 17% to 30%. 1,20 among these, atrioventricular/ventricular block (11.8%) was the highest incidence in arrhythmia, and the ratio exceeded sinus tachycardia (7.5%), sinus bradycardia (8%), atrial arrhythmias (7%), and ventricular arrhythmias (4%). 20 complete heart block and severe left ventricular dysfunction were developed in a child with covid-19 infection. 35 another case from iran also reported transient complete heart block in a patient with covid-19, 36 and a 21-year-old female patient' ecg showed nonspecific intraventricular conduction delay and multiple premature ventricular complexes. 19 in our report, st-t changes were the most common ecg abnormality in covid-19 patients, accounting for about 41% (38/93). five of these patients were diagnosed with acute myocardial infarction (ami). 20 a recent case series showed 18 patients with covid-19 who had st segment elevation in ecg, 13 (72%) patients died in the hospital (acute st segment elevation myocardial infarction: n = 4; noncoronary myocardial injury: n = 9). 21 a 61-year-old hispanic male presented with a brugada-type pattern ecg in right precordial leads, 2 days later he developed a brief episode of atrioventricular nodal reentrant tachycardia (avnrt). 37 a patient finally died within 24 hours of the occurrence of multifocal ventricular tachycardia (vt) and st segment elevation. 38 our study found a proportion of 13% (12/93) covid-19 patients had prolonged qt interval, mean qt interval was 431 milliseconds (414-454 milliseconds). 20 qt prolongation has previously been described associated with various conditions (eg, inherited arrhythmia syndromes, myocarditis toxicity, metabolic disorders, certain drugs). several antimicrobials that are currently used as potential therapeutic agents for covid-19 have uncertain benefit, and yet may induce electrocardiographic qt prolongation with potential ventricular pro-arrhythmic effects. these agents are chloroquine (cq), hydroxychloroquine (hcq), azithromycin, and lopinavir/ritonavir. 39 recent evidence indicates significant qt prolongation in patients with covid-19 receiving hcq. 40 for example, borba and colleagues 41 performed a parallel, double-blind, randomized clinical trial designed to assess the safety of cq in dosages, they found that prolongation of qtc interval was observed in 4 of 36 patients (11.1%) in the low-dose group (ie, 450 mg twice daily on day 1 and once daily for 4 days) and 7 of 37 patients (18.9%) in the high-dose group (ie, 600 mg cq twice daily for 10 days); in addition, 2 patients in the highdose group (2.7%) experienced ventricular tachycardia, 60% (3/5) patients in the high-dose group with underlying heart disease died. moreover, the patients who received hcq with concurrent treatment of azithromycin were at high risk of greater changes in qtc, 42 12% of them manifested critical qtc prolongation, and the combination caused greater prolongation than either drug alone. 43 chorin et al 44 observed qtc prolongation from a baseline average of 435 ± 24 milliseconds to 463 ± 32 milliseconds (p < .001), which was observed 3.6 ± 1.6 days after administration of hcq + azithromycin therapy. in a subset of those patients (9/84, 11%), qtc was severely prolonged to >500 milliseconds, a known ecg marker of high risk of malignant arrhythmia and sudden cardiac death. 44 a greater proportion of patients receiving hcq+azithromycin experienced cardiac arrest (15.5%) and abnormal ecg findings (27.1%), as did those in the hcq alone group (13.7% and 27.3%, respectively), compared with azithromycin alone (6.2% and 16.1%, respectively). 45 certain antifungal drugs, glucocorticoids and certain antiarrhythmic drugs lead to prolonged qt intervals as well. if these medications are used, clinicians should monitor the patient for side effects, especially prolonged qtc interval by continuous ecg monitoring. a summary of the potential mechanisms by which cardiac arrhythmias occur in sars-cov-2 infections is shown in figure 1 . 50 we speculate that an analogous mechanism may operate in cardiomyocytes. previous tissue visualization has revealed irregular shape of the myocardium, darkened cytoplasm, mild fibrosis, and mild hypertrophy of the myocardium. 51 the type of reactive oxygen species, thereby prolonging apd. 49, 63 in addition, tnf-α also reduced i cal , intracellular calcium transients. moreover, tnf-α may reduce the expression of serca2a by inducing the level of dna methyltransferase. 64 therefore, tnf-α signaling is also an important inflammatory factor leading to arrhythmia. patients with covid-19 often present with fever. in the patients with some underlying heart diseases, fever can trigger ventricular fibrillation. 65, 66 it may be related to ion channel mutations, such as scn5a in brugada syndrome. 64 besides, abnormal sodium current also plays an important role. 67, 68 in addition, fever can cause tachyarrhythmias in individuals without inherited heart disease. its presence may alter the efficacy of sodium channel blockers in terms of their antiarrhythmic effects. 69 sars-cov-2 may induce myocardial injury by inhibiting the activity of ace2. it is thought that ace2 could be internalized and shed from the membrane surface diminishing function of ace2 when sars-cov-2 binding to ace2 to enter cells. 68 the conversion of angiotensin ii (ang ii) to ang (1-7) may be reduced, which weakens the cardiovascular protection effect of ang (1-7) through the mas receptor. 70, 71 for example, ang1-7 could change i cal , ito, expression of kv4.3 potassium channel, and ca 2+ channel to prevent af ionic remodeling. 72 besides, ang ii induces automatic activities by activating ip₃ receptors and na⁺-ca 2+ exchanger in guinea pig pulmonary vein myocardium. in addition, chronic ang ii exposure induces ros production by nox2 resulting in oxidative activation of camkii, further promotes sr-ca 2+ leakage, thus increasing the possibility of delayed after depolarization (dad). 73 ang ii induces membrane depolarization and activation of i cal. 74 the accumulation of ang ii promotes myocardial fibrosis and cardiac remodeling. these will promote the occurrence of arrhythmias. many patients have disorders of coagulation and fibrinolytic system, showing hypercoagulability of blood, and even disseminated intravascular coagulation (dic). 75 the effects of hypercoagulation on the myocardium, such as acute coronary syndrome, 76 will be ischemia and hypoxia, leading to cardiac electrophysiological abnormalities. it has been changed that na + -ca 2+ exchange, i k current, and phosphorylation of proteins in the sarcoplasmic reticulum. 77, 78 next, early and late depolarization, inducing ectopic beats, and the apd changed. all these will promote the development of reentrant arrhythmias such as malignant ventricular arrhythmia. 64, 77 in addition, acute left atrial ischemia led to atp-sensitive potassium current (ikatp) conductor-dependent shortened apd, as well as spontaneous focal discharges and reentry loops. 79 chronic atrial ischemia/ infarction promoted atrial fibrillation by unprompted ectopy and sustained reentry. 80 administration of certain drugs may affect the electrophysiological properties of the myocardium. for example, the recently controversial cq and hcq can cause prolongation of qt interval. in sinoatrial node (san) myocytes, hcq decreased spontaneous action potential firing rate and the "funny" current (i f ), and it also affected i cal and i kr . 81 these changes caused a delay in the depolarization, thus lowering the heart rate. 76, 82 in addition, azithromycin can also affect the occurrence of ap promoting arrhythmias in cardiomyocytes. it is reported that azithromycin can inhibit i cal , i na , and i kr current, causing bradyarrhythmia. 83 however, azithromycin can increase i na currents in cardiomyocytes with chronic (24 hour) exposure. 84 moreover, azithromycin promoted the production of reactive oxygen species in cardiomyocytes, mitochondrial damage, 85 inducing cardiac dysfunction and eventually arrhythmia occurs. together, a number of ion channels can be adversely affected in covid-19, leading to alterations in cardiac conduction and/or repolarization properties, as well as calcium handling, which can predispose to cardiac arrhythmogenesis. clinicians should be vigilant of potential rhythm disturbances in covid19 . palpitation has been reported as the initial symptom in 7% (10/137) of covid-19 patients. 86 around 4% of covid-19 patients have a prior history of cardiac arrhythmias and may be particularly susceptible to further rhythm disorders. 87 outbreaks of covid-19 threaten public health but the associated extrapulmonary manifestations and their prolonged consequences are often overlooked. previous reports reveal that cardiac arrhythmias are one of the common complications associated with covid-19, which may sometimes be life-threatening. we would suggest that front-line clinicians monitor cardiac rhythm as part of the routine care, and the data may shed light on whether covid-19-related arrhythmic complications is an independent predictor of adverse outcomes. early 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covid-19: results of an open-label non-randomized clinical trial breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid-19 associated pneumonia in clinical studies covid-19) treatment guidelines an algorithm for managing qt prolongation in coronavirus disease 2019 (covid-19) patients treated with either chloroquine or hydroxychloroquine in conjunction with azithromycin: possible benefits of intravenous lidocaine recommendation for the diagnosis and treatment of arrhythmia complicated with covid-19. zhong hua xin lv shi chang xue za zhi cardiac arrhythmias in patients with covid-19 key: cord-289520-i6pv90s9 authors: harris, carlyn; carson, gail; baillie, j kenneth; horby, peter; nair, harish title: an evidence-based framework for priority clinical research questions for covid-19 date: 2020-03-31 journal: journal of global health doi: 10.7189/jogh.10-011001 sha: doc_id: 289520 cord_uid: i6pv90s9 background: on 31 december, 2019, the world health organization china country office was informed of cases of pneumonia of unknown aetiology. since then, there have been over 75 000 cases globally of the 2019 novel coronavirus (covid-19), 2000 deaths, and over 14 000 cases recovered. outbreaks of novel agents represent opportunities for clinical research to inform real-time public health action. in 2018, we conducted a systematic review to identify priority research questions for severe acute respiratory syndrome-related coronavirus (sars-cov) and middle east respiratory syndrome-related coronavirus (mers-cov). here, we review information available on covid-19 and provide an evidenced-based framework for priority clinical research in the current outbreak. methods: three bibliographic databases were searched to identify clinical studies published on sars-cov and mers-cov in the outbreak setting. studies were grouped thematically according to clinical research questions addressed. in february 2020, available information on covid19 was reviewed and compared to the results of the sars-cov and mers-cov systematic review. results: from the research objectives for sars-cov and mers-cov, ten themes in the literature were identified: clinical characterisation, prognosis, diagnosis, clinical management, viral pathogenesis, epidemiological characterisation, infection prevention and control/transmission, susceptibility, psychosocial, and aetiology. for covid19, some information on clinical presentation, diagnostic testing, and aetiology is available but many clinical research gaps have yet to be filled. conclusions: based on a systematic review of other severe coronaviruses, we summarise the state of clinical research for covid-19, highlight the research gaps, and provide recommendations for the implementation of standardised protocols. data based on internationally standardised protocols will inform clinical practice real-time. viewpoints research theme 6: outbreaks, especially of novel agents, create a pressing need to collect data on clinical characterization, treatment, and validation of new diagnostics to inform rapid public health response. in 2018, we conducted a systematic review to identify the most common clinical research questions asked during outbreaks of sars-cov and mers-cov. we identified ten major clinical questions and provided recommendations for standardised protocol study designs that should be designed in the case of a new outbreak of a novel respiratory pathogen. here, we review the currently available information on covid-19 to determine which clinical questions from the systematic review findings have already been addressed, what information is lacking, and compare covid-19 to sars-cov and mers-cov. we included any original study included conducted in a clinical setting during an acute outbreak of mers and sars but limited the sars studies to those published during the sars epidemic and (16 november 2002 through 5 july 2003) and 18 months thereafter to identify clinical questions relevant during the acute phases of the outbreak. therefore, for sars studies, the last publication date considered for full text review was 31 december 2004. there was no publication date restriction for mers studies as outbreaks were ongoing. search terms to capture observational study designs such as cohort studies, cross-sectional studies, case-control studies, and case series were adapted from the scottish intercollegiate guidelines network (sign) search filters [4] . search terms on diagnosis and prognosis were adapted from pubmed clinical query search filters provided in the pubmed help manual [5] . to capture studies that were conducted in the epidemic or outbreak setting, subject headings such as "disease outbreaks", "epidemics", "pandemics", etc. were included. we applied our inclusion and exclusion criteria ( table 1) for both title and abstract screening and subsequently full text screening. following data extraction, the objectives of the included studies were grouped thematically. within each theme, articles with objectives that represented similar research questions were summarised. studies must be: 1) the main objective was not the study of sars-cov or mers-cov -focused sars-cov or mers-cov 2) the study was not conducted primarily in a clinical setting (ie, population epidemiology studies, in-vitro studies, surveillance studies were excluded) -conducted in a clinical setting 3) the study was not conducted in an outbreak setting or did not analyse data that was collected in an outbreak setting -conducted on humans 4) non-human studies study designs considered: observational studies (prospective cohort, retrospective cohort, case-control, case-series) and cross-sectional studies. 5) the sample size was less than 4 6) the study was not original as this outbreak is in its initial stages, we reviewed resources such as: the world health organization disease outbreak news, ministry of health websites from affected countries, the center for disease control' s morbidity and mortality weekly report (mmwr), promed, and publications found on pubmed. for pubmed searches, the search term "novel and coronavirus" was used, with a date range starting at 1 january 2020. the search was conducted on 20 february 2020. references of articles found through these searches were also reviewed. only studies conducted in the clinical settings were included and single case reports were excluded. we compared our findings to the 2018 systematic review on sars and mers to determine which questions have already been addressed, what information is lacking, and provide recommendations for data sharing and clinical study designs to be conducted during the current outbreak. we grouped the results thematically from reviewing available resources on the novel coronavirus based on their relevance to the previously identified ten clinical questions. viewpoints research theme 6: covid-19 pandemic no funding body had any role in study design, in the collection, analysis, and interpretation of data; in the writing of the report; nor in the decision to submit the paper for publication. a total of 124 studies (71% on sars) were included for the final review and data extraction. all were conducted in a hospital setting. after thematically coding the objectives of the 124 studies, ten key themes emerged: clinical characterisation, prognosis, diagnosis, clinical management, viral pathogenesis, epidemiological characterisation, infection prevention and control/transmission, susceptibility, psychosocial, and aetiology. originally, infection prevention and control and transmission were grouped separately. however, they were combined as most of the papers in the "transmission" category were concerned with transmission to hospital workers. of note, only 16% of sars articles were published before the end of the outbreak. table 2 defines the key clinical research questions identified from each theme. this table was modelled after a publication describing harmonisation of zika virus protocols [6] . themes appear in order based on how many sars and mers articles attempted to address a question within that theme. determine effect of illness, treatment, and isolation procedures on the psychological and social well-being of those infected current state of knowledge for 2019-covid-19 here, we answer what clinical information is currently known about the novel coronavirus, using the above questions as a framework. what is the clinical presentation and spectrum of disease? the first aggregated patient data comes from a publication by chaolin huang and colleagues, who described clinical features of 41 admitted hospital patients, 6 of whom died. they collected data using an adaptation of international severe acute respiratory and emerging infection consortium' s (isaric) / world health organisation (who) internationally standardised data collection forms, updated for use with the novel coronavirus (https://isaric.tghn.org/novel-coronavirus/). they report that the novel coro-viewpoints research theme 6: navirus presentation resembles that of sars: a viral pneumonia with fever, cough, dyspnoea, and fatigue. they also found a high concentration of cytokines in critically ill patients, compared to less severe cases [7] . chen one report of pregnant patients demonstrated similar symptomology to non-pregnant patients. they also established that there was no evidence of vertical transmission to the child [11] . in the only study of infants with covid-19, wei et al. reported fever and upper respiratory symptoms common among nine infants. all infants were infected via family clusters [12] . finally, radiological studies attempted to characterise the course of disease in chest imaging. pan et al. report peak lung involvement at 10 days on ct studies [13] . of note is a case series by xie et al. that reported ground glass opacity in five patients with initial negative rt-pcr findings but suspected covid-19. they were later confirmed to be infected [14] . overall, clinical characterisation studies commonly found bilateral involvement with ground glass opacity, though a range of presentations were reported [8] [9] [10] 15] . what are the risk factors for death or severe illness? while risk factors for death and severe illness cannot be firmly established without large groups of patient data and multi-variable adjusted methods, some studies report similar risk factors among cohorts. [17] . it includes indexes such as multi-lobular infiltration, lymphopenia, bacterial co-infection, smoking, hypertension, and age. in the publication by chaolin huang and colleagues, antibiotics and oseltamivir, and oxygen support were administered to some patients. corticosteroids were used if patients were diagnosed with severe community acquired pneumonia [7] . chen et al. reported antiviral, antibiotic, and non-invasive mechanical ventilation use but did not provide comparisons or suggestions for guidelines [8] . kui et al. determined that use of systemic corticosteroids in their cohort did not show benefits, but early respiratory support improved outcomes [10] . in addition to a randomised controlled trial of lopinavir/ritonavir in adults hospitalised with covid-19 (trial registration number: chictr2000029308) [18] , over 80 clinical trials are expected to determine therapeutic options [19] . several diagnostic tests for the novel coronavirus have been developed. of note are those by corman and colleagues [20] and by hong kong university school of medicine [21] . the world health organization has provided preliminary guidance on specimen collection and shipment as well as reporting [22] . all information on diagnostic testing can be found at the who' s technical guidance site. zou et al. obtained upper respiratory specimens from 18 patients in zhuhai, china. highest viral loads were detected soon after symptom onset, with higher loads in the nose and throat. they suggest that the shedding pattern of sars-cov-2 resembles patients with influenza. asymptomatic patients were also found to have nasopharyngeal viral loads similar to symptomatic patients [23] . additionally, y. zhang et al. found live virus in stool samples [24] . zhou the world health organization has provided a case definition in their interim surveillance guidance for the novel coronavirus [28] . the definition includes patients with a severe acute respiratory infection (sari) with relevant travel history within 14 days of illness or a health care worker caring for those with sari. currently, there are no data on what clinical activities are associated with an increased risk to health care workers. as of 14 february 2020, over 1700 health care workers have been infected [29] . the world health organization has provided interim guidelines for infection prevention and control [30] . currently, it is unclear whether certain demographics of the population are more susceptible to infection with the novel coronavirus. most initial cases had contact with wuhan' s huanan seafood market, the suspected source of the outbreak, or had contact with those who had visited the market [1] . what is the causative agent of disease? sequencing analysis from lower respiratory tract samples from bronchoalveolar lavage identified the novel coronavirus. genomes were released on gisaid.org. due to similarities with related viruses, a bat reservoir is suspected [25] . currently, there are no data on the psychosocial impacts of infection, hospitalization, or quarantine among affected patients and health care workers. we summarise the available clinical information on covid-19, using results from a systematic review on sars and mers as a framework. as highlighted by david heymann in a recent lancet commentary, rapid action by clinicians and scientists to share data has made it possible to identify a causative agent, design and implement a diagnostic test, as well as begin to understand patient presentation [31] . as outlined above, there is much work to be done on understanding the clinical picture of the novel coronavirus. the world health organization r&d research blueprint and the global research collaboration for infectious disease preparedness (glopid-r) have identified similar research priorities as those we identified from our systematic review. overlapping priorities include understanding viral pathogenesis, clinical characterisation studies, infection prevention and control, and candidate therapeutics [32] . to facilitate answering these key clinical questions, we suggest the following study designs ( table 3) . notably, the world health organization released a cases and contacts investigation protocol called "the first few x (ffx)". it involves prospective case finding and follow-up to gain an early understanding of key clinical, epidemiological, and virologic characteristics of the first cases of covid-19 in a given country. they have also released a protocol to assess risk factors for infection among health care workers. in terms of clinical presentation, early recognition of symptoms and disease progression also allows for rapid isolation, early clinical care and limits onward transmission. who and isaric have released an updated version of their case report form (crf) specifically for covid-19. this can be used to collect anonymised, standardised clinical data to start to inform our understanding of the presentation and natural history of covid-19. this crf is being rolled out as a tool for public health and may or may not require ethical approval according to local regulations. a more in-depth characterisation, with the collection of serial biological samples through a research protocol and informed consent can be obtained through the isaric/who clinical characterization protocol. this a standardised, prospective, observational study for the rapid investigation of patients with severe acute infections. the protocol was designed to characterise host and pathogen features, triage and treatment of disease [33] . the who ffx protocol, described above, may be used for the earliest cases to identify key clinical characteristics in real-time. the current clinical characterisation articles are a start to our understanding of the clinical presentation and spectrum viewpoints research theme 6: covid-19 pandemic of disease but much larger cohorts are needed for greater precision around estimates and to undertake prognostic and risk factor analyses. based on the sars and mers systematic review, further clinical research in this area should include if and how symptomology, laboratory findings, and imaging studies differ between demographic groups (ie. adults vs children, immunosuppressed patients). what are risk factors for death or severe illness? based on recent data, male gender, advancing age and co morbidities seem to be associated with death and severe illness [16] . understanding prognostic factors for death or severe illness helps hospitals and public health authorities determine resource allocation [34] [35] [36] . during the sars epidemic, risk factors for mortality were advanced age, co-morbidities, and initial high inflammatory laboratory markers [37, 38] . similarly, for mers, advanced age and co-morbidities are predictors of severe illness and death [39] . many studies identified from the mers and sars systematic review were retrospective cohort studies and poor outcomes were assessed 21-30 days from symptom onset. in designing protocols for mortality or severe illness risk factors for covid-19, case-control studies or prospective cohort studies should be used with an end-point at 90 days, so as not to miss late deaths. whatever the optimal end-point for assessing outcome, standardising this outcome measure across studies will allow researchers to contribute to core data sets. while there is some preliminary descriptive data on clinical management, randomized controlled trials are needed to determine the best treatment options for covid-19. for now, the world health organization has issued interim guidelines for clinical management, adapted from their guidance for mers-cov. it includes recommendations for early recognition, early supportive therapy (oxygen, fluids, empirical antimicrobials) and against routine use of systemic corticosteroids unless indicated for another reason. they also provide guidelines for cases of septic shock [30] . clinical trials to test therapeutic efficacy are ongoing, such as a trial of lopinavir/ritonavir (https://www.pharmaceutical-technology.com/analysis/coronavirus-mers-cov-drugs/). more studies are expected soon [19] . most of studies identified in the sars and mers review were descriptive treatment studies. these observational studies are practical in the fast-paced outbreak setting, as they are easier than randomised controlled the first few x (ffx) who protocol https://www.who.int/publications-detail/the-first-few-x-(ffx)-cases-and-contact-investigation-protocol-for-2019-novel-coronavirus-(2019-ncov)-infection) what are the risk factors for death or severe illness? case-control study or prospective cohort with outcome of death or another defined poor outcome what treatments are effective? randomised controlled trials or adaptive trial designs what is the role of antivirals in treatment? who master protocol: https://www.who.int/blueprint/priority-diseases/key-action/multicenter-adaptive-rct-of-investigational-therapeutics-for-covid-19.pdf?ua=1 what is the role of steroids in treatment? what is the optimal diagnostic test for detecting the virus? what is the causative agent of disease? laboratory based study with clinical specimens, fulfilling koch' s postulates viewpoints research theme 6: covid-19 pandemic trials (rcts) to design and require less administrative effort. however, when it comes to treatment, rcts provide the best primary evidence for medical practice [40] . among these studies, there was great heterogenicity for testing efficacy of specific treatments. this reflects the lack of global research coordination in delivering medical countermeasures during the mers outbreaks and the sars epidemic. this should be kept in mind when designing treatment protocols for covid-19 and is being addressed by who. the rct on ebola therapeutics in the democratic republic of the congo is evidence that conducting clinical therapeutics research is possible in the context of an outbreak [41] . the who has released a master protocol for a multi-centre, adaptive, randomized, double-blind placebo-controlled clinical trial to evaluate safety and efficacy of therapeutic agents for the treatment of hospitalized patients with covid-19. using a master protocol across international sites can speed the implementation of clinical trials and quickly inform treatment options (https://www.who.int/blueprint/ priority-diseases/key-action/multicenter-adaptive-rct-of-investigational-therapeutics-for-covid-19.pdf?ua=1). what is the optimal diagnostic test? the rapid development of a diagnostic test for covid-19 was a critical development and the result of international collaboration. as the outbreak progresses, it is important to continue monitoring diagnostic validity, such as sensitivity, specificity, positive predictive value, and negative predictive value. during an outbreak or epidemic, it is important to also validate diagnostic tests in low prevalence areas, as predictive values may change [42] . what is the duration of viral shedding? understanding the duration of viral shedding and the shedding profile from different anatomical sites are key for both diagnosis and instituting infection prevention and control measures [43] . current data suggest that sars-cov-2 viral loads are high at the beginning of symptom onset, are found in upper respiratory specimens and stool specimens, and are detectable in asymptomatic patients at levels similar to symptomatic patients [23] . one sars study revealed that viral detection peaked at 2 weeks after onset for respiratory specimens and 2-3 weeks for stool and rectal specimens. the shedding peak in urine occurred around weeks 3-4. rarely did patients shed virus 6 weeks after onset, however it was documented in a few stool specimens [44] . to evaluate the shedding profile during the covid-19 outbreak, the isaric/who clinical characterization protocol can be adapted to prospectively and systematically collect serial samples from patients with suspected infection [33, 45] . as with studies on sars and mers, serial samples should be collected from multiple body sites, including urine, faecal, and nasopharyngeal samples. what characteristics define a "case"? in an outbreak, if multiple sites adopt a standardised protocol such as the isaric/who clinical characterization protocol to describe cases, case definitions could be created rapidly to inform accurate reports on incidence and prevalence. developing criteria for confirmed cases is usually based on laboratory diagnosis. the world health organization has provided an interim case definition, and it will likely evolve as more data are shared on patient presentation. what risk factors pre-dispose health care workers to infection or transmission? over 1700 health care workers in wuhan have been diagnosed with covid-19 and there is no research available as to how this happened. both mers and sars viruses showed nosocomial transmission amplification in the health care setting [46] . during the sars epidemic, 21% of the infected patients were health care workers, and in some countries, this rate was as high as 50% [47] . risk of sars infection was associated with inconsistent use of personal protective equipment, and less than 2 hours of infection control training [48] . during the 2015 south korea mers outbreak, 44% of the 186 cases were patients that had been exposed to nosocomial transmission in hospitals, and 83% of total transmission events were due to five super spreading events in hospitals [49] . the recently released who protocol for evaluating risks to health care workers should be implemented as soon as possible to prevent future health care worker infections. viewpoints research theme 6: what are the risk factors for infection (in patient population)? the suspected major risk factors for covid-19 are visiting the wuhan market or being in contact with someone who had visited the market. the above-mentioned who ffx protocol can be used globally to assess risk factors for infection. in the 2018 sars and mers systematic review, only three studies with a psychosocial focus were identified. however, integrating social science research into clinical and epidemiological research during an outbreak can help inform the need for psychologists, psychiatrists, and social workers. especially in diseases with human-to-human transmission, the effect of stigma and quarantine on mental health cannot be underestimated. psychosocial manifestations can be explored with mixed methods studies. what is the causative agent of disease? because of rapid data sharing and laboratory protocols by the chinese health officials and the world health organization, the causative agent of the novel coronavirus was rapidly identified. our systematic review summarises the questions that are answered in the context of new outbreaks, but this methodology cannot tell us what questions should be answered. however, we propose this as a proxy for ensuring key clinical questions are addressed early in an outbreak. we have summarised key knowledge gaps for covid19, but we do not intend to suggest that this is an exhaustive list. many of the most important discoveries hinge on the creativity and innovation to identify new questions. in this new outbreak, we need new ideas to build on the foundations that we have comprehensively summarised in this article. the suggested study designs above can be used to inform standardised research protocols and define data sets that should be collected by hospitals around the world, if they are affected by covid-19. as in any outbreak setting, priorities of local clinicians and public health authorities should be considered, especially in countries that integrate traditional medicine with western medicine. researchers may consider adopting a tiered approach as isaric has with the clinical characterisation protocols. the tiered approach allows sites to determine how much data or samples they can collect given their (limited) resources. this allows health care centres in low and middle-income countries to be represented in the data. global solidarity is needed in the clinical research community as we may face the next pandemic of the 21st century. we all benefit from the data collected and shared. who have launched a clinical data collection platform for covid-19 via the international health regulations and hope that member states will share their data. this uses an isaric who co-created crf for covid 19. thanks to lessons learned from sars and mers, the international public health and research community has been able to rapidly respond to the emergence of this novel coronavirus. based on a 2018 systematic review of sars and mers common clinical research questions, we provide a summary of the state of current clinical knowledge for the covid-19, demonstrate what clinical research gaps still need to be filled, and provide recommendations on study designs. many of the identified gaps, such as viral pathogenesis, clinical characterisation, infection prevention, and candidate therapeutics overlap with gaps identified the who' s r&d blueprint research roadmap. if health care facilities around the world collect standardised patient data and quickly share it, it is likely that these core clinical research questions can be answered in real-time to inform clinical practices for covid-19. world health organization. novel coronavirus (2019-ncov) situation report-1 a novel coronavirus from patients with pneumonia in china a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster scottish intercollegiate guidelines network harmonisation of zika virus research protocols to address key public health concerns clinical features of patients infected with 2019 novel coronavirus in wuhan epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan clinical characteristics of novel coronavirus cases in tertiary hospitals in hubei province clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records novel coronavirus infection in hospitalized infants under 1 year of age in china initial ct findings and temporal changes in patients with the novel coronavirus pneumonia (2019-ncov): a study of 63 patients in wuhan, china chest ct for typical 2019-ncov pneumonia: relationship to negative rt-pcr testing epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside wuhan, china the novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) -china clinical features predicting mortality risk in patients with viral pneumonia: the mulbsta score a novel coronavirus outbreak of global health concern more than 80 clinical trials launch to test coronavirus treatments diagnostic detection of 2019-ncov by real-time rt-pcr detection of 2019 novel coronavirus (2019-ncov) in suspected human cases by world health organization. laboratory testing for 2019 novel coronavirus (2019-ncov) in suspected human cases interim guidance sars-cov-2 viral load in upper respiratory specimens of infected patients notes from the field isolation of 2019-ncov from a stool specimen of a laboratory-confirmed case of the coronavirus disease 2019 (covid-19) discovery of a novel coronavirus associated with the recent pneumonia outbreak in humans and its potential bat origin molecular and serological investigation of 2019-ncov infected patients: implication of multiple shedding routes consistent detection of 2019 novel coronavirus in saliva surveillance case definitions for human infection with novel coronavirus (ncov) interim guidance v1 clinical management of severe acute respiratory infection when novel coronavirus (ncov) infection is suspected data sharing and outbreaks: best practice exemplified covid 19 public health emergency of international concern (pheic) global research and innovation forum: towards a research roadmap open source clinical science for emerging infections critically ill patients with severe acute respiratory syndrome risk factors for middle east respiratory syndrome coronavirus infection among healthcare personnel severe acute respiratory syndrome: clinical outcome and prognostic correlates world health organization. consensus document on the epidemiology of severe acute respiratory syndrome (sars) clinical manifestations, laboratory findings, and treatment outcomes of sars patients mers transmission and risk factors: a systematic review finding the evidence: a key step in the information process a randomized, controlled trial of ebola virus disease therapeutics understanding and using sensitivity, specificity and predictive values viral shedding patterns of coronavirus in patients with probable severe acute respiratory syndrome laboratory diagnosis of sars clinical characterization protocol transmission characteristics of mers and sars in the healthcare setting: a comparative study guide to infection control in the hospital. international society for infectious diseases sars transmission among hospital workers in hong kong middle east respiratory syndrome: what we learned from the 2015 outbreak in the republic of korea we extend our deepest thanks to emily phipps and jecko thachil of oxford university. with gail carson in 2012, they first proposed the idea of identifying key clinical questions asked in respiratory outbreaks as a means of epidemic preparedness and to emphasize the importance of data sharing. this work would not have been possible without them. authorship contributions: gc, ph, hn, and ch contributed the idea for the review. ch designed the study, conducted the review, and wrote the report. gc, ph, hn, and kb contributed to the critical review of the report. all authors reviewed and approved the final version.competing interests: all authors declare no competing interests. gc and ph are involved in the operation of isaric. kb is the isaric ccp technical lead. the authors have completed the icmje unified competing interest form and declare no further competing interests. key: cord-316029-z708c3ex authors: brunsdon, priya; saluja, bhawana; sahajwalla, chandrahas title: clinical pharmacology considerations for developing small‐molecule treatments for covid‐19 date: 2020-07-12 journal: j clin pharmacol doi: 10.1002/jcph.1697 sha: doc_id: 316029 cord_uid: z708c3ex numerous drugs are being investigated for the treatment of covid‐19, including antivirals and therapies targeting complications related to covid‐19. the clinical presentation of covid‐19 varies from mild fever, cough, and dyspnea in the early stages of disease to severe complications such as acute respiratory distress syndrome, systemic hyperinflammation, and sepsis. a thorough understanding of the disease pathogenesis and the disease complications is essential to developing effective therapies to treat this potentially life‐threatening disease. this review offers key clinical pharmacology considerations involved in the development of small molecules for the treatment of covid‐19. they are based on the major observed disease complications that impact drug absorption, distribution, metabolism, and elimination. we also address considerations regarding potential drug interactions, alternative routes and methods of administration, and dosing in patients on hemodialysis. the respiratory disease (covid-19) that was first reported in wuhan, china, in december 2019 is caused by severe acute respiratory syndrome coronavirus (sars-cov-2). 1 , which was declared a pandemic by the world health organization in march 2020, has been characterized by a rapid spread and profound impact to public health worldwide. 2 as of june 18, 2020, more than 8 242 999 reported cases and 445 535 deaths globally were attributed to the covid-19 outbreak. 3 mild cases of the disease may present only with cough, fever, myalgia, and malaise. gastrointestinal symptoms include nausea, diarrhea, and anorexia. abnormal symptoms such as total loss of taste and smell also have been reported. 4 in severe cases of covid-19, complications can include sepsis and septic shock, multiorgan failure, and acute kidney injury. in addition, observational studies detailing neurological symptoms of the disease, along with reports of large-vessel stroke in young patients indicate that the disease manifests throughout the body. 5, 6 infection with sars-cov-2 begins with viral binding to airway epithelial cells that express angiotensinconverting enzyme 2 (ace2). 7 one proposed mechanism for antiviral drugs involves blocking viral binding to ace2, thereby blocking viral entry into host cells. following viral infection, a local immune response is triggered, which can be beneficial to clearing the infection. however, the response can become dysregulated, resulting in cytokine release syndrome (or "cytokine storm"), which is an overproduction of proinflammatory cytokines such as interleukin (il)-6, il-10, and tumor necrosis factor. numerous biologics and small molecules with immunomodulatory effects have been proposed as investigational therapies targeting the inflammatory response or cytokine storm. therapies for other complications associated with covid-19, such as thrombosis, also have been proposed. at the time of writing, no specific treatment for covid-19 had been approved by the u.s. food and drug administration (fda), and most drugs sought for evaluation of efficacy are being repurposed from other clinical indications. this review will offer key clinical pharmacology considerations for developing small molecules for the treatment of covid-19 based on the major disease complications that impact drug absorption, distribution, metabolism, and elimination (adme). we also will address special scenarios such as changing the method of drug administration because of intubation/ventilation and hemodialysis. each stage of covid-19 presents unique clinical pharmacology considerations for developing covid-19 therapeutics. the major symptoms and clinical progression of covid-19 can be described within the framework of a proposed staging scheme by siddiqi et al. 8 the first stage of early infection occurs imme-diately after inoculation and is characterized by mild, nonspecific symptoms such as fever and cough. at this stage, patients normally are treated on an outpatient basis with supportive care. antiviral therapy may be most useful at this stage to diminish the escalation of viral replication. no specific antivirals have been approved for covid-19; however, remdesivir received an emergency use authorization (eua) by the fda for the treatment of covid-19 in adults and children who are hospitalized with severe disease. 9 oral formulations of chloroquine phosphate and hydroxychloroquine sulfate also received an eua for the treatment of covid-19 on march 28, 2020, which was later revoked on june 15, 2020, because of new information indicating the drugs may not be effective in treating covid-19. 10 as the viral load in the body increases, pulmonary symptoms worsen, and viral pneumonia develops. stage 2, or moderate disease severity, can be identified by an increase in pulmonary inflammation and usually results in hospitalization. although most people with covid-19 experience mild or uncomplicated illness, approximately 15% of patients develop severe disease, and 5% require admission to an intensive care unit. 11 in the later parts of this stage, development of hypoxia can result in the need for mechanical ventilation. patients who develop severe cases of covid-19 can develop respiratory infections associated with acute lung injury and acute respiratory distress syndrome (ards). management of ards can require supplemental oxygen, mechanical ventilation, and endotracheal intubation. stage 3, the most severe form of covid-19, is marked by systemic hyperinflammation and often the elevation of inflammatory cytokines. possible complications include cytokine storm, septic shock, acute kidney injury, and multiorgan failure. of major concern is sepsis, defined as "life-threatening organ dysfunction caused by a dysregulated host response to infection." 12 in 1 study, septic shock, which is distinguished by persistent hypotension, elevated serum lactate levels, and increased mortality, was a complication in about 6% of severely ill covid-19 patients. 11 both sepsis and septic shock result in a complex set of physiological changes that can impact the adme of drugs. most repurposed investigational drugs that target complications associated with the severe stages of disease, such as hyperinflammation, have not previously been evaluated in patient populations that routinely are septic or critically ill. the remainder of this review will cover the physiological changes and clinical pharmacology considerations for selection of dosing in severe covid-19 patients and will address special dosing situations. critically ill covid-19 patients may have altered rates and/or extents of drug absorption through the gastrointestinal (gi) tract because of hypoperfusion, delayed gastric emptying, and use of vasopressors. in patients with sepsis or septic shock, blood is shunted away from peripheral tissues toward vital organs in response to pronounced systemic hypotension. 13 poor blood flow to the gut combined with delayed gastric emptying can slow or allow for incomplete absorption of oral drugs. delayed absorption consequently can slow a drug's expected onset of action. vasopressors are routinely initiated in septic shock patients with hypotension that is unresponsive to fluid resuscitation. in a study of 393 consecutive covid-19 patients admitted to new york hospitals, 33% of all patients (and 95% of subjects who required mechanical ventilation) received vasopressor support. 14 vasopressors, such as norepinephrine, increase vasoconstriction to produce an increase in mean arterial pressure and improve perfusion to organs. several studies report improved splanchnic blood flow following vasopres-sor therapy. 15 whether these changes in splanchnic blood flow will translate to meaningful increases in oral drug absorption, however, is not entirely clear in light of conflicting results from previous studies. drugs administered intramuscularly or subcutaneously also can produce unpredictable alterations in absorption because of a combination of decreased perfusion of the muscle tissue and possible vasopressor therapy. 16 the potential for decreased or delayed absorption and variability associated with vasopressor therapy should be considered during the drug development process, especially with drugs for which the time to onset of action is of critical importance. the possibility of intravenous administration should be examined to reduce the variability associated with altered absorption of oral, intramuscular, and subcutaneous drugs. the safety margin and expected exposure following conversion to the intravenous route also should be considered when selecting doses for intravenous bolus or infusion. intravenous fluid resuscitation is a first-line therapy for the treatment of sepsis-induced hypoperfusion. infused fluids can increase the volume of distribution for water-soluble drugs, such as beta-lactams and aminoglycosides, leading to unexpectedly lower serum drug concentrations. for example, beta-lactam antibiotics administered in patients with increased volumes of distribution may not achieve therapeutic plasma concentrations, and consequently, risk treatment failure. 17 in a pharmacokinetic study of critically-ill patients during and after fluid resuscitation therapy while receiving treatment with gentamicin, the apparent volume of distribution was 48% greater during initial fluid resuscitation therapy, therefore necessitating higher doses of gentamicin. 18 therapeutic drug monitoring has been employed with antibacterial agents to address complications posed by increased volumes of distribution, although that approach likely is not feasible in studies with investigational drugs. for water-soluble investigational therapies that are intended for administration in the severely ill covid-19 population, thought should be given to targeting serum drug concentrations and the drug's exposure-response profile when determining if increased doses would be beneficial for patients receiving intravenous fluids. hypoperfusion of tissues in septic patients can decrease the efficacy of hydrophilic medications at the site of action. under septic conditions, reduced perfusion of peripheral tissues can be caused by an array of hemodynamic changes. 19 reduced perfusion and therefore delivery of the drug via the blood, can impede the ability of water-soluble medications to reach the desired site of action. in such cases, systemic drug concentrations may not be indicative of the drug concentration at the site of action. higher systemic plasma concentrations of hydrophilic medications should be considered to achieve target concentrations in the targeted tissues. hyperinflammatory and septic conditions can increase or decrease acute-phase plasma protein levels, impacting drug binding, volumes of distribution, and free drug fractions. albumin and a1-acid-glycoprotein (aag) are 2 major drug-binding plasma proteins. levels of negative acute-phase proteins such as albumin decrease in conditions of inflammation, possibly leading to initial increases in free drug plasma fractions for drugs extensively bound to albumin. 15 positive acutephase proteins such as aag and c-reactive protein increase during situations of infection or inflammation. hundreds of drugs, including propranolol, imatinib, and vinblastine, have been identified as binding to aag. 20 increase in production of these proteins will similarly increase drug binding and decrease free drug fractions. these changes in protein levels were observed in a retrospective analysis of 99 covid-19 patients in wuhan, china, where 98% of admitted patients had decreased albumin levels and 86% had increased c-reactive protein levels. 21 the clinical impact of these potential changes in free drug fractions on investigational therapies that are highly proteinbound is an important consideration when empirically selecting doses for critically ill covid-19 patients. septic conditions and the development of organ dysfunction in covid-19 patients can affect the metabolic capacity of the liver, leading to alterations in drug exposure. drugs that are inactivated through metabolism can have prolonged exposure because of lowered enzymatic capacity of the liver and decreased hepatic blood flow in septic conditions. 16 prodrugs that are metabolized by cytochrome p450 enzymes to active metabolites may conversely experience slowed or incomplete conversion, lessening the therapeutic exposure. the hepatic expression and activity of cytochrome p450 enzymes is decreased in situations of acute inflammation, possibly because of their direct downregulation mediated by proinflammatory cytokines. 22 in addition, decreased hepatic blood flow reduces the clearance of drugs with high hepatic extraction ratios. use of vasopressors to increase mean arterial pressure in sepsis further potentiates the decrease in hepatic blood flow. 13 in addition, because in most cases only unbound drug is capable of being metabolized, the changes in protein binding described previously can also alter the free drug concentration. renal filtration is the primary route of excretion for many drugs. these drugs carry a risk of accumulation in patients with renal impairment and often require dose reductions. drug exposure of investigational covid-19 therapies should be estimated in subjects with renal impairment based on available data to inform dosing in this population. in a survey of labels for drugs approved between 2016 and 2018, dosing information for patients with severe renal impairment or kidney failure was only available for about 50% of the drugs. 23 if a change in exposure is unknown because of lack of clinical data and cannot reliably be estimated based on the drug's elimination pathway, subjects with renal impairment may be restricted from enrollment in studies based on the severity of impairment. they may even be excluded if higher or prolonged drug concentrations pose significant safety concerns. excluding these subjects from studies, however, only addresses those with prior known renal impairment on enrollment and not those who develop impairment as part of the covid-19 disease course. in a study of 5449 covid-19 patients in new york, 37% developed acute kidney injury (aki). increased age and comorbidities such as diabetes mellitus and hypertension were determined to be predictors of aki. 24 proposed mechanisms for the development of aki in covid-19 patients include cytokine damage and intrarenal inflammation, renal hypoperfusion, fluid expansion leading to renal vein congestion, and direct cytopathic effects of the virus on kidney cells. 25, 26 sufficient monitoring plans for assessing renal function throughout the treatment period of a clinical trial are needed to detect the development of aki and implement any required dose adjustments or dose discontinuation based on the drug's toxicity profile. the standard therapies indicated for patients with aki, namely, continuous renal replacement therapy (crrt) and intermittent hemodialysis, can pose obstacles for the administration of investigational therapies. in an observational study from china, 5% of severe covid-19 patients required the use of crrt. 11 hemodialysis removes waste, toxins, and drugs from the bloodstream by diffusion through a dialyzer membrane. drugs with low molecular weight, low volume of distribution, and high solubility carry more risk of being cleared by hemodialysis. one possible dosing strategy for these drugs is to administer the dose following the end of hemodialysis. drugs with higher molecular weight diffuse more slowly and in the case of therapeutic proteins are too large to pass through the dialyzer membrane. these drugs may be dosed irrespective of dialysis because drug exposure would not be impacted by a dialysis session. furthermore, only unbound drug fractions are capable of being dialyzed; therefore, drugs with low protein binding will undergo greater clearance from dialysis. 27 the impact of hemodialysis on drug exposure is assessed infrequently during the drug development process, and clinical data for dosing during hemodialysis is unlikely to exist prior to the initiation of studies in covid-19 patients. 28 however, if an investigational therapy is at risk of clearance from hemodialysis based on its physiochemical properties and drug binding, timing of drug administration and hemodialysis needs to be spaced appropriately. if hemodialysis must resume following drug administration, the time required for absorption and distribution of the drug to the site of action and the expected time course of pharmacologic effects must be weighed. drugs under investigation for the treatment of covid-19 will need to be administered on top of the standard of care at study sites. for hospitalized covid-19 patients, this may include antivirals, antibacterial agents, acid-reducing agents (as indicated for stress ulcer prophylaxis), deep vein thrombosis prophylaxis, and other supportive care agents such as vasopressors or sedatives. other investigational therapies such as remdesivir also may be included in the standard of care. in addition, medications for preexisting comorbidities also may require continued dosing in the hospital setting. pharmacokinetic (pk) drug interactions could impact the efficacy either of the standard of care or of the investigational drug. for example, routine use of proton pump inhibitors in intubated patients, as indicated for stress ulcer prophylaxis, increases gastric ph and can reduce the solubility of drugs that require an acidic environment for absorption. in addition to pharmacokinetic interactions, potential pharmacodynamic (pd) interactions need to be assessed. pharmacodynamic interactions can cause additive or opposing physiological effects to occur. for instance, azithromycin is a qt-prolonging drug that has been previously studied for treatment of covid-19. the possibility for additive qt prolongation with investigational drugs requires assessment through adequate electrocardiogram-monitoring plans. other types of pd interactions can include competition or agonism at the target receptors through competitive and noncompetitive inhibition or allosteric modulation. additional possibilities include synergistic or antagonistic effects related to the second-messenger systems or downstream effects. a rapidly changing clinical landscape for the treatment of covid-19 means that drug interaction potential needs to be assessed using the most up-to-date standards of care. however, background medications or standards of care that include other investigational therapies may create difficulty when interpreting efficacy data, so their concomitant use should be carefully considered. most drugs proposed for the treatment of covid-19 are administered through the oral or intravenous route. given the sites of viral proliferation, however, delivery of antiviral drugs via inhalation may provide increased efficacy while reducing systemic risks. 29 in an analysis of 9 covid-19 patients with mild symptoms, high concentrations of sars-cov-2 rna were detected in the upper respiratory tract and lungs, as measured by pharyngeal swabs and sputum samples. live virus was isolated from the pharyngeal swabs, signifying active viral replication in the upper respiratory tract during the first week following the onset of symptoms. the virus was not detected at any time in blood or urine, and live virus was not detected in stool. 30 drug delivery via inhalation, especially early in the disease course, could therefore confer the benefit of targeted antiviral activity at the site of viral replication, namely, the upper respiratory tract, while reducing systemic exposure. investigational antivirals such as remdesivir may potentially benefit patients in inhaled dosage forms. remdesivir is currently administered via intravenous infusion, restricting its use to hospitalized patients. other constraints for remdesivir based on renal impairment are detailed in the eua. an inhaled formulation of remdesivir could expand its availability to patients who have less severe symptoms, are early in the disease course, or are otherwise ineligible for treatment with intravenous remdesivir. 31 lower systemic exposure after drug inhalation may also eliminate the need to exclude patients with renal impairment. commonly used inhalation devices include metereddose inhalers, dry powder inhalers, and nebulizers. in covid-19 patients, drug delivery by metered-dose inhalers or dry powder inhalers could be negatively affected by pulmonary symptoms that limit the force of inhalation, improper patient technique, and an inability to coordinate breaths with actuation. 32 for these reasons, nebulizers may be the most practical choice for drug delivery via inhalation in covid-19 patients, as it only requires tidal breathing without coordinated inhalation. in studies of chronic obstructive pulmonary disease patients, nebulizers were found to have similar efficacy to metered-dose and dry powder inhalers when properly used. 33 drawbacks of treatment of nebulizers include high intersubject variability, which may be because of differences in breathing pattern or nebulizer device type. 34 in addition, nebulizers can increase the risk of sars-cov-2 transmission to study investigators and staff through the generation of aerosols during exhalation. 35 developers of inhaled formulations that are intended to reach the site of action should consider the drug's individual characteristics, such as particle size. in addition, considerations in determining an appropriate inhalation device could include patients' ability to use proper inhalation technique, to effectively inhale given their progression of pulmonary symptoms, and the added risk to health care providers. progression of covid-19 can result in respiratory deterioration, leading to ventilator use. from a study of 1099 covid-19 patients, 39% of patients with severe disease required mechanical ventilation. 11 mechanical ventilation and endotracheal intubation often prevent drug administration through the typical oral route. enteral feeding tubes such as nasogastric (ng) tubes must be employed for oral medications if another method or route of drug administration is not available. crushing or dissolving of solid oral dosage forms can result in issues with safety/toxicity or efficacy. increased drug absorption can put the patient at risk for toxicity-related adverse events. a common medication error involves improper crushing or dissolving of modified-release formulations, leading to dose dumping. decreased first-pass metabolism can occur when feeding tubes bypass a portion of the gastrointestinal tract and terminate in the jejunum. in this case, drugs with high first-pass metabolism, such as opioids and beta-blockers, would have increased bioavailability. 36 decreased drug absorption, resulting in decreased efficacy, also may occur when modifying an oral drug for administration via feeding tube. enteric coatings of tablets protect the drug substance from breakdown by stomach acids, allow for absorption in the small intestine, and/or prevent gastric irritation. crushing or dissolving these tablets for tube administration removes the protective coating, likely reducing its systemic absorption and increasing the potential for gastric adverse events. in addition, enteral feeding solutions increase the gastric ph, which can reduce the absorption of drugs with ph-dependent solubility. 13 small-bore feeding tubes are prone to obstruction or clogging by powdered tablets or capsules and also can result in decreased drug absorption. adsorption or adherence of the drug to the feeding tube also can reduce the administered dose. 37 flushing feeding tube lines before and after drug administration may prevent clogging, but study protocols need to provide detailed instructions on volume and timing to ensure consistency in administration. 38 feeding tubes can terminate in the stomach, duodenum, or jejunum. their placement in the jejunum can decrease overall absorption time in the gi tract or impact the absorption of drugs that require an acidic gastric environment. 39 investigational study protocols for covid-19 oral therapies should assess alternative routes or methods of administration if medications cannot be taken by mouth. if administration via feeding tube is proposed, detailed instructions to ensure consistent drug administration should be established. dosing plans need to be based on the physiochemical properties of the drug (eg, solubility), site of absorption, and formulation. severe cases of covid-19 are associated with numerous complications and physiological changes that have the potential to alter investigational drug adme. when investigating new therapies to treat covid-19, these alterations need to be evaluated carefully to determine initial dosing in covid-19 patients, as well as the need for dose modifications or drug discontinuation. the average time from covid-19 symptom onset to death is estimated to be 18 days. 40 most therapeutic agents are proposed for investigation in moderate to severe covid-19 patients, leaving a limited window of time to determine appropriate dosing based on the most impactful physiological alterations in a patient. assessing potential drug interactions in covid-19 patients is an especially arduous task, given rapidly evolving therapeutic knowledge and treatments. concomitant administration of other investigational therapies may create difficulty in interpreting efficacy data; therefore, permitted and prohibited background therapies should be selected carefully based on potential pk and pd interactions with the investigational drug. existing population pharmacokinetic models can be used to simulate exposure of new doses and/or regimens and support initial dosing. however, many drugs proposed for evaluation in covid-19 patients are being repurposed from indications in which the patient population is not critically ill. some information can be extrapolated from other patient populations for empiric dosing, but blood sample collection for analysis of pk and pd end points in covid-19 patients is critical to characterizing the drug exposure in that population and optimizing dosing in future studies. a joint statement from major pharmacologic societies also describes this need to measure drug concentrations to develop pk models in covid-19 patients as part of a core clinical pharmacology principle guiding development of covid-19 treatments. 41 numerous drugs have been proposed to treat covid-19, addressing both complications and direct antiviral activity. the many clinical pharmacology considerations discussed in this review, such as alterations in absorption and distribution, relate to initial dose selection in the covid-19 population. other issues, such as the development of aki or ng tube administration of drugs, need to be specified in proposed protocols for investigational drugs. the fda's office of clinical pharmacology has frequently commented on certain protocol areas that need to be addressed, such as the lack of a dosing plan for hemodialysis. although by no means all-encompassing, following are samples of our common advice regarding investigational protocols: • "the development of acute kidney injury requiring hemodialysis has been reported as a possible complication during the disease progression of covid-19. address how the dose and regimen will be modified in the event that patients require hemodialysis (eg, dosing after hemodialysis, treatment discontinuation)." • "conditions permitting, you should collect blood samples for pk assessment in the proposed study in order to characterize pk in the covid-19 population and better inform dose selection in future studies." • "detailed dosing instructions for the scenario that patients develop the need for intubation should be included in the protocol." • "all likely concomitant medications or medications administered as part of the standard of care should be assessed for drug interaction potential with the investigational drug. dose adjustments or appropriate monitoring plans should be based on the known drug interaction potential and toxicity profile of the drug." the totality of evidence should be considered for inclusion of patients with compromised organ impairment and other comorbidities. hospitalization, criticalillness, and mortality are higher in patients with various comorbidities. most notably, diabetes, obesity, older age, and hypertension are the risk factors most strongly associated with covid-19 hospitalization. 42 exclusion of these subjects from clinical trials may delay availability of drugs to vulnerable populations. reports from new york city and chicago also show that black and latino covid-19 patients have death rates that are 2 to 3 times higher than white patients. 43, 44 current fda recommendations propose including subjects with high-risk comorbidities, older adults, and racial and ethnic minorities in clinical trials. 45 existing clinical and nonclinical adme data along with the safety profile of the drug should be leveraged to select populations for inclusion. a suitable approach for inclusion of subjects with organ impairment or other risk factors must be determined on a case-by-case basis. one possible method is to include these patients in a stepwise manner with appropriate stopping criteria for adverse events or toxicity. early collection of pk/pd data in these patients could then inform dosing in more severe patients. the nature and severity of anticipated safety events, whether they are monitorable, and whether dose reductions are possible also need to be weighed in the decision-making process. covid-19 has proven to be a unique drug development scenario because the rapid spread of severe illness has resulted in an urgent compression of the drug development timeline. clinical pharmacologists now have an added responsibility to make rapid, informed decisions, often based only on preliminary or incomplete knowledge of the drug and pathophysiology. however, this scenario also creates an opportunity for the clinical pharmacology community to positively influence the strategic, expedited development of drugs that are vital to combating a public health crisis. the species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2 who-director-general-s-opening-remarks-at-the-mediabriefing-on-covid mild or moderate covid-19 neurologic manifestations of hospitalized patients with coronavirus disease 2019 in wuhan, china large-vessel stroke as a presenting feature of covid-19 in the young the trinity of covid-19: immunity, inflammation and intervention covid-19 illness in native and immunosuppressed states: a clinical-therapeutic staging proposal emergency use authorization (eua) for remdesivir. silver spring, md: u.s. food and drug administration letter revoking eua for chloroquine phosphate and hydroxychloroquine sulfate. silver spring, md: u.s. food and drug administration clinical characteristics of coronavirus disease 2019 in china the third international consensus definitions for sepsis and septic shock (sepsis-3) introduction to drug pharmacokinetics in the critically ill patient clinical characteristics of covid-19 in new york city pharmacokinetic and pharmacodynamic considerations when treating patients with sepsis and septic shock pharmacokinetics in sepsis does beta-lactam pharmacokinetic variability in critically ill patients justify therapeutic drug monitoring? a systematic review gentamicin volume of distribution in critically ill septic patients antimicrobial pharmacokinetic and pharmacodynamic issues in the critically ill with severe sepsis and septic shock effect of alpha-1-acid glycoprotein binding on pharmacokinetics and pharmacodynamics epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study impact of infectious and inflammatory disease on cytochrome p450-mediated drug metabolism and pharmacokinetics the impact of renal impairment on patient drug response -assessing the need for a consensus approach acute kidney injury in patients hospitalized with covid-19 kidney involvement in covid-19 and rationale for extracorporeal therapies covid-19 and kidney failure in the acute care setting: our experience from seattle pharmacokinetic principles during continuous renal replacement therapy: drugs and dosage assessment of the impact of renal impairment on systemic exposure of new molecular entities: evaluation of recent new drug applications hydroxychloroquine as an aerosol might markedly reduce and even prevent severe clinical symptoms after sars-cov-2 infection virological assessment of hospitalized patients with covid-2019 working to supply remdesivir for covid-19 inhalation drug delivery devices: technology update a review of nebulized drug delivery in copd determination of the relative bioavailability of salbutamol to the lungs and systemic circulation following nebulization practical strategies for a safe and effective delivery of aerosolized medications to patients with covid-19 a guide to drug therapy in patients with enteral feeding tubes: dosage form selection and administration methods therapeutic concerns when oral medications are administered nasogastrically clogged feeding tubes: a clinician's thorn medication administration through enteral feeding tubes estimates of the severity of coronavirus disease 2019: a model-based analysis a call for the appropriate application of clinical pharmacological principles in the search for safe and efficacious covid-19 (sars-cov-2) treatments factors associated with hospital admission and critical illness among 5279 people with coronavirus disease rates of cases, hospitalizations and deaths by race/ethnicity group covid-19: developing drugs and biological products for treatment or prevention guidance for industry. silver spring, md: u.s. food and drug administration the authors thank joanne berger, fda library, and karen valentine, fda center for devices and radiological health, for manuscript editing assistance. the authors have declared no conflicts of interest for this article. key: cord-255139-hswef5ky authors: khan, safdar a. title: differential diagnosis of common acute toxicologic versus nontoxicologic illness date: 2018-11-30 journal: veterinary clinics of north america: small animal practice doi: 10.1016/j.cvsm.2018.07.003 sha: doc_id: 255139 cord_uid: hswef5ky this article provides a display table laying out the differential diagnosis of common acute toxicologic versus nontoxicologic illnesses in small animals. major clinical abnormalities are listed, along with common toxicologic rule outs and nontoxicologic rule outs. further readings are also provided. safdar a. khan, dvm, ms, phd a,b, * upon presentation of an acutely ill animal, a veterinary professional must consider poisoning as a potential cause among the differentials. a complete and thorough case history in this regard is essential for differentiating a poisoning situation from a naturally occurring disease. obtaining a clear recent history may sometimes be quite challenging, especially in situations where the pet was unsupervised before the initiation of clinical signs. history questions must include animal signalment (breed, sex, and age) and weight, previous medical history, vaccination history, type of feed used (brand; home-made or commercial) and any medications the pet is taking. initial information about any other animals present in the household, timeline of clinical signs, types of clinical signs reported by the owner, number of affected animals, pet's environment (indoor vs. outdoor; fenced or free roaming), location (urban vs. rural), time of the year (summer vs. winter), recent renovations/ updates (construction material; lead in older farms/houses), recent visitors, availability of human medications in the pet's environment (antidepressants, pain killers, stimulants, nutritional supplements), presence or recent use of chemicals (insecticides, herbicides, rodenticides) in the house/yard, information about neighboring animals (outbreaks; illnesses; death) and information about indoor/outdoor plants may help provide clues to the clinician to narrow down the search for a possible cause for the pet's illness. a good case history can help speed up the process of narrowing down a potential cause; eliminate several unnecessary steps, save time, and money. before obtaining a complete case history, the first goal should be to stabilize the patient and preserve life of the acutely ill animal irrespective of the cause. relying too much on specific antidotal treatment may be dangerous. a majority of clinical cases on presentation are treated supportively as only a very few specific antidotes are available or needed for treating specific poisonings. therefore, on presentation, make sure the animal has a patent airway and adequate ventilation. support and maintain cardiac functions. monitor heart rate, rhythm, and blood pressure, and treat cardiac arrhythmias and blood pressure changes as needed. hydration status, fluids, electrolytes, and acid-base balance should be checked and corrected accordingly. treat central nervous system abnormalities (excitation, depression, seizures) as required, and maintain body temperature within the normal range (treat hypothermia or hyperthermia). after stabilizing the vital functions, obtain a history; then, provide other necessary treatment such as decontamination (administration of activated charcoal, gastric lavage, bathing, dilution), supportive care, and carrying out other diagnostics (complete blood count, chemistries, urinalysis, radiographs, ultrasound) as needed. collect samples for toxicologic analyses if required. toxicology testing performed in a diagnostic laboratory can be expensive and time consuming and mostly, results are not available immediately. therefore, to rule in or out a suspected cause, first perform commonly used in-house diagnostics before ordering toxicology analysis. for example, monitoring prothrombin time or clotting times can be useful in anticoagulant poisoning cases. other samples for toxicology testing in a diagnostic laboratory include whole blood for heavy metal analysis (lead), blood cholinesterases (organophosphate poisoning), and presence of pesticides (anticoagulant rodenticides). similarly serum/plasma can be used for some metal analysis (zinc), drugs, alkaloids, and electrolytes (useful in sodium chloride poisoning or water intoxication). stomach contents (vomitus; freeze upon collection) can be used for detecting pesticides, metals, baits, alkaloids, and drugs. urine (chilled or frozen) can be used for some metal analysis, drugs and their metabolites, and alkaloids (strychnine). table 1 outlines some important toxicologic versus nontoxicologic rule-outs based on clinical abnormalities one must consider in an acutely ill animal. where necessary, with each rule-out, along with major clinical abnormality, a brief description of other clinical signs is also provided. an acutely ill animal with sudden onset of clinical effects may often have multiple major clinical signs/abnormalities present. the purpose here is to provide an initial guideline for considering toxicologic versus nontoxicologic rule-out. once a reasonable etiology has been narrowed down or established, the reader is encouraged to review a more detailed discussion on management of the particular poisoning or disease listed in this reference (see table 1 ). toxicology of selected pesticides, drugs, and chemicals clinical veterinary advisor: dogs and cats intoxication versus acute, nontoxicologic illness: differentiating the two quick reference to veterinary medicine investigating fatal suspected poisonings diagnostic toxicology for the small animal practitioner 2,4-d, dichlorophenoxyacetic acid; aki, acute kidney injury; alt, alanine aminotransferase; aptt, activated partial thromboplastin time; ckd, chronic kidney disease; cns, central nervous system; cv, cardiovascular; felv, feline leukemia virus; fiv, feline immunodeficiency virus; gi, gastrointestinal; npk, nitrogen, phosphorus, potassium; nsaid, nonsteroidal antiinflammatory drug; pcv, packed cell volume; pt, prothrombin time; rbc, red blood cell; slud, salivation, lacrimation, urination, defecation. key: cord-319805-b6ypt5d0 authors: siepmann, timo; sedghi, annahita; barlinn, jessica; de with, katja; mirow, lutz; wolz, martin; gruenewald, thomas; helbig, sina; schroettner, percy; winzer, simon; von bonin, simone; moustafa, haidar; pallesen, lars-peder; rosengarten, bernhard; schubert, joerg; gueldner, andreas; spieth, peter; koch, thea; bornstein, stefan; reichmann, heinz; puetz, volker; barlinn, kristian title: association of history of cerebrovascular disease with severity of covid-19 date: 2020-08-06 journal: j neurol doi: 10.1007/s00415-020-10121-0 sha: doc_id: 319805 cord_uid: b6ypt5d0 objective: to determine whether a history of cerebrovascular disease (cvd) increases risk of severe coronavirus disease 2019 (covid-19). methods: in a retrospective multicenter study, we retrieved individual data from in-patients treated march 1 to april 15, 2020 from covid-19 registries of three hospitals in saxony, germany. we also performed a systematic review and meta-analysis following prisma recommendations using pubmed, embase, cochrane library databases and bibliographies of identified papers (last search on april 11, 2020) and pooled data with those deriving from our multicenter study. of 3762 records identified, 11 eligible observational studies of laboratory-confirmed covid-19 patients were included in quantitative data synthesis. risk ratios (rr) of severe covid-19 according to history of cvd were pooled using dersimonian and laird random effects model. between-study heterogeneity was assessed using cochran’s q and i2-statistics. severity of covid-19 according to definitions applied in included studies was the main outcome. sensitivity analyses were conducted for clusters of studies with equal definitions of severity. results: pooled analysis included data from 1906 laboratory-confirmed covid-19 patients (43.9% females, median age ranging from 39 to 76 years). patients with previous cvd had higher risk of severe covid-19 than those without [rr 2.07, 95% confidence interval (ci) 1.52–2.81; p < 0.0001]. this association was also observed in clusters of studies that defined severe manifestation of the disease by clinical parameters (rr 1.44, 95% ci 1.22–1.71; p < 0.0001), necessity of intensive care (rr 2.79, 95% ci 1.83–4.24; p < 0.0001) and in-hospital death (rr 2.18, 95% ci 1.75–2.7; p < 0.0001). conclusion: a history of cvd might constitute an important risk factor of unfavorable clinical course of covid-19 suggesting a need of tailored infection prevention and clinical management strategies for this population at risk. electronic supplementary material: the online version of this article (10.1007/s00415-020-10121-0) contains supplementary material, which is available to authorized users. rapid transmission of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) and a case fatality rate that is up to 40 times higher than mortality of seasonal influenza make coronavirus disease 2019 a global threat [1, 2] . the latter is largely explained by high risk of acute respiratory distress syndrome as well as sepsis, multi-organ failure and disseminated intravascular coagulopathy, which is most pronounced in the elderly and in premorbid patients with a cardiovascular risk profile [3, 4] . in fact, patients with severe course of covid-19 have up to threefold higher rates of preexisting cardiovascular morbidity than patients with mild or moderate clinical manifestations [5] . investigation of early cohorts of covid-19 patients in china focused on the effects of classic cardiovascular risk factors such as arterial hypertension and coronary heart disease or comorbidity in general [6, 7] . by contrast, the importance of cerebrovascular disease (cvd) in the clinical course of covid-19 is poorly understood. this is a relevant research gap as patients with cvd are particularly vulnerable toward pulmonary and inflammatory complications due to their frequent disability [8, 9] . at this stage of the pandemic, where overall comorbidity has been established as substantial risk factor, in-depth characterization of particularly endangered individuals might help design tailored infection prevention plans. therefore, we aimed to assess whether history of cvd is associated with severe covid-19. to approach this question, we assessed individual multicenter data from three cohorts of covid-19 patients treated during the first months of the pandemic in germany. in order to assess consistency among regions and increase generalizability of our findings, we then went on to pool our data with published data of covid-19 patients who were being treated in wuhan and other regions in china. in a retrospective multicenter study, consecutive patients ≥ 18 years with laboratory-confirmed diagnosis of covid-19 who have been admitted to the three participating hospitals (university hospital carl gustav carus dresden, klinikum chemnitz ggmbh, elblandklinikum meißen) in saxony, germany between march 1 and april 15, 2020 were selected from the ongoing covid-19 registries. locations of participating hospitals are illustrated in fig. 1 . laboratory tests for detection of sars-cov-2 included real-time reverse transcription polymerase chain reaction (rt-pcr) assays (realstar® sars-cov-2 rt-pcr kit ruo, altona diagnostics, hamburg, germany; allplex™ 2019-ncov assay, seegene inc., seoul, republic of korea; genefindertm covid-19 plus realamp, osang healthcare co., gyeonggi-do, republic of korea) on respiratory specimen from nasal or oropharyngeal swab. we obtained data on age, sex and vascular comorbidities including arterial hypertension, hyperlipidemia, diabetes mellitus, atrial koch institute as of april 15, 2020 (www.rki.de/en/home/homep age_node.html). numbers in brackets refer to absolute numbers of patients included in the multicenter cohort fibrillation, coronary heart disease, tobacco use and past history of cvd. cerebrovascular disease was subdivided into ischemic stroke, transient ischemic attack and intracerebral hemorrhage. we also reviewed medical records and neuroimaging reports from cranial computed tomography or magnetic resonance imaging studies for evidence of previous clinically apparent or silent cvd. we detected one patient with evidence of previous lacunar stroke on cranial magnetic resonance imaging that was not diagnosed history of cvd and decided to include this patient in our analysis. in order to assess the association of past history of cvd and risk of severe clinical course of covid-19, we aimed to classify all patients in our multicenter cohort into "severe" and "non-severe" covid-19. however, previously published approaches to categorize severity of covid-19 were found to be inconsistent and all together three different most frequently reported approaches could be identified. in order to achieve comparability of outcome data with previously published cohorts, we separately applied these methods to dichotomize our patients into severe and non-severe clinical course of the disease. first, we classified severity of covid-19 in the patients of our multicenter cohort based on clinical parameters according to the classification by the national health commission guidelines on the diagnosis and treatment of covid-19 [10] . in this classification, "mild" was defined as mild clinical symptoms with no signs of pneumonia on chest imaging; "moderate" as fever, respiratory symptoms with radiologic signs of pneumonia; "severe" as respiratory distress with respiratory rate ≥ 30 per minute and/ or oxygen saturation at rest ≤ 93% and/or oxygenation index ≤ 300 mmhg and/or progression of pulmonary lesion size > 50% within 48 h, "critical" as respiratory failure requiring mechanical ventilation, hemodynamic shock, or any other organ failure with necessity of intensive care. we also categorized stages of disease by using the lean european open survey on sars-cov-2 infected patients (leoss) definition, comprising the following disease stages: "uncomplicated", asymptomatic or symptoms of upper respiratory tract infection, nausea, emesis, diarrhea, fever; "complicated", need for oxygen supplementation, partial arterial oxygen pressure at room air < 70 mmhg, oxygen saturation at room air < 90%, aspartate aminotransferase or alanine aminotransferase > 5-fold upper limit normal, new cardiac arrhythmias, new pericardial effusion > 1 cm, new heart failure with pulmonary edema, congestive hepatopathy or peripheral edema; "critical", need for catecholamines, life-threatening cardiac arrhythmia, invasive or non-invasive mechanical ventilation, liver failure with < 50% quick value (equaling approximately > 1.55 international normalized ratio), quick sequential [sepsis-related] organ failure-assessment score ≥ 2, renal failure in need of dialysis; "recovery", improvement by one phase and defervescence [11] . second, severity of covid-19 was also dichotomized for in-hospital death versus survival with death equaling severe and survival indicating non-severe course. third, patients were classified into severe or nonsevere clinical course of covid-19 based on whether they required intensive care unit (icu) treatment or underwent regular in-patient care until discharge. this systematic review and meta-analysis complied with the preferred reporting items for systematic reviews and meta-analyses (prisma) recommendations [12] . we systematically searched electronic databases including medline (accessed by pubmed), embase and cochrane library for identification of all available observational studies that reported on laboratory-confirmed covid-19 patients aged ≥18 years with information given on disease severity and past history of cvd. in addition, bibliographies of identified full-text articles and those of relevant review articles were searched manually. in order to be exhaustive, we limited our search on electronic databases to search term "covid-19" with combinations of associated medical subject headings (mesh) "covid-2019", "severe acute respiratory syndrome coronavirus 2", "2019-ncov", "sars-cov-2", "2019ncov", "wuhan", "coronavirus", "2019/12". the complete search algorithm is provided in online resource 1. our systematic search covered publications from the earliest date available until our last search date april 11, 2020. no language or other restrictions were imposed. all identified articles were screened using the following eligibility criteria: (1) observational cohorts consisting of a minimum of five patients ≥ 18 years who have been hospitalized for covid-19 laboratory-confirmed by nasal or oropharyngeal swab rt-pcr; (2) data available on past history of cvd; (3) categorization of covid-19 severity according to studyspecific outcome definitions. assessment of identified articles involved three steps: screening of titles, abstracts and full texts by two independent reviewers (t.s. and k.b.). any disagreements were resolved by consensus. abstracts that did not provide sufficient information for analysis of methodology were subject to full-text evaluation. in case of missing information or any obscurities, the corresponding authors of the identified articles were contacted for clarification. two reviewers (t.s. and k.b.) independently extracted data on included studies from the full-text articles with insertion into a standardized data extraction form (excel, microsoft, redmond, wa, usa). extracted variables were first author, publication year, study design, sample size, demographic values, vascular comorbidities including history of cvd as well as definition of severity outcomes of covid-19 and respective absolute numbers of outcome events. we used the oxford centre for evidence-based medicine rating scale to assess the quality of evidence in the included individual studies [13] . quality assessment was independently performed by two investigators (t.s. and k.b.) and disagreements were resolved by consensus. in the multicenter study, continuous and non-continuous variables are presented as median with interquartile range (iqr) for skewed data and percentages for proportional data. between-group comparisons were performed using chi-square test, fisher's exact test and mann-whitney u test, where applicable. multivariable logistic regression was performed to explore the predictive value of history of cvd for severity outcomes of covid-19 including clinical severity according to the classification by the national health commission guidelines on the diagnosis and treatment of covid-19, in-hospital death and necessity of intensive care [10]. candidate variables were identified from the betweengroup comparisons, whereas a p value of ≤ 0.25 was used for covariate inclusion in the multivariable model. the final model was conducted using a backward selection procedure, whereas covariates with a p value <0.1 were removed from the model. in the quantitative data synthesis, risk ratios (rr) and their corresponding 95% confidence intervals (95% ci) for history of cvd were calculated from the absolute numbers of patients with severe and non-severe covid-19 outcomes as provided by each study. in our main analysis, we used a composite dichotomized outcome of severity subsuming all severity outcomes that were reported by each of the included studies comprising severity based on clinical parameters, in-hospital death versus survival and necessity of intensive care versus regular in-patient care. if included studies classified severity outcome based on clinical parameters into more than two categories (e.g., mild, moderate, severe, critical), those were subsumed under severe (i.e., severe and critical) and non-severe (i.e., mild and moderate) categories. thus, in our main analysis, all patients reported in studies identified from literature search cohort were classified into severe or non-severe covid-19 based on the classification used by each study. with respect to our multicenter study, we chose to apply the approach of defining severity by clinical parameters as recommended by the national health commission guidelines on the diagnosis and treatment of covid-19 since this tended to be the most widely acknowledged method in the literature [10] . continuity correction of 0.5 was used for studies with a zero cell [14] . if a study reported two or more zero-cell events, it was excluded from respective analysis. dersimonian and laird random effects model was used to compute the pooled rr for included studies. [15] in order to allow separate assessment of clusters of studies with equal definitions of covid-19 in conjunction with our multicenter data, sensitivity analyses were conducted for severity outcomes. we clustered studies that used the same approach to define severity and pooled these data with our multicenter data by applying the same severity definition to our local cohorts. analyses were carried out for three clusters of studies: first, studies defining severity based on clinical parameters; second, studies defining severity based on necessity of intensive care; third, those defining severity by in-hospital death. assuming that only available cases with complete data on disease severity outcomes were reported in included studies, pairwise deletion method was used to handle missing outcome data. between-study heterogeneity was assessed using cochran's q test and i 2 statistics, where i 2 values of 0-40% indicated absent or low, 30-60% moderate, 50-90% substantial and 75-100% considerable heterogeneity [16] . significance level of heterogeneity was set at p < 0.1. publication bias was assessed by visual inspection of funnel plot and egger's linear regression test. statistical significance was set at p < 0.05. all statistical analyses were conducted using stata software package (version 12.1, statacorp., college station, tx). during the observational period from march 1 to april 15, 2020, 101 patients (48.5% females, median age 66 [55-78]) with laboratory-confirmed covid-19 have been admitted to participating hospitals. two patients were still hospitalized at the time of data analysis. overall, 74 of 101 (73.3%) patients showed severe or critical clinical course with necessity of icu treatment in 23 of 101 (22.8%) patients and inhospital death in 20 of 99 (20.2%) patients. in the entire multicenter cohort, a history of cvd was evident in 16 (15.8%) patients with higher frequencies in patients with severe course of covid-19 when applying the national health commission guidelines on the diagnosis and treatment of covid-19 with dichotomized severity categories subsuming categories mild, moderate in "non-severe" and categories severe and critical into "severe". (20.3% vs. 3.7%, p = 0.06) [10] . a history of cvd was also found to be more frequent in patients with severe covid-19 when severity was defined by necessity of intensive care vs. regular in-patient care (30.4% vs. 11.5%, p = 0.047) and in-hospital death vs. survival (35% vs. 11.4%, p = 0.02). a detailed description of demographic values, comorbidities and outcomes is shown in table 1 . in multivariable analysis adjusting for selected covariates (i.e., age, sex, arterial hypertension and diabetes mellitus), past history of cvd emerged as an independent predictor of severity of covid-19 when severity was defined by necessity of icu treatment (adjusted rr 4.81; 95% ci 1.34-17.3; p = 0.02), but not by clinical severity (p = 0.55) or in-hospital death (p = 0.16). a total of 3743 abstracts were retrieved from electronic databases and 19 from bibliographies of published literature. after exclusion of duplicates and articles that did not fulfill eligibility criteria, 11 studies comprising 1805 laboratoryconfirmed covid-19 patients (43.7% females, median ages ranging from 39 to 76 years) were included in quantitative data synthesis as described in detail in table 2 [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] . the flowchart showing systematic screening and selection process is depicted in figure 2 . all studies included patients from china and were of descriptive observational design. in order to avoid overlapping patient populations, we excluded two multicentric reports on chinese cohorts from our quantitative synthesis because they partially comprised data from the same hospitals that were reported by other studies included in our analyses [1, 28] . none of the included studies reported by what criteria history of cvd was defined. seven studies reported severity outcomes based on in-hospital death (n = 5) [17, 18, [22] [23] [24] [25] or necessity of intensive care (n = 2) [20, 21] , whereas three studies [19, 26, 27] categorized clinical course of covid-19 into "severe" and "non-severe" based on the national health commission guidelines on the diagnosis and treatment of covid-19 [10]. one study defined severity by length of hospitalization with a cut-off of 10 days [22] . overall distribution of demographic data and vascular risk profiles among these studies was highly congruent with data from our local german multicenter cohort with relatively high frequencies of preexisting vascular risk factors, high ranges of median ages and a rather balanced male-to-female ratio. characteristics of included studies are detailed in table 2 . pooled analysis including individual patient data from our multicenter cohort consisted of 1906 laboratoryconfirmed covid-19 patients (43.9% females, median age ranging from 39 to 76 years). patients with a history of cvd had higher risk of severe covid-19 than those without (rr 2.07, 95% ci 1.52-2.81; p < 0.0001) when using a composite dichotomized outcome of severity subsuming all severity outcomes that were reported by each of the included studies. we noted substantial heterogeneity between studies (i 2 =69%, p = 0.001, figure 3 ). consistently, an increased risk of severe covid-19 in of these, evidence of low heterogeneity was observed for the icu/non-icu cluster (i 2 =35.3%, p = 0.21), whereas no heterogeneity was noted for the clinical parameters cluster (i 2 =0%, p = 0.41) nor the in-hospital death cluster (i 2 =13.2%, p = 0.33). when considering only published data from chinese cohorts in pooled analysis (n = 1805), history of cvd was also associated with increased risk of severity of covid-19 (rr 2.39, 95% ci 1.94-2.94; p < 0.0001) with similar results on sensitivity analyses for study-specific severity outcomes (clinical parameters: rr 1.83, 95% ci 1.28-2.63; p = 0.001; necessity of intensive care: rr 2.9, 95% ci 1.61-5.24; p < 0.0001 and in-hospital death: rr 2.14, 95% ci 1.7-2.7; p < 0.0001). while there was evidence of moderate between-study heterogeneity for additional analyses of the icu/non-icu cluster (i 2 =57.2%, p = 0.13), only low or absent heterogeneity was observed for the composite (i 2 =8.4%; p = 0.37), clinical severity (i 2 =0%; p = 0.83) and in-hospital death (i 2 =17.5%; p = 0.3) outcome clusters. according to oxford centre for evidence-based medicine rating scale quality, all included studies from published literature were consistently graded as level of evidence 4. visual inspection of funnel plot showed symmetry in both studies plotted near the average, and those more distant from the average depending on their precision, thus shaping a distribution which is not suggestive of publication bias ( figure 4 ). no small study effect was seen on egger's linear regression test (p = 0.26). the major finding of our multicenter study is that a history of cvd is associated with an increased risk of developing severe course of covid-19. this observation was consistent among pooled data which included descriptive observational studies from china during the rise of the pandemic and individual multicenter patient data from the first few months after the local outbreak in germany. a strength of our analysis is that we synthesized data from two countries both hit heavily by the pandemic and both showing consistent findings in our analyses with respect to association of history of cvd and measures fig. 2 flowchart on identification of studies on covid-19 eligible for quantitative data synthesis. prisma flowchart illustrating systematic screening and selection process of published observational studies reporting on laboratory-confirmed covid-19 patients with data available on disease severity and past history of cvd of severity of covid-19. furthermore, data on distribution of demographic values as well as additional vascular comorbidities and their association with severity of covid-19 was highly congruent between the german multicenter cohort and chinese cohorts [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] . in particular, patients with severe covid-19 were older, more frequently male and more often have had a history of arterial hypertension or diabetes. consistency of our observations is also reflected by low evidence of heterogeneity among studies with equal severity outcomes indicating probable generalizability to other populations. another strength of our synthesized analysis is the strict exclusion of overlapping study populations, which is especially important during the early phase of the pandemic where multiple descriptive studies were simultaneously derived from the ground zero region of hubei, china. while an urgent need for data on the covid-19 pandemic is apparent, it is important to reduce potential sources of bias that might skew pooled effect estimates [29] . our study is limited by variance in definitions used for severity of covid-19 among studies extracted from the literature. however, risk factor association for history of cvd found in pooled analysis using a composite severity outcome subsuming all study-specific outcomes was consistent with those deriving from individual sensitivity analysis of clusters of studies that applied the same definition of severity. furthermore, data synthesized from the literature was limited by lack of explanation of how cvd was defined and therefore could not be analyzed regarding different types of cerebrovascular pathology in the context of covid-19 prognosis. in our multicenter cohort, the majority of previous cerebrovascular accidents that led to being classified as history of cvd were ischemic and only one of 101 patients had previous intracerebral hemorrhage. whether etiology of previous cvd relates to risk of covid-19 severity requires further investigation. data on pre-existing pulmonary disease were not available to an extent that would have allowed a separate analysis on how this might have influenced the observed association between a history of cvd and severity of covid-19. lastly, the association of past history of stroke and covid-19 severity was dependent on cardiovascular risk profile on multivariable analysis in our multicenter cohort when severity was classified using clinical parameters or inhospital death versus survival. however, severity defined as necessity of intensive care showed an independent association with history of stroke. this might be explained by differences in disease progression at the time of admission due to pulmonary vulnerability of stroke survivors [8, 9] . however, it needs to be acknowledged that we were not able to perform a multivariate analysis in the cohorts identified through literature research as individual patient data were not available. therefore, the actual number of patients who have had an actual history of cvd included in our multicenter cohort was relatively small (n = 16). moreover, individual descriptions of standardized critical care admission approaches among hospitals providing data to our multicenter analyses and those included in studies extracted from the literature were not consistently available. therefore, a possible independency of the link between past history of cvd and covid-19 severity requires further investigation. this analysis should be undertaken in cohorts with individual patient data available, preferably in the setting of a prospective observational study. since the outbreak of the pandemic, the impact of comorbidities on prognosis of covid-19 has been extensively discussed with cardiovascular pathologies in the spotlight [5] . in particular, recent research has focused on traditional cardiovascular risk factors such as arterial hypertension and diabetes mellitus as predictors of disease severity [6, 7, 30] . however, it might be important to take a closer look into pre-existing brain vascular pathology of covid-19 patients for several reasons. first, cvd is the leading cause of longterm acquired disability which increases the risk of pulmonary complications such as pneumonia [8, 9, 31] . while this association is not specific for infection caused by sars-cov-2, it might partly explain why in our analysis patients with a history of cvd displayed a higher risk of severe course of covid-19, which is considered a primarily respiratory disease [32] . second, accumulative evidence suggests that sars-cov-2 targets the central nervous system and may manifest with various neurological symptoms that might either be caused by direct neural damage or by neurovascular accident such as acute ischemic stroke [33] . from a pathophysiological perspective, sars-cov-2 appears to increase risk of cardiovascular events, possibly mediated by systemic inflammation compromising functional and structural integrity of the vasculature by inflammatory injury of the endothelium and increasing blood coagulability [34] . in patients, who already had experienced a cerebrovascular accident, brain vasculature might be at increased vulnerability toward these mechanisms. lastly, patients with a history of cvd frequently have cardiovascular comorbidities that fig. 3 association of history of cerebrovascular disease and severe clinical manifestation of covid-19 among included studies. forest plots illustrating associations of history of cvd and severe clinical manifestation of covid-19 for composite severity outcome subsuming all definitions of severity as reported by included studies (a) as well as for clusters of studies defining severity by grading of clinical parameters (b), whether patients required intensive care (c), and inhospital death (d). composite outcome analysis as well as assessment of each cluster included only studies that have not shown any overlap in study populations during full text evaluation. individual patient data from german multicenter cohort were evaluated for severity based on the chinese clinical guidance for covid-19 pneumonia diagnosis and treatment ◂ in turn might worsen prognosis of patients suffering from covid-19 [28, 35] . identification of populations at risk is one of the key factors in containing spread and reducing health care burden in epidemics [36] . this is even more important in a pandemic like covid-19 where neither effective antiviral treatment nor vaccine is yet available to allow broad or targeted immunization of individuals at risk. in this context, knowing that a history of cvd increases risk of developing more severe disease manifestation upon infection with sars-cov-2, viewed in conjunction with previous data on comorbidityrelated risk factor associations might be useful in designing risk-adapted prevention strategies. individuals who have a history of cvd are more likely to develop severe manifestation of covid-19. consistency among results in our pooled analyses indicates that this observation is generalizable beyond the studied regions in china and germany. however, it remains to be answered whether the increased risk of severity observed in covid-19 patients included in our analyses can be explained by a past history of cvd per se or simply reflects the additive effects of concomitant cardiovascular risk factors. anonymized data will be shared by request from any qualified investigator. clinical characteristics of coronavirus disease 2019 in china word health organization (2020) coronavirus disease 2019 (covid-19) situation report-46 clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china. a retrospective cohort study cardiovascular considerations for patients, health care workers, and health systems during the coronavirus disease 2019 (covid-19) pandemic covid-19 and the cardiovascular system cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (covid-19) clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study long-term neurological, vascular, and mortality outcomes after stroke one-year risk of pneumonia and mortality in patients with poststroke dysphagia: a nationwide population-based study assessment of publication bias. visual inspection of funnel plot is not indicative of publication bias 10. national health commission (2020) chinese clinical guidance for covid-19 pneumonia diagnosis and treatment escmid emerging infections task force (2020) lean european survey on sars-cov-2 preferred reporting items for systematic reviews and metaanalyses: the prisma statement the oxford 2011 levels of evidence. oxford centre for evidence-based medicine what to add to nothing? use and avoidance of continuity corrections in meta-analysis of sparse data meta-analysis in clinical trials cochrane handbook for systematic reviews of interventions version 6 clinical features and shortterm outcomes of 102 patients with corona virus disease 2019 in wuhan clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study covid-19 with different severity: a multi-center study of clinical features clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wsuhan coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up clinical findings in a group of patients infected with the 2019 novel coronavirus (sars-cov-2) outside of wuhan, china: retrospective case series clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study association of radiologic findings with mortality of patients infected with 2019 novel coronavirus in wuhan clinical characteristics of 140 patients infected with sars-cov-2 in wuhan clinical characteristics of 161 cases of corona virus disease 2019 (covid-19) in changsha comorbidity and its impact on 1590 patients with covid-19 in china: a nationwide analysis against pandemic research exceptionalism prevalence and impact of cardiovascular metabolic diseases on covid-19 in china the global burden of stroke: persistent and disabling the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak neurologic manifestations of hospitalized patients with coronavirus disease potential effects of coronaviruses on the cardiovascular system: a review global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (interstroke): a case-control study managing epidemics: key facts about major deadly diseases. geneva: world health organization acknowledgements open access funding provided by projekt deal.funding none. ethical standards this study was approved by the institutional review board of technical university dresden (irb number bo-ek-154042020). since data were retrieved from ongoing registries informed consent was waived.open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. key: cord-325559-di8lljoi authors: cappello, francesco; marino gammazza, antonella; dieli, francesco; conway de macario, everly; macario, alberto jl title: does sars-cov-2 trigger stress-induced autoimmunity by molecular mimicry? a hypothesis date: 2020-06-29 journal: j clin med doi: 10.3390/jcm9072038 sha: doc_id: 325559 cord_uid: di8lljoi viruses can generate molecular mimicry phenomena within their hosts. why should severe acute respiratory syndrome coronavirus 2 (sars-cov-2) not be considered one of these? information in this short review suggests that it might be so and, thus, encourages research aiming at testing this possibility. we propose, as a working hypothesis, that the virus induces antibodies and that some of them crossreact with host’s antigens, thus eliciting autoimmune phenomena with devasting consequences in various tissues and organs. if confirmed, by in vitro and in vivo tests, this could drive researchers to find effective treatments against the virus. severe acute respiratory syndrome coronavirus 2 (sars-cov-2) induced disease (covid-19) is a planetary emergency that is urging many research groups to redirect their efforts and to channel their experience towards understanding its pathogenesis. despite many clinical reports and papers on viral genetics, detailed information on pathogenic mechanisms pertaining to covid-19 is still lacking. this type of information will no doubt help physicians in patient management and in providing treatment. the paucity of data on pathogenesis is due to a considerable extent to the very low number of autopsies that have been performed on covid-19 victims [1] . while histopathological and other data from laboratory tests and autopsies will accumulate as the pandemic persists in the next few months or so, some progress can be achieved applying bioinformatics and scientific reasoning. in this brief hypothesis paper, we have organized pertinent information available not only from the growing scientific literature but also from the chats of doctors and researchers on the web that cannot be ignored at this time, although they are not official instruments for dissemination of scientific data. these are temporarily useful channels for disclosing information as it is being generated at the "war front" (i.e., the doctors' offices and clinical departments) that under normal circumstances would be available in the form of scientific publications only many months after the fact. among the numerous articles consulted, some have caught our attention [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] . by reading these and other publications, we arrived at the initial conclusion that covid-19 develops in three steps (figures 1 and 2 ). in the following considerations, we will focus on the disease caused when the virus invades the body via the upper respiratory tract disregarding the other ways of viral entry, which are considerably less frequent as per current data-nevertheless, it is very likely that the conclusions would have also applied to the latter. (1) the virus enters the body through the upper respiratory tract and invades the respiratory mucosa covering the nasal cavities, the paranasal sinuses, and the nasopharynx. here it replicates and encounters immune cells. the immune system, via the waldeyer's ring, recognizes viral antigens activating innate immunity. (2) if the virus is not eradicated at this stage, it reaches the lower airways and enters the bloodstream through the respiratory barrier. the architecture of the primary pulmonary lobules is rapidly subverted by the violent inflammatory response, including both innate and adaptive immune-systems activation (lymphocytes, macrophages, plasma cells, etc.). (3) plasma cells produce antibodies that by the bloodstream (the lung is a highly vascularized organ) can travel throughout the body. (the image of the human body is a courtesy of visible body atlas.). sars-cov-2: severe acute respiratory syndrome coronavirus 2. (1) the virus enters the body through the upper respiratory tract and invades the respiratory mucosa covering the nasal cavities, the paranasal sinuses, and the nasopharynx. here it replicates and encounters immune cells. the immune system, via the waldeyer's ring, recognizes viral antigens activating innate immunity. (2) if the virus is not eradicated at this stage, it reaches the lower airways and enters the bloodstream through the respiratory barrier. the architecture of the primary pulmonary lobules is rapidly subverted by the violent inflammatory response, including both innate and adaptive immune-systems activation (lymphocytes, macrophages, plasma cells, etc.). (3) plasma cells produce antibodies that by the bloodstream (the lung is a highly vascularized organ) can travel throughout the body. (the image of the human body is a courtesy of visible body atlas.). sars-cov-2: severe acute respiratory syndrome coronavirus 2. the first step consists of upper airway infection: the virus colonizes and multiplies in the ciliated columnar epithelial cells of the respiratory mucosa. this phase can be asymptomatic, paucisymptomatic, or symptomatic; in any case, an innate immune response against the virus is triggered. the disease can be resolved at this level (fortunately in most cases) or it can progress to the second step. . at this stage, the disease can be asymptomatic, paucisymptomatic or produce symptoms such as fever, cough, anosmia, ageusia, and shortness of breath. many subjects heal spontaneously. however, in a limited number of subjects the virus moves down to the lower airways, causing severe pneumonia. it is not clear why some patients develop pneumonia and other do not. however, cold weather, high humidity, and severe pollution can be considered prodisease factors because they may favor virus vitality outside the body and inflammatory status inside the airways. most of the patients with pneumonia manage to heal (for example, by ex juvantibus therapies, such as tocilizumab or hydroxychloroquine), however, some of them develop severe complications, i.e., a generalized activation of the immune system manifested as vasculitis, disseminated intravascular coagulation (dic), and other signs and symptoms of autoimmunity. at this point, the risk of developing a multiorgan failure (mof) is high, and the patient may die. the first step consists of upper airway infection: the virus colonizes and multiplies in the ciliated columnar epithelial cells of the respiratory mucosa. this phase can be asymptomatic, paucisymptomatic, or symptomatic; in any case, an innate immune response against the virus is triggered. the disease can be resolved at this level (fortunately in most cases) or it can progress to the second step. the second step is characterized by lung infection (bilateral interstitial pneumonia), which can be of varying severities. in the more fortunate cases, clinicians manage to contain the infection with antiviral and/or anti-inflammatory therapies (or the infection is self-limited, a possibility that cannot be excluded at this time). in more severe cases, for unknown reasons but which are probably related to a "hyperreactivity" of both innate and acquired immunities, the disease progresses towards the third step. all the pieces of information available on the internet agree in indicating that in the third step the disease is systemic (representative examples of clinical and laboratory studies are presented in table 1 ). the emerging picture is that of widespread microvascular damage, diffuse thrombosis, disseminated intravascular coagulation (dic) and, lastly, a multiorgan failure (mof), often leading to death ( figure 3 ). table 1 . examples of reports of generalized immune system activation in covid-19. highlight the association between covid-19 pathogenesis and excessive cytokine release from lungs, such as ccl2/mcp-1, cxcl10/ip-10, ccl3/mip-1a, and ccl4/mip1b. [12] clinical and laboratory compared with nonintensive care unit (icu) patients, icu patients had higher plasma levels of interleukin (il)2, il7, il10, gscf, ip-10, mcp1, mip1a, and tnfα. [13] laboratory sars-cov-2 infection significantly upregulated il6, mcp-1, cxcl1, cxcl5, and cxlc10/ip10. [14] clinical and laboratory a retrospective multicenter study of 191 patients reported more elevated il6 levels in nonsurvivors than in survivors; univariate analysis of the data revealed significant associations of elevated il6 serum levels with mortality. [2] clinical and laboratory compared to moderate cases, severe cases more frequently had dyspnea, lymphopenia, and hypoalbuminemia, with higher levels of alanine aminotransferase, lactate dehydrogenase, c-reactive protein, ferritin and d-dimer, as well as markedly higher levels of il-2r, il-6, il-10, and tnf-α. [15] clinical and laboratory elderly patients and with comorbidities showed higher plasma levels of il6, il10, lactate dehydrogenase, and c reactive protein. [16] clinical and laboratory inflammatory cytokines were more elevated in severe cases than the nonsevere ones, including il-2r, il-6, il-8, il-10, and tnf-α. immunoglobulins (ig) a, igg, and igm and complement proteins (c3 and c4) in patients with covid-19 were within normal range. there were no significant differences in the levels of iga, igg, and complement proteins c3 or c4 between the mild and severe groups, while igm slightly decreased in severe ones. [17] clinical and laboratory concentrations of alanine aminotransferase, aspartate aminotransferase, creatinine, creatine kinase, lactate dehydrogenase, cardiac troponin i, n-terminal probrain natriuretic peptide, and d-dimer were markedly higher in deceased patients than in recovered patients. [18] notes. ccl2: chemokine (c-c motif) ligand 2; mcp-1: monocyte chemoattractant protein 1; cxcl10: c-x-c motif chemokine 10; ip-10: interferon gamma-induced protein 10; ccl3: chemokine (c-c motif) ligand 3; mip-1a: macrophage inflammatory protein 1-alpha; gscf: granulocyte colony-stimulating factor; tnfα: tumor necrosis factor alpha; cxcl1: c-x-c motif chemokine 1; cxcl5: c-x-c motif chemokine 5. it is noteworthy that these patients do not show the typical features of disseminated intravascular coagulopathy (dic). typically, patients with dic present with a considerably prolonged prothrombin time and a major reduction in platelet counts. by contrast, covid-19 patients have a moderately prolonged prothrombin time and platelet counts are often in the lower range of the normal. this strongly indicates that blood-clotting activation in covid-19 is different from the standard dic clotting activation. furthermore, the moderately reduced platelet count clearly resembles an immune complex-mediated prothrombotic disorder, e.g., heparin-induced thrombocytopenia [19] . it is noteworthy that these patients do not show the typical features of disseminated intravascular coagulopathy (dic). typically, patients with dic present with a considerably prolonged prothrombin time and a major reduction in platelet counts. by contrast, covid-19 patients have a moderately prolonged prothrombin time and platelet counts are often in the lower range of the normal. this strongly indicates that blood-clotting activation in covid-19 is different from the standard dic clotting activation. furthermore, the moderately reduced platelet count clearly resembles an immune complex-mediated prothrombotic disorder, e.g., heparin-induced thrombocytopenia [19] . some reports of damage of extrapulmonary organs are listed in table 2 . in addition, at this writing there is growing evidence of autoimmune dermatitis, guillain barre syndrome, and kawasaki disease in some covid-19 patients, particularly the younger ones [20] [21] [22] . table 2 . clinical and laboratory evidence of damage to extrapulmonary organs during sars-cov-2 infection. heart blood tests on admission showed most patients had higher levels of creatine kinase isoenzyme-myocardial band (ck-mb), myohemoglobin, cardiac troponin i, and n-terminal probrain natriuretic peptide. [23] liver gastrointestinal tract sars-cov-2 rna was first detected in stool of the first reported covid-19 case in the usa, who also presented with the digestive symptoms of nausea, vomiting, and diarrhea. [4] 1 abbreviations: alt: alanine aminotransferase; ast: aspartate aminotransferase. mortality rate is very high if the patient is male, elderly, with other concomitant pathologies, especially those related to hypertension and/or diabetes [3, 5, 9, 18] . despite all the information summarized above, it is still a mystery what triggers the hyperactivation of the immune system, which is virtually always present. we have elaborated a working hypothesis [27] that we now would like to propose to the scientific community and, thus, provide food for thought and a basis to plan clinical and laboratory research. for many years our group has been studying a class of proteins highly conserved during evolution and organogenesis, the heat shock proteins (hsp), many of which are molecular chaperones. these are typically antistress proteins (asp) that have helped cells, since their origins at the beginning of life on earth, to survive environmental stresses of chemical and physical nature and have, therefore, played an important role in evolution [28] . typically, asps are overexpressed in cells exposed to various kinds of stressors including bacterial and viral infections. hsp/chaperones are essential for survival and maintenance of protein homeostasis in all organisms but, if abnormal can cause disease, the chaperonopathies [28] . understanding the role of these proteins can provide novel elements for researchers and clinicians useful in diagnosis and treatment [29] . in the course of our studies, we came to the conclusion that hsp/chaperones can be involved in molecular mimicry phenomena, most likely because of their long evolutionary history and high degree of structural conservation, which has produced a widespread sharing of various antigen within and across species. hsp/chaperones are very similar in all organisms, from the most primitive unicellular to the most complex multicellular, typically sharing many highly immunogenic epitopes. this situation sets the stage for immunological crossreactivity between hsp/chaperones from all over the spectrum of living organisms. for instance, hsp/chaperones from any organism (bacterium, virus, or protozoan) in the human skin, or gastrointestinal, respiratory, and genitourinary tracts can invade the blood and thus come in contact with the host's immune system. antibodies are formed against the foreign hsp/chaperone that will most likely crossreact with the equivalent molecule of the human host, and this would be a typical example of molecular mimicry [30] . the same can happen with other microbial and human molecules because there are epitopes shared not only between hsp/chaperones but also between them and other molecules with different functions [31] [32] [33] [34] . asps, including hsp/chaperones, are typically intracellular molecules, but following stress events that augment their intracellular levels, they undergo post-translational modifications (ptm) and translocate to the plasma-cell membrane with their antigenic epitopes exteriorized on the cell's surface [35] [36] [37] [38] . these human epitopes, in turn, can be recognized by circulating antibodies made against crossreactive microbial antigens; these antibodies behave like autoantibodies, causing the destruction of the stressed cells, representing a typical example of pathology caused by molecular mimicry and manifested as autoimmunity [30] . any asp can be affected by ptm, which may change its properties and functions and make it pathogenic against its own host, generating a chaperonopathy by mistake [39, 40] . we speculated that the progression of covid-19 from step 2 to step 3 relies on molecular mimicry phenomena, as already shown for other viruses (table 3) . table 3 . examples of molecular mimicry involving viruses in disease. alphavirus sequence alignment of structural polyproteins belonging to arthritogenic alphaviruses revealed conserved regions which share homology with human proteins implicated in rheumatoid arthritis. [41] cytomegalovirus human antibodies against ul44 (an obligate nuclear-resident, nonstructural viral protein vital for human cytomegalovirus (hcmv) dna replication) immunoprecipitated nuclear-resident systemic lupus erythematosus autoantigens (namely, nucleolin, dsdna, and ku70). [42] coronaviruses several t-cell lines isolated from multiple sclerosis patients showed cross-reactivity between myelin and coronavirus antigens. [43] enterovirus immunogenic epitopes in enterovirus capsid protein vp1 and procapsid protein vp0 have sequence similarities with diabetes-associated epitopes in tyrosine phosphatase ia-2/iar and heat shock protein 60. [44] epstein-barr virus anti-c1q in systemic lupus erythematosus (sle) patients can be induced by an ebv-derived epitope through molecular mimicry. [45] papillomavirus a potential antigenic mimicry between viral and human proteins may be causative of myalgic encephalomyelitis and chronic fatigue syndrome. [46] in active celiac disease, a subset of antitransglutaminase iga antibodies recognize the viral protein vp-7, suggesting a possible involvement of molecular mimicry in the pathogenesis of the disease. [47] varicella-zoster virus autoantibodies to protein s can induce vasculitis and direct endothelial damage. [48] west nile virus an in-silico analysis unveiled certain sequence similarities between viral antigens and receptor sequence fragments suggesting a molecular mimicry autoimmunization process. [49] zika and dengue viruses anti-non-structural protein 1 antibodies can cross-react with host platelets and endothelial cells. [50] the severe bilateral pneumonia that develops in some individuals causes a drop in the partial pressure of oxygen in the blood. this undoubtedly represents a systemic stress. all cells suffer hypoxia, and this can lead to an overexpression of stress proteins and, in turn, to their change by ptm and translocation to the plasma cell-membrane. this would trigger molecular mimicry phenomena and a pathogenic cascade leading to mof (figure 3 ). it should be clear that this cascade can be triggered also by other crossreactive proteins distinct from asp. therefore, the search for the protein responsible for molecular mimicry cannot be limited to asps but must be extended to a wider range of cellular proteins. this search, now, is really a conundrum calling for concerted efforts of many research groups worldwide (figure 4 ). it is important to bear in mind that, in addition to autoantibodies and their complexes with soluble or cell-surface antigens, other effectors of autoimmunity such as immunocompetent cells should also be sought for and characterized to obtain a comprehensive picture of the pathogenic mechanism underpinning tissue damage. , which may be irreversible without proper medical intervention. even with prompt medical intervention, the disease may follow its course and cause death. at the moment, there is no specific therapy for covid-19, but clinicians use ex juvantibus therapy based on anti-inflammatory drugs such as tocilizumab (that inhibits il6) and hydroxychloroquine (inhibits il-1 and tnf-alfa); it is noteworthy that both drugs are used with success in autoimmune diseases. we hypothesize that, at the basis of the generalized activation of the immune system, there are molecular mimicry phenomena: the antibodies produced against the virus could turn into autoantibodies against crossreactive proteins expressed on human cells, causing autoimmunity with cell destruction. what proteins? which cells? what are the predisposing factors? furthermore, can there be protective factors? all of these are open questions now, although there are several clues that show directions for research in the immediate future. for example, one possible pathogenic mechanism of tissue damage is antibody dependent enhancement (ade) of sars-cov-2 due to cross-reactivity. ade has been recently claimed as a mechanism favoring middle east respiratory syndrome coronavirus (mers-cov) entry into host cells [51] . however, in a sars-cov macaque infection model, anti-spike igg antibodies bind to the fcγr on alveolar macrophages and promote their activation with release of massive amounts of profigure 4 . working hypotheses. the establishment of generalized signs and symptoms of immune system activation indicates a serious aggravation of the covid-19, which may be irreversible without proper medical intervention. even with prompt medical intervention, the disease may follow its course and cause death. at the moment, there is no specific therapy for covid-19, but clinicians use ex juvantibus therapy based on anti-inflammatory drugs such as tocilizumab (that inhibits il6) and hydroxychloroquine (inhibits il-1 and tnf-alfa); it is noteworthy that both drugs are used with success in autoimmune diseases. we hypothesize that, at the basis of the generalized activation of the immune system, there are molecular mimicry phenomena: the antibodies produced against the virus could turn into autoantibodies against crossreactive proteins expressed on human cells, causing autoimmunity with cell destruction. what proteins? which cells? what are the predisposing factors? furthermore, can there be protective factors? all of these are open questions now, although there are several clues that show directions for research in the immediate future. for example, one possible pathogenic mechanism of tissue damage is antibody dependent enhancement (ade) of sars-cov-2 due to cross-reactivity. ade has been recently claimed as a mechanism favoring middle east respiratory syndrome coronavirus (mers-cov) entry into host cells [51] . however, in a sars-cov macaque infection model, anti-spike igg antibodies bind to the fcγr on alveolar macrophages and promote their activation with release of massive amounts of pro-inflammatory cytokines [52] . by analogy, anti-sars-cov-2/anti-asp cross-reactive antibodies may similarly mediate ade and contribute to tissue damage. this and other similar hypotheses need to be clarified. to test the proposed working hypotheses, several steps are necessary, for example: (1) in silico comparison of epitopes of viral and human proteins, considering all these as putative autoantigens; (2) screening the results from the in silico studies, using the clues provided by epidemiological and clinical data being generated as the pandemic continues, to identify the protein(s) candidates; (3) immunohistochemical and other molecular analyses of tissues obtained from autopsies of covid-19 fatalities to determine if, and where, these crossreactive molecules are expressed and are indeed reactive with pertinent antibodies. what are the main clues that epidemiology and the clinics provide to date? they are many and disparate. we have listed some of them in figure 4 and these can be classified into negative and positive prognostic factors. in brief, from an epidemiological point of view [6] , the main negative prognostic factors are the subject's advanced age, the presence of comorbidities (hypertension and dysmetabolism), and the male sex. conversely, main positive prognostic factors are young age (very few children are affected by the severe form of the disease), being female, and living in certain geographical areas. the latter might depend not only on the degree of environmental pollution or type of climate but also on genetic-driven protection that individuals might have developed by being exposed to other disease-causing agents. alongside these epidemiological indications, there are others that come from the clinic [3] [4] [5] 8, 11] . the disease, in the third step, involves endothelial cells and/or platelets and/or erythrocytes, more than other cells in the human body: this is suggested by signs of dic and anemia often found by clinicians in sars-cov-2 infected patients. furthermore, at this writing, it cannot be excluded that the renal failure that develops in many patients is not due either to the deposition of preformed circulating immune complexes or to the formation of immune complexes made by circulating antibodies bound to kidney antigens in situ. last but not least, a critical examination of the molecular mechanisms underlying the efficacy of drugs that are currently being tested with some success as ex juvantibus therapy should not be overlooked, since it may offer further cues to unveil unknown pathogenic mechanisms. all these clues, and others that may be revealed in the coming weeks from clinical and histological investigations, should guide researchers towards confirmation or exclusion of molecular mimicry as a determinant pathogenic factor. the understanding of sars-cov-2 phenotype using modern bioinformatics is critical to identify target proteins and shared epitopes between human and viral proteins. here, we want to provide some preliminary insights. many research groups have described the virus by performing structural studies or extrapolating information available pertinent to other coronaviruses. by resorting to previously known information on genome sequences and protein structures and functions as well, bioinformaticians have been successfully assisting virologists by structurally characterizing proteins of the novel virus, determining the evolutionary trajectories, identifying interactions with host proteins, and providing other important biological insights. the whole genome of sars-cov-2 was sequenced, and the sequence is available in genbank (accession number mn908947.3). structural and nonstructural proteins were identified (12 reported in genbank) and they are available in protein data bank (pdb) database and the universal protein resource (uniprot). moreover, many bioinformatics tools are currently used in the scientific literature to understand sars-cov-2 properties and in many cases are easily available online like clustal omega (embl-ebi, cambridge, uk), blast, modeller, mega-x, swiss-model (expasy, sib bioinformatics resource portal, lausanne, switzerland), just to mention a few examples. sars-cov-2 is a spherical or pleomorphic enveloped particle containing single-stranded rna associated with a nucleoprotein within a capsid comprised of matrix protein. the envelope bears club-shaped glycoprotein projections [53] . sars-cov-2, as other coronaviruses, has four structural proteins, known as the s (spike), e (envelope), m (membrane), and n (nucleocapsid) proteins. each of these proteins have a function since the n protein holds the rna genome while the s, e, and m proteins together make the viral envelope [54] . the spike protein, which has been visualized at the atomic level using cryogenic electron microscopy [55, 56] , is the protein responsible for allowing the virus to attach to and fuse with the membrane of a host cell and for this reason it has captured major interest in the scientific community [54] . experiments on the spike protein demonstrated that it has enough affinity to angiotensin converting enzyme 2 (ace2) on human cells, supporting the idea that ace2 is the cell entry receptor [10, 55, 56] . the s protein is composed of two functional subunits (s1 and s2) responsible for receptor binding and membrane fusion, respectively. the surface of the virally encoded envelope spike presents an array of host-derived glycans with each trimer displaying 66 n-linked glycosylation sites. this extensive glycosylation has important implications for vaccine design [57] . recently, a comparative analysis of sars-cov-2 proteins with human proteins was performed in search of high local homologous matches [58] . only one immunogenic epitope in sars-cov-2 had no homology to human proteins and it was concluded that, if all the parts of the epitopes that are homologous to human proteins are excluded from consideration due to risk of pathogenic priming, the remaining immunogenic parts of the epitopes may be still immunogenic and remain as potentially viable candidates for vaccine development. these results likely support our hypothesis and should prompt more investigations on this issue. covid-19 represents a global challenge for the medical community, researchers, and practitioners alike. we were not prepared from the health and social perspectives to face a pandemic, and states around the world are trying to adapt and find the best countermeasures and researchers are doing the same. at this moment, it is important not only to share the results, which may be few, but also the ideas, as these can serve as a stimulus to find solutions to the problems. with this short article, we wanted to offer our contribution, however small it might be, to face the challenge of the covid-19 pandemic, stimulating the scientific community to investigate the involvement of molecular mimicry in the pathogenesis of covid-19. this could be useful not only to reveal the pathogenetic mechanisms underpinning morbidity and mortality but also to direct the development of novel therapeutic strategies and a vaccine. acknowledgments: francesco cappello, francesco dieli and antonella marino gammazza were partially supported by the university of palermo. francesco cappello was partially supported also by iemest. everly conway de macario and alberto jl macario were partially supported by the university of maryland at baltimore-imet. this work was written under the umbrella of the agreement between iemest and imet. this is imet contribution number imet-20-011. authors declare no conflict of interest. covid-19 deaths: are we sure it is pneumonia? please, autopsy, autopsy, autopsy! 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anti-spike igg causes severe acute lung injury by skewing macrophage responses during acute sars-cov infection genotype and phenotype of covid-19: their roles in pathogenesis analysis of therapeutic targets for sars-cov-2 and discovery of potential drugs by computational methods cryo-em structure of the 2019-ncov spike in the prefusion conformation structure, function, and antigenicity of the sars-cov-2 spike glycoprotein site-specific analysis of the sars-cov-2 glycan shield pathogenic priming likely contributes to serious and critical illness and mortality in covid-19 via this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-333340-ekok0mp5 authors: graf, erin h.; pancholi, preeti title: appropriate use and future directions of molecular diagnostic testing date: 2020-02-06 journal: curr infect dis rep doi: 10.1007/s11908-020-0714-5 sha: doc_id: 333340 cord_uid: ekok0mp5 purpose of review: major technologic advances in two main areas of molecular infectious disease diagnostics have resulted in accelerated adoption or ordering, outpacing implementation, and clinical utility studies. physicians must understand the limitations to and appropriate utilization of these technologies in order to provide cost-effective and well-informed care for their patients. recent findings: rapid molecular testing and, to a lesser degree, clinical metagenomics are now being routinely used in clinical practice. while these tests allow for a breadth of interrogation not possible with conventional microbiology, they pose new challenges for diagnostic and antimicrobial stewardship programs. this review will summarize the most recent literature on these two categories of technologic advances and discuss the few studies that have looked at utilization and stewardship approaches. this review also highlights the future directions for both of these technologies. summary: the appropriate utilization of rapid molecular testing and clinical metagenomics has not been well established. more studies are needed to assess their prospective impacts on patient management and antimicrobial stewardship efforts as the future state of infectious disease diagnostics will see continued expansion of these technologic advances. while the first direct-specimen molecular testing for infectious diseases was approved by the us fda 26 years ago [1] , there has been a very recent explosion of molecular technology in two major directions: (1) direct-specimen rapid amplification and detection platforms and (2) next-generation sequencing. these advanced techniques offer an opportunity to provide laboratory diagnoses at a speed, sensitivity, and breadth never before possible with conventional microbiology. given the continued emergence and spread of novel antimicrobial resistance mechanisms paired with increasingly complex patient populations, these technologic advances may become important factors in patient care. however, each comes with its own set of significant limitations including cost considerations and potentially negative consequences, such as over-utilization. as a result, there is also room for novel stewardship strategies around these types of testing. one of the early applications in this wave of technology is species and antimicrobial resistance marker identification from positive blood culture broth. several rapid, multiplexed molecular panels received us fda clearance in the last 5 to 10 years [2] . these platforms provide significantly decreased turnaround times for limited organism and resistance marker identification. however, numerous studies, some almost a decade old, have shown that without any intervention, simply implementing this relatively expensive technology has no clinical or economic impact [3] [4] [5] . what we have learned from these studies is that in order to see some benefit from this specific technology, an antimicrobial stewardship program (asp) must be engaged to direct changes in treatment. only through this approach can the technology lead to faster time to optimal therapy, shorter hospital stays, and associated hospital cost savings for very specific scenarios [3] [4] [5] . although this is not a direct-specimen application, we can begin to draw parallels with direct-specimen molecular testing. this review will highlight recent studies developing and applying emerging molecular infectious disease technologies and touch on limited published data on clinical utility and stewardship approaches. syndromic panels "syndromic panel" is a term commonly used in clinical microbiology when referring to rapid, multiplexed amplification and detection platforms that received us fda approval or clearance for a set list of targets in a specific sample type [6] . this includes panels for gastrointestinal, central nervous system and respiratory tract infection-associated potential pathogens. there are common themes among all of these panels. first, they are superior in analytical sensitivity and speed compared to the syndromic approaches they replaced, that is viral and bacterial cultures. second, due to the fact that they emerged and were adopted quickly as a superior method to culture, adoption has outpaced evidence of clinical utility for some tests and populations [7] . ideally, we would evaluate all of these approaches via randomized controlled trials comparing patient outcomes between conventional microbiologic testing and testing including a syndromic panel; however, very limited studies addressing this have been published [8] . finally, there are also very limited studies on appropriate utilization. given the increased cost over conventional methods and potential unintended consequences of over-testing, these are areas in need of exploration [9] . how these points relate to each panel type will be discussed separately below. for a detailed review of individual respiratory tract rapid syndromic respiratory panels, readers are referred to the following references (6, 8) . while individual targets vary, in general, these panels contain most known, widely circulating respiratory viruses and a limited set of atypical upper respiratory tract bacterial targets. analytical sensitivity also varies by target for each panel. a number of studies have attempted to evaluate whether implementation of these panels results in any impact on patient care. several retrospective studies have shown mixed results when considering impact on antibiotic usage, including duration, or length of hospitalization when comparing pre-and post-panel implementation time periods or comparing patients with positive versus negative panel results [10] [11] [12] [13] [14] . one of the only randomized controlled trials also found no difference in antibiotic usage, including duration, between adults tested via syndromic panel at the point-of-care compared to patients receiving conventional testing in a hospital emergency department and inpatient unit [15] . they attributed this to the fact that antibiotics were initiated before the syndromic panel was completed. upon secondary analysis, only including patients who were not prescribed antibiotics prior to receiving the panel result, they found a small (13%) but statistically significant difference in antibiotic prescriptions. the same study also found that patients in the syndromic panel arm were discharged a mean of 1 day earlier than those receiving conventional testing. another randomized controlled trial found no difference in length of stay or antibiotic usage, including duration, comparing adult patients who received syndromic panel testing with those who received conventional microbiologic testing [16] . in many of these studies, there appears to be a significant impact only when patients test positive for influenza virus. for example, in a retrospective pre-, postimplementation analysis, rappo et al. found that an influenza diagnosis by rapid syndromic panel, compared to conventional testing, led to less admissions, shorter length of stay and duration of antibiotics, as well as less imaging [11] . in the same study, there was no impact when patients were positive for a noninfluenza virus by syndromic panel compared to conventional testing. this leaves an obvious place for antimicrobial and diagnostic stewardship. asp could provide practice-level guidance on the proper interpretation of these results; that is, with-hold antibiotics if a virus is detected when other clinical features or testing is not consistent with bacterial infection [17] . trials evaluating the success of these types of interventions are needed. the future of respiratory syndromic panels includes lower respiratory tract sampling. two panels have recently been cleared by the us fda for sputum, endotracheal aspirate and bronchoalveolar lavage specimens. one of these panels includes the same viral targets as their upper respiratory tract panel, while both have the same 18 bacterial targets and 8 to 10 antibiotic resistance genes [6] . this expansive number of bacterial targets may lead to tremendous confusion for the ordering physician if many targets are positive on the same sample, including antibiotic resistance genes that can be attributed to multiple species. one manufacturer provides semiquantitative assessment, via 10-log increments, of most of the bacterial targets to attempt to aid in interpretation. however, it is not clear what relative quantities should be considered significant. at the time of this writing, there are no published studies available; thus, we cannot comment on the clinical performance or appropriate utility of such panels. as with respiratory panels, there are a number of us fdaapproved rapid syndromic panels for gastroenteritis reviewed in the following references (6, 8) . while these tests have improved sensitivity and reduced time to result over bacterial culture for common agents of community-acquired diarrhea, they introduce new issues. first, one of the panels contains an expansive list of potential pathogens, including several low incidence targets and four e. coli targets, only one of which is tested for as part of a standard stool culture. in early clinical studies, enteropathogenic e. coli (epec) was the most frequently identified organism on the panel across all age groups [18, 19] . while this organism is a cause of pediatric diarrhea in developing countries, the unexpected prevalence in adults and a population without travel to endemic areas raised concerns about detection of colonization. epec was also more frequently found as part of co-detections than alone. further studies have repeated these findings in countries across different continents and have also identified the same issues with enteroaggregative e. coli [20] [21] [22] . false-positive detections of vibrio cholerae [23] and entamoeba histolytica [24] have been reported in patients without relevant exposures. this highlights the inherent problems with testing patients for potential pathogens without clinical indication, especially in low prevalence settings. to combat potential negative consequences of broad panel testing, antimicrobial and diagnostic stewardship partnerships are critical [25] . to this point, keske et al. evaluated the inappropriate use of antibiotics, defined as the use of antibiotics after a pathogen was detected that did not require treatment with that drug, during a pre-and post-asp intervention at a single hospital in turkey. the asp intervention was described as "educational meetings and activities among prescribers" that took place at the end of the preintervention time period. the authors saw a significant reduction in inappropriate prescriptions even with this modest intervention [22] . importantly, analysis was limited to adults with severe diarrhea and fever or bloody diarrhea. the authors did not state whether testing was also limited to this population as a diagnostic stewardship approach. to evaluate inappropriate utilization, clark et al. performed retrospective chart review on all adult outpatients from the university of virginia health system tested by syndromic gi panel in a 15-month period. they found that 32% of patients were tested inappropriately, that is, not meeting the infectious disease society of america's recommendations [26] . of these 32% of patients deemed inappropriately tested, only one had a clinically significant pathogen detected but this detection was deemed not to have impacted management. perhaps the most concerning impact of implementing a syndromic gi panel without diagnostic stewardship is the potential over-diagnosis of c. difficile infection (cdi) in colonized individuals and related financial consequences [27] . the idsa currently recommends limiting testing to individuals greater than 2 years of age with diarrhea following antimicrobial use and/or healthcare-acquired diarrhea, though individuals with persistent diarrhea lacking an etiology may be considered for testing [26] . these categories are complicated by the association of many medications, including antimicrobials, with diarrhea, as well as overlapping symptoms between cdi and viral causes of hospital-acquired diarrhea and increased likelihood of c. difficile colonization in individuals with antibiotic and healthcare exposures [28] . there is intense debate around the use of antigen testing versus molecular for the diagnosis of cdi, which is beyond the scope of this review [29] . suffice to say that diagnostic and asp partnerships are necessary to reduce syndromic gi panel testing that detects colonization and subsequent unnecessary treatment. in a prospective study, truong et al. performed real-time enforcement of testing criteria to reject specimens for c. difficile molecular testing that were from patients without diarrhea or who had received laxatives. through this intervention, they were able to detect significant reductions in tests ordered, use of oral vancomycin, and rates of hospital onset cdi [30] . while the test used in this study was not a syndromic panel, the same conclusions can be drawn to increase the value of gi panel testing. at the time of this writing, there is only one us fdaapproved multiplex molecular panel for the detection of central nervous system infection-associated pathogens in cerebrospinal fluid collected through lumbar puncture [31] . however, it is a matter of when, not if, more will be cleared [32] . we are now roughly 4 years out from the initial approval of the first panel with many lessons learned. the clinical trial and several retrospective studies performed around the time of release revealed some concerning findings [31, 33] . first, falsepositive results for bacteria found in the respiratory tract and herpes simplex virus (hsv) were commonly reported [31, 33] . the origin of this false-positivity has been hypothesized to be contamination from medical laboratory scientists, individuals collecting samples or other clinical samples processed in the same location; however, this has not been scientifically proven. second, cryptococcal meningitis should still be diagnosed by antigen testing due to superior sensitivity of that method [33] [34] [35] . third, detection of hhv-6 is common and of questionable clinical significance [36] [37] [38] . laboratories should provide an interpretive comment on the report for hhv-6 detections possibly prompting consultation with infectious diseases, though this leads to additional consult burden on these clinical teams. finally, some targets were not adequately represented in the clinical trial due to infrequent clinical presentations, which could have been predicted by statistical estimates. as a result, the sensitivity of detection for bacterial meningitis is not well documented and there is a published example of the panel failing to detect neisseria meningitidis in a sample that was only positive after a 5-fold dilution, which is a deviation from the fda approval [39] . the authors hypothesized that the patient's csf's high white blood cell count could have led to interference. more likely, the organism dna load was so high that it diluted speciesspecific primers and probes. since the panel also does not detect all possible causes of bacterial meningitis culture is still required. additionally, the panel has been shown to have lower analytical sensitivity for hsv than single-target molecular tests [40, 41] . thus, negative panel results in the setting of high clinical suspicion for hsv encephalitis or neonatal disseminated disease should be interpreted with caution. the speed and ease of testing has led to the rapid adoption of this platform in many laboratories before clinical performance and utility could be fully established. for example, many labs chose to adopt due to the fact that send out testing for hsv was expensive and led to delays [43] . the syndromic panel allows them to perform testing in house at perhaps the same cost with the potential benefit of the additional targets. however, as mentioned above, the lower analytical sensitivity for hsv raises concern. some argue that this new ease of testing has possibly led to overuse [42, 43] . however, retrospective analyses have the benefit of knowing the final diagnosis while at the time of clinical presentation, it may have been appropriate to order syndromic panel testing [43] . studies that have looked at pre-and post-panel implementation time-points have found conflicting differences in panel impact in terms of length of stay and time to appropriate antimicrobial narrowing, with some showing significant decreases [44, 45] and others showing no difference [46] . since there is no set guidance for how or if testing should be limited as a stewardship approach, it is currently unclear how to gain the most benefit from this panel. some have proposed a csf cell count-based cutoff to limit testing [47] . such cutoffs are clearly not universal to all populations or infections [48] . for example, hsv encephalitis can often present with a normal csf cell count early in the course of disease [49] . the future for syndromic panel testing may require smaller, modular, or even reflexed panels to achieve maximum financial and clinical benefit. this is in part due to recent centers for medicare and medicaid services' (cms) local coverage determinations (lcd) that deemed some components of these panels not reasonable or necessary. lcds limit reimbursement to five bacterial targets on the syndromic gi panel, unless c. difficile colitis is suspected and tested as a part of the panel, and three to five viral targets on the respiratory syndromic panels (cms, https://www.cms.gov/medicare-coveragedatabase/details/lcd-details.aspx?lcdid=37363&ver=3, accessed 10/30/2019). to potentially combat this, some manufacturers have received proprietary laboratory analyses (pla) codes (american medical association, https://www. ama-assn.org/system/files/2019-10/cpt-pla-codes-long.pdf, accessed 10/30/2019), which in theory allow for exemption from the lcds. however, at the time of this writing, it is unclear if all payers will accept these new codes and what the reimbursement rate will be. studies addressing the downstream financial benefits of testing, such as savings from reduced antibiotic use or decreased length of hospitalizations, and how these offset the cost of the testing are needed [50] . without question, the future of rapid, random-access molecular testing is moving closer and closer to the bedside or clinic room. currently, there are a number of clinical laboratory improvement amendments (clia)-waived molecular tests for influenza virus, some paired with respiratory syncytial virus, group a streptococcal pharyngitis and for chlamydia trachomatis and neisseria gonorrhoeae (ct/ng) with excellent analytical sensitivity and specificity [51, 52] . cliawaived means that these tests can be performed outside of a laboratory and by non-laboratory staff such as nurses. studies of these platforms have shown clinical impact for influenza detection in both the inpatient and ambulatory settings [53, 54] . in a prospective, single-season study of urgent care centers connected to their health system, benirschke et al. found a significant reduction in the use of antibiotics for those who tested positive for influenza by a poc molecular test compared to those who tested positive by a poc antigen test [54] . martinot et al. had similar significant reductions in length of stay, antibiotic administration, and faster oseltamivir administration after a positive influenza test in an emergency department population comparing poc molecular to a slower laboratory developed molecular influenza test [55] . group a streptococcal (gas) pharyngitis poc molecular tests are now clia-waved without the need for confirmatory culture of negative results. in a prospective primary care study comparing a clia-waved poc molecular test to conventional methods for gas, rao et al. found a small but significant reduction in inappropriate antibiotic use for children presenting with symptoms of gas pharyngitis [56] . for ct/ng, the majority of these tests are currently sent to central laboratories, leaving up to a 7-day waiting period from first visit to treatment. during that time, patients may spread infection, and many patients receiving positive results do not return for treatment. these poc tests allow people to be tested, diagnosed, and treated for stis in a single visit [57, 58] . they can also help to reduce the burden on health workers and systems and can therefore also reduce expensive laboratory costs. bringing molecular testing outside of the clinical laboratory comes with appropriate concern. first, these assays produce millions to trillions of copies of pathogen nucleic acid. while they are closed systems, there is always the possibility of amplicon contamination from a defective product and one laboratory accrediting agency has recently added new requirements to this point [59] . to investigate potential contamination, donato et al. performed weekly swabs of the surface of an actively used poc molecular gas test and surrounding environment at two different urgent care clinics [60] . they were not able to detect any contamination that amplified via the same test across the 13-week period of the study. second, as more molecular assays become cliawaved for poc use, especially those with multiple targets, the ability to provide diagnostic stewardship becomes increasingly challenging. for example, one of the large syndromic respiratory panels is now clia-waved. more data are needed on how these panels are used and interpreted in outpatient and urgent care settings. the combination of shotgun next-generation sequencing with metagenomic analyses of the data, directly from a clinical sample for the diagnosis of an infection is referred to as "clinical metagenomics". the ability to interrogate the sequencing data for any potential pathogen has resulted in tremendous promise for this methodologic approach. the first publication describing the real-time use of clinical metagenomics came in 2014 [61] . since that time, several laboratories, including the laboratory who co-authored that initial case study, have validated metagenomic analyses of next-generation sequencing data directly from a variety of clinical sample types. a detailed description of next-generation sequencing and metagenomics methods is provided in the following references (62, 63) . it is important to highlight that each laboratory has highly lab-and sample-type specific methods from sample preparation, library preparation, sequencing platform and depth, to bioinformatic analysis and interpretation. any one of these components leads to some sort of bias, and there are currently no uniformly accepted criteria for any step in this process [64] . thus, physicians who order this testing should understand, at least at a big-picture level, the associated limitations to adequately interpret results in the clinical context of their patients. at the time of this writing, only one laboratory has validated metagenomic analyses of next-generation sequencing data from csf. while this group has published several case reports over the last 5 years [65] [66] [67] [68] , they have recently published their prospective clinical study [69] . some key takeaways from this larger sample set include the fact that unique detections by clinical metagenomics were equally likely to represent a clinically significant pathogen as they were to represent an incidental finding. for those that were deemed clinically significant, 6% of the total study population, roughly half would have influenced treatment as determined by a review panel consisting of clinical microbiologists and infectious disease physicians. all of these unique, clinically significant detections were confirmed by targeted pcr or bacterial/fungal ribosomal pcr followed by sanger sequencing. this suggests that the true value of clinical metagenomics is in the unbiased nature of the method rather than improved sensitivity over targeted pcrs or ribosomal sanger sequencing in csf samples. the samples that were incidental detections included 10 detections of hiv, 7 of which were from patients known to be positive for hiv, hhv-7 (n = 3), hhv-6 (n = 2, discussed above with the syndromic csf panel), ebv (n = 1), and 1 detection each of hcv and coronavirus. how these would be interpreted on an individual patient level in real time remains to be established. equally informative are the infections not detected by their assay. in the supplemental material, the authors describe 11 cases diagnosed by serology and 7 cases diagnosed by an alternative sample type. however, there are also eight cases in which pathogen titers were considered too low to meet their cutoff for positivity, 6 of which had detectable reads below their clinically validated thresholds. this suggests that the current iteration of their test should be used in combination with conventional testing including targeted pcrs that may be more analytically sensitive for some pathogens such as mycobacterium tuberculosis. again, at the time of this writing, only one laboratory has validated clinical metagenomics from plasma. their test is based upon the hypothesis that, like placental or tumor dna, pathogen dna can be found in the bloodstream after breakdown and release from distal organs as well as from blood stream infections [70] . they call this "cell free" dna based on the terminology used in human clinical genomics. there have been a few case reports showing utility for the diagnosis of culture-negative endocarditis and invasive mycobacterium chimaera disease [71, 72] . in a single center clinical study looking at results of this test sent from children with a variety of indications, rossoff et al. found a 70% positivity rate [73] . sixty percent of these positives were also positive by conventional testing. for those that were only detected via clinical metagenomics, half were deemed clinically significant and half were considered insignificant, similar to the findings in the csf study described above. other sources that have either been validated or are close to clinical validation for metagenomics include respiratory specimens [64, 74] and prosthetic joint specimens [75] [76] [77] , respectively. studies in these sample types also detect a number of questionable or insignificant positive results, highlighting the need for careful clinical interpretation. as this methodology may become mainstream in the future of clinical microbiology, appropriate utilization and interpretation will be key to cost-effectiveness. as the landscape of infectious diseases evolves, emerging resistance mechanisms and novel therapeutics for treatmentretractile diseases will require cutting edge molecular diagnostics to evolve simultaneously. the use of metagenomic and/or transcriptomic data to assess the resistome of a clinical sample requires further exploration to understand whether phenotypic antimicrobial susceptibility testing can ever be replaced, or at least sufficiently augmented, by such techniques. tremendously promising work is also being done to understand how the microbiome influences human health and how that can be manipulated for treatment purposes for multi-drug-resistant organisms as well as c. difficile. the success of fecal microbiome transplants may someday require companion, real-time metagenomic characterization of donor stool as well as post-microbiome engraftment analyses [78] . similarly, phage therapy, with or without crispr-cas9 strategies, to combat highly antimicrobial resistant bacteria may require metagenomic analyses to assess efficacy [79, 80] . finally, advances in the speed of amplification through techniques like "extreme pcr" will no doubt lead to a nextgeneration of rapid diagnostics [81] . not mentioned in this review, due to scope, are systems like t2 biosystems and qvella, that test for bloodstream infections directly from a blood sample without the need for culture [82] . these types of technologies will no doubt continue to develop to reach the rapid state. advances in molecular speed and cost will likely also result in the availability of direct access clia-waived molecular testing that patients can perform in their homes as well as a continuously expanding menu of molecular testing to be performed at the point-of-care, including the outpatient setting [83] . hopefully, future iterations or new platforms will include smaller, modular, or even reflexive panels that lead to clinically appropriate testing for the right patient populations. studies on the clinical utility, impact, and diagnostic and antimicrobial stewardship approaches for these types of advances are very much needed. as molecular diagnostics continue to push the boundaries of speed and comprehensive and complex analyses, optimal utilization and impact will require partnership with stakeholders, particularly antimicrobial and diagnostic stewardship programs. the current pace of these technologic advances, and subsequent fda approval of a subset, has created an unfortunate lag in our ability to appropriately steward their use. while many groups have published promising data on effective utilization we are far from the optimal state. more data is needed to drive the future use and expansion of these panels, particularly as they move closer to the point-of-care. conflict of interest erin graf declares that she has no conflict of interest. preeti pancholi declares that she has no conflict of interest. human and animal rights and informed consent this article does not contain any studies with human or animal subjects performed by any of the authors. molecular methods and platforms for infectious diseases testing a review of fda-approved and cleared assays advances in rapid molecular blood culture diagnostics: healthcare impact, laboratory implications, and multiplex technologies randomized trial of rapid multiplex polymerase chain reaction-based blood culture identification and susceptibility testing an antimicrobial stewardship program's impact with rapid polymerase chain reaction methicillin-resistant staphylococcus aureus/s. aureus blood culture test in patients with s. aureus bacteremia clinical impact of a real-time pcr assay for rapid identification of staphylococcal bacteremia direct-from-specimen pathogen identification: evolution of syndromic panels multiplexed molecular diagnostics for respiratory, gastrointestinal, and central nervous system infections syndromic panel-based testing in clinical microbiology implementation of rapid molecular infectious disease diagnostics: the role of diagnostic and antimicrobial stewardship impact of multiplex molecular assay turn-around-time on antibiotic utilization and 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firoozfar, ali title: is there any potential management against covid-19? a systematic review and meta-analysis date: 2020-08-18 journal: daru doi: 10.1007/s40199-020-00367-4 sha: doc_id: 316432 cord_uid: xemz7zn9 purpose: a recent survey has shown that the covid-19 pandemic has culminated in dramatical and critical treatment particularly in acute infected patients. in fact, this systematic review-meta-analysis was directly pertained to estimation at the efficient value of some clinical managements to confront the covid-19 infection. methods: pubmed, embase, scopus, cochrane, and scholar databases were searched from inception to july 1, 2020, to identify studies reporting the current treatment process and medications (e.g. hydroxychloroquine, antiviral therapy, convalescent plasma, and immunomodulatory agents) for covid-19. a random-effects model meta-analysis was performed to calculate the relative risk (rr) with 95% confidence intervals (ci). the outcomes of this study were the frequency of negative conversion cases, clinical improvements, mechanical ventilation demand, intensive care unit (icu) entry, and mortality. the standard treatment refers to the published guidelines and specialist experience which varies in different articles, and the proposed treatment refers to the kind of interest suggested in the included studies. results: a number of 45 articles met the eligibility criteria (out of 6793 articles). among them, 26 articles involving 3263 patients were included in quantitative analysis. anti-covid-19 interventions could significantly increase clinical improvement (rr 1.17, 95% ci 1.08–1.27; i(2) = 49.8%) and reduce the mortality rate (rr 0.58, 95% ci 0.35–0.95; i(2) = 74.8%). although in terms of negative conversion, icu entry, and mechanical ventilation demand, clinical intervention had no beneficial effect. the clinical effect of immunomodulatory agents (especially tocilizumab and anakinra) was noticeable compared to other medications with rr of 0.22 (95% ci 0.09–0.53; i(2) = 40.9%) for mortality and 1.25 (95% ci 1.07–1.46; i(2) = 45.4%) for clinical improvement. moreover, antivirals (rr 1.13, 95% ci 1.01–1.26; i(2) = 47.0%) and convalescent plasma therapy (rr 1.41, 95% ci 1.01–1.98; i(2) = 66.6%) had significant beneficial effects on clinical improvement. conclusion: based on our findings, all the included interventions significantly declined the mortality and enhanced clinical improvements with no effect on negative conversion and mechanical ventilation demand. especially, immunomodulators and plasma therapy showed favorable outcomes. graphical abstract: [figure: see text] electronic supplementary material: the online version of this article (10.1007/s40199-020-00367-4) contains supplementary material, which is available to authorized users. the newly discovered coronavirus pathogenesis (sars-cov-2) has been prevalently broken out as an unprecedented epidemic public health emergency since january 30, 2020 and then it was announced globally as a pandemic on march 11, 2020 by the world health organization (who). in fact, the high rate of human to human transmission of this virus as quickly as its rapid spreading contagion aggravated the complexity of the situation [1] [2] [3] [4] . sars-cov-2, has already infected nearly 14.5 million people worldwide resulting in 607,781 deaths in 216 countries, as of july 21, 2020 [5] . the percentage of mortality attributed to covid-19 has fallen from 8.1% during week 27 to 6.4% during week 28 (july 11, 2020) but remained above baseline. the overall cumulative hospitalization rate is 113.6 per 100,000 which is a huge burden to the healthcare system [6] . besides the public health issues, it was stated that covid-19 prevalence would have considerable effect on the health market especially the pharmaceutical sector [7] . sars-cov-2 brings about a condition in which clinical manifestations start with fever, dry cough, or occasional shortness of breath and in some cases acute respiratory distress syndrome (ards), multi-organ failure, and death [8] . ling lin et al. (2020) suggested a rational hypothetical pathogenesis of sars-cov-2 infection that implies virus interaction with angiotensin converting enzyme 2 (ace2) expressed in target organs subsequent to the passage through the mucous membranes and entrance to peripheral blood from the lungs [9] . unfortunately, at this juncture, there is no specific medication or clinical approach to managing patients with covid-19. however, besides the attempts to introduce new vaccines or therapeutic agents, many different clinical trials have been launched to evaluate the efficacy of different existing medications and clinical managements like antiviral drugs, antimalarial drugs, immunomodulatory drugs, stem cell therapy, convalescent plasma therapy and etc. [10] [11] [12] [13] [14] [15] . some of these trials terminated with the beneficial influences on patients' outcomes [10, 12, 16] and some did not [8, 14, 17] . because of these contradictory reports, there is conflict on the question of which these available interventions could be more affirmatively efficacious and acceptable. considering that it has been a short time since the sars-cov-2 outbreak, most of the reported investigations have limited yields and incomplete bodies of data. in such a pandemic emergency situation, it is mandatory to provide a general overview of current management effectiveness to achieve the best strategy against covid-19. furthermore, sars-cov-2 is a rna virus so that its fast mutation can result in a resistance phenotype [18] . blind medication could trigger the emergence of resistance phenotype as well [18] , thus rapid determination of the best clinical approach is necessary. there have been several systematic review-meta-analyses about covid-19 that investigated underlying disease and comorbidities, clinical manifestations and imaging findings, paraclinical factors and biomarkers, mortality rate, maternal outcomes and etc. [19] [20] [21] [22] [23] [24] . although some systematic reviews were published in the field of therapeutic options against covid-19 and summarized the trials with inconclusive outcomes [25] [26] [27] [28] [29] [30] . zhong et al., provided a systematic review and meta-analysis including the therapies for severe acute respiratory syndrome (sars), middle eastern respiratory syndrome (mers) mainly besides covid-19 and assessed their safety and efficacy profiles [31] . due to daily update of studies regarding anti-covid-19 interventions, it is mandatory to conduct a comprehensive and updated review on this field. in this study, we conducted a systematic review and meta-analysis to synthesize the results of well-done observational studies and clinical trials to estimate the value of some clinical managements to confront covid-19. the study protocol was approved by the ethics review committee in research deputy department of shahid beheshti university of medical sciences, tehran, iran (rec code, ir.sbmu.retech.rec.1399.052). the cochrane protocol was used to conduct the systematic review [32] and search the databases which were performed and based on the prisma guideline ( fig. 1 ) [33] . international databases consisting of scopus, pubmed, cochrane, and embase were applied to search for the articles from inception to july 1, 2020. the following keywords and mesh terms consist of: "treatment" or "therapy" or "covid-19 drug treatment" or "covid-19 serotherapy" or "hydroxy chloroquine" or "antiviral agents" or "immunomodulation" or "plasma" were combined with "covid-19" or "severe acute respiratory syndrome coronavirus 2". the search strategy was attached to the supplementary section. the reference list of all identified documents was also scrutinized due to recognizing the surplus potential eligible studies. all types of studies i.e. randomized controlled trials (rcts), prospective or retrospective cohort studies, and the case series that investigated clinical outcomes and/or viral clearance among adult patients were included to conduct this study. all studies were carried out qualitatively and among them only controlled cohort survives and rcts were totally used to perform meta-analysis. meanwhile, studies with these characteristics were excluded: (a) duplicate publications (b) full text in non-english language (c) reviews, letters, conferences, case reports and correspondence (d) descriptive studies about various medications (e) recommendations and guidelines (f) about herbal medicine (g) about vaccines and (h) description on clinical and imaging findings. however, few articles which are still in press also picked out for the analysis to provide the aim of this study. other steps that must be taken into consideration are presented in fig. 1 . the outcomes of this study were the frequency of negative conversion cases, clinical improvements, mechanical ventilation demand, intensive care unit (icu) entry, and finally mortality. the standard treatment refers to the published guidelines and specialist experience which varies in different articles, and the proposed treatment refers to the kind of interest suggested in the included studies. data extraction standard forms including study characteristics (country, year, type of study), population characterization (total number of cases, sex ratio, mean age, coexisting conditions), intervention characterization (type of treatment provided, days from disease onset to clinical intervention), and outcomes (number of cases needed mechanical ventilation, number of cases need icu, number of cases with negative conversion, time to negative conversion, time to clinical improvement, and mortality) were filled independently by three investigators. discrepancies were resolved by the consensus and the final decision of the corresponding author [34] . clinical improvement was defined according to the sevenpoint ordinal scales as followed: 1, death; 2, receiving invasive mechanical ventilation; 3, receiving high-flow oxygen; 4, receiving low-flow oxygen; 5 or 6, breathing ambient air; and 7, discharging [35] . the methodological quality of the included studies was assessed independently by two reviewers using cochrane's risk of bias tool for rcts [36] , newcastle-ottawa quality assessment scale for controlled retrospective studies [37] , and nih quality assessment tool for case series [38] . we conducted a meta-analysis by utilization of stata software version 14.0. the dersimonian and laird randomeffects meta-analysis methods were used to calculate the relative risk (rr) with 95% confidence interval (cis) for the studies included in quantitative synthesis (cohort studies n =12, clinical trials n = 14) studies excluded due to lack of information (cohort studies n = 3, clinical trials n= 5, case series n= 11) fig. 1 flow diagram of the study selection process efficacy of interventions in rcts and controlled retrospective studies [39, 40] . in addition, cochrane's q-test and i 2 index were used for determining heterogeneity [41] [42] [43] . when i 2 index was lower than 50%, the fixed effect model was used and if i 2 index was higher than 50%, the random effect model was utilized [41, [44] [45] [46] [47] . publication bias was detected using egger's test [41] [42] [43] . at the 45 included studies were categorized in five groups including studies reporting the efficacy of (1) antimalarial agent [8, 48, 49] ; (2) antimalarial agent plus antibiotic [10, [50] [51] [52] [53] [54] ; (3) plasma therapy [11, [55] [56] [57] [58] [59] [60] ; (4) antiviral agents [14-16, 35, 49, 53, 54, 61-72] ; (5) immunomodulatory agents [12, [71] [72] [73] [74] [75] [76] [77] [78] [79] [80] [81] [82] [83] [84] . on the whole, 24 studies were performed in china, seven in italy, four in france, three in the u.s., two in korea, one in iran, one in hong kong and qatar, and two were conducted internationally in germany, hong kong, italy, usa, singapore, spain, taiwan japan, and france. two out of four studies evaluating hydroxychloroquine (hcq), four out of six studies evaluating hcq plus azithromycin (azm), six out of seven studies evaluating plasma therapy, four out of ten studies evaluating antiviral agents, and 11 out of 14 studies evaluating immunomodulatory agents reported crucially affirmative effects of intervention. the comparison of all these medical categories were summarized in supplementary material (table s1 ). quality assessment of included studies was also summarized in supplementary material (table s2, s3, s4) . . there was only one study on hcq plus azm excluded which ended up in treatment of all patients in both intervention and control groups (fig. 3) . there were 18 studies (2719 patients) reported data on mechanical ventilation. the overall pooled rr indicated that the interventions could not affect this demand (rr 1.16, 95% ci 0.87-1.54; i 2 = 73.5%). although, subgroup analysis illustrated decreased mechanical ventilation need after the administration of immunomodulatory agents (especially anakinra) (rr 0.75, 95% ci 0.31-1.81; i 2 = 38.2%) and antivirals (especially remdesivir and baloxavir marboxil) (rr 0.9, 95% ci 0.73-1.1; i 2 = 6.9%) with no significant difference. surprisingly, hcq in one study observed more incidence of mechanical ventilation in patients with covid-19 (rr 2.31, 95% ci 1.39-3.84). (fig. 4) . overall (fig. 6 ). the egger's test showed a significant publication bias in term of positive-to-negative conversion (coefficient = −2.71, p value <0.001) and clinical improvement (coefficient = −1.40, p value = 0.004). publication bias in other subgroups including despite a several months passed after the presentation of sars-cov-2 outbreak, no effective treatment has been submitted and there is still conflict on the efficacy of various treatments. in this pandemic situation, off-label prescription is rational and may lead to establish an effective clinical management strategy [85] . to evaluate the efficacy of current clinical managements against covid-19 we conducted a literature review focusing on patient outcomes. chloroquine (cq), an antimalarial 4-aminoquinoline, and its derivative hydroxychloroquine (hcq) have been used for the treatment and prevention of malaria and also autoimmune disorders such as lupus and rheumatoid arthritis due to anti-inflammatory properties [86] . this class of medications acts through some mechanisms against sars-cov-2 as follows [87] : prevent virus attachment to the host cell by reducing the glycosylation of ace2, inhibition of virus internalization and fusion with lysosomes by increasing the ph in these organelles, and block the production of interleukin-6 and other pro-inflammatory cytokines, which are key mediators of ards and cytokine storm. it was truly suggested that cq and hcq have beneficial effects in patients with covid-19 [48, 88] , although some other studies reported not only the ineffectiveness of cq or hcq but also their adverse effects in the patients with covid-19 [8, 89] . according to our qualitative synthesize, in terms of hcq with or without azm, the results were contradictory. it seems that the early administration of hcq would decrease the rate of hospitalized patient mortality in mild patients [52] . however, rosenberg et al., by the study of nearly 1000 patients (34% were moderate to severe patients) as the same our findings reported no benefit of hcq in this outcome [51] . although, only one study showed that hcq had superior ability in viral clearance, other outcomes were not affected by the administration of antimalarial agents or even deteriorated. we assumed that it might be due to the heterogeneity in the demographic and clinical characteristics of patients assessed in this study, as authors expressed that patients receiving hcq were more likely to be male, obese, and diabetic. some other studies were also reported the ineffectiveness of hcq [90] [91] [92] . however, the small sample size of the related studies could not produce reliable conclusions. considering previous studies and our findings, hcq with or without azm does not seem to be effective in treating patients with severe covid-19. the current recommended antiviral agents are mainly based on previous experience showing clinical benefits in treating influenza, ebola, mers, sars, and other viral infections [93] . the efficacy of lopinavir/ritonavir (as an anti-hiv agent), arbidol, favipiravir, and remdesivir were mostly assessed in this category of medications. these agents share common mechanisms of action against covid-19, namely the inhibition of cell entry, rna replication process, and some other post-entry steps [18, 66, [94] [95] [96] . it was proposed that some antivirals, including neuraminidase inhibitors (e.g., oseltamivir), ganciclovir, acyclovir, and ribavirin, would be ineffective and therefore not recommended for rcts [18] . based on our literature review, there was no consensus on the efficacy of antiviral agents in patients suffering from covid-19. this may originate from the small sample size of some studies or differences in the severity of illness in the patient's population. meta-analysis results showed that antiviral therapy could significantly alleviate symptoms in patients with covid-19. however, in terms of negative conversion, icu entry, mechanical ventilation, and mortality, antiviral therapy had no significant protective effect. the observed relative ineffectiveness may be due to the partially long period of time between the onset of illness to treatment initiation, as the best time for antiviral therapy is at the initial stages of infection [97, 98] . although, the u.s. food and drug administration (fda) announced an emergency use authorization (eua) for remdesivir in severe hospitalized patients with suspected or confirmed covid-19 [99] , although its efficacy is controversial [100] . remdesivir may be a good drug of choice, considering its promising beneficial effect in preclinical and clinical studies [101] , to conduct robust rcts immediately after the onset of illness. given the lack of active vaccination or specific clinical managements, use of passive antibody therapy (convalescent plasma transfusions) could be of great value against covid-19 [102] . the attentions on cp have been increased as a valuable therapy due to collecting a large volume per session and frequent donations are possible without any impact on the donor's hemoglobin [103] . in order to have an effective cp infusion, donor plasma should be tested for antibody and neutralization activity. it seems that cp acts through viral neutralization, cellular cytotoxicity induced by antibody, activation of complement system, and phagocytosis but the exact mechanism of action has remained elusive [102] . although, almost all included studies on cp (in severe patients) reported its effectiveness in treating the patients, only one study investigated that there was no significant difference in time to clinical improvement compared to control group [55] . as the authors explained, it might be due to the heterogeneity of patients in the duration of the illness or the early termination of the trial [55] . in our study, cp was associated with a considerable beneficial effect in the negative conversion and clinical symptom improvements that was in accordance with the previous reports [56, 104] . despite the recommendations on the administration of cp in the early stage of illness, it would be effective even initiated in the late phase of viremia [105] . consequently, plasma therapy as a safe and attractive method with wide clinical benefits would be suggested in this pandemic for moderate to severe patients. cytokine storm, inflammation, and cell death are well known physiological consequences of respiratory viral infections related to oxidative stress [106] . immunomodulatory agents (e.g., corticosteroids, interferons (ifn), monoclonal antibodies, and janus kinase inhibitors) would alleviate the cytokine storm through different mechanism of actions, including interfere with binding of inflammatory cytokines to their receptors, inhibition of cytokine signaling pathway, and alteration of inflammatory cytokine gene expression to inhibit their production [107] [108] [109] [110] [111] . vahedi et al., in a retrospective observational study reported that inclusion of short-term and low-dose of prednisolone would provide clinical value in patients with covid-19 [112] . based on our literature review, immunomodulatory therapies were associated with significant protective effects against covid-19. in agreement with previous researches, our meta-analysis results showed that the administration of immunomodulatory agents (especially tocilizumab and anakinra) significantly decreased the mortality rate and ameliorate clinical symptoms in patients with covid-19 [113, 114] . besides, co-administration of immunomodulatory agents with antivirals might give physicians more time to provide supportive treatment for patients with covid-19 [115] . therefore, we suggest that immunomodulatory agents should be considered in severely ill patients and who needs icu admission or mechanical ventilation. to the best of our knowledge, this is the first systematic review and meta-analysis that focus on only the anti-covid-19 therapies from december 2020. we included available evidences from cohort studies and rcts in our meta-analysis and excluded case reports, descriptive guidelines, and poor studies with insufficient data. in the current pandemic situation, trials are still proceeding and there are few reliable studies in the literature in case of covid-19. although articles have become more valuable since may, it is not possible to determine an effective drug with certainty and it needs more times to be clarified. different variables such as the severity of illness, underlying diseases, the hospital length of stay, experienced protocols and guidelines, specialists' point of view in choosing therapeutic strategy against covid-19 would affect the patients' outcome. moreover, in some studies multi treatments were administered in critically ill patients which provide the complex conditions for comparing the effect of medications. we suggest highly qualified studies such as large double blind rcts and cohort studies to evaluate the efficacy of current therapeutics, after the pathogenicity of the disease was truly identified. this review could be helpful for the physician in guiding decisionmaking due to lack of high quality evidences. in the pandemic situation, there are still ongoing rcts that could not help physicians to clarify turnouts in the fields of potential managements, yet. the findings in the present study indicated that, all the interventions significantly reduced the mortality and remarkably increased clinical improvements. however, compared with comparators, interventions had no significant effect on negative conversion and mechanical ventilation demand. in subgroup analysis, some classes of medications, including immunomodulators and plasma therapy showed favorable outcomes. noticeably, due to some reasons such as heterogeneity of treatments, small sample size in some studies, incomplete outcomes of large reliable rcts we could not propose a potent management against covid-19. therefore, preforming large 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(sars-cov) infection potential therapeutic agents against covid-19: what we know so far baricitinib for covid-19: a suitable treatment? lancet infect dis tocilizumab: the first interleukin-6-receptor inhibitor the mechanism of action of a single dose of methylprednisolone on acute inflammation in vivo the clinical value of two combination regimens in the management of patients suffering from covid-19 pneumonia: a single centered, retrospective, observational study current status of potential therapeutic candidates for the covid-19 crisis favorable anakinra responses in severe covid-19 patients with secondary hemophagocytic lymphohistiocytosis cytokine storm and immunomodulatory therapy in covid-19: role of chloroquine and anti-il-6 monoclonal antibodies publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-354216-4khdcjed authors: sultan, shahnaz; altayar, osama; siddique, shazia m.; davitkov, perica; feuerstein, joseph d.; lim, joseph k.; falck-ytter, yngve; el-serag, hashem b. title: aga institute rapid review of the gi and liver manifestations of covid-19, meta-analysis of international data, and recommendations for the consultative management of patients with covid-19 date: 2020-05-11 journal: gastroenterology doi: 10.1053/j.gastro.2020.05.001 sha: doc_id: 354216 cord_uid: 4khdcjed abstract background multiple gastrointestinal (gi) symptoms including diarrhea, nausea/vomiting, and abdominal pain, as well liver enzyme abnormalities have been variably reported in patients with covid-19. the aga) institute clinical guideline committee and clinical practice updates committee performed a systematic review and meta-analysis of international data on gi and liver manifestations of covid-19. methods we performed a systematic literature search to identify published and unpublished studies using ovid medline and pre-print servers (medrxiv, litcovid, and ssrn) up until april 5 2020; major journal sites were monitored for us publications until april 19 2020. we analyzed the prevalence of diarrhea, nausea, vomiting, and abdominal pain as well as lft abnormalities using a fixed effect model and assessed the certainty of evidence using grade. results we identified 118 studies and used a hierarchal study selection process to identify unique cohorts. we performed a meta-analysis of 47 studies including 10,890 unique patients. pooled prevalence estimates of gi symptoms was diarrhea 7.7% (95% ci 7.2-8.2), nausea/vomiting 7.8% (95% ci 7.1-8.5), abdominal pain 2.7% (95% ci 2.0-3.4). most studies reported on hospitalized patients. the pooled prevalence of elevated liver abnormalities was: ast 15.0% (13.6 to 16.5) and alt 15.0% (13.6 to 16.4). when analyzed comparing data from china to studies from countries other than china, diarrhea, nausea/vomiting, liver abnormalities were more prevalent outside of china with diarrhea reported in 18.3% (16.6 to 20.1). isolated gi symptoms were rarely reported. we also summarized of the gl and liver adverse effects of the most commonly utilized medications for covid19 conclusions gi symptoms are associated with covid-19 in less than 10% of patients. in studies outside of china, estimates are higher. further studies are needed with standardized gi symptoms questionnaires and lft checks on admission to better quantify and qualify the association of these symptoms with covid-19. based on findings from our meta-anlaysis, we make several best practice statements for the consultative management of covid-19. the coronavirus family has four common human coronaviruses (229e, nl63, oc43, hku1) associated with the common cold, and three strains are associated with pneumonia, respiratory failure, and death, including sars-cov (severe acute respiratory syndrome coronavirus), mers-cov (middle eastern respiratory syndrome coronavirus), and sars-cov-2 (severe acute respiratory syndrome coronavirus 2). 1 the novel coronavirus, sars-cov-2, was first described in december 2019 in patients in wuhan, china who developed severe pneumonia, and was named coronavirus-19 disease (covid-19) by the world health organization on february 11, 2020. 2 covid-19 is estimated to have resulted in 2,896,633 cases in 185 countries with 202,832 deaths as of april 25, 2020. 3 was first reported in the united states (u.s.) on january 20, 2020 and accounted for a total number of 938,154 cases and 53,755 deaths as of april 25, 2020. in the u.s., an early analysis of the first 4,226 cases from the centers for disease control and prevention (cdc) as of march 16, 2020 , revealed estimated rates of hospitalization (20.7-31 .4%), intensive care unit (icu) admission (4.9-11.5%), and case fatality (1.8-3.4%). 4 more recent data from a cohort of 5700 hospitalized patients with covid-19 within a large healthcare system in new york city revealed common comorbidities including hypertension (56.6%), obesity (41.7%), and diabetes (33.8%), and reported that 373 (14.2%) of patients required treatment in the intensive care unit, and 320 (12.2%) received invasive mechanical ventilation, in whom the mortality was 88.1% (282/320)]. 5 ace2 (angiotensin converting enzyme ii), believed to be the target entry receptor for sars-cov2, is abundantly expressed in gastric, duodenal, and rectal epithelia, thereby implicating ace2 as a vehicle for possible fecal-oral transmission. 6 furthermore, ace2 receptors may be expressed in hepatic cholangiocytes 7 and hepatocytes 8 , potentially permitting direct infection of hepatic cells. non-gi symptoms for covid-19 include fever, cough, shortness of breath, chills, repeated shaking with chills, muscle pain, headache, sore throat, and new loss of taste or smell. gastrointestinal (gi) symptoms, including anorexia, nausea, vomiting, abdominal pain, and/or diarrhea have been reported in patients with covid-19. additionally, abnormal liver enzymes are also observed. 9 however, significant heterogeneity has been observed in the reporting of gi and liver symptoms across settings. 10 the most commonly reported gi symptom in covid-19 is diarrhea, which has been reported in 1-36% of patients. 10 an updated characterization of the gi and liver manifestations across global settings is needed to further inform clinical guidance in the management of patients with covid-19. we seek to summarize international data on the gl and liver manifestations of covid-19 infection and treatment. additionally, this document provides evidence-based clinical guidance on clinical questions that gastroenterologists may be consulted for. this rapid review document was commissioned and approved by the aga institute clinical guidelines committee (cgc), aga institute clinical practice updates committee (cpuc), and the aga governing board to provide timely, methodologically rigorous guidance on a topic of high clinical importance to the aga membership and the public. this rapid review and guideline was developed by gastroenterologists and guideline methodologists from the two aga committees. the guideline panel worked collaboratively with the aga governing board to develop the clinical questions, review the evidence profiles and develop the recommendations. panel members disclosed all potential conflicts of interest according to the aga institute policy. the target audience of this guideline includes gastroenterologists, advanced practice providers, nurses, and other health care professionals. patients as well as policy makers may also benefit from these guidelines. these guidelines are not intended to impose a standard of care for individual institutions, healthcare systems or countries. they provide the basis for rational informed decisions for clinicians, patients and other health care professionals in the setting of a pandemic. we conducted a systematic literature search to identify all published and unpublished studies that could be considered eligible for our review with no restrictions on languages. in the setting of a pandemic with exponential increases in published and unpublished studies, our search strategy was multifaceted. to capture relevant published articles, we electronically searched ovid medline from inception to march 23, 2020 using the mesh term developed for covid-19. we then searched the following platforms on april 5th, 2020 for additional published and unpublished studies: medrxiv, litcovid 11 , and ssrn. an additional unpublished article in peer review was obtained through personal communication. for studies from the us, we continued to monitor major journals for additional publications until april 19 th , 2020. independent screening of titles and abstracts was performed by one reviewer (pd, ss, jf) to identify potential studies for inclusion. a second reviewer (oa) subsequently reviewed the full-text articles and identified articles for inclusion. any disagreements about inclusion were resolved through discussion. we incorporated any studies (prospective or retrospective) that reported on patient characteristics and symptoms of interest. for studies published in chinese, we used google translate to assess for potential inclusion and for data extraction. due to concerns about inclusion of the same patients in different publications, we used a hierarchical model of data extraction to minimize double counting of patients across similar institutions with coinciding dates of study inclusion. we aimed to identify and include data from the largest possible cohort from each location or hospital. 12 thus, data extraction was performed using a two-step process. the initial data extraction focused on data elements for study and patient characteristics. subsequently, we identified certainty evidence and observational studies start out as low certainty evidence but can be rated down for several reasons: risk of bias, inconsistency, indirectness, imprecision, and publication bias. additionally, evidence from well conducted observational studies start as low certainty evidence but can be rated up for large effects or dose-response. 14 a meta-analysis of prevalence of gi and liver abnormalities was performed using meta 4.11-0 package in r version 3.6.3 software. 15, 16 the prevalence was expressed as a proportion and 95% confidence interval (95% ci). we used the fixed effects model using the freeman-tukey double arcsine transformation method for proportions. this is the preferred method of transformation and avoids giving an undue larger weight to studies with very large or very small prevalence. 17, 18 the i 2 statistic was used to measure heterogeneity. 19 to explore heterogeneity, we performed subgroup analyses based on the location (region) of the study and clinical settings (inpatient versus outpatient). to assess the robustness of our results, we performed sensitivity analyses by limiting the included studies to those that clearly reported the presence of symptoms at initial presentation. a total of 57 studies were ultimately selected for complete data extraction; 56 from our search and one additional manuscript (under review) was included to provide more data on a us cohort. see supplement figure 1 for prisma flow diagram. of the 57 selected studies, 47 studies reported on unique patients based on hospital name (with no duplication of cohorts from the same hospital). an additional 10 studies were identified with potentially overlapping cohorts based on hospital name, but these were included if they provided unique information about a specific symptom (e.g., diarrhea at initial presentation when the larger cohort did not clearly state that it was at initial presentation). based on our comprehensive selection process, we believe that the included 47 studies reported data on 10,890 unique covid-19 patients. the majority of studies (70%) in our analysis were from china; these were selected out of 118 reports published or pre-published from china. see supplement figure 2 . the studies included mainly adults, although a few studies included a small proportion of pediatric patients. two studies reported on outpatients only, whereas the remaining 55 studies reported on hospitalized patients, or a combination of outpatients and hospitalized patients. based on our inclusion strategy: 55 (96%) studies provided information on any gi symptom and 32 (56%) studies reported any data on liver abnormalities. fewer studies, 21 (37%), provided information on underlying gi conditions. the overall certainty in the body of evidence was low. our confidence in the pooled estimates of prevalence was reduced because of concerns of risk of bias (selection bias, detection bias and attrition bias), heterogeneity of the tested patient populations (inconsistency), as well as issues of indirectness (the majority of studies included primarily symptomatic hospitalized patients instead of all patients with covid-19). additionally, most of the studies were retrospective cohort series and did not specify if consecutive patients were included in the analysis. other limitations included inconsistent assessment of symptoms and/or laboratory tests, missing data and/or inconsistent reporting of data, and insufficient follow up of the patients. these factors may have contributed to the heterogeneity of findings across studies. the i2 statistic ranged from 77% to 98% and was not completely explained by geographic location or by outpatient versus inpatient status. our study selection criteria prioritized including studies with diarrhea as a gi manifestation and avoiding overlap in populations, and therefore did not include a comprehensive set of studies reporting on stool shedding. a recently published systematic review by cheung (29%) stool specimens were positive for viral rna. four specimens with high copy numbers were cultured and electron microscopy was performed to detect live virus which was observed in the stool from 2 patients who did not have diarrhea. the authors concluded that although this does not confer infectivity, it raised the possibility of fecaloral transmission. 78 the small sample size of the reports that assessed the presence of live virus in stool combined with the conflicting findings limit our certainty in the evidence and thus the question of fecal-oral transmission remains unsettled. based on our inclusion strategy, 32 out of the 57 studies (56%) reported any data on liver abnormalities. 20 the overall prevalence of gi symptoms in context of covid-19, including nausea, vomiting, abdominal pain, and diarrhea, is lower than previously estimated. 10 it is important to note that the majority of studies were focused on hospitalized patients with covid-19, and the prevalence of diarrhea in patients with mild symptoms who were not hospitalized is not known. therefore, the reported prevalence rates may represent either an overestimate or underestimate. information about the frequency and severity of diarrhea symptoms was inadequately reported in the majority of studies. based on our analysis, among hospitalized patients, diarrhea as the only presenting symptom in the absence of other covid-related symptoms was very low. the majority of patients with diarrhea, nausea or vomiting also presented with accompanying symptoms typically associated with covid-19. in a handful of studies, diarrhea and nausea preceded the development of other covid-19 related symptoms. in a us casecontrol study of 278 covid-19 patients, patients with gi symptoms were more likely to have illness duration of ≥ 1 week (33%) compared to patients without gi symptoms (22%). this may have been attributable to a delay in testing. 47 therefore, in high prevalence settings, among patients presenting with new onset diarrhea, monitoring for the development of covid-19 symptoms and considering referring patients for covidtesting is reasonable especially if testing capacity is not limited. the cdc has recently expanded the criteria for covid-19 testing to include presence of olfactory and gustatory symptoms as triggers for testing, as these symptoms have been demonstrated to occur in up to 80% of patients. 79 diarrhea as an initial preceding symptom of covid-19 has not been included on the cdc symptom checklist. to more accurately inform our understanding of the true prevalence of diarrhea, nausea and vomiting as a manifestation of covid-19, it is critical to systematically collect information about onset of diarrhea, duration of symptoms and documentation of whether and how long symptoms of diarrhea, nausea and vomiting precede uri symptoms. therefore, we advise health care professionals and researchers to obtain a thorough review of systems, systematically inquire about respiratory and gi symptoms and ascertain information about exposure. there is presently inadequate evidence to support stool testing for diagnosis or monitoring of covid-19 as part of routine clinical practice. while stool shedding has been reported in a prior meta-analysis in 48.1% of specimens, 2 small case series showed conflicting findings about the presence of living virus in stool. 10, 32, 78 therefore, stool infectivity and transmission have not been confirmed. further studies are needed to determine whether isolated virus from stool specimens confers infectivity and determine the role of stool testing is in patients with covid-19. abnormal lfts were reported in approximately 15% of patients across the pooled studies but with variable reporting of mean or median values for the whole sample of patients. while the studies used in this analysis helped us to better understand the prevalence of abnormal lfts among hospitalized patients, lft abnormalities were not consistently reported across studies. also, many of the studies in this analysis did not report on how many patients had underlying liver disease and if these patients were at an elevated risk of having increased lfts in the setting of covid-19 infection. furthermore, diagnostic evaluation of abnormal lfts on admission was not routinely performed, such as testing for viral hepatitis or other etiologies. the available studies suggest that abnormal lfts are more commonly attributable to secondary effects (e.g., systemic inflammatory response syndrome, cytokine storm, ischemic hepatitis/shock, sepsis, drug hepatotoxicity) than primary virus-mediated hepatocellular injury. 7, 9, 80 however, liver histopathology from patients with covid-19 have revealed mild lobular and portal inflammation and microvesicular steatosis suggestive of either virally mediated or drug-induced liver injury. 81 in addition, some studies have revealed that abnormal lfts at hospital admission may be associated with a higher risk for severe covid-19 (or 2.73, 95% ci 1.19-6.3). 9 therefore, we advise checking baseline lfts in all patients on admission and monitoring of lfts throughout the hospitalization, particularly in patients undergoing drug therapy for covid-19 associated with potential hepatotoxicity. we additionally advise that all patients with abnormal lfts undergo an evaluation to investigate non-covid-19 causes of liver disease. there are currently no fda-approved routine treatments for covid-19. the fda has issued an emergency use authorization (eua) for three therapies: choloroquine or hydroxychloroquine, remdesivir, and convalescent plasma. 82 in china and japan, favipiravir has been approved for the treatment of covid-19. numerous medications are under investigation currently; the world health organization is currently spearheading a multinational, multicenter trial for the five treatments highlighted below. 83 we aim to provide a summary of the gl and liver adverse effects of the most commonly utilized medications for covid19 at this time irrespective of their efficacy. medication gi-related aes are summarized in supplement table 1 and 2 (direct evidence sources and indirect evidence sources. both chloroquines have reported infrequent gl (nausea, vomiting, abdominal pain, and diarrhea) adverse effects. 84, 85 the national institute of health (nih) livertox resource rates both drugs with likelihood score of d (possible rare cause of clinically apparent liver injury). 86 chloroquine is rarely linked to aminotransferase elevations or clinically apparent liver injury. in patients with acute intermittent porphyria or porphyria cutanea tarda, it can trigger a hypersensitivity attack with fever and serum aminotransferase elevations, sometimes resulting in jaundice. this is less commonly seen with hydroxychloroquine. such reactions are felt to be hypersensitivity reactions and there is no known cross-reactivity in liver injury between hydroxychloroquine and choloroquine. hydroxychloroquine is known to concentrate in the liver, thus patients with hepatitis or other hepatic diseases, or patients taking other known hepatotoxic drugs should exercise caution. moreover, cardiac conduction defects leading to clinically relevant arrhythmias are an important adverse effect of these medications. remdesivir limited data regarding gi aes are available, as phase iii trials are still underway. based on studies from ebola, there have been reports of elevated transaminases, although the severity and incidence has not been quantified. 87 there is one published case series (n=53) on compassionate use of remdesivir in covid-19. 88 in this study, the most common adverse effects were notably gl and hepatotoxicity. 5/9 (9%) of patients experienced diarrhea, and 12/53 (23%) of patients had reported elevations in hepatic enzymes associated with remdesivir. of the four patients (8%) who discontinued treatment prematurely, two of them were due to elevated aminotransferases. the combination lopinavir/ritonavir is fda-approved for the treatment of human immunodeficiency virus (hiv). more recently, it was utilized to treat mers and sars. there is one trial by cao et al which randomized 199 hospitalized patients with severe covid-19 to receive treatment to lopinavir/ritonavir (n=99) or placebo (n=100) for 14 days 89 gi adverse events were most common among those in the treatment group, and were the primary reason for medication discontinuation; of patients receiving lopinavir/ritonavir, there were 9.5% (9/99) with nausea, 6.3% (6/99) with vomiting, 4.2% (4/99) with diarrhea, 4.2% (4/99) with abdominal discomfort, 4.2% (4/99) with reported stomach ache, and 4.2% (4/99) with diarrhea. additionally, there were two serious adverse events of acute gastritis, which both lead to drug discontinuation. when lopinavir/ritonavir is used in patients with hiv, diarrhea is the most common gi ae (10-30%), greater prevalence among those receiving higher dose. other gi aes in hiv are similar to the cao rct, with nausea in 5-15% and vomiting in 5-10% of patients 90 see table 3 . the cao et al. rct did not show a significant increase in hepatotoxicity in the treatment compared to the control group. 89 however, in patients with hiv, there is a welldocumented known risk of hepatotoxicity, with liver injury severity ranging from mild enzyme elevations to acute liver failure. 91 moderate-to-severe elevations in serum aminotransferases, defined as more than five times the upper limit of normal, are found in 3-10%. 91 rates may be higher in patients with concurrent hiv and hcv co-infection. in some cases, mild, asymptomatic elevations are self-limited and can resolve with continuation of the medication, but re-challenging the medication may also lead to recurrence, and therefore, should be avoided when possible. acute liver failure, although reported, is rare. ritonavir has potent effects on cytochrome p450 and therefore affects drug levels of a large number of medications typically given in gi practices. there are two published studies on favipiravir in covid-19. the individual studies in our analysis were at high risk of bias. the majority of studies reported on cohorts of patients based on inclusion dates and did not specify if these were consecutive patients. there was an inconsistent assessment of symptoms and/or laboratory tests with missing data, and none of the studies reported if patients were systematically evaluated for gi symptoms on admission. most studies did not report on the duration of the gi symptoms preceding the presentation. when gi symptoms were reported, it was difficult to discern if these were isolated symptoms or if patients had also had concurrent typical covid-19 symptoms (e.g., fever cough, sob). lfts were mostly reported as the mean/median value of the entire cohort and without cut-off values for the institution. many of the studies did not report on underlying chronic gi or liver diseases. there was a lot of heterogeneity in our pooled estimates that could not be explained by our subgroup analysis based on geographic location. lastly, the data on prognosis was especially difficult to analyze due to insufficient follow up of the patients (the majority of the patients were still hospitalized at the time of publication). finally, there was no stratification of gi-related symptoms and severity of covid-19 or patient important outcomes, such as need for icu or survival. there may be additional limitations of our findings based on our analysis. due to concerns about overlapping cohorts, we used a hierarchical framework to identify unique cohorts based on the number of patients and the hospitals to analyze the prevalence of gi and liver symptoms. it is possible that we excluded relevant studies that provided more granularity regarding the gi and liver manifestations or had more rigorous methodology which may lead to an over or underestimation of the pooled effect estimates. however, we have high confidence that we were able to eliminate the counting of some patients in more than one report by using our selection framework, unless they were transferred from one hospital to another. an important strength of this study is the appropriate statistical analysis used to pool proportions. we also reviewed grey literature from pre-publication repositories which allowed us to include a large number of studies that have not been published yet, with data from a total of 10,890 unique covid-19 patients being included in this work. lastly, we tried to narratively describe studies that informed us on (i) the type of diarrhea symptoms (ii) whether diarrhea was reported as the only presenting symptom or (iii) diarrhea as the initial symptom that preceded other symptoms. based on our study selection process, we may have missed studies, including smaller case series that reported on this information, and studies that were published after our inclusion period, in light of the exponential number of studies in press, under review, and on pre-print servers. most of the information regarding gl aes come from indirect evidence from medications that are fda approved for other indications, such as the chloroquines and lopinavir/ritonavir. in particular, gl aes are poorly understood for both favipiravir and remdesivir, including the frequency and severity of aminotransferase elevations, and incidence of gl manifestations. as ongoing clinical trials complete regarding efficacy of therapy, additional data regarding gl aes will emerge. currently there is insufficient evidence on the impact of covid-19 on subgroups of patients, such as patients with inflammatory bowel disease, chronic liver disease, or liver transplant recipients on chronic immunosuppression. early data do not indicate excess risk among patients with ibd. [93] [94] [95] [96] [97] a number of international registries have been established that will provide extremely valuable information about covid-19 in these potentially vulnerable populations (www.covidibd.org; covidcirrhosis.web.unc.edu; www.gi-covid19.org). other clinical decisions including optimal medication management and treatment decisions are still under investigation. we encourage clinicians to contribute to these registries to further enhance understanding in these subpopulations. table 4 provides guidance for future studies of gi manifestations in patients with covid-19 or other similar pathogens. finally, peer-review remains critical to the process of disseminating information. journals should add resources to expedite reviews by increasing the number of editors and reviewers, shorten the review process, to maintain accuracy, high quality and details of the data reported, as well as to avoid overlap in patients between studies or multiple studies being published on the same cohort. 98 study design -a prospective inception cohort study is a favorable study design. -another study design that is informative especially when there is a need for rapid data evaluation is a retrospective inception cohort study. -enrollment of consecutive patients beginning at pandemic onset. -specific set of symptoms that are predictive of covid-19 infection, all symptoms should be systematically collected on presentation and before covid-19 diagnosis is established. • elicit typical uri symptoms (e.g., cough, shortness of breath, chest pain, fever) • inquire about less typical symptoms, such as gi specific symptoms: diarrhea, nausea, vomiting, and abdominal pain, and also other symptoms such as anosmia, dysguesia • describe the gi symptoms in details including initial versus late, concurrent vs. isolated, duration and frequency, prior history, and medication initiation relating to the onset of symptoms. -investigators should avoid: • undefined sampling (convenience sampling), including undefined time periods. • overlap of the same population with other publications, which can be done by coordinating efforts between the different departments within the institution. -investigators should consider stratification for gi comorbidities such as ibd, cirrhosis. -investigators should consider stratification by outpatients versus inpatients laboratory -standardized laboratory-confirmation should be based on nat (nucleic acid testing) for sars-cov-2 on respiratory specimen rather than relying on radiological suspicion on imaging studies which are less specific -liver function tests (lfts) should be obtained on admission and followed throughout the hospitalization. -changes of lfts should be reported as normal/abnormal and the cut-off for abnormal should be specified, rather than mean and median at the individual patient level. -the pattern of lfts abnormalities, hepatocellular vs cholestatic, should be reported as well as the evaluation performed to work-up the abnormalities. -when available, lfts prior to the development of the disease (baseline lfts) should be reported, and how they changed with the diagnosis of the disease and after the resolution of it should be accounted for. -report stool rna testing, when available, and presence of gi symptoms at the time of testing disease severity -use of standardized disease severity definitions, for example as per who-china joint mission 99 : • mild-to-moderate: non-pneumonia and mild pneumonia • severe defined as tachypnoea2, oxygen saturation ≤93% at rest, or pao2/fio2 ratio <300 mm hg • critical respiratory failure requiring mechanical ventilation, septic shock, or other organ dysfunction or failure that requires intensive care -patients can be stratified by: • disease severity and presence of gi symptoms • disease severity and lfts -symptoms and their duration prior to development of a severe stage of the disease should be reported. outcomes should focus on patient-important outcomes such as death, clinical improvement or disease worsening/ progression, hospital discharge; included reproducible clinical definitions (e.g., threshold reached for intubation); select sufficient follow up time to ensure outcome is obtainable. analysis should attempt to control for confounding variables; analysis of risk factors should include univariate followed by multivariate analysis to identify independent risk factors predicting more severe disease and poor outcomes *in the table, we specifically refer to covid-19 but this guidance applies to any future pathogen similar to covid-19 that presents as a viral illness with potential gi and liver manifestations. recommendations in this document may not be valid in the near future. we will conduct periodic reviews of the literature and monitor the evidence to determine if recommendations require modification. based on the rapidly evolving nature of this pandemic, this guideline will likely need to be updated within the next few months. the global covid-19 pandemic due to sars-cov-2 infection is associated with significant morbidity and mortality due to severe pneumonia, acute respiratory distress syndrome (ards), and multiorgan failure. although fever, cough, and shortness of breath remain the most common presenting complaints in affected individuals, emerging data suggest that non-pulmonary symptoms affecting the gi tract and liver may be observed. genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding clinical features of patients infected with 2019 novel coronavirus in wuhan, china an interactive web-based dashboard to track covid-19 in real time severe outcomes among patients with coronavirus disease 2019 (covid-19) -united states presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the evidence for gastrointestinal infection of sars-cov-2 liver injury in covid-19: management and challenges liver 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characteristics of 28 cases of coronavirus disease in south korea high prevalence of concurrent gastrointestinal manifestations in patients with sars-cov-2: early experience from california epidemiological and clinical features of 291 cases with coronavirus disease 2019 in areas adjacent to hubei, china: a double-center observational study clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study a report of clinical diagnosis and treatment of nine cases of coronavirus disease 2019 hypokalemia and clinical implications in patients with coronavirus disease characteristics and outcomes of 21 critically ill patients with covid-19 in washington state the cross-sectional study of hospitalized coronavirus disease 2019 patients in xiangyang, hubei province clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china detection of sars-cov-2 in different types of clinical specimens clinical features of covid-19-related liver damage pathological findings of covid-19 associated with acute respiratory distress syndrome food & drug administration solidarity" clinical trial for covid-19 treatments clinical and research information on drug-induced liver injury. bethesda (md) controlled trial of ebola virus disease therapeutics compassionate use of remdesivir for patients with severe covid-19 a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 kaletra (lopinavir and ritonavir) tablets and oral solution [prescribing information clinical and research information on drug-induced liver injury. bethesda (md) experimental treatment with favipiravir for covid-19: an open-label control study the risk of sars-cov-2 in immunosuppressed ibd patients. crohn's & characteristics and prognosis of patients with inflammatory bowel disease during the sars-cov-2 pandemic in the basque country (spain) aga clinical practice update on management of inflammatory bowel disease during the covid-19 pandemic: expert commentary management of patients with crohn's disease and ulcerative colitis during the covid-19 pandemic: results of an international meeting uneventful course in ibd patients during sars-cov-2 outbreak in northern italy will the quality of research remain the same during the covid-19 pandemic? report of the who-china joint mission on coronavirus disease 2019 (covid-19). available at 33%) compared to patients without symptoms (22%) presence of gi symptoms (diarrhea or nausea/vomiting) was associated with a 70% increased risk of testing positive age: m 61 ± 18 gender: 42.3% females gi/liver comorbidities: 1.6% ibd, 3.0% chronic liver disease, 2.4% solid organ transplant. disease severity: nr diarrhea: 22.1% (234) present on admission 7% (67/768) and outpatients 8.2% (24/291). nausea: 15.3% (168) present on admission inpatients 16.0% (123/768) and outpatients 15.5% (45/291). abdominal pain: 6.6% (72) age: m 64 (range 48-75) gender: 14% females gi/liver comorbidities: nr disease severity: nr diarrhea: 23.8% (5) present on admission nausea or vomiting survival: 2.6% died, 11.4% still hospitalized inclusion: inpatients (n=35) and outpatients (n=2) with covid-19 confirmed based on rt-pcr age: median 42 (range 2-81) gender: 34 gi/liver comorbidities: nr disease severity: nr n: 295 survival: 1.0% died inclusion: all individuals with covid-19 (both outpatients and inpatients) age: m 47 (range 0-94) gender: (approximately) 50% female comorbidities: nr disease severity: nr diarrhea: 16.3% (48) nausea/vomiting: 11 number of patients; rt-pcr, real time reverse transcription polymerase chain reaction key: cord-353330-j00jj2og authors: rej, robert title: clinical chemistry through clinical chemistry: a journal timeline date: 2004-12-01 journal: clin chem doi: 10.1373/clinchem.2004.042820 sha: doc_id: 353330 cord_uid: j00jj2og the establishment of the modern discipline of clinical chemistry was concurrent with the foundation of the journal clinical chemistry and that of the american association for clinical chemistry in the late 1940s and early 1950s. to mark the 50th volume of this journal, i chronicle and highlight scientific milestones, and those within the discipline, as documented in the pages of clinical chemistry. amazing progress has been made in the field of laboratory diagnostics over these five decades, in many cases paralleling—as well as being bolstered by—the rapid pace in the development of computer technologies. specific areas of laboratory medicine particularly well represented in clinical chemistry include lipids, endocrinology, protein markers, quality of laboratory measurements, molecular diagnostics, and general advances in methodology and instrumentation. in this overview, i have selected numerous highlights and representative articles illustrating advances in the practice of clinical chemistry as they appeared in the pages of this journal, and i have placed them in historical perspective by juxtaposing them with contemporaneous events in the broader world. i was guided by both the citation frequency of papers that had significant impact and opportunities that a paper provided to exemplify developments in technology, instrumentation, and medicine of the day. this journal timeline is not intended to be a detailed history of the journal, as many facets of our heritage have already been reported (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) . in reviewing nearly 100 000 pages of the journal, i was again struck by how much has changed, yet how much has remained the same (1 ) . over the years, many papers were devoted to general topics still very much of interest to our readers today: lipids, endocrinology, protein markers, quality of results, and advances in methodology. of course, much has also gone the way of high-button shoes and 5¢ coffee, such as thymol flocculation tests and measurement of protein-bound iodine. the development of the field of laboratory diagnostics can be seen in tracing the evolution of figures within papers, from the large number of photographs and hand-drawn diagrams of glassware that were characteristic of the first years of publication to displays of results from devices, rather than the devices themselves. i was occasionally amused by the now-quaint spellings of "technic" and "computor", as well as the liberal use of the plural "serums". the aacc annual meeting played a central role over the years, with names of speakers, awardees, and their abstracts and biographies printed as regular or supplemental pages. review of those entries will help to further document the interesting topics of the day, as well as to uncover such-today politically incorrect-entries as "ladies programs". those days, however, also boasted hotel rooms with daily rates of $7.50 in santa monica and $8.50 in boston; "charming" pictures of meeting venues also graced our pages. many of today's efforts at standardization and harmonization were more than foreshadowed in several seminal papers appearing in this journal during the 1960s and 1970s; perhaps if more attention had been paid to these papers when they were published three or four decades ago, current standardization efforts might not be so necessary, or at least not so difficult and costly in their implementation. another theme that often appeared was the role of the profession of medical laboratorians and relationships among professional societies; some of the rhetoric makes for more-thaninteresting reading that borders on voyeurism. the give and take in correspondence regarding various view points on the various issues of the day (13 ) also seemed to contain far more spleen than the tamer exchanges that are encountered today. nonetheless, it betrays an enthusiasm that can be admired whichever side one might have supported. i was also struck by the specific "personality" of the journal under each of its three editors as it evolved and developed. although they appeared on our mastheads under differing titles, their role clearly match that of "editor-in-chief" in other publishing circles. it may be happenstance that their tenures were contemporaneous with reasonably defined advances and achievements in the field: "managing editor" appleton (1955) (1956) (1957) (1958) (1959) (1960) (1961) (1962) (1963) (1964) (1965) (1966) (1967) (1968) (1969) with the period establishing the discipline as we know it today and with the automation of classical chemistry procedures; "executive editor" king (1970 king ( -1990 coincided with advances in immunoassay, computer-assisted techniques, and new instrumentation; and our current adjectiveless "editor" bruns (1991-) has been coeval with applications of molecular biology and evidence-based medicine. the journal has benefited greatly from the occupancy of the editor's chair by these three; a history of the journal's leadership appears elsewhere (12 ) . another theme that emerged in my review was the rapidity with which clinically useful procedures put major scientific discoveries to use. there are many methods and clinical applications described in our pages that swiftly followed the publication of major biomedical findings (many of which led to nobel prizes). the first research papers describing the structure of hemoglobins, immunoassays, hplc, gc/ms, monoclonal antibodies, pcr, ms/ ms, etc. were followed in very short order by a multitude of applications of the knowledge in our pages. predicting the future is tricky business. in 1967, a us senate subcommittee reportedly heard testimony forecasting that, by 1985, americans would work 22 hours each week, 27 weeks a year, or that they would retire at age 38 (14 ) . if only that had come to pass! on the other hand, some true visionaries got it just about right. "i have not been reading science fiction," wrote david seligson in 1962, on the future of clinical chemistry in these pages (15 ) . he continues: the time will come when blood is sent from a hospital to a large receiving center-that is, a laboratory which does large numbers of special analyses automatically and continually, day and night, weekends and holidays . . . special instruments can sort, analyze, punch out answers, and return reports. even the latter, the report, will probably disappear in our new way of life because we shall have instruments which identify samples, analyze them, and electronically enter the result into a computer. the latter could be as much as 100 miles away. . . . our laboratory instruments will feed the data into the computer and the computer will convert it to a final report and store the information. a physician who wishes to know the electrolyte values for his patient will not call the laboratory, he will tell the computer what he wants and the computer will direct a typewriter which will give him the information at the rate of 1000 lines per minute. the same information can be requested 10 times in one hour without irritating the laboratory secretaries or anyone else. furthermore, the laboratory will also have a computer outlet so that serial data on any patient can be observed for fluctuations. the clinical chemist will be able to get any information he needs in seconds without going to his own files or to the record room. there will be no useless files or the wasted effort of unnecessary searches. the computer will not lose data; the intern will not carry the precious report in his pocket where no one can find it. the computer will serve the laboratory in other ways too. it will provide automatic programs and will turn on and off the machines of the laboratory. it will digitalize data and provide direct readout of final answers. it will provide a new dimension for the clinical chemist. pretty remarkable insight, considering not all that much in the way of automation existed in medical laboratories four decades ago and that there were only 15 computers in the entire us in 1955, just 7 years before his commentary was written. admittedly, these prescient comments are rather atypical for our pages; the journal has generally been filled with factual and useful information that advances our knowledge and profession in an incremental fashion. i was both rather surprised and more than slightly disappointed that there was precious little in the way of extravagant or, even better, dystopic, predictions of "clinical chemistry of the future" to regale the readers of this overview. as predicted by seligson over 40 years ago (15 ) , computers have had a powerful role in clinical chemistry, as in most other disciplines. as we look back on 50 years of articles, the advances in laboratory medicine in many ways parallel the spectacular achievements in the semiconductor and computer fields: ever faster/better/cheaper. in the last decade, computers and the internet have played a dominant role in the dissemination of scientific information. our journal was one of the first to embrace these technologies, and it went "online" in 1998 with full content available back to 1997. abstracts of articles also were accessible for the period 1975-1996, and authors and titles of articles were listed for the period 1965-1974. this too will change. in the very near future, the full content of clinical chemistry, from volume 1, page 1 up to the current issue will be made available online. with this occurrence of a totally electronic version, i take a fair degree of gratification in imagining that i may well be the last person to have browsed through all 50 years of clinical chemistry in its 200-kg paper incarnation (fig. 1 ). although librarians, and atavists of all ages, may bemoan the eventual demise of the medium of choice for the past few hundred years, i shall not be among them. this project has more than reinforced my leanings toward the obsolescence of a very inefficient vehicle for communicating data, ideas, and information. the hundreds of decaying, amber-colored pages that i reviewed also challenge the idea that electronic is ephemeral and that paper is permanent. although large parts of the world remain technologically unconnected, i am confident that access to all of the information in our pages will be facilitated in those regions as a result of these initiatives. obtaining the paper copy of this, and other, journals is still impossible in many laboratories around the globe. although internet access may not be universal, access to the electronic version will be far easier-and less expensive-than is access to the print copy. this journal, and others, have shown their commitment to wide dissemination of the information in their pages by making content available without charge to institutions in developing countries (16, 17 ) . the sightings of cyber cafés in remote regions of the planet attest to the view that access to information will be increasingly electronic. in many respects, an even greater "digital divide" exists regarding access to the older literature; if information is not available electronically, it is often ignored. review of the past 50 years of this journal has underscored for me the importance of the fact that every advance is based on the findings of previous work. many today may think that use of mass spectrometry for newborn screening is a relatively new application, but this use was already described in 1972 (18 ) . with the electronic republication of the first four decades of clinical chemistry, access to many of the seminal articles in the field will be instantly available to all readers. i hope that the sampling from the journal in this timeline will inform, and occasionally amuse, and that you will be persuaded to explore the vast archive that is scheduled to be available at your desktop early in 2005. like as the waves make towards the pebbled shore, so do our min hasten to their end; each changing place with that which goes before, in sequent toil all forwards do contend. vol. 1, number 1. aacc establishes a bimonthly scientific journal-clinical chemistry-"to raise the level at which chemistry is practiced in the clinical laboratory; to stimulate the development of new methods for use in the clinical laboratory; to encourage those engaged in this field to pursue advanced studies so as more effectively to render service to the public; and to create and maintain a forum where clinical chemists may exchange ideas and information concerning their scientific, technical and professional problems." the first volume comprises some 430 pages. a multinational study of the effects of diet on serum lipid concentrations suggests the benefits of a mediterranean diet. the authors understatedly-but correctly-infer that the mechanisms by which diet affects blood lipids "must be complex". keys the role of serum lipoproteins in atherogenesis is at an early stage of development, and new analytical tools are described. the analytical variation of the newly described methods is said to be lower than "spontaneous intraindividual variability". qc for me. "[it] seems very likely that many more laboratories will organize their own systems of quality control within their own walls. there is also every indication that more countries are about to commence schemes of issuing certified samples". wootton id. standardization in clinical chemistry. clin chem 1957; 3:401-5. dry with a twist. the first routine application of reagents in a dry chemistry strip also introduces an enzyme catalyzed reaction: glucose oxidase replaces the widespread alkaline copper reduction test. clinical chemistry at a crossroads. the role of laboratory professionals and their accreditation and licensure are reviewed, and a position paper is issued; licensure is advocated as the "quality of laboratory service being abstracts make their appearance in the journal at the start of each article rather than as a final "summary" as in earlier volumes. the roles of the laboratorian and the status of the profession of clinical chemistry were covered extensively in the first 10 volumes of the journal. volume 7 had more than its share of coverage, and readers interested in the topics of concern of the day are directed to clin chem 1961;7:75-91;303-7;421-2 for a comprehensive overview. move over dr. karmen. the "international unit" is born as the preferred manner for expressing catalytic activity of enzymes (clin chem 1961;7:199). serum as a "standard"? say it isn't so. the role of reference materials in the calibration and quality control of laboratory assays is examined. calibration using serum-based materials is criticized as substituting "compensation" for reliability. klugerman not another enzyme method! lipase measurement by turbidimetry decreases analysis time from 3 h to 20 min. vogel wc, zieve l. a rapid and sensitive turbidimetric method for serum lipase based upon differences between the lipases of normal and pancreatitis serum. clin chem 1963;9:168 -81. tonks' formula. the quality of laboratory testing is examined by use of an approach based on biological variability. tonks proposes the formula, which will eventually become eponymous, that analytical variability should be less that 25% of biological variability ("1/4 of the normal range"). according to this criterion, more than 40% of 4762 results obtained in an interlaboratory survey are considered unacceptable. tonks db. a study of the accuracy and precision of clinical chemistry determinations in 170 canadian laboratories. clin chem 1963;9:217-33. more on urea. diacetyl monoxime is used to quantify urea. coulombe jj, favreau l. a new simple semimicro method for colorimetric determination of urea. clin chem 1963;9:102-8. pbi was a high-volume test. protein-bound iodine assays are automated. stevens co, levandoski ng. automation of protein-bound iodine determination. clin chem 1963;9:400 -7. benotti j, benotti n. protein-bound io-dine, total iodine, and butanol-extractable iodine by partial automation. clin chem 1963;9:406 -16. clinical chemistry to appear monthly. the price of subscriptions to the journal will be increased by $2.00 per year to $8.00 per year to cover anticipated increases in expenses with proposed monthly publication. julius sendroy is elected to chair of the board of editors as harold appleton was named to the new position of managing editor (clin chem 1963;9:640 -2). washington-to-moscow "hot line" communications link opens, designed to reduce risk of accidental war. us president kennedy is shot and killed by a sniper in dallas; lyndon b. johnson becomes president the same day. there are 15 000 us military advisers in south vietnam. the first "push-button" telephones are introduced. simultaneous automation. the first multichannel analyzer to perform eight determinations simultaneously is described. the analyzer records directly on calibrated paper, providing an "immediately usable form". one operator can perform 960 individual tests per day, equal to the output expected per person in a month with manual techniques. skeggs lt, hochstrasser h. multiple automatic sequential analysis. clin chem 1964;10:918 -36. calcium and phosphorus: a completely automated flow system. kessler g, wolfman g. an automated procedure for the simultaneous determination of calcium and phosphorous. clin chem 1964;10:686 -703. tyrosine and phenylalanine method helps to identify newborns with phenylketonuria wong p, et al. micromethods for measuring phenylalanine and tyrosine in serum. clin chem 1964;10:1098 -104. let the cards fall where they may. a notched card system organizes reprints. over 800 key words can be used. weissman n. a punched-card reference system for biochemists. clin chem 1964;10:214 -23. calcium. atomic absorption spectroscopy is applied to determination of serum calcium. the method is claimed to be the "method of choice". zettner a, seligson d. application of atomic absorption spectrophotometry in the determination of calcium in serum. a practical method is developed, suitable for screening of patients before anesthesia or after exposure to organophosphates or nerve gas. garry pj, routh ji. a micro method for serum cholinesterase. clin chem 1965;11:91-6. a punch card system for the storage and retrieval of laboratory data is described. a day's results required 2000 cards, which were processed in batches at the end of the day. nonetheless, introduction of the system profiles in serum. the biochemical profile is born. multichannel analyzers allow 10 simultaneous determinations on ͻ1 ml of serum at a rate of 60 specimens per hour. results appear on five two-pen recorders. "a very high level of preventive maintenance is required continuously." acceptance by physicians is "enthusiastic". johnson. the citation recognized his work as a pioneer in "the exact science of clinical chemistry, a specialized branch of biochemistry, represented by a profession whose members render most important support to clinicians in the diagnostic and prognostic aspects of their work in treating patients." clin chem 1966;12:453. a slippery slope? the trend to purchased reagents accelerates; a policy for "reagent sets and kits" is published (clin chem 1966;12:43-4). the semiautomated pipette is devised. "people with little or no background in laboratory work can make accurate pipettings after a short practice period." harrison nb. semiautomatic pipetting device (the governor pipet) for clinical chemistry procedures. clin chem 1966;12:890 -3 the great proletarian cultural revolution begins in china. metropolitan opera house opens in lincoln center, new york city. the first episode of the science fiction television series "star trek" airs. what is a standard? a seminal report discussing standards, standardization, reference materials and methods, and definitive methods is published. the report has its origins in the aacc "committee on standards and controls"; many issues are relevant lims arrives. the benefits of a newly implemented laboratory information system include the ability to use punch cards for requisitions and the issuing of patientsummary reports for 12 consecutive days or sets of results. the system was implemented on an ibm 1440 with "a core memory of 8k". cillo aa. a simplified, economic, working "computerassisted laboratory information system" (calis oak ridge conference. the journal publishes the proceedings of the "second annual conference on automated, high-resolution analyses", a meeting that evolved into the aacc oak ridge conference. topics include such forward-looking topics as miniature photometers for liquid chromatography, resolution of overlapping peaks by use of an on-line computer, multicolumn chromatography with computerized readout, two-dimensional thin-layer chromatography, separation of nucleic acids by high-resolution liquid chromatography, and analyses by electron spectroscopy (clin chem 1970;16:623-725). a new spin on analyses. the centrifugal analyzer is introduced to medical laboratory applications. immediate reading and following of reaction kinetics make practical the use of rate measurements for analyses that were formerly carried out only as reactions that reached near end-point or equilibrium. interferences that required deproteinization or other pretreatments were obviated. fabiny dl, et al. hard to believe that they didn't before. the fda is given regulatory responsibility for in vitro diagnostic products (clin chem 1973;19:1425-6). clinical chemistry as an "industry". dr. king muses: for better or worse, like it or not, the "compassionate science" is becoming more and more indistinguishable from general motors in its approach to the "customers," primarily of course as a result of quantum leaps in automation technology. the two major current trends foreseen for clinical chemistry in the united states are (a) a greater demand for "stat" instruments and (b) a demand for high-volume profiling machines. as an example of the latter, metpath, a commercial laboratory whose revenues reportedly increased by 45% (to $16.15 million) from 1976 to 1977, found it necessary to purchase four autochemist analyzers, and has ordered five more ($500 000 each, 5000 samples/day capacity each). this example, not typical, illustrates that clinical chemistry increasingly is filing the popular image of big business, complete with mergers, acquisitions, diversifications and all its other accoutrements. the major commercial laboratories are growing at what one official called an "absurd" rate, with pretax earnings approaching 12% and steadily rising: not surprisingly, this gives the proprietors reason to expect even closer scrutiny by the federal government (clin chem 1977;23:1956 -7). the world's last known case of smallpox appears in somalia. the number of hosts on arpanet exceeds 100. british airways inaugurates regular supersonic service on the concorde. now on film! an automated, drychemistry system is described and applied to several clinically useful analytes in serum. curme hg, et al. 1980) . other ifcc recommendations include renaming some common analytes: "carbamide" is preferred to "urea", "creatininium" to "creatinine", and "adrenalinium" to "epinephrine". editor king doubts that us clinical chemists will soon adopt these recommendations (clin chem 1979; 25:1989 from the editor's desk: "one of the greatest technological advances since sliced bread, in our view, is the word-processor, by which we mean a typewriter with a "memory," in which pages and pages of material can be stored and called forth. if the typist has a word processor, making corrections involves minutes as opposed to hours, and no brand-new errors introduced . . . [i]f you have access to such a wondrous machine, by all means lose no opportunity to utilize it. all of our lives will be happier" (clin chem 1982; 28:2005) . when was the last time you've seen these words? ifcc neologisms promulgated: entic, areic, massic, baric, and ergatic (clin chem 1982;28:1438). clinical chemistry's circulation is 13 682. harold appleton, the first editor of the journal, dies. argentina invades the falkland islands, and britain steps in to protect its territory tcp/ip communication is defined. the first computer virus, elk cloner, is written by 9th grader rich skrenta. another spin on the immunoassay ball. the latex immunoassay, a nonisotopic method based on agglutination by protein of calibrated latex particles coated with a specific antibody, is described. bernard am, lauwerys rr. continuous-flow system for automation of latex immunoassay by particle counting. clin chem 1983;29: 1007-11. ca 19-9. a carbohydrate antigenic determinant that is increased in sera from patients with adenocarcinomas is discovered and measured by a radioimmunometric sandwich assay. del villano bc, et al. radioimmunometric assay for a monoclonal antibody-defined tumor marker, ca 19-9. clin chem 1983;29:549 -52. get the phenols out. because phenolic free radicals can cause anomalous results, a method is proposed that uses proteinase k and ethanol and obviates the use of phenol. buffone gj, darlington gj. isolation of dna from biological specimens without extraction with phenol. clin chem 1985;31:164 -5. put the phenols back in! certain phenol derivatives are found to enhance light emission from luminol by ͼ1000-fold. the enhanced system enables a rapid, sensitive assay; it is applied to immunoassays for hcg, digoxin, and factor viii-related antigen. thorpe gh, et al. phenols as enhancers of the chemiluminescent horseradish peroxidase-luminol-hydrogen peroxide reaction: application in luminescence-monitored enzyme immunoassays. clin chem 1985;31:1335-41. clinical chemistry publishes guidelines that outline the requirements for hardware, software, and program design to be used in the immunoassay laboratory. nmr is used to detect, identify, and study the major normal and abnormal organic acid metabolites in urine from patients. the technique requires ͻ1 ml, requires no extraction or derivatization, and takes ͻ10 min. the authors "believe that it is particularly suitable for the rapid and acute diagnosis of inborn errors of metabolism, especially the organic acidurias, and for acute pediatric clinical care." iles ra, et al. use of proton nuclear magnetic resonance spectroscopy in detection and study of organic acidurias. clin chem 1985;31: 1795-801. tpa. specific determination of tissue plasminogen activator, and its inhibitor, in plasma allows multiple samples to be assayed simultaneously within a few hours. a procedure for improving the specificity of elisa methods also was devised. chmielewska j, wiman b. determination of tissue plasminogen activator and its "fast" inhibitor in plasma. clin chem 1986; 32:482-5. ranby m, et al. age dependence of tissue plasminogen activator concentrations in plasma, as studied by an improved enzyme-linked immunosorbent assay. clin chem 1986;32:2160 -5. heterophile antibody interference. circulating human antibodies reactive with animal proteins are demonstrated and shown to be a previously unsuspected source of interference in immunoassays. boscato lm, stuart mc. incidence and specificity of interference in two-site immunoassays. clin chem 1986;32:1491-5. clinical chemistry publishes the proceedings of the 9th annual a.o. beckman conference for the first time; previously they were issued in book form (clin chem 1986;32:b1-106). the january issue inaugurates the appearance of technical briefs as a new format to "summarize findings that are of interest to a relatively limited audience". readers are directed to contact the authors for fuller details. briefs originally were of abstract length, with no references (clin chem 1986;32:2234). following the santa fe conference in may, king editorializes on the "national laboratory human gene library project" and other "big science" projects. king js. time to think big in human biology? clin chem 1986;32:1600 -1. one of the reactors at the chernobyl nuclear plant explodes. the first laptop computer is introduced by ibm. there are now ϳ5000 hosts on arpanet. oliver north, jr., tells a congressional inquiry that higher officials approved his secret iran-contra operations. azt wins fda approval for use in the treatment of aids. digging commences for the channel tunnel. a rapid and precise assay is developed for a marker of fibrotic disease. cocaine and pregnancy. analysis of urine from neonates born to cocaine-using women shows that benzoylecgonine persists in urine for up to 5 days after delivery. cocaine-exposed infants are shown to have neurobeecl. electrochemiluminescence is used as a signal system for immunoassay. the new technology uses no radioisotopes, has stable signaling compounds, has a large dynamic range, and has limits of detection that are in the femtomole per liter range. blackburn gf, et al. electrochemiluminescence detection for development of immunoassays and dna probe assays for clinical diagnostics. clin chem 1991;37:1534 -9. dna enzyme immunoassay. a method to specifically detect products of pcr is described. mantero g, et al. dna enzyme immunoassay: general method for detecting products of polymerase chain reaction. clin chem 1991;37:422-9. more on accuracy. laboratory data must constitute "timely and trustworthy information". clia'88 is said to place a high priority on test accuracy. bowers gn jr. clinical chemistry analyte reference systems based on true value. clin chem 1991;37:1665-6. clinical chemistry publishes a detailed summary of classified documents from the former german democratic republic (east germany) dealing with government promotion of the use of drugs in highperformance sports. the report details the use of anabolic steroids by athletes in a variety of sports, but their use with adolescent girls, particularly swimmers beginning at 14 years of age, is frightening: "the treatment of young girls with androgenic hormones was especially rewarding in the medal-rich swimming events, where it secured consistent international success." the authors caution parents around the world: "even the androgenization of young girls has been, and remains, a documented practice in the sport system of countries outside the gdr and the socialist system." franke ww, berendonk b. hormonal doping and androgenization of athletes: a secret program of the german democratic republic government. clin chem 1997;43:1262-79. the aacc subcommittee on ctni standardization concludes that commercially available assays are useful for detection of cardiac injury; however, differences in ctni results are attributable to a lack of standardization and heterogeneity in the cross-reactivities of antibodies to various troponin forms (wu ahb, et al. characterization of cardiac troponin subunit release into serum after acute myocardial infarction and comparison of assays for troponin t and i. clin chem 1998;44:1198 -208). cardiac troponins t and i collected shortly after ischemic symptoms are used for predicting clinical outcomes (christenson rh, et al. cardiac troponin t and cardiac troponin i: relative values in short-term risk stratification of patients with acute coronary syndromes. clin chem 1998;44:494 -501). an approach for screening for deficiency of steroid 21-hydroxylase and congenital adrenal hyperplasia is published. krone n, et al. comprehensive analytical strategy for mutation screening in 21-hydroxylase deficiency. clin chem 1998;44:2075-82. lab-on-a-chip. a glass microchip is described in which reagents and serum samples for competitive immunoassay can be mixed, reacted, separated, and analyzed. chiem nh, harrison dj. microchip systems for immunoassay: an integrated immunoreactor with electrophoretic separation for serum theophylline determination. clin chem 1998;44:591-8. www.clinchem.org:clinical chemistry goes online! the full text of the journal is available to all subscribers; content from the previous year is also available. abstracts and titles are available, starting with issues appearing after 1964. eleven european union countries agree on a single currency, the euro. the us department of justice and 20 us states file an antitrust case against microsoft. hyperglycosylated hcg is shown to be a new marker for down syndrome screening; its measurement is claimed to improve the performance of screening protocols [cole la, et al. chechen rebels take 763 hostages in a moscow theater. terrorists detonate massive bombs in two nightclubs in kuta, bali. quaoar is discovered in our solar system. it is estimated that 11% of the world population is on line; for the english-speaking world, the proportion is 43%. start with stard. a protocol for evaluating the completeness and accuracy of biomedical research is published. a checklist and flow diagram will aid researchers in improving the quality of reporting of studies of diagnostic accuracy; this will benefit clinicians, researchers, reviewers, journals, and the public. paperless clinical chemistry. the journal embarks on a program to have all of its content-from volume 1, page 1 to the present (nearly 100 000 printed pages)available on line. previously, full content availability was limited to articles published in 1997 (volume 43) and later. vladimir putin wins a second term as president of russia. the european union expands to include poland, lithuania, latvia, estonia, the czech republic, slovakia, slovenia, hungary, malta, and cyprus. george w. bush elected to a second term as president of the united states. abbott tdx monoclonal antibody assay evaluated for measuring cyclosporine in whole blood bruns assumes the editorship. although king was not known for his indiscriminate endorsement of the latest technologies in publishing, he notes that "the days of the conventional printed scientific journal . . . may be numbered iraqi troops invade kuwait, setting off the persian gulf war. the hubble space telescope is launched. arpanet ceases to exist psa is shown to exist in serum largely as a complex that blocks epitopes for certain antibodies directed against the psa molecule. lilja h, et al. prostate-specific antigen in serum occurs rapid detection of group b streptococci fifty years of clinical chemistry clinical chemistry: the history of a journal recollections of the aacc and related activities, continued some historical perspectives on aacc clinical chemistry: a fragmentary history (1969 -1977) citation classics in clinical chemistry highlight the cumulative impact of useful methods-a tribute to editor john [sic] stanton king. essays of an information scientist: science reviews, journalism inventiveness and other essays they use enzymes for everything! citation classics in intermediary metabolism the evolution of immunoassay as seen through the journal clinical chemistry citation classics in lipid measurement and applications the clinical chemist fifty years of clinical chemistry, three pioneering editors correspondence: reference standards and substrates for alkaline phosphatase from carbons to computers: the changing american office men and machines the clinical chemist combined use of gas chromatography, mass spectrometry, and computer in diagnosis and studies of metabolic disorders i am grateful to past and present members of the editorial board of clinical chemistry who offered helpful suggestions in the preparation of this review. particular thanks go to the executive committee of the editorial board and to our publisher, mac fancher, and our editor, dave bruns, for their helpful suggestions and encouragement. i would also like to thank bonotom studio, inc., for rendering the collages of historic events and christina mcintyre, barbara paternoster, and valarie watersun for their invaluable assistance in collecting and preparing items for inclusion. clinical chemistry adopts a new cover with an abstract design suggesting molecules, globes, or possibly, the harmony of the spheres. new typography is adopted, and measurement of expression of htert, which codes for the catalytic subunit of telomerase, is shown to have the potential to discriminate between healthy and tumor cells. high-c. crp is shown to have prognostic utility in patients with acute coronary syndromes and to be a strong independent predictor of future coronary events in healthy subjects. rifai n, ridker pm. high-sensitivity c-reactive protein: a novel and promising marker of coronary heart disease. key: cord-258029-gyvg7ffa authors: moolasart, visal; wongsawat, jurai; phokhom, priyanut; thienthong, varaporn title: favipiravir-based regimen for coronavirus disease 2019 pneumonia for a 47-day-old male newborn date: 2020-10-15 journal: sage open med case rep doi: 10.1177/2050313x20964046 sha: doc_id: 258029 cord_uid: gyvg7ffa coronavirus disease 2019 pneumonia in the newborn is a difficult-to-treat condition. early clinical signs of pneumonia are nonspecific and present as respiratory distress of varying severity, and tachypnea is a predominant clinical sign. a 47-day-old, asymptomatic male newborn of coronavirus disease 2019 infected mother tested positive for coronavirus disease 2019 by reverse transcription polymerase chain reaction. during hospitalization, he developed progressive tachypnea, tachycardia, and chest radiography abnormalities, and was diagnosed as coronavirus disease 2019 pneumonia. he was treated with favipiravir, hydroxychloroquine, and lopinavir/ritonavir. a favipiravir-based regimen may be the drug of choice for coronavirus disease 2019 pneumonia in the newborn. severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is a novel coronavirus causing coronavirus disease 2019 (covid19) , which emerged in wuhan, hubei province, china, in mid-december 2019 to become pandemic disease. 1, 2 adults may have asymptomatic to lifethreatening disease, and older adults have greater risk of severe disease. 3, 4 infection in infants aged under 1 year was recently reported, 5 and those without underlying diseases had mild covid-19. 6 in hubei, pediatric cases were treated with antiviral therapy (interferon, arbidol, oseltamivir, lopinavir/ritonavir (lpv/r), or empirical antibiotics), and a few critical cases also received invasive mechanical ventilation, systemic corticosteroids, and intravenous immunoglobulin. 7 no deaths were reported. 7 to date, no recommendations from randomized controlled trials (rcts) have been published for any specific anti-sars-cov-2 treatment for patients with covid-19. favipiravir is a broad-spectrum oral antiviral agent with in vitro anti-sars-cov-2 activity. data on its effectiveness and optimal dosage for covid-19 are limited, especially in the newborn. 8 a 47-day-old, male newborn was asymptomatic but had household contact with his covid-19 infected mother. he was hospitalized due to the household contact and tested positive for covid-19 infection. he was transferred to the bamrasnaradura infectious diseases institute (bidi) for isolation in negative pressure. he was the first child of consanguineous parents and was born by cesarean section with a birth weight of 2895 g. his mother had malaise, nausea, and vomiting. the newborn had no previous hospitalizations. on admission, the newborn was alert, afebrile, and not tachypneic. his vital signs were a body temperature of 36.8°c, blood pressure of 120/70 mm hg, pulse rate of 148 beats/min, a respiratory rate of 28 to 38 breaths/min, and a peripheral oxygen saturation of 99% on room air. the patient's complete blood count results were a white blood cell count of 12,000/ml (lymphocytes 70%, neutrophil 25%), the neutrophil to lymphocyte ratio (nlr) of 0.36, hemoglobin of 10.7 g/dl, and platelet count of 326,000/ml. on the day of admission, reverse transcription polymerase chain reaction (rt-pcr) for covid-19 was positive, while a nasopharyngeal and throat swabs for influenza type a and b by rapid test, respiratory syncytial virus by rt-pcr, and hemoculture were all negative. chest radiography showed no abnormalities ( figure 1 ). azithromycin was given as empirical treatment. on day 6 of admission, he was tachypneic (a respiratory rate of 40 breaths/min) and tachycardic, and his chest radiography showed abnormalities ( figure 2 ). according to the thailand ministry of health guidelines for covid-19, 9 a cocktail regimen of favipiravir (day 1: 30 mg/kg/dose bid, days 2-10: 10 mg/kg/dose bid), hydroxychloroquine (day 1: 10 mg/kg/dose bid, days 2-10: 6.5 mg/kg/dose bid), and lpv/r (days 1-10: 300/75 mg/m 2 / dose bid) were given for a total of 10 days. on day 8 of admission, his clinical condition began to improve. on day 14, his chest radiography showed decreased haziness (figure 3 ). on day 20 of admission, he was discharged from hospital in good general condition. he and his parents were quarantined and monitored for 14 days. serial rt-pcr for covid-19 was taken every 72 h. the results were positive on days 1, 4, and 7, and then negative on day 10 of quarantine and monitoring. this study was reviewed and approved by the institutional review board of the bidi, ministry of public health, nonthaburi, thailand. the reference approval letter codes are s019h/63_exempt. initial clinical studies revealed the promising therapeutic potential of several drugs, including favipiravir, a broad-spectrum antiviral drug that interferes with the viral replication, and hydroxychloroquine, a repurposed antimalarial drug that interferes with the virus endosomal entry pathway. 8 lpv/r is a pneumonia-associated adjuvant drug, which was used in the clinical treatment of patients with covid-19, 10 and hydroxychloroquine showed good clinical outcomes among patients with covid-19, which is thought to be due to the excellent efficiency of virus clearance after administration of this combination therapy. 11 the mechanism of actions of favipiravir is thought to relate to the selective inhibition of viral rna-dependent rna polymerase. 12 in february 2020, favipiravir was studied in china as an experimental treatment for covid-19. 13, 14 a previous study showed it had a favorable safety profile regarding total and serious adverse events. however, safety concerns remain, including hyperuricemia, teratogenicity, and qtc prolongation. favipiravir may be safe and tolerable for short-term use, but more evidence is needed to assess the effects of long-term treatment. 15 chloroquine or hydroxychloroquine was reported to have potential broad-spectrum antiviral activity by increasing the endosomal ph required for virus/cell fusion and interfering with the glycosylation of cellular receptors of sars-cov. 5, 16 in early in vitro studies, chloroquine was found to block covid-19 infection at low-micromolar concentrations, with a half-maximal effective concentration (ec50) of 1.13 µm and a half-cytotoxic concentration (cc50) greater than 100 µm. 17 different radiographic patterns are seen as covid-19 progresses. typically, after the first to second week of the onset, lesions progress to bilateral diffuse pattern with consolidations. by contrast, both ground-glass opacification and consolidation were present relatively early in sars. 18 patients with covid-19 developed dyspnea within a median (interquartile range (iqr)) of 5 days (1-10) after the onset of illness, while others did not develop any respiratory distress. 19 pediatric patients with covid-19 had a mild inflammatory infiltration, 20 which indicates that they are more likely to recover than adults after symptomatic treatment. a favipiravir-based regimen may be the drug of choice for covid-19 pneumonia in the newborn, safe and tolerable in short-term use, but more evidence is needed to assess the effects of long-term treatment. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. this study was reviewed and approved by the institutional review board of the bamrasnaradura infectious diseases institute, bamrasnaradura infectious diseases institute, ministry of public health, nonthaburi 11000, thailand. the reference approval letter codes are s019h/63_exempt. the author(s) received no financial support for the research, authorship, and/or publication of this article. the patient's mother provided written permission for publication of this case report and associated images. written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article (thai language version). visal moolasart https://orcid.org/0000-0002-1151-4790 ferences 1 and world health organization. novel coronavirus (2019-ncov) situation reports epidemiological characteristics and prevention and control measures of corona virus disease 2019 in children clinical features of patients infected with 2019 novel coronavirus in wuhan, china epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study anti-malaria drug chloroquine is highly effective in treating avian influenza a h5n1 virus infection in an animal model coronavirus disease (covid-19) and neonate: what neonatologist need to know clinical characteristics of children with coronavirus disease 2019 in hubei, china a review of sars-cov-2 and the ongoing clinical trials thailand ministry of public health. thailand guideline for covid-19 clinical efficacy of lopinavir/ ritonavir in the treatment of coronavirus disease 2019 hydroxychloroquine and azithromycin as a treatment of covid-19: results of an openlabel non-randomized clinical trial the ambiguous basepairing and high substrate efficiency of t-705 (favipiravir) ribofuranosyl 5′-triphosphate towards influenza a virus polymerase therapeutic options for the 2019 novel coronavirus (2019-ncov) brief-corrected-zhejiang hisun pharma gets approval for clinical trial to test flu drug favipiravir for pneumonia caused by new coronavirus. reuters healthcare. epub ahead of print 17 a review of the safety of favipiravir-a potential treatment in the covid-19 pandemic? effects of chloroquine on viral infections: an old drug against today's diseases remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro full-genome evolutionary analysis of the novel corona virus (2019-ncov) rejects the hypothesis of emergence as a result of a recent recombination event clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china radiographic and clinical features of children with 2019 novel coronavirus (covid-19) pneumonia key: cord-308284-r546ypur authors: simpson, shmona; chakrabarti, ajoy; robinson, david; chirgwin, keith; lumpkin, murray title: navigating facilitated regulatory pathways during a disease x pandemic date: 2020-10-23 journal: npj vaccines doi: 10.1038/s41541-020-00249-5 sha: doc_id: 308284 cord_uid: r546ypur in 2018, the bill and melinda gates foundation convened over thirty subject matter experts in clinical development, manufacturing, and regulatory assessment to determine how the development and approval of medical countermeasures could be accelerated in the event of disease x. disease x is the result of a presently unknown pathogen with epidemic or pandemic potential. a key opportunity to accelerate the scientific assessment and regulatory approval of medical countermeasures exists within efficient navigation of facilitated regulatory pathways. it was identified that not all stakeholders will be able to skillfully navigate the facilitated pathways offered by the various regulatory agencies during a public health emergency. to democratize this knowledge, we have written an overview of the facilitated approaches which have been developed and refined by stringent regulatory authorities and the world health organization for the primary assessment of medical products. we discuss the conditions necessary for use of these approaches, scenarios in which certain pathways may be applicable, and the pros and cons of these approaches. we also address opportunities available to developers in, or developers who wish to access, low-income countries that may have nascent regulatory frameworks. the 2014-2016 ebola epidemic significantly impacted the global health community. between guinea's index case in december 2013 and the epidemic's end in june 2016, there were 28,000 cases and 11,325 deaths across eight countries 1 . despite years of prior research, no products were ready to deploy in time to save these lives. the question then arose: how many lives would have been saved if effective medical countermeasures had been made available sooner? the who created the research and development blueprint initiative 2 , which asked multiple agencies how to shorten the time to development of medical countermeasures for the world's most deadly pathogens. the bill and melinda gates foundation attempted to answer this question for disease x-the result of a presently unknown pathogen with epidemic or pandemic potential. in december 2018, the foundation convened a disease x working group-comprised of 30 experts in emerging infectious diseases; bioterrorism agents; non-clinical studies; clinical trials; chemistry, manufacturing, and controls; and regulatory scientific assessment 3 . the goal was to understand how the next epidemic could be controlled using medical countermeasures that arrive sooner than has been the experience to date. the control of disease x requires improvements in many areas, including disease surveillance, public health infrastructure, laboratory capacity, product manufacturing, and delivery 4 -however the remit of this working group was to focus specifically on the expedited provision of medical countermeasures. one of the key challenges identified was a perceived difficulty in navigating facilitated regulatory pathways. in this perspective, we summarize some facilitated regulatory pathways available to innovators tackling disease x and suggest how these may shorten product development and regulatory assessment timelines. we also discuss the pros and cons of these approaches and suggest in which situations they may be most applicable. so far, we have identified 50 facilitated regulatory pathways (listed in supplementary note 1), in 24 countries around the world. while many of these have critical nuances and are at various stages of refinement 5, 6 , they cannot all be adequately described in this short perspective. a broader set of considerations are available elsewhere 6, 7 . rather, some "stringent regulatory authorities" (as classified by who) have completed primary assessment of thousands of products using these facilitated approaches. these include products used in epidemic emergencies. many other national regulatory agencies (nras) have mirrored these processes, and/or rely on the scientific outcomes of these approaches to assist in their own authorization practices. this perspective provides a high-level overview of the facilitated approaches which have been developed and refined by stringent regulatory authorities and the world health organization for the primary assessment of medical products. it is possible that these represent the approaches most likely to be relied upon in the next epidemic or pandemic. we hope this paper will enable academic innovators and small and medium enterprises to navigate the flexibility that exists within regulatory approaches for products that address life-threatening diseases of unmet need. we encourage developers to make early contact with regulators in their focus countries to discuss which programs may be applicable. several potential regulatory scenarios may exist and co-exist during an epidemic: for example, (a) de-novo candidates requiring rapid development and regulatory assessment (b) de-novo products requiring assessment when the typical package of clinical efficacy data may not be available, (c) approval of de novo or repurposed products for "emergency" use only in specific populations (d) for compassionate use in specific (e.g., "named") individuals of an unauthorized medicine (e) conditional or accelerated authorization before the completion of efficacy studies or, (f) use of a licensed product outside of its approved use (e.g., for another indication, dosage regimen, or population). many regulatory agencies have instituted various programs to help navigate these scenarios (table 1) . these pathways are generally reserved for products that address a serious or life-threatening condition where there is unmet clinical need, or where the current treatment options are unsatisfactory. eventual authorization through one of these pathways depends on an evaluation of the known clinical benefits and risks of the product-in the context of the known risks of the disease. for this, regulators employ a variety of complex modeling and analytic techniques to conduct an assessment of the benefits and risks of the product and any remaining uncertainties, and compare these to the risks of the disease and the available options at the time of application 8, 9 . in an outbreak, these parameters can be highly variable; they may change depending on the pathogen, co-morbidities, evolution of the epidemic, populations and geographies affected. however, these agile facilitated regulatory pathways recognize the higher tolerance for unknown risk the community has in these situations: they allow for flexibility on the depth of certain routine data requirements given the specifics of the disease being considered. not all of these pathways facilitate a shorter assessment time: some allow for assessment to be conducted at an earlier phase of the typical product development lifecycle in instances where the benefits, at that point in time, outweigh the risks (fig 1) . a critical element for successful use of these facilitated pathways is the engagement of regulators early and often: scientific advice and pre-submission meetings are invaluable. most authorities allow rolling submissions of data and rolling reviews under these processes. this early engagement allows for on-going alignment on development plans as further data become available. it also allows sponsors to focus on the critical data requirements, identify opportunities for additional product development acceleration, and ultimately save substantial time. depending on the product and the clinical situation, a product may be eligible for any or all these facilitated programs and can be candidates in more than one program simultaneously. without active regulator engagement, it is often difficult to navigate these approaches and understand the challenges inherent in each. regulation through reliance and regionalization are critical elements for broadening the utility of facilitated pathways. reliance allows for nras to rely on the work product of a trusted authority to inform their own regulatory decision. regionalization extends the utility, allowing neighboring regulatory authorities to workshare, and share work product, within their economic or cultural blocs. this may mean that regulatory assessment and authorization in one jurisdiction, can de facto facilitate accelerated authorization in another jurisdiction thereby avoiding duplication of effort 10 . a list of regulatory harmonization initiatives is provided in the supplementary note 1. the following pathways are available under certain circumstances to expedite product development and marketing application assessment. the united states food and drug administration's (fda) priority review 11 process provides feedback on a marketing application, i.e., an authorization or complete response, within, generally, 6 months, instead of the standard 10 months. this faster application review is for products that purport to demonstrate significant efficacy or safety over a currently available therapy related to the treatment, diagnosis, or prevention of a serious condition. this designation, which comes at the time of submission, does not affect the length of the clinical trial period. many other regulatory authorities have expedited review timeframes for similar situations, and one should always check to see if the medical countermeasure would qualify in the country in which the product is intended to be used. accelerated assessment, under similar situations, is also available at the european medicines agency (ema), reducing review time from 210 days to 150 days. japan's pharmaceutical and medical devices agency (pmda) also provides a priority review option, available to products that address (1) serious diseases, (2) conditions of unmet clinical need, or where superior safety and efficacy can be provided, and (3) orphan designated products. this option reduces review time from 12 to 9 months 12,13 . fda's fast track is a program for products that have some initial evidence of efficacy or improved safety over an available therapy 14 . this designation provides an opportunity for frequent meetings and communication with the fda. most importantly, this program allows a "rolling review" process, in which the marketing application is submitted in pieces as each segment is completed rather than having to assemble the entire application and submit it all at once. this allows fda to assess each segment as it is submitted, and thus fda only must review the last segment when it is completed rather than the entire application. fda's breakthrough designation 15 is granted where a new candidate demonstrates substantial improvement over an available therapy on a clinically significant endpoint. candidates demonstrating an improved safety profile over an available therapy with similar efficacy are also considered. efficacy can be demonstrated using a pharmacodynamic biomarker, surrogate or intermediate clinical endpoint providing they strongly suggest a clinically meaningful effect. for example, pfizer's 20-valent pneumococcal conjugate vaccine candidate and janssen's prophylactic vaccine for the prevention of respiratory syncytial virus both achieved breakthrough designation following a phase 2 and 2b studies, respectively 16, 17 . a breakthrough therapy designation enables fast-track designation, intensive guidance on a drug development program, and organizational commitment. like fda's breakthrough program, investigational products to address unmet medical need are eligible for consideration under the european union's priority medicines (prime) scheme, providing early clinical data demonstrate potential benefit. in addition, applicants from the academic sector, small and medium enterprises can engage with the ema quite early based on compelling non-clinical data and tolerability data from initial clinical trials. not exclusive to these applicants, the ema also offers scientific advice and protocol assistance to ensure the most expeditious experience with applying for market authorization 18 . prime also ties in to accelerated assessment if the data ultimately demonstrate the level of improvement needed for accelerated assessment designation. the following pathways are reserved for candidates when the benefit risk analysis indicates that access should be granted even if the entire clinical trial process has not been completed. generally, these are temporary authorization statuses and are not intended to replace or circumvent ultimately finalizing the clinical trials required to support full market authorization. as a condition of approval under these pathways, it is general a requisite that the clinical trials be continued until adequate clinical efficacy and safety either are or are not demonstrated. fda's accelerated approval allows for authorization where efficacy is demonstrated via an unvalidated surrogate endpoint or an intermediate clinical endpoint 19 . these surrogate endpoints are likely predictors of clinical benefit and require that this be demonstrated by "adequate and well controlled" studies. ultimately, the requirement remains to confirm clinical benefit in post-authorization confirmatory trials that validate the approved endpoint. when these studies are completed, the fda will review the data and decide if the approval can be converted to a full authorization. the accelerated approval may be revoked if clinical benefit relative to the risks cannot be confirmed. to date, 208 compounds have been approved under this pathway. these range from numerous antiretroviral compounds in the 1990's, to janssen's levaquin for aerosolized bacillus anthracis, to the recent approval of ismed's arikayce for treatment of mycobacterium complex in 2018-all averaging an initial accelerated approval time of six months 20 . priority medicines with accelerated assessment scientific advice and protocol assistance (prime) •a strongly substantiated mechanism of action, preclinical data, and human tolerance data •academic, small and medium enterprises may apply earlier for advice and protocol assistance serious or life-threatening condition for which therapy is inadequate. rapid assessment, based on early clinical data japan pharmaceuticals and medical devices agency (pdma) priority review 22 •available for orphan designated products, and those that receive conditional approval for diseases of unmet clinical need rapid assessment, decision received within 9 months conditional term-limited approval 22 fda's expanded access (ea) is a program designed for patients with an immediately life-threatening disease to access a product that has clinical trial data (putatively showing an acceptable benefit-risk profile)-but does not yet have marketing authorization. because the authorization has not yet been granted, the product is considered investigational and therefore written informed consent of the patient must be obtained when used. generally, ea is used in situations where alternative therapies are not available. which ea program is chosen reflects the perceived need for the product in terms of number of patients. under such programs, the product can be used for: (1) a single patient, (2) immediate-size populations that occur after the fda has received a number of requests for single patient use, or (3) under a "treatment investigational new drug," designation. these are generally used during the time period after the completion of pivotal trials, but before the authorization is granted. during this period, there may be large numbers of patients that might benefit from the product during the time the marketing application is being assembled and/or the product is under review 21 . options for international expanded access exist in 21 cfr 312.110(b)(ii) 22 which allows for the export from the united states of investigational products for national emergencies elsewhere, with nra approval in the receiving country. for example, following promising animal and early-phase clinical studies (prevail ii trial) the fda supported the use of zmapp through a standing expanded access protocol prior to completion of the submission, which allowed countries to retain access to vital therapeutic agents 23 . manufacturers who provide access to product under one of the "expanded access" programs may only recover the direct costs of manufacturing their investigational product and may not recoup additional costs or make a profit. in these cases, access to product under an "expanded access" program allows for patients to receive the product when the potential benefit outweighs the known risk in the specific context of the patient(s). this sometimes provides further valuable data to help support a full marketing application. the ema also offers programs to bridge the clinical trial and full authorization gap. unlike a typical full marketing authorization, a conditional marketing authorization (cma) 24 can be granted in instances of unmet medical need where the benefit-risk assessment is positive. this is based on early data suggesting that the sponsor will be able to provide more complete data within an agreed timeframe to validate the tentative positive benefit-risk profile of the product. these data generally include more comprehensive clinical efficacy and safety data 25 . cma's are generally granted for a 12-month period, after which they are further reviewed in light on any new data available. if deemed of benefit to public health, the conditional authorization can be extended. a large number of antiretroviral compounds 26-28 and treatment for multi-drug resistant tuberculosis such as bedaquiline 29 and delamanid 30 continue to be marketed conditionally by the ema as trials are ongoing. ultimately, this pathway this may provide a route to full authorization for many of these candidates. these provisions, both in the us and eu, require postauthorization infrastructure so that further, more comprehensive data can be captured and so that any requisite safety monitoring can be performed. such infrastructure often does not exist in lowincome countries. this makes use of these pathways sometimes difficult, if not impossible, in countries without such needed infrastructure. a key feature of these mechanisms is that they often feed into each other and are not meant to be mutually exclusive. for example, in 2018, 60 degrees pharmaceutical's tafenoquine for malaria prophylaxis was awarded both fast track and priority review designations 31 . similarly, a medicine in the prime scheme could also be granted conditional marketing authorization during clinical trials, while still benefitting from accelerated assessment and eventual full authorization 32 . japan's pdma offers two conditional approval options; the first is for regenerative products which grants a term-limited approval based on exploratory phase i and ii safety and efficacy data 12 . confirmatory studies are required post-market, and applications must be submitted for complete market authorization within 7 years. this is described as conditional "term limited" approval. the second conditional approval is applied in instances of a serious disease, disease of unmet clinical need, or where it is too difficult or excessively lengthy to conduct efficacy studies. in this instance, early phase clinical studies must show some safety and efficacy, and post-market requirements will include surveillance or clinical studies 33 . japan's sakigake (or pioneer) program is available for diseases of unmet clinical need where the sponsor agrees to file the marketing application first in japan (or simultaneously first in japan and another country). for a candidate to qualify for sakigake, there must be some early phase clinical data and strong non-clinical and mechanism of action data. this program offers pre-application consultation, expedited review of around six months, and superior support from pdma. the re-examination of clinical safety and efficacy data can be lengthened for an indeterminate period of time, in order to strengthen the likelihood of full market authorization 34 . when conducting clinical trials presents insurmountable logistical, safety, or ethical challenges, the following regulatory approaches allow for efficacy to be demonstrated using an animal surrogate or clinically indicative endpoints alongside human safety data. these are reserved for when public health need is significant and human efficacy testing is not possible. in all instances, every attempt is made to procure follow-up analyses of human experience with the product post-authorization. the fda's animal rule 35 provides a pathway to approve novel candidates in the absence of the demonstration of efficacy in clinical trials. where clinical trials are impossible or unethical to conduct, determinations of efficacy are primarily based on studies in well-characterized animal models 36 . the investigator must provide: • poof that the animal model can provide plausible inference for human efficacy, • proof that the mechanism of action is the same in the model, as it would be in humans, • rationale for the dose provided to humans (which may come from human pharmacokinetic studies and animal efficacy studies). in these situations, safety is demonstrated using traditional toxicology studies and human experience data (usually from phase 1 trials in healthy human volunteers). the chemistry, manufacturing, and controls information needed to support an animal rule application follow fda guidelines for a routine new drug or biological license application. this program allows a promising candidate to be authorized for human use where a major public health need is justified. this authorization is rare: to date only 6 and 8 drug and biologic approvals, respectively, have been granted under this provision 37 . built into the "animal rule" is an iterative process where post-authorization human safety and efficacy data can be obtained and used as the product is employed to further refine the product label. aside from de-novo product authorization, the animal rule may also be used to gain authorization for a new indication. in addition to several medicines that have been approved under this provision, the anthrax vaccine biothrax was approved in 2015 for post-exposure prophylaxis making it the first vaccine to receive approval for a new indication based on the animal rule 38 . in the european union, an analogous option exists within the provisions of the "marketing under exceptional circumstances" pathway. in exceptional circumstances, when an applicant cannot reasonably be expected to conduct clinical trials, they may submit as much clinical safety as efficacy data as possible, alongside a proposal for post-approval studies that would support the original safety and efficacy claims. inability to supply a complete efficacy package may occur due to the rarity of the disease, limitations in the present state of scientific knowledge, or when it would be unethical to conduct. once marketed under exceptional circumstances, the candidate will be supplied with a summary of product characteristics stating that information regarding the candidate is incomplete, and the label may be updated 39 . in 2013, the smallpox vaccine imvanex was marketed under exceptional circumstances after exploratory data demonstrated that protective antibodies could be triggered, with only mild side effects (including in patients with hiv or atopic dermatitis). to date, the vaccine's benefits and risks continue to be studied in vaccine recipients. ultimately true efficacy could only be demonstrated if there is an outbreak of the disease in the future 40 . the following pathways are reserved for when a national or global public health emergency has been formally declared. fda's emergency use authorization (eua) is enabled once the united states secretary of health and human services declares a specific national public health emergency 41 . it considers whether the "known and potential benefits of the product outweigh the known and potential risks" providing that no reasonable alternatives exist for treating the cause of the specified national public health emergency. data to support the application may include domestic and/or foreign clinical trial data, in vivo animal data, and in vitro data that provide plausible support for clinical efficacy. access to a product under an eua is limited to the duration of the national health emergency and the specific access caveats imposed. thereafter the product is again considered investigational. for example, during the 2009 h1n1 influenza outbreak, euas were granted for the dispensing of tamiflu (oseltamivir phosphate) and relenza (zanamivir), and intravenous peramivir. these were discontinued in 2010 once h1n1 was no longer deemed a threat to the united states 42 . this pathway is applicable to medicines, biologics, vaccines, and medical devices, including in vitro diagnostics. so far, the eua has been utilized primarily for diagnostic tests for several infectious agents including influenza, anthrax, coronaviruses, ebolavirus, and zika viruses. for those developing products to be used in countries with nascent or under-resourced regulatory agencies, the who has provided the emergency use listing (eul) process to provide guidance on product quality and use during a public health emergency of international concern (pheic) or other specified public health emergency. only the director general of the who can authorize the use of the eul process. this program was developed and first used for ebola diagnostics during the 2013-2015 west african ebola outbreak and was previously referred to as the emergency use assessment and listing (eual) process. since then, it has been further refined and renamed, with the most recent guidance issued in early 2020 43 . this process was used extensively in both the ebola and zika outbreaks for in vitro diagnostic products, although the process is clearly intended for medicines and vaccines also. the first example of a vaccine advancing into the eul process is the new oral polio vaccine for type 2 virus (nopv2). this genetically modified (designed to improve safety relative to the existing oral polio vaccine, mopv2), oral polio vaccine is being developed by bio farma (indonesia) and path. on-going transmission of type 2 vaccine-derived polio virus (vdpv) in certain regions of the world has resulted in who maintaining its long-standing pheic for polio. successful completion of the eul process would facilitate the use of nopv2 in field campaigns to control vdpv events once an outbreak has been identified. use of the eul process would allow this novel vaccine to be used prior to who prequalification, enabling an improved vaccine to be utilized in this emergency in advance of obtaining all the data required for traditional product licensure pathway. during this use, data will be gathered to support the traditional who prequalification process and national product licensure pathways. while the gmp requirements are generally the same as required for the who prequalification program, the efficacy of a vaccine, for example, may be demonstrated by pre-clinical efficacy data in a suitable animal model, alongside clinical immunogenicity that is reasonably predictive of human clinical efficacy. a plan to monitor safety and efficacy in the field must be included, and an eul is granted initially for 12 months. the manufacturer's history of successfully prequalifying products may contribute to the decision -especially if specific manufacturing site inspection is difficult to obtain in a timely manner. specific to vaccines, though the who has provided the eul, at least one qualified nra is responsible for providing "oversight of batch release and other post-eul product safety and manufacturing quality assurance requirements 44 ." this is usually the agency in the manufacturing country. some countries where epidemics occur are not equipped to do this for certain vaccines. to mitigate this, national and regional regulatory agencies generally should engage with their global regulatory counterparts and who prequalification in a collaborative approach to product assessment and oversight under emergency circumstances, especially when novel outbreak etiologies and novel therapeutic and prophylactic modalities are being proffered. when clinical trials have been conducted routinely, there is little motivation for manufacturers to produce initial quantities of product in excess of what is required for the clinical trials program. however, in a public health emergency, manufacturers may be called upon to supply larger quantities of product much more quickly. this may deplete clinical trial supplies. if adequate forethought about production has not been undertaken, there may only be enough product for early clinical studies: this results in significant delay to commencement of later phase trials or early larger scale use of the product under one of these pathways, especially during an epidemic (fig. 1) . mitigation may involve rapid and significant investment of resources in manufacturing, at risk, prior to clinical proof of concept in order to be able to meet demand if the early data support wider use of the product in emergency situations. when clinical trials have not been conducted a key element to utilizing the animal rule and analogous facilitated programs is the need for a well-validated animal model. a well-validated animal model may not always exist for "disease x" and establishing a well-validated animal model can be challenging. in addition, these pathways that utilize animal surrogates may not be applicable to most outbreak scenarios involving new pathogens. once an outbreak is underway it typically would be feasible and ethical to conduct clinical trials at which point authorization under the animal rule becomes less relevant. conversely, after an outbreak ends, the opportunity to evaluate efficacy in humans also ends, but at that point the level of urgency also decreases. for novel pathogens, these approaches remain best reserved for instances where probability of human efficacy is higher and apparent at an earlier stage. without this, the chief value of this approach may be prior to an outbreak or after the outbreak has ended with the aim of supporting use rapidly in a potential future outbreak. the advantage of many of these pathways is that demand for a product with reasonable presumption of efficacy and safety may be met earlier during a public health emergency, than in a traditional product development and marketing application assessment timeline. in these situations, specific use under emergency authorization may include use in first responders, use in those infected, use in ring programs, and/or use in mass distribution as the situation warrants and as the caveats of the specific emergency use authorization dictate. manufacturers must commit to collecting further clinical efficacy and safety data, often including clinical trials where feasible and ethical, in conjunction with this emergency usebased field use. depending on the scientific robustness with which such data are collected and analyzed, these data may provide primary and/or supplementary data for later licensure. a key downside of these approaches is the data may not help differentiate the potential clinical safety risks of the product from the underlying clinical complications of the disease. uncontrolled use may confound the long-term safety and efficacy assessments of a product due to the high morbidity and mortality rates during these emergencies. the studies may also be confounded by other comorbidities and other factors typical of the geography, concomitant use of other interventions, or availability (or lack thereof) of other healthcare and medical supplies. mitigation of these challenges involves early discussions with regulators. this ensures that there is a common understanding about the natural history of the disease (where possible) and thus a way to try to differentiate drug risk from disease risk and differentiate product efficacy from disease natural history. in addition, where possible, these candidates should be deployed in a controlled clinical study to ensure that the efficacy and safety of the product is appropriately evaluated 45 . despite their challenges, these pathways can be used to potentially expedite medical countermeasure availability in a public health emergency for candidates with positive pre-clinical efficacy signals. while the abovementioned regulatory agencies have instituted various programs to help expedite the development and assessment of products for use during public health emergencies, many low, and lower-middle income countries have nascent and underresourced regulatory agencies. for products manufactured in, or used in, countries that cannot assure quality standards, who prequalification is a system developed to help procurers of prequalification eligible products determine if the products they are procuring meets international regulatory standards for product efficacy, safety and manufacturing quality. many low-income countries rely on prequalification listing and the assessment and inspections documents who provides them to inform their own national regulatory decision on that specific version of the product. this is done through the who-nra collaborative process. who cannot "authorize" a product; rather, it "lists" the versions of the products when the who assessment determines that the clinical and manufacturing data meet international standards. like routine product authorizations, routine who prequalification is generally not used in public health emergencies. several early engagement opportunities and facilitated accelerated pathways exist when one is focusing on regulators in lowincome countries. these national agencies are engaging more with their global regulatory counterparts and who prequalification program staff in a collaborative approach to assess and authorize products (both clinical trials applications and marketing applications) under emergency circumstances, especially when novel outbreak etiologies and novel therapeutic and prophylactic modalities are being proffered. who has instituted a number of pre-emergency activities, described in the latest version of the eul process 43 . the preemergency activities involve establishment of platforms for collaborations between who, subject matter experts, nras with special expertize, and nras where the products will be used (where they differ). who establishes expert advisory committees to support each stage of the eul. in addition, these platforms are used for pre-submission meetings/activities, selection of products, and assessment of submitted data. these activities allow for accelerated decision making upon declaration of a pheic or other covered public health emergency. a key benefit of these activities is that the nras are involved at early phases of product development and participate in the assessment process. together, all nras and who can align on appropriate non-clinical model and clinical study design. this allows for phase 2b and 3 trials to commence quickly and with the appropriate assistance levels. this can clarify clinical trial endpoints that would be supportive for eul by who and in the target countries. an additional opportunity for clinical trial discussions are regional health agreements in sub-saharan africa 46-48 , south america 49 , and asia 50 : these facilitate work-sharing and joint decision-making. for example, the africa vaccine regulatory forum (avaref) 51 is a continental platform of regulators sponsored by who afro and who-geneva which coordinates the joint regulatory and ethics board assessments of multinational clinical trials in africa. innovator engagement with avaref, for example, allows the benefit of joint scientific advice and clinical trial assessment meetings. in addition, avaref has established an emergency clinical trial assessment process for multi-country clinical trials. originally designed only for vaccine trials, avaref, despite its anagram, is also available for use with multinational clinical trials application assessment for medicines in africa. outside of the who eul, two other pathways exist to specifically support lower income countries with facilitated assessment, particularly of novel products. they both bring the resources of an agency with specific expertize and who to conduct scientific assessments of clinical development programs and marketing authorization applications with opportunities for engagement in the discussions by nras from the countries where the product will most likely be used. the use of such pathways brings low income country regulators into the development and assessment processes as a partner so that use of the outputs of the process can be utilized more readily by nras where the product will ultimately be used. article 58 of european commission's regulation no 726/2004 is a specific framework, in collaboration with who, designed to support lower income countries regarding products to be marketed outside of the european union 52 . the ema will assess products of major public health interest, collaborating with the who and the nras in the countries of use. regulators, experts and observers from lower income countries participate in the scientific review of the product -both during the development phase and during the marketing application phase. the ema publishes a scientific opinion regarding the marketing application. this allows under-resourced nras to make a decision that leverages the ema's assessment (including good clinical and manufacturing practice inspections) and their engagement with ema and the who during the development and marketing application assessments. recently, an option has been provided for total or partial fee waivers for the manufacturer 53 . while not marketed in the eu, the malaria vaccine rts,s/as01 received a positive scientific opinion under article 58 following trials in seven african countries 54 . likewise, in a special program to support access to innovative products in low-income countries, swissmedic deploys the marketing authorization for global health products (maghp) program. it performs similarly to the ema's article 58 regarding assessment of product development packages and marketing authorization applications in conjunction with who and the nras from the countries where the product will be used. the difference is that the product, if the assessment is positive, will receive a swiss marketing authorization even if it will not be used in switzerland. in the eu, as the product is not intended for use in the eu, the result of the process is a positive opinion, but not a european marketing authorization. both of these programs aspire to facilitate a reduction in timelines for development and authorization of products intended solely or primarily for use in lower income countries, thus making needed medicines available faster 55 . in the near future, regulatory agencies in lower income countries, that have not yet done so, must also become equipped to undertake post-eul oversight and vigilance surveillance requirements. in addition, they must develop local frameworks to allow emergency use authorization of products during public health emergencies, and that allow the use of candidates that may lack human efficacy data but have both recognized animal efficacy data and initial human safety data. accelerating availability of effective, safe, quality products is essential in a public health emergency. depending on the context, the feasibility of clinical trials, the strength of animal or clinical surrogate data, and the initial safety profile of the product, one facilitated pathway may be pursued over another or several of these pathways may be pursued simultaneously or sequentially. in these situations, regulators are generally quite willing to discuss putative development plans and regulatory pathways with product developers. developers should take advantage of such opportunities: these are key to accelerated product development, marketing authorization assessment, and patient access under these facilitated pathways. generally, this is an iterative process, with decisions being made and modified as further data regarding the emergency and product become available. meeting demand via these pathways in the case of a large public health emergency will require robust pre-clinical studies and significant at-risk investment in scaling manufacturing ahead of clinical proof of concept. because of the rapidly changing nature of public health emergencies, and the requirement for a well-validated animal model, certain pathways may not be able to be utilized in a public health emergency. historically, most regulatory pathways used in public health emergencies rely on some human efficacy data. pathways that bring together the manufacturer, nras where the product is going to be used, nras with specific needed expertize, who, and regulatory and clinical experts will accelerate the availability of needed novel medical countermeasures. the benefits of such rapid development could have major impacts, both in terms of lives saved and reduction in disease spread and intensity. received: 20 march 2020; accepted: 25 september 2020; understanding ebola: the 2014 epidemic the world health organization accelerating the development of medical countermeasures for the next pandemic the next epidemic-lessons from ebola experiences with and challenges afforded 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medicines agency the european medicines agency the united states food and drug administration the european medicines agency. support for early access japan pharmaceutical and medical device agency. correspondence to the drug conditional early approval system the united states food and drug administration product development under fda's animal rule: understanding fda's expectations and potential implications for traditional development programs the united states food and drug administration. cder drug and biologic animal rule approvals first vaccine approval under the fda animal rule guideline on procedures for the granting of a marketing authorisation under exceptional circumstances, pursuant to article 14 (8) of regulation (ec) no 726 the european medicines agency. european public assessment report-imvanex-modified vaccinia ankara virus emergency use authorization of medical products and related authorities-guidance for industry and other stakeholders c. a. termination of the 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first malaria vaccine receives positive scientific opinion from ema guidance document scientific advice maghp author contributions l contributed equally to the conceptualization of the manuscript. s.s. designed and authored the manuscript, table and figure. a.c. and m. m.l critically revised and approved the final version the authors declare no competing interests. supplementary information is available for this paper at https://doi.org/10.1038/ s41541-020-00249-5.correspondence and requests for materials should be addressed to s.s. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons. org/licenses/by/4.0/. key: cord-306351-ka6asw3m authors: alsuliman, tamim; alasadi, lugien; alkharat, banan; srour, micha; alrstom, ali title: a review of potential treatments to date in covid-19 patients according to the stage of the disease date: 2020-05-30 journal: curr res transl med doi: 10.1016/j.retram.2020.05.004 sha: doc_id: 306351 cord_uid: ka6asw3m abstract introduction and motivation: since the end of 2019, the covid-19 pandemic has affected millions of people worldwide. with the rapid spread of this virus, an immense burden has fallen upon both healthcare and economic systems. as a consequence, there is an unprecedented urgency for researchers and scientific committees from all over the world to find an effective treatment and vaccine. review structure: many potential therapies are currently under investigation, with some, like hydroxychloroquine, being authorized for emergency use in some countries. the crucial issue is now clearly to find the suitable treatment strategy for patients given comorbidities and the timeline of the illness.vaccines are also under development and phase 1 clinical trials are rolling. despite all efforts, no single drug or vaccine has yet been approved. in this review, we aim at presenting the proposed pathophysiological mechanisms of sars-cov-2 and to provide clinicians with a brief and solid overview of the current potential treatments classified according to their use at the three different currently proposed disease stages. in light of pathogenesis and proposed clinical classification, this review’s purpose is to summarize and simplify the most important updates on the management and the potential treatment of this emergent disease. after an incubation period, sars-cov-2 invades the mucosal membranes, especially nasal and oralpharyngeal membranes, causing upper respiratory infection with mild symptoms in the first phase. the virus binds to target cells through angiotensin-converting enzyme 2 (ace2). this activates the serine protease tmprss2 for s protein priming ( figure 2 ) [29] . ace2 is expressed by epithelial cells of the intestine, lung, kidney, and blood vessels [30] . treatment in this phase is based essentially on symptomatic relief, supportive and non-specific therapies, such as acetaminophen. the use of virus-targeting treatments may be beneficial in this period in order to stop viral replication [8] . although some argue that hydroxychloroquin (hcq) can be used early in stage 1. this use may have negative effects regarding loss of immunization chances due not only to its reduction of viral load, but also to its mmuno-suppressive characteristics [31] . isolation remains the cornerstone intervention for containment of covid-19 as no treatment or vaccination has yet been globally approved. supplementary oxygen, acetaminophen, and antibiotics should be administered as required. non-invasive ventilation, intubation and mechanical ventilation might be required for critically ill patients and in cases of respiratory failure in the advanced stages iib and iii. close monitoring of organ function should be undertaken for early detection of organ failure or septic shock in predisposed patients [5, 12] . antiviral therapies: remdesivir is a phosphoramidate prodrug of an adenosine c-nucleoside that targets the viral rnadependent rna polymerase (rdrp) proteins. working as a nucleotide analogue, this drug has proved its broad-spectrum antiviral activity including the effect against several human and zoonotic coronaviruses including sars-cov-2. since human safety data for remdesivir are available from several clinical trials that tested remdesivir's efficacy against ebola virus, several clinical trials are already being held in the united states and china to investigate its efficacy treating covid-19 patients [7, 26, 32] . the dose under investigation for treatment of covid-19 is 200 mg intravenously (iv) on day 1 followed by 100 mg iv daily for up to 10 days, infused over 30-60 minutes [7] . several trials of remdesivir treatment on few patients in the united states have shown early promising benefits in cases with severe pneumonia [33, 34] . in a cohort study that included 61 severe covid-19 patients from different countries, using remdesivir (200 mg iv. on day 1, then page 6 of 24 j o u r n a l p r e -p r o o f 100 mg daily for 9 days) led to a clinical improvement in 63% of patients with a median follow-up of 18 days. the total mortality rate in this study was 13% [35] . lopinavir (lpv) is a human immunodeficiency virus 1 (hiv-1) protease inhibitor which is administered in combination with the "booster" ritonavir (rtv), a potent cyp3a4 inhibitor that increases lpv half-life. even though lpv/rtv was effective against sars-cov in tissue cultures, its efficacy against mers-cov was controversial. results of a randomized, controlled, open-label trial that evaluated lopinavir-ritonavir vs. standard of care treatment in adults hospitalized adults with severe covid-19 were recently published [36] . the two arms of this study included 199 confirmed covid-19 patients and showed similar 28-day mortality rates and viral load at varying times since onset of symptoms. this study also showed withdrawal of medication in 13 patients in the lpv group due to adverse events (table 1) . however, the relatively long median time to randomization (13 days) after onset of symptoms is thought to partially explain lack of effectiveness in the covid-19 arm [37] . other clinical trials including lopinavir/ritonavir either as monotherapy or mostly in combination with other drugs have been conducted or are still ongoing. reported data from published investigations are difficult to interpret due to concomitant drug therapies, varying illness severity amongst patients and lack of comparison groups [7, 38] . china, however, has included lopinavir/ritonavir in its guidelines at an oral dose of 400 mg/100 mg twice a day for no more than 10 days. but more data are needed from ongoing studies, and caution should be taken regarding adverse effects and the real advantage over standard of care management [7, 22] . umifenovir is an antiviral agent that has been used for influenza treatment and has shown activity against sars-cov in vitro [7, 39] . its activity against sars-cov-2 was investigated recently at a dose of 200 mg every 8 hours in combination with lopinavir/ritonavir in a retrospective cohort chinese study [39] . results showed better clinical response in the combination group in comparison with the lopinavir/ritonavir monotherapy group. umifenovir is currently being tested in seven randomized trials for the treatment of covid-19 [38] . anti-endocytosis treatment: baricitinib is a selective janus kinase 1 and janus kinase 2 (jak1 and jak2) inhibitor. the mechanism of action is considered to be by modulation of viral endocytosis. but there are huge concerns that this blockage page 7 of 24 j o u r n a l p r e -p r o o f may potentiate sars-cov2 infection, and there are other safety issues related to this product's administration [40] . ace2 was identified as a key receptor for sars-cov-2. data regarding the interaction between covid-19 severity and angiotensin converting enzyme 2 (ace2) receptor inhibition is conflict, and contrary theories have been proposed so far [41, 42] . initially, concerns were raised on the basis that aceis and arbs led to an increase in the number of ace2 receptors in the cardiopulmonary circulation in experimental animals, and that this might lead to more severe outcomes due to sars-cov-2 infection [43] . on the other hand, ace2 has been found to protect the lungs from injury. and some data suggest that sars-cov-2 down-regulates ace2 expression after initial engagement with the receptor. this down-regulation of ace2 activity in the lungs might facilitate lung injury. in a recent in-vitro study hrsace2 was shown to significantly block early stages of sars-cov-2 infections [41, 42] . in a recent retrospective study that included 564 patients, hypertensive patients treated with acei/arb were less likely to develop severe pneumonia, and the study concluded that these drugs might have a protective effect [44] . until more data are available, there is no indication for patients treated with aceis or arbs to withhold their treatment (renin-angiotensin-aldosterone system inhibitors in patients with covid-19 [45] . camostat mesylate is a serine protease inhibitor, a drug approved in japan for use in pancreatic inflammation. it usually blocks tmprss2, a protease that was recently shown to be responsible for the coronavirus s protein priming, which is crucial for viral entry into target cells and for viral spread in the infected host as published by hoffman et al, in cell, from the german primate center [29] . several clinical trials are ongoing comparing camostat mesylate as a single agent vs. placebo or in combination with other drugs such as hydroxychloroquin [46, 47] . in this stage, pulmonary involvement is well settled, while we note remarkable viral multiplication and pulmonary localized inflammation. viral pneumonia, with cough, fever and hypoxia (stage iib: hypoxia defined as a pao2/fio2 of <300 mmhg) identify this period [8] . chest imaging reveals bilateral infiltrates or ground glass opacities [48] . laboratory tests show increasing lymphopenia while inflammation markers may be normal or slightly elevated [5] . normally most hospitalizations occur in this phase. with advanced disease, the virus infects the lower respiratory tract leading to pneumonia and worsens symptoms such as dyspnea and hypoxemia [4, 5, 49] . treatment usually relies on supportive measures and the aforementioned anti-viral therapies. in early parts of this stage (iia), the use of corticosteroids in patients with covid-19 may be avoided. while in stage iib, the j o u r n a l p r e -p r o o f use of anti-inflammatory treatment may be permitted, indeed, the presence of hypoxia may indicate the high probability of unfavorable systemic evolution [5, 8] . coagulopathy seems to be another issue that affects the prognosis in more severe cases. importantly, elevated d-dimer levels seem to be a marker to predict severe illness and mortality. other laboratory findings like hrombocytopenia and prolonged prothrombin time also indicate a hyper-coagulation state in covid-19 patients. the use of anticoagulant therapy has improved mortality rates in hospitalized patients with markedly elevated d-dimer or those who have sepsis-induced coagulopathy (sic) score ≥4. with all the emerging evidence, current guidelines recommend a prophylactic dose of low molecular weight heparin (lmwh) for all hospitalized patients in the absence of contraindications [50] [51] [52] in order to eliminate the virus, a good immune status is essential in this phase [4, 53] . even in elderly and immunocompromised patients, these phases tend to be respected, albeit in presenting different severe clinical manifestations [8] . treatments potentially investigable in this stage are the following: chloroquine (cq) is a 4-aminoquinoline antimalarial agent that has proven anti-inflammatory and immunomodulatory activities. cq also has anti-viral properties due to the following mechanisms: blocking virus/cell fusion; interfering with the glycosylation of cellular receptors, lysosomes and autophagosomes impairment; inhibiting viral enzymes ( i.e. viral dna and rna polymerase); increasing ph of intracellular vesicles which interferes with ph-dependent viral replication [54] [55] [56] . hydroxychloroquine (hcq) is a derivative of cq with similar characteristics but with better safety profile [56, 57] . both drugs have narrow therapeutic range which makes drug-toxicity probable especially with uncontrolled usage. cardiac toxicity (qt interval prolongation) is the major, and even lethal, concern about usage of these drugs [54, 58] . in vitro studies have demonstrated cq efficacy against sars-cov-2 [55] . with its known safety profile, clinical investigations have been held in different countries; and at least 18 trials evaluating hcq or cq are currently underway worldwide [38, 58] . a pilot randomized chinese study [59] investigated hcq in 30 confirmed covid-19 cases. fifteen patients received 400 mg of hcq per day for 5 days, while others received the conventional treatment. the primary endpoint was covid-19 nucleic acid negativity in respiratory pharyngeal swab on day 7 after randomization. the results were comparable between the study and the control group as of day 7. throat swabs were negative in 13 (86.7%) cases in the hcq group and in 14 (93.3%) cases in the control group (p ＞ 0.05). furthermore, the median duration from hospitalization to virus nucleic acid negative conversion and the median time for body temperature normalization were also comparable between the two groups. these results are comparable to another chinese open-label, randomized, controlled trial that included 150 hospitalized covid-19 patients. hcq dosage in this study was 1, 200 mg daily for 3 days with a maintenance j o u r n a l p r e -p r o o f dose of 800 mg daily for 2 or 3 weeks depending on illness severity. no difference regarding negative viral conversion was observed between the hcq and the standard of care group, but significant clinical improvement was noticed in the hcq group [60] . a preliminary brazilian randomized, double-blinded, clinical trial has investigated two different cq dosages (600 mg twice daily for 10 days vs. 450 mg for 5 days, twice daily only on the first day) in 81 patients with severe covid-19. all patients received ceftriaxone and azithromycin as well. the high dosage cq arm had higher qtc prolongation and mortality rates, with no apparent benefit of cq regarding viral clearance or mortality in either study arms [61] . of note, only 62 out of the enrolled 81 patients had been confirmed by rt-pcr. on the other hand, data emerging from other ongoing chinese trials have demonstrated that cq phosphate is superior to a control treatment in the following areas: pneumonia exacerbation inhibition, imaging findings improvement, virus negative conversion promoting, and disease course shortening [62] . additionally, a randomized chinese cohort of 62 in-hospital patients with covid-19 showed that hcq may help shorten the time to clinical recovery [63] . gautret, p. et al, reported promising results in two studies in france [64, 65] . in these studies, researchers investigated the efficacy of hcq in combination with azithromycin for the treatment of confirmed covid-19 patients. in the first study, a significant reduction in viral carriage on day 6 post inclusion compared to control group was noticed. meanwhile, the second study reports a rapid fall in nasopharyngeal viral load on day 7 (83%) and day 8 (93%) which was confirmed by pcr. in addition, virus cultures were negative in 97.5% patients on day 5. this allowed rapid discharge with a mean length of stay of five days. hcq dosage used in these studies was 600 mg per day for 10 days. combining all in-vitro and in-vivo data, some countries have authorized treating hospitalized patients, with some conditions, with cq and hcq [22, 27, 28] . however, there are serious concerns raised regarding its usage. for example, clinical data from reliable randomized controlled studies are still missing, and data published to date lacks homogeneity in terms of recommended dose concentration, treatment duration, and severity of patient illness [58] . recently, the american thoracic society has released interim guidance on treating covid-19. for hospitalized patients with pneumonia, hcq and cq may be used on a case-by-case basis, but clinicians must consider the potential benefit/risk ratio and the patient's condition must be severe. for outpatients with covid-19 or hospitalized patients without pneumonia there are no specific recommendations [66] . in contrast, the surviving sepsis campaign announced that there's insufficient evidence to declare a recommendation on the use of cq and hcq in critically ill adults with covid-19 [67] . the infectious diseases society of america (idsa), on the other hand, in its recently published guidelines [68] has recommended hcq/cq (+/-azithromycin) in the context of clinical trials only. clinical data regarding this combination in the treatment of covid-19 patients is still lacking, but several clinical trials are currently being conducted [38, 69] . the who has launched a multinational trial called "solidarity trial". this trial will test the four most promising coronavirus treatments remdesivir, lopinavir/ritonavir, lopinavir/ritonavir plus interferon b, hydroxychloroquin with the aim to end the pandemic [70] . ivermectin is a broad spectrum anti-parasitic drug, but it has also shown anti-viral activity in vitro with its confirmed ability to inhibit integrase protein (in) nuclear import and hiv-1 replication. it has also shown its ability to inhibit nuclear import of host and viral proteins [71, 72] . a recent in vitro study tested the antiviral activity of ivermectin against sars-cov-2 [72] . ivermectin treatment resulted in 99.8% reduction in all viral material within 48 h compared to control samples. these results made the authors propose ivermectin as a possible treatment for covid-19 since it's an fda approved drug with a known safety profile. nitazoxanide has shown in vitro activity against sars cov-2 with known broad antiviral activity against other viruses like influenza and rotavirus. the mechanism of action is believed to be due to interference with viral replication by targeting host regulated pathways rather than virus-specific pathways. in addition to its antiviral activity, it inhibits the production of pro-inflammatory cytokines tnf-, il-2, il-4, i-5, il-6, il-8 and il10. no clinical information is yet available on the efficacy of nitazoxanide in the treatment of covid-19 [7, 73] . this is the most severe stage in this disease stage classification and luckily it concerns a fewer number of patients with ards and cytokine storm syndrome (css) being the hallmark of the pathogenesis [8, 74] . in these severe cases, virus replication and tissue damage continue, especially in the lungs and other ace2 expressing organs, which leads to an even higher increase in pro-inflammatory cytokines released by macrophages and granulocytes [49, 53] . high levels of pro-inflammatory cytokines such as interleukin 1b (ilamong these cytokines, several have been suggested as a potential therapeutic target. il-1, for example, is activated after the binding between covid-19 and toll-like receptors (tlr). released il-1 mediates lung inflammation, fever and fibrosis. il-1 is also known for its important role in the progression of pulmonary fibrosis [49] . il-6 is also an important cytokine during respiratory viral infections, and it has been reported that, during this covid-19 pandemic, it has been correlated with pulmonary infection severity in icu patients [49, 75] . both il-1 and il-6 have been presented as potential therapeutic targets [74, 75] . in addition to potential shock, stage iii is also marked by extra-pulmonary involvement, such as vasoplegia, myocarditis, and organ failure. treatment is essentially based on the use of immunomodulatory therapies in order to improve systemic inflammation and to block consequent organ failure. the use of corticosteroids may be helpful in this phase, generally in tandem with the use of cytokine inhibitors. intravenous immune globulin (ivig) may also be considered as an immune system modulator. rapid application of such a treatment plan can potentially enhance patient prognosis, which is basically poor in this stage [8, 77, 78] . using corticosteroids to treat severe pneumonia due to covid-19 is still controversial. the who recommends against the routine use of corticosteroids in these patients [12] . data from clinical trials are widely variable in terms of participants included and results reported, that's why clinical judgment should be based on a case-by-case approach. delayed viral clearance and infection susceptibility are two major concerns that come with corticosteroid usage in covid-19 patients [7, 45, 69] . in a recent release, the surviving sepsis campaign has suggested systemic corticosteroid administration for ards adult patients with covid-19 who are mechanically ventilated. on the other hand, recommends against corticosteroid use in adults without ards [67] . five randomized controlled trials investigating methylprednisolone in covid-19 patients are also currently registered [38] . a-bio-immune-modulatory treatments: immunoglobulins have been widely used in medical practice, and their use has shown clinical benefits in previous studies of sars and mers. ivig is currently under investigation for treatment of covd-19 [38, 69, 77] . a case series of 3 severe covid-19 patients who received high-dose ivig (0.3-0.5 g/kg/day) for five days was reported [77] . all patients experienced clinical improvement shortly after administration. however, other therapeutic agents were administered for these patients including antivirals and a short course of steroids. in a pre-print retrospective study [78] , authors reported the data of 10 severe covid-19 patients who didn't respond to a combination of low-dose corticosteroid (40-80 mg/d) and immunoglobulin (10 g/d) but have considering the genetic relation between sars-cov-2 and sars-cov-1 some argue that it may be considered for further verification as a potential therapeutic, as 10 of 12 sars patients were reported, in a 2004 publication, to have an uneventful recovery after treatment with this product [4, 79] . the fda has recently approved convalescent plasma for serious or immediately life-threatening covid-19 infections under emergency investigational new drug application (einds) [80] . convalescent plasma has been previously studied during other epidemics including h1n1 influenza virus pandemic, sars-cov-1 epidemic, and the mers-cov epidemic. recently, a preliminary case series of five intubated covid-19 patients with ards showed promising results. these patients received 400 ml of convalescent plasma containing neutralizing sars-cov-2-specific antibody (igg) from recovered covid-19 donors. all patients had gradual clinical and radiological improvement within 3 days and four patients no longer required respiratory support by day 9, viral loads also became negative within 12 days after transfusion. seven clinical trials are currently registered [7, 38, 81] . tocilizumab is a monoclonal antibody (mab) that inhibits the il-6 receptor. as mentioned earlier, il-6 plays a key role in respiratory viral infections and in crs which is linked to poorer prognosis and higher mortality rate in covid-19 patients. tocilizumab is approved for the treatment of rheumatoid arthritis and its safety and efficacy profile has previously been well studied [7, 74] . preliminary data [82] included cases of 21 severe and critical pneumonia in covid-19 confirmed patients who showed clinical and radiological improvement in 75.0% (severe pneumonia) and 90.5% (critical pneumonia) of participants. lymphocyte count also returned to normal in 52.6% of cases on day 5 of drug administration. all patients received 400 mg of intravenous tocilizumab once, and three patients, due to persistent fever, received another 400 mg dose after 12 hours. despite promising primary data, when it comes to studies regarding optimal timing and il-6 threshold of tocilizumab administration during the course of covid-19, information is still lacking from larger, controlled, long-term studies. moreover, il-6 monitoring might be an obstacle in some institutions, and its adverse effects bacterial infection susceptibility, neutropenia and thrombocytopenia should be considered when a clinical decision is to be made. two clinical trials are ongoing right now which might provide further needed information [7, 38] . leronlimab is a humanized igg4 monoclonal antibodies that blocks cc chemokine cellular receptor 5 (ccr5) and plays a key role in several immunological processes. leronlimab is being evaluated for hiv and breast cancer treatment and it is believed to have an antiviral activity while mitigating the cytokine storm. some claim that leronlimab has achieved preliminary results in a few severe cases of covid-19 [83, 84] . bevacizumab is an approved treatment for multiple cancers. it is a humanized monoclonal antibody that prevents the association between vascular endothelial growth factor (vegf) and endothelial receptors flt-1 and kdr, and it may reduce the levels of vegf caused by hypoxia and severe inflammation. eventually, it might suppress the edema in patients with covid-19. bevacizumab is currently being tested in a chinese randomized controlled trial [7, 69] . c-anti-interleukin 1: anakinra® is an il-1 receptor antagonist. as mentioned earlier, il-6 seems to have a key role in the respiratory viral infections and in progression of pulmonary fibrosis. so anakinra® has been suggested as possible adjunctive treatment. but, to the best of our knowledge, no in-vitro or clinical data are available [7, 49] d-cell-based therapy: the italian college of anesthesia, analgesia resuscitation and intensive care has reported recent guidelines to treat coronavirus patients. it includes a statement that stem cells could have a serious potential to treat covid-19 by decreasing the number of patients admitted to the icu and discharging them quickly [85] . msc can theoretically inhibit immune system overreaction and improve the microenvironment that promotes endogenous repair which could potentially protect alveolar epithelial cells. this would, in theory, prevent pulmonary fibrosis and also improve lung function [86, 87] . the published studies are from china, including a small cohort 7 in the treatment group and 3 in the control group [86] and a case report [88] . some expect that clinical trials may be, nowadays or very soon, recruiting. the available data shows some promise in managing covid-19 illness, especially in critically ill patients that could be treated under a compassionate-use protocol [89] . cynk-001 (intravenous infusion of natural killer (nk) cells) is the name of yet another trial that has enrolled covid-19 patients. it aims to boost immune systems of patients at risk of more severe disease and those starting to show symptoms by applying cynk-001. the mechanism has been slowing virus replication [90] . prevention: an urgent response to the brisk expansion of covid-19 has been evoked throughout scientific communities in order to develop an effective vaccine. rapid genome sequencing and potential molecular targets have been identified, and more than 20 vaccines are currently under investigation. some of these vaccines have shown effectiveness in preclinical studies, while still others are already in phase i clinical trials [94] [95] [96] . until the final approval of a given vaccine and its effective distribution, an approach based on early case detection and isolating, laboratory testing, contact tracing and quarantining (as recommended by the who) seem the most effective way to prevent further spread of sars-cov-2 [6, 97] . growing evidence suggests a link between universal bcg vaccination policy and reduced morbidity and mortality for covid-19. comparing italy to japan, for example, the first case of covid-19 appeared in japan earlier than in italy, but japan has maintained a low mortality rate despite not implementing restrictive social isolation measures [98] . another study found that the mortality rate has been 4.28/million in countries with a bcg program compared to 40/million in countries without such a program [99] . to date, the efficacy of bcg vaccine on preventing covid-19 is controversial due to many limitations, one being the reality of comparing countries in different phases of the pandemic. this association might be clearer with upcoming data. tuberculosis vaccine (vpm1002), on the other hand, is a new vaccine based on the old bcg vaccine. the idea is that in many studies conducted on mice, the vaccinated mice had lower influenza, lower serum viral load, and less lung damage. it is claimed that the bcg vaccine may activate the immune system against viruses and possibly decrease covid-19 mortality rates [100] . while the complete pathophysiology of covid-19 needs to be better understood, urgent research for rapid solutions based on already established knowledge is still ongoing. page 15 of 24 j o u r n a l p r e -p r o o f for many physicians, these new potential strategies may be seductive. although the disastrous situation currently faced by many countries may explain the attractiveness of such treatments, the urgent need for a cure does not justify any use which is unauthorized by national health regulatory authorities. meanwhile, as the world waits for a widely approved treatment, preventive interventions coupled with clear local and international management guidelines must be always respected in order to lessen the damage and permit more exhaustive and conclusive research to be conducted. ta has received honorarium from biotest france sas. biotest ag commercializes pentaglobin®. symptomatic treatment is a basic step in all clinical stages of the disease, with oxygen therapy here reflecting all interventions that may be needed from nasal cannula to mechanical ventilation. while some argue that antiviral therapy (especially remdesivir) could be considered for some patients in stage i of the disease, other preserve it for the stage ii patients. ribavirin and ifnα-2b in particular, in our opinion shouldn't be considered in the management of stage i. more severe cases (stage iii) need more extensive interventions by adding immunomodulatory treatments to the previous management steps in the attempt to contain the hyperinflammatory response. *these treatments might also be investigated in both stage ii and iii. **these treatments might also be investigated in stage iii. ***these treatments are mainly investigated in stage iii. hydroxychloroquine (hcq) targets several levels of viral infection. it changes the glycosylation of ace2 to inhibit virus entry. being a weak base, it also affects endosomal activity by increasing, the ph of acidic intracellular organelles. finally, it 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guidance on recognition and management of coagulopathy in covid-19 covid-19 infection: the perspectives on immune responses chloroquine as a potential treatment and prevention measure for the 2019 novel coronavirus: a review remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting sars-cov-2 infection in vitro insights from nanomedicine into chloroquine efficacy against covid-19 of chloroquine and covid-19 a pilot study of hydroxychloroquine in treatment of patients with common coronavirus disease-19 (covid-19) hydroxychloroquine in patients with covid-19: an openlabel, randomized chloroquine diphosphate in two different dosages as adjunctive therapy of hospitalized patients with severe respiratory syndrome in the context of coronavirus (sars-cov-2) infection: preliminary safety results of a randomized, double-blinded, phase iib clinical trial (clorocovid-19 study) breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid-19 associated pneumonia in clinical studies efficacy of hydroxychloroquine in patients with covid-19: results of a randomized clinical trial hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 covid-19 patients with at least a six-day follow up: an observational study n covid-19: interim guidance on management pending empirical evidence. from an american thoracic societyled international task force surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) infectious diseases society of america guidelines on the treatment and management of patients with covid-19 clinical trials on drug repositioning for covid-19 treatment solidarity" clinical trial for covid-19 treatments 2020 ivermectin is a specific inhibitor of importin α/βmediated nuclear import able to inhibit replication of hiv-1 and dengue virus the fda-approved drug ivermectin inhibits the replication of sars-cov-2 in vitro nitazoxanide, a new drug candidate for the treatment of middle east respiratory syndrome coronavirus covid-19: consider cytokine storm syndromes and immunosuppression pathogenic t cells and inflammatory monocytes incite inflammatory storm in severe covid-19 patients the use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (covid-19): the experience of clinical immunologists from china short-term moderate-dose corticosteroid plus immunoglobulin effectively reverses covid-19 patients who have failed low-dose therapy pentaglobin in steroid-resistant severe acute respiratory syndrome revised information for investigational covid-19 convalescent plasma. fda 2020 treatment of 5 critically ill patients with covid-19 with convalescent plasma effective treatment of severe covid-19 patients with tocilizumab antibodies to watch in 2020 leronlimab used in seven patients with severe covid-19 demonstrated promise with two intubated patients in icu, removed from icu and extubated with reduced pulmonary inflammation transplantation of ace2-mesenchymal stem cells improves the outcome of patients with covid-19 pneumonia msc based therapies-new perspectives for the injured lung clinical remission of a critically ill covid-19 patient treated by human umbilical cord mesenchymal stem cells expanded umbilical cord mesenchymal stem cells (uc-mscs) as a therapeutic strategy in managing critically ill covid-19 patients: the case for compassionate use center for drug evaluation and research. investigational new drug (ind) application. fda 2020 use of siltuximab in patients with covid-19 pneumonia requiring ventilatory support potential interventions for novel coronavirus in china: a systematic review an orally bioavailable broad-spectrum antiviral inhibits sars-cov-2 in human airway epithelial cell cultures and multiple coronaviruses in mice nih clinical trial of investigational vaccine for covid-19 begins. national institutes of health (nih) 2020 microneedle array delivered recombinant coronavirus vaccines: immunogenicity and rapid translational development who. draft landscape of covid-19 candidate vaccines 2020 critical preparedness, readiness and response actions for covid-19 interim guidance 2020 correlation between universal bcg vaccination policy and reduced morbidity and mortality for covid-19: an epidemiological study bcg vaccination may be protective against covid bcg as a case study for precision vaccine development: lessons from vaccine heterogeneity, trained immunity, and immune ontogeny the authors thank rachel tipton, hasan iessa, phd., and danah el-refaie for the proof reading of this manuscript and layth sliman for the technical support. key: cord-283202-5fq1wxz8 authors: kent, marc title: the cat with neurological manifestations of systemic disease. key conditions impacting on the cns date: 2009-05-31 journal: journal of feline medicine & surgery doi: 10.1016/j.jfms.2009.03.007 sha: doc_id: 283202 cord_uid: 5fq1wxz8 practical relevance a number of systemic diseases are associated with neurological deficits. most systemic diseases that impact on the nervous system result in multifocal neurological signs; however, isolated deficits can also be observed. this article reviews the clinical signs, pathophysiology, diagnosis, treatment and prognosis of four important systemic diseases with neurological consequences: feline infectious peritonitis, toxoplasmosis, hypertension and hepatic encephalopathy. clinical challenges early recognition of systemic signs of illness in conjunction with neurological deficits will allow for prompt diagnosis and treatment. while neurological examination of the feline patient can undoubtedly be challenging, hopefully the accompanying articles in this special issue will enable the clinician to approach these cases with more confidence. evidence base the veterinary literature contains numerous reports detailing the impact of systemic disease on the nervous system. unfortunately, very few references provide detailed descriptions of large cohorts of affected cats. this review summarises the literature underpinning the four key diseases under discussion. knowledge of the epidemiology of fcov infection is important in order to understand the pathogenesis of fipv. feline coronavirus infection is virtually endemic, with studies revealing that: ✜ approximately 50% of cats in the united states and europe have antibodies against fcov; 3 ✜ in australia, the seroprevalence in owned cats is approximately 34%; 7 ✜ in the uk, 82% of show cats, 53% of breeding cats and 15% of single-cat homes have anti-fcov antibodies; 8 ✜ in italy, the seroprevalence is 82% in cats from breeding colonies, shelters and homes; 9 ✜ in switzerland, similarly 80% of breeding cats, and 50% of free-roaming cats, test positive for anti-fcov antibodies. 10 the significance of this worldwide distribution relates to the fact that fipv is the result of spontaneous mutation of fecv, which means that cats worldwide are susceptible to developing fip. 6 despite this, approximately 5% of cats in multicat homes and a smaller percentage of cats in single-cat homes develop fip. 3, 11, 12 notably, it is young cats and immunosuppressed cats that are most susceptible to developing fip. in addition, certain purebreed cats, specifically the birman, ragdoll, bengal, rex, abyssinian and himalayan breeds, have a greater risk of developing fip, which suggests a genetic influence on susceptibility. 13 transmission of fcov is through infected fecal material via the orofecal route, leading to enteric infection. enteric fcov infection typically results in inappetence and/or mild gastrointestinal signs such as vomiting and diarrhea. infected cats shed fecv for up to 10 months post infection; thereafter infected cats shed virus intermittently or continuously, serving as chronic carriers and thereby perpetuating reinfection of other individuals. 14 as with all coronaviruses, fecv undergoes a high rate of mutation. the degree of mutation, and therefore the development of a mutation leading to fip, appear greater in susceptible individuals as well as in individuals with a high viral load. 15, 16 in part, this may explain the fact that more than 50% of cats with fip are under a year of age. 3 the initial step in the pathogenesis of fip is the mutation of fcov, in the process of which the virus gains the ability to replicate within macrophages. once this occurs, the virus can be disseminated throughout the body. ultimately, fip is an immune complex disease that is a consequence of virus or viral antigens complexed with antiviral antibodies. 16 after distribution by macrophages, the virus may enter tissue and replicate, resulting in attrac-consisting primarily of lymphocytes, macrophages, and varying numbers of plasma cells forming perivascular cuffs. 18 subependymal periventricular inflammatory infiltrate may obstruct the mesencephalic aqueduct leading to obstructive hydrocephalus. similarly, obstruction of the central canal of the spinal cord may lead to hydromyelia. occasionally, infiltrate extends into the superficial neuropil and cranial nerve roots. 18 hematology in affected cats usually reveals a normocytic, normochromic, nonregenerative anemia, leukocytosis consisting of a neutrophilia, and lymphopenia. 22 approximately 50% of cats with the effusive form and 70% of cats with the dry form have increased serum proteins, primarily comprising a hyperglobulinemia. 23 protein electrophoresis discloses a polyclonal gammopathy, mainly involving the γ-globulins. 24 other biochemical changes may be observed depending on the severity of involvement of other organ systems including abnormal liver enzyme, bilirubin, blood urea nitrogen and creatinine levels. 25 although common clinicopathologic abnormalities in affected cats have been defined, changes in routine hematology and biochemical evaluations are often non-specific. consequently, establishing a definitive ante mortem diagnosis of fip is extremely challenging. 26 definitive diagnosis can only be achieved through histopathological identification of pyogranulomatous inflammation within tissue coupled with identification of the virus. 16 viral identification in tissue samples can be performed using immunohistochemistry or through pcr testing. however, there are several tests that may help support a presumptive ante mortem diagnosis. importantly, interpretation of results from such tests should be evaluated in conjunction with clinical signs and results of other diagnostics. taken outside the context of signs and other clinicopathologic data, most tests are unable to provide a definitive diagnosis. when present, effusions should be analyzed. typically, effusion from an affected cat should be consistent with a modified transudate. 3 cats with neurological signs should undergo magnetic resonance imaging (mri) of the brain. this may disclose hydrocephalus. 18 additionally, t2-weighted and t2weighted flair images may reveal periventricular hyperintensities consistent with periventriculitis. 18 although these findings are not pathognomonic, mri of the brain should be pursued in order to eliminate the potential that clinical signs may be a consequence of a disease process other than fipv. analysis of cerebrospinal fluid (csf) often reveals increased protein content (50-350 mg/dl) with a pleocytosis consisting of neutrophils, lymphocytes and macrophages. 20, 27, 28 the evaluation of fcov antibody titers (often erroneously referred to as an 'fip titer') in blood and other fluids has been extensively studied. however, despite years of investigation, caution should be exercised when interpreting fcov antibody titers in blood and effusions as high titers can be observed in healthy cats and low to absent titers in affected cats. 3 ✜ fipv is fatal and treatment is mainly palliative. since fip is an immune-mediated disease process, therapy has been directed at immunosuppression and/or immunomodulation with the goal of providing symptomatic care. immunosuppressive therapy using corticosteroids (prednisone at 2-4 mg/kg/day) may allow mildly affected cats to maintain an acceptable quality of life for weeks to months. in addition to corticosteroids, a wide array of drugs including chemotherapy agents (cyclophosphamide and melphalan), an antiviral (ribavrin), a thromboxane synthetase inihibitor (ozagrel hydrochloride) and a variety of immunomodulating drugs (promodulin, human interferon-α, propionibacterium acnes, and feline interferon-ω) have been investigated. 36 the interpretation of results from most studies has been hindered by a lack of control groups and the difficulty in establishing a definitive diagnosis of fip in treated cats. 36 still, most therapeutic trials have failed and, disappointingly, an effective treatment regime remains elusive. presence of neurological fipv. 18 cerebrospinal fluid fcov antibody titers correlate with serum fcov antibody titers but, most importantly, elevated csf fcov antibody titers may also be observed in cats affected by neurological diseases other than fip. 29 while pcr assays can be performed on blood and effusions in affected cats, they are unable to distinguish between the mutated fcov causing fip, and the non-pathogenic fcov. 30 in addition, healthy cats can be viremic with fcov. 31 therefore, pcr identification of virus in blood or effusions does not provide a definitive diagnosis. 32 while its application in csf has not been studied, pcr identification of virus in csf may allow a definitive diagnosis of fip. measurement of serum α1-acid glypoprotein (agp), an acute phase protein that increases during inflammation, has been used in the diagnosis of fip. 33, 34 in cats with signs and clinicopathologic data highly suggestive of fip, elevation in serum agp provides strong supportive evidence of fipv infection. 33 however, agp may also increase in other conditions associated with inflammation, such as feline immunodeficiency virus (fiv) infection, or in cats with a high viral load of fecv, which may limit its potential as a diagnostic tool for fip. 34, 35 prognosis unfortunately, the prognosis for cats with fip is grave as all affected cats succumb to the disease. to date, no therapy has been shown to alter the eventuality of humane euthanasia or death of affected cats. toxoplasmosis is caused by an obligate intracellular protozoan parasite, toxoplasma gondii. the definitive hosts are the domestic cat and other felidae. many mammals can become infected with t gondii and serve as intermediate hosts; however, fecal shedding of infective oocysts occurs only in cats. systemic and ocular toxoplasmosis have been well described in cats. the emphasis in the following discussion is on central nervous system (cns) toxoplasmosis. there are three methods of transmission of t gondii: fecal-oral, ingestion of tissue cysts, and congenital. reproduction of the organism can involve both a sexual and asexual phase. the asexual phase occurs in many mammals and birds, which serve as intermediate hosts. as the definitive host, the sexual phase of the life cycle can only occur in cats and it does so within the intestinal tract. as a result, unsporulated oocysts, which are non-infectious, are passed in the feces. these oocysts require 1-5 days for sporulation to occur, at which point they become infectious. ingestion of sporulated oocysts by another cat begins another cycle. toxoplasma gondii also displays an extraintestinal life cycle. after infectious oocysts have been ingested, the organism is capable of penetrating the wall of the intestinal tract and disseminating to multiple organs. within these other organs, asexual reproduction occurs, giving rise to tissue cysts -bradyzoites (so named given their slow replication) and tachyzoites (in which replication is rapid). ingestion of bradyzoites in tissue is probably responsible for the majority of infections. in cats it can result in intestinal replication, while ingestion of bradyzoites by other animals can only lead to extraintestinal infection. ingestion of infectious organism during gestation can also lead to congenital infection. 37 cysts that form as a result of extraintestinal infection are likely to persist for life. 38, 39 encysted bradyzoites are the most probable source of continual release of antigen and reactivation of infection. 38 reactivation of infection is thought to occur secondarily to immunosuppression. cats infected with fiv appear to be predisposed to the development of acute toxoplasmosis. 40 there appears to be a high seroprevalence of t gondii infection in cats co-infected with fiv. 41, 42 the significance of this relationship is unknown as the seroprevalence of t gondii infection in fiv-infected cats is similar to that in the general population. 39, 43 immunosuppression as a result of ciclosporin therapy has also led to acute toxoplasmosis. 44, 45 with the availability of renal transplantation in cats, the role of immunosuppression in reactivation of infection and the development of clinical disease has gained importance. [46] [47] [48] clinical signs clinical infection with t gondii is not common in cats. infections can be considered acute or chronic. 49 acute toxoplasmosis typically affects younger cats. the most common clinical signs are anorexia, lethargy, fever, dyspnea and sudden death. [49] [50] [51] [52] chronic toxoplasmosis typically affects older cats and manifests over weeks to months. signs are similar to acute infection and may include vomiting, diarrhea, anorexia, weight loss, fever and icterus. 42, [49] [50] [51] with the exception of finding t gondii in tissue, no single test provides a definitive diagnosis. serology for the detection of igg and igm anti-t gondii antibodies is widely used. 61 after experimental inoculation, an igm response is detected in 1-3 weeks and an igg response in 2-4 weeks. immunoglobulin m responses peak within 3 weeks and persist for 3-16 weeks. in cats co-infected with fiv, there is a delayed conversion from an igm to an igg response. 62 unfortunately, an igm response does not necessarily correlate with active disease as occasionally igm responses can be detected in clinically normal cats with chronic infection. likewise, a single high igg response does not predict active disease, as igg responses can last up to 6 years. 63 a rising titer is strongly suggestive of active disease, however, and maximal titers are reached within 2-3 weeks. 63 in practice, given the insidious nature of the disease many cats have reached maximal immune responses by the time they are examined by a veterinarian, making documentation of a rising titer difficult. 61 theoretically, identification of an immune response in the cns, an immunoprivileged site, would suggest infection. however, immunoglobulins may extravasate from the blood into the csf in other inflammatory diseases that disrupt the blood-brain barrier. defining a ratio between serum and csf igg responses may help eliminate the possibility of passive cross over of antibodies secondary to another disease that compromises the integrity of the blood-brain barrier. a serum:csf igg response > 1 suggests local cns production of immunoglobulin. in experimental oral inoculation, cats remain clinically normal yet develop a detectable igg response in the csf 4-12 weeks post inoculation and again 8-16 weeks after secondary exposure. 64 importantly, an igg response in the csf can occur after exposure to killed tachyzoites in previously infected cats. 65 therefore, observation of an igg response in csf does not necessarily document infection. 65 experimental inoculation does not result in an igm response in the csf. 64 potentially, therefore, detection of an igm response in the csf may be indicative of active disease, but this is yet to be confirmed. clinical signs reflecting organ involvement include lymphadenopathy, myocardial disease, pancreatitis, hepatitis, anterior uveitis and chorioretinitis. 41, 42, [49] [50] [51] 53, 54 the diagnosis of clinical toxoplasmosis can be challenging. hematologic findings are nonspecific, often consisting of non-regenerative anemia, neutrophilic leukocytosis, lymphocytosis and monocytosis. 41, 42, 50 biochemical abnormalities generally reflect organ involvement and include azotemia, elevation in liver enzymes, hyperbilirubinemia and hyperproteinemia. 41, 42, 50 thoracic radiographs may show a diffuse interstitial to bronchial pattern in which infiltrate may coalesce into areas of patchy alveolar patterns (fig 2) . [49] [50] [51] 60 neurological signs ✜ central nervous system involvement occurs in almost all clinically affected cats. 50 neurological signs typically reflect a multifocal distribution and include hypothermia, behavioral changes, seizures, ataxia, blindness, anisocoria, torticollis, vestibular disease, muscle hyperesthesia, and paresis/paralysis. 21 cerebrospinal fluid analysis typically reveals a mild lymphocytic pleocytosis predominantly, although other cell types may be observed; protein may be elevated to up to 149 mg/dl. 39 neutrophilic pleocytosis has also been reported. 58 with the exception of identifying t gondii in tissue, no single test provides a definitive diagnosis. a presumptive diagnosis is based on a combination of clinical signs, evidence of recent or active infection (gained via serology for immunoglobulins or immune complexes, or pcr), exclusion of other disease processes, and response to therapy. 39 hypertension has been defined as a sustained increase in systolic blood pressure ≥ 160-170 mmhg. 75 although the prevalence of hypertension in cats has not been accurately established, one study documented hypertension in 2% of healthy cats. 80 in cats referred for evaluation of disease associated with hypertension, or animals with clinical signs compatible with hypertension, a 30% prevalence was found. 79 hypertension can be divided into three categories: white coat, secondary and idiopathic. ✜ white coat hypertension is an artefactual increase in blood pressure that develops secondarily to excitement or anxiety, and is likely to be the result of activation of the sympathetic nervous system. 81 it is observed in cats, and results in a median increase in systolic blood pressure of 17.6 mmhg ± 1.5 mmhg. 81 although pcr assays have not been performed on csf for the detection of t gondii, pcr assays have been utilized in the aqueous humor, another immunoprivileged site. 66, 67 toxoplasma gondii can be identified in the aqueous humor of cats with uveitis using pcr; however, the organism can also be detected in the aqueous humor of clinically normal cats that have naturally been exposed to t gondii. 66 consequently, pcr detection of t gondii in aqueous humor does not provide definitive proof of active disease. a similar interpretation of pcr analysis of csf is likely. unfortunately, the prognosis is poor for cats displaying neurological signs or severe respiratory disease as most will succumb to the disease. 21, [56] [57] [58] 60, 73 despite this, cats with focal cns toxoplasmosis may achieve long term remission. 59 since the initial description of systemic hypertension in cats, 74 the impact of hypertension systemically and on the nervous system has become increasingly recognized. a testament to this is a recent consensus statement from the american college of veterinary internal medicine that has established guidelines for identification, evaluation and management of hypertension in dogs and cats. 75 in healthy cats, normal systemic blood pressure, which is often reported as a systolic measurement, is 118-162 mmhg. [75] [76] [77] the wide range in the reported normal values is likely to reflect a lack of standardization in technique and equipment used to measure blood pressure. 75 many factors affect blood pressure measurement including recording device, cuff size and operator skill, as well as patient factors such as size and demeanor of the cat. although increasing age was found to be associated with increased blood pressure in one study, other reports have found no effect of age on blood pressure. [77] [78] [79] the treatment of choice for cats with clinical toxoplasmosis is clindamycin hydrochloride at 12-25 mg/kg divided per day. 39, 42 clindamycin is almost completely absorbed after oral administration and achieves high concentrations in most tissues, including the lung. 68 concentrations in csf are low; 69,70 however, the concentration in the brain may be higher given the lipophilic nature of the drug. 71 clindamycin is well tolerated, with only minimal side effects (eg, vomiting and diarrhea) reported at dosages two and a half to four times the recommended dosage. 72 parenteral formulations can be used in animals unable to receive oral medication or those experiencing gastrointestinal toxicity. reports of successful treatment are rare, which may reflect the difficulty of establishing a definitive diagnosis. systemic clinical signs typically show improvement within 24-48 h of initiation of treatment. 39 cats with systemic or ocular disease treated with antibiotic therapy may achieve clinical remission; however, recurrence of signs is likely as antibiotic therapy is unlikely to eliminate the organism entirely. 42 chronic systemic hypertension has a variety of pathological consequences that collectively are referred to as end-organ or target organ damage. important target organ damage is observed in the kidneys, eyes, heart and nervous system. 90 in the kidney, this leads to an accelerated decline in renal function, proteinuria and death. hypertension can exist in animals at any stage of renal disease, and may be seen in nonazotemic animals. 75 in the eye, hypertension leads to hypertensive retinopathy and choroidopathy (fig 3) . exudative retinal detachment, retinal hemorrhage, multifocal retinal edema and tortuosity of the retinal vessels may be observed, and commonly result in blindness. 74, 82, 83, 89, [91] [92] [93] in the heart, hypertension may result in cardiomegaly and left ventricular hypertrophy. 74, 83, 89, 94 a systolic murmur, gallop rhythm and congestive heart failure may be observed. 82, 89 in the nervous system, hypertension may result in a hypertensive encephalopathy. 83, 85, 86, 89, 95 two studies have variously documented neurological signs in 29% and 46% of cats with hypertension. 83, 89 clinical signs since hypertension in most cats can be cat egorized as secondary, clinical signs typically reflect the underlying disease process. consequently, affected cats often demonstrate signs relating to renal disease or hyperthyroidism, given the high prevalence of hypertension with these disorders. although the pathophysiology underlying hypertensive encephalopathy remains unclear, it is thought to involve the development of vasogenic edema, which predominantly affects the white matter. 96, 97 with acute hypertension, the autoregulatory capacity of the brain vasculature may be exceeded, leading to hyperperfusion, breakdown of the blood-brain barrier, and cerebral edema. 96, 98 in experimental acute hypertension in cats, gross findings include coning of the vermis of the cerebellum, cerebel-lar herniation into the foramen magnum (fig 4) , rostral displacement of the colliculi, and widening and flattening of the cerebral gyri, all of which reflect raised intracranial pressure. 95 microscopically, the consequences of edema are observed such as marked pallor of the cerebral white matter, accentuation of the separation between axons and myelin sheaths, and widening of the perivascular space. 95 in chronic hypertension, brain vasculature may be chronically vasoconstricted leading to hypertrophy and hyperplasia of the smooth muscle. 89 as a result, fibrous changes develop, allowing leakage of plasma which ultimately causes degeneration of the vasculature predisposing to ruptures and microhemorrhages. 89 multifocal cerebral arteriosclerosis with hemorrhages has been observed in cats with spontaneous hypertension. 83 a presumptive diagnosis of hypertensive encephalopathy is relatively straightforward and requires the documentation of hypertension (systolic blood pressure ≥ 160-170 mmhg) with contemporaneous neurological signs. the gold standard for blood pressure measurement is invasive intra-arterial monitoring. however, this is often not feasible in clinical practice. 99 consequently, indirect blood pressure monitoring is used most commonly. 99 accurate and reliable indirect blood pressure measurements can be performed using doppler flow ultrasonography and oscillometry. 99 minimal, mild, moderate and severe risk categories for target organ damage have been defined based on blood pressure recordings (see below). 75 identification of hypertension should prompt investigation for an underlying disease process. a complete blood count, biochemistry profile and urinalysis should be performed in all hypertensive cats. in cats older than 5 years of age, serum thyroxine level should also be measured. when indicated, endocrinological testing for cushing's disease or diabetes mellitus should be performed. in cats with suspected or confirmed renal disease, quantification of a proteinuria should be performed. thoracic radiographs should be obtained to assess cardiovascular structures, and abdominal ultrasonography should be performed to assess renal structure and identify any concurrent disease. echocardi ography is warranted in cats with a murmur, gallop rhythm or other signs consistent with cardiac disease. in all cats with hypertension, echocardiography allows assessment of any secondary cardiac changes. in cats with severe neurological dysfunction mri may be warranted. in addition to assessing cns pathology related to hypertension, mri allows exclusion of other disease processes that can produce similar neurological signs. given the potential for raised intracranial pressure and brain herniation in hypertensive encephalopathy, caution should be exercised prior to advanced imaging; the requirement for general anesthesia can lead to deterioration or death in animals with severe raised intracranial pressure. in humans with hypertensive encephalopathy, mri of the 402 jfms clinical practice brain discloses hyperintensities in the white matter of the parietal and occipital lobes of the cerebrum on t2-weighted images. 96 less frequently, similar findings may be observed in the brainstem. 100 magnetic resonance imaging in hypertensive cats has not been studied; however, given the gross and microscopic changes observed in affected cats, similar findings would be expected. unfortunately, control of hypertension does not appear to have a significant effect on survival time. 82, 83, 108, 109 however, amlodipine does seem to reduce the degree of proteinuria in cats with renal disease, and a reduction in proteinuria appears to have a positive effect on survival time. 108, 109 unless animals are showing evidence of target organ damage, or are at severe risk of developing target organ damage (see box on page 401), there is no requirement for immediate therapeutic intervention. instead, repeated blood measurements over a period of time, combined with identification and treatment of any potential underlying disease process leading to hypertension, may be all that is needed to control blood pressure. in cats that remain hypertensive despite control of an underlying disease process, or those with idiopathic hypertension in the mild to moderate risk category for target organ damage, the decision to pursue hypertensive therapy requires a dedicated owner as treatment is generally lifelong and involves frequent re-evaluations. in animals displaying signs consistent with hypertensive encephalopathy, prompt intervention should be pursued. the treatment of choice for hypertension in cats is amlodipine besylate, a calcium channel blocker. 82,99,101-103 a dose of 0.625-1.25 mg/cat orally once to twice daily reliably reduces blood pressure with minimal risk of causing hypotension. 82,101-104 furthermore, treatment with amlodipine is not associated with increases in blood urea nitrogen and creatinine in cats with chronic renal failure. 103, 104 in cats in which amlodipine is ineffective at controlling hypertension, adjunctive therapy with the β1 selective β-blocker, atenolol, may be instituted at 6.25-12.5 mg/cat po q 12-24 h. 105 alternatively, the angiotensin-converting enzyme inhibitor, benazepril, at 0.25-0.5 mg/kg po q 12-24 h can be used. 106 however, benazepril therapy is associated with only a small but significant reduction in blood pressure in cats with chronic renal failure. 106 in acute hypertension, subcutaneous hydralazine (1.0-2.5 mg/cat) has been effective at reducing blood pressure without significant risk of hypotension. 84 while parenteral hypotensive medications may be preferable in the setting of severe hypertensive encephalopathy, the use of such medications requires continuous, direct arterial blood pressure measurement and is associated with a significant risk of hypotension. in cats with severe neurological dysfunction that do not respond to a reduction in blood pressure, treatment for raised intracranial pressure due to brain edema may be warranted. this entails diuretic therapy with mannitol (0.5 to 2 g/kg iv over 10-15 mins often combined with furosemide 0.7 mg/kg iv), or other hypertonic agents. 107 note, however, that diuretic therapy should not be used until blood pressure has normalized, as these agents can transiently increase blood pressure. 107 tre a t m e n t o f h y p e r t e n s i o n hepatic encephalopathy is the clinical syndrome of abnormal neurological function caused by portosystemic shunting, with or without intrinsic liver disease. 110 as a result, he can develop in cats with acquired or congenital liver disorders. by far the most common cause of he in cats is portosystemic shunting of blood secondary to a congenital vascular anomaly. 111 regardless of the cause of the underlying liver disease, the clinical signs of he are similar and can be divided into systemic and neurological signs. affected cats often display intermittent clinical signs that may be associated with eating. 112 cats with portosystemic shunts are generally small in stature, fail to thrive and grow, and lose weight. [112] [113] [114] [115] pytalism is a common clinical sign, occurring in approximately 75% of cats. 112, [116] [117] [118] [119] [120] other, less common clinical signs include gastrointestinal signs such as decreased appetite, anorexia, pica, vomiting, diarrhea or constipation. 112, 113, 117 cats may demonstrate polydipsia, and polyuria, pollakiuria and stranguria may occur as a consequence of cystic calculi. 112, 113, 117 affected cats may have copper-coloured irises. 121 although a complete understanding of the mechanisms underlying he remains elusive, it is clear that the pathophysiology involved is multifactorial. despite numerous potential factors, ammonia remains key in the development of he. 124 ammonia is produced by bacteria in the gastrointestinal tract, primarily the colon, as a consequence of protein metabolism. 125 it is also produced by the gastrointestinal cells as a result of metabolism of glutamine, the main cellular energy source for the epithelium. 126 a further source of ammonia is the kidneys, during states of hypokalemia or alkalosis. 126 normally, the liver efficiently removes ammonia from the portal vasculature, ultimately converting it to urea. in animals with hepatic failure or portosystemic shunts, hyperammonemia may develop. however, the severity of the neurological signs does not always correlate with the degree of hyperammonemia. 127 in fact, blood ammonia levels may be normal in cats with he. 127 this relates to a greater rate of uptake of ammonia in the cns in he, leading potentially to a high cns ammonia level in the face of a normal blood ammonia level. 128 although he is a syndrome of neuronal dysfunction, the neuropathological consequences of increased cns ammonia are played out in the astrocyte. 129 normally, cns ammonia undergoes energy-dependent metabolism to glutamine by the astrocytes. 130 with increased cns ammonia, astrocytes become overwhelmed, leading to energy depletion. 110 additionally, the increased concentration of glutamine in astrocytes may act as an osmotic stress, leading to cell swelling. 110 increased numbers of swollen astrocytes -referred to as alzeheimer type ii astrocytes -is the only structural change observed microscopically in the brain in he. 131 as a consequence of cellular edema, neurotransmitter processing in the astrocytes is affected, resulting in upregulation of neuronal benzodiazepine receptors and the production of neurosteroids which increase γ-aminobutyric acid (gaba) neurotransmission and thereby ultimately affect neuronal function. 110 ammonia may also have a direct toxic effect on neurons. 110 while ammonia remains a focal point in the pathogenesis of he, other factors are also involved. mercaptans are formed during the degradation of sulfur-containing amino acids. these substances exert a neurotoxic effect through inhibition of atpase activity, thereby potentiating the effect of ammonia. 132 short and medium chain fatty acids are derived from bacterial metabolism of carbohydrates or from incomplete β-oxidation of long chain fatty acids in the liver. 127 like mercaptans, these molecules may inhibit energy metabolism as well as inhibiting urea cycle enzymes in the liver. 126 a putative role for mercaptans, short and long chain fatty acids is unknown, but they may act synergistically with ammonia. 127 hepatic encephalopathy may develop through an imbalance of inhibitory (gaba) and excitatory (glutamate) neuro transmitters. 133 there is evidence to implicate excessive gabaergic tone in he, which would result in global inhibition of neurological function. 133 in humans with he, there are increased gaba concentrations in the cns leading to excessive gabaergic tone. 134 in addition, there may also be increased concentrations of endogenous benzodiazepines in the cns. 127, 133 benzodiazepines also bind to the gaba receptor, potentiating the effect of gaba. 126 false neurotransmitters may also play a role in he. 126 in liver disease, the production of branched chain amino acids is reduced. 127 branched and aromatic amino acids compete for the same transporter into the cns. 126 as a consequence of reduced branched chain amino acids, there may be a relative increase in the aromatic amino acids; these so-called false neurotransmitters may act like gaba and other inhibitory neurotransmitters. 135 ultimately, the clinical signs of he may be a result of global inhibition of neurotransmission. a complete blood count, biochemistry and urinalysis should be performed in all animals with clinical signs suggestive of he. on hema tol ogy, microcytosis may be present. 112 biochemical abnormalities may include low blood urea nitrogen, increased liver enzymes, decreased total protein and albumin concentrations, and hypocholesterolemia. 112 urinalysis may disclose hyposthenuria and ammonium urate crystals. 112 a presumptive diagnosis can be made by documenting altered liver function in the setting of clinical signs consistent with he. an elevated fasting blood ammonia level helps confirm the clinical suspicion. in order to provide accurate results, blood samples should be treatment should be directed at the underlying cause of he as well as controlling the clinical signs of he. one of the primary aims is to reduce blood ammonia levels. for animals with mild to moderately severe clinical signs, which are capable of taking oral medications, lactulose should be administered at a starting dose of 1 ml po q 8-12 h. 116 the dosage is adjusted based on stool consistency and response. in more severely affected cats, lactulose can also be administered per rectum. prior to rectal administration, warm water enemas should be performed to remove fecal material. lactulose is a non-aborbable disaccharide that undergoes extensive metabolism by colonic bacteria, first to constituent monosaccharides and then to volatile fatty acids. 140 ultimately, lactulose decreases the production/absorption of ammonia. 140 this is accomplished in several ways: namely, by decreasing the colonic luminal ph, leading to conversion of ammonia (nh 3 ) to ammonium (nh 4 + ), trapping it intraluminally; decreasing transit time through the osmotic cathartic effect of lactulose; and interfering with intestinal absorption of glutamine, thereby decreasing the production of ammonia. 141 antibiotic therapy is often combined with lactulose administration. antibiotics with activity against ureaseproducing bacteria are effective at reducing ammonia production. neomycin is an oral aminoglycoside antibiotic that undergoes minimal systemic absorption. it is administered at 20 mg/kg po q 8 h. 116 despite the limited systemic absorption, systemic concentrations capable of causing side effects are possible. 116 metronidazole is also effective at reducing urease-producing microbes, and is administered at 10 mg/kg po q 12 h. 116 reduced hepatic metabolism in animals with liver disease may result in an increased incidence of neurotoxicity. 142 alternatively, ampicillin or amoxicillin-clavulanate can be administered. in severely affected animals, antibiotics (ampicillin, amoxicillin or metronidazole) should be administered parenterally. there are several precipitating factors that can lead to he, and these should be identified and corrected in the individual animal. correction of dehydration, hypoglycemia and hypokalemia is imperative. animals with clinical signs suggestive of gastrointestinal bleeding, such as melena, anorexia and vomiting, should be treated with h 2 -blockers. in moderately to severely affected animals, food should be withheld until therapy results in significant improvements. once a clinically significant improvement is obtained, affected animals should be fed a diet restricted in protein, with limited aromatic amino acids and short chain fatty acids. 114 key points: hepatic encephalopathy placed in a heparinized tube and transferred to the laboratory on ice for immediate testing. red blood cells contain large amounts of ammonia; hence hemolysis may result in falsely elevated blood ammonia levels. alternatively, a presumptive diagnosis of he can be made by demonstrating altered liver function through fasting bile acid stimulation testing and on the basis of response to therapy. a suspected or confirmed diagnosis of he should prompt investigations for congenital or acquired portosystemic shunting. portosystemic shunts are most commonly diagnosed by ultrasonography or per rectal portal scintigraphy using 99m technetium pertechnetate. [136] [137] [138] [139] positive contrast portography also can be performed; however, this necessitates general anesthesia and laparotomy. 113 the prognosis for animals with he is dependent on the underlying liver disease. with treatment, most animals experience an improvement in the clinical signs related to he. severely affected animals may not respond to therapy, however. animals with increased blood ammonia tend to respond better to treatment than those with normal blood ammonia. feline infectious peritonitis, part 2 feline infectious peritonitis and feline enteric coronavirus infections. i. feline enteric coronaviruses clinical, cerebrospinal fluid, and histological data from twenty-seven cats with primary inflammatory disease of the central nervous system inflammation and changes in cytokine levels in neurological feline infectious peritonitis use of anti-coronavirus antibody testing of cerebrospinal fluid for diagnosis of feline infectious peritonitis involving the central 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mercaptans and ammonia or fatty acids in the production of coma: a possible role for mercaptans in the pathogenesis of hepatic coma experimental hepatic encephalopathy: changes in the binding of gamma-aminobutyric acid hyperammonaemia, plasma aminoacid imbalance, and blood-brain aminoacid transport: a unified theory of portal-systemic encephalopathy per rectal portal scintigraphy using 99m technetium pertechnetate to diagnose portosystemic shunts in dogs and cats diagnosis and treatment of portosystemic shunts in the cat ultrasonographic diagnosis of portosystemic shunting in dogs and cats transcolonic sodium pertechnetate tc 99m scintigraphy for diagnosis of macrovascular portosystemic shunts in dogs, cats, and potbellied pigs: 176 cases (1988-1992) the treatment of hepatic encephalopathy new mode of action for lactulose medical management of animals with portosystemic shunts available online at www.sciencedirect.com key: cord-334773-yw2qgv13 authors: lisco, giuseppe; de tullio, anna; giagulli, vito angelo; guastamacchia, edoardo; de pergola, giovanni; triggiani, vincenzo title: hypothesized mechanisms explaining poor prognosis in type 2 diabetes patients with covid-19: a review date: 2020-08-10 journal: endocrine doi: 10.1007/s12020-020-02444-9 sha: doc_id: 334773 cord_uid: yw2qgv13 purpose: epidemiological data suggest that comorbid patients, mostly those with type 2 diabetes (t2d), are predisposed to poor prognosis in coronavirus disease 2019 (covid-19), leading to serious healthcare concerns. the aim of the present manuscript is to review the main relevant mechanisms possibly contributing to worsen the clinical course of covid-19 in t2d. results: poor glucose control, high glycaemic variability and diabetes-related comorbidities at baseline, particularly cardiovascular diseases and obesity, contribute in worsening the prognosis in the above-mentioned cluster of patients. moreover, both a lower efficient innate immune system response and cytokine dysregulation predispose patients with t2d to impaired viral clearance and more serious pulmonary and systemic inflammation once the sars-cov-2 infection occurred. inconclusive data are currently available for specifically indicate or contraindicate concurrent medications for managing t2d and its comorbidities in infected patients. conclusions: t2d individuals should be considered as more vulnerable to covid-19 than general population, and thus require adequate advices about hygienic tips to protect themselves during the pandemic. a careful management of glucose levels and diabetes-related comorbidities remains essential for avoiding further complications, and patient monitoring during the pandemic should be performed also at distance by means of telemedicine. further studies are needed to clarify whether medications normally used for managing t2d and its associated comorbidities could have a protective or detrimental effect on covid-19 clinical course. background firstly identified and characterized as 2019-ncov [1] , human severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has been reported as a novel infective agent arisen at the end of the 2019 [2] . sars-cov-2 is a positivesense, single strand, enveloped rna virus belonging to the family of coronaviridae, and is the 7th beta-coronavirus recognized to infect humans [3] . first metagenomic rna sequencing of sars-cov-2 showed the single-strand rna consisted of 29,906 nucleotides, and was closely related to a group of bat sars-like coronaviruses (89,1%) [4] . further observations confirmed that sars-cov-2 was closely related (88%) with two bat sars-like coronavirus (bat-sl-covzc45 and bat-sl-covzxc21), but was distant from other two human coronaviruses responsible for severe infective pneumonia: sars-cov (79%) and middle east respiratory syndrome coronavirus (mers-cov) (50%) [5] . a high grade of homology between genomic sequences of sars-cov-2 form different patients (99.98%) has also been reported, thus confirming a human-to-human transmission of the novel infective agent [5] . phylogenetic analysis suggested that sars-cov-2 progenitors circulated in animal host including bats [6] , snakes, malayan pangolins, civets, mouse [7, 8] , and underwent to a naturally occurred selection before the zoonotic spillover finally adapting to persistently infect the new host [9] . official epidemiological report declared that the early cases of infections were detected in december 2019, and involved people who worked or visited the hua nan south china seafood market [10] , in wuhan capital city (hubei province; people's republic of china). however, it remains still debated whether the zoonotic spillover might have been occurred in other places [11] , particularly in southeast asia [12] , and consequently sars-cov-2 infection might have been imported to wuhan. epidemiological analysis showed a marked widespread of the infection within community places due to a large human-to-human transmission [13] and wuhan rapidly became the hub of a new pneumonia outbreak [14] . due to a consistent widespread of detected cases among several countries, the world health organization declared the state of pandemic on march 11, 2020 when confirmed cases raised up to 118,000, and sars-cov-2 spread into 114 countries [15] . clinical manifestations of the novel coronavirus disease 2019 (covid19) include fever (87%), cough (58%), dyspnoea (38%), muscle soreness (35%), chest distress (31%) in a context of bilateral pneumonia (76%) with ground glass opacification (70%) at ct scan due to lung interstitial involvement [16] . autoptic studies described macroscopic features of pleuro-pericarditis, lung consolidation, oedema with overall increased pulmonary weight; while microscopic hallmarks are characterized by pneumocyte hyperplasia, lymphocytic and multinucleated giant cells infiltration, hyaline membranes [17] [18] [19] . other signs and symptoms of covid-19 include acute conjunctivitis [20, 21] ; diarrhoea, abdominal pain/discomfort and vomiting [22] [23] [24] ; convulsion, headache, muscle soreness [25] ; diffuse erythematous rush and widespread urticaria [26] ; acute kidney injury [27, 28] ; pharyngodynia, nasal congestion with rhinorrhoea and smell/taste impairment [29] . sars-cov-2 may directly affect myocardial tissue, and significantly complicate the prognosis of underlying cardiovascular diseases [30, 31] . sars-cov-2 infection usually occurs asymptomatically or mildly symptomatic form of the disease but in predis posed patients with specific clinical conditions, a serious clinical course could be observed thus leading to worse prognosis or death [12] . worldwide reported case-fatality rate for covid-19 differs considerably among geographical areas [32] , and could be attributable to several variables, such as testing strategies for screen suspected cases and identification of infectious patients (statistical); accessibility to intensive care according to restricted national healthcare system capacities (organization); baseline patient age and comorbidities (medical) [33, 34] . from the latter point of view, a poor prognosis is usually observed in elderly patients [35] and worldwide age-specific case-fatality rate occurred very high among patients with one or more underlying chronic diseases including cardiocirculatory, renal, pulmonary, central nervous system and mental illness, diabetes mellitus (dm) and malignancies [36, 37] . according to the data shared by the italian national institute of health, patients who died while tested positive for sars-cov-2 exhibited an elevated mean age (78.5 years old), mostly men (70%) and with one or more pre-existent chronic diseases (2.7 in mean) [38] . of these, blood arterial hypertension (78%) and dm (34%) were the most commonly reported clinical comorbidities, followed by ischaemic heart disease (30%) and atrial fibrillation (22%). the leading cause of deaths was attributable to acute respiratory distress (97%) [38] . the global estimated prevalence of t2d accounts for more than 450 millions affected patients corresponding to 9.3% of the worldwide population [39] . therefore, the number of patients with t2d who will contract sars-cov-2 infection is expected to be considerable, and should increase over time. t2d per se does not increase the risk of contracting sars-cov-2 infection but could exacerbate the clinical course of covid-19 leading to a detrimental prognosis [40] . indeed, the frequency of diabetes in patients with covid-19 has been reported to 9-12% [41] [42] [43] , raising up to 16-20% in hospitalized patients including those who required intensive care for severe disease [44, 45] . more recently, data collected from nine hospitals from seattlearea in the united states demonstrated that 58% of patients who required hospitalization for respiratory symptoms attributable to covid-19 had t2d [46] . in severely ill patients with covid-19 a pre-existent t2d was observed in about 35% of the cases and, according to the results of an univariate analysis, the presence of t2d resulted a significant risk factor for poor prognosis in this clinical setting (or 8.14; p < 0.0001) [47] . dm has also been reported as the main clinical condition observed in non-survived patients with covid-19 (22%) [48] , thus resulting one of the most frequently associated comorbidity in covid-19 deceased patients [33] . this concern has been further confirmed by the results of a cohort study among 85 fatal cases of covid-19 in wuhan, hence defining dm as a potentially harmful comorbidity predisposing to worse clinical course or death once sars-cov-2 infection occurred [49] . different hypothesis should be considered for explaining this clinical phenomenon, including glucose control at baseline and during the infection course, pathophysiology and immune system response in sars-cov-2 infected patients with t2d, diabetes-related comorbidities and concomitant medications. herein, a point-to-point discussion about these putative mechanisms has been carried out. epidemiological data showed that t2d represents a risk factor for infectious diseases, mostly with bacterial aetiology, particularly at the level of skin and soft tissue, genitourinary, gastrointestinal and respiratory systems [50] . moreover, life expectancy in individuals with t2d may be affected due to infectious diseases and in certain clusters of patients, such as in elderly with t2d, the leading cause of mortality is attributable to severe pulmonary infections rather than other highly prevalent comorbidities, including cardiovascular diseases and malignancies [51] . on the other hand, dm increases the cumulative risk of medical consultation, hospital admission, intensive care requirement and poor prognosis because of pandemic influenza [52] . further data reported that airways and pulmonary infections with different aetiologies, including sars and mers, were more frequently diagnosed in t2d patients, also showing a severe clinical course [53] [54] [55] [56] . in dm, hyperglycaemia is considered one of the most important factor in determining this burden [57] . indeed, osteomyelitis, soft tissues infections, endocarditis, tuberculosis and sepsis are most commonly observed in diabetic patients with poor glycaemic control compared to those who achieve better glucose management, and a worse glucose control contributes to increase the rate of hospitalization and mortality, too [57] . both hyperglycaemia and high glucose variability may consistently complicate the clinical course also in case of influenza a [58] . more recently, a retrospective observational study recruiting more than 7000 cases of covid-19 from hubei province (china) and including 952 patients with a pre-existent t2d displayed a higher mortality rate (hr 1.49), more prevalence of multiorgan damage and a greater requirement of medications (antibiotics, systemic corticosteroids, vasoactive substances, oxygen inhalation and either non-invasive or invasive mechanical ventilation) in patients with dm than in nondiabetics [59] . interestingly, authors also found that, among t2d patients, those with better glucose control (glucose levels between 70 and 180 mg/dl) respective to those with worse glucose control (>180 mg/dl) during hospitalization exhibited a significantly lower rate of mortality (hr 0.14; p < 0.008), and a fewer risk of progression to acute respiratory distress syndrome (hr 0.47; p < 0.009), acute kidney (hr 0.12; p < 0.046) and myocardial (hr 0.24; p < 0.01) injury [59] . similar results were found by another observation in which worse glucose control (glucose levels >110 mg/dl) at the admission and during hospitalization was found to be an independent risk factor for progression to critical ill or death among t2d patients with confirmed covid-19 [60] . therefore, hyperglycaemia represents a relevant matter in patients with covid-19 fostering poor prognosis once the infection occurred. in addition, recent evidences suggest that sars-cov-2 may induce beta-cells damage thus leading to insulin secretion impairment. this phenomenon, in addition to a pre-existent hyperglycaemia and considering that systemic inflammation due to the infection exacerbates the insulin-resistance, is thought to play a significative role to further worsen glucose control and complicate the clinical course of covid-19 [61] . in conclusion, epidemiological data suggested that dm, particularly t2d, is a frequently observed comorbidity in patients with sars-cov-2 infection who require hospitalization, more intensive treatment and exhibit poor prognosis or death. poor baseline and ongoing glucose control in hospitalized patients rather than the presence of t2d per se seems to facilitate covid-19 progression [62] . hence, an optimal and timely blood glucose management during pandemic should be considered as an effective strategy to reduce the probability of hospitalization requirement of infected patients, and for improving the clinical course of those hospitalized for receiving either non-intensive or intensive care. innate and adaptive immune responses play a crucial role against viral infections [63] . immune response against coronaviruses has been reviewed elsewhere, highlighting the role of both innate and adaptive systems to promptly contrast virus replication, facilitate virus clearance, stimulate tissue repair and develop persistent defence [64] . immune response in covid-19 is not still completely understood making necessary further investigation to better control the pandemic evolution [65] . however, seriously ill covid-19 patients exhibit an exaggerate response of neutrophils and alveolar macrophages, and a relevant peripheral lymphocytes dysfunction [66] , which lead to an uncontrolled viral shedding, consequent viremia and further systemic immune-mediated damage, thus triggering a harmful vicious circle [66] . glucose levels may significantly influence immune response as observed in patients with dm. natural killer (nk) cells activity is weakened in case of hyperglycaemia, and is inversely related with fasting plasma glucose, 2-h postprandial glycaemia and hba1c levels [67] . macrophage activation and phagocytosis are both decreased in patients with poor glucose control, but should be restored after an adequate optimization of metabolic control [68] . neutrophil activation and phagocytosis are both impaired by hyperglycaemia as demonstrated in animal models and humans, thus suggesting a relevant impairment of innate immune response in patients with chronic hyperglycaemia [69] . in an animal model, obese and hyperglycaemic mice experienced higher rate of respiratory infection due to influenza and bacterial pneumonia and that was related to a lower efficient alveolar macrophage response against infections. in addition, a defective toll-like receptor 4 signalling has been recognized in neutrophils exposed to the gram-negative lipopolysaccharide, leading to a blunted release of chemokines and cytokine, and decreased myeloperoxidase activity [69]. moreover, t-cells function is significantly dysregulated in t2d and cd4 + lymphocytes preferentially differentiate in thelper 1 and t-helper 17 instead of t-helper 2 with a consequent imbalance between pro-inflammatory and antiinflammatory activities [70] . on the other hand, the levels of interferon gamma-which normally stimulates cd4 + t cells maturation in sense of t-helper 1 rather than t-helper 2-were found to be lower in t2d patients sera, and can contribute in a blunted t-cell response in t2d [71] . nevertheless, lower levels of interleukin (il)-10 have also been described in t2d patients. considering that il-10 is capable to suppress the release of pro-inflammatory cytokines, lower levels of il-10 could be related with higher il-6-to-ifn gamma and tnf-alpha-to-ifn gamma ratios hence suggesting an enhanced activation of circulating monocytes [71] . high levels of il-6 have been detected in diabetic patients respective to those with euglycemia, suggesting that hyperglycaemia play a crucial role in determining this immunological effect [72, 73] . in animal models, hyperglycaemia and insulin-resistance increase the level of circulating proinflammatory cytokines and oxidative stress at baseline [74] . since this pro-inflammatory background usually results reversible after an effective treatment of hyperglycaemia, a low dose endotoxemia consistently enhances systemic inflammation in a animal model [75] . therefore, hyperglycaemia may predispose to an exaggerate immune response even in case of a mild-to-moderate viral load. as known, a hyperinflammatory syndrome with cytokine dysregulation has been well recognized in seriously ill patients [76] , thus highlighting its crucial role in serious manifestations of covid-19 [77] . specific interleukins and chemokines (il-2, il-7, il-6, tnf-alpha, interferon gamma induced protein 10, granulocyte-colony stimulating factor) are upregulated in patients who exhibited a worsen prognosis [78] and particularly high levels of il-6 have been detected in case of serious pulmonary involvement or in patients requiring intensive care [79] . these findings are also more evident in elderly patients who display less vigorous immune response against viral shedding, greater susceptibility to more serious pulmonary and systemic involvement, and are finally predisposed to covid-19 progression [80] . both the number and function of t cells (both cd4 + and cd8 + ) [81, 82] , b cells depletion, and hypercoagulability have also been observed in seriously ill cases and the greater the magnitude of these haematological and biochemical alterations then the greater the severity of the prognosis [83, 84] . in conclusion, diabetic patients especially elderly individuals and those with worse baseline glucose control may exhibit immune system dysregulation that predispose them to a less effective response against sars-cov-2 and to a dysfunctional inflammation that requires to be carefully monitored in confirmed cases of covid-19, for preventing or avoiding a harmful progression of the disease. angiotensin-converting enzyme 2 (ace 2 ) is a carboxypeptidase normally involved in the cleavage of angiotensin i and angiotensin ii, and is the main receptor for sars-cov-2 playing a determinant role in viral entry into the host, and clearly explaining both the transmissibility and severity of covid-19 among humans [85] . ace 2 is expressed at the level of several tissues (transmembrane and soluble forms), such as lung [86] , oral mucosa [87] , intestine [88] , brain [89] , pancreatic islets [90] , testis [91] and kidney [92] . differentiated type 2 pneumocytes normally express ace 2 , which is essential to regulate pulmonary homoeostasis and protects against pulmonary injury [93] . indeed, low levels of ace 2 have been described in severe acute and chronic pulmonary diseases thus predisposing to poor prognosis [94] . however, ace 2 is overexpressed in chronic diseases, including t2d, and this phenomenon could be also related with chronical exposure to several medications [94, 95] . this biochemical condition is believed to facilitate the internalization of sars-cov-2 into pneumocytes, thus contributing to worse prognosis in covid-19 [94, 95] . however, the role of ace 2 overexpression in worsening the prognosis is an emergent issue, and remains currently debated [96] . cardiovascular diseases, including coronary and cerebrovascular artery disease and heart failure, are frequently observed in t2d patients and it has been estimated that about a third of them displayed these kind of complications over time [97] . cardiovascular system is the main extrapulmonary compartment extensively involved in covid-19, as suggested by a frequent myocardial involvement in affected patients especially in those having hypertension, t2d and cardiovascular diseases at baseline [98] . vascular inflammation and endothelial dysfunction [99] , myocardial injury and cardiac arrhythmias are not-infrequently observed in covid-19 confirmed cases, significantly influencing the risk of poor prognosis or death in this cluster of patients [100] [101] [102] . overweight-obesity syndrome is a multifactorial disease which significantly predispose to cardiometabolic risk, and is strictly associated with insulin-resistance, glucose metabolism impairment and t2d [103] [104] [105] . despite obesity is usually associated with decreased risk of death in patients with severe acute respiratory distress (obesity paradox), currently available data suggest that an elevated body mass index should be considered as an independent risk factor predisposing to poor prognosis [106] and death in covid-19 [107] [108] [109] [110] . indeed, the prevalence rate of obesity in this cluster of patients has been reported in 42% of the cases [111] and a bmi greater than 35 kg/m 2 has been usually observed in patients requiring hospitalization and invasive mechanical ventilation [112] also in younger patients (<60 years) [113] . pathophysiological mechanisms possibly related with poor prognosis in obese patients are not completely understood but may be attributable to a greater inflammatory background as similarly found in dm due to hyperglycaemia and insulin resistance [70] . obesity is usually associated to other severe comorbidities with high impact on cardio-metabolic health, such as fatty liver disease, vascular inflammation, cardiovascular atherosclerotic diseases and heart failure [114] that might be related with a higher burden of lethal complications, especially in hospitalized patients with covid-19 [115] . in addition to cardiometabolic risk factors, obese patients are more prone to have a decreased pulmonary ventilation or obstructive sleep apnoea, which predispose them to low levels of blood oxygenation at baseline and consequently to worse respiratory outcomes in case of acute infective respiratory diseases [116, 117] . nutritional patterns usually exhibited by obese patients are frequently characterized by an elevated dietary consumption of processed food rich in saturated fat, cholesterol, sugar and a low consumption of fibres and micronutrients, such as vitamin d [118] . these dietary patterns may affect physiological microbiome composition, weaken the immune response against microbial agent and foster immune system dysfunction [115] . in addition, vitamin d deficiency/insufficiency and sedentary lifestyle, which are highly prevalent among obese patients, should be considered as predisposing factors for worse prognosis in response to acute infections, including covid-19 [119] . abdominal obesity usually leads to a low cardiorespiratory reserve and systemic inflammatory dysfunction which predispose to a worse prognosis in covid-19 [120] . conversely, regular physical exercise, which is normally lacking in an obesogenic lifestyle, is associated to higher levels of cardiorespiratory fitness, and is believed to improve the innate immune response and attenuate cytokine dysregulation often experienced by high risk patients with the so called cytokine storm [121] . visceral obesity is also a risk factor for both the development and progression of cardiovascular diseases [114] considering that it fosters higher level of pro-thrombotic circulating factors and predisposes to thrombotic events [122] . furthermore, visceral obesity is more prevalent in men than women and this biological phenomenon has been hypothesized to have a putative role in driven poor prognosis of covid-19 especially in men. from this point of view, male obesity is usually associated with a functional hypogonadism and these clinical conditions are both associated with one other [123] , according to a complex and multifactorial pathogenesis [124] that fosters higher baseline levels of inflammation and endothelial dysfunction [125] . aromatase gene expression is enhanced by prostaglandin e 2 , whose levels were found to be higher in visceral adipose tissue of obese men [126] . an enhanced aromatase activity at the level of adipose tissue increases local levels of estradiol that is thought to be a defensive mechanism against local inflammation and insulin resistance [127] . whether augmented aromatase levels (and activity) at the level of adipose tissue in men may be responsible for a systemic testosterone-tooestrogen imbalance remains questionable. however, obese men are usually affected by this biochemical condition and body mass index is inversely correlated to testosterone-to-oestrogen ratio [128] . a low testosterone-to-estradiol ratio contributes to increase the cardiovascular risk particularly in elderly [129] and in those with previous cardiovascular diseases [130] [131] [132] . in addition, hormonal pattern associated with visceral obesity may play a relevant role in reducing the efficacy of immune response against infectious agents, predisposing to cytokine dysregulation, endothelial dysfunction, thrombosis, finally driving patients, particularly men, to poor prognosis or death [133] . moreover, ace 2 is also expressed on adipose cells [134] and a larger extension of adipose tissue in obese patients may significantly increase the number of available receptors for sars-cov-2, thus leading to a much greater viral shedding once the infection occurs [135] . in conclusion, multiple diabetes-associated chronic comorbidities, particularly obesity, have been found to worsen the prognosis in covid-19 affected patients by acting as independent risk factors. careful management and prompt interventions are thus required for improve clinical outcome predominantly in type 2 diabetic patients. pathogenetic mechanisms basically involved in sars-cov-2 infection may be exacerbated by the use of concomitant medications for the management of t2d. of note, an exaggerate pulmonary and systemic expression of ace 2 facilitates sars-cov-2 replication and may be responsible for worse clinical course and poor prognosis [94, 95] . in animal model, pioglitazone has demonstrated to increase ace 2 expression particularly at the level of hepatic and adipose tissue [136, 137] . on the other hand, the analysis of potential therapeutic targets for sars-cov-2 assessed by a computational model found pioglitazone to have a potential for inhibiting 3clpro, an essential target for viral replication [138] . these findings did not provide conclusive assumption and diabetologists can safely prescribe pioglitazone taking into account general concerns including fluid retention and heart failure [139] . gliflozins prescription is increasing over time, also considering a long-term beneficial cardiovascular and renal protection [140, 141] . many mechanisms of cardiovascular and renal protection have been proposed, including an enhanced induction of ace 2 expression at the level of heart and kidney but it is unclear whether this effect may negatively influence clinical course in covid-19 [142] . moreover, despite gliflozins reduce inflammatory injury and endothelial dysfunction, none conclusive data are currently available to confirm their potential beneficial effect in diabetics with covid-19 [143] . concerns about gliflozins use in covid-19 are attributable to volume contraction, renal insufficiency and increased risk of ketoacidosis that may be supposed to occur particularly in hospitalized patients, including those severely ills. dipeptidyl peptidase iv (dpp-iv or cd26) is a transmembrane and soluble ectopeptidase largely expressed in human tissues, including airways, lung and leucocytes [144] . particularly, dpp-iv is specifically involved in mers pathogenesis given that it mediate mers-cov-2 internalization in host cells [145] . no data actually support the role of dpp-iv in the internalization of sars-cov-2 and further study are needed to verify this aspect, and for demonstrating clear protective effects [146] . however, dpp-iv inhibitors have shown to potentiate immune response by increasing t-cells survival, consequently enhance immune response [147] , and possibly playing a relevant role in reducing the onset or progression of acute pulmonary manifestations in covid-19 [145] . glucagon-like peptide 1 receptor agonists (glp-1ras) belong to an effective class of medications approved for the treatment of t2d and for preventing diabetes-related cardiovascular and renal complications over time [148] [149] [150] [151] . immune response and systemic inflammation play a crucial role in sars-cov-2 infection, particularly in case of severe clinical course of the disease. in this clinical scenario, it is speculated that the use of glp-1ras could provide both a better glucose control and anti-inflammatory effects with consequent improvement of outcomes in covid-19 affected patients [143] . in patients with pulmonary inflammation, mononuclear circulating cells express lower level of glp-1 receptors than controls and this condition is associated with a blunted production of interferon gamma by t cells and nk cells. in addition, the expression of programmed death cell protein 1, which mediates t-cell apoptosis, is enhanced on t-cell surface and consequently the efficiency of cell-mediated immune response is weaken. liraglutide, a once-daily administered long-acting glp-1ra, demonstrated to restore the expression of glp-1 receptors on macrophage surface, and potentiate immunemediated response [152] . in addition, both dpp-iv pharmacological inhibition (linagliptin) and glp-1ra (liraglutide) were found to contrast pulmonary injury, reduce platelet activation, microvascular thrombosis, and oxidative stress in mice model of endotoxemia [153] . moreover, glp-1ras have been found to reduce the expression of pulmonary il-33, thus playing an interesting role in contrasting a il-33 mediated damage in immune-allergic diseases and viral infections [154] . considering that pancreatic islets express ace 2 , glucose impairment in covid-19 diabetic patients could be attributable to a partial insulin deficiency [56] . however, glucose impairment could also be attributable to sars-cov-2 infection-induced stress or as the consequence of some medications or treatment protocols, including high-dose glucocorticoids, particularly used in hospitalized patients [155] . insulin therapy is recommended in hospitalized patients [156] , including those with covid-19, and a basal-bolus respective to a sliding scale regimen should be preferred in infected patients for avoiding glycaemic excursion and greater glucose variability [157, 158] . hypertension is frequently observed in t2d patients leading to a consistent increase in the risk of atherosclerotic cardiovascular and renal diseases [159] . ace inhibitors and angiotensin receptor blockers compared to other antihypertensive medications demonstrated to be more effective to prevent or delay the onset of cardiovascular and renal complications in people with t2d, and are currently used as the first-line treatment in these patients [160, 161] . evidence from animal models suggested that ace inhibitors are able to increase the expression of ace 2 at the level of lung, thus leading to initial clinical concerns about the management of arterial hypertension in diabetic patients [162] . first suggestions advised to replace these medications with calciumchannel blockers in order to avoid undesirable detrimental effects of covid-19 clinical course [95] . nevertheless, no sufficient data supported the hypothesis that the use of renin-angiotensin system blockers may interfere with the internalization of sars-cov-2 in respiratory cells hence increasing its virulence [163] . in addition, ace inhibitors and angiotensin receptor blockers protect lung, heart and kidney against inflammation, thus playing a potential beneficial role also in t2d patients with covid-19 [164] . statins are usually prescribed especially in t2d patients to protect against cardiovascular complications [165] . the role of statins in covid-19 is not clearly established, however, some observation should be done. first, covid-19 is associated with higher cardiovascular mortality specifically in patients with more risk factors, including hypertension and t2d, and statins could be useful to maintain or optimize lipid management and improve endothelial dysfunction in this clinical setting [166] . in animal models, statins inhibit the myeloid differentiation primary response 88 (myd88) [167] . myd88 is a protein adaptor for inflammatory signalling pathways downstream of members of toll-like receptors and il-1 receptor families, and plays a critical function in the activation and amplification of innate immune response [168] . the inhibition of myd88 seems to reduce pulmonary inflammatory damage, and to improve survival in sars-cov and mers-cov infected mice [167] . patients with established cardiovascular disease, and those at higher risk of atherosclerotic cardiovascular disease including t2d (also in primary prevention) should be advised to maintain current statin treatment also in case of confirmed covid-19. in patient with active covid-19, an increased risk of muscular damage has been described and statin therapy could be interrupted for a short period of time in order to favour muscular recovery [169] . t2d should be considered as a risk factor for poor prognosis in covid-19 due to several reasons, including poor baseline glucose control and high glycaemic variability, diabetes-related immune dysfunction and concurrent comorbidities, also proven to act as independent risk factors for poor prognosis in this clinical setting. considering that respiratory system remains essentially the leading way for sars-cov-2 entering in host, and given that immune barriers are weaken in t2d patients, including resident pulmonary macrophages, neutrophils and t cells [70] , diabetologists could improve clinical outcomes in covid-19 simply by the use of such a medication with potential for positive immune-modulation and anti-inflammatory effects. unfortunately, inconclusive deductions are currently available for considering concomitant medications favourable (as well as detrimental) factors in covid-19 patients with t2d. despite some putative mechanisms have been identified and some speculative hypothesis have also been formulated indicating that some anti-diabetes medications may improve clinical course in covid-19 (pioglitazone, gliflozins, dpp-iv inhibitors, glp-1ra), further studies are needed to clarify the issue. a timely glucose control should be obtained in diabetic patients during pandemic for the purpose to avoid potentially harmful outcomes in case of sars-cov-2 infection [170] . anti-diabetic medications should be used with caution, also considering their impact on patient safety in case of complications related with covid-19 infection (renal failure, cardio-respiratory burden, ketoacidosis, etc). oral and non-insulin injectable medications (glp-1ras) should be considered to maintain or intensify household glucose control, while insulin treatment is currently known to be safer in case of hospitalized and seriously ill patients [171] . given this consideration, in seriously ill patients, immune response should be adequately monitored in order to carefully predict or precociously diagnose a severe disease [172] and cytokines, including il-6, may be considered as a goal for novel and more specific target therapies particularly in t2d individuals [173] [174] [175] . beyond the risks strictly related with covid-19 infections in diabetic patients, further concerns should be taken into account. social distancing and lockdown have been proposed as the most effective action to prevent and reduce spread of sars-cov-2 infection [176] . consequently, more time has been spent in household and access to public and private services has been consistently reduced. thus, several barriers exist for diabetic patients to maintain an adequate fitness status and weight management as well as access to ambulatory care for obtaining adequate treatment adjustments [177] . in the last few months, home confinement led to physical inactivity and low exposure to sunlight, with possible detrimental effects particularly in diabetic and obese patients [119] . physical exercise should be encouraged also at home or outdoor, even respecting social distancing rules, since it promotes weight loss, and improves cardiorespiratory fitness [121] ; reduces levels of cortisol thus reinforcing immune response against infections; induces t-cell differentiation and maturation [178] . importantly, patients should be advised about risks and supported regarding pandemic-related concerns. particularly, they should be elucidated about general hygienic tips to protect themselves and others from sars-cov-2 spread; promptly recognize covid-19 signs and symptoms; access orderly to approved testing if exposed; 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treatment: standards of medical care in diabetes-2020 consensus statement by the american association of clinical endocrinologists and american college of endocrinology on the comprehensive type 2 diabetes management algorithm-2020 executive summary should anti-diabetic medications be reconsidered amid covid-19 pandemic? covid-19 and diabetes management: what should be considered? dipeptidyl peptidase 4 distribution in the human respiratory tract implications for the middle east respiratory syndrome covid-19 and diabetes: can dpp4 inhibition play a role? functional assessment of cell entry and receptor usage for sars-cov-2 and other lineage b betacoronaviruses covid-19 and comorbidities: a role for dipeptidyl peptidase 4 (dpp4) in disease severity? treatment paradigm shifting implications of recent cardiovascular outcome trials: core insights on the brink of the 2020ies an overview of glp-1 agonists and recent cardiovascular outcomes trials diabetes drugs and stroke risk: intensive versus conventional glucose-lowering strategies, and implications of recent cardiovascular outcome trials glucagon-like peptide-1 receptor agonists in adult patients with type 2 diabetes: review of cardiovascular outcome trials. can glucagon-like peptide-1 receptor (glp-1r) signaling ameliorates dysfunctional immunity in copd patients glucagon-like peptide-1 receptor signalling reduces microvascular thrombosis, nitrooxidative stress and platelet activation in endotoxaemic mice glucagon-like peptide 1 receptor signaling attenuates respiratory syncytial virus-induced type 2 responses and immunopathology covid-19 infection in italian people with diabetes: lessons learned for our future (an experience to be used) relationship between hyperglycemia and infection in critically ill patients sliding scale insulin use: myth or insanity? randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (rabbit 2 trial) diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms diabetes and hypertension: a position statement by the american diabetes association first-line renin-angiotensin system inhibitors vs. other first-line antihypertensive drug classes in hypertensive patients with type 2 diabetes mellitus coronavirus disease 2019 (covid-19): do angiotensin-converting enzyme inhibitors/angiotensin receptor blockers have a biphasic effect? renin-angiotensin system blockers and the covid-19 pandemic: at present there is no evidence to abandon renin-angiotensin system blockers hypertension and covid-19 the extent to which statins have improved cardiovascular outcomes: lessons from randomized trials and observational studies of "real world" practice in people with diabetes effect of statins on endothelial function in patients with acute coronary syndrome: a prospective study using adhesion molecules and flow-mediated dilatation statins may decrease the fatality rate of middle east respiratory syndrome infection myd88: a central player in innate immune signaling. f1000prime rep is there a role for statin therapy in acute viral infections? american college of cardiology timely blood glucose management for the outbreak of 2019 novel coronavirus disease (covid-19) is urgently needed practical recommendations for the management of diabetes in patients with covid-19 hematologic, biochemical and immune biomarker abnormalities associated with severe illness and mortality in coronavirus disease 2019 (covid-19): a meta-analysis associations between immune-suppressive and stimulating drugs and novel covid-19-a systematic review of current evidence hypothesis for potential pathogenesis of sars-cov-2 infection-a review of immune changes in patients with viral pneumonia can we use interleukin-6 (il-6) blockade for coronavirus disease 2019 (covid-19)-induced cytokine release syndrome (crs)? hollingsworth, how will country-based mitigation measures influence the course of the covid-19 epidemic? letter to the editor: covid-19 in patients with diabetes: risk factors that increase morbidity exercise, immunity and the covid-19 pandemic covid-19 and endocrine diseases. a statement from the aace position statement: coronavirus (covid-19) and people with diabetes. (american association of clinical endocrinologists at the epicenter of the covid-19 pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation. nejm catalyst innovations in care delivery managing diabetes in pregnancy before, during, and after covid-19 acceptability and utilization of newer technologies and effects on glycemic control in type 2 diabetes: lessons learnt from lockdown patient empowerment using electronic telemonitoring with telephone support in the transition to insulin therapy in adults with type 2 diabetes: observational, pre-post, mixed methods study key: cord-340415-6fte7krp authors: thevarajan, irani; buising, kirsty l; cowie, benjamin c title: clinical presentation and management of covid‐19 date: 2020-07-17 journal: med j aust doi: 10.5694/mja2.50698 sha: doc_id: 340415 cord_uid: 6fte7krp the rapid spread of severe acute respiratory syndrome coronavirus 2 led to the declaration of a global pandemic within 3 months of its emergence. the majority of patients presenting with coronavirus disease 2019 (covid‐19) experience a mild illness that can usually be managed in the community. patients require careful monitoring and early referral to hospital if any signs of clinical deterioration occur. increased age and the presence of comorbidities are associated with more severe disease and poorer outcomes. treatment for covid‐19 is currently predominantly supportive care, focused on appropriate management of respiratory dysfunction. clinical evidence is emerging for some specific therapies (including antiviral and immune‐modulating agents). investigational therapies for covid‐19 should be used in the context of approved randomised controlled trials. australian clinicians need to be able to recognise, diagnose, manage and appropriately refer patients affected by covid‐19, with thousands of cases likely to present over the coming years. based on the experience in china, the typical incubation period of covid-19 infection has been estimated to be a median of 5.1 days (95% ci, 4.5-5.8 days), with 97.5% of those who develop symptoms doing so within 11 days of exposure (95% ci, 8.2-15.6 days). this has informed the use of a 14-day time period for quarantining potentially exposed individuals in an effort to limit onward spread. 2 the recognition of asymptomatic infection has been an area of intense interest in understanding the epidemiology of covid-19. the ratio of asymptomatic to symptomatic infection is currently uncertain. cross-sectional studies have reported asymptomatic infection in women attending a maternity service in new york (33 of 215 infected, 88% asymptomatic) 3 and in general population testing in iceland (87 of 10 797 infected, 41% asymptomatic). 4 in such cross-sectional studies, a proportion of those who were asymptomatic at the time of testing may in fact have been in the pre-symptomatic phase of infection. in a study conducted in a nursing home in the united states, 48 of 76 residents tested positive, with 27 (56%) being asymptomatic at the time of testing. however, 24 (89%) of these individuals went on to develop symptoms at a median of 4 days (interquartile range [iqr] , 3-5 days) after the positive test result. 5 symptomatic covid-19 infection usually presents as a respiratory syndrome, most commonly with fever and cough. 6, 7 fever has been reported in up to 99% of people at some time during the course of their illness, but importantly in one cohort, it was reported to be present at the time of hospital presentation in only 44% of patients, and at some time during the hospital admission in 89%. 8 other common symptoms are cough, dyspnoea, fatigue, anorexia, anosmia, myalgia and sometimes confusion. diarrhoea may occur in up to 10% of patients. 9 symptoms reported less frequently (< 5% of cases) include sore throat, rhinorrhoea, headache, chest pain, dizziness, abdominal pain and nausea. 6, 7 around 80% of covid-19 infections present as a mild respiratory illness in a patient who is ambulatory and can generally be managed outside the hospital. around 15% typically need hospital care (usually for moderate to severe pneumonia), and another 5% have critical illness requiring more intensive supports. 10 of those who require hospitalisation, the median time from first symptoms to onset of dyspnoea is 5 days (iqr, 1-10 days), the median time to hospital admission is 7 days (iqr, 4-8 days), and in those who develop more severe manifestations, the median time to acute respiratory distress syndrome is 8 days (iqr, 6-12 days). 6 about a quarter of patients who are hospitalised may need transfer to the intensive care unit (icu) for the management of complications such as hypoxaemic respiratory failure or hypotension requiring vasopressor support. 11 at presentation to hospital, the most common laboratory feature of covid-19 infection is lymphopenia (reported in 70.3% of cases). 6 radiological imaging may reveal a clear chest, unilateral or bilateral consolidation, or ground glass opacity. nasopharyngeal specimens, deep nasal swabs, throat swabs or lower respiratory samples (eg, sputum) sent for molecular detection of sars-cov-2 by polymerase chain reaction (pcr) are currently the best means of specific diagnosis of covid-19 in australia. faecal samples may also be pcr positive for covid-19 but the role of the oral-faecal route for transmission remains unclear. 12 patients with more severe disease tend to have higher viral loads in respiratory samples. mild cases have been shown to clear the virus earlier, with over 90% returning negative pcr test results by day 10 compared with severe cases who more often remain positive beyond day 10. 13 viral loads appear to be highest early in the illness. prolonged viral shedding after the onset of symptoms has been described. 14 • increased age and the presence of comorbidities are associated with more severe disease and poorer outcomes. • treatment for covid-19 is currently predominantly supportive care, focused on appropriate management of respiratory dysfunction. • clinical evidence is emerging for some specific therapies (including antiviral and immune-modulating agents). investigational therapies for covid-19 should be used in the context of approved randomised controlled trials. • australian clinicians need to be able to recognise, diagnose, manage and appropriately refer patients affected by covid-19, with thousands of cases likely to present over the coming years. narrative review mja 213 (3) ▪ 3 august 2020 also been detected by pcr in asymptomatic patients with comparable viral loads to those still symptomatic. 15 patients with suspected or confirmed covid-19 should be assessed for features of severe disease and risk factors for progression to severe disease. this assists in determining whether a patient can safely be managed in the community or requires referral and admission to a health care facility able to provide acute inpatient care. current data suggest that older patients and those with comorbidities have increased risk of progression to severe disease and mortality. in a large surveillance report from china including over 44 000 confirmed cases of covid-19, the case fatality rate was < 0.5% for patients aged < 50 years, but rose to 8.0% for those in their 70s, and 14.8% in those aged > 80 years. 16 while these surveillance-based case fatality rates are possibly overestimates, being influenced by under-recognition of lower severity cases, the impact of increasing age and the presence of comorbidities on risk of severe and fatal illness should be recognised, 8 17 in developing a predictive model, chinese researchers found four factors independently associated with disease progression during hospitalisation in 208 consecutive patients: presence of comorbidity, age > 60 years, lymphocyte count < 1.0 × 10 9 /l, and elevated lactate dehydrogenase levels. 18 a propensity for deterioration in the second week of illness has been recognised in some cohorts of patients, typically 5-10 days after the onset of symptoms. 19 all patients should be warned about symptoms of concern (such as increasing breathlessness), and early referral for hospital admission should be suggested for any patient with signs of clinical deterioration. individual circumstances need to be considered when determining the ideal monitoring strategy and site of care for each patient (box). it is critically important to ensure optimal infection prevention from the time a patient with suspected covid-19 is first assessed until their infection is resolved, irrespective of the site of care. this can present particular challenges for health care staff, who must learn to use personal protective equipment safely, and patients with mild disease (about 80%) 10 can often be managed in the community if they are able to self-isolate. they must also be capable of monitoring their own condition, be aware of which symptoms should prompt medical review, and be able to escalate any concerns. [19] [20] [21] for some patients, a more proactive program of monitoring by phone or telehealth or in-person monitoring (eg, hospital in the home, regular review by general practitioner, or hospital admission) may be required. strategies for care should be individualised to suit patient circumstances. patients whose home environment is not conducive to safe management, or which is unacceptable from an infection prevention perspective, may require admission either to hospital or to alternative safe accommodation. discussion with public health authorities is essential to ensure that appropriate isolation and follow-up mechanisms are in place. in the face of high health care demand during the peak of a pandemic, safe management of low risk patients in the community will likely be essential to preserve hospital capacity for the more severely ill. patients with moderate or severe illness will generally require admission to hospital. this includes those who are dyspnoeic on minor exertion, tachypnoeic at rest (respiratory rate > 22 breaths/min), hypoxaemic (pulse oximetry [spo 2 ] < 94% on room air), hypotensive (systolic blood pressure < 100 mmhg), have an acutely altered mental state, or who have extensive pulmonary infiltrates evident on chest imaging. [19] [20] [21] severe illness, indicated by, among other features, a respiratory rate > 30 breaths/min, spo 2 < 92% on room air 19,21 or sustained hypotension, warrants urgent hospitalisation and consideration of the need for intensive care if suitable for a given patient. supplemental oxygen should be administered for patients with spo 2 < 92%. 19,20 once stabilised, the target spo 2 range is usually 92-96%. the target will be lower in those with chronic hypercapnoeic respiratory failure (eg, 88-92%). [19] [20] [21] manoeuvres to improve gas exchange should be implemented, such as positioning patients appropriately in bed (on either side with regular turning), elevating the bed head to 30 degrees, encouraging deep breathing every hour while awake, sitting patients out of bed every day when possible, and mobilising when able. for mechanically ventilated patients with persistent hypoxaemia, prone positioning may be effective. 19, 22 in the setting of progressive hypoxaemia despite low or moderate flow oxygen (via nasal prongs or hudson mask), high flow oxygen can be considered. whether high flow oxygen devices (> 10 ml/min) are potentially aerosol-generating is being studied, but current guidelines 1,23 advise that airborne precautions be taken by staff (personal protective equipment including n95/ p2 masks) and single rooms where possible. there are emerging views that the respiratory dysfunction observed in covid-19 infections is not uniform. 22 initial recommendations have focused on consideration of early intubation and mechanical ventilation for patients with acute respiratory distress syndrome due to covid-19. 1,19-21 experience from a multicentre italian covid-19 patient cohort suggests that noninvasive ventilation such as continuous positive airways pressure and bilevel positive airways pressure may also have a role both within and outside icus. 24 these non-invasive ventilation devices are clearly aerosol-generating and as such should only be used with appropriate precautions in place. 1,23 advice from experts in respiratory medicine or critical care should be sought. empirical antibiotic therapy for bacterial pneumonia should be considered in patients whose illness is severe, where there is evidence of sepsis or septic shock, or where the patient is clinically deteriorating. 19,20 empirical treatment for influenza with a neuraminidase inhibitor should be considered for patients with severe pneumonia (guided by local epidemiology) until influenza pcr results are available. 20 hypovolaemia may be contributed to by reduced oral intake and increased losses, but management requires cautious administration of intravenous fluids with regular assessments given the risk of exacerbating pulmonary oedema in the setting of acute respiratory distress syndrome 19,22 and given the possibility of underlying cardiac injury. 25 a range of possible complications related to sars-cov-2 infection have been reported and their incidence is being monitored. these include thromboembolic events in the lungs 22 and cerebrovascular system, 26 prophylaxis with anticoagulants for adults with moderate, severe or critical covid-19 infection is generally recommended, unless there are contraindications. 19,21 acute cardiac injury presenting with electrocardiogram changes, arrhythmias, left ventricular dysfunction, cardiomyopathy and congestive cardiac failure have also been described, and assessment of baseline electrocardiogram is suggested for patients with moderate or severe covid-19 illness. 25, 27 there is considerable interest in monitoring large patient cohorts and conducting analysis of linked datasets at a population level to establish whether there are any rare or longer term complications or associations of covid-19 with other medical conditions. given the very recent emergence of sars-cov-2, data are currently limited but it is likely that information will emerge in coming months from populations that have experienced a high attack rate. an example of a rare condition with potential association is paediatric inflammatory multisystem syndrome temporally associated with sars-cov-2, presenting as hyperinflammatory shock with features similar to atypical kawasaki disease. 28 similarly, there is interest in monitoring long term incidence of cardiovascular complications, thromboembolic disease, chronic respiratory dysfunction, renal or neurological disorders, and post-infectious inflammatory syndromes after covid-19, in addition to inspection of large datasets for complications that are as yet unsuspected. a range of pharmacotherapies have been proposed as possible treatments for covid-19. early evidence of clinical benefit for some agents has emerged. the who interim guidance on the clinical management of covid-19 21 asserts that investigational therapeutics should be used only in approved randomised controlled trials. this position is endorsed by the australasian society for infectious diseases interim guidelines for the clinical management of covid-19 in adults, 20 guidelines for the clinical care of people with covid-19, 19 which state that even where conditional recommendations for use of disease modifying agents are made, whenever possible these should be administered in the context of randomised trials with appropriate ethical approval. the understandable interest in evaluating potential treatments has led to a large number of clinical trials being registered globally; by late april 2020, over 1100 clinical studies were registered, including over 500 randomised controlled trials. 29 lopinavir-ritonavir, a combined antiretroviral agent, was proposed as a potential treatment for severe acute respiratory syndrome in 2003, based on apparent reductions in mortality in preliminary research in hong kong. 30 given its hypothesised role, five of the first 18 patients diagnosed with covid-19 in singapore were administered this agent. 31 on 18 march 2020, a randomised controlled open label trial of lopinavir-ritonavir in 199 hospitalised adults with covid-19 in china was published. 32 no benefit was observed in participants treated with the antiviral compared with controls. nearly 14% of those receiving lopinavir-ritonavir were unable to complete 14 days of treatments owing to adverse events. chloroquine and hydroxychloroquine are antimalarial agents which also have immunomodulatory properties that led to established indications for use in the treatment of rheumatological conditions. potential adverse effects include retinal toxicity, qt interval prolongation and other cardiological and dermatological effects. in early february 2020, chloroquine was reported to inhibit sars-cov-2 replication in vitro. 33 by mid-february, treatment of covid-19 with chloroquine was being described as a "breakthrough": a published letter stated that the results of treatment in over 100 patients in china had demonstrated that chloroquine was "superior to the control treatment", but no data were provided. 34 a small french open label non-randomised clinical trial examining hydroxychloroquine with or without azithromycin suggested a significant viral load reduction in those receiving therapy; 35 however, concerns have been raised about the design and analysis of the study. 36 despite the lack of clinical evidence from randomised clinical trials, several institutional and local guidelines, and notable public figures, have supported the potential use of chloroquine or hydroxychloroquine for the treatment of covid-19. 37, 38 however, given the current lack of evidence of clinical benefit and reports of significant limitations of supply of hydroxychloroquine for patients with rheumatological conditions, in march 2020, the pharmaceutical society of australia and the australasian society for infectious diseases called for immediate cessation of prescribing and dispensing of hydroxychloroquine for indications relating to covid-19, outside use in approved clinical trials. 39, 40 on 5 june 2020, the chief investigators on the recovery trial (comprising over 11 500 patients enrolled from hospitals across the united kingdom) issued a press release stating that no beneficial effect of hydroxychloroquine had been observed. 41 no difference in 28-day mortality, duration of admission, or other outcomes were observed between the 1542 patients randomised to hydroxychloroquine and the 3132 patients randomised to usual care. further details regarding this analysis are awaited. in january 2020, the first patient diagnosed with covid-19 in the us received the investigational nucleotide prodrug remdesivir, supplied on a compassionate basis. 42 developed as a potential therapy for ebola, there is in vitro evidence that remdesivir inhibits replication of coronaviruses, including middle east respiratory syndrome coronavirus and sars-cov-2. 33 in may 2020, a randomised trial in hong kong reported results of a comparison of lopinavir-ritonavir alone (n = 24) with a combination of lopinavir-ritonavir, ribavirin and subcutaneous interferon beta-1b (n = 52). 47 the combination group experienced a faster median time to viral clearance (7 days v 13 days; p < 0.0001) and shorter median length of hospital stay (8 days v 15 days; p = 0.0030) if the combination was commenced in the first 7 days from symptom onset. importantly, the cohort of patients studied was not particularly unwell, with very few requiring icu support and no deaths in the group. interim guidance from the who states that corticosteroids should not be used in routine treatment of covid-19. 21 this is based on systematic reviews in the context of severe acute respiratory syndrome and middle east respiratory syndrome which showed lack of effectiveness, and possible harm. 48 in a study of 138 hospitalised patients with covid-19 in wuhan, 49 72.2% of icu patients and 35.3% of non-icu patients received glucocorticoid therapy. the authors commented that while the dose of methylprednisolone varied depending on disease severity, no effective outcomes were observed. however, on 22 june 2020, a preliminary report regarding interim findings from the uk recovery trial suggested that low dose dexamethasone (6 mg daily orally or intravenous for 10 days) may substantially reduce mortality in hospitalised patients with covid-19 who received supplemental oxygen or mechanical ventilation. 50 in comparing 2104 patients randomised to receive dexamethasone with 4321 randomised to receive usual care, dexamethasone was found to reduce mortality by 35% (rate ratio, 0.65; 95% ci, 0.51-0.82; p < 0.001) among ventilated patients, and for those receiving oxygen without mechanical ventilation, mortality was reduced by 20% (rate ratio, 0.80; 95% ci, 0.70-0.92; p = 0.002). no benefit of dexamethasone was observed among hospitalised patients who did not require respiratory support. while peer review and formal publication of this analysis is awaited, it is likely that these findings will be reflected in national and international guidelines. tocilizumab is a humanised monoclonal antibody which binds to interleukin 6 (il-6) receptors, resulting in reduced immune activation and inflammation. it is licensed in australia for use in autoimmune conditions including rheumatoid arthritis and giant cell arteritis. in addition to complications of immunosuppression including serious infections, adverse effects include hepatotoxicity and gastrointestinal complications. the theory behind use of tocilizumab or other agents that target the il-6 pathway (eg, sarilumab) in the context of covid-19 is that part of the pathogenesis in some patients may be attributable to an acute inflammatory syndrome or cytokine storm, which is associated with elevated il-6 levels. clinical trials of these agents are currently underway. 44 numerous immunomodulatory agents have been proposed as potential adjunctive treatments for covid-19, with a range of different immunological targets including other inflammatory cytokines. these include anakinra (an il-1 receptor antagonist), bevacizumab (an antivascular endothelial growth factor agent), and eculizumab (which inhibits terminal complement and prevents formation of the membrane attack complex). 44, 51 while clinical trials are underway overseas for several proposed agents, no data exist to support their use at this time. 44 a preliminary, uncontrolled case series of five critically ill chinese patients with covid-19 who received convalescent plasma containing high sars-cov-2-specific antibody titres was published on 27 march 2020. 52 while improvement in clinical status was reported following this intervention, the small sample size and uncontrolled nature of the study precludes drawing any conclusions regarding the efficacy of this intervention. once again, further research is needed. a global pandemic causes understandable fear and anxiety for many people in the community. for those at particular risk of worse outcomes of infection -older people and those with significant pre-existing illness or multiple comorbidities -covid-19 represents a particular threat. in addition, the health care workforce is under substantial strain and faces a potentially overwhelming challenge in delivering care to patients. ensuring emotional care for the most vulnerable and those experiencing high levels of stress will be a fundamental determinant of the resilience of our society during this challenge. for vulnerable and frail patients at particular risk of poor outcomes, it is important to provide personalised care and to develop an understanding of each individual's perspectives and preferences for health management. involving caregivers and family members in decision making and establishing goals of care is necessary. 21 discussing goals of care early and, where appropriate, assisting patients to make advance care directives or resuscitation plans early in illness (or before infection) may provide substantial peace of mind and allow families to face the pandemic openly and with unity as they support vulnerable loved ones. it is essential to ensure that all patients receive the best standard of care irrespective of the setting in which the care is delivered, or of the existence of any proposed limitations to life-extending interventions. under no circumstances should the best possible symptom control and compassionate, individualised care be denied any patient affected by covid-19. sars-cov-2 has caused a global pandemic with a profound public health impact, changing the daily lives of billions of people. it has exposed weaknesses in even strong and well resourced health systems internationally, and the economic impact alone will be staggering. however, never before has the global community had the tools currently available to address a pandemic threat. a strong commitment to social and public health strategies and communicable disease control will ensure our health system retains the capacity to address covid-19, including sufficient hospital and intensive care resources to care for those with severe illness. biomedical innovations such as new and rapid point-of-care diagnostics, effective specific treatments and preventive vaccines are very high priorities which are rightly attracting substantial attention and funding. in the interim, high quality, evidencebased clinical care -scaled up to face the pandemic challenge -together with robust public health interventions will save the lives of thousands in australia, and millions globally. narrative review mja 213 (3) ▪ 3 august 2020 spread of sars-cov-2 in the icelandic population presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of coronavirus disease 2019 in china diarrhea during covid-19 infection: pathogenesis, epidemiology, prevention and management characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china covid-19 in critically ill patients in the seattle region -case series molecular and serological investigation of 2019-ncov infected patients: implication of multiple shedding routes viral dynamics in mild and severe cases of covid-19 epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore sars-cov-2 viral load in upper respiratory specimens of infected patients novel coronavirus pneumonia emergency response epidemiology team. the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (covid-19) -china clinical characteristics of fatal and recovered cases of coronavirus disease 2019 (covid-19) in wuhan, china prediction for progression risk in patients with covid-19 pneumonia: the c all score 19 national covid-19 clinical evidence taskforce. caring for people with covid-19: living guidelines australasian society for infectious diseases limited. interim guidelines for the clinical management of covid-19 in adults world health organization. clinical management of covid-19: interim guidance management of covid-19 respiratory distress aerosol generation related to respiratory interventions and the effectiveness of a personal ventilation hood baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region clinical features of patients infected with 2019 novel coronavirus in wuhan, china neurologic manifestations of hospitalized patients with coronavirus disease 2019 in wuhan, china characteristics and outcomes of 21 critically ill patients with covid-19 in washington state hyperinlammatory shock in children during covid-19 pandemic clinical trials for the prevention and treatment of covid-19: current state of play role of lopinavir/ritonavir in the treatment of sars: initial virological and clinical findings epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore a trial of lopinavirritonavir in adults hospitalized with severe c ovid-19 remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid-19 associated pneumonia in clinical studies hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial thoughts on the gautret et al paper about hydroxychloroquine and azithromycin treatment of covid-19 infections national institute for the infectious diseases "l. spallanzani", irccs. recommendations for covid-19 clinical management specific antiviral therapy in the clinical management of acute respiratory infection with sars-cov-2 (covid-19). version 1.0, 12 prescribing hydroxychloroquine for covid-19. open letter to prescribers letter to the cmo on the use of hydroxychloroquine as prophylaxis against covid-19 statement from the chief investigators of the randomised evaluation of covid-19 therapy (recovery) trial on hydroxychloroquine we gratefully acknowledge the contributions of anna deng, louis irving, ashleigh qama and lien tran to this article. key: cord-304479-uxp1kg86 authors: goodarzi, pedram; mahdavi, farzad; mirzaei, rasoul; hasanvand, hamze; sholeh, mohammad; zamani, farhad; sohrabi, masodreza; tabibzadeh, alireza; jeda, ali salimi; niya, mohammad hadi karbalaie; keyvani, hossein; karampoor, sajad title: coronavirus disease 2019 (covid-19): immunological approaches and emerging pharmacologic treatments date: 2020-08-08 journal: int immunopharmacol doi: 10.1016/j.intimp.2020.106885 sha: doc_id: 304479 cord_uid: uxp1kg86 the sars-cov-2 virus is an etiological agent of pandemic covid-19, which spreads rapidly worldwide. no proven effective therapies currently exist for this virus, and efforts to develop antiviral strategies for the treatment of covid-19 are underway. the rapidly increasing understanding of sars-cov-2 virology provides a notable number of possible immunological procedures and drug targets. however, gaps remain in our understanding of the pathogenesis of covid-19. in this review, we describe the latest information in the context of immunological approaches and emerging current antiviral strategies for covid-19 treatment. in december 2019, many severe respiratory diseases accompanied by pneumonia appeared in wuhan, hubei province, china, with unknown etiology [1] [2] [3] . sequencing examination on lower respiratory tract specimens showed a novel coronavirus named 2019 novel coronavirus (2019-ncov) [4] [5] [6] [7] [8] . data from genome sequencing of sars-cov-2 assist the researchers in approving diagnostic examination, epidemiologic tracking, and advancement of preventive and curative strategies [9] . the clinical sign of covid-19 has a wide range from moderate, self-restraint respiratory tract illness to acute progressive pneumonia, multi-organ collapse, and death [9, 10] . up to the present, there were no licensed therapies for the therapy of 2019-ncov infection. after the rise of the sars-cov-1 in 2003, screening of licensed drugs for the therapy of sars led to the identification of some drugs (as reviewed by vijayanand and colleagues) [11] , such as protease inhibitors, nucleoside analogs, intravenous immunoglobulins, convalescent sera, tumor necrosis factor-alpha blockers, interferons, traditional chinese medicines, and glycyrrhizin. this virus causes sars in humans [11] . there are no confirmed efficacious treatments for the however, researchers made much effort to develop antiviral strategies for the treatment of covid19 . this review will describe the current evidence on significant proposed, repurposed, or experimental therapies for covid-19 and present a summary of contemporary clinical experience and treatment guidelines for this new pandemic sars-cov-2. antibodies are an essential part of host immune reactions to viral infection. due to their unique maturation process, antibodies can emerge extremely particular to viral antigens [12] . the first use of immunoglobulins (antibodies) as a therapy opportunity for viral diseases can be hunted back to the beginning 20th century, using sera of infected people, who had improved from the same condition [13, 14] . this natural therapy regimen ( serum therapy), was slowly replaced by immunoglobulins purified from merged sera, intravenous immune globulin (ivig) [15] . notwithstanding the achievement of both serum therapeutics and ivig, no meaningful advancement was made to produce antibodies as therapeutics. the hybridoma technique was continuously launched, facilitating the separation of monoclonal antibodies (mabs) from immunized mice in 1975 [16] . various approaches have been established since the mid-1980s for the effective separation of mabs toward viruses of human and animal sources [12] . to date, there are no confirmed vaccines or therapeutic medications that are special to covid-19. preventing monoclonal antibodies (mabs), owing to their fantastic antigen specificity, is among the most suitable nominees for compensating viral infection [17] . hence, recognizing and cloning of mabs that can accurately target viral superficies proteins to hinder the viral entrance to host cells is an acceptable strategy for blocking and handling covid-19, mainly when effective vaccines and therapeutics medications are unavailable in the outbreak of the covid-19 pandemic [18] . mabs targeting exposed positions on viral outside proteins are frequently identified as hopeful classes of drugs toward infectious disorders and have conferred therapeutic potency for numerous types of viruses [19, 20] . neutralizing antibodies produced against coronavirus mainly target the spike (s) glycoproteins outside the viral envelope that mediates entrance into host cells. the s protein is composed of two functional subunits, which involve cell binding (s1 subunit) and s2 subunit, which includes membrane fusion. s1 subunit the main target of the humoral immune system, that potent neutralizing antibodies often produced against it [21] [22] [23] [24] [25] [26] . a recent report by wang et al. has shown that human mabs can neutralize both sars-cov-2 and sars-cov in cell culture [27] . another report demonstrated that chen and colleagues separated two human mabs employing sars-cov-2 rbd-specific memory b cells separated from healed cases with covid-19. these two mabs could especially attach to sars-cov-2 rbd, block the interplay within sars-cov-2 rbd and the hace2 receptor, and lead to potent neutralization of sars-cov-2 s protein pseudotyped virus infection. before-mentioned human anti-sars-cov-2 rbd-ace2 blocking mabs are initially described and endure transcendent hope to be employed as specific preventive and therapeutic tools toward underway sars-cov-2 pandemic [18] . this knowledge suggests that mabs have a promising approach for tackling the covid-19 pandemic. the results of using mabs are still premature, and future studies will shed light on the feasibility of this type of biological therapy for patients with covid-19 ( figure) (table) . the sera separated to form recovered patients from the infectious disease called convalescent plasma, which has been employed to prevent and treat various infectious illnesses for longer than one century. antibodies exist in immune or convalescent plasma, intercede their curative effects through multiple mechanisms. the antibody can attach to a given infectious agent by compensating its infectivity directly. another mechanism that antibody may also contribute to its therapeutic effect includes complement activation, phagocytosis, and antibody-dependent cellular cytotoxicity. non-neutralizing antibodies attach to the infectious agent but do not intervene with their capacity to replicate in-vitro systems may also participate in prevention and expedite the rehabilitation process [28, 29] . across the previous two decades, convalescent plasma therapy has been successfully employed to manage sars, mers, and the 2009 h1n1 pandemic with competent potency and safety [30] [31] [32] [33] . a meta-analysis of 32 investigations of sars-cov and severe influenza virus infection explained a statistically meaningful decline in the pooled odds of fatality following treatment with convalescent plasma, contrasted with placebo or no treatment [34] . however, convalescent plasma treatment was unable to considerably enhance the durability of the ebola virus infection, presumably due to the lack of data on neutralizing antibody titration for stratified examination [35] . because the virological and clinical features share similarities between sars-cov-1, mers, and sars-cov-2, convalescent plasma treatment might be a confident strategy choice for covid-19 saving [36] . patients who have healed from covid-19 with a huge neutralizing antibody concentration may be a precious donor reservoir of convalescent plasma. it is worth mentioning that there are potential safety concerns on convalescent plasma therapy, including transmitting other infectious agents and a pathological event called antibodydependent enhancement (ade) [37] . ade attributes to a means of how antibodies increasing throughout a previous infection exacerbate clinical severity as an outcome of disease with a distinct viral serotype. this event is famed for some viruses, prominently the dengue virus [38] . although, in convalescent serum trials, attention, and alertness to recognize any enhanced infection, evidence will be demanded. in a recent report published in china, researchers revealed that in 10% of patients, one dose of convalescent plasma (200 ml) was well-tolerated and significantly increased or maintained neutralizing antibodies at high levels, resulting in the disappearance of viremia within a week. it can also modulate multiple parameters compared to pre-transfusion, including decreased c-reactive protein and increased lymphocyte numbers. besides, convalescent plasma therapy in seven cases who had the former viremia led to the disappearance of viremia (undetectable viral load). another finding that study was that convalescent plasma treatment was well-tolerated and conceivably improved the clinical symptoms, thereby neutralizing viremia in patients with severe covid-19. finally, the authors of this study believe that further investigations are wanted to define the optimal dose and clinical benefits of convalescent plasma therapy [39] . future studies should analyze the efficiency of convalescent plasma treatment in many patients, and the potential risk of this therapeutic method must be deeply assessed (figure) (table) . the increasing knowledge is regarding covid-19 pathogenesis has supported the role of excess inflammatory mediators in patients with covid-19. patients' pathological characteristics with covid-19 include capillary leakage of liquid and entrance of inflammatory cells, including t cells, neutrophils, and macrophages [40] , referring a function for chemokines and cytokines targeting vascular endothelium. the concentration of pro-inflammatory cytokines, including il-1, il-6, tnf-α, and ifn-γ, are elevated in the blood of cases infected with covid-19 [3, 41] . recent studies report different cytokine profiles in patients with severe covid-19 [3, [41] [42] [43] [44] [45] [46] . in a study carried out by huang and colleagues have revealed the higher concentration of il-2, il-7, il-10, tnf, g-csf, ip-10; cxcl10, mcp-1 (ccl2) and mip-1a (ccl3), but not il-6, in cases hospitalized in the intensive care unit (icu) contrasted with non-icu patients (4). another study confirmed that during acute covid-19 disease, some pro-inflammatory cytokines such as il-1β, il-1ra, il-2r, il-6, il-8 (cxcl8), il-17, ifn-γ, gm-csf elevated [42, 43, 45, 46] . in recent exciting research, the concentration of some cytokines/ chemokines, including il-6, il-10, ifnγ, tnf, and ip-10 in icu patients with covid-19, have been higher than mild to moderate non-icu patients [3, [42] [43] [44] . various strategies, including global targeting of the inflammation or compensating a single crucial inflammatory marker, are applied to cope with cytokine storm in covid-19. between key cytokines, il-6 has drawn significant attention levels, and antibodies that hinder the il-6 receptor (il-6 antagonist, tocilizumab, and sarilumab) are now following phase 2/3 clinical trials for the possible therapy of covid-19 [47] . another hopeful strategy is targeting ifn-γ, which has been remarked by beginning a clinical trial for jak-stat inhibitor (ruxolitinib) for managing covid-19 severity [48] . tnf works upstream of il-6, and anti-tnf treatments earlier revealed protecting impacts in deadly sars-cov disease [49] . a recent report by cavalli et al. have shown that the efficacy of anakinra (human interleukin-1 receptor antagonist protein) was notably higher in subjects with covid-19 contrasted with those who received standard treatment for three weeks, led to decreased levels of serum crp, improved respiratory function (72% vs. 50%), increased survival rate (90% vs. 56%). however, the study results demonstrated that bacteremia's risk was elevated in cases receiving anakinra than those receiving standard treatment [50] . although there is no particular antiviral medicine for covid-19, knowledge of cytokine storm mechanisms can help to speculate possible therapeutic interventions ( figure) (table) [51] . it is alleged that corticosteroid treatment is not supported for viral pneumonia [52] . investigations have revealed that the use of systemic corticosteroids for patients with sars-cov and mers-cov was correlated with a higher fatality rate than patients under standard treatment [53, 54] . the same finding was described in cases with influenza virus-associated pneumonia [55] . in a study performed by matsuyama et al. [56] , they utilized the nasal administration of corticosteroids for patients infected with coronaviruses. they indicated that in the cell culture models, the inhaled form of corticosteroids, such as ciclesonide, could be useful for the treatment of coronaviruses. ciclesonide exerts antiviral and anti-inflammatory activity in in-vitro models [56] . furthermore, there are some open clinical trials for the therapeutic assessment of methylprednisolone on covid-19 patients [57] . a systematic review study carried out by tahvildari and colleagues [58] , shows that at least six different published studies on the effect of corticosteroids on covid-19 patients. also, wu et al. [59] indicated that the use of corticosteroids for patients with covid-19 who developed ards could lead to a better outcome and reduce the mortality rate. these results indicate the necessity of checking the clinical conditions of covid-19 patients before prescribing corticosteroids. finally, recently, a case report study from japan shows that orally inhaled ciclesonide alleviates the local inflammation in the lung of patients with covid-19 pneumonia and inhibits the propagation of the virus by antiviral activity [60] . further studies are required to unravel the precise mechanism of corticosteroids in the exacerbation of patients with covid-19 ( figure) (table) . mesenchymal stem cells (mscs) are a subset of non-hematopoietic adult stem cells, readily isolated from various tissues. they show immunoregulatory activity and could be employed for the tissue repair process as they secrete paracrine factors [61] . cell-based therapy, remarkably stem cell therapeutics, has become an encouraging remedial field, in which many perceive possibilities to cure deadly and inflammatory disorders [62, 63] . notwithstanding the notable progress of stem cell-based treatment, immunogenicity, poor cell source, and moral problems are deemed the main therapeutic approach restrictions. among these, mscs have drawn much attention due to origin potential, a high reproduction speed, having a low invasive method, and free of moral problems. there is an extreme advantage in applying msc treatment in contrast with other approaches [64] . the results indicate that following covid-19 infection may start suppressing immune overactivity in the human body. in patients infected with sars-cov-2, the immune system generates massive volumes of inflammatory factors, prompting cytokine storm in which the immune cells produce an extreme amount of cytokines and chemokines [65] . herein, it is the opening of the msc therapy strategy in the treatment of covid-19 patients. msc cure can limit the storm release of cytokines by the immune system and raise endogenous restoration by regenerative features of stem cells [66] . recently, some countries, such as china, the usa, iran, and various other countries, have launched msc therapy, and some reports are currently available in the published literature. mscs, working their immunomodulatory features and their differentiation capacity, can inhibit lung tissue loss by hindering the cytokine storm and restoration and regeneration of damaged tissues [67] . a recent study carried by chen and co-workers indicated that the use of mscs notably improves the survival proportion of h7n9-induced ards and provides a philosophical background for treating h7n9-induced ards preclinical research and clinical research. because h7n9 and covid-19 share similar complications and are associated with multi-organ collapse, msc-based treatment could be a feasible option for the treatment of covid-19 [68] . in the same way, a recent case-report study showed that the adoptive transfer therapy of human umbilical cord blood derived-mesenchymal stem cells (hucmscs) to a chinese female patient afflicted with acute covid19 syndromes improved her laboratory tests and ct images [69] . before receiving any treatments, the percentage of her neutrophils was increased to 87.9% while the number of lymphocytes was decreased to 9.8%. she was operated with antiviral medications, including lopinavir/ritonavir, ifn-α, and oseltamivir, also the intravenous dose of moxifloxacin, xuebijing, methylprednisolone, and immunoglobulins. the case was also curbed to non-invasive mechanical ventilation to expedite breathing and decrease muscle weakness due to weak oxygenation. as the vital symptoms exacerbate, the case was treated with hucmscs solely and with α1 thymosin 5 × 107 cells per three times. the study results explained that following the second injection, serum albumin, crp, alt, and ast were steadily diminished, and other important symptoms were enhanced. after that, the patient was discharged from the ventilator and capable of walking, and the number of neutrophils and white blood cells returned to the baseline levels. most importantly, the abundance of cd3+, cd4+, and cd8+ t cells was significantly enhanced. also, the qualitative outcomes of ct images following the second and third doses of hucmscs revealed that pneumonia was attenuated. after two days of the third injection, the patient was rescued from the icu, and most of the vital symptoms and clinical laboratory parameters returned to the standard ranges. the outcomes recommended that hucmscs could be an excellent strategy choice alone or in combination with other immunomodulatory tools for covid-19 patients [69] . a recent study performed in china in cooperation with the united states recruited seven cases with covid19 pneumonia from january 23 to february 16. patients experienced mscs transplantation, and their clinical signs were consecutively checked for 14 days. the study demonstrated that the transplantation of hucmscs led to a marked decrease in the level of pro-inflammatory cytokines and a substantial improvement in clinical symptoms without any significant adverse effects [70] . the pulmonary function, along with the seven patients' clinical symptoms, were significantly improved after two days of transplantation. the number of peripheral lymphocytes also increased, while crp concentration was diminished after the treatment. additionally, the number of hyperactive cytokine-secreting immune cells, namely cxcr3+cd4+, cxcr3+cd8+, and cxcr3+ nk cells was remarkably lowered within 3-6 days after transplantation of hucmscs. moreover, the frequency of cd14+cd11c+cd11b mid regulatory dc cell population was significantly elevated. the level of tnf-α was significantly reduced, while il-10 was raised in the hucmscs-treated group contrasted with the placebo control group. besides, the gene expression characterization explained that ace2 and tmprss2 genes are not expressed in hucmscs, implying that the coronavirus would not infect these cells. hence, the intravenous transplantation of hucmscs is seemingly safe and efficient for the treatment of cases with covid-19 pneumonia, notably those in critically severe conditions [70] . as multiple clinical trials are launched worldwide, we should not have to wait long to determine if mscs are a viable and valid treatment choice for severe covid-19. considering the need for mitigating the prevailing covid-19 pandemic, with superiority to manage fatality as low as possible, the judgment that msc is reliable and can invert severe critical disease with high power is an invention designing a completely novel biological procedure that needs to be developed urgently (figure) (table) . chloroquine and hcq are both known as antimalarial drugs. clinical studies introduced these two drugs as a possible choice for covid-19 treatment due to having in-vitro antiviral and antiinflammatory properties [71] [72] [73] [74] . several studies suggested that chloroquine could improve the radiological and virological features of covid-19 [53] . chloroquine is a reliable and effective drug for covid-19 in some preclinical trials [75] and other studies [72] . in this regard, smith et al. [72] indicated that cardiac arrhythmia is a significant side effect of chloroquine. in the matter of hydroxychloroquine, reports are controversial [72, 73, 76] . in a study conducted by shamshirian et al. [76] , there was no potential clinical efficacy in prescribing hcq. simultaneously, the in-vitro anti-sars-cov-2 activity of this particular drug seems to be more than chloroquine [72, 73] . fortunately, there are currently several clinical trials being conducted on these drugs [57] . also, regardless of the solo practice for these drugs, gautret, and colleagues [77] suggested a combination of hcq and azithromycin as an effective treatment for decreasing the viral load in patients with covid-19. another aspect of these drugs is the possibility of using them in different conditions such as pregnancy. a majority of studies conducted on hcq did not reflect any serious concerns, and this drug seems to be safe for pregnant women [78] . besides, as mentioned by lother et al. [79] , clinical trials for the assessment of medicines as post-exposure prophylaxis could be helpful. a recent report noted that the severity of covid in patients treated with hcq was higher than those not receiving this medication. also, the report showed that there was no meaningful correlation within the use of hcq and intubation or mortality [80] . besides, another report demonstrated that amongst cases hospitalized in metropolitan new york with covid-19, practice with hcq, azithromycin, or both, matched with neither medication, was not meaningfully correlated with variations in an in-hospital fatality. however, the analysis of these conclusions may be restricted by the observational study [81] . the recent study also indicated that hcq did not substantially decrease symptom severity in outpatients with early, mild covid-19 [82] . at the same time, another study performed by mitjà and colleagues indicated that hcq in patients with mild covid-19 has no benefit beyond routine care [83] . moreover, arshad and co-workers [84] showed that in patients with covid-19 treated with hcq alone and combined with azithromycin, it was correlated with a decline in covid-19 associated mortality. comprehensive systematic review and meta-analysis studies and clinical trials in this field are urgently needed ( figure) (table) . ace2 (angiotensin-converting enzyme-2) is a transmembrane enzyme expressed on the exterior of epithelial cells in the many organs such as lungs, arteries, heart, kidney, and intestines [85, 86] . recently, the new coronavirus is responsible for pandemic covid-19, sars-cov-2 is thought to be mainly or exclusively bound to ace2 [87, 88] . the molecular interplay among ace2 and spike has been created [87, 88] , and manufactured compounds or antibodies, interfering with the interplay of ace2, and the viral spike protein could be produced. another therapeutic approach is the use of soluble ace2 as a virus scavenger and neutralizer. soluble ace2 formed by a proteolytic splitting of the membrane anchor is ordinarily located in the plasma; however, its concentration is shallow. an increase in the availability of soluble ace2 at tissue positions would change the rivalry with membrane-bound ace2 toward the soluble form, leading to the repression of viral entry into the cells. it is also expected that this approach would preserve tissue ace2 [89, 90] . a new study has recently shown that the recombinant form of ace2 reduces the infection and viral growth in cell culture and organoids by acting as a decoy for sars-cov-2 [89] . this study showed that by adding a genetically altered variant of ace2, termed human recombinant soluble angiotensin-converting enzyme 2 (hrsace2), the entry of covid-19 into the lung epithelial cells was halted. in this study, the results of cell culture indicated that hrsace2 decreased the load of sars-cov-2 by 1,000-5,000 times [89] . the authors also used the blood vessels and kidney organoids to explain that sars-cov-2 could directly contaminate and propagate in these tissues, suggesting a potential agent of multi-organ collapse and cardiovascular damages as a result of covid-19. the augmentation of hrsace2, too, diminished the infectivity of sars-cov-2 in these organoids [89] . in engineered models of the human blood artery and kidney organoids developed from human stem cells, it was confirmed that it could straight contaminate and replicate itself in these tissues. these findings provide crucial information about the pathogenesis of covid-19 and explain the reason for multi-organ collapse and cardiovascular injuries. in this engineered human tissues, hrsace2 also diminished the viral load of sars-cov-2. the researchers highlighted that their experiment has only tested the drug efficacy through the initial stages of sars-cov-2 infection. further investigation would be demanded to determine the fidelity of this recombinant therapy for later stages of the disease (figure) ( table) . the prescription of ribavirin for the therapy of coronaviruses returns to sars-cov and mers-cov. reports indicated that this antiviral agent's administration did not show promising results for the treatment of sars-cov [91] . meanwhile, ribavirin antiviral activity was addressed in in-vitro studies in a dose-dependent manner [91, 92] . on the other hand, a group of studies demonstrated a beneficial role of ribavirin in the treatment of mers-cov [93] . simultaneously, some investigations showed that the combination of ribavirin and interferon was unsuccessful in treating mers-cov [94] . there is limited knowledge about the efficiency of ribavirin in the amelioration of covid-19 [58] . a study conducted by elfiky et al. [95] , using bioinformatics approaches, favipiravir (also known as t-705) is an antiviral drug that selectively and robustly hinders the rna-dependent rna polymerase (rdrp) of rna viruses, was licensed in 2014 in japan to cure pandemic influenza virus diseases [97] . interestingly, despite its anti-influenza virus activity, this molecule can also halt the replication of an extensive range of rna viruses (e.g., flaviviruses, alphaviruses, filoviruses, noroviruses, arenaviruses, bunyaviruses, and other rna viruses) [97] . regarding the emergence of sars-cov-2, it is urgently essential to recognize active antiviral [98] . they indicated that patients receiving favipiravir showed improved chest imaging, faster decreased viral load, and fewer adverse effects than the control group [98] . another study performed by chen et al. compared the efficacy of favipiravir versus arbidol [99] . they showed that the clinical recovery rate on day seven and the degree of auxiliary oxygen treatment or non-invasive mechanical ventilation did not significantly vary within the favipiravir-and arbidol-treated groups. besides, the current study demonstrated that favipiravir significantly enhanced the latency to relief for fevers. also, adverse effects caused by favipiravir were mild and manageable [99] . these preliminary clinical results provide useful information about therapeutic options for sars-cov-2 infection (figure) ( table) . remdesivir (gs-5734) is a prodrug (nucleotide) with extensive antiviral action toward viruses from distinct genera in-vitro [100] . it also has therapeutic effects on nonhuman primate models of deadly ebola and nipah virus contaminations [101, 102] . investigations conducted on epithelial cells from human airway explained that remdesivir additionally hinders replicating an extensive range of coronaviruses, including mers-cov [103] . moreover, some reports indicated that remdesivir has robust action toward sars-cov-2 in-vitro [104, 105] . a recent investigation performed on rhesus macaques contaminated with sars-cov-2 noted that the treatment with a 6-day regimen of iv remdesivir launched 12 hours following virus inoculation was correlated with some therapeutic outcomes (lower disease severity rates, less pulmonary infiltrates, lower virus titers in bronchoalveolar lavage samples) contrasted with the control animals. of note, remdesivir medication did not diminish the viral load or the titer of the virus in the nasopharynx or rectal swabs compared to the control of vehicle control [106] . various clinical trials are currently being performed in the us, china, and other countries. a recent clinical trial in hospitalized patients with severe covid-19 in china showed that remdesivir treatment was not correlated with a decline in hospitalized patients' recovery period. the results indicated that patients receiving remdesivir had a lower period of hospital stay than those receiving placebo (18 vs. 23 days); however, such a reduction in hospital stay period was not statistically significant. also, the continuation of invasive mechanical ventilation was more concise (but not statistically meaningful) in the remdesivir-treated group, and only a tiny percentage of patients (0.4%) underwent invasive mechanical ventilation at the time of reception. remdesivir did not significantly reduce the viral load of sars-cov-2 in nasopharyngeal, oropharyngeal, and sputum specimens. remdesivir was stopped in 18 patients (12%) because of adverse effects [107] . however, a phase iii randomized, open-label trial performed on hospitalized patients with severe covid-19 showed that the disease severity was lower in patients who received remdesivir within 10 days after the onset of clinical symptoms compared with those treated after 10 days of the manifestation of clinical signs [108] . notably, patients treated with remdesivir had a more short recovery period than those treated with placebo. also, the mortality rate in remdesivir-treated patients (7.1%) was lower than patients receiving a placebo. however, the difference in mortality rate within the two groups was not statistically meaningful [109] . another clinical trial has been recently established in the us, china, and other countries to explore the efficacy of remdesivir in improving patients with covid-19 (table 1) . further clinical trials are wanted to determine the effect of remdesivir on patients with covid-19 (figure) ( table) . ivermectin is an fda-licensed drug that has a broad spectrum of antiparasitic activity [110] . studies have shown that this drug exerts antiviral action toward an extensive range of viruses invitro [111] [112] [113] [114] . it has been designated that ivermectin hinders the interplay within the human immunodeficiency virus-1 (hiv-1) integrase protein (in) and importin (imp) α/β1 heterodimer accountable for the nuclear import of in [115] . ivermectin has, too, been demonstrated to impede nuclear import and hiv-1 replication [114] . also, ivermectin suppresses explicitly the activity of the ns3 helicase enzyme, required for the replication of flaviviruses [116] . in the same way, ivermectin inhibits the replication of dengue virus type 2 (denv-2) in aedes albopictus [117] . another study indicated that ivermectin prevents the interaction between denv 1 and 2 ns5 with its nuclear transporter importin α/β in-vitro and make effort protection toward denv1-4 [113] . ivermectin is thought to be effective against sars-cov-2, the virus which causes pandemic covid-19 [118] . it has been reported that ivermectin can reduce the replication of sars-cov-2 when added to the cell culture 2 h post-infection. besides, ivermectin can diminish the viral load by ~5000 folds, whiting 48 h post-infection [118] . the next critical step is to examine dosing regimens that mimic the currently recommended use of ivermectin in humans [119] . a current phase iii clinical trial in thailand showed that ivermectin was safe but did not perform any clinical advantage when used for dengue viruses. however, studies recommended that dosing regimens might be improved and expanded, depending on pharmacokinetic analyses [120] . although denv differs from sars-cov-2, the design of future clinical trials should be revisited to provide valuable information about the efficacy of this drug on covid-19. current studies hold great promise for the prescription of ivermectin as a possible antiviral therapy against sars-cov-2 ( figure) (table) . β-d-n4-hydroxycytidine is a ribonucleoside analog called eidd-1931, an orally bioavailable prodrug by wide range antiviral action toward multiple independent rna viruses, which includes influenza, ebola, coronaviruses, and veev [121] [122] [123] [124] . currently, there are no specific licensed therapeutics for sars-cov-2. recently, an interesting study indicated the efficacy of eidd-2801against covid-19 in human cells and mice [123] . eidd-2801 is an orally bioavailable drug that its mechanism of action is similar to remdesivir. these drugs can mimic the function of infections caused by other types of coronaviruses [123] . clinical trials seem to be needed to investigate the probable applicability of eidd-2801 in the clinic against pandemic covid-19 ( figure) (table) . lopinavir and ritonavir are the hiv-1 fda approved drugs, which inhibitors of the hiv protease. this anti-protease activity seems to be active on the sars-cov-2 protease, either. lopinavir and ritonavir could induce adverse effects, such as qt prolongation, and must be carefully prescribed for patients with liver-associated diseases [72] . several clinical trials conducted on the combinatory use of lopinavir/ritonavir was more pronounced in patients with covid-19 than other therapeutic regimens [57, 58] . one study also showed that the combination of lopinavir/ritonavir and arbidol (an antiviral agent against rna viruses) did not significantly protect covid-19 in patients [125] . meanwhile, zhu and colleagues [126] demonstrated that arbidol monotherapy was more effective than the use of lopinavir/ritonavir and arbidol. besides, an in-vitro study performed on lopinavir did not exhibit any direct antiviral activity against sars-cov-2 [74] . regardless of these findings, the administration of lopinavir/ritonavir seems beneficial on sars-cov and mers-cov only when used at the early stage of infection [127] . in conclusion, it seems hard to introduce the lopinavir/ritonavir as a treatment option for covid-19, but further clinical trials are warranted to elucidate the effectiveness of these drugs (figure) ( table) . there is progressing proof that cases with severe covid-19 promote a hypercoagulable status, which has been correlated with weak outcomes such as increased respiratory malfunction, severe respiratory distress syndrome, or mortality [128] [129] [130] [131] [132] [133] [134] . the initial treatment with anticoagulation drugs in patients with severe covid-19 infection may diminish the risk of thrombotic complexities and promote clinical consequences [59, 131, 133, 135, 136] this increasing evidence urged researchers to focus on the potential applicability of using anticoagulating agents for covid-19. heparin is an anticoagulant agent possessing potential benefits beyond anticoagulant activity. it has been shown that heparin decreases coronary thrombosis, pulmonary emboli, and microvascular ischemia. besides, it has anti-inflammatory and antiviral properties, enabling this compound to lower the degree of lung inflammation and improving oxygenation [137] . a new retrospective report by tang et al. confirmed that anticoagulant therapy is correlated with a diminished mortality percentage in covid-19 patients with coagulopathy. also, the results recommend that patients with severe covid-19 disease or considerably elevated levels of d-dimer (>6 x uln) may have declined fatality when they receive preventive doses of heparin. researchers also proposed that anticoagulant treatment seems to be correlated with a more favorable prediction in severe covid-19 patients engaging sepsis-induced coagulopathy (sic) standards extended d-dimer [138] . however, prospective studies are demanded to validate these conclusions because the current retrospective study has limited data ( figure) (table) . rates that humanity has experienced in the 21st century after the pandemic influenza outbreak of 1918. although the gaps remain in our understanding of the pathogenesis covid-19, the velocity and mass of antiviral strategies began to examine possible medicines for covid-19 to highlight both the demand and capacity to provide high-quality data even amid a pandemic. probably the best plan for fighting with the sars-cov-2 is an effective vaccine, which prompts the immune system to produce antibodies against viral proteins or t cells that can eliminate infected cells. however, vaccine development is slower than the spread of the epidemic; therefore, the clinically useful candidate drugs would be necessary and urgent for the treatment of patients with covid-19. among the immunological approaches, cp therapy might be a trusting approach choice for covid-19 saving; however, future investigations should examine the efficacy of cp treatment in many patients, and the potential risk of this therapeutic approach must be profoundly evaluated. besides, many clinical trials are underway across the world; however, currently, no therapies have been shown useful to date for covid-19, or some drugs such as remdesivir have a limited benefit in patients with covid19. there are no conflicts to declare. this work was supported by the iran university of medical sciences. in vero cells hydroxychloroquine was found to be more potent than chloroquine to inhibit sars-cov-2 [73, 139] hcq could significantly shorten ttcr and promote the absorption of pneumonia [140] hcq significantly associated with viral load reduction/disappearance in covid-19 patients and its effect is reinforced by azithromycin [77] hcq no effect on intubation or death in patients with covid-19 [80] hcq did not substantially reduce symptom severity in outpatients with early, mild covid-19 [82] . hcq has no benefit in patients with mild covid-19 [83] . hcq with or without azithromycin was not significantly associated with differences in inhospital mortality [141] hcq alone or with azithromycin in patients with covid-19 was associated with a decline in covid-19 associated mortality [84] . chloroquine phosphate inhibit the fusion of the virus to the cell membrane by modulation of the endosomal ph in vitro activity against sars-cov-2 in infected vero e6 cells reported; some evidence it may block infection in vero e6 cells exposed to sars-cov-2 [75, 104, 139] clinical experience in treating pts with covid-19 accumulating; reports of possible clinical benefits, including decrease in viral load and duration of illness [53, 71, 75] favipiravir (fpv) rna polymerase inhibitor in vitro 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benefits [107] clinical improvement was observed in 68% of severe covid-19 patients treated with remdesivir in a cohort study [143] remdesivir was associated with shortened recovery time and decreased rate of mortality in patients with covid-19 versus the placebo group [ inhibition of viral entry into the cell in vitro hrsace2 had a dose dependent effect of viral growth of sars-cov-2 and was able to reduce it by a factor of 1,000 to 5,000 in cell cultures [89] currently no known published data regarding efficacy or safety in the treatment of covid-19ivermectin inhibiting impα/β1 which mediated nuclear import of viral proteins in some human and animal viruses.in vitro activity against some human and animal viruses in vitro evidence of activity against sars-cov-2 in infected vero-hslam cells reported with high concentrations of the drug [118] currently no known published data regarding efficacy or safety in the treatment of covid-19 key: cord-333581-icp0xwhx authors: aziz, muhammad; haghbin, hossein; lee-smith, wade; goyal, hemant; nawras, ali; adler, douglas g. title: gastrointestinal predictors of severe covid-19: systematic review and meta-analysis date: 2020-07-30 journal: ann gastroenterol doi: 10.20524/aog.2020.0527 sha: doc_id: 333581 cord_uid: icp0xwhx background: covid-19 pandemic has created a need to identify potential predictors of severe disease. we performed a systematic review and meta-analysis of gastrointestinal predictors of severe covid-19. methods: an extensive literature search was performed using pubmed, embase, web of science and cochrane. odds ratio (or) and mean difference (md) were calculated for proportional and continuous outcomes using a random-effect model. for each outcome, a 95% confidence interval (ci) and p-value were generated. results: a total of 83 studies (26912 patients, mean age 43.5±16.4 years, 48.2% female) were included. gastrointestinal predictors of severe covid-19 included the presence of diarrhea (or 1.50, 95%ci 1.10-2.03; p=0.01), elevated serum aspartate aminotransferase (ast) (or 4.00, 95%ci 3.02-5.28; p<0.001), and elevated serum alanine aminotransferase (alt) (or 2.54, 95%ci 1.91-3.37; p<0.001). significantly higher levels of mean ast (md 14.78 u/l, 95%ci 11.70-17.86 u/l; p<0.001), alt (md 11.87 u/l, 95%ci 9.23-14.52 u/l; p<0.001), and total bilirubin (md 2.08 mmol/l, 95%ci 1.36-2.80 mmol/l; p<0.001) were observed in the severe covid-19 group compared to non-severe covid-19 group. conclusion: gastrointestinal symptoms and biomarkers should be assessed early to recognize severe covid-19. covid-19, caused by sars-cov-2, has become a worldwide pandemic imposing a significant burden on healthcare systems around the globe. the virus causes a variety of manifestations, including pneumonia, acute respiratory distress syndrome, shock, sepsis, and death [1] . currently, no specific therapy (preventive or therapeutic) is available for this disease [2] . symptomatically, the virus leads to fever, fatigue, cough, shortness of breath, myalgias, arthralgias, nasal congestion, runny nose, sore throat, nausea/vomiting, and diarrhea [1] . the virus further causes laboratory abnormalities, including derangements of white cell count, platelet count, c-reactive protein, procalcitonin, lactate dehydrogenase, aspartate aminotransferase (ast), alanine aminotransferase (alt), total bilirubin (tb), creatinine, and d-dimer [1] . the pandemic nature of this disease necessitates emergent and early recognition of symptomatic patients to identify those at most severe risk and to provide supportive measures as needed, up to and including mechanical ventilation. gastrointestinal parameters (symptoms and laboratory findings) have been reported in the literature among patients with covid-19 [3] , but there is little comprehensive information regarding gastrointestinal symptoms in these patients. we performed a systematic review and meta-analysis a comprehensive literature search was performed from january 1 st , 2020, to may 31 st , 2020, using the following databases: pubmed/medline, embase, cochrane, web of science. the search strategy, using a predeveloped vocabulary for covid-19 [4] , was created by an experienced librarian (wls) and crosschecked by another reviewer (ma). an example search strategy using embase is highlighted in supplementary table 1. article screening and data extraction was performed by 2 independent reviewers (ma and hh) and any discrepancies in screening/extraction were resolved through mutual discussion. interobserver agreement was evaluated using % of agreement and cohen's kappa (κ) statistic. articles were selected if they reported data on covid-19 patients with respect to gastrointestinal symptoms (diarrhea, abdominal pain, and nausea/vomiting) or laboratory findings (serum ast, alt, or tb). we excluded articles if the data of interest were not reported or the article had not undergone a peer-review process. we further excluded case reports and retrospective studies/case series reporting <10 cases. we used the bibliography of the finalized articles to further broaden our literature search. we did not restrict our search according to language. severe covid-19 was defined as respiratory distress (rate ≥30 /min, oxygen saturation ≤93% at rest and/or pao 2 /fio 2 ≤300 mmhg) [1] , intensive care unit (icu) admission, and/or death. laboratory data (mean serum ast, alt and tb) were reported based on the local laboratory's reference parameters for each study. symptoms (diarrhea and nausea/vomiting) were reported based on initial presentation. data extraction was performed using microsoft excel (microsoft, redmond, wash, usa). continuous variables (using mean and standard deviation [sd] ) and proportional variables (using event and total patients) were compared using the dersimonian-laird approach or a random-effects model. the fixed effect model was used as a sensitivity tool; however, given the presumed heterogeneity of study data from diverse sources and clinical settings, the randomeffects model was considered more appropriate and results were reported using that approach [5, 6] . the mean and sd were calculated from median and interquartile range where applicable. results are displayed using forest plots for each summary estimate, i.e., mean difference (md) and odds ratio (or) for continuous and proportional variables, respectively. a 95% confidence interval (ci), p-value (<0.05 was considered statistically significant), and study heterogeneity using i 2 statistic (>50% was considered as substantial heterogeneity) were calculated for each outcome [7] . subgroup analysis was performed based on the definition of severe covid-19 (respiratory distress, icu admission, and death) if at least 3 studies reported the outcome. sensitivity analysis using leave-one-out metaanalysis was performed and point estimates were generated. meta-regression was attempted to assess the impact of moderator variables on study outcomes. the moderator variables assessed included female proportions in each study, region of study (asia, europe, north america, south america), and number of centers in each study (single center, dual center, multicenter). the statistical analysis was performed using open meta analyst (cebm, university of oxford, oxford, united kingdom) and comprehensive meta-analysis (biostat, englewood, nj, usa). we utilized the quality in prognostic studies (quips) tool for assessing the risk of bias in the observational studies [8] . publication bias was assessed qualitatively by visualizing the funnel plot and quantitatively using egger's regression analysis. we adhered to "preferred reporting items for systematic reviews and meta-analyses (prisma)" guidelines for the purposes of this manuscript. using the search strategy defined above, a total of 1525 records were generated. after the inclusion/exclusion criteria had been applied, a total of 83 published studies (all observational) remained that reported data on gastrointestinal symptoms and/or laboratory findings ( fig. 1) [1, 3, . all studies included laboratory-confirmed covid-19 patients. the percentage of agreement was >90% for both screening and data extraction and corresponding κ values of 0.72 and 0.69 (substantial agreement), respectively, were noted. of the 83 included studies, 42 reported data on disease severity with respect to symptoms and/or lab findings. study details and demographics of included patients are highlighted in table 1 . based on region, 70 studies originated from asia, 8 from north america, 1 from south america, and 4 from europe. the study duration was from december 11 th through may 5 th , 2020. based on the number of centers reporting data, 17 studies were multicenter, 6 were dualcenter, 57 were single-center, and 3 studies failed to mention the center from where the data originated. a total of 26,912 patients were included across these 83 studies. the patients' mean age was 43.5±16.4 years and the female proportion was 48.2%. the overall prevalence of diarrhea on admission among the study population was 13.0% (95%ci 10.8-15.5%; i 2 =95.1%). based on region, the following prevalences were noted: europe 16.8% (95%ci 2.9-57.8%; i 2 =98.0%), north america 26.2% (95%ci 20.1-33.3%; i 2 =90.6%), and asia 11.5% (95%ci 9.5-13.9%; i 2 =91.8%). the overall prevalence of nausea/ vomiting on admission among the study population was 9.5% (95%ci 7.9-11.4%; i 2 =92.6%). based on region, the following prevalences were noted: europe 8.9% (95%ci 2.1-30.4%; i 2 =94.1%), north america 18.7% (95%ci 14.6-23.6%; i 2 =83.9%), and asia 7.7% (95%ci 5.9-9.9%; i 2 =91.6%). the prevalence of abnormal ast findings on admission was 27 .7%). the prevalence of abnormal tb levels on admission was 10.6% (95%ci 5.0-21.0%; i 2 = 97.1%). all studies that reported abnormal tb were from asia. the odds of patients with diarrhea having severe disease were significantly greater compared to those without diarrhea (26 studies, or 1.50, 95%ci 1.10-2.03; p=0.01; i 2 =54.1%) ( fig. 2a liu, et al [12] zhang, et al [27] wang, et al [40] zhou, et al [44] chen, et al [48] nobel, et al [67] pan, et al [69] wang, et al [77] wang, et al [30] yang , et al [83] zhang, et al [85] elevated serum ast levels in patients were evaluated in 16 studies and greater odds of disease severity were noted compared to patients without elevated ast (or 4.00, 95%ci 3.02-5.28; p<0.001; i 2 =40.4%) (fig. 3a) . the results were consistent on leave-one-out meta-analysis (or 3.64-4.14) as well as subgroup analysis for disease severity defined based on respiratory distress ( only 5 studies evaluated elevated serum tb levels in association with disease severity, and elevated tb was associated with severe disease (or 2.09, 95%ci 1.36-3.21; p=0.001; i 2 =17.5%) (fig. 3c ). leave-one-out meta-analysis demonstrated a consistent association (or 1.89-2.51). a subgroup analysis and meta-regression were not possible because of the low number of studies. the mean serum ast level was significantly higher in the severe group compared to the non-severe group (32 studies, md 14.78 u/l, 95%ci 11.70-17.86 u/l; p<0.001; i 2 =97.5%) (fig. 4a) . the leave-one-out meta-analysis was consistent with a point estimate (md) ranging from 13. the mean serum alt level was also significantly higher for the severe group compared to the non-severe group (31 studies, md 11.87 u/l, 95%ci 9.23-14.51 u/l; p<0.001; i 2 =95.5%) (fig. 4b) . the results were consistent on leave-one-out meta-analysis (md 11.14-12.61 u/l) and subgroup analysis for severity based on respiratory distress ( on meta-regression, female proportions were inversely correlated with disease severity on the basis of mean tb level (p=0.03). based on quips tools, most of the studies (n=63) were at risk of bias for failing to account for confounders, while the remaining (n=20) accounted for some confounders. twenty studies lacked details of the statistical design (supplementary table 2 ). visible asymmetry was observed on a funnel plot based on the symptom of diarrhea; however, egger's regression did not reveal a significant publication bias (p=0.76) (supplementary fig. 1 ). our meta-analysis demonstrated significant correlations between gastrointestinal parameters (diarrhea, elevated serum alt, ast and tb) and severe disease outcomes, i.e., respiratory distress, icu admission, and/or death. although the most frequent manifestation of covid-19 is pneumonia, gastrointestinal signs/symptoms are seen in a significant number of patients and can be the presenting manifestations of the disease [90] . a systematic review by cheung et al reported diarrhea and nausea/vomiting in 13% and 10% of covid-19 patients, respectively [91] . we demonstrated a similar prevalence of diarrhea (13%) and nausea/vomiting (9.5%). we believe that the reported prevalence of diarrhea and nausea/vomiting is somewhat lower than in reality, as some of these patients only present with these symptoms and may not undergo covid-19 testing because they do not fulfill local hospital or laboratory criteria. the mechanism behind gastrointestinal symptoms is thought to be secondary to viral attachment and entry via angiotensin-guar, et al [1] huaig, et al [10] chen, et al [3] liu, et al [12] chai, et al [ chen, et al [3] liu, et al [12] zhang, et al [26] zhang, et al [35] wang, et al [40] zhou, et al [44] cai, et al [47] hcng, et al [57] vteng, et al [76] yang, et al [83] zhang, et al [85] zhang, et al [86] zhao, et al [87] converting enzyme 2 (ace2), readily expressed in ileal and colonic epithelium [92] . this can explain symptoms such as diarrhea and nausea/vomiting. furthermore, researchers have also identified viral rna in the stool of patients infected with covid-19, making diarrhea not only a marker for disease severity but a potential route of contagion [22] . given the association of diarrhea with severe covid-19 disease, based on our meta-analysis results, covid-19 patients with diarrhea should be stratified into a high-risk group for developing severe disease as described above and managed accordingly. several mechanisms have been postulated to explain the hepatotoxicity seen in covid-19 patients. one possible mechanism of hepatotoxicity of covid-19 is immune system activation. it has been shown that many of the respiratory viruses, including covid-19, lead to an activation of cytotoxic t cells and kupffer cells in the liver that eventually damage hepatocytes [93] . another mechanism is the triggering of a "cytokine storm, " leading to a massive surge in mediators such as interleukin-6, associated with sepsis, multiorgan dysfunction and death [8, 94, 95] . direct viral entry through the intestines and invasion of the portal system and, subsequently, cholangiocytes, is another hypothesized mechanism [96] . lastly, drug-induced hepatotoxicity should also be considered, as currently researchers are investigating all possible therapeutic options [97] . we demonstrated significantly increased elevation of alt, ast and tb in patients with severe covid-19 compared to non-severe patients, which can be attributed to some or all of the aforementioned mechanisms. several limitations exist with our analysis. the most notable was the lack of high quality randomized controlled trials and cohort studies. we relied on data from observational studies that reported admission data. observational studies have their own inherent biases that limit data interpretation, including selection, recall, and confounding bias. it is difficult to establish a temporal relation between cause and event using observational studies, as there is no follow up. however, as we reported admission data, we propose screening and riskstratifying individuals, based on their admission laboratory findings and symptoms, into severe and non-severe categories. we were not able to account for factors such as comorbidities, timing of hospitalization and routine home medications. we were also not able to account for these related gastrointestinal symptoms due to lack of stratified data. lastly, given that the major manifestations of covid-19 are respiratory symptoms (cough, shortness of breath, sputum production) and fever, gastrointestinal symptoms may have been underreported. despite the limitations, our analysis combines data from a large number of studies with a robust number of patients. we used admission data to avoid potential heterogeneity introduced by other factors, such as in-hospital medications, nosocomial infections, intubation, etc. the results of our study were consistent on both subgroup and sensitivity analysis. furthermore, we provided subgroup prevalence based on region, i.e., asia, europe and north america where applicable. in conclusion, patients presenting with diarrhea or elevated alt, ast and/or tb and diagnosed with covid-19 should be stratified into a high-risk group for developing severe disease outcomes (i.e., respiratory distress, icu admission, and/or death) and managed appropriately. • we performed a comprehensive systematic review and meta-analysis of the available literature through may 31 st , 2020 to assess these manifestations with respect to disease severity • our results indicate that diarrhea, abnormal alt, ast and tb were associated with severe disease (intensive care unit admission, respiratory distress, and/or mortality) • based on the current study results, patients with these manifestations should be stratified as highrisk and managed appropriately china medical treatment expert group for covid-19. clinical characteristics of coronavirus disease 2019 in china is sars-cov-2 also an enteric pathogen with potential fecal-oral transmission? a covid-19 virological and clinical review clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study van dusseldorp i. knvi biomedische informatie search blocks/zoekblokken meta-analysis in clinical 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novel coronavirus pneumonia in wuhan, china: a retrospective analysis clinical characteristics of 140 patients infected with sars-cov-2 in wuhan, china epidemiological, clinical characteristics of cases of sars-cov-2 infection with abnormal imaging findings effect of gastrointestinal symptoms in patients with covid-19 a comparative study on the clinical features of covid-19 pneumonia to other pneumonias radiological findings from 81 patients with covid-19 pneumonia in wuhan, china: a descriptive study preliminary study of the relationship between novel coronavirus pneumonia and liver function damage: a multicenter study clinical characteristics of 30 medical workers infected with new coronavirus pneumonia analysis of factors associated with disease outcomes in hospitalized patients with 2019 novel coronavirus disease liver impairment in covid-19 patients: a retrospective analysis of 115 cases from a single centre in wuhan city risk factors associated with disease progression in a cohort of patients infected with the 2019 novel coronavirus early clinical and ct manifestations of coronavirus disease 2019 (covid-19) pneumonia clinical characteristics and outcomes of 112 cardiovascular disease patients infected by 2019-ncov association of cardiac injury with mortality in hospitalized patients with covid-19 in wuhan, china clinical features of 69 cases with coronavirus disease 2019 in wuhan, china clinical characteristics of non-icu hospitalized patients with coronavirus disease 2019 and liver injury: a retrospective study covid-19 in a designated infectious diseases hospital outside hubei province, china diagnostic utility of clinical laboratory data determinations for patients with the severe covid-19 clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study laboratory predictors of death from coronavirus disease 2019 (covid-19) in the area of valcamonica, italy gi symptoms as early signs of covid-19 in hospitalised italian patients covid-19: abnormal liver function tests clinical characteristics of 145 patients with corona virus disease 2019 (covid-19 are gastrointestinal symptoms specific for covid-19 infection? a prospective case-control study from the united states high prevalence of concurrent gastrointestinal manifestations in patients with sars-cov-2: early experience from california contributors. symptom profiles and risk factors for hospitalization in patients with sars-cov-2 and covid-19: a large cohort from south america correlation between the variables collected at admission and progression to severe cases during hospitalization among patients with covid-19 in chongqing clinical features of covid-19-related liver functional abnormality wcm-gi research group. gastrointestinal and hepatic manifestations of 2019 novel coronavirus disease in a large cohort of infected patients from new york: clinical implications digestive symptoms in covid-19 patients with mild disease severity: clinical presentation, stool viral rna testing, and outcomes the clinical course and its correlated immune status in covid-19 pneumonia clinical features and outcomes of 98 patients hospitalized with sars-cov-2 infection in daegu, south korea: a brief descriptive study gastrointestinal complications in critically ill patients with covid-19 korea national committee for clinical management of covid-19. clinical course and outcomes of patients with severe acute respiratory syndrome coronavirus 2 infection: a preliminary report of the first 28 patients from the korean cohort study on covid-19 diarrhea: an underestimated symptom in coronavirus disease 2019 prevalence and clinical presentation of health careworkers with symptoms of coronavirus disease 2019 in 2 dutch hospitals during an early phase of the pandemic epidemiological, clinical, and virological characteristics of 465 hospitalized cases of coronavirus disease 2019 (covid-19) from zhejiang province in china gastrointestinal symptoms of 95 cases with sars-cov-2 infection analysis of imported cases of covid-19 in taiwan: a nationwide study clinical time features and chest imaging of 85 patients with covid-19 in zhuhai sex-specific clinical characteristics and prognosis of coronavirus disease-19 infection in wuhan, china: a retrospective study of 168 severe patients gastrointestinal symptoms and coronavirus disease 2019: a case-control study from the united states severe obesity, increasing age and male sex are independently associated with worse in-hospital outcomes, and higher in-hospital mortality clinical characteristics of covid-19 patients with digestive symptoms in hubei, china: a descriptive, cross-sectional, multicenter study acute liver injury in covid-19: prevalence and association with clinical outcomes in a large us cohort prevalence and characteristics of gastrointestinal symptoms in patients with sars-cov-2 infection in the united states: a multicenter cohort study initial gastrointestinal manifestations in patients with sars-cov-2 in 112 patients from veracruz (southeastern mexico) clinical characteristics and changes of chest ct features in 307 patients with common covid-19 pneumonia infected sars-cov-2: a multicenter study in jiangsu, china characteristics and prognostic factors of disease severity in patients with covid-19: the beijing experience enteric involvement in hospitalised patients with covid-19 outside wuhan early risk factors of the exacerbation of coronavirus disease 2019 pneumonia clinical characteristics of 28 patients with diabetes and covid-19 in wuhan, china clinical and laboratory predictors of in-hospital mortality in patients with covid-19: a cohort study in wuhan, china epidemiological and clinical features of 125 hospitalized patients with covid-19 in clinical characteristics of noncritically ill patients with novel coronavirus infection (covid-19) in a fangcang hospital diarrhea is associated with prolonged symptoms and viral carriage in corona virus disease 2019 clinical characteristics and outcomes of patients with severe covid-19 with diabetes epidemiological and clinical features of 200 hospitalized patients with corona virus disease 2019 outside wuhan, china: a descriptive study clinical features and short-term outcomes of 221 patients with covid-19 in wuhan risk factors for disease severity, unimprovement, and mortality in covid-19 patients in wuhan, china liver impairment in covid-19 patients: a retrospective analysis of 115 cases from a single centre in wuhan city clinical characteristics of patients with 2019 coronavirus disease in a non-wuhan area of hubei province, china: a retrospective study epidemiological characteristics and clinical features of 32 critical and 67 noncritical cases of covid-19 in chengdu effect of gastrointestinal symptoms in patients with covid-19 taste changes (dysgeusia) in covid-19: a systematic review and metaanalysis gastrointestinal manifestations of sars-cov-2 infection and virus load in fecal samples from a hong kong cohort: systematic review and metaanalysis the digestive system is a potential route of 2019-ncov infection: a bioinformatics analysis based on single-cell transcriptomes systemic viral infections and collateral damage in the liver elevated interleukin-6 and severe covid-19: a meta-analysis the association of low serum albumin level with severe covid-19: a systematic review and meta-analysis enteric involvement of coronaviruses: is faecal-oral transmission of sars-cov-2 possible? drug-induced liver injury or indigestion* or dysmotilit* or nausea* or vomit* or emesis* or hematemesis* or 'abdominal pain*' or amylase or lipase or alt or 'alanine aminotransferase*' or ast or 'aspartate aminotransferase*' or bilirubin or 'alk phos' or 'alkaline phosphatase*' or cea or 'carcinoembryonic antigen*' or 'ca19 9' or 'carbohydrate antigen 19 9' or ggt or 'γ glutamyltransferase*' or 'gamma glutamyltransferas3*' or 'y glutamyltransferase*' or 'fecal calprotectin*' or 'fecal leukocyte*' 1858951 2. (('coronavirinae'/exp or 'coronavirus infection'/de or coronavirus*:ti,ab,kw or 'corona virus*':ti,ab,kw or 'pneumonia virus*':ti,ab,kw or cov:ti,ab,kw or ncov:ti,ab,kw) and (outbreak:ti,ab,kw or wuhan:ti,ab,kw) or covid19:ti,ab,kw or #3 not ('conference abstract'/it or 'editorial'/it or 'review'/it or 'short survey'/it) /de or 'animal experiment'/de or 'animal model'/de or 'animal tissue'/de or 'meta analysis'/de or 'practice guideline'/de or 'systematic review /de or 'animal experiment'/de or 'animal model'/de or 'animal tissue'/de or 'meta analysis'/de or 'practice guideline'/de or 'systematic review'/de) and *searches for human or excluding nonhuman or animal studies were inconsistently indexed, so were abandoned as a strategy state the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis). data collection process 10 describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators. data items 11 list and define all variables for which data were sought (e.g., picos, funding sources) and any assumptions and simplifications made.6 (contd...) 12 describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis. table 2 results of individual studies 20 for all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot. consider their relevance to key groups (e.g., healthcare providers, users, and policy makers). limitations 25 discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).14 conclusions 26 provide a general interpretation of the results in the context of other evidence, and implications for future research. funding funding 27 describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review. key: cord-343715-y594iewi authors: gavriatopoulou, maria; korompoki, eleni; fotiou, despina; ntanasis-stathopoulos, ioannis; psaltopoulou, theodora; kastritis, efstathios; terpos, evangelos; dimopoulos, meletios a. title: organ-specific manifestations of covid-19 infection date: 2020-07-27 journal: clin exp med doi: 10.1007/s10238-020-00648-x sha: doc_id: 343715 cord_uid: y594iewi although covid-19 presents primarily as a lower respiratory tract infection transmitted via air droplets, increasing data suggest multiorgan involvement in patients that are infected. this systemic involvement is postulated to be mainly related to the sars-cov-2 virus binding on angiotensin-converting enzyme 2 (ace2) receptors located on several different human cells. lung involvement is the most common serious manifestation of the disease, ranging from asymptomatic disease or mild pneumonia, to severe disease associated with hypoxia, critical disease associated with shock, respiratory failure and multiorgan failure or death. among patients with covid-19, underlying cardiovascular comorbidities including hypertension, diabetes and especially cardiovascular disease, has been associated with adverse outcomes, whereas the emergence of cardiovascular complications, including myocardial injury, heart failure and arrhythmias, has been associated with poor survival. gastrointestinal symptoms are also frequently encountered and may persist for several days. haematological complications are frequent as well and have been associated with poor prognosis. furthermore, recent studies have reported that over a third of infected patients develop a broad spectrum of neurological symptoms affecting the central nervous system, peripheral nervous system and skeletal muscles, including anosmia and ageusia. the skin, the kidneys, the liver, the endocrine organs and the eyes are also affected by the systemic covid-19 disease. herein, we provide a comprehensive overview of the organ-specific systemic manifestations of covid-19. the sars-cov-2 virus has caused a worldwide pandemic in the past few months with a major impact on health care systems and economies. since december 2019 when the first diagnosed case was identified in wuhan, china, the highly contagious virus has spread throughout the world with detrimental consequences. sars-cov-2 belongs to the coronaviruses family of enveloped, single-stranded rna viruses [1] . notably, the main hosts of these viruses are animals. to date, 39 different species of the viruses have been identified, including two highly contagious and pathogenic species that led to two different outbreaks the past 2 decades [severe acute respiratory syndrome coronavirus (sars-cov) in 2002 and middle east respiratory syndrome coronavirus (mers-cov) in 2012] [2] . patients infected with this new coronavirus present with a variety of symptoms, which range from asymptomatic disease to mild and moderate symptoms (mild pneumonia), severe symptoms (dyspnoea, hypoxia, or > 50% lung involvement on imaging) and symptoms of critical illness (acute respiratory distress syndrome, respiratory failure, shock or multiorgan system dysfunction). the disease affects mainly elderly adults; however, younger patients without comorbidities can also be diagnosed with severe disease. the virus presents primarily as a lower tract respiratory infection transmitted via air droplets, but the multisystemic nature of the disease is becoming increasingly apparent as more data are emerging. it is postulated that it is related to the tropism of the virus for the ace-2 receptors located on several different human cells. the occurrence of other symptoms can not only coexist, but may also precede the typical phenotype of covid19 . in a recent study, sars-cov-2 viral load was quantified in 22 post-mortem autopsy tissue samples [3] ; 17 patients (77%) had more than two coexisting conditions. the number of coexisting conditions was strongly associated with sars-cov-2 affinity to the kidneys, including patients without history of chronic kidney disease. the highest levels of sars-cov-2 copies were detected in the respiratory tract, while the levels detected in kidneys, liver, heart, brain and blood were lower. these findings indicate a possible organ tropism of sars-cov-2 that might influence the course of the disease leading potentially to underlying conditions aggravation. as our knowledge on the virus mechanisms increases, our understanding on the various complications will continue to evolve. this manuscript aims to review the available literature and provide further insight on multiorgan involvement of the disease (fig. 1 ). the severity of lung involvement associated with sars-cov-2 infection ranges from lack of symptoms or mild pneumonia (in 81%) to severe disease-associated hypoxia (seen in 14%), critical disease associated with shock, respiratory failure and multiorgan failure (in 5%) or death (2.3%) [4] . it is the most common serious disease manifestation. patients may present with dry cough, fever, sputum production, fatigue and dyspnea, and the reported frequency varies based on the cohort studied [5] [6] [7] . among hospitalized patients, 20-41% will develop acute respiratory distress . what is becoming increasingly apparent as our understanding of the mechanisms of covid-19 induced lung injury expands, are the distinct or "atypical" features of covid-19-associated ards [4, 8] . based on sars-cov virus data, the genome of which is highly homologous to the sars-cov-2 genome, it is hypothesized that the human angiotensin-converting enzyme 2 (ace2) receptor is the main functional receptor for the sars-cov-2 virus. the ace2 receptor is expressed on the apical side of type ii alveolar epithelial cells in the alveolar space, and the large surface area of the lung serves as a reservoir for viral binding and replication, providing an explanation for the tropism of the sars-cov-2 virus and the lung vulnerability observed [9, 10] . sars-cov-2 infection induces alveolar injury and interstitial inflammation. dendritic cells (dcs) and alveolar macrophages phagocytose the virus-infected apoptosed epithelial cells, and t cell responses are initiated activating innate and adaptive immune mechanisms [11] . levels of proinflammatory cytokines and chemokines, such as tumour necrosis factor (tnf)-α, interleukin 1β (il-1β), il-6, and more, are increased in patients with covid-19 infection [12] . the cytokine storm is hypothesized to play a central role in the immunopathology of covid-19, but the primary source or the exact virological mechanisms behind it have not been identified yet. there is extensive hemophagocytosis which shares features but is distinct from the well-described macrophage activation syndrome (mas) [13, 14] . in addition to the proinflammatory stage and immune system activation, an immune suppression stage follows which is characterized by lymphopenia, low cd4 and cd8 t cell counts, increasing the risk of bacterial infection [15, 16] . emerging data from covid-19 pneumonia autopsy studies demonstrate acute interstitial pneumonia and diffuse alveolar damage (dad) with macrophage infiltration, formation of hyaline membranes and alveolar wall oedema and thickening. there is also microvasculature involvement with pulmonary vessel (intra and extra) hyaline thrombosis, haemorrhage, vessel wall oedema, intravascular neutrophil trapping and immune cell infiltration. in one series, in 5 out of 23 patients, major pulmonary vessel thromboemboli and/or haemorrhage were reported [14, 17, 18] . mcgonagle et al. use the term diffuse pulmonary intravascular coagulopathy (pic) to describe this lungrestricted vascular immunopathology [19] driven probably by the close anatomical positioning of type ii pneumocytes and the pulmonary vasculature. at early stages of this process, there is no systemic coagulopathy (dic) which is seen, however, at later disease stages coupled with the presence of ards. extensive microthrombi formation within the vascular bed causes pulmonary infarction, haemorrhage, pulmonary hypertension and secondary ventricular stress [20] . hypoxemia and mechanical ventilation which forces immunostimulatory molecules in the microvasculature also seem to contribute to the development of pic. findings on chest radiograph imaging are not diseasespecific and usually include ground glass opacities with bilateral, peripheral or lower lung zone distribution with or without consolidation [21] [22] [23] . chest ct is more sensitive, but no finding can 100% establish or rule out the diagnosis [24] . according to the radiological society of north america, ct findings are categorized into typical, indeterminate or atypical for covid-19 demonstrating that specificity is low even for ct [25] . in one study using rt-pcr as a reference, sensitivity was 97% but specificity very low at 25% [26] . radiological abnormalities increase over the disease course, and the typical peak is at 10-12 days post-symptom initiation. at early stages or in mild disease, imaging may not reveal any pathology, but interestingly abnormal findings on imaging can be identified in some cases prior to symptom development or even prior to pcr rna detection [27] . using ct as a screening tool is not, however, recommended. improvement of the findings lags behind symptom or hypoxia improvement [28] . hypoxia is frequently a presenting feature of covid-19 pneumonia, but interestingly, it is often insidious and paradoxically well tolerated by the patients. this unusual clinical presentation, seen at early disease stages, is referred to as "silent hypoxia" and is linked to the "atypical" features of the ards syndrome associated with covid-19 pneumonia [29] . contrary to the typical ards, lung compliance is preserved and the hypoxia-driven tachypnea allows high volumes and hypocapnia which fails to stimulate the sensation of dyspnea. a similar pathophysiological mechanism is seen in hypobaric hypoxia at high altitude [30] . a model has been recently proposed which includes two timeassociated phenotypes. the severity of infection, patient comorbidities and physiological reserve, the time elapsed between disease onset and presentation to hospital and the host immune response all contribute. the l-phenotype is seen at early disease stages; there is high lung compliance, and the ventilation-to-perfusion ratio (va/q ratio) is low, but there is dysfunctional regulation of perfusion with hypoxic vasoconstriction. at this stage, the lung weight is low and lung recruitability is low with minimal amount of non-aerated lung tissue. this develops into the h-phenotype with decreased lung compliance due to oedema, increased fraction of cardiac output perfusing the non-aerated tissue and therefore a right-to-left shunt, increased lung volume due to oedema and consolidation and therefore high recruitability. type l patients usually remain stable for some time and can then either improve or worsen and transition into type h, secondary to evolution of the covid-19 pneumonia but also injury induced by high-stress ventilation [31] . management should be adapted based on the type of phenotype and timing/stage of lung injury. a high positive end-expiratory pressure (peep) on the ventilator, at early stages of poor lung recruitability, is not very effective, but in combination with gravitational forces (using prone positioning), it may allow for perfusion redistribution and increased oxygenation [32, 33] . the initial practice of early intubation was not supported by emerging data. l-phenotype patients should receive high-flow nasal cannula fio2, continuous positive airway pressure or non-invasive ventilation with close monitoring. awake or self-proning has been incorporated in many hospital protocols in an attempt to prevent intubation and reverse hypoxemia [34] . type h patients should be treated as severe ards with higher peep volumes, prone positioning and extracorporeal support. another factor that may predispose for severe and potentially fatal ards in patients with covid-19 is the excessive increase in circulating proinflammatory cytokines including interleukins (il-1, il-6), interferon and tnf-α. this "cytokine storm" results from an inflammatory over-reaction as a response to sars-cov-2 infection that ultimately leads to endothelial cell dysfunction, damage of the vascular barrier, capillary leak and diffuse alveolar damage [35] . in this context, anti-il-6 inhibitors, such as the monoclonal antibody tocilizumab, inhibitors of jak kinases, such as baricitinib, and corticosteroids, especially dexamethasone, have been evaluated in patients with severe covid-19 and have shown promising preliminary results [36] [37] [38] [39] . among patients with covid-19, underlying cardiovascular comorbidities including hypertension, diabetes, and especially cardiovascular disease, have been associated with adverse outcomes [4, [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] , whereas the emergence of cardiovascular complications, including myocardial injury, heart failure and arrhythmias, has been associated with poor survival [6, [40] [41] [42] [43] [44] [50] [51] [52] [53] [54] . the presence of obesity is also associated with adverse cardiovascular outcomes [55] . evidence of myocardial injury in patients with covid-19 has been a remarkable finding [40-42, 44, 50-53] . ace2 expression is significantly elevated in cardiac tissue [56] and may potentially facilitate direct myocardial damage induced by viral infection. there have been also reported isolated cases of covid-19-induced myocarditis, which support the hypothesis of direct myocardial injury by sars-cov-2 [57] [58] [59] [60] . furthermore, ace2 plays an important role in the renin-angiotensin system by catalysing the conversion of angiotensin ii to angiotensin 1-7, which exerts a protective effect on the cardiovascular system [61, 62] . importantly, the binding of sars-cov-2 to ace2 is anticipated to result in loss of the external ace2 catalytic effect [63, 64] . subsequently, the theoretical downregulation of ace2 and the decrease in angiotensin 1-7 levels in patients with covid-19 may also compromise heart function [65] . in addition to the above, a non-negligible proportion of patients with covid-19 seem to experience a hyperinflammatory state, in which inflammatory cytokines and other markers of systemic inflammation are markedly increased [40] [41] [42] 66] . the circulating cytokines can stimulate macrophages and leucocyte adhesion molecule expression on the endothelial cells of underlying atherosclerotic lesions, rendering them more vulnerable for disruption and increasing the possibility of a clinically evident acute coronary syndrome [67, 68] . systemic cytokines may also activate the microvascular endothelium and induce a dysfunction of the coronary microvasculature, which may result in myocardial ischaemia and myocardial injury [68] . inflammation and subsequent dysfunction of the endothelium in several organs are the result of both the direct effect of sars-cov-2 infection of endothelial cells and the indirect effects of the host inflammatory response [69] . myocardial injury can also result secondary to a mismatch between myocardial oxygen supply and demand, known as type 2 myocardial infarction. sars-cov-2 infection may be associated with myocardial damage through increased myocardial oxygen demand along with reduced myocardial oxygen supply. severe respiratory complications and associated hypoxia have been common findings in patients with covid-19 [41, 43, 45, 51, 70] . moreover, hypotension, which is a common clinical feature both in sepsis and during the cytokine storm syndrome, can also reduce myocardial oxygen supply [68] . furthermore, systemic infection and fever increase the metabolic needs of peripheral tissues and end-organs, which elevates the metabolic demands of the myocardial cells [71] . fulminant myocarditis may be a clinical manifestation of covid-19 [57, 58] and may result in left ventricular systolic dysfunction or even cardiogenic shock [72, 73] . among 176 chinese patients with covid-19, chen et al. reported heart failure as a complication in 24.4% (n = 43), using age-related amino-terminal pro-brain natriuretic peptide (ntprobnp) cut-points [53] . interestingly, there was a significant difference in the prevalence of heart failure between covid-19 survivors and non-survivors (3.2% vs. 49.4%) [53] . another study encompassing data from 191 patients reported a 23% (n = 44) incidence of heart failure, 63.6% (n = 28) of which was fatal [41] . a meta-analysis of 43 studies involving 3600 patients reported a prevalence of heart failure as a covid-19 complication of 17.1% (95%, ci 1.5-42.2) among critically ill patients compared to 1.9% (95% ci 0.0-26.0) among non-critically ill patients [54] . guo et al. reported sustained ventricular tachycardia or ventricular fibrillation in 5.9% (n = 11) of 187 patients treated in a covid-19 specialized centre in china [52] . another retrospective study including data from the 393 consecutive patients with covid-19 in two hospitals in new york city showed that patients who received mechanical ventilation were more likely to have atrial arrhythmias (18.5% versus 1.9%) [6] . it has to be noted that sustained ventricular arrhythmias have been reported as a frequent clinical feature of acute myocarditis [73] , which may be the case in patients with covid-19 complicated by myocarditis. importantly, arrhythmias may be also induced by medical treatment for covid-19, such as chloroquine phosphate, hydroxychloroquine sulphate and azithromycin [74] . these agents and their combinations may prolong the qtc interval and predispose for torsades de pointes or other ventricular arrhythmias [75] . another characteristic manifestation of covid-19 in the cardiovascular system that has been recently reported is a kawasaki-like syndrome, which is characterized by circulatory dysfunction and macrophage activation syndrome [76] . a single-centre study conducted in bergamo, italy, reported a 30-fold increase in the incidence of kawasaki-like disease during the covid-19 pandemic, as compared with the previous year [77] . the cytokine storm associated with infection by sars-cov-2 may be the predisposing mechanism for the kawasaki-like clinical phenotype, but further insight has to be shed by future preclinical studies. the underlying pathophysiologic mechanism for the occurrence of digestive symptoms is also thought to be related to the virus's affinity for ace2 receptors located in specific enterocytes in the ileum and colon [52, 78, 79] . ace2 receptors are involved partially in inflammation mechanisms and therefore could provide an explanation for the occurrence of diarrhoea in infected patients. importantly, the binding efficiency is stronger for sars-cov-2 than the sars-cov-1, and this might be one of the reasons of high rate of transmission [80] . binding to primary intestinal epithelial cells also raises the question on whether the virus can be transmitted through the faecal-oral route, which currently remains unconfirmed [78, 79] . the largest study evaluating digestive involvement in patients with covid-19 was performed in wuhan, china. the investigators evaluated 1141 retrospective cases admitted to one single hospital over a period of 7 weeks [81] . 16% (183) of patients presented only with gastrointestinal symptoms. the most common symptom reported was loss of appetite. vomiting and nausea occurred in approximately two-third of the patients, while diarrhoea and abdominal pain were present in 37% and 25%, respectively. the main study limitations were its retrospective design along with the relatively small sample size. another cross-sectional study from hubei province reported results on digestive symptoms from patients being admitted to one of three different hospitals during january and february 2020. in total, 99 patients (48.5%) had gastrointestinal symptoms. the symptoms included anorexia (83.8%), diarrhoea (29.3%), vomiting (8.1%) and abdominal pain (4.0%), while some patients reported symptoms combinations. notably, 7 patients presented only with digestive symptoms with no evidence of respiratory involvement. in this case, the diagnosis was delayed due to the non-specific symptoms they experienced [82] . another study in china included 1099 patients and demonstrated that the most common symptoms on admission were fever (43.8%) and cough (67.8%) [43] . gastrointestinal symptoms were less common-nausea or vomiting 5% and diarrhoea 3.8%, respectively. in a single-centre case series of 138 hospitalized patients with covid-19, 10.1% reported diarrhoea and/or nausea, but the proportion of patients only with digestive symptoms was not outlined [50] . in another recent study performed in china, gastrointestinal symptoms were reported in 74 of 651 (11.4%) patients [83] . nausea, vomiting and diarrhoea were the most common. importantly, it was demonstrated that gi symptoms were more common in patients with severe covid-19 disease (23% vs. 8.1%). further data are required to understand better the role of the gastrointestinal involvement of covid-19 and clarify whether it is correlated with worse outcomes. the abovementioned studies did not test for virus rna in the stool, so there is no proof that active viral rna replication can be found in the digestive tract. a recent report of a 25-year-old female who presented with respiratory symptoms and fever indicates that the virus might be excreted in faeces [84] . ten days after admission, she underwent real-time pcr of a pharyngeal sample that was negative for sars-cov-2. a separate faecal sample was tested and found positive. the next 7 days 4 additional samples from the respiratory tract were tested and were all negative. this suggests that the gastrointestinal tract was the only documented source of the virus infection. in a recent singaporean study, 50% of patients had sars-cov-2 detected in their stool samples, but detection did not correlate with the presence of digestive symptoms [85] . in another study, the duration of viral rna detection after recovery was examined [86] . the median time from symptoms onset to first negative rt-pcr test from oropharyngeal swab was 9.5 days, but 16 .7% of the patients tested positive for viral rna from stool specimens for a median of 11 days. this observation indicates that there might be a potential faecal-oral transmission risk many days after symptoms resolution. regarding the liver-related complications of covid-19, liver test abnormalities have been described in infected patients. in one study, it was demonstrated that total bilirubin, ast and alt were elevated in 10%, 21% and 22% of patients, respectively [43] . other case series have reported alt abnormalities in 16-53% [40, 51, [87] [88] [89] [90] . to date, cases of acute liver failure have not been reported. liver dysfunction is mainly described in patients with severe disease upon presentation. however, it is difficult to discriminate the independent effect of the infection from other treatment modalities, such as antibiotics and antiviral drugs administered to these patients. additionally, these abnormalities could be attributed to the infection itself, the induced sepsis or the concurrence of hypoxia. one patient underwent liver autopsy which revealed microvesicular steatosis, mild lobular and portal inflammation [91] . ace2 receptors are located in hepatocytes and cholangiocytes; therefore, it was anticipated that the liver would also be involved. however, cholestatic abnormalities have rarely been described. underlying pre-existing liver diseases could have contributed to liver enzyme abnormalities. the exact pattern of liver injury as well as its role in mortality needs to be further investigated. finally, very recently a systemic review and meta-analyses were published in lancet gastroenterology and hepatology in order to identify the prognosis and prevalence of digestive tract involvement and liver abnormalities in patients diagnosed with covid-19. in total, 35 studies with 6686 patients were included in the analyses. the study demonstrated that gastrointestinal symptoms and hepatic toxicity are not uncommon among patients with covid-19 disease [92] . covid-19 is a systemic infection with a significant impact on the haematopoietic system and homeostasis [93] . lymphopenia may be considered as a cardinal laboratory finding, with prognostic potential. approximately, 7-14 days from the onset of the initial symptoms, there is a surge in the clinical manifestations of the covid-19 disease with a pronounced systemic increase in inflammatory mediators and cytokines, which may even be characterized as a "cytokine storm" [94] . in this context, significant lymphopenia becomes evident. neutrophil/lymphocyte ratio and peak platelet/lymphocyte ratio may also have prognostic value in determining severe cases. lymphocytes express the ace2 receptor on their surface [81] ; thus, sars-cov-2 may directly infect those cells, whereas the cytokine surge may promote lymphocyte apoptosis [95] [96] [97] . substantial cytokine activation may be also associated with atrophy of lymphoid organs, including the spleen, and further impairs lymphocyte turnover [98] . abnormalities in haematological parameters have been more prominent among severe versus non-severe cases (96.1% versus 80.4% for lymphocytopenia, 57.7% versus 31.6% for thrombocytopenia and 61.1% versus 28.1% for leukopenia). these results were consistent in four other descriptive studies that were conducted during the same period in china and included 41, 99, 138 and 201 confirmed cases with covid-19, respectively [40, 42, 50, 87] . a meta-analysis of nine studies suggested that thrombocytopenia is significantly associated with the severity of the covid-19 disease, with very high between-studies heterogeneity, though a more sizeable drop in platelet counts was noted especially in non-survivors [99] . during the disease course, longitudinal evaluation of lymphocyte count dynamics and inflammatory indices, including ldh, crp and il-6, may help to identify cases with dismal prognosis and prompt intervention in order to improve outcomes [93] . biomarkers such as high serum procalcitonin, crp and ferritin have also emerged as poor prognostic factors [41, 43, 100] . more recently, high cortisol levels at presentation may reflect disease severity and have been recognized as an adverse prognostic factor associated with poor survival among patients with severe covid-19 [101] . furthermore, blood hypercoagulability is common among hospitalized covid-19 patients, especially among those with severe disease [41, 102, 103] . elevated d-dimer levels are consistently reported, whereas their gradual increase during disease course is associated with clinical deterioration [40, 43, 50, 87, 104] . other coagulation abnormalities such as pt and aptt prolongation, increasing fibrin degradation products, with severe thrombocytopenia lead to life-threatening disseminated intravascular coagulation (dic) which necessitates continuous vigilance and prompt intervention [41, 42, 52, [105] [106] [107] [108] . endothelial dysfunction and immune deregulation may be implicated in the underlying pathophysiology [109] . covid-19 infected patients are at high risk of venous thromboembolism (vte) (up to 10% for acutely ill hospitalized patients [110] ). comorbidities, along with the possibility of endothelial cell activation/damage due to the virus binding to ace2 receptor, collectively increase the risk of vte. prompt pharmacological thromboprophylaxis with low molecular weight heparin is highly recommended [93, 111, 112] . although coronaviruses mainly cause respiratory symptoms, they have been reported to be involved in direct cns infection as well as para-infectious complications [113] . recent studies reported that over a third of infected patients developed a broad spectrum of neurological symptoms affecting central nervous system (cns), peripheral nervous system (pns) and skeletal muscles [114, 115] . in each case, it has to be noted that the challenge lies in discriminating between causal relationship and incidental comorbidity [116] . a large retrospective observational study from china showed that among 214 hospitalized patients with confirmed sars-cov-2 infection, 36.4% had neurological manifestations [114] . most neurological symptoms occurred early during the first days after hospital admission. with regard to symptom category, 24.8% of infected patients presented symptoms from cns, 8.9% from pns and 10.7% developed skeletal muscle injury. the most common cns symptoms were dizziness (16.8%) and headache (13.1%), and the most commonly reported symptoms involving pns were taste impairment (5.6%) and anosmia (5.1%). other less frequent symptoms included impaired consciousness (7.5%), acute cerebrovascular disease (2.8%), ataxia (0.5%), seizure (0.5%), vision impairment (1.4%) and nerve pain (2.7%). notably among severely infected patients the prevalence of neurological manifestation was even higher, up to 45% compared to patients with less severe disease (30.2%). the correlation of disease severity with neurological symptoms was confirmed by another retrospective study from france, reporting a prevalence of 84% of neurological manifestations in 58 hospitalized patients with acute respiratory distress syndrome (ards) due to covid-19 [115] . of note, some of the reported symptoms such as inattention, disorientation and movement disorders persisted even after discharge. several mechanisms that may overlap have been proposed to explain the link between sars-cov-2 infection and nervous system injury [117] . clinical manifestations of covid-19 might be a consequence of the viral infection per se and/ or the adverse insult of the hyperinflammatory status and dysregulated metabolic function, in combination with the multiple organ damage observed in patients after covid-19 infection [113, 118] . direct viral damage of nervous tissue might be possible in different ways. as with sars and mers viruses, sars-cov-2 may enter the cns through the hematogenous or retrograde neuronal route. infection of olfactory neurons in the nose may enable the virus to enter the brain transneuronally and spread directly from the respiratory tract to the brain [118] . ace2 receptors are also found in the nervous system and skeletal muscles [119, 120] . the expression and distribution of ace2 in brain and endothelial cells may explain how sars-cov-2 may cause direct neurological symptoms and skeletal muscle damage. direct viral damage of nervous tissue resembling in some ways herpes simplex encephalitis might be also possible, although there is no definite evidence of direct injury of cns by sars-cov-2 virus. the excessive immune response which results in a hyperinflammatory status and cytokine storm may represent another alternative mechanism. cytokines can directly pass through the blood-brain barrier causing considerable damage such as acute necrotizing encephalopathy [121] . an indirect injury related to host immune response effects after acute coronavirus infection could also be possible, explaining to some extent the occurrence of guillain-barré syndrome (gbs) cases, transverse myelitis or acute disseminated encephalomyelitis in patients with covid-19 and other virus epidemics [113, 122, 123] . neurological symptoms caused by systemic illness especially in severely ill patients could also justify neurological manifestations of covid-19 infection [114] . patients admitted to intensive care unit (icu) often develop encephalopathy, myopathy, autonomic neuropathy and polyneuromyopathy related to critical illness [124] . cerebrovascular disease represents another mechanism explaining neurological signs and symptoms in covid-19 patients, although the rate of acute stroke admissions has been significantly reduced over the covid-19 pandemic [125] . a large retrospective study from china reported a rate of 5.4% for both haemorrhagic and ischaemic strokes among critically ill patients [114] . a recent study reported a rate of 0.9% imaging proven ischaemic stroke among 3556 hospitalized patients [126] , stressing that cerebrovascular events may have been underestimated in intubated and sedated patients with severe covid-19. in a recent study based on data from the global covid-19 stroke registry, it was shown that patients with stroke and concurrent covid-19 infection had a higher risk of severe disability (p < 0.001) and death (odds ratio 4.3, 95% ci 2.22-8.30) compared with patients without covid-19 [127] . severe sars-cov-2 infection is a hypercoagulable state and may predispose to both venous and arterial thromboembolic events. systemic inflammatory response triggers autoimmune mechanisms, leading to dysregulation of the coagulation cascade as reflected by elevated d-dimers, prolonged prothrombin time, high fibrinogen levels, low anti-thrombin levels, thrombocytopenia and diffuse intravascular coagulation in severely ill patients with covid-19 [83, 106, 128] . imbalance between procoagulant and anticoagulant homeostatic mechanisms may result in endothelial damage, microvascular thrombosis and vessel occlusion. in addition, cardiac dysregulation and cardiac arrhythmias/dysrhythmias attributed to excessive inflammation and to respiratory failure, may lead to cardiac strain and myocardial injury/dysfunction facilitating cardioembolism. among covid-19 patients who suffered a stroke, the rate of cryptogenic and embolic strokes was higher, and events were more severe and affected younger patients [126, 129] . finally, blood pressure alterations, hypotension or hypertension, may lead to impaired cerebral perfusion and cerebrovascular events. although not highlighted in the initial cohort studies, olfactory (od) and gustatory (gd) sense dysfunctions have been reported as common symptoms of covid-19 from several centres worldwide. prevalence of smell and taste disturbances varies considerably depending mainly on the assessment criteria and tools used and on the degree of sense dysfunction. in a recent multicentre european study [130] , it was shown that patients with mild-to-moderate forms of covid19 present commonly with od (anosmia or hyposmia) and gd (hypogeusia or ageusia), (86% and 88%, respectively), even without nasal symptoms. women were more likely to be affected, and there was an early olfactory recovery rate of 44%, while symptoms could last even 14 days after the resolution of symptoms. another study reported a high prevalence of od (61%) in covid-19 patients, with an early and severe occurrence and a high correlation with loss of taste. od was still found more prevalent in women, but also in younger patients, while there was an association with shortness of breath [131] . a pilot quantitative study has also shown that a moderate olfactory dysfunction is present in approximately threequarters of hospitalized covid-19 patients using an objective smelling identification test [132] . a multicentre prospective study demonstrated an under-reporting of od and gd manifestations in patients with more severe covid19 disease neglecting their symptomatology. these findings confirm that od and gd are not predictors of a milder disease but are also markedly present in covid19 severe infection [133] . the american academy of otolaryngology-head and neck surgery and the british association of otorhinolaryngology suggested that anosmia-hyposmia and hypogeusia-ageusia should be considered as "significant symptoms" even in the absence of other nasal manifestations (rhinorrhea or nasal congestion), which should be used as potential markers of otherwise asymptomatic carriers of covid-19 infection (i.e. as a screening tool). in particular, the sudden onset of olfactory dysfunction could represent an early indicator of covid-19 infection [134] . these findings make clear that clinicians should take into account self-reporting od and gd symptomatology and incorporate in their assessment, the evaluation of the olfactory nerve function [135] . despite the lack of a clear pathogenetic mechanism explaining od and gd manifestations in covid19 patients, it seems that there is a specific viral neuroinvasivity and neutropism via the olfactory nerves spreading rapidly to other brain structures such as the thalamus and the brainstem, but also possibly to the temporal lobe, the amygdala, insula, limbic lobe (psycho sensorial syndrome) [88] . neurotropism may also occur via circulation and/or an upper transnasal route covid-19 to reach the brain tissue, where covid-19 spike protein binds angiotensin-converting enzyme 2 (ace2) receptors [136] . interestingly, the presence of ace-2, in host olfactory and gustatory pathways, might provide a potential explanatory mechanism for the smell and taste disorders in covid-19 patients. the expression level of ace2 in different tissues and in particular neural cells might be also important in viral neurotropism differences between patients from different geographic regions. thus, the differential ace2 expression could give an explanation of the higher prevalence of od and gd observed in european compared to asian population [114] ; however, more studies are needed to confirm such hypothesis. in the kidney, ace2 is present in several cells such as podocytes, mesangial cells, epithelium of the bowman's capsule, proximal cells brush border and collecting ducts [119] . the most frequent abnormality in patients with covid-19 is mild-to-moderate proteinuria which is mediated via several mechanisms [137] . it has been reported that patients in the icu have higher levels of il-1β, il-8, ifn-γ and tnf-α [40] . this suggests a potential role of cytokine release syndrome (crs), also known as "cytokine storm" comparable with sepsis-associated aki (sa-aki), where the uncontrolled systemic inflammatory response leads to kidney injury [40] . other studies have confirmed tropism to monocytes as well as lymphocytes, where the virus induces proinflammatory responses and cell death [138] . in addition, alterations in renal haemodynamics can induce further dysfunction [139] . acute kidney injury (aki) is infrequent in patients with mildto-moderate disease (5%). in this patient subgroup, the abnormalities are mainly subclinical. a recent prospective study, which included 701 patients with moderate or severe disease, demonstrated that 43.9% presented with proteinuria and 26.7% with haematuria at hospital admission. thirteen percentage revealed elevated levels of either serum creatinine (scr), blood urea nitrogen (bun) or both. aki occurred in 5.1% of hospitalized patients. all these abnormalities conferred for higher death risk [140] . another recent report showed that aki was more common in critically ill patients. in 52 critically ill patients who were admitted to an intensive care unit (icu) in wuhan, aki was the most common extra-pulmonary complication, occurring in 15 patients (29%). eight patients (25%) required continuous renal replacement therapy, and 12 (80%) died with a median duration from admission to icu until death of 7 days [51] . in another study previously described, a in silico analysis of publicly available data sets of single-cell rna sequencing was performed. this analysis showed that rna for angiotensin-converting enzyme 2 (ace2), transmembrane serine protease 2 (tmprss2) and cathepsin l (ctsl) is enriched in several kidney cells. this enrichment may explain the relevant affinity that induces sars-cov-2 kidney injury [3] . following that, tissue microdissection was applied on 6 kidneys biopsied to define sars-cov-2 viral load in exact kidney compartments. three patients revealed detectable sars-cov-2 viral load in all compartments examined, mainly at the glomerular cells. these extremely interesting findings indicate that renal tropism is the obvious reason leading to kidney injury, even in the absence of severe disease. these data indicate that kidney abnormalities are common and are associated with worse clinical outcomes. kidney autopsies of sars-cov patients have also demonstrated that the virus was present in tubular epithelial cells [141] . a number of case reports on skin complications observed in patients with covid-19 have been published. skin abnormalities are seen in up to 20% of covid-19 patients in some series and are very heterogenous ranging from urticarial, vesicular, purpuric to papulosquamous lesions. it is, however, not clear currently whether these skin manifestations are caused directly by the virus invasion or secondary to host immune response or treatment administration. purpuric eruptions, livedo reticularis or retiform purpura could be part of the manifestations of the vasculopathy associated with covid-19 infection [142] . the nature of the association between covid-19 and skin lesions and the systemic implications of their presence remains to be determined and requires active input and effort from dermatologists [143] [144] [145] [146] . knocking down the host's response to cortisol stress is a strategy employed by many viruses, including sars-cov to evade the host immune system. sars-cov expresses key amino acids that act as molecular mimics to the host adrenocorticotropic hormone (acth) directing antibodies to these acth residues implying a relative cortisol insufficiency. data on serum cortisol levels in sars-cov-2 patients are scarce to date. a recent study among patients with no signs of adrenal insufficiency showed that high cortisol levels at presentation may reflect systemic disease severity and have associated with dismal survival among patients with severe covid-19 [101] . autopsy studies from sars-cov viral infection have demonstrated degeneration and necrosis of the adrenal gland, and the virus has been identified in the glands themselves pointing to the likelihood that cortisol dynamics are altered in sars patients. the hypothalamic-pituitary-adrenal (hpa) axis might also be affected by sars viruses on the ground of a reversible hypophysitis or direct hypothalamic damage. ace2 is expressed on both hypothalamic and pituitary tissues explaining a possible viral tropism. a prospective study (chictr20000301150) is currently evaluating serum cortisol and acth levels in covid-19 patients [147] [148] [149] . in animals, coronaviruses have been known to cause ocular manifestations including conjunctivitis, uveitis, retinitis and even optic neuritis [150] . in humans, the eye conjunctiva is considered to be a potential site for sars-cov-2 transmission [151] , but currently there is no direct evidence to support that viral replication can cause injury and inflammation of the conjunctiva or other eye parts. among 38 covid-19 infected patients, in the hubei province case report series, 12 had ocular manifestations (31.6%). these were more common among patients with more severe systemic disease presentation (respiratory mostly) and blood test abnormalities. they included conjunctival congestion, chemosis or epiphora [152] . a recent protocol used optical coherence tomography to evaluate the retina of patients with covid-19 infection in 12 adults. hyper-reflective lesions of the inner plexiform layers and the ganglion cells were seen in all patients, and cotton wool spots and microhemorrhages in the retinal arcade of 4 patients with no effect on visual acuity or pupillary reflexes [153] . increasingly emerging data will allow better understanding of the nature and the mechanisms underlying the ocular manifestations associated with sars-cov-2. covid-19 probably represents the greatest pandemic event in modern human history. the disease presents with a broad spectrum of clinical signs and symptoms with involvement of vital organs such as the lungs, the heart, the gastrointestinal tract, the liver, the central nervous system, the blood and the kidneys. commonly, multisystemic involvement is associated with severe disease and might predict worse clinical outcomes and increased mortality. the main mechanism described is the high binding affinity of the virus with the ace2 receptors that are widely expressed in most human cells. the exact role of ace2 receptors in covid-19 pathophysiology is part of ongoing investigations. furthermore, the role of the infection on dysregulation of ace2 receptors expression, whether treatment with arbs and aces modifies this expression and whether patients with comorbidities and chronic illnesses have higher expression of ace2 receptors and are therefore more vulnerable to infection are also questions that need to be addressed in the near future. the sars-cov-2 virus enters the body through the respiratory tract and infects the epithelial cells of the trachea, bronchi, bronchioles and finally the lungs. it then infects the host, and infiltrating and circulating immune cells transfer the virus to other organs. moreover, the blood-borne sars virus infects other organs as well. immunosuppressed patients, including the elderly and patients with chronic disease, experience more severe disease with increased mortality rates. the extent of immune cell damage, represented by the lymphocyte count, is considered a strong predictor of outcome and reflects the immune status of the patient. this multisystemic disease is associated with high mortality rates; mechanical ventilation, extracorporeal membrane oxygenation, antivirals and plasma infusion are currently being 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jurisdictional claims in published maps and institutional affiliations conflict of interest the authors declare no relevant conflict of interest. key: cord-316886-qzka2dqm authors: machin, l. l.; wilkinson, mark title: making the (business) case for clinical ethics support in the uk date: 2020-07-21 journal: hec forum doi: 10.1007/s10730-020-09416-6 sha: doc_id: 316886 cord_uid: qzka2dqm this paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a uk hospital trust at a time when clinical ethics committees are dwindling in the uk. the paper provides key considerations for those building a (business) case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. we also include extracts from documents relating to, and annual reports of, existing clinical ethics support within uk hospitals, as well as extracts from our own proposal submitted to the trust board. we aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. we conclude that there is a real need for investment in clinical ethics in the uk in order to build the evidence base required to support the wider introduction of clinical ethics support into uk hospitals. furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within uk hospitals. this paper provides a series of reflections of an academic socio-ethicist's (lm) and a senior clinician's (mw) experiences of making the case for the introduction of clinical ethics support services (cess) within a national health service (nhs) trust. at the time of writing, no cess was available within the local region for hospital-and community-based practitioners, despite extensive support from healthcare professionals across the trust for the introduction of cess. the paper will outline the journey of the academic being approached by the clinician to consider setting up a cess at the trust, to being faced with the daunting task of completing a business case, to working collaboratively with clinical colleagues to prepare a proposal to the trust executive board. the reflections will focus on the drivers and agendas underpinning the aspiration to establish a cess, and the emotions and reactions generated by preparing a proposal for the trust. the paper will make reference to aspects of the hospital trust's business case template and how this was "translated" and "interpreted" when composing a proposal for a cess. as such, this paper provides key considerations for those building a (business) case for cess within nhs trusts. we draw upon published academic literature, and key reports from governmental and professional bodies. we also include extracts from documents relating to, and annual reports of, existing cess within nhs trusts, as well as extracts from our own proposal submitted to the trust board. we aim for this paper to support other ethicists and/or health care staff contemplating introducing cess into nhs trusts, to facilitate the process of making the case for cess, and to contribute to the key debates in the literature around cess. on ethical issues relating to clinical cases, (b) participation in development of guidelines for good clinical practice, (c) education, and (d) reflection on ethical issues from the acute clinical setting (andereck 1992; førde and pedersen 2011; fost and cranford 1985; rosner 1985) . the education function of cess has predominately been served by seminars and conferences on clinical-ethical topics open to all hospital employees. depending on the urgency of the support needed, the full committee, an individual clinical ethicist, or a subset of the full committee typically performs the ethics case consultations. consultation can involve clarifying the value uncertainty or conflict involved and facilitating consensus. most cess offering case consultation assumes a non-directive, facilitative role in consultation (tarzian et al. 2013) . the development of cess has tended to start "bottom up" ) and, therefore, the advent and spread of formal clinical ethics support is often described as a grassroots phenomenon. clinicians who have requested cess typically describe the experience as useful (magelssen et al. 2016) and have tended to seek support for conflict resolution, reassurance about a decision, clarification of issues, new insights on a case, and emotional support (duval et al. 2001 ). however, a range of barriers have been reported that are thought to hinder clinicians engagement with cess, including the perceptions of consultations as difficult to access, time consuming and/or intimidating ). equally, some clinicians are simply unaware of the service, fear that a committee will worsen the situation (gaudine et al. 2011) , or mean losing their autonomy in making decisions over a clinical case (orlowski et al. 2006) . cess have also been accused of being too remote from the daily activities of healthcare or of being ill-equipped to handle the ethical challenges that are most pressing (bayley 2006; mccruden and kuczewski 2006) . cess began in america and are available internationally, including france, belgium, netherlands, germany, italy, switzerland, croatia, lithuania, bulgaria, israel, and japan (mcgee et al. 2001; simon 2001; slowther et al. 2001) . cess in the united kingdom (uk) provides a unique case when contemplating cess globally. typically, cess in the uk has tended to be organised around clinical ethics committees, seminars, and conferences, whereas scandinavian countries and the netherlands have witnessed the rise of moral case deliberation and ethics reflection groups, and american hospitals usually have a clinical ethicist on hand for rapid reviews. furthermore, cess in uk is different to other countries such as america, belgium, and norway, as it is not a legal requirement for all nhs hospitals to have cess available (magelssen et al. 2016) . the establishment of cess in the uk and europe has been slower than in america (thornton and lilford 1995) , and until recently, the demand for cess was growing (mayor 2005; slowther et al. 2001; sokol 2005) , with at least 82 nhs hospitals providing cess to their staff in 2010 . however, recent figures on the uk clinical ethics network (ukcen) membership (austin 2018) suggest that doctors' access to cess has become limited, as the number of registered cess with ukcen has decreased. a worrying finding for healthcare professionals facing ethical and moral challenges within a nhs that is under immense financial strain (morley et al. 2019) and delivering care at a time of great political uncertainty nationally and internationally. with such limited formal support available, healthcare professionals in the uk are reported to most frequently access support from senior colleagues and their peers when dealing with clinical ethical dilemmas. yet, a report from the royal college of physicians showed the limitations with such an approach for those needing support, …there was an overwhelming impression that consultants did not necessarily have the broad understanding of ethical issues, and in particular the bioethical and legal framework surrounding ethical decisions to act as an entirely safe resource for junior doctors (royal college of physicians 2005, p. 34) moreover, it has been shown that clinicians often lack ethical sensitivity, failing to identify that a difficult issue or case has an ethical as well as a clinical component (mclean 2009 ). for some uk foundation doctors within the first two years of practice since finishing medical school, this means an absence of role models to serve as moral and practical guides (mcdougall and sokol 2008) . these problems could be symptomatic of the lack of ethical and legal training available once doctors qualify. medical schools cannot be expected to prepare tomorrow's doctors for all the ethical and legal challenges they will face after graduation (machin et al. 2020) . after all, there is a world of difference between discussing ethical problems in the relative safety of a seminar and acting ethically where the implications suddenly become real (sokol 2010) . at present, the training foundation doctors receive has a significant emphasis on technical and clinical competencies (linklater 2010 ) and limited content on ethics and law topics (benson 2014; levy and coward, 2010) in order to be better prepared to respond to the ethical uncertainty they face in the first two years after medical school (machin et al. 2020 ). however, as others have identified, no members of a healthcare team, irrespective of their seniority, are immune from being faced with ethical dilemmas (larcher et al. 1997 ) suggesting a need for ethics and law training and education to be available at all stages of career development (guillemin et al. 2009 ). clinical colleagues from a hospital trust in the north west of england help to facilitate clinical ethics workshops and grade clinical ethics coursework at their local medical school where medical students learn, apply, and critique clinical ethics frameworks to their own and others' cases. clinical colleagues appreciate the opportunity to be involved in such activities as they acknowledge that they had not received such in-depth ethical training when they attended medical school compared to current medical students as others have noted elsewhere (demir and büken 2016) . senior clinicians also feel the weight of expectations upon them to be able to support junior colleagues when facing ethical and legal challenges, yet are often uncertain how to approach and resolve their own as well as others' ethical dilemmas. one particular teaching activity within the medical school are the clinical ethics forums, which introduce the concept of clinical ethics support to social work, medicine, and clinical psychology students (machin et al. 2019) . the forums are multiprofessional to reflect the membership of real-life clinical ethics committees, and students use common ethical frameworks, such as four principles (beauchamp & childress 1989) , four quadrants (jonsen et al. 1982) , and seedhouse grid (seedhouse 2009) , to analyse and discuss their own dilemmas they have experienced during their training. for the clinical colleagues that facilitate the student clinical ethics forums, it confirmed the gap in the support available to them when facing ethical uncertainty in their clinical practice, as well as highlighted how support could be available within their trust. the recognition of support needed in order to overcome the felt isolation when deciding how to proceed in the face of ethical uncertainty was consolidated after a phone call took place between the authors of the paper (herein referred to as 'we', 'us', or by our initials) to discuss a particularly troubling case together. during the phone call, mw outlined key aspects of the case, and responded to lm's prompts and queries in order to get a better sense of where the value conflicts lay. in collaboration, the significant ethical, legal, and professional elements of the case were identified and explored, and possible next steps on how to proceed were considered. the decision to explore clinical ethics support via a clinical ethics committee within the trust was made, and what follows is a brief overview of the steps taken at the time of writing. we decided to hold a meeting outside typical work hours with key players within the hospital trust invited including the chief executive nurse, legal advisor, clinical and nursing leads, research and development director, and end of life representatives. a trustee from the ukcen attended and presented at the meeting, who also had experience of clinical ethics committee work and had acted as a clinical ethicist in the north of england. the purpose of the meeting was to gauge if employees within the trust also deemed a need for cess, and if so, to widen the circle of involvement, and expand the core of interested people. the idea being that if staff had learned about the cess through their respected colleagues, and had contributed to developing the innovation through early discussions, then this may foster future engagement in the cess if implemented as others have highlighted (rogers 1983; wilkerson and maxwell 1988) . we also learned of the importance of co-ownership and co-production for users of future cess from scandinavian countries and the netherlands and their use and implementation of moral case deliberation (de snoo-trimp et al. 2017 ) and, therefore, we explored various formats and functions of a cess. at the end of the meeting, there was sufficient support and interest in establishing a cess, and agreement from attendees to take the idea of establishing a clinical ethics committee in the first instance forward to senior leaders within the trust. the initial response from the senior leaders was to ask us to complete the hospital trust's business case template for the proposed clinical ethics committee. according to hospital trust's guidance, a business plan is, a proposal that seeks authorisation from an appropriate decision-making body for the allocation of resource associated with change to the business e.g. to deliver a new service… (trust guidance on completing a business case 2014) within the trust, any business case is reviewed and approved through a hierarchy of senior staff and committees, such as clinical director, finance committee, trust board, and then is either approved, with or without conditions, or rejected or recommended to be resubmitted following clarification of certain points. there is a long-standing culture of justification surrounding "ethics" in medicine (stirrat 2015) be that explaining the value of teaching ethics in "packed" medical curriculums (campbell et al. 2007; lucassen & fenwick 2014) , or defending the time away from clinical duties for foundation doctors to receive training (kirkham and baker 2012) . most ethicists are, therefore, experienced in, and prepared to, "market" the worth and value of "ethics" (papanikitas 2018 ). yet, we could not find or access any business cases for existing uk cess when first starting out, and using the internet search term "business case for ethics" unearthed material with limited content (see ukcen 2014). whilst we were inexperienced in writing business plans, and the length of the business plan template was unappealing, the real obstacle lay with the "evidence" required to complete it, which is explained further below. few commentators on cess appear to seriously doubt their importance and utility, but as healthcare has become a field dominated by questions of performance, efficiency, and cost effectiveness (millstone 2014) , ethics support appears to need to demonstrate its value to "justify adequate resourcing" (royal college of physicians 2005) and show that it does "not waste resources" (american society for bioethics and humanities 2009). while it seems self evident that cess in the institutional setting may improve the ethical dimension of patient care and so improve the overall quality of healthcare, evidence in support of this contention is hard to come by (ukcen 2014). in particular, evidence that considers the efficiency of the ethics consultation through the cost savings that it generates (bacchetta and fins 1997; daly 2000; heilicser et al. 2000) or the effectiveness of the ethics consultation service through satisfaction studies (tulsky and fox 1996) is scarce. we searched the literature and found bold claims espousing the many benefits of introducing cess for healthcare organisations, including increasing patient satisfaction (kaplan et al. 1989; tierney et al. 2001) , and improving employee morale (bischoff et al. 1999) , although it was not always clear if a direct causal relationship existed between these outcomes and the presence of a cess. others justified the moderate cost necessary for the running of any cess by claims of improved efficiency and savings, and improvements in clinical quality and safety (macdonald and worthington 2012) . for example, effective cess have been shown to improve quality of care and reduce length of stay and cost. such claims are supported in the wider business and management literature discussing the importance of developing a strong ethics culture within an organisation in order to improve performance, efficiency and productivity (verschoor 1999) . however, methodological obstacles exist in providing the evidence demanded by the business case application, such as determining how to measure the "value" of the support provided by the cess (schildmann et al. 2013), agreeing upon how it is "valued" by the various stakeholders (de snoo-trimp et al. 2017) , and how meaningful any analysis would be based on the low number of cases supported by the cess (ukcen 2014). exacerbating our challenge of completing the business case application were articles advising to stay clear from those few studies that attempted to construct the "evidence-base" for cess, particularly those that refer to the cost implications arising from ethical conflicts (see, for example, nelson et al. 2008) or the financial considerations for cess (see, for example, bacchetta and fins 1997; daly 2000; heilicser et al. 2000) . in the literature, we are advised that cost savings are not particularly meaningful in the absence of estimates of the costs of a service and, more importantly, do not capture the "intangible benefits" created by cess (mills et al. 2005) . instead, we are encouraged to focus on the value achieved through cess' contribution to the "overall good of the patient" (repenshek 2017 ) and the intellectual capital (ethics knowledge) of cess that create important, but intangible benefits, such as relieving "moral distress" (mills et al. 2005) , improving communication and relationships between healthcare professionals (de snoo-trimp et al. 2017 ). an additional problem proposed with using cost savings as an outcome is the potential for the loss of trust if clinicians or patients come to perceive cost as the primary objective of introducing cess into a trust rather than supporting staff and patients when facing ethical uncertainty (de snoo-trimp et al. 2017) . for example, the expressed aim of the cess at great ormond street hospital (gosh) "isn't to avoid costly court battles or to save the nhs money. it's about making the right decision for the right reasons" (great ormond street hospital 2017, p. 8). that said, european researchers have pointed out the subtle, but important, distinction between the goals and outcomes of cess when contemplating any financial benefits of cess. for them, the drivers for cess to be established and exist do not need to be linked with financial gains, but it is feasible and acceptable for financial benefits to result from cess and for them to be acknowledged (schildmann et al. 2013) . we were uncertain of how next to proceed. we recognised the constraints we were working within-nhs funding crisis, age of austerity (morley et al. 2019 )and had some sympathy with the need to justify spending on introducing cess into the trust. equally, at the trust, the main forum for discussion of ethical issues and dilemmas was within individual clinical units, although occasionally ethical aspects of particular cases were discussed at regular hospital clinical presentations, e.g., grand rounds, schwartz rounds. such discussions were considered ad hoc, unstructured, and constrained by time. individual members of multidisciplinary teams tended to discuss issues within their own discipline and often with their peers, rather than with their seniors or juniors. similar to other hospitals, there was a general view that this was unsatisfactory, as it could lead to tensions within teams and issues unresolved as others have noted elsewhere (hamric and wocial 2016) . more public discussion of ethical issues away from acute clinical settings was, therefore, considered necessary and perceived as being achieved through introducing cess that had consultative and educational functions, which other researchers have reported as beneficial (larcher et al. 1997) . the literature confirmed that healthcare staff need reflective spaces within institutions in which to explore and communicate values and ethical obligations as they undergird goals of patient care (hamric and wocial 2016) and the cess could play a role in creating and designing these spaces, and ensuring they remain "open, accessible and active" (walker 1993, p. 38) . we, therefore, decided to pull out the key themes within the business case application and write a proposal instead that acknowledged them. this enabled us to use the evidence available within the literature, including making the argument to avoid using financial considerations as a deciding factor on whether to introduce cess or not into the trust. however, the overwhelming financial focus of a business plan can generate a return on investment mindset for both the author and reader, and in turn the grandeur of claims surrounding the impact and influence of the proposed cess can escalate. in order to demonstrate the "value" and "contribution" of the proposed cess in our proposal then, we felt inclined to identify and outline a number of problems that could be resolved via the cess, which created another problem as described next. the challenge with "problems" when making a business case for cess is that the "problems" cannot be seen to return. instead, they should be eradicated in order to justify and warrant the investment of funding into cess. in effect, a business case application constructs a "problem-solution" mindset whereby the author lays out a problem that needs resolving and identifies possible solutions. in the case of cess, the discussion falls into "preventive" ethics. blake (2000) argues that cess should be proactive to effect changes, rather than merely reacting to the cases that staff bring. the focus and purpose of cess is then to influence and inform organisational culture. no longer is it the responsibility of one person or one group, but instead the responsibility of the whole institution that ethical practices are enacted. for example, the ethics program at the american hospital, beth israel deaconess medical center in boston, acts as a standing mechanism to influence and maintain a moral culture within the institution that, helps to shift the influence of those who "do ethics" in the institution to everyone who works here, whether at the bedside, in the laboratory or in the office. the programme enables us to enact our mission statement that ethics is part of everyone's daily work (bates et al. 2017, p. 597) recent attention has been given in the literature to providing assistance with organisational ethics, whereby the ethical issues involved in areas such as management and resource allocation and quality improvement are worked through (dorries et al. 2011; mcclimans et al. 2012) . this development responds to the critics of cess who claim the crucial ethical issues at stake are general, structural, and organisational (bayley 2006; mccruden and kuczewski 2006) . in essence, what each individual healthcare professional can and cannot do is arguably influenced by institutional policies and procedures, perceptions of legal liabilities, budgetary constraints, established patterns of communication and the tenor of the organisational culture (solomon et al. 1991) . it also reflects the rise in a "systems" approach, whereby clinical ethics are fully integrated into the institution and wider healthcare apparatus (fox et al. 2010; macrae et al. 2008; singer et al. 2001) . cess assist healthcare professionals in resolving value conflicts, whilst also improving respect for values, such as autonomy and equity, in practices at an organisational level (dörries et al. 2011) . for example, cess can contribute to the development of patient-centred policies on end of life decisions, resuscitation, or filming surgeries, and ensuring they are sufficiently responsive to patients' preferences, and respect the dignity of patients (mcclimans et al. 2011) . cess are, therefore, portrayed as providing "ethical leadership" by improving the ethical environment and culture of the organisation (magelssen et al. 2016) . the broader view required from the clinical ethicist when shifting focus to the ethical issues at an institutional level, means that it is possible to become aware of the recurring matters that come to the ethical committees. the cases highlight for clinical ethicists "gaps" or other inadequacies in policies that need addressing, and where research is needed (mills et al. 2005) . some commentators present these recurring ethical issues within an institution as the characters changing within a specific case, but the basic problem is the same (dunn et al. 2016 ). consequently, the role of cess moves from merely "reacting" to ethical conflicts as they arise to pre-empting them and responding through a system-wide approach (dunn et al. 2016) . in a systems approach, ethics support moves "upstream" to address systematic and structural elements that produce value conflict rather than remain only at the level of the particulars of the issue or case at hand. this encourages a more proactive and preventative form of ethics support (fox et al. 2010; macrae et al. 2008; nelson et al. 2010 ). the ethical issues and difficulties are perceived as recurring expressions of problematic systemic structures and processes within and between the micro and macro systems within an organisation. essentially, the cases for the cess are considered the "tip of the iceberg" (new south wales government health 2015). addressing recurring ethical challenges is important as these can create moral distress for the staff within the organisation. positioning cess as playing a role at both individual and institutional levels could be crucial as discussions could lead to development of ethics practice strategies to address and possibly decrease the stressful nature of ethical conflicts (nelson 2009 ). staff may feel at ease regarding a decision related to an ethical problem. staff may be able to make decisions in the best interests of their patients, have their ideas about patient care considered in the care plan, or may be able to relieve or reduce patients' pain and suffering (corley and minick 2002) . the aspiration of creating moral comfort for staff is reflected in the aims of an active american cess, to promote a culture in which all bidmc staff appreciate the importance of the ethical aspects of their work (their decisions, actions, character and morale), and have the support they need to do that work in accordance with bidmc's, and their own highest moral standards (bates et al. 2017, p. 595) it is important to note within the literature that it is more likely that the emotions around the conflict are addressed and hopefully reduced, rather than the conflict itself. arguably, knowing how to resolve a problem or having the means available to respond to a problem, does not mean that the problem itself ceases to exist, or that the response is flawed if it recurs, or that we will not ever have problems to respond to again in the future. the danger of the problem-solution mindset in a business case then is that the discussion becomes unrealistic, with promises of scandals averted, and conflicts and disagreement with next of kin or patients eradicated, thereby setting up cess to "fail". resisting the temptation to make such promises was challenging when composing the proposal. the trust itself had received negative publicity, with reports of dysfunctional teams, and poor standard of care within a number of departments (see, for example, dyer 2019 and goodwin 2019) and cess have been implicitly presented by various stakeholders as a response to, and a way to prevent, the failings of the nhs healthcare system equating to poor patient care and safety. we briefly outline the challenges below. the first problem with the association between the "problem" of poor teams and care practices and the "solution" of cess was how it might influence how healthcare staff perceived cess. it needed to be handled delicately in order for the cess not to be perceived by healthcare staff as a "court of law" that produced "ethical verdicts" on clinical cases and on health professionals' conduct, which others have claimed elsewhere (pedersen et al. 2009 ). equally, such breaches of ethics in nhs trusts without oversight and correction are arguably detrimental to a trust's reputation as well as financially (dunn et al. 2016) . hospital leaders have to consider carefully how they want to be perceived outside the organisation, so there may be reputational and branding benefits arising from introducing cess into trusts after such high profile scandals, inquiries, and reports. with increasing concerns about the inhumane nature of some modern medicine (weatherall 1994) , cess could promote reflection on ethical matters (larcher et al. 1997) , and could, therefore, be seen as responding to the needs of staff and patients. in turn, an effective cess could make it easier to recruit and retain quality staff (francis 2001) . the second problem with the association of cess with healthcare scandals was the lack of explicit recognition to the transformative influence of cess in recent healthcare inquiry reports and recommendations. this is surprising given the specific problems identified in the reports such as dysfunctional team work and a lack of communication between multidisciplinary teams, crippling hierarchies, and difficulty speaking up, professional obligations to a duty of candour-all of which could arguably be addressed through, and fall under the remit of, cess (carrese et al. 2012; talash et al. accepted) . at a minimum, members of cess could role model the behaviours such as humility, respect for others, building positive relations, when facing ethical uncertainty (carrese et al. 2012; talash et al. accepted) . cess could also help to establish the conditions for ethical reflection, i.e., trust, role flexibility, and enquiry (brown 1990) . so, on the one hand, whilst we were anxious to avoid the damaging impact upon staff's engagement within cess arising from the association of cess as a response to healthcare scandals, we equally struggled to find explicit references that made the association on our behalf to highlight how cess could address issues raised previously within the trust. we, therefore, had to be creative and look to other sources. the ukcen referred to the extensive failings observed in uk trusts such as mid staffordshire, basildon and thurrock when making the case for cess in the nhs (uk clinical ethics network 2014). others have conveyed a similar message (see, for example, beyleveld et al. 2002) including the care quality commission (cqc) who monitors and inspects nhs trusts to ensure people receive safe, compassionate and high quality care (care quality commission 2019). the cqc has recognised the important role of cess in their reports when visiting hospitals where cess exist, such as great ormond street hospital (gosh), "the ethics committee was regularly available and played a key role in considering difficult treatment decisions" (great ormond street hospital 2017, p. 6). this quote from the cqc is then followed within the gosh cess report by a warning, "it is worth remembering that the recent francis inquiry report highlighted what can happen if these issues are not prioritized" (great ormond street hospital 2017, p. 6) . in order to maximise this implicit association between healthcare scandals and cess, we considered the ideal time to share our proposal with the hospital trust executive board would be ahead of an upcoming visit from the cqc. however, we wished to avoid staff perceiving the cess as a mechanism of scrutiny (førde et al. 2008; gaudine et al. 2011; slowther et al. 2001) to instil discipline or a form of punishment and, therefore, opted to share the proposal when it was completed. following the lead of gosh, we pitched our proposal as having the potential to positively impact upon the organisational culture through supporting staff, supporting the organisational vision, and meeting the government statement on patient decision making, the introduction of cess at [hospital trust] will engage patients and their relatives in discussions when healthcare professionals make difficult healthcare decisions. therefore the cess supports [hospital trust's] desire to consistently deliver an excellent experience that exceeds patient and family expectations, as well as meeting the government's vision for shared decision-making in healthcare: 'no decision about me, without me' (extract from lm and mw proposal for clinical ethics support service in nhs hospital) we considered it less threatening to market the proposed cess as a way of providing a reflective space, whereby the experiences of patients and relatives could be acknowledged and considered by healthcare staff, rather than reinforcing the association that can sometimes emerge between cess and someone acting unethically (carrese et al. 2012) . the inclusion of cess in the trust would arguably, therefore, act as an explicit way of promoting shared decision-making, and in turn foster institutional awareness around "no decision about me, without me". implicitly, at an individual level, cess had the potential to inform staff's attitudes and perspectives, thereby acting as a form of staff development. to achieve this, however, it required a shift in how we perceived cess, in particular their roles and remits. as others have identified, doing clinical ethics needed to mean making ethical reflection an integral component of clinical practice, and an explicit part of the daily life of an organisation, and not just considered in the midst of or in response to a crisis (rubin and zoloth 2004; weidema et al. 2016 ). yet, cess have tended to be discussed around high profile or difficult cases, such as the charlie gard or asha king in the uk (for example, see austin 2018), which has created a sense that everyday ethics do not warrant cess. the "ethics of the ordinary" are those situations that are part of everyday practice, that occur frequently, and cause a chronic feeling of moral distress (corley and minick 2002) . furthermore, there has been a tendency to focus cess around medical specialisms, departments, and/or types of decisions or groups of patients, such as paediatrics (gold et al. 2011; larcher et al. 1997) , or intensive care (schneiderman et al. 2003) . however, ethical dilemmas arise frequently in clinical practice, irrespective of the type of unit or its area of speciality (larcher et al. 1997) . cess services are typically available within acute-care hospitals and as a result, support for community-based practitioners when facing ethical uncertainty is less commonly implemented and, therefore, can be considered an under-serviced population. small studies show where cess have been piloted within community healthcare settings, respondents have overwhelmingly reported the services meeting their needs, typically dealing with everyday ethical issues revolving around patient autonomy, privacy, confidentiality, and consent (racine and hayes 2006) . these perceptions of when cess are warranted may provide alternative explanations for the reported low referral of cases to uk cess (bates et al. 2017; slowther et al. 2012) , and the isolation and loneliness staff experience around ethically troubling matters. reports of moral distress (lamiani et al. 2017; oliver 2018) , predominately focusing on nurses and beginning to be recognised in doctors, highlight that staff can be uncertain about what is the ethically appropriate action to take, and may keep this uncertainty to themselves and not share their stress because they think they are alone in their uncertainty. alternatively, staff may raise ethical questions, but feel unsupported in acknowledging their uncertainty and are without an available resource to share and discuss the issue. equally, staff may know or believe an ethically appropriate course of action to take, but are unable to carry out the action because of an organisational obstacle (lamiani et al. 2017; nelson 2009 ). such moral distress has consequences for healthcare organisations as it can negatively influence staff morale, confidence, sense of purpose, integrity, and respect for the organisation (nelson 2009 ). it also has implications for the wider healthcare service as the higher the level of moral distress, the greater the likelihood of leaving a position (hamric and blackhall 2007; oliver 2018) , which is significant in the uk where we are informed that there are insufficient healthcare professionals to cope with patient demand (british medical association 2018; kinman and teoh 2018) , and challenges exist around staff recruitment and/or retention in certain healthcare specialities (british medical association 2017; chaudhuri et al. 2013 ). in the uk, the general medical council are conducting a review of the wellbeing of medical students and healthcare staff, and attempts are being made to support nhs staff through the provision of reflective spaces (see, e.g., gannon 2014) as recognition increases of the emotional burden that staff carry in their daily work (see, e.g., cornwell and fitzsimons 2017; kerasidou and horn 2016; ) . we are also witnessing the resurgence of schwartz rounds (goodrich 2018 ) and the introduction of resilience training (oliver 2018 ). yet, some existing cess describe themselves as providing "a space to give clinicians and families a place to discuss their concerns" (great ormond street hospital 2017, p. 8), raising questions why staff have not approached cess within their hospitals more frequently (whitehead et al. 2009 ). previously, underutilisation has been linked to a lack of understanding of the role of cess (bates et al. 2017 ) and how it might help (mclean 2009). arguably, a mismatch may exist surrounding the perceived role-reflective space-and remit-ethics of the ordinary-of cess between the providers and (potential) users of cess. collaborating with cess could then become part of delivering everyday care, rather than staff approaching the service as a last resort (hamric and wocial 2016) . reflecting on the process of proposing cess into an nhs trust has highlighted two overarching points. firstly, the significance of research when making the case for cess emerged when faced with the business case application. whilst drafting the proposal, we realised that the evidence available focusing on the uk context was limited, which might be a consequence of the voluntary nature and the lack of any specific requirement for uk healthcare organisations to have a mechanism for addressing ethical dimensions of the work. historically, cess have received little or no administrative support or funding, and members' time has been given voluntarily meaning that any formal evaluation of cess has been a lower priority for the sparse resources available (steinkamp et al. 2007; uk clinical ethics network 2014) . by searching for the evidence to fill a business case application, we became aware of the urgent need for up to date, empirical studies that analyse and evaluate the uk cess experiences, which reflect the realities of facing an ethical dilemma within the nhs environment, and can enable sharing of good practices from current cess in uk. the empirical research needed should draw on both qualitative and quantitative data that goes beyond simple description and is of interest to a range of stakeholders including ethicists, healthcare professionals, patients, and management (schildmann et al. 2013) . singer et al. (1990) have described the ways in which empirical research can advance both theory and education in clinical ethics. we cannot underestimate the cultural context of discussions surrounding cess and healthcare systems generally. in our experience, we were bolstered by the position that a lack of available evidence does not mean abandoning a good idea (new south wales government health 2015) . we realised that the cess proposed could have a research function to it and, therefore, fill some of the gaps in the uk evidence base. for example, we proposed being able to provide cess that serves both hospital-and community-based practitioners, which would position our proposed cess as a beacon for ethical, innovative and collaborative practice, and enable research into cess that crosses practice boundaries. a second overarching point that emerged when making the case for cess was the significance of how cess is perceived by all parties in healthcare. our experiences highlighted that for some nhs staff, limited support is available when they face ethical uncertainty, and some staff lack prior training on ethics and law to prepare them on how to deal with ethical uncertainty. introducing cess into a trust, therefore, should be perceived as a form of staff investment. cess can fill the current gap of ethics and law training after medical school in the uk. our reflections have emphasised that clinical ethics training can benefit staff at all stages of their career, and the educational and training arm of cess can, therefore, be viewed as supporting the continuing professional development of trust staff (hamric and wocial 2016) . our reflections have also highlighted that the perceived remit of cess in the uk needs to evolve so that cess can be seen as a source of everyday ethics support, which is causing moral distress, rather than solely for the high profile, and controversial cases, or after a trust has been caught up in a healthcare "scandal". it is worth noting that since the global pandemic of covid-19, the nhs trust discussed in this paper, along with many others across the country, established a clinical ethics advisory group. however, whether these groups continue beyond the pandemic remains to be seen. the pandemic has brought to light the value and need for cess, but again the services are being utilised for the "extreme" rather than the everyday ethical matters that arise from providing care. there is a real need to (re)educate those potentially engaging with and financially supporting cess in the uk so that it is perceived as providing opportunities for ethical reflection and a space to share and gain-something achieved in scandinavian countries and the netherlands as witnessed by the increasing use of moral case deliberation within healthcare settings (de snoo-trimp et al. 2017) . at a time when much controversy exists surrounding reflection for uk doctors (dyer and cohen 2018; launer 2018) , it is vital that the known benefits of ethical reflection, particularly within a group, are not overshadowed (hem et al. 2018) . in order to shift our perceptions of cess, we do need to acknowledge the need for ethics support for everyday challenges, for senior as well as junior staff members, for those working in the community, as well as in the hospital. if viewed in this way, cess sends the message from the organisation that people matter (levine 1977) . introducing cess into a trust can, therefore, be part of a package of support that meets the emotional and wellbeing needs of all staff. the role of cess can, therefore, be perceived as building and fostering a community, exploring and developing opportunities for staff to share and talk to each other when facing everyday ethical uncertainty, and support organisations to develop policies and practices that promote ethical decision-making. when viewed in this way, the aims of the cess can then be to reduce the ethical and emotional isolation reported by others (oliver 2018 ) through providing support and training. others have identified the need for organisations to ensure employee health programs are readily available to staff, so that employees can discuss in a confidential setting emotional issues arising in the work environment (hem et al. 2018; nelson 2009 ). there is no one size fits all, however, and cess should be viewed as part of a tool kit, that compliments existing, but different, support such as schwartz rounds and resilience training where they are available (gannon 2014; oliver 2018) . if cess are perceived as investing in staff through providing continuing professional development and supporting emotional and wellbeing needs, any evaluation of cess also needs to reflect this alternative perception. some cess use the level of engagement from all staff in activities relating to ethics within their clinical ethics program (bates et al. 2017) , whereas others consider "success" as improving the level of ethical reflection among clinicians (magelssen et al. 2016) . when proposing introducing cess into a trust, we need to be prepared to reframe the "problem", e.g., ethics and law training, ethical leadership, everyday ethical uncertainty, chronic low-level moral distress. so, when facing the "problem-solution" mind-set generated by a business case application, our language can shift from an erasure and eradication of a "problem", and importantly, we can justify the constant and permanent presence of the cess "solution". by shifting our perception of the role, function, aims, and remit of cess, we can better manage our own and other's expectations surrounding cess. we can reduce the "hype" around what cess can deliver and achieve, which is generated when completing a business case application, and ultimately setting ourselves up to fail. instead, the financial focus shifts to investment in our staff, patients, and healthcare system, through education, training, leadership, development, wellbeing, and support. whereas business plans demand timescales and deadlines, which set up a sense of finality and completion, the shift in our perceptions of cess mean that we can see cess as meeting on-going, lifelong needs. just as these needs will evolve, so should the format and structure of cess. viewed in this way, we should all be greatly concerned at the dwindling number of cess in the uk (austin 2018) , and question the optional nature surrounding nhs hospitals providing cess for their staff and patients (beyleveld et al. 2002; ukcen 2014) . as others have argued elsewhere, there is a need for the nhs to be viewed as a moral body, where its staff are part of a moral community and make moral decisions on a daily basis, and they need support to do this (austin 2007; ukcen 2014) . healthcare institutions have "ethical lives and characters just as their individual members do" (reiser 1994, p. 28) , and, therefore, need to make a public commitment to ethical issues-which can be achieved through introducing cess (royal college of physicians 2005; solomon et al. 1991) -in order to fulfil its duty of care to their staff and patients (uk clinical ethics network 2014) . in this paper, we have included extracts from our proposal submitted to the board, we have outlined the issues that we considered when developing our proposal as well as the evidence that we found and drew upon when making the case for cess. we welcome dialogue with others interested in our full proposal and experiences. in the meantime, we offer some key considerations when making the case for cess in the uk. firstly, engage senior leaders and colleagues within the trust early in the discussions around cess and collaborate with senior leaders and colleagues within the trust when designing cess. secondly, seek external support, advice, and expertise. approach established clinical ethics committees, involve ethicists at local medical schools, and draw on resources from formal clinical ethics networks. thirdly, gather support from senior leaders within the trust to work outside any paperwork expectations such as business case application when making the case. be prepared to engage with the themes, but present the material in alternative formats that shift the discussion beyond simple economics, and the problem-solution approach. fourthly, be realistic as to the goals and gains of cess. do not be tempted to overhype the impact and influence of cess in order to secure support from senior leaders and colleagues. understand and utilise the context that provides the backdrop to the cess you are attempting to establish and be open and honest about it; for example, state that a lack of research on uk cess exists, remind readers of the lack of ethics and law training nationally after medical school, and highlight the lack of uk cess available for healthcare professionals to draw on. fifthly, be mindful of your own and other's expectations of cess. even when and where cess exist, conflicts can still escalate, and can require legal intervention. as somerville (2004) points out, do not be tempted to present cess as a perfect system. when composing our proposal for introducing cess into the hospital trust, we acknowledged some of the criticisms towards cess within the literature and balanced them with the potential benefits of cess, alongside the present reality in the trust for staff and patients faced with ethical uncertainty and little formal support available. sixthly, keep in mind the readers of your proposal. others (see dubov 2015; london 2000) have drawn on aristotle's work, rhetoric, in the context of healthcare and communication to highlight the importance and power of persuasion, "people make choices and calculate associate risks not only based on what they think about an option, but also on how they feel about it" (dubov 2015, p. 500) . therefore, the emotion and needs of the readers can inform and influence how the proposal is written and how the option of a cess is presented, without 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medical hermeneutics clinical ethics committee the effect of discussions about advance directives on patients' satisfaction with primary care evaluating ethics consultation: framing the questions recognising, preventing and resolving ethical dilemmas in health care: the need for clinical ethics support in the nhs corporate performance is closely linked to a strong ethical commitment keeping moral space open: new images of ethics consulting working towards implementing moral case deliberation in mental healthcare: ongoing dialogue and shared ownership as strategy consultation activities of clinical ethics committees in the united kingdom: an empirical study and wake-up call a qualitative study of initial faculty tutors in a problem-based curriculum acknowledgements we wish to express our sincere gratitude to clinical and academic colleagues, in particular those involved in the recently established clinical ethics advisory group, the staff and leadership team at the trust, and gill vince for their continued support and encouragement for the clinical ethics collaboration. we also wish to thanks members of the uk cen who generously gave their time, advice, and guidance during our journey, in particular anne-marie slowther, mike parker, john bridson, and raj mohindra. finally, we wish to express our sincere gratitude to the reviewers of this paper. we have found their comments supportive, encouraging, and developmental.funding at the time of writing, the authors are not in receipt of any funding for this manuscript. conflict of interest the authors declare they have no conflict of interest. key: cord-345371-pjbviagq authors: lisi, lucia; lacal, pedro miguel; barbaccia, maria luisa; graziani, grazia title: approaching coronavirus disease 2019: mechanisms of action of repurposed drugs with potential activity against sars-cov-2 date: 2020-07-23 journal: biochem pharmacol doi: 10.1016/j.bcp.2020.114169 sha: doc_id: 345371 cord_uid: pjbviagq on march 11, 2020, the world health organization (who) declared the severe acute respiratory syndrome caused by coronavirus 2 (sars-cov-2) a global pandemic. as of july 2020, sars-cov-2 has infected more than 14 million people and provoked more than 590,000 deaths, worldwide. from the beginning, a variety of pharmacological treatments has been empirically used to cope with the life-threatening complications associated with corona virus disease 2019 (covid-19). thus far, only a couple of them and not consistently across reports have been shown to further decrease mortality, respect to what can be achieved with supportive care. in most cases, and due to the urgency imposed by the number and severity of the patients’ clinical conditions, the choice of treatment has been limited to repurposed drugs, approved for other indications, or investigational agents used for other viral infections often rendered available on a compassionate-use basis. the rationale for drug selection was mainly, though not exclusively, based either i) on the activity against other coronaviruses or rna viruses in order to potentially hamper viral entry and replication in the epithelial cells of the airways, and/or ii) on the ability to modulate the excessive inflammatory reaction deriving from dysregulated host immune responses against the sars-cov-2. in several months, an exceptionally large number of clinical trials have been designed to evaluate the safety and efficacy of anti-covid-19 therapies in different clinical settings (treatment or preand post-exposure prophylaxis) and levels of disease severity, but only few of them have been completed so far. this review focuses on the molecular mechanisms of action that have provided the scientific rationale for the empirical use and evaluation in clinical trials of structurally different and often functionally unrelated drugs during the sars-cov-2 pandemic. on january 30, 2020, the world health organization (who) declared the outbreak of severe acute respiratory syndrome coronavirus 2 (sars-cov-2; initially named 2019 novel coronavirus or 2019-ncov) a public health emergency of international concern, highlighting the need for a coordinated international intervention to limit virus spreading. few weeks later, on march 11, 2020, because of the rapid diffusion of the infection, the who announced that sars-cov-2 infection was a global pandemic. the first cases of respiratory disease caused by 2019-cov-2, thereafter officially named covid-19 (corona virus disease 2019), likely occurred from a zoonotic transmission in china in december 2019 and since then infection has spread across 213 countries and territories. as of july, 2020, sars-cov-2 has infected more than 14,000,000 people and caused more than 590,000 deaths (https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/ accessed july 19, 2020). coronaviridae define a family of hundreds of enveloped, positive-sense, single-stranded rna viruses that are known to cause diseases in animals. sometimes these viruses become able to overcome the species barriers (spillover event) and, so far, 7 coronaviruses are known to cause human diseases. among these, four human coronaviruses (i.e., hcov-229e, hcov-nl63, hcov-oc43 and hku1) typically affect the upper respiratory tract and cause relatively minor symptoms. however, the other three coronaviruses [severe acute respiratory syndrome coronavirus (sars-cov), middle east respiratory syndrome coronavirus (mers-cov) and sars-cov-2] are able to replicate in the lower respiratory tract and are responsible for severe forms of pneumonia that can be fatal (1). phylogenetic analysis indicates that sars-cov-2 has high similarity (88-89%) with two coronaviruses circulating in rhinolophus (horseshoe bats) (2) , but it is less closely related to the sars-cov (~79% similarity) and mers-cov (~50% similarity). based on the sequence analysis of the 29.8 kb viral genome and on the presence of bats and live animals in the seafood wholesale market in wuhan (hubei province, china), where sars-cov-2 was detected for the first time, this virus might have arisen from bats or materials contaminated by bat droppings in the chinese seafood market areas and transmitted to humans either directly or through an intermediate host (3) . similar to the other respiratory coronaviruses, sars-cov-2 is transmitted primarily via the respiratory route in the form of droplets, with a possible, though yet unproven, fecal-oral transmission route (4, 5) . the virus is stable for several hours to days in aerosols and on various types of surfaces, suggesting that transmission may occur by person-to-person droplets as well as by contact with fomites in the proximity of infected patients (6) . although many individuals remain asymptomatic, 97.5% of diseased patients display clinical symptoms within 11.5 days (7) . patients with covid-19 may exhibit mild to moderate symptoms, most commonly fever, fatigue, dry cough, anosmia/dysgeusia, or severe pneumonia with dyspnea, tachypnea, and hypoxemia. actually, dyspnea is predictive of severe covid-19 and intensive care unit (icu) admission (8) . other symptoms less frequently reported include muscle and joint pain, headache, diarrhea, nausea or vomiting, hemoptysis (9) . severe covid-19 is associated to acute lung injury (ali) and/or acute respiratory distress syndrome (ards) that generally occur 8-9 days after symptom onset. as with sars-cov infection, an aggressive inflammatory reaction is responsible for the damage to the lung, indicating that the disease severity also depends on dysregulation of the host immune responses. respiratory failure is the most common cause of death (>70%) of fatal covid-19 cases. furthermore, the massive release of cytokines by the immune system can result in cytokine storm and septic shock and/or multiple organs dysfunction syndromes in 28% of fatal cases (10, 11) . other causes of death are cardiac failure, coagulopathy and renal failure (11) . sars-cov-2 appears also to target the central nervous system with anosmia and dysgeusia as early symptoms and convulsions that may develop later on (12) . currently, the standard of care in patients showing ards includes oxygen therapy together with the administration of parenteral fluids. furthermore, many patients with severe respiratory distress, hypoxemia and ards require invasive mechanical ventilation, and, if the situation deteriorates, extracorporeal membrane oxygenation support (13) . therapeutic interventions including administration of drugs may vary from country to country and it is extremely difficult to harmonize the different protocols due also to the different disease stages of the patients (asymptomatic, pre-symptomatic, mild, severe, under mechanical ventilation). so far, there is not a standardized effective pharmacological treatment for covid-19, a part from anecdotal evidence of efficacy. the scarce knowledge of the sars-cov-2 biology and of the host-pathogen interactions leading to covid-19 has markedly hampered the prompt identification of suitable targets for the development of new therapies. a large number of exploratory clinical trials and pivotal studies are being carried out worldwide. among them, the international "solidarity trial" launched by the who on march 2020 with the aim to find an effective treatment for covid-19 patients by comparing four different treatments (i.e., lopinavir/ritonavir, lopinavir/ritonavir plus interferon-β, chloroquine/hydroxychloroquine or remdesivir) against standard of care (see also sections 2 and 3). presently, regulatory authorities all over the world underline the need of common and rigorous approaches to clinical trials in order to generate more robust evidence on the safety/efficacy of the different anti-sars-cov-2 treatments or vaccines that are being tested. here, we review the recently published literature on the pharmacological treatments used so far and/or undergoing evaluation in clinical trials, with focus on the biochemical mechanisms of action of repurposed or investigational drugs, classified as agents directly targeting the virus ( figure 1 and table 1 ) and those used to treat the respiratory distress and inflammation associated with the cytokine release syndrome ( figure 2 and table 2 ). in addition, we summarize the main clinical trials completed or still ongoing in sars-cov-2 infected patients. the first step in any viral infection entails binding of the virus to a host cell through its target receptor. both sars-cov and sars-cov-2 entry into cells requires the interaction of the viral spike (s) glycoprotein (the envelope-associated protein conferring coronaviruses the characteristic crown-like morphology) with the angiotensin-converting enzyme 2 (ace2) (14) (15) (16) . ace2 is a dimeric ectoenzyme with dipeptidyl carboxypeptidase activity. although the ace2 mrna has been detected in a variety of tissues (17) , the protein has not always been analyzed or detected. the ace2 protein is expressed at high levels on the surface of the lung alveolar epithelial cells and enterocytes of the small intestine providing an easily accessible route for sars-cov-2 infection (18) . the ace2 protein is also present in smooth muscle, pericytes and endothelial cells of the vasculature, heart, kidney and this might account for the multi-organ dysfunction observed in severe covid-19 patients (18) (19) (20) (21) (22) (23) . other tissue sites where the ace2 protein was detected include, among others, the basal epithelium of the nasal, nasopharynx oral mucosa, the basal cell layer of epidermis, and testis (18, 24) . the viral s glycoprotein is a trimer and each monomer contains two subunits, s1 and s2, of which s1 is responsible for the virus attachment to the host cell surface though the receptorbinding domain (rbd), whereas s2 is required for the fusion of the viral and cellular membranes. after the attachment step, the entry process requires the s protein priming by cellular proteases, consisting in the proteolytic cleavage at the s1-s2 boundary and at a downstream position in s2; this process leads to the exposure of a peptide that is involved in membrane fusion (25, 26) . the s proteins of coronaviruses can be cleaved by various cellular proteases; in the case of sars-cov-2, the transmembrane protease serine 2 protease (tmprss2) plays a critical role in s protein priming, whilst the endosomal cysteine protease cathepsin l may replace tmprss2 in this function in cells other than those of the lung (27,28). moreover, it has been recently demonstrated that the host cell protease furin can cleave the sars-cov-2 s protein at the s1/s2 site cleavage, an essential step for viral entry into lung cells (29). since ace2 is located within lipid rafts, cell infection by sars-cov-2 also requires interaction of the viral s protein with different raft components, including sialicacid-containing gangliosides; this interaction also facilitates the contact of the s protein with the ace2 receptor (30). after cleavage of the s protein, sars-cov-2 can be induced to fuse at both the plasma membrane and the endosomal membrane (27,31). various endocytic pathways have been described as being used for cell infection by different coronaviruses, including clathrin-coated vesicles, caveolae as well as clathrin-and caveolae-independent mechanisms (32,33). different antiviral agents or other drugs used for indications unrelated to virus infections have been used to block sars-cov-2 entry into the host cells either by i) inhibiting virus attachment and proteolytic cleavage of the s protein, ii) targeting key cellular enzymatic activities or proteins involved in the endocytic processes or iii) using a combination of both mechanisms ( figure 1 ). umifenovir (arbidol) is a small indole-derivative molecule with a broad spectrum of activity against dna/rna and enveloped/non-enveloped viruses that prevents viral entry into the host cell (attachment and internalization), behaving as host-targeting and direct-acting antiviral agent (34,35). in particular, due to its hydrophobicity, umifenovir displays high affinity for the lipids of the host cell membranes altering their fluidity and rendering them less prone to fusion with the virus. this agent is also able to interact with aromatic residues of the viral glycoproteins involved in the attachment and in the membrane destabilization necessary for the fusion process. furthermore, umifenovir markedly affects clathrin-mediated endocytosis by hampering the release of clathrin-coated pits from the plasma membrane with consequent slowing of vesicle intracellular trafficking and accumulation of clathrin-coated structures where the viral particles remain trapped (35). finally, based on structural similarities between the umifenovir binding sites in the hemagglutinin of the h3n2 influenza virus and the s glycoprotein of sars-cov-2, it has been suggested that this drug might block the trimerization of the s glycoprotein, which is essential for the virus cell adherence and entry (36). umifenovir is licensed (only in russia and china) for the prophylaxis and treatment of influenza a and b infections but it has shown in vitro activity against infections by hepatitis c and b (hcv and hbv), ebola and other viruses (37). in a clinical pilot trial conducted in sixty-nine covid-19 patients, oral treatment with umifenovir (n=36) showed a tendency to reduce viral load and mortality rate as compared to the control group receiving interferon or other non-specified antiviral agents (0% vs 16%) (38) . the results of a retrospective cohort study in patients with covid-19, without invasive ventilation, who received umifenovir plus lopinavir/ritonavir (n=16) or lopinavir/ritonavir only (n=17), showed a potential benefit of the triple combination therapy to reduce viral load and delay disease progression. in fact, after 14 days of treatment, in the umifenovir-treated group nasopharyngeal specimens were negative for sars-cov-2 in 94% of patients (vs 53% of the control group) and the chest computed tomography (ct) scans were improved in 69% of cases (vs 29% of the control group) (39) . subsequently, umifenovir was tested as monotherapy (n=34) and its activity compared to that of lopinavir/ritonavir (n=16). on day 14 after treatment, no viral load was detected in the umifenovir group, whereas the virus was still found in 44.1% of patients treated with lopinavir/ritonavir (40) . conversely, in another study with non-icu patients (n=45) umifenovir failed to improve the prognosis and virus clearance compared to the control group receiving symptomatic treatment, including the most appropriate supportive care (n=36) (41) . a similar conclusion was drawn by an observational cohort study on the real-world efficacy and safety of umifenovir used as single agent or in combination with lopinavir/ritonavir. there was no evidence that adding umifenovir to lopinavir/ritonavir could shorten the time to negative conversion of sars-cov-2 nucleic acid in pharyngeal swabs or improve the symptoms (42). however, a retrospective analysis of adverse drug reactions in 217 chinese patients with covid-19, by a hospital pharmacovigilance system, reported a lower incidence of adverse effects (that were mostly at the gastrointestinal and hepatic level) for umifenovir compared to lopinavir/ritonavir (18.1% vs 63.8%) (43) . a small retrospective cohort study has recently suggested the use of umifenovir for post-exposure prophylaxis, based on the significant reduction of infection risk observed in family members (n=66 in 27 families) and health care workers (n=124) who were exposed to patients with confirmed sars-cov-2 infection (44) . further clinical studies are ongoing to evaluate the role of umifenovir in covid-19 management, used as monotherapy [nct04260594] or in combination with other antiviral agents [nct04350684, nct04273763]. in the randomized, double-blind, placebo-controlled clinical nct04350684 trial, umifenovir is added to a therapeutic regimen including interferon-β1a, lopinavir/ritonavir and a single dose of hydroxychloroquine plus standard of care. baricitinib is a potent and selective inhibitor of the janus kinases 1/2 (jak1/jak2), currently used in the therapy of rheumatoid arthritis. based on the results of a benevolentai's knowledge graph, the small-molecule kinase inhibitor baricitinib was predicted to alter virus entry by inhibiting ap2-associated kinase 1 (aak1) and cyclin g-associated kinase (gak), which are likely involved in sars-cov-2 endocytosis (45) . the benevolentai's knowledge graphical method uses machine learning to integrate the scientific information on the biological processes involved in viral infection with that on the mechanisms of action of available drugs in order to identify potential new pharmacological targets and therapeutic indications. besides exerting potential direct antiviral effects, baricitinib might prevent the dysregulated production of pro-inflammatory cytokines typically observed in covid-19 patients via the inactivation of interleukin-6 (il6)-jak-signal transducer and activator of transcription (stat) pathway (this activity will be more deeply discussed in section 3, especially regarding the jak inhibitor ruxolitinib). some clinical trials, also including placebo-controlled studies, are evaluating the safety and efficacy of baricitinb, mostly as 2week add-on therapy in patients with mild to moderate covid-19. results from a small study in 12 patients with moderate covid-19 pneumonia, treated with baricitinib in combination with lopinavir/ritonavir [nct04358614], indicated that a 2-week oral treatment with the jak1/2 inhibitor was well tolerated. moreover, although proper control groups were missing, the authors reported improved clinical and laboratory parameters (46) . a favorable clinical course was also reported in an 87-year-old woman, with a mild-to-moderate covid-19, chronically treated with baricitinib for rheumatoid arthritis, who also received other pharmacological treatments to control viral infection (i.e., lopinavir/ritonavir, hydroxychloroquine) (47) . this patient was part of a familiar cluster of covid-19, and the three other family members (husband, son and daughter) received the same antiviral therapy with the exception of baricitinib. interestingly, the patient's husband (90 chloroquine and hydroxychloroquine are among the most frequently used drugs for the treatment of covid-19 patients in view of their potential inhibitory activity on virus entry. however, other mechanisms appear to contribute to their antiviral activity, including impaired receptor recognition by coronaviruses due to altered terminal glycosylation of ace2 (49) and inhibition of viral attachment to the lipid raft as a consequence of a reduced interaction of the sars-cov-2 s protein n-terminal domain with membrane gangliosides (30). indeed, in vitro studies have demonstrated that chloroquine is able to block sars-cov-2 infection at lowmicromolar concentrations (50) (51) (52) . furthermore, chloroquine and hydroxychloroquine exhibit immunomodulatory activity since they reduce the toll-like receptor (tlr) signaling (that plays a crucial role in the innate immune system) and production of inflammatory cytokines, as well as the expression of co-stimulatory molecules in t cells (for a comprehensive review see 53) . so far, however, there is not conclusive or robust clinical evidence on the usefulness of quinolines in covid-19. starting from mid-february, 2020, chloroquine was included in the sixth version of the covid-19 treatment guidelines by the national health commission of the people's republic of china. according to these guidelines the initial recommended chloroquine dose was 500 mg twice daily for no more than 10 days; however, due to safety concerns the maximum therapy course was reduced to 7 days and a lower dose was recommended for patients weighing less than 50 kg. based on clinical trials conducted in china in more than 10 hospitals, treatment of >100 patients with chloroquine is superior to control treatment in preventing pneumonia exacerbation, improving lung imaging results, accelerating virus-negative conversion, and shortening the disease course (54) . however, detailed information on the study design, patient characteristics or control treatment were not provided. the results of a blinded, randomized, controlled chinese trial for covid-19 pneumonia, reported a significant improvement in terms of symptoms and ct findings in patients treated with hydroxychloroquine (n=31; 400 mg/day for 5 days) compared to the control group (n=31) (55) . conversely, in a previous pilot study in 30 treatment-naïve patients with confirmed covid-19, hydroxychloroquine did not show any clinical benefit (56) . a french study on a cohort of 80 patients with severe covid-19 treated with hydroxychloroquine (600 mg/day for 10 days plus the macrolide antibiotic azithromycin for 5 days) did not reveal antiviral activity or clinical benefit (57). a published interim analysis of a double-blind, randomized, phase iib clinical trial [nct0432352] performed in brazil, after enrollment of the first 81 patients with severe ards treated with high and low chloroquine doses (i.e., 600 mg/twice/day for 10 days, n=41; 450 mg twice daily on day 1 and once daily for 4 days, n=40) indicated that the high-dosage group showed a higher incidence of cardiotoxic effects (qtc interval prolongation) and a higher mortality rate compared to the low-dosage group (39% vs 13%) (58). all these patients also received the macrolide antibiotic azithromycin that may induce cardiotoxic effects. these preliminary data indicate that high chloroquine dosage should not be recommended for treating critically ill covid-19 patients. although hydroxychloroquine is better tolerated than chloroquine, both agents may cause in the long-term life-threatening arrhythmias (an effect increased by the concomitant use of azithromycin), leucopenia, neuropsychiatric effects and retinopathy. in addition, quinoline overdose can lead to cardiovascular collapse, seizures and coma (59). therefore, the use of chloroquine/hydroxychloroquine for covid-19 management requires a careful patient selection and monitoring. based on the initial publication in the lancet of the results of a multinational registry analysis conducted by surgisphere corporation, showing that treatment with hydroxychloroquine/chloroquine (with or without a macrolide) in hospitalized covid-19 patients (n=14,888) failed to induce clinical benefit and was associated with higher risk of death and cardiovascular complications compared to control treatment (n=81,144) (60), on may 23, 2020, the who temporarily halted the solidarity trial arm with chloroquine/hydroxychloroquine. thereafter, the article was retracted by three of the four coauthors of the original article since surgisphere (owned by one of the authors) did not make available to a third-party audit the complete dataset used for the study (61) . thus, on june 3, 2020, the who announced that there was no reason to modify the solidarity trial protocol and the arm with quinolines was resumed. nevertheless, on the basis of a low benefit/risk ratio, the fda retracted the emergency use authorization (eua) previously issued to hydroxychloroquine for use in covid-19 hospitalized patients outside of clinical trials. to have a clear view on the overall risk-benefit ratio of using chloroquine/hydroxychloroquine especially in severely ill covid-19 patients we will have to wait for the conclusion of welldesigned, multi-center, randomized, controlled studies. actually, clinicaltrials.gov lists a number of phase 3 studies testing chloroquine and more frequently hydroxychloroquine, alone six of them also received azithromycin (500 mg on the first day followed by 250 mg daily) to prevent bacterial infection. all patients treated with both drugs showed negative nasopharyngeal sars-cov-2 pcr conversion compared to 57.1% of those treated with hydroxychloroquine as single agent and 12.5% of the untreated ones (62) . the results of a french retrospective non-randomized study in a total of 1061 patients treated for at least 3 days with hydroxychloroquine plus azithromycin showed that early treatment with this drug combination was well-tolerated and associated with a very low fatality rate (0.9%) (63) . the mechanism underlying the potential azithromycin activity against sars-cov-2 still needs to be clarified; recently, it has been hypothesized that this antibiotic might inhibit cd147, a glycosylated transmembrane protein that would serve as additional receptor for sars-cov-2 cell invasion (64) . furthermore, azithromycin might stimulate immune responses against the virus by inducing the synthesis of type i and iii interferons, as demonstrated in epithelial cells collected from patients with chronic obstructive pulmonary disease (65) . as mentioned above, a number of clinical trials are currently evaluating azithromycin mostly in combination with hydroxychloroquine for the treatment of covid-19 or as prophylaxis. another approach to inhibit sars-cov-2 infection consists in inhibiting the protease that cleaves the s protein, thus facilitating viral entry and activation. tmprss2 is an androgen(72, 73) . in addition, nafamostat is able to inhibit the coagulation and fibrinolytic systems, the kallikreinkinin system, the complement cascade, and activation of protease-activated receptors (74) . therefore, their anti-inflammatory, anti-coagulant and fibrinolytic properties might contribute to attenuate the symptoms and complications occurring in covid-19 patients. both agents are approved in japan for the treatment of pancreatitis, and nafamostat is also used for disseminated intravascular coagulation and as anticoagulant in extracorporeal circulation. three case reports of elderly covid-19 patients with pneumonia, all taking antivirals like lopinavir/ritonavir and hydroxychloroquine, showed that the introduction of nafamostat induced clinical and radiological improvement without significant adverse effects (75) inhibition of the viral spike protein cleavage by cathepsin l in the late endosome might also result in decreased sars-cov-2 entry into the cells (80) . once sars-cov-2 reaches the endosomes, the cysteinyl proteinase cathepsin l is the main protease that cleaves the s1 once inside the cell, sars-cov-2, like other coronaviruses, uses two third of its positivesense single-stranded rna genome as template to directly translate two open reading frames (orf1a and orf1ab), connected by a ribosomal frameshift site, into the two overlapping polyproteins, pp1a and pp1ab, which are afterward cleaved by viral proteases into 16 nonstructural proteins (nsps) (85) . some nsps (including rna-dependent rna polymerase, helicase and other enzymatic activities required for the mrna capping and proofreading) eventually contribute to form the replication-transcription complex, which is anchored to double-membrane vesicles integrated into a reticulovesicular network of modified endoplasmic reticulum membranes, also including convoluted membranes (86, 87) . the viral genomic rna is encapsulated by the nucleocapsid n protein that thereafter buds into the ergic and acquires a membrane containing the s, e and m structural proteins. finally, the virus is released by exocytosis ( figure 1 ). the 3cl pro /m pro is highly conserved among various coronaviruses, and mutations in 3cl pro /m pro are often lethal to the virus (88, 89) . therefore, 3cl pro /m pro is indispensable for viral replication and thus represents an attractive therapeutic target for inhibiting the coronavirus infection process (89) . this enzyme is a homodimeric cysteine protease whose recognition sequence at most sites of viral polyproteins is leu-gln↓(ser,ala,gly). several previous reports have indicated that the hiv aspartate protease inhibitors lopinavir and ritonavir have the potential to act also as sars-cov protease inhibitors through their binding to 3cl pro /m pro (90) (91) (92) (93) . for hiv treatment, the two drugs are used in combination, but ritonavir is administered at a dose that does not affect hiv protease activity but rather inhibits the cytochrome p450 3a4-mediated metabolism of lopinavir, thus increasing its plasma levels. both drugs bind to amino acid residues present at the active site of sars-cov-2 furthermore, based on a virtual docking prediction study, some hcv ns3/4a protease inhibitors (e.g., simeprevir, paritaprevir, grazoprevir, boceprevir, telaprevir) might also inhibit the 3cl pro /m pro (101, 102) . however, none of these agents is currently clinically evaluated for covid-19 treatment. concerning the other coronavirus protease pl pro , although considered another potential therapeutic target since it is crucial for viral replication, the development of sars-cov-2 pl pro inhibitors is still at an early stage (103), despite several investigational compounds have been found to efficiently inhibit the corresponding sars-cov and mers-cov enzyme (104). another the adenosine analogue remdesivir is one the most frequently tested anti-sars-cov-2 agents and has been firstly approved in japan for severe covid-19. remdesivir was originally developed for rna virus infections and tested for ebola during the 2018 outbreak in democratic republic of the congo but failed to show clinical benefit. it has a broadspectrum antiviral activity, including mers-cov, sars-cov and sars-cov-2, both in vitro and in vivo in animal models (52, (106) (107) (108) (109) . remdesivir is a prodrug that, after diffusion into the cells, is metabolized to the alanine metabolite gs-704277 and further converted into a nucleoside monophosphate, which is highly polar and remains trapped within the cell (106) . host cell kinases eventually convert the monophosphate derivative into a triphosphate nucleotide that is misincorporated into the nascent rna chain by the rna dependent rna polymerase with consequent inhibition of the rna synthesis (110) . remdesivir has been found to interact with the sars-cov-2 polymerase, competing with the physiological atp nucleotide, and to behave as delayed-chain-terminator, since rna synthesis is terminated after the addition of three nucleotides (105, 111, 112) . it should be noted that the efficacy of remdesivir or of other nucleoside/nucleotide-based agents, whose activity relies on their misincorporation into the viral genome, might be counteracted by a coronavirus proofreading exoribonuclease (nsp14) that would enable the virus to evade the pharmacological inhibition (113) . intravenous remdesivir was used to treat the first covid-19 patient diagnosed in the us with rapid improvement of the clinical conditions (114) and is regarded as one of the most promising agents for sars-cov-2. presently, the drug is included in the national institutes (117) . in an uncontrolled study where 61 patients (64% receiving mechanical ventilation) were treated with remdesivir on a compassionate-use basis, clinical improvement at 28 days was observed in 68% of patients (118) . however, this trial raised several criticisms on the study design and result interpretation, due to lack of control, small sample size, inappropriate data censoring, high variability of disease severity (119) (120) (121) (122) . in another study, remdesivir was administered as compassionate treatment to 32 hospitalized patients (18 of whom in icu) and beneficial effects were observed on sars-cov-2 pneumonia, mainly in non-critically ill patients (123) . remdesvir is usually well-tolerated for short courses. however, concerns were raised about its potential toxicity in patients with kidney dysfunction related not only to the drug-mediated injury of renal tubular epithelial cells, but also to the nephrotoxicity associated with the drug vehicle (i.e., sulfobutylether-β-cyclodextrin) required for the intravenous formulation (124) . another nucleoside analogue used for covid-19 is favipiravir, which acts as a competitive inhibitor of the rna-dependent rna polymerase. this agent was previously approved in japan for the treatment of influenza a and b and, in particular, for novel or re-emerging influenza viruses (125) . presently, the drug has been approved in russia for covid-19 and is investigated worldwide. favipiravir, after undergoing intracellular tri-phosphorylation, exerts antiviral effects as a guanosine analogue, through several mechanisms including chain termination, slowed rna synthesis and lethal mutagenesis (due to c-to-u and g-to-a transitions favored by the low cytosine content of sars-cov-2 genome) (126 high levels of il6 and il8 also contribute to hypercoagulation due to activation of the complement and coagulation cascades, causing disseminated intravascular coagulation (150, 151) . waiting for an effective antiviral therapy or vaccine against the virus, any treatment that can decrease the severe symptoms of covid-19 may help to attenuate the mortality rates and to improve the quality of life of severely ill patients. in this regard, several pharmacological therapies, with different mechanisms of action, have been used in order to improve the symptoms related to covid-19. in the next section, we will consider the agents directed against the: a) cytokine storm and b) cardiovascular damage. the first category includes: i) anti-cytokine drugs, such as tocilizumab, sarilumab, siltuximab, olokizumab, ruxolitinib, baricitinib, anakinra, emapalumab, mavrilimumab; and ii) immunomodulating agents, such as interferon-β, interferon-α or interferon-λ, fingolimod, ozanimod, opaganib, cd24fc, allogenic mesenchymal stem cells and the lately reappraised dexamethasone. the second group comprises: the anti-c5 complement monoclonal antibodies (mabs) eculizumab and ravulizumab; anti-thrombotic and fibrinolytic agents; the phosphodiesterase type 5 inhibitor sildenafil; the vasoactive intestinal polypeptide analog aviptadil; and the anti vegf-a mab bevacizumab ( figure 2) . however, the effects of the two drug sets are closely interconnected, as many drugs that have an impact on the circulatory system may also reduce circulating inflammatory cytokines. the first therapeutic agent used to counteract the inflammatory reaction in patients with (162) . furthermore, a larger study on 100 patients with covid-19 pneumonia accompanied by hyperinflammatory syndrome and acute respiratory failure described improvement or stabilization of the respiratory conditions in 77% of patients (163) . case reports also supported the potential benefit from tocilizumab treatment (164) . a chinese small retrospective study in 21 patients showed that tocilizumab is associated with rapid improvement of the clinical symptoms and hypoxemia, and prevention of clinical worsening in severe covid-19 patients, without serious adverse events (165) . however, tocilizumab did not reduce icu admission and mortality rates in 21 critically ill patients with severe covid-19 pneumonia (166) . tocilizumab treatment was found to be associated with an initial rise in il6 levels, as an expected consequence of the mab-mediated inhibition of il6 interaction with its receptors, followed by a significant decrease of the c-reactive protein inflammatory marker (167). however, the d-dimer, measured as an indicator of intravascular fibrin formation, remained unaffected suggesting that tocilizumab might have limited effect on the activation of the coagulation cascade (163) . furthermore, the clinical response to tocilizumab seems to be negatively affected by hyperglycemia, shown to be associated with increased il6 levels (168) . in regard to tocilizumab safety, concerns have been raised about the risk of candidemia, septic shock and possible occurrence of intestinal perforation (an adverse effects reported in rheumatoid arthritis patients), which may be favored by the altered hemodynamics observed in critically ill covid-19 patients (163, (169) (170) (171) . based on these initial data, the efficacy and safety of tocilizumab in severe covid-19 need to be corroborated by the results of the ongoing randomized controlled clinical trials. clinical studies are also testing the other anti-il6 receptor mab sarilumab (fda-and emaapproved for rheumatoid arthritis) and anti-il6 mabs such as siltuximab (fda-and ema-approved for multicentric castleman's disease) and the investigational mab olokizumab. like tocilizumab, sarilumab is able to bind both il6r and sil6r, but being a fully human mab, has a lower risk of inducing neutralizing antibodies and allergic reactions compared to chimeric/humanized mabs (172 strictly dependent on the jak/stat pathway (173, 174) , jak inhibitors have also been used in covid-19 patients with the aim of reducing the excessive inflammatory reaction. among these, the orally administered ruxolitinib is a jak1/jak2 small-molecule inhibitor approved for the treatment of myelofibrosis, polycythemia vera, and graft-versus-host disease (175) . consistently with its mechanism of action, in patients with myelofibrosis, ruxolitinib was able to reduce il6 and tnfα levels and was well-tolerated (176 (177) . furthermore, in covid-19 patients two case reports of diffuse skin reactions with purpuras and a rapid decrease of hematocrit values were described (178) . baricitinib is another jak inhibitor that besides interrupting the jak1/2-dependent signaling involved in cytokine-mediated inflammatory response to the sars-cov-2 infection, might also exert direct antiviral effects by blocking virus entry (see section 2). anakinra is a recombinant, non-glycosylated form of the natural occurring human interleukininterferon-γ, which inhibits its binding to cell surface receptors and the subsequent activation of intracellular pro-inflammatory signaling pathways. emapalumab is fda-approved to treat the severe inflammatory condition of primary hlh in which serum interferon-γ levels are elevated (186). blockade also immune responses against viruses, through enhancing antigen presentation, costimulation, and cytokine production by the effector cells of innate immune system, leading to enhanced adaptive immune responses (190) . the response mediated by type i interferons is more potent, rapid, transient, diffuse and inflammatory, whereas the type iii interferon response is less potent, slower, sustained, anatomically restricted and less inflammatory (188) . interestingly, the cytokine storm associated with covid-19 is due to an uncontrolled response of the immune system to sars-cov2 viral infection that leads not to only to an excessive production of cytokines but also a diminished/delayed interferon response (191) (192) (193) . based on preclinical studies and observations in sars-cov or mers-cov infected patients, the outcome of the interferon-mediated response to the viral infection seems to depend on the viral load and integrity of the host immune system. in particular, if the initial viral burden is low, type i interferons are promptly released and efficiently clear the infection; conversely, if the viral load is high or in elderly patients the early interferon production is hampered and a delayed interferon-mediated response may not only fail to control the infection but also result in inflammation and lung damage (194) . thus, exogenously administered type i interferons would have protective effects as prophylaxis or in the early stage of sars-cov-2 infection, whereas they may deteriorate tissue injury and pneumonia when administration is delayed. concerning the potential therapeutic role of interferon-λ, the lack of pro-inflammatory systemic effects would allow its safe administration also in an advanced phase of the infection (194) (195) (196) . although better tolerated than type i interferons that may cause severe systemic side effects due to the ubiquitous expression of ifnar, a possible disadvantage of interferon-λ is its lack of antiviral effects on infected alveolar macrophages or endothelial cells that do not express ifnlr1 but may serve as virus reservoir (197) . . in an additional trial, interferon-α1b as nasal drops is assessed for low-or high-risk medical staff exposed to sars-cov2 infected patients, as single agent or combined with thymosin α1, respectively [nct04320238]. in regard to interferon-λ, the safety and efficacy of subcutaneous pegylated interferon-λ is tested as immediate/early therapy in non-critically ill hospitalized or ambulatory patients another immunomodulating agent, fingolimod (fty720), an orally administered drug approved for multiple sclerosis, was evaluated in covid-19 patients (199) . once absorbed, fingolimod undergoes phosphorylation to form an analog of the naturally occurring s1p, a lipid signaling molecule whose activity is mediated by the interaction with four subtypes of g protein-coupled receptors (s1p1 and s1p3-5) (200, 201) . after binding to s1p1, fingolimod initially activates the receptor and thereafter down-regulates its expression, causing retention of naïve t cells and central memory t cells in the lymph nodes and induction of lymphocytopenia (202) . nevertheless, fingolimod does not substantially affect memory effector t cells, which play an important role in the defense against infectious agents (203) . moreover, it does not affect humoral immune responses and does not prevent the generation of virus-specific cytotoxic t cells in the lymph nodes (203) . thus, it has been hypothesized that patients on s1p modulators might have a reduced risk of complications from sars-cov-2 infection. furthermore, due to the s1p role in lung endothelial cell integrity (204) , in covid-19 patients, fingolimod might reduce vascular permeability and consequent lung injury (205) . in clinical trials with fingolimod for multiple sclerosis, conflicting results were reported showing either no change or increased risk of viral infections (especially herpes virus) compared controls (206) (207) (208) . severe covid-19 cases have been reported in patients with multiple sclerosis on treatment with fingolimod that was stopped upon sars-cov-2 diagnosis; in all these cases patients fully recovered from infection (205, 209, 210 another molecule that has raised some interest to control the inflammatory response associated with sars-cov-2 infection is cd24fc, a recombinant fusion protein that comprises cd24 attached to the fc region of human igg1. cd24 is a glycosylated membrane protein expressed in hematopoietic cells (including immature b and t cells, granulocytes, macrophages and some epithelial cells) that plays a regulatory role on b and t cell homeostasis (211) . in humans, cd24 is able to suppress inflammation upon interaction with the prr siglec10 and several danger-associated molecular patterns (damps), helping to reduce the host immune response against proteins released by damaged cells. preclinical studies demonstrated that the chimeric molecule cd24fc mitigates the graft-versus-host disease, by decreasing the overall inflammatory response, and, in particular, the release of il1β, il6 and tnfα release (212) . these data provided the biological rationale for the clinical testing of cd24fc also for covid-19, and a randomized, double-blind, placebocontrolled, phase 3 study is currently recruiting severely ill infected patients [nct04317040]. a cell-based approach to modulate the damage deriving from inflammation and altered activation of dexamethasone is an old corticosteroid, i.e., a drug with broad anti-inflammatory and immunosuppressant activity that reduces cell-mediated immunity and various cytokine production. its clinical indications span from pain in the joints to asthma, irritable bowel disease/crohn disease, emesis, multiple sclerosis and various autoimmune diseases, as well as different types of cancer, to name just the most prevalent. it has also been used in the previous although the clinical manifestations of covid-19 are dominated by respiratory symptoms, the disease prognosis is largely influenced by the involvement of various organs, including the heart. cardiovascular complications (i.e., myocardial infarction, acute heart failure and cardiomyopathy, shock and cardiac arrest, dysrhythmias, venous thromboembolic events, acute myocarditis) are associated with a high mortality rate and occur in about 10% of hospitalized patients (227) . furthermore, patients with pre-existing cardiovascular diseases are predisposed to sars-cov-2-induced myocardial injury and infection is associated with a high mortality rate; in these patients, the risk of heart failure and myocardial damage increases to ≥35% (228) (229) (230) . the mechanisms involved in the cardiovascular injury of covid-19 include: i) direct damage upon virus entry through ace2 present in coronary endothelial cells, cardiomyocytes and cardiac fibroblasts; ii) increased oxygen consumption deriving from fever, enhanced adrenergic tone and tachycardia; iii) increased oxidative stress as a result of ros production; iv) massive cytokine release and a state of hyperinflammation that contribute to pneumonia/ards with consequent acute heart failure, as well as endotheliitis leading to disseminated intravascular coagulation, thrombosis and infarction; v) sars-cov-2-induced ace2 downregulation due to receptor shedding or internalization with consequent increase of angiotensin ii (228, 231) . in fact, normally, ace2 degrades angiotensin ii to produce angiotensin 1-7 that is endowed with vasodilating and anti-inflammatory effects. therefore, a reduction in ace2 function after viral infection may result in a dysfunctional renin-angiotensin system, associated with an increase of angiotensin ii, which would lead to vasoconstriction and inflammation. dysregulated immunothrombosis (i.e., clot formation triggered by the interaction of innate immune system components, like macrophages, neutrophils and the complement system, with platelets and coagulation factors, that provides a first line defense against infectious agents) with diffuse microvascular thrombi formation has been also described in covid-19 and involved in multi-organ damage (232, 233 in patients with severe covid-19, high rates of venous thromboembolism and disseminated intravascular coagulation, due to dysregulation of the coagulation and fibrinolytic systems are furthermore, heparin has anti-inflammatory properties by inhibiting il6, il8, tnfα release, c-reactive protein and adhesion of neutrophils to endothelial cells (241) (242) (243) . in a retrospective cohort study, the administration of lmwh to covid-19 patients besides producing anticoagulant effects also reduced il6 levels and increased lymphocyte counts suggesting a beneficial effect towards controlling the cytokine storm (244) . in addition, ufh and lmwh have been shown to inhibit the binding of the s protein of sars-cov-2 to its cellular receptor, ace2, in an in vitro cell system expressing ace2 and tmprss2. these results suggest another mechanism through which heparin may slow down or prevent disease progression in the early phases of covid-19. (245, 246) . fibrinolytic drugs, namely tissue-type plasminogen activator (tpa) as systemic intravenous treatment or as lung-targeted nebulizer form, have been proposed for covid-19 patients (247, 248) . several clinical trials are currently assessing different heparin regimens, other anticoagulants, systemic and local fibrinolytic approaches, and antiaggregants (e.g., rivaroxaban; defibrotide; clopidogrel, aspirin) (clinicaltrials.gov). the pde-5 inhibitor sildenafil, a vasodilator that is approved for treating erectile dysfunction and pulmonary arterial hypertension (249) , is also evaluated in a phase 3 trial for patients with mild to severe covid-19 [nct04304313]. in fact, sildenafil has a wide range of antiinflammatory, antioxidant, and vasodilatory actions resulting in cardioprotective effects and improved pulmonary circulation (250) (251) (252) . aviptadil is a synthetic form of vip that increases adenosine cyclase activity with consequent smooth muscle relaxation, approved in combination with phentolamine only in certain the vegf-a is considered the most potent inducer of vascular permeability. the potential involvement of vegf-a in covid-19 has been related to the excessive production of angiotensin ii, consequent to the sars-cov-2-mediated down-regulation of ace2. in fact, angiotensin ii is able to increase vegf-a expression which in turn may exacerbate inflammation stimulating the recruitment of inflammatory cells and the release of proinflammatory cytokines (255) (256) (257) . numerous studies have confirmed a key role of vegf-a as potential therapeutic target in ali and ards due do the increased vascular permeability and pulmonary edema (258) . furthermore, vegf-a has been involved in disruption of the blood-brain barrier and may contribute to brain inflammation in the course of sars-cov-2 infection (259 bleeding, delaying wound healing, thromboembolic events). all over the world, the scientific community is racing to evaluate a huge number of drugs or [46, 47] (see table 2 ) eidd-2801 inhibition of rdrp -nct04405739 nct04405570 a nct: clinicaltrials.gov identifier data from clinicaltrials.gov accessed on june, 2020. due to the rapidly evolving situation and the increasing number of clinical trials, the reported list of clinical trials does not mean to be exhaustive. b these agents might also have additional mechanisms contributing to the antiviral activity against sars-cov-2 rdrp; rna-dependent rna polymerase. human coronaviruses with emphasis on the covid-19 outbreak, virusdisease. 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(2020) eculizumab treatment in patients with covid-19: preliminary results from real life asl napoli 2 nord experience covid and coagulation: bleeding and thrombotic manifestations of sars-cov2 infection covid-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up pulmonary embolism or pulmonary thrombosis in covid-19? is the recommendation to use high-dose heparin for thromboprophylaxis justified? incidence of thrombotic complications in critically ill icu patients with covid-19 abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia anti-inflammatory effects of heparin and its derivatives: a systematic review efficacy of low molecular weight heparin in patients with acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support unfractionated heparin alleviates sepsis-induced acute lung injury by protecting tight junctions the potential of low 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to clinical improvement in patients with severe and lifethreatening covid-19: a randomized clinical trial challenges in the production of convalescent hyperimmune plasma in the age of covid-19 a human monoclonal antibody blocking sars-cov-2 infection we would like to acknowledge the support of the "fondazione airc" to the national civil protection to help tackle the covid-19 emergency in italy and its commitment to continue supporting cancer research during the challenging times of sars-cov-2 pandemic. g.graziani is principal investigator (pi) of the airc grant ig 2017 -id. 20353 project. orphan drug for the treatment of ards, ali and sarcoidosis nct04311697 nct04360096anti-vegf-a bevacizumab cancer treatment; age-related macular degeneration (off-label) nct04305106 nct04344782 nct04275414 a nct: clinicaltrials.gov identifier data from clinicaltrials.gov accessed on june, 2020. due to the rapidly evolving situation and the increasing number of clinical trials, the reported list of clinical trials does not mean to be exhaustive.ards: acute respiratory distress syndrome; ali: acute lung injury. key: cord-324388-onc441uw authors: siddiqui, urooj; hawryluck, laura; muneeb ahmed, muhammad; brull, richard title: same-day consent for regional anesthesia clinical research trials: it’s about time date: 2020-08-12 journal: anesth analg doi: 10.1213/ane.0000000000005196 sha: doc_id: 324388 cord_uid: onc441uw nan c oronavirus disease 2019 (covid-19) has changed the way anesthesiologists engage and interact with patients. as we hopefully approach the backend of this crisis, plans for the resumption of "nonessential" anesthesia services, including providing anesthesia for elective surgeries, reopening of anesthesia preoperative assessment clinics (pac), and recruiting for regional anesthesia clinical research trials, will take shape. the covid-19 pandemic has, however, highlighted a significant challenge in the current approach to research and the advancement of scientific knowledge in the regional anesthesia field: the perceived need to obtain consent to participate in such research in advance of the actual day of surgery. notwithstanding the low-risk nature of participation in most regional anesthesia clinical trials, subject recruitment on the same day as surgery is often prohibited by local research ethics boards (reb) due to their concerns regarding patient autonomy and perceptions of patient vulnerability immediately before surgery that could impact the voluntary nature and the rigor of the informed consent process. in many centers, the anesthesia pac has long served as the sole permissible and fertile ground for subject recruitment to clinical research, presumably ensuring fully informed consent to participate in a clinical trial in the absence of any undue duress and facilitating the establishment of a mutually trustful relationship. with the covid-19-related suspension of in-person assessments in anesthesia pacs across most academic centers, recruitment for ongoing regional anesthesia clinical research trials has come to an abrupt halt and brought the long-standing controversy of same-day informed consent for low-risk clinical trials squarely back to the fore. the widespread reb concerns regarding same-day informed consent for participation in regional anesthesia research trials have not been supported in the current literature. even though anxiety in the face of impending surgery is a normal human reaction, patients are still presumed to be capable to continue to consent or to revoke consent to surgery while they wait to enter the operating room. there is no evidence that carefully conducted assessments of capacity to understand information pertaining to a research study and to appreciate how a choice to participate or not would apply to them cannot be performed in this period. there is no existing literature to suggest that patients are so vulnerable during this period that they must be systematically protected by prohibiting any discussion of potential participation in research in the immediate preoperative period. arguably, such a systematic prohibition is ethically problematic in that, on its face, it appears paternalistic and can deny patients the benefits of research participation. the anticipation of a second wave of covid-19 and the high likelihood of future pandemics from other emerging pathogens requires a more rigorous examination of such reb assumptions as prohibiting same-day consent to participate in regional anesthesia research risks stymying research and growth of this important and innovative field and fail in its goal to benefit patients in the perioperative period. the 1964 declaration of helsinki outlined the tenets of informed consent: competency, disclosure, autonomy. 1 to ensure autonomy, subjects must offer their participation voluntarily, specifically, without any element of force, fraud, deceit, duress, or coercion. these tenets remain the pillars on which clinical research involving humans is founded and inform the respective canadian and american anesthesiologists' society's guidelines for the ethical consult of clinical research. 2,3 despite adaptations and updates over several decades, a single truth has prevailed: consent is paramount and, as with treatment, no research can occur without consent. chief among the roles of rebs is to ensure the consent process is rigorous and the autonomy of clinical research participants is respected. while the meaning of consent is both uniform and clear, that is, research participants must be capable of decision-making, fully informed, with ample time for consideration of options without coercion, and their choice must be respected, 1 what constitutes ample time is not as clearly defined. the world health organization states that "subjects must be given ample opportunity to enquire about the details of the trial… sufficient time, determined by the patient's health condition." 4 the tri-council policy statement, representing canadian standards for ethical research involving humans, declares that "for consent to be informed, prospective participants shall be given adequate time and opportunity to assimilate the information provided." 5 in the united states, the american medical association is even less explicit, stating only that a valid consent process includes, "reviewing the process and any materials to ensure that it is understandable to the study population." 6 locally, the university of toronto's position on "ample time" is equally vague, only to consider "whether the contact person is known to the subject/ authorized third party, has access to the patient information as part of their normal professional duties, or is able to assess capacity to consent." 7 while there is currently no uniform explicit recommendation or absolute quantification for what constitutes adequate time for patient reflection before consenting to participate in a clinical research trial, 4, 5, 7 hospital-based rebs are also given some guidance regarding how much time is inadequate. specifically, the canadian national council on bioethics in human research likens the practice of same-day consent to intimidation, coercion, and breach of autonomy. 8 ostensibly equating quantity with quality, some rebs have strongly discouraged same-day consent practices, instead opting for a minimum of 1-2 weeks for patient contemplation, irrespective of risk involved in study participation. outside of north america, guidelines and recommendations on consenting practices for clinical research trials are similarly varied. the table summarizes available recommendations from various international professional societies and government agencies regarding consent practices in the context of clinical research. recommendations range from the oft-repeated requirement for "adequate" or "sufficient" time 9,10,13 to a more explicit demand for at least 24 hours for patient consideration. 11 a notable deviation is the proportionate approach to seeking consent for clinical trials advised by united kingdom's national health service (nhs). 14 when seeking consent for patient participation in a clinical trial, the nhs recommends that "for research involving only minimal risks and/or little deviation from normal/standard clinical practice… it may be reasonable to accept a decision taken at the time of approach." 14 additionally, the extent of information provided ought to be proportionate to the "nature and complexity of the research trial, risks, burdens, and potential benefits, the ethical issues at stake." 14 most physicians and surgeons meet with their patients on multiple occasions, affording these investigators time to identify, recruit, and enroll suitable research participants and obtain informed consent. however, specialties, such as anesthesiology, critical care, interventional radiology, and emergency medicine, have a varied pattern of practice and patient acquaintance that does not typically afford the luxury of time or, in many cases, delayed consent to research. 15 indeed, the initial encounter between anesthesiologists and patients undergoing elective procedures routinely occurs on the day of surgery. recognizing our specialty's unique practice patterns, the canadian anesthesiologists' society's guidelines on the ethics of clinical research state that "preoperative consent for clinical research in anesthesia may be obtained after admission to hospital, either before or on the day of the scheduled surgery." 2 yet an impasse is occurring in regional anesthesia with clinical investigators working in a time-limited perioperative system yet prohibited by rebs, both locally and otherwise, from consenting patients for clinical trials on the same day as surgery. 8, 15 the question of patient vulnerability and need for protection in practice concerns of inadequate patient comprehension, time for contemplation, and privacy, as well as undue duress, coercion, and anxiety, continue to undermine same-day consent for regional anesthesia clinical research trials. these concerns, however, have not been borne out in the literature. when consent is obtained on the same day as surgery, the vast majority of patients do understand the intent of the clinical anesthesia trials and recognize that participation is voluntary and that consent may be withdrawn at any time without consequence. 16, 17 patients are capable of digesting consent form documents and making informed decisions about research participation in thirty minutes or less. 16, 18 similarly, most patients feel that the perioperative setting offers adequate privacy for consent discussions. 16 purported coercion of patients by their clinician investigators in the immediate preoperative setting has also been refuted 16, 17 ; 1 anesthesia study found that 97% of patients rated the preoperative setting as "ideal" for obtaining informed consent to participate in clinical anesthesia trials. 16 "it is good practice where possible to seek the service user's consent to the proposed procedure well in advance, when there is time to respond to the service user's questions and provide adequate information." "where the research entails only minimal risk, it is sufficient if the research offers the prospect of benefits either to the participants directly or to the group which is the focus of the research and to which the participants belong." "asking a service user to provide consent just before the procedure is due to start, at a time when they may be feeling particularly vulnerable, or seeking consent from someone who is sedated, in pain or anxious, creates doubt as to the validity of the consent." "where the research poses more than minimal risk, it should … offer the prospect of direct benefits for the participants themselves and be commensurate with the level of foreseeable risk." new zealand auckland district health board (2018) 13 "sufficient time should be allowed for the patient to read the written information, and discuss this and any verbal information with whomever they wish." "the higher the probability of risk or the greater the magnitude of harm, the more care and detail in giving information is required." "the patient must be informed of rare risks that are more likely because of their particular circumstances, or which would have greater significance for that particular patient, for example, the consequences of arm nerve damage for a carpenter." united kingdom nhs health research authority (2019) 14 "there are no definitive guidelines or legislation regarding the appropriate amount of time (or minimum amount of time) that potential participants should be allowed to consider whether to take part in research or not. a proportionate approach (in a nonurgent scenario) means that for more complex or burdensome studies a longer time may need to be provided for potential participants to consider their decision than that provided for simpler studies involving lower risks…for research involving only minimal risks…it may be reasonable to accept a decision taken at the time of approach." "a proportionate approach to seeking consent, that is, adopting procedures commensurate with the balance of risk and benefits, should always be adopted so that potential participants are not overwhelmed by unnecessarily lengthy, complex, and inaccessible information sheets but instead are provided with succinct, relevant, truthful information in a user-friendly manner that better promotes their autonomy." "the methods and procedures used to seek informed consent and the level of information provided should be proportionate to: -nature and complexity of the research -risks, burdens, and potential benefits -ethical issues at stake" abbreviation: nhs, national health service. www.anesthesia-analgesia.org same-day consent for regional anesthesia research the latter is most likely explained by patient preference for physicians with whom they will and/or must establish a relationship; accordingly, same-day consent by the responsible physician is likely superior to that by any surrogate. 18 moreover, concerns of patient anxiety have not been realized as anesthesia researchers found no incremental increase in patient anxiety with same-day versus day-before recruitment and consent. 19 finally, increasing the quantity of time for patient contemplation as a means to increase the quality of the informed consent process for regional anesthesia research has not been substantiated. 20 moreover, nowhere in medicine is the direct relationship between vulnerability, quantity of time for patient contemplation, and quality of consent more poignantly questionable than in the intensive care unit (icu). rarely are patients (and their substitute decision-makers) more vulnerable than when a person is admitted to an icu with life-threatening illnesses. nonetheless and until proven otherwise, icu patients (or their substitutes) are deemed capable of making life-altering, and sometimes life-ending, and participation in research decisions in one or more moments of time. 21 furthermore, similar to academic regional anesthesiologists, emergency medicine and radiology clinician investigators have limited interaction with their potential study participants, often meeting on a single encounter with no opportunity to recruit and consent their patients in advance of that encounter. recognizing these limitations, rebs allow for deferred, targeted, or staged consent in order for patients to participate in emergency medicine clinical trials. 22 while such urgent or emergent adaptations to the standard informed consent process are not justified for the elective perioperative setting wherein most regional anesthesia clinical trials occur, the same is not true for the radiology research experience. indeed, low-risk radiology studies are generally approved for enrollment, recruitment, and consent on the same day as the radiological investigation or intervention. 23 the radiology ("x-ray") department may be unlike the operating room environment with respect to heightened patient anxiety; nonetheless, parallels are readily drawn between these 2 settings, including limited time and privacy, the potential for coercion, as well as the low-risk nature of many radiology and regional anesthesia clinical trials. one workaround to ensure a robust consent process and patient protection, adopted by many anesthesia research programs, including those at the university of toronto, has been the anesthesia pac. principally purposed to mitigate or optimize patient-related factors that may increase risk of perioperative complications, anesthesia pacs also function as the sole permissible venue (by our local rebs) for subject recruitment by research staff to low-risk clinical anesthesia research trials wherein subjects can provide informed consent days to weeks ahead of surgery. unfortunately, however, this long-standing workaround is fraught with challenges in appropriate recruitment of participants in that patients attending pacs are likely to be sicker and thus ineligible for study inclusion than those fitter patients who do not attend pac 15 and are more likely eligible for regional anesthesia clinical research. while the idea of coordinating with surgical colleagues to have healthy patients referred to pac for the secondary purpose of study recruitment may be convenient for investigators, when balanced against creating inconvenience and lost income for patients, the use of hospital resources, health care dollars, and pac time constraints, the idea quickly loses appeal. 16 another makeshift solution is preadmission telephone calls, which have been used to introduce research protocols and initiate the informed consent process. however, many institutions consider these calls a violation of patient privacy as research personnel callers are not yet within the patient's circle of care. 15 furthermore, scheduling of calls, anxiety provoked from unsolicited calls originating from the hospital, and constraints in time and manpower represent important ethical and logistical challenges. 18, 24 conceivably, the covid-19 pandemic may alter patient and provider views on telephone or videoconference as means to identify, recruit, enroll, and consent for research protocols. though the pandemic has already rendered telemedicine more applicable and acceptable to patients and practitioners alike, whether or not it could or should penetrate clinical research programs to a similar degree, especially with respect to preserving the sanctity of privacy within the circle of care, will require ongoing consideration. 18, 25 ongoing requirements for universal masking inside of hospitals may further complicate recruitment and consent for clinical trials as clinician investigators must first establish a trustful relationship with potential research participants. while it removes the physical face-to-face component of a patient-physician interaction, 1 potential advantage of telemedicine is that it does allow unencumbered facial recognition and mutual awareness of affect. thus, the persisting effects of telemedicine on clinical research programs beyond this pandemic are yet to be seen and require further study, including the patients' understanding and appreciation of disclosed information, perceptions of the consent process, concepts of ample time for decision-making, patient perceptions of coercion, and ability to make decisionmaking voluntarily and research recruitment rates. yet, our current understanding of patients' ability to provide same-day consent, 16, 17 the lack of evidence of perceived or actual coercion, the perceived value of the fiduciary relationship with the physician performing the procedure, [16] [17] [18] and its low-risk nature would seem to mandate a reconsideration of the absolute prohibition on obtaining same-day consent for regional anesthesia clinical research instead of seeking to create more workaround solutions which may be more disruptive to patients and generate more patient anxiety. most regional anesthesia clinical research trials primarily strive to improve and prolong pain control in the acute and subacute postoperative settings. in comparing the risk-benefit ratio for typical regional anesthesia clinical research trials versus that of other anesthesia subspecialties, it is evident that a proportionate approach to consent protocols is warranted. 14 prohibiting same-day consent practices threatens systematic exclusion of patients otherwise fit and competent who may benefit from participation in regional anesthesia clinical research trials. ostensibly, the issue of same-day consent and its implications for clinical research trials would apply to all fields of anesthesia, but this is not necessarily true. regional anesthesia is unique from other anesthesia subspecialties in its predilection for healthy and fit patients undergoing elective surgical procedures commonly in an ambulatory setting. in contrast, clinical trials in other anesthesia subspecialties (such as cardiac, thoracic, transplant, trauma, and obstetrical anesthesia) typically involve study of riskier interventions or care modifications with generally less resilient patients. we recognize that consenting practices for regional anesthesia research trials vary across north american institutions, and consent on the same day as surgery is permissible at some institutions that house leading regional anesthesia research programs. however, our governing institution-the university of torontopublishes the second most scholarly journal articles in our specialty, second only to harvard university, 26 yet the esteemed research hospitals affiliated with both the university of toronto and harvard university do not allow same-day consent for recruitment of patients to clinical anesthesia research trials. such prohibitive regulations regarding same-day consent must not be the model for other institutions striving to develop their own regional anesthesia clinical research portfolios. it behooves all regional anesthesia investigators to learn from the covid-19 pandemic and identify opportunities for growth thereafter. the covid-19 pandemic has unceremoniously exposed the arranged and strained marriage between our heretofore proliferative clinical regional anesthesia research program and our anesthesia pacs. during an unprecedented time in which clinical research and knowledge are driving day-to-day political, economic and health care decisions with monumental impacts locally, nationally, and globally, regional anesthesia research has been brought to a halt. while the issue of consent is not one to be taken lightly, the validity of same-day consent for low-risk anesthesia research trials has been widely supported. 8, [15] [16] [17] [18] [19] indeed, the nhs has responsibly acknowledged that the timing of consent can vary depending on the risk of study participation and that a universal "one-size-fits-all" approach to the timing of consent is not reasonable. 27 it is the process, rather than the time, that is the central to the validity of informed consent and safeguarding subject autonomy. 8 prohibiting same-day consent for low-risk regional anesthesia clinical trials is an overly burdensome exercise for both clinical investigators and research staff. and so, while we continue to practice physical distancing, it is, in our opinion, high time to distance ourselves from such a prohibitive practice. world medical association declaration of helsinki: ethical principles for medical research involving human subjects guidelines on the ethics of clinical research in anesthesia guidelines for the ethical practice of anesthesiology who guidelines for good clinical practice (gcp) for trials on pharmaceutical products: responsibilities of the investigator tri-council policy statement: ethical conduct for research involving humans www.anesthesia-analgesia.org anesthesia & analgesia same-day consent for regional anesthesia research 7. toronto academic health sciences network (tahsn). guidelines for research ethics review involving human subjects same day consent for anaesthesia research the national health and medical research council, the australian research council and universities australia clinical trials regulation: informed consent and information to patients. european patients forum guidelines about notification etc auckland district health board applying a proportionate approach to the process of seeking consent. nhs health research authority informed consent for clinical anaesthesia research consent for anesthesia clinical trials on the day of surgery: patient attitudes and perceptions are patients comfortable consenting to clinical anesthesia research trials on the day of surgery? surgical patients' attitudes regarding participation in clinical anesthesia research protocol understanding and anxiety in perioperative clinical trial patients approached for consent on the day of surgery say what? patients have poor immediate memory of major risks of interscalene block disclosed during the informed consent discussion issues of vulnerability and equality: the emerging need for court evaluations of physicians' fiduciary duties in high stakes end-of-life decisions targeted consent for research on standard of care interventions in the emergency setting an overview of informed consent for radiologists a preadmission telephone call to initiate the consent process for clinical anesthesia research perspective on covid-19: finally, telemedicine at center stage trend of academic publication activity in anesthesiology: a 2-decade bibliographic perspective balancing the quality of consent key: cord-340656-ltd6ueoi authors: grant, michael c.; geoghegan, luke; arbyn, marc; mohammed, zakaria; mcguinness, luke; clarke, emily l.; wade, ryckie g. title: the prevalence of symptoms in 24,410 adults infected by the novel coronavirus (sars-cov-2; covid-19): a systematic review and meta-analysis of 148 studies from 9 countries date: 2020-06-23 journal: plos one doi: 10.1371/journal.pone.0234765 sha: doc_id: 340656 cord_uid: ltd6ueoi background: to limit the spread of sars-cov-2, an evidence-based understanding of the symptoms is critical to inform guidelines for quarantining and testing. the most common features are purported to be fever and a new persistent cough, although the global prevalence of these symptoms remains unclear. the aim of this systematic review is to determine the prevalence of symptoms associated with covid-19 worldwide. methods: we searched pubmed, embase, cinahl, amed, medrxiv and biorxiv on 5(th) april 2020 for studies of adults (>16 years) with laboratory test confirmed covid-19. no language or publication status restrictions were applied. data were independently extracted by two review authors into standardised forms. all datapoints were independently checked by three other review authors. a random-effects model for pooling of binomial data was applied to estimate the prevalence of symptoms, subgrouping estimates by country. i(2) was used to assess inter-study heterogeneity. results: of 851 unique citations, 148 articles were included which comprised 24,410 adults with confirmed covid-19 from 9 countries. the most prevalent symptoms were fever (78% [95% ci 75%-81%]; 138 studies, 21,701 patients; i(2) 94%), a cough (57% [95% ci 54%-60%]; 138 studies, 21,682 patients; i(2) 94%) and fatigue (31% [95% ci 27%-35%]; 78 studies, 13,385 patients; i(2) 95%). overall, 19% of hospitalised patients required non-invasive ventilation (44 studies, 6,513 patients), 17% required intensive care (33 studies, 7504 patients), 9% required invasive ventilation (45 studies, 6933 patients) and 2% required extra-corporeal membrane oxygenation (12 studies, 1,486 patients). the mortality rate was 7% (73 studies, 10,402 patients). conclusions: we confirm that fever and cough are the most prevalent symptoms of adults infected by sars-cov-2. however, there is a large proportion of infected adults which symptoms-alone do not identify. a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 the novel coronavirus (sars-cov-2; 2019-ncov; covid-19) pandemic is a global crisis. as of april 10 th 2020, there were over 1.5 million confirmed cases of whom over 92,000 have died [1] . in the absence of a vaccine or treatment with proven efficacy, limiting human-to-human transmission is critical [2-4]. self-isolation (or self-quarantine) is an effective global strategy for limiting transmission following the emergence of symptoms [5] and equally, the manifestation of symptoms is used to guide testing. coronavirus is most infectious in the early phase of the illness [6, 7] [8], so screening people with compatible symptoms [9] is fundamental to determining who should be quarantined and be tested [9] . several systematic reviews have considered the symptoms of covid-19 (amongst other parameters) [8,10-14] although all of them have major limitations. none systemically searched the grey literature (e.g. preprint archives such as medrxiv and biorxiv) and in the context of a pandemic, the quality and quantity of the literature is evolving at speed [15] . without incorporating all relevant preprints the findings of any systemic review will be weeksmonths out-of-date at the time of publication [16] . furthermore, with few included studies (30 in the largest and most recent [12] ), the range of symptoms were limited and the estimates of prevalence are likely to be upwardly biased because only unwell patients (largely those admitted to hospital) were tested in the early phase of the outbreak. to facilitate the rapid dissemination of high-quality open-science, there has been a surge of preprints related to covid-19 manuscripts uploaded to the online archives medrxiv and biorxiv [15] . the necessity to address deficiencies in current literature and potential to substantially improve the precision of estimates of symptom prevalence using both indexed and (the more voluminous and up-to-date) preprint literature from multiple geographical regions, represents the rational for this review. the aim of this systematic review is to determine the prevalence of symptoms associated with covid-19 worldwide. derived from oro-or naso-pharyngeal swabs. we excluded case reports, articles which failed to disaggregate symptoms in adult and paediatric cohorts, studies of patients with prior respiratory infections (e.g. tuberculosis) or co-infections with other viruses (e.g. similar viruses sars-cov-1 or hcov-emc/2012, etc) and articles which we are unable to translate to english in a timely fashion. the incubation period of covid-19 is typically 5 days, but reported to last a maximum of 7 days [20] [21] [22] [23] [24] . the illness typically lasts 8 days [21] . therefore, we will include any symptom(s) described up to 15 days before laboratory confirmed infection and during the illness. pubmed, embase, amed and cinahl, medrxiv [25] and biorxiv were interrogated according to our search strategy (s1 appendix). searches were limited to 1 st january onwards. no language restrictions were applied. after de-duplication, all unique citations were independently screened by three review authors (mg, lg and rgw). the full texts of all potentially relevant articles were obtained. the reference lists for included articles and other systematic reviews were also scrutinised. final lists of included articles were compared and disagreements resolved by consensus discussion between five authors (mg, lg, zk, elc and rgw). two authors (mg and lg) independently extracted data and three authors (zm, elc and rgw) checked the accuracy of the extracted data using a standardised spreadsheet. disagreements were resolved by discussion. we combined the following symptoms: "chest tightness" into the more prevalent symptom of wheeze; "shivers" and "chills" into rigors; malaise and "generalised weakness" (in the absence of any objective neurological deficit) into the more widely reported symptom of fatigue; conjunctivitis, conjunctival congestion and conjunctivital secretions into conjunctivitis. where studies reported one symptom "or" another (e.g. nausea or vomiting) we did not extract this information as it was impossible to disaggregate. where studies reported one symptom "and" another (e.g. nausea and vomiting) we extracted the prevalence of both. when studies grouped symptoms together (e.g. "respiratory symptoms") without further description or definition we were not able to extract this information. the risk of bias for included studies was not assessed for two main reasons: firstly, there is no consensus on ideal tool, nor one designed specifically for studies of prevelance [26] and secondly, such assessments would not change the approach to the modelling or presentation of the data, as per our protocol. given such assessments are also time-intensive, we have taken the pragmatic decision to not perform risk of bias assessments. of the prevalence was used to normalise variance. 95% confidence intervals (cis) were computed around the study-specific and pooled prevalence based on the score-test statistic. [28] . the variation in prevalence by country was assessed by subgroup meta-analyses and metaregression. statistical heterogeneity is assessed by i 2 which corresponds with the proportion of total variation due to inter-study heterogeneity and by p-values for inter-study heterogeneity within countries, between countries and overall [29] . given the use of a random-effects model, inter-study heterogeneity within countries was only assessable when at least three studies were available. a z-test (and the corresponding p-values) assessed whether the observed prevalence was different from zero percent. publication bias was not assessed. our search returned 2403 hits in pubmed, 2234 in embase, 310 in cinahl, 1 in amed, and 434 preprints in medrxiv and biorxiv on 5 th april 2020. following deduplication, the titles and abstracts of 851 unique records were assessed against the inclusion criteria. 743 of these were deemed to be potentially eligble. full text screening then resulted in 148 included articles (fig 1) . [166, 167] , the usa [168, 169] , singapore [170, 171] , italy [172, 173] , australia [174] , japan [175] , korea [176] and the netherlands [177] . the mean age of patients was 49 years (sd 11) and where sex data were available, the ratio of males:females was 1.2:1 (10,306:8593). the characteristics of the included studies are shown in s1 table. thirty-four studies reported that 845 of 7519 patients required non-invasive ventilation (pooled prevalence 17% [95% ci 11%-24%]; i 2 98%). forty-four studies (6513 patients) reported that 970 patients were admitted to an intensive care unit (pooled prevalence 19% [95% ci 13%-26%]; i 2 97%). forty-five studies (6933 patients) reported that 495 required invasive mechanical ventilation (pooled prevalence 9% [95% ci 6%-13%]; i 2 95%). twelve studies (1486 patients) reported that 2% of patients (36) required extra-corporeal membrane oxygenation (95% ci 0%-5%; i 2 95%). of the 73 studies that reported survival in 10,402 patients, there were 938 deaths (pooled prevalence 7% [95% ci 4%-11%]; i 2 98%) which were attributable to covid-19. table 1 shows the meta-analysed prevalence of symptoms, group by bodily system, and s2 table shows the meta-analytical prevalence estimates from studies grouped by geographical region. the most prevalent symptom in patients with laboratory confirmed covid-19 was a fever, experienced by 78% of patients (99% ci 75%-81%; fig 2 and s2-s5 figs) . whilst, there was substantial heterogeneity between countries (i 2 94%) with estimates ranging from 83% in singapore (99% ci 61%-98%) to 32% in korea (99% ci 15%-51%), there was no evidence of a statistically significant difference between countries (s2 table) . a cough was the second most prevalent symptom, reported by 57% of test-positive patients (95% ci 54%-60%; fig 3 and s6 -s10 figs). whilst there was substantial heterogeneity between countries (i 2 94%) with estimates ranging from 18% in korea (99% ci 8%-36%) to 76% in the netherlands (95% ci 66%-83%), there was no evidence of a statistically significant difference. this review describes 24,410 adults with laboratory test confirmed covid-19 from 9 countries. we confirm that the purported cardinal symptoms of fever and a new persistent cough are indeed the most prevalent symptoms of covid-19 worldwide. however, we also show that at approximately 1 in 5 test-positive adults were never febrile and fewer than 3 in 5 developed a cough. since the patients in the included studies are likely to have moderate-severe disease warranting hospitalisation and thus testing, it is likely that we over-estimate the true prevalence of symptoms in the population. consequently, the use of symptoms alone to screening adults for sars-cov-2 infection is likely to miss a substantial number of infected individuals. our point estimates of the prevalence of fever (78%) and cough (57%) are approximately 10% lower than the estimates from prior reviews [8,10-13] which we feel might explained by two specific factors. firstly, prior reviews [8,10-13] did not systematically search (or search at all [8,10,11,13]) for preprints uploaded to online repositories such as medrxiv or biorxiv [15], both of which have seen a surge in uploads related to the covid-19 pandemic [15] . this . therefore, it is likely that the prior reviews [8,10-13] had a higher proportion of adults with more severe disease (given that testing was limited to those admitted to hospital in the early phase of the outbreak) whereas more recent studies are likely to include adults with mild symptoms due to the wider availability of testing alongside natural progression of the disease. conversely, more-recent studies of realtime population-wide tracking of self-reported symptoms in subsequently test-positive patients are essentially identical to our point estimates for cough [179] ; however, data concerning fever [180] are less concordant but given the variability of core body temperature, methods of measurement and the definition of this symptom, variability is expected. we acknowledge that there is both within-country and between-country differences in the estimated prevalence of different symptoms, which presents issues with regards to generalising the findings. however, the unique strength of a meta-analysis is the ability to compare datasets from difference sources, identify patterns and discrepancies [181] , and no statistical technique is able to correct for weaknesses or idiosyncrasies of the original data. differences in the study designs, settings and what types of patients (mild, moderate or critically unwell) were sampled are all likely to be responsible for the observed heterogeneity. the sampling strategy is known to bias the prevalence of conditions and ideally, prevalence studies recruit a (non-probabilistic) consecutive sample because they are more likely to represent the target population. in comparison, convenience sampling (i.e. those with available data) and purposive sampling (e.g. reports of individuals with specific clinical features) which are common in the included studies, introduce selection bias and tend to upwardly bias estimates of symptom prevalence. equally, enrolling patients from hospital settings rather than the community is more likely to upwardly bias the estimates of prevalence. overall, we suspect that our results over-estimate the true prevalence of symptoms amongst test-positive adults. in some instances, it was impossible to ascertain whether different publications which originated from the same hospital or region included (some of) the same subjects because the recruitment timeframes and sampling strategies were not sufficiently described in the study methods. we recommend that future publications detail (where possible) if their sample is also represented in other works and describe their methods in accordance with relevant reporting guidelines. the way in which we extracted some of the data might bias the findings. we dichotomised fever (based on the definition in the parent study) and thresholds differed study-to-study (between 37˚c and 38˚c, s2 table) which limits the transferability of the findings to clinical practice. we also did not extract data on combinations of symptoms (such as fever and cough together, or diarrhoea and vomiting for example) which was on oversight in the protocol development phase though equally, this was poorly reported in the literature. future researchers who wish to build upon this dataset might consider extracting combinations of symptoms alongside isolated symptoms from the few studies were this is reported [174] . we confirm that fever and cough remain the most prevalent symptoms of adults infected by sars-cov-2. however, there is a large proportion of infected adults which symptoms-alone do not identify. to expedite future iterations of this work, our data is freely available in the open science framework repository. covid-19) situation report-81. world heal clinical 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washington state epidemiological and clinical predictors of covid-19 epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore sudden hyposmia as a prevalent symptom of covid-19 infection use of siltuximab in patients with covid-19 pneumonia requiring ventilatory support non-severe vs severe symptomatic covid-19: 104 cases from the outbreak on the cruise ship "diamond princess early epidemiological and clinical characteristics of 28 cases of coronavirus disease in south korea sars-cov-2 infection in 86 healthcare workers in two dutch clinical characteristics of 50404 patients with 2019-ncov infection real-time tracking of self-reported symptoms to predict potential covid-19 a framework for identifying regional outbreak and spread of covid-19 from one-minute population-wide surveys can meta-analysis be salvaged? key: cord-312677-rwznqiib authors: razmi, mahdieh; hashemi, farideh; gheytanchi, elmira; dehghan, masoumeh; ghods, roya; madjd, zahra title: immunomodulatory-based therapy as a potential promising treatment strategy against severe covid-19 patients: a systematic review date: 2020-08-29 journal: int immunopharmacol doi: 10.1016/j.intimp.2020.106942 sha: doc_id: 312677 cord_uid: rwznqiib the global panic of the novel coronavirus disease 2019 (covid-19) triggered by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) has led to an urgent requirement for effective therapy. covid-19 infection, especially in severely ill patients, is likely to be associated with immune dysregulation, prompting the development of novel treatment approaches. therefore, this systematic review was designed to assess the available data regarding the efficacy of the immunomodulatory drugs used to manage covid-19. a systematic literature search was carried out up to may 27, 2020, in four databases (pubmed, scopus, web of science, and embase) and also clinicaltrials.gov. sixty-six publications and 111 clinical trials were recognized as eligible, reporting the efficacy of the immunomodulatory agents, including corticosteroids, hydroxychloroquine, passive and cytokine-targeted therapies, mesenchymal stem cells, and blood-purification therapy, in covid-19 patients. the data were found to be heterogeneous, and the clinical trials were yet to post any findings. medicines were found to regulate the immune system by boosting the innate responses or suppressing the inflammatory reactions. passive and cytokine-targeted therapies and mesenchymal stem cells were mostly safe and could regulate the disease much better. these studies underscored the significance of severity profiling in covid-19 patients, along with appropriate timing, duration, and dosage of the therapies. therefore, this review indicates that immunomodulatory therapies are potentially effective for covid-19 and provides comprehensive information for clinicians to fight this outbreak. however, there is no consensus on the optimal therapy for covid-19, reflecting that the immunomodulatory therapies still warrant further investigations. the panic of novel coronavirus disease 2019 (covid-19) triggered by sars-cov-2 has influenced people all over the world, which has been warned as a global health emergency [1] . sars-cov-2 belongs to the single-stranded positive-sense rna β-coronavirus family, entering the cells through applying the angiotensin-converting enzyme 2 (ace2) receptor distributed on the surface of the heart, kidney, and intestine and particularly, lungs҆ alveolar type ii (at2) epithelial cells [2] . covid-19 infection seems to be associated with more person-to-person transmissibility and less lethality than either severe acute respiratory syndrome (sars) and the middle east respiratory syndrome (mers), as the majority of the patients have experienced mild symptoms and good prognosis so far. however, it has been reported that approximately 14% of the patients with novel coronavirus pneumonia (ncp) have progressed severe or fatal conditions, along with a rising transition of the patients from the mild condition into severe pneumonia accompanied by a wide range of complications including the acute respiratory distress syndrome (ards), septic shock, and multiple organ failure, consequently leading to the death. currently, management of these critically ill patients has turned into one of the principal challenges [3] [4] [5] [6] [7] . clinically, the covid-19 infection is likely to provoke the immune responses in two phases, and therefore, each phase requires tailored treatment approaches. so that, at the earlier stages, the virus replicates and activates both innate and adaptive immune responses during the non-severe disease period, in which boosting the immune system may be a suitable strategy for eliminating the virus. at the later stages associated with the expansion of severe conditions, covid-19 is accompanied by the excessive inflammatory and dysregulated immune responses, leading to some lifethreatening obstacles [8] [9] [10] [11] . lymphopenia and higher levels of inflammatory indicators, e.g., ddimer and c-reactive protein (crp), are the main characteristics of the severe covid-19 patients, with drastically reduced numbers of the helper t cells, cytotoxic suppressor t cells, regulatory t cells, and natural killer (nk) and b cells [5, [12] [13] [14] . additionally, a large number of the leukocytes and circulating monocytes are irregularly activated, associated with the abnormal levels of cytokines/chemokines, especially, e.g., interleukin 6 (il-6), il-2, il-7, il-10, granulocyte-colony stimulating factor (gcsf), ifn-gamma-inducible protein 10 (ip-10), and tumor necrosis factorα (tnf-a) [15] [16] [17] [18] , eventually leading to the macrophage activation syndrome (mas) in some patients with severe respiratory failure (srf) [15] [16] [17] [18] [19] . all these highlight that sars-cov-2 might mainly induce the cytokine release syndrome (crs), in which the magnitude of the cytokine storm is correlated with the disease severity and fatal consequences. therefore, we need to pay close attention to the immunological status of the patients and restrain the overt inflammatory responses timely through the immunomodulators and cytokine-storm-targeted therapies to control the progression of the disease cascade and decrease the mortality among the severe covid-19 patients [18, [20] [21] [22] [23] [24] [25] . seemingly, the medicines targeting the coronavirus alone might not be appropriately effective in controlling the extremely pathogenic infections and should probably be applied along with the immunomodulatory-based therapies [26, 27] . various studies have focused on the efficacy of the immunomodulatory agents including corticosteroids, hydroxychloroquine or chloroquine, cytokine-targeted therapies (e.g., anakinra, siltuximab, or tocilizumab), passive immunotherapy (convalescent plasma and intravenous immunoglobulin), mesenchymal stem cells, and bloodpurification therapy, mostly as adjuvant therapy for treatment of the patients with severe covid-19 and partly have reported promising outcomes. to date, numerous immunomodulators have been investigated; however, data of the available literature do not provide a complete overview. therefore, the present systematic review was conducted to review the available evidence on the therapeutic value of the immunomodulatory agents for the management of the covid-19 patients. this systematic review has been registered on the international prospective register of systematic (http://www.crd.york.ac.uk/prospero), with the registration number crd42020179200. the protocol for this systematic review was conducted according to the preferred reporting item for systematic review and meta-analysis (prisma) guideline [28] . a comprehensive search was carried out on april 21, 2020, updated on may 27, 2020, from the following main electronic databases: pubmed, scopus, web of science, and embase, for studies that focused on the efficacy of immunomodulatory medicines without any language restriction. we also checked the reference lists of all principal publications for further eligible publications. we then systematically searched for the published articles in google, and for ongoing trials in clinical trial registries (clinicaltrials.gov). the following search strategy has been used regarding specific search tips of each database: "covid-19" and "immunomodulation", "anti inflammatory", "mesenchymal stem cell", "anti-interleukin-6", "tocilizumab", "siltuximab", "janus kinase inhibitor", "anakinra", "glucocorticoids", "convalescent plasma", "intravenous immunoglobulin", "hydroxychloroquine or chloroquine" or "blood purification therapy". the details of the search strategy have been provided in supporting information 1. publications eligible for inclusion were case reports, case series, case-control and cohort studies characterizing the efficacy of immunomodulatory therapies in patients with covid-19. the following exclusion criteria were considered: 1) reviews, meta-analysis, and abstracts; 2) nonhuman studies; 3) the topics were not related to the review question (e.g., when the articles addressed other virus-related diseases); 4) studies that patients received any type of anti-virals not related to immunomodulatory property; 5) studies with incomplete, non-detailed or non-useful data; 6) studies with patients coinfected with influenza virus and sars-cov-2; 7) covid-19 disease in transplant recipients with long-term immunosuppression. the selection of studies was conducted in two steps. step 1: two reviewers (mr and fh), independently, screened titles and abstracts of publications retrieved through the search strategies based on the inclusion criteria. any publications that did not fulfill the eligibility criteria were excluded. step 2: where a publication was potentially eligible, the full text was reviewed by the same reviewers. any disagreements were resolved by a third author. for each eligible publication, the following descriptive information was extracted: study characteristics (first author and study country), clinical characteristics (age, sex, population), characteristics of intervention (types, dosage, frequency, etc.), and main findings (all outcomes, mortality). the primary outcome was mortality risk. other outcomes of interest were adverse reactions, clinical laboratory benefits, and computed tomographic (ct) findings. all the retrieved information was cross-checked by mr, fh, eg, and md. it was not feasible to perform a meta-analysis because there were not adequate, appropriate research studies on this issue. in the first step, a total of 1370 publications were identified from the pubmed (718) review. fig. 1 shows a flowchart of the search and selection procedure of the studies. herein, the details of the ongoing clinical trials registered at the clinicaltrials.gov by april 21, 2020, updated on may, 27 were also provided. the resulting trials were collected, were evaluated for eligibility, and were checked to remove any duplicates. after the screening procedure, 111 ongoing clinical trials were included related to the topic of the present review ( fig. 1.) . the main objective of these included publications and clinical trials was determining the safety and efficacy of the various immunomodulatory medicines in patients with mild/moderate-tosevere covid-19. tables 1, 2, and 3 present the characteristics of the publications, patients҆ demographics, therapeutic interventions, and their main findings. the enrolled trials consisted of the registry number of trials, study design, patient population, intervention, and outcomes (supporting information 2). as described in tables 1, 2, patients with systematic corticosteroid is <1-2 mg/kg/d for 3-5 days [29] . in a retrospective study, a risk-based therapeutic strategy was developed according to the disease severity in the ncp patients, in which severely ill patients received corticosteroid immediately within the first 3 days of hospitalization in addition to the standard treatment. this treatment approach provided considerable mitigation in the clinical manifestations and imaging recovery with the mortality rate of 0% [29] , and the reduced mortality rate was also reported in the study by wu et al. [30] . another study reported that the early use of corticosteroid in the first 3−5 days of intensive care unit (icu) admission could appropriately hinder the intense inflammatory storm and improve the oxygen saturation (p=0.012) [31] . nevertheless, corticosteroids did not provide survival profit [31, 32] . even in a case-control analysis, where the cases received the adjuvant corticosteroid (100-800mg/d) in addition to the standard treatment, elevated corticosteroid dosage led to a considerable increase in the mortality rate (p=0.003) in the matched cases [33] . prolonged viral shedding has been reported as one of the main restrictions of corticosteroid therapy. a retrospective cohort study introduced corticosteroid as one of the influential factors for persistent sars-cov-2 rna shedding (p=0.025) [34] . in contrast, other retrospective studies have shown that early and short-term administration of the low-dose corticosteroid did not prolong the viral clearance in the covid-19 patients [29, 35] . other publications also demonstrated that corticosteroid-containing therapy is accompanied by either hopeful or disappointing results (table 1 ) [9, 20, [36] [37] [38] [39] [40] [41] [42] [43] . cq and its derivative hcq, the food and drug administration (fda)-approved antimalarial and autoimmune disease drugs, have been introduced as the potential broad-spectrum anti-viral chemicals. both drugs function via modifying the endosomal ph and ace2 glycosylation. additionally, these drugs possess an immune-modulatory capacity, which may synergistically reinforce their anti-viral activity in vivo. the safety profile of hcq has made it a preferred drug for therapy in the clinics [44] [45] [46] . a single-arm non-randomized clinical trial, aimed at evaluating the efficiency of hcq (200 mg, 3 times daily for 10 days) on 20 sars-cov-2-infected patients in comparison with 16 infected control patients, showed that the hcq administration leads to a considerable decrease in the viral load in the ncp patients within only 3-6 days compared to the controls (p= 0.001) [44] , and its effect was augmented by adding azithromycin (az) [44] [45] [46] . other studies have also demonstrated the immediate recovery of the patients through the use of hcq [47] and cq [48, 49] . in contrast, some studies have not supported the administration of hcq for prevention of icu admission and/or death when used alone [50, 51] or combined with az [52] , or due to the life-threatening adverse reactions [53, 54] . even a recent retrospective cohort study found the elevated overall mortality after administration of hcq alone without az [55] , as observed in a randomized, phase iib clinical trial with a higher dosage of cq (600 mg cq twice per day during 10 days) [56] . currently, there are no guidelines for the administration of hcq. most studies have applied various doses of hcq, without an optimized hcq dosing regimen required for effective treatment and reduction of the side effects. in a study, the pharmacokinetic (pk) characteristics of hcq at the dose of 600 mg orally were evaluated in the icu-hospitalized covid-19 cases and the results showed that this dosing schedule was inadequate to achieve an assumed target blood amount of 1-2 mg/l considered to be therapeutic (table 1 ) [57] . [17] . positive findings have also been reported by other recent studies conducted in italy, france, and qatar (table 2 ) [60] [61] [62] [63] [64] [65] . however, a recent case report study announced the weak outcomes of two cases with covid-19 after they were given one or two infusions of tcz [66] . two other studies indicated an elevation in the adverse effects, including the acute hypertriglyceridemia [67] and candidaemia [68] . the second il-6 antagonist, namely siltuximab, approved for treatment of the castleman's disease is a chimeric monoclonal antibody (mab) directly binding to the il-6 and blocks the il-6 pathway. in a recent study on 21 covid-19 patients developed the ards, siltuximab (at the mean dose of 900 mg) administration led to the improved clinical conditions in 7 cases and stabilized state in 9 patients; however, 24% (5/21) of them suffered a deteriorating status [69] . anakinra, as a recombinant il-1 receptor (il-1r) blocker and fda-approved rheumatoid arthritis drug, is another proposed antagonist for management of the patients with covid-19 (table 2) [ 70, 71] . a recent cohort study illustrated that the use of high-dose anakinra (5 mg/kg twice per day, with a mean duration of 9 days), in 29 ncp patients who had developed the ards, provided the survival benefit (90%) compared to the historic-control group (56%) (p=0·009), 21 days after receiving anakinra [72] . mscs, as the powerful immunomodulatory modalities, have been broadly applied to manage the autoimmune diseases, type 2 diabetes, and, more recently, infectious diseases. mscs act in two ways principally, immunomodulatory functions and tissue repair abilities, making them ideal candidates to treat the diseases related to lung injury [21, 73] . in a case report on a critical ncp case who had advanced liver injury despite receiving the intensive care treatment, the patient received three intravenous infusions of 5 × 10 7 human umbilical cord msc (hucmsc). during 4 days of the second msc infusion, the case was weaned from the ventilation. all the assessed markers, including crp, alanine aminotransferase (alt)/ aspartate aminotransferase (ast), and circulating t cell counts, returned back to the baseline ranges. no distinct adverse effects were monitored [73] . results of a placebo-controlled trial showed that transplantation of mscs led to the improvement of lung function and inflammatory indications, reduction of the proinflammatory cytokine tnf-α (p<0.05), and augmentation of anti-inflammatory factor il-10 (p<0.05) within a few days compared to the standard of care (soc)-treated group [21] . in a controlled cohort study, 41 severe ncp patients were randomly divided into 2 groups, soc-treated group (n=29) and soc-hucmscs-treated group (n=12). within the 3rd to 7th day of therapy, the infusion of hucmscs noticeably accelerated the improvement of the clinical symptoms, oxygenation, and lung inflammation absorption, along with a significant reduction in the level of crp and il-6. the 28-day mortality was equal to 0% in the soc-hucmscs-treated group, while it was equal to 10.34% for the soc-treated group [74] . a case report study also described the therapeutic efficacy of the human umbilical cord wharton's jelly-derived mscs (hwjcs) on an ncp patient ( -benefits: 1-by the third day, fever stopped in the remaining eight cases. 2-desirable outcomes including oxygen flow and blood inflammatory biomarkers were recovered. crp reduced slightly at d6 in all, and normalized in 5/8 patients at d11. 3-in all cases, an early chest ct scan controlled between d5 and d8. -adverse events: 1-among the nine cases, a patient revealed an acute respiratory failure 6 h after the first dose of anakinra, leading to withdraw. 2-anakinra was safe. however, mild elevation of transaminase and triglyceride was seen. liang china [73] the clinical outcome of hucmscs therapy in a critical ncp patient ivig, as another passive immunomodulatory therapy, is a highly purified product comprising the polyclonal igg obtained from the blood of healthy individuals. it binds to and neutralizes the components of the immune response and is clinically used for treatment of the autoimmune diseases. the recommended dosage of ivig is 0.5 g/kg daily for 5 days [82, 83] [84] . a recent multicenter cohort study showed that early administration (admission ≤ 7 days) of high-dose ivig (> 15 g/d) improved the outcomes of only critical cases with covid-19 but not severe ones [85] . in several other studies on the severely or critically ill covid-19 patients, although ivig was used, it was impossible to determine the efficacy of ivig administration on the recovery from covid-19 (tables 1 and 3 ) [40, 41, 86] . blood-purification treatments can remove the inflammatory factors and clear the pathogenic cytokines achieved using the modalities, including plasma exchange (pe), adsorption, perfusion, blood/plasma filtration, etc. a case series study reported the effectiveness of the blood purification therapy in 3 critically covid-19 patients transferred to the icu, who had deteriorated states despite receiving different kinds of treatments. blood-purification therapy led to the normalization of the inflammatory markers. eventually, 2 patients were successfully come off the ventilator and reached a stable clinical status [23] . another case report study described that a critically covid-19 case, who had failed to respond to the conventional interventions, was recovered promptly after treatment using the intensive pe followed by intravenous ivig [86] . a retrospective cohort study, in which 22 patients received the continuous renal replacement therapy (crrt) and 14 cases were given the conventional therapy (non-crrt group), indicated that the crrt independently led to a lower rate of mortality in the ncp cases requiring invasive mechanical ventilation [87] , unlike the results reported by yang et al., (table 3 ) [88] . evaluate the possibility of cp therapy in severe ncp cases -benefits: 1-leukocytosis, lymphopenia and the patient's status were immediately recovered with reduction of il-6 and crp to baseline range since day 1 after transfusion 2-improving of both lung abnormalities during 4 days. 3-there were no adverse effects during and following the therapy. 4-viremia began to reduce right following the infusion of cp in this systematic review, an overview was presented regarding the medicines having an already known or putative role in the modulation of immunity applied for management of the patients infected with sars-cov-2. since the outbreak of covid-19, there has been a comprehensive attempt to identify an effective clinical treatment scheme for control of this disease. currently, there is no fda-approved therapy for this pneumonia. it seems that drug repurposing demonstrated as a suitable drug discovery approach from available drugs, could partly control the disease until an effective vaccine is identified [89] . the studies met the inclusion criteria for entering this systematic review had identified several medicines linked to the immunomodulation, i.e., corticosteroid, hcq or cq, anti-cytokine therapies, cp, ivig, msc, and blood purification therapy. among these, cytokine antagonists, cp, and mscs were the immunomodulators that showed more hopeful results. available clinical experience regarding the immunomodulators for covid-19 relies on the case reports, case series, cohorts, and case-control studies. these studies are highly heterogeneous in nature; thus, a common conclusion could not be acquired to make strong recommendations regarding application of these medicines in the routine clinical practice. it is essential to underline that although adverse events are mostly regarded as tolerable, long-term follow up remains a serious concern making it challenging to interpret the safety profiles of the drugs. the results indicated the considerable importance of the timing, duration, and dosage of the medicines for effective therapy. fig. 2 shows a summary of the immunomodulatory therapies discussed in this review. amidst cytokine storm mediators, il-6 was the cytokine highly associated with the progression of ards and death in the ncp patients. recently, it has been reported that the il-6 over-production by the circulating monocytes leads to the low human leukocyte antigen d related (hla-dr) expression on the cd14 monocytes in the covid-19 patients with srf [19] . the use of a particular suppressor of the il-6 cascade seems to be significantly functional in the treatment of ncp patients. tcz binds to the il-6r with high affinity [63] , while siltuximab has specificity for il-6, and blocks the signal transductions [69] . included clinical studies with 1-63 participants have shown that both antagonists, specially tcz, are effective in reducing the mortality rate specially in the severely ill patients, improving the symptoms including fever resolution, oxygenation and resolved ct scans, reducing the inflammation markers (ferritin, crp, and d-dimer), weaning from the icu hospitalization and ventilation, and dampening the risk of disease progression to ards by mitigating the cytokine storm in the ncp patients [60, 62] , as applied for crs controlling in the car-t therapy [90] . the recommended dose in most studies was 4-8 mg/kg for tcz like rheumatoid arthritis, and a dosage of 11 mg/kg/day was reported for siltuximab with the infusion time of more than 1 h [58, 69] . as an il-1r blocker, anakinra was another proposed antagonist. high dosing of 5 mg/kg twice daily (intravenous) was applied for treatment of the ncp patients resulting in the survival benefit, amelioration of respiratory function, and decreased inflammatory markers, as applied off-label for management of the hyperinflammatory disorders [70, 72] . however, an enhanced risk of opportunistic infections, acute hypertriglyceridemia, and anemia induced by the il antagonists have been demonstrated among the patients with covid-19 [68] . therefore, these antagonists must be prescribed for covid-19 patients in severe phase, with precise monitoring [12] . the short half-life of anakinra (3 h) provides an immediate withdrawal and clearance from the circulation compared to tcz with a long half-life (2-3 weeks) [72] . although these immunological therapies appear to be beneficial to cure ncp cases, safety hazards and substantial costs can limit the wide use of these cytokine antagonists [12] . improved inflammation situation following receiving the msc-based therapy was also reported in some limited studies involving 1-41 patients with mild-to-severe covid-19, providing lower mortality and significant recovery of the pulmonary signs. the factors considered to be vital for effective treatment include the route, timing, dose, volume, source, and duration of the msc administration [91] . the treatment protocol used in the included publications was transplantation of hucmscs, intravenously, with the total number of approximately 1-2 × 10 6 cells/kg of weight, and the infusions lasted about 40 min to 1 h [21, [73] [74] [75] . mscs are likely to enter the human body; some of them accumulate in the lungs, leading to improvement in the lung microenvironment and prevention of the pulmonary fibrosis, besides reducing the serum amounts of pro-inflammatory cytokines [73] . similarly, a study described the improved mortality rate in the cases infected with influenza a who had developed the ards using the menstrual blood-derived mscs therapy without adverse effects in 5 patients followed-up for 5 years [92] . however, application of mscs is associated with some limitations, including the diversity in the quality of the mscs from various donors, transplantation of mscs into unfavorable environments, or even undergoing the malignant transformation [91, 92] . for overcoming these barriers, an accurate assessment of the safety is needed along with a complete consideration regarding the immunosuppression of mscs. strategies to boost the immune responses including cp therapy and ivig are other emergent treatments for serious covid-19 cases and have been successfully applied for treatment of mers, sars, and 2009 h1n1 pandemic with desirable efficacy and safety [81, 93, 94] . both products, specially cp, can quickly enhance the neutralizing antibodies (nabs), igm and igg levels in the serum, probably neutralizing the sars-cov-2 and limiting the viral entry and amplification. these interventions also regulate the overactive immune system likely via fabmediated and fc-mediated cascades [85, 95, 96] . while high-dose ivig (0.3-0.5 g/kg.d), purified from the healthy donors, has been proposed as an adjuvant therapy for severe ncp patients, it is not the particular antibody to any pathogen [95] . there are limited clinical data for its efficacy, and investigators have reported conflicting opinions on ivig usage [85] . in contrast, recently, the fda has approved the administration of plasma from the recovered donors to cure seriously ill ncp patients [97] . the key factors associated with the cp therapy are the amounts of neutralizing antibody titer, timely infusion, and suitable plasma volume. in the majority of the included studies, a dosage of 200-ml intravenous cp for each cycle (200-2400 ml depending on the severity of disease) with a high level of neutralizing antibodies could reduce the viremia and the risk of death, and tended to improve the clinical signs and shorten the course of disease without any adverse reactions [77, 93] . a recent meta-analysis study showed that cp therapy is effective for reducing the mortality rate in different types of infectious diseases [98] . nevertheless, the outcomes of cp therapy are unforeseeable because of the diversity of sera in different donors, its limited supply, and transmission of the potential pathogens [85, 99] . other pharmacological agents widely used for management of the ncp infection are cq or its derivative hcq, and corticosteroids. in the majority of investigations, hcq had been used orally at the dose of 200 mg, 3 times daily for 10 days alone or in combination with az, while the schedules for cq administration were a bit diverse in different studies, providing quick clearance of viral load, clinical recovery, shortened time to clinical recovery (ttcr), improved pneumonia, and restoration of the immune function [12, 29, 32, 44, 48] . the former unsatisfied experiences on sars with high-dose corticosteroids have led to the use of low-dose (mp, intravenous, <1-2mg/kg/d) and short-term (3-5 days) systemic glucocorticoids in the majority of studies, associated with recovery of body temperature, increase of oxygen saturation, reduction of inflammatory markers, and resolution of ct results [29, 41] . included publications, with 11-1376 participants for cq or hcq therapies and 1-244 participants for corticosteroid therapy reported the therapeutic efficacy of all the drugs. however, a number of studies highlighted the unfavorable outcomes concerning the survival benefit of all these drugs in covid-19 patients, even higher doses led to augmentation of the mortality risk [31, 33, 50-52, 55, 56] . limited publications have also described the association of persistent viral rna shedding with corticosteroid therapy [34] and cardiac toxicity, characterized by prolongation of the qt interval, with administration of cq and hcq in sars-cov-2-infected patients [54] . hcq also has particular pharmacokinetic properties requiring certain precautions. it exhibits strong tissue tropism, with a long half-life (50 days) [100] . however, these negative findings may be partly due to the lack of adequate patient selection, along with improper dosing, timing, and duration of the therapy. outcomes of this intervention may be improved by disease severity profiling of the patients prior to enrollment [29] [30] [31] . therefore, despite rapidly pushing of these drugs to the clinical testing, all the three medicines should be administered with strict rules [95] . cytokine clearance using blood-purification modules, especially plasma exchange and continuous renal replacement therapy, has also yielded certain survival efficacy on severely and critically ill ncp individuals [23, 86] , as formerly used for controlling the cytokine storm in the patients affected with influenza virus [101] . the indications for blood-purification therapy in the patients with covid-19 include 5-fold increase in the level of plasma inflammatory mediators, quick daily progression of the lung abnormalities, and comorbidities requiring blood-purification therapy [24, 95] . however, a study reported that the ncp non-survivors have a greater proportion of crrt [88] , as seen for those with mers-cov [102] . therefore, the blood-purification therapies are likely not to be feasible, yet, due to the controversial results reported in the literature. although most of the included publications have focused on the efficiency of corticosteroids and hcq and have presented the controversial results, the trials included in the present review seemed to focus mainly on the therapies with mscs, cp, and cytokine antagonists. regarding the influence provided by these trials for the academic world, it should be mentioned that the framework of the trials was mostly well-designed, despite small size or the lack of randomization in some trials. it is essential to highlight that the dosing schedules applied in these trials were mostly according to the previous experiments, causing the concern that the side effects may occur in the subjects. notably, neither these trials have posted the outcomes, nor applicable reports existed, and the trials failed to support the patients and their clinicians. therefore, no conclusion can be finalized concerning the safety, tolerability, efficacy, pharmacokinetics, and immunomodulatory capacity of these interventions. the present study had several limitations. for example, majority of the included studies lacked the proper control groups and were considered to have a moderate to high risk of bias as a consequence of combining the non-randomized evaluations, poor methodological approach for selection of the participant, small sample sizes, study designs, type of interventions, therapeutic regimens, dosage of drugs, and duration of therapies. this heterogeneous style and, most importantly, the lack of appropriate control groups did not justify us to conduct a meta-analysis. results of this systematic review revealed that the immunomodulatory-based therapies are promising and provided a valuable therapeutic strategy to the scientific community and clinicians to fight against this outbreak in real-time situation even though other approaches and studies, including vaccine candidates, would be beneficial, but only in the future. this comprehensive systematic review of the immunomodulatory therapies applied for treatment of covid-19 patients infected patients for the 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east respiratory syndrome coronavirus (mers-cov) infection: a cohort study this work was supported by iran university of medical sciences (grant # 99-1-28-18235). the authors declare that there are no conflicts of interest. key: cord-308421-22rcptor authors: perez-gracia, jose luis; awada, ahmad; calvo, emiliano; amaral, teresa; arkenau, hendrik-tobias; gruenwald, viktor; bodoky, gyorgy; lolkema, martijn p; di nicola, massimo; penel, nicolas; vera, ruth; sanmamed, miguel f; douillard, jean-yves title: esmo clinical research observatory (ecro): improving the efficiency of clinical research through rationalisation of bureaucracy date: 2020-05-10 journal: esmo open doi: 10.1136/esmoopen-2019-000662 sha: doc_id: 308421 cord_uid: 22rcptor during the last years, there has been a dramatic increase in the administrative and bureaucratic burden associated with clinical research, which has clearly had an impact on its overall efficiency and on the activity of clinical investigators and research teams. indeed, the supervision of the adherence of clinical research to good clinical practice (gcp) guidelines and legal regulations is of the utmost importance. yet, while such regulations have remained largely unchanged during recent years, the number of administrative tasks and their complexity have grown markedly, as supported by the results of a survey performed among 940 clinical investigators that we report in this manuscript. therefore, many investigators believe that it has become necessary to undertake a rigorous analysis of the causes and consequences of this issue, and to create a conduit to channel the advice from experienced investigators regarding clinical research procedures, in order to improve them. based on these premises, esmo has launched the esmo clinical research observatory (ecro), a task force that will analyse different aspects of clinical research. ecro will aim to provide the views of esmo on clinical research procedures based on the feedback from clinical investigators, under complete adherence to the declaration of helsinki, the gcp guidelines and any other applicable legal regulations, while at the same time showing profound respect for all the stakeholders involved in clinical research. this manuscript provides the background and rationale for the creation of ecro, its planned activity and an analysis of the current administrative burden in clinical research with recommendations to rationalise it. indeed, we expect that this effort shall lead to a relevant improvement in the care of patients and in the development of clinical research. during the last years, there has been a dramatic increase in the administrative and bureaucratic burden associated with clinical research, which has clearly had an impact on its overall efficiency and on the activity of clinical investigators and research teams. indeed, the supervision of the adherence of clinical research to good clinical practice (gcp) guidelines and legal regulations is of the utmost importance. yet, while such regulations have remained largely unchanged during recent years, the number of administrative tasks and their complexity have grown markedly, as supported by the results of a survey performed among 940 clinical investigators that we report in this manuscript. therefore, many investigators believe that it has become necessary to undertake a rigorous analysis of the causes and consequences of this issue, and to create a conduit to channel the advice from experienced investigators regarding clinical research procedures, in order to improve them. based on these premises, esmo has launched the esmo clinical research observatory (ecro), a task force that will analyse different aspects of clinical research. ecro will aim to provide the views of esmo on clinical research procedures based on the feedback from clinical investigators, under complete adherence to the declaration of helsinki, the gcp guidelines and any other applicable legal regulations, while at the same time showing profound respect for all the stakeholders involved in clinical research. this manuscript provides the background and rationale for the creation of ecro, its planned activity and an analysis of the current administrative burden in clinical research with recommendations to rationalise it. indeed, we expect that this effort shall lead to a relevant improvement in the care of patients and in the development of clinical research. the only thing that saves us from bureaucracy is its inefficiency. eugene mccarthy (1916 mccarthy ( -2005 growth of the burden of bureaucracy in clinical research in recent years, the administrative and bureaucratic burden associated with clinical research in oncology has grown along with its clinical success and technical complexity, generating a profound impact on the activity of investigators and clinical research teams. indeed, regulation and monitoring are fundamental to guarantee the safety and the rights of patients and the quality of the data, according to the high standards that characterise clinical research, as defined by the declaration of helsinki, 1 the guidelines for good clinical practice (gcp) 2 and the applicable regional and local legal regulations. nevertheless, in the current scenario, physicians dedicated to clinical research have begun to feel overwhelmed by such administrative tasks, and it has become difficult for them to understand the appropriateness of certain procedures, to set a limit to the amount of time dedicated to administrative tasks, or even to perform their clinical role with an adequate level of autonomy. while adherence to the declaration of helsinki, gcp guidelines and local regulations remains unquestionable, many experienced investigators believe that their overinterpretation and misinterpretation by clinical research organisations (cros), and their substitution by their own internal standard operating procedures have significantly increased the administrative burden. [3] [4] [5] the number of processes that need to be documented and the complexity of the documenting procedures and templates have increased dramatically, creating an unsustainable pressure on the investigational site staff. another layer of complexity has been added by the incorporation of cumbersome online platforms which require intricate procedures just to access them, and which generate myriads of emails that overwhelm the capacity of investigators and research teams. exhaustive training courses for administrative processes, which frequently involve examinations, are imposed on clinical research teams to qualify as trial site staff. frequently, such trainings are requested even from individuals that are not related to those specific administrative tasks. the administrative overload even affects the medical records of the patients, which are frequentlyand wrongly-considered as the most suitable place to document administrative procedures, thus distorting their true function. the number of meetings required during the development of trials has also increased relevantly, and once again, the focus of such meetings is often administrative. regrettably, investigators are unable to overcome, or even to discuss these situations. 3 the appropriateness of such procedures is justified by the 'necessity to comply with gcp and legislation', even though such regulations do not usually require such high levels of detail and complexity. yet, the decisions are non-negotiable because the flow of communication is unidirectional and does not consider other opinions, including those coming from experienced investigators. negative impact of the increased administrative burden on investigators, research teams and patients this increased burden of bureaucracy makes poor use of the limited time physicians have available, generating frustration, loss of motivation and complaints from experienced investigators 3 4 6 as well as decreasing the interest of young physicians towards developing a clinical research career. in addition, non-essential administrative procedures significantly increase the economic costs of clinical research and contribute to delays in trial implementation, 7 thus negatively impacting the flow of drug development and hampering patient access to new drugs. 8 this is particularly relevant in the setting of independent academic clinical research, 9 which is critical for patient-focused drug development. 10 more importantly, there is no evidence that this increased complexity leads to greater patient safety. a relevant example are pharmacovigilance procedures, which commonly consist of submitting all the available individual serious adverse events to investigators and documenting their reception, without any intent to summarise, prioritise or classify them. sometimes, the events even include those observed during screening periods, when the patient has not yet received the investigational drug. this leads to an excess of information that becomes unmanageable and prevents investigators from being effectively updated on the safety of investigational drugs. another example is the high number of informed consent versions generated in some studies and their complexity, which are difficult to understand by patients, 11 and may even generate distrust of the study and the research team. clinical interference of protocols with best medical practice finally, on limited occasions, discrepancies arise between investigators and sponsors or cros regarding the most appropriate clinical management for some patients participating in clinical trials. for example, some study protocols mandate discontinuation of the study treatments based on the strict application of response criteria, disregarding the medical judgement of the investigators in clinically complex situations (eg, the possibility of maintaining treatment in the case of persistent clinical benefit; or to radically treat oligometastatic progressive disease while maintaining systemic therapy). frequently, in these situations, the strict interpretation of the protocol prevails, generating clinical interference with the best clinical judgement of the physician, who is responsible for the care of the patient; and potentially compromising the rights, safety and well-being of trial participants, in clear contrast with the main goals of the declaration of helsinki and the gcp guidelines. conversely, many protocols allow physicians to take the final decisions about these complex cases, either directly or after discussion with the medical coordinator of the study, thus confirming the validity of this approach. in order to evaluate the opinions of clinical investigators on these issues, we developed an online survey that was distributed among esmo members, esmo faculty, oncologists selected for their wide experience in clinical research and investigators attending the esmo 2019 meeting in barcelona. the characteristics of the 940 responders are presented on table 1 and the responses are displayed on table 2 . the results clearly support that there is high agreement among investigators about the excessiveness of administrative procedures on clinical research (mean score: 8.3 over a 0-10 scale), which they consider an obstacle for the development of clinical research (mean score: 8.2). the survey also shows wide consensus about the feasibility to limit such procedures without compromising the safety and the rights of the patients and the quality of the data (mean score: 8.1); and about the necessity to incorporate the feedback from physicians about the procedures related to clinical research (mean score: 8.6). interestingly, scores were higher among oncologists with more than 5 years of experience in clinical research (table 2) . while we acknowledge the limitations of surveys, we believe that these results accurately reflect the opinions expressed by the vast majority of oncologists dedicated to clinical research. consequently, they should lead stakeholders to perform a profound analysis of the current situation and to implement the appropriate changes. ecro will pursue the following areas of development, which are summarised in box 1: 1. rationalisation of the bureaucratic burden associated with clinical research, based on strict adherence to current legal regulations and to any future amendments, and on showing respect to the time and expertise of clinical investigators and research teams, who should be mainly focused on clinical and research issues. importantly, the ecro will not enter into a debate on which administrative procedures are necessary and which are ancillary, but will rather support the following recommendations: a. limiting the administrative documents required for trials to those required by gcp and legal regulations: we recommend that section 8 of the gcp guidelines ('essential documents for the conduct of a clinical trial') is strictly followed, and that documents not included in that section are therefore considered non-essential. of note, gcp guidelines only request that a small number of the essential documents be signed by the investigator; and they consider it "acceptable to combine some of the documents, provided the individual elements are readily identifiable" (gcp 8.1). b. using simplified document templates: for example, while gcp guidelines merely-and reasonably-request that "the investigator should maintain a list of appropriately qualified persons to whom the investigator has delegated significant trial-related duties" (gcp 4.1.5), most study delegation logs have become extremely complex and labour-intensive to complete, and box 1 initial areas of development and methods pursued by ecro. initial areas of development usually the investigator must assume this increased complexity. instead, we recommend the use of simplified templates. c. avoid redundant documentation: a relevant example is the documentation process of the informed consent process. while gcp clearly state that the "informed consent is documented by means of a written, signed and dated informed consent form" (gcp 1.28), 2 it has become routine practice to request that investigators duplicate this documentation in the medical records, frequently including administrative details, such as the version code of the document and so on. such a process is redundant and lacks any value, since it is not signed by the patient, as required by gcp. d. avoid complex electronic resources: cumbersome applications with intricate access procedures should be replaced by user-friendly and intuitive systems, which should not require unnecessary trainings (ie, those dedicated to performing simple procedures, such as signing a document; or those dedicated to a resource that a particular member of the staff will not use). in addition, such resources should rely on single access platforms, rather than on multiple ones. e. avoid repetitive and unnecessary meetings, and control their duration: start-up and monitoring meetings should focus on the core aspects of protocols and on clinical issues, and should avoid reviewing general aspects, ancillary administrative procedures and so on. f. optimise the delegation of trial procedures from investigators to other members of the research team: indeed, the training and preparation of all the members of the research teams (ie, data managers, research nurses and so on) allows them to assume complex responsibilities. therefore, optimising the delegation procedures will facilitate the development and monitoring of trials. 2. avoid the clinical interference of protocols with best medical practice: protocols describe the methodology that should be followed to conduct the trial, but they cannot foresee the whole variety of individual clinical situations that patients undergo and therefore they cannot substitute best medical practice. consequently, protocols should avoid dictating strict and non-personalised instructions to manage clinically complex situations, such as discontinuation of an anticancer treatment whenever clinical benefit may persist, or when oligometastatic progressive disease may be controlled with radical treatment; or deny delivery of determined supportive therapy, such as palliative radiation. protocols may consider such events as progression with regard to the interpretation of the study data, but treatment discontinuation should generally be decided by the investigators, after thorough discussion with their patients. indeed, sponsors' recommendations regarding management of relevant toxicities, based on the centralised collection of information, should not be considered as clinical interference, particularly in the setting of early drug development. neither should the decision to discontinue a study or a specific cohort of a study be considered as clinical interference. nevertheless, the sponsor must inform investigators timely to avoid miscommunication with patients. institutional review boards (irbs) should specifically examine the existence of clinical interference in new protocols and should carefully review any potential situation of clinical interference in ongoing protocols, requesting appropriate amendments, as required by gcp guidelines (gcp 4.5.4). 3. pharmacovigilance administrative procedures: reporting the safety of medicines in the routine and clinical research settings is essential to maintain physicians updated about adverse events, with the objective of improving patient safety. in order to increase the efficiency and the effectiveness of the process, ecro believes that current logistical and administrative pharmacovigilance procedures for reporting events from the sponsor to the investigators should be thoroughly revised and simplified. while the development of the optimal process is beyond the scope of this manuscript, and should be defined through the collaboration and consensus of all stakeholders, we believe that the current practice of unstructured submission of all reports on individual serious adverse events to investigators is difficult to manage and may even dilute the desired effect of proper safety information. adequate procedures, such as interpreting and periodically summarising the available information, should be evaluated. ecro will employ the following methods to attain its objectives (box 12 ; the occurrence and causes of excessive delays in starting treatment in cancer patients due to centralised molecular testing [13] [14] [15] ; the broadening of eligibility inclusion criteria in clinical trials, to avoid disparities in care [16] [17] [18] ; the consequences of outsourcing the monitoring of trials 7 ; the need to simplify informed consents 11 and so on. 3. issue recommendations regarding relevant topics related to clinical research. importantly, ecro will not evaluate specific cases, given the regional differences in legislations and patient management; and since decisions must depend on the structures that are legally in place in each country (eg, irbs and other ethics committees). ecro may contact local scientific societies to seek their advice about specific regional issues. 4. foster the involvement of experienced clinical investigators in the training of study monitors, to provide them with the clinical perspective of clinical research. 5. collaborate with other national and international associations related to clinical research, especially those in the area of oncology, in order to endorse, revise and improve this initiative. the ecro will analyse different aspects of clinical research and will provide the views of esmo on clinical research procedures based on the feedback from clinical investigators, under complete adherence to the applicable legal regulations, and showing profound respect for all the stakeholders involved in clinical research. we expect that this effort shall lead to a relevant improvement in the care of patients and in the efficiency of clinical research. indeed, we expect that all the stakeholders involved in clinical research will recognise the need to critically analyse these relevant problems and to assume their responsibility in implementing the necessary changes to overcome them. consequently, rather than attempting to audit and to control clinical trial procedures, ecro will publicly acknowledge the merits of those entities (ie, cros, sponsors, irbs, clinical research teams, regulatory authorities and so on) who succeed in reviewing and simplifying procedures without compromising-or even improving-the quality of clinical research, and consequently, the well-being of patients. we also expect that our fellow physicians will support this initiative and that, while fully endorsing the need to stringently monitor clinical trials, they will demand respect of their time and their expertise and leadership in the organisation and completion of research projects and clinical care of patients wma declaration of helsinki -ethical principles for medical research involving human subjects guideline for good clinical practice e6(r2) advocating for a return to common sense in clinical research -ash clinical news available: file:///users/joseluisperezgracia/dropbox/copia seguridad jlpg/observatorio investigacioì�n cliì�nica/bibliografia/ solving the contract research agonization problem -ash clinical news bureaucracy is strangling clinical research effect of contract research organization bureaucracy in clinical trial management: a model from lung cancer impact of cancer research bureaucracy on innovation, costs, and patient care exploratory findings from a prematurely closed international, multicentre, academic trial: ravello, a phase iii study of regorafenib versus placebo as maintenance therapy after first-line treatment in ras wild-type metastatic colorectal cancer safeguarding the future of independent, academic clinical cancer research in europe for the benefit of patients a need to simplify informed consent documents in cancer clinical trials. a position paper of the arcad group thoracic oncology clinical trial eligibility criteria and requirements continue to increase in number and complexity patients with advanced nonsmall cell lung cancer: are research biopsies a barrier to participation in clinical trials? lung cancer at the intensive care unit: the era of targeted therapy the challenge of molecular testing for clinical trials in advanced non-small cell lung cancer patients: analysis of a prospective database re-evaluating eligibility criteria for oncology clinical trials: analysis of investigational new drug applications in 2015 broadening eligibility criteria to make clinical trials more representative: american society of clinical oncology and friends of cancer research joint research statement modernizing clinical trial eligibility: recommendations of the american society of clinical oncologyfriends of cancer research minimum age working group open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, any changes made are indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ 4. 0/. orcid ids jose luis perez-gracia http:// orcid. org/ 0000-0003-4941-9075 teresa amaral http:// orcid. org/ 0000-0002-2516-5181 key: cord-316647-jj8anf5g authors: shang, you; pan, chun; yang, xianghong; zhong, ming; shang, xiuling; wu, zhixiong; yu, zhui; zhang, wei; zhong, qiang; zheng, xia; sang, ling; jiang, li; zhang, jiancheng; xiong, wei; liu, jiao; chen, dechang title: management of critically ill patients with covid-19 in icu: statement from front-line intensive care experts in wuhan, china date: 2020-06-06 journal: ann intensive care doi: 10.1186/s13613-020-00689-1 sha: doc_id: 316647 cord_uid: jj8anf5g background: the ongoing coronavirus disease 2019 (covid-2019) pandemic has swept all over the world, posing a great pressure on critical care resources due to large number of patients needing critical care. statements from front-line experts in the field of intensive care are urgently needed. methods: sixteen front-line experts in china fighting against the covid-19 epidemic in wuhan were organized to develop an expert statement after 5 rounds of expert seminars and discussions to provide trustworthy recommendation on the management of critically ill covid-19 patients. each expert was assigned tasks within their field of expertise to provide draft statements and rationale. parts of the expert statement are based on epidemiological and clinical evidence, without available scientific evidences. results: a comprehensive document with 46 statements are presented, including protection of medical personnel, etiological treatment, diagnosis and treatment of tissue and organ functional impairment, psychological interventions, immunity therapy, nutritional support, and transportation of critically ill covid-19 patients. among them, 5 recommendations were strong (grade 1), 21 were weak (grade 2), and 20 were experts’ opinions. a strong agreement from voting participants was obtained for all recommendations. conclusion: there are still no targeted therapies for covid-19 patients. dynamic monitoring and supportive treatment for the restoration of tissue vascularization and organ function are particularly important. the outbreak of novel coronavirus pneumonia that was first detected in wuhan in december 2019 resulted in a worldwide pandemic. on february 11, 2020, the world health organization (who) formally named it coronavirus disease 2019 . a person with laboratory confirmation of virus causing covid-19 infection, irrespective of clinical signs and symptoms, is considered as a confirmed case [1] . globally, more than 3,750,000 confirmed individuals and over 250,000 deaths, across more than 200 countries, territories or areas have been reported [2] . approximately 14% of confirmed cases developed severe disease [3] , while the grand fatality rate was 4.2% [2] . as the virus continues to spread at an alarming rate, healthcare workers are seeking effective and actionable management for affected patients. in china, physicians have been coping with covid-19 for over 3 months. most of the people who contracted covid-19 presented with mild symptoms (80.9%), then severe (13.8%), and finally critical (4.7%) ( table 1 ) [4] . most of the confirmed cases were between the ages of 30 and 70 (86.6%), diagnosed in hubei (74.7%), with the overall fatality rate of 2.3%, and 0.3% in health workers [4] . the case fatality rate for critical cases was 49.0% [4] . patients with underlying diseases had much higher fatality rates than patients with no underlying diseases (10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, 5.6% for cancer, and 0.9% for none) [4] . the epidemic outbreak curve peaked around january 23-26, 2020, after which the decline ensued. a recent single-center study found that most critical patients developed organ dysfunction, where 67% were found to have acute respiratory distress syndrome (ards), 29% with acute kidney injury (aki), 23% with cardiac injury, 29% with liver dysfunction, and 2% with pneumothorax [5] . besides these epidemiological findings, chinese experts have gained valuable experience in the management and pathology of this disease. we consider it our responsibility to share these experiences through the expert consensus. chinese specialists in critical care medicine were organized and worked together to develop an expert statement after five rounds of expert seminars and discussions. this statement represents a synthesis of evidence and experts' consensus on critical care, despite the lack of clinical trials. critical cases are characterized by exhibited respiratory failure, septic shock, and/ or multiple organ dysfunction/failure [6] . in experts' opinion, the patients should also be considered as critical cases if they are suffering from high respiratory frequency (rr ≥ 30 bpm) and low oxygen index (arterial partial pressure of oxygen (pao 2 )/fraction of inspired oxygen (fio 2 ) ≤ 200 mmhg) under high-flow nasal cannula oxygen therapy (hfnc). the experts drew up 9 sections on the management of covid-19 disease, mostly based on the experience in wuhan. the statements were drawn up by a group of 16 front-line intensive care experts in china who fought against the covid-19 epidemic in wuhan. the group's agenda was predefined. the expert group first defined clinical questions to be addressed and then designated the experts in charge of each question after a first meeting. all the questions were formulated according to the population, intervention, control, and outcome (pico) format, which helps defining inclusion and exclusion criteria for the literature searches and identifying relevant studies. the quality of evidence was assessed using the methodology described in grades of recommendation, assessment, development, and evaluation (grade). the quality of evidence can be high, moderate, low, or very low. because of the sudden outbreak of a covid-19, the proposed question could be the subject of a recommendation as an expert opinion due to inexistent or insufficient literature. in addition, the published data on severe acute respiratory syndrome (sars), middle east respiratory syndrome (mers) and other coronaviruses infections, as well as data on supportive care in the icu from studies on influenza and other respiratory viral infections, ards and sepsis was used as indirect evidence. a total of 5 rounds of expert seminars and discussions were organized to provide trustworthy recommendation on the management of critically ill covid-19 patients (table 2) . we use the wording "we recommend", "recommended", "should" or "should not" for strong recommendations, "should probably", "should probably not" or "should probably be considered" for weak recommendations, and "the experts suggest", "the experts suggest against", "suggested" or "not suggested" for expert opinion. the implications of the recommendation strength are presented in table 3 . the proposed recommendations were discussed one by one. at least 75% of experts agree to approve a proposal for criteria, and at least 90% of experts must agree to reach a strong agreement. in the absence of strong agreement, choose to reformulate the proposal and re-rating, in order to reach consensus. only the expert opinions that give strong agreement are retained. the prevention and control of infections, diagnostic strategy, therapeutic management, and transportation of patients were defined. literatures were searched via pubmed and the cochrane library databases. only articles published in english or with an english abstract were included in the analysis focused on recent data according to an order of appraisal ranging from meta-analyses to randomized trials to observational research studies. the study population size and research relevance were considered for each study. according to the grade method and summary of the results, experts drew up 46 statements. of these guidelines, 5 had a high level of evidence (grade 1 ±), 21 had a low level of evidence (grade 2±), and 20 were expert opinions. a strong agreement was reached for all statements after two rounds of scoring. as the front-line of the covid-19 outbreak response, health care workers are exposed to a huge risk of infection. therefore, health care workers must follow the standard precautionary principles and try their best to ensure the personal protection, hand hygiene, ward management, environmental ventilation, and sanitization of the object surface, so as to avoid nosocomial cross-infection. statement 1 implementation of standard precautions, strengthening ward management, and self-management are suggested safety measures for health care workers (expert opinion). rationale averted by the current epidemic situation of covid-19, taking proper precautions is essential for avoiding the spread of infection among health care workers. thus, the following points need to be considered. as a high-risk environment, tertiary class protection is suggested for health care workers in intensive care unit (icu). personal protective equipment (ppe) includes disposable surgical cap, n95 mask, work uniform, disposable medical uniforms, disposable latex gloves, goggles, and full-face shields. full-face respiratory protective devices or powered air-purifying respirators are required when performing aerosol-generating procedures. destroying and disposing of masks properly, putting on and removing ppe, and practicing hand hygiene are necessary to avoid self-contamination. special attention should be paid to details such as the side exposure of the eyes and wrists with glove slippage, as well as the risks of infection while removing some disposable shoe covers [7] . the hand hygiene system should be strictly implemented table 2 statement timeline march 15, 2020 designating the experts in charge of each addressed question each expert made a detailed outline of their respective question march 26, 2020 discussing and resolving the problems encountered by the experts in the process of making the statements april 2, 2020 (1) discussing the experts' respective statement and rational after revision; (2) first round of scoring april 3, 2020 guideline finalization meeting for the second round of scoring table 3 recommendations according to the grade methodology grade 1+ strong recommendation "…we recommend…", "…recommended…" or "…should…" high level of evidence grade 2+ weak recommendation "…should probably…" or "…should probably be considered…" low level of evidence expert opinion recommendation in the form of an expert opinion "…the experts suggest…", "…suggested…", "…the experts suggest against…", or "…not suggested…" [8] . clinical triage system needs to be established to assess all patients at admission, allow for early recognition of possible covid-19 cases and immediate isolation of patients with suspected disease in an area separate from other patients (source control). the number of family members and visitors who are in contact with suspected or confirmed covid-19 patients should be limited or visiting should be prohibited altogether. the proper disposal of clinical waste should be ensured [9] . health care workers need to self-monitor for signs of illness and self-isolate. if illness occurs, they should report it to managers and stay at home. a sensible diet, proper rest, and adequate exercise are advised to maintain physical and psychological health. health care workers should familiarize themselves with related working procedures so as to avoid mistakes [10] . proper icu ward setting, necessary equipment and facilities, and strict icu environmental disinfection, are suggested (expert opinion). rationale it is suggested to adjust measures according to the differing conditions so as to set the icu ward rationally. contaminated areas, potentially contaminated area and clean areas need to be strictly divided. the buffer zone should be set between every two areas. posting eye-catching logos on each area is required to prevent straying into the wrong place. different points of access should be set for medical staff and patients, making sure they do not get crossed. for icu, tertiary class protection should be correctly performed in each area, which is of great importance for precaution of covid-19 [11] . the use of negative pressure rooms with natural ventilation is recommended by the who guidance to prevent the spread of airborne pathogens among rooms [7, 12] . first-aid materials and medicine such as oxygen tank, electrocardiogram (ecg) monitor, defibrillator, injection pump, infusion pump, endotracheal intubation supplies, portable vacuum extractor, noninvasive ventilator, invasive ventilator, hemofiltration equipment, extracorporeal membrane oxygenation (ecmo) equipment and so on should be prepared. other equipment, including air disinfecting machine and air cleaner, as well as medical gas systems including oxygen, compressed air, special gas, and vacuum suction systems, need to be assured too. it is of particular importance to implement effective measures to prevent the spread of covid-19 in icu. disinfection includes concomitant disinfection and terminal disinfection. concomitant disinfection must be conducted immediately for the materials and environment contaminated by the excretion of the suspected and confirmed patients. following the end of 1 day's work in icu, or the patients' recovery or death in the isolation ward, terminal disinfection needs to be done carefully. key disinfection objects include patients' living supplies such as clothes and quilt, medical supplies, ground and wall space of icu wards, the surface of desks and bed tables, as well as air [11, 13] . current evidence indicates that covid-19 is mainly transmitted from person to person through droplets, contact, and even high concentrations of aerosols [6] . large amounts of droplets and aerosol are generated by sputum suction in the airway, specimen collection, tracheal intubation, fiber bronchoscopy, tracheotomy, etc. accordingly, surgeons are at a great risk of contamination. in order to avoid occupational exposure, recommendations during the aerosol-generating procedures in covid-19 patients are the following: statement 3 if possible, covid-19 patients should probably be admitted to negative pressure rooms (grade 2+, weak recommendation). rationale negative pressure rooms are aimed to decrease the concentration of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) pathogens. in view of that, the risk of contamination would be decreased during the aerosol-generating procedures in such a setting. during the severe acute respiratory syndrome (sars) epidemic, it was reported that negative pressure settings were effective in preventing cross-contamination and protecting the staff and patients inside the room [14] . according to who recommendations for covid-19 patients, such locations should be with a minimum of 12 air changes per hour or at least 160 l/ second/patient with natural ventilation [3] . the experts suggest that operators wear a portable air-purifying respirator with level iii biosafety protection (expert opinion). rationale an observational study reported that among 138 hospitalized patients diagnosed with confirmed covid-19 in zhongnan hospital in wuhan in january, 2020, 40 were healthcare workers [15] . till march 15, 2020, it has been reported that over 3000 health workers were confirmed with covid-19, among whom 14 died. the memory of what has happened during the 2003 sars outbreak is still fresh. a systematic review showed that the healthcare workers who performed aerosol-generating procedures, including endotracheal intubation (odds ratio, 6.6), noninvasive ventilation (odds ratio, 3.1), tracheotomy (odds ratio, 4.2), and manual ventilation before intubation (odds ratio, 2.8) were at higher risk of suffering from sars infection compared with the non-performers [16] . most of the infections among healthcare workers occurred at the early stage of this outbreak when the self-protective directive has not yet been established and reinforced. after confirmation of human to human transmission of sars-cov-2, the self-protection for healthcare workers was subsequently established and reinforced from the end of january 2020. level iii biosafety protection is mandatory for intubation according to the guidance of the general office of the national health committee [17] . ppe donning process should be strictly followed during high-risk operation: disposable hair cover, fit-tested n95 respirator or equivalent, fluid-resistant gown, two layers of gloves, goggle and face shield, and fluid-resistant shoe covers. the main operator should use portable airpurifying respirator. all the donning processes should be supervised by a professional nurse or assistant. doffing process of ppe after high-risk exposure should also be followed: hand hygiene, face shield and goggle removal, fluid-resistant gown removal, outer glove removal, shoe cover removal, inner glove removal, hand hygiene, n95 respirator or equivalent removal, and hair cover removal. the doffing process seems to be of greater importance. all the processes should also be supervised so as to reduce the risk of contamination [18] . the aerosol-generating operations such as tracheal intubation and tracheotomy are suggested to be performed by senior physicians or specialists in the field. an electronic laryngoscope with light emitting diode is suggested during endotracheal intubation. if possible, disposable equipment is suggested to be used. b) fiber bronchoscopy is not suggested for patients without an artificial airway. the operation is suggested to be performed by senior physicians or professionally trained respiratory therapists. a bronchoscope with an external display is suggested for facilitating operations. if possible, the use of a disposable bronchoscope is suggested (expert opinion). rationale large amounts of aerosols generated by incubation can increase the risk of transmission and nosocomial infection [16] . thus, visual devices are recommended to facilitate the procedure, limit operation time [19] and ensure the distance between operator and patient. routine fiber bronchoscopy operations are not suggested for covid-19 patients. meanwhile, most covid-19 patients have few airway secretions [4] so that the indication of bronchoscopy should be strictly minimized. according to the recommendations by the centers for disease control and prevention (cdc) [20] and who [9] , disposable medical equipment should be used for patient care if possible. statement 6 (a) deep sedation (richmond agitation-sedation scale (rass): 3-4) is suggested for patients during the procedure of fiber bronchoscopy. (b) the artificial airway is suggested to be connected with a threeway connector allowing access to get into the airway to perform a bronchoscopy. (c) the use of a closed airway suction device is suggested (expert opinion). rationale severe covid-19 patients with artificial airway tend to suffer from severe hypoxemia [15] . the patient's secretions, droplets, and aerosols can be widely spread during the operation. patients should be intubated within 60 s [18] . the procedure of fiber bronchoscopy should be performed gently with great caution in severe covid-19 patients. during bronchoscopy, following procedures should be followed to avoid aerosols spreading: artificial airway should be connected with a disposable three-way connector to a ventilator, then (a) ventilator needs to be set to standby mode, (b) the artificial airway needs to be briefly clamped, (c) the bronchoscopy should be quickly inserted into the connector, (d) the clamp should be opened, (e) ventilation should be restored [21] . for the patients requiring mechanical ventilation, it is not advisable to disconnect patients from the ventilator. even though some clinical experts insisted that antiviral therapy is unnecessary for seriously ill patients with covid-19 since the course of disease in severe types is longer than 2 weeks, multiple virus particles have been found at the lung lesions following histopathological examination. up to date, there is no specific antiviral drug that has been testified and globally recognized effective for treating covid-19. in china, several antiviral drugs such as ribavirin, ganciclovir, oseltamivir, arbidol, alpha-interferon, chloroquine, lopinavir-ritonavir, and remdesivir have been used in clinical settings for the treatment of covid-19. among them, oseltamivir and arbidol hydrochloride are the most commonly utilized; however, these antiviral drugs were originally designed for influenza, and their efficacy and safety for covid-19 need to be further investigated. no antiviral drugs are proven effective and should probably be considered for sars-cov-2 treatment (grade 2+, weak recommendation). rationale ribavirin is a broad-spectrum antiviral drug. clinical observations have suggested that early use of this drug is efficacious in containing covid-19. to avoid possible aerosol transmission, we do not recommend alpha-interferon nebulization for covid-19 infected patients. according to a very recently published clinical study from france, hydroxychloroquine can significantly reduce viral load in covid-19 patients, and azithromycin can further enhance this effect [22] . in this study, combination use of hydroxychloroquine (hcq) and azithromycin for at least 3 days at an early stage could rapidly reduce the nasopharyngeal viral load and decrease the length of hospital stay for infected patients. it should be noted that treatment with higher chloroquine diphosphate (cq) dosage (600 mg cq twice daily) is not recommended for severe covid-19 due to its potential safety hazards, especially when taken concurrently with azithromycin and oseltamivir [23] . nonetheless, a randomized controlled trial (rct) trial conducted by cao et al. suggested monotherapy of lopinavir-ritonavir did not bring about any clinical benefits for severe covid-19 patients compared with standard supportive care, which may be partly caused by the higher throat viral loads in lopinavir-ritonavir group, delayed treatment initiation [24] . of note, these clinical studies were limited by relatively small sample sizes. more large-scale and well-designed clinical trials are needed to confirm their potential therapeutic effects. arbidol monotherapy might be better than lopinavir-ritonavir in reducing viral load in covid-19 patients [25] . a clinical study from gilead sciences showed that remdesivir could improve clinical conditions in critically ill patients with covid-19, and stop patient from receiving invasive mechanical ventilation or ecmo [26] . however, a recent multicentre study published in the lancet found no benefit of remdesivir in improvement of clinical outcomes for severe covid-19 [27] . one recent study published in n engl j med showed that compassionate use of remdesivir improved clinical outcomes in a subset of severe covid-19 patients [28] . however, the absence of control groups precludes a final conclusion. the definite therapeutic effectiveness of remdesivir in the treatment of severe covid-19 needs to be further verified. remdesivir has been approved as a potential treatment for severe covid-19 patients by the japanese ministry of health, labour and welfare (mhlw) on may 7, 2020 due to the covid-19 pandemic [29] . the main side-effects of these antivirals include qt interval elongation, bradycardia, hepatic injury, and obvious gastrointestinal reactions such as serious diarrhea and vomiting which may contributed to disease deterioration. clinical trials testing remdisivir for the treatment of severe covid-19 patients are underway (nct04365725, nct04292899). convalescent plasma therapy belongs to passive immunization, which is used for the treatment of virus infections when specific drugs and vaccines are unavailable. convalescent plasma, which has been used for more than one hundred years, can provide specific antibodies to neutralize and eradicate the viruses from the blood circulation. up to date, there is no particular treatment for covid-19. in 2014, the who recommended the use of convalescent plasma collected from patients who recovered from the ebola virus infection as an empirical treatment during the outbreak [30] . during the covid-19 epidemic period, this method was also recommended by the national health commission of china for the treatment of severe and critical patients [6] . statement 8 convalescent plasma therapy should probably be used for severe and critically ill patients with covid-19 (grade 2+, weak recommendation). rationale convalescent plasma has been testified to suppress viremia, shorten the hospital stay, and reduce mortality during several virus epidemics. in 1918 during a spanish influenza pandemic, convalescent plasma reduced the mortality rate by > 50% in severe patients [31] . since then, it was also used for prophylaxis or as a treatment for several virus infections such as measles, argentine hemorrhagic fever, influenza, chickenpox, and infection by cytomegalovirus. over the past two decades, its efficacy and safety were confirmed during pandemics of sars, mers, h1n1 and h5n1 avian flu. during the sars pandemic in 2003, eighty patients received convalescent plasma at prince of wales hospital, hong kong. by the 22nd day, a higher discharge rate was observed in patients (n = 48) given convalescent plasma before day 14 than that given plasma after day 14 (58.3% vs. 15.6%; p < 0.001) [32] . a prospective cohort study conducted by hung et al. showed that convalescent plasma therapy (n = 20) significantly reduced mortality compared to the control group (n = 73) (20.0% vs. 54.8%; p < 0.01). meanwhile, plasma treatment lowered the upper respiratory tract virus load and decreased serum cytokines levels in patients with severe pandemic (h1n1) 2009 virus infection [33] . these studies verified the efficacy of convalescent plasma in patients with virus infections. it has been reported that among three severe mers patients who received convalescent plasma infusion, just two showed neutralizing activity [34] . among five critically ill patients with covid-19 receiving mechanical ventilation convalescent plasma infusion, 3 patients were discharged, while 2 clinically ill patients improved and maintained the stable condition till the day 37 after transfusion [35] . a study performed in 10 severe covid-19 patients found that convalescent plasma treatment could improve clinical outcomes, improve immune function, and promote absorption of lung lesions [36] . nonetheless, just like any other treatment, convalescent plasma has its limitations. the main limitation refers to the reported studies, which are not randomized trials, but just prospective cohort studies or case series studies. therefore, it was not possible to eliminate the influence of baseline severity and other treatments when evaluating the effects of convalescent plasma therapy. other limitations include the risk of transmitting infections to transfusion service personnel, the need for adequate selection of donors with high neutralizing antibody titers, and the risk of other transfusion-transmitted infections [37] . however, regardless of these limitations, since there are still no specific etiological treatments for covid-19, and convalescent plasma is available, it is reasonable to use it in the treatment of covid-19 patients. respiratory failure is the primary organ dysfunction, which worsens the prognosis of covid-19 patients. oxygen therapy and respiratory support are the key treatments for covid-19-induced ards. due to inflammatory and necrosis-induced small airway occlusion, which was confirmed by autopsy of covid-19-induced ards, positive pressure ventilation is vital to restore the collapsed airway and improve gas exchanges. however, high end-inspiratory pressure increases stress and strain to normal alveoli and increases the risk of lung injury. oxygen therapy and respiratory support for covid-19-induced ards should balance airway recruitment and risk of lung injury (fig. 1 ). indication for hfnc and niv. statement 9 niv and hfnc should probably be used for covid-19-induced ards with pao 2 / fio 2 > 150 mmhg (grade 2+, weak recommendation). rationale noninvasive ventilation support (niv) and hfnc are important treatments for covid-19-induced mild and moderate ards. the mechanisms of the two treatments are positive end-expiratory pressure, decreased respiratory workload, decreased incidence of intubation, ease of use, and higher comfort. in a randomized trial of adult patients admitted to the icu for acute hypoxemic, nonhypercapnic respiratory insufficiency, continuous positive airway pressure (cpap) delivered by face mask was associated with an early improvement in oxygenation; however, it was not associated with a reduced need for intubation or with improved outcomes [38] . a trial that compared hfnc oxygen, standard oxygen via face mask and face mask niv in 310 patients with acute hypoxemic respiratory failure, reported that the intubation rate was significantly lower with hfnc oxygen than with standard oxygen or niv among patients with pao 2 /fio 2 ≤ 200 mmhg at enrollment and, for the whole group (patients with pao 2 / fio 2 ≤ 300 mmhg), patients managed with hfnc had improved survival. there were no differences in outcomes between niv and standard oxygen [39] . a substudy examined the practice of niv use in ards of lungsafe study reporting that niv was associated with higher icu mortality in patients with a pao 2 / fio 2 < 150 mmhg [40] . for covid-19, there is no sufficient evidence to prove that hfnc is superior to niv. statement 10 when using niv and hfnc, oxygenation and breathing patterns are suggested to be closely monitored, and intubation delays is suggested to be avoided (expert opinion). rationale for all cases with noninvasive support, patients should be closely monitored, as deterioration can abruptly occur [41] . in china, some patients presented with hypoxemia, later named "silence hypoxemia", since these patients were without corresponding clinical manifestations, e.g., no high respiratory rates, high heart rate, respiratory distress, and other hypoxia symptoms. these patients have a high risk of sudden death and should be closely monitored and timely provided with oxygen therapy. positive responses are usually evident soon after the initiation of niv and hfnc. if there is no substantial improvement in gas exchange and respiratory rate within a few hours, invasive mechanical ventilation should be started without delay. failure to recognize a lack of improvement during noninvasive support may result in further respiratory deterioration and/or cardiac arrest, often with devastating consequences. delayed intubation increases ards mortality; therefore, early recognition of ards severity could avoid delayed intubation. if the use of hfnc fails, endotracheal intubation is unavoidable even with the use of rescue niv [42] . the indications for hfnc and niv intubation are a higher level of severity (saps ii score > 34), hypoxemia (pao 2 /fio 2 ≤ 150 mmhg), hypoxemia that is not improved following niv treatment for 1 h, and strong spontaneous breathing (tidal volume with niv > 12 ml/ kg pbw) [43] . rox index can be used to predict hfnc failure and intubation for patients with respiratory failure; > 4.88, suggests a high chance of success, < 3.85 suggests a high risk of failure, and intubating the patient should be discussed; index between 3.85 and 4.88, suggests the patient should be monitored very closely and intubation delays should be avoided [44] . [45, 46] . another trial that employed a multilevel mediation analysis to analyze individual data from 3562 patients with ards, who were also included in nine previously reported randomized trials, identified driving pressure as the ventilation variable that best-stratified risk. decreases in driving pressure owing to changes in ventilator settings were strongly associated with increased survival [47] . low tidal volume (6-8 ml/kg pbw), limited plateau pressure (< 30 cmh2o), and driving pressure (< 15 cm h 2 o) could decrease ards mortality. bedside measurements should probably be used for the evaluation of lung recruitability (grade 2+, weak recommendation). rationale alveolar collapse is mainly generated by inflammatory lung edema, impairment of chest wall movement, and surfactant deficiency. some reports have shown different effects of recruitment maneuvers in ards patients due to lung recruitability [48] . from our experience in wuhan, most of the covid-19 patients had low lung recruitability [49] . due to the infectiousness of covid-19, ct, and the other necessary equipment cannot always be used to evaluate lung recruitability. however, some bedside measurements, such as the pressure-volume curve, recruitment to inflation ratio, and clinical parameters, can be measured by a ventilator and used to evaluate lung recruitability [50] . based on low lung recruitability in covid-19-induced ards, high peep should probably not be used, and peep setting should probably be based on various factors, including gas exchange, hemodynamics, lung recruitability, and driving pressure (grade 2+, weak recommendation). rationale use of positive end-expiratory pressure (peep) usually improves gas exchange and helps reduce the need for high fio2. in addition, appropriate levels may limit vili by maintaining lung recruitment and improving lung homogeneity [51] . when applied with a constant pplat, peep reduces the driving pressure and keeps the lung recruited. because of the lack of resources, peep selection criteria may include lung recruitability, peep/fio2 table, respiratory system compliance, optimal oxygenation, and driving pressure [46, 47, 52] . based on the available data, all peep values represent a compromise between the extent of recruitment and overdistension, and hemodynamics. the experts suggest optimizing ventilator settings to improve hypercapnia (expert opinion). rationale in china, hypercapnia has been commonly found in covid-19-induced ards. the mechanisms are related to lung injury inhomogeneity and an increase in dead space. firstly, optimization of ventilator setting is important; secondly, the prone position could decrease dead space and improve hypercapnia [53] ; thirdly, tracheal gas inflation (tgi), which influences sputum drainage, could increase alveolar ventilation and co 2 removal [54] ; fourthly, extracorporeal life support or co 2 removal equipment could improve hypercapnia. statement 15 we recommend using prone positioning in severe covid-19 patients to prevent the deterioration of patients' condition (grade 1+, strong recommendation). rationale prone positioning has a beneficial effect on oxygenation, lung recruitment, and stress distribution. the physiological effects of prone positioning include redistribution of lung densities, often with the recruitment of well-perfused dorsal regions. although prone positioning increases chest wall elastance, this change is usually accompanied by improved lung recruitment, a reduction in alveolar shunt and improved ventilation/ perfusion ratio, subsequent improvement in oxygenation and co 2 clearance, a more homogeneous distribution of ventilation and a reduced vili risk [55, 56] . indications for prone positioning include moderateto-severe ards (pao 2 /fio 2 < 150 mmhg), and/or hypercapnia. duration of prone positioning should be more than 12 h, and the termination of prone positioning should be based on the response of oxygenation, lung mechanics, and hemodynamics. because prone positioning could improve lung inhomogeneity, early prone positioning should be provided for covid-19 infected patients with/without respiratory failure [57, 58] since it could prevent respiratory failure. since covid-19 is highly infectious, implementation of the prone positioning might require more manpower, thus further increasing the workload of medical personnel. pressure injury of the skin and mucous, facial edema, corneal edema, displacement of the catheter, and airway obstruction must be avoided when placing patients in the prone position. most of the covid-19 patients presented with mild symptoms; however, about 14% of patients developed into severe cases, 5% of them were critically ill with mortality estimates of 2.3−3.83% [59] [60] [61] . mechanical ventilation alone may not be enough to resolve refractory hypoxemia and hypercapnia in these patients. ecmo could be initiated to maintain oxygenation and avoid ventilator-induced lung injury. a cross-sectional study found that 14 (6.2%) patients treated with ecmo [62] . we recommend an early use of ecmo in covid-19 patients with refractory hypoxemia or hypercapnia who have received invasive mechanical ventilation and prone positioning (grade 1+, strong recommendation). rationale the appropriate timing of ecmo in covid-19 patients might be challenging due to enormous demand and uncertainty related to the reversibility of impaired lungs. to guarantee the reversibility of compromised lungs, ecmo should be launched before injurious mechanical ventilation, which is common in critically ill patients with covid-19 [63, 64] . the primary purpose of ecmo is the maintenance of sufficient oxygenation, removal of co 2 , avoidance of high respiratory drive, and sequencing of ventilator-induced lung injury. the following traditional indications for ecmo may be suitable for covid-19 patients: pao 2 /fio 2 < 50 for over 3 h; pao 2 / fio 2 < 80 for over 6 h; irreversible ph < 7.2 for over 6 h. the experts suggest using the traditional indications for ecmo in hospitals with sufficient medical resources. however, for areas with poor medical resources, the indications for ecmo are suggested to be balanced between the available resources and expected outcomes (expert opinion). the who guidance released a statement, in which they suggest referring patients with refractory hypoxemia despite lung-protective ventilation to those settings with expertise in ecmo [3] . the latest guidance document issued by elso also suggested that ecmo should be considered according to the standard management algorithm for ards in patients with viral lower respiratory tract infections [65] . however, in reality, numerous patients who met the criteria for ecmo were admitted over a short period, which was beyond the capacity of the medical resource, including workforce and equipment. in this context, the priority of the ecmo supply should be balanced between the available medical resources and disease reversibility. younger patients with minor or no comorbidities should be given the highest priority when resources are limited. despite standard contradictions, patients who fit the criteria below may be excluded: (1) patients with significant comorbidities; (2) elderly patients with worsening prognosis; (3) patients on mechanical ventilation for more than 7 days. prone position, as well as other adjunct therapies should probably be used for critically ill patients even during ecmo (grade 2+, weak recommendation). rationale ventilation with the prone position, which is currently recommended by the guidelines, can improve lung heterogeneity as well as oxygenation [66] . it should be considered in the early stages of the disease rather than as a delayed attempt [58] . prone position ventilation is currently widely applied for severe covid-19 patients in china [67] . even if an ultraprotective ventilation strategy is implemented with the aid of ecmo, prone ventilation is considered to benefit the recovery of the lung. elevated myocardial enzymes, such as cardiac troponin t (ctnt), creatine kinase (ck), creatine kinase-mb isoenzyme (ck-mb), have been widely observed in critically ill patients with the covid-19, indicating potential myocardial injury. a significant elevation of myocardial enzymes often indicates a poor prognosis. most patients with elevated myocardial enzymes do not present compromised left ventricular systolic function (reduced ejection fraction) or abnormal electrocardiogram. left ventricular diastolic dysfunction or mild-to-moderate pulmonary arterial hypertension is common in some covid-19 patients. intensive hemodynamic monitoring should probably be considered for patients with hemodynamic instability. ecmo should probably be used for salvage therapy for patients with severe cardiac dysfunction (grade 2+, weak recommendation). rationale while sars-cov-2 and mers-cov share similar pathogenicity, it has been shown that mers-cov can induce acute myocarditis and heart failure [68] . elevation of biomarkers of cardiac injury is common among critically ill patients with covid-19 and associated with a higher risk of in-hospital mortality [63, 69] . reversible subclinical diastolic dysfunction without systolic impairment was observed in sars [70] . comparable to sars, most covid-19 patients with elevated myocardial enzymes do not present compromised left ventricular systolic function. left ventricular diastolic dysfunction or mild-to-moderate pulmonary arterial hypertension have been commonly found in covid-19 patients. from our experience, tachycardia such as sinus tachycardia and atrial fibrillation were also common, while compensatory tachycardia was absent, even in patients with severe hypoxia or hemodynamic collapse. the exact mechanism of myocardial injury in covid-19 remains unknown. it has been suggested that direct myocardial injury is mediated via angiotensin converting enzyme 2 (ace2). ace2-dependent myocardial infection was observed in the murine model infected with sars-cov [71] . one study published in n engl j med provides evidence that angiotensin-converting enzyme inhibitors (acei)/angiotensin receptor blockers (arb) medications in covid-19 patients did not show any association with increasing susceptibility to sars-cov-2 [72] . in patients with hemodynamic instability, non-invasive or invasive monitoring, such as echocardiography or thermodilution methods, should probably be used to guide fluid therapy or administration of vasoactive agents. in patients with life-threatening cardiac dysfunction, extracorporeal life support might be salvage therapy. statement 20 hypovolemia is common in critical covid-19 patients, easy-to-implement parameters should probably be considered for the assessment of the patient's volumetric status (grade 2+, weak recommendation). rationale the use of vasoactive drugs revealed that the incidence of shock in critically covid-19 patients was 35%, and 50% in non-survivor population [5] . the shock could be the result of hypovolemia, cardiac injury, and sepsis. fever and mouth breathing could cause large amounts of fluid loss in critical covid-19 patients, while decreased water intake, acute gastrointestinal injury, depression, intubation, and sedation could exacerbate hypovolemia. previous studies reported on the relationship between dehydration and mortality in severe h1n1 patients [73] . moreover, older age, comorbidities (especially diabetes and cardiovascular disease), lower lymphocyte count, and higher d-dimer levels were identified as risk factors associated with shock [5, 74] . cardiac injury was found in 23% critical covid-19 patients [5] , which meant poor fluid responsiveness and the risk of pulmonary edema. for these reasons, the patients' volumetric status, as well as the fluid responsiveness, should be dynamically assessed. one meta-analysis of 13 rcts showed that dynamic assessment of fluid responsiveness could improve the clinically relevant outcomes in icu, such as mortality reduction, reduced duration of icu length of stay, and mechanical ventilation [75] . considering the limited clinical resources in the covid-19 pandemic, we recommend using simple bedside assessments, such as passive leg raising (plr), lactate clearance, pulse pressure variation (ppv), and inferior vena cava (ivc) collapsibility or distensibility. a recent meta-analysis determined that the plr induced changes in cardiac output, with a pooled sensitivity of 0.85 and a pooled specificity of 0.91 [76] . ppv also accurately predicted fluid responsiveness in critical patients. in a meta-analysis including 22 studies and 807 patients, ppv predicted fluid responsiveness with the pooled sensitivity of 0.88 and a pooled specificity of 0.89 [77] . ivc collapsibility resulted as a simple, non-invasive bedside predictor of fluid responsiveness with a sensitivity of 0.84 and a specificity of 0.90 [78] . early lactate clearance-directed therapy was associated with reduced in-hospital mortality, shorter duration of mechanical ventilation, and shorter icu-stay [79] . a recent observational study showed higher serum lactate levels in covid-19 non-survivors (2.9 vs. 1.4 mm/l) [5] . besides, additional attention should also be paid to mental states, degree of thirst, oliguria, skin temperature, and prolonged capillary refilling time as well. conservative fluid strategy should probably be considered for covid-19 patients with ards while ensuring tissue perfusion (grade 2+, weak recommendation). rationale even though fluid management in covid-19 remains unknown, it could be assumed that these patients would respond to fluid therapy in the same way as other ards patients. previous studies have shown that higher cumulative fluid balance is related to the higher mortality of critically ill patients, especially in cases of ards [80] and/or septic shock [81] . due to pulmonary edema in critical covid-19 patients [82] , excessive fluid therapy could increase extravascular lung water and affect gas exchange, resulting in a poor prognosis. one clinical trial found that the conservative fluid strategy improved lung function, shortened the icu-stay length and duration of mechanical ventilation compared with a liberal strategy in patients with acute lung injury [83] . another study reported that more than half of critically covid-19 patients were older than 60 years [5] . when older patients develop cardiac injury and pulmonary edema, they tend to be less responsive to fluid intake [74] . conservative fluid strategies could reduce the occurrence of positive fluid balance while ensuring tissue perfusion [83] . although it has been reported that conservative fluid strategy and liberal strategy have a similar incidence of aki and the requirement for renal replacement therapy (rrt) [83] , it is still necessary to closely monitor the renal function of patients. at the same time, attention should be paid to maintaining electrolyte balance and acid-base balance. rationale to date, there are still no studies on fluid types in covid-19 patients; thus, our observations are based on relevant studies of critically ill patients in general. a systematic review of 69 studies that included 30,020 participants revealed that using colloids (such as starches, dextrans, albumin or fresh frozen plasma, or gelatins) had no difference in mortality in critically ill patients compared to crystalloids [84] . considering the price and accessibility, fluid resuscitation with crystalloids should probably be used for critically ill patients. one single-center research reported that low serum albumin (36.62 ± 6.60 g/l) was associated with the progression of covid-19 pneumonia [85] , while another study found no significant differences between the nonaggravation and aggravation patients in the early stage of the disease [86] . serum albumin level < 30 g/l was identified as an independent risk factor for the 30-day mortality in patients with community-onset pneumonia [87] . based on the previous evidence and our clinical observations, hypoproteinemia is present in most covid-19 patients; thus, albumin supplement should probably be used for patients with serum albumin levels below 30 g/l. statement 23 psychological and humanistic care should probably be considered for conscious patients with covid-19 (grade 2+, weak recommendation). rationale besides experiencing physical impairment and stressful treatments, covid-19 patients are being subjected to closing monitoring, and are also witnessing various events in the ward such as sudden deterioration of illness, emergency resuscitation procedures and death, all of which could lead to posttraumatic stress disorder, anxiety, and depression according to previous studies [88, 89] . it was reported that 10% to 18% of sars survivors had symptoms related to posttraumatic stress disorder, anxiety, and depression and that emotional support, such as communication with others and sharing worries could reduce symptom severity [88] . accordingly, psychological implications should not be ignored in coronavirus patients. psychological health services and humanistic care could have an important role in rehabilitation. the previous study confirmed that citalopram could improve reappraisal ability and anxiety symptoms in children and adolescents [90] and that olanzapine could improve psychotic symptoms [91] . therefore, citalopram or olanzapine should probably be used to improve the psychological symptoms in patients or intervention of the psychologists in the isolation ward who would perform psychological assessment and psychotherapy for patients with new coronary pneumonia. the experts suggest assessing patients' sleep quality, implementing comprehensive measures to improve sleep and reduce the incidence of delirium, thus promoting recovery (expert opinion). nonpharmacological strategies and pharmacotherapy, including dexmedetomidine and melatonin, should probably be considered to decrease the incidence of delirium (grade 2+, weak recommendation). rationale sleep abnormalities, including abnormal sleep architecture, sleep deprivation, and disruption, frequently occur in the icu. numerous factors can affect sleep in covid-19 patients, such as stress, anxiety, pain, respiratory distress, tachypnea from the underlying hypoxemia, noise levels, stage lighting in the isolation ward, implementation of healthcare, procedures of healthcare workers, and the pathophysiology of the acute illness. sleep abnormalities may not only lead to mental disorders, but could also damage tissue repair, immune regulation mechanisms and cause delirium, all of which are associated with patient's poor prognosis [92, 93] . nonpharmacological strategies for preventing sleep disturbances and treating delirium, such as keeping noise levels within 44 and 45 db range (a) during the day, and less than 35 db (a) at night [94, 95] , and providing critical patients admitted to the icu with earplugs can significantly improve patient's sleep and reduce the risk of delirium [96] . however, in patients with sleep disturbances and delirium, pharmacotherapy care may be necessary. medications such as dexmedetomidine [97] and melatonin [98, 99] may promote sleep and decrease the incidence of delirium, although only limited data are available in support of their use [100] . assessing pain and preferential use of analgesia over sedation should probably be considered for covid-19 patients (grade 2+, weak recommendation). rationale pain is defined as an uncomfortable physical and mental experience caused by physical injury, inflammation, or emotional stimuli. covid-19 patients tend to experience pain due to hypoxia, long-term immobility, inflammatory storm, impairment of heart, liver, kidney, and other organ functions, procedures, and mental stress. opioids, such as remifentanil and sufentanil, are the firstline options for analgesia in icu according to the pain, agitation/sedation, delirium, immobility, and sleep disruption (padis) guidelines [101] . sufentanil can be used for covid-19 patients receiving invasive mechanical ventilation during the early stage of severe ards because of its stronger and faster onset of analgesia, and small accumulation [102] . remifentanil is suitable for covid-19 patients receiving invasive mechanical ventilation, especially during person-ventilator confrontation [103] due to stronger respiratory depression. previous research has confirmed that music or relaxation may diminish anxiety and discomfort in some patients [104, 105] . therefore, nonpharmacological pain management strategy can be used for conscious patients with covid-19 or for patients who do not tolerate opioid therapy, such as covid-19 patients receiving hfnc oxygen therapy or non-invasive mechanical ventilation. assessment of the patient's pain is the foundation of pain management. accordingly, a numeric rating scale (nrs) should probably be used for evaluation of pain in all covid-19 patients able to self-report their pain. behavioral pain scale (bps) and critical-care pain observation tool (cpot) should be used to evaluate pain in critically ill patients unable to express the pain for themselves. the ideal target values are: nrs < 4 points, bps < 5 points and cpot < 3 points. deep sedation should be performed for patients with severe ards, especially those receiving invasive mechanical ventilation, prone position, neuromuscular blockade, or ecmo treatment (grade 1+, strong recommendation). rationale it is well known that analgesia and sedation can eliminate pain and discomfort, reduce sympathetic nerve excitement, patient's metabolic rate, oxygen consumption, the metabolic burden of various organs, stress, and inflammation. however, plenty of evidence suggests that deep sedation is associated with adverse outcomes, including prolonged mechanical ventilation and icu-stay, higher mortality, lower rates of in-hospital, and 2-year follow-up survival [106] [107] [108] [109] [110] . under 'real-life' conditions in wuhan, deep sedation was extremely important for reducing oxygen consumption and developing tolerance to mechanical ventilation by new coronavirus patients with severe ards who suffered from respiratory distress, tachypnea and respiratory overdrive even after receiving invasive mechanical ventilation. accordingly, deep sedation should be an important part of lung-protective ventilation strategy, especially during the early stage of severe ards. previous studies have confirmed that daily spontaneous awakening trials (interruption of sedatives) lead to better outcomes in patients receiving mechanical ventilation [111] . however, critically ill patients with covid-19 have a longer mechanical ventilation time, and daily sedatives interruption is not suggested for patients receiving deep sedation in order to reduce lung damage during early stage of severe ards. midazolam and propofol are the primary medications used for icu deep sedation. the sedation-agitation scale (sas) and rass are the reliable and valid sedation assessment tools used for assessing the depth and quality of sedation in covid-19 patients. the sas and rass should be used to measure the depth after administering sedatives. the target value is rass -3-4 points, sas 2 points for deep sedation, and sas 1 point. the target value of very deep sedation is rass -5 point for patients receiving neuromuscular blocking agents [112] , prone position, or ecmo treatment. we suggest a bispectral index monitoring for patients undergoing very deep sedation, if available. light sedation is suggested for severe covid-19 patients receiving hfnc oxygen therapy and non-invasive mechanical ventilation, and also for critically ill patients in the recovering stage (expert opinion). rationale agitation and anxiety, which frequently occur in covid-19 patients, may be associated with adverse outcomes. appropriate sedation can reduce anxiety and agitation while preserving patients' comfort. light sedation can maintain frequent redirection, and increase the physiologic stress response, but not increase the incidence of myocardial ischemia. we suggest the use of light sedation for covid-19 patients receiving hfnc oxygen therapy or non-invasive mechanical ventilation. in addition, light sedation should be given to recovering patients in order to reduce the time of mechanical ventilation and the time of stay in icu [113] when pao 2 / fio 2 ≥ 150-200 mmhg. dexmedetomidine can be used for patients receiving light sedation due to the small respiratory depression. the target value of light sedation is sas 3-4 points and rass − 2 to +1 points. there is some evidence that immunotherapy may be effective against novel coronavirus infection. an article [114] published on the medrixv website stated that the mortality of covid-19 patients might be negatively related to the number of lymphocytes in patients. patients tend to be below normal levels and lower level of helper t cells in the severe group. the percentage of naïve helper t cells increased, and memory helper t cells decreased in severe cases. this suggested that novel coronavirus might fight the immune system; thus, early lymphocytes and t lymphoid subgroups testing are required for early intervention, which may help to avoid lymphocyte depletion. currently, there are several available immunomodulatory drugs, including glucocorticoid, thymosin, and immunoglobulin. statement 30 systemic corticosteroids should probably not be used for the treatment of covid-19. for critically ill patients with ards at an early stage, corticosteroids should probably be prudently used at a low or moderate dose over the short course if there are no contraindications (grade 2-, weak recommendation). rationale glucocorticoid use in ards remains a controversial topic. it is well known that corticoids are beneficial in the treatment of ards since they can alleviate inflammatory response and delay fibrosis [115] . a retrospective study conducted in guangzhou revealed that proper use of corticosteroids in confirmed critical sars patients led to lower mortality and shorter hospitalization stay and was not associated with significant secondary lower respiratory infections or any other complications [116] . however, there are some inconsistencies in the existing studies. a study involving 197 patients with ards, showed improved oxygenation and lung injury score in less than 12 h but no change in 28-day mortality [117] . another study found no differences in overall mortality, while mortality was increased when steroids were started after day 14 [118] . as for viral pneumonia, a few studies have found that the administration of corticosteroids in patients with influenza pneumonia is associated with increased icu mortality [119, 120] . who does not recommend routine use of corticoids in the treatment of covid-19, while treatment with methylprednisolone may be beneficial for patients who develop ards, as was shown by a retrospective cohort study of 201 patients with confirmed covid-19 pneumonia admitted to wuhan jinyintan hospital in china [121] . given the inconclusive evidence and urgent clinical demand, the guidance published by china national health commission on march 4, 2020, suggested the use of glucocorticoids over the short time period (3 to 5 days) for patients with progressive deterioration of oxygenation indicators, rapid imaging progress, and excessive activation of inflammatory response. the dosage of methylprednisolone should not exceed 1-2 mg/kg/day. it should be noted that large doses of glucocorticoid might delay the removal of coronavirus due to immunosuppressive effects. thymosin is a peptide originally isolated from thymic tissue, which was initially selected for its ability to restore immune function to thymectomized mice. thymosin may act on precursor t cells to increase the number of activated t helper cells and expression of th1-type cytokines such as interleukin-2 and interferon-alpha. the activated dcs and th1 cells then kill bacterial, fungal, or viral infections and lead to the stimulation of differentiation of specific b cells to antibody-producing plasma cells and an improvement in response to vaccines by stimulation of antibody production [122] . the use of thymosin alpha 1 therapy in combination with conventional medical therapies may be effective in improving clinical outcomes in a targeted population of severe sepsis [123] . also, it has been observed that lower lymphocytes in covid-19 patients indicate worse prognosis [114] . thus, thymosin may theoretically have an effect on covid-19, which needs to be further investigated. immunoglobulin may regulate the host's immune response in a variety of ways, but it had no effect on mortality in previous sepsis studies. at present, it is not recommended in the treatment of covid-19. a study performed in 20 severe or critical covid-19 patients showed that tocilizumab treatment could improve clinical outcomes, promote absorption of lung lesions, improve immune function, and reduce inflammatory response [124] . however, il-6 inhibitor sarilumab was shown to be ineffective in the treatment of severe covid-19, leading to early termination of this clinical trial [125] . large sample size studies using prospective cohort designs are required to verify the therapeutic effect of il-6 inhibitors for severe covid-19. great attention should be paid to secondary infection since it may worsen the patient's prognosis. however, since the data on the epidemiology of secondary infection in covid-19 patients are lacking, we can only make some suggestions according to our own experience and some previous studies focused on h1n1. the experts suggest against using prophylactic antibiotics for covid-19 patients (expert opinion). rationale due to the nature of virus infection, it is not logical to use prophylactic antibiotics, and there is no evidence that this strategy could reduce the incidence of the secondary infection. on the other hand, according to the management guidelines of covid-19 from who and china [3, 6] , empiric antibiotic treatment should only be used based on the clinical diagnosis (communityacquired pneumonia, healthcare-associated pneumonia or sepsis), local epidemiology and susceptibility data, and treatment guidelines. based on our observations from wuhan, many severe and critical covid-19 patients did not show any signs of bacterial infection (such as elevated wbc, pct and similar); thus, we do not suggest the routine use of prophylactic antibiotics in covid-19 patients, especially at the early stage or for non-intubated patients. the experts suggest closely monitoring the signs of secondary infection, especially in critically ill patients with covid-19 who have been admitted to icu > 48 h (expert opinion). rationale both long course of the disease and immunosuppressive state place the severe and critical covid-19 patients at a high risk of secondary infection (including bacteria and fungus). unfortunately, the data on the epidemiology of secondary infection in covid-19 patients are lacking. however, based on the evidence from h1n1, secondary infection is very common in patients admitted to icu > 48 h [120, 126] . although a complete nosocomial infection prevention and control system was set up in wuhan according to the guidelines [127, 128] , ventilator-associated pneumonia and hospital acquired pneumonia were very common occurrences in the icu. we suspect this is mainly because the medical staff is wearing heavy personal protective equipment, and heavy workload adhered to the incomplete implementation of these measures. consequently, the strategies for nosocomial infection prevention should be effectively implemented, and multiple site samples (blood, sputum, etc.) should be routinely collected to monitor the signs of secondary infection. in clinical practice, coagulation dysfunction is commonly found in covid-19 patients, and the symptoms range from mild disorders of coagulation indicators to disseminated intravascular coagulation (dic). the exact etiology of covid-19-associated coagulopathy is unclear, diverse and multifactorial, and may include direct attack by the sars-cov-2 on vascular endothelial cells, cytokine storm-mediated inflammation-coagulation cascades, hypoxia, and complication with sepsis. coagulation dysfunction or thrombocytopenia is closely associated with the severity and poor prognosis in covid-19 patients [129] . clinicians should increase awareness of covid-19-associated coagulopathy, which in covid-19 patients is accompanied with the following abnormal coagulation indexes: platelet-lymphocyte ratio < 100 × 10 9 , the reduction of prothrombin time (pt) and activated partial thromboplastin time (aptt) by more than the lower limit of 99th percentile or the increase of pt by more than 3 s or aptt by more than 5 s, or the increase of fibrinogen, fibrin degradation product (fdp) and d-dimer by more than the lower limit of 99th percentile without clinical evidence of primary blood system diseases or chronic liver diseases. routinely assessing the coagulation dysfunction on admission and dynamically monitored thereafter should probably be performed to identify covid-19-associated coagulopathy as early as possible (grade 2+, weak recommendation). rationale according to the available literature, the condition of covid-19 patients is commonly complicated with coagulopathy, where the symptoms range from mild disorders of coagulation indicators to dic. the increase of d-dimer in covid-19 patients is very common, accounting for 36% to 46.4% of all cases [15, 60, 64, 130, 131] . the degree of elevation and persistent elevation are indicators of poor prognosis. the nanshan zhong team has reported that among 1099 covid-19 patients in 552 hospitals from 31 provinces (926 mild cases and 173 severe cases), the proportion of severely ill patients with d-123dimer higher than 0.5 mg/l was up to 59.6%, and the proportion for the mild patients was 43.2% [60] . zhou et al. have demonstrated that among 191 confirmed covid-19 patients (54 deaths, 171 survival), d-dimer > 1.0 g/l was an independent risk factor for clinicians to identify patients with poor prognosis at the early stage [130] . the coagulation parameters (pt and aptt) in covid-19 patients vary with different severity and the different courses of the disease. covid-19 patients in the early stage show the activation of the exogenous coagulation system, manifested as decreased pt and hypercoagulable state. along with the progression of the disease, especially when patients develop dic, pt and aptt significantly increase, which is associated with the poor prognosis of patients. tang has reported increased fibrinogen (5.16 g/l vs. 4.51 g/l, p = 0.149) and fdp values (7.6 µg/ml vs. 4 µg/ml, p < 0.001) in covid-19 patients [131] , which indicated that instead of hyperfibrinolysis observed in the late stage of dic, fibrinolysis inhibition is the main feature accompanying the progression of covid-19. the autopsies of covid-19 patients have revealed abundant transparent thrombus in the pulmonary alveoli, myocardium, portal area, and renal tubular epithelial cells, thus indicating that fibrinolysis inhibition may have a decisive role in covid-19-associated coagulation dysfunction. the incidence of dic is low in covid-19 patients. it has been reported that among the 1099 covid-19 patients, only 1 patient (0.1%) was diagnosed as dic [60] . however, tang's report has shown that the overall incidence of dic is 8.74%. the existence of dic was more common in fatal cases, where 71.4% met the isth diagnostic criteria for dic; the median time for dic diagnosis after admission was 4 days, whereas among the patients who survived, only 1 patient (0.6%) met this criterion [131] . medical institutes should dynamically detect the pt, international normalized ratio (inr), aptt, d-dimer, fibrinogen, and fdp to identify covid-19-associated coagulation disorders, which might be helpful for making timely treatment decisions. it is also suggested to use the isth score system to diagnose covid-19-associated dic [132] ; if possible, sf and pai-1 should be used to detect the pre-dic status in the shortest possible time. routinely evaluating the risk of venous thromboembolism (vte) and hemorrhage should probably be performed in covid-19 patients. for critically ill covid-19 patients with low hemorrhage risk, subcutaneous injection of low molecular weight heparin (lmwh) should probably be used for preventing vte (grade 2+, weak recommendation). rationale the most common clinical features of coagulopathy in covid-19 patients are thrombosis in the deep vein or intermuscular vein of the lower extremity, which can be identified by the coagulation parameters and ultrasonic monitoring. it has been reported that the incidence of vte or thrombotic complications in patients with severe covid-19 admitted in the icu was 25-31% [133, 134] . it is necessary to pay attention to the clinical observation of patients with bed rest lasting for more than 3 days and observe whether these patients are experiencing asymmetric pain, swelling or discomfort in unilateral lower limbs or bilateral lower limbs, or local swelling or superficial vein filling in the lateral limbs. especially when patients show chest pain, hemoptysis, dyspnea, or hypoxemia, which cannot be explained by ncp or other basal diseases, we should be alert to the occurrence of pulmonary thromboembolism. for critically ill covid-19 patients with low hemorrhage risk, a subcutaneous injection of lmwh should probably be used for the prevention of vte. for patients with severe renal dysfunction (creatinine clearance rate < 30 ml/min), unfractionated heparin is recommended. for critically ill patients whose condition is complicated with high hemorrhage risk, intermittent pneumatic compression is recommended for mechanical prevention. mild or moderate covid-19 patients should probably avoid sedentary lifestyle or dehydration and are encouraged to engage in active activities and to drink more water appropriately. for mild or moderate covid-19 patients with a high or moderately high risk of vte according to the padua or caprini evaluation model, it should probably be considered to use lmwh for 7 to 10 days until the elimination of risk factors. anticoagulation therapy should probably be used for patients with hypercoagulant state without bleeding risk. lmwh or unfractionated heparin should probably be considered to be the first choice (grade 2+, weak recommendation). rationale hypercoagulant state is common in covid-19 patients. meantime, cytokine storm-mediated inflammation-coagulation cascades may have an essential role in covid-19-associated coagulopathy. studies have found that in addition to the anticoagulant effect, heparin also has a certain anti-inflammatory effect [135] . therefore, lmwh or unfractionated heparin is the first choice for anticoagulation: tang et al. have reported that lmwh or unfractionated heparin anticoagulation was associated with improved survival in the patients with a sepsis-induced coagulopathy (sic) score ≥ 4 and in those with d-dimer levels more than 6 times of the upper limit of normal(≥ 3 mg/l) [136] . it is suggested that lmwh 100 u/kg or unfractionated heparin 5000 units subcutaneously twice daily could be given to patients without contraindication once d-dimer ≥ 3 mg/l or sic ≥ 4. heparin-induced thrombocytopenia (hit) should be prevented during heparin treatment, and platelet counting should be monitored daily. for patients with hit, other anticoagulants, such as agatraban, bevaludine, fondaparinux, and rivaroxaban, could be used. for patients at high risk of bleeding, anticoagulants are not recommend, and chinese traditional medicine could be used to improve blood circulation and dispersing stasis. although diffuse alveolar damage and ards are the main features of covid-19, the involvement of the kidney and other organs needs to be considered. aki was associated with a higher risk of in-hospital mortality. clinicians should increase awareness of aki in hospitalized covid-19 patients. kidney disease: improving global outcomes (kdigo) criteria should probably be used for the diagnosis of aki in covid-19 patients. measuring serum creatinine every 2 days should probably be performed to avoid a missed diagnosis of aki (grade 2+, weak recommendation). rationale the incidence of aki in covid-19 patients varies with different severity of illness: mild cases have an aki incidence of 0.1-2%, severe cases have an aki incidence of 3-3.2%, and the aki incidence for those critical cases that require to be admitted in icu is up to 8.3-29% [5, 15, 64, 137, 138] . according to kdigo aki diagnostic criteria, certifying aki is mainly based on changes in scr, and the frequency of scr tests has a substantial impact on the detection rate of aki. in a nationwide cross-sectional survey of hospitalized adult patients in china, the detection rate of aki was only 0.99% by kdigo criteria [139] . after adjusting for the frequency of scr, the incidence of aki in chinese hospitalized adults rose to 11.6% [140] . thus, in order to improve early recognition of aki, scr measurements should be performed more frequently throughout the course of the disease. it is necessary to measure scr every 2 days throughout the course of the disease to avoid a missed diagnosis of aki. the experts suggest using standard aki care bundle (5r principle) for covid-19-associated aki (expert opinion). rationale the exact pathogenesis of covid-19 associated aki is unclear. the etiology of kidney impairment in covid-19 patients, which is likely to be diverse and multifactorial, may include direct attack by the sars-cov-2 on target cells in the kidney, immune systemmediated damage, disease-related prerenal factors, a complication with sepsis and nephrotoxic drug-related factors [137, 141] . covid-19 associated aki is an independent risk factor for poor prognosis in patients. clinicians should address standard aki following 5r principle (risk screen, recognition in the early phase, response in time, renal replacement therapy, and rehabilitation of the kidney). aki is significantly more likely to develop in severe covid-19 patients than in nonsevere patients [5, 15, 64, 137, 138] . meanwhile, studies have shown that patients with elevated baseline scr are more likely to develop aki and develop more severe aki [137] . therefore, we should routinely screen the risk of aki in covid -19 patients, particularly for severe cases, patients with elevated baseline scr or those having proteinuria and hematuria at admission. optimizing the volume status and oxygenation, maintaining hemodynamic stability, making sure the mean blood pressure above 65 mmhg are the important measures for prevention and treatment of aki. the experts suggest using crrt for the critical cases accompanied by kidgo aki 2-3 stages, or cytokine storm syndrome (expert opinion). rationale according to the available literature [5, 15, 64, 137, 138] , the percentage of covid-19 patients who require continuous renal replacement therapy (crrt) is 1.5-9%, and particularly the percentage of critical patients admitted in icu that requires crrt is 5.6-23.0%. indications of the crrt in covid-19 patients include renal indications and non-renal indications. renal indications include severe aki (kidgo aki 2-3 stages) with hemodynamic instability. non-renal indications include complications with severe ards and persistent inflammatory fever, which cannot be controlled not even with glucocorticoid corticosteroid therapy, hypernatremia refractory to conservative medical treatment, volume overload or urine output, which cannot meet the needs of drug infusion and energy supply and diuretic resistance. multiple rct research has indicated that the application of crrt in critical patients in an early phase cannot effectively decrease the mortality rates [142, 143] . however, considering the suggestion that restrictive fluid volume management strategy should be adopted for covid-19 patients complicated by ards based on the premise of sufficient tissue perfusion, we suggest crrt initiation in severe patients within 24 h when they show rank 2 aki under kdigo criteria or accompanied with cytokine storm syndrome. in clinical practice, the doctors in charge should comprehensively evaluate conditions including the covid-19 patient's level of systemic inflammation, severity and progress of illness, severity, and progress of aki, local medical resources, and the qualification of blood purification operators to give a reasonable choice of crrt application. statement 39 crrt prescription is suggested to be target-oriented based on the patient's condition (expert opinion). rational crrt prescription should 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giovanna; nyhof-young, joyce; leung, fok-han title: wearable technology and live video conferencing: the development of an affordable virtual teaching platform to enhance clinical skills education during the covid-19 pandemic date: 2020-09-23 journal: can med educ j doi: 10.36834/cmej.70554 sha: doc_id: 341801 cord_uid: n11ilz6l nan the novel coronavirus disease 2019 (covid-19) pandemic has forced physical distancing, compelling most medical programs to move their entire preclerkship curricula online. unfortunately, clinical skills education programs are experiencing serious challenges in this setting. specifically, all pre-clerkship medical students at the university of toronto have been barred from entering clinical environments for educational purposes since march 2020 and for the foreseeable future. as a result, the university of toronto's medical school has pivoted to teaching clinical skills using online modules and pre-recorded e122 videos of physicians taking patient histories and performing physical examinations. medical students and teachers have become concerned about the resulting gaps in clinical education. their concerns stem from students' lack of active engagement with patients and tutors, which is paramount for developing bedside manner and clinical competencies. as the pandemic persists, students continue to voice their growing concern over this pause in their face-to-face clinical skills education and the effect this will have on their learning and subsequent performance in clerkship. given these new obstacles, a group of pre-clerkship medical students and faculty at the university of toronto teamed up to investigate this issue with the users in mind. wearable technologies can provide students with rich, interactive, and resource-efficient field experiences in the absence of in-person clinical training. 1,2 however, few studies have evaluated the use of point-of-view filming with wearable devices for medical education. 3 combined with live video conferencing (vc), these technologies can simulate the interactive learning of an in-person classroom while allowing students to maintain physical distancing requirements. 1 tutor use of wearable livestreaming devices can allow students to regain many of the benefits of the regular clinical skills curriculum. in this commentary, we identify an affordable and user-friendly device-accessory pairing compatible with live vc technology that can be adapted for use throughout medical or other healthcare education programs. with the support of faculty, our medical student group first conducted an online environmental scan of useful technology available for online purchase and delivery. ultimately, we chose and reviewed seven digital device-accessory pairs (see appendix a). each device-accessory pair was assessed while performing either a precordial or abdominal exam. these exams are central to undergraduate clinical skills education and have notable shortcomings in traditional pre-recorded learning aids (e.g. poor visualization of physical exam maneuvers). the medical student team reviewed the recordings, discussed findings, and reached consensus. we then assigned each device-accessory pair a maximum of 10 points according to a scoring system based on the following key criteria: all tested modalities provided clear recordings with high quality footage. notably, the modalities using gopro © devices and body-mounted smartphones provided excellent visualization of physical exam anatomy and maneuvers. however, all wrist and head straps were incompatible with covid-19 ppe requirements. furthermore, the gorillapod, © head straps, wrist strap, and tablet mount were cumbersome to don, set up, adjust mid-exam and produced less pedagogical views. the patientmounted gopro © and head strap did not capture footage beneficial for learning. all three gopro © modalities were less affordable than all other deviceaccessory pairs, given that physician educators do not commonly own them. their lack of direct vc capabilities also increases concerns about security and cost. the chest-mounted smartphone holder was affordable ($65 cad), easy to don and use, unobtrusive, and produced high quality audio and video content clearly highlighting relevant anatomy and maneuvers. the chest mount featured adjustable elastic straps that fit comfortably on both male and female users. this modality also connected directly with video conferencing technology. the chest brace did not present sanitation/infection control challenges as it could easily be wiped down or sprayed with disinfectant. after testing seven device-accessory pairings, we determined that a chest-mounted smartphone was the best device-accessory pair for physical exam demonstrations ( table 1 ). the chest mount is especially useful as it fits any smartphone, rotates easily between portrait and landscape modes, and can provide a magnified field of view to capture examination details. the chest mount harness was also made of material that could be easily wiped down or sprayed with disinfectant between uses. a different research group demonstrated the feasibility of affixing an ipad with zoom © capability to a computer on wheels to teach bedside clinical skills with covid-19 positive patients. 4 two simultaneous views on a zoom © video call easily transforms our platform into a multi-perspective learning tool. zoom © video conferencing software was also successfully used in this study and was deemed secure by hospitals associated with our medical program. tutors who already own smartphones can easily couple them with institution-provided chest straps and zoom © accounts to resume group teaching of clinical skills. furthermore, using this platform with zoom © technology can allow individual tutors to communicate with a far greater number of students. through video conferencing sessions from a physician's point of view, students will regain a crucial part of their pre-clerkship clinical skills training: the ability to interact with and ask questions of tutors and volunteer or standardized patients in real time. the affordability, versatility, and sanitation-friendly nature of our novel platform makes it ideal for implementation during the pandemic and bridges the gap in current virtual teaching affecting educational healthcare institutions globally. start-up costs for this intervention can be adjusted based on the number of students per learning group. testing will be important to determine the maximum number of students one clinical skills tutor can effectively teach using this platform. we have demonstrated that the use of a chestmounted smartphone with zoom © vc technology is an interactive, accessible, cost-effective, and feasible e124 adaptation for virtual clinical skills teaching in real time. this platform can help address key limitations of current online curricula by creating a synchronous learning environment that simultaneously allows student-tutor discussion and clear visualization of clinical interactions. we hope that our innovation, coupled with our ongoing studies of this platform, will help transform distanced clinical skills education by providing educational institutions with tools to bridge the gap created by the pandemic. conflicts of interest: the authors declare no conflicts of interest. funding: no funding was obtained for the completion of this study. reflective thoughts on the potential and challenges of wearable technology for healthcare provision and medical education going professional': using point-of-view filming to facilitate preparation for practice in final year medical students limitations in virtual clinical skills education for medical students during covid-19 virtual bedside teaching rounds on patients with covid-19 appendix a. outline of tested device-accessory pairs. key: cord-331557-8axi74nn authors: raoult, didier; fournier, pierre edouard; drancourt, michel title: what does the future hold for clinical microbiology? date: 2004 journal: nat rev microbiol doi: 10.1038/nrmicro820 sha: doc_id: 331557 cord_uid: 8axi74nn in the past decade, clinical microbiology laboratories have undergone important changes with the introduction of molecular biology techniques and laboratory automation. in the future, there will be a need for more rapid diagnoses, increased standardization of testing and greater adaptability to cope with new threats from infectious microorganisms, such as agents of bioterrorism and emerging pathogens. the combination of the new tools that are now being developed in research laboratories, the general reorganization of clinical laboratories and improved communication between physicians and clinical microbiologists should lead to profound changes in the way that clinical microbiologists work. clinical microbiology evolves in response to clinical needs 1 (fig. 1) and there have been many advances in this area during the past decade. for example, automated systems for the detection and identification of microorganisms and for the identification of resistant organisms have been developed 2 . these include automated blood-culture assays and systems for the phenotypic identification of bacteria. antibiotic-sensitivity testing and computerized interpretation systems have also been developed 3 . these developments have not led to significant changes in the microbiology itself, but rather enable more samples to be processed by fewer personnel and provide increased intra-and inter-laboratory reproducibility. similar developments have been seen with immunoassays: enzyme-linked immunosorbant assays (elisas) have been extensively automated and standardized in recent years and have also become cheaper. many of the automated tests that are now available were initially designed for the mass testing of blood that is destined for blood banks, but later innovations led to western blots for the confirmation of hiv infection and lyme disease and the development of tests for the rapid detection of anti-hiv antibodies in saliva or blood 2 . worldwide -mainly because of the cost of containment measures for infectious diseases -there has been a general tendency over the past 10 years to centralize clinical microbiology laboratories such that they serve several hospitals, therefore maximizing the efficiency of testing at the lowest cost 4 . however, such centralization of clinical microbiology laboratories can result in a lack of consultation between physicians and clinical scientists. there have also been rapid developments in the genetic detection and identification of microbial pathogens during this period, mainly through nucleicacid amplification by polymerase chain reaction (pcr). pcr using universal primers followed by sequencing of the amplification products has enabled the rapid identification of cultured and uncultured bacteria and fungi. this procedure is now available in many large university hospital laboratories and is also carried out by new companies in the private sector. genetic testing can also be used to identify dna sequences that are associated with antimicrobial resistance. viral loads can also be determined by pcr and this has been found to be a useful method for evaluating antiviral therapies. finally, molecular methods allow typing of microorganisms, which can help to analyse the epidemiology of outbreaks and identify their sources, as well as distinguishing between relapse and re-infection in the case of persisting microorganisms. indeed, infection control is now considered to be part of clinical microbiology. in the future, new technologies, changes in the availability of skilled personnel and the prevailing economic environment will all influence clinical sigma factor the subunit of the rna polymerase holoenzyme that is required for promoter-sequence recognition and the ability to initiate transcription. a dna-sequence-based approach that is used to characterize bacterial isolates of bacteria through the internet. the 18s-28s intergenic spacer. and therefore progress in clinical microbiology -has been linked to the development of online databases. scientists worldwide can now send their own sequences to these databases and there has been an explosion in the amount of sequence data that are available. of the databases that are available at present, genbank 6 strict criteria must be used when interpreting sequence data. a major drawback of online databases is that they are dependent on the quality of the sequences that are submitted by scientists. inaccurately reported sequences can lead to individual microorganisms being misidentified and even to whole groups of organisms requiring reclassification. moreover, the availability of the current data could potentially become compromised in the future and common international repositories would be useful. for bacteria, studies of 'universal' genes -such as the 16s ribosomal rna gene -have enabled the correct classification of numerous microorganisms, including some that were previously unidentifiable 7 . unfortunately, it is not possible to discriminate between all species by comparing their 16s rrna gene sequences. at present, we know of 75 genes that are present in all bacterial genomes 8 . the sequences of some of these genes -for example, rpob (which encodes the rna polymerase β-subunit) 9 and the sigma-factor genes 10 -differ between bacterial species and can therefore be used for bacterial identification. large databases of the sequences of these genes are now available. for eukaryotes, the 18s rrna gene has also been used as a 'universal' gene and there is an increasing number of 18s rrna sequences in databases 11 . by contrast, there is no common gene for the detection of all viruses, although pcr targets have been developed for virus families, such as the herpesviridae 12 . 'universal' genes cannot be used when a higher level of identification is required, such as strain typing in investigations of disease outbreaks, antibiotic resistance, nosocomial infections or suspected bioterrorism attacks. different gene sequences enable different levels of identification. depending on the gene that is used, the genus, species, subspecies or even strain of an organism can be established. when it is crucial to determine whether one or more clinical isolates are of the same strain, a comparison of several genome sequences might be required. such studies have identified highly variable genome fragments and have led to the development of several techniques, including multilocus sequence typing 13 . similar identification tools have also been developed for fungi 14 and protozoa 15 . other sequence-based typing techniques have used intergenic, non-coding spacer sequences 16 that are more likely to be variable. the one that has been the most widely used is the 16s-23s intergenic spacer for bacteria 16 and the internal transcribed spacer (its) for fungi 17 . specific, fully automated bioinformatics microbiology 5 . the use of molecular-biology techniques has dramatically changed clinical microbiology and the integration of the two disciplines is an important challenge for the future. in addition to detecting well-known pathogens, the laboratories of the future will also have to be able to recognize new pathogens and participate in food-safety monitoring and bioterrorism surveillance 4 . recent experience has shown the necessity for laboratories to be able to rapidly develop diagnostic tests for new diseases that have a high social impact, as was the case with the outbreak of severe acute respiratory syndrome (sars). means must also be available for the rapid transfer of such technology to laboratories in which routine diagnostics are carried out. a current problem is that scientific responses to emerging threats are far more rapid than are administrative responses, and there are often prolonged delays in the approval of new diagnostic tests for use outside research laboratories. in this article, we discuss the latest techniques that are available to clinical microbiologists (fig. 2) and how they are applied, and speculate about what the future might hold for clinical microbiology laboratories. sequence-based identification of microorganisms. the availability of high-throughput thermal cyclers, new dna polymerases and automated sequencers, together with reductions in the cost of reagents, has led to the sequence-based identification of microorganisms becoming a useful and reliable alternative to phenotypic methods of identification. moreover, the patent on taq dna microarrays. the development of microarray analysis has been a milestone in several areas of microbiology, and in clinical microbiology microarrays are used for microorganism detection and identification and gene-expression analysis. microarrays consist of many probes that are discretely located on a solid substrate, such as glass. the probes can be pcr products or oligonucleotides and the 'targets' can be pcr products, genomic dna, total rna, amplified rna (arna), complementary dna, plasmid dna, bacterial suspensions or clinical specimens 23 . when pcr is used to detect dna in clinical specimens, microarrays can then be used to identify the amplified products by hybridization to an array that is composed of pathogen-specific probes. using broadrange primers, such as those that amplify the 16s rrna gene, a single pcr can be used to detect multiple pathogens simultaneously. dna microarrays have been used to detect bacteria and viruses 24, 25 and, because the number of possible hybridizations is now very high, sequencing of a pcr product on an array is possible. dna microarrays can also be used for strain identification or genotyping if the arrays incorporate speciesspecific gene sequences and the reactivity profiles of isolates and reference strains are compared 26 . antigen microarrays for serology. assays with the ability to detect specific antibodies against several pathogens simultaneously have a wide application in the diagnosis of infectious diseases 27, 28 . the indirect immunofluorescence assay (ifa) is commonly used to detect antibodies to infectious agents 29 as it is easy to use, sensitive and specific. recently, protein arrays have been used to tools, such as bibi (bioinformatics bacterial identification) 20 , identify microorganisms by combining sequence databases and phylogeny-display programmes. quantitative pcr. the development of molecular beacons and other fluorescent probes (such as the taqman® probe that is produced by roche molecular systems, inc.) has made real-time monitoring of pcr amplification and quantification of nucleic acids in clinical specimens possible 21 . beacons are hairpinshaped oligonucleotide probes that have a fluorophore that emits photons and is closely associated with a quencher, which absorbs the photons. in the presence of a complementary strand of dna, the hairpin structure unfolds and fluorescence is emitted, and this can be measured to determine the amount of dna that is present. multiple targets can be monitored 22 using fluorophores with different emission spectra. this technology, which is highly sensitive, is commercially available as the taqman ® (applied biosystems; perkin-elmer corp.) and lightcycler ® (roche diagnostics corp.) systems. the advantages of real-time pcr are the rapidity of the assay (30-40 min), the ability to quantify and identify pcr products directly without the use of agarose gels, and the fact that contamination of the nucleic acids can be limited. kits are available for the detection and quantification of dna and rna in clinical samples, and the technique has been specifically developed to enable the follow-up of patients with hiv and hepatitis c infections (amplitech ame bioscience; bayer diagnostics; roche diagnostics). microscopy. microscopy techniques have evolved with respect to three factors: the nature of the signal, the user-friendliness of the equipment, and the digitalization and computerized processing of the image. electron microscopes -which were once complicated instruments that were only used in research -have been simplified and are now increasingly being used in clinical microbiology laboratories. they are useful for the rapid screening of routine clinical samples, such as stool samples, and also for detecting viruses in tissue cultures. with negative staining, a viral pathogen can be identified within 10 minutes of the arrival of a clinical or tissue-culture specimen in an electronmicroscopy laboratory 43 . electron microscopy was used to rapidly identify bacillus anthracis during the recent anthrax letters attack in the united states 43 and also to identify the genus (coronavirus) of the sars virus. the implementation of new technologies, such as automated pattern recognition 44 , remote operation of microscopes and telemicroscopy -which uses digital image acquisition and review of images through the internet 45 -will further increase the usefulness of electron microscopy. flow cytometry. flow cytometry (fcm) was originally developed as an automated method for measuring the optical or fluorescence characteristics of cells or particles in suspension 46 . it was used as early as during the second world war by the united states army to detect bacteria and spores. flow cytometers are now more user-friendly and less expensive, and are becoming increasingly important in clinical microbiology 47 . almost all microorganisms can be detected directly in clinical specimens by fcm. bacteria can be detected as particles in liquid samples in the case of bacteraemia and bacteriuria, and can also be identified using polyclonal or monoclonal antibodies that are coated with fluorescent molecules. fcm has been applied successfully to the detection of a wide range of bacteria and to patient specimens, including blood, urine, exudates and effusions, bile, bronchial-lavage fluid and even faeces 47 . flow cytometers that are designed specifically for urine analysis are now available commercially, and these simultaneously determine the concentrations of bacteria, red and white blood cells and squamous cells (for example, the uf100 flow cytometer that is manufactured by sysmex corp.). in eukaryotes, fcm studies have mostly been used for candida spp. and giardia lamblia. because of their small size, viruses cannot be detected directly using fcm, but can be detected indirectly in infected cells in clinical samples or after inoculation and culture of viruses in cell culture. fcm detects and quantifies viral antigens on the surface of, or within, infected cells. fcm can also detect and quantify viral nucleic acids by in situ hybridization of specific viral nucleic acids in cell suspensions and can simultaneously identify the infected cells by cell phenotyping. this application of fcm has been used for several viruses, including hiv and cytomegalovirus 47 . develop comparative fluorescence assays to measure the concentrations of specific proteins and antibodies in complex solutions 30 . the lack of stability of fluorescent dyes is no longer a problem with the use of new-generation alexa fluor® dyes (molecular probes), which are available in several emission colours and allow multiple stainings of the same spot. specific fluorescence is detected by confocal scanning microscopy and is quantified using internal calibration curves. the dyes have enabled the development of prototypes of antigenic microarrays to detect antibodies in human sera that are specific for one or several pathogens. an antigen microarray for lyme disease has been described 31 . similarly, a microarray with specific antigens of toxoplasma gondii, cytomegalovirus, herpesvirus 1 and 2 and rubella virus gave favourable results when used to detect reactive immunoglobulin g 32 . such pioneering studies provide evidence that antigen-microarray analysis could become an important diagnostic tool. the technique will enable ifas to be standardized and inter-operator and inter-laboratory variation will be minimized. it will also be possible to digitalize ifa photographs, which will enable them to be stored and exchanged more easily. mass spectrometry is an analytical technique that is used for the detection of minute quantities of a molecule in a complex medium 33 . refinements in instrumentation have facilitated the use of mass spectrometry in clinical microbiology laboratories. it can be used to sequence pcr amplification products instead of sanger's method, which is used at present. the molecular identification of bacteria can be based on the sequencing of the universal 16s rrna gene 34 , which is a two-day task (including culture time) that can only be performed using pure cultures of bacteria. mass-spectrometry analysis of base-specific fragmentation patterns of pcramplified dna has recently been studied as a technique for the rapid identification of bacterial isolates and for the detection of specific 16s rrna gene fragments that are amplified from complex environmental samples 35 . in this study, 300 base pairs were determined, and the technique shows promise of becoming the standard method for identification of pathogens, strain typing and determination of mutations that are associated with resistance in bacteria and viruses. mass spectrometry has also been important in the development of proteomics, in which it has been used to identify and, increasingly, quantify large numbers of proteins in complex samples. a particular form of protein-chip array technology combined with time-offlight mass spectrometry -called surface-enhanced laser-desorption/ionization time-of-flight mass spectrometry (seldi-tof-ms) -allows the determination of complex protein patterns in serum, body fluids and tissue samples 36 . this technique offers the advantages of speed, simplicity and sensitivity in conditions that are hard to diagnose, such as alzheimer's disease 37 , cancers [38] [39] [40] and autoimmune diseases 37, 41 . its use for the diagnosis of infectious diseases has been anticipated 42 , but no experimental data have been published so far. the availability of complete genome sequences in computerized databases has facilitated the rational selection of pcr and sequencing primers. primer specificity can be tested using in silico tools such as blast (basic local alignment search tool) 53 . repeated sequences can be selected to increase the sensitivity of detection 54 . another advantage is the facility to select new, specific sets of primers when contamination is encountered in a pcr assay (for example, for suicide pcr 55 ). a major pitfall in the molecular detection of microorganisms is the number of false-positive results due to contamination in 'home-made' pcrs. this problem can be overcome by fully automating the process, from processing the sample to sequence or molecular identification. the other current limitation is the presence in clinical samples of inhibitors that are not removed completely by boiling or adding bovine serum albumin 56 . in the case of viruses, the discovery of the hepatitis c virus in 1989 triggered the use of molecular methods to search for unknown viral agents in clinical specimens 57 and raised the suggestion that many human diseases of unknown aetiology might be caused by unrecognized viruses. the hepatitis c and e viruses were identified by immunoscreening or differential hybridization of libraries that were constructed without any amplification 57, 58 . the human tt virus was characterized using representational difference analysis 59 . other methods that might be useful for detecting unknown viruses include the dnase treatment of serum followed by sequence-independent single-primer amplification (sispa) 60 . serum is easy to obtain, store and send on filter paper for analysis 61 . the indirect diagnosis of infectious diseases by the detection of specific antibodies will continue to be a key approach for clinical microbiologists. both individual, ready-to-use assays that would be available in the doctor's surgery and platform tests for high-throughput screening and diagnosis could be developed.'at-doctor' serology tests would be useful for the rapid determination of the status of a patient and for speedy decision-making regarding post-exposure prophylaxis and treatment. in addition, the rapid detection of specific igms during epidemics could help to improve isolation measures for patients who are suspected to be infected. antigenic microarrays will enable testing for several pathogens in parallel using little serum and few reagents. all the pathogens that are known to be causative agents of a particular clinical syndrome could therefore be tested for simultaneously using an antigenic microarray. moreover, the versatility of this new assay will allow emerging pathogens to be quickly incorporated into the test. future developments in antigenic microarray technology will include the development of automation for the indirect diagnosis of infectious diseases. the microarray apparatus could be fully automated up to the result output; generation of output would be rapid, as the overall process will probably take less than 2 hours, and automated for serological studies, antigen-coated microspheres can be incubated with sera, and a fluorescence-conjugated antibody against human igg added in a second step. fcm can then be used to detect the fluorescent microspheres 47 . fcm can also simultaneously detect antibodies to more than one antigen by coating different antigens on different-sized particles. fcm can even analyse the antibody response to hiv by simultaneously detecting specific antibodies to the various antigens of the virus. given the versatility of fcm, it is likely that the number of applications of this technique in clinical microbiology will increase in the future. the growth of microorganisms could be evaluated and fluorogenic-substrate-hydrolysis fcm 3 could also be used. similarly, the development of portable flow cytometers could be useful in detecting acts of biowarfare. one of the main challenges of clinical microbiology is the identification of microorganisms in clinical specimens. this can be achieved using the following methods: i) growth of microorganisms in culture, using media or cell lines, with varying incubation times, temperatures and atmospheres. experience has shown that the hypothesis that some microorganisms cannot be grown in the laboratory might not necessarily be true [48] [49] [50] ; ii) detection of microorganisms within infected tissues by light or electron microscopy; and iii) detection and identification of previously unknown dna or rna fragments or antigens. the most appropriate test depends on the incidence of infection, how contagious the agent is and the health consequences for the patient and the community. cell-culture systems have made a crucial contribution to the diagnosis of infectious diseases that are caused by viruses and intracellular bacteria. such systems have not only made the direct isolation and identification of microorganisms possible, but have also enabled the production of antigens for serological assays, evaluation of the efficacy of antimicrobial agents and the production of vaccines 50 . because no single cellculture system has so far been found to be suitable for the isolation of all intracellular microorganisms, the search for other susceptible cell lines will continue. another source of progress in the development of culture media is the analysis of genome sequences. the availability of these sequences allows any important metabolic pathways that are missing to be identified, and could therefore permit the design of culture media that are specific for a particular microorganism 49 . the most spectacular advance in the diagnosis of infectious diseases has been the recent introduction of molecular detection methods, especially pcr and rt-pcr (pcr after reverse transcription of rna). molecular techniques also enable the detection of multiple infectious agents -including bacteria, viruses and fungi -by multiplex pcr 74 , microarrays (which can detect all potential agents in an infection 51 ) and quantitative assays, such as real-time pcr 52 . a strategy that analyses the differences between two complex genomes. technique that uses a single linker/primer, which is ligated to blunt-ended molecules. gene 67 . they have also been developed for virusesfor example, for hiv-1 (trugene hiv-1 genotyping kit; bayer) 68 to detect mutations of the genes that encode the hiv protease and reverse transcriptase, and for cytomegalovirus, in which resistance to ganciclovir is mainly caused by mutations of the gene that encodes phosphotransferase 69 . the panel of genes that are known to be associated with resistance is expected to increase considerably in the future. microbial surveillance and reporting. automated methods for microbial identification will allow epidemiological trends to be followed more easily in hospitals and in the community. similarly, automation in the molecular diagnosis of resistance to key antibiotics could allow bacterial resistance in hospitals to be surveyed online. this information can be updated weekly to provide data that are pertinent to the infection-control department (where one exists), and also to clinical physicians. for example, weekly tabulation of the documented cases of respiratory syncitial virus, influenza virus and rotavirus could help to establish prevention measures. likewise, regular tabulation of microbial antibiotic resistance trends will assist hospitals in making empiric recommendations for antibiotic treatment. clinical microbiology laboratories. the general organization of the clinical microbiology laboratory of the future is the subject of much controversy 4,70,71 (table 1; fig. 3) . some of the work that is now carried out in laboratories could be ceded to patients and doctors with the commercial development of self-testing kits, such as those that detect hiv infection using saliva or blood spots and those that diagnose group a streptococcus throat infections. the number of available 'at-doctor' tests might increase and could potentially include the detection of group b streptococci in the vaginas of pregnant women and detection of s. aureus in the nasal passages of patients and healthcare workers. these tests could be made available at outpatient clinics. the organization of clinical microbiology laboratories in the future might follow the current trend in the life sciences for the development of large, centralized laboratories with more organized and efficient transport of samples to these laboratories and computer-based communication of results. hospital-based laboratories have largely disappeared in the united states in microarrays could test several parameters simultaneously (for example, testing for antigens and different classes of antibody), thus allowing pathology-driven testing instead of the pathogen-driven testing that is carried out at present. as several antigens can be tested for simultaneously, this development will lead to a severalfold decrease in labour time and, consequently, a reduction in cost. these automated microarrays will be suitable both for mass screening of sera in epidemiology studies and in blood banks, and for diagnostics that are carried out on single serum samples in clinical microbiology laboratories. antimicrobial-susceptibility testing. two strategies are available for determining antimicrobial susceptibility: phenotypic and genomic methods. phenotypic methods for bacteria include dilution and disc-diffusion methods, and real-time pcr has been used for fastidious bacteria that can only be grown in tissue culture [62] [63] [64] . fcm has proved to be very useful in studying the physiological effects of antimicrobial agents on bacterial cells. it can also be used for antimicrobial-susceptibility testing and can indicate bactericidal and bacteriostatic effects. results are obtained rapidly -often in less than 4 hours -and mixed populations that might respond to antimicrobial agents in different ways can be studied. several commercial companies have produced fcm kits that enable antibiotic-susceptibility testing to be carried out rapidly in clinical microbiology laboratories. new developments in the field of fcm antibiotic-susceptibility testing include assays for slow-growing bacteria, such as mycobacteria 65 . drug resistance in parasites, although it is an increasingly recognized phenomenon, is not generally tested for in clinical laboratories at present because of a lack of standardized methods. fcm has been used successfully to detect resistance to antimalarial drugs in plasmodium spp. 66 in the case of viruses, fcm has been used to screen and understand the activity of antiviral compounds and to test the susceptibility of clinical isolates of hiv. detection of the genes or mutations that are responsible for resistance to antimicrobial agents is an alternative to phenotypic detection and can be carried out directly on clinical specimens. molecular tests for resistance have been developed commercially for bacteria such as staphylococcus aureus (lightcycler® staphylococcus kit m grade; roche), in which resistance to oxacillin is primarily mediated by the meca bactericidal an antibiotic that kills 99.99% of a bacterial population. bacteriostatic an antibiotic that inhibits the growth of a bacterial population. the technicians and engineers and the overall strategy of the laboratory, such as when to implement new tests or to stop using others; and contributing to the international scientific community by reporting cases of rare infectious diseases. it is anticipated that the capacity of laboratories to handle highly pathogenic microorganisms with the appropriate levels of safety will increase in the future. certainly, if larger laboratories are created, they would be expected to have the capacity to grow hazardous microorganisms at biosafety level 3, to detect agents that might be used in bioterrorism, to deal with emerging pathogens and to detect uncultured viruses by electron microscopy. as already mentioned, the necessity for laboratories with these advanced capabilities was shown recently in the cases of the sars outbreak and the anthrax bioterrorism attacks. these laboratories could work as reference centres and could be connected in national and international networks, servicing not only local and regional areas, but also remote areasincluding developing countries. the sampling strategies that are used in clinical microbiology need to improve in the future for several reasons. requests for laboratory tests to diagnose infectious diseases depend largely on the knowledge of the physicians who are caring for patients. as a result, there is considerable variability in the appropriateness of the samples submitted and, therefore, in the accuracy of the resulting laboratory diagnoses. for example, the standardization of sampling for infectious endocarditis (for which three blood cultures and serological testing are required for diagnosis) could dramatically reduce the number of culture-negative endocarditis patients 72 . in diseases such as pneumonia and meningoencephalitis, the number of known aetiological agents is increasing and depends on many epidemiological factors. the identification of aetiological agents should benefit from the use of versatile diagnostic tools. to be optimally efficient, sampling strategies and laboratory tests should be primarily evidence-based. to optimize diagnostic efficiency, a possible strategy would be to sample by syndrome -for example, nosocomial pneumonia, endocarditis, infectious arthritis, meningoencephalitis, uveitis or fever on return from tropical areas. such a strategy should be based on an extensive review of the international literature that identifies the potential aetiologies of a given syndrome. the most appropriate clinical samples and laboratory tests could be deduced from this information, and diagnostic kits could be developed for each syndrome. this strategy would enable a rational search for aetiological agents, limit the use of unnecessary tests and improve the costeffectiveness of diagnosis. another advantage of such a strategy is that it could be coupled to a versatile diagnostic method that enables the identification of a large panel of microorganisms. such versatile methods are available for culture, molecular detection (with broadrange standardized pcr assays), fcm detection assays and broad-range microarrays. recent times, although this has resulted in increased physician dissatisfaction with clinical microbiology services (table 1) . large, centralized laboratories, however, are more able to meet the increasing demand for specific tests that are performed infrequently, should enable increased processing of samples at night and at weekends and also provide improved access to highly specialized experts. the creation of large, centralized laboratories will require the training of technicians and engineers in the use of sophisticated techniques and instruments. in addition, the molecular identification of microorganisms requires training in bioinformatics. the roles of different types of personnel in clinical microbiology laboratories in the future might be as follows: highly qualified, dedicated technicians or engineers would be required to maintain instrument platforms, owing to their increasing complexity; diagnostic tests would be performed by technicians; new diagnostic tests would be developed by engineers. the activity of the clinical microbiologist would therefore be re-oriented towards the evaluation and interpretation of tests, including the determination of their sensitivity, specificity and predictive values; communication of results to clinicians, in particular, infectious-disease specialists; advising on antibiotic therapy and sampling strategy in conjunction with infectious-disease specialists; following trends in disease epidemiology and reporting these trends to infection-control departments; coordinating the work of pictures can be e-mailed to clinicians for incorporation into the patient's medical records. there have been substantial changes in the role of clinical microbiology laboratories over the past decade. the ongoing technological revolution has rapidly transformed research, diagnostic and therapeutic tools. however, there is still a requirement for the reliability and the standardization of sampling and biological testing to be increased as information is exchanged internationally. in future, the organization of clinical microbiology laboratories will probably follow that of other areas of the life sciences -that is, with large centralized laboratories and a local head. the position and the role of experts in clinical microbiology processes will become an important question. the interpretation of diagnostic tests can require different levels of expertise. the predictive value of a test depends on its intrinsic quality and on the prevalence of the disease in the population. therefore, the final interpretation relies on both the microbiologist and the physician. in some instances, the indications of the clinical and epidemiological data to the laboratory will make it possible for a diagnosis to be made.in other cases, communication of the intrinsic values of the test (for example, sensitivity and specificity) might allow an infectious-disease specialist to make a diagnosis on-site (fig. 1) . finally, the need for consultation on rare diseases with experts around the world using the internet will increase. in our experience, we receive queries about the diagnosis and treatment for whipple's disease and q fever several times a week. such queries for assistance will probably increase in number as experts in particular fields become more readily identified by physicians, and even patients, through the internet. a key development in clinical microbiology has been in the technology that is available to produce digital pictures, which enables image libraries to be established and readily exchanged. this includes pictures taken during clinical examinations when cutaneous signs are present, light-, confocal-and electronmicroscopy pictures, and images of microarray analyses. although it is still rare, microbiology reports can be enhanced with digital images of the organisms that are involved. the inclusion of digital photographs of gram-stain and acid-fast-stain preparations is technically possible, and precedents for providing such images have already been set by current pathology and radiology information systems. picture digitalization enables information to be sent instantly by e-mail. the feasibility of using static-image telepathology to assess gram-stained microbiological preparations has been evaluated positively, although the selection of informative microscopic fields before their transmission was a prerequisite for success 73 . a major application of these images is that they can be used to obtain expert advice. this is of particular importance with p3 emerging and re-emerging agents and with group a and b agents of bioterrorism. in such cases, microbial agents must be confined in secure laboratories, but their digital images can be freely exchanged. the e-mailing of digital pictures was recently helpful in the management of patients with suspected smallpox or anthrax. in a patient presenting with multiple haemorrhagic vesicles on the face, anonymous digital pictures of the clinical features were e-mailed to the united states centers for disease control and prevention to obtain an expert opinion 74 and the usefulness of such pictures was emphasized during the sars outbreak 75 . in addition, appropriate microbiology clinical microbiology: past, present, and future manual of clinical microbiology manual of clinical microbiology role of clinical microbiology laboratories in the management and control of infectious diseases and the delivery of health care speculations on the microbiology laboratory of the future 16s ribosomal dna sequence analysis of a large collection of environmental and clinical unidentifiable bacterial isolates sequence -evolution -function: computational approaches in comparative genomics rpob sequence analysis as a novel basis for bacterial identification rapid identification of mycobacterium tuberculosis and mycobacterium avium by polymerase chain reaction and restriction enzyme analysis within sigma factor regions mitochondrial genomes of parasitic flatworms herpes consensus pcr test: a useful diagnostic approach to the screening of viral diseases of the central nervous system multilocus sequence typing: a portable approach 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sera of men with prostatic neoplasms clinical potential of proteomics in the diagnosis of ovarian cancer the seldi-tof ms approach to proteomics: protein profiling and biomarker identification analysis of complex autoantibody repertoires by surface-enhanced laser desorption/ionization-time of flight mass spectrometry a rapid protein profiling system that speeds study of cancer and other diseases illustrates the necessity of electron microscopy in clinical microbiology laboratories application of an automated specimen search system installed in a transmission electron microscope for the detection of caliciviruses in clinical specimens ultrastructural telepathology -remote em-diagnostic via internet practical flow cytometry applications of flow cytometry to clinical microbiology cultivation of the bacillus of whipple's disease. new engl genome-based design of a cell-free culture medium for tropheryma whipplei the first illustration of genome-driven axenic-culture technique traditional 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parvovirus species diagnosis of rickettsial diseases using samples dried on blotting paper evaluation of antibiotic susceptibilities of three rickettsial species including rickettsia felis by a quantitative pcr dna assay in vitro activities of telithromycin (hmr 3647) against rickettsia rickettsii, rickettsia conorii, rickettsia africae, rickettsia typhi, rickettsia prowazekii, coxiella burnetii, bartonella henselae, bartonella quintana, bartonella bacilliformis, and ehrlichia chaffeensis molecular evaluation of antibiotic susceptibility: tropheryma whipplei paradigm cytometric detection of mycobacterial surface antigens: exposure of mannosyl epitopes and of the arabinan segment of arabinomannans flow cytometric two-color staining technique for simultaneous determination of human erythrocyte membrane antigen and intracellular malarial dna expression of resistance to methicillin antiretroviral drug resistance testing in adults infected with human immunodeficiency virus type 1: 2003 recommendations of an international aids society usa panel prediction of cytomegalovirus load and resistance patterns after antiviral chemotherapy microbiology on the merge: the business of clinical practice role of the clinical microbiology laboratory in infection control -a danish perspective a clinical study of culture-negative endocarditis telemicrobiology: feasibility study a smallpox false alarm the cdc reply: a smallpox false alarm multiplex pcr optimization and application in diagnostic virology we thank c. corona for secretarial assistance. the authors declare competing financial interests; see web version for details. key: cord-310150-j1mvr9r9 authors: wei, wei; hu, xiao-wen; cheng, qi; zhao, ying-ming; ge, ya-qiong title: identification of common and severe covid-19: the value of ct texture analysis and correlation with clinical characteristics date: 2020-07-01 journal: eur radiol doi: 10.1007/s00330-020-07012-3 sha: doc_id: 310150 cord_uid: j1mvr9r9 objective: to explore the value of ct texture analysis (ctta) for determining coronavirus disease 2019 (covid-19) severity. methods: the clinical and ct data of 81 patients with covid-19 were retrospectively analyzed. the texture features were extracted using lk2.1. the two-sample t test or mann–whitney u test was used to find the significant features. minimum redundancy and maximum relevance (mrmr) method was performed to find the features with maximum correlation and minimum redundancy. these features were then used to construct a radiomics texture model to discriminate the severe patients using multivariate logistic regression method. besides, a clinical model was also built. roc analyses were conducted to evaluate the performance of two models. the correlations of clinical features and textural features were analyzed using the spearman correlation analysis. results: of the total cases included, 60 were common and 21 were severe. (1) for textural features, 20 radiomics features selected by mrmr showed good performance in discriminating the two groups (auc > 70%). (2) for clinical features, chi-square tests or mann–whitney u tests identified 16 clinical features as significant, and 12 were discriminative (p < 0.05) between two groups analyzed by univariate logistic analysis. of these, 10 had an auc > 70%. (3) prediction models for textural features and clinical features were established, and both showed high predictive accuracy. the auc values of textural features and clinical features were 0.93 (0.86–1.00) and 0.95 (0.95–0.99), respectively. (4) the spearman correlation analysis showed that most textural and clinical features had above-moderate correlations with disease severity (> 0.4). conclusion: texture analysis can provide reliable and objective information for differential diagnosis of covid-19. key points: • ct texture analysis can well differentiate common and severe covid-19 patients. • some textural features showed above-moderate correlations with clinical factors. • ct texture analysis can provide useful information to judge the severity of covid-19. electronic supplementary material: the online version of this article (10.1007/s00330-020-07012-3) contains supplementary material, which is available to authorized users. in december 2019, coronavirus disease 2019 was discovered in wuhan, china, and then spread across the country [1] [2] [3] . according to chinese guideline, covid-19 is clinically divided into four types: mild, common, severe, and critically severe [4] . compared with healthy individuals, mild covid-19 shows no obvious ct abnormality, but the other three do. yang et al [5] reported that the mortality of severe covid-19 in wuhan exceeded 60%. therefore, early and correct evaluation of covid-19 severity and timely treatment can improve patients' prognosis. ct plays an important role in the evaluation of covid-19. clinical ct results are made by physicians through analyzing the size, shape, position, and internal density of ct images. however, this analysis fails to capture diagnostic/prognostic information about the lesion. through, texture analysis, mathematical methods are used to extract meaningful characteristics of an image at different gray levels, so as to quantify the lesion's heterogeneity [6] . this retrospective study was performed to analyze the correlations among ct texture features, clinical features, and clinical subtypes of covid-19 and to explore the value of ct texture analysis in determining the severity of covid-19. our institutional review board (irb) waived written informed consent for this retrospective study, which evaluated deidentified data and brought no potential risk to patients. to avert any potential breach of confidentiality, no link between the patients and the researchers was available. the patients' data were collected from the first affiliated hospital of university of science and technology of china and the affiliated infectious disease hospital. during the period between january 20, 2020 and february 20, 2020, patients were included if they met the following criteria: (1) exhibiting positive results of 2019-ncov nucleic acids and (2) having undergone chest ct examination during the initial diagnosis (within 3 days after admission). excluded were those who had no obvious lung ct abnormalities or had fig. 1 a common case of covid-19. a man aged 53 years presented with a 3-day history of fever, cough, and sputum. a, b on the third day after disease onset, ct imaging revealed pure ground-glass opacity (ggo) and ggo with fine grid in the bilateral lobes. c, d the area of the lesions was delineated on the axial and reconstructed images. e histogram map of the lesions pneumonia caused by other common bacterial or viral pathogens. according to the clinical classification criteria, 81 patients were enrolled (60 common cases and 21 severe cases). ct was performed for all patients within 3 days after disease onset, with a 128-slice ct detector (neuviz 128) without contrast agent. the scanning parameters were as follows: tube voltage, 120 kvp; tube current, 150 ma; rotation time, 0.8 s; slice thickness, 5 mm; slice interval, 5 mm; pitch, 1.2; matrix, 512 × 512; and breath-holding when fully aspirated. all images were segmented on the lk2.1 software package (ge healthcare). first, the images were resampled to voxel size 1 × 1 × 1 mm 3 , and a gaussian filter was applied for denoising. then, the lung was automatically segmented into five lobes, three-dimensional volumes of interest (vois) were created for each lobe, and the ct score was calculated [7] . if the automatic segmentation failed to create favorable volumes, an experienced radiologist was assigned to manually delineate the vois, and another radiologist to check the segmentation. any difference in opinions was resolved through negotiation. pyradiomics was performed to extract features. in total, 1042 features were extracted, including histogram features, gray-level co-occurrence matrix, gray-level size zone matrix (glszm), and gray-level run length matrix (glrlm) features. all statistical analyses were performed using r (version 3.5.1; www.r-project.org) software. first, for radiomics features and ct score, the independent t test or wilcoxon test was used. for clinical features described as continuous variables, the mann-whitney u test was used for abnormal distributions and t test for normal distributions. for clinical features described as nominal variables, chi-square test or fisher's exact test was used. features with p <0.05 were deemed statistically significant. second, for radiomics features, univariate logistic analysis was performed to evaluate whether the features were discriminative in two groups (p < 0.05). then, the minimum redundancy and maximum relevance (mrmr) algorithm was applied to further select the relevant and non-redundant features. for clinical factors, univariate logistic analysis was performed to find the discriminative features (p < 0.05). third, for both radiomics features and clinical features, backward a man aged 47 years presented with a 7-day history of fever, cough, and sputum. a, b on the third day after disease onset, ct imaging revealed diffuse pure ggo and ggo with fine grid in the bilateral lobes. c, d the area of the lesions was delineated on the axial and reconstructed images. e histogram map of the lesions stepwise multivariate logistic regression selection was performed, and the likelihood ratio test was used to select the subset of the most predictive features and construct the predictive model. finally, to verify the reliability of texture analysis, 100-fold leave-group-out cross-validation (lgocv) was performed. finally, spearman correlation analyses were performed to evaluate the correlations between the predictive radiomics features and clinical factors. eighty-one patients with a mean age of 51.35 ± 14.31 years diagnosed with covid-19 were included. of which, 21 (26%) had severe and 60 (74%) had common symptoms. the ct characteristics included ground-glass opacity (ggo) or ggo combined with fine grid or consolidation. patients with severe disease exhibited diffuse lesions; in four patients, initial ct images showed involvement in all the segments of both lungs. most lesions were observed in the peripheral zone of the lung field, particularly the lower lobe. figures 1 and 2 show representative images of common and severe covid-19, respectively. of the 1042 radiomics features, 511 were statistically significant when assessed by independent t test or mann-whitney test (p < 0.05). of these, 358 were selected by univariate logistic analysis (p < 0.05), then 20 were retained after mrmr analysis. the auc values of these 20 radiomics features are shown in fig. 3 a. all of them showed good predictive performance, with auc values > 70%. of the clinical fig. 3 b. after backward stepwise multivariate logistic regression and selection with the likelihood ratio test, eight radiomics features ( table 2 ) and four clinical features (table 3) were finally retained, and predictive models were constructed. both the radiomics signature and the clinical model showed favorable predictive accuracy, with auc values of 0.93 (0.86-1.0) and 0.95 (0.95-0.99), respectively (fig. 3c, d) . the sensitivity, specificity, and accuracy were calculated based on the youden index (table 4) . both the clinical model and radiomics signature showed good performance in discriminating patients with common and severe covid-19. in the clinical model, the accuracy, sensitivity, and specificity values were 0.91, 0.81, and 0.95, respectively; in the radiomics signature, these values were 0.90, 0.90, and 0.90, respectively. the mean accuracy, sensitivity, and specificity values of the 100-fold lgocv are shown in (table 5 ). both the clinical and radiomics models showed good stability, indicating that the texture analysis was valuable for discriminating common and severe covid-19 patients, and that the results were not due to overfitting. the correlations between the predictive radiomics and clinical features are shown in fig. 4 . the association was defined as strong (r = 0.7-1), moderate (r = 0.4-0.69), or low (r = 0.1-0.39). the prediction score showed strong correlations with wavelet_lll_glrlm_runlength n o n u n i f o r m i t y ( r = 0 . 8 0 , p < 0 . 0 0 0 1 ) , log_sigma_5_0_mm_3d_glszm_sizezonenonuniformity (r = 0.71, p < 0.0001), wavelet_hhl_glrlm_runlength n o n u n i f o r m i t y ( r = 0 . 7 5 , p < 0 . 0 0 0 1 ) , a n d wavelet_hll_glrlm_ runlengthnonuniformity (r = 0.79, p < 0.001). most other clinical features and radiomics features showed moderate correlations (fig. 4 ). chest ct can be used to make rapid diagnosis and assess the severity of covid-19 patients [8] . on ct images, covid-19 may be manifested with ggo, ggo combined with grid, and/or consolidation, all changing rapidly [9] . we can judge the severity of the disease by the lesion range on the ct image, the results of which may be subjective and inaccurate. in ct texture analysis, image features of different gray levels can be filtered out. an image's pixel and spatial parameters are used to quantitatively extract pathophysiological features of the lesions that cannot be recognized by naked eyes and to reveal the internal heterogeneity between tissues [10] [11] [12] . texture analysis is objective in that it evaluates lesion with gray level on the image [13] . covid-19 is an acute and highly infectious disease [12] . early prediction and timely treatment can improve patients' prognosis. the clinical stages of covid-19 have been rarely classified by texture analysis based on ct images. in this study, a radiomics texture model and a clinical model were established for 81 patients to early predict the clinical stages of covid-19, and a correlational study was conducted to reveal the associations between ct and clinical variables in common and severe patients. both radiomics and clinical models showed favorable predictive accuracy, with an auc of 0.93 (0.86-1.0) and 0.95 (0.95-0.99), respectively. the prediction model based on ct text features achieved a sensitivity of 0.80 and a specificity of 0.95, which means that ct texture analysis can early accurately assess disease severity. it has been reported that coronavirus acts mainly on lymphocytes, especially t lymphocytes, as sars-cov does. therefore, a decrease in lymphocytes can be used as a reference index for clinical diagnosis of new coronavirus infection [14] [15] [16] [17] . cd3 represents the total count of t lymphocytes, and cd4 or cd8 represents that of their subsets. among the clinical features measured in this research, the percentage and absolute count of lymphocytes and the counts of cd3, cd4, and cd8 in the severe group decreased significantly and showed high diagnostic value to differentiate patients of different covid-19 severity levels (all auc > 70%). these results suggest that the lymphocyte count in the severe group was much lower than that in the common group. feng et al [18] used a semi-quantitative scoring system to quantitatively estimate the pulmonary involvement of lung lesions. the inflammation score was correlated with the severity. our results showed that the inflammation score was also effective in the differential diagnosis between the two groups (auc = 88%). we used lgocv to verify the reliability of the multivariate logistic regression model, and the results showed that both the imaging and clinical models had good stability. in the training and validation sets, the average accuracy, sensitivity, and specificity values resulting from 100-fold cross-validation were above 0.8, indicating that the results of the model were not caused by overfitting. the results of 100-fold cross-validation in the imaging model showed that the logarithmic transformation characteristics of log_sigma_3_0_mm_ 3 d _ g l s z m _ g r a y l e v e l n o n u n i f o r m i t y a n d log_sigma_1_0_mm_3d_glszm_largeareaemphasis appeared more than 50 times during the 100 times crossv a l i d a t i o n s ( s u p p l e m e n t a r y m a t e r i a l s ) . t h e glszm_graylevelnonuniformity variable was used to measure the variability of gray-level intensity values in the image, with lower values indicating higher homogeneity of intensity values. further, glszm_largeareaemphasis was used to measure the distribution of large-sized area zones, with greater values indicating more large-sized area zones and more coarse textures. and the wavelet characteristics include wavelet_hhl_glrlm_runlengthnonuniformity and wavelet_hlh_glszm_largeareahighgraylevelemphasis, of which wavelet_glrlm_runlengthnonuniformity measures the similarity of run lengths throughout the image, with a lower value indicating more homogeneity among run lengths in the image, and wavelet_hlh_glszm_largeareahighgray levelemphasis measures the proportion in the image of the joint distribution of larger-sized zones with higher gray level. besides, the ct score also showed more than 50 times, which means these features had high stability and diagnostic values of the severity of the patients. in the clinical model, inflammation score, hscrp, cd3, pct, and other factors showed more than 50 times during the 100 times cross-validation (supplementary materials), indicating that these parameters were highly correlated with the severity of covid-19. in addition, the spearman correlation analysis was performed to evaluate the correlation between significant imaging and clinical features. the results showed that most of the clinical features (e.g., lymphocyte ratio; absolute value; cd3, cd4, and cd8 counts; crp; and d dimer) had moderate correlations with the imaging features (> 0.4). the strong correlation was found between inflammatory score and partial wavelet transform features and region size matrix glszm features (> 0.7), indicating that these image features are closely related to disease severity and can be used for clinical type classification of the covid-19 patients. this study has some limitations. firstly, this study is retrospective, and the sample size is small, especially in the severe group, with only 21 cases. secondly, some cases have small ground-glass lesions that may be missed when the roi is automatically delineated. in future studies, it is necessary to increase the number and type of samples. thirdly, in clinical practice, covid-19 should be differentiated from other pulmonary diseases or other pneumonias. but, we did not apply ctta to differentially diagnose covid-19 in this study. finally, our results may have had some bias. in this study, we did not consider the effect of patient's underlying disease, such as chronic respiratory disease (emphysema or interstitial pneumonia, etc.), on the severity judgment. we will establish a multicenter study to explore the value of ct texture analysis in the differential diagnosis of covid-19. in summary, texture analysis can provide reliable and objective information for differential diagnosis of covid-19. funding information this study has received funding by the fundamental research funds for the central universities (wk9110000002). guarantor the scientific guarantor of this publication is wei wei, md. conflict of interest one of the authors of this manuscript (ya-qiong ge) is an employee of ge healthcare. the remaining authors declare no relationships with any companies whose products or services may be related to the subject matter of the article. statistics and biometry yaqiong ge kindly provided statistical advice for this manuscript, and no complex statistical methods were necessary for this paper. informed consent written informed consent was waived by the institutional review board. ethical approval institutional review board approval was obtained. • retrospective • diagnostic or prognostic study • performed at one institution epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study world health organization. who director-generals remarks at the media briefing on there is a strong association between the correlation scores and radiomics features 4. general office of national health committee. office of state administration of traditional chinese medicine. notice on the issuance of a programme for the diagnosis and treatment of novel coronavirus (2019-ncov) infected pneumonia clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study texture analysis of medical images pulmonary sequelae in convalescent patients after severe acute respiratory syndrome: evaluation with thin-section ct temporal changes of ct findings in 90 patients with covid-19 pneumonia: a longitudinal study initial ct findings and temporal changes in patients with the novel coronavirus pneumonia (2019-ncov): a study of 63 patients in wuhan ct texture analysis: definitions, applications, biologic correlates, and challenges a review of content-based image retrieval systems in medical applicationsclinical benefits and future directions effect of probability-distance based markovian texture extraction on discrimination in biological imaging radiomics: images are more than pictures, they are data evolution of the novel coronavirus from the ongoing wuhan outbreak and modeling of its spike protein for risk of human transmission radiographic and ct features of viral pneumonia clinical features of patients infected with 2019 novel coronavirus in wuhan pathological findings of covid-19 associated with acute respiratory distress syndrome time course of lung changes on chest ct during recovery from 2019 novel coronavirus (covid-19) pneumonia publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-347189-i9rzo3j0 authors: lorusso, domenica; ray-coquard, isabelle; oaknin, ana; banerjee, susana title: clinical research disruption in the post-covid-19 era: will the pandemic lead to change? date: 2020-10-13 journal: esmo open doi: 10.1136/esmoopen-2020-000924 sha: doc_id: 347189 cord_uid: i9rzo3j0 nan the unprecedented situation we are facing has strongly disrupted the clinical research rules. nevertheless, for the scientific community, it may represent the opportunity to learn important lessons. the covid-19 pandemic suggests that it is possible to alleviate redundancy in clinical trials, and while preserving the rigour of a study, can offer a new, less burdened and more inclusive vision of clinical research for the scientific community of tomorrow. this perspective article describes clinicians' vision of how the pandemic could change the roles of clinical research. since the beginning of the sars-cov2 outbreak in wuhan, more than 24 million people have been infected all around the world and more than 800 000 have died from the disease so far. in this scenario, europe is facing one of the worst crises that our national health systems have ever encountered in the last 50 years. six months after the first covid-19 diagnosis, the lockdown is being eased in european countries and our lives are slowly adapting to 'a new normality'. providing care to immunocompromised patients with cancer during this pandemic has been extremely challenging and oncologists face many challenges in providing cancer care during the covid-19 outbreak. data from china reported that patients with cancer who are infected with covid-19 are at 3.5 times the risk of requiring mechanical ventilation or intensive care unit (icu) admission, compared with the general population. 1 additionally, the limitation of resources in outpatient settings, including administrative staff and specialists, has hindered the routine care of patients. 2 national and international cancer societies published priority-driven guidelines for the management of oncohaematological patients on therapy during the covid-19 pandemic and recommended considering treatment delays and modifications on a case-by-case basis, taking into account the characteristics of the patient and the disease. 3 in addition to routine patient care, the imperative of reducing the number of non-urgent visits to the hospitals, which characterised the last 6 months, had implications for research institutions performing clinical trials. an italian survey of medical oncologists reported that both clinical research and scientific activities were reduced in over 80% of respondents. 4 although conversion to telemedicine has maintained the continuity of care for many patients, the covid-19 pandemic has massively disrupted clinical research and many cancer centres halted clinical trial activities including patient recruitment. regulatory agencies have disseminated extraordinary measures to guide healthcare workers to continue clinical trials ensuring patient safety and maintaining data quality. the implementation of these measures has helped mitigate the negative effects of the pandemic on the clinical research field (https:// ec. europa. eu/ health/ sites/ health/ files/ files/ eudralex/ vol10/ guid ance clin ical trials_ covid19_ en. pdf). hospitals have needed to prioritise clinical activities managing patients and staff suffering from covid-19. therefore, carrying out clinical trials according to the rigid interpretation of gcp-ich (good clinical practices-international conference on harmonisation) rules was not always practically feasible. as we adapt to 'the new normal', there is a feeling among some healthcare workers that the important lessons learnt during the pandemics will disappear with the end of the emergency phase. in the field of clinical research in oncology, for instance, we learnt that a reasonable balance can be achieved between maintaining the scientific integrity of the study, patient safety and regulatory burden. during the covid-19 era, both individual researchers and research organisations have realised that there is a different way of delivering clinical research and that 'flexibility' and 'altruism', which have been keywords of the covid-19 era, may represent one of the legacies as we move forward within the post-covid-19 world. practical solutions used during the pandemic that merit the consideration of long-term implementation in clinical research include the following. 1. telemedicine: the covid-19 pandemic led to an unprecedented change in clinical operations, motivating physicians and healthcare systems worldwide to rapidly implement telemedicine programmes to reduce or replace in-person visits and to allow workforce sustainability and staffing. 5 before the pandemic, telemedicine was underused while actually, it is quickly becoming the preferred mode of delivering care for patients with cancer including follow-up, on-treatment and second opinion consultations. when asked about the perception of safety to attend research visits 'remotely' or in-person, half of clinical trial participants preferred phone visits 6 or telehealth that is enhanced by face-to-face communication. 7 a 2015 cochrane review examined the impact of telemedicine involving remote monitoring compared with in-person or telephone visits for chronic conditions, including diabetes and heart failures, and found similar health outcomes. 8 larson et al 9 showed that telemedical intervention in patients with cancer is comparable with face-to-face interaction meetings regarding the quality of life but no data exist about the oncological outcome in patients who received telemedical advice. these measures, although necessary in the context of the pandemic, serve as an opportunity to reconsider the utility of frequent in-person hospital visits for patients enrolled in clinical trials, particularly when the therapeutic is an oral drug that can be delivered by courier service. moreover, less than 5% of cancer clinical trials adequately accrue ethnic minorities (or 0.7 with respect to white patients in cancer clinical trials) 10 and a potential explanation is that travel burden to centres mandated by specific trials (eg, rare cancers) implies time off from work and family commitments for both patients and careers leading to financial repercussions. 11 therefore, reducing the frequency of in-person visits could potentially increase access to clinical trials participation and diversity in recruitment. at present, several activities can be potentially provided by electronic tools (informed consent discussion and signature, medical history collection focused on addressing eligibility criteria during the screening procedures, evaluation of the quality of life and safety with electronic patient reported outcome (epro)) and this could be permanently accepted in clinical trials procedures. the implementation of telemedicine requires funding, user guidelines, data protection integrity and management of reimbursement policies. lack of privacy and security standards plays an important role in the legal challenges facing telemedicine and may have considerable implications for the acceptance of telemedicine services. 12 moreover, the relationship between telemedicine reimbursement rules and access to care is complex; although the covid-19 pandemic has certainly brought increased coverage for telemedicine services, nationwide standardisation of payment policies is still lacking. 13 with the second-largest burden of covid-19 in the world, for instance, italy does not currently include telemedicine in the essential levels of care granted to all citizens within the national health service and no formal input was given on telemedicine by health authorities, despite high pressure on health services during the first phase of the epidemic. however, the time has arrived to change this situation, and experts from different fields should work together on this important issue. 2. remote monitoring visits: given the pandemic, alternative mechanisms of oversight and monitoring have been implemented including remote monitoring. local data protection policies in many parts of europe often precludes the remote source data verification (eg, providing the sponsor with copies or remote access to electronic medical records). it is evident that such a model cannot work alone, nevertheless, a mixed (on-site and remote), risk-based model that takes into consideration national and local restrictions and the urgency of source data verification can be permanently implemented in the new research organisational model. remote monitoring for some clinical trials is feasible and cost saving for the sponsor. this may be particularly relevant for academic-sponsored trials, given that on-site monitoring can account for about 20% of the total trial budget. 14 3. laboratory tests: during the pandemic, when it was not feasible for patients to travel to the clinical trial centre, it was acceptable that blood tests, imaging or other diagnostic tests were done at a closer local facility provided it is certified as per national requirements. the ability for tests to be carried out outside of the trial centre perhaps should be continued and integrated into clinical trial procedures-at least for some safety blood tests that do not represent the primary endpoint of the trial, and for radiological tests when a centralised evaluation (blinded independent central review (bicr)) is planned for progression-free survival end point analysis, or when overall survival is the main objective of the study. moreover, as a general strategy, methods and frequencies of safety assessments should be rationally determined in trial protocols taking into account preclinical and clinical safety data, be scientifically and ethically justified and balanced with the risks associated with hospital visits. 15 finally, the issue of funding needs to be addressed and the cost of these extra hospitals' procedures need to be traced and reimbursed to the laboratories providing the procedures by the sponsor. this may be easier if research networks are established and oncologists and radiologists of pe-ripheral centres are trained as subinvestigators with delegated duties under the supervision of the main study team. 15 uation. in italy, there are 90 ecs actively evaluating trials and the median lead time between clinical trial application (cta) submission and the site initiation visit (siv) is 202 days (median ec evaluation time 152 days). other studies report even longer duration reaching up to 10-12 months for the whole process of trial activation. 16 during the emergency, aifa (italian medical agency) appointed a unique ec for evaluating all covid-19 interventional studies and this dramatically reduced the time of approval (about 30 days between cta and siv). the outstanding lesson we learnt is that is it not more deferrable the brave decision to identify a single ec for trial (or at least for the area) to speed up the process of approval, particularly when looking at the upcoming implementation of the european portal for cta submission that imposes the identification of a central ec and defines strict times for evaluation. when the clinicaltrials directive (euctd) adopted in 2001 to facilitate and improve clinical research within europe is strictly followed, the median approval duration is 59 days. 17 lastly, a simplification of approval procedures may translate in a significant reduction of the costs of submission: a swiss trial reported a median time of 49 days and a median cost of 72.000 dollars for the submission preparation of a randomised clinical trial to the authorities. 18 5. contract negotiation: the example of the tocilizumab trial. community-based research programmes face many barriers to participation in clinical trials, and research contract and budget negotiations have been consistently identified as time-consuming procedures and a barrier to study participation. american society of clinical oncology 's (asco) community research forum conducted a survey about specific challenges in clinical research among 780 clinicians: 77% of the respondents acknowledged barriers in the process of trial activation in terms of budget negotiation and legal review. 19 after the publication of the survey, asco recommended the standardisation of negotiation processes and the creation of contract templates as necessary tools to implement the trial activation process. 19 during the pandemic, the national cancer institute of naples promoted a therapeutic trial with tocilizumab in patients with covid-19. the drug was supplied free of charge by the drug company, an electronic crf for data entry and drug order was created on the web system of the coordinating centre assuring drug delivery in 24 hours, and a single contract was signed between agenzia italiana del farmaco (aifa) and industry without any administrative acts required at peripheral centres. the fortuitous combinations of all these facilities translated in the opening of 600 centres in less than 3 weeks. aside from the exceptional circumstances of a trial using a drug reducing icu necessity during the emergency, this model suggests that the obligatory implementation of a national contract template, with an agreed line listing activity costs and minimal local negotiations to meet hospital requirements, could dramatically speed up the global process of contracts leading to a faster opening of clinical trials and access for patients. the velocity in trial activation is not an obvious guarantee of trial success in terms of results (actemra/roactemra phase 3 trial in ospitalized patients with covid-19associated penumonia (covac-ta) trial is a clear example of this) but undoubtedly contribute to the efficiency of the system and would be beneficial to all interested stakeholders, including industry sponsors, the research sites and the patients who may ultimately benefit from participation in clinical cancer research. 6. remote regulation audits: regulatory audits sponsored by the authorities are essential to confirm the quality and veracity of clinical data before placing a new molecule or new strategy at the disposal of patients. these on-site audits generally take an enormous amount of preparation time, an attendance time that varies from 3 to 5 full days and mobilises in addition to government personnel, local teams and sponsor teams over many weeks. again, the remote visits and remote controls as set up for certain studies during confinement could be an additional added value in the optimal organisation of tomorrow. 7. data sharing and generosity: the example of the ter-avolt (thoracic cancers international covid-19 collaboration) registry. the idea to collect data on mortality and disease outcome in patients with lung cancer affected by covid-19 was launched in march 2020 with a simple email immediately spread among the international community involved in lung cancer treatment, after the chinese warning that the fatality rate in patients with lung cancer was higher than in other tumours. the teravolt registry involved 21 countries worldwide and was endorsed by a number of international oncology societies and physicians who accepted to collect and share data without any form of financial support. 20 in less than a month, data on 200 patients were collected and analysed, and actually, more than 400 patients have been registered in the ecrf. the scientific community realised that, aside from individualism and personal academic glory, the necessity to collect data to take better care of patients with lung cancer was a priority and responded promptly. in the era of big data and learning machines, the generous and altruistic sharing of knowledge and data, could represent an unimaginable step forward and an unprecedented turning-point in the treatment of cancer. 8. meetings: during the covid-19 era, the majority of research conferences have been cancelled or postponed on an unparalleled scale, and attendance at confirmed meetings is likely to be lower than expected due to the fear of the disease. basically, all the international congress that took place in the last 4 months as asco, esmo breast, aacr and society of gynecologic oncology (sgo) were performed remotely and represented a great success with more people attendant remotely than on-site, reduced time away from the hospital for the physicians, less cost and carbon footprint. nevertheless, besides the current emphasis on online formats, we must honestly recognise that about half of the global population has no internet connectivity. 21 it is time for the global scientific community to recognise the challenges that our less fortunate colleagues regularly face and capture this exceptional opportunity to build a more equitable global community for the scientists of tomorrow. this pandemic has represented an unparalleled threat for all of us, but also a tremendous opportunity for gaining a new vision in the world of clinical research. covid-19 has pointed out that sometimes, high level of bureaucracy in research rules place unnecessary burdens on patients and clinicians and it suggests that it is time to alleviate bureaucracy and introduce some practical changes into research organisation that will possibly promote patient access to trials and reduce the costs of the clinical research. nevertheless, it is of utmost importance to underline that bureaucracy alleviation does not mean laxity with dramatic consequences on the quality and consistency of clinical research and a careful balance needs to be maintained between the simplification of the procedures and the reliability of data. moreover, it is time to remember to ourselves that it is patient care, not personal glory, that provides a sense of meaning in our roles, and to reconsider a more generous approach in sharing information with colleagues in order to build a robust scientific community of tomorrow. 22 given that the pandemic and its consequences are unlikely to dissipate soon, the time is arrived to fundamentally rethink study designs and procedures in order to optimise clinical cancer research. moreover, robust adaptations could make the field more resilient to future pandemics the extent to which changes should be implemented will vary by trial type and phase and although it could be easier to maximise translatability to routine practice for a phase iii trial with a standard arm comparator, it would be more challenging for a first in the human study with new class agents. 15 all these relevant changes will require a profound renewal of our tight global structures. however, if we have the will to have all innovative changes in place in a proper time frame and sharing a common vision and mission on research, then we will be creating a new era in clinical research. the who has encouraged all of us to think innovatively 23 and as walter disney said 'if you can dream it, you can do it'. contributors authors provided equal contribution to the conception, writing and final approval of the paper. funding the authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. competing interests none declared. provenance and peer review commissioned; externally peer reviewed. open access this is an open access article distributed in accordance with the creative commons attribution non commercial (cc by-nc 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, any changes made are indicated, and the use is non-commercial. see: http:// creativecommons. org/ licenses/ by-nc/ 4. 0/. cancer patients in sars-cov-2 infection: a nationwide analysis in china managing cancer care during the covid-19 pandemic: agility and collaboration toward a common goal call for ensuring cancer care continuity during covid-19 pandemic assessing the impact of the covid-19 outbreak on the attitudes and practice of italian oncologists toward breast cancer care and related research activities virtually perfect? telemedicine for covid-19 keep calm and log on: telemedicine for covid-19 pandemic response conducting clinical research during the covid-19 pandemic: investigator and participant perspectives interactive telemedicine: effects on professional practice and health care outcomes the effect of telehealth interventions on quality of life of cancer patients: a systematic review and meta-analysis participation in cancer clinical trials: race-, sex-, and age-based disparities at what cost to clinical trial enrollment? a retrospective study of patient travel burden in cancer clinical trials department of commerce the department of health and human services, national telecommunications and information administration lack of reimbursement barrier to telehealth adoption reducing clinical trial monitoring resource allocation and costs through remote access to electronic medical records rethinking cancer clinical trials for covid-19 and beyond regulatory approvals in a large multinational clinical trial: the esprit experience does the european clinical trials directive really improve clinical trial approval time? resource use, costs, and approval times for planning and preparing a randomized clinical trial before and after the implementation of the new swiss human research legislation challenges with research contract negotiations in community-based cancer research covid-19 in patients with thoracic malignancies (teravolt): first results of an international, registry-based, cohort study the global academic research organization network: data sharing to cure diseases and enable learning health systems world health organization. who director general's opening remarks at the media briefing on covid-19 -11 key: cord-255140-3dwqqgv1 authors: christian, michael d. title: biowarfare and bioterrorism date: 2013-07-04 journal: crit care clin doi: 10.1016/j.ccc.2013.03.015 sha: doc_id: 255140 cord_uid: 3dwqqgv1 bioterrorism is not only a reality of the times in which we live but bioweapons have been used for centuries. critical care physicians play a major role in the recognition of and response to a bioterrorism attack. critical care clinicians must be familiar with the diagnosis and management of the most likely bioterrorism agents, and also be adequately prepared to manage a mass casualty situation. this article reviews the epidemiology, diagnosis, and treatment of the most likely agents of biowarfare and bioterrorism. weapons and their potential use by states with the consideration of use by nonstate actors (eg, terrorists). 3 more recent definitions of bioterrorism include both a broader range of potential biological agents as well as considering more diverse groups of potential targets and impacts of biological weapons. spencer 4 defines bioterrorism as "the use of micro-organisms as weapons of catastrophic effect which can be described as: the category or method of use of a weapon system that results in a significant negative impact on a nation's physical, psychological or economic well-being, thereby causing a major modification of routine activity." this definition highlights several key points. first, it highlights that a wide range of microorganisms must be considered and that their impact is not merely physical but may also include psychological and economic factors. spencer further elaborates on his definition of bioterrorism by stating "bioterrorism is best described as the use of micro-organisms (pathogens) or the products of living organisms (toxins) to inflict harm on a wider population, including animals and crops." 4 the elaboration on his original definition highlights that not only are humans directly vulnerable to bioterrorism but we are vulnerable through indirect attacks on our livestock or crops, which has also been termed agroterrorism. 5, 6 other investigators broaden the definition further to not only include microorganisms and biotoxins but also larger organisms, specifically insects. 6 as with many other medical issues that intensivists face in their busy clinical and academic practices, pressured by ever-increasing time and budgetary restraints, there is a necessity to prioritize efforts and resources toward the most common and higherimpact concerns. it is difficult to provide a clear-cut answer as to where bioterrorism should be prioritized on this list. although some experts state that the risk of a largescale bioterrorist attack is low, 7 in a more recent analysis, us senators graham and talent quote their conclusion form the commission on the prevention of weapons of mass destruction proliferation and terrorism in 2010, which stated "unless the world community acts decisively and with great urgency, it is more likely than not that a [biologic] weapon of mass destruction will be used in a terrorist attack somewhere in the world by the end of 2013." 8 anthrax in particular remains such a concern, because of both the lethality of the agent and also the potential availability given the number of governments that produced weaponized anthrax in the past. 9 the later issue is of concern because of both the availability of expertise as well as the risk of residual caches of anthrax in failed states that are vulnerable for misappropriation. in addition, it may require less expertise to develop aerosolizable anthrax then previously believed. 8, 9 box 1 lists the capabilities required of any organization, whether state or nonstate, to conduct and deliver a bioterrorist attack. even a small or moderate bioterrorism event has the potential to overwhelm local medical resources and cause significant civil and economic disruption as a result of the psychological impact of such an attack. given the potential risk for a bioterrorism event and the major impact that could occur, these factors alone provide a strong argument as to why an understanding of bioterrorism is warranted for critical care physicians. however, if these arguments are not persuasive enough, the knowledge that critical care physicians will play a key role in a bioterrorist event, and that their effectiveness in responding to the event is dependent on their medical knowledge regarding bioterrorism agents, should compel one to take the time to read this review. agents used for bioterrorism typically cause critical illness and therefore are of clinical relevance to the intensivist. several of the category a and b organisms (see later discussion) also produce human infections in nature, and therefore, knowledge of their presentation and treatment can also be applied in nonbioterrorism settings. the us centers for disease control and prevention (cdc) has identified and categorized a list of potential bioterrorism agents ( table 1 ). the agents identified by the cdc have been accepted, by most authorities globally, as the highest priority for preparedness and research. those agents from category a form the primary focus of this article. however, relman 10 reminds us that it is important not to solely focus on the agents from the cdc list because they were largely driven by past military programs and do not include agents that were not of particular interest or relevance in the past but may be in the future given technological advances. in addition, military programs focused on weaponizing agents, whereas terrorists could seek to manipulate the natural spread of existing organisms or the development of novel strains. 10 agents this section provides a basic overview and description of the commonly considered bioterrorism threats. specific details about the epidemiology, diagnosis, treatment, and outcomes associated with each of the organisms follow in the subsequent sections. anthrax the bacteria causing anthrax is bacillus anthracis, an encapsulated, grampositive, spore-forming bacilli. 7, 9, 11, 12 when seen on a gram stain, it is often described as box cars given its appearance as a series of railway boxcars in a train viewed from above ( fig. 1) . bacillus anthracis is a soil-borne organism and can be found in the environment globally. the organism grows quickly on standard culture media (6-24 h) and its spores are highly resistant, potentially being viable for decades. in naturally occurring infections, the organism may infect humans by transcutaneous inoculation (cutaneous anthrax), ingestion (gastrointestinal [gi] anthrax, including oropharyngeal), or inhalation (thoracic anthrax). in terms of use as an organism of bioterrorism, it is most likely to be delivered in its spore form as an inhaled agent. once inhaled, bacillus anthracis spores enter alveolar macrophages by phagocytosis and are transported to regional lymph nodes, where they germinate, typically within 2 to 5 days but they may be delayed up to 60 days. 9, 13, 14 symptoms start after germination and bacterial replication begins to occur. what causes the variability in incubation period associated with the time from infection with spores to germination to the vegetative bacillus is unknown. bacillus anthracis produces 2 exotoxins: edema and lethal, comprised of 3 components: (1) edema factor (ef), which impairs neutrophil function and disrupts cell water hemostasis, resulting in massive edema; (2) lethal factor (lf), which causes release of tumor necrosis factor a and interleukin 1b, which are believed to mediate the severity of illness produced; and (3) protective antigen, found in combination with both ef and lf, which allows binding and transportation of the other 2 toxins to and across cell membranes. in addition to the toxins, there are several other virulence factors, including an antiphagocytic capsule. anthrax is not transmitted person to person, but patients should be isolated with droplet precautions as part of standard febrile respiratory infection precautions until the cause of their illness is confirmed. patients with cutaneous anthrax require contact precautions. decontamination should include removing clothing and jewelry and washing skin with soap and water. caution must be exercised not to generate secondary aerosols when handling contaminated clothing items. environmental contamination from patients exposed to an aerosol of bacillus anthracis spore can be performed with a 0.5% hypochlorite bleach solution. this procedure is not sufficient for site decontamination after the release of bacillus anthracis spores, because much more extensive decontamination is required. [15] [16] [17] plague plague is caused by yersinia pestis, a nonmotile, gram-negative, bipolar coccobacillus that can be found worldwide. 7, 18, 19 human infections occur in nature regularly, and plague is endemic in regions such as the southwest united states. yersinia pestis virulence factors include: v and w antigens, lipopolysaccharide endotoxin, capsular envelope (antiphagocytic), coagulase, and fibrinolysin. the natural reservoir for yersinia pestis is rodents and the vector to humans is the oriental rat flea (xenopsylla cheopis). plague is highly communicable in the pneumonic form and may present as any of the following clinical syndromes: bubonic plague, primary pneumonic plague, primary septicemic plague, plague meningitis, plague pharyngitis, pestis minor, and subclinical infection. aerosolized yersinia pestis likely produces a clinical presentation identical to pneumonic plague. however, yersinia pestis does not produce spores and is susceptible to destruction by drying, heat, and ultraviolet light, therefore making it significantly more challenging to weaponize it then anthrax. it is more readily transmitted via an infected vector, such as the oriental rat flea, or by person-to-person transmission. the incubation period depends on the clinical presentation; bubonic plague takes 2 to 8 days and pneumonic plague as short as hours to 3 days. isolation for plague requires droplet precautions until 48 hours of effective antibiotic therapy. decontamination is not required specifically for plague. health care institutions should follow their usual procedures for cleaning after patient discharge from a room. tularemia francisella tularensis is the organism responsible for causing tularemia; it has often been associated with rabbits and various rodents and is occasionally referred to as rabbit fever and deer fly fever. 7, [19] [20] [21] francisella tularensis is a fastidious, small gram-negative, facultative intracellular coccobacillus able to live in soil, water, and decomposing carcasses for long periods. francisella tularensis can be transmitted by direct contact with mucous membranes, cutaneous inoculation through broken skin or bites from infected ticks (or other arthropods), ingestion and inhalation (although human-to-human transmission has not been reported 20 ) . as discussed further in the epidemiology section, tularemia has been previously used as a biological weapon. the mode of deployment as a biological weapon in the past has often been through infected vectors 22 ; however, a modern bioterrorist would most like deploy the agent via aerosolization and it could present as: primary pneumonic tularemia (inhalation), oculoglandular tularemia (eye contact), ulceroglandular (broken skin contact), or oropharyngeal (mucous membrane contact without deep inhalation). tularemia is not communicable between humans, so specific isolation is not required; only standard universal precautions should be used. decontamination for aerosolized exposure should involve remove clothing and jewelry and washing the skin with soap and water. q fever the only category b bacterial organism to receive any extensive discussion in this article is the zoonotic rickettsial organism coxiella burnetii, the causative agent of q fever in humans. [23] [24] [25] coxiella burnetii is a small, obligate intracellular, gramnegative highly pleomorphic coccobacillus. it has a typical gram-negative cell wall structure, but does not stain well with gram stain although it can be seen with a gimenez stain. coxiella burnetii has 2 morphologic forms: large and small cell variants. the small cell form is the extracellular form, which is metabolically inactive and resistant to chemical agents as well as environmental and physical conditions. the large cell variant is the metabolically active and pathogenic intracellular form. the disease is called q fever for query fever, because the causative organism had not been identified at the time of the first documented large outbreaks. q fever occurs worldwide and is associated with contact with sheep, goats, or cattle, particularly during birthing when placental exposure occurs. human infection is through the inhalation of aerosolized organisms from infected animals. coxiella burnetii is highly infectious to humans, and its sporelike small cell variant form makes it a potentially viable biological weapon. most human cases of disease are zoonoses, with human-to-human infection only rarely reported; therefore, only standard infection control precautions are required in the clinical setting. however, coxiella burnetii is highly infectious from culture and therefore should always be handled under biosafety level 3 conditions. environmental decontamination should a culture spill or bioterrorism release occur is difficult given the highly resistant features of the small cell variant. 23 other bacterial agents in addition to the bacterial agents already discussed, there are several other potential organisms that could be used as bioweapons (see table 1 ). [24] [25] [26] rickettsia prowazekii is the causative agent of louse-borne typhus and, similar to q fever, efforts have been made in the past to develop it into a bioweapon. brucella sp are small, aerobic, intracellular gram-negative coccobacilli, which cause primarily zoonotic infections in sheep, cattle, goats, and other animals. brucellosis can manifest as either christian systemic or localized infections and is acquired by contact with or ingestion of fluids from infected animals, particularly by the consumption of unpasteurized milk or cheese. brucella suis was reportedly weaponized by the united states, and possibly other countries, in the past. 24 the organism was to have been aerosolized from a bomb. burkholderia pseudomallei is a gram-negative, facultative anaerobic, motile bacillus that causes melioidosis. there are naturally occurring cases of melioidosis in southeast asia and australia yearly. the disseminated form causes an acute illness, with high mortality. the disease is also known to cause abscesses, which, in some cases, do not present until many years after the initial exposure. burkholderia mallei is a gram-negative, aerobic, nonmotile bacillus that causes glanders. it exists only in living organisms and cannot survive in the external environment. glanders usually presents in humans as a nodular disease with regional lymphangitis; however, systemic dissemination of the organism does occur on occasion, producing septic shock, potentially leading to death. control measures have led to the eradication of glanders from most countries in the world, with the exception of ongoing zoonotic endemics in parts of the middle east, asia, africa, and south america. both burkholderia sp tend to be transmitted to humans through inoculation via a break in the skin, although inhalation is occasionally also a means of human infection. both organisms have been studied, and reportedly developed, as biological weapons in the past by the germans and russians. 26 given the possibility of human-to-human transmission, droplet precautions should at least initially be used for patients with systemic or pulmonary involvement. the more significant transmission risk is from cultured organism, and therefore, any cultures should be managed in a biosafety level 3 laboratory. smallpox once believed to be a disease of the past, smallpox is now one of the most significant bioterrorism threats to the world. 7, 19, [27] [28] [29] there are no animal reservoirs for smallpox and the last naturally occurring case was in somalia in 1977. 28 smallpox is caused by the dna variola virus, a member of the genus orthopoxvirus (family poxviridae), which also includes molluscum contagiosum, vaccinia (virus used in the smallpox vaccine), and monkeypox. a large vulnerable population has existed since smallpox vaccination was stopped in the late 1960s and early 1970s. variola is highly communicable, and can be transmitted by airborne, droplet, and fomite (bed linen and clothing) transmission in addition to direct contact. infection starts in mucosa of airway, then the virus replicates in regional lymph nodes before subsequently resulting in an asymptomatic primary viremia 3 to 4 days after infection with spread to the bone marrow, spleen, and lymph nodes. secondary viremia occurs (day [8] [9] [10] [11] [12] , in which the virus localizes in the dermis and oropharyngeal mucosa and is marked by the onset of symptoms and infectivity. five clinical syndromes of variola infection are seen: classic (unvaccinated only), modified (vaccinated or unvaccinated), flat (vaccinated or unvaccinated) hemorrhagic, and variola sine eruptione (vaccinated only). variola has several features that make it a potentially good bioweapon, including the ability to be made into a lyophilized form, which can be aerosolized and is heat resistant (box 2). however, the virus is easily killed, even in the lyophilized from, by ultraviolet light and disinfectants. the primary concern related to smallpox as a bioterrorism agent is that it was produced in large quantities as a bioweapon by the soviet union and the security of its viral stock remains uncertain after the collapse of the superpower. 29 mathematical models 30 suggest that even a moderate-sized attack infecting 100 to 1000 people would lead to a massive global pandemic that would require significant interventions to control, which in turn would carry with them significant economic and civic ramifications. 31 airborne and contract precautions should be used to manage patients with smallpox. clearly, in a large-scale attack or outbreak, isolation of all patients in negative pressure rooms would not be feasible. all fomites (bed linen and patient clothing) should be transported in sealed biohazard bags and autoclaved before washing or incineration. standard hospital procedures for room cleaning can be followed once a patient has been discharged from the room. viral hemorrhagic fevers viral hemorrhagic fevers (vhf) ( table 2 ) are a group of infections caused by 4 families of rna viruses (arenaviridae, bunyaviridae, filoviridae, and flaviviridae), which are believed to primarily exist within animal or arthropod reservoirs, but occasionally infect humans. 7, 19, 32 each virus is generally contained to a specific geographic region. all of the viruses have in common that they attack the vascular endothelium, leading to vascular leak and potentially producing shock or coagulopathies. with the exception of hantavirus, natural transmission is primarily by respiratory droplets and body fluids but not by airborne aerosol. aerosol transmission of hantaviruses from the urine of rodents has been well documented. most secondary (humanto-human) transmission of vhf is to family members or health care workers caring for patients with vhf. the primary mode of transmission in these cases is direct contact with infected body fluids and percutaneous exposures. however, questions still remain regarding the possibility of aerosol transmission, particularly for lassa fever or from aerosol-generating procedures. 33 several of the vhf viruses have reportedly been weaponized by the russian and the us militaries. isolation for all vhf is strict droplet and contact precautions. patients who are end stage or have significant pulmonary involvement may warrant airborne isolation in a negative pressure room, if available. for specific details regarding isolation and environmental decontamination procedures for vhf, see the cdc's interim guidance for managing patients with suspected viral hemorrhagic fever in us hospitals, available online at http://www.cdc. gov/hai/pdfs/bbp/vhfinterimguidance05_19_05.pdf (accessed january, 2013). in addition to clinical infection control precautions, it is important to minimize risk to box 2 why smallpox is a good candidate as a bioterrorism agent 1. it is transmissible by the aerosol route, both in a weaponized from and from infected to susceptible persons. 2. it is heat stable in a lyophilized form. 3. the populations of most countries contain a high proportion of susceptible persons. 4. smallpox is associated with high morbidity and about 30% mortality. 5. there is a significant psychological fear of smallpox among both the public and health care workers. 6. initial diagnosis of cases of the disease may be delayed, given that it has not been seen clinically for more than 20 years. 7. other than the vaccine, which may be effective only in the first few days after infection, there is no proven drug treatment for clinical smallpox. the laboratory and other health care workers by strictly limiting the number of samples and blood work collected. no fungal organisms are currently on the cdc list of category a or b agents, although it could be argued that some should be considered as potential category c agents. 34 coccidioidomycosis is caused by the soil-borne spore-forming organisms coccidioides immitis and coccidioides posadasii found in the americas. these organisms typically cause a self-limited respiratory illness in immunocompetent individuals. coccidioidomycosis is typically transmitted by inhalation, particularly after events such as earthquakes or dust storms, which generate airborne particulate mater from the soil. human-to-human transmission does not occur. overall, the long incubation period and mild clinical presentations in most individuals make coccidioides an unattractive agent as a bioweapon. however, given the ease of access to the organism and its natural propensity for aerosol transmission, its potential use should not be ignored. keeping an open mind about possible future bioterrorism agents is essential if we are truly going to be prepared. 10 biological toxins technically toxins are chemicals but because of their source (living organisms), biotoxins are typically classified as biological weapons. 7, 19, 24, 35 the cdc list of potential bioterrorism agents (see table 1 ) includes several toxins. in addition, there are several other toxins that also have the potential to be used as agents of bioterrorism (box 3). toxins can be deployed via aerosol dispersal devices or by contaminating food sources and have been used as bioweapons in the past ( table 4) . to be effectively deployed as an airborne agent, the toxin must be 1-3 mm for optimal aerosolization. ricin ricin is a protein toxin obtained from the organism ricinus communis (castor beans). castor beans are available worldwide and ricin is a natural by-product produced in the processing of castor beans to castor oil. the waste products resulting from the processing of castor beans contain approximately 5% ricin. 24 in its pure form, ricin is a white powder that is soluble in water and stable over a wide range of ph. chemically, ricin is a glycoprotein lectin with a and b chains joined by a disulfide bond. the b chain binds to galactose-containing proteins and lipids on cell surfaces, causing direct membrane damage and release of cytokines, whereas the a chain inhibits eukaryotic ribosomes by removal of adenine from the 28 rrna loop in the 60 subunit, therefore stopping protein synthesis, leading to cell death. ricin is less toxic by weight compared with botulinum toxin or staphylococcal enterotoxin type b (seb), but is more readily available and easy to produce in large quantities than either of these agents. ricin can be deployed as a bioweapon via several routes, including inhalation, ingestion, or injection. clearly, as a bioterrorism agent with the intent to cause mass casualties, inhalation or ingestion is more likely than injection. after exposure, decontamination should include removal of clothing and jewelry, washing with soap and water, followed by rinsing with copious amounts of water. clostridium botulinum toxin (botulism) botulinum toxin is the most poisonous substance known to man with a dose lethal to half those exposed (ld 50 ) of 1 ng/kg. clostridium botulinum is a gram-positive, spore-forming, anaerobic bacillus found in soil and water globally. rarely, the toxin is also produced by clostridium butyricum and clostridium baratii. botulinum toxin is produced in pharmaceutical grade and is commercially available for cosmetic and other medical purposes. seven types of toxins exist and are identified as types a to g, with a, b, and e causing most cases of human disease. the toxin contains 3 chains (heavy, light, nontoxic hemaglutinin). the heavy chain permits the toxin to bind with the cell, and the light chain contains zinc-dependent endopeptidase, which stops calcium release. botulinum toxin binds to peripheral presynaptic cholinergic terminals (including muscarinic and nicotinic) and blocks the calcium-dependent exocytosis process. the central nervous system is not affected by the toxin. botulism is most often considered a food-borne illness, given that most of the naturally occurring cases are the result of ingesting contaminated food products. other naturally occurring forms of toxicity are wound botulism (soil-contaminated wounds) and infantile botulism (ingestion of spores). the spores themselves are heat resistant, tolerating temperatures up to 100 c, but the toxin itself denatures and becomes inactivated with even brief exposures to temperatures higher then 85 c. use as a potential bioweapon includes contaminating food sources or via aerosolization. however, the toxin quickly degrades when exposed to environmental conditions, thus limiting its usefulness as a bioterrorism agent. botulinum toxin cannot cross the skin but can be absorbed by mucous membranes. should exposure to the toxin occur via aerosolization, decontamination should include removing clothing and jewelry, washing with soap and water, and rinsing with copious amounts of water. wash contaminated surfaces with a 0.1% hypochlorite bleach solution to destroy the toxin. micotoxins several hundred varieties of toxins are derived from fungi, with the trichothecenes and aflatoxins being most concerning. aflatoxins are produced by aspergillus flavus or aspergillus parasiticus and are common contaminants in harvested food. aflatoxins bind to and damage dna and cellular proteins. trichothecenes are produced by a large number of fungi including: fusarium, stachybotrys, trichoderma, myrothecium, and cephalosporium. the most likely toxins from the class trichothecenes to be used as bioweapons are: t2 (trichothecene) and deoxynivalenol (vomitoxin). t2 causes skin irritation/pain and can be absorbed through the skin or inhaled, and then disseminated systemically, binding to peptidyltransferase inhibiting protein synthesis. it also interferes with dna polymerase and monoamine oxidase. the organs affected first are those are with rapidly reproducing cell lines (gi tract, bone marrow, and skin) as well as impairing proteins involved in coagulation and the krebs cycle. in addition, the breakdown of serotonin, epinephrine, and norepinephrine is impaired. t2 is a yellow droplet in appearance. should exposure occur, decontamination includes removal of clothing and jewelry, scrubbing the skin with soap and water, and isolating clothing or other contaminated objects. staphylococcal enterotoxins staphylococcal enterotoxins are heat-stable toxins produced by the common staphylococcus aureus bacteria. there are more than 20 types of enterotoxins, with type a commonly known for causing food poisoning and type f causing toxic shock syndrome. the genes for staphylococcal enterotoxins are found on plasmids and bacteriophages, allowing transfer between different strains. seb can be aerosolized and has been studied as a potential incapacitating biological agent. seb is a superantigen, which produces massive stimulation of t cells and cytokine storm, which is rarely fatal but is significantly incapacitating to the victim. if there is exposure, decontamination requires removing clothing and jewelry, followed by washing skin with soap and water. clostridium perfringens epsilon toxin clostridium perfringens is an anaerobic, grampositive, spore-forming bacillus that is found in soil in all parts of the world. clostridium sp produce several toxins, one of which is the epsilon toxin, which commonly causes food poisoning. similar to seb, epsilon toxin could be another potential incapacitating bioweapon. insects were some of the earliest bioweapons ever used against an enemy (see table 4 ). 6, 22 there are 3 potential ways to use insects in bioterrorism: direct attacks, agents of agroterrorism, or as vectors of disease. direct attacks most often use stinging insects and have been used in the past to defend fortifications and rout enemies from entrenched positions (the bee hive in the log, as seen in cartoons). another insect that has been studied by the indian military as a potential bioweapon is the paederus beetle, found in the middle east, which produces the toxin pederin. pederin is potent, causing intense pain, festering lesions, and blindness if it contacts the eyes. ingestion of the beetle can be lethal, as is injecting pederin into the bloodstream. agroterrorism is "the deliberate introduction of an animal or plant disease as well as damage to crops and livestock with the goal of generating fear, causing economic losses and/or undermining social stability." 6 an example of insects used as an agent of agroterrorism is the medfly (ceratitis capitata), a fruit fly found in parts of the world but not the united states. their larvae eat many plants, causing significant crop destruction. in 1989, a group threatened to release medflies in california if the government did not stop a pesticide-spraying program. if the insects had been released, the estimated damage to the economy would have been $13.4 billion. 6 insects can be used in bioterrorism as disease vectors. table 3 lists potential vector-borne diseases of concern. epidemiology it is challenging to describe the epidemiology of agents of bioterrorism in the traditional manner for several reasons. first, as discussed in the introduction, theoretic risks are largely being discussed, with many unknown factors involved. further, given that most of the work done in the area of bioweapons has been conducted by military or state organizations, only a small percentage of the overall activities have been publically reported. to provide the best possible overall perspective on the epidemiology of bioterrorism agents, table 4 offers a comprehensive overview of past use of bioweapons as compiled from several sources. 1, 4, 6, 7, 13, 19, 22, 24, [35] [36] [37] in addition to the general risks discussed in the introduction, academic health centers potentially play a unique role in the epidemiology of bioterrorism. any public area where mass gatherings occur or any infrastructure critical for the smooth functioning of society are potential targets for bioterrorism attacks. not only do hospitals in general, and academic health centers specifically, fit this profile, but academic health centers may also be at an increased risk because they are also potential sources of agents of opportunity (ao). the term ao is used to connote the use of a routine and unregulated chemical, biological, or radiologic agent by terrorists. 36 table 3 potential bioterrorism vector-borne diseases of concern for humans vector disease two key features of an ao are (1) its availability, and (2) a practical means of dissemination. box 4 lists potential biological aos available in many academic health centers. an ao does not have to cause significant morbidity or mortality to be effective; the psychological effects on the public and impact on society/critical infrastructure functioning are sufficient to have a serious effect. aos are of significant concern to law enforcement officials because potential barriers to the development of a highly effective biological weapon are the cost and expertise required to develop them, whereas aos mitigate both of these factors. in the past, the development of bioweapons has required significant funding and labor, which typically only states can mobilize. it has been said that the us military bioweapon program employed more than 3000 staff and the ussr bioweapons sections employed more than 60,000 staff, both at costs of millions of dollars. 7 although presenting a significant obstacle in bioweapon development, cost does not always prevent nonstate actors from pursuing bioweapons; the aum shunrikyo cult may have spent more than $10 million dollars in its failed attempt to develop weapon-grade anthrax. 7 the diagnosis, or identification, of a bioterrorism event is likely the most challenging step in the response. 38 recognition of a bioterrorism event has 2 components: (1) identifying that an intentional rather then natural phenomenon has produced several cases of illness, and (2) diagnosing the specific organism or agent causing the illness. they may occur in either order depending on the circumstances. bedside clinicians, specifically critical care physicians, 39 play a crucial role in both aspects of recognizing that a bioterrorism event has occurred. 2, 39, 40 recently, a great deal of attention and money has been directed toward bioterrorism detection technologies, such as environment sampling and syndromic surveillance. however, these efforts are highly unlikely to replace the bedside clinician in recognizing the event. 2, 41 in a simulated anthrax attack designed to test the performance of a syndromic surveillance system currently in use, nordin and colleagues 41 found that performance of syndromic surveillance varies with the infection rate. based on their analysis in a metropolitan area if there was a release of anthrax at a large public venue, a syndromic surveillance system that monitored approximately 9% of the local population would detect the event most of the time if the infection rate was 20% and all of the time if the infection rate was more than 40%, but it would take 3 to 6 days in both situations. therefore, these investigators concluded that "a suspicious clinician may detect the first case of anthrax before a syndromic surveillance system sounds an alarm and public health determines it is an anthrax release." 41 identifying the important role that the beside clinician plays in recognizing a bioterrorism event is not intended to diminish or exclude the role of others in the process, especially not public health. the rapid recognition, and effective response, to a bioterrorism event requires that clinicians and public health officials work together. [42] [43] [44] in some circumstances, such as smallpox, the diagnosis of a single case triggers the alarm that a bioterrorism event has occurred. 45 however, for any of the diseases with a naturally occurring incidence, as well as with a novel organism or illness that has not yet been identified, it is the existence of a cluster of cases in a geographic area that triggers suspicion of a possible bioterrorism attack or emerging epidemic ( table 5) . recognition of a cluster of patients typically requires a level of situational awareness that is beyond what an individual clinician can acquire and is usually attainable only by a regional, state, or federal public health agency depending on how widely distributed the cases are. for example, if an anthrax attack took place in a busy international airport, the cases would be widely distributed across a nation or internationally (eg severe acute respiratory syndrome [sars]). 46 in this case, to the individual clinicians receiving the cases of inhalational anthrax, each would be an unusual, but not necessarily alarming, occurrence. however, the reporting of several cases of inhalational anthrax to a federal or international public health agency simultaneously would certainly trigger an alarm. however, we are often left with trying to distinguish between a naturally occurring event (epidemic) and an intentional event (bioterrorism). it can be difficult to distinguish between an artificial incident (terrorism) and a natural occurrence (epidemic). 47,48 box 5 lists some of the characteristics that might help christian table 5 case number triggering criteria for considering a potential bioterrorism event disease(s) a a this factor is in part based on the background incidence of disease in a geographic area and therefore varies from location to location as well as based on seasonal variations. for example, a viral encephalitis that is naturally transmitted by an endemic vector occurring in the summer when mosquitoes are prevalent would not necessarily raise concerns; however, a single case occurring in the winter or in a geographic area where that infection is not typically seen may raise concerns immediately. features that suggest a bioterrorism event rather than an epidemic 1. an epidemic curve that suggests a point source (common source) outbreak or extended source rather then a naturally propagated (transmitted) source (fig. 2) 2. identification of a cluster of cases (large numbers of patients from a similar geographic area with similar symptoms) distinguish between the 2 events based on epidemiologic features. recently, radosavljevic and belojevic 38 have developed a scoring system to help distinguish between a bioterrorism incident and an epidemic ( table 6) . these investigators use an interesting approach, which scores several qualitative and quantitative features of the incident categorized under 3 groupings: person (cases), place (spatial distribution), and time. a score of 8 or higher on this system is said to suggest that an artificial (intentional or accidental) event is more likely then a naturally occurring epidemic. the questions considered in this score have to be answered at the public health level, not the individual clinician level, because they require a level of situational awareness not attainable by a clinician in a hospital. the importance of clinicians working effectively with public health agencies is further reinforced by computer modeling work by hupert and colleagues, 49 which suggests that even minor delays in detecting (diagnosing) and initiating the response to a large-scale anthrax attack would make even perfectly executed prophylaxis campaigns ineffective in preventing the health care system from being overwhelmed by cases. as noted in the earlier discussion, identifying the disease or organism involved can be key to identifying the event as a bioterrorism incident. this section provides an overview of the clinical and investigational findings that assist in diagnosing the specific diseases. key to any biological diagnosis are laboratory, particularly microbiological, tests. 50 table 7 summarizes the appropriate specimens and tests for diagnosing potential agents of bioterrorism. however, as with many aspects in critical care, it is important not to be overly reliant on technology. the college of american pathologists regularly tests the ability of laboratories to accurately diagnose, or appropriately refer to a reference laboratory, clinical potential agents of bioterrorism. 51 in their recent testing of laboratories, the college of american pathologists found rates of acceptable identification responses were as follows: bacillus anthracis, 90% (2007) 51 although the rates of appropriate diagnosis are improving, there still remains a delay in notification of the reference laboratory and a not insignificant failure rate for diagnosing category a organisms other then anthrax. anthrax as discussed earlier, anthrax presents as 3 typically distinct clinical syndrome: cutaneous, gi, and thoracic. 7, 11, 12, 19 diagnosis of anthrax often involves a combination of clinical, radiographic, and microbiological data. the clinical presentation of the 3 anthrax syndromes is outlined in table 8 . cutaneous anthrax most often affects the hands, arms, and face. one of the main differential diagnoses for cutaneous anthrax are spider bites, and table 9 presents clues to help distinguish between the 2. the diagnosis of cutaneous anthrax can often be made clinically followed by laboratory confirmation. other laboratory and radiologic investigations are of limited use in cutaneous anthrax. conversely, in the cases of gi and thoracic anthrax, the clinical presentation is relatively nonspecific, and radiologic investigations, especially for inhalational anthrax, 52 along with laboratory and microbiological testing are essential for making the diagnosis. with thoracic anthrax, sputum cultures are rarely positive but first blood cultures are almost always positive. 7 with the relatively nonspecific findings associated with thoracic anthrax, it can be challenging for clinicians to differentiate it from the more commonly seen community-acquired pneumonia (cap). kyriacou and colleagues 53 conducted a retrospective review of cases of bioterrorism-acquired thoracic anthrax and compared them with cases of cap or influenza. these investigators found that the most accurate predictor of anthrax was mediastinal widening or pleural effusions on chest radiograph, which were 100% sensitive, 71.8% specific compared with cap, and 95.6% specific compared with influenza (see fig. 2 ). other features more common in anthrax were: nausea, vomiting, pallor, cyanosis, diaphoresis, altered level of consciousness, and increased hematocrit level. two groups 54, 55 have developed screening criteria to help diagnose anthrax after a known bioterrorism incident. however, a costeffectiveness analysis showed that although both criteria would have identified cases abbreviations: ct, computed tomography scan; cxr, chest radiograph; mri, magnetic resonance imaging. a for microbiological findings, refer to table 7 . data from refs. 7, 11, 12, 19, 52 of anthrax, the mayer criteria 55 would have screened only 4 patients (cost $1900 usd), whereas the hupert criteria 54 would have screened 273 patients ($126,025 usd). 56 although it is rare with cutaneous anthrax, any case of anthrax has the potential to develop hemorrhagic meningitis. therefore, any evidence to suggest meningitis should prompt appropriate investigations such as neuroimaging and a lumbar puncture. plague as with anthrax, the diagnosis of plague varies significantly based on the clinical syndrome as which it presents. 7, 18, 19 plague may present as any of the following clinical syndromes: bubonic plague, primary pneumonic plague, primary septicemic plague, plague meningitis, plague pharyngitis, pestis minor, and subclinical infection. the first 3 syndromes are the most common presentations and their diagnostic features are outlined in table 10 . bubonic plagues is characterized by initial lymphadenitis, most commonly inguinal, followed by the development of a systemic illness, which may include secondary plague pneumonia. primary septicemic plague is similar to bubonic plague, without the initial appearance of buboes. it remains unclear if it is the same entity with subclinical lymphadenitis or a distinct pathophysiologic process. pneumonic plague may be primary, which presents as an acute respiratory infection, or may occur as a result of hematologic spread (secondary) from bubonic or primary septicemic plague. hemoptysis is frequently seen with pneumonic plague and can help differentiate it from anthrax or tularemia. 7 general laboratory and radiologic investigations are nonspecific and the diagnosis is primarily made via microbiology testing (see table 7 ). automated culture detection systems may not detect or can misidentify yersinia pestis, and therefore, if there is a high level of suspicion for plague, the microbiology laboratory should be made aware of this when the cultures are ordered. tularemia tularemia is another disease with several distinct presentations that are variable and dependent on the mode of transmission. 7, 19 the clinical spectrum of disease includes: typhoidal, ulceroglandular, glandular, oculoglandular, oropharyngeal, and pneumonic tularemia, with the last being the most likely presentation from a bioterrorism incident. the average incubation period is 3 to 5 days, but ranges from 1 to 21 days. the pneumonic form typically presents with: fever, chills, headache, malaise, coryza, cough, chest pain, pharyngitis, abdominal pain, arthralgia, septic shock, respiratory failure, and acute respiratory distress syndrome (ards). the ulceroglandular form presents with cutaneous ulcers 0.5 to 3 cm with heaped-up edges and regional lymphadenopathy. ulceroglandular infections may progress to systemic disease similar to the pneumonic form. the typhoidal form does not involve lymphadenopathy. the typhoidal form usually involves the lung primarily, whereas the ulceroglandular form first affects the mediastinal lymph nodes, then progresses to parenchymal involvement. microbiological testing is required to make the diagnosis, although cultures are generally low yield given the difficulty growing the organism. therefore, alternative techniques for identification such as immunofluorescence and polymerase chain reaction (pcr) are preferred. 7 radiologic findings are generally nonspecific, although approximately 75% of patients with tularemia present with bronchopneumonia, typically bilateral, and may develop cavities. only approximately 33% have lymphadenopathy and pleural effusions, which is significantly lower than would be expected with thoracic anthrax. 52 q fever q fever, when seen in naturally occurring infections in humans, causes a spectrum of disease from asymptomatic fevers and fevers of unknown origin through to life-threatening infections, typically associated with endocarditis or pneumonia. 23, 24 the primary concern in a bioterrorism setting is inhaled coxiella burnetii, which presents with fever and cough alone in cases of lower inoculation through to severe pneumonia and respiratory distress with high inoculums. the diagnosis of q fever requires microbiological testing. the chest radiograph and computed tomography (ct) finding are nonspecific and consistent with any other type of pneumonia. 52 there is no significant adenopathy seen on the chest radiograph or ct, which may help to rule out anthrax. other bacteria the 2 other bacterial agents that are discussed are brucella sp and burkholderia sp. 24 brucellosis has multiple clinical presentations and can be difficult to diagnose. typically brucellosis infects organs (lung, liver, spleen), bone marrow, bones, or central nervous system and is an insidious infection, presenting primarily with constitutional symptoms and organomegaly. the incubation period ranges from 2 to 8 weeks. diagnosis of brucellosis is best made by bone marrow cultures or blood cultures, although they are less sensitive. burkholderia mallei causes the clinical disease glanders, which presents as skin nodules and lymphadenopathy after inoculation through the skin, but in a bioterrorism event with inhalation exposure, the most likely presentation would be a nonspecific systemic febrile illness, which may or may not be accompanied by a pustular rash. burkholderia pseudomallei causes the clinical syndrome of melioidosis, a disease with a broad spectrum of presentations, including skin ulcers, pneumonia, acute fulminate sepsis, and chronic abscesses. if used in a bioterrorism setting with inhalational exposure, the acute presentation would most likely be either pneumonia or sepsis. smallpox smallpox can present as 1 of 5 clinical syndromes (table 11) : classic, modified, flat, hemorrhagic, and variola sine eruptione. 7, 19, 28 the primary challenge in the diagnosis of smallpox is the lack of clinicians who have experience with the disease. the cdc has published a case definition to aid in the diagnosis of cases (box 6). classic smallpox begins with a prodrome of fever and constitutional symptoms. after 2 to 4 days, the rash begins to emerge, initially as small red spots in the mouth and throat, which develop into sores that erupt and discharge virus, making the patient highly infectious at this point. at about the same time that the sores in the mouth begin to open, a rash develops on the skin. the rash is said to spread in a centrifugal pattern, starting on the face, then spreading to the extremities. the lesions progress from macules, to papules (day 2 of rash), umbilicated vesicles (day [4] [5] , and pustules (day 7) before crusting over (fig. 3) . in contrast to chickenpox (varicella), in smallpox, all the lesions progress at the same stage and the lesions are more densely concentrated on the face and extremities (figs. 4 and 5) . a single suspected case of smallpox is a public health emergency and the local public health agency should be notified immediately if there is a suspected case. imaging does not play a major role, because the respiratory symptoms tend to develop after the skin lesions. a few individuals who care for smallpox victims, or who have been vaccinated, develop a pulmonary form of smallpox without skin lesions. in these cases, chest radiography or ct may be helpful. the chest radiograph shows ill-defined nodular opacities in the upper lung fields, which may persist for months before calcifying. 52 vhf clinical presentation of vhf depends on several factors, including specific virus, virulence of the strain, route of exposure, dose, and host factors (table 12) . 32,57 the general feature that all vhf have in common is that they cause microvascular damage, leading to symptoms associated with increased vascular permeability, potentially resulting in hypovolemic shock or frank hemorrhage. medical imaging is not helpful in diagnosing these conditions, and the general laboratory findings are nonspecific, but often reveal evidence of hepatitis and hypovolemia. the specific diagnosis depends on microbiological testing (see table 7 ). the diagnosis of a bioterrorism event secondary to the use of biological toxins depends on the presentation of unusual clusters of cases. identifying the specific toxin can be challenging but the clinical presentation of some toxidromes can be useful in suggesting the agent involved. the clinical syndromes associated with ricin poisoning vary based on the mode of entry into the body. inhalation of ricin leads to symptoms within hours, which include dyspnea, fever, cough, pulmonary edema, and chest tightness, whereas ingestion of ricin results in vomiting and diarrhea, leading to dehydration, shock, hallucinations, seizures, and hematuria. the typical onset of symptoms after ricin poisoning averages from 4 to 6 hours up to 10 hours. laboratory findings associated with ricin poisoning are nonspecific but include metabolic acidosis, increased results for liver function tests, anemia, increased creatinine level, leukocytosis, and hematuria. aerosolized botulinum toxin, likely to be experienced in a bioterrorism setting, produces disease that mimics food-borne, infant, and wound botulism clinically. the clinical features that are anticipated with the inhalation of botulinum toxin include descending paralysis starting with diplopia, ptosis, fixed dilated pupils, dysphagia, respiratory failure, urinary retention, and constipation. with the ingestion of botulinum toxin, the clinical features begin with gi symptoms, including nausea, vomiting, diarrhea, bloating, and pain, before the development of the paralysis. onset of symptoms after exposure to botulinum toxin occurs as early as 6 hours after inhalation, but if ingested typically there is a 12-hour to 36-hour delay before symptoms begin. however, the onset may be delayed as much as 10 days. the diagnosis of botulinum intoxication is based on laboratory detection of the toxin in blood, food, or stool. the clinical presentations of mycotoxins vary based on the specific toxin. aflatoxin ingestion produces clinical features acutely, including hemorrhagic liver necrosis and pulmonary edema with chronic features, including the development of hepatic cancer. the effects and clinical presentation of inhaled aflatoxin are not known. t2 can be absorbed through the skin or inhaled. the clinical presentation in the acute phase includes pain on contact with skin or eyes, conjunctivitis, blurred vision, rhinorrhea, epistaxis, dyspnea, wheezing, tachycardia, shock, vomiting, diarrhea, erythema, and blistering. delayed symptoms present approximately 1 week after exposure and include thrombocytopenia, neutropenia, anemia, and coagulopathy. seb is a superantigen, which causes massive stimulation of t cells and cytokine storm, which produces the associated clinical features. ocular exposure results in conjunctivitis and eye swelling, whereas inhalation causes fever, chest pain, gi symptoms, pulmonary edema/ards, and shock. the respiratory effects may not be seen for up to 48 hours after exposure. as with most other infectious diseases, considerations for the management of bioweapons should include consideration of (1) vaccination to prevent infection/illness, (2) treatment of infection/illness, and (3) prophylaxis after exposure to prevent clinical infection/illness. also, as is common with most other infectious diseases, there are often several antimicrobial regimens that can effectively treat a specific bioterrorism agent, and for others there are no effective treatments. table 13 presents the generally accepted international recommendations for vaccination, treatment, and prophylaxis of bioterrorism agents. however, clinicians should always consult the most recent guidelines published by their public health authority when making clinical management decisions regarding bioterrorism agents. in addition to the current therapies, new drugs and vaccines are being developed specifically to address the threat of bioterrorism. 58 with the exception of possibly cutaneous anthrax, there are no specific indications for surgical management of any bioterrorism organisms. 11 even in the case of anthrax, surgical debridement has primarily been used for injection anthrax. 59,60 supportive care for victims of a bioterrorism event involves 2 components: the care of the individual patient and the response to a mass casualty event. despite the heightened awareness of the potential for bioterrorist events since 2001, many hospitals remain unprepared for biological threats. a study of uk emergency departments (eds) revealed that 24% did not have isolation facilities, and only 61% had departments with independent ventilations systems that would allow for the department to be isolated from the rest of the hospital. 61 in addition, the survey found that isolation procedures in many eds were poor; for example, 27% would not have isolated a patient with potential sars and 23% would not isolate a patient with chickenpox. 61 the task force for emergency mass critical care provides guidelines for hospitals to prepare for and manage mass critically ill casualties from events such as a bioterrorism attack. 62 critical care physicians should be familiar with these guidelines and prepared to respond in such circumstances, because if they are not, all of their skills and knowledge for treating individual patients are of little use as the system becomes overwhelmed. supportive care of individual patients can generally be grouped into categories based on the class of agent involved: bacterial, viral, or toxin. bacterial and viral agents typically produce a sepsis syndrome with vascular leak, particularly in the case of vhf, as well as variable degrees of a systemic inflammatory response. supportive management is similar to the standard best practices for managing septic patients (box 7). particular attention needs to be directed toward ventilatory support, with lung protective ventilatory strategies to minimize the development or exacerbation of adult respiratory distress syndrome. significant fluid shifts are to be expected given the vascular leak, requiring judicious volume resuscitation and cardiovascular support with vasopressors and inotropes based on goal-directed therapy. supportive therapy for patients involved in bioterrorism attacks with biotoxins varies based on the specific toxin. in the case of exposure to botulinum toxin, the primary support required is mechanical ventilation, hydration, and nutritional support until the paralysis resolves. toxins such as seb produce a response similar to sepsis and are supported by the sepsis protocols described earlier. ricin and mycotoxins both act at the cellular level, and although supportive therapies should be attempted, they may be of little benefit in altering the outcomes for patients. for mycotoxins specifically, there may be a role for the addition of steroids as a component of supportive care. 35 data regarding patient outcomes after exposure to bioweapons or bioterrorism agents are, for the most part, lacking, given the paucity of cases and that most research has been carried out by government or military organizations and the results cannot be shared publically. table 14 summarizes the published outcomes after exposure to bioterrorism agents when data are available. however, the outcomes from previous incidents, and in particular from naturally occurring illness, may not predict future outcomes, because bioterrorism agents may undergo genetic manipulation to increase their virulence or introduce antibiotic resistance, which decreases the efficacy of treatments. although to the average clinician, bioterrorism may seem to be only a remote possibility, it is not only a reality of the times in which we live but also bioweapons have been used for centuries. critical care physicians play a critical role in the response to a bioterrorism attack, and even more importantly, in identifying that an attack has occurred in the first place. an effective response to a bioterrorism incident requires a coordinated effort between clinicians and public health. critical care clinicians must be familiar with the diagnosis and management of the most likely bioterrorism agents, and also be adequately prepared to manage a mass casualty situation. index case of fatal inhalational anthrax due to bioterrorism in the united states the anthrax attacks 10 years later biological weapons control. prospects and implications for the future potential bio-terror agents entomological terrorism: a tactic in asymmetrical warfare bioterrorism: preparing for the impossible or the improbable the threat of bioterrorism anthrax as a biological weapon, 2002: updated recommendations for management bioterrorism-preparing to fight the next war anthrax infection an overview of anthrax infection including the recently identified form of disease in injection drug users the sverdlovsk anthrax outbreak of 1979 bioterrorism-related inhalational anthrax: the first 10 cases reported in the united states a biological decontamination process for small, privately owned buildings comparative sporicidal effects of disinfectants after release of a biological agent decontamination after a release of b. anthracis spores threats in bioterrorism. i: cdc category a agents tularemia as a biological weapon: medical and public health management tularemia: the disease and the weapon insects as weapons of war, terror, and torture q fever: the neglected biothreat agent threats in bioterrorism. ii: cdc category b and c agents pathogenic rickettsiae as bioterrorism agents pathogenesis of burkholderia pseudomallei and burkholderia mallei rethinking smallpox an overview on the use of a viral pathogen as a bioterrorism agent: why smallpox? modeling potential responses to smallpox as a bioterrorist weapon the economic impact of a bioterrorist attack: are prevention and postattack intervention programs justifiable? viruses of the bunya-and togaviridae families: potential as bioterrorism agents and means of control interim guidance for managing patients with suspected viral hemorrhagic fever in us hospitals coccidioides species as potential agents of bioterrorism bioterrorism: toxins as weapons developing a consensus framework and risk profile for agents of opportunity in academic medical centers: implications for public health preparedness the history and threat of biological warfare and terrorism unusual epidemic events: a new method of early orientation and differentiation between natural and deliberate epidemics bioterrorism preparedness and response: clinicians and public health agencies as essential partners biologic and chemical weapons of mass destruction simulated anthrax attacks and syndromic surveillance late recognition of sars in nosocomial outbreak critical care and biological disasters: lessons learned from sars and pandemic influenza planning definition and functions of health unified command and emergency operations centers for large-scale bioevent disasters within the existing ics medical management of the suspected victim of bioterrorism: an algorithmic approach to the undifferentiated patient severe acute respiratory syndrome nato handbook on the medical aspects of nbc defensive operations bioterrorism and critical care predicting hospital surge after a largescale anthrax attack: a model-based analysis of cdc's cities readiness initiative prophylaxis recommendations diagnostic analyses of biological agent-caused syndromes: laboratory and technical assistance a review of sentinel laboratory performance: identification and notification of bioterrorism agents radiologic manifestations of potential bioterrorist agents of infection clinical predictors of bioterrorismrelated inhalational anthrax accuracy of screening for inhalational anthrax after a bioterrorist attack inhalational anthrax due to bioterrorism: would current centers for disease control and prevention guidelines have identified the 11 patients with inhalational anthrax from screening for inhalational anthrax due to bioterrorism: evaluating proposed screening protocols the office of the surgeon general at tmm publications state-of-the-art therapeutic medical countermeasures for viral threat agents injection anthrax causing compartment syndrome and necrotising fasciitis the surgical management of injectional anthrax emergency departments (eds) in the united kingdom (uk) are not prepared for emerging biological threats and bioterrorism summary of suggestions from the task force for mass critical care summit prevention of laboratory-acquired brucellosis comparison of efficacy of ciprofloxacin and doxycycline against experimental melioidosis and glanders key: cord-340028-6oicmeam authors: zhavoronkov, alex title: geroprotective and senoremediative strategies to reduce the comorbidity, infection rates, severity, and lethality in gerophilic and gerolavic infections date: 2020-03-31 journal: aging (albany ny) doi: 10.18632/aging.102988 sha: doc_id: 340028 cord_uid: 6oicmeam the recently identified sars-cov-2 betacoronavirus responsible for the covid-19 pandemic has uncovered the age-associated vulnerability in the burden of disease and put aging research in the spotlight. the limited data available indicates that covid-19 should be referred to as a gerolavic (from greek, géros “old man” and epilavís, “harmful”) infection because the infection rates, severity, and lethality are substantially higher in the population aged 60 and older. this is primarily due to comorbidity but may be partially due to immunosenescence, decreased immune function in the elderly, and general loss of function, fitness, and increased frailty associated with aging. immunosenescence is a major factor affecting vaccination response, as well as the severity and lethality of infectious diseases. while vaccination reduces infection rates, and therapeutic interventions reduce the severity and lethality of infections, these interventions have limitations. previous studies showed that postulated geroprotectors, such as sirolimus (rapamycin) and its close derivative rapalog everolimus (rad001), decreased infection rates in a small sample of elderly patients. this article presents a review of the limited literature available on geroprotective and senoremediative interventions that may be investigated to decrease the disease burden of gerolavic infections. this article also highlights a need for rigorous clinical validation of deep aging clocks as surrogate markers of biological age. these could be used to assess the need for, and efficacy of, geroprotective and senoremediative interventions and provide better protection for elderly populations from gerolavic infections. this article does not represent medical advice and the medications described are not yet licensed or recommended as immune system boosters, as they have not undergone clinical evaluation for this purpose. aging is a complex, multifactorial process [1] that leads to loss of function and is the primary risk factor for major human pathologies including cancer, diabetes, cardiovascular disorders, and neurodegenerative diseases [1, 2] . although there is still much debate in the scientific community, proposals have been made to classify aging as a disease in order to develop therapeutic strategies to prevent or delay the onset of age-related illnessess [3] [4] [5] . increasing frailty with age leads to an increased risk of many diseases. these diseases are commonly referred to as age-related [6] . many pathogens are more infectious and prevalent in the elderly, [7] [8] [9] [10] and may be referred to as gerophilic (from greek, géros "old man" and philia, "love"). some infections, including covid-19, are not exclusively gerophilic, as younger people may also become infected. however, these individuals have mild symptoms or remain asymptomatic, while the elderly experience substantially more severe symptoms and lethality. the term gerolavic (from greek, géros "old man", and epilavís, "harmful") may more appropriately the online resources our world in data [16] and the lancet's global burden of disease [17] provide deep visual insight into the global burden of disease by cause and demographics. in 2017, there were 56 million deaths globally; over two-thirds of these (76%) were in people over 50 years of age. according to the online period life tables put out by the us social security administration [18] , the annual chance of death in 2015 (the probability of dying within one year) for a person over 80 was 5.2%, increasing to 14.8% by the age 89. according to estimates by the us centers for disease control [19] , approximately 5,945,690 individuals older than 65 had symptomatic influenza during the 2017-2018 season, resulting in 3,329,586 medical visits, 540,517 hospitalizations, and 50,903 deaths. hence, the death rate for those hospitalized with influenza was 9.4% for patients over 65. however, many of the covid-19 patients over 65 years have one or more comorbities [20] , and it is often difficult february 11, 2020 . the figures are adopted and generated from [12] (http://weekly.chinacdc.cn/en/article/id/e53946e2-c6c4-41e9-9a9b-fea8db1a8f51). to attribute the cause of death exclusively to the gerolavic coronavirus. currently, there are no accurate statistics linking smoking status, lifestyle, and behavior to the severity and lethality of covid-19. despite this, it is possible that these factors, as well as frailty and comorbidities, play a substantial role. gerolavic diseases such as covid-19 may not significantly increase the yearly death rates for each individual age group; however, these diseases substantially accelerate death from multiple conditions, and compress the process to less than two weeks. comorbidity is also the likely cause of the substantial differences in death rates among different countries due to differences in patient demographics, levels of preparedness, when the epidemic began locally, and reporting [13] . only the data available from china, where the epidemic has subsided, and the diamond princess cruise ship were used for this study. one of the possible causes of the age-associated increases in covid-19 infection rate, severity, and lethality is immunosenescence. immunosenescence is a well-known age-related process contributing to the global burden of disease [21] . it is among the major factors underlying the difference between younger and older populations in the response rate to vaccinations and the virulence of infectious diseases [22] [23] [24] . among the factors contributing to immunosenescence is the chronic involution of the thymus gland with increased age. indeed, the infection rates of covid-19, separated by age, are correlated with involution of the thymus [12] . the thymus gland is most active early in life, reaching maximum size within the first year. its activity then declines with age until an individual reaches 40 to 50, after which there are negligible traces of the thymus remaining, replaced by fibrotic tissue [25] . as a result of thymic involution, the number of naïve t cells exiting the thymus decreases significantly, with substantial declines in older age [26] . besides thymic involution, there are many other factors driving immunosenescence and the increase in multimorbidity that occurs during aging [22, 27, 28] . figure 2 illustrates the hypothesised reciprocal relationship between immunosenescence and infectious disease acquisition. in this model, age-associated immunosenescence leads to a reduced ability to resist infection, while infection produces biological damage and loss of homeostasis. this ultimately contributes to accelerated aging and the development of age-related diseases, and further accelerates immunosenescence. in support of this model, infections and other age-related diseases are among the main causes of death in the developed world and in developing countries. due to the gerolavic nature of covid-19, the classical preventative measures and treatment strategies used for targeting infectious diseases may not be as effective, and there is a need for alternative geroprotective and senoremediative strategies. there are multiple clinical trials in progress using established medical interventions to treat covid-19, with the number of studies rapidly increasing [23] . for a list of promising sars-cov-2/covid-19 targets and treatment approaches, please refer to the global health drug discovery institute's portal dedicated to covid-19 [29] . here we compare the expected benefit of treatments for elderly populations (60 years and older) that are currently in development, including standard preventative strategies such as vaccines and antivirals targeting sars-cov-2, and the potential added benefit of speculative geroprotective strategies such as rapalogs, nad+ boosters, senolytics, and stem cell treatment. these additional measures may be used in isolation or as adjuvant therapies to reduce infection risk, symptom severity, or improve vaccine efficacy. vaccine development is one of the most successful approaches for combating viral diseases globally, and is often regarded as one of the greatest advances in biomedical science and integrated healthcare. currently, there are around 60 active clinical trials related to a sars-cov-2 vaccine, most of them taking place in china [30] . broadly speaking, the success of a vaccine partly depends on the similarity of the vaccine strain with the viral pathogenic strain in question. in addition, an individual's immune response must be sufficiently strong to mount a reaction to the vaccine that can later confer protection against the pathogen, should exposure occur. our current strategy for targeting annual influenza viral outbreaks focuses on effective vaccination based on predictions of strain variants. people >60 years of age with chronic medical conditions, such as type 2 diabetes or cardiovascular disease, direct immunosuppression from hiv, posttransplant or biologic treatment, pregnant individuals, or those with bmi>40, are believed to be at higher risk for influenza infection due to a weakened immune response [31] . similarly, vaccines do not provide complete protection in older populations due to agerelated declines in immune function and accumulation of multi-morbidities. outbreaks can occur in elderly nursing homes even when vaccination rates reach 80-98% uptake [32] . thus, even when a successful vaccine for sars-cov-2 becomes available, a geroprotective agent might be used in combination with the vaccine to boost the immune response. currently in most countries, the influenza vaccine formulation is determined 6-9 months before the expected outbreak season and the strains are based on the precedent season's viruses. as a result, vaccine efficacy is expected to differ from season to season. thus, an ongoing additive geroprotective therapy is of high importance [33, 34] and is applicable beyond the current pandemic. while vaccines may be the best preventative strategy for reducing the infection rates, severity, and lethality of covid-19, the rates to vaccines in the elderly will likely be lower [35] and vaccine potentiation strategies [36] may be explored and evaluated in clinical trials. while chemoprophylaxis is not routinely indicated and is not considered a replacement for vaccination, using influenza as an example, prophylactic treatment prior to symptom onset in high-risk groups or after close contact exposure to the virus is an alternative preventative strategy against viral disease [31] . for influenza, the neuraminidase inhibitors oseltamivir and zanamivir are occasionally given prophylactically to high-risk individuals in long-term care facilities during outbreaks [37] . nevertheless, there is currently no definitive benefit proven for antiviral treatment outside of these specific circumstances, as it comes at a cost and may be associated with side effects; for example, zanamivir can induce bronchospasms in patients with chronic respiratory disease and asthma. pharmacotherapy for individuals with infection remains the cornerstone of clinical practice. the success of antiviral treatment is condition-specific, ranging from new, direct-acting antiviral drugs that offer a potential cure for hepatitis c [38] ; to the highly active antiretroviral drugs that enable hiv positive individuals the prospect of a healthy life expectancy while on treatment; to antiviral drugs for herpes simplex types 1 and 2 that lead to symptom alleviation but do not eradicate the latent infection; to antivirals for seasonal influenza that are believed to reduce symptom duration, and reduce complications and transmission risk. other anti-influenza medications licensed for treatment, aside from oseltamivir and zanamivir, consist of an intravenous neuraminidase inhibitor, peravamir, and a novel oral inhibitor of cap-dependent endonuclease, baloxavir. neuraminidase inhibitors are effective against both influenza a and b, while an additional class of antivirals that are no longer recommended for treatment of influenza due to reduced efficacy, neurological side effects, and widespread resistance, adamantanes (m2 inhibitors, amantadine and rimantadine), are only active against influenza a [31] . although many patients with influenza exhibit minimal clinical improvement upon treatment with these medications, they are currently recommended for treatment of all hospitalised patients, even prior to laboratory confirmation of influenza infection. evidence shows that the greatest benefit is seen when these drugs are administered 24-30 hours prior to symptom onset, in which case they reduce symptom duration by 0.5-3 days and reduce transmission risk [39] [40] [41] [42] . according to the recent covid-19 treatment guidelines in china [43] , symptomatic treatment for covid-19 patients is recommended for mild cases and consists of aging rest, isolation, adequate hydration, analgesia, and antipyretic medication. moderate and severe cases (mostly hospitalized) require additional measures, such as careful fluid balance, intravenous antibiotics for superinfections, oxygen supplementation, non-invasive ventilation with or without positive pulmonary pressure, and in some cases intubation and mechanical ventilation. although the projected global infection rates are variable, we share a common concern that outside of china there may be an insufficient number of beds for hospitalization and ventilation units if the disease spread does not slow down. even asymptomatic covid-19 infections can induce lung fibrosis, which may lead to reduced function of the respiratory system. further, severe cases are often complicated by bacterial infections and pneumonia, leading to fibrosis. therefore, covid-19 rehabilitation may include antifibrotic compounds, anti-copd, and regenerative medicine therapies. there are multiple interventions proposed in the academic literature to remedy age-associated increases in infection rates, severity, and lethality for a variety of infections. for example, regular increased physical activity has been proposed to reduce immunosenescence [44] . fahy et al. [45] and horvath [46] have suggested that a combination of the potentially geroprotective compound metformin, recombinant human growth hormone (rhgh), and dehydroepiandrosterone (dhea) may reverse biological age, as measured using the methylation aging clock, and immunosenescence [45] . geroprotectors were previously proposed to enhance human radioresistance in extreme conditions [47] . while there is no clinical evidence yet suggesting age reversal or improved immune function in the elderly, efforts are being made to identify new geroprotectors using human data and artificial intelligence [48] [49] [50] . further, the use of natural compounds that mimic the effects of known geroprotectors is generally recognized as safe [51] . however, attempts have been made to develop criteria for the evaluation of geroprotectors for clinical validation. there are multiple strategies proposed to restore immune function in the elderly [52] , and multiple databases of geroprotectors exist [53, 54] . however, to date the only known geroprotectors backed by promising clinical evidence of improved immune response to viral infection in the elderly, although still limited by a lack of large clinical trials, are sirolimus (rapamycin) and everolimus. these may be used as single agents in combination with other treatments (figure 3 ). sirolimus (rapamycin) is a well-known geroprotector, known to effectively increase lifespan and slow aging in many species, including yeast [55, 56] , drosophila [57, 58] , c. elegans [59] , and mice [60] [61] [62] [63] [64] . it also delays age-related diseases in humans [65] [66] [67] [68] , and blagosklonny proposed rapamycin for the prevention of multiple age-related diseases in humans [69] [70] [71] [72] . sirolimus and rapalogs are commonly used as immunosuppressants. rapalogs, the derivatives and mimetics of rapamycin, target critical factors in the rapamycin (tor) pathway. everolimus (rad001), another close structural derivative of sirolimus developed by novartis, acts as an immunosuppressant; but like sirolimus, it has many other properties beyond immunosuppression [73] . paradoxically, these compounds also exert immunostimulatory effects, such as boosting t cell responses in reaction to pathogen infection and vaccination [74] . nevertheless, this would not be the first case of a physiological paradox in clinical medicine. the administration of beta-blockers to heart failure patients at first seemed contradictory, as these compounds slow down an already failing heart, but proved to provide the most benefit for the treatment of heart failure patients. likewise, hormonal treatment of hormone-dependent cancers, such as testosteronedependent prostate cancer, seems incongruous. however, administration of a synthetic version of gonadotropin-releasing hormone (gnrh) in a different dosing regime from the cyclical secretion that occurs physiologically, which normally indirectly increases testosterone levels, actually reduces hormone levels. therefore, it might be possible that a drug that is known to be an immunosuppressant might in a different dosing regimen prove to be an immunostimulant. however, extremely cautious clinical validation is required as this treatment might carry significant risks; indeed, there is some indication that morbidity from coronavirus infections occurs from secondary overactive immune responses [75, 76] . in addition to rapamycin, other agents that inhibit mtor, such as torin1, torin2, azd8055, pp242, ku-006379 and gsk1059615, may act similarly to rapamycin in low-doses and may have a geroprotective effect [77] [78] [79] . substantial pre-clinical validation would be required to apply these compounds to specific age-associated diseases and to explore clinical applications of these compounds in human clinical trials. multiple clinical observations suggested that patients with cytomegalovirus (cmv) disease who were treated with rapamycin demonstrated better outcomes and were better able to control cmv viremia than patients treated with standard calcineurin inhibitor-based immunosuppression following transplantation [74, 80] . in 2009, two seminal studies of sirolimus demonstrated the immunostimulatory effects of rapamycin on the cd8+ memory t cell response following pathogen infection [74, 80] . later studies also showed that monkeys treated with sirolimus exhibited increased recall responses and enhanced differentiation of memory t cells following vaccination with modified vaccinia ankara [81] . additional clinical studies by mannick et al. [82, 83] demonstrated the immunostimulatory role of rapalogs in the elderly using the novartis rapalog everolimus (rad001), a close structural analog of sirolimus (rapamycin). administration of everolimus ameliorated immunosenescence in healthy elderly volunteers and enhanced the response to the influenza vaccine by around 20% at doses that were well tolerated [82] . further studies demonstrated enhanced immune function and reduced infection in elderly patients receiving tolerable doses of everolimus. mannick et al. also conducted a phase 2a randomized, placebo-controlled clinical trial which demonstrated that a low-dose combination of dactolisib (bez235) and everolimus in an elderly population was safe and associated with a significant (p=0.001) decrease in the rate of reported infections [83] . mannick and colleagues further conducted a phase 2a randomized, placebo-controlled clinical trial that demonstrated that a low-dose combination of dactolisib (bez235), a pi3k inhibitor [84] and catalytic mtor inhibitor, and everolimus in an elderly population was safe and associated with a significant (p=0.001) decrease in the rate of reported infections [83] . a follow-up trial of dactolisib alone (bez235 rebranded as rtb101) for prevention of respiratory tract infections in the elderly did not meet the primary endpoint and further trials were withdrawn [85] . in prior studies, everolimus (rad001) was used as a standalone agent or in combination with dactolisib, which may explain the phase 3 failure of bez235/rtb101. there are over 95 phase 3 and phase 4 studies for these agents [86] , and they are generally well tolerated even in high doses. even though it may not be commercially viable due to the patent expirations, clinical trials should be conducted to evaluate the effectiveness of these agents for protection against sars-cov-2 (covid-19) and other gerophilic and gerolavic infections. metformin is a drug approved to treat type 2 diabetes but appears to target a number of aging-related mechanisms, including decreasing igf-1 levels, inhibiting mtor, and inhibiting mitochondrial complex 1. metformin is currently in the first large-scale human aging clinical trial of aging, the targeting aging with metformin (tame) study, which is investigating its effect on time to a new occurrence of a composite outcome that includes cardiovascular events, cancer, dementia, and mortality [87] . metformin would likely still be contraindicated in elderly patients with advanced chronic kidney disease and egfr<15. a reduced dose would potentially be required for egfr<30 due to a risk of lactic acidosis. the effects on gerophilic and gerolavic infections should be carefully examined in the context of the tame study, and other clinical trials involving metformin. nicotine adenine dinucleotide (nad) is a cofactor of multiple fundamental enzymes. it is involved in metabolic regulation through the krebs (citric acid) cycle, oxidative phosphorylation, and cellular signaling, as well as cellular senescence and dna repair through the poly-adp-ribose polymerases (parps), sirtuins, and cd38. nad levels decrease with aging, and benefits of nad supplementation have been reported in multiple animal studies. although no proof of a similar effect in humans has been shown, several clinical trials are in progress [88] [89] [90] [91] . supplementation with nicotinamide riboside (nr) in one human study produced an improvement in exercise capacity in a population with a mean age of 71 [92] . this compound was also shown to reduce blood pressure in hypertensive patients [93] . nicotinic acid is another nad precursor that is converted in the body to nad by the enzymes naprt, nmnat, and nads. large-scale trials of nicotinic acid for cardiovascular disease [94, 95] showed some efficacy, but produced adverse side effects, such as headache, skin flushing, and dizziness [96] . nad acts at a cellular level and it is still unclear whether oral or intravenous supplementation with nad donors, such as nr and nicotinic acid, will increase nad levels and exert a clinical benefit in humans. however, covid-19 patients may benefit tremendously from these compounds, as sars-cov-2infected patients have increased levels of cd38+, and nad has been shown to enhance dna repair via parp pathways [97] . caution should be exercised when conducting any clinical trials for nad boosters against gerophilic and gerolavic infections, as the underlying biology of nas metabolism and viral infections is still poorly understood. recent studies in humans demonstrate that nr supplementation reduces the levels of circulating inflammatory cytokines [98] , while nicotinamide mononucleotide (nmn) may reduce the expression of these cytokines [99] . other studies implicate nad in increased cytokine production [100] and the nad+consuming enzyme cd38 in increased inflammation [101] . additional immunological studies of nad boosters must be performed before clinical trials may be conducted. however, considering the large consumer base of nr and nmn supplements, it may be possible to conduct metastudies on influenza and sars-cov-2 infectivity, severity, and lethality. senolytics are drugs that are postulated to selectively destroy senescent cells, which accumulate with aging and exhibit senescence-associated secretory phenotype (sasp), through senolysis, apoptosis, immunosurveillance, or other mechanisms of action [102] . sasp is now hypothesised to lead to nad depletion and thus initiate or perpetuate an increase in sterile chronic inflammation. many drug classes, ranging from fibrates to cardiac glycosides, have been reported to have senolytic properties in animal models [103] . however, recent promising human data have been reported with the tyrosine kinase inhibitor dasatinib in combination with the plant flavonol quercetin in a trial by the mayo clinic [104] ; flavonoid polyphenols have also proven beneficial. in addition, pre-clinical and clinical data suggest that flavonoids may be used for prophylaxis in upper respiratory tract infections [105] . although senolytic drugs would have a scientifically plausible role in biological age reversal and thus reduction of mortality from gerolavic viruses like sars-cov-2, it has not been shown that these classes of drugs would protect against infection or could be used as adjuncts to vaccination. in addition, there remains the risk that senolytics would not be sufficiently specific to discriminate between deleterious senescent cells and quiescent (dormant) cells, which might still differentiate into the mature cell types of a given tissue, and could thus deplete beneficial protective stem cell reserves. it has been shown in multiple studies that calorie restriction leads to increased lifespan and improved cardiometabolic markers, even when initiated in middle age [106] . caloric restriction should be considered as a preventive measure on a long-term basis and is indicated for younger individuals. some elderly patients already have frailty syndromes and evident sarcopenia/ osteopenia, which limits the suitability of intermittent caloric restriction. nevertheless, the aging benefits of time-restricted feeding and intermittent fasting go beyond simple caloric restriction due to the production of ketones. ketones are active signaling molecules that play a major role in the ppar, sirtuin, nad and cd38 pathways, encourage autophagy (the removal of damaged cellular materials), modulate the immune response, and have been explored in clinical trials as an adjuvant therapy for cancer treatments [107] . within 8-12 hours of food restriction, ketones are believed to rise to 0.2 to 0.5mm and continue to increase within the first 48 hours to 1 to 2mm [108] . under fasting conditions the major body ketone in the plasma, beta-hydroxybutyrate (bhb), increases. bhb is believed to confer the major metabolic benefit of fasting and is in development as an independent therapeutic supplement. an age-related decrease of thymic function consequently reduces the levels of specific t cell subsets [109] . foxp3+ regulatory t (treg) cells are critical in homeostasis of the immune system and are believed to start declining in numbers at around 50-60 years of age; this remains one of the fundamental drivers of immunosenescence. there are two known origins for treg cells: thymus-derived treg cells and peripherally-derived treg (ptreg) cells. thus, inducing a peripheral treg response in older individuals might be a feasible strategy for increasing treg cell levels until we have more plausible options for thymic rejuvenation. foxp3 transcription factor (tf) is the most important regulator of tregs and ageassociated immunosenescence. foxp3 tf expression is regulated by chemical modification by sirtuin (sirt) and histone deacetylases, in particular sirt1 and hdac9 [110, 111] . interestingly, nad is essential for sirtuin action. therefore, it is plausible that nad and nad-related compounds such as nr and nmn, which are under investigation as therapeutic interventions that increase serum and cellular nad levels, also act via sirt1 along the foxp3 and treg axis, and play a role in immunosenescence and "inflammaging". a brief summary of the conventional and geroprotective and senoremediative strategies for patients 60 or older is provided in table 1 . while there are decades of clinical evidence supporting the use of rapalogs, such as sirolimus, everolimus, and metformin, substantial meta-analysis and additional clinical trials must be conducted to understand the population-level and individual effects of these drugs taken as single agents and in combination in the context of gerolavic diseases. in this paper i propose conducting clinical trials on these known geroprotectors as a preventative measure before patients are exposed to disease (figure 4 ). in the case of covid-19 as the number of cases worldwide increases, meta-analysis of infection rates, severity, and lethality should be performed rapidly to evaluate the effects of geroprotectors, with particular focus on rapamycin. since covid-19 engages the immune system to damage the lungs, it may be entirely plausible that the immunomodulatory properties of rapamycin may go beyond prevention and may provide an effective treatment option. however, this hypothesis must be validated using meta-analysis before being proposed for a clinical trial. as covid-19 causes substantial lung damage, antifibrotics, senolytics and other geroprotectors may be explored in clinical trials to assist in patient recovery to prevent a reduction in respiratory function. since senescence varies among individuals, a person's chronological age is not as important as their biological age. for several years, scientists have sought accurate aging biomarkers that may predict an individuals' biological age and, independently of immunosenescence, their risk of morbidity and mortality. these biomarkers, or "clocks", could then be used to test for the effectiveness of proposed geroprotective treatments and as surrogate markers in anti-aging clinical trials. while there are no reliable aging clocks to evaluate immunosenescence and inflamaging [112] , these biomarkers may be rapidly developed using historical data. at present, age clocks trained on clinical blood tests [113] , transcriptomic [114] and proteomic data [115] , methylation clocks [46, 116] , microbiomic clocks [117] and other clocks have been described. recent advances in artificial intelligence have enabled the development of multimodal multi-omics age-predictors, able to learn complex non-linear patterns and extract the most important features [113, 118] . none of these currently have robust clinical validation and cannot yet serve as companion biomarkers for geroprotective and antiaging interventions intended to ameliorate the population-level effects of infectious diseases during flu seasons and pandemics. we call for rigorous clinical validation and further development of biological aging clocks that could, in the future, allow us to measure the effectiveness of the numerous speculative geroprotective and senoremediative interventions described herein. covid-19 is a gerolavic infection. efficacy of the vaccine will likely be significantly reduced due to immunosenescence and multimorbidity. possible immunogenicity and mild viral prodrome symptoms as a result of vaccination. antibodies for covid-19 antibodies of serum of recovered individuals. antibodies targeting specific sars-cov-2 proteins. successfully trialed in other viral diseases including ebola. reduction in disease severity and lethality in exposed individuals. risk of systemic immune reactions and certain blood borne infections. selective small molecule inhibitors targeting sars-cov-2 proteins such as 3c-like protease. multiple examples from influenza. neuraminidase and endonuclease inhibitors. reduction in disease duration, severity, and lethality in exposed individuals. mild side effects such as nausea, vomiting, diarrhea, etc. non-steroidal antiinflammatory drugs (nsaids), antibacterials, pain management. multiple clinical trials, common use. reduction in severity of disease. mild side effects such as nausea, vomiting, diarrhea, etc. [24] . theoretically, treatments found to be effective against sars and mers are the most promising starting points for treatments likely to be effective against sars-cov-2. the sars outbreak of 2002 was rapidly contained, and no new cases have been reported since 2004 [119] . since the scale of the outbreak did not provide any commercial benefit for the pharmaceutical industry to develop effective drugs for sars, much of the discovery efforts stopped after the epidemic. when the news of sars-cov-2/covid-19 emerged in early january 2020, it was difficult to justify a business case for small biotechnology companies to allocate resources to the effort. by january 28 th , however, insilico medicine allocated resources to generate and test small molecules against the sars-cov-2 3c-like protease [120, 121] . as the scale of the current covid-19 pandemic remains uncertain, it is still difficult to justify allocating scarce company resources to full-scale drug discovery and drug development programs, which may cost tens or even hundreds of millions of dollars [122] . multiple biotechnology companies are in the same situation and will not be able to proceed without substantial backing from government agencies, nonprofit organizations, or bigger pharmaceutical companies. however, given the gerophilic and gerolavic nature of covid-19, strategies targeting age-associated pathologies and immunosenescence, which could decrease the comorbidity, infection rates, severity, and lethality of the disease, will remain commercially-viable even when the pandemic subsides. in addition, respiratory infections are now the third leading cause of death in the world, following cardiac disease and stroke [123] , further justifying the need for these interventions. considering the gerolavic nature of covid-19, where the majority of the seriously affected population is older than 60, classical prevention and treatment strategies may not be effective. given the severity and lethality of the pandemic, even healthcare systems in developed countries will find it challenging to cope with the increased disease burden and hospital needs. conventional approaches to prevention such as vaccines are much needed, but even these do not offer complete protection in the elderly due to multi-morbidity and agerelated immune declines. therefore, interventions that enable immunocompromised elderly to mount an immune response to newly developed vaccines are necessary to help eradicate the disease and reduce the associated mortality. to avoid substantial loss of life and quality of life, primarily among the elderly and vulnerable populations, governments and healthcare systems should investigate preventative and intervention strategies stemming from recent advances in aging research. as discussed in this paper, small clinical studies have shown that several geroprotective and senoremediative interventions, such as treatment with aging sirolimus and rapalogs, can induce immunopotentiation, increase resistance to infection, and reduce disease severity in the elderly, without severe side effects. serendipitously, during the revision of this article, another group utilizing computational approaches proposed using melatonin and sirolimus (rapamycin) in combination to treat the covid-19 infection outside the context of geroprotection [124] . many of these predicted geroprotectors are available as supplements; however, no meta-analysis or metaclinical trials have been performed at scale to evaluate their effectiveness. the covid-19 pandemic highlights the paucity of clinical trials on the effects of dietary supplements and drugs on aging and immunosenescence. the existence of pseudoscience and anecdotal promotion in the supplement industry does not mean that protective compounds do not exist. dietary supplement vendors and pharmaceutical companies need to actively engage in preclinical and clinical research to evaluate the effectiveness of the currently available products on immunosenescence and aging. this paper is not intended to encourage the use of rapalogs or other potential geroprotectors during the covid-19 pandemic. it may be possible that some of the potential geroprotectors described in this paper are harmful to the elderly after infection, and may actually increase disease severity and lethality. however, it may be possible to conduct clinical trials on the efficacy of geroprotectors previously tested in human clinical trials in treating covid-19 and other gerophilic and gerolavic infections. to combat the growing covid-19 pandemic, researchers have united globally to tackle a disease that is impacting lives and healthcare systems around the world. after carefully analysing preliminary data, we suggest that covid-19 has a gerophilic and gerolavic profile, being more infectious and more severe in the elderly. in this paper, we review the current literature on speculative aging reversal treatments, such as experimental geroprotective strategies using everolimus (rad001) and sirolimus (rapamycin). we summarize the current possible interventions and identify the lack of clinical evidence to support their immediate use with the aim of encouraging further, more rigorous reviews of geroprotective compounds such as rapalogs, metformin, senolytics, and conventional and investigational nad+ boosters. we also suggest that further clinical studies should be carefully designed and adequately powered to determine if these interventions might provide clinical benefit as adjuncts to vaccines and antiviral treatments by acting as immune response potentiators. lastly, as with many other diseases, covid-19 is more common and severe in elderly populations, and we thus invite further research and clinical validation in the field of biological aging clocks. these markers could potentially be used in the future to measure and analyze immunosenescence and the efficacy of interventions claimed to slow down or reverse age-related immune decline. this perspective is of a highly speculative nature presented during the time of a global covid-19 pandemic. it is intended for a professional audience to stimulate ideas and aid the global efforts of the scientific community to develop effective new treatments for this disease. this article does not represent medical advice or recommendations to patients. there is no clinical evidence to support the use of the treatments described in this article for this indication and the authors do not advise anyone to self-administer these drugs as covid-19 prevention or treatment. furthermore, this perspective is based on the limited data from the first weeks of the covid-19 outbreak. the demographic distribution of the infected and diseased may change and differ in different countries with different social customs and different ethnicities. the media should exercise caution and seek expert medical advice for interpretation when referring to this article to avoid misinterpretation or unsafe messages being delivered to the community amidst exceptional coverage of this disease in the media at present. the author would like to thank dr. quentin vahaelen of insilico medicine, dr. evelyne bischof of the jiaotong and shanghai university of medicine and the university of basel, and mr. dara vakili of imperial college london for advice and valuable contributions. the author would like to thank dr. richard faragher for the valuable suggestions and comments on the new term "gerolavic" to describe the infections harmful to the elderly, which did not previously exist; and rachel stewart for edits, formatting, and reference management. no funding has been provided for this work. alex zhavoronkov is a co-founder of insilico medicine, a leading artificial intelligence company specializing in target discovery and small molecule generation, and deep longevity, a company specializing in deep aging clocks, multimodal age predictors built using deep learning. he has multiple granted patents and patent applications on deep aging clocks, geroprotective aging interventions, generative chemistry, generative biology, and artificial intelligence techniques. the hallmarks of aging methods for structuring scientific knowledge from many areas related to aging research to help aging populations, classify organismal senescence classifying aging as a disease in the context of icd-11 editorial: should we treat aging as a disease? academic, pharmaceutical, healthcare policy, and pension fund perspectives aging, frailty and age-related diseases infection in an aging population grubeck-loebenstein b. persistent viral infections and immune aging lung infections and aging epidemiology 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prevalence and patterns of multimorbidity among the elderly in china: a cross-sectional study using national survey data measuring multimorbidity in older adults: comparing different data sources search of: recruiting, not yet recruiting, available studies | "coronavirus infections" -list results -clinicaltrials.gov centers for disease control and prevention. influenza antiviral medications: clinician summary. 2020 detection and control of influenza outbreaks in well-vaccinated nursing home populations influenza virus-related critical illness: prevention, diagnosis, treatment influenza: overview on prevention and therapy vaccine potentiation by combination adjuvants. vaccines (basel) immunosenescence and human vaccine immune responses long-term use of oseltamivir for the prophylaxis of influenza in a vaccinated frail older population overview of direct-acting antiviral drugs and drug resistance of hepatitis c virus oseltamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments zanamivir for influenza in adults and children: systematic review of clinical study reports and summary of regulatory comments oseltamivir treatment for influenza in adults: a metaanalysis of randomised controlled trials and baloxavir marboxil investigators group. baloxavir marboxil for uncomplicated influenza in adults and adolescents understanding covid-19 new diagnostic guidelines -a message of reassurance from an internal medicine doctor in shanghai can physical activity ameliorate immunosenescence and thereby reduce age-related multi-morbidity? reversal of epigenetic aging and immunosenescent trends in humans dna methylation age of human tissues and cell types vive la radiorésistance!: converging research in radiobiology and biogerontology to enhance human radioresistance for deep space exploration and colonization signaling pathway cloud regulation for in silico screening and ranking of the potential geroprotective drugs in search for geroprotectors: in silico screening and in vitro validation of signalome-level mimetics of young healthy state artificial intelligence for aging and longevity research: recent advances and perspectives towards natural mimetics of metformin and rapamycin interventions to restore appropriate immune function in the elderly the drugage database of aging-related drugs org: a new, structured and curated database of current therapeutic interventions in aging and age-related disease regulation of yeast replicative life span by tor and sch9 in response to nutrients extension of chronological life span in yeast by decreased tor pathway signaling regulation of lifespan in drosophila by modulation of genes in the tor signaling pathway target of rapamycin activation predicts lifespan in fruit flies tor signaling and rapamycin influence longevity by regulating skn-1/nrf and daf-16/foxo rapamycin fed late in life extends lifespan in genetically heterogeneous mice rapamycin increases lifespan and inhibits spontaneous tumorigenesis in inbred female mice rapamycin slows aging in mice new nanoformulation of rapamycin rapatar extends lifespan in homozygous p53-/-mice by delaying carcinogenesis rapamycin extends maximal lifespan in cancer-prone mice immunostimulatory activity of lifespan-extending agents sirolimus and secondary skin-cancer prevention in kidney transplantation sirolimus therapy after early cyclosporine withdrawal reduces the risk for cancer in adult renal transplantation rejuvenating immunity: "anti-aging drug today" eight years later validation of anti-aging drugs by treating age-related diseases prevention of cancer by inhibiting aging an anti-aging drug today: from senescence-promoting genes to anti-aging pill aging and immortality: quasiprogrammed senescence and its pharmacologic inhibition selective effects of mtor inhibitor sirolimus on naïve and cmv-specific t cells extending its applicable range beyond immunosuppression paradoxical aspects of rapamycin immunobiology in transplantation type 1 interferons and the virus-host relationship: a lesson in détente sars coronavirus and innate immunity inhibitors of mtor in aging and cancer gerosuppression in confluent cells dual mtorc1/c2 inhibitors suppress cellular geroconversion (a senescence program) decreased cytomegalovirus infection after antilymphocyte therapy in sirolimus-treated renal transplant patients sirolimus enhances the magnitude and quality of viralspecific cd8+ t-cell responses to vaccinia virus vaccination in rhesus macaques mtor inhibition improves immune function in the elderly torc1 inhibition enhances immune function and reduces infections in the elderly nvp-bez235, a novel dual phosphatidylinositol 3-kinase/mammalian target of rapamycin inhibitor, elicits multifaceted antitumor activities in human gliomas effect of rtb101 on illness associated with respiratory tract infections in the elderly search of: rad001, certican, rapamycin metformin as a tool to effect of "nicotinamide mononucleotide" (nmn) on cardiometabolic function effects of nicotinamide riboside on metabolism and vascular function nicotinamide riboside and metabolic health nicotinamide riboside in systolic heart failure acute nicotinamide riboside supplementation improves redox homeostasis and exercise performance in old individuals: a double-blind cross-over study chronic nicotinamide riboside supplementation is welltolerated and elevates nad + in healthy middle-aged and older adults plaque inflammation and dysfunctional hdl in aim-high treatment of hdl to reduce the incidence of vascular events hps2-thrive interacting nad + and cell senescence pathways complicate antiaging therapies molecular immune www.aging-us.com aging pathogenesis and diagnosis of covid-19 nicotinamide riboside augments the aged human skeletal muscle nad + metabolome and induces transcriptomic and anti-inflammatory signatures head to head comparison of short-term treatment with the nad(+) precursor nicotinamide mononucleotide (nmn) and 6 weeks of exercise in obese female mice pharmacological inhibition of nicotinamide phosphoribosyltransferase/ visfatin enzymatic activity identifies a new inflammatory pathway linked to nad cd38 is robustly induced in human macrophages and monocytes in inflammatory conditions the clinical potential of senolytic drugs cardiac glycosides are broad-spectrum senolytics senolytics decrease senescent cells in humans: preliminary report from a clinical trial of dasatinib plus quercetin in individuals with diabetic kidney disease effect of flavonoids on upper respiratory tract infections and immune function: a systematic review and meta-analysis 2 years of calorie restriction and cardiometabolic risk (calerie): exploratory outcomes of a multicentre, phase 2, randomised controlled trial the role of intermittent fasting and meal timing in weight management and metabolic health effects of intermittent fasting on health, aging, and disease regulatory t cells and foxp3 inhibition of hdac9 increases t regulatory cell function and prevents colitis in mice sirtuin-1 targeting promotes foxp3+ tregulatory cell function and prolongs allograft survival are there reliable biomarkers for immunosenescence and inflammaging deep biomarkers of human aging: application of deep neural networks to biomarker development machine learning on human muscle transcriptomic data for biomarker discovery and tissue-specific drug target identification deep learning enables rapid identification of potent ddr1 kinase inhibitors genome-wide methylation profiles reveal quantitative views of human aging rates human microbiome aging clocks based on deep learning and tandem of permutation feature importance and accumulated local effects. biorxiv deep aging clocks: the emergence of ai-based biomarkers of aging and longevity uk national health service. sars (severe acute respiratory syndrome) insilico medicine publishes molecular structures for the key protein target of 2019-ncov potential covid-2019 3c-like protease inhibitors designed using generative deep learning approaches how to improve r&d productivity: the pharmaceutical industry's grand challenge acute respiratory infections are world's third leading cause of death network-based drug repurposing for novel coronavirus 2019-ncov/sars-cov-2 key: cord-276740-4wwo9tho authors: overholser, james c. title: roll out the red carpet: the 3rd annual awards for the most valuable contributions to psychotherapy date: 2020-05-20 journal: j contemp psychother doi: 10.1007/s10879-020-09459-3 sha: doc_id: 276740 cord_uid: 4wwo9tho every spring, media coverage emphasizes the "award season", highlighting contributions made by musicians, actors, and professional athletes. unfortunately, psychologists are not included in these gala celebrations. it seems appropriate to take time to praise the hard work and dedication that is required to publish in an academic journal. the present article summarizes the results from the 3rd annual psychotherapy award program designed to highlight the valuable contributions made in eleven different categories. a total of 81 academic journals were reviewed for their articles published during 2019, and 150 papers were found useful and relevant to the field of psychotherapy. the list was then shortened to 44 articles that were organized into eleven award categories, and the best paper in each category was selected by a panel from the journal's editorial board. the hope is that all psychotherapists will value the contributions being made in these articles. every year during springtime, media coverage highlights assorted annual award ceremonies. the celebrities (actors, musicians and professional athletes) stop to recognize their achievements through a wide spectrum of elaborate award ceremonies. at these glamorous events, celebrities acknowledge the recent accomplishments of other celebrities and receive awards (e.g., an emmy, an oscar, a grammy, an espy, a tony a golden globe) for their talent during televised banquets and elaborate post-ceremony galas. i believe it is time to add the "psyche" to the list of awards, as we highlight the heroes of psychotherapy. it seems important to highlight the contributions being made by psychotherapists each year, recognizing heroes within the field of mental health providers, who work quietly to help improve the lives of their patients. colleagues who publish valuable articles that help to improve our understanding of mental health and its treatment deserve our profound respect and sincere appreciation. work as a psychotherapist can be rewarding yet challenging. effective psychotherapy typically relies on an integration of theory, research, and experience as an active clinician. the field of psychotherapy moves forward through scholarly publishing that helps to refine ideas, clarify strategies, and test hypotheses. publishing journal articles on psychotherapy requires an integration of science and practice (overholser 2007) , usually combined with innovative ideas and thoughtful integration across theories (overholser 2008) . furthermore, publishing scholarly articles requires skill in communicating ideas in written form (overholser 2011) . it is essential for scholarly journals to advance the field of psychotherapy by publishing articles that confront, explore, and refine important issues in psychotherapy without simply chasing the latest fad topic (overholser 2014a) . unfortunately, much of the work that goes into scholarly publications goes unnoticed. to publish a journal article on psychotherapy requires creative ideas, skillful writing, clinical experience, and endless persistence to deal with the process of peer review. many psychologists work their entire career without ever publishing a single article in a peer reviewed journal. starting in 2016, the journal of contemporary psychotherapy initiated an award program to celebrate and highlight the creative ideas and important advances in the field of psychotherapy. previous awards (overholser 2019; overholser and beale 2018) have highlighted important contributions across different theoretical styles and various psychiatric disorders. the goal is to psychoanalytic psychology, psychological assessment, psychological bulletin, psychological medicine, psychotherapy, psychotherapy research, rorschachiana, scandinavian journal of psychology, the behavior analyst, the clinical supervisor, the counseling psychologist, and training and education in professional psychology. additional articles that had been published in other journals were included in the review, identified through a supplemental search for each award category. the massive list of publications was then narrowed down, and 150 articles were identified that deserved a more detailed review and evaluation. numerous papers were reviewed critically and rejected from consideration because their methodology was limited to a packet of self-report questionnaires administered at one point in time, especially if the sample posed no unique value to advancing the field. then, the editor-in-chief narrowed the list down to the final four articles deemed best to represent each of the award categories. each award category has its own criteria, but across the awards, the general criteria included a focus on matters that pertain to the realities of clinical practice. manuscripts should have broad appeal, so it would be useful for most mental health professionals, even if the topic was not aligned to a specific area of interest or specialization. for review papers, the article could be a structured review of the recent literature, a meta-analysis, or a critical and opinionated review based on years of professional experience as a psychotherapist. for research studies, the projects were evaluated for its subjects, measures, and procedures. in terms of research participants, it seems obvious that research on mental health and mental illness is best conducted with medical or psychiatric patients who are struggling with behavioral, emotional or cognitive problems (overholser 2014b) . too many studies rely on participants that are not representative of the typical pool of psychiatric clients, and instead evaluate psychological issues in samples of convenience, such as college students, anonymous online surveys, or mturk methodology. too many psychological studies have collected data on weird samples (henrich et al. 2010) referring to western, educated, industrialized, rich, and democratic countries, instead of a broader sample of humanity. because so many research studies have relied on samples of convenience (fernald 2010) , the external validity of the research is quite limited (arnett 2008). the diagnosis and treatment of patients with mental illness benefit from research that is strong in external validity. thus, it is essential for research on mental illness and its treatment to be conducted on samples of medical or psychiatric patients who can describe their mental and emotional problems (overholser 2014b) . furthermore, investigators sometimes exclude from participation any "normal" participant that reported elevated scores on measures of psychiatric symptoms or psychiatric patients who meet criteria for more than one disorder. although such research may help the field to understand normal processes in normal individuals, such methodology is far removed from the heart of clinical psychology. therefore, participants need to evaluate psychological processes in medical or psychiatric patients in need of mental health services. many articles were excluded because their subjects were limited to analogue samples, such as healthy college students, anonymous online surveys, or mturk recruitment. in terms of measures used in the research, psychological assessment in clinical settings often relies on a combination of self-report questionnaires, structured diagnostic interviews, and possibly other sources such as informant reports or observational measures, often completed on several occasions over the course of therapy (overholser 2014b ). however, many research studies are limited to a packet of self-report questionnaires collected at a single point in time. furthermore, some studies rely on assessment measures that may not be optimal for clinical use, including genetic markers, biochemical measures, or neuroanatomical structures. it seems important to respect the boundaries of psychology where assessment crosses into medicine, psychiatry or neurology. research procedures were evaluated to align with standard clinical practice. in terms of the procedures used in research projects, many studies were excluded if they relied heavily on biological interventions. psychotherapy is an independent field, and psychologists do not need to accept an inferior role, serving as assistant to physicians, helping to monitor the effectiveness of drug treatments or their sideeffects. finally, some interventions are provided by online programs or graduate student trainees, using methodology that differs from standard clinical practice. the award committee members were provided with a list of eleven award categories, criteria for each award, and four nominees per category. the committee members were asked to rank order each paper within each category, rating the papers from most to least valuable to the field of psychotherapy. the different rank orders were combined to select the winner in each category. the best papers demonstrate skillful writing (overholser 2011) and an integration of theory and practice (overholser 2007 ). too many research studies are conducted in highly controlled and fairly artificial research environments. although these research projects can help to improve understanding of the mind and mental processes, it can be difficult to generalize the findings to actual clinical settings. this award highlights the value of research while maintaining a strong focus on clinical applications. thus, priority is given to scholarly review papers or empirical studies that align with clinical practice. the intent is to emphasize the importance of the scientist-practitioner model as central to the future of clinical psychology (overholser 2007 (overholser , 2010 . therefore, this award aims to highlight and promote a sincere integration of science and practice. nominees are … and the winner is femke truijens et al. (2019) for their important paper on the risks and benefits of manualized therapy. the topic of manualized therapy is central to the current emphasis on evidence-based therapy, and the article protects the creativity and flexibility that is needed in most therapy sessions. in a thorough and scholarly manner, the article exposes the limitations involved in manualized therapy, and confronts the assumed superiority of manualized approaches. according to the authors (femke fruijens, personal communication, march 26, 2020): " the most basic questions in research are often forgotten to be asked. a wide-spread and institutionalized assumption is that manualized treatment is more effective than nonmanualized treatment. but is it? we took up the challenge to scrutinize the evidence-base for manual superiority. strikingly, only six studies address this hypothesis in the margin and none provided straightforward support. this award is a great reminder to researchers that we cannot take our assumptions for granted and that we have to keep working in close dialogue with clinical practice." it is rarely helpful for psychotherapists to focus on one narrow view of therapy, and it is rarely helpful for trainees to learn one limited theoretical orientation. instead, in actual clinical practice, psychotherapy often relies on a broad, comprehensive approach that integrates a diverse array of theories and strategies. this award highlights the value of a comprehensive approach to psychotherapy, highlighting the contribution made through a published article that encourages an integrative approach to psychological treatments. the award aims not for a "horse race" competition across several different psychological treatments, but a true assimilation that reflects the integrative work that forms the foundation for actual clinical practice. papers may strive to integrate a diverse array of theories, ideas, and strategies that can help to guide therapy sessions. nominees are … and the winner is marvin goldfried and his valuable article on divergent views of psychotherapy. throughout his long and prolific career, dr. goldfried has emphasized the importance of integration in psychotherapy. his ground-breaking book (goldfried 1982) helps to protect the wisdom from many historical figures and encourage the younger generation of psychologists to focus on integration of different therapy styles. the recent article on consensus highlights the value of commonalities across diverse views, including the role of client expectations and the value of the therapeutic alliance. goldfried aims to reduce the gap between science and practice, and the role of principles of change. according to dr. goldfried (personal communication, march 20, 2020 ) "ever since i was a graduate student, which goes back some 60 years (!), i have been concerned about the schizophrenic nature of clinical psychology. it has been the researchers versus the clinicians. it has been the battle of the theoretical orientations. although psychotherapy has been in existence for over 100 years, sociologists that have studied the development of sciences still categorize psychotherapy as an infant, pre-paradigmatic field. i wrote this american psychologist article to explore what prevents us from achieving maturity, and what we need to do to finally make it happen." in many situations, the most creative ideas for therapy derive from actual clinical practice. through a series of adjustments and improvements, psychotherapy can be refined and strategies can be expanded. specific strategies are aligned with one particular approach to therapy, and when found useful, it can extend beyond any single ideological approach. this award highlights innovations in clinical practice, often related to a specific type in treatment. nominees are … utilizing metaphors in solution-focused therapy. contemporary family therapy, 41, 24-36. and the winner is lauren bonavitacola and colleagues for their article on cognitive restructuring in dialectical behavior therapy. the article includes a variety of useful suggestions for conducting therapy sessions, including a checklist of cognitive restructuring procedures and handouts for emotion regulation and interpersonal effectiveness skills. the article summarizes two detailed case examples, highlighting the use of many of these treatment procedures. according to dr. bonavitacola (personal communication, march 22, 2020) , "this paper stemmed from an observation that my colleagues and i had about the apparent lack of the traditional use of cognitive therapy in the implementation of dbt at our practice and in the larger dbt community. we thought this was interesting given that a core principle in dbt, if not the core principle, is that of dialectics, which one could argue is a cognitive concept. we were curious to see if other dbt practitioners in the field felt that the use of dialectical thinking was important to the overall outcomes of their patients and if they were targeting the increase in these strategies in their practice. once we saw that there was both an awareness of dialectical thinking's importance and a lack of formally targeting it, we thought it would be beneficial to the field to write about how to utilize this cognitive technique more intensively." depression, in its various forms, is one of the most prominent and disabling types of mental illness. when working with clients who are currently depressed and possibly suicidal, a psychologist has the rare opportunity to share words that could save a life. numerous research studies have demonstrated the effectiveness of psychological treatments for depression, and the superiority of psychotherapy over a pharmaceutical approach to treatment. however, it is now incumbent upon psychologists to refine and improve the treatments that help clients recover from depression. this award highlights the value of new ideas and valuable strategies that can guide the assessment or treatment of depression and its associated risk for suicide. nominees are … and the winner is hannah boettcher and david barlow (2019) for their article on the use of interoceptive exposure. the article explains the benefits derived from helping clients to confront the symptoms of anxiety and the associated fears, such as having a heart attack. the article includes a detailed review of ten adults who were struggling with panic disorder and claustrophobia. patients were treated effectively using interoceptive exposure therapy to refute their beliefs and habituate to the feelings of distress. because of individual differences, the authors recommend that both assessment and treatment should be adapted to the needs of each individual patient. according to the author (hannah boettcher, personal communication, march 30, 2020) : "this project was designed to illustrate the strengths of taking a single-case approach in applied research, and to better understand an underutilized component in cbt for anxiety, interoceptive exposure. single-case designs can be conducted with limited resources (the present example was a doctoral dissertation with ten participants and no study staff), and they allow for flexible, response-guided personalization. given that nonresponse to evidence-based treatment remains common, it is incumbent upon both researchers and clinicians to take an idiographic approach to treatment design where possible. for example, this study illustrated that among patients with identical diagnoses (panic disorder with claustrophobia), differences in types of feared outcomes impacted benefit from interoceptive and situational exposure. furthermore, participants found interoceptive exposure highly acceptable, even with minimal psychoeducation and no cognitive restructuring, despite common misconceptions that this intervention is dangerous or unacceptable (deacon et al. 2013 ). this project is one of the first to isolate the effects of interoceptive exposure with a clinical population". many individuals struggle with an eating disorder. problems can include a severe restriction of food intake, uncontrolled caloric consumption, or tendencies to purge. when eating disorders are present, they can be disruptive to the client as well as family members. optimal papers confront eating disorders as they occur in clinical samples, and the advice can be used to help guide psychological treatments for these patients. the award supports advances and innovations that can help to improve the treatment of clients with eating disorders. and the winner is andrea marks for her comprehensive review of cbt for eating disorders and how these strategies have evolved for the past five decades. the article includes a fascinating review of the history of anorexia and bulimia, respecting the pioneering work conducted by ernest lasegue, william gull, hilde bruch, salvador minuchin, and christopher fairburn. the paper concludes with challenges that remain for experts in this important area. in clinical practice, personality disorders are ever present. unfortunately, many researchers and some clinicians fail to navigate the complex terrain of personality pathology. when personality disorders are neglected, treatment is more difficult and improvement is unlikely. although personality pathology can be observed in any setting, the best studies are conducted on clinical samples, using measures that are appropriate for clinical practice. this award highlights the valuable contributions made to help understand, assess, or treat individuals who have a personality disorder. and the winner is shannon sauer-zavala and colleagues for their lab-based study of borderline personality disorder. the project evaluated 16 adults who met criteria for borderline personality disorder and participated in a mood induction protocol to elicit feelings of sadness, anxiety, anger or shame. then, these subjects were asked to behave in a manner that was consistent with or opposite from their normal behavioral tendencies. such an experimental protocol is rarely used in mental health research and opens many possibilities for the creative evaluation of psychopathology. according to the lead author (shannon sauer-zavala, march 23, 2020): "this study was conducted as part of my career development award (k23) from the national institute of mental health. as i was writing the grant application, i was struck by how little is known about the unique contributions of specific elements included in larger treatment packages. the overarching goal of this paper, and my larger research program, is to distill active ingredients in our treatments in order to make them as potent and efficient as possible. in disseminating the results of this project, i have also been thrilled to teach others about single-case experimental design. finally, this research would not have been possible without my wonderful team of colleagues." over the past 50 years, technology has changed the world in many ways. technological advances have been incorporated into clinical assessment and psychological treatment, with modalities that include internet-based psychoeducational programs, smart phone assessment apps, and videoconferencing as a means of communicating with clients from a distance. the future of the field will include more technology, and these changes can be integrated but not replace traditional face-to-face sessions (overholser 2013) . technology provides alternative means of communicating with clients, helping them to monitor their thoughts, moods, and behaviors, and initiate the change process. the present award highlights some useful ideas and innovative strategies that can help clinicians to incorporate contemporary technology to improve their clinical services. nominees are … and the winner is stewart cooper and colleagues for their article on telepsychology. the comprehensive and thorough article provides a wealth of information about technology, and its role in psychological treatments. the authors explain the ethical, legal, and clinical issues that arise when technology is used to extend beyond traditional psychotherapy sessions. these issues have become invaluable with various changes happening throughout the world today. according to the authors (stewart cooper, personal communication, march 23, 2020): "we saw a significant need and opportunity for counseling psychologists and other psychologists to increase their use of telehealth practice to relate telehealth to several core values central to the field including: access to services, social justice, culture, education and training. given the complexities of engaging in this work ethically and competently within the context of a highly complex set of changing legal and regulatory controls, a primer was the correct level of focus. the content covers asynchronous and synchronous practice, the application of ethics, competency training and other areas. the article was published just prior to the coronavirus pandemic in which telehealth has become the norm, not the exception." the historical foundations of psychotherapy can be found in important case studies described by sigmund freud, josef breuer, alfred adler, carl jung, and many others. the use of a case study has evolved into single-case research designs, which may be seen as the pinnacle of clinical practice. through the use of single case research designs, the psychotherapist can examine hypotheses, document changes, and demonstrate the effectiveness of their treatment. however, it can be difficult to conduct individualized research in many clinical settings. this award helps to encourage and improve the research foundation of clinical practice, even when limited to a single participant. nominees are …. and the winner is casey brown and colleagues for their article on idiographic strategies for hypothesis testing. the article provides a detailed case formulation of a client struggling with anxiety, depression and angry outbursts. the authors conducted 22 sessions of psychotherapy, and they use this case to exemplify the statistical analysis of his response to treatment. according to the authors (casey brown, personal communication, march 20, 2020) : "we began the project as two friends on a couch, discussing ways to bridge the gap between recent advances in idiographic statistical methods and real-world clinical practice. over the next three years, we began a multidisciplinary effort to develop a simple framework and online platform that clinicians could use to apply idiographic statistics to data from their individual clients. we consulted experts in idiographic clinical science, software development, affective science, and clinical practice. this paper represents the first scientific contribution from that collaboration. we hope that clinicians utilizing our platform will gain novel insights into the mechanisms of therapeutic change, and contribute their findings to the scientific literature." psychological assessment and psychiatric diagnosis lay the foundation for all major decisions regarding effective treatment. without a psychometrically-sound psychological assessment, it becomes unlikely that the therapist can identify the most accurate diagnosis, and therefore it becomes difficult to provide the best treatment. further, proper assessment helps the clinician to evaluate the impact of treatment, whether in a research setting or a clinical environment. this award highlights the improvements made in psychological assessment or psychiatric diagnosis. research reports can examine the utility of self-report questionnaires, structured interviews, or observational methods, searching for strong psychometric properties while remaining practical for use in most clinical settings. nominees are … baldwin, j., reuben, a., newbury, j., & danese, a. (2019) . agreement between prospective and retrospective measurements of childhood maltreatment. jama psychiatry, 76 (6) and the winner is jesse baldwin and colleagues for their article on optimal assessment of child maltreatment. the article reviews 16 studies, and proposes useful strategies for identifying children who may be experiencing physical, sexual or emotional abuse. the article highlights the different groups of vulnerable children who may be identified by prospective versus retrospective sources of information. according to the authors (jessie baldwin, personal communication, april 2, 2020): "childhood maltreatment can be assessed in two ways: through prospective measures collected as children are growing up, or through retrospective reports by adults years after the events happened. we conducted a meta-analysis to test whether paired prospective and retrospective measures of maltreatment identify the same individuals. across 16 studies (> 25,000 individuals), agreement between prospective and retrospective measures of childhood maltreatment was poor (kappa = 0.19). on average, 52% of individuals with prospective observations of childhood maltreatment did not retrospectively report it, and 56% of individuals retrospectively reporting childhood maltreatment did not have concordant prospective observations. these findings do not suggest that retrospective reports of maltreatment should be discredited. rather, they imply that individuals identified as having been maltreated through prospective versus retrospective measures may have different pathways to poor health, and thus might require different treatments." the field of psychotherapy has evolved in important ways (overholser 2020) . however, many older publications have played important roles in the development of psychological treatment. even more, the information contained in the article is still useful, relevant and helpful for guiding therapy, even though the article was published more than 75 years ago. these works are evaluated based on the lasting contribution that can be found in one published article. this year, several "sleeper papers" are reviewed that played a foundational role in contemporary psychotherapy but probably remain unknown to many psychologists. the article should be viewed as an independent contribution separate from estimates of the value of the pioneer's career as a whole. thus, the winning article captures ideas that were expressed long ago, but remain useful and relevant today, and the winning article should become required reading in all graduate training programs in clinical psychology. nominees are … and the winner is lightner witmer for the seminal paper on applied clinical psychology. witmer is credited with opening the first psychological clinic at the university of pennsylvania in 1886 and coining the term "clinical psychology" in 1896. he justified the term "clinic" because it was used to designate the scientific method, not a medical locale. witmer explained the role of the clinician as a scientist who searches for answers by studying the favorable or unfavorable reaction of individual patients to their treatment. throughout this classic article, witmer argues for the integration of science and practice as the guides for psychology, claiming "there is no valid distinction between a pure science and an applied science", because "what fosters one, fosters the other" (p. 4). it was another strong and productive year with many valuable papers on psychotherapy. in addition to the four papers that were nominated in each category, there are several other published articles that deserve honorable mention. some valuable papers did not reach nomination status simply because of an artificial limitation on four finalists in each category or did not align with a specific award category. for example, a recent paper by paul nestor (2019) confronted the notion of free will and how it continues to play a role when psychologists are involved in forensic work and expert testimony. although the article ends with important questions left unanswered, criminal responsibility is viewed through the lens of neuroscience, combined with legal views of insanity. some interesting papers literally and figuratively extend the perspective beyond the walls of a typical therapy office. for example, jovanovic et al. (2019) examine issues involved in designing psychiatric hospitals that could potentially increase the likelihood of social interactions. although these ideas can be traced back to the early days of institutionalization (tuke 1813), contemporary architectural designs are normally planned without input from psychologists or patients. some articles provide useful guidelines for conducting therapy sessions, but each research study usually provides one small step forward. for example, a recent study by rector et al. (2019) examined the treatment of obsessive-compulsive disorder in 94 psychiatric outpatients who were provided with either exposure-based treatment or exposure plus additional cognitive-behavioral strategies. although both interventions were effective in producing significant improvement, results showed that the addition of cognitive therapy strategies adds to the beneficial effects of exposure treatments for ocd. these findings are closely aligned with clinical experience, and these results help to refine the use of exposure strategies in the treatment of ocd. the study highlights the therapeutic value of a comprehensive approach to therapy instead of simply taking one active ingredient to push clients toward change. the project demonstrates the value of the scientist-practitioner model in action. some valuable reports describe views from the personal experience of a psychotherapist or that of a client. an interesting paper that deserves mention was published by messer (2019) who provides a thoughtful autobiographical review of his personal efforts toward psychotherapy integration. messer provides a captivating narrative, summarizing how various perspectives developed over the course of his career. messer explains the limits of a single view and the benefits of a more comprehensive integrative approach to therapy. another interesting article was published by ronald bassman (2019) who provides a different form of autobiographical narrative, summarizing his personal experiences after he was diagnosed with schizophrenia. in an insightful and captivating commentary, dr. bassman helps readers to appreciate the subjective experiences of a psychiatric patient, and confronts the stigma that remains attached to many psychiatric labels. the award program was designed to highlight, praise, and recommend the most valuable contributions to psychotherapy each year. it has been exciting to review the literature and identify many new innovations in the field. however, it remains rather troubling that there continues to be a vast schism between the great papers and the mediocre masses. from a critical perspective, it appears that the vast majority of published articles rely on weak methods, samples of convenience, and have been designed to promote ideas that could be supported by a simple combination of clinical experience and common sense. there is a risk that the field of psychotherapy will deteriorate if the people who write the books, chapters, and research articles are faculty members who no longer provide clinical services themselves. it has become easy to read a published article and tell if the lead author is an active clinician or an ivory tower academic. there remains an ever-expanding split between the researchers who publish most of the journal articles versus psychotherapists who provide most of the clinical services to those in need. a sincere integration is needed, for the benefit of clients, trainees, and the field of mental health treatment. hopefully, the "psyche" awards will highlight, recognize, and praise those scholars who publish outstanding articles at the forefront of advances in psychotherapy. editorial postscript: as editor-in-chief, i have many people to thank for their support and efforts during the past year. first, let me thank my panel of expert judges who evaluated the nominated papers and submitted their rank order preferences. i want to be especially respectful of one of my judges, ed watkins, whose publications were eligible again this year, but neurasthenia, or nervous exhaustion on the pathogenesis of some impulsions the principles of class treatment and their application to various chronic diseases for the ongoing support for the journal and allowing me the professional freedom to steer the journal as i see fit. i am highly appreciative of my editorial board and ad hoc reviewers who have provided valuable feedback about the record number of manuscripts submitted during this past year. during the past 12 months, the following professionals have served as ad hoc reviewer: jacqueline abate therapist perceptions and delivery of interoceptive exposure for panic disorder getting beyond the ''convenience sample converging themes in psychotherapy: trends in psychodynamic, humanistic, and behavioral practice the weirdest people in the world? how to design psychiatric facilities to foster positive social interaction: a systematic review in defense of free will: neuroscience and criminal responsibility the boulder model in academia: struggling to integrate the science and practice of psychology advancing the field of psychotherapy through innovation and integration in scholarly works ten criteria to qualify as a scientist-practitioner in clinical psychology: an immodest proposal for objective standards reading, writing, and reviewing: recommendations for scholarly manuscripts at the graduate and professional level technology-assisted psychotherapy (tap): adapting computerized treatments into traditional psychotherapy for depression chasing the latest fad: confronting recent and historical innovations in mental illness protesting the decline but predicting the demise of clinical psychology: can we avoid a total collapse and the winner is …": awards for the integration of science and practice in psychology the nominees for best article …": awards for the most valuable papers on psychotherapy does the addition of cognitive therapy to exposure and response prevention for obsessive compulsive disorder enhance clinical efficacy? description of the retreat, an institution near york, for insane persons of the society of friends key: cord-298899-lkrmg5qr authors: xie, yewei; wang, zaisheng; liao, huipeng; marley, gifty; wu, dan; tang, weiming title: epidemiologic, clinical, and laboratory findings of the covid-19 in the current pandemic: systematic review and meta-analysis date: 2020-08-31 journal: bmc infect dis doi: 10.1186/s12879-020-05371-2 sha: doc_id: 298899 cord_uid: lkrmg5qr background: the covid-19 pandemic has affected the world deeply, with more than 14,000,000 people infected and nearly 600,000 deaths. this review aimed to summarize the epidemiologic traits, clinical spectrum, ct results and laboratory findings of the covid-19 pandemic. methods: we scoped for relevant literatures published during 1st december 2019 to 16th july 2020 based on three databases using english and chinese languages. we reviewed and analyzed the relevant outcomes. results: the covid-19 pandemic was found to have a higher transmission rate compared to sars and mers and involved 4 stages of evolution. the basic reproduction number (r(0)) is 3.32 (95% ci:3.24–3.39), the incubation period was 5.24 days (95% ci:3.97–6.50, 5 studies) on average, and the average time for symptoms onset varied by countries. common clinical spectrums identified included fever (38.1–39.0 °c), cough and fatigue, with acute respiratory distress syndrome (ards) being the most common complication reported. body temperatures above 39.0 °c, dyspnea, and anorexia were more common symptoms in severe patients. aged over 65 years old, having co-morbidities, and developing complications were the commonest high-risk factors associated with severe conditions. leucopenia and lymphopenia were the most common signs of infection while liver and kidney damage were rare but may cause bad outcomes for patients. the bilateral, multifocal ground-glass opacification (ggo) on peripheral, and the consolidative pulmonary opacity were the most frequent ct results and the tendency of mortality rates differed by region. conclusions: we provided a bird’s-eye view of the covid-19 during the current pandemic, which will help better understanding the key traits of the disease. the findings could be used for disease’s future research, control and prevention. the emergence of covid-19 has made it the first infectious disease pandemic in the twenty-first century. as of 20th july 2020, a total of 14,348,858 people got infected, and 603,691 were confirmed dead in 213 countries, territories, and areas globally [1] . while more than 30 countries had issued the highest level of response, the sars-cov-2 (pathogen of continues to spread in different regions around the world [2] . however, the key information on the virus epidemiology, clinical spectrum, and on the pathogen was delayed in response during the early outbreaks in many countries. to fill the research gaps mentioned above, this review article systematically summarizes global findings on the natural history, clinical spectrum, transmission patterns, laboratory findings, ct results, and risk factors of the covid-19. we searched for publications in epidemiology and clinic domains of the covid-19 broadly. the databases we searched were: chkd v3.1 of the cnki [in chinese], pubmed, and medrxiv, by using such search terms as 'covid-19, sars-cov-2, and 2019 ncov' (see additional file 1). the publication date was restricted from 1st dec 2019 to 16th jul 2020. both english and chinese were applied for the search. only the full-text available human studies were eligible for selection. like the realtime data, other data were obtained from health departments of multiple countries, global ngos, and reputable media sources. the searched records were firstly screened by reading titles and abstracts. then, the rest records were screened again by full-text reading. if there were disagreements initially, the records then submitted to the whole team for further discussions. besides, a prisma diagram was conducted to illustrate the entire flows of the review (fig. 1 ). the data for the quantitative analysis was extracted and managed by using microsoft excel 2010 (microsoft©, redmond, wa, usa). the meta-analysis was performed by the r version 4.02 and rstudio (2020) [3] . the cochrane handbook for systematic reviews of interventions suggested review authors collect missing data from investigators. considered that using the imputation method to tackle the missing data problem could not reduce bias, we only analyse data available to us if we could not collect the missing data from the investigators [4] . the heterogeneity of the included studies was assessed by using i 2 . the p-value was generated by wald-type test and likelihood-ratio test. the overlapping confidence intervals (cis) were displayed by the forest plots (see additional file 4). we categorized and combined the data about epidemiologic traits, clinical spectrums, laboratory, and imageology findings in a narrative. then we further analyze the data about common symptoms, reproduction number, and incubation period through meta-analysis. the quantitative outcomes were combined with the narrative of epidemiological and clinical findings. we collected 11,366 records after removing duplications. after three batches of screening, 127 records were included in this review (see screening details in fig. 1 ). in a china based study involving 55,924 covid-19 patients, the majority of patients were aged 30-69 (77.8%) with only 2.4% of the patients being 18 years and below. the median age of the patients was 51 (ranged 2 days-100 years old) [5] . similarly, in the united states, more than half of patients were aged between 20 and 64 years (65%), with only 5% of patients being under 19 years old. older aged patients were more prone to getting infected compared to the young [6] . by gender, the male to female ratio of confirmed cases was 1.06:1.00 in china [7] . however, in south korea and iceland, the male population had a higher incidence rate than the female population [8, 9] . males had twice the secondary attack rate than females [10] . the covid-19 transmission stages could be categorized into four temporal stages according to the chronological order of case reports. the first stage: people with exposure histories to huanan seafood market (hsm) got infected [11] . forty-one patients were found to be having sars-like symptoms in december 2019, and the hsm was believed to be one of the origins of the virus. however, 13 of the 41 patients reported no prior exposure to the hsm thus indicating that the origin of the virus needed further investigation [12] . the second temporal stage is the transition from community transmissions to the outbreak in wuhan [11] . the virus was mainly spread to multiple communities directly and indirectly by people with hsm exposure histories. the interpersonal transmissions and clustered transmissions formed community transmissions [11] . an earlier study showed that the proportion of patients with hsm exposure histories decreased from 55 to 8.6% within 22 days, indicating when people who did not have exposure histories to the hsm became infected [13, 14] . the third stage: the epidemic in china. at this stage, transmissions began to expand to communities outside wuhan and the hubei province as a whole [11] . on 26th jan 2020, a study involving 62 covid-19 patients outside wuhan found that all the patients had been exposed to wuhan, which demonstrated an established local transmission outside wuhan [15] . the fourth temporal stage is the global pandemic. on 13th jan 2020, the first case outside china was reported in thailand [2] . on 30th jan 2020, the who declared a public health emergency of international concern (pheic) [2] . it subsequently took about 51 days for transmission to escalate from the first reported case to the 10,000th reported case outside china. globally, it took 16 days for the number of reported cases to increase from 10,000th cases to 100,000th cases, 21 days from 100,000th cases to 500, 000th cases, only 6 days from 500,000th cases to 1,000, 000th cases and 13 days from 1,000,000th cases to 2,000, 000th cases [2] . the main transmission route of this virus was by human-to-human spread, since only 1.18% patients among 1099 confirmed patients had history of direct contact with wild animals [16] . the vital transmission routes were through respiratory droplets and contact transmissions. there remains the possibility of aerosol transmission when exposed to high concentrations of aerosols for a long time in a relatively closed environment [17] . mother-to-child transmission has been confirmed, whiles fecal-oral transmission was also considered possible but lacked direct evidence until now [18, 19] . other suspected routes of transmission still needed further clarification. community transmission, nosocomial transmission, household transmission, and transmission in closed environments were four typical transmission patterns of the covid-19. firstly, community transmission was considered to be an important pattern in covid-19 spread [5] . in the netherlands, community transmissions were found in the noord-brabant regions [20, 21] . in north america, community transmissions were reported in winnipeg, canada, and eastern idaho, united states [22, 23] . secondly, the potential risk of transmission among medical personnel and through medical facilities was deemed high and thus extreme attention should be paid. transmissions between patients and health workers were in higher proportions during the sars outbreak, while transmission through medical facilities was higher in proportion during the mers outbreak [24] . in wuhan, the proportion of severely infected medical workers was higher than the national average [7] . in italy, 2629 health workers were reported infected with the covid-19 before 18th march and accounted for 8.3% of the total number of cases nationwide. the number however increased to 8358 by 30th march and represented 9% of the country's total number of cases [25, 26] . in spain, the number of diagnosed cases among medical workers increased to 5969 within 6 days and more than 12% of the country's confirmed cases remained among medical workers until march 30th [25] . update from another source reported an increase in the number of cases from 12 to 14% among spain healthcare workers by 31st march and this was attributed to lack of medical supplies, such as masks and gowns. other reasons accounting for these high infection rates among medical personnel varied according to different country's circumstances. an italy study pointed out hospitals as a potential hotspot for infection. facilities and medical personnel turned into untested vectors and patients [27, 28] . in the us for example, the reasons that turned hospitals into infection hotspots included the overload of covid-19 patients and inappropriate management against the pandemic in hospitals [29] . similar to the us, 200 medical workers got infected in a county hospital in romania due to inadequate hospital management. in egypt, a serious wave of emigration by physicians for years led to patient overload for remaining medical workers and placed them at higher risk of infection through continuous exposure. the emigration wave was purportedly caused by low salary, undesirable working conditions, lack of legal protection, and shortage of medical supplies and equipment [30] . thirdly, household transmission contributed to cluster infections and was the major transmission pattern observed in china. for instance, among 1836 reported cases in guangdong and sichuan provinces, most cluster infections occurred in families (78-85%) [5] . the who in this regard issued a statement that household transmission highly occurred among medical workers' families than health facility infection in china. household transmission was also a significant pattern observed in south korea and the us [2, 29] . the european centre for disease prevention and control (ecdc) had provided guidance for the control of household transmission in european countries [5, 31] . what made household transmission worse was that some groups (age < 18 and > 65) had high risk got infection within households than the general population [32] . so, children and elderly living with medical workers at a higher risk of getting than other populations. fourthly, transmissions in a closed environment besides the home should also be of a keen focus on the prevention and control of this outbreak. a japanese health department reported that a closed environment could promote super-spreading events because the transmission of the sars-cov-2 in a closed environment was the same as large-scale transmission, such as the ski chalet-cluster infection in france and the church-hospital infection clusters in south korea [33] . for example, outbreaks of the covid-19 were observed in multiple prisons in china, the uk, and the us [7, 34, 35] . cluster infections also happened on cruise ships, such as the diamond princess, grand princess, golden princess, ruby princess, phoenix reisen, ms westerdam, and punta arenas [36] . further studies are however required to identify and assess other potential transmission patterns for further prevention, especially since some cases were asymptomatic [37, 38] . in addition, patients who were considered cured and no longer needed quarantine still tested rt-pcr positive after 5 to 13 days [39] . we systematically used the data of the incubation period and the reproduction numbers for meta-analysis (see details of selected studies on additional file 2). the result suggested that the mean incubation period was 5.24 days (95% ci:3.97-6.50, 5 studies), and ranged from 3 to 7.4 days [40] [41] [42] [43] [44] . however, the incubation period in some special cases could be as long as 24 days [16] . the result also illustrated that the basic reproduction number (r 0 ) of sars-cov-2 was 3.32 (95% ci:3.24-3.39, 14 studies) and varied between 0.6-6.47 [37, [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] . this finding suggested that the transmission ability of sars-cov-2 was stronger than sars (3) and mers (≤1) [54, 55] . moreover, the median time from the first symptom to first hospital admission was 7 days with the median duration from illness development to severe symptoms development being: 5-8 days for dyspnea, 8-9 days for ards, 10.5 days for mechanical ventilation and icu admission [6, 18] . for covid-19 related deaths, the duration from the onset of symptoms to death averaged 9 days in china 5 and in italy (median) [56] , and 10 days in south korea (median) [9] . by 14th july 2020, 21 nations had reported over 100,000 covid-19 cases in each of the countries, together contributed to 81.4% of the confirmed cases and 81.3% of death in the world1. the world case fatality rate (cfr) was 4.4% on 14th july; however, it was apparently different by country. one third of these 21 countries had a cfr of over 4.4%. france (17.4%), united kingdom (15.5%), italy (14.4%), and mexico (11.6%) were the top four countries with over 10% cfr while qatar (0.1%) and saudi arabia (1.0%) were the two countries with no more than 1% cfr. most countries experienced an increase of cfr at first, and the number was then gradually becoming stable during the disease outbreak (fig. 2) . however, the cfr was high in iran (13.7% on 27th february) and the united states (7.2% on 4th march) at first, experienced a sharp decrease to 2.5% on 8th march and 1.1% on 20th march, and rebounded to 5.0 and 4.0% on 14th july, respectively. bangladesh was the only country that had high cfr of around 10% at the beginning and then continuously decreased until 1.3% on 14th july. as the pandemic outbreak continued, more surveillance is needed for the cfr of covid-19 [57] . the mortality is higher among elderly, patients requiring intensive care unit admission and male. however, mortality rate among younger age group and patients with mildly disease is less. the us's data indicated that patients younger than 19 had milder covid-19 illness, with almost no hospitalizations or deaths reported [6] . based on a worldwide data, the elderly (aged over 60) were at a high risk of developing into death [5, 6, 9, 56] . the mortality in icu was extremely higher than non-icu patients, varied from 26 to 78% [58] [59] [60] [61] . about the gender ratio, there is a seemingly unquestionable pattern that covid-19 killed more men than women [62] . unlike the less report in the research from china, south korea or other asia areas, the reports from europe and american reflect the male gender is the risk factor for heavy illness. to figure out the general situation around the world, here we analyzed the data from 53 countries, compiled centrally and individually verified by authors against country-specific reports [63], shown that the case-fatality rate among male is about 35% higher than female (ir = 1. 35 based on the data collected from selected articles [12, 15, 16, 58, (details of selected articles were put in the additional file 3), we conducted the meta-analysis using a random-effects model to identify the clinical feature of covid-19. fever (76.70, 95% ci: 64.86-85.44%) and cough (67.76, 95% ci: 60.06-74.61%) were the most fig. 2 case fatality rate of countries reported over 20,000 cases, 2020*. *data was collected until 14 july 2020 (i.e. the 196th day of year 2020). the cfr of a country was not included on those dates when the country reported less than 100 cases, with the consideration that the cfr may not be reliable if the size of infected population was small common symptoms. other common symptoms included: olfactory (44.40%), gustatory (38.16%), dyspnea (37.49%), fatigue (29.93%), sputum production (17.85%), sore throat (16.17%) and headache (15.49%). all the other data showed in table 2 . besides, studies pointed out that most patients had more than one symptom [68, 70, 71] . additionally, there were 20.9% of patients without viral pneumonia symptoms [16] , which was opposite to previous studies [69, 70] . the asymptomatic cases varied from 21.9-49.5% [66, 68, 93, 94] . the top 3 common symptoms among mild and severe patients are summarized and displayed in a figure (fig. 3) [12, 16, 61, 70, [95] [96] [97] [98] . fever was found to be the most common symptom in all patients. in a study, 43.8% of patients had fever initially and the proportion increased to 87.9% following hospitalization [16] . the body temperatures of 44-47.1% of patients ranged between 38.1-39.0°c. the higher body temperatures (above 39.0°c), dyspnea and anorexia were more frequent among patients in severe conditions [16, 64, 98] . cough and fatigue were more widely reported among mild and severe patients. additionally, another study reported that dyspnea (76%) was the most common symptom among severe patients in the united states [99] . the proportion of patients who needed icu care varied based on the local pandemic circumstances. for example, the who speculated that around 13.8% of patients were in severe conditions in china [5] . however, 23-32% of patients needed icu care in wuhan [64, 69, 70] . currently documented covid-19 related complications include ards, arrhythmia, septic shock, acute cardiac injury, myocarditis, acute coronary syndrome, cardiomyopathy, acute respiratory injury, and acute renal injury, etc. [58, 64, 67, 69, 70, 100] . the ards was the most common complication, among both mild and severe patients [58, 64, 67, 69, 70] . most icu patients had a higher risk of developing ards and having complications [12, 70] . the progress of some patients with ards to septic shock was fast and quickly evolved into multiple organ failure finally [69] . among covid -19 patients, a decrease in leukocytes such as eosinophil and lymphocyte were commonly reported. this might be because the cytokine storm caused by the novel virus changes the peripheral of white blood cells and immune cells [12, 13, 15, 16, 69, 70] . severe lymphopenia was also common among the dead patients [12, 61] . myocardial zymogram abnormality was found in many patients. for instance, 76% of patients had an increase in lactate dehydrogenase, while 13% of patients had increases in creatine kinase [69] . the level of c-reactive protein was important to evaluate the infection [16] . most patients were found to have a higher level of c-reactive protein (86%) and serum ferritin (63%) compared to the normal range [69] . the biomarkers related to liver and renal damage were found to be abnormal among covid-19 patients. the abnormality of liver-related biomarkers was not widespread but yet still common in severe cases [12, 15, 16, 101] . besides, although only 7% of patients showed renal biomarker abnormalities, renal damage might contribute to the final multi-organ failure and death outcome [102, 103] . the icu patients showed higher levels of white blood cells, neutrophil counts, d-dimer, creatine kinase, and creatine with longer prothrombin times [12, 16, 70] . compared to patients who survived, the patients who died had higher levels of d-dimer, high-sensitivity cardiac troponin i, serum ferritin, lactate dehydrogenase, il-6, blood urea, creatinine, white blood cell counts and neutrophil counts. severe lymphopenia was also common among dead patients [12, 61] . the computed tomography scan (ct scan) was widely used for disease diagnosis, prognosis, and management during the covid-19 [104] . the ct was found more sensitive for identifying sars-cov-2 patients than the rt-pcr assay (98% vs. 71%) in a study [105] . the ct evidence for confirming the highly suspected patients' positive may precede the rt-pcr results [106, 107] . most patients had ggo and the bilateral lung involvement [12, 69, [108] [109] [110] . one study found that bilateral lung involvement was more frequently shown in the intermediate course and late course, compared to the earlier clinical course [107] . the clinical course could be divided into four stages based on ct scan findings [110] . in the first stage (pre-symptom), ggo, unilateral and multifocal were observed among most patients in this stage [107, 110] . in the second stage (symptoms ≤1 week), lesions soon developed into bilateral and diffused except for ggo. this stage was considered a period from transition to consolidation. a mixed pattern of transition and consolidation develops during this stage. in the third stage (symptoms 1-2 weeks), the ggo was still common and the consolidation pattern showed. findings indicated an interstitial change, which was considered as the development of fibrosis. in the fourth stage (symptom 2-3 weeks), consolidation and mixed patterns were more common, and the ggo started to shrink [110] , the consolidation was gradually absorbed among patients who recovered at last [111] . among icu patients, the bilateral multiple lobular and sub segmental areas of consolidation were considered typical findings [12] . patients in severe condition showed diffuse lesions, with density increasing in both lungs. ct scans showed 'white lung' appearances, indicating the serious influence the infection has on patients' lung functions [112] . being old (≥65 years old), male sex, having a higher bmi value (> 35 kg/m 2 ), having co-morbidities (e.g. hypertension, diabetes, cardiovascular and cerebrovascular diseases, etc.), and developing complications were vital risk factors for patients to develop severe conditions [59, 70, 78, 95, 96, 113, 114] . the cytokine storm, raised inflammatory markers, elevated cardiac troponins, the requirement of mechanical ventilation, and the requirement of intensive care unit stay predict the bad outcome of admission patients [61] . findings from multiple studies showed that patients who are more than 65 years of age, with co-morbidities such as diabetes and heart diseases had a high mortality rate [61, 95, [115] [116] [117] . late hospitalization and bacterial infections were also considered high risk factors for disease progression [69, 96, 116] . smoking history could be a potential risk factor for developing severe conditions [69, 96] . people with underlying disorders were considered to be at a high risk of getting infected [5] . our review identified several research gaps. firstly, large amounts of data from african were missing from this review. as the number of people in african suffering from malnutrition, anemia, malaria, hiv/aids and tuberculosis is high, a large "low immunity population" has been created which has made the control and prevention of covid-19 in the region a challenge. the situation could be worsened by the limited health resources region [118] and hence, more african focused research is required to support africa in fighting the epidemic. secondly, the proportion of asymptomatic patients is large but the current transmission ability by asymptomatic patients might be weak. however, further exploration of risks posed by the group is needed as limited studies exist on the subject matter [119] . meanwhile, data on the distribution of asymptomatic patients in large-scale community groups is also lacking, prompting the need for large scale of active screening and testing to help identify them [93, 120] . this approach is however difficult and expensive for most countries to undertake as accurate strategies to identify asymptomatic currently are non-existent. further research focus on asymptomatic patients is needed. third, a 'super-spreader' was defined as infected individuals who infected numerous others during the sars outbreak. for example, a nephrotic hospitalized patient who infected 22 people was classified as a 'superspreader' during the sars in china. 19 in those 22 patients were medical workers who came in contact with the 'super-spreader'. the incidence rate among the medical workers was 59.38% (19/32) in the nephrotic department [121] . in the covid-19 era, the emergence of 'super-spreaders' were found in multiple places worldwide. a saudi arabian study linked the concept of 'super-spreaders' to 'super spreading' events noting that 'super-spreaders' might cause unexpected transmissions during the pilgrimage [122] , as huge numbers of people gather. reasons causing the super-spreading events might include: immune suppression, increased disease severity and viral load, asymptomatic individuals, and extensive social interactions [123] . however, the characteristics and features of how an individual becomes a super-spreader are still not clear [124] . summarizing the features of the 'super spreader' concept, as well as their characteristics and role in transmissions, are needed in future disease control [125] . fourth, it has been reported that some cured patients covid-19 retested positive by pcr after being discharged and quarantined at home in multiple places [39, 126] . the reason for this phenomenon is still unclear and hence further investigations are required for future pandemic control [127] . there existed some limitations in this review. firstly, this review was based on english and chinese resources only. as the covid-19 transformed from a regional outbreak to a global pandemic, comprehensive collection of the related information worldwide is needed. secondly, the clinical spectrum presented in this review is based on general population only, and thus a further subgroup analyzes in future may help to figure out more on the entire picture of the covid-19. for instance, although kawasaki disease was found in children in the uk and europe countries, other places did not report the gathering kawasaki disease cases [128] . the covid-19 had a stronger transmission ability than sars and mers, timely intervention should be conducted to reduce the spread of the disease. the common symptoms included in this study could assist in identifying the potential patients. the summary of the common complications, lab findings, ct features and risk factors could help medical personnel better manage patients who may develop into severe conditions or death. supplementary information accompanies this paper at https://doi.org/10. 1186/s12879-020-05371-2. additional file 1. searching terms. additional file 2. detail of selected studies for meta-analysis (r0&incubation period). additional file 3. detail of selected 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sars-cov-2 admitted to icus of the lombardy region clinical course and risk factors for mortality of adult in patients with covid-19 in wuhan, china: a retrospective cohort study ethnicity and covid-19: an urgent public health research priority covid-19 sex-disaggregated data tracker-sex, gender and covid-19 clinical features and outcomes of 98 patients hospitalized with sars-cov-2 infection in daegu, south korea: a brief descriptive study early epidemiological and clinical manifestations of covid-19 in japan clinical, radiological and therapeutic characteristics of patients with covid-19 in saudi arabia clinical course and potential predicting factors of pneumonia of adult patients with coronavirus disease 2019 (covid-19): a retrospective observational analysis of 193 confirmed cases in thailand characteristics, risk factors and outcomes among the first consecutive 1096 patients diagnosed with covid-19 in kuwait epidemiological and clinical characteristics of 99 cases of 2019 novel 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patients with coronavirus disease 2019 in wuhan, china smell dysfunction: a biomarker for covid-19. int forum allergy rhinol anosmia and ageusia: common findings in covid-19 patients association of chemosensory dysfunction and covid-19 in patients presenting with influenza-like symptoms self-reported taste and smell disorders in patients with covid-19: distinct features in china olfactory and gustatory dysfunction as an early identifier of covid-19 in adults and children: an international multicenter study. otolaryngol head neck surg prevalence of sars-cov-2 in spain (ene-covid): a nationwide, population-based seroepidemiological study suppression of a sars-cov-2 outbreak in the italian municipality of vo' clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study analysis of clinical characteristics of 49 patients with novel coronavirus pneumonia in jiangxi province epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore clinical features and outcomes of 221 patients with covid-19 in wuhan characteristics and outcomes of 21 critically ill patients with covid-19 in washington state a review of cardiac manifestations and predictors of outcome in patients with covid-19 preliminary study of the relationship between novel coronavirus pneumonia and liver function damage: a multicenter study caution on kidney dysfunctions of 2019-ncov patients kidney impairment is associated with in-hospital death of covid-19 patients an update on ct chest findings in coronavirus disease-19 (covid-19) sensitivity of chest ct for covid-19: comparison to rt-pcr correlation of chest ct and rt-pcr testing in coronavirus disease 2019 (covid-19) in china: a report of 1014 cases chest ct findings in coronavirus disease-19 (covid-19): relationship to duration of infection emerging 2019 novel coronavirus (2019-ncov) pneumonia imaging and clinical features of patients with 2019 novel coronavirus sars-cov-2 radiological findings from 81 patients with covid-19 pneumonia in wuhan, china: a descriptive study time course of lung changes on chest ct during recovery from 2019 novel coronavirus (covid-19) pneumonia initial ct findings and temporal changes in patients with the novel coronavirus pneumonia (2019-ncov): a study of 63 patients in wuhan, china associations with covid-19 hospitalisation amongst 406,793 adults: the uk biobank prospective cohort study severe obesity is associated with higher in-hospital mortality in a cohort of patients with covid-19 in the bronx clinical characteristics of 101 non-surviving hospitalized patients with covid-19: a single center, retrospective study clinical characteristics of 25 death cases infected with covid-19 pneumonia: a retrospective review of medical records in a single medical center clinical characteristics of 82 death cases with covid-19 covid-19 pandemic -an african perspective a study on infectivity of asymptomatic sars-cov-2 carriers advances on the asymptomatic infection of covid-19 a survey on a sars nosocomial "super-spread" event (sses) in jiangmen covid-19: preparing for superspreader potential among umrah pilgrims to saudi arabia the first case of the 2015 korean middle east respiratory syndrome outbreak who. update 30 -status of diagnostic test, significance of "super spreaders problems to be solved in sars research in china fu yang": there is no unified conclusion, and discharge management is being strengthened at present, it seems that fuyang patients are not infectious what is kawasaki disease and its possible link with covid-19 in children? publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we thank mr. peizhen zhao for technical support.authors' contributions wt designed the study protocol. yx, zw, and hl did the literature search. the titles, abstracts, and full texts were screened and selected by yx, zw, and hl. the data were extracted and analysed by yw, zw and hl. yx, zw and hl drafted the manuscript. yx, zw, gm, dw, and wt edited the draft. all authors read and approved the final manuscript. key: cord-331268-kzy33hdb authors: lynch, sharon g.; rose, john w. title: multiple sclerosis date: 1996-01-31 journal: disease-a-month doi: 10.1016/s0011-5029(96)90012-7 sha: doc_id: 331268 cord_uid: kzy33hdb abstract multiple sclerosis is a chronic disease that begins in late adolescence or adulthood. it is highly variable in its expression and severity. it is believed to be autoimmune in nature. the cause is unknown; both genetic and environmental factors have been implicated in the pathogenesis. ms generally presents with the acute or subacute onset of neurologic abnormalities that may wax and wane over many years. diagnosis is generally made by means of observation of the clinical course in conjunction with a neurologic examination and laboratory tests. these tests may include magnetic resonance imaging of the head and spine, lumbar puncture, and evoked potentials. treatment is based on general supportive care, the use of corticosteroids for relapses, and symptomatic management of ongoing problems. the frequency of relapses can be reduced with interferon-β (betaseron). copolymer 1 and interferon-β la are being evaluated by the u.s. food and drug administration for approval for use for reduction in the frequency of relapses in relapsing-remitting ms. treatment of chronic progression is often attempted with immunosuppressive agents such as corticosteroids, azathioprine, and cyclophosphamide. use of other agents is being investigated. multiple sclerosis (ms) is a chronic disease of the central nervous system that typically begins in late adolescence or early adulthood. the cause is unknown, although the disease is believed to be autoimmune in nature. both genetic and environmental factors have been implicated in the pathogenesis of ms. a viral cause has been postulated, but no single virus has been confirmed to be associated with ms. the pathologic features of ms include the presence of demyelinating areas in the white matter of the brain with perivascular in-flammation and relative sparing of the axons. plaques are commonly found in the periventricular areas of the cerebral hemispheres, in the optic nerves, the brainstem, the cerebellum, and the spinal cord. the presence of inflammation in ms plaques and the presence of oligoclonal immunoglobulin bands suggest an autoimmune basis of the disease. characterization of the inflammatory cells in the plaques and in the cerebrospinal fluid has revealed a predominance of t cells. this finding has focused a great deal of attention on the trimolecular complex, which consists of the major histocompatibility complex, the t-cell receptor, and the antigen. consistent associations with dr2, drbl501, dqb602, and the dw2 haplotypes have been identified in white persons. studies of restricted use of specific t-cell receptor regions in the immune process have not revealed a specific receptor in this disease. the antigen remains unknown, although many investigators are working with myelin basic protein and other proteins associated with myelin. two animal models, experimental allergic encephalomyelitis and theiler murine encephalomyelitis, are valuable in testing experimental immunotherapies and other aspects of autoimmune mediated demyelination. ms generally appears with the acute or subacute onset of neurologic abnormalities that may wax and wane over many years. common early symptoms include numbness, double vision, paraparesis, monoparesis, bladder control problems, optic neuritis, ataxia, or tremor. common ongoing symptoms include those just mentioned, vertigo, increasing spasticity, depression, emotional lability, gait abnormalities, fatigue, dysarthria, quadriparesis, constipation, incoordination, fatigue, and pain. diagnosis is made by means of observation of the clinical course in conjunction with the neurologic examination and laboratory tests. magnetic resonance imaging of the head and spine can be valuable in the evaluation of suspected ms. the presence of an elevated immunoglobulin g (igg) index or oligoclonal bands in the spinal fluid also can be helpful. evoked potentials can help confirm subclinical involvement of the eyes, vestibular function, or sensory tracts. the differential diagnosis of ms includes other demyelinating syndromes, particularly the monophasic syndromes, such as postinfectious encephalomyelitis, postinfectious transverse myelitis, and isolated optic neuritis. some infectious diseases, such as lyme disease, syphilis, and htlv-1 myelopathy, can be confused with ms. other autoimmune conditions, such as systemic lupus erythematosus, behcet's syndrome, sarcoidosis, and sjogren's syndrome, can cause symptoms similar to those of ms. some leukodystrophies and hereditary degenerative syndromes can be confused with ms. ms is often classified by its clinical course. benign ms is charac-dm, january terized by mild intermittent relapses with nearly complete resolution. relapsing-remitting ms is the most common form of the disease. it is characterized by episodes of acute or subacute neurologic dysfunction followed by periods of improvement and stabilization. secondary progressive ms begins with a relapsing-remitting course, but the disease gradually worsens, causing slow accumulation of neurologic signs and symptoms. ms that never has a relapsing-remitting course but begins with a slow progression of signs and symptoms is classified as primary progressive ms. treatment of ms is based on the progression of an individual case. general health measures include exercise, physical and occupational therapy, a balanced diet, and aggressive treatment of fever and overheating. treatment of relapses is recommended for moderate to severe relapses. corticosteroids are choice of treatment of relapses. steroids should be used with caution because of the large number of side effects associated with long-term use. the frequency of relapses can be reduced with interferon-i3lb (betaseron). copolymer 1 and interferon43la are being evaluated by the u.s. food and drug administration for approval for use in reduction of the frequency of relapses in relapsing-remitting ms. these drugs soon may be available for clinical use. treatment of chronic progression is often attempted with immunosuppressive agents such as corticosteroids, azathioprine, methotrexate, and cyclophosphamide (cytoxan). other agents under investigation are cladribine and intravenous immunoglobulin. symptomatic treatment of the chronic symptoms of ms is important. treatment of symptoms can help patients remain functional and comfortable even with relatively severe chronic problems. fatigue can be treated with rest breaks during the day, exercise, and energy-conservation techniques. medications that may help are amantadine hydrochloride and pemoline. spasticity is a severe problem that causes contractures, pain, insomnia, and increased fatigue. it can be treated conservatively with physical therapy, particularly stretching exercises. baclofen and diazepam can also be useful and are often used alone or in combination. in patients with severe spasticity, baclofen can be administered with an intrathecal pump. urinary dysfunction is a common problem. a urologist usually is needed to define the type of dysfunction present. a hypertonic, spastic bladder can be treated with anticholinergic agents. a hypotonic bladder may require intermittent or long-term catheterization. detrusor-sphincter dyssynergia may require a combination of anticholinergic agents and intermittent catheterization. urinary retention, which causes frequent bladder infections, may require acidification of the urine or long-term administration of antibiotics. patients with severe retention may require urinary diversion. sexual dysfunction often requires a multidisciplinary approach, including counseling, modification of sexual techniques, medication, or prosthetic devices for men. tremor can be a severe, intractable problem. medications include clonazepam, propranolol, acetazolamide, or diazepam. emotional problems are common in patients with ms. emotional lability may respond to tricyclic antidepressant medications. depression is treated with antidepressant agents and counseling. pain is a prominent concern in many patients with ms. dysesthetic pain can often be managed with tricyclic antidepressants, carbamazepine, phenytoin (dilantin), or valproic acid. musculoskeletal pain is treated with antiinflammatory medications and physical therapy. cognitive dysfunction can be a disabling and distressing component of ms. documentation with neuropsychiatric testing may be helpful in managing these problems. current investigations of ms center on the concept of autoimmunity, possibly mediated by a viral illness. studies designed to define the role of the immune system in ms may be useful. medications designed to reduce a specific autoimmune response and medications that assist in stimulation of remyelination or improvements in quality of life are being developed. over the past few years, great strides have been made in understanding the role of the immune system, in improving diagnostic capabilities, and in managing the problems associated with ms. as this trend continues, we may have more diverse and effective therapies for the management of ms. table 1 . jean martin charcot's description of the clinical and pathologic features of ms is the foundation of our knowledge of the disease.l the historical aspects of ms are reviewed in previous publications. 2s3 we are now entering a new phase of understanding brought about by careful clinical trials and the capability of monitoring the disorder with longitudinal magnetic resonance imaging (mri). in an individual patient, ms can be described by means of clinical observation. current concepts of the clinical courses, their relative frequencies, and mri characteristics of ms are portrayed in table 2 . investigations with mri have changed the concept of ms by demonstrating more evidence of disease activity than is expected from clinical examination. disease activity, as measured with mri, is particularly high among patients with chronic progressive disease. 4 the acute lesions of ms can now be demonstrated with gadolinium-enhanced mri. the initial event is associated with local disruption of the blood-brain barrier (fig. 1) . as the abnormality evolves, increased signal intensity becomes evident on t2-weighted images (figs. 2 and 3). the lesion may grow larger over a few days and then the areas of high signal intensity may begin to recede. over time, the lesions may completely resolve on tzweighted images. with each relapse, which is defined by new or newly enhancing lesions on mr images, the older areas of involvement may be reactivated. reactivation is associated with the development of permanent lesions on mr images. 5 clinical correlation is frequently observed with areas of contrast enhancement or abnormal signal intensity in the cerebellum, brainstem, or spinal cord. abnormalities in the cerebral hemispheres are frequently periventricular in distribution and only occasionally correlate with specific symptoms or signs.6,7 the accumulation of lesions in the frontal lobes is associated with a decline in memory.8 in addition, a change in the number of lesions on cranial mr images correlates with a change in overall clinical status as measured with standard scales.g observations made with mri are having a marked impact on both our basic knowledge of ms and on therapeutic trialsjo mri studies will provide considerable insight into the natural history of the disease and will be an excellent independent variable in future clinical trials. traditionally ms is thought to have a relatively high incidence in the northernmost latitudes of the northern hemisphere.l* this theory is based on the incidence of the disease in scandinavia and the northern united states. a similar association is documented in the southern hemisphere in australia and new zealand. these observations are supplemented by data from m igration studies, which demonstrate a relation between age at m igration and assumption of disease risk for the location. risk is conferred by exposure to an environcertain populations are susceptible to ms, and certain populations are resistant to ms. for example, lapps in scandinavia have a very low incidence of ms, even though they reside predominantly in the far northern latitudes. in north america the disease is infrequent among hutterites and native americans. ms is uncommon in japan. 13 the incidence of the disease in first-degree relatives of patients with ms is 20 times that of the general population,14 suggesting that genetic factors influence disease expression. the results of populatidn-based studies of twins offer evidence that environmental and genetic factors contribute to the development of ms. these investigations show that the concordance in monozygotic twins is greater than 30%. it is less than 5% in dizygotic twinp suggesting that although genetic factors are important, environmental exposure also is important for disease expression. it is now commonly accepted that multiple genes influence autoimmune diseases in both animals and human beings.16 therefore polygenic inheritance is postulated for ms. like other autoimmune diseases, ms is more frequent in women, with a ratio of 2:l. the pathologic features of multiple sclerosis were first described by charcot,l who recognized plaques in.the white matter (scleroses en plaque) during pathologic examination of brain sections. these plaques were demonstrated to lack myelin and to contain perivascular inflammation. these features were established as the pathologic hallmarks of ms. the following discussion centers on the typical findings in ms. comparisons are made between ms and other forms of inflammatory demyelinating disease. the distribution of plaques within the white matter is restricted to the central nervous system (cns). plaques are found frequently in a periventricular distribution in the cerebral hemispheres. some of these plaques may be associated with the distribution of terminal veins.17j8 plaques may occur anywhere within the white matter. when plaques are near the cortex, sparing of the subcortical myelinated fibers is often observed. plaques adjacent to gray matter may at times spread into the gray matter, including the cortex and deeper nuclei. plaques are frequently found in the white matter of the optic nerves, the brainstem, the cerebellum, and the spinal cord. plaques in these locations more frequently correlate with symptoms. within a plaque, axons are frequently preserved. 18 the evolution of a plaque is not known. mri investigations show that the blood-brain barrier is locally disrupted at the onset of symptoms. pathologists disagree as to whether demyelination precedes inflammation or is secondary to inflammation. at present the latter view predominates. in acute plaques, the inflammatory response of lymphocytes, plasma cells, and macrophages is capable of producing or augmenting demyelination by direct and indirect mechanisms. the inflammatory response is predominantly perivenular, with a lesser response at the edges of or within plaques. the macrophages associated with acute plaques characteristically contain myelin fragments or myelin breakdown products.lg lymphocytes may contribute to the pathologic process by means of direct or indirect pathways. direct mechanisms include antibodyand cell-mediated immunity. t-cell-mediated reactivity is favored because most inflammatory cells are t cells. indirect mechanisms include the secretion of lymphokines and cytokines. the ability of molecules such as tumor necrosis factor to damage myelin or oligodendrocytes is the focus of ongoing research.20 cytokines may influence macrophage activation, stimulating the phagocytosis of myelin. in addition, the release of heat shock proteins may result in stimulation of ty6 cells, resulting in increased cytotoxicity. the cns lesions of ms can be classified as early active, active, inactive, early remyelinating, and late remyelinating, according to histologic criteria. the features of these lesions are detailed in table 3 . studies of oligodendrocytes early in the course of ms have demonstrated relative preservation of these cells in some patients,z1,22 and remyelination is possible in these patients. other patients have a striking loss of oligodendrocytes, making remyelination unlikely. these differences may reflect the severity of the injury at a specific site of demyelination, or they may indicate that the pathogenesis of demyelination varies among patients with ms. this may imply that an autoimmune basis for ms has long been suspected because of the inflammation in the cns and the presence of oligoclonal bands in the cerebrospinal fluid (csf). the inflammatory response is primarily lymphocytic and mononuclear.2~3 the predominance of t cells among the lymphocytes has led investigators to evaluate the role of the t-cell receptor and its recognition of antigen combined with major histocompatibility antigens (mhc). this has been named the trimolecular complex.23 the t-cell receptor recognizes antigen in the context of the mhc molecule. in the case of mhc class ii molecules such as drz, the antigen fragments are bound in a cleft, which is presented to the tcell receptor for recognition. with regard to the components of the 18 in the context of the trimolecular complex, it is important to note that ms has been associated with certain mhc or human leukocyte antigen (hla) markers. a consistent observation is the association of dr2, drbl501, dqb602, and the du2 haplotype with ms.31 different hla associations are reported within ethnic groups. the mhc molecules may contribute to genetic susceptibility to the disorder, but they are only one of a number of factors that confer risk for the disease.32j3 the presence of oligoclonal bands in the csf of patients with ms is frequently observed (fig. 4) . these abnormal immunoglobulins are identified in a high percentage of patients with clinically definite ms, and they are present in approximately 60% of patients at the clinical onset of the disease. 34 the oligoclonal bands in ms are of unknown specificity. small percentages may bind to known viral antigens in some patients. consistent binding of these antibodies to specific viral polypeptides or viral oligopeptides with homology to myelin components has yet to be demonstrated. the oligoclonal bands are not specific to ms and can be observed in patients with cns infections such as syphilis, subacute sclerosing panencephalitis, viral encephalitis, or meningitis. 35, 36 if the infection is self-limited, the oligoclonal bands may be a transitory abnormality. in comparison, chronic infections of the cns are associated with persistence of the oligoclonal bands. in these settings, the antibodies that compose the oligoclonal bands have pathogen specificity. oligoclonal bands can be observed in patients with autoimmune diseases such as systemic lupus erythematosus. the probability that an environmental factor is involved in the pathogenesis of ms has stimulated interest in a viral cause. although viral isolates are reported from the cns of patients with ms,37-3g there are no consistent observations. attempts to detect viral nucleic acids by means of in situ hybridization and polymerase chain reaction (pcr) are in progress. these techniques are extremely sensitive and require rigorous controls. careful confirmation of any future viral isolates or viral nucleic acids by multiple laboratories is required. [40] [41] [42] [43] [44] [45] [46] recent studies of tropical spastic paraparesis demonstrate that the retrovirus human t-cell lymphotropic virus type i (htlv-i) is involved in the pathogenesis of this disorder, which shares some clinical features with ms.3ga it is clear, however, that htlv-i is not a pathogen in ms. 40 there remains the possibility that a retrovirus or endogenous retrovirus could contribute to the pathogenesis of ms. there is considerable interest in the possibility that exposure to a virus may lead to an immunopathologic condition that results in ms. of particular note are investigations that demonstrate the potential of molecular mimicry to produce autoimmunity. the term molecular mimicry arises from the demonstration of shared homology between normal human myelin proteins and viral polypeptides. if an immune response is mounted to such a viral epitope, then it may be perpetuated by exposure of the shared region on the normal human protein. in ms, homology between myelin antigens and viral peptides is established. thus this mechanism could result in cns demyelination after viral infection. autoimmunity could also result from superantigenic stimulation of t cells by viral or bacterial proteins. superantigens are capable of binding to specific t-cell receptor proteins, producing nonspecific stimulation of relatively large numbers of t cells, which might cause clonal expansion of t cells reactive to myelin or oligodendrocyte antigens.47s48 animal mqdels of demyelinating disease cns demyelination associated with inflammation is present in animal models of experimental allergic encephalomyelitis (eae) and theiler murine encephalomyelitis (tme). these models provide an opportunity for the investigation of autoimmune and virus-associated disease, respectively. eae is an autoimmune disease of the cns and a model for immunotherapy. a cd4+ t-cell population specific for a myelin antigen, either mbp or proteolipid protein, is required for initiation eae. eae and ms share characteristics that include cns demyelination, perivascular t cells, association with mhc class ii antigens, and possibly restricted tcr v-gene utilization.4g the murine adoptive transfer model has another important feature of ms: the chronic relapsing clinical course.4g this clinical course is useful for investigations of the immune response and immunotherapy not only during onset of the disease but also during relapse. the pathologic features of this murine transfer model are inflammation and prominent demyelination.4g-51 eae is not associated with an environmental factor. the tme model of immune-mediated demyelination is of particular interest because it has important parallels with postinfectious encephalomyelitis and ms. in this model, antecedent mild or even subclinical viral encephalitis is followed by a period of quiescence and the eventual onset of demyelination. 50 the virus is persistent during the demyelinating phase of the disease. this implies that either low-level expression of viral polypeptides or immunologic cross-reactivity between virus and myelin antigens is crucial for initiating demyelination. the demyelination in the tme virus model is mediated by t lymphocytes. these t cells may have viral specificity but produce demyelination. this mechanism would be relevant to ms if the suspected environmental factor were one or several viruses. as in ms and eae, t cells appear to initiate immunemediated demyelination in tme.!~~z~~ experimental immunotherapies are evaluated in these animal models and provide a basis for clinical trials in human beings. examples of these investigational treatments include cytokine transforming growth factor-i3, (tgf131,53 lymphokine-toxin,54 anti-t-cell receptor vb-specific monoclonal antibody,55,56 t-cell vaccination,57 blocking peptides, anti-adhesion molecule specific monoclonal antibodies,5g and nitric oxide synthetase inhibition. 60 these experimental models provide an invaluable resource for the study of immunotherapy. although these experimental models are not likely to mirror the pathogenesis of ms, they are extremely useful in the study of cns inflammation and demyelination. ms is primarily a disease of young adults. most patients report their first symptoms between the ages of 20 and 45 years. the disorder rarely appears before the age of 15 years or after the age of 50 years, although it has been reported to occur in both children and the elderly. the symptoms of ms in children are essentially the same as those in adults; ataxia, numbness, and visual disturbance are the most common presenting symptoms. in elderly persons, a progressive onset is more common. ms is characterized by episodes of neurologic dysfunction, followed by periods of stabilization or remission. symptoms, once they appear, may partially or completely resolve or may be permanent. these episodes tend to develop over hours or days. sometimes the symptoms occur with almost strokelike suddenness, or they may develop slowly over a few weeks. once the symptoms have developed, resolution generally occurs over weeks or months. certain signs and symptoms are more common in the early stages of ms. these include numbness, double vision, monoparesis, paraparesis, bladder control problems, optic neuritis, ataxia, or tremor (table 1) . 22 dm, january 1996 numbness can be difficult to evaluate. numbness that suggests early ms includes an ascending numbness beginning at the feet. this may be a sign of transverse myelitis. hemiparesthesia, bilateral hand numbness, and dysesthesia in both hands, both feet, or on one side of the body, also are early symptoms of ms. the numbness is usually present for days, weeks, or months. many patients describe numbness or paresthesia with no objective abnormalities. if objective sensory abnormalities occur, they are more commonly reduction of vibration, proprioception, or stereognosis rather than pain or fever. the diplopia that occurs with ms is frequently partial or complete internuclear ophthalmoplegia, which is often bilateral. a small percentage of patients have sixth nerve palsy" or, more rarely, third or fourth nerve palsy. ww sometimes monocular diplopia is a symptom of optic neuritis. optic neuritis is usually characterized by monocular blurred vision, sometimes with scotomata and often with alteration of color vision. retroorbital pain or headache is common in patients with active optic neuritis. 63 the pain may intensify with eye movement. motor weakness is usually accompanied by upper motor neuron signs, such as hyperreflexia or the babinski sign. paraparesis is the most common early symptom, but the weakness also can occur as hemiparesis or monoparesis. spas.ticity can be a later manifestation. signs and symptoms that commonly occur as ms progresses include vertigo, tremor, incoordination, increasing spasticity, depression, mood swings, cognitive abnormalities, impotence or other sexual dysfunction, weakness, lhermitte's sign, gait abnormalities, constipation, urinary incontinence, optic nerve pallor, fatigue, quadriparesis, dysarthria, loss of upper extremity coordination, and dysesthetic pain (table 1) . uncommon but important problems include seizures, atypical facial pain or tic douloureux (trigeminal neuralgia), bowel incontinence, swallowing problems, hearing loss, and dystonia. bell's palsy is sometimes seen in patients with ms (table 1) . the classic course of ms is one of intermittent neurologic signs and symptoms over many years. as time progresses, chronic problems accumulate. the amount of total disability varies from patient to patient. after a number of years, a patient's condition may stabilize permanently, but this does not always occur. d&f, january 1996 23 subtypes of disease ms can be divided into subtypes according to the course of the disease. there is a continuum among the various subtypes, and the disease in some patients does not fit into a pattern. benign ms accounts for 10% to 20% of cases and occurs more often in young women. in this type of ms, symptoms are mild and often sensory. resolution of neurologic problems is nearly complete. over the years, these patients rarely experience considerable disability. relapsing-remitting ms is the most common form of the disease. it is characterized by episodes of neurologic dysfunction [variably called exacerbations, relapses, or attacks) followed by periods of improvement and stabilization (called remissions). during a remission, not all symptoms resolve completely. the patient may be left with permanent disabilities, which may vary in severity. the condition of 30% to 50% of patients with an initial relapsingremitting course begins to worsen gradually over time, and neurologic signs and symptoms accumulate. this form of the disease is classified as secondary chronic progressive ms or relapsing-progressive ms. the latter term is also used to describe disease in patients who have sudden deteriorations in a stepwise manner without clinically significant recovery. primaryprogressive ms occurs in 10% to 20% of patients. disease in these patients begins with a slow progression of neurologic deficits with no history of relapse and may also have periods of stabilization or subacute worsening. common problems that appear and gradually worsen with time include spastic paraparesis, cerebellar ataxia, and urinary incontinence. clinical findings although no neurologic findings are pathognomonic for ms, certain abnormalities found during a physical examination can be helpful in providing a clue to the diagnosis of ms. these include internuclear ophthalmoplegia, which is rarely seen in other diseases and is especially rare in young adults. hyperreflexia and the babinski sign are common in early ms. optic nerve pallor can provide a clue to subclinical or resolved optic neuritis. altered color vision in one eye and a marcus-gunn pupil also are signs of optic neuritis. nystagmus is a common finding in patients with ms. many types of nystagmus are identified, including pendular nystagmus, small-amplitude nystagmus, or gaze-evoke nystagmus.63a65a66 absent abdominal reflexes in a slender patient who has not undergone an abdominal operation may be a helpful sign. a mild intention tremor with or without past-pointing is also an early sign, as is a positive romberg sign or difficulty with balance with 24 divz,january 1996 tandem gait. subtle motor weakness or spasticity may also be found. loss of vibratory or proprioceptive sensation in the lower extremities is common early in the course of the disease. ms should be strongly suspected in young or middle-aged adults who describe symptoms consistent with the lhermitte sign in the absence of obvious cervical cord abnormalities. the lhermitte sign consists of paresthesia or an electric shock-like sensation that radiates up the head or down the spine on neck flexion or extension. other important abnormalities are gait disturbances, persistent binocular double vision when looking in a particular direction, or a history of optic neuritis or transverse myelitis. fatigue and depression are not criteria for the diagnosis of ms. no laboratory test is universally diagnostic for ms. certain studies can be helpful in confirming the presence of separation of lesions in space and time. examination of the csf can be valuable for two reasons. first, the pattern of csf findings can help confirm the presence of demyelinating disease. the protein level is often slightly elevated but is rarely greater than 0.1 g/l unless the patient is experiencing a severe exacerbation, particularly optic neuritis or transverse myelitis. a modest elevation in cell count, generally less than 50/mm3, is seen in some patients. the cell pattern usually consists mostly of mononuclear cells. if more sophisticated testing is conducted, most cells can be identified as t lymphocytes. qualitative analysis of proteins can be helpful in suggesting the diagnosis of ms. at electrophoresis oligoclonal immunoglobulin bands can be identified in the csf but not in the serum of many patients with ms 34,67 (fig. 4) . the igg index, a comparison between igg levels in the csf and igg levels in the serum, is elevated in many patients with ms. 68,6g although these findings suggest ms, they also are found in other diseases, most commonly other inflammatory diseases of the cns. these diseases include lyme disease, systemic lupus erythematosus, progressive multifocal leukoencephalopathy, encephalitis, and subacute sclerosing panencephalitis. 35 the ver is abnormal in approximately 70% of patients with ms, regardless of whether there is a history of optic neuritis.70 a slowed ploo in a patient without a history of optic neuritis can be paraclinical evidence of a second lesion and can be used to confirm a diagnosis of ms (fig. 5) .6g the baer is more difficult to interpret than the ver and is abnormal in approximately 30% of patients with ms. in the baer, five 26 d&z, january 1996 consecutive waves are identified; these are numbered i-v the wave interval i-iii is considered the peripheral system. abnormalities in this wave suggest a lesion in the peripheral auditory nerve. the wave interval iii-v is generated from the central hearing areas in the brainstem. slowing in this area suggests a brainstem lesion. abnormalities in waves iii-v are seen in approximately 30% of patients with ms. 70 the sser is a technically more difficult study than the other responses, but it is useful for identification of slowed central conduction in the sensory pathway in the spinal cord and brain. the sser is abnormal in approximately 80% of patients with definite ms. 70 the sser also is useful in the identification of peripheral lesions, suggesting that peripheral neuropathy rather than a central lesion is the cause of numbness. the development of mri has been extremely important in both making the diagnosis of ms and helping researchers understand the dynamics of ms in patients with the disease. mri findings should be interpreted with caution, however. abnormal mri findings alone are not sufficient to confirm a diagnosis of ms without clinical evidence. 71, 72 in patients with ms, patchy areas of abnormal white matter are seen on t%weighted and spin-echo images. these are most commonly found in the cerebral hemispheres in the periventricular areas. in some patients, however, lesions also are identified in the brainstem and cerebellum. mri also helps identify lesions in the cervical and thoracic spinal cord. gadolinium enhancement can be seen around some lesions, particularly if a patient is having an exacerbation or fairly rapid chronic progression. gadolinium enhancement is considered a sign of an active lesion. (table 4 ).76-7g mr images should be interpreted with caution, particularly in patients with chronic illness of any kind or in patients older than 50 years. fazekas et a1.75 attempted to differentiate the mr images of healthy persons older than 50 years from those of patients with ms. they identified the following three criteria for the diagnosis of ms: lesions abutting the lateral ventricles, lesion diameter greater than 0.6 cm, and lesions present in the posterior fossa. if two of the three criteria were met, the specificity for ms was 88% and the sensitivity was 100%. a follow-up study in which 1500 consecutive mris were examined yielded a sensitivity of 81% and a specificity of 96%" these criteria may be useful in the interpretation of mri findings in some patients, but they should be used with caution for patients with other diseases that can affect mri, such as hypertension and diabetes mellitus. patients with those diseases were excluded from the study by fazekas et al. the size and area of the lesions present on mr images correlate poorly with the patient's disability. 4,81 many patients with large lesions on mr images have minor clinical findings, whereas some patients with small lesions have severe disability. one area in which mri may indicate the severity of the problem is in the cognitive status of the patient. an increase in the area of the lesions in the cerebral hemispheres or thinning of the corpus callosum may correlate with poor cognitive function. the presence of lesions in the spinal cord does not correlate with disease severity. a recent study in which body coil imaging was used showed that 74% of patients with ms had lesions in the spinal cord that were identified by this technique. 82 although the presence of lesions and the area and number of lesions did not correlate with a patient's level of disability, the presence of spinal cord atrophy did correlate with greater disability. 82 patients with partial or complete transverse myelitis who subsequently are found to have ms often have lesions on mr images that correspond to the level indicated by symptoms and the level of neurologic findings (simnad v, rose jw, manuscript in preparation). the use of mri for the follow-up evaluation of ms has become an integral part of research into the course of the disease. however, because mri findings do not correlate with a patient's clinical condition, new abnormalities on mr images in the absence of clinical worsening should not be treated as an exacerbation of the disease. new abnormalities can, however, indicate that the disease remains active. mri should be repeated in patients in whom the diagnosis has not been confirmed or in patients who have new symptoms that suggest a second disease. as the choice of treatments of ms increases, monitoring of disease activity may become useful in determining the course of treatment. optic neuritis is often seen as a first demyelinating episode in patients with ms. the diagnosis of ms should be considered in patients with optic neuritis, and a careful history and examination should be performed to exclude other neurologic abnormalities. however, many patients who have a single episode of optic neuritis never have other demyelinating episodes. one study of 60 patientsgo found that ms developed in 74% of women and 34% of men within 15 years of an attack of optic neuritis. transverse myelitis, inflammation of an area of the spinal cord causing ascending weakness and numbness up to the level of the lesion, can also be seen as the initial demyelinating event in ms. 88 other causes include infectious, postinfectious, and postvaccinal demyelination. 81 sometimes the cause is never determined. when transverse myelitis occurs, an imflammatory lesion can be identified on mri images of the cervical or thoracic spinal cord. estimates of the risk of ms after an isolated episode of transverse myelitis range from 50% to 80%.g1-g3 im'z, january 1996 29 the use of the cranial mr images in patients with optic neuritis or transverse myelitis may be helpful in predicting which patients are more likely to have additional problems. one prospective study identified patients with a single demyelinating episode such as optic neuritis or transverse myelitis. patients with abnormal mri findings at the time of the first episode had a 65% risk of a second episode within 5 years. patients with normal mri findings at the time of the first episode had a 5% risk of development of a second lesion in 5 years.g4 a syndrome in which optic neuritis and transverse myelitis develop with no other demyelinating events is called devic's neuromyelitis optica. in this disorder, cranial mri findings remain normal. this is considered a monophasic illness-both abnormalities occur within a year of each other, and patients may never have another demyelinating event. this is a rare syndrome.g5 the following characteristics are associated with a favorable prognosis: (1) female sex, (2) early age at onset, (3) onset of symptoms referable to a single neurologic system, (4) substantial recovery from relapses, (5) early symptoms of numbness rather than corticospinal or cerebellar symptoms. unfavorable prognosis is associated with chronic progressive disease (either primary or secondary), older age at onset, and male sex.g6-g8 dlagnostic criteria because of the difficulties involved in the diagnosis of ms, several criteria have been published to standardize the terms used to describe the certainty of the diagnosis. the two primary sets of criteria are those of poser et a1.6g and shumacher et a1. 83 the poser criteria are more recent and are summarized in table 5 . it is important to remember that no abnormality should be used as a criterion if it can be explained by another medical problem. other conditions may commonly be confused with ms and should be considered in the differential diagnosis. the differential diagnosis depends in part on the clinical and laboratory findings in an individual patient. postinfectious encephalomyelitis is a subacute syndrome, possibly caused by an autoimmune response to a viral infection. patients with this illness experience the acute or subacute onset of confusion, disorientation, gait abnormalities, loss of bowel or bladder control, weakness, or other symptoms. abnormalities in the white matter can be seen with mri, and evidence of inflammation frequently is seen in the cse the patient's condition may or may not return to normal; recovery may take months or even years. 84 lyme disease is a prominent concern and appears to be a cause of intermittent neurologic events, 85 the most common of which is bell's palsy. encephalomyelitis may develop, with vague symptoms of numbness, fatigue, and memory deficit. abnormalities in the white matter may be seen with mri, and csf findings may resemble those in ms, including mild leukocytosis and oligoclonal bands. patients may have a history of a tick bite, a rash, or recent arthralgia. lyme titers or a lyme pcr in the blood or csf may be helpful to these patients. 85 systemic lupus erythematosus is a well-known syndrome that may cause transverse myelitis, strokes, encephalopathy, and optic abnormalities. clues to the differential diagnosis are systemic abnormalities such as hematuria or leukopenia, arthritis, or an elevated antinuclear antibody titer, erythrocyte sedimentation rate, or other blood measurement. sometimes both systemic lupus erythematosus and ms occur in the same patient. primary cns vasculitis can cause a syndrome similar to ms. differentiating features include prominent headaches, confusion, and sudden strokelike episodes. an elevated erythrocyte sedimentation rate may be present in some patients, as may an elevated csf protein level. patients may have an abnormal cerebral angiogram. bi-opsy of the temporal lobe or meninges may be helpful in the diagnosis of this syndrome. 77 the htlv-i, a retrovirus, causes a syndrome known as tropical spastic paraparesis or htlv-i-associated myelopathy. it may cause progressive spastic paraparesis or generalized white matter disease. htlv-i is relatively rare in the united states but is present in some patients who have resided around the caribbean sea. 86 behqet's syndrome can cause mri findings identical to those in ms. cardinal features of behqet's syndrome include oral ulcers, genital ulcers, and uveitis. variable features include involvement of the skin, eyes, joints, lungs, intestines, and heart and venous thrombosis. neuropsychiatric symptoms, including quadriparesis, pseudobulbar palsy, cranial neuropathy, cerebellar ataxia, peripheral neuropathic lesions, or cerebral venous thrombosis may be present.7g,87 sarcoidosis and sjggren's syndrome are autoimmune diseases that may show lesions on mr images that resemble those of ms. meningeal enhancement is a clue to cns sarcoidosis. a chest radiograph may show granulomatous lesions suggestive of systemic sarcoidosis. although igg levels are raised in the csf of patients with cns sarcoidosis, oligoclonal bands are found in some patients. csf angiotensin-converting enzyme determination may be used to further differentiate cns sarcoidosis from ms.78 vitamin b deficiency and syphilis can cause posterior column abnormali& and dementia. tests for these problems should be performed when a patient with these symptoms is seen. certain leukodystrophies may appear in adulthood. these include adrenal leukodystrophy, krabbe's disease, and metachromatic leukodystrophy. mri findings in these diseases show large areas in which no normal white matter is present. female carriers of the adrenal leukodystrophy gene may have an ms-like syndrome.88~8g hereditary degenerative syndromes, such as familial spastic paraparesis, olivopontocerebellar degeneration, and spinocerebellar degeneration, may be confused with ms, particularly with primary progressive ms. in these diseases, mr images may be normal or may show atrophy of the brainstem, spinal cord, or cerebellum. the csf is normal in these patients. studies support the concept that exercise is beneficial for the patients with ms.ggjoo simple measures such as walking, using an exercise bicycle, and swimming may be of considerable value. exercise should be performed in a cool environment whenever possible to prevent heat-associated transient declines in neurologic function. swimming and water aerobics in pools that are not overly heated are particularly valuable, because the patient is cooled while exercising. physical and occupational therapy are often invaluable for maintenance or improvement of neurologic function. bracing disabled portions of limbs, particularly the ankle, provides considerable benefit. exercise regimens tailored to the patient may help to maintain or improve strength, range of motion, and mobility. devices that provide assistance with walking can be important in reducing the risk of falls, allowing for greater independence and increased activity. other assistive devices can be helpful in reducing fatigue and increasing independent activity. careful consultation with a specialist in rehabilitative medicine can assist the patient with management of work and daily activities.l"o it is advisable for persons with ms to maintain a balanced diet. weight control is a prominent concern. overweight patients with motor, sensory, or coordination deficits that impair ambulation are at particular risk of falls, which may result in serious injuries, including fractures. patients who are overweight and whose strength is decreased lose any reserve strength they may have because of their weight. some patients with ms lose weight and require dietary supplementation. patients with dysphagia may require feeding tubes to help prevent aspiration pneumonia. although various diets have been advocated for ms, there are no substantial data from controlled trials to support the assertions. as a general health measure, it is commonly suggested that patients with ms restrict cholesterol and fat in the diet. diets that meet the requirements of the american heart association are likely to be useful, because most patients with ms live into middle age and beyond. pregnancy is a concern among young women with ms. many studies of the effect of pregnancy on ms have been undertaken. an increased risk of exacerbations in the first 3 months postpartum has been reported.lol-la4 however, the risk of exacerbations during pregnancy appears to be unchanged or slightly reduced.lo5 overall longterm disability does not appear to be altered by pregnancy.lo4j05 the increased relapse rate seen during the postpartum period has been postulated to be caused by an increase in immune tolerance during pregnancy, followed by a return to normal in the postpartum dm, january 1996 33 period. it has also been postulated that the relapses are secondary to the decrease in the level of female hormones after parturition.lo*-lo3 in addition to the physical effects of pregnancy, another major concern is the care of an infant or child by a person with physical problems. persons with ms need to consider carefully whether they can handle the additional work of caring for a child. persons with chronic physical problems may need special provisions, such as extra assistance in the home or special equipment. the physician should discuss pregnancy, delivery, and child care with women of childbearing age. increased core temperature, whether due to heat exposure or to a febrile response, may lead to a transient increase in neurologic symptoms.lo6 if the event is due to heat exposure, the patient simply needs to rest in a cool environment and await recovery. if an infection is responsible, the source of the infection should be determined and treated. an antipyretic medication such as acetaminophen can then be administered. many patients with ms are susceptible to urinary tract infections and may not have clinical manifestations of the infection. in some patients this is due to impaired sensory capabilities, and some patients have chronic urinary symptoms that may not change substantially with an infection. one study of ms exacerbations pointed to an association with antecedent infection.lo7 if a patient has persistent worsening after an infection that has been appropriately treated and resolved, steroid therapy should be considered in the event the infection recurs. a relapse is considered to be the onset of new neurologic symptoms or marked worsening of old symptoms lasting longer than 24 hours. certain conditions may mimic an exacerbation and should be ruled out or treated before steroid therapy is considered. these include fever, infection (commonly urinary tract infection or viral illness), overheating, fatigue, severe emotional stress, or the effects of medications such as baclofen, which can increase weakness. if these problems are appropriately treated, the patient's condition usually improves. mild relapses may be best treated without steroid therapy. the symptoms include a mild numbness, mild changes in bladder function, mild optic neuritis (visual acuity better than 20/40), slight increase in spasticity, or a dysesthetic pain syndrome. any new abnormality that does not change a person's ability to perform his or her usual daily activities may not require steroid therapy. in these patients, rest is sometimes helpful. patients with more severe worsen-ing may benefit from steroid therapy. the symptoms include gait disturbances, severe numbness or paresthesia, moderate to severe paresis, moderate or severe optic neuritis, severe vertigo, or marked impairment of eye movement. it is often appropriate for the physician to observe the patient for a few days before making a decision about the use of steroids. standard therapy for many years, immunosuppression with corticotropin (acth) or steroids has been used in the treatment of the exacerbations of ms. the primary effect of these agents is to shorten the duration of an attack, and no benefit has been proven in the overall outcome from an attack. steroids should not be given until an abnormality resolves because this may never occur. acth was the first immunosuppressant to be widely used in ms.lo8 although it is still given to some patients who respond well to the medication, acth has been largely supplanted by other steroids, most commonly prednisone and methylprednisolone. many different regimens have been used. a typical regimen is 80 units by intravenous or intramuscular injection once a day for 10 days. prednisone is commonly used for mild or moderate exacerbations of ms. although low doses do not appear to have any effect on an exacerbation, larger doses do appear to shorten the duration of an ms attack.log there is no standard treatment regimen; a dose of at least 1 mg/kg per day is commonly recommended and should be continued for 7 to 10 days. our regimen is 80 mg once a day by mouth for 10 days, then tapered by 20 mg every 3 days. other regimens range from 10 days to 6 weeks or longer. methylprednisolone with sodium succinate (solu-medrol) is often used in the treatment of severe relapses, or when the patient's condition continues to worsen after several days of high-dose prednisone.'lo typical dosages range from 500 to 1000 mg/day and last from 3 to 14 days. a typical dose is 250 mg in 250 ml of 5% dextrose in water over 45 minutes every 6 hours to a total of 16 doses. another is 500 mg in 250 ml of 5% dextrose in water over 45 minutes every 12 hours for 10 doses. an oral prednisone taper over about 10 days to 2 weeks may be used afterward. one study of optic neuritis suggested that high-dose methylprednisolone produces more favorable results than oral prednisone for patients with poor visual acuity. this study showed only a faster recovery time; follow-up examinations at 1 year did not show any difference in final outcome."l the study involved patients who did not necessarily have a diagnosis of ms. however, a follow-up evaluation with patients in whom ms subsequently developed did suggest that the methylprednisolone-treated group had a longer time interval to the development of a second demyelinating event than dm,january 1996 3.5 those who received prednisone or placebo.l12 for this reason, some neurologists believe that all attacks of ms should be treated with intravenous methylprednisolone. the side effects of steroids are well known. these include nonspecific immunosuppression leading to opportunistic infections, induction of hyperglycemia, fluid retention, hypertension, emotional abnormalities, hypokalemia, peptic ulcers, occasional aseptic necrosis of the femoral head or other bones, and demineralization of bone. chronic use may lead to cataracts, osteoporosis, muscle wasting, hypertension, diabetes, increased susceptibility to infections, and a cushingoid appearance. steroids should be used with caution. we have found the,following precautions helpful: administration of calcium and possibly vitamin d during the administration of steroids and restriction of foods with a high sugar or sodium content. we encourage our patients to eat foods rich in potassium, such as bananas, orange juice, and tomatoes. patients who experience indigestion may benefit from the use of histamine blockers such as ranitidine. some patients may need sedation with diazepam or other agents because of severe mood swings, anxiety, or sleeplessness. patients who receive high doses of methylprednisolone should be observed for hypertension, electrolyte imbalance, and hyperglycemia. these problems should be treated appropriately. occasional psychiatric symptoms, including depression, psychosis, and severe anxiety, may necessitate cessation of steroid therapy. betaseron, a recombinant interferon-& has been approved by the u.s. food and drug administration (fda) for use in ambulatory patients with relapsing-remitting ms. this approval followed a 2year, controlled, double-blind study that showed in patients treated with 8 million units of betaseron administered subcutaneously every other day the relapse rate was reduced to 0.84 relapse per year compared with 1.27 relapses per year in patients given placebo.l13 an mri study performed with the same population revealed fewer new lesions in the treatment group than in the control group.lo the drug did not improve ongoing symptoms. the study was limited to patients with relapsing-remitting disease, and the findings should not be extrapolated to patients with chronic progressive disease. a study of the use of betaseron by patients with chronic progressive ms is planned. patients whose condition is stable would not benefit from the use of betaseron. there are problems with the use of betaseron. although the drug may be helpful in patients with frequent relapses, it does have seri-ous side effects. almost all patients experience local reactions at the site of injection, and some patients have had tissue necrosis at injection sites. the injection site must be changed regularly to reduce the likelihood of ulceration. many patients have a flulike reaction, which may include fever, chills, malaise, and myalgia. this reaction resolves with time and commonly lasts only a few months; however, it may last as long as a year. these symptoms can be partially controlled with acetaminophen or ibuprofen. liver function studies may show abnormalities, and leukopenia may be present. fatigue and emotional disturbances have been reported. our patients have experienced episodes of acute depression and anxiety, and one patient had an episode of uncontrollable rage. depression may necessitate temporary or permanent cessation of betaseron treatment. however, antidepressants, such as fluoxetine, sertraline, and paroxetine hydrochloride, may help counteract the depression. in a few cases, ms appears to worsen when the patient is taking betaseron. acute weakness develops in some patients with the first few injections. this is not always associated with fever and may resolve with time. menstrual irregularities have been reported, and betaseron cannot be used during pregnancy. some patients tolerate the medication better if the full dose is titrated up over approximately 1 month. periodic blood tests to check for leukopenia and abnormal liver function are suggested. clinical trials of other preparations of interferon-a and interferon-13 are nearing completion. one clinical trial involved administration of a weekly intramuscular injection of interferon4la. the results suggested that this drug reduces the likelihood of progression in patients with early disease. 114 a phase iii clinical trial of another investigational agent, copolymer 1, has been completed. this drug appears promising in reducing relapses and has a good safety profile.115j16 these agents will likely be available in the near future, pending fda approval. although most treatment aimed at chronic progression remains experimental, the use of intermittent intravenous methylprednisolone has become a common practice. most commonly, patients who experience subacute worsening may respond to a course of highdose solu-medrol similar to that given for a severe relapse. the condition of some patients appears to stabilize, at least temporarily, with this course of therapy. some patients with progressive disease may respond to a single dose of 1000 mg of solu-medrol in 250 ml of 5% dextrose in water given over 1 hour once a month for 6 to 12 months. subsequent treatments may be given every 6 to 8 weeks. azathioprine has been used for the treatment of chronic progres-sion with some success. studies have shown a modest benefit of azathioprine, primarily in stabilizing the condition of some patients.l17j18 patients who take this drug should be examined for leukopenia or hepatotoxicity. about 15% of patients are unable to tolerate azathioprine because of fever, rash, or nausea. patients with continued progression during therapy with azathioprine or solu-medrol may benefit from combined therapy. cyclosporine was evaluated in a multicenter clinical trial and was found to have modest clinical benefit.llg the prolonged use of cyclosporine in patients with chronic progressive ms was complicated by side effects, principally nephrotoxicity and hypertension. the use of cyclophosphamide in the treatment of chronic progressive ms is controversia1.120-122 the results of clinical trials of this agent in chronic progressive ms are contradictory. the drug may have use in rapidly progressive ms that does not respond to steroid therapy. further investigation with mri and neuropsychological testing and careful clinical assessment should resolve the controversy. a number of promising phase iii clinical trials of therapeutic agents for relapsing-remitting ms are being conducted. for two of these agents, the 2-year placebo-controlled phase has been completed. these are an interferon-& given once a week by intramuscular injection, and copolymer 1. both drugs reduce the frequency of relapses and favorably influence disability. the interferon-l3 is identical to human interferon-8 and differs from betaseron in that it has the sequence of amino acids and glycosylation of human interferon.l14 the results of a review of the safety profile of this drug compared with that of betaseron will be of considerable interest. copolymer 1 appears to have activity similar to that of betaseron with regard to reduction of relapses in ms.l15,116 the side-effect profile appears to be favorable compared with that of betaseron. laboratory investigations demonstrate additive effects of copolymer 1 and interferon-l3 in vitro. because the drugs theoretically act through different mechanisms, combined therapy might be possible. because of the results of a pilot study, oral myelin is being tested in a phase iii clinical trial. lz3 in the pilot trial, the efficacy of the drug was observed in only a subgroup of patients (dr2-negative men). two pilot studies of the use of methotrexate for ms have been performed.124j25 methotrexate in low doses is used for the treatment of rheumatoid arthritis, psoriasis, and crohn's disease. similar therapy may be of benefit to patients with advanced ms.lz5 a phase iii controlled trial and dose response testing will be of considerable interest. methotrexate should be used in clinical settings that allow careful neurologic and laboratory follow-up evaluation. 38 dm, january 1996 cladribine by intravenous administration appears to alter the progression of ms. lz6 the drug has relatively selective toxicity for lymphocytes; however, the side effects can be substantial. additional studies to evaluate dose and route of administration are being initiated. the clinical effects of repeated dosage with this medication also require study. immunoglobulin therapy may be useful in ms; however, controlled trials of intravenous immunoglobulin (ivig) must be completed.lz7 this therapy may be useful in relapsing disease and can be considered for patients with both ms and diabetes. ivig therapy is not necessarily benign and can be responsible for the transmission of viral hepatitis. several clinical trials of monoclonal antibodies are in progress. a number of monoclonal antibodies with specificities for either lymphocytes or adhesion molecules are being subjected to initial trials in human beings. a monoclonal antibody that appears to lower lymphocytes and have an appreciable effect on the lesions of patients with ms as seen on mr images is being studied.lz8 ,%klptomtic therapy one of the most important aspects of the treatment of ms is helping patients manage their ongoing symptoms. because of the chronic nature of the problems associated with ms, medication and adjustments in lifestyle are used to help patients cope with their disabilities. table 6 gives a summary of possible symptomatic treatments. fatigue can be disabling in patients with ms. it is described in different ways by different patients. the classic description of fatigue is increased weakness with exercise or as the day progresses. the patient may walk fairly well in the morning but need a cane or walker by afternoon. other descriptions include sudden attacks of sleepiness or excessive chronic sleepiness, even though the patient has had enough sleep at night.lzg patients who describe fatigue should be questioned closely about their sleep habits and other symptoms of depression. many patients with fatigue may have poor sleep habits or insomnia, which lead to daytime fatigue. depression is a common problem in patients with ms.130 if the fatigue is a product of depression, treatment of the depression should be helpful. fatigue is sometimes managed without medication. patients may respond to one or two brief (15 to 30 minutes) naps during the day. if this is not helpful or not possible, amantadine may be given to help control the problem. the mechanism of action of amantadine is not known, but it is helpful in approximately 40% of patients.lzg side effects, such as dizziness, headaches, nervousness, or edema, may limit the usefulness of the drug. pemoline is a cns stimulant that may be helpful in some patients.131 it should be used in low doses and should generally be given early in the day because it may cause insomnia. anxiety and anorexia are other problems that may occur with this drug. liver function studies should be performed periodically to monitor for hepatotoxicity. fluoxetine (prozac) may be helpful both to increase energy and to treat depression.*32 40 d&z, january 1996 vertigo vertigo can be an intractable and disabling problem. vertigo can occur in sudden spells that last a few minutes, or it can be chronic and last for hours. some physical therapy techniques involve habituation exercises to help with vertigo. medications that may be helpful include meclizine, promethazine hydrochloride, and low-dose diazepam. oscillopsia may occasionally respond to clonazepam or baclofen. vertigo with nausea and vomiting may respond to metoclopramide. spasticity can appear in many different ways. it may be seen at direct examination as a "catch" in the muscles with passive rapid movement of the limbs, or it may cause severe stiffness or rigidity. some patients may have severe spasms of the affected limb, which may be precipitated by movement or occur at night. these are most common in the lower limbs and may be either flexor or extensor spasms. the spasms can be quite painful. primary treatment of spasticity includes physical therapy with stretching exercises, combined with medication. baclofen is the most commonly used drug for spasticity, although its mechanism of action is not known. the dose of baclofen should be low when treatment begins and should be titrated slowly and carefully. patients who take an overdose of baclofen experience weakness. the dose of baclofen is extremely variable-some patients with only moderate spasticity tolerate high doses, whereas others with severe spasticity tolerate only low doses. other limiting side effects include drowsiness, confusion, and nausea. use of baclofen should not be discontinued abruptly but should be tapered over a few weeks.132 *133 diazepam in combination with baclofen may be helpful for patients with severe spasticity or those who cannot tolerate high doses of baclofen but need to control spasticity. diazepam can be used alone for spasticity, but it is not as effective as baclofen.133 diazepam can be particularly helpful for flexor or extensor spasms at night. dantrolene has limited value because of its hepatotoxicity and the weakness that accompanies the muscle-relaxant effect. it may be helpful in intractable cases of spasticity. the baclofen pump was developed for use in patients with intractable spasticity. 134 this device is an intrathecal pump with a subcutaneous reservoir of baclofen that administers continuous doses of baclofen directly into the spinal canal. this method of administration can be effective. with the lower dose delivered directly to the spinal cord, patients seem to have fewer side effects than with other routes of administration. dose levels can be programmed to change throughout the day, so patients with problems that are worse during the night or another part of the day can take increased doses of the drug during those times. tizanidine is an agent used outside the united states for spasticity. 135 it is being studied in the united states and may become available in the near future. other agents that may be useful in the treatment of spasticity include carbamazepine, phenytoin sodium, methocarbamol, and cyclobenzaprine hydrochloride. clonidine patches may be used for adjunctive therapy in patients with persisting spasms who are taking other drugs. spastic dysarthria is an uncommon symptom in ms. speech is hesitant and stuttering, and breath control is difficult. baclofen sometimes is helpful in this condition. bladder dysfunction is an extremely common problem in ms. examination of postvoid residual urine volume and urodynamic testing are extremely important in delineating the causes of bladder dysfunction. other urologic examinations, such as cystoscopy, may help eliminate mechanical problems as the cause of urinary dysfunction. consultation with a urologist skilled in the evaluation of neurologic dysfunction of the bladder is essential to the best therapeutic outcome. the most common problem is a spastic bladder. this is a small, hyperactive bladder. symptoms of this type of bladder dysfunction are urgency, increased frequency, and incontinence in which the bladder empties completely with brief warning. this condition can be treated with anticholinergic agents such as oxybutynin or propantheline .136j37 sometimes baclofen or amitriptyline can be of use in the control of this problem (table 7) . detrusor-external sphincter dyssynergia is a common problem. in this syndrome, the bladder attempts to empty, but the urethra remains closed. symptoms may be urgency and hesitancy, double voiding, and increased frequency with a feeling of incomplete emptying. anticholinergic or tricyclic agents alone may be of help with this syndrome, but more commonly a combination of anticholinergic drugs and intermittent catheterization is needed to control the problem. 137 the patient performs self-catheterization two to four times a day. a flaccid bladder is less common than the other types of bladder dysfunction. this is an enlarged bladder that empties poorly. symptoms include hesitancy, double voiding, a feeling of incomplete emptying, and dribbling incontinence. untreated urinary retention can result in hydronephrosis. urecholine can be of use in a few patients. frequently, however, a schedule of intermittent selfcatheterization may be needed (table 7) . patients with flaccid bladder or sphincter dyssynergia may have frequent urinary tract infections. acidifying agents such as hippuric acid or vitamin c may be useful in the prevention of infections.136 longterm administration of antibiotics should be avoided to reduce the risk z patients with severe bladder problems that are unresponsive to noninvasive therapy may require a chronic indwelling catheter or urinary diversion. these techniques may be required by patients who cannot perform intermittent self-catheterization. sexual dysfunction is common in both men and women with ms. women often report decreased sensation, lack of vaginal lubrication, difficulty achieving orgasm, or painful muscle spasms in the legs or pelvis during intercourse. men report diminished sensation and difficulty in achieving or maintaining an erection or experiencing orgasm. there is no simple answer to the sexual problems that occur with ms. a multidisciplinary approach is needed in which the physical and psychological aspects of sexual problems are considered. for women, treatment of muscle spasms with medications for spasticity may allow intercourse with less pain. techniques to increase vaginal and clitoral stimulation may help women experience orgasm. other methods of increasing arousal may be helpful. men are interviewed to determine whether there are other causes of erectile dysfunction. medications that may affect erectile function should be eliminated if possible. yohimbine, an a-2-adrenergic receptor antagonist, can sometimes help restore function in a patient with borderline function .138 other methods, including papaverine or phentolamine injections, a vacuum erectile device, or a penile prosthesis, may be considered.137 inappropriate affect can be a problem in patients with ms. many patients have severe mood swings that can affect both their work and their social relationships. low-dose amitriptyline or another tricyclic antidepressant is frequently helpful in controlling mood swings.13g depression is a common problem in ms.130j32,140 the suicide rate among persons with ms is estimated to be 7.5 times that of the healthy population. 130 whether the depression is a primary symptom of ms or a situational problem is not known. physicians should be alert to the possibility of depression in their patients. full-dose antidepressant medications and psychological counseling may be beneficial. tremor can be a limiting factor in many patients with ms. treatment with medications is frequently unsuccessful. agents that may be useful include clonazepam, acetazolamide, propranolol, primidone, and diazepam. 132 isoniazid has been reported to be helpful in some patients. 141 we have found clonazepam to be the most helpful of these agents in our patients, but treatment may be limited by drowsiness. a common misconception is that pain is not a symptom in patients with ms. the truth is that pain is often a problem and may be a prominent concern for patients with ms.142 this can be a primary factor in the disease, or it can be a consequence of disability associated with the disease. much of the pain reported with ms is musculoskeletal and is related to abnormal use of muscles and joints. for example, patients who use a wheelchair may experience wrist, shoulder, or elbow pain from manipulating the wheelchair. patients with paraparesis or ataxia may experience back or leg pain from poor posture and balance when walking. these problems should be treated with antiinflammatory medications and physical therapy. primary ms pain is often dysesthetic.14z the patient describes a burning sensation or perhaps even electric shock-like pain. this pain can be in any location, but it is most commonly in the lower extremities. some patients experience tic douloureux or atypical facial pain. this primary pain may be controlled with tricyclic antidepressants, phenytoin, or carbamazepine.142 in patients with refractory pain, valproic acid can be tried. 13z headaches can become a problem in patients with ms. it is not known whether these headaches are caused by ms or are a separate problem. both tension and migraine headaches are common, and treatment is similar to the treatment of headaches in patients who do not have ms. retro-orbital pain is frequently observed in patients with optic neuritis. these patients may require steroid therapy. spasticity and muscle spasms can cause severe pain. treatment of the spasticity helps the pain. many patients with ms experience cognitive abnormalities. unlike the dementia of alzheimer's disease, the cognitive deficits seem to be more scattered and tend to be retrieval deficits rather than memory loss. 143 patients can have substantial cognitive difficulties but still have normal mini-mental state examination findings. neuropsychological studies have shown that as many as 40% of patients may have some cognitive difficulties.143 these difficulties can be important in terms of disability and ability to cope with illness. only a minority of patients have severe cognitive abnormalities. mr images in patients with cognitive problems tend to show a larger number and size of lesions in the white matter of the cerebral hemispheres. frontal lesions are more common in patients with cognitive difficulties.* the corpus callosum may be thinner than normal, as seen on sagittal images.8 patients with cognitive problems should undergo careful neuropsychiatric testing. sometimes depression or anxiety can be contributing factors in these symptoms. the minnesota multiphasic personality index or the beck depression scale in conjunction with cognitive testing may be helpful in differentiating emotional problems from structural cognitive deficits. proper treatment of the anxiety or depression may lead to improved cognitive function. recognition of the areas and degree of cognitive difficulty in patients with ms may be helpful in the care of the patients. patients may be able to learn ways of working around a problem. problems with a job may be related to cognitive problems, and ways of altering the job may be found. patients may become disabled from working because of these problems. this testing also may help the family understand the need for helping the patient deal with problems that have become too difficult to handle alone. cognitive rehabilitation techniques are being tested for patients with ms in some centers. further investigation is needed to evaluate the efficacy of these techniques. careful assessment of the patient's abilities and disabilities is crucial for proper management. in many patients, chronic symptoms cannot be prevented. symptomatic therapies are often effective for alleviating the afflictions produced by ms and for allowing the patients to live a productive and comfortable life. the cause of ms is unknown. theories revolve around the idea that the disease is either autoimmune or virus-mediated. it is still reasonable to question which pathologic feature is the inciting event. much research is focused on the t cell and potential mechanisms by which these cells could initiate ms. hla associations are found in many populations; however, hla markers are neither necessary nor sufficient to confer disease susceptibility, and other factors that confer disease susceptibility are being sought. at this time there is no confirmed evidence of a viral cause of ms. investigations with in situ hybridization and pcr technology are being conducted in an attempt to identify viral nucleic acids in the cns. perhaps these techniques will assist in unraveling the pathogenesis of ms. an intriguing possibility is that molecular mimicry may be re-sponsible for the initial generation of autoreactive lymphocytes. this mechanism involves exposure to viral or bacterial antigens, which generates an immunologic response that consists of reactive t-cell populations. because t cells cross-react with myelin peptides, a potential for demyelination exists. this theoretic mechanism is known to cause demyelination in rabbits. 144 an interesting investigation of human mbp-reactive t cells demonstrates that mbp-specific t-cell clones can recognize multiple viral polypeptides presented by dr2 or dql mhc antigens. 145 this would imply that ms could be generated by exposure to any one of a number of antigenic stimuli, such as influenza viruses or herpesviruses or even bacterial antigens. selected activated t-cell populations that enter the cns could then recognize a myelin epitope and initiate the autoimmune response, which would persist long after the inciting infection was cleared. recent investigation with mr spectroscopy demonstrates that white matter outside ms plaques may be abnorma1.14" these findings may signify that there is a fundamental abnormality in the white matter. whether these findings are secondary to genetic, biochemical, autoimmune, or viral factors remains to be determined. despite the deficiencies in our understanding of disease pathogenesis, therapy for ms has advanced. phase iii clinical trials with interferon-8 and copolymer 1 have demonstrated modest but definite benefit. the mechanisms by which these drugs favorably influence the clinical course of ms remain to be elucidated. recent studies of chemotherapeutic agents suggest that control of chronic progressive disease may be a real possibility. future clinical trials will attempt to define the efficacy of and parameters for these therapies. another question that remains unanswered is whether the use of multiple-drug therapy might be beneficial in the treatment of ms. for example, combined therapy with interferon-i3lb and copolymer 1 may produce more benefit than either drug alone. in chronic progressive disease, the use of solu-medrol in combination with another immunosuppressant such as azathioprine or methotrexate also should be explored. remyelination is another topic of interest for future research. research is being conducted into the use of ivig as a remyelinating agent. in addition, oligodendrocyte transplant experiments are being conducted in canine modes and may eventually be used for human patients. research involving medications to improve the symptoms that limit the lives of many patients with ms is ongoing and should continue. 4-amino-pyridine and 2,3-diamino-pyridine are being studied as agents that may improve conduction through poorly myelinated areas. these agents may reduce double vision, improve strength, and possibly reduce tremor. more research is needed to evaluate these dm,january 1996 47 and other compounds that may improve the quality of life of many patients with ms. although the cause of ms remains a mystery, important advances have been made in the understanding and treatment of ms in the past few years. as this trend continues, we may have more diverse and effective therapies to offer patients with ms in the years to come. lectures on the diseases of the nervous system multiple sclerosis multiple sclerosis benign versus chronic progressive multiple sclerosis: magnetic resonance imaging features neuroimaging in multiple sclerosis acute vith cranial nerve dysfunction in multiple 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treatment of pathologic laughing and weeping with amitriptyline suicide in the medical patient a controlled trial of isoniazid therapy for action tremor in multiple sclerosis pain syndromes in multiple sclerosis fujinami rs, oldstone mba. amino acid homology between the encephalitogenic site of myelin basic protein and virus: a mechanism for autoimmunity molecular mimicry in t cell-mediated autoimmunity: viral peptides activate human t cell clones specific for myelin basic protein fdg-pet, mri and nmr spectroscopy of normal appearing white matter (nawm) in multiple sclerosis key: cord-336554-n8n5ii5k authors: singh, thakur uttam; parida, subhashree; lingaraju, madhu cholenahalli; kesavan, manickam; kumar, dinesh; singh, raj kumar title: drug repurposing approach to fight covid-19 date: 2020-09-05 journal: pharmacol rep doi: 10.1007/s43440-020-00155-6 sha: doc_id: 336554 cord_uid: n8n5ii5k currently, there are no treatment options available for the deadly contagious disease, coronavirus disease 2019 (covid-19). drug repurposing is a process of identifying new uses for approved or investigational drugs and it is considered as a very effective strategy for drug discovery as it involves less time and cost to find a therapeutic agent in comparison to the de novo drug discovery process. the present review will focus on the repurposing efficacy of the currently used drugs against covid-19 and their mechanisms of action, pharmacokinetics, dosing, safety, and their future perspective. relevant articles with experimental studies conducted in-silico, in-vitro, in-vivo, clinical trials in humans, case reports, and news archives were selected for the review. number of drugs such as remdesivir, favipiravir, ribavirin, lopinavir, ritonavir, darunavir, arbidol, chloroquine, hydroxychloroquine, tocilizumab and interferons have shown inhibitory effects against the sars-cov2 in-vitro as well as in clinical conditions. these drugs either act through virus-related targets such as rna genome, polypeptide packing and uptake pathways or target host-related pathways involving angiotensin-converting enzyme-2 (ace2) receptors and inflammatory pathways. using the basic knowledge of viral pathogenesis and pharmacodynamics of drugs as well as using computational tools, many drugs are currently in pipeline to be repurposed. in the current scenario, repositioning of the drugs could be considered the new avenue for the treatment of covid-19. drug repurposing is the process to identify the new indications for existing drugs and considered as an efficient and economical approach [1] . it is also known as repositioning, re-profiling, re-tasking and rescue of drugs [2] . it has been considered that 75% of known drugs could be repositioned for various diseases [1] . outbreaks of novel emerging infections such as coronavirus disease 2019 (covid19) have unique challenges in front of the health professionals to select appropriate therapeutics/pharmacological treatments in the clinical setup with very little time available for the new drug discovery [3] . further, development of a vaccine for any disease including covid-19 takes time and even if the process is put on accelerated mode it would take 18-20 months to introduce it as ready-to-use product. currently, no specific treatment is available against the new virus severe acute respiratory syndrome coronavirus 2 (sars-cov2). hence, the search for effective therapeutic agents to tackle covid-19 is vital and urgent. the discovery and licensed use of a drug come with a long-gestation period. the cost of the new drug development process amounts to more than a billion dollars extending for a period of 10-15 years [4] with the success rate of only 2.01% [5] . this creates a lag in the productivity of pharmaceutical research to develop a new drug which results in a persistent gap between therapeutic needs and available treatments [6] . considering the time and cost required for coming up with new therapies, probing the existing antiviral and other drugs against sars-cov2 is cost-effective. in recent times, repurposing of available drugs for the management of several disease conditions is increasingly becoming a popular strategy as it uses de-risked compounds with known preclinical, pharmacokinetic, pharmacodynamic profiles which can directly enter phase iii or iv clinical trial making the drug development process potentially a low-cost and relatively rapid [7] . therefore, reassessing the efficacy of licensed and experimental drugs has become go to choice of world health organization (who) and other health agencies to treat emerging health problems. drug repurposing follows mainly two concepts. one is that a single drug interacts with multiple targets, which paves the way for searching new target sites of action for the known compound [8, 9] . the other concept is that targets associated with a disease are often relevant to a number of biological processes of pathogenesis [6, 10] which paves the way for designation of a new indication for the known target. notionally, a drug that acts on these common elements can, in principle, be useful for several disorders. broadly, there are three kinds of approaches which are widely used in drug repositioning: computational approaches, biological experimental approaches, and mixed approaches. data such as gene expression, drug-target interactions, protein networks, electronic health records, clinical trial reports, and drug adverse event reports has become accessible in standardized forms. the repository of knowledge and omics data available in pharmaceutical research leads to the rise of some computational methods which are novel and exciting in the field of drug repositioning. these computational methods are capable to make a high-level integration of all the knowledge and data and help in understanding the new signaling pathways and generate novel insights into drug mechanisms, side effects, and interactions which further speed up drug discovery. a recent study presented integrative network-based systems pharmacology, methodology which quantifies the interplay between the coronavirus-human cell interactome and drug targets in the human protein-protein interaction network which help in rapid identification of repurposable drugs against sars-cov2. a study using this kind of approach was able to identify 30 potential repurposable drugs against covid-19 [11, 12] . the sars-cov2 mainly spreads through the respiratory tract [13] and affects alveolar cells. unlike, middle east respiratory syndrome coronavirus (mers-cov) which employs dipeptidyl peptidase 4 (dpp4) [14] , sars-cov and sars-cov2 adopt angiotensin-converting enzyme 2 (ace2) as receptor for entering the cell. attachment, fusion and entry of the virus are aided by spike protein which makes it an interesting target for the development of antibodies, entry inhibitors and vaccines [15] . anti-viral agents including ritonavir, lopinavir, ribavirin, interferons have been used against sars-cov and mers-cov clinically, however, clinical data is still limited [16] . currently, with the lack of effective agents against sars-cov2 as well as public-health emergency, who has identified some therapies which doctors and researchers believe are the most promising, such as a combination of two hiv drugs (lopinavir and ritonavir), anti-malarial drugs (chloroquine and hydroxychloroquine), and an experimental antiviral compound remdesivir. further, many available drugs with the intention of repurposing against covid-19 have been subjected to clinical trials [17] ( table 1) . however, the search for other agents cannot pause while waiting for the results because the demand for new effective agents is huge. human population of the twenty-first century is suffering a large-scale epidemic of highly pathogenic coronaviruses such as severe acute respiratory syndrome coronavirus (sars-cov) in 2002-03 [18] , middle east respiratory syndrome coronavirus (mers-cov) in 2012 [19] and severe acute respiratory syndrome coronavirus 2 (sars-cov2) in 2019-20. coronaviruses are pleomorphic, enveloped, positive sense, 27-32 kb large rna viruses with typical crown-shape glycoprotein spikes (peplomers) that cause respiratory and enteric diseases in humans and other animals [20] . very high recombination rates lead to constant transcription errors and rna-dependent rna polymerase (rdrp) jumps in coronaviruses [21] give them a chance to develop into diverse zoonotic pathogens such as sars-cov2. sars-cov2 is a positive-sense single-stranded rna virus classified as a strain of the species sars-cov, (genus beta-coronavirus; subgenus sarbecoronavirus; subfamily orthocoronavirinae; family coronaviridae) which earlier in 2002-03 caused an outbreak of sars in guangdong, china [22] . overall genome sequence of sars-cov2 showed 79.5% similarity with sars-cov and interestingly, 96.2% similarity with bat coronavirus ratg13, suggesting its origin from a bat virus [23, 24] . though not certain, yet it is suspected that the introduction of this new coronavirus to humans might have been facilitated by an intermediate host, the pangolins [25] . as per who report, a case of pneumonia of unknown causative pathology from wuhan city of china was first time reported to the who country office on 31 december 2019. the outbreak of the coronavirus-associated acute respiratory disease throughout the world was named as covid-19 and it was classified as 2019-ncov (sars-cov2) [26] . the classification and naming of the virus were done by the coronaviridae study group of the international committee on taxonomy of viruses. novel coronavirus genome sequencing by china was publicly available on the global in the current scenario of lacking efficient and specific treatments for sars-cov2 infections and the urgent need to restrain the pandemic, drug re-tasking appears to be the most suitable tool to find out the best therapeutic option for covid-19 [27] . the mechanisms of infection by the sars-cov2 are not clear yet, however, it is genetically similar to sars-cov and other coronaviruses [28] . hence the common mode of pathogenicity is being explored for targets of treatment. the therapeutic targets depending on the common mode of pathogenicity can be classified as virus-related targets and host-related targets. replication of sars-cov2 depends directly on the key enzyme rdrp. it is interesting to note that potential drug targets protease and polymerase for sars-cov2 and sars-cov are highly conserved with 96% and 97% overall identity. therefore, blockers developed against the sars may act as good therapeutic candidates to bind protease or polymerase sites against sars-cov2 (gisaid, 2020) ( fig. 1 ). on the basis of current knowledge about the use of remdesivir in sars-cov2 infection, remdesivir is considered as the potential drug candidate for repurposing against the covid-19. remdesivir (gs-5734) is a nucleoside analog originally developed against ebola viruses by gilead sciences inc, a usa based biopharmaceutical company ( table 2) . though the drug failed to show effect against ebola, the preliminary results from in-vitro and in-vivo preclinical studies as well as case reports indicate its efficacy against sars-cov2. recently, in vero e6 cells, remdesivir has been shown to block the viral infection at low concentration (ec 50 = 0.77 μm) with high selectivity index (si > 129.87). the ec 90 value (1.76 µm) was also low enough to be achieved in non-human primate models [29] . it also efficiently inhibited sars-cov2 infection in human liver cancer huh-7 cells [23] . in rhesus macaques, the drug showed therapeutic and prophylactic efficacy against both sars and mers coronaviruses, indicating its potential against diverse coronaviruses including sars-cov2 [30] . similarly, in a ces1c-knockout mouse model of sars-cov infection, remdesivir in both prophylactic and therapeutic use significantly reduced lung viral titers, though the survival and lung pathology were not improved [31] . treatment with intravenous remdesivir on day 7 of hospital admission, clearly improved the clinical condition from the next day in a 35-year-old covid-19 patient in washington, usa [32] . in italy, remdesivir has been used (200 mg every 12 h as a loading dose followed 100 mg every 12 h for 10 days thorough intravenous route) with other supportive therapy in the clinical management of covid-19 patients presented with a range of modified early warning score (mews) from less than 3 to more than 4 [33] . in a recent report, clinical improvement in 36 of 53 patients (68%) of severe covid-19 patients has been observed with the compassionate-use of remdesivir in a cohort study [34] . according to another study remdesivir was superior over the placebo in shortening the time to recovery in adult patients hospitalized with covid-19. in the trial that was conducted at 60 sites and 13 subsites in different parts of the world, mortality rate was 7.1% with remdesivir and 11.9% with placebo by 14 days in 1059 patients in which 538 were in remdesivir group and 521 were in the placebo group [35] . another trial, however, suggests differently, that remdesivir has no such statistically significant clinical benefits, although, patients who were administered with remdesivir showed a faster clinical improvement in numerical terms, with symptom duration of 10 days or less in a study of 237 patients in which 158 patients received remdesivir and 79 (one withdrew) were on placebo in a randomised, double-blind, placebocontrolled, multicentre trial at ten hospitals in hubei, china [36] . another clinical trial done with remdesivir in severe covid-19 patients without mechanical ventilation support indicated no significant difference between 5-day and 10-day course of remdesivir therapy, however, by day 14, a clinical improvement was noticed in 64% of patients in the 5-day group and in 54% in the 10-day group at 2 points or more on the ordinal scale out of 7-point ordinal scale [37] . being a nucleotide (adenosine) analog, remdesivir gets incorporated into the replicating genome of the virus after being converted into its triphosphate form. the triphosphate forms compete with adenosine triphosphate (atp) to act as a substrate of rdrp and have been found to cause significantly efficient incorporation as compared to atp. remdesivir adds three more nucleotides before terminating the growing rna chain [38] . the extra three nucleotides may protect the inhibitor from removal by the viral 3′-5′ exonuclease activity [39] , contributing to the lack of acquiring resistance. the pharmacokinetics, metabolism and distribution of remdesivir have been studied in non-human primates, previously. in rhesus monkeys, 10 mg/kg dose yields a half life (t 1/2 ) of 0.39 h with fast systemic elimination. the active metabolite of remdesivir, 1′-cyano-substituted adenine c-nucleoside ribose analogue (nuc) then appears which produces antiviral activity [40] . however, the drug is parenterally administered through intravenous route and is not expected to be given to mildly infected patients, though potent action is expected in mild infection. it is under clinical trial in china and usa against covid-19 by 15th of april, 2020 (nct04252664 and nct04257656). however, seven clinical trials are underway on remdesivir to evaluate its efficacy on sars-cov2 infection (https ://www.gilea d.com/purpo se/advan cing-globa l-healt h/covid -19/remde sivir -clini cal-trial s). the results of nct04257656 clinical trial showed that intravenous remdesivir was adequately tolerated by covid-19 patients [36] . in the third trial (nct04292899) with the severely infected covid-19 patients, with the use of remdesivir, common adverse effects were observed such as nausea, acute respiratory failure, increased alanine aminotransferase (alt) and constipation [37] . in all these studies ramdesivir was administered intravenously as 200 mg sid on day 1 and followed by 100 mg sid for the subsequent period. virus enters the cell by fusion of the viral spike proteins with cellular ace2 receptor, followed by ace2 downregulation. angiotensin receptor blockers (arbs), angiotensin-converting enzyme inhibitors (aceis) and statins increase ace2 expression, hence may have efficacy in this condition. 3. fusion is followed by endocytosis of the virus, where low endosomal ph helps in lysis of the viral structural proteins. disruption of this acidic environment by diprotic bases like chloroquine and hydroxychloroquine may produce an antiviral effect. 4, 5. release of nucleic acid (na) into the cytoplasm and translation of the viral proteins using host ribosomes, 6. proteolysis by viral main protease enzyme makes functional proteins e.g. rna dependent rna polymerase (rdrp). thus, inhibition of the main protease enzyme by inhibitors like lopinavir, ritonavir and darunavir, may have efficacy against the virus. 7. rdrp is essential for replication and transcription of the virus. rdrp inhibitors, remdesivir, favipiravir, ribavirin and arbidol may be effective against coronaviruses. 7, 8. subsequent translation and proteolysis into structural proteins followed by packaging makes intact virions, which get exocytosed (9) from the cell as per the information obtained from the chinese news channel by dong and co-workers, this drug got an approval against the sars-cov2 infected patients in china on 15th february, 2020 since it had drastically attenuated the illness of the sars-cov2 infected patients [41] . favipiravir (6-fluoro-3-hydroxy-2-pyrazinecarboxamide, t-705 also table 2 chemical structure of pharmacological agents reviewed marketed as avigan) was developed by a japanese firm, toyama chemical co., ltd. and has been approved in japan for influenza since 2014 ( table 2 ). the drug effectively inhibits the enzyme rdrp. in vero e6 cells this drug showed an ec 50 of 61.88 µm and selectivity index of more than 6.46 against sars-cov2 [29] . though this concentration against sars-cov2 is very high, the drug may be tested in an animal model based on its performance against ebola virus. remarkably this drug had shown 100% efficacy against ebola in a mice model although it had a very high ec 50 in vero cells [42] . randomized trials are being conducted for this drug in combination with other drugs against coronaviruses (favipiravir + interferon-α, chictr2000029600, favipiravir + baloxavir, chictr2000029544). favipiravir is a nucleoside precursor which inhibits the broad range of influenza virus strains, however, it shows antiviral activity through its ntp form (converted into an active phosphoribosylated form, t-705 rtp) via direct inhibition of the rdrp activity of influenza a virus polymerase and it has also shown lethal mutations within the viral genome [43] . nevertheless, the exact mode of action, precise molecular mechanism and its interaction between the nucleotide and the viral polymerase could be investigated in the sars-cov2 infection. favipiravir exerts its antiviral action in a dose-dependent manner [44] . its oral bioavailability is close to 100% and has a short half life of 2-5.5 h [45, 46] . in humans, the plasma protein binding of favipiravir is 54%. favipiravir undergoes metabolism in the liver mainly by aldehyde oxidase (ao) and partially by xanthine oxidase (xo) and the inactive oxidative metabolite (t-705 m1) is excreted by kidneys. a study reported that in pichindé arenavirus infection the kinetics of absorption, elimination and time to maximum drug concentration is altered. the t-705 m1 levels were higher in the infected animals [47] . further, favipiravir concentration may be increased by drugs those undergo metabolism through ao such as raloxifene, tamoxifen, estradiol, cimetidine, felodipine, amlodipine, verapamil, propafenone, amitriptyline, zaleplon, citalopram, sulindac and famciclovir. concomitant administration of acetaminophen and favipiravir showed increased area under curve (auc) of former drug possibly due to inhibition of the sulfate transferase by the latter drug [46] . the drug did not show any toxicity at the oral dose of 500 mg/kg/day for 10 days in guinea pigs [48] . this can be converted to 108 mg/kg of human equivalent dose [49] which is far greater than the dose prescribed for covid-19 on first day i.e. 53 mg/kg/day (1600 mg bid on the first day) (https ://www.clini caltr ialsa rena.com/comme nt/influ enza-favip iravi r-covid -19/). however, use of this drug may be approved with the availability of more number of clinical results. ribavirin, a broad-spectrum antiviral drug, is a guanosine analog approved for treating hepatitis c virus in combination, and respiratory syncytial virus as monotherapy. effect of this drug has been assessed in patients with sars [50] and mers [51] (table 2) . against sars-cov2, it has very high ec 50 of 109.50 μm and selectivity index more than 3.65 in vero cells. ribavirin in its monophosphate form inhibits host inosine monophosphate dehydrogenase (impdh) enzyme that controls intracellular guanosine triphosphate (gtp) pools [52] . exhaustion of intracellular gtp pool indirectly inhibits viral rdrp enzyme. it also interferes with mrna capping. ribavirin at a dose rate of 500 mg 2-3 times/day in combination with other drugs such as lopinavir/ritonavir or interferon (ifn)-α through intravenous route for not more than 10 days made the sars-cov2 infected patients more resistant to respiratory distress syndrome as well as death [41] . the oral bioavailability of ribavirin is 52%, which is due to modest first-pass metabolism in liver [53] . estimated halflife is 3.7 h [54] . ribavirin-induced hemolytic anemia is a most commonly reported adverse effect and frequently it requires dose reduction [55] . further, close monitoring of renal impairment in terms of creatinine clearance during therapy is required. old age, decreased renal function, low body weight and female gender are other risk factors to be considered during ribavirin therapy [56, 57] . animal studies have shown teratogenic potential of ribavirin. therefore, exposure during pregnancy should be avoided. other less common yet pertinent adverse effects are bronchospasm and pulmonary edema on inhalation [43, 57] . neutropenia, thrombocytopenia, skin rashes, anorexia and depression are some minor adverse effects of ribavirin that need to be monitored in the sensitive patients [58] . in a recent clinical trial with combinations of ribavirin + interferon-alpha, lopinavir/ritonavir + interferon-alpha and ribavirin + lopinavir/ritonavir + interferon-alpha in patients with mild to moderate covid-19 showed that ribavirin plus lopinavir/ritonavir combination showed a significant increase in gastrointestinal adverse effects [59] . the viral rnas get translated into polypeptide chains which get cleaved into functional proteins before packing into virions. the viral main proteases are responsible for the cleavage of these polypeptide chains [60] . sars-cov2 protease has 96% overall similarity with sars-cov [61] . protease inhibitors used in hiv-1 therapy are shown to be effective against sars-cov [62] . in-silico and in-vitro approaches have been used to validate the inhibition of sars-cov2 protease by hiv-1 protease inhibitors [63, 64] . numerous protease inhibitors are approved by fda for use in hiv therapy. the agents available from this class include saquinavir, amprenavir, indinavir, nelfinavir, ritonavir, and lopinavir. few of them are being considered against sars-cov2 (fig. 1 ). this drug combination is available under brand name kaletra and was developed by abbott laboratories, usa. this drug was approved by fda in the year 2000 as an anti-retroviral for the treatment of hiv patients. lopinavir is rapidly degraded in the human body by the host proteases, hence is given with ritonavir (another protease inhibitor) at a lower dose, which helps lopinavir remain active for a longer time by inhibiting the metabolizing enzyme cytochrome p450 [65] (table 2) . coronavirus main proteases are cysteine proteases whereas hiv main proteases are aspartic proteases. nonspecific protease inhibition by protease inhibitors used in hiv therapy has been found effective against sars-cov. lopinavir has comparable binding energies against the sars-cov2 and hiv-1 proteases [66] . in sars-cov2 patients treated with lopinavir-ritonavir, a significant virus clearance has been achieved [67, 68] . a 47-year old patient, who failed to respond to methylprednisolone and interferon therapy, got quick improvement with additional lopinavir and ritonavir tablets therapy [69] . in 36 paediatric patients between the age of 0-16 years with confirmed covid-19 from three hospitals in zhejiang, china, use of lopinavir-ritonavir (syrup twice a day) along with interferon α to 14 patients (6 patients needed oxygen inhalation but not sure whether it included lopinavir-ritonavir group) showed a mean of hospital stay time of 14 days and all were cured [70] . based on these initial successful reports, sars-cov2 main protease has been docked for 1. 3 billion protease inhibitor compounds [71] . also, lopinavir-ritonavir has been included in solidarity trial (nct04330690). however, in a recent clinical trial with 199 severely ill patients with confirmed sars-cov2 infections, lopinavirritonavir treatment did not improve the time to clinical improvement and mortality rate beyond standard care and further, some patients also showed adverse drug effects such as gastrointestinal disturbances [72] . in a study on four covid-19 patients treated with western (lopinavir 400 mg/ ritonavir in a ratio of 400 mg to 100 mg for q12 h through oral route), arbidol (0.2 g, three times in a day through oral route), and chinese traditional medicine shufeng jiedu capsule (sfjdc, 2.08 g, three times in a day through oral route) combination for 6-15 days, it has been observed that out of the two mild and two severe sars-cov2-infected pneumonic patients, three patients showed significant improvement in pneumonia associated symptoms and the remaining patient with severe pneumonia has also shown signs of improvement till the date of reporting [73] . most hiv protease inhibitors show poor bioavailability. they are extensively metabolized by microsomal cyp3a4 enzymes. other agents that induce or inhibit these metabolizing enzymes influence their effectiveness. side effects associated with the use of protease inhibitors include diarrhea, vomiting, diabetes, hypertriglyceridemia, and hypercholesterolemia. it also could cause severe hepatic damage [74] . therefore, a lot of clinical and experimental study regarding the use of lopinavir-ritonavir is required to reach a conclusive statement. the most common adverse effect of ritonavir/lopinavir is diarrhea and gastrointestinal disturbance. elevated liver enzymes, dyslipidemia, asthenia, headache and skin rashes are some minor side effects [75] [76] [77] . ritonavir/lopinavir coadministration causes mild hepatotoxicity (elevated alanine aminotransferase, alt) [78] . however, sole use of ritonavir at a higher dose (600 mg/bid) may increase the risk of severe hepatotoxicity [79] . a rarely observed adverse effect with ritonavir is retinal pigment epitheliopathy. the risk factors for the retinopathy are high dose and hepatic impairment [80] . darunavir is a second-generation non-peptide protease inhibitor effective against hiv-1. it has a distinct chemical structure that enhances binding affinity and reduces dissociation rate, making it more potent than the other protease inhibitors [81] (table 2 ). using computational drug design methods, darunavir was identified as one of the promising hits for inhibition of chymotrypsin-like protease of sars-cov2 [82] . results of a structural analysis showed no binding of darunavir to sars-cov2 protease (https ://www.eacso ciety .org/home/covid -19-and-hiv.html). anyhow, recently in shanghai, in-silico and an enzyme activity test based drug screening revealed 30 agents with potential antiviral activity against sars-cov2 including darunavir (https ://www. simm.ac.cn/xwzx/kydt/20200 1/t2020 0125_54944 17.html). interestingly, therapeutic doses of darunavir are reported to be too low to cause cytotoxic effects, affording a wide margin of safety [81] . in an in-vitro study, darunavir at 300 micromolar concentration was found to inhibit sars-cov2 virus replication by 280 times in comparison to the untreated group (https ://www.sd.china news.com/2/2020/0205/70145 .html). further, darunavir has been used (600 mg tablet every 12 h) along with other anti-viral drugs and supportive therapy in the clinical management of covid-19 patients presented with a range of mews from less than 3 to more than 4 in italy [33] . darunavir is rapidly absorbed after oral administration and has a terminal elimination half-life of 15 h. approximately 95% of the drug is plasma protein bound and metabolized exclusively by cyp3a4. therefore, co-administration of small doses of ritonavir (cyp3a4 inhibitor) increases the bioavailability of darunavir. combination therapy with other cyp3a4 inhibitors (e.g. statins) with darunavir/ritonavir requires caution or is even contraindicated [83, 84] . a recent study correlated the daurnavir use with increased risk of myocardial infarction in hiv patients and concludes that cardiovascular disease (cvd) risk increases with darunavir exposure. therefore, it may be used cautiously in patients with underlying cardiac diseases [85] . before, regular use of this drug, more pharmacological profile may further be investigated during the use in covid-19 patients. the pattern recognition receptors in immune cells recognize the viral pathogen-associated molecular pattern (pamps) to stimulate antiviral interferon responses in the host [86] . the secreted interferons activate hundreds of interferon-stimulated genes which encode proteins with profound effects against the virus (fig. 1) . the interferons (ifns) are antiviral molecules classified into type i (ifnα, ifnβ, ifnω, and ifnτ) and type ii (ifnγ). ifnα plays a critical role in innate immunity against viral infection which prompts its use in the treatment of many clinical viral infections. the recombinant ifnα is interferon alfacon-1. the pegylated types are pegylated ifnα-2a and pegylated ifnα-2b [87] . pegylated interferon alfa-2b acts to target b cells through host interferon receptor, ifnar1 signalling and enhances immune response against viral infections [88] . recombinant human ifnα-2b has been shown to possess wide antiviral spectrum, low toxicity and high therapeutic index in vitro. quantitative reverse transcriptasepolymerase chain reaction (rt-pcr) results revealed antiviral effect of recombinant human ifnα-2b on respiratory viruses such as influenza b virus, parainfluenza virus, respiratory syncytial virus and coronavirus which was stronger in comparison to the effect of ribavirin [89] . in another study, ifnα-2b administered by nasal spray reduced positive rates of immunoglobulin m (igm) antibody against all four respiratory viruses (parainfluenza virus, influenza b, adenovirus and respiratory syncytial virus) possibly suggesting the lower virus titre due to ifnα-2b [90] . in the rhesus macaque, ifnα-2b with ribavirin showed very good effect against beta-coronavirus emerged in saudi [91] , however, was unsatisfactory in humans [92] . in china, intranasal ifnα (5 × 10 6 u) twice a day in combination with ribavirin is one of the guidelines for the treatment of covid-19 patients [41, 93] . it was further showed that the infection rate of sars-cov2 was decreased by ifnα-2b sprays [94] . ifnα-2b has demonstrated potent anti-viral activities against respiratory viruses and may serve for the prevention and treatment of sars-cov2 as well. nevertheless, thorough evaluation in appropriately designed randomized trials is recommended before forging on. peg-ifnα-2b is a linear 12 kda molecule and susceptible to hydrolysis. it is absorbed quickly and distributed widely. after administration peg-ifnα-2b gets hydrolysed and the free ifnα-2b circulates in the body. most of the free ifnα-2b excreted solely through kidneys. therefore, it requires dose adjustment in patients with renal impairment. further, the clearance of peg-ifnα-2b decreases after repeated dosing. therefore, it is administered according to body weight. conversely, the peg-ifnα -2a is a 40 kda branched chain molecule which is absorbed more slowly and has poor tissue distribution. peg-ifnα -2a has long half-life. therefore, it is used at a fixed dose of 180 μg per week for the treatment of hepatitis c virus infection. peg-ifnα-2a is metabolized by both the kidneys and liver, therefore this drug does not require a major dose modification [95] . number of adverse events was recorded with peg-ifnα therapy. dizziness, headache, depression, fatigue, insomnia, alopecia, myalgia, arthralgia, pyrexia, anorexia are the most common constitutional symptoms observed with peg-ifnα-2a and peg-ifnα-2b therapy in various other diseases. hematologic adverse events such as leucopoenia, thrombocytopenia and myelosuppression, thyroid disease, lung disease and retinopathy are the other adverse events recorded in the patients receiving peg-ifnα-2a/ peg-ifnα-2b [96] [97] [98] . dose limiting, mild injection site reactions/inflammations were observed commonly in peg-ifnα -2b therapy [96] . most of the adverse events are well tolerated and become less severe during the progression of therapy. the neuropsychiatric adverse effects were observed in patients undergoing interferon-α therapy and may require timely medical interventions [99] . in the case of severe events, discontinuation and dose reduction will help to overcome these adverse events [96] . lopinavir-ritonavir along with interferon beta is undergoing clinical trial (miracle) against mers in saudi arabia wherein a total of 76 patients have enrolled till jan 2020 [100] . interferons are the antiviral weapons of the body and coronaviruses are known to reduce the host antiviral immunity by suppressing the production of interferons. so, replacement therapy with interferons or interferon inducers has the potential to reduce the viral load in the body. they augment the host response to the viral infection. lopinavir-ritonavir-interferon-β1b treatment improved the clinical findings and lowered the lung viral load in mers-affected common marmosets [101] . results of a recent clinical trial (nct04276688) on covid-19 patients showed the safety and efficacy of this combination. adverse events like selflimited nausea and diarrhoea were recorded in this study. however, there was no significant difference in the adverse effects between the combination group and ritonovir/lopinavir alone (control group) [102] . the coronaviruses enter the cell by two ways, (1) endocytosis, virus is taken up into the cell along with the endosomes, (2) fusion of the viral spike protein with the cell surface receptor ace2 [103] , the latter being the predominant pathway of virus entry [104] . blockade of entry pathways may be effective targets for treatment (fig. 1 ). chloroquine, primarily known for its anti-plasmodium actions, has antiviral activity as well. this drug originally derived from cinchona plant is now largely a synthetic drug (4-amino quinoline) discovered by bayer laboratories. chloroquine and its analogs are potent inhibitors of most coronaviruses [105] (table 2) . chloroquine and hydroxychloroquine are weak diprotic bases. these drugs take a similar pathway like the virus and concentrate in the endosomes increasing the ph of the endosomal fluid. the acidic ph of the endosomes is necessary for the optimal activity of viral enzymes responsible for proteolysis and post-translational modification of nascent proteins. disruption of acidic ph thus blocks the replication and lifecycle of the virus [106] . in addition, the drug is known to interfere with the glycosylation of the host receptor for the virus, ace2. faulty terminal glycosylation may affect the binding and subsequent entry of the virus into host cells [107] . cell culture studies in african green monkey vero e6 cells indicate significantly higher potency for chloroquine compared to hydroxychloroquine [108] . chloroquine has ec 90 value of 6.90 μm against the sars-cov2 in vero e6 cells, which can be clinically achievable after administration of 500 mg as shown in rheumatoid arthritis patients [109] . a safe dosage of 6-6.5 mg/kg per day of hydroxychloroquine could yield serum levels of 1.4-1.5 μm in humans [110] . it is speculated that with a safe dosage, hydroxychloroquine could achieve concentration in the above tissues to inhibit sars-cov2 infection. hydroxychloroquine phosphate (400 mg tablet every 12 h as a loading dose followed 200 mg tablet every 12 h for 10 days) or chloroquine phosphate (250 mg of two tablet every 12 h for 10 days) along with other anti-viral drugs and supportive therapy have been used in the clinical management of covid-19 patients presented with a range of mews from less than 3 to more than 4 in italy [33] . chloroquine and hydroxychloroquine have been considered for solidarity trial (nct04330690). hydroxychloroquine has shown side effects such as prolonged qt interval and heart failure, though controversy exists. recently, who stopped hydroxychloroquine arm of the solidarity trial to find an effective covid-19 treatment. this recommendation was developed on the basis of data obtained from solidarity trial (including the french discovery trial data and uk's recovery trial data). these trials showed that hydroxychloroquine did not result in the reduction of mortality of covid-19 patients who were hospitalized when compared with standard care (briefed on 17 june 2020 by who). use of chloroquine for sars-cov2 asks for a high dose but an overdose of chloroquine has been reported to cause poisoning and death [111] . in comparison, hydroxychloroquine is safer with 40% less toxicity in animals [112] . oral absorption of chloroquine and hydroxychloroquine in humans is efficient. both the drugs distribute similarly in different tissues with high concentrations in the liver, kidney, lungs and spleen [113] . chloroquine is two to three times as toxic in animals as hydroxychloroquine [112] . the acute toxicity of chloroquine causes death due to cardiac and respiratory arrest [111] . adverse effects of chloroquine/hydroxychloroquine therapy at the therapeutic doses include retinopathy, myopathy, electrocardiographic changes, bleaching of hair, pruritus, headaches, dizziness and gastrointestinal upset [114] [115] [116] . hydroxychloroquine retinal toxicity in the patients is far more common in patients taking this drug for greater than 5 years with the overall prevalence of 7.5% [117] . a study showed even with the recommended therapeutic dose of hydroxychloroquine produced bilateral maculopathy and it was attributed to the differential susceptibility of the retinal epithelium to hydroxychloroquine [118] . hydroxychloroquine and chloroquine are orally well absorbed and show 70-80% oral bioavailability. chloroquine is 60% bound to plasma proteins and distributed extensively. following administration, chloroquine is rapidly dealkylated to pharmacologically active desethylchloroquine and bisdesethylchloroquine. metabolism of hydroxychloroquine is similar to chloroquine except for a third metabolite desethylhydroxychloroquine which is also produced during metabolism. both hydroxychloroquine and chloroquine have prolonged half-lives, between 40 and 50 days, and low blood clearance by kidneys and liver. for both chloroquine and hydroxychloroquine, approximately 40-60% is excreted as an unchanged or metabolized drug through the kidneys, 8-25% is excreted in an unchanged or changed form in the feces, 5% is sloughed off through the skin, and 25-45% is stored long term in lean body tissues [119] [120] [121] [122] . hydroxychloroquine should be cautiously used in patients with known hepatic or renal dysfunction. the co-administered drugs with hydroxychloroquine excreted via liver/ kidney may interact with hydroxychloroquine and modulates its pharmacokinetics and toxicity. hydroxychloroquine has been reported to cause severe hypoglycaemia when coadministered with oral hypoglycaemic drugs. there have been few reports of mild to severe hepatic failure in patients with hydroxychloroquine treatment [117] . racial difference in toxicity has also been reported wherein the incidence of pericentral maculopathy was common in asian (50%) than caucasian (2%) patients [123] . further, the use of chloroquine and hydroxychloroquine may be warranted in prophylaxis strategy as well as in covid-19 patients with more number of clinical trials. arbidol, an indole-derivative, also known as umifenovir is a potent broad-spectrum antiviral agent. this drug has shown activity against a wide range of enveloped and nonenveloped viruses [124] (table 2) . it is effective against numerous pathogenic respiratory viruses and relatively very safe for use [125, 126] . arbidol is an approved therapeutic agent against influenza in russia and china [127] . arbidol and arbidol mesylate were reported to act directly on viral replication of sars-cov at an early stage in vitro [128, 129] . the anti-viral mechanism of arbidol against influenza a and b involves viral fusion inhibition by hindering the hemagglutinin fusion machinery with the membrane, thus blocks virus entry into the cell [127] . arbidol is one of the drugs in clinical trial phase 4 for pharmaceutical interventions of covid-19 and treatment of covid-19 patients with arbidol leads to a reduction in the mortality rate and increase in the recovery rate [130, 131] . arbidol treatment coupled with lopinavir/ritonavir reckoned to retard the development of pulmonary lesions concurrently reducing the respiratory and gastrointestinal covid-19 viral load thus lowering the transmission [132] . encouragingly, seasonal prophylaxis with arbidol reduced influenza morbidity in patients with asthma and copd during epidemic [133] . four cases with mild to severe sars-cov2 pulmonary symptoms were subjected to antiviral therapy consisting of arbidol, lopinavir/ritonavir, and shufeng jiedu (traditional chinese medicine) along with supportive care. following medication, three patients showed a notable reduction in pneumonia-related manifestations and two of them were discharged after testing negative for sars-cov2 [73] . in covid-19 patients, reduction in fever and cough; improvement in chest computed tomography (ct) and clinical status among the arbidol, lopinavir/ritonavir and control group remained statistically indifferent. however, arbidol was better tolerated by patients whereas test subjects administered with lopinavir/ritonavir experienced adverse events during the follow-up period [134] . the half-life of arbidol is between 17 and 21 h and 40% of the total drug excreted unchanged in feces. arbdiol conjugation with glucuronide and sulfonation is evident. the major phase i enzyme involved in its metabolism was cyp3a4, therefore, a possible interaction with cyp3a4 inducers/ inhibitors may happen [135] . the drug has oral lethal dose (ld50s) of 340-400 mg/kg in mice, and > 3000 mg/kg in rats and guinea pigs. intravenous ld50s are 109 mg/kg in mice and 140 mg/kg in rats. in long term animal studies, it showed no adverse effects with 10-50 times of human dose and no developmental toxicities were observed [127] . it has been noticed that sars-cov2 binds the ace2 receptors similar to the sars coronavirus [23] . covid-19 is associated with the acute respiratory distress syndrome (ards) and higher activity of ace2 leads to attenuation in ards [136, 137] . ace2 expression is downregulated in covid-19 patients [138] . it is a general observation throughout the world that aged persons affected with covid-19 suffer from high mortality. association between covid-19 infection and the process of chronological aging has been understood with the presence of two host receptors cd26 and ace2 which are associated with senescence. the major pathway of virus entry into the host in case of sars-cov and sars-cov2 is through the target cell ace2. spike proteins of the virus attach to the cell surface ace2 expressed in epithelial cells of the oral mucosa, lungs, intestine, blood vessels and kidney. angiotensin receptor blockers (arbs) which inhibit the action of ace, an isoform of ace2, are known to increase the expression of ace2 [139] (fig. 1; table 2 ). the patients with diabetes and cardiovascular diseases regularly take ace inhibitors and arbs. hence, they remain under continuous risk of sars-cov2 infection. however, experimental studies with ards indicate a higher level of ace2 reduces the severity of the disease [137] . increased ace2/ace ratio may improve the host response to viral infection by correcting the endothelial dysfunction common to most viral infections [140] . experimental and clinical studies are needed urgently on this aspect for repurposing of commonly used arbs or ace inhibitors (aceis). arbs are well-tolerated drugs with minimal side effects in the population. however, a lot of patients from south america, central america and spain, had stopped or intended to interrupt their treatments with anti-hypertensive drugs like aceis such as enalapril or arbs such as losartan fearing the risk of sars-cov2 infection [141] . however, another school of thought provided alternative suggestions about the use of renin-angiotensin-aldosterone system (raas) inhibitors. they suggested that though ace2 expression may be enhanced with the use of raas inhibitors, sudden withdrawal of these drugs may be responsible for higher risk in patients of covid-19 already affected with cardiovascular illnesses. therefore, the use of raas inhibitors should continue in patients with covid-19 under continuous observation [138, 142] . out of 42 covid-19 patients taking antihypertensive drugs, 17 patients who were treated with aceis/arbs showed less mortality in comparison to patients taking drugs other than aceis/arbs in shenzhen third people's hospital, china [143] . aceis and arbs may improve the clinical condition of the covid-19 patients in a clinical setting by maintaining a low level of il-6 level in peripheral blood and through increment in a cluster of differentiation cd3 and cd8 t cell counts in peripheral blood and decreased the peak viral load [143] . contrary to the previous report, another retrospective study from the union hospital of wuhan, china done on 112 patients suggested that acei/arbs medication has no difference in the critical group and general group and further, did not show any effect on the morbidity and mortality of covid-19 patients associated with cardiovascular diseases [144] . it is reported that ace inhibits the formation of ang ii in the presence of aceis; therefore, these prevent the negative effects induced due to at1r as well as positive effects derived from the ang ii binding with at2r and further, its transformation into ang-(1-7) [145] . therefore, it could be assumed that the use of aceis leads to the protective effects in the lung in covid-19 patients. angiotensin receptor blockers are the most commonly used drugs for hypertension and related cardiac problems. in general, aceis and arbs have few interactions with ritonavir [146, 147] . generally, arbs are well tolerated and the frequency of adverse reactions is less than 2%. there are no specific considerations for use in patients with hepatic and renal impairment [148] . arbs are structurally related to losartan (except eprosartan) but the individual members exhibit diverse pharmacokinetic properties. their bioavailabilities vary from 13-60% and half-lives are between 2 and 24 h. they are highly plasma protein bound (90-100%) and mostly metabolized and eliminated by the liver and, therefore, can be safely used in mild to moderate renal failure without any dose adjustment. however, losartan should be started with a lower dose in hepatic impairment and telmisartan should be avoided in case of renal impairment and congestive heart failure/digoxin therapy [149, 150] . statins, the lipid-lowering drugs, have shown pleiotropic activity through anti-inflammatory and immunomodulatory properties to prevent acute lung injury in different experimental and clinical conditions; therefore, it may be used as re-tasking drug for the covid-19 patients [151] (table 2) . statins are commonly taken for a lifetime to prevent coronary artery diseases. studies have reported that these drugs increase the ace2 expression [152] . ace2 cleaves ang ii, a peptide which promotes endothelial dysfunction and cardiovascular diseases, and produces ang-(1-7) which counters the effects of ang ii [153] . stimulation of ace2/angiotensin-(1-7)/mas and angiopoietin/tie-2 signaling axes help restoring viral infection-induced endothelial dysfunction and maintain the homeostasis of the patients [154] . ace2 activity has shown to be up-regulated with the use of arbs and atorvastatin [152, 155] (fig. 1) . statins being immunomodulatory have been hypothesized to work against mers coronaviruses [156] . however, in animal models of sars and mers infections, reduced expression of the adapters, tirdomain-containing adapter-inducing interferon-β (trif) or myeloid differentiation primary response protein (myd) 88 causes severe respiratory disease leading to death. hence, the use of statins, which can further suppress myd88 signaling, may exacerbate the disease condition [157] . fungus derived statins (lovastatin, pravastatin and simvastatin) have elimination half-lives of 1-3 h and other synthetic compounds have elimination half-lives ranging from 1 h for fluvastatin to 19 h for rosuvastatin. bioavailability of statins varies from 5-80% and 6-30% of the absorbed statins. majority of satins are metabolized by the liver and the biliary excretion is the predominant route of excretion. pravastaitn and rosuvastatin are excreted mostly unchanged by liver and kidneys. all statins are extensively bound to plasma proteins (> 90%) with the exception to pravastatin which is only 50% bound to plasma proteins [158] . myopathy and rhabdomyolysis are the most frequent adverse effect of statins. other common adverse effects include hepatotoxicity, peripheral neuropathy, cardiac toxicity, cognitive dysfunction, cataracts, diabetes mellitus and autoimmune necrotizing myopathy [159, 160] . most of the statins are cyp3a4 substrates and the inhibitors of this enzyme may increase blood levels of statins and therefore associated with adverse effects [161] . statins have potential interactions with the protease inhibitor drugs and they are contraindicated in combination therapy [162] . usfda warns using atorvastatin, lovastain, rosuvsatin, pravstatin, simvastatin with antiviral protease inhibitor drugs (for list please see https ://www.fda.gov/drugs /drug-safet y-and-avail abili ty/fda-drug-safet y-commu nicat ion-inter actio ns-betwe en-certa in-hiv-or-hepat itis-c-drugs -and-chole stero l#dose). in this case dose reduction and therapeutic drug monitoring will reduce the occurrence of adverse effects. tocilizumab is a drug used against rheumatoid arthritis as well as cytokine release syndrome/systemic inflammatory response syndrome. this drug was introduced in japan in the year 2008 and subsequently in the european union (trade name roactemra) in the year 2009. later in the year 2010, it was used in the usa (actemra) and this drug is an antihuman monoclonal antibody of the immunoglobulin g1k subclass [163] . this drug does not act on the virus but it acts to reduce the cytokine response of the host. tocilizumab is a recombinant humanized monoclonal antibody which is responsible to bind the human il-6 receptor and inhibiting its signal transduction pathway [164] (fig. 1) . a 60-year old man of wuhan, china developed symptoms of chest tightness without fever and cough on 1st february 2020 and confirmed to be the first case of covid-19 with multiple myeloma. the case was successfully treated with humanized anti-il-6 receptor antibody, tocilizumab. the patient was administered 8 mg/kg tocilizumab through iv route for one time from day 9 to day 12 upon hospital admission and a decrease in il-6 level was recorded, however, a rebound phenomenon of il-6 level was observed, may be due to the recovery of the normal t cells and the patient was cured on day 19. the patient, however, had also received other therapies like 200 mg dose of umifenovir (arbidol) tablets orally for three times daily as antiviral treatment and 400 mg of moxifloxacin iv daily for three days [165] . however, in another 56 years old covid-19 patient of end-stage renal disease (esrd) in the usa treated with tocilizumab, hydroxychloroquine and broad spectrum antibiotics, the patient remained in critical condition throughout the study period [166] . a 57 years old woman from switzerland suffering from systemic sclerosis (ssc) was on tocilizumab treatment for arthritis and ssc-associated interstitial lung disease (ssc-ild) @ 8 mg/kg body weight every 4 weeks intravenously. on the basis of observation it has been reported that tocilizumab treatment given for chronic autoimmune diseases may prevent the development of severe covid-19 [167] . a case of 42 years old patient with a respiratory failure linked to covid-19 from france showed a rapid favourable outcome after two infusions of the tocilizumab at a dose rate of 8 mg/kg through intravenous route along with other therapy like lopinavir-ritonavir [168] . tocilizumab treatment in 15 of the 20 patients showed improvement in terms of oxygen intake, lung lesion opacity (in 19 patients), lymphocytes in peripheral blood (10 patients), c-reactive protein (16 patients) and further, all patients were discharged on average 15.1 d after giving tocilizumab in a study conducted in china between 5 and 14 february 2020 [169] . a study on 100 covid-19 patients with severe pneumonia treated with tocilizumab and other supportive therapy from 9-20 march 2020 in italy, the respiratory condition was improved or stabilized in 77 patients in 10 days. 61 of these 77 patients had shown clearing of diffuse bilateral opacities on chest x-ray and 15 were discharged from the hospital; however, respiratory condition of 23 patients was worse during the treatment and 20 died out of 23 patients [170] . in another clinical study, tocilizumab administration showed a reduction in serum il-6 level in 10 patients out of 15 patients, however, it could not decrease il-6 level in four patients. still, observations suggest that tocilizumab is a good treatment option in patients who have a risk of cytokine storms [171] . however, it is difficult to reach on a conclusion regarding the use of tocilizumab in covid-19 patients with the limited number of clinical sample size. the absolute bioavailability of tocilizumab following subcutaneous administration was estimated to be 79.5% [172] . tocilizumab is eliminated from the body in a concentrationdependent manner. therefore, its half-life is directly proportional to its serum concentration. at higher serum concentration, it shows linear elimination and has the terminal half-life of 21.5 days (https ://www.acces sdata .fda.gov/drugs atfda _docs/label /2019/12527 6s127 ,12547 2s040 lbl.pdf). the notable adverse effect of tocilizumab is liver toxicity. steatosis, steatohepatitis and focal hepatocellular necrosis were seen in this drug-induced hepatotoxicity. other common adverse reactions observed were skin and soft tissue infections, dyslipidemia, transient neutropenia, headache, nausea and flu-like symptoms. therefore, a full assessment for liver injury and dose adjustment is required in patients administered with tocilizumab [173, 174] . tocilizumab also showed good efficacy in long term dosing for rheumatoid arthritis with similar adverse reactions and few malignancies also were reported [175] . in a recent study, it has been demonstrated that an antiprotozoal agent nitazoxanide has shown antiviral activity against a number of viruses which include human and animal coronaviruses. it is used orally and chemically, this drug is nitrothiazoly-salicylamide, a broad-spectrum anthelmintic and antiviral prodrug which is metabolized to an active compound tizoxanide [176, 177] (table 2 ). it had shown inhibitory potential against sars-cov2 at a low-concentration with 50% effective concentration of 2.12 μm in vero e6 cells. it has been observed that antiviral activity of this compound may be due to interference with host-regulated pathways which are involved in viral replication rather than virus-specific pathways [178, 179] . nafamostat is an anticoagulant in nature and further, its activity was also evaluated in the vero e6 cells infected with sars-cov2. this drug is a synthetic serine protease inhibitor and inhibited the sars-cov2 at 50% effective concentration of 22.50 μm in vero e6 cells. further, it is speculated that it may act through the inhibition of membrane fusion by reducing the release of cathepsin b. as this agent has previously shown potential against the mers-cov through prevention of membrane fusion, it could also be recommended for further in-vivo evaluation against covid-19 [29] (fig. 2 ; table 2 ). ivermectin is a broad-spectrum anti-parasitic agent and has also shown efficacy against some viral infections. this drug is basically a macrolide endectocide macrocyclic lactone derived from streptomyces avermitilis with anthelmintic activity (table 2) . recently, this drug has been investigated against sars-cov2 in in-vitro cell culture system in australia. it reduced the viral rna of sars-cov2 at two hours post infection in vero-hslam cells with the addition of single dose and its reduction intensity was approximately 5000-fold. this study hypothesized that ivermectin may act through inhibition of importin (imp) α/β1-mediated nuclear import of viral proteins similar to other rna viruses, however; further investigation is required to understand the precise mechanism of action in sars-cov2 [180] . it is also important to conduct the trials in in-vivo animal models and further, the pre-clinical trials in human beings are also required with fast pace if in-vivo models results have potential to mitigate the covid-19 infection (fig. 2) . cepharanthine, a naturally occurring plant alkaloid, is an anti-inflammatory and anti-neoplastic and is approved for leukopenia treatment (table 2 ). cepharanthine showed the most potent inhibition of gx_p2v infection and decreased the viral rna yield in the pangolin coronavirus gx_p2v workable model, therefore, this therapeutic agent may also be a potential candidate for repurposing against covid-19 [181] . further, it has been speculated that this drug may target host cell pathways [181] . a gold-containing triethyl phosphine coated drug, auranofin, is used as therapy for the arthritis and approved from fda for this treatment (table 2) . previously, this drug has shown effects against viral, bacterial and parasitic infections. recently, auranofin has shown inhibitory effect against viral rna in huh7 cells infected with sarscov2 fig. 2 overview of the drugs with potential for repurposing against covid-19. the drugs being considered for primary therapy of covid either acts on targets of the virus or on the targets of the host as well as a reduction in proinflammatory cytokines in an in-vitro study [182] . endoplasmic reticulum (er) stress and unfolded protein response (upr) activation are responsible for the viral replication and pathogenesis in coronavirus infection [182, 183] and high levels of upr activation has been recorded in the cells which have higher expression of sars-cov spike protein [182, 184, 185] . therefore, it is speculated that auranofin may act through the inhibition of redox enzymes such as thioredoxin reductase and induction of er stress, however, its confirmatory investigation is required [182, 186] . janus kinase inhibitors have anti-inflammatory and antiviral effects and may have a purported advantage over other immunomodulatory strategies in covid-19 [187] . jak1/2 inhibitor ruxolitinib, baricitinib, jak 1/3 inhibitor tofacitinib and pan-jak inhibitor td-0903 are presently under different phases of clinical trial and being investigated for covid-19 treatment (https ://www.pharm aceut ical-techn ology .com/comme nt/incyt e-eli-lilly -jak-inhib itor-covid -19/). a phase-i clinical study showed improvement in covid-19 inflammation score with clinical improvement by ruxolitinib. however, it has toxicity on the liver and hematopoietic system. but in this study with the short term dosage, it did not show any major adverse events [188] . baricitinib is presently under phase-iii clinical trial (https ://www.clini caltr ialsa rena.com/news/lilly -baric itini b-covid -19-trial /). initial studies showed the drug baricitinib corrected the immune dysregulation and improved clinical disease outcome with no serious adverse events [189, 190] . all the above drugs are under different phases of clinical trials and none have been approved for the treatment of covid-19. dexamethasone is a corticosteroid and it has been used in some clinical trials. the preliminary results of recovery trial conducted in 2104 patients showed dexamethasone @ 6 mg once daily for up to 10 days showed improvement in recovery with 22.9% mortality in the dexamethasone group compared to the 25.7% mortality in the usual care group [191] . however, few concerns have been raised on recov-ery trial outcome in choosing the correct steroid and dose. in another study, methylprednisolone reduced the mortality rates in covid-19 patients with ards. further, the effect of dexamethasone in geriatric patients and effects on viral load are not mentioned in the recovery trial [192] . theoharides and conti have also suggested restricting the use of dexamethasone during the initial phase of disease in severely ill patients for shorter period. using this drug in recovery phase may lead to reduced viral clearance and nosocomial infections [193] . as it suppresses immunity and it may aggravate some latent infections whose occurrence is of no importance to the developed countries. therefore, region-specific study is required before incorporating into covid-19 therapy [194] . a chemotherapeutic fluoroquinolone antibiotic, prulifloxacin, with broad-spectrum activity, and some anti-hiv drugs such as tegobuvir, (a novel non-nucleoside inhibitor of human coronavirus rna replication), nelfinavir (a protease inhibitor which inhibits the cleavage of the polyprotein gag-pol) and bictegravir (hiv-1 integrase inhibitor) have protein binding sites of the proteases which have been shown using the high throughput screening as molecular docking with bioinformatics analysis and would be considered the potential candidates for re-tasking against covid-19 in future [195] and in-vitro and in-vivo animal models may provide a lead against this disease. according to another recent molecular docking study based on rdrp modelling and multiple sequence alignment (msa) showed a binding capacity to rdrp against sars-cov2 by various antiviral agents such as sofosbuvir (fda approved against hepatitis c virus), ribavirin, remdesivir and idx-184; (under clinical trial against hepatitis c virus) [196] . elbasvir, an antiviral drug, (approved for the treatment of hepatitis c) has shown predicted multiple binding sites at rdrp, papain-like proteinase and helicase of sars-cov2 using the docking simulations and computational modelling [197] (fig. 2 ; table 2 ). in a recent review, it has been stated that azithromycin, quercetin, rapamycin and doxycycline may have senolytic activity and azithromycin and doxycycline are used to inhibit viral replication and il-6 production, therefore, these therapeutic agents may be potential re-tasking agents against covid-19 in future with proof of sufficient invitro and in-vivo studies [198] (fig. 2 ; table 2 ). peptide (ek1), tdf, 3tc (rna synthesis inhibitors), shufeng jiedu and lianhuaqingwen capsules (chinese traditional medicine) are screened using standard bioassays, chemical screening and genome and biophysical understanding of the targeted virus for being the potential drug candidates against sars-cov2 infection as described in a recent review. however, the efficacy and safety of these drugs for sars-cov2 still need to be further confirmed by clinical experiments [93] (fig. 2) . covid-19 is a pandemic and has no treatment till date including vaccine and drugs. however, there are number of available drugs with approval of fda for treatment of other diseases which could be used on the basis of the trial against covid-19 and considered as the repurposed drugs. these are antivirals, antimalarials, aceis, arbs, statins and monoclonal antibodies. it has been noticed that remdesivir, favipiravir, ribavirin, lopinavir-ritonavir combination, arbidol, tocilizumab have shown benefits in various clinical studies done on the basis of compassionate use to save the life of covid-19 patients; therefore, in future, these drugs could be the potential drug therapy against this deadly disease. however, the use of chloroquine and hydroxychloroquine has shown the controversial results in the different trials, therefore, who also stopped their solidarity trials recently. in future, chloroquine and hydroxychloroquine require a large number of research studies to reach a conclusion for its use in covid-19 patients. further, aceis and arbs could be the potential supportive therapy against this infection. some drugs are in the early phase of investigation like ivermectin and auranofin to be used against the 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polymerase (rdrp) targeting: an in silico perspective experimental treatment with favipiravir for covid-19: an open-label control study. engineering (beijing) favipiravir versus arbidol for covid-19: a randomized clinical trial fast identification of possible drug treatment of coronavirus disease-19 (covid-19) through computational drug repurposing study sars-cov-2 and sars-cov: virtual screening of potential inhibitors targeting rna-dependent rna polymerase activity (nsp12) virtual screening of potential inhibitors for sars-cov-2 main protease multidrug treatment with nelfinavir and cepharanthine against covid-19 sofosbuvir as repurposed antiviral drug against covid-19: why were we convinced to evaluate the drug in a registered/approved clinical trial nucleotide analogues as inhibitors of sars-cov-2 polymerase remdesivir, lopinavir, emetine, and homoharringtonine inhibit sars-cov-2 replication in vitro potential inhibitors against 2019-ncov coronavirus m protease from clinically approved medicines lack of antiviral activity of darunavir against sars-cov-2 arbidol: a potential antiviral drug for the treatment of sars-cov-2 by blocking trimerization of the spike glycoprotein arbidol monotherapy is superior to lopinavir/ritonavir in treating covid-19 nafamostat mesylate blocks activation of sars-cov-2: new treatment option for covid-19 three cases of treatment with nafamostat in elderly patients with covid-19 pneumonia who need oxygen therapy in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) potential drugs targeting early innate immune evasion of sars-coronavirus 2 via 2'-o-methylation of viral rna the anti-hiv drug nelfinavir mesylate (viracept) is a potent inhibitor of cell fusion caused by the sarscov-2 spike (s) glycoprotein warranting further evaluation as an antiviral against covid-19 infections targeting sars-cov-2: a systematic drug repurposing approach to identify promising inhibitors against 3c-like proteinase and 2'-o-ribose methyltransferase azithromycin and ciprofloxacin have a chloroquine-like effect on respiratory epithelial cells hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial virtual screening based on molecular docking of possible inhibitors of covid-19 main protease ruxolitinib in treatment of severe coronavirus disease 2019 (covid-19): a multicenter, single-blind, randomized controlled trial beneficial impact of baricitinib in covid-19 moderate pneumonia; multicentre study deciphering the binding mechanism of dexamethasone against sars-cov-2 main protease: computational molecular modelling approach in silico studies on therapeutic agents for covid-19: drug repurposing approach repurposing ivermectin to inhibit the activity of sars cov2 helicase: possible implications for covid 19 therapeutics tentolouris n. in vitro data of current therapies for sars-cov-2 treatment with hydroxychloroquine vs hydroxychloroquine + nitazoxanide in covid-19 patients with risk factors for poor prognosis: a structured summary of a study protocol for a randomised controlled trial publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-323940-ubazgvov authors: cafiero, concetta; re, agnese; micera, alessandra; palmirotta, raffaele; monaco, delio; romano, francesca; fabrizio, claudia; di francia, raffaele; cacciamani, andrea; surico, pier luigi; d’amato, gerardo; pisconti, salvatore title: pharmacogenomics and pharmacogenetics: in silico prediction of drug effects in treatments for novel coronavirus sars-cov2 disease date: 2020-10-13 journal: pharmgenomics pers med doi: 10.2147/pgpm.s270069 sha: doc_id: 323940 cord_uid: ubazgvov the latest developments in precision medicine allow the modulation of therapeutic approaches in different pathologies on the basis of the specific molecular characterization of the patient. this review of the literature coupled with in silico analysis was to provide a selected screening of interactions between single-nucleotide polymorphisms (snps) and drugs (repurposed, investigational, and biological agents) showing efficacy and toxicityin counteracting covid-19 infection. in silico analysis of genetic variants related to each drug was performed on such databases as pharmgkb, ensembl genome browser, www.drugs.com, and snpedia, with an extensive literature review of papers (to may 10, 2020) on covid-19 treatments using medline, embase, international pharmaceutical abstracts, pharmgkb, and google scholar. the clinical relevance of snps, known as both drug targets and markers, considering genetic variations with known drug responses, and the therapeutic consequences are discussed. in the context of clinical treatment of covid-19, including infection prevention, control measures, and supportive care, this review highlights the importance of a personalized approach in the final selection of therapy, which is probably essential in the management of the covid-19 pandemic. covid-19, an emergency all over the world, is caused by severe acute respiratory syndrome coronavirus 2 (sars-cov2), a positive-sense rna virus with higher mutation rates than dna viruses. 1, 2 laboratory tests on respiratory tract specimens (swab/saliva/tears pcr and serological tests) and computed tomography (ct; for chest or other tissue) should stage as soon as possible the presence of disease and its evolution/progression. 3, 4 sars-cov2 binds principally to the cell-membrane ace2 receptor through the viral structural spike (s) protein, although other "virus doors" have been suggested (integrins and toll-like receptors) 5 (figure 1) . at the intracellular level, the virus activates cellular processes to produce viral proteins that replicate the virus's genetic material, providing potential targets for drug therapy. 1, 5, 6 covid-19 features, diagnostic route, and early, mild, and severe covid-19 symptoms are summarized in figure 1 . virus entry and multiple signaling pathways (ca 2+ release, csrc, fak, mapk, and pi3k) occur upon spike2-rgd-integrin interaction. 7 a "cytokine storm" is locally released (il1β, il6, il8, tnfα, mip1α, and vegf), as first observed in patients showing fatal complications. 5 this specific panel was used to screen patients requiring prompt intervention to avoid acute respiratory distress syndrome (ards). 6 in a recent study, candidate drug targets for nonstructural proteins (3-chymotrypsin-like protease, papain-like protease, rnadependent rna polymerase), viral access, and related immuno regulatory pathways have been prospected for evaluation. 6, 8, 9 a wide range of pulmonary manifestations can be observed, varying from mild respiratory symptoms (cough or sore throat) to severe pneumonia, up to a sudden development of respiratory failure. 10 silent hypoxemia is a peculiar aspect frequent in frail and elderly patients that usually precedes the onset of an overt acute and severe respiratory syndrome. 11, 12 chest ct imaging is strongly recommended for an early diagnosis of novel coronavirus pneumonia. 13, 14 ct findings, including patterns associated with less frequent signs, eg, lobular, bronchial, pleural, and subpleural involvement, as well as pleural lymphadenopathy and pericardial effusion, have been described. 15 sars-cov2 initially causes airspace exudates, interstitial edema, hyaline membranes, and inflammatory infiltrates in the alveoli. 16 other than the deleterious lung effects, systemic sars-cov2 has a significant impact on the hematopoietic system and tissue homeostasis. 17 initially, lymphopenia showed interesting prognostic value, for both neutrophil:lymphocyte and platelet:lymphocyte ratios in severe sars-cov2 cases. lymphocyte parameters (count dynamics), some inflammatory indices (ldh, crp, and il6), and some recent circulating biomarkers (high serum procalcitonin and ferritin) have been suggested for identifying cases with poor prognosis (prompt intervention and improved outcomes). as observed, blood hypercoagulability, high d-dimer levels (particularly associated with disease worsening), protraction of both prothrombin (pt) time, activated partial thromboplastin time (aptt), and disseminated intravascular coagulation overview of covid-19 infection: sars-cov2-host interaction and tissue manifestation. schematic representation of sars-cov2 virus interacting with mucosa epithelia (framed) and gradual sprouting to gut, kidney, brain, and lung tissue. "virus doors" reportedwere ace2, integrin, tlr3, or tmprss2. overall symptoms are listed. briefly, most common covid-19 symptoms occur at the upper respiratory tract, together with asthenia and general malaise. early, less common clinical features include gastrointestinal symptoms (nausea, anorexia, diarrhea), anosmia and dysgeusia. severe cases encompass pneumonia or bronchopneumonia, severe acute respiratory syndrome, renal failure, up to death. the lower respiratory tract participation and complications are more frequent in people aged over 50 with pre-existing chronic diseases of cardiovascular and/or respiratory system, as well as some autoimmune diseases (diabetes). cardiac involvement represents another potentially life-threatening complication, caused by direct viral damage, hypoxic injury, microvascular dysfunction and disclosing with diverse clinical pictures (arrhythmias, myocarditis, and heart failure). finally, virus can reach central nervous system causing central (acute cerebrovascular diseases, impairment of consciousness) and peripheral complications. the evolution of infection from early detection severe complications and death (shaded arrow). as reported, molecular and serological, as well as imaging tests, are useful depending on disease evolution: real-time pcr applied to nasopharyngeal swabs, venous blood as well as conjunctival swabs can track disease ongoing, while early-released igm and late-released igg might assess for immune response, in line with cytokine storm panel (il6, tnfα, ifnγ, and il10) typifying tissue/organ complications. require constant surveillance to allow prompt intervention. in addition to upper-airway contact, conjunctivitis may be an ocular manifestation of sars-cov2 infection, if quickly detected. 18 in december 2019, a chinese ophthalmologist reported an unusual viral conjunctivitis. to date, several internet articles and scientific reports have documented the potential use of eye swabs as a tool to screen virus infection, although contrasting data are available, most probably related to progression of infection and virus detection. 19 in january 2020, a worldwide expert in infectious diseases referred to conjunctivitis during an inspection of wuhan and tested positive for sars-cov2, but quickly recovered from infection. this led to the idea of "eye infection" as a possible alternative route of sars-cov2 transmission, alternative to the respiratory one. 20 ocular secretion might represent a reservoir of virus at the early stages of contagious. 18 when pinkeye occurs as a sign of conjunctivitis, a differential diagnosis can be of great utility to screen symptomatic and even presymptomatic individuals. 21 recently, pharmacogenomics (the effects of a single genetic marker) and pharmacogenetics (the collective influence of variability across the genome to modulate an individual's drug response) have received great attention for their abilities to provide a new way to select drugs for personalized therapy (optimal dosing for maximizing drug efficacy or minimizing the risk of toxicity). 22, 23 through drug therapy, pharmacogenetics might influence both pharmacokinetics and pharmacodynamics with respect to dosing, formulation sensitivity, and adverse drug reactions (adrs), as well as drug-hypersensitivity reactions (allergic, pseudoallergic, and exaggerated pharmacological reactions to medications), determining an enhanced immunologic reaction or inflammatory response (side effects). 24 genetic assessment can predict the occurrence of drug-related toxic effects. single-nucleotide polymorphisms (snps) are the most common type of polymorphism found in the human genome, and represent the main reason for 90% of all types of genetic variations among individuals. an example of an adr is the hypersensitivity reaction occurring in snp carriers of the hla-b*5701 allele who receive the antiviral abacavir for treatment of hiv. 25, 26 covid-19 therapy is wide-ranging and multiple, and risk factors for adrs can occur. therefore, optimal doses, duration of treatment, side effects. and long-term outcomes are critical aspects of covid-19 therapy. 27 cov-mediated inflammation may be counteracted by anti-inflammatory cytokines, including il1 family members, il6, and tnfα. 28 since no specific drug/therapy for covid-19 treatment has been us food and drug administration (fda)-approved, an array of drugs approved for other diseases and under investigation (including off-label and biological drugs) have been included in clinical trials. 29, 30 as observed, the metabolic pathways of these drugs included various polymorphic cytochrome p450 enzymes, strongly suggesting genotyping for the cyp2d6*2, cyp2d6*3, cyp2d6*4, and cyp2d6*10 alleles. 31, 32 as an example, no predictability in the metabolic function of the cyp3a5*3 allele can result in alternative mrna splicing with a trunked protein, due to the formation of an untimely stop codon. moreover, haplotype cyp3a5*3 has been related to a reduced clearance of both ritonavir and lopinavir (substrates) ( table 1) . of interest is the association between polymorphisms inabcc and therapy efficacy, as the drug transporters are one of the primary mechanisms related to subtherapeutic antiretroviral-drug concentrations. 33 prominent research has highlighted the relationship between the abcb1 polymorphism (3435 c>t) and hepatotoxicity risk after antiviral treatments, and few additional studies were found regarding other nucleoside analogues. 33 more recently, the presence of grade 3-4 hyperbilirubinemia is directly proportional to the homozygosity, heterozygosity, and wild-type genotyping for the ugt1a1*28 allele in patients who receive ritonavir and lopinavir. 34 therefore, the attempt of this literature review coupled with in silico analysis was to provide a selected screening of drugs showing efficacy and toxicity effects useful for counteracting covid-19 infection. an extensive literature review of papers published until may 10, 2020 was performed based on a standard procedure (medline, embase, international pharmaceutical abstracts, pharmgkb. and google scholar). 35 search terms were "covid-19", "novel coronavirus", "sars-cov2", "pharmacogenetics", "treatment/s", "adverse side effects", "therapy", "lung", "ocular", "pulmonary infection", "drugs", "drug response", "virus", "candidate drugs", "potential inhibitors", "protease inhibitors", "personalized medicine", "individual therapy", "pneumonia", "ace", "heparin", "vasculitis", "conjunctivitis", "rhinitis", "hematological complication" and "main metabolic routes", either alone or in combination. from this manually performed analysis, drugs reported in at least two studies or in a clinical trial were included. ongoing clinical trials and the index of studies of covid-19 were identified using the search term "coronavirus infection" on clinicaltrials.gov and the chinese clinical trial registry (http://www/chictr.org/enindex.aspx). in silico analysis of genetic variants related to each drug was performed on dedicated databases, such as pharmgkb (table 2) , ensembl genome browser, www.drugs.com, and snpedia. the allelic frequency of each variant average in all populations was based on data from the 1000 genomes project phase 3. we considered snps related to both efficacy and toxicity response with allele frequencies ≥5%, as already described in previous studies. 36, 37 the quality of each study was assured, and resulting information included study design, baseline characteristics of disease, treatment regimens, and allelic frequencies of the genetic variant. drugs in use as routine therapy or in clinical trials for covid-19 include steroids and antiviral and biological humanized neutralizing antibodies against some proinflammatory cytokines, such as il1, il6, ifn, and tnfα, in addition to supportive measures and symptomatic treatment, according to the severity of the disease. 38 data analysis on registered clinical trials of covid-19 in the table 2 overview of pharmgkb • pharmgkb is one of the foremost worldwide resources for pgx knowledge, and the organization has been adapting and refocusing its mission along with the current revolution in genomic medicine. annotates drug labels containing pharmacogenetic information approved by the us food and drug administration, european medicines agency swiss agency for therapeutic products, pharmaceuticals and medical devices agency (japan) and health canada. attempts to interpret the level of action implied in each label with the "pgx level". • pharmgkb website provides a diverse array of pgx information, from annotations of the primary literature to guidelines for adjusting drug treatment based on genetic information. • pharmgkb online pharmacogenomics knowledge resource maintains a list of very important pharmacogene summaries (www. pharmgkb.org/view/vips.jsp), which (until march 2020) describes 22,919 allelic variant annotation in which allelic variation has been shown to significantly influence drug metabolism, drug transport, drug-target response, expression of genes encoding drug-metabolizing enzymes, or risk of adverse drug reactions. us is available at https://clinicaltrials.gov. nowadays, a great number of agents have been evaluated for potential use in covid-19 management, and only a fewhave been included within international and/or local protocols. 38 according to the us national institutes of health, no pharmacological agent has earned approval for safe and effective use yet, mainly because of the lack of evidence in favor or against these agents (https://covid19treatmentgui delines.nih.gov). one important aspect of a therapeutic approach consists in the choice of the right drugs throughout the natural history of disease. indeed, a three-phase pathogenetic model has been proposed, with different clinical and laboratory features, each requiring a specific treatment based on the changing role over time,of direct viral damage and host inflammatory response in the disease course. this model describes an early stage (stage i), coinciding with incubation and/or mild flulike symptoms, during which antiviral drugs might reach high effectiveness, a moderate stage (stage ii) characterized by pulmonary involvement without iia or with iib hypoxia, which may benefit from the use of antivirals and anti-inflammatory therapy (including steroids), and lastly a severe stage (stage iii), in which a dysregulated, systemic hyperinflammatory response takes place, thus requiring the administration of immunomodulating agents, several of which are currently under investigation, and in some cases already in use within management protocols. 37 gene variants associated with pharmacological responses to drugs are reported in a dedicated database -pharmgkb (https://www.pharmgkb.org) -allowing the identification of relationships between genetic variations (eg, snps, indels, repeats, haplotypes) and individual drug responsiveness. 40, 41 herein, in silico pharmacogenetic analysis shows the potential clinical efficacy and/or toxicity of the major drugs selected for covid-19 treatment. the main drugs proposed for covid-19 treatments and reference sequence (rs) related to adrs and efficacy are shown in table 1 . genes and related snps (rs) associated with drug effects and their study annotation are summarized in table 3 . major clinical information regarding "variant drug" responsiveness (clinical annotations) is highlighted. bloodstream fluidity requires a tidy balance among factors favoring flow of blood and thrombosis. any modification in this physiological balance triggers pathological conditions: deficit of coagulation factors favor bleeding, while genetic mutations of coagulation factors can determine a thrombotic risk framework characterized by differences in genetic variants of coagulation (table 4 ). all drugs used as therapeutic options and their study annotation based on pharmacogenetic data are discussed. chloroquine (cq) and hydroxychloroquine (hcq) cq is used for chemoprophylaxis of malaria and amebiasis, while hcq is used to treat autoimmune disease. 8 the mechanism of action includes the blocking of viral entry through the inhibition of glycosylation of host receptors, proteolytic processing, and endosomal acidification. 65 effects of immunomodulation on cytokine production and inhibition of autophagy/lysosomal activity have been also reported. [65] [66] [67] several randomized controlled trials (rcts) are currently investigating cq and hcq in covid-19 treatment (https:// clinicaltrials.gov). based on current data, both drugs are recommended for treatment of unhospitalized covid-19 patients, and the effects of cardiotoxicity in immunosuppressed subjects or patients with kidney or liver problems are known. recommendations for oral administration in covid-19 treatment are 500 mg twice a day and 400 mg twice a day, followed by 200 mg twice a day for cq and hcq, respectively. 68 blood monitoring is required, as hemolytic anemia might occur, particularly when the drug is delivered in association with other drugs that cause hemolysis. 69 it should not to be underestimated the extent to which both drugs may cause hemolysis in glucose-6phosphate dehydrogenase (g6pd)-deficient individuals. of note, about 39% of covid-19 patients suffering from lupus have failed to respond or were even intolerant to hcq. 70 moreover, long-term cq-hcq treatment induces retinal toxicity, and particularly when hcq-related retinopathy is diagnosed, the retinal damage endures, even after cessation of therapy. 71 high doses or prolonged administration of hcq, even at recommended doses, may increase the risk of ocular toxicity (paracentral scotomas, color-vision changes, corneal/ciliary body/conjunctival as well as retinal abnormalities), and visual disturbances (retinal and macular toxicity). 72 this would imply that accurate eye screening for confirming sars-cov2 presence in early conjunctivitis or monitoring ocular structure during covid-19 therapy is recommended to counteract early or even prevent eventual signs of ocular drug toxicity, including the retinopathy. 73 the oral combination of these two agents (fda-approved and currently authorised as anti-hiv medicine) demonstrate activity against other novel coronaviruses. 74, 75 several rcts examining lopinavir/ritonavir in covid-19 are in progress. 76 recommendations for administration in covid-19 treatment is 400 mg/100 mg twice daily for up to 14 days. 77 adverse effects of lopinavir/ritonavir include several gastrointestinal complains, such as nausea, vomiting, and diarrhea, and hepatotoxicity, pancreatitis, and cardiac conduction abnormalities. 78 these adverse effects are increased in 20%-30% of covid-19 patients with elevated transaminases. 79 previous studies have shown that these adrs with lopinavir-ritonavir combination are related to several polymorphisms present in the genes ugt1a1, ugt1a7, apoe, and apoc3 (table 1) . this antiviral drug (guanine analogue) inhibits viral rnadependent rna polymerase. ribavirin activity against covid-19 disease is limited and requires high doses or combination therapy to be effective in humans. no evidence exists for inhaled ribavirin for covid-19 treatment -no benefit over enteral or intravenous administration 79 though several studies have demonstrated possible harm due to adverse effects (hematologic and liver toxicity). 80 ribavirin causes severe dose-dependent hematologic toxicity. 81 the inconclusive efficacy and toxicity results suggest that ribavirin has limited value in treatment of covid-19. case-control pharmacogenetic association studies indicate different polymorphisms in the itpa, vdr, and slc28a2 genes that are related to toxicity and adverse effects, while an increased pharmacological response is associated when some variants of the vdr, slc29a1, ifnl3, and micb-oasl genes are present. it must be noted that numerous studies have undertaken pharmacogenetic evaluations on populations undergoing ribavirin therapy combined with peg-ifnα. 82 this is an antiviral agent that exerts a mechanism of action targeting the s protein-ace2 interaction, inhibiting membrane fusion of the viral envelope. 83 the recommendation for umifenovir oral dose (200 mg every 8 hours, 7-14 days) for influenza treatment was studied for covid-19 therapy (nct04260594). in covid-19 patients treated with umifenovir, adverse effects include allergic-reaction gastrointestinal upset and elevated transaminases, although there are no studies that describe an association of these episodes with genetic variants. 27, 83 miscellaneous agents ifnα and -β have been studied for novel covs. 84 several studies reported clinical outcomes in combination with ribavirin and/or lopinavir/ritonavir. 85 adverse effects have been described in almost every organ, clearly dosedependent. 84, 85 several toxic mechanisms for ifnα/β have 42 each variant report show the reference snp (refsnp) cluster id numbers (rs#), a code by which each snp can be queried from the dbsnp website (https://www.ncbi.nlm.nih.gov/ snp) and through which further information is available (such as functional analysis, population-specific allele frequencies, validation information, or clinical significance). 43 furthermore, for each variant, a summary of pharmgkb clinical annotations with respective identification codes (phenotype for any given genotype) is reported. using the access codes for dbsnp and pharmgkb, it is thus possible to find more information for the sequence variants and the respective variant-drug responsiveness associations. finally, the last columnshows the most significant bibliographic reference concerning the association between the genetic variant reported and individual drug responsiveness. pharmacogenomics and personalized medicine 2020:13 submit your manuscript | www.dovepress.com dovepress been investigated in recent years. much remains still to be elucidated, although most side effects disappear on dose reduction or interruption of treatment. previous genomewide association studies on the response to ifnβ in neurological degenerative diseases suggest an increase in therapeutic response with the presence of several snps in the genes cd58, znf697, and fhit. in parallel, adrs have been observed with the presence of variants of the gapvd1 and irf6 genes. as of now, the use of interferons to treat covid-19 disease is controversial. 86 although an antihelminthic agent, nitazoxanide has shown antiviral activity with a favorable safety profile. 87, 88 camostat mesylate prevents novel cov-cell entry through inhibition of the host surface transmembrane protease/serine (tmprss2), as observed by in vitro studies. 89 neither drug has pharmacogenetic studies regarding efficacy or toxicity effects associated with genetic variants. this macrolide antibiotic is used extensively in patients with viral infections to prevent severe respiratory tract infections. azithromycin-hcq combination shows a synergistic effect on covid-19 disease in vitro at concentrations comparable with that observed in human lung, 90 and has been found useful in combination with remdesivir, lopinavir/ritonavir and ifnβ. to date, the interaction between this macrolide and genetic factors is unknown. however, due to the potential risk of prolonged qt interval, remarkably increased by the mutual interaction between these two agents, their concomitant use is not recommended by several guidelines, unless within the setting of controlled trials (https://covid19treatmentguidelines.nih.gov). this anticoagulant is used to reduce thromboembolic events in patients with covid-19 infection. as known, the sars-cov2 pandemic is characterized by the development of ards that results from acute inflammation within the alveolar space and prevention of normal gas exchange. indeed, huge deposits of fibrin in the lung parenchyma and air spaces have been reported. the raising of proinflammatory cytokines within the lung leads to recruitment of leukocytes, increasing the local inflammatory response, and since the coagulation route contributes to reducing pathogen invasion by improving compartmentalization, this anticoagulant treatment has potential risk in those covid-19 patients with no significant coagulopathy. the drug enoxaparin can be started as soon as the day of covid-19 diagnosis and continued over 14 days, after baseline assessment and monitoring of pt, aptt, complete blood-cell count, and creatinine levels. clinical aggravation causing worsening and death in covid-19 inpatients appears to be thrombotic. therefore, special attention should be devoted to both risks and benefits of using heparin in covid-19 patients. prescreening is essential to highlight genetic predisposition related to thrombophilia, as these subjects with thrombophilic mutations (based on the degree found) are at greater risk of thrombotic complications. remdesivir this is an rna-polymerase inhibitor (gs-5734), a retroviral drug belonging to the class of nucleotide analogues, and a monophosphate prodrug that was discovered during a screening study of antimicrobials with antiviral activity, showing promise against the ebola virus. 91, 92 recently approved by the fda for the treatment of patients with covid-19, remdesivir is recommended as a single 200 mg dose, followed by 100 mg daily infusion. 93 besides the drug's clinical use in the treatment of ebola, several clinical trials are ongoing to evaluate the antiviral activity of remdesivir in patients with covid-19 (nct04292899, nct04292730, nct04257656, nct04252664, and nct04280705). 91 no pharmacogenetic indications are present, allowing modulation of dosage for therapy. due to its toxicity, remdesivir is not currently fda-approved, and must be obtained via compassionate use, expanded access, or enrollment in a clinical trial. favipiravir ribofuranosyl-5′-triphosphate is a retroviral drug acting as an inhibitor of viral replication (rna-polymerase inhibitor t705). this agent demonstrates broad activity against ebola infection and other rna viruses. 94 favipiravir is recommended at a dose of 2,400-3,000 mg every 12 hours (two doses) followed by maintenance doses of 1,200-1,800 mg every 12 hours. favipiravir is overall well tolerated, although a mild adverse-event profile for higher-dose regimens has been observed. [95] [96] [97] the high doses used result in hyperuricemia, diarrhea, elevated transaminases, and reduction in neutrophil count, but nothing is known about any pharmacogenetic correlations. favipiravir presents efficacy in the treatment of covid-19 disease, but to date limited clinical experience has reported support for its use. no pharmacogenetic indications are present, allowing modulation of dosage for therapy using this drug. these drugs are well-known protease inhibitors used for the treatment of aids, with good efficacy and safety profiles. while atazanavir is combined with other antiretrovirals, darunavir is used in a fixed-dose combination with cobicistat, a new pharmacokinetic enhancer. with respect to the other protease inhibitors, atazanavir is less likely to cause lipodystrophy and is preferentially used in combination with other antiviral agents (ritonavir), providing antiviral potency equivalent to lopinavir, although concomitant use of ritonavir decreases the efficacy of atazanavir. valid pharmacogenetic correlations of the efficacy of these antivirals can be deduced from studies carried out on hiv patients in which the efficacy of polymorphisms in the ugt1a1, cyp3a4, cyp3a5, and slco3a1 genes has been demonstrated. in contrast, cases of toxicity and adrs are related to sequence variants in the ugt1a1, ugt1a7, ugt1a3, apoe, and apoc3 genes. [44] [45] [46] [47] [48] 51, 55, 56, 98 in some settings, darunavir-cobicistat may be used in the presence of tolerability or availability of the lopinavir-ritonavir combination (https://covid19 treatmentguidelines.nih.gov). concerning the metabolism of azatavir, the variants cyp3a5*1, cyp3a5*3, cyp3a5*6, cyp3a5*7 in cyp3a5 (rs776746) have been reported. briefly, individuals carrying one or two copies of the *1 allele may metabolize atazanavir more rapidly than individuals with one or more copies of the *3, *6, or *7 alleles. 98 anticytokine or immunomodulatory agents (tocilizumab, sarilumab, and bevacizumab) monoclonal antibodies directed against key inflammatory cytokines represent another potential class of adjunctive anti-covid-19 therapies. 99,100 il6 is a key driver of this dysregulated inflammation. 100 the use of monoclonal antibodies against il6 shows a dampening of this process and improves clinical outcomes. tocilizumab, a monoclonal antibody il6-receptor antagonist, is used in severe covid-19 cases with success. adult doses are 400 mg or corticosteroids are used to reduce lung inflammatory responses that in many cases evolve into acute lung injury and ards. at present, the effects of corticosteroids in patients affected by covid-19 have been poorly described, so our considerations are based on observations in other viral pneumonia types, such as sars and mers. 102 these previous studies do not indicate any association between corticosteroid use and increased survival, but slower viral clearance in the respiratory and blood tracts, hyperglycemia (high blood sugar), vascular necrosis, and psychotic episodes. 103 as stated, sars-cov2 has the ability to introduce and infect the host cell using the ace2 receptor. 5 this has alarmed several researchers, who hypothesized how ace inhibitors and angiotensin-receptor blockers could interfere negatively or positively with the viral infection process. 89, 105 since ace inhibitors upregulate ace2 receptors, possible worsening of disease under ace inhibitor therapy has been hypothesized. by contrary, angiotensin-receptor blockers could theoretically prevent the entry of the virus at the cellular level. 106 some rcts specific for captopril used alone or in combination in patients with covid-19 with severe pneumonia are currently under investigation in order to understand ards (nct04355429, https://clinicaltrials.gov). since ace inhibitors are among the most frequently used drugs in medical practice, consequent knowledge on related pharmacogenetic aspects is now widely known. the polymorphisms that modulate the activity of these drugs in ace, ace2, and agtr1 genes have been widely studied and described in several recent studies. the covid-19 pandemic is due to the novel pathogenic coronavirus sars-cov2, which emerged in china and spread quickly worldwide. 1,2 therapeutic options for covid-19 are wide-ranging, and some drugs have gained emergency-use authorization from the fda and/or european medicines agency. at present, patients are treated with symptomatic therapy and vital support in severe cases. several international efforts are aimed at the investigation and development of antiviral agents, other immunotherapies, and vaccine strategies. pharmacogenomics might be a promising tool in the development of more appropriate therapies (including drug management) and the prevention of fatal-complication onset due to adrs. 27 pharmacogenomics can predict from the beginning the effect of a specific drug formulation in terms of efficacy/ toxicity with respect to individual genetic background and minimize exposure to drugs potentially less/ineffective other than toxic (precision medicine). 22, 23 as known, drug formulations can elicit different cell/tissue responses depending on individual genetic background. this is possible because each subject can have variations in nucleotide sequences belonging to genes encoding for enzymes involved in the activity of the drug that has been considered for therapy. [22] [23] [24] this aspect appears of great importance in patients having several comorbidities or simply "fragile" old patients. as there is no specific cure for covid-19, we reviewed all the therapies (drugs) actually in use to counteract sars-cov2 effects and the related adverse effects to certain drugs (antiviral, antimalarial, and several biological humanized agents able to reduce the levels of some cytokines belonging to the cytokine storm), as reported by rcts. [29] [30] [31] [32] [33] [34] [38] [39] [40] [41] response to these drugs was extremely complex, and numerous cases of toxicities and antiretroviral drug resistance (viral mutations) have been reported. 38 a possible explanation of this variability might be the presence of factors that modify pharmacokinetics/pharmacodynamics and the activity of the virus itself (viral pharmacodynamics). 40 in addition, viral pharmacodynamics and mutagenesis are still unclear with regard to covid-19 drug resistance. 38 genetic factors might account at least in part for the unpredictability of therapy among covid-19 patients. 38 merely, a significant number of snps in genes encoding proteins implicated in the transport and metabolization of drugs may be responsible for the wide variability in drug pharmacokinetics and toxicity. 32 consistently, this review, coupled with a wide in silico analysis on the relevance of identification of snps involved in drug metabolism, provides a list of specific drug-associated snps associated with efficacy (green) or toxicity (red), useful in predicting individual response to therapy in covid-19 patients. this would imply the possibility of checking variants in biological samples collected and evaluated before the beginning of therapy with the aim of predicting the outcome of a single or combined covid-19 therapy. to our knowledge, although a considerable number of adr episodes in covid-19 patients have to date been described in the literature, there has been no pharmacogenetic study attempting to correlate the clinical outcomes of drug treatment with gene variants. 27 the identification of gene variants is only the first step in a complex process prior to applicability into clinical practice. in fact, the clinical application of pharmacogenetic analysis requires previous studies confirming its validity and usefulness. to support this, essential measures applied to genetic tests are required: analytical and clinical validity and clinical utility. while analytical validity defines test accuracy, sensitivity, and specificity, guaranteeing that a "positive" or "negative" result corresponds with the real presence or absence of the sequence variant investigated, clinical validity represents the ability to identify the clinical phenotype of interest, evaluating clinical sensitivity and specificity, and positive or negative predictive values, or in other cases, the association measured as a risk or odds ratio. 107, 108 of note, clinical utility is related to the evidence that genetic testing can provide useful information for the diagnostic process, better measures for clinical outcomes, and odds ratios for patient-management decision-making (precision medicine). 107, 108 as such, a pharmacogenetic testpotentially useful for patient treatment -must improve clinical outcomes. evidence on the clinical utility of a pharmacogenetic assay is obtained by experimental studies, preferably rcts. a valid method to evaluate clinical utility is the use of prospective trials on randomized subjects undergoing genetic testing or not to compare the same treatment between the two groups. similarly, prospective trials on genetically stratified groups are also mandatory to comparing treatment outcomes between different groups. 108, 109 in other cases, clinical utility is determined by a "chain of indirect evidence" linking the results of a genetic test to intermediate data that are associated with improved clinical outcomes. 108, 110 however, pharmacogenetic research remains an expanding field, and to date there is no unanimous consensus on the best appropriate study designs to uniquely evaluate drug-response variability related to genetic variations. 109 finally, several national drug agencies are carefully evaluating risk:benefit ratios in individual cases, carefully considering the concomitant pathologies (long qt syndrome, major arrhythmias, liver or kidney failure, electrolyte disorders), pharmacological associations (in particular for drugs that increase the qt), and above all the clinical anamnesis and identification with genetic diagnosis of favism (g6pd deficiency). in our opinion, this is the first study to suggest the application of personalized medicine tools during the treatment of sars-cov2 infection. all identified snps, including allelic efficacy/toxicity, selected from an accurate in silico analysis have been identified for the most promising and repurposed drugs, and the investigational and adjunctive experimental drugs have been reported in both tables and figures. particularly, in figure 2 we graphically represent the frequency of snp alleles related to an efficacy response (green bars) or toxicity (red bars), useful in predicting individual response to therapy with the main therapies used for covid-19 patients. in this study, tocilizumab showed varying efficacy, while inside the antiviral group a divergent response was observed. therefore, to understand from the beginning specific susceptibility (efficacy/toxicity) to a drug, as displayed by the presence of specific functional clusters in the genetic background of the patient under treatment, might assist the specialist toward a more "specific" selection of therapeutic agent. this would result in a more appropriate therapeutic response, with fewer adrs. as reported in other therapies, this individualized approach dovepress appears of great utility, and particularly for the covid-19 pandemic could improve the choice of more efficient therapy. the screening is less invasive for the patient, as it is possible by venous blood or buccal-cell swab using realtime pcr analysis. any attempt to find more suitable tests, identify asymptomatic/presymptomatic and/or confirm symptomatic subjects, and therapeutic agents/strategies to sustain therapeutic decisions in covid-19-affected patients appears mandatory. herein, we performed a wide in silico study of genetic variants associated with the main drugs in use for covid-19 therapy, providing a list of genetic variants of efficacy/toxicity. this study highlights the clinical utility of a pharmacogenetic tool in planning personalized treatments that are likely to become essential in the pharmacological management of covid-19 patients. journal to which the article has been submitted, and agree to be accountable for all aspects of the work. the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest and report no conflicts of interest for this work. pharmacogenomics and personalized medicine is an international, peer-reviewed, open access journal characterizing the influence of genotype on pharmacology leading to the development of personalized treatment programs and individualized drug selection for improved safety, efficacy and sustainability. this journal is indexed on the american chemical society's chemical abstracts service (cas). the 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favipiravir, a novel antiviral agent, on qt interval in healthy japanese adults anrs 134-cophar 3 study group. effect of adherence as measured by mems, ritonavir boosting, and cyp3a5 genotype on atazanavir pharmacokinetics in treatment-naive hiv-infected patients clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study hlh across speciality collaboration, uk. covid-19: consider cytokine storm syndromes and immunosuppression. the lancet effective treatment of severe covid-19 patients with tocilizumab clinical evidence does not support corticosteroid treatment for 2019-ncov lung injury. the lancet saudi critical care trial group. corticosteroid therapy for critically ill patients with middle east respiratory syndrome research progress of drug treatment in novel coronavirus pneumonia angiotensin receptor blockers as tentative sars-cov-2 therapeutics angiotensin receptor blockers and covid-19 egapp working group. the evaluation of genomic applications in practice and prevention (egapp) initiative: methods of the egapp working group board on the health of select populations; committee on the evidence base for genetic testing. an evidence framework for genetic testing a critical appraisal of pharmacogenetic inference clinical utility of genetic and genomic services: context matters am and ac thank the italian ministry of health and fondazione roma (italy). cc, ar, am, rp, and sp conceived the study and participated in its design and coordination. cc, ar, am, and rp contributed to data collection and analysis. all authors made a significant contribution to the work reported, whether in its conception, study design, execution, acquisition of data, analysis and interpretation, or all these areas, took part in drafting, revising, or critically reviewing the article, gave final approval to the version to be published, have agreed on the key: cord-352177-05sku8a8 authors: pahus, laurie; suehs, carey meredith; halimi, laurence; bourdin, arnaud; chanez, pascal; jaffuel, dany; marciano, julie; gamez, anne-sophie; vachier, isabelle; molinari, nicolas title: patient distrust in pharmaceutical companies: an explanation for women under-representation in respiratory clinical trials? date: 2020-08-13 journal: bmc med ethics doi: 10.1186/s12910-020-00509-y sha: doc_id: 352177 cord_uid: 05sku8a8 background: patient skepticism concerning medical innovations can have major consequences for current public health and may threaten future progress, which greatly relies on clinical research. the primary objective of this study is to determine the variables associated with patient acceptation or refusal to participate in clinical research. specifically, we sought to evaluate if distrust in pharmaceutical companies and associated psychosocial factors could represent a recruitment bias in clinical trials and thus threaten the applicability of their results. methods: this prospective, multicenter survey consisted in the administration of a self-questionnaire to patients during a pulmonology consultation. the 1025 questionnaires distributed collected demographics, socio-professional and basic health literacy characteristics. patients were asked to rank their level of trust for pharmaceutical companies and indicate their willingness to participate in different categories of research (pre or post marketing, sponsored by an academic institution or pharmaceutical company). logistic regression was used to determine factors contributing to “trust” versus “distrust” group membership and willingness to participate in each category of research. results: one thousand patients completed the survey, corresponding to a response rate of 97.5%. data from 838 patients were analyzed in this study. 48.3% of respondents declared that they trusted pharmaceutical companies, while 35.5% declared distrust. being female (p = 0.042), inactive in the employment market(p = 0.007), and not-knowing the name of one’s disease(p = 0.010) are factors related to declared distrust. distrust-group membership is associated with unwillingness to participate in certain categories of trials such as pre-marketing and industry-sponsored trials. conclusion: distrust in pharmaceutical companies is associated with a specific patient profile and with refusal to participate in certain subcategories of trials. this potential recruitment bias may explain the under-representation of certain categories of patients such as women in pre-marketing drug trials. public distrust in healthcare systems and directed towards physicians, regulatory authorities and the pharmaceutical industry in general has increased over the past decades [1, 2] . a succession of health-related controversies and scandals related to safety issues involving pharmaceutical companies' or physicians' conflicts of interest has led to this erosion of trust [3] . the diffusion of selected information via mass media, which tends to sensationalize negative phenomena, greatly shapes the public's perception of healthcare systems. the influence on medical decision-making among both physicians and patients is difficult to assess [4] [5] [6] [7] . pharmaceutical companies are suspected of putting profits above public interest, using marketing techniques to distort scientific evidence, and actively influencing both physicians and health policy makers [8] [9] [10] . this weak level of trust translates into skepticism about using pharmaceutical products, thus leading to new patient behaviors ranging from poor adherence [11, 12] to strong rejection of health policies, such as vaccine campaigns [13, 14] . rejecting the implementation of medical and scientific findings not only has major consequences for current public health, but may also threaten future innovations and advances in medicine that principally rely on clinical research led by pharmaceutical companies, who have ever-growing needs for enrollment [15] . for clinicians, it can be fascinating to observe whether or not patients who have waited several weeks in order to attend a highly-specialized clinic for improving their condition are equally willing (or not) to participate in a clinical trial. in some countries, financial issues may affect this decision, but in the french health care system, all patients freely access all available drugs for a condition. one of the main motivations for attending a highly-specialized clinic in france is therefore the possibility of early access to new drugs or devices via participation in clinical research. the recruitment and retention of patients in clinical trials is challenging, but necessary, because it is the cornerstone of medical evidence production. the additional challenge is to recruit a panel of patients as representative as possible of the future target population. the latter is meant to ensure the accuracy and generalizability of the efficacy and safety conclusions generated by clinical trials. nevertheless, the representativeness of study populations vis-à-vis real-life patients has been demonstrated as quite poor due to the narrow eligibility criteria required to enter a clinical trial [16] . excessive eligibility criteria are a patient-extrinsic factor that can damage a trial's external validity. in contrast, patient-determined factors may also apply, leading to the non-inclusion of seemingly otherwise eligible patients. moreover, for geographical or investigator-determined cognitive bias some patients are never approached by centers conducting clinical trials which may weaken even more the external validity of trials [17] . in this study, we hypothesized that distrust in pharmaceutical companies is correlated with a specific psychosocial profile among patients. we sought to evaluate patient willingness to participate in different categories of clinical trials and associated predictive factors in order to determine whether or not global distrust in the healthcare system could represent a recruitment bias in clinical trials. this prospectively designed study was approved by an independent ethics committee (le comité de protection des personnes sud-méditerranée i; reference number: 14-72). as per french legislation and ethics committee approval, no written inform consent was required. patients' consent was implied upon the completion of the questionnaire. on 27 march 2017, study has been retrospectively registered on open science framework and www.clinicaltrials.gov with reference number nct03098303. anonymous self-questionnaires were filled out before consultation by consecutive patients consulting for respiratory diseases (excluding oncology and tobaccology) in the respiratory disease departments of 4 respiratory centers in southern france between december 2014 and december 2016. the participating establishments included two public (teaching/research) hospitals (the university hospitals of marseille and montpellier) and two private centers (the polyclinique saint-privat, boujan-sur-libron, and the clinique de marignane, marignane). the protoaccept questionnaire included fields corresponding to age, sex, employment, education level (university schooling or not), whether or not the participant knew the name of his/her disease (yes/no), whether or not he/she had already participated in a research protocol (yes/no/i don't know) and whether or not this was his/her first consultation in the department (yes/no). the general diagnosis (interstitial lung disease, chronic airway disease, sleep disorders, other), indicated by the investigator, was also recorded for each patient, as well as the public or private nature of the including center. patients were also asked to rank their distrust for pharmaceutical company medical research studies according to a 5-point likert scale ("i would refuse participation in a medical research study because i distrust pharmaceutical companies": strongly disagree -disagree -neither agree nor disagree -agree -strongly agree). they were further asked whether or not they would agree to test a new drug before (yes/no) or after (yes/no) commercialization, and whether or not they would agree to participate in research at different kinds of institutions (pharmaceutical company and three types of public facilities: university hospital, general hospital, or a public research institute)(yes/no for each option). this questionnaire was built by a multidisciplinary team (private and public physicians, psychologist, nurses, and a pharmacist) and validated by a psychologist in a 3 steps process. the first step included a qualitative pre-survey with thirty patients and consisting in open questions designed to capture events to report in the questionnaire. in the second step, a first version of the questionnaire was administered face to face by the psychologist to ten patients. ambiguous words were removed and medical vocabulary simplified. the final version was tested on five patients in typical survey settings, in the presence of the psychologist but without her intervention. patients who indicated that they agreed or strongly agreed with the statement "i would refuse participation in a medical research study because i distrust pharmaceutical companies" defined the "distrust" group. patients who checked one of the other three categories (neutral or disagreement) defined the "trust" group. patients who did not answer the question were not classified. the sample size was arbitrarily set at 1000 answered questionnaires. variations in count data are due to missing data, which was consistently under 20% for all questionnaire fields and therefore not otherwise addressed. all statistical analyses were carried out using the r (version 3.3.0) programming environment [18] . results are presented as numbers and percentages for qualitative variables. after evaluating the distribution of the age variable via a shapiro-wilks test, the latter was presented via medians with interquartile ranges. group comparisons were performed using unadjusted χ 2 tests for qualitative variables and mann-whitney tests for age. multiple (logistic) regressions were performed with covariates (variables were selected if their associated p value was less than 0.15 in univariate analyses and a backward procedure was used to select the final model) and then presented as adjusted odds ratios with 95% confidence intervals. the first model performed used age, gender, education, employment, doctor-reported diagnosis group, patient experience (first consult in respiratory disease ward, previous participation in research), the public/private nature of the including center and whether or not the patient knew the name of his/ her pathology to predict patient membership in "trust" versus "distrust" groups. to additionally explain patient willingness to participate in new-drug studies or research associated with pharmaceutical companies or with public institutions, further models used the same predictive variables as for the first model, plus distrustgroup-membership as an additional explanatory variable. one thousand questionnaires were answered (the response rate to this questionnaire was 97.5%.), 355 (35·5%) patients were in the "distrust" group, 483 (48·3%) in the "trust" group, and 162 (16·2%) did not answer the question (unclassified). thus, our analysis was performed on 838 patients characterized by their membership in the "trust" or "distrust" groups. as compared with the "trust" group, individuals in the "distrust" group were slightly but significantly older and significantly more often professionally inactive ( table 1 ). the two groups were statistically similar in terms of patient experience, be it as concerns previous consults in the respiratory disease ward, whether or not the latter was public or private, or as concerns previous participation in clinical research. despite similar rates of universitylevel education, the distrust group had significantly fewer patients who knew the name of their pathology, and fewer patients with a doctor-reported diagnosis relating to a sleep disorder (table 1) . in terms of selecting potential factors for predicting "distrust", the following variables provided significant (or near-significant) results at the univariate level: age, gender, inactive employment status, doctor-reported sleep disorder, and whether or not the patient knew his/her pathology. of the latter, only three variables remained significant at the multivariate level: in summary, being female, inactive in the employment market, and not knowing the name of one's pathology are factors related to the patient's declared distrust in pharmaceutical companies (adjusted odds ratios (aor) of 1·33 [1·09-1·79; p = 0·042], 1·47 [1·11-1·94; p = 0·007] and 1·56 [1·11-2·17; p = 0·010], respectively) ( table 2) . patient willingness to participate in different clinical trial subcategories 93% (778/838) of surveyed patients declared their willingness to participate in at least one subcategory of trial. 76% (638/838) indicated that they were willing to test a drug (75% (630/838) if the drug was already on the market and 29% (246/838) prior to market authorization). a (table 3 ). our study aimed at evaluating variables associated with patient willingness to participate in different categories of clinical trials and at identifying a potential recruitment bias in clinical trials related to patient distrust in the pharmaceutical industry and healthcare systems. for this purpose, we conducted a two-part analysis in respiratory disease patients surveyed about their opinions concerning clinical research and potential willingness to participate. the majority of patients surveyed suffered from chronic airway diseases (asthma, chronic obstructive pulmonary disease (copd), i.e. the most prevalent chronic respiratory diseases in france [19] . first, we compared patient characteristics on the basis of their level of trust in the pharmaceutical industry. in a second step, we assessed willingness-to-participate in clinical trials for our whole population to identify factors associated with acceptance or refusal. several studies have previously evaluated such rates and highlighted that altruism, hope for personal benefit, contribution to advances in science as well as financial benefit are the main reasons for agreeing to participate, whereas fear of adverse events, impossibility to cope with the logistic constraints accompanying participation, poor knowledge about or negative perception of clinical trials and distrust in pharmaceutical industry are potential barriers [20] [21] [22] [23] . thus, distrust in pharmaceutical companies was suspected to decrease patient willingness to participate in clinical trials but, to our knowledge, this has never been confirmed by juxtaposing patient-reported willingnessto-participate and their level of trust in pharmaceutical companies. we found that 35.5% of respiratory disease patients declared they did not trust pharmaceutical companies. one major finding is that the profile of the latter, "distrusting" patients significantly differs from trusting patients: distrust is associated with female gender, inactive professional status and lack of knowledge on one's own disease. in the second step of our analysis, we calculated rates of willingness to participate in clinical trials. such rates [20] [21] [22] [23] [24] [25] . this variation seems to depend on certain study characteristics: for example, willingness increases with disease severity [24] . clinical research is a wide and heterogeneous area with multiple methodologies, interventions and objectives. referring to "clinical trials" as a single concept is simplistic. similarly, considering willingness-to-participate in a specific subcategory of clinical trials in order to assess global perceptions of clinical research may be misleading. because we distinguished different categories of clinical trials in our survey, we were able to identify trialcategory-related barriers and associated differences in patient profiles. thus, the overall rate of willingness-toparticipate in at least one category of trial was very high (93%) among the 838 surveyed patients we analyzed. globally, patients are not reluctant to join clinical research but, as expected, we found rates that vary significantly depending on the type of trial (intervention tested, market status of the drug and type of trial sponsor) ranging from 11 to 86%. refusal of drug trials was associated with sex, women being more reluctant to join drug trials than men. among drug trials, an important difference exists in patient willingness-to-participate between pre-marketing and post-marketing studies. only 29% of patients we surveyed would have accepted enrolment in a pre-marketing drug trial, while 75% would have participated in a post-marketing trial. we assume this highlights patient trust in the regulatory health authorities responsible for marketing approval. poor knowledge about one's own disease and distrust in the pharmaceutical industry were associated with the refusal of pre-marketing drug trials, but played no role in refusing post-marketing trials. when comparing willingness-to-participate among different types of clinical trial sponsors, we found consistent results with only 11% of patients considering participation in industry-sponsored trials, while 86% would have agreed if the sponsor were academic. again, distrust in pharmaceutical companies plays a role in this difference. this is a major finding which, to our knowledge, has never been identified previously. it may also present a lever for external validity improvement in industry-sponsored trials. thus, targeted educational programs for improving knowledge on both diseases and clinical trials, as well as unbiased media communications about the benefits and risks of collaboration with pharmaceutical companies, could restore patient trust in pharmaceutical companies and increase willingness-toparticipate in clinical trials. a joint effort for education and communication involving mass media, the pharmaceutical company, regulatory authorities and physicians is crucial for both current and future public health. additionally, post-marketing academic trials should be encouraged as well as pooled analyses of industrial and academic results. the main limitation of the present survey is that it was conducted on a specific patient population, i.e. chronic respiratory disease patients. the results should not be extrapolated beyond chronic diseases which are not life-threatening in the short term. the second specificity is that the patients surveyed, living in france, have access to a robust health system which covers the costs of medical care and treatment. in some countries, participation in a clinical trial may be the only way to access care and treatment. our study does not analyze if the barriers to participation that we have identified are likely to influence decision-making in this context. one other limitation of our survey was that we assessed the hypothetical intention to participate, which has been shown to be higher than real participation rates [25] . some patients who declare they would accept participation may refuse once the offer to participate becomes real. we hypothesize that this situation may occur in any subgroup of patient and thus assume that the ranking of rates among trial subcategories, as well as refusal risk factors, are accurate. the questionnaire was developed specifically in french for this study and has not been previously published in any peer-reviewed journal. a bilingual version, provided without cultural validation of the translation, is available as additional file. in short, our results suggest that patient distrust in the pharmaceutical industry could help explain recruitment bias in industry─sponsored clinical trials conducted in similar settings. attention should be paid to this phenomenon because the majority of therapeutic innovations are provided by pharmaceutical companies able to invest significant resources in research and development [15] . moreover, we found that patient distrust is associated with a distinct patient profile. thus, we have no guarantee of the applicability of trial results for these patients. the under-representation of women, minorities and patients with poor health literacy in industrysponsored clinical trials has recently gained awareness [26] [27] [28] [29] and may threaten the generalizability of results [28] . however, there is still very little available data focusing on women enrolment by country or disease. in the french asthma population for example, percentages of women enrolled are higher in women in france in a national academic interventional cohort than in a national industry led early access program to mepolizumab (64.5 and 45%, respectively) [30, 31] . some data suggest that this under-representation of women exists worldwide even in countries where patients might be willing to participate in trials only to have their treatment free of charge [32, 33] . in this survey, we were not authorized to collect ethnicity, so we cannot conclude on this specific characteristic. however, we found that women and patients with poor knowledge concerning their disease were more likely to distrust pharmaceutical companies and are less willing to participate in industry-sponsored trials. this could at least partly explain underrepresentation of these sub-populations in industry-sponsored clinical trials and could be addressed by implementing educational strategies [34] [35] [36] as mentioned previously. the publishing process of the present manuscript takes place during the covid-19 pandemic period. it is difficult to anticipate how the current situation will shape and modify patients' perception of pharmaceutical companies. trusting opinions associated with the hope that pharmaceutical companies will find a treatment and distrusting opinions that accuse such companies of taking advantage of the situation to make money coexist. this should be the endpoint of a specific future study. distrust in pharmaceutical companies is associated with a specific patient profile and with refusal to participate in pre-marketing industry-sponsored drug trials. our results suggest that patient distrust in the pharmaceutical industry could help to explain recruitment bias in indus-try─sponsored clinical trials. further studies are needed to extrapolate results to different healthcare systems and beyond chronic diseases. a potential means for improving the external validity of industry-sponsored clinical trials is to implement educational strategies to increase unbiased knowledge of these trials. there are many ways to achieve this call to action. any initiative is beneficial and all communication media, small and large scale, are complementary. a joint effort dedicated to fighting against fake news and biased media supported by the payers and policy makers appears mandatory and eventually protective. supplementary information accompanies this paper at https://doi.org/10. 1186/s12910-020-00509-y. additional file 1. questionnaire protoaccept -french/english bilingual version. public trust in physicians--u.s. medicine in international perspective trust relations in health care--the new agenda scandals have eroded us public's confidence in drug industry medical decisions regarding hormone therapy for menopausal women are significantly influenced by the media the impact of media attention, family history, politics and maturation on women's decisions regarding hormone replacement therapy mass media and medicine: challenges and opportunities adverse publicity of serious side effects to healthy volunteers has limited effect on willingness-to-participate in clinical trials characteristics of general practitioners who frequently see drug industry representatives: national cross sectional study pharmaceutical industry sponsorship and research outcome and quality: systematic review evidence b(i)ased medicine--selective reporting from studies sponsored by pharmaceutical industry: review of studies in new drug applications patient trust-in-physician and race are predictors of adherence to medical management in inflammatory bowel disease medication adherence: truth and consequences effect of mass media on influenza vaccine coverage in the season 2014/2015: a regional survey in lazio, italy association between vaccine refusal and vaccine-preventable diseases in the united states: a review of measles and pertussis financial anatomy of biomedical research external validity of randomized controlled trials in severe asthma incentives and disincentives to participation by clinicians in randomised controlled trials r: a language and environment for statistical computing. vienna: r foundation for statistical computing so different, yet so similar: meta-analysis and policy modeling of willingness to participate in clinical trials among brazilians and indians unique perception of clinical trials by korean cancer patients involving south asian patients in clinical trials hypertensive patients' willingness to participate in placebo-controlled trials: implications for recruitment efficiency patients' willingness to participate in clinical trials and their views on aspects of cancer research: results of a prospective patient survey participants and study decliners' perspectives about the risks of participating in a clinical trial of whole genome sequencing the new nih and fda medical research policies: targeting gender, promoting justice underrepresentation of women, elderly patients, and racial minorities in the randomized trials used for cardiovascular guidelines barriers to cancer clinical trial participation among saudi nationals: a cross-sectional study sex effect on average bioequivalence clinical and biological characteristics of the french cobra cohort of adult subjects with asthma real-life experience with mepolizumab in the french early access program for severe eosinophilic asthma the more things change, the more they stay the same: a study to evaluate compliance with inclusion and assessment of women and minorities in randomized controlled trials participation of women in clinical trials supporting fda approval of cardiovascular drugs what the public knows and wants to know about medicines research and development: a survey of the general public in six european countries patient perceptions and willingness to participate in clinical trials factors associated with willingness to participate in clinical trials: a nationwide survey study publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations none. the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request after approval from all the authors.ethics approval and consent to participate this prospectively designed study (www.clinicaltrials.gov: nct03098303) was approved by an independent ethics committee (le comité de protection des personnes sud-méditerranée i; reference number: 14-72). as per french legislation and ethics committee approval, no written inform consent was required. patients' consent was implied upon the completion of the questionnaire.consent for publication n.a. none of the authors reports interests related to the present work. dr. laurie pahus reports consultancies for astra zeneca and chiesi pharmaceuticals. dr. carey suehs has no conflict of interest to declare. dr. laurence halimi reports industry-sponsored grants and lecturer activities for glaxosmithkline, actelion and novartis. dr. arnaud bourdin reports industry-sponsored grants from astrazeneca-medimmune, boehringer-ingelheim, cephalon/teva, glaxosmithkline, novartis, sanofi-regeneron; consultancies for astrazeneca-medimmune, boehringer-ingelheim, glaxosmithkline, novartis, regeneron-sanofi, med-in-cell, actelion, merck, roche, chiesi; investigator/co-investigator activities for trials promoted by astrazeneca-medimmune, boehringer-ingelheim, glaxos-mithkline, novartis, regeneron-sanofi, chiesi, actelion, merck, roche, vertex, galapagos; no personal financial support from a non-commercial source; no personal relationships with tobacco industry entities; no off-label disclosures. dr. pascal chanez, as an advisory board member, consultant or lecturer, has previously received honoraria or grants from boehringer ingeheim, almirall key: cord-279559-mob8dbcr authors: coleman, carl h. title: equitably sharing the benefits and burdens of research: covid‐19 raises the stakes date: 2020-05-14 journal: ethics hum res doi: 10.1002/eahr.500055 sha: doc_id: 279559 cord_uid: mob8dbcr one of the central principles of research ethics is that the benefits and burdens of research with human participants should be equitably distributed. this principle has important implications for where research will be conducted, how participants will be recruited, what questions will be investigated, and who will control the distribution of any innovations that result. in the context of covid‐19, key issues include providing support to clinical trials in low‐ and middle‐income countries, without taking needed resources away from other critical clinical and public health needs; designing recruitment strategies likely to generate sufficient enrollment from groups that have been disproportionately burdened by the virus, such as african americans; supporting studies designed to improve outcomes in high‐risk environments, such as nursing homes and group homes for the developmentally disabled; and ensuring that the medical products resulting from research are made available throughout the world at an affordable price. if clinical trials are not designed with equity considerations consciously in mind, the response to the pandemic may further exacerbate disparities in health status between population groups. o ne of the central principles of research ethics is that the benefits and burdens of research with human participants should be equitably distributed. 1 this principle has important implications for questions about where research will be conducted, how participants will be recruited, what questions will be investigated, and who will control the distribution of any innovations that result. in the rush to initiate clinical trials of treatments and vaccines for covid-19, careful attention to these questions is particularly important. if clinical trials are not designed with equity considerations consciously in mind, the response to the pandemic may exacerbate disparities in health status between population groups. the question of where covid-19 clinical trials will be conducted is relevant to both the burdens and benefits of research. on the burdens side, there have long been concerns about the "off-shoring" of studies to low-and middle-income countries (lmics) to take advantage of looser regulation and of populations eager to participate in research because they have no other good options for accessing health care. 2 this concern explains the outrage sparked by a french doctor's statement that covid-19 trials should be conducted in africa to take advantage of the fact that "there are no masks, treatment, or intensive care" (which would presumably make it easier to determine whether the experimental intervention was working). 3 world health organization (who) director-general tedros adhanom ghebreyesus condemned the comment as "a hangover from a colonial mentality. " 4 at the same time, excluding lmics from covid-19 research is clearly not the solution, as doing so would reduce the potential benefits of research for persons in those regions. this is because the results of clinical trials conducted in one part of the world are not necessarily applicable to persons living elsewhere, due to differences in genetic makeups, the prevalence of comorbidities, and local health care infrastructures. 5 it is therefore discouraging that the who's solidarity trial, which is comparing the safety and efficacy of four treatment options for covid-19, currently includes only a few sites in africa, latin america, and south or southeast asia. 6 the global community must commit to supporting clinical trials in lmics that contribute to the development of locally relevant interventions, while also ensuring that these efforts do not take resources away from other critical clinical and public health needs. the manner in which participants are recruited into studies also raises equity considerations. for example, in the united states, there is substantial evidence that african american and hispanic and latinx patients are underrepresented among clinical trial participants. 7 this is a problem because, just like people from different parts of the world, people from different racial and ethnic backgrounds may respond differently to medical interventions. 8 while the reasons for racial and ethnic disparities in clinical trial participation are complex, one factor is reliance on recruitment strategies unlikely to generate significant minority enrollment, such as direct recruitment by physician-investigators at academic medical centers. 9 proven strategies to increase the diversity of clinical trial participants include the development of culturally and linguistically appropriate communication materials, in-person recruitment at free clinics, and the careful use of financial incentives. 10 these and other strategies to overcome racial disparities in research will be particularly important in covid-19 clinical trials, given that the disease is infecting and killing african americans at a disproportionately high rate. 11 also important is support for research specifically focused on the unique needs of certain subpopulations. for example, residents of nursing homes and group homes for the developmentally disabled have been especially hard hit by the covid-19 outbreak. 12 because these populations have suffered a disproportionate share of the burdens of the pandemic, equity requires support for research specifically designed to reduce risk and improve outcomes in these institutional settings. similarly, studies should focus on the unique needs of other populations that may be excluded from largescale clinical trials, such as patients who are pregnant. the looming issue with respect to research on treatments and vaccines for covid-19 relates to control over any medical products that are developed. in most cases, companies that develop new medical products are entitled to patent them, even when the research is supported in part by government funds. patents enable companies to exclude competition and charge high monopoly prices, which effectively blocks large portions of the global population from access to these products. this means that, even when individuals assume risks by participating in research that leads to the development of a medical product, they have no guarantee that, once the product is on the market, it will be made available in their community at a price they can afford. efforts are already underway to ensure more equitable access to covid-19 treatments and vaccines. the who and some prominent government and industry leaders recently pledged to work together to ensure that "all people have access to all the tools to prevent, detect, treat and defeat covid-19. " 13 some companies have committed to making any such products that they develop available on a nonprofit basis. 14 one idea that will be considered at this year's world health assembly is a proposal to establish a mechanism for companies to "pool" patents and other intellectual property rights over covid-19 products, making it easier for developers to access new technologies and for generic manufacturers to produce needed products at an affordable price. 15 yet, while these are encouraging developments, they remain insufficient. the trump administration has made clear that it has no interest in supporting any who-led initiatives, and, in any event, the who lacks the authority to override national intellectual property laws. while voluntary corporate philanthropy is admirable, with more than 100 vaccine candidates currently in development, there is no assurance that the companies making philanthropic pledges will be the ones whose candidate vaccines ultimately succeed. what is needed is an international governance system to oversee access to covid-19 vaccines and treatments. given the fundamental ethical principle of equity in research, advocating for such a system should be a priority for everyone involved in designing, conducting, and funding clinical trials. s carl h. coleman, jd, is a professor of law at seton hall university school of law. council for international organizations of medical sciences (cioms), international ethical guidelines for health-related research involving humans clinical trials in developing countries french doctor apologizes after suggesting africa for coronavirus tests presidential commission for the study of bioethical issues african nations missing from coronavirus trials disparity of race reporting and representation in clinical trials leading to cancer drug approvals from racial and ethnic minorities in clinical trials a step towards equitable clinical trial recruitment: a protocol for the development and preliminary testing of an online prostate cancer health information and clinical trial matching tool lessons learned for recruitment and retention of low-income african americans the coronavirus is infecting and killing black americans at an alarmingly high rate global-leadersunite-to-ensure-everyone-everywhere-can-access-new-vaccines-tests-and-treatments-for-covid-19. 14 key: cord-029332-yn603pvb authors: nan title: full issue pdf date: 2020-07-15 journal: jacc case rep doi: 10.1016/s2666-0849(20)30838-x sha: doc_id: 29332 cord_uid: yn603pvb nan t he coronavirus disease-2019 (covid19) pandemic has revolutionized clinical practice in recent months unlike any other health emergency in recent years. jacc: case reports has taken this challenge very seriously, dedicating to it an entire issue. we have received excellent case reports from across the world. our goal is to provide a comprehensive report of representative cardiovascular involvement in covid-19 (central illustration). besides the concern regarding qt interval prolongation with hydroxychloroquine and azithromycin treatment, covid-19 is strongly associated with the occurrence of sudden unexpected arrhythmias. given the general ignorance of the pathophysiological mechanisms of the virus at the time of submission of these case reports, it is hard to state with certainty that covid-19 has been the cause of these arrhythmias, but they surely offer an interesting direction for future research in the field. included are cases of brugada type i pattern positivization (1) in the context of fever, one of the most common presenting symptoms of the disease (2); electrical ventricular storm (3); transient atrioventricular block in the absence of myocarditis (4); sinus node dysfunction requiring pacemaker implantation (5) ; and finally a provocative report on the use of amiodarone as a possible treatment for covid-19 (6) . overall, the cytokine storm has proved to have a strong impact on the conduction system. the clinical presentation of patients with covid-19 has ranged from asymptomatic to acute respiratory distress syndrome requiring mechanical ventilation. one cause of sudden respiratory deterioration is the increased risk for venous thromboembolic disease in these patients (7) (figure 1 ). these events have been noted both early and in the recovery phase of covid-19. furthermore, thromboembolic events have occurred despite the use of prophylactic anticoagulation or even full anticoagulation (8) . a majority of patients have elevated levels of d-dimer and laboratory findings consistent with sepsis-induced diffuse intravascular coagulation, suggesting a coagulopathic process, yet no prospective studies have demonstrated the predictive nature of these markers for the occurrence of a thromboembolic event, only a higher risk for mortality (9) . the early recognition and treatment of venous thromboembolic disease has therefore been a dilemma. we therefore provide commentary and suggest treatment algorithms (10) . we received case reports in 4 general categories detailing an increased risk or arterial thrombosis during the covid-19 pandemic. causing stemi in infected patients (11, 12) . second, there were a number of cases of stemi in patients younger than 30 years without risk factors for atherosclerosis (13) . this phenomenon occasionally occurred before covid-19, but the increased incidence reminds us to always include myocardial infarction in the differential diagnosis of a younger patient with chest pain and to always consider performing screening electrocardiography. third, a number of cases of stemi mimics were submitted, including patients with st-segment elevation due to myopericarditis, brugada pattern, takotsubo cardiomyopathy, or endothelial dysfunction due to infection or cytokine storm. as many as 40% of patients with covid-19 and st-segment elevation may have normal coronary arteries on angiography, complicating the decision whether to administer fibrinolytic therapy to patients without early access to primary percutaneous coronary intervention. finally, there were reports of spontaneous thrombosis (14) involving the ascending and descending aorta, the cerebrovascular arteries, the mesenteric and renal arteries, and the peripheral arteries, underscoring an increased systemic risk for arterial thrombosis in patients with covid-19. the development of heart failure in patients infected with severe acute respiratory syndrome coronavirus-2 has been described to involve 2 different, and overlapping, mechanisms. one is cytokine release resulting in myocardial inflammation (figure 3) , and affected patients has demonstrated both inflammatory infiltrates and viral particles. the heart failure cases presented in this special issue, however, describe more varied presentations of patients, some with pre-existing heart failure and others with no known cardiac disease prior to becoming ill with infection. in addition to cases of direct myocardial injury, some with pathological evidence, we also present 2 cases of takotsubo cardiomyopathy (16, 17) two cases highlight the special circumstances faced by patients with left ventricular assist devices (18, 19) , which include the inability to tolerate prone positioning to augment respiratory support because of the mechanical equipment and the hypothesis that mechanical circulatory support may provide a type of protection against the most serious hemodynamic consequences of severe acute respiratory syndrome coronavirus-2 infection. included also is a case series of pediatric patients who had hemodynamic collapse and cardiac dysfunction (20) , a presentation that has been rare in this younger age group. the now well-recognized thromboembolic disorders encountered with this disease include a case in this issue of massive pulmonary embolism and resultant severe right heart failure (8) . and 2 separate reports describe patients with concomitant noncardiac disease, 1 with human immunodeficiency virus infection (18) and 1 with influenza (21) . all the cases of heart failure represent the investigators' best attempts at providing supportive and emerging therapies at a time when they had no established guidelines and no best practices to follow. from the beginning of the pandemic, we believed that it was very important to publish the "voices" of our frontline colleagues across the world, to help cardiologists to get acquainted with mechanical ventilation (22) , to describe the first evidence of sex differences in covid-19 (23) , and to discuss the significant changes in health care with telemedicine and virtual clinics. the impact of covid-19 on african americans has also recently been described in jacc (table 1 ) revealed leukopenia, normocytic anemia, thrombocytopenia, and significant increase in c-reactive protein levels. a nasopharyngeal swab sample tested positive for severe acute respiratory syndrome-coronavirus-2 (sars-cov-2) using real time-reverse transcriptionpolymerase chain reaction. the patient had a medical history of bipolar disorder and hypothyroidism. he reported having fever for 1 week. given the patient's presentation of prolonged asystole, differential diagnosis included metabolic disorders, pharmacologic agents and extracardiac diseases with special attention to thyroid hormone levels. to recognize cardiovascular complications among covid-19 patients. to demonstrate arrhythmic risk related to covid-19 disease. to manage sick sinus dysfunction in covid-19 disease. during the following days, the patient had episodes of asystole associated with hypotension but without loss of cardiac output ( figure 3 ). moreover, alternating episodes of bradycardia and tachycardia note bilateral ground glass opacities. once reversible causes were excluded, symptoms were related to dysfunction of the intrinsic sinus node, and the patient underwent dual-chamber ratemodulated implantation of a pacemaker (pm) ( figure 4 ). because of evidence of sinus tachycardia, bisoprolol was administrated. further and later pm control showed only this episode. transthoracic echocardiography was repeated before the patient was discharged and showed no differences from the previous one. in consideration of his progressive clinical improvement, the endotracheal tube was removed, and the patient began to breath spontaneously. on psychiatric indication, therapy for bipolar disorder was reintroduced. this could be due to hypoxia and electrolyte abnormalities, which could lead to episodes of cardiac arrhythmia, or due to central nervous system alterations caused by sars-cov-2 disease. increasing evidence shows that covs are not always confined to the respiratory tract but may also invade the central nervous system, inducing neurological diseases (1, 3) , and some covs have been shown to be able to spread to the medullary cardiorespiratory center through chemoreceptors and mechanoreceptors in the lung and lower respiratory airways through a synapse-connected route (4) . considering that most covs share a similar viral structure and infection pathway (5) , the infection mechanisms previously found for other covs may also be applicable to sars-cov-2. furthermore, the transsynaptic transfer also has been reported for avian bronchitis virus (6) in fact, the intrinsic cardiac nervous system has regional control over different cardiac functions, such as sinus node electrical activation and propagation, as well as atrioventricular nodal conduction, and consists of ganglia composed of afferent, efferent, and interconnecting neurons to other cardiac ganglia. these ganglia coordinate the sympathetic and parasympathetic inputs received from the rest of the cardiac autonomic nervous system. generally, autonomic dysfunction refers to a disorder of an autonomic nervous system that may arise from intrinsic or extrinsic mechanisms. intrinsic autonomic dysfunction arises from diseases that directly affect the autonomic nerves, such as diabetes mellitus and the various syndromes of primary autonomic failure. extrinsic autonomic dysfunction often is secondarily induced by cardiac or other disease (9) . patients with autonomic dysfunction commonly have poor long-term prognosis, and death can occur from pneumonia, acute respiratory failure, sudden cardiopulmonary arrest, or fatal arrhythmias related, for example, to ssd. specifically, ssd includes a spectrum of heart rhythm disturbances related to abnormal sinus impulse formation or propagation (10) and has different presentations, such as bradycardia, alternating episodes of bradycardia and tachycardia and sinoatrial block. in some cases, ssd presents with sinus node arrest and prolonged asystole, such as in the present patient. symptoms related to ssd are generally fatigue and syncope or presyncope, but patients can be asymptomatic in the early phase of the disease. when symptoms are related to dysfunction of sinus node, pm implantation is required. currently, data regarding the neuroinvasive potential of sars-cov-2 with subsequent autonomic dysfunction are less described. furthermore, to these authors' knowledge, this is the first case in medical literature of ssd related to covid19 infection. an improved understanding is crucial primarily for guiding the need for additional arrhythmia monitoring during hospitalization and after discharge (2) . the present authors believe that recognition by the scientific community of these risks related to covid-19 disease may be helpful for strict monitoring of affected patients and also for furthering knowledge of such complications for global public health. diagnostic coronary angiography performed through the right radial approach revealed angiographically normal coronary arteries (figures 3 and 4) . ventriculography confirmed the globally mildly reduced ejection fraction. the patient was admitted to a dedicated coronavirus disease-2019 (covid19) intensive care unit. the covid-19 results became available within 24 h and were positive. his condition continued to improve, and he required minimal supplemental oxygen to maintain arterial saturation. all serial troponin values were negative. two days later he developed a brief episode of supraventricular tachycardia that was successfully terminated with intravenous adenosine ( figure 5 ). four days after the initial presentation, he was doing well without fever. the c-reactive protein level had decreased to 25.4 mg/l, and the ecg demonstrated nearly complete resolution of the initial brugada-like ecg pattern ( figure 6 ). the patient was discharged to home after the 1-week hospital stay. diagnosis and treatment of st-segment elevation myocardial infarction during the covid-19 pandemic present multiple diagnostic and logistic challenges (1) . myocardial injury, myocarditis, acute coronary syndromes, and arrhythmias have all been described in the setting of covid-19 infection (2) . st-segment elevation in the right precordial leads and brugada-like ecg patterns have previously been associated with various conditions (e.g., fever, myocarditis toxicity, metabolic disorders, certain drugs). these brugada-like patterns usually disappear once the inciting event is removed (3) . a brugada-like ecg pattern presents an additional diagnostic and therapeutic challenge because it may be seen in patients presenting with chest pain, thus mimicking st-segment elevation. atrioventricular nodal re-entrant tachycardia, such as developed in our patient, has similarly been associated with brugada syndrome (4) . most recently, covid-19 infection has been described as unmasking brugada syndrome in a patient who presented with syncope (5). our case is important because it demonstrates the need to differentiate between the brugada syndrome and the brugada-like ecg configuration. given that our patient had a covid-19-associated brugada ecg pattern with no history of syncope, observation therapy was recommended because the risk of major adverse cardiac events is low (6) . covid-19 manifests mainly as a respiratory syndrome that includes pneumonia and, in the worst case scenario, acute respiratory distress syndrome (3) . we have also learned that, in a not negligible number of cases, the virus can provoke myocardial ischemia and/or inflammation, with or without an associated respiratory syndrome (4) . there are already numerous cases of covid-19 manifesting as st-segment elevation myocardial infarction that have triggered activation of primary percutaneous coronary intervention protocols. the cause of this stsegment elevation is unknown: it has been linked to traditional plaque rupture in those patients who have required coronary angioplasty, but it has been suggested that myocarditis or microvascular thrombosis could be the cause when no obvious thrombus or coronary flow interruption is detected. if all this were not sufficient, here comes brugada type i pattern, interfering with and complicating the lives of interventional cardiologists. indeed, in the case reported by vidovich (2) , the patient presented with shortness of breath, substernal chest pain, and fever. the electrocardiogram showed a brugada type i pattern in the right precordial leads with no reciprocal changes; the presence of chest pain, shortness of breath, and reduction of systolic left ventricular function, assessed with a 2-dimensional echocardiogram, led to urgent coronary angiography, which excluded an ongoing acute coronary syndrome. no significant electrolyte imbalance was found. vidovich's (2) conclusion was that the brugada type i pattern, completely unknown to the patient until this admisa link between fever and a brugada type i pattern is very well known and has been described extensively (5) (6) (7) . in fact, the international guidelines on sudden cardiac death recommend lowering body temperature as soon as possible in those patients with an established diagnosis of bs, as well as in carriers of the mutations with a proved inducible brugada type i pattern (8) . the increase in body temperature has indeed been proven to cause a higher degree of inactivation of sodium channels, both mutated and wild ones: in the subjects who are genetically predisposed, this reduced sodium flow can result in a dangerous transmural heterogeneity that is the basis for phase 2 re-entry ventricular arrhythmias and sudden death (9, 10) . it would also be of interest understand whether the virus itself could interact directly with the myocardial ion channels and provoke the electrocardiographic modification typical of bs. the take-home message is therefore that patients with bs and concomitant covid-19 infection should be monitored in the intensive care unit or in the telemetry ward until the fever is resolved, regardless of their respiratory conditions. further research will be needed to help clinicians to navigate this uncharted sea. a 49-year-old man presented to the emergency department with acute-onset high-grade fevers accompanied by dry cough and shortness of breath that had been ongoing for a week before presentation. he denied any associated nausea or vomiting, diarrhea, sore throat, congestion, or skin rash. of note, he had recently returned from a high-prevalence area for coronavirus disease-2019 (covid-19) within the united states and was in self-quarantine. he was monitoring his symptoms; however, when his shortness of breath was not improving with his asthma medications (albuterol inhaler and cetirizine), he presented to the emergency department. on arrival, he was noted to be febrile at 102.5 f, he was tachypneic to 22 breaths/min, he was normotensive at 125/75 mm hg, his heart rate was 75 beats/min, and he was saturating 98% oxygen on room air. physical examination was remarkable for decreased breath sounds bilaterally. his past medical history was significant for mild intermittent asthma. our patient's clinical presentation was concerning for viral or bacterial lower respiratory tract infection. an electrocardiogram revealed normal sinus rhythm with normal pr (172 ms) and qrs (94 ms) intervals to anticipate and diagnose conduction disturbances associated with the novel coronavirus. to understand the mechanism responsible for high-degree av block associated with covid-19 without evidence of overt myocarditis. ( figure 1 ). no acute st-t wave changes were noted. a single-view chest radiograph showed blunted costophrenic angles bilaterally with concern for right middle lobe opacity ( figure 2 inflammatory markers were mildly elevated; the ferritin level was 571 mg/ml (normal range 0 to 400 ng/ml), and c-reactive protein was elevated at 1.2 mg/dl (normal range 0 to 0.9 mg/dl). the procalcitonin level was negative at 0.039 ng/ml (normal range 0 to 0.080 ng/ml), and thyroid hormone levels were within normal limits. his nasopharyngeal swab tested positive for sars-cov-2 ribonucleic acid. given the patient's underlying asthma, which predisposed him to an increased risk for pulmonary patients were noted to have cardiac arrhythmias (2) . covid-19 involvement of the heart has ranged from asymptomatic myocardial injury to acute coronary syndrome, mild to fulminant myocarditis, stress cardiomyopathy, and cardiogenic shock; however, the mechanism of cardiac involvement is not exactly clear (3) . furthermore, underlying cardiovascular disease or risk factors and myocardial injury have been shown to portend poor prognosis in these patients (4) . in this case, we present a patient with moderate covid-19 infection who showed evidence of transient conduction disturbances with highdegree atrioventricular (av) block. high-degree av block is known to be an uncommon presentation of acute myocarditis in adults, more commonly seen in cardiac sarcoidosis and giant cell myocarditis (5) . however, because our patient did not have any other overt evidence of myocardial involvement, with normal cardiac biomarkers and a normal echocardiogram, his presentation is unusual and interesting. it is possible that covid-19 may have caused subclinical myocarditis leading to high-degree av block in this case. ace2 receptors are abundant in the heart and are present in multiple cell types, including macrophages, endothelial cells, smooth muscle cells, and cardiomyocytes (6) . further, animal models have shown the presence of ace2 receptors in sinoatrial nodal cells in rats (7) , and conduction disturbances and ventricular fibrillation have been noted with overexpression of the ace2 receptor in experimental mice models (8) . hence, another possibility is that isolated involvement of the av node and infra-hisian conduction system by sars-cov-2 may have caused transient high-grade av block. whether this block is secondary to direct viral involvement or is an autoimmune response is unknown at this time. our patient did not have a recurrence of these conduction disturbances after he was started on supportive her medical history included mild asthma, heart failure with preserved ejection fraction, coronary artery disease (percutaneous coronary intervention 2010), paroxysmal atrial fibrillation (af), hypertension, obesity, and total hip arthroplasty 1-month prior. her differential diagnosis included bacterial/viral pneumonia, acute on chronic heart failure with preserved ejection fraction, pulmonary embolism, and coronavirus disease-2019 (covid19) . on arrival she was hemodynamically stable: heart rate 62 beats/min, blood pressure 130/84 mm hg, respiratory rate of 18, and oxygen saturation 98% on 6l nasal canula. physical examination noted bilateral rales. chest x-ray showed patchy bilateral consolidations with mild interstitial edema ( figure 1) . a computed tomography pulmonary angiogram revealed no pulmonary embolism but bilateral interlobular septal thickening and peripheral ground glass opacities most prominent in the posterior and lower zones. laboratory tests were remarkable for a white blood cell count of 6.0 k/ml, absolute lymphocyte count of 350/ml, the differential for electrical storm in covid-19 remains broad. myocarditis and cytokine storm may not be universal drivers of cardiac sequelae in covid-19. management of these arrhythmias requires consultation with expert, multidisciplinary teams. hemoglobin 8.8 mg/dl (7.7 mg/dl 1 month prior), hyponatremia to 129 mmol/l, ferritin of 1,167 ng/ml, nterminal pro-brain natriuretic peptide of 721 pg/ml, and c-reactive protein of 4.9mg/dl (figure 2a ). remaining laboratory tests were within normal limits. a nasopharyngeal swab was sent for severe acute respiratory syndrome-coronavirus-2 (sars-cov-2) and respiratory viruses, blood cultures were collected, vancomycin and cefepime were started, and the patient was admitted to a negative-pressure room. were mildly elevated at admission and continued to rise with ast, reaching a peak on day 7 of admission. similarly, alt peaked on day 9 of admission. by discharge, the transaminase levels were downtrending ( figure 4 ). an abdominal ultrasound showed normal liver size (15.5 cm) with increased liver echogenicity and a nodular contour suggestive of liver fibrosis, likely due to fontan associated liver disease (fald). his cbc was trended with normalization of his platelet count by day 6 of hospitalization. in the emergency room, the patient was hypoxic with oxygen saturations of 86% on right atrium with accompanying dyspnea. he was placed on 4 to 6 l of oxygen via a nasal cannula, which led to an improvement in the oxygen saturations to low 90s. ggt (g-glutamyl transferase) being the most common (12) . this patient had modest transaminitis likely due to the effects of covid-19 on his underlying fald (13) . the patient was discharged after a 10-day hospitaliover the 12-month period preceding the sars-cov-2-related stay-at-home order, a total of 4 patients followed by the achd service at the university of washington medical center with defects of various severities died in an acute setting. in this report we unexpected mortality among patients with achd appears to have acutely increased at a single academic achd center during the sars-cov-2 pandemic. the ongoing sars-cov-2 pandemic appears to be contributing to increased achd mortality by delaying patient contact with health care. routine follow-up care for high-risk groups, including those with congenital heart disease, during the sars-cov-2 pandemic is critical to ensure appropriate triage and care for vulnerable populations. even with prior clinical stability, these populations remain at risk for acute cardiovascular complications and increased mortality. describe a series of 4 acute-setting achd deaths that occurred within a single week at the time of the effective stay-at-home order. acute-onset death was defined as death that occurred either out of the hospital or within 24 h of presentation to a medical facility. with the exception of 1 patient (case 4) who was called but did not answer the phone 2 days prior to being found dead at home, none of the patients had a missed clinic appointment since the initiation of the stay-at-home order, and none had made contact with the medical system to report concerning symptoms prior to their deaths. a after the procedure, the impella cp catheter was removed without complications, and the femoral access was closed with the use of 2 proglide closure systems (abbott vascular, santa clara, california). the staff allowed to enter the catheterization lab since its outbreak in italy in mid-february, covid-19 has spread rapidly, with over 40,000 cases and more than 3,000 deaths to date. epidemiologic analysis shows that the presence of comorbidities significantly increases mortality: 10.5% in patients with cardiovascular diseases; 7.3% in patients with diabetics; 6.3% in patients with chronic respiratory diseases; 6% in patients with hypertension; and 5.6% in oncologic patients (7) . given the high number of infected patients, we often diagnose cardiovascular diseases at different stages during the viral pathology. in this perspective, some selected patients could benefit from treatments that deviate from current guidelines. we report the first case of a patient with covid-19 and acute coronary syndromes treated in italy for unprotected lmca stenosis with protected percutaneous coronary intervention. the use of the impella cp cardiac assist system to provide left ventricular support during high-risk percutaneous coronary interventions is recommended in such settings, because its efficacy is supported by randomizedcontrolled trials (8) and large registries (9,10). nevertheless, this case also highlights the importance the patient had no significant medical history. he never smoked. there was no family history of cardiovascular disease (cvd). an early viral panel polymerase chain reaction was negative for multiple respiratory viruses. a severe acute respiratory syndrome-coronavirus-2 (sars-cov-2) nucleic acid amplification test early and rapid testing is critically necessary in patients with suspected covid-19 to prevent severe evolution. ecg st-segment elevations in inferior leads have been described in several covid-19 patients, with variable clinical significance. an accurate evaluation of the true incidence of acute myocardial injury related to covid-19 requires a standardized definition, which should include a combination of ecg changes, biochemical markers, and imaging abnormalities. given the very low pre-test probability for coronary artery disease and the absence of coronary calcifications on the chest ct scan, a coronary ct angiogram was not indicated, and the patient was not referred for invasive coronary angiography. the patient was treated conservatively, without thrombolytic agents or initiation of the acute coronary syndrome management protocol. the covid-19 pandemic represents the largest worldwide health care challenge to date. limited but rapidly emerging data have documented the role of cvd in increasing both the risk of infection and the severity of its clinical presentation (1) (2) (3) (4) . in particular, cvd is associated with a sharp increase in overall mortality, which reaches almost 20% of patients hospitalized (5) . however, although such an association can be anticipated to a certain degree (on the basis of existing data from previous outbreaks of influenza and severe acute respiratory syndrome), the incidence of myocardial injury in covid-19 infection appears to be higher (6) . furthermore, the definition of covid-19-associated "myocardial injury" lacks standardization and is based primarily on elevated (and highly variable) serum levels of cardiac-specific troponins as the single most common defining markers. this myocardial injury has been associated with possibilities. logistically, we now understand that the decision to proceed with angiography carries a significant risk for nosocomial spread of the virus endangering hospital staff. we are also learning that acute kidney injury is quite prevalent and highly associated with mortality in covid-19 patients (6). one should think twice before administering intravenous contrast medium in these patients. consensus documents from our professional societies that are based on early covid-19 observations have resurrected considering the use of fibrinolytic therapy for stemi (7) . in a setting of limited staffing and resources, and where time to treatment is expected to be significantly delayed, fibrinolytic therapy provides a more rapid and logistically easier approach to reperfusion therapy while reducing staff exposure to infection. however, contraindications to fibrinolytic therapy have to be absent, and stemi mimics have to be excluded. the fibrinolytic strategy is probably most reasonable for hospitals without pci capability or immediate availability. at pci-capable hospitals with adequate staffing, primary pci is still preferred (8, 9) . until there is universal availability of rapid testing (<5 min) for both the virus and the antibodies, our approach to stemi will have to be modified. this is primarily the result of new infection control considerations that will have to be included in our daily workflow. the current door-to-balloon time quality metric should be suspended by hospital quality improvement committees as a measure of system performance because of the current diagnostic and logistical challenges in delivering stemi care. in the american college of cardiology national cardiovascular data registry cathpci registry reporting form, noting a "system delay" as a reason for a prolonged door-to-balloon time will avoid any external quality of care penalties. we now work in the era of covid-19 stemi care. the patient remained asymptomatic, and no confirmatory tests were performed for the same reason as in the first patient. very late lad artery stent thrombosis was found, and a new des was implanted. the patient was asymptomatic, but because the covid-19 pandemic had reached its peak, a pre-admission polymerase chain reaction test was performed, with a positive result. the patient had a favorable course and was discharged 5 days later. as antiplatelet therapy. ten days later, prasugrel was replaced by clopidogrel (after antiviral treatment was completed), and the patient was discharged. the covid-19 pandemic has significantly decreased worldwide interventional cardiology activity. in spain, cardiac catheterization procedures have been reduced by 48%, with a reduction of 40% for primary angioplasty (2) . similar data have been reported in we present 1 case of acute stent thrombosis and 3 very late stent thrombosis cases ( table 1) . despite no initial covid-19 testing in 2 cases, symptoms and subsequent testing ( figures 3a to 3d ) supported that the patients were infected at the time of stent thrombosis ( table 2) . the patient reported an active lifestyle with a history of playing competitive football and had a body mass st-segment elevation myocardial infarction with a high thrombus burden can appear as the first and only onset of covid-19 symptoms. plaque rupture in predisposed patients with cardiovascular risk factors can be enhanced by severe inflammation and worsened by prothrombotic characteristics of this new infectious disease. in the course of this covid-19 pandemic, sars-cov-2 infection should probably be ruled out in patients with unusual or severe thrombotic and ischemic events, even when there are no symptoms of covid-19 disease. index of 27 kg/m 2 . he had no significant medical history except for past smoking (20 pack-years), which he had quit 2 years before. he had no family history of cardiovascular disease and was taking no medication or drugs. no diagnosis other than a stemi was possible. the initial electrocardiogram displayed a sinus rhythm with an anterior st-segment elevation and q waves with negative t waves in the inferior leads the patient did not develop heart failure, or heart rhythm disturbances, or other complications of myocardial infarction. furthermore, he remained free of covid-19 disease symptoms. in the context of the covid-19 pandemic, unusual myocardial infarction presentations, such as in young individuals at low cardiovascular risk, should lead to with t-wave inversion in diii and avf ( figure 1 ). the patient had no past medical history and was not on any medications. to describe the management of patients with refractory ards requiring coronary angiography. to describe the feasibility of coronary angiography with the patient in prone position. the differential diagnosis included acute myocardial infarction, myocarditis, and takotsubo syndrome. there was no evidence of obstructive coronary disease, and the final diagnosis was myocarditis, although we were not able to perform cardiac magnetic resonance in this highly unstable patient. with a rapid spread worldwide, covid-19 has become a public health emergency of international concern (1). the clinical course of sars-cov-2 infection is mostly characterized by respiratory tract symptoms, including fever, cough, pharyngodynia, fatigue, and complications related to pneumonia and ards, often in a patient in prone position, the geometry and orientation of the heart as well as the coronary anatomy do not allow to obtain perfectly symmetric pictures of the coronary arteries using usual views. consequently, the interpretation of coronary angiography was simply done following the heart's shape. with unchanged cranial/caudal tilts (8, 9) or using the double-inversion technique to normalize all angiographic pictures such as in a left-located heart (10) is usually enough to perform and analyze coronary angiography in such patients. finally, even though we did not perform percutaneous coronary intervention, performing percutaneous coronary intervention with a patient in prone position would not be a critical issue for an experienced operator. pandemic, the most plausible diagnosis seemed to be a severe acute respiratory syndrome-coronavirus-2 (sars-cov-2) infection. tables 1 and 2 summarize the biochemical tests and atrial blood gas analysis before, during, and after amiodarone therapy. figure 1 shows the illness clinno adverse events were reported. the patient was discharged on day 8. infection in cell cultures and mouse models (4, 5) . amiodarone is a widely available, low-cost antiarrhythmic drug that in the past has been considered as a possible antiviral medication (6) . amiodarone and its main metabolite (mono-n-desethyl amiodarone) were shown to inhibit the entry of filoviruses (a family of single-stranded, negative-sense rna viruses that includes ebola virus) at the same serum concentration found in patients treated for arrhythmias (7, 8) . amiodarone also proved able to remain to be investigated, and drug interaction with other treatments (e.g., hydroxychloroquine, lopinavir/ritonavir, atazanavir, and darunavir/cobicistat) are major concerns (10) . notably, amiodarone toxicity at follow-up visit, 10 days after discharge, the patient was asymptomatic. in this case, amiodarone was given for research purposes in a hospital setting. this is an approach still under investigation. do not try this at home. to diagnose acp in patients with sars-cov-2-related ards. to appreciate potential role of almitrine in improving oxygenation and rv function. to understand sars-cov-2-related atypical type of ards. medical history included only an overweight with a body mass index of 38.9 kg/m 2 . the differential diagnosis included pulmoand septal dyskinesia disappeared ( figure 1c ). moreover, rv global longitudinal strain improved from -14.8% to -22.7% ( figure 1d ). twelve hours following almitrine infusion, rvswi decreased from 19.7 to 17.5 g/m/beat/m 2 . the clinical spectrum of sars-cov-2-related cardiovascular complication includes myocarditis, pericarditis, vasoplegia, rv failure, and acute coronary syndromes (1, 2) . in this case, we highlight the rv dysfunction another explanation is the impact of ards and mechanical ventilation on the rv. acp is a well-known complication of ards despite a protective ventilation, with an incidence of 25%. hence, acp may be related to a high driving pressure, leading to an increased rv afterload (4) . moreover, the patient was on norepinephrine, which may increase rv afterload. another explanation is that hypoxia could lead to rv dysfunction in its own right (5). ventilation-to-perfusion ratio (8) . moreover, previous studies in the 1990s showed that at a low dose, the deleterious effect on pulmonary vascular resistance was negligible, especially when associated with nitric oxide (9) . hence, we hypothesized that almitrine use in the case of sars-cov-2 atypical ards might be useful. in the present case, almitrine infusion was associated with rv function improvement and decrease in pulmonary vascular resistance. this is probably due not only to a better oxygenation, but also to a better distribution of pulmonary vascular flow to aerated lung areas. before almitrine infusion, we observed a high rvswi with a normal-to-low range of ci, suggesting a hemodynamic disconnection between the rv and left ventricle. the reduction in rv afterload by almitrine infusion resulted in an improvement in this disconnection (decreased rvswi and improved ci). as almitrine infusion could induce reversible lactic acidosis and hepatic dysfunction (10) to describe high-risk clinical features in a patient on durable lvad support who developed covid-19. to illustrate potential complications and clinical dilemmas in managing covid-19 in a patient supported with a durable lvad. reverse transcription polymerase chain reaction results for severe acute respiratory syndrome-coronavirus-2 (sar-cov-2) was positive at the initial emergency department visit and at the authors' institution. serial laboratory and imaging tests are detailed in table 1 . several markers of disease severity were abnormal including absolute lymphocyte count, c-reactive protein level, and cardiac enzymes. chest radiographs showed bilateral infiltrates concerning for atypical pneumonia (figure 1 ). the patient was quarantined in a negative-pressure intensive care room. the host response to covid-19 infection is often localized in the lung parenchyma, but a surge in proinflammatory cytokines can occur (3, 4) . known as a "cytokine storm," this phenomenon is described in dynamics. we should closely monitor for: 1) rv failure and need for inotropic support; 2) drops in lvad speed or suction events, low flow, or pulsatility index events due to vasoplegia associated with infection. to limit health care workers' exposure to covid-19, nonessential testing such as echocardiograms, the antimalarial medication hydroxychloroquine, which was chosen as the initial treatment agent for our patient, was shown to reduce in vitro sar-cov-2 cell entry, and a retrospective study suggested its clinical benefit in covid-19 (3, 4) . a major side effect is qtc prolongation, so the present protocol provides monitoring guidance of this complication. immunomodulatory biological agents such as tocilizumab are reserved for severe covid-19, defined by the values in bold are in-hospital values that were consistent with baseline values. *last visit values were the latest values obtained within the previous 6 months. baseline ldh, wbc, platelet, absolute polymorphonuclear leukocytes, and absolute lymphocytes were recorded as an average of the previous 3 values measured within 1 year. â� this patient was placed on ventilator support on the night of hod 2 and was given tocilizumab on the evening of hod 3. â�¡this patient experienced pulseless electrical activity arrest after the return of spontaneous circulation. krelative change is the percentage of increase or decrease from baseline value. alt â¼ alanine aminotransferase; ards â¼ acute respiratory distress syndrome; ast â¼ aspartate aminotransferase; bnp â¼ b-type natriuretic peptide; ck-mb â¼ creatine kinase mb; cvp â¼ central venous pressure (obtained from right heart catherization at baseline, and from central venous line in the hospital); egfr â¼ estimated glomerular filtration rate; fio2 â¼ fraction of inspired oxygen; hod â¼ hospital day; ldh â¼ lactate dehydrogenase; lvad â¼ left ventricular assist device; map â¼ mean arterial pressure (obtained from doppler or arterial line); pao2 â¼ arterial partial pressure of oxygen; wbc â¼ white blood cell. presence of both worsening respiratory failure and a cytokine storm as shown by increasing inflammatory markers. still, caution is warranted as major adverse effects of tocilizumab include infection, infusion reactions, dyslipidemia, neutropenia, and potential malignancy (7) . patients on lvad support are particularly vulnerable to infectious complications due to the inherent presence of hardware and driveline finally, prone ventilation is beneficial in cases of severe ards. the maneuver has been effective in improving lung mechanics and gas exchanges, and in some cases, it may prevent the need to escalate to venous-venous extracorporeal membrane oxygenation (8, 9) . although there are no published outcomes, early experience in wuhan, china indicates that prone position was widely used in patients with covid-19-related severe ards with possible benefits (9) . nonetheless, it may be prohibitive in heart failure patients on lvad support. a 58-year-old woman presented with productive cough, fatigue, fever, and diarrhea for the previous 5 days. physical abbreviations as in figure 2 . (6) . stress cardiomyopathy has also been reported with viral infections (7) . histological studies have shown mild inflammatory infiltration (8, 9) , and it is possible that heightened inflammation with viral infections, particularly that seen with covid-19, may contribute to development of stress cardiomyopathy. overall, the prognosis of stress cardiomyopathy is favorable, with the majority of patients fully recovering lv function by 2 months (4). twitter: @ferrasdabbagh1. he had a history of hypertension and was taking lisinopril. the differential diagnosis included sars-cov-2 causing severe ards and acute cardiac injury from direct viral toxicity (i.e., myocarditis), acute coronary syndrome (acs), demand ischemia, and stress cardiomyopathy. prevalence and prognostic implications of cardiac injury (defined as troponin elevation >99th percentile upper reference limit) in covid-19. considerations for differentiating causes of cardiac injury in covid-19. management strategies for myocarditis and severe ards in covid-19. and mortality benefit in animal models (11) . improved airway inflammation has also been observed in animals treated with aris (12) . other viral infections such as influenza and respiratory syncytial virus were considered, but the pre-test probability for covid-19 was high because other residents at the facility had been diagnosed with covid-19 recently. in the emergency department, the patient was tachypneic with an initial oxygen (o 2 ) saturation 98%. table 1 lists the results of his initial laboratory testing including normal levels of ferritin, procalcitonin, interleukin (il)-1, and il-6. levels of c-reactive protein, lactate dehydrogenase, and troponin were elevated. there was a reduced white blood cell count without lymphopenia. a chest radiograph had no air space or interstitial infiltrates (figure 1 ). there was a single low-flow lvad alarm noted 3 days prior to presentation. based upon the adequate room air saturation, absence of pulmonary infiltrates, and minimally abnormal inflammatory markers, the patient was classified as having a mild case of covid-19. due to persistent breathlessness, hydroxychloroquine was initiated on day 2 with qtc monitoring. to the best of our knowledge, this is the first rein the current covid-19 pandemic, lopinavir/ritonavir was studied in a randomized, controlled trial in table 2) . the patient was discharged to his nursing facility on hospital day 5 once a room was available where he could be quarantined, and he continued to feel well 10 days later. mahmood et al. to make a diagnosis of fulminant myocarditis concomitant with covid-19 pneumonia. to understand the value of serial cardiac magnetic resonance after myocarditis due to covid-19. sinus tachycardia (100 beats/min) with negative t waves from v 2 to v 4 . to be able to arrive at the differential diagnosis of acute cardiac dysfunction in the setting of severe covid-19 disease early after heart transplantation. to understand the need for individualized management, balancing risks of infection and rejection in heart transplantation recipients with severe infections early after transplantation. was discharged to isolation at home with pulse oximetry and plans for daily telemedicine assessments. three days later the patient presented to the emergency department with rapidly progressive respiratory distress and hypoxia. the patient had a history of end-stage nonfigure 1 . the patient reported continued gradual recovery by weekly telemedicine assessments after discharge. he had a history of pityriasis lichenoides chronica. he had no personal or family history of congenital heart disease, immunodeficiency, or autoimmune disease. the differential diagnosis included viralinduced myocarditis or underlying cardiomyopathy unmasked by an acute viral illness. table 1) . the patient has had no recurrent episodes of chb since day 4 of admission, and a repeat echocardiogram on day 12 of admission demonstrated lownormal biventricular systolic function. and conduction abnormalities appears to be a rare manifestation of sars-cov-2 infection in children (3) (4) (5) . nonetheless, evaluation for myocardial injury may be warranted in pediatric patients with symptomatic sars-cov-2 infection, particularly in patients whose clinical symptoms (e.g., dyspnea, hypoxia) seem out of proportion to chest imaging findings. on autopsy, histopathologic examination of the heart showed mild to moderate myocyte hypertrophy with mild to moderate diffuse interstitial and perivascular fibrosis (figures 2a and 2b) . the impact of influenza co-infection in this patient with covid-19 must also be considered because this virus is known to contribute to cardiovascular morbidity and mortality secondary to up-regulation of the inflammatory response and endothelial dysfunction (2) . as such, influenza a likely had significant effects on her cardiac functioning. coinfection with sars-cov-2 is of great concern, with limited data delineating the the patient's medical history showed arterial hypertension, dyslipidemia, and impaired fasting blood sugar. covid-19 has extrapulmonary and cardiovascular manifestations. covid-19 may be associated with exaggerated inflammatory response with an abnormal activation of coagulation, so a screening of coagulation setup may be indicated. covid-19 may show up with takotsubo syndrome. the differential diagnosis included acute myocardial infarction, takotsubo syndrome, myocarditis, and coronary embolism. the patient was transferred to our center for an urgent coronary angiography, which revealed nonsignificant coronary atherosclerosis. figures 5 and 6 , videos 3 and 4). our priority was to treat the patient with enoxaparin 7,000 iu twice daily as per the patient's weight. during the first days of hospitalization, and taking into consideration that the patient was hypotensive (systolic blood pressure: 80 mm hg; mean blood pressure: <65 mm hg), we treated the patient with chest radiography was repeated in the following days and showed progressive reduction of interstitial pneumonia. also, blood test results revealed an improvement of inflammation indexes ( table 1) . on day 7 of hospitalization, the nasopharyngeal swab was repeated, with a positive result. the first negative result was registered on day 15. on the 14th day, we performed another transthoracic echocardiography, which showed the resolution of the 2 thrombi ( figure 7) and a complete restoration of lvef (57%) (video 5). his past medical history was notable for type 2 diabetes mellitus, remote prostate cancer, and ventricular tachycardia. covid-19 and concern over prolonged separation from his family. our service is modeled after previously published "e-consultation" workflow recommendations in "peacetime" prior to the sars-cov-2 outbreak (4). in phase 2, we implemented these processes, and all emergent cases were treated as puis. as we approach phase 3, our processes continue to undergo iterative improvements and all cases coming to the ccl will be considered puis. our approach to stat and routine tee is outlined in remote monitoring is used for electrophysiology clinic device checks, with patients triaged to present for evaluation if they develop concerning arrhythmias, heart failure alerts, or device-related issues. *vt storm that has failed medical treatment including at least 2 antiarrhythmic drugs (including propranolol), treatment of underlying reversible condition if present (qtc prolongation due to ischemia, medications, or metabolic/electrolyte imbalance), general anesthesia, and left stellate ganglion block (if available). â� not reversible or fails to respond to chronotropic drugs such as isoproterenol, dopamine, and/or scopolamine, and temporary pacing cannot be safely maintained in an intensive care setting. in this scenario a screw-in active fixation lead connected to an externalized generator or an active fixation temporary pacing lead may be considered depending on the patient's clinical condition and could be performed in the intensive care setting under fluoroscopic guidance (if available) or in an operating room with negative airflow capabilities and fluoroscopy. cied â¼ cardiac implantable electronic devices; eos â¼ end of service; eri â¼ elective replacement indicator; vt â¼ ventricular tachycardia. in the wake of this pandemic, formal medical student and trainee didactics were disbanded to allow for social distancing. additionally, several states expe her past medical history included hypertension and diabetes mellitus. the differential diagnosis included communityacquired pneumonia, atypical pneumonia, and corofigures 3a and 3b ). the patient was started on therapeutic enoxaparin and was closely monitored for hemodynamic instability. she declined to take hydroxychloroquine, recommended by some experts for management for covid-19. she remained hemodynamically stable and was transitioned to oral anticoagulant therapy (apixaban) with plans to continue anticoagulation for 6 months. the covid-19 outbreak is an unprecedented global public health challenge. since the end of december 2019, when the first cases of sars-cov-2 infection were detected in wuhan, china, the disease has spread exponentially (1). on january 30, 2020, the world health organization declared covid-19, the disease caused by the novel coronavirus, a public health emergency of international concern and later officially upgraded it to a global pandemic. as of april 24, 2020, more than 2,790,000 confirmed cases from more than 180 countries and more than 195,000 deaths have been documented worldwide. the projected u.s. death toll is >240,000, with an estimated total burden of more than 1 million covid-19 cases. in approximately 88% of cases, fever is the most common presentation, followed by cough (68%), vomiting (5%), and diarrhea (3.8%) (2) . in up to 15% of patients, the natural course of the disease is complicated by severe interstitial pneumonia, which can lead to acute respiratory distress syndrome, multiorgan failure including acute kidney injury, dissemi to suspect pe early in the disease process in confirmed or suspected covid-19 patients. to identify high-risk patients early and to offer appropriate therapies while mitigating patient and provider risk. the patient was managed with intravenous unfractionated heparin (ufh) and dobutamine; infection. cdt is associated with early improvement in rv function and hemodynamics in deteriorating patients with lower doses of tpa (8, 9) ; however, pui approximately 10 times less frequent (15, 16) . importantly, a substantial proportion of the thrombotic events were diagnosed very early during the hospital stay, suggesting that they had already occurred before admission (15) . in view of the previously mentioned (preliminary) findings, and although it cannot yet be concluded with safety that the thrombosis risk among patients with severe covid-19 is substantially higher than that of patients with severe infection caused by other bacterial or viral pathogens (19, 20) , thrombotic events are very likely to be a key aspect of covid-19-associated morbidity and mortality (21) . it is therefore now necessary to make the patient's medical history was notable only for obesity (body mass index 31 kg/m 2 ) and type 2 diabetes. the primary differential diagnosis for the patient's the usual risk stratification schema for acute pe rely on a combination of hemodynamic clinical parameters, such as hypoxemia, tachycardia, and hypotension along with serum biomarkers, such as troponin or brain natriuretic peptide, followed by confirmatory imaging tests (12) . severe covid-19-related ards may present with many similar hemodynamic and biomarker derangements masking underlying vte. illness. figure 2 ). an axillobifemoral bypass was performed, followed by therapeutic anticoagulation with good initial results. the patient died 7 days after surgery from a major hemorrhage. case 3. the third patient was a 72-year-old male with history of hypertension, diabetes, and coronary artery disease ( table 1 ) who was admitted for hypoxic ct angiography of patient 1 shows a nonobstructive thrombus formation of descending aorta (arrow) in an axial view (a) and a sagittal view (b). disease. a recent paper attributes this state "to excessive inflammation, platelet activation, endothelial dysfunction, and stasis" (5) . others have suggested that formation and polymerization of fibrin are responsible for this hypercoagulability (6) . therefore, recent recommendations insist on thromboprophylactic measures to prevent thromboembolism (4, 7, 8) . a recent publication found evidence of the presence of virus in endothelial cells (9) . one explanation is that the angiotensin-converting enzyme 2 receptor that the virus uses to infect cells is widely expressed in endothelial cells. this causes endotheliitis, which could explain why covid-19 patients seem prone to venous and arterial thrombosis. this paper (9) blockade may also be considered (7) . it should be noted that mild ards may be managed with noninvasive forms of ventilation. however, during the present pandemic, modifications to usual critical care may be necessary. given concern for viral transmission, current recommendations advise it is also important to monitor the patient's driving pressure, or difference between the peep and plateau pressure, as increased driving pressures have been associated with higher mortality in ards (10) . with a basic understanding of these fundamentals, it is possible for all cardiologists to provide safe and effective care for our patients with covid-19. as many of us prepare to use skill sets long forgotten, it will be important to remember to ask for help when needed. one of the few bright spots in this pandemic has been the resurgence of interdisciplinary teamand is thought to protect against lung injury. these 2 functions may be due to differences in the location of the ace2 proteins, transmembrane or in the plasma (16) . the ace2 gene is located on the x chromosome, which suggests that women might have higher ace2 levels and thus be protected against more severe disease compared to men (17) . there has been recent concern in the cardiology community about the possible negative effect of italy, as it has done in the past, will improve its health and economic systems after this tragedy. probably nothing will be like before, and this catastrophe will be a great opportunity to further improve an efficient and effective national universal health system. heroes, we look like prey in heroes' capes. that kind of bravery, that work integrity, is not boundless. no one is so fearless or short-sighted as to discount all risks. when i try to figure out how i feel in this moment, the italian motto "andrã  tutto bene" ("everything will be alright") that has been viral since the onset of the the ccl nursing staff was reinforced to speed up procedures. all noncritical equipment or supplies were removed from the ccl to facilitate cleaning and disinfection procedures. availability of ppe is a concern, so we created 2 sets of ppe to best manage available resources: a mid-level kit and a fullprotection kit for suspected and confirmed cases. despite the concern of the medical community, we believe society has largely adhered to the social isolation recommendations, as we are looking at a constant drop in admissions to intensive care units and an increase in patients successfully discharged. the availability of masks for everyone is still not a reality as we are conceiving the first draft of a plan to reduce restriction measures. subsequently, as we are receiving more papers, we have decided to divide jacc: case reports publications into 5 sections: acute coronary syndromes, heart failure, arrhythmias, thromboembolic events, and stories from the front line, in the format of "voices of cardiology" papers. all these papers have been highlighted in this issue (4) . recognizing the value of not overloading our audience with publications, and in an effort to keep the quality high and up to the standards of jacc journals, we accepted approximately 8% to 10% of the manuscripts submitted. we selected the best of the best cases and brought together world-renowned specialists to write editorials. although we understand that clinical cases have been of crucial importance for our understanding of covid-19, it is of equal importance that they cannot substitute for large studies and pharmacological trials. therefore, unless we were dealing with an impressive side effect of a medicine, we have been very cautious in publishing pharmacological evidence, as large trials would prove the benefits and side effects of these medicines currently under trial. another important task of jacc: case reports is that to ease navigation on the acc covid-19 hub, its content was organized into sections on clinical guidance, practice considerations, and frontline perspectives. given the novelty and rapidity of the covid-19 pandemic, most of the initial content was based on analyses of frontline experiences and expert opinion. the hub executive team and sqc worked to ensure that the content struck a balance between reasonable, actionable suggestions and acknowledgment that more rigorous research was needed to better inform the best approach to covid-19 management. going forward, the hub will continue to generate content but now turn its attention to highlighting the growing peer-reviewed research on covid-19 and cv disease. the acc has commissioned a task force to promote research in this area, and the hub will serve as a primary dissemination platform, in conjunction with jacc and other cardiology-focused journals. in addition, the hub will highlight best practices and frontline experiences from its membership on "reopening" protocols. with projections that covid-19 will ebb and flow worldwide over the next several years, our membership will need to navigate the best way to continue to treat cv disease during this time. the acc covid-19 hub has proved to be a useful resource to assembling and distributing information broadly during a rapidly evolving pandemic. lessons learned include the need to build a nimble process to commission, organize, and distribute content, an ability to engage with experts to generate content, a method to closely monitor of member and community needs to inform content development, and an emphasis on highlighting rigorously conducted research and expert consensus over mere opinion and speculation. sars-cov-2 infection in children available at: https:// picsociety.uk/news/pics-statement-regardingnovel-presentation-of-multi-system-inflammatorydisease covid-19 and the heart sars-cov-2 and viral sepsis: observations and hypotheses myocardial localization of coronavirus in covid-19 cardiogenic shock: covid-19 does not spare the heart cardiac involvement in a patient with coronavirus disease 2019 (covid-19) the cytokine release syndrome (crs) of severe covid-19 and interleukin-6 receptor (il-6r) antagonist tocilizumab may be the key to reduce the mortality epidemiology of covid-19 among children in china cardiac dysfunction and shock in pediatric patients with covid-19 an outbreak of severe kawasaki-like disease at the italian epicentre of the sars-cov-2 epidemic: an observational cohort study hyperinflammatory shock in children during covid-19 pandemic cardiac dysfunction and thrombocytopenia-associated acute heart failure in multisystem inflammatory syndrome in children (mis-c) in the context of global sars-cov-2 pandemic cdc covid-19 response team. coronavirus disease 2019 in children-united states covid-19 epidemic: disease characteristics in children sars-cov-2 infection in children-understanding the immune responses and controlling the pandemic projected growth of the adult congenital heart disease population in the united states to 2050: an integrative systems modeling approach prevalence and predictors of gaps in care among adult congenital heart disease patients: heart-achd (the health, education, and access research trial) the demand for hospital emergency services: trends during the first month of covid-19 response covid-19: a&e visits in england fall by 25% in week after lockdown seattle-early lessons learned long-term evolution of premature coronary artery disease stsegment elevation in patients with covid-19-a case series acute infection and myocardial infarction cardiac complications in patients with community-acquired pneumonia: incidence, timing, risk factors, and association with short-term mortality international consensus group on cardiovascular magnetic resonance in myocarditis. cardiovascular magnetic resonance in myocarditis: a jacc white paper world health organization. pneumonia of unknown cause-china clinical features of patients infected with 2019 novel coronavirus in wuhan, china cardiovascular complications of severe acute respiratory syndrome cardiac involvement in a patient with coronavirus disease 2019 (covid-19) molecular biology and pathogenesis of viral myocarditis advances in the understanding of myocarditis genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding management of critically ill adults with covid-19 the variety of cardiovascular presentations of covid-19 first cases of covid-19 in heart transplantation from china epidemiological and clinical characteristics of heart transplant recipients during the 2019 coronavirus outbreak in wuhan, china: a descriptive survey report typical takotsubo syndrome triggered by sars-cov-2 infection myocardial localization of coronavirus in covid-19 cardiogenic shock clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study the science underlying covid-19: implications for the cardiovascular system the impact of 2019 novel coronavirus on heart injury: a systemic review and meta-analysis sars-cov-2 infection in children severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection in children and adolescents. a systematic review epidemiology of covid-19 among children in china clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china transient complete heart block in a patient with critical covid-19 cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (covid-19) potential effects of coronaviruses on the cardiovascular system: a review rates of co-infection between sars-cov-2 and other respiratory pathogens cardiac involvement in a patient with coronavirus disease 2019 (covid-19) cardiac tamponade secondary to covid-19 acute myocarditis presenting as a reverse tako-tsubo syndrome in a patient with sars-cov-2 respiratory infection typical takotsubo syndrome triggered by sars-cov-2 infection intraventricular thrombus and severe mitral regurgitation in the acute phase of takotsubo cardiomyopathy: two case reports endothelial cell infection and endotheliitis in covid-19 isth interim guidance on recognition and management of coagulopathy in covid-19 abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia acute pulmonary embolism and covid-19 pneumonia: a random association? clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study direct oral anticoagulants for the treatment of left ventricular thrombus-a new indication? a meta-summary of case reports doacs in left ventricular thrombosis decision making in advanced heart failure: a scientific statement from the american heart association informing candidates for solid-organ transplantation about donor risk factors united states public health service. phs guideline for reducing human immunodeficiency virus, hepatitis b virus, and hepatitis c virus transmission through organ transplantation disclosure of infectious risk to heart transplant candidates: shared decision-making is here to stay decline of increased risk donor offers on waitlist survival in heart transplantation heart expand continue access protocol prevalence of comorbidities in the middle east respiratory syndrome coronavirus (mers-cov): a systematic review and meta-analysis acute myocardial infarction after laboratoryconfirmed influenza infection clinical characteristics of coronavirus disease 2019 in china integrating inpatient electronic consultations in cardiology fellowship clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china covid-19 and the cardiovascular system catheterization laboratory considerations during the coronavirus (covid-19) pandemic: from acc's interventional council and scai quote from a venture capitalist meeting in california covid-19 and health care's digital revolution making emergency supplemental appropriations for the fiscal year ending september 30, 2020, and for other purposes association of veterans health administration home-based programs with access to and participation in cardiac rehabilitation cardiac arrest deaths at home in new york city have increased by a startling 800% long distance tele-robotic-assisted percutaneous coronary intervention: a report of first-inhuman experience large-scale assessment of a smartwatch to identify atrial fibrillation a novel coronavirus from patients with pneumonia in china clinical characteristics of coronavirus disease 2019 in china analysis of deaths during the severe acute respiratory syndrome (sars) epidemic in singapore: challenges in determining a sars diagnosis anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study characteristics, causes, diagnosis and treatment of coagulation dysfunction in patients with covid-19 covid-19 complicated by acute pulmonary embolism and right-sided heart failure difficulties of managing submassive and massive pulmonary embolism in the era of covid-19 for the cuimc pert team. right ventricular clot in transit in covid-19: implications for the pulmonary embolism response team prevention and treatment of venous thromboembolism associated with coronavirus disease 2019 infection: a consensus statement before guidelines clinical characteristics of coronavirus disease 2019 in china clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study covid-19: consider cytokine storm syndromes and immunosuppression complement associated microvascular injury and thrombosis in the pathogenesis of severe covid-19 infection: a report of five cases anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy hematologic parameters in patients with covid-19 infection acute pulmonary embolism and covid-19 pneumonia: a random association? pulmonary embolism in covid-19 patients: awareness of an increased prevalence venous and arterial thromboembolic complications in covid-19 patients admitted to an academic hospital in incidence of thrombotic complications in critically ill icu patients with covid-19 prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia high incidence of venous thromboembolic events in anticoagulated severe covid-19 patients vte incidence and risk factors in patients with severe sepsis and septic shock venous thromboembolism in critically ill patients. observations from a randomized trial in sepsis covid-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up european society of cardiology. esc guidance for the diagnosis and management of cv disease during the covid-19 pandemic isth interim guidance on recognition and management of coagulopathy in covid-19 covid-19 and haemostasis: a position paper from italian society on thrombosis and haemostasis (siset) guidelines for management of venous thromboembolism: heparin-induced thrombocytopenia esc guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the risk of covid-19 illness in native and immunosuppressed states: a clinicaltherapeutic staging proposal isth interim guidance on recognition and management of coagulopathy in covid-19 covid-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up clinical pathology of critical patient with novel coronavirus pneumonia (covid-19) pulmonary artery thrombosis in a patient with severe acute respiratory syndrome acute pulmonary embolism and covid-19 pneumonia: a random association? covid-19 complicated by acute pulmonary embolism and right-sided heart failure prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia incidence of thrombotic complications in critically ill icu patients with covid-19 acute respiratory distress syndrome: the berlin definition diagnosis, treatment and follow up of acute pulmonary embolism: consensus practice from the pert consortium diagnosis of dvt: antithrombotic therapy and prevention of thrombosis, 9th ed: american college of chest physicians evidence-based clinical practice guidelines abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia new criteria for sepsis-induced coagulopathy (sic) following the revised sepsis definition: a retrospective analysis of a nationwide survey anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy severe acute proximal pulmonary embolism and covid-19: a word of caution comparison of clinical and pathological features between severe acute respiratory syndrome and coronavirus disease 2019 isth interim guidance on recognition and management of coagulopathy in covid-19: a comment covid-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up covid-19-related severe hypercoagulability in patients admitted to intensive care unit for acute respiratory failure thromboembolic risk and anticoagulant therapy in covid-19 patients: emerging evidence and call for action prevention and treatment of venous thromboembolism associated with coronavirus disease 2019 infection: a consensus statement before guidelines endothelial cell infection and endotheliitis in covid-19 clinical characteristics of coronavirus disease 2019 in china covid-19 and italy: what next? acute respiratory distress syndrome: advances in diagnosis and treatment acute respiratory distress syndrome: pathophysiology and therapeutic options ards definition task force acute respiratory distress syndrome: the berlin definition surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19) prone positioning reduces mortality from acute respiratory distress syndrome in the low tidal volume era: a meta-analysis care for critically ill patients with covid-19 for the acc critical care cardiology working group. positive pressure ventilation in the cardiac intensive care unit driving pressure and survival in the acute respiratory distress syndrome key words acute respiratory distress syndrome, coronavirus, coronavirus disease-2019, mechanical ventilation available at: http:// globalhealth5050.org/covid19 clinical characteristics of patients who died of coronavirus disease 2019 in china clinical characteristics of coronavirus disease 2019 in china sex differences in public restroom handwashing behavior associated with visual behavior prompts gender differences in the utilization of health care services characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for figure 1 sex differences in risk factors and mortality from the covid-19 disease control and prevention characteristics of covid-19 patients dying in italy the pattern of middle east respiratory syndrome coronavirus in saudi arabia: a descriptive epidemiological analysis of data from the saudi ministry of health sex differences in immune responses sex chromosome complement contributes to sex differences in coxsackievirus b3 but not influenza a virus pathogenesis the x chromosome and sexspecific effects in infectious disease susceptibility clinical characteristics of pregnant women with covid-19 in wuhan, china angiotensin converting enzyme 2: a double-edged sword. circulation the ace2 expression in human heart indicates new potential mechanism of heart injury among patients infected with sars-cov-2 soluble angiotensin-converting enzyme 2: a potential approach for coronavirus infection therapy? sex differences in angiotensin-converting enzyme modulation of ang (1-7) levels in normotensive wky rats key words covid-19, mortality, sex differences eerie emptiness of ers worries doctors: where are the heart attacks and strokes? reduction in st-segment elevation cardiac catheterization laboratory activations in the united states during covid-19 pandemic sented at: international conference and exhibition on pediatric cardiology professor sir magdi yacoub and the aswan heart centre pitfalls of judgment during the covid-19 pandemic covid-19 faq's in pediatric cardiac surgery resource allocation and decision making for pediatric and congenital cardiac catheterization during the novel coronavirus sars-cov-2 (covid-19) pandemic: a u.s. multiinstitutional perspective covid-19: crisis management in congenital heart surgery considerations for triaging lessons from sars: a retrospective study of outpatient care during an infectious disease outbreak effects of response to ebola outbreak on deaths from malaria, hiv/aids, and tuberculosis, west africa critical care utilization for the covid-19 outbreak in at the epicenter of the covid-19 pandemic and humanitarian crises in italy: changing perspectives on preparation and mitigation covid-19 and italy: what next? italy's health performance, 1990-2017: findings from the global burden of disease study coronavirus infections-more than just the common cold the obelisk press-seurat editions, 1939; new address for correspondence: dr e-mail: george.collins@ucl.ac.uk. twitter: @drgeorgecollins clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan, china the use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (covid-19): the experience of clinical immunologists from china exploring personal protection during high-risk pci in a covid-19 patient: impella cp mechanical support during ulmca bifurcation stenting for the american college of cardiology's interventional council and the society for cardiovascular angiography and interventions. catheterization laboratory considerations during the coronavirus (covid-19) pandemic: from the acc's interventional council and scai reacquainting cardiology with mechanical ventilation in response to the covid-19 pandemic the covid-19 pandemic and cardiovascular complications: what have we key: cord-349210-8t4a5qqo authors: ji, ping; chen, jianmeng; golding, amit; nikolov, nikolay p.; saluja, bhawana; ren, yunzhao r.; sahajwalla, chandrahas title: immunomodulatory therapeutic proteins in covid‐19: current clinical development and clinical pharmacology considerations date: 2020-08-10 journal: j clin pharmacol doi: 10.1002/jcph.1729 sha: doc_id: 349210 cord_uid: 8t4a5qqo the covid‐19 pandemic caused by infection with sars‐cov‐2 has led to more than 600,000 deaths worldwide. patients with severe disease often experience acute respiratory distress characterized by upregulation of multiple cytokines. immunomodulatory biological therapies are being evaluated in clinical trials for the management of the systemic inflammatory response and pulmonary complications in patients with advanced stages of covid‐19. in this review, we summarize the clinical pharmacology considerations in the development of immunomodulatory therapeutic proteins for mitigating the heightened inflammatory response identified in covid‐19. this article is protected by copyright. all rights reserved severe acute respiratory syndrome coronavirus 2 (sars-cov-2). it belongs to the beta-coronavirus family and is phylogenetically close to the severe acute respiratory syndrome (sars) virus. 1 as of august 1, 2020, sars-cov-2 infection has been confirmed in over 17 million people worldwide and caused 680, 894 deaths as reported on the world health organization website. about 5-10% of covid-19 patients developed lung injury and respiratory distress that progressed to acute respiratory distress syndrome (ards). 2 according to statistics emerging from around the world, different demographics may have different susceptibilities to covid-19. patients who are male, elderly or with pre-existing medical conditions are facing worse outcomes with higher death rates in this pandemic. 3 other potential risk factors that have been identified to date include race/ethnicity, background co-medications, and poverty and crowding, among others. 4 at this time, no drugs or other therapeutics have been approved by the u.s. food and drug administration (fda) to prevent or treat covid-19. 5 in may 2020, the fda issued an emergency use authorization for the drug remdesivir authorizing its emergency use by licensed health care providers to treat adults and children hospitalized with severe covid19. 6, 7 current clinical management includes secondary infection prevention, symptom control and supportive care, such as supplemental oxygen and mechanical ventilatory support when indicated. 4 while most drug development programs take years before an effective drug can reach the market, drug development programs and regulatory review of potential covid-19 therapies consider the urgent need for treatment and prevention options while adhering to the fda's robust standards for demonstrating the safety and effectiveness of drug products. clinical pharmacology is playing an increasingly crucial role in assessing the drug activity, efficacy and safety during development and regulatory review. although covid-19 presents a significant challenge both from drug development and regulatory review standpoints, it offers a unique opportunity for the clinical pharmacology community to facilitate clinical development of therapies. 8 in this review, we summarize the role of clinical pharmacology during the covid-19 pandemic, focusing on immunomodulatory therapeutic proteins. this article is protected by copyright. all rights reserved. currently, no drugs, biologics or other therapeutics have been approved by the fda to prevent or treat covid19 . because clinical information about the optimal management of covid-19 is evolving quickly, recommendations by the covid-19 treatment guidelines panel on the use of any agents for pre-or post-exposure prophylaxis against sars-cov-2 in patients with covid-19 outside of the clinical trial setting are updated frequently as published data and other authoritative information become available. 9 in the clinical trial setting, consideration of clinical manifestation is critical to any antiviral or immunomodulatory treatment strategy. patients infected with sars-cov-2 can experience a range of clinical manifestations, from no symptoms to critical illness. 10 the symptomatic phases include: 1) mild illness, with such signs and symptoms as fever, cough, sore throat, malaise, headache, muscle pain without shortness of breath or abnormal imaging; 2) moderate illness, with evidence of lower respiratory disease; 3) severe illness, with dyspnea, hypoxia or evidence of greater than 50% lung involvement on imaging tests; and 4) critical illness, with respiratory failure, septic shock and/or multiple organ dysfunction. the chinese center for disease control and prevention reported that of 44,500 confirmed infections, most infected patients (80%) experienced mild or moderate forms of the illness, 14% developed severe illness and 5% developed critical illness. 11 the four clinical manifestations seem to be controlled by the underlying two distinct but overlapping pathologic subsets: viral pathogenicity and host inflammatory response, based on which siddiqui et al. proposed a staging system to characterize the disease course of covid-19. 12 during the first week of infection, the innate immunity reaction is involved, followed by the adaptive immunity reaction starting at about the second week, including antigen-specific t cells and antibodies which are produced for more efficient viral clearance and blocking. at the initial stage of the illness, most patients experience mild to moderate forms of illness and recover on their own with minimal intervention. a minority of covid-19 patients will transition into the severe and critical stages of the illness, which manifest as an extrapulmonary systemic hyperinflammation syndrome. the aggravation of symptoms often is associated with increased levels of acute phase reactants (erythrocyte sedimentation rate, c-reactive protein (crp), ferritin), coagulopathy (elevated titers of d-dimers, disseminated intravascular coagulation) and cell lysis (serum creatine kinase, lactate dehydrogenase). 13, 14 these clinical and laboratory parameters are correlated with increased levels of this article is protected by copyright. all rights reserved. proinflammatory cytokines such as interleukin (il)-1, il-6 and tumor necrosis factor (tnf)-α. 15, 16, 17 massive and rapid release of these detrimental proinflammatory mediators identified as so-called "cytokine storm" is associated with ards and multiple organ failure. 18 as such, the potential of immunomodulatory therapeutic proteins in blocking the inflammatory pathway has been hypothesized to prevent or mitigate disease progression of covid-19. these also likely provide additional benefits in conjunction with the standard of care, and with other potential treatments such as high doses of polyvalent immunoglobulins or convalescent serum. 15 these hypotheses of immunomodulatory therapeutic proteins in covid-19 are being evaluated in various clinical settings and are elaborated below. in this review, we classify immunomodulatory therapeutic proteins in two categories: 1) fdaapproved drug products, and 2) drug products that have not been fda-approved but are currently under investigation for illnesses other than covid-19 (table 1 ). both categories involve repurposed drugs being evaluated for their ability to control the underlying hyperinflammatory syndrome in advanced stages of covid-19. the available nonclinical and clinical experience is helpful for scientists in selecting candidate therapeutic proteins. for therapeutic proteins already approved for other indications, the known or anticipated benefits and risks for the approved indication (s), as well as reasonably anticipated adverse events, can be used to aid the benefit/risk assessment in covid-19-related clinical trials. for novel investigational therapeutic proteins still in early development stages, information on benefits and risks mostly is obtained from limited early clinical data and nonclinical assessment; therefore, they likely involve a higher degree of uncertainty than do the repurposed approved therapeutic proteins. at this writing, over 110 covid-19-related clinical studies evaluating immunomodulatory therapeutic proteins have been registered in clinicaltrials.gov (supplemental table) . we categorize these registered clinical studies by the corresponding immunomodulatory targets ( figure 1 ) and summarize them below. this article is protected by copyright. all rights reserved. il-6 is considered a key driver of the uncontrolled hyperinflammatory response/cytokine release storm (crs) that accompanied ards in some covid-19 patients. 19 a recent retrospective analysis that evaluated 201 patients with confirmed covid-19 showed that the level of il-6 was significantly higher (2.9-fold) in patients with ards compared with patients without ards. 20 as such, targeting the il-6 pathway is one of the approaches that has gained substantial attention for the potential treatment of covid-19-associated ards. currently, il-6 pathway inhibitors evaluated in one or more clinical trials for covid-19 include anti-il-6 receptor monoclonal antibodies tocilizumab, sarilumab and levilimab; and anti-il-6 monoclonal antibodies clazakizumab, olokizumab and siltuximab. targetmediated clearance can be observed at low drug concentrations for the three anti-il-6 receptor antibodies, but not for the three anti-il-6 antibodies. tocilizumab has been evaluated in multiple clinical trials, either alone or in combination with other drugs in patients with covid-19. although the studied population overall fit in the moderate-critical criterion level, individual studies varied slightly in their patient enrollment criteria, for example, patients with at least moderate pneumonia, patients with severe pneumonia, patients hospitalized in intensive care, patients hospitalized with high risk of progression, and patients with confirmed infection and with evidence of systemic inflammation. the approved dosing regimen of tocilizumab for ra is 4 mg/kg iv every four weeks with an option of increasing to 8 mg/kg iv based on the clinical situation. in some covid-19 trials, the tocilizumab dose selected was 8 mg/kg, with an option of one additional dose more than eight hours later, which is consistent with the dose of tocilizumab approved for the treatment of crs. higher total tocilizumab doses than those for autoimmune diseases such as ra evaluated in these clinical trials are likely due to concern about increased clearance under hyperinflammation in advanced stages of covid-19. other than the iv route, subcutaneous (sc) dosing of tocilizumab also is being explored for the treatment effect in hospitalized patients with sars-cov-2 infection. tocilizumab also is being evaluated in numerous smaller clinical trials to decipher covid-19 and explore its mechanism of action such as the role of il-6 and soluble il-6 receptor as predictors of efficacy in patients with severe covid-19, the role of anti-il-6 on calming the virus-induced cytokine storm, etc. the use of sc route of administration of sarilumab, the approved dosing route in ra, is planned in moderate-to-severe covid-19 patients and moderate covid-19 patients. iv dosing regimen of sarilumab, although not approved, is considered to achieve peak concentration faster and hence have been evaluated in several covid-19 trials. the dose for siltuximab of 11 mg/kg iv evaluated in patients with severe or critical covid-19 is consistent with the approved one for multicentric this article is protected by copyright. all rights reserved. castleman's disease. levilimab is currently under development for the treatment of ra; single sc administration of levilimab at a dose of 324 mg is being evaluated for its efficacy and safety in patients with severe covid-19. the sc dosing of olokizumab, also under development for the treatment of ra, is being evaluated in patients with severe covid-19 to assess the proportion of those responding to therapy. for clazakizumab, the sc route is being evaluated in ra and transplant patients. however, the iv route of 25 mg or 12.5 mg is being assessed in multiple clinical trials of covid-19 for its treatment effect in patients with covid-19. in addition to some preliminary studies, 21 26 in this trial, sarilumab was added to best supportive care and compared to best supportive care alone (placebo). a higher number of adverse events occurred in the drug-treated group than in the placebo group (80% to 77%) within the primary analysis population. it remains to be seen what the results will be in other trials, including in combination with antiviral therapy. il-1 production is induced in response to inflammatory stimuli and mediates various physiologic responses, including inflammatory and immunological responses. patients with ards secondary to influenza and sars have shown evidence of cytophagocytosis on histopathological examination. 27 cytophagocytosis is a hallmark of macrophage activation syndrome (mas), which is an inflammasome/il-1-mediated disease. 28 its levels have been elevated in covid-19 patients with this article is protected by copyright. all rights reserved. severe illness. il-1 has been suspected to exert a negative impact on cardiac function, which may be the link to the myocardial injury in many covid-19 patients. 29 pharmacodynamic (pd) assessments such as crp, serum ferritin and d-dimer are among the many secondary outcome assessments. canakinumab 300 or 600 mg iv is being evaluated in a study testing the proof of concept that early treatment prevents progressive heart and respiratory failure in patients with covid-19 infection. sc dosing of 150 mg canakinumab is being assessed in covid-19 pneumonia patients. anakinra was approved for the treatment of ra at a daily dose of 100 mg sc and for cryopyrin-associated periodic syndromes at a daily dose of 1-2 mg/kg sc. it is being evaluated in multiple clinical trials for covid-19, either alone, or jointly with other drug(s). because of its short half-life of four to six hours, it is administered once daily or more frequently than daily. in a retrospective cohort study of patients with covid-19 and ards managed with non-invasive ventilation outside of the intensive care unit (icu), treatment with high-dose anakinra of 5 mg/kg twice daily iv was safe and associated with clinical improvement in 72% of patients. 31 another study on the off-label use of anakinra in 52 patients who were admitted to hospital for severe forms of covid-19 with symptoms indicative of worsening respiratory function showed that anakinra reduced both need for invasive mechanical ventilation in the icu and mortality, without serious side-effects. 32 randomized controlled trials are being conducted in patients with moderate to critical pneumonia associated with covid-19 at iv doses up to 400 mg daily. sc anakinra is being evaluated at 100 mg once daily or every 6 to 16 hours in patients with covid-19. interferons (ifns) are a group of cytokines that communicate between cells against pathogens. they play a critical role in the immune system, such as activating natural killer cells and macrophages, as well as inducing flu-like symptoms of various diseases. 33 because of their in vitro and in vivo antiviral properties, type i (ifn-α, β, ε, κ, and ω) and type ii (ifn-γ) interferons are being evaluated extensively for their efficacy in patients with uncomplicated covid-19 disease. on the other hand, the hyperproduction of pro-inflammatory ifn- during the later stages may be responsible for covid-19-associated acute lung injury. therefore, the removal of this cytokine by anti-ifn- antibodies during the late stage of the disease is believed to block this pathologic pathway and provide therapeutic benefit. 34 emapalumab, a monoclonal antibody directed against ifn-γ and approved for the treatment of hemophagocytic lymphohistiocytosis (hlh), is being evaluated in a phase 2/3, randomized trial in covid-19 patients experiencing hyperinflammation and respiratory distress. the dosing regimen being investigated is iv 6 mg/kg on day 1 followed by 3 mg/kg on days 4, 7, 10 and 13, which is borrowed from the approved dosing regimen for hlh. the primary outcome measure of the trial is the proportion of patients not requiring invasive mechanical ventilation or extracorporeal membrane oxygenation. low-dose il-2 il-2, a pleiotropic cytokine, plays a key role in the development and function of regulatory t cells (treg). 35 low-dose il-2 has been shown to control autoimmune and inflammatory disorders by enhancing tregs. 36 as such, aldesleukin (ilt-101), a human recombinant il-2, was repurposed for covid-19 to investigate its therapeutic benefit as a treg inducer for controlling sars-cov2-related ards. ilt-101 was given as a once-daily sc administration for 10 consecutive days, which differs from the approved iv dosing of every 8 hours in one cycle of 14 doses in metastatic melanoma and metastatic renal cell carcinoma. il-8, also known as cxcl8, is a proinflammatory cytokine orchestrating the recruitment of neutrophils in tissue injuries. 37 it was reported to be positively correlated with disease severity of covid-19, with severe cases having the highest il-8 levels. 38 il-17 expression was reported to be elevated in patients with covid-19 and its level was correlated with severity of lung injury. 40 this indicates that il-17 may serve both as a biomarker of disease severity and as a potential target of therapy to mitigate the damage of sars-cov-2, particularly to the lung. secukinumab, a human igg1κ monoclonal antibody that binds to the il-17a, is being repurposed for covid -19 in an open-label, prospective randomized, small trial with 300 mg sc as the first dose and then 150 mg twice a day sc for 10 days. this dosing regimen is more frequent than the approved dosing regimens (150 or 300 mg once every week for the loading dose or once every four weeks) for the treatment of psoriasis, ankylosing spondylitis, and psoriatic arthritis. tnf-α is produced during inflammation and is important in the coordination and development of the inflammatory response. blockade of tnf-α alleviates inflammation and suppresses the production of other proinflammatory cytokines. the tnf-α level is upregulated in patients with covid-19, especially in those with severe disease in icu. 41 duret 43 currently, anti-tnf-α monoclonal antibodies such as adalimumab, infliximab and xpro1595 are being evaluated in covid-19 studies. a randomized, open-label, controlled trial for the efficacy and safety of adalimumab in patients with elevated tnf-α levels in the critical stages of severe covid-19 is ongoing in shanghai, china, with the main outcome of time to clinical improvement. 44 the dosing of adalimumab is not reported. a phase 2 trial of the efficacy and safety of infliximab was initiated to evaluate whether early institution of tnf-α inhibitor therapy in patients with severe covid-19 infections could prevent further clinical deterioration and reduce the need for advanced cardiorespiratory support and early mortality at a 5 mg/kg iv single dose. xpro1595, an investigational anti-tnf-α antibody, is being evaluated for prevention of disease progression in patients ≥ 65 years of age who have a diagnosed covid-19 infection with pulmonary complications. this is a high-risk group of patients whose condition can deteriorate rapidly, requiring intensive care beds and increased respiratory support. the dose of 1 mg/kg sc once a week up to two doses in the covid-19 trial is within the dosing range for xpro1595 evaluated in patients with alzheimer's disease. the complement system, which is involved both in innate and in adaptive immunity, is considered an essential defense system against invading pathogens. on the other hand, an over-activated complement system has been reported to be associated with microvascular injuries and multiorgan failures in patients with covid-19, and blocking complement overactivation may attenuate the proinflammatory sequelae of sars-cov-2 infection. 45 mastaglio et al. reported a favorable course in a patient with covid-19 severe pneumonia with systemic hyperinflammation after the treatment with the compastatin-based c3 inhibitor amy-101. 46 preliminary data on anti-complement c5 therapy with eculizumab as an off-label agent in four covid-19 patients admitted to icu showed that all four patients recovered with reduction of serum crp levels. 47 these four patients received eculizumab 900 mg iv for two doses. eculizumab is being evaluated in a randomized controlled clinical trial at a dosing regimen of 1200 mg iv on days 1, 4 and 8 then at 1200 mg or 900 mg on day 12 in patients with covid-19 infection to assess its efficacy and safety. ravulizumab, an approved anti-c5 monoclonal antibody, also is being repurposed to evaluate its potential for treatment of covid-19 disease. the approved dosing for ravulizumab in paroxysmal nocturnal hemoglobinuria and in atypical hemolytic uremic syndrome is being used in the covid-19 patients. further, the safety and efficacy assessment of avdoralimab (anti-c5ar) and ifx-1 (anti-c5a) in patients with severe covid-19-induced pneumonia is underway. immunostimulants: tlr agonist, il-15 agonist, pd-1 inhibitor and tim-3 inhibitor pd-1 (programmed cell death protein-1) is a lymphoid cell surface protein of the immunoglobin superfamily and a member of the extended cd28/ctla-4 (cytotoxic t-lymphocyte-associated protein 4) family of t cell regulators. it is known to act as a mature t cell checkpoint for the modulation of apoptosis. pd-1 interaction with either of its ligands constitute significant negative immune checkpoints in the pathway responsible for blunting cell-mediated immune responses, specifically cd8+ responses, and for upregulating resulting pathologies (e.g., covid-19) and malignancies. 48, 49, 50, 51 t lymphocytes (lt) counts are decreased in patients with covid-19, which is responsible for host anergy towards viral infection, leading to increased risk of severe forms of covid-19. it has been shown that healing from covid-19 is associated with lt pd1 expression normalization. 52 nivolumab, a pd-1 blocker, was approved for metastatic melanoma at 3 mg/kg iv given once every two weeks. it is being evaluated for its efficacy and safety nivolumab in this article is protected by copyright. all rights reserved. toll-like receptors (tlrs) in innate immunity participate in the first line of defense against invading pathogens and play a significant role in inflammation, immune cell regulation, survival, and proliferation. 53 bdb-001, a tlr agonist with potential immune-stimulating and antineoplastic activities, is being assessed in covid-19 patients with severe pneumonia, or acute lung injury/ards. il-15 is a pleiotropic cytokine that plays a key role in immunotherapy. 54 its overexpression promotes innate immune responses via the induction of natural killer cells, cd8 + t and treg cells that may suppress the induced t helper type 2 (th2)-related cytokines. this results in decreased levels of il-4, il-5, and il-13, thus mitigating sars-cov-2 induced inflammation and fibrosis via ifn-γ and il-10, which inhibit viral replications and reduce viral loads. 55 il-15 agonist n-803, a fusion protein, is being evaluated in a phase 1b, randomized, blinded, placebo-controlled study in adult subjects with covid-19 to assess its safety and immunostimulatory activity, such as changes in lymphocyte counts. hematopoietic cytokines: il-7 and gm-csf il-7 is important for differentiation of hematopoietic stem cells into lymphoid progenitor cells and activation of cytotoxic t lymphocyte (ctl) responses. paradoxically, its expression is reported to be depleted during certain viral infections. 56 as such, il-7-based therapies also are proposed to restore the lymphopenic status in patients with covid-19. indeed, treatment with cyt107 in lymphopenic covid-19 patients improved the absolute lymphocyte count from randomization to day 30 when administered im at 10 μg/kg twice a week for two weeks. in another trial, administration of il-7 was reported not to affect the plasma concentrations of tnf-α, il-1β and il-12p70 in 12 covid-19 patients. 57 gm-csf (granulocyte-macrophage colony stimulating factor) is used as a medication to stimulate the production of white blood cells following chemotherapy. this strategy may prove useful for stabilizing alveolar macrophage and epithelial cell function, increasing sars-cov-2 clearance, protecting against secondary infection and contributing to lung repair mechanisms. 58 ccr5 (c-c chemokine receptor type 5) plays a central role in modulating immune cell trafficking to sites of inflammation, inhibition of which may suppress the hyperactive immune response observed in covid-19 patients. 59 leronlimab, a ccr5 antagonist, is being evaluated in patients who experience respiratory illness as a result of covid-19 at a single dose of 700 mg iv, consistent with the dose used in the ongoing breast cancer trial. cd147, a receptor on host cells, is considered a novel route for sars-cov-2 invasion, and it is hypothesized that there exists an inhibitory potential for drugs interfering cd147 on sars-cov-2 invasion. 60 meplazumab, a humanized anti-cd147 monoclonal antibody, is in the early clinical development stage for the potential to mediate both treatment and prophylaxis of falciparum malaria. it is known to inhibit both t cell chemotaxis and virus cell entry. in an open-label study in patients with covid-19 pneumonia, the time to virus eradication in the meplazumab group given two doses of 10 mg iv once daily was significantly shorter than in the control group. 61 il-33, an inflammatory cytokine, has been identified as an endogenous alarm signal to alert various types of immune cells in reaction to trauma. 62 the population of il-33-producing cells was found to increase with disease severity of covid-19. 63 sc mstt1041a, an il-33 inhibitor, is being evaluated in asthma indication; the iv route is being assessed in a phase 2, randomized, double-blind, placebo-controlled, multicenter study in patients hospitalized with covid-19 pneumonia. csf (colony stimulating factor) supports survival, clonal expansion and differentiation of hematopoietic progenitor cells. csf-1r plays a key role in the differentiation, recruitment and this article is protected by copyright. all rights reserved. activation of tissue-associated macrophages, which has been associated with survival in classic hodgkin's lymphoma and other lymphoma types. 64 axatilimab (sndx-6352), a high-affinity antibody targeting csf-1r, is being evaluated in a randomized, double-blind, placebo-controlled, 29-day study to assess its efficacy and safety in patients with respiratory signs and symptoms secondary to covid-19 after iv dosing on days 1 and 15. it also is being evaluated in patients with intrahepatic cholangiocarcinoma at the same dosing route and frequency as in covid-19 patients. cd24 is an innate checkpoint against the inflammatory response to tissue injuries or dangerassociated molecular patterns. 65 cd24fc, a fusion protein that regulates host inflammatory response to tissue injuries, is in the phase 2/3 clinical development stage. a single dose of cd24fc 480 mg iv is being evaluated in hospitalized subjects with severe covid-19. ang2 (angiopoietin 2) levels were increased in ards patients. 66 ly3127804, an investigational selective monoclonal antibody against ang2, is being evaluated in pneumonia patients hospitalized with covid-19 who are at a higher risk of progressing to ards. in this trial, ly3127804 is given iv, same dosing route as in the study of ctgf (connective tissue growth factor) is involved in fibrotic and proliferative diseases and may promote vascular leakage and lead to pulmonary edema. 69 pamrevlumab, an anti-ctgf monoclonal antibody, may mitigate or reverse this edema, and thus improve oxygenation in patients with covid-19-induced pneumonia. it is being evaluated hospitalized patients with acute covid-19 disease at a dosing regimen of 35 mg/kg iv on days 1, 7, 14 and 28. the levels of light, a cytokine in the tnf superfamily that can drive inflammation and induce many other cytokines, have been shown to be elevated in covid-19-infected patients. 70 the efficacy and safety of cerc-002 is being studied in patients with severe covid-19 over a 28-day period as a single dose on top of standard of care at 16 mg/kg sc to a maximum dose of 1200 mg. vegf(vascular endothelial growth factor) plays an essential role in vascular endothelial homeostasis and endothelial cell activation. 71 significantly higher vegf concentrations were observed in covid-19 patients than in healthy controls, and it was shown as one important indicator related to the severity of covid-19. 72 bevacizumab, an anti-vegf monoclonal antibody, is being evaluated in hospitalized covid-19 patients at the dose level consistent with the approved doses in oncology indications for bevacizumab. the kallikrein-kinin system is a zymogen system that is known to lead to the release of the nonapeptide bradykinin after activation. binding of bradykinin to the b2r on endothelial cells can lead to capillary leakage which causes angioedema. 73 van de veerdonk proposed that kallikrein-kinin blockade may have the potential to prevent ards in patients with covid-19. lanadelumab, a human monoclonal antibody targeting plasma kallikrein, was approved to prevent angioedema in patients with hereditary angioedema. it is being repurposed to evaluate its safety, pk and pd in adults hospitalized with covid-19 pneumonia at a dose level consistent with the approved one. in general, a master protocol is designed to evaluate more than one investigational drug at a time, enabling comparison of individual drug candidates to a single control group. few platform trials are ongoing as referenced on clinicaltrials.gov. for example, trial nct02735707 is evaluating the effect of a range of interventions for improving outcomes of patients admitted to icu with communityacquired pneumonia. 78 the trial has implemented a sub-platform to assess multiple interventions or treatments for covid-19. nct04354428 is another randomized platform trial with four drugs planned in the protocol for severe sars-cov-2 infection in high-risk adults not requiring hospital admission. 79 additional information on these trials is available at clinicaltrials.gov. the treatment goal of immunomodulatory therapeutic proteins in hyperinflammation management of covid-19, as with most clinical therapeutics, is to achieve the desired benefit with minimal adverse effects. the contribution of clinical pharmacology to benefit/risk assessment largely resides in dosing regimen selection through the assessment of pharmacology, pk, pd and intrinsic and this article is protected by copyright. all rights reserved. extrinsic factors ( route of administration: as described before, the immunomodulatory therapeutic proteins currently in clinical trials for the treatment of covid-19 mostly are directed towards patients with moderate and severe stages of the disease. given the acute severity of the disease, 84 especially in the advanced disease stage, rapid onset of drug action is necessary to neutralize the elevated cytokines and rebalance the immune response. iv dosing has the advantage of providing rapid onset of maximum concentration, which often is achieved at the end of the infusion, just minutes to a few hours following treatment initiation. on the other hand, the maximum concentration after sc dosing often is reached after a few days to a week, and the peak drug level often is significantly less than that after iv dosing. in this regard, sc dosing may not provide an advantage. some researchers have hypothesized that covid-19 patients also may benefit from certain therapeutic protein treatment earlier in the disease course -prior to progressing to severe respiratory decompensation -through early cytokine inhibition, thus preventing disease progression to the severe or critical stages. as such, sc dosing likely fits in this scenario, as a week or so may be needed for the biologic to reach the maximum concentration. although this hypothesis appears plausible, the timing chosen should not compromise a patient's innate immune response, which is necessary for fighting off the virus and avoid the risk of infection. 85 this article is protected by copyright. all rights reserved. comorbidity: the presence of underlying comorbidities is one important risk factor for sars-cov-2 infection and the fatality rate of patients with comorbidities was reported to be much higher than that of patients without comorbidities. 86 treatment decisions related to these comorbidities are further complicated with the potential risks of clinical therapies for covid-19, such as those posed by immunomodulatory therapeutic proteins for autoimmune diseases. it is well known that immunomodulatory therapeutic proteins are associated with increased risk of serious bacterial or opportunistic infection; however, information on their association with the risk of viral infection is limited. nevertheless, in various academic societies, concern about the potential increased risks of immunomodulatory biological therapies for covid-19 remains. the american college of rheumatology recommended temporarily holding or stopping all non-il-6 biologics in the context of documented or presumptive covid-19, as well as in covid-19 following known sars-cov-2 exposure. 87 similarly, the american academy of dermatology recommended that patients discontinue or postpone biologic therapy until they recover from covid-19. 88 the academy also recommended benefit-risk assessment for patients currently considered candidates for biologic therapy. this highlights the importance of the treatment window in biologic therapies for covid-19. these recommendations, however, have been debated. data from a u.s. biologics registry showed that the rates of severe covid-19 or complications were lower in patients prescribed ustekinumab, and that there appeared to be little difference in mild cases between patients prescribed il-17 and il-23 antagonists and those in corresponding placebo groups. 89, 90 as with other diseases, treatment interruption may have a profound impact as well. the treatment decision recommendation balances benefits and risks of ongoing cancer therapy during the covid-19 pandemic. 91 collectively, although no general rule on the treatment decision recommendation exists, caution should be taken, and the impact of treatment interruption should be evaluated carefully. in this situation, modeling and simulation could potentially be useful, as it considers such factors as covariates and facilitates decision-making. 92 critically ill covid-19 patients are likely to be susceptible to secondary infections and may have an increased risk of comorbid chronic infections, such as hepatitis b and tuberculosis. 93, 94 in these cases, the treatment goal is to prevent or attenuate life-threatening inflammation while minimizing the potential for secondary infection. 95 for this reason, immunomodulatory treatments should be used cautiously. the use of prophylactic antibiotics may be indicated, and bacteriologic and fungal assessments are of great importance. as discussed above, many therapeutic biologics already approved for other applications are being pediatrics: most covid-19 patients have been adults. although some children and infants have been infected with covid-19, they generally experience mild, cold-like symptoms, such as fever, runny nose and cough. 96 however, severe outcomes have been reported in infants under one year, and children with underlying medical conditions such as chronic lung disease, moderate to severe asthma, serious heart conditions or weak immune systems might be at higher risk of serious illness from covid-19 than are other children. 22 the centers for disease control and prevention (cdc) and its partners also are investigating reports of multisystem inflammatory syndrome in children which is associated with covid-19 and includes features similar to those of kawasaki disease. 97, 98, 99, 100, 101 some ongoing clinical trials investigating immunotherapies in pediatric patients are registered in clinicaltrials.gov, and off-label use of biologics in pediatric patients has been reported. 102 the clinical management of covid-19 complications with immunomodulatory therapeutic proteins in pediatric patients often takes body weight into consideration, since weight-based dosing regimens generally are used in these patients. it is noteworthy that as immunomodulatory therapeutic proteins often are used in many patients with more severe forms of asthma or allergies, concern exists that the treatments may compromise these patients' immune systems. regarding treatment of severe allergic diseases with therapeutic proteins, a recent expert opinion article published by the european academy of allergy and clinical immunology suggested continuing them in otherwise healthy patients during the covid-19 pandemic, but pausing until recovery in sars -cov-2-positive patients. 103 this article is protected by copyright. all rights reserved. geriatric: according to cdc, the risk for severe illness from covid-19 increases with age; the greatest risk for severe illness is among those aged 85 or older. 104 can be used to simulate exposures and predict relevant doses in pregnant women. 108, 109 concomitant medications: in clinical trials, the treatment strategy for covid-19 often combines an investigational drug with the standard of care (e.g., acetaminophen for fever reduction). investigators manage patient care with supportive therapies as clinically indicated and per local standard practice. a theoretical concern exists regarding the potential modulation of cyp enzyme expression by cytokine level in covid-19. the expression level of cyp450 enzymes has been shown to be suppressed by increased levels of cytokines (e.g., il-6) in some chronic diseases. 110 therefore, for biologics that antagonize cytokine activity, such as tocilizumab, it is expected that the expression of cyp450 enzymes could be increased to normal levels. accordingly, ra patients treated with tocilizumab may exhibit restoration of cyp450 activities to higher levels than those in patients not covid-19 is indicated to be associated with damages to lungs, heart, brain, kidneys and other organs. 111, 112 elevated serum cytokine levels have been suspected to be associated with these organ damages. 113 as such, multiple immunomodulatory therapeutic proteins are being investigated in covid-19 patients with multi-organ impairment. in this situation, biodistribution of therapeutic proteins to tissues likely is needed for neutralization of cytokines or their downstream effect. extravascular distribution for therapeutic proteins is generally limited due to large molecular size. this article is protected by copyright. all rights reserved. however, it is unknown whether tissue distribution changes in covid-19 patients with organ impairment due to the damage/impairment of the vascular endothelial system. hepatic and renal damage have been reported to be associated with sars-cov-2 infection. alan kliger reported that 14% to 30% of covid-19 patients in new york, ny and wuhan, china icus lost renal function and later required dialysis. 114 this article is protected by copyright. all rights reserved. in china, crp levels decreased significantly and returned to normal in 84.2% of patients (16 of 19) following tocilizumab treatment. 22 crp also is being explored for the potential of a simple crp measurement to inform decision making for which patients are to be hospitalized due to risk of developing more severe affection. 118 immunogenicity furthermore, the use of real-world data sources for surveillance and adverse event reporting systems around the world presents an opportunity for clinical pharmacologists to study the relationships between dose and reported outcomes of potential therapies. using real-world data sources that are fit-for-purpose may contribute to our understanding of disease risk factors and identification potential treatment options. this article is protected by copyright. all rights reserved. we still are in the midst of this pandemic, and it is a rapidly evolving situation. clinical trials assessing the safe and effective use of these immunomodulatory therapeutic proteins in the management of ards and crs in covid-19 are ongoing. the safe and effective use of these products in the management of ards and crs in covid-19 remains to be proven. as clinical pharmacologists, we are facing the prospect of an unprecedented timeline for covid-19 drug development; namely, optimizing dose and dosing regimens for repurposed drug products to be evaluated in clinical trials. these optimizations involve potential changes of dosing route, identification of target cytokine levels, special considerations in various specific populations, and mitigation of the potential for drugdrug interactions. clinical pharmacologists also consider the impact of treatment interruption and comorbidities, if present. in the long term, we also must take a deliberative approach and think proactively and strategically in order to prepare for future challenges facing the discipline. while we remain focused on dose regimen selection in the traditional randomized controlled trial setting, we also must embrace the potential advantages of platform trial designs, real-world data analysis and the potential integrate this knowledge into a new paradigm. a novel coronavirus from patients with pneumonia in china q&a: influenza and covid-19 -similarities and differences existing conditions of covid-19 cases and deaths covid-19) covid-19). centers 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multidisciplinary review and evaluation the authors thank joanne berger, fda library, for manuscript editing assistance. this article is protected by copyright. all rights reserved. key: cord-280093-w71e0ex9 authors: jung, so-young; kang, jung won; kim, tae-hun title: monitoring in clinical trials of complementary and alternative medicine date: 2020-09-23 journal: integr med res doi: 10.1016/j.imr.2020.100666 sha: doc_id: 280093 cord_uid: w71e0ex9 background: clinical trial monitoring is an essential activity for quality assurance (qa) to ensure the protection of human rights and the reliability and transparency of the data collection process. the purpose of this article is to enhance the understanding of monitoring process and major findings in clinical trials of complementary and alternative medicine (cam). methods: based on international conference on harmonization of technical requirements for registration of pharmaceuticals for human use (ich-gcp), we summarized main concept of monitoring process. personal experiences on monitoring for cam studies were also narratively described. results: in this brief article, the basic concept of qa and quality control (qc), various monitoring activities during the study process, and major findings regarding clinical trials of cam are suggested in an effort to improve understanding of monitoring in clinical research on cam. conclusion: when performing clinical trials for cam-related interventions, the monitoring recommended in gcp is needed to be recognized as a mandatory element in the course of cam research. "safeguarding the health of the people" is the primary mission of the medical profession. 1 in line with this proposition, clinical research should be designed and implemented ethically and scientifically. clinical trials in humans are inevitable in new drug or medical device development to ensure the efficacy and safety of the intervention. however, protection of human rights is paramount. clinical research relies on the dedication of participants who willingly take expected or unexpected risks. the principal aim of a clinical trial should be the contribution that can be made to human health and well-being by expansion of medical knowledge. therefore, the results of clinical trials should be transparent and reliable. monitoring in the context of a clinical trial entails many types of systematic activity to ensure that the study is conducted and data are acquired according to the planned protocol in compliance with good clinical practice (gcp) and relevant legislation. 2 the reliability of the data collected cannot be ensured by the investigators' efforts alone and is only possible through systematic planned supervision of research procedures. from this point of view, monitoring has come to be recognized as an important procedure in clinical research. 3 the research purpose and strategy in clinical studies involving complementary and alternative medicine (cam) are different from those in trials of pharmacological interventions conducted for the purpose of gaining regulatory approval to market a new drug entity. the majority of cam interventions have long been used without supporting evidence from clinical trials, and most researches have been focused mainly on establishing the safety of cam and its effectiveness relative to conventional treatments in an effort to establish clinical evidence for cam interventions. 4 protection of human rights, overseeing the research steps in the study plan, and confirming the accuracy of the data collected are also essential in clinical trials of cam. the purpose of this brief review is to enhance the understanding of researchers about monitoring process in general and major considerations of cam trials. j o u r n a l p r e -p r o o f a clinical trial should be conducted based on a predefined study protocol, and the data generated need to be documented accurately. furthermore, the trial data must be analyzed and reported according to the study plan. of particular importance is that the ethical conduct of the study should be in compliance with relevant regulations. quality assurance (qa) is defined as any type of planned systematic activity intended to ensure transparency in the conduct of clinical trials, reliability of study data, and protection of human rights. while qa is a comprehensive principle, quality control (qc) refers to specific operational techniques and activities that ensure the quality of research. 2 the quality of clinical trials reflects multidimensional factors that range from the design of the study to reporting of the results, whereas qc and qa directly reflect how rigorously the study was conducted according to the research protocol and accurate collection of research data. 5 ensuring the quality of clinical trials is important, given that when pharmaceutical and medical device companies develop a new chemical entity or device, they cannot conduct the necessary clinical trials themselves. instead, they must take a sponsorship role and rely on hospital-based investigators who are responsible for clinical practice and day-to-day conduct of a clinical trial. therefore, it is necessary to have a detailed study plan and a strategy for determining whether or not the study is being conducted correctly. qa and qc are needed to ensure that a clinical trial is performed in accordance with the established protocol, standard operating procedures (sops), gcp, and relevant regulations set out by the sponsor. 2 using a strict monitoring procedure, the sponsor can evaluate the overall status of research under way at a participating institution and address any problems identified in monitoring reports so that the study is well conducted. thus, monitoring is essential to guarantee internal validity of clinical trials. 2 according to the international conference on harmonization of technical requirements for registration of pharmaceuticals for human use (ich-gcp), on-site monitoring is recommended before, during, and after the trial procedure, whereas central monitoring is advised only in exceptional j o u r n a l p r e -p r o o f circumstances, which often leads to misunderstandings regarding whether or not on-site monitoring is mandatory and has priority for all cases. 6 however, there is evidence suggesting that intensive on-site monitoring is not always effective in identifying errors and has a significant cost burden. 3 in response, the current ich-gcp version (r2) has added the potential benefit and role of central monitoring to its addendum section. 7 the 2020 covid-19 pandemic has rendered regular on-site monitoring impossible at present, and reliance on central monitoring is increasing. however, there are still some logistical inadequacies that make it difficult to rely on central monitoring alone. central monitoring must include the ability to identify adverse reactions in research participants, but it is impossible to obtain the relevant data without visiting the study site. therefore, a better qc strategy is needed to resolve the significant challenges of data monitoring in the current climate. sponsors need to have sops for clinical trials that include detailed procedures and designated personnel to perform the necessary monitoring activities. gcp states that sponsors need to decide the nature and extent of monitoring based on the specific features of the study, such as objectives, design, complexity, and size. 2 sponsors may directly employ full-time monitors or appoint a contract research organization to perform monitoring activities on their behalf. the monitors should be trained and have appropriate knowledge on the investigational product, study protocol, how to complete informed consent forms, the sponsor's sop, and regulatory requirements, including gcp and the relevant legislation. monitors should be appropriately qualified in accordance with gcp 2 and usually have an academic degree in a health-related discipline such as nursing. the main roles of a monitor are defined by gcp, and are classified according to the principal purpose of monitoring as follows: first, they must ensure protection of human rights during the trial by checking that all study participants have provided written informed consent; second, they must ensure that the data collected are accurate and complete by checking the source documents; and third, they must confirm whether or not the study is conducted on-site monitoring is classified according to the status of a clinical trial (figure 1 ). the pre-study site visit recommended by gcp is not mandatory for monitoring. sponsors identify the most appropriate research center for conducting a clinical trial and send a trained representative who is either employed directly by the sponsor or a clinical research associate affiliated to a contract research organization that performs trial-related duties and provides expertise as part of their contract with the sponsor. 2 during the pre-study site visit, the research capability of the site is assessed considering the adequacy of facilities, recruiting ability, and the expertise of the investigator (s). after the study protocol is approved by the institutional review board and local regulatory agency (if necessary) and the investigational products are ready for delivery, a site initiation visit is made to train the research team and prepare the necessary documents and equipment needed at the institution. the site initiation visit is the last opportunity to check that all study-related issues have been addressed and that preparation is complete before recruitment starts. essential documents for evaluation of trial conduct and the quality of the study data according to ich-gcp 2 need to be updated and kept secure in the research institution and sponsor site in a timely manner. the clinical research associate usually prepares packages including informed consent forms, investigator site files, and worksheets for distribution at the site initiation visit. monitoring visits, which are the most important activity in terms of the qa and qc of a clinical trial, start after the first participant is recruited and end when the final subject has been evaluated. source document verification (sdv), which is not clearly referred to in ich-gcp, is a systematic process for j o u r n a l p r e -p r o o f identifying the completeness, accuracy, and validity of data collected for each study participant and requires comparison between the source data and the case report form (crf). 8 source data include all types of information in the original or certified copies of original records obtained during clinical trials. they are contained in the source documents, which are medical charts, laboratory reports, or work sheets, including instruments or tools for patient-reported outcomes. 2 a crf is specially prepared for each participant in a clinical trial and records all information that will be used for the analysis. 2 an sdv is necessary to confirm that the data collected in the crf are accurate and reliable and that none have been incorrectly entered or omitted because of transcription errors. it is not always possible to review every single item of study data during the sdv, and there is no clear evidence that an sdv significantly improves the integrity of the data. therefore, partial onsite sdvs combined with centralized, risk-based monitoring are considered acceptable. 9 when using this approach, monitors usually categorize data into critical (e.g., related to informed consent, evaluation for selection of participants, and adverse events) or noncritical. critical data are monitored in all study participants, whereas noncritical data are checked in only a small sample (for example, 25%) of crfs at a monitoring visit. 8 the entire monitoring process needs to be documented, and monitoring reports must be submitted to the sponsors. 2 a close-out visit is conducted generally after the last follow-up visit for the final study subject. all queries that arise during the sdv need to be resolved, and all documents related to the clinical trials should be checked at this visit. any documents that are missing in the investigator site file or trial master file should be tracked and included at this visit. finally, the clinical research associate must return any unused study equipment and investigational drugs or medical devices to the sponsor. when there is often a difference in documentation between the general informed consent form and the consent form required for collection of biological samples. questionnaires and patient diaries, which are completed by the study participants themselves, could contain errors that need to be corrected using appropriate criteria. researchers require education and training in how to adjust for such errors so that they can assess outcomes in a consistent way. another common problem is lack of efficient management of clinical trial documents; for example, the investigator site file is not updated in many cases. furthermore, essential crf documents are sometimes missing because the information was not entered at the time of the subject's visit. all these deviations can be prevented by education and training of researchers and monitoring to improve the quality and credibility of the study data through a qa plan. monitoring is a major component of qa that can ensure the transparency and credibility of data this research did not receive funding from any source. there is no data which might be related to the ethical issue. there is no conflict of interest in all the authors. there is no available data as this work used available literature. code of ethics of the world medical association (declaration of helsinki) e6 (r2) good clinical practice: integrated addendum to ich e6 (r1 ensuring trial validity by data quality assurance and diversification of monitoring methods researching complementary and alternative treatments-the gatekeepers are not at home. bmc medical research methodology assessing the quality of controlled clinical trials the value of source data verification in a cancer clinical trial integrated addendum to ich e6 (r1): guideline for good clinical practice e6 (r2). current step a review of the source document verification process in clinical trials the impact of clinical trial monitoring approaches on data integrity and cost-a review of current literature the study of workload and task difficulty for clinical research associate (cra) seoul: pharmaceutical medicine and industry figure 1 . on-site monitoring in the different stages of a clinical trial key: cord-283779-mudwcypl authors: lauretani, fulvio; ravazzoni, giulia; roberti, maria federica; longobucco, yari; adorni, elisa; grossi, margherita; de iorio, aurelio; la porta, umberto; fazio, chiara; gallini, elena; federici, raffaele; salvi, marco; ciarrocchi, erika; rossi, francesca; bergamin, marina; bussolati, giacomo; grieco, ilaria; broccoli, federica; zucchini, irene; ielo, giuseppe; morganti, simonetta; artoni, andrea; arisi, arianna; tagliaferri, sara; maggio, marcello title: assessment and treatment of older individuals with covid-19 multi-system disease: clinical and ethical implications date: 2020-05-11 journal: acta biomed doi: 10.23750/abm.v91i2.9629 sha: doc_id: 283779 cord_uid: mudwcypl covid-19 infection is a multisystem disease more frequent in older individuals, especially in those with multiple chronic diseases. this multimorbid and frail population requires attention and a personalized comprehensive assessment in order to avoid the occurrence of adverse outcomes. as other diseases, the covid-19 presentation in older patients is often atypical with less severe and unspecific symptoms. these subjects both at home and during hospitalization suffer isolation and the lack of support of caregivers. the geriatric care in covid-19 wards is often missing. the application of additional instruments would be necessary to facilitate and personalize the clinical approach, not only based on diseases but also on functional status. this narrative review starts from diagnostic evaluation, continues with adapted pharmacologic treatment and ends with the recovery phase targeting the nutrition and physical exercise. we developed a check-list of respiratory, gastro-intestinal and other less-specific symptoms, summarized in a table and easily to be filled-up by patients, nurses and general practitioners. as second step, we reported the clinical phases of this disease. far to be considered just viral infective and respiratory, this disease is also an inflammatory and thrombotic condition with frequent bacterial over-infection. we finally considered timing and selection of treatment, which depend on the disease phase, co-administration of other drugs and require the monitoring of renal, liver and cardiac function. this underlines the role of age not just as a limitation, but also an opportunity to increase the quality and the appropriateness of multidisciplinary and multidimensional intervention in this population. (www.actabiomedica.it) these countries differ in terms of percentages of population over 65, the most afflicted by infection, with italy reaching 23%. italy for instance has higher life expectancy than the majority of countries affected by covid-19 infection (83.4 overall vs 76.7 in china) (2) . these demographic differences could also explain the different outcomes between countries. italy has one of the highest covid-19 mortality (26,644 deaths) and case-fatality rate (7.2%), much higher than china (2.3%). interestingly, the case-fatality rate in italy and china are very similar for age-groups 0 to 69 years, but rates are higher in italy especially among those aged 80 years or older (52% of deaths and 20% of case fatality rate). this difference can be at least partially explained by the higher number of people aged 80 years or older (n=11563), age group having a very high fatality rate (22.7%) and not reported in china (2) . gender issue has been raised by scientists and epidemiologists with men experiencing higher prevalence (64.2 % in the last italian report) and severity (they die more and at earlier age) of covid-19 infection than women. many hypotheses have been formulated to explain this difference between two sexes. cov-id-19 virus can be localized in the testes, which are potential target of sars-cov-2 infection, and one of the reasons for the rapidly spreading disease. moreover, testosterone, the male hormone, has been shown to upregulate the expression of transmembrane protease, serine 2 (tmrpss2) which is an enzyme involved in the penetration of virus in the lung cells. age is accompanied by changes in immune competence and a higher prevalence of inflammation, socalled "inflammaging" (3) . the chronic increase in inflammatory cytokines, augmented by covid-19 infection, may explain the higher tendency for "the cascade leading to pulmonary fibrosis and insufficiency and activation of clotting" and poorer clinical prognosis, especially in multimorbid older persons (4) . multimorbidity defined by the concomitant presence of two or more chronic diseases, is highly prevalent in older persons, affecting more than 60% of people aged 65+ (5) . data collected in 21.551 sars-cov-2 italian patients who died from covid19 show that the mean number of diseases is 3.2 (median sd 3 ±1.9). seventy patients (3.7 % of sample) had no diseases, 273 (14.4%) 1 disease, 400 (21.2%) 2 diseases, and 1147 (68.7%) 3 or more (2) . cardio-renalrespiratory (heart failure, atrial fibrillation, chronic renal failure, copd), metabolic diseases (obesity and type 2 diabetes), active cancer during the last 5 years and dementia seem to be the clusters more associated with adverse clinical outcomes. as a consequence of multimorbidity, polypharmacy defined as the number of drugs reported at hospital admission and the potential drug-drug interactions require a careful evaluation in older covid-19 patients. the combination of antiviral and anti-inflammatory drugs (never tested before in these individuals) and the concomitant treatment for other chronic diseases, especially in subjects with smoking exposition or sarcopenic obesity, increase the risk of adverse drug effects. diarrhea, dehydration, acute kidney insufficiency and liver failure can frequently occur and need to be monitored (6) . diseases, drugs and the primum movens cov-id-19 are also associated with hyperactive delirium, especially in hospitalized patients with preexisting dementia and cognitive impairment (7) . this syndrome requires a multidisciplinary evaluation balancing cost/effectiveness of therapeutic treatment (sedation or precipitation of respiratory and cardiac failure) and opens a large window of ethical issues, especially in older patients (8) . as suggested by nice rapid guideline and the canadian frailty network, the assessment of all adults for frailty, irrespective of age and covid-19 status, is highly recommended especially at hospital admission (6) . as already reported for other diseases, the cov-id-19 clinical presentation in older patients is often atypical with less severe symptoms. these subjects both at home and during hospitalization also suffer the isolation and the lack of fundamental support of formal and informal caregivers required for their safety (9) . despite the peculiar aspects of older patients and the epidemiology of the phenomenon, the geriatric culture and care in covid-19 wards is often missing. their application together with additional instruments would be such necessary to facilitate and personalize the clinical approach, not only based on number of diseases but also on functional status of older patient (10) . this narrative review has the specific aim to address different aspects of covid-19 multi-system disease starting from diagnostic evaluation, continuing with innovative classification of phases and proposing sequential adapted pharmacological treatment. the document wants also focus on the recovery phase and ethical considerations regarding the risk of limited access of care and accelerated exitus in this vulnerable age-category. the most common symptoms of covid-19 disease in the adults are represented in table 1 . this table describes a check-list of more frequent symptoms in adults and would be a guide to orient patients and primary care physicians in assessing older patients with suspected covid-19 infection. the range of symptoms is similar for covid-19 and influenza infection, although the fraction with severe disease is different. for covid-19, actual data suggest that 80% of infections are mild or asymptomatic, 15% are severe infections, requiring oxygen and 5% are critical infections, requiring ventilation. these fractions of severe and critical infection would be higher than influenza infection (11, 12) . symptoms can be traditionally classified into two main groups, including respiratory and gastro-intestinal, and a third group of less organ specific. the quality and severity of symptoms can be different in older persons. the most common symptoms are fever (98%), cough (77%), dyspnea (63.5%) and muscle/joint soreness (13) . the rationale of symptoms distribution across organs is partially explained by the concentration of angiotensin-converting enzyme 2 (ace-2) virus receptors, which is particularly higher in the lung and lower in the gut. this can explain why less common symptoms include abdominal pain, vomiting and diarrhea and virus might be detected in stool samples although gastro-intestinal transmission remains to be demonstrated (14) . it has been also hypothesized that covid-19 virus can also alter central nervous system directly or alternatively disrupt the gut-barrier permeability and induces the gut-brain link via vagus nerve. this justifies the reduced sense of taste and smell, headache, dizziness and vertigo also observed in covid-19 patients (15) . elderly patients, especially with multiple chronic conditions, display less severe and atypical symptoms. the presence of mild symptoms is disproportionate to the severity of their illness (16) . they might be afebrile, without cough or sputum production, and show higher prevalence of muscle-joint pain, tachypnea, altered mental status or delirium, unexplained tachycardia and decrease in blood pressure (17) . atypical presentation may be due to several factors, including physiologic changes with age, comorbidities, and inability to provide an accurate history given the constant lack of caregivers during covid-19 hospitalization (18) . despite the presence of less severe and atypical symptoms, older patients have a significantly higher mortality. as nicely shown in an elegant retrospective study male sex, time from disease onset to hospitalization, abnormal kidney function, and elevated procalcitonin levels were all significant predictors of increased mortality (14) . swab and or lung ct scan. the diagnosis of covid-19 requires the combination of swab and radiologic features. the algorithm initially considers a swab performed with sterile cotton wool suitably rolled around the end of a glass or metal rod, and intended to be swiped on the surface of a natural pharynx and nose cavity. the main nasal swab tests examine the nasopharynx, where the back of the nose meets the top of the throat. this requires a trained hand to perform and some portion of the false negatives arises from improper procedures and poor compliance especially in older adults with acute confusion state (19) . the pharyngeal and nasal swab, once carried out (in some centers not even getting out of the car but with the prior authorization and appointment of the public health office of the local healthcare companies) is sent to an authorized laboratory where the presence of viral rna or genetic material of the virus is appreciated. in case of positivity, there is the certification that the subject has a covid-19 infection. but even if done correctly, the swab may produce a negative result. that is because as the disease progresses, the virus passes from the upper to the lower respiratory system. importantly, the swab test has a sensitivity of 60-70% and strictly depends on the timing of assessment. this means that in 30-40% of cases, even in the case of a negative buffer, the presence of the virus cannot be excluded. in these cases, the patient may be asked to try to cough up sputum -mucus from the lower lungs -or doctors may need to take a sample more invasively when a patient is under sedation. radiological findings are useful complements in the diagnosis covid-19 and in the management of one of its most common complications, pneumonia. the most common computed tomography (ct) findings of the covid-19 pneumonia are ground glass and/or consolidation, and mainly reflect the diffuse and bilateral alveolar damage and/or organizing interstitial pneumonia. it has also been reported a strong correlation between the severity of ct pulmonary findings and patients' outcome. hence, it has been suggested that chest ct could be used as a reliable diagnostic test in the emergency workup of covid-19, complementing pcr. a further confirmation of the covid-19 infection comes from a chest x-ray or even better from a high-resolution chest ct scan (hrct) which highlights the percentage of lungs and the number of lung lobes affected by the virus. the radiologist, using specific software, processes a visual score or score in percentage. the higher the visual score the greater the severity of the lung involvement of virus. visual scores at the time of admission to the hospital of more than 70% are usually associated with a bad prognosis and more than 50% identify a severe disease. another parameter assessed through the ct scan is the number of lung lobes affected by the infection, which can vary from 0/5 to 5/5. also in this case, the greater the number of lung lobes involved, the greater the severity of the ongoing lung involvement of virus. the diagnostic process is the first step of clinical assessment of the patient. interestingly the initial hypothesis that the covid-19 is just an infectious disease has been gradually abandoned. an intriguing recent theory suggests that there are different phases in the same disease ( figure 1 ). the viral disease is limited to phase 1, where an early infection (8 days of duration) predominates and the host fights to solve the infection. however, if the attempt fails, the activation of an exaggerated response is capable to damage different tissues and organs (kidney, liver, myocardium, brain). another interesting theory suggests an early endothelial cell damage induced by covid-19 as common mechanism of vascular impairment across different organs (20) . three other phases (mainly depicting the host response to virus) are even more important for the clinical course and the outcomes of the patients. more effective will be the host response to virus, more chances the individuals have to survive. together with clinical evaluation (for instance peripheral capillary oxygen saturation), the functional assessment should also guide clinicians in the admission to intensive care unit (icu), in selecting therapeutic choices, and in predicting clinical and functional responses. both uk and canadian frameworks suggest the usefulness of easy to use instruments such as the clinical frailty scale to assess frailty (10) . other additional tests include chair stand test (cst) which is one of the best and validated physical performance tests for older people, and it is reported to be associated with muscle strength of the lower leg. the cst is a simple and feasible physical performance test, even for evaluating older people with limited mobility. then, many representative cohort studies have demonstrated that the cst is a predictor of disability and falls in older people (21) . (figure 1 and table 2 ) phase 1. infectious-virological phase or early infection phase 1 (max duration 8 days). the virus is present in the upper airways and digestive tract and usually induces specific symptoms (dry cough, fever, fatigue with normal peripheral oxygen saturation, diarrhea, headache, conjunctivitis) in the adult individuals (13) . the body response produces immune (igm in phase 1, viral response predominates and respiratory and gastrointestinal symptoms can be treated at home with hydroxychloroquine and antivirals. in phase 2: pulmonary, fever and dyspnea worsen and rapid diagnosis by ct and hospitalization is required. in phase 3, pulmonary and hyperinflammatory, clinically represented by ards, corticosteroids and il-6 receptor antagonists should be started in sub-intensive wards. in phase 4, thrombotic, anticoagulant therapy should be introduced and admission to icu indicated. there is a transverse phase: bacterial over infection, typically characterized by high fever, increased white blood cells and procalcitonin, where broad-spectrum antibiotic therapy is the choice treatment. legend of figure . both responses, especially if supported by appropriate pharmacological treatment, translate into an infective resolution in 80% of cases. the different response in older patients and in different categories (fit, frail, disable) is an interesting topic to be investigated (12) . the phase 1 treatment includes drugs with mixed anti-viral and anti-inflammatory activity (hydroxychloroquine) and antibacterial drug with minimal anti-viral action (azithromycin) (14, 17) . these drugs act synergistically on heart rhythm and require, because of the frequent concomitant use and especially in subjects with previous cardiac disease, electrocardiogram (ekg) trace to monitor qtc interval (22) . low molecular weight heparin, in the presence of good renal and liver function, at prophylaxis doses is also suggested (23) . in older patients, these specific aspects require additional and careful evaluation given the inadequate formulas currently used to assess for instance renal function (24) . in about 80% of cases, the disease ends at this stage and can be managed at home. however, the onset and persistence of symptoms within 2-3 days requires an immediate communication to primary care physician (or general practitioner) for a timely diagnosis and therapy. pharmacological treatment must be accompanied by the adoption of home behavioral measures in order to avoid contagion of the other family members. if the fever is persistently higher ≥38°c, especially for more than 3-4 days, or if peripheral oxygen saturation drops below 95% and/or dyspnea increases, we should suspect an exaggerated inflammatory response and the extension to the lung and recommend the hospitalization. the typical serum biomarker picture of this phase could be represented by low wbc, crp and d-dimer mildly increased, normal troponin i hs levels ( table 2) . this phase usually occurs after 10 days on average from the onset of symptoms in which the virus migrates to the lower respiratory tract lung. characterizing symptoms lasting 5 days or longer, range from shortness of breath to severe dyspnea and fatigue. this phase can be characterized by low peripheral oxygen saturation (spo2 <95%). endothelial and initial cardiac damage are also possible (25) . at this stage, hospitalization in semi-intensive wards could be necessary. acute confusional state in older persons is frequently observed and sedative and palliative treatment are important and detrimental confounders. men experience more clinical complications than women. this different exposure can be explained by higher expression pattern of ace2 receptors in adult human testes at the level of single-cell transcriptome suggesting that this organ is a potential target of sars-cov-2 infection, and one of the reasons for the rapidly spreading disease (26) . the typical serum biomarker picture of this phase could be represented by normal wbc, further increase in crp and d-dimer levels, troponin i hs levels that require to be monitored for the potential involvement of myocardium and pericardium ( table 2) . phase 3. pulmonary-hyper-inflammatory phase 3, which is characterized by systemic symptoms with multi-organ involvement (ards sirs/ shock cardiac failure) (27, 28) . individualized treatment in this phase is required, considering for example corticosteroids (methylprednisolone 1 mg/kg/day or dexamethasone at 20 mg/day intravenously), human immunoglobulin, inhibitors of the il-6, il-2, and jak2 receptor. this phase requires hospitalization in icus or respiratory intensive care unit (29) . the typical biomarker picture of this phase could reproduce phase 2 ( table 2) . phase 4. vasculitic-thrombotic phase 4 (coexisting or immediately following the previous phase) consists of endothelial damage, local and diffuse thrombotic phenomena and pulmonary hypertension (30) . there is the rationale, especially in this phase, to support, at high dosages, and based on weight and renal function, the use of enoxaparin, very known also for its antiviral activity (31, 32) . the presence of pulmonary hypertension suggests also the potential usefulness of phosphodiesterase inhibitors releasing nitric oxide such as sildenafil (33) . the typical serum biomarker picture of this phase could be represented by normal wbc, very-high levels of d-dimer and troponin i hs levels that require to be monitored for the potential occurrence of thrombotic events in different organs ( table 2) . the separation of different phases of disease contributes to delineate a specific timing for starting appropriate pharmacological treatment and establishing setting (home and hospital wards) at increased intensity of care. in case of persistent fever, higher than 37.5°c for a time longer than 3 days and peripheral oxygen level lower than 95% after starting therapy, we should consider and proceed to hospitalization especially in multimorbid older patients with cardiac, respiratory diseases and diabetes. the use of antivirals is poorly supported by randomized controlled clinical trials performed only in adult patients (34) and should be limited to the initial phase of the disease. antivirals are poorly indicated during phase 2 (35), and not indicated at all during phases 3 and 4. vice-versa, the anti-inflammatory-immunosuppressive therapy, are contraindicated during phases 1 and 2 in which the organism/host is elaborating or implementing its defensive strategy. corticosteroids and other anti-inflammatory medications should be also carriedout, once having careful evaluated specific contraindications, during phases 3 and 4, where the combination anti-inflammatory/ anticoagulant therapy is suggested in case of significant increase of d-dimer and/or positive pulmonary ct with contrast. late phases are usually characterized by exaggerated phase response of the host which is harmful to the host and needs to be attenuated (28, 36) . this might be particularly detrimental in older patients where a chronic inflammatory status is often present. every single phase of the pathology is also influenced by the undergoing pharmacological treatment and related side effects. drug-drug interaction deserves particular attention especially in older persons with polypharmacy. all these medications may induce gastro-intestinal symptoms (especially diarrhea) and worsen kidney and liver function. the ekg at the basal entry should be carried out on regular basis to monitor the qtc interval and to exclude the potential myocardial and pericardial damage induced by the infectious process. treatment in this phase, usually lasting about 7-8 days, consists of drugs with anti-inflammatory activities. these drugs, such as chloroquine or hydroxychloroquine should be started as soon as possible (37) . however, their utilization is actually based on in vitro data (38, 39) and single open label non-randomized trial conducted in 36 patients with covid-19 (40) . antiviral drugs derive their use from trials verifying their effective treatment of other viruses including sars (severe acute respiratory syndrome-related coronavirus) and mers (middle east respiratory syndrome coronavirus). in particular, preliminary genomic studies on 2019-ncov showed that the sequence has similarities with the corresponding sars and mers enzymes, and this justifies why repurposing exiting sars and mers inhibitors for 2019-ncov (14) . although the use of many anti-viral drugs has been proposed, particular attention received lopinavir/ ritonavir and remdesivir. the first antiviral drug, lopinavir/ritonavir, has specific indication for treat hiv and was also utilized in the 2003 for sars. convincing evidence of its therapeutic effects on covid-19 is lacking. moreover, a recent randomized clinical trial found no different clinical effect compared to standard care on 2019-ncov infection. only in the modified intention-to-treat analysis, which excluded three pa-tients with early death, the between-group difference in the median time to clinical improvement (median, 15 days vs. 16 days) was significant, albeit modest (34) . another virally targeted agent is the remdesivir, a very promising drug, which is a drug currently being investigated as a potential covid-19 treatment through several clinical trials. in details, two phase iii randomized, placebo-controlled double-blind, multicenter trials were initiated in early february to investigate remdesivir in two different dosages 200 mg/day and 100 mg/day for 9 days with estimated complete results at the end of april 2020 (41) . finally, the favipiravir, an antiviral drug manufactured by japanese pharmaceutical company fujifilm toyama chemical, was approved for treatment of novel influenza on february 15, 2020 in china, and clinical trials testing this medication are undergoing. preliminary data from 80 patients indicated that favipiravir had more potent antiviral effect than lopinavir/ ritonavir and even with lower side-effects (42) . however, given that no current definitive specific treatment for covid-19 infection has been proved based on randomized clinical trial, who has now launched the solidarity trial to investigate four potential treatments: remdesivir, chloroquine/hydroxychloroquine; lopinavir and ritonavir; and lopinavir and ritonavir plus interferon-β. 1 the only limitation of this study is that will not be double blind, but it will include thousands of patients from several countries (43) . this phase normally is associated in the adults with the presence of persistent high fever. this symptom often requires admission to emergency department and hospitalization for the execution of pulmonary ct scan. this technique is the gold standard for the diagnosis of typical interstitial pneumonia. the most important observation of this infection phase is the rapid progression into pulmonary impairment with a rapid worsening hypoxia. therefore, patients who failed to standard oxygen therapy required an advanced oxygen/ventilatory. patients may also have increased work of breathing, demanding positive pressure breathing assistance, which could be guaranteed by non-invasive ventila-tion (including continuous positive airway pressure [cpap] or bi-level positive airway pressure [bipap]) in patients with hypoxemic respiratory failure. prone ventilation in patients with persistent severe hypoxic failure should be considered. finally, patients who are acutely deteriorating undergo intubation and mechanical ventilation. two thirds of patients who required critical care in the uk had mechanical ventilation within 24 hours of admission (44) . in this phase, the presence of elevated serum levels of inflammatory cytokines, such as il-6 could induce pulmonary damage or proliferative pulmonary phase. il-6 receptor antagonists (e.g., tocilizumab, sarilumab, siltuximab) can be used. in particular, the tocilizumab which is a monoclonal antibody that blocks the il-6 signalling pathway is currently used to treat rheumatoid arthritis. however, given the limited evidence on the safety or efficacy of the drug in clinical treatment of covid-19, the fda launched through a double blind, a randomised phase iii clinical trial as a treatment for severe covid-19 pneumonia with tocilizumab in combination with standard of care (44) . acute respiratory distress syndrome (ards) is an acute, diffuse, inflammatory form of lung injury related with high mortality. diagnostic criteria (berlin definition 2012) include non-cardiogenic respiratory failure, with respiratory symptoms, bilateral opacities on ct scan and presence of a moderate to severe impairment of oxygenation (45, 46) . the pao2/fio2 defines the severity of the ards (calculated data with a positive end-expiratory pressure (peep) or continuous positive airway pressure (cpap) ≥5 cm h2o) in the absence of cardiac failure or fluid overload. • mild ards -pao2/fio2 is >200 mmhg, but ≤300 mmhg. • moderate ards -pao2/fio2 is >100 mmhg, but ≤200 mmhg. • severe ards -the pao2/fio2 is ≤100 mmhg (47) . excessive inflammatory response is an essential characteristic of ards pathophysiology, with an increase of interleukin-1 beta (il-1β), interleukin-2 (il-2), il-6, interleukin-17 (il-17), interleukin-8 (il-8), tumor necrosis factor-α (tnf-α) and c-c motif chemokine ligand 2 (ccl2) (48) . it is known that in patients with ards, elevated plasma il-6 at baseline predict a poor survival (28) . also in covid-19 patients, higher il-6 levels are associated with an increased risk of hospitalization and other negative outcomes (49) . at this stage of the disease, patients typically show dyspnea, tachypnea, fever and tachycardia. they can also show severe, acute confusion (especially in older persons), respiratory distress and cyanosis. as lung dysfunction progresses, it is necessary to increase oxygen-therapy until non-invasive mechanical ventilation is required (50, 51) . the use of corticosteroids could be beneficial to modulate the excessive immune response, but their use is controversial. a recent study shows that the use of corticosteroids in ards reduced all-cause mortality and duration of mechanical ventilation, and increased ventilator-free days (52) . in this regard, we hypothesized that patients already taking corticosteroids for other diseases, such asthma, pulmonary fibrosis, rheumatologic diseases and without indication for bacterial over-infections, can take advantage from adequate dosages of corticosteroids. however, future clinical trials are required to verify these aspects. in this phase, convalescent plasma from patients who have recovered from viral infections can be used as a treatment. clinical trials to determine the safety and efficacy of convalescent plasma that contains antibodies to sars-cov-2 in patients with covid-19 have started. a small preliminary case-series of five critically ill patients reported clinical improvement after convalescent plasma transfusions (53) . another study of 10 patients with severe illness in china noted symptomatic improvement within 3 days. viral load was undetectable within 7 days in 70% of patients. no serious adverse reaction was noted. covid-19 and ards can evolve into thrombotic phenomena. prolonged inflammation is responsible for a pro-coagulation state, with activation of the endothelial vasoconstrictors and formation of lung micro thrombi, also found during autoptic examination (52, 54, 55) . intriguingly, sars-cov-2 can directly infect engineered human blood vessel organoids in vitro. very recent case-series in patients with cov-id-19 have demonstrated an endothelial cell involvement across vascular beds of different organs especially in those with preexisting thrombotic disease (32, 56) . for all these reasons, a vasculitic/thrombotic phase can be hypothesized during covid ards. clinically, episodes of intense dyspnea and respiratory distress may occur. fever can be resolved. the pro-coagulant state is characterized by an increase in the d-dimer, which must therefore be regularly analyzed (28) . in details, if d-dimer level, normally performed every three days, increase more than 6 times from admission to later check, this parameter represents a good index for identifying high-risk groups of venous thromboembolism and anticoagulant treatment, if not contraindicated, should be prescribed (57) . respiratory distress syndrome (ards) is a common complication of covid-19 infection. ozoline and colleagues demonstrated that in patients with ards higher plasma concentrations of tissue factor and plasminogen activator inhibitor-1 were present at day seven compared to non-ards (58) . the mechanisms contributing to this lung coagulopathy are localized tissue factor-mediated thrombin generation, and depression of bronchoalveolar plasminogen activator-mediated fibrinolysis, mediated by the pai-1 increase (59) . thus, treatment with heparin might be helpful in mitigating this pulmonary coagulopathy. moreover, adjunctive treatment with low-molecular-weight heparin (lmwh) within the initial seven-day onset of ards reduces the risk of 7-day mortality by 48% with a meaningful improvement of the pao2/fio2 ratio (31) . in the same study, the risk of 28-day mortality was reduced by 37% as well. in a report from a wuhan university hospital, heparin use was associated with lower mortality in patients with sepsis-induced-coagulopathy (sic) score ≥4 (40.0% vs 64.2%, p=0.029), but not in those with sic score <4 (29.0% vs 22.6%, p=0.419). in the same report patients with d-dimer > 3.0 ug/ml experienced a 20% mortality reduction after heparin treatment (32.8% vs 52.4%, p=0.017) (57) . another fascinating concept is the antiviral role of heparin which has been studied in experimental models. given its polyanionic nature, heparin can bind to several proteins and thus act as effective inhibitors of viral attachment (60). one example is in herpes simplex virus infections. heparin competes with the virus for host cell surface glycoproteins inhibiting the virus entrance in the cells. also, in zika virus infection, it prevents virus-induced cell death (61) . finally, the use of heparin at a concentration of 100 μg/ml halved the infection in an experimental model of cells injected with sputum from a patient with sars-associated cov pneumonia (62) . however, the clinical benefits in any of these viral infections are yet to be determined. moreover, heparin may also be helpful in microvascular dysfunction and this is of importance given the well-known role of endothelial dysfunction in the cardiac failure, another increasingly recognized complication of covid-19. finally, a recent document of the italian national drugs agency (63) advices to consider the use of lmwh in serious cases of covid-19 (defined by the presence of one of the following conditions: pao2/fio2 < 300, respiratory rate > 30/min and spo2< 93% at rest) when the d-dimer is markedly increased (4-6 fold) and the sic score is > 4 ( table 2 ) and myocardial infarction or other thrombotic events cannot be excluded. however, high rate of high incidence of venous thromboembolic events may occur in severe covid-19 patients, irrespective of anticoagulation (64) . all previous phases of the covid-infection can be complicated by the presence of bacterial over-infection. this condition should be suspected when specific serum biomarkers such as wbc and procalcitonin are pathologically elevated (table 2) (65) . in this case, specific antibiotic therapy should be promptly prescribed, even in accordance with suggested guidelines (66) . polypharmacy is one of the main characteristics in older subjects. there is an increased risk of adverse events in this specific age-group. although there are no food and drug administration (fda)-approved drugs to prevent or treat covid-19, nevertheless pre-liminary clinical research, based on in vitro-data, have suggested the use of pharmacologic agents as chloroquine or hydroxychloroquine, azithromycin, lopinavir/ritonavir and other anti-retrovirals (67) . some of these drugs may increase risk of qt prolongation, ventricular proarrhythmia and sudden cardiac death. some of the current covid-19 repurposed drugs have known risk of us food and drug administration adverse event reporting system (faers), long qt syndrome and torsade de points (tdp) and cardiac arrest for azithromycin, and hydroxychloroquine, and possible risk for lopinavir/ritonavir. in the prevention of qtc-prolongation, special attention should go to high-risk patients. age is one of the main determinants of this risk score which has been derived and validated by tisdale et al. (68) , for prediction of drug-associated qt prolongation among cardiac-care-unit-hospitalized patients. the application of this scale identifies maximum risk score of 21 and three different classes of risk, low (score ≤ 6 points), moderate (7-10 points) and high (≥ 11 points) ( table 3 ) (69) . the goal of qtc screening in this setting is not to identify patients whom are not candidates for therapy, but to identify those who are at increased risk for tdp in order that aggressive countermeasures may be implemented. 1. baseline a. discontinue and avoid all other non-critical qt prolonging agents. b. assess a baseline ecg, renal function, hepatic function, serum potassium and serum magnesium. c. when possible, have an experienced cardiologist/ electrophysiologist measure qtc, and seek pharmacist input in the setting of acute renal or hepatic failure. 2. relative contraindications (subject to modification based on potential benefits of therapy) a. history of long qt syndrome, or b. baseline qtc >500 msec (or >530-550 msec in patients with qrs greater than >120 msec) 3. ongoing monitoring, dose adjustment and drug discontinuation a. place on telemetry prior to start of therapy. b. monitor and optimize serum potassium daily. c. acquire an ecg 2-3 hours after the second dose of hydroxychloroquine, and daily thereafter. d. if qtc increases by >60 msec or absolute qtc >500 msec (or >530-550 msec if qrs >120 msec), discontinue azithromycin (if used) and/ or reduce dose of hydroxychloroquine and repeat ecg daily. e. if qtc remains increased >60 msec and/or absolute qtc >500 msec (or >530-550 msec if qrs >120 msec), reevaluate the risk/benefit of ongoing therapy, consider consultation with an electrophysiologist, and consider discontinuation of hydroxychloroquine (70) . during covid-19 infection adult and older patients may also experience a higher incidence of gastrointestinal symptoms including diarrhea. the ongoing treatment with antivirals and anti-inflammatory could worsen this symptomatology, increasing potassium and magnesium deficiency and amplifying the risk already described of cardiac events and arrhythmia. in older patients it is widely observed the chronic, not always appropriate, use of proton pump inhibitors (ppi). one year ppi treatment has been associated with increased risk of all-cause mortality (71) . authors suggest that magnesium deficiency, clostridium difficile infection and intestinal colonization with multidrug-resistant microorganisms might justify the link between inappropriate use of ppi and mortality (72) (73) (74) . interestingly their chronic use has been associated with malnutrition and functional decline (75, 76) , two main aspects to be assessed and monitored in older patients with covid-19 infection. older age and the presence of multimorbidity are almost invariably associated with impaired nutritional status and sarcopenia (77) . some studies have demonstrated that hospitalization and associated bed rest even for short time-period (20 days) promote detrimental reduction in muscle mass, strength and physical function, with altered aerobic exercise capacity (78, 79) . covid-19 also amplifies these symptoms if we consider that muscle pain and fatigue are frequent symptoms also in older persons. the bed rest and high inflammatory and hypercatabolic status following covid-19 infection can promote a further reduction in walking speed, stair ascent power and chair stand test. these functional parameters, as well as the loss of strength, may compromise the recovery of functional skills in the elderly and induce the loss of autonomy. although albumin and prealbumin circulating levels should not be considered as nutritional markers in patients with acute inflammatory response, studies have shown an association between low prealbumin levels and increased risk of respiratory failure with increased need for mechanical ventilation (80) . all infected patients at hospital admission, especially those at nutritional risk should undergo nutritional assessment and receive nutritional support as early as possible. there is evidence that nutritional derangements should be systematically and urgently managed in patients affected by covid-19, also considering that the immune response is weakened by inadequate nutrition. nutritional intervention should be complementary to pharmacological treatment and the presence of a standardized protocol would be extremely helpful. for example, in italy, a nutritional protocol has been developed and proposed by university of milan and pavia in lumbardy which is one of the main italian regions affected by the italian covid-19 crisis (81) . this is based on systematic supplementation of certain nutrients (e.g. vit. d, whey proteins and omega 3 fatty acids) with anabolic and anti-inflammatory activity, oligo-elements stimulating immune system and particularly indicated in this high systemic inflammaheart failure 3 one qtc-prolonging drug 3 * a cut-off ≥ 7 can be used to assess moderate-severe risk. modified by reference 69. tory and catabolic condition. obesity can be considered a specific type of malnutrition, where the excess of macronutrients intake could also be accompanied by micronutrients deficiency (82) . the centers for disease control and prevention considers those with bmi ≥ 40 kg/m 2 as being at risk for flu complications. during the 2009 h1n1 pandemic, obesity was recognized as an independent risk factor for complications from influenza (80) . it is now well accepted that obesity increases one's risk of being hospitalized with, and dying from, an influenza virus infection, and it can be considered a predictor for poor outcome during covid-19 infections (83) . it has been reported that the presence of obesity in a group of metabolic associated fatty liver disease (mafld) patients was associated with a ~ 6-fold increased risk of severe covid-19 illness (unadjusted-or 5.77, 95% ci 1.19-27.91, p=.029). given the high prevalence of obesity and overweight in european countries (30-70%), the challenge for virus pandemics is therefore to protect these subjects (84) . although the effects of covid-19 on patients with obesity have not yet been well-described, it is well known the impact of h1n1 influenza the care of patients with obesity and with severe obesity, due to its adverse effect on pulmonary function (85) . the increased morbidity associated with obesity in covid-19 infections may be explained by increased inflammatory cytokines, other important determinants of severity infection include basal hormone milieu, defective response of both innate and adaptive immune system and sedentariness. it has been suggested by recent evidences that a large obese population increases the chance of appearance of more virulent viral strain, prolongs the virus shedding throughout the total population and eventually may increase overall mortality rate of an influenza pandemic (86) . finally, some authors outlined a framework whereby adipose tissue may be as a reservoir for more extensive viral spread with increased shedding, immune activation and cytokine amplification (83) . even, there are no specific studies on nutrition management in covid-19 infection, espen promotes considerations based on the best of knowledge and clinical experience. first, patients at risk for poor outcomes and higher mortality following infection with sars-cov-2, namely older adults and multimorbid individuals, should be checked for malnutrition through screening and assessment. criteria can be used are the must criteria or, for hospitalized patients, the nrs-2002 criteria. recently it has been introduced the glim (global leadership initiative on malnutrition) criteria for malnutrition diagnosis. obese individuals should be screened and investigated according to the same criteria, as they are malnourished. in a recent review about potential interventions for novel coronavirus based on the chinese experience authors suggested that the nutritional status of each infected patient should be evaluated before the administration of general treatments (87) . subjects with malnutrition should optimize their nutritional status, ideally by diet counseling from an experienced professional. macronutrients intake proposed by espen are the following. energy needs can be assessed or predicted by equations or weight-based formulae such as: • 27 kcal per kg body weight and day; total energy expenditure for polymorbid patients aged >65 years; • 30 kcal per kg body weight and day; total energy expenditure for severely underweight polymorbid patients*; • 30 kcal per kg body weight and day; guiding value for energy intake in older persons, this value should be individually adjusted with regard to nutritional status, physical activity level, disease status and tolerance. *the target of 30 kcal/kg body weight in severely underweight patients should be cautiously and slowly achieved, as this is a population at high risk of refeeding syndrome. protein needs are usually estimated using formulae such as: • 1 g protein per kg body weight and day in older persons; the amount should be individually adjusted with regard to nutritional status, physical activity level, disease status and tolerance. • ≥ 1 g protein per kg body weight and day in polymorbid medical inpatients in order to prevent body weight loss, reduce the risk of complications and hospital readmission and improve functional outcome. fat and carbohydrate needs are adapted to the energy needs while considering an energy ratio from fat and carbohydrates between 30:70 (subjects with no respiratory deficiency) to 50:50 (ventilated patients) percent. also micronutrients, such as vitamins and minerals, should be ensured to potentially reduce disease negative impact, by supplementation and/or adequate provision. low levels or intakes of micronutrients such as vitamins a, e, b6 and b12, zn and se have been associated with adverse clinical outcomes during viral infections (86) . recently, a chinese review (88) proposed that also vitamin c, omega-3 polyunsaturated fatty acids, as well as selenium, zinc and iron should be considered in the assessment of micronutrients in covid-19 patients. oral nutritional supplements (ons) should be used whenever possible to meet patient's needs, when dietary counseling is not sufficient to reach nutritional goals. individuals infected with sars-cov-2 outside of the icu should therefore be treated to prevent or improve malnutrition. the oral route is always preferred when practicable. nutritional treatment should start early during hospitalization (within 24-48 h) and targets should be met gradually to prevent refeeding syndrome. ons provide energy-dense alternatives to regular meals and may be specifically enriched to meet targets in terms of protein as well as micronutrients (vitamins and trace elements). the daily estimated requirements of these nutrients should be regularly provided. nutritional treatment should continue after hospital discharge with ons and individualized nutritional plans; this is particularly important since preexisting nutritional risk factors continue to apply and acute disease and hospitalization are likely to worsen the risk or condition of malnutrition. according to espen statements, in multimorbid inpatients and in older persons with reasonable prognosis, when nutritional requirements cannot be met by the oral route, enteral nutrition (en) should be preferred to parenteral nutrition (pn), because of a lower risk of complications (related or not related to infectious). pn should not be started until all strategies to maximize en tolerance have been attempted. about the nutritional management of covid-19 patients admitted to intensive care units, espen guidelines on this specific topic are available giving suggestions on different stages of treatment according to patients' condition and respiration. infected patients not intubated who do not reach nutritional requirements by normal diet, first should be supplemented by ons, then en treatment can be considered. when limitations are present to en, pn can be prescribed. in covid-19 intubated and ventilated icu patients, enteral nutrition (en) should be started through a nasogastric tube; post-pyloric feeding should be performed in patients with gastric intolerance after prokinetic treatment or in patients at high-risk for aspiration; the prone position per se does not represent a limitation or contraindication for en. patients' energy expenditure can be derived from ventilator (vo2, oxygen consumption from pulmonary arterial catheter or vco2, carbon dioxide production), and energy is administered according to its value. hypocaloric nutrition (not exceeding 70% of ee) should be administered in the early phase of acute illness with increments up to 80 and 100% after day 3. regarding protein intake, 1.3 g/kg protein equivalents per day can be delivered progressively. in obese subjects, 1.3 g/ kg "adjusted body weight" protein equivalents per day is recommended. adjusted body weight is calculated as ideal body weight + (actual body weight -ideal body weight) * 0.33. after mechanical ventilation, patients may present swallowing difficulties and texture-adapted food can be considered after extubation. if swallowing is proven unsafe, en should be administered. in cases with a very high aspiration risk, post-pyloric en or, if not possible, temporary pn during swallowing training with removed naso-enteral tube can be performed. hydration status of patients should be considered and assessed after the acute and critical phases. high grade of inflammation and infectious status with long lasting fever period may cause dehydration which needs to be treated before discharge. furthermore, some patients with covid-19 show intestinal disease, thus nutritional and gastrointestinal function should be assessed for all patients. some authors suggest that nutritional support and application of prebiotics or probiotics should be suggested to regulate the balance of intestinal microbiota and reduce the risk of secondary infection due to bacterial translocation (89) . almost no information is available on metabolic and nutritional needs of icu survivors, and known nutritional practices reveal a poor nutritional performance during icu stay and after discharge. a few evidences showed that currently poor nutritional practices are adopted for older patients who leave the icu in the ward, and further research are needed to fill the gap. following hospital discharge, especially patients should comply with high-protein targets either by prolonged tube feeding or by enhanced high-protein oral nutrition (supplement) intake. further, nutritional and metabolic therapies such as anabolic/anti-catabolic agents in the recovery need urgent studies (90) . nutritional intervention should be combined (whether possible) with physical exercise in order to optimize its anabolic effect (91) . different phases and week programs could be also followed with the specific aim of recovering physical and motor skills (table 4) . phase 1. recover of orthostatism. once the acute phase has been resolved, the multidomain intervention should include exercise and target the recovery of orthostatic and motor skills. it would be important progressively increase the anti-gravity position starting from the sitting position on the bed with slow exercises and movements to be repeated several times a day, until the complete recovery of the upright position. phase 2. train balance and coordination of movements. following this first phase, static and dynamic balance exercise should be performed for improving balance impairment. holding on the back of a chair, stand on tiptoe and then return to the starting position, or keep the balance in monopodalic support. phase 3. regain muscle strength. low intensity muscle strengthening exercises might be useful for recovering strength and functional autonomy, improving stability, balance and reducing the risk of falls. for example, sitting back on a chair, slowly raise left leg until it is fully extended, pause for a breath, then slowly lower left leg back to the ground. this sequence should be repeated 10 times both sides. phase 4. start endurance training. aerobic exercise, like walking inside the house or stationary bike, can be started after the regaining of motor skills and strength, initially 10 minutes of activity then up to 20 minutes. maintenance: individual multicomponent exercise program. at the end of the total recovery, a multicomponent exercise program can include aerobic, resistance, balance, coordination and mobility training exercises (92) . twenty minutes of aerobic exercise every day and three days a week of resistance exercises at low and medium intensity should be the ideal choice for older people to enhance the protective role of physical activity (93) (94) (95) . the pathophysiology of the covid-19 infection especially in older adults requires a dynamic process with important clinical and ethical implications in the hospital and community care. now it is quite clear that the infection produces a systemic disease with different phases at increasing severity of symptoms. older patients infected by covid-19 often experience atypical and less severe symptoms in older persons, side-effects of the drugs and require specific nutritional and motor treatment for avoiding disability and death. by expanding the proposal of hasan k et al. (96) , we added to the already known infective, pulmonary and inflammatory, a potential iv phase for emphasizing the presence of a vascular-thrombotic process more frequent during the severe pulmonary disease. we also underlined the bacterial over-infection, which can be transversally present in all phases and requires the need of antibiotic treatment. as addressed by italian ethics committee it is ethically unacceptable, each selective care criterium based on «age, gender, condition and social role……and disability». these principles have been often ignored, especially in older covid-19 patients. examples reported from the sociologist giuseppe de rita and coming from uk or holland, describe that patients 70 year or older are invited to sign a declaration where they refuse to be cured if another younger patient requires the same treatment. a statement signed on march 23rd 2020 by the european geriatric medicine society (eugms) (97) suggests that advanced age should not by itself be a criterion for excluding patients from specialized hospital units and care. simplified models of comprehensive geriatric assessment and tailored interventions (including evaluation of frailty, hydration and nutritional with body mass index and cst, social and psychological support, management of polypharmacy) are mandatory to guide appropriate clinical approaches, especially if older subjects are really fit, without any cognitive and motoric dysfunction, and to improve the patient's quality of life (98) . these principles should be applied to every setting of care including community/primary care, hospital and nursing home placement. innovative organizing multidisciplinary models are especially important during the transition care and coronavirus outbreak, because older people might experience an understandable slowing down of physi-cal and mental capacities in the discharge from acute care with prolonged hospital stays and increased risk of iatrogenic consequences. all the necessary 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that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a conflict of interest in connection with the submitted article key: cord-317952-4oa9hfb4 authors: bourgonje, arno r.; abdulle, amaal eman; timens, wim; hillebrands, jan‐luuk; navis, gerjan j.; gordijn, sanne j.; bolling, marieke c.; dijkstra, gerard; voors, adriaan a.; osterhaus, albert d. m. e.; van der voort, peter h. j.; mulder, douwe j.; van goor, harry title: angiotensin‐converting enzyme‐2 (ace2), sars‐cov‐2 and pathophysiology of coronavirus disease 2019 (covid‐19) date: 2020-05-17 journal: j pathol doi: 10.1002/path.5471 sha: doc_id: 317952 cord_uid: 4oa9hfb4 angiotensin‐converting enzyme‐2 (ace2) has been established as the functional host receptor for severe acute respiratory syndrome coronavirus 2 (sars‐cov‐2), the virus responsible for the current devastating worldwide pandemic of coronavirus disease 2019 (covid‐19). ace2 is abundantly expressed in a variety of cells residing in many different human organs. in human physiology, ace2 is a pivotal counter‐regulatory enzyme to ace by the breakdown of angiotensin ii, the central player in the renin‐angiotensin‐aldosterone system (raas) and the main substrate of ace2. many factors have been associated with both altered ace2 expression and covid‐19 severity and progression, including age, sex, ethnicity, medication and several co‐morbidities, such as cardiovascular disease and metabolic syndrome. although ace2 is widely distributed in various human tissues and many of its determinants have been well recognised, ace2‐expressing organs do not equally participate in covid‐19 pathophysiology, implying that other mechanisms are involved in orchestrating cellular infection resulting in tissue damage. reports of pathologic findings in tissue specimens of covid‐19 patients are rapidly emerging and confirm the established role of ace2 expression and activity in disease pathogenesis. identifying pathologic changes caused by sars‐cov‐2 infection is crucially important as it has major implications for understanding covid‐19 pathophysiology and the development of evidence‐based treatment strategies. currently, many interventional strategies are being explored in ongoing clinical trials, encompassing many drug classes and strategies, including antiviral drugs, biological response modifiers and raas inhibitors. ultimately, prevention is key to combat covid‐19 and appropriate measures are being taken accordingly, including development of effective vaccines. in this review, we describe the role of ace2 in covid‐19 pathophysiology, including factors influencing ace2 expression and activity in relation to covid‐19 severity. in addition, we discuss the relevant pathological changes resulting from sars‐cov‐2 infection. finally, we highlight a selection of potential treatment modalities for covid‐19. this article is protected by copyright. all rights reserved. introduction microbial ecology. in fact, transplantation of gut microbiota from ace2-knockout mice resulted in an increased propensity to develop severe colitis [21] . previously, we investigated the immunolocalization of ace2 in healthy human organs [7] . ace2 was highly expressed on lung alveolar epithelial cells and small intestinal epithelial cells, consistent with potential routes of viral transmission of sars-cov-2, as both respiratory and gastrointestinal systems share interfaces with the external environment. additionally, ace2 was present on vascular endothelial cells and smooth muscle cells in all organs studied. in the kidney, ace2 was strongly expressed in the brush border of proximal tubular cells and moderately or weakly in parietal epithelial cells and podocytes, whereas ace2 staining was weak or negative in glomerular endothelial cells and mesangial cells. ace2 was also present in the basal epidermal layer of the skin and in the oral and nasal mucosa. in contrast, ace2 was absent in lymphoid tissues and hepatobiliary structures [7] . the intense staining on various epithelial cells (small intestine, kidney, skin) strongly suggests raas-independent functions of ace2. these findings trigger alternative hypotheses regarding ace2 involvement in viral transmission pathways. furthermore, we previously noted that endothelial ace2 was upregulated in the glomerular and interstitial capillaries in kidney diseases independent of the initial trigger, indicating that ace2 may also be viewed as a damage marker [22] . summarising, ace2 is widely expressed in human tissues, both in principal target organs of sars-cov-2 and in organs that play a seemingly less important or even unknown role in covid-19 pathophysiology. this article is protected by copyright. all rights reserved. recently, ace2 was unequivocally established as the functional host receptor for sars-cov-2 (figure 3) [8]. binding kinetics revealed a 10-20-fold higher binding affinity as compared to the sars-cov-1 virus [8, 23] . these findings may partially explain the apparently easier transmissibility of sars-cov-2 and that increased ace2 expression may confer increased susceptibility to host cell entry of sars-cov-2. it was previously shown that a specific region within the sars-cov-1 spike protein interacts with ace2, leading to fusion with the host cell membrane [15, 24] . an experimental animal study in ace2-knockout mice further underlined the importance of this receptor in the pathogenesis of sars caused by sars-cov-1 [25] . the authors hypothesised that infection with sars-cov-1 results in ace2 downregulation through its internalisation, induced by binding of sars-cov-1 to ace2, as a mechanism contributing to the severity of lung pathologies [25] . consequently, this would lead to impairment of the protective effect of ace2 on the severity of acute respiratory distress syndrome (ards). this, as well as a harmful effect of ang ii, was previously demonstrated in several animal models of ards [26] [27] [28] [29] . the interaction between ace2 and sars-cov-1 and with sars-cov-2, and further downstream effects, exhibit a high level of similarity between each other [8] . during hypoxia, ang ii-induced pulmonary vasoconstriction occurs, aimed to restore the ventilation-perfusion mismatch, but simultaneously inducing adverse pro-fibrotic effects, which both are ameliorated by concomitant upregulation of ace2 [30] . under similar circumstances, sars-cov-2-induced downregulation of ace2 could impair clearance of ang ii and hence lead to aggravation of this article is protected by copyright. all rights reserved. tissue damage. on the other hand, one may speculate that ace2 downregulation by sars-cov-2 results in decreased opportunity for further viral cell entry, thereby limiting viral spread. however, as one may hypothesise that sars-cov-2 infects ace2-expressing cells with greater efficiency compared to sars-cov-1, presumably through exploiting cellular factors promoting viral attachment and entry, it is likely that sars-cov-2 viruses would need less ace2 to enable viral spread. taken together, the role of ace2 in sars-cov-2 cellular infection is complex and not yet defined, which makes it interesting to study if and how sars-cov-2 interferes with ace2 expression and/or its regulation, and how this influences viral replication. genetic factors ace2 is encoded by a gene located on chromosome xp22 and consists of at least 18 exons and 20 introns, amounting to approximately 40 kb of genomic dna [31] . the genetic architecture closely resembles the structure of the ace gene and may lead to a variety of alternative rna transcripts. the ace2 gene is characterised by a number of polymorphisms, which have been associated with diversity of raas-system pathologies, such as essential hypertension [32] . however, the genetic background of ace2 expression and functionality across different populations in relation to sars-cov-2 is largely unknown. comparative systematic analysis of coding-region variants and expression quantitative trait loci (eqtl) variants of ace2 across different populations, showed higher allele frequencies of eqtl variants associated with higher ace2 tissue expression levels in east asian compared to this article is protected by copyright. all rights reserved. european populations. this may imply a differential susceptibility to sars-cov-2 infection across different populations. however, no evidence supporting potential s-protein bindingresistant ace2 mutants was obtained [33] . structural modelling and superimposition analyses of the native ace2-and ace2-s-protein complex were used to study changes in ace2 variants and the intermolecular interactions with the s-protein. most ace2 coding variants showed high structural similarity and highly similar binding affinity with the s-protein of sars-cov-2. however, two allelic variants were identified that demonstrated considerable variation in intermolecular interaction with the s-protein, showing varying spatial orientation of key interacting residues of ace2 [34] . these ace2 genetic variations may provide a basis for relative or complete potential resistance against sars-cov-2 infection. ace2 expression in the lungs and sars-cov-2 viral load have been suggested to increase with age, which might provide an explanation to the higher disease severity observed in older patients with covid-19 [35] . advancing age is increasingly recognised as one of the strongest predictors for severe covid-19 [6] . older adults (aged above 60 years) are at increasing risk of contracting severe covid-19 with higher complication and case fatality rates [36] . similar to influenza and other respiratory viral infections, gradually decreasing innate and adaptive immune responses may be expected to play an important role in this agerelated increased susceptibility. accumulating data also show the existence of a genderassociated predisposition to covid-19, with men being more prone to develop severe disease than women [37] . ace2 expression may be a contributing factor to this association as single-this article is protected by copyright. all rights reserved. cell transcriptomics demonstrated that ace2 expression was higher among asian men than asian women [38] . observational data indicated higher frequencies of males among critically ill patients [39, 40] . in line, males appeared to be more frequent among deceased patients compared to recovered patients [41] . possible explanations of male predominance among covid-19 patients may be differences in exposure, smoking behaviour, other lifestyle factors, differences in chromosomal ace2 expression, ace2 expression in testicular tissue, sex hormone-driven immune system regulation, or gender differences in raas regulation [37, [42] [43] [44] . interestingly, in two independent cohorts of patients with heart failure, plasma concentrations of ace2 were higher in men than in women [45] . obese patients with covid-19 may have an increased risk of icu-admission and mortality. although obese patients frequently present with mechanical hypoventilation (leading to hypercapnic respiratory failure), those with covid-19 present with hypoxic respiratory failure. this led to discussions about a potential role of fat tissue in covid-19 pathogenesis in relation to ace2 expression. granting that obesity predisposes to developing chronic disease, obesity could also be an independent risk factor for covid-19 [46] . bmi is significantly higher among covid-19 patients with critical disease requiring icu-admission compared to less severe cases [47] . likewise, the proportion of patients with bmi > 25 kg/m 2 was significantly elevated in deceased patients compared to survivors. a chinese multi-centre study reported significantly higher bmi values among patients with severe disease compared to patients having only mild disease [48] . in other emerging large case series, obesity remains this article is protected by copyright. all rights reserved. common and may be a risk factor for respiratory distress, eventually requiring mechanical ventilation [49, 50] . these observations are analogous to other respiratory viral infections, for instance the h1n1 influenza virus infection. during that 2009 pandemic, obesity also emerged as an independent risk factor for hospitalisation and death [51, 52] . this could be attributed to obesity-induced impairment of the immune response, as has been welldocumented for h1n1 influenza [53] . mechanistically, adipose tissue-derived inflammation in obesity leads to substantial metabolic disturbances that could eventually lead to complications such as dyslipidaemia, hypertension, diabetes, cardiovascular disease (metabolic syndrome or syndrome x) and chronic respiratory failure [54] . visceral fat tissue can induce pro-inflammatory effects, which are regulated by adipokines and ang ii. interestingly, ace2 is abundantly present on visceral adipocytes [7, 55] . ace2 on adipocytes exerts systemic effects on the cardiovascular system and experimental studies demonstrated interactions between gender, adipocyte ace2 and complications of obesity, e.g. hypertension [56] . of note, leptin is one of the most important adipokines driving these pro-inflammatory effects and higher leptin availability has been associated with increased ang ii levels as well as decreased ace2 expression and activity [57] . in addition, high leptin levels have been associated with accumulation of alveolar fluid and increased inflammation upon hypoxia and ards [58] . therefore, it may be hypothesised that excess visceral adipose tissue in patients with covid-19 may drive disease progression -whether or not affected by genderespecially through aggravating the cascade of hyperinflammatory reactions in the disease [59] . ultimately, this 'cytokine storm' may lead to multiple organ failure in patients with this article is protected by copyright. all rights reserved. a recent meta-analysis of 46,248 patients diagnosed with covid-19 reported that severe disease was associated with hypertension, chronic respiratory disease and cardiovascular disease [60] . in another report including over 44,000 patients with confirmed covid-19, hypertension, chronic respiratory disease, diabetes mellitus, cardiovascular disease and cancer emerged as the most common comorbidities [1] . many of these comorbidities are characterised by either increased or decreased ace2 expression and/or activity, as well as a shift in ace/ace2 balance in both directions. this could be related to underlying conditions and/or to treatment with raas inhibitors (discussed in: 'pathogenesis and treatment options for covid-19'). however, the relative contribution of each of these underlying conditions to disease severity and mortality remains undetermined. many of the currently available reports were unadjusted for potential confounding factors, including age, sex, and lifestyle factors such as smoking and diet. similarly, many studies were uncontrolled, had relatively short follow-up periods, or were likely affected by inaccurate scoring or under-diagnosis [61] . in general, it is advised that patients using immunosuppressive drugs should not preemptively stop their medication, because there is still much unknown about potential risks or benefits. for instance, transplanted patients frequently use ciclosporin, which has been shown to have antiviral activity against sars-cov-1 [62] . patients with chronic immune-mediated inflammatory diseases (imids, e.g. rheumatoid arthritis [ra] this article is protected by copyright. all rights reserved. [ibd]) who are treated with cytokine inhibitors (e.g. tnf-antagonists, anti-il6r therapy) do not seem to be at an automatically increased risk of developing severe covid-19 [63] . although at first sight these treatments may seem to lead to immune suppression and may therefore be considered potentially harmful in the context of covid-19, they specifically target individual inflammatory cytokines or mediators instead of a broad panel of immune system components. in fact, cytokine inhibitors potentially attenuate the hyperinflammatory state associated with covid-19 and may therefore exert beneficial effects. this concept is supported by observations that the pro-inflammatory cytokines induced in covid-19 seem to be more crucial for the host inflammatory response compared to those involved mainly in viral clearance [63] . patients with solid malignancies treated with immune checkpoint inhibitors (icis), including anti-programmed death(-ligand)-1 (pd-1/pd-l1), anti-cytotoxic t-lymphocyte-associated protein-4 (ctla-4) and chimeric antigen receptor (car) t-cell therapy for certain b-cell related haematologic malignancies, frequently experience t-cellengaging immunomodulatory effects [64] . well-known immune-related adverse events include cytokine release syndrome (crs) and pneumonitis [65, 66] , which in theory might render patients more vulnerable to infections [67] . interestingly, these complications resemble the clinical presentation of advanced covid-19 and respond well to anti-il6r therapy [68] , providing a strong rationale for anti-il6r therapy in covid-19 [69] . as described, ace2 expression and activity is ubiquitously present within the human body, but many of its determinants on tissue level dynamics are unknown. however, in covid-19 this article is protected by copyright. all rights reserved. pathophysiology, there is seemingly huge spatiotemporal heterogeneity in organ involvement, presumably because multiple pathophysiological mechanisms may be causally involved in the observed tissue damage. both sars-cov-2 infection, directly mediated by ace2 expression and activity, and superimposed disease triggers may be responsible for the observed pathological findings. detailed pathological study of tissue specimens is therefore urgently needed to improve our understanding by disentangling the potential origins of tissue damage. the initial clinical presentation of covid-19 consists of respiratory symptoms such as fever, dry cough, shortness of breath, rhinitis, and, additionally, chest pain, myalgia and/or fatigue [70] [71] [72] [73] . in more severe cases needing hospitalisation, viral pneumonia develops with progressive ground-glass opacities on chest computed tomography (ct). in clinically critical cases, this is accompanied by further complications including ards, cardiac pathology and secondary infections. given the similarities between sars-cov-1 and sars-cov-2, lung pathology shows considerable equivalence [74, 75] . hitherto, there are limited reports of mainly autopsy cases describing lung pathological findings [76] [77] [78] [79] . similar to sars, covid-19-associated pathological changes in the lungs generally constitute extensive diffuse alveolar damage with bilateral oedema, proteinaceous or fibrin alveolar exudates and diffuse reactive hyperplasia of type ii pneumocytes (figure 4a-b) . in more advanced pathology, hyaline membrane formation was observed with thickened alveolar septa caused by interstitial fibroblast proliferation consistent with fibrosis ( figure 4b ). in addition, variable presence of patchy mainly interstitial infiltration of mononuclear cells has been reported ( figure 4a) , and in some cases, multinucleated giant cells in alveoli with associated viral changes. in contrast to sars, there is seemingly more thrombo-embolic pathology observed in specimens from patients with covid-19 (discussed in 'thrombo-embolic risk'). also, intra-alveolar deposition of neutrophilic granulocytes was reported in a few instances, most likely due to superimposed bacterial infection. another case report showed immunostaining of the rp3 np protein from sars-cov-2, which was prominently expressed on alveolar epithelial cells, as well as in cell debris within the alveolar space [80] . along the respiratory tract, ace2 has been observed in nasal and bronchial epithelial cells. in addition, ace2 is abundantly expressed on the surface of alveolar type ii pneumocytes, which also co-express several other genes that are involved in the regulation of viral reproduction and transmission, including tmprss2 [38, 81] . type ii pneumocytes usually produce surfactant, maintain their self-renewal and exert immunoregulatory functions. importantly, these cells share the same basement membrane with closely apposed capillary endothelial cells, also expressing high ace2 levels. these data indicate that type ii pneumocytes together with the related capillary endothelium may be a primary site of sars-cov-2 entrance, resulting in damage to those cells and the alveolo-capillary membrane and ongoing reactive hyperplasia of type ii pneumocytes. as type ii pneumocytes remain targets of viral entry and replication, this may lead to a vicious circle of continuing alveolar wall destruction and repair, eventually culminating in progressive severe diffuse alveolar damage. ace2 upregulation has also been described in airways in patients with chronic respiratory disease who are smokers, which, together with disturbed ciliary movement and abnormal this article is protected by copyright. all rights reserved. mucus viscosity, may increase disease vulnerability [82] . however, clinical evidence may indicate that smoking does not necessarily lead to increased vulnerability [83] . recently, it was suggested that the virus could also exploit goblet cells and ciliated cells in the nasal epithelia as entry portals, a plausible primary infection site in many patients [10] . although covid-19 is primarily a severe respiratory illness, acute myocardial injury is frequently observed, manifested by increased levels of high sensitivity cardiac troponin i (ctni) or cardiac troponin t (ctnt) in up to 28% of laboratory-confirmed covid-19 patients [84, 85] . the presence of myocardial injury was associated with worsened outcome, with 7-to 11-fold increased mortality rates. the highest mortality rates were observed in patients with both elevated tnt levels and pre-existing cardiovascular disease. reciprocally, pre-existing cardiovascular disease predisposes for sars-cov-2-induced myocardial injury and covid-19-associated mortality. whereas the relation between myocardial injury (associated with myocardial infarction, heart failure and ventricular arrhythmias) and mortality is evident, the aetiology of acute myocardial injury in response to sars-cov-2 infection is still unresolved. however, several potential mechanisms have been proposed, including sars-cov-2-induced myocarditis, cytokine-mediated injury (i.e. a systemic cardiotoxic cytokine-storm), microvascular injury, or stress-related cardiomyopathy or myocardial infarction [86, 87] . virus-induced myocarditis due to infection of cell populations residing in the heart has also been proposed, though this is still unproven [88] . scattered individual cardiomyocyte necrosis was observed in cardiac tissue from deceased covid-19 patients, however without clear this article is protected by copyright. all rights reserved. signs of myocarditis [88] . given the critical role of ace2 for sars-cov-2 cell entry, resident ace2-expressing cell populations in the heart can be potentially infected. single-cell rna sequencing of discarded donor hearts revealed that pericytes, but not cardiomyocytes, express highest ace2 levels [89] . this suggests that cardiac pericytes form a potential sars-cov-2 target cell, which may cause capillary endothelial cell dysfunction upon infection culminating in myocardial injury. so far, only one case report has been published on the presence of sars-cov-2 in the heart and demonstrated viral particles in interstitial cytopathic cells, most likely macrophages, but not cardiomyocytes or endothelial cells [90] . direct cardiotoxic effects and presence of sars-cov-2 in the heart needs to be confirmed in larger series. as ace2 is abundantly expressed by endothelial cells throughout the body, it loses its ability to prevent thrombosis upon cell entry of sars-cov-2 [12] . in human umbilical vein endothelial cell cultures in vitro, ace2 has been shown to have a role in protection of endothelial function and inhibition of the inflammatory response [91] . in experiments with spontaneously hypertensive rats, ace2 activation reduced thrombus formation and platelet attachment to vessels, while these effects were reversed by inhibition of ace2 [92] . putatively, direct infection of endothelial cells by sars-cov-2 could result in systemic impaired microcirculatory function in different vascular beds. in fact, sars-cov-2 has recently been shown to directly infect engineered human blood vessel organoids in vitro [93] . the permissiveness of endothelial cells in vivo for sars-cov-2 was demonstrated in renal glomerular endothelial cells by electron microscopy [94] . however, since no immunohistochemistry or immune electron microscopy was performed, it remained difficult this article is protected by copyright. all rights reserved. to distinguish between intracellular viral inclusions and normal subcellular organelles, as the latter may masquerade as viruses [95] . furthermore, covid-19 was associated with endotheliitis in various organs such as lung, liver, heart, kidney and small bowel [94, 96] . this suggests that direct infection of endothelium and/or perivascular inflammation may result in endothelial dysfunction, tissue oedema and a pro-coagulant state culminating in microvascular pathology, in particular in patients with pre-existing endothelial dysfunction. thrombo-embolic risk covid-19 patients are at particular risk for developing coagulopathy reminiscent of disseminated intravascular coagulation (dic) which was associated with mortality, possibly due to both venous and arterial thrombosis [97] . arterial thrombosis includes ischaemia of extremities, cerebral infarctions and myocardial infarctions [98] . after initial reports of an increased rate of venous thromboembolism (vte), including deep venous thrombosis (dvt) and pulmonary embolism (pe), a recent dutch study demonstrated a vte incidence of 27% and ~4% arterial thrombosis in covid-19 patients admitted to the icu [99] . in this study, the vast majority (80%) of patients with vte suffered from pe. pe could be an important factor in abrupt worsening of respiratory failure in patients with advanced covid-19 [100] . furthermore, several autopsy studies showed thrombi in the pulmonary vessels, which can be proximal large emboli but are most frequently identified as microthrombi. this microvascular thrombosis is predominantly observed in an environment of marked inflammatory changes including mononuclear cell infiltrates, virally infected cells and diffuse alveolar damage [88] . this article is protected by copyright. all rights reserved. in clinical studies, strongly elevated levels of circulating biomarkers of endothelial activation have been reported [101] . also, a clear picture of hypercoagulability is observed, with elevated d-dimers being most strikingly elevated in patients with severe disease [40, [102] [103] [104] [105] . d-dimer is a fibrin-degradation product that develops after a blood clot is degraded by fibrinolysis. moreover, d-dimer levels at hospital admission predict a worse clinical outcome [6, 97] . although d-dimers are a biomarker for thrombosis, they are also known as strong acute-phase reactants. however, high d-dimer levels seem to persist in advanced covid-19 patients in whom inflammatory markers such il-6 have already decreased, stressing that their elevation is not solely secondary to systemic inflammation [6] . furthermore, as covid-19 patients generally present with normal to slightly elevated platelet levels, strongly increased fibrinogen and normal to only slightly prolonged prothrombin and activated partial thromboplastin time [106] , thromboembolic events in these patients do not seem to be a result of an hypofibrinolytic consumptive diffuse intravasal coagulation as generally observed in sepsis [99] . interestingly, strongly increased levels of antiphospholipid (anticardiolipin and anti-β2glycoprotein i) antibodies have been reported in covid-19 patients with venous and arterial thromboembolisms, which is a feature of the antiphospholipid syndrome (aps) [102, 107] . patients with systemic lupus frequently present with aps and limb ischaemia caused by vasculopathy. in a clinical study in systemic lupus, anti-ace2 antibodies were found to be elevated in almost every patient and correlated with the relative activity of serum ace2 [108] . furthermore, systemic lupus patients overexpress ace2 as a result of hypomethylation, and their vascular complications respond very well to hydroxychloroquine this article is protected by copyright. all rights reserved. treatment, being circumstantial evidence of a speculative link between ace2 and vascular complications in covid-19 [109] . in summary, these observations underline that the hypercoagulable state in covid-19 may be of a systemic nature, and not limited to pe [110] . gastrointestinal (gi) symptoms are commonly observed in patients with covid-19. in a meta-analysis of 4,243 patients, pooled prevalence of gastrointestinal symptoms was 17.6% [111] . moreover, viral rna has been repeatedly detected in stool samples [112, 113] : in the aforementioned study, the pooled prevalence of positive samples was 48.1%. commonly observed gi symptoms include anorexia, diarrhoea, vomiting, and abdominal pain [114] . in this study, diarrhoea as initial disease symptom was reported in 17% of patients, but seemingly no bloody diarrhoea. in addition, patients with digestive symptoms seemed to have a longer time from disease onset to hospital admission and presented with evidence of prolonged coagulation and elevated liver enzyme levels [114] . theoretically, sars-cov-2 could directly invade the gastrointestinal epithelium via ace2. in a single-cell transcriptome study, ace2 was found to be highly expressed in oesophageal upper and stratified epithelium, as well as in absorptive enterocytes derived from both ileum and colon [115] . in addition, ace2 was co-expressed with the tmprss2 prime protein in absorptive enterocytes and upper oesophageal epithelial cells. in our previous study from 2004, we found ace2 to be expressed in enterocytes of all parts of the small intestine, including duodenum, jejunum, and ileum, but not in colonic enterocytes [7] . more specifically, ace2 was densely stained at the villous brush border, but also deeper into the intestinal wall, particularly in smooth muscle this article is protected by copyright. all rights reserved. previously, proteomics analyses demonstrated that ace2 protein is increased in ibd [116] . furthermore, ace2 activity and elevated angiotensin(1-7) concentrations were described in patients with ibd [117] . in that study, it was shown that ang ii and angiotensin (1-7) influence colonic myofibroblast proliferation and collagen secretion, and the use of aceinhibitors (aceis) and angiotensin-receptor blockers (arbs) associated with improved disease outcome in ibd patients [118] . until now, there is no evidence for increased susceptibility for covid-19 in patients with ibd. the implications of covid-19 for immunomodulation in ibd have recently been reviewed [119] . previously, viral rna in faeces could be detected after viral rna in the respiratory tract became negative and evidence for gastrointestinal infection of sars-cov-2 was documented recently, i.e. infectious virus could be isolated from the stool [120, 121] . however, another recent study did not find evidence for the presence of infectious virus in rna-positive stool samples [122] . altogether, these observations suggest that sars-cov-2 actively infects and replicates within the gi tract, implying a possible role for a faecal-oral viral transmission route. liver manifestations have also been reported in covid-19 patients. biochemical signs of mild-to-moderate liver injury are frequently observed, including elevated liver function tests (ast, alt, γ-gt and alp), hypoalbuminaemia, prolonged prothrombin time, and increased crp, ldh and hyperferritinaemia, which may be reflective signs of acute-phase inflammation [123] . liver damage may be primarily attributed to direct viral infection this article is protected by copyright. all rights reserved. causing hepatitis, but may also be interpreted as drug toxicity by administration of high-dose antiviral medications, antibiotics or steroids [124] . ace2 is expressed in the liver, mainly on cholangiocytes instead of hepatocytes, and it has been suggested that ace2 might be upregulated by compensatory hepatocyte proliferation upon cholangiocyte injury [125] . to date, however, little is known about direct viral infection of the liver by sars-cov-2. one study on liver biopsy specimens showed moderate microvascular steatosis and mild lobular and portal activity, though it was unclear whether this was caused by sars-cov-2 infection or by drug toxicity [126] . another study observed mild lobular infiltration by small lymphocytes, patchy necrosis and centrilobular sinusoidal dilation [127] . interestingly, a recent single-cell transcriptomics study found high ace2 expression on cholangiocytes, suggesting that sars-cov-2 may also lead to damage of intrahepatic bile ducts [128] . taken together, one may hypothesise that hepatobiliary involvement in covid-19 primarily results from biliary infection, with secondary injury to hepatocytes. recent evidence points towards significant involvement of the kidney in covid-19. whereas initial studies reported a relatively modest risk for acute kidney injury (aki), subsequent studies reported an incidence rate up to 15% [129] . occurrence of aki in covid-19 patients is associated with higher disease severity in icu-admitted patients, and is an adverse prognostic sign for survival [130] . small studies of covid-19 patients have reported signs of proteinuria and haematuria in about 40% of hospital-admitted patients [131] . ace2 expression has been confirmed on the brush border of proximal tubular cells and on this article is protected by copyright. all rights reserved. podocytes, whereas glomerular endothelial and mesangial cells were weakly positive or negative for ace2 [7] . in the previous sars outbreak, renal involvement was a rare phenomenon, although, if present, aki was often a fatal disease complication [132] . further research provided evidence that this renal involvement, in the form of aki, may be more attributed to processes behind multi-organ failure rather than active viral replication of sars viruses [132, 133] . for instance, crs or cytokine storms have been reported as prior events leading to severe renal damage [134] . more recently, sars-cov-2 viral antigens have been detected in post-mortem specimens, specifically in kidney tubules [135, 136] . in another recent study, histopathological analysis of post-mortem findings revealed diffuse acute tubular injury (ati) with loss of brush border, non-isometric vacuolar degeneration and even necrosis, as well as prominent erythrocyte aggregates occluding the capillary lumina with resulting endothelial damage (figure 4c-d) [137] . in line with the tissue distribution of ace2 in the kidney, coronavirus-like particles were identified in tubular epithelium and in podocytes. based on these recent findings, it is suggested that sars-cov-2 directly targets the kidney parenchyma, especially the renal tubular epithelium and podocytes, with secondary endothelial injury that may induce aki and lead to proteinuria and elevated serum creatinine levels in these patients. moreover, sars-cov-2 infections seem to be more frequently associated with aki compared to sars-cov-1 [131] . the increased binding affinity of sars-cov-2 to ace2 may explain this phenomenon, as it would allow for greater renal infectivity. this article is protected by copyright. all rights reserved. in skin, ace2 has been demonstrated in the basal epidermal layer and eccrine sweat glands [7] . however, reports on skin involvement started to emerge only recently. the extent and origin (reactive, direct viral damage, thrombosis, vasculitis) of skin involvement in covid19 , and the relation to severity of covid-19, remains to be established. following two large covid-19 cohort descriptions only mentioning 'skin rash' without further details in a minority of patients [40, 138] , several case reports have emerged reporting abnormalities ranging from erythematous rash, urticarial plaques, purpura, to chickenpox-like vesicles, without information on histopathology [139] [140] [141] [142] [143] [144] [145] [146] . in addition, recalcati et al. reported skin alterations similar to the aforementioned case reports in 18 of 88 (20.4%) medication-naive covid-19 patients [147] . again, no histopathology was available. very recently, one case report linked covid-19 to the occurrence of immune thrombocytopenic purpura [145] . additionally, another study reported purpura and livedo racemosa in several severely affected covid-19 patients with small vessel thrombosis with co-localization of complement and sars-cov-2 spike proteins on histopathology [148] .this indicates direct viral infection of the small skin vessels. however, the diversity of skin features reported in covid-19 patients suggests other pathogenic mechanisms as well. in healthy skin, the layers above the ace2expressing stratum basale, including the stratum corneum, likely provide a barrier to the virus. however, the clear expression of ace2 in skin suggests that if sars-cov-2 gets the chance to reach its receptor there, for example through damaged skin, it may be able to render itself a porte d'entrée in keratinocytes. given that sars-cov-1 was previously found in sweat [149] , this raises the question whether sars-cov-2 could be excreted in sweat, thereby adding to its transmission potential. in addition, it raises the question whether sars-cov-2 is this article is protected by copyright. all rights reserved. able to infect through binding to ace2 in the eccrine sweat glands of palmar skin, where they are abundantly expressed. pregnancy is a unique physiological state in which a semi-allogeneic fetus (and placenta) is accepted by the maternal immune system, whilst at the same time this system has to maintain the protective capacity for defence against pathogens. due to the necessary adaptations in the immune system and a variety of physiological adaptations (e.g. increased oxygen consumption, mucosal oedema of the respiratory tract), pregnant women are generally characterised by increased susceptibility to respiratory pathogens, and consequently, severe pneumonia. although there is no evidence that pregnant women are more susceptible to sars-cov-2 infection, they may be at increased risk of developing severe illness when contracting sars-cov-2 infection. currently, there is limited evidence regarding the possibility of mother-fetal intra-uterine vertical transmission in covid-19. most descriptions of sars-cov-2 infected pregnant women reported infections during the third trimester of pregnancy [150] [151] [152] [153] . however, uncertainty prevails about whether vertical transmission of covid-19 may occur in any phase of pregnancy [105] [106] . placentas, amniotic fluid samples or newborns (directly after delivery) with positive rt-pcr results have not been described, which means that there is no virological evidence of intra-uterine infection at the maternal-fetal interface [150, [154] [155] . neonatal covid-19 has been reported, but infection could have occurred through other routes as there was no direct evidence for intrauterine vertical transmission [150, 152, 154, 157, 158] . in a small case series, fetal growth restriction this article is protected by copyright. all rights reserved. (fgr) has been described in sars-cov-1-positive women, but no details of the placental histopathological lesions were described [159] . there is one report that described seven placentas that were evaluated histopathologically after maternal infection with sars-cov-1. placentas from infection in the first trimester were normal (n=2). increases in intervillous and subchorionic fibrin deposition were observed once delivered in the acute stage of infection (n=3) which is possibly not sars-cov-specific, but rather related to disturbances in maternal placental blood flow due to hypoxic respiratory disease. third trimester convalescent infection resulted in extensive fetal thrombotic vasculopathy (ftv) with sharply demarcated zones of avascular fibrotic villi resulting in fgr (n=2). the aetiology of the ftv might be related to thrombotic tendency due to sars-cov infection or placental hypoxia [160] . ace2 ould also play a role in this process. however, although placental ace2 expression is found on both the fetal site (umbilical cord, placental villi in the syncytiotrophoblast, cytotrophoblast, vascular endothelium and smooth muscle cells) and on the maternal site (e.g. in the invading and intravascular trophoblast and decidual cells), regulation of placental ace2 expression has not yet been described in relation to sars-cov-2 infection [161, 162] . sars-cov-2 has been implicated to have neurotropic potential in covid-19 [163] . indeed, some patients presented with symptoms that could be attributed to neurological involvement, such as headache, confusion, anosmia, dysgeusia, nausea and vomiting [164, 165] . previous research showed that sars-cov-1 and mers-cov infect the central nervous system with significant involvement of the brainstem [163] . it has been suggested that neuroinvasion of this article is protected by copyright. all rights reserved. the brainstem may be at least partially responsible for respiratory symptoms in covid-19 patients, by compromising neurons within the respiratory centres and chemosensitive neural cells involved in respiratory and cardiovascular regulation [166] . ace2 may play a role in sars-cov-2 neuroinvasion, as it is expressed in the brain on neurons and glial cells, particularly in the brainstem and cardiovascular regulatory areas, including the nucleus tractus solitarius, paraventricular nucleus and the rostral ventrolateral medulla [167, 168] . in addition, ace2 is expressed in the cerebral vascular endothelium, which could lead to endothelial damage subsequently leading to viral access to the brain [169, 170] . in an experimental animal study, it was demonstrated that the sars-cov-1 enters the brain primarily via the olfactory bulb, followed by transneuronal spread of the virus [171] . this could explain the underlying pathophysiology of covid-19-associated anosmia. however, detailed neurological investigation of covid-19 autopsies could further clarify the occurrence and underlying neurological pathology characteristic for sars-cov-2 infection. initially, sars-cov-2 may pass through either the mucous membranes in the upper respiratory tract, primarily the nasal and pharyngeal epithelia, or directly entering the lower respiratory tract and infect bronchial and alveolar epithelial cells [10] . the main symptoms of respiratory infection are fever and cough. in this initial phase, the virus can enter the peripheral bloodstream via the lungs and may result in viraemia [172] . the virus may then proceed to affect other organs expressing ace2, such as the heart and blood vessels, the kidneys and the gi tract. however, the gi tract may also have direct infection by the oral this article is protected by copyright. all rights reserved. route. patients with an increased risk of developing severe disease may experience severe pulmonary involvement resulting in systemic inflammation [6] . the massive inflammatory process at that time results in a severe cytokine storm also affecting other organs in the body. this seemingly occurs in line with other blood-derived viruses entering organs via ace2 on activated endothelium causing, for example, renal or gi problems. in the vasculature, this coincides with red blood cell aggregation and thrombosis. the clinical phase progresses from the initial viraemia to an acute phase (pneumonia), followed by either recovery or severe disease (including ards, aki and eventually multi-organ failure) requiring icu admission [173] . the distinction would depend on patient comorbidity, obesity-induced pre-existent inflammation, immune function and ace/ace2 balance in already affected organs. each phase demands its own treatment regimen ranging from virus entry and replication inhibition in the initial phase to anti-inflammatory and anti-thrombotic medication at later stages. in the following paragraphs, we aim to highlight some of the most commonly advocated treatment strategies being explored to combat covid-19. hydroxychloroquine (hcq) and chloroquine (cq) are two widely used antimalarial, antiviral and anti-rheumatic drugs. recently, in vitro results and small clinical studies emerged that demonstrated antiviral activity of these drugs against sars-cov-2 infection [174] [175] [176] [177] [178] [179] . beneficial effects were presumed to arise from blockage of viral host cell entry by increasing endosomal ph and interference with glycosylation of ace2 [180] . two studies from france this article is protected by copyright. all rights reserved. reported that hcq could lead to viral load reduction within six days, especially when combined with azithromycin. however, these studies were impaired by several methodological constraints [181] . similarly, two chinese trials were performed: one study reported no significant difference in nasopharyngeal viral carriage between hydroxychloroquine treatment and standard supportive care, whereas the other study demonstrated shorter clinical recovery time for patients receiving hcq compared to placebo [178, 179] . for the latter study, however, it was not possible to extrapolate to critically ill patients, which is crucially important because this subgroup of patients may be of particularly increased risk of serious adverse effects upon treatment with hcq/cq, such as ventricular arrhythmias, hepatic failure and cardiac toxicity [181, 182] . indeed, recent studies reported concerns about potential safety hazards as higher dosages were associated with higher mortality and excessive qt interval prolongation, especially when taken concurrently with azithromycin and oseltamivir [183, 184] . another large observational study indicated that hcq/cq may not help in critically ill patients as its administration was not associated with either a significantly lowered or an increased risk of a composite endpoint of intubation or death [185] . thus, currently available data on hcq/cq treatment for covid-19 are inconclusive, but appear far from promising. therefore, upcoming prospective randomised clinical trials will have to determine if treatment with hcq/cq would be a reasonable therapeutic strategy for covid-19 patients and what would be the most suitable timing within the disease course to initiate treatment. this article is protected by copyright. all rights reserved. remdesivir, a rna polymerase inhibitor, was demonstrated to be effective against sars-cov-1 and mers-cov. for instance, remdesivir improved disease outcome and reduced viral load in sars-cov-1 infected mice [186] . in 53 hospitalised patients with covid-19, improvement of clinical status was observed in 36 after receiving at least one dose of remdesivir [187] . furthermore, a recently conducted randomised controlled trial evaluated the role of lopinavir and ritonavir in 199 covid-19 patients, 99 treated with lopinavir/ritonavir while 100 received standard treatment [188] . the authors concluded that patients treated with lopinavir/rotinavir did not demonstrate any significant improvement in hazard ratio for earlier clinical improvement or reduction in mortality at 28 days. in contrast to the primary outcome, patients treated with lopinavir/ritonavir demonstrated clinical improvement 1 day earlier than the control group and were discharged 5 days earlier from the icu. although large clinical trials investigating the therapeutic effect of these antiviral therapies in covid-19 are lacking, it can be hypothesised that the available studies possibly included patients with severe disease alone, and, therefore, future studies may consider evaluating the role of these antiviral drugs earlier in the course of covid-19 [188] . the worldwide growth of sars-cov-2 infections raised serious concerns about the widespread use of antihypertensive drugs, i.e. aceis and arbs, which are also used in treatment of cardiovascular diseases, chronic kidney disease and diabetes mellitus [189] . discussions emerged about whether these drugs may exert beneficial or deleterious effects in covid-19. many opinion papers have been published recently that predominantly state that this article is protected by copyright. all rights reserved. there is no scientific evidence to change the prescription of aceis or arbs for the management of hypertension in the context of preventing or treating sars-cov-2 infection. the use of aceis and arbs as risk factors for developing or aggravating covid-19 has been suggested because of their capacity to upregulate ace2 [190] [191] [192] . however, others have advocated beneficial and protective effects of these drugs in the development of covid-19 [14, 189] . in some animal studies, aceis or arbs increase ace2 levels, whilst other studies failed to demonstrate such shifts in ace2 [12, 19, [193] [194] [195] [196] [197] [198] [199] [200] , although shifts in ace/ace2 balance were noted [19] . therefore, it remains relevant to question whether raas blockers actually increase susceptibility to sars-cov-2 infection by increasing ace2. ace2 is protective against severe lung injury in animal models and ace2 blockade or genetic ace2knockouts result in extensive lung damage and decreased survival after respiratory syncytial virus infection [201] . similarly, at1r blockade by losartan attenuates lung injury in mice administered with the spike glycoprotein of sars-cov-1 [25] . although few human studies have been performed investigating potential effects of raas therapy on ace2 expression and/or activity, it was recently reported that aceis and arbs did not increase plasma ace2 concentrations [45] . similarly, others reported no clear direct effects of aceis on ace2 activity (as evaluated by angiotensin(1-7) levels) [202, 203] . several hypotheses exist about how increased tissue ace2 expression may be protective rather than harmful during sars-cov-2 infection [204] . for example, increased ace2 expression may lead to enhanced sequestration of sars-cov-2, but does not imply automatic activation of further downstream processes essential for viral entry, such as this article is protected by copyright. all rights reserved. involvement of tmprss2, which is required for spike glycoprotein priming, or adam metallopeptidase 17 (adam17), which is required for cleavage of the ace2 ectodomain resulting in increased ace2 shedding. furthermore, arbs lead to competition with ang ii for at1r, resulting in increased ang ii to be processed by ace2. this increases ang(1-7) levels, which results in vasodilating and anti-fibrotic effects, providing crucial protection during coronavirus infections [25] . furthermore, increased binding of ace2 to circulating ang ii could induce a conformational change resulting in less favourable binding of sars-cov-2 to its receptor and decreased internalization of the virus when bound to ace2 [204, 205] . we previously observed a positive shift in plasma ang(1-7)/ang ii balance in favour of the beneficial ang(1-7) peptide, particularly in circumstances of low sodium intake [19] . importantly, however, plasma ace2 levels may be less indicative of the risk of sars-cov-2 infection or membrane-bound ace2 activity, as ace2 shedding by adam17 appears to be regulated separately [206] . interestingly, however, plasma ace2 concentrations appear to be higher in older men with heart failure independent of raas inhibition [45] . clinical trials investigating the potential (side-)effects and safety of aceis and arbs on ace2 expression and activity in covid-19 are ongoing. from a clinical perspective, it may be preferable to await these results instead of discontinuing raas inhibitors, which may lead to clinical derangement especially in patients at high-risk for covid-19 [207] . since currently available evidence indicates that aceis and arbs significantly reduce mortality in cardiovascular disease, reduce progression of ckd, and are crucial in treatment of heart this article is protected by copyright. all rights reserved. failure and hypertension, most clinicians tend to maintain these regimens for their patients, regardless of sars-cov-2 [189] . immunomodulating drugs or biological response modifiers alter the host immune system by interacting with a specific target crucial for disease pathogenesis [208] . many of these compounds enrich the therapeutic armamentarium of several malignancies, autoimmune disorders, transplantation rejection, as well as infectious diseases. especially since vaccine development is time-consuming and antiviral drugs may have a limited therapeutic window, targeted immunomodulators are attractive alternatives. furthermore, these therapies may be crucial to control the hyperactivation of host inflammatory responses and 'cytokine storm' as has been described for covid-19 [209] . however, caution should be taken towards this therapeutic strategy as it will remain challenging to target immune system components without compromising the host defence mechanisms necessary to fight sars-cov-2 infection. in this respect, targeting specific or limited effector mechanisms (e.g. production of pro-inflammatory cytokines or reactive oxygen species), should be preferred over blockage of more proximal immune targets (e.g. pattern recognition receptors) that play a more significant role in regulating host immune defence [209] . the current hypothesis is that a cytokine storm can induce or further aggravate sars-cov-2 infection, and thereby suggests that blocking cytokine pathways could attenuate the disease this article is protected by copyright. all rights reserved. course. among these, interleukin-6 (il-6) is thought to play a prominent role. il-6 is a cytokine with both anti-and pro-inflammatory effects. it can be produced by almost all stromal and immune system cells (monocytes, lymphocytes, macrophages, endothelial cells, mast cells, dendritic cells) and is believed to play a central role in the development of cytokine storm [210, 211] . in line with this reasoning, anti-il6r therapy is a potential therapeutic option in covid-19. currently available humanised monoclonal antibodies against the interleukin-6-receptor (tocilizumab and sarilumab) are being tested in covid-19. a small study demonstrated that tocilizumab ameliorated the increased crp in all 15 patients, which is a direct effect of its pharmacological action. moreover, in critically ill patients with elevated il-6 levels, repeated doses of tocilizumab could be beneficial. however, objective clinical endpoints were not reported [212] . although others have shown comparable results, data on the use of tocilizumab are still preliminary and larger randomised controlled trials are needed [213] [214] [215] . whether anti-il6r therapy should be started early in the course of the disease or restricted to patients with signs of a cytokine storm is still of debate [210] . in addition, other cytokines such as il-1, ifn-γ and tnf-α are abundant in the cytokine storm, and blocking these pathways with appropriate biological being investigated [216] . inhibition of the jak-stat signalling pathway has also been suggested as a potential targeted therapy for covid-19 and several clinical trials are ongoing [217, 218] . inhibitors blocking jak2, such as fedratinib, have been suggested to block viral entry and combating the th17-component of the host inflammatory cytokine storm, without altering interferon this article is protected by copyright. all rights reserved. signalling [219] . sars-cov-2 enters host cells via ace2-mediated endocytosis, which is controlled by upstream regulators including ap2-associated protein kinase 1 (aak1) and cyclin g-associated kinase (gak). one of several high-affinity inhibitors of these regulators is the jak inhibitor baricitinib, which may limit viral host cell entry and intracellular assembly of viral particles through disrupting aak1 and gak. baracitinib may be of particular value during the hyperinflammatory phase, in which high levels of cytokines occur that signal through the jak-stat pathway. however, the optimal time to administer cytokine inhibitors still needs to be determined and results from the aforementioned clinical trials should be awaited. the association between obesity and the progression to hypoxic respiratory failure in patients with covid-19, requiring mechanical ventilation, has led to the assumption that leptin and adipokines may play a key role in this subpopulation of sars-cov-2 infected patients. resveratrol, an antioxidant and food supplement, has been suggested to be of potential therapeutic value because of a triple action. first, in some studies, resveratrol reduces leptin levels [220] . second, resveratrol could suppress ang ii, which might reduce inflammation [221] . third, antioxidant effects in the lung may reduce oxidative stress-induced lung damage [222] . this food supplement is safe in its use (up to 2-3 grams per day) and should be studied in covid-19 patients as an additive to other treatments. this article is protected by copyright. all rights reserved. as a result of the increased risk of thrombotic events in covid-19, guidelines currently advocate liberal use of prophylactic systemic anticoagulation [223] . the international society on thrombosis and haemostasis recently recommended that all hospitalised covid-19 patients, even those not admitted to icu, should receive prophylactic-dose low-molecularweight heparin (lmwh) unless they have contraindications (active bleeding and platelet count <25x10 9 /l) [224] . however, a recent study showed that despite adequate treatment with prophylactic low-dose lmwh, covid-19 patients admitted to icu were still at a substantial risk for pe [99] . this has made the dutch federation of internists decide to recommend a double dose of lmwh in icu patients with covid-19, when bleeding risk allows this strategy [225] . other guidelines advocated prophylactic systemic anticoagulation with unfractionated heparin rather than lmwh [226] , which may be needed in high dosages because of heparin resistance [227] . however, it is unlikely that anticoagulant treatment has a direct disease-modifying effect and it should be stressed that the initial viral load, as well as the systemic inflammatory response, needs to be attenuated since these are the driving forces for vte in covid-19 [228] . future studies are warranted to determine the most suitable approach for thrombosis prophylaxis in covid-19. scientific findings about ace2 and its role in covid-19 pathophysiology, it is crucial to maintain integration of available pathological and molecular evidence to establish the definite role of these potential modulating factors. unraveling the pathologic basis of covid-19 is essential for our understanding of the pathophysiology of the disease. unsurprisingly, severe pathological findings are mainly observed in specific target organs of sars-cov-2, such as the lungs and kidneys. in severe cases, this may lead to ards and multi-organ failure not directly related to ace2 expression and activity. this review focused on the role of widespread ace2 tissue expression, which may become a reasonable therapeutic target together with its effector pathways, for example through implementation of recombinant human ace2 (rhace2) therapy or by targeting bradykinin metabolism in the lungs. however, it will also be important to focus on additional mechanisms that may be involved in cellular infection and may regulate the interaction between sars-cov-2 and ace2. future studies featuring higher numbers of patients are warranted to reliably assess potential differences in ace2 expression, activity and regulation under a variety of physiological circumstances, such as present or lacking interaction with co-receptor or coactivating molecules, as well as in the context of commonly observed underlying conditions, including cardiovascular disease, hypertension, diabetes, obesity, smoking and respiratory disease. in particular, pathological studies of larger series of autopsy findings, probably in human and non-human primate models alike, are required to more accurately determine the relative contribution of each pre-existent co-morbidity and to discriminate between specific sars-cov-2-associated pathology and superimposed pathological changes. furthermore, the this article is protected by copyright. all rights reserved. development of appropriate animal and in vitro models could help to learn more about the sars-cov-2 infection process itself and, most importantly, the disease progression pattern observed in humans. in any case, it is indisputable that devoting scientific efforts to analyse aspects of ace2 in relation to covid-19 pathophysiology is paramount to fuel the development and augmentation of future therapeutic strategies. the current covid-19 pandemic is a major challenge for public health and clinical medicine. for public health, reduction or prevention of virus transmission as well as reduction of predisposing lifestyle factors need to be implemented. for clinical management in the foreseeable future, we should strive to adopt a personalised medicine approach aimed to provide individually tailored treatment in patients affected by covid-19. as highlighted in this review, this should take into account individual patient differences in mutual ace2-sars-cov-2 interactions with their consequences for covid-19 pathophysiology. to achieve this, it is of cardinal importance to carefully register the individual patient phenotype and to integrate this with diagnostic (e.g. laboratory and imaging results) and therapeutic information (e.g. drug toxicity and side-effect profiles). mainly because of low patient numbers in individual studies, currently ongoing trials are challenged to take into account between-subject differences or cohort heterogeneity, which may be considered likely to explain the majority of variation in disease outcome. however, detailed phenotypical stratification of individual patients during their disease course will 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full body rash as a presenting symptom reply to "covid-19 can present with a rash and be mistaken for dengue": petechial rash in a patient with covid-19 infection covid-19 can present with a rash and be mistaken for dengue immune thrombocytopenic purpura in a patient with covid-19 a distinctive skin rash associated with coronavirus disease cutaneous manifestations in covid-19: a first perspective complement associated microvascular injury and thrombosis in the pathogenesis of severe covid-19 infection: a report of five cases organ distribution of severe acute respiratory syndrome (sars) associated coronavirus (sars-cov) in sars patients: implications for pathogenesis and virus transmission pathways clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records clinical features and obstetric and neonatal outcomes of pregnant patients with covid-19 in wuhan, china: a retrospective, single-centre, descriptive study a case report of neonatal covid-19 infection in china novel coronavirus infection and pregnancy possible vertical transmission of sars-cov-2 from an infected mother to her newborn unlikely sars-cov-2 vertical transmission from mother to child: a case report neonatal early-onset infection with sars-cov-2 in 33 neonates born to mothers with covid-19 in wuhan, china vertical transmission of coronavirus disease 2019 (covid-19) from infected pregnant mothers to neonates: a review late-onset neonatal sepsis in a patient with covid-19 225-management guidelines for obstetric patients and neonates born to mothers with suspected or probable severe acute respiratory syndrome (sars) the placentas of patients with severe acute respiratory syndrome: a pathophysiological evaluation distribution of angiotensin-(1-7) and ace2 in human placentas of normal and pathological pregnancies the sars-cov-2 receptor ace2 expression of maternalfetal interface and fetal organs by single-cell transcriptome study the neuroinvasive potential of sars-cov2 may play a role in the respiratory failure of covid-19 patients neurological manifestations of hospitalized patients with covid-19 in wuhan, china epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study neuroinfection may potentially contribute to pathophysiology and clinical manifestations of covid-19 angiotensin ii regulation of angiotensin-converting enzymes in spontaneously hypertensive rat primary astrocyte cultures angiotensin-converting enzyme 2: central regulator for cardiovascular function neurotropism of sars-cov 2: mechanisms and manifestations covid 19 and intracerebral hemorrhage: causative or coincidental? severe acute respiratory syndrome coronavirus infection causes neuronal death in the absence of encephalitis in mice transgenic for human ace2 hypothesis for potential pathogenesis of sars-cov-2 infection-a review of immune changes in patients with viral pneumonia characteristics and outcomes of 21 critically ill patients with covid-19 in washington state hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting sars-cov-2 infection in vitro in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 covid-19 patients with at least a six-day follow up: an observational study a pilot study of hydroxychloroquine in treatment of patients with moderate coronavirus disease-19 (covid-19) efficacy of hydroxychloroquine in patients with covid-19: results of a randomized clinical trial remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro hydroxychloroquine in the management of critically ill patients with covid-19: the need for an evidence base use of hydroxychloroquine and chloroquine during the covid-19 pandemic: what every clinician should know effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection: a randomized clinical trial safety of hydroxychloroquine, alone and in combination with azithromycin, in light of rapid wide-spread use for covid-19: a multinational, network cohort and self-controlled case series study observational study of hydroxychloroquine in hospitalized patients with covid-19 broad-spectrum antiviral gs-5734 inhibits both epidemic and zoonotic coronaviruses compassionate use of remdesivir for patients with severe covid-19 covid-19 -the search for effective therapy renin-angiotensin-aldosterone system inhibitors in patients with covid-19 are patients with hypertension and diabetes mellitus at increased risk for covid-19 infection? preventing a covid-19 pandemic can angiotensin receptor-blocking drugs perhaps be harmful in the covid-19 pandemic? enalapril attenuates downregulation of angiotensin-converting enzyme 2 in the late phase of ventricular dysfunction in myocardial infarcted rat localization of ace2 in the renal vasculature: amplification by angiotensin ii type 1 receptor blockade using telmisartan perinatally administered losartan augments renal ace2 expression but not cardiac or renal mas receptor in spontaneously hypertensive rats effect of angiotensin ii blockade on a new congenic model of hypertension derived from transgenic ren-2 rats human intestine luminal ace2 and amino acid transporter expression increased by ace-inhibitors upregulation of angiotensin-converting enzyme 2 after myocardial infarction by blockade of angiotensin ii receptors myocardial infarction increases ace2 expression in rat and humans combination renin-angiotensin system blockade and angiotensin-converting enzyme 2 in experimental myocardial infarction: implications for future therapeutic directions angiotensin-converting enzyme 2 inhibits lung injury induced by respiratory syncytial virus evidence against a major role for angiotensin converting enzyme-related carboxypeptidase (ace2) in angiotensin peptide metabolism in the human coronary circulation effects of captopril related to increased levels of prostacyclin and angiotensin-(1-7) in essential hypertension should covid-19 concern nephrologists? why and to what extent? the emerging impasse of angiotensin blockade ace2 x-ray structures reveal a large hingebending motion important for inhibitor binding and catalysis tumor necrosis factor-α convertase (adam17) mediates regulated ectodomain shedding of the severe-acute respiratory syndrome-coronavirus (sars-cov) receptor, angiotensin-converting enzyme-2 (ace2) ace inhibition and cardiometabolic risk factors, lung ace2 and tmprss2 gene expression, and plasma ace2 levels impact of host genetics and biological response modifiers on respiratory tract infections coronavirus infections and immune responses the role of cytokines including interleukin-6 in covid-19 induced pneumonia and macrophage activation syndrome-like disease a combined set of four serum inflammatory biomarkers reliably predicts endoscopic disease activity in inflammatory bowel disease tocilizumab treatment in covid-19: a single center experience favorable changes of ct findings in a patient with covid-19 pneumonia after treatment with tocilizumab rapid and severe covid-19 pneumonia with severe acute chest syndrome in a sickle cell patient successfully treated with tocilizumab off-label use of tocilizumab in patients with sars-cov-2 infection preventing covid-19-induced pneumonia with anticytokine therapy baricitinib for covid-19: a suitable teatment? -authors' reply baricitinib as potential treatment for 2019-ncov acute respiratory disease th17 responses in cytokine storm of covid-19: an emerging target of jak2 inhibitor fedratinib the inhibitory effect of resveratrol on leptin secretion from rat adipocytes effects of resveratrol on the renin-angiotensin system in the aging kidney resveratrol attenuates intermittent hypoxia-induced lung injury by activating the nrf2/are pathway pulmonary embolism in patients with covid-19: time to change the paradigm of computed tomography isth interim guidance on recognition and management of coagulopathy in covid-19 this article is protected by copyright. all rights reserved leidraad covid-19 coagulopathie isth interim guidance on recognition and management of coagulopathy in covid-19: a comment thromboembolic events and apparent heparin resistance in patients infected with sars-cov-2 thromboinflammation and the hypercoagulability of covid the authors would like to express their gratitude towards else koning for her valuable help in the graphical design of the figures and martin bourgonje for critically proofreading the manuscript. in addition, the authors would like to thank dr. jan von der thüsen (department of pathology, erasmus medical center, rotterdam, the netherlands) and dr. hua su (department of nephrology, union hospital, wuhan, china) for kindly providing us with histological images. key: cord-315730-fzgxuak7 authors: penman, sophie l.; kiy, robyn t.; jensen, rebecca l.; beoku‐betts, christopher; alfirevic, ana; back, david; khoo, saye h.; owen, andrew; pirmohamed, munir; park, b. kevin; meng, xiaoli; goldring, christopher e.; chadwick, amy e. title: safety perspectives on presently considered drugs for the treatment of covid‐19 date: 2020-07-17 journal: br j pharmacol doi: 10.1111/bph.15204 sha: doc_id: 315730 cord_uid: fzgxuak7 intense effort is underway to evaluate potential therapeutic agents for the treatment of covid‐19. in order to respond quickly to the crisis, the repurposing of existing drugs is the primary pharmacological strategy. despite the urgent clinical need for these therapies, it is imperative to consider potential safety issues. this is important due to the harm‐benefit ratios that may be encountered when treating covid‐19, which can depend on the stage of the disease, when therapy is administered and underlying clinical factors in individual patients. treatments are currently being trialled for a range of scenarios from prophylaxis (where benefit must greatly exceed risk) to severe life‐threatening disease (where a degree of potential risk may be tolerated if it is exceeded by the potential benefit). in this perspective, we have reviewed some of the most widely‐researched repurposed agents in order to identify potential safety considerations using existing information in the context of covid‐19. taleb-gassabi, & dayer, 2017) . a standard dose of lopinavir-ritonavir is 400 mg/100 mg twice a day for hiv-1 treatment, and this has also been used for sars-cov-2 treatment . the most frequent reported aes for lopinavir-ritonavir treatment are gastrointestinal disturbances including diarrhoea, nausea and vomiting (chandwani & shuter, 2008) . dose-related diarrhoea have been reported in up to 25 % of patients and are thought to occur through a number of mechanisms including decreased proliferation of intestinal epithelial cells, disruption of intestinal barrier function, inducing endoplasmic reticulum stress and activating the unfolded protein response (x. wu, li, peng, & zhou, 2014) . diarrhoea is also a symptom in some covid-19 patients and so lopinavir-ritonavir has the potential to exacerbate this. pancreatitis has been reported in a small number of patients following lopinavir-ritonavir treatment although this was more frequent in those with a pre-existing history of pancreatitis (chandwani & shuter, 2008; oldfield & plosker, 2006) . additionally, patients with underlying liver diseases should have regular monitoring of hepatic function (palacios et al., 2006) . caution should be exerted for those patients taking concomitant medication as lopinavir-ritonavir inhibits p-glycoprotein (p-gp) and cytochrome p450 (cyp) -3a4, which therefore may alter the pk of other compounds (l. zhang, zhang, & huang, 2009) . a covid-19 drug interaction website has been developed by the liverpool drug interaction group which details ddis with lopinavir-ritonavir and a number of drugs, which in some cases can lead to potentially serious and/or life-threatening reactions (group, 2020; abbvie inc., 2016) . since the sars-cov-2 outbreak, 79 clinical trials have been registered (up to 8 th july 2020) to test lopinavir-ritonavir as a potential treatment for sars-cov-2 with variable outcomes in terms of efficacy. in one trial of 199 patients with confirmed sars-cov-2, 13 patients on the lopinavir-ritonavir arm were withdrawn due to aes . in a different trial, patients who were administered lopinavir-ritonavir (200 mg/ 50 mg) also experienced gastrointestinal aes (y. li et al., 2020) . chloroquine and its derivative, hydroxychloroquine, are widely used as inexpensive and safe antimalarial drugs. in particular, the established good tolerability of chloroquine/hydroxychloroquine has made them safe to use even in pregnancy (villegas et al., 2007) . in addition to anti-malarial activity, both drugs have immunomodulating effects and are used for the treatment of autoimmune diseases including systemic and discoid lupus erythematosus, psoriatic arthritis, and rheumatoid arthritis. chloroquine/hydroxychloroquine concentrate extensively in acidic vesicles including the endosomes, golgi vesicles, and the lysosomes (ohkuma & poole, 1981) . this leads to lysosomal membrane permeabilisation or dysfunction of several enzymes including acid hydrolases and palmitoyl-protein thioesterase 1 (rebecca et al., 2019; savarino, boelaert, cassone, majori, & cauda, 2003; schrezenmeier & dorner, 2020) . although the precise mechanisms of the anti-viral effects are not fully understood, it has been proposed that chloroquine/hydroxychloroquine can prevent virus infection (pre-infection) by interfering with the glycosylation of cellular receptors and impair viral replication by increasing endosomal ph (post-infection) (savarino et al., 2003; savarino et al., 2004; vincent et al., 2005) . owing to their efficacy against viruses (mostly demonstrated in vitro) including influenza, hiv, coronavirus oc43, and sars-cov, a large number of clinical trials (>230) have been registered worldwide using chloroquine/hydroxychloroquine alone, or in combination with other drugs (e.g. azithromycin) for the treatment of covid-19. despite promising in vitro antiviral results for hydroxychloroquine/chloroquine, there is no convincing evidence of efficacy at present (gao, tian, & yang, 2020; gautret, lagier, parola, hoang, meddeb, mailhe, et al., 2020; gautret, lagier, parola, hoang, meddeb, sevestre, et al., 2020; magagnoli, 2020; mathian et al., 2020; million et al., 2020; tang, 2020; yao et al., 2020) . a post-exposure prophylaxis randomised controlled trial of 821 participants failed to show any benefit of hydroxychloroquine (n=414) compared with placebo (n=407) (boulware et al., 2020) . at the time of writing, the recovery trial (clinical trial identifier nct04381936) which is the largest randomised control trial so far conducted for the treatment of covid, has stopped recruiting to the hydroxychloroquine arm (1542 patients compared with 3132 on standard care) because of no beneficial effect either in terms of mortality or hospital stay (p. . there are still many other trials on-going testing the efficacy of hydroxychloroquine for either prophylaxis or treatment. both chloroquine and hydroxychloroquine have been in clinical use for many years for rheumatoid diseases, and thus their safety profile is well established. dose-dependent retinal toxicity has long been recognized as the major ae with long-term use of chloroquine/hydroxychloroquine (marmor et al., 2011) . besides retinal toxicity, gastrointestinal, liver and renal toxicity have also been reported (giner galvan, oltra, rueda, esteban, & redon, 2007; michaelides, stover, francis, & weleber, 2011; mittal, zhang, feng, & werth, 2018) . as both drugs are mainly metabolised in the liver and excreted by renal clearance, their use in patients with liver or renal impairment may worsen the function of these organs. for chloroquine treatment, prescribing information recommends the full dose at all degrees of renal impairment but suggests that monitoring of renal function may be useful . for hydroxychloroquine, reductions in dosage are advised for patients with impaired renal function, as well as those taking concomitant medications with known risks of kidney damage (concordia pharmaceuticals inc, 2017) . this article is protected by copyright. all rights reserved. a serious ae associated with chloroquine/hydroxychloroquine is cardiotoxicity, which can take many forms including cardiomyopathy in rare instances. prolonged treatment or high dosage of chloroquine/hydroxychloroquine has been shown to increase of the risk of qt interval prolongation, polymorphic ventricular tachycardia, and sudden cardiac death (chatre, roubille, vernhet, jorgensen, & pers, 2018) . a large epidemiological analysis in patients with rheumatoid arthritis has recently shown that 30-day cardiovascular mortality was increased by more than 2-fold when hydroxychloroquine was combined with azithromycin. the lethal ventricular arrhythmias are primarily due to inhibition of a potassium channel (the inward rectifier kir2.1 channel) and may occur at low µm concentrations (ic50=8.7 m) (rodriguez-menchaca et al., 2008) . while therapeutic doses of chloroquine typically result in plasma concentrations of 2-5 µm, much higher concentrations in the heart are expected based on a 400-fold increase observed in rat pk studies (mcchesney, banks, & fabian, 1967; walker, dawodu, adeyokunnu, salako, & alvan, 1983) . both drugs act on various potassium channels including the inward rectifier currents (kir2.1 and kir6.2) and rapid delayed rectifier currents (kv11.1/herg) (ponce-balbuena et al., 2012; rodriguez-menchaca et al., 2008; sánchez-chapula, navarro-polanco, culberson, chen, & sanguinetti, 2002) . the binding of chloroquine to the inward rectifier kir2.1 channel can be stabilized by negatively charged and aromatic amino acids (rodriguez-menchaca et al., 2008) . to a lesser extent, chloroquine also blocks the rapid delayed rectifier ikr, possibly through cation-π and π-stacking interactions with tyrosine 652 and phenylalanine 656 in the s6 domain of herg (sánchez-chapula et al., 2002) . the effect of inhibition of these potassium channels on the heart rate appears to be complex. however, blocking the herg channel has proven to be the most common mechanisms by which drugs cause qt interval prolongation (traebert & dumotier, 2005) . the binding of chloroquine/hydroxychloroquine to proteins is also stereoselective, but whether one of the chloroquine/hydroxychloroquine enantiomers has a stronger interaction with the kir2.1 channel is not known. caution is needed when hydroxychloroquine is used in combination with other drugs (including azithromycin), which increase the qt interval because of a pharmacodynamic synergistic interaction. given the comorbidities in many patients with covid-19, especially those with underlying cardiovascular disease, and the fact that covid-19 itself is associated with cardiac manifestations, this may increase the risk of cardiotoxicity associated with the use of chloroquine/hydroxychloroquine. indeed, excessive qtc prolongation was observed in 36 % of patients as reported by bessiere at al. and greater qtc prolongation was also seen in patients taking the combination of hydroxychloroquine and azithromycin than those taking hydroxychloroquine alone, highlighting the importance of pharmacodynamic interactions (bessiere et al., 2020; mercuro et al., 2020) . furthermore, a phase iib trial in brazil showed that a higher dose of chloroquine (600 mg twice daily) in patients hospitalised with covid-19 had a higher fatality rate (30 %) compared with 15 % in the lower dose (450 mg twice daily) group (borba et al., 2020) . qtc interval prolongation >500 msec was observed in 19 % of the high dose group compared with 11 % of the low dose group. the us prophylaxis randomised control trial however did not show any increase in cardiovascular aes (boulware et al., 2020) . we await the publication of the recovery trial to determine whether there was an excess of cardiovascular events. however, it is important to note that despite the size of the recovery trial (n = 1542 patients), it may still be under-powered to identify an excess number of cardiovascular events when compared with standard of care. remdesivir is an investigational compound that was developed for the treatment of ebola (mullard, 2018; tchesnokov, feng, porter, & gotte, 2019) . remdesivir is a monophosphoramidate prodrug and acts as a broad-spectrum antiviral that can be incorporated into viral rna (agostini et al., 2018; sheahan et al., 2020; warren et al., 2016) . many anti-virals are proving to be ineffective against covid-19 due to the presence of a proofreading exoribonuclease (exon) specific to coronaviruses, encoded in non-structural protein 14 (nsp14) (agostini et al., 2018) . remdesivir is able to evade this viral proofreading, meaning its incorporation into viral rna results in the inhibition of rna-dependent rna polymerases (rdrps), thereby preventing subsequent viral replication (warren et al., 2016) . furthermore, arshad et al. suggest that the maximum serum concentration (cmax) of remdesivir is sufficient to inhibit 90 % of sars-cov-2 replication, a parameter which is suspected to be of vital importance in the treatment of covid-19 (arshad et al., 2020) . remdesivir is administered intravenously, with single doses ranging between 3 to 225 mg being well patients receiving remdesivir via the uk early access to medicines scheme (eams) is similar to that which was evaluated for ebola treatment: a loading dose of 200 mg on day 1, followed by 100 mg daily for 5 -10 days depending on symptom severity (medicines and healthcare products regulatory agency, 2020b). as such, it is likely that many of the aes observed in the ebola study will translate to covid-19 patients treated with remdesivir. this article is protected by copyright. all rights reserved. mild to moderate alt and aspartate transaminase (ast) elevations were observed in several ebola patients during the multiple-dose study, thus reflecting observations made in human hepatocytes in vitro (clinical trials.gov, 2019; world health organisation, 2018) . this is likely to be due to the high cell permeability of hepatocytes, in combination with the effective intracellular metabolism of remdesivir to its active form within the liver (world health organisation, 2018) . emerging data has suggested that sars-cov-2 may target ace2 on hepatocytes leading to liver injury as evidenced by a significant increase in alt and bilirubin in severe cases of covid-19 (guan et al., 2020) . therefore, it is likely that differentiating between covid-19-induced transaminase elevations and those induced by remdesivir presents challenges (bangash, patel, & parekh, 2020; c. zhang, shi, & wang, 2020) . however, a recent study found that only 4.1 % of covid-19 patients receiving remdesivir treatment suffered serious (grade 3 or 4) transaminase elevations, with there being no significant difference between the remdesivir-and placebo-treated groups (beigel et al., 2020) . this data implies that remdesivir is relatively well-tolerated in sars-cov-2-positive patients. regardless, as advised by the drug manufacturer, daily liver function tests are essential in any patients receiving remdesivir, with suggested discontinuation of the drug in patients whose alt levels reach ≥ 5 times the upper limit of normal (uln) (gilead, 2020) . adhering to these guidelines is of particular importance in patients with pre-existing liver disease, or in those taking other medications which can also induce transient alt and ast elevation (world health organisation, 2018) . the reported differences between preclinical and clinical data regarding the safety of remdesivir highlight the inadequacies of preclinical models in some contexts. for example, with regards to covid-19, a concerning element of theoretical toxicity is that which affects the respiratory system. a study using mice models of middle east respiratory syndrome coronavirus (mers-cov) found remdesivir improved pulmonary pathology in infected mice and rhesus monkeys, and no respiratory toxicity was observed (gilead, 2020; sheahan et al., 2020) . in contrast, a respiratory safety study in rats showed that remdesivir had no impact on tidal volume or minute volume, but did increase respiratory rate, which returned to baseline by 24 hours post-dose (world health organisation, 2018). clearly, increased respiratory rate is a manifestation of covid-19, and there would be problems in assessing causality if remdesivir was also likely to cause of respiratory problems in a clinical setting. fortunately, a recent double-blind, randomized, placebo-controlled trial showed there to be no significant differences in adverse respiratory events between the remdesivir-treated and control arms (beigel et al., 2020) . in addition to this, preclinical safety studies performed in rats and cynomolgus monkeys suggested that the kidney was the target organ for remdesivir-induced toxicity (gilead, 2020) . this was a significant concern before the initial covid-19 clinical trials, as it is known that sars-cov-2 can cause acute kidney failure in severe cases (ronco, reis, & husain-syed, 2020) . however, this has not this article is protected by copyright. all rights reserved. been reflected in covid-19 clinical trials, where the presence of biomarkers indicative of renal injury have not differed in patients treated with remdesivir compared to those on placebo (beigel et al., 2020; gilead, 2020) . however, due to the inclusion of the solubility enhancer sulfobutylether βcyclodextrin sodium (sbecd) within remdesivir formulations, remdesivir is contraindicated in patients with severe renal impairment (egfr < 30 ml/min) (european medicines agency, 2020). finally, remdesivir is not exempt from ddis. co-administration of remdesivir with several antibiotics including rifampicin is contraindicated, which could cause problems for any patients being treated concomitantly for tuberculosis (group, 2020) . this occurs because of enzyme induction which reduces systemic exposure to remdesivir. a similar interaction has also been seen with enzyme-inducing anticonvulsants, including carbamazepine, phenytoin, and phenobarbital (group, 2020) , where reduction in remdesivir exposure may lead to inadequate treatment of covid-19. favipiravir is another broad-spectrum anti-viral prodrug which undergoes intracellular phosphoribosylation to produce its active form, favipiravir-ribofuranosyl-5′-triphosphate (favipiravir-rtp) (yousuke furuta, komeno, & nakamura, 2017) . it is thought that this anti-viral primarily acts by inducing lethal mutagenesis of rna viruses, although it also selectively and potently inhibits viral rdrp by acting as a pseudo purine nucleotide (dawes et al., 2018; sangawa et al., 2013) . favipiravir is currently licensed in japan for the treatment of novel and re-emerging influenza (yousuke y. furuta et al., 2002) . its extensive spectrum of activity against various rna virus polymerases led to favipiravir being cited as a potentially 'crucial pandemic tool', even before the outbreak of the novel coronavirus, covid-19 (adalja & inglesby, 2019) . the pk of favipiravir was initially characterised in healthy japanese volunteers (madelain et al., 2016) . a cmax of 51.5 µg/ml was found to occur 2 hours post-administration, but plasma concentrations decreased rapidly due to the relatively short half-life of favipiravir (between 2 and 5.5 hours) (madelain et al., 2016) . however, both cmax and half-life increase slightly after multiple doses and it has been suggested that favipiravir is capable of reaching a cmax in humans sufficient to inhibit 90 % of sars-cov-2 replication, thus establishing it as an important compound in the ongoing search for covid-19 therapies (arshad et al., 2020) . marked differences in cmax have been observed between japanese and american patients with cmax values in japanese subjects being on average 13.26 µg/ml greater than those in american subjects (pmda, 2014) . this highlights the need for relevant covid-19 clinical trials to include a diverse range of subjects so that factors such as weight and ethnicity can be considered to optimise dose. the bioavailability of favipiravir is high at 97.6 % and only 54 % of the drug is plasma protein-bound, suggesting high tissue penetration would be likely (madelain et al., 2016; pmda, 2014) . in vivo work in mice showed that the half-life of favipiravir in the lungs is double that of favipiravir in plasma, indicating slower elimination from the lungs (pmda, 2014) . this is thought to be of high importance in covid-19, where viral load is particularly high in the lungs. for influenza treatment in adults, 1600 mg favipiravir is given twice on day 1 of treatment, followed by 600 mg twice daily from days 2 to 5 (pmda, 2014). however, the dosing period has been extended in ongoing covid-19 clinical trials: up to 10 days in chictr2000029996 and 14 days in chictr2000029548 (guan et al., 2020) . it is therefore essential that all pk parameters are monitored in these trials as differences, including increased cmax and decreased clearance, are expected during this prolonged dosing regimen which may impact upon safety. favipiravir has been linked to teratogenicity and embryotoxicity, and is therefore contraindicated in pregnancy (yousuke furuta et al., 2013) . overall, favipiravir is generally thought to have a good safety profile (asrani, devarbhavi, eaton, & kamath, 2019; group, 2020; nhs, 2019) . this is likely to be due to the fact that unlike other antiviral drugs such as ribavirin, favipiravir does not appear to disrupt non-viral rna or dna synthesis. however, very little is known about the long-term safety of favipiravir, as in previous clinical trials patient follow-up has been as little as 5 days . this is perhaps less of a concern in covid-19 as treatment is time-limited. drug-drug interactions have been reported with favipiravir. for example, coadministration with favipiravir can increase exposure to paracetamol by around 15 %, which may be a concern for patients with pre-existing liver disease as paracetamol is the leading cause of acute drug-induced liver injury (dili) in the uk and usa (asrani et al., 2019; group, 2020) . favipiravir can also increase patient exposure to many contraceptives, including progesterone-only pills, combined pills, and several contraceptive implants, which may cause discomfort, prolonged vaginal bleeding, and nausea (group, 2020; nhs, 2019) . whether the increased exposure to oestrogens caused by concomitant treatment with favipiravir can enhance the risk of thrombosis is not known but should be monitored, given the overwhelming evidence that covid-19 increases the risk of blood clots (atallah, mallah, & almahmeed, 2020; di micco et al., 2020; spiezia et al.) . interestingly , large clots are most common in patients under the age of 50; almost 25 % of women aged between 15 -49 in the usa currently use either oral or long-acting contraceptives, and thus represent a particular risk group (hurley, 2020; prevention, 2019). sars-cov-2 virus is capable of eliciting an immune reaction in the infected individual. laboratory examinations have revealed that inflammatory factors such as interleukin (il)-6, il-1, il-10 and tumour necrosis factor-α (tnfα) are upregulated during infection and can instigate an inflammatory response in the lower airways leading to lung injury in some instances guo et al., 2020) . additionally, in patients with severe symptoms of covid-19, there may be activation of a cytokine storm, which can cause significant tissue damage (mehta, mcauley, et al., 2020; shi et al., 2020) . a smaller proportion of patients can progress to a hyper-inflammatory state which in covid-19 has been suggested to resemble secondary haemophagocytic lymphohistiocytosis (shlh), a rare syndrome characterised by uncontrollable fever, cytopenia, raised ferritin levels and acute respiratory distress (seguin, galicier, boutboul, lemiale, & azoulay, 2016) . interleukin and tnf-α levels show the greatest increase in those who require admission to the intensive care unit (icu), suggesting that the cytokine storm is instrumental in severe covid-19 cases (huang et al., 2020) . therefore, there has been a logical progression towards the use of immunosuppressive agents as potential therapies to alleviate inflammation and hyperinflammation associated with covid-19 (mehta, mcauley, et al., 2020) . dexamethasone is a glucocorticoid that can be administered both orally and intravenously. it acts as a glucocorticoid receptor agonist and is over 20 times more potent than endogenous cortisol, thus resulting in dose-dependent suppression of pro-inflammatory genes through a number of pathways in common with other steroids (papich, 2016; whelan & apfel, 2013; yasir & sonthalia, 2019) . low doses of glucocorticoids have an anti-inflammatory effect while higher doses are immunosuppressive (buttgereit et al., 2002) . dexamethasone can be used for inflammatory diseases such as rheumatoid arthritis (crohn's & colitis foundation, 2018; freeman, 2008) , but is recommended for short-term treatment (spanning from one to 21 days) because of the major adverse effects which can occur with long-term treatment. one of the commonest uses of dexamethasone is for reducing cerebral oedema. as of 8 th july 2020, dexamethasone was undergoing evaluation in 17 clinical trials. on 16 th june, the results of the dexamethasone arm of the recovery trial were announced. the trial results, which are available in preprint form, showed that 2104 patients had received either oral or intravenous lowdose (6 mg) dexamethasone daily for ten days (peter horby et al., 2020) . when compared to 4321 control patients receiving usual care only, it was shown that dexamethasone reduced deaths by one third in sars-cov-2 positive patients requiring ventilation, and by one fifth in patients receiving this article is protected by copyright. all rights reserved. oxygen. no benefit was observed for patients with milder covid-19 symptoms who did not require respiratory support (peter horby et al., 2020) . recent work has found that tissue inflammation and organ dysfunction seen in fatal cases of covid-19 are not consistent with sars-cov-2 distribution in tissues and cells (dorward et al., 2020) . tissuespecific tolerance to the virus may therefore important, and suggests that fatalities arising from covid-19 may be mainly due to host-mediated immune response rather than pathogen-mediated end-organ inflammation. this is consistent with the dexamethasone result in the recovery trial. dexamethasone has a bioavailability of 70-78 % and is 77 % protein bound in plasma (spoorenberg et al., 2014) . it is 6-hydroxylated by hepatic cyp3a4 to 6α-and 6β-hydroxy-dexamethasone, and can also be reversibly metabolised to 11-dehydroxymethasone and back to dexamethasone by renal corticosteroid 11-beta-hydrogenase isozyme 1 (diederich et al., 1998; diederich, hanke, oelkers, & bähr, 1997; tomlinson, maggs, park, & back, 1997) . unlike many glucocorticoids which are predominantly excreted in urine, only about 10% of dexamethasone is excreted in urine (dexcel pharma technologies ltd.). glucocorticoids are generally safe drugs when given at low doses and for short periods of time (< 3 weeks), with the risk of adverse events increasing with dose and therapy duration (yasir & sonthalia, 2019 ). short-term use of dexamethasone can result in increased appetite, mood changes, and insomnia, but most of the adverse reactions are self-limiting (nhs, 2020). dexamethasone can lead to b and t cell depletion, and hence lymphopenia (marinella, 2020) , which interestingly is also found in up to 80 % of patients with covid-19 (liu, blet, smyth, & li, 2020) . however, despite this, the recovery trial was able to show a mortality benefit in the most severely affected covid-19 patients. a critical issue may be the dose that is administered -in recovery, 6 mg/day was administered over 10 days, which is a relatively low dose. a recent systematic review and meta-analysis of corticosteroid treatment in patients with coronavirus infection suggested that corticosteroids were associated with higher rates of bacterial infections, longer time spent in hospital and higher rates of mortality (z. yang et al., 2020) . however, most of the studies analysed in this meta-analysis were retrospective observational studies, generally of poor quality and did not analyse the effects according to steroid dose. other studies which have used low-to-moderate-dose corticosteroids as treatment for diseases such as viral and bacterial pneumonia reflect the results of the recovery trial, with low dose corticosteroids resulting in decreased mortality and morbidity in patients with severe pneumonia (h. li et al., 2017; stern et al., 2017) . in these studies, low-to-moderate dose corticosteroids (40-50mg prednisolone, which equates to 6-7.5 mg dexamethasone) were given to patients for between 7 and 10 days (stern et al., 2017) (national institute for health and care excellence, 2020b). in keeping with the known adverse effects of corticosteroids, the systematic review showed that hyperglycaemia was significantly more frequent in the corticosteroid-treated group (stern et al., 2017) . dexamethasone can be involved in both pharmacokinetic and pharmacodynamic interactions. combining it with other immunosuppressants may increase the risk of serious infection (national institute for health and care excellence, 2020c). co-treatment with ibuprofen or other nsaids increases the risk of gastrointestinal bleeding (national institute for health and care excellence, 2020c), while its gluconeogenic effects can lead to hyperglycaemia, which in diabetic patients can lead to increased insulin doses being required (consilient health ltd., 2020). dexamethasone is a cyp3a4 inducer, and may therefore interact with remdesivir, a cyp3a4 substrate, potentially reducing its plasma exposure. although clinicians should be aware of this interaction, the risk is small given that both drugs are indicated for 10 days or less. both tocilizumab and sarilumab are humanised anti-il-6 receptor monoclonal antibodies used for the treatment of moderate -severe rheumatoid arthritis, whereas siltuximab is a chimeric, human-mouse anti-il-6 receptor monoclonal antibody used for treatment of multicentric castleman's disease (mcd) (deisseroth et al., 2015 ; national institute for health and care excellence, 2020e). due to their long half-life, il-6 inhibitors do not need to be taken daily; however, given that they are currently indicated for chronic diseases, patients receive il-6 inhibitor treatments for life or until treatment failure (janssen biotech inc; roche pharma; sanofi-aventis). clinical trials to assess the efficacy and safety of tocilizumab, sarilumab and siltuximab for the treatment of the inflammatory phase of covid-19 are ongoing. whilst the exact dosing regimens vary between trials, covid-19 patients will be receiving a single or short course intravenous infusion or subcutaneous injection of the il-6 inhibitor (clinical trial identifiers nct04317092, nct04315298, nct04327388, nct04330638, nct04322188). due to their similarity, it is not surprising that tocilizumab, sarilumab and siltuximab have comparable safety profiles. thus far, evidence from clinical trials in patients with rheumatoid arthritis and mcd or post-marketing have revealed that il-6 inhibitors are generally well-tolerated. participants were enrolled on these trials for a minimum of 6 months and in some cases up to 24 months. individuals with diabetes, a history of recurrent infection, age ≥ 65 and corticosteroid use have been shown to be at an increased risk of developing a more serious infection following il-6 inhibitor use (jones et al., this article is protected by copyright. all rights reserved. 2010). whilst adverse reactions were typically seen following chronic il-6 inhibitor treatment, the potential for covid-19 patients to develop an adverse drug reaction (adr) following a single or small number of doses should not be ignored. the most common infections reported in patients receiving anti-il6 therapy include skin infections, respiratory infections, urinary tract infections and in some cases, opportunistic infections ranging from tuberculosis to herpes (emery et al., 2008; smolen et al., 2008) . liver injury has also been reported with a liver biopsy from a female patient who had taken tocilizumab for a month revealing focal this article is protected by copyright. all rights reserved. necrosis of hepatocytes with steatosis and early fibrosis (mahamid et al., 2011) . covid-19 also has effects on the liver, and again causality assessment may be difficult (guan et al., 2020) . the prescribing instructions for tocilizumab and sarilumab indicate that liver function tests are required every 4 -8 weeks following treatment commencement and then every 3 months thereafter (roche pharma; sanofi-aventis). if liver enzymes are 1 -3 x uln, the dose of tocilizumab and sarilumab can be reduced until alt or ast have normalised and then treatment resumed at the therapeutic dose. where laboratory findings are > 3 -5 x uln, treatment with il-6 inhibitors must be paused and then recommendations for 1 -3 x uln followed. if elevations persist or are > 5 x uln, tocilizumab and sarilumab treatment must be discontinued immediately (roche pharma; sanofi-aventis). whilst sarilumab and siltuximab are associated with abnormalities in liver function tests, they are typically short-lived and asymptomatic (livertox, 2016 (livertox, , 2017b . pre-existing liver disease can worsen symptoms of dili, and in some cases increase susceptibility (david & hamilton, 2010) . tocilizumab, sarilumab and siltuximab are expected to undergo metabolism via catabolic pathways and not cyp450 processes (mccarty & robinson, 2018) . therefore, due to the lack of hepatic metabolism, it is assumed that the pk of the il-6 inhibitors will not be altered in patients with preexisting liver disease (abou-auda & sakr, 2010). however, tocilizumab, sarilumab and siltuximab have been shown to restore and improve cyp levels (janssen biotech inc, 2019; roche pharma, 2013; sanofi-aventis, 2017). this is of particular importance as cyp levels may remain elevated following treatment discontinuation due to the long half-life of the compounds. therefore, this may be a consideration for further evaluation for any dosing adjustment requirements if patients are taking medication that are metabolised by cyp enzymes. anakinra is a 17 kd, recombinant human il-1 receptor antagonist that blocks the activity of proinflammatory cytokines il-1α and il-1β (cawthorne et al., 2011; dinarello, simon, & van der meer, 2012) . anakinra is primarily used in combination with methotrexate for reducing the symptoms and slowing the progression of joint damage in rheumatoid arthritis (national institute for health and care excellence, 2020a). it is also used for rare inflammatory conditions such as cryopyrin-associated periodic syndromes and still's disease (national institute for health and care excellence, 2020a). it is administered via subcutaneous injection and is supplied as a single-use, pre-filled syringe containing 100 mg/0.67 ml (swedish orphan biovitrum ltd, 2007) . rheumatoid arthritis patients and those with still's disease and a body weight > 50 kg must be administered 100 mg anakinra, while patients with still's disease with a body weight < 50 kg should have weight-based dosing starting at 1 -2 mg/kg this article is protected by copyright. all rights reserved. (swedish orphan biovitrum ltd, 2007). the recommended starting dose for patients with cryopyrinassociated periodic syndromes is 1 -2 mg/kg. if tolerated, the dose can be increased to 3 -4 mg/kg to a maximum of 8 mg/kg (swedish orphan biovitrum ltd, 2007) . anakinra has a short terminal half-life of approximately 4 -6 hours and so must be administered daily, preferably at the same time each day (amgen inc., 2001) . anakinra is currently not licensed for intravenous administration or treatment of shlh but its use is endorsed by clinicians, where intravenous infusion, as opposed to subcutaneous injection, can achieve quicker and greater maximal plasma concentrations (carter, tattersall, & ramanan, 2018; la rosée et al., 2019; mehta, cron, hartwell, manson, & tattersall, 2020) . thus far, 21 clinical trials have been registered to assess the use of anakinra in patients with severe covid-19. additionally, two recent studies have reported positive outcomes with anakinra in covid-19 induced acute respiratory distress syndrome (cavalli et al., 2020; clinical trials.gov, 2020c; huet et al., 2020) . participants were dosed 100 mg twice daily subcutaneously for 72 hours followed by 100 mg daily for 7 days in addition to standard of care (huet et al., 2020) . this retrospective study found that anakinra reduced rates of mortality and the need for mechanical ventilation in icu patients (huet et al., 2020) . anakinra was administered either subcutaneously or intravenously in the covid-19 biobank study (huet et al., 2020) . participants received subcutaneous injections at a dose of 100 mg twice daily or via slow intravenous infusion at 10 mg/kg per day until there was a 75 % reduction in serum c-reactive protein levels and sustained respiratory improvements (cavalli et al., 2020) . whilst no safety concerns emerged with anakinra administered subcutaneously, it was discontinued due to a lack of clinical improvement and limited reduction in c-reactive protein (cavalli et al., 2020) . by contrast, intravenous anakinra was well-tolerated and improved clinical outcomes. notably, 72 % of patients had improved respiratory function in comparison to 50 % within the standard treatment group (cavalli et al., 2020) . in both studies, cases of alt ≥ 3 x uln were observed in both the anakinra and the standard treatment arms. four cases of bacteraemia following intravenous anakinra were reported in the covid-19 biobank study, but there were no cases of bacterial infection in the ana-covid study (cavalli et al., 2020; huet et al., 2020) . whilst both studies are encouraging, they should be considered proof-of-concept trials and larger randomised trials are still needed (cavalli et al., 2020; huet et al., 2020) . subcutaneous administration of anakinra is associated with injection site reactions (kaiser et al., 2012) . in a review of five rheumatoid arthritis clinical trials, 71 % of participants receiving anakinra therapy reported injection site reactions in comparison to 28 % of participants on placebo (mertens & singh, 2009) . injection site reactions can range from immediate to delayed. in immediate cases, the reaction manifests as a burning sensation whereas delayed reactions present as a rash, pruritus or swelling (kaiser et al., 2012) . anakinra has also been reported to lead to infection, neutropenia, this article is protected by copyright. all rights reserved. thrombocytopenia, headache, and blood cholesterol increase when administered subcutaneously (swedish orphan biovitrum ltd, 2007) . injection site reactions that arise immediately can be eased by placing an ice pack on the injection site before and after anakinra administration and delayed reactions can be treated with topical corticosteroids or anti-histamines (kaiser et al., 2012) . increases in serious infection rate are common following anakinra use and frequently include upper respiratory infections, sinusitis, urinary tract infection and bronchitis (bresnihan et al., 1998; cohen et al., 2002; r. m. fleischmann et al., 2003) . whilst rare, cases of opportunistic infection have been reported in anakinra monotherapy or in those receiving anakinra in combination with immunosuppressive agents (salvana & salata, 2009; swedish orphan biovitrum ltd, 2007) . neutrophil counts must be monitored during the first six months of anakinra treatment and quarterly henceforth (swedish orphan biovitrum ltd, 2007) . in patients where the anc is < 1.5 x 10 9 /l, treatment must be discontinued immediately (swedish orphan biovitrum ltd, 2007) . the higher doses being used in covid-19 trials and the potential for a greater cmax due to intravenous administration potentially raise additional safety concerns. however, earlier detection of aes should be possible since the duration of treatment will be shorter than that used in rheumatoid arthritis, coupled with the fact that patients will already be hospitalised. anakinra is catabolised and eliminated via glomerular filtration (swedish orphan biovitrum ltd, 2007; b.-b. yang, baughman, & sullivan, 2003) . caution should be exercised and dose-adjustments may be required in moderate to severe renal impairment (swedish orphan biovitrum ltd, 2007; b.-b. yang et al., 2003) . during general infections and inflammatory diseases, cyp enzymes are primarily downregulated (mallick, taneja, moorthy, & ghose, 2017) . similar to il-6 inhibitors, it may be possible that anakinra treatment restores cyp levels in infected patients (swedish orphan biovitrum ltd, 2007) . therefore, caution should be exerted in covid-19 patients receiving concomitant medications with a narrow therapeutic window drug. mild interactions can occur between anakinra and warfarin, clopidogrel, clozapine and phenytoin (group, 2020) . baricitinib is an oral disease-modifying anti-rheumatic drug (dmard), traditionally used in the treatment of moderate to severe active rheumatoid arthritis (al-salama & scott, 2018). by acting as an atp-competitive kinase inhibitor, baricitinib can selectively and potently inhibit janus kinases (jaks) -1 and -2 in a reversible manner. jaks are essential in the transduction of intracellular signals for various cytokines involved in the inflammatory and immune responses, and so by inhibiting these kinases, baricitinib is able to relieve symptoms of rheumatoid arthritis for many patients (fridman et al., 2010) . as described previously, a common characteristic of covid-19, much like another beta-coronavirus disease sars, is a profuse inflammatory response (huang et al., 2020; stebbing et al., 2020) . increased levels of pro-inflammatory cytokines, such as interferon (ifn) -γ and il-1β, have been observed in confirmed covid-19 cases (huang et al., 2020; mehta, mcauley, et al., 2020; russell et al., 2020) . furthermore, the levels of some specific cytokines appear to be related to disease severity; patients requiring admission to intensive care units show increased levels of tnfα and monocyte chemoattractant protein 1 (mcp1). the rationale behind repurposing baricitinib as a treatment for covid-19 is centred on this potential for severely ill patients to present with a cytokine storm (mehta, mcauley, et al., 2020; russell et al., 2020) . by dampening the inflammatory response, it is postulated that baricitinib will be able to relieve covid-19 symptoms. data modelled using artificial intelligence techniques suggests baricitinib may work by inhibiting virus entry into cells via an endocytic regulator known to be involved in coronavirus internalisation, ap2-associated protein kinase 1 (aak1) (burkard et al., 2014; richardson et al., 2020) . baricitinib, as well as being capable of jak1 and jak2 inhibition, is a high-affinity inhibitor of aak1 . patients tend to tolerate baricitinib well, and it has a relatively good safety profile (keystone et al., 2015) . however, as with tocilizumab and sarilumab treatment, a very common (≥ 1/10) ae observed in patients taking baricitinib, but not in the placebo arm, is upper respiratory tract infection, which may be related to its ability to suppress the immune system (eli lilly, 2017) . patients taking baricitinib have the potential to develop respiratory tract infections which may make it difficult to distinguish whether any deterioration is due to covid-19 or a secondary infection. other opportunistic infections including herpes zoster and urinary tract infections were also more common in the treated arm compared to placebo, and dose reduction is recommended for patients with a history of chronic infections (eli lilly, 2017; josef s. smolen et al., 2018) . secondary infections are not uncommon in severe covid-19 patients and so the use of a drug that may make patients increasingly prone to infections will depend on the harm-benefit ratio for severe cases of covid-19 (world health organisation, 2020a). baricitinib is currently still being trialled in patients with covid-19 with a therapeutic dose of 2 -4 mg once daily which is the same as the recommended dosage for the treatment of rheumatoid arthritis (cantini et al., 2020; richardson et al., 2020) . there have been a small number of reports from patients taking this recommended dosage for the treatment of rheumatoid arthritis presenting with deep vein thrombosis (dvt), which was severe in some of these cases (taylor et al., 2019) . this is a cause for this article is protected by copyright. all rights reserved. concern as there are increasing reports of covid-19 patients, especially those who are critically ill and in the icu, with thrombotic complications including pulmonary embolism and other venous and arterial thrombotic events (klok et al., 2020; middeldorp et al.) . as baricitinib has been reported to cause dvt, there is the potential for disease-drug interactions with covid-19 patients taking baricitinib potentially more likely to develop thrombotic complications. in order to mitigate this risk, alternative jak inhibitors, which have a lower risk of thrombotic events, such as ruxolitinib, may be considered in the context of covid-19 (alvarez-larran et al., 2018) . however, unlike baricitinib, ruxolitinib is primarily metabolised by cyp3a4 (l. p. h. yang & keating, 2012) . this means that prescribing ruxolitinib instead of baricitinib may increase the risk of cyp3a4-related ddis (ogu & maxa, 2000) . baricitinib is not predicted to be involved in any problematic ddis. coadministration with both cyp3a inhibitors (fluconazole) and inducers (rifampicin) failed to result in any clinically relevant changes to baricitinib exposure (eli lilly, 2017). emerging reports have revealed that patients with covid-19 experience renal impairment, which could be attributed ace2 receptor expression on kidney endothelial cells (varga et al., 2020) . baricitinib should not be given to patients with renal impairment as the majority of the drug is cleared through the kidneys, and monitoring of renal function will be important to prevent aes related to over-exposure to baricitinib in those with deteriorating renal function (eli lilly, 2017) . type 1 ifns are a group of cytokines produced during viral infection. notably, ifn-β-1a has a leading role in activating genes involved in immunomodulation, suppressing the inflammatory response and anti-viral effects (sallard, lescure, yazdanpanah, mentre, & peiffer-smadja, 2020) . whilst a variety of type 1 ifns exist, in vitro evidence has shown that ifn-β-1a and ifn-β-1b are the most potent in the inhibition of sars-cov and mers-cov (chan et al., 2013; hensley et al., 2004) . within the lungs, ifnβ-1 has been shown to upregulate levels of the enzyme cluster of differentiation 73 (cd73), which inhibits vascular leakage, increases the secretion of anti-inflammatory adenosine and preserves pulmonary endothelial barrier function (kiss et al., 2007; sallard et al., 2020) . however, in vivo research has revealed that timing of administration of ifn-β-1 is imperative for positive effects. when administered shortly after mers-cov infection, ifn-β-1 protected mice from lethal infection, whereas delayed administration failed to effectively inhibit viral replication or pro-inflammatory cytokines, leading to fatal pneumonia (channappanavar et al., 2019) . interestingly, in vitro evidence has revealed this article is protected by copyright. all rights reserved. that sars-cov-2 is more sensitive to ifn-β-1 treatment than mers-cov and sars-cov, and thus supports the tenet that treatment with ifn-β-1 may be beneficial for covid-19 patients (lokugamage, schindewolf, & menachery, 2020; sheahan et al., 2020; thiel & weber, 2008) . it is assumed that treatment of covid-19 patients with ifn-β-1 will strengthen the host immune response and prevent the worsening of severe respiratory tract manifestations. ifn-β-1 therapy has been used for the long-term management of multiple sclerosis (ms) and has been associated with a number of aes. when administered subcutaneously in ms patients, the most common aes were flu-like symptoms, injection site reactions, worsening of ms symptoms, menstrual disorders, mood alterations and laboratory abnormalities (walther & hohlfeld, 1999) . the most common laboratory abnormalities were neutropenia, leukopenia, lymphopenia and raised aminotransferases (walther & hohlfeld, 1999) . a genome-wide association study of patients with ifnβ induced liver injury showed that rs2205986 which has been linked to differential expression of interferon regulatory factor (irf)-6 is a predisposing factor (kowalec et al., 2018) . this may be related to the fact that irf6 leads to apoptosis in the presence of ifn-β. depression is a common ae reported in patients receiving subcutaneous ifn-β-1 therapy, and thus caution is needed when administering to those with a previous or current history of depressive disorder (biogen) . whilst rare, careful monitoring of clinical manifestations such as new onset hypertension, thrombocytopenia, impaired renal function and fever are required in order to identify cases of thrombotic microangiopathy (tma) (biogen) . tma is rare and has been reported at different time points of ifn-β-1 therapy (biogen; nishio et al., 2016; yam, fok, mclean, butler, & kempster, 2018) . laboratory findings of a decreased platelet count, increased serum lactate dehydrogenase (ldh) and red blood cell fragmentation are suggestive of tma (biogen) . if diagnosed, patients must discontinue ifn-β-1 therapy and will require plasma exchange (biogen) . sng001 is an inhaled form of ifn-β-1a produced by synairgen. the company have tested the efficacy and safety of the drug for the prevention and treatment of symptoms associated with respiratory viral infection in asthma and chronic obstructive pulmonary disease (copd) (synairgen plc, 2018). a randomised, placebo-controlled phase 2 trial is currently ongoing to assess the safety and efficacy of inhaled sng001 for the treatment of patients with covid-19 (nct04385095). data from the asthma trials have revealed that when administered via inhalation, high levels of ifn-β-1a are achieved within the lungs with lower levels within the circulation leading to improvements in lung function, antiviral responses and better asthma control (djukanović et al., 2014) . inhaled sng001 seems to have a good safety profile; 5 patients within the sng001 arm reported cardiac palpitations whereas no cases were reported in the placebo arm, but symptoms were mild and not considered clinically significant (djukanović et al., 2014) . this article is protected by copyright. all rights reserved. a clinical trial has been undertaken in hospitalised covid-19 patients where the triple combination of ifn-β, lopinavir-ritonavir and ribavirin was compared to lopinavir-ritonavir and ribavirin (hung et al., 2020; shalhoub, 2020) . patients in the triple combination therapy arm achieved negative tests results faster than those in the control arm, with improved patient symptoms, decreased viral shedding and decreased overall length of stay in the hospital compared to those in the control group (hung et al., 2020) . aes reported in both groups included nausea and diarrhoea. however, due to polypharmacy in this trial, it was difficult to determine the effect of ifn-β on sars-cov-2 alone. ifn-β has reported ddis with other covid-19 therapies including chloroquine and hyrdroxychloroquine, and with anakinra, sarilumab and tocilizumab (group, 2020) . ddis have also been reported with metamizole (analgesic), linezolid (antibacterial), clozapine (antipsychotic), zidovudine (hiv antiretroviral therapy) and some immunosuppressants (adalimumab, azathioprine and pirfenidone) (group, 2020) . reviewing the safety of potential covid-19 treatments (table 1) is complex due to the fast-moving pace of research in this field. for example, chloroquine and hydroxychloroquine with or without an accompanying macrolide antibiotic, have consistently been at the forefront of covid-19 research efforts since the outbreak began. however, the astonishing developments over a week or so have led to retraction of a highly publicised paper, and results from a post-exposure prophylaxis trial and a treatment trial (recovery), both of which have shown no beneficial effect of hydroxychloroquine (boulware et al., 2020; mehra, ruschitzka, & patel, 2020) . this highlights that the rapid rate of discoveries surrounding covid-19 therapies generates the need to update this perspective frequently, in order to ensure that the safety of any newly repositioned therapies, novel developmental compounds, or new therapeutic combinations are investigated. for example, the potential use of heparin in novel forms, including nebulised therapy (clinical trial identifier nct04397510), as an antiviral agent is currently the subject of several investigational trials. in addition, the potential utility of nitazoxanide is currently the subject of several clinical trials (clinical trials.gov, 2020a; pepperrell, pilkington, owen, wang, & hill, 2020; rajoli et al., 2020) . it is clearly essential that the harm:benefit ratio of any pharmaceuticals being considered for use in the treatment of covid-19 are thoroughly considered. this ratio changes dependent upon the disease stage and is correlated to potential mortality. for example, a higher risk may be accepted for patients in the later stage of severe disease than the same therapeutic agent administered in mild disease. this difference in harm-benefit analysis becomes even more striking when considering the use of such agents to prevent infection. as is the case for many highly contagious viruses, prevention by prophylaxis would be incredibly valuable. some of the agents described in this review, including chloroquine and ritonavir have been suggested as potential prophylactic agents, but to date, data on efficacy have been disappointing (rathi, ish, kalantri, & kalantri, 2020; spinelli, ceccarelli, di franco, & conti, 2020) . clearly, treatment duration for prophylaxis is expected to be longer than for treatment of covid-19, and this may further alter the harm-benefit ratio, reinforcing the need for safety considerations at the outset of any clinical trials. similarly, the evaluation of therapy risk also applies to long-term recovery. as the current pandemic progresses, it is becoming apparent that being discharged from hospital does not necessarily mean that patients are free from covid-19 symptoms. large numbers of patients who have survived severe sars-cov-2 infection may have incurred long-term health problems, including some permanent loss of lung and kidney function (foundation, 2020; su et al., 2020; summers, 2020) . consequently, it is probable that long-term therapies will be required for many patients to maintain, or ideally restore, normal physiological organ function. it is vital that therapies which will be used to treat patients during their long-term recovery are also undergoing evaluation for their safety, particularly as many of these agents may need to be administered over much longer periods of time than initial covid-19 treatments. the identification and characterisation of biomarkers of disease and safety will be invaluable in the further development and deployment of therapies for covid-19. disease biomarkers, for example of lung injury or the hyperinflammatory reponse, may allow the stratification of therapy in order to select the agent best suited to the stage of disease. moreover, biomarkers should be considered to monitor patient safety in cases of known aes. for example, the manufacturer's guidelines for remdesivir recommend daily liver function tests due to the risk of transaminase elevations (gilead, 2020) . these tests are essential, particularly with regards to covid-19 where increased alt levels are reported to be common amongst hospitalised patients (bangash et al., 2020; l. zhang et al., 2009 ). looking to the future, improvements in the specificity, predictivity and reliability of drug-induced organ damage, through academic-industry partnerships such as the biomarker qualification program in the critical path institute in the us, and the european innovative medicines initiative consortium transbioline, will help improve clinical assessment of covid-19 drug safety issues. continued enhancements in the speed, predictivity, and human translation of safety assessment for toxicity of anti-viral compounds is clearly warranted, and this may include animal models of sars-cov-2 as well as in vitro models, in order to assess efficacy alongside safety. such a full understanding for individual therapies will indicate the combinations that can have the potential to provide the best this article is protected by copyright. all rights reserved. synergy for benefit, while forewarning of the potential for increased risk/harm through pharmacokinetic or toxicodynamic interaction. although outside the scope of this review, a vaccine for covid-19 remains the greatest hope to end the pandemic and protect the population. as of 8 th july 2020, according to who there are 21 vaccines in clinical trial stages and 139 in preclinical stages of evaluation (world health organisation, 2020b). currently, potential vaccines are only just beginning to be tested for efficacy in humans in early phase studies, and therefore safety data will begin to emerge as larger numbers of individuals are administered the vaccine. safety data regarding preliminary vaccinations against sars and mers are limited, but the available information may be useful during the development of covid-19 vaccines due to the similarities between the coronavirus strains (padron-regalado, 2020). one safety concern relevant to coronaviruses is the potential for the induction of antibody-dependent enhancement (ade), a phenomenon which was observed in cats vaccinated against feline infectious peritonitis coronavirus, and has also been seen in patients vaccinated against zika virus and dengue virus (khandia et al., 2018; padron-regalado, 2020; vennema et al., 1990) . ade can occur when nonneutralising antibodies bind to virus particles and increase their uptake into host cells, instead of rendering them non-infectious (padron-regalado, 2020; tirado & yoon, 2003) . this caused concern in initial sars vaccine development, but can reportedly be avoided by using truncated versions of the viral s glycoproteins (he et al., 2004) . acknowledging safety concerns such as this, as well as the ways they can be attenuated, may be paramount in the timely development of a vaccine against covid-19. in conclusion, although expanding extremely rapidly, the field of therapies to treat covid-19 remains in its infancy. safety will continue to play a major role in therapeutic success, as apparent with recent reports of increased cardiac toxicity associated with the use of chloroquine/hydroxychloroquine in the treatment of covid-19, despite its long history of use as an antimalarial. above all, this perspective has exemplified the need to view safety concerns in the context of the individual and specific phase of disease in order to formulate a comprehensive harm-benefit balance. importantly, an awareness of potential safety concerns will support the development of the next stage of therapy targeting prophylaxis and recovery post-covid infection. it is imperative that safety scientists look to rise to the challenge of covid-19 by utilising their expertise in mechanistic understanding, biomarker development and toxicokinetic modelling in order to support the development of covid-19 therapies that can be used effectively and safely. aa, bkp, cbb, ceg, rlj, rtk, shk, slp and xm declare that that they have no conflicts of interest. ao declares no direct conflict of interest but is director and cso for tandem nano ltd and a co-inventor of patents relating to drug delivery of infectious disease medicines. aec reports no direct conflict of interest but receives research funding for the support of sp and rlj from servier pharmaceuticals and astrazeneca, these are unrelated to the published work. aec receives additional unrelated research funding from janssen pharmaceuticals. ao has received consultancy and /or research funding from viiv healthcare, merck, astrazeneca, gilead, and janssen unrelated to the current paper. db received educational grants and/or consultancy from abbvie, novartis, merck, gilead and viiv healthcare outside the submitted work. mp receives research funding from various organisations including the mrc, nihr, eu commission and health education england. he has also received partnership funding for the following: mrc clinical pharmacology training scheme (co-funded by mrc and roche, ucb, eli lilly and novartis); and a phd studentship jointly funded by epsrc and astra zeneca. he has also unrestricted educational grant support for the uk pharmacogenetics and stratified medicine network from bristol-myers squibb and ucb. none of the funding received is related to the current paper. figure 1 : overview of the mechanisms of action of the repurposed drugs undergoing clinical trials for the treatment of covid-19 that will be reviewed in this perspective. compounds in red represent those that are viral entry inhibitors, compounds in green represent disruptors of cellular viral processing, compounds in blue are modulators of the hyperinflammatory phase of infection and compounds in yellow stimulate host immunomodulatory and anti-viral activity. abbreviations: ace2, angiotensin converting enzyme 2; il-6, interleukin-6; il-1, interleukin-1; jak, janus kinase; rdrp, rna-dependent rna polymerases; stat, signal transducer and activator of transcription proteins; p, phosphate; nf-κb, nuclear factor kappalight-chain-enhancer of activated b cells; ifn-β, interferon-beta; isre, interferon stimulated response element. tocilizumab: a new anti-rheumatic drug broad-spectrum antiviral agents: a crucial pandemic tool coronavirus susceptibility to the antiviral 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coronavirus infection: a systematic review and meta-analysis in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) liver injury in covid-19: management and challenges scientific and regulatory perspectives on metabolizing enzyme-transporter interplay and its role in drug interactions: challenges in predicting drug interactions single-cell rna expression profiling of ace2, the putative receptor of wuhan 2019-ncov. biorxiv covid-19 and the cardiovascular system key: cord-282261-wcmc5mh6 authors: rhodus, elizabeth k.; bardach, shoshana h.; abner, erin l.; gibson, allison; jicha, gregory a. title: covid-19 and geriatric clinical trials research date: 2020-09-16 journal: aging clin exp res doi: 10.1007/s40520-020-01705-x sha: doc_id: 282261 cord_uid: wcmc5mh6 nan the sars-cov-2 pandemic has wrought tremendous upheaval to daily life, spreading rapidly and causing millions to contract covid-19. the long-term effects are yet unknown, but scientists are studying the disease and searching for solutions. in geriatric clinical trials research, the problems presented by covid-19 are multifaceted: older adults face increased risk of morbidity and mortality due to covid-19, and so ongoing clinical trials that enroll geriatric participants have been disrupted, appropriately so, in light of these increased risks [1] . yet, the interruption of ongoing trials may further increase risks to older adults as critical research on treatments for highly prevalent diseases and conditions is slowed or stopped. further, older adults are substantially underrepresented in clinical trials research, and this situation may worsen this discrepancy. scientists in aging appreciate the necessity of older adults' inclusion within clinical trials, but the vulnerability to increased exclusion in clinical trials of this population is high, now more than ever. attention to clinical trial development with special attention to need for inclusion of older adults and precautions is greatly needed to sustain current efforts, at minimum, and ideally, enhance recognition of the value of including older adults in clinical trial research. the covid-19 crisis affects every aspect of clinical trial research engagement including: recruitment and retention; ability to ensure participant safety while engaged in experimental interventions; study procedures, including consideration of remote assessments, impact on populations with health disparities, and generalizability of future results; outcome measures, including biomarker assessment; impact on the clinical trial workforce, including attrition; impact on dissemination of results and scientific collaborations, which move the clinical trial infrastructure forward; current and future funding allocations; and regulatory considerations in regards to management of altered study conduct and change of outcome measures (fig. 1) . the purpose of this article is to highlight the impact of disasters such as the covid-19 pandemic on geriatric clinical trials research and propose approaches for the scientific community to continue pushing forward. disruptions due to disaster can often result in disruptions to study protocols, challenges to data interpretation, the need for institutional review board (irb) amendments, and the introduction of new biases [2] . prior research highlights the importance of proactive plans to minimize study disruption, the need to adapt rapidly to changing constraints, and the importance of ongoing communication with contract research organizations and sponsors and to share and develop strategies to mitigate participant-related protocol deviations and violations. application of these actions should all occur in the context of local conditions. researchers have not previously seen this global level of disruption to clinical trials. effects of covid-19 on geriatric clinical trials research will be long-lasting. trials in their enrollment phase will at a minimum be delayed in achieving full recruitment, leading to lags in, or losses of, discovery. depending on the duration of stay-at-home orders, some studies may be permanently disrupted and discontinued. for more established trials, if attrition leads to final sample sizes much smaller than those required by the a priori power estimates, then these ongoing studies may not have enough statistical power to identify positive findings. trials that involve in-person cognitive assessment face challenges as they move to other modalities for testing, which may influence results. efforts to validate existing measures through remote assessment should continue, to enable meaningful cognitive measures to be assessed remotely. in addition, investment in low cost technology to support these efforts, for participants who may not have remote access, may enable studies to continue with limited disruption, while also ensuring those of lower socioeconomic status are not left behind. clinical trials involving those with cognitive impairment face unique challenges during such crises [1] . these individuals depend on routine for optimal functioning, as well as access to health care, and supportive community engagement. at a time of social distancing, routines and support systems are dramatically altered. social cohesion and community can offer protections and resiliency for older adults during the time of disaster management. maintaining and supporting active participant and recruitment engagement is essential. for example, the addition of virtual connection, training, and additional contact may prove highly beneficial. efforts to maintain engagement will need to be complemented by efforts to evaluate safety and efficacy. many of the existing safety and efficacy measures within current trials are coming to a halt or being offered through non-traditional means, with unknown validity. individuals continuing to take experimental medications may continue to have checkin safety calls but may have delays in bloodwork and imaging scans that would otherwise provide reassurance regarding any potential adverse medication effects. for infusion studies, medication delivery may be halted, but lingering effects of existing dosages are still possible. careful evaluation of potential drug effects and critical safety measures will optimize the likelihood that safety is not compromised. behavioral studies have additional challenges due to the prolonged proximity of participants and researchers required in some intervention. while the impact of abrupt halting of these trials is yet to be known, maintaining vigilance while planning to resume is essential. there is need for attention to implement gradual, careful restart processes that aim to keep participants safe while minimizing disruption to trials. assessing efficacy will be more complex, as the evaluation will necessitate consideration of history effects within studies including the upheaval to daily routines and changes in cognitive and social stimulation that covid-19 has created. methodological counterpoints will need to be considered including the role of randomization in distributing the psychosocial effects across groups, the timing of enrollment within the pandemic onset, and testing or controlling for psychological sequelae of covid-19, such as controlling for depressive symptoms or the impact of social isolation and loneliness. further, as noted above, changing test administration from in-person to digital modalities that can be conducted remotely out of the office will introduce additional variability into efficacy assessments. in the us, morbidity and mortality early in the covid-19 pandemic has disproportionately affected older adults and black/african-american and hispanic-american communities [3] . there are often perceptions in these communities, which arose through a long history of mistreatment by biomedical researchers and healthcare providers, that healthcare offers assistance but also potentially contributes to individual and community harm. if healthcare centers are seen as a focal point for contagion, engagement that requires in-person visits to healthcare facilities may be problematic. existing barriers to engaging hard to reach participants will likely be exacerbated. clinical discoveries should benefit everyone, and diversity and inclusiveness improve the generalizability of clinical trial findings. we must make concerted efforts in recruitment and retention to ensure advancements we have made in regard to increasing the representative population sample engaged in clinical trial research are sustained. recent past and anticipated future successes in clinical trial activity in the area of aging and dementia have relied on biomarker assessments including: brain imaging (mri, pet and other), which requires shared and repetitive usage of common acquisition facilities; retinal imaging and eeg, which require the use of shared equipment that may be difficult to sterilize or sanitize between participants. biomarker outcomes are an increasingly important part of clinical trial research [4] . discovery of disease-modifying therapies in the area of dementia research, especially preclinical dementia, is dependent on such measures. coordination of using shared medical facilities such as imaging equipment including mri and pet scanners for continued conduct has been a challenge due to concerns of covid-19 transmission, despite the critical need for the acquisition of essential imaging and safety information mandated by participant status and clinical trial conduct. development of specific and diligent methods to sterilize, sanitize, and convey these safety precautions to the public will allow continued engagement in clinical research activities. as with prior disasters, many research sites in the us have been forced to shut down and/or limit activities as a result of local or state restrictions due to covid-19. in addition, site staff in many areas of the us are under 'remote work' or 'stay at home' orders that limit access to their workspace. thus, critical research activity that supports the financial infrastructure of these research sites may be diminished and/ or completely disappear. it may not be possible for some investigators to continue to provide salary support for their well-trained research staff members, not only leading to dissolution of the existing research site infrastructure but also contributing further to the ongoing societal burden of the covid-19 crisis. such impact may also impede advancement of researchers' careers. the need for the cultivation and maintenance of a workforce trained for enhancing older adults' engagement in clinical trial activities has been overlooked for years. hiring and retaining qualified and experienced study coordinators, recruiters, psychometrists, and even phlebotomists in the geriatric research setting can be extremely difficult. developing such skill sets and desires to work in research may be severely limited by the covid-19 crisis unless we are able to ensure stability of the underlying research infrastructure. otherwise, we will lose many preciously talented individuals who have entered the field of geriatric clinical research. the call for advocacy is needed for sustained funding mechanisms that offer emergency support and stable institutional standing to ensure continuity and protection of these positions. given the heightened public interest in advancing scientific and medical initiatives to combat the covid-19 crisis, as well as the financial burden the crisis is posing globally, there is increasing competition for resources that have long been lacking in the field. funding increases for agingrelated research were moving at a rapid pace but funds now may be in jeopardy with this competing need. large-scale funding from the nih is being redirected to directly combat the covid-19 pandemic. while immediate repercussions on the budget for national institute on aging has not yet occurred, we hope that specific aging-related research continues to receive the funds necessary to move the field forward. representation and advocacy for aging science by stakeholders is imperative to protect current availability of geriatric clinical trial research. as scientists consider lasting implications of covid-19, future study design planning and management will likely be altered. specifically, increased utilization of participantcentered design while maintaining rigor and reproducibility is crucial. study design that promotes engagement in a way that meets older adults' unique needs with enhanced ease in access will be needed. current and ongoing recruitment avenues and disaster preparedness plans must acknowledge ways to mitigate decreased contact with older participants who do not use email or computers. further, care for participants that typically occurs during clinical trials under the supervision of medical professionals will need to be adjusted to maintain safety. development, maintenance, and implementation of disaster and business continuity plans within clinical trial design is needed in future planning. mische and wilkerson [5] describe the need for preparation using risk analyses, response during disasters with implementation of essential functions, recovery efforts, and mitigation of losses to clinical trial data and resources. clinical trial continuity for interventions and care of older adults, especially those with cognitive impairment, is paramount. the vulnerability of older adults to covid-19 is a critical reminder for the need to prepare for disasters during clinical trial design. future changes in regulatory and industry perspectives on trial conduct could be profound. new trial design methodologies will need to be developed to take into account significant periods of time for subpopulation and/or total population of subjects that may not be able to conduct regular research activities. our patient population regularly encounters unexpected healthcare, social, and/or personal crises that are considered significant disruptions to smooth research conduct. the potential for increasing recognition of such confounds in interpreting clinical trial data could help to smooth regulatory pathways for studies that encounter such obstacles in the future. scientists face unprecedented challenges with long-lasting impacts due to covid-19. by learning from prior disasters and epidemics, we can be prepared to address current and upcoming changes. the resilience and ability of researchers to move science forward for the success of advanced care for older adults will have benefits for decades to come. increased acknowledgement of a variety of social determinants of health will allow improved efforts to ensure innovative analytic approaches, as well as structures to support the research workforce and opportunities that keep research dissemination and scientific discovery active and productive. covid-19 in older adults when disasters strike: navigating the challenges of "sudden science virus is twice as deadly for black and latino people than whites in n.y.c the national institute on aging-alzheimer's association framework on alzheimer's disease: application to clinical trials disaster and contingency planning for scientific shared resource cores authors' contribution all authors contributed to the design, writing, and revision of the resulting manuscript. authors thank matt hazzard and tom dolan, medical illustrators, university of kentucky-college of medicine for visual contributions.funding the first author is funded by nih t32 ag057461: "training in translational research in alzheimer's and related dementias (triad)". all authors are affiliated with university of kentucky alzheimer's disease cohort participants funded by nih/nia p30 ag028383. availability of data and material is not applicable. conflict of interest the authors declare that they have no conflict of interest. this article does not contain any studies with human participants or animals performed by any of the authors.informed consent for this type of article, formal consent is not required. key: cord-311806-3zy5kgo5 authors: leoni, chiara; giorgio, valentina; onesimo, roberta; tarani, luigi; celli, mauro; selicorni, angelo; zampino, giuseppe title: the dark side of covid‐19: the need of integrated medicine for children with special care needs date: 2020-06-24 journal: am j med genet a doi: 10.1002/ajmg.a.61722 sha: doc_id: 311806 cord_uid: 3zy5kgo5 nan during the coronavirus disease 2019 (covid-19) outbreak, the italian healthcare system dramatically changed in terms of delivery of standard of care. in italy, about 2 million patients are affected by various rare disorders (70% of these are pediatric patients). a multidisciplinary approach is routinely performed in third-level specialized centers in order to provide an assessment of global disease impact and to prevent and manage disease sequelae and comorbidities. against this background context, the covid-19 pandemic completely altered a previously well-organized and carefully planned approach. medical attention was invariably focused on covid-19, overshadowing any other potential clinical issue. families of children affected by rare diseases were often geographically/physical isolated far from their normal treatment centers, and physicians were unable to fulfill their "traditional" role in caring for these patients. in this suddenly and drastically changed system, three main issues have been unmasked; these involve the prevention and management of sequelae and comorbidities in children with rare diseases. we discuss these issues in turn, and describe specific examples we have observed to illustrate these points. in this section, we discuss about how lack of knowledge and experience related to congenital disorders may inadvertently lead to severe medical complications. each genetic condition, especially when the pathogenesis is relatively well known and delineated, is usually characterized by a distinct phenotype and multiple organ involvement; secondary medical complications may frequently impact the everyday life of affected patients. these complications can impact the patient's outcome and the overall family well-being. one crucial role of a physician who is an expert on rare disorders is to recognize the cardinal features related to the syndrome and to be aware of potential complications in order to plan a personalized care plan so as to monitor signs and symptoms, prevent secondary complications, and support interconnections with local healthcare providers. two girls (15 and 25 years of age) affected by classical cornelia de lange syndrome (kline et al., 2018) , with severe intellectual disability, developed gastrointestinal symptoms (vomiting, abdominal pain) associated with irritability. contact of local professionals via the parents led to suspicion of acute gastroenteritis; a rehydration and "watchful waiting" approach was suggested. due to persistent vomiting, and worsening of self-aggressive behavior, the parents phoned the referring expert doctors, who recommended urgent clinical evaluation at local hospitals for suspicion of intestinal occlusion (a common medical complication related to the syndrome); this was offered despite advice to wait for the clinical features' evolution because of issues related to the covid-19 pandemic. bowel occlusion and malrotation was diagnosed in both girls, and large bowel resection was performed. they were both admitted to intensive care unit; the younger girl was discharged after 21 days of hospitalization, while the older one died after 6 days due to sepsis. oropharyngeal swabs were negative for severe acute respiratory syndrome-coronavirus-2 (sars-cov-2) in both. this section refers to how lack of experience about clinical management of specific genetic conditions may affect patient's outcome even angelo selicorni and giuseppe zampino contributed equally to this study. covid-19 in children: initial characterization of the pediatric disease diagnosis and management of cornelia de lange syndrome: first international consensus statement delayed access or provision of care in italy resulting from fear of covid-19 management of osteogenesis imperfecta kabuki syndrome: review of the clinical features, diagnosis and epigenetic mechanisms we want to thank the families who provided the clinical information despite the touching experiences. data available on request from the authors. chiara leoni conceptualized and designed the study, wrote the manuscript, reviewed and revised the final manuscript. valentina giorgio acquired clinical data on case 1 (first patient), reviewed, and revised the manuscript. roberta onesimo drafted and reviewed the article. luigitarani acquired clinical data on case 3, reviewed, and revised the manuscript. mauro celli acquired clinical data on case 2, reviewed, and revised the manuscript. angelo selicorni acquired clinical data on case 1 (second patient), reviewed, and revised the manuscript. giuseppe zampino critically reviewed and revised the manuscript for important intellectual content. all authors approved the final version of the manuscript as submitted and they agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work. https://orcid.org/0000-0002-4089-637xroberta onesimo https://orcid.org/0000-0003-3128-6657angelo selicorni https://orcid.org/0000-0001-6187-3727giuseppe zampino https://orcid.org/0000-0002-2661-4831 key: cord-262784-r9gq2oan authors: tian, suochen; chang, zhenqin; wang, yunxia; wu, min; zhang, wenming; zhou, guijie; zou, xiuli; tian, hui; xiao, tingfang; xing, junmin; chen, juan; han, jian; ning, kang; wu, tiejun title: clinical characteristics and reasons for differences in duration from symptom onset to release from quarantine among patients with covid-19 in liaocheng, china date: 2020-05-12 journal: front med (lausanne) doi: 10.3389/fmed.2020.00210 sha: doc_id: 262784 cord_uid: r9gq2oan objective: this study aimed to identify additional characteristics and features of coronavirus disease (covid-19) by assessing the clinical courses among covid-19 patients in a region outside hubei province. methods: we analyzed retrospective data regarding general characteristics, epidemiologic history, underlying chronic diseases, clinical symptoms and complications, chest computed tomography findings, biochemical monitoring, disease severity, treatments, and outcomes among 37 adult patients with covid-19. according to the duration from symptom onset to release from quarantine, the patients were divided into the ≤20 and >20-day groups, and the similarities and differences between them were compared. results: among the 37 patients, five had mild disease, 30 had moderate disease, one had severe disease, and one was critically ill. all of the patients were released from quarantine, and no mortality was observed. the average duration from symptom onset to release from quarantine was 20.2 ± 6.6 days. the average duration from symptom onset to hospitalization was 4.1 ± 3.7 days, and the patients were hospitalized for an average of 16.1 ± 6.2 days. the average age was 44.3 ± 1.67 years, and 78.4% of cases were caused by exposure to a patient with confirmed disease or the workplace of a patient with confirmed disease. the main symptoms were cough (67.6%), fever (62.2%), shortness of breath (32.4%), fatigue (24.3%), sore throat (21.6%), vomiting, and diarrhea (21.6%). white blood cell count was decreased in 27.0% of patients, and lymphocyte count was decreased in 62.2% of the patients, among whom 43.5% patients had counts of ≤0.6 × 10(9)/l. on admission, 86.5% of patients showed pneumonia in chest ct scans, including some asymptomatic patients, while 68.8% of patients showed bilateral infiltration. in the >20-day group, the average age was 49.9 ± 1.38 years, and the average duration from symptom onset to hospitalization was 5.5 ± 3.9 days. compared with the ≤20-day group, patients in the >20-day group were older and the duration was longer (p < 0.05). all of the seven asymptomatic patients belonged to the ≤20-day group. when the 37 patients were released from quarantine, the white blood cell count of 16.2% of the patients was <4.0 × 10(9)/l, the lymphocyte count of 59.5% of the patients was <1.1 × 10(9)/l, and the absolute counts of white blood cells and lymphocytes were 5.02 ± 1.34 × 10(9)/l and 1.03 ± 0.34 × 10(9)/l, respectively, compared with those recorded on admission (p > 0.05). conclusion: the majority of covid-19 cases in the study area were mild and moderate, with good clinical outcomes. there were some special characteristics in the clinical course. the reasons for differences in the duration from symptom onset to release from quarantine were complex. there was no significant change in the number of granulocytes at the time of release from quarantine compared to that at the time of admission. >20-day group, the average age was 49.9 ± 1.38 years, and the average duration from symptom onset to hospitalization was 5.5 ± 3.9 days. compared with the ≤20-day group, patients in the >20-day group were older and the duration was longer (p < 0.05). all of the seven asymptomatic patients belonged to the ≤20-day group. when the 37 patients were released from quarantine, the white blood cell count of 16.2% of the patients was <4.0 × 10 9 /l, the lymphocyte count of 59.5% of the patients was <1.1 × 10 9 /l, and the absolute counts of white blood cells and lymphocytes were 5.02 ± 1.34 × 10 9 /l and 1.03 ± 0.34 × 10 9 /l, respectively, compared with those recorded on admission (p > 0.05). conclusion: the majority of covid-19 cases in the study area were mild and moderate, with good clinical outcomes. there were some special characteristics in the clinical course. the reasons for differences in the duration from symptom onset to release from quarantine were complex. there was no significant change in the number of granulocytes at the time of release from quarantine compared to that at the time of admission. keywords: covid-19 patients, quarantine, epidemiologic characteristic, clinical characteristic, granulocyte count background previous articles have described the clinical characteristics and outcomes of coronavirus disease (covid-19) (1-6). these mainly reported on early cases diagnosed in hubei province, particularly in wuhan. the limitations imposed by non-optimal medical conditions at that time had some impact on the outcomes and treatment of covid19 . differences have been noted in the clinical characteristics and outcomes of patients diagnosed inside and outside hubei province (1) . one article reported on the early clinical characteristics of 13 covid-19 patients outside hubei province; however, the number of patients was small, and the article only described the early clinical characteristics (7) . liaocheng city, in the middle east region of china, is a prefecture-level city located in shandong province with a population of more than 6 million. as a region outside hubei province, what are the similarities and differences between the characteristics of the cases diagnosed here and those diagnosed in hubei province and even other countries and regions? also, are there any special characteristics of patients who cannot be released from quarantine for a long period? these are a few of the questions that need to be answered. this study thus aimed to identify additional characteristics and features of covid-19 by assessing the clinical courses of covid-19 patients in a region outside hubei province. patient diagnosis, release from quarantine, and disease severity among all cases were determined according to the "protocol for the diagnosis and treatment of novel coronavirus pneumonia" issued by the national health commission of the people's republic of china and the national administration of traditional chinese medicine (8, 9) . a confirmed case was defined by a positive result to real-time reverse-transcription polymerase chain reaction (rt-pcr) assay of nasal and pharyngeal swab specimens (2) . the criteria for release from quarantine for all cases were as recommended in the above protocol, starting with the following three: (1) body temperature returns to normal for more than 3 days, (2) respiratory symptoms improve significantly, and (3) pulmonary imaging shows significant absorption of acute exudative lesions. based on these criteria, quarantined persons could be released if strictly negative nucleic acid test results were obtained after 5 days in the hospital and in tests performed every 2 days. individuals for whom nucleic acid tests yielded negative results when instead tested every 24 h could be released from quarantine if three consecutive test results are negative. during the dynamic test, if cases for whom nucleic acid test results were negative showed positive results, the above steps were restarted. some patients were kept in the hospital for 14 days after they were released from quarantine. severe cases were identified in accordance with the respiratory criteria, excluding those who did not meet the respiratory criteria and required intensive care (10) . one of the 38 patients, a 5-month-old child identified by screening and released from quarantine after 9 days in hospital, was excluded from the analysis. the other 37 patients were all adults. regarding the incubation period and considering the characteristics of the patients in this study, it was difficult to tell the precise time of first infection with sars-cov-2; therefore, this was not discussed. the present study retrospectively analyzed the general characteristics, epidemiological history, chronic underlying diseases, clinical symptoms, complications, chest computed tomography (ct) findings, biochemical features, disease severity, treatment plans, and outcomes of 37 patients. the results of examinations were reported at study time nodes of ±24 h. in addition, these patients were divided into the ≤20-day group and >20-day group according to the duration of release from quarantine. we compared the similarities and differences between the two groups in the clinical process to identify relevant factors among patients who continued to test positive for nucleic acid. continuous variables are expressed as means and standard deviations or as medians and interquartile ranges (iqrs), as appropriate. categorical variables are summarized as counts and percentages in each category. continuous variables were analyzed using the t-test or wilcoxon rank-sum test, as appropriate. categorical variables were analyzed using fisher's exact test. rank classification of variables was performed using the wilcoxon rank-sum test. all statistical analyses were performed using spss version 23.0 (ibm corp., armonk, ny, usa). the duration from symptom onset to admission ranged from 1 to 10 days among the 37 patients with confirmed disease. the shortest length of stay was 7 days, and the longest was 32 days. the shortest duration from symptom onset to release from quarantine was 8 days, and the longest was 34 days. the duration from symptom onset to release from quarantine was 29 days for one patient with severe disease and 11 days for one critically ill patient. according to the pneumonia severity index (psi) on admission, 89.2% (17 + 16/37) of patients were classified as at the low risk grades i and ii. regarding epidemiological history, all of the six patients initially diagnosed had a history of sojourn in wuhan, and patients diagnosed subsequently had mainly been in contact with the confirmed cases or their workplaces. a high proportion of patients had symptoms on admission, including cough, fever, shortness of breath, fatigue, sore throat, vomiting, or diarrhea, and 87.0% of the patients had a low fever. no abnormalities in platelets and levels of creatine kinase or creatinine were observed on routine blood biochemistry tests performed on admission ( table 1) . during treatment, two patients had acute respiratory distress syndrome (ards) (mild, n = 1; moderate, n = 1) (11) and received high-flow nasal cannula (hfnc) oxygen therapy without non-invasive or invasive mechanical ventilation. critically ill patients with moderate ards underwent plasma exchange. no patient experienced serious complications such as shock, kidney injury, pulmonary embolism, or diffuse intravascular coagulation. regarding treatment, one critically ill patient received an antifungal drug, and all patients received two or more antiviral drugs. the order of the rates of application of other therapeutic measures, descending, was as follows: thymosin, oxygen therapy, albumin, hormone, and immunoglobulin. a 100 percent of patients received traditional chinese medicine (tcm), including chinese medicine preparations, acupuncture, and moxibustion ( table 2) . patients in the >20-day group were older and had a longer duration from onset to hospitalization (p > 0.05). regarding the clinical symptoms on admission, all of the seven asymptomatic patients belonged to the ≤20-day group. the rates of the symptoms of fatigue, sore throat, and shortness of breath were higher in the >20-day group ( table 1) . these patients were more frequently treated with albumin and thymus peptide ( table 2 ) and had longer hospital stays ( table 3) . there was no significant improvement in granulocyte counts at the time of release from quarantine compared to the time of admission ( table 4) . although the small number of cases included in this study affected the statistical analysis of some of the variables, many important characteristics were noted. a majority of the 37 patients had mild and moderate disease, with only one severe case, and one critically ill case. all patients were finally released from quarantine without death, and the clinical outcome was significantly better than that observed in hubei province (1, 5, 6, 12) . the main reasons for this may be that the patients had relatively mild disease and that the availability of adequate medical facilities and personnel made the patients less likely to experience severe or critical conditions. after hospitalization, all patients were stratified according to psi, which may be a better strategy to improve the outcome of covid-19 patients, particularly in an outbreak when medical resources are relatively insufficient (13) . although the proportion of patients with chronic underlying diseases in this group was 21.6%, it did not seriously affect the outcome, since most of the patients were about 44 years old. according to the epidemiological histories, some of the patients in this study had been in direct contact with patients with confirmed disease. some worked at the same workplace and did not meet the conceptual standard of close contact, which suggested the existence of a transmission route of covid-19 via aerosol. among these patients, asymptomatic patients constituted 18.9% of all patients. in some patients, a chest ct scan still revealed pneumonia and decreased white blood cell and lymphocyte counts. among the first few symptoms recorded on admission, the rate of shortness of breath and gastrointestinal symptoms was high, which did not exclude the influence of psychological factors. in addition, the proportion of patients with fever was not high, and the rate of fever was low. these characteristics were different from those of other highly infectious viral respiratory infections (14, 15) . among the variables assessed on routine blood biochemistry tests on admission, the most common was a reduction in the lymphocyte count. in nearly half of these patients, the lymphocyte count was ≤0.6 × 10 9 /l. white blood cell counts were mostly normal; less than a third of patients had lower white blood cell counts. other abnormalities with relatively high proportions were the levels of esr, albumin, saa, and crp; however, most of the changes were slight and less specific. thus, a decrease in lymphocyte count may be the most important feature in routine biochemical tests (1, 6) . changes in chest ct scans observed in this group were similar to those observed in other covid-19 studies and were significantly different from the characteristics of h1n1 pneumonia (16) . treatment measures instituted among the patients in this group were mainly performed in accordance with the protocol (8, 9) . although the patients mainly had mild and moderate conditions, their treatment was complicated due to the particularity of the epidemic (17, 18) . two-thirds of the patients were given antibiotics, although there was not sufficient evidence of bacterial infection. although no specific antiviral drugs were recommended, the patients in this group were given antiviral drugs routinely; two-thirds were given two antiviral drugs, and one-third were given three antiviral drugs. the effects of thymosin, glucocorticoid, albumin, and immunoglobulin on covid-19 need to be investigated further, particularly in patients with mild and moderate disease. many studies have demonstrated the important role of tcm in inhibiting coronavirus (19) (20) (21) . although the patients in this study mainly had mild and moderate disease, there were significant differences in the duration from symptom onset to release from quarantine. the most important basis for release from quarantine is the persistence of negative nucleic acid test results. thus, the duration from symptom onset to release from quarantine reflects the time it takes for the virus to be released from the respiratory tract of the patient. the average time from the onset of symptoms to release from quarantine was 20 days. patients could only be released from quarantine after three consecutive negative nucleic acid test results, tests could be performed at 24-h intervals, and the incubation period reported in previous literature was considered (1) ; thus, the average duration of virus release in this study should be similar to that reported by zhou et al. (22) . some items in the ≤20-day and >20-day groups were significantly different, which may explain why the patients could not be released from quarantine for a long time. patients in the >20-day group were older, and the time from onset to admission was longer, suggesting that although there was no specific antiviral drug for covid-19, systematic supportive treatment administered after admission could improve outcomes, even among patients with mild and moderate disease. there were no differences in psi score, underlying chronic disease, or epidemiological history on admission between the two groups, possibly due to the small number of cases or mild illness. regarding symptoms reported on admission, seven asymptomatic patients screened recovered quickly, which may be related to the viral load and individual differences. among symptomatic patients, fatigue and pharyngeal pain were more obvious among patients in the >20-day group, for unknown reasons. in terms of routine blood biochemical examination and pulmonary imaging, although the proportions of individual abnormal indicators in the >20-day group were higher than those in the ≤20-day group, the number of samples was not large enough to yield sufficient clinical significance. there was no significant difference in the number of patients between the two groups, which was related to the fact that almost all the patients had mild and moderate diseases, while one critically ill patient was quickly released from quarantine. these clinical results may suggest that there is a cross relationship between sustained positive test results for nucleic acid to sars-cov-2 observed in respiratory tract specimens and the severity of the disease (1, 22, 23) . however, it was not a linear relationship, and the reasons for the sustained positive nucleic acid test results are complex. the >20-day group received more drugs, which may be related to eagerness to ensure that negative nucleic acid test results were obtained. there was no significant improvement in the white blood cell and lymphocyte counts at the time of release from quarantine and at the time of admission in either the ≤20 or >20-day groups. the reasons need to be studied further. this study had certain limitations. first, the number of cases in this study was not large; it had obvious regional characteristics, and the majority of patients had mild and moderate diseases, which cannot represent the characteristics of a large number of patients in a large geographical range. the study was also not representative of patients with severe and critical conditions. nevertheless, this study can still provide a reference and help in the prevention and control of covid-19 in other comparable smaller-sized outbreaks. most cases of covid-19 recorded in liaocheng city were mild and moderate. the main source of infection was exposure to a patient with confirmed disease or to the workplace of a patient with confirmed disease. the main clinical symptoms were cough, fever, and fatigue; however, shortness of breath, sore throat, and gastrointestinal symptoms were also common. a chest ct scan showing features of pneumonia and a reduced lymphocyte count were the most important adjunctive examination findings. the duration between symptom onset and release from quarantine was related to age, the length of time from onset to admission, and the presence or absence of symptoms and was not related to the mildness or normality of the type. there was no significant improvement in white blood cell and lymphocyte counts at the time of release from quarantine compared to the time of admission. with the permission of the corresponding author, we can provide participant data for further statistical analysis. the study was conducted in accordance with the principles of the declaration of helsinki, and the study protocol was approved by the ethics committee of liaocheng people's hospital. the need for informed consent was waived on account of the retrospective nature of the study. st and tw had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. st and zc contributed to study design and writing. yw, mw, wz, gz, tx, and jx contributed to acquisition, analysis, or interpretation of data. tw, xz, and ht performed critical revision of the manuscript for important intellectual content. jc, jh, and kn contributed to study supervision. clinical characteristics of 2019 novel coronavirus infection in china clinical features of patients infected with 2019 novel coronavirus in wuhan epidemiological and clinical characteristics of 99 cases of pneumonia in wuhan, china: a descriptive study clinical characteristics of 140 patients infected with sars-cov-2 in wuhan characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected 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in wuhan, china the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright © 2020 tian, chang, wang, wu, zhang, zhou, zou, tian, xiao, xing, chen, han, ning and wu. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-318209-llucxztc authors: öztürk, selçuk; elçin, ayşe eser; koca, ayça; elçin, yaşar murat title: therapeutic applications of stem cells and extracellular vesicles in emergency care: futuristic perspectives date: 2020-08-24 journal: stem cell rev rep doi: 10.1007/s12015-020-10029-2 sha: doc_id: 318209 cord_uid: llucxztc regenerative medicine (rm) is an interdisciplinary field that aims to repair, replace or regenerate damaged or missing tissue or organs to function as close as possible to its physiological architecture and functions. stem cells, which are undifferentiated cells retaining self-renewal potential, excessive proliferation and differentiation capacity into offspring or daughter cells that form different lineage cells of an organism, are considered as an important part of the rm approaches. they have been widely investigated in preclinical and clinical studies for therapeutic purposes. extracellular vesicles (evs) are the vital mediators that regulate the therapeutic effects of stem cells. besides, they carry various types of cargo between cells which make them a significant contributor of intercellular communication. given their role in physiological and pathological conditions in living cells, evs are considered as a new therapeutic alternative solution for a variety of diseases in which there is a high unmet clinical need. this review aims to summarize and identify therapeutic potential of stem cells and evs in diseases requiring acute emergency care such as trauma, heart diseases, stroke, acute respiratory distress syndrome and burn injury. diseases that affect militaries or societies including acute radiation syndrome, sepsis and viral pandemics such as novel coronavirus disease 2019 are also discussed. additionally, featuring and problematic issues that hamper clinical translation of stem cells and evs are debated in a comparative manner with a futuristic perspective. [figure: see text] regenerative medicine (rm) is an emerging interdisciplinary field aiming to repair, replace or regenerate damaged or missing tissue or organs to function as close as possible to its physiological architecture and functions. there have been tremendous advancements in this evolving discipline in the past decades including small molecule drugs, cell and gene therapies, and tissue and organ engineering. however, the main focus of rm has been human cells particularly stem cells for years, which may be somatic, adult stem, embryo-derived or reprogrammed cells [1] . stem cells, which are defined as undifferentiated cells retaining self-renewal potential, excessive proliferation and differentiation capacity into offspring or daughter cells that form different lineage cells of an organism, are considered among landmark steps in the evolution of cell-based rm approaches. their distinctive characteristics make them an ideal source for replacing and/or regenerating damaged tissues [1, 2] . briefly, they are classified according to their tissue of origin and differentiation ability. embryonic stem cells (escs) and induced pluripotent stem cells (ipscs) are considered as pluripotent, which means that they can differentiate into all cell types from ectodermal, endodermal, and mesodermal origin, whereas hematopoietic stem cells (hscs) and mesenchymal stem cells (mscs) are examples of multipotent cells that can differentiate into various cell types of a single germ layer [2] . the main goal of stem cell therapies can be summarized as the replacement of dysfunctional or dead cells and tissues with physiologically functioning cells, prevention of further damage, microenvironment modification of the tissue such as antiinflammatory and immunosuppressive activity, and activation of self-regenerative and reparative mechanisms [2, 3] . for these reasons, they have been investigated extensively in various experimental studies and in phase-1/3 clinical trials of cancer, cardiovascular diseases, immune system disorders, neurological diseases, liver, lung, kidney, orthopedic, ocular, urological, skin diseases, etc. [3] [4] [5] . although most preclinical studies have demonstrated encouraging results, translation of stem cell therapies into clinics and success in clinical trials have not been at the desired level yet. except for a few wellestablished indications such as hematological cancers, stem cell therapies have not exactly improved patient outcomes and cured the disease. unfortunately, evidence mostly coming from small, uncontrolled trials and a few well-controlled, randomized clinical studies have still been somewhat not fully satisfactory [6] . extracellular vesicles (evs) are small sized, lipid membrane enclosed, heterogenous membrane vesicles secreted from all cell types, and they comprise three subgroups according to their biogenesis namely exosomes, microvesicles and apoptotic bodies. briefly, exosomes are 40-120 nm sized vesicles resulting from intraluminal budding of multivesicular bodies and fusion of these multivesicular bodies with cell membrane via the endolysosomal pathway. microvesicles are 50-1000 nm sized vesicles secreted from cell surface by budding of the cell membrane. apoptotic bodies, which are out of scope of this review, are 50-2000 nm sized vesicles and released from the cell surface through outward budding of apoptotic cell membrane [7] . there are various isolation methods for evs with their inherent principles, advantages and disadvantages, which are reviewed in detail elsewhere [8] . in addition, lack of individual markers for ev subtypes and their overlapping characteristics regarding size, density and composition make the nomenclature problematic. in this context, the term "extracellular vesicle" is suggested for use as a generic nomenclature to describe vesicles isolated from body fluids and cell cultures by the international society for extracellular vesicles [9] . however, nomenclature issue is still a matter of debate in the scientific community and exosomes, microvesicles and evs have been frequently used interchangeably in the biomedical literature since years [10] . therefore, we chose not to strictly distinguish them and preferred to use the definition "extracellular vesicle" in this review unless otherwise stated in the related article. evs carry various types of cargo between cells which make them vital mediators of intercellular communication. ev cargo encapsulated within a lipid membrane consists diverse combinations of proteins, lipids, peptides, carbohydrates and nucleic acids including dna, mrna, microrna (mirna) and long noncoding rna, allowing transmission of biological signals between cells. they represent the native characteristics of donor cell resulting with de novo gene expression, posttranslational modification or new transcript translation in the recipient cell [11] . not only they regulate the physiological processes in cells, they are tightly linked to various disease pathogenesis. evs are secreted by all cell types in the organism and can be detected in all body fluids, which make them an attractive source for biomarker investigations. because they carry cargo between cells, they can be ideal candidates to be utilized as carriers for drug delivery [7, 12] . in addition, their inherent role in pathological conditions highlight their potential role as novel targets for therapeutic interventions as cell-free therapies in various diseases [7, 11, 12] . given the prolonged human life and survival expectancy, the number of people requiring emergency care and emergency department admissions are increasing all over the world [13, 14] . these mostly include trauma patients, cardiovascular disease, neurological disease patients and patients suffering from organ failures such as acute respiratory failure or thermal burns. in addition, biological or chemical threats causing mass casualty situations such as pandemics, sepsis, and radiation related incidents are significant issues for communities, militaries and local medical systems. although rm approaches including stem cell applications and ev based therapies are in their infancy hitherto, they promise as novel therapeutic targets from a futuristic perspective (fig. 1) . in this context, this review aims to summarize and discuss the therapeutic potential of stem cells and evs in patients suffering from diseases requiring acute emergency care. trauma related injury is a significant cause of mortality and disability all over the world. despite the reductions in mortality from cancer and cardiovascular diseases in the last years, death rates from trauma have remained constant. however, there have been significant achievements in the management of trauma patients including timely prehospital care, rapid diagnostic tests, hemorrhage control, transfusion and surgical approaches. traumatic brain injury (tbi), spinal cord injury (sci), chest trauma, abdominal trauma and musculoskeletal injuries are among subtypes of traumatic injuries. the most common causes of death from traumatic injuries include tbi and hemorrhagic shock [15, 16] . besides being an important civilian health issue, trauma related injuries are also a significant concern for militaries in time of war [17] . in general, trauma causes structural damage to tissues, disrupts perfusion and provokes inflammation subsequently resulting with irreversible tissue damage, loss of organ function and finally death. host defense response, which involves local and systemic release of acute phase proteins, proinflammatory cytokines, metabolites and hormonal mediators, plays major role in the clinical outcomes including mortality after trauma [18] . optimal healing in a tissue after a traumatic injury can be provided by the reversal to preinjury situation and function without scarring and is associated with the nature and degree of the traumatic injury, intrinsic biological activity and regenerative capacity of the affected tissues. theoretically, optimal healing can be accomplished by optimizing the healing process through augmenting patient biology. due to their abilities to modulate inflammation, cell death, vascular dysregulation and tissue damage, which also underlies the complex and heterogeneous pathogenesis of traumatic injury, stem cell therapies may hold a promise for promoting organ and tissue repair after a traumatic process including civilian as well as military populations [19] [20] [21] . for these purposes, the therapeutic potential of stem cells have been widely investigated in various preclinical models of trauma such as tbi, sci, musculoskeletal injury, circulatorypulmonary tissue injury, skin injury, postinjury organ failure and ocular-auditory injuries with encouraging results [19] [20] [21] [22] [23] [24] . mscs from various tissue sources and donor types have been the most investigated cell type in animal models of trauma. their beneficial effects in trauma can be summarized as migration and integration into the site of injury and respond to immunostimulatory molecules defined as damageassociated molecular patterns. besides, they generate an anti-inflammatory and pro-regenerative microenvironment through secreting factors that activate the growth and differentiation of adjacent cells, stimulate angiogenic activity, regulate functions of endothelial cells and fibroblasts, and inhibit fibrosis [25] . a previous systematic review and meta-analysis study investigating the efficacy of msc transplantation in animal models of tbi suggested that mscs might have beneficial effects on locomotor recovery [26] . likewise, systemic and local administration of allogeneic bone marrow (bm)-mscs promoted fracture healing in rats [27] . percutaneous intraspinal injection of autologous neurogenically-induced bm-mscs provided clinical benefits in paraplegic dogs lacking deep pain perception after spinal trauma in a study performed by our research team previously [28] . our research group also demonstrated that msc infusion is associated with improved local inflammation and histological findings in rats subjected to polytrauma model comprising bone fracture and liver trauma [29] . clinical data of stem cell therapies in trauma patients mostly come from tbi and sci patients. a phase-1 clinical trial investigating autologous bm-derived mononuclear cell (bm-mnc) infusion in pediatric tbi patients indicated that fig. 1 main pathological conditions requiring acute emergency care that can benefit from stem cell therapies or extracellular vesicle therapies in the future harvesting and infusion of stem cells is safe in children with no infusion related toxicity or death [30] . a retrospective analysis of this study with age-and severity-matched control group demonstrated that stem cell therapy is associated with lower treatment intensity required to manage tbi in children [31] . another phase-1/2a trial conducted by the same group evaluated the safety and efficacy of autologous bm-mnc infusion in adult tbi patients and demonstrated the safety and feasibility of cell treatment. there was a potential signal of treatment effect regarding structural preservation and down-regulation of inflammatory biomarkers after cell infusion [32] . autologous bm-msc therapy was also proven to be safe and effective when administrated through lumbar puncture in the subacute stage of tbi [33] . there are also ongoing clinical trials evaluating the therapeutic effects of stem cells in tbi patients in which the results are highly anticipated and briefly summarized in the related papers [34, 35] . there have been numerous clinical studies testing stem cells for neuronal repair in sci patients. human escderived oligodendrocyte progenitor cells were transplanted to sci patients into the site of injury in a phase-1 trial sponsored by geron corp., but the study was halted. although complete results have not been published, it was announced that there were no safety issues regarding cell treatment. the study has been in progress under the direction of another company [4, 36] . besides, bm-mscs have been investigated in many clinical trials of sci with diverse study designs and outcomes. although no adverse reactions or side effects were reported, favorable outcomes were limited in these studies compared to expectations. among these studies, few of them appeared to encourage cell therapy in sci patients. there are also ongoing clinical trials which will probably improve our knowledge about the clinical effects of stem cells in sci treatment [37] . increasing line of evidence suggests that beneficial effects of stem cell therapies are mediated through evs and their mirnas released from the transplanted cells. this evidence raises the possibility that instead of cell transplantation, evs can be used for the treatment of several traumatic injuries as cell-free agents. evidence demonstrating that severe traumatic injury is associated with elevation of circulating procoagulant and proinflammatory evs underlies the significance of evs in trauma patients [38] . however, our understanding about their therapeutic role in trauma comes from animal model studies. for example, a recent study showed that administration of exosomes derived from human bm-mscs improve functional recovery of injured animals after tbi [39] . likewise, exosomes from bm-mscs improved fracture healing in a rat model of femoral nonunion through enhancing osteogenesis and angiogenesis [40] . due to encouraging preclinical data coming from several works, they have been suggested as an alternative cell-free treatment in several subtypes of trauma including bone fractures [41] and neurotraumas [42, 43] . the mechanisms underlying the beneficial effects of evs in trauma may be the modulation of immune system and systemic inflammatory response that occurs in the acute phase of trauma. besides, increased angiogenesis and vascular density, prevention of cell death, transfer of their cargo between cells, stimulating endogenous reparative mechanisms might mediate their therapeutic functions [43] . however, lack of clinical data especially in polytrauma patients hampers to make a clinical judgement about possible therapeutic applications of evs in traumatic injuries. coronary heart diseases including acute myocardial infarction (ami) and the leading heart failure (hf) are the main causes of mortality all over the world and constitute a major problem of global health causing frequent acute hospital admissions and hospitalizations. although long term survival of ami and hf patients has improved thanks to improvements in coronary interventions, medical treatments and surgical therapies, prognosis is still poor and admission to emergency departments, hospitalization rates and economic costs are high [44, 45] . the main pathophysiological mechanism of poor outcomes in ami and hf patients is the lack of adequate cardiomyocyte renewal capacity in the failing heart and formation of a fibrotic scar tissue in the infarcted myocardium with progressive cardiomyocyte death subsequently resulting with pump failure. besides, none of the current treatment strategies except heart transplantation can reverse these mechanisms back and induce a true regeneration in the heart [46, 47] . in recent decades, cell-based therapies including skeletal myoblasts, bm-derived stem cells, mscs, cardiac progenitor cells and pscs have been investigated in order to generate new and functional myocardial tissue and/or activate endogenous repair mechanisms in the heart. after encouraging preclinical studies with small and large animal models, the regenerative potential of these cells have been tested in multiple clinical trials with miscellaneous results and heterogenous outcomes which may be attributed to diversities in study designs such as cell types, cell preparation techniques, delivery route, dose, timing of application, study endpoints and followup methods of patients. in brief, there have been no safety issues regarding these cell therapies, but their efficacy has mostly been neutral or at most marginally positive outcomes [46] [47] [48] . among adult tissue sources, mscs preferably obtained from bm or adipose tissue might be promising due to their high secretory profile and paracrine effects. in addition, cardiac cells derived from pscs may provide superior benefits when compared to other cell types although comparative studies are needed to support this hypothesis. it should also be kept in mind that the use of pscs are restricted due to ethical issues and/or teratoma formation risk although they have a robust differentiation potential than other cell types [48, 49] . evidence mostly coming from large animal models also points to arrhythmogenic potential of cardiomyocytes derived from pscs [50] . a recent phase-1 study investigated the safety of fibrin patch embedded cardiac progenitor cells derived from human escs in six severe hf patients. the results of the study demonstrated short-and medium-term safety and technical feasibility of the surgical procedure pioneering future efficacy studies [51] . initially, the hypothesis that the transplanted stem cells reach their target tissue, differentiate into cardiomyocytes, engraft into the host myocardium electromechanically and improve cardiac functions was thought to be the main mechanism for therapeutic effects of stem cells. however, subsequent researches demonstrated that cardiac differentiation and engraftment of stem cells into the myocardial tissue are very rare [52, 53] . the recognition that stem cells secrete a variety of evs that act in a paracrine manner and these evs mediate the beneficial effects of stem cells has shifted the stem cell paradigm into a new concept defined as "paracrine hypothesis" [54] . exosomes, specifically secreted from pscs and mscs, were shown to exert regenerative effects in the heart and vasculature by modulating apoptosis, inflammation, fibrosis and angiogenesis [55] . besides, beneficial effects of these secretomes released from other stem cell populations such as cardiac and endothelial progenitor cells (epcs) in the cardiovascular system were demonstrated. accordingly, they have been suggested as a potential cell-free therapy to regenerate the diseased heart instead of stem cell applications [54, 55] . cardioprotective effects of evs and exosomes have been investigated in several preclinical models including mi [56] [57] [58] and chronic hf [59, 60] rendering the potential of these cell-free agents as therapeutic biological medications. besides, a recent study compared the cardiac regenerative effects of intramyocardially-injected ipscs and ipscderived evs in a murine mi model and demonstrated that ipsc-derived evs are safer than ipsc injection in regard to teratoma formation. on the other hand, ipsc-derived evs exhibited superior cardiac repair effects than ipscs in terms of left ventricular function, angiogenesis, reduction of apoptosis and hypertrophy [58] . an immunocompetent mouse mi model study to investigate the immunological effects of evs obtained from human cardiac progenitor cells demonstrated that intramyocardial delivery of these evs does not induce an allogenic immune response and likely to have a systemic antiinflammatory effect. however, the hypothesis that whether the systemic delivery of evs would trigger similar antiinflammatory effects with positive outcomes on heart functions needs to be tested in future studies which might intensify and accelerate the clinical translation of therapeutic ev applications [61] . accumulating evidence suggests that cardioprotective effects of evs are mostly mediated through specific mirnas [62] . they carry information and mediate the cross-talk between cells in tissue of interest such as cardiomyoctes, stem cells, endothelial cells, smooth muscle cells, fibroblasts and others to modulate cellular changes and disease phenotypes. there are numerous cardiac-related mirnas in the heart, which are secreted from various sources of cells with varying functions such as enhanced cardiomyocyte survival and functions, attenuation of cardiac fibrosis, induction of angiogenesis, inhibition of apoptosis and oxidative stress, and regulation of sarcomeric genes and ion channel/automaticity genes [62] [63] [64] [65] . stroke is a serious neurological condition with high mortality and disability rates worldwide [66] . ischemic stroke, which occurs suddenly due to thromboembolic occlusion of a major artery that supplies blood to the brain, represents the most common type and requires restoration of blood flow immediately. thrombolytic agents and endovascular mechanical thrombectomy are the only treatment options to achieve recanalization with their limited therapeutic time window and side effects such as risk of hemorrhage [67] . on the other hand, hemorrhagic stroke occurs secondary to rupture and bleeding of a vessel in the brain and requires immediate surgery to remove clots and blood and decrease intracranial pressure [68] . irrespective of stroke origin, the integrity of neurovascular unit, which includes numerous cellular components and tissue-related proteins, is impaired in the early times of stroke leading to disruption of blood-brain barrier (bbb) and ischemic cell damage. from a pathophysiological perspective, a series of molecular and cellular pathways are activated during this process such as inflammation, apoptosis and oxidative stress-related pathways subsequently resulting with neuroinflammation, neurodegeneration and irreversible tissue injury. the aforementioned therapies can improve neurological functions and mortality in the acute phase of stroke but their therapeutic effects are limited in the subacute and chronic stages [69] . it is known that some stroke patients show spontaneous recovery owing to limited plasticity and remodeling capacity of the brain. therefore, activation of intrinsic reparative processes in the brain may promise as a therapeutic strategy for stroke theoretically. there is also increasing evidence that stem cells, particularly neural stem cells located in the brain niches, contribute to remodeling and recovery processes by activating angiogenesis, neurogenesis and neuroprotection after stroke, subsequently provoking improved neurological outcomes [69, 70] . in this context, stem cell therapies with their wider therapeutic window may represent a new treatment paradigm to ameliorate the subacute and chronic phases of stroke. beyond stem cells, exosomes are known to regulate intercellular communication between neurovascular system and other system cells and contribute to brain repair processes after stroke putting forward them as promising cell-free agents in stroke therapy [42, 70, 71] . the regenerative potential of various types of stem cells, with different sources, dosages, delivery routes, application times and end-points has been investigated in preclinical animal models and human clinical trials with the expectation that these cells would successfully engraft into the damaged brain tissue, differentiate into functional neuronal and vascular system cells and promote full recovery after stroke. a recently published systematic review of 76 studies testing stem cells in rodent ischemic stroke models and 4 randomized human clinical trials encompassing ischemic stroke patients treated with autologous stem cells with at least one year follow-up period demonstrated that stem cell therapies show beneficial effects in terms of behavior and histological outcomes in rodents. pooled data of 4 human clinical trials failed to show functional recovery although there were some improvements in terms of neurological outcomes [72] . likewise, translational deficiency was observed from animal models to clinical studies in a systematic review and meta-analysis study investigating the efficacy of mscs in subacute or chronic ischemic stroke [73] . therapeutic applications of evs for stroke may confer some pros when compared to stem cell applications, which are discussed in detail in the subsequent sections of this paper and related review articles. emerging evidence indicates that the neurorestorative effects of stem cells are mediated through release of exosomes and their mirna cargo instead of integration into neural networks [42, 70, 71] . besides, exosomes mediate dynamic cross-talk between neural system cells and endothelial cells [42] . comparative studies of stem cells and evs in stroke treatment mostly come from animal models. a previously published study demonstrated that msc-derived evs have similar functional tissue regeneration capacity as mscs in mice subjected to stroke [74] . another rat stroke model study indicated that msc-derived evs possess better rehabilitation effects than msc treatment in stroke repair which might be due to higher bbb permeability of evs compared to mscs [75] . in a recent study, systemic application of msc-derived exosomes loaded with mirna-124 was shown to stimulate cortical neural progenitors to obtain neuronal identity and ameliorate ischemic injury by cortical neurogenesis in mice subjected to stroke suggesting a great potential for clinical translation [76] . accordingly, a phase 1-2 clinical trial (nct03384433) aims to investigate the safety and efficacy of allogenic bm-msc-derived exosomes genetically enriched with mirna-124 in ischemic stroke patients. the primary endpoint is safety including treatment-related adverse events in 12 months such as deteriorating or recurrent stroke, brain edema, seizures and hemorrhagic transformation. the secondary endpoint is efficacy measured by the improvement in the modified rankin score at 12 months. the results of the study have not been posted yet and are awaited. acute respiratory distress syndrome (ards), in other words acute respiratory failure, is a life-threatening acute lung injury characterized by diffuse alveolar damage and hypoxemia in the lungs with high morbidity and mortality rates [77] . among several inciting events such as toxic substance inhalation, trauma, burns and pneumonia, sepsis is the most common cause of ards. a complex interaction between the immune system and the alveolar-capillary barrier, and widespread uncontrolled inflammation in the lungs underlies the pathophysiology of the disease. treatment of ards patients relies on supportive strategies such as mechanical ventilation, fluid management, neuromuscular blockade and prone positioning, because there is no specific pharmacological therapy proven to be effective and reduce mortality in this patient group [78, 79] . in fact, numerous pharmacological agents such as surfactant, nitric oxide, corticosteroids, antifungals, phosphodiesterase inhibitors, antioxidants and immune modulating agents have been attempted in acute lung injury and/or ards with unfavorable outcomes and no effect in mortality [80] [81] [82] . therefore, novel therapies for treating or preventing ards are highly needed. stem cells yield substantial promise as a novel treatment strategy for ards patients due to their differentiation abilities to various cells, immune system modulation and antiinflammatory characteristics [83] . for this purpose, various type of stem cells such as mscs, epcs, escs, ipscs have been investigated in preclinical models with encouraging results. among all cell types, mscs obtained from different sources mostly bm and umbilical cord (uc) have attracted much more attention than other cell types. mscs have been shown to modulate anti-inflammatory and antiapoptotic pathways, ameliorate epithelial and endothelial cell recovery, and increase microbial and alveolar fluid clearance in several animal models of ards. these beneficial effects of mscs resulting with improved lung and distal organ functions and survival have moved msc therapies to a clinical stage [79, 83, 84] . a previous case report of an ards patient demonstrated short term beneficial effects of uc-msc treatment although the patient could not survive in the long-term period [85] . likewise, allogeneic bm-mscs were demonstrated to improve hemodynamic status and multiorgan failure of two severe ards patients who did not respond to treatments such as mechanic ventilation and extracorporeal membrane oxygenation. besides, clinical improvement of these patients was shown to be mediated through reduction of several pulmonary and systemic inflammatory markers [86] . a previous phase-1 trial of allogeneic adipose tissue-derived msc treatment in ards patients demonstrated safety of systemic infusion with limited efficacy [87] . according to the results of another phase-1 dose escalation trial, allogeneic bm-msc infusion was well-tolerated and there were no infusion related adverse events in moderate to severe ards patients [88] . subsequently performed phase-2a trial by the same group with a single intravenous infusion dose (10x10 6 cells/kg) of allogeneic bm-mscs demonstrated safety of the treatment. when it comes to efficacy, there were no differences between the placebo and cell-treated groups in terms of clinical outcomes. however, there was a tendency for improvement in oxygenation index in cell-treated group. according to biomarker measurements, endothelial injury was significantly improved in cell-treated patients, and msc viability after thawing emerged as a potentially important factor for the efficacy of cell treatment [89] . although stem cells promise an emerging role for ards treatment, it is known that secretion of soluble mediators acting in a paracrine manner such as evs, which are also highly abundant in the conditioned medium of stem cells, mediate the therapeutic effects of these cells. besides, evs secreted from various type of cells are closely linked with the pathogenesis of ards. therefore, in recent years there has been a growing interest in exploring the effects of evs specifically derived from mscs in ards treatment. the biological rationale for the therapeutic use of these cell-free agents is comparable to stem cells including immune modulation and antiinflammatory effects, promoting alveolar epithelium and endothelium repair, alveolar fluid clearance improvement, antimicrobial effects and inhibition of lung fibrosis [90, 91] . preclinical studies investigating evs in ards as a therapeutic approach are in their infancy yet but several encouraging reports indicate that evs derived from stem cells confer similar beneficial effects when compared to administration of stem cells themselves [90] [91] [92] . management and treatment of ards has attracted much more interest than previous times because of the pandemic of novel coronavirus disease 2019 (covid-19) pneumonia, which has spread worldwide in a very short time. clinical course of this viral infection may progress to ards and death, and there is no effective pharmacological therapy or vaccine yet. increased inflammatory situation with cytokine activation named as cytokine storm underlies the pathogenetic mechanism of infection. due to close intersection between the disease pathogenesis and mechanism of action of stem cells regarding immune modulation and anti-inflammatory activity, stem cells and/or their secretomes have been considered as a possible therapeutic agent for covid-19 pneumonia [93, 94] . a recent case study of a severe covid-19 pneumonia patient reported improved clinical course and inflammatory biomarker levels after human uc-msc infusion [95] . likewise, clinical grade msc infusion was reported to be safe and effective in a pilot study including seven covid-19 pneumonia patients. laboratory tests of these patients demonstrated improved inflammatory status and according to in-vitro tests infused mscs were not infected with the virus [96] . in addition to these reports, there are several registered clinical studies to test stem cells, specifically mscs obtained from diverse sources, in covid-19 pneumonia patients. among these recorded studies, two of them (chictr2000030484 and nct04276987) aim to investigate therapeutic potential of exosomes [97, 98] . the results of these studies are highly anticipated. in parallel with ards, treatment of sepsis and septic shock is an unmet medical need. despite intensive efforts to decrease morbidity and mortality associated with sepsis, there is no specific therapy yet and management includes symptomatic approaches. in addition, it is the most common cause of ards. altered immune homeostasis with a hyperinflammatory response and subsequent immune suppression are the main pathophysiological processes during the initiation and progression of the disease [99] . mscs have been supposed to have beneficial effects in sepsis through different ways depending on the origin such as bacterial or viral sepsis. their immune and inflammation modulating capacity, antibacterial actions and organ protective effects, which have been demonstrated in various animal models of sepsis with varying outcomes, yield msc therapies as an attractive cure for sepsis and septic shock [100] . a recent pilot clinical trial showed that single dose msc administration was safe and well-tolerated in neutropenic patients with septic shock. although msc therapy was associated with improved outcomes such as faster hemodynamic stabilization, vasodepressor withdrawal, improvement in respiratory failure and decrease in neutropenic period, it did not prevent death from the sepsis related organ failure [101] . however, a meta-analysis study evaluating the efficacy of msc therapies in animal models of sepsis demonstrated lower mortality rates underlining the potential therapeutic effects of mscs in sepsis and the need for future studies [102] . on the other hand, evs as cell-free agents and/or drug carriers may have therapeutic functions in sepsis. animal model studies are promising but the need for further preclinical and clinical data comes to the fore [103] . radiation-related nuclear accidents or weapons have been a growing concern worldwide since the past century due to the fact that they are associated with high morbidity and mortality rates in affected societies [104] . acute radiation syndrome (ars) refers to a wide spectrum of clinical conditions occurring in stages during hours to weeks after a large portion of the body is exposed to a high dosage of ionizing radiation thereby altering organ and tissue functions at varying levels. although bm toxicity and myelosuppression have been considered as the major causes of morbidity and mortality, ars is also accompanied by gastrointestinal failure, neurological damage and multiorgan dysfunction. from a pathophysiological point of view, acute ionizing radiation exposure disrupts physiological recovery of cellular systems through the depletion of radiosensitive stem cells and genotoxic damage [105, 106] . it is also a challenging issue for health care providers to identify and appropriately treat highly exposed victims in a real-life situation where a large number of community are exposed to high doses of radiation and exceed the limited capacity of local medical systems [105] . management of ars generally includes prophylaxis and therapy of infections, detoxification, parenteral nutrition, topical and surgical therapies for damaged skin, correction of secondary toxic metabolic disturbances, and bm transplantation including growth factors and hsc transplantation in selected patients [107] . given that exposure to high doses can be fatal in hours to weeks, palliative care may also be required. prognosis mostly depends on recovery of the bm and cell transplantation should only be considered if growth factors fail to reconstitute the hematopoietic system [106] . beyond the preclinical animal model studies demonstrating favorable effects of stem cell therapies in ars [108] [109] [110] , our understanding about the clinical outcome of stem cell transplantation in ars patients mostly comes from previous tragic nuclear accidents and natural disasters. clinical data of these victims concluded that the survival benefit of cell transplantation is limited probably due to late administration time, graft rejection, accompanying organ failures and inhomogeneous radiation exposures [111, 112] . therefore, hsc transplantation is only recommended if severe aplasia persists despite cytokine treatment in ars patients [106, 113] . despite these limitations, stem cells have an immense potential to combat the early and late complications of radiation exposure. besides taking a role in hematopoietic system reconstitution, they can also impact the recovery of neurological, pulmonary, gastrointestinal system organs and cutaneous wounds, which are highly affected after radiation exposure in acute and long term. mscs isolated from the bm and uc have been at the forefront of investigations [111, 112] . local autologous bm-msc administration was associated with a favorable clinical outcome and no recurrence of radiation inflammatory waves during eight month follow-up of a patient suffering from ars with very severe radiation burns [114] . currently, there is not any stem cell product approved by the regulatory authorities for radiation injuries to use in the context of a mass casualty incident. however, intramuscular injection of human placenta-derived plx-r18 cells developed by pluristem therapeutics, inc. was associated with improved survival in mice after radiation injury suggesting that plx-r18 cells may be beneficial for ars treatment [115] . similarly, clt-008 cells derived from myeloid progenitors and developed by cellerant therapeutics, inc. improved survival in irradiated mice suffering from hematopoietic and gastrointestinal subsyndromes of ars even cell treatment initiated days after irradiation [116] . these two "off-the-shelf" products developed by different companies appear to be promising for future clinical applications of ars after a mass casualty radiological or nuclear incident. our knowledge about the therapeutic role of evs in ars is limited yet and entirely origins from preclinical studies. however, there is a growing body of evidence that these cell-free agents play role in radiation-induced genomic instability and bystander effects suggesting a possible pathogenetic effect of these molecules in radiation injury [117] [118] [119] . exosomes derived from bm-mscs and endometrial regenerative cells were demonstrated to increase proliferation of thymidine-incorporated hscs in a previous experimental work [120] . human neural stem cell-derived microvesicles were able to reverse or prevent radiation-induced cognitive dysfunction in brain-irradiated mice suggesting a possible therapeutic effect of microvesicles for radiation-induced injury in the brain [121] . culturing macrophages with exosomes derived from lipopolysaccharide-primed mscs was shown to improve survival through hematopoietic system recovery in a mouse model of ars [122] . in the light of these data, it might be reasonable to suggest that evs may be an attractive approach in ars treatment with the help of future studies as discussed in a workshop held in france in july 2015 cosponsored by national institute of allergy and infectious diseases and institut de radioprotection et de sûreté nucléaire [111] . burns exert significant consequences in the community including death, disability, economic and social loss. a significant portion of burn cases occur in low-to middle-income countries. there are various types of burns according to the origin, but thermal burns are the most common type of burn injuries [123] . in addition, thermal burns are a significant cause of morbidity during war time accounting approximately 5% to 20% of conventional war casualties [124] . appropriate wound healing of the damaged skin constitutes an important part of the healing process in acute full-thickness burns. skin grafts and skin substitute products containing somatic cells are widely used for this purpose with their inherent limitations such as lack of enough skin to cover the burns and/or effectiveness. considering the challenges of available therapies and systemic consequences of burns, it is evident that rm approaches to treat acute burn injuries are essential [20] . cutaneous tissue maintains robust regeneration capacity and various stem cell types such as interfollicular epidermal stem cells, hair follicle stem cells, sebaceous gland stem cells, melanocyte stem cells and neural progenitor cells that reside in different compartments of the skin [125] . skin wound healing includes coordinated complex series of overlapping events occurring in four phases namely hemostasis, inflammation, proliferation and remodeling. stem cells of the skin and other organs play role at all these stages in a coordinated fashion to regenerate the skin. however, several factors influence this process such as the degree and size of burn, patient related conditions such as age, immune status and comorbid situations, and materials covering the burn wounds [125, 126] . in this context, autologous or allogenic stem cell therapies might emerge as a promising and effective treatment strategy both for wound healing and systemic effects of the burns such as inflammation, hypermetabolism and immune suppression. various stem cell types from different sources, especially mscs have been investigated for this purpose [127] . a phase-1 clinical trial (nct02104713) collaborated by united states department of defense aims to investigate the safety of allogenic msc application to second degree burn wounds. in addition, the study aims to investigate maximum safe dose that will be used in phase-2 investigations. the estimated study completion date is february 2020 and the results have not been posted yet. another phase 1-2 clinical trial (nct01443689) aimed to investigate the safety and efficacy of allogeneic human uc-mscs and human cord blood mncs in patients with acute moderatesevere full thickness burn but the results have not been published although the estimated study completion date was july 2013. in addition to these studies, there are several clinical trials evaluating therapeutic effects of stem cells in cutaneous burn injury patients recorded in the national institute of health clinical trials website with various study protocols, cell types and outcomes, in which the results are highly anticipated. evs and their related mirnas are known to modulate therapeutic effects of stem cells. therefore, they have been suggested as alternative cell-free agents for the treatment of burn injuries. similar to stem cells, various evs have been demonstrated to play role in the pathophysiological processes of burn wound healing at all stages. their therapeutic role has also been tested successfully in various animal model studies, being msc-derived exosomes or evs the prevailing source of origin [128, 129] . a phase-1 clinical trial (nct02565264) aiming to investigate the beneficial effect of plasma-derived exosomes in cutaneous wound patients with ulcer is currently in enrollment status. although the study protocol does not specifically include acute burn injury patients, the results of this study may shed light on our knowledge about possible therapeutic potential of evs in cutaneous burn injury patients. rm holds an immense potential for a variety of diseases in which there is a high unmet clinical need. despite the relatively slow rate of translational success from laboratory to clinics, expectations, optimism and excitement surrounding this field remain great. rm involves cell and gene therapies, and tissue engineering applications, however stem cells have been at the center of interest for years because of their biological potential [1, 3, 130] . on the other hand, secretomes of cells namely evs have attracted great attention as therapeutics in recent years and have been suggested as alternative to stem cell therapies as cell-free agents [7, 12] . there are many challenges that need to be addressed in order to improve translation of stem cell therapies and evs into clinical practice with sustainable and clinically significant benefits. however, it is obvious that both stem cell therapies and ev therapies are in their infancy ages with their inherent and/or similar pros and cons which are briefly summarized in table 1 . bioprocessing of stem cells for transplantation relies on successful isolation from the donors and this can be achieved by either an autologous or allogeneic source. in autologous transplantation, stem cells are obtained from the patients' own tissue which does not carry a risk for immune rejection but need sufficient time in order to obtain high quality cells with adequate numbers. in addition, isolation procedure involves an invasive and painful procedure and obtaining cells with high quality may be problematic because of impaired stem cell functions in patients with comorbid diseases and genetic alterations. this limitation might be specifically evident in aged and frail patients. on the other hand, allogeneic stem cells are isolated from healthy individuals and expanded in large numbers and efficient quality. they can be stored and administered as "off-the-shelf" products, which make them an attractive option for acute emergency conditions and mass casualty settings and enable diverse and multiple dosing strategies (fig. 2) . however, allogeneic cell transplantation requires immunological matching between host and donor [131] . it is reasonable to question which stem cell source is superior to another. for example, comparison of autologous and allogeneic stem cells in large animal models of ischemic heart disease showed similar effect size [132] . likewise, allogeneic and autologous bm-mscs compared in randomized clinical trials demonstrated no significant difference in terms of safety and improvement in left ventricular ejection fraction in ischemic cardiomyopathy and nonischemic hf patients [133, 134] . a preclinical meta-analysis study of stem cells for experimental stroke showed that autologous cells were better than allogeneic cells to ameliorate infarct volume, whereas allogeneic cells were better for improving functional outcomes [135] . according to another meta-analysis study investigating mscs in locomotor recovery of rat models of sci, cell source was a significant predictor of improved outcome as autologous and allogeneic cells performed better than xenogeneic and syngeneic cell sources [136] . such comparative studies have not been performed with regards to ev therapies yet. although first clinical studies tested autologous dendritic cell-derived exosomes in cancer patients [137, 138] , the field has shifted to allogeneic sources and most companies are developing allogeneic products because of difficulties of harvesting autologous evs in sufficient quantities [11, 139] . in this context, a previous clinical case of a graft-versus-host disease patient refractory to steroid therapy indicated promising outcomes after allogeneic mscderived ev administration [140] . stem cells are a group of heterogeneous cells that have the ability to self-renew and differentiate into mature cells through asymmetric cell division [3] . among all stem cell types, mscs are numerically the most used cell type in preclinical and clinical settings. they are considered as the ideal cell type for transplantation. this may be due to their pleiotropic properties such as antiapoptotic, antifibrotic, anti-inflammatory and angiogenic activities, growth factor production, and immune system modulation in addition to their differentiation capacity to various cells of lineages. their immune privileged abilities also render mscs an ideal source for allogeneic applications [4, 5] . mscs can be obtained from various sources of tissues in the body including but not limited to bm, adipose tissue and uc. when compared among themselves, adipose tissuederived mscs seem to be ahead because of higher number of cells per gram of tissue, higher cell proliferation rate compared to others and technical convenience to obtain cells [141] . in the light of these advantages, it is reasonable to suggest that adipose mscs may be an ideal source for acute emergency conditions as well as autologous applications. however, tissue source of mscs may be a challenging task for translational activity. for example, a recent study demonstrated that mscs obtained from adipose tissue are more efficient than those obtained from uc and endometrial tissue in terms of in-vitro and in-vivo angiogenic activity [142] . likewise, neuro-regenerative potential of mscs derived from human bm, adipose tissue and wharton's jelly was shown to be non-equal in a recent study. although bm-mscs were inefficient than other cell types in terms of neurotrophic growth factor secretion and gene expression, secretome of all cell lines had pronounced neurotrophic potential regarding composition and in-vitro paracrine activity [143] . pscs, namely escs and ipscs, hold the potential to differentiate into all cells in the organism and are considered as the future of cell transplantation. however, they possess two despite the fact that escs are obtained from an embryo, there remain ethical problems and restrictions with their use. in fact, ipscs were generated to overcome ethical issues surrounding escs but both of these cell types also carry a risk for teratoma formation which limit their translation into clinics [1] [2] [3] . preclinical data suggest that mscs derived from ipscs have superior effects than bm-mscs to attenuate lung disease in rats [144] . the first human clinical trial using ipscs focused on macular degeneration, but the trial was suspended because of legal issues after the first patient was treated with autologous ipscderived retinal pigment epithelium cell sheet. in addition, genetic alterations were detected in the ipscs of the second patient and transplantation was canceled. there was no safety concern including tumor formation and immune rejection at 25 months of follow-up of the treated patient [145] . however, the study group revised the study protocol and announced that they implanted ipsc-derived retinal pigment epithelial cells obtained from an allogeneic donor to a man first time [146] . when it comes to acute emergency situations such as critical organ injuries including mi, stroke, trauma, or mass casualty settings including radiation injury, burns, pandemics and combat injuries, ipsc biobanking can be an alternative solution to obtain sufficient numbers of cells in short times. biobanking of allogeneic stem cells may also help to reduce costs, by eliminating the need to prepare limited doses of cells for each patient. however, immunogenicity still remains as a drawback tried to be solved through donors who are homozygous at human leukocyte antigen alleles namely "super donors". fortunately, encouraging efforts have come from the united states, european union, and japan in recent years in order to expedite approval processes for translation of stem cell therapies into the clinics including pscs [147, 148] . significant limitations exist while considering the optimal dose, transplantation route and timing of administration for stem cell therapies and ev-based therapeutics. for example, a dose of four million cells is considered as effective for intravenous transplantation in a stroke rat weighing 250 g, which corresponds to 840 million cells in a 75 kg man suffering from stroke. if cells are transplanted through stereotaxic route, 200k cells in a 250 g rat is considered as effective dose, which is equivalent to 56 million cells in a 75 kg stroke patient [149] . however, most of the clinical trials investigating stem cells in stroke patients use cells below these doses and vary among each other [150] . it should also be kept in mind that higher number of cell transplantation does not mean more improved o u t c o m e s . f o r i n s t a n c e , t h e l o w e s t n u m b e r o f transendocardially injected mscs were associated with the greatest improvements in left ventricular volume and ejection fraction in a dose escalation study of ischemic cardiomyopathy patients [133] . there are a wide range of transplantation routes for stem cells and evs varying according to disease characteristics but the optimal route for a specific disease is not fully known yet. according to a previous rat study of ventilator-induced lung injury, intratracheal msc application was found to be as effective as intravenous msc therapy [151] . on the other hand, msc transplantation through intravenous route was found to be more effective compared to intraperitoneal route for improving liver injury in a rat polytrauma model [29] . although intravenous injection is the most common way of transplantation, it is evident that stem cells are trapped in lungs and eliminated from circulation, which is named as "pulmonary first-pass effect". in a previous rat tbi model study, a significant proportion of mscs were localized into the lungs at 48 hours of intravenous infusion and less than 4% of the cells reached the arterial system. moreover, this study demonstrated that very few proportion of cells (0.0005%) reached into the cerebral tissue [152] . however, this problem might be achieved through multiple infusions instead of single bolus administration [5, 153] . despite the fact that evs can easily cross the bbb and they do not carry a risk for vascular obstruction, they promise for systemic applications in neurological diseases such as stroke and tbi compared to stem cells [42, 70, 71, 75] . a recent study found that biodistribution of evs can be affected by varying dosages, routes of injection, and cellular origin of evs [154] . organ specific applications such as intracoronary route for cardiac diseases or intratracheal and inhalation route for lung diseases may be an alternative solution regarding the limitations of systemic infusions. in addition, topically applied allogeneic msc-derived evs are being planned to be tested in a phase-1/2a trial of a rare genetic skin disorder (nct04173650) [139] . combination of stem cells and evs with tissue engineering modalities such as scaffold-based technologies, cell sheets and injectable biomaterials might be promising strategies for local or percutaneous applications specifically in cardiac diseases [155, 156] . optimal time window for application is not well-defined, however it may depend on disease characteristics and availability of donors. for example, delivery of stem cells at early times may be beneficial to decrease proinflammatory processes which occur at the first days of tbi [35] . likewise, a clinical study testing allogeneic multipotent adult progenitor cells in acute stroke patients showed that patients treated before 36 hours were more likely to benefit from cell therapy [157] . one potential limitation of early treatment is the harsh microenvironment at the injury region surrounded by toxic and inflammatory cells that may attenuate the therapeutic effects of cells. in addition, if cell treatment is planned at early times as in such diseases exemplified in this paper, use of autologous sources may not be possible because of time needed for harvesting procedure [20, 35] . beside the invaluable contribution of animal model studies to understand disease pathogenesis, and stem cell and ev biology, an important aspect is the ability to test the efficacy of the products before moving to clinical trials. however, it is evident that translational success obtained from clinical trials has been modest despite the encouraging data coming from animal models [158] . several reasons exist for this discrepancy mostly regarding methodological and interpretative issues observed in preclinical and clinical studies. lack of animal models that exactly match phenotypically and physiologically with the related human disease with similar organ size is a significant limitation. it is known that cellular functions of stem cells such as homing and niche activities, intercellular contact, cytokine and growth factor secretion may differ among various species [158, 159] . likewise, biological functions of evs obtained from mscs of different species such as human and murine may vary [160] . publication bias is a significant problem for both preclinical and clinical studies, which may result with inaccurate interpretation of efficacy and decelerate the translational process [161, 162] . the most relevant example of this effect comes from animal stroke studies leading to overstatement of efficacy [161] . in fact, registration to public databases such as clinicaltrials.gov are encouraged to reduce bias in clinical studies in line with the declaration of helsinki-ethical principles for medical research involving human subjects, but publication and reporting of results are not at desired levels [162, 163] . similarly, there are now public based platforms for preclinical studies including preclinicaltrials and animal study registry in order to reduce bias. however, it should be noted that neutral or negative results do not impress researchers, sponsors, authors, peer reviewers and editors, and such papers are most likely to be rejected by the journals [163] . diversities in study protocols, outcomes, patient populations and interpretation may be another significant hurdle of clinical translational in rm therapies. for instance, according to an analysis of autologous bm-derived stem cell clinical studies for ischemic heart disease, a significant proportion of studies contain factual discrepancies regarding the enhancement in ejection fraction [164] . fortunately, strategies for standardization of clinical trials of stem cells and evs are being developed [165, 166] . such efforts are also being performed to standardize design, organization and reporting of in-vitro research and animal model studies [167, 168] . stem cells tend to lose their biological functions after isolation and long term culture in-vitro. furthermore, when they are injected into the body, they challenge with a harsh microenvironment accompanying death signals because of the inadequate interaction between the cells and surrounding extracellular matrix (ecm). therefore, various strategies have been developed in order to enhance survival, engraftment rate, immunosuppressive, immunomodulatory and regenerative functions of stem cells, and improve their efficacy. preconditioning with physical, chemical and biological factors, genetic modification, and optimization of culture conditions are the prevailing strategies [169] . combinatory approaches using tissue engineering and biotechnology applications might also enhance the therapeutic activity of stem cells. for example, in a study performed by our research group, encapsulation of bm-mscs in platelet rich plasma-derived fibrin microbeads yielded accelerated regeneration period with better myofiber orientation in volumetric muscle loss injury of rats [170] . furthermore, mscs seeded on decellularized bovine small intestinal submucosa contributed healing process of a critical-sized full-thickness skin defect in rodents [171] . similar approaches can also have beneficial effects on evs such as increased production in numbers or improved functions [172] . for instance, a tbi rat model demonstrated that cultivating human mscs in three-dimensional collagen scaffolds yielded enhanced exosome number and therapeutic outcomes compared to exosomes derived from mscs cultured in two-dimensional conventional conditions [39] . besides, overexpression of specific mirnas and transcription factors, or gene editing may be a feasible approach to improve beneficial effects of evs. mscs overexpressing particular mirnas were shown to have neuroprotective and cardioprotective effects in animal models [172] . indeed, cultivation of macrophages with exosomes obtained from lipopolysaccharidetreated mscs increased secretion of cytokines and expression of growth factors. these macrophages improved survival in mouse with ars [122] . genetically modified cell lines such as nt2n, ctx0e03 and sb623 have been widely investigated in preclinical and clinical studies of stroke. there were no safety concerns in clinical trials of these cell lines but genetic stability including ectopic tissue formation and tumorigenesis are potential caveats before moving into clinics [69] . on the other hand, genetically engineered evs in contrast to naive evs may allow for production of more potent and disease-specific subset of evs with specific therapeutic effects. these engineered evs may be translated into novel strategies for effective use in clinics and may be the treatment choice of future [91] . however, genetic modification of evs by using viral capsids may provoke an adverse immunological reaction, which can be avoided by using chemically synthesized peptides [42] . for example, modification of msc-derived exosome surface by a functional chemically synthesized cyclopeptide provided more efficiently targeting of ischemic region compared to unmodified exosomes in a mouse model of cerebral ischemia [173] . furthermore, genetically modified allogeneic mscderived exosomes enriched with mirna-124 are being tested in acute ischemic stroke patients in a phase-1/2 clinical study (nct03384433). the recognition that homing and migratory effects of stem cells are limited, and paracrine mediators secreted from cells constitute their major regenerative functions has highlighted a new perspective into rm therapeutics. subsequently, there has been a shift of interest from cell transplantation to conditioned medium and/or ev-based therapeutics. conditioned medium from bm-mscs overexpressing akt mediated cardioprotective effects both in-vitro and in-vivo [174] . multidimensional protein identification technology and cytokine antibody array analysis of the conditioned medium of mscs derived from escs demonstrated various gene products associated with cardiovascular biology, bone development and hematopoiesis suggesting a therapeutic potency of conditioned medium without cell transplantation [175] . moreover, microvesicles derived from human mscs were as effective as their parent stem cells in mice suffering from severe bacterial pneumonia [176] . cell-free therapies may have several advantages in contrast to cell applications. there is a thrombogenic potential of stem cells in the vasculature as well as arrythmia in the heart, ossification and calcification. in addition, cryopreservation may decrease viability of stem cells. on the other hand, cell-free applications do not require robust and expensive strategies for isolation and expansion, which make them an attractive source in acute conditions or military applications. in general, there are two types of cell-free products namely conditioned medium concentrates, which also contain evs, and evs free from soluble factors such as growth factors [177] . at this point, one can ask whether conditioned medium or evs have more therapeutic potential. although it is difficult to give a definite answer, a previous study of hyperoxia-induced bronchopulmonary dysplasia demonstrated that ev deficient conditioned medium has no therapeutic effect, whereas both evs and conditioned medium containing evs improved lung inflammation and morphologic alterations [178] . in addition, utilization of evs as biomarkers and their abilities as drug delivery systems put evs a step forward in rm [7, 12] . when compared to stem cells, ev transplantation seem to be less risky than live stem cells. they cannot replicate and the risk of transformation into malign cells is less. due to the fact that they are smaller in size, the risk of elimination in the vasculature is less and they can easily pass the bbb, a property which makes them an ideal source for drug carrying and/ or transplantation in neurological diseases. besides, they do not evoke an immune response after transplantation, so there is no need for immunosuppression [7, 12, 42] . they can also display systemic beneficial effects even in local applications as demonstrated in a recent mouse mi model study [61] . although they have similar functional effects, their content such as mrna, mirna and proteins may vary compared to their parent cells. for example, comparative analyses of adipose tissue-derived mscs and their evs demonstrated diverse genetic cargo including mrna and mirna, and protein contents that play role in angiogenesis, adipogenesis, apoptosis, regulation of inflammation, blood coagulation and ecm remodeling [179, 180] . moreover, protein levels and surface markers also differ between evs and their parent cells [181, 182] . a rat mi model study showed superior beneficial effects of msc-derived exosomes in contrast to mscs in cardiac repair. this superiority was attributed to differences in expression profiles of several mirnas from that of mscs detected through mirna sequence analysis, raising the possibility that evs can be used alone and are superior to mscs in promoting cardiac repair [183] . a recent cutaneous wound model study reported that intradermal injection of evs derived from adipose and bm-mscs were superior to stem cell injection invivo. furthermore, adipose msc-derived evs enhanced wound closure better than their bm-derived counterparts suggesting diverse therapeutic effects of evs obtained from different sources in an organism [184] . at this point, it is reasonable to speculate that one size does not fit all in ev-based therapies. among diverse cell sources, evs derived from mscs are the most investigated type of evs compared to other cell sources such as pscs. for example, comparison of exosomes obtained from ipsc-derived mscs and synovial membranederived mscs yielded greater therapeutic effect of ipscderived msc exosomes in an osteoarthritis model [185] . however, evs derived from pscs may be tumorigenic despite their high regenerative capacity because they carry the characteristics of their parent cells. on the other hand, superior safety profile regarding teratoma formation and therapeutic effect of ipsc-derived evs in contrast to ipscs were shown in terms of cardiac repair [58] . given their inherent role in pathological processes and systemic effects, ev applications can induce spreading of tumor growth, autoimmunity, neurodegenerative diseases, prion diseases or viral infections because they are able to transfer their contents to recipient cells. exosomes derived from mscs of multiple myeloma patients had decreased tumor suppressor mirna-15a expression levels compared to normal msc-derived exosomes. besides, exosomes derived from multiple myeloma patients expressed higher levels of oncogenic proteins, cytokines, and adhesion molecules, and promoted tumor growth, whereas exosomes of normal mscs inhibited the growth of multiple myeloma cells [186] . actually, it should be kept in mind that this feature of evs makes them highly suitable candidates for drug delivery, particularly therapeutic nucleic acid delivery. however, risk of tumorigenesis remains as a concern because of systemic and diverse effects of their cargo though their acellular nature [7] . the mechanism of action of evs has not been wellunderstood yet but it is thought that they perform their functions through mirnas. the proportion of mirnas accounts for less than 1% of total rna cargo in evs but they are considered as the leading molecules in regulating functions of evs. it is also evident from multiple knockdown experiments that diverse mirnas might take role for the same effect in different tissues. indisputably, there may be contribution of other components such as proteins and lipids, which are highly abundant in the ev cargo [177] . on the other hand, the content and function of evs may depend on the metabolic properties of the donors and/or conditioned medium, which might make donor selection and manufacturing process more problematic [166, 177, 187] . in addition, systemic effects of mirnas should be kept in mind if systemic therapy is the preferred route. for example, mirna-126 regulates brainheart interaction after ischemic stroke [188] . mirnas involved in cancer pathogenesis should also be kept in mind [189] . these limitations highlight the significance of tissue specific applications. furthermore, short half-life, off-target effects and insufficient endocytosis remain as major limitations of evs that need to be improved during clinical translation process [154, 190] . there exist significant limitations while considering the isolation, characterization, tracking procedures and clinical grade production of ev-based therapeutics. there are various isolation and characterization methods of evs such as ultracentrifugation, density gradient, filtration, size exclusion chromatography, precipitation, magnetic based capture or combinatory methods, while ultracentrifugation is the most commonly used technique for isolation according to a worldwide survey. techniques for characterization also vary but western blotting is the most preferred method [191] . however, it is not surprising that the other techniques are also widely used in different studies all over the world [8, 190, 191] . on the other hand, efforts to standardize these procedures and confusions regarding the nomenclature are ongoing [9] . likewise, databases built up to provide information about the composition and functions of evs such as exocarta, evpedia, and vesiclepedia will likely to contribute to clinical translation process [190] . when it comes to clinical-grade large scale production, evs must be produced and stored under current good manufacturing practice (cgmp) conditions in order to meet market demands. this includes a strict workflow including manufacturing through bioreactors, quality analyses and screening, and preservation in appropriate conditions in order to maintain the stability and integrity of evs. similar strict production flows are also relevant for clinical-grade stem cell production but evs have a simplified cold chain process when compared to stem cells. because of the acellular nature of evs, lower risk of spontaneous dna transformation might be an advantage during cryopreservation [192] . despite limitations discussed above, evs have moved to clinical studies rapidly. results coming from oncological patients were encouraging in terms of safety and shed light on future studies [137, 138] . moreover, administration of evs derived from uc-mscs was safe and ameliorated the inflammatory immune status and improved the kidney functions in a clinical study [193] . clinical case report of a graft-versus-host disease patient also demonstrated improved outcomes after ev therapy [140] . in addition, several clinical trials have been designed and conducted in order to investigate therapeutic potential of evs in various diseases including cancer, type 1 diabetes, pleural effusion, ulcers, ischemic stroke, bronchopulmonary dysplasia, etc. however, there is an inevitable need for well-designed, well-conducted clinical trials in order to expedite clinical translation of ev-based therapeutics for acute emergency and/or mass casualty situations. rm with personalized biologics are the future of medicinal sciences. although they are not considered as a drug or pharmacologic agent yet, stem cells promise a potential for the treatment of various diseases with unmet clinical needs. on the other hand, their secretomes namely evs have been the new therapeutic target due to the fact that they are the prominent components that regulate functions of stem cells. both stem cells and evs have demonstrated their therapeutic potential in preclinical models of various diseases but there are many limitations and caveats that need to be considered and improved during the translational process. they are also in their infancy ages and well-designed clinical trials will help to identify their therapeutic activity in human beings. this review aimed to summarize and understand the therapeutic potential of stem cells and evs in diseases requiring acute emergency care such as trauma, heart diseases, stroke, ards and burn injury. diseases that affect militaries or societies including ars, sepsis, and viral pandemics such as covid-19 have also been discussed. in addition, featuring and problematic issues which hamper clinical translation of stem cells and evs have been debated with a futuristic perspective. their advantages and disadvantages have been discussed in a comparative manner by keeping in mind the need for future studies and with the belief that these rm therapies will help to prolong human life and improve quality of 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tissue-derived mesenchymal stem cells comparative proteomic analysis of stem cell rev and rep extracellular vesicles isolated from porcine adipose tissue-derived mesenchymal stem/stromal cells proteomic analysis of microvesicles derived from human mesenchymal stem cells mirna-sequence indicates that mesenchymal stem cells and exosomes have similar mechanism to enhance cardiac repair extracellular vesicles derived from mesenchymal cells: perspective treatment for cutaneous wound healing in pediatrics comparison of exosomes secreted by induced pluripotent stem cell-derived mesenchymal stem cells and synovial membranederived mesenchymal stem cells for the treatment of osteoarthritis bm mesenchymal stromal cell-derived exosomes facilitate multiple myeloma progression the metabolic syndrome modifies the mrna expression profile of extracellular vesicles derived from porcine mesenchymal stem cells mir-126 affects brain-heart interaction after cerebral ischemic stroke cancer hallmarks and micrornas: the therapeutic connection prospects and challenges of extracellular vesicle-based drug delivery system: considering cell source techniques used for the isolation and characterization of extracellular vesicles: results of a worldwide survey to protect and to preserve: novel preservation strategies for extracellular vesicles umbilical cord mesenchymal stem cells derived extracellular vesicles can safely ameliorate the progression of chronic kidney diseases publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-350793-bftztg0e authors: nizami, shermeen; green, james r.; mcgregor, carolyn title: implementation of artifact detection in critical care: a methodological review date: 2018-04-30 journal: ieee reviews in biomedical engineering doi: 10.1109/rbme.2013.2243724 sha: doc_id: 350793 cord_uid: bftztg0e artifact detection (ad) techniques minimize the impact of artifacts on physiologic data acquired in critical care units (ccu) by assessing quality of data prior to clinical event detection (ced) and parameter derivation (pd). this methodological review introduces unique taxonomies to synthesize over 80 ad algorithms based on these six themes: (1) ccu; (2) physiologic data source; (3) harvested data; (4) data analysis; (5) clinical evaluation; and (6) clinical implementation. review results show that most published algorithms: (a) are designed for one specific type of ccu; (b) are validated on data harvested only from one original equipment manufacturer (oem) monitor; (c) generate signal quality indicators (sqi) that are not yet formalised for useful integration in clinical workflows; (d) operate either in standalone mode or coupled with ced or pd applications; (e) are rarely evaluated in real-time; and (f) are not implemented in clinical practice. in conclusion, it is recommended that ad algorithms conform to generic input and output interfaces with commonly defined data: (1) type; (2) frequency; (3) length; and (4) sqis. this shall promote (a) reusability of algorithms across different ccu domains; (b) evaluation on different oem monitor data; (c) fair comparison through formalised sqis; (d) meaningful integration with other ad, ced and pd algorithms; and (e) real-time implementation in clinical workflows. hysiologic signals exhibit trends, dynamics and correlations reflecting the complexity of underlying patient physiology [1, 2] . continuous monitoring of physiologic data assists clinicians in making diagnoses and prognoses in critical care units (ccu), including intensive care (icu), paediatric intensive care (picu), neonatal intensive care units (nicu), and the operating room (or) [3] . clinical event detection (ced) techniques analyze these data to identify clinically significant events and early onset indicators of various pathophysiologies as in [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] . parameter derivation (pd) techniques derive clinically useful low frequency parameters from high frequency input data as in [17] [18] [19] [20] [21] [22] [23] . artifacts are extraneous signals with randomly varying amplitudes, frequencies and duration that interfere with physiologic signals acquired in clinical settings [24] . longitudinal studies [25] [26] [27] [28] infer that original equipment manufacturer (oem) patient monitors have relatively simplistic built-in data preprocessing for artifact detection (ad). in this paper, the term ad encompasses one or more of the following mechanisms: (a) identification, detection or annotation of artifacts, (b) elimination of artifacts or artifact-laden data and (c) suppression or filtering of artifacts e.g., by using ensemble averaging or adaptive filtering [29] . the terms noise and cleaning have been used in publications as alternatives for the terms artifacts and ad respectively. oem monitors typically come with a black box approach to preprocessing artifacts in physiologic data. clinicians debate the reliability of oem monitor data as they deduce that some built-in algorithms employ a reductionist approach that oversimplifies complex human physiology [30] . artifacts can mimic physiologic data [31] [32] [33] , adding to the challenge of distinguishing between the two. as a result, data logged by oem monitors remains impacted by artifacts [34] [35] [36] . this increases false alarm rates in monitors [36] [37] [38] , which leads to staff desensitization [30, 39, 40] . clinicians cannot rely on analysing artifact-laden monitor data [41] , which in the past has resulted in incorrect diagnoses [33, 42] ; unnecessary therapy; surgery and iatrogenic diseases [32] . independent research groups have developed a variety of post processing techniques to address the problem of artifacts in oem monitor data. fig. 1 shows the ad configurations reviewed in this paper. the purpose of ad is identical in any configuration, i.e., to assess and enhance the quality of physiologic data. fig. 1 depicts signal quality indicators (sqi) among other output variables. latest ad research shows increasing interest in devising sqis [43] [44] [45] [46] . this paper conducts a critical review of the development and utility of sqis. this methodological review introduces six thematic taxonomies for a critical analysis of the state-of-the-art in ad. the objective is to synthesize the status of clinical evaluation and implementation of ad in various ccus. reviewed publications are listed in table i . section ii discusses past reviews of ad. section iii briefly describes research methodology followed by detailed development of a unique taxonomy for each of the six themes. review results are thematically synthesized in table ii . section iv concludes the review by highlighting open research problems. it also provides specific recommendations for new research directions in promoting implementation of ad in real-time clinical workflows. historically, ad has been reviewed with significantly different scope and context from this paper, which makes this review a novel contribution in this research space. borowski et al. [47] have conducted a comprehensive review on alarm generation in medical devices. their primary focus is care: a methodological review ergonomics and human factors engineering, although, they briefly synthesize some ad algorithms and, as a result, recommend using multivariate alarm systems. schettlinger et al. [48] have largely reviewed their own research in developing univariate filters for outlier, trend and level shift detection in various icu data types. they extensively describe filter development and compare advantages and disadvantages of different filter designs. chambrin [49] infers that multivariate techniques can reduce false alarm rates in icus. numerous publications, such as [37, 43, 48, [50] [51] [52] , provide comparative numeric summaries of performance metrics of ad algorithms. this review neither reiterates algorithmic details nor performance comparison as that falls outside its scope. takla et al. [28] note that while ad techniques developed by independent researchers may have higher specificity than built-in algorithms in oem monitors, extensive studies are required to evaluate their accuracy prior to real-time implementation in clinical environments. siebig et al. [38] demonstrate agreement amongst clinical staff, including intensivists, that integrative monitoring through data fusion can potentially yield better results as compared to simpler univariate threshold detection methods. imhoff et al. [37, 52] emphasize that methodological research is needed for integrating multivariate ad algorithms in real-time clinical systems. however, they do not present a conceptual framework to conduct such research. papers of interest were located in scopus, ieee xplore and pubmed databases using the keywords artifact, artefact, artifact detection, alarm, physiologic monitoring, intensive care, neonatal intensive care, operating room and patient monitors amongst others. no constraints were applied on the publication year. google scholar was also used. literature was then methodologically reviewed using six thematic taxonomies developed in this section: (1) critical care unit, (2) physiologic data source, (3) harvested data, (4) data analysis, (5) clinical evaluation and (6) clinical implementation. fig. 2 depicts an overview of the thematic taxonomies. this theme catalogues domain specific ad research to examine its reusability and portability across other ccus. the taxonomy developed for this theme is: icu, picu, nicu, or and other relevant studies. this taxonomy, tabulated in table i , reveals that almost all techniques are evaluated in a single domain, with the exception of [23] which is evaluated in the icu, picu and or. in general, trends in physiologic signals display similar dynamics across ccu domains [53] . this drives the hypothesis that ad algorithms could be modified for use across different critical care settings. however, domain specific information such as types and frequency of data, and patient demographics such as range of age, weight and medical condition may be directly, or indirectly, hard coded in the algorithm. therefore, it is important to consider the original domain of clinical application prior to attempting application elsewhere. this theme synthesizes the methodologies used to source physiologic data. the theme taxonomy is: physiologic monitor, inclusion/exclusion criteria and sample size, as tabulated in the second column of table ii . the types, frequency, numeric values and quality of data produced by patient monitors (and probes) differs between models from the same or different oems. this is due to different built-in proprietary signal preprocessing, inclusive of ad [28, 54] [55] ; nellcor oximax n-600x (covidien-nellcor, boulder, co, usa) [55, 56] ; philips fast mp50 [56] and philips intellivue mp70 (philips, germany) [57] . therefore, knowledge of the monitor oem and model is important for recognizing different biases introduced in the data. some studies may collect data under certain inclusion and exclusion criteria as shown in table ii . sample size is almost always given in the literature. the discretion generally lies with the researcher to determine if enough data is available to draw a statistically and clinically sound decision. sample size may be deduced based on trial, availability of resources and study requirements. the taxonomy developed under this theme is: data type and acquisition/sampling or storage frequency. in table ii , the top half of each cell in column three summarizes the types and frequencies of data harvested in each study. knowledge of the oem is also a convenient indicator of this information. routinely harvested or monitored physiologic data types in critical care include: electrocardiograph (ecg), heart rate (hr), breathing or respiratory rate (rr), impedance respiratory wave (irw), noninvasive oxygen saturation (spo 2 ), invasive or noninvasive arterial oxygen saturation (sao 2 ), temperature (temp), the set of blood pressure (bp) measurements (namely systemic artery, pulmonary artery, central venous, systolic (sbp), diastolic (dbp) and mean (mbp) pressures, arterial (abp)), maximal airway pressure (map), expired air volume (ev), minute ventilation (mv) and transcutaneous partial pressures of carbon dioxide (tpco 2 ) and oxygen (tpo 2 ). frequency of the data is restricted by analog to digital sampling capability of the monitor [58] . storage frequency depends on data logging capabilities of both the oem monitor and the hardware and software mechanism used for storing study data. the synthesis in table ii demonstrates that physiologic data are acquired, derived, sampled and stored at varying frequencies. it is common for ad algorithms to be hard coded to input particular types of data streams having specific frequencies. high frequency signals, such as continuous waveforms of ecg, abp and ppg, are sampled at 100 hz or more. data that form low frequency time series, such as hr, sbp, dbp and spo 2 , are either time-averaged at a rate of once every second to once every minute from high frequency signals; or measured intermittently every half hour to an hour such as temperature and non-invasive bp. analytic aspects of ad algorithms are reviewed using the following thematic taxonomy: dimensionality, focus, signal quality and clinical contribution. theme findings are summarised in table ii , in the bottom half of each cell in column three. dimensionality represents the number of variables or data types that an algorithm is capable of analyzing. according to imhoff et al. [37] , both the clinical problem and the approach to solving it are (a) univariate when a single feature of a specific data stream is analysed; or (b) multivariate when results are derived from simultaneous analysis of multiple variables; and in between these two approaches lays (c) the univariate clinical problem solved using multivariate data. a new definition for multivariate analysis has emerged in recent research, and as such should be appended to the above as: (d) an algorithm is multivariate if it analyses different metrics derived from the same physiologic signal. examples of multivariate type (d) research on the ppg is found in [59] and on multi-lead ecg in [34, 50, [60] [61] [62] [63] a uniquely different approach to multivariate analysis is found in [64, 65] , where two different data streams were acquired from the same probe making their physiologic correlation easier to exploit. the data analysis theme characterizes the focus of each algorithm as: (1) stream; (2) patient; and/or (3) disease-centric. a stream-centric algorithm aims to indicate, quantify or improve signal quality of the data stream for increased reliability. although the term patient-centric has broad implications in health care, it means here that the algorithm was trained on patient specific data and is therefore heavily tailored to each sample patient in the study. for example, baseline data from a particular patient may be required to instantiate an algorithm. biosign [66] is an example of a realtime, automated, stream and patient-centric system. it produces a single-parameter representation of patient status by fusing five dimensions of vital sign data. a disease-centric methodology focuses on identifying or predicting a specific disease or a clinically significant outcome. the bradycardia detector in [67] and the prognostic tool for late onset neonatal sepsis (lons) in [68] are both examples of stream and disease-centric approaches. the clinical contribution taxonomy reveals two unique configurations of ad: (i) standalone ad and (ii) coupled ad. as fig. 1 illustrates, standalone ad techniques typically output filtered or original physiologic data, annotations and sqi. standalone techniques are labeled as ad under clinical contribution in table ii . coupled ad techniques are coded as part of algorithms that identify and/or filter artifacts similar to standalone ad techniques with the additional ability for ced or pd. coupled ad configuration is shown in fig. 1 and documented under clinical contribution in table ii. signal quality is a key element in this taxonomy. missing segments, error, noise and artifacts inevitably affect data quality thus adversely impacting analytic accuracy and reliability [69] . to address this issue, clifford et al. [70] recommend that an sqi calibrated to provide a known error rate for a given value of the sqi be made available for each datum. nizami et al. [71] infer that it suffices for sqis to be available at a frequency relative to the requirement of another ad, ced or pd application that consume the sqis. the latter is particularly relevant when down sampled data is required by ced or pds. it is hypothesized that the performance of post processing ad algorithms can improve by consuming streaming sqis output in parallel for each data stream by patient monitors [72] . however, use and delivery of sqis is not yet standardised across oem monitors. for example, in case of a lead disconnection the philips intellivue (philips, germany) monitor outputs a random value above 8 million in data streams such as the ecg, irw, hr, rr, spo 2 and bp. this also generates a corresponding alert type of 'medium priority technicalalarm'loggedatavalueof"2".however,thisvalue is qualitative and not quantitative. the delta, gamma, vista, kappa and sc6002 -sc9000 monitor series (dräger medical systems, lubeck, germany) output an sqi value between 0-100% for the electroencephalography (eeg) channel. this sqi is calculated using sensor impedance data, artifact information and other undisclosed variables. the same monitors also output a fixed label 'artf' indicating artifact on any monitored data stream [73, 74] . for example, the monitor classifies qrs complexes only at ecg values > 0.20 mv for widths > 70ms. an artifact condition 'artf' may be declared when the ecg signal does not meet these minimum criteria. although oem monitors may output signal quality information, there is no logical way to compare the sqis produced by different monitors. two confounding reasons are: (1) difference in quantification of sqi; and (2) lack of literature on proprietary algorithms. this reduces researchers' ability to determine how data has been affected from acquisition to logging. as a result, a post processing ad algorithm may need to be strictly matched to input data sourced from a particular oem monitor as shown in fig. 1 . comparative studies led by masimo [75, 76] declare that its 510 (k) fda approved radical set technology has the highest quality measure called performance index (pi) as compared to 19 other oem pos. in these publications, masimo defines and calculates pi as the percentage of time during which a po displayed a current spo 2 value that was within 7% of the simultaneous control value. however, the masimo set technology does not automatically evaluate or log this quantitative sqi. another quality measure called dropout rate (dr) was calculated in [76] , which equals the percentage of measurement time during which no current spo 2 values are displayed. although masimo set showed equal or worse dr than two datex-ohmeda pos, the reasons for this data loss are not discussed by masimo. independent research groups that compared oem pos in [55] [56] [57] neither researched the effect of the difference in data characteristics on sqis nor did they mention if the pos output sqis. through a recent discourse in [77] on historic developments of the masimo set technology, its oem has replied to van der eijk et al. [56] , claiming greater accuracy in unstable conditions, such as motion artifact and low perfusion, leading to lower false alarm rates. however, [77] does not describe any sqis that can be consumed meaningfully by other ad, ced or pd applications. this review recommends that ad algorithms that produce sqis, such as pi and dr amongst others, be evaluated upon data acquired in [55] [56] [57] to contribute towards future ad research. it follows that ad algorithms designed to post process oem monitor data must also consume and deliver standardised sqis. in this way another ad algorithm or a ced or pd mechanism can make informed choices concerning data quality and validity. review results in table ii show the increasing trend in sqi development. however, no framework exists to uniformly deliver, compare or combine these sqis for integration with clinical workflows. patient safety requires clinical evaluation of algorithms prior to real-time clinical implementation. this theme reviews clinical evaluation methods bases on this taxonomy: data annotation, mode and performance metric. results are given in table ii , in the top half of each cell of column four. there are no rules that define gold standards for clinical evaluation of ad performance. each study sets its own gold standard against which its performance is evaluated. this includes evaluations of oem monitors. annotated physiologic data, where available, typically serve as the gold standard for validation studies. events of interest in the data, such as artifacts and clinically significant events, are marked in realtime or retrospectively. the onus of perceiving what constitutesan"event"isontheexpertreviewers,whoidentify the event to the best of their knowledge. inter-reviewer variability is the significant [78] or subtle [27, 79] difference known to arise when the same dataset is annotated by different reviewers. retrospective data annotation has been supported by video monitoring in [27, 31, 36] . video monitoring is only useful when the event is visually perceptible such as sleep movements, certain seizures and routine care. however, it cannot capture crucial physiologic changes such as hr deceleration or bp elevation. the advantage of real-time annotations is recording of richer and more accurate content with input from staff on duty. however, this can be costly and requires cooperation from busy staff. study data is either collected in real-time from patient monitors or acquired in an "offline"mode for secondary analysis from existing databases. review results show that majority of ad techniques were validated on offline patient data and very few were tested in real-time ccu environments. table ii also documents the types of performance metrics used in each research. it shows the common trends that will help future researchers to design and compare different algorithms by evaluating them using the same metrics. numeric comparison of these performance metrics can be found elsewhere in [37, 43, 48, [50] [51] [52] . performance metrics need to be interpreted very carefully since statistical significance, or absence thereof, is not always representative of clinical significance, or absence thereof. for example, one missed clinical event may not signify a statistical difference in the sensitivity of one oem monitor over another. however, the same event could be very important clinically and crucial that it not be missed even once. theoretically, a missed event or a false alarm are caused by artifacts of various types; for example, motion artifact and power line or optical noise induced in an attached or detached sensor. studies that collected real-time annotated data or video monitored data, such as [27, 31, 36, 80-86] among others, can utilise the same data sets to develop and validate sqis. compatible sqis can be used to compare performance of different ad algorithms and oem monitors. performance metrics, for example sensitivity and specificity in alarm studies, can be re-evaluated taking into consideration the sqi at each alarm instance this theme reviews the clinical implementation status of ad techniques. theme results are given in table ii , in the bottom half of each cell in column four. this review reveals that the vast majority of ad techniques that are published have not been put into clinical practice. this section critically reviews implementation of some commercialized oem monitors and the very few techniques developed by independent research groups that made their way into clinical workflows. the philips intellivue monitoring system (royal philips electronic, netherlands) features guardian early warning score (ews) allowing each hospital to choose its own scoring criteria; neonatal event review which detects apnoea, bradycardia and desaturation; oxy-cardiorespirography (oxy-crg) with compressed trends of a neonate's hr, rr, and spo 2 ; and protocolwatch that is claimed to reduce sepsis mortality rates. presumably intellivue preprocesses patient data for artifacts prior to ced or pd, however, no validation studies or algorithm details of this system are published. ge intellirate tm monitor (milwaukee, wi, usa) issues asystole, bradycardia and tachycardia alerts by fusing ecg, abp and po data. it was evaluated by ge on a small population of 55 ccu patients in 2002 [87] . the evaluation was critiqued in [88] for lack of description of patient demographics and algorithm specifications. ge has republished the exact same study in 2010. the saphire clinical decision support system [89] uses intellirate tm technology, but does not evaluate it. multi-lead ecg arrhythmia detection is deployed by ge in datex-ohmeda bedside arrhythmia monitoring (milwaukee, wi, usa), mars ambulatory ecg system and mars enterprise (freiburg, germany). mars uses the oem's ek-pro arrhythmia detection algorithm which has been evaluated in over 2000 monitored hours spanning at least 100 patients. surely, these techniques fall under the category of ad coupled with ced and pd. however, literature lacks comparison between different models marketed by the same or different oems. oem covidien-nellcor (boulder,co, usa) has developed rr oxi , a coupled ad and pd technology that derives rr from po. rr oxi has been validated in real-time on 139 healthy subjects in [18] . the oem is commended for this substantial evaluation. however, healthy subjects are not representative of patient populations which the device is intended to monitor. rr oxi has been validated retrospectively in 12 patients with congestive heart failure, by evaluating 20 minutes of data from each patient [19] . however, larger studies that investigate patient populations with several different pathophysiologies are required to convince clinicians to adopt another patient monitoring technology in their workflows. fidelity 100 is an fda 510 (k) approved wireless ecg monitor developed by signalife (studio city, ca, usa), which was evaluated in real-time in 54 patients undergoing percutaneous coronary intervention [83] . although these monitors come with different settings applicable for use in different types of ccus, validation studies on population data from all application domains are not found. there are a growing number of online open source physiologic databases, such as capnobase [90, 91] , fda ecg warehouse [92] , hemodynamic parameter database [93] , and physionet [94] . it is recommended that these databases be used to compare and validate oem monitors of different makes and models. rest of this section reviews clinical implementation of ad research developed by independent research groups. cimva (therapeutic monitoring systems inc., ottawa, canada) is a patented multi-organ variability analytics technology developed by seely et al. [95] [96] [97] [98] . it is an online tool comprising of multiple coupled ad and ced algorithms with sqis. its ad performance is evaluated in [97] . cimva research can benefit from the recommendations made in the next section regarding common interfaces and formalised sqis. this will allow for new ad, ced and pd algorithms to be integrated and tested as part of the cimva architecture. otero et al. have implemented trace, a graphical tool which allows clinicians to edit monitoring rules and criteria in realtime. coupled ad and ced algorithms based on fuzzy set theory input these customized criteria to generate patient alarms in [81, 99] , and detect sleep apnoea in [100] . given its promising results, evaluation of trace against similar oem monitors is recommended. the research conducted in 1999 by schoenberg et al. [54] was integrated as part of the commercially available imdsoft clinical information system [101]. however, algorithmic details and evaluation were never published. artemis is a real-time data analytics system currently undergoing clinical evaluation in multiple nicus around the globe [102] [103] [104] . as part of the artemis framework, nizami et al. [71] present sqi processing to improve the performance of coupled ad and ced algorithms for lons. ongoing artemis research includes ad [80] ; ced of apnoea of prematurity [5, 15, 105] ; as well as pain management [9] . adoption of the structured approach to ad recommended in this review can enhance the clinical performance of coupled ad and ced in artemis. the coupled ad and ced algorithm for bradycardia by portet et al. [67] was evaluated on offline nicu data with the intent of integration with the babytalk project. babytalk's proof of concept has been described in several publications [106] [107] [108] [109] [110] . however, latest research by hunter et al. in 2012 [111] infers that a long road lies ahead, including necessary clinical trials, before babytalk could be implemented in real-time clinical workflows. several new ad and ced algorithms can be tested to improve outcomes of this project by incorporating formalised interfaces as recommended in this review. the patented hero™ system (medical predictive science corp., charlottesville, va, usa) that scores neonatal heart rate variability (hrv) for predicting lons is developed using coupled ad and ced algorithms [68] . it conducts a multivariate type (d) analysis of the ecg with multiple coefficients yielding a more sensitive result [84] . the algorithms in this 510 (k) fda approved device have been extensively described and evaluated both offline and in realtime by moorman et al. [84, [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] . this pioneering research has shown promising reduction in neonatal mortality by 2% in a randomized control trial on 3003 preterm babies across nine nicus in the us [114] . the drawback of this trial was a 10% increase in blood work and 5% more days on antibiotics in the monitored infants. ironically, this constitutes the original problem this research set out to resolve in [119] . it is recommended that other variability measures, such as those of rr as in [10] and ppg as in [123] , be evaluated in comparisonwiththehero™hrvscoretocomeupwith(a) individual scores for each data type; and (b) a composite score that exploits sensor fusion for improved outcomes. biosign [66] has been evaluated retrospectively and in real-time in a number of clinical studies including randomized control trials in europe and the us before 2006. however, no later publications could be located. this section derives conclusions from the thematic review. post processing ad techniques are highly domain specific. this necessitates modification for validation and reuse in a different ccu domain. algorithms may be hard coded to input oem specific data types and frequency. this limits their use with different oem monitor data. they may be validated under certain inclusion/exclusion criteria which need to be considered when applying the techniques in other contexts. acquisition and sampling frequency play an important role in patient management since a critically ill patient's condition may deteriorate to a life threatening extent within seconds. reusability is deterred when such implicit limitations are not expressed. therefore, adoption of a standardised structured approach for design and reporting of standalone and coupled ad research is recommended. conformity to generic input and output interfaces will ensure presence of all pertinent information. these interfaces, with common definitions for data type, frequency, length and sqis, shall allow for matched selection and composition with other ad, ced or pd algorithms. results from the first three themes are useful in selecting one or more ad algorithms that fulfill data requirements of given ced or pd techniques. selected ad algorithms can be mixed and matched to discover optimal compositions for varying clinical requirements. oem monitors marketed for use across different ccus have undisclosed built-in preprocessing algorithms, inclusive of ad. moreover, studies validating their use in different ccu domains and patient population are scarce. the resulting unknown bias imparted in oem data leads to inevitable variance in analytic results which can effect clinical decisions. this variability can be decreased if monitors output comparable standardised sqis. as of yet, sqis do not conform to any standards and are derived differently in each publication, whether it be sqis delivered by oem patient monitors or by ad algorithms developed by independent research groups. interestingly, none of the reviewed algorithms reported using sqis provided by oem monitors. clinical utility of sqis can be enhanced by using formalised definitions such that sqis output by different preprocessing and post processing ad algorithms are comparable as well as compatible. an sqi matched to the same set of definitions is also proposed as a requirement at the input of ad, ced or pd algorithms. the objective is to enable the ad, ced or pd algorithm to compare the incoming sqis generated by one or more ad techniques with their required sqi value. the ced or pd algorithm may then accept or reject incoming data segments based on fulfillment of the required sqi value. in conclusion, standardised sqis are vital to allow informed clinical choices concerning use and validity of physiologic data. results of the clinical evaluation theme show that majority of ad techniques are validated on offline data and very few have been evaluated in real-time ccu environments. clinical implementation theme reveals that ad techniques developed by independent research groups have rarely found their way into clinical implementation. this leads to the inference that a gap exists between research efforts in ad and their utilization in real-time clinical workflows. whereas real-time clinical implementation of ad algorithms is noticeably lacking, there is growing interest amongst clinicians to use ced and pd for automated clinical decision support in ccus, such as in [8, 104, [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] . physiologic signal quality assessment through integration of ad can improve the outcome, reliability and accuracy of ced and pd research. the conclusions and recommendations of this review provide new research direction for promoting integration of ad in real-time clinical workflows. salatian [26] oem not specified/ 1 data segment bp at 1 hz not discussed/ offline/ graphical display univariate/ stream-centric/ no sqi/ ad none why should we integrate biomarkers into complex trials? review and classification of variability analysis techniques with clinical applications why doesn't healthcare embrace simulation and modeling? what would it take analysis of continuous oxygen saturation data for accurate representation of retinal exposure to oxygen in the preterm infant classifying neonatal spells using real-time temporal analysis of physiological data streams: algorithm development test characteristics of an automated age-and temperature-adjusted tachycardia alert in pediatric septic shock accuracy of an expanded early warning score for patients in general and trauma surgery wards a novel technique for identifying patients with icu needs using hemodynamic features identification of noxious events for newborn infants with a neural network variability analysis with analytics applied to physiological data streams from the neonatal intensive care unit a process mining driven framework for clinical guideline improvement in critical care pulse oximetry saturation patterns detect repetitive reductions in airflow implementation of a real-time computerized sepsis alert in nonintensive care unit patients using modified multivariate bag-of-words models to classify physiological data a framework for multidimensional real-time data analysis: a case study for the detection of apnoea of prematurity online apnea-bradycardia detection using hidden semi-markov models deriving respiration from photoplethysmographic pulse width developing an algorithm for pulse oximetry derived respiratory rate (rr oxi): a healthy volunteer study accuracy of continuous noninvasive respiratory rate derived from pulse oximetry in congestive heart failure patients artificial arterial blood pressure artifact models and an evaluation of a robust blood pressure and heart rate estimator robust heart rate estimation from multiple asynchronous noisy sources using signal quality indices and a kalman filter a robust sensor fusion method for heart rate estimation robust sensor fusion improves heart rate estimation: clinical evaluation instrumentation and practice standards for electrocardiographic monitoring in special care units. a report for health professionals by a task force of the council on clinical cardiology anaesthesia monitor alarms: a theory-driven approach filtering of icu monitor data to reduce false alarms and enhance clinical decision support collection of annotated data in a clinical validation study for alarm algorithms in intensive care-a methodologic framework the problem of artifacts in patient monitor data during surgery: a clinical and methodological review signal quality measures for pulse oximetry through waveform morphology analysis patterns of unexpected in-hospital deaths: a root cause analysis electroencephalography (eeg) recording techniques and artefact detection in early premature babies common electrocardiographic artifacts mimicking arrhythmias in ambulatory monitoring artifactual electrocardiographic change mimicking clinical abnormality on the ecg signal quality indices and data fusion for determining clinical acceptability of electrocardiograms reducing hospital noise: a review of medical device alarm management the wolf is crying in the operating room: patient monitor and anesthesia workstation alarming patterns during cardiac surgery smart alarms from medical devices in the or and icu users' opinions on intensive care unit alarms -a survey of german intensive care units managing alarm fatigue in cardiac care monitor alarm fatigue: an integrative review randomized trial of automated, electronic monitoring to facilitate early detection of sepsis in the intensive care unit automatic detection of ecg electrode misplacement: a tale of two algorithms signal quality in cardiorespiratory monitoring electrocardiogram signal quality measures for unsupervised telehealth environments applications of supervised learning to biological signals: ecg signal quality and systemic vascular resistance improving the quality of ecgs collected using mobile phones: the physionet/computing in cardiology challenge medical device alarms robust filters for intensive care monitoring: beyond the running median alarms in the intensive care unit: how can the number of false alarms be reduced? threshold-based system for noise detection in multilead ecg recordings real-time signal processing by adaptive repeated median filters alarm algorithms in critical monitoring a cusum-based multilevel alerting method for physiological monitoring making icu alarms meaningful: a comparison of traditional vs. trend-based algorithms oxygen targeting in preterm infants using the masimo set radical pulse oximeter new-generation" pulse oximeters in extremely low-birth-weight infants: how do they perform in clinical practice? letters: comparing oxygen targeting in preterm infants between the masimo and philips pulse oximeters online pattern recognition based on a generalized hidden markov model for intraoperative vital sign monitoring dynamic time warping and machine learning for signal quality assessment of pulsatile signals reducing false intracranial pressure alarms using morphological waveform features qrs detection based ecg quality assessment evaluation of an algorithm based on single-condition decision rules for binary classification of 12-lead ambulatory ecg recording quality automatic ecg quality scoring methodology: mimicking human annotators clinical diagnosis of pneumothorax is late: use of trend data and decision support might allow preclinical detection artifact detection in the po2 and pco2 time series monitoring data from preterm infants integrated monitoring and analysis for early warning of patient deterioration evaluation of on-line bradycardia boundary detectors from neonatal clinical data hero technical publications decision tool for the early diagnosis of trauma patient hypovolemia robust parameter extraction for decision support using multimodal intensive care data service oriented architecture to support real-time implementation of artifact detection in critical care monitoring on-line novelty detection for artefact identification in automatic anaesthesia record keeping instructions for use: infinity delta series infinity gateway vf5.0 protocol handbook performance of three new-generation pulse oximeters during motion and low perfusion in volunteers motion-resistant" pulse oximetry: a comparison of new and old models reply to "'new-generation' pulse oximeters in extremely low-birth-weight infants individual and joint expert judgments as reference standards in artifact detection the practical management of artifact in computerised physiological data on the integration of an artifact system and a real-time healthcare analytics system addressing the flaws of current critical alarms: a fuzzy constraint satisfaction approach classifying alarms in intensive care -analogy to hypothesis testing evaluation of novel ecg signal processing on quantification of transient ischemia and baseline wander suppression heart rate characteristics monitoring for neonatal sepsis an annotated data collection system to support intelligent analysis of intensive care unit data crying wolf: false alarms in a pediatric intensive care unit executive summary: intellirate technology for patient monitoring reducing false alarm rates for critical arrhythmias using the arterial blood pressure waveform ist-27074 saphire: intelligent healthcare monitoring based on a semantic interoperability platform photoplethysmogram signal quality estimation using repeated gaussian filters and cross-correlation respiratory rate estimation using respiratory sinus arrhythmia from photoplethysmography the cardiac safety research consortium ecg database thedatabase of the cardiovascular system related signals physiobank, physiotoolkit, and physionet : components of a new research resource for complex physiologic signals continuous multiorgan variability monitoring in critically ill patients -complexity science at the bedside annual international conference of the ieee monitoring and identification of sepsis development through a composite measure of heart rate variability feasibility of continuous multiorgan variability analysis in the intensive care unit continuous multi-parameter heart rate variability analysis heralds onset of sepsis in adults intelligent alarms for patient supervision a structural knowledgebased proposal for the identification and characterization of apnoea episodes trends and opportunities for integrated real time neonatal clinical decision support next generation neonatal health informatics with artemis real-time analysis for intensive care: development and deployment of the artemis analytic system a framework to model and translate clinical rules to support complex real-time analysis of physiological and clinical data using temporal constraints to integrate signal analysis and domain knowledge in medical event detection automatic generation of textual summaries from neonatal intensive care data text content and task performance in the evaluation of a natural language generation system from data to text in the neonatal intensive care unit: using nlg technology for decision support and information management summarising complex icu data in natural language automatic generation of natural language nursing shift summaries in neonatal intensive care: bt-nurse predictive monitoring for early detection of subacute potentially catastrophic illnesses in critical care cardiovascular oscillations at the bedside: early diagnosis of neonatal sepsis using heart rate characteristics monitoring mortality reduction by heart rate characteristic monitoring in very low birth weight neonates: a randomized trial nearest-neighbor and logistic regression analyses of clinical and heart rate characteristics in the early diagnosis of neonatal sepsis heart rate characteristics and clinical signs in neonatal sepsis heart rate characteristics: novel physiomarkers to predict neonatal infection and death sample asymmetry analysis of heart rate characteristics with application to neonatal sepsis and systemic inflammatory response syndrome abnormal heart rate characteristics preceding neonatal sepsis and sepsis-like illness sample entropy analysis of neonatal heart rate variability toward the early diagnosis of neonatal sepsis and sepsis-like illness using novel heart rate analysis the dynamic range of neonatal heart rate variability peripheral photoplethysmography variability analysis of sepsis patients a pattern-based approach for representing condition-action clinical rules into dsss photoplethysmographic derivation of respiratory rate: a review of relevant physiology cosara: integrated service platform for infection surveillance and antibiotic management in the icu keto: a knowledge editing tool for encoding condition -action guidelines into clinical dsss clinical knowledge-based inference model for early detection of acute lung injury detection of qt prolongation using a novel electrocardiographic analysis algorithm applying intelligent automation: prospective blinded evaluation using the cardiac safety research consortium electrocardiographic database impact of sedation and organ failure on continuous heart and respiratory rate variability monitoring in critically ill patients: a pilot study informatics infrastructure for syndrome surveillance, decision support, reporting, and modeling of critical illness implementation and evaluation of electronic clinical decision support for compliance with pneumonia and heart failure quality indicators an architecture for online comparison and validation of processing methods and computerized guidelines in intensive care units a modular clinical decision support system clinical prototype extensible into multiple clinical settings assemblies of heterogeneous technologies at the neonatal intensive care unit predictive combinations of monitor alarms preceding in-hospital code blue events robust heart beat detection from photoplethysmography interlaced with motion artifacts based on empirical mode decomposition reducing false alarms of intensive care online-monitoring systems: an evaluation of two signal extraction algorithms on-line adaptive trend extraction of multiple physiological signals for alarm filtering in intensive care units on-line segmentation algorithm for continuously monitored data in intensive care units specificity improvement for network distributed physiologic alarms based on a simple deterministic reactive intelligent agent in the critical care environment reduction of false arterial blood pressure alarms using signal quality assessement and relationships between the electrocardiogram and arterial blood pressure detection of artifacts in monitored trends in intensive care patient-specific learning in real time for adaptive monitoring in critical care event discovery in medical time-series data poor prognosis for existing monitors in the intensive care unit robust classification of neonatal apnoea-related desaturations a new algorithm for detecting central apnea in neonates automatic detection of apnoea of prematurity factorial switching linear dynamical systems applied to physiological condition monitoring building icu artifact detection models with more data in less time multiple signal integration by decision tree induction to detect artifacts in the neonatal intensive care unit on the road to predictive smart alarms based on a networked operating room sensor fusion using a hybrid median filter for artifact removal in intraoperative heart rate monitoring an evaluation of a novel software tool for detecting changes in physiological monitoring real-time pulse oximetry artifact annotation on computerized anaesthetic records physiologic trend detection and artifact rejection: a parallel implementation of a multi-state kalman filtering algorithm detection of false alarms using an integrated anesthesia monitor the association between vital signs and major hemorrhagic injury is significantly improved after controlling for sources of measurement variability improvement of ecg signal quality measurement using correlation and diversity-based approaches signal quality estimation with multichannel adaptive filtering in intensive care settings information technology in biomedicine computer algorithms for evaluating the quality of ecgs in real time cinc challenge -assessing the usability of ecg by ensemble decision trees data driven approach to ecg signal quality assessment using multistep svm classification automated detection of sleep apnea from electrocardiogram signals using nonlinear parameters modeling respiratory movement signals during central and obstructive sleep apnea events using electrocardiogram heart disease classification through hrv analysis using parallel cascade identification and fast orthogonal search data fusion for improved respiration rate estimation multivariate analysis of blood oxygen saturation recordings in obstructive sleep apnea diagnosis detection of decreases in the amplitude fluctuation of pulse photoplethysmography signal as indication of obstructive sleep apnea syndrome in children detection of obstructive sleep apnea in children using decreases in amplitude fluctuations of ppg signal and hrv a method for automatic identification of reliable heart rates calculated from ecg and ppg waveforms trace, tool for analyzing and discovering patterns key: cord-276495-q22jnkn2 authors: belizário, josé ernesto title: trained innate immunity, covid-19 therapeutic dilemma, and fake science date: 2020-07-06 journal: clinics (sao paulo) doi: 10.6061/clinics/2020/e2124 sha: doc_id: 276495 cord_uid: q22jnkn2 nan when we get sick, our body's first line of defense, the immune cells, responds and stores a memory of the pathogen; this is called immunological memory (1) . two types of functionally distinct memories have been described, i.e., innate memory (non-specific) and acquired memory (specific). there are two ways by which t and b cells form an acquired immunological memory. the first is based on genetic mechanisms that involve the recombination of membrane receptor genes (tcr) and selection of t cell clones capable of perfectly recognizing self and non-self antigens (e.g. proteins belonging to pathogens). the second, is based on the recombination of immunoglobulin genes (antibody genes) that recognize the proteins expressed by pathogens and the selection of memory b cell clones. memory b cells express membrane receptors (bcr)-or bound antibody molecules with high affinity-that recognize the pathogens in the event of a second infection. however, the big question is, ''how are antibodies produced against an infectious pathogen or vaccine?'' first, dendritic cells phagocytize and degrade the pathogen and present its pieces in the form of epitopes (protein fragments) to cd4+ t lymphocytes. then, helper cd4+ t cells communicate with lymphocytes b, which initiate the production of different classes of antibodies (humoral soluble response) against these epitopes. b lymphocyte clones die at the end of the infection and only few clones that contain the code (memory) for the synthesis of specific antibodies remain. another population of lymphocytes, called effector cd8+ t lymphocytes (cellular response), also recognizes pathogen-related antigens in infected cells. these cytotoxic lymphocytes attack the pathogens by releasing cytokines, toxins, and enzymes that lead to cell death via apoptosis and necroptosis. these cytotoxic lymphocytes also die at the end, and only a few clones survive. the survivors are programmed to become memory cd8+ t lymphocytes that would recognize the pathogen in the event of a second infection. how is memory in cd8+ t cells formed chemically? what we know is that cytosine and guanine (cpg)-rich regions in the promoters of genes encoding for various proteins, such as transcription factors, cytotoxic proteins, and cytokines involved in lymphocyte activation, undergo chemical modifications (methylation and demethylation, i.e., addition or removal of methyl groups). such modifications form a silencing or activating on/off switch for the transcription of immune response genes. histone proteins that bind dna molecules also undergo methylation and acetylation at their lysine and arginine residues. these types of chemical changes are referred to epigenetic and non-genetic (non-hereditary) modifications, as they do not cause any changes (mutations) in the dna molecule, nor are they transmitted to the next generation. therefore, children need to receive vaccines that protected their parents from pathogen, for example, the measles vaccine, to develop their own immune responses. bone marrow progenitor myeloid cells that give rise to blood leukocytes, such as neutrophils, monocytes, and natural killer cells (nks), are the innate cells participating in the non-specific innate response and trained immunity (2) . studies have shown that monocytes and macrophages are ''educated or trained'' during the first infection, and thus they acquire the ability to fight more effectively in subsequent infections. monocytes are trained through stimulation with lipopolysaccharide (lps)-a gram-negative bacterial membrane protein-or beta-glucan, a component of the fungal cell wall. for example, the bacillus calmette-guérin (bcg) vaccine can increase the production of pro-inflammatory cytokines, such as tumor necrosis factor (tnf), interleukin-1 (il-1), and il-6, up to 5 times on second contact with the pathogen. this type of immunological memory or epigenetic programming to a pre-activated state allows the generation of a sustained and more effective non-specific response, even after years, although in the protocols of these studies, the innate immunity was evaluated after 3 months (2). biochemical analyses on chromatin showed that trained monocytes are characterized by an increase in histone 3 acetylation, in particular h3k27ac and h3k4me3 as well as by an increase in the metabolism of glucose (glycolysis) and glutamine (glutaminolysis), and by high levels of fumarate, a metabolite of the tricarboxylic acid cycle or krebs cycle (2) . it has also been observed that after the training of human monocytes with candida albicans (a human opportunistic pathogen) beta-glucan, the induced innate immunity protects not only against fungi, but also against bacteria, viruses, and parasites (2) . in addition, the training of human monocytes by saccharomyces cerevisiae (another human opportunistic pathogen) chitin greatly increased their ability to eliminate microbes such as candida albicans, staphylococcus aureus (a gram-positive bacterium), and escherichia coli (a gram-negative bacterium) in comparison with untrained doi: 10.6061/clinics/2020/e2124 copyright & 2020 clinics -this is an open access article distributed under the terms of the creative commons license (http://creativecommons.org/licenses/by/ 4.0/) which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is properly cited. no potential conflict of interest was reported. human monocytes. more interesting, the non-specific effects of bcg vaccination improved the effects of low-efficiency vaccines, such as the vaccine against typhus-caused by salmonella typhi (www.clinicaltrials.gov, number nct0217 5420)-or the influenza vaccine. this protective effect has been known for decades in many countries (e.g. in denmark and south africa) where the bcg vaccine is administered to babies a few days after birth. in these countries, there was a 38-70% reduction in infant mortality associated with pneumonia and sepsis (3) . however, to the best of our knowledge, none of the studies have determined if a similar phenomenon occurs in vaccinated babies in brazil. various clinical trials are underway to evaluate trained immunity through bcg vaccination in healthy volunteers under the coordination of dr. mihail netea (radboud university medical center, nijmegen, the netherlands). clinical trials brace (www.clinicaltrialgov, number nct04327206) and bcg-corona (www.clinicaltrial.gov, number nct04328 441) are employing large cohorts of health professionals in the netherlands, denmark, germany, england, france, tanzania, uganda, colombia, and uruguay (3). the objective is to demonstrate whether immunization with bcg vaccines produced using different strains and titers of the bacillus calmette-guérin-the vaccine against tuberculosis-can protect these professionals against sars-cov-2 infection (3). a similar study will be carried out in brazil (www. clinicaltrial.gov, number nct04369794). dr. netea said that preliminary results showed that in a large number of human volunteer cohorts, the bcg vaccine induced trained immunity (450%; as stated in https://www.youtube.com/watch? v=3w36p40pols). it is expected that the volunteers, if infected, will respond mildly or asymptomatically to the sars-cov-2 infection. the scientific basis for this hypothesis comes from studies undertaken on human volunteers previously immunized with the live bcg vaccine and then with the vaccine for the yellow fever virus that causes a hemorrhagic disease (4) . it has also been verified through epidemiological and observational clinical studies that the number of deaths caused by coronaviruses in low-income countries, such as india and some countries in africa and the americas, are significantly lower than those in countries with medium and high levels of economic development, such as italy, belgium, holland, and the united states of america (5) . despite the presence of evidences regarding the efficacy of bcg, the latter countries have not adopted the universal policy of mandatory immunization against tuberculosis (6) . live or attenuated vaccines against measles and smallpox as well as the oral polio vaccine are also effective in inducing innate cross-protection against other unrelated viral infections. the hypothesis that all vaccinated children are protected or are less likely to develop severe symptoms of the sars-cov-2 has been contested by many investigators (7, 8) . therefore, we need to wait for the results of the clinical trials that are currently underway. in brazil, epidemiological data on tuberculosis, published by the ministry of health on march 2019, indicates that the incidence of the disease (30-35 cases/100 thousand inhabitants) has not changed in the last 10 years (9). rio de janeiro, amazonas, pará, roraima, and acre are the states with a tuberculosis incidence higher than the national average. in addition, mortality is higher than the national average (2.2 deaths /100 thousand inhabitants) in rio de janeiro, amazonas, pernambuco, rio grande do sul, pará, maranhão, rio grande do norte, ceará, and acre. vaccination, although recommended by the who (world health organization) for vulnerable populations, is not routinely employed, and only newborns receive the vaccine in brazil. since 2010, the butantan institute has stopped the production of oral bcg (live strain); now, it only produces the bcg vaccine formulated using the recombinant tuberculin protein. to our knowledge, there are no published articles or clinical evidences that show that bcg immunization protects against sars-cov-2 in brazil. is innate memory more effective against sars-cov-2 than acquired memory? could bcg vaccination be a more promising therapeutic alternative than chloroquine? these are the questions that need to be addressed. scientific knowledge is accepted or rejected based on measures of probabilities. how evidence is transformed into scientific knowledge depends on statistical methods that define whether certain types of interferences (errors, biases, or confounding factors)-that occur either randomly or systematically-are leading to relevant clinical outcomes in patient cohorts (10) . chloroquine has been used in the prevention and treatment of malaria since 1947 (11) . its clinical use in the treatment of rheumatoid arthritis and lupus erythematosus has been approved using pre-established protocols and doses based on the disease stage and the clinical conditions of the patient. the side effects of chloroquine, such as retinopathy and ventricular arrhythmia, are well-known, and are rarely reported by patients (11) . chloroquine should not be used in the absence of any medical supervision in patients with diabetes and heart problems, neither in people over 65 who-among other problems-may have reduced kidney function. therefore, any clinical study aimed at assessing the therapeutic effects of chloroquine should not include volunteers or patients having such comorbidities; therefore, these caveats should be included as a part of the trial protocol when establishing the inclusion and exclusion criteria. a previous study in a small patient cohort showed evidence that chloroquine could exhibit therapeutic effects in patients with covid-19 (12) . the journal the lancet, in may 2020, published the results of an observational, longitudinal, and retrospective clinical study based on medical records of covid-19 patient cohorts treated across 6 countries and 671 hospitals, with different technical capabilities and diverse drug protocols (13) . the results suggested that chloroquine and hydroxychloroquine-and their combination with azithromycin-did not result in any clinical benefit; on the contrary, they worsened the condition of the patients. however, in these studies, patients with several comorbidities were evaluated, including those with cardiovascular disease (including congestive heart failure and history of heart failure arrhythmia), current or previous smoking history, history of hypertension, diabetes, or hyperlipidemia, or chronic obstructive pulmonary disease (copd). these trials also reported that 47% of the treated patients needed admission to an intensive care unit (icu) and assisted ventilation (severe case of the disease) against only 5% in the control group. the authors concluded that all underlying diseases (comorbidities)-considered as confounding factors-influenced the mortality rate; this was the most relevant outcome of the study. the secondary outcome of interest was related to ventricular arrhythmia. it was mentioned that, among the 81 000 patients in the control group, a small population (16%, 14 300) had a history of heart disease, whereas 890 (1%) suffered from de novo ventricular arrhythmia, along with in-hospital treatment, and survived. of the 14 800 patients in the treatment group, 10 600 died. a large number of patients in the non-survival population (33%, 3 500 patients) had a history of cardiovascular disease. these were the patients for whom chloroquine treatment was not recommended because of the high risk of suffering from adverse effects, such as the prolonged qt interval and arrhythmia. in this group, as expected, 400 patients (3.7%) suffered from de novo ventricular arrhythmia (13) . whether this effect was observed before or during the treatment, was not specified by the authors. the episodes of de novo ventricular arrhythmia could be induced by several factors and clinical conditions; these include treatment with chloroquine, hydroxychloroquine, or a combination of chloroquine and azithromycin or that of hydroxychloroquine and azithromycin, and-finally-the pathology caused by sars-cov-2 (as it was observed in patients in the control group). i think that the study was not useful-or was partially useful-for assessing the cause and effect relationship of the medications because of the heterogeneity of the confounding factors. in fact, this paper was retracted a few days after its publication. therefore, further studies are required to assess the effect of the tested medicaments in patients only having covid-19 illness at the early phase, in which the drugs appear to exhibit the expected therapeutic benefits. the uncertainties and dilemmas regarding covid-19 and its treatment can be attributed to the fact that everything we know about this disease is still insufficient. there is no other way to prove the veracity of scientific findings without the replication of facts and experiences. clinical trials in humans must be guided by the practice standards, norms, and rules established in the international conference on harmonization / good clinical practices (ich/gcp), while following the ethical principles of the helsinki declaration, proclaimed in june 1964 (www.wma.net), and the hippocratic oath, the origin of the modern medical ethics. to develop evidence-based effective public health strategies, all clinical protocols must be based on evidence, which is defined as the link between excellent scientific research and good clinical practices. transparency in clinical trials begins with trial registration at the who international clinical trials registry platform (ictrp), clinicaltrials.gov; as detailed before, the brazilian clinical trials registry (rebec) is involved in this process in brazil (14) . although scientists are widely trusted and feted for their discoveries, they are repeatedly required to reexamine their findings using new technological strategies and new knowledge. the randomized clinical study (rct) is a scientific innovation; a way to draw better conclusions about cause and effect of medications or clinical procedures in matched and paired cohort groups. a doubleblind randomized clinical study is another scientific innovation; a way to avoid the interference of patients and investigators on the results. in this context, the effects of the placebo (inert drug) must be tested, and the effectiveness of the drug/vaccine must be higher in the treatment group than that in the placebo group. surrogate markers and secondary endpoints are commonly used in clinical trials to anticipate absolute primary outcomes, which will result in beneficial or adverse effects in the patients. equally important are the adoption of new strategies to analyze the data and draw scientific conclusions. robust statistical methods and welldesigned experiments are the fundamental requirements for testing novel treatments and repurposing existing drugs. the studies in progress-to evaluate the therapeutic effects of bcg and chloroquine in covid-19-need to continue to answer these important questions and to reinstate peoplé s trust in science. in the meantime, many lives may be lost. therefore, we must exercise caution as to what types of evidence we can accept and share, and the types of arguments and reasons to publish any fact on a social network. ' acknowledgments my thanks to my colleagues at the clinics hospital and medical school of the university of são paulo for insights and productive discussions, and to the financial support from conselho nacional de desenvolvimento científico e tecnológico (grants 486048/2011 and 312206/2016-0312206/2016-0). immunological memory defining trained immunity and its role in health and disease considering bcg vaccination to reduce the impact of covid-19 bcg vaccination protects against experimental viral infection in humans through the induction of cytokines associated with trained immunity correlation between universal bcg vaccination policy and reduced morbidity and mortality for covid-19: an epidemiological study the bcg world atlas: a database of global bcg vaccination policies and practices is bcg vaccination causally related to reduced covid-19 mortality? version 2 sars-cov-2 rates in bcg-vaccinated and unvaccinated young adults boletim epidemiológico secretaria de vigilância em saúde -ministério da saúde número especial why clinical trial outcomes fail to translate into benefits for patients chloroquine analogues in drug discovery: new directions of uses, mechanisms of actions and toxic manifestations from malaria to multifarious diseases hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial retracted: hydroxychloroquine or chloroquine with or without a macrolide for treatment of covid-19: a multinational registry analysis practical and conceptual issues of clinical trial registration for brazilian researchers key: cord-272727-a5ngjuyz authors: bertsimas, d.; boussioux, l.; cory wright, r.; delarue, a.; digalakis, v.; jacquillat, a.; lahlou kitane, d.; lukin, g.; li, m. l.; mingardi, l.; nohadani, o.; orfanoudaki, a.; papalexopoulos, t.; paskov, i.; pauphilet, j.; skali lami, o.; stellato, b.; tazi bouardi, h.; villalobos carballo, k.; wiberg, h.; zeng, c. title: from predictions to prescriptions: a data-drivenresponse to covid-19 date: 2020-06-29 journal: nan doi: 10.1101/2020.06.26.20141127 sha: doc_id: 272727 cord_uid: a5ngjuyz the covid-19 pandemic has created unprecedented challenges worldwide. strained healthcare providers make difficult decisions on patient triage, treatment and care management on a daily basis. policy makers have imposed social distancing measures to slow the disease, at a steep economic price. we design analytical tools to support these decisions and combat the pandemic. specifically, we propose a comprehensive data-driven approach to understand the clinical characteristics of covid-19, predict its mortality, forecast its evolution, and ultimately alleviate its impact. by leveraging cohort-level clinical data, patient-level hospital data, and census-level epidemiological data, we develop an integrated four-step approach, combining descriptive, predictive and prescriptive analytics. first, we aggregate hundreds of clinical studies into the most comprehensive database on covid-19 to paint a new macroscopic picture of the disease. second, we build personalized calculators to predict the risk of infection and mortality as a function of demographics, symptoms, comorbidities, and lab values. third, we develop a novel epidemiological model to project the pandemic's spread and inform social distancing policies. fourth, we propose an optimization model to reallocate ventilators and alleviate shortages. our results have been used at the clinical level by several hospitals to triage patients, guide care management, plan icu capacity, and re-distribute ventilators. at the policy level, they are currently supporting safe back-to-work policies at a major institution and equitable vaccine distribution planning at a major pharmaceutical company, and have been integrated into the us center for disease control's pandemic forecast. america is applying our infection risk calculator to determine 97 how employees can safely return to work. a major hospital 98 system in the united states planned its intensive care unit 99 (icu) capacity based on our forecasts, and leveraged our opti-100 mization results to allocate ventilators across hospitals when 101 the number of cases was rising. our epidemiological predic-102 tions are used by a major pharmaceutical company to design 103 a vaccine distribution strategy that can contain future phases 104 of the pandemic. they have also been incorporated into the 105 us center for disease control's forecasts (7). early responses to the covid-19 pandemic have been in-108 hibited by the lack of available data on patient outcomes. 109 individual centers released reports summarizing patient char-110 acteristics. yet, this decentralized e ort makes it di cult to 111 construct a cohesive picture of the pandemic. to address this problem, we construct a database that ag-113 gregates demographics, comorbidities, symptoms, laboratory 114 blood test results ("lab values", henceforth) and clinical out-115 comes from 160 clinical studies released between december 116 2019 and may 2020-made available on our website for broader 117 use. the database contains information on 133,600 covid-19 118 patients (3.13% of the global covid-19 patients as of may 119 12, 2020), spanning mainly europe (81, 207 patients), asia 120 (19, 418 patients) and north america (23, 279 patients). to 121 our knowledge, this is the largest dataset on covid-19. a. data aggregation. each study was read by an mit re-123 searcher, who transcribed numerical data from the manuscript. 124 the appendix reports the main transcription assumptions. each row in the database corresponds to a cohort of 126 patients-some papers study a single cohort, whereas oth-127 ers study several cohorts or sub-cohorts. each column reports 128 cohort-level statistics on demographics (e.g., average age, gen-129 der breakdown), comorbidities (e.g., prevalence of diabetes, 130 hypertension), symptoms (e.g., prevalence of fever, cough), 131 treatments (e.g., prevalence of antibiotics, intubation), lab 132 values (e.g., average lymphocyte count), and clinical outcomes 133 (e.g., average hospital length of stay, mortality rate). we also 134 track whether the cohort comprises "mild" or "severe" patients 135 (mild and severe cohorts are only a subset of the data). due to the pandemic's urgency, many papers were published 137 before all patients in a cohort were discharged or deceased. ac-138 cordingly, we estimate the mortality rate from discharged and 139 deceased patients only (referred to as "projected mortality"). using a similar nomenclature, figure 2a d. discussion and impact. our database is the largest avail-184 able source of clinical information on covid-19 assembled 185 to date. as such, it provides new insights on common symp-186 toms and the drivers of the disease's severity. ultimately, this 187 database can support guidelines from health organizations, 188 and contribute to ongoing clinical research on the disease. another benefit of this database is its geographical reach. 190 results highlight disparities in patients' symptoms across 191 regions. these disparities may stem from (i) di erent reporting 192 criteria; (ii) di erent treatments; (iii) disparate impacts across 193 di erent ethnic groups; and (iv) mutations of the virus since 194 it first appeared in china. this information contributes to 195 early evidence on covid-19 mutations (14, 15) and on its 196 disparate e ects on di erent ethnic groups (16, 17). the insights derived from this descriptive analysis highlight 203 the need for personalized data-driven clinical indicators. yet, 204 our population-level database cannot be leveraged directly 205 to support decision-making at the patient level. we have 206 therefore initiated a multi-institution collaboration to collect 207 electronic medical records from covid-19 patients and de-208 velop clinical risk calculators. these calculators, presented in 209 the next section, are informed by several of our descriptive 210 insights. notably, the disparities between severe patients and 211 the rest of the patient population inform the choice of the fea-212 tures included in our mortality risk calculator. moreover, the 213 geographic disparities suggest that data from asia may be less 214 predictive when building infection or mortality risk calculators 215 designed for patients in europe or north america-motivating 216 our use of data from europe. throughout the covid-19 crisis, physicians have made dif-219 ficult triage and care management decisions on a daily basis. 220 oftentimes, these decisions could only rely on small-scale 221 clinical tests, each requiring significant time, personnel and 222 equipment and thus cannot be easily replicated. once the 223 burden on "hot spots" has ebbed, hospitals began to aggregate 224 rich data on covid-19 patients. this data o ers opportu-225 nities to develop algorithmic risk calculators for large-scale 226 decision support-ultimately facilitating a more proactive and 227 data-driven strategy to combat the disease globally. 228 we have established a patient-level database of thousands of 229 covid-19 hospital admissions. using state-of-the-art machine 230 learning methods, we develop a mortality risk calculator and an 231 infection risk calculator. together, these two risk assessments 232 provide screening tools to support critical care management 233 decisions, spanning patient triage, hospital admissions, bed 234 assignment and testing prioritization. . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted june 29, 2020. . table 1 . count and prevalence of symptoms among covid-19 patients, in aggregate, broken down into mild/severe patients, and broken down per continent (asia, europe, north america). mild and severe patients only form a subset of the data, and so do patients from asia, europe and north america. a "-" indicates that fewer than 100 patients in a subpopulation reported on this symptom. all patients discriminative ability of the proposed models. we report in 286 the appendix average results across all random data partitions. 287 we also report in the appendix threshold-based metrics, 308 † hm hospitals patients were not included since no negative case data was available. c. discussion and impact. the models with lab values provide 309 algorithmic screening tools that can deliver covid-19 risk 310 predictions using common clinical features. in a constrained 311 healthcare system or in a clinic without access to advanced 312 diagnostics, clinicians can use these models to rapidly identify 313 high-risk patients to support triage and treatment decisions. the models without lab values o er an even simpler tool 315 that could be used outside of a clinical setting. in strained 316 healthcare systems, it can be di cult for patients to obtain 317 direct advice from providers. our tool could serve as a pre-318 screening step to identify personalized infection risk-without 319 visiting a testing facility. while the exclusion of lab values 320 reduces the auc (especially for infection), these calculators 321 still achieve strong predictive performance. our models provide insights into risk factors and biomark-323 ers related to covid-19 infection and mortality. our results 324 suggest that the main indicators of mortality risk are age, 325 bun, crp, ast, and low oxygen saturation. these findings 326 validate several population-level insights from section 1 and 327 are in agreement with clinical studies: prevalence of shortness 328 of breath (23), elevated levels of crp as an inflammatory 329 marker (24, 25), and elevated ast levels due to liver dysfunc-330 tion in severe covid-19 cases (11, 26). turning to infection risk, the main indicators are crp, 332 leukocytes, calcium, ast, and temperature. these findings 333 are also in agreement with clinical reports: an elevated crp 334 generally indicates an early sign of infection and implies lung 335 lesions from covid-19 (27), elevated levels of leukocytes 336 suggest cytokine release syndrome caused by sars-cov-2 337 virus (28), and lowered levels of serum calcium signal higher 338 rate of organ injury and septic shock (29) . since our findings 339 agree with clinical observations, our calculators can be used 340 to support clinical decision making-although they are not 341 intended to substitute clinical diagnostic or medical expertise. 342 when lab values are not available, the widely accepted 343 risk factors of age, oxygen saturation, temperature, and heart 344 rate become the key indicators for both risk calculators. we 345 observe that mortality risk is higher for male patients (blue in 346 figure 3b ) than for female patients (red), confirming clinical 347 reports (30, 31). an elevated respiratory frequency becomes 348 an important predictor of infection, as reported in (32). these 349 findings suggest that demographics and vitals provide valuable 350 information in the absence of lab values. however, when lab 351 values are available, these other features become secondary. a limitation of the current mortality model is that it does 353 not take into account medication and treatments during hos-354 pitalization. we intend to incorporate these in future research 355 to make these models more actionable. furthermore, these 356 models aim to reveal associations between risks and patient 357 characteristics but are not designed to establish causality. overall, we have developed data-driven calculators that 359 allow physicians and patients to assess mortality and infection 360 risks in order to guide care management-especially with 361 scarce healthcare resources. these calculators are being used 362 by several hospitals within the asst cremona system to 363 support triage and treatment decisions-alleviating the toll of 364 the pandemic. our infection calculator also supports safety 365 protocols for banco de credito del peru, the largest bank in 366 peru, to determine how employees can return to work. the inverse tangent function provides a concave-convex re-404 lationship, capturing three phases of government response. 405 in phase i, most activities continue normally as people 406 adjust their behavior. in phase ii, the infection rate 407 declines sharply as policies are implemented. in phase 408 iii, the decline in the infection rate reaches saturation. 409 the parameters t0 and k can be respectively thought of 410 as the start date and the strength of the response. ultimately, delphi involves 13 parameters that define 412 the transition rates between the 11 states. we calibrate six of 413 them from our clinical outcomes database (section 1). using 414 of the pandemic (7). it has also been used by the hartford healthcare system-the major hospital system in connecticut, 472 us-to plan its icu capacity, and by a major pharmaceutical 473 company to design a vaccine distribution strategy that can 474 most e ectively contain the next phases of the pandemic. b. delphi-presc: toward re-opening society. to inform the 476 relaxation of social distancing policies, we link policies to the 477 infection rate using machine learning. specifically, we predict 478 the values of "(t), obtained from the fitting procedure of 479 delphi-pred. for simplicity and interpretability, we consider 480 a simple model based on regression trees (35) and restrict the 481 independent variables to the policies in place. we classify 482 policies based on whether they restrict mass gatherings, school 483 and/or other activities (referred to as "others", and including 484 business closures, severe travel limitations and/or closing of 485 non-essential services). we define a set of seven mutually 486 exclusive and collectively exhaustive policies observed in the 487 us data: (i) no measure; (ii) restrict mass gatherings; (iii) 488 restrict others; (iv) authorize schools, restrict mass gatherings 489 and others; (v) restrict mass gatherings and schools; (vi) 490 restrict mass gatherings, schools and others; and (vii) stay-491 at-home. 492 we report the regression tree in the appendix, obtained 493 from state-level data in the united states. this model achieves 494 an out-of-sample r 2 of 0.8, suggesting a good fit to the data. 495 as expected, more stringent policies lead to lower values of 496 "(t). the results also provide comparisons between various 497 policies-for instance, school closures seem to induce a stronger 498 reduction in the infection rate than restricting "other" activ-499 ities. more importantly, the model quantifies the impact of 500 each policy on the infection rate. we then use these results 501 to predict the value of "(t) as a function of the policies (see 502 appendix for details), and simulate the spread of the disease 503 as states progressively loosen social distancing policies. 504 figure 4d plots the projected case count in the state of new 505 york (ny), for di erent policies (we report a similar plot for 506 the death count in the appendix). note that the stringency of 507 the policies has a significant impact on the pandemic's spread 508 and ultimate toll. for instance, relaxing all social distancing 509 policies on may 12 can increase the cumulative number of 510 cases in ny by up to 25% by september. using a similar nomenclature, figure 4e shows the case 512 count if all social distancing policies are relaxed on may 12 vs. 513 may 26. note that the timing of the policies also has a strong 514 impact: a two-week delay in re-opening society can greatly 515 reduce a resurgence in ny. the road back to a new normal is not straightforward: 517 results suggest that the disease's spread is highly sensitive to 518 both the intensity and the timing of social distancing policies. 519 as governments grapple with an evolving pandemic, delphi-520 presc can be a useful tool to explore alternative scenarios and 521 ensure that critical decisions are supported with data. we model ventilator pooling as a multi-period resource 565 allocation over s states and d days. the model takes as input 566 ventilator demand in state s and day d, denoted as v s,d , as 567 well as parameters capturing the surge supply from the federal 568 government and the extent of inter-state collaboration. we 569 formulate an optimization problem that decides on the number 570 of ventilators transferred from state s to state s õ on day d, 571 and on the number of ventilators allocated from the federal 572 government to state s on day d. we propose a bi-objective 573 formulation. the first objective is to minimize ventilator-day 574 shortages; for robustness, we consider both projected shortages 575 (based on demand forecasts) and worst-case shortages (includ-576 ing a bu er in the demand estimates). the second objective 577 is to minimize inter-state transfers, to limit the operational 578 and political costs of inter-state coordination. mixed-integer 579 optimization provides modeling flexibility to capture spatial-580 temporal dynamics and the trade-o s between these various 581 objectives. we report the mathematical formulation of the 582 model, along with the key assumptions, in the appendix. put on a ventilator, which we use to estimate the demand for 589 ventilators. we also obtain the average length of stay from 590 our clinical outcomes database (figure 2 ). we discuss these trade-o s further in the appendix. a similar model has been developed to support the re-626 distribution of ventilators across hospitals within the hartford 627 healthcare system in connecticut-using county-level fore-628 casts of ventilator demand obtained from delphi-pred. this 629 model has been used by a collection of hospitals in the united 630 states to align ventilator supply with projected demand at a 631 time where the pandemic was on the rise. looking ahead, the proposed model can support the alloca-633 tion of critical resources in the next phases of the pandemic-634 spanning ventilators, medicines, personal protective equipment 635 etc. since epidemics do not peak in each state at the same 636 time, states whose infection peak has already passed or lies 637 weeks ahead can help other states facing immediate shortages 638 at little costs to their constituents. inter-state transfers of 639 ventilators occurred in isolated fashion through april 2020; 640 our model proposes an automated decision-making tool to 641 support these decisions systematically. as our results show, 642 proactive coordination and resource pooling can significantly 643 reduce shortages-thus increasing the number of patients that 644 can be treated without resorting to extreme clinical recourse 645 with side e ects (such as splitting ventilators). this paper proposes a comprehensive data-driven approach to 648 address several core challenges faced by healthcare providers 649 and policy makers in the midst of the covid-19 pandemic. 650 we have gathered and aggregated data from hundreds of clini-651 dimitris bertsimas et al. pnas | may 26, 2020 | vol. xxx | no. xx | 9 . cc-by 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted june 29, 2020. . cal studies, electronic health records, and census reports. we sophia xing and cynthia zheng from 672 our extended team for helpful discussions persistence of coronaviruses on inanimate sur-674 faces and its inactivation with biocidal agents high contagiousness and rapid spread of severe acute respiratory 676 how will country-based 680 mitigation measures influence the course of the covid-19 epidemic? economic effects of coronavirus outbreak (covid-19) on the world economy. 683 available at ssrn the global macroeconomic impacts of covid-19: seven scenarios. 685 cama work covid-19 forecasts check if you have coronavirus symptoms 694 clinical characteristics of coronavirus disease 2019 in china clinical characteristics of covid-19 in factors associated with hospitalization and critical illness among 4,103 701 patients with covid-19 disease in new york city phylogenetic network analysis of sars-cov-2 703 genomes an 81 nucleotide deletion in sars-cov-2 orf7a identified from sentinel 705 surveillance in arizona hospitalization rates and characteristics of patients hospitalized with laboratory-707 confirmed coronavirus disease 2019-covid-net, 14 states racial and ethnic disparities in sars-cov-2 pandemic: analysis of a covid-19 710 observational registry for a diverse us metropolitan population positive rt-pcr test results in patients recovered from covid-19 missing value estimation methods for dna microarrays xgboost: a scalable tree boosting system in proceedings of the 22nd 716 acm sigkdd international conference on knowledge discovery and data mining a unified approach to interpreting model predictions in advances in 719 neural information processing systems 30 from local explanations to global understanding with explainable ai for 722 trees unique epidemiological and clinical features of the emerg-724 ing 2019 novel coronavirus pneumonia (covid-19) implicate special control measures the covid-19 epidemic chest ct features of covid-19 in rome, italy clinical features of patients infected with 2019 novel coronavirus in wuhan, 730 china c-reactive protein levels in the early stage of covid-19 covid-19 infection: the perspectives on immune responses serum calcium as a biomarker of clinical severity and prognosis in patients with 735 coronavirus disease 2019: a retrospective cross-sectional study covid-19: risk factors for severe disease and death neutrophil-to-lymphocyte ratio as an independent risk factor for mortality in 738 hospitalized patients with covid-19 clinical course and risk factors for mortality of adult inpatients with covid-19 in 740 china: a retrospective cohort study. the lancet projecting the transmission dy-742 namics of sars-cov-2 through the postpandemic period classification and regression trees effects of prone positioning on lung protection in patients with acute 748 the standard of care of patients with ards: ventilatory settings and rescue 751 therapies for refractory hypoxemia intubation and ventilation amid the covid-19 outbreakwuhan's experience critical supply shortages-the need for ventilators and per-755 sonal protective equipment during the covid-19 pandemic stockpiling ventilators for influenza pandemics a model of supply-chain decisions for 759 resource sharing with an application to ventilator allocation to combat covid-19 key: cord-334433-oudvxb4d authors: beane, joal d.; dedhia, priya h.; ejaz, aslam; contreras, carlo m.; cloyd, jordan m.; tsung, allan; pawlik, timothy m. title: conducting clinical trials in the time of a pandemic date: 2020-06-08 journal: ann surg doi: 10.1097/sla.0000000000004114 sha: doc_id: 334433 cord_uid: oudvxb4d nan mini abstract: the novel human coronavirus (sars-cov-2) has created formidable challenges to the conduct of clinical trials and research.herein we describethe unparalleled response to these challengesand the effort to advance clinical trials in the face of the pandemic. the covid-19 pandemic has created formidable challenges to the conduct of clinicaltrials and research.overcoming these challenges has requiredcreativity and resourcefulness to mount broad-sweeping changes. responses to mitigate the effects of the pandemichave included: 1) thedevelopment of strategies to support research programs during unforeseen economic loss, 2)establishment of institutionalguidelines for clinical trials, 3)measures to ensure a healthy clinical research team, 4) useof innovative technologies to maintain access to clinical trials, 5) amendment of protocols to avoid costly trial closures, and 6) the strategic reopening of suspended clinical trials. herein we discuss how each of these strategies has been used to sustainclinical trials and surgical research in the face of extraordinaryadversity. the covid-19 pandemic has caused significant financial ramifications to all stakeholders in clinical trials -pharmaceutical and device companies, patients, and healthcare systems. as such,institutional leadership may need to reprioritize clinical research efforts and shift resources away from high-risk pilot studies and phase i trials to support more advanced phase iii studies. in addition, increasing efforts in grant submissions, other public and private funding, and charitable donations are needed to boost funds to support clinical research. while the economic impact will be felt for years and is well beyond the control of the academician and clinical trialist, using the principles outlined below to reduce costly errors and to preserve ongoing trial efforts may be our best chance to mitigate the effects of the covid-19 pandemic. institutional guidelines should be established relative to initiating new clinical trials, managing accrual efforts to current studies, and discerning between essential and non-essential studies. patient safety must remain top priority and a reappraisal of ongoing clinical trialsis vital to ensure appropriate balance of risks and benefits to the patient and the health system.navigating these types of decisions can be difficult and errors in judgement can be copyright © 2020 wolters kluwer health, inc. unauthorized reproduction of this article is prohibited. costly.decisions should include all stakeholders and be informed by guidelinespublished by thefood and drug administration (fda). 1 in addition to these guidelines and frequent updates from the irb, our institution has established a monitoring team that is readily available to review evolving research decisions. specifically, an irb "hotline" has been established to ensure accessibility to this team. experienced researchers and clinical trialists are available to help navigate unexpected challenges and ensuring patient safety and trial integrity. maintaining the wellbeing of the clinical research workforce is paramount to preserving clinical trials during a pandemic. however, the availability of staff can decrease by as much as 40-50% due to illness, death, absenteeism related to fear and anxiety, as well as competing needs such as caring for children or ill family members. 2 one of the most important strategies to help preserve the workforce is to ensure adherence to national and international guidelines regarding the use of ppe. 3 in addition to physical safety, measures to ensure mental fitness are just as important to ensuring the research team's health and wellbeing.while many centers have already experienced their surge of covid-19 infections and the clinical burden is waning, the psychological impact of the pandemic may linger. 2, 4 in addition, as clinical volume and research begin to ramp back up, a strained workforce may result in extended hours for clinical staff. as such,it is imperative that employees are provided with resources to safeguard mental health( figure) . 4 these strategies may be helpful for nonclinical research staff, as well as individuals who may be anxious about the timing of laboratory reopenings and/or the ability to obtain research funding or grant extensions. at our institution, telemedicine is being used to interface with patients to discuss diagnoses, review imaging, and provide multidisciplinary consultation. in addition, telemedicine is being employed to contact trial participants, enroll and screen patients, as well as assess the status of patients already accrued in clinical trials. in march, over the course of one week, the volume of telemedicine visits jumped from less than 100 encounters per day to well over 2,200 per day. in addition to maintaining access to clinical trials, the improved communication afforded by telemedicine has aided in reassuring participants that their involvement remains copyright © 2020 wolters kluwer health, inc. unauthorized reproduction of this article is prohibited. important during this time,which has helped to prevent costly dropouts or nonadherence. 5 recently, telemedicine has also been approved as a means to have discussions regarding informed consent as long as a document that can be mailed to and signed by the patients is completed.these benefits have resulted in an exponential increase in telemedicine utilization that have been invaluable to preserving access to clinical trials and research and to capturing important data points with regards to efficacy and adverse events that otherwise would have been lost. while technology and telemedicine platforms may improve access to care and clinical trials, the availability of specific devices or implants may threaten continuity of certain trials. for essential clinical trials, investigators should work closely with the trial sponsor and device manufacturer. in addition, for multicenter studies excess inventory at one center can be shared with other participating centers to ensure that equitable trial accessibility is maintained. efforts to modify protocols in order to comply with the emergency public health response and the guidelines established by the fda and irbareencouraged.investigators need to prioritize collection of data, focusing on the primary endpoint and important secondary endpoints to remain in compliance.clinical protocols should be reexamined thoroughly and amendments should be made to reduce superfluous clinical visits.while many protocol changes typically required an amendment and lengthy review process, to avoid costly delays, reviews of amendments at our institution are being waived or expedited if the adjustment pertains to patient safety in the setting of covid-19. for other modifications, a more formalized process is generally necessary, but should be expedited when possible. amendments should be used primarily to protect patientsand research staff, but can also be used strategicallytoadapt protocols andavoid trial suspension. in this way, investigators may be able tomaintain accrual of new patients or continue to collect important data from currently enrolled patients. for example, an amendment to monitor remotely an implanted device may facilitate continued treatment and collection of important data when nonessential interactions must be suspended. alternatively, for patients receiving infusion therapy, an amendment can be written that allows the medication to be administered by a home health nurse to avoid crowded outpatient infusion centers.protocols should be updated with ongoing data collection. for copyright © 2020 wolters kluwer health, inc. unauthorized reproduction of this article is prohibited. example, collecting patient-reported endpoints for device or implant studies may include mailed or telephone surveys to replace scheduled in-person visits. 5 in summary, adapting protocols todeliver an intervention or collect valuable outcomes can help to avoid costly suspensions,and updating trial procedures to ensure patient safety are important in order to mitigate the challenges posed by the covid-19 pandemic. given the current environment, irbs should be prepared for a significant increase in protocol deviations. at our institution we are actively increasing the capacity of the irb to review and address deviations expeditiously since a timely review is important to preserving trial integrity.to this end, deviationsto clinical protocols should be tracked carefully, as well as documented, reported, and dealt with according to institutional guidelines.guidelines distributed by the department of health and human resourceshelp to define protocol deviations.for any type of deviation, thorough documentation in the medical record is vital to maintaining trial integrity. it is important to note that major protocol violations may not result in a corrective action plan or even a protocol amendment if related to challenges posed by the covid-19 pandemic. a thorough reappraisal of all trials should be conductedregularly to reassess the development ofnew risks to participants, the availability of clinical staff andof the investigational drug or device,and disruptions related to quarantines, site closures, or travel limitations (table) . 1 a reduction in clinical research staff may force clinical trials and other studies to be suspended. in addition, multiple, major deviations in study protocolor errors in data collection related to the pandemicmay lead to afailed clinical trial, or worse, erroneous conclusions. as such, one may need to consider suspending aclinical trial until conditions improve. 6 thoughtful, timely appraisals and a multidisciplinary approach to these decisions can helpavoid costly failures and ensure the safety of patients and providers, as well as the integrity of the trial, remain intact. now that many centers are beyond the anticipated surge, guidelines should be established for reopening clinical trials that were suspended during the peak response to covid-19. disease copyright © 2020 wolters kluwer health, inc. unauthorized reproduction of this article is prohibited. site leaders should work with treating physicians, research teams, clinical trial offices, as well as irb leadership to create a succinct list of feasible studies that could be reactivated. the should be limited to essential trials that provide needed treatment for patients with limited alternatives. trials of lower complexity and research-only procedures should be prioritized. careful consideration should be given to whether more complex studies that involve extensive visits to the medical center or those trials that pose a challenge to social distancing should be included. in addition, only studiesin whichthe protocol calendar can be followed without excessive deviationshould be considered. when prioritizing trials, investigator-initiated studies may be more desirable since these studies can be amended more readily to permit changes in procedures and thus avoid protocol deviations. the ramp-up period must provide ample time for coordinators and the research team to begin returning to campus as needed and for acquiring the necessary approval from sponsors to begin enrolling again.to ensure safety and avoid costly errors,the reopening of clinical trials should occur in phases, based on priority, and within the guidelines established for social distancing. in summary, the covid-19 pandemic has created many unforeseen challenges that threaten important and costly clinical trials and research efforts. while the impact of this pandemicis broad, the research team mustremaindedicatedtocreatinginnovative approaches to advanceclinical research for our patients. copyright © 2020 wolters kluwer health, inc. unauthorized reproduction of this article is prohibited. copyright © 2020 wolters kluwer health, inc. unauthorized reproduction of this article is prohibited. fda guidance on conduct of clinical trials of medical products during covid-19 pandemic. 2020. fda.gov/media/136238/download accessed 18 disease control priorities: improving health and reducing poverty strategy and technology to prevent hospitalacquired infections: lessons from sars, ebola, and mers in asia and west africa mental health in the covid-19 pandemic preserving clinical trial integrity during the coronavirus pandemic estimated costs of pivotal trials for novel therapeutic agents approved by the us food and drug administration wolters kluwer health, inc. unauthorized reproduction of this article is prohibited key: cord-279255-v861kk0i authors: dhama, kuldeep; khan, sharun; tiwari, ruchi; sircar, shubhankar; bhat, sudipta; malik, yashpal singh; singh, karam pal; chaicumpa, wanpen; bonilla-aldana, d. katterine; rodriguez-morales, alfonso j. title: coronavirus disease 2019–covid-19 date: 2020-06-24 journal: clin microbiol rev doi: 10.1128/cmr.00028-20 sha: doc_id: 279255 cord_uid: v861kk0i in recent decades, several new diseases have emerged in different geographical areas, with pathogens including ebola virus, zika virus, nipah virus, and coronaviruses (covs). recently, a new type of viral infection emerged in wuhan city, china, and initial genomic sequencing data of this virus do not match with previously sequenced covs, suggesting a novel cov strain (2019-ncov), which has now been termed severe acute respiratory syndrome cov-2 (sars-cov-2). although coronavirus disease 2019 (covid-19) is suspected to originate from an animal host (zoonotic origin) followed by human-to-human transmission, the possibility of other routes should not be ruled out. compared to diseases caused by previously known human covs, covid-19 shows less severe pathogenesis but higher transmission competence, as is evident from the continuously increasing number of confirmed cases globally. compared to other emerging viruses, such as ebola virus, avian h7n9, sars-cov, and middle east respiratory syndrome coronavirus (mers-cov), sars-cov-2 has shown relatively low pathogenicity and moderate transmissibility. codon usage studies suggest that this novel virus has been transferred from an animal source, such as bats. early diagnosis by real-time pcr and next-generation sequencing has facilitated the identification of the pathogen at an early stage. since no antiviral drug or vaccine exists to treat or prevent sars-cov-2, potential therapeutic strategies that are currently being evaluated predominantly stem from previous experience with treating sars-cov, mers-cov, and other emerging viral diseases. in this review, we address epidemiological, diagnostic, clinical, and therapeutic aspects, including perspectives of vaccines and preventive measures that have already been globally recommended to counter this pandemic virus. o ver the past 2 decades, coronaviruses (covs) have been associated with significant disease outbreaks in east asia and the middle east. the severe acute respiratory syndrome (sars) and the middle east respiratory syndrome (mers) began to emerge in 2002 and 2012, respectively. recently, a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2), causing coronavirus disease 2019 (covid19) , emerged in late 2019, and it has posed a global health threat, causing an ongoing pandemic in many countries and territories (1) . health workers worldwide are currently making efforts to control further disease outbreaks caused by the novel cov (originally named 2019-ncov), which was first identified in wuhan city, hubei province, china, on 12 december 2019. on 11 february 2020, the world health organization (who) announced the official designation for the current cov-associated disease to be covid-19, caused by sars-cov-2. the primary cluster of patients was found to be connected with the huanan south china seafood market in wuhan (2) . covs belong to the family coronaviridae (subfamily coronavirinae), the members of which infect a broad range of hosts, producing symptoms and diseases ranging from the common cold to severe and ultimately fatal illnesses, such as sars, mers, and, presently, covid-19. sars-cov-2 is considered one of the seven members of the cov family that infect humans (3) , and it belongs to the same lineage of covs that causes sars; however, this novel virus is genetically distinct. until 2020, six covs were known to infect humans, including human cov 229e (hcov-229e), hcov-nl63, hcov-oc43, hcov-hku1, sars-cov, and mers-cov. although sars-cov and mers-cov have resulted in outbreaks with high mortality, others remain associated with mild upper-respiratory-tract illnesses (4) . newly evolved covs pose a high threat to global public health. the current emergence of covid-19 is the third cov outbreak in humans over the past 2 decades (5) . it is no coincidence that fan et al. predicted potential sars-or mers-like cov outbreaks in china following pathogen transmission from bats (6) . covid-19 emerged in china and spread rapidly throughout the country and, subsequently, to other countries. due to the severity of this outbreak and the potential of spreading on an international scale, the who declared a global health emergency on 31 january 2020; subsequently, on 11 march 2020, they declared it a pandemic situation. at present, we are not in a position to effectively treat covid-19, since neither approved vaccines nor specific antiviral drugs for treating human cov infections are available (7) (8) (9) . most nations are currently making efforts to prevent the further spreading of this potentially deadly virus by implementing preventive and control strategies. in domestic animals, infections with covs are associated with a broad spectrum of furthermore, it acts as a critical factor for tissue tropism and the determination of host range (45) . notably, s protein is one of the vital immunodominant proteins of covs capable of inducing host immune responses (45) . the ectodomains in all covs s proteins have similar domain organizations, divided into two subunits, s1 and s2 (43) . the first one, s1, helps in host receptor binding, while the second one, s2, accounts for fusion. the former (s1) is further divided into two subdomains, namely, the n-terminal domain (ntd) and c-terminal domain (ctd). both of these subdomains act as receptorbinding domains, interacting efficiently with various host receptors (45) . the s1 ctd contains the receptor-binding motif (rbm). in each coronavirus spike protein, the trimeric s1 locates itself on top of the trimeric s2 stalk (45) . recently, structural analyses of the s proteins of covid-19 have revealed 27 amino acid substitutions within a 1,273-amino-acid stretch (16) . six substitutions are located in the rbd (amino acids 357 to 528), while four substitutions are in the rbm at the ctd of the s1 domain (16) . of note, no amino acid change is seen in the rbm, which binds directly to the angiotensinconverting enzyme-2 (ace2) receptor in sars-cov (16, 46) . at present, the main emphasis is knowing how many differences would be required to change the host tropism. sequence comparison revealed 17 nonsynonymous changes between the early sequence of sars-cov-2 and the later isolates of sars-cov. the changes were found scattered over the genome of the virus, with nine substitutions in orf1ab, orf8 (4 substitutions), the spike gene (3 substitutions) , and orf7a (single substitution) (4) . notably, the same nonsynonymous changes were found in a familial cluster, indicating that the viral evolution happened during person-to-person transmission (4, 47) . such adaptive evolution events are frequent and constitute a constantly ongoing process once the virus spreads among new hosts (47) . even though no functional changes occur in the virus associated with this adaptive evolution, close monitoring of the viral mutations that occur during subsequent human-to-human transmission is warranted. the m protein is the most abundant viral protein present in the virion particle, giving a definite shape to the viral envelope (48) . it binds to the nucleocapsid and acts as a central organizer of coronavirus assembly (49) . coronavirus m proteins are highly diverse in amino acid contents but maintain overall structural similarity within different genera (50) . the m protein has three transmembrane domains, flanked by a short amino terminus outside the virion and a long carboxy terminus inside the virion (50) . overall, the viral scaffold is maintained by m-m interaction. of note, the m protein of sars-cov-2 does not have an amino acid substitution compared to that of sars-cov (16) . the coronavirus e protein is the most enigmatic and smallest of the major structural proteins (51) . it plays a multifunctional role in the pathogenesis, assembly, and release of the virus (52) . it is a small integral membrane polypeptide that acts as a viroporin (ion channel) (53) . the inactivation or absence of this protein is related to the altered virulence of coronaviruses due to changes in morphology and tropism (54) . the e protein consists of three domains, namely, a short hydrophilic amino terminal, a large hydrophobic transmembrane domain, and an efficient c-terminal domain (51) . the sars-cov-2 e protein reveals a similar amino acid constitution without any substitution (16) . the n protein of coronavirus is multipurpose. among several functions, it plays a role in complex formation with the viral genome, facilitates m protein interaction needed during virion assembly, and enhances the transcription efficiency of the virus (55, 56) . it contains three highly conserved and distinct domains, namely, an ntd, an rna-binding domain or a linker region (lkr), and a ctd (57) . the ntd binds with the 3= end of the viral genome, perhaps via electrostatic interactions, and is highly diverged both in length and sequence (58) . the charged lkr is serine and arginine rich and is also known as the sr (serine and arginine) domain (59) . the lkr is capable of direct interaction with in vitro rna interaction and is responsible for cell signaling (60, 61) . it also modulates the antiviral response of the host by working as an antagonist for interferon (ifn) and rna interference (62) . compared to that of sars-cov, the n protein of sars-cov-2 possess five amino acid mutations, where two are in the intrinsically dispersed region (idr; positions 25 and 26) , one each in the ntd (position 103), lkr (position 217), and ctd (position 334) (16) . besides the important structural proteins, the sars-cov-2 genome contains 15 nsps, nsp1 to nsp10 and nsp12 to nsp16, and 8 accessory proteins (3a, 3b, p6, 7a, 7b, 8b, 9b, and orf14) (16) . all these proteins play a specific role in viral replication (27) . unlike the accessory proteins of sars-cov, sars-cov-2 does not contain 8a protein and has a longer 8b and shorter 3b protein (16) . the nsp7, nsp13, envelope, matrix, and p6 and 8b accessory proteins have not been detected with any amino acid substitutions compared to the sequences of other coronaviruses (16) . the virus structure of sars-cov-2 is depicted in fig. 2 . sequence percent similarity analysis. we assessed the nucleotide percent similarity using the megalign software program, where the similarity between the novel sars-cov-2 isolates was in the range of 99.4% to 100%. among the other serbecovirus cov sequences, the novel sars-cov-2 sequences revealed the highest similarity to bat-sl-cov, with nucleotide percent identity ranges between 88.12 and 89.65%. meanwhile, earlier reported sars-covs showed 70.6 to 74.9% similarity to sars-cov-2 at the nucleotide level. further, the nucleotide percent similarity was 55.4%, 45.5% to 47.9%, 46 .2% to 46.6%, and 45.0% to 46.3% to the other four subgenera, namely, hibecovirus, nobecovirus, merbecovirus, and embecovirus, respectively. the percent similarity index of current outbreak isolates indicates a close relationship between sars-cov-2 isolates and bat-sl-cov, indicating a common origin. however, particular pieces of evidence based on further complete genomic analysis of current isolates are necessary to draw any conclusions, although it was ascertained that the current novel sars-cov-2 isolates belong to the subgenus sarbecovirus in the diverse range of betacoronaviruses. their possible ancestor was hypothesized to be from bat cov strains, wherein bats might have played a crucial role in harboring this class of viruses. splitstree phylogeny analysis. in the unrooted phylogenetic tree of different betacoronaviruses based on the s protein, virus sequences from different subgenera grouped into separate clusters. sars-cov-2 sequences from wuhan and other countries exhibited a close relationship and appeared in a single cluster (fig. 1 ). the covs from the subgenus sarbecovirus appeared jointly in splitstree and divided into three subclusters, namely, sars-cov-2, bat-sars-like-cov (bat-sl-cov), and sars-cov (fig. 1) . in the case of other subgenera, like merbecovirus, all of the sequences grouped clinical microbiology reviews than italy. a john hopkins university web platform has provided daily updates on the basic epidemiology of the covid-19 outbreak (https://gisanddata.maps.arcgis.com/ apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6) (238) . covid-19 has also been confirmed on a cruise ship, named diamond princess, quarantined in japanese waters (port of yokohama), as well as on other cruise ships around the world (239) (fig. 3) . the significant events of the sars-cov-2/covid-19 virus outbreak occurring since 8 december 2019 are presented as a timeline in fig. 5 . at the beginning, china experienced the majority of the burden associated with covid-19 in the form of disease morbidity and mortality (65), but over time the covid-19 menace moved to europe, particularly italy and spain, and now the united states has the highest number of confirmed cases and deaths. the covid-19 outbreak has also been associated with severe economic impacts globally due to the sudden interruption of global trade and supply chains that forced multinational companies to make decisions that led to significant economic losses (66) . the recent increase in the number of confirmed critically ill patients with covid-19 has already surpassed the intensive care supplies, limiting intensive care services to only a small portion of critically ill patients (67) . this might also have contributed to the increased case fatality rate observed in the covid-19 outbreak. the novel coronavirus was identified within 1 month (28 days) of the outbreak. this is impressively fast compared to the time taken to identify sars-cov reported in foshan, guangdong province, china (125 days) (68) . immediately after the confirmation of viral etiology, the chinese virologists rapidly released the genomic sequence of sars-cov-2, which played a crucial role in controlling the spread of this newly emerged novel coronavirus to other parts of the world (69) . the possible origin of sars-cov-2 and the first mode of disease transmission are not yet identified (70) . analysis of the initial cluster of infections suggests that the infected individuals had a common exposure point, a seafood market in wuhan, hubei province, china (fig. 6 ). the restaurants of this market are well-known for providing different types of wild animals for human consumption (71) . the huanan south china seafood market also sells live animals, such as poultry, bats, snakes, and marmots (72) . this might be the point where zoonotic (animal-to-human) transmission occurred (71) . although sars-cov-2 is alleged to have originated from an animal host (zoonotic origin) with further humanto-human transmission (fig. 6 ), the likelihood of foodborne transmission should be ruled out with further investigations, since it is a latent possibility (1). additionally, other clinical microbiology reviews potential and expected routes would be associated with transmission, as in other respiratory viruses, by direct contact, such as shaking contaminated hands, or by direct contact with contaminated surfaces (fig. 6) . still, whether blood transfusion and organ transplantation (276) , as well as transplacental and perinatal routes, are possible routes for sars-cov-2 transmission needs to be determined (fig. 6 ). from experience with several outbreaks associated with known emerging viruses, higher pathogenicity of a virus is often associated with lower transmissibility. compared to emerging viruses like ebola virus, avian h7n9, sars-cov, and mers-cov, sars-cov-2 has relatively lower pathogenicity and moderate transmissibility (15) . the risk of death among individuals infected with covid-19 was calculated using the infection fatality risk (ifr). the ifr was found to be in the range of 0.3% to 0.6%, which is comparable to that of a previous asian influenza pandemic (1957 to 1958) (73, 277) . notably, the reanalysis of the covid-19 pandemic curve from the initial cluster of cases pointed to considerable human-to-human transmission. it is opined that the exposure history of sars-cov-2 at the wuhan seafood market originated from humanto-human transmission rather than animal-to-human transmission (74) ; however, in light of the zoonotic spillover in covid-19, is too early to fully endorse this idea (1). following the initial infection, human-to-human transmission has been observed with a preliminary reproduction number (r 0 ) estimate of 1.4 to 2.5 (70, 75) , and recently it is estimated to be 2.24 to 3.58 (76) . in another study, the average reproductive number of covid-19 was found to be 3.28, which is significantly higher than the initial who estimate of 1.4 to 2.5 (77) . it is too early to obtain the exact r 0 value, since there is a possibility of bias due to insufficient data. the higher r 0 value is indicative of the more significant potential of sars-cov-2 transmission in a susceptible population. this is not the first time where the culinary practices of china have been blamed for the origin of novel coronavirus infection in humans. previously, the animals present in the liveanimal market were identified to be the intermediate hosts of the sars outbreak in china (78) . several wildlife species were found to harbor potentially evolving coronavirus strains that can overcome the species barrier (79) . one of the main principles of chinese food culture is that live-slaughtered animals are considered more nutritious (5) . after 4 months of struggle that lasted from december 2019 to march 2020, the covid-19 situation now seems under control in china. the wet animal markets have reopened, and people have started buying bats, dogs, cats, birds, scorpions, badgers, rabbits, pangolins (scaly anteaters), minks, soup from palm civet, ostriches, hamsters, snapping turtles, ducks, fish, siamese crocodiles, and other animal meats without any fear of covid-19. the chinese government is encouraging people to feel they can return to normalcy. however, this could be a risk, as it has been mentioned in advisories that people should avoid contact with live-dead animals as much as possible, as sars-cov-2 has shown zoonotic spillover. additionally, we cannot rule out the possibility of new mutations in the same virus being closely related to contact with both animals and humans at the market (284) . in january 2020, china imposed a temporary ban on the sale of live-dead animals in wet markets. however, now hundreds of such wet markets have been reopened without optimizing standard food safety and sanitation practices (286) . with china being the most populated country in the world and due to its domestic and international food exportation policies, the whole world is now facing the menace of covid-19, including china itself. wet markets of live-dead animals do not maintain strict food hygienic practices. fresh blood splashes are present everywhere, on the floor and tabletops, and such food customs could encourage many pathogens to adapt, mutate, and jump the species barrier. as a result, the whole world is suffering from novel sars-cov-2, with more than 4,170,424 cases and 287,399 deaths across the globe. there is an urgent need for a rational international campaign against the unhealthy food practices of china to encourage the sellers to increase hygienic food practices or close the crude live-dead animal wet markets. there is a need to modify food policies at national and international levels to avoid further life threats and clinical microbiology reviews economic consequences from any emerging or reemerging pandemic due to close animal-human interaction (285) . even though individuals of all ages and sexes are susceptible to covid-19, older people with an underlying chronic disease are more likely to become severely infected (80) . recently, individuals with asymptomatic infection were also found to act as a source of infection to susceptible individuals (81) . both the asymptomatic and symptomatic patients secrete similar viral loads, which indicates that the transmission capacity of asymptomatic or minimally symptomatic patients is very high. thus, sars-cov-2 transmission can happen early in the course of infection (82) . atypical clinical manifestations have also been reported in covid-19 in which the only reporting symptom was fatigue. such patients may lack respiratory signs, such as fever, cough, and sputum (83) . hence, the clinicians must be on the look-out for the possible occurrence of atypical clinical manifestations to avoid the possibility of missed diagnosis. the early transmission ability of sars-cov-2 was found to be similar to or slightly higher than that of sars-cov, reflecting that it could be controlled despite moderate to high transmissibility (84) . increasing reports of sars-cov-2 in sewage and wastewater warrants the need for further investigation due to the possibility of fecal-oral transmission. sars-cov-2 present in environmental compartments such as soil and water will finally end up in the wastewater and sewage sludge of treatment plants (328) . therefore, we have to reevaluate the current wastewater and sewage sludge treatment procedures and introduce advanced techniques that are specific and effective against sars-cov-2. since there is active shedding of sars-cov-2 in the stool, the prevalence of infections in a large population can be studied using wastewater-based epidemiology. recently, reverse transcription-quantitative pcr (rt-qpcr) was used to enumerate the copies of sars-cov-2 rna concentrated from wastewater collected from a wastewater treatment plant (327) . the calculated viral rna copy numbers determine the number of infected individuals. the increasing reports of virus shedding via the fecal route warrants the introduction of negative fecal viral nucleic acid test results as one of the additional discharge criteria in laboratory-confirmed cases of covid-19 (326) . the covid-19 pandemic does not have any novel factors, other than the genetically unique pathogen and a further possible reservoir. the cause and the likely future outcome are just repetitions of our previous interactions with fatal coronaviruses. the only difference is the time of occurrence and the genetic distinctness of the pathogen involved. mutations on the rbd of covs facilitated their capability of infecting newer hosts, thereby expanding their reach to all corners of the world (85) . this is a potential threat to the health of both animals and humans. advanced studies using bayesian phylogeographic reconstruction identified the most probable origin of sars-cov-2 as the bat sars-like coronavirus, circulating in the rhinolophus bat family (86) . phylogenetic analysis of 10 whole-genome sequences of sars-cov-2 showed that they are related to two covs of bat origin, namely, bat-sl-covzc45 and bat-sl-covzxc21, which were reported during 2018 in china (17) . it was reported that sars-cov-2 had been confirmed to use ace2 as an entry receptor while exhibiting an rbd similar to that of sars-cov (17, 87, 254, 255) . several countries have provided recommendations to their people traveling to china (88, 89) . compared to the previous coronavirus outbreaks caused by sars-cov and mers-cov, the efficiency of sars-cov-2 human-to-human transmission was thought to be less. this assumption was based on the finding that health workers were affected less than they were in previous outbreaks of fatal coronaviruses (2) . superspreading events are considered the main culprit for the extensive transmission of sars and mers (90, 91) . almost half of the mers-cov cases reported in saudi arabia are of secondary origin that occurred through contact with infected asymptomatic or symptomatic individuals through human-tohuman transmission (92) . the occurrence of superspreading events in the covid-19 outbreak cannot be ruled out until its possibility is evaluated. like sars and mers, covid-19 can also infect the lower respiratory tract, with milder symptoms (27) . the basic reproduction number of covid-19 has been found to be in the range of 2.8 to 3.3 based on real-time reports and 3.2 to 3.9 based on predicted infected cases (84) . coronavirus infection in humans is commonly associated with mild to severe respiratory diseases, with high fever, severe inflammation, cough, and internal organ dysfunction that can even lead to death (92) . most of the identified coronaviruses cause the common cold in humans. however, this changed when sars-cov was identified, paving the way for severe forms of the disease in humans (22) . our previous experience with the outbreaks of other coronaviruses, like sars and mers, suggests that the mode of transmission in covid-19 as mainly human-to-human transmission via direct contact, droplets, and fomites (25) . recent studies have demonstrated that the virus could remain viable for hours in aerosols and up to days on surfaces; thus, aerosol and fomite contamination could play potent roles in the transmission of sars-cov-2 (257) . the immune response against coronavirus is vital to control and get rid of the infection. however, maladjusted immune responses may contribute to the immunopathology of the disease, resulting in impairment of pulmonary gas exchange. understanding the interaction between covs and host innate immune systems could enlighten our understanding of the lung inflammation associated with this infection (24) . sars is a viral respiratory disease caused by a formerly unrecognized animal cov that originated from the wet markets in southern china after adapting to the human host, thereby enabling transmission between humans (90) . the sars outbreak reported in 2002 to 2003 had 8,098 confirmed cases with 774 total deaths (9.6%) (93) . the outbreak severely affected the asia pacific region, especially mainland china (94) . even though the case fatality rate (cfr) of sars-cov-2 (covid-19) is lower than that of sars-cov, there exists a severe concern linked to this outbreak due to its epidemiological similarity to influenza viruses (95, 279) . this can fail the public health system, resulting in a pandemic (96) . mers is another respiratory disease that was first reported in saudi arabia during the year 2012. the disease was found to have a cfr of around 35% (97) . the analysis of available data sets suggests that the incubation period of sars-cov-2, sars-cov, and mers-cov is in almost the same range. the longest predicted incubation time of sars-cov-2 is 14 days. hence, suspected individuals are isolated for 14 days to avoid the risk of further spread (98) . even though a high similarity has been reported between the genome sequence of the new coronavirus (sars-cov-2) and sars-like covs, the comparative analysis recognized a furin-like cleavage site in the sars-cov-2 s protein that is missing from other sars-like covs (99) . the furin-like cleavage site is expected to play a role in the life cycle of the virus and disease pathogenicity and might even act as a therapeutic target for furin inhibitors. the highly contagious nature of sars-cov-2 compared to that of its predecessors might be the result of a stabilizing mutation that occurred in the endosome-associated-protein-like domain of nsp2 protein. similarly, the destabilizing mutation near the phosphatase domain of nsp3 proteins in sars-cov-2 could indicate a potential mechanism that differentiates it from other covs (100) . even though the cfr reported for covid-19 is meager compared to those of the previous sars and mers outbreaks, it has caused more deaths than sars and mers combined (101) . possibly related to the viral pathogenesis is the recent finding of an 832-nucleotide (nt) deletion in orf8, which appears to reduce the replicative fitness of the virus and leads to attenuated phenotypes of sars-cov-2 (256) . coronavirus is the most prominent example of a virus that has crossed the species barrier twice from wild animals to humans during sars and mers outbreaks (79, 102) . the possibility of crossing the species barrier for the third time has also been suspected in the case of sars-cov-2 (covid19) . bats are recognized as a possible natural reservoir host of both sars-cov and mers-cov infection. in contrast, the possible intermediary host is the palm civet for sars-cov and the dromedary camel for mers-cov infection (102) . bats are considered the ancestral hosts for both sars and mers (103) . bats are also considered the reservoir host of human coronaviruses like clinical microbiology reviews hcov-229e and hcov-nl63 (104) . in the case of covid-19, there are two possibilities for primary transmission: it can be transmitted either through intermediate hosts, similar to that of sars and mers, or directly from bats (103) . the emergence paradigm put forward in the sars outbreak suggests that sars-cov originated from bats (reservoir host) and later jumped to civets (intermediate host) and incorporated changes within the receptor-binding domain (rbd) to improve binding to civet ace2. this civetadapted virus, during their subsequent exposure to humans at live markets, promoted further adaptations that resulted in the epidemic strain (104) . transmission can also occur directly from the reservoir host to humans without rbd adaptations. the bat coronavirus that is currently in circulation maintains specific "poised" spike proteins that facilitate human infection without the requirement of any mutations or adaptations (105) . altogether, different species of bats carry a massive number of coronaviruses around the world (106) . the high plasticity in receptor usage, along with the feasibility of adaptive mutation and recombination, may result in frequent interspecies transmission of coronavirus from bats to animals and humans (106) . the pathogenesis of most bat coronaviruses is unknown, as most of these viruses are not isolated and studied (4) . hedgehog coronavirus hku31, a betacoronavirus, has been identified from amur hedgehogs in china. studies show that hedgehogs are the reservoir of betacoronavirus, and there is evidence of recombination (107) . the current scientific evidence available on mers infection suggests that the significant reservoir host, as well as the animal source of mers infection in humans, is the dromedary camels (97) . the infected dromedary camels may not show any visible signs of infection, making it challenging to identify animals actively excreting mers-cov that has the potential to infect humans. however, they may shed mers-cov through milk, urine, feces, and nasal and eye discharge and can also be found in the raw organs (108) . in a study conducted to evaluate the susceptibility of animal species to mers-cov infection, llamas and pigs were found to be susceptible, indicating the possibility of mers-cov circulation in animal species other than dromedary camels (109) . following the outbreak of sars in china, sars-cov-like viruses were isolated from himalayan palm civets (paguma larvata) and raccoon dogs (nyctereutes procyonoides) found in a live-animal market in guangdong, china. the animal isolates obtained from the live-animal market retained a 29-nucleotide sequence that was not present in most of the human isolates (78) . these findings were critical in identifying the possibility of interspecies transmission in sars-cov. the higher diversity and prevalence of bat coronaviruses in this region compared to those in previous reports indicate a host/ pathogen coevolution. sars-like coronaviruses also have been found circulating in the chinese horseshoe bat (rhinolophus sinicus) populations. the in vitro and in vivo studies carried out on the isolated virus confirmed that there is a potential risk for the reemergence of sars-cov infection from the viruses that are currently circulating in the bat population (105) . the disease caused by sars-cov-2 is also named severe specific contagious pneumonia (sscp), wuhan pneumonia, and, recently, covid-19 (110) . compared to sars-cov, sars-cov-2 has less severe pathogenesis but has superior transmission capability, as evidenced by the rapidly increasing number of covid-19 cases (111) . the incubation period of sars-cov-2 in familial clusters was found to be 3 to 6 days (112) . the mean incubation period of covid-19 was found to be 6.4 days, ranging from 2.1 to 11.1 days (113) . among an early affected group of 425 patients, 59 years was the median age, of which more males were affected (114) . similar to sars and mers, the severity of this ncov is high in age groups above 50 years (2, 115) . symptoms of covid-19 include fever, cough, myalgia or fatigue, and, less commonly, headache, hemoptysis, and diarrhea (116, 282) . compared to the sars-cov-2-infected patients in wuhan during the initial stages of the outbreak, only mild symptoms were noticed in those patients that are infected by human-to-human transmission (14) . the initial trends suggested that the mortality associated with covid-19 was less than that of previous outbreaks of sars (101) . the updates obtained from countries like china, japan, thailand, and south korea indicated that the covid-19 patients had relatively mild manifestations compared to those with sars and mers (4). regardless of the coronavirus type, immune cells, like mast cells, that are present in the submucosa of the respiratory tract and nasal cavity are considered the primary barrier against this virus (92) . advanced in-depth analysis of the genome has identified 380 amino acid substitutions between the amino acid sequences of sars-cov-2 and the sars/sarslike coronaviruses. these differences in the amino acid sequences might have contributed to the difference in the pathogenic divergence of sars-cov-2 (16) . further research is required to evaluate the possible differences in tropism, pathogenesis, and transmission of this novel agent associated with this change in the amino acid sequence. with the current outbreak of covid-19, there is an expectancy of a significant increase in the number of published studies about this emerging coronavirus, as occurred with sars and mers (117) . sars-cov-2 invades the lung parenchyma, resulting in severe interstitial inflammation of the lungs. this is evident on computed tomography (ct) images as ground-glass opacity in the lungs. this lesion initially involves a single lobe but later expands to multiple lung lobes (118) . the histological assessment of lung biopsy samples obtained from covid-19-infected patients revealed diffuse alveolar damage, cellular fibromyxoid exudates, hyaline membrane formation, and desquamation of pneumocytes, indicative of acute respiratory distress syndrome (119) . it was also found that the sars-cov-2infected patients often have lymphocytopenia with or without leukocyte abnormalities. the degree of lymphocytopenia gives an idea about disease prognosis, as it is found to be positively correlated with disease severity (118) . pregnant women are considered to have a higher risk of getting infected by covid-19. the coronaviruses can cause adverse outcomes for the fetus, such as intrauterine growth restriction, spontaneous abortion, preterm delivery, and perinatal death. nevertheless, the possibility of intrauterine maternal-fetal transmission (vertical transmission) of covs is low and was not seen during either the sars-or mers-cov outbreak (120) . however, there has been concern regarding the impact of sars-cov-2/covid-19 on pregnancy. researchers have mentioned the probability of in utero transmission of novel sars-cov-2 from covid-19-infected mothers to their neonates in china based upon the rise in igm and igg antibody levels and cytokine values in the blood obtained from newborn infants immediately postbirth; however, rt-pcr failed to confirm the presence of sars-cov-2 genetic material in the infants (283) . recent studies show that at least in some cases, preterm delivery and its consequences are associated with the virus. nonetheless, some cases have raised doubts for the likelihood of vertical transmission (240) (241) (242) (243) . covid-19 infection was associated with pneumonia, and some developed acute respiratory distress syndrome (ards). the blood biochemistry indexes, such as albumin, lactate dehydrogenase, c-reactive protein, lymphocytes (percent), and neutrophils (percent) give an idea about the disease severity in covid-19 infection (121) . during covid-19, patients may present leukocytosis, leukopenia with lymphopenia (244), hypoalbuminemia, and an increase of lactate dehydrogenase, aspartate transaminase, alanine aminotransferase, bilirubin, and, especially, d-dimer (244) . middle-aged and elderly patients with primary chronic diseases, especially high blood pressure and diabetes, were found to be more susceptible to respiratory failure and, therefore, had poorer prognoses. providing respiratory support at early stages improved the disease prognosis and facilitated recovery (18) . the ards in covid-19 is due to the occurrence of cytokine storms that results in exaggerated immune response, immune regulatory network imbalance, and, finally, multiple-organ failure (122) . in addition to the exaggerated inflammatory response seen in patients with covid-19 pneumonia, the bile duct epithelial cell-derived hepatocytes upregulate ace2 expression in liver tissue by compensatory proliferation that might result in hepatic tissue injury (123) . coronavirus can cause disease in several species of domestic and wild animals, as well as humans (23) . the different animal species that are infected with cov include horses, camels, cattle, swine, dogs, cats, rodents, birds, ferrets, minks, bats, rabbits, snakes, and various other wild animals (20, 30, 79, 93, 124, 125, 287) . coronavirus infection is linked to different kinds of clinical manifestations, varying from enteritis in cows and pigs, upper respiratory disease in chickens, and fatal respiratory infections in humans (30) . among the cov genera, alphacoronavirus and betacoronavirus infect mammals, while gammacoronavirus and deltacoronavirus mainly infect birds, fishes, and, sometimes, mammals (27, 29, 106) . several novel coronaviruses that come under the genus deltacoronavirus have been discovered in the past from birds, like wigeon coronavirus hku20, bulbul coronavirus hku11, munia coronavirus hku13, white-eye coronavirus hku16, night-heron coronavirus hku19, and common moorhen coronavirus hku21, as well as from pigs (porcine coronavirus hku15) (6, 29) . transmissible gastroenteritis virus (tgev), porcine epidemic diarrhea virus (pedv), and porcine hemagglutinating encephalomyelitis virus (phev) are some of the coronaviruses of swine. among them, tgev and pedv are responsible for causing severe gastroenteritis in young piglets with noteworthy morbidity and mortality. infection with phev also causes enteric infection but can cause encephalitis due to its ability to infect the nervous system (30) . bovine coronaviruses (bocovs) are known to infect several domestic and wild ruminants (126) . bocov inflicts neonatal calf diarrhea in adult cattle, leading to bloody diarrhea (winter dysentery) and respiratory disease complex (shipping fever) in cattle of all age groups (126) . bocov-like viruses have been noted in humans, suggesting its zoonotic potential as well (127) . feline enteric and feline infectious peritonitis (fip) viruses are the two major feline covs (128) , where feline covs can affect the gastrointestinal tract, abdominal cavity (peritonitis), respiratory tract, and central nervous system (128) . canines are also affected by covs that fall under different genera, namely, canine enteric coronavirus in alphacoronavirus and canine respiratory coronavirus in betacoronavirus, affecting the enteric and respiratory tract, respectively (129, 130) . ibv, under gammacoronavirus, causes diseases of respiratory, urinary, and reproductive systems, with substantial economic losses in chickens (131, 132) . in small laboratory animals, mouse hepatitis virus, rat sialodacryoadenitis coronavirus, and guinea pig and rabbit coronaviruses are the major covs associated with disease manifestations like enteritis, hepatitis, and respiratory infections (10, 133) . swine acute diarrhea syndrome coronavirus (sads-cov) was first identified in suckling piglets having severe enteritis and belongs to the genus alphacoronavirus (106) . the outbreak was associated with considerable scale mortality of piglets (24,693 deaths) across four farms in china (134) . the virus isolated from the piglets was almost identical to and had 95% genomic similarity with horseshoe bat (rhinolophus species) coronavirus hku2, suggesting a bat origin of the pig virus (106, 134, 135) . it is also imperative to note that the sads-cov outbreak started in guangdong province, near the location of the sars pandemic origin (134) . before this outbreak, pigs were not known to be infected with bat-origin coronaviruses. this indicates that the bat-origin coronavirus jumped to pig by breaking the species barrier. the next step of this jump might not end well, since pigs are considered the mixing vessel for influenza a viruses due to their ability to be infected by both human and avian influenza a viruses (136) . similarly, they may act as the mixing vessel for coronaviruses, since they are in frequent contact with both humans and multiple wildlife species. additionally, pigs are also found to be susceptible to infection with human sars-cov and mers-cov, making this scenario a nightmare (109, 137) . it is only a matter of time before another zoonotic coronavirus results in an epidemic by jumping the so-called species barrier (287) . the host spectrum of coronavirus increased when a novel coronavirus, namely, sw1, was recognized in the liver tissue of a captive beluga whale (delphinapterus leucas) (138) . in recent decades, several novel coronaviruses were identified from different animal species. bats can harbor these viruses without manifesting any clinical disease but are persistently infected (30) . they are the only mammals with the capacity for self-powered flight, which enables them to migrate long distances, unlike land mammals. bats are distributed worldwide and also account for about a fifth of all mammalian species (6) . this makes them the ideal reservoir host for many viral agents and also the source of novel coronaviruses that have yet to be identified. it has become a necessity to study the diversity of coronavirus in the bat population to prevent future outbreaks that could jeopardize livestock and public health. the repeated outbreaks caused by bat-origin coronaviruses calls for the development of efficient molecular surveillance strategies for studying betacoronavirus among animals (12) , especially in the rhinolophus bat family (86) . chinese bats have high commercial value, since they are used in traditional chinese medicine (tcm). therefore, the handling of bats for trading purposes poses a considerable risk of transmitting zoonotic cov epidemics (139) . due to the possible role played by farm and wild animals in sars-cov-2 infection, the who, in their novel coronavirus (covid-19) situation report, recommended the avoidance of unprotected contact with both farm and wild animals (25) . the live-animal markets, like the one in guangdong, china, provides a setting for animal coronaviruses to amplify and to be transmitted to new hosts, like humans (78) . such markets can be considered a critical place for the origin of novel zoonotic diseases and have enormous public health significance in the event of an outbreak. bats are the reservoirs for several viruses; hence, the role of bats in the present outbreak cannot be ruled out (140) . in a qualitative study conducted for evaluating the zoonotic risk factors among rural communities of southern china, the frequent human-animal interactions along with the low levels of environmental biosecurity were identified as significant risks for the emergence of zoonotic disease in local communities (141, 142) . the comprehensive sequence analysis of the sars-cov-2 rna genome identified that the cov from wuhan is a recombinant virus of the bat coronavirus and another coronavirus of unknown origin. the recombination was found to have happened within the viral spike glycoprotein, which recognizes the cell surface receptor. further analysis of the genome based on codon usage identified the snake as the most probable animal reservoir of sars-cov-2 (143) . contrary to these findings, another genome analysis proposed that the genome of sars-cov-2 is 96% identical to bat coronavirus, reflecting its origin from bats (63) . the involvement of bat-derived materials in causing the current outbreak cannot be ruled out. high risk is involved in the production of bat-derived materials for tcm practices involving the handling of wild bats. the use of bats for tcm practices will remain a severe risk for the occurrence of zoonotic coronavirus epidemics in the future (139) . furthermore, the pangolins are an endangered species of animals that harbor a wide variety of viruses, including coronaviruses (144) . the coronavirus isolated from malayan pangolins (manis javanica) showed a very high amino acid identity with covid-19 at e (100%), m (98.2%), n (96.7%), and s genes (90.4%). the rbd of s protein in cov isolated from pangolin was almost identical (one amino acid difference) to that of sars-cov-2. a comparison of the genomes suggests recombination between pangolin-cov-like viruses with the bat-cov-ratg13-like virus. all this suggests the potential of pangolins to act as the intermediate host of sars-cov-2 (145) . human-wildlife interactions, which are increasing in the context of climate change (142) , are further considered high risk and responsible for the emergence of sars-cov. covid-19 is also suspected of having a similar mode of origin. hence, to prevent the occurrence of another zoonotic spillover (1), exhaustive coordinated efforts are needed to identify the high-risk pathogens harbored by wild animal populations, conducting surveillance among the people who are susceptible to zoonotic spillover events (12) , and to improve the biosecurity measures associated with the wildlife trade (146) . the serological surveillance studies conducted in people living in proximity to bat caves had earlier identified the serological confirmation of sars-related covs in humans. people clinical microbiology reviews living at the wildlife-human interface, mainly in rural china, are regularly exposed to sars-related covs (147) . these findings will not have any significance until a significant outbreak occurs due to a virus-like sars-cov-2. there is a steady increase in the reports of covid-19 in companion and wild animals around the world. further studies are required to evaluate the potential of animals (especially companion animals) to serve as an efficient reservoir host that can further alter the dynamics of human-to-human transmission (330) . to date, two pet dogs (hong kong) and four pet cats (one each from belgium and hong kong, two from the united states) have tested positive for sars-cov-2 (335) . the world organization for animal health (oie) has confirmed the diagnosis of covid-19 in both dogs and cats due to human-to-animal transmission (331) . the similarity observed in the gene sequence of sars-cov-2 from an infected pet owner and his dog further confirms the occurrence of human-to-animal transmission (333) . even though asymptomatic, feline species should be considered a potential transmission route from animals to humans (326) . however, currently, there are no reports of sars-cov-2 transmission from felines to human beings. based on the current evidence, we can conclude that cats are susceptible to sars-cov-2 and can get infected by human beings. however, evidence of cat-to-human transmission is lacking and requires further studies (332) . rather than waiting for firmer evidence on animal-to-human transmission, necessary preventive measures are advised, as well as following social distancing practices among companion animals of different households (331) . one of the leading veterinary diagnostic companies, idexx, has conducted large-scale testing for covid-19 in specimens collected from dogs and cats. however, none of the tests turned out to be positive (334) . in a study conducted to investigate the potential of different animal species to act as the intermediate host of sars-cov-2, it was found that both ferrets and cats can be infected via experimental inoculation of the virus. in addition, infected cats efficiently transmitted the disease to naive cats (329) . sars-cov-2 infection and subsequent transmission in ferrets were found to recapitulate the clinical aspects of covid-19 in humans. the infected ferrets also shed virus via multiple routes, such as saliva, nasal washes, feces, and urine, postinfection, making them an ideal animal model for studying disease transmission (337) . experimental inoculation was also done in other animal species and found that the dogs have low susceptibility, while the chickens, ducks, and pigs are not at all susceptible to sars-cov-2 (329) . similarly, the national veterinary services laboratories of the usda have reported covid-19 in tigers and lions that exhibited respiratory signs like dry cough and wheezing. the zoo animals are suspected to have been infected by an asymptomatic zookeeper (335) . the total number of covid-19-positive cases in human beings is increasing at a high rate, thereby creating ideal conditions for viral spillover to other species, such as pigs. the evidence obtained from sars-cov suggests that pigs can get infected with sars-cov-2 (336). however, experimental inoculation with sars-cov-2 failed to infect pigs (329) . further studies are required to identify the possible animal reservoirs of sars-cov-2 and the seasonal variation in the circulation of these viruses in the animal population. research collaboration between human and animal health sectors is becoming a necessity to evaluate and identify the possible risk factors of transmission between animals and humans. such cooperation will help to devise efficient strategies for the management of emerging zoonotic diseases (12) . rna tests can confirm the diagnosis of sars-cov-2 (covid-19) cases with real-time rt-pcr or next-generation sequencing (148, 149, 245, 246) . at present, nucleic acid detection techniques, like rt-pcr, are considered an effective method for confirming the diagnosis in clinical cases of covid-19 (148) . several companies across the world are currently focusing on developing and marketing sars-cov-2-specific nucleic acid detection kits. multiple laboratories are also developing their own in-house rt-pcr. one of them is the sars-cov-2 nucleic acid detection kit produced by shuoshi biotechnology (double fluorescence pcr method) (150) . up to 30 march 2020, the u.s. food and drug administration (fda) had granted 22 in vitro diagnostics emergency use authorizations (euas), including for the rt-pcr diagnostic panel for the universal detection of sars-like betacoronaviruses and specific detection of sars-cov-2, developed by the u.s. cdc (table 1) (258, 259) . recently, 95 full-length genomic sequences of saras-cov-2 strains available in the national center for biotechnology information and gisaid databases were subjected to multiple-sequence alignment and phylogenetic analyses for studying variations in the viral genome (260) . all the viral strains revealed high homology of 99.99% (99.91% to 100%) at the nucleotide level and 99.99% (99.79% to 100%) at the amino acid level. overall variation was found to be low in orf regions, with 13 variation sites recognized in 1a, 1b, s, 3a, m, 8, and n regions. mutation rates of 30.53% (29/95) and 29.47% (28/95) were observed at nt 28144 (orf8) and nt 8782 (orf1a) positions, respectively. owing to such selective mutations, a few specific regions of sars-cov-2 should not be considered for designing primers and probes. the sars-cov-2 reference sequence could pave the way to study molecular biology and pathobiology, along with developing diagnostics and appropriate prevention and control strategies for countering sars-cov-2 (260) . nucleic acids of sars-cov-2 can be detected from samples (64) such as bronchoalveolar lavage fluid, sputum, nasal swabs, fiber bronchoscope brush biopsy specimen, pharyngeal swabs, feces, blood, and urine, with different levels of diagnostic performance (table 2) (80, 245, 246) . the viral loads of sars-cov-2 were measured using n-gene-specific quantitative rt-pcr in throat swab and sputum samples collected from covid-19-infected individuals. the results indicated that the viral load peaked at around 5 to 6 days following the onset of symptoms, and it ranged from 10 4 to 10 7 copies/ml during this time (151) . in another study, the viral load was found to be higher in the nasal swabs than the throat swabs obtained from covid-19 symptomatic patients (82) . although initially it was thought that viral load would be associated with poor outcomes, some case reports have shown asymptomatic individuals with high viral loads (247) . recently, the viral load in nasal and throat swabs of 17 symptomatic patients was determined, and higher viral loads were recorded soon after the onset of symptoms, particularly in the nose compared to the throat. the pattern of viral nucleic the results of the studies related to sars-cov-2 viral loads reflect active replication of this virus in the upper respiratory tract and prolonged viral shedding after symptoms disappear, including via stool. thus, the current case definition needs to be updated along with a reassessment of the strategies to be adopted for restraining the sars-cov-2 outbreak spread (248) . in some cases, the viral load studies of sars-cov-2 have also been useful to recommend precautionary measures when handling specific samples, e.g., feces. in a recent survey from 17 confirmed cases of sars-cov-2 infection with available data (representing days 0 to 13 after onset), stool samples from nine cases (53%; days 0 to 11 after onset) were positive on rt-pcr analysis. although the viral loads were lower than those of respiratory samples (range, 550 copies per ml to 1.21 ϫ 10 5 copies per ml), this has essential biosafety implications (151) . the samples from 18 sars-cov-2-positive patients in singapore who had traveled from wuhan to singapore showed the presence of viral rna in stool and whole blood but not in urine by real-time rt-pcr (288) . further, novel sars-cov-2 infections have been detected in a variety of clinical specimens, like bronchoalveolar lavage fluid, sputum, nasal swabs, fibrobronchoscope brush biopsy specimens, pharyngeal swabs, feces, and blood (246) . the presence of sars-cov-2 in fecal samples has posed grave public health concerns. in addition to the direct transmission mainly occurring via droplets of sneezing and coughing, other routes, such as fecal excretion and environmental and fomite contamination, are contributing to sars-cov-2 transmission and spread (249) (250) (251) (252) . fecal excretion has also been documented for sars-cov and mers-cov, along with the potential to stay viable in situations aiding fecal-oral transmission. thus, sars-cov-2 has every possibility to be transmitted through this mode. fecal-oral transmission of sars-cov-2, particularly in regions having low standards of hygiene and poor sanitation, may have grave consequences with regard to the high spread of this virus. ethanol and disinfectants containing chlorine or bleach are effective against coronaviruses (249) (250) (251) (252) . appropriate precautions need to be followed strictly while handling the stools of patients infected with sars-cov-2. biowaste materials and sewage from hospitals must be adequately disinfected, treated, and disposed of properly. the significance of frequent and good hand hygiene and sanitation practices needs to be given due emphasis (249) (250) (251) (252) . future explorative research needs to be conducted with regard to the fecal-oral transmission of sars-cov-2, along with focusing on environmental investigations to find out if this virus could stay viable in situations and atmospheres facilitating such potent routes of transmission. the correlation of fecal concentrations of viral rna with disease severity needs to be determined, along with assessing the gastrointestinal symptoms and the possibility of fecal sars-cov-2 rna detection during the covid-19 incubation period or convalescence phases of the disease (249) (250) (251) (252) . the lower respiratory tract sampling techniques, like bronchoalveolar lavage fluid aspirate, are considered the ideal clinical materials, rather than the throat swab, due to their higher positive rate on the nucleic acid test (148) . the diagnosis of covid-19 can be made by using upper-respiratory-tract specimens collected using nasopharyngeal and oropharyngeal swabs. however, these techniques are associated with unnecessary risks to health care workers due to close contact with patients (152) . similarly, a single patient with a high viral load was reported to contaminate an entire endoscopy room by shedding the virus, which may remain viable for at least 3 days and is considered a great risk for uninfected patients and health care workers (289) . recently, it was found that the anal swabs gave more positive results than oral swabs in the later stages of infection (153) . hence, clinicians have to be cautious while discharging any covid-19infected patient based on negative oral swab test results due to the possibility of fecal-oral transmission. even though the viral loads in stool samples were found to be less than those of respiratory samples, strict precautionary measures have to be followed while handling stool samples of covid-19 suspected or infected patients (151) . children infected with sars-cov-2 experience only a mild form of illness and recover immediately after treatment. it was recently found that stool samples of sars-cov-2-infected children that gave negative throat swab results were positive within ten days of negative results. this could result in the fecal-oral transmission of sars-cov-2 infections, especially in children (290) . hence, to prevent the fecal-oral transmission of sars-cov-2, infected covid-19 patients should only be considered negative when they test negative for sars-cov-2 in the stool sample. a suspected case of covid-19 infection is said to be confirmed if the respiratory tract aspirate or blood samples test positive for sars-cov-2 nucleic acid using rt-pcr or by the identification of sars-cov-2 genetic sequence in respiratory tract aspirate or blood samples (80) . the patient will be confirmed as cured when two subsequent oral swab results are negative (153) . recently, the live virus was detected in the selfcollected saliva of patients infected with covid-19. these findings were confirmative of using saliva as a noninvasive specimen for the diagnosis of covid-19 infection in suspected individuals (152) . it has also been observed that the initial screening of covid-19 patients infected with rt-pcr may give negative results even if they have chest ct findings that are suggestive of infection. hence, for the accurate diagnosis of covid-19, a combination of repeated swab tests using rt-pcr and ct scanning is required to prevent the possibility of false-negative results during disease screening (154) . rt-pcr is the most widely used test for diagnosing covid-19. however, it has some significant limitations from the clinical perspective, since it will not give any clarity regarding disease progression. droplet digital pcr (ddpcr) can be used for the quantification of viral load in the samples obtained from lower respiratory tracts. hence, based on the viral load, we can quickly evaluate the progression of infection (291) . in addition to all of the above findings, sequencing and phylogenetics are critical in the correct identification and confirmation of the causative viral agent and useful to establish relationships with previous isolates and sequences, as well as to know, especially during an epidemic, the nucleotide and amino acid mutations and the molecular divergence. the rapid development and implementation of diagnostic tests against emerging novel diseases like covid-19 pose significant challenges due to the lack of resources and logistical limitations associated with an outbreak (155) . sars-cov-2 infection can also be confirmed by isolation and culturing. the human airway epithelial cell culture was found to be useful in isolating sars-cov-2 (3). the efficient control of an outbreak depends on the rapid diagnosis of the disease. recently, in response to the covid-19 outbreak, 1-step quantitative realtime reverse transcription-pcr assays were developed that detect the orf1b and n regions of the sars-cov-2 genome (156) . that assay was found to achieve the rapid detection of sars-cov-2. nucleic acid-based assays offer high accuracy in the diagnosis of sars-cov-2, but the current rate of spread limits its use due to the lack of diagnostic assay kits. this will further result in the extensive transmission of covid-19, since only a portion of suspected cases can be diagnosed. in such situations, conventional serological assays, like enzyme-linked immunosorbent assay (elisa), that are specific to covid-19 igm and igg antibodies can be used as a high-throughput alternative (149) . at present, there is no diagnostic kit available for detecting the sars-cov-2 antibody (150) . the specific antibody profiles of covid-19 patients were analyzed, and it was found that the igm level lasted more than 1 month, indicating a prolonged stage of virus replication in sars-cov-2-infected patients. the igg levels were found to increase only in the later stages of the disease. these findings indicate that the specific antibody profiles of sars-cov-2 and sars-cov were similar (325) . these findings can be utilized for the development of specific diagnostic tests against covid-19 and can be used for rapid screening. even though diagnostic test kits are already available that can detect the genetic sequences of sars-cov-2 (95), their availability is a concern, as the number of covid-19 cases is skyrocketing (155, 157) . a major problem associated with this diagnostic kit is that it works only when the test subject has an active infection, limiting its use to the earlier stages of infection. several laboratories around the world are currently developing antibody-based diagnostic tests against sars-cov-2 (157). chest ct is an ideal diagnostic tool for identifying viral pneumonia. the sensitivity of chest ct is far superior to that of x-ray screening. the chest ct findings associated with covid-19-infected patients include characteristic patchy infiltration that later progresses to ground-glass opacities (158) . early manifestations of covid-19 pneumonia might not be evident in x-ray chest radiography. in such situations, a chest ct examination can be performed, as it is considered highly specific for covid-19 pneumonia (118) . those patients having covid-19 pneumonia will exhibit the typical ground-glass opacity in their chest ct images (154) . the patients infected with covid-19 had elevated plasma angiotensin 2 levels. the level of angiotensin 2 was found to be linearly associated with viral load and lung injury, indicating its potential as a diagnostic biomarker (121) . the chest ct imaging abnormalities associated with covid-19 pneumonia have also been observed even in asymptomatic patients. these abnormalities progress from the initial focal unilateral to diffuse bilateral ground-glass opacities and will further progress to or coexist with lung consolidation changes within 1 to 3 weeks (159). the role played by radiologists in the current scenario is very important. radiologists can help in the early diagnosis of lung abnormalities associated with covid-19 pneumonia. they can also help in the evaluation of disease severity, identifying its progression to acute respiratory distress syndrome and the presence of secondary bacterial infections (160) . even though chest ct is considered an essential diagnostic tool for covid-19, the extensive use of ct for screening purposes in the suspected individuals might be associated with a disproportionate risk-benefit ratio due to increased radiation exposure as well as increased risk of cross-infection. hence, the use of ct for early diagnosis of sars-cov-2 infection in high-risk groups should be done with great caution (292) . more recently, other advanced diagnostics have been designed and developed for the detection of sars-cov-2 (345, 347, (350) (351) (352) . a reverse transcriptional loopmediated isothermal amplification (rt-lamp), namely, ilaco, has been developed for rapid and colorimetric detection of this virus (354) . rt-lamp serves as a simple, rapid, and sensitive diagnostic method that does not require sophisticated equipment or skilled personnel (349) . an interactive web-based dashboard for tracking sars-cov-2 in a real-time mode has been designed (238) . a smartphone-integrated home-based point-of-care testing (poct) tool, a paper-based poct combined with lamp, is a useful point-of-care diagnostic (353) . an abbott id now covid-19 molecular poct-based test, using isothermal nucleic acid amplification technology, has been designed as a pointof-care test for very rapid detection of sars-cov-2 in just 5 min (344) . a crispr-based sherlock (specific high-sensitivity enzymatic reporter unlocking) diagnostic for rapid detection of sars-cov-2 without the requirement of specialized instrumentation has been reported to be very useful in the clinical diagnosis of covid-19 (360) . a crispr-cas12-based lateral flow assay also has been developed for rapid detection of sars-cov-2 (346) . artificial intelligence, by means of a three-dimensional deep-learning model, has been developed for sensitive and specific diagnosis of covid-19 via ct images (332) . tracking and mapping of the rising incidence rates, disease outbreaks, community spread, clustered transmission events, hot spots, and superspreader potential of sars-cov-2/covid warrant full exploitation of real-time disease mapping by employing geographical information systems (gis), such as the gis software kosmo 3.1, web-based real-time tools and dashboards, apps, and advances in information technology (356-359). researchers have also developed a few prediction tools/models, such as the prediction model risk of bias assessment tool (probast) and critical appraisal and data extraction for systematic reviews of prediction modeling studies (charms), which could aid in assessing the possibility of getting infection and estimating the prognosis in patients; however, such models may suffer from bias issues and, hence, cannot be considered completely trustworthy, which necessitates the development of new and reliable predictors (360) . recently emerged viruses, such as zika, ebola, and nipah viruses, and their grave threats to humans have begun a race in exploring the designing and developing of advanced vaccines, prophylactics, therapeutics, and drug regimens to counter emerging viruses (161) (162) (163) 280) . several attempts are being made to design and develop vaccines for cov infection, mostly by targeting the spike glycoprotein. nevertheless, owing to extensive diversity in antigenic variants, cross-protection rendered by the vaccines is significantly limited, even within the strains of a phylogenetic subcluster (104) . due to the lack of effective antiviral therapy and vaccines in the present scenario, we need to depend solely on implementing effective infection control measures to lessen the risk of possible nosocomial transmission (68) . recently, the receptor for sars-cov-2 was established as the human angiotensin-converting enzyme 2 (hace2), and the virus was found to enter the host cell mainly through endocytosis. it was also found that the major components that have a critical role in viral entry include pikfyve, tpc2, and cathepsin l. these findings are critical, since the components described above might act as candidates for vaccines or therapeutic drugs against sars-cov-2 (293) . the majority of the treatment options and strategies that are being evaluated for sars-cov-2 (covid-19) have been taken from our previous experiences in treating sars-cov, mers-cov, and other emerging viral diseases. several therapeutic and preventive strategies, including vaccines, immunotherapeutics, and antiviral drugs, have been exploited against the previous cov outbreaks (sars-cov and mers-cov) (8, 104, (164) (165) (166) (167) . these valuable options have already been evaluated for their potency, efficacy, and safety, along with several other types of current research that will fuel our search for ideal therapeutic agents against covid-19 (7, 9, 19, 21, 36) . the primary cause of the unavailability of approved and commercial vaccines, drugs, and therapeutics to counter the earlier sars-cov and mers-cov seems to owe to the lesser attention of the biomedicine and pharmaceutical companies, as these two covs did not cause much havoc, global threat, and panic like those posed by the sars-cov-2 pandemic (19) . moreover, for such outbreak situations, the requirement for vaccines and therapeutics/drugs exists only for a limited period, until the outbreak is controlled. the proportion of the human population infected with sars-cov and mers-cov was also much lower across the globe, failing to attract drug and vaccine manufacturers and clinical microbiology reviews producers. therefore, by the time an effective drug or vaccine is designed against such disease outbreaks, the virus would have been controlled by adopting appropriate and strict prevention and control measures, and patients for clinical trials will not be available. the newly developed drugs cannot be marketed due to the lack of end users. the s protein plays a significant role in the induction of protective immunity against sars-cov by mediating t-cell responses and neutralizing antibody production (168) . in the past few decades, we have seen several attempts to develop a vaccine against human coronaviruses by using s protein as the target (168, 169) . however, the developed vaccines have minimal application, even among closely related strains of the virus, due to a lack of cross-protection. that is mainly because of the extensive diversity existing among the different antigenic variants of the virus (104) . the contributions of the structural proteins, like spike (s), matrix (m), small envelope (e), and nucleocapsid (n) proteins, of sars-cov to induce protective immunity has been evaluated by expressing them in a recombinant parainfluenza virus type 3 vector (bhpiv3). of note, the result was conclusive that the expression of m, e, or n proteins without the presence of s protein would not confer any noticeable protection, with the absence of detectable serum sars-cov-neutralizing antibodies (170) . antigenic determinant sites present over s and n structural proteins of sars-cov-2 can be explored as suitable vaccine candidates (294) . in the asian population, s, e, m, and n proteins of sars-cov-2 are being targeted for developing subunit vaccines against covid-19 (295) . the identification of the immunodominant region among the subunits and domains of s protein is critical for developing an effective vaccine against the coronavirus. the c-terminal domain of the s1 subunit is considered the immunodominant region of the porcine deltacoronavirus s protein (171) . similarly, further investigations are needed to determine the immunodominant regions of sars-cov-2 for facilitating vaccine development. however, our previous attempts to develop a universal vaccine that is effective for both sars-cov and mers-cov based on t-cell epitope similarity pointed out the possibility of cross-reactivity among coronaviruses (172) . that can be made possible by selected potential vaccine targets that are common to both viruses. sars-cov-2 has been reported to be closely related to sars-cov (173, 174) . hence, knowledge and understanding of s protein-based vaccine development in sars-cov will help to identify potential s protein vaccine candidates in sars-cov-2. therefore, vaccine strategies based on the whole s protein, s protein subunits, or specific potential epitopes of s protein appear to be the most promising vaccine candidates against coronaviruses. the rbd of the s1 subunit of s protein has a superior capacity to induce neutralizing antibodies. this property of the rbd can be utilized for designing potential sars-cov vaccines either by using rbd-containing recombinant proteins or recombinant vectors that encode rbd (175) . hence, the superior genetic similarity existing between sars-cov-2 and sars-cov can be utilized to repurpose vaccines that have proven in vitro efficacy against sars-cov to be utilized for sars-cov-2. the possibility of cross-protection in covid-19 was evaluated by comparing the s protein sequences of sars-cov-2 with that of sars-cov. the comparative analysis confirmed that the variable residues were found concentrated on the s1 subunit of s protein, an important vaccine target of the virus (150) . hence, the possibility of sars-cov-specific neutralizing antibodies providing cross-protection to covid-19 might be lower. further genetic analysis is required between sars-cov-2 and different strains of sars-cov and sarslike (sl) covs to evaluate the possibility of repurposed vaccines against covid-19. this strategy will be helpful in the scenario of an outbreak, since much time can be saved, because preliminary evaluation, including in vitro studies, already would be completed for such vaccine candidates. multiepitope subunit vaccines can be considered a promising preventive strategy against the ongoing covid-19 pandemic. in silico and advanced immunoinformatic tools can be used to develop multiepitope subunit vaccines. the vaccines that are engineered by this technique can be further evaluated using docking studies and, if found effective, then can be further evaluated in animal models (365) . identifying epitopes that have the potential to become a vaccine candidate is critical to developing an effective vaccine against covid-19. the immunoinformatics approach has been used for recognizing essential epitopes of cytotoxic t lymphocytes and b cells from the surface glycoprotein of sars-cov-2. recently, a few epitopes have been recognized from the sars-cov-2 surface glycoprotein. the selected epitopes explored targeting molecular dynamic simulations, evaluating their interaction with corresponding major histocompatibility complex class i molecules. they potentially induce immune responses (176) . the recombinant vaccine can be designed by using rabies virus (rv) as a viral vector. rv can be made to express mers-cov s1 protein on its surface so that an immune response is induced against mers-cov. the rv vector-based vaccines against mers-cov can induce faster antibody response as well as higher degrees of cellular immunity than the gram-positive enhancer matrix (gem) particle vector-based vaccine. however, the latter can induce a very high antibody response at lower doses (167) . hence, the degree of humoral and cellular immune responses produced by such vaccines depends upon the vector used. dual vaccines have been getting more popular recently. among them, the rabies virus-based vectored vaccine platform is used to develop vaccines against emerging infectious diseases. the dual vaccine developed from inactivated rabies virus particles that express the mers-cov s1 domain of s protein was found to induce immune responses for both mers-cov and rabies virus. the vaccinated mice were found to be completely protected from challenge with mers-cov (169) . the intranasal administration of the recombinant adenovirus-based vaccine in balb/c mice was found to induce long-lasting neutralizing immunity against mers spike pseudotyped virus, characterized by the induction of systemic igg, secretory iga, and lung-resident memory t-cell responses (177) . immunoinformatics methods have been employed for the genomewide screening of potential vaccine targets among the different immunogens of mers-cov (178) . the n protein and the potential b-cell epitopes of mers-cov e protein have been suggested as immunoprotective targets inducing both t-cell and neutralizing antibody responses (178, 179) . the collaborative effort of the researchers of rocky mountain laboratories and oxford university is designing a chimpanzee adenovirus-vectored vaccine to counter covid-19 (180) . the coalition for epidemic preparedness innovations (cepi) has initiated three programs to design sars-cov-2 vaccines (181) . cepi has a collaborative project with inovio for designing a mers-cov dna vaccine that could potentiate effective immunity. cepi and the university of queensland are designing a molecular clamp vaccine platform for mers-cov and other pathogens, which could assist in the easier identification of antigens by the immune system (181) . cepi has also funded moderna to develop a vaccine for covid-19 in partnership with the vaccine research center (vrc) of the national institute of allergy and infectious diseases (niaid), part of the national institutes of health (nih) (182) . by employing mrna vaccine platform technology, a vaccine candidate expressing sars-cov-2 spike protein is likely to go through clinical testing in the coming months (180 (298) . the process of vaccine development usually takes approximately ten years, in the case of inactivated or live attenuated vaccines, since it involves the generation of long-term efficacy data. however, this was brought down to 5 years during the ebola emergency for viral vector vaccines. in the urgency associated with the covid-19 outbreaks, we expect a vaccine by the end of this year (343) . the development of an effective vaccine against covid-19 with high speed and precision is the combined result of advancements in computational biology, gene synthesis, protein engineering, and the invention of advanced manufacturing platforms (342) . the recurring nature of the coronavirus outbreaks calls for the development of a pan-coronavirus vaccine that can produce cross-reactive antibodies. however, the success of such a vaccine relies greatly on its ability to provide protection not only against present versions of the virus but also the ones that are likely to emerge in the future. this can be achieved by identifying antibodies that can recognize relatively conserved epitopes that are maintained as such even after the occurrence of considerable variations (362) . even though several vaccine clinical trials are being conducted around the world, pregnant women have been completely excluded from these studies. pregnant women are highly vulnerable to emerging diseases such as covid-19 due to alterations in the immune system and other physiological systems that are associated with pregnancy. therefore, in the event of successful vaccine development, pregnant women will not get access to the vaccines (361) . hence, it is recommended that pregnant women be included in the ongoing vaccine trials, since successful vaccination in pregnancy will protect the mother, fetus, and newborn. the heterologous immune effects induced by bacillus calmette guérin (bcg) vaccination is a promising strategy for controlling the covid-19 pandemic and requires further investigations. bcg is a widely used vaccine against tuberculosis in high-risk regions. it is derived from a live attenuated strain of mycobacterium bovis. at present, three new clinical trials have been registered to evaluate the protective role of bcg vaccination against sars-cov-2 (363) . recently, a cohort study was conducted to evaluate the impact of childhood bcg vaccination in covid-19 pcr positivity rates. however, childhood bcg vaccination was found to be associated with a rate of covid-19-positive test results similar to that of the nonvaccinated group (364) . further studies are required to analyze whether bcg vaccination in childhood can induce protective effects against covid-19 in adulthood. population genetic studies conducted on 103 genomes identified that the sars-cov-2 virus has evolved into two major types, l and s. among the two types, l type is expected to be the most prevalent (ϳ70%), followed by the s type (ϳ30%) (366) . this finding has a significant impact on our race to develop an ideal vaccine, since the vaccine candidate has to target both strains to be considered effective. at present, the genetic differences between the l and s types are very small and may not affect the immune response. however, we can expect further genetic variations in the coming days that could lead to the emergence of new strains (367) . there is no currently licensed specific antiviral treatment for mers-and sars-cov infections, and the main focus in clinical settings remains on lessening clinical signs and providing supportive care (183) (184) (185) (186) . effective drugs to manage covid-19 patients include remdesivir, lopinavir/ritonavir alone or in a blend with interferon beta, convalescent plasma, and monoclonal antibodies (mabs); however, efficacy and safety issues of these drugs require additional clinical trials (187, 281) . a controlled trial of ritonavirboosted lopinavir and interferon alpha 2b treatment was performed on covid-19 hospitalized patients (chictr2000029308) (188) . in addition, the use of hydroxychloroquine and tocilizumab for their potential role in modulating inflammatory responses in the lungs and antiviral effect has been proposed and discussed in many research articles. still, no fool-proof clinical trials have been published (194, 196, 197, (261) (262) (263) (264) (265) (266) (267) (268) (269) (270) (271) (272) . recently, a clinical trial conducted on adult patients suffering from severe covid-19 revealed no benefit of lopinavir-ritonavir treatment over standard care (273) . the efforts to control sars-cov-2 infection utilize defined strategies as followed against mers and sars, along with adopting and strengthening a few precautionary measures owing to the unknown nature of this novel virus (36, 189) . presently, the main course of treatment for severely affected sars-cov-2 patients admitted to hospitals includes mechanical ventilation, intensive care unit (icu) admittance, and symptomatic and supportive therapies. additionally, rna synthesis inhibitors (lamivudine and tenofovir disoproxil fumarate), remdesivir, neuraminidase inhibitors, peptide (ek1), antiinflammatory drugs, abidol, and chinese traditional medicine (lianhuaqingwen and shufengjiedu capsules) could aid in covid-19 treatment. however, further clinical trials are being carried out concerning their safety and efficacy (7) . it might require months to a year(s) to design and develop effective drugs, therapeutics, and vaccines against covid-19, with adequate evaluation and approval from regulatory bodies and moving to the bulk production of many millions of doses at commercial levels to meet the timely demand of mass populations across the globe (9) . continuous efforts are also warranted to identify and assess viable drugs and immunotherapeutic regimens that revealed proven potency in combating other viral agents similar to sars-cov-2. covid-19 patients showing severe signs are treated symptomatically along with oxygen therapy. in such cases where the patients progress toward respiratory failure and become refractory to oxygen therapy, mechanical ventilation is necessitated. the covid-19-induced septic shock can be managed by providing adequate hemodynamic support (299) . several classes of drugs are currently being evaluated for their potential therapeutic action against sars-cov-2. therapeutic agents that have anti-sars-cov-2 activity can be broadly classified into three categories: drugs that block virus entry into the host cell, drugs that block viral replication as well as its survival within the host cell, and drugs that attenuate the exaggerated host immune response (300) . an inflammatory cytokine storm is commonly seen in critically ill covid-19 patients. hence, they may benefit from the use of timely anti-inflammation treatment. anti-inflammatory therapy using drugs like glucocorticoids, cytokine inhibitors, jak inhibitors, and chloroquine/hydroxychloroquine should be done only after analyzing the risk/benefit ratio in covid-19 patients (301). there have not been any studies concerning the application of nonsteroidal anti-inflammatory drugs (nsaid) to covid-19-infected patients. however, reasonable pieces of evidence are available that link nsaid uses with the occurrence of respiratory and cardiovascular adverse effects. hence, as a cautionary approach, it is better to recommend the use of nsaids as the first-line option for managing covid-19 symptoms (302) . the use of corticosteroids in covid-19 patients is still a matter of controversy and requires further systematic clinical studies. the guidelines that were put forward to manage critically ill adults suggest the use of systemic corticosteroids in mechanically ventilated adults with ards (303) . the generalized use of corticosteroids is not indicated in covid-19, since there are some concerns associated with the use of corticosteroids in viral pneumonia. stem cell therapy using mesenchymal stem cells (mscs) is another hopeful strategy that can be used in clinical cases of covid-19 owing to its potential immunomodulatory capacity. it may have a beneficial role in attenuating the cytokine storm that is observed in severe cases of sars-cov-2 infection, thereby reducing mortality. among the different types of mscs, expanded umbilical cord mscs can be considered a potential therapeutic agent that requires further validation for managing critically ill covid-19 patients (304) . repurposed broad-spectrum antiviral drugs having proven uses against other viral pathogens can be employed for sars-cov-2-infected patients. these possess benefits of easy accessibility and recognized pharmacokinetic and pharmacodynamic activities, stability, doses, and side effects (9) . repurposed drugs have been studied for treating cov infections, like lopinavir/ritonavir, and interferon-1␤ revealed in vitro anti-mers-cov action. the in vivo experiment carried out in the nonhuman primate model of clinical microbiology reviews common marmosets treated with lopinavir/ritonavir and interferon beta showed superior protective results in treated animals than in the untreated ones (190) . a combination of these drugs is being evaluated to treat mers in humans (miracle trial) (191) . these two protease inhibitors (lopinavir and ritonavir), in combination with ribavirin, gave encouraging clinical outcomes in sars patients, suggesting their therapeutic values (165) . however, in the current scenario, due to the lack of specific therapeutic agents against sars-cov-2, hospitalized patients confirmed for the disease are given supportive care, like oxygen and fluid therapy, along with antibiotic therapy for managing secondary bacterial infections (192) . patients with novel coronavirus or covid-19 pneumonia who are mechanically ventilated often require sedatives, analgesics, and even muscle relaxation drugs to prevent ventilator-related lung injury associated with human-machine incoordination (122) . the result obtained from a clinical study of four patients infected with covid-19 claimed that combination therapy using lopinavir/ritonavir, arbidol, and shufeng jiedu capsules (traditional chinese medicine) was found to be effective in managing covid-19 pneumonia (193) . it is difficult to evaluate the therapeutic potential of a drug or a combination of drugs for managing a disease based on such a limited sample size. before choosing the ideal therapeutic agent for the management of covid-19, randomized clinical control studies should be performed with a sufficient study population. several classes of routinely used antiviral drugs, like oseltamivir (neuraminidase inhibitor), acyclovir, ganciclovir, and ribavirin, do not have any effect on covid-19 and, hence, are not recommended (187) . oseltamivir, a neuraminidase inhibitor, has been explored in chinese hospitals for treating suspected covid-19 cases, although proven efficacy against sars-cov-2 is still lacking for this drug (7) . the in vitro antiviral potential of fad-approved drugs, viz., ribavirin, penciclovir, nitazoxanide, nafamostat, and chloroquine, tested in comparison to remdesivir and favipiravir (broad-spectrum antiviral drugs) revealed remdesivir and chloroquine to be highly effective against sars-cov-2 infection in vitro (194) . ribavirin, penciclovir, and favipiravir might not possess noteworthy in vivo antiviral actions for sars-cov-2, since higher concentrations of these nucleoside analogs are needed in vitro to lessen the viral infection. both remdesivir and chloroquine are being used in humans to treat other diseases, and such safer drugs can be explored for assessing their effectiveness in covid-19 patients. several therapeutic agents, such as lopinavir/ritonavir, chloroquine, and hydroxychloroquine, have been proposed for the clinical management of covid-19 (299) . a molecular docking study, conducted in the rna-dependent rna polymerase (rdrp) of sars-cov-2 using different commercially available antipolymerase drugs, identified that drugs such as ribavirin, remdesivir, galidesivir, tenofovir, and sofosbuvir bind rdrp tightly, indicating their vast potential to be used against covid-19 (305). a broadspectrum antiviral drug that was developed in the united states, tilorone dihydrochloride (tilorone), was previously found to possess potent antiviral activity against mers, marburg, ebola, and chikungunya viruses (306) . even though it had broad-spectrum activity, it was neglected for an extended period. tilorone is another antiviral drug that might have activity against sars-cov-2. remdesivir, a novel nucleotide analog prodrug, was developed for treating ebola virus disease (evd), and it was also found to inhibit the replication of sars-cov and mers-cov in primary human airway epithelial cell culture systems (195) . recently, in vitro study has proven that remdesivir has better antiviral activity than lopinavir and ritonavir. further, in vivo studies conducted in mice also identified that treatment with remdesivir improved pulmonary function and reduced viral loads and lung pathology both in prophylactic and therapeutic regimens compared to lopinavir/ritonavir-ifn-␥ treatment in mers-cov infection (8) . remdesivir also inhibits a diverse range of coronaviruses, including circulating human cov, zoonotic bat cov, and prepandemic zoonotic cov (195) . remdesivir is also considered the only therapeutic drug that significantly reduces pulmonary pathology (8) . all these findings indicate that remde-sivir has to be further evaluated for its efficacy in the treatment of covid-19 infection in humans. the broad-spectrum activity exhibited by remdesivir will help control the spread of disease in the event of a new coronavirus outbreak. chloroquine is an antimalarial drug known to possess antiviral activity due to its ability to block virus-cell fusion by raising the endosomal ph necessary for fusion. it also interferes with virus-receptor binding by interfering with the terminal glycosylation of sars-cov cellular receptors, such as ace2 (196) . in a recent multicenter clinical trial that was conducted in china, chloroquine phosphate was found to exhibit both efficacy and safety in the therapeutic management of sars-cov-2-associated pneumonia (197) . this drug is already included in the treatment guidelines issued by the national health commission of the people's republic of china. the preliminary clinical trials using hydroxychloroquine, another aminoquinoline drug, gave promising results. the covid-19 patients received 600 mg of hydroxychloroquine daily along with azithromycin as a single-arm protocol. this protocol was found to be associated with a noteworthy reduction in viral load. finally, it resulted in a complete cure (271) ; however, the study comprised a small population and, hence, the possibility of misinterpretation could arise. however, in another case study, the authors raised concerns over the efficacy of hydroxychloroquine-azithromycin in the treatment of covid-19 patients, since no observable effect was seen when they were used. in some cases, the treatment was discontinued due to the prolongation of the qt interval (307) . hence, further randomized clinical trials are required before concluding this matter. recently, another fda-approved drug, ivermectin, was reported to inhibit the in vitro replication of sars-cov-2. the findings from this study indicate that a single treatment of this drug was able to induce an ϳ5,000-fold reduction in the viral rna at 48 h in cell culture. (308) . one of the main disadvantages that limit the clinical utility of ivermectin is its potential to cause cytotoxicity. however, altering the vehicles used in the formulations, the pharmacokinetic properties can be modified, thereby having significant control over the systemic concentration of ivermectin (338) . based on the pharmacokinetic simulation, it was also found that ivermectin may have limited therapeutic utility in managing covid-19, since the inhibitory concentration that has to be achieved for effective anti-sars-cov-2 activity is far higher than the maximum plasma concentration achieved by administering the approved dose (340) . however, ivermectin, being a host-directed agent, exhibits antiviral activity by targeting a critical cellular process of the mammalian cell. therefore, the administration of ivermectin, even at lower doses, will reduce the viral load at a minor level. this slight decrease will provide a great advantage to the immune system for mounting a large-scale antiviral response against sars-cov-2 (341). further, a combination of ivermectin and hydroxychloroquine might have a synergistic effect, since ivermectin reduces viral replication, while hydroxychloroquine inhibits the entry of the virus in the host cell (339) . further, in vivo studies and randomized clinical control trials are required to understand the mechanism as well as the clinical utility of this promising drug. nafamostat is a potent inhibitor of mers-cov that acts by preventing membrane fusion. nevertheless, it does not have any sort of inhibitory action against sars-cov-2 infection (194) . recently, several newly synthesized halogenated triazole compounds were evaluated, using fluorescence resonance energy transfer (fret)-based helicase assays, for their ability to inhibit helicase activity. among the evaluated compounds, 4-(cyclopent-1-en-3-ylamino)-5-[2-(4-iodophenyl) hydrazinyl]-4h-1,2,4-triazole-3-thiol and 4-(cyclopent-1-en-3-ylamino)-5-[2-(4-chlorophenyl) hydrazinyl]-4h-1,2,4-triazole-3-thiol were found to be the most potent. these compounds were used for in silico studies, and molecular docking was accomplished into the active binding site of mers-cov helicase nsp13 (21) . further studies are required for evaluating the therapeutic potential of these newly identified compounds in the management of covid-19 infection. monoclonal antibodies (mabs) may be helpful in the intervention of disease in clinical microbiology reviews cov-exposed individuals. patients recovering from sars showed robust neutralizing antibodies against this cov infection (164) . a set of mabs aimed at the mers-cov s protein-specific domains, comprising six specific epitope groups interacting with receptor-binding, membrane fusion, and sialic acid-binding sites, make up crucial entry tasks of s protein (198, 199) . passive immunization employing weaker and strongly neutralizing antibodies provided considerable protection in mice against a mers-cov lethal challenge. such antibodies may play a crucial role in enhancing protective humoral responses against the emerging covs by aiming appropriate epitopes and functions of the s protein. the cross-neutralization ability of sars-cov rbd-specific neutralizing mabs considerably relies on the resemblance between their rbds; therefore, sars-cov rbd-specific antibodies could cross-neutralized sl covs, i.e., bat-sl-cov strain wiv1 (rbd with eight amino acid differences from sars-cov) but not bat-sl-cov strain shc014 (24 amino acid differences) (200) . appropriate rbd-specific mabs can be recognized by a relative analysis of rbd of sars-cov-2 to that of sars-cov, and cross-neutralizing sars-cov rbd-specific mabs could be explored for their effectiveness against covid-19 and further need to be assessed clinically. the u.s. biotechnology company regeneron is attempting to recognize potent and specific mabs to combat covid-19. an ideal therapeutic option suggested for sars-cov-2 (covid-19) is the combination therapy comprised of mabs and the drug remdesivir (covid-19) (201) . the sars-cov-specific human mab cr3022 is found to bind with sars-cov-2 rbd, indicating its potential as a therapeutic agent in the management of covid-19. it can be used alone or in combination with other effective neutralizing antibodies for the treatment and prevention of covid-19 (202) . furthermore, sars-cov-specific neutralizing antibodies, like m396 and cr3014, failed to bind the s protein of sars-cov-2, indicating that a particular level of similarity is mandatory between the rbds of sars-cov and sars-cov-2 for the cross-reactivity to occur. further assessment is necessary before confirming the effectiveness of such combination therapy. in addition, to prevent further community and nosocomial spread of covid-19, the postprocedure risk management program should not be neglected (309) . development of broad-spectrum inhibitors against the human coronaviral pathogens will help to facilitate clinical trials on the effectiveness of such inhibitors against endemic and emerging coronaviruses (203) . a promising animal study revealed the protective effect of passive immunotherapy with immune serum from mers-immune camels on mice infected with mers-cov (204) . passive immunotherapy using convalescent plasma is another strategy that can be used for treating covid-19-infected, critically ill patients (205) . the exploration of fully human antibodies (human single-chain antibodies; huscfvs) or humanized nanobodies (single-domain antibodies; sdab, vh/vhh) could aid in blocking virus replication, as these agents can traverse the virus-infected cell membranes (transbodies) and can interfere with the biological characteristics of the replicating virus proteins. such examples include transbodies to the influenza virus, hepatitis c virus, ebola virus, and dengue virus (206) . producing similar transbodies against intracellular proteins of coronaviruses, such as papain-like proteases (plpro), cysteinelike protease (3clpro), or other nsps, which are essential for replication and transcription of the virus, might formulate a practical move forward for a safer and potent passive immunization approach for virus-exposed persons and rendering therapy to infected patients. in a case study on five grimly sick patients having symptoms of severe pneumonia due to covid-19, convalescent plasma administration was found to be helpful in patients recovering successfully. the convalescent plasma containing a sars-cov-2specific elisa (serum) antibody titer higher than 1:1,000 and neutralizing antibody titer more significant than 40 was collected from the recovered patients and used for plasma transfusion twice in a volume of 200 to 250 ml on the day of collection (310) . at present, treatment for sepsis and ards mainly involves antimicrobial therapy, source control, and supportive care. hence, the use of therapeutic plasma exchange can be considered an option in managing such severe conditions. further randomized trials can be designed to investigate its efficacy (311) . potent therapeutics to combat sars-cov-2 infection include virus binding molecules, molecules or inhibitors targeting particular enzymes implicated in replication and transcription process of the virus, helicase inhibitors, vital viral proteases and proteins, protease inhibitors of host cells, endocytosis inhibitors, short interfering rna (sirna), neutralizing antibodies, mabs against the host receptor, mabs interfering with the s1 rbd, antiviral peptide aimed at s2, and natural drugs/medicines (7, 166, 186) . the s protein acts as the critical target for developing cov antivirals, like inhibitors of s protein and s cleavage, neutralizing antibodies, rbd-ace2 blockers, sirnas, blockers of the fusion core, and proteases (168) . all of these therapeutic approaches have revealed both in vitro and in vivo anti-cov potential. although in vitro research carried out with these therapeutics showed efficacy, most need appropriate support from randomized animal or human trials. therefore, they might be of limited applicability and require trials against sars-cov-2 to gain practical usefulness. the binding of sars-cov-2 with ace2 leads to the exacerbation of pneumonia as a consequence of the imbalance in the reninangiotensin system (ras). the virus-induced pulmonary inflammatory responses may be reduced by the administration of ace inhibitors (acei) and angiotensin type-1 receptor (at1r) (207) . several investigations have suggested the use of small-molecule inhibitors for the potential control of sars-cov infections. drugs of the fda-approved compound library were screened to identify four small-molecule inhibitors of mers-cov (chlorpromazine, chloroquine, loperamide, and lopinavir) that inhibited viral replication. these compounds also hinder sars-cov and human covs (208) . therapeutic strategies involving the use of specific antibodies or compounds that neutralize cytokines and their receptors will help to restrain the host inflammatory responses. such drugs acting specifically in the respiratory tract will help to reduce virus-triggered immune pathologies in covid-19 (209) . the later stages of coronavirus-induced inflammatory cascades are characterized by the release of proinflammatory interleukin-1 (il-1) family members, such as il-1 and il-33. hence, there exists a possibility that the inflammation associated with coronavirus can be inhibited by utilizing anti-inflammatory cytokines that belong to the il-1 family (92) . it has also been suggested that the actin protein is the host factor that is involved in cell entry and pathogenesis of sars-cov-2. hence, those drugs that modulate the biological activity of this protein, like ibuprofen, might have some therapeutic application in managing the disease (174). the plasma angiotensin 2 level was found to be markedly elevated in covid-19 infection and was correlated with viral load and lung injury. hence, drugs that block angiotensin receptors may have potential for treating covid-19 infection (121) . a scientist from germany, named rolf hilgenfeld, has been working on the identification of drugs for the treatment of coronaviral infection since the time of the first sars outbreak (19) . the sars-cov s2 subunit has a significant function in mediating virus fusion that provides entry into the host cell. heptad repeat 1 (hr1) and heptad repeat 2 (hr2) can interact and form a six-helix bundle that brings the viral and cellular membranes in close proximity, facilitating its fusion. the sequence alignment study conducted between covid-19 and sars-cov identified that the s2 subunits are highly conserved in these covs. the hr1 and hr2 domains showed 92.6% and 100% overall identity, respectively (210) . from these findings, we can confirm the significance of covid-19 hr1 and hr2 and their vital role in host cell entry. hence, fusion inhibitors target the hr1 domain of s protein, thereby preventing viral fusion and entry into the host cell. this is another potential therapeutic strategy that can be used in the management of covid-19. other than the specific therapy directed against covid-19, general treatments play a vital role in the enhancement of host immune responses against the viral agent. inadequate nutrition is linked to the weakening of the host immune response, clinical microbiology reviews making the individual more susceptible. the role played by nutrition in disease susceptibility should be measured by evaluating the nutritional status of patients with covid-19 (205) . for evaluating the potential of vaccines and therapeutics against covs, including sars-cov, mers-covs, and the presently emerging sars-cov-2, suitable animal models that can mimic the clinical disease are needed (211, 212) . various animal models were assessed for sars-and mers-covs, such as mice, guinea pigs, golden syrian hamsters, ferrets, rabbits, nonhuman primates like rhesus macaques and marmosets, and cats (185, (213) (214) (215) (216) (217) (218) . the specificity of the virus to hace2 (receptor of sars-cov) was found to be a significant barrier in developing animal models. consequently, a sars-cov transgenic mouse model has been developed by inserting the hace2 gene into the mouse genome (219) . the inability of mers-cov to replicate in the respiratory tracts of animals (mice, hamsters, and ferrets) is another limiting factor. however, with genetic engineering, a 288-330 ϩ/ϩ mers-cov genetically modified mouse model was developed and now is in use for the assessment of novel drugs and vaccines against mers-cov (220). in the past, small animals (mice or hamsters) have been targeted for being closer to a humanized structure, such as mouse dpp4 altered with human dpp4 (hdpp4), hdpp4-transduced mice, and hdpp4-tg mice (transgenic for expressing hdpp4) for mers-cov infection (221) . the crispr-cas9 gene-editing tool has been used for inserting genomic alterations in mice, making them susceptible to mers-cov infection (222) . efforts are under way to recognize suitable animal models for sars-cov2/covid-19, identify the receptor affinity of this virus, study pathology in experimental animal models, and explore virus-specific immune responses and protection studies, which together would increase the pace of efforts being made for developing potent vaccines and drugs to counter this emerging virus. cell lines, such as monkey epithelial cell lines (llc-mk2 and vero-b4), goat lung cells, alpaca kidney cells, dromedary umbilical cord cells, and advanced ex vivo three-dimensional tracheobronchial tissue, have been explored to study human covs (mers-cov) (223, 224) . vero and huh-7 cells (human liver cancer cells) have been used for isolating sars-cov-2 (194) . recently, an experimental study with rhesus monkeys as animal models revealed the absence of any viral loads in nasopharyngeal and anal swabs, and no viral replication was recorded in the primary tissues at a time interval of 5 days post-reinfection in reexposed monkeys (274) . the subsequent virological, radiological, and pathological observations indicated that the monkeys with reexposure had no recurrence of covid-19, like the sars-cov-2-infected monkeys without rechallenge. these findings suggest that primary infection with sars-cov-2 could protect from later exposures to the virus, which could help in defining disease prognosis and crucial inferences for designing and developing potent vaccines against covid-19 (274). in contrast to their response to the 2002 sars outbreak, china has shown immense political openness in reporting the covid-19 outbreak promptly. they have also performed rapid sequencing of covid-19 at multiple levels and shared the findings globally within days of identifying the novel virus (225) . the move made by china opened a new chapter in global health security and diplomacy. even though complete lockdown was declared following the covid-19 outbreak in wuhan, the large-scale movement of people has resulted in a radiating spread of infections in the surrounding provinces as well as to several other countries. large-scale screening programs might help us to control the spread of this virus. however, this is both challenging as well as time-consuming due to the present extent of infection (226) . the current scenario demands effective implementation of vigorous prevention and control strategies owing to the prospect of covid-19 for nosocomial infections (68) . follow-ups of infected patients by telephone on day 7 and day 14 are advised to avoid any further unintentional spread or nosocomial transmission (312) . the availability of public data sets provided by independent analytical teams will act as robust evidence that would guide us in designing interventions against the covid-19 outbreak. newspaper reports and social media can be used to analyze and reconstruct the progression of an outbreak. they can help us to obtain detailed patient-level data in the early stages of an outbreak (227) . immediate travel restrictions imposed by several countries might have contributed significantly to preventing the spread of sars-cov-2 globally (89, 228) . following the outbreak, a temporary ban was imposed on the wildlife trade, keeping in mind the possible role played by wild animal species in the origin of sars-cov-2/covid-19 (147) . making a permanent and bold decision on the trade of wild animal species is necessary to prevent the possibility of virus spread and initiation of an outbreak due to zoonotic spillover (1) . personal protective equipment (ppe), like face masks, will help to prevent the spread of respiratory infections like covid-19. face masks not only protect from infectious aerosols but also prevent the transmission of disease to other susceptible individuals while traveling through public transport systems (313) . another critical practice that can reduce the transmission of respiratory diseases is the maintenance of hand hygiene. however, the efficacy of this practice in reducing the transmission of respiratory viruses like sars-cov-2 is much dependent upon the size of droplets produced. hand hygiene will reduce disease transmission only if the virus is transmitted through the formation of large droplets (314) . hence, it is better not to overemphasize that hand hygiene will prevent the transmission of sars-cov-2, since it may produce a false sense of safety among the general public that further contributes to the spread of covid-19. even though airborne spread has not been reported in sars-cov-2 infection, transmission can occur through droplets and fomites, especially when there is close, unprotected contact between infected and susceptible individuals. hence, hand hygiene is equally as important as the use of appropriate ppe, like face masks, to break the transmission cycle of the virus; both hand hygiene and face masks help to lessen the risk of covid-19 transmission (315) . medical staff are in the group of individuals most at risk of getting covid-19 infection. this is because they are exposed directly to infected patients. hence, proper training must be given to all hospital staff on methods of prevention and protection so that they become competent enough to protect themselves and others from this deadly disease (316) . as a preventive measure, health care workers caring for infected patients should take extreme precautions against both contact and airborne transmission. they should use ppe such as face masks (n95 or ffp3), eye protection (goggles), gowns, and gloves to nullify the risk of infection (299) . the human-to-human transmission reported in sars-cov-2 infection occurs mainly through droplet or direct contact. due to this finding, frontline health care workers should follow stringent infection control and preventive measures, such as the use of ppe, to prevent infection (110) . the mental health of the medical/health workers who are involved in the covid-19 outbreak is of great importance, because the strain on their mental well-being will affect their attention, concentration, and decision-making capacity. hence, for control of the covid-19 outbreak, rapid steps should be taken to protect the mental health of medical workers (229) . since the living mammals sold in the wet market are suspected to be the intermediate host of sars-cov-2, there is a need for strengthening the regulatory mechanism for wild animal trade (13) . the total number of covid-19 confirmed cases is on a continuous rise and the cure rate is relatively low, making disease control very difficult to achieve. the chinese government is making continuous efforts to contain the disease by taking emergency control and prevention measures. they have already built a hospital for patients affected by this virus and are currently building several more for accommodating the continuously increasing infected population (230) . the effective control of sars-cov-2/covid-19 requires high-level interventions like intensive contact tracing, as well as the quarantine of people with suspected infection and the isolation of infected individuals. the implementation of rigorous control and preventive measures together might control the r 0 number and reduce the transmission risk (228) . clinical microbiology reviews considering the zoonotic links associated with sars-cov-2, the one health approach may play a vital role in the prevention and control measures being followed to restrain this pandemic virus (317) (318) (319) . the substantial importation of covid-19 presymptomatic cases from wuhan has resulted in independent, self-sustaining outbreaks across major cities both within the country and across the globe. the majority of chinese cities are now facing localized outbreaks of covid-19 (231) . hence, deploying efficient public health interventions might help to cut the spread of this virus globally. the occurrence of covid-19 infection on several cruise ships gave us a preliminary idea regarding the transmission pattern of the disease. cruise ships act as a closed environment and provide an ideal setting for the occurrence of respiratory disease outbreaks. such a situation poses a significant threat to travelers, since people from different countries are on board, which favors the introduction of the pathogen (320). although nearly 30 cruise ships from different countries have been found harboring covid-19 infection, the major cruise ships that were involved in the covid-19 outbreaks are the diamond princess, grand princess, celebrity apex, and ruby princess. the number of confirmed covid-19 cases around the world is on the rise. the success of preventive measures put forward by every country is mainly dependent upon their ability to anticipate the approaching waves of patients. this will help to properly prepare the health care workers and increase the intensive care unit (icu) capacity (321) . instead of entirely relying on lockdown protocols, countries should focus mainly on alternative intervention strategies, such as large-scale testing, contract tracing, and localized quarantine of suspected cases for limiting the spread of this pandemic virus. such intervention strategies will be useful either at the beginning of the pandemic or after lockdown relaxation (322) . lockdown should be imposed only to slow down disease progression among the population so that the health care system is not overloaded. the reproduction number (r 0 ) of covid-19 infection was earlier estimated to be in the range of 1.4 to 2.5 (70); recently, it was estimated to be 2.24 to 3.58 (76) . compared to its coronavirus predecessors, covid-19 has an r 0 value that is greater than that of mers (r 0 ͻ 1) (108) but less than that of sars (r 0 value of 2 to 5) (93) . still, to prevent further spread of disease at mass gatherings, functions remain canceled in the affected cities, and persons are asked to work from home (232) . hence, it is a relief that the current outbreak of covid-19 infection can be brought under control with the adoption of strategic preventive and control measures along with the early isolation of subsequent cases in the coming days. studies also report that since air traffic between china and african countries increased many times over in the decade after the sars outbreak, african countries need to be vigilant to prevent the spread of novel coronavirus in africa (225) . due to fear of virus spread, wuhan city was completely shut down (233) . the immediate control of the ongoing covid-19 outbreaks appears a mammoth task, especially for developing countries, due to their inability to allocate quarantine stations that could screen infected individuals' movements (234) . such underdeveloped countries should divert their resources and energy to enforcing the primary level of preventive measures, like controlling the entry of individuals from china or countries where the disease has flared up, isolating the infected individuals, and quarantining individuals with suspected infection. most of the sub-saharan african countries have a fragile health system that can be crippled in the event of an outbreak. effective management of covid-19 would be difficult for low-income countries due to their inability to respond rapidly due to the lack of an efficient health care system (65) . controlling the imported cases is critical in preventing the spread of covid-19 to other countries that have not reported the disease until now. the possibility of an imported case of covid-19 leading to sustained human-to-human transmission was estimated to be 0.41. this can be reduced to a value of 0.012 by decreasing the mean time from the onset of symptoms to hospitalization and can only be made possible by using intense disease surveillance systems (235) . the silent importations of infected individuals (before the manifestation of clinical signs) also contributed significantly to the spread of disease across the major cities of the world. even though the travel ban was implemented in wuhan (89) , infected persons who traveled out of the city just before the imposition of the ban might have remained undetected and resulted in local outbreaks (236) . emerging novel diseases like covid-19 are difficult to contain within the country of origin, since globalization has led to a world without borders. hence, international collaboration plays a vital role in preventing the further spread of this virus across the globe (237) . we also predict the possibility of another outbreak, as predicted by fan et al. (6) . indeed, the present outbreak caused by sars-cov-2 (covid-19) was expected. similar to previous outbreaks, the current outbreak also will be contained shortly. however, the real issue is how we are planning to counter the next zoonotic cov epidemic that is likely to occur within the next 5 to 10 years or even sooner (fig. 7) . several years after the global sars epidemic, the current sars-cov-2/covid-19 pandemic has served as a reminder of how novel pathogens can rapidly emerge and spread through the human population and eventually cause severe public health crises. further research should be conducted to establish animal models for sars-cov-2 to investigate replication, transmission dynamics, and pathogenesis in humans. this may help develop and evaluate potential therapeutic strategies against zoonotic cov epidemics. present trends suggest the occurrence of future outbreaks of covs due to changes in the climate, and ecological conditions may be associated with humananimal contact. live-animal markets, such as the huanan south china seafood market, represent ideal conditions for interspecies contact of wildlife with domestic birds, pigs, and mammals, which substantially increases the probability of interspecies transmission of cov infections and could result in high risks to humans due to adaptive genetic recombination in these viruses (323) (324) (325) . the covid-19-associated symptoms are fever, cough, expectoration, headache, and myalgia or fatigue. individuals with asymptomatic and atypical clinical manifestations were also identified recently, further adding to the complexity of disease transmission dynamics. atypical clinical manifestations may only express symptoms such as fatigue instead of respiratory signs such as fever, cough, and sputum. in such cases, the clinician must be vigilant for the possible occurrence of asymptomatic and atypical clinical manifestations to avoid the possibility of missed diagnoses. the present outbreak caused by sars-cov-2 was, indeed, expected. similar to clinical microbiology reviews previous outbreaks, the current pandemic also will be contained shortly. however, the real question is, how are we planning to counter the next zoonotic cov epidemic that is likely to occur within the next 5 to 10 years or perhaps sooner? our knowledge of most of the bat covs is scarce, as these viruses have not been isolated and studied, and extensive studies on such viruses are typically only conducted when they are associated with specific disease outbreaks. the next step following the control of the covid-19 outbreak in china should be focused on screening, identification, isolation, and characterization of covs present in wildlife species of china, particularly in bats. both in vitro and in vivo studies (using suitable animal models) should be conducted to evaluate the risk of future epidemics. presently, licensed antiviral drugs or vaccines against sars-cov, mers-cov, and sars-cov-2 are lacking. however, 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hotspot in iran-implications for travellers covid-19: preparing for superspreader potential among umrah pilgrims to saudi arabia geographical tracking and mapping of coronavirus disease covid-19/severe acute respiratory syndrome coronavirus 2 (sars-cov-2) epidemic and associated events around the world: how 21st century gis technologies are supporting the global fight against outbreaks and epidemics policy decisions and use of information technology to fight 2019 novel coronavirus disease prediction models for diagnosis and prognosis of covid-19 infection: systematic review and critical appraisal consider pregnancy in covid-19 therapeutic drug and vaccine trials rational vaccine design in the time of covid-19 bacillus calmette guérin (bcg) vaccination use in the fight against covid-19 -what's old is new again? sars-cov-2 rates in bcg-vaccinated and unvaccinated young adults high throughput and comprehensive approach to develop multiepitope vaccine against minacious covid-19 on the origin and continuing evolution of sars-cov-2 covid-19: the race for a vaccine all authors substantially contributed to the conception, design, analysis, and interpretation of data and checking and approving the final version of the manuscript, and we agree to be accountable for its contents.this compilation is a review article written, analyzed, and designed by its authors and required no substantial funding to be developed.all authors declare that there are no existing commercial or financial relationships that could, in any way, lead to a potential conflict of interest. with 25 years of research and teaching experience in the areas of microbiology, immunology, virology, public health, medicine, and biomedicine as an eminent researcher, he has developed several diagnostics, vaccines, immunomodulatory modules, and hypotheses to counter infectious diseases of animals, poultry, and public health concerns. he has to his credit 600 publications, 6 books, and 65 book chapters. dr. dhama has been recognized as an extremely productive researcher in the journal nature. he has been honored with 50 best paper awards and other recognitions. he is an naas (national academy of agricultural science, india) associate and has worked as nodal officer, wto, and member, wildlife health specialist group (iucn). he is actively serving as editor-in-chief, co-eic, editor, and member, editorial board, of nearly 20 scientific journals. his google scholar h-index is 47 and scopus h-index is 31. sharun khan, m.v.sc., is currently working as a researcher in the stem cell laboratory, division of surgery, icar-indian veterinary research institute, izatnagar, india. his area of interest is regenerative medicine with a focus on understanding cell biology and molecular pathways involved in the maintenance and differentiation of stem cells originating from different tissues. he has particular interest and knowledge in the fields of veterinary medicine, pharmacology, infectious diseases of animals, wildlife diseases, diagnosis and therapy of animal diseases, nutrition, and biomedicine. with excellent academic records, he has received awards and recognitions (fellowships and scholarships) and participated in national and international workshops, training programs, and courses. he has a keen interest in learning excellent scientific writing skills and has published 30 papers, including in international journals of repute. he is highly enthusiastic about gaining knowledge of advancements in educational and scientific research areas.ruchi tiwari is currently working as assistant professor in the department of veterinary microbiology, college of veterinary sciences, duvasu, mathura, india. she is currently pursuing her ph.d. (hons) degree from duvasu. with an excellent academic record and 10 years of research and teaching experience, she has expertise in the field of diagnosis, prevention, and control of important livestock/poultry diseases/pathogens having public health significance, along with particular reference to veterinary microbiology, immunology, ethnoveterinary medicine, alternative and complementary therapies, and bacteriophage therapy. dr. tiwari has published 150 research/review articles and 5 book chapters. she has been honored with the young scientist award, best paper awards (10) key: cord-273973-3uxg97tu authors: guenette, alexis; husain, shahid title: infectious complications following solid organ transplantation date: 2019-01-31 journal: critical care clinics doi: 10.1016/j.ccc.2018.08.004 sha: doc_id: 273973 cord_uid: 3uxg97tu infections in solid organ transplant recipients are complex and heterogeneous. this article reviews the clinical syndromes that will likely be encountered in the intensive care unit and helps to guide in the therapy and management of these patients. immunosuppression plays an integral role in solid organ transplant (sot) recipients because it increases graft survival; however, there are unintended consequences, such as infectious complications. one strategy aimed at assessing the functionality of the immune system consists of non-pathogen-specific immune monitoring, consisting of serum immunoglobulins, serum complement factors, peripheral blood lymphocyte subpopulations, soluble cd30, and iatp in cd4 1 t cells. 1 ideally, these would help to demonstrate one aspect of the overall "net state of immunosuppression." the "net state of immunosuppression" comprises all factors that may contribute to the risk of infection; this includes preexisting immune deficits, colonization with antimicrobial-resistant pathogens, immunosuppressive agents, acquired immunodeficiency, prior antimicrobial therapies, mucocutaneous barrier integrity, fluid collections, neutropenia, lymphopenia, and viral coinfections. 2 disclosure statement: a. guenette has no relationships with a commercial company that has a direct financial interest in subject matter or materials discussed in article or with a company making a competing product. s. husain has received grants from astellas, pfizer, and merck. a division of infectious disease, university health network, university of toronto, 585 university avenue, 11 vaccinations, surgical prophylaxis, universal prophylaxis, preemptive or presymptomatic therapy, targeted prophylaxis, and education avoidance are preventative strategies that have been implemented in sot recipients. trimethoprim/sulfamethoxazole prophylaxis is given in most institutions for 3 months to a lifetime to prevent pneumocystis pneumonia along with toxoplasma gondii, cyclospora cayetanensis, and many nocardia and listeria species. antiviral prophylaxis along with nucleic acid-based assays to prevent cytomegalovirus (cmv) and other herpesvirus infections has also transformed posttransplant care. 2 infections in sot recipients reflect the net balance between the recipient's epidemiologic exposures and immunosuppression. 2 alterations to the balance can be seen with antimicrobial prophylaxis, immunosuppression, and improved graft survival. 2 this balance is also affected during a period of graft rejection or intensification of immunosuppression (fig. 1 ). 2 in this article, the authors review infectious syndromes encountered in intensive care units among sot recipients. bloodstream infections (bsis) are associated with poor outcomes along with being the leading cause of mortality and morbidity in sot. [3] [4] [5] mortality as high as 24% 4,6,7 has been described, and in fact, once septic shock develops, mortality can reach 50%, 4, 8 although kalil and colleagues 9 demonstrated that there may be a decrease in mortality of transplant patients compared with nontransplant patients. it is thought that sot recipients do not necessarily clinically behave in the same manner due to underlying immunosuppression, and in fact, tend to present with organ failure and thrombocytopenia during sepsis. 10 universal risk factors for sepsis, regardless of transplanted organ, are cmv serology mismatch, particularly positive donor to negative recipient, cmv disease, which inherently demonstrates an immunomodulatory effect predisposing recipients to higher rates of bacterial and fungal sepsis, prolonged duration of graft cold ischemia, prolonged duration of surgical transplantation procedure, and requirement of large amounts of blood transfusion. 10, 11 management should consist of rapid initiation of intravenous antibiotics, rapid diagnosis, source control, aggressive search for pathologic condition that mimics severe sepsis, and reduction in immunosuppressive drugs. 10 nosocomial bsis are associated with an even increased risk of septic shock and failure of cure when compared with other bsis in sot patients. [3] [4] [5] 8, 12 grampositive bacteria are the most frequent source of bsis and are likely to be associated with intravascular catheters, especially in the nosocomial setting. 3, 4 however, with kidney transplant recipients (ktrs), gram-negative bacteria likely related to urinary tract infections (utis) are the primary source, regardless of the time period. the overall incidence of multidrug-resistant organisms (mdro) is increasing. mdro gram-negative organisms accounted for about 14% of isolates. 4 fluconazoleresistant candida spp accounted for up to 46% of cases of candidemia according to moreno and colleagues. 4, 13 vancomycin-resistant enterococci (vre) have become an emerging pathogen with studies documenting an incidence of up to 20.5% of nosocomial enterococcal spp bsis consistent with vre. these findings along with previous microbiological history and local antibiotic resistance patterns should be considered when determining empiric antimicrobial therapy. overall, there are limited studies on infective endocarditis (ie) in sold organ transplant recipients. the incidence of ie in a single center was 1%, with an estimated 171-fold higher incidence as compared with the general population, 14 with an overall mortality up to 57%. 15 there are limited data on the mode of infection and predisposing factors in sot recipients. underlying structural abnormalities may not appear to be a risk factor for ie as compared with the general population. 14, 15 according to paterson and colleagues, 15 50% of infections were due to aspergillus fumigatus or staphylococcus aureus, and 4% were due to viridans streptococci, which is in contrast to the general population. a combination of antibiotic therapy as described in infectious diseases society of america (idsa) guidelines, infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications and surgical management, if warranted, is the current management. empiric management of suspected sepsis/bsi should include gram-positive coverage, in the presence of intravascular catheters, and broad gram-negative coverage. the choice of the antibiotic is dependent on the local epidemiology and previous microbiological data. empiric candida or antifungal coverage is not required, because the early initiation of antifungal has not been shown to improve the outcome in randomized controlled trials of mostly immunocompetent patients. 16, 17 bacterial pneumonia is the most common cause of lower respiratory tract infections. [18] [19] [20] [21] [22] [23] [24] according to giannella and colleagues, 25 community-acquired pneumonia (cap) was found in 40.7% and hospital-acquired pneumonia (hap) was found in 59.3% of sot recipients treated for pneumonia. in lung transplant recipients, bacterial pneumonia or bronchitis accounts for 32% to 63% of all infections with the incidence of bacterial pneumonia peaking in the first 4 to 8 postoperative weeks and then declines by the fourth month. perioperative antibiotics, which are focused on preoperative cultures from the recipient and donor, reduce the incidence of early bacterial pneumonia to less than 10%. 20, 21 regarding cardiac, hepatic, and renal transplants, the incidence of early bacterial pneumonia is 15%, 9%, and 4% to 6%, respectively, [18] [19] [20] 26, 27 with a mortality of 21% to 35% in liver and kidney transplant recipients. however, mortality between nosocomial and community-acquired infection was extreme at 58% compared with 8% 20-22 with mechanical ventilation and nosocomial infections at a higher increased risk for death. 18, [20] [21] [22] 24 in the initial perioperative infectious complications period, nosocomial pathogens, such as pseudomonas aeruginosa, escherichia coli, klebsiella species, acinetobacter species, and s aureus, including methicillinresistant s aureus (mrsa), should be considered in the immediate perioperative period; however, prolonged mechanical ventilation following transplant increases the risk for nosocomial pneumonia. [20] [21] [22] community-acquired pathogens, such as haemophilus influenzae, streptococcus pneumoniae, and legionella species, may be seen. with the implementation of trimethoprim-sulfamethoxazole prophylaxis, the incidence of nocardia pneumonia has decreased; however, it is still reported. 20, 28 empiric treatment should take into consideration previous microbiological data, local epidemiology, and recent clinical history with regards to empiric antibiotic coverage. respiratory viral infections are a significant cause of mortality and morbidity among transplant recipients, including influenza, respiratory syncytial virus, parainfluenza virus, rhinovirus, human metapneumovirus, and coronavirus. the seasonal pattern usually follows that of the general public. [29] [30] [31] disease can consist of mild congestion and rhinorrhea to more severe tracheobronchitis, bronchiolitis, and pneumonia. clinical manifestation can range from mild or atypical symptoms, including absence of fever, with lung transplant recipients presenting with a more severe clinical course and complications. 29 ,32 viral shedding is usually prolonged and seen even with the use of antivirals. 29, 32 transplant recipients are at higher risk of infectious complications, including fungal and bacterial pneumonia. respiratory viral infections appear to be a risk factor for both acute and chronic rejection, especially in lung transplant recipients. 29, [33] [34] [35] [36] diagnostic workup should consist of a nasopharyngeal swab, wash, or aspirate. if upper tract samples fail to document the cause or if there is clinical or radiological evidence of lower tract involvement, bronchoalveolar lavage (bal) should be considered. polymerase chain reaction (pcr)-based assays are commercially available with many centers adopting them because they are the most preferred mode of testing given the high sensitivity along with most allowing for simultaneously detecting a broad range of respiratory pathogens from a single sample. treatment, as is outlined in fig. 2 , includes supportive care and reduction in immunosuppression. adenovirus is a nonenveloped, lytic double-stranded dna virus that can be acquired de novo, through reactivation of a latent infection of the recipient, or from transplant organ. transmission occurs by respiratory route, person-to-person contact, or fecal-oral route. the true incidence among sot recipients is unknown, with most infections occurring within the first year after transplantation. 37 clinical manifestations can vary; however, when affecting lung transplant recipients, it can produce a range of clinical manifestations, including acute flulike illness, diffuse alveolar damage, or necrotizing pneumonia along with chronic changes, such as bronchiolitis obliterans, interstitial fibrosis, or bronchiectasis. [38] [39] [40] [41] viral culture, direct antigen detection, molecular methods, and histopathology are available for diagnosis with histopathologic evaluation, as the gold standard for the diagnosis of invasive disease. rapid antigen detection kits, in particular, immunofluorescence assays when processing respiratory specimens, are commercially available, which yield rapid and specific results. pcr, qualitative and quantitative, has emerged as a widely used tool for detection because it is highly sensitive and rapid. recovery of adenovirus from respiratory samples does not necessarily confirm disease because patients can shed asymptomatically for a prolonged period of time; therefore, it is essential to correlate with clinical findings along with detection of virus from other sites and histopathological findings. cidofovir has the best evidence to support its use in the treatment of adenoviral infections. brincidofovir, the lipid conjugate of cidofovir, has also demonstrated in vitro susceptibility and appears to be promising in vivo with regards to sot recipients; however, further studies are warranted. 42 cmv is a major pathogen in sot recipients, with the ability to cause end-organ disease. the immunomodulatory effects of cmv, impaired t-cell and phagocytic function, and cytokine dysregulation can lead to opportunistic infections, rejection, graft loss, and reduced survival. 43, 44 the transplant recipients who are at highest risk are seronegative recipients of seropositive organ, d1/rà, because they have no preexisting immunity, and seropositive recipients, dà/r1, are at intermediate risk. there is little difference between d1/r1 and dà/rà groups, with potentially worse outcomes in d1/r1 (fig. 3) . 43 clinical presentation consists of dyspnea, fever, and malaise with the identification of characteristic cmv cells in lung tissue. radiographic changes are nonspecific and include diffuse haziness, focal haziness, focal lobar consolidation, and no change. 20 diagnosis is made via cell culture viral isolation; however, this can be time consuming. therefore, the detection of cmv dna by pcr in the peripheral blood leukocytes, providing a sensitivity of 92% and specificity of 76% for cmv pneumonitis, along with the bal cmv dna pcr, is an alternative means to diagnosis. 20, 45 however, with regards to the bal findings, it would be imperative to differentiate between infections versus shedding; hence, the concomitant peripheral blood leukocyte pcr along with the clinical picture is necessary to help determine the diagnosis. treatment consists of ganciclovir or the oral alternative, valganciclovir. foscarnet and cidofovir are alternative options; however, they are primarily reserved when there is a concern for resistance or documented resistance because their side-effect profiles are less desirable. 20 cmv immunoglobulin in conjunction with treatment offers limited efficacy. 43 maribavir, brincidofovir, and letermovir are novel agents that may provide alternative options for treatment; however, further studies are warranted. candida is a frequent colonizer of lung transplant recipients, but less than 10% of patients colonized develop invasive disease. 20, 46 bronchial anastomotic infections may occur early in the postoperative setting, which can lead to anastomotic failure, parenchymal lung infection, and mediastinitis. [47] [48] [49] [50] [51] [52] artificial bronchial stents can serve as a potential site for infection. 47, 48 candida tracheobronchitis is based on visual inspection and histologic confirmation along with positive cultures from an appropriate specimen. 47 aspergillus species, a saprophytic organism, has higher rates of mortality, up to 54%, and an incidence of 3% in lung, 2.4% in heart, 2% in liver, and 0.2% in kidney transplant recipients. 47 infection may be due to reactivation or de novo infection following inhalation of the mold. renal failure, hemodialysis, repeated bacterial infections, leukopenia, cmv disease, high levels of immunosuppression, retransplantation, chronic exposure of the transplanted lung to the environment, and abnormal anatomic and physiologic function of the transplanted and, if still present, the native lung, airway ischemia, hypogammaglobulinemia, cystic fibrosis, and bronchial stent are all risk factors for invasive aspergillosis. 47, [53] [54] [55] [56] in lung transplant recipients, 20% to 40% are colonized with aspergillus with complicated infections affecting up to 13% of all patients. 20, [57] [58] [59] [60] colonization can also lead to bronchiolitis obliterans syndrome after lung transplantation. 47, 61 clinical manifestations can range from asymptomatic colonization to tracheobronchitis, invasive pulmonary aspergillosis, empyema, and disseminated disease, 47, 62 with symptoms including purulent sputum, fever, malaise, respiratory distress, and hemoptysis. 20, 63 aspergillus tracheobronchitis can cause airway obstruction, ulcerations, and pseudomembrane formation. 47 nonaspergillus mycelial fungi are also increasing with frequency, as high as 30%, and an overall mortality of 55% 20,64 ; however, zygomycosis (rhizopus and mucor species) and non-aspergillus hyalohyphomycosis (scedosporium apiospermum and fusarium species) have an even higher mortality of up to 100%. 20 endemic fungi, coccidioides immitis, histoplasma capsulatum, blastomyces dermatitidis, and cryptcoccus are additional pathogens that may need to be considered. radiological findings may demonstrate nodules, cavitary lesions, focal consolidation or patchy densities, wedge-shaped pleural-based lesions, air-filled bronchi with an intraluminal lesion, "air crescent" sign, and halo of decreased density. tissue invasion by fungal organisms is the gold standard for diagnosis of invasive fungal pneumonia. however, this may be difficult to obtain; therefore, international society for heart and lung transplantation developed guidelines, a 2010 working formulation for the standardization of definitions of infections in cardiothoracic transplant recipients, to assist in the diagnosis of not only fungal infections but also bacterial and viral infections. these definitions may also be applied to abdominal transplant recipients. treatment is as follows in fig. 4 ; however, be aware of drug-drug interactions with regards to immunosuppressive agents. it is important to note, however, that empiric management of mold infections in sot recipients is seldom necessary. the optimal approach is to pursue the diagnostic workup aggressively and treat accordingly even in lung transplant recipients. pneumocystis jirovecii, t gondii, mycobacterium tuberculosis, and nontuberculosis mycobacteria are other pathogens to also consider as possible causes of respiratory tract infections along with the other pathogens listed in fig. 5 . central nervous system (cns) infections can account for approximately 5% to 10% of cns lesions in transplant recipients. 20, 64 routine prophylaxis aimed at opportunistic infections along with a more conservative approach regarding immunosuppression has led to noticeable trends in infections in transplant recipients. for example, routine administration of trimethoprim-sulfamethoxazole for p jirovecii has likely contributed to the reduction in infections owing to t gondii, nocardia, and listeria monocytogenes along with acyclovir and valganciclovir attributing to the likely decline in herpesviridaerelated infections. 65, 66 clinical presentation will vary and may include fever, headache, meningismus, kernig and brudzinski signs, new-onset seizure, papilledema, altered sensorium, and/or focal neurologic deficits; however, because of their underlying immunosuppression, these may be subtle or absent. 65, 67 as listed in fig. 6 , possible causes range from community-acquired organisms, donor-derived infections, reactivation, to opportunistic pathogens. metastatic or direct lesions along with "pulmonary-brain" syndrome are also considerations in such organisms as cryptococcus, nocardia, aspergillus, zygomycetes, strongyloides, and toxoplasma; therefore, further investigations are warranted (eg, computed tomography of sinus and computed tomography of chest). 2, 67 evaluation should include neuroimaging along with lumbar puncture as soon as possible if no contraindication exists. cerebral spinal fluid examination should always include cell counts and differential, glucose, protein; routine smears; and cultures for bacteria, fungi, and mycobacteria. 65, 67 additional specialized testing, such as viral pcr, antigen or antibody, and 16s ribosomal rna, may be required depending on the clinical scenario. 65, 67 however, brain biopsy with appropriate staining may be the definitive diagnosis if findings are inconclusive. empiric treatment should cover common bacterial and viral pathogens; however, additional agents may be needed depending on the epidemiologic history. cholangitis is a common infection after liver transplant, and in fact, is the most common infection more than 1 year after liver transplant. 68 most cases occurred within 5 years and were associated with primary sclerosing cholangitis and rouxen-y anastomosis. 68 the most frequently identified bacteria are enterococcus spp and e coli 68, 69 ; however, other gram-negative bacilli and anaerobes should also be considered. 68, 69 bile leaks can occur in 2% to 25% of cases after liver transplantation, especially in living liver donor transplants. 70 clinical presentation varies with extent of the leak; however, symptoms can include abdominal pain, fever, or any sign of peritonitis. however, because of underlying immunosuppression, they can also be asymptomatic. 70 in these cases, elevations in serum bilirubin, fluctuations in cyclosporine, or bilious ascites should raise suspicion for a bile leak. 70 biliary strictures at the site of anastomosis can also present with fever, abdominal pain, but also jaundice and asymptomatic biochemical cholestasis. 70 bilomas can represent an additional source of infection. 41, 70 hepatic artery thrombosis, although more common in living donor liver transplants (ldlts), is uncommon with deceased donor liver transplant (ddlt) with an overall incidence up to 9% and can lead to complications, including hepatic abscesses, necrosis, sepsis, and graft loss. 71 vancomycin-resistant enterococcus faecium (vref) is of particular concern in liver transplant. pretransplant colonization increases rates of intra-abdominal and bsis after transplantation. 72, 73 in fact, hospital and intensive care unit stays are longer for patients with vref versus vancomycin-sensitive e faecium infections. 72 liver, pancreas, and intestinal recipients are at particular risk for fungal infections, most often caused by candida species. 41, 74, 75 regarding ddlt versus ldlt, there are variations with infectious complications. the rate of infection appears to be similar to ddlt; however, because of the more complex nature of the surgery, there are observable difference and specific concerns as detailed in box 1. [76] [77] [78] the clinical syndrome of hepatic dysfunction can range from mild elevated liver enzymes to hepatitis to fulminant hepatic failure. hepatic dysfunction can present in any sot recipient; however, of utmost concern would be liver transplant recipients. causes can range from infectious to noninfectious with noninfectious causes primarily an issue with liver transplant recipients regarding postoperative complications, recurrence of primary disease, drug-induced complications, and rejection. 79 the infectious causes listed in fig. 7 can range from donor-derived infections, postoperative complications, community-acquired organisms, reactivation, to opportunistic pathogens. evaluation should include imaging (eg, ultrasound, computed tomography, or mri) along with the appropriate infectious workup (eg, blood cultures, serum pcr, serology, antigen, and/or antibodies). if the diagnosis remains inconclusive, a liver biopsy may need to be pursued with appropriate staining obtained. diarrhea following transplantation is frequently observed and is estimated to occur in 22% to 52% of patients. [80] [81] [82] [83] [84] it can be associated with allograft loss and increased mortality. 80, 82, 85, 86 in fact, it results in 900,000 hospitalizations and 6000 deaths annually. 87, 88 the severity and cause of diarrhea can lead to hypovolemia and/or septic shock. diarrhea is a recognized side effect of some immunosuppressive agents; however, infectious causes should be considered based on the clinical picture. causes are detailed in fig. 8 . evaluation should include stool culture, ova and parasite and giardia antigen along with appropriate pcr, antigen testing, and/or special staining. imaging may include a computed tomography to evaluate for bowel wall edema along with colonic wall thickening and dilation. 87 esophagogastroduodenoscopy (egd) and/or colonoscopy along with biopsy may also be warranted. cmv colitis is diagnosed via histopathology obtained during a biopsy. serum pcr can be low to undetectable in this setting. if there is a clinical suspicion (eg, elevated serum pcr along with diarrhea, however the patient is unable to undergo colonoscopy), this may warrant empiric treatment. clostridium difficile infection (cdi) is among the most common health careassociated pathogen and is the most common cause of nosocomial infectious diarrhea. 89 the highest incidence of cdi in sot occurs within the first 3 months following the transplant and is likely related to frequent exposure to antimicrobials, health care settings, and immunosuppressants. 89 proton pump inhibitors (ppis) are known to be a risk for cdi and may still be used in the setting of mechanical ventilation, versus h2 blockers. 90 hospitalized patients who use ppis are twice as likely to develop cdi. 89, 91 fulminant colitis develops in up to 13% of sot recipients with cdi. 89, 92 relapsing disease is common, and protracted courses of therapy are often essential. 74, 93, 94 idsa and society for healthcare epidemiology of america recently updated the clinical practice guidelines for clostridium difficile infection in adults and children for 2017, and although this is for immunocompetent patients, these guidelines can be applied to sot recipients because there have been limited studies into the treatment of cdi in sot patients. the most common infectious complication in sot is uti, accounting for 45% to 72% of all infections, and 30% of all hospitalizations for sepsis in ktrs. 19, [95] [96] [97] [98] [99] most uti are seen within the first 6 months after transplant; however, it can occur any time after transplantation. 96, 100, 101 empirical treatment is imperative, as it has been demonstrated that inappropriate antibiotic therapy is associated with an increase in mortality. 100, 102, 103 to guide empirical therapy, local epidemiologic data, patient's microbiological history, and prior antibiotic use need to be taken into account. 95, 100 the most frequent organisms causing utis are gram-negative bacilli 100, 104 ; however, when a urinary catheter is involved, enterococci and s aureus should also be considered. the duration of treatment varies from 7-21 days depending on the clinical syndrome. recurrent uti, defined as 3 or more episodes of symptomatic utis over a 12month period or 2 in the previous 6 months, should prompt further investigation regarding anatomic and functional abnormalities along with behavioral modifications (eg, postcoital voiding) and may need a prolonged course of antibiotics, possibly 4 to 6 weeks. 95, 100, 101 asymptomatic bacteriuria should only be treated during the early postoperative period and up to 1 month after transplant in renal transplant patients. 100 the data on uti related to candida spp in sot are limited and mostly include ktr. in ktr, candida spp are the most frequently isolated fungal cause of uti. unfortunately, there are no clinical trials in the management of candida uti in sot. 100 candiduria is frequent, occurring in up to 11% of ktr; however, it is mostly asymptomatic. 95 asymptomatic candiduria is usually treated as there is concern regarding the allograft and potential for complications regarding the upper urinary tract; however, it should only be treated if the patient is neutropenic, or undergoing a urologic procedure. 95, 100 candiduria should be classified based on risk factors for disseminated candidiasis. urinary catheters should be removed or exchanged, and candiduria should be confirmed with a second, clean voided urine culture. disseminated candidiasis may be considered if clinical manifestations are consistent (eg, positive blood cultures, a second urine culture after removal or replacement of the urinary catheter, funduscopic examination, cultures from any other significant site, and kidney imaging). persistent candiduria along with infectious complications no indwelling catheters should prompt imaging of the kidneys and collecting system to exclude renal abscess, fungus balls, or other urologic abnormalities. treatment options can range from fluconazole treatment of choice, to echinocandins, amphotericin b, and flucytosine depending on the clinical situation and organism sensitivities with durations from at least 14 days for uti to 2 to 4 weeks for pyelonephritis (box 2). 100 sot recipients are a complex group of patients with diverse causes given the underlying immunosuppression. as with all infectious processes, rapid identification of the always consider previous microbiological data and local epidemiology with regards to empiric antibiotics if an intravascular catheter is involved, consider broad gram-positive cocci, including mrsa, coverage in addition to broad gram-negative coverage, including esbls and cres, if warranted empiric antifungal is not needed, unless there is a high index of suspicion always consider previous microbiological data and local epidemiology with regards to empiric antibiotics cap should include empiric coverage for atypicals along with community-associated organisms hap and vap should include broad gram-positive coverage, especially mrsa, along with broad gram-negative coverage, including esbls and cres if warranted influenza is the only virus with approved treatment, oseltamavir; therefore, this should be started empirically if there is a concern antifungals should not be started empirically, even in lung transplant recipients; however, fungal infections should be worked up thoroughly pathogen, source control, and adjustment of immunosuppression is the hallmark of treatment. there is a summary of the management of infections in sot recipients included in box 3. empiric therapy should consist of ceftriaxone and vancomycin ae acyclovir always consider previous microbiological data and local epidemiology with regards to empiric antibiotics if vre positive, will need to consider coverage using high-dose daptomycin or linezolid along with broad gram-negative coverage, including esbls and cres, if warranted regarding c difficile infections, oral vancomycin should be initiated empirically, if suspected, as first-line therapy always consider previous microbiological data along with local epidemiology with regards to empiric antibiotic decisions asymptomatic bacteriuria should only be treated in renal transplant patients during the first month posttransplantation antimicrobials should be tailored to the causative agent, with durations that generally range from 7 to 21 days depending on the clinical context fluconazole is the treatment of choice for cystitis and pyelonephritis if candida is the causative organism abbreviations: cre, carbapenem-resistant enterobacteriaceae; esbl, extended spectrum betalactamase inhibitors; vap, ventilator-associated pneumonia. clinical immune-monitoring strategies for predicting infection risk in solid organ transplantation from the classic concepts to modern practice epidemiology and risk factors for nosocomial bloodstream infections in solid organ transplants over a 10-year period bloodstream infections among transplant recipients: results of a nationwide 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recipients empirical fluconazole versus placebo for intensive care unit patients: a randomized trial empirical micafungin treatment and survival without invasive fungal infection in adults with icu-acquired sepsis, candida colonization, and multiple organ failure: the empiricus randomized clinical trial pulmonary infections in liver transplant recipients receiving tacrolimus. changing pattern of microbial etiologies infectious complications after kidney transplantation: current epidemiology and associated risk factors pneumonia infection in organ transplant recipients pneumonia in solid organ recipients: spectrum of pathogens in 217 episodes microbiologic features and outcome of pneumonia in transplanted patients infectious pulmonary complications in lung transplant recipients a standardized protocol for the treatment of severe pneumonia in kidney transplant recipients pneumonia in solid organ transplant recipients: a prospective multicenter study the diagnosis of pneumonia in renal transplant recipients using invasive and noninvasive procedures pulmonary complications in cardiac transplant recipients nocardiosis following solid organ transplantation: a single-centre experience rna respiratory viruses in solid organ transplantation respiratory viral infections in immunocompetent and immunocompromised persons clinical implications of respiratory virus infections in solid organ transplant recipients: a prospective study respiratory viral infections in transplant recipients respiratory viruses and chronic rejection in lung transplant recipients respiratory viral infections are a distinct risk for bronchiolitis obliterans syndrome and death clinical impact of community-acquired respiratory viruses on bronchiolitis obliterans after lung transplant a single-season prospective study of respiratory viral infections in lung transplant recipients respiratory viruses in transplant recipients: more than just a cold. clinical syndromes and infection prevention principles 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of risk factors aspergillus colonization of the lung allograft is a risk factor for bronchiolitis obliterans syndrome prevalence and outcome of invasive fungal infections in 1,963 thoracic organ transplant recipients: a multicenter retrospective study. italian study group of fungal infections in thoracic organ transplant recipients aspergillus infection in single and double lung transplant recipients opportunistic mycelial fungal infections in organ transplant recipients: emerging importance of non-aspergillus mycelial fungi cns infections in solid organ transplant recipients infections of the central nervous system in transplant recipients central nervous system syndromes in solid organ transplant recipients infectious complications more than 1 year after liver transplantation: a 3-decade nationwide experience the importance of late infections for the long-term outcome after liver transplantation biliary complications following liver transplantation etiology and management of hepatic artery thrombosis after adult liver transplantation infections in solid-organ transplant recipients hepatitis g virus in patients with cryptogenic liver disease undergoing liver transplantation life-threatening infection in transplant recipients fungal infections in transplant and oncology patients epidemiology and risk factors for infection after living donor liver transplantation infections after living donor liver transplantation in children infectious complications in living-donor liver transplant recipients: a 9-year single-center experience abnormal liver tests after liver transplantation diagnostic yields in solid organ transplant recipients admitted with diarrhea severe diarrhea in renal transplant patients: results of the didact study incidence and risk factors for diarrhea following kidney transplantation and association with graft loss and mortality gastrointestinal complications in liver transplant recipients: mitos study gastrointestinal complications in renal transplant recipients: mitos study gastrointestinal complications in renal transplant patients: a large, single-center experience diarrhoea following renal transplantation diarrhea in organ transplant recipients clinical practice. acute infectious diarrhea clostridium difficile infection in solid organ transplant patients histamine-2 receptor antagonists vs proton pump inhibitors on gastrointestinal tract hemorrhage and infectious complications in the intensive care unit strategies to prevent clostridium difficile infections in acute care hospitals fulminant clostridium difficile: an underappreciated and increasing cause of death and complications clostridium difficile infection in solid organ transplant recipients early and late onset clostridium difficileassociated colitis following liver transplantation urinary tract infections in solid organ transplantation urinary tract infections in renal transplant recipients hospitalizations for bacterial septicemia after renal transplantation in the 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recipients key: cord-274283-ukhgs6z1 authors: goel, sunny; jain, tarun; hooda, amit; malhotra, rohit; johal, gurpreet; masoomi, reza; kamran, haroon; krishnamoorthy, parasuram melarcode; senguttuvan, nagendra boopathy; sharma, abhishek; gidwani, umesh title: clinical characteristics and in-hospital mortality for covid-19 across the globe date: 2020-07-18 journal: cardiol ther doi: 10.1007/s40119-020-00189-0 sha: doc_id: 274283 cord_uid: ukhgs6z1 introduction: numerous case series have reported on the baseline characteristics and in-hospital mortality of patients with covid-19, however, these studies included patients localized in a specific geographic region. the purpose of our study was to identify differences in the clinical characteristics and the in-hospital mortality of patients with a laboratory-confirmed diagnosis of covid-19 internationally. methods: a comprehensive search of all published literature on adult patients with laboratory-confirmed diagnosis of covid-19 that reported on the clinical characteristics and in-hospital mortality was performed. groups were compared using a chi-square test with yates correction of continuity. a two-tailed p value of less than 0.05 was considered as statistically significant. results: after screening 516 studies across the globe, 43 studies from 12 countries were included in our final analysis. patients with covid-19 in america and europe were older compared to their asian counterparts. europe had the highest percentage of male patients. american and european patients had a higher incidence of co-morbid conditions (p < 0.05 for all variables). in-hospital mortality was significantly higher in america (22.23%) and europe (22.9%) compared to asia (12.65%) (p < 0.0001), but no difference was seen when compared with each other (p = 0.49). conclusions: there is a significant variation in the clinical characteristics in patients diagnosed with covid-19 across the globe. in-hospital mortality is similar between america and europe, but considerably higher than asia. why carry out this study? numerous case series have reported on the baseline characteristics and in-hospital mortality of patients with covid-19, however, these studies included patients localized in a specific geographic region. there is a significant variation in the clinical characteristics in patients diagnosed with covid-19 across the globe. what was learned from the study? we found american and european patients diagnosed with covid-19 are older and had a higher incidence of comorbid conditions as compared to asian patients. coronavirus disease (covid-19) was declared a pandemic by the world health organization on march 11, 2020 [1] , and has placed an unprecedented burden on the various health care systems across the globe [2] . numerous case series have reported on the baseline characteristics and inhospital mortality of patients with covid-19, however, these studies included patients localized in a specific geographic region [3] [4] [5] [6] [7] [8] . the purpose of our study was to identify differences in the clinical characteristics and the in-hospital mortality of patients with a laboratory-confirmed diagnosis of covid-19 internationally. we performed a comprehensive search of pubmed, medline, scopus, and web of sciences databases for studies published between january 1, 2020, and may 1, 2020. the following keywords were used for search in different combinations: ''coronavirus 2019'', ''covid-19'', ''novel coronavirus'', ''sarscov2'', ''clinical characteristics'', ''baseline demographics'', ''mortality'', ''all-cause mortality'', ''in-hospital outcomes'', and ''outcomes''. we included studies that had more than ten adult patients ([ 18 years), and reported clinical characteristics of patients diagnosed with laboratory-confirmed covid-19, along with all-cause mortality as one of the outcomes. we excluded studies from publicly available databases, which did not report clinical characteristics. in addition, we excluded nationwide in-hospital sample datasets and multicenter registries to avoid an overlap in patient populations. all studies from china were thoroughly evaluated for duplication of patients. if a single center had multiple publications, studies with a smaller sample size and those lacking outcomes of interest were excluded. this article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors. the database used in the study is publicly available and can be found at https://pubmed.ncbi.nlm.nih.gov/ ?term=covid-19?and?clinical?characterstic ?and?mortality&sort=date&size=100. after screening 516 studies across the globe, 43 studies from 12 countries were included in our final analysis. we categorized these studies into three geographical areas: america [11 studies (10-united states; 1-brazil)], asia [24 studies (20-china; 1-india; 1-iran; 1-korea; 1-singapore)], and europe [8 studies (3-italy; 2-france; 1-denmark; 1-ireland; 1-spain)]. of the 43 studies, 11 of them reported data strictly on patients who were in critical condition [4-6, 10, 11, 22, 32, 35, 38, 42, 45] . a chi-square test with yates correction of continuity for (fig. 1) . in-hospital mortality was significantly higher in america and europe compared to asia (p \ 0.0001), but no significant difference in in-hospital mortality was seen when compared with each other (p = 0.49), despite most of the reported patients from europe being critically ill. to the best of our knowledge, this study is the first to systematically evaluate the overall prevalence of comorbid conditions and in-hospital mortality among patients diagnosed with covid-19 across the globe. when comparing patients based on their geographic location, a significant difference in the clinical characteristics and in-hospital mortality was seen among patients diagnosed with covid-19. despite considerable variations in the individual studies due to the sample size, severity of disease (mild illness vs. critical illness) and geographical region, cardiovascular comorbidities such as htn, dm, and cad/cvd were the most common comorbidities in patients diagnosed with covid-19. apart from cardiovascular diseases, respiratory conditions [lung disease, copd, or asthma], ckd, and immunosuppression/hiv were also prevalent among covid-19 patients. our results should be interpreted with the caveat that most studies did not have complete follow-up data, and the majority of patients were still hospitalized without a definite fig. 1 clinical characteristics and in-hospital mortality of covid-19 patients across the globe outcome (i.e., mortality). therefore, it is difficult to ascertain an accurate case fatality rate from this study. in addition, patient age was reported as mean in some studies and median in others, and as a result, we cannot determine if patient age was significantly different between the groups. there is a significant variation in the clinical characteristics in patients diagnosed with covid-19 across the globe. in-hospital mortality is similar between america and europe, but considerably higher than asia. funding. no funding or sponsorship was received for this study or publication of this article. authorship. all named authors meet the international committee of medical journal editors (icmje) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published. compliance with ethics guidelines. this article is based on previously conducted studies and does not contain any studies with human participants or animals performed by any of the authors. the database used in the study is publicly available and can be found at https:// pubmed.ncbi.nlm.nih.gov/?term=covid-19? and?clinical?characterstic?and?mortality& sort=date&size=100 data availability. the datasets during and/ or analyzed during the current study are available from the corresponding author on reasonable request. open access. this article is licensed under a creative commons attribution-noncommercial 4.0 international license, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/bync/4.0/. who declares covid-19 a pandemic covid-19-navigating the uncharted clinical characteristics of covid-19 in new york city characteristics and outcomes of 21 critically ill patients with covid-19 in washington state baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region characteristics, treatment, outcomes and cause of death of invasively ventilated patients with covid-19 ards in clinical characteristics of 225 patients with covid-19 in a tertiary hospital near wuhan epidemiological and clinical features of 125 hospitalized patients with covid-19 in clinical features, laboratory characteristics, and outcomes of patients hospitalized with coronavirus disease 2019 (covid-19): early report from the united states sars-cov-2 in spanish intensive care units: early experience with 15-day survival in vitoria covid-19 in critically ill patients in the seattle region-case series effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection: a randomized clinical trial clinical progression of patients with covid-19 in shanghai epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics and outcomes of older patients with coronavirus disease 2019 (covid-19) in wuhan, china: a single-centered, retrospective study characteristics of emergency department patients with covid-19 at a single site in northern california: clinical observations and public health implications clinical features of covid-19-related liver damage covid19 coagulopathy in caucasian patients prognostic value of nt-probnp in patients with severe covid-19 clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 covid-19 patients with at least a six-day follow up: a pilot observational study clinical and epidemiologic profile of the initial covid-19 patients at a tertiary care centre in india comparing rapid scoring systems in mortality prediction of critical ill patients with novel coronavirus disease clinical course and outcomes of patients with severe acute respiratory syndrome coronavirus 2 infection: a preliminary report of the first 28 patients from the korean cohort study on covid-19 a cross-sectional comparison of epidemiological and clinical features of patients with coronavirus disease (covid-19) in wuhan and outside wuhan. china risk factors for severity and mortality in adult covid-19 inpatients in wuhan clinical features of covid-19 in elderly patients: a comparison with young and middle-aged patients association between platelet parameters and mortality in coronavirus disease 2019: retrospective cohort study epidemiology of covid-19 in a long-term care facility in king county. washington risk of qt interval prolongation associated with use of hydroxychloroquine with or without concomitant azithromycin among hospitalized patients testing positive for coronavirus disease characteristics of hospitalized adults with covid-19 in an integrated health care system in california epidemiological characteristics of coronavirus disease 2019 (covid-19) patients in iran: a single center study initial experiences from patients with covid-19 on ventilatory support in denmark prevalence and characteristics of gastrointestinal symptoms in patients with sars-cov-2 infection in the united states: a multicenter cohort study presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area high prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (sars-cov-2) requiring invasive mechanical ventilation clinical impact of renin-angiotensin system inhibitors on in-hospital mortality of patients with hypertension hospitalized for covid-19 clinical features and treatment of covid-19 patients in northeast chongqing suppressed t cellmediated immunity in patients with covid-19: a clinical retrospective study in wuhan clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (covid-19): a multi-center study in wenzhou city epidemiologic features and clinical course of patients infected with sars-cov-2 in singapore analysis of clinical characteristics and laboratory findings of 95 cases of 2019 novel coronavirus pneumonia in wuhan, china: a retrospective analysis risk factors for disease severity, unimprovement, and mortality in covid-19 patients in wuhan. china clinical characteristics of patients with 2019 coronavirus disease in a non-wuhan area of hubei province, china: a retrospective study clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study potential benefits of precise corticosteroids therapy for severe 2019-ncov pneumonia key: cord-276255-0ofsa40u authors: cheong, mark wing loong title: ‘to be or not to be in the ward’: the impact of covid‐19 on the role of hospital‐based clinical pharmacists ‐ a qualitative study date: 2020-08-12 journal: j am coll clin pharm doi: 10.1002/jac5.1315 sha: doc_id: 276255 cord_uid: 0ofsa40u introduction: the coronavirus disease 2019 (covid‐19) pandemic has significantly affected health care systems around the world. in many hospitals and health care facilities, services and health care workers have been reorganized and restructured to meet the demands of the pandemic. the impact of the pandemic on hospital‐based clinical pharmacists and their ability to deliver pharmaceutical care is currently unknown. objective: this study aimed to explore the impact of the covid‐19 pandemic on hospital‐based clinical pharmacists working in malaysia and the implications on how clinical pharmacy is perceived as a health care service. methods: a qualitative study was designed to meet the research objectives. nineteen hospital‐based clinical pharmacists consented and participated in one‐on‐one, semi‐structured interviews. the interviews were transcribed and analyzed using an iterative thematic analysis approach. results: the experiences and views of the participants were reported. three main themes were developed: ‘reassignment and other changes in clinical pharmacist roles’, ‘adapting clinical pharmacy services to covid‐19’, and ‘the need for clinical pharmacists in the ward’. the findings indicate that in many cases, clinical pharmacy services were fully or partially withdrawn from the ward to reduce the risk of infection and to conserve the usage of personal protective equipment. despite this, clinical pharmacists continued to support patient care in hospitals through the use of technology. the withdrawal of clinical pharmacy services, however, raises concern that the role of clinical pharmacists is still poorly recognized. conclusion: clinical pharmacists in hospitals continue to support patient care despite the disruption caused by the covid‐19 pandemic. greater support and recognition of their role is required in order to empower and enhance their ability to deliver pharmaceutical care. this article is protected by copyright. all rights reserved. around the world, health care systems have been significantly impacted by the coronavirus disease 2019 (covid19) pandemic. health care facilities have been forced to restructure their services and systems in order to prioritize infection control and manage covid-19 patients. 1 there have been reports of health care workers being reassigned to areas deemed more essential, as well as the cancellation of 'elective' treatments during this pandemic. 2, 3 the role of pharmacists in preserving the medication supply chain and in facilitating the access to new or previously unused medicines has been rightfully deemed as essential. as such, pharmacists around the world have remained on the front lines of the pandemic to ensure that medicines and other medical supplies remain available to patients and health care workers. 4, 5 but what of clinical pharmacy? clinical pharmacy is defined by the american college of clinical pharmacy (accp) as, "a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention." 6 there is a large body of evidence which demonstrates the benefits of clinical pharmacy services and the role of clinical pharmacists as an essential part of the health care team. [7] [8] [9] [10] [11] despite the evidence, however, the implementation, funding, and staffing of clinical pharmacy services continues to face numerous challenges. [12] [13] [14] as such, clinical pharmacy services can be particularly sensitive to changes that affect the allocation of resources within the health care facility. while there has been some discussion about the roles of clinical pharmacists during the pandemic, it is unknown how the pandemic has affected clinical pharmacy services in hospitals. [15] [16] [17] [18] there is concern that the reprioritization of health care resources, as well as limited supplies of essential items such as personal protective equipment (ppe), may result in clinical pharmacy services in this article is protected by copyright. all rights reserved. hospitals being fully or partially withdrawn, and clinical pharmacists being reassigned to supplyfocused roles. 19 malaysia is a middle-income country in southeast asia. health care is provided by both a taxpayerfunded public health care system as well as a free-market private health care sector. clinical pharmacy services have been implemented since the 1990s, although mainly in public hospitals. 20 the implementation of clinical pharmacy services has not been uniform as decisions on resource allocation for the development of clinical pharmacy are often left to the discretion of individual facilities. clinical pharmacists in malaysia are pharmacists who have been assigned to work in the hospital wards, where they provide pharmaceutical care to patients and support the health care team with information and guidance for the effective use of medicines. they usually have little to no role in the inpatient or outpatient supply of medicines, unlike other pharmacists working in the hospital. this study aims to explore the impact of the covid-19 pandemic on hospital-based clinical pharmacists in malaysia and the implications on how clinical pharmacy is perceived as a health care service. potential participants were identified through a recruitment call via social media, email contact via the researcher's professional network, and through the use of snowballing, where participants referred the researcher to other potential participants. potential participants were provided with explanatory statements that explained the details of the study. those who agreed to participate in the study signed consent forms and the interviews were arranged. the inclusion criteria for participants in this study were: 1) pharmacists registered to practice in malaysia, and 2) were this article is protected by copyright. all rights reserved. presently or immediately prior to the covid-19 pandemic, working as hospital-based clinical pharmacists. all the participants took part in one-on-one, semi-structured interviews. each interview was carried out using an interview topic guide that allowed for participants and the researcher to explore subjects in varying length and detail. the topics included the impact of the covid-19 pandemic on the role of clinical pharmacists, the delivery of clinical pharmacy services, and the perception of clinical pharmacy as an essential health care service. all interviews were transcribed verbatim. this study received ethical approval from the monash university human research ethics committee (project id: 24390). an iterative thematic analytic approach was used. a critical realist paradigm was adopted which assumes that there is an independent reality and each individual's interpretation of that reality is influenced by their experiences, culture, language, and context. all transcripts of the interviews were coded by the researcher. throughout the coding process, implicit views were taken into consideration and analytical memos were made to complement the process. constant comparative techniques were employed throughout the entire coding process for the development of themes that described impact of the covid-19 pandemic on clinical pharmacy services and the roles of clinical pharmacists. this article is protected by copyright. all rights reserved. nineteen participants from 15 different hospitals were interviewed for this study. the participant characteristics are summarized in table 1 . the coding and subsequent analysis of the findings of this study led to the development of 3 main themes: 'reassignment and other changes in clinical pharmacist roles', 'adapting clinical pharmacy services to covid-19', and 'the need for clinical pharmacists in the ward'. a common change experienced by the participants was reassignment from their clinical pharmacist role in the ward to other roles such as medication supply in the inpatient or outpatient pharmacy, or the production of personal protective equipment (ppe). common reasons given to the participants for their reassignment included reducing the usage of ppe, reducing their risk of being infected, and to prevent the spread of infection throughout the pharmacy which risked disrupting the medication supply chain. for example, one participant explained, "some of our pharmacy staff became 'persons under investigation' as they had close contacts with patients who were covid-19 positive and that led to many of us being quarantined at home as we were in close contact with them (rph04, area of practice -endocrinology)." study participants who were not reassigned, instead experienced changes in their job scope. these changes included having medicine supply and ppe production duties added on to their role, resulting in a reduction of the time spent in the ward providing pharmaceutical care. some participants were this article is protected by copyright. all rights reserved. the participants remained committed to providing pharmaceutical care, despite being excluded from the wards. some of the participants expressed that they felt obliged to continue providing support to the patient care team they usually worked with as well as an obligation to provide care to the patients in "their ward". one participant described, "i've been working with this team of doctors and nurses as well as the patients in this ward for years. even though i cannot be in the ward, the this article is protected by copyright. all rights reserved. in order to continue providing pharmaceutical care, adaptations were required. for example, the participants maintained contact via phone calls or text messages with the patient care team in the ward in order to provide drug information. this was also supplemented with the remote screening of medication charts to identify medication-related issues. some participants also arranged for videocalls with physicians to discuss the management of complex patient cases. where the participants were not allowed to provide bedside counselling to patients in the ward, they adapted by filming videos of themselves giving instructions on how to use medical devices. they also made use of videocalls with the patients to provide counselling on medication adherence and proper use of medicines. this article is protected by copyright. all rights reserved. there were differing opinions among the participants regarding the need to be in the ward during the pandemic. some of the participants argued that it was important for them to be there. these participants mentioned that being away from the patients in the ward decreased their effectiveness in providing both pharmaceutical care and preventing medication errors. this, to them, was doubly important during the pandemic as they had to manage complex cases using constantly changing guidelines and unfamiliar drugs. for some of them, the pandemic represented the opportunity to live up to the claim that clinical pharmacists were an essential part of the health care team. one participant responded, "if we say that clinical pharmacy service is essential, but then when a pandemic happens, we back off from the wards, it gives the impression that we are not that important anyway. so that is why i kept telling myself, "this is not the time for us to back off. we should stay in the wards and provide our usual service." only then, will we gain the recognition we need. but at a time when you are needed the most and you back away, then the doctors will feel that you are not important anymore. so, this is the time that we show up and work with the doctors and the nurses and tell them that, "hey, we are together as a team (rph10, area of practice -critical care)." other participants felt that it was reasonable during this pandemic to be excluded from the ward and the patient's bedside. three common reasons were given. the first was that the adaptation and remote provision of clinical services, while not perfect, was sufficient to meet the needs of the patients' and the health care team. the second reason was the potential risk of infection. the participants suggested that it was important to prevent any infections among the pharmacists as it would lead to the quarantine of the pharmacy department, resulting in a disruption of the this article is protected by copyright. all rights reserved. medication supply chain. the third reason was the conservation of ppe. some participants commented that it was explained to them that their presence in the ward would "increase the usage of ppe", "be a waste of the ppe available", and that "ppe should be reserved for essential health care workers". when asked about how this reflected on the importance of clinical pharmacists in a hospital, most of the participants felt that clinical pharmacists were essential, but that perception was not shared by the hospital administration. one participant expressed, "in my opinion, it is essential for clinical pharmacists to be in the wards. however, pharmacists should be recognized as essential front line health care workers. unfortunately, hospital administrators tend to think of pharmacists as 'support staff', as we supposedly don't touch patients and so they don't give us enough ppe and they don't let us into the wards (rph17, area of practice -general medicine)." a few participants, however, shared their belief that clinical pharmacists play only a supporting role, and because that support could be provided remotely, ppe could be conserved for other front line health care workers. one participant wrote, "i actually agree with (redeployment) because as i mentioned earlier the clinical pharmacists in government hospital service are support staff. so, we will try to support the main clinical service as much as possible. so, i am okay with the redeployment, yeah (rph09, area of practice -general medicine)." the participants, however, unanimously agreed that if given the choice along with adequate ppe, they would prefer to be in the ward and by the patients' bedside. the reasons for this included their preference for their usual clinical role over supply-focused roles, and the feeling that their ability to provide pharmaceutical care was less effective. one participant explained, "personally, i feel it is lacking in that we can't provide bedside counselling when a patient needs it. but we did try to come out with guidelines and possible alternatives, such as if covid-19 patients are prescribed with this article is protected by copyright. all rights reserved. inhalers but have never used it before, we will supply them with a spacer and teach the nurses how to use it (rph08, area of practice -critical care)." the participants also felt that the continual demand for their services by other members of the health care team emphasized how important clinical pharmacists were. several participants shared that the demand for their services increased during the covid-19 pandemic due to the increased use of unfamiliar drugs in complex patient cases. one participant described, "the nurses are not used to these drugs, neither are the doctors. the doctors need to discuss with us frequently regarding dosing and so on. we have consultants come up to us asking tough questions sometimes such as, 'why are the french using 600 mg of hydroxychloroquine?' or 'which is better, chloroquine or hydroxychloroquine?' or 'how do statins interact with these antivirals, exactly?' (rph01, area of practice -respiratory medicine)" the findings of this study indicate that the covid-19 pandemic has disrupted the delivery of pharmaceutical care in the ward by clinical pharmacists. the disruption experienced is partly due to the challenges posed by heightened infection control practices. these challenges have also been reported by pharmacists in other countries. nevertheless, pharmacists, both in this study and elsewhere, have made creative use of technology in order to deliver health information that is needed for the effective use of medicines as well as medication adherence. 16, 18, 21 a major source of disruption, however, appears to be the institutional directives that either fully or partially withdrew clinical pharmacy services. while the intention may be to keep clinical pharmacists safe, it raises the uncomfortable question of whether clinical pharmacists and the work that they do are essential. this study does not provide the answer, but instead raises some this article is protected by copyright. all rights reserved. questions: where clinical pharmacists are not allowed patient contact in the wards, or not provided adequate ppe because both of these have been restricted to 'essential' staff, are they then considered 'optional'? similarly, when a service can be withdrawn during a time of crisis, is it still essential? it is striking that in the current literature on covid-19, little has been said about the role of clinical pharmacists in providing patient care as compared with their role in providing drug information, developing formularies, and preserving the medication supply chain. 16, 18, 22, 23 there has, instead, been more reported about the provision of pharmaceutical care by community pharmacists. 5, 21, 23, 24 one wonders then, whether clinical pharmacists have been silently withdrawn in many hospitals. this is not to say that clinical pharmacists are not doing their best to provide pharmaceutical care. certainly, the responses in this study indicate that they continue to do so in innovative ways, despite being directed to withdraw. their contributions however are diminished by the lack of awareness and recognition of their role, especially among the public, politicians, and hospital administrators. 17 that their role is essential should not be in dispute, as evidenced by the continual demand for clinical pharmacy services from other health care workers. onozato and colleagues highlighted the importance of both administrative and political support in the implementation of clinical pharmacy services within health care institutions. 25 unfortunately, clinical pharmacists seem to be trapped in a catch-22 situation: while individual clinical pharmacists can and want to deliver pharmaceutical care to patients, this lack of support hampers their ability to do so. on the other hand, without being able to demonstrate the need for their presence in direct patient care, clinical pharmacists lose the opportunity to gain said support. as such, much work needs to be done to help clinical pharmacists gain the support that they need. this article is protected by copyright. all rights reserved. there are a few steps that may help clinical pharmacists address these problems. the first is to document and showcase the innovations developed during this pandemic. these innovations can be used as evidence to raise awareness and demonstrate the role of clinical pharmacists to the public and other stakeholders. secondly, an evaluation of clinical pharmacy services provided during the pandemic that incorporates feedback from other members of the health care team should be conducted. an in-depth evaluation will be necessary for pharmacists themselves to identify which of their clinical activities are essential and must be done at the bedside, and which activities can actually be done at a high-level through the use of technology. the feedback from other members of the patient care team can further triangulate these points, as well as highlight the demand for clinical pharmacy services. this can be used to prevent any withdrawal of clinical pharmacy services and to justify greater support for clinical pharmacists in the ward. this study had some limitations. the number of participants in this study was small and restricts the extent to which the findings reported in this study can be generalized. the participants in this study also self-reported their experiences which may result in the overrepresentation of certain findings and introduce potential bias in the data. this study only interviewed clinical pharmacists. the perceptions of other health care workers were not represented. as such, future studies should attempt to incorporate input from hospital administrators and other health care workers. the participants also represent a self-selected sample which may be biased. the study was also conducted by a single researcher which may have led to some interpretation of the data being affected by the researcher's own experience. where clarification was needed, however, the interpretation of the data was checked with the participants. this article is protected by copyright. all rights reserved. finally, the qualitative nature of this study meant that the significance or prominence of specific findings could not be determined in any meaningful way. it is worth bearing in mind, however, that this study was designed to elicit and highlight the wide variety of experiences and views of clinical pharmacists in malaysia. further research investigating the relative prominence of the experiences and views highlighted in this study is recommended. the covid-19 pandemic has disrupted clinical pharmacists and their ability to deliver pharmaceutical care. while clinical pharmacists have worked to continue delivering support to the health care team, their ability to deliver pharmaceutical care to hospitalized patients has been impaired in varying degrees. greater support and recognition of the role of clinical pharmacists is required to empower and enhance their ability to deliver optimum patient care. this article is protected by copyright. all rights reserved. the experiences of health-care providers during the covid-19 crisis in china: a qualitative study covid-19 significantly impacts health services for noncommunicable diseases million elective surgeries may be cancelled worldwide: how non-covid-19 medical care is suffering sars-cov-2 outbreak: how can pharmacists help? community pharmacist in public health emergencies: quick to action against the coronavirus 2019-ncov outbreak impact of a clinical pharmacy admission medication reconciliation program on medication errors in "high-risk" patients pharmacist contributions as members of the multidisciplinary icu team economic evaluations of clinical pharmacist interventions on hospital inpatients: a systematic review of recent literature economic, clinical, and humanistic outcomes (echos) of pharmaceutical care services for minority patients: a literature review a systematic review and meta-analysis of pharmacist-led fee-for-services medication review factors affecting the implementation of clinical pharmacy services in china survey of hospital pharmaceutical care in china and the status quo of clinical pharmacy practice (part 3): attitude of the personnel involved in clinical pharmacy perceived barriers to the implementation of clinical pharmacy services in a metropolis in northeast brazil roles of the chinese clinical pharmacist during the covid-19 roles of the clinical pharmacist during the covid-19 pandemic hero clinical pharmacists and the covid-19 pandemic: overworked and overlooked fighting against covid-19: innovative strategies for clinical pharmacists covid-19 and clinical pharmacy worldwide -a wake up call and a call to action challenge to clinical pharmacy practice in malaysia medication management and adherence during the covid-19 pandemic: perspectives and experiences from low-and middle-income countries pharmacists at the frontline beating the covid-19 covid-19: guidelines for pharmacists and the pharmacy workforce role of pharmacists during the covid-19 pandemic in china this article is protected by copyright. all rights reserved factors influencing the implementation of clinical pharmacy services for hospitalized patients: a mixedmethods systematic review key: cord-353887-f4yd7guj authors: tang, yujun; liu, jiajia; zhang, dingyi; xu, zhenghao; ji, jinjun; wen, chengping title: cytokine storm in covid-19: the current evidence and treatment strategies date: 2020-07-10 journal: front immunol doi: 10.3389/fimmu.2020.01708 sha: doc_id: 353887 cord_uid: f4yd7guj severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is the pathogen that causes coronavirus disease 2019 (covid-19). as of 25 may 2020, the outbreak of covid-19 has caused 347,192 deaths around the world. the current evidence showed that severely ill patients tend to have a high concentration of pro-inflammatory cytokines, such as interleukin (il)-6, compared to those who are moderately ill. the high level of cytokines also indicates a poor prognosis in covid-19. besides, excessive infiltration of pro-inflammatory cells, mainly involving macrophages and t-helper 17 cells, has been found in lung tissues of patients with covid-19 by postmortem examination. recently, increasing studies indicate that the “cytokine storm” may contribute to the mortality of covid-19. here, we summarize the clinical and pathologic features of the cytokine storm in covid-19. our review shows that sars-cov-2 selectively induces a high level of il-6 and results in the exhaustion of lymphocytes. the current evidence indicates that tocilizumab, an il-6 inhibitor, is relatively effective and safe. besides, corticosteroids, programmed cell death protein (pd)-1/pd-l1 checkpoint inhibition, cytokine-adsorption devices, intravenous immunoglobulin, and antimalarial agents could be potentially useful and reliable approaches to counteract cytokine storm in covid-19 patients. in december 2019, an outbreak of a novel coronavirus-based disease was reported in wuhan, china. on 11 february 2020, the world health organization (who) named this coronavirus "severe acute respiratory syndrome coronavirus 2" (sars-cov-2) and the disease that it caused "coronavirus disease 2019" (covid19) . as of 25 may 2020, sars-cov-2 has affected over 212 countries, and about 5,529,195 cases have been confirmed around the world, of which 347,192 people have died. the reason for these deaths is suspected to be the "cytokine storm" [also called "cytokine storm syndrome" (css)]. the international classification of diseases (icd) does not include the cytokine storm or css. cron and behrens bring the current knowledge of css (1) . they define that "cytokine storm" is an activation cascade of auto-amplifying cytokine production due to unregulated host immune response to different triggers. the triggers involved infections, malignancy, rheumatic disorders, etc. another scholar described that cytokine storm is a systemic inflammatory response to infections and drugs and leads to excessive activation of immune cells and the generation of pro-inflammatory cytokines (2) . a similar entity is termed "cytokine release syndrome" (crs), which is not defined in the textbook of css (1) . crs is an acute systemic inflammatory syndrome characterized by multiple-organ dysfunction (mod). it has been reported that chimeric antigen receptor (car)-t-cell therapy could help to distinguish crs from a cytokine storm (2) . of note, the textbook described the criteria of css based on hemophagocytic lymphohistiocytosis (hlh) and secondary hlh (shlh) associated with rheumatic disorders, such as macrophage activation syndrome (mas) (1) . thus, it may be not applicable in covid-19 because the covid-19 is a contagious disease and relatively irrelevant to a genetic disorder. up to date, there is still a lack of clinical and laboratory criteria to identify the cytokine storm. in this review, we referred covid-19 associated cytokine storm as the patients who are severely ill along with a high concentration of pro-inflammatory cytokines. for patients with covid-19, the number of white blood cells, neutrophils, as well as levels of procalcitonin, c-reactive protein, and other inflammatory indices, are significantly higher in the intensive care unit (icu) cases than in non-icu cases (3, 4) . many studies showed that severely ill patients tended to have a higher concentration of pro-inflammatory cytokines, especially interleukin (il) 6, than moderately ill patients in covid-19 (5) (6) (7) (8) (9) . the result of the bronchoalveolar lavage fluid (balf) cells, which tested by transcriptome sequencing, reveals excessive chemokines releasing caused by sars-cov-2 infection, such as cxcl10 and ccl2 (10) . the high level of cytokines also indicates a poor prognosis in covid-19 (6, 11, 12) . furthermore, the pathology of postmortem examination of the lung, from who was died of covid-19, demonstrated the existence of acute respiratory distress syndrome (ards) and t-cell overactivation chen and subbarao (21) ]. method of detection (number of patients studied) cba (20) cba ( chemokines (13) . this phenomenon is due to an increase in the number of t-helper (th) 17 cells and the high cytotoxicity of the cd8 + t cells (13) . the innate and adaptive immune responses activated by sars-cov-2 infection lead to uncontrolled inflammatory responses and ultimately cause the cytokine storm (14) . the cytokine storm can lead to apoptosis of epithelial cells and endothelial cells, and vascular leakage and, finally, result in ards, other severe syndromes, and even death (15) . to lower mortality due to cytokine storm, we summarized the clinical and pathology features of the coronavirus-related cytokine storm. we explored the efficacy and safety of potential treatments and their molecular mechanism. there is still lacking sufficient evidence supporting the regulation of cytokine expression may be beneficial to the mortality of covid-19. the early-stage clinical characteristics of mers and sars are influenza-like symptoms (16) (17) (18) : pyrexia, sore throat, dry cough, myalgia, and dyspnea. those symptoms are very similar to the characteristics of early covid-19 and progress rapidly to pneumonia (3, 19, 20) . it has been found that the regulation of several cytokines is disordered in the peripheral blood of sars patients, as summarized by chen and colleagues (21) and listed in table 1 . table 1 shows an increase in levels of cytokines and chemokines and a decrease in levels of anti-inflammatory cytokines such as il-10. of note, the release of pro-inflammatory cytokines, especially interferon (ifn)-α and ifn-γ, is correlated with lethal sars (22, 23) . the cytokines with increased levels in fatal sars are il-6, il-1β, ifn, and cxcl10. these cytokines are secreted mainly by dendritic cells (dcs) and macrophages, indicating that innate immunity plays a pivotal part in lethal sars. ccr4 + ccr6 + th17 cells have many chemokine receptors and may share the same mechanism and function in cell-cell interactions in sars. cytokines secreted by dcs and macrophages induce the infiltration and recruitment of pro-inflammatory th17 cells. analyses of lungs from sars patients have revealed diffuse alveolar damage as a crucial feature. histopathological studies have shown lung consolidation and edema with pleural effusions and focal hemorrhage, all of which resemble covid-19 features (13, 24) . besides, the lungs of sars patients are infiltrated extensively with neutrophils and macrophages, which are not observed in covid-19. in peripheral blood, numbers of cd4 + and cd8 + t cells are reduced in cases of covid-19 and sars (13, 25) and are associated with death in the latter (25) . interestingly, unlike mers and sars, a high concentration of pro-inflammatory cc chemokine receptor (ccr)4 + ccr6 + th17 cells are found in covid-19 (13) . the innate and adaptive immune system takes multiple measures to respond to virus infection. mers-cov infects human epithelial cells and leads to these cells inducing significant but delayed responses by ifn, pro-inflammatory cytokines (e.g., il-1β, il-6) and chemokines (e.g., il-8) (26, 27) . sars-cov infects airway epithelial cells and results in delayed release of chemokines such as ccl3, ccl5, ccl2, and cxcl10 (28) . besides, mers-cov infects hematopoietic cells such as monocytes, macrophages, and dcs, which is not seen in those cells upon sars-cov infection (29) (30) (31) (32) . mers-cov infects the cells mentioned above to induce delayed (but increased) levels of pro-inflammatory cytokines (e.g., il-2) and chemokines (e.g., ccl2, ccl3) (27, 30) . although sars-cov is abortive in macrophages and dcs, the virus induces an increase in levels of pro-inflammatory cytokines and chemokines (31, 32) . sars-cov and sars-cov-2 infect cells using the same receptor: angiotensin-converting enzyme-2 (33) . hence, it has been postulated that both viruses can affect the same spectrum of cells. in the aspects of murine models of coronavirus, infection with sars-cov in balb/c mice has been shown to induce an increase in the number of pathogenic inflammatory monocytemacrophages (imms) (34) . through stimulation of ifnα/β receptors, the accumulating imms produce monocyte chemokines (e.g., ccl2, ccl7, ccl12) and pro-inflammatory cytokines [e.g., tumor necrosis factor (tnf), il-6, il1β], which results in further accumulation of pathogenic imms. targeting of ifn signaling, imms, or pro-inflammatory cytokines could offer protection from lethal sars-cov infection. in this way, the chemokines (produced by activated monocytes and macrophages) lead to the recruitment of neutrophils, monocytes, and t cells into the lungs (28) . after chemotaxis, activated effector t cells migrate to the lungs and destroy pneumocytes/permissive cells due to response to the virus infection (35) . the damage caused by neutrophils, monocytes, and t cells results in lung-parenchyma changes, such as diffuse alveolar damage, which leads to ards (35) . in summary, the excessive cytokines and chemokines caused by lethal coronavirus infection involve mainly antigen-presenting cells (apcs) (such as macrophages) and t cells. however, cytokines secreted by immune cells are produced to eliminate viral infection, and deficiency of such cytokines may be harmful to the body. for example, virus titers are significantly higher in toll-like receptor (tlr)3 −/− , tir-domain-containing adapterinducing interferon-β (trif) −/− , and il-6 −/− mice compared with their wild-type counterparts, and are associated with severe lung damage (36, 37) . in china, we classified the stage of covid-19 according to the guidelines (38) issued by the national health commission of the people's republic of china (nhc). according to the instructions, nhc defines severe illness of covid-19 as one of the following conditions: respiratory rate ≥30 breaths/min in the resting state; oxygen saturation ≤93%; arterial blood oxygen partial pressure (pao 2 )/fraction of inspired oxygen concentration (fio 2 ) ≤300 mmhg. critical illness as one of the following conditions: respiratory failure and requiring mechanical ventilation; shock; complication of other organ failures, and needs intensive care. the most common symptoms of covid-19 were fever, cough, shortness of breath, fatigue, and myalgia (5, 7, 39, 40) , and severe cases tend to be older with more basic diseases and suffer from dyspnea, more complications (5, 40) . in covid-19, 14% of patients progress to severe disease and 5% to critical illness (41) . a prospective study reported that the computerized tomography (ct) of the lungs of covid-19 (6) . the lung lesions increase and the scope expands as the disease progresses, and ground-glass opacity coexisted with consolidation or striated shadow. some severe patients showed diffuse lesions in both lungs. up to date, the inflammatory disorders (insufficient in chemokines) in covid-19 have been reported in many clinical studies. the covid-19 is inclined to cause a decrease of lymphocyte count and an increase of c reactive protein (crp), especially in severely ill patients (5) (6) (7) (42) (43) (44) . the major subsets of the t lymphocytes (t cell) (cd3 + cd4 + t cell and cd3 + cd8 + t cells) are reduced in the covid-19 and are significantly lower in the severe cases (5, 12, 42, 43, 45, 46) ; however, controversial results are also reported in some studies (7, 40) . the results of the other immune cells, the b cell and natural killer (nk) cell, have more inconsistency in recent researches. il-6 was observed increased in all studies, and only one study show il-10 was not elevated. about half of the studies we collected showed tnf-α was increased. only huang et al. (9) inspected the multiple types of chemokines and found that severe patients had higher levels of g-csf, gm-csf, ip-10, mcp-1, mip-1a, mip-1b, rantes, and il-8. the inflammatory disorders of covid-19 were summarized in table 2 . comparison objects il-6 il-1β il-10 tnf-α ifn-γ il-2(r) the pathologic features of covid-19 showed the lungs were infiltrated with excessive ccr6 + th17 cells and high cytotoxicity of cd8 + t cells (13) . but high cytotoxicity of cd8 + t cells does not mean they exert the normal function. the sars-cov-2 could lead to cytotoxic lymphocytes (mainly involving nk cells and cd8 + t cells) exhaustion, which is manifested as the upregulated exhaustion markers, such as nkg2. the exhaustion markers return to normal in patients who have recovered or are convalescent (47, 48) . balf cells were found extreme cytokine releases, such as ccl2, cxcl10, ccl3, and ccl4 (10). furthermore, xiong et al. (10) use the transcriptome dataset approach to discover that sars-cov-2 can activate apoptosis and p53 signaling pathway (one of the pathways responsible for the survival of the cell) in lymphocytes. these results could provide some reasons for the cause of patients' lymphopenia. another team of chen and his colleagues studied the mechanisms for lymphopenia (49) . their results demonstrate that sars-cov-2 infected the cd169 + macrophages in spleens and lymph nodes (lns), and lead to lymphoid tissue damage, such as splenic nodule atrophy and lymph follicle depletion, etc. the cd169 + macrophages express high fas and cause activation-induced cell death (aicd) through fas/fasl interactions. furthermore, sars-cov-2 selectively induced macrophages to produce il-6, not tnf-α and il-1β, to directly promotes lymphocyte necrosis. the analysis of peripheral blood mononuclear cells (pbmcs) revealed that non-structural protein (nsp) 9 and nsp10 of sars-cov-2 target nkrf (nf-κb repressor) to promote il-6/il-8 production (50) . as a consequence, it recruits neutrophils and induces uncontrollable host inflammatory response. collectively, the clinical, immunological, and pathologic features of covid-19 have something in common with sars and mers. for example, all the viruses can cause lymphopenia and influenza-like symptoms in the early stage. sars and covid-19 do not lead to the upgrade of tnf-α, but the increase of il-6 and il-10 is more prevalent in covid-19. the il-6 plays a crucial role in the pathologic of covid-19, including the chemotaxis of neutrophils and lymphocyte necrosis. importantly, covid-19 is more able to cause cytotoxic lymphocytes exhaustion. tocilizumab (tcz) is a recombinant humanized anti-human il-6 receptor monoclonal antibody, preventing il-6 binding to its receptor to exert the immunosuppression promoted by il-6. michot et al. (51) reported that 42-year-old male suffering from respiratory failure due to sars-cov-2 infection. after 4 days of tcz treatment, the crp decreased from 225 to 33 mg/l and ultimately clinically fully recovered. similarly, some case reports showed tcz is an efficacy and safety approach in covid-19, even patients with other diseases combined, such as multiple myeloma, end-stage renal disease, and sickle cell disease (52) (53) (54) . recently, a retrospective study (55) found that tcz decreased crp in all patients (n = 15) rapidly, but three of them, who are critically ill, still dead. the dead patients show continuously rising of il-6 even after the administration of tcz and methylprednisolone, indicating that repeat doses of tcz may be needed in covid-19 patients who are critically ill. another retrospective study (56) demonstrated that tcz showed a quick control of severe covid-19 manifestation, such as fever, respiratory function. all patients (n = 21, two were critically ill), have recovered and have been discharged from hospital, and no adverse event was reported during the treatment. a prospective open-label, multicenter single-arm study manifests the pilot results of the off-label application of tcz in severe patients with covid-19 (57) . the study involved 63 patients with severe covid-19, and tcz succeeded in improving respiratory and laboratory parameters, such as pa0 2 , fi0 2 , consequently, increased the likelihood of survival (the death rate of the study is 11%). it is worth mentioning that a cautionary case report by radbel et al. (58) . two patients were diagnosed with covid-19 complicated by crs and treated with tcz. unfortunately, both patients progressed to severe hlh, and one developed to viral myocarditis. all the cytokines produced by immune cells are responsible for viral clearance. suppression of cytokine release at an early stage of disease as treatment is controversial. application of synthetic disease-modifying antirheumatic drugs (dmards) and biologic dmards to downregulate cytokine expression in ra increases the risk of infection (59, 60) . the timing and the doses of the intervention still need to be inspected clearly. sars-cov-2 mainly causes a dramatic increase in il-6 and does not remarkably promote other pro-inflammatory factors, such as il-1β and ifn-γ. although treating covid-19 with tcz is an off-label use, it may be relatively appropriate and safe in coping with covid-19 associated cytokine storm basing on the current evidence. it still needs more large samples and high-quality studies to evaluate the exact efficacy and safety in covid-19. the ongoing trials of potential treatments and other treatments focus on inflammatory disorders in covid-19 are available in supplementary table 1 . glucocorticoid therapy is used widely among critically ill patients with other coronavirus infections (e.g., sars, mers). corticosteroids have been administered to icu patients infected with sars-cov-2 (3, 4, 20) . glucocorticoids exhibit pharmacologic effects at any therapeutically relevant dose through classic genomic mechanisms. some immunosuppressive effects are based on transactivation, and glucocorticoid induces gene transcription and protein synthesis of nf-κb inhibitors and lipocortin-1. through inhibition of nf-κb signaling, glucocorticoids induce inhibition of synthesis of downstream proteins such as il-1, il-6, granulocyte-macrophage colony-stimulating factor, and inducible cyclooxygenase-2 (61, 62) . glucocorticoids reduce the proliferation, activation, differentiation, and survival of t cells and macrophages (63) . glucocorticoids proffer inhibitory actions on the transcription and action of various cytokines. the th1 and macrophage-based pro-inflammatory cytokines il-1β, il-2, il-6, tnf-α, and il-17 are inhibited by glucocorticoids (63) . however, it is controversial whether corticosteroids are beneficial in the treatment of severe covid-19 patients. a comment and a meta-analysis, which mainly bases on the evidence of sars and mers (64, 65) , stated that corticosteroid would increase mortality and delayed clearance of viral in coronavirus infection diseases. thus, the corticosteroids should not be administrated for the treatment of sars-cov-2 induced lung injury or shock. newly published studies also indicate that the use of corticosteroids is not beneficial for covid-19 patients (not severe cases), and high-dose corticosteroids are associated with mortality (44, 66, 67) . most covid-19 patients discussed in these studies are not severe cases. inspecting the studies included and analyzed by the meta-analysis, only one study (68) described the numbers of patients with corticosteroids and non-corticosteroids treatment in the severe group and non-severe group. the study demonstrated the benefit of corticosteroids use in severe sars-cov infection. another comment (69) , which was written by front-line physicians from china, showed corticosteroids might have some benefit for critically ill patients with covid-19. systematic corticosteroid therapy could promote oxygen saturation and pao 2 /fio 2 . however, corticosteroids might not improve mortality in critical covid-19 patients. current evidence shows that sars-cov-2 induces an increase in a small range of cytokines. it might be overuse to administrate corticosteroids to counteract a wide range of cytokines. furthermore, sars-cov-2 causes relatively serious lymphocytopenia and lymphocytes exhaustion. glucocorticoidmediated stimulation of the "hypothalamic-pituitary-adrenal axis" might also exacerbate lymphocytopenia (70) . thus, the use of corticosteroid is a double-edged sword in covid-19. the dose, duration, and timing of corticosteroid therapy will be crucial if administrated to covid-19 patients. as stated above, lymphocytes exhaustion is one of the characteristics of covid-19, and pd-1 checkpoint-inhibitor might some help in reversing the anergy of lymphocytes. up to 4 may 2020, no study of pd-1 checkpoint-inhibitor has been reported in the treatment of covid-19. the pathway consisting of the receptor pd-1 and its ligands, pd-l1 and pd-l2, play crucial parts in the maintenance of peripheral tolerance. treatments with antibodies targeting pd-1/pd-1 ligands have elicited an increased response in different cancer types and, in tandem with antibodies targeting cytotoxic-tlymphocyte-associated antigen-4, have changed cancer therapy radically (71) . unfortunately, signaling regulated by the pd-1/pd-l pathway is also related to substantial inflammatory effects (e.g., sepsis), as this pathway plays a role in balancing protective immunity and immunopathology (72) . increased pd-l1 expression in monocytes is associated with mortality in patients with septic shock (73) . a meta-analysis of checkpoint inhibitors showed that such therapy increased the chance of survival (74) . nivolumab (anti-pd-1) and bms-936559 (anti-pd-l1) had completed phase-ib randomized studies for severe sepsis. they revealed that giving a checkpoint inhibitor did not result in unexpected safety findings or indicate a cytokine storm (75, 76) . also, cd4 + and cd8 + t cells were hyperactivated, as revealed by the high proportions of human leukocyte antigen-dr isotype and cd38, in covid-19; cd8 + t cells harbored high levels of cytotoxic granules in covid-19 patients, in which the phenotype is similar to fatal h7n9 disease (13, 77) . those results suggest that lethal covid, along with h7n9, may be related to defective activation and exhaustion of t cells, which also suggest that checkpoint-inhibitor administration may reverse this status. cytokine adsorption involves using a method, such as extracorporeal membrane oxygenation (ecmo), to filter harmful substances directly. an extracorporeal cytokine hemoadsorption device called cytosorb r (cytosorbents, monmouth, nj, usa) has been reported to capture and reduce inflammatory mediators. bruenger and colleagues reported that the plasma level of il-6 and procalcitonin decreased in one patient with severe ards after treatment with ecmo using a hemoadsorption device (78) . a 45-year-old patient with severe ards showed that venous arterial-ecmo combined with hemoadsorption therapy decreased plasma concentrations of il-6 and il-8. moreover, hemodynamic stabilization, respiratory improvement, and a decline in capillary leakage can be achieved in combination therapy (79) . two trials employing hemoadsorption therapy for infection-related cytokine storm are ongoing (nct04195126, nct03685383). a similar therapy involves dialysis. the mainly water-soluble mediators are removed from plasma, and the hemofilters can have additional adsorptive properties (80) . continuous venovenous hemofiltration and adsorption for severe septic shock are being tested in one clinical trial (nct03974386). neutralizing excessive cytokines with hemoadsorption devices might be relatively effective. the disadvantage is like corticosteroids: a wide range of cytokines would be adsorbed. thus, it would lead to the a lack of cytokines, which are at reasonable or even insufficient levels. we suggest treating the cytokine storm in covid-19 should base on the laboratory results of cytokines and chemokines. meanwhile, adjusting the parameters of the devices (e.g., treatment duration) for preventing overtreatment. ivig can elicit passive immunity, anti-inflammatory, and immunomodulatory effects that can improve treatment effects and increase survival in severe infection. an igg molecule binds to a specific target antigen through the humoral and cellular arms of the immune system. for example, igg molecule blocks the cellcell interactions mediated by cell-surface receptors (such as cd95 and cd95 ligand), neutralize the autoantibodies by anti-idiotypic antibodies, expanse the regulatory t (treg) cell populations via the blockade of immune complex binding to low-affinity fcγ receptors (fcγrs), to exert the functions of immunomodulation (81). ma and colleagues detailed a severe case of glandular fever treated with ivig (82) . levels of th1 cytokines (ifn-γ, il-12, soluble tumor necrosis factor receptor 1 (stnfr1), cxcl10, cxcl9, ccl3), and viral loads eventually recovered after the combination of prednisolone with ivig. a multicenter, doubleblind, randomized controlled trial for cases with severe influenza a (h1n1) infection demonstrated that ivig reduced the serum concentration of cytokines, viral load, and reduced mortality (83) . a meta-analysis of 17 studies (1,958 participants) found igm-enriched polyclonal and standard ig molecules decreased mortality in adults with severe sepsis or septic shock. however, a meta-analysis did not reveal a benefit in adult mortality with polyclonal ivig using high-quality trials only (84) . despite a lack of clinical evidence, the us gave emergency approval to hcq, a member of antimalarial agents, in covid-19 on 28 march (85) . a meta-analysis included the studies up to 5 april 2020 (86) and showed that four clinical trials and three observational studies are eligible for the study. unfortunately, the authors concluded that hcq has no clinical effect on patients with covid-19. however, a randomized clinical trial published on 24 april, which included the patients (n = 81) with critically ill covid-19 (such as high respiratory rate, peripheral oxygen saturation lower than 90%, shock), indicated 15.0% patients (6 of 40) have died in the low-dosage group (i.e., 450 mg twice daily on day 1 and once daily for 4 days). the critically ill death rate is over 50%, as reported by who (87) . thus, low-dosage of hcq could be beneficial for critically ill patients with covid-19. the study also indicates high dosage hcq might not be suitable for critically ill patients because of its potential safety hazards. traditional chinese medicine (tcm) has an essential role in the latest sars epidemic. several studies (88) (89) (90) (91) (92) (93) have shown that the add-on of tcm to western medicine can shorten the duration of hospitalization, alleviate symptoms, reduce mortality (including for critically ill patients), and reduce the prevalence of adverse reactions in sars. compared with a control group (western medicine only), a combination of tcm with western medicine has shown advantages in terms of symptom alleviation and preventing covid-19 (94) (95) (96) . however, the quality of the studies must be improved. the administration of tcm in a standard manner worldwide is complicated because of the different decoctions used and the matching of herbs. artemisinin can be obtained from artemisia annua, and one kind of antimalarial agents. hou and colleagues showed that extracts from artemisinin-family drugs could regulate cells from the innate and adaptive immune system, and lead to anti-inflammatory and immunomodulatory actions (97). the scope of application for artemisinin-family medicines includes infectious disease and autoimmune diseases, and artemisininfamily shows a difference in immune regulation compared with hydroxychloroquine (98-100). as stated above, ali and aki are crucial mortality factors in infectious diseases. artesunate is a derivative of artemisinin and can lessen the pathologic changes and neutrophil infiltration in the lungs of ali patients, and decrease sepsis-induced mortality (101) . by inhibiting expression of nf-κb signaling and enhancing heme oxygense-1 expression, the artesunate can lower the concentrations of tnf-α and il-6 in serum and bronchoalveolar lavage fluid. huang and colleagues discovered that dihydroartemisinin could attenuate lipopolysaccharide (lps)-induced ali through suppressing nf-κb signaling in a nuclear factor erythroid 2-related factor 2 (nrf2)-dependent fashion, thereby leading to a decrease in expression of the pro-inflammatory cytokines il-1β, tnf-α, and il-6 (102). hu and colleagues explored a new and efficacious approach for ali (103) . "artesunate liposomes" were prepared using film dispersion and then lyophilized to obtain liposomal artesunate dry powder inhalers (ladpis). after treatment with ladpis, a rapid reduction in accelerated inhalation, ali syndromes, and levels of tnf-α and il-6 has been observed in rats. besides, kidney impairment in hospitalized covid-19 patients is associated with a high risk of in-hospital death (104). cheng et al. (105) observed that dihydroartemisinin lessened glomerular injury and relieving increases in the urine albumin: creatinine ratio and serum levels of creatinine. current evidence of pathologic changes of covid-19 suggests the dysregulation of the cytokines involves mainly macrophages/monocytes. in a burn-based sepsis model balb/c mice, concentrations of adhesion molecules and neutrophil infiltration in the lungs and heart, and mortality rate are significantly increased, but those phenotypes could be reversed by artemisinin (106) . the authors discovered that artemisinin downregulates protein levels of nod-, lrr-and pyrin domaincontaining protein 3 (nlrp3) and caspase 1 in macrophages in burn-induced sepsis mice. also, a reduction in levels of the pro-inflammatory cytokines il-1β and il-18 has been observed post-therapy. nlrp3 is a sensor component expressed mainly in macrophages and which undergoes transcription by nf-κb. nlrp3 is responsible for the maturation and secretion of il-1β and il-18 (107) (108) (109) . nf-κb also increases the level of il-10 in the macrophages infected by plasmodium falciparum, and artemisinin could reduce il-10 production in animal models (110) , as well as in the clinic (111) . two studies focused on the relationship among tlr, nf-κb, nucleotide-binding oligomerization domain-containing protein (nod)2, and macrophages. tlr2 mainly locates outside the cell membrane of macrophages, dcs, and granulocytes, and recognizes bacteria (112) . tlr2 induces nf-kb activation through recruitment of tir domain containing adaptor protein (tirap) and myeloid differentiation primary response (myd)88 in macrophages and dcs. in inflammatory monocytes, tlr2 is expressed within endosomes and induces the release of type-i ifns via interferon regulatory factor 3 (irf3) and irf7 in response to viruses (113) . artesunate increases survival of mice challenged with live staphylococcus aureus/methicillin-resistant staphylococcus aureus (mrsa) compared with antibiotics alone, and its protection may be associated with reductions in tnf-α levels. artesunate reduces the expression of tlr2 mrna and nod2 mrna that upregulated by s. aureus/mrsa and also inhibits the activation of nf-κb (114) . kuang and colleagues found that the artesunate attenuated the release of tnf-α and il-6 from macrophages by inhibiting tlr4-mediated autophagic activation (115) . tlr4 also locates in the endolysosomal compartment, can recognize gram-negative bacteria and viruses (112) , shares the same pathway as the activation of nf-κb, and induces the release of type-i ifns via the tnf receptorassociated factor (traf3)-tank binding kinase 1 (tbk1)-irf3 axis (113) . however, kuang and co-workers discovered that artesunate attenuates the cytokine release by the traf6-beclin1-class iii phosphatidylinositol 3-kinase (pi3kc3) pathway. in a model of severe acute pancreatitis in rats, artesunate attenuates the release of il-1β and il-6 via the tlr4-nf-κb axis (116) . in addition, dihydroartemisinin inhibited the activation of tlr4 and irf3 in the spleen cells of systemic lupus erythematosus (sle)-prone mrl/lpr mice, which lead to a decrease in levels of ifn-α and ifn-β (117) . the mitogen-activated protein kinase (mapk) signaling pathway plays a vital part in the development, differentiation, proliferation, transformation, and apoptosis of cells (118) . the extracellular signal-regulated kinase (erk), jnk/stressactivated protein kinases (sapk), and p38 mapk are the dominant members of the mapk family. the cascades can be summarized as the erk pathway (raf-mek-erk), jnk pathway (tak1-mkk-jnk), and p38 pathway (tak1-mkk-p38). proinflammatory cytokines such as il-1 and tnf-α, ifnα, and ifnγ can induce activation of the p38 pathway, and p38 can regulate nf-κb-dependent transcription after its nuclear translocation. meanwhile, nf-κb is a crucial transcriptor for il-6, which could activate the il-6-janus kinase (jak)-signal transducer and activator of transcription (stat) pathways (119). wang and colleagues (120) found that another artemisinin derivative, sm905, suppressed generation of nitric oxide, tnf-α, il-1β, and il-6 in lps-induced macrophages. the underlying mechanism was that sm905 reduced activation of p38 and erk, and jnk suppressed iκbα degradation. furthermore, they observed that nf-κb was inhibited correspondingly in sm905-treated cells. in another lps-induced macrophage model, artemisinin has a property of prohibiting stat1 activation, and it leads to the reduction of no (an inflammatory-cascade inducer) in macrophages (121) . except for stat1, stat3, and stat5 in the splenocytes of sle-prone mrl/lpr mice could be inhibited by sm934, an artemisinin derivative (122) . artesunate therapy has been shown to improve the survival of mice infected with the herpes simplex virus. artesunate can lower levels of il-1β, il-2, il-6, ifn-γ, ccl2, ccl3, and ccl4 in these mice. these cytokines are produced primarily by apcs and th1 cells. previous studies have suggested that the artesunate can regulate th cells in virus infections. du and colleagues (123) demonstrated that the artesunate downregulated the th1 response and reduced levels of ifn-γ, tnf-α, il-12, il-18, ccl2, cxcl9, and cxcl10 in an experimental model of cerebral malaria. ra is an autoimmune disease manifested by dysfunction of various immune cells (e.g., apcs, th1, th17), which leads to a high concentration of il-1, il-6, tnf-α, and chemokines in plasma and tissues (124) . in the experimental models of ra, the proliferation of th17 cells and the production of il-17a and il-6 are inhibited by sm905 therapy and, correspondingly, the expression of retinoic acid receptor-related orphan nuclear receptor gamma t (rorγt) (a specific transcription factor for th17 cells) is also reduced (125) . fan et al. (126) demonstrated similar data and found that dc32 (an artemisinin derivative) can restore the t reg /th17 balance and reduce transcription of cxcl12 and cx3cl1. t reg can be anti-inflammatory, secrete anti-inflammatory cytokines (e.g., il-10), target th17 cells and macrophages, as well as reduce the concentration of il-1, il-6, tnf-α, and il-17 (127) . the immunosuppressive mechanisms of artemisinin on t cells include inhibiting differentiation of th17 cells by regulating the figure 1 | artemisinin-family drugs for cytokine storm in covid-19. the dysregulation of the cytokine storm involves mainly apcs. tlr2 and tlr4 locate mainly outside macrophages, dcs, and granulocytes. also, they are expressed within endosomes, play a role in recognizing bacteria and viruses. through myd88-dependent or trif-dependent pathway, tlr2 and tlr4 transmit signals for the activation of irf3 and nf-κb to induce the type i interferon and cytokines. besides, tlr2 leads to the activation of ap-1, which is responsible for the transcription of inflammatory cytokines. the cytokines target at the naïve t helper cell, to result in the naïve t helper cell to differentiate to th1 cell and th17 cell, subsequently to secrete the inflammatory cytokines and chemokines. moreover, the il-6, il-8, and il-10 secreted by monocytes and macrophages could activate cytokines receptors (i.e., il-6r, il-8r), lead to the activation of jak-stat signaling pathways and cell migration. the artemisinin-family drugs target at a variety of molecules (red and blueness nodes) in the inflammatory networks, such as nf-κb, irf3, erk (not shown in the figure), and rorγt, which inhibit the differentiation of inflammatory cells and the production of cytokines and chemokines. il-10 is an anti-inflammatory cytokine. it could be secreted by virtually all immune cells, including macrophages, dcs, nk cells, t cells, and b cells. at the moment, the high concentration of il-10 in severely ill patients with covid-19 is a mystery. on the one hand, it might play a role in antagonizing the biological function induced by il-6. on the other hand, the high concentration of il-10 might contribute to the lymphocytes exhaustion. ap-1, activating protein-1; ccl, c-c motif chemokine ligand; cxcl, c-x-c motif chemokine ligand; ikk, iκb kinase; ifn, interferon; irf3, interferon response factor 3; jak, janus kinase; jnk, jun n-terminal kinase; myd88, myeloid differentiation primary response protein 88; nf-κb, nuclear factor κ b; nlpr3, nod-, lrr-and pyrin domain-containing protein 3; mkk, mitogen-activated protein kinase kinase; smad5, smad family member 5; rorγt, retinoic acid receptor-related orphan nuclear receptor gamma t; stat, signal transducer and activator of transcription; tak1, tgfβ-activated kinase; t-bet, t-box transcription factor 21 (also known as tbx21); tlr, toll-like receptor; traf, tnf receptor-associated factor; tram, trif-related adaptor molecule; trif, tir domain-containing adaptor protein inducing interferon-β. il, interleukin. expression of rorγt and maybe also inhibition of activation of the erk pathway (ras-raf1-erk1/2) (128). in the model of ra-fibroblast-like synoviocytes (fls), artesunate decreased the production of il-6, il-8, and il-1β through preventing nf-κb translocation and iκbα degradation (129) . artemisinin-family drugs have shown efficacy and safety in treating malaria. one study reported 32 patients with severe malaria caused by plasmodium falciparum. ten patients suffered renal failure, eight had cerebral malaria, and 14 had other causes of severe malaria. after artesunate treatment, concentrations of il-6, and soluble il-6 receptor in plasma were normalized within 24 h (130). in recent years, artemisinin-family drugs have been shown to be beneficial against infection caused by the human cytomegalovirus, hepatitis-b virus, ebola virus, and human immunodeficiency virus (131) . shapira and co-workers reported the first case of the treatment of hcmv infection with artesunate (132) . germi and collaborators (133) reported that the artesunate led to an effective response in three cases with mild hcmv infection but was not efficacious in two patients with severe hcmv infection. the elevations of il-6 and il-10 are highly consistent in covid-19. il-6 targets the il-6 receptor, and the letter recruit jak, which transit cascade signal to activate signal transducer and activator of transcription 3 (stat3) (119) . some physicians suggest tofacitinib, a small molecule compound target jak1 and jak3, could be applied in the treatment of covid-19, and tofacitinib success in treating a covid-19 patient complicated with ulcerative colitis (134) . il-10, a cytokine with anti-inflammatory properties, could be secreted by virtually all immune cells, including macrophages, dcs, nk cells, t cells, and b cells (135) . we might tend to regard the high levels of il-10 as negative feedback of counteracting the increase of il-6 because il-10 can block the activity of nf-κb to downregulate the production of il-6 (135). however, an abundance of il-10 also inhibits the function and proliferation of immune cells (e.g., th1, nk cells, and cd8 t cells), which delays the clearance of viruses (135) . therefore, a mass of il-10 might be responsible for the normal levels (one study report low level) of ifn-γ (a cytokine for the clearance of viruses) and the exhaustion of lymphocytes. the il-10 inhibitor in the treatment of covid-19 also needs to be considered. even the combination of il-10 and il-6 inhibitor could be designed in future prospective studies. when using any method to regulate the dysregulation of cytokines, we might better closely monitor the laboratory index for preventing overtreatment. for example, if we use tcz to reduce the levels of il-6, we could check il-6 levels once every 2 days to keep it at a suitable concentration, which should be studied in the future. also, the dose and duration would be illuminated. the current evidence indicates that tcz, an il-6 inhibitor, is relatively effective and safe. based on the therapeutic mechanisms, we classified the remaining therapies, corticosteroids, pd-1/pd-l1 checkpoint inhibition, cytokine-adsorption devices, intravenous immunoglobulin, and antimalarial agents, as "less potential treatments." no literature of covid-19 except for corticosteroids mentions the effectiveness and safety of the less potential treatments. the benefits, dose, duration, and timing of corticosteroids still in debate, and the other less potential treatments need clinical evidence to validate. although the experimental model of infectious disease (e.g., malaria and sepsis) and autoimmune disease (e.g., ra and sle) indicates that artemisinin-family drugs could target the inflammatory networks to decrease the levels of cytokines (e.g., il-6 and tnf-α) and chemokines (e.g., il-8, cxcl10) (figure 1) . the effect and safety of antimalarial agents still need to be validated in the high-quality clinical studies and the sars-cov-2 infection disease model. a precise definition of a cytokine storm is needed urgently. mehta et al. (136) suggest that the criteria of shlh could be applied. moreover, the term needs to be placed in the icd code. the icd code would bring the standardization of disease names, the convenience of electronic medical records (emr) management, and the efficiency in information sharing. for example, the characteristic of cytokine storm would be more accessible to be collected for a retrospective study. yt: manuscript preparation and wrote the main part of the manuscript. jl: evidence collection, wrote the parts of the manuscript, and manuscript editing. dz: helped to perform the analysis with constructive discussions. zx: helped to revise the manuscript and gave many professional suggestions. jj: ideas, formulation of overarching research goals, and aims. cw: critically reviewed the manuscript, project funding, and study initiation. all authors approved the final version of the manuscript. we thank the charlesworth group (https://www.cwauthors.com. cn) for its linguistic assistance during 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use of antimalarial drugs against viral infection. microorganisms artesunate as a potent antiviral agent in a patient with late drug-resistant cytomegalovirus infection after hematopoietic stem cell transplantation success and failure of artesunate treatment in five transplant recipients with disease caused by drug-resistant cytomegalovirus case report of a sars-cov-2 infection in a patient with ulcerative colitis on tofacitinib il-10: a multifunctional cytokine in viral infections covid-19: consider cytokine storm syndromes and immunosuppression key: cord-348244-1py0k53e authors: buyse, marc; trotta, laura; saad, everardo d.; sakamoto, junichi title: central statistical monitoring of investigator-led clinical trials in oncology date: 2020-06-23 journal: int j clin oncol doi: 10.1007/s10147-020-01726-6 sha: doc_id: 348244 cord_uid: 1py0k53e investigator-led clinical trials are pragmatic trials that aim to investigate the benefits and harms of treatments in routine clinical practice. these much-needed trials represent the majority of all trials currently conducted. they are however threatened by the rising costs of clinical research, which are in part due to extensive trial monitoring processes that focus on unimportant details. risk-based quality management focuses, instead, on “things that really matter”. we discuss the role of central statistical monitoring as part of risk-based quality management. we describe the principles of central statistical monitoring, provide examples of its use, and argue that it could help drive down the cost of randomized clinical trials, especially investigator-led trials, whilst improving their quality. medical practice largely relies on the evidence generated by clinical trials, particularly randomized controlled trials (rcts). these are considered the gold-standard approach for evaluating therapeutic interventions due to their capacity to allow for inferences about causal links between treatment and outcomes [1] . a general property of experimental research is that internal validity (i.e., the reliability of results) and external validity (i.e., their generalizability) tend to move in opposite directions in response to attempts to control trial features such as the population, the intervention, and the assessment of outcomes. this gives rise to different attitudes towards clinical trials in general, and rcts in particular: one that prioritizes internal validity (the explanatory attitude), and one that places more emphasis on the generalizability of results (the pragmatic attitude) [2] . industrysponsored trials, here defined as trials that aim to investigate experimental drugs with largely unknown effects, are typically characterized by an explanatory approach, which is suitable for the development of these novel agents or combinations. in contrast, investigator-led clinical trials, here defined as trials that aim to investigate the benefits and harms of treatments in routine clinical practice, are typically characterized by a pragmatic attitude. table 1 characterizes some of the contrasts between an explanatory and a pragmatic approach to clinical trials. these contrasts have direct implications on the conduct of investigator-led trials, notably with regards to ways of ensuring their quality, which is the focus of this paper. investigator-led clinical trials belong to a research area known as comparative-effectiveness research. we note that "real-world evidence" is a broader concept, given that it is often applied to observational research, something that falls outside the scope of our paper [1, 3] . industry-sponsored clinical trials are essential for the development of new treatments. these clinical trials need to fulfil commercial interests and market expectations, which may not always address all patients' needs [4] . moreover, clinical trials that lead to the approval of novel drugs or devices often have shortcomings that have been recognized for decades. such shortcomings include the strictness of the eligibility criteria, the choice of comparators, the effect size of interest, the choice of outcomes, and insufficient data on long-term toxicity [5] . arguably, some of these shortcomings are a by-product of the general principles underlying marketing approval by regulatory agencies, such as the japanese pharmaceutical and medical devices agency (pmda), the european medicines agency (ema), and the us food and drug administration (fda). these agencies must determine whether a new drug is sufficiently safe and effective to be made available for clinical use, which requires a careful assessment of the quality of the pivotal trial design, conduct, data and analysis whilst allowing safe and effective new drugs to enter the market quickly [6] . however, the need remains to generate additional, post-approval evidence on novel drugs or devices [6, 7] . such evidence is required for clinical practice, as it provides a far better understanding of the effectiveness and safety of competing interventions in "real life". moreover, it allows the assessment of patients and settings not necessarily covered by the initial approval, thus leading to potential extensions of indications and refinement of the drug usage in patient subgroups. even for newly approved drugs, many questions of clinical interest typically remain unanswered at the time of approval, including the duration of therapy, dose or schedule modifications that may lead to a better benefit/risk ratio, combinations of the new drug with existing regimens, and so on. likewise, repurposing of existing drugs, whose safety and efficacy profile is well documented in other indications, is more likely to be attractive in the setting of investigator-led trials than to pharmaceutical companies for whom a given product ceases to be financially attractive towards the end of its life-cycle [8] . finally, large, simple trials that address questions of major public health importance have been advocated for decades as one of the pillars of evidence-based medicine [9] . all in all, more and larger investigator-led trials are needed, and it is crucially important to identify ways of conducting them as cost-effectively as possible [10, 11] . in particular, excessive regulation of investigator-led trials, using industrysponsored trials as a model, is both unnecessary and counterproductive [11] . taruno (table 3) in [12] ). publicly available clinical-trial registries are useful to assess the importance of investigator-led clinical trials in worldwide clinical research. the longest established and largest registry is clinicaltrials.gov, with 333,529 trial protocols as of march 19, 2020. clinicaltrials.gov contains trial protocols from both the us and other countries, and distinguishes between four major types of funders: (1) industry (e.g., pharmaceutical and device companies), (2) the us national institutes of health, (3) other federal agencies (e.g., fda, centers for disease control and prevention, or department of veterans affairs), and (4) all others (including individuals, universities, and community-based organizations). for the purposes of this paper, we focus on clinical trials conducted by sponsors other than the pharmaceutical and device industry, i.e., funder types (2)-(4), as opposed to funder types (1). we call these trials "investigator-led" clinical trials for simplicity. figures 1 and 2 show the number of registered interventional clinical trials in oncology, by funder type and year the trial started, in the us (fig. 1 ) and all other countries (fig. 2 ). in the us, about 2000 such trials were reported to have started in 2019, about 1000 being industry trials and about 1000 investigator-led trials (roughly half of which sponsored by nih and other federal agencies, and half by other sponsors). in other countries, about 2600 such trials were reported in 2019, about 800 being industry trials versus about 1800 investigator-led trials (with there may be substantial under-reporting of clinical trials to clinicaltrials.gov, especially for non-us trials and for investigator-led trials, so it is conservative to assume that investigator-led trials outnumber industry-sponsored trials worldwide. as such, investigator-led trials have the potential to generate much of the evidence upon which the treatment of cancer patients is decided. yet, as stated above, investigator-led trials may be under threat because of excessive regulation and bureaucracy, and the accompanying direct and indirect costs. the rising costs of clinical trials have been a matter of major concern for some time [13] . the contribution of clinical trials to the overall costs of drug development is not known with precision, but recent estimates suggest that pivotal clinical trials leading to fda approval have a median cost of us$ 19 million; such costs are even higher in oncology and cardiovascular medicine, as well as in trials with a long-term clinical outcome, such as survival [14] . interestingly, the cost of clinical trials was found to have huge variability, with more than 100-fold differences at the extremes of the cost distribution among the 138 trials surveyed [14] . the extent to which the skyrocketing costs of clinical research depend on individual components of clinical-trial conduct can vary substantially across trials, and likely when industry-sponsored studies are compared with investigator-led trials. in industry-sponsored trials, a great deal of resources are spent in making sure that the data collected in clinical trials are free from error. this is usually done through on-site monitoring (site visits) including source-data verification and other types of quality assurance procedures, alongside with centralized monitoring including data management and the statistical monitoring that is the focus of the present paper. while some on-site activities make intuitive sense, their cost has become exorbitant in the large multicenter trials that are typically required for the approval of new therapies [15] . it has been estimated that for large, global clinical trials, leaving aside site payments, the cost of on-site monitoring represents about 60% of the total trial [16] . the high costs of monitoring could be justified if monitoring activities were likely to have an impact on patient safety or on the trial results [17] . yet, there is no evidence showing that extensive data monitoring has any major impact on the quality of clinical-trial data, and none of the randomized studies assessing more intensive versus less intensive monitoring has shown any difference in terms of clinically relevant treatment outcomes [18] [19] [20] [21] [22] . besides, there may also be a lack of effectiveness of sending large numbers of data queries to the centers as part of the data management process. in one limited study, only six queries were found (0.4% of 1395 queries) that might have influenced the results of three phase 1 cancer clinical trials, had the discrepancy not been revealed [23] . but without question, the most time-consuming and least efficient activity is source-data verification, which can take up to 50% of the time spent for on-site visits, hence it is especially important to make sure that such time is well spent. a large retrospective study of 1168 industrysponsored clinical trials has shown that only 1.1% of all data were changed as a result of source-data verification [24] . moreover, it has been shown via simulations that random errors, which comprise most of the errors detected during source-data verification, have a negligible impact on the trial results [25] . in contrast, systematic errors (those that create a bias in the comparison between the treatment groups of a randomized trial) can have a huge impact on the trial results, but these types of errors can either be prevented or detected and corrected centrally [25, 26] . all in all, the monitoring of clinical trials needs to be re-engineered, not just for investigator-led trials, but also for industry-sponsored trials. to instigate and support this much-needed transition, regulatory agencies worldwide have advocated the use of risk-based quality management, including risk-based monitoring and central statistical monitoring (csm) [27, 28] . the central principle of risk-based quality management is to "focus on things that matter". what matters for a randomized clinical trial is to provide a reliable estimate of the difference in efficacy and tolerance between the treatments being compared. it is important to stress that the criteria to assess efficacy and tolerance may differ between industrysponsored trials and investigator-led trials. for instance, in terms of efficacy, industry-sponsored trials often use the centrally reviewed progression-free survival (pfs), which may provide the most sensitive indicator of the antitumor effect of a treatment, while investigator-led trials use the locally assessed pfs, which may provide the most relevant indicator of disease progression for clinical decision-making (for instance to change therapy). neither of these two assessments of pfs is better than the other; they serve different purposes and have their own advantages and limitations. centrally reviewed pfs is arguably a "cleaner" endpoint, but it is quite expensive to measure and does not reflect clinical routine; as such it is neither feasible nor desirable in investigator-led trials. in terms of safety, investigator-led trials can collect much simpler data than industry-sponsored trials of drugs for which safety has not yet been demonstrated. typically, in investigator-led trials, the occurrence of common terminology criteria for adverse events grade 3 or 4 toxicities will suffice, plus any unexpected toxicity not known to be associated with the drug being investigated. finally, medical history and concomitant medications, which may be important to document drug interactions with an experimental treatment, serve no useful purpose in investigator-led trials. all in all, investigator-led trials should collect radically simpler data than industry-sponsored trials. similarly, data quality needs to be evaluated in a "fit for purpose" manner: while it may be required to attempt to reach 100% accuracy in all the data collected for a pivotal trial of an experimental treatment, such a high bar is by no means required for investigator-led trials, as long as no systematic bias is at play to create data differences between the randomized treatment groups (for instance, a higher proportion of missing data in one group than in the other) [25] . both types of trials may benefit from central statistical monitoring of the data; industry-sponsored trials to target centers that are detected as having potential data quality issues, which may require an on-site audit, and investigatorled trials as the primary method for checking data quality. central statistical monitoring (csm) is part of risk-based quality management [29] . as shown in fig. 3 , the process starts with a risk assessment and categorization tool (ract) [30] . csm helps quality management by providing statistical indicators of quality based on data collected in the trial from all sources. a "data quality assessment" of multicenter trials can be based on the simple statistical idea that data should be broadly comparable across all centers [31] . note that this idea is premised on the fact that data consistency is an acceptable surrogate for data quality. note also that other tools of central monitoring can be used in addition, to uncover situations in which data issues occur in most (or sometimes all) centers; these other tools, which include "key risk indicators" and "quality tolerance limits", are beyond the scope of this article. taken together, all these tools produce statistical signals that may reveal issues in specific centers. actions must then be taken to address these issues, such as contacting the center for clarification, or in some cases performing an on-site audit to understand the cause of the data issue (fig. 3) . although it is a simple idea to perform a central data quality assessment based on the consistency of data across all centers, the statistical models required to implement the idea are necessarily complex to properly account for the natural variability in the data [32, 33] . essentially, a central data quality assessment is efficient if: 1. data have undergone basic data management checks, whether automated or manual, to eliminate obvious errors (such as out-of-range or impossible values) that can be detected and corrected without a statistical approach; 2. data quality issues are limited to a few centers, while the other centers have data of good quality; 3. all data are used, rather than a few key data items such as those for the primary endpoint or major safety variables; 4. many statistical tests are performed, rather than just a few obvious ones such as a shift in mean or a difference in variability. it is worth emphasizing the last two points, namely that it is statistically preferable to run many tests on all data collected than on a few data items carefully selected for their relevance or importance. hence, what matters for a reliable statistical assessment of data quality is volume rather than clinical relevance. the reason is that the power of statistical detection comes from an accumulation of evidence, which would not be available if only important items and standard tests were considered [34] . in addition, investigators pay more attention to key data (such as the primary efficacy endpoint or important safety variables), which, therefore, do not constitute reliable indicators of overall data quality. this being said, careful checks of key data are also essential, but such checks, for the most part, are not statistical in nature. figure 4 shows a made-up example of systolic blood pressure, measured during six successive visits, in nine centers (numbered c1-c9) of a fictitious multicentre trial. each colored line represents one patient. it is easy, even visually, to spot centers that deviate from the norm: a lack of variability is apparent in center c3, an upward shift in mean in center c5, and data propagation in center c7. while these inconsistencies are too extreme to be commonly seen in practice, others may escape visual scrutiny and yet be revealing of issues worth investigating further. for instance, the fig. 3 the risk-based quality management process data of center c6 may well be inconsistent with the data of other centers, as it seems to have smaller variability, but it is impossible to tell from fig. 4 if this inconsistency falls beyond the play of chance. figure 4 depicts only one variable, but the power of the statistical approach is to perform many tests on all variables. this can lead to a large number of tests: in a trial of 100 centers, if data are available on 400 variables, and if five tests on average are performed on each variable, the system generates 100 × 500 × 5 = 200,000 tests. there is obviously a need to summarize the statistical information produced by all these tests in an overall inconsistency index. essentially, if p ij represents the p value of the j th statistical test in center i, the data inconsistency score for center i is equal to where w j is a weight that accounts for the correlation between the tests. put simply, the dis is a weighted geometric mean of the p values of all tests performed to compare center i with all other centers. in fact, the calculation of the dis is more complex than this formula suggests, but the technical details are unimportant here [35] . venet et al. discusses other ways of combining many statistical tests to identify data issues in multicenter trials [31] . it is visually useful to display the dis as a function of center size, as shown in fig. 5 [36] . when the trial includes many centers, it may be useful to limit the number of centers found to have statistical inconsistencies by setting the false discovery rate to a low probability, such as 5% [37] . timmermans et al. provide a detailed example of csm applied to a completed trial, the stomach cancer adjuvant multi-institutional trial (samit) group trial, involving 1495 patients across 232 centers in japan, which was subsequently published [36, 38] . this trial, like many trials in oncology, included many centers with only a couple of patients [36] . table 2 shows the main findings of csm in this trial, which led to further checks and data corrections prior to final analysis [38] . this example shows the power of csm to identify data issues even in small centers, providing a large enough number of patient-related variables are included in the analysis [34] . table 2 also shows the actions taken, when required, to correct the few data issues that remained in this final dataset. it is noteworthy that some of the statistical findings led to no action if an explanation was found for them (e.g., visits on unusual days of the week), or if, upon further investigation, the findings seemed likely to be due to the play of chance. experience from actual trials [29, 31, 32, 36, 39] as well as extensive simulation studies [35] have shown that a statistical data quality assessment based on the principles outlined above is quite effective at detecting data errors. experience from actual trials suggests that data errors can be broadly classified as: 1. fraud, such as fabricating patient records or even fabricating entire patients [34, 39, 40] 2. data tampering, such as filling in missing data, or propagating data from one visit to the next [31] 3. sloppiness, such as not reporting some adverse events, making transcription errors, etc. [33] 4. miscalibration or other problems with automated equipment [32] fig. 4 a made-up example of systolic blood pressure, measured during six successive visits, in 9 centers (numbered c1-c9) of a multicentre trial. each colored line represents the systolic blood pressure of one patient over time whilst some of these data errors are worse than others, in so far as they may have a more profound impact on the results of the trial, all of them can potentially be detected using csm, at a far lower cost and with much higher efficiency than through labor-intensive methods such as source data verification and other on-site data reviews. investigatorled trials generate more than half of all randomized evidence on new treatments, and it seems essential that this evidence be submitted to statistical quality checks before going to print and influencing clinical practice. the magic of randomization versus the myth of real-world evidence explanatory and pragmatic attitudes in therapeutical trials real-world evidence -what is it and what can it tell us? safeguarding the future of independent, academic clinical cancer research in europe for the benefit of patients design characteristics, risk 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and diversification of monitoring methods reflection paper on risk based quality management in clinical trials department of health and human services (2013) food and drug administration guidance for industry. oversight of clinical investigations. a risk-based approach to monitoring data-driven risk identification in phase iii clinical trials using central statistical monitoring available at https ://trans celer atebi ophar mainc .com/asset s/rbm-asset s/ (accessed 14 a statistical approach to central monitoring of data quality in clinical trials linear mixed-effects models for central statistical monitoring of multicenter clinical trials use of the betabinomial model for central statistical monitoring of multicenter clinical trials a hercule poirot of clinical research detection of atypical data in multicenter clinical trials using unsupervised statistical monitoring statistical monitoring of data quality and consistency in the stomach cancer adjuvant multi-institutional the control of the false discovery rate in multiple testing under dependency sequential paclitaxel followed by tegafur and uracil (uft) or s-1 vs. uft or s-1 monotherapy as adjuvant chemotherapy for t4a/b gastric cancer (samit): a phase 3 factorial randomised controlled trial fraud in clinical trials the role of biostatistics in the prevention, detection and treatment of fraud in clinical trials guidance for industry, investigators, and institutional review boards. fda guidance on conduct of clinical trials of medical products during covid-19 pandemic key: cord-281391-0qkku2jd authors: miller-handley, hilary; luckett, keith; govil, amit title: treatment options for covid-19 in patients with reduced or absent kidney function date: 2020-09-17 journal: adv chronic kidney dis doi: 10.1053/j.ackd.2020.09.001 sha: doc_id: 281391 cord_uid: 0qkku2jd covid-19, the disease caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) virus, was first identified in the hubei province of china in late 2019. currently the only role for therapy is treatment of the disease, as opposed to post-exposure prophylaxis, however multiple clinical trials are currently ongoing for both treatment and prophylaxis. treating covid-19 relies on two components; the first is inhibition of the viral entrance and replication within the body and the second is inhibition of an exacerbated immune response which can be seen in patients with severe disease. many drugs have shown in vitro antiviral activity, however clinical trials have not been as promising. remdesivir has shown a shortening in the time to recovery in hospitalized adults, however currently no mortality benefit demonstrated. dexamethasone has shown improved mortality in patients requiring respiratory support, but not otherwise. current research is ongoing in immunomodulation with monoclonal antibodies including interleukin (il)-6 receptor antagonists and janus kinase (jak) inhibitors. this review summarizes the current data for the most commonly used drugs for covid-19, and will cover the unique factors that may affect the dosing of these medications in patients with chronic kidney disease (ckd). while clinical trials are ongoing, most are in patients with normal kidney function. during a pandemic when patients with ckd are at higher risk of both infection and death, it is imperative to include patients these patients in the clinical trials. • while active trials are ongoing, currently no known benefit of providing post-exposure prophylaxis. • active research is ongoing to determine the ideal treatment for covid-19 including antiviral therapy and immunomodulation. • current evidence that remdesivir may shorten the time to recovery in hospitalized patients, however multiple clinical trials are still ongoing. • ongoing studies of interleukin-6 receptor antagonists and janus kinase inhibitors in patients with severe covid-19 disease. • dexamethasone has shown improved mortality in patients requiring respiratory support • patients with reduced kidney function are a high risk category and may need special attention for drug dosing/interactions. in late 2019 a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2) was identified as the cause of a familial cluster of pneumonia in the hubei province of china [1]. human to human transmission was identified, and it spread worldwide with cases in the united states first identified in january 2020 [2] . on march 11, 2020, the world health organization (who) declared covid-19, the disease caused by sars-cov2, a world-wide pandemic [3] . as of august 1, 2020 the virus has killed over 675,060 people worldwide with over 20% of those recorded deaths within the united states [4] . sars-cov-2 is a positive strand rna virus belonging to the betacoronavirus which also contains severe acute respiratory syndrome coronavirus (sars-cov) (virus cause of sars) and middle east respiratory syndrome coronavirus (mers-cov) [5] . the virus utilizes its structural spike (s) protein to attack the target cells and binds to the host angiotensin-converting enzyme 2 (ace2) protein. it is primed by the host transmembrane protease, serine 2 encoded by tmprss2 gene, to enter the cell using the host cell endosomes [6] . viral polyproteins are then synthesized and encode for the replicase-transcriptase complex. rna is synthesized via its rna-dependent rna polymerases. proteins are then synthesized together leading to completion of assembly and release of viral particles [7] . an understanding of the viral mechanism of infection helps identify potential drug targets. j o u r n a l p r e -p r o o f multiple randomized controlled trials are ongoing to determine the efficacy of several therapies targeting sars-cov-2. currently there is limited data to determine which patients require therapy and which patients improve without complications. known risk factors for severe disease include chronic kidney disease, chronic obstructive pulmonary disease, cancer, immunocompromised state from solid organ transplant, serious cardiac disease, type 2 diabetes mellitus and obesity ( body mass index >30) [8, 9, 10] . progressive hypoxia and high inflammatory markers including c-reactive protein (crp) and ferritin are also associated with progression of disease [11] . despite recognizing these risk factors, it is unclear if treatment early in disease is associated with improved outcomes. while current practice seems to be targeting patients at highest risk of progression, limited data is also available to identify the ideal candidate for therapy. the infectious disease society of america (idsa) guidelines have rapidly changed as new evidence has emerged, but currently recommend only the use of remdesivir and corticosteroids outside of clinical trial [12] . multiple studies are actively being performed to assess the need for post-exposure prophylaxis including use of remdesivir, and convalescent plasma. although early in the pandemic, there was some excitement for the use of hydroxychloroquine prophylaxis, a recent randomized, doubleblind, placebo-controlled trial evaluating hydroxychloroquine as post exposure prophylaxis did show no difference between hydroxychloroquine therapy versus placebo, and therefore j o u r n a l p r e -p r o o f hydroxychloroquine is unlikely to provide post-exposure protection [13] . while other trials are currently pending, the idsa currently recommends against the use of prophylaxis therapy outside of the clinical trial setting [12] . chloroquine is a widely-used drug, commonly used for malaria therapy and autoimmune diseases including rheumatoid arthritis, systemic lupus erythematosus. hydroxychloroquine is an analog of chloroquine with less drug interactions and less side effects. in sars-cov-2, chloroquine was hypothesized to block viral infection by increasing the endosomal ph required for virus/cell fusion leading to defective protein degradation, endocytosis, and exocytosis [14, 15] . studies performed in vitro showed that chloroquine and hydroxychloroquine both decreased the viral replications in a dose-dependent manner when given at treatment dosing, however the inhibition rate was much lower when pretreated with hydroxychloroquine and chloroquine suggesting less of an effect if given as prophylaxis prior to infection [16] . besides its antiviral properties, it also has some immunomodulation which could also be beneficial in treatment of because of these findings, chloroquine and hydroxychloroquine were used as early therapies in the treatment of covid-19, and its use was further propagated by a small, retrospective, biased study from france with 36 patients which showed decrease in viral burden, and improved outcomes in patients treated with hydroxychloroquine [17] . this small biased study received discontinued early due to toxicity in the higher dosage group with no benefit identified [19] . a retrospective study from the veterans affairs, looked at hospitalized patients who received hydroxychloroquine and showed no evidence that use of hydroxychloroquine reduced the risk of progression of disease including mechanical ventilation and death [20] . this study also showed a higher risk of death associated with the hydroxychloroquine group, even after a calculated propensity score, there is a bias as the hydroxychloroquine group represented the sickest patients [20] . in. multiple large observational studies out of new york also found no differences in outcomes between patients treated with hydroxychloroquine and those with no therapy [21, 22] . in may 2020, the lancet published an article which showed patients treated with hydroxychloroquine had a higher mortality and no benefit for therapy. this study, however, was later retracted by authors given concern of the validity of the database [23] . other studies including a new england journal of medicine paper on the relationship between mortality and angiotensin-converting enzyme (ace) inhibitors and angiotensin ii receptor blockers was also retracted for using the same database. while the majority of the data associated with hydroxychloroquine has shown no difference, there was a paper from arshad et al. that suggested a mortality benefit associated with the use of hydroxychloroquine and azithromycin [24] . this was a retrospective study performed within one hospital system, but they found treatment with hydroxychloroquine alone improved mortality. more prospective clinical trials worldwide are ongoing, however hydroxychloroquine j o u r n a l p r e -p r o o f is currently not recommended as therapy given the overwhelming negative data outside of this trial. while azithromycin has no antiviral effects, the gautret study above also described 6 patients who received dual treatment with azithromycin and hydroxychloroquine with 100% of these patients having negative nasopharyngeal pcrs by day 6 [17] . multiple further studies have not shown any difference in virologic clearance or clinical outcomes when treated with both hydroxychloroquine and azithromycin [25] . furthermore, studies looking at qtc prolongation associated with combination of hydroxychloroquine and azithromycin showed a prolonged qtc in at least 30% of patients, with 11% of patients having a qtc longer >500ms [26] . based on this data, the current idsa guidelines recommend against the usage of hydroxychloroquine with and without azithromycin outside of a clinical trial. while hydroxychloroquine is non-dialyzable and kidney clearance accounts for 15-25% of total clearance of hydroxychloroquine no dose adjustment is recommended in patients with chronic kidney disease or those on dialysis [27] . recently there has been significant interest in the usage of remdesivir, in vitro activity has been noted against other rna viruses including ebola virus, marburg, mers-cov, and sars-cov [28] . remdesivir is an adenosine analog that inhibits rna-dependent rna polymerase by incorporating into the viral rna chains causing premature termination [29, 30] . in vitro data shows that it can inhibit sars-cov-2 infection effectively in human cell lines [30] . in a j o u r n a l p r e -p r o o f nonhuman primate model, remdesivir prevented progression of disease both prophylactically and therapeutically [31] . while multiple clinical trials are ongoing, some data has been released for remdesivir therapy. compassionate usage data showed that patients with severe disease had a 68% improvement in oxygen support class, however this was just an observational study [32] . the actt-1 trial was published may 2020, which was a double-blind, randomized, placebo controlled trial where they used intravenous remdesivir hospitalized patients with covid-19. with an enrollment of 1063, this was the largest clinical trial to date for remdesivir [33] . this study showed a 31% faster recovery (11 days for patients treated with remdesivir compared to 15 days for patients who received placebo). there was also a trend to survival benefit (mortality rate of 7.1% for remdesivir and 11.9% with placebo), however not significantly different [33, 34] . based on this data, the idsa guidelines currently recommend antiviral therapy over non-antiviral therapy. multiple other clinical trials are in process. the pharmacokinetics of remdesivir in patients with kidney impairment has not been well studied. clinical trials have included patients with a creatinine clearance greater than or equal to 30 ml/min and therefore no changes in dosing required [35] . currently there are no dosing recommendations for individuals on dialysis and with those with a creatinine clearance of less than 30 ml/min. the biggest concern in the patients with impaired kidney function is the accumulation of the sbecd carrier [36] . sbecd is a large cyclic, oligosaccharide whose accumulation in animal studies has shown to lead to liver necrosis and kidney tubular obstruction. sbecd is readily removed by hemodialysis and continuous renal replacement j o u r n a l p r e -p r o o f therapy. it is also speculated that a short course (e.g. 5-10 days) is unlikely to cause such significant disease. nevertheless more data is needed in patients with kidney dysfunction [36] . other drugs that affect the rna polymerase include favipiravir, ribavirin and eidd-2801. favipiravir is a pyrazine carboxamide derivative that inhibits the influenza viral rna-dependent rna polymerase. it currently holds approval for the treatment of influenza in both japan and ribavirin is a guanosine analogue. studies on sars-cov showed some improvement of outcomes compared to historical outcomes when treated with ribavirin and lopinavir/ritonavir [39] . another systemic review of 26 studies was inconclusive for the benefit of ribavirin for sars-cov [40] . high concentrations of ribavirin however were needed for viral suppression [30] . further studies are needed. use is contraindicated inpatients with creatinine clearance of <50 ml/min. eidd-2801 is an experimental nucleotide analog drug that inhibits sars-cov-2 replication in a cellular assay [41, 42] . it has been showed to be 2-10 times more potent than remdesivir in blocking sars-cov-2 replications in vitro [29] . currently no clinical data is available on this drug, and it is currently in early clinical trials. lopinavir/ritonavir was originally developed for treatment of human immunodeficiency virus (hiv). it works by binding to protease and inhibiting the cleavage of viral proteins. although sars-cov-2 has a different protease than hiv, studies have shown lopinavir/ritonavir has some in vitro activity against sars-cov-2 [43] . while still in clinical studies, currently there is no clear clinical benefit of lopinavir/ritonavir. early case studies showed that the usage of lopinavir/ritonavir caused reduction in coronavirus viral load [44] . in a small randomized, controlled, open-labeled trial out of china 199 patients were randomized 1:1 into standard therapy versus standard therapy with lopinavir/ritonavir. no differences were found in the clinical deterioration, time to clinical improvement, or duration of viral detectability. there was a numerically lower mortality rate, but the study was not powered to determine a significant difference in mortality [45] . based on these studies the idsa guidelines recommend against the use of lopinavir/ritonavir outside of clinical trials [12] . currently per manufacturer guidance, no dosage adjustment needed for patients with chronic kidney disease including those on kidney replacement therapy. because of the in vitro data, other protease inhibitors, including darunavir, were trialed given a drug shortage of lopinavir/ritonavir. while unpublished, data released from janssen, darunavircobicistat parent company, shows that darunavir has no in vitro activity against sars-cov-2 [46] . therefore darunavir-cobicistat is not recommended as therapy for covid-19. data. oseltamivir is a neuraminidase inhibitor used for influenza, however neuraminidase is not found in the coronavirus, and while used in china and used in some clinical trials, it is currently not recommended for usage [8] . nitazoxanide is a commercial antiprotozoal agent with a broad range of antiviral activity including coronavirus. in vitro it also has some activity against sars-cov-2 [30] . no in vivo data has been published to this point. ivermectin is a broad spectrum anti-parasitic agent that has also been shown to have some broad anti-viral activity including activity against human immunodeficiency virus-1 (hiv-1), dengue virus, west nile virus, and influenza. in vitro studies have shown that ivermectin has some activity against sars-cov-2. no in vivo studies have been performed, and no clinical data is currently available [47] . while antiviral discovery and treatment is important, many of the pathological findings including acute respiratory distress syndrome (ards) are believed to be secondary to an extreme immune response. early studies that compared patients with mild disease and patients with severe disease found that patients with severe disease had a higher ferritin, crp and il-6 which lead to further treatment with these immunomodulators [48, 49] . symptoms described originally were suggestive of cytokine release syndrome which had been previously described in chimeric antigen receptor t cell (car-t cell) therapy. cytokine release syndrome has been well described in car-t cell therapy. it is associated with fever, organ dysfunction including acute kidney injury, and hepatitis, hypotension, and acute respiratory distress syndrome [50] . given the similarities between covid-19 and cytokine release syndrome, immune modulating agents have been attempted as discussed below. tocilizumab is a recombinant humanized monoclonal antibody that is directed against interleukin-6 receptor (il-6r). importantly it binds both the il-6r that is soluble and membranebound. it was originally approved by the fda for cytokine release syndrome associated with car t-cell therapy in 2019 based on some retrospective data [51] . in the car-t cell therapy, they showed significant improvement in the hypotension, oxygenation, and organ dysfunction [51] . because of the correlation between cytokine release syndrome and covid-19, tocilizumab was used early in the pandemic. an early observational study of 21 patients after treatment of tocilizumab showed improvement of fever, respiratory infection, and oxygen requirements however there was no control arm to this study [52] . a more recent retrospective case-control study out of france showed a significantly lower mortality in patients treated with tocilizumab compared to those treated with standard of care [53] . multiple clinical trials are currently ongoing. sarilumab is another il-6 ra which also binds the soluble and membrane bound receptors. it is clinically improved for rheumatoid arthritis. while no clinical data is present for sarilumab, multiple clinical trials are ongoing. both of these drugs are not metabolized through the kidney, and therefore no changes in dosing is required for patients with kidney dysfunction, although limited data is available in patients with creatinine clearance of less than 30 ml/min [54] . il-6 is an important cytokine in immunity against mycobacterium infections as well as hepatitis b infection, and therefore testing for these infections is important prior to initiation of therapy if possible, and active disease is a contraindication to therapy. other contraindications include greater than 1.5 times the upper limit of normal of the aspartate transaminase (ast) and alanine aminotransferase (alt). currently the idsa recommends use of tocilizumab only in the setting of a clinical trial. the jak inhibitors, ruxolitinib, tofacitinib, and baricitinib, are fda approved for steroidrefractory graft versus host disease and rheumatoid arthritis [55] . cytokine release syndrome is also treated with jak inhibitors, spawning interest in their use for covid-19 inflammatory response. these agents act through jak1 and jak 2 inhibition leading to inhibition of the il-6 and interferon (ifn)-g, but also inhibit il-2 and the ifn-a/b signaling cascade [56] . clinical trials are currently ongoing looking at therapy with jak inhibitors. infection is a high concern for jak inhibitors including increase risk of disseminated herpes simplex virus and fungal infections [57, 58] . interferon has been used in a variety of treatment models including hepatitis c and mers-cov. in a nonhuman primate model infected with mers-cov, treatment with ifn-b1b showed improved clinical scores and lower mean viral load [59] . corticosteroids usage in covid-19 was originally controversial, because some data in sars patients found no difference between steroid usage and no steroid usage in clinical outcomes; although studies were small, and mostly non-randomized [40] . one was a randomized, doubleblind, placebo-controlled trial for patients with sars that found delayed viral clearance if steroids were given at the first week of illness but found no clinical benefit of the steroids [61] . another was a case control trial which showed a higher risk of psychosis in patients treated with steroids, and again no benefit noted [62] . other studies have shown steroid use for sars resulting in steroid induced diabetes mellitus and avascular necrosis. it was for these reasons corticosteroids were originally thought to be contraindicated in covid-19 pneumonia. more recently, benefit has been suggested from steroid usage in patients with acute respiratory distress in covid-19 pneumonia. in the recovery trial, the use of dexamethasone at 6 mg/day for 10 days had a significantly improved mortality for those requiring mechanical ventilation at the time of randomization (29.3% vs. 41.4% mortality) and those requiring oxygen (23.3% vs 26.2%) [63] . this supported early observational studies which showed patients outside of acute respiratory distress had no improvement on steroids. some studies even showed improved outcomes in progressive disease treated with methylprednisolone but for patients with acute j o u r n a l p r e -p r o o f respiratory distress [64] . clinical trials are still ongoing to evaluate use of steroids during ards in covid-19 pneumonia. the idsa now recommends use of steroids in patients requiring oxygen. prior use of convalescent plasma has been trialed for other viruses including ebola virus, mers-cov, sars-cov, h5n1 avian influenza, and h1n1 influenza [65] . trials during the pandemic influenza a (h1n1) in 2009 showed treatment with convalescent plasma resulted in reduction of respiratory tract viral load, serum cytokine response and mortality [66] . of note, this was a cohort study and not a randomized control trial with control being patients who declined to get plasma. in covid-19, a small case-series of 5 patients who received convalescent plasma had improvement of disease including improved respiratory requirements, decreased in respiratory viral loads and 3/5 of the patients were discharged by day 37 after transfusion [65] . another case control study with 10 controls had a 30% mortality group in the control group as opposed to no deaths in the convalescent plasma therapy group [67] . these case series were the basis of evaluation of convalescent plasma. currently there are multiple clinical trial ongoing using convalescent plasma for both treatment as well as prophylaxis therapy. these trials may also provide more data on its use in high risk patient groups esp. with chronic kidney disease or kidney transplant recipients which may include remote risk of transmission of blood-borne diseases like hepatitis b, hepatitis c or hiv and of sensitization in a pre-transplant recipient [68] . j o u r n a l p r e -p r o o f currently there are no vaccines available for the sars-cov-2 virus, however multiple vaccines are actively in clinical trials. these include vaccines using an adenovirus-vector encoding the spike protein for sars-cov2 (chadox1 ncov-19) , which currently has shown promise. studies using rhesus macaques, showed that after a sars-cov-2 challenge, macaques that were pre-vaccinated had lower viral burden, and developed no signs of clinical pneumonia [69]. this vaccine is currently in phase 3 trials in the united states. another vaccine currently showing promise is the mrna-1273. in phase 1 clinical trials, this vaccine induced anti-sars-cov-2 immune responses in all participants [70] . nonhuman primate studies have been performed using this vaccine as well, and they developed a robust sars-cov-2 neutralizing antibodies. these nonhuman primates also had significantly less pulmonary inflammation, and reduced bronchoalveolar lavage viral loads [71] . this vaccine, and other variations of this vaccine are in clinical trials throughout the united states. since the first cases of covid-19, a variety of treatment options have been tested. currently standard of care is supportive care, however multiple clinical trials are ongoing, and therefore recommended treatment of these patients is changing rapidly. as more trials return, the need to look at the usage in all patients including those patients with kidney disease. j o u r n a l p r e -p r o o f a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster first case of 2019 novel coronavirus in the united states who declares covid-19 a pandemic coronavirus disease (covid-19) situation report -194 the proximal origin of sars-cov-2 sars-cov-2 cell entry depends on ace2 and tmprss2 and is blocked by a clinically proven protease inhibitor pharmacologic treatments for coronavirus disease 2019 (covid-19): a review epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of coronavirus disease 2019 in china characteristics and outcomes of 21 critically ill patients with covid-19 in washington state risk factors of fatal outcome in hospitalized subjects with coronavirus disease 2019 from a nationwide analysis in china infectious diseases society of america guidelines on the treatment and management of patients with covid-19 a randomized trial of hydroxychloroquine as postexposure prophylaxis for covid-19 review: hydroxychloroquine and chloroquine for treatment of sars-cov-2 (covid-19). open forum infect dis chloroquine is a potent inhibitor of sars coronavirus infection and spread in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial swinging the pendulum: lessons learned from public discourse concerning hydroxychloroquine and covid-19 effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection: a randomized clinical trial outcomes of hydroxychloroquine usage in united states veterans hospitalized with covid-19. medrxiv observational study of hydroxychloroquine in hospitalized patients with covid-19 association of treatment with hydroxychloroquine or azithromycin with in-hospital mortality in patients with covid-19 in retracted: hydroxychloroquine or chloroquine with or without a macrolide for treatment of covid-19: a multinational registry analysis treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with covid-19 no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid-19 infection qt interval prolongation and torsade de pointes in patients with covid-19 treated with hydroxychloroquine/azithromycin therapy and pharmacological properties of hydroxychloroquine and chloroquine in treatment of systemic lupus erythematosus, rheumatoid arthritis and related diseases broad-spectrum antiviral gs-5734 inhibits both epidemic and zoonotic coronaviruses structural basis for inhibition of the rna-dependent rna polymerase from sars-cov-2 by remdesivir remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro prophylactic and therapeutic remdesivir (gs-5734) treatment in the rhesus macaque model of mers-cov infection compassionate use of remdesivir for patients with severe covid-19 remdesivir for the treatment of covid-19 -preliminary report clinical trial shows remdesivir accelerates recovery from advanced covid-19 act sheet for health care providers emergency use authorization (eua) of remdesivir (gs-5734tm) remdesivir in patients with acute or chronic kidney disease and covid-19 potential repurposing of favipiravir in covid-19 outbreak based on current evidence experimental treatment with favipiravir for covid-19: an open-label control study. engineering (beijing role of lopinavir/ritonavir in the treatment of sars: initial virological and clinical findings sars: systematic review of treatment effects an orally bioavailable broad-spectrum antiviral inhibits sars-cov-2 in human airway epithelial cell cultures and multiple coronaviruses in mice potential therapeutic agents against covid-19: what we know so far repurposing antiviral protease inhibitors using extracellular vesicles for potential therapy of covid-19. viruses case of the index patient who caused tertiary transmission of covid-19 infection in korea: the application of lopinavir/ritonavir for the treatment of covid-19 infected pneumonia monitored by quantitative rt-pcr a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 lack of evidence to support use of darunavir-based treatments for sars-cov-2. janssen medical information face sheet the fda-approved drug ivermectin inhibits the replication of sars-cov-2 in vitro clinical predictors of mortality due to covid-19 based on an analysis of data of 150 patients from wuhan, china clinical features of 69 cases with coronavirus disease astct consensus grading for cytokine release syndrome and neurologic toxicity associated with immune effector cells fda approval summary: tocilizumab for treatment of chimeric antigen receptor t cell-induced severe or life-threatening cytokine release syndrome effective treatment of severe covid-19 patients with tocilizumab tocilizumab therapy reduced intensive care unit admissions and/or mortality in covid-19 patients actemra® (tocilizumab) injection, for intravenous or subcutaneous use jak-inhibitors. new players in the field of immune-mediated diseases immunomodulation in covid-19 a systematic review and meta-analysis of infection risk with small molecule jak inhibitors in rheumatoid arthritis ruxolitinib treatment for steroid refractory acute and chronic graft vs host disease in children: clinical and immunological results treatment with lopinavir/ritonavir or interferon-beta1b improves outcome of mers-cov infection in a nonhuman primate model of common marmoset triple combination of interferon beta-1b, lopinavir-ritonavir, and ribavirin in the treatment of patients admitted to hospital with covid-19: an open-label, randomised, phase 2 trial effects of early corticosteroid treatment on plasma sars-associated coronavirus rna concentrations in adult patients factors associated with psychosis among patients with severe acute respiratory syndrome: a case-control study dexamethasone in hospitalized patients with covid-19 -preliminary report risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease treatment of 5 critically ill patients with covid-19 with convalescent plasma convalescent plasma treatment reduced mortality in patients with severe pandemic influenza a (h1n1) 2009 virus infection effectiveness of convalescent plasma therapy in severe covid-19 patients use of convalescent whole blood or plasma collected from patients recovered from ebola virus disease for transfusion, as an empirical treatment during outbreaks an mrna vaccine against sars-cov-2 -preliminary report evaluation of the mrna-1273 vaccine against sars-cov-2 in nonhuman primates key: cord-014337-nnuvrb6o authors: byrne, s. title: scientific rigour date: 2020-11-13 journal: br dent j doi: 10.1038/s41415-020-2362-4 sha: doc_id: 14337 cord_uid: nnuvrb6o nan for dental education and training, while measures are in place to control the spread of covid-19. version 2. 1 september 2020. available at: https://www. gdc-uk.org/news-blogs/news/detail/2020/09/01/ joint-statement-on-arrangements-for-dental-educationand-training-while-measures-are-in-place-to-control-thespread-of-covid-19-(version-2-dated-1-september-2020) (accessed november 2020). https://doi.org/10.1038/s41415-020-2360-6 oral research sir, i read with interest the paper by sampson et al. 1 regarding a possible link between the severity of sars-cov-2 infections and oral hygiene. their call for excellent oral hygiene as a strategy to potentially aid the prevention of bacterial superinfections in patients with sars-cov-2 infections is not in question here. however, i draw attention to the interpretation of research findings by the authors, and would caution against reporting associations between covid-19 symptoms and oral bacteria without the support of adequate data. postgraduate periodontal training at the university of texas health science center at houston (houston, tx, usa) in response to substantial interruptions in didactic and clinical training. first, we identified our immediate goals: 1. to evaluate the existing curricula and reorganise them by adopting the commission on dental accreditation (coda) compliance protocols on the interruption of education and distance education to allow for a continuation of the pgrs' hands-on and didactic learning 2. to calibrate all full-and part-time periodontal faculty 3. to transition the residents through their respective clinical curricula 4. to provide feedback on the residents' surgical skills. once these goals were met, we aimed to implement the following sessions to allow for the transition of pgrs through the updated curricula: 1. case-based classroom videos from the american academy of periodontology (aap) and webinars allowed residents to enhance their didactic knowledge on clinical techniques 2. clinical case presentations through online sessions allowed continued pgrs' feedback to enhance their presentation and treatment planning skills as well as surgical techniques 3. sessions with invited speakers allowed pgrs to learn clinical management with the experts in the field and receive constructive feedback of greatest concern, sampson et al. 1 report that sequencing data indicate high reads for prevotella, staphylococcus and fusobacterium in patients severely infected with sars-cov-2. the supporting data come from a letter by chakraborty. 2 it is unclear in which publication this letter appears or whether it has been through a peer review process. in the letter, metagenomic sequencing data from five patients are presented. 2 no methods, including no source for the samples is given. this, along with a lack of data from healthy subjects, makes it impossible to draw any conclusions about the number of sequencing reads relating to these genera and any association with sars-cov-2 infection. these data can therefore not be used to associate 4. collaborative seminars in surgical, prosthetic and restorative dentistry with the department of periodontics at the university of illinois at chicago allowed pgrs to get exposed to world-class periodontists and dental implantologists and ask one-on-one questions 5. suturing training modules allowed pgrs to practise suturing at home and learn indications of various techniques 6. virtual sedation cases were utilised to accomplish pgrs' sedation competencies 7. mock periodontal oral board sessions allowed pgrs to prepare for the aap specialty board examination and fulfil temporary coda requirements in certain competencies 8. as laboratory research activities were suspended, pgrs were asked to work towards their master's thesis writing and analysis of the existing data. despite facing changes in a teaching format, especially in clinical training, our approaches, including the use of online portals and modules, maintained and enhanced pgrs' hands-on and didactic experiences. we expect to implement these new teaching approaches in future curricula. the authors also refer to nagaoka et al. 5 as evidence for a relationship between prevotella intermedia and severe pneumonia. this is an in vivo study examining the effect of a bacterial supernatant on experimentally induced pneumonia in mice, and not an observed relationship in human subjects. a global health crisis such as we are experiencing places huge pressure on health professionals and the research community in the rapid search for knowledge. whilst sir, the pandemic has forced dental institutions to change approaches to teaching undergraduate dental students and postgraduate residents (pgr). with great interest we have read recent letters and publications in the bdj 1,2 and elsewhere that outline the approaches our european colleagues have taken. in this letter, we would like to describe our approaches to modify   improving oral hygiene is unlikely to be detrimental, it has never been more important to uphold scientific rigour in the interpretation and reporting of research findings to help build our collective understanding of the aetiology and prevention of disease. s recommendation. this will make handovers concise and easy to follow • make sure to rest properly in your spare time -the job can be demanding so this is vital to stay alert. and lastly, enjoy this time! you will see extremely interesting cases through to the weird and wonderful; you have an amazing opportunity to learn new things in a supported environment so take advantage of it! a. kazmi, liverpool, uk https://doi.org/10.1038/s41415-020-2363-3 sir, i write further to the letter of kalsi et al. 1 in which they described that the product alvogyl (septodont, cedex, france) used in the management of acute fibrinolytic alveolar osteitis had been superseded by a chemically different product alveogyl (septodont) with potentially significant clinical ramifications. these colleagues make a very valuable and important point in that the formulations of not only pharmaceuticals but also dental materials and biomaterials may be changed by manufacturers surreptitiously. this may be necessary due to product development, regulatory demands and ongoing product safety. whilst this is both laudable and proper, the clinician should be mindful of potential changes in product formulation as this may have a significant bearing on how the product is mixed and/or handled clinically. it therefore follows that the failure of the dental team to fastidiously use the material as intended may result in inferior clinical performance. one way of ensuring best practice would be that the directions for use of each new batch of product are read carefully and then stored in a centrally placed file in the clinic, easily accessible to all members of the dental team. a ring binder folder containing punched pockets is ideal and the responsibility of keeping the file contemporaneous should lie with the member of staff responsible for stock management. 2 furthermore, dissemination of any change in handling protocol etc should also be communicated to all appropriate clinical staff. such a measure will ensure that all products intended for clinical use are used correctly to ensure the best outcome for the patient. s. j. bonsor, aberdeen, uk https://doi.org/10.1038/s41415-020-2365-1 emergency dentistry sir, having completed a year as an omfs dct in a major trauma unit, i thought it would be useful for fellow colleagues to have some know-how of how to survive an on call: • if in doubt, ask: senior colleagues will know you haven't done the job before. they have experience of training dcts and will be more than happy to assist you • get to know the paperwork. as laborious as it may be, paperwork is extremely important, and the more you are aware of what needs to be filled in, the smoother the process will be • prioritise your jobs. you will have calls coming from multiple different places at the same time, so you need to know which jobs need to be finished urgently, and which jobs can be completed later • keep a logbook -preferably electronic but if it is in paper form, make sure there is no patient information which will make them identifiable, and make sure to get it verified by your consultant • practise suturing at home. i know it sounds simple, but practising a little can go a long way! you will come across as more confident in front of the patient and will feel less fazed • watch videos on how to cannulate -once again, it will be unlikely you will have sir, thank you for publishing martin kelleher's article (bdj 2020; 229: 225-229). martin has long been highly respected as an excellent teacher and communicator, and a voice of reason in our profession. the first part is a truly appalling account of just one problem at the gdc. the second is an excellent reminder that we must not let lawyers overrule common sense in the way we practise. the profession needs a regulator (note not plural) with an understanding of what comprises good dental practice. in the meantime we look to the bda and its esteemed journal to continue the fight on behalf of our profession. p. s. nayler, brighton, uk https://doi.org/10.1038/s41415-020-2364-2 sir, there is an increasing number of dentists who have started to provide specialist skin care. may i emphasise, i do not mean facial aesthetics courses (botulinum toxin and fillers). this is after they have gone to a alternative teaching aids vr systems in dental education alvogyl or alveogyl a clinical guide to applied dental materials key: cord-309080-1r8t8yxv authors: tay, yi xiang; cai, sihui; chow, hwei chuin; lai, christopher title: the needs and concerns of clinical educators in radiography education in the face of covid-19 pandemic date: 2020-10-19 journal: j med imaging radiat sci doi: 10.1016/j.jmir.2020.10.004 sha: doc_id: 309080 cord_uid: 1r8t8yxv nan it has been more than 8 months since singapore reported its first covid-19 case on january 23 rd , 2020 1 . since then, there have been more than 57, 000 cases and have resulted in 27 deaths in singapore from the severe acute respiratory syndrome coronavirus 2 (sars-cov-2), which was first detected in wuhan, china 2 . having experienced sars outbreak in 2003 which resulted in 33 deaths including healthcare worker, the feeling of déjà vu was vivid 3 . risk measures were implemented and strengthened progressively as the situation escalated, both globally and in singapore. initially, public health interventions were raised to contain the first covid-19 wave, allowing schools and most businesses in singapore to remain open 4 . however, despite the measures to contain the outbreak, community cases increased, and infections began to surface in the population of foreign workers housed in dormitories across the island 4 . in response, nationwide strict restrictions in the form of a "circuit breaker" was instituted by the singapore government -resulting in closure of schools and all non-essential businesses, forcing majority of the population to be confined to their homes 4 . in tandem, education of healthcare professionals was also affected, including the clinical training of radiographers 5 . like nursing, midwifery and many allied health education programmes, clinical training is an important cornerstone of radiographer education -equipping students to safely and competently transit into complex healthcare environments 6, 7 . during clinical training, students are supported by clinical educators who are usually registered professionals who facilitate clinical education alongside clinical and j o u r n a l p r e -p r o o f academic colleagues 8 . collectively in singapore, a clinical educator may be a radiographer formally appointed by an academic institution or have education and training role recognised within their job role. formal appointed clinical educators differ from the latter as they are primarily responsible for signing off competency and evaluation, based upon standards provided by academic institutions. nonetheless, all clinical educators are expected to support students in the workplace to gain appropriate experience and skills. similar to singapore, many countries have undertaken drastic measures to prevent further spread of the virus. this has substantially affected clinical training where clinical placement are suspended or clinical exposure has significantly reduced 9 . thus, it is important to ensure that clinical educators are successful at responding to this challenge of maintaining high-quality clinical training amid the pandemic. this paper aims to provides insights on the needs and concerns of clinical educators in the face of the covid-19 pandemic. drawn from the first-hand experiences as clinical educators from one of the tertiary hospitals in singapore, this paper examined the ways in which clinical educators faced during the health crisis while facilitating the clinical radiography teaching. this will serve as a springboard for other educators who must overcome the massive and rapid change made during this period to continue to facilitate and improve clinical training. the sars epidemic posed many challenges in radiography service, but valuable lessons learnt enabled progression in many areas, including clinical education 10 . lessons from sars could be translated to covid-19 -innovations and contingency j o u r n a l p r e -p r o o f plans that allowed clinical teaching to continue without actual patient contact 11 . as majority of the young clinical educators did not experience the uncertainties and damaged caused by the 2003 sars outbreak, many could not relate to the painful chapter of the outbreak. inevitably, it was difficult for some to stay calm when this new and unknown bug emerged in wuhan and subsequently imported into singapore. the clinical educators' ability to deal with disruptions were first tested at our hospital when international students' clinical training was disrupted at the onset of the outbreak. such a decision not only cause the students to suffer financial losses, but also loss of opportunities of acquiring additional competencies gained in a foreign healthcare system 7 . nevertheless, it was clear that such decisions were deliberated and never made lightly with priority and emphasis on the health and well-being of all students, staff and patients. however, as all the overseas students were selffinanced, the potential of additional emotional and psychological challenges had to be considered 12 one of the ways of support for the clinical educators came in the form of encouragement from notes of appreciation and gifts from the public, and the hospital senior managements to all frontline heroes -showing how much their efforts were valued through these gestures of care and appreciation. moreover, as highlighted in the editorial by gibbs 20 , the pandemic has driven teamworking of radiographers, supports motivation and improves psychological well-being. coupled with encouragement among colleagues, there was a sense of safety and togetherness 19 . this provided much-needed encouragement for the clinical educators to work even harder, to remain unfazed and to press on for the education of the future radiography profession. as the clinical educators prepared to welcome the return of radiography students in their penultimate year, it was essential to understand the perspectives from these students who had to recover lost ground after missing months of clinical experience while dealing with the threat of delayed graduation 21 in fact, many covid-19 era publications surfaced, advocating the importance on reporting students' perspectives 16, [23] [24] [25] . these publications were also timely as many of our current students were generation z (born in 1997 or later), and educators (baby boomer/generation x and millennial); preventing a "culture clash" as a result of generational difference in medical education 4 . generation z consists of active problem solvers, independent learners and learners who are better technological integrated, but with increased risk of suffering from psychological distress 4 . indeed, these characteristics of generation z students will certainly affect how clinical educators provide education in the covid-19 pandemic. in the radiography profession, clinical placement is crucial to develop knowledge and skills acquired theoretically -allowing students to consolidate knowledge, socialising into the radiographer role and acquiring values 26 . in a commentary on the perspectives of student radiographers in singapore, the students highlighted their need to put theories into practice to bridge the gap between the two 24 . this phenomenon of theory-practice gap had been identified across multiple healthcare disciplines and might have implications on professional competence and future progression from student to novice professional 27 while clinical placements had resumed, the duration, movement and rotation were reduced. the return of students for clinical placement was also staggered and numbers of students kept to minimal. this was in line with the practices in the united kingdom (uk), australia, and north america where students were to learn in much smaller and stable social bubbles 28 . modification was also made to the clinical assessment -previous summative clinical examination conducted by academic institution appointed examiner had been replaced with multiple formative assessments throughout the duration of the clinical placement. like the medical students, radiography students must comply with strict personal hygiene, physical distancing and were not allowed to enter high-risk areas nor participate in risky, aerosol-generating procedures 4 . clinical educators were instituted to ensure that students comply with the risk control measures, while focusing on the students' core clinical learning outcomes and competencies 4 . these made teaching and supervising students in clinical settings more challenging than pre-covid. in similar vein, midwifery educators who shared comparable workplace characteristics with the radiographers -mainly not possible to maintain physical distancing in the line of work but had to deliver effective education safely, echoed similar concern 7 . it was undeniable that academic institution had tried to reduce demands on the learning can take place everywhere and covid-19 has forced us to rethink the educational strategies for the generation z students. as the covid-19 situation evolved, all non-essential appointments and elective procedures had to be deferred as part of enhanced safe-distancing measures. radiographic examinations were reduced and impacted on the students' hands-on opportunity. their movement were restricted, and they could only have placement in low risk areas. these posed a potential challenge to the generation z students who preferred hands-on experience and on-the-job-learning 36 . as clinical educators, they had to mitigate the loss in learning opportunity based on the profile of the students. the student to educator ratio of 2:1 was reduced to 1:1, and it allowed an increased direct observation of the assigned student and other teaching opportunities such as self-reflection and roleplaying 35 . with the new ratio, clinical educators were able to provide the students with more guidance, frequent immediate feedback and encouragement to learn from their mistakes -meeting the generation z students' learner perspectives [36] [37] . since it was emphasis to all clinical educators at the onset that they had to jointly teach and meet service requirements, clinical educators were more prepared. with the youngest generation now entering clinical placement, clinical educators had to modify their teaching strategies to account for the learner perspectives. transformation includes strong mentoring relationships, collaborative work with ground radiographers, reflective activities, real-time feedback, frequent interactions, case-based learning and more importantly technology in education [35] [36] [37] . the pandemic had caught the clinical educators unprepared in the incorporation of technology into teaching, and presented a diversion from the traditional methods of teaching. perhaps, it would be timely for clinical educators to consider creative ways such as interactive tutorials and the use of social media sites 35, 36, 44 . in times of uncertainty, it was crucial for clinical educators to actively manage the well-being of students. the covid pandemic would likely lead to increased distress and burnout of the students given the dramatic changes to their learning environment and plans 6, 9 . the negative well-being could lead to depression, burnout and anxiety 45 . this was of great concern as generation z was shown to be more prone to psychological distress than earlier generations 37 . when a radiographer working at the community care facility was reported to have tested positive for covid-19, there was fear that the student's psychological well-being would be affected 46 . in concordance with the approaches adopted by the medical educators, j o u r n a l p r e -p r o o f clinical educators checked-in with the students through electronic communication and provided reassurance on the risk measures in the clinical environment 9, 47 . it was crucial for the clinical educators to be available on demand while providing support to normalise stress. in addition, clinical educators worked to develop a sense of belonging and safety for the students 47 . routine instructions from the hospital disease outbreak taskforce were disseminated regularly to the students. students were also invited to attend radiographers' continuing professional development sessions and radiographers' led tutorials -creating a community for the students in the face of physical distancing 47 . in addition, like the radiographers, students were also issued tokens of appreciation -recognising them for their dedication and hard work, supporting their esteem and well-being needs 47 . with no silver bullet in sight 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clinical educator supervision -guidance for occupational therapists and their managers what impact do students have on clinical educators and the way they practise an investigation of nurse educator's perceptions and experiences of undertaking clinical practice how and why are educators using instagram understanding singaporean medical students' stress and coping singapore reports 741 new covid-19 cases, including healthcare workers at singapore expo community care facility. channelnewsasia; 2020 leading change to address the needs and well-being of trainees during the covid-19 pandemic key: cord-353528-8a3f5hxu authors: levy, oren; kuai, rui; siren, erika m. j.; bhere, deepak; milton, yuka; nissar, nabeel; de biasio, michael; heinelt, martina; reeve, brock; abdi, reza; alturki, meshael; fallatah, mohanad; almalik, abdulaziz; alhasan, ali h.; shah, khalid; karp, jeffrey m. title: shattering barriers toward clinically meaningful msc therapies date: 2020-07-22 journal: sci adv doi: 10.1126/sciadv.aba6884 sha: doc_id: 353528 cord_uid: 8a3f5hxu more than 1050 clinical trials are registered at fda.gov that explore multipotent mesenchymal stromal cells (mscs) for nearly every clinical application imaginable, including neurodegenerative and cardiac disorders, perianal fistulas, graft-versus-host disease, covid-19, and cancer. several companies have or are in the process of commercializing msc-based therapies. however, most of the clinical-stage msc therapies have been unable to meet primary efficacy end points. the innate therapeutic functions of mscs administered to humans are not as robust as demonstrated in preclinical studies, and in general, the translation of cell-based therapy is impaired by a myriad of steps that introduce heterogeneity. in this review, we discuss the major clinical challenges with msc therapies, the details of these challenges, and the potential bioengineering approaches that leverage the unique biology of mscs to overcome the challenges and achieve more potent and versatile therapies. multipotent mesenchymal stromal cells (mscs) have been extensively investigated as a cell therapy, showing promise in treating an array of diseases by restoring organ homeostasis in inflamed, injured, or diseased tissues. bone marrow-derived mscs (bm-mscs) were first described by friedenstein et al. (1) in the late 1970s and continue to be the most commonly studied msc source in preclinical and clinical studies. mscs can also be easily isolated from multiple tissues including adipose tissue (at), umbilical cord (uc), wharton's jelly, and the placenta (2) . while initial therapeutic efforts were based on their multipotency, the discovery of their immunomodulatory and trophic properties motivated harnessing mscs as a treatment for neurodegenerative and inflammatory diseases. to this end, mscs have been investigated as a treatment for graft-versus-host disease (gvhd), multiple sclerosis (ms), crohn's disease (cd), amyotrophic lateral sclerosis (als), myocardial infarction (mi), and acute respiratory distress syndrome (ards), among others (table 1) (3) (4) (5) . mscs are generally distinct from other cell therapies as their therapeutic effect not only is dictated by cell-cell contact but also may include a so-called hit-and-run mechanism. here, paracrine effectors from their secretome, including soluble cytokines, growth factors, hormones, and mirna, are transferred to target cells such as immune cells and cells of damaged tissues through secretion, the uptake of biologics-loaded submicrometer extracellular vesicles (evs), and immunemediated phagocytosis (6) (7) (8) (9) , which can lead to long-term effects. in line with this, many studies have shown that secreted biologics and msc-derived evs containing biologically active molecules (such as proteins, lipids, and nucleic acids) retain the biological activity of parental mscs and demonstrate a similar therapeutic effect in selected animal models (10) . because the properties of secreted biologics and msc-derived evs have been thoroughly reviewed elsewhere (11) (12) (13) , the current article focuses on msc therapies. with more than 300 completed clinical trials using mscs as of 2020, there is a wealth of information available to better understand what dictates their success and failure when investigated in humans. the tigenix/takeda phase 3 clinical trial that studied the use of mscs for complex perianal fistulas in cd is arguably the most successful late-stage msc trial to date (nct01541579). in this study, adult cd patients with treatment-refractory, draining, complex perianal fistulas were enrolled in a randomized, double-blind, placebo-controlled phase 3 trial and treated with either a single intralesional injection of 120 million allogeneic at-mscs (alofisel) or saline (14) . at the primary end point of 24 weeks, combined remission was significantly higher in patients treated with alofisel (~50% in treated group versus ~34% in placebo group). greater incidences of remission in the alofisel treatment group persisted in a subsequent 52-week follow-up (~56% in treated group versus ~38% in placebo group), demonstrating the potential of mscs to substantially improve the standard-of-care in chronic illnesses like cd. as complex perianal fistulas refractory to conventional medical treatment strategies often require surgery with suboptimal outcomes, the success of this trial validated alofisel as a novel therapeutic for addressing an unmet clinical need. as a result, alofisel was granted both orphan drug status and central marketing authorization approval for cd by the european medicines agency (ema), becoming the first allogeneic stem cell therapy to do so in the european union. this designation enabled alofisel to be processed through an expedited regulatory path, and alofisel was approved in europe for the treatment of complex perianal fistulas refractory to cd in 2018. the cost-effectiveness of alofisel compared to standard of care will ultimately dictate its successful integration as a viable treatment for eligible patients. alofisel has thus far been approved by the ema for use in <10,000 patients under an orphan medicinal product designation (15) . although the mechanism of action in human patients is not well elucidated, results from pre-clinical studies of alofisel indicate that induction of indoleamine 2,3-dioxygenase (ido) in the presence of inflammatory factors such as interferon- (ifn-) is critical for the therapeutic effect of mscs. this is because the enzymatic activity of ido can inhibit t cell function and proliferation and increase the number of regulatory t cells, leading to an increase in anti-inflammatory cytokines [e.g., interleukin-10 (il-10)] and decrease in pro-inflammatory cytokines [e.g., ifn- and tumor necrosis factor- (tnf-)] (14) . in addition to alofisel, there are 10 globally approved msc therapies including prochymal (osiris, approved in canada and new zealand), temcell hs (jcr pharmaceuticals, approved in japan), cartistem (medipost, approved in south korea), and cellgram-ami (fcb-pharmicell, approved in south korea) (16) . the major approved indications are gvhd, cd, als, and mi (table 2) . several companies including mesoblast, athersys, pluristem, stempeutics, cynata, and others are repurposing their msc products for new indications. for example, mesoblast has recently investigated the use of remestemcel-l to treat coronavirus disease 2019 (covid19) patients with moderate to severe ards, which is the major cause of death. the survival rate was 83% in ventilator-dependent covid-19 patients when treated with two intravenous infusions of remestemcel-l. by comparison, the survival rate was only 12% in ventilator-dependent covid-19 patients receiving standard of care during the same period (17) . the capability of remestemcel-l to down-regulate pro-inflammatory cytokines and increase anti-inflammatory cytokines is believed to be the key mediator of the promising therapeutic efficacy for covid-19 patients (18) . despite the success of these therapeutics, most of the msc therapies either have had no success in late-stage clinical trials or did not progress beyond preclinical studies. while mscs demonstrate an exceptional safety profile, they have generally been therapeutically ineffective in humans. there are several factors that likely contribute to their suboptimal clinical outcomes, including heterogeneity in the potency of the msc product, variable biodistribution and pharmacokinetics with different administration routes, and a limited understanding of the impact the host response has on therapeutic efficacy after administration (19, 20) . in this review, we summarize major clinical challenges for msc therapies. these challenges are divided into three different categories, including challenges resulting from the manufacturing of mscs (fig. 1a) , from administration of mscs (fig. 1b) , and from the recipients (fig. 1c) . under each challenge, we discuss major factors leading to the heterogeneity of the clinical outcome. we then highlight several examples that leverage bioengineering solutions to address the clinical challenges arising from msc product quality, administration, and host factors and conclude that bioengineering strategies can and should be used to develop more potent and predictable msc therapies (21) (22) (23) . while the current clinical successes of msc therapies are encouraging, albeit limited, the predominating failures emphasize the difficulty in predicting immunomodulatory and regenerative effects within human trials. this unpredictability is partially rooted in defining meaningful critical quality attributes (cqas) of the msc product. the international society of cell and gene therapy (isct) initially defined human mscs (hmscs) according to three minimal phenotypic criteria based on their morphology, surface markers, and trilineage differentiation (24) . these criteria were reflective of the msc "stemness," not their immunomodulatory and regenerative effects that dictate their therapeutic properties. in 2019, isct updated their criteria for defining mscs to include (i) tissue origin and (ii) associated functional assays to define their relevant therapeutic mode of action (25) . isct also called for a moratorium on referring to mscs as "mesenchymal stem cells" in literature, unless rigorous evidence for stemness both in vitro and in vivo is presented. furthermore, as msc therapies have reached a critical mass in clinical trials, regulatory authorities have mandated new minimal cqas for mscs related to in vitro potency (e.g., suppression of t cell proliferation or ido expression), in addition to the evaluation of identify, viability, purity, potency, proliferative capacity, genomic stability, and microbiological testing (26, 27) . measuring these cqas is a unique challenge in the field of cell therapy, as mscs, for example, unlike traditional chemical drugs whose structure and potency can be narrowly defined, are dynamic "living therapies." living msc therapies are an inherently heterogeneous population of cells whose therapeutic gene and protein expression profiles vary with the characteristics of the donor, msc tissue of origin (2, 20) , isolation method (28) , and in vitro preparation methods (e.g., cell culture protocol and scale-up) (26, 29) . the extraordinary heterogeneity of msc product introduced during the manufacturing process emphasizes the need for both meaningfully characterizing and ultimately controlling the therapeutic potency of the msc product (fig. 1a) . standardizing therapeutic potency of the msc product is crucial before beginning clinical trials (30) . this need has prompted research efforts toward developing improved in vitro potency assays that can accurately correlate the cqas of the msc product with their therapeutic function (31) (32) (33) (34) (35) . currently, the most widely used potency assay for the msc product is based on in vitro inhibition of t cell proliferation using activated cd4 + t cells (26, 36, 37) . this measurement is believed to be more representative of potency compared to surrogate markers for immunomodulatory function (i.e., ido expression or tnf- receptor expression) as it provides a direct readout of bioactivity (26) . while each msc product is completely different, other than useful observations, currently accessible data are insufficient to conclusively determine how tissue source, isolation method, and culture/scaleup during msc product development can affect the therapeutic efficacy of mscs (fig. 1a) . to highlight this point, we consider the phase 3 trial using remestemcel-l conducted for both adult and pediatric gvhd populations (nct00366145) that was unable to meet primary clinical end points in a mixed-age patient population, despite demonstrating a positive impact on the liver and gut in earlier stages of the study (38) . all remestemcel-l mscs used in the phase 3 trial were derived from a single donor, requiring cells to be expanded to passages 3 and 4 during manufacturing to yield enough mscs to treat all 240 participants. conversely, a separate phase 2 trial on therapeutic mscs conducted by the university hospital frankfurt avoided this failure for the same clinical indication in a similar patient population. in this study, pooled mscs were used to treat 26 patients with gvhd using passage 1 and 2 mscs from eight donors to yield sufficient quantities of mscs (39) . results from this study demonstrated improved clinical efficacy in gvhd patients at the primary end point (day 28), with an overall response rate of 77%. while this comparison appears to illustrate the importance of msc sourcing and manufacturing at the commercial scale (29, 40) , differences highlighted here as well as subtle differences in the preparation of the msc product make it challenging to draw conclusions. while potency assays may improve product quality by excluding mscs with low potential therapeutic efficacy, strategies are needed to instead generate high-quality mscs in sufficient quantities for large clinical trials. several biomaterial strategies have been explored to maintain more homogeneous mscs during the expansion phase of msc manufacturing. for example, rao et al. (41) showed that expanding hmscs on soft poly(ethylene glycol) hydrogel matrices was able to avoid reductions in cell surface marker expression and cytokine expression that was observed when hmscs were serially passaged on polystyrene. growing mscs in three-dimensional (3d) culturing systems has also been beneficial in maintaining early-passage msc phenotype during expansion (42, 43) . at the clinical stage, efforts to overcome msc product heterogeneity have been best exemplified by cynata therapeutics, who developed a strategy for obtaining highly homogeneous mscs using induced pluripotent stem cells (ipscs). because ipscs have an exponentially larger proliferation capacity without undergoing differentiation compared to mscs, they can be easily expanded to generate large quantities of ipscs and then differentiated into mscs after expansion to yield commercial quantities of mscs (ipsc-mscs) with a low passage number (44) . for example, upward of 1 × 10 22 passage 1 mscs can be produced from a single ipsc population, with similar potency to low-passage bm-mscs harvested from donors as assessed by t cell suppression (44, 45) . the ipsc-msc approach serves as an excellent solution for scaling msc manufacturing without sacrificing therapeutic potency through the passage and expansion of cells (46) . one caveat is that the intrinsic self-renewal and pluripotency of ipscs may also be responsible for tumorigenic potential (47) . however, this appears to be de-risked by clinical studies, showing that ipsc-mscs are safe and effective. for example, cynata's lead product cyp-001 was shown to be effective for the treatment of steroidresistant gvhd in a phase 1 clinical trial (nct02923375) without showing any sign of tumorigenesis. another phase 2 clinical trial including 448 osteoarthritis patients is expected to commence in early 2020 (48) . other approaches have used crispr-cas9 technology to create a reversibly immortalized bm-msc line, which avoids the phenotypic changes that occur with continued passaging and expansion (49) . the loss of msc potency following cryopreservation is another important challenge in the development of high-quality msc products. this clinical obstacle may be best addressed by optimizing the handling of mscs rather than engineering their physical and functional properties. the preparation of most msc therapeutics involves expanding cells ex vivo, cryogenically banking them until needed, thawing the banked mscs at the bedside, and administering them to the patient (29) . msc processing between thawing and administration varies widely between clinical trials, which can have significant implications on the therapeutic effect of mscs once administered. for example, a phase 2 study assessing mscs as a treatment against the chronic inflammatory disorder ards was unable to achieve a significant clinical improvement compared to control groups, despite promising results in phase 1 and a satisfactory safety profile (50) . retrospective analysis of the msc doses found that the viability of the freshly thawed and washed mscs ranged widely from 36 to 85%, despite no significant changes in viability between doses before cryopreservation. furthermore, only mscs with the highest viability (70 to 85%) were able to improve oxygenation in patients compared to the placebo (51) . fundamental studies on msc cryopreservation have demonstrated that freshly thawed mscs have stunted immunosuppressive capabilities, with a reduced capacity to suppress t cell proliferation (52) . cell damage following cryopreservation can also alter their post-infusion biodistribution, engraftment, and clearance kinetics (22, 53) . furthermore, thawed mscs exhibit diminished structural integrity upon rewarming, as the freezing process disrupts the actin cytoskeleton (53) . this abnormal membrane structure marks thawed mscs as a target for activated t cells, expediting the onset of immune clearance and significantly diminishing the lifetime of intact mscs in patients following infusion (54) . some investigators have avoided the detrimental effects caused by cryopreservation by changing the way in which mscs are handled before administration. for example, the successful phase 3 clinical trial on alofisel for perianal fistulas "culture-rescued" mscs after thaw, a process that involves the "recovery" of freshly thawed mscs under cell culture for a period of at least 24 hours between thawing and infusion (14) . the clinical success of mscs handled in this manner suggests that the associated detrimental effects of thawing not only are reversible but also introduce a feasible strategy for improving msc product quality (52, 54) . clinical trials to date demonstrate that mscs can be safely infused in high doses (55) and display promising responses in some clinical indications. quality control protocols to standardize msc product potency may help reduce the risk of clinical failure, but they are unlikely to resolve the problem completely, as the innate function of mscs is not always therapeutically sufficient for disease treatment (51, 56) . to maximize clinical potency while preserving ease of use, simple alternative bioengineering strategies should be explored that can boost the innate function of mscs, independent of cryopreservation, passage number, and donor and tissue source. furthermore, bioengineering can serve as a powerful platform for translating new (2). mscs can be harvested from multiple different sources, such as bone marrow, at, and uc, causing additional variations in potency (20) . furthermore, different methods of isolating cells (needle versus biopsy) from these tissues and obtaining cells (enzymatic dissociation versus mechanical dissociation) can affect the potency of mscs (28) . the culture conditions, including the medium composition, oxygen levels, confluence, culture surface, flasks/bioreactors, passage number, and cell surface modification, are also reported to affect potency/homing (26, 29) . last, cryopreservation and thaw/culture rescue protocols can affect the viability, function, and homing of mscs (50, 52, 53) . (b) outlines the major variables associated with the administration of mscs that can affect the therapeutic outcome. the administration route (local/systemic), injection site (dense/nondense tissue), injection device properties (needle size/geometry), injection/infusion buffer, and cell carrier materials can affect the residence time, viability, and homing of mscs (81, 84) . (c) outlines the major factors associated with the msc recipients that can affect the therapeutic outcome. host cytotoxic responses against mscs are shown to have strong correlations with the therapeutic outcome (58) . the therapeutic outcome is also dependent on the host disease/severity, which can result in highly variable microenvironmental factors (inflammation status, hypoxia, and ecm) that shape the function of mscs (151) . insights gained from the fundamental understanding of msc behavior after infusion into more effective therapies (fig. 2) . "priming" mscs with small molecules represents a simple strategy to exogenously boost their therapeutic function. several "primed" neuroregenerative msc products already have reached clinical investigation, with the most notable being brainstorm cell therapeutics msc product, nurown. nurown is a primed msc product in which the innate regenerative capacity of mscs is boosted using proprietary culture medium to express multiple neurotrophic factors (ntfs) including glial-derived neurotrophic factor (gdnf), brain-derived neurotrophic factor (bdnf), vascular endothelial growth factor (vegf), and hepatocyte growth factor (hgf) (57, 58) . when administered to patients with neurodegenerative diseases, nurown has been demonstrated to simultaneously deliver multiple ntfs, in addition to the immunomodulatory components innately secreted by mscs (59) . this combination has demonstrated impressive therapeutic efficacy in clinical trials, evidenced by a phase 2 clinical trial (nct02017912) where als patients who received nurown demonstrated reduced als progression 24 months after infusion compared to controls. brainstorm cell therapeutics is currently in the process of expanding the therapeutic scope of nurown, recruiting patients for a phase 2 clinical trial for ms (nct03799718). while small-molecule priming has utility, the effects only last several hours to a few days (60) . with the emergence of techniques to improve the survival of transplanted cells, approaches to extend the exposure of small molecules to transplanted cells have also been developed. for example, loading mscs with small-molecule encapsulating microparticles (mps) has been used to boost the duration of product potency (61, 62) . mps comprise biocompatible materials that can be therapeutically tuned according to their composition, polymer molecular weight, extent of drug loading, and drug release. mscs loaded with degradable mps containing the steroid budesonide exhibited fourfold enhanced ido activity in vitro compared to free budesonide-preconditioned mscs and native mscs. this led to a twofold improvement in the suppression of stimulated peripheral blood mononuclear cells (pbmcs) following ifn- stimulation (63) . mscs can also be engineered to serve as a producer and carrier of biologics (table 3) . to produce the desired biologic within the msc, viral dna transduction and mrna/dna transfection are the most common approaches. for example, a study by suresh et al. (64) reported that mscs genetically engineered to express thioredoxin-1 (trx1)-a powerful antioxidant, transcription factor, and growth factor regulator-improved cardiac function following mi in a rat model compared to unmodified mscs. although preclinical priming mscs with small molecules is a simple and promising approach to induce the secretion of immunomodulatory and regenerative molecules, but the effect of small molecules only lasts a few hours to a few days. (b) mscs can also be engineered with drug-loaded particles. these particles are intracellularly loaded into mscs to sustain their immunosuppressive profile for an extended period of time, regardless of the source of mscs, but particle preparation can increase the cost and complexity when compared to the use of free small molecules. (c) mscs can be genetically engineered to overexpress a variety of different therapeutic molecules, including anti-inflammatory cytokines and growth factors, either to boost their innate functions or to overexpress other therapeutics and broaden their application to other diseases such as cancer. viral vector-based genetic engineering typically has more efficient and durable gene expression but has some safety concerns because genes are integrated into the target cell genome. nonviral vectors are safer, but the transfection efficiency is typically lower and gene expression is less durable. (d) ovs have also been used to engineer mscs. mscs function by shielding viruses to avoid immunogenicity and by releasing the virus in tumor tissue to kill tumor cells. one limitation is that regular ovs have only moderate infectivity, although this can be overcome by using certain viral variants with higher infectious capacity. studies have shown promising results, it remains to be seen how these engineered mscs may improve the therapeutic outcome in a clinical setting. bioengineering is a powerful approach for expanding the therapeutic scope of mscs beyond their innate functions. this can be achieved by engineering mscs to secrete either poorly expressed or non-native therapeutic proteins (fig. 2) . a key example of this approach is in the use of mscs to generate anticancer therapeutics. systemic drug toxicity is a pressing concern in chemotherapy and related cancer treatment (65) . unlike synthetic biomaterials such as nanoparticles, mscs have intrinsic capability to temporarily evade the immune response and home to tumors (66) . with these unique carrier features, engineered mscs have been reimagined as anticancer "trojan horses" that are able to safely deliver large doses of cancer-targeting biologics with a single msc dose (table 4 ). this approach was validated by sasportas et al. (67) , in which engineered msc trojan horses delivered tnf-related apoptosis-inducing ligand (trail) to cancer cells, suppressing tumor growth in a highly malignant glioblastoma mouse model. mscs have also been used to express other proteins, including herpes simplex virus-thymidine kinase (hsv-tk), enzymes for converting chemotherapy prodrugs into their active toxic compound (i.e., ganciclovir) (68, 69) , soluble vegf receptor-1, and thrombospondin-1, all of which have an antitumor effect (table 4) . to avoid the off-target toxicity of the antitumor biologics produced by mscs, mscs have been engineered to only release their biologics in response to stimuli such as mechanical cues that are unique to the tumor's physical characteristics, rather than release the biologics nonspecifically throughout the body (70). this was accomplished using a yap/taz promoter, which is activated when the cells sense the stiff, collagen-rich matrix environment of solid tumors. yap/taz-engineered mscs targeted sites of high collagen deposition in the lungs of mice inoculated with metastatic luc-rfp-231 breast cancer cells (70) . by placing expression of the prodrug-activating enzyme cytosine deaminase under the control of the yap/taz promoter, mscs were able to locally activate the prodrug 5-fluorocytosine and reduce tumor burdens in collagen-rich areas of mice, without inducing drug-related systemic toxicity (70) . oncolytic viruses (ovs) are a relatively recent development in cancer therapy, which uses viruses that are engineered to either directly lyse tumor cells or trigger antitumor immunity against cancerous cells (71) . however, humoral immunity responses can quickly neutralize the efficacy of systemically injected ovs through various processes, including inactivation by complement proteins and immune-mediated phagocytosis (72, 73) . to protect ovs from the recipient humoral immune system, cell-based carriers have been demonstrated as a useful approach for both producing ovs in vivo and delivering them to the tumor site (74) . one limitation of using mscs as ov carriers is that mscs demonstrate only moderate infectivity when transduced (75) . to overcome unsatisfactory infectivity, certain viral variants (i.e., ad5/3 oncolytic adenovirus) can be used that are able to infect mscs with higher viral loads (76) . several msc-based anticancer therapeutics have reached the clinical stage. for example, an ongoing phase 1/2 study of intraperitoneally administered at-mscs expressing both the oncolytic measles virus and a membrane-bound sodium iodine symporter is being investigated to enhance the measles virus' therapeutic potency in patients with recurrent ovarian cancer (nct02068794) (77) . another phase 1/2 trial (treat-me1, nct02008539), involving intravenously administered autologous mscs engineered to express the tumor-specific hsv-tk gene, was also investigated for the treatment of gastrointestinal tumors (78) . while the study was terminated in 2016 due to an insufficient number of patients meeting the eligibility criteria, investigators reported favorable safety and tolerability in patients who received the treatment (78) . last, trailreleasing mscs (msc-trail) are also being clinically investigated as a therapeutic against inoperable lung adenocarcinomas, and recruitment is currently underway for a phase 1/2 clinical trial (nct03298763). these examples demonstrate that engineered mscs may provide a novel axis for developing a reproducible product, where quality control and potency hinge on the engineered behavior of the cells, rather than their comparatively unpredictable innate immunomodulatory properties. although we focused on examples in anticancer therapeutics, there are many other instances of mscs being engineered beyond their innate immunomodulatory and regenerative functions to treat various diseases (79) . for example, mscs have been preconditioned toward an insulin-secreting phenotype for the treatment of diabetes mellitus. administration of these insulin-secreting mscs in clinical trials has been shown to be safe and provide long-term control of hyperglycemia through a decreased exogenous insulin requirement and elevated levels of c-peptide, a molecule co-released with insulin from the pancreas (80) . regardless of the application, while engineered mscs have the potential to better control therapeutic function compared to unaltered mscs, ideally, the approach should be simple, robust, and amenable to large-scale cost-effective manufacturing. just as living cell-based therapies pose unique challenges for meaningfully assessing in vitro potency, the behavior of mscs, including the pharmacokinetic and biological properties of the infused mscs, can be affected by the mode of administration (81) (82) (83) (84) . specifically, factors such as the injection site, injection device properties, and properties of the carrier materials/buffer can affect the administration of cells (fig. 1b) . for example, different injection sites can cause variations in backpressure/reflux, and injection device properties (needle size/ geometry) can cause variations in shear rate and shear stress during injection that are known to affect the viability of injected cells. the impact of these factors and potential solutions has been thoroughly reviewed elsewhere (84) . in this section, we will summarize the various clinical challenges encountered with locally and systemically administered mscs, and how these clinical findings can be leveraged to engineer more therapeutically consistent and effective msc therapies. local administration is commonly used in clinical indications as it provides direct access to the disease site. as of 2018, 49% of registered msc clinical trials use localized delivery (85) . most msc therapies that have progressed to late-stage clinical trials have used local msc administration (i.e., intrathecal, intralesional, and endocardial) within various clinical indications including lower back pain, perianal fistulas, and chronic heart failure (86) . local administration of mscs is a more controlled delivery approach, making it easier to access the disease site that often results in better therapeutic responses (87) . in ischemic stroke, for example, locally administering mscs to the damaged site has shown to be more effective than intra-arterial and intravascular msc injection in improving the neurological severity score (88) . however, there are still clinical challenges associated with local administration that hinder therapeutic efficacy, primarily due to insufficient retention and survival of transplanted mscs at the site of administration. retention here is defined as the duration of localization of cells at the target site. the lack of retention following local administration has been attributed to multiple issues after administration, including cell death due to the hostile environment encountered at the disease site and poor engraftment into the tissue (89, 90) . although highly dependent on the clinical application, some cases have shown that less than 5% of administered cells remain at the site of injection in the hours following transplantation (91) . for example, in a study using intracoronary injection of bone marrow stem cells in patients with mi, only 2.1% of radiolabeled stem cells remained at the site of injection after ~1 hour. in addition, most of the remaining signal was found primarily in the liver and spleen (92) . this clinical study highlights that, despite injecting mscs directly at the damaged tissue site, retention in these regions is still a major concern. furthermore, the cells that are at the target site are often no longer viable due to immune-mediated damage and apoptosis (89, 91, 93) . for instance, an in vivo rat study showed an undetectable level of viable mscs 2 days following local injection at the site of mi (94) . moreover, limited diffusion of nutrients and oxygen can also affect the survival of cells following administration. cells must be within ~200 m of the nearest blood vessel for sufficient nutrients and oxygen, but it may take many days for vascularization to reach the cells, leading to cell death (95) . because nonviable cells have a reduced capacity to produce therapeutic biologics, this can compromise the potency of the mscs. together, these studies highlight that both the retention and survival of mscs following local administration of mscs must be enhanced to improve the therapeutic outcome. while local delivery of mscs can help deliver paracrine factors directly to the diseased tissue, local administration is not a feasible option for many clinical indications, as more invasive injections can cause serious complications in many diseases (96) . alternatively, intravenous injection of mscs is used, but the therapeutic utility has been limited due to insufficient homing to the target site. furthermore, using systemic administration of mscs has led to key challenges, namely, the instant blood-mediated inflammatory reaction (ibmir) and insufficient residence time at the target site. elevated concentrations of procoagulants like tissue factor (tf) on the surface of msc serve as a potent trigger for ibmir, compromising cell engraftment, cell lifetime, and therapeutic potency (97) (98) (99) . tf triggers the extrinsic pathway of coagulation, leading to thrombin generation, platelet activation, and fibrin cross-linking, which all contribute to adverse clinical outcomes. for instance, the intravenous infusion of allogeneic uc-mscs into two patients with renal transplantation and chronic kidney disease triggered thrombosis in both patients and required emergency treatment to dissolve the resulting thromboemboli (98) . interestingly, both tf expression and the magnitude of ibmir with msc products used in clinical trials depend on the tissue and donor source as well as the passage number (100-102). in addition to triggering coagulation, ibmir following msc contact with human serum has been demonstrated to activate complement in all three classical, alternative, and lectin pathways (103) . complement and coagulation pathways are known to strongly interact in vivo, with cross-talk between the two paths leading to synergistic effects that enhance therapeutic msc dysfunction and cytotoxicity (104) . consequently, the clinical safety of systemic msc therapies in patients relies on the optimal control of ibmir. when mscs are delivered systemically, a key factor for exerting maximal therapeutic benefit is their ability to remain in circulation for long enough to deliver therapeutic payloads to the damaged tissue. however, it is well known that intravenously administered mscs are immediately concentrated in the lung capillaries and phagocytosed by monocytes within 24 hours (88, (105) (106) (107) . this limits the msc's ability to deliver therapeutic payloads to the host environment via secreted paracrine factors to a short period of time following injection (106, 108) and limits cell homing to target tissues (i.e., bone marrow and nervous system). entrapment of mscs in the lung capillaries also increases susceptibility to immune clearance (83, 108) . for example, clinical studies on intravenous administration of radiolabeled mscs for mi showed a complete lack of msc homing in the infarcted myocardium following intravascular injection (92, 109) . in addition, a recent phase 1 clinical trial by schweizer et al. (110) indicated that unmodified mscs did not home to primary prostate tumors in adequate levels to warrant further development, although this may have been due to insufficient sensitivity for msc detection. alternatively, it is also possible that mouse tumors are not representative of human tumors, and therefore, promising preclinical results fail to be translated to human patients, highlighting the need to use large animal models or develop alternative models that can recapitulate key features of human diseases before the clinical study. nevertheless, these clinical findings illustrate that systemically injected mscs often fail to properly home to target tissues, making them insufficient at delivering therapeutic payloads to diseased sites. to improve the local administration of mscs, multiple strategies have been investigated (fig. 3) . among these strategies, priming mscs in vitro is a simple approach. for example, hypoxic priming up-regulated expression of prosurvival factors such as hypoxiainducible factor 1, which can help mscs adapt to the disease site that is typically hypoxic. consequently, hypoxia-primed mscs exhibited ~40% less cell death on day 3 after intramyocardial injection compared with nonprimed mscs in a rat model of mi, resulting in improved vascularization in the infarcted myocardium and better therapeutic efficacy (111) . however, the effect of priming may not be preserved upon cryopreservation/thawing because the expression of prosurvival factors is highly dependent on the environment. using biomaterials to encapsulate mscs is another promising strategy to overcome challenges associated with local administration. for example, when a rat model of mi was treated with alginateencapsulated human bm-mscs or non-encapsulated mscs, alginate encapsulation significantly increased the retention of mscs at the infarction site and improved the therapeutic outcome with respect to increased microvasculature and decreased scar formation (112) . while it was not clear in this study whether cell survival was also improved, biomaterial encapsulation has been demonstrated to prolong msc survival by providing a mechanical barrier that helps both position cells at the target site and shield them from immune attack (91, 93) . for example, in a separate rat mi model, immunohistology studies in vivo showed that msc survival was sustained for up to 16 days following delivery of hgf-overexpressing mscs in a synthetic peptide-based hydrogel compared to native mscs that did not survive past day 2. this engineered msc therapy demonstrated superior reduction in scar formation, accelerated angiogenesis, and increased ventricular wall thickness compared with native msc (94) . in another study, when alginate encapsulated mscs were subcutaneously inoculated in mice with gvhd, a high percentage of encapsulated mscs were alive 30 days after subcutaneous inoculation. interestingly, subcutaneous inoculation of free mscs also had a similar therapeutic effect in the same study, indicating that alginate encapsulation of mscs may be not required in this specific condition. however, the lack of viability data for free mscs makes this conclusion questionable, as free mscs can survive for less than 30 days in the injection site; thus, the lack of difference may simply be because the gvhd animal model is relatively easy to treat, and it is hard to see the benefit of alginate encapsulation (113) . compared with the above in vivo studies, where some key quantitative information is missing due to difficulty of extracting non-encapsulated mscs, the difference between free mscs and encapsulated mscs has been more precisely characterized in vitro. for example, when mscs were encapsulated in a fibrin-based scaffold, more than 95% of mscs were viable for 14 days; in contrast, non-encapsulated mscs had a viability of ~80.4 ± 10% on day 6 and 76.7 ± 3.6% on day 14 in vitro. moreover, when encapsulated mscs or non-encapsulated mscs were added to the upper chamber of a transwell system, whose lower chambers were filled with pbmcs stimulated with phytohemagglutin, only 1.8 ± 0.7% of encapsulated mscs migrated out of the scaffolds, while 88.7 ± 8.1% of non-encapsulated mscs migrated away from the initial site after 2 days. consequently, encapsulated mscs exhibited up to 10-fold higher local secretion of beneficial soluble factors, such as vegf and hgf, in comparison to non-encapsulated cells, with the secretion highly dependent on cell number (114) . furthermore, hydrogels have been engineered more recently to boost mscs potency in vitro. tuning the in situ mechanical properties, such as pore size and stiffness, of 3d hydrogels that encapsulate injected mscs has been shown to influence the relative cell proliferation, cell survival, and secretion of beneficial cytokines (115) (116) (117) . for instance, cai et al. (116) varied the amount of the thermoresponsive polymer poly(n-isopropylacrylamide) to alter the shear storage moduli of an encapsulating hydrogel. the best formulations showed more than twofold increases in cell proliferation on day 14 and up to threefold higher mrna expression of relevant factors, such as angiopoietin and fibroblast growth factor-2, compared to formulations without the thermoresponsive polymer. along with tuning mechanical properties, synthetic hydrogels with added linker molecules, including activated peptides and pro-inflammatory cytokines like ifn-, have also been explored as a technique to enhance msc survival, persistence at the target site, and cytokine secretion (118, 119) . for example, hydrogels engineered with the adhesive integrin-specific peptide gfoger compared to the nonadhesive peptide gaoger have been shown to significantly enhance the in vitro secretion of relevant cytokines, such as il-8 and vegf, and subsequently enhance msc survival, engraftment, and bone repair in an in vivo mouse bone defect model (118) . while these studies demonstrated the impact of biomaterial encapsulation on the retention and survival of mscs in vitro, additional work is still needed to further validate this in vivo. nevertheless, promising results from the above preclinical studies using biomaterials to encapsulate mscs have motivated their advancement to clinical trials. for example, anterogen ltd. is investigating the use of a hydrogel sheet containing allogeneic at-mscs in a multitude of diseases, including a phase 3 study on diabetic foot ulcers (nct03370874), a phase 2 study on burn injury (nct03183648), a this can be achieved through genetic engineering, antibody conjugation, or polymer coating of mscs, but more work is required to achieve a critical mass of mscs at the target site that can predictably modulate the biological signaling pathways. (e) mscs can be engineered with intracellular iron oxide to efficiently direct mscs to reach the target sites under guidance by an external magnetic field. iron oxide also makes it possible to monitor the biodistribution of mscs using magnetic resonance imaging, but more work is needed to understand whether the properties of iron oxide-engineered mscs can be maintained during cryopreservation/thawing, which can cause leakage of iron oxide from mscs. phase 1/2 study on epidermolysis bullosa (nct03183934), and phase 2 study on tendon injury (nct03449082). bioengineering strategies are being studied to address challenges from systemic administration related to both ibmir and the insufficient residence time and homing of mscs (fig. 3) . to attenuate ibmir, moll et al. (85) have recently advocated for the regular use of low-dose anticoagulants like heparin in the clinical setting. in addition, abo antigens, complement, and coagulation factors that may be found in the ab plasma (abp) used in msc culture medium can amplify ibmir in vitro (120) . replacing the abp with a more defined, nonimmunogenic human serum albumin (hsa)based supplement for msc culture medium has been suggested as an approach to reduce the risk of ibmir in msc products. recent clinical studies on gvhd showed an improved therapeutic effect when replacing abp with hsa-supplemented medium and adding a low dose of heparin to msc therapies (121, 122) . this study highlights a simple, scalable, and clinically translatable technique for potentially improving the outcomes of many msc therapies. in addition to the solutions discussed above, other bioengineering approaches have served as a useful platform in addressing msc-mediated ibmir. for instance, genetic engineering approaches (i.e., crispr-cas9 or antisense rna) to reduce expression of tf by mscs, as well as engineering the mscs with heparin cell surface coatings to prevent coagulation and complement properties, are bioengineering alternatives to systemic anticoagulation that have shown promise in preventing msc-mediated ibmir (97) (98) (99) 123) . furthermore, engineering mscs to express blood regulatory molecules, such as cd46 and tf pathway inhibitor (85, 124) , may be a beneficial strategy for suppressing ibmir following systemic msc administration. there are many promising bioengineering solutions to mitigate the effects of ibmir. translating these approaches into a clinical setting may provide a new tool for avoiding adverse ibmir-related events following systemic msc administration. independent of ibmir, additional protective bioengineering strategies to increase msc residence time and sufficiently deliver mscs to target tissues have been developed in recent years. to enhance residence time, mao et al. recently demonstrated a microencapsulation technique, in which individual mscs were encapsulated in alginate-poly-d-lysine (pdl)-alginate (apa) microgels (particulate hydrogels with dimensions in the range of 30 to 50 m). using a single-cell microgel encapsulation approach has several distinct advantages compared to typical larger multicellular hydrogels for systemic administrations: the advantages include a reduced fibrotic capsule formation, a reduction in diffusion limitations that lead to hypoxic effects, and a higher surface area to volume ratio, which facilitates the release of biologics from encapsulated cells (125) . specifically, in the study by mao et al., unlike a regular hydrogel that has a large volume and is not suitable for intravenous injection, the encapsulating microgel layer is on the order of 10 m and can be easily injected intravenously. furthermore, the encapsulating material did not interfere with the ability of mscs to secrete therapeutic anti-inflammatory cytokines. encapsulating mscs into microgels significantly increased their residence time in vivo. interestingly, encapsulating multiple cells per microgel had a half-life of >50 hours, whereas encapsulating a single cell per microgel had a half-life around 20 hours, although both were longer than unmodified mscs that had a half-life of <2 hours in a mouse model (88, 108) . further analysis indicated that, compared with single-cell microgel encap-sulates, multicellular microgel encapsulates had higher levels of collagen i and lower oxygen tension, both of which positively contributed to the prolonged residence time of encapsulated mscs. these results indicate that controlling the cell number inside microgels is an important consideration to achieve the desired residence time of mscs. moreover, this improved in vivo residence time of apa-treated mscs occurred despite the presence of innate and adaptive immune clearance mechanisms, leading to a significant improvement of therapeutic outcome in a bone marrow transplant model (108) . engineering approaches that up-regulate ligands on mscs have also improved homing by improving the interaction between mscs and the inflamed endothelium or chemokines proximal to the disease site. many studies have used various cocktails of soluble factors to increase the expression of cxcr4 and matrix metalloproteinases (mmps), an approach that has yielded preclinical success in homing and disease recovery (126) (127) (128) (129) (130) . for example, priming mscs with valproic acid and lithium induced cxcr4 and mmp-9 up-regulation, which subsequently increased msc homing, improved functional recovery, and reduced the infarct volume in the brain when tested in a rat model of cerebral ischemia (128) . alternatively, rna-or dna-based genetic engineering is a well-established approach that can be used to induce the continuous synthesis of homing ligands in vivo. for example, mrna transfection was used to induce the expression of the homing ligands psgl-1/slex as well as the antiinflammatory cytokine il-10 in mscs (131) . the engineered mscs displayed increased homing to sites of inflammation/disease and showed an improved therapeutic impact in mouse models of skin inflammation (131) and experimental autoimmune encephalomyelitis (132) . in addition, viral transduction protocols have been used to permanently overexpress homing factors in mscs. most notably, overexpression of cxcr4 increased the homing of engineered mscs to the ischemic myocardium (133, 134) , bone marrow (135, 136) , and damaged intestinal mucosa (137) in preclinical models. other bioengineering techniques have been investigated to chemically engineer the cell surface to improve msc adhesion and homing, including hyaluronic acid coatings (138) , enzymatic modifications (139, 140) , binding of adhesion molecules (141) (142) (143) , and the attachment of docking systems to bind homing antibodies such as psgl-1 (22, 144) . magnetically labeled mscs have also been investigated as a means to direct cells to the target tissue with an external magnetic field (145) (146) (147) . iron oxide has no perceivable effects on msc function in vitro and in vivo at treatment doses of ~23 pg per cell, and is deemed a safe material for msc bioengineering (146, 148) . iron oxide-labeled mscs demonstrated a 10-fold increase in retinal homing following intravenous infusion in a rat model, with magnetic mscs better penetrating the inner and outer retina compared to nonmagnetic mscs 1 week after injection (147) . furthermore, the improved homing of magnetic mscs enhanced the overall expression of il-10 in the retina, although this is believed to be largely due to increased endogenous expression of cytokines from retinal cells rather than from the mscs directly (149) . overall, there has been a vast amount of preclinical investigation into bioengineering strategies to improve the residence time and homing, but few have been translated into clinical trials. these bioengineering strategies may help to improve clinical outcomes for various diseases by addressing the challenges of insufficient msc residence time and homing to diseased sites. while the potency of the msc product and the route of administration are critical parameters for the efficacy of msc therapies in clinical trials, host factors are also an important consideration. variations in the host cytotoxic response, inflammation status, and tissue microenvironment such as hypoxia and extracellular matrix (ecm) (stiffness) have been demonstrated as important factors in the efficacy of mscs after administration (fig. 1c) (58) . this was most recently demonstrated in a study characterizing the pbmcs of patients who had variable therapeutic responses to intravenously administered mscs (7) . in this study, 16 patients with severe steroid-resistant grade 3 to 4 gvhd were treated with mscs, and pbmcs were collected from each individual 24 hours after intravenous msc administration. subsequent analysis of the host pbmcs revealed that clinical responders to the msc treatment elicited ex vivo cytotoxicity against mscs that was almost fourfold higher than clinical nonresponders (7) . this study demonstrated that the magnitude of immunosuppression in vivo is correlated to the recipient cytotoxic response against the infused mscs. although the mechanisms underlying the role of the host response in a clinical setting are still unclear, several preclinical observations provide useful insight into its correlation with therapeutic outcome. in 2017, galleu et al. (7) published an important study that identified a mechanism contributing to the immunosuppressive efficacy of intravenously administered mscs that was not dependent on the typical cqas of the cell product in isolation (i.e., ido and tnf- receptor expression). in a mouse model, it was observed that intravenously injected hmscs underwent perforin-dependent apoptosis induced by the recipient immune system. the subsequent phagocytosis of apoptotic mscs by recipient macrophages triggered the immune cells to produce additional ido intracellularly, increasing the overall systemic ido expression by ~2.5-fold. furthermore, de witte et al. (82) demonstrated in a mouse model that the phagocytosis of infused hmscs by monocytes in the first 24 hours following injection triggered the immune cells to adopt an immunoregulatory phenotype. a separate study found that monocytes containing phagocytosed msc debris then migrated to multiple tissues and established further immunotolerance in the adaptive immune system by promoting an immunoregulatory phenotype in lymphocytes (82) . together, these observations demonstrate that, in some clinical indications, stronger cytotoxic responses against mscs improve the therapeutic effect of immunosuppressive mscs by facilitating the adoption of a systemic immunoregulatory phenotype in the host. to this end, evaluating in vitro pbmc-mediated cytotoxicity using host immune cells may potentially be used as an indicator for success when recruiting patients for msc treatment. the importance of the host immune response on the efficacy of msc therapy is also demonstrated in other diseases, such as cardiac ischemia (150) . for example, a recent study has shown that the therapeutic benefit of cardiac stem cell therapy is not due to the production of new cardiomyocytes but through an acute sterile immune response mediated by host derived ccr2 + and cx3cr1 + macrophages. these macrophages resulted in the alteration of cardiac fibroblast activities, reduction in the ecm content, and functional improvement. intracardiac injection of a chemical inducer, which induced a similar level of ccr2 + and cx3cr1 + macrophages locally, also provided functional improvement in the cardiac ischemic injury model. together, while the exact mechanism may vary depending on the disease and cell therapies used, the host immune responses play important roles in mediating the therapeutic benefit provided by cell-based therapies. therefore, variations in the host immune response can also be responsible for the variability of cell therapies. in addition to the cytotoxic response, host factors related to the stage of disease progression and disease microenvironment may also have implications in better predicting the clinical efficacy of msc therapies. for example, many studies have suggested that early treatment is better than late treatment to achieve maximal therapeutic efficacy in certain indications. this has been best illustrated by a recent phase 2 study conducted by athersys inc. (nct01436487), which investigated their allogeneic msc product, multistem, for treating ischemic stroke. the study was a clinical failure, showing no improvement in neurological outcome compared to placebo controls (151) . however, retrospective analysis demonstrated that patients treated <36 hours following the onset of stroke had improved secondary outcomes compared to those treated between 36 and 48 hours. hoping to leverage the temporal dependency of multistem's regenerative potency, the therapy will now be administered exclusively within the first 36 hours following stroke for their phase 3 study (nct03545607). at the clinical level, there has been limited progress in understanding the connection between therapeutic outcome and disease stage/severity, in part, due to difficulties in routinely sampling acutely ill patients (151) . however, evidence from preclinical studies indicate that the microenvironment of the tissue surrounding the mscs may be a contributing factor to the therapeutic efficacy in different disease stages. inflammation, hypoxia, and the ecm in the disease site microenvironment are dynamic, and each parameter can influence msc function in vivo (20) . first, mscs appear to be more potent in suppressing gvhd when inflammation is high and less potent when inflammation is low (20) . second, previous studies on environmental hypoxia have indicated that exposing mscs to hypoxic conditions can induce various soluble bioactive molecules and enhance their angiogenic and regenerative potential (152) . third, in vitro studies on the impact of the ecm demonstrate that mscs seeded on stiff surfaces have reduced suppression of allogeneic lymphocyte activation compared to mscs seeded in softer, collagenbased 3d scaffolds (153) . the stiffness of the ecm is positively correlated with the severity of fibrotic disease, which is highly variable between patients, thus likely contributing to mixed therapeutic outcomes (154) . moreover, along with the variations in inflammation, hypoxia, and the ecm, the increase in the number of damageinflicting cells (t cells) with increasing disease severity may also influence the therapeutic effect of mscs in vivo. for example, effector t cells in gvhd increase from nondetectable levels in the early disease stages to 90% of the total disease population in the late stage (155) . hence, the msc doses (i.e., the number of infused mscs) administered in late-stage gvhd become therapeutically insufficient, as they are substantially outnumbered by effector t cells. together, these observations demonstrate that while cell engineering is able to boost the potency of mscs, evaluating the status of recipientsespecially the disease stage-will help optimize the dosing regimen and improve the clinical predictions of therapeutic response to msc therapies. in addition to the host immune response, other host factors may also affect the recruitment of mscs to the disease site, which, in turn, can affect the therapeutic outcome for some clinical indications. for example, capillaries (10 to 15 m in diameter) trap systemically infused mscs (~20 m in diameter) (83) , compromising msc homing to other organs. moreover, msc homing is also highly dependent on the secretion of chemokines, as the magnitude of chemokine secretion by the target organ in the host may be insufficient to recruit mscs efficiently (156) . continued investigation of bioengineering strategies that can overcome these issues may represent a novel strategy to fully unleash the therapeutic potential of mscs. clinical and preclinical observations related to the role of the host in facilitating the msc therapeutic response have inspired novel approaches to controlling these factors in a clinical setting. patient stratification based on the host cytotoxic responses against mscs or the disease severity/stage can be a simple strategy to help recruit patients who can likely benefit from msc therapies (fig. 4) . this can be achieved by incubating mscs with pbmcs from patients and testing the ability of pbmcs to induce msc apoptosis in a cytotoxic assay (7) . priming the hosts to establish a microenvironment that can better use the therapeutic potential of mscs represents another avenue to improve their potency and resulting response rate. for example, the water-soluble antioxidant vitamin c has the capacity to prevent oxidative stress and reduce damage to transplanted cells (157) . in a spinal cord injury model, animals receiving intraperitoneal injection of vitamin c in combination with local injection of mscs at the site of spinal cord injury had a better therapeutic outcome compared with mscs or vitamin c alone (157) . msc recipients can also be primed with vasodilators such as sodium nitroprusside before systemic infusion of mscs to circumvent msc entrapment by the host capillaries (158) . preclinical studies have indicated that, following vasodilation, the accumulation of mscs in the lungs was reduced by 15% and the recruitment of mscs to the bone marrow was increased by 10 to 50% compared to untreated control hosts. boosting the chemokine secretion by the target organ in the host has also been used to improve msc homing (156) . for example, preclinical studies have shown that, before systemic infusion of msc, animals primed with irradiation had msc homing to bone marrow increased by twofold compared to unirradiated controls. irradiation of the animals increased the secretion of the chemoattractant sdf-1 at the damaged bone marrow site, which facilitated improved homing of mscs in the irradiated population (156) . although host priming remains at the preclinical stage, continued investigation into this approach through irradiation, vasodilation, or other methods may represent a novel strategy to fully unleash the therapeutic potential of mscs. last, an improved understanding of the role of the host environment in msc function can also be used to guide novel approaches for msc engineering. for example, priming mscs with inflammatory cytokines or hypoxia represents an interesting bioengineering approach to boost their potency toward therapeutic applications (152, 159) . it may also be useful to engineer the msc secretome so that it functions independently from the surrounding microenvironment. for example, mscs overexpressing anti-inflammatory cytokines such as il-10 or il-35 have been shown to improve the therapeutic effect compared with native mscs (160, 161) . by exogenously secreting anti-inflammatory factors in a pro-inflammatory environment, mscs can more efficiently reduce inflammation and better achieve their desired function. although mscs undoubtedly have immunomodulatory and regenerative therapeutic properties, attempting to apply mscs "as is" without a clear target has proved to be unsuccessful in most clinical studies. without a well-defined target, developing more effective "next-generation" msc therapies will be limited. specifically, a clear definition of the targets, ideally from the beginning of a project, is critical to guide the design of better msc therapies. thinking more about the target up front will help researchers to see how the baseline levels achieved by mscs are typically suboptimal to activate target biology. this will also help provide a solid rationale to engineer mscs to more efficiently act on these targets by secreting relevant factors and/or by interacting with the target cells through cell-cell contact and ultimately improve the therapeutic outcome. moreover, enormous challenges remain for msc therapiesfrom the diverse origins of mscs, the highly variable culture and cryopreservation conditions, the challenges associated with administration of mscs, and the challenges of the host environmentthat can also lead to unpredictable therapeutic outcomes. continued exploration of engineering approaches that address these challenges should significantly improve the therapeutic efficacy for a broad range of clinical indications. in particular, boosting the potency of mscs through engineering strategies such as small-molecule priming, mp engineering, and genetic modification (fig. 2) provides a measurable property that can be examined throughout all stages of preclinical and clinical development, from well-defined potency assays and cqas to therapeutic biomarkers in human clinical studies. it is also critical to ensure that these cqas are preserved following cryopreservation and thawing at both the preclinical and clinical stages. recent development of single-cell rna sequencing will also enhance our understanding of msc heterogeneity and phenotype shift during culture, which, in turn, may provide critical insights to improve the msc manufacturing process (162) . coupled with other technologies such as ipsc-based mscs and crispr-cas9-based gene editing, there are many possibilities regarding what mscs can functionally achieve. furthermore, while local injection can position mscs directly at the target site, the insufficient retention of mscs can compromise the potency and duration of the therapeutic effect. although strategies such as the use of biomaterials can help address these challenges, most studies have not decoupled cell survival from retention in vivo. additional studies are needed to clarify this, which, in turn, may provide novel insights about the bottlenecks limiting the retention or survival of mscs and guide the design of engineering approaches to develop better msc therapies. for systemic administration, it is critical to properly engineer mscs to modulate the ibmir and improve the homing of infused mscs (fig. 3) . learning how the host factors impact function and delivery of mscs will help both inform engineering strategies and inspire new approaches to prime the host (fig. 4) . one caveat is that preclinical mouse models often have limitations in recapitulating the key features of human diseases. moreover, the infusion volume and number of cells used in mouse models are also very different from those in clinical patients. for example, when mscs are intravenously injected into rodents, the dose is typically around 50 million/kg. however, the dose for intravenous injection in human patients is typically 1 million to 2 million/kg (19) . because the paracrine factors secreted from mscs are dependent on cell number, different dosing can significantly affect the therapeutic outcome, assuming the mechanism of action is similar for different species. consequentially, many promising preclinical results cannot be translated into clinical success. to obtain meaningful results, future studies should explore the use of large animal models that can better mimic the host disease conditions and dosing regimen in clinical settings. last, it should be noted that many of the failures in characterization, cell delivery, and thawing variability are limitations in process development, which is critical for ensuring that all procedures are robust and reliable and deliver the expected and intended outcomes in a repeatable manner. process development is particularly important when large doses of mscs need to be manufactured for clinical use. preclinical work should shift to using mscs manufactured under good manufacturing practice (gmp) to facilitate clinical translation. rather than just be hopeful that msc efficacy will be preserved from preclinical to clinical studies (and during scale-up) and that the mechanism of action will include a relevant target with a robust response, engineering strategies can and should be used to engineer the mechanism of action with specific target biology in mind. while nature provides a basic therapeutic framework for msc-based treatments, bioengineering tools will be the key to shatter translational barriers. fibroblast precursors in normal and irradiated mouse hematopoietic organs different populations and sources of human mesenchymal stem cells (msc): a comparison of adult and neonatal 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anti-angiogenesis therapy based on the bone marrow-derived stromal cells genetically engineered to express sflt-1 in mouse tumor model antiangiogenic variant of tsp-1 targets tumor cells in glioblastomas stem cells loaded with multimechanistic oncolytic herpes simplex virus variants for brain tumor therapy oncolytic adenovirus-loaded menstrual blood stem cells overcome the blockade of viral activity exerted by ovarian cancer ascites human menstrual blood-derived mesenchymal stem cells as potential cell carriers for oncolytic adenovirus we would like to thank s. aboulhouda and s. aday for reading the manuscript and providing critical feedback. funding: we are grateful for the funding support from u.s. nih grants hl095722 (to j.m.k.) and ns107857 (to k.s.) and department of defense grant ca180698 (to k.s.). a grant (to j.m.k., a.a., a.h.a., and k.s.) from king abdulaziz city for science and technology through the center of excellence for biomedicine (cebm) was also used to support this body of work. e.m.j.s. would also like to thank the friedman award for scholars in health, which funded her contribution. author contributions: all authors contributed to the discussion, writing, and revising of the manuscript. competing interests: during the drafting of this manuscript, j.m.k. has been a paid consultant and or equity holder for companies including stempeutics, sanofi, celltex, lifevaultbio, takeda, ligandal, camden partners, stemgent, biogen, pancryos, frequency therapeutics, quthero, and mesoblast. k.s. has been a consultant for stem cell and oncology companies including mesoblast, cynata, and merrimack. j.m.k. is also an inventor on a patent that was licensed to mesoblast. j.m.k. holds equity in frequency therapeutics, a company that has licensed ip generated by j.m.k. that may benefit financially if the ip is further validated. the interests of j.m.k. were reviewed and are subject to a management plan overseen by his institutions in accordance with its conflict of interest policies. k.s. owns equity in and is a member of the board of directors of amasa therapeutics inc., a company developing cell-based therapies for cancer. k.s.'s interests were reviewed and are managed by brigham and women's hospital and partners healthcare in accordance with their conflict of interest policies. d.b. is a consultant at amasa therapeutics inc. j.m.k. and k.s. also have a multi-year collaborative grant from king abdulaziz city for science and technology through the center of excellence for biomedicine (cebm) that involves training of saudi students. the authors declare no other competing interests. data and materials availability: all data needed to evaluate the conclusions in the paper are present in the paper. key: cord-274802-7ioiwsd8 authors: varghese, praveen mathews; tsolaki, anthony g.; yasmin, hadida; shastri, abhishek; ferluga, janez; vatish, manu; madan, taruna; kishore, uday title: host-pathogen interaction in covid-19: pathogenesis, potential therapeutics and vaccination strategies date: 2020-08-19 journal: immunobiology doi: 10.1016/j.imbio.2020.152008 sha: doc_id: 274802 cord_uid: 7ioiwsd8 abstract the current coronavirus pandemic, covid-19, is the third outbreak of disease caused by the coronavirus family, after severe acute respiratory syndrome and middle east respiratory syndrome. it is an acute infectious disease caused by severe acute respiratory syndrome coronavirus 2 virus (sars-cov-2). the severe disease is characterised by acute respiratory distress syndrome, septic shock, metabolic acidosis, coagulation dysfunction, and multiple organ dysfunction syndromes. currently, no drugs or vaccine exist against the disease and the only course of treatment is symptom management involving mechanical ventilation, immune suppressants, and repurposed drugs. as such the severe form of the disease has a relatively high mortality rate. last 6 months have seen an explosion of information related to the host receptors, virus transmission, virus structure-function relationships, pathophysiology, co-morbidities, immune response, treatment and most promising vaccines. this review takes a critically comprehensive look at various aspects of host-pathogen interaction in covid-19. we examine genomic aspects of sars-cov-2, modulation of innate and adaptive immunity, complement-triggered microangiopathy, and host transmission modalities. we also examine its pathophysiological impact during pregnancy, in addition to various gaps in our knowledge. the lessons learnt from various clinical trials involving repurposed drugs have been summarised. we also highlight the rationale and likely success of the most promising vaccine candidates. receptor on enterocytes in the small intestine and is consistent with clinical reports of gastrointestinal symptoms and viral shedding in faeces (34, 35) . this has been further resolved with the comprehensive identification of host cells/tissues expressing both ace2 and tmprss2 ( figure 2 ). thus, likely targets for sars-cov-2 primarily include secretory goblets of the nasal mucosa, lung type ii pneumocytes and absorptive erythrocytes of the small intestine (36) . of note, this study also showed that the ace2 receptor is an interferonstimulated gene in sars-cov-2 infection in the cells of the human upper nasal epithelium and lung, predominatly mediated by ifn-α2 and ifn-γ (36) . moreover, bystander cells are subject to interferon-mediated effects (upregulation of ace2 receptor) rather than sars-cov-2 infected cells, suggesting a mechanism of enhanced viral targeting and entry during pathogenesis and a possible avenue for therapeutic intervention (36) . analysis of genetic variation in the ace2 gene has identified single nucleotide polymorphisms (snps) that differ in frequency globally among the human population, particularly between males and females (37). characterising these snps more fully with epidemiological and clinical data on covid-19 will in time shed light on the precise molecular mechanisms of transmission and disease. furthermore, in the sars-cov-2 viral s protein, 27 amino acid substitutions have been described, although these occurred outside the rbd that directly interacts with ace2 (14) . of paramount importance is characterising the genetic variation and its consequences in the s protein and its rbd, as this will determine whether the sars-cov-2 virus is evolving and is likely to be a seasonal infection with new variants for the human population. undoubtedly, variation in the s protein and ace2, the central interface of hostpathogen interaction in covid-19 will have evolved from natural selection contributing to the pathogenesis of this disease. proteins and transported into the endoplasmic reticulum (er). these proteins are processed via the secretory pathway and are transported into the er-golgi intermediate compartment (69, 70) , where the full-length viral genomes are packaged with the nucleocapsid n protein, budding from the membrane, and thus forming the enveloped mature virion (71) . the n protein has two domains that can bind the rna genome, with the aid of nsp3 protein, and attaching it to the rtc, facilitating the packaging of the virus (72) (73) (74) . the viral m protein has three transmembrane domains and is responsible for the majority of protein-protein interactions needed for virus assembly, including membrane curvature and binding the nucleocapsid (75, 76) . pseudo-virus particles can also only be formed when there is a co-expression of m protein and e protein, indicating the requirement of both these two proteins to form the coronavirus envelope (77) . the viral e protein is also involved in structural shaping of the viral membrane envelope and in inhibiting m protein aggregation, as well as a role in pathogenesis (78) (79) (80) (81) . after the assembly of the mature virions, they are transported in vesicles, where they are released from the infected cell via exocytosis (82) . unlike sars, covid-19 patients had the highest viral load near presentation, which could account for the fast-spreading nature of this epidemic. in a study involving covid-19 patients in hong kong recorded high viral load on presentation with the onset of symptoms and also when the symptoms are mild (83) . sars cov-2 viral rna load was detected in the deep throat (posterior oropharyngeal) saliva samples for 20 days or even longer. the peak of the viral load correlated positively with age. viral load in posterior oropharyngeal saliva samples was higher during the first week of symptom onset, which gradually declined. thus, the location of sample collection and the timing for the onset of symptoms both are important factors to be considered for the detection of sars cov-2 positive cases. in the same study, most of the patients showed rising antibody titres 10 days after symptom onset, though the serum antibody levels did not show correlation with clinical severity (83) . the patient's antibody to sars-cov-2 viral nucleocapsid protein using infected cell lysates was identified on the 10th day after symptom onset by western blot (84) . in another study involving 285 patients with covid-19, all were tested positive for antiviral igg within 19 days after symptom onset. both igg and igm titres reached a plateau within 6 days after seroconversion (85) . in wuhan tongji hospital, around 60 convalescent patients tested positive for the igg against the virus, while 13 patients tested negative for igm, where igg titre was higher comparatively. both the antibody titres showed a decrease when tested weeks apart (86) . thus, titres of sars-cov-2 antibodies can reflect the progress of viral infection and can be a vital component to understand the development and prognosis of the disease and similarly timing of antibody seroconversion is also crucial for determining the optimum duration for collecting serum specimens for antibody diagnosis. as previously mentioned, several other studies also confirmed the presence of sars-cov-2 nucleic acids in the faecal, urine samples and rectal swabs of covid-19 patients and thus it becomes essential to ascertain viral load dynamics in such samples too (87) (88) (89) . transmission sars-cov-2 is transmitted through "respiratory droplets", which are large droplets of virusladen mucus or through close contact with infected individuals (90) (91) (92) (93) . at the same time virus has also been reported to spread via asymptomatic but infected individuals in several countries, including china, germany, usa, and india (91, (94) (95) (96) (97) . a systematic review and meta-analysis of 172 observational studies with no randomised controlled trials and 44 relevant comparative studies in health-care and non-health-care settings revealed transmission of virus decreased as physical distancing increased to 1 metre or more (98) . eye protection, n95 or similar respirators in health-care settings and 12-16-layer cotton or surgical masks in the community were found to greatly control the transmission (98) . studies have also established that the median half-life of the aerosolised virus is ~1.2 hours under lab conditions, similar to the sars-cov. however currently, no evidence supports real-world airborne transmission of the virus through aerosols (99) . sars-cov-2 was found to remain viable for up to 4 hours on copper surfaces, up to 24 hours on cardboard surfaces, and up to 72 hours on plastic and stainless-steel surfaces. thus, there exists a possibility of contact transmission to occur, although no confirmed cases of contact transmission have been reported (99) . the virus was also found in the faeces of infected patients showing that the virus can survive and replicate in the digestive system (100) . this suggests that there may be a possibility of an oral-faecal route of transmission, though again no confirmed cases have been reported (101) . the royal college of obstetricians and gynaecologist uk have reported that transmission from mother to baby antenatally or intrapartum is possible although this requires further study for confirmation; there appears to be no evidence supporting vertical transmission to the foetus (102) (103) (104) . additionally, as reported by who and cdc, the virus has not been found to be transmitted by breastfeeding and has not been found in breastmilk of covid-19 mothers (105, 106) . covid-19 was found to have low severity and mortality than sars, but it is highly contagious and affecting comparatively more men than women (94, 107, 108) . the difference in fatality rate between males and females may probably be explained by the fact that as ace2 is located on the x chromosome. there may be alleles that confer resistance to covid-19, at the same time, oestrogen and testosterone sex hormones have different immunoregulatory functions that may contribute to protection or severity of the disease (109, 110) . the disease has also been found to disproportionately affect older aged persons and people suffering from social deprivation, diabetes, severe asthma, cardiovascular disease, obesity, haematological malignancy, recent cancer, kidney, liver, neurological or autoimmune conditions (111) . studies have also reported that members of minority communities such as the black and south asian populations, are at a higher risk of the disease (111) . the incubation period of the disease ranges between 2 to 14 days and the median incubation period is approximately 4-5 days before symptom onset (87, 92, 112, 113) . during the onset of the illness, the common symptoms that most patients exhibited were fever and cough. other symptoms include conjunctivitis, myalgia (muscle pain) or fatigue, headache, dyspnoea (short of breath), chest pain, diarrhoea, nausea, rhinorrhoea (runny nose), vomiting, loss of appetite, abdominal pain, gastrointestinal bleeding, autoimmune haemolytic anaemia, and sometimes haemoptysis (coughing of blood) (108, (114) (115) (116) (117) (118) . patients have also reported anosmia (loss of smell), dysgeusia (distortion of the sense of taste) (119) (120) (121) (122) . for sars-cov-2 asymptomatic patients, anosmia, hyposmia, or dysgeusia are symptoms that were suggested for screening (123) . in addition to these, neurological manifestations such as dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, seizure, nerve pain, skeletal muscular injury manifestations, intracerebral haemorrhage, central nervous system vasculitis, encephalopathy, encephalitis, cranial neuropathies and psychosis were reported predominantly in older people (124) (125) (126) . in paediatric patients, an autoimmune and autoinflammatory disease, paediatric inflammatory multisystem syndrome (pims), also known as multisystem inflammatory syndrome in children (mis-c), has been reported to occur after sars-cov-2 infection (127) (128) (129) (130) (131) (132) (133) (134) . cutaneous manifestations of covid-19 have also been reported (135) (136) (137) . a case report from strasbourg, france reported purpuric lesions in the lower extremity (137) . an italian study reported patients presenting with an erythematous rash, urticaria and chickenpox-like vesicles mainly in the trunk with little or no itching that did not correspond to disease severity (138) . the prolonged use of personal protective equipment and repeated washing have also led to an increase in dermal conditions such as pressure injury, contact dermatitis, itch, pressure urticaria, and exacerbation of pre-existing skin diseases (124) . the first step of infection is the inhalation of viral particles present in respiratory droplets from an infected host. once inhaled, the virion enters the nasal cavity of a healthy host and likely binds to goblet and ciliated cells in the nose that express ace2 (32) . at this time, a limited innate immune response may occur, and the virus replicates and moves further down the respiratory tract via the conducting airways. as the virions proliferate and spread towards the upper respiratory tract, usually a robust innate immune response is triggered by the detection of the virions by pattern recognition receptors (prrs) like toll-like receptors, rig-1, and mda-5. this may present several symptoms starting from dysphonia (hoarseness), ulceration of the epiglottis and subglottis, and profound oedema and granulations in the subglottis and also in the upper trachea (139) . in a few patients, mild tachypnoea and coarse breath sounds were also observed while the virus is in the upper airway (91) . furthermore, the detection by prr leads to the expression of type 1 interferons (ifn) in the early stages of infection, which helps establish an anti-viral state in the cells by producing inflammatory cytokines and chemokines. the sars-cov produces an enzyme that adds 2' o-methyl group to viral rna, which helps it evade detection by mda-5, thereby delaying the induction of ifn. studies have established that unlike an early ifn response, a delayed ifn response causes an inability to control viral replication, leading to cellular damage of airway epithelia and the lung parenchyma and an eventual lethal inflammatory cytokine storm (140) (141) (142) . the sars-cov-2 papain-like protease, which is essential to generate the rtc, has been shown to preferentially cleave the ubiquitin-like protein isg15 from interferon responsive factor 3 (irf3), attenuating type i interferon responses (143) . the c-terminus of the sars-cov-2 non-structural protein 1 was reported to bind to the 40s ribosomal subunit and block the mrna entry tunnel (144) . this obstruction effectively inhibits the rig-i-dependent innate immune response (144) . accordingly, no significant expression of ifn was detected up to 48 hours post-infection with sars-cov-2. only il-6, which correlates with respiratory failure, acute respiratory distress syndrome (ards), and adverse clinical outcomes were upregulated. monocyte chemoattractant protein-1 (mcp1), c-x-c motif chemokine (cxcl) 1, cxcl5, and cxlc10, were also upregulated 48 h post-infection with sars-cov-2 (145) . the suppression of innate immune activation and annihilation of t cells can help explain the mild or even the lack of symptoms in many infected patients. the increased viral replication efficiency in the respiratory tract early on leads to the highly efficient person-to-person transmission of the virus in the community (145) . the virions further migrate towards the lower respiratory tract and reaches the alveoli where it binds to the type 2 pneumocytes and begins replication. as the type 2 pneumocytes undergo apoptosis after viral release, they secrete inflammatory mediators like cxlc proteins that attract macrophages and neutrophils ( figure 5 ) (146) . the stimulated macrophages further secrete cytokines such as il-1β, il-6 and tumor necrotic factor α (tnf-α). the released cytokines trigger a "cytokine storm", which stimulates the release of vascular endothelial growth factor (vegf), monocyte chemoattractant protein-1 (mcp-1), il-8, and additional il-6, as well as reduced e-cadherin expression on endothelial cells causing vasodilation and increase capillary permeability (147) . this causes the plasma to leak into the interstitial spaces and alveoli, increasing interstitial and alveolar oedema. the increased alveolar oedema decreases the level of surfactant in the alveoli. this causes an increase in the surface tension in the alveoli, which leads to alveolar collapse. oedema and alveolar collapse may present as multiple peripheral ground-glass opacities in subpleural regions of both lungs, which is observed in many patients (148) . chest ct scan of patients also revealed bilateral multifocal infiltrates and mediastinal and hilar lymphadenopathy in some patients (91) . these decrease the gas exchange efficiency causing hypoxemia and increased work of breathing presenting as dyspnoea (shortness of breath), culminating in ards (149) . abnormal coagulation parameters, mainly elevated d-dimers seem to be associated with a higher risk of development of ards in covid-19 patients (150) . the aberrant wound healing may even lead to fibrosis than other forms of ards (151) . stimulated neutrophils secrete reactive oxygen species (ros) and proteases which destroy both infected and uninfected type 1 and type 2 pneumocytes, leading to further reduced gas exchange and alveolar collapse, respectively (152) . furthermore, the dead pneumocytes slough off into alveoli filling them up with fluid, protein deposits, cell debris, macrophages, and neutrophils. this causes pulmonary consolidation, which leads to altered gas exchange and causes hypoxemia (153, 154) . the consolidation also leads to productive cough. the hypoxemia can further trigger chemoreceptors that stimulate the sympathetic nervous system (sns) that causes tachycardia (increased heart rate) and tachypnoea (increased respiratory rate) (155, 156) . the central nervous system (cns) is also affected by the high concentrations of il-1β, il-6 and tnf-α in the blood, as these cytokines stimulate the hypothalamus to release prostaglandins such as pge2, which causes an increased body temperature leading to fever (157) . studies have also reported elevated levels of myeloperoxidase (mpo)-dna and citrullinated histone h3 (cit-h3), which are markers used to detect neutrophil extracellular traps (nets), in the serum of covid-19 patients (158) . furthermore, control neutrophils treated with covid-19 patient serum exhibited netosis (158) . nets, while protecting the host from invasive pathogens, have been attributed to play a role in many autoimmune and vascular diseases. for example, nets are known to contribute to ards, pathogen-induced acute lung injury, thrombosis and can contribute to further cytokine release lading to the inflammation (158) . an increased frequency of neutrophils, eosinophils and monocytes was reported in severe covid-19 positive patients; severe patients showed further increase in neutrophils though their activation status had not altered. there was no significant change in the immature granulocyte frequencies. however, there was an inverse correlation between frequency of immature granulocytes in moderate and severe patients with the duration since the appearance of symptoms. severe patients exhibited lower percentages of both conventional and plasmacytoid dendritic cells (dc) (159) . response syndrome (sirs). the spread of the inflammation from the lungs into the circulatory system causes increased capillary permeability within the systemic circulation. this leads to a decrease in blood volume along with increased vasodilation of systemic arteries, leading to decreased peripheral resistance. the decreased blood volume, along with peripheral resistance, causes hypotension (decreased blood pressure), which decreases perfusion to other organs leading to multisystemic organ failure (mof) (160-162). the cytokine storm has also been shown to trigger autoimmune haemolytic anaemias (aiha) (with warm or cold antibodies) (117, 163, 164) . most of the studies report manifestation of aiha early, during the active phase of covid-19 (within 4 to 13 days), a timeframe matching that of the cytokine storm (117, 127, 163, 164) . as a result of ards, sirs and mof, patients suffering from severe sars-cov-2 infection exhibit significantly elevated levels of, il-2, il-8, il-17, g-csf, gm-csf, mip-1α, crp, and ddimer, in addition to il-6, il-1β and tnf-α (145). there are reports suggesting that in addition to the lungs, sars-cov-2 infection may induce the multiorgan injury in patients involving brain, heart, liver, kidney, intestine and eyes (165, 166) . covid-19 associated neurological complications the neurological pathologies observed in covid-19 are similar to those observed in previous coronavirus epidemics (167) . myoclonus and demyelination are reported in a few cases (126, 168, 169) . a study conducted in wuhan, china involving 214 covid-19 patients, reported that 78 patients developed neurological manifestations (125) . in another study from strasbourg, france where effectively 58 patients were recruited for an observational study, reported agitation in 69% of the patients, confusion in 65%, and 67% of the patients had corticospinal tract signs (170) . a systemic review and meta-analysis of literature databases for psychiatric and neuropsychiatric presentations in coronavirus infections reported transient encephalopathies with features of delirium and psychosis (171) . the study also reported cognitive dysexecutive syndrome and delirium with agitation in a few cases (171) . there is also a reported case of autoimmune encephalitis with the typical clinical features of opsoclonus and myoclonus, and another case of autoimmune encephalitis with a radiological imagery showing typical limbic encephalitis (167) . the exact mechanism for encephalopathy may be multifactorial (effect of sepsis, hypoxia, and/or cytokine storm) (172) . a few cases of guillain-barré syndrome (gbs) associated with sars-cov-2 have been reported from italy (173) . however, further epidemiological and mechanistic study is required to confirm the incidents of gbs in covid-19. the binding of the virus to the ace-2 receptors on endothelial cells causes extravasation of red blood cells leading to cerebral microbleeds (137, 167) . there have also been reports of severe strokes in covid-19 patients, but further study is required to determine its association with covid-19 (167) . magnetic resonance imaging (mri) revealed abnormalities such as meningeal enhancement, ischaemic stroke, perfusion changes, microhaemorrhages, medial temporal lobe signal abnormalities similar to that seen in viral or autoimmune encephalitis (170, 174) . very few cases have been reported where sars-cov-2 was detected in csf and its supportive histopathological features; no reports of the virus in the brain exist yet (167, 175, 176) . thus, it is important to establish whether the above-described syndromes may be caused due to either direct viral injury, hyperinflammation, vasculopathy and/or coagulopathy, autoantibody production to neuronal antigens, sepsis and hypoxia, or a combination of these (172) . out of the first 41 patients diagnosed with covid-19 in wuhan, 5 of them had myocardial injury associated with the sars-cov-2, which mainly manifested as an increase in highsensitivity cardiac troponin i (115) . the hemogas analysis showed hypoxia; laboratory tests showed elevation of c-reactive protein, transaminases and lactate dehydrogenase, and lymphopenia (177) . several patients showed abnormal myocardial zymogram, showing high levels of creatine kinase (112) . because of an excessive inflammation, hypoxia, immobilisation and diffuse intravascular coagulation (dic), covid-19 patients may predispose to both venous and arterial thromboembolic disease (87, 115, 178) . it has also been observed that concomitant acute thrombosis of the abdominal aorta and pulmonary embolism induces cardiovascular complications in covid-19 patients, suggesting an association of hypercoagulable condition with the disease (179) . covid-19 patients with abnormal liver function were also documented, where patients had alanine aminotransferase (alt) or aspartate aminotransferase (ast), bilirubin, acute phase recants (apr) like crp, fibrinogen and il-6 above the normal range (112, 180) . sepsis, hypovolaemia, and nephrotoxins were found to be important contributors to kidney damage in covid-19 patients. cardiorenal syndrome, particularly right ventricular failure, might lead to kidney congestion and acute kidney injury in covid-19 patients (112) . symptoms such as olfactory and gustatory dysfunctions were also found to be related to covid-19 (181) . sars-cov-2, facilitated by tmprss2 and tmprss4, was found to infect and reproduce in ace-2 + mature enterocytes (100) . however, the virions released into the intestinal lumen were inactivated by stimulated human colonic fluid and no infectious virions were recovered in stool samples, in spite of the presence of viral rna in stools. this study thus established the intestine as a site of viral replication and its effect on local and systemic illness and overall covid-19 progression (100). as in the case respiratory infections by respiratory syncytial virus and sars-cov, the eyes have been shown to act as a portal of entry for the virus. while there have been no reports of sars-cov-2 transmission in humans via ocular tissues, further studies are required to exclude the eyes as a source of infection and as a portal of entry. moderate conjunctivitis could be the first sign of severe respiratory distress in covid-19 patients (182) . studies from china on patients with covid-19 reported conjunctivitis and other ocular manifestations, such as epiphora, conjunctival congestion, or chemosis in patients with severe covid-19 (183) (184) (185) (186) . the studies also reported a few patients with positive conjunctival swab for covid-19 determined by rt-pcr (183, 184, 186) . similar results were also reported in a study conducted by the national institute for infectious diseases in rome, italy (187) . in addition to the conjunctivitis, the ocular swabs were positive for sars-cov-2 even when nasopharyngeal swabs tested negative for the virus. this suggests that the conjunctiva may sustain viral replication for an extended period of time (118) . there are reports from france, italy, united kingdom and the united states of america, suggesting the presentation of autoimmune and auto inflammatory diseases in children, especially in children of african descent, such as paediatric inflammatory multisystemic syndrome (pims), also known as, multisystemic inflammatory syndrome in children (mis-c) (127) (128) (129) (130) (131) (132) (133) (134) . this syndrome includes kawasaki-like disease, kawasaki disease shock syndrome, toxic shock syndrome, myocarditis and macrophage activation syndrome (127) (128) (129) (130) (131) (132) (133) (134) . the exact cause for kawasaki disease remains unknown; however, it is believed that it is caused by an apparent atypical immune response to pathogens in genetically predisposed individuals (188) (189) (190) . previous studies have implicated the pathogenesis of kawasaki disease with the infection of certain members of the coronavirus family (191, 192) . the temporal association between the beginning of covid-19, sars-cov-2 infection and the onset of pims suggest a causal link (129) . this is further supported by the fact that in most cases, the patients exhibiting pims tested positive for igm or igg sars-cov-2 antibodies (127) (128) (129) (130) (131) (132) (133) (134) . the presence of igg antibodies clearly indicates a delayed onset of pims following sars-cov-2 infection (127) (128) (129) (130) (131) (132) (133) (134) . the onset of pims occurred 4-5 weeks after acute covid-19 (193) . the patients presented with fever, diffused skin rashes, rash/oedema of hands and feet, conjunctivitis, dry cracked lips, cervical lymphadenopathy and arthritis. the kawasaki-like disease caused by covid-19 exhibited a few differences in both clinical and biochemical features from patients suffering from kawasaki disease without sars-cov-2 infection. clinically, the patients suffering from covid-19 associated kawasaki-like disease were older and the disease occurred in both sexes, unlike the classical kawasaki disease that occurs in younger male children (193) . the covid-19 associated kawasaki-like disease also had a higher incidence of abdominal pain and/or more frequent diarrhoea, meningeal and respiratory involvement, and a strikingly different myocarditis severity and frequency when compared to classical kawasaki disease (127) (128) (129) (130) (131) (132) (133) (134) . biochemically the patients exhibited leukopenia with thrombocytopenia, increased ferritin, elevated myocarditis markers and high levels of procalcitonin, crp and cytokines were observed when compared to classical kawasaki disease (127) (128) (129) (130) (131) (132) (133) (134) . nearly 62% patients also showed resistance to the initial treatment with intravenous ivig infusion, and required a second infusion for successful treatment (128, 132) . while the children exhibited the devastating effects of the cytokine storm associated with covid-19, such as heart failure, pneumonia, gastrointestinal, neurological and renal manifestations, the paediatric patients in the french study rarely had respiratory manifestations (128) . this suggests a different host immune response in children compared to adults. treatment for pims involves the administration of il-1 receptor antagonist, il-6 receptor blockers such as tocilizumab or sarilumab, ivig, and steroids or biologics to control inflammation (128, 132) . covid-19 is known to affect older members of the population disproportionately, with adults over the age of 65 years making up to 80% of hospitalization and having a 23-fold greater risk of death (111, 194) . one possible explanation for this could be the increased baseline inflammation, called inflammaging, commonly observed in individuals over the age of 60 (195) . studies have shown increased baseline serum concentrations of crp and cytokines such as il-6 and il-8 (196) . inflammaging could be the result of the accumulation of mis-folded proteins, compromised gut barrier, obesity and impaired clearance of dead or dying cells (196, 197) . senescent nonlymphoid cells have been known to secrete inflammatory cytokines, chemokines, growth factors, and matrix metalloproteinases (195, 198) . this increased baseline inflammation inhibits antigen-specific immunity affecting the efficacy of many vaccines (199) . studies have shown that treatment with rapamycin, mapk inhibitor or steroids reduces this excessive inflammation and enhances vaccine efficacy (195, 200, 201) . in case of covid-19, this baseline inflammation may itself not be detrimental but contributes to the initiation of an inflammatory cascade that ends in the deadly cytokine storm (195) . furthermore the accumulation of senescent cells in the lungs of older patients could inhibit t cell response, induce nkr ligand expression, which marks the cells for elimination by infiltrating t cells expressing nkrs (195) . as observed in the case of vaccines against other respiratory viruses, inflammaging may reduce the efficacy of covid-19 vaccinations in this already disproportionately affected group. as with any infection, both the innate and adaptive arms of the immune system are required to mount a successful defence against a viral incursion. in case of covid-19, a decrease in the circulating t helper cells (cd4 + cells), cytotoxic t cells (cd8 + cells), b cells, natural killers cells, lymphocytes, monocytes, eosinophils and basophils has been reported (108, 149, 159, 202) . a retrospective, single-centre study involving 452 patients revealed a significant decrease in the total number of regulatory t cells, memory t cells and suppressor t cells (203) . the study also reported an increase in the percentage of naïve t cells (203) . as naïve t cells help respond to novel pathogens that the immune system has not yet encountered by managing release of cytokines, this may help explain the hyperinflammation (204) . the lower levels of memory t cells reported may also explain the relapses reported in covid-19 convalescent individuals (204) . direct infection of thp-1 cells, human peripheral blood monocyte-derived macrophages and dendritic cells by mers-cov and infection of t cells and macrophages by sars-cov has been reported (6, 205) . hence, it can be speculated that sars-cov-2 may also infect monocytes and macrophages by a mechanism that is yet to be elucidated (204) . receptors such as cd147 on the surface of t cells and other immune cells may mediate viral entry (206) . the clinical trial with anti-cd147 monoclonal antibody, meplazumab, showed promising efficacy and safety in covid-19 patients (207) . however, cd147 did not show a direct interaction with the s protein of sars-cov-2 (208) . similarly, lymphopenia can be attributed to sars-cov-2 direct infection and lymphocyte death, destruction of the lymphatic organs, and/or high levels of the programmed cell death protein 1 (pd-1) on cd8 + t cells (which is known to trigger t cell exhaustion) (204, 209, 210) . lymphocytopenia, neutrophilia and neutrophil-to-lymphocyte ratio are being used as a predictor for the severity of the illness during early stages of infection and a poor outcome in covid-19 (159, 202, 211, 212) . this further alludes to the hyper-inflammatory nature of covid-19. furthermore, covid-19 patients were reported to have elevated serum levels of highsensitivity c-reactive protein and procalcitonin, whose levels have been associated with high risks of mortality and organ injury (213) . lower percentage and count of cd3 + , cd4 + , and cd8 + lymphocytes populations serve as a prognostic marker for mortality, organ injury, and severe pneumonia (213) . sars-cov exposed as well as a subset of non-exposed people exhibit a cross-reactive t cell repertoire (214) . studies have also reported the presence of sars-cov-2 spike glycoprotein-reactive cd4 + t cells in peripheral blood of a subset of donor who were not infected with sars-cov-2 (215, 216) . these s reactive cd4 + t cells were found to primarily react with the c-terminal of the s epitope (216) . this binding preference could be attributed to the presence of overlapping human coronavirus mhc-ii epitopes in the c-terminal domain. hence, these cd4 + t cells are cross reactive clones generated during previous infections with endemic human coronavirus (216) . a long-term information and knowledge for ageing -camden' (linkage) sub-study is currently underway to study if pre-existing antibodies and specific t cells contribute to the devastating effect observed in old people (217) . the b cell response occurs alongside the t helper cell response (~1 week post infection) in covid-19 patients and helps mount a humoral response via antibodies that would help neutralise the virus (109) . characterisation of the transcriptome during the recovery stage of the disease revealed significantly lower levels of naive b cells, while plasma b cell levels had increased in peripheral blood mononuclear cells (159, 218) . it was found that a certain subset of patients who contract the disease may not develop long-lasting antibodies against the pathogen; it is possible that these patients may be susceptible to the re-infection (109) . immune cell profiling of covid-19 patients in the recovery stage by single-cell sequencing has identified several new b cell-receptor changes such as ighv3-23 and ighv3-7, and isotypes used earlier for vaccine development including ighv3-15, ighv3-30, and igkv3-11 (218) . the strongest pairing frequencies, ighv3-23-ighj4, has been suggested to indicate a monoclonal state associated with sars-cov-2 specificity (218) . antibodies analysed from the serum of covid-19 patients revealed no cross-reactivity with the s1 subunit of the sars cov spike antigen, while some reactivity was observed between the nucleocapsid antigens of sars-cov and sars-cov-2 (85) . the rbd-specific igm and igg antibodies were significantly elevated in the severe and recovered patients (159) . investigations conducted on covid-19 recuperating rhesus macaque models, re-infected with sars-cov-2, reported no measurable viral spreading, clinical manifestations, or histopathological changes associated with covid-19 (219) . the study found lower viral loads in nasopharyngeal or anal swabs 5 or 7 days after reinfection, compared to the recorded viral loads 5 or 7 days after the initial infection with sars-cov-2 at similar sites. similarly, increased levels of leukocytes and neutrophils were recorded 14 days after reinfection, compared to the levels measured during the initial infection. significantly higher specific antibody titres were recorded 14 day post reinfection. there were also increased activation of cd8 + t cells, changes in cd4 + tcm cells and memory b cells. thus, increased production of neutralising antibodies protected the primates against covid-19 re-infection (220, 221) . a study on 149 covid-19 convalescent individuals revealed that plasma collected after 39 days of symptom manifestation had a variable half-maximal pseudovirus neutralizing titres of less than 1:50 in 33%, below 1:1,000 in 79%, and only 1% showed titres above 1:5,000 (222) . interestingly, in spite of the low titres reported, antibodies specific to three distinct epitopes on the rbd of the sars-cov-2 s protein neutralized at half-maximal inhibitory concentrations as low as single digit ng/ml (222) . hence, a vaccine that can elicit the production of such highly potent antibodies, or monoclonal antibodies raised against the rbd of the sars-cov-2 s protein, may be highly protective. however, studies on sars-cov and mers-cov revealed that neutralizing antibodies to s protein can potentially augment severe lung injury by exacerbating inflammatory responses (109, (223) (224) (225) . hence, therapeutic antibodies should be carefully studied to minimise any unwanted pro-inflammatory activity while retaining maximum virus neutralizing capacity. additional specific insights on the intracellular life cycle have also been gained from nextgeneration sequencing (ngs) studies on the transcriptome and epi-transcriptome profile of sars-cov-2 virus and infected host cell. this fundamental approach has given an insight into the specific molecular dialogue between the pathogen and the host cell. this dialogue is complex. the sars-cov-2 transcriptome has been studied in high resolution. it has revealed its highly complex nature, mainly as a result of numerous discontinuous transcription events, revealing canonical and non-canonical rna transcripts with rna modifications (16) . in addition to the canonical full-length genome and other 9 sgrnas, this study also found numerous non-canonical rna transcripts of unknown orfs that contained rna modifications. 41 putative rna medications were identified at an aagaa motif. these previously unknown orfs represent the epi-transcriptome of sars-cov-2 and has revealed numerous viral transcripts that may be involved in pathogenesis (16) . another study looked at transcriptome profiling in the primary human lung epithelium and compared differences between sars-cov-2 and sars-cov infection and identified several pathways potentially involved in pathogenesis and gender-specific differences in clinical presentation (226) . among the genes that were upregulated were a cluster involved in the cytokine-mediated signalling pathways, and in particular, the il-17 signalling pathway (226) . specifically, cytokine pathways driven by nuclear factor kappa-light-chain-enhancer of activated b cell (nf-κb), toll-like receptors (tlrs), mitogen-activated protein kinase (mapk), bone marrow stromal cell antigen 2 (bst2), il-32, tnf alpha induced protein 3 (tnfaip3), tnfaip3 interacting protein 1 (tn1p1), intercellular adhesion molecule 1 (icam-1), intercellular adhesion molecule 2 (icam-2), matrix metallopeptidase 9 (mmp9), baculoviral iap repeat containing 3 (birc3), and rho family gtpase 1 (rnd1), were significantly upregulated during sars-cov-2 infection, suggesting a significant role in pathogenesis (226) . moreover, rela (nf-κb p65 subunit) seems to be significantly upregulated in sars-cov-2 infection, leading to il-8 involvement (226) . of note is the expression of oestrogen receptor 1 (esr1), which was also enhanced under sars-cov-2 infection, suggesting sex hormones may be involved in differential expression during viral infection and may have implications for the differences in clinical severity seen between genders (226) . additionally, over 24 and 48 hour post-infection, cxcl-2 was significantly upregulated in sars-cov-2 infection compared to sars-cov (226) . a recent study using single-cell rna-seq in human, non-human primate and mouse tissues/cells was able to resolve further the host cellular targets for sars-cov-2 and their abundance in specific tissue/cell types (36) . the study identified ace2 and tmprss2 co-expressing cells (lung type ii pneumocytes, ileal absorptive enterocytes and nasal goblet secretory cells) and also determined that that ace2 is induced by interferon-stimulated gene, suggesting a possible mechanism for enhanced viral infection (36) . the clinical pathways of covid-19 disease severity may also depend on host-specific factors that may contribute to the 'cytokine storm', or cytokines release syndrome (crs), which is the massive release of pro-inflammatory cytokines including cytokines (il-1β, il-2, il-6, il-7, il-8, and tnf-α) and chemokines such as cxcl10 and ccl2 in the lungs (172, 227) . these genomic approaches also shed light on the specific genetic host factors that predispose individuals to this severe clinical presentation. proteomic and transcriptomic studies on bronchoalveolar lavage (bal) samples from covid-19 patients have also revealed considerable insights into the expression of sars-cov-2 receptors, co-receptors, immune responses, as well as risk factors for severe disease e.g. age and co-morbidities. asthma, chronic obstructive pulmonary disease (copd), hypertension, smoking, obesity, and male gender status were all associated with higher expression of ace2 and cd147 in bal, as well as bronchial biopsy and blood from covid-19 patients (206) . furthermore, there was a positive correlation between the expression of cd147-related genes in bal and the age and body mass index (bmi) of covid-19 patients (206) . in another study on bal from covid-19 patients, an association was observed between covid-19 severity and enhanced levels of certain cytokines, e.g. ccl2/mcp-1, cxcl10/ip-10, ccl3/mip-1a, and ccl4/mip1b (228) . this study also found that sars-cov-2 triggered apoptosis and the p53 signalling pathway in lymphocytes, probably causing additional lymphopenia in these patients (228) . a comparison of transcriptome profiles between patients with covid-19 and influenza a virus infection revealed an absence of significant type i interferon/antiviral responses with sars-cov-2 infection, with enhanced expression of genes involved in metabolic pathways e.g. haem biosynthesis, oxidative phosphorylation and tryptophan metabolism, suggesting an important role for mitochondria during sars-cov-2 infection (229) . furthermore, a meta-analysis on bal data from covid-19 patients also revealed an excess for neutrophils and chemokines (229) . in meta-transcriptomic sequencing of bal from 8 covid-19 patients, the expression of proinflammatory genes, especially chemokines, was significantly elevated in these patients compared to community-acquired pneumonia patients and healthy controls, suggesting hypercytokinemia (230) . it also revealed enhanced dendritic cell and neutrophil activity (230) . in contrast to sars-cov, which induces an ineffective interferon response, sars-cov-2 was found to strongly initiate expression of numerous interferon stimulated genes, which are thought to significantly contribute to immunopathogenesis (230) . similarly, an analysis of rna-seq data sets of bal from covid-19 patients identified upregulation of neutrophil, inflammatory genes and chemokines, which may be involved in immunopathology, e.g. tnfr, il-8, cxcr1, cxcr2, adam10, gpr84, mme, anpep, and lap3 (231) . chronic co-morbidities for covid-19 patients include cardiovascular disease, hypertension, diabetes, stroke and malignant tumour (112) . it was also found that parameters such as older age, underlying hypertension, high cytokine levels (il-6, il-10, and tnf-α), and high lactate dehydrogenase level were significantly associated with severe covid-19 during hospital admission (166) . in a study involving 184 icu patients with covid-19 pneumonia, all of them showed an incidence of thrombotic complications such as symptomatic acute pulmonary embolism (pe), deep vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism (165) . approximately, one-third of patients experienced gastrointestinal symptoms. during hospitalization, a substantial proportion of patients presented cardiac injury, liver, and kidney dysfunction, and hyperglycaemia. icu covid-19 patients had higher plasma levels of il-2, il-7, il-10, gscf, ip10, mcp-1, mip-1, and tnf-α, compared to non-icu patients. majority of icu patients diagnosed with covid-19 were found to be at highest thrombotic risk (165) . patients with severe covid-19 likely developed ards and died of respiratory failure. biopsy samples at autopsy from a patient who died from severe covid-19 showed bilateral diffuse alveolar damage with cellular fibromyxoid exudates, and mononuclear inflammatory lymphocytes in both lungs (149, 177) . diffuse alveolar damage with fibrin rich hyaline membranes are pathological results of covid-19. in a study, 12 covid-19-infected cancer patients were found to have underlying diseases, such as hypertension, diabetes and chronic obstructive pulmonary disease (232) . cancer patients with accompanying covid-19 infection showed deteriorating conditions and poor outcomes, and thus it was recommended to avoid treatments causing immunosuppression (233) . the complement system is an integral part of the innate immune response. it consists of a group of plasma proteins produced mainly by the liver or membrane proteins expressed on cell surface. these proteins interact in a cascade that leads to the opsonization of pathogens and the induction of inflammatory responses. the complement system comprises of three distinct activation pathways, i.e. classical, alternative or lectin (mbl). the activation of these pathways is based on different molecules present on the pathogen surfaces. the classical pathway is initiated by the binding of c1q to the pathogen surface or antibody complex. the initiation of the alternative pathway is triggered by the binding of a spontaneously activated complement component to pathogen surface. the binding of the mbl to mannose-containing carbohydrates on pathogens triggers the initiation of the lectin pathway. the early events of three pathways eventually converge to generate a protease called, c3 convertase, which is covalently bound to the pathogen. the c3 convertase then cleaves c3, present in plasma, into c3a and c3b. the c3b binds to the pathogen and targets it for destruction by phagocytes. furthermore, c3b binds with the c3 convertase to form c5 convertase, which produces c5a and c5b. c5b triggers the late events of the complement cascade, which are a series of polymerization reactions where c6, c7, c8 and c9 interact with each other to form the membrane attack complex (mac). the mac can damage the membrane of certain pathogens by creating a pore in it. the c5a and c3a produced are important small peptide mediators of inflammation [reviewed in (234) ]. studies in c3 -/-(gene-deficient) mice infected with sars-cov revealed the presence of c3 activation products such as c3a, c3b, ic3b, c3c, and c3dg 1 day post infection (235) . the c3 deficient mice showed significantly less respiratory dysfunction and lower weight loss as compared to control. the mice also showed significantly lower levels of neutrophils and monocytes compared to the control. lower il-6, tnf-α and il-1 levels were reported in the lungs of the c3 deficient mice (235) . the study also reported lower weight loss in mice deficient in factor b or c4. in view of the critical role of the complement system in sars-cov infection since the first day of infection, it raised possibility for complement involvement in sars-cov-2. levels of the terminal component of the complement system (mac) and c5a are increased in patients with ards (236, 237) . mac is known to damage endothelial cells, and thus, regulation or inhibition of mac by its known regulators such as cd59 or clusterin could be a potential treatment for endothelial dysfunction/damage in ards or covid-19 (238) (239) (240) . considering the lectin pathway of the complement system, mbl was shown to bind sars-cov in vitro and inhibit its infectivity (241) . the n-protein of sars-cov and sars-cov-2 has been shown to interact with mbl-associated serine proteases-2 (masp2), which is known to initiate the lectin pathway (242) , leading to over-activation of the complement system. this same study also highlighted excess complement proteins found in post-mortem covid-19 patient lungs (242) . furthermore, deletion of masp2 or perturbance of the masp-2-n protein interaction was found to reduce lung injury. these studies, along with human proteomic studies, demonstrate the activation of multiple complement pathways during a coronavirus infection. in case of covid-19, the alternative and lectin pathways of the complement system seem to be preferentially activated (243) . increased levels of plasma c5a and mac were recorded in patients with moderate and severe covid-19 (244) . a post-mortem study of lung and skin vasculature in 5 covid-19 patients showed significant deposits of mac and c4d that colocalized with the sars-cov-2 s-protein, and masp2 in the micro-vasculature. this study did not find prominent classical features of ards such as hyaline membranes and inflammation in the histopathological examination (245) . a recent study reported an increase in levels of c5a, which correlated with increased covid-19 disease severity, as well as high levels of expression of c5ar1 in blood and pulmonary myeloid cells of covid-19 patients (246) . furthermore, use of anti-c5ar1 monoclonal antibodies in human c5ar1 knock-in mice was found to successfully prevent c5a-mediated myeloid cell recruitment and activation, thereby inhibiting acute lung injury (246) . a recent genetic study in covid-19 patients as reported that gene variants associated with complement regulatory protein, cd55 (decayaccelerating factor, which accelerates the decay of complement proteins, and thus inhibits complement activation) is associated with increased risk in clinical outcome (odds ratio 2.34-2.4); gene variants that map to c3 showed some protective effect (odds ratio 0.66-0.68) (247) . neutrophils along with the complement system are another important component in the defence of the host against invading pathogens. neutrophil infiltration in pulmonary capillaries, acute capillaritis with fibrin deposition, extravasation of neutrophils into the alveolar space, and neutrophilic mucositis have been reported in the case of sars-cov-2 infection (158) . the neutrophilic extracellular traps (nets) and the neutrophils activated by sars-cov-2 infection contain c3, factor b and properdin, triggering the alternative pathway of the complement system (243) . while this is usually beneficial, the sustained activation and nets formation leads to a hyper-inflammatory immune response that damages and destroy surrounding tissue. this aberrant behaviour, in concert with the abnormal complement activation, leads to the well recorded clinical manifestations observed in the case of covid-19 such as ards and pulmonary inflammation (248) . additionally, nets have been reported to induce the production of excessive thrombin and subsequently generate c5a (248) . hence, it has been speculated that feedback loop that begins with complement activation leading to netosis causing an increases in thrombin production, that further stimulates the complement activation causing enhanced net formation (243) . microangiopathy refers to a disease of the small blood vessels. the term is used when small blood vessels pathologically thicken or weaken, which leads to impaired flow of blood as well as leaking of cells and proteins. sustained inflammation in the vascular system due to the sars-cov-2 infection leads to thrombosis and microangiopathy (109, 249) . this is supported by reports of increased lactate dehydrogenase, bilirubin, activation of platelets, elevated d-dimer levels and hyper-fibrinolysis (250) . a post-mortem case series of 4 patients with covid-19 found thrombotic microangiopathy, which was restricted to the lungs, along with diffuse alveolar damage could have contributed to causing death (251) . another such study of 21 cases found similar diffuse alveolar damage with significant capillary congestion and microthrombi despite anti-coagulation therapy (252) . due to the presence of severe pulmonary vascular dysfunction in ards, it has been argued that ards is a type of vascular microthrombotic disease with lung phenotype involvement. this argument is supported by the association of mortality in ards with thrombocytopenia and mof as a result of disseminated intravascular coagulation (253) (254) (255) . in recent times, a couple of theories on the pathogenesis of ards in sepsis have evolved: the 'two-path unifying theory' in which certain homeostasis mechanisms lead to microthrombogenesis, and the 'twoactivation theory of the endothelium' in which the complement mac leads to inflammation via cytokines and microthrombogenesis via platelet activation (256, 257 ). the complement system plays a key role in the pathogenesis of thrombotic microangiopathy. this is a syndrome characterised by thrombocytopenia (low platelet count), microangiopathic haemolytic anaemia and systemic organ damage. atypical haemolytic uremic syndrome (ahus) is an example of such a disorder that typically leads to kidney damage. it is caused by excessive activation of the alternative pathway due to mutations in complement regulators factor h (common), factor i, membrane-cofactor protein, or c3. analysis of renal tissue morphology from autopsies of covid-19 patients revealed strong c5b-9 staining (via the alternative pathway) on the apical brush border of tubular epithelial cells with minimal deposition on glomeruli and capillaries of the kidney (258) . treatment with eculizumab (c5 inhibitor) dramatically improved outcomes of survival in ahus. features similar to complement-mediated thrombotic angiopathy such as kidney and cardiac injury increased lactate dehydrogenase and d-dimer, and decreased platelets were observed in covid-19 (137, 259) . eculizumab was used successfully as part of management of four covid-19 patients with severe pneumonia or ards in the intensive care unit, and this preliminary data is being used to conduct further full-fledged clinical trials with eculizumab (260) . considering the overlap with complement-mediated thrombotic angiopathy in covid-19, few studies are underway to test the effectiveness of complement regulators. a recent case study demonstrated a favourable outcome for the compstatin-based c3 inhibitor amy-101. the study, which involved a 71-year-old caucasian male with severe pneumonia and systemic inflammation, found that amy-101 was safe and had a favourable outcome in improving the clinical presentation of the patient significantly (261) . furthermore, treatment with a recombinant c5a antibody on 2 male covid-19 patients aged 54 and 67 years showed significant benefit in suppressing complement hyperactivation, which contributes to the excessive immune response causing aggravated inflammatory lung injury, a hallmark of sars-cov-2 pathogenesis and lethality (242) . one of the many challenges includes determining patients who have a dysregulated complement activation. c3 bound to erythrocytes has been detected in patients with covid-19 (262) , which may prove to be a useful blood marker as well as in identifying patients who potentially merit intervention with complement regulators (263) . in covid-19, endothelial injury has been found to be a key pathophysiological feature. a case series found direct evidence of viral infection of endothelial cells and endothelial inflammation, leading to endothelial cell death (264) . in covid-19 patients, endothelial cell abnormalities were recorded in the kidney, lung, heart, small bowel, and liver. 5 of 26 deceased covid-19 patients were found to have suffered endothelial cell swelling with variable foamy degeneration in the glomeruli and an additional 3 patients were found to have severe injury to the endothelium due to segmental fibrin thrombi in glomerular capillary loops (264) (265) (266) . mac deposition has been observed in the endothelium of covid-19 patients (245) . such studies have led to notion that in covid-19, there are strong vascular and inflammatory components as well, which play a significant role in the pathophysiology of the illness (267) . consistent with endothelial injury, the significantly elevated levels of von willebrand factor found in the patient with severe covid-19 has led to the idea that the infection of the ace2 expressing endothelium by sars-cov-2 induces injury and activates the complement , which sets up a feedback loop that maintains a state of inflammation (243, (268) (269) (270) . it is worth noting that ards may occur in covid-19 despite well-preserved lung gas volume, which could indicate a key role for inflammatory processes, leading to vascular constriction and subsequent low oxygen levels in the blood (271) . furthermore, d-dimer (a fibrin degradation product) levels are also found to be elevated in covid-19 and are associated with poorer prognosis (268, 272) . these factors add to the importance of understanding vascular changes in this disease, including microangiopathic processes and coagulopathies in patients with covid-19. pregnancy is associated with several maternal adaptations in both immune function (immunosuppression) and cardiovascular physiology (increased cardiac output, physiological anaemia, cardiac hypertrophy) that would likely alter susceptibility to viral respiratory infections including sars-cov-2. maternal death occurred in 15% of patients admitted to the icu for covid-19 and in 25% of those who required invasive mechanical ventilation (273) . to date, the literature consists of case reports, case series and retrospective studies. the most common presenting symptoms of maternal covid-19 are fever, cough, dyspnoea, and gastrointestinal symptoms (274) . clinical findings of respiratory manifestations were similar to those seen in the non-pregnant populations, with similar ct findings together with elevations in c-reactive protein with decreased white blood cell counts (275) . although the portal of entry is inhalational, there are widespread systemic effects. the immobility, hypoxia and acute inflammation lead to a prothrombotic hypercoagulable state, and indeed, elevated ddimers are correlated with disease severity (276) . covid-19 is thus associated with venous or arterial thromboembolism (277) . the mechanism by which this occurs is currently thought to be as a result of inflammatory cytokines (203) inducing production of tissue factor with subsequent thrombin activation. the elevations of d-dimer (often seen in acute phases of infection) may be related to this increased thrombin generation. while serious maternal morbidity has been seen, the vast majority of pregnant women with sars-cov-2 infection remained asymptomatic for respiratory symptoms (278) (279) (280) . pregnancy is coupled to physiological changes in cardiorespiratory status (281) which might be expected to alter susceptibility to a respiratory upset. nevertheless, the evidence suggests that this is less prevalent than thought. however, the changes in immune function and coagulation in pregnancy appear to increase some complications. similarly, the coagulopathies seen in covid-19 in the non-pregnant population might be expected to have deleterious effects in pregnancy, which is already a prothrombotic state. covid-19 has been seen to be associated with preeclampsia (274, 282) with one non-peerreviewed report suggesting a causal link (283) . the placenta has also been reported as having vascular malperfusion and thrombosis (284, 285) , which may provide an underlying explanation for the preeclampsia, a disease, associated with poor placental perfusion and altered vascular function (286) . evidence of increased clotting at the placental surface suggests that this mechanism may be responsible (in part) for the increased incidence of preeclampsia. sars-cov-2 virions have been seen in the syncytiotrophoblast, the part of the placenta responsible for the angiogenic imbalance seen in preeclampsia and effects on the release of known factors associated with the disease (sflt-1 -soluble fms like tyrosine kinase 1 and plgf -placental growth factor) are unknown. the disease is also linked to preterm premature rupture of membrane (pprom) (104, 282) , and preterm labour (287) , both of which are linked to inflammation. the underlying mechanism by which pprom occurs is not entirely elucidated. however, reports have suggested that activation of the coagulation system and thrombin causes fetal membrane weakening and subsequent rupture of membranes (288, 289) . the alterations in clotting and thrombin seen in covid-19 may well provide a mechanism for this. similarly, thrombin has been related to the induction of preterm labour and weakened fetal membranes by induction of decidual colony-stimulating factor (csf)-2 (290). at present, there are no drugs, therapeutics, or vaccines approved for curing, preventing, or treating sars-cov-2 specifically. as of june 2020, a total of 239 (147 in human trails, 92 in preclinical development) therapeutic drugs are under development against covid-19. the current treatment for sars-cov-2 patients involves the management of clinical symptoms and providing supportive care. while research into developing new drugs and treatments against sars-cov-2 are ongoing, much of the effort currently focuses on the repurposing existing medicines used against viruses, multiple sclerosis, arthritis, blood plasma derivatives and malaria. moreover, although immunosuppressive treatments, e.g. corticosteroids have shown promise for covid-19, there is considerable concern about possible side effects. other immunotherapeutic approaches given as adjunct therapy and based on neutralizing inflammatory cytokines and other immunomodulators, passive viral neutralization to reduce lung pathology and viral load, could be a promising approach (291) . a number of these approaches are discussed below. the antiviral drug remdesivir, developed by gilead sciences, is an adenosine analogue, which incorporates into nascent viral rna chains and results in premature termination, effectively inhibiting viral rna synthesis (292) . it was developed for the treatment of ebola and marburg virus infections (293) , and animal studies have shown that it is effective against the other coronavirus (294) . in vitro studies have established its efficacy against sars-cov-2 (295) . an open-label trial across the united states, europe, canada and japan showed clinical improvement of 36 of the 53 covid-19 patients who were treated with a 10-day course of remdesivir on a compassionate basis (296) . however, a follow-up multi-centre, randomized, double-blinded, placebo-controlled trial of 237 patients showed that the drug was not associated with a difference in time to clinical improvement. compared to the placebo, the drug was found to have a non-significant but, numerically faster time to clinical improvement in patients with a symptom duration of 10 days or lower (297) . currently, japan and the usa have allowed the use of the drug under emergency use authorization for the treatment of covid-19. in a randomized, open-label, multi-centre phase 3 clinical trials, a 5-day course remdesivir brought about a significant clinical improvement compared to standard alone in patients with moderate covid-19. this clinical study assessed the effect of 5-day (n=191) and 10-day (n=193) investigational remdesivir courses plus standard of care, versus standard of care alone (n=200) on clinical improvement on day 11 (298) . in case of patients with severe disease, both 5 day and 10 courses of the drug have been found to have similar clinical outcomes, but as the study lacked placebo control, the magnitude of benefit cannot be determined (299) . umifenovir, marketed as arbidol, is a derivative of indole carboxylic acids used for the treatment of influenza a and b virus infection, and other arboviruses (300) . it functions by incorporating into cell membranes and interfering with the hydrogen bonding network of phospholipids, blocking both the fusion of the virus to the cell membrane and the virusendosome fusion (301) . in vitro studies have established anti-viral efficacy against ebola virus, human herpesvirus 8, hepatitis c virus, tacaribe arena virus, sars-cov and sars-cov-2 (302) (303) (304) . a retrospective study on 81 sars-cov-2 patients treated with umifenovir did not reveal any improvement in clinical prognosis or accelerated viral clearance (304) . currently, two randomized and open-label trials to determine the safety and efficiency of the drug are ongoing in china. favipiravir, another anti-viral drug, developed by fujifilm toyama chemical (as avigan) and zhejiang hisun pharmaceutical, is a pyrazinecarboxamide derivative. it is converted into an active phosphoribosylated form (favipiravir-rtp) in cells and is recognized as a substrate by viral rna polymerase, thereby blocking the activity of rna-dependent rna polymerase. it was developed as a treatment against influenza. the drug is currently approved for the treatment of sars-cov-2 in china and italy. a study with 80 sars-cov-2 patients treated using the drug has reported that better efficacy was observed in anti-viral activity and lower adverse reactions compared to the control group that was treated with lopinavir/ritonavir (303) . another prospective, multi-centre, open-label, randomized superiority study with 240 sars-cov-2 infected patients was conducted at three hospitals. they showed faster recovery from clinical symptoms when compared to the controls that were treated with umifenovir, even though similar numbers required the use of ventilators and oxygen (305) . there are currently six trials ongoing in china evaluating the efficiency of this drug against other antivirals for the treatment of covid-19 and a phase 3 clinal trial to assess its effectiveness and safety is scheduled in japan and usa. anti-malaria drugs, chloroquine and hydroxychloroquine, are lysosomotropic agents that function by increasing late endosomal and lysosomal ph, which results in impaired viral release from the endosome or lysosome (306) (307) (308) . in vitro studies have shown antiviral activity against sars-cov-2 with hydroxychloroquine, a weak diprotic base, to have higher potency against the virus (295, 309) . in sars-cov-2, chloroquine, along with its lysosomotropic activity, is believed to reduce glycosylation of ace2 affecting the binding of the virus to the cells (310) . furthermore, chloroquine is also shown to block the production of proinflammatory cytokines such as il-6 preventing ards (311); hydroxychloroquine was found to possess an anti-inflammatory effect on th17-related cytokines (il-6, il-17 and il-22) (312) . initial clinical studies in china involving 100 sars-cov-2 infected patients, who were treated with chloroquine, showed amelioration of pneumonia, shortened disease progression, increased resolution of lung lesions on ct, and a better virus-negative conversion (313, 314) . hydroxychloroquine and combination therapy with azithromycin was found to reduce viral load in a french open-label non-randomised clinical trial and in an observational pilot study (315, 316) . nevertheless, these studies were plagued with several limitations, such as small sample size, very short observation period, no randomisation, lack of reports on clinical progression, poorly described inclusion and exclusion criteria, and low national early warning score (87, 315, 316) . another trial with 30 sars-cov-2 infected patients treated with hydroxychloroquine for seven days in china and a study with effectively 10 sars-cov-2 patients, revealed no significant difference in the nasopharyngeal viral carriage when compared to the controls that were provided with the local standard care (317, 318) . a third randomized clinical trial conducted in china with 62 patients exhibiting mild sars-cov-2 when treated with hydroxychloroquine were found to have recovered faster from cough and fever when compared to the placebo. however, the result of this study cannot be extrapolated to patients with severe sars-cov-2 (319). a retrospective cohort study of 1438 random sample of inpatients with laboratory-confirmed sars-cov-2 admitted to hospitals in the new york city was conducted. it did not find any significant differences in in-hospital mortality associated with the treatment with hydroxychloroquine, azithromycin, or both, compared to the controls where the patients were given neither of the drugs (320). the us fda and european medicines agency (ema) and many other countries like india and poland have authorized emergency use of hydroxychloroquine to treat sars-cov-2 infected patients. however, the fda and ema have issued warnings against the reported side effects of the drugs. these include abnormal electrical activity that affects the heart rhythm (qt interval prolongation, ventricular tachycardia, and ventricular fibrillation), particularly when taken at high doses or in combination with the antibiotic azithromycin. other side effects reported are liver and kidney problems, nerve cell damage that can lead to seizures and hypoglycaemia (321, 322) . around 30 clinical trials have been registered to study the effects of hydroxychloroquine and chloroquine independently or in combination with each other on sars-cov-2 have been registered in the usa and china (323) . another anti-parasitic drug, ivermectin, has been shown to be effective against sars-cov-2 in vitro (324) . a clinical trial to assess the efficiency of ivermectin against sars-cov-2 has been planned to take place in japan soon. the corticosteroid, dexamethasone, functions as an immunosuppressant. the drug is believed to modulate the lung injury caused by a dysregulated immune system, thereby reducing the progression to respiratory failure and death (325) . in a randomized, controlled, open-label, adaptive, platform trial, 2,104 patients treated with 6 mg of dexamethasone (orally or intravenously) for 10 days were found to have a significantly reduced 28 day mortality rate among those receiving mechanical ventilation by 33.33%, and by 20% among those receiving oxygen without mechanical ventilation, compared to 4,321 patients treated with standard care (325) . treatment with the drug did not provide any benefit to patients who did not require oxygen or mechanical ventilation, hinting at possible harm. the use of corticosteroid in the case of severe respiratory infections requires the use of "the right dose, at the right time, in the right patient" (325) . this is because a high or an early dose may help the virus proliferate by suppressing the immune system, instead of reducing inflammation. in case of covid-19, the peak of viral shedding is higher early in the disease. the benefit of dexamethasone when patients require respiratory support or after the first week of the disease suggest that this stage is dominated by an irrepressible immune response versus active viral replication (325) . dexamethasone is the first drug found to reduce mortality in covid-19 (326). lopinavir/ritonavir is a drug combination. lopinavir is a protease inhibitor, developed by abbott laboratories against hiv-1 that functions by blocking essential viral proteases (327) . due to poor pharmacokinetics, it is administered exclusively in combination with ritonavir which increases lopinavir's plasma half-life through inhibition of cyp3a-mediated metabolism of lopinavir, thereby increasing its exposure and improving the anti-viral activity of the drug (327) . in vitro studies have revealed that lopinavir inhibited the replication of the sars-cov-2 virus in vero e6 cell (328) . in a randomized, controlled, open-label trial with 199 patients with laboratory-confirmed sars-cov-2 infection, no benefit was observed with lopinavir-ritonavir treatment beyond standard care (329) . another single-blind randomised controlled trial in china treated 44 patients with mild/moderate covid-19 for 14 days, or umifenovir or standard care with no antiviral (219) . in the study, no differences were found in the time taken for viral clearance, as assessed by pcr of nasopharyngeal swabs, fever, cough, or lung ct findings. clinical status deterioration to severe/critical from mild or moderate clinical status and gastrointestinal side effects was seen highest in patients treated with lopinavir/ritonavir when compared to umifenovir treated or those treated with standard care and no antivirals (219) . both these randomised clinical trials suffer from small sample sizes and lack of blinding. a multi-centre, prospective, open-label, randomised, phase 2 trial in hong kong with 127 sars-cov-2 infected patients involved treatment for 14 days with only lopinavir-ritonavir (control), or with a combination of lopinavir-ritonavir, ribavirin, an oral hepatitis c virus drug, and ifn-. it found that the combination treatment was effective in reducing symptoms and viral shedding faster, as well as duration of hospital stay (330) . currently, about a dozen trials are studying the effect of the drug against sars-cov-2. one such study is a phase 4 randomized controlled trial in china in which the effectiveness of lopinavir-ritonavir against influenza drugs, umifenovir and oseltamivir, is to be studied. another south korean trial is looking to compare the efficacy of lopinavir-ritonavir against hydroxychloroquine. the who solidarity trial and uk-based recovery trial is looking to study the effectiveness of lopinavir-ritonavir independently; the who solidarity trial also looks to the explore the drug in combination with interferon-. another second-generation protease inhibitor against hiv-1, darunavir, has shown significant inhibition of sars-cov-2 replication (in vitro). according to a press release by johnson & johnson, an unpublished single-centre, open-label, randomized, and controlled trial in china in which 30 sars-cov-2 patients were treated with darunavir and cobicistat was not effective in treating sars-cov-2 (331). however, a further three clinical studies in china are scheduled. other drugs currently being tested against sars-cov-2 include tocilizumab, a monoclonal antibody against il-6 developed by roche, which is used for the treatment of moderate to severe rheumatoid arthritis by blocking il-6 activity. the drug was found to have helped cure 19 of 20 covid-19 patients in a trial conducted in china (332) . another open multi-centre randomized controlled trial french study awaits publication, in which 129 patients were split into two groups, i.e. routine treatment with and without tocilizumab: in the group treated with tocilizumab, the combination of ventilation requirement (mechanical or non-invasive) or death was achieved in a significantly lower proportion of patients (333) . a phase 3 trial to test its efficacy in treating patients with severe covid-19 has been authorised by the fda. moreover, an italian multi-centre, retrospective study of 544 patients with severe covid-19 pneumonia, revealed that the use of tocilizumab given either intravenously or subcutaneously was associated with reduced risk of mechanical ventilation and death (334) . anakinra is a recombinant il-1 receptor antagonist that has shown promise in treating severe covid-19 disease. in a retrospective cohort study of patients with covid-19 and ards that were managed with non-invasive ventilation (outside the icu), their treatment with high-dose anakinra was observed to be safe and associated with clinical improvement in 72% of patients (335) . another study has also described the early use of anakinra in covid-19 patients with cytokine storm syndrome (css) and acute hypoxic respiratory failure (ahrf) which may be beneficial in preventing the need for mechanical ventilation (336) . these results have encouraged further clinical trials to validate its safety and efficacy (337) . approaches targeting inhibition of bruton tyrosine kinase (btk) has also shown promise. btk plays a significant role in human innate immune responses. tlrs recognize ssrna of viruses like sars-cov-2 and induce signalling via btk-dependent activation of nf-κb, initiating a pro-inflammatory response (338) (339) (340) (341) . btk also plays a key role in the activation of the nlrp3 inflammasome, resulting in maturation and secretion of il-1β, a key pro-inflammatory cytokine (342) (343) (344) . thus, btk seems a favourable target against the cytokine storm in covid-19. in one study, acalabrutinib (a selective inhibitor of btk) was given to 19 patients with severe covid-19 and clinical improvements were observed over a 2-week treatment period, with reduced biomarkers of inflammation (c-reactive protein and il-6) to normal levels (345) . other dual inhibitors e.g. ibrutinib which target btk/il-2-inducible t-cell kinase (itk) signalling have also shown promise (346) . in one study of patients given ibutinib for treatment of b-cell malignancies and chronic graft-versus-host disease (cgvhd), there was evidence that ibutinib may also protect against pulmonary injury in covid-19, which these patients subsequently had, suggesting ibutinib as a possible prophylactic for vulnerable patient groups (347) . similar findings demonstrating a possible protective role of btk inhibitors in cancer with covid-19 have also been subsequently described (348) (349) (350) . these promising findings now merit a controlled randomised trial to demonstrate efficacy and drug safety of these btk inhibitors. intravenous immunoglobulin (ivig) is a pooled preparation of normal igg obtained from several thousand healthy donors. it is generally used in the immunotherapy of several autoimmune and inflammatory diseases, (351) , and thus has been investigated for treating covid-19 to mitigate the css. ivig therapy has shown promise through several studies, although careful selection of covid-19 patients and timing of ivig administration appear to be the key for good clinical outcome. preliminary findings from one multi-centre study showed that early administration of high dose ivig improved the prognosis of critical patients with covid-19 (352) . similarly, 3 patients with severe covid-19 who received high-dose ivig made a satisfactory recovery (353) . in another study, the use of ivig as an adjuvant treatment for covid-19 pneumonia within 48 hours of admission to the icu reduced the use of mechanical ventilation, icu and hospital time, and the 28-day mortality rate of patients with severe covid-19 pneumonia (354) . in a case study of a covid-19 patient with respiratory failure and shock, treatment with plasma exchange before ivig treatment resulted in prompt recovery without the need for mechanical ventilation and may be an additional early treatment step to treat critically ill covid-19 patients (355) . ivig treatment of severely-ill covid-19 patients on mechanical ventilation has also shown promise. in one study of 5 patients, treatment with ivig improved clinical and respiratory outcome, particularly saturation o2 levels, resulting in earlier extubation of the patients (356) . furthermore, ct graphs obtained after ivig therapy also revealed improvements in pulmonary lesions of these patients (356) . convalescent plasma therapy (cpt) is another classical adaptive immunotherapy used for the treatment of infectious disease for over a century. it has currently been approved for covid-19 by the fda under compassionate use rules. the treatment involves the transfusion of high neutralizing antibody titre containing blood plasma from sars-cov-2 recovered patients. this provides immediate short-term immunity. this is accomplished by binding of the pathogen to the antibody, which results in the activation of the immune system causing cellular cytotoxicity, phagocytosis, or direct pathogen neutralisation. five clinical studies, conducted involving 27 covid-19 patients who were treated with cpt, revealed significantly lower viral titres, increased levels of neutralizing antibody, improved clinical symptoms such as apyrexia, resolved ards and unassisted breathing (357) (358) (359) (360) (361) . among the 27 cpt-treated patients, no fatalities were recorded, and no severe adverse reactions or treatment complications associated with cpt were reported (357) (358) (359) (360) (361) . while providing with valuable initial data, these studies suffer from several limitations such as lack of proper control groups, non-randomized evaluations, concomitant drug treatments, poor participant selection, lack of proper cpt dosage, and duration of therapy (362) . three clinical trials are currently being evaluated by the fda to test the safety and efficiency of cpt in patients who have been exposed to the virus and are at high risk of developing severe covid-19, patients who are admitted in hospital with acute respiratory symptoms, and for covid 19 patients under mechanical ventilation (363) . further trials are also planned or ongoing in china, columbia, iran, mexico and the netherlands (363) . early safety indicators of covid-19 cpt were evaluated in a study of 5,000 patients and showed that the mortality rate was not unduly high and concluded that transfusion of convalescent plasma appears safe in hospitalized patients with covid-19 (364) . while the repertoire of antivirals and repurposed drugs tested against sars-cov-2 are expected to help manage the disease, the development of a safe and effective vaccine would help cut down the overall number of deaths and prevent the population from getting the disease in the first place. a recent study suggested that mandatory bcg vaccination can possibly be associated in flattening the curve in the spread of covid-19. it analysed the rate of day-wise increase in positive cases in 135 countries and deaths in 134 countries for the first 30-day period (365) . while arguments for the potentially beneficial effects of pre-existing vaccines have been sporadically made, including giving mmr (mumps, measles and rubella) vaccines to elderly population, generating a sars-cov-2 specific vaccine seems a logical and obligatory choice. as of 31 july 2020, the who landscape document reports 139 candidate vaccines developed on various platforms ( figure 6 ) in preclinical stages of development: only 26 are under clinical evaluation. mrna-1273 vaccine is a sequence optimized mrna/lnp expressing a perfusion stabilized form of sars-cov-2 s-2p a transmembrane anchored protein with the native furin cleavage site, developed by moderna in collaboration with the national institute of allergy and infectious diseases vaccine research center (366, 367) . the vaccine is undergoing an openlabel phase 1 clinical trial that started in march, 2020 with 45 healthy adult (18-55-year-old) volunteers for six weeks in three dose cohorts (25µg, 100µg and 250µg) as two doses approximately 28 days apart via intramuscular injection in the upper arm. three cohorts of 56-70-year-old volunteers and three cohorts of healthy volunteers aged 71 and above are being enrolled in addition to the initial volunteers. the volunteers will be followed through 12 months after the second vaccination to assess safety data, common vaccination symptoms, review trial data and advise niaid (367) . a phase ii trial with 600 healthy participants in two cohorts (18-55 years old adults and adults aged 55 years and above) treated with a placebo, a 50μg or a 250μg dose has begun from may, 29 th , 2020. the in vivo studies in murine models suggested the vaccine to be immunogenic and could elicit igg2a and igg1 subclass s-binding antibodies. mrna-1273 immunized mice splenocytes showed higher secretion of ifn- than il-4, il-5 or il-3 upon re-stimulation with peptide pools (s1 and s2). a dose of 1μg of mrna-127 was found to induce robust cd8 + t cell response to the s1 peptide pool with balanced th1/th2 ab isotype response in mice. thus, a 100 μg dose of vaccine has been decided for human trial in phase 3 study, which is equivalent to 1μg dose induced in mice (368) . the fda has granted fast track designation for the vaccine. the pfizer licensed biontech's bnt162 vaccine development programme has developed four coronavirus vaccine candidates (366) . two of the vaccines contain mrna coding for the spike protein of sars-cov-2, while the other two contain only the rbd of the spike protein (369) . furthermore, the four vaccine candidates are made of three different mrna formats. two of the vaccine are based on nucleoside modified mrna (modrna), which incorporates modified nucleosides in the mrna (370). this suppresses intrinsic immune activation and the production of anti-drug antibodies against the mrna itself (370). the suppressed immune activity against the therapeutic mrna helps produce the antigenic protein for longer periods (370). the next vaccine candidate is based on the optimised unmodified mrna (urna) format (370). urna uses uridine in the mrna, making it more immunogenic (370). finally, the last vaccine candidate uses self-amplifying mrna (sarna) (370). it is based on the principle of viral replication. the sarna, in addition to encoding a protein of interest, also encodes, replicase (370). this enables the self-amplification of the mrna inside the cell (370). the dsrna intermediate created during the replication of the rna triggers an immune response making sarna a potent activator of the immune system (370). a phase 1/2, randomized, placebo-controlled, observer-blind, dose-finding, and vaccine candidate-selection study to evaluate the safety, tolerability, immunogenicity, and potential efficacy of the candidate in 200 healthy adult volunteers is ongoing (100). another frontrunner among the candidates is cansino bio's ad5-ncov (366) . it is a genetically engineered vaccine candidate with the replication-defective adenovirus type 5 (live virus) as the vector to express sars-cov-2 spike protein. this would help the body to produce neutralizing antibodies against sars-cov-2. it has been shown to induce a strong anti-viral activity against sars-cov-2 in animal and in vitro studies. a single-centre, non-random, open, and dose-escalation phase i clinical trial for recombinant novel coronavirus vaccine (adenoviral vector) in 108 healthy adults aged between 18 and 60 years were conducted. the vaccine has been administered as a liquid formulation intramuscularly in the deltoid muscle (371) . three different doses were chosen: (a) low dose of 5x10 10 viral particles/0.5ml; (b) intermediate dose of 1.5x10 11 viral particles/ml; and (c) high dose combines both low and intermediate dose (one in each arm). the volunteers are assessed for a period for 6 months to study any adverse reactions or other relevant outcomes (371) . most common systematic adverse reaction observed were fever, fatigue, headache and muscular pain but with no serious adverse effect were noted within 28 days. participants showed four-fold increase in anti-rbd antibodies in all the groups; neutralizing antibodies increased gradually being highest at 28 days post vaccination. ad5 neutralizing antibody titres were boosted significantly postvaccination. il-2 and tnf- were detected and polyfunctional memory cd4 + t cell phenotypes were higher than cd8 + t cells. this suggested ad5 vectored covid-19 vaccine to be immunogenic and capable of stimulating both b and t cell response. for phase 2 clinical trial, intermediate dose was chosen and is expected to be completed by 31 january 2021 (372) . the vaccine may have some negative effects in older age people thus in the 2 nd clinical trial participants above 60 years will be included. t cell response peaked earlier from 14 th day after the 1 st shot of vaccine whereas the antibodies production level peaked at 28 th day post vaccination. the study also highlighted the possibility of negative effect on vaccine elicited immune response due to pre-existing ad5 immunity (372) . chadox1-ncov19 is being developed by oxford university, uk (366) . it is a replication deficient simian adenovirus vector chadox1, containing full length s-protein of sars cov-2 along with a tissue plasminogen activator leader sequence. the vaccine is reported to be effective in inducing an antiviral response in animal models (373) . chadox1-ncov19 was found to be immunogenic in mice mounting robust anti-viral response. single dose of this vaccine was capable of inducing humoral and cellular immune response in rhesus macaques (373) . a phase i/ii single-blinded, randomised, multi-centre study to determine efficacy, safety and immunogenicity of the vaccine in about 1090 healthy adult volunteers aged 18-55 years was initiated on april 23 rd , 2020 (374). the volunteers have been subjected to either one dose of 5x10 10 vp of chadox1 ncov-19, an additional booster dose of 2.5x10 10 vp of chadox1 ncov-19, or a control of menacwy vaccine delivered intramuscularly (374). the volunteers were assessed for a period for 6 months to study any adverse reactions or other relevant outcomes (375) . the results showed increase in s-specific antibodies with a single dose by 28 th day and increase in neutralizing antibodies with booster dose in all participants. chadox1-ncov19 was also capable of inducing heightened effector t-cell response quite earlier than antibody response. t cell response peaked on day 14 th and sustained up to 56 days. the results showed chadox1 ncov-19 vaccine to be safe, tolerant and immunogenic, which further supported phase 3 trial which is now underway (375) . picovacc is a purified inactivated sars-cov-2 vaccine candidate which is capable of inducing neutralizing antibodies in mice, rats, and nonhuman primates specific to sars-cov-2. cn2 strain of sars cov-2 virus was chosen to develop picovacc which was inactivated with β-propiolactone. this inactivated vaccine candidate was able to produce about 10-fold higher s-specific antibody titres in murine model when compared to covid-19 recovered patients. efficacy of picovacc was also tested in rhesus macaques with an intramuscular low (1.5µg), medium (3 µg) and high (6 µg) dose administered three times (0, 7 th and 14 th day) and on day 22 nd sars cov-2 cn1 strain was inoculated through intratracheal (lungs) route. all vaccinated macaques showed protection towards sars cov-2 infection and their viral loads declined significantly. no notable haemato-and histopathological changes were observed; human clinical trials are awaited (376) . a group of us scientists have come up with a series of prototype dna vaccines expressing variants of the sars-cov-2 spike protein. the efficacy of the dna vaccine candidates was evaluated in 35 rhesus macaques (6-12-year-old). intramuscular dose (5mg) of dna vaccine was administered, followed by booster dose on 3 rd week and antigenic challenge (1.2 x 10 8 viral particles) on 6 th week (both intranasal and intratracheal route). dna vaccine was found to be protective with dramatic reduction of viral replication and enhanced production of sspecific binding as well as neutralizing antibodies compared to controls. the study has not yet addressed the possibility of mutations that may emerge in escaping neutralizing antibodies, though it seems to be protective in primates against sars-cov-2 (377). j o u r n a l p r e -p r o o f ino-4800, developed by inovio, is a dna vaccine candidate (366) . the optimized spike protein of sars-cov-2 virus dna plasmids are introduced into cells by the use of a proprietary platform, cellectra®, via electroporation (378) . once inserted, the plasmids are expected to strengthen the body's own natural response. a phase i open-label study to evaluate the safety, tolerability and immunogenicity of ino-4800 as a prophylactic vaccine against sars-cov-2 in 40 healthy volunteers aged 18-50 years is ongoing (378) . the volunteers will be treated with either one or two doses of 1 mg of vaccine administered intradermally followed by electroporation the following day (378) . the volunteers will be assessed for a period for 1 year to study any adverse reactions or other relevant outcomes (378) . once the initial safety and immunogenicity of the vaccine are satisfied, phase ii efficacy studies are planned. qualitative and quantitative properties of cd4 + and cd8 + t cell responses in covid-19 and prophylactic vaccine development necessitate identifying viral regions and potential epitopes. thus, a total of 423 peptides (15-to 18-mer), which span the full proteome of the sars-cov-2 excluding orf-1, were designed and used to assess the memory t cell responses upon challenge on 42 patients following recovery from covid-19. 39 peptides were identified containing cd4 + and/or cd8 + epitopes. the memory of t cell responses from convalescent individuals with covid-19 was found to be greater in severe covid-19 cases compared to mild ones. immunodominant epitope clusters and peptides were most markedly observed to belong to spike, m, and orf3 proteins. in about 35% of study groups, strong cd8 + t cell responses specific to the np protein were observed, suggesting the possibility of inclusion of non-spike proteins in future covid-19 vaccine design (379) . in another study, a comprehensive immunogenicity map of the sars-cov-2 virus was carried out; 65 peptide sequences (33-mers) were generated based on computational algorithms. a single 33-mer peptide containing multiple epitopes that can possibly present on hla class i and class ii across majority of population and provide long-term immunity in most people acting as b and t cell epitopes had been identified. this in silico analysis needs further evaluation for safety and efficacy as a vaccine (380) . in an unprecedented short span of time and speed since the beginning of the covid-19 pandemic, significant progress has been made in our understanding of the pathogenesis of sars-cov-2 infection. however, there are endless unanswered questions; hopefully and most likely, they will be answered in near future. why there are a huge population that are asymptomatic carriers? what are the genetic contributors to susceptibility and resistance to developing covid-19? how pregnant women are so resilient to developing covidsymptoms; for that matter young children as well! what happens during the period of latency, i.e. between being infected and showing symptoms? how far the lung surfactant system gets affected during severe symptoms? what triggers thrombotic microangiopathy in addition to complement activation. on the adaptive immune aspects, what variations exist within population in terms of the proportion of neutralising antibodies? persistence of neutralising antibodies and recall memory magnitude following second infection (on vaccination trials) will yield serious information about how to finetune the dose, duration and vaccination strategies. in this acute crisis, a number of existing drugs have been repurposed empirically; clinical trials have yielded variable results. it is becoming clear that combination therapies are more likely to be successful. deciphering, at high resolution, the mechanisms and consequences of hostpathogen interactions in covid-19 will lead to novel therapies and preventative vaccination strategies. primary cellular host and co-receptor for sar-cov-2. 1) attachment and entry of sar2-cov-2 requires priming by transmembrane serine protease 2 (tmprss2) which cleaves the s protein into s1 and s2 portions, facilitating, 2), s1 targeting and binding of the receptor angiotensin-converting enzyme 2 (ace2), followed by receptor-mediated endocytosis of the virion into the host cell. j o u r n a l p r e -p r o o f tmprss2 is the key protease involved in priming sars-cov-2, which forms a receptorprotease complex with ace2 on the host cell surface, thus facilitating viral targeting and entry to the host cell. co-expression of aec2 and tmprss2 has been found in proximal as well in distal airways. the nasal cavity has the highest expression of both the receptors in ciliated and secretory (goblet) cells compared to lung bronchi (ciliated and secretory cells) and lung parenchyma (alveolar type 2 progenitor cells, at2). structural conformation of receptor-binding domain (rbd) present in s1 region of sars-cov-2 spike protein is capable of influencing the ace2-binding affinity. in case of sars-cov-2, the rbd contains a four-residue motif glycine-valine/glutamine-glutamate/threonineglycine which enables the binding loop to take a different conformation. it can undergo two possible conformational changes, a "lying down state" which has low affinity towards aec2 and a "standing up state" with high binding affinity. sars-cov-2 rbd is found mostly in lying down state, and thus being less accessible to aec2. this hidden conformation of rbd in the spike protein can possibly be a masking strategy for immune evasion by sars-cov-2. (1) the sars-cov-2 binds to the cell via the ace2 receptor using the s1 subunit of the spike protein. once bound, the s2 subunit facilitates virus-cell membrane fusion by two tandem domains, heptad repeats 1 (hr1) and heptad repeats 2 (hr2) to form a six-helix bundle (6-hb) fusion core, bringing viral and cellular membranes into close proximity for fusion and infection. type ii pneumocytes infected with sars-cov 2 trigger the release of cytokines, chemokines and interferons. the secreted inflammatory mediators recruit macrophages, neutrophils and activated t cells. the stimulated macrophages secrete il-1, il-6 and tnf-α. this increases capillary permeability, causing plasma to leak into the interstitial space and the alveolus. the stimulated neutrophils release reactive oxygen species and proteinases, which destroy infected cells. the cell debries and the plasma combine to form a protein-rich fluid. the increasing fluid leads to dyspnoea and pneumonia. it also dilutes the surfactant 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(bcg) vaccination predicts flattened curves for the spread of covid-19 world health organization. draft landscape of covid-19 candidate vaccines -15 phase i, open-label, dose-ranging study of the safety and immunogenicity of 2019-ncov vaccine (mrna-1273) in healthy adults sars-cov-2 mrna vaccine development enabled by prototype pathogen preparedness a close look at the frontrunning coronavirus vaccines as of may 1 (updated) chinese clinical trial registry. a randomized, double-blinded, placebo-controlled phase ii clinical trial for recombinant novel coronavirus (2019-ncov) vaccine (adenovirus vector) safety, tolerability, and immunogenicity of a recombinant adenovirus type-5 vectored covid-19 vaccine: a dose-escalation, open-label, non-randomised, first-in-human trial chadox1 ncov-19 vaccination prevents sars-cov-2 pneumonia in rhesus macaques a study of a candidate covid-19 vaccine (cov001) -full text view -clinicaltrials.gov safety and immunogenicity of the chadox1 ncov-19 vaccine against sars-cov-2: a preliminary report of a phase 1/2, single-blind, randomised controlled trial development of an inactivated vaccine candidate for sars-cov-2 dna vaccine protection against sars-cov-2 in rhesus macaques tolerability and immunogenicity of ino-4800 for covid-19 in healthy volunteers broad and strong memory cd4 + and cd8 + t cells induced by sars-cov-2 in uk convalescent covid-19 patients identification of sars-cov-2 vaccine epitopes predicted to induce long-term population-scale immunity key: cord-287607-d3k26aar authors: emamaullee, juliet; bowdish, michael; yan, pui yuk; rodina, valentina; sher, linda s. title: rapid adaptation of a surgical research unit to conduct clinical trials during the coronavirus-19 pandemic. date: 2020-06-29 journal: j surg res doi: 10.1016/j.jss.2020.06.049 sha: doc_id: 287607 cord_uid: d3k26aar the coronavirus disease 2019 (covid-19) pandemic has brought most ongoing clinical trials to a standstill, while at the same time emphasizing the need for new therapeutic treatments and strategies to mitigate the morbidity and mortality related to covid-19. recent publication of several observational studies has generated much discussion surrounding efficacy of drugs including hydroxychloroquine, azithromycin, and remdesivir, stressing the need for high-quality prospective, randomized control trials in patients with covid-19. ongoing ‘stay at home’ orders and institutional policies mandating ‘work from home’ for non-essential employees, which includes most research personnel, have impacted the ability to implement and conduct clinical studies. this article discusses the approach of an experienced clinical trials unit to make adjustments for ongoing studies and ensure the safety of study participants. at the same time, plans were implemented to continue collection of data to achieve endpoints, safely enroll and follow participants in studies offering potential benefit, and quickly implement new covid-19 clinical trials. the existence of a division of clinical research with regulatory, budgeting, contracting, and coordinating expertise within a department of surgery can successfully accommodate a crisis situation and rapidly adapt to new requirements for the safe, efficient, and effective conversion to a remote work force without compromising the research process. concerns over high transmissibility, an unknown burden of disease, variable clinical presentation, and mortality associated with coronavirus disease 2019 (covid-19) have led to extensive, governmentmandated 'stay at home' orders since early march 2020, including all non-essential industries and employees. there has been a broad and dramatic reduction in clinical trial activity following implementation of these policies. 1 several factors have contributed to this acute decline in clinical research: avoidance of in-person encounters to promote study participant safety, efforts to reduce risk to research coordinator staff and comply with work from home orders, and strategies to minimize the unintended consequences of covid-19 infections on primary and secondary end points in ongoing studies. this has required a careful assessment of ongoing studies to determine if enrollment should be held or if enrollment should continue if there is a significant potential benefit to a participant. further, for studies with ongoing or newly enrolled participants, adjustments are required for safe follow up for the participant and the study personnel. in parallel, there has been a pressing need to develop and study new anti-viral and anti-inflammatory medications and other interventions to treat the most serious clinical manifestation of covid-19, severe acute respiratory syndrome of coronavirus-2 (sars-cov-2). at the onset of the pandemic, there were no fda-approved specific treatments for sars-cov-2, and the subset of patients who develop this syndrome are highly contagious, require invasive ventilation, and experience significant mortality. 2 with only a series of small observational studies reported, generating much discussion about efficacy, study design, and safety of medications including hydroxychloroquine, azithromycin, and remdesivir, among others, [3] [4] [5] there was and remains an urgent need for infrastructure that allows for rapid implementation of high-quality, multi-center randomized control trials. recognizing the evolving challenges of the covid-19 pandemic, the division of clinical research in the university of southern california (usc) department of surgery proactively implemented a strategic plan to address the needs of ongoing studies and re-deploy our experienced clinical trials team towards covid clinical trials unit 4 covid-related studies. in this article, we outline our approach to provide guidance to other institutions and promote timely and expanded efforts at implementation of covid-19 related clinical trials and continue non-covid studies in the setting of a pandemic. clinical trials provide new drugs, devices, and treatment strategies with the ultimate goal of reducing the burden of disease. regardless of the source of funding for clinical trials, specific resources are required to assure efficient and effective implementation and conduct of these studies. depending upon the investigator, sponsor and/or institution, major limiting factors to participating in clinical trials include investigator experience, research staff expertise, institutional regulatory bodies, financial support, institutional resources, the available patient population, and cooperation among referring physicians and insurance companies. the division of clinical research in the surgery department was established in 2013 to provide a consistent foundation and support structure for the conduct of clinical trials within the department. creation of the division involved pooling resources including existing coordinator staff from individual surgical investigators and required financial investment from the departmental leadership. by centralizing the clinical trials process within the department and under the guidance of an experienced chief and seasoned research team, the capacity for clinical studies has increased substantially while maintaining a stable number of study personnel (figure 1) . the division was self-funded through industry and publicly funded study budgets within the first year of its creation. on average, the overall operational budget for the division is approximately $1,100,000/year. the current team includes a physician division chief and associate chief, two regulatory and budget specialists, a 0.6 fte biostatistician, a research nurse and eight study coordinators that each has expertise in specific clinical specialties and an ability to effectively provide coverage to other service lines, across a department that includes >100 surgical faculty. importantly, the division offers 24 hour/7 day a week coverage to guarantee that enrollment is efficient and that adverse event reporting can be completed according to federal, institutional, and sponsor requirements. the division has established and administered a general use tissue and blood biorepository for research endeavors. by the time of the site initiation visit, representatives of all areas of the hospital have been brought together to assure appropriate training. a primary and a backup coordinator are assigned to every study, and they work together to coordinate all details alongside the pi. prior to the covid-19 pandemic, twice weekly team meetings were convened to review study progress, address any concerns, and discuss new amendments, reportable events, or regulatory issues to assure timely submission and resolution. a series of internal quality metrics have been monitored including time to activation, number of studies, number of pis, patient enrollment, sponsor feedback, food and drug administration (fda) audits, study reimbursement, and protocol adherence (i.e. number of deviations). we have also incorporated a biostatistician and established a relationship with our departmental data science group to further streamline data collection and analysis. shortly after the first covid-19 related death in washington state in february 2020 and subsequent outbreak in the u.s., the first covid-19 related death in california was reported on march 4, 2020. 6 accepting that moving forward with ongoing clinical trial activity would be fraught with uncertainty, plans were immediately implemented on march 8 to prepare for social distancing, prior to formal policy changes related the california stay at home order announced on march 16, 2020. departmental administrators were requested to establish remote access to the electronic medical record, network drives, and virtual desktop environments for every team member on march 13, and all non-physician personnel began working from home on march 16. these efforts were directed at the identification of the following areas that would require modification: minimization of direct patient care for routine study activities, logistics of research staff working from home, and study-specific protocol deviations, enrollment pauses, and remote site monitoring visits (figure 3) . prior to covid-19, there were twice weekly in person meetings. beginning on march 16, biweekly team meetings were changed to a daily virtual format, as a brainstorming and troubleshooting session to address issues in real time. to determine how to continue to follow ongoing study participants as well as to determine how to proceed with enrollment, each coordinator communicated with their study sponsors to obtain amendments outlining safe virtual follow up, address potential protocol deviations, aspects of consent and enrollment criteria in the face of the covid-19 pandemic. research coordinators also contacted study participants to explain changes in study protocols and visits. there was an urgent need from sponsors to accommodate remote monitoring of ongoing studies. remote, hippa-compliant access to the electronic health records (emr) were provided to study monitors, and we provided instruction and oversight for remote emr training capability for monitors who were not initially trained to use our system. pis, sponsors, and the study team communicated to identify the subset of non-covid-19 studies that would remain open to enrollment due to the potential benefit of access to investigational medications or devices for patient populations with serious or life-threatening conditions. 7, 8 the continuation of these types of studies was in accordance with institutional guidelines, which were reviewed frequently as plans evolved to gradually phase in more non-covid-19 clinical studies. 9 divisional leadership participated in campus-wide task forces formed to develop and implement clinical research activity, and as a result, was able to communicate policy changes to the research staff during daily team meetings. sponsors were highly responsive, providing amendments to allow for study adjustments, including suspension of enrollment when appropriate for a specific study, protocol modifications to allow for remote follow up and designed for participant safety as well as to assure that data collection to achieve endpoints could be collected, and implementation of remote monitoring, etc. in response to the special needs for limiting contact, the irb and office for the protection of research subjects implemented remote hippa-compliant consenting methods, which were included as amendments where appropriate. over the last two weeks of march, more than 50 protocol amendments were submitted to the irb to address these issues. the irb policy of rapid turnover of amendments related to covid-19-related study adjustments resulted in expedited approvals and implementation of safety measures within days of submission. within our surgical research unit, high priority studies were identified to continue or to start. these included provision of devices or drugs with a significant potential for participant benefit and new covid-19 studies. enrollment in many ongoing elective clinical trials was temporarily halted, but participants already enrolled continue to be followed according to the individual study amendments. further, close contact has been maintained to assure the safety of the participants and timely reporting of any events. organizational plans have been implemented for the continued enrollment and conduct of the studies managed by our team. these included the following measures: 1. reallocation of study personnel on a voluntary basis to covid-19 studies that might require occasional work at the hospital. 2. study personnel asked to self-assess for risk factors to exclude themselves as volunteers for new covid-19 studies. 3. initially, non-physician study personnel were not permitted to have direct patient contact and attendance in the hospital was only permitted in non-clinical offices adjacent to the hospital and not in patient care areas. communications were sent to the departmental faculty to notify them of the changes and to request that all new study patients be discussed with the division chief to determine the need for enrollment and to develop a plan for the safest conduct of the study. the initial response of the clinical trial unit was designed to make appropriate safety adjustments for study personnel and study participants. once a remote working process was enacted and found to continue to be efficient and effective, the additional and important benefits of our streamlined trial assessment and implementation process became apparent during discussions surrounding new covid-19 related clinical trials. the institution took prompt action in providing important recommendations and guidelines for research, across the spectrum of clinical and laboratory-based research. 9 a covid-19 scientific merit review board, which included divisional leadership, was quickly instituted to guide investigators and coordinate covid-19 related clinical trials. this was accompanied by institutional commitments for rapid institutional review board reviews of covid-19 related amendments and studies and expedited contract completion with sponsors. frequent and bidirectional communication with these entities has allowed for extremely effective collaboration. the changes and adjustments that were made for the purpose of the departmental studies proved invaluable in preparing for and implementing covid-19 trials. the organization described above was also appropriate for these studies. in addition, the institution and irb facilitated the ability to adjust the consenting process by permitting: 1. implementing remote electronic and telephone consents for legally authorized representatives of incapacitated patients. 2. developing non-paper consents and hipaa records to avoid maintaining potential fomites. the potential impact on research personnel in the covid-19 pandemic has created unique challenges. the pis work closely with the study coordinators to assure that studies are conducted safely and according to gcp. direct patient contact only involves the caregivers already involved in the patient care who are educated in the administration of study drugs and sample collection. study coordinators communicate throughout the process with all caregivers and have remote access to records to assure that all data is collected and that all serious adverse events are reported according to the sponsor, irb, and fda guidelines. the coordinators organize the various hospital services to conduct the study including but not exclusively, the pharmacy, laboratory, and imaging. all covid-19 study related activity is reviewed in the daily team meetings. as an example of striving for efficiency, after receipt by the study team of documents for an nih-funded randomized control trial, irb approval was obtained within one week. the team developed an organizational chart including remote tasks and on campus tasks and worked with various hospital services to prepare for the study. a safety plan was implemented for study personnel. all preparations were completed including contracting and site initiation within four weeks of document receipt and screening began, with the first randomization occurring two days after study activation. using this approach, our surgical research unit has enrolled >20 covid+ intensive care unit patients in studies over a four-week period. implementation of covid-19 clinical trials in a pandemic setting presents many challenges and can overwhelm even an experienced study team. based on our experience, the following are critical components to successful study implementation and enrollment: 1. each institution should establish a mechanism of prioritization of studies as there may be studies that compete for a specific patient population. some protocols may limit non-study protocol therapies and/or prevent future enrollment in new covid-19 trials. we would recommend considering various cohorts based on the world health organization covid-19 ordinal scale for clinical improvement and creation of multidisciplinary teams to review these cohorts to determine study prioritization. 10 2. the pi must be prepared to be engaged in study initiation, screening, enrollment, and conduct of the study including direct patient contact when required. 3. mechanisms should be established for remote and electronic consents to prevent fomites related to paperwork. 4. ancillary services including inpatient pharmacies, laboratory, and radiology must be engaged to assure that the study is feasible and to strategize implementation. 5. we do not permit our research coordinators to have direct patient contact. a study team with discrete roles for the pi and study coordinators allows for efficient enrollment and maintenance of data collection and event reporting. specific roles and tasks should be designated for research staff as these are complicated and generate a great deal of paperwork. 6 . the nurses in the various units should be educated so that they can work with the team to provide drugs and obtain data. 7 . plans for frequent troubleshooting and communication among divisional leadership and study staff should be implemented prior to activation. financial viability while our division has been self-funded through ongoing activities, allowing for all salaries to be covered through the next academic year, the slow-down of "elective" research was expected to have an effect on our future financial viability. several strategies will be required to maintain financial viability in the face of decreased enrollment, all aimed at preparing for the reopening of ongoing study activities, resuming enrollment, and activation of new studies. as part of our 'work from home' team management, we have continued to set targets for irb approvals, budgeting, and contracting that will allow new studies to start in a timely fashion when the institution has eased restrictions on research activities. at the same time, observational and registry studies that do not require close or frequent patient contact have continued with timely data entry into sponsor websites. lastly, research team members have been provided additional work from home activities, including data collection for investigator-initiated studies and pending grant proposals. to date, these adjustments have allowed for maintenance of financial viability and support for research staff. over time, it will become more evident if and how this has been impacted. research staff were reassigned to accommodate the growing number of covid-19 studies. in ongoing and new covid-19 studies, pis and divisional leadership have worked together to develop an organized approach to control coordinator exposures while assuring that studies continue according to gcp. these studies are labor-intensive, and budgets should be designed to account for the increased time and effort required to complete them effectively. for departments and institutions that are unable to maintain financial viability, options include furlough, administrative leave and even potential layoffs. after nearly three months of experience using our adapted organizational structure, several beneficial aspects of the modified workflow have emerged. moving forward, we anticipate that personnel will maintain the option to work remotely when research activities do not require them to be on-site. studies similar to the covid-19 trials that involve rapid enrollment and time-intensive documentation will be assigned a coordinator team, rather than 1-2 individuals, to maintain enrollment capacity, data entry, and event reporting in a timely manner and avoid excessive overtime activity. pandemic era study modifications including telehealth patient visits, screening of study participants for symptoms of infection prior to coming on site, and emphasis on hygiene and personal protective equipment, even in a post-covid-19 world, will become routine. the benefits of a dedicated clinical trials unit within a department of surgery include consistency, efficiency, timely study implementation, conduct according to gcp, financial viability, and the ability to educate young investigators and encourage increased participation in clinical research. the value of this approach has been evident at our institution, as indicated by the increase in the number of studies, competitive enrollment, number of investigators, sponsor satisfaction, and financial solvency of the division. most importantly, in a crisis situation, as we are experiencing with the covid-19 pandemic, we have demonstrated that a dedicated clinical research team can quickly adjust to the new 'normal'. our approach has allowed surgical pis to continue to efficiently manage study participants, enroll patients in beneficial studies, engage with sponsors, handle regulatory issues, and ultimately be prepared to swiftly implement new covid-19 trials and continue ongoing clinical trials that predate the current pandemic. coronavirus pandemic brings hundreds of u.s. clinical trials to a halt. heal news from npr clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid-19 infection compassionate use of remdesivir for patients with severe covid-19 first case of 2019 novel coronavirus in the united states fda guidance on conduct of clinical trials of medical products during covid-19 pandemic: guidance for industry, investigators, and institutional review boards covid-19 research guidance & policies the authors would like to recognize the following individuals for their contributions to the division of key: cord-263936-8yud5o6c authors: wang, gary x.; chou, shinn-huey s.; lamb, leslie r.; narayan, anand k.; dontchos, brian n.; lehman, constance d.; miles, randy c. title: opportunities for radiology trainee education amid the covid-19 pandemic: lessons from an academic breast imaging program date: 2020-10-03 journal: acad radiol doi: 10.1016/j.acra.2020.09.009 sha: doc_id: 263936 cord_uid: 8yud5o6c the covid-19 pandemic required restructuring of radiology trainee education across us institutions. while reduced clinical imaging volume and mandates to maintain physical distancing presented new challenges to traditional medical education during this period, new opportunities developed to support our division in providing high-quality training for residents and fellows. the accreditation council for graduate medical education (acgme) core competencies for diagnostic radiology helped guide division leadership in restructuring and reframing breast imaging education during this time of drastic change and persistent uncertainty. here, we reflect on the educational challenges and opportunities faced by our academic breast imaging division during the height of the covid-19 pandemic across each of the acgme core competencies. we also discuss how systems and processes developed out of necessity during the first peak of the pandemic may continue to support radiology training during phased reopening and beyond. challenges posed by the covid-19 pandemic required restructuring of radiology training programs across us institutions. 1, 2 medical training has traditionally relied on experiential learning gained through the performance of clinical work under attending supervision. while reduced clinical imaging volume and mandates to maintain physical distancing have presented challenges to traditional medical education, opportunities have arisen to develop new methods for effective training based on existing educational frameworks. 1 during the height of the pandemic, the american college of radiology and american society of breast surgeons recommended nationwide deferment of mammography screening examinations. 3 weekly mammography volumes decreased by over 90% nationwide compared to pre-covid levels. 4, 5 consequently, the same spectrum of educational challenges broadly confronted by all radiology training programs were not only present but magnified for breast imaging. in turn, an understanding of the challenges, solutions, and opportunities encountered in breast imaging training may serve as a useful case study for radiology educators from all subspecialities. the accreditation council for graduate medical education (acgme) core competencies for diagnostic radiology can help guide educators in restructuring and reframing radiology training during this time of ongoing change and uncertainty. (table 1) 6 here, we reflect upon educational challenges and opportunities faced by our program during the covid-19 pandemic, which may serve as a case study for programs from all subspecialites. this discussion will be structured using the acgme core competencies framework to better help educators extend and adapt lessons learned to their own programs. we will explore in detail the challenges and opportunities for continued growth across the core comptency domains ( table 2 ). we will also discuss how systems and processes developed out of necessity during the first peak of the pandemic may continue to support radiology training during phased reopening and beyond. this core competency covers patient safety, quality assurance and improvement, and patient care coordination. the development and implementation of unprecedented measures to mitigate risk and maintain healthcare system capacity in the face of the pandemic provided our fellows with invaluable lessons, as they were central in implementation of risk mitigation measures. prior to the pandemic, our division readily accommodated five fellows and up to four residents. fellows and residents were assigned to a primary role each day including: screening mammography, diagnostic clinic (mammography/ultrasound), mri, biopsy/aspiration, needle localization, and second opinion consultation on outside facility imaging. trainees interpreted imaging studies, performed ultrasound examinations, drafted preliminary reports, and performed mammogram-, ultrasound-, and mri-guided procedures under attending supervision. readouts, attending review of cases after trainee evaluation, were performed in person with the attending and trainee seated next to each other. starting in march 2020, when the first cases of covid-19 were identified in our state, clinical schedules were promptly modified in response to deferment of screening mammography and mri examinations to respond to risk mitigation measures and declining volumes. in support of institutional guidelines to limit in-hospital personnel to those essential for clinical care, one attending and fellow were each assigned to work on-site each day. a reserve attending and fellow staff were also assigned each day, who could also cover clinical duties based on changes in clinical volumes until the peak of the pandemic. a step-wise process of incrementally increasing attending and fellow coverage was then enacted, as volumes began to increase following the peak of the pandemic. to support risk mitigation measures in the setting of low clinical volumes, residents previously scheduled for breast imaging rotations were placed into a residency-wide pool of offsite residents from march to june. these residents were taught through a comprehensive virtual curriculum covering topics across radiology managed by the residency leadership. while all senior residents had already fulfilled acgme breast imaging requirements prior to implementation of the virtual curriculum, the schedule for the next academic year (2020-2021) was constructed to ensure remaining junior residents fulfilled their required 12 weeks of clinical breast imaging rotations prior to graduation. to support physical distancing measures, the on-site fellow and attending were separated into different reading rooms and used telecommunication tools to review imaging together. telecommunication tools were also used to navigate patients throughout the clinic, while communicating with technologists and administrative staff. use of these resources also helped to eliminate the need to transfer paperwork between patients, physicians, and ancillary staff for all phases of care. fellows participated in the implementation of new clinical workflows designed to limit the number of personnel present for hand-held ultrasound exams and procedures to the absolute minimum necessary. for example, ultrasound-guided procedures previously involved a technologist operating the ultrasound unit, while the fellow performed the procedure under direct attending supervision. this was adjusted to require only the presence of a fellow and an attending. these workflows were efficient and feasible during our fellows last quarter of training before proceeding to independent practice. when communicating results or reviewing procedural issues in person, only one provider was present to further support risk mitigation measures. same day care was instituted for all examinations. biopsies and aspirations were performed on the same day as diagnostic imaging visits whenever possible to minimize the number of times patients traveled to the hospital. similarly, we collaborated with our surgical oncology colleagues to ensure patients who might benefit from a surgical consultation, including those with highly suspicious findings for malignancy, were evaluated by a breast surgeon on the same day as the imaging visit. our fellows were central in implementing these processes and coordinating patient care. finally, fellows gained experience through taking part in broader risk mitigation processes, including universal use of personal protective equipment and performance of mandatory daily covid-19 symptom attestations for on-site work. prior to the pandemic, all fellows participated in daily team huddles held in the diagnostic imaging clinic at 8:00 am, which were attended in-person by all in-house personnel that day including assistants, technologists, and practice managers. during this huddle, the team reviewed assigned clinical roles, diagnostic imaging and procedure schedules, and updates which may impact clinical workflow. to support physical distancing during the pandemic, this in-person daily huddle adopted a virtual format with a group videoconference at 8:00 am. these huddles assumed even greater importance, as they provided an opportunity to review and reinforce risk mitigation processes within the division and at the departmental and institutional level. off-site fellows and attendings joined virtually, to stay informed of daily clinical volumes, case types amid the pandemic, and important updates pertaining to divisional changes. over this period, fellows learned to prioritize, facilitate, and coordinate patient care via clear and effective telecommunication with their peers, attending radiologists, and technologists. with all parties using facemasks, fellows continued to hone their verbal communication skills by conveying results and recommendations to patients in an empathetic and comprehensible manner. role modeling of effective telecommunication by attending radiologists, as well as clear and frequent constructive feedback to trainees, also aided in enhancing trainees' interpersonal and communication skills. growth along this competency was heavily impacted by decreased volumes. as a result, only one to two fellows worked on-site every day amid the peak period of the pandemic. although off-site fellows could not directly participate in patient care, technological solutions were used to maximize their exposure to clinical cases and create a "remote" clinical learning environment. through use of our institutional vpn and application virtualization tools, off-site fellows could access our picture archiving and communication system (pacs), mammography information system, and electronic health record to review clinical cases encountered each day. fellows also had the opportunity to receive 4k ultra-high definition monitors from our department to supplement home workstations. monitors were used to review mammogram, ultrasound, and mri images for educational purposes. these monitors also allow off-site fellows to observe and participate in multidisciplinary conferences. interpretation from home workstations for clinical purposes was not performed since this would require workstations to meet mammography practice parameters, including testing by a medical physicist prior to clinical use 7 . to support continued training in screening mammography for our fellows, worklists on our pacs were created containing screening mammograms previously finalized over one year ago for fellows to interpret using clinical workstations when on-site. fellows were able to interpret studies blinded to final outcomes, simulating the experience of a real-world clinical setting and helping to augment the clinical volume. fellows were responsible for comparing their own personal assessment with the true clinical outcome, with on-site attending staff readily available to answer questions and discuss specific cases. this learning opportunity was also provided to residents, who could read screening exams from remote work stations. to maximize exposure to clinical cases for off-site fellows, the division continued daily 4:00 pm videoconferences, which were attended by all attendings and fellows. the on-site fellow led the conference under the supervision of the on-site attending. teaching points encountered over the course of the clinical day were presented. radiology-pathology concordance was then discussed for biopsy results completed each day. during these conferences, fellows reviewed clinical history, diagnostic work-up, biopsy images using pacs, and pathology results. radiology-pathology concordance was established through staff consensus. discussions focused on the rationale behind steps in management of complex cases, biopsy approaches (modality and techniques), and alternative options for technically challenging cases. time was allotted for fellows to ask questions about the diagnostic pathway and clinical management decision steps for each case. as previously mentioned, we minimized the number of personnel present in the room during procedures. the attending radiologist generally assumed operation of the ultrasound machine, while directly supervising the fellow during ultrasound procedures. this new workflow helped promote greater confidence and independent in decision making, and aided in strengthening procedural competence. continued advancement of our fellows within this core competency was supported by a redesigned virtual didactic conference schedule (table 3 ). prior to embarking on this new academic calendar, technological support was provided to all attendings and fellows to ensure the successful use of videoconference tools for these virtual conferences. previously scheduled weekly, hour-long faculty-led educational conferences on thursday afternoons continued. guest lecturers were invited from related specialties including genetics, breast surgery, and medical oncology to provide additional learning opportunities. fellows also presented on breast cancer related topics and led journal clubs to support peer-to-peer teaching and to promote self-learning while working remotely. in addition, the daily afternoon radiologypathology conference provided off-site fellows with continued exposure to clinically encountered cases, while also serving as informal didactic sessions. finally, all fellows could attend virtual multidisciplinary breast oncology clinics (which review patients with new cancer diagnoses) and breast oncology tumor board (which reviews patients with known cancer facing complex management questions), attended by breast surgery, breast oncology, radiation oncology, pathology, and breast imaging services. prior to the pandemic, only the fellow assigned to tumor board would be present to derive learning points from these sessions. switching to a videoconference format provided accessibility for all fellows including those working off-site. finally, breast imaging, faculty-led virtual resident educational lectures were also accessible via videoconferencing for our fellows. remote-work solutions allowed fellows to continue their work on quality improvement and research projects. during the peak months, fellows were provided the opportunity to prepare manuscripts for their accepted abstracts to annual conferences that had been canceled due to the pandemic. a centralized fellows' educational folder and reference library was created for educational presentations, in addition to journal club and research articles. as part of the residency-wide virtual education curriculum for off-site residents, attending physicians within the breast imaging division held live videoconference-based hourlong lectures on a weekly basis. a web-based mammography learning program developed by faculty within our division, was made available for residents to support remote learning. the program consisted of 35 case-based learning modules. each case module began with standard screening mammography images that trainees could interpret, answer case-based questions, and determine next steps in management. answers were provided to trainees immediately following completion of each module. scores were automatically stored and sent to educational leadership, which could be used to guide targeted feedback fellows continued to progress within this domain through continued participation in clinical work. in particular, temporary suspension of nonessential elective procedures during the pandemic necessitated alternative management approaches to breast cancer treatment. through their continued participation in daily multidisciplinary oncology conferences via videoconferencing, our fellows participated in complex decision-making processes involved in delivering appropriate cancer care during this period. furthmore, the process of adapting to rapid changes in clinical workflow and maintaining high-quality care delivery amid ongoing uncertainty, created new opportunities for self-reflection and insight into one's strengths and limitations. at its highest level, professionalism means identifying and addressing barriers to ethical care, taking ownership of healthcare system outcomes, and meeting high professional expectations. at our institution, as in others across the country and around the world, models of professional behavior in response to the covid-19 pandemic have been abundant. the fellows' consistent participation in weekly divisional planning meetings, as well as department/institution-wide town hall forums, allowed them to contribute to implementation of safe, high quality, and equitable care during a period of system-wide stress and uncertainty. the hospital and department provided resources to support emotional and physical health, with webinars and informational resources addressing topics ranging from managing parental challenges, particularly with regard to childhood education, to exercising in the era of covid-19. virtual group yoga, strength training, and home cooking session were also provided. these webinars and informational resources were made available for access at any time on hospital and departmental wellness websites, and the availability of these resources were widely broadcasted through daily and weekly emails. in addition, resources to support mental health during this period were widely distributed to all trainees. educational leadership within the division also scheduled regular check-in meetings and were readily available for discussions with the fellows, both collectively and individually, to help manage trainee anxiety and concerns. as we reflect on the changes that occurred within our academic breast imaging program during the height of the pandemic, it became apparent that new opportunities have arisen to support the continued growth of our trainees largely through maximizing the use of remote work and communications tools. the shift of multidisciplinary oncology conferences to a virtual format has expanded access of these rich learning opportunities to all fellows. in addition, the creation of fellow-led, peer-to-peer educational conferences have provided the chance for fellows to improve their teaching skills and allowed the division to include trainees both on-and offservice. through our phased reopening, these processes will be continued with incoming fellowship and resident classes, who have returned to on-site clinical rotations. simulated screening mammography worklists are still being used to support clinical education for all trainees. continued risk mitigation practices including paperless clinical workflow and same day care have helped our division to optimize our care delivery process, demonstrating to trainees innovative methods on how to improve patient care and workflow efficiency. finally, videoconferencing capabilities have also helped to support social and wellness activities, in addition to educational, clinical, and research activities. many of these changes will continue indefinitely, which will benefit trainees for years to come. coronavirus disease 2019 (covid-19) and radiology education-strategies for survival the impact of covid-19 on radiology trainees asbrs and acr joint statement on breast screening exams during the covid-19 pandemic preventive cancer screenings during covid-19 pandemic impact of the coronavirus disease 2019 (covid-19) pandemic on imaging case volumes the accreditation council for graduate medical education acr-aapm-siim practice parameter for determinants of image quality in digital mammography key: cord-003316-r5te5xob authors: balloux, francois; brønstad brynildsrud, ola; van dorp, lucy; shaw, liam p.; chen, hongbin; harris, kathryn a.; wang, hui; eldholm, vegard title: from theory to practice: translating whole-genome sequencing (wgs) into the clinic date: 2018-12-17 journal: trends microbiol doi: 10.1016/j.tim.2018.08.004 sha: doc_id: 3316 cord_uid: r5te5xob hospitals worldwide are facing an increasing incidence of hard-to-treat infections. limiting infections and providing patients with optimal drug regimens require timely strain identification as well as virulence and drug-resistance profiling. additionally, prophylactic interventions based on the identification of environmental sources of recurrent infections (e.g., contaminated sinks) and reconstruction of transmission chains (i.e., who infected whom) could help to reduce the incidence of nosocomial infections. wgs could hold the key to solving these issues. however, uptake in the clinic has been slow. some major scientific and logistical challenges need to be solved before wgs fulfils its potential in clinical microbial diagnostics. in this review we identify major bottlenecks that need to be resolved for wgs to routinely inform clinical intervention and discuss possible solutions. hospitals worldwide are facing an increasing incidence of hard-to-treat infections. limiting infections and providing patients with optimal drug regimens require timely strain identification as well as virulence and drug-resistance profiling. additionally, prophylactic interventions based on the identification of environmental sources of recurrent infections (e.g., contaminated sinks) and reconstruction of transmission chains (i.e., who infected whom) could help to reduce the incidence of nosocomial infections. wgs could hold the key to solving these issues. however, uptake in the clinic has been slow. some major scientific and logistical challenges need to be solved before wgs fulfils its potential in clinical microbial diagnostics. in this review we identify major bottlenecks that need to be resolved for wgs to routinely inform clinical intervention and discuss possible solutions. thanks to progress in high-throughput sequencing technologies over the last two decades, generating microbial genomes is now considered neither particularly challenging nor expensive. as a result, whole-genome sequencing (wgs) (see glossary) has been championed as the obvious and inevitable future of diagnostics in multiple reviews and opinion pieces dating back to 2010 [1] [2] [3] [4] . despite enthusiasm in the community, wgs diagnostics has not yet been widely adopted in clinical microbiology, which may seem at odds with the current suite of applications for which wgs has huge potential, and which are already widely used in the academic literature. common applications of wgs in diagnostic microbiology include isolate characterization, antimicrobial resistance (amr) profiling, and establishing the sources of recurrent infections and between-patient transmissions. all of these have obvious clinical relevance and provide case studies where wgs could, in principle, provide additional information and even replace the knowledge obtained through standard clinical microbiology techniques. this review reiterates the potential of wgs for clinical microbiology, but also its current limitations, and suggests possible solutions to some of the main bottlenecks to routine implementation. in particular, we argue that applying existing wgs pipelines developed for fundamental research is unlikely to produce the fast and robust tools required, and that new dedicated approaches are needed for wgs in the clinic. at the most basic level, wgs can be used to characterize a clinical isolate, informing on the likely species and/or subtype and allowing phylogenetic placement of a given sequence relative to an existing set of isolates. wgs-based strain identification gives a far superior resolution in principle, wgs can provide highly relevant information for clinical microbiology in near-real-time, from phenotype testing to tracking outbreaks. however, despite this promise, the uptake of wgs in the clinic has been limited to date, and future implementation is likely to be a slow process. the increasing information provided by wgs can cause conflict with traditional microbiological concepts and typing schemes. decreasing raw sequencing costs have not translated into decreasing total costs for bacterial genomes, which have stabilised. existing research pipelines are not suitable for the clinic, and bespoke clinical pipelines should be developed. compared to genetic marker-based approaches such as multilocus sequence typing (mlst) and can be used when standard techniques such as pulsed-field gel electrophoresis (pfge), variable-number tandem repeat (vntr) profiling, and maldi-tof are unable to accurately distinguish lineages [5] . wgs-informed strain identification could be of particular significance for bacteria with large accessory genomes, which encompass many of the clinically most problematic bacteria, where much of the relevant genetic diversity is driven by differences in the accessory genome on the chromosome and/or plasmid carriage. somewhat ironically, the extremely rich information of wgs data, with every genome being unique, generates problems of its own. clinical microbiology tends to rely on often largely ad hoc taxonomical nomenclature, such as biochemical serovars for salmonella enterica or mycobacterial interspersed repetitive units (mirus) for mycobacterium tuberculosis. while the rich information contained in wgs should in principle allow superseding traditional taxonomic classifications [6, 7] , defining an intuitive, meaningful and rigorous classification for genome sequences represents a major challenge. for strictly clonal species, which undergo no horizontal gene transfer (hgt), such as m. tuberculosis, it is possible to devise a 'natural' robust phylogenetically based classification [8] . unfortunately, organisms undergoing regular hgt, and with a significant accessory genome, do not fall neatly into existing classification schemes. in fact, it is even questionable whether a completely satisfactory classification scheme could be devised for such organisms, as classifications based on the core genome, accessory genome, housekeeping genes (mlst), genotypic markers, plasmid sequence, virulence factors or amr profile may all produce incompatible categories ( figure 1 ). beyond species identification and characterization, genome sequences provide a rich resource that can be exploited to predict the pathogen's phenotype. the main microbial traits of clinical relevance are amr and virulence, but may also include other traits such as the ability to form biofilms or survival in the environment. sequence-based drug profiling is one of the pillars of hiv treatment and has to be credited for the remarkable success of antiretroviral therapy (art) regimes. prediction of amr from sequence data has also received considerable attention for bacterial pathogens but has not led to comparable success at this stage. resistance against single drugs can be relatively straightforward to predict in some instances. for example, the presence of the sccmec cassette is a reliable predictor for broad-spectrum beta-lactam resistance in staphylococcus aureus, with strains carrying this element referred to as methicillin-resistant s. aureus (mrsa). in principle, wgs offers the possibility to predict the full resistance profile to multiple drugs (the 'resistome'). possibly the first real attempt to predict the resistome from wgs data was a study by holden et al. in 2013, showing that, for a large dataset of s. aureus st22 isolates, 98.8% of all phenotypic resistances could be explained by at least one previously documented amr element or mutation in the sequence data [9] . since then, several tools have been developed for the prediction of resistance profiles from wgs. these include those designed for prediction of resistance phenotype from acquired amr genes, including resfinder [10] and abricate (https://github.com/tseemann/abricate), together with those also taking into account point mutations in chromosome-borne genes such as arg-annot [11] , the sequence search tool for antimicrobial resistance (sstar) [12] , and the comprehensive antibiotic resistance database (card) [12] . of these, resfinder and card can be implemented as online methods that, dependent on user traffic, can be considerably slower than most other tools that only use the command-line. they are, however, superior in terms of broad usability and are more intuitive than, for example, the glossary accessory genome: the variable genome consisting of genes that are present only in some strains of a given species. many of the organisms representing the most severe amr threats are characterised by large accessory genomes containing important components of clinically relevant phenotypic diversity. antimicrobial resistance (amr): the ability of a microorganism to reproduce in the presence of a specific antimicrobial compound. also referred to as antibiotic resistance (abr or ar). the sum of the detected amr genes in a sequenced isolate is sometimes referred to as the resistome. horizontal gene tranfer (hgt): the transmission of genetic material laterally between organisms outside 'vertical' parent-to-offspring inheritance, including across species boundaries. genetic elements related to clinically relevant phenotypes such as amr and virulence are often transmitted via hgt. k-mer: a string of length k contained within a larger sequence. for example, the sequence 'attgt' contains two 4-mers: 'attg' and 'ttgt'. the analysis of the k-mer content of raw sequencing reads allows for rapid characterization of the genetic difference between isolates without the need for genome assembly. multilocus sequence typing (mlst): a scheme used to assign types to bacteria based on the alleles present at a defined set of chromosome-borne housekeeping genes. also referred to as sequence typing (st). phylogenetic tree: a representation of inferred evolutionary relationships based on the genetic differences between a set of sequences. also referred to as a phylogeny. transmission chain: the route of transmission of a pathogen between hosts during an outbreak. this can often be characterized using wgs compared to traditional epidemiological inference based on, for example, tracing contacts between patients. virulence: broadly, a pathogen's ability to cause damage to its host, for example through invasion, adhesion, immune evasion, and toxin production. however, virulence is currently loosely defined by indirect proxies either phenotypically (e.g., through serum-killing assays) or genetically (e.g., by the presence of genes involved in capsule synthesis or hypermucosvisity). whole-genome sequencing (wgs): the process of determining the complete nucleotide sequence of an organism's genome. this is generally achieved by 'shotgun' sequencing of short reads that are either assembled de novo or mapped onto a high-quality reference genome. graphical user interface of sstar. other tools exist for richer species-specific characterization such as phyresse [13] and patric-rast [14] . further tools have been developed to predict phenotype directly from unassembled sequencing reads, bypassing genome assembly [15, 16] . it has been proposed that wgs-based phenotyping might, in some instances, be equally, if not more, accurate than traditional phenotyping [16] [17] [18] [19] . however, it is probably no coincidence that the most successful applications to date have primarily been on m. tuberculosis and s. aureus, which are characterised by essentially no, or very limited, accessory genomes, respectively. other successful examples include streptococcal pathogens, where wgs-based predictions and measured phenotypic resistance show good agreement even in large and diverse samples of isolates [20, 21] . on the whole, however, predicting comprehensive amr profiles in organisms with open genomes, such as escherichia coli, where only 6% of genes are found in every single strain [22] , is challenging and requires extremely extensive and well curated reference databases. the transition to wgs might appear relatively straightforward if viewed as merely replacing pcr panels which are already used when traditional phenotyping can be cumbersome and unreliable. however, to put the problem in context, there are over 2000 described b-lactamase gene sequences responsible for multiresistance to b-lactam antibiotics such as penicillins, cephalosporins, and carbapenems [23] . whilst b-lactam resistance in some pathogens, including s. pneumoniae, can be predicted through, for example, penicillin-binding protein (pbp) typing and machine-learning-based approaches [24] , the general problem of reliably assigning resistance phenotype based on many described gene sequences is commonplace. at this stage, many of the amr reference databases are not well integrated or curated and have no minimum clinical standard. they often have varying predictive ranges and biases and produce fairly inaccessible output files with little guidance on how to interpret or utilise this information for clinical intervention. perhaps because of these limitations, although of obvious benefit as part of a diagnostics platform, both awareness and uptake in the clinic has been limited. additionally, with some notable exceptions, such as the pneumococci [24] , most amr profile predictions from wgs data are qualitative, simply predicting whether an isolate is expected to be resistant or susceptible against a compound despite amr generally being a continuous and often complex trait. the level of resistance of a strain to a drug can be affected by multiple epistatic amr elements or mutations [25] , the copy number variation of these elements [26] , the function of the genetic background of the strain [27-29], and modulating effects by the environment [30] . the level of resistance is generally well captured by the semiquantitative phenotypic measurement minimum inhibitory concentration (mic), even if clinicians often use a discrete interpretation of mics into resistant/susceptible based on fairly arbitrary cut-off values. quantitative resistance predictions are not just of academic interest. in the clinic, low-level resistance strains can still be treated with a given antibiotic but the standard dose should be increased, which can be the best option at hand, especially for drugs with low toxicity. the majority of efforts to predict phenotypes from bacterial genomes have been on amr profiling. yet, some tools have also been developed for multispecies virulence profiling: the virulence factors database (vfdb) [31] or virulencefinder [32] as well as the bespoke virulence prediction tool for klebsiella pneumoniae, kleborate [33] . one major challenge is that virulence is often a context-dependent trait. for example, in k. pneumoniae various imperfect proxies for virulence are used. these include capsule type, hypermucovisity, biofilm and siderophore production, or survival in serum-killing assays. while all of these traits are quantifiable and reproducible, and could thus in principle be predicted using wgs, it remains unclear how well they correlate with virulence in the patient. given that virulence is one of the most commonly studied phenotypes, yet lacks a clear definition, the general problem of predicting bacterial phenotype from genotype may be substantially more complex than the special case of amr, which is itself far from solved for all clinically relevant species. beyond phenotype prediction for individual isolates, wgs has allowed reconstructing outbreaks within hospitals and the community across a diversity of taxa ranging from carbapenemresistant k. pneumoniae [34] [35] [36] and acinetobacter baumannii [37] to mrsa [38, 39] , streptococcal disease [40] , and neisseria gonorrhoea [41] , amongst others. wgs can reveal which isolates are part of an outbreak lineage and, by integrating epidemiological data with phylogenetic information, detect direct probable transmission events [42] [43] [44] [45] . timed phylogenies, for example generated through beast [46, 47] , can provide likely time-windows on inferred transmissions, as well as dating when an outbreak lineage may have started to expand. approaches based on transmission chains can also be used to identify sources of recurrent infections (so called 'super-spreaders'), and do not necessarily rely on all isolates within the outbreak having been sequenced, allowing for partial sampling and analyses of ongoing outbreaks [48] . in this way wgs-based inference can elucidate patterns of infection which are impossible to recapitulate from standard sequence typing alone [35] . however, wgs-informed outbreak tracking is usually performed only retrospectively. typically, the publication dates of academic literature relating to outbreak reconstruction lag greatly, often in the order of at least 5 years since the initial identification of an outbreak [49, 50] . even analyses published more rapidly are generally still too slow to inform on real-time interventions [38] . some attempts have been made to show that near-real-time hospital outbreak reconstruction is feasible retrospectively [51, 52] or have performed analyses for ongoing outbreaks in close to real-time [53, 54] , but these studies are still in a minority and remain largely within the academic literature. some of this time-lag probably relates to the difficulty of transmission-chain reconstruction at actionable time-scales. this can be relatively straightforward for viruses with high mutation rates, small genomes, and fast and constant transmission times, such as ebola [55] and zika virus [56] , but conversely, reconstructing outbreaks for bacteria and fungi poses a series of challenges. available tools tend to be sophisticated and complex to implement, and the sequence data needs extremely careful quality control and curation. unfortunately, in some cases insufficient genetic variation will have accumulated over the course of an outbreak, and a transmission chain simply cannot be inferred without this signal [57, 58] . furthermore, extensive within-host genetic diversity (typical in chronic infections) can render the inference of transmission chains intractable [59] . these complexities mean that a 'one-size fits all' bioinformatics approach to outbreak analyses simply does not exist. one of the key promises of wgs is in molecular surveillance and real-time tracking of infectious disease. this relies on transparent and standardized data sharing of the millions of genomes sequenced each year, together with accompanying metadata on isolation host, date of sampling, and geographic location. with enough data, surveillance initiatives have the potential to identify the likely geographic origin of emerging pathogens and amr genes, group seemingly unrelated cases into outbreaks, and clearly identify when sequences are divergent from other circulating strains. in a hospital setting, surveillance can help to detect transmission within the hospital and inflow from the community, optimize antimicrobial stewardship, and inform treatment decisions; at national and global scales, it can highlight worldwide emerging trends for which collated evidence can direct both retrospective but also anticipatory policy decisions. amongst the most successful global surveillance initiatives and analytical frameworks are those relating specifically to the spread of viruses. influenza surveillance is arguably the most developed, with large sequencing repositories such as the gisaid database (gisaid.org) and online data exploration and phylodynamics available through web tools such as nextflu [60] and nextstrain (http://nextstrain.org), which also allows examination of other significant viruses including zika, ebola, and avian influenza. another popular tool for the sharing of data and visualization of phylogenetic trees and their accompanying meta-data is microreact (microreact.org) [61] , which also allows for interactive data querying and includes bacteria and fungi. a further tool, predominately for bacterial data, is wgsa (www.wgsa.net). wgsa allows the upload of genome assemblies through a drag-and-drop web browser, allowing for a quick characterization of species, mlst type, resistance profile, and phylogenetic placement in the context of the existing species database based on core genes. at the time of writing wgsa comprises 20 649 genomes predominantly from s. aureus, n. gonorrhoeae, and salmonella enterica serovar typhi, together with ebola and zika viruses, all with some associated metadata. although an exciting initiative, wgsa and associated platforms are still a reasonably long way off characterizing all clinically relevant isolates and often rely entirely on the sequences uploaded already being assembled. more generally, the success of any wgs surveillance is dependent on the timely and open sharing of information from around the globe. while sequence data from academic publications is near systematically deposited on public sequence databases (at least upon publication), such data are near useless if the accompanying metadata (see above) are not also released, as remains the case far too often. additionally, as more genomes are routinely sequenced in clinical settings as part of standard procedures, ensuring that the culture of sharing sequence data persists beyond academic research will become increasingly important. for wgs to be routinely adopted in clinical microbiology, it needs to be cost-effective. it is commonly accepted that sequencing costs are plummeting with the national human genome research institute (nhgri) estimating the cost per raw megabase (mb) of dna sequence to 0.12 usd (www.genome.gov/sequencingcostsdata). this has led to claims that a draft bacterial genome can currently cost less than 1 usd to generate [62] . this is a misunderstanding as one cannot simply extrapolate the cost of a bacterial genome by multiplying a highthroughput per dna megabase (mb) sequencing cost by the size of its genome. for microbial sequencing, multiple samples must be multiplexed for cost efficiency, which is easier to achieve in large reference laboratories with high sample turnover. excluding indirect costs such as salaries for personnel, preparation of sequencing libraries now makes up the major fraction of microbial sequencing costs ( figure 2 ). the precipitous drop in the cost of producing raw dna sequences in recent years (figure 2a ) mostly reflects a massive increase in output with new iterations of illumina production machines. these numbers ignore all other costs and simply reflect output relative to the cost of the sequencing kits/cartridges. realistic cost estimates for a microbial genome including library preparation on the best available platforms give a different picture ( figure 2b ). since the introduction of the illumina miseq platform in 2011, new sequencing kits generating higher output have only marginally affected true microbial genome sequencing costs, as library preparation makes up a significant portion of the total (60 usd of a total of 74 usd for a typical bacterial genome in 2018). these costs have remained stable over time and are unlikely to go down significantly in the near future. indeed, the market seems to be consolidating in fewer hands (e.g., represented by the procurement of kapa by roche in 2015), which economic theory predicts will not favor price decrease. it is also important to keep in mind that these costs are massive underestimates which do not include indirect costs such as salaries for laboratory personnel and downstream bioinformatics. such indirect costs are difficult to estimate precisely in an academic setting but are far from trivial. per-genome sequencing and analysis costs are likely to be even higher in a clinical diagnostics environment due to the need for highly standardised and accredited procedures. however, a micro-costing analysis covering laboratory and personnel costs estimated the cost of clinical wgs to £481 per m. tuberculosis isolate versus £518 applying standard methods, representing relatively marginal cost savings but with significant time savings [63] . wgs does indeed represent a potentially cost-effective and highly informative tool for clinical diagnostics, but for microbiology-scale sequencing we seem to be in a post-plummeting-costs age. one key feature of useful diagnostics tools is their ability to rapidly inform treatment. most applications of wgs so far have been for lab-cultured organisms (bacteria and fungi). traditional culture methods require long turnaround time, with most bacterial cultures taking 1-5 days, fungal cultures 7-30 days, and mycobacterial cultures up to 14-60 days. in this scenario, wgs is used as an adjunct technology primarily to provide information on the presence of amr and virulence genes, which is particularly useful for mechanisms that are difficult to determine phenotypically (e.g. carbapenem resistance). this use of wgs, whilst solving some of the current clinical problems, does not speed up the diagnosis of infection; it is more the case that new technology is replacing some of the more cumbersome laboratory techniques whilst providing additional information. wgs is more appealing as a microbiological fast diagnostics solution when combined with procedures that circumvent (or shorten) the traditional culture step. this can be achieved through direct sampling of clinical material (box 1) or by using a protocol enriching for sequences of specific organism(s). such enrichment methods, generally based on the capture of known sequences though hybridization, are a particularly tractable approach for viruses due to their small genome size. for example, the vircap virome capture method targets all known viruses and can even enrich for novel sequences [64] . similar methods targeting specific organisms have been developed and successfully deployed, representing an attractive option for unculturable organisms [16, [65] [66] [67] [68] . relative to the time required for culture and downstream analysis of the data, variation in the speed of different sequencing technologies is relatively modest. there is considerable enthusiasm for the oxford nanopore technology (ont) which outputs data in real time, although the ont requires a comparable amount of time to the popular illumina miseq sequencer to generate the same volume of sequence data. sequencing on the miseq sequencer takes between 13 to 56 hours, but as run time correlates with sequence output and read length, researchers tend to systematically favour runs of longer duration. in the context of this review, genetic material from the human patient present in clinical samples represents contamination, a major obstacle to obtaining a high yield of microbial dna. protocols exist to deplete human dna prior to sequencing [69, 70] but these are not completely problem-free as the depletion protocol is likely to bias estimates of the microbial community, and some human reads will likely remain. in particular, levels of human dna are significantly higher in faecal samples from hospitalized patients compared to healthy controls [71] , box 1. wgs beyond single genomes wgs in the strict sense usually refers to sequencing the genome of a single organism, and it is common to distinguish between the sample (the material that has actually been taken from the patient) and the isolate (an organism that has been cultured and isolated from that sample). wgs methods traditionally sequence a cultured isolate to reduce contamination from other organisms, or sometimes rely on enrichment strategies targeting sequences from a specific organism [66, 67] . however, this represents only a small fraction of the total microbial diversity present in a clinical sample. in contrast, metagenomic approaches sequence samples in an untargeted way. this approach is particularly relevant for clinical scenarios where the pathogen of interest cannot be predicted and/or is fastidious (i.e., has complex culturing requirements). example applications of clinical metagenomics include: when the disease causing agent is unexpected [74, 75] ; investigating the spread of amr-carrying plasmids across species [35] ; and characterizing the natural history of the microbiome [76] . the removal of the culture requirement can drastically decrease turn-around time from sample to data and enable identification of both rare and novel pathogens. different samples however present different challenges. easy-to-collect sample sites (e.g., faeces and sputum) typically also have a resident microbiota, so it can be challenging to distinguish the etiological agent of disease from colonizing microbes. conversely, sites that are usually sterile (e.g., cerebrospinal fluid, pleural fluid) present a much better opportunity for metagenomics to contribute to clinical care. metagenomic data are more complex to analyze than single species wgs data and tend to rely on sophisticated computational tools, such as the desman software allowing inference of strain-level variation in a metagenomic sample [77] . such approaches can be difficult to implement, are computationally very demanding, and are unlikely to be deployable in clinical microbiology in the near future, although cloud-based platforms may circumvent the need for computational resources in diagnostic laboratories. furthermore, some faster approaches for rapid strain characterization from raw sequence reads, such as mash [78] and kmerfinder [10, 79] , could find a use in diagnostics microbiology, with the latter having been shown to identify the presence of pathogenic strains even in culture-negative samples [10] . however, the differences between these methods should not obscure their fundamental similarities. obtaining singlespecies genomes from culture is one end of a continuum of methods that stretches all the way to full-blown metagenomics of a sample. in principle, all methods produce the same kind of data: strings of bases. furthermore, in all cases what is clinically relevant represents only a small fraction of these data. integrating sequencing data from different methods into a single diagnostics pipeline is therefore an attractive prospect to quickly identify the genomic needles in the metagenomic haystack in a species-agnostic manner. for example, the presence of a particular antibiotic-resistance gene in sequencing data may recommend against the use of that antibiotic; whether the gene is present in data from a single-species isolate or from metagenomes is irrelevant. as an example, leggett et al. used minion metagenomic profiling to identify pathogen-specific amr genes present in a faecal sample from a critically ill infant all within 5 h of taking the initial sample [80] . suggesting that the problem is exacerbated in clinical settings. therefore, the ethical and legal issues raised by introducing human wgs into routine healthcare [72] cannot be avoided by microbially focused clinical metagenomics. dismissing these concerns as minor may be an option for academic researchers uninterested in these human data, but it is naive to think that hospital ethics committees will share this view. even in the absence of human dna, metagenomic samples from multiple body sites can be used to identify individuals in datasets of hundreds of people [73] . managing clinical metagenomics data in light of these concerns should be taken seriously, not only as a barrier to implementation but because of the real risks to patient privacy. a major problem in the analysis of wgs data is that there are currently very few (if any) accepted gold standards. the fundamental steps of wgs analyses in microbial genomics tend to be similar across applications and usually consist of the following steps: sequence data quality control; identification/confirmation of the sequenced biological material; characterization of the sequenced isolate (including typing efforts as well as characterization of virulence factors and putative amr elements/mutations); epidemiologic analysis; and finally, storage of the results ( figure 3 ). however, how these analyses are implemented varies widely, both between microbial species and human labs. despite some commercial attempts at one-stop analysis suites such as ridom seqsphere+ (http://www.ridom.com/seqsphere/), most laboratories use a collection of open-source tools to perform particular subanalyses. typically, these tools are then woven together into a patchwork of software (a 'pipeline'). the idea of a pipeline is to allow within-laboratory standardized analysis of batches of isolates with relatively little manual bioinformatics work. such pipelines can be highly customizable for a wide range of questions. there are also some communal efforts at streamlining workflows across laboratories. as an example, galaxy (https://usegalaxy.org) is a framework that allows nonbioinformaticians to use a wide array of bioinformatics tools through a web interface. one major limitation to rapidly attaining useful information in a clinical setting is that analysis pipelines for microbial genomics have generally been developed for fundamental research or public health epidemiology [81] . this usually means that the pipeline permits a very thorough and sophisticated workflow with a large number of options and moving parts. for example, at the time of writing (may, 2018), the 'qc and manipulation' step in galaxy alone consists of 35 different tools, tests, and workflows that can be applied to an input sequence. while this is desirable from a researcher's perspective, it is clearly prohibitive for real-time analysis in a clinical setting. a user requires in-depth knowledge about the purpose each tool serves, the relative strengths and weaknesses of each approach, and a functional understanding of the important parameters. furthermore, most analysis pipelines require proficiency in linux systems and navigating the command line, something clinical microbiologists are rarely trained for. the road to stringent, exhaustive analysis of wgs data is long and paved with good intentions. in order to move towards real-time interpretable results for clinics it will be necessary to take certain shortcuts. the focus should be on rapid, automated analysis and clear, unambiguous results. some steps in the pipeline can simply be omitted for clinical purposes. as an example, genome assembly might appear to be a bottleneck for real-time wgs diagnostics, but is probably rarely required; sufficient characterization of an isolate can be made by analysis of the k-mers in the raw sequence data, which is orders of magnitude faster. accurate identification of an isolate can be made rapidly with minhash-based k-mer matching methods such as mash [78] , and amr elements can be identified from k-mers alone [14] . another example of a computationally intensive step that could be omitted from a default pipeline is sophisticated phylogenetic inference. best practice for the creation of phylogenetic trees may involve evaluating the individual likelihood of a very wide range of possible trees given a sequence alignment or other distance metric, repeated for thousands of bootstrapped replicates, giving a tree with high confidence but with extreme computational time costs. a clinical pipeline could use much faster approaches and still provide an informative phylogenetic tree [82] . in figure 3 we outline our schematic vision of a computational pipeline specific to diagnostics in clinical microbiology. the clinical pipeline would only encompass a small subset of the research pipeline aimed at generating rapid and interpretable output. for epidemiological inference, pairwise distances between strains would be computed as a matrix of jaccard distances on the shared proportion of k-mers as outputted by mash [78] . this matrix could be used to generate a phylogenetic tree using a computationally inexpensive method (e.g., neighbor-joining). additionally, a correlation between pairwise genetic distance and sampling date could be performed steps on the right marked with an asterisk represent simplified versions optimised for speed. cgmlst, core genome multilocus sequence typing; snp, single-nucleotide polymorphism; wgmlst, whole genome multilocus sequence typing. to test for evidence of temporal signal in the data (i.e., accumulation of a sufficient number of mutations over the sampling period). in the presence of temporal signal, the user would be provided with a transmission chain based on a fast algorithm such as seqtrack [83] . any bespoke pipeline for clinical diagnostics would need to be linked with regularly updated multispecies databases containing information about the latest developments in typing schemes, as well as clinically important factors such as amr determinants. results would have to be continuously validated, and international accreditation standards met at regular intervals. at a national level, accreditation bodies (e.g., ukas in the uk) may lack the expertise required. in our experience, many promising databases have collapsed after funding expired or the responsible postdoc left for another job. if wgs is ever to make it into the clinic it will be necessary to secure indefinite funding of both infrastructure and personnel for such databases. the lack of uptake of wgs-based diagnostics may also be in part due to an understandable desire to maintain the 'status quo' in a busy hospital environment with already established treatment and intervention systems. additionally, and perhaps significantly, it also highlights the difficulty to communicate the potential benefits of wgs to the day-to-day life of a clinic. the main proponents of wgs tend to be based in the public health/research environment and are rarely actively involved in clinical decision-making. this in itself can present something of a language barrier, challenging meaningful dialogue over how adoption of new approaches can lead to quantifiable improvements in existing systems. further, the physical planning, implementation and integration of wgs diagnostics may be unlikely to succeed without carefully planned introduction and continued training of its user base. this is of course challenged by the already resource-limited infrastructure of many clinical settings. despite its immense promise and some early successes, it is difficult to predict if and when wgs will completely supersede current standards in clinical microbiology. there are several major bottlenecks to its implementation as a routine approach to diagnose and characterise microbial infections (see outstanding questions). these include, among others: the current costs of wgs, which remain far from negligible despite a common belief that sequencing costs have plummeted; a lack of training in, and possible cultural resistance to, bioinformatics among clinical microbiologists; a lack of the necessary computational infrastructure in most hospitals; the inadequacy of existing reference microbial genomics databases necessary for reliable amr and virulence profiling; and the difficulty of setting up effective, standardized, and accredited bioinformatics protocols. focusing in the near future on wgs applications that fulfil unmet diagnostic needs and demonstrate clear benefits to patients and healthcare professionals will help to drive the cultural changes required for the transition to wgs in clinical microbiology. however, irrespective of how this transition occurs and how complete it is, it is likely to feel highly disruptive for many clinical microbiologists. there is also a genuine risk that precious knowledge in basic microbiology will be lost after the transition to wgs, particularly if investment prioritises new technology at the expense of older expertise. more positively, irrespective of the future implementation of wgs in clinical microbiology, we should not forget that the availability of extensive genomic data has been instrumental in the development of a multitude of routine non-wgs typing schemes. efforts to develop wgs-based microbial diagnostics have unsurprisingly focused on highresource settings. though, we can see an opportunity for low-/medium-income countries to outstanding questions can wgs be used to develop robust classification schemes that account for the genetic diversity of organisms with open genomes? which clinically relevant phenotypes can be reliably predicted using wgs, and for which organisms? how can phylogenetic analyses of outbreaks be speeded up to meaningfully contribute to infection control at actionable time scales? how can publicly available databases be reliably maintained to the required clinical accreditation standards over long time periods? will the true cost of generating a bacterial genome remain stable as the sequencing market consolidates in fewer hands? how can clinical metagenomic data be managed safely in line with the ethical considerations applicable to identifiable human dna? how can unwieldy bioinformatics pipelines developed with academic research in mind be adapted for a clinical setting? can current expertise in traditional clinical microbiology be maintained in the transition to wgs? get up to speed with the latest wgs-based developments in real-time clinical diagnostics, rather than adopting classical microbiological phenotyping which might eventually be largely phased out in high-income countries. one precedent for the successful adoption of a technology without transitions through its acknowledged historical predecessors is the widespread use of mobile phones in africa. this has greatly increased communication and allowed access to e-banking, despite the fact that many people previously had no traditional bank account and only limited access to landlines. most hospitals in the developing world do not currently benefit from a clinical microbiology laboratory. the installation of a molecular laboratory based around a standard sequencer, such as a benchtop miseq, might constitute an ideal investment, as it is neither far more expensive nor more complex than setting up a standard clinical microbiology laboratory. high-throughput sequencing and clinical microbiology: progress, opportunities and challenges transforming clinical microbiology with bacterial genome sequencing routine use of microbial whole genome sequencing in diagnostic and 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in immunocompromised patients human coronavirus oc43 associated with fatal encephalitis natural history of the infant gut microbiome and impact of antibiotic treatment on bacterial strain diversity and stability desman: a new tool for de novo extraction of strains from metagenomes mash: fast genome and metagenome distance estimation using minhash rapid whole-genome sequencing for detection and characterization of microorganisms directly from clinical samples rapid minion metagenomic profiling of the preterm infant gut microbiota to aid in pathogen diagnostics whole genome sequencing in clinical and public health microbiology evaluation of phylogenetic reconstruction methods using bacterial whole genomes: a simulation based study reconstructing disease outbreaks from genetic data: a graph approach we are grateful to nadia debech and jan oksens for their help with digging up historic pricing information for sequencing key: cord-310027-846vp7ii authors: ma, lin-lu; yin, xuan; li, bing-hui; yang, jia-yu; jin, ying-hui; huang, di; deng, tong; wang, yun-yun; ren, xue-qun; ji, jianguang; zeng, xian-tao title: coronavirus disease 2019 related clinical studies: a cross-sectional analysis date: 2020-09-02 journal: front pharmacol doi: 10.3389/fphar.2020.540187 sha: doc_id: 310027 cord_uid: 846vp7ii objective: the quality and rationality of many recently registered clinical studies related to coronavirus disease 2019 (covid-19) needs to be assessed. hence, this study aims to evaluate the current status of covid-19 related registered clinical trial. methods: we did an electronic search of covid-19 related clinical studies registered between december 1, 2019 and february 21, 2020 (updated to may 28, 2020) from the clinicaltrials.gov, and collected registration information, study details, recruitment status, characteristics of the subjects, and relevant information about the trial implementation process. results: a total of 1,706 studies were included 10.0% of which (n=171) were from france, 943 (55.3%) used an interventional design, and 600 (35.2%) used an observational design. most of studies (73.6%) aimed to recruit fewer than 500 people. interferon was the main prevention program, and antiviral drugs were the main treatment program. hydroxychloroquine and chloroquine (230/943, 24.4%) were widely studied. some registered clinical trials are incomplete in content, and 37.4% of the 1,706 studies may have had insufficient sample size. conclusion: the quality of covid-19 related studies needs to be improved by strengthening the registration process and improving the quality of clinical study protocols so that these clinical studies can provide high-quality clinical evidence related to covid-19. introduction covid-19, which broke out at the beginning of 2020, has spread rapidly (zhou p. et al., 2020) . its clinical manifestations are very similar to severe acute respiratory syndrome (sars). in severe cases, patients may go on to develop acute respiratory distress syndrome (ards). patients with severe covid-19 need intensive care to decrease mortality . as of july 13, 2020, there have been more than 12.8 million confirmed cases and 568,000 deaths globally (johns hopkins university, 2020) . covid-19 is an emerging infectious disease for which, there is no specific treatment to date. healthcare professionals have only been able to alleviate patients' symptoms based on their experience as up to now they have had insufficient knowledge of this disease. hence, randomized clinical trials (rcts) are necessary to verify the safety and effectiveness of the proposed drugs. many scientists and clinicians have conducted clinical investigations, diagnostic accuracy tests, and treatment evaluations to understand the progress of covid-19 and to improve clinical diagnosis and treatment. it is thus essential to evaluate the rationality and the potential value of proposed clinical trials because so many studies have emerged in such a short period and some of them might lack scientific value. therefore, we performed this survey in order to have a comprehensive understanding of the current clinical trials related to covid-19. this study analyzed the characteristics of the clinical studies of covid-19 registered in clinicaltrials.gov (https://clinicaltrials. gov/) between december 1, 2019 and february 21, 2020 (updated to may 28, 2020). all covid-19 related studies, including etiology, risk factors, prevention, diagnosis, treatment, prognosis, and psychology were included. the search terms were: 2019-ncov, 2019 novel coronavirus, novel coronavirus pneumonia, covid-19, coronavirus disease 2019, sars-cov-2. we extracted the following information from registered studies: registration number, registration date, registration title, primary sponsor, funding source, study type, study phase, study objectives, study design, length of the study, intervention, countries of recruitment and research settings, recruiting status, allocation, sample size, participant age, gender, masking, the time and method of sharing individual participant data (ipd), data management committee. descriptive statistics were used to summarize the characteristics of all included clinical studies. categorical variables were expressed as percentages and frequencies. all data were summarized using microsoft excel 2019. a total of 1,706 studies were included. among these clinical studies (table 1) , the first one was registered on january 23, 2020, and the number of trials registered daily subsequently increased, peaking at 51 in a single day (figure 1 ). for the total study period, 73.8% studies (n = 1259) planned to continue for less than 12 months and 25.1% more than 12 months. of them, 943 (55.3%) used an interventional design and 600 (35.2%) used an observational design. as for the recruitment status, 82 (4.8%) studies had completed recruitment, 922 (54.0%) were recruiting, and 683 (40.0%) had not yet started recruiting, while some others were terminated/withdrawn (n = 12, 0.7%) or suspended (n = 7, 0.4%). for sample sizes, most of them (n = 1255, 73.6%) aimed to recruit less than 500 participants, 6.5% (n = 111) recruited 100 to 499 participants, 18.9% recruited more than 1,000, and 1.1% (n = 18) studies did not specify the number of participants recruited. almost all studies recruited both males and females (n = 1662, 97.4%), 83.1% studies (n = 1417) included adults and only 16.9% (n = 289) involved children. among the 943 interventional studies, the primary purpose was treatment of the disease (n = 714, 75.7%). seven hundred eightyone (82.8%) were designed with at least two groups, most commonly parallel assignment (n = 717, 76.0%). seven hundred twenty (76.4%) were randomized and 78 (8.3%) were non-randomized. more than 56.2% studies (n = 530) were open label, and only 33.0% being double, triple, or quad-masked. as for the 600 observational studies, 376 (62.7%) were cohort studies, and 377 (62.8%) were prospective design. for the 145 diagnostic studies, 32 studies (22.1%) focused on imaging studies, 36 studies (24.8%) focused on nucleic acid detection, and 15 studies (10.3%) focused on specific antibody. details are shown in table 2 . of the 1,706 studies, 1,200 (70.3%) were initiated by researchers from hospitals, universities, or scientific research institutions; whereas a few (9.8%) were initiated by companies, and 338 (19.8%) were funded by others, such as individuals or community-based organizations. the highest number of studies were conducted in france (n = 171, 10.0%) and the second highest in the united states (n = 108, 6.3%). of the 1,706 studies, only 33 studies (1.9%) were funded by national institutes of health (nih) or u.s. federal agencies, 255 (14.9%) were funded by pharmaceutical or device companies, and 83.1% were funded by others, such as individuals, universities, or community-based organizations. six hundred ten (35.8%) clearly reported the existence of a data monitoring committee, and 192 (11.3%) had ipd sharing statement. details are shown in table 3 . among the 943 interventional studies, 416 studies (44.1%) explored the effectiveness and/or safety of drugs commonly used in preventing and treating covid-19, such as hydroxychloroquine (hcq), chloroquine (cq), immunotherapy (including stem cell therapy, monoclonal antibody, immunoregulation), lopinavir/ritonavir, glucocorticoids, interferon, targeted therapy (baricitinib, ruxolitinib, imatinib), favipiravir, and remdesivir. in addition, 66 studies (7.0%) focused on convalescent plasma. other interventions, such as dietary supplements, devices and behavioral programs, accounted for 48.9%. details are shown in table 4 . the covid-19 epidemic is still raging around the world. exploring the characteristics of registered clinical studies related to covid-19 and clarifying the direction of further research can help reduce the potential disease burden of covid-19 (gupta et al., 2020) . there was a cross-sectional study that reviewed the drug and plasma registration trials in march 2020, characterizing the scope, objectives and content of clinical studies . with the rapid increase in registration research, the status of registration studies may also change. this survey conducted a comprehensive summary of covid-19 related studies registered in the clinicaltrials.gov as of may 28, 2020. results showed that most studies with an interventional design were aimed at adult participants, and were conducted using multicenter, randomized, parallel assignments, and open-label methods. a systematic review showed that compared with adults, children with covid-19 have a milder disease course, with better prognosis and extremely low mortality (ludvigsson, 2020) . as a result, only 16.9% of registered studies involved children. as a factor of disease outcomes (hou et al., 2019) , only 2.5% studies focus on the participants' gender. the included clinical studies involved disease prevention, diagnostic accuracy, drug treatment, medical devices, prognosis, as well as treatment of critical covid-19. a number of these studies (n=638, 37.4%) may have had insufficient sample size. registration of covid-19 related clinical studies is ongoing. the underlying methodological quality limitations of these clinical studies should be noted, such as lack of control group, insufficient sample size, or non-randomization, which might preclude drawing concrete conclusions (bauchner and fontanarosa, 2020; ma et al., 2020) . our results found that nearly half of the registered trials did not exceed 6 months, and 37.4% of the registered trials recruited less than 100 people. the inclusion of less than 100 people does not automatically indicate that the study results are unreliable. different studies need to estimate sample size according to outcomes. more studies are needed which use samples based on the estimated sample size. insufficient or under-estimated sample size is a major shortcoming of the current clinical trials, which can cause false negative or false positive results, reduce credibility, and even have catastrophic consequences (ruberg and akacha, 2017) . therefore, although some studies had reported that some interventions may shorten intubation time, hospitalization time or reduce mortality; these findings did not represent the actual therapeutic effect of the drug (gautret et al., 2020) . the outbreak of the epidemic may pressurize researchers to quickly find targeted therapeutic drugs which are effective in the short term. however, if the length of the study was too short, it might preclude carrying out multiple follow-ups on the patients, and the long-term effect index of drug treatment cannot be obtained. our results found that of the intervention study 82.8% of the registered trials were designed for at least two groups, 76.4% were assigned randomly, 56.2% were open label, and 75.7% were mainly for treatment. of the observational studies, most utilized cohorts (62.7%) and prospective (62.8%) designs. randomization can largely avoid confusion and reduce selection bias in treatment comparison (sessler and imrey, 2015). however, rcts often require large sample size, long research duration, incur high costs and may also be difficult to implement. at this time, adaptive trial design can usually be adopted (bhatt and mehta, 2016) . however, it should be noted that observational research will be accompanied by some biases and limitations, and it is necessary to interpret the test results carefully (shang et al., 2020) . besides, some of these studies did not have a control group or lack a real "control", which will limit the effective inferences that can be drawn. there is a need for rigorous design and attention to trial protocols for research drug management to discover the true efficacy of interventions (bauchner and fontanarosa, 2020) . more and more researchers realize that clinical trials need to be registered before the recruitment, and registration is beneficial for sharing clinical trial information and reducing publication bias (aslam et al., 2013) . it is understandable that clinical trials must be launched and implemented quickly due to the sudden covid-19 epidemic; however, a properly designed clinical trial is still the core to provide scientific evidence and achieve clinical conclusions. randomized controlled trials are considered to be the highest quality clinical research methods, and random sequence generation, blinding, and allocation concealment during the implementation of the study are critical to the success of the study (schulz and grimes, 2002b; schulz and grimes, 2002a; sessler and imrey, 2015) . it is thus essential for clinical trials to be designed by a professional team to meet the requirements of a successful study before registration. an appropriate research design should be selected according to the research purpose, with sample size being estimated in advance, and timely submission of the research plan to the ethical committee to avoid deficiencies. at the time of registration, the person responsible for the registration should have a comprehensive understanding of the characteristics of the study protocol and clinical trial, so as not to cause confusion to other researchers due to the ambiguity of registration content, such as countries of location, presence or absence of data monitoring committee. we found some registered clinical trials have incomplete content. therefore, clinical trial registration agencies should strengthen supervision of trial registration. after the study completion, collation and strict statistical analysis the researchers should upload the resulting data to the registration agency in a timely manner (goldacre, 2017) . ipd sharing helps to accelerate the conversion of clinical resources and promote scientific breakthroughs. hence, we call on researchers to share ipd to promote transparency, so that effective conclusions drawn from trials can be quickly applied to control the epidemic, and to provide a basis for covid-19 prevention and treatment. covid-19 is a new infectious disease, which has affected health insurance (gheorghe et al., 2019) , and its underlying mechanisms of transmission and pathogenesis are still being explored. high quality clinical studies are the basis of clinical practice guidelines, especially who's emergency guidelines (norris et al., 2019) . some clinical trials focus on the prevention of covid-19. it is widely believed that sars-cov-2 is transmitted through respiratory droplets and by close contact . earlier studies have shown that masks are very effective for filtering influenza viruses (zhou et al., 2018) . however, there are no clinical study results that can prove that wearing masks can prevent covid-19. a study has analyzed the pandemic trends and mitigation measures of covid-19 in wuhan, china, italy, and new york city. results showed that the difference between with and without facial masks represents the determinant of pandemic trends in the three epicenters. the authors thought that wearing a mask is the most effective way to prevent interpersonal transmission in public places . in hospitals, healthcare professionals are at greater risk of exposure to sars-cov-2 than public. a multicenter rct (registration number: nct04296643) from canada is expected to recruit 576 nurses to compare and analyze the preventive effects of medical masks with n95 respirators on covid-19. in addition, some clinical studies have focused on the preventive effects of drugs for covid-19, such as cq and hcq. chloroquine and hydroxychloroquine are both antimalarial drugs, and the mechanism of preventing and treating covid-19 is not yet clear. some researchers thought cq and hcq may confer antiviral effect at the pre-infection stages (zhou d. et al., 2020) . however, the possible cardiac side effects caused by the combination of cq or hcq and az, such as prolonged qt interval must be considered. hence, clinical studies are needed to confirm the preventive effect of cq or hcq on covid-19 (registration number: nct04303507, nct04334148). an accurate diagnosis is the fundamental prerequisite for efficient control of covid-19. we included 145 clinical studies exploring the diagnosis of covid-19. these diagnostic accuracy tests mainly focus on imaging examination, nucleic acid detection, and igm/igg. detection of sars-cov-2 rna by reversetranscription polymerase chain reaction (rt-pcr) is the most commonly used to diagnose covid-19. early studies have shown that rt-pcr has relatively poor sensitivity, and false negative test results will miss some potential infected persons, which has a huge impact (fang et al., 2020) . furthermore, the standard rt-pcr test takes about 3 h to complete. the cost of each test is about $10. the high cost per test may limit the number of tests (esbin et al., 2020) . hence, researchers wanted to design some test kits in order to detect sars-cov-2 quickly and conveniently (chu et al., 2020; shirato et al., 2020; yu et al., 2020) . covid-19 patients also have some typical computed tomography (ct) manifestations, such as ground glass opacities (fang et al., 2020; lu et al., 2020; . as a fast and effective method, ct can be used for auxiliary diagnosis. however, it should be noted that some patients may have atypical ct imaging manifestations lu et al., 2020; wang w. g. et al., 2020) . in addition, as the product of human immune system reaction to sars-cov-2, igm/igg can provide information about the course of the virus infection over time and provide the basis for the diagnosis of covid-19. some researchers have developed an igm-igg combined antibody test kit with a sensitivity of 88.66% and a specificity of 90.63%, but there were still false negative and false positive results . the sensitivity and specificity of the igm/igg rapid diagnostic kit are currently being evaluated in some studies (registration number: nct04346186, nct04348864). drug treatment is a very important part of the registration studies. few drugs were used to treat covid-19, such as cq, hcq, ifn, lopinavir/ritonavir, oseltamivir, umifenovir, dexamethasone. there is currently no clear evidence that these drugs are specific drugs for the treatment of covid-19 other than dexamethasone (gautret et al., 2020; recovery collaborative group, 2020; tang et al., 2020) . the recovery trial claims that dexamethasone can reduce the risk of death for patients on ventilators (rr 0.64; 95% ci, 0.51 to 0.81) and patients on oxygen (rr 0.82; 95% ci, 0.72 to 0.94) (recovery collaborative group, 2020) . the national institutes of health recommends the use of dexamethasone to treat covid-19 patients who require supplemental oxygen in its guidelines (covid-19 treatment guidelines panel, 2020) . as a new experimental broad-spectrum antiviral medication, remdesivir is considered to be effective in inhibiting the replication of sars coronavirus and mers coronavirus. two rct studies showed that compared with placebo, the use of remdesivir could shorten the recovery time of patients with covid-19 (beigel et al., 2020; . as of june 2020, it has been authorized for emergency treatment of covid-19 in the us, singapore, japan, and the uk. cq was first used to treat malaria, hcq as its analogue is less toxic than cq. cq/hcq is other drugs under consideration for treating covid-19. so far, the drugs have been controversial. some studies have shown that the drugs have significant efficacy in alleviating symptoms (sarma et al., 2020; tang et al., 2020) , but some studies have reported that cq/hcq has potential cardiac side effects, such as prolonging qt interval (borba et al., 2020) . in june 2020, the u.s. food and drug administration revoked the emergency use authorization for hcq. a clinical trial to evaluate the safety and effectiveness of hcq for the treatment of covid-19 has been stopped by the nih. after its fourth interim analysis, the data and safety monitoring board concluded that while there was no harm, hcq was unlikely to be beneficial to hospitalized covid-19 patients (nih, 2020). in july 2020, who discontinued the solidarity trial's hcq and lopinavir/ritonavir arms. although lopinavir/ritonavir can reduce sars-cov-2 viral loads (lim et al., 2020) , the solidarity trial's interim results showed that compared with standard treatment, hcq and lopinavir/ritonavir produce little or no reduction in the mortality of hospitalized covid-19 patients (who, 2020). ifn has been used to treat sars and mers, and can improve patient survival (haagmans et al., 2004; mustafa et al., 2018) ; liu et al. reported that the efficacy is not clear for the treatment of covid-19 using ifn. hence, a clinical trial has been investigating the efficacy of ifn for the treatment covid-19 (registration number: nct04254874). a study (tian et al., 2020) reported a new coronavirus-specific human monoclonal antibody-cr3022, which can bind sars-cov-2 receptorbinding domain, and has potential function to prevent and treat sars-cov-2 infections. in addition, there have been some clinical studies investigating the convalescent plasma for the treatment of covid-19. a few limitations should be noted in this study. because covid-19 is a new disease, its name as well as the name of virus changed many times, so there may be a small number of studies using other names for the registration, which may not have been retrieved. additionally, due to the worldwide spread of covid-19, studies will continue to be registered every day and the number of clinical studies is growing, which may also cause some bias. in addition, this study only retrieved trials registered in clinicaltrials.gov. although clinicaltrials.gov includes more than 3.4 million research studies in 214 countries, some studies may not have been registered on this platform. in conclusion, the number of registered covid-19 related clinical studies has increased rapidly since the outbreak, involving epidemiology, risk factors, prevention, diagnosis, treatment, rehabilitation, and psychological aspects. however, some registration parameters are not complete, so it is necessary to strengthen the registration monitoring and supervision for providing high-quality clinical evidence. the datasets generated for this study are available on request to the corresponding authors. x-tz and jj take responsibility for the integrity of the data and the accuracy of the data analysis. concept and design: x-tz, x-qr, and jj. acquisition, analysis, or interpretation of data: all authors. drafting of the manuscript: l-lm, b-hl, and dh. critical revision of the manuscript for important intellectual content: all authors. statistical analysis: xy, y-yw, and j-yy. administrative, technical, or material support: y-yw, b-hl, and xy. supervision and review: x-tz, x-qr, and jj. this work was supported (in part) by the national key research and development program of china (2020yfc0845500). we express our gratitude to jean glover from tianjin golden framework consulting company for english editing. we also express our gratitude for the contribution of all authors of included clinical studies. the supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fphar.2020. 540187/full#supplementary-material registration of clinical trials: is it really needed? n randomized clinical trials and covid-19: managing expectations remdesivir for the treatment of covid-19 -preliminary report adaptive designs for clinical trials effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection: a randomized clinical trial molecular diagnosis of a novel coronavirus, (2019-ncov) causing an outbreak of pneumonia coronavirus disease 2019 (covid-19) treatment guidelines (national institutes of health) overcoming 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of 14 patients remdesivir in adults with severe covid-19: a randomised, double-blind, placebo-controlled, multicentre trial who discontinues hydroxychloroquine and lopinavir/ritonavir treatment arms for covid-19 (world health organization) measures for diagnosing and treating infections by a novel coronavirus responsible for a pneumonia outbreak originating in wuhan clinical characteristics of 140 patients infected by sars-cov-2 in wuhan assessment of a respiratory face mask for capturing air pollutants and pathogens including human influenza and rhinoviruses covid-19: a recommendation to examine the effect of hydroxychloroquine in preventing infection and progression a pneumonia outbreak associated with a new coronavirus of probable bat origin the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.copyright â© 2020 ma, yin, li, yang, jin, huang, deng, wang, ren, ji and zeng. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord-293151-g3758oes authors: nemzek, jean a.; lester, patrick a.; wolfe, a. marissa; dysko, robert c.; myers, daniel d. title: biology and diseases of dogs date: 2015-07-10 journal: laboratory animal medicine doi: 10.1016/b978-0-12-409527-4.00012-2 sha: doc_id: 293151 cord_uid: g3758oes historically, the dog played an important role as a laboratory animal in biomedical research. although numbers are declining, the use of dogs continues to be common in pharmacokinetics and cardiovascular studies. the normal biology of the dog as both a laboratory and a companion animal has been well studied and reference values are presented here as a clinical and experimental resource. this provides the necessary background to discuss the spontaneous diseases, including infectious and neoplastic conditions, prevalent in purpose bred as well as random source dogs used in biomedical research. in addition, diseases and conditions that arise secondary to the housing and experimental manipulation of dogs is discussed with emphasis on treatment and prevention. laboratory animal medicine mellitus. a comprehensive but concise review of the use of the dog as a research subject is available in gay (1984) . the breed of dog most commonly bred for use in biomedical research is the beagle. some commercial facilities also breed foxhounds or other larger dog breeds for use in surgical research studies. some specific breeds with congenital or spontaneous disorders have also been maintained by research institutions (see examples below). random-source dogs used in research are most frequently mongrels or larger dog breeds (e.g., german shepherd, doberman pinscher, labrador and golden retrievers) that are used for surgical research and/or training. according to a computerized literature search for "beagle" for the years 2012-2013, a significant portion of the biomedical scientific publications identified were in the fields of pharmacology or toxicology. especially common were studies focusing on pharmacokinetics, alternative drug delivery systems, and cardiovascular pharmacology. other common areas of research using beagles were dental and periodontal disease and surgery, orthopedic surgery, skeletal physiology, and imaging studies. other research areas that utilized beagles included canine infectious disease, prostatic urology, and ophthalmology. most large-sized dogs (either purpose-bred or randomsource) are used in biomedical research because of their suitability for surgical procedures. anesthetic protocols and systems for dogs are well established and the organs of larger dog breeds are often an appropriate size for trials of potential pediatric surgical procedures. surgical canine models have been used extensively in cardiovascular, orthopedic, and transplantation research. there are also some unique spontaneous conditions for which dogs have proven to be valuable animal models. a colony of gray collies had been maintained at the university of washington (seattle) for the study of cyclic hematopoiesis. this condition is manifested by periodic fluctuations of the cellular components of the blood, most notably the neutrophil population. these dogs can be used to study the basic regulatory mechanisms involved with hematopoiesis, as well as possible treatments for both the human and the canine conditions (brabb et al., 1995) . golden retrievers affected with muscular dystrophy have been used as models of duchenne muscular dystrophy in human children. duchenne muscular dystrophy is caused by an absence of the muscle protein dystrophin, inherited in an x-linked recessive manner. the dystrophy in golden retrievers is caused by the absence of the same protein and is inherited in the same way. the clinical signs (such as debilitating limb contracture) are also similar between the canine and human conditions (kornegay et al., 1994) . other genetic disorders studied in dog colonies include hereditary canine spinal muscle atrophy (cork, 1991) and narcoplepsy in doberman pinschers (ripley et al., 2001) . bedlington terriers have been used to study copper storage diseases (such as wilson's disease) and the development of spontaneous diabetes mellitus and hypothyroidism has been studied in several breeds of dogs for comparisons with the human conditions. although historically the dog has been a common laboratory animal, their use in research has waned over the past 30 years. according to the u.s. department of agriculture (usda), animal and plant health inspection service (1998, 2011) , the number of dogs used in research has declined from 211,104 in 1979 to 75,429 in 1997 (prior to the previous edition of this text) and 64,930 in 2010. this decrease was caused by a variety of factors, including (but not limited to) decreased availability, local restrictive regulations, conversion to other animal models (such as livestock or rodents), increased cost, and shift in scientific interest from pathophysiology to molecular biology and genetics. dogs used for research are generally segregated into two classes: purpose-bred and random-source. purposebred dogs are those produced specifically for use in biomedical research; they are intended for use in long-term research projects and/or pharmacologic studies in which illness or medication would require removal from the study. usually these dogs are either beagles or mongrel foxhounds, although other breeds may be available. purpose-bred dogs typically receive veterinary care throughout their stay at the breeding facility. they are usually vaccinated against rabies virus, canine distemper virus, parvovirus, adenovirus type 2, parainfluenza virus, leptospira serovars canicola, icterohaemorrhagiae, grippotyphosa, and pomona, and bordetella bronchiseptica (jasmin, personal communication). purpose-bred dogs are also usually treated prophylactically for intestinal helminths and ectoparasites, and possibly given a heartworm preventative. random-source dogs are not bred specifically for use in research. they may be dogs bred for another purpose (e.g., hunting and racing) or stray dogs collected at pounds or shelters. the health status of these dogs can be the same quality as purpose-bred dogs, or it can be an unknown entity. random-source dogs that have been treated and vaccinated in preparation for use in research are termed conditioned dogs. these dogs are then suitable for long-term studies or terminal preparations that require unperturbed physiologic parameters. conditioned dogs are often tested for heartworm antigen because of the implications that infestations can have on cardiovascular status and surgical risk. nonconditioned random-source dogs are useful only in a limited number of research studies, such as nonsurvival surgical training preparations and tissue/organ harvest. options for procurement of dogs for biomedical research typically include purchase from a usdadesignated class a or class b licensed dealer or directly from a municipal pound. the requirements for usda licensure are detailed in code of federal regulations (cfr), title 9, chapter 1 (1-1-92 edition), subchapter a, animal welfare, 1.1 definitions, and 2.1 requirements and application (office of the federal register, 2002) . briefly, class a licensees are breeders who raise all animals on their premises from a closed colony. class b licensees purchase the dogs from other individuals (including unadopted animals from municipal pounds) and resell them to research facilities. there are additional regulations that apply to class b dealers (such as holding periods and record-keeping documentation) because of the public concern that stolen pets could enter biomedical research facilities in this manner. in december 2013, the national institutes of health (nih) issued notice not-od-14-034 entitled notice regarding nih plan to transition from use of usda class b dogs to other legal sources (national institutes of health, 2013) . this nih policy begins in the fiscal year 2015 and prohibits the procurement of dogs from class b dealers using nih grant funds. from that point forward, dogs on nihfunded studies will have to be obtained from class a vendors, privately owned colonies (such as institutional breeding colonies), or client-owned animals (e.g., animals participating in veterinary clinical trials). the best resource for identification of possible vendors are online 'buyer's guide' sites or 'buyer's guide' issues of trade periodicals. online sites include the buyer's guide of the american association of laboratory animal science (http://laboratoryanimalbuyersguide.com), and the trade journals lab animal (http://guide.labanimal. com) and animal lab news (http://www.alnmag.com/ content/buyers-guide). a 'buyer's guide' typically lists sources for both purpose-bred and random-source dogs, and denotes such features as pathogen-free status, health status, and availability of specific breeds and timed pregnant females. some suppliers also have separate advertisements within issues of the journals. federal regulations promulgated by the animal and plant health inspection service, usda, in response to the animal welfare act (7 cfr 2.17, 2.51, and 371.2[g] ) are described in 9 cfr chapter 1 (1-1-92 edition), subchapter a, animal welfare (office of the federal register, 2002) . regulations pertaining specifically to the care of dogs used in research are found in subpart a, specifications for the humane handling, care, treatment, and transportation of dogs and cats of part 3 (standards) of subchapter a. particular attention should be paid to section 3.6c (primary enclosures-additional requirements for dogs) because the space required for housing dogs is calculated using body length rather than weight (a parameter used for other species and also for dogs in the national research council (nrc) guidelines). section 3.8 (exercise for dogs) describes the requirements that dealers, exhibitors, and facilities must follow in order to provide dogs with sufficient exercise. the institute for laboratory animal research (ilar) has written the guide for the care and use of laboratory animals (national research council, 2011) . the 'guide' is the primary document used by institutional animal research units to develop their programs and by animal care evaluation groups, such as the association for assessment and accreditation of laboratory animal care international (aaalac international), to facilitate site visits and inspections. the primary difference between the 7th and 8th editions of the 'guide' (national research council, 1996 regarding the care of dogs is the notation that "enclosures that allow greater freedom of movement and unrestricted height (i.e., pens, runs, or kennels) are preferable." the ilar committee on dogs authored dogs: laboratory animal management (national research council, 1994) . this publication describes "features of housing, management, and care that are related to the expanded use of dogs as models of human diseases" and includes "an interpretive summary of the animal welfare regulations and the requirements of the public health service policy on humane care and use of laboratory animals." the reader is encouraged to use these publications to obtain further information on care and husbandry of dogs in the biomedical research setting. the information presented in the tables represents a range of normal values that can vary depending on the analytical method, as well as the age, breed, and sex of the animal. cohen, covance laboratories, inc., cumberland, va (2013) . physiological data for a mixed population of dogs of both sexes. fig. 12 .1 demonstrates the normal weights and corresponding ages for both male and female beagle and hound dogs. tables 12.2 and 12.3 feature hematology data from beagles of both sexes from two commercial facilities. tables 12.4 and 12.5 list serum chemical data for beagles of both sexes from two commercial facilities. representative blood gas, coagulation data, and normal urinalysis parameters can be found in tables 12.6-12.8, respectively. finally, the reviews in arterial and venous blood gas anaylses (rieser, 2013) and the manual of canine and feline cardiology (tilley et al., 2007) are excellent resources. good nutrition and a balanced diet are essential to the health, performance, and well-being of the animal. the nrc of the united states national academy of sciences is the leading provider of nutrient recommendations for dogs and provides average requirements needed to maintain growth and prevent deficiencies (subcommittee on dog and cat nutrition, 2006) . the nrc publications form the basis for the association of american feed control officials (aafco) nutrient profiles, which are updated periodically (baldwin et al., 2010) . the aafco is an advisory body comprising state representatives from across the united states. it provides a mechanism for developing and implementing uniform and equitable laws, regulations, standards, and enforcement policies, and establishes nutrient profiles for cat and dog foods (dzanis, 1994; thatcher et al., 2010) . additional resources should be consulted for details on the nutritional requirements for dogs of all ages (dzanis, 1994; subcommittee on dog and cat nutrition, 2006; baldwin et al., 2010; thatcher et al., 2010; hand et al., 2010) . recommendations for feeding the appropriate amount of diet are determined by the dog's metabolic requirements. the maintenance energy requirement (mer) is the amount of energy used by a moderately active adult animal in a thermoneutral environment. the mer for most breeds may be calculated using the following equation: mer (metabolizable kcal/day) = bw × 0.75 × 550 kj de, where bw = body weight (kg), kj = kilojoules, de = digestable energy (kienzle and rainbird, 1991) . in-depth overviews of diets used in biomedical research are available in diet-specific literature. open-formula diets have defined concentrations of all ingredients and the information is publicly available. this allows researchers to control for this important environmental variable and enables retrospective analysis of possible diet composition effects on research results (barnard et al., 2009) . open-formula diets occasionally may require changes in formulation to maintain nutrient composition or meet changing nutrient requirements. these changes in quantitative ingredient formulation are made public when open-formula diets are modified. in contrast, closed-formula diets are commercially available, balanced diets that meet and label the minimum requirements for protein and fat and the maximum values for ash and fiber; however, the exact composition of ingredients may vary from batch to batch. ingredient composition varies as the manufacturer applies a leastcost strategy, referring to formulating diets to maximize profit by using the least-expensive ingredients. although the ingredients are listed, the quantitative ingredient formulation is not publicly available and can vary without public disclosure, due to proprietary nature of commercial diets produced and marketed under vendor trade names. closed-formula diets have also been referred to as as 'fixed formula' or 'constant nutrition' (labdiets, pmi nutrition international, st. louis, missouri) by manufacturers (barnard et al., 2009) . in fixed-formula diets, the quantitative ingredient formulation does not change; however, this information is proprietary and therefore laboratory animal medicine not disclosed publically (barnard et al., 2009) . semipurified and purified diets provide the strictest control of ingredients and are formulated from purified components: amino acids, lipids, carbohydrates, vitamins, and minerals. although purified and semipurified diets do differ in the types of ingredients used, the terms are generally used to mean the same thing. purified-ingredient diets are generally 'open' formulas, meaning that they are published and available to the scientific community. the animal care provider should be aware of the manufacture date of the diet, which should be clearly visible on the bag. as a general rule, diets are safe for consumption up to 6 months following the manufacture date when stored at room temperature. refrigeration may prolong the shelf-life, but the best strategy is to feed only fresh diets and use each lot based on the date of manufacture. specifications for feeding and watering of dogs are provided in the regulations of the animal welfare act. management of a breeding colony requires broad knowledge of the dog's anatomy, reproductive physiology, and behavioral needs during breeding, gestation, and parturition. although a comprehensive discussion of the biology of canine reproduction is beyond the scope of this chapter, essential features of the broad topics noted above are presented. from dr. asheley wathen, covance laboratories, inc., madison, wi, and dr. kimberley cohen, covance laboratories, inc., cumberland, va (2013) . overall health, body condition, nutrition, and age greatly influence reproductive efficiency (gavrilovic et al., 2008; johnson, 2008) . therefore, only normal, healthy animals in excellent body condition should be used in breeding programs. beagles between 2 and 3.5 years of age have the best conception rates and litter size with the lowest neonatal mortality. after 5 years of age, conception rates and litter size decline and neonatal mortality increases (johnson, 2008) . the vagina is a long, musculomembranous canal that extends from the uterus to the vulva. during physical examination, the gloved finger or examination instrument should be introduced through the dorsal commissure of the vulva, avoiding the deep ventral clitoral fossa. examination should proceed at an angle of approximately 60° until the instrument or fingertip has passed over the ischial arch, after which it can be directed further craniad toward the cervix. the uterus consists of the cervix, uterine body, and uterine horns. the cervix is an abdominal organ, located approximately halfway between the ovaries and the vulva. when the bitch is in proestrus and estrus, the cervix can be distinguished during abdominal palpation as an enlarged, turgid, walnut-shaped structure. female dogs are monoestrous, typically nonseasonal, spontaneous ovulators that have a spontaneous luteal phase approximately 5 days longer than the 65 ± 1 days of pregnancy followed by obligate anestrus. puberty (beginning of the first estrus) occurs between 6 and 14 months in most breeds. the time of onset positively correlates with the body size (concannon, 2011) . the canine cycle is divided into four phases: proestrus, estrus, diestrus, and anestrus. the duration of laboratory animal medicine proestrus is 5-20 days with an average of 9 days and reflects the follicular phase rise in estrogen. during this stage, the vulva is enlarged and turgid, and a serosanguinous vaginal discharge is present (concannon, 2011) . estrus may be from 5 to 15 days in duration but generally lasts 9 days. the endocrine feature of estrus is the first abrupt increase in progesterone (>5 ng/ml), which occurs concomitantly with the luteinizing hormone (lh) surge 95% of the time, followed by ovulation within 24-72 h. the vulva is softer and smaller than in proestrus. the vaginal discharge persists and may remain serosanquinous or become straw colored. diestrus begins approximately 9 days after the onset of standing heat. the end of this stage is 60 days later, which would be coincident with whelping if the bitch had become pregnant. defined behaviorally as starting when estrous behavior ceases (concannon, 2011) , diestrus represents the peak of serum progesterone. anestrous may last from 80 to 240 days and is the stage of reproductive quiescence. it is characterized by an absence of ovarian activity and serum progesterone levels of less than 1 ng/ml. the onset of puberty in the male ranges from 5 to 12 months of age and is affected by breed, season, nutrition, and disease status. this process is initiated by the secretion of lh from the anterior pituitary, which stimulates the production of testosterone by the interstitial or leydig's cells. at this time, the testicular growth is rapid, the seminiferous tubules begin to differentiate, and sertoli cells form the blood-testis barrier. secretion of follicle-stimulating hormone (fsh) by the anterior pituitary stimulates the production of other key hormones by the sertoli cells, including, inhibin, androgen binding protein, and estrogen. fsh stimulates spermatogenesis in the presence of testosterone, whereas inhibin and estrogen provide negative feedback to the pituitary gland to decrease fsh production. spermatogenesis in the dog is completed in 45 days, with subsequent maturation of sperm occurring in the epididymis for approximately 15 days. thus, the entire process from the initiation of spermatogonial mitosis to the delivery of mature sperm to the ejaculate is 60 days. a breeding soundness exam should be conducted to assess the probability of a male dog's successful production of offspring. factors affecting male fertility include libido, ability to copulate, testicular size, and quality semen production. supression of sexual behavior and problems with libido may occur in dogs due to early weaning, isolation, or inherited abnormalities. animals with poor hind limb conformation or trauma to the back may be unable to properly mount the female. there is a positive correlation between scrotal circumference and the number of sperm produced. finally, the quality of sperm is assessed by motility, morphology, volume, and concentration. an ejaculate (5 ml) that contains approximately 500 million progressively motile sperm without significant morphological abnormalities is a good indicator of normal male fertility. complete anatomy of the bitch and dog can be found in miller's anatomy of the dog (evans and de lahunta, 2012) . cells of the vaginal epithelium mature to keratinized squamous epithelium under the influence of estrogen. because of the rise in estrogen throughout proestrus, with peak levels occurring just prior to the onset of standing heat, the vaginal smear can be used as an indicator of the bitch's readiness for breeding. the smear will not confirm the presence of ovulation nor is it of prognostic value in normal bitches during anestrus. the percentage of vaginal epithelial cell cornification is an index of estrogen secretion by the ovarian follicles. cornification occurs approximately 2 days prior to the estrogen peak and 4 days prior to standing heat. as cornification of vaginal epithelial cells proceeds, the cells become larger, with more angular borders. the nuclear/ cytoplasmic ratio decreases until the nuclei reach a point where they no longer take up stain (coincident with the onset of estrus). the cells appear 'anuclear' and are classified as 'cornified' or 'anuclear squames.' the vaginal cytology smear of the bitch changes from predominantly cornified to noncornified 6 days after ovulation. the day of this change is the first day of diestrus. other epithelial cell types noted on vaginal cytology include superficial cells (large, angular cells with small nuclei); intermediate cells (round or oval cells with abundant cytoplasm and large, vesicular nuclei); and parabasal cells (small round or elongated cells with large, well-stained nuclei, and a high nuclear/cytoplasmic ratio). based on vaginal cytology, the estrous cycle is classified as follows: although vaginal cytology is a useful tool, observation of behavioral estrus is the best criterion to use in breeding management. during proestrus, the male is attracted to the bitch and will investigate her hindquarters, but she laboratory animal medicine will not accept breeding. estrus is characterized by proactive receptivity to mounting by males and increased male-seeking behavior (concannon, 2011) . during this stage, the bitch will exhibit 'flagging,' or elevation of her tail with muscular elevation of the vulva to facilitate penetration by the male. in order to maximize the conception rate and litter size, it is recommended to breed the bitch on days 1, 3, and 5 of the standing heat. due to the long life span of canine sperm, fertilization occurs in the oviduct up to 8 days after coitus. the ovulated oocyte is a primary oocyte that must undergo two meiotic divisions before fertilization can occur. this overall maturation process takes approximately 2 days. after maturation, the oocyte remains viable for 4-5 days. optimal conception rates tend to occur when the bitch is bred from 4 days before to 3 days after ovulation; best litter size is achieved when the bitch is bred 2 days after ovulation. implantation is evident by areas of local endometrial edema 17-18 days after breeding. there is no correlation between the number of corpora lutea and the number of fetuses in the corresponding uterine horn, suggesting transuterine migration of embryos. the dog has endotheliochorial placentation. the endothelium of uterine vessels lies adjacent to the fetal chorion, mesenchymal, and endothelial tissues, so that maternal and fetal blood are separated by four layers. the canine placenta is also classified as zonary, indicating the placental villi are arranged in a belt, and deciduate, reflecting that maternal decidual cells are shed with fetal placentas at parturition. the length of gestation is 59-63 days. luteal progesterone is responsible for maintaining pregnancy and canine corpora lutea retain their structural development throughout gestation. serum progesterone rises from less than 1 ng/ml in late proestrus to a peak of 30-60 ng/ml during gestation, and then declines to 4-5 ng/ml just prior to parturition. progesterone is essential for endometrial gland growth, secretion of uterine milk, attachment of the placentas, and inhibition of uterine motility (johnson, 2008; verstegen-onclin and verstegen, 2008) . pregnancy detection can be performed by several methods. abdominal palpation of the uterus may be most informative at approximately 28 days after breeding. the embryos and chorioallantoic vesicles form a series of ovoid swellings and are approximately 2 inches in length at 28-30 days. by day 35, the uterus begins to enlarge diffusely and the vesicles become difficult to identify by palpation. radiology can be used to confirm pregnancy and facilitate determination of gestational age, beginning 45 days after the lh surge (lopate, 2008) . bitches in which a difficult whelping is anticipated should be radiographed in late pregnancy to determine the litter size and to evaluate the size of the fetal skulls in relation to the bony maternal birth canal. ultrasonography can be used to confirm pregnancy beginning on days 18-22, at which point the gestational sacs will be approximately 1 cm in diameter, and until parturition (shille and gontarek, 1985; lopate, 2008) . ultrasonography can assess fetal viability by visualizing fetal heartbeats and fetal movement beginning on gestational days 23-25 and 35, respectively (lopate, 2008) . it can also predict gestational age using the inner diameter of the chorionic cavity in early pregnancy and the biparietal diameter in late pregnancy luvoni and beccaglia, 2006) . however, ultrasonography for determination of gestational age is most accurate at day 30 of pregnancy when using correction factors for small (< 9 kg) and large (> 40 kg) body weight dogs (kutzler et al., 2003) . thermal support should be provided prior to parturition. dogs housed on grated flooring should be provided with mats and those on solid floors would benefit from blankets placed in a corner of the primary enclosure. shavings are discouraged because they may adhere to the umbilical cord and predispose to ascending infections. heat lamps may be placed 24 h prior to parturition and remain until all neonates demonstrate vigorous suckling behavior. however, the use of heat lamps necessitates strict supervision in order to prevent thermal burns. if possible, whelping bitches should be housed in a quiet corridor in order to decrease periparturient stress, especially in primiparous or young mothers. monitoring of parturition is important, but human intervention should be minimal in order to prevent stressinduced cannibalism. an abrupt drop in body temperature to less than 100°f indicates impending parturition within 18-24 h. the process of parturition has been divided into three stages. stage 1 of labor lasts 6-12 h and is characterized by uterine contractions and cervical dilation. during this stage, the bitch may appear restless, nervous, and anorexic. other common clinical signs include panting and increased pulse rate (johnson, 2008) . fetal expulsion occurs during stage 2, which lasts approximately 3-6 h. as the fetus engages the cervix, there is release of oxytocin, referred to as the ferguson reflex, which strengthens the uterine contractions and may elicit abdominal contractions as well. the bitch is able to inhibit this stage of labor if disturbed. the chorioallantois ruptures either during passage of each neonate through the birth canal or by the bitch's teeth at birth. interestingly, posterior presentation is common in dogs but does not predispose to dystocia. the time interval between deliveries of each pup is irregular, but the average is less than 1 h between pups. veterinary assistance laboratory animal medicine is necessary if the bitch remains in stage 2 for more than 5 h without delivering the first pup, or for more than 2 h before delivering subsequent pups. during stage 3 of labor, the placentas are expelled either immediately or within 15 min of delivery of each pup. if two pups are delivered from alternate uterine horns, then the birth of both puppies may precede expulsion of the respective placentas. the bitch will lick the newborn vigorously to remove the membranes from its head and to promote respiration. she will also sever the umbilical cord. the bitch may ingest the placentas, although they confer no known nutritional benefit and may induce a transient diarrhea. the peripartum use of oxytocin is required only in the event of uterine inertia, stillbirths, or agalactia. oxytocin should not be used in the event of systemic illness or abnormalities precluding vaginal delivery. indications for its use include lack of delivery 24 h after onset of stage 1 labor, greater than 1 h of unproductive stage 2 labor, inadequate contractions, or abnormal vaginal discharge. in these cases, radiographs are recommended to assess fetal size in relation to the birth canal and any possible obstructions, followed by 0.25-2.00 iu of oxytocin intramuscularly or subcutaneously. the oxytocin can be repeated 30-60 min after the first dose for a total of two doses (plunkett, 1993) . in some cases, treatment with 0.5-1.5 ml/kg of 10% calcium gluconate, delivered slowly iv while monitoring closely for bradycardia, and 25% dextrose iv may be indicated. uterine involution occurs during anestrus within 4-5 weeks of parturition. during this time, a greenish to red-brown vaginal discharge, or lochia, is considered normal. the presence of an odiferous, purulent discharge, accompanied by systemic signs of illness, indicates metritis or pyometra. desquamation of the endometrium begins by the 6th postpartum week, with complete repair by 3 months. newborn puppies are easily sexed by examination of the anogenital distance. in female puppies, the vulva is evident a short distance from the anus, whereas the prepuce of male puppies is nearly adjacent to the umbilicus. eyes are open at approximately 12 days, and ears are patent at approximately 12-20 days. solid food can be introduced between 4.5 and 6 weeks of age, and puppies can be weaned at 6-8 weeks. artificial insemination (ai) is indicated when the male is physically incapable of mounting or penetrating the bitch, when there are vaginal abnormalities such as a vaginal-vestibular stricture, narrow vagina, vaginal septum, and vaginal hyperplasia, or if there is a behavioral incompatibility between the male and female dogs (kutzler, 2005) . semen is collected using a plastic centrifuge tube and rubber latex artificial vagina. the male is introduced to the scent of an estrous bitch and manually stimulated. the first two fractions are collected followed by a sufficient amount of the third fraction (predominantly of prostatic fluid) to bring the total semen volume to 4-6 ml. the semen can be introduced into the cranial vagina or directly into the uterus either through trans-cervical catheterization with a norwegian ai catheter or utilizing fiberoptic endoscopy. use of the norwegian ai catheter for intrauterine insemination of frozen-thawed, fresh, and chilled-extended semen results in significantly higher whelping rates than intravaginal insemination (linde-forsberg et al., 1999; thomassen and farstad, 2009) . for trans-cervical insemination, the bitch is either standing on all four legs or standing with hindquarters raised. the ai catheter and guiding tube are inserted into the vestibulum as far as the pseudocervix. firm abdominal palpation is then used to locate and fix the cervix in the other hand, at which point the catheter is further inserted along the dorsal vaginal fold until the cervical opening is located and semen is deposited into the uterus lumen (thomassen and farstad, 2009) . surgical and laparoscopic ai has been used successfully for intrauterine and intratubal insemination; however, these techniques are invasive and require anesthesia. therefore, the nonsurgical techniques mentioned above are recommended, as these approaches are less invasive and can be completed without anesthesia in nonsedated or sedated dogs depending on the experience of the personnel and personality of the dogs. ai with freshly collected sperm can be done on days 1, 3, and 5 of standing heat or on days of maximal vaginal cornification. the viability of frozen-thawed sperm is significantly reduced compared to fresh or chilled sperm that may live up to 5 or 6 days in the reproductive tract of the bitch; frozen-thawed sperm live only a few hours. therefore, the ova must be mature and insemination with frozen-thawed semen must be done 2-3 days after ovulation in the bitch as determined by serum progesterone concentrations (thomassen et al., 2006) . false pregnancy (pseudocyesis), a stage of mammary gland development and lactation associated with nesting or mothering behavior, is common in the bitch. the condition occurs after the decline in serum progesterone toward the end of diestrus. there is no age or breed predisposition. pseudopregnancy does not predispose the bitch to reproductive disease or infertility. a comprehensive review of canine pseudocyesis exploring its cause, clinical features, and treatments is covered by c. gobello (gobello et al., 2001) . reproductive performance in the bitch is optimal prior to 4 years of age. cycling does not completely cease; however, after 5-8 years of age, bitches demonstrate significant decreases in conception rate and the number of live pups whelped. by 8-9 years of age, pathologic conditions of the uterus, such as cysts, hyperplasia, atrophy, and neoplasia, are extremely common. dogs prefer living in a social environment. dogs have well developed olfactory glands, vision, and auditory and tactile senses that allow them to gain environmental cues and information from other dogs and humans (field and jackson, 2006; joint working group on refinement, 2004) . much of their instinctive behavior is dependent on learning to interact with other members of their species. beagles have been a popular animal model because of their docile nature. they are easily handled and, for the most part, respond favorably to repetitive manipulations such as body weight measurements, physical examination, electrocardiograms (ecgs), oral gavage, and venipuncture. although sexually mature by 6-9 months of age, dogs are not socially mature until 18-36 months of age. the socialization process should begin early during development, when puppies are receptive to conspecific and human contact. for example, from 3 to 8 weeks of age, puppies are most capable of learning about how to interact with other dogs. between weeks 5 and 12, puppies are most capable of learning how to interact with people. by 10-12 weeks of age, dogs voluntarily wander and explore new environments. thus, early handling and mild stress (such as vaccination) appear to be extremely beneficial components of a dog's social exposure. canid social systems use signals and displays that minimize the probability of outright aggression. these behavior patterns are most likely elicited during distressful situations, such as strange environments, being handled by strange people, or encountering new animals. an excellent, illustrated discussion of normal canine behavior patterns can be found in the canine behavior section of the manual of clinical behavioral medicine for dogs and cats (overall, 2013) . by virtue of the dog's status as a companion animal, there are many veterinary publications and reference texts on the diagnosis, medical management, pathology, and epidemiology of its disorders. the authors of this chapter have chosen to emphasize those diseases that are more frequently encountered in the research setting, especially infectious diseases associated with the use of random-source dogs and conditions seen frequently in the beagle. for more thorough and detailed discussion of these diseases, as well as those not discussed in this chapter, the reader should consult standard veterinary textbooks. etiology canine infectious respiratory disease (cird) is a highly contagious illness and several organisms have been incriminated including bordetella bronchiseptica; streptococcus equi subsp. zooepidemicus; canine parainfluenza virus (cpiv); canine influenza virus (civ); canine respiratory coronavirus; canine adenovirus type 2 (cav-2); canine herpesvirus; canine reovirus types 1, 2, and 3; and mycoplasma and ureaplasma. naturally occuring infection can result in coinfection by two or more organisms (garnett et al., 1982; ford, 2012) . clinical signs cird can be subdivided into mild or severe forms. the mild form is more common and is characterized by an acute onset of a loud, dry, hacking cough. increased formation of mucus sometimes results in a productive cough, followed by gagging or retching motions. cough may be elicited by tracheal palpation and may be more frequent with excitement or exercise. otherwise, dogs are typically asymptomatic. mild tracheobronchitis usually lasts 7-14 days, even when untreated. the severe form results from poor general health, immunosuppression, or lack of vaccination. secondary bronchopneumonia can occur and can be the determinant of severity (sherding, 1994) . animals are clinically ill and may be febrile, anorexic, and depressed. productive cough and mucopurulent naso-ocular discharge are more common than in the mild form. epizootiology and transmission the natural reservoir for b. bronchiseptica is the respiratory tract (bemis, 1992) , and it is very easily spread by aerosol and direct contact. transmission is heightened by confined housing of multiple animals. bordetella bronchiseptica is highly infectious with an incubation period of 3-10 days. pathogenesis the most common clinical isolates are cpiv and b. bronchiseptica (mochizuki et al., 2008) . however, b. bronchiseptica is often recovered from clinically healthy animals (chalker et al., 2003) . during clinical infection, b. bronchiseptica attaches to the cilia of the upper airway epithelium, causing suppurative tracheobronchitis and bronchiolitis. infections with cpiv laboratory animal medicine or cav-2 alone are usually subclinical but can cause necrotizing tracheobronchiolitis (dungworth, 1985) . diagnosis and differential diagnosis diagnosis is often based on clinical signs and known history; however, cough elicited by tracheal palpation may be inconsistent and should not be used for definitive diagnosis. presumptive diagnosis can be made by isolation of b. bronchiseptica or mycoplasma by nasal swabs. viral isolation or paired serology is often impractical and expensive. if cough persists for more than 14 days, other disease conditions should be considered. differential diagnoses include civ, canine distemper virus, pneumonia, heartworm disease, tracheal collapse, mycotic infections, and diseases resulting in tracheal compression (johnson, 2000) . prevention prevention is best achieved by avoiding exposure to infected animals. dogs should be vaccinated prior to or upon admission to the animal facility. intranasal vaccines protect against infection and disease and can be given to dogs as young as 3 weeks of age (greene and levy, 2012) . combination vaccines for b. bronchiseptica, cav-2, and cpiv are preferred. vaccinations should be boostered every 6 months when multiple animals are housed in a confined area. control staff must practice proper hygiene to prevent transmission by fomites. sanitation, proper ventilation, and proper humidity are critical for control. symptomatic animals should be isolated and kennels should be disinfected with agents such as bleach, chlorhexidine, or quaternary ammonium chloride. treatment bordetella bronchiseptica is sensitive to potentiated sulfas, chloramphenicol, quinolones, tetracyclines, gentamicin, and kanamycin. use of antibiotics is indicated when severe or persistent clinical signs occur and should be continued for 14 days. for severe or unresponsive infection, treatment should be based on bacterial culture/sensitivity patterns. nebulized gentamicin or kanamycin may be helpful in severe cases. antitussives should be avoided if the cough is productive; however, their use is indicated if coughing is causing discomfort or interfering with sleep. bronchodilators such as aminophylline, theophylline, or terbutaline can be helpful in reducing reflex bronchoconstriction. research complications due to the altered respiratory tract physiology, infected animals should not be used for pulmonary studies. etiology β-hemolytic lancefield's group c streptococcus (s. equi ssp. zooepidemicus) is a gram-positive, non-spore-forming coccus that causes pneumonia and sepsis in dogs. clinical signs clinical signs vary based on the organ system affected. pneumonic disease is typically associated with sudden onset of clinical signs including coughing, weakness, fever, dyspnea, and hematemesis. the rapid progression of disease is similar to that seen in humans with toxic shock syndrome (tss) caused by streptococcus pyogenes. peracute death has been reported in research and shelter dogs (bergdall et al., 1996; pesavento et al., 2008) . epizootiology and transmission streptococcus equi ssp. zooepidemicus is not considered a commensal of healthy dogs as most of the β-hemolytic commensal organisms belong to group g, specifically streptococcus canis. asymptomatic carriers are suspected to be the route by which infection enters populations. streptococcus equi ssp. zooepidemicus is considered an opportunistic pathogen and stressful factors such as transport can predispose to disease (priestnall et al., 2010) . pathologic findings in peracute cases, hemorrhage from the mouth and nose and within the pleural cavity can be the most striking lesion. ecchymotic and petechial hemorrhages can be noted on several organs ( fig. 12 .2). 'bull's-eye' lesions may be observed on the pleural surface of affected lung lobes. histologic lesions can include fibrino-suppurative, necrotizing, and hemorrhagic pneumonia. gram-positive cocci can be found in intracellular clusters throughout the lung ( fig. 12. 3), tonsils, and spleen of affected animals (bergdall et al., 1996; priestnall and erles, 2011) . pathogenesis predisposing factors such as transport stress and viral coinfection have been shown to contribute to the virulence of s. zooepidemicus (priestnall and erles, 2011) . due to the similarities with the clinical signs seen in human cases of tss, superantigens are thought to contribute to the virulence of s. zooepidemicus in cases of acute hemorrhagic pneumonia. these superantigens work by bypassing the conventional mechanisms of antigen presentation and binding to major histocompatibilitity complex class ii receptors. as a result, there is a hyperactive proinflammatory response and an 'avalanche' of cytokines including interleukin 1β (il-1β), interleukin 6 (il-6), and tumor necrosis factor alpha (tnf-α). three novel superantigen-encoding genes have been identified from a case of acute fatal hemorrhagic pneumonia, szef, szen, and szep. however, it is currently unclear what effect these superantigens have in vivo priestnall et al., 2010) . while superantigens have been detected in some isolates, there is not enough data to determine if superantigens play a role in the pathogenesis (byun et al., 2009; kim et al., 2007) . diagnosis and differential diagnosis definitive diagnosis is based on bacterial culture of nasal swabs or transtracheal lavage. polymerase chain reaction (pcr) can be done on post-mortem lung tissue. bacterial pneumonias or bacteremias can be caused by other pathogenic streptococcus spp., staphylococcus spp., escherichia coli, pasteurella multocida, pseudomonas spp., klebsiella pneumoniae, and b. bronchiseptica. nonbacterial causes of respiratory disease include rodenticide intoxication, coagulopathies, heartworm disease, pulmonary thromboembolism, ruptured aneurysm, and left-sided congestive heart failure. prevention and control there is no vaccine for prevention of s. zooepidemicus. the organism has been isolated from the environment during active outbreaks (pesavento et al., 2008) , so dogs diagnosed with s. zooepidemicus should be quarantined and any potential fomites (e.g. food bowls, enrichment) should be properly disinfected. treatment antibiotic therapy should be based on culture and sensitivity. resistance to doxycycline and tetracycline has been demonstrated (garnett et al., 1982; pesavento et al., 2008) . research complications dogs with severe hemorrhagic pneumonia or systemic disease are not appropriate for research study. the association between epizootics of this disease and transportation supports operational policies that require adequate acclimation periods for animals upon arrival. etiology serovars canicola, bratislava, and grippotyphosa result in renal or hepatic disease, whereas serovars icterohaemorrhagiae and pomona predominantly result in hepatic disease . clinical signs canine leptospirosis can present as subclinical, acute, or chronic disease. clinical signs in acute infection can be nonspecific and include lethargy, depression, abdominal discomfort, stiffness, anorexia, vomiting, muscle tenderness, and pyrexia. clinical signs can be related to renal failure including polyuria and polydipsia, with or without azotemia, oliguria, or anuria. leptospirosis can also lead to hepatic failure with signs such as icterus or bleeding abnormalities. peracute leptospirosis is characterized by shock, vascular collapse, and rapid death. uveitis, abortions, stillbirths, and pulmonary hemorrhage have also been associated with leptospirosis (klopfleisch et al., 2010; van de maele et al., 2008) . bivalent vaccines against the most common canine serovars, icterohaemorrhagiae and canicola, have resulted in the increased prevalence of other serovars including grippotyphosa, pomona, bratislava, and autumnalis. increased movement of wild animal reservoirs (rats, raccoons, skunks, opossums) into urban/suburban areas have also contributed to the greater prevalence of previously uncommon serovars (sykes et al., 2011) . transmission occurs primarily through environmental contact, although direct transmisson between hosts may also occur. leptospires passing from urine into water is the most common route of contamination (goldstein, 2010) . leptospirosis is a zoonotic disease. pathologic findings the kidneys consistently have gross and microscopic lesions. in the acute phase, the kidneys are swollen with subcapsular and cortical ecchymotic hemorrhages. petechial or ecchymotic hemorrhages and swelling of the lungs may also be noted. hepatic lesions during the acute phase consist of diffuse hemorrhage and necrotic foci (searcy, 1995) . in chronic stages of leptospirosis, the kidneys become small and fibrotic. endothelial cell degeneration and focal to diffuse lymphocytic-plasmacytic interstitial nephritis are the characteristic histopathological findings. pathogenesis the severity and course of leptospirosis depend on the causative serovar as well as the age and immune status of the dog. infection occurs after the leptospires penetrate a mucous membrane or abraded skin. the organisms then invade the vascular space and multiply rapidly, reaching the renal tubular epithelium several days postinfection. acute or progressive renal failure leading to oliguria or anuria may occur. nephritis may or may not be accompanied by hepatitis, uveitis, pulmonary hemorrhage, and meningitis. disseminated intravascular coagulation is often a secondary complication. diagnosis and differential diagnosis paired serology for the microscopic agglutination test is the most reliable means of definitive diagnosis, and successive serum sampling should be done 7-14 days after the first sample. pcr can be used to identify active infection early in the disease when serologic testing is negative or in previously vaccinated animals (sykes et al., 2011) . differential diagnoses include other causes of acute renal failure and hepatitis. prevention and control according to the american animal hospital association's 2011 vaccination guidelines, vaccination for leptospirosis is recommended based on geographic location and exposure risk (welborn et al., 2011) . both quadrivalent and bivalent inactivated bacterins are available. quadrivalent bacterins protect against canicola, icterohaemorrhagiae, grippotyphosa, and pomona serovars, whereas bivalent bacterins cover only canicola and icterohaemorrhagiae. immunization does not prevent the development of the carrier state or protect against other serovars. control requires preventing contact with wildlife reservoirs as well as identification of carrier animals. treatment doxycycline is the drug of choice as it can eliminate renal colonization. if vomiting or allergic reactions prohibit treatment with doxycycline, ampicillin or other penicillins should be utilized. aggressive fluid therapy and supportive care may also be needed. research complications due to the zoonotic potential, dogs with clinical leptospirosis should not be used in research studies. etiology campylobacter spp. are thin, curved or spiral, microaerophilic, thermophilic motile gram-negative rods. many species of campylobacter have been isolated from normal and diarrheic animals; however, the most common pathogenic species include campylobacter jejuni ssp. jejuni and c. coli (marks et al., 2011) . clinical signs most adult animals infected with c. jejuni are asymptomatic carriers; clinical signs are most commonly noted in dogs that are less than 6 months of age (greene, 2000; burnens et al., 1992) . in cases of clinical illness, mild and intermittent mucoid or watery diarrhea, with or without frank blood, is most commonly noted. signs typically last 5-21 days but can persist for several months. tenesmus, inappetance, vomiting, and a mild fever may accompany the diarrhea (marks et al., 2011) . bacteremia and cholecystitis secondary to c. jejuni have also been documented in dogs (fox, 2012) . epizootiology and transmission the role of campylobacter spp. as a primary pathogen has been questioned; it may require a coenteropathy to produce disease (sherding and johnson, 1994) . stress or immunosuppression may make animals more susceptible. transmission is via the fecal-oral route, mostly through contaminated food or water. campylobacter jejuni can be zoonotic with immunocompromised individuals at greatest risk. pathologic findings lesions depend on the mechanism of the enteropathy (van kruiningen, 1995) . enterotoxin production results in dilated, fluidfilled bowel loops, with little or no histopathologic alteration. cytotoxin-mediated disease results in a friable, hemorrhagic mucosal surface. histologically, the mucosa is ulcerated with lymphoplasmacytic infiltration. translocation can result in edema and congestion of the lamina propria with focal accumulation of granulocytes. epithelial hyperplasia and decreased goblet cell numbers are also noted. campylobacter jejuni may be visualized between enterocytes with warthin-starry silver-stained sections. pathogenesis clinical disease may be produced by several different mechanisms as campylobacter spp. have a variety of virulence factors including enterotoxins, cytotoxins, and adherence or invasion properties. campylobacter jejuni can cause an erosive enterocolitis by invasion of epithelium and production of the cytolethal distending toxin (cdt) (fox, 2012; van kruiningen, 1995) . in addition, c. jejuni can produce illness via translocation to regional lymph nodes causing a mesenteric lymphadenitis. diagnosis and differential diagnosis fresh feces (per rectum) can be used for presumptive diagnosis by demonstration of highly motile, curved or spiral organisms with dark-field or phase-contrast microscopy. gram-stained c. jejuni appear as gull-winged rods. definitive diagnosis requires isolation of the organism (sherding and johnson, 1994) . culture requires selective isolation media, and growth is favored by reduced oxygen tension and a temperature of 37°c. a pcr multiplex assay for differentiation of c. jejuni, c. coli, c. lari, c. upsaliensis, and c. fetus ssp. fetus has been developed (wang et al., 2002) . any disorder that can cause diarrhea in dogs should be considered as a differential diagnosis. prevention and control proper environmental sanitation, waste disposal, and food storage can prevent campylobacteriosis. in enzootic situations, group housing should be avoided. outbreaks are controlled by isolation and treatment of affected individuals. treatment antibacterial treatment should be considered in severely ill dogs. erythromycin, neomycin, enrofloxacin, clindamycin, and doxycycline are all effective. resistance to quinolones and ciprofloxacin has been documented (acke et al., 2009) . treatment should be a minimum of 10-14 days with bacterial cultures repeating 1 and 4 weeks after treatment. research complications dogs with clinical campylobacteriosis have temporary derangements to digestive and absorptive functions. etiology helicobacters are gram-negative, microaerophilic, spiral bacteria that infect the gastrointestinal tract. helicobacter spp. can be separated into gastric and enterohepatic groups. the gastric helicobacters commonly identified in dogs are referred to as non(haesebrouck et al., 2011; joosten et al., 2013) . the most common enterohepatic species found in dogs include h. bilis, h. canis, and h. cinaedi (castiglioni et al., 2012; dewhirst et al., 2005; fox, 2012 (haesebrouck et al., 2009; fox, 2012) . clinical signs most infections are subclinical in the dog. gastric infections may present with vomiting, diarrhea, and fever, accompanied by anorexia, pica, or polyphagia. enterohepatic helicobacters have been linked with inflammatory bowel disease in experimental animal models. heavy infections in dogs have been associated with inflammatory lesions of the large intestine (castiglioni et al., 2012; nguyen et al., 2013) . epizootiology and transmission the epizootiology and transmission of helicobacter spp. in the dog remain unknown. both oral-oral and fecal-oral routes for transmission have been suggested in humans, but transmission via canine saliva is a less reliable source of infection (craven et al., 2011) . enterohepatic infections of pet dogs are as high as 52% (castiglioni et al., 2012) . prevalence of gastric helicobacter infections in colony or shelter dogs can be as high as 82-100% (fox, 1995; hermanns et al., 1995) . pathologic findings gastritis is usually mild and characterized by reduced mucus content of the surface epithelium with vacuolation, swelling, karyolysis, and karyorrhexis of parietal cells. multifocal infiltrates of plasma cells and neutrophils occur around blood vessels and between gastric pits (hermanns et al., 1995) . intestinal lesions include mild to moderate lymphoplasmacytic infiltration as well as crypt dilation and crypt hyperplasia (castiglioni et al., 2012) . pathogenesis gastric helicobacters are urease positive, which assists with survival in the acidic environment of the stomach (kusters et al., 2006; uberti et al., 2013) . enterohepatic helicobacters are urease negative and typically reside in the lower intestine. the mechanism by which enterohepatic helicobacters colonize the liver is thought to be through portal circulation after uptake by enterocytes or through retrograde movement from the intestine into the bile duct (fox, 2012) . diagnosis and differential diagnosis organisms may be demonstrated with histopathology on endoscopic or surgical biopsy tissue samples. warthin-starry silver stain may increase the sensitivity for histopathologic diagnosis. culture may be difficult depending on the helicobacter spp. for species that produce urease, a positive urease test on a gastric biopsy specimen may give a presumptive diagnosis. the urea breath test has been successfully used to diagnose helicobacter spp. in laboratory beagles with a sensitivity and specificity of 89% (kubota et al., 2013) . western blot has been used to detect serum antibodies to enterohepatic species and pcr can be used to detect helicobacter spp. in fecal samples (oyama et al., 2012; wadström et al., 2009) . any causes of acute or chronic vomiting and diarrhea in the dog are differential diagnoses. prevention and control until more is known about the epizootiology and transmission of helicobacter spp., specific recommendations cannot be made for prevention and control. treatment for gastric species, combination therapy of amoxicillin (10 mg/kg q12 h), metronidazole (30 mg/kg q24 h), and sucralfate (0.25-0.5 mg/kg q8 h) has proven to be most effective (hall and simpson, 2000) . replacing sucralfate with famotidine, omeprazole, or bismuth subsalicylate may also be effective (marks, 1997; jenkins and bassett, 1997; denovo and magne, 1995) . recurrence rates within 60 days of treatment can be as high as 80% (anacleto et al., 2011) . treatment of enterohepatic helicobacters may depend on species susceptibility. aminoglycosides have been successful in treating h. cinaedi, but resistance to fluoroquinolones has been documented (tomida et al., 2013) . combination therapy of amoxicillin, clarithromycin, metronidazole, and omeprazole in medicated chow has been successful in eliminating various enterohepatic helicobacters from mice (del carmen martino-cardona et al., 2010) . long-term antibiotic treatment at a minimum of 21 days is suggested for enterohepatic and gastric helicobacters. research complication dogs used in gastrointestinal physiology or oral pharmacology studies should be free from helicobacteriosis. etiology parvoviral enteritis in dogs is caused by canine parvovirus strain 2 (cpv-2) of the family parvoviridae, genus protoparvovirus, species carnivore protoparvovirus 1. currently, there are three antigenic variants, 2a, 2b, and 2c. parvoviruses are nonenveloped, single-stranded dna viruses. clinical signs while parvoviral infection can affect the gastrointestinal tract, bone marrow, myocardium, and nervous tissues, the most common manifestation of disease is acute enteritis. clinical signs usually appear 5 days after fecal-oral inoculation and include anorexia, fever, depression, vomiting, and profuse intractable diarrhea which may become hemorrhagic. excessive fluid and protein losses through the gastrointestinal tract result in rapid and severe dehydration. dogs can develop severe leukopenia with a total leukocyte count of 1000 cells/μl or less. repeated hemograms may provide prognostic value, as rebounds in leukocyte counts are indicative of impending recovery. terminally ill dogs may develop hypothermia, icterus, or disseminated intravascular coagulation due to endotoxemia. epizootiology and transmission parvovirus can infect dogs of any age, but puppies between 6 and 20 weeks of age are particularly susceptible. puppies less than 6 weeks of age are protected by passive maternal antibody. strain cpv-2c has been associated with severe disease in adult vaccinated dogs (calderon et al., 2009) . pathogenesis canine parvovirus has an affinity for rapidly dividing cells of the intestine and causes acute enteritis with intestinal crypt necrosis and villus atrophy. the virus also has tropism for the bone marrow and lymphoid tissues; thus, leukopenia and lymphoid depletion accompany the intestinal destruction. diagnosis and differential diagnosis parvovirus can be detected with a commercially available fecal enzyme-linked immunosorbent assay (elisa). due to intermittent and brief shedding of the virus, fecal elisas can have false-negative results. pcr can be used to confirm an elisa result and to differentiate the viral strain. at necropsy, diagnosis is based on gross and histopathologic evidence of necrosis and dilatation of intestinal crypt cells with secondary villous collapse. prevention and control parvoviral-positive animals should be quarantined for at least 10 days as the infectious virus is shed for several days after onset of clinical signs. although pcr has been used to detect viral dna in feces for up to 6 weeks (decaro et al., 2005) , it is currently unknown if the material being shed at this time is still infectious. disinfection of exposed areas with dilute bleach (1:30) or a commercial disinfectant is essential for elimination of the virus. six-week-old puppies should be vaccinated every 2-4 weeks with a modified live vaccine until at least 16 weeks of age. treatment treatment is largely supportive and aimed at restoring fluid and electrolyte balance. antimicrobial therapy is recommended due to intestinal compromise and risk of sepsis. early nutritional support continued throughout the disease has been shown to decrease recovery times (mohr et al., 2003) . research complications infection with parvovirus precludes the use of a particular dog in an experimental protocol. due to the significant discomfort of the animal, as well as the intensive therapy required, humane euthanasia is usually chosen in a research setting. etiology rabies virus is a lyssavirus belonging to the family rhabdoviridae. clinical signs clinical progression of neurologic disease occurs in three stages. the first, prodromal, stage is characterized by a change in species-typical behavior. the loss of the instinctive fear of humans by a wild animal is a classic sign of impending rabies. in the second, furious, stage, animals are easily excited or hyperreactive to external stimuli and will readily bite at inanimate objects. the third, paralytic, stage is characterized by incoordination and ascending ataxia of the hindlimbs due to viral-induced damage of motor neurons. death due to respiratory failure usually occurs after onset of the third stage. wild animals such as raccoons, skunks, and bats are common reservoirs of infection for domestic animals, which in turn are the principal source of infection for humans. transmission occurs primarily by contact with infected saliva, usually via bite wounds. pathogenesis the incubation period for rabies is 3-8 weeks to the onset of clinical signs but can range from 1 week to 1 year. bites to the head and neck result in shorter incubation periods due to the close proximity to the brain. following infection, the virus migrates centripetally via peripheral nerve fibers to neurons within the brain, resulting in neurologic dysfunction. on reaching the brain, the virus migrates centrifugally to the salivary glands, thus enabling shedding and subsequent transmission. diagnosis and differential diagnosis definitive diagnosis is based on immunofluorescence of the virus in negri bodies of hippocampal cells. submission of the whole, unfixed brain, including the cerebellum and proximal brain stem, should be done within 48 h of collection. the tissue should be kept refrigerated as freezing can cause delays in testing. differential diagnoses laboratory animal medicine include pseudorabies, canine distemper, bacterial meningitis, and toxicants that affect neurologic function. prevention and treatment puppies should be vaccinated by 16 weeks of age, again at 1 year, and then annually or triennially, depending on state and local laws. research complications immuno-prophylaxis is recommended for animal care and research personnel who may have work-related risks of exposure. due to risk of human exposure, animals with suspected infection should be humanely euthanized and brain tissue should be submitted for confirmation. giardiasis giardia lamblia, also known as g. duodenalis and g. intestinalis, is a binucleate flagellate protozoan that usually causes subclinical infestation of the small intestine. clinical disease is usually seen in young dogs and the characteristic sign is voluminous, light-colored, foul-smelling, soft to watery diarrhea, which is the result of malabsorption and hypersecretion. giardia has a direct life cycle with infection resulting after consuming cyst-contaminated food or water. the change in ph between the stomach and duodenum activates excystation and trophozoites then attach to the enterocytes. for diagnosis, direct fecal smears are considered best for observing trophozoites and zinc sulfate centrifugation is preferred for detection of cysts. a commercial elisa kit is licensed for use in dogs, but the positive predictive value is poor and zinc sulfate centrifugation techniques should be used in conjunction with elisa (rishniw et al., 2010) . pcr assays are also available for diagnosing giardiasis. differential diagnoses for giardiasis include bacterial and protozoal enteritis, coccidiosis, and whipworm infestation. metronidazole at 25-30 mg/kg po q12 h for 5-10 days is effective at treating giardiasis as well as other enteric protozoans, which may be potential differential diagnoses or coinfections. albendazole, fenbendazole, pyrantel, and praziquantel are also effective. coccidiosis intestinal coccidia associated with enteropathy in dogs include isospora canis, i. ohioensis, i. neorivolta, i. burrowsi, and hammondia heydorni (dubey and greene, 2012) . coccidian oocysts can be found in feces of clinically healthy dogs, as well as animals with diarrhea. clinically affected animals are young or immunosuppressed and develop diarrhea, which can vary from soft to watery and may contain blood or mucus. vomiting, dehydration, lethargy, and weight loss can also be seen. coccidia oocysts are typically spread by fecal-oral transmission, but dogs can ingest monozoic cysts in intermediate host tissues. the coccidian life cycle is both sexual and asexual, and results in the release of unsporulated eggs, which sporulate under appropriate environmental conditions. other causes for diarrhea should be excluded before a coccidial etiology is implicated. treatment may not be necessary, as infections are typically self-limiting and clinically insignificant. treatment may help to limit the number of oocysts shed in a kennel-housing situation and may be necessary in cases of protracted clinical illness. possible choices for treatment include daily administration of sulfadimethoxine (50-60 mg/kg po q24 h for 10-20 days) or trimethoprim sulfa (30 mg/kg po q8 h for 10 days). ascarids roundworms of dogs are most often toxocara canis; however, toxascaris leonina can also affect dogs. clinical illness is usually only seen in young animals with large worm burdens. diarrhea, vomiting, dehydration, and abdominal discomfort with vocalization can be seen. puppies may have a classical 'potbellied' appearance. heavy infestations can cause intussusception and/or intestinal obstruction. puppies that experience lung migrations of larval worms can develop fatal pneumonia. toxascaris canis can infect dogs by transplacental migration, transmammary migration, or ingestion of infective eggs. the infective stage of t. canis is the third-stage larva (l3). in transplacental infections, puppies may be born with l3 larvae in their lungs (sherding, 1989) . for diagnosis, large (70-85 μm in diameter) and relatively round ascarid eggs can be seen by standard fecal flotation methods. monthly administration of milbemycin or ivermectin plus pyrantel pamoate is recommended for prevention (hall and simpson, 2000) . most anthelmintics are effective for treatment. puppies should be treated early and often (every other week until 16 weeks of age) because of the possibility of prenatal or neonatal infection. pregnant bitches can be treated with extended fenbendazole therapy (50 mg/kg po once a day from day 40 of gestation through day 14 of lactation). hookworms the most common and most pathogenic hookworm of dogs is ancylostoma caninum. ancylostoma braziliense can also be found in dogs, but only a. caninum infestation typically results in clinical illness. puppies with hookworm infections can present as anemic with bloody diarrhea or melena. other clinical signs include lethargy, anorexia, dehydration, vomiting, and poor weight gain. these signs are a direct result of the worms' consumption of blood and body fluids. infective larvae (l3) are ingested from the environment and develop directly in the intestinal tract. infestation can also be transmammary, from ingestion of a paratenic host, and, less often, by transplacental migration. on histological sections, embedded worms with mouthparts may be identified. diagnosis is made by identification of eggs or larvae by either fecal flotation or direct smear. a differential diagnosis of parvovirus should be considered for puppies with bloody diarrhea, and autoimmune hemolytic anemia should be considered in young dogs with anemia. pyrantel pamoate is the anthelmintic of choice because it is safest in young ill animals. monthly administration of milbemycin or ivermectin plus pyrantel pamoate is recommended for prevention and control (hall and simpson, 2000) . due to transplacental or milkborne infection, puppies should be treated q2 weeks from 2 to 16 weeks of age. whipworms trichuris vulpis, the canine whipworm, can cause acute or chronic large intestinal diarrhea. the adult worm resides in the cecum or ascending colon. most infections are subclinical, but in symptomatic cases, the typical clinical sign is diarrhea with blood and/or mucus. abdominal pain, anorexia, and weight loss may also be seen. dogs may have eosinophilia, anemia, and/or hypoproteinemia on clinical hematology. trichuris vulpis has a direct life cycle with eggs passed in the feces. the penetration of the adult worm into the enteric mucosa, and the associated inflammation, can lead to diarrhea. factors that influence development of clinical symptoms are the number and location of adult whipworms; the severity of inflammation, anemia, or hypoproteinemia in the host; and the overall condition of the host. whipworm infestation is diagnosed by the presence of barrel-shaped, thickwalled eggs with bipolar plugs on fecal flotation. adult worms intermittently release eggs; therefore, negative results do not exclude infection. differential diagnoses for whipworm infestation include giardiasis, coccidiosis, and bacterial enteritis. fenbendazole, oxibendazole, and milbemycin have all been recommended for treatment of whipworms. treatment for whipworm infestation should be at monthly intervals for 3 months (jergens and willard, 2000) . several species of cestodes parasitize the small intestine of dogs. the most common is dipylidium caninum. other species include taenia pisiformis and, more rarely, echinococcus granulosus, multiceps spp., mesocestoides spp., and spirometra spp. most cestode infestations are subclinical, but severe infestations with dipylidium can cause diarrhea, weight loss, and poor growth. the cestode requires an intermediate host, which for d. caninum are fleas and lice. ingestion of these arthropods results in transmission of the tapeworm. definitive diagnosis is usually made by the identification of egg capsules or proglottids (tapeworm segments) on the surface of the feces or around the anus. the most significant means to limit cestode infestation is to control flea and/or louse exposure. praziquantel at 5-12.5 mg/kg orally or subcutaneously is the standard treatment for cestodiasis, especially taenia or echinococcus species. fenbendazole, mebendazole, or oxfendazole may also be effective against d. caninum (hall and simpson, 2000) . demodicosis canine demodicosis is caused by demodex canis, a commensal mite that lives in the hair follicles and is passed from dams to nursing pups. localized demodicosis is typically asymptomatic, but disease can present with variable and nonspecific clinical signs, such as alopecia, erythema, pruritus, crusts, and hyperpigmentation. it can occur anywhere on the body but is often seen on the feet and face, and around the ears (demanuelle, 2000a). generalized demodicosis can develop in juvenile or adult populations and is indicative of an underlying immunosuppressive disorder. demodex has a characteristic 'cigar shape' and can be identified from deep skin scrapings mounted on mineral oil (campbell, 2000; noli, 2000) . differential diagnoses include dermatophytosis, allergic contact dermatitis, and seborrheic dermatitis. the primary differential diagnosis for generalized demodicosis is primary bacterial pyoderma, which is also a common secondary complication of generalized demodicosis. ivermectin at 200-600 μg/kg and oral milbemycin at 1-2 mg/kg/day are effective treatments. treatment duration can be extensive and must be accompanied by repeated skin scrapings. sarcoptic mange canine sarcoptic mange is caused by sarcoptes scabiei var. canis, which is zoonotic. the most common clinical sign is an intense pruritus, usually beginning at sparsely furred areas of the ear pinnae, elbows, ventral thorax, and abdomen. lesions are characterized by alopecia and yellowish dry crusts with a macular papular eruption. these lesions may be exacerbated by excoriation due to the pruritic nature of the condition. adult mites, mite eggs, or mite feces may be observed on superficial skin scrapings, but diagnosis may be difficult because multiple skin scrapings may yield negative results. even if scrapings are negative, a therapeutic trial should be initiated if the clinical signs and history suggest a sarcoptes etiology. demonstration of anti-mite ige either in the serum or via an intradermal antigen test can be used as a diagnostic aid (campbell, 2000) . histologic examination is nondiagnostic; however, suggestive lesions include small foci of edema, exocytosis, degeneration, and necrosis . an important differential diagnosis is flea allergy dermatitis (fad). unless antiparasitic therapy would interfere with research objectives, all dogs with sarcoptic mange should be treated. in addition, their kennel mates should also be treated due to the contagious nature of the disease and its zoonotic potential. the usual means of treatment is either ivermectin at 200-400 μg/kg q14 days or milbemycin at 2 mg/kg q7 days for three oral doses . ticks ticks are obligate arachnid parasites that require vertebrate blood as their sole food source. genera that more commonly infest dogs in the united states include species of rhipicephalus, dermacentor, amblyomma, and ixodes. the primary significance of tick infestation is vector-borne infectious diseases, including rocky mountain spotted fever (rickettsia rickettsii), lyme disease (borrelia burgdorferi sensu stricto), thrombocytic anaplasmosis (anaplasma platys), and canine monocytic ehrlichiosis (ehrlichia canis). ticks alone cause minimal signs unless the dog develops a hypersensitivity reaction leading to a more granulomatous response at the bite location (merchant and taboada, 1991) . some species (primarily dermacentor andersoni and d. variabilis) produce a salivary neurotoxin that causes an ascending flaccid paralysis (malik and farrow, 1991) . uncomplicated tick bites and tick-bite paralysis are diagnosed by identification of the tick and clinical signs of paralysis. dogs with tick-bite paralysis usually show improvement within 24 h of tick removal, with complete recovery within 72 h (malik and farrow, 1991) . formamidines (amitraz), pyrethroids, and phenylpyrazoles (fipronil) are available as spot-ons, collars, sprays, and foggers to treat tick infestations in both the animal and the environment (halos et al., 2014; beugnet and franc, 2012) . differential diagnoses for tick-bite paralysis include botulism, snakebite, polyradiculoneuritis, and idiopathic polyneuropathy (malik and farrow, 1991) . fleas the most common flea to infest dogs is ctenocephalides felis felis, the cat flea (sousa, 2010) . flea infestations usually cause foci of alopecia and pruritus. dogs that are hypersensitive to antigenic proteins in flea saliva develop severe fad, which features papules, crusting, and excoriations over the lumbosacral region, flanks, thighs and abdomen. these animals may require oral corticosteroids to relieve clinical signs (muller et al., 1983) . secondary bacterial and fungal infections can also develop. fleas can also transmit other parasitic diseases, such as dipylidium tapeworms. flea infestations and fad are definitively diagnosed by observing the fleas on the host's skin; however, the presence of flea excrement can support a presumptive diagnosis (demanuelle, 2000b) . treatment of flea infestations should use an integrated pest management (ipm) approach that targets adult fleas, immature stages, and environmental contamination in order to limit the risk of chemoresistance. combining ovicidal treatments, such as lufenuron and selamectin, with adulticidal treatments, such as fipronil, spinosad, selamectin, and imidacloprid, is recommended (halos et al., 2014; beugnet and franc, 2012; dryden et al., 2012) . certain chemicals (i.e., imidacloprid and selamectin) have both adulticidal and larvacidal abilities, but the principles of ipm preclude the use of one product solely for both adulticidal and larvacidal properties (schwassman and logas, 2009 ). differential diagnoses include mite and louse infestations, bacterial folliculitis, and allergic or atopic conditions that present with skin lesions in dogs. canine dermatophytoses are commonly caused by microsporum spp., trichophyton spp., and epidermophyton spp. (moriello and deboer, 2012) . uncomplicated infections are characterized by circular areas of alopecia and crusting with or without follicular papules, usually around the face, neck, and forelimbs. dermatophytes infect the hair shaft and follicle, as well as the surrounding skin. infected hairs become brittle and broken shafts remain infective in the environment for months. dermatophytoses are zoonotic and easily transmitted to other animals through the environment or by direct contact. definitive diagnosis is made using dermatophyte test medium for culture. hair and crust material from infected sites can be plucked and placed on culture; however, the 'toothbrush' method is more effective for sampling multiple sites. the brush is used to comb hairs and scales from several infected sites and then pressed into the culture media. media plates should be visually inspected daily for 14 days. positive cultures will become red at the same time as growth of a fluffy white colony. microscopic examination of hairs and scales to visualize fungal elements can be done using skin scrapings in 20% koh or mineral oil; however, this method is not very sensitive. topical and systemic therapy should be initiated together after all suspected areas are clipped to reduce spreading of contaminated fragile hairs. wholebody topical therapies with antifungal shampoos, rinses, and creams are recommended rather than spot treatment. systemic therapy can be achieved with griseofulvin, ketoconazole, itraconazole, or fluconazole. due to the highly infective nature of this disease, animals should be isolated and the environment thoroughly disinfected. chlorhexidine and virkon ® s are ineffective at clearing environmental spores, but lime sulfur (1:33), enilconazole (0.2%), and bleach (1:10) are effective across many strains of microsporum canis (moriello and deboer, 2002) . although the incidence of hypothyroidism in the canine population is not high (kemppainen and clark, 1994) , deficiency in thyroid hormone can significantly laboratory animal medicine affect basal metabolism and immune function. because these factors are important in many biomedical research studies, it is imperative that laboratory animal veterinarians be able to recognize, diagnose, and treat this problem. etiology primary hypothyroidism affects the thyroid gland directly, whereas secondary hypothyroidism has indirect effects through dysfunction of the pituitary gland (seguin and brownlee 2012) . both of these causes result in a gradual loss of functional thyroid tissue (avgeris et al., 1990; kemppainen and clark, 1994) . the majority of cases of canine hypothyroidism are due to lymphocytic thyroiditis, an autoimmune disorder, or idiopathic atrophy of the thyroid gland. lymphocytic thyroiditis is the major cause of hypothyroidism in laboratory beagles and appears to be familial in that breed (tucker, 1962; beierwaltes and nishiyama, 1968; manning 1979) . rarely, congenital defects or nonfunctional tumors may cause hypothyroidism (peterson and ferguson, 1989; kemppainen and clark, 1994) . clinical signs because it affects metabolism in general, hypothyroidism can produce a large number of clinical signs referable to many organ systems. an individual dog with hypothyroidism may have one or any combination of clinical signs. hypothyroidism reduces the dog's metabolic rate, which then produces such signs as obesity, lethargy, cold intolerance, and constipation. additionally, hypothyroidism can produce several dermatologic abnormalities, including nonpruritic, bilaterally symmetrical alopecia, hyperpigmentation, seborrhea, and pyoderma (avgeris et al., 1990; peterson and ferguson, 1989; panciera, 1994) . several clinicopathologic abnormalities have also been reported in a large percentage of hypothyroid dogs. these aberrations include increased serum cholesterol and triglycerides due to a decrease in lipolysis and decreased numbers of low-density lipopolysaccharide receptors (peterson and ferguson, 1989; panciera, 1994) . normocytic, normochromic, nonregenerative anemia may be seen in approximately one-half of the cases (avgeris et al., 1990) . increased serum alkaline phosphatase and creatine kinase have also been reported in a significant number of hypothyroid dogs (peterson and ferguson, 1989; panciera 1994) . neurologic signs of hypothyroidism, which include lameness, foot dragging, and paresis, may be caused by several mechanisms such as segmental nerve demyelination or nerve entrapment secondary to myxedema (peterson and ferguson, 1989) . mental impairment and dullness have also been reported in hypothyroid dogs, secondary to atherosclerosis and cerebral myxedema (peterson and ferguson, 1989) . hypothyroidism has been implicated in other neurological abnormalities such as horner's syndrome, facial nerve paralysis, megaesophagus, and laryngeal paralysis; however, these conditions do not always resolve with treatment (bichsel et al., 1988; panciera, 1994) , and a true causal relationship with hypothyroidism has not been completely defined (panciera, 1994) . myopathies associated with hypothyroidism are caused by metabolic dysfunction and atrophy of type ii muscle fibers and can present with signs similar to neurological disease (peterson and ferguson, 1989) . hypothyroidism can also cause abnormalities of the cardiovascular system including bradycardia, hypocontractility, increased vascular volume, and atherosclerosis (seguin and brownlee 2012) . abnormalities that may be detected by ecg include a decrease in p-and r-wave amplitude (peterson and ferguson, 1989 ) and inverted t waves (panciera, 1994) . these ecg abnormalities are caused by lowered activity of atpases and calcium channel function. an association between hypothyroidism and von willebrand disease has been suggested. however, the relationship is probably one of shared breed predilection and not a true correlation. contradictory studies have shown either deficient (avgeris et al., 1990) or normal (panciera and johnson 1994, 1996; avgeris et al., 1990) von willebrand factor antigen and bleeding times in hypothyroid dogs. most importantly, hypothyroidism does not appear to cause overt, clinical von willebrand disease. however, it may exacerbate existing subclinical von willebrand disease (seguin and brownlee, 2012) . epizootiology the prevalence of hypothyroidism in the general canine population is reportedly less than 1% (panciera, 1994) . the disorder occurs most often in middle-aged, larger breed dogs (avgeris et al., 1990) , and reports suggest a higher incidence of hypothyroidism in spayed, female dogs (panciera, 1994; peterson and ferguson, 1989) . doberman pinschers and golden retrievers appear to have a higher incidence of hypothyroidism compared with other breeds (panciera, 1994; peterson and ferguson, 1989; scarlett, 1994) . there have been several reports about hypothyroidism in laboratory colonies of beagles (manning, 1979; tucker, 1962; beierwaltes and nishiyama, 1968) . diagnosis and differential diagnosis because of the large number of clinical manifestations in dogs, the recognition of hypothyroidism is not always straightforward. likewise, the diagnosis of hypothyroidism can be difficult because of the lack of definitive diagnostic tests available for the dog. a complete understanding of the diagnosis of hypothyroidism requires a familiarity with thyroid hormone metabolism and function that is beyond the scope of this writing. for additional information, the reader is referred to one of several manuscripts available (peterson and ferguson, 1989; ferguson, 1994) . currently, the ability to diagnose hypothyroidism relies heavily on the measurement of serum total t 4 (thyroxine) and free t 4 (peterson and ferguson, 1989; ferguson, 1994) . t 4 serves primarily as a precursor for t 3 and is heavily protein bound. free t 4 represents the laboratory animal medicine unbound fraction that is available to the tissues (peterson and ferguson, 1989) . the measurement of total t 4 carries a sensitivity of around 95% and can be used as a good screening tool. with the measurement of both serum total t 4 and free t 4 , hypothyroidism can usually be ruled out if the values are within the normal range or higher. if both hormone concentrations are low, it is highly likely that the patient has hypothyroidism, and a therapeutic trial may be in order (peterson and ferguson, 1989) . however, nonthyroidal illnesses and some drugs (e.g., glucocorticoids, anticonvulsants, phenylbutazone, salicylates) can falsely lower these values (peterson and ferguson, 1989; ferguson, 1994) . therefore, low values do not always indicate that hypothyroidism is present and animals should not be treated solely on the basis of serum hormone levels if clinical signs are not present. if the clinical signs are equivocal or only total t 4 or free t 4 is decreased, further diagnostic testing is warranted (peterson and ferguson, 1989) . although t 3 is the most biologically active form of thyroid hormone, the measurement of serum t 3 levels is an unreliable indicator of hypothyroidism (peterson and ferguson, 1989; ferguson, 1994) . serum t 3 can be falsely lowered by many nonthyroidal illnesses and many drugs (see above). in addition, t 3 may be preferentially released and conversion of t 4 to t 3 may be enhanced by the failing thyroid (peterson and ferguson, 1989; ferguson, 1994) , particularly early in the disease. in one study, t 3 was within normal limits in 15% of the hypothyroid dogs (panciera, 1994) . autoantibodies can be responsible for false elevations in the concentrations of t 3 and t 4 found in these respective assays. it has been recommended that free t 4 , measured by equilibrium dialysis, be assayed in dogs that are suspected of hypothyroidism and have autoantibodies with normal or high t 3 and t 4 . autoantibodies have been found in less than 1% of the samples submitted to one laboratory (kemppainen and behrend, 2000) . other means of diagnosing hypothyroidism have been described. in humans, endogenous thyroid-stimulating hormone (tsh) levels provide reliable information on thyroid status, and an assay is available for dogs. however, endogenous tsh levels can be normal in some dogs with hypothyroidism and high tsh levels have been noted in normal dogs and sick animals that are actually euthyroid. it is therefore recommended that tsh levels be considered along with other information (clinical signs, t 4 ) prior to diagnosis and treatment (kemppainen and behrend, 2000) . tsh stimulation testing using exogenous bovine tsh provides a good and reliable method for establishing a diagnosis. unfortunately, the availability and expense of tsh limit the use of this diagnostic tool (peterson and ferguson, 1989; ferguson, 1994) . another drawback of tsh testing is that the test must be postponed for 4 weeks if thyroid supplementation has been given (peterson and ferguson, 1989) . when tsh is available for testing, there are several recommendations for dosage, routes of administration, and sampling times. one recommendation is 0.045 u of tsh per pound of body weight (up to a maximum of 5 u) to be administered iv. for this protocol, blood samples are taken prior to administration of tsh and 6 h after. a normal response to the administration of tsh should create an increase of t 4 levels at least 2 μg/dl above the baseline levels or an absolute level that exceeds 3 μg/dl (peterson and ferguson, 1989; wheeler et al., 1985) . treatment the treatment of choice for hypothyroidism in the dog is l-thyroxine (sodium levothyroxine). a recommended dosing regimen is 0.01-0.02 mg/kg once a day (avgeris et al. 1990 ). if drugs that decrease thyroxine levels are being administered concurrently, it may be necessary to divide the thyroxine dose for twice daily administration. after the supplementation has begun, the thyroid hormone level should be rechecked in 6-8 weeks, and blood samples should be drawn 4-8 h after the morning pill. a clinical response is usually seen in 6-8 weeks and would include weight loss, hair regrowth, and resolution of other signs (panciera, 1994) . ecg abnormalities also return to normal (peterson and ferguson, 1989) . for dogs with neurologic signs, the prognosis is guarded, because the signs do not always resolve with supplementation (panciera, 1994) . weight gain and eventual obesity are frequent findings in dogs in the research environment. because obesity can adversely affect several body systems as well as general metabolism, the laboratory animal veterinarian must address obesity and its potential effects on animal welfare and research results. etiology obesity is defined as a body weight 20-25% over the ideal. in general, obesity occurs when the intake of calories exceeds the expenditure of energy, the result of overeating or eating an unbalanced diet. overeating is a common cause of obesity in pet dogs and may be triggered by boredom, nervousness, or conditioning (macewen, 1992) . in addition, pet animals are often subjected to unbalanced diets supplemented with high-fat treats. in the laboratory animal setting, overeating is less likely than in a household because access to food is more restricted, and diets are usually a commercially prepared balanced ration. however, obesity can still be a problem if specific guidelines for energy requirements are not followed. in addition, the necessary caging of dogs in the research environment and limitation to exercise reduces energy expenditure. it is also important to realize that other factors may predispose dogs to obesity, even when guidelines for caloric intake and energy laboratory animal medicine expenditure are followed (butterwick and hawthorne, 1998) . as in humans, genetics plays an important role in the development of obesity in dogs, and certain breeds are more predisposed toward obesity. in a study of dogs visiting veterinary clinics in the united kingdom, labrador retrievers were most likely to be obese. other breeds affected included cairn terriers, dachshunds, basset hounds, golden retrievers, and cocker spaniels. the beagle was also listed as a breed predisposed to obesity in the household environment (edney and smith, 1986) . several metabolic or hormonal changes are also associated with obesity. it has been well established that neutering promotes weight gain. in one study, spayed female dogs were twice as likely to be obese compared with intact females (macewen, 1992) . the authors proposed that the absence of estrogen promotes an increase in food consumption. a similar trend toward obesity was found in castrated male dogs (edney and smith, 1986 ). in addition, hypothyroidism and hyperadrenocorticism may present with obesity as one of the clinical signs (macewen, 1992) . differential diagnosis the diagnosis of obesity is somewhat subjective and relies on an estimate of ideal body weight. the ideal body condition for dogs is considered to be achieved when the ribs are barely visible but easily palpated beneath the skin surface. when the ribs are not easily palpated and/or the dog's normal function is impaired by its weight, the animal is considered obese. there are few objective, quantifiable methods for establishing this diagnosis. ultrasound has been evaluated for measurement of subcutaneous fat in dogs, and measurements taken from the lumbar area can be used to reliably predict the total body fat (wilkinson and mcewan, 1991) . after a diagnosis of obesity has been made, additional diagnostic tests should be performed to determine if there is an underlying cause for the problem. a complete physical exam should be performed to look for signs of concurrent disease and to establish if obesity has adversely affected the individual. serum thyroid hormones should be evaluated (see above), and serum chemistry may reveal an increased alkaline phosphatase associated with hyperadrenocorticism. treatment restricting food intake readily treats obesity, and this is easily done in the research setting. it has been suggested that a good weight loss program involves restriction of intake to 60% of the calculated energy requirement to maintain ideal body weight. it has been shown that restriction of calories down to 50% produces no adverse health effects. however, t 3 levels will decrease in direct proportion with caloric intake. ideally, weight loss will occur at a rate of 1-2% of body weight per week (laflamme et al., 1997) . with more severe calorie restriction and more rapid weight loss, the individual is more likely to have rebound weight gain after restrictions are relaxed. there has been a great deal of attention in humans as to the correct diet to encourage weight loss. likewise, the type of diet fed to dogs has been examined. as mentioned above, the restriction of calories is most important, and feeding less of an existing diet can do this. alternatively, several diet dog foods are available, and there is some evidence that these diets are superior to simple volume restriction (macewen, 1992) . there has been much concern about the addition of fiber to the diet as a method for reducing caloric intake while maintaining the volume fed. studies in dogs have examined the addition of both soluble and insoluble fibers to calorie-restricted diets. these studies have shown that the addition of fiber does not have an effect on satiety in dogs and therefore does not have a beneficial effect in weight loss protocols (butterwick et al., 1994; butterwick and markwell, 1997) . research complications it is important to control weight gain in research animals because of the association of obesity with metabolism. although an association between obesity and reproductive, dermatologic, and neoplastic problems has been reported (macewen, 1992) , this relationship is not consistently apparent (edney and smith, 1986) . joint problems including osteoarthritis and hip dysplasia have also been related to obesity (macewen, 1992; kealy et al., 1997) . in addition, diabetes mellitus has been linked to obesity and obesity-induced hyperinsulinism in several experimental models (macewen, 1992) . a recent study demonstrated metabolic disease, typified by hyperinsulinemia and hypoadiponectinemia, in approximately 20% of obese dogs (tvarijonaviciute et al., 2012) . research that requires anesthesia may be complicated by a greater risk of cardiovascular diseases (edney and smith, 1986) including hypertension and compromise to the respiratory tract. etiology in the laboratory setting, the majority of traumatic wounds will be small in size and quickly observed. occasionally, dogs may sustain minor trauma during transport or have a small, previously undetected, chronic wound upon arrival at the facility. when dogs are group housed, they may sustain bite wounds during early socialization periods. under these conditions, proper initial treatment will lead to uncomplicated wound healing. complications such as infection and delayed healing arise when wounds are not noticed immediately or when the basic principles of wound management are not followed. clinical signs the signs and appearance of a traumatic wound will vary with the cause and the duration of time since wounding. abrasions, sustained by shear forces, are partial thickness skin wounds characterized laboratory animal medicine by minimal bleeding or tissue disruption. puncture wounds have a small surface opening but penetrate into deep tissues with the potential for contamination. lacerations are wounds caused by sharp separation of skin that may extend to deeper tissues. acute wounds are characterized by bleeding tissue, sharp edges and no obvious devitalization. they have variable degrees of contamination. chronic wounds generally do not exhibit active bleeding and will have curled or rounded edges. these wounds often have necrotic tissue and are considered contaminated. treatment to aid decision making about wound therapy, several classification systems have been developed for traumatic injuries. at one time, decisions about wound therapy were largely based upon the length of time since wounding, or the concept of a 'golden period.' it is now recognized that several factors must be considered prior to initiating wound care, including (but not limited to) the type and size of the wound, the degree of wound contamination, and the competence of the host's defense systems (swaim, 1980; waldron and trevor, 1993) . one of the most widely used classification systems is based upon wound contamination and categorizes wounds as clean, clean-contaminated, contaminated, or dirty (see table 12 .9). the vast majority of the wounds seen in the laboratory setting will fall into the clean and clean-contaminated categories. these wounds may be treated with the basic wound care described below and primary closure of the wound. contaminated and dirty wounds require more aggressive therapy. postsurgical infections or complications of initial therapy would be considered dirty wounds. when in doubt as to the classification of a wound, the worst category should be presumed in order to provide optimal therapy and reduce the chance for complications. the initial treatment of a wound is the same regardless of its classification. when first recognized, the wound should be covered with a sterile dressing until definitive treatment can be rendered. bleeding should be controlled with direct pressure; tourniquets are discouraged because of the complications that may arise with inappropriate placement (swaim, 1980) . it is best to avoid using topical disinfectants in the wound until further wound treatment (culture, debridement, lavage) has been performed (swaim, 1980) . anesthesia or analgesia may be necessary and the choice of agent will depend on the size and location of the wound as well as the preference of the clinician. if the wound is contaminated or dirty, bacterial cultures, both aerobic and anaerobic, should be performed. then a water-soluble lubricant gel may be applied directly to the wound to prevent it from further contamination during the hair removal process. a wide margin of hair should be clipped and a surgical scrub performed around the edges of the wound. povidone-iodine alternating with alcohol or chlorhexidine gluconate scrub alternating with water is most often recommended for surgical preparation of the skin surface (osuna et al., 1990a, b) . simple abrasions that involve only a partial thickness of the skin do not generally require further treatment. full-thickness wounds require further attention, including irrigation with large quantities of a solution delivered under pressure. several irrigation solutions have been recommended (lozier et al., 1992; waldron and trevor, 1993; sanchez et al., 1988) , but type may not be as important as the volume and pressure of delivery. it has been suggested that 8 psi is required to obtain adequate tissue irrigation, and this may be achieved by using a 35-ml syringe with an 18-or 19-gauge needle (waldron and trevor, 1993) . for wounds that are contaminated or dirty, debridement is an important part of initial therapy. debridement usually proceeds from superficial to deeper layers. skin that is obviously necrotic should be removed. although it is often recommended to remove skin back to the point at which it bleeds, this may not be feasible with large wounds on the limbs. in addition, other factors such as edema or hypovolemia may reduce bleeding in otherwise viable skin (waldron and trevor, 1993) . if one is unsure about tissue viability in areas that are devoid of waldron and trevor (1993) . extra skin, the tissue may be left (swaim, 1980; waldron and trevor, 1993) , and nonviable areas will demarcate within 2-3 days (waldron and trevor, 1993) . necrotic fat should be resected liberally, because it does not have a large blood supply and will provide an environment for infection. often, resection of subcutaneous fat is necessary to remove debris and hair that could not be removed during wound irrigation. damaged muscle should also be liberally resected (swaim, 1980) . the wound should be irrigated several times during debridement and again after completion. after initial wound treatment, the options concerning wound closure must be weighed. the principles of basic surgery are discussed in several good texts, and readers are encouraged to pursue additional information. primary wound closure is defined as closure at the time of initial wound therapy and is the treatment of choice for clean and clean-contaminated wounds. closure is performed in two or more layers, carefully apposing tissues and obliterating dead space. if dead space will remain in the wound, a drain should be placed. subcutaneous closure should be performed with absorbable suture such as polydioxanone, polyglactin 910, or polyglycolic acid. it is best to use interrupted sutures and avoid leaving excess suture material in the wound. it may be necessary to choose tension-relieving suture patterns, such as horizontal mattress. skin closure is generally performed with nylon (3-0 or 4-0). in situations where gross contamination cannot be completely removed, closure of the wound should be delayed or avoided. after debridement and irrigation, the wound should be bandaged. the wound may be covered by a nonadherent dressing such as vaseline-impregnated gauze (swaim, 1980) . the contact layer is covered by cotton padding, and the entire bandage is covered by a supportive and protective layer. the bandages should be changed once or twice daily, depending upon the amount of discharge coming from the wound. wound closure within 3-5 days of wounding (prior to the formation of granulation tissue) is considered delayed primary closure. when the wound is closed after 5 days, this is considered secondary closure (waldron and trevor, 1993) . second-intention healing involves allowing the wound to heal without surgical intervention. this type of healing is often used on limbs when there is an insufficient amount of skin to allow complete closure (swaim, 1980) . it is important to note that second-intention healing will take longer than with surgical repair, and, in the case of large wounds, it will be more expensive because of the cost of bandaging materials. several factors must be weighed when considering the use of antibiotics in traumatic wound care, including the classification and site of the wound, host defenses, and concurrent research use of the animal. when wounds are clean or clean-contaminated, antibiotics are seldom necessary unless the individual is at high risk for infection. when wounds have been severely contaminated or are dirty, antibiotics are indicated and the type of antibiotic will ultimately depend on culture and sensitivity results. until such results are available, the choice of antibiotic is based on the most likely organism to be encountered. topical application of bacitracin, neomycin sulfate, and polymixin b combinations may be used in wounds with minor contamination. in skin wounds with more extensive contamination, staphylococcus spp. are generally of concern, whereas pasteurella multocida should be considered in bite wounds. when systemic antibiotics are necessary, cephalosporins, amoxicillinclavulanate, and trimethoprim sulfas are often recommended for initial antibiotic therapy (waldron and trevor, 1993) . prevention in facilities with good husbandry practices and a diligent staff, potentially injurious equipment or surfaces are identified quickly. appropriate attention to surgical technique and to initial wound care will generally reduce the occurrence of postprocedure wound infection. etiology pressure sores (decubital ulcers) can be a problem in long-term studies and housing situations that require chronic skin contact with hard surfaces. decubital ulcers often develop over a bony prominence such as the elbow, tuber ischii, tarsus, or carpus. the compression of soft tissues between hard surfaces results in vascular occlusion, ischemia, and ultimately tissue death (swaim and angarano, 1990) . several factors that increase pressure at the site and/or affect the integrity of the skin will predispose an individual to develop pressure sores, including poor hygiene, self-trauma, low-protein diet, preexisting tissue damage, muscle wasting, inadequate bedding, and ill-fitting coaptation devices (swaim and angarano, 1990) . clinical signs initially, the skin will appear red and irritated. over time, constant trauma can result in full-thickness skin defects and can progress to necrosis of underlying tissues. the severity of the sores may be graded from i to iv according to the depth of the wound and the tissues involved, from superficial skin irritation to involvement of underlying bone (waldron and trevor, 1993) . epizootiology the problem usually occurs in large dog breeds, but any type of dog can be affected. prevention and control minimizing or eliminating predisposing factors is important to both the prevention and treatment of this condition. if a dog will experience long periods of recumbency, adequate bedding or padding must be provided. recumbent animals should be moved frequently, ideally every 2 h, to prevent continuous compression on a specific laboratory animal medicine area (waldron and trevor, 1993) . skin hygiene is of the utmost importance when trying to prevent or treat pressure sores. the skin should be kept clean and dry at all times. if urine scalding is a problem, the affected area should be clipped, bathed, and dried thoroughly at least once or twice daily. finally, an appropriate diet to maintain body weight will minimize compressive forces experienced over areas susceptible to ulceration (swaim and angarano, 1990) . treatment the treatment of pressure sores must involve care of the wound and attention to the factors causing the wound. the extent of initial wound management will largely depend on the depth of the wound. for simple abrasions and small wounds involving the skin only, simple wound cleansing and openwound management provide adequate treatment. when wounds involve deeper tissues, including fat, fascia, or bone, more aggressive diagnostics and therapy must be performed. the affected area should be radiographed to assess bone involvement and the wound should be cultured. all of the damaged tissue should be debrided and basic wound management guidelines should be followed (see above). when a healthy granulation bed has formed over the entire wound, a delayed closure over a drain may be performed (swaim and angarano, 1990) . with extensive lesions, reconstruction with skin flaps may be necessary (waldron and trevor 1993) . bandaging should be performed on all full-thickness wounds; however, it is important to remember that illfitting or inadequately padded bandages or casts may worsen the problem. the area over the wound itself should not be heavily padded. the wounded area should be lightly covered and then a doughnut, created from rolled gauze or towel, should be fitted around the wound, in order to displace pressure over a larger area and onto healthier tissue. the doughnut is then incorporated into a padded bandage. if a cast has been applied to the area for treatment or research purposes, a hole can be cut over the wound to reduce pressure in that area and allow treatment of the wound (swaim and angarano, 1990) . bandages should be removed at least once or twice a day to allow wound care. etiology an acral lick granuloma is a skin lesion caused by self-trauma. in a few cases, the self-trauma is due to initial irritation caused by an identifiable neurologic or orthopedic condition (tarvin and prata, 1980) . allergy may also be a source of irritation that leads to self-trauma. however, the majority of cases begin because of repetitive licking by dogs that are confined and lack external stimuli (swaim and angarano, 1990) . it has been theorized that the self-trauma promotes the release of endogenous endorphins, which act as a reward for the abnormal behavior (dodman et al., 1988) . the laboratory environment could promote the abnormal behavior and lead to acral lick granuloma. epizootiology the lesions associated with acral lick granuloma are seen most often in large dog breeds, particularly dobermans. however, any type of dog can be affected (walton, 1986) . clinical signs early lesions appear as irritated, hairless areas usually found on the distal extremities (swaim and angarano, 1990) . the predilection for the limbs may be due to accessibility or possibly a lower threshold for pruritus in these areas. as the lesions progress, the skin becomes ulcerated and the wound develops a hyperpigmented edge. the wounds may partially heal and then be aggravated again when licking resumes. diagnosis and differential diagnosis acral lick granulomas must be differentiated from several other conditions, including bacterial or fungal infection, foreign bodies, and pressure sores. in addition, mast cell tumors and other forms of neoplasia can mimic the appearance of acral lick granuloma. many of the aforementioned problems can be ruled out by the history of the animal. however, a complete history may be unavailable in the laboratory setting. fungal cultures and allergy testing may aid in diagnosis. biopsy of the affected area would rule out neoplasia. an uncomplicated acral lick granuloma would feature hyperplasia, ulceration, and fibrosis without evidence of infection or neoplasia (walton, 1986) . prevention and control behavior modification and relief of boredom are important aspects of preventing (and treating) acral lick granuloma. environmental enrichment including exercise, co-housing and various toys is already a basic requirement and may be increased to combat self injurious behaviors. treatment several treatments have been reported for acral lick granuloma and the selection of a treatment should be based on the underlying cause. one of the most important aspects of treatment is to break the cycle of self-trauma. mechanical restraint with an elizabethan collar is one of the easiest methods to accomplish this goal. several direct treatments have been examined, including intralesional and topical steroids, perilesional cobra venom, acupuncture, radiation, and surgery (swaim and angarano, 1990; walton, 1986) . opioid antagonists have been applied as treatments for acral lick granulomas and self-injurious behaviors with the theory that this will block the effects of endogenous opioids. naltrexone and nalmefene have been used successfully to reduce excessive licking behaviors and resolve associated lesions. however, lesions did recur after the drugs were discontinued (dodman et al., 1988; white, 1990) . the topical administration of a mixture of flunixin meglumine, steroid, and dimethyl sulfoxide has also been shown to be effective (walton, 1986) . in addition, psychoactive drugs have been suggested to relief of laboratory animal medicine boredom or anxiety. these have included phenobarbital, megestrol acetate, and progestins. however, side effects have been reported (swaim and angarano, 1990) . other behavior-modifying medications such as clomipramine may be effective in the treatment of compulsive anxiety disorder. the potential for effects that could interfere with experimental results must be determined prior to initiation of treatment. it is important to note that none of the above-mentioned treatments have been successful in all cases. the overall prognosis for acral lick granuloma should be considered guarded since the lesions often recur when treatment is discontinued. etiology hygromas are fluid-filled sacs that develop as a result of repeated trauma or pressure over a bony prominence. the area over the olecranon is most frequently affected, but hygromas have been reported in association with the tuber calcis, greater trochanter, and stifle (newton et al., 1974) . epizootiology elbow hygromas are most frequently reported in large and giant breeds of dogs, less than 2 years of age (johnston, 1975; white, 2003; cannap et al., 2012) . elbow hygromas are seen infrequently in the laboratory animal setting because the commonly affected breeds are seldom used in research. however, the housing environment of research dogs, especially cage bottoms and cement runs, may predispose them to hygromas. for this reason, laboratory animal veterinary and husbandry staff should be familiar with this condition. clinical signs the clinical presentation will depend upon the chronicity of the problem. a dog with an elbow hygroma usually presents with a painless, fluctuant swelling over the point of the elbow without signs of lameness. the condition may be unilateral or bilateral. over a long period of time, elbow hygromas may become inflamed and ulcerated. if the hygroma becomes secondarily infected, the animal may exhibit pain and fever (johnston, 1975; white, 2003) . pathology the fluid-filled cavity in the hygroma is lined by granulation and fibrous tissue. hygromas lack an epithelial lining and therefore are not true cysts. the fluid within the cavity is a yellow or red serous transudate. this fluid is less viscous than joint fluid and elbow hygromas do not communicate with the joint (johnston, 1975) . treatment the treatment of elbow hygromas should be conservative whenever possible. conservative management of the elbow hygroma is aimed at relieving the source of pressure at the point of the elbow. in early and mild cases, simply providing padding to cover hard surfaces will result in resolution of the hygroma. a soft padded bandage or doughnut bandage around the affected site may also be of benefit. neoprene/polyester sleeves that cover the elbows and fit over the shoulders are also available as an option for either prevention or treatment of hygromas (cannap et al., 2012) . more aggressive therapies, including needle drainage and injection of corticosteroids into the hygroma, have been described but are not recommended due to the risk of infection (johnston, 1975) . surgical options should be reserved for complicated or refractory cases. even simple excision can be associated with complications such as wound dehiscence and ulceration (johnston, 1975) due to the location of the bony prominence at the surgical site. this issue may be avoided by using a skin advancement flap (white, 2003) that allows intact, healthy skin to cover the boney prominence. a muscle advancement flap has also been described (green et al., 2008) . regardless of the method used to treat an elbow hygroma, recurrence of the problem is likely unless the predisposing factors are identified and relieved. etiology in the research environment, corneal ulcers are most often associated with direct trauma, contact with irritating chemicals, or exposure to the drying effects of air during long periods of anesthesia. chronic or recurrent corneal ulcers may also be associated with infection or hereditary causes in some breeds of dogs; however, these would be rare in the laboratory setting. clinical signs the signs of corneal ulceration are blepharospasm, epiphora, and photophobia. the eye may appear irritated and inflamed. in minor cases, the cornea may appear normal however, in cases of deeper ulceration, the cornea may appear roughened or have an obvious defect. in addition, the periocular tissues may be swollen and inflamed because of self-inflicted trauma from rubbing at the eye. diagnosis a tentative diagnosis of corneal ulcer or abrasion may be based on the clinical signs. a definitive diagnosis of corneal ulcers is made by the green appearance of the cornea when stained with fluorescein dye. when a corneal ulcer has been diagnosed, the eye should be inspected for underlying causes such as foreign bodies, abnormal eyelids, or abberant cilia. treatment the treatment of corneal ulcers will depend on the depth and size of the affected area, as well as the underlying cause. superficial abrasions are generally treated with topical application of antibiotics. a triple antibiotic ointment that does not contain steroids given three times a day for 2-3 days usually provides adequate treatment. simple corneal ulcers are restained with fluorescein after 3 days and should show complete healing at that time. if the ulcer is not healed, this may indicate that the ulcer has an undermined edge impeding proper healing. topical anesthetic should be applied to the eye, and a cotton-tipped applicator can be rolled over the surface of the ulcer toward its edge. this will remove the unattached edge of the cornea and healing should progress normally after debridement. deep ulcers may require further debridement and primary repair. in such cases, a third eyelid or conjunctival flap may be applied to the eye until experienced help can be obtained. in all cases, an elizabethan collar or other restraint may be necessary to prevent additional trauma to the eye. ulcers caused by entropion, ectropion, or dystichiasis will not resolve until the condition is repaired, and descriptions for this can be found elsewhere. prevention the proper application of lubricant eye ointment at the time of anesthesia will prevent drying due to exposure and may also protect the eye from scrub solutions applied near the eye. early treatment of superficial ulcers should prevent self-trauma and progression of the wound. etiology research protocols often require the placement of chronic implants. implants such as cardiac or other biomedical devices may be the primary focus of the research study. implants may also be used as chronic monitoring devices, for delivery of compounds, or to collect serial samples. infection may occur at the time of implant. alternatively, the implant may serve as a nidus after hematogenous spread from other sources. one of the most common sources of infection is from colonization of the device from an external component, which is a frequent complication with indwelling catheters. the actual incidence of complications associated with indwelling vascular catheters in dogs is unknown. one study (hysell and abrams, 1967 ) examined the lesions found at necropsy in animals with chronic indwelling catheters, which included traumatic cardiac lesions, visceral infarcts, and fatal hemorrhages. these lesions were primarily associated with catheter-induced trauma or secondary to embolization of fibrin. in a veterinary clinical setting, infections in peripheral catheters were more likely when the catheters were used for blood collection immediately after placement and when a 't' connector rather than a 'y' connector was used. . intestinal access ports have been used to study the pharmacokinetics of drugs at various levels in the intestinal tract. these catheters are usually vascular access ports with several modifications to allow secure placement in bowel (meunier et al., 1993) . the most frequently reported complication associated with these catheters is infection around the port site (meunier et al., 1993; kwei et al., 1995) . clinical signs dogs with implant infections may not exhibit signs initially . localized swelling around the implant may occur. in the case of indwelling catheters, signs may include redness and swelling of the skin around the external port or discharge from the skin wound. vascular access ports may develop fluctuant subcutaneous abscesses. in more severe cases, systemic signs may be noted (bach et al., 1998; hysell and abrams, 1967) . the systemic signs of infection are covered elsewhere in this chapter. treatment the treatment of catheter infections almost invariably requires removal of the catheter, as demonstrated in both dogs and monkeys (ringler and peter, 1984; darif and rush, 1983 ). superficial wound irritation or infection may be treated locally with antibiotic ointment, sterile dressing changes, and efforts to minimize catheter movement; however, more extensive problems require aggressive therapy. localized abscesses or sinus tracts may be managed by establishing drainage and copious flushing. aerobic and anaerobic cultures of blood and locally infected sites should be performed prior to initial treatment (ringler and peter, 1984) . systemic antibiotic therapy should be initiated for a 10-day period. the choice of drug will ultimately be based on previous experience and culture results. if retention of a catheter is important, the catheter lumen may be safely disinfected with chlorine dioxide solution (dennis et al., 1989) . the solution is removed after 15 min and replaced with heparinized saline. all of the extension lines and fluids used with an infected catheter should be discarded. the blood cultures should be repeated 3 days after the antibiotic therapy has ceased. if bacteria are still cultured, the catheter must be removed. prevention it is highly desirable to prevent complications that may result in loss of an implanted device. catheters and other implants should be made of nonthrombogenic material and be as simple as possible. a catheter with extra ports or multiple lumens requires additional management and supplies more routes for infection. the initial placement of an indwelling catheter must be done under aseptic conditions by individuals who are familiar with the procedure. intravenous catheters that are used for delivery of drugs or blood sampling should be positioned in the vena cava and not in the right atrium, thereby minimizing trauma to the tricuspid valve. ideally, catheters are secured to reduce movement and irritation of the skin, which may predispose to infection around external ports. the use of vascular access ports that lie entirely under the skin eliminates many problems with infection. it has also been found that long extension tubing connected to the port may actually reduce the potential for infection of the catheter (ringler and peter, 1984) . for intestinal access ports, catheter security may be improved with a synthetic cuff added to the end of the catheter allowing better attachment to the intestine (meunier et al., 1993) . after any catheter placement, animals should be observed daily for signs of either local or systemic infection. the catheter entry site should be disinfected, coated with antibiotic ointment, and rebandaged every other day. once a month, the catheter line may be disinfected with chlorine dioxide. in addition, a solution of the antibiotic ceftazidime used on alternate days with the heparin locking solution has been shown to effectively reduce infections in indwelling vascular catheters (bach et al., 1998) . throughout the life of the catheter, injections into and withdrawals from the catheter should be done in a sterile manner, and the number of breaks in the line should be kept to a minimum. periodically, the placement of an indwelling catheter may be verified by radiography. when placed and managed correctly, catheters and ports of any kind may remain in place for months without complications. etiology sepsis is defined as the systemic response to infection caused by bacteria (gram negative and/or gram positive), fungi, or viruses. in laboratory animals, sepsis is most often seen as a complication of surgical procedures or associated with chronic implants. sepsis may also be seen as a complication of infectious diseases such as parvovirus. clinical signs the signs of sepsis can vary, depending on the source of the infection and the stage of the disease. early in the course, dogs may present with signs of a hyperdynamic sepsis, including increased heart rate, increased respiratory rate, red mucous membranes, and a normal-to-increased capillary refill time. systemic blood pressure and cardiac output will be increased or within the normal range. the animals will often be febrile. later in the course of the syndrome, the animals may show classic signs of septic shock including decreased temperature, pale mucous membranes, and a prolonged capillary refill time. cardiac output and blood pressure are decreased as shock progresses. peripheral edema and mental confusion have also been reported (hauptman and chaudry, 1993) . pathogenesis the pathophysiology of sepsis is complex and is mediated by immune responses involving mediators such as cytokines, eicosinoids, complement, superoxide radicals, and nitric oxide. the body responds to overwhelming infection with an attempt to optimize metabolic processes and maximize oxygen delivery to tissues. however, if inflammation is left unchecked, the system may be unable to compensate, and the result is cardiovascular collapse. diagnosis in general, a presumptive diagnosis of sepsis is made based on the occurrence of several in a group of signs, including altered body temperature, increased respiratory and/or heart rate, increased or decreased white blood cell (wbc) count, increased number of immature neutrophils, decreased platelet count, decreased blood pressure, hypoxemia, and altered cardiac output. however, extreme inflammation without infection (e.g., pancreatitis, trauma) may create similar signs. one study examined the diagnosis of sepsis in canine patients at a veterinary hospital based on easily obtainable physical and laboratory findings. that study found that septic individuals had higher temperatures, wbc counts, and percentage of band neutrophils than nonseptic individuals, whereas platelet counts were lower in the septic dogs. there were no differences in respiratory rate or glucose levels between the groups. using these criteria, the results had a high sensitivity and a tendency to overdiagnose sepsis (hauptman et al., 1997) . ultimately, the presence of a septic focus simplifies diagnosis greatly; however, the focus may not be obvious. if the signs of sepsis are evident but the focus is not, several areas should be evaluated for infection, including the urinary, reproductive, respiratory, alimentary, and cardiovascular systems, as well as the abdominal cavity (kirby, 1995) . treatment the treatment of sepsis has three aims. the first aim is to support the cardiovascular system. all septic animals should be treated with fluids to replace deficits and to maximize cardiac output. crystalloids are most frequently used to maintain vascular volume, primarily because of their low cost. colloids offer the advantage of maintaining volume without fluid overload and may have other positive effects on the cardiovascular system. acid-base and electrolyte imbalances should also be addressed. after the animal has stabilized, the treatment of sepsis should be aimed at removing the septic focus. obvious sources of infection should be drained or surgically removed. if an implant is infected, it should be removed. antibiotic therapy should also be instituted. the choice of antibiotic will ultimately depend upon the results of culture; however, the initial choice of antibiotics is based on previous experience, source of infection, and gram stains. the organisms associated with sepsis are often gram-negative bacteria of gastrointestinal origin or are previously encountered nosocomial infections. ideally, the antibiotic chosen for initial therapy should be a broad-spectrum, bactericidal drug that can be administered intravenously. second-or thirdgeneration cephalosporins provide good coverage, as does combination therapy with enrofloxacin plus metronidazole or penicillin. finally, the treatment of sepsis is aimed at blocking the mediators of the systemic response. this category of sepsis treatment is the focus of much research. several studies have examined the effects of steroids, nonsteroidal anti-inflammatory drugs, and antibodies directed against endotoxin, cytokines, or other mediators of the inflammatory response; however, none of these treatments have proven greatly effective in clinical trials. consequently, there is no 'magic bullet' for the treatment of sepsis at this time. successful therapy remains dependent on aggressive supportive care coupled with identification and elimination of the inciting infection. etiology in research animals, aspiration may occur accidentally during the oral administration of various substances or by the misplacement of gastric tubes. aspiration of gastric contents may also occur as a complication of anesthesia. in pet animals, aspiration is often seen as a result of metabolic and anatomical abnormalities; however, such occurrence would be rare in the research setting. pathogenesis aspirated compounds can produce direct injury to lung tissue, but more importantly, the aspiration provokes an inflammatory response, probably mediated by cytokines. the result is a rapid influx of neutrophils into the lung parenchyma and alveolar spaces. the inflammation leads to increased vascular permeability with leakage of fluid into the alveolar spaces and can eventually lead to alveolar collapse. if the condition is severe, it may result in adult respiratory distress syndrome and respiratory failure. it should be noted that infection is not present in the early stages of this condition but may complicate the problem after 24-48 h. clinical signs the severity and clinical manifestation of aspiration lung injury are dependent upon the ph, osmolality, and volume of the aspirate. the signs of aspiration lung injury may include cough, increased respiratory rate, pronounced respiratory effort, and fever. when respiration is severely affected, the oxygen saturation of blood will be decreased. the diagnosis of this problem is based on witness of aspiration, history consistent with aspiration, and/or the physical findings. classically, radiographs of the thorax demonstrate a bronchoalveolar pattern in the cranioventral lung fields. however, these lesions may not appear for several hours after the incident of aspiration. in addition, the location of the lesions may be variable, depending on the orientation of the animal at the time of aspiration. treatment the treatment of aspiration lung injury is largely supportive and depends upon the severity of the inflammation and the clinical signs. if the aspiration is witnessed, the mouth and, idealy, the upper airway should be cleared of residual material. when small amounts of a relatively innocuous substance (e.g., barium) have been aspirated, treatment may not be necessary. when severe inflammation is present, systemic as well as localized therapy may be necessary. oxygen therapy may be instituted; however, the concentration and time frame are controversial, because lung injury may be exacerbated by long-term administration of oxygen at high concentrations (nader-djahal et al., 1997) . fluid therapy may also be necessary in severe cases; however, cardiovascular support should be performed judiciously as fluid overload could lead to an increase in pulmonary edema. the use of colloids is also controversial because of the increase in vascular permeability that occurs in the lungs. several studies have addressed the use of anti-inflammatory agents to reduce lung injury associated with aspiration; however, none are used clinically in human or veterinary medicine at this time. corticosteroids are contraindicated (raghavendran et al., 2011) . in humans, antibiotics are reserved for cases with confirmed infection, in order to prevent the development of antibiotic-resistant pneumonia. it has been suggested that dogs should be immediately treated with antibiotics when the aspirated material is not acidic or has potentially been contaminated by oral bacteria associated with severe dental disease. amoxicillin-clavulanate has been recommended as a first line of defense, reserving enrofloxacin for resistant cases (hawkins, 2000) . the presence of pneumonia should be verified by tracheal wash and cultures. prevention aspiration of drugs and other compounds may be avoided through careful administration of oral medications by experienced individuals. likewise, gavage or orogastric administration of liquids should be performed by experienced individuals, and the procedure should be aborted if coughing or other respiratory signs occur. the aspiration of stomach contents can largely be avoided by appropriate fasting prior to anesthesia for at least 12 h for food and 2 h for water. if appropriate fasting times are not observed, anesthesia should be postponed whenever possible, particularly if intended procedures require manipulation of the viscera or head-down positioning of the dog. if anesthesia cannot be avoided, it should be rapidly induced and the dog should be intubated. during recovery from anesthesia, the endotracheal tube should be removed with the cuff partially inflated and with the dog in a head-up position (haskins, 1993) . based on the source of energy, burn wounds may be categorized into four groups: thermal, chemical, radiation, and electrical. in laboratory animals, accidental burns are usually the result of thermal injury (heating pads, water bottles), chemicals (strong alkalis, acids, disinfectants, drugs), or experimental irradiation protocols. etiology inappropriate use of external heating devices is the most common cause of burns in laboratory animal medicine. the insult to the skin results in desiccation of the tissue and coagulation of proteins. in addition, the severely injured area is surrounded by a zone of vascular stasis, which promotes additional tissue damage. even small burns can result in significant inflammation that could affect the outcome of some research investigations and cause considerable discomfort to the animal. the proper and immediate treatment of burn wounds can reduce the effects of the injury on both the individual and the research. clinical signs the clinical signs vary with the depth, location, and surface area of burn injury. classification systems for thermal burns are generally based on the depth of the injury, varying from superficial involvement of only epidermis to complete destruction of skin and subcutaneous tissues (bohling, 2012) . superficial burns appear erythematous and inflamed. in some cases, matting of the overlaying hair with exudate may be the first sign of a previously undetected skin lesion. progressive hair and skin loss may be evident over the first few days after injury (johnston, 1993) . although blistering is a characteristic of partial thickness burns in humans, this is rarely seen in dogs (bohling, 2012) . uncomplicated, superficial burn wounds heal by reepithelialization within 3-5 days. deeper burn wounds are characterized by a central area of nonviable tissue surrounded by edematous, inflamed tissues. a thick eschar, composed of the coagulated proteins and desiccated tissue fluid, develops over deep burn wounds. these wounds heal by granulation under the eschar, which will eventually slough. the amount of pain associated with burns depends upon several factors including the depth and area of the wound, procedural manipulations, and movement at the affected site (bohling, 2012) . pain associated with superficial burn wounds usually subsides in 2-3 days. theoretically, deep burns destroy nerve endings and result in less pain than superficial burns. however, inflammatory pain may still be present due to the tissue reaction around the necrotic site. in addition, sharp procedural pain and breakthrough pain have been described in humans during the healing phases of burn injuries and should be considered as potential complications in dogs as well (bohling, 2012) . severe and widespread accidental burn injury can result in clinical signs associated with multiple organs including the pulmonary, gastrointestinal, hematopoietic, and immune systems. in addition, extensive burn injury can predispose to infection and even sepsis. this type of injury with the associated complications would be extremely rare in the laboratory setting. treatment appropriate and timely treatment of a burn wound will reduce the extent of tissue damage and associated pain. thermal injuries should be immediately exposed to cool water (15°c) to reduce edema and pain. exposure to very cold water and ice does not improve outcomes (bohling, 2012) . topical wound dressings are recommended in the early stages of treatment for both partial-and full-thickness burns that are of small size. systemic antibiotics are unable to penetrate eschar and are not adequately distributed through the abnormal blood supply of burned tissues. therefore, a thin film of a water-soluble, broad-spectrum antibiotic ointment should be applied to the wound surface. silver sulfadiazine has a broad spectrum, penetrates eschar, and is often the preparation of choice for burn wound therapy. povidone-iodine ointment will also penetrate thin eschar and provides a broad spectrum. mafenide has a good spectrum that covers gram-negative organisms well and is often used to treat infected wounds, although it has been associated with pain upon application (demling and lalonde, 1989) . once a topical antibiotic has been applied, a nonadherent dressing should be placed on the wound. burn wounds covered in such a manner tend to epithelialize more rapidly and are less painful than uncovered wounds (demling and lalonde, 1989; bohling, 2012) . after the initial treatment, burn wounds should be gently cleansed two to three times a day, followed by reapplication of the topical antibiotic and rebandaging (demling and lalonde, 1989) . systemic antibiotics are indicated in cases where local or systemic infection is present and their ultimate selection should be based on culture results. burn wounds can be extremely painful, and analgesia should be instituted immediately and adjusted accordingly throughout the treatment period. surgical intervention may be necessary in some cases. with small or moderately sized wounds, the eschar over the burn wound may actually impede wound contraction and reepithelialization. in such cases, once the eschar has become fully defined, a complete resection may improve wound healing. with large and severe burn wounds, repeated debridement by surgery or other means might be necessary. in the laboratory setting, a decision to pursue extensive surgical intervention would be dependent upon full consideration of the effects on animal welfare and research results. prevention thermal burns can be prevented in the research setting. electric heating pads and heat lamps should be avoided if possible. only heated water blankets or circulating warm air devices should be used to provide warmth to the animals. in rare instances, heated water blankets have also caused burns; therefore, these devices should be carefully monitored. as a precaution, a thin towel may be placed between the animal and the water blanket. basic fire prevention precautions should be taken particularly around oxygen sources and flammable agents etiology chemical injury may be due to skin contact with concentrated solutions such as disinfectants or inadvertent exposure to laboratory chemicals. in addition, perivascular injection of certain drugs (pentobarbital, thiamylal, thiopental, thiacetarsemide, vincristine, vinblastine, and doxorubicin) have been associated with extensive tissue damage (swaim and angarano, 1990; waldron and trevor, 1993) . the mechanism of action will vary depending upon the ph, osmolality, and chemical composition of the agent and may include oxidation, reduction, disruption of lipid membranes, or other reactions (bohling, 2012; swaim, 1990; waldron and trevor, 1993) . clinical signs surface contact with chemicals may result in mild irritation and redness of superficial layers of the skin. however, many agents may cause progressive injury until the chemical reaction has been neutralized. this may result in tissue necrosis and secondary infection. the immediate signs of perivascular injection are withdrawal of the limb or other signs of discomfort and swelling at the injection site. the area may appear red, swollen, and painful as inflammation progresses. there may eventually be necrosis of the skin around the injection site. in cases of doxorubicin extravasation, signs may develop up to a week after the injection, and the affected area may progressively enlarge over a 1-to 4-month period. this is because the drug is released over time from the dying cells (swaim and angarano, 1990) . treatment in cases of skin contact with chemical agents, the affected area should be thoroughly and repeatedly lavaged with warm water to dilute or remove the substance. the material safety data sheet for the substance should be consulted for any possible neutralization protocol. additional treatment will depend upon the severity of the tissue damage and will follow the same guidelines as for the thermal injury described earlier. for the treatment of perivascular injections, dilution of the drug with subcutaneous injections of saline is recommended. in addition, steroids may be infiltrated locally to reduce inflammation. topical application of dimethyl sulfoxide (dmso) may also be helpful in reducing the immediate inflammation and avoiding the development of chronic lesions. the addition of lidocaine to subcutaneous injections of saline has been used in cases of thiacetarsemide injection (hoskins, 1989) . the local infiltration of hyaluronidase accompanied by warm compresses has been suggested for perivascular vinblastine (waldron and trevor, 1993) and for doxirubicin. the use of dmso or another free radical scavenger, dexrazoxane, infused at the site has also been suggested for doxorubicin toxicities. despite these treatments, necrosis of skin may be observed and would require serial debridement of tissues with secondary wound closure or skin grafting. in cases of doxorubicin extravasation, early excision of affected tissues is advocated to prevent the progressive sloughing caused by sustained release of the drug from dying tissues (swaim and angarano, 1990) . in all cases, the condition can be painful and analgesia should be addressed. prevention prior to the use of any substance, the investigator should be aware of its chemical composition and the potential for problems. the material safety data sheets should be available for all compounds and storage recommendations followed closely. for intravenous administration of toxic compounds, insertion of an indwelling catheter is extremely important. prior to the injection, the catheter should be checked repeatedly for patency by withdrawal of blood and injection of saline. any swelling at the catheter site or discomfort by the subject indicates that the catheter should not be used. access to a central vessel such as the cranial or caudal vena cava is preferred over the use of peripheral vessels. when peripheral catheters are used, the injection should be followed by a vigorous amount of flushing with saline or other physiological solution and removal of the catheter. additional injections are best given through newly placed catheters in previously unused vessels. the repeated use of an indwelling peripheral catheter should be approached cautiously and done only out of necessity. etiology radiation burns are generally a complication of therapeutic administration and are a result of free oxygen radical formation (waldron, 1993) . the severity of radiation burns and their treatment will depend upon the dose, frequency, total surface area, and location of the radiation. damage to epithelial layers of the skin can lead to desquamation. direct injury to fibroblasts results in decreased collagen production and poor wound healing. in addition, there may be fibrosis of blood vessels (pavletic, 2010) and subsequent hypoxia causing necrosis of deeper tissues. clinical signs the tissues most often affected are the skin and mucus membranes. with superficial injury, affected skin may exhibit hair loss and erythema, and produce a clear exudate. the intensity of the inflammation may increase for 1-2 weeks after the completion of radiation treatment. deeper and more serious injury manifests with subcutaneous fibrosis and can lead to disfigurement . the skin and underlying deep structures including the bone may become necrotic over several weeks (pavletic, 2010) . these deeper injuries are prone to infection due to their lack of blood supply. systemic signs such as vomiting are rare in dogs unless there has been direct radiation treatment to organs . treatment with superficial skin burns, the wound should be kept clean and should be covered if possible. in cases of oral mucous membrane damage, there may be special feeding requirements. when wounds are ulcerated, avascular tissues should be excised. treatments with silver sulfadiazine, mafenide acetate, or other topical agents are recommended to control infection. in addition, infection is avoided by closure of the wound as soon as possible. the goal of surgery is to cover the wound with healthy tissue to promote vascularization of the area. in some cases, this may require muscle and/ or skin grafts. prevention radiation burns can be limited by selection of appropriate, fractionated therapy and application of shielding to reduce exposure. prompt treatment of the injuries can reduce the occurrence of infection. since radiation is associated with poor wound healing, complications may arise when additional procedures are required. it is recommended to wait at least 1 week (pavletic, 2010) or even longer (laing, 1990) prior to administering radiation to a surgical site. after radiation, routine surgeries should be avoided for 1-2 months (pavletic, 2010 ). the prevalence of cancer in the general canine population has increased over the years (dorn, 1976) . this can be attributed to the longer life spans resulting from improvements in nutrition, disease control, and therapeutic medicine. because of these changes, cancer has become a major cause of death in dogs (bronson, 1982) . in a lifetime cancer mortality study of intact beagles of both sexes, albert et al. (1994) found death rates similar to the death rate of the at-large dog population (bronson, 1982) . approximately 22% of the male beagles died of cancer. the majority of the tumors were lymphomas (32%) and sarcomas (29%), including hemangiosarcomas of the skin and fibrosarcomas. of the female beagles dying of cancer (26% of the population studied), three-quarters had mammary cancer (40%), lymphomas (18%), or sarcomas (15%). of the sarcomas in females, one-third were mast cell tumors. in addition to these tumors that cause mortality, the beagle is also at risk for thyroid neoplasia (hayes and fraumeni, 1975; benjamin et al., 1996) . because of the popularity of the beagle as a laboratory animal, discussion of specific neoplasms will focus on the tumors for which this breed is at risk, as well as tumors that are common in the general canine population. a complete review of clinical oncology in the dog is beyond the scope of this chapter but can be found elsewhere (withrow et al., 2013) . fine-needle aspirates are generally the first diagnostic option for palpable masses, because they can easily be performed in awake, cooperative patients. this technique allows for rapid differentiation of benign and neoplastic processes. in cases where cytologic results from fine-needle aspirates are not definitive, more invasive techniques must be used. needle-punch or core biopsies can also be performed in awake patients with local anesthesia. an instrument such as a tru-cut ® needle (travenol laboratories, inc., deerfield, illinois) is used to obtain a 1-mm × 1-1.5-cm biopsy of a solid mass. a definitive diagnosis may be limited by the size of the sample acquired using this technique. incisional and excisional biopsies are utilized when less invasive techniques fail to yield diagnostic results. excisional biopsies aid in histopathological examination and are the treatment of choice when surgery is necessary, because the entire mass is removed. surgical margins should extend at least 1 cm around the tumor and 3 cm if mast cell tumors are suspected (morrison et al., 1993) . incisional biopsies are performed when large softtissue tumors are encountered and/or when complete excision would be surgically difficult or life-threatening. when performing an incisional biopsy, always select tissue from the margin of the lesion and include normal tissue in the submission. etiology lymphomas are a diverse group of neoplasms that originate from lymphoreticular cells. canine lymphoma represents 5-7% of canine tumors and a majority (85%) of canine hematopoetic disease (ettinger, 2003; vail and young, 2013) . whereas retroviral etiologies have been demonstrated in a number of species (e.g., cat, mouse, chicken), conclusive evidence of a viral etiology has not been established in the dog. in humans, data implicate the herbicide 2,4-dichlorophenoxyacetic acid as a cause of non-hodgkin's lymphoma, but studies in dogs with similar conclusions have come under scrutiny (macewen and young, 1991) . in addition, tobacco smoke, environmental chemicals, and waste emissions are considered possible risk factors (marconato et al., 2009; gavazza et al., 2001) clinical signs multicentric high-grade lymphoma (mhgl) accounts for the majority of reported cases of canine lymphoma. depending upon grade, immunophenotype, and location involved, dogs with mhgl usually present with painless, enlarged lymph nodes and nonspecific signs such as anorexia, weight loss, polyuria, polydypsia, fever, and lethargy. when the liver and spleen are involved, generalized organomegaly may be felt on abdominal palpation. less commonly, dogs develop alimentary, mediastinal, cutaneous, and extranodal lymphomas. alimentary lymphoma is associated with vomiting and diarrhea, in addition to clinical signs associated with mhgl. dogs with mediastinal lymphoma often present with respiratory signs (dyspnea and exercise intolerance) secondary to pleural effusion or cranial vena caval syndrome. hypercalcemia is most frequently associated with this form of lymphoma and may result in polyuria, polydypsia, and weakness. cutaneous lymphoma is an uncommon epitheliotrophic form of lymphoma. it is often referred to as mycosis fungoides and is typically of a cd8+ t-cell immunophenotype. it varies in presentation from solitary to generalized and may mimic any of a number of other inflammatory skin disorders including oral mucosal lesions. the lesions may occur as erythema, plaques, erosions, scales, nodules, crusts, hypopigmentation, and alopecia (fontaine et al., 2009) . approximately half of the cases are pruritic. a number of extranodal forms of lymphoma have been reported, including tumors affecting the eyes, central nervous system, kidneys, or nasal cavity. clinical presentation varies, depending on the site of involvement (e.g., nervous system: seizures, paresis, paralysis). epizootiology the incidence of lymphoma is highest in dogs 5-11 years old, accounting for 80% of cases. although the neoplasm generally affects dogs older than 1 year, cases in puppies as young as 4 months have been reported (dorn et al., 1967) . no gender predilection has been reported. diagnosis and pathologic findings a fine-needle aspirate is initially performed on accessible lymph nodes. thoracic radiographs and abdominal ultrasound ± fine needle aspiration of the liver or spleen can be used if mediastinal or abdominal involvement is suspected. additional staging can be determined through complete blood counts, serum biochemistry, flow cytometry for immunotyping, bone marrow aspiration, or surgical lymphadenectomy and histology. enlarged neoplastic lymph nodes vary in diameter from 1 to 9 cm and are moderately firm. some may have areas of central necrosis and are soft to partially liquefied. the demarcation between cortex and medulla is generally lost, and on cut section, the surface is homogenous. the spleen may have multiple small nodular masses or diffuse involvement with generalized enlargement. the enlarged liver may have disseminated pale foci or multiple large, pale nodules. in the gastrointestinal tract, both nodular and diffuse growths are observed. these masses may invade through the stomach and intestinal walls. flow cytometry and lymphoblastic markers (cd34) can aid in diagnosis and subtyping of tumors. in addition, positron emission tomography is being explored for detection of extranodal and metastatic lymphoma (leblanc et al., 2009; marconato, 2011; elstrom et al., 2003) . classification of lymphoma types is based upon cytological, morphological, and immunological characteristics using the kiel classification criteria (vail and young, 2013) . histologically, the most common lymphomas are classified as intermediate to high grade and of large-cell (histiocytic) origin. the neoplastic lymphocytes typically obliterate the normal architecture of the lymph nodes and may involve the capsule and perinodal areas. lymphoma subtypes can be further characterized based upon genetic, molecular, and immunological criteria (ponce et al., 2004) . pathogenesis all lymphomas regardless of location should be considered malignant. a system for staging lymphoma has been established by the world health organization. the average survival time for dogs without treatment is 4-6 weeks. survival of animals undergoing chemotherapy is dependent on the treatment regimen as well as the form and stage of lymphoma (macewen and young, 1991) . median survival time with aggressive therapy is generally less than 12 months. hypercalcemia is a paraneoplastic syndrome frequently associated with lymphoma. the pathogenesis of this phenomenon is not fully understood but may be a result of a parathormone-like substance produced by the neoplastic lymphocytes. differential diagnosis differential diagnoses for multicentric lymphoma include systemic mycosis; salmon-poisoning and other rickettsial infections; lymph node hyperplasia from viral, bacterial, and/or immunologic causes; and dermatopathic lymphadenopathy. alimentary lymphoma must be distinguished from other gastrointestinal tumors, foreign bodies, and lymphocytic-plasmacytic enteritis. in order to make a definitive diagnosis, whole lymph node biopsies and full-thickness intestinal sections for histopathologic examination may be needed. treatment therapy for lymphoma primarily consists of one or a combination of several chemotherapeutic agents. in addition, radiation therapy and bone marrow transplantation have been utilized. the treatment regimen is based on the staging of the disease, the presence of paraneoplastic syndromes, and the overall condition of the patient. although treatment may induce clinical remission and prolong short-term survival, most treatment is palliative and aimed at improving quality of life. a thorough discussion of therapeutic options for the treatment of lymphomas in the dog can be found elsewhere (chun, 2009; marconato, 2011) . future directions include development of molecular and cellular targeted therapies to enhance traditional chemotherapy treatment, prolong remission, and treat immunologic subtypes of lymphoma (e.g., t-cell lymphoma). research complications given the grave prognosis for lymphoma with or without treatment, euthanasia should be considered for research animals with significant clinical illness. etiology mast cells are derived from cd34+ bone marrow progenitor cells. neoplastic proliferations of mast cells are the most commonly observed skin tumor of the dog and may account for up to 21% of canine skin laboratory animal medicine tumors (bostock, 1986; welle et al., 2008) . mast cells are normally found in the connective tissue beneath serous surfaces and mucous membranes, and within the skin, lung, liver, and gastrointestinal tract. current research has linked mast cell tumor development to multifactorial causes including breed predisposition and a genetic component, chronic inflammation, and mutations in the surface growth factor, c-kit (ma et al., 1999; reguera et al., 2000; webster et al., 2006) . clinical signs well-differentiated mast cell tumors are typically solitary, well-circumscribed, slow-growing, 1-to 10-cm nodules in the dermis and subcutaneous tissue. alopecia may be observed, but ulceration is not usual. poorly differentiated tumors grow rapidly, may ulcerate, and may cause irritation, inflammation, and edema to surrounding tissues. mast cell tumors can be found on any portion of the dog's skin but frequently affect the trunk and hind limb extremeties along with perineal and preputial areas. the tumors usually appear to be discrete masses, but they frequently extend deep into surrounding tissues. abdominal organs are rarely involved but may be associated with anorexia, vomiting, melena, abdominal pain, and gastrointestinal ulceration. mast cell tumors have also been reported in extracutaneous areas such as the salivary glands, larynx, nasopharynx (london and thamm, 2013) and conjunctiva (fife et al., 2011) . mast cell tumors within the perineal, preputial, or inguinal areas are associated with a greater predilection for recurrence or metastasis (misdorp, 2004) . epizootiology these tumors tend to affect middleaged dogs but have been observed in dogs ranging from 4 months to 18 years (pulley and stannard, 1990) . pathologic findings because of the substantial variation in histologic appearance of mast cell tumors, a classification and grading system described by patnaik et al. (1986) has become widely accepted. in this system, grade i has the best prognosis and are well differentiated, with round to ovoid, uniform cells with distinct cell borders. the nuclei are round and regular, the cytoplasm is packed with large granules that stain deeply, and mitotic figures are rare to absent. grade ii (intermediately differentiated) mast cell tumors have indistinct cytoplasmic boundaries with higher nuclear-cytoplasmic ratios, fewer granules, and occasional mitotic figures. grade iii (anaplastic or undifferentiated) mast cell tumors have the worst prognosis. the cells contain large, irregular nuclei with multiple prominent nucleoli and few cytoplasmic granules. mitotic figures are much more frequent. cells are pleomorphic with indistinct borders. in addition to associated skin lesions (e.g., ulceration, collagenolysis, necrosis, and infection), mast cell tumors have been associated with gastric ulcers in the fundus, pylorus, and/or proximal duodenum, most likely secondary to tumor production of histamine. histamine stimulates the h 2 receptors of the gastric parietal cells, causing increased acid secretion. gastric ulcers have been observed in large numbers (>75%) of dogs with mast cell tumors (howard et al., 1969) . pathogenesis although all mast cell tumors should be considered potentially malignant, the outcome in individual cases can be correlated with the histologic grading of the tumor. grade iii tumors are most likely to disseminate internally. this spread is usually to regional lymph nodes, spleen, and liver, and less frequently to the kidneys, lungs, and heart. diagnosis and differential diagnosis using fineneedle aspiration, mast cell tumors can be distinguished cytologically from other round cell tumors (such as histiocytomas and cutaneous lymphomas) by using toluidine blue to metachromatically stain the cytoplasmic granules red or purple. mast cell granules can also be stained with wright's, giemsa, and romanowsky stains. in addition, mast cells may contain tryptase, chymase, or both (fernandez et al., 2005) . histological evaluation is generally required for grading. examination of regional lymph nodes may be warranted if metastatic or systemic disease is suspected. in addition, radiographs and ultrasound with guided aspirates of the liver, spleen, or sublumbar lymph nodes can be used to determine metastatic disease. treatment depending upon the grade, initial treatment for mast cell tumors is generally wide surgical excision (3-cm margins), which may be followed by radiation, chemotherapy, or glucocorticoid therapy. aspiration or surgical removal of regional lymph nodes is recommended if lymphatic tumor drainage is suspected. if the tumor is not completely resectable or is grade ii or iii (moderately to undifferentiated), then debulking surgery and adjunct therapy may be used. treatment algorithms are outlined elsewhere (withrow et al., 2013) research complications because of the potential for systemic release of substances such as histamine, vasoactive substances, heparin, eosiniphilic chemotactic factor, and proteolytic enzymes, along with the possibility of delayed wound healing and tumor recurrence, dogs with mast cell tumors are not good candidates for research studies. grade i mast cell tumors may be excised, allowing dogs to continue on study; however, monitoring for local recurrence should be performed monthly. grade ii tumors are variable; animals that undergo treatment should be monitored for recurrence monthly, and evaluation of the buffy coat should be performed every 3-6 months for detection of systemic mastocytosis. because of the poor prognosis for grade iii tumors, treatment is unwarranted in the research setting. etiology also known as infectious or venereal granuloma, sticker tumor, transmissible sarcoma, and contagious venereal tumor, the canine transmissible venereal tumor (ctvt) is transmitted horizontally to the genitals by coitus (nielsen and kennedy, 1990) . ctvt is a 'parasitic-like' tumor that appears to have originated from dogs or wolves thousands of years ago and despite immense mutation, ctvt adapted, survived, and spread across multiple continents making it the oldest known continuously passaged somatic cell line (rebbeck et al., 2009; murchison et al., 2014; murgia et al., 2006) . it has been described as a round cell tumor of histiocytic origin. although this tumor has been reported in most parts of the world, it is most prevalent in tropical or temperate climates (macewen, 1991) . clinical signs the tumors are usually cauliflowerlike masses on the external genitalia, but they can also be pedunculated, nodular, papillary, or multilobulated. these friable masses vary in size up to 10 cm, and hemorrhage is frequently observed. in male dogs, the lesions are found on the caudal part of the penis from the crura to the bulbus glandis or on the glans penis. less frequently, the tumor is found on the prepuce. females typically have lesions in the posterior vagina at the junction of the vestibule and vagina. when located around the urethral orifice, the mass may protrude from the vulva. these tumors have also been reported in the oral cavity, skin, and eyes. epizootiology and transmission ctvts are most commonly observed in young, sexually active dogs. transmission takes place during coitus when injury to the genitalia allows for exfoliation and transplantation of the tumor. genital to oral to genital transmission has also been documented (nielsen and kennedy, 1990) . extragenital lesions may be the result of oral contact with previously traumatized areas. pathologic findings histologically, cells are arranged in compact masses or sheets. the cells are round, ovoid, or polyhedral, and have large, round nuclei with coarse chromatin. the cytoplasm is eosinophilic with small vacuoles arranged in a 'string of pearls' pattern. pathogenesis tumor growth occurs within 2-6 months after mating or implantation, and then growth generally slows. metastasis is rare (<5-17% of cases) but may involve the superficial inguinal and external iliac lymph nodes as well as distant sites. spontaneous regression may occur within 6-9 months of tumor development. diagnosis and differential diagnosis transmissible venereal tumors have been confused with lymphomas, histiocytomas, mast cell tumors, and amelanotic melanomas. however, cytological examination of impression smears, swabs, and fine-needle aspirates generally provide a definitive diagnosis. although not usually required, histopathology of a biopsy from the mass can aid in diagnosis. prevention thorough physical examinations prior to bringing new animals into a breeding program should prevent introduction of this tumor into a colony. control removing affected individuals from a breeding program should stop further spread through the colony. treatment surgery and radiation can be used for treatment, but chemotherapy is the most effective. vincristine (0.5-0.7 mg/m 2 ) iv once weekly for four to six treatments will induce remission and cure in greater than 90% of the cases (macewen, 1991) . research complications experimental implantation of ctvts has been shown to elicit formation of tumor-specific igg (cohen, 1972) . this response may occur in natural infections and could possibly interfere with immunologic studies. etiology dogs are susceptible to a wide variety of mammary gland neoplasms, most of which are influenced by circulating reproductive steroidal hormones. clinical signs single nodules are found in approximately 75% of the cases of canine mammary tumors. the nodules can be found in the glandular tissue or associated with the nipple. masses in the two most caudal glands (fourth and fifth) account for a majority of the tumors. benign tumors tend to be small, well circumscribed, and firm, whereas malignant tumors are larger, invasive, and coalescent with adjacent tissues. inflammatory mammary carcinomas may mimic mastitis or severe dermatitis and must be ruled out to prevent misdiagnosis. epizootiology mammary tumors are uncommon in dogs under 5 years of age with the incidence rising sharply after that. the median age at diagnosis is 10-11 years. a longitudinal study of a large beagle colony showed that significant risk for development of mammary tumors begins at approximately 8 years of age (taylor et al., 1976) . mammary tumors occur almost exclusively in female dogs, with most reports in male dogs being associated with endocrine abnormalities, such as estrogen-secreting sertoli cell tumors. pathologic findings the t (tumor size), n (lymph node involvement), and m (metastasis) system is commonly used to stage mammary tumors. based on histologic classification of mammary gland tumors, approximately half of the reported tumors are benign (fibroadenomas, simple adenomas, and benign mesenchymal tumors), and half are malignant (solid carcinomas, tubular adenocarcinomas, papillary adenocarcinomas, anaplastic carcinomas, sarcomas, and carcinosarcomas) (bostock, 1977) . histopathologic grades are scored based upon tubule formation, nuclear pleomorphism, and mitosis (elston and ellis, 2002) . extensive discussions of classification, staging, and histopathologic correlations can be found elsewhere (moulton, 1990; sorenmo et al., 2011) . pathogenesis mammary tumors of the dog develop under the influence of hormones. receptors for both estrogen and progesterone can be found in 60-70% of tumors. malignant mammary tumors typically spread through the lymphatic vessels. metastasis from the first, second, and third mammary glands is to the ipsilateral axillary or anterior sternal lymph nodes. the fourth and fifth mammary glands drain to the superficial inguinal lymph nodes where metastasis can be found. many mammary carcinomas will eventually metastasize to the lungs and extraskeleton. diagnosis and differential diagnosis both benign and malignant mammary tumors must be distinguished from mammary hyperplasia, mastitis, and severe dermatitis. cytological evaluation from fine-needle aspirates correlates well with histological examination of benign and malignant tumors (simon et al., 2009) . radiographs and possibly ultrasound should be performed to rule out metastatic disease prior to surgery. prevention the lifetime risk of developing mammary tumors can effectively be reduced to 0.5% by spaying bitches prior to the first estrus (schneider et al., 1969) . this is commonly done in the general pet population at 6 months of age. the protective effects of early spay rapidly decrease after several estrus cycles. dogs spayed prior to the first estrus had a risk of 0.8%, whereas dogs spayed after the first and second estrus had risks of 8% and 26%, respectively. treatment surgery is the treatment of choice for mammary tumors, because chemotherapy and radiation therapy have not been reported to be effective. the extent of the surgery is dependent on the area involved. single mammary tumors should be surgically removed with 2-cm lateral margins or margins wide enough for complete resection. deep margins may include removing sections of abdominal fascia or musculature en bloc with mammary tumor. multiple mammary tumors should be removed via regional or unilateral chain mastectomies. bilateral, staged mastectomies are reserved for more aggressive tumors. there is insufficient evidence at this time to recommend routine complete unilateral or bilateral chain mastectomies. at the time of surgery, axillary lymph nodes are removed only if enlarged or positive on cytology for metastasis. sorenmo et al. (2013) provide a thorough review of canine mammary gland neoplasia. research complications treatment of early-stage or low-grade mammary tumors may be rewarding, allowing dogs to continue on study. if removed early enough, malignant masses could yield the same results. all dogs should be monitored regularly for recurrence and new mammary tumors. beagles are subject to many of the inherited and/ or congenital disorders that affect dogs in general. in a reference table on the congenital defects of dogs (hoskins, 2000) , disorders for which beagles are specifically mentioned include brachyury (short tail), spina bifida, pulmonic stenosis, cleft palate-cleft lip complex, deafness, cataracts, glaucoma, microphthalmos, optic nerve hypoplasia, retinal dysplasia, tapetal hypoplasia, factor vii deficiency, pyruvate kinase deficiency, pancreatic hypoplasia, epilepsy, gm 1 gangliosidosis, globoid cell leukodystrophy, xx sex reversal, and cutaneous asthenia (ehlers-danlos syndrome). other defects observed include cryptorchidism, monorchidism, limb deformity, inguinal hernia, diaphragmatic hernia, hydrocephaly, and fetal anasarca. each of these other congenital defects occurred at less than 1.0% incidence. etiology benign prostatic hyperplasia (bph) is an age-related condition in intact male dogs. the hyperplasia of prostatic glandular tissue is a response to the presence of both testosterone and estrogen. clinical signs bph is often subclinical. straining to defecate (tenesmus) may be seen because the enlarged gland impinges on the rectum. urethral discharge (yellow to red) and hematuria can also be presenting clinical signs. epizootiology and transmission bph typically affects older dogs (>4 years), although glandular hyperplasia begins as early as 3 years of age. approximately 95% of inact male dogs will develop bph by 9 years of age (smith, 2008) . pathologic findings in the early stages of bph, there is hyperplasia of the prostatic glandular tissue. this is in contrast to human bph, which is primarily stromal in origin. eventually, the hyperplasia tends to be cystic, with the cysts containing a clear to yellow fluid. the prostate becomes more vascular with a honeycomb appearance (resulting in hematuria or hemorrhagic urethral discharge), and bph may be accompanied by mild chronic inflammation. pathogenesis bph occurs in older intact male dogs because increased production of estrogens (estrone and estradiol), combined with decreased secretion of androgens, sensitizes prostatic androgen receptors to dihydrotestosterone. the presence of estrogens may also increase the number of androgen receptors, and hyperplastic prostate glands also have an increased ability to metabolize testosterone to 5α-dihydrotestosterone (kustritz and klausner, 2000) mediating bph. diagnosis and differential diagnosis bph is diagnosed in cases of nonpainful symmetrical swelling of the prostate gland in intact male dogs, with normal hematologic profiles and urinalysis that may be characterized by hemorrhage. a prostatic biopsy can be performed to confirm diagnosis. differential diagnoses include squamous metaplasia of the prostate, para-prostatic cysts, bacterial prostatitis, prostatic abscessation, and prostatic neoplasia (primarily adenocarcinoma). these differential diagnoses also increase in frequency with age and, except for squamous metaplasia, can also occur in castrated dogs. as such, these conditions do not necessarily abate or resolve with castration. prevention castration is the primary means for prevention of benign prostatic hyperplasia. treatment the first and foremost treatment for bph is castration. in pure cases of bph, castration results in involution of the prostate gland detectable by rectal palpation within 7-10 days. for most dogs in research studies, this is a viable option to rapidly improve the animal's condition. the alternative to castration is hormonal therapy, primarily with estrogens. this may be applicable in cases where semen collection is necessary from a valuable breeding male (e.g., genetic diseases). if the research study concerns steroidal hormone functions, then neither the condition nor the treatment is compatible. finasteride, a synthetic 5α-reductase inhibitor, has been used in dogs to limit the metabolism of testosterone to 5α-dihydrotestosterone. treatment at daily doses of 0.1-0.5 mg/kg orally for 16 weeks was shown to reduce prostatic diameter and volume without affecting testicular spermatogenesis (sirinarumitr et al., 2001) . upon discontinuation of finasteride, the prostate generally returns to its pretreatment size within several months (smith, 2008) . gonadotropin-releasing hormone analogs such as desorelin inhibit production of testosterone and estrogen via negative feedback on the hypothalamus-pituitary axis. this is available in a sustained release subcutaneous implant, which has demonstrated efficacy in reducing prostatic size in dogs (junaidi et al., 2009) . however, medical therapy has not shown to be as advantageous as castration. research complications bph can cause complications to steroidal hormone studies, in that the condition may be indicative of abnormal steroidal hormone metabolism, and neither castration nor estrogen therapy is compatible with study continuation. the development of tenesmus as a clinical sign may also affect studies of colorectal or anal function. research model older dogs with benign protastic hypertrophy are used in research to evaluate the use of ultrasonic histotripsy as a precise nonsurgical urethralsparing alternative to prostate surgery (lake et al., 2008; hall et al., 2009; schade et al., 2012) . etiology juvenile polyarteritis syndrome (jps), also known as steroid-responsive meningitis-arteritis, is a painful disorder seen in young beagles (occasionally reported in other breeds) caused by a systemic necrotizing vasculitis. the cause of the vasculitis has not been established but appears to have an autoimmune-mediated component and may have a hereditary predisposition. clinical signs clinical signs of jps include fever, anorexia, lethargy, and reluctance to move the head and neck. the dogs tend to have a hunched posture and/ or an extended head and neck. most dogs seem to be in pain when touched, especially in the neck region. neurological examination may reveal proprioceptive deficits, paresis, or paralysis. the syndrome typically has a course of remissions and relapses characterized by 3-7 days of illness and 2-4 weeks of remission (scott-moncrieff et al., 1992) . there may be a component of this condition that is subclinical, given that vasculitis has been diagnosed postmortem in beagles that had no presenting signs. epizootiology and transmission jps typically affects young beagles (6-40 months), with no sex predilection. jps has been reported in other breeds including sibling welsh springer spaniels (caswell and nykamp, 2003) . pathologic findings on gross necropsy, foci of hemorrhage can be seen in the coronary grooves of the heart, cranial mediastinum, and cervical spinal cord meninges (snyder et al., 1995) . local lymph nodes may be enlarged and hemorrhagic. histologically, necrotizing vasculitis and perivasculitis of small to mediumsized arteries are seen. these lesions are most noticeable where gross lesions are observed, but they may be seen in other visceral locations. arterial fibrinoid necrosis leading to thyroid gland hemorrhage and inflammation was also reported (peace et al., 2001) . the perivasculitis often results in nodules of inflammatory cells that eccentrically surround the arteries. the cellular composition of these nodules is predominantly neutrophils, but it can also consist of lymphocytes, plasma cells, or macrophages (snyder et al., 1995) . fibrinous thrombosis of the affected arteries is also seen. a subclinical vasculitis has also been diagnosed in beagles post mortem; it is not known whether this subclinical condition is a different disorder or part of a jps continuum. this subclinical vasculitis often affects the coronary arteries (with or without other sites). pathogenesis the initiating factors for jps are unknown. it was once presumed to be a reaction to test compounds by laboratory beagles, but this may have been coincident to the fact that the beagle is the breed most often affected with jps. immune mediation of jps is strongly suspected, because the clinical signs have a cyclic nature and respond to treatment with corticosteroids, and the affected dogs have elevated α 2 -globulin fractions and abnormal immunologic responses. there may be hereditary predisposition, given that pedigree analysis has indicated that the offspring of certain sires are more likely to be affected, and breeding of two affected dogs resulted in one in seven affected pups (scott-moncrieff et al., 1992) . diagnosis and differential diagnosis differential diagnoses include encephalitis, meningitis, injury or degeneration of the cervical vertebrae or disks, and arthritis. in the research facility, the disorder may be readily confused with complications secondary to the experimental procedure, or with postsurgical pain. beagles with jps that were in an orthopedic research study were evaluated for postsurgical complications and skeletal abnormalities prior to the postmortem diagnosis of systemic vasculitis (authors' personal experience). prevention and control no prevention and control measures are known at this time. treatment clinical signs can be abated by administration of corticosteroids. prednisone administered orally at 1.1 mg/kg, q12 h, was associated with rapid relief of clinical symptoms. maintenance of treatment at an alternate-day regimen of 0.25-0.5 mg/kg was shown to relieve symptoms for several months. however, withdrawal of corticosteroid therapy led to the return of clinical illness within weeks. research complications because of the potentially severe clinical signs and the need for immunosuppressive treatment, jps is often incompatible with use of the animal as a research subject. it is unknown whether subclinical necrotizing vasculitis causes sufficient aberrations to measurably alter immunologic responses. etiology interdigital cysts are chronic inflammatory lesions (not true cysts) that develop in the webbing between the toes. the cause for most interdigital cysts is usually not identified unless a foreign body is present. bacteria may be isolated from the site, but the lesions may also be sterile (hence the synonym 'sterile pyogranuloma complex'). clinical signs dogs with interdigital cysts are usually lame on the affected foot, with licking and chewing at the interdigital space. exudation may be noticed at the site of the lesion. the lesion appears as a cutaneous ulcer, usually beneath matted hair, with possible development of sinus tracts and purulent exudate. epizootiology and transmission interdigital cysts are common in a variety of canine breeds, including german shepherds. beagles have been affected in the research setting. interdigital cysts usually occur in the third and fourth interdigital spaces (bellah, 1993) . a retrospective study of beagles housed in a research industry setting, linked development of interdigital cysts to body codition score, age, location of cyst, and type of caging, and may result from chronic interdigital dermatitis (kovacs et al., 2005) . pathologic findings histopathologically, interdigital cysts are sites of chronic inflammation, typically described as pyogranulomatous. pathogenesis initial development of the cysts is unknown, except for those cases in which a foreign body can be identified. diagnosis and differential diagnosis bacterial culture swabs and radiographs should be taken of the cysts to rule out bacterial infection and radiopaque foreign bodies or bony lesions, respectively. a biopsy should be taken if neoplasia is suspected. treatment if a foreign body is associated with the lesion, then removal is the first order of treatment. if biopsy of the site provides a diagnosis of sterile pyogranuloma complex, then systemic corticosteroid therapy (e.g., prednisolone at 1 mg/kg q12 h) can be initiated and then tapered once the lesion heals. interdigital cysts that are refractory to medical therapy require surgical removal. excision includes the removal of the lesion and the interdigital web, and a two-layer closure of the adjacent skin and soft tissues is recommended (bellah, 1993) . the foot should be put in a padded bandage and a tape hobble placed around the toes to reduce tension when the foot is weight-bearing. the prognosis for idiopathic interdigital cysts is guarded, because the cysts tend to recur (bellah, 1993) . research complications research complications from the cysts are minimal, unless the dogs need to be weight-bearing for biomechanic or orthopedic studies. treatment with systemic steroids could be contraindicated with some experimental designs. etiology 'cherry eye' is a commonly used slang term for hyperplasia and/or prolapse of the gland of the nictitating membrane (third eyelid). this is not considered a congenital anomaly, but there is breed disposition for this condition, including beagles. a specific etiology is not known. clinical signs the glandular tissue of the nictitating membrane protrudes beyond the membrane's edge and appears as a reddish mass in the ventromedial aspect of the orbit. excessive tearing to mucoid discharge can result, and severe cases can be associated with corneal erosion. pathologic findings typically, the glandular tissue is hyperplastic, possibly with inflammation. rarely is the tissue neoplastic. pathogenesis prolapse of the gland may be a result of a congenital weakness of the connective tissue band between the gland and the cartilage of the third eyelid (helper, 1989) . prevention hyperplasia of the third eyelid cannot be prevented, but dogs that develop this condition unilaterally should have the other eye evaluated for potential glandular prolapse. preventative surgical measures might be warranted. treatment corticosteroid treatment (topical or systemic) can be used to try to reduce the glandular swelling. however, surgical reduction or excision of the affected gland is typically required to resolve the condition. in the reduction procedure, the prolapsed gland is sutured to fibrous tissue deep to the fornix of the conjunctiva (helper, 1989 ). if reduction is not possible (as with deformed nictitating cartilage) or is unsuccessful, removal of the gland can be performed. such excision is fairly straightforward and can be done without removal of the nictitating membrane itself. the gland of the third eyelid is important in tear production; although the rest of the lacrimal glands should be sufficient for adequate tear production, keratoconjunctivitis sicca is a possible consequence after removal of the gland of the nictitating membrane. research complications in most cases, research complications would be minimal, especially if treated adequately. either the presence of the hyperplastic gland or its removal might compromise ophthalmologic studies. antimicrobial resistance profiles and mechanisms of resistance in campylobacter jejuni isolates from pets life span and cancer mortality in the beagle dog and human studies of distribution and recurrence of helicobacter spp. gastric mucosa of dogs after triple therapy plasma von willebrand factor concentration and thyroid function in dogs catheter-related infections in long-term catheterized dogs. observations on pathogenesis, diagnostic methods, and antibiotic lock technique aaha nutritional assessment guidelines for dogs and cats open-and closed-formula laboratory animal diets and their importance to research comparison of the accuracy of two ultrasonographic measurements in predicting the parturition date in the bitch dog thyroiditis: occurrence and similarity to hashimoto's struma surgical management of specific skin disorders bordetella and mycoplasma respiratory infections in dogs and cats associations between lymphocytic thyroiditis, hypothyroidism, and thyroid neoplasia in beagles diagnostic exercise: peracute death in a research dog insecticide and acaricide molecules and/ or combinations to prevent pet infestation by ectoparasites neurologic manifestations associated with hypothyroidism in four dogs veterinary surgery: small animal neoplasms of the skin and subcutaneous tissues in dogs and cats neoplasia of the skin and mammary glands of dogs and cats pancreatic adenocarcinoma in two grey collie dogs with cyclic hematopoiesis variation in age at death of dogs of different sexes and breeds comparison of campylobacter carriage rates in diarrheic and healthy pet animals advances in dietary management of obesity in dogs and cats effect of amount and type of dietary fiber on food intake in energy-restricted dogs effect of level and source of dietary fiber on food intake in the dog an outbreak of fatal hemorrhagic pneumonia caused by streptococcus equi subsp. zooepidemicus in shelter dogs molecular characterization of canine parvovirus strains in argentina: detection of the pathogenic variant cpv2c in vaccinated dogs external parasites: identification and control orthopedic coaptation devices and small-animal prosthetics enterohepatic helicobacter spp. in colonic biopsies of dogs: molecular, histopathological and immunohistochemical investigations intradural vasculitis and hemorrhage in full sibling welsh springer spaniels respiratory disease in kennelled dogs: serological responses to bordetella bronchiseptica lipopolysaccharide laboratory animal medicine do not correlate with bacterial isolation or clinical respiratory symptoms lymphoma: which chemotherapy protocol and why? detection of humoral antibody to the transmissible venereal tumor of the dog laboratory animal management: dogs reproductive cycles of the domestic bitch hereditary canine spinal muscular atrophy: an animal model of motor neuron disease. can evaluation of the helicobacteraceae in the oral cavity of dogs management of septicemia in rhesus monkeys with chronic indwelling catheters clinical and virological findings in pups naturally infected by canine parvovirus type 2 glu-426 mutant eradication of helicobacter spp. by using medicated diet in mice deficient in functional natural killer cells and complement factor d client information series: canine demodicosis client information series: fleas and flea allergy dermatitis management of the burn wound burn trauma chlorine dioxide sterilization of implanted right atrial catheters in rabbits current concepts in the management of helicobacter associated gastritis discordant 16s and 23s rrna gene phylogenies for the genus helicobacter: implications for phylogenetic inference and systematics use of narcotic antagonists to modify stereotypic selflicking, self-chewing, and scratching behavior in dogs epidemiology of canine and feline tumors epizootiologic characteristics of canine and feline leukemia and lymphoma evaluation of the ovicidal cctivity of lufenuron and spinosad on fleas' eggs from treated dogs enteric coccidiosis the respiratory system the association of american feed control officials dog and cat food nutrient profiles: substantiation of nutritional adequacy of complete and balanced pet foods in the united states study of obesity in dogs visiting veterinary practices in the united kingdom pathological prognostic factors in breast cancer. i. the value of histological grade in breast cancer: experience from a large study with long-term follow-up utility of fdg-pet scanning in lymphoma by who classification principles of treatment for canine lymphoma miller's anatomy of the dog update on diagnosis of canine hypothyroidism immunohistochemical and histochemical stains for differentiating canine cutaneous round cell tumors the laboratory canine canine conjunctival mast cell tumors: a retrospective study canine cutaneous epitheliotropic t-cell lymphoma: a review canine infectious respiratory disease helicobacter-associated gastric disease in ferrets, dogs, and cats enteric bacterial infections hemorrhagic streptococcal pneumonia in newly procured research dogs association between canine malignant lymphoma, living in industrial areas, and use of chemicals by dog owners reproductive patterns in the domestic dog-a retrospective study of the drever breed the dog as a research subject a review of canine pseudocyesis leptospirosis surgical treatment of an elbow hygroma utilizing microvascular free muscle transfer in a newfoundland bacterial diseases immunoprophylaxis leptospirosis gastric helicobacters in domestic animals and nonhuman primates and their significance for human health non-helicobacter pylori helicobacter species in the human gastric mucosa: a proposal to introduce the terms h. heilmannii sensu lato and sensu stricto diseases of the small intestine histotripsy of the prostate: dose effects in a chronic canine model flea control failure? myths and realities small animal clinical nutrition operating room emergencies shock evaluation of the sensitivity and specificity of diagnostic criteria for sepsis in dogs pulmonary parenchymal disease canine thyroid neoplasms: epidemiologic features magrane's canine ophthalmology helicobacter-like organisms: histopathological examination of gastric biopsies from dogs and cats current veterinary therapy x: small animal practice congenital defects of the dog gastric and duodenal ulcers in dogs with mastocytoma complications in the use of indwelling vascular catheters in laboratory animals helicobacter infection diseases of the large intestine pregnancy management in the bitch tracheal collapse. diagnosis and medical and surgical treatment hygroma of the elbow in dogs thermal injuries joint working group on refinement factors contributing to the contamination of peripheral intravenous catheters in dogs and cats diversity in bacterium-host interactions within the species helicobacter heilmannii sensu stricto morphological study of the effects of the gnrh superagonist deslorelin on the canine testis and prostate gland five-year longitudinal study on limited food consumption and development of osteoarthritis in coxofemoral joints of dogs cvt update: interpretation of endocrine diagnostic test results for adrenal and thyroid disease etiopathogenesis of canine hypothyroidism maintenance energy requirement of dogs: what is the correct value for the calculation of metabolic body weight in dogs? outbreak and control of haemorrhagic pneumonia due to streptococcus equi subspecies zooepidemicus in dogs kirk's current veterinary therapy xii: small animal practice an emerging pulmonary haemorrhagic syndrome in dogs: similar to the human leptospiral pulmonary haemorrhagic syndrome? tarsal joint contracture in dogs with golden retriever muscular dystrophy an epidemiological study of interdigital cysts in a research beagle colony value of the (13)c-urea breath test for detection of gastric helicobacter spp. infection in dogs undergoing endoscopic examination pathogenesis of helicobacter pylori infection prostatic diseases semen collection in the dog accuracy of canine parturition date prediction using fetal measurements obtained by ultrasonography chronic catheterization of the intestines and portal vein for absorption experimentation in beagle dogs evaluation of weight loss protocols for dogs problems in wound healing associated with chemotherapy and radiation therapy histotripsy: minimally invasive technology for prostatic tissue ablation in an in vivo canine model 18fdg-pet imaging in canine lymphoma and cutaneous mast cell tumor comparison of fertility data from vaginal vs intrauterine insemination of frozenthawed dog semen: a retrospective study withrow & macewen's small animal clinical oncology estimation of gestational age and assessment of canine fetal maturation using radiology and ultrasonography: a review effects of four preparations of .05% chlorhexidine diacetate on wound healing in dogs the prediction of parturition date in canine pregnancy clustering of activating mutations in c-kit's juxtamembrane coding region in canine mast cell neoplasms transmissible venereal tumors kirk's current veterinary therapy 11: small animal practice canine lymphoma and lymphoid leukemias the staging and treatment of multicentric highgrade lymphoma in dogs: a review of recent developments and future prospects association between waste management and cancer in companion animals tick paralysis in north america and australia thyroid gland and arterial lesions of beagles with familial hypothyroidism and hyperlipoproteinemia bacterial gastroenteritis in dogs and cats: more common than you think enteropathogenic bacteria in dogs and cats: diagnosis, epidemiology, treatment, and control dermatologic aspects of tick bites and tick-transmitted diseases a chronic access port model for direct delivery of drugs into the intestine of conscious dogs mast cells and canine mast cell tumours: a review etiologic study of upper respiratory infections of household dogs effect of early enteral nutrition on intestinal permeability, intestinal protein loss, and outcome in dogs with severe parvoviral enteritis determination of strain variability of microsporum canis to disinfectants cutaneous fungal infections diagnosis of neoplasia tumors of the mammary gland transmissible dog cancer genome reveals the origin and history of an ancient cell lineage clonal origin and evolution of a transmissible cancer notice regarding nih plan to transition from use of usda class b dogs to other legal sources (not-od-14-034) guide for the care and use of laboratory animals surgical closure of elbow hygroma in the dog colitis and colon cancer in waspdeficient mice require helicobacter species tumors of the genital system practical laboratory methods for the diagnosis of dermatologic diseases animals and animal products, subchapter a, parts 1, 2, and 3 comparison of three skin preparation techniques in the dog comparison of three skin preparation techniques in the dog. part 2: clinical trial in 100 dogs manual of clinical behavioral medicine for dogs and cats. mosby-year book identification of and screening for human helicobacter cinaedi infections and carriers via nested pcr identification of three novel superantigen-encoding genes in streptococcus equi subsp. zooepidemicus, szef, szen, and szep hypothyroidism in dogs: 66 cases (1987-1992) plasma von willebrand factor antigen concentration in dogs with hypothyroidism plasma von willebrand factor antigen concentration and buccal bleeding time in dogs with experimental hypothyroidism canine cutaneous mast cell tumor: morphologic grading and survival time in 83 dogs atlas of small animal wound management and reconstructive surgery what's your diagnosis? fever and leukocytosis in a young beagle. canine juvenile polyarteritis syndrome (beagle pain syndrome) a clonal outbreak of acute fatal hemorrhagic pneumonia in intensively housed (shelter) dogs caused by streptococcus equi subsp. zooepidemicus thyroid diseases urogenital emergencies emergency procedures for the small animal veterinarian prognostic significance of morphological subtypes in canine malignant lymphomas during chemotherapy streptococcus zooepidemicus: an emerging canine pathogen characterization of pneumonia due to streptococcus equi subsp. zooepidemicus in dogs tumors of the skin and soft tissue aspiration-induced lung injury origins and evolution of a transmissible cancer canine mast cell tumors express stem cell factor receptor arterial and venous blood gas analyses dogs and cats as laboratory animals hypocretin levels in sporadic and familial cases of canine narcolepsy comparison of 4 giardia diagnostic tests in diagnosis of naturally acquired canine chronic subclinical giardiasis effects of chlorhexidine diacetate and povidone-iodine on wound healing in dogs genetic evidence for an east asian origin of domestic dogs urethral-sparing histotripsy of the prostate in a canine model factors influencing canine mammary cancer development and postsurgical survival how to treat common parasites safely muller and kirk's small animal dermatology systemic necrotizing vasculitis in nine young beagles thomson's special veterinary pathology, second ed. mosby-year book thyroid and parathyroid glands diseases of the small bowel canine infectious tracheobronchitis (kennel cough complex) diseases of the intestines the use of ultrasonography for pregnancy diagnosis in the bitch cytologic examination of fine-needle aspirates from mammary gland tumors in the dog: diagnostic accuracy with comparison to histopathology and association with postoperative outcome effects of finasteride on size of the prostate gland and semen quality in dogs with benign prostatic hypertrophy canine prostatic disease: a review of anatomy, pathology, diagnosis, and treatment pathologic features of naturally occurring juvenile polyarteritis in beagle dogs development, anatomy, histology, lymphatic drainage, clinical features, and cell differentiation markers of canine mammary gland neoplasms withrow & macewen's small animal clinical oncology nutrient requirements of dogs and cats (nutrient requirements of domestic animals) trauma to the skin and subcutaneous tissues of dogs and cats chronic problem wounds of dog limbs acvim small animal consensus statement on leptospirosis: diagnosis, epidemiology, treatment, and prevention lumbosacral stenosis in dogs mammary neoplasia in a closed beagle colony complete mitochondrial genomes of ancient canids suggest a european origin of deomestic dogs artificial insemination in canids: a useful tool in breeding and conservation artificial insemination with frozen semen in dogs: a retrospective study of 10 years using a non-surgical approach manual of canine and feline cardiology comparative evaluation of agar dilution and broth microdilution methods for antibiotic susceptibility testing of helicobacter cinaedi thyroiditis in a group of laboratory dogs: a study of 167 beagles obesity-related metabolic dysfunction in dogs: a comparison with human metabolic syndrome pro-inflammatory properties and neutrophil activation by helicobacter pylori urease of agriculture, animal and plant health inspection service annual report animal usage by fiscal year. available from: <www leptospirosis in dogs: a review with emphasis on clinical aspects thomson's special veterinary pathology, second ed. mosby-year book endocrinology of pregnancy in the dog: a review immunoblot analysis as an alternative method to diagnose enterohepatic helicobacter infections management of superficial skin wounds psychodermatosis colony multiplex pcr assay for identification and differentiation of campylobacter jejuni, c. coli, c. lari, c. upsaliensis, and c. fetus subsp. fetus the role of c-kit in tumorigenesis: evaluation in canine cutaneous mast cell tumors aaha canine vaccination guidelines canine mast cell tumours: a review of the pathogenesis, clinical features, pathology and treatment serum concentrations of thyroxine and 3,5,3′-triiodothyronine before and after intravenous or intramuscular thyrotropin administration in dogs surgical treatment of specific skin disorders naltrexone for treatment of acral lick dermatitits in dogs use of ultrasound in the measurement of subcutaneous fat and prediction of total body fat in dogs mammal species of the world: a taxonomic and geographic reference withrow & macewen's small animal clinical oncology the authors thank dr. bambi jasmin of marshall farms for contributions on preventive health practices for class a dogs. key: cord-282298-8tcw3cll authors: wang, jie; xiong, xingjiang title: current situation and perspectives of clinical study in integrative medicine in china date: 2012-02-21 journal: evid based complement alternat med doi: 10.1155/2012/268542 sha: doc_id: 282298 cord_uid: 8tcw3cll integrative medicine is not only an innovative china model in clinical practice, but also the bridge for tcm toward the world. in the past thirty years, great achievements have been made in integrative medicine researches, especially in clinical practice. the clinical achievements mainly include the following three: innovating methodology of disease-syndrome combination, excavating the classical theory in traditional chinese medicine (tcm), preventing and curing refractory diseases. the development ideas and strategies of integrative medicine for future mainly include (a) standing on frontier field of international medicine and improving the capability of preventing and curing refractory diseases; (b) moving prevention and control strategy forward and improving the curative effect of common and frequent disease; (c) excavating the classical theory of tcm and broadening the treatment system of modern medicine; (d) improving the innovation level of new high effective drugs on the basis of classical prescriptions and herbs in tcm; (e) rerecognizing the theory of formula corresponding to syndrome in tcm and enhancing the level of clinical research evidence based on evidence-based medicine. integrative medicine will do obtain greater achievements in creating new medicine and pharmacology and make more tremendous contributions for the great rejuvenation of the chinese nation and human health care. the coexistence of western medicine (wm) and traditional chinese medicine (tcm) began to appear when wm was introduced to china from the middle of 16th century. the tendency of "confluence of chinese and western medicine" appeared as the two medical systems contacting and influencing with each other since then. with the development of modern medical technology, intercourse, and cooperation between tcm and wm, integrative medicine was established in the 1980s. under the guidance of "system learning, comprehensively mastering, sorting, and improving," predecessors of integrative medicine have been exploiting the complementary advantages of macro and micro, global and local, structure and function, traditional and modern, disease differentiation, and syndrome differentiation in wm and tcm, in order to create new medicine and pharmacology theory. through unremitting efforts of integrative medicine staffs at home and abroad, remarkable achievements have been made in health care, teaching, researching, academic development, discipline construction, talent training, and so forth. so we can say that integrative medicine is not only an innovative china model in clinical practice, but also the bridge for tcm toward the world [1] [2] [3] . now the clinical achievements of the past 30 years and developing strategies of integrative medicine are described as follows. research. the relationship between disease and syndrome is thought to be one of the most significant problems in tcm clinical and basic practice. as a new mode for syndrome research, disease-syndrome combination mainly refers to absorbing the idea and theory of disease differentiation in western medicine (wm) as 2 evidence-based complementary and alternative medicine well as syndrome differentiation in tcm. the mode, which originates from the medical practice since more than half a century ago, has realized mutual compensation of advantages of tcm and wm [1, 2] . combining whole thinking, imagery thinking, and dialectical thinking in tcm with materialism of modern medical sciences, the mode can be regarded as a good cut-in point and successful control pattern for integrative medicine [3] . it has complementary advantages of wm and tcm and marks a new era created by integrative medicine in clinical researches. seminar on the academician chen keji's academic thinking about "the new mode of disease-syndrome combination and its application in clinical practice" was held in beijing on may 23, 2011. professor chen and his students discussed the scientific connotation of this new mode and its application in diagnosis, treatment, and scientific research together. china news of traditional chinese medicine, a famous domestic media, made followup report on the symposium, which had evoked large repercussions. academician chen keji pointed out that modern view of disease-syndrome combination includes six aspects: (a) mode of disease differentiation by wm combined with syndrome differentiation by tcm; (b) mode of syndrome differentiation and treatment combined with specific prescription for certain illness; (c) mode of treating according to disease staging; (d) mode of differentiation of the basic pathogenesis combined with syndrome differentiation and treatment in tcm; (e) mode of treating according to syndrome differentiation rather than disease differentiation when there's no disease can be diagnosed in wm; (f) mode of treating according to disease differentiation rather than syndrome differentiation when there's no syndrome can be diagnosed in tcm [4] . the emphasis of the mode could be played on either syndrome or disease. as the connotation of syndrome in tcm is significantly different from disease in wm, laying special emphasis on syndrome means that syndrome is just the basis of therapeutic scheme. on the contrary, effective therapeutic plans should be formulated according to disease differentiation when special emphasis is laid on disease. this new mode is beneficial to the original innovation in diagnosis and treatment. the advantages of the mode include four aspects as follows. (a) definitely diagnosing. as the disease diagnosis in tcm is vague and extensive, it is entirely necessary and possible to absorb some relevant achievements of disease diagnosis in wm for definitely diagnosing. (b) targeted treating. as the new mode pays more attention to the therapeutic evaluation of disease, it could achieve more definite therapeutic targets and stable curative effect compared with syndrome differentiation mode alone. (c) accurately prognosing. summarization of clinical phenomena is the principal judgment basis for prognosis in tcm, therefore, the prognosis judgment is always not very accurate. however, the new mode has vital guidance value for treatment and prognosis judgment. (d) deepening classics. due to the succinctness and conciseness of tcm classics, the essential features of the disease and syndrome could be rerecognized and deepened through combining with the modern cognition of pathology, diagnostics and pharmacology study in wm. syndrome is not only the core of tcm basic theory and syndrome differentiation, but also the bridge to associate disease and formula. different from diagnosis based on pathological mechanism, syndrome is a classification according to subjective symptom and objective sign collected by physical examination [5] [6] [7] . premise studies on diseasesyndrome combination lies in syndrome diagnostic criteria and therapeutic evaluation system. researches on syndrome diagnostic criteria aim at establishing the scientific and normative diagnosis system, while researches on therapeutic evaluation aim at constructing an objective evaluation system. under the leadership of academician chen keji, we are the first to study and report on blood stasis syndrome in coronary heart disease based on the new mode. contributed to the diagnosis of blood stasis syndrome in coronary heart disease, 19 items such as precordial pain, dark purple tongue color, and erythrocyte deformability were selected based on the calculation analysis of 48 kinds of examination items in 92 cases patients with coronary heart disease. and the clinical diagnosis accordance rate was 89%. 6 items giving the greatest contribution to diagnosis such as blood viscosity and total cholesterol (tc) were confirmed by a stepwise regression analysis for 21 items such as hemorheology and blood lipid [8] . correlation analysis of blood stasis syndrome and pathological changes shown in coronary angiography with coronary heart disease showed that the blood stasis syndrome score was significantly correlated to the maximal stenosis degree and coronary lesion score demonstrated by coronary angiography before percutaneous coronary intervention (pci), and the correlation was increased along with the increasing of the patients' age and the course of the disease. conclusions were also verified in our related researches [9] [10] [11] . through mathematical statistics method and computational intelligence approach, it was found out that the major syndrome factors of coronary heart disease are blood stasis, qi deficiency, turbid phlegm, qi stagnation, heat deposition, yang deficiency, yin deficiency, and cold coagulation based on calculation analysis of 5099 cases patients reported on literatures and 1069 cases patients with coronary heart disease validated by coronary angiographic. we also constructed the diagnosis scales of blood stasis syndrome and its accompanied syndromes in coronary heart disease, such as qi deficiency and blood stasis syndrome and qi stagnation and blood stasis syndrome [12] [13] [14] . in the study of therapeutic evaluation system, taking coronary heart disease as example, important indexes such as syndrome evaluation scale, clinical critical events, and quality of life were selected on the basis of completely evaluating the present indexes through application of clinical epidemiology-/evidencebased medicine method. meanwhile, high validity and reliability of therapeutic evaluation system of coronary heart disease was constructed through comprehensive analysis of various index by the hall for workshop of metasynthetic engineering. clinical efficacy scale of tcm syndrome and the primitive entry pool of scale for patient-reported outcomes of coronary heart disease were established by our team [15] . evidence-based complementary and alternative medicine 3 it is meaningful to promote the original innovation in integrative medicine researches through further understanding the connotation of syndrome diagnosis, therapeutic principle, and classical prescription by modern science and technology. among these studies, three researches below are honored. the first one is blood stasis syndrome theory and the clinical application of the method of promoting blood circulation and removing blood stasis. blood stasis syndrome theory is first recorded in the songs of chu, a classical literature written in ancient china. shuo wen jie zi (text notes and word explanations) written by xu shen in the eastern han dynasty explained that blood stasis is hematocele. and it was frequently mentioned in tcm classics such as the canon of internal medicine, treatise on febrile diseases, and synopsis of golden chamber. inspired by the prominent tcm doctor guo shikui's experience in treating angina pectoris by decoction for removing blood stasis, a classic formula developed by wang qingren in qing dynasty, academician chen keji advocated treating coronary heart disease by activating blood circulation to dissipate blood stasis principally. his team was the first to study the diagnostic criteria of blood stasis syndrome and report the quantitative scoring method, which had been extensively used in domestic and was the first study in using objective quantitative method in tcm syndrome study. objectified study of abdomen diagnosis on blood stasis syndrome was also superior to the research methods of japan in the same period. standards of syndrome differentiation and therapeutic evaluation of coronary heart disease were formulated according to above-mentioned researches, which had already become national standards. the essence of blood stasis syndrome and mechanism of treating coronary heart disease by activating blood circulation to dissipate blood stasis had been elucidated at various levels of intact animal, tissue, cell, molecule, and gene protein expression. as coronary restenosis after coronary artery balloon injury and stent placement have been considered an international difficult problem, academician chen firstly treated it by decoction for removing blood stasis and optimized the prescription to a more simplified and effective recipe, xiong shao capsule (xsc). a randomized controlled trial (rct) about xsc showed that the restenosis rate in xsc group treated by xsc on the basis of routine western therapy was decreased by 45% compared with routine western therapy group, and the experimental studies showed that xsc could suppress the gene expression of proliferation of vascular smooth muscle cells [16] [17] [18] [19] . with important academic value and clinical significance, the study has promoted the academic development of tcm greatly, which had been awarded the first award of national science and technology progress in 2003. the second study is the theory of dispelling interior pathogenic factors and purgation and its application in the treatment of acute abdomen. according to the theoretical basis of "the six fu-viscera function well when unobstructed," academician wu xianzhong began to explore integrative medicine therapy on acute abdomen in early years. through unifying standard for syndrome differentiation and defining operative indication, his team accumulated a large number of valid acute abdomen cases with the therapeutic method of expelling pathogens by purgation. under the leadership of professor wu, the multidisciplinary and prospective researches included the effects of dispelling interior pathogenic factors and purgation on the splanchnic blood flow and caecal single smooth muscle cell, the clinical characteristics of multiple organ dysfunction syndrome (mods) caused by several different kinds of elements, the changes of nerve-endocrine-immunological network in mods and the effects of purgative herbs on information transmission mechanism of immune cells through four times of different scale joint research in the seventh to tenth five-year plan period. after years of efforts, significant progress had been made and the operation rate had been reduced in the treatment of acute abdomen, such as severe acute cholangitis, acute severe pancreatitis, and complicated biliary stones, which was awarded the second award of national science and technology progress in 2003 [20] [21] [22] . the third one is the theory of "treating the toxifying disease with poisonous agents" and researches for arsenic trioxide (as 2 o 3 ) treating acute promyelocytic leukemia (apl). the theory is a traditional simple understanding of hypertoxic drug treating difficult and complicated diseases. it was recorded in compendium of materia medica that the herbal nature of arsenolite is very hot and poisonous, while white arsenic sublimed from arsenolite is more poisonous. white arsenic is a traditional external drug for removing the necrotic tissue and promoting granulation plaster, the effective component of which is as 2 o 3 . the research was enlightened by the prominent tcm doctor's experienced external prescription for treating skin cancer. on the basis of verification of curative effects and optimizing prescription, researchers developed the arsenous acid injection from the experienced external prescription, which had definitive curative effect for the patients with apl and reached the top level in the world [23] [24] [25] [26] . the mechanism of arsenous acid treating apl was illustrated from the perspective of molecular oncology, including degradation of pml/rara fusion proteins, downregulating gene expression of bcl2 and inducing apoptosis in leukemia cells. arsenous acid became the first antileukemia drug of inducing apoptosis in the world arousing the medical research fever of arsenic trioxide [27] [28] [29] . it was honored as "ancient remedy performs new tricks" in 1996 by science [30] . sloan-kettering and his coworkers reported that 12 patients with recurrence of apl after conventional chemotherapies were treated with as 2 o 3 , and 11 cases of them relieved completely in 1996. this paper, published in new england journal of medicine, directly led to the widely acceptance of as 2 o 3 in the treatment of apl in the international medical field [31] . as the frontier field and hot issue of cardiovascular diseases, restenosis after percutaneous coronary intervention and myocardial ischemia reperfusion injury (miri) during open heart surgery of cardiopulmonary bypass has become the best innovative points of clinical studies in integrative medicine. researches showed that restenosis after percutaneous coronary intervention was closely related to blood stasis syndrome. predominantly evaluated by restenosis (rs) rate estimated by coronary angiography (cag), a prospective randomized controlled study was carried out on rs after pci to observe the intervention effect of xiong shao capsule (xsc). compared with the control group, the incidence of rs rate in the xsc group was significantly lower (24.1% versus 48.5%, p < 0.05) and the extent of angiostenosis and diameter of the culprit arteries, determined by cag, also significantly reduced after patients had been treated for 6 months with [(2.21 â± 0.85) mm versus (1.72 â± 0.99) mm, p < 0.05], and [(26.58 â± 20.72) % versus (41.19 â± 30.92) %, p < 0.05], respectively. the incidence of clinical end-point event was significantly lower in the xsc group than that in the control group (11.7% versus 27.6%) and the p value was close to statistical significance (p = 0.051). comparing with the control group, the blood-stasis syndrome score in the xsc group was also significantly lower (p < 0.01). the results showed that xsc had a wide range of therapeutic effects including effectively preventing rs after pci in combination with conventional western medical treatment, decreasing the attack of angina pectoris and improving the blood stasis syndrome. experimental researches on blood activating herbs showed that it can significantly inhibit pathological vascular remodeling after balloon injury, thus reduce late lumen loss and prevent restenosis [32] [33] [34] [35] [36] . as the establishing the cardiopulmonary bypass of open heart surgery is key point of successful operation, myocardial ischemia reperfusion injury (miri), which is very obvious during the recovery of circulation, has become the hot issue needed to be resolved. some scholars found that the pathogenesis of miri during open heart surgery of cardiopulmonary bypass is deficiency of heart qi in the origin and excess of heart blood stasis and internal turbid toxin in the superficiality and the therapeutic principles are boosting qi and nourishing heart, activating blood circulation and resolving toxin simultaneously. it was proposed that of astragalus injection and tetramethylpyrazine injection for boosting qi and activating blood circulation should be given by vein injection during operation and hu xin bao (compatibility of extracts of ginseng and panax notoginseng with taurine) for boosting qi, activating blood circulation, and resolving toxin should be given by oral administration before operation. the research showed that astragalus injection combined with tetramethylpyrazine injection could reduce the content of mda and myocardial enzymes' release and improve the activity of sod, no, and nos. serial studies demonstrated that boosting qi combined with activating blood circulation have significantly synergetic effects, and boosting qi, activating blood circulation, combined with resolving toxin were superior to those simple boosting qi, activating blood circulation, resolving toxin, and boosting qi combined with activating blood circulation [37, 38] . multiple organ dysfunction syndrome (mods) is one of the difficult problems in the field of the critical care medicine, which is characterized by acute onset, rapid progress, and extremely high mortality. since the 1970s of 20th century, some scholars began to take vigorous action to explore a new way of preventing and treating mods by integrative medicine and a new theory of "bacteria and bacterial toxin treated simultaneously" was presented ultimately. they also perfected schemes for the diagnosis procedure and treatment standard of mods by both tcm and integrative medicine. and four therapeutic principles for the main types of syndromes were put forward, such as activating blood circulation to dissipate blood stasis therapy on blood stasis syndrome, clearing heat and toxin therapy on heat toxin syndrome, reinforcing the vital energy and consolidating the constitution therapy on acute deficient syndrome, and dispelling interior pathogenic factors and purgation therapy on yangming fu-organ syndrome. integrative medicine therapy can effectively improve the clinical efficacy and shorten the course of the disease thus reducing mortality. a famous injection of chinese medicine, "shen nong 33," with the effect of activating blood circulation to dissipate blood stasis and antiendotoxin, was developed, which has reduced the mortality of international recognized infectious four or more organs failure from 100% to 50% and reached the international advanced level. furthermore, a new strategy of "bacteria, bacterial toxin, and inflammatory mediator treated simultaneously" was put forward on the basis of the theory of "bacteria and bacterial toxin treated simultaneously." xue bi jing injection, the first chinese medicine preparation in emergency medicine, was developed, which have made great contributions to the advancement of critical care medicine [39] [40] [41] [42] [43] . chronic hepatitis b is the common disease in china, as well as in the world, causing great affliction to patients. it has become the major issue in the treatment of chronic liver disease. the progression of chronic hepatitis b may lead to liver cirrhosis and hepatocellular carcinoma. hepatic fibrosis is the common pathological end stage of various chronic liver diseases regardless of the etiology, and blocking the occurrence and development of fibrosis of liver is very important in chronic hepatic diseases' treatment and prognosis. tcm has become the important therapy in treating chronic hepatitis, liver fibrosis, and liver cirrhosis. some scholars put forward the hypothesis that liver fibrosis and early liver cirrhosis can be reversed. they found out that the basic pathogenesis of liver fibrosis is weakened body resistance and blood stasis, so therapeutic method of strengthening body resistance and dispelling stasis was established, and "fu zheng hua yu capsules," a new drug for treating liver fibrosis, was developed. predominantly evaluated by liver tissue fibrosis, clinical researches were carried out to observe the curative effect of the therapeutic method of strengthening body resistance and dispelling stasis. the total inversion rate of liver tissue fibrosis was 52% to 58.3% compared before and after treatment, which also confirmed that liver fibrosis can be reversed and treated. the mechanism includes significantly inhibiting lipid peroxidation, the proliferation of hepatic stellate cell and activation of collagen expression, reducing inflammation of hepatocytic injury model, increasing the activity of matrix metalloproteinases, promoting the degradation of pathological liver collagen, and so on [44] [45] [46] . combining the macroscopic view with microscopic view, syndrome differentiation with disease differentiation, regional with global, taking stopgap measures with taking radical measures, supporting healthy aspects with eliminating pathogens, tumor treatment model by integrative medicine emphasizes contriving individual treatment plan and evaluation standard on the basis of biological characteristics and the course of disease. malignant tumors could be treated by tcm therapies such as reinforcing the vital energy and consolidating the constitution, supplementing qi and nourishing yin, and clearing away heat and toxic materials, combined with conventional therapies such as radiotherapy, chemotherapy, and surgery. tcm treatment has significances in decreasing toxicity and increasing efficacy on radiotherapy and chemotherapy. integrative medicine theory has a remarkable effect in alleviating symptoms such as dry mouth in hyperpyrexic consumption of yin syndrome and deficiency of both qi and yin syndrome caused by head and neck cancer after radiotherapy, relieving symptoms such as cough caused by acute radiation pneumonitis, improving immune function, and survival quality of postoperative patients, preventing the tumor from recurrence or metastasis and prolonging survival time. the new model of combining tcm and modern cancer treatment has attracted widespread attention in the world, which is known as "china model for cancer treatment" [47] . in addition, screening of tumor inhibition from more than 3,000 species of chinese herbs and nearly 300 chinese herbal compound, effective components having directly killing effect on cancer cell such as indirubin, camptothecin, vinblastine, matrine, and aclitaxel were extracted. some chinese herbs, having the effect of immunological enhancement and biological response modifier-like action such as polyporus, poria cocos, and mushroom, were also found out. apl is a special type of acute leukemic (al). tcm suggests that the pathogenesis of apl is weakened body resistance and excessiveness of pathogen, so therapeutic method of eliminating pathogenic factors and strengthening body resistance was established. some scholars developed the compound realgar natural indigo tablets (realgar, indigo naturals, salvia and radix pseudostell) on the basis of clearing away heat and toxic materials and supplementing qi with activating blood circulation and promoting hemogenesis method. 155 cases of apl patients were treated by the compound realgar natural indigo tablets and the remission rate was 97.42% after treating for 6 months. no side effect, serious infection, bleeding, and dic were found during the treatment course. it was also characterized by higher negative conversion rate of pml-rarî± fusion gene and simple application. the results demonstrated that the complete remission rate of treatment of the compound realgar natural indigo tablets were 10-15% higher than that of all-trans retinoic acid (atra). on this basis, the effect of post-remission therapy mainly with compound realgar natural indigo tablets on long-term survival of 74 cases patients with apl showed that the median remission time was 48 months with recurrence rate only 14.86% and 10-year survival probability was 75.38% [48] [49] [50] . since the 1970s of 20th century, the basic syndrome of type 2 diabetes included yin deficiency with internal excessive heat, deficiency of both qi and yin, and deficiency of both yin and yang, therefore, iii-type differentiation of type 2 diabetes was established and developed. it had already been adopted by national guidelines for new drug in the late 1980s. as deficiency of both qi and yin was the important basic syndrome of the disease, "jiang tang jia tablets," a new chinese herb of supplementing qi and nourishing yin, could improve insulin resistance, islet î²cell function, and the level of glucose and lipid metabolism, the total effective rate of which was 76.54%. in addition, researches of tang wei kang capsule treating early diabetic nephropathy and tang xin ping treating diabetic cardiopathy have gotten progress [51, 52] . some scholars also found out that blood stasis was another significant pathogenesis of type 2 diabetes due to the changes of hemorheology with different degree were found. so they advocated treating the disease by promoting blood circulation and removing blood stasis principally. based on this idea, promoting blood circulation by removing blood stasis recipes, such as nourishing yin and activating blood recipes and xian zhen tablet of reinforcing kidney and activating blood, were developed. those recipes have multilevel and multitarget effects, including improving symptoms, reducing blood glucose, improving blood rheology and blood flow, lowering triglycerides (tgs), and malondialdehyde (mda), enhancing activity of erythrocyte sod, na + -k + -atp enzyme and ca 2+ -mg 2+ -atp enzyme, and so forth. the experimental studies showed that the effect of xian zhen tablet includes lowering blood glucose and glycosylated hemoglobin, decreasing urine protein excretion, improving renal function, reducing the pathological changes of glomerular mesangial expansion and basement membrane thickening, decreasing ages amounts of renal cortex, and downregulating rage-mrna expression in renal cortex and endothelia of heart vessel. it provided a new idea for preventing and treating diabetic and chronic vascular complications [53, 54] . severe pancreatitis, namely, acute hemorrhagic necrotizing pancreatitis, is characterized by acute onset, rapid progress, high mortality, and poor prognosis. 65% of the death cases are due to complicating with acute respiratory distress syndrome (ards). according to the theoretical basis that "the six fu-viscera function well when unobstructed" and "the lung and the large intestine are interior-exteriorly related," acute pancreatitis is treated by expelling pathogens by purgation, and the average cure rate reached to 97%, while the average cure rate of severe pancreatitis was 80%. compared with our country and abroad, the mortality has reached the lowest level. qing yi decoction, a famous antipyretic and purgative prescription, protected the lung from injury in many aspects, by preserving the damage of gut barrier function, reducing or eliminating endotoxemia derived from the gut, inhibiting the production, and release of tnf, il-6, and the translocation of bacteria. the results may fully show the superiority of integrative medicine in treating serious diseases [55, 56] . a certain progress was also made on dermatosis and burn medicine by integrative medicine therapy. vitiligo was effectly treated by taking modified tao hong si wu decoction, external application of compound tar traditional chinese rubbing-drugs and melagenine extracted from placenta. evidence-based complementary and alternative medicine 243 patients with vitiligo were treated by modified tao hong si wu decoction and the total effective rate was 68.2%, the mechanism of which was related to upregulation of tyrosinase activity, increasing the melagenine content, and promoting melanocyte proliferation [57] . moist exposed burn therapy (mebt), a new therapeutic system of burn medicine in integrative medicine, has become the leading enabler throughout the world. it is found out that the burn wound should be kept in a moist but not macerated environment in order to promote in nature recovery and generation of the skin rather than in traditional dry environment. and the exact curative effect was obtained by mebt and moist exposed burn ointment (mebo) [58] . severe acute respiratory syndrome (sars) has aroused international attention for strong infectiousness, rapid progression, poor prognosis, and high mortality, which has no special effective therapy yet. 524 patients of sars in china were divided into integrative medicine treatment group (n = 318) and western medicine treatment group (n = 206). the existence rates for the symptoms of weakness, short breath, dyspnea in the first group were significantly lower than that in the second group after treatment. the duration of weakness was averagely shortened by 1.5 days in the first group. and short breath, dyspnea, and muscle aching pain were averagely shortened by 2 days, 1 day, and 2 days, respectively. researches showed that the effect of integrated therapy of tcm and wm for treating sars was superior to wm treatment alone, and the integrative medicine could improve clinical symptoms such as weakness, short breath, and dyspnea [59] [60] [61] . the exact clinical curative effect was also recognized by world health organization (who). diseases. previous achievements in clinical researches of integrative medicine showed that it is absolutely necessary to keep a foothold at frontier field of international medicine and life science and derive the wisdom and new theories from these subjects in order to find the innovation and breakthrough from subject cross and osmosis. aiming at the hot issues and knotty problems confronted in clinical medicine, we could put forward scientific hypotheses in exploring the etiology and pathogenesis of the disease and seek for the effective therapeutic principles and classical prescriptions. basing on the research mentioned above, the clinical efficacy should be objectively evaluated by randomized controlled trials (rct), and the potential mechanism should be illustrated ultimately. by summarizing the clinical regularity in time, it will contribute to the innovation of the medical theory and guide clinical practice. taking coronary heart disease as example, despite great advancements in the fields of basic and clinical researches made by modern medicine, there are still some issues to be resolved, such as acute coronary syndrome complicated by microvascular thrombosis, myocardial ischemia-reperfusion injury, no-reflow phenomenon, stent thrombosis, obvious subjective symptoms such as hypodynamia and shortness of breath remained after percutaneous coronary intervention (pci), and ventricular remodeling following myocardial infarction [62] [63] [64] . previous study showed that the prospects of integrative medicine is brightening in treatment for coronary stent thrombosis and protecting the myocardial ischemia-reperfusion injury. in addition, as viral infectious disease belonged to the category of epidemic febrile disease in tcm thousands years ago, chinese ancients had accumulated rich experience and formed a systematic and complete theory in treatment. currently, better therapeutic efficacy of viral infectious diseases could be achieved by combining two medical systems, especially in sars, n1h1, and bird flu. also, more similar breakthrough points of integrative medicine can be found, for instance, improving the low success rate of assisted reproductive technology (art) by combining art with tcm therapeutic method of reinforcing kidney and activating blood, and so forth. disease. "moving prevention and control strategy forward" is a national macrohealth policy, which well adapted to the new medical model, "physiological-psychological-socialenvironmental" model. it means that the focal point of medicine will be transferred from treating disease to health care, and disease prevention will be paid more attention to. therefore, the policy of "prevention first" will be carried out instead of traditional ideological concept "treatment is more major than prevention." it is similar to the tcm theory of "preventive treatment of disease," including principles of "preventing measure taken before the occurrence of disease" and "preventing measure taken after the occurrence of disease" in canon of internal medicine. concrete measures of "moving prevention and control strategy forward" include concept forward, funding forward, emphasis of the researches forward, and measures to be carried out forward. it could reduce the incidence of the major diseases from the origin and effectively control the medical expense and save resources in medicine and health. integrative medicine researches should also observe the principles above and pay more and more attention to improve the curative effect of common and frequent diseases. taking cardiovascular disease, for example, there are about 30% of the population in the world died from cardiovascular and cerebrovascular events, among which 62% of stroke and 49% of cardiovascular events were directly caused by hypertension [65] . according to the china cardiovascular reports (2008-2009), the occurrence and mortality of cardiovascular disease is still increasing in our country, and it is estimated that the number of patients with cardiovascular disease is at least 230 million. it also demonstrated that there were about 200 million hypertensive patients in china with more than 10 million patients increased annually. as the primary cardiovascular risk factor, the risk level of hypertension is equivalent to three other cardiovascular risk factors together. that is why more evidence-based complementary and alternative medicine 7 emphasis should be taken on prevention and intervention of earlier-stage hypertension in clinical researches of integrative medicine. additionally, hyperlipidemia, hyperglycemia, obesity, and other risk factors also should be paid more attention to. it is reported by world health organization (who) that if risk factors were controlled as early as possible, 80% of the disease can be prevented effectively, such as coronary heart disease, stroke, and diabetes. furthermore, paying 1 yuan in prevention will save 7-8 yuan in treatment. broadening the treatment system of modern medicine. jama, an international authoritative journal, have commented that traditional medicine should joint tracks with modern medicine. it suggested that not only should we inherit traditional academic thoughts but also keep an eye on modernization of tcm and study it in a scientific and systematic way [66] . the target is to fully digest the traditional chinese medicine, and apply it to modern medical system. how to do it? the first is further understanding of the essence in tcm, while giving up the dross. the second is illustrating the mechanism of the traditional therapy by using advanced scientific technology in order to improve the safety of the treatment and alleviate the toxicity adverse effect. viscera, meridians, prescriptions, and syndromes, the precious wealth in tcm left by our ancients, are worth deeply researching into. however, as the theory is profound, classical, and concise, combining with clinical practice is the unique way to understand the connotation. for example, the lung and the large intestine are interior-exteriorly related, that is to say, the lung was associated with the large intestine by meridians. in the clinical practice, dysfunction of the large intestine conduction could cause no descending of the lung qi, conversely, no descending of the lung qi also can result in obstruction of fu-qi. it is reported that introducing fuunblocking and purgation therapy into adults' acute pneumonia is a rapid and effective treatment. in the 70th of the last century, professor wang had applied liang ge san (cool diaphragm powder) to treat sirs and mods, which mainly manifested as yangming visceral substantive syndrome. the result demonstrated that the respiratory function of 80% patients with respiratory failure was rapidly improved, and the recovery was greatly promoted. among the patients with acute pancreatitis accompanied with mods, the therapy also received superior efficacy. all of these theories mentioned above, including blood stasis syndrome theory, theory of dispelling interior pathogenic factors and purgation, and theory of "treating the toxifying disease with poisonous agents," were all worth deeply excavated, which have being greatly broadened the treatment system of modern medicine. compared with tcm theory, chinese herbs are much easier to be modernized and recognized. therefore, it is of great significance in promoting modernization, industrialization, and industrialization of the chinese herbs, by ways of combining modern technology with fully understanding of classical prescriptions and herbs. china is a great power with rich herb resources. according to the records in formula dictionary of traditional chinese medicine, there are approximately 100 thousand prescriptions, including special prescriptions and herbs for certain diseases. the classical prescriptions and herbs provided with definite clinical indications are of more meaning to be developed. that will provide an effective shortcut to improve the capability of developing new drugs, which is characterized by definite chemical structure, explicit action mechanism, obviously curative effect, advanced formulations, convenience for taking, and low price. at present, the effective fractions and monomers extracted from chinese herbs had obtained reliable clinical benefits. for instance, artemisinin extracted from sweet wormwood (artemisia annua l.) have a definite effect in the treatment of falciparum malaria, which had been confirmed by multinational joint researches. the new therapy developed by professor tu youyou has saved millions of lives across the globe, especially in the developing world, which had also been listed in the catalog of "essential medicines" by the world health organization (who) [67] [68] [69] [70] [71] . therefore, professor tu was awarded the 2011 laskerâ�¼debakey clinical medical research award for the discovering artemisinin and its utility for treating malaria. the research will raise a new global round of climaxes of modernization and internationalization of tcm. in addition, indirubin extracted from indigo naturals in danggui long hui wan (pill of angelica sinensis, gentian and aloe) could treat leukemia. diterpenonid versicolaction extracted from tripterygium wilfordii hook can be used as immunosuppressive agents for treating rheumatoid arthritis (ra). biphenyl dimethyl dicarboxylate (ddb) extracted from schisandra chinensis could decrease the alt and ast activity. tetramethylpyrazine extracted from ligusticum chuanxiong hort has showed a good effect for ischemic cerebrovascular disease. cantharidin extracted from mylabris could treat liver cancer. moreover, other active components such as ginsenoside, total puerarin flavonoids, polyporus umbellate polysaccharides, ganoderma lucidum polysaccharide, anisodamine, tanshinone, trichosanthin, tetrahydropalmatine, tetrandrine, rubidate, ilexonin a, and ferulic acid sodium. evidence-based medicine (ebm) is a new subject quickly developed in the clinical medicine field in the 1990s. the core thinking is to combine evidence, personal experiences, and patients' actual situation to formulate scientific measures for preventing diseases, promoting the recovery and improving life quality. among them, clinical evidence originates mainly from randomized controlled trial (rct), systematic review, and meta-analysis. with medical science transforming from traditional experience medicine into evidence-based medicine, fundamental changes have taken place in clinical medicine. therefore, following the principle of respecting science and evidence, it is of the utmost importance to enhance the level of clinical research evidence in tcm and integrative medicine [72] [73] [74] . it is noteworthy that the treatment concept, formula corresponding to syndrome, lied in classical works of tcm, is similar to the ideas of ebm. however, it had been ignored for a long time. the theory of syndrome differentiation and formula corresponding to syndrome are two characteristic inheritance veins in tcm. generally speaking, the former is always the mainstream ideology in tcm, while the latter has been paid little attention. clinical medication based on pathogenesis is the core idea of syndrome differentiation, while clinical medication based on formula syndrome is not exactly the same as it. the most significant difference between them is whether giving attention to the objective evidences of formula utilization. the theory of formula corresponding to syndrome attaches great importance to the objective indications of herbs, which mainly comes from long-term, large-scale and repeated clinical trials by chinese ancients. as the indications of herbs are objective and concrete, clinical effect could be repeated at anytime, anywhere, and for anybody. so it is suggested that, facing with one patient, 10 tcm physicians may prescribe the identical prescription and get rapid treatment effect simultaneously according to the indications of formulae and herbs. this is just the reason why the significant curative effect can be by classical prescriptions get in treating severe and lingering illness. the extractive process of indications is similar to the evidencebased research, and indications of herbs have probably exceeded the category of expert experience in ebm. therefore, carrying out clinical studies under guidance of ebm and formula corresponding to syndrome is helpful to summarize the indications of formulae and herbs, and enhance the level of clinical research evidence in tcm [75] [76] [77] [78] [79] . the history of man's science development showed that the crossing and blending of two kinds of knowledge systems will be able to set up a new knowledge system. integrative medicine, an unprecedented task in present world, is a new pattern of medicine, which is formed by the integration of tcm and wm. the current situation of integrative medicine career was highly evaluated by academician han qide. he pointed out that integrative medicine is an inevitable choice for the development of chinese medicine and the breakthrough point of development for modern medicine, which have unique advantages and will play an important role in china. with changing of the disease chart, increasing of metabolic disease, malignant tumor, iatrogenic disease and drug-induced disease, and the coming of senile society as well as the change of people's views on health and medical mode, both opportunities and challenges have been brought to the development of integrative medicine. thus we believed that under the guidance of "pay equal attention to both wm and tcm" and "implementing the integrative medicine and developing tcm," integrative medicine will obtain great achievements in creating new medicine and pharmacology, which builds on the combination of both wm and tcm, and make tremendous contributions for the great rejuvenation of the chinese nation and human health care [80] . mao zd and integrative medicine chinese medicine pattern diagnosis could lead to innovation in medical sciences integrative medicine: the experience from china past and present of combination of disease differentiation and syndrome differentiation a systematic analysis of the theory and practice of syndrome differentiation pondering on syndrome 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rats clinical observations on 6 cases of leukemia treated by ailing injection study on chinese herbs containing arsenic treating leukemia studies on treatment of leukemia with traditional chinese drugs containing arsenic arsenic trioxide, a therapeutic agent for apl use of arsenic trioxide (as 2 o 3 ) in the treatment of acute promyelocytic leukemia (apl): i. as 2 o 3 exerts dose-dependent dual effects on apl cells use of arsenic trioxide (as 2 o 3 ) in the treatment of acute promyelocytic leukemia (afl): ii. clinical efficacy and pharmacokinetics in relapsed patients in vitro studies on cellular and molecular mechanisms of arsenic trioxide (as 2 o 3 ) in the treatment of acute promyelocytic leukemia: as 2 o 3 induces nb4 cell apoptosis with downregulation of bcl-2 expression and modulation of pml-rarî±/pml proteins ancient remedy performs new tricks complete remission after treatment of acute promyelocytic leukemia with arsenic trioxide clinical study on effect of xiongshao capsule on 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traditional medicine with biomedicine towards a patient-centered healthcare system the current work was partially supported by the national basic research program of china (973 program no. 2003cb517103) and the national natural science foundation project of china (no. 90209011). the first author and the corresponding author contributed equally in this paper. all authors manifest that there is no conflict of interests. key: cord-296692-t5p09le8 authors: elgin, t.g.; fricke, e.m.; hernandez reyes, m.e.; tsimis, m.e.; leslein, n.s.; thomas, b.a.; sato, t.s.; mcnamara, p.j. title: the changing landscape of sars-cov-2: implications for the maternal-infant dyad date: 2020-09-07 journal: journal of neonatal-perinatal medicine doi: 10.3233/npm-200460 sha: doc_id: 296692 cord_uid: t5p09le8 the covid-19 pandemic represents the greatest challenge to date faced by the medical community in the 21st century. the rate of rapid dissemination, magnitude of viral contagiousness, person to person transmission at an asymptomatic phase of illness pose a unique and dangerous challenge for all patients, including neonatal and obstetric patients. although scientific understanding of the pathophysiology of the disease, nature of transmission, and efficacy of mitigation strategies is growing, neither a cure or vaccine have been developed. while covid-19 is primarily a disease of older patients, infection is now seen across all age demographics with reports of illness in pregnant patients and infants. altered hormone status and predominance of th-2 immune helper cells may result in increased predisposition to sars-cov-2. case reports of pregnant patients demonstrate a clinical presentation comparable to non-pregnant adults, but evidence of vertical transmission to the fetus is controversial. neonatal reports demonstrate an inconsistent and non-specific phenotype, and it is often difficult to separate covid-19 from the underlying conditions of prematurity or bacterial infection. the development of international registries to enable risk profiling of covid-19 positive pregnant mothers and/or their offspring may facilitate the development of enhanced mitigation strategies, medical treatments and effective vaccinations. in december of 2019 cases of an unknown viral pneumonia were reported from wuhan, hubei, china although much uncertainty remains, regarding the natural history and demographics of covid19 , the virus appears to primarily cause infection in adults over 51 with case fatality rates increasing dramatically with age [5] . appearance of symptoms, which usually include fever, cough, fatigue, and dyspnea with occasional gastrointestinal tract symptoms [6] , typically occurs following five days of incubation [7] . in addition to pulmonary infection, the virus appears to have manifestations in the central nervous system [8] and heart [9] .the published literature largely focuses on the biologic effects of covid-19 in adults, the burden to adult health care systems, and repercussions on society. the impact on perinatal health care is unique; specifically, the risks to maternal health may extend not only to health care providers in the delivery room, but to the newly born infant, and neonatal intensive care unit providers. as the disease spreads and testing capabilities expand, the likelihood of encountering covid-19 positive pregnant women and/or neonates increases. the true magnitude of the pandemic to maternal, fetal, and neonatal health will only be realized as the case mix rises. the goal of this review is to examine the pathobiology of maternal covid disease and possible effects on the developing fetus, provide an overview of published evidence related to the mother, and to appraise strategies to modulate the burden of illness. genetic sequencing identified that the virus belongs to the coronavirus family. coronaviridae are enveloped, positive sense, single stranded rna viruses with a large genome [10] . coronavirus often infects bats and other mammalian hosts but, particularly the genera betacoronavirus, has the potential to infect human populations. severe acute respiratory syndrome (sars-cov) and middle east respiratory syndrome (mers-cov) are betacoronaviruses that have led to recent epidemics. sequencing has determined that the cause of covid-19, officially named sars-cov-2, is also a member of the betacoronarvirus genera [11] , and its genome is nearly 80% identical to sars-cov. sars-cov-2 is a novel enveloped rna betacoronavirus, which infects host respiratory epithelial cells. it is thought to act through angiotensin-converting enzyme 2 (ace2), a membrane-bound aminopeptidase, which functions as its putative receptor. whilst ace2 is predomi-nantly expressed within type ii alveolar cells of the lung, the receptor is also present in several extrapulmonary sites including the mucosa of the oral cavity [12] . sexual diamorphism has been hypothesized based on cellular studies which reveal attenuated expression of ace2 in females. in general, the magnitude of the physiological and mechanical changes induced by pregnancy place the mother at increased risk of infection. these are likely to be exaggerated when respiratory health is adversely compromised or in an advanced stage of pregnancy when functional residual capacity decreases steadily, due to diaphragmatic splinting by the gravid uterus. both the spanish (1918) and asian (1968) flu pandemics were characterized by increased mortality in pregnant mothers and infants less than one year. on the contrary, sars-cov-2 appears to be less pathogenic in these patients. there is immunologic evidence that the pregnancy bias towards t-helper 2 (th2) system dominance and fetus protection leaves the mother vulnerable to viral infections, which are more effectively contained by the th1 system. in pregnancy, the attenuation in cell-mediated immunity by th1 cells due to the physiological shift to a th2 cell dominant environment contributes to increased maternal susceptibility to intracellular pathogens like viruses [13] . non-pregnant patients with covid-19 demonstrate activation of both th1 and th2 immunity, characterized by the presence of both microbicidal/pro-inflammatory cytokines (ifn␥ and il-1␤) in addition to anti-inflammatory cytokines (il-4 and il-10) [1] . in pregnant mothers with covid-19 the immune responses may be variable and characterized by early adaptive immune responses predictive of milder disease severity [14] . it has been postulated that the combined effects of changes in the hormonal milieu of pregnancy which negatively influence immunological responses to viral pathogens [15] and the biological transition to a th2 predominant environment, result in a less severe covid-19 clinical phenotype compared to non-pregnant female. these biologic factors may place pregnant mothers, their fetus and health care workers who take care of them at increased risk compared to individuals of a comparable age, although there is no published evidence to substantiate these concerns. while respiratory secretions appear to be the primary means, evidence exists to suggest that transmission may occur through multiple routes, including ocular and fecal oral routes [16] . patients with active covid-19 have been reported to have elevated inflammatory markers, d-dimer, and proinflammatory cytokines [1] . of particular concern are the risks of covid-19 infection to healthcare workers and the ability of spread to occur through asymptomatic patients; for example in lombardi, italy up to 20% of health care workers became infected [17] . coivd-19 is highly transmissible and infection can occur with a very short exposure time. diagnosis of covid-19 has largely been based on the combination of a clinical presentation, lab data and viral testing; however, computerized tomography (ct) imaging has played an additional supportive role. the radiologic findings ( fig. 1 ) are non-specific and include bilateral (64 (79%) patients), peripheral (44 (54%) patients), ill-defined (66 (81%) patients), and ground-glass opacification (53 (65%) patients), and mainly involving the right lower lobes in 225 (27%) of 849 affected patients [18] . ct findings have been categorized into different phases: an early phase defined as 0-7 days from symptom onset, and a late phase defined as 7-14 days from symptom onset [6] . early phase appearance has been categorized predominantly by bilateral peripheral ground glass opacities. as the disease progresses to the late phase, there is increased lung involvement and the development of linear opacities, ground glass opacities with reticulation ("crazy paving" pattern) and "reverse halo" sign [6] .the overall sensitivity for ct to identify the signs of pneumonia is high, however, its ability to perform as a diagnostic tool specific for covid-19 remains unknown. data from a chinese cohort revealed that the sensitivity, specificity, positive predictive value (ppv), and negative predictive (npv) value of a chest ct in diagnosing covid-19 are 97%, 25%, 65%, and 83% respectively [19] . the clinical utility of ct needs further characterization, particularly in pregnant females where the adverse effects of ionizing radiation to the mother and the fetus need to be considered. in total, 55 pregnant women who have been positive for covid-19 have been reported in the literature, all of whom were diagnosed in the third trimester [20] . of those infected, there have been no published cases of maternal death and two cases of severe infection [20, 21] . a recent review draws attention to two maternal deaths, secondary to ards following delivery, reported by the iranian ministry of health and medical education; however at the time of this publication these cases were not listed on pubmed [22] . most evidence supports that pregnant women present with symptoms like non-pregnant adults [20] . there are, however, emerging case reports of pregnant mothers who test positive for covid-19 infection and who remain either completely asymptomatic [23] and or manifest mild symptoms in the subsequent 24 hours following delivery. recent data from universal screening in a new york urban center revealed [50] 2020 china case control 16 no difference in rates of fetal distress, meconium, preterm birth or neonatal asphyxia. significantly higher rates of uterine atony requiring uterotonics di mascio et al. [33] 2020 italy, usa metanalysis 32 pooled analysis of above studies concluded significantly higher rates of preterm birth, preeclampsia and perinatal death breslin et al. [28] 2020 usa case series 7 asymptomatic carriers are present in substantial numbers and respiratory deterioration is relatively rapid yu et al. [29] 2020 china case series 7 symptoms included fever (n = 6), cough (n = 1), sob (n = 1), diarrhea (n = 1). lab abnormalities included lymphopenia, thrombocytopenia, elevated liver function tests, elevated c-reactive protein, elevated d-dimer. all delivered by cesarean section. all treated with oxygen but no icu admissions. no adverse neonatal outcomes abbreviations: dic, disseminated intravascular coagulation; sob, shortness of breath. that 13.5% of asymptomatic women were positive for sars-cov-2 [24] . in sick patients, symptoms include low grade fever and mild respiratory symptoms [25] . from a diagnostic standpoint, pregnant women appear to have similar findings on laboratory evaluation, chest x-ray and ct scan. imaging findings include peripheral airspace shadowing, bilateral multi-lobar ground-glass opacities or consolidation [20] . table 1 provides a summary of all case series of pregnant mother illness at the time of the current review. a retrospective review, published in lancet, described the clinical findings in nine covid-19 positive women. seven of the nine woman presented with fever, four presented with cough, but none developed severe pneumonia or required intubation. six women developed lymphopenia and elevated c-reactive protein and three had elevation of liver enzymes [26] . zhu et al. reported similar characteristics from nine covid-19 positive mothers and their 10 neonates. fever and cough were the predominant presenting symptoms, and six of the nine women had symptoms appear either before or on the day of delivery [27] . in these two reports, premature delivery was common but attributed to maternal illness. although, four of nine [44%, range 36-36 +6 weeks gestation] and six of ten [60%, range31-33 +6 weeks gestation] were delivered preterm, no fetal or neonatal deaths were reported. breslin et al. report that two of seven women presenting in new york were asymptomatic, despite positive covid-19 testing [28] . a retrospective study by yu et al., involving seven pregnant women admitted to tongji hospital, reveals additional clinical information [29] . their average age was 32 years, illness incubation period was 5 days, and gestational age at delivery was 39 +1 weeks. all received oxygen via nasal cannula, however none required critical care. symptoms included fever (n = 6), cough (n = 1) shortness of breath (n = 1) and diarrhea (n = 1). three women had coinfection with influenza h1n1 or legionella pneumophilia, and ct imaging for six of the women demonstrated bilateral pneumonia. all women underwent caesarian section, and all were discharged home. only one infant tested positive. this neonatal symptoms have been reported, but it important to note that distinguishing the phenotype and separating the etiology of the symptoms as specific to covid-19, rather than bacterial infection or prematurity, has yet to occur. patient was 36 hours of age at the time of diagnosis, was transferred to a local children's hospital, remained well and was ultimately discharged home after 2 weeks and repeat negative testing [29] . pregnancy complications associated with covid-19 include miscarriage (2%), intrauterine growth restriction (10%), and preterm birth (39%) [20] . there is little evidence to date regarding the impact of covid-19 infection on the developing fetus in the 1st or early 2nd trimester. concern exists, however, based on evidence from prior viral epidemics that early gestation may represent a period of increased fetal and maternal risk [30] . during the sars outbreak in 2003, there were several reported first trimester spontaneous miscarriages and evidence suggests that ongoing pregnancies were complicated by intrauterine growth restriction and neonatal ischemic gut injury [31] . there is a high rate of cesarean section among those affected; however, this may relate to delivery trends in china which predated the pandemic or maternal illness. of those who attempted vaginal delivery, there is some evidence of higher rates of fetal distress, although there is no reported increased rate of hypoxic-ischemic encephalopathy or need for therapeutic hypothermia [32] . the impact of covid-19 on preterm birth has recently been examined in a meta-analysis of pregnant patients from three coronavirus-related outbreaks, which includes data from six studies on 41 pregnant mothers who were infected with covid-19 [33] . the authors concluded increased risk of preterm birth in covid-19 positive pregnant mothers. unfortunately, the relatively high rate of preterm birth was not subdivided into spontaneous and iatrogenic preterm delivery, which is vital to discerning the role of covid-19 on development of preterm labor. the incidence of pre-eclampsia and perinatal death was also elevated in the covid-19 cohort, although the strength of this association was attenuated. of note, as with the individual series mentioned previously, pooled proportions show that >90% of patients presented with some form of pneumonia and the cesarean section (cs) rate was 91%. in contrast, outcomes such as preterm premature rupture of membranes (pprom) and fetal growth restriction (fgr) were not significantly elevated in the covid-19 group. neither sars nor mers demonstrated evidence of vertical transmission, however the mortality rate in pregnant women reached 25% and 37%, respectively [34] . the risk of vertical transmission of covid-19, however, is biologically plausible given wide expression of the ace2 receptor in the placenta [35] . although clinical evidence is lacking, the case numbers to date of covid-19 in pregnancy remain very low [32] and case reports of two neonates who tested positive for sars-cov-2 shortly after birth lends some credence to the concern. the methods of perinatal transmission through other maternalsymptoms were mild and none died. case 1 -born at 40 weeks' gestation via c/s due to meconium-stained amniotic fluid and maternal covid-19 pneumonia. infant was admitted to nicu on day 2 with lethargy and fever. cxr showed pneumonia. procalcitonin was elevated. nasopharyngeal and anal swabs were positive for sars-cov-2 on days 2 and 4 but negative on day 6. case 2 -born at 40 weeks' gestation via c/s for maternal covid. infant presented with fever, lethargy, vomiting on postnatal day 2. lab testsleucocytosis/lymphocytopenia. cxr showed pneumonia. nasopharyngeal/anal swabs were positive for sars-cov-2 on days 2, 4 but negative on day 6. case 3 -born at 31 weeks' gestation by c/s due to fetal distress and confirmed maternal covid-19 pneumonia. resuscitation was required. apgar scores were 3, 4, and 5 at 1, 5, and 10 minutes. cxr revealed respiratory distress syndrome and pneumonia. symptoms resolved by postnatal day 14 after treatment with non-invasive ventilation, caffeine, and antibiotics. he also had sepsis, with an enterobacter agglomerates-positive blood culture, leukocytosis, thrombocytopenia, and coagulopathy, which improved with antibiotic treatment. nasopharyngeal and anal swabs were positive for sars-cov-2 on days 2, 4 but negative on day 7. dong et al. [37] 2020 fetal-neonatal exposures remain unclear. samples of amniotic fluid, cord blood, breast milk,and neonatal throat swabs have failed to yield any viral isolates [26] and there has been no evidence of covid-19 in placental specimens. in summary, pregnant women represent a population at risk for the development of covid-19 related illness. alterations to the immune system and increased susceptibility to respiratory pathogens during pregnancy represent known risk factors for intrapartum sepsis. the magnitude of the impact of covid-19 remains unclear, due to the limited number of cases reported, however in most cases the illness is mild. future studies should investigate the currently presumed differential impact of sars-cov2 on the health of pregnant mothers, compared to prior pandemics, the effect of illness earlier in preg-nancy, and long-term consequences to both maternal and infant health. as of may 12th, there has yet to be a single published report of a case of neonatal covid-19 illness in the unites states, although anecdotal evidence suggests otherwise. the evidence for neonatal transmission, immune susceptibility, viral penetrance, and clinical phenotype remains scarce. to date, limited case studies describe the clinical phenotype of early onset neonatal infection which would appear to be mild (fig. 2) . in one of the largest maternal case series from china, of 33 infants born to covid-19 positive mothers only three (11%) infants tested positive [36] . all mothers had evidence of pneumonia on ct and had positive nasopharyngeal (np) swabs for sars-cov-2. none required the provision of intensive care. all infants were delivered by caesarian section and noted to be appropriately grown, without dysmorphic features or malformation sequences. nasopharyngeal and anal swabs were positive on postnatal days 2 and 4, but negative between days 6 and 7. two of the three infants were born at term and all survived. the third infant was born by caesarian section, secondary to maternal distress, at 31 week's gestation. the infants apgar scores were 3, 4 and 5 at 1, 5 and 10 minutes respectively. a clinical diagnosis of respiratory distress syndrome (rds) was made and the infant required intubation. the infant developed a sepsis-like illness with hemodynamic instability and coagulopathy. routine blood culture was, however, positive for an enterobacter species which was managed with antibiotics. the infant's symptoms could not be solely attributed to covid-19, due to concurrent prematurity, sepsis and relative asphyxia. in a research letter, dong et al. reported a possible case of vertical transmission in a 29 year old women with radiographic evidence of pneumonia and a positive np swab for covid-19 [37] . the mother received antibiotics, oxygen, corticosteroids, and antiviral drugs prior to delivery. the mother wore an n95 mask and did not hold the infant following the delivery. the infant was asymptomatic at birth, had apgar scores of 9 and 10 and was immediately quarantined. of note, the infant demonstrated elevated sars-cov-2 igm and igg levels at two hours of life, but serial np swabs for sars-cov-2 were negative. at time of discharge, immunoglobin levels were still elevated. the presence of igg levels at two hours of life could be explained by elevated maternal levels, however igm antibodies do not freely cross the placenta [38] . it is difficult to determine whether the elevated igm was due to fetal infection, delivery, or an unrelated process. without testing amniotic fluid or placenta specimens, no definitive conclusions can be drawn. increased availability of igg and igm testing has improved the quality of surveillance and detection of sars-cov-2. zeng et al. reported immunoglobulin levels from six infants born to covid-19 positive mothers between february 16th and march 6th [39] . all mothers underwent caesarian section and the infants were immediately isolated following delivery. neonatal viral throat and serum swabs were all negative for sars-cov-2, but igg and igm were elevated in five and two respectively, out of the six infants. while the sample size is small and no evaluation of the placenta or amniotic fluid occurred, the report raises concern of placental involvement and fetal exposure to the virus. in the series published by zhu et al., the clinical status of 10 neonates were reported. none of the infants born to covid-19 positive mothers demonstrated a positive throat swab pcr [27] . one infant, born at 34 weeks' gestation, developed hemorrhagic shock, secondary to profound gastrointestinal bleeding and ultimately died secondary to multi end organ failure. a second infant, born at 34 week's gestation, developed fever and gastrointestinal (gi) bleeding, but responded to supportive therapies. with negative testing, and without evaluation of placental tissue or amniotic fluid, it is difficult to draw any conclusions regarding the biologic nature of the gi symptoms or any putative relationship to covid-19 exposure. clinical symptoms in neonates are non-specific and appear similar to the classic presentation of respiratory distress syndrome [40] . additionally, radiologic imaging may demonstrate pneumonia, which is difficult to distinguish from premature lung disease. it is important to have a high degree of suspicion when managing neonates born to positive mothers, while recognizing more information is needed to truly develop a consistent neonatal phenotype. there is currently no specific treatment for covid-19 infection, nor access to an available vaccine. the american academy of pediatrics (aap) and the centers for disease control (cdc) have developed guidelines to aid in the care of infants born to covid-19 positive mothers (table 4) . recent guidelines prioritize universal maternal testing and recommend a shared decision-making process related to whether the infant should stay with the mother or be isolated. treatment of patients with active sars-cov-2 illness has focused on the provision of supportive care according to illness severity. this may range from oxygen therapy and/or prone positioning to intubation, icu support in patients with shock or adult respiratory distress syndrome (ards). table 3 provides an overview of current strategies that have been implemented or are under investigation to either mitigate the risk of transmission or modulate the disease course. [55, 56] shortening of the disease course [46] lopinavir no antiretroviral protease inhibitor [55] rct, no benefit in clinical improvement demonstrated [57] rct, randomized controlled trial; fda, food and drug administration. prevention has been used as a primary means to control the growth of covid-19. as virus spread primarily relates to"person to person" interaction and has demonstrated familial clustering [41] , limitation strategies that minimize human interaction, or social distancing, may help diminish transmission. it has been difficult to accurately determine the basic reproduction number (r o ) of sars-cov-2, which is used to determine how quickly the virus can spread throughout a population [42] , across various countries and cities with differing population densities. currently studies indicate the virus has a r o of 2.2, meaning each infected individuals has the potential to spread the virus to 2.2 other individuals. until the r o drops to less than 1 the outbreak is likely to continue with aggressive spread. mitigation measures such as social distancing, school closures, quarantine of exposed individuals have been determined through simulation and observational studies to have the potential to reduce transmission of previous pandemics, although there is no published evidence of the efficacy of this strategy in the setting of the current pandemic. vaccination research has started, with several academic centers and pharmaceutical companies having taken on the challenge, however the timeline needed to ensure patient safety remains considerable [43] . modulation of the spread within the health care system is of vital importance. wu et al. reported that 3.8% of their positive covid-19 population in china were infected health care personnel [44] . the impact to health care workers in italy is even greater; in some situations, hospitals have closed because of the magnitude of transmission among health care workers [45] . protection of healthcare workers has been made especially challenging due to an insufficient global supply of personal protective equipment and disruptions within the supply chain. to help combat this shortage, given that pregnant mothers may be either be asymptomatic carriers or undiagnosed due to limited testing, the vague or mild nature of symptoms, andthe potential for comorbid disease states, it is incumbent on healthcare systems to ensure that neonatal teams have efficient processes to protect vulnerable front-line workers and mitigate both covid-19 spread and access to healthcare delivery for other neonatal icu patients. an array of medications are in current use to treat patients with covid-19. anti-viral agents such as oseltamivir, ganciclovir, lopinavir/ritonavir and remdesivir have been used for critically ill patients. remdesivir is a nucleotide analogue that interferes with viral replication. a clinical trial is currently in progress at multiple centers in wuhan province. additionally, the anti-malarial agent chloroquine phosphate has been used to treat pneumonia symptoms, as it possesses anti-viral and anti-inflammatory properties and has demonstrated positive clinical effect in the treatment of covid-19 [46] . clinical trials of the efficacy of chloroquine are also being conducted in china. finally, lopinavir has demonstrated inhibition of protease activity in coronavirus species and is currently under investigation [47] . there are no reports of use of these agents in pregnant mothers or their infants. use of convalescent plasma, as a means of generating passive immunity, has been the subject of recent investigation. this therapeutic strategy was previously investigated during the sars and mers outbreaks; specifically, a metanalysis demonstrated a significant reduction in mortality compared to placebo [48] . in addition, clinical experience from five covid-19 positive individuals in china with ards demonstrated clinical improvement following the receipt of convalescent plasma [49] . while this was not a randomized controlled study, the report is compelling and suggests biological and therapeutic plausibility. while many of the current treatments under investigation hold promise, due diligence and scientific rigor are essential to minimize the potential of unintended or unanticipated patient harm. there is currently no scientific evidence to justify any approach to treatment in pregnant mothers or in neonates. centers should develop institutional guidelines based on best available evidence and resources available to them. the covid-19 pandemic represents one of the greatest threats to human existence seen in the last one hundred years, with rapid spread across the globe and throughout the united states. the impact of rapid case escalation on the italian and spanish health care systems has forced the establishment of triaging committees to determine access to mechanical ventilation and intensive care resources. although knowledge increases daily, it is incumbent on health care professionals, medical societies and governing bodies to establish comprehensive registries to track disease progression and enable an enhanced understanding of clinical presentation and risk profiles for those patients greatest at risk. these registries are even more relevant for obstetrics and neonatology where individual centers are likely to see low volumes of maternal cases, and even lower volumes of neonatal illness. covid-19 does not appear to be particularly aggressive in pregnant women, neonates or children, based on the limited data that is available. due to the dynamic nature and rapid evolution of our scientific understanding of this condition, these premises are likely to change as knowledge grows. the clinical experiences from countries (e.g. italy, spain, iran) where covid-19 has crippled icu resources and preventative strategies from countries (e.g. south korea, singapore) where rapid dissemination has been limited will enable the development of standardized guidelines and frameworks for practice that may be universally adopted across the world. the ramifications of the pandemic to society have yet to be assessed, but are likely to be profound from personal, fiscal, and global health perspectives. the world beyond covid-19 is likely to be a very different place. no additional acknowledgements outside of authorship. no honorarium, grant, or other form of payment received to produce the manuscript. clinical features of patients infected with 2019 novel coronavirus in wuhan understanding of covid-19 based on current evidence world health organization. who director-general's opening remarks at the media briefing on covid-19 -12 coronavirus disease 2019 (covid-19) in italy ct features of coronavirus disease 2019 (covid-19) pneumonia in 62 patients in wuhan the epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak evidence of the covid-19 virus targeting the cns: tissue distribution, host-virus interaction, and 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10.1016/b978-0-12-374418-0.00011-6 sha: doc_id: 21494 cord_uid: 9glqvzfx nan radiographic examination, fluid tests (blood, urine, sputum, stool), and possibly tissue biopsy. radiographically, abnormalities in abundance, density or chemical microenvironment of tissues allows distinction from surrounding normal tissues. traditionally, the absorption of electromagnetic waves by tissues led to summation differences in exposure of silver salt photographic film. tomographic approaches such as ct (1972) and nmr (1973) complemented summation radiology, allowing finely detailed visualization of internal anatomy in any plane of section. in the same era, ultrasound allowed visualization of tissue with density differences, such as a developing fetus or gallbladder stones. more recently, physiology of neoplasms can be screened with positron emission tomography (pet, 1977) for decay of short half-life isotopes such as fluorodeoxyglucose. neoplasms with high metabolism can be distinguished physiologically from adjacent low-metabolism tissues, and can be localized with respect to normal tissues by pairing pet with standard ct. the result is an astonishingly useful means of identifying and localizing new space-occupying masses, assigning a risk for malignant behavior and, if malignant, screening for metastases in distant sites. this technique is revolutionizing the preoperative decisionmaking of clinical teams, and improves the likelihood that patients undergo resections of new mass lesions only when at risk for morbidity from malignant behavior or interference with normal function. pathologically, disease is diagnosed by determining whether the morphologic features match the set of diagnostic criteria previously described for each disease. multivolume texts are devoted to the gross and microscopic diagnostic criteria used for diagnosis, prognosis, and prediction of response to therapy. pathologists diagnose disease by generating a differential diagnosis, then finding the best fit for the clinical presentation, the radiographic appearance, and the pathologic (both clinical lab and morphologic) findings. logically, the venn diagram of the clinical, radiologic, and pathologic differential diagnoses should overlap. unexpected features expand the differential diagnosis and may raise the possibility of previously undescribed diseases. for example, legionnaire's disease, human immunodeficiency virus (hiv), hantavirus pneumonia, and severe acute respiratory syndrome (sars) are examples of newly described diagnoses during the last 30 years. the mental construct of etiology (cause), pathogenesis (progression), natural history (clinical outcome), and response to therapy is the standard approach for pathologists thinking about a disease. a disease may have one or more etiologies (initial causes, including toxins, mutagens, drugs, allergens, trauma, or genetic mutations). a disease is expected to follow a particular series of events in its development (pathogenesis), and to follow a particular clinical course (natural history). disease can result in a temporary or lasting change in normal function, including patient death. multiple diseases of different etiologies can affect a single organ, for example, infectious and neoplastic diseases involving the lung. different diseases can derive from a single etiology, for example, emphysema, chronic bronchitis, and small cell lung carcinoma in long-term smokers. the same disease (for instance, emphysema of the lung) can derive from different etiologies (emphysema from a-1-antitrypsin deficiency or cigarette smoke). modern diagnostic pathology practice hinges on morphologic diagnosis, supplemented by histochemical stains, immunohistochemical stains, cytogenetics, and clinical laboratory findings, as well as the clinical and radiographic findings. sections that meet all of these criteria are diagnostic for the disease. if some, but not all, of the criteria are present to make a definitive diagnosis, the pathologist must either equivocate or make an alternate diagnosis. thus, a firm grasp of the diagnostic criteria and the instincts to rapidly create and sort through the differential diagnosis must be possessed by the diagnostic pathologist. the pathologic diagnosis has to make sense, not only from the morphologic perspective, but from the clinical and radiographic vantage points as well. it is both legally risky and professionally erosive to make a clinically and pathologically impossible diagnosis. in the recent past, limited computer networking meant numerous phone calls to gather the relevant clinical and radiographic information to make an informed morphologic diagnosis. for example, certain diseases such as squamous and small cell carcinomas of the lung are extremely rare in nonsmokers. thus, a small cell carcinoma in the lung of a nonsmoker merits screening for a nonpulmonary primary site. fortunately for pathologists, computing and networking technologies now allow us access to preoperative clinical workups, radiographs/reports, clinical laboratory data, and prior pathology reports. all of these data protect pathologists by providing them with the relevant clinical and radiographic information, and protect patients by improving diagnostic accuracy. just as research scientists ". . . ignore the literature at their peril. . .", diagnostic pathologists ". . . ignore the presentation, past history, workup, prior biopsies, and radiographs at their peril. . . ." there are limitations to morphologic diagnosis by h&e stains. first, lineage of certain classes of neoplasms (including small round blue cell tumors, clear cell neoplasms, spindle cell neoplasms, and undifferentiated malignant neoplasms) is usually clarified by immunohistochemistry, frequently by cytogenetics (when performed), and sometimes by electron microscopy. second, there are limitations inherent in a snapshot biopsy or resection. thus, the etiology and pathogenesis can be obscure or indeterminate, and rates of growth, invasion, or timing of metastasis cannot be inferred. third, the morphologic changes may not be specific for the underlying molecular abnormalities, particularly the rate-limiting (therapeutic target) step in the pathogenesis of a neoplasm. for example, ret gain of function mutations in a medullary thyroid carcinoma will require dna level screening to determine germline involvement, familial risk, and presence or absence of a therapeutic target. fourth, the same morphologic appearance may be identical for two different diseases, each of which would be treated differently. for example, there is no morphologic evidence by h&e stain alone to distinguish host lymphoid response to hepatitis c viral (hcv) antigens from host lymphoid response to allo-hla antigens in a liver allograft. this is obviously a major diagnostic challenge when the transplant was done for hcv-related cirrhosis, and the probability of recurrent hcv infection in the liver allograft is high. paraffin section immunohistochemistry has proven invaluable in neoplasm diagnosis for clarifying lineage, improving diagnostic accuracy, and guiding customized therapy. if neoplasms are poorly differentiated or undifferentiated, the lineage of the neoplasm may not be clear. for example, sheets of undifferentiated malignant neoplasm with prominent nucleoli could represent carcinoma, lymphoma, or melanoma. to clarify lineage, a panel of immunostains is performed for proteins that are expressed in some of the neoplasms, but not in others. relative probabilities are then used to lend support (rule in) or exclude (rule out) particular diagnoses in the differential diagnosis of these several morphologically similar undifferentiated neoplasms. the second role is to make critical distinctions in diagnosis that cannot be accurately made by h&e alone. examples of this would include demonstration of myoepithelial cell loss in invasive breast carcinoma but not in its mimic, sclerosing adenosis ( figure 11 .1), or loss of basal cells in invasive prostate carcinoma (figure 11 .2). the third role of immunohistochemistry is to identify particular proteins, such as nuclear estrogen receptor (er) (figure 11 .3) or the plasma membrane her2 proteins (figure 11.4) , both of which can be targeted with inhibitors rather than generalized systemic chemotherapy. morphology remains the gold standard in this diagnostic process, such that immunohistochemical data support or fail to support the h&e findings, not vice versa. probability and statistics are regular considerations in immunohistochemical interpretation, since very few antigens are tissue-specific or lineage-specific. cytokeratin is positive in carcinomas, but also in synovial and epithelioid sarcomas. this example may imply aspects of the lineage of these two sarcomas that may be helpful in our categorization of these neoplasms. another example would be the diagnosis of small cell carcinoma in the lung of a nonsmoker. because lung primary small cell carcinoma is extremely uncommon, in non-smokers, this diagnosis would prompt the pathologist to inquire about screening results for other, nonpulmonary, primary sites. likewise, immunohistochemistry results are always put into the context of the morphologic, clinical, and radiographic findings. for example, an undifferentiated cd30(þ) neoplasm of the testis supports embryonal carcinoma primary in the testis, whereas a lymph node effaced by sclerotic bands with admixed cd30(þ) reed-sternberg cells supports nodular sclerosing hodgkin's disease. a wealth of information is conveyed to a service pathologist in a tried-and-true h&e section. analogous to the fact that a plain chest x-ray is the sum total of all densities in the beam path, the morphologic changes in diseased cells and tissues are the morphologic sum total of all of the disequilibria in the abnormal cells. for most neoplastic diseases, morphologic criteria are sufficient to predict the risk of invasion and metastasis (the malignant potential), the pattern of metastases, and the likely clinical outcomes. for example, the etiology and pathogenesis in small cell lung carcinoma can be inferred (cigarette smoking, with carcinogeninduced genetic mutations) and the outcome predicted (early metastasis to regional nodes and distant organs, with high probability of death within 5 years of diagnosis). new molecular data for both neoplastic and non-neoplastic diseases will most likely benefit unaffected individuals by estimating disease risk, and will most likely benefit patients by defining the molecular subset for morphologically defined diagnostic entities, thus guiding individualized therapy. diagnostic pathology will continue to use morphology and complementary data from protein (immunohistochemical) and nucleic acid (cytogenetics, in situ hybridization, dna sequence, and rna abundance) screening assays. new data will be integrated into the diagnostic process by reducing the cost and turnaround time of current technologies, and by development of new technologies, some of which are described. for transplant candidates, major histocompatibility complex (mhc, hla in human) screening is evolving from cellular assays and serology toward sequencing of the alleles of the class i and ii hla loci. rapid sequencing of these alleles in newborn cord blood would allow databasing of the population's haplotypes, facilitating perfect matches for required bone marrow or solid organ transplants. current uses of in situ hybridization to screen for viruses (such as ebv), light chain restriction (in b lymphomas), and copy number variation (for instance, her2 gene amplification) demonstrate the benefit of in situ nucleic acid hybridization assays. it is possible that interphase fish/cish will become rapid enough to be used in the initial diagnostic workup of certain patients, including for sarcomaspecific translocations, ploidy analysis in hydatidiform moles, and gene amplification of receptor tyrosine kinase genes. current uses of nucleic acid screening for bcr-abl translocation, donor:recipient ratios after bone marrow transplant, microsatellite instability, quantitative viral load (for ebv, bk, cmv, and others), and single gene mutations (for cftr, factor 2, a-1-antitrypsin) demonstrate the benefit of nucleic acid screening in diagnosis and management. it is possible that each new neoplasm will be promptly defined as to ploidy, translocations, gene copy number differences, dna mutations, and rna expression cluster subset, allowing residual disease screening as well as individualized therapy. current uses of morphology, immunohistochemistry, and molecular pathology demonstrate their benefit through improved diagnostic accuracy. however, diagnosis, extent of disease, and molecular subsets are currently imperfect estimators of prognosis and response to therapy. relational databases which correlate an individual's demographic data, family history, concurrent diseases, morphologic features, immunophenotype, and molecular subset, and which integrate disease prevalence by age, sex, and ethnicity using bayesian probabilities, should improve accuracy of prognosis and prediction of response to therapy. as risk correlates are developed, it is possible that healthy individuals will be screened and given risk estimates for development of different diseases. current uses of normal ranges for serum chemistry assumes a similar bell-curve distribution across ages, sexes, and races. this may be true for most but not all analytes. computer reference databases will likely generate normal ranges specific for the particular age/sex/ethnicity of individual patients. similarly, familial risk for an inherited disease may vary by ethnic group, and this variation should be used in bayesian calculations to define risk for unaffected at-risk family members. current uses of liver and renal impairment to guide drug dosage demonstrate the benefit of using patient physiology to customize therapy. it is likely that individual differences in enzymatic metabolism of particular drugs (for instance, warfarin or tamoxifen) will be defined at the enzyme sequence level, and that gene haplotype data will be determined for new patients prior to receipt of these drugs. current uses of prostate-specific antigen (psa) to screen for prostate carcinoma and its recurrence demonstrates the benefit of serum biomarkers in common neoplasms. it is likely that high-sensitivity screening of single and clustered serum analytes will lead to improved methods for early detection and persistence of neoplasms, autoimmune diseases, and infections. pathologists consider each disease to have a natural, mechanical, physicochemical basis. each disease has an etiology (initial cause), a pathogenesis (stepwise progression), and a natural history with effects on normal function (clinical outcome). pathologists collect the data needed to answer patients' and clinicians' questions, simply phrased as "what is it?" (diagnosis), "how it going to behave?" (prognosis), and "how do i treat it?" (prediction of response to therapy). instincts and diagnostic criteria, as well as the optical, mechanical, chemical, and computing technologies described previously, are the basis for modern service pathology. as the human genome is deciphered, and as the complex interactions of cellular biochemistry are refined, risk of disease in unaffected individuals will be calculable, disease diagnosis will be increasingly accurate and prognostic, and molecular subsets of morphologically defined disease entities will be used to guide customized therapy for individual patients. it is a great time in history to be a pathologist. n clinically, diseases present to front-line physicians as patients with sets of signs and symptoms. symptoms are the patient's complaints of perceived abnormalities. signs are detected by examination of the patient. the clinical team (including the pathologist) evaluate the patient based on the possible causes of the signs and symptoms (the differential diagnosis). n pathologically, disease is diagnosed by determining whether the morphologic features match the set of diagnostic criteria previously described for each disease. pathologists diagnose disease by generating a differential diagnosis, then finding the best fit for the clinical presentation, the radiographic appearance, and the pathologic (both clinical lab and morphologic) findings. n etiology describes the causes of a disease. one disease entity can have more than one etiology, and a single etiology can lead to more than one disease. for example, emphysema, chronic bronchitis, and small cell lung carcinoma can all occur in longterm smokers (different diseases derived from a single etiology). likewise, the same disease (for instance, emphysema of the lung) can derive from different etiologies (emphysema from a-1-antitrypsin deficiency or cigarette smoke). n the pathogenesis of a disease describes its stepwise progression after initiation in response to a specific etiologic factor (or factors). pathogenesis can refer to the changes in the structure or function of an organism at the gross/clinical level, and it can refer to the stepwise molecular abnormalities leading to changes in cellular and tissue function. n the natural history of a disease describes the expected course of disease, including chronicity, functional impairment, and survival. however, not all patients with a given disease will naturally follow the same disease course, so differences in patient outcome do not necessarily correspond to incorrect diagnosis. variables that independently correlate with clinical outcome differences are called independent prognostic variables, and are assessed routinely in an effort to predict the natural history of the disease in the patient. n likewise, variables that independently correlate with response to therapy are called independent predictive variables, and are assessed routinely in an effort to optimize therapeutic response for each patient. localization of antigen in tissue cells; improvements in a method for the detection of antigen by means of fluorescent antibody general nature of the genetic code for proteins an immunoglobulin heavy chain variable region gene is generated from three segments of dna: vh, d and jh in search of the origins of modern surgical pathology formation and detection of rna-dna hybrid molecules in cytological preparations expression in escherichia coli of chemically synthesized genes for human insulin contagiousness of puerperal fever berliner klinische wochenschrift continuous cultures of fused cells secreting antibody of predefined specificity initial sequencing and analysis of the human genome the immunology of transplantation specific enzymatic amplification of dna in vitro: the polymerase chain reaction the rna code and protein synthesis ignac semmelweis and the etiology of fetal and neonatal sepsis product differentiation by analysis of dna melting curves during the polymerase chain reaction the continuing role of morphology in the molecular age dna sequencing with chainterminating inhibitors fluorescence detection in automated dna sequence analysis rudolf virchow-father of cellular pathology the sequence of the human genome molecular structure of nucleic acids; a structure for deoxyribose nucleic acid key: cord-319933-yp9ofhi8 authors: ruiz, sara i.; zumbrun, elizabeth e.; nalca, aysegul title: chapter 38 animal models of human viral diseases date: 2013-12-31 journal: animal models for the study of human disease doi: 10.1016/b978-0-12-415894-8.00038-5 sha: doc_id: 319933 cord_uid: yp9ofhi8 abstract as the threat of exposure to emerging and reemerging viruses within a naive population increases, it is vital that the basic mechanisms of pathogenesis and immune response be thoroughly investigated. by using animal models in this endeavor, the response to viruses can be studied in a more natural context to identify novel drug targets, and assess the efficacy and safety of new products. this is especially true in the advent of the food and drug administration's animal rule. although no one animal model is able to recapitulate all the aspects of human disease, understanding the current limitations allows for a more targeted experimental design. important facets to be considered before an animal study are the route of challenge, species of animals, biomarkers of disease, and a humane endpoint. this chapter covers the current animal models for medically important human viruses, and demonstrates where the gaps in knowledge exist. well-developed animal models are necessary to understand the disease progression, pathogenesis, and immunologic responses in humans. furthermore, to test vaccines and medical countermeasures, well-developed animal models are essential for preclinical studies. ideally, an animal model of human viral infection should mimic the host-pathogen interactions and the disease progression that is seen in the natural disease. a good animal model of viral infection should allow many parameters of infection to be assayed, including clinical signs, growth of virus, clinicopathological parameters, cellular and humoral immune responses, and virus-host interactions. furthermore, viral replication should be accompanied by measurable clinical manifestations, and pathology should resemble that of human cases such that a better understanding of the disease process in humans is attained. there is often more than one animal model that closely represents human disease for a given pathogen. small animal models are typically used for first-line screening, and for initially testing the efficacy of vaccines or therapeutics. in contrast, nonhuman primate (nhp) models are often used for the pivotal preclinical studies. this approach is also used for basic pathogenesis studies, with most experiments performed in small animal models when possible, and nhps only used to fill in remaining gaps in knowledge. the advantages of using mice to develop animal models are low cost, low genetic variability in inbred strains, and abundant molecular biological and immunological reagents. specific pathogen-free (spf), transgenic, and knockout mice are also available. a major pitfall of mouse models is that the pathogenesis and protection afforded by vaccines and therapeutics cannot always be extrapolated. additionally, blood volumes for sampling are limited in small animals, and viruses often need to be adapted through serial passage in the species to induce a productive infection. the ferret's airways are anatomically and histologically similar to that of humans, and their size enables larger or more frequent blood samples to be collected, making them an ideal model for certain respiratory pathogens. ferrets are outbred, with no standardized breeds or strains; thus, greater numbers are required in studies to achieve statistical significance and overcome the resulting variable responses. additionally, spf and transgenic animals are not available, and molecular biological reagents are lacking. other caveats making ferret models more difficult to work with are their requirement for more space than mice (rabbit-style cages), and the development of aggressive behavior with repeated procedures. nhps are genetically the closest species to humans; thus, disease progression and host-pathogen responses to viral infections are often the most similar to that of humans. however, ethical concerns of experimentation on nhps, along with the high cost and lack of spf nhps raise barriers for such studies. nhp studies should be carefully designed to ensure that the least amount of animals are used, and the studies should address the most critical questions regarding disease pathogenesis, host-pathogen responses, and protective efficacy of vaccines and therapeutics. well-designed experiments should carefully evaluate the choice of animal, including the strain, sex, and age. furthermore, route of exposure and the dose should be as close as possible to the route of exposure and dose of human disease. the endpoint for these studies is also an important criterion. depending on the desired outcome, the model system should emulate the host responses in humans when infected with the same pathogen. in summary, small animal models are helpful for the initial screening of vaccines and therapeutics, and are also often beneficial in obtaining a basic understanding of the disease. nhp models should be used for a more detailed characterization of pathogenesis and for pivotal preclinical testing studies. ultimately, an ideal animal model may not be available. in this case, a combination of different well-characterized animal models should be considered to understand the disease progression and to test medical countermeasures against the disease. in this chapter, we will be reviewing the animal models for representative members of numerous virus families causing human diseases. we will focus on the viruses for each family that are the greatest concern for public health worldwide. poliovirus (pv) is an enterovirus in the picornavirus family and causes poliomyelitis. 1 humans are the only natural host for the virus, but a number of nhp species are also susceptible. all three serotypes of pv cause paralytic disease, but it is relatively rare with only 1-2% of infected individuals ultimately developing paralysis. humans typically acquire and transmit the virus by the oral-fecal route, although transmission by aerosol droplets may also be possible. 2 the virus replicates in the oropharyngeal and intestinal mucosa, made possible by the resistance of pv to stomach acids. 3 cd155 expression in peyer's patches and m cells suggest that these cell types may be important during initiation of infection. 4 replication at extraneural sites 38 . in vivo models of viral diseases affecting humans precedes invasion into the central nervous systems (cnss), when it occurs. two effective vaccines, the salk killed polio vaccine delivered by the intramuscular route and the sabin live attenuated polio vaccine delivered orally, have been used very successfully to eliminate the disease from most parts of the world. 5 the world health organization has led a long and hard-fought global polio eradication campaign, with much success, but full eradication has not yet been achieved. since 2003, between 1000 and 2000 cases of pv infection are reported worldwide each year. 6 thus, animal models are also needed to test new vaccine approaches that could be used toward eradication of polio in the areas where it still persists. additionally, the recent focus of work with pv animal models has been fraught with urgency, as to gain understanding of pv pathogenesis before the eradication effort is complete and work with this virus ceases. animal models for the study of pv consist of nhp models and mouse models. mice are susceptible to certain adapted pv strains: p2/lansing, p1/lsb, and a variant of p3/leon. mice infected intracerebrally with p2/lansing develop disease with some clinical and histopathological features resembling that of humans. 7 wild-type mice are not susceptible to wildtype pv; however, the discovery of the pv receptor (cd155) in 1989 led to the use of hcd155 transgenic mice as a model of pv infection. 8 these mice are not susceptible to pv by the oral route and must be exposed intranasally or by intramuscular infection to induce paralytic disease. 9 interestingly, hcd155 mice that have a disruption in the interferon (ifn)-a/b receptor gene are susceptible to oral infection. 10 this finding has given rise to speculation that an intact ifn-a/b response may be responsible for limiting infection in the majority of individuals exposed to pv. thus, mouse models have proven to be very useful in gaining a better understanding of pv disease and pathogenesis. rhesus macaques are not susceptible to pv by the oral route, but they have been used extensively to study vaccine formulations for safety and immunogenicity, for monitoring neurovirulence of the live attenuated sabin vaccine, and in the past for typing pv strains. 11 bonnet monkeys are also susceptible to oral inoculation of pv, which results in the gastrointestinal shedding of virus for several weeks, with paralysis occurring in only a small proportion of animals. consistent paralytic disease can be induced in bonnet monkeys (macaca radiata) through exposure to pv by infection into the right ulnar nerve (at the elbow), resulting in limb paralysis that resembles human paralytic poliomyelitis both clinically and pathologically. 12 as such, bonnet monkeys can be used to study pv distribution and pathology and the induction of paralytic poliomyelitis or provocation paralysis. 13 hepatitis a virus causes jaundice, which is a public health problem worldwide. the incubation period lasts from 15 to 45 days with an average of 28 days. transmission between humans occurs by the oral-fecal route, person-to-person contact, or ingestion of contaminated food and water. 14 hepatitis a virus causes an acute and self-limited infection of the liver with a spectrum of signs and symptoms ranging from subclinical disease, to jaundice, fulminant hepatitis, and in some cases death. 15, 16 the disease can be divided into four clinical phases: (1) incubation period, during which the patient is asymptomatic but virus replicates and possibly transmits to others. (2) prodromal period, which might last from a few days to a week with patients generally experiencing anorexia, fever (<103 f), fatigue, malaise, myalgia, nausea, and vomiting. (3) icteric phase, in which increased bilirubin causes characteristic dark brownish colored urine. this sign is followed by pale stool and yellowish discoloration of the mucous membranes, conjunctiva, sclera, and skin. most patients develop an enlarged liver, and approximately 5-15% of the patients have splenomegaly. (4) convalescent period, with resolution of the disease and recovery of the patient. rarely, during the icteric phase, extensive necrosis of the liver occurs. these patients show a sudden increase in body temperature, marked abdominal pain, vomiting, jaundice, and the development of hepatic encephalopathy associated with coma and seizures, all signs of fulminant hepatitis. death occurs in 70-90% of patients with fulminant hepatitis. 16 experiments showed that hepatitis a causes disease only in humans, chimpanzees, several species of south american marmosets, stump-tailed monkeys, and owl monkeys via the oral or intravenous (iv) routes. [17] [18] [19] [20] it is known that cynomolgus macaques are infected with hepatitis a virus in the wild. 21 amado et al. used cynomolgus macaques (macaca fascicularis) for experimental hepatitis a infections. 17 the animals did not exhibit clinical signs of disease, but viral shedding was observed in saliva and stool as early as 6 h postinoculation (pi) and 7 days pi, respectively. although mildto-moderate hepatic pathology was observed in all macaques, seroconversion and mildly increased alanine aminotransferase (alt), an enzyme associated with liver function, were observed in some of them. because this study had a very small group of animals (four macaques), the data should not be considered as conclusive, and more studies are needed to better define the cynomolgus macaque model. although hepatitis a virus is transmitted by the oralfecal route, studies in chimpanzees and tamarins showed that the iv route was much more infectious than oral route was. there was no correlation between dose and development of clinical disease for either species or experimental routes, and similar to cynomolgus macaques, none of these species showed clinical signs of disease. 20 inoculation of common marmosets (callithrix jacchus) with hepatitis a virus did not produce clinical signs of disease as seen in other nhp models. 22, 23 liver enzyme levels increased on day 14 pi, and monkeys had measurable antihepatitis a antibodies by day 32 pi. an experimental study with cell culture-adapted hepatitis avirus in guinea pigs challenged by oral or intraperitoneal routes did not result in clinical disease, increase in liver enzymes, or seroconversion. 24 viral load was detected in stool and serum between days 14 and 52 and 21 and 49 days, respectively. liver pathology showed mild hepatitis. furthermore, histopathology indicated that virus replicated in extrahepatic tissues such as spleen, regional lymph nodes, and intestinal tract. in summary, none of the animal models for hepatitis a infection is suitable for studying pathogenesis of the virus because all clinical and most of the laboratory parameters remain within normal range or only slightly increased after the infection. one possibility is to test the safety of vaccines against hepatitis a virus in those models with demonstrable viral shedding. noroviruses, of which norwalk is the prototypic member, are responsible for up to 85% of reported food-borne gastroenteritis cases. in developing countries, this virus is responsible for approximately 200,000 deaths annually. 25 a typical disease course is self-limiting, but there have been incidences of necrotizing enterocolitis and seizures in infants. 26, 27 symptoms of infection include diarrhea, vomiting, nausea, abdominal cramping, dehydration, and fever. incubation normally is for 1-3 days, with symptoms enduring for 2-3 days. 28 viral shedding is indicative of immunocompromised status within an individual with the elderly and young having a prolonged state of shedding. 29 transmission occurs predominately through the oral-fecal route with contaminated food and water being the major vector. 30 a major hindrance to basic research into this pathogen is the lack of a cell culture system. therefore, animal models are used not only to determine the efficacy of novel drugs and vaccines but also for understanding the pathogenesis of the virus. therapeutic intervention consists of rehydration therapy and antiemetic medication. 31 no vaccine is available, and development of one is expected to be challenging given that immunity is short lived after infection. 32 nhps including marmosets, cotton-top tamarins, and rhesus macaques infected with norwalk virus can be monitored for the extent of viral shedding; however, no clinical disease is observed in these models. disease progression and severity are measured exclusively by assay of viral shedding. 33 it was determined that more virus was needed to create an infection when challenging by the oral route than when challenging by the iv route. chimpanzees were exposed to a clinical isolate of norwalk virus by the iv route. although none of the animals developed disease symptoms, viral shedding within the feces was observed within 2-5 days postinfection and lasted anywhere from 17 days to 6 weeks. viremia never occurred, and no histopathological changes were detected. the amount and duration of viral shedding were in line with what is observed upon human infection. 34 a recently identified calicivirus of rhesus origin, named tulane virus, was used as a surrogate model of infection. rhesus macaques exposed to tulane virus intragastrically developed diarrhea and fever 2 days postinfection. viral shedding was achieved for 8 days. the immune system produced antibodies that dropped in concentration within 38 days postinfection, mirroring the short-lived immunity documented in humans. the intestine developed moderate blunting of the villi as seen in human disease. 35 a murine norovirus has been identified and is closely related to human norwalk virus. however, clinically, the viruses present a different disease. the murine norovirus does not induce diarrhea nor vomiting and can develop a persistent infection in contrast to human disease. [36] [37] [38] porcine enteric caliciviruses can induce diarrheal disease in young pigs and an asymptomatic infection in adults. 39 gnotobiotic pigs can successfully be infected with a passaged clinical noroviruses isolate orally. diarrheal disease developed in 74% of the animals, and 44% were able to shed virus in their stool. no major histopathological changes or viral persistence was noted. 40 calves are naturally infected with bovine noroviruses. experimentally challenging calves with an oral inoculation of a bovine isolate resulted in diarrheal disease [14] [15] [16] the link between equine cases and the human disease was confirmed in 1938 by observing 30 cases of fatal encephalitis in children living in the same area as the equine cases. during this outbreak, eeev was isolated from the cnss of these children as well as from pigeons and pheasants. 44 eeev primarily affects areas near salty marshes and can cause localized outbreaks of disease in the summer. the enzootic cycles are maintained in moist environments such as coastal areas, shaded marshy salt swamps in north america (na), and moist forests in central america and south america (sa). 45 birds are the primary reservoir, and the virus is transmitted via mosquitoes. furthermore, forest-dwelling rodents, bats, and marsupials frequently become infected and may provide an additional reservoir in central america and sa. despite known natural hosts, the transmission cycles in these animals are not well characterized. 44 reptiles and amphibians have also been reported to become infected by eeev. eeev pathogenesis and disease have been studied in several laboratory animals. as a natural host, birds do not generally develop encephalitis except pheasants or emus, in which eeev causes encephalitis with 50-70% mortality. 46 young chickens show signs of extensive myocarditis in early experimental infection and heart failure rather than encephalitis is the cause of death. 47 besides the heart, other organs such as pancreas and kidney show multifocal necrosis. additionally, lymphocytopenia has been observed in the thymus and spleen in birds. 45 eeev causes neuronal damage in newborn mice, and the disease progresses rapidly, resulting in death. 48 similarly, eeev produces fatal encephalitis in older mice when administered via the intracerebral route, whereas inoculation via the subcutaneous route causes a pantropic infection eventually resulting in encephalitis. 49, 50 guinea pigs and hamsters have also been used as animal models for eeev studies. 51, 52 guinea pigs developed neurological involvement with decreased activity, tremors, circling behavior, and coma. neuronal necrosis was observed and resulted in brain lesions in these animals. 52 subcutaneous inoculation of eeev produced lethal biphasic disease in hamsters with severe lesions of nerve cells. the early visceral phase with viremia was followed by neuroinvasion, encephalitis and death. in addition, parenchyma necroses were observed in the liver and lymphoid organs. 51 intradermal, intramuscular, or iv inoculations of eeev in nhps cause disease but does not always result in symptoms of the nervous system. intracerebral infection of eeev results in nervous system disease and fatality in monkeys. 53 the differences in these models indicate that the initial viremia and the secondary nervous system infection do not overlap in monkeys when they are infected by the peripheral route. 54 intranasal and intralingual inoculations of eeev also cause nervous system symptoms in monkeys, but less drastic than those caused by intracerebral injections. 54 the aerosol route of infection also progresses to uniformly lethal disease in cynomolgus macaques. 55 in this model, fever was followed by elevated white blood cells and liver enzymes. neurological signs subsequently developed, and nhps became moribund and were euthanized between days 5 and 9 days postexposure. meningoencephalomyelitis was the main pathology observed in the brains of these animals. 56 similar clinical signs and pathology were observed when common marmosets were infected with eeev by the intranasal route. 57 both aerosol and intranasal nhp models had similar disease progression and pathology as those seen in human disease. a common marmoset model was used for comparison studies of sa and na strains of eeev. 57 previous studies indicated that the sa strain is less virulent than na strain for humans. common marmosets were infected intranasally with either the na or sa strain of eeev. na strain-infected animals showed signs of anorexia and neurological involvement and were euthanized 4-5 days after the challenge. although sa strain-infected animals developed viremia, they remained healthy and survived the challenge. epizootics of viral encephalitis in horses were previously described in argentina. more than 25,000 horses died from western equine encephalitis virus (weev) in the central plains of the united states in 1912. 58 weev was first isolated from the brains of horses during the outbreak in the san joaquin valley of california in 1930. although it was suspected, the first diagnosis of weev as a cause of human encephalitis occurred in 1938, when the virus was recovered from the brain of a child with fatal encephalitis. 44 in horses, the signs of disease are fever, loss of coordination, drowsiness, and anorexia, leading to prostration, coma, and death in about 40% of affected animals. 59 weev also infects other species of birds and often causes fatal disease in sparrows. weev infection occurs throughout western na and sporadically in sa as it circulates between its mosquito vector and wild birds. 44 chickens and other domestic birds, pheasants, rodents, rabbits, ungulates, tortoises, and snakes are natural reservoirs of weev. 60,61 weev has caused epidemics of encephalitis in humans, horses, and emus, but the fatality rate is lower than that for eeev. 62 predominately young children and those older than 50 years demonstrate the clinical symptoms of the disease. 63 severe disease, seizures, fatal encephalitis, and significant sequelae are more likely to occur in infants and young children. 64, 65 typically, the disease progresses asymptomatically with seroprevalence in humans being fairly common in endemic areas. species used to develop animal models for weev are mice, hamsters, guinea pigs, and ponies. studies with ponies resulted in viremia in 100% of the animals 1-5 days pi. fever was observed in 7 of 11 animals, and six exhibited signs of encephalitis. 44 after subcutaneous inoculation with weev, suckling mice started to show signs of disease by 24 h and died within 48 h. 66 in suckling mice, the heart was the only organ in which pathologic changes were observed. conversely, adult mice exhibited signs of lethargy and ruffled fur on days 4-5 postinfection. mice were severely ill by day 8 and appeared hunched and dehydrated. death occurred between days 7 and 14, and both brain and mesodermal tissues such as heart, lungs, liver, and kidney were involved. 66, 67 intracerebral and intranasal routes of infection resulted in a fatal disease that was highly dependent on dose, while intradermal and subcutaneous inoculations caused only 50% fatality in mice regardless of the amount of virus. 49 studies demonstrated that although the length of the incubation period and the disease duration varied, weev infection resulted in mortality in hamsters by all routes of inoculation. progressive lack of coordination, shivering, rapid and noisy breathing, corneal opacity, and conjunctival discharge resulting in closing of the eyelids were indicative of disease in all cases. 68 cns involvement was evident with intracerebral, intraperitoneal, and intradermal inoculations. 68 weev is highly infectious to guinea pigs. 69 intraperitoneal inoculation of weev is fatal in guinea pigs regardless of virus inoculum, with the animals exhibiting signs of illness on days 3-4, followed by death on days 5-9 (nalca, unpublished results). very limited studies have been performed with nhps. the intranasal route of infection causes severe, lethal encephalitis in rhesus macaques. 54 reed et al. exposed cynomolgus macaques to low and high doses of aerosolized weev. the animals subsequently developed fever, increased white blood counts, and cns involvement, demonstrating that the cynomolgus macaque model would be useful for testing of vaccines and therapeutics against weev. 70 venezuelan equine encephalitis virus (veev) is maintained in nature in a cycle between small rodents and mosquitoes. 45 the spread of epizootic strains of the virus to equines leads to high viremia followed by a lethal encephalitis, and tangential spread to humans. veev can easily be spread by the aerosol route making it a considerable danger for laboratory exposure. in humans, veev infection causes a sudden onset of malaise, fever, chills, headache, and sore throat. 45, 71, 72 symptoms persist for 4-6 days, followed by a 2-to 3-week period of generalized weakness. encephalitis occurs in a small percentage of adults ( 0.5%); however, the rate in children may be as high as 4%. neurologic symptoms range from nuchal rigidity, ataxia, and convulsions to the more severe cases exhibiting coma and paralysis. the overall mortality rate in humans is <1%. 45 laboratory animals such as mice, guinea pigs, and nhps exhibit different pathologic responses when infected with veev. the lymphatic system is a general target in all animals infected with cns involvement variable between different animal species. the disease caused by veev progresses very rapidly without showing signs of cns disease in guinea pigs and hamsters. mortality is typically observed within 2-4 days after infection and fatality is not dose dependent. 44 veev infection lasts longer in mice, which develop signs of nervous system disease in 5-6 days and death 1-2 days later. lethal dose in mice changes depending on the age of mice and the route of exposure. 56 in contrast to guinea pigs and hamsters, the time of the death in mice is dose dependent. mortality is observed generally within 2-4 days after infection and fatality is not dose dependent. subcutaneous/dermal infection in the mouse model results in encephalitic disease very similar to that seen in horses and humans. 73 virus begins to replicate in the draining lymph nodes at 4 h pi. eventually, virus enters the brain primarily via the olfactory system. furthermore, aerosol exposure of mice to veev can result in massive infection of the olfactory neuroepithelium, olfactory nerves, and olfactory bulbs and viral spread to brain, resulting in necrotizing panencephalitis. 74, 75 aerosol and dermal inoculation routes cause neurological pathology in mice much faster than other routes of exposure do. the clinical signs of disease in mice infected by aerosol are ruffled fur, lethargy, and hunching progressing to death. 56, 74, 75 intranasal challenge of c3h/hen mice with high dose veev caused high morbidity and mortality. 76 viral titers in brain peaked on day 4 postchallenge and stayed high until animals died on day 9-10 postchallenge. protein cytokine array done on brains of infected mice showed elevated interleukin (il)-1a, il-1b, il-6, il-12, monocyte chemoattractant protein-1 (mcp-1), ifng, mip-1a, and regulated and normal t-cell expressed and secreted levels. this model was used successfully to test antivirals against veev. 77 xi. viral disease veev infection causes a typical biphasic febrile response in nhps. initial fever was observed at 12-72 h after infection and lasted <12 h. secondary fever generally began on day 5 and lasted 3-4 days. 78 veev-infected nhps exhibited mild symptoms such as anorexia, irritability, diarrhea, and tremors. leucopenia was common in animals exhibiting fever. 79 supporting the leucopenia, observed microscopic changes in lymphatic tissues such as early destruction of lymphocytes in lymph nodes and spleen, a mild lymphocytic infiltrate in the hepatic triads, focal myocardial necrosis with lymphocytic infiltration have been observed in monkeys infected with veev. surprisingly, characteristic lesions of the cns were observed histopathologically in monkeys in spite of the lack of any clinical signs of infection. 78 the primary lesions were lymphocytic perivascular cuffing and glial proliferation and generally observed at day 6 postinfection during the secondary febrile episode. cynomolgus macaques develop similar clinical signs including fever, viremia, lymphopenia, and encephalitis upon aerosol exposure to veev. 80 chikungunya virus is a member of the genus alphaviruses, specifically the semliki forest complex, and has been responsible for a multitude of epidemics mainly within africa and southeast asia. 45 the virus is transmitted by aedes mosquitoes. given the widespread endemicity of aedes mosquitoes, chikungunya virus has the potential to spread to previously unaffected areas. this is typified by the emergence of disease for the first time in 2005 in the islands of the southwest indian ocean, including the french la reunion island, and the appearance in central italy in 2007. 81, 82 the incubation period after a mosquito bite is 2-5 days followed by a self-limiting acute phase that lasts 3-4 days. symptoms during this period include fever, arthralgia, myalgia, and rash. headache, weakness, nausea, vomiting, and polyarthralgia have all been reported. 83 individuals typically develop a stooped posture due to the pain. for approximately 12% of infected individuals, joint pain can last months after resolution of primary disease, and has the possibility to relapse. underlying health conditions, including diabetes, alcoholism, or renal disease, increase the risk of developing a severe form of disease that includes hepatitis or encephalopathy. children between the ages of 3 and 18 years have an increased risk of developing neurological manifestations. 84 there is no effective vaccine or antiviral. wild-type c57bl/6 adult mice are not permissive to chikungunya virus infection by intradermal inoculation. however, it was demonstrated that neonatal mice were susceptible, and severity was dependent upon age at infection. six-day-old mice developed paralysis by day 6, and all died by day 12, whereas 50% of nine-day-old mice were able to recover from infection. by 12 days, mice were no longer permissive to disease. infected mice developed loss of balance, hind limb dragging, and skin lesions. neonatal mice were also used as a model for neurological complications. 85, 86 an adult mouse model has been developed by injection of the ventral side of the footpad of c57bl/6j mice. viremia lasted 4-5 days accompanied by foot swelling and noted inflammation of the musculoskeletal tissue. 87, 88 adult ifna/br knockout mice also developed mild disease with symptoms including muscle weakness and lethargy, symptoms that mirrored human infection. all adult mice died within 3 days. this model was useful in identifying the viral cellular tropism for fibroblasts. 85 imprinting control region (icr) cd1 mice can also be used as a disease model. neonatal mice subcutaneously inoculated with a passaged clinical isolate of chikungunya virus developed lethargy, loss of balance, and difficulty in walking. mortality was low, 17% and 8% for newborn cd1 and icr mice, respectively. the remaining mice fully recovered within 6 weeks after infection. 86 a drawback of both the ifna/ br and cd1 mice is that the disease is not a result of immunopathogenesis as occurs in human cases, given that the mice are immunocompromised. 89 long-tailed macaques challenged with a clinical isolate of the virus developed a similar clinical disease to humans. initially, the monkeys developed high viremia with fever and rash. after this period, viremia resolved and virus could be detected in lymphoid, liver, meninges, joint, and muscle tissue. the last stage mimicked the chronic phase in which virus could be detected up to two months after infection, although no arthralgia was noted. 90 dengue virus is transmitted via the mosquito vectors aedes aegypti and aedes albopictus. 91 given the endemicity of the vectors, it is estimated that half of the world's population is at risk for exposure to dengue virus. this results in approximately 50 million cases of dengue each year, with the burden of disease in the tropical and subtropical regions of latin america, south asia, and southeast asia. 92 it is estimated that there are 20,000 deaths each year caused by dengue hemorrhagic fever (dhf). 93 there are four serotypes of dengue virus, numbered 1-4, which are capable of causing a wide spectrum of disease that ranges from asymptomatic to severe with the development of dhf. 94 incubation can range from 3 to 14 days, with the average being 4-7 days. the virus targets dendritic cells and macrophages after a mosquito bite. 95 typical infection results in classic dengue fever (df), which is self-limiting and has flu-like symptoms in conjunction with retroorbital pain, headache, skin rash, and bone and muscle pain. dhf can follow, with vascular leak syndrome and low platelet count, resulting in hemorrhage. in the most extreme cases, dengue shock syndrome (dss) develops, characterized by hypotension, shock, and circulatory failure. 94 thrombocytopenia is a hallmark clinical sign of infection, and aids in differential diagnosis. 96 severe disease has a higher propensity to occur upon secondary infection with a different dengue virus serotype. 97 this is hypothesized to occur due to antibodydependent enhancement (ade). there is no approved vaccine or drug, and hospitalized patients receive supportive care including fluid replacement. in developing an animal model, it is important to note that mosquitoes typically deposit 10 4 -10 6 pfu, and is therefore the optimal range to be used during challenge. a comprehensive review of the literature regarding animal models of dengue infection was recently published by zompi et al. 98 several laboratory mouse strains including a/j, balb/c, and c57bl/6 are permissive to dengue infection. however, the resulting disease has little resemblance to human clinical signs, and death results from paralysis. [99] [100] [101] a higher dose of an adapted dengue virus strain induced dhf symptoms in both balb/c and c57bl/6. 102, 103 this model can also yield asymptomatic infections. a mouse-adapted (ma) strain of dengue virus 2 introduced into ag129 mice developed vascular leak syndrome similar to the severe disease seen in humans. 104 passive transfer of monoclonal dengue antibodies within mice leads to ade. during the course of infection, viremia was increased, and animals died due to vascular leak syndrome. 105 another ma strain injected into balb/c caused liver damage, hemorrhagic manifestations, and vascular permeability. 103 intracranial injection of suckling mice with dengue virus leads to death and has been used to test the efficacy of therapeutics. 106 scid mice engrafted with human tumor cells develop paralysis upon infection, and are thus not useful for pathogenesis studies. 107,108 df symptoms developed after infection in nod/scid/il2rgko mice engrafted with cd34 ã¾ human progenitor cells. 109 rag-hu mice developed fever, but no other symptoms upon infection with a passaged clinical isolate and laboratory-adapted strain of dengue virus 2. 110 a passaged clinical isolate of dengue virus type 3 was recently used to create a model in immunocompetent adult mice. interperitoneal injection in c57bl/6j and balb/c caused lethality by day 6-7 postinfection in a dose-dependent manner. the first indication of infection was weight loss beginning on day 4 followed by thrombocytopenia. a drop in systolic blood pressure along with noted increases in the liver enzymes, aspartate aminotransferase (ast) and alt, were also observed. viremia was established by day 5. this model mimicked the characteristic symptoms observed in human dhf/dss cases. 111 a novel model was developed that used infected mosquitoes as the route of transmission to hu-nsg mice. female mosquitoes were intrathoracically inoculated with a clinical isolate of dengue virus type 2. infected mosquitoes then fed upon the mouse footpad to allow for the transmission of the virus via the natural route. the amount of virus detected within the mouse was directly proportional to the amount of mosquitoes it was exposed to, with four to five being optimal. detectable viral rna was in line with what is observed during human infection. severe thrombocytopenia developed on day 14. this model is intriguing given that disease was enhanced with mosquito delivery of the virus in comparison to injection of the virus. 112 nhp models have used a subcutaneous inoculation in an attempt to induce disease. although the animals are permissive to viral replication, it is to a lower degree than that observed in human infection. 113 the immunosuppressive drug, cyclophosphamide enhances infection in rhesus macaques by allowing the virus to invade monocytes. 114 throughout these preliminary studies, no clinical disease was detected. to circumvent this, a higher dose of dengue virus was used in an iv challenge of rhesus macaques. hemorrhagic manifestations appeared by day 3 and resulted in petechiae, hematomas, and coagulopathy; however, no other symptoms developed. 115 further development would allow this model to be used for testing of novel therapeutics and vaccines. although primates do not develop disease upon infection with dengue, their immune system does produce antibodies similar to those observed during the course of human infection. this has been advantageous in studying ade. sequential infection led to a crossreactive antibody response, which has been demonstrated in both humans and mice. 116 this phenotype can also be seen upon passive transfer of a monoclonal antibody to dengue and subsequent infection with the virus. rhesus macaques exposed in this manner developed viremia that was 3-to 100-fold higher than was previously reported; however, no clinical signs were apparent. 117 the lack of inducible dhf or dss symptoms hinders further examination of pathogenesis within this model. japanese encephalitis virus ( jev) is a leading cause of childhood viral encephalitis in southern and eastern asia and is a problem among military personnel and travelers to these regions. it was first isolated from the brain of a patient who died from encephalitis in japan in 1935. 118 culex mosquitoes, which breed in rice fields, transmit the virus from birds or mammals (mostly domestic pigs) to humans. the disease symptoms range from a mild febrile illness to acute meningomyeloencephalitis. after an asymptomatic incubation period of 1-2 weeks, patients show signs of fever, headache, stupor, and generalized motor seizures, especially in children. the virus causes encephalitis by invading and destroying the cortical neurons. the fatality rate ranges from 10% to 50%, and most survivors have neurological and psychiatric sequelae. 119, 120 jev virus causes fatality in infant mice by all routes of inoculation. differences in pathogenesis and outcome are seen when the virus is given by intraperitoneal inoculation. 121 these differences depend on the amount of virus and the specific viral strains used. the biphasic viral multiplication after peripheral inoculation is observed in mice tissues. primary virus replication occurs in the peripheral tissues and the secondary replication phase in the brain. 122 hamsters are another small animal species that are used as an animal model for jev. fatality was observed in hamsters inoculated intracerebrally or intranasally, while peripheral inoculation caused asymptomatic viremia. studies with rabbits and guinea pigs showed that all routes of inoculation of jev produce asymptomatic infection. 123 serial sampling studies with 12-day-old wistar rats inoculated intracerebrally with jev indicated that jev causes the overproduction of free radicals by neurons and apoptosis of neuronal cells. 124 following a study in 2010 by the same group, showed that although cytokines tumor necrosis factor (tnf)-a, ifn-g, il-4, il-6, il-10, and chemokine mcp-1 increased gradually and peaked on days 10 pi with jevin rats, the levels eventually declined, and there was no correlation with the levels of cytokines and chemokines and neuronal damage. 125 intracerebral inoculation of jev causes severe histopathological changes in brain hemispheres of rhesus monkeys. symptoms such as weakness, tremors, and convulsions began to appear on days 6-10, with indicative signs of encephalomyelitis occurring on days 8-12 postinfection for most of the animals followed by death occurring on days 8-12 postinfection for most of the animals followed by death. 126 although intranasal inoculation of jev results in fatality in both rhesus and cynomolgus monkeys, peripheral inoculation causes asymptomatic viremia in these species. 123, 127 west nile virus west nile virus (wnv) was first isolated from the blood of a woman in the west nile district of uganda in 1937. 128 after the initial isolation of wnv, the virus was subsequently isolated from patients, birds, and mosquitoes in egypt in the early 1950s 129, 130 and was shown to cause encephalitis in humans and horses. wnv is recognized as the most widespread of the flaviviruses, with a geographical distribution that includes africa, the middle east, western asia, europe, and australia. 131 the virus first reached the western hemisphere in the summer of 1999, during an outbreak involving humans, horses, and birds in the new york city metropolitan area. 132, 133 since 1999, the range of areas affected by wnv quickly extended. older people and children are most susceptible to wnv disease. wnv generally causes asymptomatic disease or a mild undifferentiated fever (west nile fever), which can last from 3 to 6 days. 134 the mortality rate after neuroinvasive disease ranges from 4% to 11%. 131, [135] [136] [137] the most severe complications are commonly seen in the elderly, with reported case fatality rates from 4% to 11%. hepatitis, myocarditis, and pancreatitis are unusual, severe, nonneurologic manifestations of wnv infection. although many early laboratory studies of wn encephalitis were performed in nhps, mice, rat, hamster, horse, pig, dog, and cat models were used to study the disease. [138] [139] [140] [141] [142] [143] [144] inoculation of wnv into nhps intracerebrally resulted in the development of either encephalitis, febrile disease, or an asymptomatic infection, depending on the virus strain and dose. viral persistence is observed in these animals regardless of the outcome of infection (i.e. asymptomatic, fever, encephalitis). 141 thus, viral persistence is regarded as a typical result of nhp infection with various wnv strains. after both intracerebral and subcutaneous inoculation, the virus localizes predominantly in the brain and may also be found in the kidneys, spleen, and lymph nodes. wnv does not result in clinical disease in nhps although the animals show a low level of viremia. 145, 146 wnv has also been extensively studied in small animals. all classical laboratory mouse strains are susceptible to lethal infections by the intracerebral and intraperitoneal routes, resulting in encephalitis and 100% mortality. intradermal route pathogenesis studies indicated that langerhans dentritic cells are the initial viral replication sites in the skin. 147, 148 the infected langerhans cells then migrate to lymph nodes, and the virus enters the blood through lymphatic and thoracic ducts and disseminates to peripheral tissues for secondary viral replication. virus eventually travels to the cns and causes pathology that is similar to human cases. [149] [150] [151] [152] tesh et al. developed a model for wn encephalitis using the golden hamster, mesocricetus auratus. hamsters appeared normal during the first 5 days, became lethargic at approximately day 6, and developed neurologic symptoms by days 7-10. 143 many of the severely affected animals died 7-14 days after infection. viremia was detected in the hamsters within 24 h after infection and persisted for 5-6 days. although there were no substantial changes in internal organs, progressive pathologic differences were seen in the brain and spinal cord of infected animals. furthermore, similar to the above-mentioned monkey experiments by pogodina et al., persistent wnv infection was found in the brains of hamsters. the etiologic agent of severe acute respiratory syndrome (sars), sars-coronavirus (cov), emerged in 2002 as it spread throughout 32 countries in a period of 6 months, infecting >8000 people and causing nearly 800 deaths. 153, 154 the main mechanism of transmission of sars-cov is through droplet spread, but it is also viable in dry form on surfaces for up to 6 days and can be detected in stool, suggesting other modes of transmission are also possible. 155 although other members of the family usually cause mild illness, sars-cov infection has a 10% case fatality with the majority of cases in people over the age of 15 years. 156, 157 after an incubation period of 2-10 days, clinical signs of sars include general malaise, fever, chills, diarrhea, dyspnea, and cough. 158 in some sars, cases, pneumonia may develop and progress to acute respiratory distress syndrome (ards). fever usually dissipates within 2 weeks and coincides with the induction of high levels of neutralizing antibodies. 159 in humans, sars-cov replication destroys respiratory epithelium, and a great deal of the pathogenesis is due to the subsequent immune responses. 160 infiltrates persisting within the lung and diffuse alveolar damage (dad) are common sequelae of sars-cov infection. virus can be isolated from secretions of the upper airways during early, but not later stages of infection as well as from other tissues. 161 sars-cov can replicate in many species, including dogs, cats, pigs, mice, rats, ferrets, foxes, and nhps. 162 chinese palm civets, raccoon dogs, and bats are possible natural hosts. no model captures all aspects of human clinical disease (pyrexia and respiratory signs), mortality (w10%), viral replication, and pathology. 163 in general, the sars-cov disease course in the model species is much milder and of shorter duration than in humans. viral replication in the various animal models may occur without clinical illness and/or histopathologic changes. the best-characterized models use mice, hamsters, ferrets, and nhps (table 38 .1). mouse models of sars-cov typically are inoculated by the intranasal route under light anesthesia. young, 6-to 8-week old balb/c mice exposed to sars-cov have viral replication detected in the lungs and nasal turbinates, with a peak on day 2 and clearance by day 5 postexposure. there is also viral replication within the small intestines of young balb/c mice. however, young mice have no clinical signs, aside from reduced weight gain, and have little to no inflammation within the lungs (pneumonitis). intranasal sars-cov infection of c57bl/6 (b6) also yield reduced weight gain and viral replication in the lungs, with a peak on day 3 and clearance by day 9. 171 in contrast, balb/c mice 13-14 interstitial pneumonitis, alveolar damage, and death also occur in old mice, resembling the age-dependent virulence observed in humans. 129s mice and b6 mice show outcomes to sars-covinfection similar to those observed for balb/c mice but have lower titers and less prolonged disease. one problem is that it is more difficult to obtain large numbers of mice older than 1 year. a number of immunocompromised knockout mouse models of intranasal sars-cov infection have also been developed. 129svev mice infected with sars-cov by the intranasal route develop bronchiolitis, with peribronchiolar inflammatory infiltrates, and interstitial inflammation in adjacent alveolar septae. 172 viral replication and disease in these mice resolve by day 14 postexposure beige, cd1ã�/ã�, and rag1ã�/ã� mice infected with sars-cov have similar outcomes to infected balb/c mice with regard to viral replication, timing of viral clearance, and a lack of clinical signs. signal transducer and activator of transcription-1 (stat1) ko mice infected intranasally with sars-cov have severe disease, with weight loss, pneumonitis, interstitial pneumonia, and some deaths. the stat1 ko mouse model is therefore useful for studies of pathogenicity, pathology, and evaluation of vaccines. syrian golden hamsters (strain lvg) are also susceptible to intranasal exposure of sars-cov. after the administration of 10 3 tcid 50 (tissue culture infective dose), along with a period of transient viremia, sars-cov replicates in nasal turbinates and lungs, resulting in pneumonitis. there are no obvious signs of disease, but exercise wheels can be used to monitor decrease in nighttime activity. some mortality has been observed, but it was not dose dependent and could have more to do with genetic differences between animals because the strain is not inbred. 163 damage is not observed in the liver or spleen despite detection of virus within these tissues. several studies have shown that intratracheal inoculation of sars-cov in anesthetized ferrets (mustela furo) results in lethargy, fever, sneezing, and nasal discharge. 167 clinical disease has been observed in several studies. sars-cov is detected in pharyngeal swabs, trachea, tracheobronchial lymph nodes, and high titers within the lungs. mortality has been observed around day 4 postexposure as well as mild alveolar damage in 5-10% of the lungs, occasionally accompanied by severe pathology within the lungs. 173 with fever, overt respiratory signs, lung damage, and some mortality, the ferret intratracheal model of sars-cov infection is perhaps most similar to human sars, albeit with a shorter time course. sars-cov infection of nhps by intransal or intratracheal routes generally results in a very mild infection, which resolves quickly. sars-cov infection of old world monkeys, such as rhesus macaques, cynomolgus macaques (cynos), and african green monkeys (agms) have been studied with variable results, possibly due to the outbred nature of the groups studied or previous exposure to related pathogens. clinical illness and viral loads have not been consistent; however, replication within the lungs and dad are features of the infections for each of the primate species. some cynos have no illness, but others have rash, lethargy, and respiratory signs and pathology. 170 rhesus have little to no disease and only have mild findings upon histopathological analysis. agms infected with sars-cov have no overt clinical signs, but dad and pneumonitis have been documented. viral replication has been detected for up to 10 days in the lungs of agms; however, the infection resolves and does not progress to fatal ards. farmed chinese masked palm civets, sold in open markets in china, were thought to be involved in the sars-covoutbreak. intratracheal and intranasal inoculation of civets with sars-covresults in lethargy, decreased aggressiveness fever, diarrhea, and conjunctivitis. 174 leucopenia, pneumonitis, and alveolar septal enlargement, with lesions similar to those observed in ferrets and nhps, have also been observed in laboratory-infected civets. common marmosets have also been shown to be susceptible to sars-cov infection. 175 vaccines have been developed for related animal covs in chickens, cattle, dogs, cats, and swine have used live-attenuated, killed, dna and viral-vectored vaccine strategies. 176 an important issue to highlight from work on these vaccines is that cov vaccines, such as those developed for cats, may induce a more severe disease. 177 as such, immune mice had th2-type immunopathology upon sars-cov challenge. 178 severe hepatitis in vaccinated ferrets with antibody enhancement in liver has been reported. 179 additionally, rechallenge of agms showed limited viral replication but significant lung inflammation, including alveolitis and interstitial pneumonia, which persisted for long periods of time after viral clearance. 180 mouse and nhp models with increased virulence may be developed by adapting the virus by repeated passage within the species of interest. ma sars and human ace2 transgenic mice are available. 181 all mammals experimentally or naturally exposed to rabies virus have been found to be susceptible. this highly neurotropic virus is a member of the lyssavirus genus and is transmitted from the bite of an infected animal to humans. 182 the virus is able to replicate within the muscle cells at the site of the bite, and then travel to the cns. once reaching the cns by retrograde axonal transport, the virus replicates within neurons creating inflammation and necrosis. the virus subsequently spreads throughout the body via peripheral nerves. 183 a typical incubation period is 30-90 days, and is highly dependent upon the location of the bite. proximity to the brain is a major factor for the onset of symptoms. the prodromal stage lasts from 2 to 10 days and is when the virus initially invades the cns. flu-like symptoms are the norm in conjunction with pain and inflammation at the site of the bite. subsequently, there are two forms of disease that can develop. in 80% of cases, an individual develops the encephalitic or furious form. this form is marked by hyperexcitability, autonomic dysfunction, and hydrophobia. the paralytic, or dumb form, is characterized by ascending paralysis. ultimately, both forms result in death days after the onset of symptoms. once the symptoms develop, there is no proven effective therapy. in the developing world, death is caused by the lack of access to medical care including postexposure prophylaxis. in na, fatal cases result because of late diagnosis. 184 syrian hamsters have been challenged with rabies virus intracerebrally, intraperitoneally, intradermally, and intranasally. all animals died as a result of the exposure, although intracerebral and intranasal inoculation led to only the furious form depicted by extreme irritability, spasms, excessive salivation, and cries. the virus used had been isolated from an infected dog brain and passaged in swiss albino mice. animals inoculated by intracerebral injection develop disease within 4-6 days, whereas all other routes of entry develop disease within 6-12 days. 185 this model has been used to study and test novel vaccine candidates. 186 mice have been extensively studied as an animal model for rabies. it was shown that swiss albino mice intracerebrally injected with a virus isolated from a dog developed only the paralytic form of disease 6 days after the initial challenge. balb/c mice are universally susceptible to intracerebral injection of rabies virus within 9 days. disease symptoms include paralysis, cachexia, and bristling appearing 1-3 days before death. 187 a more natural route of infection via peripheral injection into masseter muscles was tested on icr mice. these mice developed neurological signs including limb paralysis, and all died within 6-12 days. 188 icr mice have been instrumental in analyzing novel vaccines and correlates of protection. 189 this line of mice was also used to assess the value of ketamine treatment to induce coma during rabies infection. 190 another mouse line used is the p75 neurotrophin receptor-deficient mouse. this mouse developed a fatal encephalitis when inoculated intracerebrally with the challenge virus standard. 191 bax-deficient mice have also been used to determine the role of apoptotic cell death in the brain during the course of infection. 192 a viral isolate from silver-haired bats can also be used in the mouse model. this strain is advantageous given that it is responsible for the majority of deaths in north na. 193 early death phenomenon is typified by a decrease to time of death in a subset of individuals and animals that have been vaccinated and subsequently exposed to rabies. 194 this trend has been demonstrated experimentally in swiss outbred mice and primates. 195, 196 cynomolgus and rhesus were both infected with passaged rabies virus to create an nhp model. a high titer of virus was needed to induce disease, but exposure was found to not be universally fatal. the animals that survived beyond 4 weeks within the experiment did not develop clinical disease nor succumb to infection. primates that did develop disease refused food and had progressively less activity until death. this lasted from 24 h up to 4 days, with all animals with symptoms dying within 2 weeks. 196 bats have been experimentally challenged with rabies. vampire bats, desmodus rotundus, intramuscularly injected with a bat viral isolate displayed clinical signs including paralysis in half of the population of the study animals. of those who did develop disease, the duration was 2 days, and incubation period ranged from 7 to 30 days. regardless of disease manifestation, 89% of challenged animals died. 197 skunks can be challenged intramuscularly or intranasally with either challenge virus strain or a skunk viral isolate. interestingly, the challenge virus strain more readily produced the paralytic form, whereas the street form of rabies developed into the furious form. however, the challenge strain virus resulted in a shorter incubation period of 7-8 days in comparison to 12-14 days seen with the street virus. 198 filoviridae consists of two well-established genera, ebola virus and marburg virus (marv) and a newly discovered group, cuevavirus 199 (table 38 200 two other ebola viruses are known; ta㯠forest (tafv; previously named cote (circumflex over the 'o') d'ivoire) (ciebov) and reston (restv), which have not caused major outbreaks or lethal disease in humans. the disease in humans is characterized by aberrant innate immunity and a number of clinical symptoms such as fever, nausea, vomiting, arthralgia/myalgia, headaches, sore throat, diarrhea, abdominal pain, anorexia, and numerous others. 201 approximately 10% of patients develop petechia and a greater percentage, depending on the specific strain, may develop bleeding from various sites (gums, puncture sites, stools, etc.). 199 natural transmission in an epidemic is thought to be through direct contact or needle sticks in hospital settings. however, much of the research interest in filoviruses primarily stems from biodefense needs, particularly from aerosol biothreats. as such, intramuscular, intraperitoneal, and aerosol models have been developed in mice, hamsters, guinea pigs, and nhps for the study of pathogenesis, correlates of immunity, and for testing countermeasures. 202 because filoviruses have such high lethality rates in humans, scientists have looked for models that are uniformly lethal to stringently test efficacy of candidate vaccines and therapeutics. immunocompetent mice have not been successfully infected with wild-type filoviruses due to the control of the infection by the murine type 1 ifn response. 203 however, wild-type inbred mice are susceptible to filovirus that has been ma by serial passage. 204 balb/c mice, which are the strain of choice for intraperitoneal inoculation of ma-ebov, are not susceptible by the aerosol route. 205 for aerosol infection of immunocompetent mice, a panel of bxd (balb/ c ã� dba) recombinant inbred strains were screened, and one strain, bxd34, was shown to be particularly susceptible to airborne ma-ebov, with 100% lethality to low or high doses (w100 or 1000 pfu). these mice developed weight loss of >15% and succumbed to infection between days 7 and 8 postexposure. the aerosol infection model uses a whole-body exposure chamber to expose mice aged 6-8 weeks to ma-ebov aerosols with a mass median aerodynamic diameter (mmad) of approximately 1.6 mm and a geometric standard deviation of approximately 2.0 for 10 min. another approach uses immunodeficient mouse strains such as scid, stat1 ko, ifn receptor ko, or perforin ko with a wild-type ebov inoculum by intraperitoneal or aerosol routes. 206 mice are typically monitored for clinical disease "scores" based on activity and appearance, weight loss, and moribund condition (survival). coagulopathy, a hallmark of filovirus infection in humans, has been observed, with bleeding in a subset of animals and failure of blood samples to coagulate late in infection. liver, kidney, spleen, and lung tissue taken from moribund mice have pathology characteristic of filovirus disease in nhps. although most mouse studies have used ma-ebov or ebov, an intraperitoneal ma marv model is also available. 207 ma-marv and ma-ebov models are particularly useful for screening novel antiviral compounds. 208 hamsters are frequently used to study cardiovascular disease, coagulation disorders, and thus serve as the basis for numerous viral hemorrhagic fever models. 209 an intraperitoneal ma-ebov infection model has been developed in syrian hamsters. 210 this model, which has been used to test a vesicular stomatitis virus vectored vaccine approach, uses male 5-to 6-week-old syrian hamsters that are infected with 100 ld50 of ma-ebov. virus is present in tissues and blood collected on day 4, and all animals succumbed to the disease by day 6. detailed accounts of this model have been presented at international scientific meetings by ebihara and feldmann et al. but have not been reported in a scientific journal at the time of writing this chapter. 211 guinea pig models of filovirus infection have been developed for intraperitoneal and aerosol routes using guinea pig-adapted ebov (gp-ebov) and marv (gp-marv). 212, 213 guinea pigs models of filovirus infection are quite useful in that they develop fever, which can be monitored at frequent (hourly) intervals by telemetry. additionally, the animals are large enough for regular blood sampling in which measurable coagulation defects are observed as the infection progresses. hartley guinea pigs exposed to aerosolized gp-marv or gp-ebov become moribund at times comparable to that of nhps, generally succumbing to the infection between 7 and 12 days postexposure. by aerosol exposure, gp-ebov is uniformly lethal at both high and low doses (100 or 1000 pfu target doses) but lethality drops with low (<1000 pfu) presented doses of airborne gp-marv, and more protracted disease is seen in some animals. 213 weight loss of between 15% and 25% is a common finding in guinea pigs exposed to gp-ebov or gp-marv. fever, which becomes apparent by day 5, occurs more rapidly in gp-ebov exposed guinea pigs than with gp-marv exposure. lymphocytes and neutrophils increase during the earlier part of the disease, and platelet levels steadily drop as the disease progresses. increases in coagulation time can be seen as early as day 6 postexposure. blood chemistries (i.e. alt, ast, alkaline phosphatase (alkp), and blood urea nitrogen) indicating problems with liver and kidney function are also altered late in the disease course. nhp models of filovirus infection are the preferred models for more advanced disease characterization and testing of countermeasures because they most closely mimic the disease and immune correlates seen in humans. 214 old world primates have been primarily used for the development of intraperitoneal, intramuscular, and aerosol models of filovirus infection. uniformly lethal filovirus models have been developed for most of the virus strains in cynomolgus macaques, rhesus macaques, and to a lesser degree, in agms and marmosets. [215] [216] [217] [218] [219] low-passage human isolates that have not been passaged in animals have been sought for development of nhp models to satisfy the food and drug administration (fda) animal rule. prominent features of the infections are onset of fever by day 5 postexposure, alteration in liver function enzymes (alt, ast, and alkp), decrease in platelets, and increased coagulation times. clinical disease parameters may have a slightly delayed onset in aerosol models. petichial rash is a common sign of filovirus disease and may be more frequently observed in cynomolgus macaques than in other nhp species. dyspnea late in infection is a prominent feature of disease after aerosol exposure. a number of pronounced pathology findings include multifocal necrosis and fibrin lesions, particularly within the liver and the spleen. lymphocytolysis and lymphoid depletion are also observed. multilead, surgically implanted telemetry devices are useful in the continuous collection of temperature, blood pressure, heart rate, and activity levels. as such, blood pressure drops as animals become moribund and heart rate variability (standard deviation of the heart rate) is altered late in infection. the most recently developed telemetry devices can aid in plethysomography to measure respiratory minute volume for accurate delivery of presented doses for aerosol exposure. hendra and nipah virus are unusual within the paramyxoviridae family given that they can infect a large range of mammalian hosts. both viruses are grouped under the genus henipavirus. the natural reservoirs of the viruses are the fruit bats from the genus pteropus. hendra and nipah have the ability to cause severe disease in humans with the potential for a high case fatality rate. 220 outbreaks caused by nipah virus have been recognized in malaysia, singapore, bangladesh, and india, while hendra outbreaks have yet to be reported outside of australia. 221, 222 hendra was the first member of the genus to be identified and was initially associated with an acute respiratory disease in horses. all human cases have been linked to transmission through close contact with an infected horse. there have been no confirmed cases of direct transmission from human to human or bat to human. nipah has the distinction of being able to be transmitted by humans, although the exact route is unknown. 223 the virus is susceptible to ph, temperature, and desiccation, and thus close contact is hypothesized to be needed for successful transmission. 224 both viruses have a tropism for the neurological and respiratory tract. hendra virus incubation period is 7-17 days and is marked by a flu-like illness. symptoms at this initial stage include myalgia, headache, lethargy, sore throat, and vomiting. 225 disease progression can continue to pneumonitis or encephalitic manifestations, with the person succumbing to multiorgan failure. 226 nipah virus has an incubation period of 4 days to 2 weeks. 227 much like hendra, the first signs of disease are nondescript. severe neurological symptoms subsequently develop including encephalitis and seizures that can progress to coma within 24-48 h. 228 survivors of infection typically make a full recovery; however, 22% suffer permanent sequelae, including persistent convulsions. 229 at this time, there is no approved vaccine or antiviral, and treatment is purely supportive. animal models are being used to not only test novel vaccines and therapeutics, but also deduce the early events of disease because observed human cases are all at terminal stages. the best small animal representative is the syrian golden hamster due to their high susceptibility to both henipaviruses. clinical signs upon infection recapitulate the disease course in humans including acute encephalitis and respiratory distress. challenged animals died xi. viral disease 38 . in vivo models of viral diseases affecting humans within 4-17 days postinfection. the progression of disease and timeline are highly dependent on dose and route of infection. intranasal inoculation leads to imbalance, limb paralysis, lethargy, and breathing difficulties whereas intraperitoneal resulted in tremors and paralysis within 24 h before death. virus was detected in lung, brain, spleen, kidney, heart, spinal cords, and urine, while the brain was the most affected organ. this model has been used for vaccination and passive protection studies. [230] [231] [232] the guinea pig model has not been widely used due to the lack of a respiratory disease upon challenge. 233, 234 inoculation with hendra virus via the subcutaneous route leads to a generalized vascular disease with 20% mortality. clinical signs were apparent 7-16 days postinfection with death occurring within 2 days of cns involvement. higher inocula have been associated with the development of encephalitis lesions. intradermal and intranasal injections do not lead to disease, although the animals are able to seroconvert upon challenge. inoculum source does not affect clinical progression. nipah virus challenge only develops disease upon intraperitoneal injection and results in weight loss and transient fever for 5-7 days. virus was shed through urine and found to be present in the brain, spleen, lymph nodes, ovary, uterus, and urinary bladder. 235 ferrets display the same clinical disease as seen in the hamster model and human cases. 236, 237 upon inoculation by the oronasal route, ferrets develop severe pulmonary and neurological disease within 6-9 days including fever, coughing, and dyspnea. lesions do develop in the ferrets' brains, but to a lesser degree than seen in humans. cats have also been used as an animal model for henipaviruses. disease symptoms are not dependent upon the route of infection. the incubation period is 4-8 days and leads to respiratory and neurological symptoms. 238, 239 this model has proven to be useful in a vaccine challenge model. squirrel and agms are representative of the nhp models. within the squirrel monkeys, nipah virus is introduced by either the intranasal or iv route and subsequently leads to clinical signs similar to that in humans, although intranasal challenge results in milder disease. upon challenge, only 50% animals develop disease manifestations including anorexia, dyspnea, and acute respiratory syndrome. neurological involvement is characterized by uncoordinated motor skills, loss of consciousness, and coma. viral rna can be detected in the lung, brain, liver, kidney, spleen, and lymph nodes but is only found upon iv challenge. 240 agms have been found to be a very consistent model of both viruses. intratracheal inoculation of the viruses results in 100% mortality, and death within 8.5 and 9-12 days postinfection for hendra and nipah, respectively. the animals develop severe respiratory and neurological disease with generalized vasculitis. 241, 242 the reservoir of the viruses, gray-headed fruit bats, has been experimentally challenged. due to their status as the host organism for henipaviruses, the bats do not develop clinical disease. however, hendra virus can be detected in kidneys, heart, spleen, and fetal tissue and nipah virus can be located in urine. 243 pigs have been investigated as a model as they develop a respiratory disease upon infection with both nipah and hendra. [244] [245] [246] oral inoculation does not produce a clinical disease, but subcutaneous injection represents a successful route of infection. live virus can be isolated from the oropharynx as early as 4 days postinfection. nipah can also be transmitted between pigs. nipah was able to induce neurological symptoms in 20% of the pigs, even though virus was present in all neurological tissues regardless of symptoms. 247 within the pig model, it seemed that nipah had a greater tropism for the respiratory tract, while hendra for the neurological system. horses also are able to develop a severe respiratory tract infection accompanied with fever and general weakness upon exposure to nipah and hendra. oronasal inoculation led to systemic disease with viral rna detected in nasal swabs within 2 days. 248, 249 animals died within 4 days postexposure and were found to have interstitial pneumonia with necrosis of alveoli. 250, 251 virus could be detected in all major systems. mice, rats, rabbits, chickens, and dogs have been tested but found to be nonpermissive to infection. 232, 252 suckling balb/c mice succumb to infection if the virus is inoculated intracranially. 253 embryonated chicken eggs have been inoculated with nipah virus leading to a universally fatal disease within 4-5 days postinfection. 254 respiratory syncytial virus is responsible for lower respiratory tract infections of 33 million children under the age of 5 years, which in turn results in three million hospitalizations and approximately 200,000 deaths. 255 within the united states, hospital costs alone amount to >600 million dollars. 256 outbreaks are common in the winter. 257 the virus is transmitted by large respiratory droplets that replicate initially within the nasopharynx and further spreads to the lower respiratory tract. incubation for the virus is 2-8 days. respiratory syncytial virus is highly virulent leading to very few asymptomatic infections. 258 disease manifestations are highly dependent upon the age of the individual. primary infections in neonates produce nonspecific symptoms including the overall failure to thrive, apnea, and feeding difficulties. infants present with a mild upper respiratory tract disease that could develop into bronchiolitis and bronchopneumonia. contracting the virus at this age results in an increased chance of developing childhood asthma. 259 young children develop recurrent wheezing, whereas adults exacerbate previous respiratory conditions. 260 common clinical symptoms are runny nose, sneezing, and coughing accompanied with fever. mortality rates in hospitalized children are 1-3% with the greatest burden of disease seen in 3-4-month-olds. 261 there is no vaccine available, and ribavirin usage is not recommended for routine treatment. 262 animal models were developed in the hopes of formulating an effective and safe vaccine unlike the formalin-inactivated respiratory syncytial virus vaccine (fi-rsv). this vaccineinduced severe respiratory illness in infants who received the vaccine and were subsequently infected with live virus. 263 mice can be used to model disease, although a very high intranasal inoculation is needed to achieve clinical symptoms. 264, 265 strain choice is crucial to reproducing a physiological relevant response. 266 age does not affect primary disease manifestations. 267 however, it does play a role in later sequelae showing increased airway hyperreactivity. 268 primary infection produces increased breathing with airway obstruction. 264, 269 virus was detected as early as day 3 and reached maximum titer at day 6 postinfection. clinical illness is defined in the mouse by weight loss and ruffled fur as opposed to runny nose, sneezing, and coughing as seen in humans. cotton rats are useful given that it is a small animal disease model. the virus is able to replicate to high titers within the lungs and can be detected in both the upper and lower airways after intranasal inoculation. 270, 271 it has been reported that viral replication is 50-to 1000-fold greater in the rat model than in the mouse model. 272 the rats develop mild-to-moderate bronchiolitis or pneumonia. 273 although age does not seem to factor in clinical outcome, it has been reported that older rats tend to take longer to achieve viral clearance. viral loads peak by the fifth day, dropping to below the levels of detection by 8. the histopathology of the lungs seems to be similar to that in humans after infection. 274 this model has limited usage in modeling the human immune response to infection as challenge with the virus creates a th2 response, whereas humans tend to skew toward th1. [275] [276] [277] fi-rsv disease was recapitulated upon challenge with live virus after being vaccinated twice with fi-rsv. chinchillas have been challenged experimentally via intranasal inoculation. the virus was permissive within the nasopharynx and eustachian tube. the animals displayed an acute respiratory tract infection. this model is thought to be useful in studying mucosal immunity during infection. 278 chimpanzees are permissive to replication and clinical symptoms of respiratory syncytial virus including rhinorrhea, sneezing, and coughing. adult squirrel monkeys, newborn rhesus macaques, and infant cebus monkeys were also challenged but did not exhibit any disease symptoms nor high levels of viral replication. 279 bonnet monkeys were also tested and found to develop an inflammatory response by day 7 with viral rna detected in both bronchial and alveolar cells. 280 the chimpanzee model has proven to be useful for vaccine studies. 281, 282 sheep have also been challenged experimentally since they develop respiratory disease when exposed to ovine respiratory syncytial virus. 283 lambs were also found to be susceptible to human respiratory syncytial infection. 284, 285 when inoculated intratracheally, the lambs developed an upper respiratory tract infection with cough after 6 days. some lambs went on to develop lower respiratory disease including bronchiolitis. the pneumonia resolved itself within 14 days. during the course of disease, viral replication peaked at 6 days, and rapidly declined. studying respiratory disease in sheep is beneficial given the shared structural features between them and humans. 286, 287 the influenza viruses consist of three types: influenza a, b, and c, based on antigenic differences. influenza a is further classified by subtypes; 16 ha and 9 na subtypes are known. seasonal influenza is the most common infection and usually causes a self-limited febrile illness with upper respiratory symptoms and malaise that resolves within 10 days. 288 the rate of infection is estimated at 10% in the general population and can result in billions of dollars of loss annually from medical costs and reduced work-force productivity. approximately 40,000 people in the united states die each year from seasonal influenza. 289 thus, vaccines and therapeutics play a critical role in controlling infection, and development using animal models is ongoing. 290 influenza virus replicates in the upper and lower airways, peaking at approximately 48 h postexposure. infection can be more severe in infants and in children under the age of 22 years, people over the age of 65 years, or immunocompromised individuals in whom viral pneumonitis or pneumonia can develop or bacterial superinfection resulting in pneumonia or sepsis. 291 pneumonia from secondary bacterial infection, such as streptococcus pneumonia, streptococcus pyrogenes, and neisseria meningitides, and more rarely, staphylococcus aureus, is more common than viral pneumonia from the influenza itself, accounting for approximately 27% of all influenza-associated fatalities. 292 death, often due to ards can occur as early as 2 days after the onset of symptoms. lung histopathology in severe cases may include dad, alveolar edema and damage, hemorrhage, fibrosis, and inflammation. 288 the h5n1 avian strain of influenza has lethality rates of approximately 60% (of known cases), likely because the virus preferentially binds to the cells of the lower respiratory tract, and thus, the potential for global spread is a major concern. 293 the most frequently used animal models of influenza infection include mice, ferrets, and nhps. a very thorough guide to working with mouse, guinea pig, ferret, and cynomolgus models was published by kroeze et al. 294 lethality rate can vary with the virus strain used (with or without adaptation), dose, route of inoculation, age, and genetic background of the animal. the various animal models can capture differing diseases caused by influenza: benign, severe, superinfection and sepsis, severe with ards, and neurologic manifestations. 290 also, models can use seasonal or avian strains and models have been developed to study transmission, important for understanding the potential for more lethal strains such as h5n1 for spreading among humans. mouse models of influenza infection are very predictive for antiviral activity and tissue tropism in humans, and are useful in testing and evaluating vaccines. 295 inoculation is by the intranasal route, using approximately 60 ml of inoculum in each nare of anesthetized mice. exposure may also be to small particle aerosols containing influenza with an mmad of <5 mm. most inbred strains are susceptible, with particularly frequent use of balb/c followed by c57bl/6j mice. males and females have equivalent disease, but influenza is generally more infectious in younger 2-to 4-week-old (8-10 g) mice. mice are of somewhat limited use in characterizing the immune response to influenza. mice lack the mxa gene, which is an important part of the human innate immune response to influenza infection. the mouse homolog to mxa, mx1, is defective in most inbred mouse strains. 296 weight loss or reduced weight gain, decreased activity, huddling, ruffled fur, and increased respiration are the most common clinical signs. for more virulent strains, mice may require euthanasia as early as 48 h postexposure, but most mortality occurs from 5 to 12 days postexposure accompanied by decreases in rectal temperature. 297 pulse oximeter readings and measurement of blood gases of oxygen saturation are also used to determine the impact of influenza infection on respiratory function. 298 virus can be isolated from bronchial lavage fluids throughout the infection and from tissues after euthanasia. for influenza strains with mild-tomoderate pathogenicity, disease is nonlethal and virus replication is detected within the lungs, but usually not other organs. increases in serum alpha-1-acidglycoprotein and lung weight are also frequently present. however, mice infected with influenza do not develop fever, dyspnea, nasal exudates, sneezing, or coughing. mice can be experimentally infected with influenza a or b, but the virus generally requires adaptation to produce clinical signs. mice express the receptors for influenza attachment in the respiratory tract; however, the distribution varies and sa 2,3 predominates over sa 2,6 which is why h1, h2, and h3 subtypes usually need to be adapted to mice and h5n1, h2, h6, and h7 viruses do not require adaptation. 299 to adapt, mice are infected intratracheally or intranasally by virus isolated from the lungs, and reinfected into mice and then the process is repeated a number of times. once adapted, influenza strains can produce severe disease, systemic spread, and neurotropism. however, h5n1 and the 1918 pandemic influenza virus can cause lethal infection without adaptation. 300 h5n1 infection of mice results in viremia and viral replication in multiple organ systems, severe lung pathology, fulminant diffuse interstitial pneumonia, pulmonary edema, high levels of proinflammatory cytokines, and marked lymphopenia. 301 as in humans, the virulence of h5n1 is attributable to damage caused by an overactive host immune response. additionally, mice infected with the 1918 h1n1 influenza produces severe lung pathology and oxygen saturation levels that decrease with increasing pneumonia. 302 in superinfection models, a sublethal dose of influenza is given to mice followed 7 days later by intranasal inoculation of a sublethal dose of a bacterial strain such as s. pneumoniae or s. pyrogenes. 303 morbidity, characterized by inflammation in the lungs, but not bacteremia, begins a couple of days after superinfection and may continue for up to 2 weeks. at least one transmission model has also been developed in mice. with h2n2 influenza, transmission rates of up to 60% among cage mates can be achieved after infection by the aerosol route and cocaging after 24 h. 304 domestic ferrets (mustela putorius furo) are frequently the animal species of choice for influenza animal studies because the susceptibility, clinical signs, peak virus shedding, kinetics of transmission, local expression of cytokine mrnas, and pathology resemble that of humans. [305] [306] [307] ferrets also have airway morphology, respiratory cell types, and a distribution of influenza receptors (sa 2,6 and sa 2,3) within the airways similar to that of humans. 308 influenza was first isolated from ferrets infected intranasally with throat washes from humans harboring the infection and ferret models have since been used to test efficacy of vaccines and therapeutic treatments. 309 when performing influenza studies in ferrets, animals should be serologically negative for circulating influenza viruses. infected animals should be placed in a separate room from uninfected animals. if animals must be placed in the same room, uninfected ferrets should be handled before infected ferrets. anesthetized ferrets are experimentally exposed to influenza by intranasal. inoculation of 0.25-0.5 ml containing approximately 10 4 -10 6 egg id50 dropwise to each nostril. influenza types a and b naturally infect ferrets, resulting in an acute illness, which usually lasts 3-5 days for mildly to moderately virulent strains. 310 ferrets are more susceptible to influenza a than to influenza b strains and are also susceptible to avian influenza h5n1 strains without adaptation. 311 virulence and degree of pneumonitis caused by different influenza subtypes and strains vary from mild to severe and generally mirror that seen in humans. nonadapted h1n1, h2n2, and h3n2 have mild-to-moderate virulence in ferrets. strains of low virulence have predominant replication in the nasal turbinates. clinical signs and other disease indicators are similar to that of humans with a mild respiratory disease, sneezing, nasal secretions containing virus, fever, weight loss, high viral titers, and inflammatory infiltrate in the airways, bronchitis, and pneumonia. 312 replication in both the upper and lower airways is associated with more severe disease and greater mortality. additionally, increased expression of proinflammatory mediators and reduced expression of antiinflammatory mediators in the lower respiratory tract ferrets correlates with severe disease and lethal outcome. h5n1-infected ferrets develop severe lethargy, greater ifn response, transient lymphopenia, and replication in respiratory tract, brain, and other organs. 313 old and new world primates are susceptible to influenza infection and have an advantage over ferret and mouse models, which are deficient for h5n1 vaccine studies because there is a lack of correlation with hemagglutination inhibition. 314 of old world primates, cynomolgus macaque (m. fascicularis) are most frequently used for studies of vaccines and antiviral drug therapies. 315, 316 h5n1 and h1n1 1918 infections of cynos are very similar to those in humans. 317 cynos develop fever and ards upon intranasal inoculation of h5n1 with necrotizing bronchial interstitial pneumonia 318 nhps are challenged by multiple routes (ocular, nasal, and tracheal) simultaneously 1 ã� 10 6 pfu per site. virus antigen is primarily localized to the tonsils and pulmonary tissues. infection of cynos with h5n1 results in fever, lethargy, nasal discharge, anorexia, weight loss, nasal and tracheal washes, pathologic and histopathologic changes, and alveolar and bronchial inflammation. the 1918 h1n1 caused a very high mortality rate due to an aberrant immune response and ards and had >50% lethality (humans only had a 1-3% lethality). ards and mortality also occur with the more pathogenic strains, but nhps show reduced susceptibility to less virulent strains such as h3n2. 299 influenzainfected rhesus macaques represent a mild disease model pathogenesis for vaccine and therapeutic efficacy studies. 319 other nhp models include influenza infection of pigtailed macaques as a mild disease model and infection of new world primates such as squirrel and cebus monkeys. 320 rats (f344 and sd) inoculated with rat-adapted h3n2 developed inflammatory infiltrates and cytokines in bronchoalveolar lavage fluids, but had no lethality and few histopathological changes. 321 additionally, an influenza transmission model has been developed in guinea pigs as an alternative to ferrets. 322 cotton rats (sigmodon hispidus) have been used to test vaccines and therapeutics in a limited number of studies. 323, 324 cotton rats have an advantage over mice in that the immune system is similar to humans (including the presence of the mx gene) and influenza viruses do not have to be adapted. 325, 326 nasal and pulmonary tissues of cotton rats were infected with unregulated cytokines and lung viral load peaking at 24 h postexposure. virus was cleared from the lung by day 3 and from the nares by day 66, but animals had bronchial and alveolar damage, and pneumonia for up to 3 weeks. there is also a s. aureus superinfection model in cotton rats. 327 coinfection resulted in bacteremia, high bacterial load in lungs, peribronchiolitis, pneumonitis, alveolitis, hypothermia, and higher mortality. domestic pig influenza models have been developed for vaccine studies for swine flu. pigs are susceptible in nature as natural or intermediate hosts but are not readily susceptible to h5n1. 328, 329 although pigs infected with influenza may have fever, anorexia, and respiratory signs such as dyspnea and cough, mortality is rare. 330 size and space requirements make this animal difficult to work with, although the development of minipig (ellegaard gottingen) models may provide an easier-to-use alternative. incubation period, animals exhibit signs of fever, hepatitis, and abortion, which is a hallmark diagnostic sign known among farmers. 331 mosquito vectors, unpasteurized milk, aerosols of infected animal's body fluids, or direct contact with infected animals are the important routes of transmission to humans. 332,333 after 2-6 days of incubation period, rvfv causes a wide range of signs and symptoms in humans ranging from asymptomatic to severe disease with hepatitis, vision loss, encephalitis, and hemorrhagic fever. [334] [335] [336] depending on the severity of the disease when the symptoms start, 10-20% of the hospitalized patients might die in 3-6 days or 12-17 days after the disease onset. 334 hepatic failure, renal failure or disseminated intravascular coagulation (dic), and encephalitis are demonstrated within patients during postmortem examination. mice are one of the most susceptible animal species to rvfv infection. subcutaneous or intraperitoneal routes of infection cause acute hepatitis and lethal encephalitis at a late stage of the disease in mice. 337, 338 mice start to exhibit signs of decreased activity and ruffled fur by day 2-3 postexposure. immediately after these signs are observed, they become lethargic and generally die 3-6 days postexposure. ocular diseases or hemorrhagic form of the disease has not been observed in mice models so far. 334 increased viremia and tissue tropism were reported in mice with 338 increased liver enzymes and lymphopenia observed in sick mice. rats and gerbils are also susceptible to rvfv infection. rats' susceptibility is dependent on the rat strain used for the challenge model. there was also noted an age dependence in susceptibility of rats. although wistar-furth and brown norway strains and young rats are highly susceptible to rvfv infection, fisher 344, buffalo and lewis strains, and old rats demonstrated resistance to infection. 339, 340 similar pathologic changes such as liver damage and encephalopathy were observed in both rats and mice. there was no liver involvement in the gerbil model and animals died from severe encephalitis. the mortality rate was dependent on the strain used and the dose given to gerbils. 341 similar to the rat model, the susceptibility of gerbils was also dependent on age. so far, studies showed that rvfv does not cause uniform lethality in an nhp model. intraperitoneal, intranasal, iv, and aerosol routes have been used to develop the nhp model. rhesus macaques, cynomolgus macaques, african monkeys, and south american monkeys were some of the nhp species used for this effort. 342 monkeys showed a variety of signs ranging from febrile disease to hemorrhagic disease and mortality. temporal viremia, increased coagulation parameters (pt, aptt), and decreased platelets were some other signs observed in nhps. animals that succumbed to disease showed very similar pathogenesis to those seen in humans such as pathological changes in liver and hemorrhagic disease. there was no ocular involvement in this model. recently, smith et al. compared iv, intranasal, and subcutaneous routes of infection in common marmosets and rhesus macaques. 343 marmosets were more susceptible to rvfv infection than were rhesus macaques with marked viremia, acute hepatitis, and late onset of encephalitis. increased liver enzymes were observed in both species. necropsy results showed enlarged livers in the marmosets exposed by iv or subcutaneous routes. although there were no gross lesions in the brains of marmosets, histopathology showed encephalitis in the brains of intranasally challenged marmosets. crimean-congo hemorrhagic fever virus (cchfv) generally circulates in nature unnoticed in an enzootic tick-vertebrate-tick cycle and similar to other zoonotic agents, seems to produce little or no disease in its natural hosts, but causes severe disease in humans. cchfv transmits to humans by ixodid ticks, direct contact with sick animals/humans, or body fluids of animals/humans. 344 incubation, prehemorrhagic, hemorrhagic, and convalescence are the four phases of the disease seen in humans. the incubation period lasts 1-9 days. during the prehemorrhagic phase, patients show signs of nonspecific flu-like disease for approximately a week. the hemorrhagic period results in circulatory shock and dic in some patients. 345, 346 over the years, several attempts have been made to establish an animal model for cchf in adult mice, guinea pigs, hamsters, rats, rabbits, sheep, nhps, etc. [347] [348] [349] [350] until recently, the only animal that manifests disease is the newborn mouse. infant mice infected with cchfv intraperitoneally caused fatality around day 8 postinfection. 351 pathogenesis studies showed that virus replication was first detected in the liver, with subsequent spread to the blood (serum). virus was detected very late during the disease course in other tissues including the heart (day 6) and the brain (day 7). the recent studies using knockout adult mice were successful to develop a lethal small animal model for cchfv infection. 352, 353 bente et al. infected stat1 knockout mice by the intraperitoneal route. in this model, after the signs of fever, leucopenia, thrombocytopenia, viremia, elevated liver enzymes, and proinflammatory cytokines, mice were moribund and succumbed to disease in 3-5 days of postexposure. the second model was developed by using ifn-alpha/beta (ifna/b) receptor knockout mice. 353 similar observations were made in this model as in the stat1 knockout mouse model. the animals were moribund and died 2-4 days after exposure with high viremia levels in the liver and spleen. other laboratory animals, including nhps, show little or no signs of infection or disease when infected with cchfv. 348 butenko et al. used agms (cercopithecus aethiops) for experimental cchfv infections. except one monkey with a fever on day 4 postinfection, the animals did not exhibit signs of disease. antibodies to the virus were detected in three out of five monkeys, including the one with fever. in 1975, fagbami et al. infected two patas monkeys (cercopithecus erythrocebuserythrocebus) and one guinea baboon (papio papio) with cchfv. 347 although all three animals had low level viremia between days 1 and 5 after inoculation, only the baboon serum had neutralizing antibody activity on day 137 postinfection. similar results were obtained when horses and donkeys have been used for experimental cchfv infections. donkeys develop a low-level viremia, 354 and horses developed little or no viremia, but high levels of virus-neutralizing antibodies, which remained stable for at least 3 months. these studies suggest that horses may be useful in the laboratory to obtain serum for diagnostic and possible therapeutic purposes. 355 shepherd et al. infected 11 species of small african wild mammals and laboratory rabbits, guinea pigs, and syrian hamsters with cchfv. 349 although scrub hares (lepus saxatilis), cape ground squirrels (xerus inauris), red veld rats (aethomys chrysophilus), white-tailed rats (mystromys pumilio), and guinea pigs had viremia; south african hedgehogs (atelerix frontalis), highveld gerbils (tatera brantsii), namaqua gerbils (desmodillus auricularis), two species of multimammate mouse (mastomys natalensis and m. coucha), and syrian hamsters were negative. all species regardless of viremia levels developed antibody responses against cchfv. iv and intracranially infected animals showed the onset of viremia earlier than those infected by the subcutaneous or intraperitoneal routes. the genus hantavirus is unique among the family bunyaviridae in that it is not transmitted by an arthropod vector, but rather by rodents. 356 rodents of the family muridae are the primary reservoir for hantaviruses. infected host animals develop a persistent infection that is typically asymptomatic. transmission is achieved by the inhalation of infected rodent saliva, feces, and urine. 357 human infections can normally be traced to a rural setting with activities such as farming, land development, hunting, and camping as possible sites of transmission. rodent control is the primary route of prevention. 358 the viruses have a tropism for endothelial cells within the microvasculature of the lungs. 359 there are two distinct clinical diseases that infection can yield; hemorrhagic fever with renal syndrome (hfrs) due to infection with old world hantaviruses or hantavirus pulmonary syndrome (hps) caused by new world hantaviruses. 360 hfrs is mainly seen outside of the americas and is associated with the hantaviruses dobrava-belgrade (also known as dobrava), hantaan, puumala, and seoul. 358 incubation lasts two to three weeks and presents as flulike in the initial stages that can further develop into hemorrhagic manifestations and ultimately renal failure. thrombocytopenia subsequently develops, which can further progress to shock in approximately 15% patients. the overall mortality rate is 7%. infection with dobrava and hantaan viruses are typically linked to the development of severe disease. hps was first diagnosed in 1993 within the southwestern united states when healthy young adults became suddenly ill, progressing to severe respiratory distress and shock. the etiological agent responsible for this outbreak was identified as sin nombre virus. 361 this virus is still the leading cause within na of hps. hps due to other hantaviruses has been reported in argentina, bolivia, brazil, canada, chile, french guiana, panama, paraguay, and uruguay. 362, 363 the first report of hps in maine was recently documented. 361 andes virus was first identified in outbreaks in chile and argentina. this hantavirus is distinct in that it can be transmitted between humans. 364 the fulminant disease is more lethal than that observed for hfrs with a mortality rate of 40%. there are four phases of disease including prodromal, pulmonary, cardiac depression, and hematologic manifestation. 365 incubation typically occurs 14-17 days after exposure. 366 unlike hfrs, renal failure is not a major contributing factor to the disease. there is a short prodromal phase that gives way to cardiopulmonary involvement accompanied by cough and gastrointestinal symptoms. it is at this point that individuals are typically admitted to the hospital. pulmonary function is hindered and continues to suffer within 48 h after cardiopulmonary involvement. interstitial edema and air-space disease normally follow. in fatal cases, cardiogenic shock has been noted. 367 vaccine development has been hampered by the vast diversity of hantaviruses and the limited number of outbreaks. 368 syrian golden hamsters are the most widely used small animal models for hantavirus infection. hamsters inoculated intramuscularly with a passaged andes viral strain died within 11 days postinfection. clinical signs did not appear until 24 h before death at which point the hamsters were moribund and in respiratory distress. mortality was dose dependent, with high inoculums leading to a shorter incubation before death. during the same study, hamsters were inoculated with a passaged sin nombre isolate. no hamsters developed any symptoms during the course of observation. although an antibody response to the virus that was not dose dependent was determined via an enzymelinked immunosorbent assay. hamsters infected with andes virus were found to have significant histopathological changes to their lung, liver, and spleen. all had an interstitial pneumonia with intraalveolar edema. infectious virus could be recovered from these organs. viremia began on day 8 and lasted up to 12 days postinfection. infection of hamsters with andes virus yielded a similar clinical disease progression as is seen in human hps including rapid progression to death, fluid in the pleural cavity, and significant histopathological changes to the lungs and spleen. a major deviation in the hamster model is the detection of infectious virus within the liver. 369 lethal disease can be induced in newborn mice but does not recapitulate the clinical symptoms observed in human disease. 370 adult mice exposed to hantaan virus leads to a fatal disease dependent upon viral strain and route of infection. the disease progression is marked by neurological or pulmonary manifestations that do not mirror human disease. 371, 372 knockout mice lacing ifn-a/b were found to be highly susceptible to hantaan virus infection. 373 in a study looking at a panel of laboratory strains of mice, c57bl/6 mice were found to be most susceptible to a passaged hantaan viral strain injected intraperitoneally. animals progressed to neurological manifestation including paralyses and convulsions and succumbed to infection within 24-36 h postinfection. clinical disease was markedly different than that observed in human cases. 372 nhps have been challenged with new world hantaviruses; however, no clinical signs were reported. 374, 375 cynomolgus monkeys challenged with a clinical isolate of puumala virus developed a mild disease. 376, 377 challenge with andes virus to cynomolgus macaques by both iv and aerosol exposure led to no signs of disease. all animals did display a drop in total lymphocytes within 5 days postinfection. aerosol exposure led to 4 of 6 monkeys and 8 of 11 iv injected monkeys developed viremia. infectious virus could not be isolated from any of the animals. the family arenaviridae is composed of two serogroups: old world arenaviruses including lassa fever virus and lymphocytic choriomeningitis virus and the new world viruses of pichinde virus and junin virus. all these viruses share common clinical manifestations. 378 lassa fever virus is endemic in parts of west africa and outbreaks are typically seen in the dry season between january and april. 379 this virus is responsible for 100,000-500,000 infections per year, leading to approximately 5,000 deaths. 380 outbreaks have been reported in guinea, sierra leone, liberia, nigeria, and central african republic. however, cases sprung up in germany, the netherlands, the united kingdom, and the united states due to transmission to travelers on commercial airlines. 381 transmission of this virus typically occurs via rodents, in particular the multimammate rat, mastomys species complex. 379 humans become infected by inhaling the aerosolized virus or eating contaminated food. there has also been noted human-to-human transmission by direct contact with infected secretions or needle-stick injuries. the majority of infections are asymptomatic; however, severe disease can occur in 20% of individuals. the incubation period is from 5 to 21 days, and the initial onset is characterized by flulike illness. this is followed by diarrheal disease that can progress to hemorrhagic symptoms including encephalopathy, encephalitis, and meningitis. a third of patients develop deafness in the early phase of disease, which is permanent for a third of those affected. the overall fatality is about 1%; however, of those admitted to the hospital, it is between 15% and 25%. there is no approved vaccine, and besides supportive measures, ribavirin is effective only if started within 7 days. 382, 383 the primary animal model used to study lassa fever is the rhesus macaque. 384 aerosolized infection of lymphocytic choriomeningitis virus has been a useful model for lassa fever. both rhesus and cynomolgus monkeys exposed to the virus developed disease, but rhesus more closely mirrored the disease course and histopathology observed in human infection. 385 iv or intragastric inoculation of the virus led to severe dehydration, erythematous skin, submucosal edema, necrotic foci in the buccal cavity, and respiratory distress. the liver was severely affected by the virus as depicted by measuring the liver enzymes ast and alt. 386 disease was dose-dependent with iv, intramuscular, and subcutaneous inoculation requiring the least amount of virus to induce disease. aerosol infections and eating contaminated food could also be used, and mimic a more natural route of infection. 387 within this model, the nhp becomes viremic after 4-6 days. clinical manifestations were present by day 7, and death typically occurred within 10-14 days. 388, 389 intramuscular injection of lassa virus into cynomolgus monkeys also produced a neurological disease due to lesions within the cns. 390 this pathogenicity is seen in select cases of human lassa fever. 391, 392 a marmoset model has recently been defined using a subcutaneous injection of lassa fever virus. virus was initially detected by day 8 and viremia achieved by day 14. liver enzymes were elevated, and an enlarged liver was noted upon autopsy. there was a gradual reduction in platelets and interstitial pneumonitis diagnosed in a minority of animals. the physiological signs were the same as seen in fatal human cases. 393 mice develop a fatal neurological disorder upon intracerebral inoculation with lassa, although the outcome of infection is completely dependent upon the major histocompatibility complex (mhc) background and age of animal along with the route of inoculation. 394 guinea pig inbred strain 13 was found to be highly susceptible to lassa virus infection. the outbreed hartley strain was less susceptible, and thus, strain 13 has been the preferred model given its assured lethality. the clinical manifestations mirror those seen in humans and rhesus. 395 infection with pichinde virus that has been passaged in guinea pigs has also been used. disease signs include fever, weight loss, vascular collapse, and eventual death. 396, 397 the guinea pig is an excellent model given that it not only results in similar disease pattern as humans but also the viral distribution is similar along with the histopathology and immune response. 398, 399 infection of hamsters with a cotton rat isolate of pirital virus is similar to what is characterized in humans, and the nhp and guinea pig model. the virus was injected intraperitoneally resulting in the animals becoming lethargic and anorexic within 6-7 days. virus was first detected at 3 days and reached maximum titers within 5 days. neurological symptoms began to appear at the same time, and all the animals died by day 9. pneumonitis, pulmonary hemorrhage, and edema were also present. 400 these results were recapitulated with a nonadapted pichinde virus. [401] [402] [403] globally, diarrheal disease is the leading cause of death with rotavirus being one of the main etiological agents responsible. according to the world health organization, rotavirus alone is responsible for a third of all hospitalization related to diarrhea and 500,000-600,000 deaths per year. 404 the virus is very stable due to its three-layer capsid, which allows it to be transmitted via the oral-fecal route, depositing itself in the small intestine. rotavirus is highly contagious, and only 10 viruses are needed to cause symptomatic disease. 405 the host determinant with the greatest influence on clinical outcome is age. neonates typically are asymptomatic, which is suggested to be due to the existence of maternal antibodies. hence, the most susceptible age group is 3 months to 2 years, coinciding with a drop in these protective antibodies. 406 within this age range, children will develop noninflammatory diarrhea. virus replicates in the intestinal villus enterocytes resulting in their destruction and malabsorption of needed electrolytes and nutrients. symptoms of disease include watery, nonbloody diarrhea with vomiting, fever, and potentially dehydration that lasts up to a week. 407 there is a short episode of viremia during the course of infection. 408 mice can be used as both an infection and disease model depending upon age at challenge. mice <14 days old develop disease, whereas older mice are able to clear the infection before the onset of symptoms. 409 this halts the study of active vaccination against disease in the infection model. in the adult mouse model, the course of the infection is monitored via viral shedding within the stool. 410 infant mice, specifically balb/c, receiving an oral inoculation of a clinical strain of virus developed diarrhea within 24 h postinfection, and 95% of those exposed developed symptoms within 72 h postinfection. symptoms lasted from 2 to 4 days with no mortality. viral shedding was at its peak at 24 h and lasted up to 5 days. there were noted histopathological changes within the small intestine localized to the villi that was reversible. 407 within the adult mouse model, oral inoculation of a mouse rotavirus strain showed viral shedding by 3 days lasting up until 6 days postinfection. 410 these mouse models have been used to study correlates of protection and therapeutic efficacy including gastro-gard ã� . 409, 411, 412 rats can also be used as disease models depending upon the strain of rat. 413, 414 suckling fischer 344 rats were exposed to a simian strain of rotavirus orally. the rats were susceptible to diarrheal disease till they were 8 days old with age determining the length of viral shedding. 415 rats have mainly been used to study the correct formulation for oral rehydration. these rodents are large enough to perform in situ intestinal perfusions. within these studies, 8-day-old rats were infected with a rat strain of rotavirus by orogastric intubation. within 24 h postinfection, the rats developed diarrhea, at which point the small intestine was perfused to compare differing solutions of oral rehydration. 416 gnotobiotic pigs are also used given that they can be infected with both porcine and human strains. 417 they are susceptible to developing clinical disease from human strains up to 6 weeks of age. they allow for the analysis of the primary immune response to the virus given that they do not receive transplacental maternal antibodies and are immune competent at birth. 418 another advantage of this model is that the gastrointestinal physiology and mucosal immune system closely resemble that of humans. 419 this model has been useful in studying correlates of protection. gnotobiotic and colostrum-deprived calves have also been used as an experimental model of rotavirus infection. they are able to develop diarrhea and shed live virus. 420 gnotobiotic lambs can also develop clinical disease upon oral inoculation with clinical strains. 421 infant baboons, agms, and rhesus macaques have all proven to be infection models with severity measure by viral shedding. 422, 423 retroviridae human immunodeficiency virus type 1 the lentiviruses are a subfamily of retroviridae, which includes human immunodeficiency virus (hiv), a virus that infects 0.6% of the world's population. a greater proportion of infections and deaths occur in sub-saharan africa. worldwide, there are approximately 1.8 million deaths per year with >260,000 being children. transmission of hiv occurs by exposure to infectious body fluids. there are two species, hiv-1 and hiv-2, with hiv-2 having lower infectivity and virulence (confined mostly to west africa). the vast majority of cases worldwide are hiv-1. 424 hiv targets t-helper cells (cd4ã¾), macrophages, and dendritic cells. 425 acute infection occurs 2-4 weeks after exposure, with flu-like symptoms and viremia followed by chronic infection. symptoms in the acute phase may include fever, body aches, nausea, vomiting, headache, lymphadenopathy, pharyngitis, rash, and sores in the mouth or esophagus. cd8ã¾ t-cells are activated which kill hiv-infected cells, and are responsible for antibody production and seroconversion. acquired immune deficiency syndrome (aids) develops when cd4ã¾ t-cells decline to <200 cells per microliter; thus, cell-mediated immunity becomes impaired, and the person is more susceptible to opportunistic infections and certain cancers. humanized mice, created by engrafting human cells and tissues into scid mice, have been critical for the development of mouse models for the study of hiv infection. a number of different humanized mouse models allow for the study of hiv infection in the context of intact and functional human innate and adaptive immune responses. 426 the scidhu hiv infection model has proven to be useful, particularly in screening antivirals and therapeutics. 427 a number of different humanized mouse models have been developed for the study of hiv, including rag1ã�/ã�gcã�/ã�, rag2ã�/ ã�gcã�/ã�, nod/scidgcã�/ã� (hnog), nod/ scidgcã�/ã� (hnsg), nod/scid blt, and nod/ scidgcã�/ã� (hnsg) blt. cd34ã¾ human stem cells derived from the umbilical cord blood or fetal liver are used for humanization. 428 hiv-1 infection by intraperitoneal injection can be successful with as little as 5% peripheral blood engraftment. 429 vaginal and rectal transmission models have been developed in blt scidhu mice in which mice harbor human bone marrow, liver, and thymus tissue. hiv-1 viremia occurs within approximately 7 days pi. 430 in many of these models, spleen, lymph nodes, and thymus tissues are highly positive for virus, similar to humans. 431 importantly, depletion of human t-cells can be observed in blood and lymphoid tissues of hiv-infected humanized mice, and at least some mechanisms of pathogenesis that occur in hiv-infected humans also occur in the hiv-infected humanized mouse models. 432 the advantage of these models is that these mice are susceptible to hiv infection, and thus, the impact of drugs on the intended viral targets can be tested. one caveat is that although mice have a "common mucosal immune system," humans do not, due to the differences in the distribution of addressins. 433 thus, murine mucosal immune responses to hiv do not reflect those of humans. there are a number of important nhp models for human hiv infection. simian immunodeficiency virus (siv) infection of macaques is widely considered to be the best platform for modeling hiv infection of humans. importantly, nhps have similar, pharmacokinetics, metabolism, mucosal t-cell homing receptors, and vascular addressins to those of humans. thus, although the correlates of protection against hiv are still not completely known, immune responses to hiv infection and vaccination are likely comparable. these models mimic infection through the use of contaminated needles (iv), sexual transmission (vaginal or rectal), and maternal transmission in utero, or through breast milk. [434] [435] [436] there are also macaque models to study the emergence and clinical implications of hiv drug resistance. 437 these models most routinely use rhesus macaques (macaca mulatta), cynomolgus macaques (macaca fasicularis), and pigtailed macaque (macaca nemestrina). animals of all ages are used, depending on the needs of the study. for instance, the use of newborn macaques may be more practical for evaluating the effect of prolonged drug therapy on disease progression; however, adult nhps are more frequently used. studies are performed in bsl-2 animal laboratories, and nhps must be of simian type-d retrovirus free and siv seronegative. siv infection of pigtailed macaques is a useful model for hiv peripheral nervous system pathology, wherein an axotomy is performed and regeneration of axons is studied. 438 challenges may be through a single high dose. iv infection of rhesus macaques with 100 tcid 50 of the highly pathogenic siv/deltab670 induces aids in most macaques within 5-17 months (mean of 11 months). 439 peak viremia occurs around week 4. aids in such models is often defined as cd4ã¾ t-cells that have dropped to <50% of the baseline values. alternatively, repeated low-dose challenges are often used, depending on the requirements of the model. 440, 441 because nhps infected with hiv do not develop an infection with a clinical disease course similar to that in humans, siv or siv/hiv-1 laboratory-engineered chimeric viruses (simian-human immunodeficiency virus or shiv) are used as surrogates. nhps infected with pathogenic siv may develop clinical disease, which progresses to aids and are thus useful pathogenesis models. a disadvantage is that siv is not identical to hiv-1 and is more closely related to hiv-2. however, the polymerase region of siv is 60% homologous to that of hiv-1, and it is susceptible to many reverse transcriptase (rt) and protease inhibitors. siv is generally not susceptible to nonnucleoside inhibitors; thus, hiv-1 rt is usually put into siv for such studies. 442 sivmac239 is similar to hiv in the polymerase region and is therefore susceptible to nucleoside, rt or integrase inhibition. 443 nhps infected with sivmac239 have an asymptomatic period and disease progression resembling aids in humans, characterized by weight loss/wasting, cd4ã¾ t-cell depletion. additionally, sivmac239 uses the cxcr5 chemokine receptor as a coreceptor, similar to hiv, which is important for drugs that target entry. 444 nhps infected with shiv strains may not develop aids, but these models are useful in testing vaccine efficacy. for example, rt-shivs and env-shivs are useful for the testing and evaluation of drugs that may target the envelope or rt, respectively. 442 one disadvantage of the highly virulent env-shiv (shiv-89.6 p) is that it uses the cxcr4 coreceptor. of note, env-shivs that do use the cxcr5 coreceptor are less virulent; viremia develops and then resolves without further disease progression. 445 simian-tropic (st) hiv-1 contains the vif gene from siv. infection of pigtailed macaques with this virus results in viremia, which can be detected for three months, followed by clearance. 446 a number of routes are used for siv or shiv infection of nhps, with iv inoculation being the most common route. mucosal routes include vaginal, rectal, and intracolonic. mucosal routes require a higher one-time dose than does the iv route for infection. for the vaginal route, female macaques are treated with depo-provera (estrogen) one month before infection to synchronize the menstrual cycle, thin the epithelial lining of the vagina, and increase the susceptibility to infection by atraumatic vaginal instillation. 447 upon vaginal instillation of 500 tcid50 of shiv-162p3, peak viremia was seen around 12 days postexposure with >10 7 copies per milliliter and dropping thereafter to a constant level of 10 4 rna copies per milliliter at 60 days and beyond. in another example, in an investigation of the effect of vaccine plus vaginal microbicide on preventing infection, rhesus macaques were vaginally infected with a high dose of sivmac251. 448 an example of an intrarectal model used juvenile (2year-old) pigtailed macaques, challenged intrarectally with 10 4 tcid 50s of siv mne027 to study the pathogenesis related to the virulence factor, vpx. 449 here, viremia peaked at approximately 10 days with >10 8 copies per milliliter. viral rna was expressed in the cells of the mesenteric lymph nodes. the male genital tract is seen as a viral sanctuary with persistently high levels of hiv shedding even with antiretroviral therapy. to better understand the effect of highly active antiretroviral therapy on virus and t-cells in the male genital tract, adult (3-to 4-year old) male cynomolgus macaques were intravenously inoculated with 50 aid50s of sivmac251, and the male genital tract tissues were tested after euthanasia by pcr, ihc, and in situ hybridization. 450 pediatric models have been developed in infant rhesus macaques through the infection of siv, allowing for the study of the impact of developmental and immunological differences on the disease course. 451 importantly, mother-to-infant transmission models have also been developed. 452 pregnant female pigtailed macaques were infected during the second trimester with 100 mid 50 shiv-sf162p3 by the iv route. four of nine infants were infected; one in utero and three either intrapartum or immediately postpartum through nursing. this model is useful for the study of factors involved in transmission and the underlying immunology. nhps infected with siv or shiv are routinely evaluated for weight loss, activity level, stool consistency, appetite, virus levels in blood, and t-cell populations. cytokine and chemokine levels, antibody responses, and cytotoxic t-lymphocyte responses may also be evaluated. the ultimate goal of an hiv vaccine is sterilizing immunity (preventing infection). however, a more realistic result may be to reduce severity of infection and permanently prevent progression. strategies have included live attenuated, nonreplicating and subunit vaccines. these have variable efficacy in nhps due to the genetics of the host (mhc and terminal-repeat retrotransposon in miniature (trim) alleles), differences between challenge strains, and challenge routes. 453 nhp models have led to the development of antiviral treatments that are effective at reducing viral load and indeed transmission of hiv among humans. one preferred variation on the models for testing the longterm clinical consequences of antiviral treatment is to use newborn macaques and treat from birth onward, in some cases more than a decade. 454 unfortunately, however, successes in nhp studies do not always translate to success in humans, as seen with the recent step study that used an adenovirus-based vaccine approach. 455 vaccinated humans were not protected and may have even been more susceptible to hiv, viremia was not reduced, and the infections were not attenuated as hoped. with regard to challenge route, iv is more difficult to protect than mucosal and is used as a "worst-case scenario." however, efficacy at one mucosal route is usually comparable to that at other mucosal routes. human and animal papillomaviruses cause benign epithelial proliferations (warts) and malignant tumors of the various tissues that they infect. 456 there are >100 human papillomaviruses (hpvs), with different strains causing warts on the skin, oropharynx, nasopharynx, larynx, and anogenital tissues. approximately a third of these are transmitted sexually. of these, virulent subtypes such as hpv-16, hpv-18, hpv-31, hpv-33, and hpv-45 place individuals at high risk for cervical and other cancers. major challenges in the study of these viruses are that papillomaviruses generally do not infect any other species outside of the natural hosts and can cause a very large spectrum of severity. thus, no animal models have been identified that are susceptible to hpv. however, a number of useful surrogate models exist that use animal papillomaviruses in their natural host, or a very closely related species. 457, 458 these models have facilitated the recent development of useful and highly effective prophylactic hpv vaccines. 459 wild cottontail rabbits (sylvilagus floridanus) are the natural host for cottontail rabbit papillomavirus (crpv), but this virus also infects domestic rabbits (oryctolagus cuniculus), which are a very closely related species. 460 in this model, papillomas can range from cutaneous squamous cell carcinomas on the one end of the spectrum, and spontaneous regression on the other. lesions resulting from crpv in domestic rabbits do not typically contain infectious virus. canine oral papillomavirus (copv) cause florid warty lesions in the mucosa of the oral cavity within 4-8 weeks postexposure in experimental settings. 461 the mucosatrophic nature of these viruses and the resulting oropharyngeal papillomas that are morphologically similar to human vaginal papillomas caused by hpv-6 and hpv-11 make this a useful model. 462 these lesions typically spontaneously regress 4-8 weeks after appearing; this model is therefore useful in understanding the interplay between the host immune defense and viral pathogenesis. male and female beagles, aged 10 weeks to 2 years, with no history of copv, are typically used for these studies. infection is achieved by the application of a 10 ml droplet of virus extract to multiple 0.5 cm 2 scarified areas within the mucosa of the upper lip of anesthetized beagles. 463 bovine papillomavirus (bpv) has a wider host range than do most papillomaviruses, infecting the fibroblasts cells of numerous ungulates. 458 bpv-4 infection of cattle feeding on bracken fern, which is carcinogenic, can result in lesions of the oral and esophageal mucosa that lack detectable viral dna. bpv infections in cattle can result in a range of diseases such as skin warts, cancer of the upper gastrointestinal tract and urinary bladder, and papillomatosis of the penis, teats, and udder. finally, sexually transmitted papillomaviruses in rhesus macaques and cynomolgus macaques, rhesus papillomavirus, is very similar to hpv-16 and is associated with the development of cervical cancer. 464 mice cannot be used to study disease caused by papillomaviruses unless they are engrafted with relevant tissue, but they are often used to look at immunogenicity of vaccines. 465, 466 herpesviridae please see chapter 25. monkeypox virus (mpxv) causes disease in both animals and humans. human monkeypox, which is clinically almost identical to ordinary smallpox, occurs mostly in the rainforest of central and western africa. the virus is maintained in nature in rodent reservoirs including squirrels. 467, 468 mpxv was discovered during the pox-like disease outbreak among laboratory java macaques in denmark in 1958. no human cases were observed during this outbreak. the first human case was not recognized as a distinct disease until 1970 in zaire (the present drc) with the continued occurrence of a smallpox-like illness despite eradication efforts of smallpox in this area. during the global eradication campaign, extensive vaccination in central africa decreased the incidence of human monkeypox, but the absence of immunity in the generation born since that time and increased dependence on bush meat have resulted in renewed emergence of the disease. in the summer of 2003, a well-known outbreak in the midwest was the first occurrence of monkeypox disease in the united states and the western hemisphere. among 72 reported cases, 37 human cases were laboratory confirmed during an outbreak. 469, 470 it was determined that native prairie dogs (cynomys sp.) housed with rodents imported from ghana in west africa were the primary source of outbreak. the virus is mainly transmitted to humans while handling infected animals or by direct contact with the infected animal's body fluids, or lesions. person-toperson spread occurs by large respiratory droplets or direct contact. 471 most of the clinical features of human monkeypox are very similar to those of ordinary smallpox. 472 after a 7-to 21-day incubation period, the disease begins with fever, malaise, headache, sore throat, and cough. the main sign of the disease that distinguishes monkeypox from smallpox is swollen lymph nodes (lymphadenitis), which is observed in most of the patients before the development of rash. 471, 473 typical maculopapular rash follows the prodromal period generally lasting 1-3 days. the average size of the skin lesions is 0.5-1 cm, and the progress of lesions follows the order macules through papules, vesicles, pustules, umblication then scab and desquamation and lasts typically 2-4 weeks. fatality rate is 10% among the unvaccinated population and death generally occurs during the second week of the disease. 469, 471 mpxv is highly pathogenic for a variety of laboratory animals, and so far, many animal models have been developed by using different species and different routes of exposure (table 38. 3). because of the unavailability of variola virus to develop animal models and resulting disease manifestations in humans that are similar, mpxv is one of the pox viruses that are used very heavily to develop a number of small animal models via different routes of exposure. wild-derived inbred mouse, stat1-deficient c57bl/6 mouse, prairie dogs, african dormice, ground squirrels are highly susceptible to mpxv by different exposure routes. [474] [475] [476] [477] [478] [479] [480] [481] cast/eij mice, one of the 38 inbred mouse strains tested for susceptibility to mpxv, showed weight loss and dose-dependent mortality after intranasal exposure to mpxv. studies with the intraperitoneal route of challenge indicated a higher susceptibility to mpxv with an almost 50-fold less ld50 when compared to the intranasal route. 474 scid-balb/c mice were also susceptible to the intraperitoneal challenge route, and the disease resulted in mortality day 9 postinfection. 476 similarly c57bl/6 stat1 ã�/ã� mice were infected intranasally with mpxv, and the infection resulted in weight loss and mortality 10 days postexposure. mice models mentioned here are very promising for screening of therapeutics against pox viruses, but testing in additional models will be required for advanced development. high doses of mpxv by intraperitoneal or intranasal route caused 100% mortality in 6 days postexposure and 8 days postexposure, respectively, in ground squirrels. 480 the disease progressed very quickly, and most of the animals were lethargic and moribund by day 5 postexposure without any pox lesions or respiratory changes. a comparison study of usa mpxv and central african strain of mpxv in ground squirrels by subcutaneous route resulted in systemic disease and the mortality in 6-11 days postexposure. the disease resembles hemorrhagic smallpox with nose bleeds, impaired coagulation parameters, and hemorrhage in the lungs of the animals. because in the us outbreak the virus was transmitted by infected prairie dogs, this animal model has recently been studied much further and used to test therapeutics and vaccines compared to other small animal models. 475, 481, 491, 492 studies using intranasal, intraperitoneal, and intradermal routes of exposure showed that mpxv was highly infectious to prairie dogs. by using the west african mpxv strain, the intraperitoneal route caused a more severe disease and 100% mortality than challenge by the intranasal route. anorexia and lethargy were common signs of the disease for both exposure routes. in contrast to the intraperitoneal route, the intranasal route of exposure caused severe pulmonary edema and necrosis of lungs in prairie dogs, while splenic necrosis and hepatic lesions were observed in intraperitoneally infected animals. 481 recent studies by hutson et al. used intranasal and intradermal infections with west african and congo basin strains and showed that both strains and routes caused smallpox-like disease with longer incubation periods and generalized pox lesions. 475 therefore, this model can be used for testing therapeutics and vaccines against pox viruses. the african dormouse is susceptible to mpxv by the foodpad injection route or intranasal route. 478 mice exhibited decreased activity, hunched posture, dehydration, conjunctivitis, and weight loss. viral doses of 200 and 2000 pfu provided 100% mortality with a mean time to death of 8 days. upper gastrointestinal hemorrhage, hepatomegaly, lymphadenopathy, and hemorrhage in lungs were observed during necropsy. with the hemorrhage in several organs, this model resembles hemorrhagic smallpox. considering the limited availability of ground squirrels and african dormice, lack of reagents to these species, and resemblance to hemorrhagic smallpox disease, these models are not very attractive for further characterization and vaccine and countermeasure testing studies. nhps were exposed to mpxv by several different routes to develop animal models for mpxv. 482, 483, 485, 489, 490 during our studies by using an aerosol route of exposure, we observed that macaques had mild anorexia, depression, fever, and lymphadenopathy on day 6 postexposure. 482 complete blood count and clinical chemistries showed abnormalities similar to those of human monkeypox cases with leukocytosis and thrombocytopenia. 493 whole-blood and throat swabs had viral loads peak around day 10, and in survivors, gradually decrease until day 28 postexposure. because doses of 4 ã� 10 4 , 1 ã� 10 5 , or 1 ã� 10 6 pfu resulted in lethality for 70% of the animals, whereas a dose of 4 ã� 10 5 pfu resulted in 85% lethality, survival was not dose dependent. the main pitfall of this model was the lack of pox lesions. with the high dose, before animals can develop pox lesions, they succumbed to disease. with the low challenge dose, pox lesions were observed, but they were few in comparison to the iv model. mpxv causes dose-dependent disease in nhps when given by the iv route. 490 studies showed that with 1ã� 10 7 pfu iv, challenge results in systemic disease with fever, lymphadenopathy, macula-papular rash, and mortality. an intratracheal infection model deposits virus into the trachea, delivering directly to the airways without regard to particle size and the physiological deposition that occurs during the process of inhalation by skipping the upper respiratory system. fibrinonecrotic bronchopneumonia was described in animals that received 10 7 pfu of mpxv intratracheally. 489 although a similar challenge dose of intratracheal mpxv infection resulted in a similar viremia in nhps than with the aerosol route of infection, the timing of the first peak was delayed by 5 days in intratracheally exposed macaques compared to aerosol infection, and the amount of virus detected by qpcr was approximately 100-fold lower. this suggests that local replication is more prominent after aerosol delivery compared to that after intratracheal delivery. an intrabronchial route of exposure resulted in pneumonia in nhps. 490 delayed onset of clinical signs and viremia were observed during the disease progression. in this model, similar to aerosol and the intratracheal route of infection models, the number of pox lesions was much less than in the iv route of the infection model. a major downside of the iv, intratracheal and intrabronchial models is that the initial infection of respiratory tissue, incubation, and prodromal phases are circumvented with the direct inoculation of virus into the blood stream or into the lung. this is an important limitation when the utility of these models is to test possible vaccines and treatments in which the efficacy may depend on protecting the respiratory mucosa and targeting subsequent early stages of the infection, which are not represented in these challenge models. although the aerosol model is the natural route of transmission for human variola virus (varv) infections and a secondary route for human mpxv infections, the lack of pox lesions is the main drawback of this model. therefore, when this model is decided to be used to test medical countermeasures, the endpoints and the biomarkers to initiate treatment should be chosen carefully. hepatitis b is one of the most common infections worldwide with >400 million people chronically infected and 316,000 cases per year of liver cancer due to infection. 494 the virus can naturally infect both humans and chimpanzees. 495 hepatitis b is transmitted parenterally or postnatally from infected mothers. it can also be transmitted by sexual contact, iv drug use, blood transfusion, and acupuncture. 496 the age at which one is infected dictates the risk of developing chronic disease. 497 acute infection during adulthood is self-limiting and results in flu-like symptoms that can progress to hepatocellular involvement as observed with the development of jaundice. the clinical symptoms last for a few weeks before resolving. 498 after this acute phase, life time immunity is achieved. 499 of those infected, <5% will develop the chronic form of disease. chronicity is the most serious outcome of disease as it can result in cirrhosis or liver cancer. hepatocellular carcinoma is 100 times more likely to develop in a chronically infected individual than in a noncarrier. 500 the viral determinant for cellular transformation has yet to be determined, although studies involving the woodchuck hepadna virus suggest that x protein may be responsible. 501 many individuals are asymptomatic until complications emerge related to chronic carriage. chimpanzees have a unique strain that circulates within the population. 502, 503 it was found that 3-6% of all wild-caught animals from africa are positive for hepatitis b antigen. 504 natural and experimental challenge with the virus follows the same course as human disease; however, this is only an acute model of disease. 505 to date, the use of chimpanzees provides the only reliable method to ensure that plasma vaccines are free from infectious particles. 506 this animal model has been used to study new therapeutics and vaccines. chimpanzees are especially attuned to these studies given that their immune response to infection directly mirrors humans. 507 other nhps that have been evaluated are gibbons, orangutans, and rhesus monkeys. although these animals can be infected with hepatitis b, none develop hepatic lesions or liver damage as noted by monitoring of liver enzymes. 508 mice are not permissible to infection, and thus, numerous transgenic and humanized lines that express hepatitis b proteins have been created to facilitate their usage as an animal model. these include both immunocompetent and immunosuppressed hosts. the caveat to all of these mouse lines is that they reproduce only the acute form of disease. 495 recently, the entire genome of hepatitis b was transferred to an immunocompetent mouse line via adenovirus. this provides a model for persistent infection. 509 hepatitis b can also be studied using surrogate viruses, naturally occurring mammalian hepadna viruses. 510 the woodchuck hepatitis virus was found to induce hepatocellular carcinoma. 511 within a population, 65-75% of all neonatal woodchucks are susceptible to chronic infection. 512 a major difference between the two hepatitis isolates is the rate at which they induce cancer; almost all chronic carriers developed hepatocellular carcinoma within 3 years of the initial infection in woodchucks, whereas human infection takes much longer. 513 the acute infection strongly resembles what occurs during the course of disease in humans. there is a self-limiting acute phase resulting in a transient viremia that has the potential of chronic carriage. 514 challenge with virus in neonates leads to a chronic infection, while adults only develop the acute phase of disease. 515 a closely related species to the woodchuck is the marmota himalayan. this animal is also susceptible to the woodchuck hepadna virus upon iv injection. it was found to develop an acute hepatitis with a productive infection. 516 hepatitis d is dependent upon hepatitis b to undergo replication and successful infection in its human host. 517 there are two modes of infection possible between the viruses: coinfection in which a person is simultaneously infected or superinfection in which a chronic carrier of hepatitis b is subsequently infected with hepatitis d. 518 coinfection leads to a similar disease as seen with hepatitis b alone; however, superinfection can result in chronic hepatitis d infection and severe liver damage. 519 both coinfection and superinfection can be demonstrated within the chimpanzee and woodchuck by inoculation of human hepatitis d. 520 a recently published report demonstrated the use of a humanized chimeric mouse to study the interactions between the two viruses and drug testing. 521 the ideal animal model for human viral disease should closely recapitulate the spectrum of clinical symptoms and pathogenesis observed during the course of human infection. whenever feasible, the model should use the same virus and strain that infects humans. it is also preferable that the virus be a low passage clinical isolate; thus, animal passage or adaptation should be avoided if model species can be identified that are susceptible. ideally, the experimental route of infection would mirror that which occurs in natural disease. to understand the interplay and contribution of the immune system during infection, an immunocompetent animal should be used. the above characteristics cannot always be satisfied, however, and often virus must be adapted, knockout mice must be used, and/or the disease is not perfectly mimicked in the animal model. well-characterized animal models are critical for licensure to satisfy the food and fda's "animal rule." this rule applies to situations in which vaccines and therapeutics cannot safely or ethically be tested in humans; thus, licensure will come only after preclinical tests are performed in animal models. many fields in virology are moving toward standardized models that can be used across institutions to test vaccines and therapeutics. a current example of such an effort is within the filovirus community, where animal models, euthanasia criteria, assays, and virus strains are in the process of being standardized. the hope is that these efforts will enable results of efficacy tests on medical countermeasures to be compared across institutions. this chapter has summarized the best models available for each of the viruses described. fields' virology pathogenesis of poliomyelitis: reappraisal in the light of new data one hundred years of poliovirus pathogenesis expression of the poliovirus receptor in intestinal epithelial cells is not sufficient to permit poliovirus replication in the mouse gut present status of attenuated live-virus poliomyelitis vaccine world health organization. polio global eradication initiative annual report pathogenesis of human poliovirus infection in mice. ii. age-dependency of paralysis the poliovirus receptor protein is produced both as membranebound and secreted forms poliovirus pathogenesis in a new poliovirus receptor transgenic mouse model: agedependent paralysis and a mucosal route of infection establishment of a poliovirus oral infection system in human poliovirus receptor-expressing transgenic mice that are deficient in alpha/beta interferon receptor macaque models of human infectious disease ulnar nerve inoculation of poliovirus in bonnet monkey: a new primate model to investigate neurovirulence experimental poliomyelitis in bonnet monkey. clinical features, virology and pathology hepatitis a in day-care centers. a community-wide assessment persistence of hepatitis a virus in fulminant hepatitis and after liver transplantation acute liver failure: redefining the syndromes experimental hepatitis a virus (hav) infection in cynomolgus monkeys (macaca fascicularis): evidence of active extrahepatic site of hav replication experimental hepatitis a virus (hav) infection in callithrix jacchus: early detection of hav antigen and viral fate animal models of hepatitis a and e relative infectivity of hepatitis a virus by the oral and intravenous routes in 2 species of nonhuman primates wild malaysian cynomolgus monkeys are exposed to hepatitis a virus histopathological and immunohistochemical studies of hepatitis a virus infection in marmoset callithrix jacchus intragastric infection induced in marmosets (callithrix jacchus) by a brazilian hepatitis a virus (haf-203) experimental hepatitis a virus infection in guinea pigs systematic literature review of role of noroviruses in sporadic gastroenteritis norovirus infection as a cause of diarrhea-associated benign infantile seizures outbreak of necrotizing enterocolitis caused by norovirus in a neonatal intensive care unit progress in understanding norovirus epidemiology natural history of human calicivirus infection: a prospective cohort study foodborne viruses: an emerging problem pediatric norovirus diarrhea in nicaragua clinical immunity in acute gastroenteritis caused by norwalk agent experimental norovirus infections in nonhuman primates chimpanzees as an animal model for human norovirus infection and vaccine development experimental inoculation of juvenile rhesus macaques with primate enteric caliciviruses molecular characterization of three novel murine noroviruses persistent infection with and serologic cross-reactivity of three novel murine noroviruses [comparative study research support, n.i.h., extramural research support gastrointestinal norovirus infection associated with exacerbation of inflammatory bowel disease porcine enteric caliciviruses: genetic and antigenic relatedness to human caliciviruses, diagnosis and epidemiology pathogenesis of a genogroup ii human norovirus in gnotobiotic pigs infection of calves with bovine norovirus giii.1 strain jena virus: an experimental model to study the pathogenesis of norovirus infection an epizootic of equine encephalomyelitis that occurred in massachusetts in 1831 eastern equine encephalomyelitis virus: epidemiology and evolution of mosquito transmission vaccines and animal models for arboviral encephalitides fields virology studies on avian encephalomyelitis. ii. flock survey for embryo susceptibility to the virus the occurrence in nature of "equine encephalomyelitis" in the ring-necked pheasant eastern equine encephalitis virus infection: electron microscopic studies of mouse central nervous system a comparative study of the pathogenesis of western equine and eastern equine encephalomyelitis viral infections in mice by intracerebral and subcutaneous inoculations influence of age on susceptibility and on immune response of mice to eastern equine encephalomyelitis virus the hamster as an animal model for eastern equine encephalitiisdand its use in studies of virus entrance into the brain pathogenesis of aerosolized eastern equine encephalitis virus infection in guinea pigs eastern equine encephalitis. distribution of central nervous system lesions in man and rhesus monkey encephalomyelitis in monkeys severe encephalitis in cynomolgus macaques exposed to aerosolized eastern equine encephalitis virus pathology of animal models of alphavirus encephalitis common marmosets (callithrix jacchus) as a nonhuman primate model to assess the virulence of eastern equine encephalitis virus strains arbovirus investigations in argentina historical aspects and description of study sites western encephalitis in illinois horses and ponies medically important arboviruses of the united states and canada the ecology of western equine encephalomyelitis virus in the central valley of california an epizootic attributable to western equine encephalitis virus infection in emus in texas epidemiologic observations on acute infectious encephalitis in california, with special reference to the 1952 outbreak neurologic, intellectual, and psychologic sequelae following western encephalitis. a follow-up study of 35 cases louis encephalitis; preliminary report of a clinical follow-up study in california pathological changes in brain and other target organs of infant and weanling mice after infection with nonneuroadapted western equine encephalitis virus necrotizing myocarditis in mice infected with western equine encephalitis virus: clinical, electrocardiographic, and histopathologic correlations the pathogenesis of western equine encephalitis virus (w.e.e.) in adult hamsters with special reference to the long and short term effects on the c.n.s. of the attenuated clone 15 variant viruses of the bunya-and togaviridae families: potential as bioterrorism agents and means of control aerosol exposure to western equine encephalitis virus causes fever and encephalitis in cynomolgus macaques venezuelan equine encephalitis recovery of venezuelan equine encephalomyelitis virus in panama. a fatal case in man role of dendritic cell targeting in venezuelan equine encephalitis virus pathogenesis mechanism of neuroinvasion of venezuelan equine encephalitis virus in the mouse comparative neurovirulence and tissue tropism of wild-type and attenuated strains of venezuelan equine encephalitis virus administered by aerosol in c3h/hen and balb/c mice c3h/hen mouse model for the evaluation of antiviral agents for the treatment of venezuelan equine encephalitis virus infection treatment of venezuelan equine encephalitis virus infection with (-)-carbodine studies on the virus of venezuelan equine encephalomyelitis. i modification by cortisone of the response of the central nervous system of macaca mulatta experimental studies of rhesus monkeys infected with epizootic and enzootic subtypes of venezuelan equine encephalitis virus aerosol infection of cynomolgus macaques with enzootic strains of venezuelan equine encephalitis viruses chikungunya outbreaksdthe globalization of vectorborne diseases infection with chikungunya virus in italy: an outbreak in a temperate region changing patterns of chikungunya virus: re-emergence of a zoonotic arbovirus chikungunya and the nervous system: what we do and do not know [review] a mouse model for chikungunya: young age and inefficient type-i interferon signaling are risk factors for severe disease an animal model for studying the pathogenesis of chikungunya virus infection chikungunya virus arthritis in adult wild-type mice a mouse model of chikungunya virus-induced musculoskeletal inflammatory disease: evidence of arthritis, tenosynovitis, myositis, and persistence mouse models for chikungunya virus: deciphering immune mechanisms responsible for disease and pathology chikungunya disease in nonhuman primates involves long-term viral persistence in macrophages aedes albopictus in the united states: tenyear presence and public health implications epidemic dengue/dengue hemorrhagic fever as a public health, social and economic problem in the 21st century dengue: an update dengue haemorrhagic fever: diagnosis, treatment, prevention, and control tropism of dengue virus in mice and humans defined by viral nonstructural protein 3-specific immunostaining clinical and laboratory features that differentiate dengue from other febrile illnesses in an endemic areadpuerto rico risk factors in dengue shock syndrome animal models of dengue virus infection manifestation of thrombocytopenia in dengue-2-virus-infected mice liver injury and viremia in mice infected with dengue-2 virus early activation of natural killer and b cells in response to primary dengue virus infection in a/j mice induction of tetravalent protective immunity against four dengue serotypes by the tandem domain iii of the envelope protein essential role of platelet-activating factor receptor in the pathogenesis of dengue virus infection murine model for dengue virus-induced lethal disease with increased vascular permeability lethal antibody enhancement of dengue disease in mice is prevented by fc modification inhibitory potential of neem (azadirachta indica juss) leaves on dengue virus type-2 replication genetic basis of attenuation of dengue virus type 4 small plaque mutants with restricted replication in suckling mice and in scid mice transplanted with human liver cells study of dengue virus infection in scid mice engrafted with human k562 cells dengue virus tropism in humanized mice recapitulates human dengue fever dengue virus infection and immune response in humanized rag2(ã�/ã�) gamma(c)(ã�/ã�) (rag-hu) mice a model of denv-3 infection that recapitulates severe disease and highlights the importance of ifn-gamma in host resistance to infection mosquito bite delivery of dengue virus enhances immunogenicity and pathogenesis in humanized mice studies on the pathogenesis of dengue infection in monkeys. 3. sequential distribution of virus in primary and heterologous infections studies on dengue 2 virus infection in cyclophosphamide-treated rhesus monkeys dengue virus-induced hemorrhage in a nonhuman primate model an in-depth analysis of original antigenic sin in dengue virus infection monoclonal antibody-mediated enhancement of dengue virus infection in vitro and in vivo and strategies for prevention the arboviruses: epidemiology and ecology screening of protective antigens of japanese encephalitis virus by dna immunization: a comparative study with conventional viral vaccines immunogenicity, genetic stability, and protective efficacy of a recombinant, chimeric yellow fever-japanese encephalitis virus (chimerivax-je) as a live, attenuated vaccine candidate against japanese encephalitis studies on host factors in inapparent infection with japanese b encephalitis: influence of age, nutrition and luminal induced sleep on the course of infection in mice relation of the peripheral multiplication of japanese b encephalitis virus to the pathogenesis of the infection in mice field's virology free radical generation by neurons in a rat model of japanese encephalitis sequential changes in serum cytokines and chemokines in a rat model of japanese encephalitis experimental infections of monkeys with langat virus. i. comparison of viremia following peripheral inoculation of langat and japanese encephalitis viruses intranasal infection of monkeys with japanese encephalitis virus: clinical response and treatment with a nuclease-resistant derivative of poly (i).poly (c) a 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virus infection in the golden hamster: studies on its mechanism and possible implications for other flavivirus infections experimental encephalitis following peripheral inoculation of west nile virus in mice of different ages immunogenicity and protective efficacy of a recombinant subunit west nile virus vaccine in rhesus monkeys molecularly engineered live-attenuated chimeric west nile/dengue virus vaccines protect rhesus monkeys from west nile virus tissue tropism and neuroinvasion of west nile virus do not differ for two mouse strains with different survival rates phenotypic changes in langerhans' cells after infection with arboviruses: a role in the immune response to epidermally acquired viral infection? interleukin-1beta but not tumor necrosis factor is involved in west nile virusinduced langerhans cell migration from the skin in c57bl/6 mice profound and prolonged lymphocytopenia with west nile encephalitis innate and adaptive immune responses determine protection against 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and hepatocellular carcinoma hepatitis b virus replication in primary macaque hepatocytes: crossing the species barrier toward a new small primate model animal models of hepatitis delta virus infection and disease experimental hepatitis delta virus infection in the chimpanzee expression of the hepatitis delta virus large and small antigens in transgenic mice experimental hepatitis delta virus infection in the animal model humanized chimeric upa mouse model for the study of hepatitis b and d virus interactions and preclinical drug evaluation key: cord-342756-rgm9ffpk authors: senger, mario roberto; evangelista, tereza cristina santos; dantas, rafael ferreira; santana, marcos vinicius da silva; gonçalves, luiz carlos saramago; de souza neto, lauro ribeiro; ferreira, sabrina baptista; silva-junior, floriano paes title: covid-19: molecular targets, drug repurposing and new avenues for drug discovery date: 2020-10-02 journal: mem inst oswaldo cruz doi: 10.1590/0074-02760200254 sha: doc_id: 342756 cord_uid: rgm9ffpk coronavirus disease 2019 (covid-19) caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is a highly contagious infection that may break the healthcare system of several countries. here, we aimed at presenting a critical view of ongoing drug repurposing efforts for covid-19 as well as discussing opportunities for development of new treatments based on current knowledge of the mechanism of infection and potential targets within. finally, we also discuss patent protection issues, cost effectiveness and scalability of synthetic routes for some of the most studied repurposing candidates since these are key aspects to meet global demand for covid-19 treatment. at the moment, the prevention aimed at reducing transmission in the community is the best alternative, indicating that enhanced public health interventions, including social distancing, use of masks and movement restrictions should be implemented to bring the covid-19 pandemic under control. aggressive isolation measures including travel restriction in china, have successfully led to a progressive reduction of covid-19 cases. (8) kissler and colleagues, simulated the relaxation of the protective measures using a post-pandemic mathematical model. (9) the authors demonstrated that social isolation will be necessary at the best scenario until 2021, and reaffirmed the need and importance of maintaining social isolation. they also suggested that in the absence of such restrictions, the pandemic could last until 2024. thus, in this context, the search for new medicines available to combat this disease is urgent. coronaviruses are members of the family coronaviridae that present crown-like spikes on their surface visualised by electron microscopy. the subfamily coronavirinae contains the four genera alpha, beta, gamma, and deltacoronavirus. coronaviruses infect birds (gamma and deltacoronaviruses) and several mammalian species (mainly alpha and betacoronaviruses), including humans. (10, 11) coronaviruses have been isolated from diverse species, including mammals like bats, rodents, bovines, swine, felines, pangolins, horses and others. (12, 13) human coronavirus was first identified in 1966 by tyrrell and bynoe. (14) nowadays the seven coronaviruses that can infect humans (hcovs) are classified in alpha coronavirus (229e, nl63) or beta coronavirus [oc43, hku1, middle east respiratory syndrome coronavirus (mers-cov), severe acute respiratory syndrome coronavirus (sars-cov) and more recently the sars-cov-2]. 229e, nl63, oc43, and hku1 can cause upper and lower respiratory tract infection in adults and children. after the 2000s, two epidemic covs have arisen in humans: the sars-cov and the mers-cov which were reported in 2003 and 2012, respectively. (15, 16) in 2019, after the first report of novel pneumonia in wuhan, china, the seventh hcov was described. it also causes severe acute respiratory syndrome (therefore called sars-cov-2) and spreads very quickly worldwide . coronavirus are single-stranded positive-sense rna viruses and their genome size is approximately 30 kb, which encodes some important structural proteins. (17) the spike (s) glycoprotein is a well characterised protein that mediates coronavirus entry into host cells via fusion of the viral and cellular membranes through a pre to post fusion conformation transition. (18) the s protein s1-s2 subunits bind to cellular receptors that vary according to the coronavirus species: angiotensin-converting enzyme 2 (ace2) in sars-cov, sars-cov-2 and hcov-nl63; and dipeptidyl peptidase 4 (dpp4) and aminopeptidase n (apn) in mers or others alphacoronaviruses like tgev (porcine transmissible gastroenteritis coronavirus) and porcine respiratory coronavirus (prch). (18, 19, 20) other structural proteins are mandatory to assemble the complete viral particle like nucleocapsid protein (n), membrane protein (m) and the envelope protein (e). furthermore, they can be involved in other processes like morphogenesis, envelope formation, budding or pathogenesis. (17, 21, 22) by genomic sequencing analysis of other coronavirus strains and sars-cov-2, andersen and collaborators demonstrated that sars-cov-2 has mutations resulting in six different amino acids at the receptor-binding domain (rbd) that appears to be optimised for binding to the human receptor ace2. (23) they also showed that the gene encoding the spike protein has an insertion of 12 nucleotides giving it a polybasic (furin) cleavage site at the s1-s2. in this way, the high-affinity of the sars-cov-2 spike protein to the human ace2 is a consequence of natural selection on a human or human-like ace2. they suggest some possibilities to explain that: emergence in an animal host before zoonotic transfer; natural selection in humans following zoonotic transfer; or natural selection during the passage. (23) other researchers did a phylogenetic analysis of 160 genomes of sars-cov-2. (24) they showed 3 important variations in the composition of amino acids that allowed them to classify into different groups. group a has two subclusters that are distinguished by the synonymous mutation t29095c. while b is derived from a by two mutations t8782c and c28144t, type c differs from its parent type b by mutation of g26144t. the a and c types are found more often outside east asia, in europeans and americans. while the b type is the most common type in east asia. (24) in december 2019, covid-19 was initially reported as a new viral pneumonia, due to the clinical characteristics of the large number of cases that emerged in wuhan, china. (25, 26) sars-cov-2 typically causes respiratory sickness, the major clinical characteristics ob-served in infected patients are high fever, dry cough and dyspnea (shortness of breath or difficulty in breathing). minor symptoms include headache, diarrhea, nausea, vomiting, loss of smell and taste. (27) this clinical condition can progress to moderate or severe pneumonia. (28) in this case, first there is an accumulation of macrophages in alveoli, followed by release of cytokines and accumulation of fluids. neutrophils can also be recruited by the immune system leading to the destruction of type i and type ii alveolar epithelial cells causing a collapse of the alveoli function and consequently the acute respiratory distress syndrome (ards). in the severe condition, with an increase of the inflammation, the protein rich fluid from lungs enter in the bloodstream causing the systemic inflammatory syndrome (sirs). (29, 30) these complicating factors can lead to a multi-organ failure and septic shock, causing patient death. furthermore, some pre-existing conditions can enhance the risk to develop the severe form of the disease, including age over 60 years and a history of chronic diseases like chronic lung disease, asthma, heart diseases, immunosuppressed patients, cancer, diabetes or chronic kidney disease. (31, 32, 33, 34, 35) finally, the vast majority of people have mild symptoms or are asymptomatic, which is a big problem because they can also transmit the virus to the non-infected population. (36) drug repositioning, repurposing, reprofiling or retasking is the evaluation of existing drugs for new therapeutic purposes. (37) a candidate drug (investigational or approved) for repurposing efforts already has a known safety and toxicity profile, based on at least successful phase i or phase ii clinical trials. (38) considering the whole process, costs of bringing a repurposed drug to the market have been estimated to be ten times lower and the time is shortened by around a half, compared with a new drug. (38) even though the clinical phase iii and regulatory aspects remain similar for developing a new drug, drug repurposing possesses many advantages over developing a new drug from scratch: the reduced time and financial investment for development, the lower risk of failure and a consolidated pharmaceutical supply chain for production and distribution to the patients that effectively need treatment. (39) emerging or reemerging viruses pose major public health concerns globally. (40) for several pathogenic viruses, considerable efforts have focused on vaccine development and other therapies, like transfusion of convalescent plasma. (41, 42) however, during pandemics infected individuals need urgently to be treated on a large scale. a medicine armamentarium for the covid-19 outbreak is needed immediately and drug repurposing could be one of the best strategies to deal with this pandemic. (43, 44) computational and experimental approaches can be used, alone or combined, to achieve a more holistic point of view and increased chance of success in drug repurposing. in the following topic, we will review sars-cov-2 structure and mechanism of infection in order to discuss molecular targets from the virus or its human host that are being considered for drug repurposing and perhaps future development of new drugs. ongoing drug repurposing efforts will be described in more details later in this article, along with some clinical trials that have been carried out so far for covid-19 treatment. finally, as treatment availability is of utmost importance when dealing with a pandemic, we bring a discussion on patent protection and ease of large-scale production of some of the drugs that are more advanced in clinical studies. sars-cov-2: structure, mechanism of infection and drug targets sars-cov-2 structure -electron microscopy imaging of sars-cov-2 virions indicates that they have a spherical or pleomorphic shape, with diameters ranging from 60 to 140 nm, showing prominent spikes of 9-12 nm in their surfaces that resemble a solar corona, hence the name "coronavirus". (45, 46, 47, 48) sars-cov-2 is an enveloped virus with a single-stranded positive sense (5'-3') rna (+ssrna) (~ 30 kb) containing a 5'cap structure and a 3'-poly-a tail. (49, 50) its genomic rna (grna) has a variable number of open reading frames (orfs) that are predicted to encode 16 non-structural (nsp), 4 structural and several accessory proteins ( fig. 1 ). (26, 51, 52, 53, 54) orf1a and orf1b represent more than 2/3 of the whole length of grna, and encode two polyproteins: pp1a (440-500 kda) and pp1ab (740-810 kda). (53, 55) the polyprotein pp1a is translated from orf1a while pp1ab from orf1a/orf1b using a -1 ribosomal frameshift mechanism that occurs near the 3' end of orf1a which allows continued translation of orf1b. (53) together, pp1a and pp1ab originate all nsps (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) , such as m pro (nsp5) protease and rdrp (nsp12) rna polymerase, which form viral replicase/transcriptase complexes (rtcs), and are encapsulated in double-layered vesicles originated from the endoplasmic reticulum (er). (56, 57, 58) the orfs near the 3' end of the grna encode the structural and accessory proteins of sars-covs. (58) the first ones have a crucial role in the assembly of viral particles and virus invasion. (56, 58) the main structural proteins are named: spike (s), envelope (e), nucleocapsid (n) and membrane (m) proteins. most of them reside on the virion surface (s, e, m proteins) while n proteins are found in the core of the particle bound to grna. (59) s proteins are essential for virus attachment and entry into the host cells, tissue tropism and pathogenesis. (58, 60) e proteins exert several roles in virus infection, such as helping in virus assembly and release from infected cells, creating ion channels in cell membranes and suppressing host stress response. (58, 61, 62) n proteins interact with grna to form the ribonucleoprotein. (56, 62) m proteins have a role in virion assembly and in determining the shape of the envelope. they also bind to all other structural proteins promoting, for instance, the stabilisation of n protein-rna complexes. (56, 63) sars-cov-2 mechanism of infection -at present, the mechanisms that underlie sars-cov-2 infection have not been directly described. nonetheless, they seem to be similar to those proposed for other coronaviruses. (58) in one proposal, virus infection starts with the binding of its s proteins to host receptor ace2, a membrane protein largely expressed in the lung and small intestine cells (fig. 2 ). (44, 59, 64) after attachment, s protein is cleaved by host proteases initiating the fusion of virus and cell membranes that culminates in viral grna release into the cytoplasm. this event is proposed to occur through two distinct ways: via plasma membrane (early pathway) or via endosomes (late pathway). in the early pathway, s protein is cleaved by host plasma membrane proteases (e. g., tmprss2) while in the late pathway by endosomal proteases (e. g., cathepsin l). the route taken by the virus to enter the cell appears to be dependent on the availability of these proteases. (59, 64, 65) once in the cytoplasm, grna is readily translated into viral polyproteins (pp1a/pp1ab), which are cleaved into the individual nsps that compose the rtcs (fig. 2) . these complexes recognise transcriptional regulator sequences in grna and begin to transcribe a series of subgenomic rnas that encode structural and accessory proteins, otherwise the whole grna is replicated. (57, 58, 59) upon translation, s, e and m structural proteins are driven to the er-golgi intermediate compartment (ergic) where s proteins go through post-translational modifications (e. g., proteolysis, n-glycosylation). in parallel, a copy of the grna and n proteins bind in the cytoplasm to form the nucleocapsid and move into the ergic. in this compartment, nucleocapsid and the other (1) virus infection initiates with the binding of virus s proteins to the ace2 cellular receptors. after attachment, the virus may enter the cell through two distinct mechanisms: early and late pathways. (2) in the early pathway the genomic ssrna (grna) is liberated into the cytoplasm after the fusion between viral and cell cytoplasmic membranes, an event triggered by membrane proteases (e. g., tmprss2). (3) the grna is immediately translated into two polyproteins that undergo proteolytic cleavage giving rise to all nonstructural proteins (nsps). (4) the nsps form the replication-transcription complexes (rtcs) where the grna (blue ribbon) is replicated and the subgenomic rnas (red ribbon) are transcribed. (5) the subgenomic rnas are translated into viral structural and accessory proteins in the cytosol. (6) upon translation, e, m and s structural proteins are inserted into er and follow the secretory pathway to the er-golgi intermediate compartment (ergic). (7) meanwhile, a copy of the grna binds to n proteins in the cytoplasm forming the nucleocapsid, which is transported to the ergic. (8) virion assembly in the ergic. (9) the new virion travels through the cytoplasm inside a vesicle and leaves the cell by exocytosis. (10) alternatively, in the late pathway, the virus can undergo endocytosis to initiate the infection. (11) the virion membrane merges with the endosome membrane after s protein proteolysis by endosomal proteases (e. g., cathepsin l), allowing the grna to be released into the cytoplasm. from this point on, the cycle follows the same pathway described in 3-9 steps. the red arrows indicate the general replication pathway and the blue arrows indicate the grna movement through the cycle. some viral and host proteins have been explored as potential targets for drug repurposing. some of these drug candidates are shown with their site of action indicated in the cycle. (44, 59, 66, 67) viral proteins are assembled into a virion which travels through the cytoplasm inside a vesicle and leaves the cell by exocytosis. (48, 56, 59) candidate drug targets -in the search for a treatment for covid-19, several viral and host molecular proteins have been explored as potential drug targets. overall, they participate in key events of the virus infection cycle, such as cell entry and replication, as well in host metabolic pathways and immune response. in the following topics we will address in more details some of these targets. drugs under investigation for blocking the main steps of the sars-cov-2 virus replication cycle are indicated in fig. 2 . virus targets -during sars-cov-2 grna translation, two proteases, namely m pro and pl pro , act in concert to cleave and release from pp1a/pp1ab the 16 nsps that compose the rtc. (58) therefore, these proteases are essential for virus replication and represent useful targets for therapeutic intervention. recently, sars-cov-2 m pro and pl pro had their 3d structures published -pdb 6lu7, 2.16 å and pdb 6w9c, 2.70 å, respectivelywhich make them particularly useful for computational structure-based drug design methods. (68) 3-chymotrypsin-like protein (synonyms: coronavirus main protease, m pro , 3cl pro ) of sars-cov-2 is a 33.8 kda homodimeric protein (306 aa) that belongs to the cysteine protease class (possibly from c30 family and pa clan). (68, 69) this enzyme catalyses the hydrolysis of peptide bonds of polyproteins (possibly e.c. 3.4.22.69) at sites whose amino acid sequences generally follow the pattern leu-gln* (ser, ala, gly) (*marks the cleavage site). (70, 71) m pro is part of pp1a/pp1ab polyproteins (nsp5). (57) during polyproteins translation, m pro suffers autolyt-ic cleavage and is released from its polyprotein precursor, reaching a mature state that cleaves pp1a/pp1ab at no less than 11 sites downstream of the nsp4 coding region. (57, 68, 70, 72) each protomer of sars-cov-2 m pro is divided into three domains: chymotrypsin and picornavirus 3c protease-like i and ii domains, composed by antiparallel β-barrel structures, and domain iii which contains five α-helices arranged into an antiparallel globular cluster responsible for protease dimerisation (fig. 3a) . domains ii and iii are connected by a long loop, where lies a cleft that serves as a substrate binding site and where catalysis occurs using the cys 145 -his 41 dyad (fig. 3b ). (68, 70, 73) m pro has been widely explored in drug discovery campaigns using experimental and/or computational approaches. (68, 73, 74, 75, 76, 77) moreover, m pro has no human homologue, which reduces the chances of toxic effects of a given inhibitor. (68) potential sars-cov-2 m pro inhibitors include fda-approved antivirals, such as inhibitors of hiv-1 [e. g., lopinavir (1) /ritonavir (2) ] and hcv [e.g., boceprevir (3)] proteases, as well as antineoplastic [e.g. carmofur (4)] and antibacterial [e.g., doxycycline (5)] drugs. (73, 78, 79, 80, 81, 82) chemical structures for compounds 1-14 are shown in fig. 4 . nsp3 is the largest protein encoded by covs (~200 kda). in sars-covs it has 16 domains which include a papain-like proteolytic enzyme from the cysteine protease class (c16 family and ca clan for sars-cov). (57, 69, 83) pl pro is composed of a catalytic domain, an extended right-handed thumb-palm-finger structure with a cys-his-asp catalytic triad, and a ubiquitin-like domain (ubl) (fig. 5a ). the catalytic cys is located in the thumb subdomain while his and asp in the palm subdomain (fig. 5b ). pl pro catalyses the hydrolysis reaction of peptide bonds of pp1a/pp1ab at three sites (nsp1/nsp2, nsp2/nsp3 and nsp3/nsp4) that share the xlxgg* pattern (*represents the cleavage site). (57, 71, 83, 84) this activity is responsible for nsp3 release from polyproteins. pl pro also recognises and hydrolyses ubiquitin and isg15 from cellular proteins. (83, 84) the deubiquitination and deisgylation activities are proposed to modulate the post-translational modifications of signaling molecules that trigger innate immune response of the host. (85) these functions are pivotal for virus infection justifying the search for sars-covs pl pro inhibitors. (84, 86, 87, 88, 89, 90) putative inhibitors of sars-cov-2 pl pro include fda-approved drugs such as fostamatinib disodium (6) (a tyrosine kinase inhibitor used in the treatment of chronic immune thrombocytopenia) and natural products [e.g., platycodin d (7)]. (89, 91) rna-dependent rna polymerase (rdrp, nsp12) is an essential protein responsible for rna synthesis during viral rna transcription and replication cycles. (89) as described for sars-cov, the rna polymerase activity of sar-cov-2 rdrp (804 aa) also seems to require the binding of nsp7 and nsp8 cofactors to enhance rdrp binding and processivity. (92, 93) the overall rdrp structure has a "right hand" rdrp domain, composed by three subdomains (palm, fingers and thumb), and a nidovirus-unique n-terminal extension domain that forms a nidovirus rdrp-associated nucleotidyltransferase (niran) structure. these domains are connected by an interface domain. additionally, this protein also has a n-terminal β-hairpin (fig. 6a) . the active site of rdrp contains conserved polymerase motifs located in the palm subdomain and its configuration is similar to other rna polymerases. (94) rdrp substrates, rna template/primer and nucleotide triphosphate (ntps), access the catalytic centre through the template and ntp entry paths, respectively, while the product-template hybrid is released through the rna exit path. (92, 94) sars-cov-2 rdrp shares 96% identity in amino acid sequence with sars-cov protein. (93) moreover, the accessory proteins also have a high degree of amino acid sequence identity between these viruses: 98.1 % for nsp7 and 97.5 % for nsp8 -sequences obtained from pdb 7bv2 (2.5 å) and pdb 6nur (3.1 å) entries. (92, 95) therefore, it is reasonable to suggest that sars-cov rdrp inhibitors may also bind to the homologous enzyme from sars-cov-2, as demonstrated for remdesivir (8) (fig. 6b) , an adenosine triphosphate analog. (92, 93, 96) other potential inhibitors include clinically available drugs, such as favipiravir (9), a purine nucleic acid analog used in the treatment of influenza, and ribavirin (10), a synthetic guanosine nucleoside indicated for the treatment of hepatitis c virus (hcv) infection. (97, 98) the crucial role of rdrp and the lack of a host homolog turns this enzyme into a valuable target for anti-covs agents. (93) helicase (nsp13) is a multifunctional protein (predicted to have 596 aa in sars-cov-2) essential for sars-covs rna replication and proliferation. (74, 99) sars-cov helicase belongs to helicase superfamily 1 (sf1) and can unwind double-stranded dnas/rnas (helicase activity) in the 5'-3' direction, an energyconsuming process that is driven by the hydrolysis of nucleosides triphosphate (ntpase activity). (57, 100, 101) its structure contains five domains arranged in a triangular pyramid-shape: the triangular base is composed by two "reca-like" (1a and 2a) and 1b domains whereas the zinc binding domain (zbd), in the n-terminal, and the stalk domain are oriented towards the apex. the zbd and 1b domains are connected by the stalk domain ( fig. 7) . (101) the same domain arrangement is predicted to occur in sars-cov-2 enzyme. (74) sars-cov helicase has been explored as a potential target for drugs. (99, 100, 102) recently, some efforts have also been made to predict inhibitors for sars-cov-2 helicase. (74, 103, 104, 105) they include drugs used in the clinics to treat acquired immunodeficiency syndrome (aids), such as vapreotide (11) (somatostatin analog) and atazanavir (12) (hiv protease inhibitor), as well anti-hcv protease inhibitors [e.g., daclatasvir (13) ] and bismuth salts [e.g., bismuth potassium citrate (14) , a compound used in clinical treatment of gastrointestinal diseases]. (103, 104, 106) sars-covs replication also requires other enzymatic activities including (guanine-n7)-methyltransferase (n7-mtase), 2'-o-methyltransferase (2'-omtase) and exoribonuclease (exon). (57, 107, 108) the n7-mtase domain at the c-terminus of nsp14 is responsible for adding a methyl group in the n7 position of rna 5'-guanosine forming the 5'-cap structure of viral rnas. (108) additionally, nsp14 also has a catalytic domain in its nterminus with 3'-5' exon activity, which participates in rna proofreading mechanism (fig. 8 ). (57) 2'-omtase (nsp16) catalyses the methylation reaction at the ribose 2'-o position of the first and second nucleotide of the mrnas and it is one of the sars-cov-2 proteins whose 3d structure has already been resolved (pdb: 6w61, 2.0 å) (fig. 9 ). (109) both nsp14 and 16 use nsp10 as a cofactor to enhance their 3'-5' exon and 2'-omtase activities, respectively. (110) together, these proteins are responsible for inducing rna modifications that are essential for its stability and translation as well to avoid the activation of host immune response. (57, 107, 109) thus, nsp14 and 16 have been considered as potential targets for anti-sars agents that may affect their functions in a direct or indirect way (e.g., by blocking nsp 10 binding). (108,109,110,111,112 ,113,114,115) some compounds have been regarded as potential inhibitors of sars-cov-2 methyl transferases, such as adenine dinucleoside s-adenosylmethionine analogs [e.g., dinucleoside 13 (15) ], predicted for sars-cov n7-mtase activity, and some clinically available drugs [e.g., raltegravir (16) -a hiv integrase inhibitor], predicted for sars-cov-2 2'-omtase activity. (112, 115) chemical structures for compounds 15-29 are shown in fig. 10 . spike protein (s) is a viral type i transmembrane glycoprotein (~180-200 kda) responsible for covs interaction and invasion of host cells. (59, 64) this protein is synthesised as a monomer and suffers post-translational modifications in the er before becoming a trimeric glycosylated protein. (59, 116) its structure is divided into three main domains: an extracellular, a transmembrane and a short intracellular domain (fig. 11 ). (117) the former protrudes from the surface of the virus particle creating a crown-like halo and contains two functional subunits: s1 (bulbous shape), which binds to cellular receptors (e.g., ace2), and s2 (stalk shape) that promotes the fusion between cell and virus membranes. (59) in turn, s1 subunit has two domains: a n-terminal and a c-terminal domain. the latter serves as a rbd for sars-covs being responsible for ace2 recognition and binding. (59, 64, 117) apart from s1 and s2, sars-cov-2 s protein also has a ganglioside-binding subdomain at the tip of n-terminal domain, which may allow this protein to interact with gangliosides on cells' surface. in theory, this domain could facilitate virus attachment to the cell and facilitate the contact with ace2, being a potential site for drug interference. (118) fig. 9: ribbon representation and vdw surface of the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) 2'-o-methyltransferase 3d structure (pdb 6w61, 2.0 å, nsp16, pink) in complex with its nsp10 cofactor (light blue). the zinc and chloride ions are represented as gray and green spheres, respectively. image created using maestro, release 2020-1 (maestro, schrödinger, llc, new york, ny, 2020). covs s proteins require proteolytic priming or cleavage to become fusion competent. (59) this is achieved by host proteases (e.g., tmprss2, cathepsin l, furins) which cleave the s2 subunit of s protein at two main positions: s1/s2 interface and s2'. the latter is located immediately upstream of the fusion peptide (fp), the fusion functional element of s2. contrary to sars-cov, sars-cov-2 s2 subunit also has an additional cleavage site for furin proteases in the s1/s2 region, something that also occurs in mers-cov. (60) it is still unclear its role in sars-cov-2 infection, but it is speculated that the ubiquitous expression of furins may increase cell and tissue tropism of sars-cov-2 in comparison to sars-cov, as well altering its transmissibility and pathogenicity. (60, 117) taken together, host proteases represent potential targets for anti-sars-cov-2 drugs, and thus some of them will be discussed in the following topics. (60, 64, 119) covs e proteins are small integral membrane polypeptides (76 -109 aa) encoded by subgenomic rnas. in sars-cov, they are found in virions, but also in large amounts in the ergic where they participate in virus budding and trafficking. their structures are divided into three main domains: n-terminal, transmembrane (tmd) and c-terminal domain. tmd is able to form pentameric α-helical bundles creating ion conductive pores in membranes. (120, 121, 122) the ion channel (ic) activity of e protein has been proposed to alter ion homeostasis, as well induce inflammatory response, which may lead to pulmonary damage. (123, 124) thus, the use of inhibitors of ic activity may represent a possible therapeutic strategy for covs-related diseases, including covid-19. ( this can be exemplified by the fda-approved drugs gliclazide (17), a sulfonylurea administered to non-insulin-dependent diabetes mellitus patients, and memantine (18) , an n-methyl-d-aspartate receptor antagonist used in the management of alzheimer's disease, which have shown ic inhibitory activity in bacteria expressing sars-cov-2 e proteins. (126) host cell targets -a key step in sars-covs infection is the attachment of s protein to host angiotensinconverting enzyme 2 (ace2), a membrane-bound carboxypeptidase (family: m2, clan: ma). (25, 65, 69) this enzyme catalyses the hydrolysis of angiotensin i and angiotensin ii into angiotensin-(1-9) and angiotensin-(1-7) peptides, respectively. (127) ace2 is expressed in the upper respiratory system, type i and ii alveolar epithelial cells in the lungs, heart, endothelial cells, kidney tubular epithelium and other tissues. (128) its role as a functional receptor of sars-cov-2 s protein in host cells makes this protein a potential drug target to treat covid-19. there are several therapeutic strategies targeting ace2 which include: vaccines based on s protein, exogenous administration of a soluble form of ace2, and administration of small molecules [e.g., arbidol (19) , an anti-influenza drug] or antibodies (e.g., sti-1499, an anti-spike antibody) to block the interaction of ace2 with s protein. (66, 129, 130) additionally, compounds could also have an anti-sars-covs activity by disturbing ace2 glycosylation, as proposed for chloroquine (20) . (131) renin-angiotensin-aldosterone system (raas) inhibitors, such as ace inhibitors [ace-i, e.g., captopril (21) ] and angiotensin receptor blockers [arb, e.g., losartan (22) ], are commonly used in clinics to treat hypertension and cardiovascular/renal diseases. (132, 133) recently, some researchers have debated over the administration of these drugs to patients with known or suspected covid-19. (133, 134, 135, 136) the main reason for this discussion is that raas inhibitors may induce ace2 expression, which, in theory, could increase the severity of the infection. (133, 136) nonetheless, evidence suggests that these drugs may protect patients from lung injury by suppressing angiotensin ii signaling mediated by angiotensin receptor 1 (at1r). (135, 136, 137) further investigation is still required to determine whether ace-i and arb have a beneficial or deleterious role in covid-19 treatment. (134) in order to become fusion-competent, sar-covs s proteins must be cleaved by host proteases. in sars-cov-2, this process appears to be mediated primarily by tmprss2 in the plasma membrane. (65) tmprss2 (transmembrane protease, serine 2) is a transmembrane protein (predicted to have 492 aa) from the serine protease class (family: s1 clan: pa). (69, 138) it is highly expressed in the epithelial cells of the prostate, and relatively less in lungs, colon, liver, kidney, and pancreas. its physiological function is still unclear. (138) tmprss2 has a major role in sars-cov-2 cell entry and replication, and thus represents an interesting therapeutic target since its inhibitors could potentially block virus infection in its initial stages. (65, 138) potential tmprss2 blockers include some serine protease inhibitors [e.g., camostat mesylate (23)], commercially available compounds [e. g., zinc64606047 (24), 3-[[5-(3-fluorophenyl)pyrimidin-2-yl]amino~(n)-(4-methyl phenyl)benzamide]] and natural products [e.g., withanone (25) ]. (65, 139, 140, 141) in the absence of exogenous or membrane-bound proteases (e g. tmprss2) to promote sars-covs infection on cells' surface, the virus can also be internalised via endocytosis, also known as "late pathway". (59) this process comprises several factors that operate in a sequential and partially overlapping fashion. (142) endocytosis initiates with the recruitment of endocytic coat proteins (e. g., clathrins) from the cytosol to gather on the inner leaflet of the plasma membrane. then, protein-coated pits bud into vesicles originated from plasma membranes and fuse with each other or with pre-existing early endosomes. (142, 143) gradually, early endosomes mature to late endosomes which have an acid environment (approx. ph 5.5), activating endosomal cathepsin l cysteine proteases (family: c1, clan: ca). (59, 69, 143) these enzymes are responsible for triggering the fusion activity of s protein and subsequent insertion of viral sars-cov grna into the cytosol, especially in cells with lower expression of tmprss2. (64, 65) some key elements of endocytosis have been explored as potential targets for anti-sars-cov drugs, such as agents that increase endosomal ph (avoiding cathepsin l activation) [e.g., chloroquine (20) and hydroxychloroquine (26) ] and cathepsin l inhibitors [e.g., teicoplanin (27) , a glycopeptide antibiotic]. (49, 131, 144) cytokines are short-lived small size proteins (15-20 kda) that exert an important role in autocrine, paracrine, and endocrine signaling controlling the development and function of several immune and nonimmune cells. (145, 146) they are classified in families based on certain properties of their receptor complexes, such as their structure, specificity and composition. (145) one example is interleukin (il)-6 family which includes several cytokines, such as il-6, that use the common signaling receptor subunit glycoprotein 130 kda (gp130). il-6 signaling requires the binding of il-6 to il-6 receptor (il-6r) which consists of a soluble il-6 binding domain (cd126) and membrane-bound gp130. il-6 acts as the main inducer of fever, inflammation and of hepatic acute phase proteins. therefore, il-6/il-6r antagonists have a therapeutic effect in inflammatory diseases. (145, 146) their use in covid-19 treatment may be beneficial to avoid the "cytokines storm" syndrome that some patients with the severe form of the disease may develop. (147) this deleterious event is caused by an amplified immune response and cytokine release that can damage the organs, including the lungs. (66) tocilizumab and sarilumab are two examples of humanised monoclonal antibodies that act as il-6r antagonists which are currently under clinical trials for covid-19 treatment. (148) other targets -apart from sars-covs infection, some relevant molecular targets of other viral diseases and host metabolism have also been investigated in covid-19 drug discovery, such as viral neuraminidases and the dpp4 cell receptor. neuraminidases (na) or sialidases, are glycoside hydrolases (family: gh34) largely found attached to the envelope of influenza viruses. (149, 150) they catalyse the hydrolysis of glycosidic bonds between sialic acid and adjacent sugar residues (ec 3.2.1.18) in glycoproteins, glycolipids and oligosaccharides. (149) na is mainly responsible for cleaving sialic acid acids from cell receptors and on carbohydrate side chains of nascent virion, facilitating its release from infected cells. (150) its critical role in virus infection and proliferation has been exploited by na inhibitors [e.g., oseltamivir (28) ] which are administered in clinics to combat influenza infections. apparently, this therapeutic strategy was employed at the beginning of co-vid-19 outbreak during the peak of influenza season in china when the etiologic agent of this disease was yet unknown. so far, there is no evidence that na inhibitors may have a role in covid-19 management. (66) dipeptidyl peptidase-4 (ddp4), also known as adenosine deaminase complexing protein 2 or t-cell activation antigen cd26, is a type ii transmembrane glycoprotein of 766 aa largely expressed in many tissues (e.g. lungs and immune cells). (151, 152) ddp4 belongs to serine protease group (family: s9, clan: sc) and catalyses the hydrolysis of n-terminal dipeptide, xaa-yaa-|-zaa-, (preferentially when yaa is a proline, as long as zaa is neither proline or hydroxyproline), from a variety of peptide substrates (ec 3.4.14.5), such as chemokines, neuropeptides, vasoactive peptides and growth factors. (69, 71, 152) therefore, it participates in many physiologic and pathological processes, including glucose/insulin metabolism and immune/inflammatory response. (153) in addition, dpp4 acts as the functional cell receptor of mers-cov s protein, helping virus entry into the cell. theoretically, this role may also be played in sars-cov-2 infection, as predicted by computational analysis. (154) recently, there has been a discussion about the use of ddp4 inhibitors, such as sitagliptin (29) (anti-diabetic drug), in the treatment of covid-19. (152, 153, 155, 156) in principle, these inhibitors could be beneficial for type 2 diabetes patients (or even without diabetes) with covid-19 since it could potentially block virus cell entry/replication, as well suppress inflammatory response. (152, 155) however, there is not enough evidence yet to prove this hypothesis. (152, 153, 156) computational approaches -the sars-cov-2 pandemic is creating a fertile ground for computational approaches to identify viable therapeutic options in the short-term, with the number of published studies growing rapidly. (157, 158) classical target-and ligand-based strategies (e.g., molecular docking and similarity analysis), are being applied to fda-approved drugs and compounds in clinical trials to explore possible interactions with viral proteins. (75, 159, 160) artificial intelligence (ai) methods are also being extensively applied to large molecule databases to find existing drugs that could be repurposed based on previously reported antiviral activities. (103, 161, 162, 163) ai approaches can even explore hidden connections between drugs, human and viral targets to find novel bioactivities and even combinations of drugs. (52, 161, 164) these studies emphasize how important computational methods are in modern drug discovery to analyse the huge amount of biomedical data available. table i summarises a selection of studies that suggested potential drugs for repurposing. below we will describe the main computational methods and results. smith and smith performed a large virtual high-throughput screening to identify drugs, natural products and metabolites that could disrupt the interaction between sars-cov-2 s protein and human ace2 receptor. the authors used a supercomputer called summit to conduct the simulations, which included structural modeling of the s protein:ace2 complex, generation of an ensemble of conformations for the complex and molecular docking. (160) the ensemble generation was a crucial step in this work, allowing the authors to explore different conformations of the complex and identify drugs that could interact with binding sites not easily identified in static conformations. using the gromacs molecular dynamics simulation suite, six different clusters of conformations were generated by restrained temperature replica-exchange molecular dynamics simulation (t-remd) and submitted to docking with autodock vina using the sweet-lead compound collection. (170, 171, 172) the authors explored two strategies, consisting of disrupting the s protein: ace2 complex and preventing its formation by docking on the isolated proteins. from this analysis, four compounds [pemirolast (30) , nitrofurantoin (31), isoniazid pyruvate (32) and eriodictyol (33) ] displayed potential to disrupt the s protein: ace2 interaction, and three natural compounds [cepharanthine (34) , ergoloid (35) and hypericin (36) ] showed potential to block host recognition. (160) chemical structures for compounds 30-49 are shown in fig. 12 . ge and coworkers constructed a virus-related knowledge graph (or network) by combining seven networks with information about target-drug and protein-protein interactions, molecule similarity and sequence similarity of human and viral sources to predict drugs targeting sars-cov-2. (164) well known biological and interaction databases were employed, such as drugbank, chembl, bindingdb, and uniprot . (173, 174, 175, 176) the final knowledge graph was assembled by merging the nodes and edges of the seven networks, where each node represent drugs or targets, while the edges between them are the identified relations, such as similarity (i.e., molecular and sequence similarities) and drug-target or target-target interactions. (164) a graph convolutional network (gcn) was used to learn and extract the hidden information on the nodes and edges of the knowledge-graph, allowing the authors to access novel drug-target and target-target interactions and find molecules that could be repurposed to sars-cov-2. (164) gcn's are powerful neural networks that can access the rich information within the nodes of a graph and return insights about possible relations (e.g., potential drugs and targets interactions), representing a valuable tool in the modern drug discovery scenario, where massive biological data are available in databases such as drugbank and chembl. (177, 178) the final knowledge-graph was then mined to gather an initial list of drugs, which was further refined by extracting previous evidence of antiviral activity from pubmed using a deep learning method called biomedical entity relation extraction (bere) and manual inspection. (179) in a subsequent step, the authors elaborated a final list of drug candidates using transcriptome analysis of ten sars-cov patients. the poly-adp-ribose polymerase 1 (parp1) inhibitor, mefuparib hydrochloride (cvl218) (37) , currently in phase i clinical trials, was identified as a potential drug for repurposing. in vitro and in vivo validation showed promising inhibition and safety profiles. concretely, compared to arbidol (19) , one of the standard treatments for covid-19 in china, cvl218 showed higher antiviral efficacy and higher concentration in lungs of rats. (164) the authors also found that cvl218 significantly inhibited the production of il-6 induced by the cpg oligodeoxynucleotide 1826 (cpg-odn1826) in peripheral blood mononuclear cells (pmbc) indicating it might be an alternative to treat the inflammation caused by sars-cov-2. furthermore, cvl218 showed favorable pharmacokinetics and toxicity profiles in rats and monkey models. (164) this integration of artificial intelligence with wet-lab experiments highlights the importance of in silico methods to mine baricitinib (39) rheumatoid arthritis human ap2-associated protein kinase 1 (aak1) knowledge-graph a pilot trial indicated that baricitinib (39) improved clinical parameters (e.g., cough and dyspnea) in a small group of patients. c (161) toremifene (40) (41) and mercaptopurine (42) ] and angiotensin receptor blockers [irbesartan (43) ]. d (52) a: cepharanthin (34) has been shown to decrease the expression levels of s-protein in mrc-5 cells infected with human coronavirus oc43 (hcov-oc43). (165) flavonoids have been described as inhibitors of m pro and ligands of the s-protein of sars-cov, which could give insights on possible antiviral activities of eriodictyol (33), hypericin (36) and other flavonoids on sars-cov-2. (166, 167) b: a recent study showed that atazanavir (12) inhibited m pro in vitro with greater potency than lopinavir (1). (168) c: despite the small size (12 patients) and open label, non-randomised format, baricitinib (39) showed potential safety when used in combination with lopinavir (1) / ritonavir (2). (169) as large amounts of data from databases and accelerate the discovery of potential drugs for the covid-19 pandemic. beck et al. used a natural language processing (nlp)-based approach to estimate the binding affinity of 3,410 fda-approved drugs against potential targets of sars-cov-2, including 3cl pro , s protein, rdrp, helicase, endornase, 3'-to-5'-exonuclease and 2'-o-ribose methyltransferase. (103) the premise of their approach is analogous to understanding text in different languages, for instance by learning the semantic relationships of words to execute a task, such as predicting the most probable word in a text or the sentiment expressed by it. (180, 181, 182) their model, called molecular transformerdrug target interaction (mt-dti) was trained on 1 billion smiles strings and the fasta sequence of target proteins, which bypass the need for 3d structures (e.g., x-ray) of protein-target complexes. (183) the pre-training approach allows the model to be used for other related tasks without the need to train from scratch, which is especially important when not enough data is available, which is the case for sars-cov-2 inhibitors. in addition, this approach is able to transfer more general features learned by the model, making it extremely flexible to deal with related tasks. (184, 185) therefore, the task consisted of training the model to understand the chemical structure of small compounds and protein targets. the authors found that atazanavir (12), remdesivir (8) and efavirenz (38) are potential inhibitors of m pro , while atazanavir (12) also yielded nanomolar predicted binding affinity for rdrp, helicase, endornase, 3'-to-5'-exonuclease and 2'-o-ribose methyltransferase. (103) it is important to highlight that although these drugs were predicted as nanomolar inhibitors, experimental confirmation is essential to validate the computational analysis. researchers at the uk-based company benevolen-tai (https://www.benevolent.com/) analysed medical data from different sources to create a knowledge graph of biomedical information, showing possible drug-target interactions on its nodes and edges (similar to the previously mentioned approach adopted by ge et al.) to explore new strategies for sars-cov-2. (161, 164) among the drugs identified by mining the hidden information within the graph, there were 378 inhibitors of the p2associated protein kinase 1 (aak1), a regulator of viral endocytosis in at2 alveolar epithelial cells. (161) inhibitors of aak1 could then potentially block viral entry into alveolar cells. however, the authors argued that only one of these drugs, baricitinib (39), a janus kinase inhibitor, has an acceptable safety profile. in addition, the low therapeutic dosing of baricitinib (39) (2mg or 4mg daily) makes it a promising drug for repurposing. (161) baricitinib (39) will be further discussed below. zhou et al. developed a network-based approach to identify potential repurposable drugs based on the interactions between their human targets and coronavirusassociated proteins. (52) the premise is that protein targets that are associated with viral infections are part of a subnetwork of the human protein-protein interaction network. the targets of a repurposable drug should be in or close in proximity to this subnetwork. the authors identified many potential targets, such as poly [adp-ribose] polymerase 1 (parp-1), glycogen synthase kinase 3 (gsk-3), and also biological pathways that could be explored, such as nf-kappa b signaling. (52) the most interesting drugs selected by the authors are from a diverse set, including toremifene (40) (selective estrogen receptor modulator), sirolimus (41) (immunosuppressant), mercaptopurine (42) (antineoplastic) and irbesartan (43) (antihypertensive). an interesting finding was that the selected molecules and targets have reported links to viral infection and some have been used for treatment of coronavirus-related disease, such as emodin (44) in sars-cov, and mercaptopurine (42) and toremifene (40) in sars-cov and mers-cov. (52) in addition to identifying repurposable drugs, possible synergistic combinations between them were also suggested by the network, such as sirolimus (41) and dactinomycin (45) , and mercaptopurine (42) and melatonin (46) . (52) in vitro and in vivo studies -genome and replication kinetics of sars-cov, mers-cov and sars-cov-2 viruses are very similar, suggesting that these diseases could be treated by a single drug that modulates the activity of a common target or mechanism among them. (52, 186) so far, no clinically available antiviral drugs have been developed for any of these three viruses. (187) this fact demonstrates that we did not learn a suitable strategy for treatment from these two prior diseases, and we are not yet prepared to deal with this new coronavirus epidemic, regarding therapeutic options. (188) experimental target validation (e.g., by genetic and proteomic approaches), cellular in vitro and in vivo animal models of sars-cov-2 infection, are pivotal for the discovery of molecular pathways involved in pathogenesis, supporting the discovery of new drugs. (189, 190) sars-cov-2 genome encodes less than 30 proteins that can be explored for generating new avenues for further research. heterologous viral protein expression could be used in a myriad of structural and functional targetbased biochemical studies. (191) these assays do not need to be performed in biosafety level 3 laboratory, democratising the early research on searching for a new drug candidate for covid-19 treatment. (192) genome-wide expression studies, nucleotide sequences, protein structures and associated sequences are available online providing a foundation for preclinical drug discovery and development research against sars-cov-2 (available from: https://www.ncbi.nlm.nih.gov/genbank/sars-cov-2-seqs/). it is good to point out that many drugs show in vitro effect (e.g., target and/or cellular assays) that may not last in vivo, in animal models, including humans. an ideal animal model of covid-19 should reflect the clinical signs, viral replication and pathology reported in humans. (193) in vivo animal infection experiments with sars-cov-2 require infrastructure of a biosafety level 3 laboratory, restricting scientific research to well-equipped research groups. animal models are indispensable, because they could identify toxic hits or molecules that could enhance covid-19 pathogenicity. table ii lists some compounds that have the potential to be clinically tested and that will be discussed in more details below in this topic. remdesivir (8) , a nucleotide analog pro-drug developed by gilead sciences inc. to fight ebola, acts on viral replication by inhibiting rna polymerase. (96) this molecule was also active against sars and mers viruses. (200, 201, 202) wang et al. demonstrated reduced viral copy numbers in cell culture supernatant of vero e6 cells infected with ncov-2019betacov/wuhan/wiv04/20192, in the presence of varying concentrations of remdesivir (8) . (194) this compound blocked virus infection at lowmicromolar concentration (ec 50 = 0.77 μm) and showed a high selectivity index (> 100). the authors also disclosed that remdesivir (8) inhibited virus infection efficiently in human liver cancer huh-7 cells. chloroquine (cq; 20) and its less toxic derivative, hydroxychloroquine (hcq; 26) , are used to treat malaria and lupus/rheumatoid arthritis, respectively. both drugs have already been described as possible antivirals. (195, 203, 204) cq (20) and derivatives probably act by decreasing acidity in endosomes and lysosomes, intervening on glycosylation of cellular virus receptors and modulating host immunological activity. (118, 205) studies in cultures of vero e6 cells have suggested that hcq (26) can affect the virus sars-cov-2 in both entry and post entry stages at host cells. (194) this molecule presented an ec 50 (196) the authors also performed in vitro physiologically based pharmacokinetic models for both drugs, separately. interestingly, when comparing toxicity in five animal models, mcchesney et al. demonstrated that hcq (26) is two to three times less toxic than cq (20) itself. (207) it is also good to point out that chloroquine (20) has shown in vitro activity against many different viruses, but no significant beneficial effect on animal models. (208) the association ritonavir (2)/lopinavir (1) is used together with other antiretrovirals for the treatment of human immunodeficiency virus since the beginning of the century. (209) ritonavir (2) is a potent cyp3a inhibitor therefore inhibiting the metabolism of lopinavir (1), increasing its plasma levels. both are reported as peptidomimetic molecules that inhibit hiv-1 protease activity in a competitive manner. (210) the m pro plays a major role in homeostasis of viral polyproteins essential for viral function and replication, being considered a validated drug target. (211) this combination may be useful against (194) chloroquine (20) (194, 195, 196) ritonavir (2) + lopinavir (1) lopinavir (1) nd (197) nitazoxanide (47) broad-spectrum antiparasitic and antiviral still needs confirmation 2.1 μm 16.8 (194) ivermectin (48) broad-spectrum antiparasitic still needs confirmation 2 μm nd (198) teicoplanin (27) antibiotic for gram-positive bacteria still needs confirmation 1.7 μm nd (199) sars-cov-2 virus by acting on its main protease, an enzyme essential in processing polyproteins translated from viral rna. (212) choy et al. demonstrated that it inhibits sars-cov-2 replication in vero e6 cells with ec 50 value of 26.6 μm. (197) these results corroborate with the study of de wilde et al. that demonstrated antiviral in vitro effect of lopinavir (1), but not ritonavir (2), against sars-cov, mers-cov, and hcov-229e, with mean ec 50 varying from 6.6 to 17.1 μm. (213) other compounds were also tested against sars-cov-2 in vitro. nitazoxanide (47), a broad-spectrum antiparasitic and antiviral, inhibits a low-micromolar range with an ec 50 of 2.1 μm but has a selective index of only 16.8. (194) ivermectin (48), another broad spectrum antiparasitic agent also demonstrated in vitro anti-sars-cov-2 activity. its ec 50 was determined to be 2 μm when added to vero-hslam cells 2 h post-infection and measuring viral rna at 48h post-infection. (198) teicoplanin (27) , an antibiotic used against gram-positive bacterial infections, was found to be active in vitro against sars-cov-2 with an ec 50 value of 1.7 μm, but in vivo efficacy still needs to be determined. (199) a robust preclinical drug discovery pipeline comprising in vitro, and in vivo models of sars-cov-2 infection is particularly important to identify new antivirals for human covid-19 treatment. this pipeline can munition clinical studies with molecules that have a higher chance to become a drug, decreasing attrition rates. clinical studies -over 1452 clinical trials have been unveiled, until the publication of this manuscript, focusing on covid-19 treatment interventions (available from: https://clinicaltrials.gov/ct2/results?cond=covid-19). with a growing number of patients suffering from acute severe respiratory symptoms and hospital capacities reaching its limit, therapeutic options are urgently essential to avoid human mass deaths. drug repurposing approaches of approved (with safe and effectiveness proven) and unapproved molecules, that were promising in pre-clinical and early stages of clinical studies of sars and mers, are in vogue. with this premise, world health organization (who) organised a simplified dynamic platform comparing the effectiveness of treatment strategies around the globe. this clinical trial design, called solidarity, can shrink by 80% the time of clinical studies, compared with the "gold standard" double-blind, placebo-controlled trials. this strategy could overcome the uncertainty of multiple small trials that do not produce a solid base necessary to establish the relative success of arising probable treatments. on the other hand, this shorter time required reflects the compassionate characteristic of the studies, that cannot rule out placebo effects and patient severe adverse effects, including death. (214) currently, who is focusing on four most promising therapies: remdesivir (8); cq (20) or hcq (26) ; ritonavir (2)/lopinavir (1); ritonavir (2) /lopinavir (1) plus interferon-beta, an immune response modulator. (44) a selection of studies with these drugs, alone or in combination, are summarised in table iii. for other studies, the reader can refer to kupferschmidt and cohen, which summarised several clinical studies on drug repurposing for covid-19 reported so far. (44) it is worth noting that many clinical studies are beginning to be carried out in different parts of the world and their number is increasing rapidly day by day. remdesivir (8), a nucleoside analogue that acts by inhibiting rna synthesis, is already in clinical studies for treatment of covid-19. (96) this prodrug was already investigated in clinical trial testing for ebola virus with no effect but showed efficiency against different types of coronaviruses in cell culture and animal models. (200, 221) from the drugs in the solidarity trial, remdesivir (8) has the best potential to be used in clinics, having a low toxicity profile to humans. (44) this molecule was used compassionately in the first covid-19 patient diagnosed in the united states by intravenous treatment and improved patient clinical condition. (222) grein et al. reported a study in a cohort of patients hospitalised for severe covid-19 who were treated with compassionateuse remdesivir (8) , clinical improvement was observed in 68% of the patients (36 of 53). (223) there are two clinical trials at phase iii, being designed to evaluate the efficacy and safety of parenteral remdesivir (8) in mild/moderate (nct04252664) and severe (nct04257656) hospitalised adults with covid-19. (224) these trials are evaluating intravenous remdesivir (8) at a dose of 200 mg on the first day plus 100 mg once daily, for an additional 9 consecutive days. the randomised, double-blind, placebocontrolled, multicentre trials were recently suspended (nct04252664) or terminated (nct04257656) because no eligible patients for enrollment were found, due pandemic control in china. (215) the study nct04257656 showed that remdesivir (8) was not associated with statistically significant clinical benefits in severe forms of covid-19. however, the authors observed a numerical reduction in time to clinical improvement in those treated earlier, but still requires confirmation. another study, performed by beigel et al. (with the same dosage and treatment period than the previous works cited above) enrolled 1063 patients with lower respiratory tract infection, demonstrated that individuals that were treated with remdesivir (8) had a shorter time to recovery than placebo group (11 days compared with 15 days). (216) even with a small scientific ballast, due to limited information about safety and effectiveness of using remdesivir (8), u.s. food and drug administration (fda) approved its emergency use on severe covid-19. (225) the approval was based on review of the topline data on two studies that are recruiting patients, (nct04280705) and (nct04292899). other clinical studies are being conducted to address the effect of remdesivir (8) on co-vid-19 treatment (available from: https://clinicaltrials. gov/ct2/results?cond=covid-19&term=remdesivir&cn try=&state=&city=&dist=). other phase iii clinical trials evaluated for co-vid-19 treatment included cq (20)/hcq (26) . these studies were endorsed by promising in vitro data that suggested an impairment of viral replication by acting on endosome-mediated viral entry or later phases of viral replication. (194, 226) both molecules have a well-studied toxicity profile being used for more than half-century as antimalarials, but in some cases can induce heart side (8) was not associated with clinical benefits in severe forms. however, an observed numerical reduction in time to clinical improvement in patients treated earlier, but still requires confirmation (215) ; nct04257656 (terminated by epidemic control in china with no eligible patients) remdesivir (8) (216) ; nct04280705 chloroquine (20) multicentre > 100 patients 500 mg per day, for 10 days compilation of various clinical studies that are in course, authors conclude that the dosage used could be sufficient (217) phase iib double-blind, randomised 81 patients 600 mg twice daily for 10 days and 450 mg twice on the first day, once daily for more 4 days higher dosage of chloroquine (20) has toxic effects and increased lethality, with any clinical benefit (218) hydroxychloroquine (26) non-randomised, non-double-blind, non-placebo-controlled 36 patients 600 mg of hydroxychloroquine (26) daily for 10 days hydroxychloroquine (26) significantly reduces viral load despite small sample size (219) ritonavir ( effects. (227) these drugs have already been examined against at least five other viruses with good initial in vitro results, but without significant effects in animal models and humans. (205) clinical trials to measure the effectiveness of cq (20) at 500 mg of chloroquine diphosphate (corresponding to 300 mg of chloroquine (20) base) per day, for ten consecutive days on the treatment of covid-19 were performed. (217) based on results for a very limited number of patients (100) , it was concluded that cq (20) presented apparent efficacy and acceptable safety against cov-id-19 associated pneumonia. borba et al. performed a double-blind, randomised clinical trial designed to assess the safety of cq (20) in two dosages: 600 mg twice daily for 10 days with an initial dose of 450 mg twice daily on the first day, decreasing to once daily for four more days. (218) the study suggests that the higher dosage should not be recommended for critically ill patients with covid-19 because of its potential side effects. it is important to note that both doses studied were above the brazilian recommended dose. a controversial study performed by gautret et al. with a small sample size demonstrated that hcq (26) treatment daily at 600 mg significantly decreases viral load in covid-19 patients and its effect is reinforced by azithromycin (az; 49) combination. (219) until this moment there is clinical robustness to support az (49) therapy in covid-19. (228) mehra et al. performed a registry analysis of 96,032 hospitalised patients regarding the use of cq (20) or hcq (26, combined or not with a macrolide) for treatment of covid-19. (229) the observational study verified that with covid-19 requiring hospitalisation a regimen containing cq (20) or hcq (26) had no evidence of benefit, but instead was associated with an increase in the risk of ventricular arrhythmias and a greater hazard for in-hospital death with covid-19. these findings suggest that these drug regimens should not be used outside of clinical trials and urgent confirmation from randomised clinical trials is needed. after the publication, the paper was retracted, which influenced who to return the studies on cq (20) and hcq (26) . (230) recently, on 17 june 2020, who stopped the hcq (26) arm of the solidarity trials again based on the recovery trials (available from: https://www.recoverytrial.net/). in this study 1542 patients were randomised to hcq (26) and compared with 3132 patients randomised to usual care alone. there was no significant difference in any of the parameters evaluated: the primary endpoint of 28-day mortality, hazard ratio and hospital stay duration or other issues. other study reported that hcq (26) did not prevent covid-19 when used as postexposure prophylaxis within 4 days after moderate or high-risk exposure. (231) robust data from well-designed control randomised clinical trials with large number of patients is still expected for concluding on the efficacy of hydroxychloroquine (26) . ritonavir (2) and lopinavir (1) were developed to target hiv-1 protease and postulated to inhibit the 3-chymotrypsin-like protease of sars and mers, being associated with improved clinical outcomes. (232) the combination has beneficial effects in marmoset monkeys infected with the mers-cov virus. (233) (1)/(2) may have clinical efficacy against sars-cov-2, as seen in the response against sars-cov. (234) in vitro sensitivity and satisfactory response in a preliminary non-randomised clinical trial of sars-cov to (1)/(2) have already been reported, encouraging its testing in sars-cov-2. (235) a total of 199 patients confirmed severe sars-cov-2 infection were randomly designated to be given either (1)/(2) (400 mg/100 mg) twice a day for 14 consecutive days plus standard care or standard care alone. (220) this first trial was not promising, no benefit was observed on clinical improvement, mortality and viral loads on severe covid-19 patients. other clinical trials are being carried out and should decide whether these drugs are useful for covid-19 treatment or not. ritonavir (2)/lopinavir (1) plus interferon-beta, a cytokine involved in inflammatory modulation, is the last bet of the solidarity megatrial. sheahan et al. demonstrated that this combination improves pulmonary function but does not reduce virus replication or severe lung pathology in mice model of mers-cov. (236) this combination also showed promising results in mers-cov infection in a nonhuman primate model. (233) the study (nct04276688) administered ritonavir (2)/lopinavir (1) 400 mg + 100 mg/ml twice daily for 14 days and interferon beta-1b 0.25 mg subcutaneous, every alternate day for 14 days. another study (nct04343768) will perform a randomised trial to verify the effects of interferon beta 1a, compared to interferon beta 1b and the base therapeutic treatment in moderate to severe covid-19. currently, there is a lot of research around the world examining drugs that can be used for the treatment of covid-19. unfortunately, until this moment no therapeutic options are promptly effectively available. most of the studies have a small number of patients with variable dose and/or duration, fact that hinders a comparison. to successfully undertake the covid-19 pandemic with new medicines, synchronised clinical trials with randomised, double-blind, placebo-controlled are still needed. infection prevention by social distancing and supportive medical care, are the only strategies to deal with this disease until this moment. the goal of this session is to consider potential obstacles for effective adoption of a repurposed drug to widespread treatment of covid-19. both patent protection and scalability of manufacturing processes are key aspects to consider while choosing the best therapeutic option to adopt when dealing with a pandemic. a patent can be defined as a government license that confers the owner the exclusivity over a new invention or medication. with the patent, the inventor is able to exclude others from making and selling the invention for a determined period of time. when it comes to medication, the market exclusivity granted by the patent generates enormous economic profit for the patent holder, once the company will have the monopoly over the product for around 20 years. once the patent term finishes, generic companies can start producing and selling the drug, increasing the market competition over the product. a strategy adopted by some companies is to maximise the term of patent of successful products, extending market exclusivity, for instance, increasing economic rewards with the invention. in order to extend patent terms, the companies can apply for new formulations, new routes of administration, new uses of the drug among other strategies. (237, 238) this is very important when considering drug repurposing, once those strategies can make it harder to patent a new method of use for the drug, compromising the legal rights of the new repurposed indication. as a consequence, the expected profit associated with repurposing can be severely affected. (39) remdesivir (8) a good example of maximising the term of patent is the drug remdesivir (8) , which was developed by the american pharmaceutical company gilead sciences, inc. in 2011. nowadays, (8) has shown promising results as a suitable repurposed drug in the treatment of the covid-19 disease. indeed, there are many ongoing clinical trials with this drug in cov-id-19 patients. (239, 240) due to the good results concerning remdesivir (8) , in january 2020, the wuhan institute of virology applied for a patent on gilead's remdesivir (8) for the treatment of coronavirus, in an attempt to protect china's economic and medical interests. however, remdesivir (8) has already 133 patents related to the coronavirus filed by gilead science in 43 countries around the globe since 2011. in fact, the company has a robust patent portfolio that includes structures of remdesivir-related compounds (family 1), the manufacturing method of the drug (family 2), the use of remdesivir (8) in treating coronaviridae infection (family 3), among other patents that claims the use of (8) for the treatment of a series of viral infections (families 3 and 4) (fig. 13) . (241) practically, this means that if the (8) is proved to be efficient for the treatment of covid-19, gilead science is the only pharmaceutical company owing the market exclusivity of the drug, at least until 2031. in fact, the company has already started to produce larger amounts of the drug and they already made improvements to optimise the drug manufacturing timeline. now, the company can produce the drug in 6 months, half the time that they used to need to get the final product. in addition, the company has been donating remdesivir (8) to ongoing clinical trials, a gesture that will not only help the trial patients, but gilead itself. (242) baricitinib (39) -in 2009, a patent assigned to incyte corporation disclosed the preparation of several active compounds as jak inhibitors, including baricitinib (39). in the same year, lilly and incyte made an agreement allowing lilly co. to manufacture and commercialise the medicine worldwide, making it lilly co. the only supplier around the globe. (243) there are two patents that protect the drug, one concerning its synthetic pathway and another disclosing the use of (39) in the treatment of rheumatoid arthritis. both of them will expire in nine years, which could open opportunities for generic drug companies to produce baricitinib (39) . nowadays, (39) has been investigated as a drug that could be used in the treatment of covid 19 patients, since its anti-inflammatory activity could minimise inflammatory compli-cations in covid 19 patients. according to the platform clinicaltrials.gov, there are 14 ongoing clinical trials to evaluate the efficacy and safety of baricitinib (39) in the treatment of covid 19. (244) if the drug succeeds, there will be a need for larger and faster production and distribution of the medicine worldwide. there are two patents disclosing a synthetic method for the preparation of (39). the first one is from 2009 and owned by incyte co. and the latest is from 2016, by lilly co. (245, 246) the main difference between them is how the central pyrazole ring is installed in the molecule. in the patent from 2009, baricitinib (39) is obtained by a convergent synthesis. the synthetic pathway starts with the protection in position 7 of 4-chloro-7h-pyrrolo[2,3d]pyrimidine (50) using 2-(trimethylsilyl)ethoxymethyl chloride (51) , affording intermediate (52) . next step is a suzuki-miyaura reaction, coupling the fused ring system to a 4-pyrazoleboronic acid pinacol ester (53), giving key intermediate (54) . parallelly, a couple of steps starting from 2-(chloromethyl)oxirane (55) lead to 1-boc-3-azetidinone (58) that reacts with diethyl cyanomethylphosphonate (59), affording key intermediate (60) . next, the key intermediates (54) and (60) react in the presence of dbu, giving (61) . then, steps involving hydrolysis of the boc, sulfonation and pyrrolopyrimidine deprotection afford (39) with an overall yield of 21 % (fig. 14) . (246) the synthetic pathway described in the patent from 2016 has only six steps in a linear approach, as a consequence, the product is obtained in a higher overall yield when compared to the synthetic pathway discussed above. intermediate (67) is obtained from azetidine-3-ol (64) in a couple of steps, including a sulfonation, an oxidation and the installment of the cyanomethylene moiety (fig. 15 ). furthermore, it is not necessary to protect any position in this sequence. additionally, the oxidation step can be performed under flow conditions. then, intermediate (67) is reacted with ester (53), affording (68) . a suzuki-miyaura reaction involving 7-boc-4-chloro-7hpyrrolo [2,3-d] pyrimidine (69) is applied, allowing the formation of the bound between the azetidinylpyrazole group and the pyrrolo[2,3-d]pyrimidine system. last step is a hydrolysis of the boc, affording baricitinib (39) with an overall yield of 50 % (fig. 15 ). (245) off-patent drugs -fortunately, a number of drugs that have been tested as possible agents in the covid-19 treatment are off-patent, meaning that generic drug companies already manufacture and commercialise the medicine, making it easier for drug repurposing. (39) the off-patent drugs that have been tested in covid-19 clinical trials include cq (20) , hcq (26), ritonavir (2) and lopinavir (1) . (239, 240) a recent research article published by hill and collaborators estimated the minimum cost of production associated with these drugs, showing that all the treatments under evaluation in current clinical trials are cheap to manufacture. however, list prices can be over 100 times higher than the costs to produce the drug. (247) if any of those drugs become approved for the treatment of covid-19, its demand will increase dramatically. therefore, it is important to consider the challenges associated with scaling up the production to meet the demand. for instance, there are few regulatory approved production facilities, and drug manufacturers rely on low-cost suppliers of raw materials in india and china, which might be scarce during a pandemic. consequently, it would be difficult to ensure short term global availability of the treatment, since the production depends on different countries. (248) those conclusions are very helpful in showing the importance of optimising the way of manufacturing the candidate drugs presented above. for this reason, recent and optimised synthetic pathways found in patents and articles for some ritonavir (2) and lopinavir (1) are discussed below, as cq (20) and hcq (26) have now been abandoned. finally, we will briefly discuss the ease of manufacturing in large scale each of the drugs we had the synthesis reviewed here. ritonavir (2) -the first disclosure of ritonavir (2) is presented in a patent from 1994, assigned to abbott laboratories. even though the patent consists of a range of markush structures, among which is found (2), its synthesis is not presented. (249) the synthetic pathway to obtain (2) was disclosed for the first time in a second-generation patent in 1995, by the same company. (250, 251) some drawbacks related to the synthesis presented by abbott include the employment of expensive condensing agents, as 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide (edc) and poor reaction yields on the first steps of the synthetic pathway, making this strategy too expensive and not suitable for scale-up production. considering the above deficiencies, a recent chinese patent concerning the synthesis of ritonavir (2) has been released. the synthetic pathway described in the patent starts with a nucleophilic addition-elimination reaction between the starting material (2-isopropylthiazol-4-yl)-nitro-methylamine (71) and n-[(2,2,2-trichloroethoxy)carbonyl]-l-valine (72), generating intermediate (73) . the intermediate is mixed with p-toluenesulfonyl chloride and triethylamine to activate the acid function, followed by the addition of reagent (74) in a one-pot procedure. the condensation allows the formation of intermediate (75) , which is submitted to acidic conditions for a boc deprotection, followed by another nucleophilic additionelimination reaction with reagent (76), thus obtaining the final product ritonavir (2) (fig. 16) . (252) when comparing both patents, it is possible to highlight important advantages present in the latest one, including the use of cheap and easily available reagents, for instance, the use of ptoluenesulfonyl chloride as an amide condensing agent, the synthetic pathway has a high yield (79% overall), low cost and it is ease to scale-up the production. lopinavir (1) -the first synthetic methods related to the synthesis of lopinavir (1) are present in a patent from 1996 owned by abbott laboratories. (249) (1) has 4 chiral centres, and the synthetic strategies reported by abbott are similar, involving the synthesis of a key intermediate amino alcohol unit, that is then connected to the appropriated side chains. some drawbacks that can be pointed out in the synthesis include the use of 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (edc) as a condensing agent and the weak base 1-hydroxybenzotriazole, both expensive reagents, making the synthesis not suitable from the viewpoint of cost and industrial ap-plication. in addition, one of the methods described by abbott includes the synthesis of an acid chloride as an intermediate, which is very unstable, and it can be easily decomposed by humidity, making the synthesis not suitable for industrial production. the most recent patent related to the synthesis of lopinavir (1) is dated 2018 and it is from the chinese company shanghai desano pharmaceuticals co. ltd. (253) the patent is described as technical, with the aim of improving the synthesis of (1) presented in the patent from 1996, by abbott laboratories. the patent describes the synthesis of lopinavir (1) by a one-pot procedure starting with the formation of an acid chloride from (2s)-(1tetrahydropyramid-2-one)-3-methylbutanoic acid (77) followed by addition of a weak base and the reactant (78) to the reaction system. the amine function of (78) allows a nucleophilic addition-elimination reaction to occur, affording (1) after treatment with nahco 3 (fig. 17 ). therefore, it is possible to synthesise lopinavir (1) in high yield (90%) in an optimised method, which involves a few reagents, mild conditions and is performed in a one-pot procedure. synthetic scalability and cost-effectiveness -the synthetic pathways described above show how much improvement has been done concerning the preparation of these drugs in a more cost-effective way. furthermore, when comparing the drugs discussed above, it is worth pointing out which one could be the easiest one to produce when analysing the factors that influence the final cost of a synthetic pathway, such as chiral centres, cost of starting materials, number of steps and overall yield. regarding chiral centres, ritonavir (2) and lopinavir (1) have four chiral centres each, and they are not sold as racemate mixtures. moreover, to synthesise those compounds the chiral centres do not come from natural molecules, but have to be synthetically installed, which makes the chiral starting materials more expensive and enantiomeric excess has to be accessed more carefully at the end of the synthetic pathway. as a consequence, it can take longer and more expensive to obtain the final product. on the other hand, baricitinib (39) does not have any chiral centres, making the synthetic pathway easier and cheaper to perform. concerning the number of steps and overall yield, baricitinib (39) has the highest number of steps and lower overall yield when compared to ritonavir (2) and lopinavir (1) . however, one of the steps in the synthesis of baricitinib (39) can be performed under flow conditions, which is very interesting from the industrial point of view. therefore, when taking into account the most recent synthetic pathways proposed for these drugs, the synthesis of baricitinib (39) is the most cost-effective of the three of them. in conclusion -sars-cov-2 infection is a lifethreatening disease with such a high transmission rate that can surpass even the most well-structured health systems in developed high-income countries. while vaccines are the ideal solution for preventing the spread of infectious diseases like covid-19 their development cycle have intrinsic challenges and safety checking steps that require several months or years to complete their development. a similar situation is found for developing new drugs for covid-19 (as with any other disease), because of the long process involving discovery, validation and safety evaluation of new chemical entities for use in human health. in this scenario, repositioning drugs already in clinical use for treatment of covid-19 is an important shortcut, as we have discussed. data are accumulating about the molecular pathology of covid-19 as well as structural information on the viral and host proteins involved in the infection mechanism. this knowledge is essential for allowing researchers to have new insights on approved or investigational drugs that can be repurposed to treat sars-cov-2 infection. as reviewed here, over 10 targets distributed amongst distinct steps of the sars-cov-2 replication cycle or host cell mediators are currently being investigated. here, we highlighted several up-to-date examples of potential repurposable drug candidates proposed from either computational approaches or experimental trials (or their combination) at different levels of validation and stages of development. noteworthy, ai methods hold a great promise in finding occult links between drugs, human and viral targets to find novel bioactivities and even combinations of drugs. remdesivir (8) , cq (20)/hcq (26) (alone or in association with other drugs) and the association lopinavir (1)/ritonavir (2) have been the focus of most clinical studies. so far, results have been mostly disappointing with these trials, stressing the importance of carefully performed studies in patients to attest that biological activities observed in vitro actually be translated into clinical efficacy and safety. at the moment, even with limited information about safety and effectiveness, remdesivir is the only drug approved by the fda for emergency use on severe covid-19. as discussed here, a major concern with drugs for effectively fighting the pandemic is the drug's industrial production cost and its impact on final treatment cost. gilead, remdesivir's owner company, has recently signed non-exclusive voluntary licensing agreements with five generic pharmaceutical 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combination of pharmacophore modeling, molecular docking and molecular dynamics simulation approaches withanone and withaferin-a are predicted to interact with transmembrane protease serine 2 (tmprss2) and block entry of sars-cov-2 into cells mechanisms of clathrin-mediated endocytosis the endosomal-lysosomal system: from acidification and cargo sorting to neurodegeneration cathepsin l-selective inhibitors: a potentially promising treatment for covid-19 patients interleukin-6 family cytokines cytokines and cytokine receptors covid-19: consider cytokine storm syndromes and immunosuppression covid-19: consider il-6 receptor antagonist for the therapy of cytokine storm syndrome in sars-cov-2 infected patients the carbohydrate-active enzymes database (cazy) in 2013 influenza virus neuraminidase structure and functions coronavirus infections and type 2 diabetesshared pathways with therapeutic implications dpp4 inhibition: preventing sars-cov-2 infection and/or progression of covid-19? covid-19 and diabetes: can dpp4 inhibition play a role? emerging wuhan (covid-19) coronavirus: glycan shield and structure prediction of spike glycoprotein and its interaction with human cd26 dipeptidyl peptidase-4 (dpp4) inhibition in covid-19 is dpp4 inhibition a comrade or adversary in cov-id-19 infection boosting the arsenal against covid-19 through computational drug repurposing déjà vu: stimulating open drug discovery for sars-cov-2 repurposing therapeutics for covid-19: supercomputer-based docking to the sars-cov-2 viral spike protein and viral spike protein-human ace2 interface peptide-like and small-molecule inhibitors against covid-19 baricitinib as potential treatment for 2019-ncov acute respiratory disease de novo design of new chemical entities (nces) for sars-cov-2 using artificial intelligence deeppurpose: a deep learning library for drug-target interaction prediction and applications to repurposing and screening a data-driven drug repositioning framework discovered a potential therapeutic agent targeting covid-19 natural bis-benzylisoquinoline alkaloids-tetrandrine, fangchinoline, and cepharanthine, inhibit human coronavirus oc43 infection of mrc-5 human lung cells inhibition of sars-cov 3cl protease by flavonoids small molecules blocking the entry of severe acute respiratory syndrome coronavirus into host cells atazanavir inhibits sars-cov-2 replication and pro-inflammatory cytokine production baricitinib therapy in covid-19: a pilot study on safety and clinical impact gromacs: high performance molecular simulations through multi-level parallelism from laptops to supercomputers autodock vina: improving the speed and accuracy of docking with a new scoring function, efficient optimization, and multithreading sweetlead: an in silico database of approved drugs, regulated chemicals, and herbal isolates for computer-aided drug discovery drugbank 5.0: a major update to the drugbank database for 2018 chembl: towards direct deposition of bioassay data bindingdb: a web-accessible database of experimentally determined proteinligand binding affinities uniprot: the universal protein knowledgebase graph convolutional neural networks for predicting drug-target interactions graph convolutional networks: a comprehensive review bere: an accurate distantly supervised biomedical entity relation extraction network recent trends in deep learning based natural language processing deep learning in natural language generation from images deep learning self-attention based molecule representation for predicting drug-target interaction inductive transfer learning for molecular activity prediction: next-gen qsar models with molpmofit a survey on deep transfer learning the sars, mers and novel coronavirus (covid-19) epidemics, the newest and biggest global health threats: what lessons have we learned? covid-19, sars and mers: are they closely related? overlapping and discrete aspects of the pathology and pathogenesis of the emerging human pathogenic coronaviruses sars-cov, mers-cov, and 2019-ncov drug target validation: hitting the target coronaviridae study group of the international committee on taxonomy of viruses. the species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2 multiparametric assays for accelerating early drug discovery laboratory safety aspects of sars at biosafety level 2 animal models for sars and mers coronaviruses remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro to zika and destroy: an antimalarial drug protects fetuses from zika infection in vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) remdesivir, lopinavir, emetine, and homoharringtonine inhibit sars-cov-2 replication in vitro the fda-approved drug ivermectin inhibits the replication of sars-cov-2 in vitro teicoplanin potently blocks the cell entry of 2019-ncov broad-spectrum antiviral gs-5734 inhibits both epidemic and zoonotic coronaviruses an orally bioavailable broad-spectrum antiviral inhibits sars-cov-2 in human airway epithelial cell cultures and multiple coronaviruses in mice prophylactic and therapeutic remdesivir (gs-5734) treatment in the rhesus macaque model of mers-cov infection potential antivirals and antiviral strategies against sars coronavirus infections chloroquine and hydroxychloroquine in covid-19 targeting endosomal acidification by chloroquine analogs as a promising strategy for the treatment of emerging viral diseases hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting sars-cov-2 infection in vitro animal toxicity and pharmacokinetics of hydroxychloroquine sulfate of chloroquine and covid-19. antiviral res hiv protease inhibitors: a review of molecular selectivity and toxicity anti-hiv drugs: 25 compounds approved within 25 years after the discovery of hiv 3clpro inhibitors as a potential therapeutic option for covid-19: available evidence and ongoing clinical trials computational studies of drug repurposing and synergism of lopinavir, oseltamivir and ritonavir binding with sars-cov-2 protease against covid-19 screening of an fda-approved compound library identifies four small-molecule inhibitors of middle east respiratory syndrome coronavirus replication in cell culture treating covid-19 -off-label drug use, compassionate use, and randomized clinical trials during pandemics remdesivir in adults with severe covid-19: a randomised, double-blind, placebo-controlled, multicentre trial remdesivir for the treatment of covid-19 -preliminary report breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of covid-19 associated pneumonia in clinical studies effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 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out a winner fierce pharma gilead turbocharges production of covid-19 hopeful remdesivir lilly and incyte announce collaboration for development and commercialization of oral anti-inflammatory and autoimmune therapies search results: baricitinib | covid-19 processes and intermediates for the preparation of {1(ethylsulfonyl)-3 inventors; incyte corporation assignee 2009. azetidine and cyclobutane derivatives as jak inhibitors. united states patent us 2009/0233903 a1 minimum costs to manufacture new treatments for covid-19 dozens of coronavirus drugs are in development -what happens next? inventors; abbott laboratories assignee 1995. process for the preparations of a substituted 2,5-diamino-3-hydroxyhexane discovery of ritonavir, a potent inhibitor of hiv protease with high oral bioavailability and clinical efficacy zhou z, inventors; guizhou yongnuo feite bio pharmacy co ltd assignee 2019. preparation method of ritonavir. chinese patent cn 109369562a inventors; yancheng desano pharmaceutical co ltd assignee 2018. method used for preparing lopinavir using one-pot method. chinese patent cn 108218791a all authors contributed to writing, reviewing and editing the manuscript. mrs, tcse and rfd contributed equally to this manuscript; fps-jr performed the manuscript conceptualisation and final review. the authors declare no conflict of interest concerning this manuscript. key: cord-003878-nmyyt51x authors: de campos, fernando peixoto ferraz title: what does the future hold? date: 2012-03-30 journal: autops case rep doi: 10.4322/acr.2012.001 sha: doc_id: 3878 cord_uid: nmyyt51x nan since ancient times the knowledge of the human body and physiologic theories were obtained secretly, against the laws of the catholic church, through exhumation followed by anatomic dissection of newly buried persons. from those times, the importance of post-mortem study for the advance of medical knowledge was noted. in this context, the nineteenth century saw the heyday of the autopsy. since then, autopsy has been responsible for the progression of clinical medicine, medical education, epidemiology, and public health. from the 1950s up until 1990, 87 diseases were identified by autopsy. the discovery of severe acute respiratory syndrome (sars) epidemic in 2003 and the avian flu epidemic in 2006 were through autopsy as well. many researchers recognize the immeasurable value of autopsy for clinical, educational, epidemiological, and research purposes. dr. lundberg, a pathologist and former editor of jama, once said: "medicine without the autopsy would not be worth being part of." the information obtained from autopsies not only instructs and confirms diagnoses, but also serves as a pathway of study and a source of investigation, a necessary tool in elucidating the changing spectrum of diseases. autopsies have, in the past, shed light on the mechanisms of diseases that cannot be elicited in the living being and they continue to do so to this day. knowledge of diseases of the brain and the heart relies greatly on autopsies. important examples include the recognition of variant creutzfeldt-jakob disease, delineation of reye's syndrome, wernicke-korsakoff syndrome and thiamine deficiency, and so on. as an instrument for teaching, by correlating pathology with clinical context, autopsy remains unrivalled. teaching based on autopsies furnish valuable skills, some of which are not easily learnt elsewhere. autopsies' most powerful benefit is a quality assurance instrument. the continuous study of the clinico-pathological discrepancies may show the improvement of medical care in time. the discovery of these discrepancies in the autopsy room is a powerful tool for identifying faults in medical practice and shows the need for clinical audits. autopsy results improve death certificate accuracy. they may also alleviate the grieving process by furnishing sensitive and reasonably full information concerning the death; they may even provide the disclosure of a genetic malady, which can be investigated among the close relatives. infectious diseases may also be detected during the autopsy that could affect family members. regardless of all these advantages, conversely, there is a gradual and progressive decline in the number of hospital autopsies undertaken. at present, anecdotal evidence suggests that the average non-coronial hospital autopsy rate of adult deceased is less than 10%. this decline extends overseas to the east, including china and oceania. several reasons are speculated to explain this process that has been occurring most notably in the last 40 years. one of the main contributing factors to this decline is that clinicians do not want autopsies done. their reasons vary from distaste for the procedure to a belief that the accuracy of modern investigative techniques avoids the need of autopsy in elucidating nothing extra to the clinical picture. the self-confidence comes mainly from the improvement in the imaging techniques and laboratory resources. their increasing clinical confidence in the ante-mortem diagnoses supplants their need to request autopsies. this approach does not match the scientific basis, since several reports show persistent clinico-pathological discrepancies of 10-30%. these discrepancies may be higher in the context of hiv, elderly patients, critically-ill patients, as well as fetus and neonate autopsies. paradoxically, community doctors generally show that they appreciate receiving autopsy reports and that, in a high proportion of cases, the findings are unexpected and could influence their future clinical practice. fear of malpractice suits may also have a role in discouraging physicians to ask for post-mortem examinations. moreover, in many instances, pathologists fail to give sufficient priority to autopsies, probably due to increasing workloads from surgical resections, biopsies, and cytology. the continuous changes in medical school curricula results in many students graduating without ever having seen an autopsy due to competing departmental demands, limited curriculum time, and an insufficient number of hospital autopsies. how can it be expected that these future doctors may believe in the benefits of the autopsy and request it in their routine practice? other reasons for fewer autopsy requests include the doctor's discomfort in asking for the family's consent. doctors are not trained for, nor even convinced of, the gain of going ahead with the procedure. it is common in many institutions for the clinician to have no contact with the family before the patient's death. this makes it more difficult for a clinician to approach the family for an autopsy. we believe that obtaining consent from a family, in most cases, can be easier than expected. the family quite often feels relief with the autopsy information. in most cases the clear understanding of the disease and death process accompanied by the disclosure that nothing else could be done that would have altered the fatal evolution, promotes some comfort. in contrast, in the uk, an increased demand for alternative procedures for post-mortem examinations due to religious objections to autopsy, among the jewish and muslim communities has been noticed. therefore, post-mortem imaging was introduced with minimally invasive alternatives. many studies try to validate this approach to the diagnosis of the cause of death in coronial autopsies. in this case, computed tomography seems to be slightly superior than magnetic resonance image. despite the fact that radiologists can provide a cause of death accepted by the coroner without autopsy in 90% of cases, other investigators doubt this accuracy. a major discrepancy existed in 30% of randomly selected cases between autopsy and imaging. due to these limitations, in the context of the determination of the cause of death, we dare to consider imaging as an auxiliary instrument to improve autopsy accuracy-but it is far from a substitute method. much effort and commitment is needed to reverse the declining number of autopsies trend. this reversion process involves the medical school's graduation committee, those involved in teaching programs, the pathology department of the hospital, and the hospital administration. also, the general community needs to be better informed about the value of autopsy. it is fundamental to discuss issues related to autopsies in a similar manner to organ donations. pathologists and clinicians as a whole should engage in measures to enhance community knowledge of the autopsy and its value. does modern medicine still need autopsy? the answer is affirmative. if clinical autopsy rates continue to decline, the future practice of medicine will be blind to many adverse consequences of clinical actions and omissions. we advocate close communication between pathologists and clinicians in the context of the results of autopsy findings. this relationship is a strong instrument in the perpetuation of autopsy for the excellence of clinical practice. in this regard, our institution promotes weekly autopsy meetings and publishes a scientific journal with autopsy reports. in the near future, we hope to extend these meetings to other institutions by video conferences. as teachers in a teaching hospital, we still face the challenge of ensuring that medical students and residents take part in these clinico-pathological debates and sessions focused on autopsies. post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: validation study fluctuations in the rate of autopsy in china the impact of declining clinical autopsy: need for revised healthcare policy what does the future hold? the conventional autopsy in modern medicine the royal college of pathologists of australasia autopsy working party. the decline of the hospital autopsy: a safety and quality issue for healthcare in australia death of the teaching autopsy são paulo/sp -brazil e-mail: ffcampos@usp.br 7. the royal college of pathologists of australasia. autopsies and the use of tissues removed from autopsies. document number 106581. durham hall a survey of general practitioners' views on autopsy reports key: cord-336563-hwemigk7 authors: bhimraj, adarsh; morgan, rebecca l; shumaker, amy hirsch; lavergne, valery; baden, lindsey; cheng, vincent chi-chung; edwards, kathryn m; gandhi, rajesh; muller, william j; o’horo, john c; shoham, shmuel; murad, m hassan; mustafa, reem a; sultan, shahnaz; falck-ytter, yngve title: infectious diseases society of america guidelines on the treatment and management of patients with covid-19 date: 2020-04-27 journal: clin infect dis doi: 10.1093/cid/ciaa478 sha: doc_id: 336563 cord_uid: hwemigk7 background: there are many pharmacologic therapies that are being used or considered for treatment of covid-19. there is a need for frequently updated practice guidelines on their use, based on critical evaluation of rapidly emerging literature. objective: develop evidence-based rapid guidelines intended to support patients, clinicians and other health-care professionals in their decisions about treatment and management of patients with covid-19. methods: idsa formed a multidisciplinary guideline panel of infectious disease clinicians, pharmacists, and methodologists with varied areas of expertise. process followed a rapid recommendation checklist. the panel prioritized questions and outcomes. then a systematic review of the peer-reviewed and grey literature was conducted. the grading of recommendations assessment, development and evaluation (grade) approach was used to assess the certainty of evidence and make recommendations. results: the idsa guideline panel agreed on 7 treatment recommendations and provided narrative summaries of other treatments undergoing evaluations. conclusions: the panel expressed the overarching goal that patients be recruited into ongoing trials, which would provide much needed evidence on the efficacy and safety of various therapies for covid-19, given that we could not make a determination whether the benefits outweigh harms for most treatments. a c c e p t e d m a n u s c r i p t it is important to realize that guidelines cannot always account for individual variation among patients. they are assessments of current scientific and clinical information provided as an educational service; are not continually updated and may not reflect the most recent evidence (new evidence may emerge between the time information is developed and when it is published or read); should not be considered inclusive of all proper treatments methods of care, or as a statement of the standard of care; do not mandate any particular course of medical care; and are not intended to supplant physician judgment with respect to particular patients or special clinical situations. whether and the extent to which to follow guidelines is voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances. while idsa makes every effort to present accurate, complete, and reliable information, these guidelines are presented "as is" without any warranty, either express or implied. idsa (and its officers, directors, members, employees, and agents) assume no responsibility for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with these guidelines or reliance on the information presented. the guidelines represent the proprietary and copyrighted property of idsa. copyright 2020 infectious diseases society of america. all rights reserved. no part of these guidelines may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of idsa. permission is granted to physicians and health care providers solely to copy and use the guidelines in their professional practices and clinical decision-making. no license or permission is granted to any person or entity, and prior written authorization by idsa is required, to sell, distribute, or modify the guidelines, or to make derivative works of or incorporate the guidelines into any product, including but not limited to clinical decision support software or any other software product. except for the permission granted above, any person or entity desiring to use the guidelines in any way must contact idsa for approval in accordance with the terms and conditions of third-party use, in particular any use of the guidelines in any software product. executive summary covid-19 is a pandemic with a rapidly increasing incidence of infections and deaths. many pharmacologic therapies are being used or considered for treatment. given the rapidity of emerging literature, idsa identified the need to develop living, frequently updated evidence-based guidelines to support patients, clinicians and other health-care professionals in their decisions about treatment and management of patients with covid-19. summarized below are the recommendations with comments related to the clinical practice guideline for the treatment and management of covid-19. a detailed description of background, methods, evidence summary and rationale that support each recommendation, and research needs can be found online in the full text. in brief, per grade methodology, recommendations are labeled m a n u s c r i p t as "strong" or "conditional". the word "recommend" indicates strong recommendations and "suggest" indicates conditional recommendations. in situations where promising interventions were judged to have insufficient evidence of benefit to support their use and with potential appreciable harms or costs, the expert panel recommended their use in the context of a clinical trial. the guideline panel used the word "only" in recommendations about therapeutic agents with higher uncertainty and/or more potential for harm. these recommendations acknowledge the current "knowledge gap" and aim at avoiding premature favorable recommendations for potentially ineffective or harmful interventions. the panel expressed the overarching goal that patients be recruited into ongoing trials, which would provide much needed evidence on the efficacy and safety of various therapies for covid-19. the panel determined that when an explicit trade-off between the highly uncertain benefits and the known putative harms of these therapeutic agents were considered, a net positive benefit was not reached and could possibly be negative (risk of excess harm). the panel acknowledges that enrolling patients in rcts might not be feasible for many frontline providers due to limited access and infrastructure. should lack of access to clinical trials exist, we encourage setting up local or collaborative registries to systematically evaluate the efficacy and safety of drugs to contribute to the knowledge base. each clinician can play a role in advancing our understanding of this disease through a local registry or other data collection efforts. m a n u s c r i p t background the first cases of coronavirus disease 2019 (covid-19) were reported from wuhan, china in early december 2019 [1] , now known to be caused by a novel beta-coronavirus, named as severe acute respiratory syndrome coronavirus 2 (sars-cov-2). within a span of months covid 19 has become pandemic due to its transmissibility, spreading across continents with the number of cases and deaths rising daily [2] . although most infected individuals exhibit a mild illness (80%+), 14% have serious and 5% have critical illness. approximately 10% will require hospital admission due to covid-19 pneumonia, of which approximately 10% will require icu care, including invasive ventilation due to acute respiratory distress syndrome (ards) [3] . while mortality appears to be more common in older individuals and those with comorbidities, such as chronic lung disease, cardiovascular disease, hypertension and diabetes, young people with no comorbidities also appear to be at risk for critical illness including multi-organ failure and death. there has been an expanding number of studies rapidly published online and in academic journals; however, some of these may be of limited quality and are pre-published without sufficient peerreview. critical appraisal of the existing studies is needed to determine if the existing evidence is sufficient to support currently proposed management strategies. given the rapid global spread of sars cov-2 and the difficulty for the overburdened front-line providers and policymakers to stay up to date on emerging literature, idsa has recognized the necessity of developing a rapid guideline for the treatment of covid-19. the guideline panel used a methodologically rigorous process for evaluating the best available evidence and providing treatment recommendations. two additional guidelines on diagnostic testing and infection prevention are also under development. these guidelines will be frequently updated as substantive literature becomes available and will be accessible on an easy to navigate web and device interface at http://www.idsociety.org/covid19guidelines. the guideline panel considered making a recommendation for therapeutic agents that were currently available for use. the panel chose not to give a recommendation for remdesivir as it is mostly available in the context of ongoing trials with limited availability for compassionate use and expanded access use. we anticipate data from rcts for remdesivir will be soon available; at that point, we will update the guidelines to provide formal recommendations on its use. there are several ongoing trials evaluating therapeutic agents for the treatment of covid-19. as data becomes available from these trials and if there is a preponderance of evidence to suggest the use of a therapeutic agent even in the context of clinical trials is no longer warranted it will be removed from future updates of the guideline (and the removal will be noted in the updated a c c e p t e d m a n u s c r i p t guidelines). if there is emerging evidence on the efficacy or safety of a therapeutic agent not mentioned in the current version of the guideline it will be included in future updates of the guideline. these recommendations are intended to inform patients, clinicians, and other health professionals by providing the latest available evidence. this guideline was developed using the grade approach for evidence assessment. in addition, given the need for an urgent response to a major public health crisis, the methodological approach was modified according to the gin/mcmaster checklist for the development of rapid recommendations [4] . the panel was composed of nine members including front line clinicians, infectious diseases specialists who are members of the idsa, the hiv medical association (hivma), the society for healthcare epidemiology of america (shea), and the pediatric infectious diseases society (pids). they represented the disciplines of public health, pharmacology, pediatrics, medical microbiology, preventive care, critical care, as well as hepatology, nephrology and gastroenterology. the evidence foundation provided technical support and guideline methodologists for the development of this guideline. the conflict of interest (coi) review group included two representatives from idsa who were responsible for reviewing, evaluating and approving all disclosures. all members of the expert panel complied with the coi process for reviewing and managing conflicts of interest, which required disclosure of any financial, intellectual, or other interest that might be construed as constituting an actual, potential, or apparent conflict, regardless of relevancy to the guideline topic. the assessment of disclosed relationships for possible coi was based on the relative weight of the financial relationship (i.e., monetary amount) and the relevance of the relationship (i.e., the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). the coi review group ensured that the majority of the panel and chair was without potential relevant (related to the topic) conflicts. the chair and all members of the technical team were determined to be unconflicted. m a n u s c r i p t clinical questions were developed into a pico format (population, intervention, comparison, outcomes) [5] prior to the first panel meeting. panel members prioritized questions with available evidence that met the minimum acceptable criteria (i.e., the body of evidence reported on at least a case-series design, case reports were excluded). panel members prioritized patient-important outcomes such as mortality, development of ards (need for non-invasive or invasive ventilation) and clinical improvement (such as disease-oriented outcomes inferred by radiological findings or virologic cure), and severe adverse events leading to treatment discontinuation. additional drug specific harms were evaluated when clinically relevant, including possible drug-drug reactions, if applicable. the nice highly-sensitive search was reviewed by the methodologist in consultation with the technical team information specialist and was determined to have high sensitivity [6] . an additional term, covid, was added to the search strategy used in addition to the treatment terms identified in the pico questions (supplementary table s1 ). ovid medline and embase were searched from 2019 through april 4, 2020. horizon scans were performed daily during the evidence assessment and recommendation process to locate additional grey literature and manuscript pre-prints. reference lists and literature suggested by panelists were reviewed for inclusion. no restrictions were placed on language or study type. two reviewers independently screened titles and abstracts, as well as eligible full-text studies. when acceptable randomized controlled trials of effectiveness were found, no additional non-randomized studies or non-comparative evidence (i.e., single arm case series) were sought. evidence from single arm studies reporting on non-comparative rates of outcomes of interest were included if a historical control event rate could be estimated from the literature. reviewers extracted relevant information into a standardized data extraction form. for several interventions, no direct evidence was available other than case reports or mechanistic considerations. the panel either decided to include plausible indirect evidence and make a recommendation (e.g., from studies of sars-cov) or to provide a short narrative discussion of the intervention. m a n u s c r i p t data extracted from the available evidence included: mortality, clinical progression or improvement as reported in the studies, virologic clearance, and adverse events. where applicable, data were pooled using random effects model (fixed effects model for 2 or less trials or pooling of rates) using revman or openmeta [7] . cochrane risk of bias tools for randomized clinical trials (rcts) and observational studies and modified domains were used in assessing confounding bias, selection bias, and misclassification bias [8] . the certainty of evidence was assessed using the grading of recommendations assessment, development and evaluation (grade) approach [9] . within grade, the body of evidence across each outcome is assessed for domains that may reduce or increase one's certainty in the evidence. factors that may reduce one's certainty include risk of bias (study limitations), inconsistency (unexplained heterogeneity across study findings), indirectness (applicability or generalizability to the research question), imprecision (the confidence in the estimate of an effect to support a particular decision) or publication bias (selective publication of studies). one's certainty in the evidence may be strengthened if the following considerations are present: large or very large magnitude of effect, evidence of a dose-response gradient, or opposing residual confounding. grade summary of findings tables were developed in gradepro guideline development tool [10] . the panel considered core elements of the grade evidence in the decision process, including certainty of evidence and balance between desirable and undesirable effects. additional domains were acknowledged where applicable (feasibility, resource use, acceptability). for all recommendations, the expert panelists reached consensus. voting rules were agreed on prior to the panel meetings for situations when consensus could not be reached. as per grade methodology, recommendations are labeled as "strong" or "conditional". the words "we recommend" indicate strong recommendations and "we suggest" indicate conditional recommendations. figure 1 provides the suggested interpretation of strong and weak recommendations for patients, clinicians, and healthcare policymakers. for recommendations where the comparators are not formally stated, the comparison of interest is implicitly referred to as "not using the intervention". the guideline panel used the word "only" in recommendations about therapeutic agents with higher uncertainty and/or more potential for harm. for example, the toxicity of hydroxychloroquine/chloroquine plus azithromycin (recommendation 2) carries particular risk for patients in the outpatient setting who may not be enrolled in a trial and therefore may have inadequate monitoring; or, for recommendation 6, there is concern related to tocilizumab shortages for other indications and potential toxicity of worsening infection/drug interactions. these recommendations acknowledge the current "knowledge gap" and aim at avoiding premature favorable recommendations for their use and to avoid encouraging the rapid m a n u s c r i p t diffusion of potentially ineffective or harmful interventions. detailed suggestions about the specific research questions that should be addressed are found in the table (see supplementary table s2 ). m a n u s c r i p t regular, frequent screening of the literature will take place to determine the need for revisions based on the likelihood that any new data will have an impact on the recommendations. if necessary, the entire expert panel will be reconvened to discuss potential changes. two rcts of patients with confirmed covid-19 with mild pneumonia (e.g., positive ct scan without oxygen requirement) or non-severe infection admitted to the hospital treated with hydroxychloroquine (hcq) reported on mortality at 14 days, clinical progression (radiological progression on ct scan), clinical improvement, failure of virologic clearance (pcr), and adverse events (both) [11, 12] (table 1 ). in addition, we identified four publications describing three trials of combination treatment with hcq plus azithromycin (az) among hospitalized patients with covid-19 reporting on the outcomes of mortality, failure of virologic clearance (assessed with pcr test), and adverse events (i.e., significant qt prolongation leading to treatment discontinuation) [13] [14] [15] [16] (table 2) . the currently available best evidence failed to demonstrate or to exclude a beneficial effect of hcq on clinical progression of covid-19 (as inferred by radiological findings; rr: 0.61; 95% ci: 0.26, 1.43; see figure s2 ), or on viral clearance by pcr tests (rr: 2.00; 95% ci: 0.02, 20.00; see figure s3 ), although a somewhat higher proportion in the hcq group experienced clinical improvement (rr: 1.47; 95% ci 1.02, 2.11). however, the certainty in the evidence was rated as very low mainly due to small sample sizes (sparse data), co-interventions, and risk of bias due to methodological limitations. in addition, the selected outcomes should be considered indirect, as important patient outcomes (e.g., mortality, rate of progression to ards and need for mechanical ventilation) were unavailable. m a n u s c r i p t studies evaluating the addition of azithromycin to hcq provided indirect comparisons of failure of virologic clearance to historical controls. the observed risk of mortality among patients receiving hcq+az during hospital stay was 3.4% (6/175 patients). however, an estimated mortality rate in an untreated cohort was not provided in the manuscript. when compared to a lack of viral clearance in historical controls (100% virologic failure), 12 symptomatic patients were compared at day 5 or 6 from a separate hospital in france. patients receiving treatment with hcq+az experienced numerically fewer cases of virologic failure (43% pooled virologic failure; 29/71 patients) (figure s3 ). there is very low certainty in this comparison of treatment effect mainly due to very high-risk selection bias, making any claims of effectiveness highly uncertain. in addition, relying on intermediary outcomes, such as viral clearance to determine patient-important outcomes (including a reduction in development of pneumonia, hospital or icu admission, or need for intubation) add another layer of imprecision. two studies described significant qt prolongation in 10 of 95 treated patients, either resulting in an qt increase to over 500 ms or discontinuation of the hcq/az treatment, illustrating the high risk for clinically relevant arrhythmias for this treatment [15, 16] . in addition, several case reports of qt prolongation related to hydroxychloroquine have also been published [17] [18] [19] [20] . in another prospective cohort study in 224 covid-19 uninfected patients with sle who received either chloroquine or hydroxychloroquine for routine care, gastrointestinal side effects occurred in 7% of patients [21] . several case reports have been published citing the risk of a prolonged qt prolongation, torsades de pointes, and ventricular tachycardia in patients receiving azithromycin alone. in a large cohort study, patients taking a five-day course of azithromycin had an increased risk of sudden cardiac death with a hazard ratio of 2.71 (1.58-4.64) vs. 0.85 (0.45-1.60), compared to patients receiving no antibiotic or amoxicillin, respectively [22] . given the cumulative effect on cardiac conduction seen with hydroxychloroquine and azithromycin, if this combination was to be used in the context of a clinical trial, baseline and follow-up ecg monitoring would be indicated, as well as careful surveillance for other concomitant medications known to prolong the qt interval. renal clearance accounts for 15-25% of total clearance of hydroxychloroquine, however dose adjustments are not recommended according to package labeling. chloroquine and hydroxychloroquine are metabolized by cytochrome p450 isoenzymes 2c8, 2d6, and 3a4 [23] , therefore inhibitors and inducers of these enzymes may result in altered pharmacokinetics of these agents. providers are encouraged to visit resources such as the newly created website, https://www.covid19-druginteractions.org/ to aid in the evaluation and management of drug interactions with current and emerging investigational agents for covid-19. azithromycin is low risk for cytochrome p450 interactions [24] ; however additional pharmacologic adverse events including gastrointestinal effects and qt prolongation need to be carefully considered particularly in the outpatient setting where frequent ecg monitoring is not feasible. a c c e p t e d m a n u s c r i p t the panel agreed that the overall certainty of evidence was very low due to concerns with risk of bias, inconsistency, indirectness, imprecision, and publication bias. the guideline panel recommends that, because of uncertainty regarding its risks and benefits, the use of hcq should be in the context of a clinical trial. because of the potential for toxicity, the panel recommends that the hcq+az combination only be used in the context of a clinical trial. this recommendation does not address the use of azithromycin for secondary bacterial pneumonia in patients with covid-19. additional randomized controlled trials and prospective outcome registries are needed to inform research for treatment with hcq alone or in combination with azithromycin for patients with covid-19 (table s2 . best practices/suggestions for research of treatments for patients with covid-19). one rct and two case studies reported on treatment with combination lopinavir/ritonavir for hospitalized patients with covid-19 [25] [26] [27] (table 3) . cao et al. randomized 199 hospitalized patients with severe covid-19 to receive treatment with lopinavir/ritonavir in addition to standard of care (n=99) or standard of care alone (n=100) for 14 days. the trial reported on the following outcomes: mortality, failure of clinical improvement (measured using a 7-point scale or hospital discharge), and adverse events leading to treatment discontinuation. based on a modified intention to treat analysis, treatment with lopinavir/ritonavir failed to show or exclude a beneficial effect on mortality (rr: 0.67; 95% ci: 0.38, 1.17), although failure of clinical improvement was lower in the lopinavir group (rr: 0.78; 95% ci: 0.63, 0.97; itt analysis). nearly 14% of lopinavir/ritonavir recipients were unable to complete the full 14-day course of administration due primarily to gastrointestinal adverse events, including anorexia, nausea, abdominal discomfort, or diarrhea, as well as two serious adverse episodes of acute gastritis. two recipients also had self-limited skin eruptions. the risk of hepatic injury, pancreatitis, severe cutaneous eruptions, qt prolongation, and the potential for multiple drug interactions due to cyp3a inhibition, are all well documented with this drug combination. the panel elected to inform their decision based on the rct [27] . the panel determined the certainty of evidence to be very low due to concerns with risk of bias (lack of blinding) and imprecision. in the randomized clinical trial conducted by cao et al, the group that received lopinavir/ritonavir and the group that did not had similar rates of viral decay. this finding suggests that lopinavir/ritonavir is not having a measurable antiviral effect, its purported mechanism of action. the guideline panel recommends the use of lopinavir/ritonavir only in the context of a clinical trial. additional clinical trials or prospective outcome registries are needed to inform research for treatment with lopinavir/ritonavir and other hiv-1 protease inhibitors for patients with covid-19 (supplementary table s2) . the panel determined that due to the limitation of direct covid-19 data, indirect evidence from the 2003 sars outbreak and from mers would also be considered. a systematic review [30] reported on 15 studies, 13 of which were inconclusive to any benefits of corticosteroids. one rct reported that sars-cov-1 viral loads showed delayed viral clearance associated with corticosteroid use. the same review also reported on a subset of ards patients (three trials). one small rct in 24 patients using a lower dose methylprednisolone for two days showed possible improvement of ards; however, two larger trials showed little or no effect in critically ill patients with pulmonary failure. the authors concluded that despite widespread use of corticosteroids during the sars outbreak, conclusive evidence of benefit was lacking and that administering steroids early in the disease process before viral replication is controlled may lead to a delay in viral clearance. the panel deemed the certainty of the direct evidence as very low owing to concerns with risk of bias, inconsistency, and imprecision. the panel based their decision to conditionally recommend against the use of corticosteroids among patients admitted to the hospital on the indirect findings from the systematic review on sars-cov. m a n u s c r i p t as covid-19is a self-limited viral illness in most cases, a small subset of patients progresses from covid-19 pneumonia to develop ards. based on limited data from other coronaviruses, there is no clear benefit and potential harm from corticosteroids. carefully designed rcts and prospective outcome registries are needed to determine the dose, route, timing, and duration of such treatment on the prevention of clinical deterioration and to better understand the potential harms associated with its use. if a person is on a steroid (inhaled or systemic) for another indication (e.g., asthma), the steroid should be continued. m a n u s c r i p t a c c e p t e d m a n u s c r i p t a c c e p t e d m a n u s c r i p t studies reporting on the pathogenesis of sars and mers-cov suggest a release of proinflammatory cytokines including interleukins-6 (il-6) [31] during the clinical illness. our search identified one study [31] that reported on 21 severe or critical patients with covid-19 treated with tocilizumab, an il-6 blocker ( table 6 ). this study had no control group. to estimate a control group rate in patients who did not get treatment with tocilizumab, xu et al. described findings from yang 2020, which suggested a baseline mortality rate of 60% in critical patients and 11% in severe patients admitted to the icu [32] . we estimate that the patients in xu 2020 (21 patients, 4 critical and 17 severe) would have a baseline mortality risk of 20% as matched in severity. therefore, treatment with tocilizumab may have reduced mortality since there were no deaths reported out of 21 patients. however, this conclusion remains highly uncertain given the lack of a contemporaneous control or adjustments for confounding factors. out of 21 patients, 19 were discharged from the hospital suggesting a 9.5% rate of failure of clinical improvement in the ct scan findings. xu et al. reported no serious adverse events [31] . however, patients receiving tocilizumab are often at an increased risk of serious infections (bacterial, viral, invasive fungal infections, and tuberculosis) and hepatitis b reactivation [33] . cases of anaphylaxis, severe allergic reactions, severe liver damage and hepatic failure, and intestinal perforation have been reported after tocilizumab administration in patients without covid-19. tocilizumab is not metabolized by the cytochrome p450 isoenzyme system, however elevated il-6 levels seen in inflammatory states have been shown to inhibit these enzymes, thereby slowing the metabolism of drugs through these pathways. as the 3a4 pathway is responsible for metabolism of many commonly used medications, administration of il-6 inhibitors like tocilizumab may result in enhanced metabolism in drugs utilizing the cytochrome p450 system [34, 35] . the panel determined that the overall certainty of the evidence was very low due to concerns of high risk of bias due to confounding, indirectness, and imprecision. m a n u s c r i p t the guideline panel recommended tocilizumab only in the context of a clinical trial. additional clinical trials are needed to inform research on the effectiveness of treatment with tocilizumab for patients with covid-19 (supplementary table s2 ). m a n u s c r i p t a c c e p t e d m a n u s c r i p t our search identified two case series of a total of 15 patients reporting on the outcomes of mortality, failure of clinical improvement (as inferred by need for continued mechanical ventilation), and treatment related adverse events among hospitalized patients with covid-19 (table 7 ) [36, 37] . all five patients in shen 2020 were mechanically ventilated at time of treatment compared with three out of 10 patients in the duan et al study. duan 2020 included a comparison of the 10 treated patients to 10 historical control patients matched on age, gender, and severity of illness. both studies lacked adjustments for critical confounders including co-treatments, baseline characteristics, disease severity, and timing of plasma delivery. compared with a 30% mortality rate in the historical control (3/10), no deaths were reported among patients receiving covid-19 convalescent plasma. out of eight patients across both studies on mechanical ventilation at time of treatment, 50% (n=4) were extubated at time of data collection. among 10 patients, no serious adverse reactions or safety events were recorded following covid-19 convalescent transfusion. the panel agreed on the overall certainty of evidence as very low due to concerns with risk of bias and imprecision. continuation of mechanical ventilation was used as a surrogate for failure of clinical improvement; however, the panel recognized the importance of the timeframe for extubation when associating it to plasma transfusion. given the limited information provided about time of extubation, the panel recognized an additional knowledge gap with the assessment of this outcome. the guideline panel recommends covid-19 convalescent plasma in the context of a clinical trial. additional clinical trials are needed to inform research for treatment with covid-19 convalescent plasma for patients with covid-19 (supplementary table s2 ). m a n u s c r i p t in addition to the clinical questions addressed above, the panel identified several treatments currently undergoing evaluation for which additional data are needed to formulate recommendations. narrative summaries for these treatments are provided below. in-vitro antiviral activity of darunavir against sars-cov-2 showed no activity at clinically relevant concentrations. three randomized, open-label clinical trials are currently listed on clinicaltrials.gov evaluating darunavir/cobicistat as a potential therapeutic option for covid-19. janssen, the manufacturer of darunavir/cobcistat has reported that one of these trials [38] has concluded that darunavir/cobicstat plus conventional treatments was not effective in achieving viral clearance at day seven post randomization, m a n u s c r i p t compared to conventional treatments alone. clinical outcomes of this trial including rate of critical illness and mortality 14 days after randomization, have not been reported to date. lopinavir-ritonavir is a combination of protease inhibitors for the treatment of hiv infection. lopinavir-ritonavir has been shown to have in-vitro antiviral activity against beta-coronaviruses such as sars-cov, and mers-cov [39] [40] [41] [42] . since lopinavir-ritonavir is not specifically designed for treatment of coronavirus, lopinavir-ritonavir alone may not demonstrate a difference from placebo in reducing viral load when treatment was initiated at a median of 13 days after symptoms onset [41] . in an open label treatment trial, lopinavir-ritonavir with ribavirin reduced the mortality and requirement of intensive care support of hospitalized sars patients compared with historical control [41] . many interferons, especially interferon beta have been shown to have modest in-vitro antiviral activity against sars-cov and mers-cov [39, 40] . lopinavir-ritonavir or interferon beta-1b has been shown to reduce viral load of mers-cov and improve lung pathology in a nonhuman primate model of common marmoset [42] . lopinavir/ritonavir and interferon-β1b alone or in combination are being evaluated in clinical trials. there is a long history of using convalescent plasma as treatment for infectious diseases, including severe viral lower respiratory tract infections [43] . individuals who have recovered from sars-cov-2 infection may generate neutralizing antibodies [44, 45] that could have application to prevention of infection in certain settings, such as individuals with underlying conditions predisposing to severe disease and those with high-risk exposure. monoclonal antibodies against other respiratory viruses have been shown to be protective against hospitalization in specific high-risk populations [46, 47] and animal models have suggested utility in prophylaxis against sars coronavirus infection [48] . there are some risks associated with the use of convalescent plasma like transfusion-related acute lung injury or a theoretical risk of antibody-dependent enhancement of infection (ade). ade can occur in several viral diseases and involves an enhancement of disease in the presence of certain antibodies [49] . a trial from patients recovered from sars-cov-2 infection for use as prophylaxis in adults with a high -risk exposure is expected to begin recruiting shortly [50] . there are only in vitro data available on the activity of ribavirin on sars-cov-2 currently. the ec50 (half maximal effective concentrations) was significantly higher than for chloroquine and remdesivir, so it appears less potent in vitro compared to these agents [51] . there are limited clinical studies in sars-cov-1 and mers-cov infections. in a systematic review of ribavirin treatment in patients infected with sars-cov-1, 26 studies were classified as inconclusive, and four showed possible harm [30] . in a retrospective observational study in patients with mers-cov infection, the combination of ribavirin and interferon, compared to no antiviral treatment, was not associated with improvement in the 90-day mortality or more rapid mers-cov rna clearance [52] . m a n u s c r i p t oseltamivir oseltamivir is a neuraminidase inhibitor used for prophylaxis and treatment of influenza. given its specificity for an enzyme not found on coronaviruses, it is unclear what the mechanism of action would be against covid-19. however, this has been used in combinations of antiviral therapy in wuhan [53] and continues to be explored as a therapeutic option as part of combination regimens. two trials evaluating combination regimens are underway in wuhan [54, 55] as well as a trial in thailand proposing different combinations [56] . none of the trials or case reports have examined oseltamivir as monotherapy. intravenous immunoglobulin (ivig) has been used as an adjuvant to treat a variety of pathogens either as a pooled product or in a concentrated more pathogen focused (hyperimmune) form. as the community from which a given batch of ivig is derived from includes increasing numbers of individuals who have recovered from sars-cov-2, the possibility of protective antibodies being present in the pooled product is increased. however, the potential utility of ivig for the treatment of sars-cov-2 is unknown at this time. its use has been reported in a few patients with covid-19 [57] , but studies are needed to determine if there may be a role for ivig in the treatment of sars-cov-2. remdesivir (gs-5734) is a broad-spectrum antiviral nucleotide prodrug with potent in vitro activity against a range of rna viruses including ebola virus, marburg, mers-cov, sars-cov, respiratory syncytial virus, nipah virus, and hendra virus [58] [59] [60] . the mechanism of action of remdesivir is premature termination of viral rna transcription [60] . its use improved disease outcomes and reduced viral loads in sars-cov-infected mice [59] . the efficacy of prophylactic and therapeutic remdesivir was tested in a rhesus macaque model of mers-cov infection [61] . prophylactic remdesivir treatment initiated 24 hours prior to inoculation completely prevented mers-cov-induced clinical disease, strongly inhibited mers-cov replication in respiratory tissues, and prevented the formation of lung lesions [61] . therapeutic remdesivir treatment initiated 12 hours postinoculation reduced clinical signs, virus replication in the lungs, and decreased the presence and severity of lung lesions. a recent case series of 53 patients with severe covid-19 pneumonia who received remdesivir under a compassionate-use protocol reported clinical improvement in 68% after a median follow-up of 18 days, with 13% mortality and a generally acceptable toxicity profile [62] . however, there was no comparison group of similar patients who received standard care at the participating institutions. because rcts for remdesivir have not been completed, formalized recommendations will be made once the entire body of evidence for remdesivir is available. m a n u s c r i p t should nsaids be stopped in patients infected with covid-19? the role of nsaids in the management of sars-cov2 has been discussed widely. recent anecdotal reports and subsequent warnings from health officials have suggested against the use of nsaids in the care of patients with covid-19; however, neither fda, ema, or who have identified evidence linking nsaids to covid-related clinical deterioration. human coronaviruses, including sars cov-2, use ace2 to bind to human targets and gain entry into target cells [63] . it has been theorized that nsaids, due to upregulation in ace2 in human target cells, may lead to a more severe course of covid-19 in those taking nsaids. while no causal evidence of adverse outcomes with nsaids in the management of covid-19 have been published, there are well known risks of nonsteroidal anti-inflammatory agents including cardiovascular, gastrointestinal and renal adverse events [64, 65] . in the setting of bacterial pneumonia, nsaids may impair recruitment of polymorphonuclear cells, resulting in a delayed inflammatory response and resolution of infection, however a causal relationship has not been established [66, 67] . rcts are needed to better understand the safety of nsaids in the management of patients with covid-19. one rct is currently underway to evaluate the role of naproxen in those critically ill with covid-19 [68] . should ace and arb's for hypertension be stopped in patients infected with covid19? angiotensin converting enzyme 2 (ace2) is the receptor for sars cov-2 on human cells. because angiotensinconverting enzyme (ace) inhibitors and angiotensin receptor blockers (arbs) may increase ace2 expression, the possibility has been raised that these drugs may increase the likelihood of acquiring sars-cov-2 or may exacerbate the course of covid-19. to date, however, there are no clinical data to support this hypothetical concern. for this reason, the american heart association, the heart failure society of america and the american college of cardiology all recommend that ace inhibitors or arbs be continued in people who have an indication for these medications [69] . during epidemics like the current covid-19 pandemic, when there are no clinically proven treatments, the tendency is to use drugs based on in vitro antiviral activity, or on anti-inflammatory effects or based on limited observational studies. it is commendable that observational studies are done during an epidemic, but often they do not have concurrent controls, have a significant risk of bias, and use surrogate outcomes like viral clearance rather than patient-important outcomes. medications that were thought to be effective m a n u s c r i p t based on in vitro studies and observational studies for other diseases were later proven to be ineffective in clinical trials [70] . due to the understandable urgency in producing, synthesizing and disseminating data during the current pandemic, there has been a noticeable increase in fast track publication of studies. in addition to wellestablished concerns that may decrease our certainty in the available evidence, there may be additional issues that will ultimately influence the trustworthiness of that evidence, including: 1) circumvention of usual research steps (delay of irb approval [71] , inclusion of same patients in several studies); 2) limited peer-review process (the usual due diligence from editors and reviewers is side-stepped, potentially leading to unnoticed errors in data and calculations, incomplete reporting of methods and results, as well as underestimation of study limitations); 3) increased potential for publication bias (in the interest of showing promising data and in the race to achieve recognition, there may be added inclination to publish positive results and disregard negative ones). the extent and impact of these considerations remain currently uncertain but were acknowledged in the development of this guideline. despite these limitations, the recommendations were based on evidence from the best available clinical studies with patient-important endpoints. the panel determined that when an explicit trade-off between the highly uncertain benefits (e.g., the panel was unable to confirm that hcq increases viral cure or reduces mortality) and the known putative harms (qt prolongation and drug-drug interactions) were considered, a net positive benefit was not reached and could possibly be negative (risk of excess harm). the safety of drugs used for the treatment of covid-19, especially in patients with cardiovascular disease, immunosuppressive conditions, or those who are critically ill with multi-organ failure has also not been studied. drugs like azithromycin and hydroxychloroquine can cause qt prolongation and potentially lifethreatening arrhythmias. steroids and il-6 inhibitors can be immunosuppressive and potentially increase risk of secondary infections. steroids may produce long term side effect such as osteonecrosis [72] . given that the panel could not make a determination whether the benefits outweigh harms for these treatments it would be ethical and prudent to enroll patients with covid-19 in clinical trials, rather than use clinically unproven therapies [73] . there are multiple ongoing trials, some with adaptive designs, which potentially can quickly answer pressing questions on efficacy and safety of drugs in the treatment of patients with covid-19. we acknowledge that enrolling patients in rcts might not be feasible for many frontline providers due to limited access and infrastructure. should lack of access to clinical trials exist, we encourage setting up local or collaborative registries to systematically evaluate the efficacy and safety of drugs to contribute to the knowledge base. without such evaluations we often attribute success to drugs and failure to disease (covid-19) [70] . during such a pandemic, barriers to conducting studies and enrolling patients in trials for already overburdened front line providers should be minimized while ensuring the rights and safety of patients [74] . for clinical trials and observational studies, it is critical to determine a priori standardized & practical definitions of patient populations, clinical syndromes, disease severity and outcomes. observational and non-experimental studies can sometimes answer questions not addressed by trials, but there is still a need for standardized definitions. for clinical syndromes clearly distinguishing between asymptomatic carrier state, upper respiratory tract infection and lower respiratory tract infection is important. illness severity should be reasonably defined using readily available clinical criteria of end organ failure, like the degree of m a n u s c r i p t respiratory failure using sa02 or fi02:pa02 ratios for lower respiratory tract infection, as opposed to location-based severity determinations such as icu admission, which can lead to bias based on resource limitations (i.e., bed availability) or regional/institutional practice patterns [75] . for outcomes of prophylaxis trials, the primary endpoint should be prevention of infection and for therapeutic trials patient centered outcomes like reduction of mortality (both short term and long term) [76] . trials should also study treatments in high risk populations or special populations like immunosuppressed patients, people with hiv, patients with cardiovascular comorbidities and pregnant women. the panel expressed the overarching goal that patients be recruited into ongoing trials, which would provide much needed evidence on the efficacy and safety of various therapies for covid-19. this is a living guideline that will be frequently updated as new data emerges. updates and changes to the guideline will be posted to the idsa website. clinical characteristics of coronavirus disease 2019 in china world health organization. coronavirus disease 2019 (covid-19) situation report -75. geneva: world health organization characteristics of and important lessons from the coronavirus disease 2019 (covid-19) outbreak in china: summary of a report of 72314 cases from the chinese center for disease control and prevention development of rapid guidelines: 3. gin-mcmaster guideline development checklist extension for rapid recommendations grade guidelines: 2. framing the question and deciding on important outcomes national institute for health and care excellence. scoping. interim process and methods for developing rapid guidelines on covid-19 (pmg35). london: national institute for health and care excellence closing the gap between methodologists and end-users: r as a computational back-end cochrane handbook for systematic reviews of interventions grade guidelines: 1. introduction-grade evidence profiles and summary of findings tables gradepro guideline development tool available at: gradepro.org efficacy of hydroxychloroquine in patients with covid-19: results of a randomized clinical trial a pilot study of hydroxychloroquine in treatment of patients with common coronavirus disease-19 (covid-19) hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 covid-19 patients with at least a six-day follow up: an observational study no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid-19 infection the qt interval in patients with sars-cov-2 infection treated with hydroxychloroquine/azithromycin suspected hydroxychloroquine-associated qt-interval prolongation in a patient with systemic lupus erythematosus chronic hydroxychloroquine use associated with qt prolongation and refractory ventricular arrhythmia syncope in a patient being treated for hepatic and intestinal amoebiasis conduction disorder and qt prolongation secondary to long-term treatment with chloroquine discontinuation of antimalarial drugs in systemic lupus erythematosus azithromycin and the risk of cardiovascular death therapy and pharmacological properties of hydroxychloroquine and chloroquine in treatment of systemic lupus erythematosus, rheumatoid arthritis and related diseases drug interactions of clinical significance early, low-dose and short-term application of corticosteroid treatment in patients with severe covid-19 pneumonia: single-center experience from wuhan, china clinical features and progression of acute respiratory distress syndrome in coronavirus disease 2019 a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 medication patterns and disease progression among 165 patients with coronavirus disease 2019 (covid-19) in wuhan, china: a single-centered, retrospective, observational study risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease sars: systematic review of treatment effects effective treatment of severe covid-19 patients with tocilizumab clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, retrospective, observational study actemra® (tocilizumab) injection, for intravenous or subcutaneous use interleukin-6 and cytochrome-p450, reason for concern? a physiologically based pharmacokinetic modeling approach to predict disease-drug interactions: suppression of cyp3a by il-6 treatment of 5 critically ill patients with covid-19 with convalescent plasma the feasibility of convalescent plasma therapy in severe covid-19 patients: a pilot study efficacy and safety of darunavir and cobicistat for treatment of pneumonia caused by 2019-ncov (daco-ncov) in vitro susceptibility of 10 clinical isolates of sars coronavirus to selected antiviral compounds broad-spectrum antivirals for the emerging middle east respiratory syndrome coronavirus role of lopinavir/ritonavir in the treatment of sars: initial virological and clinical findings treatment with lopinavir/ritonavir or interferon-beta1b improves outcome of mers-cov infection in a nonhuman primate model of common marmoset the effectiveness of convalescent plasma and hyperimmune immunoglobulin for the treatment of severe acute respiratory infections of viral etiology: a systematic review and exploratory meta-analysis characterization of spike glycoprotein of sars-cov-2 on virus entry and its immune cross-reactivity with sars-cov establishment and validation of a pseudovirus neutralization assay for sars-cov-2 the impact-rsv study group. palivizumab, a humanized respiratory syncytial virus monoclonal antibody, reduces hospitalization from respiratory syncytial virus infection in high-risk infants palivizumab prophylaxis reduces hospitalization due to respiratory syncytial virus in young children with hemodynamically significant congenital heart disease human monoclonal antibody as prophylaxis for sars coronavirus infection in ferrets the convalescent sera option for containing covid-19 efficacy and safety human coronavirus immune plasma (hcip) vs. control (sars-cov-2 non-immune plasma) among adults exposed to covid-19 (cssc-001). available at remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-ncov) in vitro ribavirin and interferon therapy for critically ill patients with middle east respiratory syndrome: a multicenter observational study epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study a prospective/retrospective, randomized controlled clinical study of antiviral therapy in the 2019-ncov pneumonia a randomized, open, controlled clinical study to evaluate the efficacy of asc09f and ritonavir for 2019-ncov pneumonia various combination of protease inhibitors, oseltamivir, favipiravir, and hydroxychloroquine for treatment of covid19 : a randomized control trial (thdms-covid19) high-dose intravenous immunoglobulin as a therapeutic option for deteriorating patients with coronavirus disease gs-5734 and its parent nucleoside analog inhibit filo-, pneumo-, and paramyxoviruses broad-spectrum antiviral gs-5734 inhibits both epidemic and zoonotic coronaviruses therapeutic efficacy of the small molecule gs-5734 against ebola virus in rhesus monkeys prophylactic and therapeutic remdesivir (gs-5734) treatment in the rhesus macaque model of mers-cov infection compassionate use of remdesivir for patients with severe covid-19 sars-cov-2 cell entry depends on ace2 and tmprss2 and is blocked by a clinically proven protease inhibitor vascular and upper gastrointestinal effects of nonsteroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials non-steroidal anti-inflammatory drug induced acute kidney injury in the community dwelling general population and people with chronic kidney disease: systematic review and meta-analysis nonsteroidal antiinflammatory drugs may affect the presentation and course of community-acquired pneumonia risks related to the use of non-steroidal anti-inflammatory drugs in community-acquired pneumonia in adult and pediatric patients efficacy of addition of naproxen in the treatment of critically ill patients hospitalized for covid-19 infection (enacovid) hfsa/acc/aha statement addresses concerns re: using raas antagonists in covid-19 treating covid-19-off-label drug use, compassionate use, and randomized clinical trials during pandemics editorial concern-possible reporting of the same patients with covid-19 in different reports steroid therapy and the risk of osteonecrosis in sars patients: a dose-response meta-analysis the ebola clinical trials: a precedent for research ethics in disasters clinical research ethics for critically ill patients: a pandemic proposal early observational research and registries during the 2009-2010 influenza a pandemic choosing outcomes for clinical trials: a pragmatic perspective key: cord-348137-dzmbfp2g authors: bi, qifang; hong, chengcheng; meng, juan; wu, zhenke; zhou, pengzheng; ye, chenfei; sun, binbin; kucirka, lauren m; azman, andrew s; wang, tong; chen, jiancong; wang, zhaoqin; liu, lei; lessler, justin; edwards, jessie k; ma, ting; zhang, guoliang title: characterization of clinical progression of covid-19 patients in shenzhen, china date: 2020-04-27 journal: nan doi: 10.1101/2020.04.22.20076190 sha: doc_id: 348137 cord_uid: dzmbfp2g the covid-19 pandemic has stressed healthcare care systems throughout the world. understanding clinical progression of cases is a key public health priority that informs optimal resource allocation during an emergency. using data from shenzhen, china, where all cases were monitored in hospital and symptom profiles and clinical and lab results were available starting from early stages of clinical course, we characterized clinical progression of covid-19 cases and determined important predictors for faster clinical progression to key clinical events and longer use of medical resources. epidemiological, demographic, laboratory, clinical, and outcome data were extracted from electronic medical records. we found that those who progressed to the severe stage, developed acute respiratory distress syndrome, and were admitted to the intensive care unit (icu) progressed on average 9.5 days (95%ci 8.7,10.3), 11.0 days (95%ci 9.7,12.3), and 10.5 days (95%ci 8.2,13.3) after symptom onset, respectively. we estimated that patients who were admitted to icus remained there for an average of 34.4 days (95%ci 24.1,43.2) and the average time on a ventilator was 28.5 days (95%ci 20.0,39.1) among those requiring mechanical ventilation. the median length of hospital stay was 21.3 days (95%ci, 20.5, 22.2) for the mild or moderate cases who did not progress to the severe stage, but increased to 52.1 days (95%ci, 43.3, 59.5) for those who required icu admission. clear characterization of clinical progression informs planning for healthcare resource allocation during covid-19 outbreaks and provides a basis that helps assess the effectiveness of new treatment and therapeutics. the epidemic of coronavirus sars-cov-2 has led to 1.6 million infections and over 100,000 deaths over 4 months after the first case was detected 1 , causing severe shortage of essential medical supplies and equipment, medical staff, and hospital beds 2 . complementary to data from covid-19 epicenters like wuhan (china) or lombardy (italy), data from places where healthcare capacity was not exceeded and patients were treated early and free of charge has the potential to shed light on the near complete clinical trajectory of cases. clear characterization of covid-19 clinical trajectory under the current standard of care informs planning for healthcare resource allocation during covid-19 outbreaks and provides a basis that helps assess the effectiveness of new treatment and therapeutics. here, we use rich data on clinical progression of all covid-19 cases diagnosed and treated in the only designated hospital in shenzhen, china. because all clinically confirmed cases, including a sizable portion detected through contact tracing, were required to be hospitalized for isolation purposes regardless of their clinical presentation and symptom profile, this dataset allows us to examine clinical progression of cases without the considerable selection bias typically seen in hospital-based studies. we estimate time from symptom onset to key clinical events, such as first clinical diagnosis, progression to severe clinical stages, development of acute respiratory distress syndrome (ards), admission to the critical care unit (icu), and discharge. we also estimate duration hospitalized, in the icu, and on ventilators. we determine the key predictors of faster clinical progression to a series of clinical events and longer use of healthcare resources. this single-centre, observational study was conducted at shenzhen third people's hospital, which is the designated hospital to treat all patients with covid-19 in shenzhen. we prospectively collected data of all 420 patients diagnosed and hospitalized with covid-19 in shenzhen between january 11th and march 10th 2020, regardless of their clinical severity and symptom profile. epidemiological, demographic, laboratory, clinical, and outcome data were extracted from electronic medical records using a standardised data collection form. all information was updated as of april 7th 2020. data were reviewed by multiple reviewers (bs, jc, jz, pz), and any disagreement between reviewers was resolved by consultation with an attending physician (jm). data from patients with severe or critical clinical assessment were extracted by an attending physician (jm) and reviewed with a reviewer (ch) to ensure data quality. we obtained information on demographic characteristics, mode of detection, and date of onset for each symptom. date of symptom onset before admission was self-reported and date of symptom onset after admission was recorded by an attending physician. clinical severity was defined based on guidelines issued by the national health commission of the people's republic of china, and the severity definition was generally consistent over time (see supplemental table 3 for guidelines in each version) 7 . we recorded clinical severity at initial diagnosis and date of severity progression. clinical severity was assessed daily when mild or moderate and was assessed twice a day when severe or critical. dates of icu admission and discharge were recorded, as well as dates beginning and ending invasive ventilator use. patients were eligible for discharge from the hospital or transfer to a non-covid ward for treatment if they met all of the following: 1) no fever for over 3 days, 2) drastic improvement in respiratory symptoms, 3) pulmonary imaging showing significant reduction in inflammation, and 4) two consecutive negative rt-pcr results from respiratory sampling conducted over one day apart 7 . we counted time in non-covid wards for treatment of covid-19 related complications towards the duration of hospitalization. we recorded patients' self-reported medical history (see table 1 for a list of baseline comorbidities). we reviewed laboratory results and created binary variables indicating presence of any abnormalities and the date when such abnormalities were detected (see table1 for a complete list of lab indicators and abnormality cutoff). the x-ray computed tomography (ct) results were extracted from radiological examinations. we recorded the lowest cycle threshold values from the available rt-pcr testings and the date when the testing was performed. we also recorded complications developed during hospitalization. the primary endpoints in this study include patients' time from symptom onset to clinical progression beyond the moderate stage, icu admission, invasive ventilator use, and discharge. we also examined other endpoints including time to when pao2/fio2 dropped under 300mmhg and time to developing ards. we estimated cumulative incidence of developing key clinical events in the presence of competing risks (i.e., death and hospital discharge) using the aalen-johansen estimator 8,9 . outcomes included progression to severe stage, low pao2/fio2 ratio, ards, icu admission, use of invasive ventilator, and hospital discharge. we estimated patients' duration of hospitalization by calculating the area above the cumulative incidence of hospital discharge or death, which was estimated using the aalen-johansen estimator 8, 9 . in addition, we estimated the time patients admitted to the icu ultimately spent in the icu as the area between the cumulative incidence functions for icu entry and icu exit among those who were admitted into icu. we treated death while in the icu and icu discharge as a composite event when estimating cumulative incidence of icu exit. similarly, we estimated the duration of invasive ventilator use among patients requiring ventilation, as the area between . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april 27, 2020. . the cumulative incidence functions for ventilator initiation and ventilator discontinuation. we treated death during ventilator use and withdrawal of ventilator support as a composite event when estimating ventilator discontinuation. we compared times in each state estimated using the nonparametric approach described above with times estimated using a parametric accelerated failure time models to examine improvements in precision seen when invoking a parametric approach (see text s2 for detailed method). we used bootstrap simulation to construct confidence intervals (2000 bootstrap simulations for time to recovery and time to ards, and 200 bootstrap simulations for time to icu entry/discharge and ventilator use/withdrawal). 95% confidence intervals were the 2.5th and 97.5th percentiles of the distribution of point estimates from the bootstrap samples. we used competing risk regressions according to the methods of fine and gray 10 to estimate subdistribution hazard ratios comparing the rate of clinical progression between subgroups that were defined a priori (see table 3 for the list of subgroups). we compared the rate of clinical progression to severe stage, icu admission, ards, and hospital discharge between subgroups. except for the models where time to hospital discharge was the outcome, hospital discharge and death were treated as competing events and end of study as administrative censoring for those still in treatment. we used a flexible approach to stratify cases into three risk strata for the purpose of visualizing different clinical trajectories. we constructed a random survival forest model (rsf) and divided cases into low, medium, and high risk groups based on tertiles of rsf out-of-bag predictions. the candidate predictors used in the rsf model included 1) demographic information, 2) baseline comorbidities, 3) symptom profile, lab and ct results within 5 days of any symptom onset. hospital discharge was treated as a competing event. all four deaths occurred after cases progressed beyond the severe stage, thus they were not treated as competing events. we calculated auc over time since symptom onset (tauc), providing a measure of model performance across all possible classification thresholds and based on the observed number of cases entering the severe stage by each time point 11 . we fit 1000 trees, considered 5 random splits for each candidate splitting variables, and used the log-rank test as the split function. four-hundred and twenty cases were admitted and hospitalized to shenzhen third people's hospital between january 11th and march 10th, 2020 ( figure s1 ). fifteen percent (63/420) of cases were detected through contact tracing (table 1) . on average, the first clinical diagnosis occurred 1.9 days (95% ci 1.6,2.3) and hospitalization occurred 4.2 days (95%ci 3.8,4.6) after symptom onset. of the 420 cases, there were approximately equal numbers of males (47.6%, n=200) and females (52.4%, n=220) ( table 1) . a large portion (38.8%, n=163) were under the age of 40 and the majority (83.1%, n=349) were detected through symptom-based surveillance. 21.9% . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april 27, 2020. . https://doi.org/10.1101/2020.04.22.20076190 doi: medrxiv preprint (92/420) of cases had at least one self-reported comorbidity on admission, with hypertension (n=49) and diabetes (n=24) being the most prevalent. fever, cough, sputum production were the most common initial symptoms, with 68.6% (288) of patients showing fever, 60.0% (252) with cough, and 31.2% (131) with sputum production within 5 days of initial symptom onset (see supplemental figure for onset time distribution of each symptom). 25.2% (106) of patients never had fever, and 26.9% (113) of patients never had cough. at the initial clinical assessment, 23 patients (5.5%) were clinically mild, the vast majority (93.8%, n=394) were moderate, and only 3 patients were clinically severe or critical ( figure s2 ). we estimated the proportion of the initially mild or moderate cases in each stage (mild/moderate, severe, icu, death or discharge) over time following symptom onset, taking into account patients both transitioning into and out of each stage ( figure 1a ). the total number of patients in the severe stage reached its peak 12 days after symptom onset. among the 417 patients who were classified as mild or moderate at the time of initial assessment, 21.6% (90/417) progressed to the severe stage. 9.6% (95%ci, 6.8%, 12.4%) progressed to the severe stage within 7 days after symptom onset, and 20.4% (95%ci, 16.5%, 24.3%) progressed within 14 days (figure 1 and 2) . those who progressed to the severe stage progressed on average 9.5 days (95%ci 8.7,10.3) after symptom onset. among the 417 patients who were classified as mild or moderate at the time of initial assessment, 8.6% (36/417) developed ards. 2.6% (95%ci 1.1%,4.2%) developed ards within 7 days from symptom onset, and 7.7% (95%ci 5.1%, 10.2%) within 14 days. those who developed ards developed ards on average 11.0 days (95%ci 9.7,12.3) after symptom onset. as of april 7th, 19 patients had been admitted to icu, among which 18 patients required invasive mechanical ventilation support, 4 patients died (1 patient died after initial hospital discharge with viral clearance), and 4 patients remained hospitalized in critical condition. we estimated that among the 417 patients who were classified as mild or moderate at the time of initial assessment, 3.3% (95%ci, 1.6%, 5.1%) of patients required icu admission within 14 days from symptom onset (same for patients who required mechanical ventilators support). those who required icu admission were admitted into icu on average 10.5 days (95%ci 8.2,13.3) after symptom onset. using data from the 19 patients who were admitted into icu, we estimated the average time in icu was 34.4 days (95%ci 24.1,43.2) ( table 2 ). using data from the 18 patients who required mechanical ventilator support, we estimated the average time on a ventilator was 28.5 days (95%ci 20.0,39.1). the median length of hospital stay was 21.3 days (95%ci, 20.5, 22.2) for the mild or moderate cases who did not progress to the severe stage, and increased to 30.3 days (95%ci, 26.7, 31.4) for cases who reached the severe stage but did not enter icu and 52.1 days (95%ci, 43.3, 59.5) for the cases who required icu admission. of note, patients in shenzhen were required to . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april 27, 2020. be hospitalized for about 2 weeks for isolation; 21% (86/417) of the cases that were initially mild or moderate were discharged within 14 days from hospitalization, 34% (140/417) within 16 days. the duration of hospitalization for the mild or moderate cases was likely inflated as a result. all patients who were clinically mild at the time of initial assessment stayed mild until discharge ( figure s1 ). we then identified a priori-defined patients' characteristics that were associated with faster clinical progression. we found that having hypertension and diabetes at baseline was strongly associated with faster clinical progression to various clinical events, including progression to the severe stage (shr=3.2, 95%ci 2.1,5.1 for hypertension and shr=3.0, 95%ci 1.6,5.4 for diabetes), to developing ards (shr=3.6, 95%ci 1.8,6.9 for hypertension and shr=5.5, 95%ci 2.7,11.3 for diabetes), and to icu admission (shr=4.6, 95%ci 1.8,11.6 for hypertension and shr=4.7, 95%ci 1.6,14.1 for diabetes) ( table 3) . having more baseline comorbidities was also associated with a higher rate of clinical progression to these events (table 3) . although many lab abnormalities measured within 5 days of symptom onset were strongly predictive of faster clinical progression, including low lymphocyte count, low platelet count, high concentration of creactive protein, and high concentration of d-dimer, notably, a low pao2/fio2 ratio close to symptom onset was very strongly associated with faster clinical progression. we observed a 22.3 times (95%ci 8.4, 58.8) increase in the subdistribution hazard of icu admission among those with early measures of low pao2/fio2 ratio (table 3) . older age was one of the most important predictors of faster clinical progression (table 3 ). all four patients who died were male over the age of 60. about half (46.3%, 50/108) of cases aged 60 or above progressed to the severe or critical stage (table 1) . although the vast majority of those under the age of 40 did not progress beyond the moderate stage, 6% (9/163) of cases in this younger age group became clinically severe or critical and none of them had any known underlying comorbidities. sex was strongly associated with clinical progression of cases, though the difference by sex was mostly driven by the difference among older patients. we did not observe a significant difference in time to icu admission between males and females under the age of 60 (shr = 0.7, 95%ci 0.1,4.3 comparing males with reference to females; table s1, figure 2b ). however, we observed a noteable difference in progression to require icu admission between males and females aged 60 or above; males in this older age group had a 10-fold increase in the subdistribution hazard of icu admission compared to females in the same age group (shr=10.5, 95%ci 1.0, 108.6), despite the similar sex-specific age distribution in this age group (males: mean 67, iqr 63,69 vs. females: mean 65, iqr 62,66) (table s1 ). differences in baseline comorbidities between older males and females did not explain the disparity; after adjusting for having any underlying comorbidity, the subdistribution hazard ratio remained unchanged (table s1) . similarly, we found that males aged 60 or above had a lower rate of hospital discharge compared to females in the same age group, and no significant difference by . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april 27, 2020. . sex in the younger age group (figure 2c) . however, we did not find significant disparities in clinical progression to severe stage or to developing ards by sex in any age group (table s1) . using linear regression, we found that the minimum rt-pcr cycle threshold values for the severe cases were significantly lower than the mild cases after adjusting for time of sample collection with reference to symptom onset. we observed a general trend of lower minimum cycle threshold values in patients with more severe clinical presentation and in patients in the older age group though the association with age was not statistically significant ( figure s5 ). based on the random survival forest results, the most important predictors of faster progression to the severe stage were low pao2/fio2 ratio, low platelet count, and high c-reactive protein concentration ( figure s8a) . we observed very different clinical trajectories of patients in each risk group (figure 1b) , highlighting the effectiveness of risk stratification produced by the rsf model. in the low-risk group, no case required icu admission and only 3% (95%ci, 0.1%,6%) of cases became severe within 14 days from symptom onset. whereas in the high-risk group, we estimated that 43% (95%ci, 35, 52) cases became severe and 9% (95%ci, 4%,14%) required icu admission within 14 days from symptom onset. all but one case that required icu admission were classified into the high-risk group, and we estimated that the duration in icu for those in the high-risk group was 35.1 days (95%ci, 26.1,45.1) (table 2, figure s8 ). risk stratification produced by a rsf model that excluded lab and ct results from the candidate predictors also differentiated clinical trajectory of patients well ( figure s7 , figure s8 c-d) . the analysis of clinical data from covid-19 patients in shenzhen third people's hospital provides insights into clinical progression of cases starting early in the course of infection. we estimate the proportion of cases in each severity stage over 80 days following symptom onset. we present patient characteristics associated with faster clinical progression and longer use of medical resources. because treatment of covid-19 was free of charge and hospitalization for all cases was mandatory in shenzhen, we expect that our results are not strongly affected by the selection bias that plagues many hospital-based studies. therefore, our results provide a clear picture of the composition of cases in a city in terms of disease severity and the clinical trajectories of these cases. although healthcare resources in shenzhen were rarely overwhelmed by influx of covid-19 patients, we show that the trajectory of clinical progression of cases in shenzhen were similar to the trajectory in wuhan, china, with mean time to icu admission and mean time to developing acute respiratory distress syndrome to be around 10 days 3, 4 . patient characteristics previously reported to be associated with ards and death 5 including hypertension, diabetes, and various lab results were also highly predictive of faster clinical progression to various key clinical events including progression to severe stage, ards, and icu admission. previous studies reported that most cases were males and median age was over 45 3,6 and a higher percentage of men required icu care 3 . we further show differences in clinical progression between males and females that were primarily driven by the stark difference in the older age group independent of differences in baseline comorbidities. this study has a number of limitations. dates of symptom onset were extracted from physicians' notes that were not recorded to explicitly ascertain information on symptom onset. when the date of symptom onset could not be determined, we assumed onset date was the date of initial diagnosis. we performed sensitivity analyses to assess patient characteristics for clinical progression to severe stage and icu admission and the results remained qualitatively the same (table s4) . we also performed the rsf analyses using symptom profile and lab results within 5 days of initial diagnosis as candidate predictors, and the integrated auc remained relatively unchanged ( figure s9 ). our estimates of duration of icu stay and ventilator use were somewhat imprecise, likely due to the small sample size for those reaching the critical stage. even though estimating duration using our non-parametric approach showed improvement in precision compared to times estimated using parametric accelerated failure time models, the estimated time within subgroups needs to be interpreted with caution because of the small sample size (table s3) . finally, the association presented between clinical progression and patient characteristics should not be interpreted as causal given the variation in treatment and numerous confounders that were not accounted for in this study. we demonstrate that patient characteristics near symptom onset have tremendous potential to inform covid-19 triage, grouping patients into risk sets with different outlook of clinical progression. while our rsf model performs well based on out-of-bag predictions ( figure s8 ; text s4), we would be highly cautious of triaging patients in other settings using the important variables identified here due to our limited sample size. however, this is an important first step towards an applicable triage risk screening tool once well recorded data on clinical courses for more patients become available. strategic response and allocation of medical resources for ongoing outbreaks may also benefit from a dynamic risk scoring system that incorporates new patient-level lab and symptom information as it is updated over time. in conclusion, we provided quantitative characterization of the clinical progression of covid-19 patients beginning from early clinical stages. our estimates form the basis for assessing effectiveness of new treatments and inform planning for healthcare resource allocation during covid-19 outbreaks. table 1 . demographic characteristics, surveillance method, baseline comorbidity, symptom profile, and lab and ct results by the highest clinical severity assessment. comorbidities were self-reported on admission. table 2 : estimated length of hospital stay, duration in icu, and length of invasive ventilator use. we estimated duration in icu among those who were admitted into icu and estimated duration on ventilator among those who required ventilation. ^three cases whose initial severity was either severe or critical were excluded from estimating risk-group specific duration of hospital stay, duration in icu, and duration on ventilator. . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted april 27, 2020. . https://doi.org/10.1101/2020.04.22.20076190 doi: medrxiv preprint table 3 : the association of demographic characteristics, baseline comorbidity, initial symptoms, and initial lab results with rate of clinical progression to severe stage, acute respiratory distress syndrome, and icu admission . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april 27, 2020. . https://doi.org/10.1101/2020.04.22.20076190 doi: medrxiv preprint figure 1 : clinical progression within 80 days following symptom onset for a) all cases with mild or moderate initial assessment, and b) cases in each of three risk subgroups obtained from random survival forest (see results for the list of predictors). from the top to the bottom, the four curves show the time-varying proportions of all admitted cases who 1) have not been discharged, i.e., still hospitalized or have died in hospital, 2) were severe, in the icu, or have died, 3) were in the icu or have died, and 4) have died. successive differences between the four curves over 80 days from symptom onset were highlighted in distinct colors and show daily composition of cases in each of four stages (mild/moderate, severe, icu, died). . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april 27, 2020. . https://doi.org/10.1101/2020.04.22.20076190 doi: medrxiv preprint figure 2 : cumulative incidence to clinical events and difference by age and sex. a) cumulative incidence of advancing to severe stage, pao2/fio2 dropping below 300mmhg, requiring icu admission, and developing acute respiratory distress syndrome. b) cumulative incidence of icu admission by age group and sex. c) cumulative incidence of hospital discharge by age group and sex. . cc-by-nd 4.0 international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted april 27, 2020. . https://doi.org/10.1101/2020.04.22.20076190 doi: medrxiv preprint tm were funded by the emergency response program of harbin institute of technology (hiterp010) and emergency response program of peng cheng laboratory (pclerp001). jl and qb were funded by a grant from the us centers for novel coronavirus (2019-ncov) situation reports critical supply shortages -the need for ventilators and personal protective equipment during the covid-19 pandemic clinical features of patients infected with 2019 novel coronavirus in wuhan clinical characteristics of coronavirus disease 2019 in china risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region nonparametric estimation of partial transition probabilities in multiple decrement models a proportional hazards model for the subdistribution of a competing risk time-dependent roc curves for censored survival data and a diagnostic marker the statistical analysis of failure time data we thank all patients and their families involved in the study; as well as the front line medical staff and public health workers who collected this critical data. gz was funded by the national science and technology major project for control and prevention of major infectious diseases this work was conducted in support of an ongoing public health response, hence was determined not to be human subjects research after consultation with the johns hopkins bloomberg school of public health irb. the study was approved by the ethics committees of shenzhen third people's hospital. key: cord-266469-n484zqq1 authors: king, michael j.; lewis, sara; el homsi, maria; hernandez meza, gabriela; bernheim, adam; jacobi, adam; chung, michael; taouli, bachir title: lung base ct findings in covid-19 adult patients presenting with acute abdominal complaints: case series from a major new york city health system date: 2020-07-04 journal: eur radiol doi: 10.1007/s00330-020-07040-z sha: doc_id: 266469 cord_uid: n484zqq1 objective: to describe demographic, clinical, and lung base ct findings in covid-19 patients presenting with abdominal complaints. methods: in this retrospective study, 76 covid-19 patients who underwent abdominal ct for abdominal complaints from march 1 to april 15, 2020, in a large urban multihospital health system were included. those with positive abdominal ct findings (n = 14) were then excluded, with 62 patients undergoing final analysis (30m/32f; median age 63 years, interquartile range (iqr) 52–75 years, range 30–90 years). demographic and clinical data were extracted. ct lung base assessment was performed by a cardiothoracic radiologist. data were compared between discharged and hospitalised patients using wilcoxon or fisher’s exact tests. results: the majority of the population was non-elderly (56.4%, < 65 years) and most (81%) had underlying health conditions. nineteen percent were discharged and 81% were hospitalised. the most frequent abdominal symptoms were pain (83.9%) and nausea/vomiting/anorexia (46.8%). lung base ct findings included ground-glass opacities (95.2%) in a multifocal (95.2%) and peripheral (66.1%) distribution. elevated laboratory values (when available) included c-reactive protein (crp) (97.3%), d-dimer (79.4%), and ferritin (68.8% of males and 81.8% of females). older age (p = 0.045), hypertension (p = 0.019), and lower haemoglobin in women (p = 0.042) were more frequent in hospitalised patients. there was no difference in lung base ct findings between discharged and hospitalised patients (p > 0.165). conclusions: covid-19 patients can present with abdominal symptoms, especially in non-elderly patients with underlying health conditions. lung base findings on abdominal ct are consistent with published reports. radiologists should be aware of atypical presentations of covid-19. key points: • covid-19 infected patients can present with acute abdominal symptoms, especially in non-elderly patients with underlying health conditions, and may frequently require hospitalisation (81%). • there was no difference in lung base ct findings between patients who were discharged and those who were hospitalised. • lung base ct findings included multifocal and peripheral ground-glass opacities, consistent with published reports. following its initial discovery in december 2019 in wuhan, china, the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) was declared a global pandemic by the world health organization (who) on march 11, 2020 [1] . sars-cov-2, transmitted between symptomatic and asymptomatic humans through respiratory droplets and direct contact, can result in severe pneumonia, acute respiratory distress syndrome (ards), and multiorgan failure [2] . coronavirus disease 2019 , the term for the clinical illness caused by sars-cov-2, has placed immense stress on the global healthcare apparatus and has resulted in profound economic disruption. as of 2 june 2020, there have been approximately 6 million confirmed cases and 371,000 deaths worldwide, with an estimated $2.7 trillion in global economic losses [3, 4] . approximately 1.9 million of those cases and 107,000 of those deaths are within the usa, with 372,000 cases and 24,000 deaths within new york state [3] . currently, there is no specific anti-viral therapy or vaccine available for covid -19. although typically characterised by fever and respiratory symptoms, gastrointestinal (gi) and/or genitourinary (gu) complaints as an initial presentation of covid-19 have recently been described, albeit to a lesser extent [5] [6] [7] [8] [9] [10] . in a metaanalysis of 69 studies including 4302 covid-19 patients in asia, 17.6% of patients reported gi symptoms [11] . viral rna was detected in stool samples from 48.1% of these patients [11] . a multicentre study from china with 204 patients showed that 50.5% reported gi symptoms on presentation [12] . interestingly, and as we have observed clinically within our major multihospital health system in new york city (nyc), many covid-19 patients present with abdominal symptoms either in isolation or in combination with respiratory complaints. these patients commonly undergo computed tomography (ct), with incidental findings of peripheral ground-glass opacities (ggos) and/or consolidative opacities noted at the lung bases, which have been described in the setting of covid-19 [13] [14] [15] [16] . data is rapidly emerging given the novel nature of this devastating disease, with a paucity of published reports investigating abdominal presenting symptoms and subsequent ct imaging findings in covid-19 patients. it remains to be determined how certain clinical and demographic factors including ethnic minority status, advanced age, or a lower income neighbourhood in nyc impact imaging findings or outcomes. to our knowledge, only a few small case series and case reports have been published on this topic to date [17] [18] [19] [20] . the purpose of our study is to describe the demographic, clinical, biological, and lung base ct findings in covid-19 patients presenting with acute abdominal complaints, either in isolation or in combination with respiratory complaints. this retrospective, health insurance portability and accountability act (hipaa)-compliant study was approved by our institutional review board with exemption for patient consent. the department of radiology imaging database was queried for abdominal or abdominopelvic ct examinations performed out of the emergency department (ed) throughout the hospitals in our health system located within nyc (including 6 hospitals in manhattan) between march 1, 2020, and april 15, 2020, using the search term 'viral pneumonia'. inclusion criteria were the following: (1) patient age > 20 years; (2) acute abdominal symptoms (with or without respiratory complaints); (3) patients who underwent abdominal or abdominopelvic ct for evaluation of their symptoms; and (4) patients with confirmed positive covid-19 reverse transcriptase polymerase chain reaction (rt-pcr) nasopharyngeal swab test obtained during the same ed visit. exclusion criteria were the following: (1) lack of a positive covid-19 rt-pcr test or (2) incomplete clinical information. the initial patient population consisted of 150 patients, with 74 cases excluded for various reasons (fig. 1) , resulting in a remaining population of 76 patients (37m/39f, median age 61.5 years, iqr 51-74 years, range 20-90 years). demographic and clinical data was recorded for each patient from the electronic medical records (emr). patients were stratified by age, sex, race, ethnicity, and nyc borough of residence. the following presenting symptoms were recorded: fever (oral temperature at ed presentation ≥ 37.0°c ), abdominal pain, nausea/vomiting/anorexia, diarrhoea, dysuria/haematuria/oliguria, cough, shortness of breath, chest pain, symptoms commonly attributable to viral syndromes (including myalgia, malaise, fatigue, headache, rhinorrhoea, and sore throat), and other symptoms (including syncope, weakness, dizziness, and altered mental status). the following underlying medical conditions were recorded: obesity (defined as body mass index (bmi) ≥ 30 kg/m 2 ), hypertension, diabetes mellitus, cardiovascular disease (including coronary artery disease, cerebrovascular disease, peripheral vascular disease, and/or congestive heart failure), chronic renal disease, asthma/chronic obstructive pulmonary disease (copd), and any cancer history or other reasons for immunosuppression. blood laboratory values were recorded, including aspartate aminotransferase (ast), alanine aminotransferase (alt), creactive protein (crp), procalcitonin, d-dimer, ferritin, lipase, white blood cell (wbc) count, lymphocyte percentage, and haemoglobin (hb). abdominal ct examinations were performed at several eds across our health system using clinically available platforms, including ge medical systems revolution (n = 12), ge medical systems lightspeed vct (n = 20), siemens somatom (n = 16), and toshiba aquilion (n = 14) scanners. the ct examinations were performed on the abdomen or the abdomen and pelvis, with (n = 39) or without (n = 23) isovue-370 intravenous contrast (iopamidol 76%, bracco diagnostics), in the supine or prone position depending on initial patient complaint. ct scanning parameters were as follows: matrix size of 512 × 512, kvp values ranging from 80 to 140 msv, slice thickness reconstructed at 3 mm, and pixel spacing (in-plane resolution) range of 0.596-0.977 mm in the axial plane. coronal and sagittal reconstructions were generated automatically by the scanners. lung base images were reconstructed using a lung kernel with reconstructed slice thickness of 3 mm. the abdominal ct examinations were reviewed by two board-certified fellowship-trained abdominal radiologists (m.k. and s.l.) in consensus with 2 and 10 years of experience, respectively, using pacs (centricity 3.0, general electric medical systems), to confirm the absence/presence of findings in the abdomen that could explain the clinical symptoms. the lung base findings were then independently reviewed by a board-certified fellowship-trained cardiothoracic radiologist (m.c.) with 5 years of experience, who was aware of the presence of covid-19 diagnosis but blinded to clinical symptoms. the lung bases were qualitatively assessed for the presence or absence of the following findings: groundglass opacities (ggos), consolidation, lesions with a rounded morphology, septal thickening, 'crazy paving' pattern, peripheral distribution, lung base multifocal involvement, bilateral involvement, and pleural effusion. two patients underwent chest ct at the same time as their abdominal ct. in both cases, the chest portion of the study was not evaluated, and only the lung base findings on the abdominal scan were included in our analysis for consistency. the following patient outcomes were recorded: (1) discharge from the ed (mild disease); (2) hospitalisation, including admission to an intensive care unit (icu); and (3) death. for patients who were admitted, the duration of hospitalisation or the time from admission to death was recorded. a final review of the patient's emr was undertaken on april 24, 2020. demographic, clinical, biological, and imaging data were summarised using descriptive statistics. the wilcoxon test was used for continuous variables. fisher's exact test was used for categorical variables. data were compared between groups of patients who were either discharged from the ed or hospitalised (including patients who died). a p value ≤ 0.05 represented an acceptable level of statistical significance in our study. all statistical tests were conducted using r statistical software (version 3.6.3). of the initially included patients (n = 76), those found to have a positive ct finding within the abdomen or pelvis (n = 14) were excluded from analysis. the final study population comprised 62 patients (30m/32f; median age 63 years, interquartile range (iqr) 52-75 years, range 30-90 years). the fourteen patients who were excluded due to the presence of positive findings within the abdomen or pelvis at ct had gi diagnoses (oesophagitis (n = 1), perforated duodenal ulcer (n = 1), small bowel enteritis (n = 1), small bowel obstruction (n = 1), large bowel obstruction (n = 1), colitis (n = 2), perianal abscess (n = 1), biliary distention (n = 1), cholelithiasis (n = 1), or acute pancreatitis (n = 1)) or gu diagnoses (nephrolithiasis and/or hydronephrosis (n = 5), pyelonephritis (n = 1), or postcystectomy fluid collection (n = 1)). four patients had both gi and gu diagnoses. demographic and clinical characteristics of the study population are summarised in table 1 . most patients lived in manhattan (45%, n = 28/62) and a majority (81%, n = 50/ 62) had at least one underlying medical condition. the median time interval between scanning and confirmed covid-19 diagnosis via rt-pcr was 0.5 days (iqr 0-1). patients were stratified by demographic, clinical, biological, and lung base ct findings according to patient outcomes. in our study sample, 19% (n = 12/62) of patients were discharged from the ed without hospital admission, while 81% (n = 50/62) were hospitalised. of the hospitalised patients, 10% (n = 6/62) died while the remaining 71% (n = 44/62) were discharged. the 6 patients who died had a median age of 69 years (range 58-83 years); 1 died of cardiopulmonary arrest with covid-19 pneumonia and diabetes listed as contributing factors despite attempted resuscitation, 4 died of covid-19 respiratory failure in the setting of a do not resuscitate/do not intubate (dnr/dni) order, and 1 died of covid-19 respiratory failure and acute renal failure in the setting of a dnr/dni order. no patients were ventilated or admitted to the icu. of those hospitalised, the median duration of hospitalisation (until discharge or death) was 5.0 days (iqr 3.0-9.0 days). the hospitalised patients were older than those discharged from the ed (median age 63.0 years (iqr 55.8-77.8 years) vs. 54.5 years (iqr 46.0-65.0 years), p = 0.045, respectively). the hospitalised patients were managed clinically at the discretion of the medical teams, and none received subsequent abdominal imaging throughout their hospital stay. there was no difference in sex or bmi (all p values > 0.844) between the 2 groups. hypertension was more frequent in hospitalised patients (p = 0.019), whereas cough (p = 0.044) and shortness of breath (p = 0.038) were more frequent in those discharged from the ed. otherwise, there was no significant difference in the frequency of presenting symptoms (all p values > 0.116) or underlying health conditions (all p values > 0.085) ( table 1 ). the median and interquartile ranges of selected blood laboratory values (when available) are summarised in table 2 . although a majority (57.4%, n = 31/54) of patients demonstrated a mildly elevated ast, the most frequent abnormalities were acute markers of inflammation. median haemoglobin was lower for female patients hospitalised compared with those discharged from the ed (median hb 11. a summary of the lung base ct findings in the whole patient population and stratified by outcome is described in table 3 . all patients demonstrated at least one lung base finding on abdominal ct. an overwhelming majority of patients demonstrated ggos (95.2%), with findings described in a multifocal (95.2%) and bilateral (93.6%) pattern (figs. 2 and 3 ). only 1 patient (1.6%) demonstrated pleural effusion. there was no significant difference in the frequency of imaging findings at the lung bases between the discharged and hospitalised groups (p > 0.165). in this study, we described demographic, clinical, biological, and lung base ct findings in a population of covid-19 patients who presented to our health system with acute abdominal complaints, either in isolation or in combination with respiratory complaints. nineteen percent of the patients were discharged from the ed without hospital admission and 81% were hospitalised. of those hospitalised, the median duration of hospitalisation (until discharge or death) was 5 days. less than 10% of our patient population died, all of whom were admitted to the hospital, but not to the icu. the higher median age observed in patients that died is consistent with anecdotal evidence and with one of the earliest and largest published clinical reports on covid-19 from wuhan, china [5] . interestingly, our 0% icu admission rate is in line with very recent reports-including one from a neighbouring academic institution in nyc consisting of 278 patientssupporting an emerging concept that patients presenting with gi complaints may have milder disease severity with lower icu admission and mortality rates [7, 8] . however, these findings contrast with a study of 204 chinese patients with gi symptoms that demonstrated a 7.8% icu admission rate [12] . our mortality rate is in line with other reported mortality rates for covid-19, which vary between 1.4 and 28% depending on the series [5, 9, 21, 22] . most patients (81%, n = 50/62) in our study had underlying medical conditions, which likely mirrors the us public health situation. the only risk factor associated with need for hospitalisation was hypertension, contrasting with a recent chinese report that suggested diabetes be considered a poor prognostic risk factor in covid-19 [23] . a recent report of 107 patients suggested that lymphopenia is an indicator of disease severity in covid-19 patients [24] . the most frequent laboratory abnormalities in our study were acute markers of inflammation (including crp, d-dimer, and ferritin); however, the only significant difference in laboratory values was for hospitalised women having a lower haemoglobin compared with those discharged from the ed. table 2 blood laboratory values in patients with covid-19 in relation to outcomes (discharged vs hospitalised). data between each patient group were compared using the wilcoxon test. values are given as median with interquartile range in parentheses unless otherwise stated. reference ranges are given below each laboratory value name in brackets these discrepancies in our results compared with prior studies are likely due to our small sample size and differences in the study population. our lung base ct findings are consistent with numerous published reports on nonspecific imaging features that are typical for covid-19, including ground-glass opacities and consolidation, often with a rounded morphology with a bilateral, peripheral, and/or multifocal distribution, while lymphadenopathy and pleural effusions are characteristically absent [13, [25] [26] [27] [28] . as our study suggests, the lower lobe predominance of these findings requires abdominal radiologists to keep covid-19 diagnosis in mind even when patients present solely with abdominal complaints, and to suggest it as a differential diagnosis where appropriate. interestingly, no differences were found between the frequencies of lung base ct findings between the two patient groups. understanding the exact mechanism of sars-cov-2 resulting in abdominal symptoms remains both interesting and challenging. potential explanations include direct viral infection of the gi or gu systems, co-infection with another pathogen, or referred pain from infection at the lung bases [29] . similar to the 2003 coronavirus sars-cov but with a much higher affinity, sars-cov-2 infection in humans depends on the ability of the virus to bind with the angiotensinconverting enzyme 2 (ace2) receptor [30, 31] . ace2 is expressed in the human lung, upper oesophagus, ileum, colon, renal proximal tubules, and urinary bladder, providing a conceivable explanation for viral involvement at these sites [32, 33] . viral infection of enterocytes is likely to cause an alteration of intestinal permeability, leading to a spectrum of gi symptoms including abdominal pain, nausea/vomiting, and diarrhoea [34] . according to roman et al, there is no clear description of autonomous nervous system involvement with covid-19 at this point [35] . given this, a study of 204 patients with acute respiratory illnesses with confirmed nasopharyngeal swabbing for viral pathogens, including human coronavirus, found that gi symptoms could not be explained by the presence of viral respiratory pathogens in stool samples [29] . abdominal symptoms have been described in other closely related coronavirus infections, fig. 2 a 58-year-old male presenting with abdominal pain for 7 days, who was subsequently discovered to be covid-19positive. (a) axial and (b) coronal ct at the level of the lung bases show multifocal bilateral groundglass opacities with a rounded morphology (arrows); many of which are peripheral in distribution. this patient was hospitalised and ultimately died 10 days later from respiratory failure related to covid-19 fig. 3 a 63year-old female with abdominal pain, nausea, and diarrhoea for 7 days, who was subsequently discovered to be covid-19-positive. axial ct of the lung bases at two different levels (a, b) shows predominantly peripheral, multifocal, and bilateral ground-glass (white arrows) and consolidative (black arrows) opacities with a region of 'crazy paving' attenuation (dashed arrow), a less commonly seen imaging finding in covid-19. this patient was discharged home after being hospitalised for 8 days with gi symptoms and diarrhoea reported with high frequency (23-70%) in severe acute respiratory syndrome (sars) and in > 33% of patients with middle eastern respiratory syndrome (mers) [36] [37] [38] . a recent preliminary, non-peer-reviewed study also suggested that ace2 is also expressed in cholangiocytes, perhaps providing a mechanism for liver dysfunction and elevated serum liver enzymes [39] . of note, there was mild elevation in serum ast in our study. the renal and urinary bladder expression of ace2 may explain the urinary symptoms in our study sample. further work is warranted to elucidate the mechanism of action in this regard. our study has several limitations. first, our data was obtained retrospectively from available data within the emr, which may limit the generalisability of our results. much of the clinical and radiologic literature published to date has been from asia; more robust studies from the usa, a region with marked demographic and clinicopathologic differences (including higher rates of obesity and diabetes, for example), need to be performed in order to see how our results compare. we had incomplete race/ethnicity information, which has limited our ability to assess any meaningful associations related to these parameters. additionally, future studies from the usa should incorporate longer follow-up periods and larger patient populations, including assessment for viral particles in stool and urine, an important clinical component missing in our analysis. in conclusion, we report demographic, clinical, biological, and lung base ct findings in a group of patients presenting to our health system with acute abdominal complaints who were found to have covid-19. it is essential that the abdominal radiologist be aware that patients presenting with a wide variety of abdominal complaints may have covid-19 infection in the absence of other findings in the abdomen or pelvis. further work in a larger patient population is needed to evaluate these findings in relation to disease severity and outcome, especially given the urgency and widespread nature of covid-19 infection. funding information the authors state that this work has not received any funding. guarantor the scientific guarantor of this publication is bachir taouli, md. the authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article. statistics and biometry one of the authors has significant statistical expertise. informed consent written informed consent was waived by the institutional review board. ethical approval institutional review board approval was obtained. • retrospective • observational • performed at one health system comprised of 6 hospitals world health organization declares covid-19 a 'pandemic clinical features and chest ct manifestations of coronavirus disease 2019 (covid-19) in a single-center study in shanghai, china coronavirus covid-19 global cases by the center for systems science and engineering coronavirus could cost the global economy $2.7 trillion. here's how clinical characteristics of coronavirus disease 2019 in china clinical features of 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events, which starts with activation of leukocytes. pyrogenic factors released from the leukocytes increase the thermoregulatory set point in the hypothalamus. signs that may be associated with fever include: • elevated body temperature. • reluctance to move. • anorexia. • depression. • hyperpnea. • muscle or joint stiffness/discomfort. • shivering. • inflammation anywhere in the body can result in elevation of core body temperature above 39.2˚c (102.5˚f). • the most common etiology for fever in the cat is percutaneous cellulitis or abscess. viral diseases such as fiv, felv and fip are important diseases to consider. conjunctivitis is the predominant sign and is often initially unilateral and becomes bilateral. ocular discharge is serous initially then mucopurulent, but is usually mild. fever, anorexia and lethargy may occur. true fever must be differentiated from hyperthermia, which can be caused by increased muscle activity, increased environmental temperature and stress. true fever results from activation of leukocytes that release factors (pyrogens) such as interleukin-1 and tumor necrosis factor. • these factors cross the blood-brain barrier and increase the thermoregulatory set point in the hypothalamus. • leukocytes are activated by a multitude of infectious agents, neoplasia, tissue necrosis and immune-mediated diseases. fever is defined as systemic elevation of core body temperature above 39.2˚c (102.5˚f). the most accurate measurement of core body temperature is obtained rectally. aural temperature is approximately −17.2˚c (0.5˚f) lower than the rectal temperature. fever is a general clinical sign that can be associated with many different diseases. the most common disease causing fever in the cat is percutaneous cellulites or abscess. many viral and bacterial diseases cause fever because leukocytes are recruited and activated as part of the general immune response. organ inflammation, such as pancreatitis, cholangiohepatitis and myocarditis, can be associated with an elevated temperature even when an infectious agent is not present. classical signs • fever. • anorexia (partial or complete). • reluctance to move, lethargy and depression. • pain, heat or swelling at site of abscess or cellulitis. cellulitis usually precedes an abscess, and if treated appropriately, the abscess may not even form. cellulitis may be the only evidence of a previous abscess. an abscess may rupture spontaneously, and the owner may notice foul-smelling, purulent discharge on the fur. • some abscesses resolve on their own with or without rupture, if they have been present long enough. regional lymphadenopathy may occur near the affected site. cellulitis spreads rapidly with the development of multiple fistulae and a febrile response. • lameness from septic arthritis is a common sequelae to infection with l forms. joints are affected by the hematogenous route and may be distant to the initial site. lower limbs (tarsus and carpus) are most commonly affected. the joints often ulcerate with a grayish mucinous exudate. infection remains confined to subcutaneous tissues and joints without systemic spread to internal organs. history supports access to outdoors or conflict with other cats indoors. palpation reveals a tender area or fluctuant swelling, with or without evidence of puncture wounds. microscopic examination of a fine-needle aspirate of the abscess reveals a heterogeneous population of bacteria, numerous degenerate neutrophils and intracellular bacteria. a complete blood count will generally show neutrophilia. l forms are not visible in tissue samples even with special stains, nor do they grow on culture. on electromicroscopy, organisms are visible intracellularly within phagocytes. diagnosis is often made by response to tetracyclines in a therapeutic trial (doxycycline 10 mg/kg po, q 24 h). response is rapid and evident within 48 h. non-healing abscesses should have histopathology and culture of tissue. causes include nocardia, fungi, mycobacteria, and tumors. see page 1081, the cat with non-healing wounds. in plague-endemic regions, yersinia pestis (plague) must be considered, if the swelling is predominately in the neck region and the cat's fever is in the region of 40.5˚c (105˚f). cautionary measures such as gloves, masks and isolation of the suspect cat should be taken until diagnosis established. (see below for discussion of y. pestis infections). fracture. ligament/tendon injury. neoplasia. clip area looking for evidence of puncture wounds. drainage of the purulent material is the key to treatment. surgical drainage can be done under sedation or general anesthesia with a #15 blade. make a 1/4-1/2" incision over the dependent area, or the area most likely to allow for continued drainage. flush the wound thoroughly with sterile saline or a saline/betadine mixture. explore the wound with a sterile cotton swab or hemostats to assess the extent of dead-space and to look for a possible foreign body. leave the wound open to allow drainage of further purulent material. do not suture incision closed, as this will only allow the abscess to reform. a penrose drain may be placed for 2-3 days to allow maximum drainage for abscesses that close too early. antibiotic therapy for 7-10 days directed against anaerobes: penicillins, cephalosporins, clindamycin and metronidazole are reasonable choices. most abscesses respond extremely well to drainage and amoxicillin at 10-20 mg/kg po q 12 hours for 7 days or amoxicillin/clavulonic acid (12.5 mg/kg po q 12 hours). l-forms and mycoplasma spp. respond to doxycycline or tetracycline within 48 hours, but not other antibiotics. if the wound is not healing well, or the cat has had recurrent abscesses, felv/fiv testing is recommended to rule out an underlying immunodeficiency. further considerations are inappropriate antibiotics (consider culture and sensitivity testing) or the presence of an undetected foreign body (consider surgical exploration of the area) or involvement of underlying bone (osteomyelitis). prognosis is good unless there is an underlying immunodeficiency. restrict the cat to an indoor environment only; although less effective, confine cat indoors at least from dusk to dawn. neuter male intact animals to decrease territorial behavior. felv and fiv serology should be repeated 2-4 months following bite wounds. classical signs acute onset of sneezing followed by oculonasal discharge. discharge progresses from serous to mucoid to mucopurulent. severe conjunctivitis with tearing, photophobia and chemosis. hypersalivation may occur as an initial sign before the classic signs of upper respiratory tract appear. punctate corneal ulcers that may coalesce to larger ulcers or perforation. fever of 1-2 days duration, anorexia and depression. retching or coughing may occur. cats with anterior uveitis have occasionally have herpesvirus 1 in the aqueous humor. presumptive diagnosis can be made on the basis of history and clinical signs because treatment for feline herpes virus-1 and calicivirus are similar. ocular ulcerations and chemosis are more suggestive of fhv-1. definitive diagnosis is by direct ifa of cells obtained from conjunctival or nasal scrapings, or by viral isolation or polymerase chain reaction assays from oropharyngeal or nasal swabs. sudden onset of serous ocular discharge and mild conjunctivitis; these signs may begin unilaterally, but often progress bilaterally. initial signs are rapidly followed by sneezing, which are not paroxysmal and are less prominent than in herpesvirus. nasal discharge is primarily serous to mucoid and rarely progresses to purulent. oral ulcerations are common, especially on the tongue, and may be associated with drooling or hypersalivation. ulcers may also occur at the mucocutaneous junction, hard palate and nose. fever generally spikes initially after infection prior to onset of signs, and returns with onset of clinical signs. viral pneumonia occurs occasionally with certain strains, and may produce significant mortality. death is often sudden and preceded by laboured respiration. a rare variant strain (fcv-ari) reported from the united states, produces a high fever, facial and paw edema (50% of cats), ocular and nasal discharge, conjunctivitis and ulcerative stomatitis (50% of cats), hemorrhage from the nose, git, etc. (30-40% of cats), icterus (20% of cats) and rapid death. mortality is high (30-50%). presumptive diagnosis can be made on basis of history and clinical signs because treatment for feline herpes virus-1 and calicivirus are similar. oral ulcerations or clinical signs of pneumonia are more suggestive of calicivirus. definitive diagnosis is by viral isolation or reverse transcriptase polymerase chain reaction assays from swabs taken from the oropharynx, ideally in the first week of illness. demonstration of increasing serum antibody titers to feline calicivirus in paired samples is also useful, whereas measurement of a single titer is not useful because many cats have titers from vaccination. identification of fcv-ari is based on the clinical syndrome, pathology and culture of virus from blood, nasal or ocular discharge, spleen or lungs. clinical signs are often non-specific and include fever, anorexia and weight loss. dyspnea and harsh lung sounds without coughing is common. peripheral and visceral lymphadenopathies are frequently present. pale mucous membranes, icterus, hepatomegaly or splenomegaly may be evident. ocular signs are uncommon, but can occur. gastrointestinal signs are uncommon in cats compared to dogs, and include chronic diarrhea, mesenteric lymphadenopathy and anorexia. osseous lesions produce soft tissue swelling and lameness. diagnosis is by demonstration of the organism in lymph nodes, draining tracts, bone lesions or vitreous humor. the organism has a thin capsule and is intracellular within macrophages. no reliable serologic test available. genetic predisposition appears to play a role. fip is most common in catteries and multi-cat households. there are two clinical forms of fip, effusive or wet form and non-effusive or dry form. both are characterized by a fluctuating fever unresponsive to antibiotics, anorexia, lethargy and weight loss. typical age of onset is 6 months to 2 years, but any age can be affected. the effusive form may have any of the following signs: • abdominal effusion that is non-painful but progressive. the amount of effusion varies from volumes causing abdominal enlargement, to amounts only detectable by abdominocentesis. fluid is straw-colored and highly viscous, like egg white. • pleural effusion resulting in dyspnea occurs in 30% of cats with the effusive form. pericardial fluid may be evident on ultrasound. usually it not associated with clinical signs, but occasionally can produce cardiac tamponade. • male cats may present with scrotal swelling. the non-effusive form may have any of the following signs: • ocular signs result from pyogranulomatous inflammation of the iris and ciliary body. they include bilateral uveitis, perivascular exudates (cuffing), retinal hemorrhage, retinal detachment. • neurologic signs include cerebral and cerebellarvestibular signs such as seizures, personality changes, nystagmus, head tilt, circling, head tremor and hyperesthesia. • dysfunction of any organ system may result from granuloma formation within the tissue of that organ, e.g., liver, kidney, spleen, intestines, lungs, etc., however, organ failure producing clinical signs only rarely occurs, and most dysfunction is only detected on biochemical tests. • granulomatous masses may be palpable in abdominal viscera especially mesentery, mesenteric lymph nodes and omentum as tender, irregular masses. occasionally vomiting or diarrhea results from extensive lesions on the bowel wall. jaundice may occur with either form of the disease. histopathology of affected tissues provides the only definitive antemortem diagnosis. the classic fip lesion is pyogranulomatous infiltration around venules. the following are typical abnormalities associated with fip. all asterisked items must be present for a high likelihood of fip; if any one parameter is not present, fip is unlikely. a negative coronavirus ("fip") titer suggests fip is not the cause of the fever, although a few cats with the effusive form of the disease are titer negative. lymphopenia (< 1.5 × 10 3 cells/μl).* occurs in many cats with fip, and many cats without fip. except where the classical effusive fluid is present, definitive diagnosis of fip requires organ biopsy and demonstration of classical histopathological lesions. various non-specific abnormalities may be evident on laboratory tests, including increased total white cell count, mild to moderate anemia, and increased concentrations of bilirubin, liver enzymes, bun, creatinine, fibrinogen, globulin and mild proteinuria. csf typically has increased protein (> 2 g/l) and cell counts (>100 cells/ml) which are predominantly nonlytic neutrophils. ocular signs: toxoplasmosis, fungal agents. neurologic signs: toxoplasmosis, neoplasia (e.g., lymphoma), trauma, congenital abnormalities in young cats. other clinical signs: rule out other diseases associated with the apparent organ dysfunction. lymphocytic, plasmocytic cholangiohepatitis occasionally produces a high protein abdominal fluid similar to that of effusive fip. fip is a fatal disease with no known treatments. the therapies listed below have been used in an attempt to slow progression and/or to improve quality of life. glucocorticoids at immunosuppressive doses (prednisolone 4 mg/kg/day). cyclophosphamide (200-300 mg/m 2 q 2-3 weeks or 2.2 mg/kg daily for 4 days each week) or chlorambucil (20 mg/m 2 q 2-3 weeks). +/− broad-spectrum antibiotics to control secondary bacterial infections while the cat is immunosuppressed. prognosis is poor. the mortality is > 95%. fecal-oral transmission is most likely; transplacental transmission is rare. fomites, e.g., food bowls and litter trays, may be an important mode of transmission, as some strains of fcov survive in dried secretions for several weeks. a seronegative cat introduced into a household where coronavirus is endemic has a 1 in 6 chance of developing fip; a seropositive cat under the same conditions has a 1 in 12 chance. both young and old animals seem to be most susceptible due to vulnerable immune systems. maternal antibodies that protect kittens wane at approximately 5-6 weeks of age. reduce fecal-oral contamination by providing one litterbox for every 1-2 cats, cleaning litterboxes daily, and placing litterboxes away from feeding areas. minimize stress, especially crowding in catteries. do not introduce fcov-positive cats into a multi-cat household. wean kittens at 5 weeks and remove from the queen's environment if she is seropositive. an intranasal vaccine is available for use in seronegative cats. however, efficacy has not yet been demonstrated against wild strains. classical signs see main reference on page 540 for details (the anemic cat). onset of illnesses occurs over an extended period of time (months to years), although young kittens can become acutely ill. chronic, opportunistic infections occur that do not respond to appropriate antibiotic therapy and are primarily due to immunosuppression. fever may occur in any age cat but is primarily seen initially in the viremic stage or later in response to neoplastic, inflammatory or immunosuppressive effects. chronic fever occurs in later stages of disease. weight-loss/cachexia. non-regenerative anemia. thrombocytopenia. lymphoma is associated with felv-positive cats, especially thymic and multicentric forms. history and clinical signs may be suggestive. complete blood count showing anemia, thrombocytopenia, leukemias, increased mcv and leukopenia are supportive. bone marrow aspirate may show myeloproliferation and arrested erythroid differentiation. a positive felv antigen test (viral core antigen p27) on whole blood using an ifa (can also be done on bone marrow sample) or an elisa test (also on serum, plasma, saliva, tears). see page 543 for interpretation. polymerase chain reaction is available from some laboratories. • pale mucous membranes. see main reference on page 530 for details (the anemic cat). classical signs are pale mucous membranes and/or icterus primarily from extravascular hemolysis due to complement binding of infected erythrocytes. severe, regenerative hemolytic anemia may ensue. anorexia and depression are typical. fever occurs in 50% of cats in the acute phase, and may occur intermittently in chronic infections. history and clinical signs are suggestive, especially if an immunosuppressive disorder is present concurrently. diagnosis is via demonstration of the organism on the surface of erythrocytes. use a marginated blood sample for diagnosis, e.g., ear vein. multiple blood smears over a number of days may be required as most of the organisms are removed from circulation by the time clinical signs are apparent. infected cats may be coomb's positive. a polymerase chain reaction test is available in some laboratories for diagnosis. classical signs gastrointestinal signs, primarily abdominal discomfort and small bowel diarrhea, are due most likely to replication of the organism (tachyzoites) in enteroepithelial cells resulting in necrosis. clinical signs in the acute, fatal form of extraintestinal disease are caused primarily by tissue damage from the rapidly dividing tachyzoites. tachyzoites begin to disappear from tissues approximately 3 weeks after infection. the organism may persist in tissues as tissue cysts containing bradyzoites. chronic disease may be a result of delayed hypersensitivity reactions and tissue reaction to antibody-antigen complex deposition. concomitant illness, such as felv, fiv and immunosuppression with glucocorticoids, has been reported in some cases. gastrointestinal disease. • mild, self-limiting small bowel diarrhea may occur in the definitive host (cats), but only after ingestion of tissue cysts, oocysts or sporulated oocysts. • young kittens are more likely to have gastrointestinal signs, although mild clinical disease has been reported in adult cats as well. all newborn kittens experimentally infected developed severe diarrhea 5-6 days later. • fatal extraintestinal disease is most likely to occur in transplacentally infected kittens. • kittens may be stillborn or exhibit signs that are severe and rapidly progressive and reflect involvement of the lungs, liver and cns tissues. these signs may also be observed in postnatally infected kittens and include: -a distended abdomen from an enlarged liver and/or ascites. -icterus from hepatitis or cholangiohepatitis. -dyspnea is present in most kittens and cats with signs of acute infection. -neurologic deficits; continuous vocalization; excessive sleeping. -fever, anorexia, depression often accompanies the tissue-specific signs. • cats may have a moderate fever, lethargy and depression that waxes and wanes. • hyperesthesia and stiff painful joints or shifting lameness may be evident, presumably due to an immune-mediated process. • unilateral or bilateral anterior or posterior uveitis may occur with possible sequelae of lens luxation, glaucoma or retinal detachment. • seizures and ataxia may be present if cns tissues are involved. • rarely, a toxoplasma granuloma (tissue cyst) forms in the gastrointestinal tract or pancreas causing chronic vomiting. clinical signs consistent with toxoplasmosis are suggestive, especially when other causes of the signs have been ruled out. igm titers > 1:64 and a four-fold increase in igg:igm titers within 2 weeks correlate best with clinical toxoplasmosis. however, some cats do not develop detectable igm titers, and in other cats, positive igm titers can persist for months to years after infection. elevated ocular and csf titers relative to serum titers in cats with ocular or neurologic signs, respectively, are very suggestive. coefficient values > 1.0 are highly suspect and > 8.0 strongly suggest local production of t. gondii antibodies. response to therapy for toxoplasmosis is a useful indicator of infection. definitive diagnosis requires demonstration of the organism in inflamed tissues by histology, immunohistochemistry or polymerase chain reaction assay. rule out diseases associated with affected organs, e.g., fip for neurologic and ocular signs. clindamycin at 10-12 mg/kg orally q 12 hours for 4 weeks is usually effective. • cats should respond within several days of treatment. • if no response is evident after 3 weeks of antibiotic therapy, reconsider the diagnosis. • the chronic form may recur even after successful treatment, as drugs tend to suppress replication rather than kill the parasite. other systemic drugs with potential efficacy include the trimethoprim sulfas combination, doxycycline, minocycline, azithromycin and clarythromycin. cats with ocular lesions should also be treated with corticosteroids, either topically (e.g. topical 0.5% prednisolone acetate drops applied q 6-12 h) or systemically to control inflammation and its sequelae (glaucoma, lens luxation). gastrointestinal disease has a good prognosis, although it may lead to inflammatory bowel disease in rare cases. acute extraintestinal disease has a guarded to poor prognosis. chronic extraintestinal disease has a fair to good. • the placenta or milk with tachyzoites. • ingestion of meat infected with tissue bradyzoites, e.g., rodents. • ingestion of sporulated oocysts in food or water. t. gondii has a zoonotic potential. infection of humans can occur via: • ingestion of undercooked meat containing tissue bradyzoites (most common mode of transmission). • ingestion of sporulated oocysts from the environment. • transplacentally, if first-time exposure to the organism occurs during pregnancy. only cats host the sexual replication that results in oocysts in the feces. • oocysts are shed for 1-2 weeks. • most seropositive cats do not shed oocysts on repeat exposure. oocysts must sporulate to be infectious: • sporulation occurs 1-5 days after environmental exposure, thus handling individual cats rarely results in infection of humans. transplacental transmission occurs in cats and people after primary exposure. discourage cats from going outdoors and hunting behavior. do not feed cats undercooked meat. • cook meat at 80˚c (176˚f) for 15 minutes. • use gloves when gardening or changing the litterbox, and wash hands well. • change litterboxes daily. use litterbox liners or clean with scalding water. • lethargy and anorexia. see main reference on page 272 for details (the cat with depression, anorexia or dehydration). the classical signs are not as well-defined for cats as for dogs for the following reasons: • cats tend to have intermittent bouts of chronic pancreatitis. • diagnostic tests for pancreatitis are not as reliable in cats. • there is poor correlation of biochemical parameters with pancreatitis in the cat. lethargy and anorexia is variable depending on chronicity. vomiting only occurred in 35% of cases in one study. dehydration occurred in 50% of cases in the same study. abdominal pain is quite variable. fever is variably present, and generally mild. in severe acute pancreatitis it may progress to hypothermia, which is a poor prognostic sign. diagnosis is unreliable based on a biochemistry panel. lipase may be increased or normal in pancreatitis. • hyperbilirubinemia and elevated liver enzymes may be present. • hypocalcemia occurs in 40% (total serum calcium) or 60% (plasma ionized calcium concentration) of cats due to soponification of fat. cats with a plasma ionized calcium concentration < 1.00 mmol/l (< 4.00 mg/dl) have a grave prognosis (77% mortality) and aggressive medical treatment is indicated. pancreatic lipase immunoreactivity is probably a more sensitive diagnostic tool for confirming pancreatitis in cats than measurement of plasma lipase concentration or trypsin like immunoreactivity. a feline-specific assay must be used. abdominal ultrasound to visualize an enlarged pancreas or heterogeneous echogenicity in the area of the pancreas is considered by many to be most sensitive. demonstration of higher lipase levels in abdominal fluid compared to those of the serum is suggestive. diagnostic peritoneal lavage may be necessary to obtain a fluid sample. clinical signs may be acute, chronic or intermittent. typically, there is anorexia and depression together with icterus or increased bilirubin and liver enzymes on a biochemistry panel. vomiting and dehydration may be present. fever, especially in the suppurative form occurs in approximately 38% of the cases. chronic cholangiohepatitis may lead to end-stage liver disease and the cat may present with ascites and hepatic encephalopathy. multiple causes include bacterial, protozoal (t. gondii) and immune-mediated disease. complete blood count may show neutrophilia with a left shift, and mild non-regenerative anemia. biochemistry panel shows hyperbilirubinemia, elevated liver enzyme activities (alp, alt, ggt), +/− elevated serum bile acids. • signs of late-stage liver disease are occasionally present, such as decreased bun, glucose and albumin concentrations. abdominal ultrasound should be performed to evaluate the gall bladder and bile duct for cholelithiasis, bile sludging and cholecystitis. liver aspirates/biopsy allows for differentiation of suppurative from non-suppurative forms of cholangiohepatitis. clinical signs are primarily due to immunosuppression, i.e., chronic recurring infections that do not respond to appropriate therapy. gingivitis, stomatitis and peridontitis are more common findings in fiv infections than in felv, although one study suggests that these signs may be to an effect of age, rather than a consequence of fiv infection. fever is chronic and is related to production of tumor necrosis factor and/or il-1 in infected cats. weight loss/cachexia are common in the late stages of fiv, as in human hiv infections. diarrhea resembles a panleukopenia-type syndrome that may be due to actual enterocyte infection by the virus or secondary to inflammation. cats are often thin and scruffy with an unkempt haircoat, and may have miliary dermatitis. diagnosis may be suspected based on history and clinical signs, but requires antibody or antigen tests for confirmation. virus isolation and polymerase chain reaction for virus detection is available at some research facilities. cats infected with fiv can be co-infected with felv. chronic nasal discharge can be unilateral or bilateral and is generally serosanguineous. sneezing and stertorous breathing is often present. facial deformity may occur due to invasion of the surrounding bone. chronic low-grade fever may be present. depression, anorexia and weight-loss are signs of disseminated disease. neurologic signs occur via hematogenous spread or invasion into the cns through the cribiform plate but are uncommon. signs include seizures, blindness, depression and ataxia. the skin form typically produces nodules which often ulcerate. diagnosis is by demonstration of narrow-based budding yeast with a very thick capsule from affected tissue or by culture of affected tissue or csf. demonstration of cryptococcus antigen in serum, urine or csf is also diagnostic. occurs in cats of all ages, with and without outdoor access. progressive clinical signs occur over a period of 1-4 weeks. according to one study, non-supportive meningoencephalitis may be the most common cause of seizures in cats. systemic signs, which are not present in all cats, include fever, anorexia, lethargy, vomiting, diarrhea and lymphadenopathy. the condition, however, does not appear to be contagious to other cats. csf tap can be very useful to rule out other causes of cns signs, specifically toxoplasmosis and fip; csf analysis reveals a normal or mild protein elevation (typically < 1 g/l) and/or an increased white cell count (< 50 cells/μl). complete blood count findings are non-specific and may include leukopenia or leuko-cytosis, eosinophilia and anemia. • uniphasic or biphasic fever. • depression. • lethargy. • mild generalized lymphadenopathy. • +/-signs of cardiac failure. • viral, e.g., fip has been shown to cause cardiac infection. • trypanosoma cruzi, which causes chagas' disease in humans. • streptococcus and borrelia (lyme's disease) in certain geographic areas. no single agent has been identified, and the disease may be multifactorial. fever is biphasic in 50% of the cats; if biphasic: • first fever occurs approximately 10 days after exposure, lasts 1-3 days and peaks at 39.3-40.7˚c (102.7-105.2˚f). • second fever occurs 1-2 weeks after the first fever (at 3-4 weeks post-exposure), lasts 5 days and peaks at 39.9-40.9˚c (103.8-105.6˚f). appetite is mildly decreased in some cats, but most continue to eat and drink. some animals exhibit mild generalized lymphadenopathy. irritable disposition and hyperesthesia may occur, and are most likely due to fever and malaise. in a few case reports, cats have died from peracute cardiac failure, but this outcome is not common. myocarditis/diaphragmitis is a diagnosis of exclusion. biochemistry and complete blood counts are unremarkable, except for a mild to moderate increase in ck in less than 50% of experimentally infected cats. definitive diagnosis can only be made at necropsy. histopathology shows a neutrophilic infiltrate with a foci of myonecrosis in myocardium and diaphragm. any other causes of fever should be ruled out including infectious, inflammatory, immune-mediated, drugs, neoplasia and metabolic. other causes of cardiac failure that should be ruled out include congenital deformities, hypertrophic cardiomyopathy, restrictive cardiomyopathy and dilatative cardiomyopathy. supportive therapy is indicated if dehydration or cardiac disease are present. broad-spectrum antibiotics are indicated if complete blood count supports an infectious cause. fever and depression resolve spontaneously in the majority of cats. prognosis is poor if peracute cardiac failure is present with systemic signs of fever and depression. although an infectious agent is suspected, no single etiologic agent has been identified, making recommendations for prevention difficult. • cardiovascular or respiratory compromise. • external signs of injury. cardiovascular compromise may result in tachycardia, hypovolemia or hypotension. respiratory compromise may produce dyspnea/ tachypnea due to pneumothorax, hemothorax or pyothorax. internal injuries may result in abdominal pain from organ rupture, bone/joint pain or focal swelling. diagnosis is based on clinical signs and history. radiographs of the chest, abdomen and/or limbs may be required to characterize the injury. complete blood count and biochemistry panel is indicated to rule out specific organ injury and primary infection. • alert, febrile cat being treated with antibiotics or antifungal agents. history of treatment with antibiotics or antifungal agents. fever does not correspond to clinical appearance of animal. cats are bright, alert and responsive, despite a temperature in the range of 39.4-40˚c (103-104˚f). onset of fever is idiosyncratic and variable, but the fever is generally present for the duration of the drug treatment. tetracycline is the most common antibiotic cause of drug-induced fever in cats. amphotericin b can cause fever by disrupting cell membranes and releasing pyrogens into circulation. be aware that other drugs (griseofulvin, chloramphenicol and chemotherapeutic drugs) can cause bone marrow suppression leading to a cat with fever, neutropenia and secondary bacterial infection. these cats are obviously sick, whereas the drug-induced fever animals are bright and alert in comparison. • history is of treatment with fever-inducing drugs, especially tetracycline and amphotericin b. • clinical signs are inappropriate, that is, the cat appears bright and alert although febrile. temperature normalizes after drug is discontinued. classical signs • sneezing. • conjunctivitis and ocular discharge. see main reference on page 13 for details (the cat with acute sneezing or nasal discharge). marked conjunctivitis is the predominant sign, which often starts unilaterally, but usually progresses to both eyes. classic triad of upper respiratory infection signs including oculonasal discharge and sneezing. serous ocular discharge accompanied by blepharospasm, chemosis and conjunctival hyperemia are initial signs. discharge becomes mucopurulent over the course of the disease. mild to moderate fever can be seen in the acute phase. pneumonia is rarely associated with this infection. history and clinical signs are highly suggestive. cytology of conjunctival scrapings reveal dark blue inclusion bodies (giemsa stain). immunofluorescent antibody staining or polymerase chain reaction assay to demonstrate the organism in conjunctival scrapings is available from some laboratories. • acute onset of depression. • acute onset of vomiting. rapid onset of depression, anorexia, and vomiting especially in peracute and acute disease. fetid diarrhea (may be hemorrhagic) typically follows 1-2 days after initial onset of signs. severe dehydration and electrolyte abnormalities. initial fever followed by hypothermia as the disease progresses. high mortality rate when signs are severe. the disease should be suspected in cats less than one year of age with no history of vaccination and a rapid clinical course. panleukopenia evident on hematology. parvoviral antigen can be detected in feces using the canine parvoviral antigen tests or electron microscopy. histopathologic changes include denuded intestinal crypts and blunted villi (often a post-mortem diagnosis). classical signs francisella tularensis is a gram-negative coccobacillus. clinical signs are associated with gram-negative endotoxins and bacteremia. there are two main strains of the organism, both of which have been isolated from cats. • associated with tick-rabbit cycle. • found only in north america. • highly virulent for laboratory rabbits. • associated with more severe disease in humans. • associated with a more complex cycle involving rodents, ticks, mosquitoes, mud and water. • found throughout the northern hemisphere. • avirulent for laboratory rabbits. history of contact with rabbits, especially if the cat is a hunter. any age of cat can be infected, but younger cats are more susceptible to developing septicemia. the spectrum of illness varies from severely affected to asymptomatic. fever is generally > 40˚c (104˚f). marked depression, anorexia and lethargy, with or without vomiting are typical. on physical examination, peripheral lymphadenopathy, icterus and palpable splenomegaly and hepatomegaly are reported. oral, lingual or pharyngeal ulcers may be present. clinical signs together with a history of exposure to wild rabbits is highly suggestive. hematologic and serum biochemical abnormalities may include panleukopenia, with severe toxic changes in neutrophils, high band neutrophil count, thrombocyto-penia and hyperbilirubinemia. definitive diagnosis is via identification of the bacterial agent by ifa or bacterial culture, but should only be performed in a qualified laboratory. • samples can be obtained from affected lymph nodes, bone marrow, urine or blood. serum antibody titers > 1:120 or a four-fold increase in serum antibodies in samples collected during acute and convalescent phases (10-14 days) are considered diagnostic. fip, fiv, panleukopenia. toxoplasmosis. multicentric lymphoma. antimicrobial efficacy studies have not been done in the cat, therefore therapy is derived from case reports and/or human therapy regimens. enrofloxacin (5 mg/kg q 12 hours iv or po). tetracycline and chloramphenicol may be effective, but because they are bacteriostatic for f. tularensis, relapses can occur. in humans, the drugs of choice are streptomycin and gentamycin. prognosis is poor to fair as mortality rate varies across case reports. f. tularensis has a serious zoonotic potential if there is contact with infected animal tissue. bites from infected ticks, deer flies or mosquitoes are the most common method of transmission. infection can also occur via ingestion of infected meat. • this is the most common method of transmission to humans in cat-associated cases. • the infected cat may have no obvious signs of illness, but have a history of hunting wild animals, especially rabbits. inhalation of aerosolized organisms may also transmit the disease. care should be taken by veterinary and laboratory personnel handling suspected animals or samples being prepared for ifa or culture. discourage hunting behavior in cats. ectoparasite control, especially tick control. onset of illness occurs 24-72 hours after exposure to the organism. transmission to cats is either via ingestion of infected rodents or a fleabite from infected fleas. rapid multiplication of organism causes tissue damage and necrosis. the host immune response contributes to pathology. three forms of the plague exist: bubonic (local infection), bacteremic/septicemic and pneumonic. bacteremia occurs in many cases, resulting in the septicemic or pneumonic form of plague. endemic regions of the world include the western usa, south america, africa, asia, eastern europe. history of hunting rodents, especially in known endemic areas. current flea infestation is evident. acute onset of fever, anorexia, depression over a period of 2-6 days. the clinical course may last 6-20 days. submandibular or cervical swelling associated with lymph nodes (can be unilateral or bilateral). the inflamed, swollen lymph node is referred to as a bubo. subcutaneous abscessation may occur and appear similar to a cat bite abscess. in the pneumonic form (~10% of cases), upper and lower respiratory signs may be present, including sneezing, nasal discharge, coughing, dyspnea/tachypnea. initially, microscopic examination of a lymph node aspirate, especially a markedly swollen lymph node (bubo) should reveal a homogeneous population of bipolar-staining coccobacilli. • blood should be examined in cats with the bacteremic/septicemic form. fluorescent antibody testing of sample provides a definitive diagnosis. culture of organism should be performed by a qualified laboratory only. a four-fold rise in antibody titers (taken 10-14 days apart) is suggestive of plague. these results must be interpreted carefully, as high titers can persist for up to one year after infection. chest radiographs may reveal patchy, nodular lesions if the pneumonic form is present. be aware that the risk of exposing other staff members to the disease should be weighed against the benefit of the diagnostic test. reactive lymph nodes from a percutaneous abscess or tooth-root abscess. • aspirates of cat bite abscesses contain a mixed bacterial population compared to y. pestis, which is homogeneous. neoplasia, although it is less common in the us for cats with lymphoma to have peripheral lymphadenopathy. respiratory signs may be due to other upper respiratory infections (calicivirus, herpesvirus, chlamydophila) or lower respiratory disease (parenchymal lung disease, pleural disease). other diseases which cause high fever (tularemia, toxoplasmosis, fip, etc.). absolute caution must be practiced in all suspect plague cases. cautionary measures include gloves, mask, isolation of animal and limited exposure to other staff members. doxycycline/tetracycline: (1) doxycycline at 5 mg/kg q 12 hours po for 14-21 days or (2) tetracycline 25 mg/kg q 8 hours po. • begin treatment immediately after samples for diagnosis have been collected. • doxycycline is preferred as tetracycline has been associated with relapse. consider aminoglycosides or enrofloxacin (5 mg/kg im q 8 hours) for the first 3 days to avoid placing hands into the cat's mouth (see transmission section below). prognosis for bubonic plague is fair to good. prognosis for the pneumonic form is guarded to fair. prognosis for septicemic form is guarded. persistent fever > 40˚c (104˚f) despite treatment is associated with a poor prognosis. y. pestis has a serious zoonotic potential, and great care should be taken in suspect cats to prevent transmission to humans and other cats. • infected cats are no longer a zoonotic risk after 3 days of antibiotic therapy. infection can also occur via inhalation of aerosolized organism, either from aspirates of infected tissue or nasal discharge/sneezing of cats with pneumonic form. discourage hunting behavior especially during the peak flea season (april to october). provide effective flea control to prevent flea bites. • anorexia and weight loss. see main reference on page 547 for details (the anemic cat). this disease is uncommonly reported in cats and is difficult to diagnose because of its vague and variable clinical signs. age range of cats with documented disease was 2-10 years of age, with no breed or sex predilection reported. infection has a variable effect on appetite, from mild inappetence to anorexia and mild to moderate weight loss. chronic intermittent fever in the moderate range is common. lymphadenopathy was reported in three of 23 cats. hyperesthesia, joint pain or irritable disposition is common. complete blood counts may show a non-regenerative anemia with a leukopenia or a leukocytosis; thrombocytopenia is present in about 25% of the cats. biochemistry abnormalities are uncommon, except for hyperglobulinemia in about 33% of documented cases. a complete blood count and biochemistry panel consistent with chronic ehrlichia spp. infection is suggestive. diagnosis is by demonstrating e. canis and/or anaplasma phagocytophilum serum antibody titers or a positive ifa test. demonstration of morulae in mononuclear cells, neutrophils or eosinophils (rare) is diagnostic. pcr assays can be positive. • anorexia, lethargy, weight loss. • ± fever. • signs depend on tumor type and organ system involved. anorexia, lethargy and weight loss. poorly groomed coat. some cats have a fever associated with neoplasia, which is generally a secondary neoplastic syndrome. tumors which destroy the bone marrow and result in neutro-penia are classically associated with fever. fever may occur with other tumors via other mechanisms, including antibody stimulation from tumor antigens, and tissue necrosis which activates leukocytes to release pyrogenic factors. signs are specific to the organ system involved. lymphoma (mediastinal, gi, renal) , mammary adenocarcinoma, squamous cell carcinoma (nasal, oral) and mast cell tumor are the most common tumors in cats. hematology, biochemistry panel, radiology, ultrasound and/or bone marrow aspirates may be necessary to provide evidence that a tumor is present, especially if it involves the hematopoietic system (leukemia) or is located internally (splenic mast cell tumor). identification of the tumor type is via fine-needle aspirates and/or biopsies. organ dysfunction due to infectious or degenerative disease process. felv/fiv or other immunosuppressive illness. benign masses (granulomas, abscesses, reactive lymph nodes, benign tumors). treatment involves surgical excision of identifiable masses +/− regional lymph nodes, especially for mammary adenocarcinoma, nasal squamous cell carcinoma, splenic mast cell tumor, etc. chemotherapy may be effective and needs to be based on tumor type, e.g., cop (cyclophosphamide, vincristine, prednisolone) protocol in lymphoma cases. radiation therapy is used for local disease only, and response to radiation therapy is tumor dependent (e.g., squamous cell carcinoma). • radiation therapy is most effective after surgical debulking of the primary mass. the effectiveness of radiation therapy may be enhanced with concurrent chemotherapy. classical signs acute onset of fever and malaise are initial clinical signs. vomiting, diarrhea and abdominal pain may occur, however, approximately 50% do not have gastrointestinal signs. dehydration. shock may occur if septicemia/bacteremia develops. mortality rate approaches 10% and may be higher if the cat is concurrently immunosuppressed. typically, the cat is an outdoor cat with a history of hunting behavior, especially of birds. complete blood count and biochemistry panel supports infectious diarrhea or septicemia, e.g., neutropenia with a left shift, bacterial rods in blood leukocytes if overwhelming sepsis present, hypoglycemia, hypoproteinemia, pre-renal azotemia. blood cultures provide the best definitive diagnosis if positive. three separate samples over a 4-6 hour period should be taken during febrile episodes using aseptic techniques. fecal cultures may isolate salmonella organisms, but because many animals are subclinical carriers, positive culture does not prove that the organism is the cause of the clinical signs. • skin lesions. • respiratory signs. • ocular lesions. • fever, anorexia, depression. the geographical distribution includes south-west usa, central america and south america in areas that have sandy soil with low rainfall and high temperatures. soil is the reservoir for infection, and the highest frequency of cases occur when the soil is dry and dusty, and organisms are disseminated in the wind. most humans and animals in endemic areas become infected, but the majority of infections are subclinical or cause only mild, transient clinical signs. cats are more resistant to infection and signs are less common than in dogs. infection is contracted via inhalation, and only a few organisms are required to produce signs, which occur after 1-3 weeks. initial infection is confined to the respiratory tract, but dissemination may occur resulting in chronic disease over months or years with signs referable to bones, eyes, central nervous system and abdominal organs. localized infection following a penetrating skin wound appears to be rare. cats appear to be resistant to clinical disease. skin lesions are the most frequent types of infection in cats and were reported in 56% of cats in one study. • lesions begin as small bumps and progress to abscesses, ulcers or draining tracts. • in cats, underlying bone involvement is uncommon. systemic signs such as fever, anorexia and depression are commonly reported (44% of cats) and can be seen with skin lesions. respiratory signs such as coughing and wheezing are less common in cats and occur in approximately 25% of cases. musculoskeletal signs such as lameness, with or without painful bone swelling, were reported in 19% of cats. ocular lesions are seen infrequently and include chorioretinitis and anterior uveitis. ocular or cns signs were reported in 19% of cats. most cats have clinical signs for less than 4 weeks prior to diagnosis. hyperproteinemia is present in approximately 50% of cats. definitive diagnosis is by identification of the organism via biopsy of lesions. antibody detection is available using latex agglutination (igm), agid (igm) or elisa (igm or igg). tube precipitin (tp) for igm and complement fixation (cp) for igg were previously thought to be less reliable in cats, but have been subsequently demonstrated to detect feline infections. itraconazole (10 mg/kg po if possible, q 24 h or 5 mg/kg q 12 h) is the treatment of choice. treatment is required for 4-6 months and must be continued for at least 2 months after all signs have resolved. • some cats develop anorexia, and less commonly vomiting or diarrhea. stop the drug for a few days until the cat is eating, and then restart at 1/2 the dose for 7-10 days, before increasing back to the full dose, which is usually then tolerated. amphoteracin b is also effective (0.25 mg/kg in 30 ml dextrose 5% iv over 15 minutes q 48 h or given subcutaneously) -see page 26, for cyptococcosis in the cat with signs of chronic nasal disease. continue amphotericin b therapy until a cumulative dose of 4 mg/kg is given or until bun > 17.9 mmol/l (50 mg/dl). amphotericin has the disadvantage of requiring frequent parenteral or subcutaneous administration and causes significant nephrotoxicity. • because of its quick onset of action, amphoteracin b in combination with itraconazole is useful in cats with severe pulmonary signs that are rapidly deteriorating. if the cat survives, after a few weeks treatment can be continued with itraconazole alone. • lipid-complexed amphoteracin formulations allow higher dosages with less toxicity, and should be used in cats with severe pulmonary signs, although the cost is higher. dose at 2-3 mg/kg iv 3 days per week for a total of 9-12 treatments (cumulative dose of 24-27 mg). dilute to a concentration of 1 mg/ml in dextrose 5% and infuse over 1-2 hours. if the titer has decreased four-fold and there is a similar improvement in physical and radiographic signs, treatment can be stopped after 4-6 months. antibodies may persist for long periods and obtaining a zero titer is not a useful treatment goal. classical signs • fever. • respiratory signs. • ocular signs. • lymphadenopathy. the geographical distribution includes north america, central america and africa. soil is believed to be the reservoir for infection, and living near a lake or river increases the risk of infection in dogs. signs are more common in dogs than in the cats. disseminated disease is primarily contracted via inhalation. respiratory signs include coughing, dyspnea and harsh lung sounds. ocular disease, such as uveitis, glaucoma and retinal detachment, is a frequent finding. fever, anorexia, depression, weight loss and lymphadenopathy are systemic signs associated with disseminated disease. draining skin lesions may occur and are usually a manifestation of systemic disease rather than local disease. neurological signs are associated with cns involvement of the brain or spine and include circling, disorientation, anisocoria, paresis, decreased conscious proprioception, or upper motor neuron signs, hyperesthesia and extensor rigidity. definitive diagnosis is by demonstration of an extracellular, broad-based budding yeast in aspirates or biopsies from lymph nodes, draining tracts, bone lesions or vitreous humor. an antibody detection test is available, but may be negative. itraconazole (10 mg/kg po if possible, q 24 h or 5 mg/kg q 12 h) is the treatment of choice. treatment is required for 4-6 months and must be continued for at least 2 months after all signs have resolved. • some cats develop anorexia, and less commonly vomiting or diarrhea. stop the drug for a few days until the cat is eating, and then restart at 1/2 the dose for 7-10 days, before increasing back to the full dose, which is usually then tolerated. amphoteracin b is also effective (0.25 mg/kg in 30 ml dextrose 5% iv over 15 minutes q 48 h or given subcutaneously) -see page 26, for cyptococcosis in the cat with signs of chronic nasal disease. continue amphotericin b therapy until a cumulative dose of 4 mg/kg is given or until bun > 17.9 mmol/l (50 mg/dl). amphotericin has the disadvantages of requiring frequent parenteral or subcutaneous administration and causing significant nephrotoxicity. • because of its quick onset of action, amphoteracin b in combination with itraconazole is useful in cats with severe pulmonary signs that are rapidly deteriorating. if the cat survives, after a few weeks treatment can be continued with itraconazole alone. • lipid-complexed amphoteracin formulations allow higher dosages with less toxicity, and should be used in cats with severe pulmonary signs, although the cost is higher. dose at 2-3 mg/kg iv 3 days per week for a total of 9-12 treatments (cumulative dose of 24-27 mg). dilute to a concentration of 1 mg/ml in dextrose 5% and infuse over 1-2 hours. classical signs see main reference on page 534 for details (the anemic cat). primarily found in the south-central and southeast united states. the north american bobcat is the natural host. there is usually a history of exposure to ticks in the previous 5-20 days (incubation period is 5-20 days). the clinical course of disease is approximately 1 week and often ends in death. clinical signs are the result of an overwhelming hemolytic crisis. rapid onset of fever, dyspnea, anorexia, pale mucous membranes, icterus and dark-colored urine are typical. collapse and death occur 2-3 days after the fever peak. hypothermia occurs in the terminal stages. there appear to be non-pathogenic strains as well. a complete blood count reveals regenerative anemia, hemoglobinemia and neutrophilia or neutropenia. the biochemistry panel commonly has hyperbilirubinemia. urinalysis may show evidence of hemoglobin and bilirubin. demonstration of the organism in erythrocytes (merozoite stage) is possible only relatively late in the disease, approximately 1-3 days before death. parasitemic cats usually have only 1-2% of rbcs affected, and up to 50% of cats have parasitemias that are very low or undetectable. demonstration of the organism in macrophages from bone marrow, spleen, liver or lymph node aspirates may be possible even when organisms are not evident in blood. serum antibody levels and direct fa test for detection of tissue phase are available through some labs. weight loss in spite of normal to increased appetite. polyuria/polydipsia. behavioral changes which often include hyperactivity and aggression. unkempt, rough hair coat and sometimes overgrown nails. tachycardia accompanied by a "gallop" rhythm and/or a systolic murmur. mild fever which may be intermittent in nature and reflect the increased metabolic rate in this disease. these cats are easily stressed and may present dyspneic and tachycardic with a mildly elevated temperature, usually not greater than 39.4˚c (103.0˚f). enlarged thyroid glands are often evident on palpation of the neck. diagnosis is based on clinical signs and history and confirmed by demonstrating increased thyroid hormone concentrations (total t4, free t4). thyroid glands can be palpated in approximately 80% of cats with hyperthyroidism, and are unilaterally or bilaterally enlarged. • enlarged thyroid glands may not be palpable if the abnormal thyroid tissue is within the thoracic inlet. complete blood count and a biochemistry panel are required to rule out diseases such as diabetes mellitus, renal disease, etc. a trh stimulation test may be necessary when clinical signs are highly suggestive and total and free t4 are in the upper region of the reference range for normal cats. thyroid radionuclide uptake and imaging with pertechnetate ( 99m tc) is also available at some institutions. response to therapy with anti-rickettsial drugs (tetracycline or doxycycline) is highly suggestive. • subclinical or mild fever and occasional ocular signs. bartonella henselae is an intracellular bacterium within erythrocytes. bacteremia is present in many healthy cats in the population, and cats are reservoirs for infection. b. henselae is an important pathogen because of its zoonotic potential in immunocompromised humans. • humans may develop fever, malaise, lymphadenopathy and skin eruptions following cat scratches or bites. • b. henselae causes bacillary angiomatosis, bacillary peliosis and encephalitis in human aids patients. naturally infected cats usually only develop subclinical infection. mild, self-limiting fever lasting 48-72 hours has been documented in some experimentally infected cats. anterior uveitis and fever were documented in naturally exposed cats. lymphadenopathy. atypical seizures occur in some cats. antibody titers are prevalent in healthy cats, but there is a poor correlation with blood culture and pcr assay results. intermittent bacteremia may occur for longer than one year following infection, with 25-41% of healthy cats bacteremic for up to 22 months. the organism is present within erythrocytes, therefore, hemolyzing red blood cells increases the sensitivity of the culture. other causes of mild transient fever need to be considered, such as mild cellulitis following a cat fight. other infectious causes of anterior uveitis need to be ruled out, such as toxoplasmosis, fungal diseases, felv, fiv, cuterebra or dirofilaria. antimicrobial efficacy has not been clearly demonstrated. clinical signs of disease have resolved when the cats are administered doxycycline at 25-50 mg po q 12 h for 28 days. azithromycin is used in humans and is a safe alternative in cats when administered at 10 mg/kg po q 24 h for 28 days fluoroquinolones also may be effective. while clinical signs resolve, bacteremia is usually only temporarily suppressed. b. henselae has very low pathogenicity in cats. once cleared of infection, cats are resistant to re-infection by innoculation, but are still susceptible if transmitted via blood transfusion. transmission is via arthropod vectors. in endemic areas, cats infested with fleas and/or ear mites are more likely to be seropositive. the organism survives in flea feces for at least 9 days. because of the frequency of bacteremia in healthy cats, blood transfusions are a likely route of infection. primary immune-mediated disease is extremely rare in cats. stimulation from primary infectious disease antigens is the most common cause of immune-mediated disease in cats, and is most often associated with hemobartonella (mycoplasma) and calicivirus. systemic lupus erythematosus is rare in cats. a multitude of signs may occur including fever, weight loss and cutaneous lesions. immune-mediated hemolytic anemia is most commonly associated with hemobartonellosis. signs include anemia, icterus, fever and anorexia. cats with immunosuppressive disorders such as felv may be more susceptible. immune-mediated thrombocytopenia is rarely reported in cats. felv-positive cats, however, may have thrombocytopenia that is thought to be the result of an immune-mediated response. immune-mediated polyarthritis is uncommon in cats, but has been documented in kittens and adult cats with post-calicivirus vaccination. 19 -the pyrexic cat 391 a bacteriologic investigation of subcutaneous abscesses in cats clinical, clinicopathologic, and pathologic features of plague in cats: 119 cases (1977-1988) bacterial diseases; fungal diseases; and protozoal diseases feline toxoplasmosis: interpretation of diagnostic test results bartonella spp. antibodies and dna in aqueous humor of cats feline toxoplasmosis and the importance of the toxoplasma gondii oocyst feline infectious peritonitis. part i. etiology and diagnosis feline infectious peritonitis. part ii. treatment and prevention consensus statement of ehrlichial disease of small animals from the infectious disease study group of the acvim feline infectious myocarditis/diaphragmitis diagnostic approach and medical treatment of seizure disorders an appraisal of the value of laboratory tests in the diagnosis of feline infectious peritonitis tularemia in two cats key: cord-267608-0odu8lus authors: chen, daohong; qi, eric yining title: innovative highlights of clinical drug trial design date: 2020-06-03 journal: transl res doi: 10.1016/j.trsl.2020.05.007 sha: doc_id: 267608 cord_uid: 0odu8lus clinical trials serve as the gold standard to evaluate the efficacy and safety of tested drugs prior to marketing authorization. nevertheless, there have been a few challenging issues well noted in traditional clinical trials such as tedious processing duration and escalating high costs among others. to improve the efficiency of clinical studies, a spectrum of expedited clinical trial modes has been designed, and selectively implemented in contemporary drug developing landscape. herein this article presents an update on the innovated human trial designs that are corroborated through coming up with approval of notable therapeutic compounds for clinical utilization including delivery of several blockbuster products. it is intended to inspire clinical investigators and pharmaceutical development not only timely communicating with the regulatory agencies, but also insightful translating from cutting-edge scientific discoveries. the randomized clinical trials (rcts) of sequential three phases have been traditionally regarded as an official paradigm during drug development for decades. while phase i study is to define the tolerability, pharmacokinetics and adverse effects, subsequently phase ii and then iii studies are to examine the therapeutic efficacy in exploratory and confirmatory manners respectively [ 1， 2] . although rcts historically played and are still playing a decisive role in evaluating efficacy and safety of a therapeutic agent prior to the marketing authorization, the implementing practice also came up with several challenges including tedious processing duration, ever-escalating costs and lack of subgroup differentiation for maximizing clinical benefits [2, 3] . to circumvent these problems, the significant advancement in disease biology and clinical pharmacology has inspired emergence of a spectrum of innovated clinical trial designs in contemporary drug developing landscape [2, 3, 4] . overlapping with the essential principles of classic rcts, these recently emerged clinical studying models are characterized by an impressive list of additional strengths such as improved time and cost effectiveness among others [3] . based upon the progresses in bio-assays of clinical pharmacology, the usa food and drug administration (fda) made a policy change known as hatch-waxman act in 1984, which officially determined the human pharmacokinetic bio-equivalence (be) to replace traditional rcts for developing generic medications [4] . as a result, the be policy was also implemented for chemical generics by european union in 2009 [4] . consistently in 2016, chinese state council initiated a campaign requiring the quality of generic drugs be reevaluated through running clinical be studies, compared to that of original reference products [5] . in the field of innovative medicine, dramatic breakthroughs from life science have revolutionized our understanding in a number of aspects of disease biology, including therapeutic targets and diagnostic bio-markers [2，6], thus inspiring some flexible modification of traditional rcts in order to deliver novel medicine to the patients in need more efficiently [3] . accordingly in late 2016, the 21 st century cure act was passed into law by usa congress, and instructed fda to update the adaptive design guidance for investigational drugs and biological therapies [7] . to date, certain modes of these updated trial protocols have exceptionally contributed to timely translating contemporary scientific discoveries into innovative drugs that addresses unmet clinical needs [ 2， 8] . in this light, the article herein highlights an array of outstanding developments in the perspective of drug trial design, being corroborated by notable successes in the clinical settings. it has been well recognized that pharmacological effects of drugs are dependent on their targeting tissue concentration which is usually proportional to their distribution in circulation system, known as bio-availability. of note, the latter can be affected by various pharmacokinetic-associated factors including active compound, formulation, manufacture, drug-drug interaction, among others [4, 9] . in this sense, major pharmacokinetic parameters, such as area under curve (auc) and maximal concentration (cmax), are utilized as the surrogate parameters to compared efficacy and safety of a generic agent with those of the reference product in clinical be studies [9] . most drugs are thereby accepted to be therapeutically equivalent when their auc and cmax fall in the range between of 80%-125% regarding limits of 90% confidence interval [4] . while having been significantly contributing to development of most chemical generics, be is recently noted as an efficient approach that can not be completely replaced by in vitro methodology even in some high solubility and high permeability products [10] . in parallel, be study is frequently applied for comparing certain innovative agents in terms of formulation changes or fixed dose combinations; for example just being approved in 2018, consensi consists of a combination of amlodipine and celecoxib to treat concomitant hypertension and osteoarthritis [11] . realistically for evaluating a generic version of the polysaccharide drug heparin, the activities of anti-factors xa and iia instead of pharmacokinetic parameters are used to be the official standard for human be trials [12] . in consistent with the policy of fda, european medicines agency (ema) has recently accepted the be investigation in healthy human subjects for generic development of low molecular weight heparin (lmwh) without requiring rcts in thromboembolism prone patients anymore [13] . besides, utility of be study is being expanded into the field of evaluating biosimilar products such as antibodies and fusion proteins which represent much larger and more complex molecules [4] . interestingly based upon a human be investigation in healthy volunteers and non-inferiority rcts in the patients, the biosimilar version of etanercept, a medication of fusion protein neutralizing inflammatory cytokine tumor necrosis factor- (tnf), has just be approved for managing rheumatoid arthritis (ra), psoriatic arthritis, and ankylosing spondylitis [14] . contemporary pharmaceutic innovation is facing a serious realty of declined successful rates from research and development, in contrast to much more new compounds/new targets for examination in clinical investigation. in this regard to reduce a wast of the resources, fda issued a guideline of an alternative approach for first-in-human trials in 2006, which was termed exploratory investigational new drug application (eind, or phase 0) allowing a flexible amount of data needed for ind application based upon the specific circumstances of each proposed human trial [15] . tending to bridge the gap between preclinical studies and traditional clinical development, phase 0 investigation differs from phase i trial in fewer human subjects, short processing time and no tolerability test. as a result, phase 0 study can accelerate the "goor-no go" decision making prior to a formal rct, namely improving the efficiency of identifying drug-like candidates and terminating non-promising compounds [15, 16] . the strengths of phase 0 study have been validated in various aspects of drug development including intra-target micro-dosing, clinical pharmacology, vulnerable populations, among others [15] . interestingly, micro-dosing of insulin through limb artery injection was capable of achieving targeted control of local glucose level with minimal systemic exposure of the drug [17] ; it offered insights into local application of medications, in particular for those with narrow therapeutic windows, to deliver clinical efficacy precisely while remarkably diminishing the systemic toxic effects [18] . impressively, an unique role of phase 0 trial has been recently highlighted in the drug development against brain tumor. as a cell cycle-associated kinase inhibitor, azd1775 was revealed to have a strong anti-glioblastoma efficacy and poor blood-brain barrier (bbb) penetration in preclinical studies. it was through a phase 0 investigation demonstrating that the compound substantially crossed bbb and induced the expected biomarker alterations clinically, which thus made a moving-forward decision for this project [16] . besides, microdosing study appears particularly beneficial for vulnerable populations in which new drug trials are restricted, including children, liver/kidney function impaired, mutipharmacy, among others [15] . in contrast to a classical clinical trial of sequential three-phases with interval times in between for analysis to determine the next design, seamless development integrates the three phase-processing into a comprehensive clinical study without gaps [2, 3] . while reserving the core strength of traditional clinical trials in terms of defining efficacy and safety regarding tested compounds, seamless clinical study significantly improves time and cost efficiency to translate the scientific breakthroughs into innovative medicine [2] . a seamless phase i/ii design is to examine the toxicity and efficacy in one trial, during which a reasonable dosing set need to be screened out at the first stage, and then forwarded to evaluate the efficacy at the second stage [3, 19] . in a similar sense, a seamless phase ii/iii trial is performed with multiple dosing levels of the investigated drug at the exploratory stage to define the most efficacious dose based upon some surrogate end-points such as objective response rate (orr), and this dose is then continued into the confirmatory stage for further testing without a timing gap, to obtain more definitive end-points such as overall survival (os) [8, 19] . given the flexibility for modification upon interim analysis, seamless development allows to study accumulating data from the ongoing clinical trial for early assessment of toxicity, efficacy or futility, and thus to decide the terminating or continuing/expanding treatment arms accordingly for further investigation [19] . it was through a well-designed seamless clinical trial that the programmed death 1 (pd-1)-blocking antibody keytruda achieved accelerated approval by fda [2, 18] . in this scenario, a dosing-escalation study was carried out at the first stage of the trial, to evaluate safety, tolerability and possible efficacy (orr) in a spectrum of patient cohorts with advanced cancer of various types [18, 19] . based upon the interim analysis, the cohorts of melanoma and non-small cell lung cancer (nsclc) were determined to be expanded for the continuing clinical trial on treatment with keytruda at the selected dosages of 2mg/kg or 10mg/kg [20, 21] . as a result, keytruda was demonstrated to confer a therapeutic benefit for the patients with melanoma (orr: 38%~40%) and nsclc (orr: 19.4%); moreover, with the bio-marker stratification of pd-l1 + above 50%, an even better orr (45.2%) was achieved in the subset of patients with nsclc [21] . additionally, beyond successful application for oncological drug development, seamless clinical study has substantially contributed to therapeutic innovation in other medical fields [3] . of note, the efficiency of clinical developing inhaled indacaterol, a long-acting 2-agonist for treatment of chronic obstructive pulmonary disease (copd), was clearly improved through a seamless clinical trial [3, 22] . historically human disease is categorized and managed according to anatomic location of body organs and histological types of pathology， which forms a solid basis for therapeutic indications designed in conventional clinical drug development [23] . however, since the rise of targeted medicine in recent two decades, the landscape of pharmaceutical innovation has been transformed to modulate an aberrant biological pathway that can contribute to pathogenesis across a number of diseases [24] , such as a gene mutation occurred in various neoplastic disorders [25] . intriguingly, a mutational target is typically present only in a portion of the patients with each tumor type due to inter-personal heterogeneity, thus inspiring emergence of basket trials in the clinic [2, 23] . in this light, a targeted compound is simultaneously examined across numerous disease baskets, for example different cancer types, in order to determine not only whether the drug is efficacious but also what tumor types and more precisely which patient subsets are sensitive to this therapy [23, 25] . the first stage of a basket trial is to select the therapeutically sensitive disease types and patient sub-populations, with a bio-marker-based companion diagnosis if possible [19, 26] . following interim analysis, the futile tumor type baskets are terminated, and the efficacious subjects are enriched from the responsive baskets, to be thus forwarded to further clinical investigation at the second stage [23, 26] . as a selective tropomyosin receptor kinases (trk) inhibitor, larotrectinib represents the newly approved medicine targeting a wide spectrum of tumor types, reflecting a dramatic success of basket clinical study [25, 27] . aberrant trk activation drives oncogenic pathogenesis, and is expressed in more than 20 distinct tumor types. nevertheless, except a few types of rare neoplasms such as congenital fibrosarcomas, trk alterations occur in very low frequencies in common cancers of various tissue/cell lineage origins, for instance below 5% in lung adenocarcinoma [26] . based upon a basket trial design to investigate the clinical efficacy of larotrectinib, the subjects were selectively enrolled from patients with the aberrant trk activity in tumors across 16 histological types. impressively, larotrectinib was demonstrated to be well tolerated, conferring an orr of 80% and a median progression-free survival (pfs) of 9.9 months [25, 26] . as such, this novel targeted agent stands out to address the unmet clinical need of combating the rare neoplasms and numerous common tumor types with the rare genetic mutations [26, 27] . besides the validation in field of anti-cancer drug development, basket clinical has been proposed to go beyond oncology into cardiology, such as therapeutic innovation for preserved ejection fraction (hfpef) across diverse etiologies, pathobiologies, and clinical presentations [28] . to identify the best therapeutic benefit(s) of a testing drug, the flexibility of adaptive clinical trials can be implicated in indication changes based upon accumulating data or/and cutting-edge scientific discoveries [7] . depending on bio-medical contexts, such dynamic updating of clinical applications may be pre-planned or inspired by certain serendipitous observations, through shifting from a therapeutic hypothesis to an alternative one or multiple ones [2, 29] . in this sense, a study design allows to examine beyond the intend-to-treat disease, thus being re-purposed to an alternative indication according to the initial assignment upon lack of efficacy or safety issues [7] ; otherwise, a clinical trial can also be optimized to cover more therapeutic directions with the emerged evidence of certain additional efficacy [24, 30] . in the era of precision medicine, there has been a consensus that therapeutic outcomes can vary significantly among subgroups of patients with differential genetic profiles [2, 27] . accordingly taking the advantage of interim analysis based on novel biomarker approach for detecting the pathogenesis-specific molecular alteration(s), an adaptive clinical study can select the drug-sensitive sub-population from patients with initially targeted disease or an alternative indication, to continue the investigation for an optimized therapeutic efficacy [7] . as a selective 5-phosphodiesterase inhibitor, sildenafil was designed to manage angina pectoris in the initial clinical trial. disappointingly this compound appeared non-efficacious in relieving anginal pain, with a side-effect of inducing penile erection [31] . inspired by this serendipity, the clinical development was successfully re-directed to come up with a major innovative product of anti-erectile dysfunction [29, 31] . in the field of oncology, crizotinib was initially identified as a potent inhibitor of mesenchymal-epithelial transition factor (met), thus tending to treat the relevant neoplasms such as nsclc and gastrointestinal tumors [2] . whereas this compound was then revealed to suppress anaplastic lymphoma kinase (alk) as well, and impressively to exert a clear efficacy of tumor shrinkage in the nsclc with alk rearrangement during a phase i clinical study. in this regard, the therapeutic indication of crizotinib was re-focused and successfully developed through following-up clinical trials, to be a precisely targeted medication for managing a subset of lung cancer patients with alk aberrations [2, 32] . interestingly in recent years, besides serving as an exceptional type of medicine for controlling tape 2 diabetes, the clinical trials of sodium glucose cotransporter 2 (sglt2) inhibitors are being expanded or re-positioned to manage heart failure and protect renal function through blood glucose loweringdependent or/and -independent mechanisms [29, 33] . orphan drugs are developed to treat a particular spectrum of medical conditions with low morbidity, termed rare disease, resulting from genetically linked pathogenesis in most cases. of note, definition of rare disease varies among different countries depending on epidemic incidence of each illness geographically [34, 35] . to address this largely unmet clinical need and meanwhile to deal with the challenging issue of limited market size for profits, fda announced an incentive policy known as the orphan drug act (oda) in 1983, offering research & development funding, market exclusivity, among other attractive benefits [35] . since then there were similar policies coming forth from other countries, encouraging an increased interest in this regard for pharmaceuticals; orphan drugs have been representing more than 40% of innovative medications marketed through last three decades [34] . interestingly in recent years, certain orphan drugs are revealed to be overlapped with blockbuster products, which appear more notable in the field of oncology [18, 21] . in this scenario, a novel medicine can be initially approved for a rare disease, and subsequently go beyond to treat additional types of disease; vice versa a conventional drug may occasionally obtain orphan status upon expanding its therapeutic indications toward a rare medical condition [21, 34] . clinical development of orphan drugs often involves expedited trial designs described above, and may even be further simplified or alternatively designed under particular circumstances [35, 36] . for instance, the approval of orphan drug xuriden was based upon a minimal seamless trial for 6 weeks with only four patients, to treat hereditary orotic aciduria representing a rare disease of only 20 cases worldwide [37] . in addition, a viral inhibitor tecovirimat has recently been authorized to treat smallpox upon the waive of clinical efficacy study due to lack of patients with the naturally occurred disease. setting the first record in regulatory history, this innovative medication was exceptionally approved based on positive results from the preclinical efficacy studies in animal models of rabbits and monkeys, along with a phase i trial of clinical pharmacology and safety in healthy human subjects [38] . impressively, certain orphan drug-based clinical trials can also come up with a broad spectrum of efficacy covering multiple indications. as a hallmark success of targeted medicine with orphan status, to combat philadelphia chromosomepositive chronic myelogenous leukemia (cml) imatinib was launched onto the market through the accelerated approval following a phase ii trial consisting of three open-label, single-arm clinical studies [6, 39] . moreover, imatinib was subsequently evaluated in a basket clinical trial and demonstrated to be efficacious for an array of extra-therapeutic indications beyond cml, dramatically transforming this orphan drug toward being a blockbuster medication [40] . besides, an interesting basket clinical study has recently been designed to investigate a target-specific monoclonal antibody for controlling an array of complement-mediated rare disorders, including bullous pemphigoid, antibody-mediated rejection of organ transplants and and warm autoimmune hemolytic anemia [41] . clinical trial plays an indispensable role in evaluating efficacy and safety of therapeutic agents prior to marketing for human use, and has been constantly co-evolving along with the dynamic interactions between cutting-edge scientific discoveries and regulatory policy updating [2, 3] . in this light, a number of agile clinical developing modes were designed through past decades, and impressively some of them have been further corroborated upon the contemporary achievements evidenced by successfully delivering innovative medicine to the patients in a more efficient manner [7] . while human bioequivalence study is increasingly contributing to evaluation of emerging formulation and bio-similar agents besides chemical generics [4] , several adaptive trial designs have been capable of translating the scientific breakthroughs into novel therapeutic benefits with shorter processing time and lower financial costs, to address the unmet clinical needs [3, 19] . moreover with the assistance of bio-marker-based companion diagnosis, certain innovative trial designs have been streamlined to precisely confer selective therapeutic efficacy to the responding subgroups of patients with an array of serious diseases such as cancer and beyond [6, 27] . of note, to preserve the strength of clear defining efficacy and safety of tested drugs, the innovative designs of clinical study are substantially overlapped with classic trial protocols of three phases which still serve as the mainstream approach of clinical investigation [3, 7] . realistically, the medications through expedited processing appeared having a higher rate of post-approval black-box warnings than that of regularly approved drugs in terms of safety issues [42] . it has accordingly been proposed that single-armed phased ii studies to be accepted only for accelerated approval (aa) applications regarding refractory diseases. otherwise, interim analysis of ongoing phase iii trials may be able to support aa processes, with the follow-up studies required to provide further evidence for the drug's effects on human bodies [43] . whereas precision medicine-inspired trials represent an unique highlight in contemporary clinical studies to optimize the therapeutic efficacy for preferable subsets of patients with certain diseases upon enrichment strategies [3, 27] , the validated biomarkers are limited and even much less than established drug-target molecules [2, 44] . moreover, there still is a lack of the bio-markers to predict drugtriggered adverse events such as heparin-induced thrombocytopenia or immune checkpoint inhibitor-resulted hyper-progressive disease [45, 46] . hence, it takes a dialectic perspective to appreciate the high efficiency of these innovated designs, with mindful efforts on circumventing their imperfectness. replaces rcts biosimilar enoxaparin [12] biosimilar etanercept [14] phase 0 trial exploratory trial azd1775 [16] with microdosing midazolam ddi [15] seamless trial integrated trial keytruda [18, 21] without phase gaps indacaterol [22] basket trial one trial for numerous larotrectinib [27] types of disease tafamadis [28] therapeutic shifting therapeutic sildenafil [31] re-purpose indication during a trial crizotinib [2, 32] empagliflozin [33] orphan drug various expedited xuriden [37] trial designs tecovirimat [38] imatinib [6, 40] assessing the gold standard--lessons from the history of rcts cancer clinical trials: the rear-view mirror and the crystal ball adaptive designs for clinical trials chemisimilars and biosimilars: is clinical testing fit for purpose? make up a missed lesson-new policy to ensure the interchangeability of generic drugs in china targeted therapy : resistance and re-sensitization adaptive design clinical trials: a review of the literature and clinical trials.gov adaptive clinical trials: advantages and disadvantages of various adaptive design elements the new european medicines agency guideline on the investigation of bioequivalence investigating the discriminatory power of bcs-biowaiver in vitro methodology to detect bioavailability differences between immediate release products containing a class i drug consensi) for hypertension and osteoarthritis bioequivalence of a biosimilar enoxaparin sodium to clexane ® after single 100 mg subcutaneous dose: results of a randomized, double-blind, crossover study in healthy volunteers the introduction of biosimilars of low molecular weight heparins in europe: a critical review and reappraisal endorsed by the italian society for haemostasis and thrombosis (siset) and the italian society for angiology and vascular medicine (siapav) focus on biosimilar etanercept -bioequivalence and interchangeability microdosing and other phase 0 clinical trials: facilitating translation in drug development phase 0 trail of azd1775 in first-recurrence glioblastoma patients intra-target microdosing-a novel drug development approach: proof of concept, safety, and feasibility study in humans cellular immunity augmentation in mainstream oncologic therapy adaptive clinical trial designs in oncology using model-based "learn and confirm" to reveal the pharmacokinetics-pharmacodynamics relationship of pembrolizumab in the keynote-001 trial pembrolizumab keynote-001: an adaptive study leading to accelerated approval for two indications and a companion diagnostic intergrating indacaterol dose selection in a clinical study in copd using an adaptive seamless design an efficient basket trial design dual targeting autoimmunity and cancer: from biology to medicine efficacy of larotrectinib in trk fusion-positive cancers in adults and children basket trial of trk inhibitors demonstrates efficacy in trk fusion-positive cancers a next-generation trk kinase inhibitor overcomes acquired resistance to prior trk kinase inhibition in patients with trk fusion-positive solid tumors innovative clinical trial designs for precision medicine in heart failure with preserved ejection fraction the role of serendipity in drug discovery translating recent results from the cardiovascular outcomes trials into clinical practice: recommendations from the central and eastern european diabetes expert group (ceedeg) the serendipitous story of sildenafil: an unexpected oral therapy for erectile dysfunction development of crizotinib, a rationally designed tyrosine kinase inhibitor for non-small cell lung cancer sodium glucose cotransporter-2 inhibition in heart failure: potential mechanisms, clinical applications, and summary of clinical trials orphan drugs and their impact on pharmaceutical development challenges in orphan drug development and regulatory policy in china clinical research for rare disease: opportunities, challenges, and solutions fda approves ultra-orphan drug on a 4-patient trial oral tecovirimat for the treatment of smallpox gleevec for the treatment of chronic myelogenous leukemia: us. food and drug administration regulatory mechanisms, accelerated approval, and orphan drug status phase ii, open-label study evaluating the activity of imatinib in treating life-threatening malignancies known to be associated with imatinib-sensitive tyrosine kinases combined integrated protocol/basket trial design for a first-in-human trial safety related label changes for new drugs after approval in the us through expedited regulatory pathways: retrospective cohort study accelerated approval of cancer drugs: improved access to therapeutic breakthroughs or early release of unsafe and ineffective drugs? antxr1, a stem cellenriched functional biomarker, connects collagen signaling to cancer stem-like cells and metastasis in breast cancer heparin-induced thrombocytopenia hyperprogressive disease in patients with advanced non-small cell lung cancer treated with pd-1/pd-l1 inhibitors or with single-agent chemotherapy we thank our colleagues for encouragement. the authors declare no conflict of interest. key: cord-034340-3ksfpaf7 authors: nan title: proceedings of the 26th european paediatric rheumatology congress: part 2: virtual. 23 26 september 2020 date: 2020-10-28 journal: pediatr rheumatol online j doi: 10.1186/s12969-020-00470-5 sha: doc_id: 34340 cord_uid: 3ksfpaf7 nan introduction: juvenile idiopathic arthritis (jia) represents the most common pediatric chronic rheumatic disease. children with jia present an increased risk of infections, due to the immune-regulatory effects of disease modifying antirheumatic drugs (dmards); many of these infections are vaccine-preventable. nevertheless, suboptimal vaccinations rates are reported in children with jia. objectives: to evaluate vaccination coverage in a population of children with jia and to describe the prevalence of the adverse events following immunization (aefis) in our cohort. methods: a single-centre retrospective study was conducted by reviewing medical records of all jia patients, diagnosed according to ilar criteria, admitted to the pediatric rheumatology unit of university of naples federico ii from january to december 2019. parents were asked to provide the vaccinations records in form of the vaccination booklet. the occurrence of aefis was explored by telephone interviews. introduction: intrarticular corticosteroid injections (iaci) are widely used in the management of patients with juvenile idiopathic arthritis (jia). general anesthesia can be avoided in case of a small number of joints to inject or in older children. however, pain and anxiety may reduce the patient compliance to iaci, and may compromise the accuracy of the procedure. in order to overcame such problems, the use of appropriate methods of pain and anxiety control is advisable. objectives: to assess the effectiveness and satisfaction of patients undergoing iaci with the use of topical numbing agent or under minimal sedation. methods: patients with jia who underwent an iaci of up to 3 joints were recruited. depending on age and number of joints to treat, a group of patients (group a) were injected with the application 30 minutes prior the procedure of a topical numbing agent (prilocaine+lidocaine) to the skin over the injection site. another group of patients (group b) were treated under minimal sedation (ketorolac/tramadol or morphine + midazolam). the physician was asked to record the degree of motion and pain of the patient during the procedure and the patient (or parents for patients aged less than 4 years) was asked to report the degree of pain and satisfaction on a visual analogue scale (vas) from 0 to 10. results: twenty-seven patients were enrolled for a total of 30 procedures, 17 and 13 of them in group a and b, respectively. the median age at the procedure was 10 years for group a and 11 years for group b. for group a median pain scores for patients, parents and physicians were 2, 2 and 1.5, respectively. in patients of group b who underwent the iaci under ketorolac/tramadol the median pain scores for patients, parents and physicians were 3, 5.25 and 2.5, whereas in patients treated with morphine median pain scores were 6, 6 and 2, respectively. overall, we found that pain as reported by the patient/parent were higher with increase in the number of sites injected (and, consequently, duration of procedure) and age of patient. amount of motion during procedures was overall negligible. the majority of patients/parents was satisfied for the procedures. only 2 patients treated with midazolam had psychomotor agitation during the iaci. conclusion: iaci in a small number of sites without the use of general anesthesia is well tolerated by patients. the level of pain perceived from patients is irrespective of the power of the painkiller used, but seems to correlate with the duration of the procedures. it is possible that, in the paediatric age, the psychoemotional component seems to be decisive, with a progressive loss of tolerance with the increase in the number of injected joints. for gc-ms analysis of the steroid hormone metabolites age and sexmatched healthy controls were matched to each patient. patients were excluded if they were treated with corticosteroids in the preceding 3 months. results: of the 35 metabolites measured, 23 were significantly lower in jia patients before the etanercept treatment compared to the healthy control group. one day after the injection only 5 metabolites were still significantly lower in the jia patients and all the other 30 metabolites normalized and were similar to the control group. urine metabolite ratios reflecting cyp21 and 11β-hsd2 enzymatic activity indicate that these two enzyme activities were lower in jia patients. the slowest recoveries noted were for metabolites of dheas and 17 oh pregnenolone. conclusion: prior to etanercept treatment almost all urine adrenal metabolites were significantly lower mainly due to the active inflammatory process. immediately after the treatment many metabolites raised to normal values as in the control group. the two adrenal enzymes that were found to be affected in jir are cyp21 and 11β-hsd2. blocking tn alpha immediately restore adrenal function in jia. introduction: patients with juvenile idiopathic arthritis (jia) receive adalimumab treatment. adalimumab is a monoclonal antibody that blocks tnf-α and is structurally and functionally similar to human igg 1 . nevertheless, there are reports of the development of anti-drug antibodies. the production of these antibodies may be associated with treatment failures (a decrease in the effectiveness of therapy or drug inefficiency that developed over time) and hypersensitivity reactions. to our knowledge, there is currently limited information on the availability of adalimumab antibodies (aaa) in patients with jia. objectives: to evaluate the prevalence rate and the clinical significance of aaa in patients with jia on adalimumab treatment. methods: 26 patients with jia were examined, 17 of whom had the oligoarticular form of the disease, 7 of them with uveitis, and 9 patients had the polyarticular form of the disease, 3 of them with uveitis. among them, there were 13 (50%) girls and 13 (50%) boys. the mean age was 11.0 ± 3.4 years; the mean disease duration was 4.1 ± 2.2 years. patients received adalimumab (at least 1 year before the study) with concomitant administration of methotrexate (mtx) or adalimumab only -13 children who did not receive mtx for at least 3 months prior to the study as a result of either adverse events of mtx administration (5 patients) or permanent drug remission (8 patients). before starting adalimumab therapy, all participants were treated with mtx. the mean duration of adalimumab treatment for these patients was 1.8 ± 1.0 years. the serum aaa level of antibodies was determined using the enzyme immunoassay (eia) method. this method determines both free and bound antibodies to adalimumab at reference values less than 10 au/ml. a and was used every 2 weeks for 3 months. the values were presented as mean ± standard deviation. data processing and analysis were carried out using pearson's chi-squared test and spearman's correlation test. results: 8 (31%) of the 26 patients enrolled in the study had aaapositive results. the mean aaa level in positive patients was 40.8 ± 20.1 au/ml. further disease relapses tended to occur significantly more often in aaa-positive patients than in aaa-negative ones (χ2 = 5.46, p = 0.019). thus, 5 of 8 (62.5%) aaa-positive children had at least 1 exacerbation of the disease within 3 months, compared with 3 of 18 (16.7%) in aaa-negative ones. 7 out of 8 (87.5%) aaapositives did not take mtx for at least 3 months compared to 6 out of 18 (33.3%) in aaa-negative ones. thus, aaas are found to be significantly more frequent without concomitant administration of mtx in the treatment of jia (χ2 = 6.5, p = 0.01). there were no observed adverse events or side effects during adalimumab therapy. no significant correlation was found between the presence of aaa and sex, introduction: advances on molecular medicine, illumination of the cytokine network and the immune pathways shed light on the etiopathogenesis for a better understanding of juvenile idiopathic arthritis (jia). however, the fact that the course of the disease differs individually strongly suggests the effect of external factors. objectives: the current study was undertaken to evaluate sociodemographic and sociocultural features, parent behavior, the gestation and breastfeeding period, nutritional status of early childhood in our patients with jia, and to determine their relationship with disease activity, damage index, remission time, and relapse rate. methods: the study was conducted with a face-to-face questionnaire method with the parents of 171 patients with jia and 183 healthy children. the medical patient records were reviewed. juvenile arthritis disease activity score (jadas) 27, wallace clinical inactive disease criteria, juvenile arthritis damage index (jadi), and relapse rates were used to assess the general medical condition of each patient. results: the median age of jia patients (n = 171) was 13 (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) , with a female ratio of 59,1%. age at disease onset was 7 (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) years. the first remission time was 5(1-17) months. the patients were evaluated according to disease subtypes and treatment modalities. there was no difference in the duration of breastfeeding according to the distribution of the subtypes (p = 0,97). when the breastfed and formula-fed patients were compared, there was a marginally significant difference in terms of first remission time (p = 0,05), whereas there was a significant difference in relapse rate in patients who introduced to cow milk early (<12 months) (p = 0,019). the early risk factors and their relationship with the disease are presented in table 1 . both breastfeeding durations and maternal literacy levels showed a significant difference in terms of relapse rates (p = 0,01; p=0,03, respectively). there was no significant difference in breastfeeding durations and gestational risks between the patients and the healthy group (p = 0,1; p= 0,65), respectively. however, the smoking rate among family members was significantly higher in the patient group (p = 0,03). conclusion: in patients with juvenile idiopathic arthritis, breastfeeding rate and duration did not differ when compared to healthy controls. however, breastfeeding duration, cow's milk commence age, and maternal literacy appeared to be relevant to the relapse rates. going to preschool both influence the remission time and relapse rate. these findings suggest a role for parental attitude and nutritional status during early childhood in the course of jia. none declared introduction: immunogenicity and low trough concentrations have been associated with adalimumab treatment failure in several studies of paediatric inflammatory diseases, indicating the possible value of therapeutic drug monitoring (tdm). adalimumab efficacy may be improved by changing dose or treatment intervals based on drug concentrations. however, lack of standardization, assay heterogeneity, and paucity of research hinder the implementation of tdm in clinical practice. objectives: to assess the relationship of trough concentrations, immunogenicity and adalimumab response in paediatric patients with jia. methods: monocentric cohort study of patients ≤18 years with jia treated with adalimumab due to active arthritis. clinical data and plasma samples were collected during routine follow-up. adalimumab trough concentrations were measured by liquid chromatographytandem mass spectrometry (lc-ms/ms). anti-adalimumab antibodies were measured in samples with trough concentrations <5mg/l. disease activity was evaluated using the clinical juvenile arthritis disease activity score with 71 joint count (cjadas71). response to adalimumab was defined as at least 50% reduction of disease activity within 3 months of therapy followed by clinical inactive disease or minimal disease activity after 6 months. the latter was defined as cjadas71 ≤1.5 and ≤2.5, for oligoarthritis and polyarthritis, respectively, or an active joint count equal to zero when cjadas71 was unavailable. results: 36 adalimumab trough samples were available from 35 jia patients. although there was no significant difference in median adalimumab dose, trough concentrations were significantly lower in patients with secondary failure compared to primary failure or an adequate adalimumab response (p-values <0.01). in addition, there were 11 samples with trough concentrations <5mg/l, 9 in the group with secondary failure and 2 in the group with adequate adalimumab response (table 1) . conclusion: adalimumab trough concentrations were significantly lower in jia patients with secondary failure compared to primary failure or an adequate response to adalimumab. anti-adalimumab antibodies were present in 8 out of 11 samples with trough concentrations <5mg/l. adalimumab trough concentration measurements may identify jia patients that would benefit from increased doses or shorter treatment intervals. in addition, jia patients with primary failure and adequate adalimumab trough concentrations may respond better to biologic agents with other therapeutic targets. although biologic agents have improved disease outcome of patients with jia, concentration measurements using reliable and cost-effective methods, such as lc-ms/ms, could further improve efficacy of biologic agents and guide treat-to-target strategies. introduction: most studies of physical fitness (pf) in juvenile idiopathic arthritis (jia) have shown decreased levels of maximal oxygen consumption (vo 2 max) compared to healthy peers. in jia, boys have higher pf-levels than girls and younger children have higher levels than adolescents, congruently with data of healthy peers. previously, we have shown that more than half of jia-patients had below normative average of vo 2 max. however, monitoring physical activity (pa) using accelerometry, 68% of boys and 39% of girls with jia fulfilled the recommendations of who of ≥1 hour of pa per day, which was comparable to normative values (61%/39%). moreover, patients reporting engagement more than 7 hours per week in club-sports exceeded accelerometry values of healthy peers. objectives: to explore the association between pf and specific sport habits in 10 to 16-year-old jia-patients, related to gender, bmi, disease activity, and pain, and comparing the most fit quartile (q4) of patients (respectively boys and girls) to the least fit quartile (q1). methods: sixty patients with jia performed an indirect ergometertest of vo 2 max (watt max test) and answered the physical activity and sport questionnaire (pasq). objective pa-monitoring for one week was conducted using the gt1m accelerometer. cut-offs for moderate-high and high intensity pa were set to >1000 and >2500 counts per minute, respectively. disease activity was assessed with the jadas-27, current pain and worst pain last week were measured on visual analogue scales (vas) and in a one-week pain diary using the faces pain scale-revised (fps-r). results: girls with jia (n=36) had lower mean pf than the boys (n= 24) (36.5±8.2/43.4±6.73 ml/kg/min), being below normative values, respectively. in both genders the most fit boys and girls (q4; 49.3-57/ 40.9-54) had average to well-above normative average pf. the least fit boys (q1; 33.5-37.4) all had pf-levels well-below normative average. in girls q1-levels (18.7-30.9) were well-below to below normative average. we found significant differences between most fit (q4) and least fit (q1) patients regarding patient´s global wellbeing (p=0.040) and pain diary (p=0.026). these differences were not significant when separating genders, though differences were more pronounced in girls. the least fit girls (q1) had significantly higher disease activity (jadas-27) than the most fit girls (q4)(p=0.019). the most fit boys and girls (q4) engaged equally in high intensity sports (soccer: 3/24; 2/36, handball: 0/24; 2/36, gymnastics: 2/24; 4/ 36, rowing: 1/24; 0/36). however, more boys than girls played soccer (11/24; 3/36), whereas more girls preferred sports of lower intensity (riding: 8/36; 0/24). eight of 11 boys in soccer and 2 boys in gymnastics or rowing had below average to well-above normative average of pf (q3+q4: 41.6-57). three girls in gymnastics, 2 girls in soccer, and 2 girls in handball were in q4 (40.9-54) with levels of average to well-above average pf. the third girl in soccer was in q2 (31-36.3) with levels of well-below to below normative average. none of the riding girls were in q4 and only 1 was in q3 (36.3-40.8) (below to average normative pf). comparing accelerometer-monitored values of pa-intensity in girls with low (q1) and high (q4) pf, pavalues of q1 were significantly lower than in q4. the same tendency was observed in boys, but not to significance. conclusion: our results are in accordance with most other studies of pf in jia, adding to the knowledge of gender-specific differences in pf and type and behavior in sport activities. it emphasizes the need of regular pf-testing and guidance in high intensity pa and sport in order to improve pf and avoid the risks of inactivity and lifestyle diseases in jia. pg/ml), which also showed the highest the frequency of detection of its increase. it was absent in sjia (7.52±4.74 pg/ml). the highest values of il-17r (1849836.4±176751 pg/ml) were in the middle age group. the data obtained suggest the compensatory value of increasing il-17r and the simultaneous initiation of inflammatory and anti-inflammatory processes during exacerbation of jia. assessment of the ratios of stimulating and inhibiting cytokines showed in patients with uveitis, the ratio of ifn-γ/il-1β (4379.29 ±476.83) was higher than with other jia (from 60.84 ± 14.92 in ojia to 105.20± 66.01 in pjia) and ifn-γ/il-17r (4474.01 ±3899.19 versus from 20.14± 11.48 in ojia to 934.55±931.37 in sjia). an increase of il-1β/il-17r ratio was characteristic only for sjia (34.12±26.17). all of these ratios increased with disease activity (r=0.22-0.37) & they did not reflect the unpleasant course of the disease. methods: in this multicenter, case-control study, 113 fecal samples were collected from 91 children with jia, with 72 of these samples collected from untreated children (67 of whom were treatment-naïve children). samples from 28 children with jia were collected during treatment with mtx as single treatment and samples from 13 children during treatment with etn. of those 13 children, four were treated with etn as single treatment and nine had a combination of etn and mtx. we compared 28 children on single treatment with mtx with 57 untreated children (52 treatment-naïve), and 13 children on treatment with etn (nine in combination with mtx) with 62 untreated children (57 treatment-naïve). we also did pairwise comparisons of samples taken before any medication was given (n = 22) and samples taken during ongoing treatment with mtx (n = 14) or etn (n = 8, four in combination with mtx). the microbiota was characterized by sequencing amplicons from the v3 and v4 regions of the 16s rrna gene. alpha diversity of the fecal samples was measured using the chao-1 index and the shannon diversity index. to compare these indices between treated children and untreated children, we used a logistic regression model with age at sampling as a covariate. for pairwise analyses, we used the wilcoxon signed-rank test. to analyze the community composition of the microbiota, principal coordinate analysis (pcoa) plots based on bray-curtis distances were generated for visual comparisons, and analysis of similarity (anosim) was used to test for differences. analyses for relative abundances of taxa were performed at three taxonomic levels (phyla, families, and genera), and logistic regression with age as a covariate was used for calculations of differences between treated and untreated children, while the wilcoxon signedrank test was used for pairwise comparisons. significance was set to p < 0.05 and corrections for multiple comparisons were made using the benjamini-hochberg method. results: analyses showed no significant differences in α-diversity between children treated with mtx or etn and untreated children, and pairwise comparisons of samples before and during treatment with mtx or etn also showed no differences. pcoa plots for children treated with mtx or etn, in comparison with untreated children, did not show any clustering. anosim showed no significant differences between treated and untreated children. pcoa plots were also made for the pairwise comparisons of children sampled before and during treatment, and according to that analysis the community compositions of microbiota did not change in any uniform way during treatment with either mtx or etn. furthermor, analyses of relative abundances of specific taxa did not reveal any significant results in any of the comparisons, after adjustment for multiple analyses. conclusion: treatment with mtx or etn did not alter the composition of fecal microbiota in children with jia. introduction: juvenile idiopathic arthritis (jia) is the most common rheumatic disease in childhood and an important cause of shortterm and long-term disability if patients are not treated appropriately. by definition, jia clinically presents with peripheral joint inflammation of unknown origin, persisting for at least six consecutive weeks and starting before the age of 16 years. the predominant subtypes, i.e. oligoarticular (oligo) and polyarticular (poly) jia, have long been assumed autoimmune diseases caused by dysregulation of the adaptive immune system, with a central role for autoreactive t cells belonging to the th1 and th17 lineages and autoantigens that may include aggrecan, fibrillin, matrix metalloproteinase (mmp)-3 and heat shock proteins. nevertheless, the original t cell-centered hypothesis has been challenged since it does not cover nor completely explain the full spectrum of immune-pathological phenomena observed in patients. lien.desomer@uzleuven.b objectives: emerging evidence suggests a potentially important role for neutrophils in jia pathogenesis. here, we investigated extensively the phenotypical features of neutrophils present in the peripheral blood and inflamed joints of jia patients. methods: synovial fluids and parallel blood samples from patients with oligo-or polyjia and blood samples from healthy children were collected. multicolor flow cytometry panels allowed for in-depth phenotypical analysis of neutrophils, focusing on the surface expression of adhesion molecules, activation and maturation markers, chemoattractant-and toll-like receptors. multiplex technology was exploited to quantify pro-and anti-inflammatory cytokines in plasma and synovial fluids. results: the vast majority of synovial fluid neutrophils displayed a strongly activated, hypersegmented phenotype with decreased lselectin (cd62l) expression and increased numbers of nuclear lobes, upregulation of adhesion molecules cd66b, cd11b and cd15 and downregulation of chemokine receptors cxcr1/2. an elevated percentage of cxcr4-expressing aged neutrophils was detected in synovial fluids from patients. strikingly, significant percentages of synovial fluid neutrophils showed a profound upregulation of atypical neutrophil markers, including cxcr3, icam-1 and hla-dr. conclusion: our data indicate that neutrophils present in inflamed joints of jia patients are strongly activated cells with elevated proinflammatory and antigen presenting potential. this detailed molecular analysis supports the notion that a complex intertwining between these innate immune cells and adaptive immune events drives jia. none declared the main factors, associated with incomplete vaccination againts measels, parotitis, rubella and diphtheria in 170 juvenile idiopathic arthritis patients n. lyubimova 1 , i. objectives: the aim of our study was to evaluate the rate and the main factors of incomplete vaccination against measels,parotitis, rubella (mmr) and diphtheria in jia patients. methods: in the present study were included data 170 jia(55 boys and 115 girls)aged from 2 to 17 years,who received scheduled vaccination before the age of 2 years and before jia onset against measles,parotitis,diphtheria and rubella.incomplete vaccination means the reduced number of vaccine to age.in all patients the ig g anti-vaccine antibodies levels were detected with elisa.jia categories were:oligoarthritis -73,polyarthritis -61,systemic-16 and enthesitisrelated arthritis-20.data presented with median and 25%>75% results: incomplete vaccination against mmr was in 50 (42%)diphtheria in 85 (50%) of the jia patients. the main differences in the studied groups are in the table.there were no differences in sex,jia categories and treatment, except biologics compare to complete and complete vaccination in all vaccines.no differences in antimeasels(p=0.18),antiparotitis (p=0.1) and anti-rubella(p=0.17)vaccination between complete and incomplete vaccination group.number of patients with protective level of anti-vaccine antibodies was similar, except parotitis(70% vs 84.2%, p=0.035).the anti-diphtheria antibodies igg level was lower in the patients with incomplete vaccination group (0.07 iu/ml [95%ci:0.03; 0.22] vs 0.2 [95%ci:0.06; 0.4], p=0.001)as well as number of patients with protective level(34% vs 54%, p=0.002). in the multiple regression model only jia onset age(p=0.00001)and methotrexate treatment duration(p=0.003) were predictors of incomplete vaccination against mmr and methotrexate treatment duration(p=0.005) and biologic treatment(p=0.05) for diphtheria incomplete vaccination.incomplete mmr vaccination influence on the maintenance of the protective anti-parotitis level(p=0.036)in regression model.in correlation analysis the number of vaccination influences on anti-diphtheria antibodies level(p=0.017)and number of patients with protective level of anti-diphtheria antibodies(p=0.017). the main predictors in logistic regression for incomplete vaccination for mmr were:onset age<6 years(or=7. 8 conclusion: younger onset of jia age, longer duration of jia and methotrexate treatment, biologics and more than 1 biologics are the main predictors of incomplete vaccination againt mmr and diphtheria. introduction: the prevalence of autoimmune thyroid disorders (aitd) has been reported to be higher in patients with juvenile idiopathic arthritis (jia) in comparison to the general population. nevertheless, there is a lack of studies investigating risk factors for aitd development in children with jia. objectives: to investigate the co-occurrence of jia and autoimmune thyroiditis in southern italy and to identify potential predisposing factors to anti-thyroid antibodies (ata) positivity in a jia population. methods: a single-centre retrospective study was conducted. all jia patients admitted to the pediatric rheumatology unit of the university of naples federico ii, from january 2001 to december 2019, tested for ata at least once and with a minimum of 6-months follow-up, were included. for each patient, demographic, clinical and laboratory data were extracted from clinical charts. differences between patients affected by jia with or without ata were analyzed. results: three hundred thirty jia patients (247 females; median age 12.5 years, iqr 9.1-16.1) were included in study. median age at jia onset was 4 years (iqr: 2.2-7.8). twenty-three patients [7% (95% ci 4.5-10. 3)] presented ata positivity. twenty-one of them (91.3%) were females. anti-thyroperoxidase was positive in 18/23 patients (78.2%) while 12 patients presented anti-thyroglobulin positivity (52.1%). both antibodies were present in 8/23 (34.8%). 19 patients showed the typical ultrasound findings of autoimmune thyroiditis, resulting in a prevalence of hashimoto's thyroiditis of 5.7% (95% ci 3.5-8.8) in our cohort. three female patients developed subclinical hypothyroidism, whereas one male patient presented subclinical hyperthyroidism. the remaining 19 patients were euthyroid. no statistically significant difference was observed in regard to age of jia onset, follow-up duration and jia subtype between the patients with or without ata. the proportion of females was marginally significantly higher (p=0.059) in the group with ata positivity compared to children without thyroid antibodies (91.3% vs 73.6%, respectively). 56.5% of patients with ata showed ana positivity compared to 37.5% of patients without ata (p=0.07). family history for aitd was significantly higher in children with thyroid antibodies positivity (p= 0.01). anti-tnf-alpha inhibitors were administered in only 3 children (13%) with thyroid antibodies before their detection compared to 35 .5% of patients without thyroid antibodies (p=0.028). multivariate regression analysis showed that patients with a family history for aitd were about four times more likely to develop ata (or 3.75, 95% ci 1.401-10.017, p=0.008) and confirmed that ata positivity is less likely to occur in patients undergone anti-tnf-alpha therapy (or 0.127, 95% ci 0.031-0.518, p=0.004). conclusion: a high prevalence of ata positivity and hashimoto's thyroiditis in patients with jia was found in our wide southern italian cohort. as expected, a positive family history of aitd was found to be associated with a higher risk to ata development during the follow-up. this finding supports the usefulness of an active screening for aitd in jia children, in particular in patients with relatives affected by thyroid disorders. notably, patients treated with tnf-alpha inhibitors resulted less likely to develop thyroid antibodies. further studies are needed to investigate the effect of anti-tnf-alpha therapy on thyroid autoimmunity in jia. introduction: the knee is considered by far the joint most frequently affected at jia onset. nonetheless, jia onset may present with unusual musculoskeletal involvement, eventually leading to a delay in the diagnosis and treatment. objectives: to identify the type and number of musculoskeletal sites affected at jia onset in consecutive patients seen at the study center in an 8 years period. methods: records of patients with new diagnosis of jia from june 2012 to may 2020 available information in the medical history and standardized joint assessment at diagnosis, were retrospectively reviewed. systemic jia subtype according to ilar classification criteria were excluded. demographic and clinical features, including the type and number of joints at disease onset and diagnosis, were registered. data were analyzed through descriptive statistics. results: of a total of 333 caucasian patients included in the study (75.7% females), 241 patients (72.4%) had oligoarthritis, 79 (23.7%) rf-negative polyarthritis, 7 (2.1%) rf-positive polyarthritis, 1 (0.3%) psoriatic arthritis, 5 (1.5%) enthesitis-related arthritis (era). antinuclear antibody (ana) were positive in 188 patients (56.5%). the median age at onset was 4.8 years (iqr 2.3-9.3). at diagnosis 103 (30.9%) patients had only 1 active joint, 143 (43.0%) had 2-4 active joints, 87 (26.1%) had ≥ 5. as expected the knee, the tibiotalar and the wrist were the most frequently affected joints (77.2%, 41.1%, 21.0%, respectively); cervical spine was involved only in patients with polyarthritis (n=13). notably, of 103 patients with monoarthritis at diagnosis 98 presented with large joints involvement, among which n=2 isolated elbow and n=2 isolated wrist, and 5 with small joints involvement (table 1) . no sufficient data were available regarding the involvement of tendons and bursae, since the standard joint assessment form did not include them. nonetheless, additional 4 patients, not included in the sample analysis, had isolated tenosynovitis involvement at diagnosis (n=1 both-sided ulnar extensor tendons; n=2 isolated tenosynovitis of the flexor digiti proprius; n=1 tenosynovitis of 2 flexors digiti proprii). conclusion: our study confirms the knee, the tibiotalar and the wrist as the most frequently affected joints at jia diagnosis. on the other hand, musculoskeletal sites, such as small joints of hands and feet, the hip and the shoulder, usually involved in polyarticular jia, can be the site of disease presentation in oligo-and also mono-articular jia. further, jia may present with isolated tendon involvement. our results foster not to delay jia diagnosis in persistent synovitis occurring in infrequent joints and to include musculoskeletal sites, other than joints, in the standard articular evaluation. this could be realized by merging clinical and imaging (i.e. ultrasound) musculoskeletal examinations in the same assessment. none declared introduction: treatment response in jia is currently viewed as a binary outcome: response or non-response. however, jia is a heterogeneous disease and it is likely that different, identifiable subgroups of children and young people (cyp) may demonstrate different patterns of disease following treatment. identifying these response subgroups can assist the tailoring of stratified treatment approaches in jia. objectives: to identify subgroups of cyp defined by different trajectories of juvenile arthritis disease activity score (jadas) components following methotrexate (mtx) initiation for jia. methods: mtx-naïve cyp with jia were selected if enrolled prior to january 2018 in the bspar etanercept cohort register or the biologics for children with rheumatic diseases study at point of starting mtx. jadas components (active joint count, physician's global assessment (pga, 0-10cm), parental global evaluation (pge, 0-10cm) and standardised esr (0-10) were calculated based on data collected in the year following mtx initiation. multivariate group-based trajectory models were used to explore mtx response clusters across the different jadas components, which were log1p transformed for analysis. optimal models were selected based on a combination of model fit (bic, relative entropy, average posterior probabilities), parsimony and clinical plausibility. clinical and demographic characteristics and achievement of acr pedi 30/90 by six months were compared across identified groups. results: of 658 cyp selected, the majority were female (68%) and of white ethnicity (86%), with rf-negative jia the most common disease category (35%). six subgroups of cyp were identified with differing patterns of disease activity following mtx initiation. two groups improved across all jadas components: fast improvers (11%), and slow improvers (16%). persistent pga (8%), and persistent pge (13%) groups maintained one persistent disease feature but otherwise improved. one group relapsed (7%) and a final group had persistent disease overall (44%). there were no differences in active joint counts at mtx initiation between subgroups and all ilar categories were represented across each subgroup. however, cyp in persistent disease and slow improver groups had higher chaq, pga and pge scores at mtx initiation. those with persistent disease were also older at mtx initiation. the majority of cyp fulfilled acr pedi 30 response (>60% across every group). acr pedi 90 achievement was low at 6 months for slow improvers (30%) and high in the relapse group (68%). between 41% and 73% achieved acr pedi 90 response in groups with persistent disease in one jadas component. we identify different patterns of disease activity within cyp initiating mtx, suggesting a simple responder/non-responder analysis at a set point may be over-simplistic. commonly used response measures did not adequately describe these heterogeneous response patterns. understanding both clinical factors associated with, and biological mechanisms underpinning, these subgroups would aid stratified medicine in jia. introduction: despite modern treatment and improved disease control, pain is the most common complaint in juvenile idiopathic arthritis (jia). knowledge about pain thresholds and pain sensitivity among young adults with jia is sparse. objectives: to study pressure pain thresholds (ppts) in young adults with jia, 16 years after disease onset compared with controls. methods: consecutive newly diagnosed children with jia and a disease onset between 1997-2004 from central norway, were included in this prospective population-based long-term follow-up study. children with onset 1997-2000 were part of the nordic jia cohort 1,2 . age-and sex-matched controls were drawn from the national population register of norway. inactive disease and remission were defined according to wallace 3, 4 . at the follow-up between 2015-17, data from a clinical examination and blood tests were included in addition to an investigator-blinded quantification of ppts. a digital algometer was used to manually apply pressure three times with an even rate at the upper and lower limb. ppts from jia and controls, and from subgroups of jia defined by disease status, were compared with multilevel models in stata. results: among the 96 participants with jia, 71% were female, median age was 22.7 (iqr 18.7-26.2) years, median disease duration was 16.1 (iqr 14.2-17.1) years, 47% had an oligoarticular disease (persistent or extended), and 45% were in remission off medication. in the control group, 71% were female and median age was 23.5 (iqr 20.2-26.7) years. results from the multilevel regression model showed significantly lower ppts among participants with jia compared to controls (table 1 ). in the jia group, participants with inactive disease had lower ppts than both jia in remission off medication and jia with active disease ( table 1 ). the results were consistent for both upper and lower limb. conclusion: in this long-term follow-up study of young adults with jia, we found significantly lower ppts compared to controls. this may indicate that young adults with jia have altered pain sensitivity possibly due to accumulated earlier pain experiences. introduction: juvenile idiopathic arthritis (jia) represents the most common chronic rheumatic disease in childhood. non-steroidal antiinflammatory drugs (nsaids) and intra-articular steroids are the first line treatment for jia. systemic steroids, disease modifying antirheumatic drugs (dmards) and biologic drugs are used in children with severe disease. it is not possible at onset of disease to predict when a child can suspend pharmacological treatment, so children affected from jia have to continue pharmacological treatment for several months or years. anecdotal reports showed that rarely jia could present renal involvement due to uncontrolled inflammation or to long exposure to drugs. objectives: because no cohort studies investigating renal injury in children with jia are available, we designed this kind of study in our population. methods: we retrospectively evaluated 110 patients suffering from jia. jia diagnosis was made according to ilar criteria, treatment was assigned with acr recommendations. for each patient we recorded the type and the duration of pharmacological treatment and the presence of renal injury. renal injury was defined by the presence of hypertension (systolic and/or diastolic blood pressure >95 th percentile for age, sex and height), proteinuria (persistentconfirmation within 3 months-urinary protein/creatinine ratio>0.5 mg/mg for children <2 years old and >0. 2 introduction: juvenile idiopathic arthritis (jia) is a pediatric rheumatic disease with partially unknown etiology and pathogenesis. neutrophils are the most common immune cell present in synovial fluid from inflamed joints in oligoarticular jia, but the role of neutrophils in the immunopathogenesis of oligoarticular jia has not been investigated. objectives: to characterize neutrophil phenotypes and effector functions in the circulation and in the inflamed joint during active arthritis in children with oligoarticular jia. methods: paired samples of blood and synovial fluid from 17 children with oligoarticular jia were investigated regarding surface markers, phagocytic ability and oxidative burst. healthy blood neutrophils exposed to cell-free jia synovial fluid and healthy oral cavity neutrophils were studied as controls for synovial fluid exposure and transmigration respectively. results: synovial neutrophils had a shifted phenotype, characterized by high surface levels of neutrophil activation markers cd11b and cd66b, and mannose receptor cd206 and decreased levels of adhesion molecule cd62l compared to circulating neutrophils. in comparison to oral cavity neutrophils, synovial neutrophils had higher levels of cd11b and a different overall phenotype, suggesting that the phenotype shift in synovial compared to circulating neutrophils is not dependent on transmigration alone. jia synovial fluid in itself induced activation of healthy blood neutrophils, measured as increased cd11b levels. synovial fluid neutrophils had impaired ability to phagocytose opsonized e. coli and to produce oxygen radicals upon neutrophil activation with phorbol-myristateacetate (pma) compared to circulating neutrophils. the impaired effector functions in synovial neutrophils was not dependent on the synovial fluid alone, as addition of cell-free synovial fluid to blood neutrophils did not alter phagocytosis and oxidative burst. conclusion: jia synovial fluid neutrophils are activated, have a "polarized" phenotype and impaired effector functions compared to neutrophils in the circulation. this study will help bridge the current knowledge-gap regarding the role of neutrophils in the immunopathogenesis in oligoarticular jia. methods: a case report is described. data was extracted from the medical chart of the patient and a literature review was undertaken. results: a 7-year-old girl was transferred to our tertiary center after being admitted for prolonged intermittent fevers, abdominal pain, fatigue and polyarthralgias. on examination, there was symmetrical proximal muscle weakness, a vasculitic lower limb rash, facial erythema with eyelid edema (fig. 1 ) and oral mucositis. initial laboratory exams revealed pancytopenia, high muscle enzymes, increased erythrocyte sedimentation rate with moderately elevated reactive c-protein, and hypocomplementemia. she also had non-nephrotic proteinuria, without hematuria.further investigations showed a positive direct antiglobulin test, antinuclear antibodies, antidouble-stranded dna, anti-mi 2 and anti-ku. serositis (pericardial and pleural effusions, ascitis) and hepatosplenomegaly were present. lower limb mri documented diffuse muscle edema. the diagnosis of an overlap syndrome of jsle and iim was established. while being treated for concomitant bacteremia, the patient became ill-appearing, with persistent fevers, worsened cytopenias, low fibrinogen and high ferritin and triglycerides, and a macrophage activation syndrome (mas) diagnosis was assumed. the patient received antibiotics and intravenous immunoglobulin, followed by methylprednisolone pulses, iv cyclosporine (cyc), hydroxychloroquine and supportive therapy with progressive improvement. due to hypertension (possibly related to cyc) and persistent proteinuria a renal biopsy was performed showing class iv lupus nephritis. after achieving clinical stability, cyc was switched to mycophenolate mofetil as an induction treatment, which is ongoing. conclusion: imm with sle os is uncommon, and has seldom been described in children. in addition to fulfilling sle criteria, our patient had clinical, laboratory and imagiologic evidence of imm. the presence of myositis specific antibodies (especially anti-mi 2) further supports the diagnosis of an os rather than an atypical presentation of a lupus myopathy. juvenile dermatomyositis appears to be the imm subtype -it is associated with anti-mi 2, and mild heliotrope and eyelid edema are compatible. facial rash sparing the nasolabial folds is more suggestive of sle. mas is a rare but life-threatening condition that should be suspected in rheumatologic conditions and might be triggered by infections or disease flares. its identification may be particularly challenging at presentation, especially in sle where cytopenias are common. the reported prevalence in adult sle ranges from 0.9% to 4.6%; disease-specific criteria have been proposed. mas has occasionally been described in iim. in a patient with a predisposing condition, persistent fevers and illappearance must always prompt a mas workup, since early diagnosis and treatment are paramount. due to an early referral to a pediatric rheumatology center, the patient received a prompt diagnosis and treatment, which probably improved her prognosis. results: four of the five patients were female (80%) and all aged between 6 and 10 years. four of them had calcinosis at the time of diagnosis, although they may have had symptoms for 12 to 18 months prior to diagnosis. skin involvement was severe requiring multiple systemic and topical therapeutic agents in four out of the five patients -significantly more affected than the muscles. one patient had amyopathic subtype with normal childhood myositis assessment score (cmas) throughout. none of them had cardiac involvement. all had weakly positive anti-nuclear antibodies (ana); but were negative for myositis antibodies except the patient with most severe skin involvement and calcinosis (patient 2), who was positive for anti-tif1gamma antibodies. two of the three patients with calcinosis at onset had cyclophosphamide as the second line agent (chosen due to calcinosis) following systemic corticosteroids with complete resolution of the lesions after six cycles at 500mg/m2. one patient responded to infliximab, which failed to work after 20 months, following which cyclophosphamide was tried with good response. the other two patients were given cyclophosphamide after they failed to respond to rituximab, which did work for muscle disease. one patient had recurrent episodes of calcinosis needing surgical curettage despite initial response to cyclophosphamide and later ivig. introduction: systemic juvenile idiopathic arthritis (sjia) is a unique form of childhood arthritis. according to current understanding sjia is primarily driven by innate immune mechanisms at disease onset, but can progress towards chronic destructive arthritis, which can involve t cellular immunity. for yet incompletely understood reasons, sjia can be complicated by macrophage activation syndrome (mas), a severe hyperinflammatory condition characterized by a catastrophic cytokine storm resulting in multiple organ failure and high mortality. objectives: the sjia/mas working party (wp) aims to promote knowledge and international multidisciplinary collaboration among experts in the field of mas and sjia and to foster translational research in order to improve the care and outcome of these patients methods: currently 60 pres members participate to the mas/sjia wp. the wp arranges an annual meeting during the pres congress, open to all members activities. the mas/sjia wp core team frequently report about ongoing activities by email. results: several studies are currently ongoing. a project aimed to establish and validate a risk score for mas in sjia patients using routine laboratory parameters of disease activity and severity has already completed the construction phase. recently, building of a validation cohort comprising data form 182 patients from 10 paediatric rheumatologic centers has been accomplished and is awaiting analysis (claudia bracaglia). a second project focused on mas patients with systemic thrombotic microangiopathy (tma) has just completed the collection of 27 patients with mas and tma from 18 centers in 9 countries and results will soon be published (francesca minoia). furthermore, the mas/sjia wp participated in the data collection phase of a project on the development of new criteria for primary hlh (jan-inge henter and annacarin horne introduction: hemophagocytic lymphohistiocytosis (hlh) is an immunological disorder characterized by clinical signs and symptoms of severe uncontrolled inflammation, due to massive release of inflammatory cytokines. a delay in diagnosis is common, and is one of the factors that determine the poor outcome. hlh is classified into primary (phlh) and secondary (shlh). it is important to differentiate between the two as management differs. objectives: to describe the clinical and laboratory profile of hlh in infancy. methods: the electronic case files of children (age<1 year) diagnosed with hlh at the aims, kochi, kerala, between january 2012 and december 2019, was retrospectively reviewed and described. results: eight infants, with age range 1.5 months to 7 months, were clinically diagnosed with hlh. all were immunised and had normal development for age. none had a family history suggestive of hlh. third degree consanguinity was present in parents of patient no.5 and second degree for patient no.7. duration of symptoms before presentation ranged from 2 days to 68 days. duration of follow up with us ranged from 12 days to 192 days, for those who expired. all, eight of them, had fever, anemia, thrombocytopenia, hyperferritinemia, transaminitis, raised ldh and crp. lymphadenopathy was present only in patient no.4. before starting specific treatment patient no. 7 had pseudomonas sepsis, patient no.5 had roseomonas gilardii infection; patient no.3 and 4 were igm cmv positive but their pcr was negative. both of them had received prior blood transfusion. before making a definitive diagnosis of hlh patients were treated for puo, sepsis ? cause and acute liver failure. there was a delay in diagnosis for all patients except patient no.7. all of them were treated with hlh 2004 protocol with modification according to clinical status of the patient. later, broad spectrum antibiotics, antifungals and antivirals were used for all. anakinra was tried for patient no.5. five patients (phlh) succumbed to sepsis and mods and three (one phlh and two shlh) are continuing follow up. hsct was not done in any of them. other clinical features are shown in table 1 . conclusion: making a timely diagnosis of hlh is difficult. differentiating phlh from shlh is very important as the management differs. genetic testing should be done for all infants with hlh. negative genetic study doesn't rule out phlh. the only curative treatment for phlh is hsct. shlh infants, once their primary condition is treated, can have normal survival. hyperbilirubinemia, splenomegaly, neutropenia, hepatomegaly, tissue hemophagocytes and hypertriglyceridemia were more common in phlh. health, kolkata diagnosed as having mas, admitted between july 2008 and april 2020 was tabulated and retrospectively analyzed . objectives: to evaluate the clinical features, laboratory findings and outcomes in pediatric mas, assess the response to different pharmacological therapies, and finally to identify possible factors associated with an unfavourable outcome. methods: the data of patients diagnosed with mas over the study period was analyzed for the clinical and laboratory features, treatment details, response to therapy and outcome. results: 35 patients were diagnosed as having mas. primary illness was sjia in 29 (82%), sle in 5 (14%) and kawasaki disease (kd) in 1(4%). all had fever with varying degrees of multi systemic involvement. hyperferritinemia was universally present. in the absence of anakinra in india, pulse methylprednisolone with cyclosporine was used for treating the majority.10 patients (28.5%) expired. patients on biologics and steroids can present with a silent mas which may be difficult to diagnose. conclusion: mas is a near fatal complication with protean manifestations and multi organ dysfunction. hyperferritinemia is characteristic, higher values being associated with increased mortality. patients resistant to steroids and cyclosporine had a poor prognosis. early recognition with aggresive management forms the backbone of a successful outcome as reflected by improved prognosis over successive years. late presentations with multiorgan dysfunction are associated with the poorest outcomes. methods: case report's description results: a two-year-old boy presented with one month history of fever associated with limping gait, cervical lymphadenopathy and skin rash. laboratory tests showed elevation of inflammatory markers and ferritin. by exclusion criteria, sjia was diagnosed and steroid therapy started. after a soft tissue bacterial infection, fever relapsed and laboratory tests were consistent with mas (day 1): hb 8.5 g/dl, plt 44000/mm3; fdp 1522 ug/l, crp 100 mg/l, ferritin 2200 ug/l. high doses intravenous metilprednisolone and oral cyclosporin a (csa) were started. on day 2 he presented a systemic capillary leak syndrome and acute myocarditis. he was admitted into the pediatric intensive care unit (picu) where intravenous immunoglobulin and subcutaneous anakinra (ana) were added. on day 4, due to an introduction: sjögren's syndrome is a systemic autoimmune disease characterized by dry syndrome and lymphocytic infiltration of the exocrine and extraglandular glands. pulmonary involvement in primary sjögren's syndrome occurs in 9-20% of patients, with very heterogeneous manifestations, and occasionally as an initial mani-festation¹. diffuse interstitial lung involvement is one of the most characteristic pulmonary manifestations and the most frequent subtypes in lung biopsy are interstitial lymphocytic pneumonia and nonspecific interstitial pneumonia². objectives: 14-year-old girl presented to our hospital because of bilateral interstitial involvement with ground glass areas in lower lobes of both lungs on thorax and abdominal ct scan after for kidney stones follow-up. the patient had grade 1 mmrc dyspnoea and dry cough but denied having symptoms of arthralgia or arthritis, photosensitivity, oral and genital ulcers, raynaud's phenomenon or episodes of dry mucosa. she had no history of autoimmune disease nor family antecedents of any autoimmune disease. a physical examination disclosed no finger clubbing or swollen superficial lymph nodes but indicated crackles on pulmonary auscultation. laboratory work showed elevated acute phase reactants, positive rheumatoid factor, positive antinuclear antibodies (1/ 40), positive cytoplasmic antineutrophil antibodies (1/320) and igg and iga hypergammaglobulinemia. an examination for autoantibodies were negative for anti-ss-a, anti-ss-b, anti jo-1, anticentromere and anti-scl-70 antibodies. iontophoresis with pilocarpine and 6-minute walk test was also normal. pulmonary function tests demonstrated a mild restrictive impairment and a reduced percent diffusion capacity for carbon monoxide of 55%. fibreoptic bronchoscopy showed acute inflammation in bronchial mucosa. flow cytometry of bronchoalveolar lavage and cytology showed lymphocytosis with a 15% of cd4 and 85% of cd8 lymphocytes in bronchoalveolar lavage fluid. finally, a transbronchial lung biopsy lead to a definitive diagnosis, showing mixed interstitial inflammation and lymphocytic follicular hyperplasia with formation of germinal centers, suggestive of a lymphoid interstitial pneumonia of unreleased autoimmune etiology. throughout time, the patient reported progression of her symptoms with increasing dyspnoea, persistent dry cough, xerostomia and arthralgia. schirmer and rose bengal dye test were negative, and a salivary gland biopsy showed interstitial plasmacytosis and no igg4 plasma cells expression which suggested sjogren's disease. a high resolution computerized axial tomography was requested, suggesting organizing pneumonia in the context of sjogren's disease. methods: several studies indicate that lung involvement in sjögren is more frequent in advanced stages of the disease and rarely as an initial manifestation. sjögren's syndrome in paediatric age is rare and the subtype of secondary sjogren's is the most common. the course is longer, and the symptoms are more heterogeneous than in adulthood 5 . the diagnosis in children is delayed, because children less frequently report dryness and frequently present with extraglandular clinical features suggestive of other autoimmune diseases. a systematic review on primary sjögren's syndrome in male and paediatric population reported a 2.4% of pulmonary involvement in paediatric patients. 6 pulmonary involvement is associated with an increase in the mortality of patients with sjögren's, therefore, it is essential to periodically monitor patients with respiratory symptoms, making an early diagnosis and treatment of the disease. results: -conclusion: we present a case of a patient with childhood sjögren's disease with atypical onset of disease with lung involvement. introduction: sarcoidosis is a multi-system disorder. little is known about its pathogenesis. in children, the early onset sarcoidosis phenotype including blau syndrome is more often seen. 1, 2 the diagnosis of sarcoidosis is confirmed by demonstrating a typical non-caseating granuloma on a biopsy specimen. other granulomatous diseases should be excluded, in particular mycobacterial infections, crohn's disease and immunodeficiencies. the clinical presentation may vary depending on the organs involved and the age of the patient. 3, 4 objectives: we are reporting the case of a boy with a presentation of bone sarcoidosis at a young age. this is a rare phenotype in children. methods: clinical details were retrospectively collated using routine clinical records. confirmation of diagnosis was confirmed with bone biopsy. results: a 5 year old non-identical twin boy of ghanaian descent born in the uk had a slowly growing, painless frontal bone mass which started to develop from 7 months of age. he was developmentally normal, with no history of fever, rashes or joint pains. examination findings revealed frontal bossing while the remainder of the musculoskeletal examination was normal. there was no evidence of rashes, hepatosplenomegaly and ocular examination was normal. the patient was initially referred for neurosurgical review with suspected fibrous dysplasia, after an initial mri scan of the head revealed abnormal marrow signal and expansion of the frontal bone, with no soft tissue swelling. however, the ct scan of the calvarium was not suggestive of fibrous dysplasia. consequently, bone biopsy was performed demonstrating inflammation with granuloma formation. he was referred to infectious diseases and rheumatology. there was no travel history and no tb contact. quantiferon tb was negative. infectious work-up was negative especially for mycobacterial infections. rheumatology work-up identified on skeletal survey another bone location: a well-defined lytic lesion in the right distal fibula that was biopsied. infection cultures and pcr were negative. histopathology identified fibrous tissue and poorly formed granulomas. laboratory investigations revealed a mild microcytic anaemia with iron deficiency and eosinophilia. he had normal serum calcium and vitamin d and his esr was 25 mm/hr. ana, anca and rheumatoid factor were negative, and complement c3 and c4 were normal. his serum angiotensin converting enzyme (ace) level was raised at 125 nmol/ ml/min (normal <40 nmol/ml/min). investigations revealed mild renal impairment with normal urinary tests including normal calcium, protein and tubular proteins. ultrasound of the kidneys was normal. chest x-ray was normal. lung function was performed and was normal. dlco couldn't be performed due to low lung volume. vascular and inflammation genetic panel identified a variant in the nemo gene. functional studies excluded nemo deficiency and patient did not display any of the clinical features. however, a pattern of dysregulated t cells response was identified. he was treated with oral steroids and methotrexate. the oral steroids were successfully weaned off. he has been successfully treated with methotrexate 10mg s/c to initially stabilise disease with no bone growth, and had no significant side effects. repeat mri 2 years later showed increased burden of disease with other newly affected sites however, including the right femoral diaphysis and signal changes in the left tibial metaphysis. based on the mri and increasing musculoskeletal pain, decision was made to escalate to anti-tnf (adalimumab) with good clinical response. conclusion: bone sarcoidoisis is rare in children but this should be considered in the differential diagnoses when granulomatous inflammation is identified on histopathology. response to steroids and methotrexate is usually good but some patients will need escalation to anti-tnf. the most worrisome non-rheumatic condition causing persistent night pain in children which closely mimics arthritis is malignancy 1, 4 . it is vital to pick up subtle clues at an early stage especially in absence of hematological manifestations , organomegaly and lymphadenopathy. to reveal early clinical clues in pediatric patients with predominant musculoskeletal (msk) night pains who were initially diagnosed as suffering from some form of chronic arthritis but ultimately turned out to be affected by malignancy. methods i gathered a data of five pediatric patients fulfilling above mentioned criteria who were seen at dev children's hospital between january 2019 and march 2020. it included demographics, clinical presentation and laboratory results. all above cases reemphasize the need for an extremely detailed history pertaining to characteristics of pain & pattern recognition in pediatric rheumatology. prolonged fever , persistent msk night pain, persistent limp, upper limb and hip joint involvement which is unlikely for jia at onset are proven to be the earliest subtle clues which should not be missed. 1 other constitutional symptoms, respiratory, cardiovascular, ophthalmologic or osteoarticular involvement were absent. growth was unaffected. auditory tests were normal. systemic antibiotic treatment and local steroids were ineffective. laboratory findings were unremarkable, with only mild elevation of esr (28mm/1 st hr). ana and anca were absent in repeat meausrements (3 months intervals). cardiovascular disease was excluded. abdominal us was normal. on the basis of relapsing bilateral auricular chondritis and confirmatory histological findings revealing inflamed cartilage from the pinna of the ear with chondrocyte degeneration, perichondrial infiltrates of lymphocytes, plasma and polymorphonuclear cells and replacement of cartilage with fibrous tissue perivascular infiltrates of polymorphonuclear cells and lymphocytes, relapsing polychondritis was diagnosed. one month nsaids trial, pending histology results was ineffective. methotrexate sc and steroids 1mg/kg/d gradually tapered over a 3-month period were given with significant improvement of auricular inflammation and normalization of markers of inflammation. auricular chondritis worsened after steroid withdrawal and adalimumab was added to treatment with significant improvement of auricular inflammation in 2 months. in the following 8 months auricular chondritis relapsed during uris with mild elevation of esr (25mm 1st hr) and crp (13 mg/l). after 15 months of treatment, in an effort to prolong the intervals of adalimumab administration, bilateral auricular chondritis relapsed. after 24 months of mtx and 21 months of adalimumab administration inflammation was put in complete remission. the following year no flares or involvement of other systems were observed, under methotrexate and adalimumab treatment. conclusion: in this patient isolated auricular relapsing polychondritis was unresponsive to nsaids. steroids and methotrexate greatly improved inflammation but did not induce complete remission. complete remission was achieved by addition of adalimumab to methotrexate treatment, which also allowed for steroids discontinuation. none declared first ever single center study revealing spectrum of rheumatic diseases in 114 children from an indian state of gujarat d. b. pandya, on behalf of dr mehul mitra, pankaj buch, sonal shah, there is very limited information and awareness about pediatric rheumatic and immunodeficiency diseases amongst primary physicians 1, 2, 3 in gujarat and to make this matter even worse, we are not having a single exclusive pediatric rheumatology and immunology centre for a population of around 60 million. to guesstimate a status of children with rheumatic and immunodeficiency diseases in gujarat and spectrum of these diseases at dev children's hospital. methods i gathered a retrospective data of 174 patients who attended dev children's hospital between january 2019 and january 2020. out of these, 114 children with confirmed diagnosis of inflammatory rheumatic diseases and suspected primary immunodeficiencies were included. patients with non-inflammatory musculoskeletal(msk) pains and non-rheumatic diseases causing msk pains were excluded. my collected data included referral details, demographics, clinical presentation, laboratory results and diagnosis. majority of the cases were referred by pediatricians, orthopedicians, hemato-oncologist and general physicians. main reasons for referral were joint involvement , undiagnosed fever , multisystem disease and elevated inflammatory markers. many physicians had put a diagnosis like rheumatoid/rheumatic arthritis, autoimmune disease or connective tissue disease. almost 80% of patients had been evaluated with rf, aso titer, ana and joint imaging irrespective of clinical pattern by their primary physicians before referral. fever , msk involvement, extreme fatigue, constitutional symptoms, skin and mucosal involvement were prominent complaints noted by me. family history of rheumatic, primary immunodeficiency (pid) or consanguinity was found in 1/3 of patients. anemia of chronic disease, elevated esr and thrombocytosis were almost universal laboratory findings in our cohort. rheumatic diseases in children are not anymore rare but due to lack of expertise and awareness , these children are not getting diagnosed. many cases were advised unnecessary rheumatological investigations even before referral. results: a 10-year-old female patient was referred to the rheumatology clinic at our hospital with a previous history of fever of 39°c (102.2ºc), loss of appetite, and acute polyarthritis of wrist, knees, and ankles. at that time, laboratory exams revealed a hemoglobin of 11.1 g/dl, c reactive protein 78.6 mg/l, and antistreptolysin o titers of 400 ui/ml (normal range <200ui/ml. clinical symptoms were relieved only after using nsaids. after 6 months, the patient returned to our hospital with a 7-month history of weight loss and claudication related to pain and daily morning stiffness (15 minutes) on her right ankle. new laboratory findings demonstrated positive antinuclear antibodies 1:320, negative rheumatoid factor, and alpha-1-acid glycoprotein of 171 mg/dl (normal range: 44-113mg/dl). clinical signs suggestive of chronic arthritis with exuberant swelling of the ankles were observed on physical examination (figure a). she was screened for tuberculosis (tb) and had a positive (18mm) tuberculin skin test (figure b). chest ct revealed infiltrative soft tissue mass in the posterior mediastinum, with homogeneous contrast enhancement (figure c). magnetic resonance imaging of both ankles was performed and demonstrated bilateral and symmetrical tibiotalar arthritis and prominent tenosynovitis of extensors, flexors, and fibularis tendons (figure d). right ankle synovial biopsy revealed no granulomas and joint fluid culture was negative for mycobacterium tuberculosis, confirming reactive arthritis (poncet's) and tenosynovitis, that may follow mycobacterial infection with no infective agent in the joints. conclusion: to our knowledge, there is no report of poncet's disease associated with inflammatory tenosynovitis, showing the particularity of this case. the patient's symptoms resolved after two months of anti-tb therapy. introduction: cacp is characterized by congenital or early-onset camptodactyly (usually bilateral); non-inflammatory arthropathy (more frequently in the wrists, knees, ankles, elbows, and hips); coxa vara (reduction of the angle between the neck and shaft of the femur); and non-inflammatory pericardial effusion (a late manifestation, less frequently reported). recognizing the radiological aspects of this syndrome and differentiating it from jia is crucial since cacp has no effective treatment and jia is usually treated with nsaids and methotrexate (2, 3) . objectives: to report a rare case of cacp syndrome mimicking jia. methods: case report and literature review. results: a 5-year-old male patient presented with arthropathy characterized by painless progressive swelling and restricted movement of the hands, hips, knees, and ankles since the first year of life. he had a family history of camptodactyly from his paternal grandfather. on physical examination, symmetric camptodactyly of the hands and feet was observed (a). he had no history of rash or weight loss and inflammatory markers were unremarkable. the echocardiogram was normal. the pelvic radiograph showed a widening of the joint space and bilateral coxa vara. magnetic resonance imaging (mri) of the hips (b) and knees (c) was performed and depicted large joint effusions (arrows, b and c) with normal synovial thickness and mild synovial enhancement in all joints, without bone marrow edema-like signal. a synovial biopsy of the knee was performed and revealed mild synovial hyperplasia without inflammatory cells. the patient was diagnosed with camptodactyly-arthropathy-coxa vara-pericarditis syndrome (cacp -omim 208250), a recently described genetic disorder with no gender predominance identified to date (1). conclusion: an important differential diagnosis of cacp is juvenile idiopathic arthritis (jia), a painful inflammatory chronic arthritis that can cause not only joint effusions due to synovial inflammation, but arthritis was the most frequent extraglandular manifestation. renal tubular acidosis represented the typical expression of renal involvement (19 cases). neuromyelitis optica and aseptic meningoencephalitis (6 and 9 cases, respectively) were the most typical neurologic manifestations. two cases of interstitial lung disease and one of pulmonary hypertension were reported. almost all patients had autoantibodies, mostly ana (200/224 patients) and anti-ssa/ro (170/208 patients). the schirmer test was performed in less than half of the patients, of whom 62% tested positive. a positive result of minor salivary biopsy was reported in 129/140 cases with available data. juvenile idiopathic arthritis was the most frequently associated disease, followed by systemic lupus erythematosus (16 and 8 cases, respectively). no significant differences between patients with or without parotitis were found except that patients with parotitis showed increased levels of crp more frequently than those without it (p= 0.00). patients with anti-ssa/ro had more frequently a positive schirmer test (p= 0.04). the presence of rf was significantly associated with dry mouth (p= 0.00), arthritis (p= 0.00), and rash (p= 0.04). a positive minor salivary biopsy was more common in children with dry eyes than in those without this clinical feature (p= 0.02). arthritis was more frequent in patients with other diseases than in those with primary ss (p= 0.00). we further investigated ss features according to the age groups (≤ 6 years, 7-11 years, ≥ 12 years). parotid involvement was inversely proportional to the age and occurred more frequently in younger patients (79% of those ≤ 6 years; p= 0.03). interestingly, the rate of anti-ssa/ro positivity increased with age (97% of those ≥ 12 years; p= 0.00). conclusion: even though parotitis was the most frequently reported feature, a wide range of clinical manifestations in children with ss has been reported so far. a better knowledge of css features will help to pave the way for the development of css specific diagnostic criteria. none declared introduction: pachydermodactyly (pdd) is a rare benign fibromatosis, characterized by progressive painless swelling of soft tissue of proximal interphalangeal (pip) joints without inflammation signs. generally pdd affects pip joints of the fingers, rarely of the thumb. the involvement is typically symmetrical, in few cases unilateral. it usually occurs more frequently in young males. etiology is unknown, but it arises from mechanical stimulation of periarticular skin (i.e repetitive rubbing, interlacing, and cracking of fingers). pdd has to be considered in the differential diagnosis of arthritis (i.e. juvenile idiopathic arthritis, jia) and many syndromes (i.e. progressive pseudorheumatoid dysplasia). prognosis is good with cessation of mechanical stimulation 1 the recurrent paroxysmal appearance of inflammatory lumps (local erythematous tender swellings, which partially respond to antiinflammatory agents), accompanied by elevated inflammatory markers during flares, suggest that fop may be an autoinflammatory disease. the episodic formation of bone, often following a trivial injury, suggests that innate immune-related triggers induce tissue transformation through the bmp pathway. moreover, interleukin-1β (il-1β), a well-known mediator of the innate immune system, has been linked to ho and mineralization in mesenchymal stem cell cultures derived from human bone marrow. we hypothesized that treating fop patients with anti-il-1 agents could help ameliorate the progression of this devastating disease. we report our experience treating two fop patients with anakinra and canakinumab. objectives: to decrease the frequency of fop paroxysms, and/or limit the symptoms and extent of residual lesions, by using anti-il-1 agents. methods: patients' data and blood il-1 levels were analyzed to characterize the efficacy of anti-il-1 treatments in ameliorating the natural progression of fop. results: a 13.5 year old boy and a 5 year old girl were diagnosed with fop, both clinically and genetically (the typical r206h mutation was found). various treatments, including high-dose corticosteroids, pamidronate infusions, celecoxib, monteleukast and sirolimus, did not change the course of the disease. both patients are receiving canakinumab (the male patient was initially treated with anakinra). the male patient has been treated for over 2 years. flare rate was markedly reduced from one new lump every 8 days to approximately one every 25 days ( figure 1 ). the lumps involved in almost all of these flares are the same: at the left scapular base and within the sternocleidomastoid muscle. the female patient has been treated for a year, and has not experienced any ho flares during canakinumab treatment. temporarily withholding canakinumab in both patients, led to serious flares 8 weeks after the last dose. notably, while undetectable levels of il-1β (<0.125 pg/ml) were found in the three plasma samples obtained from the male patient during treatment with anakinra or canakinumab, high levels (up to 21.52 pg/ml, about 90-fold higher compared to average levels measured in healthy controls) were found in his plasma samples collected during the flare ( figure 2 ). in contrast, il-18 and il-6 plasma levels, measured before, during and after withholding treatment, were comparable or slightly higher than those observed in healthy controls ( figure 3a , b). conclusion: we report here, for the first time, that anti-il-1 agents were found efficacious in treating two fop patients. we also found markedly increased il-1β levels during flares, which normalized following the treatment. we suggest a role for il-1β in the pathogenesis of this disease. although it is too soon to conclude whether fop may be included under the umbrella of auto-inflammatory syndromes, anti-il-1 agents can be effective in ameliorating the natural progression of fop. introduction: musculoskeletal symptoms are one of the common reasons for applying to rheumatology departments in general practice 1 . although inflammatory causes are generally considered in the foreground, it is known that non-inflammatory causes including genetic diseases may also be responsible. the absence of signs of inflammation (morning stiffness, redness, tenderness) and normal inflammatory markers in laboratory findings may support nonrheumatologic diseases 2 . objectives: to present genetic disorders that can mimic rheumatologic symptoms and to answer when genetic diseases should be considered in the differential diagnosis in patients presenting with rheumatological complaints. methods: we retrospectively evaluated 60 patients who applied to hacettepe university pediatric rheumatology department with musculoskeletal compliants between january 2015 and december 2019 and had been consulted to genetics departmant. the rate and degree of consanguinity, clinical diagnosis, indication for consultation, accompanying musculoskeletal and other findings had been recorded. the diagnosis of genetic diseases were based on physical examination, radiological evaluations and genetic analysis. results: a total of 60 patients, 19 boys (31.6%), with a mean age 12.46 ± 1.41 years were included in the study. the rate of consanguinity was 25.0%. the most frequent referral to the genetic department was the presence of skeletal anomalies (n:12) such as camptodactyly, clinodactyly, and bone shortness accompanying joint findings. other causes include short stature (n:4), joint deformity (n:5), joint hyperlaxicity (n:10), dysmorphic findings such as atypic facial appearance (n:9), accompanying diseases that may be part of a syndrome (n:11), genetic diagnosis suspicion according to the results of radiological examination (n:4) and joint findings without clinical and laboratory signs of inflammation (n:5). distribution of joint involvement in 20 patients with genetic disease were hands, knees, and hips respectively. in the laboratory evaluation of patients presenting with joint swelling and arthralgia, acute phase reactants (erythrocyte sedimentation rate and c-reactive protein concentrations) were within normal reference values. one third of the patients (33.3%) had a final diagnosis of a genetic disease. the diagnoses of these patients were as follows; cacp (camptodactyly, arthropathy, coxa vara deformity and pericarditis) syndrome (n:3), trichorhinophalangeal syndrome (n:1), progressive pseudoromatoid dysplasia (n:2), lig4 syndrome (n:1), 3m syndrome (n:1), h syndrome (n:1), spencd (spondyloenchondrodysplasia, n:3), and nonspecific connective tissue disease (n:8). conclusion: genetic syndromes with musculoskeletal findings are often unrecognized and misdiagnosed as rheumatologic diseases leading to unnecessary procedures and treatments. summarizing the genetic diagnosis spectrum that can be detected in these patients will increase the awareness of physicians. results: according to the results of observation, the disease was more common in the age group of 7-11 years (65%), to a lesser extent among children in the group of 12-15 years (35%), less often in the group of 3-7 years (5%). when examining infectious agents, zoonotic infection was detected in 41% (listeria monozytogenes, yersinia enterocolitica). clinical course of nodular erythema in this group was characterized by an expressed activity of the inflammatory process with multiple elements in the lower and upper extremities, joint syndrome, increased esr to 45± 3.8 mm per hour, crp 28± 2.5 mg\l. the disease was preceded by an episode of acute infection with an increase in body temperature, intoxication, in some cases with short-term intestinal syndrome, pharyngitis. the rashes were persistent and recurrent, with a slow regression of laboratory activity. streptococcal etiology of nodular erythema was detected in 37% of cases. there was an increase in esr to 25±3.8 mm per hour, crp 15± 2.7 mg/l, a significant increase in antistreptolysin on average 480± 34% iu / ml. with an increase in individual cases to 870 iu/ml. in 13% of cases, erythema nodosum developed after an intestinal infection. among the pathogens were identified sh. disenteria, e. coli, yersinia enterocolitica, enterovirus. the disease was characterized by moderate activity, a good response to etiological therapy and a short course of nsaids . an interesting fact was the development of nodular erythema in 4% of cases caused by the epstein-barr virus in groups of children from 3 to 7 years and 7-9 years. they had clinic picture with normothermia, no symptoms of intoxication, periodically occurring elements of nodular erythema on the shins, no blood changes. therapy aimed at eliminating the virus gave a positive result and did not require specific anti-rheumatic therapy. in 5% of cases, the etiology of nodular erythema was not defined. the clinical course of nodular erythema in children depends on the infectious agent that was the trigger of the pathological process. the higher activity and duration of the disease is caused by zoonotic infection, which requires more active antiinflammatory therapy with corticosteroids, which may be associated with the activation of autoimmunity. this group of children was taken for further observation as a group at risk of developing systemic connective tissue disease. changes in the etiological structure of nodular erythema and treatment tactics require further study. introduction: sjögren syndrome (ss) is a chronic autoimmune disorder characterized by inflammation of the lacrimal and salivary glands leading to oral and ocular dryness. childhood ss is rare and poorly defined and underdiagnosed owing to the lack of childspecific diagnostic or classification criteria. objectives: the purpose of this study is to describe 12 cases with pediatric ss in order to better clarify the characteristics of the disease in the pediatric age. methods: we retrospectively reviewed medical records of patients (pts) with pediatric ss referring to three italian pediatric rheumatology centers. due to lack of childhood validated ss-specific criteria, physician diagnosis was the only inclusion criteria. results: we collected data on 12 pts (9 females). the mean age of disease onset is 10.0 yrs (median 10.2, range 4-17). the mean age of diagnosis is 11.83 (median 11.45, range 6-18). the follow up period varied from 0.1 to 9.3 yrs (mean 3.95, median 5.0). the most common manifestations were articular involvement (mainly with arthralgia) (9/12 pts) and parotid/salivary glands swelling (8/12 pts). xerostomia and xerophthalmia were found in 6/12 pts and in 4/12 respectively. vaginal dryness was reported only by one pt. fever and fatigue occurred in 3/12 and 7/12 pts respectively. we also recorded 3 cases of circulating immune complexes manifestations in 3 pts, purpura (n=2) and glomerulonephritis (n=1). we observed an endocrine involvement in 3 pts (1 metabolic syndrome, 2 autoimmune thyroiditis). abdominal pain was found in 4/12 pts. all pts were positive for autoantibodies (positivity for ana or anti-ssa or anti-ssb or fr) at presentation. rf test results were available in 8 pts, all positive. positive ana (titer>1/320) and anti-ssa were present in 10/12 pts and in 9/12 respectively. hypergammaglobulinemia (range 1,6-8.04 g/dl) was found in 8/11 pts (1 na). abnormal schirmer test was observed in the half of cases (6/12). minor salivary gland biopsy was performed in 10 pts resulting in histological evidence of focal lymphocytic sialadenitis in 9/10. sonographic evaluation of salivary glands was abnormal in all of the patients (10/10). with regard to treatment, 6/12 pts received corticosteroids and eight were also treated with one or more dmards such a hydroxychloroquine (n=8), methotrexate (n=3), azathioprine (n=1), leflunomide (n=1). biological therapy was used in 3 patients for systemic involvement: 1 received belimumab and then rituximab, while the other patients received rituximab. conclusion: xerostomia and keratoconjunctivitis sicca were not common in our series while recurrent parotid swellings were more frequent than what reported in adults. pediatric recurrent parotitis should increase the suspicion for sjögren syndrome. current diagnostic criteria for ss do not include parotitis and therefore, the incidence of ss may be under-recognized in childhood. the disease is not always benign and patients with severe course may need second line treatment including immunosuppressant and biologics. introduction: improving our understanding of pediatric rheumatological (pr) patient population is crucial for pediatric rheumatologists to know rheumatic disease epidemiology and to raise awareness leading to early detection. we didn't find studies of pr disorders presenting in the first year of life. objectives: the aim of this study is to assess the prevalence of pr disorders with onset in the first year of life. methods: we retrospectively studied patients observed in our pediatric rheumatology unit between january 1 st of 1987 and december 31 st of 2019. we defined acute (<2 weeks), subacute (≥2 and <6 weeks) and chronic (≥6 weeks). results: a total of 3751 patients were observed in 32 years. diseases' onset occurred in the first decade of life in 2290 patients (61%) and in the first year of life in 158 (4,2%). among the latest group, chronic inflammation was the most frequent group of diagnosis (30%), followed by recurrent inflammation (23%), acute inflammation (11%), infection (9%), infiltrative/ degenerative disorders (8%) and subacute inflammation (3%). the remaining patients (16%) were diagnosed with other disorders classified as miscellaneous. among chronic inflammation group, 14 patients were diagnosed with juvenile idiopathic arthritis (4 systemic); 14 had neonatal lupus and one patient had polyarteritis nodosa. among recurrent inflammation group, 13 patients were later diagnosed with pfapa (periodic fever, aphthous stomatitis, pharyngitis and adenitis), 8 were diagnosed with behçet disease and 6 had an autoinflammatory disorder. acute vasculitis was diagnosed in 13 patients (9 kawasaki disease and 4 acute hemorrhagic edema of infancy). among infectious diseases group, there were two cases of congenital syphilis with arthritis and two cases of osteomyelitis secondary to bcg vaccination. conclusion: rheumatological diseases presenting in the first year of life are not exceptional. although many patients didn't have a definitive diagnosis at the beginning of the symptoms, many of them were later diagnosed with rheumatic disorders, mostly chronic inflammation (30%), which requires early diagnosis, specific treatment and long-term follow-up. rheumatic diseases must be considered as differential diagnosis in the first year of life in order to avoid delayed intervention and long term disabilities and sequelae. (1), on the other side measles-induced mas has rarely been reported (2). objectives: we present the case of a child known to have sjia in remission, who presented a measles primary infection and a secondary kd complicated by mas. methods: a 5 years old girl, not fully vaccinated and known to have sjia in remission under methotrexate, presented for frequent high grade fever of 3 days duration associated with flat flash red spots on the face and trunk as well as the palms and soles. a koplik's spot was identified. conjunctivitis and coryza were also present. initial viral serology, including measles, returned negative. fever persisted and on day 7, edema of both hands and feet appeared with bilateral cervical adenopathy, erythematous tonsils, gingivitis, cracked lips and hepatomegaly was noted. all cultures were negative and chest x-ray was normal. inflammatory markers rose up. viral serology was repeated and measles igm came back positive. cardiac ultrasound ruled out coronary aneurism and the ophthalmic exam showed no uveitis. kd criteria were met and 2g/kg of intravenous immunoglobulins (ivig) were administered. after 48 hours of clinical improvement, fever reappeared and the patient returned to be ill looking although the rash regressed. we noted high ferritine(2016 ng/ml) together with low c3, decrease in platelets(170 x10 3 /ml) and elevation of hepatic enzymes, ldh and cpk, without increase in the inflammatory biomarkers. mas was suspected and a bone marrow aspirate showed the presence of mild macrophage hemophagocytosis. antibodies for lupus and auto-immune myositis were all negative. steroids were given, fever disappeared, and spectacular clinical and biological improvements were objected. 2 weeks later, desquamation of all extremities was noted. sars-cov-2 was not investigated because historically this case presented 1 year earlier than the pandemic. results: we hereby report, for the first time, kd and mas triggered by measles infection in a child with sjia in remission. the exact mechanism involved in kd-induced mas and measles-induced mas has not yet been defined but a defective immune response is suspected (3). conclusion: significant similarities and overlap between measles, kd, sjia and mas make an early diagnosis very challenging (1)(3). the recent covid19 pandemic emphasizes how a viral illness can be responsible of kd and sometimes degenerating in mas. we report this clinical case as an example of a systemic inflammatory syndrome (sis) taking place after a viral infection to measles. in the era of covid19 pandemic and secondary sis in children, an additional challenge is present in regions lacking measles vaccine coverage. none declared the musculoskeletal manifestations of scurvy: a diagnostic challenge for the rheumatologist p2 was a 5-year-old boy, with autism spectrum disorder, malnutrition and severe food selectivity, admitted to our unit for refusal to bear weight and bruises in lower limbs. the auxological evaluation showed a strongly dystrophic aspect. coagulation profile and main organ function markers were normal. at nutritional biochemical parameters evaluation, iron and vitamin c deficiencies were detected (vitamin c: 2 μmol/l). oral vitamin c therapy was started, with prompt clinical response. p3 was a 7-year-old boy with autism spectrum disorder, admitted to our unit for lameness and difficulty in walking for a month. at clinical examination, a mottled skin at lower limbs was noted. joint examination was normal. auxological parameters and main blood tests were adequate for age. given the presence of food selectivity, he underwent serum vitamin c dosage (11 μmol/l); hence he started oral vitamin c therapy, with rapid clinical improvement. p4 was a 2 years old boy who was referred for coxalgia and fever. at clinical examination, pale skin, gingival hyperemia, and pain in mobilization of the left hip were present. microcytic anemia was detected, but main organ and inflammatory markers were normal. no evidence of infection was present. x-ray of femur and knee showed morpho-structural alteration of the distal metaphysis bilaterally. a low intake of fruit and vegetables was reported; hence, dosage of vitamin c was performed, resulting reduced (2.5 μmol/l). he started vitamin c oral therapy with clinical response. p5 was a 13-year-old girl with behavioral disorder and intellectual disability, admitted for fever and right knee swelling which appeared two days after a right leg burning. c-reactive protein and esr were elevated and ultrasound exam confirmed intra-articular knee effusion. suspecting a septic arthritis, antibiotic therapy was started with laboratory normalization and partial clinical improvement. considering the persistence of knee swelling after nine days of intravenous antibiotic therapy, the presence of gingival hyperemia and history of food selectivity, vitamin c dosage was practiced (12 μmol/l). oral vitamin c was administered with complete clinical resolution. conclusion: although scurvy is considered a disease of the past, it still occurs nowadays. food selectivity associated to autism is a major risk factor for vitamin c deficiency in childhood. rheumatologists should take into account the diagnosis of scurvy in the diagnostic approach of musculoskeletal disorders in children, especially when development disorders are present. 15.4%), juvenile dermatomyositis (n=1), sarcoidosis (n=1), granulomatous polyangiitis (gpa) (n=1), sting-associated vasculopathy with onset in infancy (savi) (n=1), and oligoarticular jia (n=1). respiratory symptoms were present in 6 (46.2%) patients at the time of primary diagnosis. in other patients, the time period between the diagnosis of the rheumatic disease and the onset of the respiratory symptoms ranged from 1 to 12 years. cough, the most common symptom, was present in 10 (76.9%) patients. six patients manifested with cough and sputum. six (46.2%) patients had shortness of breath and one patient had hemoptysis. on the physical examination of one patient, rales and clubbing were detected. high resonance computerized tomography (hrct) was performed in all patients. hrct findings were as follows; lymphadenopathy in 8 patients (61.5%), ground glass appearance in 10 patients (76.9%), consolidation in one patient, pleural effusion in one patient, pulmonary nodule in 4 patients (30.8%), fibrosis in one patient, cystic lesions in 3 patients (23.1%), septal thickening in 5 patients (38.5%), bronchiectasis in one patient, and reverse halo sign in one patient. in echocardiographic examination, only one patient had pulmonary hypertension. three patients underwent open lung biopsy, and diagnosis was made with pathological examination of the lung tissue. of these three patients, two (15.4%) had lymphocytic interstitial pneumonia (lip), and one patient had chronic inflammation and focal fibrosis. infectious lung disease was not detected in any patient. ten patients (76.9%) had interstitial lung disease associated with rheumatic disease, one patient had pulmonary hemorrhage, one patient had pulmonary involvement of gpa, one patient had pulmonary involvement of sarcoidosis. there was no statistically significant difference between the first and last spirometry and dlco values during the follow-up period. mortality was 7.5% (1/ 13) in this cohort. active disease was significantly associated with abnormal tc, hdl, and tg levels (p=0.04*), (p=0.03*) and (p=0.04*) respectively. multivariate analysis of the factors affecting abnormal cholesterol level revealed that sle is a significant predictor of abnormal cholesterol level . presence of jsle increase risk of abnormal cholesterol 9 times more than cases without jsle. the overall percent predicted was 80%. active disease is a significant risk factor for abnormal tg with increased risk of abnormal tg by 3.2 among cases with active disease than cases with inactive disease. the overall percent predicted was 75.6%. conclusion: children with rheumatic diseases showed significant lipid profile abnormalities. abnormal tc, hdl and tg are significantly associated with active disease. presence of jsle increase risk of abnormal cholesterol. active disease is a significant risk factor for abnormal tg. therefore, lipid levels should be monitored regularly and managed in patients with paediatric rheumatic diseases to minimize the longterm risk of cvd. methods: non-experimental, cross-sectional and descriptive study. a confidential survey was conducted online, aimed at residents and attendings who deal with musculoskeletal pain. were addressed with the definitions of arthralgia, arthritis, myalgia, allodynia and hyperesthesia (between five to seven options) with only one correct answer. correct definitions: arthralgia (pain localized to the joint or periarticular structures, as a only manifestation); arthritis (criterion one or criterion two: 1 -joint swelling or intra-articular effusion / 2 -limitation of joint mobilization associated with at least one of the following: a) pain b) tenderness c) swelling d) heat); myialgia (pain with muscular origin or referred to muscle, regardless of its etiology); allodynia (pain resulting from usually non-painful stimulus); hyperesthesia (coexistence of allodynia plus hyperalgesia -exaggerated responses to tactile and thermal nociceptive and nonnociceptive stimuli the association of pure red cell aplasia (prca) with thymoma led to the discovery of the autoimmune mechanisms involved in the pathogenesis of this rare disease. till date many adult case reports have revealed a strong link between prca and autoimmune diseases, endocrine disorders, rheumatic diseases, autoinflammation and immune dysregulation. [1] [2] [3] [4] [5] objectives to stimulate a search for the genetic and immunological roots for a 2.5 years old girl with syndromic face, pure red cell aplasia, type 1 diabetes and polyarthritis. methods this is a story of a 2.5 years old girl with pure red cell aplasia, type 1 diabetes and polyarthritis. she was normal till 7 months of age. at the age of 8 months, she was diagnosed with type 1 diabetes. she was evaluated by her paediatrician in view of generalized hypotonia, deformed pinna, low set ears, midfacial hypoplasia, blue sclera, umbilical hernia and retracted eyelids. she had multiple episodes of seizures during next few months. to me, she was presented with one year history of polyarthritis with severe pallor requiring frequent blood transfusions. family history was inconclusive. musculoskeletal examination showed polyarthritis involving right knee, bilateral ankles, fingers and toes. further examination revealed haemolytic facies and hepatosplenomegaly. i was not able to make out any facial dysmorphism mentioned earlier by her paediatrician. results: table 1 conclusion early age of onset, pure red cell aplasia, autoimmune and endocrine manifestations with some doubtful facial dysmorphism inspired me to suspect some known or unknown immune dysregulation syndrome in this child. genetic analysis would be the best possible option in this scenario if financial condition permits. introduction: galactosialidosis (gs) is a rare inherited lysosomal storage disorder (lsd) which is characterized by a defect in the lysosomal glycoprotein catabolism. here we report, for the first time, a case of a child affected by gs who presented with recurrent episodes of extensive joint inflammation in both knees. knowledge on gs related inflammatory joint pathology is lacking, which hampers evaluation of possible mechanisms that could give an explanation for the significant arthritic joint abnormalities as observed in our patient. objectives: the aim of this study is to describe the clinical presentation as well as the laboratory, radiologic and microscopic features of this extremely rare presentation of gs. furthermore, we conduct a literature review on lsd's complicated by arthritis in order to evaluate potential mechanisms that could explain the extensive inflammatory joint swelling observed in our patient. methods: in this study we present a 12-year-old turkish boy who was diagnosed with gs (late infantile form) at 17 months of age. from the age of 8 years, the boy presented with episodes of inflammatory joint pathology of the knee. informed consent was obtained. alongside the case report, a literature review using medline was conducted. an extensive list of known lsd's was combined with the terms: "arthritis", "joint inflammation", "synovitis" and "synovial inflammation". cases in which joint inflammation was based on a probable cause other than the underlying lsd were excluded. results: in the present case, owing to comprehensive examinations (i.e. laboratory tests, imaging and microscopic examination) multiple possible causes for the recurrent inflammatory joint pathology could be rejected (i.e. no signs of infectious arthritis, reactive arthritis, osteoarthritis, arthritis secondary to a malignancy or crystal induced arthritis). a diagnosis which could explain the clinical picture is the jia subtype: ana negative oligo-articular jia. however, microscopic examination showed numerous foamy macrophages with extensive vacuolization in the synovial tissue of the inflamed joint, which is not associated with jia. given the evidence of storage products within the macrophages of the inflamed synovial tissue and no conclusive diagnosis, gs itself should be considered as the primary cause for the recurrent arthritis. an in-depth literature review using medline for data on inflammatory joint pathology in lsd's showed that 7 lsd subtypes (i.e. fabry disease, farber lipogranulomatosis, gaucher disease type 1, mucopolysaccharidosis ix, a-mannosidosis, fucosidosis and cystinosis) could present with disease related arthritis. multiple potential arthritic mechanisms secondary to storage product accumulation in lsd's have been described, such as: dysregulation of innate immunity and increased upregulation of numerous pro-inflammatory proteins. conclusion: given the evidence of storage products within macrophages of the inflamed synovial tissue and the absence of other etiological clues, our hypothesis is that gs itself is the primary cause for the inflammatory joint pathology in our patient. although, gs cannot be linked directly to joint inflammation, lysosomal defects have been associated to pro-inflammatory effects that possibly could result in arthritic disease. future identification of other patients with gs is required to support the hypothesis of an arthritic clinical phenotype of gs and to assess underlying pathophysiology. introduction: joint pain (jp) is a relatively common complaint among children and adolescents. a painful joint in children for many years continues to maintain the status of the most common symptom of juvenile arthritis. however this symptom should not always be interpreted as a manifestation of rheumatic diseases. objectives: the aim of current review is to debate of the structure in children with the chief complaint of jp. methods: we retrospectively analysed our series of 600 children which attending outpatient department with complaint about pain lasting longer than two months in one or more joints. the clinical, instrumental and laboratory pictures were collected. special attention was paid to certain aspect of medical complaints, a complete and accurate history and physical examination. different categories as possible etiologies of jp in children were systematize and detailed. results: all children were divided into several groups based on their anatomical and physiological characteristics of osteoarticular system: the first group consisted of 240 children under 6-7 years old, the second group -220 children 7-12 years old, the third group -140 children over 12 years old. research suggests that more preschool children were experience bilateral lower extremity pain by "post-walk genesis" due to natural hypermobility, immaturity of sensory innervation of the joints and imbalance of the leg muscles (e.g. growing pains). the second most common cause of jp was associated with intra -or postinfectious factor (viral, streptococcal and chronic focal of infection). the frequency of juvenile arthritis and other rheumatic diseases in children of this age group did not exceed 10%. special attention was paid to fever, chills, malaise, nightpain and constitutional symptoms with changes in blood lab tests to exclude osteomyelitis (inc specific cause), malignancies manifestation and other bone tumors (less 5%). the most common causes of joint pain of school-age children were hypermobility syndrome and enthesopathy (primary, secondary). secondary enthesopathy were result of changes in nutrition, rapid growth and excessive exercise. also enthesopathy were manifestation of endocrine, gastrointestinal or infectious diseases. the proportion of children with the onset of chronic inflammatory arthropathy also did not exceed 10%. hypermobility child's syndrome was characterized by harmless pain (inc low back pain), linked to physical activity (less morning stiffness). over the past decade, we've seen a gradual increase in the number of children (95% were girls) with knee pain by diagnosed patellofemoral and mediopatellar plica syndromes, patellar tendinitis or idiopathic cause. in most cases children was complicated by syndrome of increased anxiety. the share of true chronic inflammatory arthropathies, including spondylitis, in children of this age group did not exceed 10%. fibromyalgia were diagnosed less 5%. introduction: a significant part of patients in rheumatologist's practice is children and teenagers with complaints of pain. the further volume of examination and the choice of treatment course depends on the capability of the rheumatologist to define the inflammatory and non-inflammatory genesis of pain. that makes the problem of differential diagnosis very important. objectives: to conduct a comparative analysis of patients with a principal pain complaint to determine if there are significant differences in the groups with the inflammatory and noninflammatory pain genesis. methods: the retrospective study included children who consulted a rheumatologist in the outpatient clinic in the period 2018-2020 without preliminary selection (n = 176). of them there were selected children with principal pain complaint (n = 120). according to the diagnosis, the children were divided into 2 groups: those who have inflammatory genesis of pain (a, n =59) and those with noninflammatory genesis of pain (b, n =61). the group a included children with such diagnoses as: reactive, poststreptococcal and juvenile idiopathic arthritides. the group b included children with arthralgia, chronic pain syndrome, orthopedic pathology, fibromyalgia. results: 1. groups a and b differ in the average age of the first complaints onset (t-criterion for equality of means) with a high degree of statistical significance (group a = 7,4 years; group b = 9,3 years; p = 0.019). which means that in group a more often than in group b first complaints appear in the age between 1 to 10 while in group b more often than in group a it happens in the age between 11 to 16. 2. there was a statistically significant difference in the means between groups a and b in time between the onset of first complaints and the first visit to a rheumatologist (p = 0.03) also in favor of this conclusion speaks the fact that in group a the number of visits to a rheumatologist in the same year when the first complaints appear is almost 2 times higher than in group b. 56% of cases in group a consulted the rheumatologist the same year when the first complaints appeared in comparison to group b where only 31% of patients did the same. below is the table with distribution of cases by the number of years between the first complaints onset and the first visit to a rheumatologist in both groups: conclusion: in children with arthritides, the first pain complaints appear at an earlier age (an average of 7.4), and in group b (an average of 9.3). patients with arthritis more often visit a rheumatologist earlier (within 1 year after the first complaints) than those with non-inflammatory genesis of pain complaints. the most common cause of recurrent musculoskeletal pain is growing pain (gp) in children. differential from rheumatic diseases could be challenging in some cases since there are no diagnostic criteria for gp. objectives: to analyze gp characteristics in a large cohort of patients in comparison with other non-inflammatory and inflammatory diseases causing limb pain, and to simplify the gp's diagnosis process by using machine learning (ml) techniques. methods: this is a multicenter cross-sectional study. introduction: it is a well-known fact that the period of intensive growth in children is associated with the processes of active bone mass accumulation and coincides with them in time. one of the most distinctive indicators of an increase in the disease incidence among children for the recent decade (+105,3%) can be found in the skeletal disorders resulting from disrupted calcium metabolism and vitamin d deficit. the latter is widespread in ukraine as it is observed in 92% of schoolers. objectives: establish the specifics of the structural and functional status of the bone tissue in children during the growth spurt, taking account of the degree of vitamin d3 sufficiency. methods: the examination covered 147 children aged 9-17 who were divided into three groups depending on the presence of the growth spurt (gs) and its intensity: group 1 -35 children who had become 8-12 cm taller for the year in question; group 2 -32 children who had become taller by 12 cm or more, group 3 -80 children who had experienced no growth spurt. inclusion criteria were the following: no chronic somatic or endocrine pathologies, no musculoskeletal disorders or mineral homeostasis disruptions; physical exertion corresponding to their age; the children had not been taking any complexes of vitamins and minerals, including vitamin d 3 for 6 months before the examination. conclusion: children aged 9-17 showed deficiency of vitamin d 3 reaching 100% which had no correlation with the presence or intensity of the growth spurt. in children who experienced growth spurt, a reduced bmd proved more frequent and correlated with the spurt intensity, however, it did not depend on sufficiency of vitamin d 3. therefore, during the growth spurt, disrupted mineralization of the bone tissue was influenced not only by the vitamin d deficit but also by the correlation between the bone tissue mineralization rate and intensity of growth in the children. methods: a self-reported 25 question online survey on qol of patients with sjia and aosd was developed by the non-profit organizations, the autoinflammatory alliance, kaisz/vaisz, enca and sjia foundation in english and translated to dutch. respondents were recruited by convenience sampling through online social media posts. data on flares, triggers, family history, and correlation of symptoms with labs were collected in addition to detailed information on qol during and in-between flares. results: between 2017 and 2019, there were 109 responses; 54 were from parents of children with sjia, 18 from adults with sjia, and 37 from adults with aosd. interestingly, adults (whether diagnosed with sjia or aosd) were more likely to report pain, fatigue, joint swelling or arthritis, nausea & vomiting, and diarrhea during flares than children. adults were also more likely to describe flares >one month. 80% of patients reported being "greatly" or "severely" limited during flares. between flares, 20% reported being "greatly" or "severely" limited while 59% were "somewhat" limited. 80% felt their condition affected their studies, job, and career, including 66% of children with sjia, 100% of adults with sjia, and 92% with aosd. respondents were asked open-ended questions regarding their experience with disease flares and impact on their lives, and specifically how sjia and aosd affected work, career and schooling. responses regarding the disease experience were classified into 7 theme areas: 1) experience with disease onset and process of diagnosis; 2) health care access, quality, and drug safety concerns; 3) physical impact of the disease including pain and chronic fatigue; 4) social impact of the disease; 5) mental health and emotional impact of the disease; 6) impact on work, career, and employment; and 7) broad impact on life and lifestyle. responses regarding effect on work, career, and schooling were categorized into 3 theme areas: 1) physical impact negatively influencing school/work productivity; 2) lost work and wages, including unemployment and needing disability benefits, and parents missing work to care for the child; and 3) the socialemotional impact as well as negative effects on mental health. about half of patients regardless of age reported the name sjia did not represent well the disease, specifically that it did not emphasize the systemic symptoms, and that the disease gets confused with other types of arthritis. adult patients with sjia did not like to have juvenile in the name. conclusion: children and adults with sjia and aosd report high levels of qol limitation and effect on school, work, and career, both during and between flares. our qualitative data emphasizes the importance of multidimensional evaluation of disease with ongoing input from the patients, which will provide a foundation for asking more relevant research questions to foster better care and improve qol. results: in total 111 participants were included in the study : 62 juvenile idiopathic arthritis (jia) patients, and 49 their parents. the mean age of the patients was 13.7 ± 2.3 years. significant differences were found between patients and healthy children in such hrqol survey categories like "autonomy" and "financial resources" (p < 0.05). although quality of life in children's with juvenile idiopathic arthritis was lower than in healthy children in hrqol survey category "self perception" (p < 0.05). after analyzing data no significantly differences were found between patients and parents' assessment scores in hrqol survey categories (p > 0.05). conclusion: juvenile idiopathic arthritis has a moderate negative influence on hrqol survey categories "self perception", "autonomy" and "financial resources" (p < 0.05) according kidscreen-52 queationnaire. introduction: juvenile dermatomyositis (jdm) is often first identified by parents and carers as the red facial rash develops. the rash can progress and lead to young people being misdiagnosed with eczema, scarlet fever or psoriasis. however, over time the obvious signs of jdm can become "invisible" as treatment calms the rashes and masks the outward signs of jdm, until a flare occurs, when the rashes can be a marker for disease activity or progression. as part of a larger study, children around the united kingdom were asked to discuss their views on whether they wanted people to be able to see their jdm. objectives: to understand the implications for children and young people from having a disease that has visible and invisible phases and whether they want others to see their jdm, or not. methods: children and young people around the united kingdom who were already consented and enrolled into the uk juvenile dermatomyositis cohort and biomarker study were asked to complete a bespoke questionnaire. there was a mix of open and closed questions, and it was administered in paper format to all children and young people between the ages of 8 and 19 years of age for self-completion, either on the paper forms, or via a secure web-based software system. the questionnaires were administered at the end of 2018. numeric data were described and qualitative data were analysed using standard content analysis. results: 246 questionnaire packs were sent out, with 127 (52%) being returned. of these 4 could not be used due to practical reasons, such as only demographic data being completed, which left a sample of 123. 98 (80%) of the 122 who responded said other people could not see their jdm, with only 11 (9%) saying it was visible and 13 (11%) saying they did not know if others can see it. 1 did not respond to the question as said their jdm has gone away. they were then asked whether it was a good or bad thing for others to be able to see their jdm or for others not to be able to see it. 41 young people left comments as to why it was a good thing, 36 left comments as to why it was a bad thing and 14 left comments to why they said don't know, table 1 presents the top ranking response for the three multichoice answers. conclusion: this study has highlighted the disparity between young people wanting others to see their jdm so that they gain more understanding and empathy from those around them, but equally, wanting their jdm to be invisible, so that they feel the same as their peers. whilst many paediatric rheumatic conditions are in fact invisible, our data illustrate that jdm often gives children and young people a taste of both visible and invisible phases of disease activity. as one young person said "it's not good, nor badit's good that it's invisible sometimes so i can blend in without the disabled stereotype. however, sometimes it needs to be seen so i can be understood and not challenged". disclosure of interest: none declared multidimensional assessment report (j-fimar) which includes comprehensive patient self-report questionnaire and numerical rating scales to measure pain, fatigue, headache, sleep quality, physical function, psychological state, health-related quality of life, satisfaction with illness course. the j-fimar has been devised according to the outcome measure in rheumatology (omeract) guidelines. discriminant ability of the multidimensional tool was evaluated by testing it in a control group including healthy controls and patients affected by active juvenile idiopathic arthritis (jia). the psychosocial consequences of chronic pain were evaluated by using the children depression index (cdi) and the multidimensional anxiety scale for children (masc). the objective sleep quality was measured by overnight polysomnography. results: table 1 shows characteristics and the most represented somatic symptoms in our cohort of jfs patients at the study enter. polysomnography was performed in 21 patients with sleep disturbance; 8/21 (38.1%) showed an electroencephalographic pattern of alpha wave intrusion in slow wave sleep (sws). the presence of objective sleep disorders was significantly correlated to cdi score rs -0,775 (p≤0,0001) and masc 0,61 (p=0,005). from november 2016 to april 2020 j-fimar was completed by 43 jfs patients (f 35 (81.4%), median age 14.7 years [7.1-17.6], median disease duration 1.9 years [0.1-7.8]) in 125 visits. all patients filled out the questionnaire in a short time (<15 minutes) and considered it simple and easy to understand. jfs patients showed significantly higher score for pain, fatigue, poor physical function and measure of psychological distress than healthy controls and jia patients (p<0.05 for each item). conclusion: jfs patients presented significantly higher pain experience, functional disability, and impaired quality of life than patients with active jia. a relevant percentage of jfs patients experience sleep disturbances, which were correlated with mood and anxiety disorders. our multidimensional tool was feasible and able to quantify global jfs severity. this multidimensional tool, by measuring the main domains affected by the disease, could be promising to individualize treatment strategy and to test its efficacy. disclosure of interest: none declared introduction: fatigue is a subjective state of overwhelming, sustained exhaustion and decreased physical and mental capacity, which is not relieved by rest. fatigue is the most common complaint in children and teens with an autoinflammatory disease, besides the disease related flares. the purpose for this study was to show that fatigue is a serious issue for children and young people with autoinflammatory diseases. we hypothesized that age, gender and/ or the type of autoinflammatory disease could have differing effects on the fatigue experience. objectives: we aimed to investigate fatigue in children and young people (cyp) with autoinflammatory disease, including how this affected them on a daily basis. methods: cyp with autoinflammatory diseases were invited to complete an online survey, providing details about their fatigue and how it affected them. the survey was developed by the non-profit organizations autoinflammatory alliance and kaisz/vaisz, in english. respondents were recruited by convenience sampling through online social media posts. data on age, gender and disease were collected in addition to information on their experience of fatigue on school and social interaction. a total of 114 cyp (age range 7-18 years) with an autoinflammatory disease responded to the survey (52% female). results: the majority of respondents (81%) reported experiencing both mental and physical fatigue. respondents were asked how much their fatigue affected them, on a scale of 0 to 10; overall, the mean fatigue score was 6.6. however, young people aged 15 or over reported a significantly higher impact than those aged 11-14 years (mean 7.5, p=0.012). different autoinflammatory diseases were surveyed: crmo 25%, caps 20%, pfapa 12% also unclassified said (usaid) with 23%. in the open-response portion of the survey, 81% of respondents reported that fatigue was physical, as well as mental, in their experience. most (89%) reported that someone had doubted their fatigue in the past; 29% had found their teachers had doubted them, 26% had friends who doubted them, and 24% reported that they felt their doctors had doubted them. children and young people also felt a number of activities made their fatigue worse (table 1) ." conclusion: cyp with autoinflammatory diseases experience physical and mental fatigue. health professionals and teachers should listen to patients reporting fatigue, validate their experience, and help find ways to support them. identifying resources to help the patients with fatigue, and referrals to therapy and mental health resources as needed may help the patients to better cope and manage their chronic disease. further studies will include patient engagement in designing questionnaires about all aspects of life and autoinflammatory disease will help our understanding of these complex conditions and how they affect patients. introduction: scleromyositis is the most common overlap syndrome but is rarely observed in childhood. this disorder involves two different autoimmune diseases: systemic scleroderma (ssc) and polymyositis (pm). objectives: to describe the clinical course of a ssc/pm syndrome in a young girl. methods: case report results: an 11-year-old female was admitted to the neurological unit of our hospital for creatine phosphokinase (cpk) increase and hypertransaminasemia associated to sporadic episodes of right calf pain. familiarity for muscular dystrophy was reported in the maternal branch. muscle tone and trophism were preserved at initial neurological evaluation. laboratory investigation confirmed increased muscle enzyme levels, including cpk (x70) (ck-mm 94.5%, ck-mb 5.5%), aldolase (x7), cardiac troponin (x10) and myoglobin (x10). suspecting a primary muscle disease, she underwent a total body stir-mri which showed a diffuse edema of gluteus medius bilaterally and a muscle biopsy revealing a marked muscle damage with dystrophic aspects and normality of the tested proteins. a genetic extended panel for congenital myopathies resulted negative. after 4 months, a new clinical examination showed the occurrence of general skin induration, sclerodactyly and tightening of the face skin. appearance of dysphagia was also reported, and muscle enzyme increase persisted. in suspicion of an ssc/pm overlap syndrome, she was referred to our unit. nailfold capillaroscopy showed capillary dilatation and branching, megacapillaries and diffuse microhemorrhages. reduction of esophageal contractions amplitude and hypotensive lower esophageal sphincter pressure were observed at esophageal manometry test. high-resolution ct of lungs and pulmonary function testing were normal. skin biopsy showed sclerodermiform findings. immunological studies revealed a positivity of antinuclear antibody (1:320) and anti-ku. anti-pm-scl resulted negative. an oral corticosteroid therapy (prednisone, 1.5 mg/kg/day) was started in association with subcutaneous methotrexate (15 mg/m 2 /week) and intravenous immunoglobulins (ivig) (2gr/kg every two weeks). improvement of skin manifestation, joint mobility, as well as normalization of serum cpk levels were observed. over 3 months, prednisone and ivig were slowly discontinued up to the ongoing dosage of 0.9/mg/day and 2 gr/kg every 4 weeks, respectively. mtx is still ongoing at the same dosage. conclusion: the diagnosis of overlap connective tissue disease syndromes may be challenging in pediatric age. different symptoms may be prevalent at different stages throughout the course of the disease. in our patient, a localized myositis preceded the ss onset by about four months. even though the use of high dose of corticosteroids is associated to a higher incidence of renal crisis in patients with css, a combined therapy with high doses of oral steroids, ivig and mtx was safe and effective in skin, muscle and joint symptoms in our patient. results: a total of 336 images were obtained from 118 healthy children included in the study and 708 capillary measurements were made. capillary density was significantly higher in group 4 than in groups 1 and 2. arterial width was significantly lower in group 1 as compared to group 3 and 4, and in group 2 as compared to group 4. apical loop width and capillary distance were significantly lower in group 1 compared to group 2 and 3 and 4. there was no significant difference between the age groups in terms of capillary length and venous width. there was no difference between the groups in terms of capillary morphology. in total 336 image evaluations, capillary tortuosity was <50% in 67.8%, and > 50% in 4.2%, and capillary crossing were <50% in 52.5% and> 50% in 3.4%. while the enlarged capillary was 4.7% and the avascular area was 4.2%, capillary branching, capillary meandering, microhemorrhage, and giant capillary were not detected in any case. there was a good level of agreement between the researchers, as 20 cases with 120 capillaries were evaluated with a good level of agreement (table 1) . conclusion: this is the first study to evaluate capillary morphology in healthy turkish children. this study also adds that some special forms such as enlarged capillary and avascular area, which is always named as pathological in adult age, can be seen in healthy children. these data will be guiding in capillaroscopic studies in various patient groups, particularly in children with collagen vascular diseases. methods: 308 patients with jia were tested for hla-b27. they were divided into 2 groups: 1) hla-b27 positive and 2) hla-b27 negative. results: 100 patients (32,5%) were hla-b27 positive and all of them are fulfilled the eular criteria of entesitis-related arthritis (era). the group 2 consists of 208 patients (67.5%). there's no statistical difference between both groups in active joint count, ana-positivity and uveitis frequency, the rate of use methotrexate and time before biologics. no difference in axial cervical spine 12 (12.0%) vs 21 (10.1%) (p=0.613) and sacroiliac joints 18 (18.0%) vs 23/207 (11.1%) (p=0.097) involvement was observed. hla b27(+) patients often received pulse therapy with methylprednisolone due to increased inflammatory activity and severe arthritis (22% vs 11.1%, p=0.011). other parameters are listed in table1. conclusion: patients with hla-b27 positivity were characterized by male predominance, more often hip involvement, higher laboratory activity and the need for more frequent use biologics. the rate of axial involvement wasn't different in hla-b27 positive and negative patients, that needs further study and creating more accurate classification criteria for jsa. disclosure of interest: none declared introduction: although gut is increasingly recognized as origin and/or target of inflammation in adult onset spondyloarthritis (spa), the incidence of gut involvement in juvenile spa (jspa) patients is still largely unknown, mostly due to the lack of reliable non-invasive tests. objectives: we performed a cross-sectional study of fecal calprotectin (fcal), a surrogate marker of gut inflammation, in patients with jspa, other forms of juvenile idiopathic arthritis (jia) and noninflammatory (ni) conditions. methods: fcal was measured by commercially available assay in stool samples of enthesitis related (era), psoriatic (psa) and patients with other jia subtypes (oligo-and poly-articular) who fulfilled ilar criteria, as well as in children with ni causes of musculoskeletal pain (ni-msd), regardless of the gastrointestinal (gi) symptoms (table 1 ). fcal was compared among different groups of patients and correlated with demographic data, clinical characteristics, treatment modalities and disease activity measured by jspada. the values were also dichotomized to <50 mg/kg, 50-200 mg/kg, and >200 mg/kg, which was regarded as normal, slightly increased and increased, respectively. ileocolonoscopy was performed in one patient. our study has shown that fcal levels are significantly higher in era patients compared to other jia (p=0.03) and/or ni-msd (p=0.03) patients. moreover, almost a third of patients with era had levels of fcal above the range regarded as normal, which adds to the number of evidences for a gut inflammation in this particular type of jia. besides, the fcal levels were higher in those with axial involvement, which further suppots the association of gut and axial inflammation in children with era. although endoscopy remains a gold standard for the diagnosis of gut inflammation, fcal can help to select children with era who might benefit from this invasive procedure, regardless of the gi symptoms, as shown in one patient with the highest fcal concentration in our study. moreover, fcal levels seems not to be influenced by disease characteristic and/or concomitant therapy intake. therefore, fcal should be a part of diagnostic workup in children with any type of jia, but most importantly in those with era. evaluate potential predictor variables of magnetic resonance imaging (mri) sij remission methods: retrospective review of prospectively collected data. we included patients with era (according to ilar criteria) continuously treated with anti-tnf agents for ≥ 12 months who had at least two mris of the sacroiliac joints performed before starting anti-tnf therapy (baseline) and during the follow up ( > 12 months after anti-tnf treatment). si joints were examined using t1-weighted images, t2 fastsuppressed and short-tau inversión recovery. the sparcc-sis was scored by two pediatric radiologists. sparcc-sis assessed the presence, depth and intensity of bone marrow edema (bme) on consecutive six slices in the iliac and sacrum bones . scoring is composed by: bme (0-48), bm intensity (0-12), bm depth (0-12 introduction: several paediatric patients manifest conditions commonly misdiagnosed as spider bites, which however, can include other arthropods bites; bacterial, viral, and mycotic infections; vasculitis; dermatological diseases; miscellaneous conditions as drug reactions, chemical injuries. objectives: in italy, spiders which are likely to be associated with severe toxin mediated tissue damage are uncommon, especially in urban zones. however, a minor trauma may be a precipitating factor for pyoderma gangrenosum particularly over the legs, in association with inflammatory bowel disease, haematologic diseases and juvenile idiopathic arthritis (jia). methods: we describe a 11-years old boy with pyoderma gangrenosum complicated spider bite in association with systemic jia (sjia). the patient was in clinical remission after the start of the sjia, occurred two months before, still treated with tapering doses of steroids and canakinumab, with the normalization of inflammatory parameters (crp, esr, saa, ferritin) and clinical manifestations. only a mild arthritis of the knee persisted and for this reason he was still treated with steroids. furthermore, he developed hyperglycemia, requiring insulin treatment. the first dermatological manifestation which he referred was a red dot of the leg skin. in a few days, the erythema enlarged, involving an area of 7 x 7 cm, with oedema, pain, and blisters, evolving in a necrotic lesion, with purulent exudate, surrounded by a haemorrhagic zone. results: haematological controls revealed neutrophilic leucocytosis, increased crp and procalcitonin. he started treatment with intra venous administration of teicoplanin plus ceftriaxone, with no resolution of the clinical manifestations and the reduction of leukocytosis, crp, procalcitonin. a culture swab was performed and was positive for pseudomonas aeruginosa, confirmed by pcr on the culture. he started ciprofloxacin and surgical curettage of the lesion, with the resolution of the lesion and the normalization of biochemical parameters. conclusion: the aspect of the lesion and its evolution were evocative of a spider bite suggested by anamnestic records, complicated by a pyoderma gangrenosum secondary to pseudomonas aeruginosa. the underlying disease, the immune suppressive treatment, with steroids and biological drugs, the hyperglycaemic pattern of the patient allowed the severe evolution of the spider bite. children in treatment with immune suppressive and/or biologic drugs are at high risk of infections. skin lesions, as arthropods bites, can be a facility for superinfection, with possible haematological and systemic diffusion. the strict application of the ilar 1 requirement for the presence of documented arthritis for the diagnosis of sjia, early in the disease course, may result in unnecessary delays in initiating appropriate treatment. in preliminary printo 2 classification criteria for sjia, this mandatory requirement of documented arthritis has been modified. to measure performance of preliminary printo classification criteria for sjia in our indian cohort. methods i gathered a data of seven sjia patients who attended dev children's hospital between jan 2019 and jan 2020. my data included demographics,clinical presentation, laboratory parameters and outcome of these patients. all these patients were diagnosed at an early stage by clinical judgement irrespective of fulfilment of ilar criteria. i applied preliminary printo classification criteria for all. average age of selected children (4 girls and 3 boys) was 5.1 years. conclusion a preliminary printo classification criteria for sjia has been validated in our cohort. there are many raised inflammatory markers in most of these patients other than wbc count. these markers should be considered to be added in supportive laboratory criteria to be more specific towards the diagnosis. it is important to add pid in exclusion list especially in a case of sjia with mas at onset. 3 trial registration identifying number leningrad's regional children' two patient stopped treatment within 6 months from therapy start: due to primary inefficiency (1) and allergic reaction (1). five (5/11) patients were-co-administered with cdmards, other 5with oral gc, and 6 subjects had been previously exposed to other biologic drugs. whole 5 patients stopped therapy due to secondary inefficiency: 2 patients were switched on toc, other children were switched on eta (1) introduction: systemic juvenile idiopathic arthritis (sjia) is a rare, complex auto-inflammatory disease with significant morbidity including fever, rash, serositis and articular problems. with the availability of interleukin-1 (il-1) and il-6 inhibitor treatment, morbidity has significantly reduced and the outcome for sjia patients has improved. however, differences in access to care and differences in treatment strategies between countries in and outside of europe remain a concern. objectives: the single hub and access point for paediatric rheumatology in europe (share) consortium aimed to develop best practices for paediatric rheumatic diseases in order to decrease differences in care between european countries. here, we present the final results of the literature review and a series of consensus meetings on defining overarching, diagnostic and therapeutic recommendations for diagnosis and treatment of sjia. methods: the share methodology has been previously published, including the use of the eular standardized operating procedure for developing best practice recommendations. as per these guidelines, a methodologist provided supervision during the process and consensus meetings. conclusion: hscore seems to perform slightly better than ms-score for the diagnosis of mas in our cohort. early inhibition of il-1 is discussed to play an important role in the disease course of sjia 1 . assuming that pretreatment with other dmards leads to a later start of therapy with canakinumab, this analysis evaluates the effectiveness of canakinumab as first-line vs. second-line dmard. to evaluate the effectiveness of canakinumab as first used biological dmard in sjia compared to canakinumab in sjia-patients pretreated with other dmards. methods sjia-patients documented in the german biologic registry for pediatric rheumatology (biker), who were exposed to canakinumab, were identified. for the first-line (fl) group dmard naïve patients were selected, prior treatment with corticosteroids and/or nsaids was allowed. patients receiving any dmard prior to canakinumab entered the second-line (sl) group. both groups were compared in a retrospective intention-to-treat-analysis. effectiveness canakinumab treatment showed good effectiveness in sjia both as first-and second-line dmard. after 6 months the use of canakinumab as first-line dmard is associated with higher response rates compared to second-line use. our data support the hypothesis that early treatment with canakinumab is associated with good therapeutical response and a positive effect on the disease course of sjia. results: a total of 11 children (9 girls) with sle were identified. median age of symptom onset and diagnosis was 14 years(range 8-17 years) and 11 years respectively. the presenting manifestations were fever(5), oral ulcers(3), alopecia(3), malar rash(4), photosensitivity(5), renal involvement (5), seizures(1) and gastrointestinal complaints (1) apart from some unusual manifestations of isolated peripheral arthritis(1), isolated bilateral pleural effusion(1), macrophage activation syndrome(2). laboratory investigations: hemogram revealed anemia in 8 children and thrombocytopenia in 5. urine examination showed nephrotic range proteinuria in 1 child and subnephrotic proteinuria in 2. microscopic hematuria was noted in 2 pateints. renal function tests were deranged in 2 cases. ana, anti dsdna positivity and hypocomplimentemia were present in all. renal biopsy was done in 4 patients, 2 had class iv, one class iii and one had class v lupus nephritis. all patients were initiated on hydroxychloroquine and photoprotection. children with renal involvement were given pulse methylprednisolone followed by tapering doses of oral prednisolone and intravenous, monthly cyclophosphamide. azathioprine was used as maintenance therapy in all. subcutaneous weekly methotrexate was used in 2 patients. one child (mas) died during disease course. disease continues to be in remission in rest. conclusion: we found a significant female preponderance in our study group. renal involvement was the commonest presentation. some unusual presentations were also seen. early recognition of sle is critical for timely initiation of appropriate treatment. this is the first report of a cohort of pediatric sle from this part of india. introduction: autoantibodies in ahai may be igg/igm/iga. ahai can be divided into primary or secondary (e.g. sle, lymphoproliferative diseases, infections, medications). it is also classified based on the temperature at which the antibody reacts to erythrocytes, and can be warm (igg or iga) or cold (igm or c3). in warm ahai, the antibodies react at temperatures ≥37ºc, not activating the complement system and not undergoing agglutination in vitro. in cold ahai, antibodies react at temperatures below 37ºc, activating the complement system with in vitro agglutination.mixed aiha (warm and cold) is rare and occurs in <10% of aiha cases and can occur at any age, but is extremely rare in children. the prevalence of the mixed form is less than 1/1,000,000 patients with ahai. objectives: to report a rare case of mixed ahai and idiopathic intracranial hypertension(iih) in a 15-years old female patient with a previous diagnosis of sle and aps. methods: case report and literature review. results: a 15-years old female adolescent previously diagnosed with sle/aps since 2017 was in remission on hydroxychloroquine(400mg);azathioprine(150mg);aspirin(100mg);vitamind3(1.000iu);calcium(1g), and sunscreen. in april 2020 , she had a relapse presenting with fatigue, myositis, headache, hypocomplementemia, and severe autoimmune hemolytic anemia (hb of 4g/dl) (sledai-2k=18 points). mixed ahai was diagnosed base on a direct/indirect coombs test 4/4+;directantiglobulintesting showing anti-iga(weak),anti-igm(3+/4+),anti-igg(3+/4+),anti-c3c(weak),anti-c3d (3+/4+);igg1/3subclasses with a reaction of 1:100(2+/4+);an eleven cell antibody panel positive revealing a cold and warm antibody, and adsorption technique revealing a cold and warm autoantibody. chest ct showed bibasilar subsegmental atelectasis, head ct/mri was normal and lp showed a high opening pressure of 45cmh2o with a normal cell count. after the procedure, the patient reported improvement in the pain and was diagnosed with iih. the patient was screened for secondary causes for ahai (table 1) due to the unusual mixed type pattern and serology was positive for chlamydia trachomatis (igm) and mycoplasma pneumoniae (indeterminate-igm/positive-igg) suggesting a recent infectious trigger causing reactivation of the underlying disease with a probable cross-reactivity. the patient treated with 10-days of clarithromycin. before the infectious screening came back negative, ahai was treated with a single dose of ivig(1g/kg) and then, with 3-days of methylprednisolone(1g/day). azathioprine was replaced by mycophenolate mofetil. due to headache recurrence, acetazolamide(500mg/day) was started, and the patient referred no pain. the patient was discharged with a resolution of the symptoms. objectives: to our knowledge, the association of gbs and bbe has been described in adults only. methods: we here describe a child presenting at sle disease-onset with an overlap of peripheral (gbs) and central (bbe) nervous system manifestations, highlighting the possible association between these two entities in children. results: an 11-year-old healthy girl presented with acute ataxia, ophtalmoparesis and altered level of consciousness, rapidly followed by areflexia, facial paresis, swallowing difficulties, sensory deficits, paresis in all four limbs and respiratory insufficiency. these symptoms were accompanied by pleuro-pericardial serositis, proteinuria and hypertension. immunological investigations revealed the presence of positive ana and ds-dna antibodies. the renal biopsy showed a stage iii lupus nephritis. hence, the clinical, laboratory findings and biopsy report led to the diagnosis of psle. brain and spine mri did not show any abnormalities; diffuse slowing compatible with nonspecific encephalopathy was seen on eeg. nerve conduction studies (ncs) confirmed the clinical suspicion of acute polyradiculoneuropathy with proximal interruption of motor nerve conduction, compatible with guillain-barré-like syndrome. csf analysis (performed twice) remained normal. the patient was treated with glucocorticoids, intravenous immunoglobulins, cyclophosphamide as well as plasmapheresis. the neurological and physical symptoms improved gradually with complete neurological recovery four months after onset. conclusion: overlapping forms of bbe/gbs have never been described in association to sle in children. our patient's presentation and evolution fulfilled the criteria for such an overlap, occurring at psle onset. although sle and bbe/gbs are rare entities, our case suggests that there may be a common underlying immune background. this association should be recognized early for rapid and appropriate treatment initiation. infantile antiphospholipid antibody syndrome: acquired and de novo apl appearance in four infants t. giani 1 , g. ferrara 2 , a. mauro 3 , r. cimaz 4 introduction: antiphospholipid syndrome (aps) is a rare condition in the neonatal age. in most cases it is considered a passively acquired autoimmune disease, due to a transplacental passage of maternal antiphospholipid antibodies (apl). exceedingly unusual is the de novo production of apl in newborns and infants. objectives: to describe four infants who developed an early brain stroke with increased and persistent levels of apl, even after six months of life. methods: we reviewed the clinical charts of four such infants, followed from diagnosis up to two years after the disappearance of apl. conclusion: common characteristics of these four children are the development of brain stroke and the increased and persistent apl levels even after six months of life. this opens the window on a gray zone related to the origin of these antibodies (maternal or neonatal) and on their role in the pathogenesis of the infantile brain stroke. patients had over 20% of their monitoring completed but only 2 had over 80%. aspects of monitoring that were more time intensive or were required less regularly were most frequently overlooked. there was a statistically significant increase in the percentage of completed monitoring in those patients for whom the lupus checklist was used compared to patients where a checklist was not used (p=0.00). conclusion: there is significant room for improvement in the monitoring of these patients with jsle in the rheumatology clinic. this audit illustrates that more diligent use of the lupus checklist and an overall improvement in sustained use of the checklist will help to improve monitoring of these patients. evidence suggests that checklists are underutilised in medicine and wider implementation of this simple tool could improve patient outcomes. 3, 4, 5 interventions such as in person or electronic reminders, or audits with feedback to physicians could improve usage over time. the application of the lupus checklist or a similar document in other paediatric clinics is important for comprehensive monitoring of a condition as complex as jsle and has the potential to prevent ongoing damage and medication toxicity in this high-risk population. juvenile onset and this cluster have may more severe kidney, neuropsychiatric or hematological involvement. objectives: the aim of this study was to assess the clinical and laboratory characteristics, disease activity, and treatment response of patients with juvenile sle (jsle). methods: this is a retrospective study involving patients between 1 july 2016 and 1 january 2020. the data of patients diagnosed with jsle and followed up for a minimum of 6 months, were collected. the sledai-2k scores at initiation and at the follow-up (1st, 3rd, 6th, and 12th months of treatment) were examined. the sledai-2k score was considered to be ≤4, for disease remission status. results: a total of 49 children were included in to the study. the female/male ratio was 4.4/1 and the median age of the patients at the diagnosis was 13 (iqr: 11.1-15.2) years. the median follow-up of patients was 19 (iqr: 12-25) month. four of the patients were diagnosed with monogenic sle. two siblings were diagnosed with c3 deficiency and two were diagnosed with familial chilblain lupus. the most common clinical findings were found musculoskeletal complaints (69.4%), malar rash (51%), oral ulcers (38.8%), and fever (30.6%), respectively in over all the group. the frequency of involvement of the system and organs was as follows; mucocutaneous 77.6%, musculoskeletal 69.4%, renal 44.9%, hematological 34.7%, serous membranes 16.3%, neuropsychiatric 12.2%, respectively. all patients had anti-nuclear antibody positivity, while 46.9% had anti-ds dna, 14.3% had anti-sm and 8.2% had antiphospholipid antibody positivity. while all patients received hydroxychloroquine treatment, 22.4% of the patients were received were mycophenolate mofetil, 22.4% were azathioprine, 14.3% cyclophosphamide, 12.2% methotrexate and 10.2% were rituximab. the median sledai-2k score was 14 (iqr: 10-18.5) at admission, besides it was found to 6 (iqr: 4-12), 4 (iqr: 2-6), 2 (iqr: 0-6) in the 1st, 6th and 12th months of treatment, respectively. while 98% of the patients had active disease at admission, 67.3% at 1 months, 32.7% at 6 months and 22.4% at 12 months still had active disease (sledai-2k >4). patients with initially high sledai-2k scores had significantly lower remission rates in the first month (p=0.003). it was observed that patients with high sledai-2k scores in admission were more resistant to conventional immunosuppressive treatments and the use of rituximab was more frequent in these patients. at least one major organ (renal, hematological, neurological) were affected in 57% of patients. the remission rate of these patients at 6 months was found significantly decreased compared to the others (p <0.005). renal biopsy was performed in 21 patients (42.9%). 12 of them had type 4 lupus nephritis (ln), 5 had type 2, 2 had type 3, and 1 had type 5. it was observed that patients with renal involvement were the group that reached remission latest. conclusion: the presence of high initial sledai-2k scores and the major organ involvement have poor predictive value to achieve inactive disease. a two year old girl of consanguineous parents presented to hospital at 13 months of age with fever and erythematous macular rash on her cheeks which spread to her nose, chin, and ears. the rash started a month prior, and progressed over her entire body. a skin swab grew staphylococcus aureus but the rash didn't respond to topical antibiotics. review of systems was unremarkable except for longstanding oral thrush and diaper rash. birth and family history were unremarkable. on exam she had a diffuse, erythematous, morbilliform eruption over her face and body. she had facial swelling, orbital edema and vasculitic oral ulcers. she had leukopenia mainly neutropenia, low hemoglobin, with normal platelets. her liver enzymes and erythrocyte sedimentation rate (esr) were high while c-reactive protein, immunoglobulins, c3 and c4 were normal. cultures were negative, however she was positive for adenovirus, mycoplasma and ebv (ebv load was 6000 iu/ml ). autoimmune hepatitis work up was negative. the direct coombs test, antinuclear antibodies (1:640), ro, rnp and smd were positive. ch50 came low as well as c1q level of 4 mg/dl (normal range 12-22 mg/dl). lymphocyte subsets showed reduced cd4 and nk cells. bone marrow aspiration showed active marrow. skin biopsy showed chronic non-specific inflammation (immunofluorescence and electron microscopy were not available). echocardiogram showed dilatation of the left coronaries. she was treated with intravenous immunoglobulin (ivig) for kawasaki disease with no improvement. therefore pulse steroid 30mg/kg followed by 2 mg/kg was initiated. her rash, facial swelling and abnormal blood counts improved dramatically. whole exome sequence showed homozygous variant c.469g>t p.g157c at the c1qa gene. while tapering steroids she flared so subcutaneous methotrexate was started. unfortunately, she continued to have rash, leukopenia and high liver enzymes, so treatment was switched to mycophenolate mofetil and hydroxychloroquine. however she did not improve and started to have recurrent bacterial and viral infections that included cellulitis, gastroenteritis and upper respiratory tract infection. we started her on regular ivig, which helped with infections and allowed for weaning of steroids. however she developed alopecia and lower limb spasticity with delayed walking. mri brain and spine was normal. upon reanalysis of the wes, two other homozygous mutations at kif1c and apg7 were identified and associated with spastic paraplegia, but reported as variants of unknown significant. fresh frozen plasma (ffp) transfusions were started, initially weekly, then every two weeks and subsequently every four weeks. the rash disappeared, leukopenia and esr improved and we were able to discontinue steroids conclusion: early-onset sle with a severe course of disease raises the possibility of a genetic etiology. we are reporting, for the first time, a rare missense mutation g>t in exon 3 of the c1qa gene that resulted in an amino acid substitution that is pathogenic. interestingly, she had other mutations associated with neurological manifestation that never reported together before and altered her phenotype. she has responded well to ffp as has been reported in a few case reports results: a total of 148 psle under the age of 13 years were included, 30% (n = 44) were males. the overall mean age at diagnosis was 7.6 ± 3.5 years and median disease duration was 9.5 (5-13) years. huv was diagnosed in 34.5% (n = 51) of psle cohort. psle with uv were more likely to be males (57% vs 15%; p < 0.001), diagnosed at a younger age (5.9 vs 8.5 years; p < 0.001), have a family history of sle (53% vs 36%; p = 0.044) and have conjunctivitis more frequently (32% vs 5.3%; p < 0.001) than psle without uv. psle with uv were also less likely to have cns involvement (7.6% vs 20%; p = 0.045) and hematological manifestations such as leukopenia (9.4% vs 24%; p = 0.028) and thrombocytopenia (5.7% vs 18%; p = 0.045). in addition, psle with uv were more likely to be associated with low c3 complement count (94% vs 66%; p < 0.001) and positive cytoplasmic anca (11% vs 0%; p = 0.022).however, the psle with uv cohort were less likely to be associated with ana (65% vs 83%; p = 0.016), dsdna (56% vs 72%; p = 0.042) and perinuclear anti-neutrophil cytoplasmic antibodies (33% vs 55%; p = 0.047). conclusion: we report a high occurrence of huv in psle cohort (34.5%) associated with unique demographic, clinical features and laboratory features. the debate regarding whether huv is a rare subset or unusual type of sle, or is a separate entity altogether, continues. however, the overlap in clinical, laboratory and genetic mutation supports the notion that huv and sle fall into the same spectrum of autoimmune disease with similar disease pathogenesis. however, further studies are needed to reach clear conclusions regarding the relationship between huv and sle. introduction: the last decade has brought a lot to the approaches to the diagnosis and treatment of juvenile arthritis. in russia, the actualization of the problem of diagnosis and treatment of jia required the development of federal standards, which provide the most detailed algorithms for medical care, both at the stage of inpatient and outpatient care. in the regions of the russian federation, the effective use of these documents required a whole range of additional educated activities, both with students of medical universities, as well as with the medical and nursing community, in addition, a set of work was carried out to create a regional regulatory framework. in the total biological therapy pool, 67% of patients receive tnf-alpha inhibitors, antibodies to il-6 receive 27% of patients, antibodies to il-1 -6,25%. it is worth noting that when using biological agents in 60% of cases, the criterion of an inactive disease was achieved by 4-5 months, which was characterized by the absence of acute inflammatory symptoms, normalization of esr and crp. monitoring of patients with jia receiving biological agents required the conduct of a number of educational activities for medical personnel, the creation of an additional methodological base. for further training of young specialists at the regional medical university, a program of an additional educational course in pediatric rheumatology was developed and introduced. a regional patient organization was established and also required a set of information activities by the medical community. conclusion: in the saratov region of the russian federation, about 20% of patients with jia receive biological therapy, which corresponds to the average indicators according to the literature. in the structure of the biological drugs used, the group of tnf-alpha inhibitors is preserved -67%. the introduction of modern methods of treatment using biological agents in jia has significantly increased the effectiveness of treatment, but it required the organization of additional information support for medical personnel. disclosure of interest: none declared introduction: immunogenicity and development of anti-drug antibodies have been associated with treatment failure and adverse events during biologic treatment. anti-drug antibodies (adas) have been reported in 21% of juvenile idiopathic arthritis patients treated with adalimumab. however, their role in reducing adalimumab efficacy is still debated due to conflicting results. no study has been directed toward identification of neutralizing adas in paediatric rheumatic disorders. objectives: aim of our study was to detect adas, along with their clinical relevance, using a new theranostic peptide-base assay in a cohort of children with inflammatory chronic diseases on adalimumab treatment. methods: six candidate adalimumab derived peptide antigens (hc-cdr1, hc cdr2, hc cdr3, lc cdr1, lc cdr 2, lc cdr3) have been developed and optimized to be tested. their performance has been compared with commercial elisa kit and a spr-based optical assay (biacore®). assays have been performed in sera of a cohort of children receiving adalimumab due to an inflammatory chronic disease. mean age, disease duration, concomitant treatment with methotrexate (mtx), ana positivity, disease activity parameters and scores at the time of ada determination have been recorded. chisquare, and fisher exact test were used to compare data. pearson's and spearman's correlation tests were used to determine correlation coefficients for entered variables. results: eighteen (14 f, median age 12.6, range 3.8-16, yrs) patients were enrolled: 16 affected by juvenile idiopathic arthritis, 7 of whom complicated by jia -associated chronic uveitis, and 2 patients affected by chronic idiopathic uveitis. peptide assay revealed adas in 8 children, biacore in 6, commercial elisa in 5. of note, we found total concordance among the 3 tests just in 2 patients. no significant correlation has been proven among the 3 ada determinations. biacore and elisa determination showed significant concordance (r s : 0.72, p<0.006). the presence of hc cdr3 and lc cdr 3 resulted significantly correlated with disease activity (r s : 0.57, p<0.05), and, inversely, with disease remission on treatment (r s = -0.523, p<0.05). no patient experienced severe adverse events and no correlation with adas has been revealed conclusion: in chronic rheumatic disorders, novel reliable methods are urgently required to guide clinical decision and support decisions about switching within or between drugs in refractory children. the 3 different methods, since based on different antigenic probes, detect different antibody populations. the present peptide-based assays might contribute to identify neutralizing adas in patients treated with adalimumab. further validation in larger cohort is required. introduction: non-bacterial multifocal osteomyelitis (nbo) is a rare polygenic autoinflammatory disease, which is difficult to diagnose and treat. because of combination of bone lesions with arthritis and/ or axial skeleton damage in most cases the diagnosis of juvenile idiopathic arthritis (jia) or juvenile ankylosing spondylitis (jas) may be establish as a concurrent diagnosis, so this allows to legal use of biologics (ba) for the treatment. objectives: to analyze the single center experience of clinical and laboratory features of multifocal nbo in patients (pts) who were treated by ba for the last 8 years. methods: the study involved a retrospective cohort of multifocal nbo pts treated by different ba in our clinic from 2013 to 2020. all of them underwent standard rheumatological examination. in order to examine all localizations of the bone damage, a scintigraphy and/ or "whole body" mri scan was performed. results: among the whole group of pts with nbo (n=40) we identified 13 pts treated by ba (tnf-inhibitors only). the majority were girls (n=9, 69 %). age at disease onset was 10.2 years in average (me 10.2 range 1.3-16.5). for legal reason of ba administration, we classified our patients according to rheumatological features as jia or jas. 7 pts had jia (5 girls), 6 pts had jas (4 girls). among 13 pts 9 had oligoarthritis (69%), 4 had polyarthritis of low limbs (hip, knee, ankle). axial involvement was represented by active erosive sacroiliitis with deep bone marrow edema on mri scan in 9 pts (69%), active spondylitis of several bodies in thoracic spinein 2; erosive arthritis with partial ankyloses of facet joints of neck in 3 pts, multiple syndesmophytes in 1 girl. we found that definite axial lesions in nbo developed in very young children (in 2 y.old at minimum), much earlier than in "idiopathic" jas. hla b27 was presented in 5 pts (39%), 5 pts had ana in high titer (all of those hla b27-negative). the pts had bone lesions in different parts of skeleton: vertebral bodies -5 pts, clavicle -1, sternum, ribs -1, extremities bones, metaphysic mostly (tibial, fibular -7 pts), sacroiliac region -4 pts. extraskeletal manifestations were observed in 3 pts, one in each condition -uveitis, psoriasis pustulosus, acnae conglobate. in a girl with very severe course of disease, not responded to any therapy nbo was combined with familial mediterranean fever. high level of laboratory activity were detected before biologics in 10 pts (77%): esr acceleration up to 60 mm/h, increase of crp up to 80 mg/l. treatment included nsaids (all), methotrexate (7 pts), sulfasalazine (6 pts, but it was withdrawn in all pts), bisphosphonates (1 pt), prednisolone (3 pts). because of high activity of nbo with appearance of new bone lesions and persistent arthritis tnf inhibitors were administrated: etanercept in 10 pts, adalimumab -4 (2 as first line, 2second line), golimumab -1. at the start of ba the average age was 13.7 years (range 7.2-17.9); mean disease duration was 3,4 years (range 0.3-8.1). there were 2 cases of withdrawals. due to inefficacy etanercept was switched to adalimumab. disease activity decreasing was reached in the most of the patients (12 from 13). among them 2 pts developed the whole remission with resolving of active arthritis and bone marrow edema spots. skin lesions (psoriasis pustulosis and acnae conglobate) were significantly improved. there were no adverse events during the tnf therapy. conclusion: our experience of the therapy with tnf inhibitors in patients with high nbo activity has shown that this is a good and safe therapeutic option that is expected to prevent progression and bone destruction. . ae were reported for 71.7% of patients, most within 24 to 48 hours after the first or second injection: flu-like symptoms (57.5%), hypocalcaemia (37.5%) and hypophosphatemia (20%). underweight patients (body mass index < 18.5 kg/m²) accounted for 50% of hypocalcaemia. the frequency of all the ae not significantly decreased with the reduction of the first dose. only one serious hyponatremia occurred corresponding to a patient with renal failure before treatment. conclusion: our results were similar to those previously published: bisphosphonates are safe for osteoporosis in children. in the literature, sae are very rare in children, being limited to anecdotal osteopetrosis in cases of higher doses and long-term treatment, and delayed bone healing. anecdotal osteonecrosis of the jaw in adults has never been described in children. the use of bisphosphonates beforehand requires dietary measures (vitamin d and calcium supplementation). furthers systematic collection on efficacy and safety parameters for each bisphosphonates drug should confirm these data. introduction: the use of biosimilars in rheumatology has increased significantly over the last 5 years and has resulted in considerable cost savings. objectives: to assess the effectiveness and tolerability of the adalimumab biosimilar abp 501 in patients with jia. methods: a database of patients prescribed adalimumab in our service has been screened to identify patients with jia, who switched from the originator to the biosimilar. only patients who had a clinical review since they had started the biosimilar were included. a paired-samples t-test was conducted to compare the number of active joints at the clinic appointment before and after the initiation of the biosimilar treatment. the frequency and type of side effects, the clinical response and the number of patients who switched back to the originator have been collected. results: sixty-one patients who switched to the biosimilar abp 501 between february 2019 and february 2020 were included. they were comprised of 30 enthesitis-related arthritis (era), 13 polyarthritis, 9 oligoarthritis, 6 psoriatic and 3 systemic jia patients. their baseline characteristics and outcomes are summarised in table. the mean duration of follow-up after the switch to biosimilar was 10 months (range 2-23). eleven patients (18%) reported side effects; the most common side effect (n=7, 63.6%) was injection site reactions and the remaining 4 consisted of anaphylaxis, druginduced lupus, dizziness and bone pain, respectively. seven patients (11.5%) reverted to the adalimumab originator, 4 as a result of side effects, 3 because of ineffectiveness and one patient for both reasons. in addition, 3 patients were changed to a different biologic, one patient due to allergy to both the originator and biosimilar and the other two patients had active disease on the originator and biosimilar adalimumab. two patients stopped the biosimilar and remained off any biologic, in the first case this was due to a side effect and in the second case it was patient's choice. on the whole, 78.7% of patients had remained on abp 501 at their last visit. there was no significant difference in the active joint count before the biosimilar was started (mean 0.55+/-1.11) and after the switch (mean 0.6+/-1.59), (p= 0.855). introduction: golimumab (gol) is approved for polyarticular juvenile idiopathic arthritis (pjia) in patients of ≥2years but long-term safety data are limited. objectives: prospective monitoring of long-term safety and effectiveness of gol in routine care using the biker-registry. methods: baseline demographics, clinical characteristics, disease activity and safety parameters were compared to a contemporary 1:2 matched control cohort using alternative tnf inhibitors or methotrexate without exposure to a biologic. efficacy outcomes were jadas10, joint counts and functional status. safety assessments were based on adverse events (ae) reports. results: in this ongoing study, 65 pts initiating gol were matched to 130 with alternative tnfi and 65 biologic-naïve pts. pts starting gol had a longer disease duration (p<0.0001) and use of gol was significantly more often second line (84.6% vs 22.3%, p< 0.0001) and thus disease activity was lower at baseline. pts in the gol cohort used less corticosteroids, otherwise patients were comparable with pts treated with other tnfi (table 1 ). in gol treated ps a marked clinical response was noted at 6 months and beyond, indicating the effectiveness of gol in the treatment of pjia. a significant decrease of the mean jadas 10 11.3 to 5.3 (p= 0.0008) after 6 months of treatment was observed, as well as jia acr 30/50/70/90 response rates of 61/59/42/29%. jadas remission and minimal disease activity was observed in 27% and 53.7% after 6 months and in 39% and 54% after 12 months of treatment. rates of ae, sae and infectious ae were comparable in the gol cohort (87.5/100py, 3.4/100py and 11.1/100py), the alternative tnfi cohort (92.3/100py, 2.9/100py and 9.7/100py) and the mtx only cohort (121.2/100py, 2.1/100py and 18.5/100py). sae reported in the gol cohort were flares of uveitis and of jia (each 1) and fibromyalgia syndrome (1) . sae reported in the alternative tnf cohort was two serious infections (both influenza), one knee ligament injury, one flare of arthritis and one hyperventilation . no case of pregnancy, malignancy or death was reported. conclusion: golimumab seems an effective in treatment of pjia. tolerability was acceptable and comparable to alternative tnfi or mtx. recruitment to the project is ongoing. disclosure of interest none declared introduction: methotrexate (mtx) is one of the most commonly used disease-modifying anti-rheumatic drug in rheumatology practice. it has some side effects that can impair quality of life. the most common of them is associated with the gastrointestinal tract. objectives: the aim of the study is to evaluate and compare the frequency of methotrexate intolerance in adult and pediatric patients. methods: patients with rheumatologic diseases followed in hacettepe university pediatric rheumatology and rheumatology departments who used oral or parenteral methotrexate for at least 3 months were included in the study. methotrexate intolerance was assessed using 'methotrexate intolerance severity score (miss) questionnaire. the miss questionnaire consisted of 5 parts: abdominal pain, nausea, vomiting, fatigue and behavioral symptoms. the patients scored the severity of each symptom separately; 0: no symptoms, 1: mild symptoms, 2: moderate symptoms, 3: severe symptoms. a total score of 6 or more was defined as mtx intolerance. visual analogue scale (vas) ranging from 0 cm to 10 cm was performed to each patient concurrently with the miss questionnaire. in the pediatric patient group, miss questionnaire and vas assessment were applied to both patients and families. results: a total of 100 patients, 50 of whom were children, enrolled in the study. the mean age for children and adults were 11.78 (± 3.4) and 52.9 (± 11.8) respectively. the most frequent diagnosis of patients was juvenile idiopathic arthritis (78.0%) in children and rheumatoid arthritis in adults (68.0%). the mean mtx dose in adults and pediatric group was 12.5 (±3) mg vs 14.5 (± 3.6) mg (p: 0.004). the prevalence of mtx intolerance in children and adults were 66.0% (n:33) and 14.0% (n:7) respectively. the mean miss score in the pediatric group was higher compared with the adults (12.4±9.4 vs 1.84±4.5, p<0.001). similarly, the mean vas scores were higher in pediatric group (1.2±2.4 vs 4.2±3.2 (p<0.001)). there was a strong correlation between miss and vas scores between family and child evaluations (p <0.01, r = 0.95 / p <0.01, r = 0.94). abdominal pain, nausea, vomiting and behavioral symptoms were observed more frequently in children compared to adults. results: 3(4%) out of 73 patients were diagnosed with psoriasis denovo. one patient was treated with ada (a girl with undifferentiated arthritis who had positive hla-b 27, anf and family history of psoriasis -her grandmother had psoriasis), 2 patients were treated with eta (both female, one patient had undifferentiated arthritis, the other had enthesitis-related arthritis; both patients had positive hla -b 27 and anf negative). 2 patients achieved significant improvement after changing tnfalpha inhibitor (1-ada, 1-eta), 1 patient (was treated with eta) had significant improvement after discontinuation of biological therapy. conclusion: this single-center observational study demonstrates the possibility of developing psoriasis de-novo in patients with jia receiving tnf-alpha inhibitors. although more extensive research is needed, our data suggest that discontinuing the tnf-alpha inhibitor or switching to another tnfalpha inhibitor in patients with psoriasis de-novo should be considered as a treatment strategy in such cases. objectives: long-term surveillance of patients newly initiating toc treatment for at least 5 years compared to a cohort of patients newly initiating a comparator biologic using the biker-registry. methods: baseline demographics, clinical characteristics and disease activity, efficacy and safety parameters were compared. efficacy outcomes were jadas10, joint counts and functional status safety was assessed by adverse events (ae) reports. results: 161 patients with 161 matched controls have been recruited. patients starting on toc were older at treatment start (12.1 vs. 10.1 years (y); p<0.0001) and had a longer disease duration (p< 0.0001). toc was significantly more often a second line biologic (p< 0.0001). baseline jadas10 (17+/-10 vs 15+/-6), chaq-di (0.63+/-0.63 vs 0.65+/-0,64), esr 18+/-15 mm/h vs. 21+/-21 mm/h and active joint counts (7+/-7 vs. 6+/-5) were comparable. upon toc a substantial response with a significant reduction in jadas 10 from 16.8 to 3.4 (p<0.0001) after 12 months of treatment was observed. there were no significant differences between patients from the toc cohort and their matched controls in the jia acr 30/50/70/90 criteria, jadas 10, jadas remission and minimal disease activity was reached by comparable numbers (toc 37% and 58%; control cohort 37% and 60%). the total number of ae was comparable (toc cohort n=201 ae; (77/ 100py); control cohort n=207; (65/100py; rr 1.2; 95%ci 0.99-1.4). more serious ae (sae) were reported with toc. serious infections were documented at lower frequency with toc. uveitis events were documented at significantly higher frequency with tnf inhibitors most likely due to a selection bias (table 1) . sae with toc were depression (n=3) in 2 with suicidal intent, exacerbation of jia (n=2), septic arthritis, gastrointestinal infection, abdominal pain, colitis, paronychia and fracture. sae in the control cohort were depression, osteomyelitis, gastrointestinal infection and disease flare. no significant differences regarding cytopenias and elevated transaminases were observed. no gastrointestinal perforation, no vascular events and no deaths occurred. conclusion: toc was effective and comparable to treatment with alternative biologics. tolerability was acceptable. as toc was given as a second-line biologic in the vast majority of patients comparisons between the 2 cohorts have to be interpreted carefully. observation is ongoing. conclusion: in this retrospective cohort study in pediatric patients on rtx-treatment, we found undetectable low drug levels in adapositive patients, indicative for their neutralizing capacity. consequently, the lack of b-cel depletion leads to reduced treatment efficacy. patients with sle seem more susceptible to develop ada. if ada are detected, continuation of treatment seems non-effective and changing medication is advised. certainly when considering that, in this study, anaphylactic reactions only occurred in ada-positive patients. none declared objectives: the aim of this study was to evaluate retrospectively the long-term efficacy and safety of adalimumab in patients with jiaassociated uveitis. methods: we have retrospectively analysed nineteen jia patiens data with associated uveitis from our centre registry between 2010 and 2020, treated with adalimumab after failure of treatment with corticosteroids and metotrexate. demografic data and blood samples were collected at different time points while uveitis activity was evaluated by slit-lamp biomicroscopy. adverse events were recorded. results: registry records provided 10 years follow up of 19 jia patients data with associated uveitis. eleven patients were females (57.90 %) diagnosed as oligo/extended oligoarticular jia while eight (42.10 %) were males diagnosed as enthesitis related arthritis (era). before adalimumab was prescribed, all patients were previously treated with metotrexate during 3.5 years in avarage dose of 10 mg/ m 2 weekly. the mean uveitis duration, before adalimumab administration was 9 months. ten years long follow up period have showed that there were no new relapsis of uveitis while patients were receiving adalimumab and metotrexate. all of our patients were able to gradually tapper and stop treatment with topical steroids two months after adalimumab commencing. seven patients were able to stop biological treatment after 4.3 years of adalimumab usage. uveitis relapsed three monts after the adalimumab discontinuation only in one patient. two patient were lost to follow up during the transitional period. no serious adverse events were recorded. conclusion: during the long term follow up period adalimumab have shown good efficacy and safety profile in jia patients with active inflammatory ocular disease. introduction: post-streptococcal syndrome is a systemic immunemediated complication of beta-haemolytic streptococci infection, mostly seen as post-streptococcal arthritis, rheumatic fever or glomerulonephritis. uveitis is an uncommon manifestation of this syndrome. objectives: case report methods: case report results: a previously healthy 7-year-old female was admitted at the emergency department with prolonged fever, arthritis and red eye. she had a 4-month history of febrile episodes every two weeks, with axillary temperature ranging from 37,8 to 39ºc. migratory arthralgia affecting both knees and tibiotarsal joints showed up two months after the fever onset and worsened in the previous week, with refusal to walk. non-painful bilateral red eye for several weeks was mentioned. other symptoms were absent. recent infections were denied and family history was irrelevant. physical examination revealed lower limb muscular atrophy, knees pain and impaired function and bilateral tibiotarsal arthritis with inability to walk. ophthalmological observation showed a bilateral non-granulomatous anterior uveitis. sequential laboratory work up revealed a maximum eritrocitary sedimentation rate of 135 mm/h, maximum c-reactive protein of 5,3 mg/dl, microcytic hypochromic anemia, positive antistreptolysin o titer (asot) (initial result of 1250 that increased to 2500 in 4 weeks and later decreased to 500) and negative anti-nuclear antibodies. cardiac involvement was excluded. the diagnosis of rheumatic fever with concomitant poststreptococcal uveitis was assumed and the patient was treated with oral and topical ophthalmic corticosteroids with prompt clinical resolution of fever, acute polyarthritis and uveitis. no relapse occurred in a 5-year follow-up. conclusion: juvenile idiopathic arthritis (jia) is the most common cause of uveitis in childhood. although our patient clinical course could initially raise the possibility of systemic jia (sjia), the criteria that define this entity weren't all present and clinical and laboratory findings were more supportive of rheumatic fever. besides, uveitis occurs exceptionally in sjia, which turned this diagnosis even less reasonable. in our rheumatology unit, among 563 patients diagnosed with jia in 32 years, 89 had uveitis. however, in the group of 51 patients with sjia only one had ocular involvement, a boy with isolated vitritis. post-streptococcal uveitis (psu) typically presents as bilateral, non-granulomatous anterior uveitis, as described in this case. as streptococcal infection is very common among children and many patients may experience subclinical infection. psu should be considered in all patients with uveitis along with positive asot and negative routine investigations for other causes. although psu has been described in literature, to the best of our knowledge, this is the first reported case of concomitant rheumatic fever and psu. . ada was first tapered to every 3 weeks by 76% of the responders and then to every 4 weeks by 49% before discontinuing. fewer respondents used or tapered ifx, toc or aba. around 65% tapered the interval and 20% tapered the dose and interval for aba, 26% for toc and 37% ifx there were differences in the duration of tapering prior to discontinuation of specific medications. for ada it was 6 months in 62%, 12 months in 36% ,and 24 months in 10%. for ifx it was 6 months in 27%, 12 months in 45%, and 24 months in 33%. for toc it was 40% after 4 weeks, 87% after 6 weeks and 53% after 24 weeks. for aba i.v. it was 30% after 8 weeks, and 90% after 12 weeks. if combination therapy was used, 36% tapered the bdmard first, 62% csdmard first, and 12% both simultaneously. conclusion: this is the first survey to describe "real world" medication tapering and discontinuation practices of pediatric rheumatologists and ophthalmologists globally. most physicians start to taper medication after 24 months of remission on medication and discontinue after the 6 to 12 months of tapering. we would like to thank all the participating colleagues, who took time to fill out our surve introduction: jia-associated uveitis (jia-u) occurs in 10-20% of children with juvenile idiopathic arthritis (jia) and typically asymptomatic, and sight-threatening complications occur in 50% of children, (i.e. cataracts, vision loss). frequent ophthalmic examinations are important for early diagnosis and monitoring of uveitis activity. even after uveitis is controlled, risk of disease exacerbation still exists. therefore, frequent ophthalmic screening and monitoring is important for detection and management of jia-associated uveitis (jia-u). s100 proteins, cytokines, and chemokines detected in aqueous humor of patients with uveitis are also detected in tears. biomarker discovery using tears is promising since collection is noninvasive, feasible, well-tolerated, and close to the target organ. objectives: we aim to determine if s100 proteins, cytokines, and chemokines levels differ in tears of children with jia and jia-u and in children with jia-u by uveitis activity. methods: tears were collected using schirmer strips from children ≥5 years old with oligo-or polyarticular rf negative jia with (jia-u) and without uveitis (jia-no-u), and in children with jia-u at time of active and inactive eye disease. activity was defined by standardization of uveitis nomenclature (sun) criteria. active uveitis was anterior chamber inflammation grade ≥0.5+ cells. s100a8, a9, and a12 were measured by elisa, and il-18, il-8, ip-10, mcp-1, rant es, and sicam-1 by luminex assays. biomarker levels were compared in children with 1) jia-no-u (n=8) to active jia-u (n=8), and 2) jia-u (n=8) at time of active and inactive uveitis. results: children with jia-no-u and jia-u were matched by jia subtype and arthritis activity. they had primarily oligoarticular jia (63%), active arthritis (25%), and were on systemic medication (75%). at time of active uveitis, 75% had grade 0.5+, and 25% had 1+ and mean interval between time of active and inactive disease was 11 months. we found that levels of biomarkers in tears of children with jia-no-u compared to active jia-u were similar. although not statistically significant, levels of s100a12 (mean difference 12,190 pg/ml [95% ci -4847 to 29,227], p= 0.14) and sicam-1 (5329 pg/ml [95% ci -5372 to 16,031], p=0.28) were higher when uveitis was active compared to inactive. conclusion: our results suggest that s100a12 and sicam-1 are potential biomarkers of uveitis activity in jia-u, but not uveitis diagnosis. thus, neutrophils may play a role in the pathogenesis of anterior uveitis which has been reported in an animal model of acute anterior uveitis. identifying biomarkers using tears provides a noninvasive and objective method of monitoring uveitis. limitations are our heterogeneous cohort that varied by arthritis severity and immunosuppression, and minimally active uveitis. we were underpowered to detect statistically significant differences and continue to collect tears prospectively in children with jia-u with goal of n=28. despite low uveitis activity, we were still able to detect differences. further studies in larger and diverse cohorts are necessary to assess the role of s100a12 and sicam-1 in jia-u. objectives: to report an extremely rare presentation of gpa in a 12 year old with acute digital ischemia. a 12 year old boy, with a background of poorly controlled type 1 diabetes and hypothyroidism, initially presented to hospital unwell with diabetic ketoacidosis. treatment was initiated promptly with good response. furthermore, he was found to have weight loss, productive cough and hearing loss over the past 3 months. he was haemodynamically stable, but very pale and cachectic. he had reduced air entry and crackles on the right. there was hypertonia and clonus in his lower limbs. blood tests showed microcytic hypochromic anaemia (hb 82g/l), normal white cell count, thrombocytosis and raised inflammatory markers (crp 138mg/l and esr 68 mm/hr). his chest x-ray showed enlargement of the right hilum with consolidation/ atelectasis extending into the middle and lower lobes. mri scans of head and spine were normal apart from fluid opacification in the paranasal sinuses. he was screened for infections including tuberculosis and started on intravenous antibiotics. on day 13, he developed painful bluish discolouration of his left hand, particularly his thumb, index and middle fingers. his left radial and brachial pulses weren't palpable. a heparin infusion was started. a doppler scan showed occlusion of radial and ulnar arteries proximal to the wrist with no clear thrombus. he had a ct thoracic aorta with contrast which showed proximal left radial artery occlusion and distal ulnar artery occlusion with no evidence of proximal embolic source or vasculitis. it showed multiple perihilar masses (lymph nodes) in the right lung and peripheral parenchymal masses in both lungs, suggestive of atypical infection or connective tissue disease. blood tests still showed raised inflammatory markers(crp 107mg/l, esr 86 mm/hr and platelets 658 10 9 /l). an autoantibody screen showed positive anca with strongly positive anti pr3(>100 u/ml); other autoantibodies, including ana, ds dna and anti-phospholipid antibodies, were negative. he developed further ischaemia with bluish, painful discoloration of his right foot, especially right great toe, with a weakly palpable dorsalis pedis pulse. doppler scan revealed occlusion/narrowing of the posterior tibial artery 6cm proximal to the ankle. following vascular team advice, he was started on ilioprost infusion to aid reperfusion of the extremities involved, with good results. based on clinical and lab features of systemic inflammation, evidence of upper airway involvement(bilateral conductive hearing loss and sinusitis on mri scan), parenchymal lesions on ct chest and strong pr3 positivity, a diagnosis of gpa was made. results: our patient responded well to therapy including multiple pulses of high dose methylprednisolone and cyclophosphamide, with improvement of all organs involved and no further digital ischemia. conclusion: although gpa is very rare in children, it is associated with high morbidity and mortality. many studies show that the spectrum of paediatric gpa is not vastly different from adults, except for higher gender bias towards female, more constitutional and musculoskeletal symptoms and higher risk of subglottic stenosis. although there are a handful of case reports of digital ischaemia in adults with gpa, to our knowledge this is the first case report of acute digital ischaemia in paediatric gpa. early diagnosis and prompt treatment with a multidisciplinary team approach is paramount for good outcome. introduction: adenosine deaminase-2 deficiency (dada2) is a monogenic vasculitis syndrome whose presentation ranges from recurrent fevers and livedo reticularis to systemic vasculitis, hematologic and immunologic abnormalities, and early-onset stroke. it is characterized by biallelic loss-of-function mutations in the encoding gene of ada2 protein and low levels of ada2 enzymatic activity in the peripheral blood. the genotype and phenotype features of dada2 has a wide spectrum. treatment with anti-tnf inhibitors is effective in controlling vascular inflammation and reducing strokes. objectives: to describe two sisters with different presentations of dada2 and a deletion mutation on exon 7 of the ada2 gene. methods: medical data was used to describe the clinical manifestations of two siblings. parental informed consent was obtained. results: patient 1: a 10-year-old female had presented with fever, rash, arthralgia, hepatosplenomegaly, and coombs positive autoimmune hemolytic anemia (aiha) at the age of 7 years. she had been followed with a suspected diagnosis of systemic lupus erythematosus (sle) and steroids, azathioprine, mycophenolate mofetil had been used. her ana and complement levels were normal. because of unmet classification criteria of sle, genetic testing had been done, and no mutation found in the ada2 gene. cranial mr and mr angiography was normal. she was referred to our clinic after 2.5 years of the first manifestation. physical examination revealed raynaud phenomenon on both hands and feet, livedo reticularis, arthritis, and splenomegaly. laboratory tests indicated an increase in acute phase reactants, cd19, cd20, and switched memory b cell lymphopenia, and hypogammaglobulinemia. because of prolonged fevers, a thorax ct was obtained and aneurisms of the renal artery were seen. abdominal ct angiography indicated multiple aneurysms of both renal, intercostal, and hepatic arteries. repeated genetic analysis of the ada2 gene showed a homozygous deletion mutation on exon 7. she has been followed on anti-tnf and iv immunoglobulin without severe symptoms for a year. patient 2: the older sister had been followed with a diagnosis of familial mediterranean fever with e148q heterozygous mutation because of recurrent fever, abdominal pain, erysipelas-like erythema, elevated acute phase reactants, and splenomegaly. she did not have any other cutaneous or systemic findings. because of parental consanguinity, the ada2 gene was analyzed and a homozygous deletion mutation on exon 7 was found. she has been followed without any symptoms after anti-tnf treatment. throat swab was negative. abdomen ultrasound showed bowel wall thickening, testis ultrasound was normal. hsp diagnosis was confirmed. methylprednisolone iv was administered for three days, then oral prednisone was started. purpuric lesions, abdominal pain persisted, so we decided to add mmf (600mg/ m 2 /day) and prednisone was tapered in a month. results: thanks to mmf vasculitis lesions and abdominal symptoms disappeared in few days. mmf was continued for a month, tapered in 6 months. there was no evidence of relapse in a 6 months follow up. conclusion: these cases suggest that mmf may be useful to induce and maintain remission of recurrent hsp with gastrointestinal involvement. multicenter clinical trials with long-term follow up to confirm the efficacy of mmf in the treatment of hsp with gastrointestinal involvement are needed. introduction: henoch-schönlein purpura (hsp), the most common childhood vasculitis. cholecystitis is extremely rare in patients with hsp. this is the first case of a libyan child presenting with hsp complicated by calculus cholecystitis hsp nephritis. objectives: our aim is to present an unusual case of gall bladder involvement in an 8-year-old libyan female affected by hsp. methods: a case reports study results: : we report an unusual case of gall bladder involvement in an 8-year-old libyan female with hsp. she was referred to a rheumatology clinic due to hsp with chronic calculus cholecystitis and distended small bowel with fluid-like fecal material with no evidence of intussusception on an abdominal ultrasound. the patient had a one-month history of abdominal pain, purpuric lesion on lower limbs and swelling in both feet. she was admitted 3 times to another hospital before being referred to the rheumatology clinic. an abdominal sonography revealed a distended small bowel with fluid-like fecal material with no evidence of intussusception and chronic calculus cholecystitis; they treated her with urosdoxycholic acid tab at 250mg per day and ibuprofen syrup. then referred to our rheumatology clinic. after 40 days, she showed a purpuric rash over her lower extremities, mainly over her thighs and buttocks, microscopic hematuria, no arthritis, no fever, no abdominal pain; her blood pressure was normal at90\55mmhg, and she had normal laboratory tests (cbc, wbc 7.7, hgb 10.8, platelets 356 esr 20ml\hour, crp 1mg\dl was negative, c3 was 150mg\dl within normal range 90-180mg\dl, c4 was 35.4 mg\dl within normal range 10-40, anca, ana, as well antidsdna ab yielded negative, antistreptolysin-o (aso) titer was 250 todd , lft included total bilirubin , direct , indirect gpt,got, u�, creatinine ) except urine routine showed mild microscopic hematuria rbc 100 hpf , protein was nil ) urine for pro-tein disclosure of interest none declared p161 correlation of serum neopterin levels with disease activity and moneta 1 1 division of rheumatology, irccs, ospedale pediatrico bambino gesù, roma; 2 university of genova a multinational study of thrombotic microangiopathy in macrophage syndrome clinical impact of a targeted next-generation sequencing gene panel for autoinflammation and vasculitis laboratory biomarkers to facilitate differential diagnosis between measles and kawasaki disease in a pediatric emergency room: a retrospective study a rare case of measles-associated hemophagocytic lymphohistiocytosis in an infant. cureus children's interstitial and diffuse lung disease respiratory complications of the rheumatological diseases in childhood on behalf of dr nishant dharsandiya and dr j.p. keshrani paediatric rheumatology & immunology, dev children's hospital arthritis care res (hoboken) disclosure of interest: none declared development and initial validation of the ms score for diagnosis of macrophage activation syndrome in systemic juvenile idiopathic arthritis development and validation of the hscore, a score for the diagnosis of reactive hemophagocytic syndrome double-blind, placebo-controlled study of anakinra in pediatric and adult patients with still's disease l. schanberg 1 , p. nigrovic 2 duke children's hospital & health center, durham; 2 boston children's hospital, boston; 3 children's mercy kansas city, kansas city; 4 university of alabama at birmingham, birmingham; 5 nationwide children's hospital, columbus; 6 university of iowa hospitals and clinics children and adolescents with sle: not just little adults severe disease presentation and poor outcomes among pediatric systemic lupus erythematosus patients in south africa the checklist manifesto: how to get things right clinical review: checklists -translating evidence into practice the who surgical safety checklist: a review pehlivanoğlu 3 p283 gastrointestinal henoch-schönlein purpura treated with mycophenolate mofetil: description of two case reports venous vessel wall thickness in lower extremity is increased in male patients with behcet's disease increased vein wall thickness in behçet disease polyarteritis nodosa: a contemporary overview eular / printo / pres criteria for henoch -schönlein purpura , childhood polyarteritis nodosa , childhood wegener granulomatosis and childhood takayasu arteritis : ankara six patients were treated with canakinumab and 2 patients with anakinra. conclusion: it is known that excessive production of il-1β can cause inflammatory bone loss and abnormality. vitamin d deficiency and osteopenia/ osteoporosis may cause additional musculoskeletal problems besides arthritis and joint destruction in caps. we think that ca metabolism and bone mineral density measurements should be a part of routine controls in patients with caps. disclosure of interest none declared ab007 clinical and genetic features of patients with periodic syndrome associated with mutation of the tumor necrosis factor receptor gene and juvenile arthritis having mutations in tnfrsf1a gene m active arthritis in 8/9, it was poly in 2, oligo in 6. when assessing the clinical symptoms and laboratory activity of patients with jia, it was revealed that in the onset of the disease, systemic manifestations were observed in 8/12: fever in 8/12, rash in 4/12, hepatosplenomegaly in 5/ 12, pneumonitis in 2/12, carditis in 1/12 and lymphadenopathy in 5/12. high laboratory activity was recorded in 11/12. active arthritis in 10/12, it was polys in 4, oligo in 6. in all 100% of patients, the nucleotide variants of the tnfrsf1a gene were identified in the study. 9/21 of patients were diagnosed with traps. the most frequent heterozygous variant of tnfrsf1a gene with nucleotide substitution of c.362g>a was found in 7/9 of patients, in 1/9 of patients it was found homozygous variant with nucleotide substitution of c.362g>a, in 1/9 of children it was found heterozygous variant with deletion of c.337_339del. all of these variants are pathogenic. 12/21 of patients were diagnosed with ja: juvenile arthritis with a systemic onset was in 7/12, paucarticular arthritis was in 2/12, in 1/12 it was poly rf-and in 1/12 it was psoriatic arthritis. it is worth noting to note that in 6/12 a heterozygous version of the tnfrsf1a gene was detected with a nucleotide substitution c.362g> a, however, considering the absence of clinical manifestations of autoinflammatory disease and active articular syndrome in these patients, children were diagnosed with ja. in addition dvoryakovskaya: none declared, a. mamutova speaker bureau of: novartis, k. isayeva: none declared, r. denisova speaker bureau of: novartis covid-19 and relapsing kawasaki disease: a case report during the pandemia m. c. maggio ab009 introduction: the pandemia of covid-19 remains a global health alarm with high incidence of lethality, especially in older age groups who suffer from underlying medical conditions. however, children are less likely to manifest severe conditions. objectives: covid-19 was correlated to a higher incidence and a suspected increased risk of kawasaki disease (kd) in children anamnestic records revealed a previous kd, without coronary artery lesions (cal), 1 year before. results: he was treated with antibiotics, intravenous infusion of immunoglobulins (ivig) (2 gr/kg), acetylsalicylic acid (asa) (50 mg/kg in 4 doses/day) and reached defervescence into 2 days. echocardiography excluded cal. the nasopharyngeal swab for sars-cov-2 was doubt. the second throat swab done the day after ivig infusion, was negative; however, the third nasopharyngeal swab for sars-cov-2, done 4 days after ivig infusion, was positive. chest x-ray showed a significant lung interstitial thickening. il-6 levels were < 6.25 pg/ml (n.v. < 6.25 pg/ml). he continued treatment with antibiotics, asa (5 mg/kg/day), with the progressive resolution of the clinical symptoms and of the normalization of laboratory findings. conclusion: the peculiar outcome of the patient is the correlation of covid-19 with kd, recently reported as associated. kd is considered as a multifactorial autoinflammatory disease, induced by a cytokine hypersecretion with a systemic vasculitis. covid-19 is considered a cytokine storm syndrome, with a severe systemic vasculitis. sars-cov-2 infection could be the trigger that could lead to hyperinflammation of kd. the ivig infusion could explain the transient negative swab for sars-cov-2, with the successive positive relieve lasting 7 days, and the normal levels of il-6, detected after ivig infusion. relapsing kd is rare (1.7-3.5%); in our patient this event could be triggered by the documented sars-cov-2 infection. disclosure of interest none declared disclosure of interest none declared ab012 spectrum of systemic inflammatory syndrome in children during covid 19 pandemic in india d. b. pandya, on behalf of dr haresh dobariya pediatric rheumatology & immunology, dev children's hospital ab025 rituximab for treatment of resistant paediatric mctd v. paisal, s. compeyrot-lacassagne paediatric rheumatology the diagnosis and classification of of mixed connective tissue disease mixed connective tissue disease in children -case series the value of rituximab treatment in primary sjögren's syndrome juvenile idiopathic arthritis a multifaceted approach is essential for robust rehabilitation m methods: in a retrospective study 92 children (89% girls) aged median (iqr) 4,2 (1,6 -7,6) years with oligoarticular onset jia without extra-articular manifestations (oligo-ja) who did not received dmards were monitored. all children were met ilar criteria. ttriamcinolone acetonide (ta) was administered intra-articular at a dose of 20-40 mg with an injection interval of 3-6-12 months which was depended on the activity of the disease. the maximum allowable number of consecutive isolated intra-articular injections (is-iai) was 3-4. a total of 218 active joints were injected with ta: knees -156 injections, ankles -62 injections. all children were divided into two groups: active / inactive arthritis based on the effectiveness of local corticosteroid treatment. the average follow-up was 48 and physicians' assessment of jia disease activity efficacy is-iai of ta was no associated significantly with number of active joint of onset oligo-ja, cjadas10, serum level of crp mg/ml, esr mm/h, il6 pg/ml and tnf-α pg/ml, titer of anf. the mean inflamed synovial fluid of il6 levels 2208 abstracts from conferences and relevant studies were added. rcts were included if (i) patients were aged ≤ 20 years, (ii) patients had a previous defined pediatric rheumatic diagnosis and (iii) rct met predefined outcomes. studies were excluded in case of (i) observational or single arm study or (ii) sample size ≤ 5 patients. study design, location, duration, treatment, population, sample size, age criteria, gender, concomitant treatments and primary outcome was extracted. results: out of 550 screened references, 62 references reporting 35 unique rcts in pird. all 35 rcts reported efficacy while 34/35 rcts provided safety outcomes and 15/35 rcts provided pk data. ten of 17 reviewed bdmards are approved for pirds by the food and drug administration (fda). of these, seven had ≤ 2 rcts. the most common intervention was tnf inhibitors (63%) treatment with intravenous immunoglobulin (ivig) significantly reduces the risk of caas. however, up to 20% of cases are ivig resistant with a higher risk of cardiovascular complications. currently several second-line treatments are available for refractory kd. nonetheless, the existing literature is still unable to identify which treatment is the most effective. recent studies suggest that a il-1 receptor antagonist (anakinra) may be an effective therapy in refractory kd. objectives: we report the case of a 3 year-old boy diagnosed with kd refractory to conventional treatment, who developed giant caas successfully treated with subcutaneous (sc) anakinra. methods: case report. results: a 3 year-old boy was referred to our pediatric rheumatology unit 18 days after the onset of a typical refractory kd. he had been previously treated at a local hospital with two doses of ivig (2 g/kg), infused respectively 8 and 11 days after the onset of the fever. afterwards, given the persisting fever, doses of pulse intravenous (iv) methylprednisolone (mpdn 30 mg/kg/day) have been used for 3 days followed by oral prednisone (2 mg/kg/day). treatment with acetylsalicylic acid (60 mg/kg/day q8h) was also started. following a transient defervescence the day after the first iv pulse mpdn, fever relapsed and the echocardiography showed caas of left main coronary artery (lmca), left anterior descending (lad) and right coronary artery (rca) rationale and study design for a phase i/iia trial of anakinra in children with kawasaki disease and early coronary artery abnormalities (the anakid trial) the use of interleukin 1 receptor antagonist (anakinra) in kawasaki disease: a retrospective cases series there are few reports of acute kidney injury (aki) in kd, defined as serum creatinine level elevation to more than 1.5 times of baseline level. objectives: to describe the case of kawasaki disease complicated by aki methods: a 5-year-old female was admitted to our rheumatology unit with persistent fever (6 days), widespread polymorphous exanthema, change in lips and in oral mucosa. family history was unremarkable. she had no chronic underlying disease nor history of previous hospitalization. at admission, she appeared stable. body temperature was 38.9°c, o2 saturation was 96% in ambient area, blood pressure was 118/75 mm hg, heart rate was 90 bpm, respiratory rate was 21 breaths per minute. on examination she presented widespread polymorphous exanthema, changes in lips and in oral mucosa, cervical lymphadenopathy and bilateral conjunctival injection. results: exams revealed: white blood cells 11980/μl, hb 10.4 g/dl, platelets 389.000/μl, albumin 2.5 g/dl, serum sodium 126 meq/l, serum chloride 90 meq/l. transaminases were in normal range. creatinine was 1.5 mg/dl disclosure of interest none declared ab041 paediatric extra-pulmonary large vessel arteritis, a forme fruste of pediatric behcet's disease? we presented two siblings from a consanguineous marriage with different clinical presentations of dada2. further, we emphasize that genetic testing should be repeated in the presence of clinical suspicion. introduction: there are several scoring systems developed in japan that are clinically used to stratify high risk kd patients and thus identify the ones that may benefit from early adjunctive therapy. there are increasing reports from all over the world on poor performance of these scores in other ethnic populations. objectives: the aim of our study was to evaluate the kobayashi, egami, sano and kawamura scores in our population which is homogenous caucasian. methods: hospital database was retrospectively searched for code m30.3 of the international classification of diseases, 10th revision, clinical modification code: mucocutaneous lymph node syndrome [kawasaki] , over the period from january 2006 to december 2019. all patients who were seen in this period for the first time for complete or incomplete kawasaki disease, as defined by the american heart association, were included. we applied ivig resistance prediction scores (kobayashi, sano, egami and kawamura scores) to our cohort. only patients who received 2g/ kg ivig within the first 10 days of the disease were included in this analysis. the scores of prediction models were calculated for each patient and patients were assigned to high-or low-risk group accordingly. results: during the study period a total of 169 children were diagnosed with kd (61.5 % males, median age 3.28 years). all of them were caucasian except one child who was biracial (caucasian and african american). among them, 158 children were hospitalized in the acute phase of the disease and 11 children were seen in the subacute phase of the disease. 151 children were followed-up for at least one year to evaluate persistent coronary artery aneurysms (caa), which were observed in 8 (5.3 %) patients. among them, 2 were not treated with ivig and 2 received ivig after 10 days of illness. 125 patients were treated with ivig within first 10 days of illness and were included in the calculation of ivig resistance prediction scores. 24 (19.2 %) were ivig resistant. sensitivity of kobayashi, sano, egami and kawamura scores were 0.53, 0.47, 0.61and 0.58, respectively. specificity of those scores were 0.77, 0.87, 0.75 and0.58, respectively. we found no difference in demographic or clinical characteristics between ivig resistant and ivig responsive patients. patients with ivig resistance had significantly higher alt (p = 0.025), neutrophil-to-lymphocyte ratio (p = 0.036) and lower serum sodium (p = 0.009). conclusion: by applying the japanese scores to our population, we were able to identify most of the low-risk, but missed many of the high-risk patients. our results are consistent with caucasi n based population studies available to date. introduction: varicella zoster virus (vzv) related arterial ischemic stroke (ais) has been described in literature in pediatric age. however, the long-term course of post-vzv vasculopathy need to be inquired: clear information about prevalence of recurrence and severity of clinical outcome are lacking, even if a favorable evolution was initially described, and therapeutic protocols are not currently standardized. objectives: we aimed to describe the clinical, laboratory and neuroradiologic features of children affected by ais due to post-vzv referred to our institute and to present our experience in their therapeutic management. methods: we selected 22 pediatric patients (6 females) with ais and a cns confirmed vzv reactivation and/or with a vzv history in the previous 12 months. other causes of pediatric stroke (systemic disease, cardiac disease, trauma, major thrombophilia) were excluded. clinical, neuroimaging, laboratory and treatment data were reviewed, focusing on pediatric score outcome measure (psom) and executive functions final outcome. results: average age of ais onset, vzv primary infection and interval between infection and ais were: 4 years 10mo (range: 1 year and 8 mo-9 years and 11 months), 4 years and 5 months (range 8 months-9.4 years), and 7 months (range 10days-34 months), respectively. the ais involved the nucleo-capsular region in 18 cases, the cerebral cortex in 9 cases, the thalamus in 4 cases, and the pons in 3 subjects. seventeen patients had inflammatory focal cerebral arteriopathy (ifca). virological confirmation (vzv-dna or anti-vzv igg in the cerebrospinal fluid) was obtained in 11 patients. three patients were treated with trombectomy and one with rtpa. thirteen patients were treated with antiviral agents associated with steroids in 8 cases, with different administration schedules. only in one case steroid treatment was given without association with antiviral agents. one patient received a short course of steroid and antiviral treatment at the time of the stroke and then a more prolonged course after six months at the time of the virological diagnosis. prophylactic antiaggregants were administered to all patients. mean follow-up was 2 years and 5 months (range 6 mo -10 years) ; ifca was persistent in 12 cases and transient in 5 subjects. four patients presented a recurrence of post vzv arteriopathy, two of them presenting new stroke events. twelve patients presented a variable motor deficit at last follow up. the mean psom score of the cohort at the last visit was 1 (range 0-2). executive functions were evaluated at last follow up in twelve patients, showing no deficit in seven patients, a mild deficit in two patients and a severe deficit in the last three. conclusion: albeit a favourable evolution was initially described, our experience suggests that vzv-related ais may result in persistent fca and significant neurological impairment in the majority of cases. therapeutic approach, particularly involving steroid administration, still need to be validated. introduction: iga vasculitis/ henoch schönlein purpura (igav/hsp) is the most common vasculitis of childhood and renal involvement is the most serious long-term complication. a better understanding of the pathophysiology of the progression to kidney disease is required for better treatment to be achieved and current biomarkers of ig a vasculitis with nephritis (igavn) lack the predictive value. objectives: in this study, an untargeted metabolomics approach was performed to reveal the underlying molecular mechanism of disease pathogenesis and to find potential biomarkers of plasma samples from patients with igav and igavn.methods: igav was diagnosed according to the ankara criteria in 2008 (1). forty-five patients, including 39 active igav patients (h), 6 igavn (n), and 6 age-and gender-matched healthy controls (c), were enrolled in the study. plasma samples from subjects were collected on the same day of igav(hsp) diagnosis and before steroid or other immunosuppressive treatment initiated. this study has utilized liquid chromatography-mass spectrometry (lc-ms/ q-tof) to investigate the alterations in plasma metabolomic profiles. three separate pools, health controls, active igav , and igavn were created. peak picking, grouping, and comparison parts were performed (metabolite profiling) via xcms (https://xcmsonline.scripps.edu/) software. results: totally 2618 peaks were detected for group h, n and c. among them 355 peaks were found to be statistically significant and reliable (p< 0.05) and 155 of these peaks were found to be changed (fold change >1.5) between the groups c and h. on the other hand, 66 peaks were found to be changed (fold change >1.5) between the groups h and n. the number of the peaks on the intersection of the peaks found to be changed between the groups (c and h) and (h and n) was 39. based on putative identification results, 15 peaks were matched with 11 metabolites. we found an up-regulated level of dhap(18:0), prostaglandin d2/i2, 5methyltetrahydrofolic acid, porphobilinogen and n-acetyl-4-o-acetylneuraminic acid/n-acetyl-7-o-acetylneuraminic acid, 5-aminopentanamide /5-aminopentanoic acid, glycocholic acid, saccharopine, n2-succinyl-l-ornithine, gamma tocopherol, and galactosylsphingosine /glucosylsphingosine in igav patients. in conclusion, we have identified a number of metabolites that may be associated with the pathogenesis of igav. we also suggest that dhap (18:0), prostaglandin d2/i2, porphobilinogen, 5-methyltetrahydrofolic acid and n-acetyl-4-oacetylneuraminic acid/n-acetyl-7-o-acetylneuraminic acid may serve as biomarkers for predicting kidney disease since they were increased only in the patients who developed renal involvement at follow-up. children were divided into four groups: those with jia who didn't receive mtx yet (group 1); those who received mtx less than one gram during whole treatment (group 2); those who received mtx from 1 to 3 grams (group 3); children, received more than 3 grams of mtx (group 4). the autoimmune inflammatory process in jia can cause formation of pathological changes in the liver, even before the start of treatment. it is confirmed by a statistically significant correlation of bfgf level in 1st group with liver steatosis according to ultrasound examination (r = 0.8) and the level of c-reactive protein (r = 0.7). this indicates a close relationship between the intensity of the inflammatory process and collagen synthesis activation, which can further provoke liver fibrosis. alterative processes in the liver associated with autoimmune inflammation, as evidenced by the presence of a positive correlation between the level of alt and bfgf (r = 0.5). upon reaching mtx dose 1 gram and 3 grams, it is possible that compensatory processes in the liver are triggered, as evidenced by the negative correlation between the content of bfgf and hgf (r = -0.6).conclusion: the use of modern markers with routine laboratory and instrumental studies is appropriate for the timely determination of the risks of developing irreversible pathological changes in the liver during jia treatment with mtx. objectives: the aim of our study is to evaluate the efficacy of (iag) injections in hip in children with (jia) and to assess the factors predicting the improvement of this management. methods: this is a retrospective study, between 2006 and 2009, including patients with jia diagnosed according to the ilar criteria. the socio-demographic data were collected as well as the parameters of the disease. the activity was evaluated by jadas. the functional impact was assessed by the lequesne score. the treatments taken have been specified as well as the infiltrations received. the improvement after infiltration was assessed by jadas and lequesne score.results: fourteen patients were included, with mean age 17.21 +6.8 . the mean age at the onset of symptoms was 11 +0.5 [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] . subtypes of jia according to the ilar were: enthesitis-related arthritis in 7 cases, seropositive polyarticular jia in 2 cases, seronegative polyarticular jia in 2 cases, oligoarticular jia in 2 cases and juvenile psoriatic arthritis in one case. all the patients had hip arthritis, inaugural in 90% of the cases. of these, 92.8% had a flexion deformity and lower limb inequality. the average lequesne index was 8.5 +4.6. the treatments taken were methotrexate in 57.14% of the cases, sulfasalazine in 14.28% of the cases, and the combination of the two in 21.4% of the cases. eleven patients underwent hip infiltration, and three of them required more than one. eighty one percent improved thereafter. the number of infiltrations was not statistically associated with the lequesne index (p = 0.069). improvement after infiltration was negatively associated with the prior existence of an inequality of the lower limbs (p = 0.04). the existence of a flexion deformity was not associated with good results after infiltration (p = 0.476, r=-0,624). ten patients (90%) among those who had an infiltration did not have to resort to surgery. conclusion: iag injection is an adjunct therapy in aji with hip involvement offering a good results and delay surgery in the majority of cases. the presence of lower limb inequality is associated with less improvement of iag. conclusion: synovial rice bodies are rarely described in juvenile idiopathic arthritis, even less at disease onset. their presence has not been associated to a worse disease prognosis or joint outcome but awareness of the existence of this particular form of intraarticular loose bodies may encourage the clinician to use lower gauge needle during arthrocentesis procedure; this can prevent arthroscopy, as occurred in our case 1. arthroscopy may be necessary in some cases to achieve full drainage of the joint. in our series the duration of arthritis correlated with the size of rice bodies and the number and agressiveness of procedures needed to evacuate them. objectives: we described a case of liver involvement in sle presenting with emphasis on the differential diagnosis with autoimmune hepatitis. methods: case report study results: : an 8-year-old female patient was referred to the rheumatology clinic with complaints icteric sclera for 10 months anorexia, malaise, pain in the both knees, ankles joints and both wrists accompanied by swelling, and remarkable motion limitations. laboratory revealed t bilirubin 4.9 mainly direct 3.9 with elevated liver enzymes got 401, gpt 189, alkp 520, high glutamyl transpeptidase 56u\l her wbc 7.4 hgb 10, ptl 317, except very high esr 105ml\hr, crp was positive 190mg\dl, viral screen (hcv, hbsag, hiv) was normal, serology tests ana was positive with high titer 1280, anti ds-dna ab was positive 320, anti-sm was negative, anti lkm1 antibodies negative, anti smooth muscle ab negative soluble liver antigen were negative, antimitohondrial ab( m1,m2,m3). ultrasound abdomen revealed mild enlarged spleen, abnormal diffused increased liver echogenicity with early stage of liver cirrhosis treated her by fresh frozen plasma 5 times, vit k 10mg once\ day then was referred to rheumatology clinic regarding her serology tests & developed arthritis of her joints suspected psle! she was performed liver biopsy showed lesions necrotic inflammatory portal and lobular severe in eosinophilic polynuclear with cirrhosis evoking a syndrome of overlap associating a primary biliary cirrhosis and an autoimmune hepatitis. laboratory data revealed liver dysfunction and liver biopsy suggesting autoimmune hepatitis, and she underwent treatment for hepatitis (prednisolone with azathioprine), urosdoxycholic acid with fat-soluble vitamins k, d&a, e. however, with the elimination of jaundice and decreased hepatic enzyme levels, the prednisolone dose was tapered within 2 months and stopped before they were referred to rheumatology clinic. on her review of systems, she has malar rash, generalized fatigability. on physical examination, we found malar rash, levidoreticularis of her skin, swelling and limitation of movement in the knees, ankles, wrists joints. there was hepatosplenomegaly. laboratory data revealed liver treatment for hepatitis, ana still high titer 1:1280, antids dan positive with titer 307 iu\ml, antisma was negative .wbc 4.5, hgb 11.8, plt 268, esr 68ml\hr, her ultrasound abdomen: revealed slightly heterogeneous liver with coarse echotexture without focal lesion with liver span 14 cm.these paraclinical results together with the clinical findings strongly suggested systemic lupus erythematosus (sle) as the definitive diagnosis. indeed, in this case, aih was associated with sle, prednisolone orally for 2 months, after that dose was tapered and continued, rapid clinical improvement in arthritis, malaise, and general condition. azathioprine was continued. in addition, daily hydroxycholoquine sulfate overlapping of sle and aih should be suspected when aih patients present with a malar or other skin rash. the prompt diagnosis and adjustment of further treatment plans can improve disease outcomes and prevent liver disease progression. introduction: juvenile systemic lupus erythematosus (sle) is a chronic autoimmune disease characterized by multi-visceral involvement with an unpredictable prognosis. the diagnosis is usually made in young women aged between 20 to 40years, however, it can affect people at any age and it is classified as a juvenile illness when it starts before the age of 16. objectives: we are reporting the epidemical, clinical, therapeutical and evolutional characteristics of a series done in the pediatric pole in setif with 13 girls and 1 boy. methods: the average age of onset is 13 years. the average time limits of the diagnosis is 7 months. the clinical features is done with cutaneous, articular manifestations and fever respectively in 100% 71% and 57% of the cases ,followed by kidney damage in 42% of the cases , the cardiac, pulmonary and ophthalmological participations are reported with low percentage. haematological involvement was detected in 85% of the patients and the inflammatory syndrome was almost constant. a positive titer of anti-nuclear antibodies and anti-dna is objectified, as well as a reduction in the complement rate. antibodies anti gp 2 and anti cardiolopine are positive in 57% of cases. kidney damage was diagnosed in 42% of the cases , and only one case of overlap syndrome with dermatomyosits was reported. concerning the neurological form it was present in only one addolecent girl ,and only one case of familial lupus.results: the diagnosis is based on the classification of the american college of rheumatology (acr) 1982 revised on 1997 and the new criteria slicc"systemic lupus international collaborating clinics" . the clinical characteristics of our series relies on global data of literature with the predominance of cutaneous and articular involvement. with however some specific characteristics which are individualized by a more advanced age of onset, 13 years on average in our study versus 10 years and 12 years, the rarity of familial forms (1 case), a lower percentage of kidney damage (42% versus 63% and 80%).the therapeutic management was based on corticosteroid therapy and hydroxychloroquine in the majority of cases, the use of immunosuppressants has been reserved for severe forms. conclusion: lupus is an autoimmune disease with protean clinical manifestations, the prognosis of which is dominated by renal, neurological and thrombotic disorders. cortisonic treatments and immunosuppressants have significantly improved the prognosis for life . trial registration identifying number: lupus is an autoimmune disease with protean clinical manifestations, the prognosis of which is dominated by renal, neurological and thrombotic disorders. cortisonic treatments and immunosuppressants have significantly improved the prognosis for life . onset of inactive and active oligo-ja were not significantly differ. the analysis revealed a correlation between a short phase of beneficial effect after is-iai of ta and risk of activity disease (with an inactive phase of arthritis less than 3 months, the risk activity was or = 2.09, p <0.001; with an inactive phase less than 2 months -or = 8.9, p < 0.001). rtx was administered to patients who had received high-dose cs with 2-3 dmards; in all cases combined pulse therapy cs № 2-10 was preliminarily used. rtx 500 mg № 2 was applied after 6mo-2y from the debut of the disease. in all 5 cases, its use led to clinical improvement after 1-5 mo with normalization of laboratory activity indicators, in 4 cases a decrease in the level of b cells to 0-0.56 in μl was noted (3 with agammaglobulinemia). after 2 months 3 patients had severe infectious complications, 2 of them ended fatally. 2 another patients had a second stroke. the 1st patient survived, had a kidney allotransplantation, there is no disease activity. the 2nd patient, in connection with the development of the demyelinating process of cns, attempted to continue therapy using golimumab with ivig. it led to an increase in the infectious syndrome, therefore, we decided to refrain from continuing with itnf as well. the patient died after 2 years from the administration of rtx due to the progression of neurological disorders. 2 cases with auto-inflammatory syndromes were: chronic infantile neurologic cutaneous and articular syndrome received tcz; it was unsuccessful (hyperthermia and rash persisted, eye lesions progressed, there were no increase in height), later switched to anakinra. family mediterranean fever, received adalimumab (ada). the 1-year-course of ada leaded to the disappearance of articular and abdominal syndrome while maintaining persistent increased levels of esr and crp and periodic fever. the use of tcz in 2 patients with ssd was more successful. the first patient received it subcutaneously for 1 year, cs&dmards (3 were used) had already been canceled, lung and kidney lesions were contained, blood pressure normalized, escsg-ai decreased from 7 to 1, mrss decreased from 18 to 14. in the second case, the patient received tcz for 6 months i/v, decrease of escsg-ai 6.5 to 1, mrss 33 to 21 were noted, the dose of cs was halved, he also continued treatment with cyclophosphamide. we introduce a 13-year-old girl patient who has been admitted to our clinic with suspicion of an erythema nodosum. she had painful subcutaneous nodules for 4 weeks, especially on the lower extremities and her face. macroscopically, central necrotizing skin rashes could be seen. she had frank arthritis of both knee and ankle joints. the comprehensive serological diagnosis (including hepatitis serology and anti-streptolysin titer) were normal except for a slight increase in crp 0,9 mg/dl and esr 36 mm/h. the patient also complained of abdominal pain and bloody stools. calprotectin was 3613 μg/g. a gastro-coloscopy revealed a small mariske and a minimal inflammation of the ileocecal valve, without signs of vasculitis or chronic bowel disease. a skin biopsy revealed leukocytoclastic vasculitis of the small arteries. angiography of the intestinal arteries was rejected by the family. initially we started a treatment with methylprednisolone pulses followed by oral prednisolone. the patient showed a very good response with quick resolution of the skin symptoms and abdominal pain. the medication could be quickly tapered and discontinued at full remission after one month results: pan is classified as a cutaneous pan (cpan) when there are exclusive skin manifestations, besides arthralgia or arthritis. a systemic pan must be diagnosed with the involvement of internal organs. however, cutaneous pan may evolve into systemic pan. in our patient, the skin and joints were primarily affected. if the existing gastrointestinal complaints are part of a systemic pan or chronic bowel disease could not be cleared yet, due to refusal of further investigations. conclusion: cpan must be considered as a suspected diagnosis in patients with necrotizing skin nodules. as transition of the cutaneous into the systemic form cannot be predicted regular monitoring is mandatory. introduction: prevalence of behcet's disease in children is not known, but is probably very low. extra-pulmonary large vessel arteritis in these cases is even rarer as a presenting manifestation. objectives: to report two cases of paediatric extrapulmonary large vessel arteritis with a 'behcet like disease'. methods: we present case reports of two cases who presented to paediatric rheumatology opd to our department. ms. f, a 16 year old girl was referred to us with history of short duration of fever, generalized lymphadenopathy, neutrophilic leucocytosis, thrombocytosis, hyperglobulinemia and high inflammatory markers. on detailed history and examination she was found to have a healed palatal ulcer and her maternal aunt was found to have a history of recurrent oral ulcer, genital ulcer and enthesitis. patient's montoux test was positive but the gene expert for mtb was negative. md-ct showed a circumferential thickening of aorta, subclavian and bilateral renal artery with stenosis at origin of both renal arteries indicating a vasculitis. few necrotic nodes were also noted in lungs. lymph node biopsy suggested a reactive hyperplasia. tissue typing showed presence of hla b 44, b 51. she improved clinically with oral prednisolone and mycophenolate mofetil and had no recurrence till her recent follow up visit. second case, master fkn an 11 year old child was referred to us with a background of 2 week history of fever, non migratory arthritis, raised inflammatory markers and a symptomatic severe aortic regurgitation with pandiastolic flow reversal on 2d echo. his evaluation showed negative montoux, normal igg4 levels and hla b35 b 51 on tissue typing. his aortic wall thickness resolved with 1 mg/kg oral prednisolone and mycofenolate mofetil. results: both these cases have features similar to behcet's disease. these cases do not fulfil isg, icbd 2014 or icbd criteria for pediatric behcet's disease. however, the aortitis and other clinical features responded well to the treatment in both cases.conclusion: paediatric case with extra-pulmonary large vessel arteritis that do not meet criteria for behcet's disease but have specific clinical or laboratory features do respond well to immunosuppression. therefore, after ruling out other causes of the large vessel vasculitis, a possibility of form fruste of behcet's disease should be under consideration. publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. these abstracts have been published as part of pediatric rheumatology, volume 18, supplement 2, 2020: proceedings of the 26th european paediatric rheumatology congress (pres 2020). the full contents of the supplement are available at https://ped-rheum. biomedcentral.com/articles/supplements/volume-18-supplement-2. please note that this is part 2 of 2. key: cord-258049-l55mx4lp authors: mansbach, jonathan m.; clark, sunday; piedra, pedro a.; macias, charles g.; schroeder, alan r.; pate, brian m.; sullivan, ashley f.; espinola, janice a.; camargo, carlos a. title: hospital course and discharge criteria for children hospitalized with bronchiolitis date: 2015-01-28 journal: j hosp med doi: 10.1002/jhm.2318 sha: doc_id: 258049 cord_uid: l55mx4lp background: for children hospitalized with bronchiolitis, there is uncertainty about the expected inpatient clinical course and when children are safe for discharge. objectives: examine the time to clinical improvement, risk of clinical worsening after improvement, and develop discharge criteria. design: prospective multiyear cohort study. setting: sixteen us hospitals. participants: consecutive hospitalized children age <2 years with bronchiolitis. measurement: we defined clinical improvement using: (1) retraction severity, (2) respiratory rate, (3) room air oxygen saturation, and (4) hydration status. after meeting improvement criteria, children were considered clinically worse based on the inverse of ≥1 of these criteria or need for intensive care. results: among 1916 children, the median number of days from onset of difficulty breathing until clinical improvement was 4 (interquartile range, 3–7.5 days). of the total, 1702 (88%) met clinical improvement criteria, with 4% worsening (3% required intensive care). children who worsened were age <2 months (adjusted odds ratio [aor]: 3.51; 95% confidence interval [ci]: 2.07‐5.94), gestational age <37 weeks (aor: 1.94; 95% ci: 1.13‐3.32), and presented with severe retractions (aor: 5.55; 95% ci: 2.12‐14.50), inadequate oral intake (aor: 2.54; 95% ci: 1.39‐4.62), or apnea (aor: 2.87; 95% ci: 1.45‐5.68). readmissions were similar for children who did and did not worsen. conclusions: although children hospitalized with bronchiolitis had wide‐ranging recovery times, only 4% worsened after initial improvement. children who worsened were more likely to be younger, premature infants presenting in more severe distress. for children hospitalized with bronchiolitis, these data may help establish more evidence‐based discharge criteria, reduce practice variability, and safely shorten hospital length‐of‐stay. journal of hospital medicine 2015;10:205–211. © 2015 society of hospital medicine although bronchiolitis is the leading cause of hospitalization for us infants, 1 there is a lack of basic prospective data about the expected inpatient clinical course and ongoing uncertainty about when a hospitalized child is ready for discharge to home. 2 this lack of data about children's readiness for discharge may result in variable hospital length-of-stay (los). [3] [4] [5] one specific source of variability in discharge readiness and los variability may be the lack of consensus about safe threshold oxygen saturation values for discharge in children hospitalized with bronchiolitis. 6, 7 in 2006, the scottish intercollegiate guidelines net-work recommended a discharge room air oxygen (rao2) saturation threshold of 95%. 8 the same year, the american academy of pediatrics (aap) bronchiolitis clinical practice guideline stated that oxygen is not needed for children with rao2 saturations 90% who are feeding well and have minimal respiratory distress. 9 there is a need for prospective studies to help clinicians make evidenced-based discharge decisions for this common condition. we performed a prospective, multicenter, multiyear study [10] [11] [12] to examine the typical inpatient clinical course of and to develop hospital discharge guidelines for children age <2 years hospitalized with bronchiolitis. we hypothesized that children would not worsen clinically and would be safe to discharge home once their respiratory status improved and they were able to remain hydrated. we conducted a prospective, multicenter cohort study for 3 consecutive years during the 2007 to 2010 winter seasons, as part of the multicenter airway research collaboration (marc), a program of the emergency medicine network (www.emnet-usa.org). the number of participating sites varied over the 3 years: 13 in year 1, 16 in year 2, and 14 in year 3. each month from november 1 until march 31, site investigators across 12 us states used a standardized protocol to enroll a target number of consecutive patients from the inpatient wards and the intensive care unit (icu). we aimed to enroll 20% of our total sample from the icu. to over sample children in the icu, the ward and icu enrollments were separate. once the site reached their target enrollment for that month, the investigators would stop enrollment until the beginning of the following month. all patients were treated at the discretion of the treating physician. inclusion criteria were an attending physician's diagnosis of bronchiolitis, age <2 years, and the ability of the parent/guardian to give informed consent. the exclusion criteria were previous enrollment and transfer to a participating hospital >48 hours after the original admission time. therefore, children with comorbid conditions were included in this study. all consent and data forms were translated into spanish. the institutional review board at each of the 16 participating hospitals approved the study. of the 2207 enrolled children, we excluded 109 (5%) children with a hospital los <1 day due to inadequate time to capture the required data for the present analysis. among the 2098 remaining children, 1916 (91%) had daily inpatient data on all factors used to define clinical improvement and clinical worsening. thus, the analytic cohort was comprised of 1916 children hospitalized for bronchiolitis. investigators conducted detailed structured interviews. chart reviews were conducted to obtain preadmission and daily hospital clinical data including respiratory rates, daily respiratory rate trends, degree of retractions, oxygen saturation, daily oxygen saturation trends, medical management, and disposition. these data were manually reviewed, and site investigators were queried about missing data and discrepancies. a follow-up telephone interview was conducted with families 1 week after discharge to examine relapse events at both 24 hours and 7 days. we used the question: "how long ago did the following symptoms [eg, difficulty breathing] begin [for the] current illness?" to estimate the onset of the current illness. pulse was categorized as low, normal, or high based on age-related heart rate values. 13 presence of apnea was recorded daily by site investigators. 14 nasopharyngeal aspirate collection and virology testing as described previously, site teams used a standardized protocol to collect nasopharyngeal aspirates, 11 which were tested for respiratory syncytial virus (rsv) types a and b; rhinovirus (rv); parainfluenza virus types 1, 2, and 3; influenza virus types a and b; 2009 novel h1n1; human metapneumovirus; coronaviruses nl-63, hku1, oc43, and 229e; enterovirus, and adenovirus using polymerase chain reaction. 11, [15] [16] [17] defining clinical improvement and worsening clinical improvement criteria were based on the 2006 aap guidelines. 9 for respiratory rate and oxygen saturation, clinicians estimated average daily respiratory rate and oxygen saturation based on the recorded readings from the previous 24 hours. this estimation reflects the process clinicians use when rounding on their hospitalized patients, and thus may be more similar to standard clinical practice than a calculated mean. the respiratory rate criteria are adjusted for age. 18, 19 for daily estimated average oxygen saturation we used the aap criteria of rao2 saturation of 90%. considering that oxygen saturation is the main determinant of los, 20 healthy infants age <6 months may have transient oxygen saturations of around 80%, 21 and that errors in estimation may occur, we included a lowest rao2 of 88% in our improvement criteria. by combining the dichotomized estimated oxygen saturation (90% or not) with the lower limit of 88%, there was little room for erroneous conclusions. a child was considered clinically improved on the earliest date he/she met all of the following criteria: (1) none or mild retractions and improved or stable retractions compared with the previous inpatient day; (2) daily estimated average respiratory rate (rr) <60 breaths per minute for age <6 months, <55 breaths/minute for age 6 to 11 months, and <45 breaths/minute for age 12 months with a decreasing or stable trend over the course of the current day; (3) daily estimated average rao2 saturation 90%, lowest rao2 saturation 88% 21 ; and (4) not receiving intravenous (iv) fluids or for children receiving iv fluids a clinician report of the child maintaining oral hydration. children who reached the clinical improvement criteria were considered clinically worse if they required intensive care or had the inverse of 1 of the improvement criteria: moderate/severe retractions that were worse compared with the previous inpatient day, daily average rr 60 with an increasing trend over the current day, need for oxygen, or need for iv fluids. all analyses were performed using stata 12.0 (stata-corp, college station, tx). data are presented as proportions with 95% confidence intervals (95% cis), means with standard deviations, and medians with interquartile ranges (iqr). to examine potential factors associated with clinical worsening after reaching clinical improvement, we used v 2 , fisher exact, student t test, and kruskall-wallis tests, as appropriate. adjusted analyses used generalized linear mixed models with a logit link to identify independent risk factors for worsening after reaching clinical improvement. fixed effects for patient-level factors and a random site effect were used. factors were tested for inclusion in the multivariable model if they were found to be associated with worsening in unadjusted analyses (p < 0.20) or were considered clinically important. results are reported as odds ratios with 95% cis. we performed several sensitivity analyses to evaluate these improvement criteria: (1) we excluded the lowest rao2 saturation requirement of 88%, (2) we examined a 94% daily estimated average rao2 saturation threshold, 22 (3) we examined a 95% daily estimated average rao2 saturation threshold, 8 and (4) we examined children age <12 months with no history of wheeze. there were 1916 children hospitalized with bronchiolitis with data on all factors used to define clinical improvement and clinical worsening. the median number of days from the beginning of difficulty breathing until admission was 2 days (iqr, 1-5.5 days; range, 1-8 days) and from the beginning of difficulty breathing until clinical improvement was 4 days (iqr, 3-7.5 days; range, 1-33 days) ( figure 1 ). the variance for days to admission was significantly less than the variance for days to clinical improvement (p < 0.001). in this observational study, clinicians discharged 214 (11%) of the 1916 children before meeting the definition of clinical improvement. thus, 1702 (89%; 95% ci: 87%-90%) children reached the clinical improvement criteria, had a los >1 day, and had data on all factors ( figure 2 ). of the 1702 children who met the clinical improvement criteria, there were 76 children (4%; 95% ci: 3%-5%) who worsened ( figure 2 ). the worsening occurred within a median of 1 day (iqr, 1-3 days) of clinical improvement. forty-six (3%) of the children required transfer to the icu (1 required intubation, 1 required continuous positive airway pressure, and 4 had apnea), 23 (1%) required oxygen, and 17 (1%) required iv fluids. eight percent of children met multiple criteria for worsening. a comparison between children who did and did not worsen is shown in table 1 . in general, children who worsened after improvement were younger and born earlier. these children also presented in more severe respiratory distress, had moderate or severe retractions, oxygen saturation <85% at hospitalization, inadequate oral intake, and apnea documented during the hospitalization. neither viral etiology nor site of care influenced whether the children worsened after improving. however, stratified analysis of children based on initial location of admission (ie, icu or ward) showed that among the children admitted to the icu from the emergency department (ed), 89% met the improvement criteria and 19% clinically worsened. in contrast, among children admitted to the ward from the ed, 89% met the improvement criteria, and only 2% clinically worsened. stratified multivariable models based on the initial location of admission from the ed (ie, icu or ward) were not possible due to small sample sizes after stratification. none of these children had relapse events requiring rehospitalization within either 24 hours or 7 days of discharge. on multivariable analysis (table 2) , independent risk factors for worsening after reaching the clinical improvement criteria were young age, preterm birth, and presenting to care with more severe bronchiolitis represented by severe retractions, inadequate oral intake, or apnea. to further evaluate the improvement criteria in the current analysis, multiple sensitivity analyses were conducted. the frequency of clinical worsening after reaching the improvement criteria was stable when we examined different ra02 criteria in sensitivity analyses: (1) excluding ra02 as a criterion for improvement: 90% met improvement criteria and 4% experienced clinical worsening, (2) changing the average ra02 threshold for clinical improvement to 94%: 62% met improvement criteria and 6% experienced clinical worsening, and (3) changing the average ra02 threshold for clinical improvement to 95%: 47% met improvement criteria and 5% experienced clinical worsening. furthermore, stratifying by age <2 months and restricting to more stringent definitions of bronchiolitis (ie, age <1 year or age <1 year 1 no history of wheezing) also did not materially change the results (see supporting figure 1 in the online version of this article). we compared the 214 children who were discharged prior to reaching clinical improvement with the 1702 children who reached the clinical improvement criteria. the 214 children were less likely to be age <2 months (22% vs 30%; p 5 0.02). these 2 groups (214 vs 1702) were similar with respect to in this large, multicenter, multiyear study of children hospitalized with bronchiolitis, we found that children present to a hospital in a relatively narrow time frame, but their time to recovery in the hospital is highly variable. nonetheless, 96% of children continued to improve once they had: (1) improving or stable retractions rated as none/mild, (2) a decreasing or stable rr by age, (3) estimated average rao2 saturation 90% and lowest rao2 saturation of 88%, and (4) were hydrated. the 4% of children who worsened after clinically improving were more likely to be age <2 months, born <37 weeks, and present with more severe distress (ie, severe retractions, inadequate oral intake, or apnea). based on the low risk of worsening after clinical improvement, especially among children admitted to the regular ward (2%), we believe these 4 clinical criteria could be used as discharge criteria for this common pediatric illness with a predominantly monophasic clinical course. variability in hospital los for children with bronchiolitis exists in the united states 3 and internationally. 4,5 cheung and colleagues analyzed administrative data from over 75,000 children admitted for bronchiolitis in england between april 2007 and march 2010 and found sixfold variation in los between sites. they concluded that this los variability was due in part to providers' clinical decision making. 5 srivastava and colleagues 23 addressed variable clinician decision making in bronchiolitis and 10 other common pediatric conditions by embedding discharge criteria developed by expert consensus into admission order sets. they found that for children with bronchiolitis, the embedded discharge criteria reduced the median los from 1.91 to 1.87 days. in contrast to the single-center data presented by white and colleagues, 24 the prospective, multicenter marc-30 data provide a clear understanding of the normal clinical course for children hospitalized with bronchiolitis, determine if children clinically worsen after clinical improvement, and provide data about discharge criteria for children hospitalized with bronchiolitis. although there is a lack of rigorous published data, the lower tract symptoms of bronchiolitis (eg, cough, retractions) are said to peak on days 5 to 7 of illness and then gradually resolve. 25 in the present study, we found that the time from the onset of difficulty breathing until hospital admission is less variable than the time from the onset of difficulty breathing until either clinical improvement or discharge. although 75% of children have clinically improved within 7.5 days of difficulty breathing based on the iqr results, the remaining 25% may have a more prolonged recovery in the hospital of up to 3 weeks. interestingly, prolonged recovery times from bronchiolitis have also been noted in children presenting to the ed 26 and in an outpatient population. 27 it is unclear why 20% to 25% of children at different levels of severity of illness have prolonged recovery from bronchiolitis, but this group of children requires further investigation. given the variability of recovery times, clinicians may have difficulty knowing when a child is ready for hospital discharge. one of the main stumbling blocks for discharge readiness in children with bronchiolitis is the interpretation of the oxygen saturation value. 6, 8, 9, 20, 28 however, it should be considered that interpreting the oxygen saturation in a child who is clinically improving in the hospital setting is different than interpreting the oxygen saturation of a child in the ed or the clinic whose clinical course is less certain. 22 in the hospital setting, using the oxygen saturation value in in the aap guideline, 9 4% of children clinically worsened after they met the improvement criteria, a clinical pattern observed previously with supplemental oxygen. 28 this unpredictability may explain some of the variation in providers' clinical decision making. 5 the children who worsened, and therefore deserve more cautious discharge planning, were young (<2 months), premature (<37 weeks gestational age), and presented in more severe distress. those children admitted to the icu from the ed worsened more commonly than children admitted to the ward (19% vs 2%). interestingly, the viral etiology of the child's bronchiolitis did not influence whether a child worsened after reaching the improvement criteria. therefore, although children with rv bronchiolitis have a shorter hospital los than children with rsv bronchiolitis, 11 the pattern of recovery did not differ by viral etiology. in addition to unsafe discharges, clinicians may be concerned about the possibility of readmissions. although somewhat controversial, hospital readmission is being used as a quality of care metric. [29] [30] [31] one response to minimize readmissions would be for clinicians to observe children for longer than clinically indicated. 32 however, shorter los is not necessarily associated with increased readmission rates. 33 given that the geometric mean of hospital charges per child with bronchiolitis increased from $6380 in 2000 to $8530 in 2009, 34 the potential for safely reducing hospital los by using the discharge criteria proposed in the current study instead of other criteria 8 may net substantial cost savings. furthermore, reducing los would decrease the time children expose others to these respiratory viruses and possibly reduce medical errors. 35 our study has some potential limitations. because the study participants were all hospitalized, these data do not inform admission or discharge decisions from either the ed or the clinic; but other data address those clinical scenarios. 22 also, the 16 sites that participated in this study were large, urban teaching hospitals. consequently, these results are not necessarily generalizable to smaller community hospitals. although numerous data points were required to enter the analytic cohort, only 9% of the sample was excluded for missing data. there were 214 children who did not meet our improvement criteria by the time of discharge. although the inability to include these children in the analysis may be seen as a limitation, this practice variability underscores the need for more data about discharging hospitalized children with bronchiolitis. last, site teams reviewed medical records daily. more frequent recording of the clinical course would have yielded more granular data, but the current methodology replicates how data are generally presented during patient care rounds, when decisions about suitability for discharge are often considered. we documented in this large multicenter study that most children hospitalized with bronchiolitis had a wide range of time to recovery, but the vast majority continued to improve once they reached the identified clinical criteria that predict a safe discharge to home. the children who worsened after clinical improvement were more likely to be younger, premature infants presenting in more severe distress. although additional prospective validation of these hospital discharge criteria is warranted, these data may help clinicians make more evidence-based discharge decisions for a common pediatric illness with high practice variation, both in the united states 3 and in other countries. 4, 5 infectious disease hospitalizations among infants in the united states a hospital is no place to be sick variation in inpatient diagnostic testing and management of bronchiolitis watson ph international variation in the management of infants hospitalized with respiratory syncytial virus. international rsv study group population variation in admission rates and duration of inpatient stay for bronchiolitis in england impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations pulse oximetry in pediatric practice in: nhs quality improvement scotland. edinburgh, scotland: scottish intercollegiate guidelines network diagnosis and management of bronchiolitis prospective multicenter study of children with bronchiolitis requiring mechanical ventilation prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis apnea in children hospitalized with bronchiolitis evaluation of the cardiovascular system: history and physical evaluation apnea in children hospitalized with bronchiolitis respiratory viral infections in patients with chronic, obstructive pulmonary disease evaluation of real-time pcr for diagnosis of bordetella pertussis infection evaluation of three real-time pcr assays for detection of mycoplasma pneumoniae in an outbreak investigation normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies development of heart and respiratory rate percentile curves for hospitalized children effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. pediatrics longitudinal assessment of hemoglobin oxygen saturation in healthy infants during the first 6 months of age. collaborative home infant monitoring evaluation (chime) study group prospective multicenter study of bronchiolitis: predicting safe discharges from the emergency department delays in discharge in a tertiary care pediatric hospital using quality improvement to optimise paediatric discharge efficiency bronchiolitis in infants and children: treatment; outcome; and prevention wolters kluwer health duration of illness in infants with bronchiolitis evaluated in the emergency department duration of illness in ambulatory children diagnosed with bronchiolitis a clinical pathway for bronchiolitis is effective in reducing readmission rates measuring hospital quality using pediatric readmission and revisit rates pediatric readmission prevalence and variability across hospitals preventability of early readmissions at a children's hospital. pediatrics hospital readmission: quality indicator or statistical inevitability? children's hospitals with shorter lengths of stay do not have higher readmission rates trends in bronchiolitis hospitalizations in the united states preventable adverse events in infants hospitalized with bronchiolitis key: cord-001687-paax8pqh authors: henkel, jan; woodruff, maria a.; epari, devakara r.; steck, roland; glatt, vaida; dickinson, ian c.; choong, peter f. m.; schuetz, michael a.; hutmacher, dietmar w. title: bone regeneration based on tissue engineering conceptions — a 21st century perspective date: 2013-09-25 journal: bone res doi: 10.4248/br201303002 sha: doc_id: 1687 cord_uid: paax8pqh the role of bone tissue engineering in the field of regenerative medicine has been the topic of substantial research over the past two decades. technological advances have improved orthopaedic implants and surgical techniques for bone reconstruction. however, improvements in surgical techniques to reconstruct bone have been limited by the paucity of autologous materials available and donor site morbidity. recent advances in the development of biomaterials have provided attractive alternatives to bone grafting expanding the surgical options for restoring the form and function of injured bone. specifically, novel bioactive (second generation) biomaterials have been developed that are characterised by controlled action and reaction to the host tissue environment, whilst exhibiting controlled chemical breakdown and resorption with an ultimate replacement by regenerating tissue. future generations of biomaterials (third generation) are designed to be not only osteoconductive but also osteoinductive, i.e. to stimulate regeneration of host tissues by combining tissue engineering and in situ tissue regeneration methods with a focus on novel applications. these techniques will lead to novel possibilities for tissue regeneration and repair. at present, tissue engineered constructs that may find future use as bone grafts for complex skeletal defects, whether from post-traumatic, degenerative, neoplastic or congenital/developmental “origin” require osseous reconstruction to ensure structural and functional integrity. engineering functional bone using combinations of cells, scaffolds and bioactive factors is a promising strategy and a particular feature for future development in the area of hybrid materials which are able to exhibit suitable biomimetic and mechanical properties. this review will discuss the state of the art in this field and what we can expect from future generations of bone regeneration concepts. after 15 years of tissue engineering & regenerative medicine 1.0 and another 10 years of 2.0 versions ( 1) the era of tissue engineering 3.0 has begun. this review will des-care outcomes. today major reconstructive surgeries (due to trauma or tumour removal) are still limited by the paucity of autologous materials available and donor site morbidity. recent advances in the development of scaffold-based tissue engineering (te) have given the surgeon new options for restoring form and function. there are now bioactive biomaterials (second generation) available that elicit a controlled action and reaction to the host tissue environment with a controlled chemical breakdown and resorption to ultimately be replaced by regenerating tissue. third-generation biomaterials are now being designed to stimulate regeneration of living tissues using tissue engineering and in situ tissue regeneration methods. engineering functional bone using combinations of cells, scaffolds and bioactive factors are seen as a promising approach and these techniques will undoubtedly lead to ceaseless possibilities for tissue regeneration and repair. there are currently thousands of research papers and reviews available on bone tissue engineering, but there is still a major discrepancy between scientific research efforts on bone tissue engineering and the clinical application of such strategies. there is an evident lack of comprehensive reviews that cover both the scientific research aspect as well as the clinical translation and practical application of bone tissue engineering techniques. this review will therefore discuss the state of the art of scientific bone tissue engineering concepts and will also provide current approaches and future perspectives for the clinical application of bone tissue engineering. bone as an organ has next to its complex cellular composition a highly specialised organic-inorganic architecture which can be classified as micro-and nanocomposite tissue. its mineralised matrix consists of 1) an organic phase (mainly collagen, 35% dry weight) responsible for its rigidity, viscoelasticity and toughness; 2) a mineral phase of carbonated apatite (65% dry weight) for structural reinforcement, stiffness and mineral homeostasis; and 3) other non-collagenous proteins that form a microenvironment stimulatory to cellular functions (2) . bone tissue exhibits a distinct hierarchical structural organization of its constituents on numerous levels including macrostructure (cancellous and cortical bone), microstructure (harversian systems, osteons, single trabeculae), sub-microstructure (lamellae), nanostructure (fibrillar collagen and embedded minerals) and subnanostructure (molecular structure of constituent elements, such as mineral, collagen, and non-collagenous organic proteins) ( figure 1 ) (3) . macroscopically, bone consists of a dense hard cylindrical shell of cortical bone along the shaft of the bone that becomes thinner with greater distance from the centre of the shaft towards the articular surfaces. cortical bone encompasses increasing amounts of porous trabecular bone (also called cancellous or spongy bone) at the proximal and distal ends to optimise articular load transfer (2) . in humans, trabecular bone has a porosity of 50-90% with an average trabecular spacing of around 1mm and an average density of approximately 0.2 g·cm -3 (4) (5) (6) . cortical bone has a much denser structure with a porosity of 3-12% and an average density of 1.80 g·cm -3 (5, 7) . on a microscopic scale, trabecular struts and dense cortical bone are composed of mineralized collagen fibres stacked parallel to form layers, called lamellae (3-7 µm thick) and then stacked in a±45° manner (2) . in mature bone these lamellae wrap in concentric layers (3-8 lamellae) around a central part named haversian canal which containings nerve and blood vessels to form what is called an osteon (or a haversian system), a cylindrical structure running roughly parallel to the long axis of the bone (3) . cancellous bone consists of interconnecting framework of rod and plate shaped trabeculae. on a nanostructural level, the most prominent structures are the collagen fibres, surrounded and infiltrated by mineral. at the sub-nanostructural level three main materials are bone crystals, collagen molecules, and non-collagenous organic proteins. for further details the reader is referred to (3) . mineralised bone matrix is populated with four boneactive cells: osteoblasts, osteoclasts, osteocytes and bone lining cells. additional cell types are contained within the bone marrow that fills the central intramedullary canal of the bone shaft and intertrabecular spaces near the articular surfaces (8) . bone has to be defined as an organ composed of different tissues and also serves as a mineral deposit affected and utilised by the body's endocrine system to regulate (among others) calcium and phosphate homeostasis in the circulating body fluids. furthermore, recent studies indicate that bone exerts an endocrine function itself by producing hormones that regulate phosphate and glucose homeostasis integrating the skeleton in the global mineral and nutrient homeostasis (9) . bone is a highly dynamic form of connective tissue which undergoes continuous remodelling (the orchestrated removal of bone by osteoclasts followed by the formation of new bone by osteoblasts) to optimally adapt its structure to changing functional demands (mechanical loading, nutritional status etc.). from a material science point of view bone matrix is a composite material of a polymer-ceramic lamellar fibre-matrix and each of these design and material aspects influence the mechanical properties of the bone tissue (10) . the mechanical properties depend on the bone composition (porosity, mineralisation etc.) as well as the structural organisation (trabecular or cortical bone architecture, collagen fibre orientation, fatigue damage etc.) (11) . collagen possesses a young's modulus of 1-2 gpa and an ultimate tensile strength of 50-1 000 mpa, compared to the mineral hydroxyapatite which has a young's modulus of ~130 gpa and an ultimate tensile strength of ~100 mpa. the resulting mechanical properties of the two types of bone tissue, namely the cortical bone and cancellous bone, are shown in table 1 . age and related changes in bone density have been reported to substantially influence the mechanical properties of cancellous bone (12) . as outlined above, bone shows a distinct hierarchical structural organization and it is therefore important to also define the mechanical properties at microstructural levels ( table 2) . although the cancellous and cortical bone may be of the same kind of material, the maturation of the cortical bone material may alter the mechanical properties at the microstructural level. bone tissue is also known to be mechano-receptive; both normal bone remodelling and fracture or defect healing are influenced by mechanical stimuli applied at the regenerating defect site and surrounding bone tissue (17) (18) (19) (20) . in contrast to most other organs in the human body, bone tissue is capable of true regeneration, i.e. healing without the formation of fibrotic scar tissue (21) . during the healing process basic steps of fetal bone development are recapitulated and bone regenerated in this way does not differ structurally or mechanically from the surrounding undamaged bone tissue (22) . however, despite this tremendous regenerative capacity, table 1 mechanical properties of compact (cortical) and spongy (cancellous) bone. reproduced and modified from (13) . dry specimen (submicrostructure) (16) 22 5-10% of all fractures are prone to delayed bony union or will progress towards a non-union and the development of a pseudarthrosis (23) (24) . together with large traumatic bone defects and extensive loss of bone substance after tumour resection or revision surgery after failed arthroplasties, these pathological conditions still represent a major challenge in today's clinical practice. the rangeof bone graft materials available to treatsuch problems in modern clinical practice essentially include autologous bone (from the same patient), allogeneic bone (from a donor), and demineralised bone matrices, as well as a wide range of synthetic bone substitute biomaterials such as metals, ceramics, polymers, and composite materials. during the last decades, tissue engineering strategies to restore clinical function have raised considerable scientific and commercial interest in the field of orthopaedic surgery as well as reconstructive and oromaxillofacial surgery. yet, the treatment of bone defects and the search for bone substitute materials is not just a modern day phenomenon, with its history reaching back through millennia. the quest for the most efficient way to substitute for lost bone and to develop the best bone replacement material has been pursued by humans for thousands of years. in peru, archaeologists discovered the skull of a tribal chief from 2000 bc in which a frontal bone defect (presumably from trepanation) had been covered with a 1 mm-thick plate of hammered gold (25) . trephined incan skulls have been found with plates made from shells, gourds, and silver or gold plates covering the defect areas (26) . in a skull found in the ancient center of ishtkunui (armenia) from approx. 2000 bc, a 7 mm diameter skull defect had been bridged with a piece of animal bone (27). these pursuits are not limited to skull surgeries involving bone substitutes. ancient egyptians have been shown to have profound knowledge of orthopaedic und traumatological procedures with surgeons having implanted iron prostheses for knee joint replacement as early as 600 bc, as analyses of preserved human mummies have revealed (28). the first modern era report of a bone xenograft procedure is believed to be the dutch surgeon job janszoon van meekeren in 1668 (29-30). a skull defect of a russian nobleman was successfully treated with a bone xenograft taken from the calvaria of a deceased dog. the xenograft was reported to have become fully incorporated into the skull of the patient. in the 1800s, plaster of paris (calcium sulphate) was used to fill bone cavities in patients suffering from tuberculosis (31). attempts were also made to fill bone defects with cylinders made from ivory (32). in 1820 the german surgeon phillips von walters described the first clinical use of a bone autograft to reconstruct skull defects in patients after trepanation (33). walters successfully repaired trepanation holes, following surgery to relieve intracranial pressure, with pieces of bone taken from the patient's own head. in 1881, scottish surgeon william macewen described the first allogenic bone grafting procedure: he used tibial bone wedges from three donors that had undergone surgery for skeletal deformity correction (caused by rickets) to reconstruct an infected humerus in a 3-year-old child (34) major contributions leading to the development of modern day bone grafting procedures and bone substitutes have been made by ollier and barth in the late 1800s. louis léopold ollier carried out extensive experiments to study the osteogenic properties of the periosteum and other various approaches to new bone formation, mainly in rabbit and dog models. he also meticulously reviewed the literature on bone regeneration available at that time and in 1867 he published his 1 000-page textbook 'traite experimentel et clinique de la regeneration des os et de la production artificielle du tissu osseux', in which he described the term 'bone graft' ("greffe osseuse") for the first time (35) . in 1895 the german surgeon arthur barth published his treatise 'ueber histologische befunde nach knochenimplantationen' ('on histological findings after bone implantations') presenting his results of various bone grafting procedures involving the skull and long bones (humerus, forearm bones) of dogs and rabbits including histological assessment (36) . today, both ollier's and barth's work are considered to be milestones in the development of present day bone grafting procedures and bone substitute materials. with the development of new orthopaedic techniques and increased numbers of joint replacement procedures (prostheses), the demand for bone grafts increased in the 20 th century, leading to the opening of the first bone bank for allogenic bone grafts in new york in 1945 (37) . but the risk of an immunological reaction from transplanted allogenic bone material was soon recognized and addressed in various studies (38) (39) . several procedures such as the use of hydrogen peroxide to macerate bone grafts ("kieler span") in the 1950s and 1960s to overcome antigenity were not successful (40) (41) . today, bone substitute materials such as (bovine) bone chips are routinely used in clinical practice after being pretreated to remove antigen structures. however, due to the processing steps necessary to abolish antigenicity, most of these grafts do not contain viable cells or growth factors and are therefore inferior to viable autologous bone graft options. when allografts with living cells are transplanted, there is a risk of transmitting viral and bacterial infections: transmission of human immunodeficiency virus (hiv), hepatitis c virus (hcv), human t-lymphozytic virus (htlv), unspecified hepatitis, tuberculosis and other bacteria has been documented (mainly) for allografts (mainly from those containing viable cells) (42) . as early as 1932, the work of the swiss h. matti proved the paramount meaning of autologous cancellous bone grafts for bone regeneration approaches (43) . having conducted various experiments on the osteogenic potential of autologous and allogenic bone, schweiberer concluded in 1970 that the autologous transplant remains the only really reliable transplantation material of the future, if applied to bring about new bone formation or crucially to support the bridging bone defects (44) . even though this statement was made more than 50 years ago, it still remains valid today, when bone is still the second most transplanted material, second only to blood. worldwide more than 3.5 million bone grafts (either autografts or allografts) are performed each year (45) . recent advances in technology and surgical pro-cedures have significantly increased the options for bone grafting material, with novel products designed to replace both the structural properties of bone, as well as promote faster integration and healing. the number of procedures requiring bone substitutes is increasing, and will continue to do so as the population ages and physical activity of the elderly population increases. therefore, while the current bone grafting market globally is estimated to be in excess of $2.5 billion us each year, it is expected to increase at a compound annual growth rate of 7-8% (45) . although the last decades have seen numerous innovations in bone substitute materials, the treatment of bone defects with autologous bone grafting material is still considered to be the 'gold standard' against which all other methods are compared (46) . autologous bone combines all the properties desired in a bone grafting material: it provides a scaffold for the ingrowth of cells necessary for bone regeneration (=osteoconductive); it promotes the proliferation of stem cells and their differentiation into osteogenic cells (=osteoinductive) and it holds viable cells that can form new bone tissue (= osteogenic) (22, 47) . however, the available volume of autologous bone graft from a patient is limited and an additional surgical procedure is required to harvest the grafting material which is associated with a significant risk of donor site morbidity. 20-30% of autograft patients experience morbidity such as chronic pain or dysaesthesia at the graft-harvesting site (48) . large bone defects (>5 cm) may be treated with bone segment transport or free vascularized bone transfer (49) , as the use of an autologous bone graft alone is not recommended because of the risk of graft resorption despite good soft tissue coverage (50) . the vascularised fibula autograft (51) and the ilizarov method (52) (53) (54) are the most commonly used treatment methods for larger bone defects; however, complications are common and the process can be laborious and painful for the patient as she/he may be required to use external fixation systems for up to one and half years (49, (55) (56) . the limitations of existing bone grafting procedures, either autologous or allogenic in nature, and the increased demand for bone grafts in limb salvage surgeries for bone tumours and in revision surgeries of failed arthroplasties have renewed the interest in bone substitute materials and alternative bone grafting procedures (57) . in 1986, masquelet and colleagues (58) first described a new two-stage technique taking advantage of the body's immune response to foreign materials for bone reconstruction. the authors called it the 'concept of induced membranes' -soon to become known as the 'masquelet technique': in a first step, a radical debridement of necrotic bone and soft tissue is followed by the filling of the defect site with a polymethylmethacrylate (pmma) spacer and stabilisation with an external fixator. after the definitive healing of the soft tissue, a second procedure is performed 6-8 weeks later, when the pmma spacer is removed and a morcellised cancellous bone graft (from the iliac crest) is inserted into the cavitiy (59-60). the cement spacer was initially thought to prevent the collapse of the soft tissue into the bone defect and to prepare the space for bone reconstruction. however, it was soon discovered that the pmma spacer does not only serve as a place holder, but that a foreign body reaction to the spacer also induces the formation of a membrane that possesses highly desirable properties for bone regeneration (60-61): the induced membrane was shown to be richly vascularised in all layers; the inner membrane layer (facing the cement) composed of synovial like epithelium and the out part is made from fibroblasts, myoblasts and collagen. the induced membrane has also been shown to secrete various growth factors in a time-dependent manner: high concentrations of vascular endothelial growth factor (vegf) as well as transforming growth factor β (tgf β) are secreted as early as the second week after implantation of the pmma spacer; bone morphogenetic protein 2 (bmp-2) concentration peaks at the fourth week. the induced membrane stimulates the prolifera-tion of bone marrow cells and differentiation towards an osteoblastic lineage. finally, clinical experience has shown that the cancellous bone inside the induced membrane is not subject to resorption by the body. ever since its introduction the 'induced membrane'-technique has been used very successfully in various clinical cases (see (59) and references therein). however, the masquelet technique still requires the harvesting of an autologous bone graft, and with that come all the potential aforementioned complications. furthermore, the use of alternate bone substitute materials, such as hydroxyapatite tricalcium phosphate, in combination with the masquelet technique has so far yielded results inferior to the use the masquelet technique with autologous bone grafting material (59, 62) . besides the masquelet technique, a more recent innovation has also significantly improved the clinical approach to restoring bone defects. the development of the reamer-irrigator-aspirator (ria © )-system (depuy-synthes) has given clinicians an alternative to iliac crest harvesting to retrieve bone grafting materials from patients: the ria system provides irrigation and aspiration during intramedullay reaming, allowing the harvesting of finely morselised autologous bone and bone marrow for surgical procedures requiring bone grafting material (63). the ria was initially developed to lower the intramedullary pressure during the reaming of long bones to reduce the risk of fat embolisms and pulmonary complications such as the acute respiratory distress syndrom (ards), as well as to reduce local thermal necrosis of bone tissue (64) (65) . however, the finely morselised autologous bone and bone marrow that is collected by the ria has been shown to be rich in stem cells, osteogenic cells and growth factors and has been recognized to be a suitable bone graft alternative to the iliac crest autograft tissue (66) (67) . also, ria enables the harvesting of larger bone graft volumes compared to the iliac crest (approx. 40 cm 3 for the femur and 33 cm 3 for the tibia) (48, 65) . furthermore, the risk of complications from the harvesting procedure has been reduced significantly (ria 6% vs. 19.37% for iliac crest autografts) (68) . since its introduction, the indications for use of ria have been further extended to include the treatment of postoperative osteomyelitis (69) and the harvesting of mesenchymal stem cells (mscs) (70) . the innovation driven by the ria systems was so significant, that the journal "injury" has dedicated a complete issue to the data available on ria and its applications recently (71) . a systematic review on the reamer-irrigator-aspirator indications and clinical results has recently been published by cox et al (72) . the masquelet technique as well as the ria-system is nowadays frequently used in clinical practice, in-dependently. however, the two techniques may also be combined to further improve their effectiveness when treating severe bone defects, for example in posttraumatic limb reconstruction (73) . an example of a case from one of our author's clinical practice (m.s.) combining the use of masquelet technique and the use of the ria-system to treat a complex case of tibial nonunion is provided in figure 2 . both the masquelet technique and the development of the ria-system represent significant improvements in today's clinical approach to bone reconstruction and regeneration. however, utilising these techniques, we have still not been able to replace autologous bone grafting in order to avoid surgical graft retrieval procedures with all the associated disadvantages. however, with research looking towards increasingly sophisticated bone tissue engineering techniques and their first clinical applications, the quest for developing improved bone substitute material advances to the next level. bone substitutes can be defined as "a synthetic, inorganic or biologically organic combination-biomaterialwhich can be inserted for the treatment of a bone defect instead of autogenous or allogenous bone" (74) . this definition applies to numerous substances and a variety of materials have been used over time in an attempt to substitute bone tissue. although merely of historic interest and with no significance in modern therapies, the use of seashells, nuts, gourds and so forth show that humans have strived for bsm for thousands of years. with the introduction of tissue engineering and its clinical application the regenerative medicine in 1993 (75) the modern day quest for bsms has undergone a significant change. the limitations of current clinical approaches have necessitated the development of alternative bone repair techniques and have driven the development of scaffold-based tissue engineering strategies. in the past, mostly inert bone substitute materials have been used, functioning mainly as space holders during the healing processes. now a paradigm shift has taken place towards the use of new 'intelligent' tissue engineering biomaterials that would support and even promote tissue re-growth (76) . according to the "diamond concept" of bone tissue engineering (77) (78) , an ideal bone substitute material should offer an osteoinductive three-dimensional structure, contain osteogenic cells and osteoinductive factors, have sufficient mechanical properties and promote vascularisation. despite extensive research in the field of bone tissue engineering, apart from the "gold standard" figure 2 clinical case combining the masquelet-technique and the ria-system to treat a tibial non-union. 51 year old male acquired a gustillo 3b fracture of the right tibia and fibula and was treated with a stage procedure with locked plating and a free flap . the patient's progress was very slow and an implant failure occurred 8 months post-operatively (a). the patient was then referred for the further management and underwent debridement of the non-union site on the distal tibia by lifting the flap (b). the size of the extensive bone defect is shown in b (intraoperative image of situs and x-ray image with retractor in defect site). additionally, a pmma bone cement spacer was inserted into the tibial defect as part of the masquelet technique. postop x-ray images after surgery with the pmma spacer (circles) in place (c). 8 weeks later the pmma spacer was removed and the induced membrane at the defect site was packed with autologous cancellous bone graft obtained from the femur using the reamer-irrigator-aspirator (ria) technique. (d) shows assembled ria system, insert showing morselised autologous bone and bone marrow graft obtained. postop films after the second surgery (e). 7 weeks after bone grafting the defect showed good healing and patient was able to fully bear weight as tolerated. over the following 2 months x-ray images showed progressive bridging of the zone and he was able to return to work with light duties. he was reviewed again 7 months post-surgery and had returned to work full-time and was walking long distances without any support (f). autograft bone, no currently available bsm can offer these properties in one single material. therefore, the fundamental concept underlying tissue engineering is to combine a scaffold or three-dimensional construct with living cells, and/or biologically active molecules to form a "tissue engineering construct" (tec), which promotes the repair and/or regeneration of tissues (79) (80) . currently used bsm can be classified into different subgroups according to their origin (76, 81): 1) bsm of natural origin this group consists of harvested autogenous bone grafts as well as allogenic bsm, such demineralised bone matrix, corticocancellous or cortical grafts, cancellous chips (from either cadavers or living donors) (82) (83) (84) . xenogenic materials, for example porous natural bone hydroxyapatite from animal bones (bovine, equine, porcine etc.) are also part of this group (85) . phytogenic materials such as bone-analogue calcium phosphate originally obtained from marine algae or coral derived materials, also fall into this category (86-87). this groups contains ceramics such as bioactive glasses (88) , tricalciumphosphates (tcp) (89) (90) , hydroxyapatite (ha) (91) (92) (93) and glass ionomer cements as well as calcium phosphate (cp) ceramics (94) . metals such as titanium also belong to this group. furthermore polymers including polymethylmethacrylate (pmma), polylactides/ poliglycolides and copolymers as well as polycaprolactone (pcl) (95) are summarised in this group (76, 79, (96) (97) . 3) composite materials bsm combining different materials such as ceramics and polymers are referred to as composite materials (92, (98) (99) . by merging materials with different structural and biochemical properties into composite materials, the properties of composite materials can be modified to achieve more favourable characteristics, for instance with respect to biodegradability (79, 97) . 4) bsm combined with growth factors natural or recombinant growth factors such a bone morphogenic protein (bmp), platelet-derived growth factor (pdgf), transforming growth factor-ß (tgf-β), insulin-like growth-factor 1, vascular endothelial growth factor (vegf) and fibroblast growth factor can be added to increase the biological activity of bsm (100-101). for example, a composite material made of medicalgrade polycaprolactone-tricalcium phosphate (mpcl-tcp) scaffolds (combined with recombinant human bmp-7) has been demonstrated to completely bridge a critical-sized (3 cm) tibial defect in a sheep model (102) . 5) bsm with living cells mesenchymal stem cells (103) (104) (105) , bone marrow stromal cells (106) (107) , periosteal cells (108) (109) , osteoblasts (110) and embryonic (111) as well as adult stem cells (112) have been used in bone tissue engineering (22, 101, (113) (114) (115) (116) . these cells can generate new tissue alone or can be used in combination with scaffold matrices. bsms can also be classified according to their properties of action. an overview of the currently available bsm for clinical (orthopaedic) use and their mode of action is given in table 3 (reproduced from (117)). scaffolds serve as three-dimensional structures to guide cell migration, proliferation and differentiation. in load bearing tissues, it also serves as temporary mechanical support structure. scaffolds substitute for the function of the extracellular matrix and need to fulfil highly specific criteria. an ideal scaffold should be (i) three-dimensional and highly porous with an interconnected pore network for cell growth and flow transport of nutrients and metabolic waste; (ii) should have surface properties which are optimized for the attachment, migration, proliferation and differentiation of cell types of interest (depending on the targeted tissue); (iii) be biocompatible, not elicit an immune response and be biodegradable with a controllable degradation rate to compliment cell/tissue in-growth and maturation; (iv) its mechanical properties should match those of the tissue at the site of implantation and (v) the scaffold structure should be easily and efficiently reproducible in various shapes and sizes (97) . biocompatibility represents the ability of a material to perform with an appropriate response in a specific application (118) . as a general rule, scaffolds should be fabricated from materials that do not have the potential to elicit immunological or clinically detectable primary or secondary foreign body reactions (119) . parallel to the formation of new tissue in vivo, the scaffold may undergo degradation via the release of by-products that are either biocompatible without proof of elimination from the body (biodegradable scaffolds) or can be eliminated through natural pathways from the body, either by simple filtration of by-products or after their metabolisation (bioresorbable scaffolds) (97) . due to poor vascularisation or low metabolic activity, the capacity of the surrounding tissue to eliminate the by-products may be low leading to a build up of the by-products thereby causing local temporary disturbances (97) : a massive in vivo release of acidic degradation by-products leading to inflammatory reactions has been reported for several (120) (121) (122) . another example is the increase of osmotic pressure or ph caused by local fluid accumulation or transient sinus formation from fibre reinforced polyglycolide pins used in orthopaedic applications (120) . it is also known that calcium phosphate biomaterial particles can cause inflammatory reactions after being implanted (although this inflammatory reaction may be considered desirable to a certain extent as it subsequently stimulates osteoprogenitor cell differentiation and bone matrix deposition) (123) . these examples illustrate that potential problems related to biocompatibility in tissue engineering constructs for bone and cartilage applications may be related to the use of biodegradable, erodible and bioresorbable polymer scaffolds. therefore, it is important that the three dimensional tissue engineering construct (tec) is exposed at all times to sufficient quantities of neutral culture media when undertaking cell culture procedures, especially during the period where the mass loss of the polymer matrix occurs (97) . for applications in vivo, it is of course not possible to expose the tec to neutral media, and one therefore has to carefully take into account the local specifications (ph, vascularisation, metabolic activity etc) of the tissue to be engineered when accessing biocompatibility of a tec. the design of tissue engineering scaffolds needs to consider physico-chemical properties, morphology and bio-mechanical properties as well as degradation kinetics. the scaffold structure is expected to guide the development of new bone formation by promoting attachment, migration, proliferation and differentiation of bone cells. parallel to tissue formation, the scaffold should also undergo degradation in order to allow for ultimate replacement of scaffold material with newly formed, tissue engineered bone. furthermore, the scaffold is also responsible for (temporal) mechanical support and stability at the tissue engineering site until the new bone is fully matured and is able to withstand mechanical load. as a general rule, the scaffold material should be sufficiently robust to resist changes in shape resulting from the introduction of cells into the scaffold (each of which should capable of exerting tractional forces) and from wound contraction forces that would be evoked during tissue healing in vivo (79) . in order to achieve optimal results, it is therefore necessary to carefully balance the biomechanical properties of a scaffold with its degradation kinetics. a scaffold material has to be chosen that degrades and resorbs at a controlled rate, giving the tec sufficient mechanical stability at all times, but at the same time allowing new in vivo formed bone tissue to substitute for its structure. figure 3 depicts the interdependence of molecular weight loss and mass loss of a slow degrading composite scaffold and also shows the corresponding stages of tissue regeneration (80) . at the time of implantation the biomechanical properties of a scaffold should match the structural pro-perties of the tissue it is implanted into as closely as possible (124) . it should possess sufficient structural integrity for the period until the engineered tissue ingrowth has replaced the slowly disappearing scaffold matrix with regards to mechanical properties. in bone tissue engineering the degradation and resorption kinetics of the scaffold have to be controlled in such a way that the bioresorbable scaffold retains its physical properties for at least 6 months to enable cell and tissue remodelling to achieve stable biomechanical conditions and vascularisation at the defect site (97) . apart from host anatomy and physiology, the type of tissue that is aimed to be engineered also has a profound influence on the degree of remodelling: in cancellous bone the remodelling takes 3-6 months, while cortical bone will take twice as long, approximately 6-12 months, to remodel (79) . whether the tec will be part of a load bearing or non-load bearing site will also significantly influence the needs for mechanical stability of the tec as mechanical loading can directly affect the degradation behaviour as well (79) . utilising orthopaedic implants to temporarily stabilise the defect area also influences the requirements for biomechanical stability of the tec significantly (18, 125) . it is therefore crucial to meticulously select the scaffold material individually for each tissue engineering approach to tailor the mechanical properties and degradation kinetics exactly to the purpose of the specific tec (97) . consequently, there is not one "ideal scaffold material" for all bone tissue engineering purposes, but the choice depends on the size, type and location of the bone tissue to be regenerated. the surface area of a scaffold represents the space where pivotal interactions between biomaterial and host tissue take place. the performance of a tec depends fundamentally on the interaction between biological fluids and the surface of the tec, and it is often mediated by proteins absorbed from the biological fluid (126) . the initial events include the orientated adsorption of molecules from the surrounding fluid, creating a specific interface to which the cells and other factors respond to the macrostructure of the scaffold as well as the microtopography and chemical properties of the surface determine which molecules are adsorbed and how cells will attach and align themselves (127) . the focal attachments made by the cells with their substrate then determines cell shape, which in turn transduces signals via the cytoskeleton to the nucleus resulting in expression of specific proteins which may be structural or signal-related and contribute towards the cell phenotype. due to technical progress, we are now able to manipulate materials at the atomic, molecular, and supramolecular level, and bulk materials and surfaces can be designed at a similar dimension to that of the nanometer constituent components of bone (2): in natural bone, hydroxyapatite plates are approximately between 25 nm in width and 35 nm in length while collagen type 1 is a triple helix 300 nm in length, 0.5 nm in width and with a periodicity of 67 nm (128) . "nanomaterials" commonly refers to materials with basic structural units in the range 1-100 nm (nanostructured), crystalline solids with grain sizes between 1 and 100 nm (nanocrystals), individual layers or multilayer surface coatings in the range 1-100 nm (nanocoatings), extremely fine powders with an average particle size in the range 1-100 nm and fibres with a diameter in the range 1-100 nm (nanofibres) (2) . the close proximity of the scale of these materials to the scale of natural bone composites makes the application of nanomaterials for bone tissue engineering a very promising strategy. surfaces with nanometer topography can promote the availability of amino acid and proteins for cell adhesion to a great extent, for example, the adsorption of fibronectin and vitronectin [two proteins known to enhance osteoblast and bone forming cell function (129) ] can be significantly increased by decreasing the grain size on the scaffold/implant surface below 100 nm (130) . it has also been shown that calcium-mediated cell protein adsorption on nanophase material promotes unfolding of these proteins promoting bone cell adhesion and function (130) . current literature supports the hypothesis that by creating surface topographies with characteristics that approximate the size of proteins, a certain control over protein adsorption and interactions will be possible. since the surface characteristics regarding roughness, topography and surface chemistry are then transcribed via the protein layer into information that is comprehensible for the cells (127) , this will enable the fabrication of surface properties directly targeted at binding specific cell types. in vitro, osteoblast adhesion, proliferation and differentiation and calcium deposition is enhanced on nanomaterials with grain sizes less than 100 nm (130) (131) . the adherence of osteoblasts has been shown to increase up to threefold when the surface is covered with nanophase titanium particles instead of conventional titanium particles (132) . nano-and microporosiy has also been shown to promote osteogenic differentiation (133) and osteogenesis (134) . the use of nanomaterials to achieve better osteointegration of orthopaedic implants and for bone tissue engineering approaches has been extensively summarised in several recent reviews (2, 135-138) and will not be reviewed in its entirety here. however, it becomes clear that rough scaffold surfaces favour attachment, proliferation and differentiation of anchorage-dependent bone forming cells (139) . osteogenic cells migrate to the scaffold surface through a fibrin clot initially established immediately after implantation of the tec from the haematoma caused by the surgical procedure (101) . the migration causes retraction of the temporary fibrin matrix and, if not well secured, can lead to detachment of the fibrin from the scaffold during wound contraction leading to decreased migration of the osteogenic cells into the scaffold (140) (141) . with regards to surface chemistry, degradation properties and by-products (relating to ph, osmotic pressure, inflammatory reactions etc.) are of importance and have been briefly discussed already. in the following section, the role of calcium phosphate in the osteoinductivity of biomaterials will be summarized as an example of how surface chemistry may be manipulated to benefit scaffold properties. to date, most synthetic biomaterials that have been shown to be osteoinductive contained calcium phosphate underlining the crucial role of calcium and phosphate in osteoinduction properties of biomaterials (142) . as summarised above, adequate porosity and pore size is crucial for bone tissue engineering scaffolds in order to allow sufficient vascularisation and enable a supply of body fluids throughout the tec. together with this nutrient supply, a release of calcium and phosphate ions from the biomaterial surface takes places and is believed to be the origin of bioactivity of calcium phosphate biomaterials (143) (144) (145) . this process is followed by the precipitation of a biological carbonated apatite layer (that contains calcium-, phosphate-and other ions such as magnesium as well as proteins and other organic compounds) that occurs when the concentration of calcium and phosphate ions has reached super saturation level in the vicinity of the implant (142, (146) (147) . this bone-like biological carbonated apatite layer is thought to be physiological trigger for stem cells to differentiate down the osteogenic lineage or could induce the release of growth factors that complement this process (142) . for biomaterials lacking calcium phosphate particles, the roughness of the surface is considered to act as a collection of nucleation sites for calcium phosphate precipitation from the hosts' body fluids, thereby forming a carbonated apatite layer. comparing calcium phosphate (cap) coated fibrous scaffolds (fibre diameter approx 50 μm) made from medical grade polycaprolactone (mpcl) with non-coated mpcl-scaffolds, we have shown that cap-coating is beneficial for new bone formation in vitro, enhancing alkaline phosphatase activity and mineralisation within the scaffolds (148) . interestingly, other research has shown that the implantation of highly soluble carbonated apatite ceramics alone did not result in bone induction in vivo (149) , suggesting that a relatively stable surface (e.g. through a composite material that contains a less soluble phase) is needed for the facilitation of bone formation as discussed above (see "mechanical properties and degradation kinetics"). bone formation requires a stable biomaterial interface and therefore, too rapid in vivo dissolution of calcium phosphate materials has been shown to be unfavourable for the formation of new bone tissue (150) (151) . chai et al. and barradas et al. have recently reviewed the effects of calcium phosphate osteogenicity in bone tissue engineering (150, 152) . further comprehensive reviews on the influence of surface topography and surface chemistry on cell attachment and proliferation for orthopaedic implants and bone tissue engineering are available (2, 126, 142, 150, 153) . porosity is commonly defined as the percentage of void space in a so called cellular solid (the scaffold in bone tissue engineering applications) (154) . using solid and porous particles of hydroxyapatite for the delivery of the growth factor bmp-2, kuboki et al. showed that pores are crucial for bone tissue formation because they allow migration and proliferation of osteoblasts and mesenchymal cells, as well as vascularisation; no new bone formed on solid particles (155) . a porous scaffold surface also improves mechanical interlocking between the implanted tecs and the surrounding natural bone tissue, providing greater mechanical stability at this crucial interface in tissue engineering (156) . scaffold porosity and pore size relate to the surface area available for the adhesion and growth of cells both in vitro as well as in vivo and to the potential for host tissue ingrowth, including vasculature, to penetrate into the central regions of the scaffold architecture. in assessing the significance of porosity several in vivo studies have been conducted utilising hard scaffold materials such as calcium phosphate or titanium with defined porous characteristics (157) . the majority of these studies indicate the importance of pore structure in facilitating bone growth. increase of porosity as well as pore size and spacing of pore interconnectivity has been found to positively influence bone formation in vivo, which is also correlated with scaffold surface area. pore interconnections smaller than 100 μm were found to restrict vascular penetration and supplementation of a porous structure with macroscopic channels has been found to further enhance tissue penetration and bone formation (97, 158) . interestingly, these results correlate well with the diameter of the physiological haversian systems in bone tissue that possess an approximate diameter of more than 100 µm. the ability of new capillary blood vessels to grow into the tec is also related to the pore size, thereby directly influencing the rate of ingrowth of newly formed bone tissue into the tec: in vivo, larger pore sizes and higher porosity lead to a faster rate of neovascularisation, thereby promoting greater amounts of new bone formation via direct osteogenesis. in contrast, small pores favour hypoxic conditions and induce osteochondral formation before osteogenesis occurs (92) . pores and pore interconnections should be at least 300 microns in diameter to allow sufficient vascularisation. besides the actual macroporosity (pore size >50 µm) of the scaffold microporosity (pore size < 10 µm) and pore wall roughness also have a large impact on osteogenic response: microporosity results in larger surface areas contributing to higher bone-inducing protein adsorption and to ion exchange and bone-like apatite formation by dissolution and re-precipitation (139, 157) . as outlined above, sub-micron and nanometre surface roughness favours attachment, proliferation and differentiation of anchorage-dependent bone forming cells (139) . although increased porosity and higher pore size facilitate bone ingrowth, it also compromises the structural integrity of the scaffold, and if the porosity becomes too high it may adversely affect the mechanical properties of the scaffold at the same time (79) . in addition, the rate of degradation is influenced by the porosity and pore size (for biodegradable scaffolds). a higher pore surface area enhances interaction of the scaffold materials with host tissue and can thereby accelerate degradation by macrophages via oxidation and/or hydrolysis (157) . therefore, scaffolds fabricated from biomaterials with a high degradation rate should not have high porosities (>90%) in order to avoid compromise to the mechanical and structural integrity before adequate substitution by newly formed bone tissue. scaffolds made from slowly degrading biomaterials with robust mechanical properties can, in contrast, be highly porous (157) . table 4 illustrates mechanical properties and degradation kinetics in relation to the porosity for many commonly used composite scaffolds. this illustrates that there are a number of advantages and disadvantages associated with any changes made to the porosity or pore size of scaffolds. it is inevitable to find a balance between these pros and cons in order to tailor the scaffold properties ideally to the demands of the tissue engineering approach used. for comprehensive reviews on role of porosity and pore size in tissue engineering scaffolds, the reader is referred to two recently published reviews (157, 159) . it becomes clear that a multitude of factors have to be taken into account when designing and fabricating scaffolds for bone tissue engineering. however, it is beyond the scope of this review to present all of them in detail and a number of comprehensive reviews have been published recently on this topic (2, 5, 79, 97, 101, (160) (161) . the three-dimensional design characteristics in combination with the material properties of a scaffold are crucial for bone tissue engineering purposes. not only does the scaffold structure need to be controlled on a macroscopic level (to achieve sufficient interposition of the scaffold into the defect site), but also on a microscopic level (to optimise tissue engineering properties with regards to osteoinduction, osteoconduction, osteogenesis and vascularisation as well as mechanical stability) and even down to nanostructural configuration (to optimise protein adsorption, cell adhesion, differentiation and proliferation related to desired tissue engineering characteristics of the tec). it is therefore necessary to exert strict control over the scaffold properties during the fabrication process. conventional techniques for scaffold fabrication include solvent casting and particulate leaching, gas foaming, fibre meshes and fibre bonding, phase separation, melt molding, emulsion freeze drying, solution casting and freeze drying (162) . all of these techniques are subtractive in nature, meaning that parts of the fabricated scaffold are removed from the construct after the initial fabrication process in order to generate the desired three-dimensional characteristics. hence a number of limitations exist regarding these fabrication methods: conventional methods do not allow a precise control over pore size, pore geometry, pore interconnectivity or spatial distribution of pores and interconnecting channels of the scaffolds fabricated (92, (163) (164) . in addition, many of these techniques require the application of organic solvents and their residues can impose severe adverse effects on cells due to their potentially toxic and/or carcinogenic nature, reducing the biocompatibility of the scaffold significantly (165) . the introduction of additive manufacturing (am) techniques into the field of bone tissue engineering has helped to overcome many of these restrictions (92, 162, 166) . in am three-dimensional objects are created in a computer-controlled layer-by-layer fabrication process. in contrast to subtractive conventional methods of scaffold fabrication, this technique is additive in nature and does not involve removal of materials after the initial fabrication step. these techniques have also been named "rapid prototyping" or "solid free form fabrication" in the past, but in order to clearly distinguish them from conventional methods the latest astm standard now summarises all of these techniques under the term "additive manufacturing" (167) . the basis for each am process is the design of a three-dimensional digital or in silico model of the scaffold to be produced. this computer model can either be created from scratch using "computer aided design" (cad) methods or can be generated using data from a 3d-scan of existing three-dimensional structures (such as the human skeleton) (168) . the digital model is then converted into an stl-file that expresses the three-dimensional structure as the summary of multiple horizontal two-dimensional planes. using this stl-file an am-machine then creates the three-dimensional scaffold structure in a layer-bylayer fabrication method in which each layer is tightly connected to the previous layer to create a solid object. a number of different am techniques are currently applied using thermal, chemical, mechanical and/or optical processes to create the solid three-dimensional object (166) . these methods include laser-based methods such as stereolithography (stl) and selective laser sintering (sls), printing-based applications (e.g. 3d-printing, wax-printing) and nozzle-based systems like melt extrusion/ fused deposition modeling (fdm) and bioplotting. the multitude of am techniques and their specifications were reviewed by several authors lately (162, 166, (169) (170) . am techniques have been used since the 1980s in the telecommunication industry, in jewelry making and production of automobiles (171) . from the 1990s onwards, am was gradually introduced to the medical field as well (172) : am was initially used to fabricate threedimensional models of bone pathologies in orthopaedic maxillofacial neurosurgical applications to plan surgical procedures and for haptic assessment during the surgery itself (173-174). with recent technical advances am is nowadays applied to make custom-made implants and surgical tools (175) and to fabricate highly detailed, custom-made three-dimensional models for the indivi-dual patient (using data from ct, mri, spect etc.) to plan surgical approaches, specifically locate osteotomy sites, choose the correct implant and to predict functional and cosmetic outcomes of surgeries (176) (177) . thereby the operating time as well as the risk of complications has been reduced significantly. the application of am in bone tissue engineering represents a highly significant innovation that has drasticcally changes the way scaffolds are being fabricated; am has more or less become the new gold standard for scaffold manufacturing (92) . the advantages of rapid prototyping processes include (but are not limited to) increased speed, customisation and efficiency. am technologies have relatively few process steps and involve little manual interaction, therefore, three-dimensional parts can be manufactured in hours and days instead of weeks and months. the direct nature of am allows the economical production of customized tissue engineering scaffolds. the products can be tailored to match the patient's needs and still sustain economic viability as compared to traditional techniques which must manufacture great numbers of devices. the conventional scaffold fabrication methods commonly limit the ability to form complex geometries and internal features. am methods reduce the design constraints and enable the fabrication of desired delicate features both inside and outside the scaffold. using stl, the am technique with the highest precision, for example objects at a scale of 20 µm can be fabricated (178) . a two-photon stl-technique to initiate the polymerisation can be used to pro-duce structures even at micrometer and sub-micrometer levels (179) . am methods allow for variation of composition of two or more materials across the surface, interface, or bulk of the scaffold during the manufacturing. thereby, positional variations in physicochemical properties and surface characteristics can be created and utilized to promote locally specific tissue engineering signals. several am techniques operate without the use of toxic organic solvents. this is a significant benefit, since incomplete removal of solvents may lead to harmful residues that can affect adherence of cells, activity of incorporated biological agents or surrounding tissues as already described. am allows the control of scaffold porosity leading to the applications that may have areas of greater or lesser structural integrity and areas of encouraged blood flow due to increased porosity. fabricating devices and/or implants with differences in spatial distribution of porosities, pore sizes, mechanical and chemical properties can mimic the complex composition and architecture of natural bone tissue and thereby optimise bone tissue engineering techniques. in addition, scaffolds with gradients in porosity and pore sizes can be functionalised to allow vascularisation and direct osteogenesis in one area of the scaffold, while promoting osteochondral ossification in the other, which is an appealing approach to reproduce multiple tissues and tissue interfaces within one and the same biomaterial scaffold (157) . table 5 summarises the advantages of scaffolds designed and fabricated by am techniques. musculoskeletal conditions are highly prevalent and cause a large amount of pain, illness and disability to patients. these conditions are the second most common reason for consulting a general practitioner, accounting for almost 25% of the total cost of illness and up to 15% of primary care (180) . in addition, the impact of musculoskeletal conditions is predicted to grow with the increasing incidence of lifestyle-related obesity, reduced physical fitness and increased road traffic accidents (180) . the impact of bone trauma is significant-the consequences of failing to restore full function to an injured limb are dramatically demonstrated by the statistic that only 28% of patients suffering from severe open fractures of the tibia are able to resume full function and hence return to previous employment (180) . along with trauma, tumour resection is another major cause of large bone defects. cancer is a major public health challenge, with one in four deaths in the united states currently due to this disease. recent statistics indicate that 1 638 910 new cancer cases and 577 190 deaths from cancer are projected to occur in the united states in 2012 (181) . as outlined above, the number of procedures requiring bone implant material is increasing, and will continue to do so in our aging population and with deteriorating physical activity levels (57) . the current bone grafting market already is estimated to be in excess of $2.5 billion each year and is expected to increase by 7-8% per year (45) . with the introduction of tissue engineering the hopes and expectations were extremely high to be able to substitute natural organs with similar (or even better) tissue engineered replacement organs. however, at the time it was stated that "few areas of technology will require more interdisciplinary research than tissue engineering" (75) and this assessment holds true today. in the years to follow, numerous private and public institutes conducted scientific research and clinical translation efforts related to tissue engineering. at the beginning of 2001, tissue engineering research and development was being pursued by 3 300 scientists and support staff in more than 70 start-up companies or business units with a combined annual expenditure of over $600 million usd (182) . the us national institutes of health (nih), accounting for the largest cumulative us federal research expenditures, has increased the funding in tissue engineering from 2.36 billion usd in the fiscal year 2003 to more than 614 billion usd for the fiscal year 2006 (183) . between 2000 and 2008 the number of papers published on tissue engineering and scaffolds per year increased by more than 400% and more than 900%, respectively (184) . but despite the increasing research expenditure and the magnitude of discoveries and innovations in bone tissue engineering since its introduction more than three decades ago, the translation of these novel techniques into routine clinical applications on a large scale has still not taken place. as scott j. hollister has pointed out, there is, on the one hand, a stark contrast between the amount of tissue engineering research expenditures over the last 20 years and the resulting numbers of products and sales figures. on the other hand, there is also a significant discrepancy between the complexities of intended tissue engineering therapies compared to the actual therapies that have reached clinical applications (184) . this evident gap between research and clinical application/commercialisation is commonly termed the "valley of death" due to the large number of ventures that "die" between scientific technology development and actual commercialization due to lack of funds ( figure 4 ) (184) . the valley of death is particularly large for tissue engineering approaches because this field of research often utilises immensely cost intensive high-tech biotechnologies for technological development eating up large parts of the funding available, but then additionally faces the challenges of funding large scale preclinical studies and clinical studies to gain approval by regulatory bodies, demonstrate product safety and gain clinical acceptance (184) (185) (186) . to bridge the gap between the bench and bedside, the scaffold is required to perform as a developmentally conducive extracellular niche, at a clinically relevant scale and in concordance with strict clinical (economic and manufacturing) prerequisites ( figure 5 ) (187) . in this context the scaffold facilitates for smaller and medium sized defects the entrapment of the hematoma and prevents it's "too early" contraction (188) . for large and high-load bearing defects the scaffold can also deliver cells and/or growth factors to the site of damage and provides an appropriate template for new tissue formation. the scaffold should thus constitute a dynamically long-lasting yet degradable three-dimensional architecture, preferably serving as a functional tissue substitute which, over time, can be replaced by cell-derived tissue function. designing and manufacturing processes are believed to be the gatekeepers to translate tissue engineering research into clinical tissue engineering applications and concentration on the development of these entities will enable scaffolds to bridge the gap between research and clinical practice (184) . one of the greatest difficulties in bridging the valley of death is to develop good manufacturing processes and scalable designs and to apply these in preclinical studies; for a description of the rationale and road map of how our multidisciplinary research team has addressed this first step to translate orthopaedic bone engineering from bench to bedside see below and refer to our recent publication (185) . in order to take bone tissue engineering approaches from bench to bedside, it also imperative to meticulously assess the clinical demands for specific scaffold characteristics to achieve a broad and optimised range of clinical applications for the specific tissue engineering approach. a sophisticated bone tissue engineering technology will not necessarily have multiple clinical applications just because of its level of complexity, and defining specific clinical target applications remains one of the most underestimated challenges in the bridging the valley of death (184) . there is often a great level of discrepancy between the clinical demands on a tissue engineering technique and the scientific realisation of such technique, hampering the clinical translation. thus a scaffold that is realistically targeted at bridging the valley of death should (187): (i) meet fda approval (for further details on this topics see reviews by scott j. hollister 2011 and 2009) (184, 189) ; (ii) allow for cost effective manufacturing processes; (iii) be sterilisable by industrial techniques; (iv) enable easy handling without extensive preparatory procedures in the operation theatre; (v) preferably, be radiographically distinguishable from newly formed tissue; and (vi) allow minimally invasive implantation (190) (191) . in targeting the translation of a (bone) tissue engineering approach from bench to bedside, there is a distinct hierarchy and sequence of the type of studies that need to be undertaken to promote the translation process (192) : having identified clinical needs and based on fundamental discoveries regarding biological mechanisms, a novel tissue engineering approach is designed and first studies are undertaken to characterise mechanical and chemical properties of the tec to be used. the next step involves feasibility and bioactivity testing and should be carried out in vitro and in vivo. in vitro assays using cell culture preparations are used to characterise the effects of materials on isolated cell function and for screening large numbers of compounds for biological activity, toxicity and immunogenicity (193) (194) . however, due to their nature using isolated cells, in vitro models are unavoidably limited in their capacity to reflect complex in vivo environments that the tec will be exposed to and are therefore inadequate to predict in vivo or clinical performances. therefore, in vivo models (that is animal models) are required in order to overcome the limitations of in vitro models to provide a reproducible approximation of the real life situation. in vivo feasibility testing is almost exclusively done in small animals, mainly in rodents and rabbits (192, (195) (196) (197) . the advantages of small animal models include relatively easy standardisation of experimental conditions, fast bone turnover rates (=shorter periods of observation), similar lamellar bone architecture and similar cancellous bone thinning and fragility, similar remodelling rates and sites, common availability and relatively low costs for housing and maintenance. disadvantages of rodent and rabbit models include different skeletal loading patterns, open epiphyses at various growth plates up to the age of 12-14 months (or for lifetime in rats), minimal intra-cortical remodelling, the lack of harversian canal systems, a smaller proportion of cancellous bone to total bone mass and their relatively small size for testing of implants (196) . whilst a large number of studies in rodents and rabbits have established proof of concept for bone tissue engineering strategies, scaling up to larger, more clinically relevant animal models has presented new challenges. quoting thomas a. einhorn, when conducting animal studies, one has to keep in mind that "in general, the best model system is the one which most closely mimics the clinical situation for which this technology is being developed, will not heal spontaneously unless the technology is used, and will not heal when another technology is used if that technology is less advanced than the one being tested" (198) . the most effective animal models will therefore 1) provide close resemblance of the clinical and biological environment and material properties, 2) encompass highly standardised measurement methods providing objective parameters (qualitative and quantitative) to investigate the newly formed bone tissue and 3) are able to detect and predict significant differences between the bone tissue engineering methods investigated (192) . for clinical modelling and efficacy prediction of the tissue engineering strategy to be translated into clinical application, up-scaling to large animal models is therefore inevitable. thereby, the tissue engineering therapy can be delivered in the same (or similar) way in which it will be delivered in clinical settings utilising surgical techniques that match (or closely resemble) clinical methods at the site that matches the setting in which it will be used later as closely as possible (192) . the advantage of large animal models (using nonhuman primates, dogs, cats, sheep, goats, pigs) is the closer resemblance of microarchitecture, bone physiology and biomechanical properties in humans. they encompass a well-developed haversian and trabecular bone remodelling, have greater skeletal surface to volume areas, show similar skeletal disuse atrophy, enable the use of implants and techniques similar to the ones used in humans and show highly localised bone fragility associated with stress shielding by implants. however, the use of large animal models has disadvantages as well, including the high cost and maintenance expenses, extensive housing and space requirements, relatively long life spans and lower bone turnover rates (making longer study periods necessary), difficulties in standardisation to generate large, homogenous samples for statistical testing as well as various ethical concerns depending on the species used (e.g. primates) (196) . but despite several disadvantages, it is inevitable to perform the final pre-clinical in large animals, as realistically as possible, with relevant loading conditions and with similar surgical techniques as used in the final procedure in humans (197) . large animal models provide mass and volume challenges for scaffold-based tissue engineering and require surgical fixation techniques that cannot be tested either in vitro or in small animal models (184) . in general, preclinical translation testing is performed in large skeletally mature animals, the species most utilised are dog, sheep, goat and pig (192, 199) . if sufficient preclinical evidence for the efficacy and safety of the new bone tissue engineering system has been generated utilising large animal models, clinical trials care undertaken to prove clinical significance and safety, ultimately leading to the translation of the technology into routine clinical practice. taking composite scaffold based bone tissue engineering from bench to bedside in accordance with the above outline rationale for translating bone tissue engineering research into clinical applications, during the last decade our interdisciplinary research team has focussed on the bench to bedside translation of a bone tissue engineering concept based on slowly biodegradable composite scaffolds made from medical grade polycaprolactone (mpcl) and calcium phosphates [hydroxyapatite (ha) and tricalcium phosphate (tcp)] (80, 200) . detailed descriptions of the scaffold fabrication protocol can be found in our recent publications (102, 109, (200) (201) (202) . the scaffolds have been shown in vitro to support cell attachment, migration and proliferation; degradation behaviour and tissue in-growth has also been extensively studied (203) (204) (205) (206) . we subsequently took the next step towards clinical translation by performing small animal studies using rat, mice and rabbit models (207) (208) (209) . as reviewed in detail in reference (200) , we were able to demonstrate the in vivo capability of our composite scaffolds in combination with growth factors or cells to promote bone regeneration within ectopic sites or critical sized cranial defects in the small animal models. studies in large animal models that closely resemble the clinical characteristics of human disease, with respect to defect size and mechanical loading, then became essential to advance the translation of this technology into the most difficult and challenging clinical applications in orthopaedic tumour and trauma surgery. the choice of a suitable large animal model depends on the ultimate clinical application, and consequently there is no such thing as "one gold standard animal model". over the last years, our research team has investigated the application of our composite scaffolds in several preclinical large animal models addressing different clinical applications: load-bearing, critical-sized ovine tibial defect model well-characterised, reproducible and clinically relevant animal models are essential to generate proof-ofprinciple pre-clinical data necessary to advance novel therapeutic strategies into clinical trial and practical application. our research group at the queensland university of technology (qut; brisbane, australia) has spent the last 5 years developing a world-leading defect model to study pre-clinically different treatment options for cases of large volume segmental bone loss (159, 210) . we have successfully established this 3 cm critical-sized defect model in sheep tibiae to study the mpcl-tcp scaffold in combination with cells or growth factors including bone morphogenic proteins (bmps) (211) (212) . this model has not only generated a series of highly cited publications (211) (212) (213) (214) (215) , but also has attracted large interest in the orthopaedic industry to be used as a preclinical test bed for their bone graft products under development. the model enables control of experimental conditions to allow for direct comparison of products against a library of benchmarks and gold standards we have developed over the last 5 years (we have performed more than 200 operations using this model todate). our preclinical tibial defect model developed at qut is one of the only available models internationally, which is suitable from both reproducibility and cost point of view for the evaluation of large segmental defect repair technologies in statistically powered study designs. we have chosen this critical sized segmental defect model of the tibia for our large animal model because tibial fractures represent the most common long bone fractures in humans and are often associated with significant loss of bone substance (216) (217) . also, tibial fractures result in high rates of non-unions or pseudarthroses (216, 218) . from an orthopaedic surgeons point of view it can be argued that amongst all bone defects seen in the clinical practice, segmental defects of the tibia are often the most challenging graft sites. this owes to the grafts being required to bear loads close to physiological levels very soon after implantation, this is despite internal fixation, which often provides the necessary early stability, but also suffers from the poor soft tissue coverage (vascularisation issue) of the tibia compared to the femur. hence, in a bone engineering strategy for the treatment of segmental tibial defects, the scaffold must bear (or share) substantial loads immediately after implantation. the scaffold's mechanical properties (strength, modulus, toughness, and ductility) are determined both by the material properties of the bulk material and by its structure (macrostructure, microstructure, and nanostructure). matching the mechanical properties of a scaffold to the tibial graft environment is critically important so that progression of tissue healing is not limited by mechanical failure of the scaffold prior to successful tissue regeneration. similarly, because mechanical signals are important mediators of the differentiation of cell progenitors, a scaffold must create an appropriate stress environment throughout the site where new tissue is desired. hence, one of the greatest challenges in scaffold design for load bearing tibial defects is the control of the mechanical properties of the scaffold over time. by trialing our bone tissue engineering strategies in a tibial defect model, we will therefore address a highly relevant clinical problem and are creating valuable pre-clinical evidence for the translation from bench to bedside. with the 3 cm critical defect being regenerated successfully by applying our mpcl-tcp scaffold in combination with bmp (102), we are now investigating bone regeneration potentials in even larger sized tibial defects ( figure 6 ). spinal fusion has been investigated in animal models for one hundred years now and a lot of the knowledge we have today on how spinal fusion progresses was gained through animal models (219) (220) . with regards to the above pictured rationale for translating bone tissue engineering approaches to clinical practice, it is of importance to note that the physical size of the sheep spine is adequate to allow spinal surgery to be carried out using the same implants and surgical approaches that are used in humans as well. also, sheep spines allow for an evaluation of the success of the study using fusion assessments commonly used in clinical practice. when considering spinal fusion in large animal models, it is apparent that due to the biomechanical properties of the spine a biped primate animal model [such as in (221) ] should ideally preferred over a quadruped large animal model [for example ovine (222) or porcine (223) ]. but given the expenses and limited availability of primate testing as well as ethical concerns due to the close phylogenical relation, it is more feasible to trial large numbers of scaffold variations in the most appropriate quadruped large animal models and then evaluate the best performing scaffold in a primate model, if possible (184) . we have outlined above that defining specific clinical target applications is a critical prerequisite for successful bone tissue engineering research that is meant to be translated into clinical practice. in accordance with this we have selected the thoracic spine for our animal model because we have identified idiopathic scoliosis as clinically highly relevant thoracic spine pathology. idiopathic scoliosis is a complex three-dimensional deformity affecting 2-3% of the general population (224) . scoliotic spine deformities include progressive coronal curvature, hypokyphosis or lordosis in the thoracic spine and vertebral rotation in the axial plane with posterior elements turned rotated toward the curve concavity. scoliotically deformed vertebral columns are prone to accelerated intervertebral disc degeneration, initiating more severe morphological changes of the affected vertebral joints and leading to chronic local, pseudoradicular, and radicular back pain (225) . one of the critical aspects in surgical scoliosis deformity correction is bony fusion to achieve long-term stability (226) . autologous bone grafting is still the gold standard to achieve spinal fusion and superior to other bone grafts for spinal fusion (227) (228) (229) . nonetheless, the use of autologous bone grafting material has significant risks as outlined in detail above. a number of animal models for the use of tissue-engineered bone constructs in spinal fusion exists (230) and the use of bone morphogenetic proteins for spinal fusion has been studied extensively (219, 222, (231) (232) . however, to the best of our knowledge, our ovine thoracic spine fusion model is the first existing preclinical large animal model on thoracic interverte-bral fusion allowing the assessment of tissue-engineering constructs such as biodegradable mpcl-cap scaffolds and recombinant human bone morphogenetic protein-2 (rhbmp2) as a bone graft substitute to promote bony fusion (figure 7 ) (233) . we have been able to show that radiological and histological results at 6-months post surgery indicated had comparable grades of fusion and evidenced new bone formation for the mpcl-cap scaffolds plus rhbmp-2 and autograft groups. the scaffold alone group, however, had lower grades of fusion in comparison to the other two groups. our results demonstrate the ability of this large animal model to trial various tissue engineering constructs against the current gold standard autograft treatment for spinal fusion in the same animal. in the future, we will be able to compare spinal fusion tissue engineering constructs in order to create statistically significant evidence for clinical translation of such techniques. the tibial diaphysis (c-d) and the periosteum is removed from the defect site and additionally also from 1cm of the adjacent bone proximally and distally. special care is taken not to damage the adjacent neurovascular bundle (e, bundle indicated by asterisk). the defect site is then stabilised using a 12 hole dcp (synthes) (f). afterwards 6cm mpcl-tcp scaffold loaded with prp and rhbmp-7 is press fitted into the defect site to bridge the defect (g-h) and the plate is fixed in its final position. xray analysis at 3 months after implantation (i) shows complete bridging of the defect site with newly formed radio-opaque mineralised tissue (in order to provide sufficient mechanical support, the scaffold is not fully degraded yet and scaffold struts appear as void inside the newly formed bone tissue). the interdisciplinary research group has evaluated and patented the parameters necessary to process medical grade polycaprolactone (mpcl) and mpcl composite scaffolds (containing hydroxyapatite or tricalciumphosphate) by fused deposition modeling (97) . these "first generation scaffolds" have undergone more than 5 years of studies in clinical settings and have gained federal drug administration (fda)-approval in 2006 and have also been successfully commercialised (www. osteoporeinternational.com). the scaffolds have been used highly successfully as burr whole plugs for cranioplasty (234) and until today more than 200 patients have received burr whole plugs, scaffolds for orbital floor reconstruction and other cranioplasties (figure 8 ) (92) . with their extensive, multidisciplinary approach the research team has achieved one of the rare examples of a highly successful bone tissue engineering approach bridging the gap between scientific research and clinical practice leading to significant innovations in clinical routines. as shown above, "second generation scaffolds" produced by fdm and based on composite materials have already been broadly studied in vitro plus in vivo in small animal models and are currently under preclinical evaluation in large animal studies conducted by our research group. available data so far clearly supports the view that further translation into clinical use will take place and that a broad spectrum of targeted clinical applications will exist for these novel techniques. our we herein propose that regenerative medicine 3.0 has commenced. we foresee that the complexity and great variety of large bone defects require an individualized, patient-specific approach with regards to surgical reconstruction in general and implant/tissue engineering selection in specific. we advocate that bone tissue engineering and bioengineering technology platforms, such as additive manufacturing approaches can be used even more substantially in bone grafting procedures to advance clinical approaches in general and for the benefit of individual patient in particular. the tremendous advantage of scaffolds made by additive manufacturing techniques such as fused deposition modeling (fdm) is the distinct control over the macroscopic and microscopic shape of the scaffold and thereby control over the shape of the entire tec in total. additive manufacturing enables the fabrication of highly structured scaffolds to optimise properties highly relevant in bone tissue engineering (osteoconductivity, osteoinductivity, osteogenicity, vascularisation, mechanical and chemical properties) on a micro-and nanometre scale. using high-resolution medical images of bone pathologies (acquired via ct, µct, mri, ultrasound, 3d digital photogrammy and other techniques) (168), we are not only be able to fabricate patient-specific instrumentation (235) (236) (237) , patient-specific conventional implants (238-242) or allografts (243) , but also to realise custom-made tissue engineering constructs (tec) tailored specifically to the needs of each individual patient and the desired clinical application (168, 174, 244) . we therefore predict that the commencing area of regenerative medicine 3.0 will hold a significant leap forward in terms of personalised medicine. we have already proven the clinical application of this concept by fabricating a custom-made bioactive mpcl-tcp implant via cad/fdm that was used clinically to successfully reconstruct a complex cranial defect (245) . we have also recently provided a rationale for the use of cad/fdm and mpcl-tcp scaffolds in contributing to clinical therapy concepts after resection of musculoskeletal sarcoma (figures 9 and 10 ) (246) . although it has to be mentioned that our approaches presented in this review are at different stages of clinical translation, their entity clearly represents a promising and highly significant 21 century approach in taking bone tissue engineering strategies from bench to bedside and into the era of regenerative medicine 3.0. in conclusion, the field of bone tissue engineering has significantly changed the millennia old quest by humans indicate osteotomy planes to achieve tumour free margins, after which, after which the cad model is virtually resected (e). a custom made scaffold to fit the defined defect is then created by mirroring the healthy side of the pelvis, adjusting the size of the scaffold accordingly and fabricating the scaffold from the virtual model using am techniques (f). flanges, intramedullary pegs and other details can be added to the porous scaffold structure to facilitate surgical fixation and to enhance its primary stability after implantation (g). images d-g reproduced with permission from (246) , © the authors to optimise the treatment of bone defects and to identify suitable bone substitute materials. we have reviewed the historic development, current clinical therapy standards and their limitations as well as currently available bone substitute materials. we have also outlined current knowledge on scaffold properties required for primary stability and even load distribution is achieved by using an internal fixation device (4) . secondary stability is achieved by osseointegration of both the fibula and the porous tissue engineering scaffold. over time, the scaffold is slowly replaced by ingrowing tissue engineered bone and the defect is completely bridged and regenerated (5) . h partly reproduced with permission from (246), © the authors. bone tissue engineering and the potential clinical applications as well as the difficulties in bridging the gap between research and clinical practice. although the clinical 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long bones a tissue engineering solution for segmental defect regeneration in long bones establishment of a preclinical ovine model for tibial segmental bone defect repair by applying bone tissue engineering strategies autologous vs. allogenic mesenchymal progenitor cells for the reconstruction of critical sized segmental tibial bone defects in aged sheep prevalence of long-bone non-unions epidemiology of adult fractures: a review path analysis of factors for delayed healing and nonunion in 416 operatively treated tibial shaft fractures animal models for preclinical assessment of bone morphogenetic proteins in the spine animal models for spinal fusion the use of recombinant human bone morphogenetic protein 2 (rhbmp-2) to promote spinal fusion in a nonhuman primate anterior interbody fusion model. spine (phila pa osteogenic protein versus autologous interbody arthrodesis in the sheep thoracic spine. a comparative endoscopic study using the bagby and kuslich interbody fusion device. spine (phila pa lateral surgical approach to lumbar intervertebral discs in an ovine model scoliosis and its pathophysiology: do we understand it? spine (phila pa back pain and function 22 years after brace treatment for adolescent idiopathic scoliosis: a casecontrol study-part i. spine (phila pa 1976) challenges to bone formation in spinal fusion bone graft substitutes for spinal fusion an update on bone substitutes for spinal fusion bone graft substitutes in spinal surgery spinal fusion surgery: animal models for tissue-engineered bone constructs bone morphogenetic protein in spinal fusion: overview and clinical update bone morphogenetic proteins for spinal fusion establishment and characterization of an open minithoracotomy surgical approach to an ovine thoracic spine fusion model cranioplasty after trephination using a novel biodegradable burr hole cover: technical case report patient-specific instrumentation for total knee arthroplasty: a review a review of rapid prototyped surgical guides for patient-specific total knee replacement new technologies in planning and performance of osteotonics: example cases in hand surgery computer-assisted prefabrication of individual craniofacial implants cad/cam dental systems in implant dentistry: update uncemented computer-assisted designcomputer-assisted manufacture femoral components in revision total hip replacement: a minimum follow-up of ten years uncemented custom computer-assisted design and manufacture of hydroxyapatite-coated femoral components: survival at 10 to 17 years ct lesion model-based structural allografts: custom fabrication and clinical experience rapid prototyping for biomedical engineering: current capabilities and challenges calvarial reconstruction by customized bioactive implant can bone tissue engineering contribute to therapy concepts after resection of musculoskeletal sarcoma? sarcoma key: cord-022467-j2trahab authors: loo, may title: select populations: children date: 2009-05-15 journal: complementary and alternative medicine doi: 10.1016/b978-0-323-02028-2.50015-2 sha: doc_id: 22467 cord_uid: j2trahab nan the majority, usually seeking cam therapy as an adjunctive management for pain and other discomforts related to the oncologic illness or to medications. 207 in the general pediatric population, chiropractic is the most common form of cam treatment used by children. reports indicate that children made up 1% of chiropractic patients in 1977 and 8% in 1985. 303 a survey of the boston metropolitan area revealed that an estimated 420,000 chiropractic visits were made by children in 1998. 237 childhood disorders being treated include pain, respiratory and gastrointestinal tract problems, ear infection, enuresis, and hyperactivity. 303 homeopathy was the second most popular form of cam therapy used by children in spiegelblatt's 1994 report. 386 in 2001, however, the university of pittsburgh found that homeopathy was the most common cam therapy used by children who visited an emergency department (ed). 329 also, in a 2000 survey of homeopathic practitioners in massachusetts, children constituted one third of patient visits. 236 homeopathic remedies are highly diluted substances that induce self-healing. these remedies are readily available from a variety of sources, including some grocery stores. although homeopathy may be safe and effective in many childhood conditions, many practitioners believe that homeopathic remedies are best used as adjunctive therapy to conventional medicine in chronic conditions and in acute disorders that respond poorly to conventional therapy. 197, 198 acupuncture is the third most common therapeutic method used in children 386 but has the largest body of scientific data compared with other cam therapies. 248 a harvard survey of 47 patients with a median age of 16 years who received acupuncture treatment, which included needle insertion, moxa/heat, cupping, and magnets, reported that 67% of patients rated the therapy as pleasant and 70% thought treatment helped their symptoms. 209 electrical stimulation, laser, heat, magnet methods, and acupressure or acumassage 324 are effective alternatives to needles for treating children with needle phobia. acupuncture and traditional chinese medicine (tcm) have been used in asia and europe to treat a wide spectrum of childhood illnesses. their use in the united states has been recent but is growing rapidly in popularity. naturopathy ranks with acupuncture as the third most common complementary therapy used by children, 385 although scientific data are sparse. currently, evidence-based information is limited about safety and efficacy of herbal remedies, especially in terms of dosage and application in infants and children, who may be more susceptible to some of the adverse effects and toxicities because of differences in physiology and immature metabolic enzyme systems. 293, 412 other cam treatments used in children include touch therapy (therapeutic touch), osteopathy, oligotherapy, and hypnosis. religious practices such as prayer have also become prevalent in the pediatric population. 22 children have reported the ability to readily feel energy field from touch therapy. 118 the increasing support for therapeutic touch (tt) 223, 226 has been anecdotal with little scientific data. approximately 9% of children receiving treatment with cam therapies seek osteopaths, 386 who claim success in treating many common childhood conditions, including colic and otitis. 19 approximately 4% of pediatric cam visits are to oligotherapists, 386 who administer poorly absorbed trace elements such as copper, manganese, and zinc to improve health. relaxation training and imagery are forms of hypnosis that have also been effective in children. 309 in fact, children seem to be able to learn relaxation training better and faster than adults. 122 table 11 -1 summarizes the cam therapies most often used to treat various pediatric conditions. box 11-1 lists additional and recent surveys and reviews of cam therapies used to treat pediatric conditions. vaccination is an essential component of pediatric well-child care and has both public health and educational ramifications because up-to-date vaccination is required for vaccine safety is monitored closely. adverse events are reported to the vaccine adverse event reporting system (vaers), administered by the centers for disease control and prevention (cdc) and the u.s. food and drug administration (fda). approximately 10,000 adverse cases are reported each year. data are shared internationally by independent scientific experts on the joint committee on vaccination and immunization and committees of the medicines control agency. surveillance results in product withdrawal when there is clear evidence of a safety issue. 300 currently, several serious pediatric conditions are controversially attributed to vaccination: immune compromise, 377 neurologic sequelae, autism, and crohn's disease. the medical community has expressed concern about the effects of vaccination on an immature immune system, especially in neonates. 419 controversial debates are ongoing regarding the possible connection between vaccination and autoimmune illnesses, such as the association between measles and anti-hepatitis b virus (hbv) vaccines with multiple sclerosis. tetanus toxoid, influenza vaccines, polio vaccine, and others have been related to autoimmune phenomena ranging from autoantibody production to full-blown illness, such as rheumatoid arthritis and guillain-barré syndrome. recent evidence suggests that autism may be related to the immune system. 273 the mechanism of autoimmune reactions after immunization has not yet been elucidated. one possibility is molecular similarity between some viral antigen (or other component of the vaccine) and a self-antigen. this similarity may be the trigger to the autoimmune reaction. 16, 374 before 1991, whole-cell pertussis vaccine was used, composed of a suspension of formalin-inactivated bordetella pertussis b cells. convulsions occurred in 1 case to 1750 doses administered, and acute encephalopathy occurred rarely, at 10.5 cases per million doses administered. sudden infant death syndrome (sids) and infantile spasms have also been suggested to be associated with diphtheria-pertussis-tetanus (dpt) vaccination. 103 in the 1970s, reports linking pertussis vaccine with infant brain damage attracted media attention, 227 which in turn caused great parental and professional anxiety; the immunization rate fell from 80% to 30%. between 1976 and 1988, three major pertussis epidemics occurred in the united states, resulting in more than 300,000 hospitalizations and at least 70 deaths. 300 in countries such as sweden, japan, united kingdom, ireland, italy, and australia, antivaccine movements targeted pertussis whole-cell vaccines. 129 opponents to the pertussis vaccine have argued that the risks of vaccination outweigh the benefits. 103 the largest study to date conducted by the national institute of child health and human development at the national institutes of health (nih) revealed that sids was actually less likely to occur in recently vaccinated infants. 165 another large study showed that the permanent neurologic sequelae due to pertussis vaccine are so rare as to be unquantifiable. 280 nevertheless, concerns about brain damage led to the development of acellular pertussis vaccine (dtap) that contains purified, inactivated components of b. pertussis cells. this form is associated with a lower frequency of adverse events and is more effective in preventing pertussis disease. dtap was first licensed for the fourth and fifth doses of the pertussis series in 1991 and for the primary series in 1996. several studies conducted in europe and africa revealed that u.s.-licensed dtap vaccines have efficacy ranging from 71% to 84%. currently, only acellular pertussis vaccine is used. 103 no encephalopathy has been reported. hypotonic hyporesponsive episode (hhe) is the sudden onset of hypotonia, hyporesponsiveness, and pallor or cyanosis that occurs within 48 hours of vaccination, usually after pertussis vaccine administered to children under 2 years of age. hhe occurred in approximately 1 of every 1750 dta vaccinations. the largest published report of 40,000 cases concluded that although hhe does occur after the administration of dtap and other non-pertussis-containing vaccines, it is generally benign, self-limited, and nonrecurrent. 92 the connection of encephalopathy with pertussis vaccine was biologically more plausible than the proposed link between pertussis, measles vaccines, and autism. 300 the incidence of autism has increased from 1 in 10,000 in 1978 to 1 in 300 in 1999 in some u.s. communities. a study of 60 autistic children suggests that autism may be caused by a pertussis toxin found in the dpt vaccine. the toxin separates the g-alpha protein from retinoid receptors, which are critical for vision, sensory perception, language processing, and attention-characteristic problems of autism. those children most at risk have at least one parent with a preexisting g-alpha protein defect, presenting clinically with night blindness, pseudohypoparathyroidism, or adenoma of the thyroid or pituitary gland. natural vitamin a may reconnect the retinoid receptors. 273 in recent years, discussion has increasingly centered on the controversy concerning the possible association of the measles-mumps-rubella (mmr) vaccine with autism and crohn's disease.* the chinese were among the first populations to vaccinate, beginning with smallpox vaccine, which was injected intranasally. tcm considers most childhood illnesses to occur at superficial levels, and vaccination actually introduces pathogens, still considered energetically active, into deeper blood levels of the body. in addition, tcm also posits that the body can usually effectively handle only one process at a given time. when two separate processes occur at the same time, the human system could become overwhelmed, especially the tender system of an infant or a young child. therefore, although multiple vaccines given at the same time are less traumatic for children and save nursing time, they can easily overwhelm an immature immune system and make the child weak and deficient. 352 although the fear of epidemics motivates the chinese to vaccinate all their children, tcm practitioners in the west often advise against immunization. 320 there is discrepancy among the homeopaths regarding recommendation of conventional vaccines. a german questionnaire survey reported that homeopathic physicians generally do not refuse vaccinations but show a preference for the dpt vaccines. 239 a british survey conducted between 1987 and 1993 reported that preference for homeopathic remedies for illnesses and religion were the most common reasons parents refused immunization; 21% believed the risk of diseases to be less than the risk of vaccination and would seek homeopathic treatment if any illness developed in their children, and 17% believed that children "are protected by god and not by vaccines." 379 a u.s. cross-sectional descriptive survey of 42 homeopathic practitioners and 23 naturopathic practitioners in massachusetts revealed that the majority of the practitioners did not actively recommend immunizations. 236 many homeopaths recommend homeopathic vaccines, which are not yet supported by scientific data. 399 a random sample survey by mail of 1% of american chiropractors revealed that one third believe there is no scientific proof that immunization prevents disease, that vaccinations cause more disease than they prevent, and that contracting an infectious disease is safer than immunization. 66 a reported 81% believed that immunization should be voluntary and that spinal adjustment is a viable alternative. a crosssectional, descriptive survey of 90 chiropractics in the boston metropolitan area reported that only 30% actively recommended childhood immunization. 237 the decision of whether or not to immunize a child is difficult for both parents and practitioners. the advantages of vaccination are difficult to refute, but the temporal relationship between immunization and side effects and the controversies surrounding potential risks are disconcerting. although data are insufficient on cam approaches to vaccination today, practitioners should be aware of the slow yet steady trend toward alternatives and should properly address parental concerns and questions regarding immunization. 348 each practitioner needs to inform parents of the most up-to-date pros and cons of vaccination, be as objective as possible, put aside personal belief systems, and be supportive and understanding of whichever decision the parents make. parents need to become as informed as possible, consider all the pros and cons, weigh the risks and benefits, and realize that ultimately they must live with the outcome of their decision. the common cold is the most frequent infection in children in the united states and throughout the industrialized world. 394 a preschool-aged child has an average of 4 to 10 colds per year. the clinical symptoms vary greatly without any correlation with specific viruses. 94, 121 the majority of the symptoms are mild, consisting of rhinorrhea, sneezing, nasal congestion and obstruction, postnasal drip, and cough. there may often be additional symptoms of low-grade fever, sore throat, clear eye discharge, digestive discomfort, and general malaise. 180, 213, 276 some common viruses that cause upper repiratory tract infections (uris) include rhinovirus, coronavirus, adenovirus, respiratory syncytial virus (rsv), influenza virus, and parainfluenza virus. 101, 121, 139 transmission varies with different viruses. for example, rsv spreads primarily through contact with symptomatic children and contaminated objects, whereas influenza spreads mainly through airborne droplets. the precise route of transmission for rhinovirus remains controversial. 139 the virulence of rhinovirus is maximum in infants before 1 year of age (median age 6.5 months) 327 and in immunocompromised children. 330 wheezing is associated with rsv in children younger than 2 years of age and with rhinovirus in those over age 2. 338 simultaneous infection by more than one virus, such as rsv and adenovirus together, can also occur frequently in the pediatric population. many children may also have associated bacterial infection, such as haemophilus influenzae conjunctivitis. 327 the viruses gain entry into host cells through specific viral surface proteins, which cause tissue injury and result in clinical disease. 432 recent studies suggest that the host's response to the virus, not the virus itself, determines the pathogenesis and severity of the common cold. proinflammatory mediators, especially the cytokines, appear to be the central component of the response by infected epithelial cells. 158, 417 specific viral diagnosis is not necessary because of the benign, self-limiting nature of the disease 294 and the prevalence of different viruses overlapping from fall to spring, which makes it difficult to determine precisely which virus or viruses are causing the symptoms. 121 current medical management of uri remains symptomatic, controversial, and in most cases, ineffective. fluid, rest, humidifier, and saline nose drops constitute the mainstay of nonpharmacologic treatment. topical adrenergic agents do not have systemic side effects, but overuse can result in rebound congestion. 84, 114 antihistamine and combinations of antihistamine with decongestants are the ingredients in at least 800 over-the-counter (otc) cold remedies. the majority of studies have concluded that antihistamines are of marginal or no benefit in treating cold symptoms. 47, 110, 153, 254, 383 dextromethorphan is an antitussive that is abundant in otc formulations. although this medication is reportedly safe when taken in the recommended dosages, there have been cases of "recreational" use by teenagers, and deaths by overdose have been reported. 291 codeine is ineffective in controlling uri cough. 95 medications are often overprescribed, leading to higher health care costs 102 and dangerous side effects, such as greater antibiotic resistance. 257 more steroids are prescribed, which leads to a myriad of complications. 274 although interferon has been shown to produce good protection against infection, the high doses necessary to produce a prophylactic effect are often associated with serious undesirable side effects, including nasal stuffiness, bloody mucus, and mucosal erosions, 213 and the trauma of daily intramuscular injection makes it an unlikely remedy for children. 169 research for new medical therapies for the common cold is directed toward increasing resistance to or immunity against the viruses. histamine antagonists are not indicated in the common cold. 369 antiinflammatory mediators 417 and specific antiviral agents 361 may be promising. development of an effective vaccine against the common cold is unlikely because of the large number of viral serotypes. 213 rhinovirus, for example, has at least 100 different immunotypes. 158 although viral uri is a benign illness of short duration, it can lead to bacterial complications such as otitis media, sinusitis, lower respiratory tract infections, mastoiditis, and even meningitis. 330 scientific data on cam treatment for the common cold are surprisingly sparse. in 1971, linus pauling carried out a meta-analysis of four placebo-controlled trials and concluded that vitamin c alleviates cold symptoms, but subsequent reviews indicated that the role of vitamin c in uri is still controversial. [146] [147] [148] 199 although breast-feeding has been believed to protect against infection in infants, studies have been inconsistent in demonstrating its efficacy. in a 4-year prospective study that actively tracked breast-feeding and respiratory illnesses in 1202 healthy infants, breast-feeding was found to reduce significantly the duration of respiratory illnesses during the first 6 months of life. 75 a retrospective review from saudi arabia of randomly selected charts revealed that a direct correlation exists between duration of breast-feeding and frequency of uri in the first 2 years of life. 1 a hospital-based descriptive recall study from sri lanka examined the relationship between breastfeeding and morbidity from respiratory illnesses in infants. of the 343 infants, 285 were admitted and 58 were controls. an inverse relationship was found between the length of breast-feeding and incidence of respiratory illnesses. 319 a nutritional study of 170 healthy newborns followed for 6 months demonstrated that breast-feeding lowers frequency and duration of acute respiratory tract infection compared with formula feeding. 251 a more recent japanese study examined the incidence of pathogenic bacteria isolated from the throat of 113 healthy infants fed with different methods. 166 no pathogens were detected in breast-fed and mixed-fed infants, while h. influenzae and moraxella catarrhalis were isolated from the oropharynx of formula-fed infants. the investigators suggest that breast milk may inhibit the colonization by respiratory bacterial pathogens of the throat of infants. the mechanism was thought to be enhancement of mucosal immunity against respiratory tract infection. in addition to the presence of secretory immunoglobulin a (iga), another mechanism may be the presence of complex carbohydrates in human milk. these glycoconjugates may exert various antipathogenic effects, such as inhibiting the binding of pathogens to the receptors and reducing the production of bacterial toxins. 299 however, a u.s. study that examined nasopharyngeal swabs from 211 infants at 1 month of age and swabs from 173 of these infants at 2 months of age (keeping environmental parameters similar, e.g., number of children in household, number of siblings in day care, proportion with recent uri) revealed that the exclusively breast-fed (n = 84) and exclusively formula-fed (n = 76) infants did not differ significantly in the number of pathogens. 196 a multicenter randomized trial was conducted in 31 hospitals in the republic of belarus. 228 evaluation within the first year revealed that breastfeeding had no significant reduction in respiratory tract infection compared with the control group. a survey from singapore of breast-feeding mothers at 6 months postpartum revealed no significant differences in the rates of uri between breast-fed and non-breast-fed infants. 64 data are sparse on acupuncture, herbal, and homeopathic remedies for treatment of uri, especially in children. most data are uncontrolled, clinical reports. current information on adults supports efficacy of acupuncture for treating the common cold. 172, 311, 454, 462 acupuncture has been shown to increase the velocity of the nasal mucociliary transport in chronic rhinitis patients. 454 one possible use of acupuncture in uri is its potential effect on the immune system. 322 when chinese herbs were pasted onto acupoints for treating rhinitis and bronchitis in infant, serum immunoglobulin m (igm), igg, complement c3, and especially iga levels increased. 461 acupuncture has also been shown to increase t lymphocytes. 404 even massaging local acupoints was effective in relieving symptoms and in enhancing immune functions, with increases in immune indices that persisted for at least 6 months. 466 one report of acu massage of only one point for just 30 seconds resulted in clinical relief from nasal congestion, even though there was no change in nasal airway resistance or airflow. 403 these reports are encouraging for parents because acupressure can be easily learned by nonprofessionals, is well tolerated by children of all ages (including infants), has no side effects, and costs nothing. a clinical trial administering a nontoxic chinese herbal mixture to 305 infants demonstrated more than 95.1% effectiveness in treatment of uri. 465 in a single-blind trial using a chinese herb for acute bronchiolitis with serologic evidence of rsv, 96 hospitalized children were randomized into three treatment groups: herbs, herbs with antibiotics, and antibiotics alone. herbal treatment was found to decrease symptoms and duration of illness without adverse effects. 218 in a randomized, controlled trial using an herbal mixture, 89 children in the treatment group demonstrated 92% efficacy versus 67% of 61 children in the control group. 255 there was no description in the abstract (original article in chinese) of what constituted control (e.g., placebo herb, no treatment, conventional drugs) or what constituted efficacy (e.g., improvement in symptoms, duration, of illness). further rigorous studies are needed to demonstrate safety and efficacy of herbal treatment. a recent clinical trial that included children over age 12 years and used a fixedcombination homeopathic remedy for a mean 4.1 days of treatment reported that 81.5% reported subjective feelings of being symptom free or significantly improved without complaint of any adverse side effects. 4 a randomized, double-blind, placebocontrolled study from great britain of 170 children with a starting median age of 4.2 years in the experimental group and 3.6 years in the placebo group concluded that individually prescribed homeopathic remedies seem to be ineffective in reducing symptoms or decreasing the use of antibiotics in pediatric patients with uri. 78 otitis media (om) represents a continuum of conditions that include acute om, chronic om with persistent effusion, chronic suppurative om, recurrent om, unresponsive om, and om with complications. 28 acute otitis media (aom) is most prevalent in young children 8 to 24 months of age. approximately two thirds of all children will have had at least one episode of aom before age 3 years, and half of them will have recurrences or chronic serous om with effusion into early elementary school years. 132 by the time the child reaches adolescence, aom occurs infrequently. 443 almost one third of pediatric office visits are for treatment of aom. 109 the most common etiologic factors are allergic rhinitis 72,336 and ascending bacterial or viral agents from the nasopharynx attributable to eustachian tube dysfunction. the most common viral culprits are rsv, 10 influenza virus, 153 and adenovirus. 108 two thirds of middle ear infections are caused by bacteria. 109 the predominant organisms are pneumococci, h. influenzae, m. catarrhalis, 53, 305, 358, 388 and group b streptococcus. 325 bacterial pathogens adhere to mucous membranes, and colonization ensues. the severity of infection or the response to the invading bacteria depends on the health of the child's immune system. 53 the humoral system is especially significant in protecting the middle ear cavity from disease, and the nasopharyngeal lymphoid tissues are the first line of defense against bacterial colonization. 335, 359 the sterility of the eustachian tube and tympanic cavity depends on the mucociliary system and on secretion of antimicrobial molecules, such as lysozyme, lactoferrin, and betadefensins. 313 evidence indicates that a number of children with recurrent episodes of aom have minor immunologic defects. 359 pneumococcus is by far the most virulent of aom bacteria. it causes approximately 6 million cases of om annually in the united states. 468 uncontrolled pneumococcal otitis can lead to meningitis. 416 the incidence of aom is higher in winter and early spring. clinically, the child with aom presents with earache and fever, usually accompanied by upper respiratory symptoms such as rhinorrhea. on otoscopic examination the tympanic membrane varies from hyperemia with preservation of landmarks to a bright-red, tense, bulging, distorted appearance. in advanced stages of suppuration the tympanic membrane ruptures with a gush of purulent or blood-tinged fluid from the ear. 108 because viral or bacterial om usually cannot be distinguished by otoscopic examination, aom is usually treated empirically, using antibiotics such as amoxicillin that have a high concentration in the middle ear fluid. 214, 224 however, the widespread use of antibiotics has resulted in increasing resistance to the more common medications. 53, 358 currently, 10% of children with aom are recalcitrant to antibiotic therapy. 277 the prevalence of resistant organisms tends to increase in the winter months. 43 economically, treatment failure due to drug resistance has been responsible for further escalating the billions of dollars spent treating aom. 287 in addition, antimicrobials suppress normal flora, which is beneficial to the host because the antibiotic can interfere with and therefore prevent pathogenic infections and may enhance recovery from uris. 43 on the other hand, since the advent of antibiotics, complications such as mastoiditis and intracranial infections have significantly decreased. 297 the current focus is on prevention of aom. breast-feeding confers lifesaving protection against infectious illness, including otitis. 134, 156 pneumococcal conjugate vaccine (pcv), approved in 2000 for use in the united states, covers the seven serotypes that account for about 80% of invasive infections in children younger than age 6 years. pcv was demonstrated to have more than 90% efficacy 468 and has resulted in a modest reduction of total episodes of aom. 317 the goal of pcv is to prevent symptomatic infections in the middle ear and prevent colonization of the pneumococci that can cause subsequent middle ear infections. 41 pcv may eliminate nasopharyngeal carriage of pneumococci. 235 however, because pcv only prevents disease caused by the most common serotypes, there is concern that the nonvaccine serotypes will become more common, especially in children less than 2 years of age. 317 an effective rsv vaccine for the infant and young child could greatly decrease om disease. 10 intranasal spray of attenuated viruses is currently under investigation, in the hope that early antiviral therapy would reduce the risk of om after uri. 137, 153 chronic otitis media with effusion (ome) is one of the most common diseases in childhood. 91 ome is associated with infection, eustachian tube obstruction, allergic or immunologic disorders, and enlarged adenoids. 108 the serous fluid still contains bacteria, such as h. influenzae and pneumococci. 48 ome has been implicated to be an immune-mediated disease 91 because immune complexes have been demonstrated in the middle ear effusion, 268 and highly organized lymphatic tissue has been found in the middle ear mucosa. 422 the rationale for treating ome is prevention of recurrence of aom. currently, a once-daily antibiotic regimen is the recommended prophylaxis. the benefit is also weighed against the increasing risk of emergence of resistant bacteria. 134 when antibiotics fail to control recurrent om, a short trial of prednisone may be prescribed. surgery is recommended when medical treatment fails, 277 especially when the child has hearing loss. 305 tympanostomy tubes appear to be beneficial in ome but are of less value in chronic suppurative otitis. 134 increase in hearing loss has been reported with insertion of ventilation tubes. 144 adenoidectomy is sometimes recommended, 193 especially after tympanostomy tube failure. 134 any safe and effective cam therapy for om would be an important contribution to the pediatric population. large-scale, randomized, controlled studies for cam treatment would need medical collaboration, especially for otoscopic examination and tympanometry. 366 in addition, since aom has a high rate of spontaneous resolution, any clinical study must also prove that treatment effect is faster than natural improvement. although breast-feeding has been found to reduce uri, data concerning its association with frequency or duration of om have been conflicting. epidemiologic reports consistently provide evidence of protection of young children from chronic otitis with prolonged breast-feeding. 138 a u.s. study that followed 306 infants at well-baby visits in two suburban pediatric practices reported that the cumulative incidence of first om episodes increased from 25% to 51% between 6 and 12 months of age in infants exclusively breast-fed versus 54% to 76% in infants formula-fed from birth. 89 there was a two-fold risk of first episodes of aom or ome in formulafed babies in the first 6 months. a danish study that evaluated 500 infants using monthly questionnaires reported no statistical difference in the breast-fed versus formula-fed infants in incidence of om. 355 an earlier jewish study comparing 480 infants visiting a pediatric ed with 502 healthy infants found that breast-feeding significantly reduced infectious diseases, including om in infants under 5 months of age. 76 a study from switzerland evaluated 230 children with aom by administering individualized homeopathic medicine in the pediatric office. 119 if there was insufficient pain reduction after 6 hours, a second (different) homeopathic medicine was given. antibiotics were given if there was lack of response to the second dose. pain control was achieved in 39% of the patients after 6 hours, with another 33% after 12 hours. the resolution rate was 2.4 times faster than in placebo controls. no complications were observed in the study group. 119 in a u.s. double-blind, placebo-controlled pilot study, 75 children ages 18 months to 6 years with ome and ear pain and/or fever for more than 36 hours were randomized into individualized homeopathic medicine or placebo group. 181 no statistically significant results were noted. a british nonblinded, randomized pilot study was done with 33 children ages 18 months to 8 years who had ome and hearing loss greater than 20 db and an abnormal tympanogram. 150 the results revealed that the homeopathy group had more children with a normal tympanogram, fewer referrals to specialists, lower antibiotic consumption, and a higher proportion with a hearing loss less than 20 db at follow-up. however, the differences were not statistically significant. further research with larger groups is needed for a definitive trial. in a prospective, observational study carried out by one homeopath and four conventional ear-nose-throat (ent) physicians, a single (nonindividualized) homeopathic remedy was compared with nasal drops, antibiotics, and antipyretics. 125 children between 6 months and 11 years of age were included in the study. homeopathic treatment was given to 103 children and conventional treatment to 28 children. homeopathic remedies were found to be significantly more effective in reducing duration of pain and in preventing relapses. because om tends to affect predominantly young children, it would be more appropriate for studies to compare results in children of similar age rather than a wide range of ages, from infancy to preadolescence. a retrospective, nonrandomized study of 46 children under 5 years of age receiving 3 weeks of treatment from a single chiropractor reported a decrease in om symptoms. the limitations to this study included retrospection and a lack of comparison with the natural course of ear infections. 124 an israeli controlled clinical trial examined the efficacy and tolerance of ear drops made with naturopathic extracts in the management of aom pain. 362 ranging in age from 6 to 18 years, 103 children were randomized into the treatment group and control group using a conventional anesthetic ear drop. there was statistically significant improvement in both groups, indicating that the naturopathic ear drops were as effective as the anesthetic ear drops. the university of arizona has initiated a study of the use of echinacea, a dietary supplement, in the prevention of recurrent om. 261 acupuncture data are lacking on treatment of om in children. 411 the theoretical potential benefit of acupuncture would appear to be its effect on the immune system, as discussed in the section on uri. allergic rhinitis affects 5% to 9% of children. 113 perennial rhinitis is related to allergens that children are exposed to continuously, such as animal dander, house dust mites, mold, and feathers. seasonal rhinitis is related to seasonal pollenosis and rarely affects children under age 4 or 5 years. 100 allergic diseases are major causes of morbidity in children of all ages, 437, 447, 448 and allergic rhinitis is a significant cause of middle ear effusions. 72, 267, 336, 452 conventional therapy usually consists of avoidance of allergens, use of air-clearing devices, desensitization shots, and medication with antihistamines and at times steroids, both of which are frequently abused. 179, 200 antihistamines may be beneficial when sneezing and itching are present. 114 cam therapy is common among children with allergic diseases in sweden 155 and is becoming more popular in the united states, although scientific data specifically on children are still lacking. physicians have become more aware of the importance of nutrition 384, 424 and environmental factors in the development of allergic symptomatology in childhood. 289, 396, 446 a prospective, longitudinal study of healthy infants followed from birth to 6 years of age concluded that recurrent wheezing is less common in nonatopic children who were breast-fed as infants. 450 hypnosis has been reported anecdotally to be effective in hay fever. 439 homeopathic efficacy has received increasing attention in recent years, 342 but data consist of adult studies. an international multicenter study involving 30 investigators in four countries and 500 patients with three diagnoses, including upper and lower respiratory tract allergies, concluded that homeopathy appeared to be at least as effective as conventional medicine. 345 another multicenter study using a randomized, double-blind, placebo-controlled parallel group design also demonstrated that homeopathic preparations differ from placebo for allergic rhinitis. 408 homeopathic remedies for allergic children are unsupported by scientific studies at this time. an adult study using changes in conductance of specific acupuncture points for diagnosis and treatment demonstrated statistically significant changes that correlated with clinical improvement. 195 in a randomized study of 143 patients that included older teenagers, desensitization was compared with specific acupuncture treatment for allergic asthma, allergic rhinitis, or chronic urticaria. the study was ridden with multiple, tedious variables. the conclusion that acupuncture was significantly more effective than desensitization in improving symptoms and in reducing recurrence in all three conditions did not give a breakdown in age groups. 228 in a clinical report of 75 chronic allergic rhinitis cases that included three cases in children 6 to 10 years of age and 17 cases in 11-to 20-year-olds, two different acupuncture treatments were administered according to tcm diagnoses. there was a cumulative 40% cure rate without age differentiation. 454 asthma is the most common cause of chronic illness in childhood, with approximately 10% of children in the united states carrying the diagnosis. 259, 297, 442 a significant number of school days are lost because of asthma. a wide variation of incidence is found in different countries, with the highest rates in the united kingdom, australia, and new zealand and the lowest rates in eastern europe, china, and india. 296, 442 in recent years, prevalence of asthma is increasing worldwide, especially in children under 12 years of age. 17, 382 although asthma can have onset at any age, 80% to 90% of asthmatic children have their first symptoms before 4 to 5 years of age. 297 children up to age 4 years have distinct symptoms and require special consideration. 36 they have increased health service utilization, including a higher annual rate of hospitalization, 298 which has almost doubled in the united states from 1980 to 1992 for children 1 to 4 years of age. 17 the same trend is observed by other nations worldwide. 9,18 among american children ages 5 to 14 years, asthma death rates almost doubled from 1980 to 1995. 17 new zealand and canada have observed a similar increase in severity and mortality. 73, 387 asthma is a diffuse, reversible, obstructive lung disease with three major features: bronchial smooth-muscle spasm, edema and inflammation of the mucous membrane lining the airways, and intraluminal mucus plugs. 442 during the last two decades, chronic airway inflammation, rather than smooth muscle contraction alone, has been recognized as playing the key role in the pathogenesis of asthma in adults. 63, 131 although this association is less well established in children, recent guidelines for managing asthma in the pediatric population still have emphasized that treatment be directed toward the inflammatory aspects of the disease. 206, 402, 440 chronic inflammation is caused by the local production of inflammatory mediators and an increase in recruitment of inflammatory cells, predominantly eosinophils and mast cells. studies in young adults suggest that the chronic inflammation may be responsible for longterm pulmonary changes, including bronchial hyperresponsiveness, airway remodeling, and irreversible airflow obstruction. because of difficulties in conducting studies in infants and young children, pediatric information is incomplete. 230 limited studies have detected increases in inflammatory cells and thickening of the lung basement membrane in infants and young children and have found that asthmatic children have significantly lower lung function at 6 years of age compared with nonwheezers when both groups of children began with the same baseline at age 6 months. these data support the possible presence of an asthmalike inflammation at a very early age that is associated with nonreversible impairment of lung function. 263 the excessive inflammatory changes indicate that asthma is caused by a poorly regulated "immunologic runaway response" that, instead of protecting the host, destroys normal structure. increased concentrations of proinflammatory mediators, such as histamine and leukotrienes, are found in the airways as well as the blood and urine of asthmatic patients 131 during an acute attack and after allergen and exercise challenge. 34 strong evidence correlates asthma with rsv infection; children who enter day nursery before age 12 months and who are exposed to viruses early in life have built up immunity, with decreased development of allergies. 88 in most children, whose asthma is triggered mainly by respiratory infections at a younger age, asthma symptoms appear to remit by the adolescent years. 263 in older children and teenagers, emotions play a significant role both as the cause of symptoms and as the result of interplay of a chronic illness affecting the child's self-image and family dynamics. 297 the latest asthma management guidelines classify pediatric asthma into four groups of severity: mild intermittent, mild persistent, moderate persistent, and severe. 206 mild intermittent asthma can be typified by exercise-induced asthma, a common pediatric condition. status asthmaticus, defined as progressive respiratory failure that does not respond to conventional management, is becoming more prevalent in american children. 442 conventional treatments for pediatric asthma vary from allergen avoidance to state-of-the-art biochemical therapy. avoiding allergens has been a successful management of asthma since the sixteenth century. asthma is a much more complex problem today because of the increasing number of pollutants and chemicals in the environment that are potential allergens for children. 157 parental education, especially in regard to smoking, can reduce hospital admissions. 449 because infections that trigger asthma attacks are mostly viral, 31 antibiotics are not routinely indicated. medication consists primarily of bronchodilators and inhaled steroids, which are now justified as first-line therapy, 191 both as long-term management 402 and for acute attacks. 231 because growth suppression due to inhaled corticosteroids has been well documented, 61 it is important to distinguish infants with early-onset asthma from those with transient wheezing. 469 recently, the fda has also approved leukotriene receptor antagonists for use in asthmatic children under 4 years of age. 380 these agents counteract the hyperimmune response, resulting in diminished airway inflammation and decreased eosinophilia in the airway mucosa and peripheral blood. 34 parents turn to cam for their asthmatic children because of drug side effects or fear of taking long-term medication, especially steroids. 11,62 a recent survey from texas of 48 multicultural parents of children with asthma reported the usage of a variety of cam therapies, including homeopathy, herbal therapy, vitamins, and massages. hispanic parents were more likely to use herbal and massage therapies, whereas african-american parents often turned to prayers. 269 the relatively abundant studies on cam therapy in asthma are on adults and often have flaws in methodology. significant improvement 15,308,310 and even complete cure 83 have been demonstrated with hypnosis, although most studies had weak designs. hypnosis was recommended for children because they were found to be more hypnotizable, 68 but it is unclear whether the efficacy of hypnosis in asthmatic children is a reflection of children's greater suggestibility or a result of a more reversible disease process. 439 in a recent preschool program, 25 children ages 2 to 5 years received treatment with seven hypnotherapy sessions. the number of physician visits was reduced, and parental confidence in self-management skills increased. 217 tcm has been used to treat asthma for centuries. asthma epitomizes the chinese medicine concept of "winter disease, summer cure," which means the best treatment for asthma should be given during the summer, when the child is symptom free. in china, many asthmatic children who were treated with herbal patches applied to acupoints during the summer had minimal or no symptoms during asthmatic seasons. 37, 58, 320 although several recent adult studies used herbs for asthma, 107 only two involved children. a controlled study comparing herbal treatment of 30 children with penicillin and aminophylline treatment of another 30 children revealed no significant difference in the response from the two groups. 242 a multicenter doubleblind, placebo-controlled clinical herbal study from taiwan evaluated 303 asthmatic children using tcm diagnoses. 170 the children were randomized into three different herbal and placebo groups. although both groups showed improvement, the herbal groups showed greater improvement in symptomatology and in biochemical changes, such as increase in total t cells and decrease in histamine. an animal experiment using a 13-herb concoction revealed 99.1% efficacy in easing bronchial spasm. 170 another animal study with an herbal preparation demonstrated strong smooth muscle relaxation through inhibition of histamine and acetylcholine. 242 from the pediatric standpoint, it would be worthwhile to follow the development of external tcm approaches and noninvasive acupuncture. one clinical obser-vation of pasting chinese herbs to acupuncture points in 72 infants with acute bronchitis showed high cure and improvement rate, especially in infants. 461 humoral immune substances, especially iga, were found to be increased after treatment. another clinical observation reported 78% efficacy in 46 children treated with external application of plasters made of herbal mixtures with antitussive and antiasthmatic properties and 88% efficacy in 17 children treated with antiasthmatic herbal patches. success was also reported with a different herbal patch for acute attacks. the patches were well received by the children. 401 improvement from acupuncture treatment has been reported in asthmatic adults. 392, 406, 428, 463 despite methodologic weaknesses, it still seems that acupuncture may help asthma, especially drug-induced or allergic asthma. 439 in some european countries, almost a fourth of general practitioners believe in the efficacy of acupuncture in the treatment of asthma. 216 its role in the united states is still controversial; some physicians accept acupuncture's effectiveness, 426 whereas others criticize data based on poorly conducted studies. 5 the few current studies and clinical reports on acupuncture treatment of children with asthma are generally favorable. 168, 457 a german practitioner reported good results treating asthmatic children using a simple acupuncture regimen in uncontrolled clinical experience. 145 one study demonstrated that although acupuncture did not affect the basal bronchomotor tone, when administered 20 minutes before exercise, acupuncture was shown to be effective in attenuating exercise-induced asthma, 128 which is common in children. one possible mechanism of acupuncture is in reducing the reflex component of bronchoconstriction, but not in influencing direct smooth muscle constriction caused by histamine. 460 for children who are fearful of or who cannot tolerate needles, safe and painless treatments such as cupping and auricular press pellets, 457 laser acupuncture, 288, 292 and massage of acupuncture points 168 have also been found to be effective. the most interesting future role for acupuncture in asthma lies in its potential both in stimulating an immune response and, more importantly, in regulating or modulating a hyperimmune response. at this time, ample biochemical data in the literature support the theory that acupuncture activates both the humoral and the cellular immune systems to protect the host.* studies have also demonstrated that acupuncture can modulate the synthesis and release of proinflammatory mediators. 192, 256, 458 current hypotheses suggest that this is most likely mediated through a common pathway connecting the immune system and the opioids, 30,321,363 which has been well known to be associated with analgesic effects of acupuncture. homeopathic remedies have been reported to be remarkably effective in asthma in adults, 120, 345, 427 and homeopathic doses of allergens have been shown to alleviate allergic symptoms and desensitize patients to allergens. 433 however, there is paucity of scientific data on homeopathy in both children and adults, as well as a lack of consensus among homeopaths as to the appropriate treatment, administration regimen, or potency for asthma. 439 homeopathic practitioners believe that in chronic conditions such as asthma, homeopathic remedies can stimulate the child's innate healing ability, thereby leading to improvement. 197, 198 two recent large reviews on the role of homeopathy in clinical medicine concluded that, except for the occasionally demonstrated benefit, little scientific evidence exists to support the use of homeopathy in most clinical settings. 159, 439 the availability of homeopathic, nutritional, and herbal remedies without a prescription is appealing to the asthmatic adolescent's desire for independence. 12 in a number of european countries, chiropractic is often used for treatment of asthma. 186 one of the many difficulties in evaluating chiropractic efficacy lies in the varying abilities of the manual therapy practitioners. natural human differences exist in manual applications and techniques. the practitioners have various training backgrounds, including physiotherapy, respiratory therapy, chiropractic, and osteopathy. a danish questionnaire survey of 115 families with children up to age 7 years reported that 92% of parents who sought chiropractic help considered the treatment beneficial for their children. 77, 423 an australian survey reported that the most common cam visits were to chiropractors. 87 a u.s. prospective, observer-blinded, clinical pilot evaluated 36 children from 6 to 17 years of age with mild to moderate persistent asthma for chiropractic treatment in addition to optimal medical management. 42 children were randomized into treatment and sham spinal manipulative therapy (smt) for 3 months. the children with combined smt and medical treatment rated their quality of life substantially higher and their asthma severity substantially lower, and their improvements were maintained at 1-year follow-up. however, there were no significant changes in lung function or hyperresponsiveness. further research is needed to determine which components of the chiropractic encounter are responsible for the improvements. a controlled, patient-blinded trial of chiropractic manipulation for 91 children with mild or moderate asthma randomized the children into an active or a simulated chiropractic manipulation for 4 months. 20 each subject was treated by 1 of 11 participating chiropractors, selected by the family according to location. no significant benefit was observed in the treatment group. a few studies in adults generated statistically insignificant data. 176 one study found subjective but not objective improvements in individuals with asthma who received treatment in a chiropractic clinic. 186 a 2001 systematic review revealed that the majority of the studies on smt had poor methodology; the two good studies did not demonstrate significant differences between chiropractic smt and sham maneuver. 167 the reviewers concluded that the evidence is still insufficient at this time to support the use of manual therapies for patients with asthma. a german pilot study of 15 children ages 5 to 11 years with bronchial asthma combined relaxation using various techniques, including progressive muscle relaxation, autogenic training, fantasy travels, mantras, and periodic music, and demonstrated significant improvement in a number of pulmonary function parameters. 142 however, it is difficult to interpret the results because of the variety of techniques used. 143 a u.s. review of anecdotal reports indicated that massage therapy can improve asthmatic symptoms. [110] [111] [112] diarrhea acute diarrhea is a common occurrence in the pediatric population and a significant cause of pediatric morbidity and mortality in both developed and underdeveloped countries. 79, 302, 354 each year an estimated 54,000 to 55,000 u.s. children are hospitalized for diarrhea, 136 and more than 4 million infants and young children worldwide die of acute infectious diarrhea. 354 infants under 3 months of age have the highest risk for hospitalization and mortality. 304 children under age 3 years have an average of approximately 2.5 episodes of gastroenteritis per year in the united states. 143, 302 internationally, the average is approximately 3.3 episodes annually. 354 both diagnosis and treatment continue to be problematic in the pediatric population. 260 the infectious pathogens that cause acute diarrheal episodes in children include viruses, bacteria, and parasites. 229 transmission is most likely through the fecal-oral route, from ingesting contaminated food or water, 434 or in infants and toddlers, by mouthing contaminated toys. the nature of food-borne diseases is changing as more mass-produced, minimally processed, and widely distributed foods result in nationwide and international outbreaks of diarrheal disease instead of just a few individuals who shared a meal. 143 a majority of the cases are caused by viral infections. rotavirus is the most prevalent, 264 and human astrovirus (hastv) is a significant cause of diarrheal outbreaks. 434 frequently, children are co-infected by several viruses. viral diarrhea tends to involve the small bowel, producing large, watery, but relatively infrequent stools. 82 these illnesses usually have short, self-limiting courses, 6 typically lasting 3 to 7 days. 264 however, the diarrheal bouts can be devastating to children with compromised immune systems or structural abnormalities of the gastrointestinal tract. 143 the most common bacterial agents are enteropathogenic escherichia coli, shigella/salmonella, and campylobacter. 82, 264 these are much more virulent pathogens that usually cause mucocal injury in the small and large intestines, producing frequent, often bloody stools containing leukocytes. 82 e. coli has become an important public health problem in recent years, causing more than 20,000 cases of infection and up to 250 deaths per year in the united states. 220, 381 transmission of infection is most often linked to consumption of contaminated meat, water, unpasteurized milk, leafy lettuce, alfalfa sprouts, and goat's milk, 220, 413 and exposure to contaminated water in recreational swimming sites. 413 the most common parasitic infection is giardia lamblia, which often causes secretory diarrhea without blood 264 and frequently leads to chronic diarrhea. 161 diagnosis and treatment are still inconsistent. because most acute diarrheal conditions are self-limited, physicians often do not obtain stool cultures or examination for ova and parasites because the results are not available sometimes for several days. stool culture can identify different types of bacteria, but detection of specific enteropathogenic strains of e. coli requires specific serotyping that is not performed in routine stool cultures. 220 it is expensive, time-consuming, and often not sufficiently specific or sensitive and therefore is not recommended for routine diagnosis. 151 the primary treatment focus is on correction of dehydration, 275 which is the most important cause of morbidity and mortality in acute diarrhea. 243 oral rehydration treatment (ort) with solutions containing appropriate concentrations of electrolytes and carbohydrates is recommended by the world health organization (who) and has significantly reduced mortality. 82, 140, 367 after rehydration, early refeeding with a lactose-free 82 or normal, age-appropriate diet 229 is important for reducing diarrheal duration, severity, and nutritional impact. supplementation with specific dietary ingredients that are lost in diarrhea, such as vitamin a, zinc, and folate, is also recommended. 140 because most of the acute infectious diarrheal conditions are viral, patients do not require antimicrobial therapy. 326, 333 the rotavirus vaccine was put on the market in the united states in october 1998. this vaccine, as the natural infection, decreases the risk of acute rotavirus diarrhea by 50% and the risk of severe diarrhea with dehydration by more than 70%. 367 improving hygiene such as handwashing is also important, especially in day care. breast-feeding is one of the most important preventive measures. 351 continuation of breast-feeding has been found to control acute diarrheal episodes 140 and lower the frequency and duration of acute diarrhea, especially in infants under 6 months of age. 251 a large-scale randomized trial was conducted in 31 hospitals in the republic of belarus. evaluation within the first year revealed that breast-feeding significantly reduced the risk of gastrointestinal tract infection compared with the control group. 228 however, a survey from singapore of breast-feeding mothers at 6 months postpartum revealed no significant differences in the rates of diarrheal diseases between breast-fed and non-breast-fed infants. 64 treatment with antimicrobial therapy must be instituted carefully and only with specific identification of pathogen and drug sensitivity. with the increasing frequency of antibiotic resistance, common antibiotics may be ineffective in patients with acute diarrhea. 143, 351, 367 treatment of salmonellosis with antibiotics can prolong the carrier state and lead to a higher clinical relapse rate. 143 injudicious antimicrobial therapy may also lead to susceptibility to other infections, enhance colonization of resistant organisms, 29, 143 and disrupt the normal intestinal flora, the body's natural defense against infection. 270 homeopathy has the most convincing evidence of efficacy in treating diarrhea in children. a randomized, double-blind clinical trial comparing homeopathic medicine with placebo in the treatment of acute childhood diarrhea was conducted in nicaragua in 1991. eighty-one children 6 months to 5 years of age were given treatment with individualized homeopathic medicine. standard ort was also given. there was a statistically significant decrease in the duration of diarrhea in the treatment group. 182 although criticisms of the study include homeopathic theory being inconsistent with scientific belief 378 and possible toxicity of the dilute homeopathic remedies, 210 the report was also praised for being an impressive, 54 well-designed 44 study that paves the way for future research into the efficacy of homeopathy and other cam therapies. 115 using the predefined measures based on the 1991 study, the same group of researchers more recently carried out a similar study and replicated the same findings of decrease in the duration of diar-rhea and number of stools in 126 children in nepal, ranging in age from 6 months to 5 years. 183 a few studies have demonstrated effectiveness of acupuncture in pediatric diarrhea. the treatment protocols in point selections generally depend on tcm diagnoses, with the majority of points chosen on the two major digestive channels. 109, 190, 245, 398, 455 acupuncture has also been shown to induce favorable anatomic and biochemical changes in improving intestinal peristaltic function and in enhancing both humoral and cellular immunity. 244 a randomized study comparing shallow acupuncture treatment (needles inserted superficially and withdrawn swiftly) with drugs in 761 children ages 1 to 35 months reported significantly higher therapeutic effect in the acupuncture group. 244 the diagnosis and subsequent choice of points were based on tcm principles, not on stool culture results. unlike the homeopathy study, this investigation grouped together patients with acute and chronic diarrhea. in a clinical trial using one chinese herbal formula for treatment of acute diarrhea, there was significant reduction of symptoms and duration of diarrhea. 38 a clinical report of 20 years' application of a seven-herb concoction in 419 children demonstrated 96.4% improvement and 90% cure rate. 241 this nonrandomized, nonblinded report used tcm diagnoses that encompassed a variety of diarrheal conditions, including acute, chronic, infectious, and noninfectious diarrhea. the mechanisms were hypothesized as eliminating pathogenicity, improving immunity, accelerating intestinal digestion, and inhibiting intestinal peristalsis. in a clinical report comparing chinese herbs to western medicine in 158 children with diarrhea due to rotavirus, the herbs were reported to be superior and had a viral inhibitory rate of 71.43%, but no mention was made of the efficacy of conventional medicine. 435 chronic nonspecific diarrhea of childhood differs from acute diarrhea in that it is not associated with significant morbidity. once potentially serious causes are excluded, appropriate diet can be instituted to minimize complications, and reasonable time is then allowed for spontaneous resolution. 414 in a nonrandomized clinical trial involving 30 children ages 3 months to 8 years with chronic diarrhea of 2 to 4 months' duration that was unresponsive to western medicine and tcm, individualized acupuncture treatment eliminated symptoms and normalized stools. 109 infantile colic is estimated to affect 20% to 30% of all infants under 4 months of age and remains a medical enigma of nature versus nurture. colic may represent a heterogeneous expression of developmental variance, unmet biologic needs, psychologic or emotional distress from poor parent-infant interaction, intrinsic temperamental predisposition, colonic hypermotility, 278 or milk allergy.* although colic is selflimiting by 3 to 4 months of age, treatment is mandated because the psychologic consequences may result in a disturbed mother-infant relationship. 174, 355 evidence suggests that uncontrollable crying is the precipitating factor in many cases of infant abuse. 178, 441 because the precise etiology is not understood, the therapeutic goal of western medicine is not aimed at "curing" colic but at containment of the crying. 328 removing cow's milk protein from the mother's diet, changing formula, and prescribing antispasmodic medications are the mainstays of conventional treatment and may be helpful. 69 treatment is often directed toward behavioral changes in mothers. parents may be referred for therapy to learn parenting and coping skills. cam treatments yield inconsistent results. herbs have not yet been proven to be efficacious, 265 although a survey of 51 hispanic mothers in an urban neighborhood in texas revealed that herbal teas were commonly used for colic. 346 evidence is controversial for chiropractic treatment of colic. a multicenter prospective, uncontrolled study of 316 colicky infants involving 73 chiropractors in 50 clinics in the united kingdom for 3 months demonstrated efficacy with chiropractic smt in controlling colic, as reported by mothers in 94% of cases. 215 a retrospective questionnaire study in 1985 revealed satisfactory results of chiropractic treatment in 90% of infants. 301 a randomized, blinded, placebo-controlled clinical trial of 100 infants with typical colic reported that chiropractic manipulation was no more effective than placebo. 307 however, a randomized, controlled, 2-week trial comparing smt with the drug dimethicone demonstrated significantly better results in the chiropractic treatment group. 444 craniosacral therapists empirically claim success in treatment of colic. 19 massage therapists have also found empirically that touch therapy can decrease severity of colic. 111 in a finnish clinical trial, 58 infants less than 7 weeks of age perceived as colicky by their parents were randomized into an infant massage group (n = 28) and a crib vibrator group (n = 30). 173 over 4 weeks there was no difference in the reduction of colicky crying between infants receiving massage and those with a crib vibrator, leading the investigators to conclude that the decrease of crying reflects more the natural course of early infant crying and colic than a specific effect of intervention. therefore infant massage is not recommended as treatment for colic. enuresis is defined as inappropriate or involuntary voiding during the night at an age when urinary control should be achieved. 7 enuresis is a complex disorder with poorly understood pathogenicity and pathophysiology. it affects children worldwide, 297 with about 5 to 7 million children affected in the united states 281 and as many as 30% of school-age children in italy. 48 the condition is classified as primary nocturnal enuresis (pne) when the child has never been dry at night or secondary nocturnal enuresis (sne) when wetting follows a dry period, usually after an identifiable stress. 203, 297 by age 8 years, 87% to 90% of children should have nighttime dryness. 65 in 85% of pne patients, bedwetting is monosymptomatic, with a spontaneous remission rate of 15% per year of age. both the etiology and the pathophysiology of enuresis are still not well understood. multiple factors may interplay: genetic and psychologic predispositions, delayed maturation of the central nervous system, sleep disorders, urinary reservoir abnormalities, detrusor-sphincter incoordination, and urine production disorders. 48 although enuresis is benign, treatment is warranted because of adverse personal, family, and psychosocial effects. 281, 282 nocturnal enuresis delays early autonomy and socialization because of a decrease in self-esteem and self-confidence and a fear of detection by peers. the child may be at increased risk for emotional or even physical abuse from family members. 368, 438 the conventional treatment modalities are still controversial. because the vast majority of pne cases resolve spontaneously with time, treatment should carry minimal or no risk. the moisture alarm is both safe and inexpensive and should be the treatment of choice in most cases 65, 286, 357 but is often the one least prescribed. 15, 258 the medications imipramine and ddavp were frequently chosen as first-line treatment choices. adjunctive therapy may include bladder-stretching exercises, which have a success rate of 30%, and behavioral conditioning. 357 numerous cam therapies are available for childhood enuresis; the most common are hypnosis, acupuncture, and biofeedback. less common cam therapies are chiropractic and nutrition management. hypnotherapy has been recognized by conventional practitioners as a potentially effective therapy. 262, 286 uncontrolled studies have reported high rates of success. 24, 67, 74, 308, 310 in one comparative study of imipramine and direct hypnotic suggestion with imagery for functional nocturnal enuresis in 5-to 16-year-old patients, 76% of the imipramine group and 72% of the hypnosis group had positive response. 21 after termination of treatment, the hypnosis group continued practicing self-hypnosis. at 9-month follow-up, 64% of the hypnosis group maintained dryness compared with only 24% of the imipramine group. hypnosis and self-hypnosis were found to be less effective in younger children (ages 5 to 7 years) compared with imipramine treatment. hypnotherapy has the added advantage that nonphysician health care professionals, such as nurse practitioners, can easily learn the technique to help children. 163 a recent review of controlled studies reported promising findings for hypnosis in children with enuresis, but none of the interventions can currently qualify as efficacious. a major limitation is the lack of treatment specification via a manual of its equivalent. 283 the requirement that the child practice the self-hypnosis technique several times a day limits compliance with the program. 286 acupuncture has been used as an effective treatment for enuresis since at least the 1950s. 459 current worldwide literature in general demonstrates its viability as either a primary or an adjunctive therapy for the enuretic child.* a turkish clinical study on 162 subjects treated with electroacupuncture therapy reported a success rate of 98.2%. 418 acupuncture has been found to be successful both in decreasing the occurrence of enuresis during treatment and in exerting a long-term effect after treatment. 35, 48, 370 parents also report a decrease in sleep arousal threshold. 35 although the precise mechanism of acupuncture is still unknown, a multidisciplinary approach that included acupuncture demonstrated on electroencephalography (eeg) that treatment normalized activities of the cerebral cortex. 415 data from china usually consist of clinical reports of large sample populations. results in one study of 500 patients treated with acupuncture on only two body points demonstrated cure in 476 patients (98%), improvement in 14, and no response in 10 patients. 459 number of treatments ranged from one to three in 453 patients and four to six in 23. another study of 302 enuretic children ages 3 to 15 years (10 over 15 years; oldest 23 years) used tcm diagnosis of organ imbalance and different combinations of acupuncture points, with 10 treatments constituting one course. 453 the results showed that 221 patients were cured, 71 showed marked improvement, and 10 were "effectively" treated. treatment using scalp acupuncture has also been reported to be successful. in one clinical study, 59 children ages 4 to 17 years were treated for 10 to 15 sessions, and some needed a second course. 61 cure was obtained in 9 children, marked improvement in 27, improvement in 19, and no response in 4 children. in all these clinical reports, subjects of a wide range of ages were included in the same study; the discussions were short and generalized, giving very few or no details about the children (e.g., types of enuresis, duration of enuresis, number of wet nights, types of improvement); the methods of treatment were laden with numerous variables (e.g., number of points, treatment courses). a clinical study from italy of 20 children with bladder instability due to uninhibited contractions of the detrusor muscle reported that acupuncture treatment was successful in gradual elimination of enuresis in 11 and improvement of symptoms in 7 children. the mechanism was not clarified. 284 a russian clinical trial of using acupuncture specifically for enuresis due to neurogenic bladder dysfunction demonstrated that acupuncture was beneficial in 17 of 25 children. 194 in a clinical report of 54 enuretic children, short-term success in reducing wet nights was 55% with acupuncture versus 79% with ddavp, whereas long-term success rates were 40% and 50%, respectively. 48 a zagreb report of a clinical trial of acupuncture treatment on 37 children with mean age of 8 years who failed psychotherapy demonstrated a statistically significant decrease in enuresis even at 6 months after treatment. 350 a self-controlled regulating device operating on the principles of acupuncture was found to be effective in the treatment of nocturnal enuresis attributable to neurogenic bladder dysfunction. 233 a controlled clinical study of 40 children between 5 and 14 years of age randomly selected into four groups of 10: treatment with ddavp alone, acupuncture alone, combined ddavp with acupuncture, and placebo. efficacy of treatment, expressed as a percentage of dry nights, was high in both ddavp and acupuncture groups, but the combined-treatment group had the best results. 52 a scandinavian clinical trial used traditional chinese acupuncture for treatment of primary persistent pne in 50 children ranging in age from 9 to 18 years. the response rate was monitored at 2-week, 4-week, and 3-month intervals. 370 within 6 months, 43 (86%) of children were completely dry and 2 (10%) were dry on at least 80% of nights, leading the clinicians to conclude that acupuncture is effective, with stable results. another scandinavian study investigated the efficacy of electroacupuncture in treating 25 children ranging in age from 7 to 16 years. 35 twenty treatments were administered over 8 weeks. the number of dry nights consistently increased when the children were reevaluated at 3 weeks, 3 months, and 6 months after treatment. five children had more than 90% reduction of wet nights at 6 months, and 65% had more dry nights at the 6-month follow-up. a recent teaching round at the china academy of traditional chinese medicine in beijing discussed successful acupuncture treatment of a complicated case of enuresis in a 16-year-old student who had previously failed both western and chinese medicines for his physical and emotional sequelae. 171 using tcm diagnosis of organ imbalances, the treatment combined body acupuncture, scalp acupuncture, and auricular acupressure seed. the patient began improving after three treatments in the first week. he received 3 more weeks of treatment, with no recurrence of enuresis at 6month follow-up. children are often unwilling to undergo needle acupuncture because of fear of pain, 61 prompting researchers to use noninvasive forms of acupuncture. simple acumassage has been previously reported to be beneficial to the enuretic child. 21 an austrian prospective, randomized trial evaluated efficacy of laser acupuncture versus desmopressin in 40 children over age 5 years with pne. 337 at 6-month follow-up, the desmopressin-treated group had 75% success rate with complete resolution of symptoms, an additional 10% had a more than 50% reduction in wet nights, and 20% did not respond. the laser acupuncture group had 65%, 10%, and 15% rates, respectively. the results were not statistically significant. therefore laser acupuncture should be considered as an alternative, noninvasive, painless, cost-effective, and short-term therapy in children with normal bladder function and high nighttime urine production. worldwide reports have demonstrated efficacy in treating enuresis with biofeedback, 164, 250, 318, 332 which aims at learning or relearning of influence of involuntary functions. 266 a clinical study from italy treated 16 boys and 27 girls ages 4 to 14 years with detrusor-sphincter dyssynergy. biofeedback was successful in all the children, with sne resolving significantly sooner than pne and girls responding better than boys. two-year follow-up still revealed an 87.18% success rate, with 80% at 4 years. 332 in a french study, 120 children with three predominant urinary disorders that included nocturnal enuresis were treated with biofeedback. detrusor-sphincter discoordination was diagnosed in 33 children. pelvic floor biofeedback produced excellent results in these children. 323 belgian investigators reported a clinical biofeedback study of 24 children with median age of 10.4 years who did not respond to anticholinergics. 164 seventeen subjects had complete resolution of enuresis, six had a decrease in symptoms, and one child did not respond. at 6-month follow-up, two children in the cured group had recurrence of enuresis. another study from belgium also reported success in using biofeedback in 26 children with pseudo-detrusor-sphincter dyssynergy; 17 were completely cured, and 5 improved considerably. 266 a spanish study used biofeedback to treat unstable detrusor in 65 enuretic children; complete disappearance of symptoms was seen in 70.5%, with improvement in 78.2%. 318 in a u.s. report of 8 boys and 33 girls ages 5 to 11 years who underwent an average of 6 hours of biofeedback for nocturnal and diurnal enuresis, improvement was noted in 90% of nocturnal enuresis and 89% of diurnal enuresis. 272 another u.s. clinical study used biofeedback for 21 children with dysfunctional voiding; 17 (81%) had an excellent response, 3 (14%) had a fair response, and 1 (5%) was too inconsistent to rate. 70 the average number of sessions to achieve a consistent urodynamic response was 3.7 (range 2 to 14). average follow-up was 34 months (range 14 to 51 months). the investigators recommended biofeedback as an effective method that requires only a short period for treating dysfunctional voiding. 70 all these worldwide studies were clinical reports, not randomized, controlled, blinded studies. the efficacy of chiropractic manipulation in enuresis has been inconsistent. one clinical report identified an 8-year-old boy with functional enuresis who had successful treatment with manipulation. 37 in an uncontrolled study of 175 children ages 4 to 15 years, with responses monitored by parents, chiropractic manipulation resulted in only 15.5% success. 234 however, a randomized, controlled clinical trial of 57 children demonstrated that 25% of the treatment group had 50% or more reduction in enuretic symptoms, although the pretreatment to posttreatment change in wet night frequency was not statistically significant, and there was no long-term follow-up. 341 a comprehensive review of the literature revealed that smt was no more effective than the natural regression of enuresis with age. 225 food allergy as a cause of enuresis has been in the literature for several decades. 106 a recent study of children with severe migraine or attention deficit disorder (add) included 21 children with enuresis. oligoantigenic diets were successful in curing 12 children and improving enuresis in 4 other children. relapse of wetting occurred when foods were reintroduced; the substances implicated most often were chocolate, citrus, fruits, and milk from cows. 281 although no studies are available on naturopathic approaches, which focus on natural remedies (e.g., corn silk and tea, tea and honey), physicians should not dismiss parental opinion that these remedies may be safe and effective. the future of treatment for enuresis should combine various methods to increase the probability of treatment success and minimize risk to the child. 281 atopic dermatitis affects almost 10% of all children 56 and 20% of children ages 3 to 11 years. 201, 202 it accounts for more than 30% of outpatient pediatric visits. 95 most children with atopic dermatitis typically come to medical attention with cradle cap and facial and extremity rashes by age 2 to 3 months. 95 despite considerable research, the etiology of allergic disease remains poorly understood. 16 allergic dermatitis can be thought of as an inherited skin "sensitivity" that reacts to various external allergens and changes in psychologic states. 357 food causes atopic dermatitis in 50% of infants, 20% to 30% of young children, and 10% to 15% of children after puberty. 395 topical steroids remain the main therapeutic method. dermatologists tend to prescribe antibiotics and use potent topical steroids, 343 which are more readily absorbed in children and can result in hypothalamic-pituitary-adrenal axis suppression. 179 new immune modulators have shown promise in severe atopic dermatitis. 149, 212 cam therapies are increasingly used for dermatitis, 127 although most of the information is in clinical reports, and research data are limited. a database review of 272 randomized clinical trials of atopic eczema covering at least 47 different interventions revealed that evidence is still insufficient to make recommendations on maternal allergen avoidance for disease prevention, herbs, dietary restrictions, homeopathy, massage therapy, hypnotherapy, or various topical cam therapies. 162 a multicenter randomized clinical trial conducted in 31 hospitals in the republic of belarus reported that breast-feeding significantly reduced the risk of atopic eczema compared with the control group in the first year of life. 228 psoriasis was found to worsen with cam treatments such as herbs, dietary manipulation, and vitamins. 116 dietary management with evening primrose oil, rich in gamma-linolenic acid, has been found to be inconsistently effective in small studies. fish oil supplements (enriched in n-3 polyunsaturated fatty acids) have also been used. 357 various herbs offer relief for eczema. 127 a placebo-controlled, double-blind trial used a chinese herbal prescription specifically formulated for widespread nonexudative atopic eczema. thirty-seven children were randomly assigned to 8-week active treatment and placebo, with an intervening 4-week "washout" period. the response to active treatment was significantly superior to placebo, without evidence of hematologic, renal, or hepatic toxicity. 373 the same investigators monitored the children over the following 12 months. eighteen children had at least a 90% reduction in eczema, and five showed lesser degrees of improvement. 374 two randomized, double-blind placebo-controlled trials from singapore revealed that a concoction of 10 chinese herbs was efficacious in the treatment of atopic dermatitis in both children and adults, and that the mechanism may be through the beneficial immunosuppressive effects. toxicity is a concern, however, because exact dosing of the active derivatives is difficult to achieve. 339 acupuncture treatment of acne has been reported to be successful 247 in as many as 91.3% of adolescents given treatment. 456 other tcm techniques have also been reported to be helpful. 57 a clinical trial treated 20 children with severe, resistant atopic dermatitis with hypnosis. 393 nineteen showed immediate improvement, 10 maintained improvement in itching, and 9 maintained improvement in sleep disturbance 18 months after treatment. homeopathy is frequently used to treat dermatitis. in one homeopathic clinic in israel, more than 80% of the patients expressed satisfaction with treatment. however, the authors of the survey believed that homeopathic medicine complements conventional medicine and is not an alternative. 316 chiropractic treatment has also been sought by children for allergic problems. 303 a small british study tested the hypothesis that massage with essential oils (aromatherapy) used as a complementary therapy in conjunction with normal medical treatment would help to alleviate the symptoms of childhood atopic eczema. 9 eight children were randomized into the treatment group, who were massaged with oil, and the control group, massaged without essential oil. no significant difference was found between the two groups. there was a later deterioration of eczema in the oil massage group, suggesting allergic contact dermatitis provoked by the essential oils themselves. attention deficit-hyperactivity disorder (adhd) is the most common neurodevelopmental disorder of childhood, with a prevalence rate between 2% and 11%, 373 averaging about 5%. 14, 371, 405 the road constellation of hyperactive, inattentive, and impulsive symptoms combined with the multiple comorbid conditions makes the definition and adhd controversial and the diagnosis flawed. 405 adhd is a chronic, heterogeneous condition with academic, social, and emotional ramifications for the school-age child. 371 the disabling symptoms persist into adolescence in approximately 85% of children and into adulthood in approximately 50%. 14, 32 there is a developmental pattern in the primary symptoms of the disorder; hyperactivity diminishes while attentional deficits persist or increase with age. 371 the precise etiology of adhd is still unknown, and assessment and management remain diverse. medication continues to be the mainstay of treatment, with methylphenidate (ritalin) the treatment of choice. 141 the tricyclic antidepressants were added as an alternative medication in the 1970s, 32 with clonidine, buspirone (buspar), and other antidepressants and neuroleptics added to the list in the 1980s. 55, 60 although it is generally agreed that drugs are beneficial on a short-term basis, there is a paucity of data on the long-term efficacy and safety of medications, especially in children younger than 3 years of age. these drugs have not been shown to produce long-term gains academically or socially. 90 besides pharmacotherapy, a multimodal approach using a combination of drugs and other methods, such as cognitive-behavioral therapy (cbt), psychotherapy, social skills training, and school interventions, is frequently prescribed for adhd. cbt represents the most widely used alternative to pharmacotherapy, although previous studies have shown disappointing results. 2, 3, 45, 177 in 1992 the national institutes of mental health (nimh) began a 14-month, multisite clinical trial, the multimodal treatment study of adhd (mta). 160, 189 the results indicated that high-quality medication management (with careful titration and follow-up) and a combination of medication and intensive behavioral therapy were substantially superior to behavioral therapy and community medication management. there is slight advantage of combination of medication and behavioral therapy over medication alone. psychotherapy can be an effective adjunct to medication 364,365 but usually requires a long-term commitment to several years of treatment. concerns about side effects of medication, 232,391 treatment acceptability, 27,334 and compliance are additional factors that complicate management of the adhd child. clearly, there is room to explore safe, acceptable, and relatively easy alternatives. interest is increasing in more natural, holistic integrative approaches to adhd. studies using cam therapy for treating adhd encompass more than the usual research difficulties because of the complexity and heterogeneity of the disorder, as well as subjective evaluation by parents and teachers of a wide range of 18 characteristics that may qualify for several different diagnoses. a majority of the cam therapies to date continue to have mostly anecdotal and empiric evidence. the few welldesigned studies include biofeedback, herbal medicines, dietary modifications or supplements, and acupuncture. 46 studies have demonstrated that there is a significant difference in baseline eeg measurements in children with attention deficit disorder (add) compared with normal-achieving preadolescent males. these differences occur mainly in the parietal region for on-task conditions 187 and in the cortex and corticothalamic excitatory and inhibitory interactions. 252, 255 biofeedback or neurofeedback is a technique for modifying neurophysiology for learning. 252 in 1991 a critical review of 36 studies in which biofeedback was used as a treatment for hyperactivity indicated that biofeedback alone had not been effectively evaluated, and methodologic problems limit generalizations that it may be applicable to the entire hyperactive population. 238 a 2001 review continues to indicate that although anecdotal and case reports cite promising evidence, methodologic problems coupled with a paucity of research preclude any definitive conclusions as to the efficacy of enhanced alpha and hemisphere-specific eeg biofeedback training. 340 some recent studies using more sophisticated technology claim that neurofeedback can improve attention, behavior, and intellectual function in the child with add, 49, 246, 253 with measurable eeg improvement in the frontal/central cortex. 295 its stabilizing effect has also been found to last as long as 10 years after treatment. 407 hypnotherapy and biofeedback do not appear to alter the core symptoms of adhd but may be helpful in controlling secondary symptoms. these methods allow children to become active agents of their own coping strategies. 26 a mailed questionnaire survey of 381 children with adhd with a 76% response rate reported that 69% were using stimulant medication and that 64% of the respondents used or were using a nonprescription therapy. diet therapies constitute the most common cam therapy (60%). 397 one review of cam therapy lends support to individualized dietary management and specific trace element supplementation in some children with adhd. 26 nutritional management of add includes elimination diet, megavitamins, 26,372 supplements, and trace element replacement. simple sugar restriction seems ineffective. 14 the well-known feingold diet eliminates natural salicylates, food colors, and artificial flavors. studies have demonstrated mixed results. 211 megavitamins were demonstrated to be ineffective in the management of add in a two-stage study with clinical trial and double-blind crossover. potential hepatotoxicity is a major concern with use of megavitamins. 152 in a recent longitudinal, nonrandomized clinical trial, 17 adhd children were given a glyconutritional product containing saccharides known to be important in healthy functioning and a phytonutritional product containing flash-dried fruits and vegetables. 93 five children were not receiving methylphenidate (ritalin), six children were taking prescribed doses of methylphenidate, and the remaining six children had their medications reduced by half after 2 weeks. the glyconutritional supplement was administered for the entire 6 weeks, and the phytonutritional supplement was added after 3 weeks. the teachers and parents rated behavioral items for adhd, oppositional defiant disorder, and conduct disorder. the conclusion was that the glyconutritional supplement decreased the number and severity of adhd, associated odd and cd symptoms, and side effects of medications during the first 2 weeks of the study; there was little further reduction with the addition of the phytonutritional supplement. the three groups did not differ statistically in degree or reduction of symptoms. 93 this 6-week study had too many variables and too few subjects without control for a definitive conclusion, although the concept of simple nutritional supplement is important to explore. there is increasing interest in abnormality of fatty acid metabolism as the etiology of at least some features of adhd. 344 these abnormalities can range from genetic abnormalities in the enzymes involved in phospholipid metabolism to symptoms that were reportedly improved after dietary supplementation with long-chain fatty acids. 436 in a randomized, double-blind, placebo-controlled trial of docosahexaenoic acid (dha) supplementation, 63 children ages 6 to 12 years receiving stimulant medication were randomly assigned to receive dha supplementation or placebo for 4 months. there was no significant improvement in the treatment group. 429 oligotherapy focuses on deficiency of trace elements in children with add. 221, 389 in a polish controlled clinical trial, magnesium deficiency was found in blood and in hair of hyperactive children. 390 fifty 7-to 12-year-old add children were given a magnesium supplement of 200 mg/day for 6 months while the control group of 25 children continued on their medical regimen. increase in magnesium contents in hair correlated with a significant decrease of hyperactivity in the treatment group, whereas hyperactivity actually intensified in the control group. the same investigators also found deficiencies of copper, zinc, calcium, and iron, with magnesium being the most common deficiency, in 116 children with adhd. 389 a thorough literature review of alternative treatments for adhd identified 24 cam therapies and reported that chinese herbal treatment has promising pilot data. 14 a clinical trial using chinese herbs in the treatment of 66 children with a diagnosis of hyperkinesia based on the american psychiatric association's diagnostic and statistical manual of mental disorders, ed 3 revised (dsm-iiir) criteria demonstrated 84.8% effectiveness in ameliorating hyperactivity and improved attention and school performance. 401 the herbal remedy was prepared according to the tcm diagnosis of common energetic (qi) imbalance found in these children. clinical observations were substantiated by laboratory findings of significant increase in urinary content of norepinephrine, dopamine, dihydroxyphenylacetic acid, cyclic adenosine monophosphate, and creatinine. 401 in a randomized study, chinese herbal treatment was found to be comparable to methylphenidate but had fewer side effects. 464 research is currently being conducted to investigate the efficacy of herbal and homeopathic remedies because current evidence is inconsistent or lacking. 26 in a prospective, randomized, double-blind pilot study funded by nih that integrated dsm-iv diagnostic criteria, conventional theories of frontal lobe dysfunction, and neurotransmitter abnormalities with traditional chinese theories of energetic imbalances, laser acupuncture was used in the treatment of adhd in 7-to 9-year-old children. 249 preliminary data on the six children in the treatment group showed promise in reducing signs and symptoms of adhd. using conners scale as a weekly follow-up measure, improvement in classroom behavior was reflected by substantial drops in the teachers' scores before and after treatment in five of six children. the parents' scores dropped in three children but did not change in the other three children (figures 11-1 and 11 -2). one child was promoted to the gifted program, and another demonstrated marked improvement in learning disabilities. there are no data at this time on homeopathic or chiropractic treatment of adhd, although many practitioners claim anecdotal success with the use of homeopathic desipramine (norpramin) and manipulation. pediatric use of cam therapies continues to increase. 385 it is therefore advisable for physicians who treat children to take a thorough history of cam use, especially in those with chronic disorders, to become knowledgeable about the various alternative therapies that can complement conventional care. this allows practitioners to consider possible adverse effects or interactions of cam with conventional therapy, to open lines of communication with cam providers, and even to consider integrating effective cam therapy into their medical regimen. although cam therapy is in general considered safe, there have been a few reports of significant side effects. 219, 271 continuous research is needed to investigate the safety and efficacy of cam therapies for children; to address explicitly the tremendous heterogeneity between and among the practices, beliefs, and providers of professional and lay services; and to study how cam may enhance the quality of mainstream health services. 208 although children are entitled to new therapies, pediatric research in cam is further complicated by children's vulnerability to violation of their personal rights and to risk exposure. 420 in children of the same age, varying cognitive capacity can be required for informed consent. 315, 353 differences in physiologic maturation can change the kinetics, end-organ responses, and toxicity of therapy, so data from adult studies cannot be extrapolated for children. 240 even in conventional medicine, children are often rendered "therapeutic orphans" 376 because of history of abuses in pediatric research, a heightened sensitivity to risks in children-especially since the thalidomide disaster-and a limited market potential. 353 in the united states, 80% of drugs have age limits or contain disclaimers for pediatric use. 135 therefore protecting children by giving them only scientifically proven therapies is counterbalanced by denying them access to possible safe and effective treatment that may not be proven for many years to come. a frequently expressed concern is that visits to cam practitioners may cause delay in diagnosis. 467 a more serious concern is the lack of formal pediatric training in many cam therapists so that they may fail to recognize potentially serious illnesses, especially in infants. 236 conventional medicine is endowed with superb technologic support for making physical diagnoses, whereas some cam practitioners may claim the ability to diagnose a discomfort on an "energetic level" that is not yet defined biomedically. an integration of these disciplines should provide a better understanding of human health and disease. currently, many medical 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observer alternative/complementary medicine: wider usage than generally appreciated environmental control in the prevention and treatment of pediatric allergic diseases prospects for the prevention of allergy in children atopic disease, rhinitis and conjunctivitis, and upper respiratory infections allergen avoidance: does it work surveys of complementary and alternative medicine. i. general trends and demographic groups relationship of infant feeding to recurrent wheezing at age 6 years current treatment of allergic rhinitis and sinusitis 302 cases of enuresis treated with acupuncture treatment of acne with ear acupuncture-a clinical observation of 80 cases 14 cases of child bronchial asthma treated by auricular plaster and meridian instrument acupuncture of guanyuan (ren 4) and baihui (du 20) in the treatment of 500 cases of enuresis effect of acupuncture on bronchial asthma acupuncture treatment of chronic rhinitis in 75 cases immediate antiasthmatic effect of acupuncture in 192 cases of bronchial asthma preliminary study of traditional chinese medicine treatment of minimal brain dysfunction: analysis of 100 cases clinical and experimental study on yifei jianshen mixture in preventing and treating infantile repetitive respiratory infection clinical investigation on massage for prevention and treatment of recurrent respiratory tract infection in children pneumococcal conjugate vaccine for young children prevention of asthma morbidity: recent advances key: cord-026009-rdhuc2n2 authors: anderson, nancy l. title: pet rodents date: 2009-05-15 journal: saunders manual of small animal practice doi: 10.1016/b0-72-160422-6/50179-0 sha: doc_id: 26009 cord_uid: rdhuc2n2 nan many small rodents are commonly kept for companionship and enjoyment. this chapter provides information needed to diagnose and treat the most frequently encountered problems of mice, rats, gerbils, hamsters, guinea pigs, and chinchillas. • cages should be made of stainless steel, hard plastic, or glass. these materials are cleaned and sanitized easily and are resistant to gnawing or corrosion from urine and fecal matter. minimum floor space and height requirements are listed for each species in • guinea pigs can be housed in open-topped enclosures with walls higher than 10 inches. ensure that dogs, cats, wild animals, and small children do not have unsupervised access to these cages. • clean cages as needed, usually 1 to 3 times per week for most rodents. a scrub brush, dish soap, and water work well. if cages are not kept clean, ammonia, other irritants, moisture, and bacteria concentrations rise to harmful levels, predisposing animals to disease. • disinfect the cage twice a month with 1 part sodium hypochlorite (household bleach) mixed in 30 parts water. let the bleach solution stand for at least 15 minutes. rinse the cage well afterward. • all solid-floored cages need to be covered in bedding. shredded paper, non-resinous wood shavings, wood wool, and corn cobs are all acceptable. provide at least 2 inches of bedding. most rodents enjoy burrowing in deeper bedding when it is provided in one corner of a cage. do not, however, fill the entire cage with deeper bedding. this usually leads to poor sanitation as a result of owners' failure to recognize buildup of hidden wastes such as moisture from leaking water bottles, cached foods, urine, and feces. • wire mesh floors can be used successfully only if the dimension of the mesh is correct. size the openings to be just large enough for an adult to retract a tarsal joint back through the mesh. larger holes make it difficult for the animals to walk and cause pressure sores. smaller openings may cause injuries such as tibial fractures and self-mutilation while struggling to free trapped appendages. bedding above the wire keeps waste from dropping through the wire and therefore is not recommended. wire bottom cages do not work well for breeding animals because neonatal rodents must be surrounded by nesting material to maintain moisture in the nest and prevent dehydration. young rodents often cannot walk correctly on mesh sized for adult feet. • all pet rodents require visual security. tubes, jars, or cans made of nontoxic, nonabrasive substances work well for this purpose. also provide objects for gnawing. rodents possess open-rooted teeth, and constant wear is necessary to maintain normal dentition. mice, rats, gerbils, and hamsters enjoy and benefit from exercise wheels. • a good room temperature range for most pocket pets is 70°f to 75°f. keep rodents with disease at 85°f to 90°f unless hyperthermia is of concern (some chinchillas). • provide 10 to 12 hours of darkness to 12 to 14 hours of light. this light cycle is essential if breeding is desired. • hamsters, guinea pigs, and chinchillas that are exposed to temperatures below 65°f may hibernate for a few days or until the ambient temperature rises. heart rates may be less than 5 bpm during hibernation. m key point feed pet rodents laboratory animal chow appropriate for their species (table 177 -2). seed diets are deficient in protein and contain excessive fat. • seeds, as well as vegetables and other foods, may be fed as treats but not to provide more than 15% of calories. intermittent exposure to vegetables and seeds causes mild, transient diarrhea. • supplementation of vitamin c is recommended for all guinea pigs. • adult chinchillas that are not obese should be fed high quality, fresh grass hay ad libitum. obese animals may need to have the hay rationed. chinchillas require 1 / 8 to 1 / 4 -cup of fresh pellets per animal each day. feeding pellets free choice leads to obesity, and the high protein and calcium levels in these diets may predispose animals to urinary tract disease. most pellets also do not provide sufficient fiber to maintain normal gastrointestinal (gi) motility. • store food in tightly sealed containers at less than 60°f; keep food refrigerated if possible. • feed all diets within 90 days of milling to ensure the highest nutritional value. encourage owners to check dates on packages and ask pet store managers about providing dates on bulk items. • if possible, feed pet rodents except guinea pigs from overhead racks. these devices reduce wastage and eliminate fecal contamination of food. covered hoppers, heavy crocks, or stainless steel bowls that are attached to the side of the cage to eliminate spillage are acceptable and recommended for guinea pigs. • feed breeding females and their litters from the floor of their cages until the young are large enough to reach overhead feeders or crawl in and out of crocks. • cannibalism of neonates commonly occurs as the result of stress associated with cage cleaning. to minimize cannibalism, clean the cage and provide a 10to 13-day food supply 1 to 2 days before parturition. m key point provide fresh water in clean containers daily. • do not provide water in open crocks. these are contaminated or spilled easily and are a common cause of dehydration and poor sanitation. • sipper tubes and water bottles work well. clean with dish soap and water daily and disinfect them weekly. guinea pigs expel food from their mouths into their sipper tubes, so more frequent cleaning is needed. • some water bottles have special valves to minimize backflow. supplement guinea pigs' water daily with 200 mg vitamin c/l. if the water is not dechlorinated, it will inactivate the vitamin c. quarantine all newly acquired animals in a different room from current pets for a minimum of 30 days. feed and handle quarantined animals last. recommend that caretakers wash their hands and change clothes before handling current pets. avoid the introduction of adult animals because this frequently results in fighting. instead, place animals together while young and allow them to mature together. avoid keeping more than one male per cage because this also usually leads to fighting. a systematic history and physical examination are mandatory. many disease syndromes are caused by poor husbandry. pets that have been kept isolated from other rodents or acquired from a private breeder are less likely to harbor infectious disease than animals obtained from a pet store, laboratory, or wholesaler. see table 177 -3 for normal physiologic data. obtain the following information: • observe the pet in its cage for mentation, activity, locomotion, dyspnea, head posture, haircoat, and any grossly observable abnormalities. • note respiratory and heart rates before restraint when possible. observe the condition of cagemates. m key point if dyspnea or severe depression is detected, warn the owner that the animal is critically ill and could die of stress brought on by an examination. • handle such animals as little as possible. initially, treat severely ill animals symptomatically, then • note the type of diet and bedding as well as the level of sanitation and compare these with what was described in the history. • observe quantity and quality of feces and urine. diarrhea, soft stools, absence of stools, copious urine, and discolored urine all can be signs of illness. • coprophagy is a normal behavior in rodents. • check the diet and water supply for freshness, quantity, source, and accessibility. • evaluate the presence and suitability of cage furniture. adequate visual security and the ability to exercise and gnaw are extremely important. • an accurate weight in grams is extremely important for evaluating an animal's body condition, calculating drug dosages, and monitoring treatment. the easiest method of weighing a pet rodent is to place it in a box and then subtract the weight of the container. • restraint of pet rodents is easy with experience. pets that have been handled frequently and gently by the owners require only minimal restraint. gentle pressure directs the animal as needed. grasp less cooperative patients (except chinchillas and guinea pigs) by the scruff over the back of the neck with thumb and forefinger ( fig. 177-1) . take care to pinch enough skin to prevent the animal from turning around, yet leave enough slack for respiration. on smaller specimens, hold the base of the tail, if present, between the fourth and fifth fingers to provide additional restraint. • hold docile guinea pigs with the palm of one hand supporting the chest while the other hand supports the hind quarters ( fig. 177 -2). place the thumb and forefinger of the first hand in the axillas for additional control. • take care to minimize damage to the fur when handling chinchillas because they lose hair easily. grasp the animal by the tail and scoop it up into the palm of the same hand ( fig. 177-3 ). if necessary, grasp the thorax just behind the axillas. • calm uncooperative rodents by placing an appropriately sized towel over the head. complete the physical examination by wrapping the patient in a towel and exposing only needed areas. even oral, ophthalmic, and aural examinations can be performed with minimal effort if the animal is given the chance to relax in the towel "burrow." • remove particularly aggressive patients from their cages by scooping them up in a can or bucket; then slide them out onto a slick surface and pick them up or transfer them to a holding area or scale. m key point lift the hind quarters of mice and rats by the base of their tails to facilitate scruffing. never use the tip of the tail for restraint, or the skin of the tail may slough. once the animal is restrained properly, examine the head. assess the cranial nerves. check the nose for presence and character of discharge. examine the mouth for ptyalism, swelling, overgrown incisors, or discharges. to inspect the oral cavity, place an avian speculum across the mouth just caudal to the incisors. use a light source and a pair of hemostats as retractors to improve access. alternatively, use an otoscope with a pediatric head to examine the premolars and molars of guinea pigs and chinchillas for overgrowth. examine the cheek pouches of hamsters for swelling, impaction, or discharge. an ophthalmic examination, including a fundic examination, is important. • use a slit lamp to identify superficial pathology, especially corneal ulcers or foreign bodies. • if indicated, perform fluorescein stain and conjunctival scrapings or cultures. • note the presence of conditions such as discharge, asymmetry, and exophthalmos. m key point gerbils, rats, and mice produce red tears (chromodacryorrhea) with stress or disease. do not confuse them with hemorrhage. • guinea pigs suffering from hypovitaminosis c often produce dry, white tears. • check ears for discharge, foreign bodies, and mites. bluish discoloration of the ears is a sign of cyanosis. bright red injected coloration is associated with septicemia. sores behind the ears and on the neck are often a sequela of aural disease. • evaluate submandibular, axillary, inguinal, and popliteal lymph nodes for size and consistency. enlargements usually indicate infectious or neoplastic disease. • reevaluate respirations and heart rate after the stress of handling and compare them with the resting rate noted when the animal was in the cage. note dyspnea or respiratory sounds. auscultate animals weighing more than 200 g. counting every third or fourth beat and multiplying by the appropriate factor allows recording of heart rates up to 500 bpm. • palpate the abdomen. pay special attention to differentiating pregnancy from the bladder, kidneys, abdominal masses, enlarged cecum, and fecal balls in the colon. while palpating the abdomen, examine the mammary chain of all female rodents for signs of mastitis, lactation, or neoplasia. also check male mice and rats for mammary neoplasia. mammary tissue extends from the base of the neck to the base of the tail. gerbils typically have an elliptical sebaceous gland on their ventral midline. do not confuse this with neoplasia or infection. check the rectum and perineal area for signs of diarrhea, prolapse, irritation, parasites, and bite wounds. note that coprophagy is normal in rodents. • evaluate the urogenital tract for signs of inflammation, foreign bodies, urine scalding, and vaginal discharge. locate and palpate the testicles in males. the easiest method of determining sex in pet rodents is to compare the anogenital distance, which is twice as long in males as in females. other characteristics that allow the determination of sex are as follows: • visualization or palpation of testicles or extrusion of the penis from the prepuce indicates a male. • the presence of two external openings (i.e., anus and urethra) indicates a male. • the presence of three openings (i.e., anus, vagina, and urethra) indicates a female. • examine the skin and fur for conditions such as crusts, alopecia, masses, herniations, and wounds. • check tail and feet for swellings, coloration, sores, length of toenails, and condition of footpads. • evaluate the extremities for trauma or other abnormalities. apply cellophane tape to crusted areas of the skin and view under a microscope as an aid in diagnosing ectoparasites such as lice, mites, and fleas. skin scrapings are beneficial in detecting mites and dermatophytes. dermatophytes are diagnosed best through culture of broken hairs or crust on dermatophyte test medium. use small, cotton-tipped swabs to obtain ear swabs from animals weighing more than 25 g. mix debris with mineral oil and view under low magnification to test for ear mites, or roll onto a glass slide and gram stain to look for bacterial or yeast infections. collect urine by placing the rodent in a clean meshbottomed cage with a plastic liner. after enough urine has been produced, collect it off the bottom of the cage with hematocrit tubes or a syringe and a 25-gauge needle. perform cystocentesis on non-pregnant animals weighing more than 100 g with a 25-to 27-gauge needle. collect feces over several hours to provide a volume sufficient for fecal flotation. flotation allows the detection of nematodes and some trematodes and cestodes. cellophane tape applied to the perineal area and then viewed under a microscope often reveals oxyurid eggs. use a fresh saline smear or fecal sedimentation to diagnose protozoal parasites. fecal cultures are useful in diagnosing bacterial diarrhea. radiology is an extremely useful tool. machines capable of exposures as low as 40 kvp and 3 to 10 mas effectively image mice. most radiograph machines are capable of generating diagnostic radiographs of guinea pigs, chinchillas, and mature rats at settings used for kittens. positioning is accomplished with masking tape or velcro straps. sedate unruly animals. techniques used in cats for contrast studies of both urinary and gi systems are modified easily for use in pocket pets. • use lateral or medial saphenous veins to obtain samples in animals heavier than 100 g. liberally clip the area to allow exposure of the vessel before attempting venipuncture. place a 25-to 27-gauge needle in the vein and collect blood into microtainers or hematocrit tubes as it drips from the hub of the needle (fig. 177-4) . take extreme care not to col-lapse and lacerate the vein with overzealous aspiration if a syringe is attached to the needle. • it is also possible to use the cephalic vein in guinea pigs. • jugular veins are good alternatives in thin individuals under sedation. • an alternative technique that is useful in smaller animals is to coat the skin over the vein with a thin layer of petroleum jelly and then to puncture the vessel. blood is collected with a hematocrit tube as it exits the wound. samples up to 1% of the animal's weight are considered safe, even in stressed animals. m key point attempt tail bleeding only as a last resort in mice, rats, gerbils, and hamsters. these techniques often are not acceptable to owners. to bleed the tail, warm the tail with water or compresses to dilate the tail vessels. in large rats, perform venipuncture with a needle and obtain blood in the usual fashion. in smaller animals, lacerate the tip of the tail. blood from the wound is collected as described previously. see tables 177-5 and 177-6 for hematology and chemistry values. incorporate oral medications into a treat, or administer them in liquid form. if the medication is palatable, administer it by placing the tip of a dosing syringe into the diastema. m key point take care not to place the tip into the contralateral cheek pouch, or the patient may store the medication and expel it later. administer medication in small amounts. ensure that the animal swallows the medication in its mouth before more is administered. this technique is useful for force-feeding pellet gruels to anorexic pets if the caregiver is patient. medication or food that is administered too quickly will be spit out or aspirated. for rodents that are intractable or for administration of unpalatable substances, pass a stomach tube per os. • metal feeding needles, red rubber urinary catheters, or infant feeding tubes work well. selection is based on the size of the animal and individual preference. metal feeding needles with ball tips frequently are used in patients weighing less than 100 g . the metal provides the necessary stiffness to pass a tube of small diameter. the ball at the end of the needle makes it difficult (but not impossible) to pass the tube into the trachea. these tubes have the potential to create esophageal tears with improper restraint or when excessive force is applied. • measure the length from the tip of the nose to the last rib. ventroflex the head slightly, and place the tip of the tube through the diastema and over the tongue. if the tube does not pass easily down the esophagus to the premeasured distance, check the tube size and/or reposition the tube before attempting further advancement. the needle is easily palpable percutaneously if it is placed correctly. it is usually safe to administer up to 3 ml/100 g body weight. • a flexible catheter is ideal for use as a stomach tube in larger rodents ( fig. 177-6 ). use a speculum to prevent chewing on the tube. an otoscope head, avian speculum, or piece of wood or plastic with a hole drilled in the center works well. measure and mark the tube for the distance from the tip of the nose to the last rib. place the speculum in the mouth and over the tongue. pass the tube while holding the speculum in place and slightly ventroflexing the head. resistance is encountered if the tube is malpositioned or is an inappropriate size. the tube must pass over the tongue before it can be advanced down the esophagus. this is difficult in some animals. palpate the throat to confirm the presence of the feeding tube in the esophagus. m key point because the placement of a stomach tube is a blind procedure, administer a small volume of sterile saline into the tube before administering the medication to ensure that the tube is not in the trachea. misplaced medications are fatal. • this method is also useful for administration of nutrition to anorexic patients. place a pharyngostomy tube if repeated dosing is necessary, using the technique for cats. flush pharyngostomy tubes with water at least every 4 to 6 hours. nasogastric tubes are not recommended because they are difficult to place and maintain patency because of their small size. securely suture all tubes to the skin. place a tube collar made of radiographic film or use rear leg hobbles to prevent removal of tubes. • nutritional support is critical in rodents because of their high metabolic rate. provide supplements in animals that are anorexic for longer than 12 hours. if the gi tract is capable of digestion, use a slurry of pellets mixed with a high-calorie supplement. if the tube diameter is too small for this mixture, use avian hand-feeding formula or a mixture of vegetable and cereal baby foods in place of the pellets. if the ability of the gi tract to tolerate enteral feeding is questionable, first try isotonic electrolyte or dextrose solutions. parenteral nutrition is used successfully in research animals and may be feasible in select pet cases. administer sc injectable medications or fluids over the shoulder blades or in folds of skin on the flank. • avoid irritating substances in rats and mice because their mammary tissue extends into these areas. the resulting inflammatory response is thought to increase the occurrence of mammary neoplasia. m key point in general, avoid streptomycin and the carrier procaine in all pet rodents because of a high incidence of toxicity and hypersensitivity reaction. give im injections in the semimembranous and semitendinous muscles. inject only small volumes of nonirritating substances, or tissue damage with resulting self-mutilation may occur. use the epaxial or triceps muscles if repeated injections are necessary. m key point use intraperitoneal (ip) injections only as a last resort for large volumes of fluids or for irritating injections that cannot be administered via an iv or io route. express the bladder and aseptically prepare the abdomen. restrain the rodent with its head down to move the abdominal organs cranially. give the injection 0.5 to 2 cm lateral to the midline in the caudal abdomen. aspirate before injecting to ensure that the injection is not being given into the bladder or bowel. never use this technique in pregnant animals. give iv injections into any of the veins as previously described. in addition, the penile vein may be used in hamsters and guinea pigs. placement of iv catheters is possible in animals heavier than 100 g. for small rodents, give a bolus of fluids every 2-4 hours, followed by a diluted heparin flush. a pediatric iv pump is used for continuous infusion of fluids to mark distance from nose to last rib larger animals. maintenance of catheters in active animals is extremely difficult. for io injections, place a spinal needle into the proximal tibia or femur following the technique used for placing an intramedullary pin. once the needle is seated, remove the stylet. aspirate and check the hub of the needle for bone marrow. the tip of the needle should be in the bone marrow cavity that directly drains into the central venous system in normal bones (i.e., the cortex must be intact). administer drugs, blood, or fluids at a rate similar to that used for iv catheters. • in chinchillas and guinea pigs, withhold food for 6 hours before anesthesia. withhold food from smaller, mature rodents for 2 hours. withhold food from immature animals for up to 1 / 2 hour depending on age and condition. • use heat lamps and heating pads to prevent hypothermia. have a prewarmed incubator available for recovery. preoperative or intra-operative warmed sc or iv fluids are strongly recommended. place iv or io catheters whenever possible. • administer atropine preoperatively to reduce airway secretions. acepromazine, diazepam, or midazolam work well as premedications for other anesthetics. avoid acepromazine in gerbils because it potentiates seizures. see table 177 -7 for anesthetic drugs and dosages. surgical anesthesia is reached when toe, tail, and ear pinch fail to generate a withdrawal reaction. depth of anesthesia is best monitored by pulse and respiratory rate and character. pulses drop to within normal ranges after induction. further reduction, especially to less than 80% of the original stabilized value, is an indication to lighten the plane of anesthesia. monitor the electrocardiogram (ecg) of small patients by clamping the alligator clips onto the hubs of all-metal 27-gauge needles or steel sutures placed through the skin at the usual sites. tape cables to the table to maintain placement. doppler units taped over the chest also provide accurate heart rates. pulse oximeters are easier to use, more sensitive, and more expensive than the instruments mentioned previously. these instruments are easily taped to the patient's ear, foot, or tail and provide heart rates as well as information regarding oxygenation. respirations are often shallow and rapid during induction. they become deep and regular as a surgical plane of anesthesia is reached. the corneal reflex varies markedly between individuals and anesthetic agents. if the animal has a corneal reflex after induction and then loses it, reduce the anesthetic. induce gas anesthesia using small face masks purchased from laboratory supply houses or make them from syringe cases and latex gloves ( fig. 177-7) . induction in an anesthetic chamber is also possible. all rodents induced and maintained on gas anesthesia require some form of non-rebreathing system. usual induction is achieved between 2% and 3% for isoflurane and 2% and 4% for halothane. maintenance for isoflurane and halothane varies from 0.25% to 2%. there is marked individual variation in the amount of anesthetic required for induction and maintenance. use of 50% nitrous oxide in oxygen reduces anesthetic concentration requirements for other gases. m key point some chinchillas and guinea pigs hold their breath while being induced with gas anesthetics and then take deep rapid breaths. if the concentration of anesthetic gases is high enough, this behavior results in death. the risk of this behavior is reduced by premedication with tranquilizers, initial induction with nitrous oxide with later addition of primary anesthetic gas after relaxation, and low induction settings. changes in respirations, especially erratic or apneustic patterns and decreased respiratory rates, indicate deepening anesthesia. most pet rodents are not intubated for anesthesia because of their small size. when necessary, as in prolonged oral and other procedures, endotracheal intubation is accomplished with the animal in dorsal or ventral recumbency, depending on the clinician's preference. small non-cuffed or cole endotracheal tubes work well. a stylet usually is required to provide enough stiffness for the tube to pass the larynx. extend the animal's head and neck. grasp the tongue with forceps and use gentle traction. the tip of the tube then is advanced above the tongue and just past its base. the hard palate is used to deflect the tip of the tube ventrally into the glottis. this is a blind procedure that is difficult to master. use of a laryngoscope is helpful in larger rodents. another technique is to place an over-the-needle catheter in the trachea and move it up retrograde through the larynx to act as a guide. the catheter is removed after the endotracheal tube is in place. it is extremely important that the tube be checked for patency. rodents produce copious respiratory secretions, which frequently clog endotracheal tubes. the small diameter allows these tubes to collapse or kink, resulting in asphyxiation of the patient. check patency at least every 2 minutes by applying positive pressure ventilation at 10 to 15 cm water and watching for excursion of the chest wall. if extending the head and neck does not result in air flow, suction the tube. if this is either not successful or impossible, remove the tube and continue anesthesia with a mask or reintubate the animal with a new tube. because of the small diameter of the trachea, endotracheal tube-induced tracheitis and subsequent swelling of the trachea may become a life-threatening situation. doses and routes for injectable anesthetics are listed in table 177 -7. needed doses for injectable anesthetics are tremendously variable among species and individuals. most injectable anesthetics provide safe sedation for minor procedures, but very few induce a safe surgical plane of anesthesia on a consistent basis. • ketamine in combination with diazepam is easily obtainable, is given intramuscularly, and has a wide margin of safety, but it does not provide good analgesia. • intraperitoneal injections of barbiturates provide surgical anesthesia but have a low margin of safety and a significant mortality rate. barbiturate anesthesia can result in fatal ileus. euthanasia is performed easily by induction of inhalant anesthetic through a mask or chamber followed by an overdose of barbiturates given intraperitoneally, iv, or intracranially. euthanasia by ip injection of barbiturates alone causes pain in some animals. • surgical techniques for pet rodents are similar to those used in cats and birds. • hemostasis is critical because of small blood volumes. • electrosurgery for incisions and cautery is highly recommended. • if necessary, give fresh blood transfusions drawn from a donor of the same species and mixed with sodium heparin (1000 iu/ml) at a rate of 0.005 ml/1 ml of blood directly into an iv or io line. • the lack of a filter creates a potential for thrombosis. • transfusion reactions are possible. administer postoperative analgesics to all rodents undergoing surgical or dental procedures. common analgesics include buprenorphine, butorphanol, ketoprofen, carprofen and meloxicam. see table 177 -7 for dosages. the most common surgeries are laceration repair and removal of dermal or sc masses. • most rodents will not gnaw on skin sutures. • if this occurs, use steel sutures, subcuticular sutures, or tissue glue. • if an animal still chews at its suture line, physical restraint, such as a tube or an elizabethan collar, is required. castration is a common procedure in guinea pigs. this usually is performed when owners want to house more than one male together or do not wish to breed their female any longer. common abdominal surgeries include cystotomy for urolith removal in guinea pigs and rats, and cesarean section (c-section) in guinea pigs and chinchillas because of dystocia. use a technique similar to those described for dogs and cats. preplaced stay sutures are recommended to define incision edges for closure. use 4-0 polyglactin 910 or polydioxanone (pds) on a taper needle and suture in a simple continuous pattern to close the body wall. close the skin with a subcuticular suture (absorbable) or interrupted skin monofilament, nonabsorbable suture. fracture fixation is accomplished best with intramedullary pinning or kirschner apparatus. rodents gnaw on bandages until they remove them. if they are unable to remove a splint, self-mutilation often results in self-amputation. if a cast or splint is necessary, physical restraint often is required. healing usually takes 3 to 6 weeks. incisors can be trimmed with nail trimmers, but this technique often fractures the tooth, causing abscesses of the root. instead, use a high-speed dental burr or a flat cutting disk on a dremel hand tool. trim molars with a high-speed drill or pediatric rongeurs. a mouth speculum that deflects the tongue and other soft tissues is essential to prevent lacerations and provide working space ( fig. 177-8) . intubate the trachea to prevent aspiration pneumonia when working on molars. if a tooth is abscessed, extract both it and the occlusal tooth. • if necessary, approach cheek teeth via an incision through the cheek. • use a fine dental elevator to loosen the teeth. • patience and firm but gentle pressure are needed, or the root or surrounding bone may fracture. • the roots of the maxillary incisors curve dramatically back into the head. take care to follow the curve of the tooth. • packing an infected tooth socket with a calcium hydroxide paste may decrease the occurrence of persistent infection. remove the paste in 3 to 4 days. • administer meloxicam, carprofen or ketoprofen postoperatively to control pain. see table 177 -7 for dosages. in chinchillas with dental malocclusion, the roots of the molars can become impacted, causing swelling of the mandible or exophthalmos and epiphora. these teeth are extremely difficult to extract without causing extensive bony and soft-tissue damage. discourage breeding of animals with malocclusion, unless it was acquired as a result of trauma or infection, because this trait is hereditary. most pet and laboratory mice are derived from mus musculus, which is the common house mouse. mice sold in the pet trade are randomly bred and less likely to suffer from the genetic problems associated with inbred laboratory rodents. mice possess brown fat tissues between their scapulae that also are known as hibernating glands; these are thought to provide an energy store. the spleen in male mice is 50% larger than that of females. ectoparasites usually are found in new acquisitions. • alopecia and pruritus, especially on the back of the head and dorsal midline, usually are associated with lice (polyplax serrata), mites, or fleas. • mite infestation (e.g., mycoptes musculinus, myobia musculini, radfordia affinis) often causes a greasy haircoat and folliculitis. transmission of lice and mites occurs via direct contact. fleas are transmitted by other household pets, such as cats and dogs. • diagnosis is based on clinical signs, history, visualization of parasite, skin scrape, and cellophane tape test. • treatment of fleas and lice is with pyrethrin powder. ivermectin is recommended for treatment of mites (see table 177 -8). • change the bedding and thoroughly clean the cage between treatments to prevent reinfestation. occasionally, the surrounding environment needs to be treated with a premises spray used for killing fleas. • alopecia also may be the result of dermatophytes (see chapter 42). lesions are often hyperkeratotic. • diagnosis is made by skin scrape or isolation on culture. most dermatophytes found in pet rodents do not fluoresce under a wood's lamp. • treatment is with lime-sulfur dip or griseofulvin (table 177 -9). • ulcerative dermatitis is a common syndrome caused by staphylococcus aureus characterized by pododermatitis, mastitis, and abscesses in other areas. • administer antibiotics based on culture and sensitivity tests. chloramphenicol is recommended pending culture results (see table 177 -9). the application of hot packs, local drainage, and topical medications are also beneficial in selected cases. • mastitis also may be caused by escheria coli or pasteurella, klebsiella, pseudomonas, or streptococcus species. mastitis usually is caused by poor sanitation, abrasive bedding, or overly aggressive young. • preputial gland abscesses are fairly common in males and are usually caused by e. coli or s. aureus. local flushing and topical treatment are usually adequate. • sc abscesses can be the result of the aforementioned bacteria or actinobacillus spp. or corynebacterium kutscheri. corynebacteria is associated with widespread abscesses, septic arthritis, gangrene, and ulcerated draining tracts. diagnosis is based on finding grampositive pleomorphic rods on gram stain and isolation on culture. • the bacteria are usually sensitive to ampicillin, chloramphenicol, and tetracycline (see table 177 -9). • lymphoma and mammary neoplasia are common causes of sc masses. mammary neoplasia is usually malignant in mice, and metastasis to the lungs is common. (mice have five pairs of mammary glandsthree thoracic and two abdominal.) • obtain thoracic radiographs before surgery. • give a guarded prognosis for long-term survival. • other possibilities for sc masses are fungal granulomas, nodules from the psorergates simplex mite, hematoma, hernia, non-neoplastic lymphadenopathy, or emphysema. • otitis externa usually is caused by ear mites, although bacteria or fungi also may cause primary or secondary otitis. • clinical signs include erythema, pruritus, waxy debris, and excoriations behind the ears. • mites may be diagnosed by identification on otoscopic examination or microscopic examination of ear swabs (see "techniques"). • treatment requires cleaning debris from ears with a commercial ear cleanser followed by administration of three doses of ivermectin at 2-week intervals or topical acaricides used daily for 3 to 4 weeks (see table 177 -9). • bacterial and fungal otitis is diagnosed by identification of organisms or gram-stained specimens and isolation on culture. • treatment is similar to that used in cats. • otitis media/interna usually are caused by hematogenous spread or local invasion of bacteria from a primary abscess. • clinical signs include head tilt, circling, facial nerve paralysis, and otitis externa. • rule out mouse hepatitis virus as the cause of the head tilt (see "gastroenterology"). • if treatment of the primary disease is successful, the otitis media usually resolves, although a residual head tilt may persist. • if a cluster of pseudomonas infections occurs in a population, evaluate the water source and produce for contamination. use sodium hypochlorite in the drinking water at 10 ppm to control an outbreak while water quality is being restored. • damage to the pinnae can be associated with trauma, dermatitis, pox virus, hypersensitivity reactions, and vasculitis. dry gangrene is a common sequela and is usually self-limiting. i have observed a steroid-responsive pruritus in pet mice. the pruritus is severe enough to result in significant self-mutilation. this condition has been nonresponsive to treatment with ivermectin, lime-sulfur dips, griseofulvin, multiple antibiotics, oral prednisolone, and antihistamines. attempts at bacterial and fungal culture have failed to identify a pathogen. an inflammatory response is observed on histologic examination. mice with this condition respond to repository methylprednisolone injections every 2 to 4 weeks (1.0 mg/kg im). most owners have not elected to continue injections for longer than a few months. once the injections are stopped, the pruritus returns, often requiring euthanasia of the affected mouse. • bilateral alopecia found around the muzzle associated with no other abnormalities usually is caused by friction from overhead feeders. • alopecia occurring in smaller, weaker individuals is often the result of barbering. removal of the mice in best condition from the cage results in normal appearance of barbered mice in 2 to 3 weeks. • tailhead alopecia and scabbing are usually the result of aggression. separate affected animals, or additional trauma may occur. • other rare causes of alopecia are endocrinopathies, leprosy, and hereditary alopecia in nude mice. • epiphora is a common condition of pet mice. the most common causes in pets owned for longer than 2 months are ammonia fumes and overgrown incisors. • ammonia causing contact irritation is diagnosed by examining an uncleaned cage and checking for odor. • treatment is improved sanitation. • overgrown incisors are diagnosed easily by oral examination. treat by trimming the affected teeth and providing opportunities for gnawing. • foreign bodies and the resultant corneal ulcers can cause epiphora. an eye examination, including fluorescein stain, is indicated. treat by removing the foreign body and administering an ophthalmic antibiotic (gentamicin, tetracycline, or chloramphenicol in affected eye, q8h-q6h). • in newly acquired pets, epiphora is often the first clinical sign of an upper respiratory infection. pasteurella pneumotropica is the most common pathogen, although salmonella spp., mycoplasma, sendai virus, lymphocytic choriomeningitis, and mouse pox also may cause epiphoria. the ocular discharge later appears mucopurulent (see "respiratory"). retinal degeneration can be either hereditary or (in albino mice) may be caused by exposure to highintensity lighting. the resulting blindness often goes undetected because patients adapt well and behave normally in their cages. • clinical signs include dyspnea (often described as chattering), mucopurulent oculonasal discharge, hunched posture, and anorexia. animals with a chronic history of this disease are often cachexic. • radiology aids in determination of the extent and severity of the pneumonia and the absence or presence of distant foci of infection. • treatment with tylosin is successful in controlling the disease if it is not too advanced. tetracycline, enrofloxacin, and chloramphenicol also have been used (see table 177 -8). • many patients need nutritional support. • mice with pyometra or other abscesses require surgical debridement. • recovered animals are carriers and stress elicits clinical signs. strictly quarantine these animals. a common cause of pneumonia in newly acquired mice is sendai virus. acute fatalities are seen in suckling or weanling mice. • transmission is by aerosol or direct contact. • clinical signs in adults are caused by secondary bacterial infections and are similar to those in mrm. • diagnosis is based on clinical signs and serologic testing. • treat with antibiotics to control the secondary bacterial infection and provide supportive care as needed. • prohibit breeding for 4 to 6 weeks. • a killed vaccine is available. • recovered animals are resistant to new infection. common primary or secondary pathogens causing respiratory signs in mice are streptococcus pneumoniae, corynebacterium kutscheri, pasteurella pneumontropica, pseudomonas aeruginosa, and klebsiella pneumoniae. treatment is empiric or based on culture and sensitivity of a tracheal swab sample. dyspnea often is caused by metastasis to the lungs from mammary adenocarcinomas. primary lung tumors, especially pulmonary adenomas, also occur frequently. although not frequently diagnosed, cardiac disease can result in signs of respiratory disease. diagnosis is based on radiographic evidence of cardiomegaly and pulmonary edema. • tapeworms usually do not cause clinical signs. occasionally, heavy burdens may cause diarrhea or weight loss. the chief concern is the zoonotic potential of one species, hymenolepis nana, which is directly transmissible to humans. • diagnosis is made from visualization of eggs in the feces. treat with praziquantel or niclosamide (see table 177 -8). improve sanitation, and remove indirect hosts (e.g., fleas, beetles, roaches). • pinworms (syphacia obvelata, aspiculuris tetraptera) may cause anal pruritus and, in severe cases, rectal prolapse. • diagnosis is based on clinical signs and observation of eggs on cellophane tape after application to the perineal region. treat with piperazine or mebendazole every 7 to 10 days for three treatments or with fenbendazole once daily for 5 days (see table 177 -8) and provide improved sanitation. • the protozoal parasite spironucleus muris causes diarrhea and slow growth associated with a pot-bellied appearance in young mice. • diagnosis is by fecal wet mount, although falsenegative findings are common. • treat with oxytetracycline (see table 177 -9). supportive care to combat dehydration and hypothermia is extremely important. • control is achieved with improved sanitation. • giardia spp. and, rarely, eimeria falciformis show signs similar to spironucleus. giardiasis is zoonotic. treat with metronidazole. treat eimeria with sulfadiazine/trimethoprim (see table 177 -9). most other protozoa are considered nonpathogenic. • cysticercus fasciolarus causes nonpathologic cysts of the liver. these cysts are the infective form of taenia taeniaformis in carnivores. viral diseases • diagnosis is based on clinical presentation, serology, and presence of syncytial giant cells in the epithelium of the small intestine. • treat supportively, and quarantine affected individuals. the prognosis is grave. • although less commonly seen in pet mice, reovirus occurs in older suckling mice. it is characterized by an oily diarrhea, which results in a greasy haircoat. other signs are conjunctivitis, stunted growth, and tremors. transmission is by ingestion. • diagnosis is based on clinical signs, histology, and serology. • treat supportively. the long-term prognosis is grave. initial survivors are weak and jaundiced, suffer from alopecia, and eventually die. • transmissible murine colonic hyperplasia (mch) caused by citrobacter freundii is characterized by diarrhea followed by rectal prolapse and stunted growth. transmission is feco-oral. • diagnosis is made by clinical signs and fecal culture. • treat with neomycin, tetracycline, or sulfamethazine until sensitivity results are available (see table 177 -9). severe thickening of the distal half of the colon is observed at necropsy. • salmonellosis, also known as mouse typhoid, is transmitted by latent carriers or contaminated feed or bedding. incubation lasts for 3 to 6 days. • clinical signs are lethargy, anorexia, purulent conjunctivitis, arthritis, and diarrhea. • diagnosis is based on clinical signs and fecal culture. treat supportively. use of antibiotics is controversial. • quarantine survivors. • sanitation is extremely important because salmonella spp. are zoonotic. on gross postmortem examination, erythema of distal ileum and congestion of the spleen and liver are seen. with more chronic infections, necrotic foci are seen in the liver, spleen, and lymph nodes. prevent infection by feeding a fresh laboratory chow from a reputable source. thoroughly wash all produce and then dip it in a diluted bleach solution. rinse completely before feeding. • tyzzer disease is caused by bacillus piliformis. transmission is feco-oral. • clinical signs are precipitated by stress and consist of anorexia, diarrhea, and high mortality in weanlings. • diagnosis is made by clinical signs or isolation on culture. enteritis and multiple gray-yellow necrotic foci in the liver are seen on gross postmortem examination. • administer tetracycline for 4 to 5 days (see table 177 -9) and reduce stress to control the disease. breeding systems vary; from one to six females may be placed with one male. all animals are housed together, and the young are removed after weaning. females in proestrus have swollen vulvas. vaginal plugs are present post-copulation. female mice that have been bred within 4 days abort if a new male is placed in the cage. inappropriate light cycle, inappropriate age, crowding, and poor nutrition are the most common causes of infertility in pet mice. pyometra due to pasteurella pneumontropica, mycoplasma spp., or other bacteria is also common. desertion of litters is usually a result of stress, lack of nesting materials, agalactia, or mastitis. • urethral obstruction from proteinaceous plugs of inspissated ejaculum may develop in aged male mice. pseudomonas, e. coli, or proteus are the most frequently cultured pathogens. before complete obstruction, chronic hematuria may be noticed by the owner. • antibiotics, which are chosen based on the results of urine culture, are often curative with early presentation. complete obstruction requires surgical removal. • glomerulonephritis is very common in geriatric mice. it frequently is secondary to chronic viral infection. clinical signs are anorexia, lethargy, dehydration, and cachexia. urinalysis demonstrates proteinuria. as the disease progresses, the urine becomes isosthenuric, the blood urea nitrogen (bun) and creatinine levels rise, and other electrolyte abnormalities typical of chronic renal failure occur. treat supportively. prognosis for long-term survival is grave. • coccidia (e.g., klosseilla muris) occasionally is found in the urine. the clinical significance of its presence is unknown. • mice can be asymptomatic carriers of leptospirosis; however, this is rarely seen in pet mice. • diagnosis is based on darkfield microscopy of urine, serology, or histopathology. euthanasia of carriers is recommended. • infectious polyarthritis or mouse rheumatism is caused by streptobacillus moniliformis. in humans, it is known as rat bite or havernill fever. transmission is by direct contact. clinical signs are cachexia, keratitis, edema and ulceration of the appendages, and ankylosing arthritis. • diagnosis is based on the bacterial culture findings or the presence of caseous pericarditis and arthritis on necropsy. • treat with antibiotics chosen through the results of culture and sensitivity tests. use penicillin while awaiting results. supportive care is important. animals that recover remain arthritic. control is achieved through quarantine and sanitation. • the most frequently diagnosed neurologic disease in pet mice is head tilt resulting from bacterial otitis media (see "otitis"). the second most common cause of neurologic signs is trauma. • diagnosis is based on history and clinical signs. consider neoplasia in aged mice with slowly progressive signs. • lymphocytic choriomeningitis is a zoonotic arenavirus. transmission is airborne, transplacental, or by direct contact, fomites, or insect vectors. acute signs usually occur in mice that are 3 to 6 weeks old. approximately 20% of infected individuals show acute clinical signs, which include lethargy and photophobia followed by convulsions and paralysis. in animals that are latently infected, glomerulonephritis develops later. mice infected after weaning and before 1 year in age lose weight, appear arthritic, and show signs of conjunctivitis and photophobia. the virus runs its course in several weeks. animals that recover show no residual signs. • diagnosis is based on clinical signs and the presence of immunofluorescent antibody (ifa). pleural effusion, splenomegaly, and hepatic lipidosis are found on necropsy. treat supportively. house survivors separately. • prevent the disease by improving sanitation, providing pest control, and cleaning produce. consider euthanasia because of the zoonotic potential of the virus. • mouse poliomyelitis/encephalomyelitis, also known as theiler disease, causes clinical signs in 1 in 10,000 infected mice. two-thirds of healthy mice are carriers. transmission is by oral or respiratory routes. mice younger than 4 weeks of age show signs of encephalitis. animals that are 6 to 10 weeks old are weak in the rear legs and progress to paralysis. the tail may remain mobile. affected mice continue to eat and be alert. albino mice are predisposed to show clinical signs. • diagnosis is based on clinical signs, serology, or histopathology that shows necrosis of the ganglionic cells of the anterior horn of the spinal cord. • treat supportively. consider euthanasia because of poor prognosis. • seizures in mice commonly result from otitis media, trauma, liver or kidney failure, toxin, bacterial meningitis, neoplasia, or viral encephalitis. • leukemia in mice is usually viral in origin. transmission is trans-mammary or trans-placental. • clinical signs are anemia, dyspnea (with thymic involvement), and those signs that are compatible with chronic disease. • diagnosis is based on complete blood count (cbc), bone marrow aspirate, or histopathology. prognosis is grave. • eperythrozoon coccoides is a rickettsial red blood cell (rbc) parasite of mice. affected mice are usually asymptomatic. occasionally, fever, anemia, and splenomegaly develop in infected animals. transmission is through the louse polyplax serrata. control is by extermination of the louse. • treat with tetracyclines. pet rats are derived from the norwegian or brown rat (rattus norvegicus), which did not originate from norway, but from asia. breeds of rats are called strains when they are inbred extensively and stocks when strains are hybridized. rats have brown fat, as discussed in the section on mice. they do not possess a gallbladder. their mandibular symphysis is articulated normally. rats are neophobic; therefore, make gradual changes in food or environment when possible. • fleas, mites (e.g., radfordia ensifera, ornithonyssus bacoti), lice (i.e., polyplax spinulosa), ear mites (i.e., notoedres muris), and dermatophytes cause similar signs in both mice and rats. treatment also is similar (see "mouse"). • sc masses in rats are similar to mice. pasteurella pneumotropica is a very common pathogen in mastitis and sc abscesses. • treat with chloramphenicol until culture results are available (see table 177 -9). • mammary cancer develops in 50% to 90% of adult female rats and in approximately 15% of male rats. always submit biopsy specimens for histologic examination. most, but not all, of these tumors are fibroadenomas, which are benign. prognosis for longterm survival after surgical removal is good. other common neoplasms include interstitial cell tumors of the testes, which cause sc swellings in the inguinal region, and squamous cell carcinomas of the zymbals gland of the external ear canal. • ulcerative dermatitis occurs in rats as well as mice. staphylococcus aureus is the causative agent. c. kutscheri follows a similar course in rats and mice (see "mouse"). • ringtail is the formation of constrictive bands of fibrous tissue around the tail in nestling rats. these bands result in gangrene of the distal tail. this disease occurs when environmental humidity is less than 40%. • treat by making a longitudinal incision of the ring to release the stricture and apply topical dimethyl sulfoxide (dmso), steroid, and antibiotic solution (10 ml dmso, 6 ml 50 mg/ml amikacin, 4 ml 2 mg/ml dexamethasone) four times daily. • to prevent ringtail, keep humidity above 50%, use solid-bottom cages and provide ample nesting material. prognosis for life is excellent. prognosis for retention of the distal tail is guarded. • epiphora and blepharospasm are caused mostly by ammonia fumes, overgrown incisors, or foreign bodies (see "mouse"). • sialodacryoadenitis virus is a coronavirus that is endemic in many rat populations. • clinical signs vary from mild keratoconjunctivitis to blepharospasm, chromodacryorrhea, severe uveitis, hyphema, buphthalmos, periorbital swelling, and pneumonia. the clinical course of the disease lasts 10 to 14 days. rats maintain normal activity levels and appetite. • treatment is not necessary for mild infections. place rats showing marked ocular disease or discomfort on the appropriate ophthalmic ointments (e.g., atropine, antibiotic, steroid) based on presentation. administer parenteral antibiotics to animals that show signs of respiratory problems. recovery is usually complete unless the eye ruptures or selfmutilation occurs. • control is achieved by not introducing new animals for 4 weeks. • in contrast to mice, sendai virus rarely causes clinical signs in rats. • mucopurulent ocular discharge also may be caused by infection with mycoplasmosis, streptococcus pneumoniae, pseudomonas spp., and other less common bacterial or viral agents that cause pneumonia. • cataracts are primary hereditary defects or occur secondary to severe uveitis or diabetes mellitus. retinal dystrophy and colobomas are also inheritable traits in rats. retinal degeneration occurs in rats housed under intense lighting. • mrm is extremely common in pet rats. its presentation is similar to the disease in mice (see "mouse"). • streptococcus pneumoniae is normal flora for rats. however, during stressful situations, bacteremia may occur, resulting in pneumonia. clinical signs are similar to mrm. differentiation is based on culture and the presence of extensive fibrinopurulent pleural effusion on necropsy. • ampicillin controls clinical signs if treated early in the course of disease (see table 177 -9). prevent the condition by minimizing stress. • corynebacterium kutscheri and pasteurella pneumotropica cause signs similar to mrm (see "mouse"). there is a serologic test for c. kutscheri. see the mouse section for a discussion of pseudomonas aeruginosa. • pneumocystosis carinii is an uncommon protozoa that infects the lung. cysts and trophozoites live in the alveoli. clinical signs occur only in immunocompromised or geriatric individuals. signs are cachexia, cyanosis, and dyspnea. • diagnosis is based on clinical signs, tracheal wash, response to therapy, or histologic examination. • treat with sulfadiazine/pyrinrethamine (see table 177 -9). • myocardial degeneration and subsequent congestive heart failure are fairly common in geriatric rats. diagnosis is based on radiographs of the thorax and clinical signs. treat supportively, and use furosemide and digitalis at cat dosages to alleviate pulmonary edema. • polyarteritis nodosa is an idiopathic condition of geriatric rats that results in thickening and tortuosity of arteries, especially in the mesentery, pancreas, and testicles. affected areas are predisposed to clot formation and aneurysms. • nematode (syphacia muris), cestode, and intestinal protozoal parasite infestations are similar to those in mice. • capillaria hepatica has no clinical significance. yellow streaks on the liver are an incidental finding at necropsy. the causes and treatment of malocclusion are similar to those for mice. • epizootic diarrhea of suckling rats is a viral disorder found in rats 7 to 14 days old. the infection causes a mild diarrhea. most animals recover. occasionally, stunting occurs. treat supportively. • salmonellosis in rats is similar to that in mice. • if breeding is desired, take females showing signs of estrus (e.g., lordosis, hyperactivity, quivering ears, and swollen vulva) to a male rat's cage for 24 hours, or keep one male in a cage with up to six females. check females for a post-copulatory plug to confirm breeding. remove females just before parturition, and house females individually while raising the young. a vaginal discharge is seen 1.5 to 4 hours before labor. parturition is accompanied by stretching and extension of the rear legs. all neonates usually are delivered within 1 to 2 hours. • two extremely common conditions in geriatric rats are nephrocalcinosis and chronic progressive nephropathy. clinical signs are compatible with those of chronic renal failure. enlarged or small irregular kidneys may be found on physical or radiographic examination. isosthenuria and marked proteinuria are found in urinalysis. • definitive diagnosis is based on renal biopsy. • treat supportively. prognosis for long-term survival is grave. • trichasomoides crassicauda is an uncommon parasite of the urogenital tract. the adult worms usually reside in the kidney, but they occasionally may wander into the genital tract. the ova are passed in the urine. • clinical signs are hematuria and stranguria. proliferative mucosa of the bladder occasionally may be palpated as an abdominal mass. • treatment is somewhat successful with methyridene (see table 177 -8). sanitation is critical in control of this disease. • klossiella muris is an incidental coccidia of the urinary tract. • many geriatric pet rats have chronic progressive radiculoneuropathy. • clinical signs are compatible with cauda equina syndrome, including posterior paresis progressing to paralysis, urine retention, and incontinence. prognosis is grave. • treat supportively or euthanize. • streptobacillus moniliformis, a normal bacteria found in the oral, nasal, and pharyngeal cavities of rodents, is isolated from 43% of middle ear infections and 35% of chronic pneumonias in rats. the bacteria is nonpathogenic for gerbils and guinea pigs. • clinical signs vary with the site of infection. head tilt and circling, septic arthritis, and respiratory disease commonly are seen. • diagnosis is based on isolation on culture. the clinical signs mimic many other diseases, especially mrm and pseudomonas infection (see "mouse"). • head tilt in rats also may be the result of trauma or neoplasia, especially pituitary adenomas. • hemobartonella muris is an rbc parasite of rats that is nonpathogenic unless the rat is immunocompromised or splenectomized. transmission is through the louse polyplax spinulosa. • clinical signs result from hemolytic anemia and hemoglobinuria. • treat with tetracyclines (see table 177 -9). mesocricetus auratus, better known as the golden or syrian hamster, is a primarily nocturnal rodent that originated in the middle east. almost all hamsters in the united states are the offspring of three siblings imported in the 1930s. many color variations are available. long-haired hamsters are called "teddy bear" hamsters. the stomach has two compartments, a non-glandular forestomach, which functions like a rumen, and a glandular stomach. hamsters are very territorial. they possess flank glands, which are larger in males, that are rubbed against objects to mark their territory. females are larger than males. except during estrus, they use this size advantage to attack males. do not allow groups to estivate together or recently awakened animals may cannibalize sleeping hamsters. m key point hamsters are extremely sensitive to antibiotics. penicillins, clindamycin, lincomycin, streptomycin, tylosin, erythromycin, and cephalosporins eliminate the normal intestinal flora, allowing overgrowth of pathogenic bacteria, particularly clostridium difficile. diarrhea, which is almost always fatal within 3 to 7 days, subsequently occurs. even antibiotics considered to be safe can have this effect. treat by discontinuing antibiotics, providing a lactobacillus supplement, and giving supportive therapy. • hamsters are susceptible to demodex criceti and d. aurati mites. d. criceti is limited to skin folds. d. aurati causes hyperpigmentation, alopecia, and seborrhea sicca affecting the dorsal midline. demodex is carried by many normal-appearing hamsters. • clinical signs occur in immunosuppressed animals, as would occur with stress, chronic infection, pregnancy, or malnutrition. • diagnosis is based on clinical signs and deep-skin scrapings. • treat with amitraz every 2 weeks for two treatments past two consecutive negative skin scrapings. use the manufacturer's recommended dilution for dogs. • sarcoptes mites infrequently cause facial alopecia. diagnosis is based on skin scraping. treat with ivermectin (see table 177 -8). do not confuse this condition with alopecia caused by contact with feeders or barbering. • notoedres mites affect only the external ear canal in female hamsters but may affect the ears, feet, geni-talia, and tail in males. diagnosis is made by observation of mites on samples from ear swabs, skin scrapings, or both. treat with ivermectin (see table 177 -8). • other less common causes of alopecia in hamsters are dermatophytosis, endocrinopathies, and genetic defects. • dermal sc masses are usually abscesses caused by pasteurella pneumotropica, s. aureus, or streptococcus spp. treatment is based on results of culture and susceptibility testing. use chloramphenicol until culture results are available. other frequent causes of sc swellings are distended cheek pouches and testicles, mastitis, hernias, neoplasia, and lymphadenopathy. • epiphora and conjunctivitis are caused most frequently by increased environmental ammonia concentrations, incisor overgrowth, foreign body, or lymphocytic choriomeningitis (see "rat"; "mouse"). • mucopurulent discharge is caused by secondary infection by pasteurella or streptococcus spp. • hamsters are predisposed to rupture of the eye following trauma or infection. surgical enucleation is advised. electrosurgery is extremely helpful in controlling bleeding but do not apply heat to the stump of the optic nerve or vessels, or thermal injury to the brain may result. place gelfoam in the socket to enhance clot formation. • hamsters are susceptible to viral respiratory infections of humans. • clinical signs include nasal discharge, sneezing, otitis media, fever, and pneumonia. uncomplicated cases last 5 to 7 days. complications are usually the result of secondary bacterial infections. • treat supportively. use of antibiotics is indicated if copious nasal discharge, dyspnea, anorexia, or marked lethargy is observed. overuse of antibiotics may cause diarrhea-related death in hamsters that might have recovered uneventfully if left untreated. • most dyspnea in hamsters is caused by blunt thoracic trauma. hamsters often bite when startled. reflex actions on the part of humans, especially children, cause hamsters to be flung against hard objects. • diagnosis is by history and presence of fresh epistaxis. • treat supportively. emergency shock therapy, consisting of supplemental heat, oxygen administration, parenteral fluids, and glucocorticoids, frequently is required. • sendai virus can cause death in suckling hamsters housed with mice. adults show no clinical signs (see "mouse"). • primary bacterial pneumonia most frequently is caused by yersinia pseudotuberculosis, pasteurella pneumotropica, or streptococcus. clinical signs are compati-ble with those of pneumonia seen in other species, as well as weight loss and conjunctivitis. all three agents have a tendency to form distant abscesses, especially in the uterus. • diagnosis is based on clinical signs and isolation on culture. • treat with chloramphenicol until antibiotic susceptibility results are available. abscesses require surgical debridement; however, anesthesia in affected animals is very risky. recovered hamsters are carriers and must be quarantined from other rodents. prognosis is guarded. • cardiac thrombosis is seen in 73% of geriatric hamsters. most thromboses occur in the left atrium and are secondary to degenerative cardiomyopathy, cardiac amyloidosis, sepsis, or calcification of the great vessels. congenital myocardial necrosis also occurs. • clinical signs include cyanosis, dyspnea, and acute death. enlargement of the cardiac silhouette and pulmonary edema sometimes can be seen on thoracic radiographs. • furosemide and digitalis (using standard cat doses) may temporarily alleviate clinical signs. • hamsters can carry the zoonotic tapeworm h. nana (see "mouse"). • treat with niclosamide or praziquantel (see table 177 -8) and provide improved sanitation. • pinworms (aspicularis tetraptera, syphacia muris, s. obvelata) occur in hamsters as well as in mice. • treat with fenbendazole (see table 177 -8). • hamsters are predisposed to dental caries. a large percentage of affected teeth become abscessed, causing facial swelling, ptyalism, and anorexia. • diagnosis is based on clinical signs, oral examination, skull radiographs, and isolation on culture. • extract the tooth and administer antibiotic therapy based on results of susceptibility testing. prognosis is variable depending on the condition of the animal, tooth affected, and extent of the abscess (see "mouse"). • overgrown incisors also occur, as in mice. • the cheek pouches are very distensible. impaction of the pouches occurs on occasion. • clinical signs vary from ptyalism to swelling from abscess. in simple cases, removal of the material from the pouch with fine forceps is sufficient. sedation usually is not required. • if a fungal or bacterial infection of the pouch is present, remove the exudate, submit samples for gram staining and bacterial or fungal culture, and flush the pouch with diluted iodine solution. if cellulitis is present, administer systemic antibiotics as well. fistulas often heal spontaneously. • proliferative ileitis (i.e., wet-tail disease) is thought to be caused by a campylobacter-like organism with or without concurrent bacterial or viral infections. more than 90% of animals with clinical signs die. the highest morbidity and mortality rates occur in hamsters 3 to 8 weeks of age. teddy bear hamsters may be more susceptible to infection than shorter-haired varieties. transmission is feco-oral. • clinical signs include diarrhea, which mats on the ventrum and perineum, and results in anorexia, dehydration, and a hunched posture. the abdomen frequently seems painful on palpation. bowel loops often are distended on palpation because of ileal obstruction or intussusception. rectal prolapse usually occurs. • administer neomycin, gentamicin, metronidazole, or tetracycline (see table 177 -9). supportive care is critical. prognosis is grave, even with treatment. gross postmortem findings include gas and yellow diarrhea in the distal intestinal tract, mucosal thickening in the ileum and distal jejunum, peritonitis, and liver abscesses. • other common causes of bacterial diarrhea include e. coli, tyzzer disease, or salmonella spp. (see "mouse"). in hamsters older than 1 year of age, liver cysts that are derived from the biliary duct often develop. less frequently, similar cysts arise from the pancreas, epididymis, and seminal vesicles. this syndrome is called polycystic disease. no clinical signs are associated with cysts in these structures, which are an incidental finding on abdominal palpation. no treatment is recommended. • timing is critical to prevent injury to the male when breeding hamsters. transfer the female to the male's cage in the early evening 3 days after a creamy, viscous vaginal discharge is noticed. monitor the pair carefully. remove the male immediately if the female is aggressive. remove the male after mating or after 1 to 2 hours even if mating has not occurred. two days after successful copulation, a gray malodorous vaginal discharge is observed. pregnancy is highly likely if there is no translucent vaginal discharge 5 to 9 days post-breeding. pseudopregnancies last 8 to 12 days. normal gestation is 15 to 16 days. before par-turition, a hemorrhagic vaginal discharge appears, and the female may pant. hamsters rarely suffer from pregnancy toxemia (see "guinea pig"). • infertility may be caused by pyometra (see p. pneumotropica and lymphocytic choriomeningitis). • cannibalism is most frequently a result of stress or mastitis. • in almost 90% of geriatric hamsters, renal amyloidosis develops. the disease tends to develop more rapidly in females. • clinical signs include edema and ascites due to protein loss in the urine, as well as the typical signs of chronic renal failure. • treat supportively. prognosis for long-term survival is grave. • head tilt is usually secondary to otitis media. also consider lymphocytic choriomeningitis or neoplasia as differential diagnosis (see "rat"). • in hamsters fed all-seed diets and deprived of exercise, cage paralysis syndrome often develops. usually pets are presented for acute posterior paresis which, in reality, was slowly progressive. the distinction is important in ruling out trauma. in mild cases, the hamster is able to move its hind limbs but unable to support weight. vitamin d and e supplementation, along with nutritional improvement and providing exercise, is curative in 1 to 2 weeks. in severe cases, recovery is negligible or incomplete. lymphoma and lymphosarcoma may be viral in origin. diagnosis is made by biopsy or fine-needle aspiration of affected lymph nodes. rule out lymphadenopathy caused by lymphadenitis from infection with streptobacillus moniliformis (see "rat"). although many hamsters initially respond well to chemotherapy protocols established for cats and dogs, prognosis for long-term survival is grave. • rarely, demodex spp. mites cause alopecia in gerbils. • diagnosis is based on skin scraping. • treat with rotenone ointment or amitraz dips every 2 weeks for three to six treatments. use manufacturer's recommended dilution for dogs. • acute moist dermatitis usually is caused by s. aureus infection. infection on the face often begins with the harderian glands. the gland secretion is viscous and causes matting, with secondary staphylococcal infection occurring under the mats. attempts at grooming spread the infection to the feet and abdomen. • diagnosis is based on clinical signs and isolation on culture. • administer enrofloxacin, tetracycline, or chloramphenicol and apply warm, moist compresses to remove dried debris. remove possible irritants from cage (e.g., pine or cedar shavings, ammonia). occasionally, surgical removal of a chronically infected or inflamed gland is needed. • alopecia of the facial area, especially when it is symmetric, is usually the result of self-trauma from feeders, cage bars, or overzealous burrowing. • treat by changing cage construction or providing better visual security. • gerbils that catch their tails in crevices or are restrained inappropriately by their tails often are presented for avulsion of the skin from their tails. • treat initially by controlling hemorrhage and hypovolemic shock. • amputate the tail after patient stabilization to prevent ascending infection. in some animals, the infection is localized to the distal tail, which is sloughed in approximately 3 to 4 weeks. • generalized alopecia is normal in some weanling gerbils. the hair grows in as the animals mature. • melanomas are found most frequently on the ears, feet, or base of the tail. • diagnosis is based on biopsy. • treat by surgical removal. • sebaceous gland disease is usually the result of bacterial infections or neoplasia. • diagnosis is based on cytologic examination, culture, histologic examination, and response to antibiotic therapy. • treat bacterial infections with parenteral or topical antibiotics based on the severity of signs. • sebaceous gland adenomas, basal cell tumors, and squamous cell carcinomas are the most frequently encountered neoplasms. • take a radiograph of the thorax to diagnose metastases. prognosis for long-term survival is based on tumor type, stage, and character. • treat by surgical excision. chromodacryorrhea and epiphora occur as in mice. tapeworms (i.e., h. nana and h. diminuta) and pinworms (i.e., syphacia obvelata, dentostomella translucida, and aspicularis tetraptera) occur as in mice. incisor overgrowth occurs as in mice. • salmonella spp. cause transient diarrheas in gerbils. the source of infection is usually unwashed greens, contaminated feed, or carrier rodents of another species. most recover. animals that die have a fibrinosuppurative peritonitis. • treat supportively. use antibiotics in severe cases based on results of culture and susceptibility testing. • tyzzer disease, caused by bacillus piliformis, is seen most often in weanlings at 3 to 7 weeks of age and in post-partum females. • clinical signs include anorexia, lethargy, rough haircoat, and sometimes diarrhea. gross postmortem findings include yellow-gray nodules in the liver and hemorrhage at the ileocecal junction. • diagnosis is based on postmortem examination or response to therapy. • treat with oxytetracycline (see table 177 -9) and supportive care. hepatic lipidosis and gallstones are frequent sequela to lipemia in gerbils fed diets with excessive fat. • breeding is most successful if animals are paired at weaning and kept in these pairs. male gerbils aid in raising the young. pairing older animals causes fighting. an average of 20% of neonates fail to survive to weaning. this is usually the result of agalactia and crushing. • chronic hemorrhagic discharge from the vulva is usually the result of cystic ovaries or ovarian tumors. most tumors occur in animals older than 2 years of age and consist of granulosa cell tumors or theca cell tumors. leiomyomas of the uterus also cause similar clinical signs. • rule out urinary tract disease by performing a urinalysis via cystocentesis. large masses may be visualized on abdominal ultrasound. definitive diagnosis is based on vaginal cytology followed by exploratory laparotomy. • ovariohysterectomy is curative for cystic ovaries and tumors if they have not metastasized. • chronic renal failure develops in most gerbils older than 2.5 years of age. • clinical signs are polyuria, polydipsia, weight loss, and anorexia. urinalysis demonstrates proteinuria, hematuria, casts, and an increase in white and red blood cells. • treat supportively. prognosis for long-term survival is grave. • up to 50% of gerbils in certain family lines suffer spontaneous epileptiform seizures. the seizures are induced by stress and are self-limiting. seizures usually start as the gerbil reaches 2 months of age. • treatment is unnecessary. chinchilla laniger and c. brevicaudata are nocturnal rodents from the andes mountains in south america. most animals kept in the united states are the descendants of 11 animals. aside from pets, chinchillas are raised commercially for their pelts. the most common coat color is gray; the most valuable coat color is black. m key point chinchillas are sensitive to antibiotics (see "hamster"); therefore, avoid use of penicillins, lincomycin, erythromycin, and cephalosporins. house chinchillas in a cool environment because they are prone to overheating. if heat stroke occurs, treat with tepid water baths and supportive therapy. • chinchillas require dust baths to keep their skin in condition. use commercially available chinchilla dust only. sand substitutions do not condition the coat and occasionally cause conjunctivitis. offer dust at least once a week. • dermatophytosis occurs as in guinea pigs. • fur chewing is a serious problem in chinchillas that are farmed for pelts and often is seen in pet chinchillas that are recent culls from a ranch. the etiology of fur chewing is unknown. some cases seem to be related to chronic disease, malnutrition, poor caging, or stress. theories for undiagnosed cases include genetic abnormality; undiagnosed dermatophytosis; or adrenal, pituitary, or thyroid gland abnormalities. • diagnostics such as skin scraping, fungal culture, fecal, cbc, history profile, and biopsy are recommended. in general, if changes in diet and husbandry do not elicit a response or an underlying treatable disease condition is not discovered, prognosis for cure is grave. • one source advocates plucking all remaining underfur in chewed areas in an attempt to stimulate new hair growth. place collars after this procedure until the fur has grown in completely. • cystic sc masses may be caused by the intermediate stage of multiceps serialis. transmission is by ingestion of feed contaminated with canine feces. • diagnosis is made by histopathologic or cytologic examination of tissue samples. treat by surgical removal of the masses. • otitis caused by pseudomonas spp. occurs as in rats. • conjunctivitis occurs as in mice. • cataracts are congenital or developmental. • asteroid hyalosis occurs as a degenerative change. pneumonia occurs as in guinea pigs. parasites tapeworms (i.e., h. nana) occur as in mice. malocclusion of incisors and cheek teeth occurs as in guinea pigs. • diarrhea is caused most often by coccidia or giardia spp. or a bacterium. • clinical signs range from soft stools and weight loss to fluid diarrhea, dehydration, bloating, septicemia, and sudden death. • the protozoal parasites are best diagnosed on fresh saline smear or necropsy. • bacterial diarrhea is most often caused by contaminated feed and is diagnosed by isolation on culture. clostridium spp., pseudomonas aeruginosa, e. coli, salmonella enteritidis, and pasteurella spp. are the most common isolates. • treat supportively and use appropriate antiprotozoal or antibiotic drugs. • pasteurella pseudotuberculosis causes acute death from septicemia or a chronic weight loss with intermittent diarrhea. enlarged mesenteric lymph nodes are a hallmark of this disease. • diagnosis is based on clinical signs, histopathologic examination of tissue samples, and isolation on culture. • treat with sulfa drugs until sensitivity results are available. prognosis for recovery is poor. gross postmortem examination reveals yellow to white necrotic foci in the liver. • check male chinchillas four times per year for penile hair rings. roll back the prepuce and expose the penis. roll hair rings off the penis after application of a water-soluble lubricant. treat ulcerations topically or systemically as needed. • dystocia is fairly common in chinchillas (see "guinea pig"). • metritis is suspected when post-partum vaginal discharge, failure to return to a normal estrus cycle, anorexia, weight loss, polydipsia, polyuria, and chewing at flank and abdomen are present. • diagnosis is based on history, physical examination, abdominal radiographs, culture, ultrasound, and cbc. it usually is caused by bacteria introduced by the male or spread from an internal abscess. retained placentas, macerated fetuses, and dystocia are predisposing factors toward metritis. • treat with ovariohysterectomy after stabilization. females used only for breeding purposes may be treated with antibiotics alone, but the prognosis is poor. • female chinchillas are aggressive toward male chinchillas when not in estrus. breeding operations usually have separate cages for females and an interconnecting run for the male. females are kept out of the male's run by their larger size or collars. the young are precocious and do not need a nest. chinchillas only produce two litters per year. • clinical signs include hot, swollen mammary glands. suspect mastitis if previously healthy neonates become restless, then lethargic. • perform bacterial cultures on milk samples, and treat with antibiotics based on susceptibility testing. administer sulfa drugs until susceptibility results are available. local hot packing is also beneficial. occasionally, surgical drainage is required. foster neonates to another female if possible, or use puppy or kitten milk replacers to hand-raise babies. • chinchillas seem to be particularly sensitive to listeria monocytogenes. clinical signs can mimic p. pseudotuberculosis and include anorexia, lethargy, abortion, generalized central nervous system (cns) signs, hepatitis, mild enteritis, and mild emphysematous pneumonia. necropsy shows yellow foci in the liver. • diagnosis is based on isolation on culture. • treat with sulfa drugs (see table 177 -9) until sensitivity results are available. the prognosis is poor. • other less common causes of neurologic disease in chinchillas include lymphocytic choriomeningitis, streptococcus spp., balisascaris procyonis (i.e., aberrant migration of raccoon roundworm), lead poisoning, and thiamine deficiency. guinea pigs (caviae porcellus) are nocturnal rodents that originated in the andes mountains. they are known for their dietary need for vitamin c. they are used as a food source in their native lands. there are three basic types: english, which have short hair; abyssinian, which have short, cowlicked hair; and peruvian, which have long hair. male guinea pigs are known as boars and the females as sows. guinea pigs become neophobic as they mature. offer a variety of foods early in life and make changes in diet or environment gradually. guinea pigs stampede when excited. square cages and strategically placed barriers on external walls prevent the trampling of small or weak animals. the smooth muscle of the bronchial tree is quite developed in guinea pigs. this places them at high risk for asthmatic-type anaphylactic reactions. both male and female guinea pigs have one pair of inguinal mammary glands; however, only the female's are well developed. m key point antibiotic toxicity (see "hamster"): guinea pigs also may be sensitive to tetracyclines. • fleas occur as in mice. • lice (i.e., gliricola porcelli, gynopus ovalis) usually cause no clinical signs except occasional alopecia, seborrhea, and trauma secondary to pruritus. • diagnosis is made by observation of lice on skin scraping. • treat with ivermectin, 5% malathion dust, or pyrethrin shampoo (see table 177 -8). • the mite trixacarus caviae causes severe pruritus and is zoonotic. it mainly affects the dorsal midline and is difficult to find on skin scraping. it occurs most frequently in recently post-partum females, in which alopecia is the predominant clinical sign. treat with excellent sanitation and ivermectin (see table 177 -8). • chirodiscoides caviae lives on the hair shaft of the perineal regions. it does not cause clinical signs. • treat with 5% carbaryl or lime-sulfur dip (1:40) (see table 177 -8). sanitation is critical in preventing reinfestation. • about 6% to 13% of guinea pigs are carriers of trichophyton mentagrophytes. • clinical signs are alopecia and seborrhea sicca, usually starting on the face and spreading along the dorsum. • treat with lime-sulfur dips or griseofulvin (see table 177 -9) combined with topical povidone iodine or chlorhexadine shampoos. • other causes for alopecia are barbering, alopecia of the flanks in late-gestation females, and generalized alopecia of young at weaning. subclinical hypovitaminosis c causes a poor hair coat and seborrhea sicca, as well as anorexia and large, malodorous stools. • "lumps" is the lay terminology for cervical lymphadenitis, which is characterized by lymphadenopathy in the ventral neck region. • pododermatitis and sore hocks are very common in guinea pigs. predisposing factors are untrimmed toe nails, poor sanitation, and wire flooring. s. aureus is the most commonly cultured pathogen. • clinical signs range from small ulcers on the soles of the feet to abscesses and gangrene. radiography is essential in determining whether bony involvement is present. untreated pododermatitis usually develops into osteomyelitis, which is very difficult to cure. • treat mild cases by improving sanitation and grooming. place affected individuals in solidfloored cages with paper bedding. use sulfa drugs (see table 177 -9) until results of susceptibility testing are available. surgically remove or curette abscesses, and apply topical therapy and hot packing. amputation may be necessary when severe osteomyelitis exists. • conjunctivitis and epiphora occur as in mice. • inclusion body conjunctivitis is caused by chlamydia psittaci and is self-limiting in 3 to 4 weeks. • perform a conjunctival scraping to differentiate inflammatory conjunctivitis secondary to infection from allergy. i have observed an idiopathic, topical steroid-responsive lymphoplasmacytic conjunctivitis in guinea pigs. • white, dry ocular discharge is an early sign of hypovitaminosis c. • "pea-eyes" is the lay terminology for subscleral fatty deposits or protrusion of the lacrimal gland through the lower conjunctiva. the condition is thought to be hereditary. treatment is not required. • cataracts occur and are either congenital or developmental. • diabetes mellitus in guinea pigs also may cause cataracts. usually, no other clinical signs are present and urine glucose is greater than 100 mg/dl whereas blood glucose remains within normal limits. • corneal or scleral calcification is usually an incidental finding. a thorough workup, including serum chemistry profile and radiographs, is recommended to ensure that generalized metastatic calcification is not present. • pneumonia in guinea pigs usually is caused by infection with s. pneumoniae, s. zooepidemicus, or bordetella bronchiseptica. s. aureus, p. aeruginosa, klebsiella pneumoniae, and pasteurella multocida also are cultured frequently. transmission is by direct contact, fomites, or aerosol. hypovitaminosis c and stress often predisposes guinea pigs to bacterial respiratory infections. weanlings are particularly susceptible. clinical signs and diagnosis are similar to other small mammals (see "mouse"). • take radiographs to rule out abscesses, pleural effusion, or pericardial effusion in refractory cases. • treat with chloramphenicol, sulfa drugs, or enrofloxacin (see table 177 -9) and vitamin c (table 177 -10) until results of culture and susceptibility testing are available. cats, dogs, rabbits, and rats are reservoirs for bordetella spp. as in other rodents, respiratory infections may lead to otitis interna/media. bordetella spp. also cause pyometra and abortions. • nasal discharge is most frequently a sign of upper respiratory tract infection but also may be associated with allergies or volatile irritants. • the diagnosis of allergic rhinitis is made by exclusion and through response to antihistamines or environmental changes. • bronchogenic papillary adenoma develops in approximately 30% of guinea pigs older than 3 years of age. • diagnosis is often an incidental finding when thoracic radiography is performed for another problem. • occasionally, clinical signs are seen as a result of pressure on the heart or great vessels. • dyspnea most frequently is caused by heat stress or trauma. other causes are pregnancy toxemia, gastric bloat, volatile irritants, pleural effusion, pneumonia, or pulmonary edema. rhabdomyomatosis is a common necropsy finding. gross lesions appear as pale foci located on the endomyocardium and valves. histologic examination reveals myocardial cells that have stored excessive glycogen. do not confuse these areas with thrombi, abscesses, or neoplasia. their clinical significance is unknown. • paraspidodera ucinata is the cecal pinworm of guinea pigs. they are generally asymptomatic, but heavy infestations can cause diarrhea and weight loss. • diagnosis is based on fecal examination or cellophane tape test. • treat with piperazine or fenbendazole (see table 177 -8). • coccidiosis caused by eimeria caviae is a fairly common cause of diarrhea in guinea pigs recently purchased from pet stores. • clinical signs are tenesmus, diarrhea, dehydration, and death. • diagnosis is based on fecal examination. on gross postmortem examination, petechiation and thickening of the colon are seen. • treat supportively and administer sulfa drugs (see table 177 -9). • cryptosporidium wrairi and giardia spp. are found rarely. they cause a chronic enteritis. balantidium spp. are thought to be nonpathogenic. • malocclusion in guinea pigs is diagnosed on oral examination. • clinical signs are ptyalism and anorexia. the premolars are the most commonly affected teeth. • long-standing hypovitaminosis c predisposes guinea pigs to malocclusion. • treat malocclusion as in other rodents (see "dental procedures"). • hypovitaminosis c (i.e., scurvy) is associated with soft, malodorous feces. degeneration of the epithelium of the intestinal tract adversely affects digestion and absorption and allows secondary bacterial infections. • diagnosis of scurvy is based on clinical signs, the exclusion of other causes of diarrhea, and response to vitamin c therapy (see table 177 -10). • salmonellosis usually is contracted through contaminated feed. • clinical signs range from sudden death to diarrhea and anorexia. the diarrhea is frequently light colored. sepsis is common and may cause conjunctivitis, shock, pneumonia, abortion, and neurologic symptoms. • diagnosis is based on isolation on culture of feces or other appropriate tissue samples. • treatment is controversial because recovered individuals remain carriers. use sulfa antibiotics or enrofloxacin (see table 177 -9) until sensitivity testing results are available. supportive care is essential. • e. coli, arizona, and clostridium are other commonly cultured diarrhea-causing organisms. clostridium are diagnosed most easily by finding large numbers of spores on a gram stain fecal specimen. treat with metronidazole (see table 177 -9). • yersinia pseudotuberculosis either causes an acutely fatal diarrhea or localizes into regional lymph nodes. • diagnosis is based on culture. • treat by surgical removal or drainage of abscessed lymph nodes. mesenteric lymph node involvement necessitates abdominal surgery. treat with sulfa drugs or enrofloxacin until susceptibility testing results are available (see table 177 -9). • one male usually is housed with four to six females for breeding purposes. signs of estrus are vulvar swelling, lordosis, and opening of the vaginal closure membrane. fetuses are palpable at 4 to 5 weeks of gestation. parturition occurs within 48 hours after the pubic symphysis has reached 15 mm. neonates weighing less than 60 g have a grave prognosis for survival even with intensive care. neonates normally do not nurse for the first 12 to 24 hours. litters with five or more fetuses usually result in abortion. • dystocia commonly occurs in females bred after the age of 6 to 9 months. after this age, the symphysis fuses and is unable to open the 2 to 3 cm required to allow passage of a fetus. dystocia in younger guinea pigs may be caused by obesity, large fetal size, fetal malpresentation, subclinical ketosis, or uterine inertia. on presentation, check the pelvic symphysis. if active contractions are present and the symphyseal gap is less than 2 cm, perform a c-section. normal parturition is very rapid, with a rest of only 3 to 7 minutes between fetuses. • perform a c-section if active straining does not produce a fetus within 15 to 20 minutes. radiograph sows with a history of weak contractions to determine the stage of pregnancy and evaluate the size of the fetuses. if well-developed skeletons of appropriate size are seen and the pubis has not yet fused, give oxytocin and calcium (see table 177 -10). if no fetuses are produced within 15 to 20 minutes, perform a c-section. • if poorly developed fetuses are seen radiographically, consider fetal death, ketosis, or a nonreproductive disorder as possible causes of dystocia. m key point pregnancy toxemia usually is seen in obese sows with large litters in late pregnancy. other risk factors include systemic disease or diet change causing anorexia, genetics, stress, and first litter. • clinical signs are tachypnea, depression, malodorous breath, seizures, and icterus. a urine ph of less than 6 with marked proteinuria is compatible with pregnancy toxemia. a marked hyperkalemia and elevation of liver enzymes often occurs. thrombocytopenia may be present. • treat with iv or io saline, dextrose, glucocorticoids, and calcium. surgical abortion of the fetuses may be attempted, but the anesthesia risk is quite high. prognosis for survival is grave. do not rebreed affected females. do not breed sows heavier than 900 g. • large litters can cause a hemorrhagic syndrome. compression of the portal vein and liver causes hepatic dysfunction, which results in vitamin k and clotting factor deficiency. • treat with vitamin k supplementation (see table 177 -10). response is poor in severely compromised patients. affected individuals are at risk of ketosis developing. prognosis is guarded. • vaginitis in guinea pigs frequently is caused by foreign bodies, usually bedding. • diagnosis is made on vaginal examination. • treat by flushing the vagina to remove the foreign material. • vaginal discharge also can be caused by pyometra, uterine torsion, urinary tract infection, or urogenital neoplasia. • diagnosis is based on findings on abdominal palpation, vaginal cytology and culture, urinalysis, abdominal radiographs, ultrasound, and exploratory. • treatment varies with the condition and is similar to that used in cats. • ovarian teratomas and uterine tumors occasionally are diagnosed and usually resolve with ovariohysterectomy. • a symmetric alopecia with concurrent abdominal enlargement may be seen in female guinea pigs with cystic ovaries. • diagnosis is based on abdominal palpation, cytology, and ultrasound. • treat by performing an ovariohysterectomy. if the guinea pig is not a good candidate for surgery, human chorionic gonadotropin (hcg, 1000 usp units im, repeat in 1 week) may temporarily resolve clinical signs. • male guinea pigs are prone to preputial foreign bodies. a preputial discharge is the usual presenting complaint. • diagnosis is based on physical examination. • treat by removing foreign bodies and performing local flushing. chronic problems require a change in bedding. • male guinea pigs produce sebaceous secretions in the folds around their perineal area. clean these areas with soap and water semiannually to prevent localized pyoderma. • if pyoderma occurs, treat with topical therapy and oral antibiotics. bacterial cystitis and urolithiasis are relatively common in guinea pigs. diagnosis is based on a history of stranguria, hematuria, painful abdomen, and anorexia, in addition to abdominal palpation, urinalysis, urine culture, abdominal radiographs, and ultrasonography. treatment consists of antibiotics based on results of culture and susceptibility testing and surgical removal of calculi, if present. prevention of recurrence is difficult if the calculi are not caused by a bacterial infection. addition of vitamin c to the drinking water as well as changing the brand of diet are sometimes helpful in preventing recurrence of metabolic stones. klossiella cobayae is a coccidia that lives in the renal tubules. it has no clinical significance. the most common orthopedic problem seen in guinea pigs is overgrown toenails. this leads to pododermatitis and sore hocks as well as to degenerative joint disease and a predisposition to tibial fractures. tibial fractures are the most common fracture seen in guinea pigs. they most frequently occur after foot entanglement. internal fixation with an im pin or application of a kirschner apparatus is the repair of choice. m key point signs of hypovitaminosis c or scurvy start to develop in guinea pigs as early as 10-15 days if they are placed on diets 100% deficient in vitamin c. early signs are soft, malodorous stools, weight loss, poor hair coat, and anorexia. later, petechia, gingivitis, cutaneous and oral sores, swollen costochondral junctions, joint pain and hemorrhage resulting in lameness, and conjunctivitis become apparent. treat supportively and administer parenteral vitamin c (25 mg/day). • lymphocytic choriomeningitis occurs as in mice. • guinea pig paralysis syndrome starts with mild pyrexia and urinary incontinence, followed by weight loss and posterior paresis that progresses to paralysis. currently, the etiology is unknown, but it does not appear to be contagious. • treat with supportive care. prognosis for long-term survival is grave. • head tilt is usually the result of otitis or trauma (see "mouse"). cavian leukemia has a viral etiology. the liver, spleen, and lymph nodes are the primary organs involved. there is no current treatment. quarantine exposed individuals. death usually occurs within 5 days after discovery of lymphoblasts in the peripheral blood. neutrophils normally have red granules. kurloff bodies are normally occurring eosinophilic intracytoplasmic inclusion bodies that are found in mononuclear cells. they are seen most frequently in females and appear to correspond positively with estrogen levels. metastatic calcification occurs in most guinea pigs older than 1 year of age. it is more severe in females than in males. the stomach is one of the first organs affected. dysfunction in motility causes obstruction. the tendency appears to be exacerbated by high calcium and low phosphorus diets. exotic animal formulary the biology and medicine of rabbits and rodents veterinary clinics of north america key: cord-022034-o27mh4wz authors: olano, juan p.; peters, c.j.; walker, david h. title: distinguishing tropical infectious diseases from bioterrorism date: 2009-05-15 journal: tropical infectious diseases doi: 10.1016/b978-0-443-06668-9.50124-1 sha: doc_id: 22034 cord_uid: o27mh4wz nan bioterrorism can be defined as the intentional use of infectious agents or microbial toxins with the purpose of causing illness and death leading to fear in human populations. the dissemination of infectious agents with the purpose of attacking livestock and agricultural resources has similar motives. many of the agents that could potentially be used in bioterror (bt) attacks are also responsible for naturally occurring infectious diseases in the tropics. as such, naturally occurring outbreaks must be differentiated from bt attacks for public health, forensic, and security reasons. if a bt attack occurs in tropical underdeveloped countries, owing to their weak public health infrastructure, the public health implications would be even more dramatic than in developed countries. an outbreak of smallpox due to a bt attack would probably require vaccination and mandatory quarantine of millions of people in order to control the outbreak and quell global public unrest. this chapter will concentrate on selected infectious agents that have the potential to be used as bioterror agents in human populations. the first step in managing the damage from a covert biological dissemination is recognition of the attack and the organism(s). as in most emerging infections, we predict that in bioterrorist attacks the etiological diagnosis will be made by a clinician or pathologist and the recognition of a bioterrorist event will be through geographical and epidemiological anomalies. we have very limited environmental detection capability at this time, and there are no comprehensive pointof-care diagnostics for most of the high-impact bt agents. some diseases such as inhalational anthrax or smallpox may be relatively readily recognized by an alert clinician because of their very distinctive presentation in many cases. however, the leading edge of a bt epidemic may arrive on a pathologist' s doorstep without prior suspicion. for example, individual cases of pneumonic plague as the earliest harbingers of an attack will presumably present as community-acquired pneumonia and probably die without clinical diagnosis. given the short window available for successful treatment, the recognition of these earliest cases is paramount. sartwell 1 has demonstrated empirically that incubation periods follow a log-normal distribution, which results in "front-loading" of cases ( fig. 119-1 ). delay in recognizing the epidemic through reliance on syndromic surveillance or other surrogates will likely result in most of the cases of diseases such as plague and tularemia being well into their disease course and perhaps unsalvageable. 2 bioterrorist events will enlarge our knowledge of tropical diseases. for example, inhalational anthrax and several viral hemorrhagic fevers (vhf) thought to be transmitted mainly by aerosol 3 are under-represented in naturally occurring case series, and a bt attack would provide an opportunity to answer questions about the underlying host factors and pathogenesis. indeed, the extension of the risk population to include children, the elderly, and the immunosuppressed is likely to provide considerable insight into these oftenunderstudied groups. it is also likely that our lack of information about them will challenge our current diagnostic algorithms. in october 2001, anthrax spores were distributed covertly in the u.s. postal service, leading to 22 cases of human anthrax and billions of dollars spent on controlling the potentially devastating effects of a small inhalational anthrax epidemic. 4, 5 this attack was by no means the first intentional attempt to use infectious agents as weapons of terror. ever since the times of the ancient greeks and romans, humans have tried to inflict damage by the use of contagion on other populations. 6, 7 less than 4% of the people or groups responsible for terrorist attacks on human populations take responsibility for their actions. 8 therefore, the use of biological weapons is ideal to conduct covert attacks. in addition, it has been estimated that to kill the same number of human beings with biological weapons as compared to chemical or nuclear weapons, the cost is far less with biological weapons ($2/human casualty) compared with chemical ($2000/ human casualty) and nuclear ($2,000,000/human casualty) weapons. 6 hypothetical bt attacks would range from an overt attack of a large city with a bomb containing several kilograms of an agent (weaponized bacteria, viruses, or toxins) to discrete or covert intentional release of the infectious agent through a delivery system, such as spray devices, postal service, ventilation ducts, water supplies, and food supply. based on transmissibility, severity of morbidity and mortality, and likelihood of use (availability, stability, weaponization), potential bt agents are divided into three categories (table 119-1) . this chapter will concentrate on selected agents from categories a and b and on the diagnostic challenges posed by illnesses caused by such agents. table 119 -1 are capable of producing illness under natural circumstances. therefore, the first challenge is to identify the infectious agent responsible for a certain disease correctly, followed by a thorough epidemiologic and microbiologic analysis of the epidemic or outbreak. in some circumstances, the identification of a bt attack would be obvious. a case of smallpox in any human population is an international emergency that would trigger a massive response of the public health systems around the world. sophisticated epidemiological investigations would follow in order to characterize the outbreak, identify the source, and possibly label it "intentional." in other cases, the identification of the outbreak as secondary to intentional dissemination of an infectious agent will require the use of sophisticated epidemiological and molecular tools, especially for diseases endemic to the area where the outbreak occurs. the need to use genetic sequences as markers has spawned a new discipline referred to as microbial forensics, sister to phylogenetics and "molecular epidemiology." differentiation between natural infections and a biological warfare attack rests firstly on disease patterns given by several epidemiological clues. they include presence of disease outbreaks of the same illness in noncontiguous areas, disease outbreaks with zoonotic impact, different attack rates in different environments (indoor versus outdoor), presence of large epidemics in small populations, increased number of unexplained deaths, unusually high severity of a disease for a particular pathogen, unusual clinical manifestations owing to route of transmission for a given pathogen, presence of a disease (vector-borne or not) in an area not endemic for that particular disease, multiple epidemics with different diseases in the same population, a case of a disease by an uncommon agent (smallpox, viral hemorrhagic fevers, inhalational anthrax), unusual strains of microorganisms when compared to conventional strains circulating in the same affected areas, and genetically homogenous organisms isolated from different locations. 9, 10 these are a few guidelines that could prove helpful when investigating an outbreak, but it has to be kept in mind that the deduction will not be based on any single finding but rather the pattern seen in its totality. first and foremost, the possibility of an attack must be ever in mind, or differentiation of a covert bt attack and a natural outbreak of an infectious disease may not be made. in fact, the outbreak of salmonellosis in oregon in 1984 was due to a covert attack planned by the rajneeshee leadership and accompanied by distinctive epidemiological clues. it was not labeled as intentional until somebody came forward with the information leading to the responsible group; as in most of medicine, the unsuspected diagnosis is the easiest to miss. 11 an increasing number of public health departments are now acquiring the technology necessary to perform syndromic surveillance. this new method of surveillance is based on syndromic disease rates such as respiratory, gastrointestinal, and neurological syndromes or analysis of other health-related activities such as laboratory test requests and results, purchasing rates for certain pharmaceutical agents, unexplained death rates, and veterinary surveillance. 2, 10, 11 the purpose of syndromic surveillance is to detect a bt attack as early as possible by analyzing the previously mentioned variables by extracting and analyzing data through computer networks. the rationale behind syndromic surveillance is the nonspecific nature of early signs and symptoms of many of the illnesses caused by bt agents. examples of proposed syndromes are as follows: gastroenteritis of any apparent infectious etiology, pneumonia with the sudden death of a previously healthy adult, widened mediastinum in a febrile patient, acute neurologic illness with fever, and advancing cranial nerve impairment with weakness. 12 a key component factors affecting syndromic surveillance include selection of data sources, definition of syndrome categories, selection of statistical detection thresholds, availability of resources for follow-up, recent experiences with false alarms, and criteria for initiating investigations. it must be emphasized that these systems are experimental and not yet of proven value in managing bt attacks. they are expensive, require follow-up confirmation, have unproven sensitivity and specificity, and ultimately depend on the clinician. 2 they may prove to be more useful in managing an event than in expeditiously detecting one. conventional epidemiological investigations are by no means obsolete with the availability of more sophisticated methods to study possible bt attacks. they include the confirmation of an outbreak once it is suspected. confirmation is based in many cases on laboratory analysis of patients' samples or autopsy material. a case definition is constructed to increase objectivity of the data analyzed and to enable determination of the attack rate. other variables are included in the analysis, such as time and place, and an epidemiological curve can be constructed. 10 epidemiological curves are an important tool to analyze epidemics and suggest the mode of transmission and propagation. a point source epidemic curve is classically log-normal in distribution 1 and would suggest a common exposure of a population to an infectious agent. of course, there can be variations depending on the presence of susceptible subpopulations (e.g., children, immunosuppressed, aged) and on varying doses of the agent. propagative curves are more characteristic of highly communicable agents such as smallpox. a short description of selected category a and b agents follows. all these pathogens are addressed as naturally occurring disease agents in other chapters of this book. bacillus anthracis (anthrax) b. anthracis (see chapter 39) is without a doubt the microorganism that has received the most attention as a bt agent due to its high lethality (inhalational form), ease of propagation, and high environmental stability. fortunately, the disease is not transmitted from person to person. however, the first three characteristics make it one of the ideal bioweapons. anthrax presents in humans as four different clinical syndromes, depending on the portal of entry: cutaneous (the most common form of the disease resulting from contact with infectious animal products), gastrointestinal and oral/oropharyngeal (both secondary to ingestion of contaminated meat), and inhalational (woolsorter' s disease), secondary to inhalation of spores from the environment. in the event of a bioterror attack, either overt or covert, the clinical presentation of the patients affected by the attack would be that of inhalational anthrax. this form of anthrax is so rare that a single case of inhalational anthrax should raise immediate suspicion, as dramatically demonstrated during the bt attacks in the fall of 2001. [13] [14] [15] during those attacks, 50% of cases were cutaneous anthrax thought to be secondary to handling of anthraxlaced mail envelopes or environmental surface contamination in the presence of minor cutaneous lesions, providing a portal of entry for the spores. 5 an outbreak of inhalational anthrax also took place in sverdlovsk (former soviet union) as a result of an accidental release into the air of b. anthracis spores from a facility producing anthrax for the bioweapons program in the ussr. 5, [16] [17] [18] inhalational anthrax should be suspected clinically in any individual presenting with fever and a widened mediastinum on chest radiograph (due to hemorrhagic mediastinitis). 19, 20 the incubation period is normally 3 to 5 days, but in some cases it can be as short as 2 days and as long as 60 days depending on inoculum and the time of germination of the spore. 17 based on research performed on rhesus monkeys, the ld 50 is estimated to be 8000 to 10,000 spores. [21] [22] [23] however, as few as 1 to 3 spores may be capable of producing a fatal outcome in approximately 1% of those exposed to these quantities. 24 the initial symptoms are nonspecific and consist of fever, malaise, anorexia, fatigue, and dry cough. these symptoms are followed in 3 to 4 days by an abrupt onset of respiratory insufficiency, stridor, diaphoresis, and cyanosis. the subsequent clinical course is rapid, and patients usually die within 24 to 36 hours after clinical deterioration. mortality is 100% without antibiotic therapy. 20, [25] [26] [27] early diagnosis, aggressive treatment with antimicrobial agents to which the bacteria are susceptible, and aggressive supportive therapy decreased the mortality to 40% in the 2001 attacks. 5 pathologic studies performed on the sverdlovsk victims confirmed some of the findings in animal models of inhalational anthrax, such as hemorrhagic lymphadenitis and mediastinitis. however, many patients also developed hematogenous hemorrhagic pneumonia. pleural effusions were usually large and frequently led to severe lung atelectasis. in about half of cases, hemorrhagic meningitis developed, leading rapidly to central nervous system (cns) manifestations terminating in coma and death. 16, 28, 29 yersinia pestis (plague) y. pestis (see chapter 42) is a gram-negative, aerobic, nonsporulating coccobacillus, member of the enterobacteriaceae with a wide host range, including rodents, felines, and humans. 30 the most important reservoirs are urban rats, and its main vector is the rat flea. in rural epizootics, reservoirs include prairie dogs and squirrels in the united states. 31 y. pestis has been responsible for some of the most devastating pandemics in human history in the preantibiotic era (6th, 14th, and 19th centuries). 32 public health measures have made this disease a rarity in the united states (around 20 cases/year) and around the world, although approximately 1000 cases are reported to the world health organization (who) every year (countries reporting plague include madagascar, tanzania, and peru, among others). clinical presentation in naturally acquired infections takes five forms, namely bubonic, septicemic, pneumonic, cutaneous, and meningeal. the pneumonic form is the most likely presentation in a case of plague due to a bt attack. it is worth mentioning that plague has already been used as a bt agent when japan dropped thousands of y. pestis-infected fleas over china leading to small outbreaks of bubonic plague in continental china during world war ii. 33, 34 the incubation period for pneumonic plague is short, ranging from 2 to 3 days. it is the rarest form in natural infections (1% or less) but has the highest mortality, reaching 100% in untreated patients. the initial presentation is nonspecific and consists of cough, fever, and dyspnea. cough may be productive (bloody, purulent, or watery in the initial phases). this is followed by a rapid clinical course leading to respiratory failure and the patient' s demise if not treated with antibiotics early in the course of the disease. 30, 31, 35 the factors that led to the severe manchurian pneumonic plague outbreaks in the early 20th century are unknown, but weather, hygiene, and crowding were important factors. more recent outbreaks worldwide and particularly in the united states have been much smaller and readily controlled. pneumonic cases are common in the united states, but secondary transmission has been rare in the last 50 years. modeling of pneumonic transmission using eight small outbreaks to derive the parameters find average of secondary cases per primary case (ro) to be approximately 1.3 prior to any control measures. 36 this is one of the most scientifically neglected microorganisms with bt potential. tularemia is a zoonotic infection caused by a strictly aerobic, gram-negative, nonsporulating small coccobacillus. two subspecies are recognized, namely f. tularensis subspecies holarctica (jellison type b) and f. tularensis subspecies tularensis (jellison type a). 37 type a is by far the more virulent and is present only in north america. of the bacteria with potential as bt agents, f. tularensis has by far the widest host range, including wild and domestic animals, humans, fish, reptiles, and birds. vectors are also numerous and include ticks, fleas, mosquitoes, and biting flies. 37, 38 this is an impressive range for any human pathogen. in contrast to other diseases described in this chapter, tularemia does not have the remarkable history that some of the other pathogens have. in europe, tularemia was first described in 1532; in the united states, it was first described in 1911 in california in the aftermath of the san francisco earthquake. 38 in natural infections, the most common source of infection is a tick bite and manipulation of infected animals such as wild rabbits. six different clinical syndromes have been described as follows: ulceroglandular, glandular, oculoglandular, pharyngeal, pneumonic, and typhoidal. marked overlap exists among all these forms, and for practical purposes two syndromes (ulceroglandular and typhoidal) have been proposed. [39] [40] [41] as a bt agent, f. tularensis will most likely cause a disease with a primary pulmonary component with secondary dissemination (typhoidal/systemic). in natural infections, both ulceroglandular and typhoidal forms can have a hematogenous pulmonary component, although it is more common in typhoidal forms. pulmonary features include cough, pleural effusions, and multifocal bronchopneumonic infiltrates. if not treated promptly, patients usually develop adult respiratory distress syndrome leading to respiratory insufficiency and the patient' s demise. case-fatality rate approaches 30% if not treated with appropriate antibiotics. 41 smallpox eradication remains the single most important victory in the war against infectious diseases. smallpox (see chapter 58) is the only disease so far eradicated from the face of the earth due to human intervention. the who declared smallpox eradicated in 1980 after the last case of natural disease was diagnosed in somalia in 1977, 42 and vaccination ceased around the world, rendering humankind vulnerable to reintroduction of the virus. [43] [44] [45] a laboratory accident was responsible for two more cases in 1978 in england. this accident prompted the who to restrict the frozen virus to two places in the world: the cdc in atlanta, georgia, and the institute for polyomyelitis and viral encephalitides in moscow, later moved to npo vector, novosibirisk, russia. however, it is suspected that secret military repositories exist after the fragmentation of the soviet union and the subsequent exodus of scientists involved in its bioweapons program (biopreparat). 46, 47 the agent responsible for this disease is an orthopox virus with no known animal reservoir, but high aerosol infectivity, stability, and mortality. although not a category a agent, monkeypox is responsible for outbreaks in africa and is the only other member of the orthopox genus capable of producing systemic disease in humans. the clinical disease is potentially indistinguishable from smallpox, where mortality rates in tropical africa are around 10% to 15%. in may and june 2003, an outbreak of monkeypox occurred in the united states. 48 thirty-seven infections were laboratory-documented and involved humans exposed to infected prairie dogs that had become infected because of contact with infected gambian rats and dormice, two animal species shipped from africa earlier that year. infected humans included veterinarians, exotic pet dealers, and pet owners. the clinical spectrum in this outbreak ranged from asymptomatic seroconversions to febrile illness with papulovesicular rash. no deaths were associated with this outbreak. however, phylogenetic analysis of the virus placed it in the west africa clade as opposed to the central africa clade which carries the previously mentioned case-fatality rate of 10% to 15%. a single case of smallpox would trigger a massive public health response in order to contain the outbreak. an outbreak in germany in 1970 resulted in 19 cases with 100,000 people vaccinated to contain the infection. in 1972, yugoslavia underwent an epidemic with a total of 175 cases (35 deaths) and a vaccination program that included 20 million people in order to contain the outbreak and obtain international confidence. vaccination with the vaccinia virus (a related orthopox virus) is the most effective way to prevent the disease and can be administered up to 4 days after contact with ill patients. strict quarantine with respiratory isolation for 17 days is also mandatory. the newer generation of antivirals that have been developed after the disease was eradicated has never been tested in human populations, but in vitro data and experiments in animal models of poxvirus disease suggest some antiviral activity for the acyclic nucleoside phosphonates such as cidofovir. 49 the only vaccine available in the united states is dryvax, and sufficient doses have been manufactured to cover the entire u.s. population. however, newer vaccines that may have fewer side effects are being developed. the clinical presentation is characteristic. the incubation period ranges from 10 to 12 days. the initial phase is nonspecific, common to other viral syndromes, and is characterized by abrupt onset of fever, fatigue, malaise, and headaches. during this prodromal phase in 10% of patients with fair complexion, a discrete erythematous rash appears on the face, forearms, and hands. the typical smallpox rash has a centrifugal distribution (that is, more abundant on the face and extremities than on the trunk and abdomen). an enanthem also develops with presence of oral ulcerations by the time the exanthem appears. systemic manisfestations begin to subside once the rash appears and can reappear with superinfection of skin lesions or superimposed bacterial bronchopneumonia. progression of the lesions is synchronous (maculopapules, vesicles, pustules). after pustules rupture, scabs form and detach in 2 to 3 weeks, leaving depigmented, scarred areas. this form of the disease, called variola major, is fatal in up to 30% of unvaccinated patients and 3% of vaccinated individuals. various hemorrhagic forms exist. in some cases, the rash progresses very slowly and hemorrhage develops into the base of the lesions, which remain flat and soft instead of tense, carrying a bad prognosis. in some other cases, the disease is hemorrhagic from the beginning, leading to death 5 to 7 days after the initial symptoms appear (case-fatality rate: 100%). finally, in some cases, a severe and overwhelming illness is followed by dusky skin lesions; these patients have a large quantity of virus and are extremely dangerous epidemiologically. previously vaccinated individuals usually develop a milder disease that consists of a mild pre-eruptive phase followed by few skin lesions that appear more superficial, evolve more rapidly, and are not as synchronous as the classical type. 50 viral hemorrhagic fever (vhf; see chapter 65) is caused by a heterogenous group of rna viruses that belong to several different families. the cdc identified filoviruses (ebola and marburg viruses), arenaviruses (lassa, junin, machupo, guanarito, and sabia), and bunyaviruses (crimean-congo hemorrhagic fever [cchf] and rift valley fever [rvf]). [51] [52] [53] the common denominator in these infections is the increased vascular permeability in the microcirculation leading to hemorrhagic diathesis and systemic manifestations such as pulmonary edema and cerebral edema related to leaky capillaries. 54 these viruses usually have a very narrow geographic range determined by their natural reservoirs and vectors. humans are accidental hosts. these diseases have caught great public attention due to their high mortality. this, combined with their aerosol infectivity, has led to the use of biosafety level 4 laboratories in their study. clinical presentation is usually nonspecific and consists of fever and malaise, followed by signs of increased vascular permeability and circulatory compromise. vhf usually terminates in shock, generalized mucocutaneous hemorrhages, and multiorgan failure. differences exist among the clinical details and pathogenesis of the different viruses (see chapter 65 for an overview and the individual chapters for details). for example, vhf due to filoviruses usually have prominent hemorrhagic manifestations and disseminated intravascular coagulation (dic) as a terminal event. rvf virus leads to liver damage, dic, and hemorrhagic manifestations in approximately 1% of patients with severe disease. cchf also behaves like the filoviral infections with prominent hemorrhagic manifestations. lassa fever has few neurologic or hemorrhagic manifestations. the south american arenaviral hemorrhagic fevers usually have hemorrhagic and neurologic components. toxins in the context of bt agents are substances of biologic origin that are capable of producing human illness. toxins are usually proteins synthesized by living bacteria, fungi, or plants. toxins are generally less dangerous than infectious agents. the most potent biological toxin is that from clostridium botulinum and it is 10-fold or more less lethal than anthrax on a weight basis. other toxins such as ricin are more than a 1000-fold less toxic than botulinum toxin and sarin is 30-fold less toxic than ricin. there are seven similar toxins produced by seven different serotypes of c. botulinum (a to g), all leading to the same clinical manifestations and with the same lethality. the toxins have a molecular weight of approximately 150 kda and block neurotransmission at the presynaptic level in cholinergic neurons including the neuromuscular junction, leading to progressive palsies of cranial nerves and skeletal muscle. botulinal toxins are among the most lethal substances known to mankind with ld 50 of 0.001 î¼g/g of body weight when administered parenterally. 25, 55, 56 the aerosol route decreases its lethality 80 to 100 times. both aerosol attacks and contamination of food supplies are potential bt scenarios. clinical manifestations consist of progressive bulbar and skeletal paralysis in the absence of fever, including diplopia, dysphagia, blurred vision, ptosis, dysarthria, dysphonia, mydriasis, dry mucosae, and descending paralysis. 25, 56 the cause of death in lethal cases is respiratory insufficiency due to paralysis of respiratory muscles. onset of symptoms is variable and depends on the inoculum, ranging from 24 hours to several days after exposure. most cases of naturally occurring intoxication are related to consumption of improperly sterilized canned food or ingestion of preserved fish. rare cases of inhalational botulism were documented in germany in the early 1960s due to accidental laboratory exposure. the rapid absorption through the respiratory tract may offer a different pathogenesis and it is not known if antitoxin is useful in therapy, although animal models show efficacy in prophylaxis. all the agents in category a are generally recognized as serious threats for causing extensive casualties. categories b and c are much more heterogeneous. they were considered to provide significant threat potential but there are continuing reassessments. these conditions are caused by the genus alphavirus, family togaviridae (eastern, western, and venezuelan equine encephalitis [vee] viruses; see chapter 74). natural infections are usually transmitted by mosquitoes, but aerosol transmission is the notorious cause of numerous laboratory infections and is the basis of its historic weaponization. 52, 57 most of these viruses cause systemic illness characterized by fever, myalgias, and prostration. clinically apparent involvement of the central nervous system is present in some cases and varies among the different viruses. eastern equine encephalitis (eee) is by far the most virulent, leading to case-fatality rates of 50% to 75%, and survivors usually have severe neurologic sequelae. 58, 59 vee, in contrast, leads to cns manifestations in no more than 4% of cases and almost all vee infections are symptomatic even in the absence of cns involvement. [60] [61] [62] rickettsia prowazekii (epidemic typhus) and r. rickettsii (rocky mountain spotted fever) typhus (see chapter 51) is another disease that has played a historic role in human populations. [63] [64] [65] [66] millions of people perished in world war i and world war ii due to epidemic, louse-borne typhus. large outbreaks of the disease still occur in tropical regions around the world in areas stricken by war, famine, and poverty. rocky mountain spotted fever (rmsf), on the other hand, is transmitted by tick bites and occurs endemically in south and central america as well as north america. rickettsiae target the microvascular endothelium leading to leaky capillaries systemically. 67 the main causes of morbidity and mortality are noncardiogenic pulmonary edema and cerebral edema leading to diffuse alveolar damage and meningoencephalitis. clinical manifestations are nonspecific and include fever, malaise, headache, myalgias/arthralgias, cough, nausea, vomiting, confusion, stupor, and coma in severe cases. skin rash ranges from maculopapular to petechial, depending on the severity, and is observed in around 90% of patients with rmsf and 2% to 100% of cases of epidemic typhus, depending on the darkness of cutaneous pigmentation. rickettsiae are remarkably underestimated biothreats as they are highly infectious by low-dose aerosol exposure, possess a stable extracellular form, and are resistant to most empirically administered antibiotics, including î²-lactams, aminoglycosides, and macrolides, and are exacerbated by sulfonamides. case-fatality rates can be as high as 40% to 50% without antibiotic therapy and 3% to 5% with adequate antibiotic coverage. lethal cases are usually due to delayed diagnosis. 64, 65, 68 these rickettsiae are highly infectious by aerosol and are potent bt agents. they are often discounted because of their susceptibility to tetracycline and chloramphenicol. however, the severity of the illness, the exhaustion of antibiotics in the face of a mass attack, and the existence of antibiotic-resistant organisms suggest they are still formidable players. this gram-negative, obligately intracellular bacterium has a high degree of infectivity (one organism is capable of causing infection by inhalation) and low lethality. [69] [70] [71] [72] the distribution of q fever is worldwide and results from exposure to animals such as sheep, cattle, goats, cats, rabbits, and others. c. burnetii has spore-like characteristics that can withstand harsh environmental conditions and be transported by wind to other places. in natural infections, 60% of cases are asymptomatic and are diagnosed by seroconversion. in symptomatic cases, the presentation is nonspecific and includes malaise, fever, myalgias, cough, chills, headaches, anorexia, weight loss, and in some cases pleuritic chest pain. hepatomegaly and splenomegaly are sometimes observed, although not frequently. transmission occurs by exposure to infected animal products (meat, milk). less common routes of infection are inhalational and cutaneous. the clinical presentation of brucellosis is highly variable, even after inhalational exposure. the clinical spectrum ranges from asymptomatic seroconversion to severe acute systemic disease. intermediate forms include undulant fever or chronic disease, characterized by presence of brucella in virtually any organ. acute systemic disease is highly incapacitating with high fever, headache, nausea, vomiting, chills, severe sweating, and, in very severe cases, delirium, coma, and death. undulant fever is characterized by relapses of fever, weakness, generalized aching, and headache. chronic infections may have manifestations related to several organ systems such as the gastrointestinal and genitourinary tracts, cns, joints, and bones. [73] [74] [75] developing countries with insufficient water treatment and food security are more vulnerable to enteric bt attack. these agents include shigella dysenteriae, salmonella spp., enterohemorrhagic e. coli, vibrio cholerae, and cryptosporidium parvum. shigella and salmonella have in fact already been used as agents of biorevenge or biopolitics in small-scale attacks: one (shigella) in an office setting by a disgruntled employee and one in oregon by a religious sect that led to nearly 1000 cases of salmonella-related gastroenteritis. 11, 76 these agents are indeed ideal for small-scale attacks since large-scale attacks would require contamination of large water supplies which, because of enormous dilution factors and susceptibility of all these agents (except for c. parvum) to standard chlorinating procedures, would decrease the number of bacteria to below that required to infect large numbers of people. 69 occasional outbreaks of nontyphoidal salmonella and shigella infections occur in the united states. shigella is a highly infectious organism that requires very low numbers (10 2 -10 3 organisms) to provoke clinical disease. the illness caused by shigella and enterohemorrhagic e. coli is explosive and starts with fever, vomiting, severe abdominal cramping, bloody diarrhea, and systemic manifestations such as hypotension, and circulatory collapse if not treated rapidly. both microorganisms produce an exotoxin responsible for most of the systemic manifestations associated. a distinct complication, hemolytic uremic syndrome, occurs in a small percentage of cases, being more common in children younger than 10 years of age, leading to renal failure and hemolysis. salmonella is less infectious and less explosive than shigella, and leads to fever, vomiting, diarrhea, abdominal cramping, and in some cases to typhoidal manifestations. imported cases of v. cholerae have been diagnosed in the united states in the past. however, the disease occurs in southern asia and latin america as large outbreaks. the clinical illness is characterized by explosive watery diarrhea that leads to rapid dehydration and circulatory collapse. c. parvum infections are characterized by watery diarrhea and abdominal cramping for 2 to 3 weeks. the disease is self-limited except in patients with acquired immunodeficiency syndrome (aids) or other conditions of compromise, in whom illness can last for months or years if immune function is not restored. c. parvum is resistant to standard chlorine concentrations in water supplies. 77 the largest outbreak in this country occurred in milwaukee in the early 1990s and was responsible for thousands of cases and increased mortality among those with aids. 69, 78, 79 this section addresses other toxins considered of potential bt use, such as staphylococcal enterotoxin b (seb) and ricin toxin (derived from castor beans, which in turn are the fruit of the ricinus communis plant). the ricin toxin is composed of two glycoproteins of approximately 66,000 kda. 80 the toxin inhibits protein synthesis by blocking elongation factor 2 (ef2) at the ribosomal level. ricin toxin is not a weapon of mass destruction since its lethal dose in humans is much higher than previously believed. however, the use of the toxin in small bt attacks is possible in the tropics because of its ready availability and relatively easy extraction from the beans. clinical presentation depends on the route of administration as does the ld 50 . in cases where large amounts of the toxin are ingested, the manifestations include nausea, vomiting, severe abdominal cramping, rectal hemorrhage, and diarrhea. as the clinical course progresses, anuria, mydriasis, severe headaches, and shock supervene leading to the patient' s demise in 2 to 3 days. clinical manifestations usually appear within 10 hours after ingestion of the toxin. inhalational exposure leads to prominent pulmonary manifestations 8 to 28 hours after exposure and fever, dyspnea, progressive cough, cyanosis, and death. histologically, there is widespread necrosis of pulmonary parenchyma and pulmonary edema. a single case of parenteral intoxication was documented. a defector from bulgaria was injected with a pellet containing ricin from a weapon disguised in an umbrella, resulting in local necrosis, regional lymphadenopathy, gastrointestinal hemorrhage, liver necrosis, nephritis, and dic. 81 staphylococcus aureus enterotoxin b (seb) is a 28-kda, heatstable exotoxin produced by certain strains of s. aureus and is responsible for food poisoning after ingestion of the preformed exotoxin in improperly handled food. in bt scenarios, exposure can occur either by inhalation or ingestion leading to seb food poisoning or seb respiratory syndrome. the toxin is highly incapacitating and not very lethal. the dose that causes symptoms in half of exposed persons and ld 50 differ by a magnitude of 5 log scales for inhalational exposure. 82 thus, it is thought of as an incapacitating agent. incubation time after ingestion is short (4-12 hours) followed by explosive vomiting that persists for several hours. weaponization of the toxin as an aerosol is possible due to its high stability. manifestations after inhalation of the seb are related to the respiratory system and consist of fever, cough, chills, myalgias, chest pain, and pulmonary insufficiency due to alveolar edema. general symptoms and signs are universal and consist of multiorgan failure secondary to a cytokine storm. 25 these toxins are superantigens due to their ability to bind to major histocompatibility complex (mhc) class ii molecules on large numbers of lymphocytes and macrophages, leading to a hyperactivation of the immune system and massive cytokine release including interferon-gamma (ifn-î³), tumor necrosis factor-alpha (tnf-î±), interleukin (il-6), and other mediators such as leukotrienes and histamine. 82 the role of the clinical laboratory in the diagnosis of possible cases related to a bt attack is of utmost importance. 83, 84 on the one hand, standard clinical microbiology laboratories will be receiving specimens for diagnostic purposes, and communication with clinicians regarding their suspicions is critical. certain isolates in the laboratory are not pursued further (bacillus spp. is a classic example) unless specifically requested due to the frequent isolation of contaminants with similar characteristics. in addition, handling of certain specimens will require added biosafety level requirements due to their infectivity (table 119-2) . certain samples will have to be shipped to highly specialized laboratories for initial or further work-up. environmental testing is challenging due to the complexity of the samples to be analyzed. 85, 86 this type of testing takes place in highly specialized laboratories and is not undertaken by the standard clinical microbiology laboratory. the bacterial diseases caused by the bt agents outlined in this chapter, with the exception of c. burnetii and rickettsia spp., can be diagnosed by standard isolation techniques in clinical microbiology laboratories. isolation of rickettsiae and the bt viruses requires specialized laboratories with bsl-3 or bsl-4 biocontainment. 87 serological assays are available for detection of antibodies against all bt agents. however, for many organisms serological assays require the presence of rising antibody titers, and therefore the serologic diagnosis is usually retrospective in nature. for some viral diseases, a reliable diagnosis can be established based on elevation of immunoglobulin m (igm) titers in the acute phase of the disease. with the advent of molecular techniques, rapid and sensitive diagnostic tests are becoming available for bt agents during the acute phase of the disease. [88] [89] [90] this is of utmost importance in a bt event since identification of the first cases would be critical for a rapid and effective public health response. in addition, treatment and prophylactic measures can also be initiated as quickly as possible. molecular diagnostic techniques can be applied to potential bt agents in an additional setting: as part of the epidemiological and forensic investigations that a bt attack would immediately trigger. postmortem diagnosis is also possible by analysis of frozen or paraffin-embedded tissues by immunohistology or nucleic acid-based amplification techniques. rapid diagnosis of the initial case (cases) in a bt event requires a high degree of clinical suspicion from the physicians having contact with such patients in the emergency room or outpatient setting. the clinical laboratories would then play a critical role in detecting the suspected agent and/or referring the appropriate specimens to higher level laboratories for specialized testing (table 119-3) . 83, 85, 91 several of the agents discussed in this chapter are zoonotic diseases. therefore, diagnosis of certain zoonotic diseases in animals may be important in identifying some bt attacks. in such situations, animals could be seen as either direct victims of the attack or as sentinel events in a human outbreak. there are currently efforts to establish a network of laboratories dedicated to diagnosis of veterinary agents. 85 bsl-1 suitable for work involving well-characterized agents not known to cause disease in healthy bacillus subtilis adult humans and of minimal potential hazard to laboratory personnel and the environment. naegleria gruberi canine hepatitis virus bsl-2 suitable for work involving agents of moderate potential hazard to personnel and the measles virus environment. laboratory personnel have specific training in handling pathogenic agents salmonella spp. and are directed by competent scientists; access to the laboratory is limited when work toxoplasma spp. is being conducted; extreme precautions are taken with contaminated sharp items; and hepatitis b virus certain procedures in which infectious aerosols or splashes may be created are conducted in biological safety cabinets or other physical containment equipment. bsl-3 suitable for work with infectious agents which may cause serious or potentially lethal coxiella burnetii disease as a result of exposure by the inhalation route. in addition to the requirements rickettsia spp. described for work in bsl-2 environment, all procedures are conducted within biological m. tuberculosis safety cabinets, or other physical containment devices, and by personnel wearing alphaviruses appropriate personal protective clothing and equipment. laboratory should be located in a separate building or an isolated zone within a building. laboratories are equipped with double door entry, directional inward flow, and single-pass air. bsl-4 required for work with dangerous and exotic agents that pose a high individual risk of filoviruses aerosol-transmitted laboratory infections and life-threatening disease. members of the arenaviruses laboratory staff have specific and thorough training in handling extremely hazardous infectious agents. they are supervised by competent scientists who are trained and experienced in working with these agents. access to the laboratory is strictly controlled by the laboratory director. the facility is either in a separate building or in a controlled area within a building, which is completely isolated from all other areas of the building. all activities are confined to class iii biological safety cabinets, or class ii biological safety cabinets used with one-piece positive pressure personnel suits ventilated by a life support system. the biosafety level 4 laboratory has special engineering and design features to prevent microorganisms from being disseminated into the environment. the diagnosis of inhalational anthrax is based on isolation and identification of b. anthracis from a clinical specimen collected from an ill patient. in cases of inhalational anthrax, samples of sputum, blood, or cerebrospinal fluid (csf) may yield growth of the agent. demonstration of b. anthracis from nasal swabs has more epidemiological and prophylactic implications than clinical importance. standard diagnostic techniques are based on visualization and isolation in the clinical microbiology laboratory and serological demonstration of antibodies against b. anthracis. [92] [93] [94] [95] [96] visualization of b. anthracis from clinical specimens (blood cultures, csf, and cutaneous lesions) by gram stains is not difficult. b. anthracis appears as large gram-positive, spore-forming rods with a bamboo appearance. isolation is achieved by inoculating standard sheep blood agar plates, and colonies appear as small, gray-white, nonhemolytic colonies. a selective medium (polymyxin-lysozyme-edta-thallous acetate agar) is available mostly for environmental samples and inhibits the growth of other bacillus spp., such as b. cereus. growth is rapid (24-48 hours) . 93 confirmatory tests include î³-phage lysis, detection of specific cell wall and capsular antigens, and polymerase chain reaction (pcr) amplification of dna followed by sequencing. 90 serological tests available for clinical diagnosis are based on detection of antibodies directed against protective antigen (pa). cross-reactive antibodies decrease the specificity of this test. assays based on toxin detection are available in specialized centers and are based on capture of anthrax toxins by using antibodies. antibody-coated immunomagnetic beads are then analyzed by electrochemiluminescence technology. the analytical sensitivity of this technique for detection of anthrax toxin is at the picogram to femtogram level (10 â��12 to 10 â��15 ). 97, 98 immunoliposomal technology combined with real-time pcr (for a dna reporter sequence) is also in the early stages of development for several toxins (ricin, cholera, and botulinum) and appears promising with analytical sensitivity in the attomolar to zeptomolar (10 â��18 to 10 â��21 ) range for cholera toxin. 99 the specificity of this assay is given by the toxin-capturing antibody. nucleic acid amplification techniques (pcr) are also available both in standard format and real-time format. extraction of dna from spores is challenging and requires modification of dna extraction protocols in order to facilitate release of dna from spores or induction of germination prior to dna extraction. 90 real-time pcr tests have been developed by applied biosystems (taqman 5' nuclease assay) and roche applied science (lightcycler). [100] [101] [102] the analytical sensitivity of both techniques is extremely high, and testing times have been decreased to 1 to 2 hours. portable pcr instruments are being developed for rapid deployment to the field. 103 examples include the rugged advanced pathogen identification device (rapid), 100 the smartcycler (cepheid, ca), 101 and the miniature analytical thermal cycler instrument (matci) developed by the department of energy' s lawrence livermore national laboratory. 104 this instrument later evolved into the advanced nucleic acid analyzer (anaa) and handheld advanced nucleic acid analyzer (hanaa). 105 molecular subtyping of b. anthracis is also possible by using the 16s ribosomal rna (rrna) subunit gene, multiplelocus vari-able number tandem repeat analysis of eight genetic loci, and amplified fragment length polymorphism (aflp) techniques. 106, 107 environmental testing also plays a role in the investigation of a bt event. in this setting, detection of b. anthracis relies heavily on molecular techniques for confirmation of potentially contaminated samples (e.g., surfaces, air). 108, 109 postmortem diagnosis is also possible by using gram stains on paraffin-based tissues or immunohistochemical procedures using polyclonal or monoclonal antibodies against various anthrax antigens. diagnosis of y. pestis is based on demonstration of the bacillus in blood or sputa from patients. standard diagnostic techniques in the laboratory include visualization of gramnegative coccobacilli, which by giemsa, wright, or wayson stains reveal a "safety pin" appearance. isolation is performed in blood and mcconkey agar plates on which colonies appear as nonlactose fermentors. the organisms are identified preliminarily by direct immunofluorescent assay with y. pestisspecific antibodies, with final identification based on biochemical profiles in clinical microbiology laboratories. 110 molecular diagnostic techniques based on real-time pcr have become available in recent years and involve detection of y. pestis genes such as plasminogen activator (pla), genes coding for the yop proteins and the capsular f1 antigen, and the 23s rrna gene, which allows distinction from other yersinia spp. [111] [112] [113] assays have been developed to detect resistance to particular antibiotics. the importance of these diagnostic techniques in a disease such as plague is evident. the log-normal epidemic curve with a narrow dispersion of the incubation periods (see fig. 119 -1) and the short interval for successful antibiotic therapy mandate recognition of the earliest cases if the bulk of the exposed are to be saved. molecular subtyping of y. pestis is also possible by analyzing polymorphic sites in order to identify the origin of strains in the event of a bt attack. diagnosis is made in the clinical laboratory by demonstration of the microorganisms in secretions (sputa, exudates) by direct immunofluorescence or immunohistochemically in biopsy specimens. isolation in the clinical laboratory may be achieved by using regular blood agar plates, posing a risk to laboratory personnel not employing bsl-3 facilities and procedures. the procedure for isolation of f. tularensis in the laboratory is very similar to that described for y. pestis. final identification in the clinical laboratory is based on the biochemical profile. 114 molecular diagnostic techniques are based on pcr detection of f. tularensis by using primers for different genes such as outer membrane protein (fop) or tul4 and real-time detection systems. 90, 115, 116 smallpox virus diagnosis of variola major is suggested by its clinical presentation and the visualization of guarnieri bodies in skin biopsy samples. preliminary confirmation requires visualization of the typical brick-shaped orthopox virus by electron microscopy, followed by isolation from clinical specimens and accurate molecular identification to differentiate it from the morphologically (and sometimes clinically) similar monkeypox virus. confirmation of this diagnosis is performed only under bsl-4 containment facilities at the cdc. 47 molecular techniques are based on pcr amplification using real-time or standard technology followed by sequencing or use of restriction fragment length polymorphism (rflp) for accurate identification. 117 technologies so far developed for smallpox molecular testing include taqmanand lightcycler-based assays with primers designed for the hemagglutinin gene and a-type inclusion body proteins. [118] [119] [120] [121] sequencing of the smallpox genome has been completed for some asian strains of variola major and one of variola minor. other strains are being sequenced and will provide more information for probe design and treatment targets. 90 diagnosis of these diseases is performed in highly specialized centers in the united states because special isolation procedures and highly contained laboratories are required. initial diagnosis of these diseases is suspected on clinical and epidemiologic grounds. laboratory diagnosis involves isolation, electron microscopy, and serological assays. immunohistochemical detection of hemorrhagic fever viral antigens in paraffin-embedded tissues is also performed in highly specialized centers such as the cdc. [122] [123] [124] [125] [126] molecular diagnostic techniques have also improved dramatically during the last few years. serum or blood is the most common specimen used for reverse transcriptase-pcr amplification of viral nucleic acids. both standard and realtime techniques are available. design of primers for this heterogenous group of rna viruses that are highly variable is one of the limitations. 90 therefore, multiplex pcr techniques are required to detect as many targets as possible in a single assay. 127, 128 real-time pcr based on detection of the target sequence using fluorescent probes therefore limits the number of targets that can be identified because of the limited wavelength range for fluorescent applications (usually only four different wavelengths can be detected at the same time). [128] [129] [130] the use of microchips containing several thousands of oligonucleotides from all viruses known to be pathogenic to humans is an encouraging development. in fact, the rapid identification and characterization of the novel human coronavirus responsible for the sars outbreak in 2003 is an excellent example of the power of hybridization-based microchips. the creation of an automated and easily deployable instrument capable of detecting all possible potential bt agents based on highly sensitive techniques such as electrochemoluminescence (ecl) or pcr would be ideal. the nonspecific nature of presenting symptoms is a major problem with several of the agents. the rapid recruitment of cases into the infected cohort requires that an early diagnosis of the epidemic be established, particularly for organisms such as y. pestis in which there is only a short window for successful treatment. in fact, such projects are already in the making. an example of this system is the automated biological agent testing system (abats) that combines the techniques mentioned previously. 86 the system is the result of integrating several commercially available technologies into a single automated and robotized instrument for detection of viruses, bacteria, and parasites considered potential bt agents. the technologies incorporated into this "super system" include automated specimen preparation (both nucleic acid-based and protein-based such as immunodiagnostics), thermocyclers for pcr detection, chemiluminescent detectors for immunobased assays, sequencers, and software programs for sequence analysis. rickettsia prowazekii (epidemic typhus) and r. rickettsii (rocky mountain spotted fever) diagnosis of these infections in the clinical microbiology laboratory currently rests on the identification of antibodies in serum during the acute and convalescent period in order to demonstrate seroconversion or rising titers. the diagnosis is therefore retrospective. 131, 132 detection of rickettsial dna from blood or skin samples during the acute phase of the disease is possible via pcr assays. however, these assays are not standardized and are not commercially available. primers have been designed for amplification of several rickettsial genes including citrate synthase, 17-kda protein gene, ompa, and ompb. [132] [133] [134] [135] [136] the clinical sensitivity and specificity of standard or real-time pcr techniques have not been determined. most likely real-time pcr is superior due to the higher analytical sensitivity of this technique and low risk of sample contamination with dna amplicons when compared to standard pcr amplification methods. isolation of rickettsiae from clinical specimens is performed in very few specialized laboratories in the nation and requires the use of cell monolayers, embryonated eggs, or animals. detection of rickettsial antigens or whole bacteria in blood specimens is theoretically possible by using ultrasensitive methods, but such assays are currently only in the early phases of development. immunohistochemical detection of rickettsiae in paraffin-embedded tissue has also been applied to tissue samples obtained pre-or postmortem. [137] [138] [139] salmonella spp., shigella dysenteriae, vibrio cholerae, and cryptosporidium parvum (acute enteric syndromes) diagnosis of salmonella, shigella, and vibrio infections is based on isolation of the offending agent on standard microbiological media in the clinical laboratory, followed by specialized confirmatory tests to identify the specific serotype involved. 140 diagnosis of c. parvum is based on visual identification of the protozoan in fecal specimens by using modified trichrome stain. 140 the diagnosis rests on serological demonstration of antibodies by immunofluorescent assay (ifa) or enzyme-linked immunosorbent assay (elisa). antibodies remain elevated for years after the acute infection, and therefore a fourfold rise in titers is the gold standard for diagnosis. pcr detection of c. burnetii dna from blood or tissues also yields a diagnosis of q fever. 88 brucella spp. diagnosis of brucellosis requires a high degree of clinical suspicion due to the protean manifestations related to this disease. laboratory diagnosis is based on isolation of the microorganism from blood, bone marrow, or other tissue samples. isolation is not easy due to the slow-growth of brucella spp. colonies usually appear after 4 to 6 weeks, and therefore communication with the clinical laboratory is important so that appropriate media will be used and the cultures will be held long enough for colonies to be detected. 90 serologic assays for demonstration of rising antibody titers are available, although the diagnosis is retrospective. pcr detection is promising, but it is not standardized. [141] [142] [143] alphaviruses (encephalitic syndromes: venezuelan, eastern, and western equine encephalomyelitis) diagnosis is based on isolation of the virus from serum or brain (postmortem specimens) in a bsl-3 environment. pcr detection of viral sequences is also possible. serologic diagnosis is based on demonstration of antibodies in acute and convalescent sera. [144] [145] [146] botulinum toxins the diagnosis of botulism relies heavily on clinical parameters. an afebrile patient with signs and symptoms of progressive bulbar palsies and descending neuromuscular paralysis is highly suspected of having botulism. demonstration of the toxin in cases of botulism due to ingestion of contaminated food is made from gastric samples, feces, blood, and urine. however, detection of minute amounts of toxin (and contacts with samples from cases may prove fatal due to the toxin' s potency) would be difficult by current immunoassay systems such as elisa platforms. 146 detection techniques based on electrochemiluminescence and immunoliposomes are currently under development. 99, 147 pcr assays can be performed in cases of ingestion of contaminated food in order to detect the genetic material present in c. botulinum. if weaponized toxin is used in the absence of c. botulinum organisms, detection of the genetic material would be difficult and would rely on the presence of residual dna after toxin purification procedures. if inhalational botulism is suspected, respiratory secretions and nasal swabs should be obtained as early as possible. postmortem samples of liver and spleen can be used for detection of botulinum toxins. diagnosis is also based on clinical presentation and requires a high index of suspicion due to the nonspecific nature of the signs and symptoms. laboratory diagnosis rests on detection of the toxin in body fluids by immunoassays (capture elisa and igg elisa). 146 a new generation of tests using more sensitive detection methods is under development (see preceding discussion). diagnosis is also suspected on clinical grounds and confirmed by demonstration of the toxin in nasal swabs early in the disease process, feces, and, in fatal cases, from kidney and lung tissue. serum can be analyzed by elisa, and pcr can be performed for detection of toxin genes of s. aureus if present. 146 the distribution and incubation periods of 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detection of r. conorii in circulating endothelial cells: a 6-year follow-up differentiation of spotted fever group rickettsiae by sequencing and analysis of restriction fragment length polymorphism of pcr-amplified dna of the gene encoding the protein rompa differentiation among spotted fever group rickettsiae species by analysis of restriction fragment length polymorphism of pcr-amplified dna diagnostic tests for rocky mountain spotted fever and other rickettsial diseases immunohistochemical diagnosis of typhus rickettsioses using an anti-lipopolysaccharide monoclonal antibody monoclonal antibody-based immunohistochemical diagnosis of rickettsialpox: the macrophage is the principal target investigation of foodborne and waterborne disease outbreaks rapid laboratory confirmation of human brucellosis by pcr analysis of a target sequence on the 31-kilodalton brucella antigen dna the 18-kda cytoplasmic protein of brucella species-an antigen useful for diagnosis-is a lumazine synthase characterization of an 18-kilodalton brucella cytoplasmic protein which appears to be a serological marker of active infection of both human and bovine brucellosis genus-specific detection of alphaviruses by a semi-nested reverse transcription-polymerase chain reaction standardization of immunoglobulin m capture enzyme-linked immunosorbent assays for routine diagnosis of arboviral infections toxins as weapons of mass destruction: a comparison and contrast with biological warfare and chemical warfare agents sensitive detection of biotoxoids and bacterial spores using an immunomagnetic electrochemiluminescence sensor key: cord-007321-7gi6xrci authors: chow, anthony w.; hall, caroline b.; klein, jerome o.; kammer, robert b.; meyer, richard d.; remington, jack s. title: evaluation of new anti-infective drugs for the treatment of respiratory tract infections date: 1992-11-17 journal: clin infect dis doi: 10.1093/clind/15.supplement_1.s62 sha: doc_id: 7321 cord_uid: 7gi6xrci these guidelines deal with the evaluation of anti-infective drugs for the treatment of respiratory tract infections. five clinical entities are described: streptococcal pharyngitis and tonsillitis, otitis media, sinusitis, bronchitis, and pneumonia. a wide variety of microorganisms are potentially pathogenetic in these diseases; these guidelines focus on the bacterial infections. inclusion of a patient in a trial of a new drug is based on the clinical entity, with the requirement that a reasonable attempt will be made to establish a specific microbial etiology. microbiologic evaluation of efficacy requires isolation of the pathogen and testing for in vitro susceptibility. alternatively, surrogate markers may be used to identify the etiologic agent. the efficacy of new drugs is evaluated with reference to anticipated response rates. establishment of the microbial etiology of respiratory tract infections is hampered by the presence of “normal flora” of the nose, mouth, and pharynx, which may include asymptomatic carriage of potential pathogens. this issue is addressed for each category of infection described. for example, it is suggested that for initial phase 2 trials of acute otitis media and acute sinusitis tympanocentesis or direct sinus puncture be used to collect exudate for culture. acute exacerbations of chronic bronchitis also present difficulties in the establishment of microbial etiology. these guidelines suggest that clinical trials employ an active control drug but leave open the possibility of a placebo-controlled trial. for pneumonia, the guidelines suggest the identification and enrollment of patients by the clinical type of pneumonia, e.g., atypical pneumonia or acute bacterial pneumonia, rather than by etiologic organism or according to whether it was community or hospital acquired. for each respiratory infection, the clinical response is judged as cure, failure, or indeterminate. clinical improvement is not acceptable unless quantitative response measures can be applied. these guidelines deal with the evaluation of anti-infective drugs for the treatment of respiratory tract infections. five clinical entities are described: streptococcal pharyngitis and tonsillitis, otitis media, sinusitis, bronchitis, and pneumonia. a wide variety of microorganisms are potentially pathogenetic in these diseases; these guidelines focus on the bacterial infections. inclusion of a patient in a trial of a new drug is based on the clinical entity, with the requirement that a reasonable attempt will be made to establish a specific microbial etiology. microbiologicevaluation of efficacy requires isolation of the pathogen and testing for in vitro susceptibility. alternatively, surrogate markers may be used to identify the etiologic agent. the efficacy of new drugs is evaluated with reference to anticipated response rates. establishment of the microbial etiology of respiratory tract infections is hampered by the presence of "normal flora" of the nose, mouth, and pharynx, which may include asymptomatic carriage of potential pathogens. this issue is addressed for each category of infection described. for example, it is suggested that for initial phase 2 trials of acute otitis media and acute sinusitis tympanocentesis or direct sinus puncture be used to collectexudate for culture. acute exacerbationsof chronic bronchitis also present difficulties in the establishment of microbial etiology. these guidelines suggest that clinical trials employ an active control drug but leave open the possibility of a placebo-controlled trial. for pneumonia, the guidelines suggest the identification and enrollment of patients by the clinical type of pneumonia, e.g., atypical pneumonia or acute bacterial pneumonia, rather than by etiologic organism or according to whether it was community or hospital acquired. for each respiratory infection, the clinical response is judged as cure, failure, or indeterminate. clinical improvement is not acceptable unless quantitative response measures can be applied. this is one of a series of disease-specific guidelines that have been prepared to assist sponsors and investigators in the development, conduct, and analysis of studies of new antiinfective drugs. these guidelines deal with the conduct of phase 1 through phase 4 clinical trials and are subsets of the general guidelines for the clinical evaluation of anti-infective drug products, which should be consulted for prerequisites to conducting studies in humans. these guidelines for the evaluation of drugs for the treatment of respiratory tract infections include acute streptococcal pharyngitis and tonsillitis, acute otitis media, acute and chronic sinusitis, acute exacerbations of chronic bronchitis, and acute infectious pneumonia (table 1). the focus is primarily on infections of bacterial etiology, especially those due to respiratory pathogens such as streptococcus pyogenes, streptococcus pneumoniae, haemophilus irfiuenzae, and moraxella (branhamella) catarrhalis and respiratory anaerobes (e.g., bacteroides species, fusobacterium nucleatum, and peptostreptococcus species). readers should consult the specific guidelines for the evaluation of new anti-infective drugs for mycobacterial and fungal infections. the guidelines for clinical microbiology provide important background information and should be used in concert with the current guidelines. the respiratory tract infections considered in these guidelines are among the most frequent disease entities encountered in both children and adults. they are associated with potentially serious morbidity if unattended or treated subop-timally. they also are infections in which evaluation of specific anti-infective therapy may be difficult. the reasons for the difficulties include: (1) routine noninvasive collection of specimens and culture techniques are often inadequate, and specimens are regularly contaminated by the indigenous microflora of the oropharynx and the upper airways; (2) the microbial etiology is often complex and polymicrobial; and (3) newly recognized etiologic agents continue to emerge (e.g. , legionella species, chlamydia pneumoniae, and coxiella burnettii). even with the use of sophisticated sampling and microbiologic techniques, the causative agents can be identified only for a small proportion (60%-80% at best) of patients. furthermore, good clinical practice requires empiric initiation of anti-infective therapy for these conditions (with the possible exception of group a streptococcal pharyngitis) on the basis of a presumptive initial diagnosis before confirmatory microbiologic data are available. frequently, the microbiologic response to therapy cannot be definitively evaluated, even when the etiologic agent has been identified. this is often the case in otitis media, sinusitis, and pneumonia, when the use of invasive procedures such as tympanocentesis, sinus puncture, or transtracheal aspiration to confirm microbial eradication in the patient who is improving clinically generally is considered unjustified. thus, whereas microbiologic failure can be documented by repeat cultures, microbiologic eradication can only be assessed presumptively on the basis of clinical response. the current standards of anti-infective therapy for the respiratory tract infections encompassed in these guidelines are summarized in table 1. in addition to the changing trends in microbial etiology, several controversial areas exist: (1) the clinical significance of ,b-iactamaseproduction among respiratory pathogens and the respiratory tract infections under study should be categorized according to the ageof the patient, chronicity of the disease, and anyunderlying or concomitant disease(s) in the patient. theinvestigational drugshould have in vitroactivity against the specific respiratory tract pathogen to be evaluated in a pathogen-specific studyandactivity against the vastmajority ofstrains ofthemost likely encountered pathogens in a diseasespecific study. evaluation oftheinfluence ofcombination therapy is desirable, as is assessment of the emergence of resistance in vitro. information obtained from studies in animals maybe of assistancein identifying preliminary dosage schedules for humans. evaluations of efficacy in standardized animalmodels of infection may be performed. determination of drug levels in respiratorytract secretions (suchas sinus, middle-ear, or endotracheal aspirates) or in tissue (such as pulmonary parenchyma) is not required because at present the clinical significance of these concentrations is uncertain. institutions should be capable of performing the following studies relevant to the management of respiratorytract infections when appropriate to a specific protocol: nucleic acid probeanalysis foridentification ofselected respiratory pathogens, radiography andcomputerized tomography (ct) and/or magnetic resonance imaging of the head and neck, sinuses, and chest; arterialblood gasdeterminations; tympanocente-sis; sinus puncture; thoracentesis; and bronchoscopy. these studies should be done in addition to routine diagnostic microbiologic testing. alternatively, special studies may be performed at a reference laboratory skilled in these procedures and approved by the appropriate authorities. the preferred design is the randomassignment of patients to the investigational-drug and active-control-drug groups. therandomization schedule shouldbe maintained bya study monitor. patients should be stratified according to age, severity of infection, presence of underlying disease, and concomitant non-antibacterial therapy. blinding of both subjects and investigators to treatment group(double-blind design) is encouraged whenever feasible. in all cases, the inclusion and exclusion criteria should be clearly identified prior to initiation of the study. all patients enrolled in the study should be assessed on the basis of "intention to treat." a uniform approach to clinical and microbiologic assessment duringand after therapy shouldbe implemented. endpointsforbothclinicaland microbiologic evaluation should be clearly stated, and whenever possible a quantitative scoring system should be devised. patient compliance shouldbe verified (e.g., by pill counts or by appropriate assays of drug concentrations in serum or other body fluids). the clinical entity addressed in this guideline is group a j3-hemolytic streptococcalpharyngitis and tonsillitis. not included are clinical cases of pharyngitis due to other agents or cases in which streptococcihavebeen isolated in cultures of throatspecimens but have notbeen documented to be group a j3-hemolytic streptococci. 28 groupa j3-hemolytic streptococcal pharyngitis remains one of the most frequentacute infections seen in ambulatory patients, especially school children between 5 and 8 years of age [1] [2] [3] [4] [5] [6] . antibiotic therapy for streptococcalpharyngitis is aimed not only at symptomatic improvement of the acute infection [7] [8] [9] [10] [11] [12] and the prevention of suppurative complications but also, and most importantly, at the prevention of the subsequent occurrenceof acute rheumatic fever [1, 13] . the incidence of acute rheumatic fever in the united states has declined dramatically overthe past severaldecades, suchthat by the 1980sit wasa rare sequelaof streptococcal pharyngitis [1, 5, 6] . however, between1984and 1986fourmajor outbreaks of acute rheumatic fever in three states resulted in a heightened concern for optimal treatment of streptococcal pharyngitis [14] [15] [16] . penicillin, given orally or intramuscularly, has generally beenconsidered the drug of choiceand the drugagainst which other regimens havemost often been judged. a full 10 days of oral therapy or a single injection of benzathine penicillin is required [3] [4] [5] [6] . shortening a course of penicillin by even a few days has been shown to resultin an appreciable increase in the rate of treatment failure. however, even withthe recommended 10 days of oral therapy, the failure rate may still be high [3] [4] [5] [6] . in recent studies, penicillintherapy, givenorally or intramuscularly, has been associated withratesof microbiologic failure as high as 20%-30%, in contrast to the rates of5%-10% seen 20 years ago. the reasons for this increase are not clear,although the presenceof j3-lactamase-producing organisms in the throat flora and an increasein the tolerance of streptococci to penicillin havebeen suggested as contributing causes. resistanceto erythromycin, a frequently used algroup a j3-hemolytic streptococcalpharyngitiscan not be diagnosed accuratelyon clinical grounds alone because it is frequently difficult to differentiate this entity from pharyngitis caused by other organisms. therefore, diagnosis requires a positiveculture for group a j3-hemolytic streptococcifrom a throatswab specimen in a patientwith symptomatic pharyngitis. alternatively, the diagnosismaybe made by use of one of therapiddiagnostic kitsthatcandetectgroupa j3-hemolytic streptococcal antigen directly from a throat swab specimen [19] [20] [21] [22] . for the purposeof the evaluation of newdrugs, however, the diagnosis shouldbe confirmedwith a throat culture, since the sensitivity (37%-100%, most 60%-95%) and specificity (70%-100%, most >90%) of the rapid detection kits are quite variable [19] [20] [21] [22] . drugsused for the treatmentof group a j3-hemolytic streptococcalpharyngitis shouldhavebeen shown to havebactericidal activity against group a j3-hemolytic streptococci and to haveundergone relevant phase 1 studiesprior to the initiation of clinical investigations. the drug under consideration shouldhave a lowindex of toxicity in bothchildrenandadults, sincea numberof otheragents existthat offer acceptabletherapyfor group a j3-hemolytic streptococciand since streptococcal pharyngitis is usually a minor disease. furthermore, the drug shouldresult in clinical improvement within 24-48 hoursoftheinitiation oftherapy, withresolution offever within 48 hours in uncomplicated streptococcalpharyngitis, as can be expected withpenicillin andother antimicrobial agents currentlyapproved for treatmentof streptococcalpharyngitis [3, [7] [8] [9] [10] [11] [12] . the drug under considerationalso should provide an acceptably low rate of microbiologic failure associated with recurrence or persistent carriage and a rate no greater than that associatedwith current standard therapy with penicillin (10 %-20 %) [3] [4] [5] [6] . the drug shouldbe capableof preventing the suppurative complications of group a streptococcal pharyngitis and, ideally, of preventing rheumatic fever. it would be desirable to have data indicating that the drug is capable ofpreventing rheumatic fever, but it is recognized that this goal may not be achievable. a current concern in the treatment of acute streptococcal pharyngitis is whether the failure rate for penicillin therapy will continue to climb and whether penicillin should still be considered the standard therapy. in addition, there is controversy about when antimicrobial therapy should be initiated. clinical differentiation of group a streptococcal pharyngitis from other causes of sore throat is not alwayspossible, a problem that raises the question of whether antibiotic therapy should be initiated before bacteriologic confirmation is available. furthermore, prompt treatment of group a (3-hemolytic streptococcal pharyngitis has been shown to interfere with the antibody response and possibly to result in a higher rate of recurrence than that seen in patients whose therapy is delayed for a few days [17] . last, controversy exists concerning whether post-treatment cultures should be obtained to detect bacteriologic failures and whether asymptomatic carriage necessitates treatment [18] . patients eligible for study entrance are children or adults with symptomatic pharyngitis or tonsillitis of acute onset clinically consistent with infection with group a i3-hemolytic streptococci and from whom group a (3-hemolytic streptococci have been isolated in cultures of throat -swab specimen or for whom a rapid screening test has indicated the presence of streptococci. to be evaluable for efficacy, the screening test results must be confirmed by culture. the guideline generally applies to ambulatory patients. signs and symptoms of acute pharyngitis or tonsillitis of acute onset include sore throat and evidence on physical examination of inflammation of the uvula and pharynx or tonsils, including erythema, often with edema of the tissues, with or without exudate. fever mayor may not be present. a single culture specimen should be obtained from the posterior pharynx prior to initiation of anti-infective therapy. at least 10 colonies of group a i3-hemolytic streptococci should be present on the culture plate. a throat specimen for culture is obtained with use of a throat swab that is passed over both sides of the posterior pharynx and the uvula [3] . the preferred culture medium is sheep's-blood agar. all cultures negative at 24 hours should be reincubated for another 24 hours. reduced oxygen tension may enhance identification of group a (3-hemolytic streptococci. such a reduction may be achieved in a simple manner by stabbing the agar after the sample is streaked or by using a coverglass pressed onto the primary zone of inoculation [19] . group a streptococci are identified by the bacitracin method or by an-other method of at least equal sensitivity and specificity [3, 19, 21] . if a rapid diagnostic test is used for identification of group a streptococci, the findings must be confirmed by culture [20] [21] [22] . the streptococci obtained on culture should be saved for subsequent typing when possible. the drug under consideration should be active in vitro against group a (3-hemolytic streptococci. the institution or the investigator should have access to a clinical microbiology laboratory where the following tests can be performed: culture of throat swabs on sheep's-blood agar and identification of group a (3-hemolytic streptococci. alternatively, a single laboratory may process samples referred from participating centers. clinical studies should include patients of different age groups, since the clinical manifestations of group a streptococcal pharyngitis and tonsillitis may vary with age of the patient. streptococcal pharyngitis is uncommon in children <3 years of age. classic exudative pharyngitis is most frequently observed in school-aged children. group a streptococcal pharyngitis in teenagers and adults is often atypical. children, adolescents, and adults of both sexes should be included. for other considerations, see general guidelines, section ix. it is not considered ethical to use a placebo control. an active control drug should be used. the control agent should be selected on the basis of previous experience demonstrating that it is among the most effective agents for the treatment of group a (3-hemolytic streptococcal pharyngitis at standardized and well-tolerated doses. the study should compare the trial drug with the active control drug. the treatment regimens should be randomized and of a double-blind design whenever possible. phase 1 studies shouldprovide adequateinformation concerning dose, dosage interval, andotherpharmacokinetic characteristics. the usefulness of monitoring concentrations in serumor other bodyfluids or tissuesshouldhave been determined. the form of the drug (liquid, tablet, capsule)should be acceptable for patients of any age included in the study and should be an accurate dose (e.g., no cutting of tablets required). theusualtreatment coursewithstandard regimens (e.g., penicillin or erythromycin) is 10days. the optimalduration of therapy with the study drug maybe determined by additional studies. the initiation of therapy should be standardized, i.e., at the time of clinical diagnosis or at the time of culture confirmation. ifit proves necessary to add a seconddrug or to substitute a newantimicrobial drug, treatment is considered to have failed clinically. in the eventof allergy to or failure of either drug being evaluated, the patient shouldbe treated with an alternative, standard active drug. response should be evaluated by both clinical and bacteriologic assessment. clinical assessment should include history andphysical examination. documentation of the clinical response with regard to symptoms and signs, including fever, shouldbe obtainedat 3-5 days after initiation of therapy and at weekly intervals (±2 days) thereafteruntil the patient is asymptomatic. the 3-to 5-day assessment may take the form of a telephone call. patients should be observed posttherapy for a sufficient time to permit detection ofrelapse of disease and/orpost-streptococcal nephritisor carditis. the periodof post-treatment evaluation will varywithknowledge of the durationof anti-infective activitysubsequent to terminationof administration of the test drugs. asa generalguide, patients shouldbe followed-up for 2-4 weeks after termination of therapy. evaluation of thebacteriologic response requires a repeated throatcultureat the firstfollow-up visit, within4-7 days after the end of therapy, and at any time clinical symptoms recur. additional posttreatment throatculturesmaybe necessary for patients treatedwith drugs known to remain in serum or tissue for intervals beyond the initial4-to 7-day evaluation. all organisms recovered should be saved for typing if possible. groupa streptococci recovered duringtherapy or at the time of the follow-up visit should be evaluated for their in vitro susceptibility to the study drug. theserologic response to groupa~hemolytic streptococci may be evaluated in acute-and convalescent-phase sera for titersofantibody to streptolysin-o (aso) or otherstreptococcal antigens. serologic evaluation, however, is not required for evaluation of drug efficacy. compliance shouldbe evaluated by the return of all medicationcontainers andof anyremaining drugat the endoftherapy. documentation of drug in the urine or blood may also be used to assess compliance. (1) definition ofclincial response. clinical cureis defined as complete disappearance of signs and symptoms without recurrence; clinical cure with recurrence is defined as the development of symptomatic pharyngitis documented to be causedbygroupa~hemolytic streptococci beforeor during follow-up in patients who were asymptomatic at the initial follow-up assessment; and clinical failure is defined as lack of any response to therapy. (2) definition of microbiologic response. microbiologic eradication is defined as eradication of group a ,8-hemolytic streptococci at the initialand subsequent follow-up examinations; microbiologicpersistence is defined as failure to eradicate group a ,8-hemolytic streptococci at the time of initial follow-up; andmicrobiologic relapse is defined as initialsuppression of groupa~hemolytic streptococci withsubsequent positive cultures for group a ,8-hemolytic streptococci. thefinal assessment of efficacy maybe categorized according to both clinical and microbiologic criteria as in table 3. otitis media is the most frequent diagnosis recorded for infants and children who visit physicians because of illness [23] . before 3 years of age more than two-thirds of children have had one or more episodes of acute otitis media (aom) and more than one-third have had three or more episodes [24] . the highest incidence of aom is in children 6-24 months of age. the incidence declines with age except for a limited reversal of the downward trend at the time of entry into day care or school. although middle-ear infection is considered uncommon in adults, a recent survey identified almost 4 million visits to physicians by adults each year for this problem [25] . males have a significantly increased risk for aom, and native americans and canadian and alaskan eskimos have high rates and severe disease. incomplete data suggest that american blacks have fewer episodes of ear infection than do members of other racial groups in the united states. early occurrence of the first episode of aom, sibling history of recurrent aom, not being breast fed, and attendance in day care are all associated with increased risk for recurrent aom [24, 26] . since aom and secretory otitis media (som) are defined by the presence of middle-ear effusion (mee), techniques to determine the presence of air or fluid in the middle ear are critical to diagnosis. three methods are available: the standard technique of pneumatic otoscopy, typanometry, and acoustic reflectrometry. tympanometry uses an electroacoustic impedance bridge to record compliance of the tympanic membrane (tm) and provides objective evidence of the status of the middle ear and the presence or absence of fluid. technical difficulties limit the use of tympanometry in children during the first 6 months of life. the acoustic otoscope or reflectometer is a hand-held instrument that utilizes principles of reflected sound waves to diagnose the presence of air or fluid in the middle ear. the microbiology of aom has been documented by appropriate cultures of mee obtained by needle aspiration. many studies have been performed in the united states, scandinavia, and japan. the bacteriologic results are consistent in demonstrating the importance of s. pneumoniae, h. influenzae (90 % nontypable, 10% type b), and m. catarrhalis [27] . s. pneumoniae is the most important bacterial cause of otitis media and is defined in mee of about one-third of children with aom. otitis media due to h. irfiuenzae has been associated with 20%-30% of cases of aom, and rv20%-30% ofthese strains produce j3-lactamase. m. catarrhalis has been isolated from mee in 7%-20% of cases of aom, and a majority of these strains produce j3-lactamase. virologic and epidemiologic data suggest that viral infection frequently is associated with aom. mycoplasma pneumoniae does not appear to playa role in aom, although some patients with lower respiratory tract disease due to m. pneumoniae may have con-comitantaom. c. trachomatis is a cause of aom but almost exclusively in infants <6 months of age. the microbiologic diagnosis of aom can be made only by aspiration of mee. this procedure should be done only by persons skilled in the technique. cultures of throat and nasopharyngeal swab specimens are of no value because they are neither sensitive nor specific when compared with culturs of isolates from the middle ear. the results of cultures of middle-ear fluids from the two ears are disparate in rv20 % of cases of aom (e.g., effusion from one ear may be sterile while the effusion from the other yields a bacterial pathogen, or different bacterial pathogens are isolated from the two ears). therefore, for evaluation of new drugs or vaccines, it is important that each diseased ear be aspirated for a complete microbiologic assessment and that outcome for each ear be evaluated separately [28] . suppurative sequelae such as mastoiditis and other infratemporal and intracranial complications occur but are uncommon in developed countries. hearing loss is the most important complication of aom and mee. patients with mee suffer from hearing loss of variable severity. on average, a patient with fluid in the middle ear has a 25-decibel hearing loss. since intellectual development is dynamic during infancy, when the incidence of aom is highest, there is concern that any impediment to reception or interpretation of auditory stimuli might have an adverse effecton development of speech, language, and cognitive abilities. some studies suggest that children with histories of recurrent aom have lower scores in tests of linguistic and cognitive abilities than do their diseasefree peers [29] . the clinical entity discussed in this guideline is limited to aom (synonyms include acute suppurative om and acute purulent om). the microorganisms considered are s. pneumoniae, h. infiuenzae, and m. catarrhalis. not included in this guideline are secretory otitis media and chronic suppurative otitis media. som is defined as the presence of mee behind an intact tm without acute signs or symptoms (synonyms include chronic om with effusion, persistent mee, om with effusion, and serous om). chronic suppurative om is defined as chronic discharge from the middle ear through a perforation of the tm (synonym includes chronic om). tympanocentesis and culture of mee is required for microbiologic diagnosis of aom. nose and throat cultures are of no value. tympanocentesis is a safe procedure when performed by skilled and experienced persons. the procedure provides not only specific microbiologic diagnosis but also symptomatic relief of acute pain by decompressing the em 1992;15 (suppl 1) middle-earabscess. there is transientpain during the few seconds of the procedure. rare untoward events may occur, including bleeding, tearing of the tympanic membrane, and ossicular dislocation. approximately one-third of children with aom caused by a bacterial pathogen improve without treatment with antibacterial drugs. clinical resolution may occur because the contents of the middle ear are spontaneously discharged, either through the eustachian tube or by means of a spontaneous perforation of the tm. with appropriate antimicrobial therapy, however, signs and symptoms of aomimprovewithin48-72 hours. mee maypersist (even though sterile) for weeks to months after onset of aom. the goals of antimicrobial therapy for aom are the rapid resolution of signs and symptoms of disease; sterilization of the mee; prevention of suppurative sequelae; reduction of the occurrence of relapse and recurrences; and decrease in time spent with mee. the preferredantimicrobialagent for the patient with aom must be active againsts. pneumoniae, h. irfluenzae, and m. catarrhalis. group a streptococci, staphylococcus aureus, gram-negative enteric bacilli, and anaerobic bacteria are infrequent causes of aomand need not be considered in initial therapeutic decisions. amoxicillin or an equivalenthas been the standard regimenfor aomsinceit is effective againstmost strains of the three major pathogens and is well tolerated, producing limited adverse effects. however, since at present 20%-30% of h. irfluenzae strainsand 50%-70% of m. catarrhalis strains in the united states produce~-lactamase, ã -lactamase-stable agent (such as amoxicillinplus a~-lacta mase inhibitor, a second-or third-generation cephalosporin) or a combination such as trimethoprim-sulfamethoxazole or erythromycin/sulfisoxazole may also be used. clinical trials with these agents indicate that all regimens are of approximately equal clinical efficacy when the bacterial pathogens are susceptible [30] . the control drug chosen for a clinical trial should be among the most effective and safe agentsavailable for treatment. it is expected that an effective agent will sterilize the middle-ear fluid of bacterial pathogens in >80% of infected ears within 72 hours. a second aspiration of middle-earfluidshouldbe consideredfor anypatientfor whom the outcome at 72 hours is clinical failure. chemoprophylaxis has been shown to be of value in the prevention of acute illness in children who have had recurrent aom [31] . more than 10 studies in which a penicillin, a sulfonamide, or erythromycinwas used haveidentifiedprotective efficacy against new episodes of aom in 60%-90% of cases in comparisons with a placebo control group. the changing susceptibilitypatterns of bacterial pathogens associatedwith aomwarrant considerationof new and effectivedrugs with activityagainstall major pathogens. newdrugs should have advantages over currently available agents, including (1) ease of administration to ensure compliance and greater conveniencefor the patient (e.g., once-a-day dosing, drug stabilityat room temperature, prolongeddrug shelf-life); (2) reduced incidence of relapse and recurrence; and (3) reduced duration of mee after resolution of acute signs and symptoms. newdiagnostic instrumentswith improvedcapacity for examinationof the middle ear (of most importance is diagnosis of the presence of fluid in the middle ear) also are needed. even the most experienced otoscopists are accurate in diagnosing the presence of mee in only rv80% of cases. tympanometryand acoustic reflectometry are of value in assisting the otoscopist but are insufficiently sensitive and specific to assure accuracy of diagnosis for all children enrolled in clinical trials. a noninvasive technique for determining the organisms present in mee is needed for the facilitation of appropriate microbiologic diagnosis and optimal use of approved drugs. currently, only needle aspiration of the fluid from both middle ears assures definition of the etiologicagentsof aom. patients eligible for inclusion in studies will be children or adults with symptomsand signs clinicallycompatiblewith aom. (1) clinical criteria. aom is defined as inflammation of the middle ear evidencedby the presence of fluid and accompanied by specific signs or symptoms such as ear pain, ear drainage, hearing loss, or nonspecific findings such as fever, lethargy, irritability, anorexia, vomiting, or diarrhea. thepresence ofmee is definedby pneumatic otoscopy with or without use of tympanometry or acoustic reflectometry. (2) microbiologic criteria. specific microbiologic diagnoses of aom can be determinedonly by aspirationof mee. both ears should be aspirated when the patient has bilateral aom. tympanocentesis is a standard procedure and is described in various texts on otolaryngology [32] . the procedure should be performed only by qualified personnel with previous experience. nose and throat cultures are of no value in the microbiologic diagnosis of aom since they are neither sensitive nor specific for predicting bacteria present in mee. specimens for such cultures may be obtained from selected patients for monitoring change in susceptibility patterns of nasopharyngeal or oropharyngeal isolates during the course of antimicrobial therapy. the drug under consideration should have proven in vitro activity against s. pneumoniae, h. injluenzae, and m. catarrhalis. group a streptococci, s. aureus, gram-negative enteric bacilli, and anaerobic bacteria are infrequent causes of adm and need not be considered in initial therapeutic decisions. in vivo evidence of sterilization of bacterial pathogens should be obtained with use of an appropriate dosage schedule in an animal model of adm. the chinchilla has been used most frequently in assessments of pathogenesis and therapy and should be considered for such in vivo studies. the investigator or the institution should have access to a clinical microbiologic laboratory where personnel can perform the following tests: culture of mee for the isolation and identification of common pathogens in adm and in vitro susceptibility testing, including tests for ,b-iactamase production. the institution should have appropriate facilities and investigators experienced in middle-ear examination and aspiration of mee. clinical studies should be conducted with patients of different age groups and racial backgrounds. in newborns and infants up to 6 weeks of age, the bacterial pathogens in adm differ from those in older children and include organisms acquired during delivery. in addition, pharmacologic considerations are different for older infants and children. the incidence of adm is highest between the ages of 6 and 24 months. the risk for adm is significantly increased in males, native americans, and canadian and alaskan eskimos, and the risk may be lower for black americans than for white americans. children, adolescents, and adults of both sexes should be included in studies. phase 1 evaluations may include singledose administration before tympanocentesis to assess the penetration of drug into middle-ear fluids. initial clinical studies should not include children with focal anatomic, physiologic, or systemic immune defects; children who had received a systemic antimicrobial agent within the past 7 days for treatment of an illness other than adm; and neonates or infants <12 weeks of age. the control agent should be selected on the basis of expected patterns of in vitro susceptibility of the most common pathogens (s. pneumoniae, h. injluenzae, and m. catarrhalis) in the community. because of the difficulties in obtaining reliable cultural information in adm even under protocol conditions, it may be appropriate to adopt a sequential study strategy: (1) a small (r'-ji00 patients) phase 2 trial can be conducted in which mee aspiration and culture is performed for all patients to document the unique microbiology of the population to be studied. in vitro antimicrobial susceptibility testing should be performed for all mee isolates, and both clinical and presumed microbiologic outcome should be assessed (see definitions below). repeat aspiration ofmee is required only if there is evidence of clinical failure. in the phase 2 trial, an "open" uncontrolled study may be conducted. because the number of centers that perform tympanocenteses is presently limited and a second aspiration of mee cannot be recommended for children who are clinically cured or improved, the microbiologic response is correctly termed presumptive eradication. clinical and presumed microbiologic efficacyfor a minimum of 60 patients with documented adm, with 20 cases each due to the three major bacterial pathogens (s. pneumoniae, h. injiuenzae, and m. catarrhalis, respectively) should be sufficient to determine whether the drug is effective on an organism-specific basis. both organism-specific and disease-specific responses should be evaluated. for the purpose of organism-specific evaluation, a minimum of 20 isolates from~20 patients is required for evaluation. (2) if the preliminary assessment is favorable (i.e., a clinical and presumed microbiologic response rate of~80 %), a larger, comparative phase 3 trial with an active control should be conducted. a double-blind study design is desirable whenever feasible; in any event, the evaluator should be blinded. aspiration of mee for microbiologic diagnosis before treatment is desirable but not required, but aspirates from those patients who fail to respond clinically are required. all drugs will be provided to the patient by the investigator or his or her designee. for young children unable to swallow tablets or for those with a small body mass, the use of a suspension or other acceptable formulation is necessary for accurate dosing. it is not anticipated that addition of a new antimicrobial agent will be required. if there is clinical failure (see definition below) after 72 hours of therapy, tympanocentesis should be performed; modification of antimicrobial therapy will be based on the data obtained from culture and from susceptibility testing. both clinical and presumed microbiologic responses should be assessed. after enrollment, observations should be made 3-5 daysafter initiation of therapy and at least 2 and 4-6 weeks later. the precise period of posttreatment evaluation will vary according to knowledge of the anticipated duration of antiinfective activity subsequent to termination of administration of the test drugs. at each visit an interval medical history should be obtained and otoscopic examination, including tympanometry or acoustic reflectometry, should be performed to determine the status of the middle ear. during reexaminations, children should be assessed for other foci of infection and for adverse effects of the test drug. the treatment outcomes for the study and control groups should be compared according to the proportion of patients in the following outcome categories: (1) clinical cure with presumed microbiologic eradication; (2) clinical failure with microbiologic persistence; and (3) clinical relapse or recurrence. (1) definition of clinical response. clincal cureis defined as resolution of signs and symptoms (e.g., pain, fever, vomiting), exclusive of mee, within 72 hours in a child who remains well throughout the course of therapy and follow-up. clinical failure is defined as lack of resolution of signs and symptoms, exclusive of mee, within 72 hours of onset of therapy. relapse is defined as reappearance of signs and symptoms of adm after initial response during or within 4 days of conclusion of therapy. recurrence is defined as reappearance of signs and symptoms of adm~5 days after the conclusion of therapy. (2) definition ofmicrobiologic response. it is recognized that whereas the microbiologic response can be accurately assessedonly by repeat aspirationsof mee during or after com-pletion of antimicrobial therapy, repeat tympanocentesis in a patient who is clinically improving is generally not warranted. all patients for whom outcome is classified as clinical failure, relapse, or recurrence should undergo repeated aspiration of mee before their antimicrobial regimens are toms of acute sinusitis are often difficult to distinguish from those of the common cold or from allergic (vasomotor) rhinitis. the most common complaints are cough (80 %) and nasal discharge (75 %). parents often notice a malodorous breath among preschoolers (50% of cases) who have neither signs of pharyngitis nor poor dental hygiene [34, 35] . in adults, postnatal purulent discharge and facial pain over the affected sinus that worsens with movement or percussion are the cardinal symptoms [36, 37] . fever occurs in <50% of cases. hyposmia, jaw pain with mastication, nasal congestion, and a history of recent upper respiratory infection are other manifestations. in patients with nosocomial sinusitis secondary to prolonged nasotracheal intubation, the clinical features, except for unexplained fever, may be relatively silent. symptoms associated with chronic sinusitis are usually less intense but more protracted than those in acute sinusitis. fever is uncommon. fatigue, general malaise, and an ill-defined feeling of unwellness and irritability can be more prominent than local symptoms of nasal congestion, facial pain, or postnasal drip [38] . the precise microbial etiology of sinusitis can be determined only by direct aspiration of the sinus, since nasopharyngeal secretions are regularly contaminated by the indigenous flora and culture results correlate poorly with results for sinus aspirates [36, 39] . this difficulty may limit the ability to make a definitive assessment of the microbiologic response to anti-infective therapy. s. pneumoniae and unencapsulated h. influenzae are responsible for >50% of cases of acute sinusitis in adults, while m. catarrhalis in addition to s. pneumoniae and h. influenzae account for two-thirds of cases in children [34, 39, 40] (table 4 ). s. aureus is a common nasal contaminant and an infrequent cause of acute sinusitis. obligate anaerobes are uncommonly isolated in acute sinusitis. in contrast, the microbiology of chronic sinusitis is usually logic persistence, emergence of resistance, or superinfection and optional determinations of drug concentrations in mee for such patients; (3) repeated hematologic, hepatic, and renal function studies as appropriate; (4) monitoring of change in susceptibility patterns of bacterial isolates in nasoor oropharyngeal culture specimens for selected patients; and (5) recording of allergic or toxic reactions or important adverse effects, which will be grounds for terminating the use of either the study drug or the standard drug. patients should be followed up clinically and by otoscopy biweekly until mee has completely resolved. repeated aspiration of mee should be performed for patients with clinical relapse or recurrence. the time to resolution of mee should be recorded. laboratory studies to monitor resolution of infection and adverse reactions should be repeated according to the protocol. c. sinusitis sinusitis is a common disorder both in children and adults. approximately 0.5 % of upper respiratory infections in children are complicated by acute sinusitis, and 0.02 % of adults have chronic sinusitis. because of the location and rich vascular supply of the sinuses, these infections are potentially life-threatening in that intracranial suppurative complications may result, including epidural or subdural empyema, brain abscess, or cavernous sinus thrombosis. early diagnosis and effective antimicrobial therapy are critical for the prevention of such complications as well as chronic sequelae. the paranasal sinuses are lined with ciliated pseudo-columnar epithelium and are connected to each other through small tubular openings, the sinus ostia, which drain into various regions of the nasal cavity. the paranasal sinuses are generally considered to be sterile, although transient colonization by the resident upper respiratory flora does occur [33] . conditions that affect the patency of the sinus ostia, .the normal mucociliary function of the sinus epithelium, or immune defenses of the upper airways or events that facilitate direct introduction of microorganisms into the paranasal sinuses are the key predisposing factors to sinus infection [34] . such conditions include viral upper respiratory tract infections, respiratory allergies, alterations in mucus (e.g., cystic fibrosis), and selective deficiencies in immunoglobulins. dental extraction or periapical infections of the maxillary molar teeth are a particularly important cause of maxillary and chronic sinusitis. the clinical manifestations of sinusitis vary greatly depending on the duration of infection (i.e., acute or chronic) and the age of the patient (i.e., child or adult). in children, symp[41, 42] . viridans streptococci and nonencapsulated h. infiuenzae are the major aerobic isolates. nosocomially acquired sinusitis secondary to head trauma or prolonged nasotrachea1 intubation is commonly causedbypolymicrobial gram-negative bacilli and s. aureus as well as by anaerobes [43] . fungal sinusitis is rare, but aspergillus, mucor, candida, pseudoallescheria boydii (scedosporium spiospermum) and other saprophytic fungi can cause invasive diseaseusually in the debilitated host. although antecedent viral upper respiratory infection is an important cause of acute sinusitis, viruses (e.g., rhinovirus, influenza, parainfluenza, and adenovirus) are isolated only in 15%of antralaspirates [39] . the clinical entities included in this guideline are acute sinusitis (symptoms present for~4 weeks) and chronic sinusitis (symptoms present for~3 months). not included in this guideline are subacute cases (symptoms lasting 1-3 months), whichhave a variable naturalhistory and in which the bacterial etiology is poorly defined. the goals of antimicrobial therapy for acute sinusitis are (1) the eradication of the causative pathogens; (2) the provision of symptomatic relief; (3) the restoration and improvementof sinusfunction; and (4) the prevention of intracranial complications and chronic sequelae. although many management options are available, antimicrobial agents are the mainstay of therapy for acute sinusitis. the therapeutic efficacy of anti-infective agents for acute sinusitis hasbeenestablished by placebo-controlled clinical trials [44] and in studies that employed sinus aspiration before and after treatment [39, 45] . standardtherapy is usuallyselected on anempiricbasisanddirected against themost likely pathogens, including h. infiuenzae, s. pneumoniae, and m. catarrhalis (see table 4 ). oral therapy with a j3-lactam agent suchas ampicillin for 10-14 days is generally prescribed and is considered the standardregimenfor acute sinusitis in bothchildren and adults. a favorable rate ofclinical response of70%-80% canbe expected withthisregimen. in penicillinallergic patients, a second-generation cephalosporin (e.g., cefaclor), a macrolide/sulfonamide (e.g., erythromycin/sulfisoxazole) or trimethoprim/sulfonamide (such as trimethoprimsulfamethoxazole) combinations have yielded comparable results. penicillins (such as amoxicillin plus a j3-lactamase inhibitor) or cephalosporins thathavea more-extended spectrum have not yielded superior results in controlled trials [44] [45] [46] even though theprevalence ofj3-lactamase-producing strains among respiratory pathogens appears to be increasing(upto 20% ofh. influenzae strains, 50%-70% ofm. catarrhalis strains,and20%-30% of respiratoryanaerobes) [47] . in 'patients with chronic sinusitis, surgical procedures to facilitate sinus drainage through the creationof an artificial ostium and submucosal resection of diseased tissue appear to be the mainstays of treatment. the role of anti-infective agents in chronic sinusitis is not as clear as that in acute sinusitis. conservative therapy with anti-infective agents or sinusirrigationwithout surgical intervention is successful in onlyone-thirdof cases [36, 48] . withcombined medicaland surgical treatment, the curerate forchronicmaxillary sinusitis is >60% after 3 years of follow-up [48] . anti-infective agents useful forchronic sinusitis should have broad-spectrum activity against respiratory anaerobes as well as against viridansstreptococci, s. pneumoniae, h. influenzae, and m. catarrhalis. several issuesin the management of acute and chronic sinusitis remain controversial. these include: (1) the optimal duration of therapy for acute and chronic sinusitis; (2) the clinicalrelevance of the increasing prevalence of in vitro resistanceto j3-lactam agents among upper respiratorypathogens; (3)the roleofrespiratory allergy in recurrent or chronic sinusitis; (4) the value of adjunctive measures such as oral or topical decongestants, antihistamines, and intranasal steroids in the treatment of acuteand chronic sinusitis (such measures must be standardized in both study and control groups during initialassessment of new antibiotic regimens for both acute and chronic sinusitis); (5) the optimal mode of surgical management in chronic sinusitis (i.e., preservation of sinus epithelium vs. radical mucosal resection); (6) avoidance of the need for sinus puncture by the use of endoscopic sinoscopy for performing quantitative cultures. patients eligible for study will be children or adults with symptoms and signs clinically compatible with acute or chronic sinusitis. (i) clinical criteria. acute sinusitis is defined as inflammation of the sinuses associated with symptoms lasting~4 weeks. clinical findings suchas fever, headache, malartenderness, andnasal discharge (which are often nonspecific) should be supported by objective localizing studies such as radiography, ultrasonography, or ct. transillumination of the s75 sinuseshas a relatively low sensitively (74%) and specificity (47%) for acute sinusitis [39] and should not be used as the solediagnostic criterion. transillumination is alsoless informativein children<6 years of age (40% concordanceand 20% discordance compared with radiographic findings) because of either poor cooperationof the child in performingthe test or thedevelopmental variations of the sinuses in this agegroup [34] . anterior rhinoscopy mayrevealhyperemicand edematous nasal turbinates, often with purulent dischargefrom the middle meatus where the orifices of the maxillary, frontal, andanteriorethmoidal sinusesenterthe intranasal cavity [49] . imaging studies (roentgenography, ultrasonography, or ct) should be performed in all cases. other laboratory studies suchas neutrophil count, erythrocyte sedimentation rate, and c-reactive protein should also be performed. chronic sinusitis is definedas inflammation of the sinuses associated with symptoms lasting >3 months that are compatiblewithradiographic abnormalities (determined byroentgenography, ultrasonography, or ct). if possible, chronic sinusitis should be confirmedby endoscopic sinoscopy with direct visualization of the sinusmucosa, appropriatemicrobiologic sampling, and histopathologic evaluation [49, 50] . (2) microbiologic criteria. the precise microbial etiology of sinusitis can be determined only by direct aspiration or injection wash of the sinus cavity. cultures of the surface of the nasal vestibule or the nasopharynx are unreliable becauseof their regularcontamination bythe residentmicroflora and should not be used for assessment of microbiologic efficacy of study regimens. access to the maxillary sinus can be obtainedintranasally througha puncturebelow the inferior turbinate and to the frontal sinus through a puncture below the infraorbital rim oftheeye. thorough cleansing of thepuncture site with an appropriate antiseptic is important to minimize contamination of the specimen with surface bacteria. if no fluid is obtained, 1 ml of sterile normal saline without bactericidalpreservativeshouldbe instilledand the washings reaspirated. specimens should be sent to the laboratory for leukocytecounting, gram staining, and culture for aerobes, anaerobes, fungi, and mycobacteria. viral cultures are of investigational interest. withthe appropriate technique, >76% of such specimenswill yield positivecultures in acute maxillary sinusitis [40] . furthermore, if organisms are seen on gram-stained preparations of antral secretions, a presumptive diagnosis can be made by assessing the bacterial morphotype in up to 90% of cases [51] . quantitative cultures (~103 cfu/ml of aspirate) are usefulin distinguishing true infection from colonization or contamination [39, 52] , but such studies are labor-intensive and are not required for microbiologic diagnosis in clinical trials. in chronic sinusitis, microbiologic diagnosis can be confirmedby cultureof diseasedmucosaobtainedby biopsyduring endoscopicsinoscopy or surgery. in such cases, the culture results should be correlated with the histopathologic findings to exclude the possibility of specimen contamination. for a pathogen-specific evaluation, the drug under consideration should haveprovenin vitro activity against the specific bacteriaprevalent in sinusitis, and for a disease-specific evaluation (i.e., acute vs. chronic, pediatric vs. adult), the drug should havea broad range of activity against the most prevalent pathogens. the investigator or subinvestigator should have the necessary skillsto perform sinuspuncturefor microbiologic evaluationsof acuteandchronicsinusitis and endoscopic sinoscopy for studies of chronic sinusitis. the institution should have the facilities and personnel with expertise to perform and interpret radiographs, ultrasonography, or ct and microbiologic studies of the paranasal sinuses. clinical evaluation of new treatment regimens should be conducted with patients grouped by specified age, underlying disease, duration of symptoms, and presence or absence of respiratory allergy. since these factors appear important both in predictingthe microbial etiologyand in overallprognosis,their contribution to treatmentoutcomeshouldbe carefully controlledby appropriate randomizationduring patient enrollment or by stratification eitherprospectively or posthoc during analysis of results. children, adolescents, and adults of both sexesare eligible for inclusion. patientswho havereceivedother antimicrobial therapy within the preceding 2 weeks, patients with hypersensitivity reactions to drugs of a similar class, and patients with other concurrent, acute infectious illnesses should be excluded. in acute sinusitis, an active control regimen with proven efficacy againsts. pneumoniae, h. injluenzae, and m. catarrhalis shouldbe used. in chronicsinusitis, a placebo-controlled trial is consideredjustified since the role of antimicrobial therapy for this condition remains unclear at this time. because of the difficulties in obtaining reliable cultural information about sinusitis even under protocol conditions, it may be appropriate to adopt the following sequential study strategy. (1) conduct a small (rvloo patients) phase 2 trial in which sinus puncture and culture is performed for all patients to document the unique microbiology of the intended study population, with at least 20 cases of each of three major bacterial pathogens implicated (s. pneumoniae, h. irfiuenzae, m. catarrhalis). in vitro antimicrobial susceptibility testing of all sinus isolates should be performed. both clinical and presumed microbiologic outcomes are assessed (see definitions below). repeated aspiration of the sinus is required only if there is evidence of clinical failure. in the phase 2 trial, an "open" uncontrolled study may be conducted, although a randomized comparative double-blind trial with an active control is still desirable despite the clearly inadequate size of the sample for meaningful comparisons of clinical response rates. a conrolled comparison provides additional information regardmg the expected response rate in a particular community. both organism-specific and disease-specific responses should be evaluated. for purposes of organism-specific evaluation a minimum of 20 isolates from~20 patients is required for evaluation. (2) if the preliminary assessment is favorable (i.e., a clinial and presumed microbiologic response rate of~70 %), it is reasonable to conduct a larger, comparative phase 3 trial with at1 active control. sinus puncture for microbiologic diagnosis and sinus radiography before treatment are desirable but not required, but examination of aspirates and sinus radiographs is necessary for those patients who fail to respond clinically. in vitro antimicrobial susceptibility testing should be performed for all isolates from cultures. use of adjunctive medications such as oral or nasal decongestants, antihistamines, or intranasal steroids should be standardized such that hey~re used either in both the study and control groups or in neither of the groups. similarly, in studies of chronic sinusitis, the mode of concomitant surgical therapy (i.e., endoscopic sinuscopy with limited mucosal curettage vs. a more conventional approach of radial mucosal resections) should also be standardized or stratified. the projected sample size must include consideration of the expected difference in efficacy of the study and control regimens, the expected proportion of cases due to each of the major bacterial pathogens (and that one-fourth of all cases of acute sinusitis are due to nonbacterial causes that would not be affected by either antibacterial agent), and an anticipated rate of spontaneous clinical cure of rv30 %among children with acute sinusitis [34] . the treatment course is usually 10-14days for acute sinus-itis. si.nce the opt~mal duration of therapy has not been clearly estabhshed for either acute or chronic sinusitis, this could be the mainfocus of evaluationin phase 4 trials. patients should be assigned randomly to the test or "control" group, and if p~e~reatment cultures of the sinuses are not performed, the chmcal and presumed microbiologic response should be evaluated by a blinded observer. for children unable to swallow tablets or whose body mass is small, either a suspension or an acceptable alternative formulation of the study drug or the control drug is necessary for precise dosing. modification of the study by the addition of a new antimicrobial agent may be necessary if the clinical response after 3-5 days of therapy is suboptimal. in such instances sinus aspiration for documentation of the microbiologic response is required before the therapeutic regimen is modified. addition of a new antimicrobial agent constitutes a clinical failure of the initial treatment regimen. both clinical and presumed microbiologic responses should be~s~:ss.ed. clinical evaluation should be made 3-5 days after imuation of therapy and weekly or biweekly thereafter until the resolution of all symptoms and signs. use of a scoring system, pa:ticularly a binomial (yes/no) objective scoring system, for signs and symptoms such as fever, pain, headache, tenderness, nasal discharge, and purulence is strongly encouraged. imaging studies (roentgenography, ultrasonography, or ct) should be repeated at least at the completion of antimicrobial therapy. patients with chronic sinusitis should be further assessed by repeated endoscopic sinoscopy before or after completion of therapy. information about concentrations ?f dru~in sinus aspirates or mucosal biopsies may be of value iii studies of chronic sinusitis, but they are not critical to studies of efficacyin acute sinusitis and are not required for final evaluation. since a repeat of sinus puncture is generally not justified in patients who have responded clinically to therapy, the microbiologic response in such patients can only be judged presumptively. comparisons of treatment outcomes in the study and control groups should be made according to the proportion of patients in the following outcome categories: (1) clinical cure with presumed microbiologic eradication; (2) clinical failure with microbiologic persistence; (3) clinical and/or microbiologic relapse and recurrence; and (4) indeterminate. (1) definition ofclinical response. clinical cure is defined as complete resolution of signs and symptoms at the conclu-sio~of antimicrobial therapy and at follow-up. clinical failure is defined as lack of improvement in signs and symptoms within a defined period of therapy (72 hours for acute sinusi-sn tis and 2 weeksfor chronic sinusitis). earlyrelapse is defined as reappearane of signsand symptoms or newclinicalfindings of sinusitis within 14daysafter the conclusionof therapy. late relapse is definedas the reapearrance of signs and symptoms or new clinical findings of sinus infection after 14 days but within 1 month after the conclusion of therapy. (2) definition of microbiologic reaponse. presumed microbiologic eradication is definedas cases in whichpretreatment cultures of sinus aspirates were positive, clinical signs and symptoms resolvecompletely, and posttreatmentculturesare not performed because clinical response is complete. confirmed microbiologic response is defined as cases in which the causativeorganismcannot be isolated in cultures of sinus aspirates performed after 72 hours of antimicrobial therapy. such repeated cultures of sinus aspirates are likely to be performed only in the setting of clinical failure. a statement as to microbiologic eradication is not possible because of the influence ofconcomitantantimicrobial therapy. microbiologic persistence is defined as a positive culture of sinus aspirates after at least 72 hours of antimicrobial therapy. if a pretreatment culture of sinus aspirate was performed and was positive, the isolation of the same organism after~72 hours of therapy is considered confirmed microbiologic persistence. if no pretreatment culture of sinus aspirates was performed, isolation of a pathogen after~72 hours of treatment is considered presumptive microbiologic persistence. superinfectionis defined as the emergenceof new or resistant organisms in cultures of sinus aspirates after~72 hours of antimicrobial therapy. (1) initial clinical evaluation and imaging (roentgenography, ultrasonography, or ct) of the paranasal sinuses; (2) hematologic, hepatic, and renal function studies; (3) sinus puncture and microbiologicstudies for phase 2 trials and optionallyfor phase 3 trials; and (4) endoscopic sinoscopy, bacterial cultures,andoptionaltissuebiopsyfor studiesof chronic sinusitis. (b) assessment during the course of therapy should include: (1) clinical evaluation at 2-3 and 5-7 days after initiation of antimicrobial therapy, and weekly or biweekly thereafter until resolution of all symptoms and signs; (2) aspiration of sinuses for microbiologic studies for patients who fail to respond clinically after at least 72 hours of antimicrobial therapy to define microbiologic persistence, emergence of resistance, or superinfection; and (3) repeated imaging, hematologic. hepatic, and renal function studies as appropriate. patients should be followed up clinically and with imaging for at least 2 weeksafter completionof antimicrobial therapy to assess relapse or recurrence, clinical complications, and adverseeffects of the antimicrobialregimen. sinus aspiration should be performed for those patients with clinical relapse or recurrence. bronchitis is an inflammatory conditionof the tracheobronchial tree. it is both acute and chronic and is caused by a variety of irritants and infectiousagents. productive cough is the commondenominator of this condition, and the sputum produced ranges from mucoid to frankly purulent. acute bronchitis is generally an infectious process. it occurs in all age groups and is most common in the winter months, when acuterespiratory infections are prevalent. most cases are thought to be due to respiratory viruses, including those associatedwith the common cold and other respiratory viruses involved in infections of the lower respiratory tract (e.g., adenovirus, rhinovirus, coronavirus, influenza, parainfluenza, respiratory syncytial virus, coxsackievirus). m. pneumoniae, c. pneumoniae, and legionella specieshave also been implicated in some cases. the frequency of infection due to these pathogens is not certain. chronic bronchitis generally is defined as a condition characterized by cough and excessive secretion of mucus in patients who have coughed up sputum on most days during 3 consecutive months for >2 successive years. this disease is caused by prolonged exposure to pulmonary irritants, the mostprominentof whichis cigarette smoke.atmospheric pollution also playssome role, as do recurrent episodes of infection. chronic bronchitis results in widely ranging degrees of respiratoryembarrassment. in its most severe forms, obstructive pulmonary disease, emphysema, and respiratory failure occur. patientswith chronic bronchitis frequently experienceepisodes of acute disease superimposedon the chronic process. these exacerbationsare characterized by some combination of increasing cough, sputum volume and purulence, and respiratory distress. the role of infectionin these episodes has been difficult to define. the bacterial speciesmost oftenmentioned as potential etiologic pathogens include s. pneumoniae, typable(especially typeb)and nontypable h. irfiuenzae, and m. catarrhalis. however, the same organisms, particularly haemophilus species, can be isolated from the respiratory secretionsof patientswith chronic bronchitiswho do not present with evidence of acute exacerbation [53] . gump et al. did report an association between purulence of sputum and an increase in the number of pneumococciin the sputum em 1992;15 (suppl 1) of patients with acute exacerbations [54] . haemophilus parainfluenzae, viridans streptococci, and strains of enterobacteriaceae also are isolated from patients with acute exacerbations of bronchitis, but their pathogenic role is even less welldefined. viruses, m. pneumoniae, c. pneumoniae, andperhapslegionella speciesplayan etiologic role in some cases of acute exacerbations. the only clinical entity included in this guidelineis acute exacerbation of chronic bronchitis. considerable controversy surrounds the use of antibacterial agents for patientswith acute exacerbations of chronic bronchitis [55, 56] . tager and speizer [57] reviewed the existing studies in 1975 and concluded that the role of antimicrobial agentsin the management of these patients needed reassessment and that respiratory infections appeared to contribute to worsening of episodesof coughand productionof sputum. a recent double-blind randomizedplacebo-controlled study by anthonisen et al. [58] showed a significant clinicalbenefit in association withantibacterial therapy. the recovery of peak air flow wasmore rapid and the rate of clinicaldeteriorations requiring therapeutic intervention was lower in antibiotictreatedpatients. response to treatment wasevidenced by the trilogy of decreased dyspnea, sputum volume, and sputum purulence. treatment success wasdefined as resolution within 21 days of all symptoms that accompanied the exacerbation. no attempt at microbiologic confirmation wasperformed in this study. antibacterial agentsutilizedin thetreatmentgroup included trimethoprim-sulfamethoxazole, amoxicillin, and doxycycline. althoughcontroversy aboutpossiblemicrobialpathogenesis persists, most clinicianselect to treat the acute exacerbations as infectious events and direct that therapy at s. pneumoniae andh. influenzae and, morerecently, at m. catarrhalis. the duration of therapy is generally 7-10 days. it should be recognized that up to 25%of strains of h. influenzae and 50%-70% of m. catarrhalis strains produce (3-lactamase. the etiologicrole of viruses, m. pneumoniae, c. pneumoniae, and legionella in acute exacerbations of chronic bronchitis needs clarification. determination of their role will be facilitated by the application of more sensitive and specific microbiologic diagnostic techniques (e.g., nucleic acidprobes, polymerase chain reactions, antigen detection). patients eligible for study will primarily be adults with symptoms and signscompatible with acute exacerbations of chronic bronchitis. (1) clinical criteria. patients must (a) havehad a chronic cough and sputumproduction for >2 consecutive years and on mostdaysfor 3 consecutive monthsand (b) haveevidence of acute exacerbation as indicated by some combination of increasedcough and/or dyspnea, increased sputumvolume, or increased sputum purulence. (2) microbiologic and other laboratory criteria. these criteria include (a) negative chest roentgenogram to rule out pneumonia; (b) productionof purulent sputumas defined by the presence on a gram-stainedpreparation of >25 polymorphonuclear leukocytes and <10 squamous epithelial cells per low-power magnification (x 10) field(thepresenceofpredominant bacterialmorphology maybe noted); (c) documentation of the presence or absence of potential bacterial pathogens and monitoringof emergenceof resistant isolates during antimicrobial therapyby sputumcultureand susceptibility tests. the drug under consideration should have provenin vitro activityagainsts. pneumoniae, h. influenzae, and m. catarrhalis. dosage ofthe studydrugmustbe determined by means of pharmacokinetic and in vitro studies. the investigator or subinvestigator shouldhavethe necessary skills to assesspulmonary functionand interpret radiographicstudies. the institution shouldhave adequate facilities for performance of laboratorystudies, including hematologic, hepatic, andrenalfunction testsandstudies ofpulmonary function, especially arterial blood gas analysis, forced vital capacity, fev! (forcedexpiratory volumein 1 sec), total lung capacity, and peak flow spirometry. 5 . design and implementation of phase 1, 2, and 3 clinical trials onlyadultpatients(~18 years)with stablechronicpulmonary disease should be included. patients who are experiencing an acute exacerbation of chronic bronchitis are eligible. patients with cystic fibrosis, patients unable to give informed consent, and patients with a known history of hypersensitivity to the study or control drug should be excluded. steroid use is not necessarily a criterion for exclusion. even though the use of antibacterial agents for treatment of acute exacerbations of chronic bronchitis is controversial, the presence of s. pneumoniaeand other potential pathogens in some patients and the concomitant need for corticosteroids in some patients suggest the need for an active control drug. both control and study drugs should be active in vitro against s. pneumoniae, h. influenzae type b, and m. catarrhalis. placebo-controlled trials may be conducted. in phase 1 studies, human pharmacologic and pharmacokinetic studies should demonstrate sufficient absorption and achievement of peak serum concentrations that exceed the mic90 for the major respiratory pathogens. in phase 2 and 3 trials, study patients should be stratified according to major host factors (e.g., history and duration of smoking). whenever feasible, studies should be prospective, randomized, and of double-blind design. no additional antimicrobial agent is permitted. concurrent medications (e.g., bronchodilators) should be administered in the same manner to study and control groups. the study patients may be stratified according to the use of concomitant steroid therapy. another strategy might be to design a four-arm randomized comparison: (1) study drug with steroids; (2) control drug with steroids; (3) study drug with no steroids; and (4) control drug with no steroids. in projecting a sample size, consideration must be given to the expected difference in efficacy of the study and control regimens and the desirability of undertaking poststudy subset analysis of pertinent patient variables. variables include (1) the presence or absence of adjunctive treatment; (2) the presence or absence of fever; (3) status of pulmonary function; and (4) characteristics of sputum. duration oftreatment is generally 7-10 days. however, the optimal duration of therapy could be a main focus of evaluation. in comparative studies, patients should be assigned randomly to the test or "control" group, and insofar as possible, the study should be blinded. for patients who do not demonstrate clinical improvement (i.e., decreased dyspnea, cough, and volume and purulence of sputum production) or whose clinical conditions worsen after 3-5 days of treatment, clinical failure will be declared and such patients will be removed from the study. the addition of an antimicrobial agent that is not a study drug will also result in a designation of clinical failure. clinical response and results of pulmonary function tests and/or arterial blood gas analyses can be used to assess efficacy. the effect of treatment on sputum microbiology will be monitored. failure to eradicate a potential pathogen in a patient with a complete clinical response is common in this disease. the bronchial secretions of many patients remain "colonized" after the acute episode resolves. all patients entered into the study should be assessed on the basis of intent to treat. the clinical response in both the study and control group will be classified as (1) clinical cure, (2) clinical improvement (which requires measurement of an objective end point, e.g., volume and/or purulence of sputum), (3) clinical failure, and (4) indeterminate. patients will be evaluated at 3-5 days after initiation of treatment, and weekly thereafter. (1) definitions ofclinical response. clinical cureis the resolution of acute symptoms and signs to a baseline level of dyspnea, cough, sputum production, and, if elevated at enrollment, resolution of fever. clinical improvement is the subjective improvement in dyspnea, with reduction in cough, a quantified reduction in 24-hour volume or purulence of sputum, and a return of the temperature to normal if the patient is initially febrile. clinicalfailure is the lack of any resolution in the magnitude of the dyspnea, sputum purulence, or fever (if present) that prompted enrollment of the patient in the study. clinical response indeterminate should be substantitated by stated reasons. the clinical response definition may be supported by improvement or lack of improvement in sequential measurements of the patient's white blood cell count, oxygen saturation, and/or pulmonary function tests. (2) definitions ofmicrobiologic response. the categories of microbiologic response commonly encountered include eradication, persistence, relapse, reinfection, and superinfection consult general guidelines, section xiii.c, for detailed definitions. (1) initial history and physical examination should be performed just before enrollment. (2) chest radiography should be performed to rule out pneumonia. (3) hematologic, hepatic, renal, pulmonary function, and arterial blood gas studies (with room air) should be performed. (4) gram stain and ern 1992;15 (suppl 1) culture of sputum plus determintion of 24-hour sputum volume should be performed; nucleic acid probes and culture for mycoplasma and legionella may be included. (1) at a minimum, patients should undergo clinical evaluation 3-5 days after initiation oftherapy and weekly thereafter until completion of therapy. (2) for febrile patients the body temperature should be determined a minimum of four times daily. (3) quantitation of the volume of sputum produced daily and/or daily assessments of the degree of sputum purulence may assist in assessment of the patient's clinical response. (4) it is helpful to monitor patient's arterial blood gases and/or expiratory flow rates at periodic intervals. the precise frequency depends on the individual protocol (e.g., every 3-5 days for hospitalized patients and perhaps once during therapy for outpatients). (5) repeated chest radiographic, hematologic, hepatic, and renal studies are appropriate at 3-5 days after treatment has begun and within 48 hours after the end of treatment. (6) a sputum culture during therapy is indicated if there is evidence of clinical failure. in individual patients, such cultural data may be useful in identifying the emergence of bacterial resistance or in documenting failure to eradicate a potential bacterial pathogen (e.g., s. pneumoniae). patients should undergo clinical and microbiologic assessment within 48 hours, 7-14 days, and 21-28 days after completion of therapy. the clinical assessment should include assessment of cough, dyspnea, sputum volume, and sputum purulence. oximetry to determine oxygen saturation and spirometry should be performed. a chest radiograph is not required unless clinically indicated, since the presence of a pulmonary infiltrate precludes enrollment. sputum should be submitted for gram staining, culture, and sensitivity testing, or-in the case of mycoplasma or legionella infections -for nucleic acid probe tests. lower respiratory tract infections include bronchitis, bronchiolitis, and pneumonia and its complications. the relative frequency of isolation of various etiologic agents that cause community-acquired pneumonia differ according to age group, socioeconomic status, underlying disease, time of year, and possible concomitant viral illnesses. prospective studies of the causes of community-acquired pneumonia are often difficultto interpret because of imprecise methods of microbio-logic diagnosis, such as reliance on sputum culture and/or serologic testing. however, it is generally accepted that in north america viral agents (e.g., respiratory syncytial virus and parainfluenza virus type 3) are most important for children <5 years of age. the inability to obtain sputum from infants and children is a major deterrent to microbiologic diagnosis of pneumonia in this population. m. pneumoniae is considered to be a major cause of community-acquired pneumonias in north americans 5-25 years of age. in older individuals, mycoplasmas and viruses are less common causes, while bacterial agents are more prevalent. a majority (50%-90%) of cases of pyogenic pneumonia with acute onset in middle-aged or older adults are due to s. pneumoniae [59, 60] . pneumonias due to h. injtuenzae (either ampicillin-susceptible or ampicillin-resistant), s. aureus, mixed aerobicanaerobic bacteria, and aerobic facultative gram-negative bacilli such as klebsiella pneumoniae, in rank order, are less common. legionella species, (determined primarily on the basis of serologic studies) account for a variable proportion of cases of community-acquired pneumonia in adults (e.g., in 1% of patients not requiring hospitalization and in 5 %-20 % of those hospitalized). legionella species probably account for 10%-15 % of cases of so-called atypical pneumonia [61, 62] . other agents that cause nonpyogenic, or atypical, pneumonia include m. pneumoniae, c. bumetii, c. pneumoniae, and, rarely, chlamydia psittaci. in classic pneumonias, the isolation of certain pathogens can often be linked to certain specific conditions of the host (e.g., infection with group a ,6-hemolytic s. pyogenes, s. aureus, h. irfiuenzae, or s. pneumoniae following influenza). both typable and nontypable strains of h. influenzae are pathogenic primarily among smokers, patients with chronic obstructive pulmonary disease (copd), and some patients with lymphoma or other malignancies. aspiration pneumonia in the community is believed to involve mostly the normal oropharyngeal aerobic and anaerobic flora. in the nursing home or nosocomial setting, infections with aerobic gramnegative bacilli and s. aureus are additional considerations in aspiration pneumonia. data for nosocomial pneumonias prior to 1988 from the centers for disease control (cdc) may not be completely reliable because they appear to be based primarily on results of sputum cultures and cultures of endotracheal suction specimens. nonetheless, the rank order of pathogens in the last reported cdc survey of nosocomial infections is pseudomonas aeruginosa (16.9%), s. aureus (12.9%), klebsiella species (11.6%), and enterobacter species (9.4%), followed by escherichia coli, serratia marcescens, and proteus species [63, 64] . data based on the results of transtracheal aspiration performed on members of a high-risk population of elderly men in a veterans administration hospital and nursing home in the 1970s give a different perspective on nosocomial pneumonia. bartlettet al. [65] relied only on isolates from blood cultures, pleural fluid, andtranstracheal aspirates. they found gram-negative bacilliin about one-halfof 159 patients studied, anaerobes (peptostreptococcus species were the most common isolates) in about one-third, and s. pneumoniae in about one-fourth. klebsiella species were the most commonly isolated gram-negative aerobic bacilli. the isolates were polymicrobial in about one-half of the patients. gram-negative bacilli are morelikely to be involved in nosocomial pneumonia in high-risk populations, such as those in intensive care units, than in other patients. outbreaks of nosocomial pneumonia dueto someorganisms, including aerobic gram-negative bacilli and organisms not usually appreciated as nosocomial pathogens, may present particular problems. thelattergroupincludes s. pneumoniae, ampicillin-resistant h. infiuenzae, and m. catarrhalis [66] [67] [68] . the timely use of appropriate systemic antibacterial therapyshould eradicatethe pathogen in a largenumberof cases of pneumonia and lead to a reduction in morbidity as well as mortality. efficacy ofnewagents should at leastequalthose of established regimens when evaluated in prospective, randomized, controlled trials (active treatmentconcurrentcontrol) [69, 70] . if l3-lactamase-producing pathogens are suspected (e.g., h. influenzae), both the study and control drugs should have in vitro activity against such pathogens. theefficacy ratesfora newdrug for etiologic agents andclinicalsyndromes in which thereis noestablished therapy should at least equal those in recent historical controls. data from open studies may be useful in these instances. dataobtained frompartsoftheworldotherthanthe united states may be considered supporting evidence of efficacy. however, possible regional differences in resistance patterns mustbe notedandmay preclude directcomparison (e.g., appreciably higher resistance to penicillin g among s. pneumoniae strainsisolated in south africa and to erythromycin in spain than in north american isolates). the local antimicrobial susceptibility patterns will clearlybe the predominant influence on the choice of concurrentactive treatment control regimens. (1) clinical entities to be included are common communityacquired or nosocomial bacterial pneumonias. clinical entities not included are bronchitis, bronchiolitis, lowerrespiratory tract infections in patients withcystic fibrosis, lowerrespiratory tract infections caused by infrequent and/or difficultto-diagnose entities (e.g., infections withanaerobic bacteria; psittacosis, qfever, tularemia, andplague; andinfections with mycobacteria, viruses, or fungi). (2) microorganisms included in the guideline are s. pneumoniae (prototype), h. injluenzae, s. aureus, facultative aerobic gram-negative bacilli, pseudomonas species, m. pneumoniae, and legionella species. the diagnosis of infectious pneumonia combines clinical, laboratory, andmicrobiologic data. a compatible clinical picture (fever, cough, and/orauscultatoryfindings such as rales and/or evidence of pulmonary consolidation) together with confirmatory chestradiographic findings and isolationof the causative pathogen(s) from suitable respiratory specimens (e.g., expectorated sputum, transtracheal aspirate,bronchial washings or lavage, pleuralfluid) or bloodestablishes the diagnosis of bacterialpneumonia. pneumonia due to m. pneumoniae is identified by culture or nucleic acid probe and/or by documentation of a fourfold or greater rise in titer of complement-fixing antibody. detection of cold agglutinins does not establishthe diagnosis. the diagnosis of legionella pneumonia requires isolation of the organism from sputum, a bronchoalveolar lavage specimen, pleural fluid, or blood. alternatively, legionella antigen may be detected by immunofluorescence in respiratory secretions or byradioimmunoassay in urine. also, legionella maybe detected in respiratorysecretions withnucleic acidprobes. testing forantibody in acute-and convalescent-phase sera, except for antibody to l. pneumophila serogroup 1, is not specific enough for reliablediagnosis oflegionellosis, especially in areas of lowdisease prevalence. diagnostic methods for detection of c. pneumoniae are under development. the bacterialpathogens isolated shouldbe tested for susceptibility to antimicrobial agents by standardized methods. determinations of mbcs, postantibiotic effect, or effect of subinhibitory concentrations of antibiotics are notdone routinely andare notgenerally required forassessment of efficacy. when mycoplasma or legionella is isolated, antimicrobial susceptibility testing is not done routinely. selection of empiricantimicrobial therapy is based on the suspected pathogens and their anticipated susceptibility in vitro. penicillin g remainsthe drug of choice for almostall s. pneumoniae infections in the unitedstates [71] . ampicillin or a cogeneris the drug of choice for pneumonia due to non-sdactamase-producing h. injluenzae. aspiration pneumonia acquired in the community is treated with penicillin g, usually without the benefit of culture results. a lincosamide or a combination of a penicillin and a 13-lactamase inhibitor are alternatives. a macrolide (e.g., erythromycin) or tetracycline is preferred forpneumonia dueto m. pneumoniae or c. pneumoniae, and erythromycin is the choice for legionella infections [61, 72] . a semisynthetic penicillinaseresistantpenicillin is the treatment of choicefor pneumonia dueto methicillin-sensitive s. aureus. a combination ofa suitable cephalosporin or penicillin and an aminoglycoside is frequently employed for infections due to facultative gramnegative rods or to pseudomonas. in most other instances of community-acquired pneumonia, combination therapy is usually not required. oral preparations of the aforementioned parenteral compounds or oral drugs with comp~able in vi.tro activity can be used in milder cases. the optimal duration of therapy varies, but uncomplicated s. pneumoniae pneumonia is usually treated for 7-10 days [71] . for treatment of nosocomial pneumonias (e.g., associatew ith ventilator use), combination therapy with an extendedspectrum penicillin or cephalosporin and an aminoglycoside is commonly employed. initial therapy must be directed at the suspected pathogens in a given hospital and their known susceptibility profile. determination of the concentration of antimicrobial agent(s) in serum, other bodily fluids, or tissues is not done routinely. most often, cure is defined by clinical criteria alone. with resolution of the inflammatory process, the patient is unable to provide secretions from the lower airway for documentation of eradication of the causative pathogen. patients requiring tracheostomy or endotrachĩ ntubation may have persistent, presumably tracheal, colomzation with an etiologic organism after the criteria for clinical cure of pneumonia are met. relief of endobronchial obstruction and/or drainage of empyema fluid remains a mainstay of therapy for lower respiratory tract infections. the probability of cure for s. pneumoniae pneumonia is variable and ranges from 95 % in uncomplicated infection to (\)50%-80% with bacteremic disease [71] . relapse is not a significant problem with s. pneumoniae. newer methods for more precise microbiologic diagnosis of pneumonia, such as the use of semiquantitative cultures of protected endoscopic brushings or bronchoalveolar lavage specimens, are promising.· the practice of changing parenteral therapy to therapy with an oral agent such as a fluoroquinolone after 5-7 days is gaining increasing acceptance, as is the use of intravenous antimicrobial therapy in the home for follow-up management. it is likely that the number and precision of diagnostic techniques that rely on antigen detection or nucleic acid detection will increase. patients eligible for study are adults and children of both sexes with confirmed or presumptive diagnosis of communityacquired or nosocomial pneumonia. these guidelines may be adapted to treatment of patients in either a hospitalized or ambulatory setting or for patients that progress from hospital to an outpatient setting. (1) clinical criteria. patients must have signs and symptoms consistent with bacterial pneumonia (chest pain, cough, and/or ausculatory findings such as rales and/or evidence of pulmonary consolidation) with or without fever (oral temperature >38°c [100.4of]) or leukocytosis (blood leukocyte count >10,000/mm 3 or >15% band forms), and there must be radiographic or other laboratory evidence that supports the diagnosis (see below). (2) microbiologic and otheretiologic (noncultural) criteria. specimens obtained by expectoration or by endotracheal aspiration should be screened microscopically for suitability of culture (presence of >25 polymorphonuclear leukocytes and <10 squamous epithelial cells/low-magnification field [x 10]). suitable specimens should be cultured aerobically in appropriate media. blood specimens should be cultured for all patients, and pleural fluid, if present, should be aspirated, examined by microscopy, and cultured for both aerobes and anaerobes. the microbiologic diagnosis of infectious pneumonia is confirmed by the following criteria: (a) purulent expectorated sputum-identification of a predominant suspected pathogen by culture and/or microscopy (e.g., with s. pneumoniae by finding an average of >10 lancetshaped diplococci/oil-immersion field [x 1,000] for 10 fields examined) (material from endotracheal suctioning may also be used, and slides should be saved and made available as part of the case record) or (b) transtracheal aspirate, bronchial brushings, or biopsy material (obtained under direct visualizationwith a fiberopticbronchoscope, preferablydoublesheathed) -gram stain reveals neutrophils and a predominant pathogen is suspected by smear or culture; quantitative cultures of endobronchial brushes from potentially infected ventilator-dependent patients may be of value; (c) pleuralfluid or direct lungaspirateidentification of a predominant pathogen on gram stain or by culture; (d) positiveblood cultureyields a pathogen in a patient with a compatible clinical syndrome of bacterial pneumonia in the absence of another source of bacteremia. ifan organism is isolated, it should be susceptible to both the study and the control drug. clinical improvement or stabilization must be documented by 72 hours to permit retention in the study. (e) surrogate markersdetection of antigen or specific nucleic acid by non-culture methods may be used as a surrogate marker of infection. culture or other non-cultural methods for confirmation ofthe diagnosis of pneumonia must follow within 24-72 hours of starting therapy to retain the patient in the study. isolation by culture is not required for the diagnosis of pneumonia due to m. pneumoniae, legionella, or c. see general guidelines, section ii.d. use of accepted animal models for pneumoniacaused by specific pathogens is desirablefor evaluations of dosage, duration of therapy, achievable serum concentrations, and comparisons with other agents for efficacy and relative toxicity, as described in general guidelines, section ii.e. determinations of levels of antimicrobial agents in respiratory tract secretions and tissue are optionalsince there is a lack of accepted interpretation of results physicians should be available who are competent in the following procedures: bronchoscopy, endobronchial protectedbrush sampling, bronchoalveolar lavage, and thoracentesis. in addition to standard clinical microbiology, the laboratory should have access to nucleic acid probes for detection of legionella and mycoplasma, detectionof legionella species antigen, and determination of titers of specific antibody to mycoplasma and legionella. for most studies, adults (18-65 years of age) and elderly patients (~65 years of age) will be the prototype groups to be studied. additional potential study populations are neonates, infants, children, and immunosuppressed patients. male andfemale patients willbe included. pregnantor lactating women will be excluded. patientswith severeunderlying diseases (e.g., aids, metastatic tumor, shock) will be excluded. patients are excluded if they have received prior therapy witha potentially effective anti-infective agentfor~24 hours. see generalguidelines, sectionix, for additional details. it is notconsidered ethical to usea placebo control in studies evaluating the efficacy of a new anti-infective drug for treatment of pneumonia. active or historical controls are needed to assess the relative value ofthenewdrug. thehistoricalcure rate of uncomplicated (nonbacteremic) pneumonia due to s. pneumoniae in healthy hosts is 1'\j95 %. whenever feasible, the use of a control drug is desirable. the control anti-infective agent should be a drug, or one of several drugs, approved for pneumonia and still recognized by authoritative publications as "standard" treatment. other considerations are discussedin the general guidelines, section x. whenever possible, the study design shouldbe randomized, prospective, and double-blind. see general guidelines, sections x and xi, for details. the spectrumof organisms that causepneumoniais the result of the interplay of multiplehost factors and environmental factors. only somedeterminant factors in the host-parasite relationship are understood, e.g., the presenceor absence of oropharyngeal binding sites for microorganisms, patientage, immune status prior to infection, aspiration of oropharyngeal secretions, concomitant chronic diseases and/or organ failure, or damageto nonspecific or specific portions of the host defenses against microbial invasion. in a given patient, one or more factors may apply. (1) community-acquired vs. hospital-acquired pneumonia. thetraditional distinction between community-acquired and hospital-acquired pneumonia has blurred. traditional community-acquired pathogens, such as s. pneumoniae or l. pneumophila, are now recognized as causes of hospitalacquired pneumonia. patients with chronic diseases, e.g., lung, heart, renal, and/or hepatic failure, are cared for with increasing frequency outside of the hospital. these disease statesincrease the likelihood of colonization ofthe oropharyngeal secretions with facultative gram-negative bacilli and, hence, increase the risk of pneumonia due to this class of organisms traditionally associated withnosocomial pneumonia. (2) patient selection based on clinical category. because of this blurring between community-and hospital-acquired pneumonia, it is reasonable to select patients as trial candidateson thebasisofthe clinical picture. the greaterthehomogeneity of the randomized population of patients with pneumonia, the greaterthe likelihood thetrial results willhave clinicalimport. somepatientsmay fit in more than one category. suggested categories for patients with pneumoniaare presented in table 5. by necessity, the categories are arbitrary and will requireperiodic revision as new insights into pathogenesisemerge. in clinicaltrials ofpatientswhopresent with signsand symptoms of atypical pneumonia, mostpatients enrolled will be ambulatory. in trials of acute bacterial pneumonia, mostpatients willbehospitalized. atthetimeofpatient for statistical considerations, it is strongly recommended that patients be stratified into no more than three clinical categories of pneumonia. for example, in a comparative trial of two parenteral drugs with an appropriate spectrum of activity, patients could be categorized in one of three categories, i.e., acute bacterial pneumonia, aspiration pneumonia, or respirator-associated pneumonia, and then randomized. subsequent to the end of the study, patient response can be analyzed by type of infecting organism, presence of organ failure, severity of pneumonia, and other factors. alternatively, a trial may be designed to study the response of only those patients who meet the clinical criteria for atypical pneumonia. in this example, no stratification would occur prior to randomization. (3) compromised host. pneumonia, and other infections in the compromised host, is discussed in detail in the guide-lines on infections in the febrile, neutropenic patient. the compromised host mayor may not be neutropenic, have inadequate immunoglobulins, or exhibit abnormal lymphocyte function. a wide variety of opportunistic pathogens cause pulmonary infection in the compromised patient. development of a pulmonary infiltrate in a patient with a hematologic malignancy (e.g., leukemia or lymphoma) is a grave prognostic sign and requires an urgent, aggressive, and carefully planned approach to diagnosis and management. for example, local signs of infection in patients who are neutropenic often are fewer and less severe than those in the non-neutropenic person. frequently, neutropenic patients have distant sites of infection from which organisms may have disseminated to the lungs. no symptoms, signs, or roentgenographic features are specific for a given opportunistic infection in the compromised patient. noninfectious pulmonary pathologic conditions are common in this population and may mimic infection. these include radiation pneumonitis, drug toxicity, involvement by the underlying malignancy, pulmonary hemorrhage, pulmo-nary infarction, and congestive heart failure. concurrentand sequential infections of the lung are commonin this population, making the relationship of disease manifestations to a single pathogen difficult to ascertain. early diagnosis is often critical for these patients. guidelines used for diagnosis by examination of pulmonary infiltrates in healthy patients maynot be applicable for diagnosisin patients whoare compromised. for example, severely neutropenic patients may not have neutrophils in their sputum despite having significant bacterial or fungal pneumonia, and for some pathogens the sputum culture may be negative despitethe presenceof invasive lung infection (e.g., aspergillus pneumonia) ..the diagnosis of pulmonary infection in the compromised host may require the performance of an invasive procedure, e.g., percutaneous needle aspirationof the lung, transtracheal aspiration, bronchial lavage and brushingfor quantitative bacteriology, transbronchial biopsy, or open lung biopsy. pneumonia in the compromised patient may be rapidly fatal-hence, the need for empiric antimicrobial therapy. in addition, it is oftennecessaryto reduce the dosageof the immunosuppressive therapeuticagent. thus, the combinedexpertise of all involved physicians is desirable. the duration of treatmentvaries with the clinical category of pneumonia, with the results of blood cultures, and with the status of host defenses. for acute bacterial pneumoniain noncompromised hosts, it maybe desirable to treat until the patient's temperature has returnedto and remained in the normal range for a specific period, e.g., 3-5 days. the possible routesof administration and conversion fromone routeof administration to another are discussed in the general guideline, section xii. see general guidelines, section xii.f. clinical evaluation is based on resolutionor improvement of clinicaland laboratory signsof infectionsuch as fever and leukocytosis, purulent sputumproduction, and radiographic lung infiltrates. hospitalized patients will be assessed every day during treatment and within 5-7 days after completion of treatment. bodytemperaturewill be measuredat least every 8 hours during treatment, and the peak temperature for eachdaywillbe recorded. measurements ofvital signs(blood pressure, heart, and respiratory rates) will be obtained before enrollment and on each day at approximately the same time. the character of the sputum (color, consistency, volume, and number of neutrophils per low-magnification field [x 10d will be recorded when the patient enters the study and at regular intervals thereafter. arterial blood gas determinations will be performed as clinicallyindicated. a chest radiographwill be obtained 3 days after initiationof therapy, within 72 hours of completion of therapy, and at any other time the investigator deems necessary. the location and extent of pneumonic involvement (e.g., segmental, lobar) and the presenceof pleural effusion must be notedand recorded. whenever possible, the same radiologist (or a panel of radiologists) from the sameinstitutionshould interpret all radiographs. other special radiographic studies (e.g., ct scan) will be obtained as clinically indicated. repeated culturesof respiratory tract secretions,if obtainable, will be performed at48-72hoursafterinitiation oftherapy, within 72 hours of the completion of therapy, and whenever clinically indicated. standardized susceptibility testing (disk diffusion or broth dilution) will be performed on all isolates considered potentially significant. blood cultures will be repeatedif initially positiveor if the patient fails to respond to treatment. collectionof specimens that require the use of semi-invasive techniques (e.g., collection of pleural fluid, transtracheal aspiration, bronchoscopy) should be repeated onlyif the clinicalresponseis suboptimal. tests for surrogate markers will be repeatedif these were originally used for diagnosis. for all patients a posttherapy evaluation is necessary for collecting information that will assist in makinga precise assessmentof the patient's clinical and microbiologic response to therapy. patients who have received at least 5 days of therapy and at least 80% or more of prescribed medicationwill have an assessment of clinical response. (1) clinical cure is defined as complete resolution of all signs and symptoms of pneumonia and improvement or lack of progression of all abnormalities on the chest radiograph. (2) clinical failure is defined as anyof the following conditions: persistence or progression of all signs and symptoms after 3-5 days of therapy; development of new pulmonary or extrapulmonary clinical findings consistent with active infection; persistence or progression ofradiographic abnormalities; deathdue to pneumonia; or an inability to complete the study because of adverse effects. (3) indeterminate indicates that extenuating circumstances preclude classification as cure or failure. (2) definition of microbiologic response (1) microbiologic eradication is defined as elimination of the original causative organism(s) from the same site (e.g., expectoratedsputumor normally sterile body fluids such as pleural fluidor blood)during or upon completion of therapy. (2) presumed microbiologic eradication is defined as absence of appropriate material for culture (e.g., sputum or pleural fluid) for evaluation because the patient has improved clinically and does not produce sputum or because repeated aspiration of pleural fluid is not clinically justified. (3)microbiologic persistence is defined as failure to eradicate the original causative organism(s) from sites previously listed, whether or not signs or inflammation are present. (4) microbiologic relapse is defined as recurrence of pulmonary infection with the same organism(s) within 5 days after discontinuation of treatment or during treatment after two consecutive cultures have been negative. (5)superinfection is defined as development of a new lower respiratory tract infection (documented by fever, chest radiograph, and/or auscultatory findings) during treatment or within 3 days after treatment has been completed that is due to a new or resistant pathogen not recognized as the original causative organism(s). (6) colonization is defined as the development of a positive sputum culture that yields a bacterial strain other than the primary causative isolate that appears >48 hours after initiation of therapy, persists in at least two repeated cultures, and is not associated with fever, leukocytosis, persistence or progression of pneumonia, or evidence of infection at a distant site. (7) eradication and reinfection is defined as elimination of the initial infecting pathogen followed by its replacement with a new species or with a new serotype or biotype of the same organism in sputum, pleural fluid, or blood in the presence of signs or symptoms of infection after completion of therapy. for new or additional antimicrobial therapy because of continued infection at the original site in the absence of microbiologic data. (9) indeterminate is defined as circumstances in which it is not possible to categorize the microbiologic response because of death and the lack of opportunity to perform further cultures, the withdrawal of the subject from the study before follow-up cultures can be obtained, incomplete microbiologic data, or concurrent treatment of the patient with a potentially effective anti-infective agent that is not part of the study protocol. the name of the agent and the dose and duration of this therapy must be recorded. the duration of therapy will affect decisions about patient evaluability and outcome. (10) otherconsiderations-when more than one pathogen is present, a separate analysis must be made for each organism. (a) baseline assessment (1) blood for initial cultures, respiratory tract secretions (sputum), and/or pleural fluid, and/or surrogate markers of infection will be obtained. a complete history and physical examination will be performed. (2) tests of hematologic, re-nal, hepatic, and pulmonary function will be performed. (3) radiographic studies such as chest radiography or ct scanning will be performed. arterial blood gas determinations and other tests, such as a diagnostic bronchoscopy, will be done if clinically indicated. (1) culture of sputum will be repeated at 48-72 hours if available; blood cultures will be repeated at 48-72 hours if initially positive. semi-invasive tests will be repeated only if there is a suboptimal clinical response. (2) hematologic, renal, hepatic, and pulmonary function tests will be repeated on days 3-5 of therapy and at least every 5-7 days during therapy. (3) antimicrobial concentrations in blood will be determined if possible, but pharmacokinetic studies of respiratory secretions and other body fluids are optional. (1) if sputum is available, follow-up cultures should be done within 72 hours after completion of therapy. (2) hematologic, renal, hepatic, and pulmonary function tests will be repeated at 72 hours after completion of therapy. (3) chest radiography will be performed within 72 hours of completion of therapy, but other imaging (e.g., ct) and semi-invasive studies (e.g., bronchoscopy) will be performed only if the clinical response is suboptimal. response to therapy will be judged by a combination of clinical and microbiologic criteria and analyzed by intention to treat. clinical response is paramount. comprehensive review of morbidity and mortality trends for rheumatic fever, streptococcal disease, and scarlet fever: the decline of rheumatic fever streptococcal disease world-wide: present studies and prospects beta-hemolytic streptococcal diseases streptococcal pharyngitis pharyngitis: management in an era of declining rheumatic fever streptococcal pharyngitis in the 1980s effect of penicillin and aureomycin on the natural course of streptococcal tonsillitis and pharyngitis comparative effects ofpenicillin, aureomycinand terramycin on streptococcal tonsillitis and pharyngitis effect of treatment on streptococcal pharyngitis: is the issue really settled does penicillin make johnny's strep throat better? streptococcal pharyngitis: placebo controlled double-blind evaluation of clinical response to penicillin therapy the effect of penicillin therapy on the symptoms and signs of streptococcal pharyngitis prevention of rheumatic fever acute rheumatic fever: the come-back of a disappearing disease the fall and rise of rheumatic fever in the united states resurgence of rheumatic fever in the intermountain area of the united states adverse and beneficial effectsof immediate treatment of group a beta-hemolytic streptococcal pharyngitis with penicillin the group a streptococcal carrier state. a reexamination suitability of throat culture procedures for detection of group a streptococci as reference standards for evaluation of streptococcal antigen kits specificity study of kits for detection of group a streptococci directly from throat swabs identification of streptococcal pharyngitis in office laboratory: reassessment of new technology rapid strep tests: making sense of a crowded market. contemporary office visits to pediatricians. national ambulatory medical care service greater boston otitis media study group. epidemiology of otitis media during the first seven years of life in children in greater boston: a prospective, cohort study middle ear disease in samples from the general population. ii. history of otitis media and otorrhea in relation to tympanic membrane pathology, the study of men born in 1913 and 1923 frequency and severity of infection in day care disparate cultures of middle ear fluids the greater boston otitis media study group. otitis media in infancy and intellectual ability, school achievement, speech, and language at age 7 years otitis media in infants and children: management sulfisoxazole as chemoprophylaxis for recurrent otitis media -a double-blind crossover study in pediatric practice otitis media in infants and children: tympanocentesis bacteriology of the maxillary sinuses in patients with cystic fibrosis the diagnosis and management of sinusitis in children: proceedings of a closed conference acute maxillary sinusitis in children sinus infections etiology and antimicrobial therapy of acute maxillary sinusitis chronic maxillary sinusitis. definition, diagnosis and relation to dental infections and nasal polyposis etiology and antimicrobial treatment of acute sinusitis bacteriologic findings of acute maxillary sinusitis in young adults bacteriological study in chronic maxillary sinusitis anaerobic infection of the paranasal sinuses clinical characteristics of nosocomial sinusitis comparative effectiveness of amoxicillin and amoxicillin-elavulanatepotassium in acute paranasal sinus infections in children. a double-blind, placebo-controlled trial treatment of acute maxillary sinusitis in childhood-a comparative study of amoxicillin and cefaclor treatment of acute maxillary sinusitis -amoxicillin, azidocillin, phenylpropanolamine and pivampicillin beta-lactamase producing bacteria in head and neck infection short and long-term treatment results in chronic maxillary sinusitis endoscopic paranasal sinus surgery headaches and sinus disease. the endoscopic approach macroscopic purulence, leukocyte counts and bacterial morphotypes in relation to culture findings for sinus secretions in acute maxillary sinusitis sinusitis of the maxillary antrum management of acute and chronic respiratory tract infections role of infection in chronic bronchitis erythromycin in the treatment of acute bronchitis in a community practice a placebo-controlled, double-blind trial of erythromycin in adults with acute bronchitis role of infection in chronic bronchitis antibiotictherapy in exacerbations of chronic obstructive pulmonary disease community-acquired pneumonia and acutebronchitis prospective study of the aetiology and outcome of pneumonia in the community howcommonis legionnaire's disease? nationalnosocomial infection studyreport. annual summary hospital-acquired pneumonia bacteriology of hospital-acquired pneumonia nosocomialpneumococcal bacteremia a nosocomial outbreak of ampicillinresistant haemophilus influenzae type b in a geriatric unit a nosocomial outbreak of branhamella catarrhalis confirmed by restriction endonuclease analysis theclinicalevaluation of antibacterial drugs guidelines for evaluating new antimicrobial agents principles and practice of infectious diseases acute pneumonia key: cord-002626-jzwwses4 authors: kaul, karen l.; sabatini, linda m.; tsongalis, gregory j.; caliendo, angela m.; olsen, randall j.; ashwood, edward r.; bale, sherri; benirschke, robert; carlow, dean; funke, birgit h.; grody, wayne w.; hayden, randall t.; hegde, madhuri; lyon, elaine; murata, kazunori; pessin, melissa; press, richard d.; thomson, richard b. title: the case for laboratory developed procedures: quality and positive impact on patient care date: 2017-07-16 journal: acad pathol doi: 10.1177/2374289517708309 sha: doc_id: 2626 cord_uid: jzwwses4 an explosion of knowledge and technology is revolutionizing medicine and patient care. novel testing must be brought to the clinic with safety and accuracy, but also in a timely and cost-effective manner, so that patients can benefit and laboratories can offer testing consistent with current guidelines. under the oversight provided by the clinical laboratory improvement amendments, laboratories have been able to develop and optimize laboratory procedures for use in-house. quality improvement programs, interlaboratory comparisons, and the ability of laboratories to adjust assays as needed to improve results, utilize new sample types, or incorporate new mutations, information, or technologies are positive aspects of clinical laboratory improvement amendments oversight of laboratory-developed procedures. laboratories have a long history of successful service to patients operating under clinical laboratory improvement amendments. a series of detailed clinical examples illustrating the quality and positive impact of laboratory-developed procedures on patient care is provided. these examples also demonstrate how clinical laboratory improvement amendments oversight ensures accurate, reliable, and reproducible testing in clinical laboratories. the field of pathology offers the opportunity to better understand the science behind the mechanisms of disease, to lead innovation of new diagnostic technologies, to provide quality oversight of these developments, and to have enormous impact on the lives of patients every day. patients benefit from laboratory medicine testing throughout their lives as every medical decision can be impacted by the result of a laboratory test. laboratory results constitute the majority of data in a patient's electronic medical record, and our procedures dictate the majority of downstream medical decisions for patients. 1, 2 clinical laboratory medical professionals have the unique responsibility to patients for assessing the performance of technologies in providing the most accurate information to ensure the most appropriate and efficient course of care. it is an understatement to say that the medical field is rapidly changing. technology and new genomic data developed as a result of the human genome project are leading to an explosion of knowledge applicable to individual patient care; this is the promise of precision medicine. we must continue to innovate and integrate novel diagnostic tools, genomic information, and new treatments into clinical practice. considerable technologic advances allow clinical laboratory professionals to offer new testing that provides more information than ever before and often within a time frame that allows rapid patient care and better outcomes. next-generation sequencing (ngs) in genetics and oncology, maldi-tof in the clinical microbiology laboratory, and a variety of mass spectroscopy-based methods in clinical chemistry now allow precise and rapid testing with demonstrated improvements in patient care. it is often thought that when "laboratory tests" are done to reach a diagnosis, they are done with a kit or on a machine, but in fact, most are procedures done with the direct involvement of a laboratory professional or physician. laboratory tests are generally not fully encompassed by a "test kit" but often start with the pathologist examining the tissue section, bone marrow aspirate, or gram stain and determining what additional information is needed to provide the clinician with the best scenario so that the patient can be treated most effectively. often, clinical laboratory professionals lead the development and optimization of these approaches to improve care and fill a clinical need, and their involvement in the process helps ensure that the highest quality standards are maintained. ongoing development of these novel methods is critical to medicine and must be done with the highest level of safety and accuracy, yet simultaneously addressing growing demands to lower the cost of medical care in the united states. the regulatory oversight of laboratory-developed testing procedures (ldps) has a critical impact on patients' access to testing and diagnosis. currently, there is national discussion regarding the optimal regulatory oversight of laboratory tests and procedures that will balance the needed accuracy and safety with ensuring that new tests are made available to patients safely and expeditiously. oversight provided by the clinical laboratory improvement amendments (clia) and the food and drug administration (fda) currently exists in the clinical laboratory. it must be noted that a spectrum of testing activities take place in clinical laboratories. these activities range from complex procedures, such as evaluation of a tissue biopsy, classification of a tumor, or culture of a microbe, to more automated or standardized tests for which an fdaapproved kit is utilized. all of these activities take place under the direction of a laboratory professional and in accordance with the detailed requirements of clia. the fda review process is well suited for diagnostic assays that are commercially marketed as kits designed to operate across a spectrum of laboratory settings, in laboratories with a range of expertise. currently, fda approval or clearance requires prospective clinical trial data and a lengthy review process, and thus, fda approval takes considerable effort and time. the investment needed for this process impacts the types of tests, and also sample types, that are submitted for approval, as manufacturers must recover their investment afterward. additionally, fda approval for an in vitro diagnostic (ivd) specifies the sample type, clinical purpose, and other aspects of performance of the assay. when a new clinical need for the ivd arises, the need to use a new sample type arises, or any needed modification that arises in response to the ongoing and sometimes rapid advancements seen in medicine, incorporation of these improvements renders the test an ldp, with the validation needs of an ldp under clia. laboratories can be caught between the regulations and the needs to best serve their patients. the clia provide for oversight of clinical laboratories by defining all aspects of laboratory operation, including the quality programs required for clinical tests, personnel requirements, and the validation requirements for ldps. the clia certification of laboratories can be accomplished through several deemed agencies such as the college of american pathologists (cap) or the new york state department of health (nys-doh). these organizations provide operational guidelines and perform on-site inspections based upon checklists developed via consensus of laboratory experts, which include hundreds of pages of requirements and data points. compliance with clia has been built into clinical laboratory operations, mechanisms for data collection, training, proficiency testing (pt), and test implementation. laboratories are subject to unannounced inspections and must demonstrate satisfactory performance characteristics for any test offered to ensure that results are accurate. for testing not reviewed by the fda, such as ldps, laboratories must go through a rigorous validation process before offering the test for clinical use. under clia, the validation data collected by these laboratories are subject to ongoing peer review. in particular, organizations with deemed status overseeing laboratories (such as cap and nysdoh) conduct rigorous peer-inspection using detailed criteria developed specifically for molecular pathology. laboratories also participate in required pt to demonstrate assay quality, with interlaboratory data sharing and assessment (most often led by the cap) that leads to ongoing broad improvement in ldps. recent public documents have presented examples of specific ldps in which the clinical validity of the test, the interpretation or use by clinicians, or the reproducibility of the laboratory data was questioned, raising concern about the safety and efficacy of this category of tests. 3, 4 enhanced regulatory oversight has been proposed to help ensure laboratories are delivering meaningful, high-quality results to patients. however, additional regulations have the potential to slow innovation and to limit and delay patient access to novel testing that impacts their clinical care, as well as add redundant reporting efforts and significant cost. expanded oversight of laboratories through a revised clia process has also been proposed (http://www.cap.org/showproperty?nodepath=/ucmcon/con tribution%20folders/webcontent/pdf/2015-cap-ldt-legisla tive-proposal.pdf. accessed april 27, 2017). 5 in an effort to illustrate the need for and positive impact of laboratorydeveloped procedures on patient care, the following series of vignettes have been assembled. in each case, timely and highquality laboratory-developed procedures filled a key clinical need. the impact on patient care has been summarized. as possible, data describing interlaboratory comparisons are provided to demonstrate the quality of these ldps, as validated and performed in accordance with clia. these examples also serve to highlight the quality efforts and interlaboratory comparisons that take place before ldps are offered by laboratories for clinical use; these activities and data are often unknown to the clinicians who utilize these testing services. table 1 provides a guide to the examples included and summarizes the impact of each assay along with key points about its utility. encephalitis is the most serious complication of herpes simplex virus (hsv) infection. 6 while rare, hsv is commonly included among causes of viral encephalitis. since hsv infection can be treated effectively with acyclovir, it is critical to rapidly and accurately establish the diagnosis and initiate treatment to reduce morbidity and mortality. culture of cerebrospinal fluid (csf) is insensitive for the diagnosis of hsv encephalitis, so brain biopsy, a very invasive procedure with significant morbidity, was historically required to make a diagnosis, with results not available for days afterward. several studies demonstrated that detection of viral dna by polymerase chain reaction (pcr) using csf samples performed equivalently to brain biopsy, including a landmark study in 1995. [7] [8] [9] given the ease of collecting csf samples, the lower risk of complication, the lower cost, and speed of results, pcr became the standard of care for diagnosing hsv cns infections in the mid-1990s, with ldps used for nearly 20 years. it was not until 2014 that the first fda-cleared pcr test for the diagnosis of hsv encephalitis became available, with a second test cleared in 2015. laboratory-developed testing procedures dramatically improved the quality of care for many patients and continue to be used successfully today, as the 2 cleared tests have limitations, requiring specific instrumentation not standard in many laboratories. additionally, one of the tests is highly multiplexed, which may not be appropriate in all clinical situations. herpes simplex virus can also cause infections in neonates, with a frequency of 1:3500 to 1:5000 deliveries in the united states. the infection is acquired by exposure to maternal genital secretions. the presentation of neonatal hsv varies and includes skin, eye, and mouth infection, with encephalitis and disseminated disease in over 50% of cases. again, rapid diagnosis is needed to prevent morbidity and sequelae from encephalitis. the diagnosis of encephalitis is made via pcr of csf samples, while testing of plasma or serum is critical to diagnose disseminated disease. the ability to use plasma or serum is very important as it may be difficult to obtain enough csf from a newborn to assess all diagnoses in the differential. although there are 2 fdacleared assays to test csf for hsv, there are no assays cleared for testing serum and plasma. laboratory-developed testing procedures continue to play a critical role in the diagnosis and management of disseminated hsv infection in newborns. additionally, ldps have performed with a high degree of accuracy and interlaboratory agreement. blinded pt samples were distributed to 383 laboratories as part of a cap pt survey for analysis of hsv; 91.6% correctly identified hsv-2, and 7.8% identified hsv, but not noting the subtype; an overall accuracy of 99.4% was obtained. previous proficiency surveys showed similar results for samples containing hsv1. over 90% of the laboratories used ldps. 10 bk virus infection is very common, with a seroprevalence in the adult population of *90%. after primary infection, the virus colonizes the renal and urinary tracts; healthy individuals will occasionally shed virus in their urine without consequence. however, in renal transplant recipients, bk virus is the major cause of polyomavirus-associated nephropathy (pvan), putting 1% to 15% of kidney transplant patients at risk of premature allograft failure. 11 given the lack of effective antiviral therapy for bk virus, the key to preventing allograft loss is to identify at-risk renal transplant recipients early and reduce immunosuppressive therapy before pvan develops. reduction of immunosuppressive therapy helps control viral replication and in most cases prevents the development of pvan. 12 there is a critical balance between too much immunosuppressive therapy, which can lead to pvan, and too little immunosuppression causing rejection. the ability to monitor bk virus levels in the blood allows for informed clinical decisions. studies have shown that monitoring patients with viral load testing during the first 2 years after transplant can dramatically reduce the development of pvan. consensus guidelines recommend that screening for bk replication be performed at least every 3 months during the first 2 years posttransplant and then annually until the fifth year posttransplant. 13 when the plasma viral load value rises above a threshold (10 000 to 50 000 copies/ml), a renal biopsy may be performed to assess for pvan, and immunosuppressive therapy is reduced based on the results of the biopsy. viral load testing is also done if there is an increase in serum creatinine, as the level of bk virus aids in distinguishing rejection from pvan. although bk viral load testing has been the standard of care for several years and is used in transplant centers across the country, there is no fda-cleared or fda-approved test available. all testing is performed using ldps. if these ldps were not available, most cases of pvan would not be identified promptly, leading to negative patient outcomes such as allograft loss or rejection. cytomegalovirus (cmv) can cause a wide range of complications among both solid organ transplant and hematopoietic stem cell transplant recipients, as well as in other immunocompromised patients. cytomegalovirus has a high seroprevalence, and large numbers of transplant patients experience reactivation or primary infection, with probability increasing based on pre-transplant serostatus, severity of pretransplant conditioning, and allograft relatedness. 14, 15 although infection can be subclinical, high or increasing viral load signals increased the risk of symptomatic disease, which can range from relatively mild constitutional symptoms to severe end-organ infection or potentially fatal disseminated disease. preemptive therapy of high-risk patients based on the detection of increasing cmv load in peripheral blood was shown to be effective in the 1990s 16, 17 ; however, the first fda-approved ivd test did not appear on the market until 2012. 18 in the intervening years, laboratory-developed assays played a critical role in bridging the gap. the presence of such methods and their adoption across the country enabled the routine use of cmv screening for asymptomatic patients in transplant centers soon after data supported its utility. the availability of such methods has likely saved many lives over the years, supporting early diagnosis, preemptive treatment strategies, and the assessment of therapeutic treatment efficacy. 14, [18] [19] [20] the widespread use of ldp cmv quantitative methods produced a generation of transplant physicians comfortable with the use of such methods and changed the epidemiology of posttransplant cmv disease, markedly reducing the incidence of early disease in such patients. over the years of ldp use, numerous studies focused on continuous improvement and optimization of methods, 21 including the development of international quantitative standards in 2010. 22 the ability to rapidly incorporate advances in technology (including the advent of real-time quantitative methods) has been demonstrated by the improvement in sensitivity and other performance characteristics of such tests over time. the data accumulated throughout these experiences informed the development of the first commercially available cmv ivd assays. in fact, the absence of ldps and the vast clinical and laboratory experience that they provided likely would have delayed the availability of commercial methods, and their performance characteristics taken longer to optimize to today's levels. human papilloma virus (hpv), the causative agent of genital warts, has been implicated in the development of *99% of cervical cancers. 23 more than 200 hpv genotypes have been described, 24 and approximately 40 are capable of infecting the human genital tract. 25 of these, a relative few are known to cause cervical cancer and other malignancies; these can be identified by genotyping. today, 4 assays are fda approved for detecting high-risk hpv genotype strains in cervical specimens. [26] [27] [28] [29] these tests are routinely used to confirm the presence of an hpv infection, screen for cervical cancer, and refer cases with an indeterminate cytology examination. 30 during the past decade, a rise in oropharyngeal squamous cell cancer, primarily in 40 to 55-year-old caucasian males with limited alcohol and tobacco exposure, has been described. 31 unexpectedly, investigators discovered the frequent presence of high-risk hpv genotype strains in these lesions. human papilloma virus-positive head and neck cancer is biologically distinct from hpv-negative disease. patients with hpv-driven tumors have a significantly better prognosis, including response to chemoradiation therapy and overall survival, compared to hpv-negative patients. 32 therefore, testing head and neck cancer specimens for high-risk hpv genotypes has become standard of care and is used to guide treatment. 33, 34 however, the hpv tests that are fda approved for cervical specimens have not been approved for head and neck cancer, leaving a critical gap for patient care. clinical laboratories have thus had to develop new assays or modified the existing fda-approved ones to detect high-risk hpv genotypes in head and neck cancer specimens. inclusion of patients in several clinical trials is based on these ldps (www.clinicaltrials.gov. accessed april 27, 2017). without laboratory-developed tests, patients with head and neck cancer cannot benefit from personalized treatment strategies. clinical laboratories must be highly vigilant for infectious disease outbreaks, since they are likely the first to recover the pathogen and recognize the potential for an outbreak. recent examples of emerging or reemerging pathogens causing substantial human morbidity and mortality include avian influenza virus ("bird flu"), chikungunya virus, ebola virus, middle eastern respiratory syndrome virus, severe acute respiratory syndrome virus, and zika virus. 35, 36 at the time of their emergence, no fda-approved tests were available to detect any of these pathogens. in response, many clinical laboratories developed, validated, and implemented the ldps needed to care for patients at their institutions. 37, 38 these assays were based on extensive data sets and reported in peer-reviewed journals, supporting their quality claims. since performance characteristics such as analytic sensitivity (limit of detection) may vary between different assay designs, 39 as was recently discussed for several different zika virus tests, 40 these sorts of collaborative efforts are essential. in many cases, laboratories leading these efforts collaborated with one another to share validation materials, perform interlaboratory comparisons, and exchange blinded testing samples (http://www.usatoday.com/story/ news/2016/02/23/texas-hospitals-develop-rapid-zika-test/ 80776382/. accessed april 27, 2017). while perhaps not ideal, there is an urgent need for a more integrated and coordinated mechanism for rapid diagnosis of novel infectious agents that incorporates both the public health and hospital laboratories. the recent emergence of zika virus, which has been linked to severe birth defects, 41 underscores the need for clinical laboratories to have rapid access to diagnostic tools. when the secretary of health and human services declared zika virus to be a public health emergency, the first fda emergency use authorization for zika virus testing was granted to a test available only to the public health laboratory system, not to hospital laboratories on the front lines of patient care (https://www.fe deralregister.gov/documents/2016/03/28/2016-06888/authori zation-of-emergency-use-of-an-in-vitro-diagnostic-device-fordiagnosis-of-zika-virus. accessed april 27, 2017). as a result, the public health system quickly became overwhelmed, as it has been during past outbreaks, such as influenza. 42 in many areas, turnaround times for zika virus testing exceeded 4 to 8 weeks (http://www.nytimes.com/2016/09/13/us/zika-testdelays-florida-pregnant.html?_râ¼0. accessed april 27, 2017, http://medicalxpress.com/news/2016-10-lab-constraints-zikaresults.html. accessed april 27, 2017, http://www.miamiher ald.com/news/health-care/article104856631.html. accessed april 27, 2017). these delays critically impact patient care, particularly for pregnant women with possibly affected fetuses. in comparison, many hospital-based and national reference laboratories are able to report results within hours (http:// www.usatoday.com/story/news/2016/02/23/texas-hospitalsdevelop-rapid-zika-test/80776382/. accessed april 27, 2017, http://www.nytimes.com/2016/09/13/us/zika-test-delays-flor ida-pregnant.html?_râ¼0. accessed april 27, 2017). for example, in miami-dade florida, where more than 1000 people have been confirmed zika positive and the virus is circulating in the local mosquito population, the public health laboratory system encountered a backlog of nearly 1000 untested specimens (http://www.miamiherald.com/news/health-care/arti cle104856631.html. accessed april 27, 2017). diagnostic assays for zika and other emerging pathogens will continue to evolve, 43 but it is clear that rapid identification of pathogens during other outbreaks facilitates rapid treatment and appropriate isolation of patients, leading to improved patient outcomes and potentially slowing the spread of infections such as influenza (http://www.cdc.gov/flu/professionals/diagnosis/molecu lar-assays.htm. accessed april 27, 2017). implementation of the first rapid diagnostic tests for influenza was directly associated with reduced length of hospital stay, decreased mortality, and reduced costs. 44 access to diagnostic tests, early in the course of an outbreak and in hospital laboratories, has a positive public health impact. the kras gene encodes a gtpase critical in signal transduction that is known to be mutated in a wide range of tumor types. 45 a landmark study presented at the american society of clinical oncology (asco) meeting in 2007 demonstrated that patients with metastatic colorectal cancer harboring a mutated kras failed to respond to targeted therapy with cetuximab. 46, 47 at the time, there were no clinical tests for kras mutations available. molecular pathology laboratories worked quickly to fill this need, to define the best analytic approaches, and to ensure that test results done in one laboratory matched those done in another. [48] [49] [50] within a few months, laboratories were able to offer fully validated kras assays that worked reliably and were safe for patient care. under clia, the validation data collected by these laboratories were subject to ongoing peer review, and laboratories participate in ongoing pt to demonstrate consistent assay quality. in 2009, the asco and the national comprehensive cancer network (nccn) recommended mutational profiling of kras exons 12 and13 before institution of anti-epidermal growth factor receptor (egfr) therapy for patients with metastatic colorectal cancer; it became standard of care to assess formalin-fixed paraffin-embedded tumor tissues from patients with metastatic colon cancer for kras mutation status. 51, 52 it was not until 5 years later that the fda cleared qiagen's therascreen kras test, designed to detect the presence of 7 mutations in the kras gene in colorectal cancer. 53 by this time, new data demonstrated that kras analysis alone was not enough; mutation analysis of other genes was necessary, 54, 55 and the fda-approved assay was already inadequate for patient testing compliant with national treatment guidelines. without ldps, an estimated 10% of patients with non-exon 2 kras mutations would be overtreated with expensive anti-egfr therapy. 56 the use of ldps has thus persisted in clinical practice to provide patients with the most complete information to guide treatment. in the cap kras-b-2015 mailing, 204 laboratories reported results from testing 3 blinded proficiency-testing specimens. the specimens contained recurring somatic mutations in kras exons 12 or 13 (nm_004985.3), c.35g>t (p.g12 v), and c.38g>a (p.g13d). an acceptable response was reported by over 96% of the laboratories for both mutations (197/204 for p.g12v and 195/202 for p.g13d). the vast majority of reporting laboratories utilized ldps. 57 kras and ras family gene mutation analysis is also critical in the management of patients with non-small-cell lung cancer (nsclc) and other tumors, 58 for which fda approval of kits has not occurred; ldps or off-label use of kits is required. braf belongs to a family of serine-threonine protein kinases that participate in signal transduction cascades involving ras, raf mek, and erk family members. this pathway is important in the regulation of normal cell proliferation and differentiation. 59 activating mutations in braf can lead to increased proliferation and prolonged cell survival in a variety of tumor types. 60 laboratories will typically test for braf mutations in low-grade gliomas (for diagnosis), colorectal cancer (to establish the sporadic origin of msi-h tumors and response to anti-egfr therapy), hairy cell leukemia (for diagnosis), lung adenocarcinomas (to predict response to therapy), thyroid cancer (for preoperative detection of thyroid cancer in fna samples and prognosis in papillary thyroid carcinoma), or melanoma (to predict response to braf kinase inhibitors). for one of these indications, malignant melanoma, fdaapproved companion diagnostics are available. vemurafenib (zelboraf) is a kinase inhibitor indicated for the treatment of patients with unresectable or metastatic melanoma with braf v600e mutation. dabrafenib (tafinlar) is a kinase inhibitor indicated as a single agent for the treatment of patients with unresectable or metastatic melanoma with braf v600e mutation or in combination with trametinib (mekinist) for the treatment of patients with unresectable or metastatic melanoma with braf v600e or v600k mutations (www.fda.gov. accessed april 27, 2017). the cobas 4800 braf v600 mutation test (roche molecular systems, pleasanton, ca, usa) sporadically cross reacts with braf v600k and braf v600d mutations 61,62 and thus is neither sensitive for braf v600 mutations nor specific for braf v600e mutations, confounding accurate outcome evaluations and preventing its usefulness in selecting patient for tafinlar therapy. the thxid braf kit (biomerieux, boston, ma, usa) does detect both braf v600e and braf v600k mutations (but not other braf v600 mutations) and is necessary to distinguish between alternate therapeutic options (single agent vs combination therapy). it is important to note that increased cell proliferation has been seen in tumors treated with braf inhibitors with normal braf. 61 it is therefore important to identify all braf activating mutations to assist in the selection of appropriate therapy. the fda-approved assays are therefore not adequate for current clinical needs. in a 2015 european multicenter study, 62 420 consecutive tumor samples of histologically proven melanoma tumor tissue were assessed for braf mutation status by the cobas system and a variety of laboratory developed procedures. testing was concordant for 392 (93.3%) of 420 samples but discordant for 28 (6.7%). among the discordant cases, 11 had invalid results (8 samples with the cobas and 3 with ldps). of 10 samples with braf v600 mutations detected by the ldps (but not by the cobas mutation test), 5 were v600k, d, or r mutations, and 2 contained only 20% tumor cells. for the 7 samples with braf v600 mutations detected by the cobas but not by the ldps, 4 were confirmed with retesting, 1 was not mutated, and 2 were considered invalid results. this study documents similar results between the performance of braf ldps and ivds. further data can be gathered from the cap pt program. in the braf-b-2015 cap proficiency survey, 173 laboratories reported on the detection of v600e and other braf mutations by a variety of analytic methods. two of the well-characterized specimens in the proficiency test contained braf v600e alleles, and 98.8% and 99.4% of laboratories correctly reported the mutation. the majority of these laboratories used ldps. 63 there are no currently available braf mutation tests approved for use in other tumor types such as those mentioned above, and use of the existing ivd tests would constitute offlabel use and hence ldps. microsatellite instability is the presence of hypermutability in repetitive dna sequences resulting from impaired dna mismatch repair. microsatellite instability can be an inherited or acquired feature of tumors. microsatellite instability occurs in approximately 15% of all colorectal carcinomas and is a consistent feature of colorectal and other tumors in patients with lynch syndrome. 64 tumors are classified as showing high levels of msi (msi-h phenotype) if 2 or more of 5 microsatellite markers (or !30%) exhibit instability, a microsatellite-stable phenotype if none of the markers show instability, and an msilow phenotype if only 1 of 5 or less than 30% of the markers show instability. 65 studies have confirmed that the appropriate cutoff for determining an msi-h phenotype is the finding of instability in 30% or more of the markers tested. the finding of an msi-h phenotype is consistent with the presence of defective dna mmr in the tumor. 66 the finding of an msi-h phenotype in a crc increases the likelihood that the patient has ls but is not specific for ls. the definitive establishment of a diagnosis of ls requires the finding of a pathogenic germline mutation in one of the dna mmr genes. additional testing that can be offered to determine whether a patient with an msi-h crc is likely to have ls includes testing the tumor for dna mmr protein expression using ihc, braf v600e point mutation analysis (since braf-mutated msi-h colorectal carcinomas are known to have sporadic mmr gene mutations), and mlh1 promoter hypermethylation. studies have shown that an msi-h phenotype is a favorable independent prognostic indicator in patients with crc. 67 in addition, some reports indicate that msi-h tumors may not be responsive to 5-fluorouracil-based therapies. 68 recent draft guidelines developed collaboratively by 4 professional societies recommend that deficient mismatch repair/microsatellite instability testing must be performed in all colorectal cancers for prognostic stratification and identification of patients with lynch syndrome. 69 although numerous laboratories offer msi testing using ldps, there are currently no fda-approved tests for the evaluation of microsatellite instability. a summary of cap pt results 70 demonstrates excellent performance of laboratories participating in the msi proficiency surveys. this good performance of laboratories over the years may be partly due to the educational nature of the cap pt, which provides laboratories with an external mechanism to monitor the quality status of their testing. epidermal growth factor receptor is a membrane-bound tyrosine kinase which activates several signaling pathways known to be altered in human cancer, including nsclcs. [71] [72] [73] nonsmall cell lung cancer tumors with egfr-activating mutations are responsive to gefitinib and erlotinib, small molecule tyrosine kinase inhibitors of egfr. 74, 75 the fda approval of anti-egfr therapies based on clinical trial outcomes data resulted in the need for clinical laboratories to test tumor tissue for the egfr-sensitizing mutations in order for patients to be eligible for treatment. with no fda-approved "companion" diagnostic test on the market, clia-licensed laboratories developed and validated ldp tests for the 2 most common egfr mutations as early as 2004. 73 the fda followed with approval of the roche cobas egfr mutation test in 2013 along with the qiagen therascreen egfr rgq kit. both assays tested for the exon 19 deletions and the exon 20 l858r point mutation. of note was that each test was approved for specific therapeutic indications and specimen types. as new drugs became available, approval for new claims was needed. laboratory-developed procedures continue to be the method of choice due to the limitations of claims made for fda-approved assays and performance characteristics, including types of mutations being detected. 76 clinical laboratories participate in twice-yearly proficiency test challenges of unknown samples that must be analyzed and reported, with results graded and compared to other laboratories performing the testing. in the cap egfr-b-2015 proficiency test, 192 laboratories reported results from testing 3 unknown proficiency-testing specimens in late 2015. the specimens connote: some laboratories do not test for certain mutations, hence, the denominator is often less than 192. 77 as patients being treated with these new targeted anti-egfr therapies began to relapse, further studies revealed that egfr harbors both sensitizing and resistance mutations. the clia laboratories have demonstrated the ability to detect all mutations in the egfr gene as well as in other genes using ngs assays to sequence panels of cancer-related genes. 78 this panel approach allows the laboratory to provide the oncologist with a more comprehensive profile of the tumor, using a costeffective technology that makes maximal use of small tissue samples and thus makes treatment strategies more effective. in addition, the time saved by testing a broader panel of gene targets can result in better outcomes for the patient as well as fewer adverse drug reactions. for the payer, the cost savings of such an approach versus algorithm-based testing with single gene assays is significant. currently, there are no fdaapproved sequencing assays for egfr mutation status, and ldps are solely used for the detection of these mutations that define therapy selection. the complexity of cancer biology and the ever-evolving therapeutic approach to management of the patient with cancer more often requires expanded knowledge of the tumor beyond single-gene mutation status. over the past several years, the laboratory's ability to multiplex testing for several genes or genetic variants has been limited by the available technologies. next-generation sequencing or massively parallel sequencing has allowed the laboratory to provide a more comprehensive genomic profile of tumor cells in a single assay than previous methods. the ability to detect numerous mutations in multiple genes results in information that can allow the oncologist to develop a more accurate treatment strategy including therapies selected based on a "responsive" tumor profile and those not selected based on the presence of resistance mutations. [79] [80] [81] instrumentation from thermo fisher (thermo fisher life-technologies, carlsbad, ca, usa) and illumina (illumina, san diego, ca, usa), the personal genome machine (pgm), and miseq, have made ngs suitable for routine clinical laboratory testing. [82] [83] [84] in 2015, the miseq dx obtained fda approval. despite this approval and the routine use of ngs in ldps setting, there are no currently fda-approved ngs tests for application in oncology. although many drug package inserts require or allude to the use of a companion diagnostic for eligibility, very few companion diagnostic tests are fda approved and none using ngs technology. as an ldp, clinical laboratories are required to demonstrate rigorous performance criteria for wet-bench testing and analysis pipelines to ensure the test is functioning properly for its intended clinical purpose. 73, [85] [86] [87] most ngs testing for therapeutic selection in cancer consists of panels of genes that range from 10 to 400 or more genes. each test can be designed to detect hotspots of known mutations in those genes, to sequence the entire coding region of the genes, or to sequence the entire gene. the end result is a comprehensive profile of the tumor genome that can then be used to tailor therapy for the individual patient. although ngs assays cost more than single-gene assays, the cost per gene sequence is dramatically reduced and results in cost savings over using multiple single-gene tests. furthermore, ngs panels can be applied to very small specimen samples, using as little as 10 to 250 ng of input dna depending on the analytic platform utilized. since evaluation of therapeutic biomarkers is usually needed in the setting of advanced disease and such patients often have only limited tissue samples available for testing, ngs assays allow for much more extensive genomic information to be obtained compared to single-gene assays, each of which can require dna input comparable to that of an entire ngs panel. a total of 111 laboratories recently participated in a capsponsored proficiency assessment of ngs cancer panel testing (ngsst-a-2016), with data collection on 10 gene mutations (akt1, alk, braf, egfr, fbxw7, idh1, kit, kras, nras, and pik3ca). of 1010 genotyping calls across the spectrum of mutations tests, 993 (98.3%) were called concordantly (unpublished data). 88 no other ldp in the field of oncology has had a greater impact on patient care than has the quantitation of rna in chronic myelogenous leukemia (cml). one of the first (and arguably most successful) molecularly targeted cancer therapies is the bcr-abl1-targeted tyrosine kinase inhibitor, imatinib, which was fdaapproved in 2001. in those very early days of targeted therapy, long before the advent of fda-approved "companion diagnostics," the ubiquitous and obvious method to determine the efficacy of novel leukemia treatments was to directly quantitate the target of the inhibitor drug, namely, the cancer cellspecific bcr-abl1 fusion gene. a reduction in posttreatment bcr-abl1 rna levels, as measured by sensitive laboratorydeveloped pcr-based methods, was shown to be the best available test for predicting therapeutic response and long-term progression-free survival in tki-treated patients with cml. 89 consensus oncology practice guidelines in both the united states (nccn) 90 and europe (eln), 91 going back at least a decade, have universally recommended that tki-treated patients with cml should be serially monitored with a (laboratory-developed) bcr-abl1 rt-pcr blood test at least every 3 to 6 months during their lifelong course of tki therapy. the nccn and eln guidelines have also long recommended serial bcr-abl1 rna testing to directly inform not only the appropriate dose of tki (to overcome developing resistance) but also the therapeutic switch from one tki to another (depending on the drug's known resistance profile). to directly support optimal therapeutic decision-making in the routine care of patients with cml, clinical laboratories have been offering accurate and sensitive pcr-based laboratory-developed procedures for bcr-abl1 for at least the last 15 years. recognizing that standardization of these ldp's was necessary to promote uniform therapeutic decisionmaking, the laboratory community undertook an extensive multiyear project to create a standardized "international scale" (is) of measurement for bcr-abl1 messenger rna. 92 follow-up efforts resulted in the creation of a world health organization-recognized panel of reference materials directly linked to the bcr-abl1 is 93 and the subsequent creation of secondary is-calibrated reference materials that could be used for routine daily qc in clinical laboratories. 94, 95 recognizing the additional need for pt, the cap has been offering semiannual bcr-abl1 pt surveys for at least 10 years, with a progressive increase in the number of participating laboratories (from *100 in 2009 to *190 in 2016). as proof of the nearuniversal recognition of assay standardization, approximately 90% of these accredited laboratories now report their pcr results using the standardized is. a 2016 cap survey confirmed excellent interlaboratory precision, with over 90% of laboratories reporting a bcr-abl1 is result within internationally acknowledged acceptable tolerance limits (0.5 logs) for is reporting of a sample with an approximate 1000-to 10 000-fold reduction in pretreatment bcr-abl1 levels 96 the primary driving force behind the remarkable increase in longevity and quality of life for patients with cml over the past 15 years has no doubt been the availability of noveltargeted tki therapies. this has become the paradigm for personalized/precision cancer medicine programs, coupled with parallel effort of the laboratory community toward building, improving, and standardizing accurate, precise, and sensitive laboratory-developed tests for bcr-abl1. of note, this 15year targeted therapy program for cml occurred entirely without the availability of fda-approved bcr-abl diagnostic reagents, which have only become available in 2016. these fda-approved assays were based upon those developed in clinical laboratories; they are not approved for diagnosis of cml nor do they cover the spectrum of breakpoints that occur in the disease. during those ground-breaking first 15 years of the targeted cancer therapy era, if the laboratory community had been prohibited from providing high-quality, standardized ldp-based testing under existing clia guidelines, the negative consequences to patient care in the past and the future would have been substantial. fragile x (fx) syndrome is one of the most common inherited causes of intellectual disability. the causative molecular mechanism is an expansion of a cgg repeat region of the 5 0 regulatory region of the fmrp gene. when the cgg repeat expands beyond approximately 200 cgg repeats, the gene is methylated and silenced. laboratory testing for fx includes sizing the number of repeats as well as methylation analysis and has been available for clinical diagnostic and carrier status testing for over 20 years. the american college of medical genetics and genomics (acmg) has published practice guidelines for appropriate test ordering. 97 it is a first tier test for individuals and families in which an x-linked inheritance pattern of intellectual disability is suspected. once an expanded fx allele has been identified, other family members can be tested to identify premutation carriers at risk of having affected offspring. prenatal (fetal) or preimplantation genetic diagnostic testing is available for known fx carriers. according the genetic test registry, over 50 laboratories in the united states offer testing for fx (https://www.ncbi.nlm. nih.gov/gtr/; accessed 11-01-2016). currently, all fx testing is performed as ldps: no fda-cleared assay is available. pcr primers and southern blot reagents are available commercially as analyte-specific reagents (asr) or as investigational use only. clinical laboratories use these commercial reagents, or design primers or probes, combine them internally to develop the assay and establish performance characteristics. the acmg has published standards and guidelines for clinical laboratories that perform this test. 98 reference materials to standardize sizing were developed through the genetic testing reference material program 99 sponsored by the centers for disease control and prevention (cdc), the national institute of standards and technology (https://www.nist.gov/node/ 608501, accessed november 1, 2016), and the world health organization. 100 proficiency testing through the cap has demonstrated the excellent performance of clinical laboratories of this high-complexity ldp. 101 as the genetic basis for many human diseases became apparent, sequence-based diagnostic testing was implemented as a way to provide definitive diagnoses for patients and their families. many laboratories began offering sequence-based testing for heritable disorders in the 1990s, using a variety of mutationscanning techniques, such as single-strand conformation polymorphism, denaturing hplc, mlpa, and others. 102 sanger-based sequencing was the gold standard, despite being slow and expensive. the multigenic nature of some of these disorders made these sequencing approaches challenging due to the sheer number of genes and size of the sequence requiring analysis. in recent years, however, most of this testing has been converted to ngs, which offers significant advantages in terms of analytic capabilities, quality, speed, and cost. 103 the repetitive sequence reads in a single region ensure an enhanced level of quality, and ngs assays can be designed to interrogate anything from small to large gene panels, whole exomes, and beyond, depending on the clinical need being addressed. consensus guidelines for ngs assays have been developed by multiple professional societies and address the development, validation, and quality control of these assays. 104, 105 the cap has developed inspection checklists for laboratories performing ngs for detection of somatic mutations in cancers as well as germline mutations that cause heritable diseases. progress has also been made in the planning and production of reference materials and proficiency samples. 106 together, these practices and resources have yielded laboratory-developed assays that can be demonstrated to meet the quality levels needed for patient care. in addition to continuous quality assessment of the "wet laboratory" procedures, ongoing national and international efforts to share data, and construct and maintain up-to-date curated databases for variant interpretation, are critical for quality care. as new mutations and variants are detected, interpretation and assessment of clinical impact, including determination of the clinical importance of variants of undetermined significance, is critical. rapid generation of genomic data, disorganized data sharing, and a lack standardization have created challenges, and a more consistent approach to clinical sequence interpretation is needed, along with centralized and openly accessible databases for sequence and clinical information. in recognition of the urgent need for up-to-date variant classification resources, the acmg and association for molecular pathology released a landmark guidance document in 2015, 105 which has been implemented by us and international laboratories. additional resources are outlined and include ncbi's clinvar database (https://www.ncbi.nlm.nih.gov/clinvar/), which has quickly become a valuable centralized resource for clinically classified variants, and the clinical genome resource (clingen, www.clinicalgenome.org), which serves as a centralized site for managing genomic knowledge surrounding genes and variants. with exome and genome sequencing being increasingly implemented, guidance has been issued by the acmgg on how to deal with the incidental identification of variants in the so-called "actionable" genes in patients tested for unrelated conditions. 107 additionally, quality assessment focusing on the informatics pipeline and variant interpretation could effectively utilize sequence data sets, as has been recently outlined. 108 the genetics and pathology communities are increasingly embracing data sharing, which will lead to needed improvements in divergent interpretation of gene sequence variants. these interpretative tasks would be beyond the scope of an fda approval for a kit, or the clia oversight of an ldp, but have a critical impact on patient care based on genomic information. next-generation sequencing analysis of a variety of gene panels has become routine in clinical care and has had a positive impact on the diagnosis and treatment of patients and families with complex syndromes and disorders. examples of 3 of the most common clinical settings in which gene panels are tested for potential germline mutations are provided below, along with information on the clinical setting, potential benefits, and also challenges in utilizing these approaches. inherited cardiomyopathies are common disorders and include hypertrophic cardiomyopathy (hcm), dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and restrictive cardiomyopathy. 109, 110 several characteristics of all inherited cardiomyopathies provide compelling reasons for genetic testing and include (1) a substantial genetic component with detection rates currently ranging between 30% and 50%, 111, 112 (2) long presymptomatic phases with acute disease onset typically not before adolescence, and (3) a predisposition to sudden cardiac death (scd), which can be the first presenting sign. frequent and heartbreaking publicity following cases of sudden death of competitive athletes has brought these diseases to public attention, 113 and a recent study shows that 16% of scd cases are due to an underlying unrecognized inherited cardiomyopathy. 114 the importance of these heritable abnormalities is underscored by the fact that nearly a third of the genes for which the acmg recommends return of results, regardless of the test indication, are made up of these cardiomyopathy genes. these disorders are heterogeneous, which can lead to clinical diagnostic uncertainty or error; hence, large multigene panels are particularly useful to cover the spectrum of genes that may cause a clinical disorder. importantly, the identification of pathogenic variants in affected individuals can inform medical management of family members and can identify those at risk early and also release negative individuals from clinical screening. 111 genetic testing can also identify phenocopies such as fabry disease, which can masquerade as isolated hcm. while fabry disease is rare, disease-modifying treatment is available, and therefore, genetic testing provides essential clinical information for these patients. epilepsy is a common disorder of the central nervous system characterized by periodic loss of consciousness with or without convulsions associated with abnormal electrical activity in the brain. this can significantly affect the quality of life and has major psychological and socioeconomic consequences. it is estimated that there are more than 50 million people with epilepsy worldwide, and an estimated 1 in 26 people in the united states will develop epilepsy at some point in their lifetime. a significant proportion of cases show a familial distribution, and there is an increased risk of epilepsy with a family history. the prime requirements for successful management of epilepsy are a complete diagnosis and selection of an optimal treatment to benefit the patient. development of epilepsy may involve multiple gene abnormalities or a gene abnormality in concert with an environmental trigger. more than 100 genes have been shown to be associated with epilepsy, and a precise genetic diagnosis can help in deciding the accurate treatment and follow-up. 115, 116 evaluation of all genes implicated in epilepsy is most efficiently accomplished using an ngs panel to provide accurate information to the physician for treatment planning. nextgeneration sequencing assays are performed as ldps under clia. an example of such one gene is scn1a, which causes dravet syndrome and can be successfully treated. 117 it is important to avoid treatment with sodium channel blockers as these can worsen seizures in dravet syndrome. these include phenytoin (dilantin), fosphenytoin (cerebyx, prodilantin), carbamazepine (tegretol), and other medications. as ongoing research reveals new genes and mutations relevant to these diseases, it is important to classify newly found variant quickly and accurately. open access to new information and consensus efforts to define standards for classification and reporting of variants and vuss will be critical in ensuring that patients get the most upto-date and complete information from genomic testing. 104, 105 another example is the recently discovered gene tbckrelated epilepsy. 118 tbck-related intellectual disability syndrome is rare with developmental delay, hypotonia, and seizures. children with lower levels of the tbck protein have slower cell mtor signaling, which can be improved by the addition of leucine, which may provide future therapeutic options. it is important that clinical laboratories adapt their ngs panels to incorporate new targets as clinical utility is established. neuromuscular diseases (nmds) refer collectively to the many disorders that affect the peripheral nervous system, either by impairing the proper development or functioning of muscles or by damaging the associated nerves or neuromuscular junctions. muscular dystrophies that form the majority of inherited nmds share clinical, genetic, and pathological characteristics, including muscle degeneration and wasting, progressive muscle weakness, hypotonia, and variably elevated serum creatine kinase levels. cardiac involvement is often present, accounting for high morbidity and mortality. there are 80 different genetically defined types of muscular dystrophies categorized based on the age of onset, the specific muscles involved, and common characteristic clinical features. [119] [120] [121] [122] congenital muscular dystrophies and limb-girdle muscular dystrophies are the 2 major subgroups; these are genetically heterogenous, with many new genes being implicated in recent years. lack of pathognomonic signs or specific biochemical markers and the presence of high phenotypic overlap with other forms of nmds make diagnosis difficult. molecular assessment is critical not only to establish a diagnosis but also to allow participation in clinical trials of therapeutic treatments that are designed for a specific set of variants or variant types. an extensive diagnostic workup involving protein studies on muscle biopsy may be used to narrow the number of single genes to be tested, but many patients never are specifically diagnosed. comprehensive approaches to expedite molecular diagnosis now include ngs-based panel testing for sequence analysis of all disease-associated genes in a single analysis. [123] [124] [125] heritable cancer panel genomic testing for familial cancer syndromes has become routine over the past 2 decades. approximately 50 heritable cancer syndromes are recognized and are causative of 5% to 10% of all cancers. although familial breast cancer has perhaps become the most publicly known example of testing, genes for other inherited cancer syndromes may be included in ngs multigene panels. patients who carry a germline mutation of brca1 or 2 have a lifetime risk of breast cancer of 60% to 70%. the us preventative task force recommends brca1 and 2 testing for women who have family members with breast, ovarian, fallopian tube, or peritoneal cancer or meet other criteria. 126 numerous studies have demonstrated the psychosocial benefits of genetic counseling and testing. 126, 127 for patients who carry a germline mutation of brca1 or 2, surgical interventions may significantly reduce the risk of cancer or death. contralateral mastectomy has been shown to reduce the risk of death in carriers by 48%. 128 prophylactic salpingooophorectomy has been shown to dramatically reduce the mortality due to ovarian cancer or breast cancer in brca1 mutation carriers. 129 similarly, identification of lynch syndrome mutations can permit surveillance leading to earlier detection and marked improvement in survival in patients developing colorectal, endometrial, or ovarian cancer. 130 although more than 2 decades have passed since sequencebased analysis of high-penetrance cancer genes has been performed, only laboratory-developed procedures have been available. countless patients and families have benefited from the availability of these ldps. epidermolysis bullosa (eb) is an inherited skin and connective tissue disease that causes skin and oral blistering with only mild trauma (http://www.niams.nih.gov/health_info/epidermolysis_ bullosa/epidermolysis_bullosa_ff. accessed november 4, 2016) . the severity of the disorder depends on the layer of skin where the tissue separation occurs. 131 approximately 99% of patients with biopsy-proven eb will have mutation(s) in 1 of 18 genes known to cause the disorder (http://www.niams.nih.gov/health_info/epider molysis_bullosa/epidermolysis_bullosa_ff. accessed november 4, 2016). knowledge of the specific gene can direct therapy and provide reproductive options for the family. for many years, it was possible only to sequence the suspect genes one by one, taking months to years, and only on a research basis. recently, with the advent of ngs technology, a small number of clinical laboratories have stepped in to develop a rapid multigene ngs approach that provides answers quickly in time to make treatment decisions as well as to provide carrier and prenatal testing in at-risk families. 131, 132 as new candidate genes have been identified, ngs has been validated and offered for clinical testing. under clia, the validation data collected by the laboratory was subject to ongoing peer review, and the laboratory participates in ongoing pt to demonstrate assay quality. as the disease is rare (200 children born with eb annually), 133 the cost of bringing such a test through fda for approval is prohibitive. without an available ldp, patients and families affected by this disease would go without specific diagnoses, be unable to enroll in gene/mutation specific therapies (currently in development by at least 4 pharmaceutical companies and academic centers) (http://www.debra.org/research-trials. accessed november 4, 2016), or have control over their reproductive lives. whole-exome sequencing (wes) involves evaluating the coding regions of all *20 000 human genes at once, to search for the underlying molecular cause of an undiagnosed but presumed genetic disorder. these tests are used for patients who already have undergone extensive genetic diagnostic testing and exhausted the (limited) fda and ldp singlegene tests or in cases where it is more cost-and timeeffective to start with wes. whole-exome sequencing is used for the so-called "diagnostic odyssey" patient and has a high diagnostic yield for these patients, with 25% to 30% of studies yielding a diagnosis. 134, 135 the tests are highly complex and involve capture of the relevant dna segments, sequencing of those segments, bioinformatics approaches to sequence alignment and identification of variants (differences between patient dna and reference), interpretation of the identified variants, and report generation. under clia and nysdoh, the technical validation data collected by the laboratory prior to offering wes are required, and the laboratory participates in ongoing pt (through cap and sample exchanges) to demonstrate assay quality. as this is cutting-edge science and medical practice, the capture and sequencing technology, bioinformatics, and interpretation tools are evolving at a very fast pace. to provide the best service to patients, laboratories must frequently update, revalidate, and offer new services. whole-exome sequencing is offered as an ldp by laboratories which have extensive experience in genetic testing. the time delay involved in bringing this test and its frequent modifications to the fda is prohibitive. as these tests serve the rare disease community, and reimbursement is limited by the lack of pricing for a specific cpt code, the cost of bringing wes through fda approval would be a major deterrent. innovation would be slowed, and likely several laboratories would remove the test from test menus. with 30 000 affected individuals in the united states, 136, 137 huntington disease (hd) falls under the category of a rare (or orphan) disorder, and given its limited market, no commercial genetic testing platform has been developed or submitted to the fda for review. the relatively small number of laboratories offering diagnostic or predictive (presymptomatic) testing for this disorder must therefore rely entirely on ldps, without which patients with hd and their at-risk relatives would have no access to testing and diagnosis. despite the characteristic clinical features (the movement disorder [chorea] along with intellectual decline), and lack of preventive or curative treatment for hd, genetic testing is widely relied upon by hd families and their physicians. onset of symptoms is often insidious and nonspecific, and definitive early diagnosis can only be accomplished at the dna level. 132 presymptomatic testing, which is offered to the adult offspring of patients with hd (who are at 50% risk of inheriting this autosomal dominant disease), can only be accomplished using ldps and allows crucial life-planning decisions, such as educational pursuits and career choices, marriage, and whether to have children (and if so, affording the ability to pursue prenatal diagnosis) and whether to begin planning for inevitable disability. without this test, all of these at-risk relatives (of which there are an estimated 200 000 in the united states) 137 would lead their lives anxiously waiting for the symptoms to begin, when half of them are actually at no risk because they did not inherit the mutant gene from their affected parent. although there are at-risk relatives who choose not to avail themselves of the predictive test, the many who do opt to be tested credit it with freeing them of years of obsessive uncertainty. the results can afford the affected patients the opportunity to enroll in clinical trials (involving drugs or neuronal stem cells), with the aim of preventing or delaying the onset of symptoms. 138 although these studies are still in an early phase with no outcome data yet available, they give patients some hope for the future, perhaps for themselves but also for future patients. given the mechanism of gradual neuronal cell death in the basal ganglia, it stands to reason that the earlier such intervention is initiated-ideally in the presymptomatic stage-the higher the chances of success. huntington disease is one of the trinucleotide repeat disorders, caused by expansion of a tandem repeat of cag in the first intron of the huntingtin (htt or it15) gene. in contrast to fx syndrome and some of the other trinucleotide repeat disorders, the difference between the mutated and nonmutated repeat length can be as little as a single repeat (ie, 3 nucleotides). thus, extreme care is required in the sizing of the repeat, especially when it falls near the cutoff length of 40 40 repeats or higher which is diagnostic or predictive of hd, with 100% penetrance. fortunately, the ldps in current use, relying on capillary electrophoresis, are very accurate in determining repeat length, as attested by the excellent performance in cap proficiency surveys. busulfan is a bifunctional dna alkylating agent typically given to patients as a conditioning agent prior to hematopoietic cell transplantation (hct) for the treatment of hematologic malignancies. therapeutic drug monitoring (tdm) is crucial for the safe and efficacious use of busulfan due to a narrow therapeutic index based on area under the curve (auc) calculations. too low a dose places the patient at risk of either graft failure or early relapse. 139, 140 on the other hand, too high a dose increases the risk of neurotoxicity 141 as well as a severe and life-threatening complication termed hepatic sinusoidal obstruction syndrome (sos). 139, 142 hepatic sos, previously termed hepatic veno-occlusive disease (vod), refers to the occlusion of terminal hepatic venules and hepatic sinusoids. severe cases of vod can lead to hepatorenal syndrome, causing multi-organ failure, hepatic encephalopathy, and death. veno-occlusive disease typically occurs in the context of hct, particularly after administration of conditioning regimens prior to hct. it is one of the most feared complications of hct and accounts for a significant fraction of hct-related mortality. 143 severe cases, which account for approximately 25% to 30% of sos, are almost always fatal. 142, 144, 145 despite a clear need for busulfan tdm, there are currently no fda-approved assays available for the quantitation of busulfan in blood. for this reason, various bioanalytical methods have been developed 146 and are currently in use by multiple laboratories. data from a busulfan proficiency program organized by the university of washington/seattle cancer care alliance show a total of 24 participating laboratories at the present time. of these, 6 laboratories use gas chromatography (gc) methods, 3 use hplc methods, and 14 use liquid chromatography-tandem mass spectrometry (ms) methods. 147 all of these methods are non-fda-approved tests independently developed and validated for clinical use by their respective clinical laboratories. the use of these methods is also driven by the need for high precision and accuracy. current criteria for acceptable laboratory performance in the analysis of busulfan is +10% of the known concentrations for medium and high concentrations and within +15% of the known concentration for low concentrations. 147 this is due to the fact that dosing change decisions are based on auc calculations, which depend on blood concentrations of busulfan measured from multiple timed blood draws. multiple small analytical errors can easily add up to big differences in calculated auc values. busulfan testing is currently available from reference laboratories. however, many busulfan regimens call for intravenous infusions every 6 or 24 hours for 3 to 4 days. bone marrow transplant teams need quicker turnaround times than can be reasonably provided by sendout testing in order to be able to make dosing adjustments within this limited timespan. guidelines have also been recently published by the american society for blood and marrow transplantation guidelines committee advocating for personalized busulfan dosing using busulfan tdm in certain busulfan regimens. 148 for these reasons, laboratory-developed methods for busulfan will continue to play key roles in the management of hematologic malignancies at cancer centers throughout the world. very sensitive measurements of serum androgens are important in adult and pediatric endocrinology and oncology. very-low-level testosterone (te) measurements are needed for adult women, whose values are routinely <50 ng/dl, in children, and men undergoing antiandrogen therapy whose values are usually <10 ng/dl. 149 the most commonly used methods for steroid analysis are fda-approved immunoassays because they are rapid and sensitive enough for most routine applications involving healthy adult males. however, te immunoassays lack the sensitivity requirements for chemically castrated males, women, and children. many immunoassays also lack specificity and accuracy as immunoassays may show cross-reactivity with structurally similar compounds. [150] [151] [152] in addition, most immunoassays are not standardized against internationally recognized standards. for these reasons, a number of sensitive and specific assays using ms have been described for te. [153] [154] [155] the lack of sufficient accuracy and standardization of te assays is a major concern for the clinical and public health communities. 156 several years ago, the endocrine society, in partnership with the cdc, convened a meeting with various relevant professional societies and industrial partners to create the partnership for the accurate testing of hormones (path) whose mission is to improve the accuracy and standardization of a variety of steroid hormone tests. [156] [157] [158] the path has worked with the cdc and begun to address this concern through its host program, which provides laboratories with specimens spanning their analytical measurement range that have been previously analyzed using the cdc reference method. 155 many assays using ms have been approved by the cdc host program, 159 however not a single fda-approved immunoassay has met the performance requirements. testosterone is a perfect example of an ldp that is indispensable for patient care and allows for accurate measurements to be made on children, women, and male patients with cancer receiving antiandrogen medication. ethylene glycol is a colorless, sweet-tasting liquid commonly encountered in automobile antifreeze. because of this widespread availability, it is also a commonly encountered toxicological agent in both accidental and self-inflicted poisonings with 6078 exposures in 2014. 160 ethylene glycol poisoning classically presents with a metabolic acidosis caused by the production of toxic metabolites, primarily glycolic acid and oxalic acid. this is also often accompanied by an anion gap and osmolal gap. untreated ethylene glycol poisoning can also progress to acute renal failure when high levels of oxalate anions combine with calcium to develop crystals in the kidneys and urinary tract. 161 ethylene glycol poisoning is an urgent, toxicological emergency. once ethylene glycol is identified, the drug fomepizole is typically administered. fomepizole inhibits alcohol dehydrogenase, the enzyme that metabolizes ethylene glycol, to slow the accumulation of toxic metabolites. fomepizole and ethanol dramatically lengthen the half-life of ethylene glycol, and therefore, hemodialysis is often required to clear the poison. 162 both the diagnosis and treatment of ethylene glycol poisoning are heavily dependent on laboratory measurements. no fda-approved assays for ethylene glycol are currently available, and all testing is performed by laboratory-developed procedures. the 3 most common methods for the analysis of ethylene glycol are gc with flame ionization detector, gc with ms, and enzymatic assays. 163, 164 gas chromatography with mass spectrometry is considered the gold standard for the analysis of ethylene glycol, as it can differentiate it from interferences that plague the other 2 methods. 163, 165 in addition to initial detection needed for diagnosis, the ethylene glycol blood concentration is used to determine when hemodialysis has cleared ethylene glycol to undetectable levels. measurement of thyroglobulin (tg) in serum has proven useful for detecting recurrence of treated differentiated thyroid carcinoma (dtc). according to the american cancer society, the united states has over 60 000 new thyroid cancer cases each year. the death rate is almost 2000 per year. differentiated thyroid cancer accounts for over 90% of cases. differentiated thyroid cancer produces tg, making its measurement useful as a tumor marker for detecting recurrence. the nccn and american thyroid association (ata) guidelines recommend tg testing following total thyroidectomy and radioiodine ablation treatment, including tests at baseline, 6 to 12 weeks after treatment, 6 months, 12 months, and annually thereafter. patients free of disease have undetectable tg. older competitive tg-ria methods are available but produce falsely high tg results in the presence of tg autoantibodies (tg-ab). 166 newer fda-cleared tg assays are immunometric immunoassays (tg-ia) and can detect tg at concentrations down to approximately 0.1 ng/ml. generally, tg is captured with a solid-phase antibody, then quantitated using a detection anti-tg reagent. the signal is directly proportional to the amount of tg. the assay design is susceptible to interference from endogenous anti-tg-ab. 166 the intended use of these tg-ia are tg measurement in tg-ab-negative (tg-ab ã� ) patients. the fda requires tg-ab testing whenever tg is measured using these cleared methods. depending on the method used, up to 36% of treated patients with dtc are tg-ab positive (tg-ab ã¾ ). thus, many of these patients have falsely low or even falsely negative tg results when measured by ia. four tg-ab assays are in common use and are not harmonized, detecting tg-ab in widely divergent numbers of treated patients with dtc. 167 in addition, the degree of tg interference cannot be predicted from the magnitude of the tg-ab result. thus, up to 20% of patients with recurrence are missed by tg-ia testing. to circumvent the tg-ab interference, hoofnagle and wener developed and validated a ms tg method (tg-ms) using tryptic digestion and immunocapture of tg-specific peptides followed by ms focused on those peptides. 167 they demonstrated the tg-ms method accurately measures tg in the presence of tg-ab. 162 the tryptic digestion destroys the tg-ab, eliminating their interference with the assay. four national reference laboratories have adopted versions of this method, and harmonization efforts are underway. a recent clinical outcome study compared tg-ia, tg-ria, and tg-ms in both tg-ab ã� and tg-ab ã¾ patients. as predicted from the assay designs, all methods were equivalent for tg-ab ã� cases, but the tg-ms was more accurate for tg-ab ã¾ cases. tg-ia methods had more false negatives and tg-ria had more false positives. 168 although tg-ms has not yet been incorporated into the current guidelines, the ata guideline mentions it as a promising new technique. without tg-ms, thyroid cancer recurrence in tg-ab ã¾ patients can be missed, thus delaying follow-up and creating patient harm. antimicrobial susceptibility testing, used to determine whether antibiotic treatment will be successful, is an essential component of the microbiology culture report. emerging resistance among pathogenic bacteria and new antimicrobial agents require frequent updates to both testing methods and interpretation of the results. most laboratories use automated instruments to perform minimal inhibitory concentration (mic) testing to determine whether a patient's isolated bacteria are susceptible, susceptible dose dependent, intermediate, or resistant to a panel of antibiotics. these interpretations are based on fda breakpoint criteria published at the time of drug approval and periodically updated to respond to the appearance of new resistance mechanisms. 169 the fda also clears automated instrumentation used to determine mic values (via the 510k process). 170 although the mic testing process may not be changed, new breakpoints added to the instrument software require a revised 510k application. because the fda does not have the authority to require manufacturers to submit data for revised breakpoints within a specified time frame, manufacturers may elect to use outdated breakpoints rather than face the expense of a 510k resubmission. a recent example was the 3year delay between the release of updated breakpoints for diagnosing carbapenem-resistant enterobacteriaceae in 2010 and the ability to use these breakpoints in the clinical laboratory. this delay was used to calculate the potential for additional carriers of multidrug-resistant enterobacteriaceae in southern california health-care systems. as many as 1821 additional carriers of mdro enterobacteriaceae were estimated to have occurred in orange county, california because of this delay. 171 the disastrous spread of mdro enterobacteriaceae can be mitigated by laboratories validating testing methods that enable use of updated antimicrobial breakpoint interpretations before fda-cleared testing is available. specifically, modifying a manufacturer's instructions, including interpreting mic results using a revised breakpoint other than that listed in the product insert, is a change that renders the procedure an ldp. without the option of using an ldp, one is left reporting outdated interpretations that miss resistant strains leading to unacceptable patient care. as illustrated, ldps are an integral part of the spectrum of tests and procedures performed by clinical laboratories which fulfill a critical need for patient care, particularly in rapidly evolving areas such as testing for personalized medicine. laboratory testing should be consistent with national/international consensus treatment guidelines, which may require development of procedures earlier or for new clinical purposes not fulfilled by fda-approved kits. in such cases where clinical testing needs exist beyond the original fda purpose, laboratories must be able to perform additional validation of new sample types or develop additional assays to include new mutations or analytes that are needed. as illustrated by these case examples, laboratories and professional organizations often work together to broadly compare and optimize assay performance, creating consensus standards that raise the quality of testing overall. in contrast, the current structure for fda approval requires review of assay kits individually, or in comparison with the predicate method, rather than assessing and improving performance across the spectrum of assay options available. the science of laboratory medicine has advanced dramatically in the almost 3 decades since clia was enacted, and updates and expansions to clia regulations could be useful. additional resources, such as reference materials, and consensus practice guidelines would extend the quality framework that all laboratories and manufacturers utilize. for example, consensus guidelines that include such details as the target for percent allele frequency detectable, requirements for percent tumor cell content, what mutations and variants should be included, and sample types to be tested would be useful as a guide for assay validation as well as in standardization of the practice. professional expert groups are already generating assay and practice guidelines. 69, 73, [172] [173] [174] [175] ideally, clinical laboratories and kit manufacturers would utilize appropriate reference materials to help standardize the results obtained for any particular analyte regardless of technology platform or laboratory setting. to address the needs for reference materials to facilitate assay result standardization, a multistakeholder initiative, the diagnostic quality assurance pilot, has been launched to design, develop, and evaluate traceable reference sample materials (referred to as reference materials) to better provide molecular pathology laboratories with the means to demonstrate equivalent performance of ldps and companion diagnostic ivds for targeted cancer therapy. this quality pilot emerged from the sustainable predictive oncology therapeutics and diagnostics working group, launched in 2013 by tapestry networks (waltham, massachusetts), which was composed of diverse stakeholders (oncologists, pathologists, patient advocates, third party payers, and regulators) for the purpose of designing a quality pilot to advance these goals (http://www.ta pestrynetworks.com/initiatives/healthcare/oncology-therapeu tics-and-diagnostics/diagnostic-quality-assurance-pilot.cfm. accessed april 27, 2017). 176 the tapestry pilot proposes that laboratories would be allowed to utilize assays that best serve the needs of their patients based upon performance, quality, clinical needs, and the test menus and volumes of that particular laboratory. it is not critical that laboratories all use the identical assay or test platform, provided that all are able to get the correct answer. to close, the overarching goal is the efficacy and safety of our clinical laboratory tests and procedures for patients. pathologists and laboratory professionals need the best and most upto-date tools to do their jobs and optimize patient care. some of these will be fda approved or cleared kits, and others will be laboratory-developed procedures performed under clia; both have their place. laboratories have a long history of success performing ldps, as illustrated by these case studies. as much as possible, these capabilities need to be performed on-site to insure that the results can be integrated with other clinical and laboratory findings, interpreted as a whole and completed in a timely fashion. also important is the handson training of the next generation of physicians, for whom, we hope, maximal use of genomic and other laboratory information will be a way of life as they treat human disease. that is the promise of personalized medicine! the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. the '70% claim': what is the evidence base? evidence-based laboratory medicine the public health evidence for fda oversight of laboratory developed tests: 20 case studies the public health evidence for fda oversight of laboratory developed tests: 20 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document m100-s27 but no tests! the challenge of antimicrobial susceptibility testing in the current us regulatory landscape impact of delays between clinical and laboratory standards institute and food and drug administration revisions of interpretive criteria for carbapenem-resistant enterobacteriaceae the spectrum of clinical utilities in molecular pathology testing procedures for inherited conditions and cancer next-generation sequencing for infectious disease diagnosis and management: a report of the association for molecular pathology laboratory practice guidelines for detecting and reporting jak2 and mpl mutations in myeloproliferative neoplasms the role of mgmt testing in clinical practice diagnostic quality assurance pilot: a model to demonstrate comparative laboratory test performance with an oncology companion device assay the authors would like to thank the college of american pathologists, dr jason merker and ms patty vasalos, for facilitating access and allowing use of data from cap interlaboratory proficiency testing programs. ms mary williams, dr barbara zehnbauer, dr peter hulick, and dr david klimstra provided valuable comments on the manuscript. ms laura metz provided clerical support. key: cord-023528-z9rc0ubj authors: wilkins, pamela a. title: disorders of foals date: 2009-05-18 journal: equine internal medicine doi: 10.1016/b0-72-169777-1/50021-4 sha: doc_id: 23528 cord_uid: z9rc0ubj nan before the 1980s, intensive management of the compromised neonate was unusual and little was known regarding many of the problems of this special patient population. although some specific conditions had been described by astute clinician-researchers, most notably the "dummy" foal syndrome 1 and respiratory distress syndrome caused by primary surfactant deficiency, 2 little information regarding the diagnosis and management of conditions of the foal during the neonatal period was available, although at least one active group was investigating fetal and neonatal physiology of the horse in great britain. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] when treatment of compromised foals was undertaken, the approach most commonly resembled treating them as small adults with little understanding of the different physiology of the equine neonate. the advent of improved management of reproductive efficiency of mares led naturally to increased interest in preservation of the conceptus to parturition and the foal thereafter. interested clinicians, taking their lessons from the field of human perinatology/neonatology and sometimes working hand-in-hand with their counterparts in the human field, pioneered investigations into these small patients and created the fields of equine perinatology and equine neonatal intensive care. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] because of the foresight and energy of these early investigators, the field of veterinary perinatology/neonatology exploded in the 1980s, leading to the creation of equine neonatal intensive care units throughout the united sates and the world. from these units information about the normal and abnormal physiology of foals, the medical conditions affecting them, and methods for treatment and management of these problems has been developed through observational, retrospective, and prospective studies. this veritable explosion of information over the last 20 years has improved greatly the ability of all practitioners to provide appropriate care for these patients, whether in the field or at an equine neonatal intensive care unit. the ability not only to save the lives of these patients but also to treat them in such a manner as to allow them to fulfill their purposes, whether as pleasure animals or racing athletes, has improved almost exponentially from those early days. [20] [21] [22] [23] this chapter aims to provide the clinician with some of the most current information regarding the management of these patients, recognizing that much still remains unknown and that advances will continue to be made in this dynamic field. the reader is cautioned that much of this chapter is flavored by the experiences of the author and that variation in approach and treatment of specific problems exists between neonatal intensive care units (nicus) and between clinicians in the same nicu and that each year results in change. in some cases, information that is presented has been gleaned from human nicu studies, essentially using the critically ill infant as the experimental model. many of the problems of the newborn foal have their genesis in utero. identification of high-risk pregnancies is an important component of prenatal care of the foal, and some of the most commonly encountered problems of the dam resulting in abnormal foals include previous or concurrent disease, poor reproductive history, poor perineal or pelvic conformation, poor general health, poor nutritional condition, prolonged transport, history of previous abnormal foals, placental abnormalities, and twins. 24 some of the more common causes of abortion can result in the birth of severely compromised foals of variable gestation lengths (box 19-1). these include pa m e l a a . wi l k i n s infectious causes such as equine herpesvirus (ehv) types 1 (most commonly) and 4 (rarely), equine infectious anemia, equine arteritis virus, bacterial and fungal placentitis, leptospirosis, equine ehrlichiosis, and gram-negative septicemia/endotoxemia. [25] [26] [27] noninfectious causes of abortion include twinning and noninfectious placental abnormalities such as extensive endometrial fibrosis, body pregnancy, and abnormal length (long or short) of the umbilical cord. 24, 28 to the equine neonatologist opportunities for intervention may appear limited, and in the case of many of the aforementioned causes of fetal loss, this is true. however, one can do much in an attempt to preserve the pregnancy and in effect treat the fetus. when one is faced with a threatened pregnancy, one has various ways of evaluating the fetus and its environment and may use many potential therapies. once one identifies a pregnancy as high risk, one should evaluate the fetus for viability. evaluation should include as thorough an evaluation as possible of the reproductive tract, placenta, and fetal fluids. prepartum disorders in the mare usually are readily recognizable, but disorders of the fetus and placenta can be more subtle and difficult to determine. the first step is to take a thorough history of the mare. of particular interest is any history of previous abnormal foals, but the history taking should include questions regarding transportation; establishment of an accurate breeding date (sometimes more difficult than one would suspect); any pertinent medical history including any diagnostic testing performed for this pregnancy such as culture, endometrial biopsy, and cytologic results; and any rectal and ultrasound examination results. additionally, one should obtain information regarding possible ingestion of endophyte-infected fescue or exposure to potential infectious causes of abortion. 29, 30 a complete vaccination and deworming history is requisite, as is a complete history of any medications and supplements administered during pregnancy. after obtaining a history, one examines the mare per rectum. this examination should include palpation of the cervix, uterus, fetus, and all palpable abdominal contents. one should note any abnormalities. the cervix should be tight throughout gestation; the late gestation uterus will be large and distended with fluid and usually pulled craniad in the abdomen. palpation of the fetus frequently results in some fetal movement; however, one should interpret lack of movement with caution, for some normal fetuses do not respond. ultrasonographic evaluation of the uterus and conceptus per rectum can provide valuable information, particularly regarding placental thickness if placentitis is a concern. one may evaluate fetal fluids and estimate fetal size from the size of the eye later in gestation. 31 in the author's hospital the practitioners choose not to perform vaginal examinations or speculum examinations because of an association between these examinations and the subsequent development of placentitis. unless placentitis is recognized with ultrasonograhic evaluation per rectum and culture is desirable, these types of examinations are generally not necessary. following examination per rectum, one performs transabdominal ultrasonographic evaluation of the uterus and conceptus. 28 one can generate a biophysical profile of the fetus from this examination in the late-term fetus and readily determine viability. 32, 33 one also readily can determine the presence or absence of twins in the late pregnant mare in this manner. one performs the sonogram through the acoustic window from the udder to the xiphoid ventrally and laterally to the skinfolds of the flank. imaging of the fetus usually requires a lowfrequency (3.5-mhz) probe, whereas examination of the placenta and endometrium requires a higher-frequency (7.5-mhz) probe. a complete description of this examination is beyond the scope of this chapter, but the reader will find several complete descriptions of the technique and normal values for specific gestation lengths within the relevant veterinary literature. 33 the utility of this examination lies in its repeatability and low risk to the dam and fetus. sequential examinations over time allow the clinician to follow the pregnancy and to identify changes as they occur. a companion to transabdominal ultrasongraphy is evaluation of the fetal electrocardiogram (ecg). one can measure fetal ecgs continuously using telemetry or can obtain them using more conventional techniques several times throughout the day. 24, 28, 34 one places electrodes on the skin of the mare in locations aimed at maximizing the magnitude of the fetal ecg. because the fetus frequently changes position, multiple sites may be needed in any 24-hour period. to begin, one places an electrode dorsally in the area of the sacral prominence with two electrodes placed bilaterally in a transverse plane in the region of the flank. the fetal ecg maximal amplitude is low, usually 0.05 to 0.1 mv, and can be lost in artifact or background noise, so one commonly must move electrodes to new positions to maximize the appearance of the fetal ecg. the normal fetal heart rate during the last months of gestation ranges from 65 to 115 beats/min, a fairly wide distribution. the range of heart rate of an individual fetus can be narrow, however. bradycardia in the fetus is an adaptation to in utero stress, most commonly thought to be hypoxia. by slowing the heart rate, the fetus prolongs exposure of fetal blood to maternal blood, increasing the time for equilibration of dissolved gas across the placenta and improving the oxygen content of the fetal blood. the fetus also has altered the distribution of its cardiac output in response to hypoxia, centralizing blood distribution. 35, 36 tachycardia in the fetus can be associated with fetal movement, and brief periods of tachycardia should occur in the fetus in any 24-hour period. persistent tachycardia is a sign of fetal distress and represents more severe fetal compromise than bradycardia. the author has recognized dysrhythmias in the challenged fetus, most commonly as atrial fibrillation but also apparent runs of ventricular tachycardia. the ability to monitor the fetus in a high-risk pregnancy inevitably has led to questions of whether, how, and when to intervene. most equine neonatologists would agree that removal of the fetus from the uterus before its attainment of readiness for birth is not desirable. one of the difficulties in determining fetal preparedness for birth is that prediction of parturition is difficult in these mares. many of the parameters used in normal mares are unreliable in the high-risk pregnant mare. one must have an accurate history of any previous gestation length in terms of days for the specific mare in question to allow a more accurate estimate of her usual gestational length. evaluation of the usual mammary gland parameters, including size, the presence of "wax," and alteration of electrolyte concentrations, is not generally predictive in the high-risk mare, for in the author's experience many of these mares have changes predictive of parturition for weeks before actual parturition. 37, 38 this circumstance may be related to the observation that many high-risk pregnant mares, particularly those with placentitis, are presented for a primary complaint of early onset lactation. although pulmonary system maturity in human beings can be assessed with some degree of accuracy using measurement of lecithin/sphingomyelin ratios, this measurement-along with sphingomyelin, cortisol, and creatinine concentrations in the amnionic fluid-has proved to be of no benefit in the horse. [39] [40] [41] amniocentesis carries a high risk of abortion in the horse, even with ultrasound guidance, and is not a clinically useful technique at this time. 41 currently, no clear-cut guidelines are available as to when to intervene, but the presence of persistent fetal tachycardia or prolonged absence of fetal movements, including breathing movements, as determined by transabdominal ultrasound evaluation, should initiate discussion regarding the appropriateness of induction of parturition or elective cesarean section. the goal of induction or cesarean section is to remove a pregnancy that is threatening the survival of the dam with no thought to fetal survival or to remove the fetus from a threatening environment to improve its likelihood for survival. preterm induction is ill advised if fetal survival is desirable because of the limited ability to treat severely immature neonates. timing of intervention in these circumstances remains an art, not a science. the approach to management of the high-risk pregnancy is dictated to some degree by the exact cause for concern, but for many mares therapy is similar. many high-risk mares have placentitis, primarily caused by ascending bacterial or fungal infections originating in the region of the cervix. these infections can cause in utero sepsis or compromise the fetus by local elucidation of inflammatory mediators or altered placental function. 42, 43 premature udder development and vaginal discharge are common clinical signs. treatment consists of administration of broad-spectrum antimicrobial agents and nonsteroidal antiinflammatory drugs (table 19 -1). in the author's clinic, trimethoprim-sulfonamide drugs have been the antimicrobial of choice based on unpublished studies performed at the facility demonstrating increased concentration of these agents in the fetal fluids compared with penicillin and gentamicin. however, if culture and sensitivity results are available, one should institute directed therapy. nonsteroidal antiinflammatory agents such as flunixin meglumine are useful to combat alterations in prostaglandin balance that may be associated with infection and inflammation. although the efficacy of these agents is best when administered before the development of clinical signs, to date no detrimental effects have been reported in the fetus or dam when chronically used at low doses in well-hydrated patients. tocolytic agents and agents that promote uterine quiescence have been used and include altrenogest, isoxuprine, and clenbuterol. [44] [45] [46] [47] [48] altrenogest usually is administered, although its need in late gestation has been challenged. the efficacy of isoxuprine as a tocolytic in the horse is unproven, and bioavailability of orally administered isoxuprine appears to be highly variable. 48 the long-term use of clenbuterol is inadvisable because of receptor population changes associated with chronic use and its unknown effects on the fetus at this time. clenbuterol may be indicated during management of dystocia in preparation for assisted delivery or cesarean section. 46 the intravenous form of clenbuterol is not currently available in the united states. one can use three additional strategies in managing high-risk pregnancy patients. in mares with evidence of placental dysfunction, with or without signs of fetal distress, the author provides intranasal oxygen supplementation in the hope of improving oxygen delivery to the fetus. intranasal oxygen insufflation of 10 to 15 l/min to the mare significantly increases pao 2 and percent oxygen saturation of hemoglobin. 49 because of the placental vessel arrangement of the horse, improvement of these two arterial blood gas parameters should result in improved oxygen delivery to the fetus. blood gas transport is largely independent of diffusion distance in the equine placenta, particularly in late gestation, and depends more on blood flow. information from other species cannot be extrapolated to the equine placenta because of its diffuse epitheliochorial nature and the arrangement of the maternal and fetal blood vessels within the microcotyledons. 50,51 umbilical venous po 2 is 50 to 54 mm hg in the horse fetus, compared with 30 to 34 mm hg in the sheep, whereas the maternal uterine vein to umbilical vein po 2 difference is near 0. also unlike the sheep, the umbilical venous po 2 values decrease 5 to 10 mm hg in response to maternal hypoxemia and increase in response to maternal hyperoxia. [52] [53] [54] vitamin e (tocopherol) is administered orally to some high-risk mares as an antioxidant. administration of large doses of vitamin e before traumatic brain injury improves neurologic outcome in experimental models and has been examined as possible prophylaxis for human neonatal encephalopathy. [55] [56] [57] extrapolation of that information to the compromised equine fetus suggests that increased antioxidant concentrations in the fetus may mitigate some of the consequences of uterine and birth hypoxia, but no evidence is available to date demonstrating that protection occurs or that vitamin e accumulates in the fetus in response to supplementation of the mare. finally, many high-risk mares are anorectic or held off feed because of their medical condition. these mares are at particularly great risk for fetal loss because of their lack of feed intake, which alters prostaglandin metabolism. 58 therefore one should administer 2.5% to 5% dextrose in 0.45% saline or water (5% dextrose) intravenously at maintenance fluid rates to these patients. perhaps the most important aspect of managing high-risk pregnancy mares is frequent observation and development of a plan. one should observe mares at least hourly for evidence of early-stage labor and should put them under constant video surveillance if possible. depending on the primary problem, the team managing the mare should develop a plan for handling the parturition once labor begins and for fetal resuscitation following delivery. any equipment that might be needed should be readily available stallside, and a call sheet, listing contact numbers for all involved, should be posted on or near the stall. the plan should include a decision as to how to handle a complicated dystocia, should it occur, with permission for general anesthesia and cesarean section obtained before the event so that time is not wasted. an important question to be posed to the owner at the outset is which is most important to the owner, the mare or the foal, for the answer may dictate the direction of the decision tree once labor begins. 59 early recognition of abnormalities is of utmost importance for successful management of critically ill foals. to recognize the abnormal, one must know the normal. immediately following birth, foals effect several important physiologic and behavioral changes. chief among these changes is the adaptation of the cardiovascular and respiratory systems to extrauterine life. the normal transition of the respiratory tract involves opening closed 1384 part ii disorders of specific body systems alveoli and absorption of fluid from the airway, accomplished by a combination of breathing efforts, expiration against a closed glottis (grunting), and a change in sodium flux across the respiratory membrane from net secretion to net absorption. [60] [61] [62] [63] [64] the transition from fetal to neonatal circulatory patterns requires resolution of the pulmonary hypertension present in the fetus, normally shunting blood flow through the lower resistance ductus arteriosus in the fetal state, to direct cardiac output to the pulmonary vasculature for participation in gas exchange. this change is achieved by the opening of alveoli, decreasing airway resistance and providing radial support for pulmonary vessels, functional closure of the ductus arteriosus, and increasing the oxygen tension in the lung, reversing pulmonary vasoconstriction mediated by hypoxia. 65, 66 pulmonary tree vasodilators (prostacyclin, nitric oxide [no] ) and vasoconstrictors (endothelin-1, leukotrienes) play apparently well-coordinated, but as yet not fully elucidated, roles. in the normal newborn this change is smooth and rapid. these critical events are undermined by factors such as inadequate lung development, surfactant deficiency (primary or secondary), viral or bacterial infection, placental abnormalities, in utero hypoxia, and meconium aspiration. spontaneous breathing should begin in the neonate within 1 minute of birth, many foals attempt to breathe as their thorax clears the pelvic canal. during the first hour of life, the respiratory rate of a healthy foal can be as high as 80 breaths per minute but should decrease to 30 to 40 breaths per minute within a few hours. similarly, the heart rate of a healthy newborn foal has a regular rhythm and should be at least 60 beats/min at the first minute. 67, 68 one usually can auscultate a continuous murmur over the left side of the heart, although its loudness may vary with position. this murmur is thought to be associated with some shunting through the ductus arteriosus. one may auscultate variable systolic murmurs, thought to be flow murmurs, during the first week of life. 69 one should investigate more thoroughly murmurs that persist beyond the first week of life in an otherwise healthy foal, along with any murmur associated with persistent hypoxia. auscultation of the thorax shortly after birth reveals a cacophony of sounds as airways open and fluid is cleared. end-expiratory crackles are consistently audible in the dependent lung during and following lateral recumbency. for a normal newborn foal to appear slightly cyanotic during this initial adaptation period is not unusual, but this should resolve within minutes of birth. the equine fetus, as do all fetuses, exists in a moderately hypoxic environment, but the equine fetus has a greater partial pressure of oxygen, around 50 mm hg. 70 because the fetus is well adapted to low oxygen tensions, cyanosis is rarely present in newborn foals once adaption occurs, even those with low oxygen tensions. although in many species the fetal blood oxygen affinity is greater than the maternal blood, in the equine fetus the oxygen affinity of its hemoglobin is only about 2 mm hg greater than the maternal blood because of decreased levels of 2,3-diphosphoglycerate compared with other species. 71 the result is enhanced oxygen unloading in the equine fetus compared with others. 2,3-diphosphoglycerate concentration increases after birth in the foal and reaches mature levels by 3 to 5 days of age. the major blood adaptation of the equine fetus to chronic hypoxia is an increase in packed cell volume of up to 20%, increasing the oxygen content of the blood as compensation for decreased oxygen delivery at the placenta. 72 a larger than expected packed cell volume in any newborn foal should alert the clinician for possible sequelae from chronic hypoxia. the presence of significant cyanosis that persists should prompt the clinician to evaluate the foal thoroughly for cardiac anomalies resulting in significant right-to-left shunting or separated circulations, such as transposition of the great vessels. the chest wall of the foal is compliant, facilitating passage through the pelvic canal during parturition. this compliance requires that the foal actively participate in inspiration and expiration with several potential consequences. first, restriction of the thorax or the abdomen can result in impaired ventilation, which can occur easily when one restrains a foal and may result in spuriously abnormal arterial blood gas values (see the discussion on arterial blood gas evaluation, respiratory diseases associated with hypoxemia in the neonate). second, foals with primary pulmonary parenchymal disease resulting in poorly compliant lungs develop paradoxical chest wall motion, with the thorax moving inward during inspiration. [73] [74] [75] [76] the work of breathing can increase greatly, resulting in respiratory failure because of respiratory muscle fatigue. a foal that appears suddenly to improve a previously abnormal respiratory rate and pattern may in fact be in greater respiratory difficulty because of fatigue. one can observe a reduction in respiratory rate or abnormal breathing pattern in premature/dysmature foals or foals subjected to peripartum hypoxia/asphxia. although the genesis of these patterns is not understood fully, cheyne-stokes (lengthy periods of apnea interrupted by short breaths that wax and wane in depth), cluster (short periods of apnea interspersed with long periods of breathing), and biot's breathing (periods of apnea and breathing with no discernible pattern) may occur in these cases. foals attempting to maintain an adequate lung volume expire against a partially closed glottis, called valsalva's maneuver, producing an audible grunt. foals are normally nonresponsive while in the birth canal but should respond to stimulation immediately after birth. 67 the lack of responsiveness while in the birth canal has lead to presumption of fetal death during dystocia. because of this, one should attempt other tests before determining that a foal is dead intrapartum. one possibly may detect pulses in the tongue, neck, or any presented limbs or palpate the thorax for a heartbeat. in the author's facility, nasotracheal intubation of the foal combined with measurement of co 2 tensions in the exhaled gas aids practitioners in cases where they can reach the nose. nasotracheal intubation of foals under these circumstances actually can be performed readily with minimal practice. having long endotracheal tubes available of several different diameters (7 to 12 mm outer diameter) with an inflatable cuff is important. one can pass the tube blindly using a finger in one nostril for guidance and can check the position frequently by palpation of the throatlatch region. one inflates the cuff and begins manual ventilation with 100% oxygen or room air using an ambu-bag or equivalent. one can obtain continuous measurement of co 2 tension using a capnograph or single-use disposable end-tidal co 2 monitor attached to the ambu-bag or the nasotracheal tube. in a dead foal the end-tidal co 2 measurement will be negligible after the first 10 to 20 breaths. one must ensure tube placement and seal integrity and allow for multiple breaths. some co 2 will "wash out" with the first few breaths and can result in false hope initially. end-tidal co 2 varies in living intrapartum foals, depending on cardiac output and ventilation frequency, but should be consistently greater than 20 mm hg and is usually closer to 30 mm hg. once one establishes manual ventilation of a living foal, one must continue ventilation until the foal is delivered satisfactorily. the author has resuscitated and maintained many foals successfully in this manner throughout induction of general anesthesia in the mare and cesarean section delivery of the foal. the nasotracheal tube also provides a convenient site for administration of intratracheal medications such as epinephrine used for extrauterine intrapartum resuscitation of the foal. the reader is cautioned that intratracheal epinephrine increases endtidal co 2 measurements transiently, even in a dead foal, because of local actions on tissues. one should allow a washout period after intratracheal administration of epinephrine. the righting reflex is present as the foal exits the birth canal, as is the withdrawal reflex. cranial nerve responses are intact at birth, but the menace response may take as long as 2 weeks to develop fully. one should not consider lack of a menace reflex diagnostic of visual deficits in the newborn foal. within an hour of birth the normal foal will demonstrate auditory orientation with unilateral pinna control. the normal pupillary angle is ventromedial in the newborn foal; this angle gradually becomes dorsomedial over the first month of life. foals should begin attempting to stand shortly after birth and should be able to achieve this on their own within 2 hours of birth. 67 the normal newborn foal has a suck reflex shortly after birth and should be searching for an udder even before it stands. the expectation is that a normal foal will be sucking from the dam unaided by 3 hours post partum; many foals are overachievers and will be sucking well before this time. the normal foal may defecate shortly after standing but may not attempt defecation until after it first successfully sucks from the dam. urination varies more, with filly foals usually urinating before colt foals, but both usually do not urinate for several hours following birth, up to 12 hours for some colts. 67 for colt foals to fail to drop their penises when urinating over the first few days of life is not unusual. the gait of the newborn foal is hypermetric and the stance is base wide. extreme hypermetria of the forelimbs, usually bilateral but occasionally unilateral, has been observed in some foals and is associated with perinatal hypoxic/ischemic insults, but this gait abnormality usually resolves without specific therapy within a few days. spinal reflexes tend to be exaggerated, whereas the crossed extensor reflex may not be fully present until 3 weeks of age. 77 foals also exhibit an exaggerated response to external stimuli (noise, sudden visual changes, touch) for the first few weeks of life. foals are not bonded strongly to their mother for the first few weeks of life and will follow any large moving object, including other horses and human beings. orphan foals bond with surrogate mothers until they are several months of age; their primary motivation appears to be appetite. conversely, mares strongly bond with their foals shortly after parturition; the process begins once the chorioallantois ruptures and is driven more by olfaction and taste than by vision or hearing. interference with this process, by medical intervention or excessive owner manipulation of the foal, can disrupt normal bonding and result in foal rejection by the dam. 78 most newborn foals make the transition to extrauterine life easily. however, for those in difficulty, recognition of the condition immediately and institution of appropriate resuscitation is of utmost importance. a modified apgar scoring system has been developed as a guide for initiating resuscitation and assessing probable level of fetal compromise (table 19 -2). 79 one also must at least perform a cursory physical examination before initiating resuscitation, for issues of humaneness are associated with with serious problems such as severe limb contracture, microophthalmia, and hydrocephalus, among others. the initial assessment begins during presentation of the fetus. although the following applies primarily to attending the birth of a foal from a high-risk pregnancy, one can perform quiet and rapid evaluation during any attended birth. the goal in a normal birth with a normal foal is to disturb the bonding process minimally. this goal also applies to high-risk parturitions, but some disruption of normal bonding is inevitable. the lead clinician should control tightly the number of persons attending, and the degree of activity surrounding, the birth. one should evaluate the strength and rate of any palpable peripheral pulse and should evaluate the apical pulse as soon as the chest clears the birth canal. bradycardia (pulse <40 beats/min) is expected during forceful contractions, and the pulse rate should increase rapidly once the chest clears the birth canal. persistent bradycardia is an indication for rapid intervention. the fetus is normally hypoxemic compared with the newborn foal, and this hypoxemia is largely responsible for the maintenance of fetal circulation by generation of pulmonary hypertension. the fetus responds to conditions producing more severe in utero hypoxia by strengthening the fetal circulatory pattern, and the neonate responds to hypoxia by reverting to the fetal circulatory pattern. 80 during a normal parturition, mild asphyxia occurs and results in fetal responses that pave the way for a successful transition to extrauterine life. if more than mild transient asphyxia occurs, the fetus is stimulated to breathe in utero; this is known as primary asphyxia. 81 if the initial breathing effort resulting from the primary asphyxia does not correct the asphyxia, a second gasping period occurs in several minutes, known as the secondary asphyxia response. if no improvement in asphyxia occurs during this period, the foal enters secondary apnea, a state that is irreversible except with resuscitation. therefore the first priority of neonatal resuscitation is establishing an airway and breathing pattern. one should assume that foals not spontaneously breathing are in secondary apnea and should clear the airway of membranes as soon as the nose is presented. if meconium staining is present, one should suction the airway before delivery of the foal is completed and before the foal breathes spontaneously. one should continue to the trachea if aspiration of the nasopharynx is productive. overzealous suctioning worsens bradycardia as it worsens hypoxia. one should stop suctioning once the foal begins breathing spontaneously, as hypoxia will worsen with continued suction. if the foal does not breathe or move spontaneously within seconds of birth, one should begin tactile stimulation. if tactile stimulation fails to result in spontaneous breathing, one immediately should intubate the foal and manually ventilate the foal using an ambu-bag or equivalent. one can use mouth-to-nose ventilation if nasotracheal tubes and an ambu-bag are not available. the goal of this therapy is to reverse fetal circulation, and hyperventilation with 100% oxygen is the best choice for this purpose. however, recent evidence suggests that no clinical disadvantages are apparent in using room air for ventilation of asphyxiated human neonates rather than 100% oxygen. 82, 83 human infants resuscitated with room air recovered more quickly than those resuscitated with 100% oxygen in one study as assessed by apgar scores, time to the first cry, and the sustained pattern of breathing. 84 in addition, neonates resuscitated with 100% oxygen exhibited biochemical findings reflecting prolonged oxidative stress, present even after 4 weeks of postnatal life, which did not appear in the group resuscitated with room air. thus the current accepted recommendations for using 100% oxygen in the resuscitation of asphyxiated neonates needs further discussion and investigation. 85, 86 almost 90% of foals requiring resuscitation respond to hyperventilation alone and require no additional therapy. one can initiate nasotracheal intubation while the foal is in the birth canal if the foal will not be delivered rapidly, such as with a difficult dystocia. this technique is "blind" and requires some practice but may be beneficial and lifesaving. once spontaneous breathing is present, one apgar score in the foal should provide humidified oxygen via nasal insufflation at 8 to 10 l/min. one should initiate cardiovascular support in the form of chest compression if the foal remains bradycardic despite ventilation and a nonperfusing rhythm is present. one should make sure the foal is on a hard surface in right lateral recumbency with the topline against a wall or other support. approximately 5% of foals are born with fractured ribs and an assessment for the presence of rib fractures is in order before initiating chest compressions. 87 palpation of the ribs identifies many of these fractures, which usually are multiple and consecutive on one side of the thorax and located in a relatively straight line along the part of the rib with the greatest curvature dorsal to the costochondral junction. unfortunately, ribs 3 to 5 frequently are involved, and their location over the heart can make chest compression a potentially fatal exercise. auscultation over the ribs during breathing results in a recognizable click, identifying rib fractures that may have escaped detection by palpation. one should initiate drug therapy if a nonperfusing rhythm persists for more than 30 to 60 seconds in the face of chest compression. epinephrine is the first drug of choice (table 19-3) . practitioners pose various arguments regarding the best dose and the best frequency of administration for resuscitation. however, most of the data are acquired from human cardiac arrest studies and are not strictly applicable to the equine neonate because the genesis of the cardiovascular failure is different. 88, 89 vasopressin is gaining attention as a cardiovascular resuscitation drug, and although the author has used this drug in resuscitation and as a pressor, experience is limited at this time. 90 the author does not use atropine in bradycardic newborn foals because the bradycardia usually is caused by hypoxia, and if the hypoxia is not corrected, atropine can increase myocardial oxygen debt. 89 the author also does not use doxapram because it does not reverse secondary apnea, the most common apnea in newborns. because birthing areas are generally cold, one should dry the foal and place it on dry bedding once resuscitation is complete. the fetus has some homeothermic mechanisms, but its size in relation to its mother and its position within her body means that it is in effect a poikilotherm. the body temperature of the foal generally reflects that of its environment, namely its mother, although the human fetal temperature directly measured at cesarean section, induction of labor, or during labor is approximately 0.5â°c higher than the mothers. 91, 92 adaptation from poikilothermy to homeothermy normally takes place rapidly following birth. the fetus is capable of nonshivering thermogenesis, primarily through the oxidation of brown fat reserves, but this type of thermogenesis is inhibited in utero, probably by placental prostaglandin e 2 and adenosine. 93, 94 immediately after birth the foal must adapt to independent thermoregulation. local physical factors, including ambient temperature and humidity, act to induce cold stress, and the newborn must produce heat by metabolic activity. in response to the catecholamine surge associated with birth, uncoupling of oxidative phosphorylation occurs within mitochondria, releasing energy as heat. this nonshivering thermogenesis is impaired in newborns undergoing hypoxia or asphyxiation and in those that are ill at birth. infants born to mothers sedated with benzodiazepines are affected similarly, a consideration in the choice of sedative and preanesthetic medications in mares suffering dystocia or 1388 part ii disorders of specific body systems undergoing cesarean section. [95] [96] [97] heat losses by convection, radiation, and evaporation are high in most areas where foals are delivered, resuscitated ,and managed, and one must take care to minimize cold stress in the newborn and the critically ill foal. supplementary heat, in the form of radiant heat lamps or warm air circulating blankets, may be required. one should use fluid therapy conservatively during postpartum resuscitation, for the neonate is not volume depleted unless excessive bleeding has occurred. some compromised newborn foals are actually hypervolemic. fluid therapy of the neonate is discussed in more detail later in this chapter. because the renal function of the equine neonate is substantially different from the adult, one cannot simply scale down fluid therapy from adult therapy. [98] [99] [100] if intravenous fluids are required for resuscitation and blood loss is identified, administration of 20 ml/kg of a non-glucose-containing polyionic isotonic fluid over 20 minutes (about 1 l for a 50-kg foal) once intravenous access is established can be effective. the author stresses non-glucose-containing polyionic intravenous fluids because hyperglycemia, but not hypoglycemia, immediately after fetal or neonatal asphyxia interfered with the recovery of brain cell membrane function and energy metabolism in neonatal piglets in one recent study. 101 these findings suggest that post-hypoxic-ischemic hyperglycemia is not beneficial and might even be harmful in neonatal hypoxic-ischemic encephalopathy. indications for this shock bolus therapy include poor mentation, poorly palpable peripheral pulses, and the development of cold distal extremities, compatible with hemorrhagic shock. one should reassess the patient after the initial bolus and administer additional boluses as necessary. ideally, one should follow up on blood pressures and ecg readings and initiate appropriate pressor therapy if needed. again, these procedures are discussed in detail later in the chapter. one can administer glucose-containing fluids after resuscitation at a rate of 4 to 8 mg/kg/min (about 250 ml/hr of 5% dextrose or 125 ml/hr of 10% dextrose) to the average 50-kg foal, particularly in the obviously compromised foal. this therapy is indicated to help resolve metabolic acidosis, to support cardiac output because myocardial glycogen stores likely have been depleted, and to prevent postasphyxial hypoglycemia. under normal conditions, the fetal-to-maternal blood glucose concentration gradient is 50% to 60% in the horse, and glucose is the predominant source of energy during fetal development. 102, 103 glucose transport across the placenta is facilitated by carrier receptors (glucose transporter [glut] receptors), and a direct relationship exists between maternal and fetal blood glucose concentration when maternal glucose is in the normal range. 102 the glut receptors in the placenta are stereospecific, saturable, and energy independent. 104 although the enzyme kinetics for glut isoform 1 suggest that they are not saturable under conditions of euglycemia, equine maternal hyperglycemia results in increased fetal glucose concentration to a plateau point, likely caused by glut saturation. at term, the net umbilical uptake of glucose is 4 to 7 mg/kg/min, with most of the glucose being used by the brain and skeletal muscle. [105] [106] [107] the fetus only develops gluconeogenesis under conditions of severe maternal starvation. a certain percentage of the delivered glucose is used to develop large glycogen stores in the fetal liver and cardiac muscle in preparation for birth, and at birth the foal liver produces glucose at a rate of 4 to 8 mg/ kg/min by using these stores. fetal glycogen stores also are built using the substrates lactate, pyruvate, and alanine; fetal uptake of lactate across the placenta is about half that of glucose. 102, 108 the transition to gluconeogenesis, stimulated by increased circulating catecholamine concentration from birth and by stimulation of glucagon release at the time the umbilical cord breaks takes 2 to 4 hours in the normal foal, and glycogenolysis supplies needed glucose until feeding and glucose production are accomplished. 109 in the challenged foal, glycogen stores may have been depleted and gluconeogenesis delayed, so provision of glucose at rates similar to what the liver would normally produce during this period is requisite. persistent pulmonary hypertension (pph) also is known as reversion to fetal circulation or persistent fetal circulation, and its genesis lies in the failure of the fetus to make the respiratory and cardiac transition to extrauterine life successfully or reversion of the newborn to fetal circulatory patterns in response to hypoxia or acidosis. differentiating this problem from other causes of hypoxemia in the newborn requires some investigation, and multiple serial arterial blood gas analyses are necessary to confirm suspicion of this problem (see the section on arterial blood gas analysis, respiratory diseases associated with hypoxemia in the neonate). however, one should suspect the condition in any neonate with hypercapnic hypoxemia that persists and worsens; these foals are in hypoxemic respiratory failure. the fetal circulatory pattern, with pulmonary hypertension and right-to-left shunting of blood through the patent foramen ovale and ductus arteriosus, is maintained in these cases. pulmonary vascular resistance falls at delivery to about 10% of fetal values, while pulmonary blood flow increases accordingly. 110 early in the postnatal period these two changes balance each other, and mean pulmonary and systolic pressures remain increased for several hours. systolic pulmonary pressures can remain equivalent to systemic pressure for up to 6 hours of age in human infants, although diastolic pulmonary pressures are well below systemic diastolic pressures by 1 hour. 111 mean pulmonary artery pressures fall gradually over the first 48 hours. 112 the direct effects of lung expansion and increasing alveolar oxygen tension probably provide the initial stimulus for pulmonary arteriolar dilation and partly result from direct physical effects, but vasoactive substances are released in response to physical forces associated with ventilation, for example prostacyclin. 110 other vasoactive mediators thought to play a role in regulating pulmonary arteriolar tone include no, prostaglandins d 2 and e 2 , bradykinin, histamine, endothelin-1, angiotensin ii, and atrial natriuretic peptide. the increase in alveolar and arterial oxygen tensions at birth is required for completion of resolution of pulmonary hypertension. much of this increase is thought to be mediated by no, evidence for this being the parallel increase during gestation of the pulmonary vasodilation response to hyperoxia and the increase in no synthesis. 113 however, inhibition of no synthesis does not eliminate the initial decrease in pulmonary artery resistance occurring because of opening of the airways. 114 when these mechanisms fail, one can recognize pph. right-to-left shunting within the lungs and through patent fetal conduits occurs and can result from many factors, including asphyxia and meconium aspiration, but in many cases the precipitating trigger is unknown. inappropriately decreased levels of vasodilators (no) and inappropriately increased levels of vasoconstrictors (endothelin-1) currently are being examined as potential mechanisms. chronic in utero hypoxia and acidosis may result in hypertrophy of the pulmonary arteriolar smooth muscle. 115 in these cases, reversal of pph can be difficult and cannot be achieved rapidly. treatment of pph is twofold: abolishment of hypoxia and correction of the acidosis, for both abnormalities only bolster the fetal circulatory pattern. initial therapy is provision of oxygen intranasally at 8 to 10 l/min. some foals respond to this therapy and establish neonatal circulatory patterns within a few hours. failure to improve or worsening of hypoxemic respiratory failure following intranasal oxygen administration should prompt intubation and mechanical ventilation with 100% oxygen. this serves two purposes, one diagnostic and one therapeutic. ventilation with 100% oxygen may resolve pph and, if intrapulmonary shunt and altered ventilation-perfusion relationships are causing the hypoxic respiratory failure, arterial oxygen tension (pao 2 ) should exceed 100 mm hg under these conditions. failure to improve pao 2 suggests pph or large right-to-left extrapulmonary shunt caused by congenital cardiac anomaly. the vasodilators prostacyclin and telazoline (an î±-blocking vasodilator) cause pulmonary vasodilation in human infants with pph, but the effects on oxygenation vary and the sideeffects (tachycardia, severe systemic hypotension) are unacceptable. 116 recognition of no as a potent dilator of pulmonary vessels has created a significant step forward in the treatment of these patients, for inhaled no dilates vessels in ventilated portions of the lung while having minimal effects on the systemic circulation. 117 based on evidence presently available, use of inhaled no in an initial concentration of about 20 ppm in the ventilatory gas seems reasonable for term and near-term foals with hypoxic respiratory failure and pph that fails to respond to mechanical ventilation using 100% oxygen alone. 117, 118 the author has used this approach in the clinic, administering a range of 5 to 40 ppm no with success. hypoxic ischemic encephalopathy (hie), currently referred to as neonatal encephalopathy in the human literature, is one systemic manifestation of a broader syndrome of perinatal asphyxia syndrome (pas), and management of foals with signs consistent with a diagnosis of hie requires the clinician to examine other body systems fully and to provide therapy directed at treating other involved systems. 119 although pas primarily manifests as hie, the gastrointestinal tract and kidneys frequently are affected by peripartum hypoxia/ischemia/ asphyxia, and one should expect complications associated with these systems. hypoxic ischemic encephalopathy also may affect the cardiovascular and respiratory systems, and one also may encounter endocrine disorders in these patients. hypoxic ischemic encephalopathy has been recognized as one of the most common diseases of the equine neonate for generations. 1, 10, 12 in the past hie has been known as dummy foal syndrome and as neonatal maladjustment syndrome. the designation hie, although not perfect, attempts to describe the syndrome in terms of the suspected underlying pathophysiology. a wide spectrum of clinical signs is associated with hie and can range from mild depression with loss of the suck reflex to grand mal seizure activity. typically, affected foals are normal at birth but show signs of central nervous system abnormalities within a few hours after birth. some foals are obviously abnormal at birth, and some do not show signs until 24 hours of age. hypoxic ischemic encephalopathy commonly is associated with adverse peripartum events, including dystocia and premature placental separation, but a fair number of foals have no known peripartum period of hypoxia, suggesting that these foals result from unrecognized in utero hypoxia (box 19-2). severe maternal illness also may result in foals born with pas. in human beings, ascending placental infection now is suspected of being a major contributor to neonatal encephalopathy in infants, and the incidence of neonatal encephalopathy increases with the presence of maternal fever, suggesting a role for maternal inflammatory mediators. 120 the underlying pathophysiologic details of hie in the foal are unknown, and to date accurate experimental models of hie and pas in the foal have not been described. however, a great deal of attention has been paid to peripartum hypoxia/asphyxia by human counterparts because the effects of adverse peripartum events in the human neonate have far ranging implications for the affected human neonate and for society. therefore equine neonatologists have long looked to human studies and models of the human disease for understanding of the syndrome in the equine neonate. perinatal brain damage in the mature fetus usually results from severe uterine asphyxia caused by an acute reduction of uterine or umbilical circulation. the fetus responds to this challenge by activation of the sympathetic adrenergic nervous system, causing a redistribution of cardiac output that favors the central organs: brain, heart, and adrenal glands. 121, 122 if the hypoxic insult continues, the fetus reaches a point beyond which it cannot maintain this centralization of circulation, cardiac output falls, and cerebral circulation diminishes. 122 the loss of oxygen results in a substantial decrease in oxidative phosphorylation in the brain with concomitant decreased energy production. the na + /k + pump at the cell membrane cannot maintain the ionic gradients, and the membrane potential is lost in the brain cells. in the absence of the membrane potential, calcium flows down its large extracellular/intracellular concentration gradient through voltage-dependent ion channels into the cell. this calcium overload of the neuron leads to cell damage by activation of calcium-dependent proteases, lipases, and endonucleases. protein biosynthesis is halted. calcium also enters the cells by glutamate-regulated ion channels as glutamate, an excitatory neurotransmitter, is released from presynaptic vesicles following anoxic cellular depolarization. once the anoxic event is over, protein synthesis remains inhibited in specific areas of the brain and returns to normal in less vulnerable areas of the brain. loss of protein synthesis appears to be an early indicator of cell death caused by the primary hypoxic/anoxic event. 123 a second wave of neuronal cell death occurs during the reperfusion phase and is thought to be similar to classically described postischemic reperfusion injury in that damage is caused by production of and release of oxygen radicals, synthesis of no, and inflammatory reactions. 124 additionally, an imbalance between excitatory and inhibitory neurotransmitters occurs. 123 part of the secondary cell death that occurs is thought to be caused by apoptosis, a type of programmed cell death termed cellular suicide. secondary cell death also is thought be caused by the neurotoxicity of glutamate and aspartate resulting again from increased intracellular calcium levels. 125, 126 in human infants the distribution of lesions with hypoxic-ischemic brain damage following prenatal, perinatal, or postnatal asphyxia falls into distinct patterns depending on the type of hypoxia-ischemia rather than on postconceptual age at which the asphyxial event occurs. 126 periventricular leukomalacia was associated with chronic hypoxia-ischemia, whereas the basal ganglia and thalamus were affected primarily in patients experiencing acute profound asphyxia, providing direct evidence that the nature of the event determines the severity and distribution of neurologic damage in human beings. these remarkably selective patterns of injury in children, with differential variability in the damage caused to regions anatomically located within millimeters of each other, resulted in the hypothesis that location within neurotransmitter-specific circuitry loops is important. this hypothesis has important implications in the design of neuroprotective strategies and therapies for neonates experiencing hypoxic-ischemic-asphyxial events. now the evidence is overwhelming that the excitotoxic cascade that evolves during hie extends over several days from the time of insult and is modifiable. 125, 126 in brain injury, traumatic or hypoxic, the mechanisms underlying delayed tissue injury still are understood poorly. many believe that neurochemical changes, including excessive neurotransmitter release, are pivotal in the pathophysiology of secondary neuronal death. excitatory amino acid neurotransmitters and magnesium are known to play at least a minimal role in secondary cell death following brain injury; a fair body of literature regarding these factors has been generated over the last 10 years. the activation of the n-methyl-d-aspartate (nmda) subtype of glutamate receptors is implicated in the pathophysiology of traumatic brain injury and is suspected to play a role in hie. [125] [126] [127] mechanically injured neurons demonstrate a reduction of voltage-dependent mg 2+ blockade of nmda current that can be restored partially by increasing extracellular mg 2+ concentration or by pretreatment with calphostin c, a protein kinase c inhibitor. 128 this finding suggested that administration of mg 2+ to patients with brain injury could lead to improved outcome. subsequently, magnesium sulfate solution was shown to improve dramatically the immediate recovery of rats from hypoxia. 129 however, although pretreatment with magnesium sulfate protected against hypoxic ischemic brain injury, postasphyxial treatment worsened brain damage in 7-day-old rats, suggesting an age-related response in the rat. 130 delayed magnesium treatment of mature rats following severe traumatic axonal brain injury improved motor outcome when administered up to 24 hours after injury, with early treatments providing the most benefit. 131 maternal seizure in rats is associated with fetal histopathologic changes that are abolished by administration of magnesium sulfate to the mother, and magnesium sulfate has been demonstrated to protect the fetal brain from severe maternal hypoxia. 132 clinical trials investigating the efficacy of magnesium treatment following hypoxia in infants are under way, with few reports currently in the medical literature. magnesium sulfate was used to treat nine infants after perinatal asphyxia in one study (no control group), and all children were neurologically normal at 1 year of age. seizures did not occur in any of these children, nor were any adverse side effects noted. 133 magnesium sulfate administration failed to delay the global impairment in energy metabolism after hypoxia ischemia, characteristic of severe brain damage, in newborn piglets; at 48 hours after hypoxia ischemia, no difference could be found in the severity of injury in piglets treated with magnesium compared with piglets treated with placebo, suggesting magnesium may not be protective with severe acute injury. 134 in developing countries, birth hypoxia frequently is associated with hie, and although this finding is attributed most frequently to inadequate obstetric care, poor nutrition also may play a role. red blood cell magnesium levels were measured in more than 500 women in labor at a teaching hospital in south africa. 135 fifty five of the women delivered infants with hie and had significantly lower levels of magnesium than controls; the infants with hie also had significantly lower magnesium levels than controls. the large majority (54 of 55) of the women giving birth to hie infants were from poor social circumstances, suggesting nutrition might play a role in some cases of hie, with maternal magnesium levels affecting outcome in the infants. the authors suggested an early pregnancy intervention study may help determine the role of magnesium in the pathogenesis of hie in human infants born to at-risk mothers. therapy for the various manifestations of hypoxiaischemia involves control of seizures, general cerebral support, correction of metabolic abnormalities, maintenance of normal arterial blood gas values, maintenance of tissue perfusion, maintenance of renal function, treatment of gastrointestinal dysfunction, prevention and recognition and early treatment of secondary infections, and general supportive care. control of seizures is important because cerebral oxygen consumption increases fivefold during seizures. one can use diazepam for emergency control of seizures (table 19 -4). if diazepam does not stop seizures readily or one recognizes more than two seizures, then one should replace diazepam with phenobarbital given to effect. the half-life of phenobarbital can be long in the foal (100 hours), and one should keep this in mind when monitoring neurologic function in these cases after phenobarbital administration (j.e. palmer, personal communication, 1998). 136 earlystage, preseizure administration of phenobarbital has been advocated by some investigators for prevention of neonatal encephalopathy. however, one recent study in asphyxiated human infants demonstrated that early phenobarbital treatment was associated with a threefold increase in the incidence of subsequent seizures and consequently a trend toward increased mortality. seizures per se were associated with almost a twentyfold increase in mortality. their findings suggest that early phenobarbital administration may produce adverse rather than beneficial effects following asphyxia. because this was an observational study; the results need to be confirmed by appropriate randomized trials in similar clinical settings. 137 if phenobarbital fails to control seizures, one may attempt phenytoin therapy. in cases of hie, one should avoid ketamine and xylazine because of their association with increased intracranial pressure. one must protect the foal from injury during a seizure and also ensure the patency of the airway to prevent the onset of negative pressure pulmonary edema 138 or aspiration pneumonia. probably the most important therapeutic interventions are aimed at maintaining cerebral perfusion, which is achieved by careful titration of intravenous fluid support, neither too much nor too little (see fluid therapy in neonates) and judicious administration of inotropes and pressors to maintain adequate perfusion pressures (see pressor and inotrope therapy in neonates). cerebral interstitial edema is only truly present in the most severe cases 139, 140 ; in most cases the lesion is intracellular edema and most of the classic agents used to treat cerebral interstitial edema (e.g., mannitol) are minimally effective treating cellular edema. occasionally the author uses thiamine supplementation in the intravenous fluids to support metabolic processes, specifically mitochondrial metabolism and membrane na + ,k + -atpases, involved in maintaining cellular fluid balance. 141, 142 this therapy is rational and inexpensive but unproven in efficacy. only if cellular necrosis and vasogenic edema are present are drugs such as mannitol and dimethyl sulfoxide indicated, and again these cases are usually the most severely affected. in the author's clinic, practitioners rarely have used dimethyl sulfoxide in neonates for the last several years and have recognized no change in outcome by discontinuing its use. when the practitioners use intravenously administered dimethyl sulfoxide, they do so within the first hour after an acute asphyxial insult and use it primarily for its hydroxyl radical scavenging effects and its theoretical modulation of postischemic reperfusion injury. 143 naloxone has been advocated for treating hie in human beings and in foals, [144] [145] [146] perhaps based on a study suggesting that postasphyxia blood-brain barrier disruption was related causally to poor neurologic outcome in a lamb model of hie and that naloxone prevented disruption and neurologic dysfunction among those survivors with an intact blood-brain barrier. 145 however, other studies have demonstrated that naloxone exacerbates hypoxic-ischemic brain injury in 7-day-old rats subjected to unilateral common carotid artery ligation and hypoxia. moreover, systemic acidosis and cellular edema were no different in naloxone-treated animals compared with animals treated with saline solution. the authors concluded that high doses of naloxone in fact may reduce the resistance of the fetus to hypoxic stress. 146 the use of naloxone in human neonatal resuscitation remains controversial, for whether the contradictory effects are related to a reduction in acute neuronal swelling by osmotic effects or by a more direct receptor-mediated mechanism is currently unknown. 147 naloxone is most effective in resuscitation of compromised human infants born to mothers addicted to drugs. some practitioners are using î³-aminobutyric acid adrenergic agonists to manage hie in foals, based on evidence showing neuroprotection when used in ischemia alone and combined with nmda antagonists. [148] [149] [150] the author currently has no experience with these compounds and cannot comment regarding their efficacy in foals. regional hypothermia also is being investigated as a potential therapy for global hypoxia/ischemia; published data are consistent with the theory that cooling must be continued throughout the entire secondary phase of injury (about 3 days) to be effective. 151 experimentally, this approach has resulted in dramatic decreases in cellular edema and neuronal loss; its practical application remains to be demonstrated. despite a lack of consensus regarding the use of magnesium to treat infants with hie, the author has used magnesium sulfate infusion as part of the therapy for selected foals with hie for the past several years. the rationale is based primarily on the evidence demonstrating protection in some studies and a failure of any one study to demonstrate significant detrimental effects. the clinical impressions of the author to date suggest that the therapy is safe and may decrease the incidence of seizure in patients. the author administers magnesium sulfate as a constant rate infusion over 1 hour after giving a loading dose. the author has continued the infusion for up to 3 days without demonstrable negative effect beyond some possible trembling. given the current evidence, a 24-hour course of treatment may be effective and all that is necessary. postasphyxial treatment certainly may be beneficial in foals with hie, and maternal magnesium therapy may be beneficial in certain high-risk pregnancy patients. foals with pas often have a variety of metabolic problems including hypo-or hyperglycemia, hypo-or hypercalcemia, hypo-or hyperkalemia, hypo-or hyperchloremia, and varying degrees of metabolic acidosis. although one needs to address these problems, one should not forget the normal period of hypoglycemia that occurs postpartum and should not treat aggressively so as to avoid worsening the neurologic injury. foals suffering from pas also have frequent recurrent bouts of hypoxemia and occasional bouts of hypercapnia. intranasally administered oxygen is generally needed in these cases as a preventative therapy and as direct treatment, for the appearance of the abnormalities can be sporadic and unpredictable. additional respiratory support, particularly in those foals with centrally mediated hypoventilation and periods of apnea or abnormal breathing patterns, include caffeine (per os or per rectum) and positive pressure ventilation. caffeine is a central respiratory stimulant and has minimal side effects at the dosages used (10 mg/kg loading dose; 2.5 mg/kg as needed). 152 the author purchases whatever oral form of caffeine is available at the local convenience store or drug store and administers it dissolved in warm water per rectum. foals treated with caffeine have an increased level of arousal and are more reactive to the environment. adverse effects generally are limited to restlessness, hyperactivity, and mild to moderate tachycardia. mechanical ventilation of these patients can be rewarding and generally is required for less than 48 hours. one must monitor and maintain blood ph within the normal range. metabolic alkalosis can develop in some of these foals and requires clinician tolerance of some degree of hypercapnia. ph is important in evaluation and consideration of alternatives for treatment. if the respiratory acidosis is not so severe as to affect the patient adversely (generally >70 mm hg), and the ph is within normal limits, the foal may tolerate hypercapnia. 153 the goal is to normalize ph. foals with respiratory acidosis as compensation for metabolic alkalosis do not respond to caffeine. metabolic alkalosis in critically ill foals frequently is associated with electrolyte abnormalities, creating differences in strong ion balance. one handles this ph perturbation best by correcting the underlying electrolyte problem. maintaining tissue perfusion and oxygen delivery to tissues is a cornerstone of therapy for pas to avoid additional injury. one should maintain the oxygen-carrying capacity of the blood; some foals require transfusions to maintain a packed cell volume greater than 20%. adequate vascular volume is important, but one should take care to avoid fluid overload in the foal. early evidence of fluid overload is subtle accumulation of ventral edema between the front legs and over the distal limbs. fluid overload can result in cerebral edema, pulmonary edema, and edema of other tissues, including the gastrointestinal tract. this edema interferes with normal organ function and worsens the condition of the patient. one maintains perfusion by supporting cardiac output and blood pressure by judicious use of intravenous fluid support and inotrope/pressor support. the author does not target therapy to a specific systolic, mean, or diastolic pressure but monitors urine output, mentation, limb perfusion, gastrointestinal function, and respiratory function as indicators that perfusion is acceptable. for these patients to require pressor therapy is not unusual, but in some cases the hypoxic damage is sufficiently severe to blunt the response of the patient to the drugs. the kidney is a target for injury in patients with pph, and for renal compromise to play a significant role in the demise of these foals is not unusual. clinical signs of renal disease are generally referable to disruption of normal control of renal blood flow and tubular edema leading to tubular necrosis and renal failure. these foals have signs of fluid overload and generalized edema. one must balance urine output and fluid therapy in these cases to prevent additional organ dysfunction associated with edema. although evidence has accumulated that neither dopamine nor furosemide play a role in protecting the kidney or reversing acute renal failure, these agents can be useful in managing volume overload in these cases. [154] [155] [156] the aim is not to drive oliguric renal failure into a highoutput condition but rather to enhance urine output. overzealous use of diuretics and pressors in these cases can result in diuresis requiring increased intravenous fluid support and can be counterproductive. the author's approach is more conservative. low doses of dopamine administered as a constant rate infusion of 2 to 5 âµg/kg/min are usually effective in establishing diuresis by natriuresis. one should avoid large doses of dopamine (>20 âµg/kg/min) because high doses can produce systemic and pulmonary vasoconstriction, potentially exacerbating pph. 157 one can administer a bolus (0.25 to 1.0 mg/kg) or constant rate infusion (0.25 to 2.0 mg/kg/hr) of furosemide, but once furosemide diuresis is established, one must evaluate electrolyte concentrations and blood gas tensions frequently because potassium, chloride, and calcium losses can be considerable and because significant metabolic alkalosis can develop from strong ion imbalances. the author does not aim for urine production rates of 300 ml/hr, as has been presented by other authors as a urine output goal for critically ill equine neonates. 158 rather the author looks for urine output that is appropriate for fluid intake and does not attempt to drive urine output to an arbitrary goal by excessive fluid administration or pressor use. although the average urine output for a normal equine neonate is about 6 ml/kg/hr (~300 ml/hr for a 50-kg foal), these values were obtained from normal foals drinking a milk diet with a large free water component. [98] [99] [100] the urine of normal newborn foals is dilute, reflecting the large free water load they incur by their diet. expecting critically ill foals to produce such large volumes of urine, particularly those on restricted diets or receiving total parenteral nutrition, is an exercise in futility, and manipulating fluid, pressor, or diuretic therapy in attempt to meet an artificial goal is inappropriate. fluid therapy in the critically ill neonate is discussed later in this chapter. one final caveat regarding renal dysfunction in pas is that one should perform therapeutic drug monitoring when it is available. many antimicrobial agents used to manage these cases, most notably the aminoglycosides, depend on renal clearance. aminoglycoside toxicity occurs in the equine neonate and exacerbates or complicates the management of renal failure originally resulting from primary hemodynamic causes. the author monitors aminoglycoside concentrations for 30-minute peak and 23-to 24-hour trough values in these cases and adjusts dosage and frequency of drug administration based on these results. the author considers a trough value of less than 2 âµg/dl as desirable for gentamicin and amikacin. foals with pas suffer from a variety of problems associated with abnormalities within the gastrointestinal tract. 159 commonly they have ileus, recurrent excessive gastric reflux, and gas distention. these problems are exacerbated by constant feeding in the face of continued dysfunction and continued hypoxia. frequently, enteral feeding cannot meet their nutritional requirements, and partial or total parenteral nutrition is required. one must give special attention to passive transfer of immunity (see failure of passive transfer) and glucose homeostasis in these cases. although some practitioners use prokinetic agents as therapy for ileus in these cases, the author's approach is again more conservative. appearance of damage to the gastrointestinal tract can be subtle and lag behind other clinical abnormalities for days to weeks. low-grade colic, decreased gastrointestinal motility, decreased fecal output, and low weight gain are among the most common clinical signs of gastrointestinal dysfunction in these case, but more severe problems, including necrotizing enterocolitis and intussusception, have been associated with these cases. the return to enteral feeding must be slow in many of these cases. a currently debated topic is constant versus pulsed enteral feeding. [160] [161] [162] the author uses pulsed feeding through an indwelling small-gauge feeding tube. in many foals these tubes stay in place for weeks and cause no problems as the foals are returned to their dams for sucking or are trained to drink from a bottle or bucket. foals with pas are also susceptible to secondary infection. treatment of recognized infection is covered under sepsis in this chapter. if infection is recognized in these patients after hospitalization, one should give attention to the likelihood of nosocomial infection and should direct antimicrobial therapy based on known nosocomial pathogens in the nicu and their susceptibility patterns until culture and sensitivity results become available. one should make repeat determinations of immunoglobulin g (igg) concentration; additional intravenous plasma therapy may be required. nosocomial infections are often rapidly overwhelming, and acute deterioration in the condition of a foal with pas should prompt a search for nosocomial infection. the prognosis for foals with pas is good to excellent when the condition is recognized early and aggressively treated in term foals. up to 80% of these neonates survive and go on to lead productive and useful athletic lives. [20] [21] [22] [23] the prognosis decreases with delayed or insufficient treatment and concurrent problems such as prematurity and sepsis. in human nicus the survival rates of low-gestationlength infants has increased dramatically since the 1980s concurrent with improvements in obstetric and neonatal care. the now routine, well-validated use of antenatal steroid and artificial surfactant therapies has contributed greatly to the enhanced survival of this patient population, although the use of these particular therapies is not common or frequently indicated in the equine nicu. 163, 164 however, with improved care, outcomes in the equine nicu population have improved also, with survival of premature patients in many nicus exceeding 80%. 21 in the equine population, gestation length is much more flexible than in the human population; however, the definition of the term prematurity needs reexamination. traditionally, prematurity is defined as a preterm birth of less than 320 days of gestation in the horse. given the variability of gestation length in the horse, ranging from 310 days to more than 370 days in some mares, a mare with a usual gestation length of 315 days possibly could have a term foal at 313 days, whereas a mare with a usual gestation length of 365 days may have a premature foal at 340 days, considered the normal gestation length. foals that are born postterm but are small are termed dysmature; a postmature foal is a postterm foal that has a normal axial skeletal size but is thin to emaciated. dysmature foals may have been classified in the past as small for gestational age and are thought to have suffered placental insufficiency, whereas postmature foals are usually normal foals that have been retained too long in utero, perhaps because of an abnormal signaling of readiness for birth, and have outgrown their somewhat aged placenta. postmature foals become more abnormal the longer they are maintained, also may suffer from placental insufficiency, and are represented best by the classic foal born to a mare ingesting endophyteinfested fescue. 165 box 19-3 compares the characteristics of premature/dysmature foals with those of postmature foals. the causes of prematurity/dysmaturity/postmaturity include the causes of high-risk pregnancy presented in box 19-1. additional causes include iatrogenic causes such as early elective induction of labor based on inaccurate breeding dates or misinterpretation of late-term colic or uterine bleeding as ineffective labor. most causes remain in the category of idiopathic, with no discernible precipitating factor. despite lack of an obvious cause, premature labor and delivery does not just happen, and even if undetermined, the cause may continue to affect the foal in the postparturient period. all body systems may be affected by prematurity, dysmaturity, and postmaturity, and thorough evaluation of all body systems is necessary. respiratory failure is common in these foals, although the cause usually is not surfactant deficiency. immaturity of the respiratory tract, poor control of respiratory vessel tone, and weak respiratory muscles combined with poorly compliant lungs and a greatly compliant chest wall contribute to respiratory failure in these cases. most require oxygen supplementation and positional support for optimal oxygenation and ventilation. one must extend effort to maintain these "floppy foals" in sternal recumbency. some foals may require mechanical ventilation. these foals also require cardiovascular support but are frequently unresponsive to commonly used pressors and inotropes: dopamine, dobutamine, epinephrine, and vasopressin. careful use of these drugs and judicious intravenous fluid therapy are necessary. the goal should not be one of achieving specific pressure values (e.g., mean arterial pressure of 60 mm hg) but of adequate perfusion. renal function, reflected in low urine output, is frequently poor initially in these cases because of delay in making the transition from fetal to neonatal glomerular filtration rates. 166 the delay can result from true failure of transition or from hypoxic/ischemic insult. one should approach fluid therapy cautiously in these cases; initial fluid restriction may be in order to avoid fluid overload. many premature/dysmature/postmature foals have suffered a hypoxic insult and have all of the disorders associated with pas, including hie. treatment is similar to that of term foals with these problems. these foals also are predisposed to secondary bacterial infection and must be examined frequently for signs consistent with early sepsis or nosocomial infection. the gastrointestinal system of these foals is not usually functionally mature, which may result from a primary lack of maturity or from hypoxia. dysmotility and varying degrees of necrotizing enterocolitis are common. one commonly encounters hyperglycemia and hypoglycemia. hyperglycemia generally is related to stress, increased levels of circulating catecholamines, and rapid progression to gluconeogenesis, whereas hypoglycemia is associated with diminished glycogen stores, inability to engage gluconeongenesis, sepsis, and hypoxic damage. 167 immature endocrine function is present in many of these foals, particularly regarding the hypothalamic-pituitary-adrenal axis, and contributes to metabolic derangements. 168, 169 one should delay enteral feeding when possible until the foal is stable regarding metabolic and cardiorespiratory parameters. on intiating enteral feeding, one should provide small volumes initially and slowly increase the volume over several days. one frequently encounters musculoskeletal problems, particularly in premature foals, that include significant flexor laxity and decreased muscle tone. postmature foals frequently are affected by flexure contracture deformities, most likely because of decreased intrauterine movement as they increase in size. premature foals frequently exhibit decreased cuboidal bone ossification that predisposes them to crush injury of the carpal and tarsal bones if weight bearing is not strictly controlled. physical therapy in the form of standing and exercise is indicated in the management of all these problems, but one should take care to ensure that the patient does not fatigue or stand in abnormal positions. bandaging of the limbs is contraindicated because this only increases laxity, although light bandages over the fetlock may be necessary to prevent injury to that area if flexor laxity is severe. the foals are predisposed to angular limb deformity and must be observed closely and frequently for this problem as they mature. 170 the overall prognosis for premature/dysmature/ postmature foals remains good with intensive care and good attention to detail. many of these foals (up to 80%) survive and become productive athletes. 21 complications associated with sepsis and musculoskeletal abnormalities are the most significant indicators of poor athletic outcome. the last 20 years have seen an explosion of new therapeutic agents purportedly useful for treating sepsis. unfortunately, clinical trials investigating these new therapies have failed to demonstrate a positive effect, have shown negative results, or have resulted in diametrically opposed study results, one showing a benefit and another showing no benefit or a detrimental effect. on a positive note, the survival rate of foals being treated for sepsis has improved. work was done regarding foal diseases and their treatment in the 1960s, but the field did not attract much serious attention until the 1980s. since that time almost every major veterinary college and many large private referral practices have constructed nicus or their equivalent. next to hypoxic ischemic asphyxial syndromes, sepsis is the number one reason for presentation and treatment at these facilities. neonatal septicemia of the horse has been the subject of three international workshops, 171-173 and a perinatology lecture covering some aspect of neonatal sepsis has been presented at almost every large continuing education meeting attended by equine veterinarians. concensus criteria conferences 1 in the early 1990s defined sepsis and septic shock for human beings. 174, 175 sepsis was defined as the systemic response to infection manifested by two or more of the following conditions as a result of infection: a) temperature >38â°c or <36â°; b) heart rate >90 beats/min; c) respiratory rate >20 breaths per minute or paco 2 <32 torr; and d) white blood cell count >12,000 cell/âµl, <4,000 cell/âµl, or >10% immature (band) forms. septic shock was defined as sepsis induced hypotension or the requirement for vasopressors/ionotropes to maintain blood pressure despite adequate fluid resuscitation along with the presence of perfusion abnormalities that may include lactic acidosis, oliguria, or acute alteration in mental status. these definitions are broadly acceptable and applicable to neonatal sepsis in foals, and many of the treatment modalities in human medicine have been applied in some manner to the equine neonatal patient. additional definitions that have come into vogue that are actually useful at times, include the following: sirs, the systemic inflammatory response system; mods, multiple organ system dysfuction; and mofs, multiple organ failure syndrome. (sirs is sick, mods is sicker, and mofs is dying.) the compensatory response syndrome (cars) ideally balances sirs and keeps it from becoming detrimental. if balance is achieved, recovery is possible. imbalance progresses to septic shock, mods, and mofs. in horses, mods is manifested most commonly as renal failure, hepatic failure, central nervous system dysfunction, and disseminated intravascular coagulation. managing the septic patient involves early recognition of all the potential alphabet combinations and supporting the patient or intervening in the face of multiple clinical consequences, termed chaos (cardiovacular compromise; homeostasis; apoptosis; organ dysfunction; suppression of the immune system). 176 inflammatory mediators are involved in all these processes and can be beneficial or detrimental, depending on timing and opposing responses. neutrophils, platelets, lymphocytes, macrophages, and endothelial cells are involved, and the implicated inflammatory molecules grow daily in numbers. sepsis in the foal initially can be subtle, and the onset of clinical signs varies depending on the pathogen involved and the immune status of the foal. for the purposes here, the discussion is limited to bacterial sepsis, but the foal also is susceptible to viral and fungal sepsis, which can appear similar to bacterial sepsis. failure of passive transfer (fpt) of immunity can contribute to the development of sepsis in a foal at risk. 177, 178 testing for and treating fpt has received attention in the veterinary literature. it remains true, however, that foals presented to nicus that have an ultimate diagnosis of sepsis have fpt. 16, 19 the current recommendation is that foals have igg levels greater than or equal to 800 mg/dl for passive transfer to be considered adequate. other risk factors for the development of sepsis include any adverse advents at the time of birth, maternal illness, or any abnormalities in the foal. although the umbilicus frequently is implicated as a major portal of entry for infectious organisms in the foal, the gastrointestinal tract may be the primary site of entry. 179 other possible portals of entry include the respiratory tract and wounds. early signs of sepsis include depression, decreased suck reflex, increased recumbency, fever, hypothermia, weakness, dysphagia, failure to gain weight, increased respiratory rate, tachycardia, bradycardia, injected mucous membranes, decreased capillary refill time, shivering, lameness, aural petechia, and coronitis. if sepsis is recognized early, patients with sepsis may have a good outcome, depending on the pathogen involved. gram-negative sepsis remains the most commonly diagnosed, but increasingly gram-positive septicemia is being recognized. 180 foals in intensive care units and at referral hospitals have an additional risk of nosocomial infection. an attempt to isolate the organim involved early in the course of the disease becomes important. if possible, one should obtain blood cultures, and if localizing signs are present, one should obtain samples as deemed appropriate. cultures should be aerobic and anaerobic. recently, work has been done evaluating real-time polymerase chain reaction technology in sepsis in the foal as a means of identifying causative organisms. 181, 182 until one obtains antimicrobial sensitivity patterns for the pathogen involved, one should initiate broad-spectrum antimicrobial therapy (table 19 -5). intravenously administered amikacin and penicillin are good first-line choices, but one should monitor renal function closely. other first-line antimicrobial choices might include high-dose ceftiofur sodium or ticarcillin/clavulanic acid. one should treat failure of passive transfer if present. one should provide intranasal oxygen insufflation at 5 to 10 l/min even if hypoxemia is not present to decrease the work of breathing and provide support for the increased oxygen demands associated with sepsis. 183 should arterial blood gas analysis reveal significant hypoventilation, one may administer caffeine orally or per rectum to increase central respiratory drive. mechanical ventilation may be necessary in cases of severe respiratory involvement such as with acute lung injury or acute respiratory distress syndrome. if the foal is hypotensive, one may administer pressor agents or inotropes by constant rate infusion (table 19-6) . inotrope and pressor therapy generally is restricted to referral centers where these drugs can be given as constant rate infusions and blood pressure can be monitored closely. some practitioners use nonsteroidal antiinflammatory agents and, in specific circumstances, corticosteroids. use of these drugs should be judicious because they may have several negative consequences for the foal including renal failure and gastric/dunodenal ulceration. [184] [185] [186] nursing care is one of the most important aspects of treating septic foals. foals should be kept warm and dry. they should be turned at 2-hour intervals if they are recumbent. feeding septic foals can be a challenge if gastrointestinal function is abnormal, and total parenteral nutrition may be needed. if at all possible, foals should be weighed daily and blood glucose levels monitored frequently. some foals become persistently hyperglycemic on small glucose infusion rates. these foals may benefit from constant rate low-dose insulin infusions (table 19-7) . recumbent foals must be examined frequently for decubital sore development, the appearance of corneal ulcers, and for heat and swelling associated with joints and physis. the prognosis for foals in the early stages of sepsis is fair to good. once the disease has progressed to septic shock the prognosis decreases, although short-term botulism is a neuromuscular disease of foals characterized by flaccid paralysis. 187 although the disease is discussed in detail elsewhere in this text, the form most commonly observed in foals, the toxicoinfectious form, deserves some specific comments. the causative organism is clostridium botulinum, an anaerobic organism. although affected adults usually acquire the disease by ingestion of preformed toxin elucidated from the organism, in the foal less than 8 months of age the organism can survive and multiply in the gastointestinal tract and produce necrotic foci within the liver, giving the foal constant exposure to newly formed toxin. the horse is exquisitely sensitive to the toxin, and only small quantities of toxin are required to produce clinical signs and death in affected animals. the îµ-toxin of c. botulinum binds to the presynaptic membrane of motor neurons and prevents transmission of impulses by blocking the release of acetylcholine from the presynaptic vessicles. this block produces the clinical signs of muscle weakness, manifested in foals as trembling (shaker foals) or acute recumbency. 188 pupillary dilation, dysphagia, tremors, recumbency, and terminal respiratory distress caused by respiratory muscle paralysis occur. foals can be found acutely dead. in endemic areas (the northeast and mid-atlantic regions of united states), for these foals to be evaluated first as having colic is not unusual. treatment aims to neutralize the toxin by administration of botulinum antitoxin and to provide antimicrobial treatment of the infection with penicillin, metronidazole, and/or oxytetracycline. 189, 190 at a minimum, feeding of milk replacer via indwelling nasogastric tube at 20% of the body weight of the foal per day divided into every 2-hour meals is required. many of these foals require respiratory support (in the form of intranasal oxygen insufflation), because of respiratory muscle paralysis. respiratory acidosis is present on arterial blood gas analysis in most of these foals because of hypoventilation and lateral recumbency, but they can tolerate some degree of hypercapnia (paco 2~7 0 mm hg) if the ph is normal and oxygenation (pao 2 >70 mm hg; percent oxygen saturation of hemoglobin, >90%) is adequate. metabolic alkalosis can accompany the respiratory acidosis, but this is a compensatory change and resolves once gas exchange is normalized. some of these patients require mechanical ventilation, which may be lifesaving. one may discontinue mechanical ventilation as clinical signs resolve and the respiratory muscles gain strength. nursing care is important, and these foals should be turned every 2 hours. they should be maintained in sternal recumbency if possible and kept warm and dry. with good nursing care, good nutritional support, and adequate respiratory support, the prognosis for these foals is good. the limiting factor in the prognosis for life is often financial. 190 foals that recover from the acute stage of this disease eventually fully recover. botulism is an expensive disease to treat and is also an entirely preventable disease. 189, 190 all pregnant mares in endemic areas should be vaccinated against c. botulinum. vaccination does not prevent all cases of botulism, particularly if the foal has failure of passive transfer or acquires the disease after maternal immunity wanes and before its own vaccination. nutritional muscular dystrophy or white muscle disease is a vitamin e/selenium-responsive muscle disease of horses of all ages probably caused by a dietary deficiency of selenium and vitamin e. 191 the condition occurs most commonly in geographic areas with low selenium levels in the soil, generally the northeastern, northwestern, great lakes and mid-atlantic regions of the united states. two forms of the disease are described in foals: the fulminant form, in which the foal is found acutely dead, and the subacute form. in the fulminant form, death usually is attributed to myocardial lesions resulting in cardiovascular collapse. the subacute form is characterized by dysphagia and gait abnormalities primarily caused by stiffness of the muscles of locomotion. paralysis, if present, is not flaccid as in botulism. abnormal function of respiratory muscles may complicate the clinical situation. aspiration pneumonia may be present following problems associated with swallowing; the tongue and pharyngeal muscles frequently are affected in the early stages of disease. 191 foals with severe disease may have widespread muscle necrosis leading to hyperkalemia, which can be severe and result in death of the foal. serum activities of the muscle enzymes creatine kinase and aspartate aminotransferase may be greatly increased. diagnosis is confirmed at necropsy or ante mortem by determination of decreased vitamin e, selenium, and glutathione peroxidase concentrations in the blood of the foal before supplementation. myoglobinuria and acute renal failure are not uncommon in these foals. treatment of foals with nutritional muscular dystrophy is primarily supportive. one should address all metabolic abnormalities. some foals require intranasal oxygen insufflation. affected foals are unable to suck effectively, and one should provide enteral (via an indwelling nasogastric tube) or parenteral nutritional support. because of the high likelihood of aspiration pneumonia, one should administer broad-spectrum antimicrobial therapy parenterally. the patient should be kept quiet and should be stimulated minimally. affected foals should receive parenteral (intramuscular) vitamin e and selenium supplementation. selenium is toxic in large doses. the prognosis for severely affected foals is guarded. for less severely affected foals the prognosis is good with appropriate treatment. the disease is preventable by ensuring that mares receive sufficient vitamin e and selenium while pregnant and by supplementing foals with parenteral injections of vitamin e and selenium at birth in endemic areas. a more complete discussion of the pathophysiology of this disease and the nutritional management is presented elsewhere in this text. primary liver disease is uncommon in the foal and occurs primarily as a sequela to sepsis. clinical signs of severe liver disease may include depression, ataxia, and seizures. in affected foals, increases in serum liver enzyme activities and concentrations of ammonia and bile acids frequently can be identified. the mechanism(s) underlying hepatoencephalopathy are not delineated clearly, although increased excitatory neurotransmitters, or compounds that mimic their activity, are implicated. hepatoencephalopathy is discussed in more detail elsewhere in this text. tyzzer's disease (clostridium piliformis infection) rarely causes primary liver disease in foals from 4 to about 40 days of age. this disease is almost uniformly fatal. the incubation period is short, and the mare is thought to be the carrier. [192] [193] [194] [195] [196] clinical signs range from acute death to depression, fever, and pronounced icterus. the feces of affected foals may appear white to grey because of the lack of bile. clinicopathologic abnormalities include leukopenia, hyperfibrinogenemia, metabolic acidosis, and hypoglycemia. 197, 198 liver lesions at postmortem are characterized microscopically by multiple foci of necrosis. one usually can demonstrate variable numbers of elongated, slender intracytoplasmic bacilli within hepatocytes bordering the necrotic foci. infiltration of the portal triads with inflammatory cells and biliary duct hyperplasia and degeneration are observable. the bacillus also occurs in association with myocardial lesions. lesions in the intestine are characterised by mucosal necrosis with inflammatory cell infiltration, increased mucus production, submucosal lymphoid hyperplasia, and submucosal hemorrhage. necrosis of lymphoid follicles, congestion, and hemorrhage can be present in the spleen and mesenteric lymph nodes. 196 affected foals may have a profound metabolic acidosis that is unresponsive to treatment. the clinical course is short, and most affected foals die within a few hours of developing neurologic signs. primary liver disease has been reported in association with ferrous sulfate administration in a probiotic compound. 199 the lesion was massive hepatocellular necrosis and liver failure. the product is no longer commercially available. portosystemic shunt is rare in the foal but has been reported in foals as young as 3 months of age. [200] [201] [202] most infectious causes of neurologic abnormalities in foals are associated with sepsis. although rarely reported, halicephalobus gingivalis (deletrix) infection has been reported in three foals; in one case the foal was 3 weeks of age. 203, 204 possibly transmission in these cases was transmammary; the dam in one case died 1 year later with confirmed h. deletrix infestation of her udder. listeria monocytogenes has been reported as a cause of neurologic disease in foals. 205 recently, sarcocystis neurona was identified as the causative agent of central nervous system disease in a foal, and equine herpes myeloencephalitis has been diagnosed in individual foals and in herd outbreaks involving foals. 206, 207 neospora also was reported in one foal recently. 208 rhodococcus equi abscesses can form in the central nervous system or cause neurologic signs associated with compression, as with vertebral body abscesses. [209] [210] [211] cerebellar hypolasia, occipitoatlantoaxial malformation, and agenesis of the corpus callosum with cerebellar vermian hypoplasia have been reported in foals. [212] [213] [214] [215] [216] [217] ivermectin toxicity and moxidectin toxicity have been reported. 218, 219 electrolyte abnormalities such as extreme hypo-or hypernatremia may result in neurologic manifestations of disease. 220, 221 cervical stenotic myelopathy and degenerative myelopathy also have been reported in foals, although the age at onset is usually more than 4 months. 222 idiopathic epilepsy of arabian foals usually is associated with another infectious disease and is thought to be temporary and self-limiting. causes, diagnosis, and treatment of fpt of immunity are covered in detail elsewhere in this text. failure of passive transfer occurs when a foal fails to ingest a significant quantity of good-quality colostrum. failure of passive transfer may occur by several mechanisms: failure of the foal to suck from the dam for any reason and failure of the dam to produce sufficient quantity of quality colostrum. box 19-4 presents causes of fpt. several methods are available for measuring igg concentration in blood; the most reliable are enzyme-linked immunosorbent assay and single radial immunodiffusion technology-based tests. [223] [224] [225] [226] [227] [228] [229] foals usually are tested at 24 hours of age, but one may test the foal earlier if colostrum ingestion has occurred and a concern exists regarding the passive transfer of immunity status of the foal, recognizing that additional increases in igg concentration may occur with additional time. 230, 231 the concentration of igg in the blood of the foal has been used as an indicator of the adequacy of passive transfer, but the actual blood concentration at which fpt is diagnosed has been challenged in recent years. [232] [233] [234] foals with sepsis commonly have a serum igg concentration of less than 800 mg/dl. 16, 19 foals with fpt are more likely to die from sepsis. 177, 178, [235] [236] [237] one should consider the igg concentration only as a marker for adequacy of colostral absorption. all the measured igg is unlikely to be directed against the specific pathogen affecting any particular neonate, and igg is not the only immune protection afforded the foal by colostrum. many factors that confer local and more general immunity to the newborn are present in colostrum; these include growth factors, cytokines, lactoferrins, cd14, leukocytes, and other yet to be described proteins. [240] [241] [242] [243] [244] by considering igg a marker of adequacy for passive transfer, similar to î³-glutamyltransferase in calves, the clinician can make choices for replacement that are more beneficial to the patient. 245 after one identifies fpt in a foal, treatment depends on the current condition of the foal and its local environment. foals not presently ill and on well-managed farms with low population density and low prevalence of disease may not require treatment if their igg concentration is between 400 and 800 mg/dl. critically ill neonates with fpt in an equine nicu are by definition ill and in an environment with high disease prevalence. these patients require immediate treatment of fpt and frequent reassessment of their passive immunity status. critically ill foals often fail to demonstrate the expected increase in blood igg concentration based on grams of igg administered per kilogram of body mass compared with healthy, colostrum-deprived foals. 235, 246, 247 sick foals also demonstrate a more rapid decline in igg concentration than do healthy foals because they use and catabolize available protein. one may treat foals with fpt by oral or intravenous administration of various products containing igg. one can attempt oral administration of additional colostrum or igg-containing products such as plasma, serum, or lyophilized colostrum in foals less than 12 to 24 hours of age. [248] [249] [250] depending on the age of the foal and the maturity and function of the gastrointestinal tract, this treatment may be effective. many nicus and large breeding farms maintain colostrum banks for this purpose. one should administer plasma intravenously if the foal is not expected to absorb additional colostrum or if the enteral route is unavailable. commercially available hyperimmune plasma products designed for use in foals are available and can be stored frozen. plasma and banked colostrum should be stored in a non-frost-free freezer to minimize protein loss associated with freeze-thaw cycling. 251 one should administer plasma through special tubing with an in-line filter and should monitor patients closely for transfusion reactions. 252 one may use serum and concentrated igg products, but the practitioner should be aware that many of these products focus on igg retention and not on other factors associated with passive transfer of immunity. one should measure igg concentration after transfusion and provide additional plasma as necessary. administration of plasma to critically ill foals without fpt may be beneficial through provision of other factors present in the plasma. in these situations, fresh frozen plasma or fresh plasma may be best, particularly if transfusion of clotting proteins is desired. neonatal isoerythrolysis is a hemolytic syndrome in newborn foals caused by a blood group incompatibility between the foal and dam and is mediated by maternal antibodies against foal erythrocytes (alloantibodies) absorbed from the colostrum. the disease most often affects foals born to multiparous mares and should be suspected in foals less than 7 days of age with clinical signs of icterus, weakness, and tachycardia. a primiparous mare can produce a foal with neonatal isoerythrolysis if she has received a prior sensitizing blood transfusion or has developed placental abnormalities in early gestation that allowed leakage of fetal red blood cells into her circulation. many are the causes of jaundice in newborn foals, including sepsis, meconium impaction, and liver failure, but these usually can be differentiated readily from neonatal isoerythrolysis by measuring the packed cell volume, which is usually less than 20% in foals with neonatal isoerythrolysis. foals with neonatal isoerythrolysis are born clinically normal then become depressed and weak and have a reduced suckle response within 12 to 72 hours of birth. the rapidity of onset and severity of disease are determined by the quantity and activity of absorbed alloantibodies. affected foals have tachycardia, tachypnea, and dyspnea. the oral mucosa is initially pale and then becomes icteric in foals that survive 24 to 48 hours. hemoglobinuria may occur. seizures caused by cerebral hypoxia are a preterminal event. the salient laboratory findings are anemia and hyperbilirubinemia. most of the increased bilirubin is unconjugated, although the absolute concentration of conjugated bilirubin generally is increased well above normal. urine may be red to brown and is positive for occult blood. the natural development of neonatal isoerythrolysis has several prerequisites. first, the foal must inherit from the sire and express an erythrocyte antigen (alloantigen) that is not possessed by the mare. blood group incompatibility between the foal and dam is not particularly uncommon, but most blood group factors are not strongly antigenic under the conditions of exposure through previous parturition or placental leakage. factor aa of the a system and factor qa of the q system are highly immunogenic, however, and nearly all cases of neonatal isoerythrolysis are caused by antibodies to these alloantigens. the exception is in the case of mule foals in which a specific donkey factor has been implicated. [253] [254] [255] mares that are negative for aa or qa or both are considered to be at risk for producing a foal with neonatal isoerythrolysis. the risk involves approximately 19% and 17% of thoroughbred and standardbred mares, respectively. second, and perhaps most important, the mare must become sensitized to the incompatible alloantigen and produce antibodies to it. the mechanism for this is not known in many instances but generally is believed to result from transplacental hemorrhage during a previous pregnancy involving a foal with the same incompatible blood factor. 255 sensitization via transplacental contamination with fetal erythrocytes earlier in the current pregnancy is possible, but an anamnestic response is generally necessary to induce a pathogenic quantity of alloantibodies. 256 ten percent of thoroughbred mares and 20% of standardbred mares have antibodies to the ca blood group antigen without known exposure to erythrocytes. 255 some common environmental antigen is postulated possibly to lead to production of anti-ca antibodies. data suggest that these natural antibodies may suppress an immune response to other blood group antigens because mares negative for aa that have anti-ca antibodies often do not produce antibodies to aa of the erythrocytes in their foals that also contain ca antigen. this antibodymediated immunosuppression is thought to result from the destruction of fetal cells before the dam mounts an immune response to other cell surface antigens. natural alloantibodies have not been associated with neonatal isoerythrolysis in horses. after the mare becomes sensitized to the erythrocytes of her foal, alloantibodies are concentrated in the colostrum during the last month of gestation. unlike the human neonate, which acquires alloantibodies in utero and thus is born with hemolytic disease, the foal is protected from these antibodies before birth by the complex epitheliochorial placentation of the mare. thus the final criterion for foal development of neonatal isoerythrolysis is ingestion in the first 24 hours of life of colostrumcontaining alloantibodies specific for foal alloantigens. immunoglobulin-coated foal erythrocytes are removed prematurely from circulation by the mononuclear phagocyte system or are lysed intravascularly via complement. the rapidity of development and severity of clinical signs are determined by the amount of alloantibodies that was absorbed and their innate activity. alloantibodies against aa are potent hemolysins and generally are associated with a more severe clinical syndrome than antibodies against qa or other alloantigens. the highest alloantibody titers are likely to be produced by mares that were sensitized in a previous pregnancy and then subsequently reexposed to the same erythrocyte antigen during the last trimester of the current pregnancy. prior sensitization of a mare by blood transfusion or other exposure to equine blood products may predispose to neonatal isoerythrolysis. 256 one can make a tentative diagnosis of neonatal isoerythrolysis in any foal that has lethargy, anemia, and icterus during the first 4 days of life. blood loss anemia caused by birth trauma is attended by pallor. icterus caused by sepsis or liver dysfunction would not be associated with anemia. one must base the definitive diagnosis of neonatal isoerythrolysis on demonstration of alloantibodies in the serum or colostrum of the dam that are directed against foal erythrocytes. the most reliable serodiagnostic test for neonatal isoerythrolysis is the hemolytic cross-match using washed foal erythrocytes, mare serum, and an exogenous source of absorbed complement (usually from rabbits). 5 although this test is impractical in a practice setting, a number of qualified laboratories routinely perform this diagnostic service. the direct antiglobulin test (coombs' test) may demonstrate the presence of antibodies on foal erythrocytes; however, false negatives occur frequently. most human or veterinary hematology laboratories can perform routine saline agglutination cross-match between mare serum and foal cells. because some equine alloantibodies act only as hemolysins, agglutination tests may be falsely negative. most field screening tests of colostrum have not proved to be reliable enough for practical use. if one recognizes neonatal isoerythrolysis when the foal is less than 24 hours old, one must withhold the dam's milk and feed the foal an alternative source of milk during the first day of life. one can accomplish this by muzzling the foal and feeding it via nasogastric tube. the minimum necessary amount of milk is 1% of body mass every 2 hours (e.g., a 50-kg foal should receive 500 ml or 1 pint of mare's milk or milk replacer every 2 hours). the udder of the mare should be stripped regularly (at least every 4 hours) and the milk discarded. in most instances, clinical signs are not apparent until after the foal is 24 hours old, when colostral antibodies have been depleted or the absorptive capacity of the foal's intestine for immunoglobulin has diminished. withholding milk at this point is of minimal benefit. supportive care to ensure adequate warmth and hydration is paramount. the foal should not be stressed and exercise must be restricted. confining the mare and foal to a box stall is a best. intravenous fluids are indicated to promote and minimize the nephrotoxic effects of hemoglobin and to correct any fluid deficits and electrolyte and acid-base imbalances. antimicrobials may be necessary to prevent secondary infections. one should monitor foals carefully for the necessity of blood transfusion, although transfusion should be used only as a lifesaving measure. when the packed cell volume drops below 12%, blood transfusion is warranted to prevent life-threatening cerebral hypoxia. erythrocytes from the dam are perfect in terms of nonreactivity with the blood of the foal; however, the fluid portion of the blood of the mare has to be removed completely from the cells to prevent administration of additional harmful alloantibodies to the foal. one can pellet the erythrocytes of the dam from blood collected in acid-citrate-dextrose solution by centrifugation or gravity and then aseptically draw off the plasma by suction apparatus or syringe and replace it with sterile isotonic (0.9%) saline. one thoroughly mixes the cells with the saline and then repeats the centrifugation or sedimentation, followed by aspiration and discarding of the saline. one should perform this washing process at least three times. one then can suspend the packed erythrocytes in an equal volume of isotonic saline for administration. erythrocyte washing by centrifugation is more desirable than gravity sedimentation because antibody removal is more complete and packed cell preparations can be prepared more quickly (each gravity sedimentation requires 1 to 2 hours). packed red blood cells are advantageous in overcoming the problem of volume overload. when equipment or conditions do not allow the safe use of dam erythrocytes, an alternative donor is necessary. because the alloantibodies absorbed by the foal generally are directed against aa or qa and because the latter are highly prevalent among most breeds of horses, a compatible blood donor is difficult to identify. the odds of finding a donor without aa or qa are higher in quarter horses, morgans, and standardbreds than in thoroughbreds and arabians. previously blood-typed individuals negative for aa and qa and free of alloantibodies are optimal. one should give 2 to 4 l of blood or 1 to 2 l of packed erythrocytes over 2 to 4 hours. these allogeneic cells have a short life span and represent a large burden to the neonatal mononuclear phagocyte system, which may cause increased susceptibility to infection. in addition, these cells sensitize the foal to future transfusion reactions. one must measure all potential harm against the benefit in each situation. if a mule foal is the patient, one should not use blood from a female previously bred to a donkey. in cases in which transfusion will be delayed, one cannot identify a compatible donor, or the packed cell volume is so low as to be life-threatening (hemoglobin <5 mg/dl), one may administer polymerized bovine hemoglobin products at a dose of 5 to 15 ml/kg. 257 one may use dexamethasone (0.08 mg/kg) to treat peracute neonatal isoerythrolysis if the packed cell volume is less than 12% and transfusion may be delayed or is not fully compatible, but dexamethasone has detrimental effects on blood glucose regulation in the neonate, and because the antibody in question is of maternal origin, corticosteroid therapy in immunosuppressive doses probably is not indicated. intranasal oxygen insufflation (5 to 10 l/min) may be beneficial. most foals with neonatal isoerythrolysis have adequate passive transfer of immunity, but antimicrobial therapy is indicated to protect against secondary sepsis resulting from the compromised condition of the foal. supportive care and good nursing care, including keeping the foal warm and quiet are essential. one should expect the packed cell volume to decline again 4 to 7 days after transfusion. 258 the prognosis for neonatal isoerythrolysis in foals depends on the quantity and activity of absorbed antibodies and is indirectly proportional to the rate of onset of signs. in peracute cases the foal may die before the problem is recognized, whereas foals with slowly progressive signs often live with appropriate supportive care. like most diseases, neonatal isoerythrolysis is much more effectively prevented than treated. 259 any mare that has produced a foal with neonatal isoerythrolysis should be suspect for the production of another affected foal; thus one should provide all subsequent foals with an alternative colostrum source and discard the colostrum of the dam unless she is bred to a stallion with known blood type compatibility. mares negative for aa and qa alloantigens are most at risk of producing affected foals, thus they should be identified by blood-typing. subsequently, breeding of these mares may be restricted to aa-and qa-negative stallions, thus eliminating the possibility of producing an affected foal. in breeds with a high prevalence of aa or qa alloantigens (e.g., thoroughbreds and arabians), a stallion negative for these and suitable based on other criteria may be difficult to identify. if these "at risk" mares are bred as desired, their serum should be screened in the last month of pregnancy for the presence of erythrocyte alloantibodies. one must test mares with low or equivocal titers closer to the time of parturition. if one detects alloantibodies, the colostrum of the dam should be withheld and the foal then should be provided with an alternative colostrum source. maternal alloantibodies to ca do not appear to mediate neonatal isoerythrolysis in foals and actually may be preventive by removing potentially sensitizing cells from the circulation 56 ; therefore one should not deprive foals of colostrum from mares possessing anti-ca antibodies, even when ca is present on their erythrocytes. rarely, the antigens de, ua, pa, and ab have been associated with neonatal isoerythrolysis in foals; however, to consider mares without these alloantigens to be at risk for neonatal isoerythrolysis is not practical. these syndromes recently have been recognized and described within the veterinary literature, although they have been recognized widely in human neonatology for many years. [260] [261] [262] [263] affected foals demonstrate these hematologic abnormalities within the first week of life, and the mechanism is similar to neonatal isoerythrolysis following ingestion of maternal antibody directed against the platelet or the neutrophil. in general, affected foals are healthy but may demonstrate bleeding tendencies if thrombocytopenia is severe or they may be more susceptible to sepsis. one confirms the diagnosis by appropriate testing for platelet-and neutrophil-associated antibody. 264 one must rule out other causes of neonatal thrombocytopenia and neutropenia, particularly sepsis. foals born to the mare in the future seem likely to be at risk for developing similar problems, and one should treat future foals as one treats neonatal isoerythrolysis foals: prevent sucking from the dam and provide an alternate source of passive immunity in the form of banked colostrum or intravenous plasma. one should provide an alternative nutritional source, such as foal milk replacer, to the foal for the first 48 hours of life and should muzzle the foal while it is in the company of its dam for that period of time. treatment is primarily supportive, but in the case of severe thrombocytopenia, transfusion of platelet-enriched fresh plasma may be indicated. granulocyte colony-stimulating factor has been used in foals with neutropenia, but substantial efficacy has yet to be demonstrated. broad-spectrum antimicrobial therapy may be prudent in cases of alloantibody-associated neutropenia. treatment with immunosuppressive doses of corticosteroids is probably unwarranted, given the increased risk of infection, because the antibody in question is of maternal origin. other specific diseases of the immune system of foals, severe combined immunodeficiency, selective igm deficiency, transient hypogammaglobulinemia, agammaglobulinemia, and other unclassified immunodeficincies are covered in detail elsewhere in this text. the neonate can experience respiratory distress immediately after birth because of several congenital respiratory tract or cardiac anomalies. chief among these causes are bilateral choanal atresia, stenotic nares, dorsal displacement of the soft palate caused by anatomic deformity or neurologic impairment, accessory or ectopic lung lobes, lung lobe hypertrophy, lung lobe dysplasia, cardiac anomalies with right-to-left shunting, and miscellaneous causes such as subepiglotic cysts and severe edema of the larynx. [264] [265] [266] [267] [268] [269] [270] [271] one must evaluate and treat these situations immediately and should consider them true emergencies. one readily can recognize foals with airway occlusion by the lack of airflow through the nostrils despite obvious attempts to breathe and by respiratory stridor. these foals may demonstrate open-mouth breathing and their cheeks may puff outward when they exhale. one foal with congenital bilateral choanal atresia was recognized during extrauterine intrapartum resusucitation because of an inability to pass a nasotrancheal tube. one can establish an effective airway by orotracheal intubation in these cases under most circumstances, but some foals require an emergency tracheostomy. one diagnoses the underlying problem by endoscopy or radiography in most cases. treatment of choanal atresia and cystic structures is surgical, whereas severe laryngeal edema and laryngeal paralysis frequently respond to medical management. until the underlying problem is resolved in these cases, one should administer broad-spectrum antimicrobial therapy and feed the foal by intubation or total parenteral nutrition. one can give colostrum, but these foals frequently develop aspiration pneumonia if allowed to suck from their dams, so intravenously administered plasma also may be necessary to provide sufficient passive immunity. arterial blood gas determinations are the most sensitive indicator of respiratory function readily available to the clinician. the most readily available arteries for sampling are the metatarsal arteries and the brachial arteries. portable arterial/venous blood gas analyzers now are making arterial blood gas analysis more practical in the field, and the technique is no longer reserved for large referral practices. managing a critically ill equine neonate without knowledge of arterial blood gas parameters is veritably impossible. pulse oximetry is useful, but these monitors only measure oxygen saturation of hemoglobin. desaturation can occur rapidly in critically ill neonates. the utility of these monitors in the foal has yet to be demonstrated clearly, particularly in cases of poor peripheral perfusion. 272 the most common abnormalities recognized with arterial blood gas analysis are hypoxemia with normo-or hypocapnia and hypoxemia with hypercapnia. hypoxemia is defined as decreased oxygen tension of the arterial blood (decrease pao 2 ), and hypoxia is defined as decreased oxygen concentration at the level of the tissue, with or without hypoxemia. hypoxia results from hypoxemia, decreased perfusion of the tissue bed in question, or decreased oxygen-carrying capacity of the blood resulting from anemia or hemoglobin alteration. five primary means by which hypoxemia may develop are (1) low concentration of oxygen in the inspired air such as in high altitude or in an error mixing ventilator gas; (2) hypoventilation; (3) ventilation/perfusion mismatch; (4) diffusion limitation; and (5) intrapulmonary or intracardiac right-to-left shunting of blood. hypoxemia is not an uncommon finding in neonates but must be evaluated in terms of the current age of the foal and its position. 15, [273] [274] [275] [276] one also must consider the difficulty encountered in obtaining the sample because severe struggling can affect the arterial blood gas results. table 19 -8 presents normal arterial blood gas parameters for varying ages of foals. the normal foal has a small shunt fraction (~10%) that persists for the first few days of life and contributes slightly to a blunted response to breathing 100% oxygen compared with the adult. hypoxemia frequently occurs in foals with prematurity, pas, and sepsis, although other conditions also result in hypoxemia in the neonate. in the early stage of sepsis associated hypoxemia, paco 2 may be within normal limits or decreased if the foal is hyperventilating for any reason. if the lung is involved significantly in the underlying pathologic condition, such as with severe pneumonia, acute lung injury, or acute respiratory distress syndrome, increased paco 2 may well be present, representing respiratory failure. 277 hypoxemia usually is treated with intranasal humidified oxygen insufflation at 4 to 10 l/min. hypercapnia is not a simple matter to treat. one must try to distinguish between acute and chronic hypercapnia. acute hypercapnia usually is accompanied by a dramatic decrease in blood ph of 0.008 ph units for each 1 mm hg increase in paco 2 . this acidemia can promote circulatory collapse, particularly in the concurrently hypoxemic and/or hypovolemic patient. the effects of more chronic co 2 retention are less obvious because the time course allows for adaptation. the ph change is less, about 0.003 ph units per 1 mm hg increase in paco 2 , because it is balanced by enhanced renal absorption of bicarbonate by the proximal renal tubule. most foals with acute respiratory distress are in the acute stages of respiratory failure, but chronic adaptation begins to occur within 6 to 12 hours and is maximal in 3 to 5 days. one will note an increase in bicarbonate, particularly if the acidemia is primarily respiratory in origin. intravenous administration of sodium bicarbonate to correct respiratory acidosis/ acidemia should be done cautiously in these foals because co 2 retention may only be increased. also, one should remember that 1 meq of sodium is administered with each meq of bicarbonate and hypernatremia has been seen in foals treated exuberantly with sodium bicarbonate. foals with hypercapnia of several days' duration also may develop a blunted respiratory drive to increased co 2 . in these foals, oxygen administration, although essential to treat hypoxemia, may further depress ventilation and further decrease ph. this effect is caused by a loss of hypoxic drive following oxygen therapy. one should consider these foals candidates for mechanical ventilation if the paco 2 is greater than 70 mm hg or is contributing to the poor condition of the foal, such as causing significant ph changes. if hypercapnia is caused by central depression of ventilation, as frequently occurs in foals with pas, one can administer caffeine (10 mg/kg loading dose; then 2.5 mg/kg as needed) per rectum or orally in foals with normal gastrointestinal function. other clinicians may recommend continuous rate infusions of doxapram hydrochoride (dopram; 400 mg/total dose at 0.05 mg/ kg/min) for these foals. if this therapy fails, one should consider mechanical ventilation. mechanical ventilation of foals with central respiratory depression is rewarding and may be necessary only for a few hours to days. a special category is the foal with botulism exhibiting respiratory failure caused by respiratory muscle paralysis. these foals do well with mechanical ventilation, although the duration of mechanical ventilation is more prolonged, frequently more than 1 week. foals with primary metabolic alkalosis usually have compensatory respiratory acidosis. treatment of hypercapnia is not necessary in these cases because it is in response to the metabolic condition. these foals do not respond to caffeine, and they should not be ventilated mechanically if this is the only disorder present. in the neonate, bacterial pneumonia usually results from sepsis or aspiration during sucking. foals with sepsis can develop acute lung injury or acute respiratory distress syndrome as part of the systemic response to sepsis, and this is frequently a contributor to the demise of foals in septic shock. the best way to diagnose bacterial pneumonia is by cytologic examination and culture of a transtracheal aspirate, but blood culture may aid in early identification of the causative organism and allow for early institution of directed antimicrobial therapy. a second frequent cause of bacterial pneumonia in the neonate is aspiration caused by a poor suck reflex or dysphagia associated with pas, sepsis, or weakness. one must take care to ensure that aspiration is not iatrogenic in foals being bottle fed. auscultation over the trachea while the foal is sucking helps identify occult aspiration. one should suspect occult aspiration pneumonia in any critically ill neonate that is being bottle fed or is sucking on its own that has unexplained fever, fails to gain weight, or has a persistently increased fibrinogen level. older foals develop bacterial pneumonia, frequently following an earlier viral infection. 278 bacterial pneumonia is discussed in depth elsewhere in this text, but a few comments specific to the foal are necessary. one should auscultate and percuss the thorax of the foal, but results may not correlate closely with the severity of disease. the most commonly isolated bacterial organism in foal pneumonia is streptococcus zooepidemicus, and one may isolate it alone or as a component of a mixed infection. [278] [279] [280] transtracheal aspirate for culture and cytologic examination is recommended because mixed gram-positive and gram-negative infections are common, and antimicrobial susceptibility patterns can be unpredictable. one should split the obtained aspirate and submit samples for bacterial culture, virus isolation, and cytologic examination. additional diagnostics include radiography, ultrasonography, and serial determination of white blood cell counts (with differential) and blood fibrinogen concentrations. treatment includes administration of appropriate antimicrobial therapy. some foals may benefit from nebulization with saline or other local products. ascarid larval migration through the lung can mimic bacterial pneumonia. 281 in these cases the foal may not respond to antimicrobial therapy and should be dewormed with ivermectin. deworming the mare within 1 month of parturition and frequent deworming of the foal prevent ascarid migration pneumonia in most foals. a special category of bacterial pneumonia in foals is rhodococcus equi bronchopneumonia. this pneumonia of young foals was described first in 1923. 282 the organism originally was known as corynebacterium equi and is a gram-positive pleomorphic coccobacillus usually less than 1 âµm in diameter and 2 âµm in length. the organisms frequently are associated in l-and v-shaped clusters that have been termed chinese character formations. r. equi has an acid-fast staining characteristic under some growing circumstances because of the presence of mycolic acid in its cell wall, similar to mycobacterium and nocardia species. mycolic acid promotes granuloma formation. the organism is able to multiply in and destroy macrophages as it prevents phagosome lysosome fusion. 283, 284 much attention has been paid to this organism in recent years, given its propensity to produce enzootic and epizootic outbreaks of disease. the organism is thought to be primarily an opportunistic pathogen, and it lives in the soil of most geographic areas. foals are affected most frequently between the ages of 1 and 6 months, when maternally derived immunity has begun to wane. the disease is insidious, and foals may have significant pulmonary involvement before developing noticeable clinical signs. phagocytosis of r. equi by equine macrophages is not associated with a functional respiratory burst and, at least in human beings, the l-arginine-no pathway is not required for intracellular killing of this organism. 285, 286 optimal binding of r. equi to mouse macrophages in vitro requires complement and is mediated by mac-1, a leukocyte complement receptor type 3 (cr3, cd11b/ cd18). 287 opsonisation of r. equi with specific antibody is associated with increased phagosome-lysosome fusion and enhanced killing of r. equi, suggesting that the mechanism of cellular entry is important. 283 neutrophils from foals and adult horses are fully bactericidal, and killing of r. equi is enhanced considerably by specific opsonizing antibody. 288 the ability of r. equi to induce disease in foals likely depends on host and microbial factors. knowledge of the virulence mechanisms of r. equi was speculative until the discovery of the virulence plasmid. 289 as opposed to most environmental r. equi organisms, isolates from clinically affected foals typically contain 85-to 90-kb plasmids encoding an immunogenic virulence-associated protein (vapa) that is expressed on the bacterial surface in a temperature-regulated manner. 290 plasmid-cured bacteria lose their ability to replicate and survive in macrophages and are cleared from the lungs within 2 weeks of intrabronchial challenge without producing pneumonia. 291 however, expression of vapa alone is not sufficient to restore the virulence phenotype. six other genes have approximately 40% overall amino acid identity with vapa, and the identification of multiple genes with considerable homology suggests these genes constitute a virulence-associated gene family in r. equi. 292 other candidates for virulence factors include capsular polysaccharides and cholesterol oxidase, choline phosphohydrolase, and phospholipase c exoenzymes ("equi factors"), but their roles have not been defined clearly. the primary manifestation of disease caused by r. equi infection is severe bronchopneumonia with granuloma, abscess formation, or both. up to 50% of foals diagnosed with bronchopneumonia also have extrapulmonary sites of infection. 293 as the pneumonia progresses, clinical signs may include decreased appetite, lethargy, fever, tachypnea, and increased effort of breathing characterized by nostril flaring and increased abdominal effort. cough and bilateral nasal discharge are inconsistent findings. a smaller percentage of affected foals may have a more devastating, subacute form. these foals may be found dead or have acute respiratory distress with a high fever and no previous history of clinical respiratory disease. hyperfibrinogenemia is the most consistent laboratory abnormality in foals with r. equi pneumonia. neutrophilic leukocytosis (>12,000 cells/âµl), with or without monocytosis, is common. 294 thoracic radiography is a useful diagnostic aid, frequently revealing a prominent alveolar pattern with poorly defined regional consolidation and/or abscessation. ultrasonography is a helpful diagnostic tool when the disease involves peripheral lung tissue. although a number of serologic tests have been described, serologic diagnosis of r. equi infections is controversial and difficult because exposure of foals to this organism at a young age leads to production of antibody without necessarily producing clinical disease. 295, 296 serologic tests may be more useful at the farm level to detect overall exposure than at the individual level. bacteriologic culture combined with cytologic examination of a tracheobronchial aspirate remains the most definitive method for accurate diagnosis of r. equi pneumonia. however, foals without clinical disease exposed to contaminated environments may have r. equi in their tracheae from inhalation of contaminated dust; therefore one should interpret culture results in the context of the overall case presentation. 297 culture results in one study were as sensitive as polymerase chain reaction-based assays and offered the advantage of allowing in vitro antimicrobial susceptibility testing. 298 however, polymerase chain reaction is likely to be a useful tool, and results from a second trial suggest the assay is more sensitive and specific than culture of tracheobronchial aspirates for diagnosis. 299 the combination of erythromycin and rifampin has become the treatment of choice for r. equi infections in foals, and the combination reduces the likelihood of resistance to either drug. the recommended dosage regimen for rifampin is 5 mg/kg every 12 hours or 10 mg/kg every 24 hours orally. the recommended dose of estolate or ethylsuccinate esters of erythromycin is 25 mg/kg every 8 or 12 hours orally. 300 recently, azithromycin has been recommended for treatment of r. equi infection at a dosage of 10 mg/kg orally every 24 hours for 5 to 7 days and then every other day. 301 alternatively, clarithromycin at 7.5 mg/kg every 12 hours orally, in combination with rifampin, may be therapeutically effective. severely affected foals may require intranasal oxygen insufflation, intravenous fluid support, and nutritional support. treatment generally continues for 4 to 10 weeks until all clinical and laboratory evidence of infection is resolved. although well tolerated by most foals, erythromycin can result in soft feces. this diarrhea is generally self-limiting and does not require cessation of therapy, but one should monitor affected foals carefully. an idiosyncratic reaction characterized by severe hyperthermia and tachypnea has been described in foals treated with erythromycin during periods of hot weather. 302 affected foals should be moved to a colder environment and treated with antipyretic drugs and alcohol baths if necessary. clostridium difficile enterocolitis has been reported in the dams of nursing foals treated with erythromycin given orally. 303 the dam is exposed to active erythromycin by coprophagy or by drinking from a communal water source where the foal has "rinsed" its mouth. prevention of r. equi pneumonia on farms with recurrent problems is problematic. the most clearly demonstrated prophylactic measure to date has been the administration of plasma that is hyperimmune to r. equi to foals within the first week of life and then again when maternal immunity begins to wane at around 30 days of age. [304] [305] [306] [307] [308] [309] [310] [311] no effective vaccination protocols for the dam or foal have been described to date. farm management is important in preventing disease, and control measures include frequent manure removal, avoidance of overcrowded conditions, and planting of dusty or sandy soils. 304 the prognosis for r. equi bronchopneumonia is fair to good in foals with the more chronic form of the disease. foals with acute respiratory distress have a more guarded prognosis, as do foals with sites of significant extrapulmonary infection. the long-term prognosis for survival for foals with r. equi bronchopneumonia is good, and many foals perform as expected as athletes. 312 the most commonly identified causes of viral pneumonia in foals are equine herpesviruses 1 and 4 (ehv-1 and ehv-4), equine influenza, and equine arteritis virus (eva). equine herpesvirus 1 is probably the most clinically important, but outbreaks of eva in neonates have occurred and are devastating. 27, [313] [314] [315] [316] [317] [318] adenovirus is reported sporadically and as a problem in arabian foals with severe combined immunodeficiency. [319] [320] [321] in the neonate, infection with ehv-1 or eva is almost uniformly fatal and antemortem diagnosis is difficult, even once an outbreak on a particular farm is identified. several factors appear common to foals with ehv-1, including icterus, leukopenia, neutropenia, and petechial hemorrhage, but these problems also are identified in foals with severe sepsis. 315, 322, 323 the antiviral drug acyclovir (10 to 16 mg/kg orally or per rectum 4 to 5 times per day) has been used in cases of ehv-1 in neonates, with some evidence of efficacy in mildly affected foals or foals affected after birth. 323 if viral pneumonia is a possibility, one should collect blood and tracheal aspirates at presentation for bacterial and virus isolation. the lungs of foals with ehv-1 or eva are noncompliant, and pulmonary edema may be present. mechanical ventilation of these cases may prolong life, but death is generally inevitable because of the magnitude of damage to the lungs. foals suspected of having ehv-1 or eva should be isolated because they may be shedding large quantities of virus and pose a threat to other neonates and pregnant mares. foals with eva generally are born to seronegative mares, and intravenous treatment with plasma with a high titer against eva may prove beneficial because passive immunity appears to have a large role in protection against this disease in neonates. 318, 324 older foals and weanlings may be affected by herpesviruses. disease is usually mild, although a fatal pulmonary vasculotropic form of the disease has been described recently in young horses. 325, 326 the clinical signs of disease are indistinguishable from influenza and include a dry cough, fever, and serous to mucopurulent nasal discharge, particularly if secondary bacterial infection occurs. rhinitis, pharyngitis, and tracheitis may be present. treatment of affected foals is primarily supportive. foals also may become infected with ehv-2. the predominant clinical signs are fever and lymphoid hyperplasia with pharyngitis. 327, 328 diagnosis is by virus isolation. rib fractures have been recognized in 3% to 5% of all neonatal foals and can be associated with respiratory distress. 87 potential complications of rib fractures include fatal myocardial puncture, hemothorax, and pneumothorax. rib fractures frequently are found during physical examination by palpation of the ribs or by auscultation over the fracture sites. one can confirm the diagnosis by radiographic and ultrasonographic evaluation. often multiple ribs are affected on one side of the chest. specific treatment is generally unnecessary, but direct pressure on the thorax should be avoided in all cases. some specific patients may benefit from surgical stabilization of some fractures, particularly those fractures overlying the heart. pneumothorax can occur spontaneously or following excessive positive pressure ventilation 329 or following tracheostomy surgery or trauma. any foal being ventilated mechanically that suddenly has respiratory distress and hypoxemia should be evaluated for pneumothorax. diagnosis is by auscultation and percussion of the thorax, but one can confirm the diagnosis with radiographic and ultrasonographic evaluation of the thorax. needle aspiration of air from the pleural space also confirms the diagnosis. treatment is required in cases in which clinical signs are moderate to severe or progressive and involves closed suction of the pleural space. subcutaneous emphysema can complicate treatment of this problem. idiopathic or transient tachypnea has been observed in clydesdale, thoroughbred, and arabian breed foals. in human infants, transient tachypnea can be related to delayed absorption of fluid from the lung, perhaps because of immature sodium channels. 330 in foals, tachypnea generally occurs when conditions are warm and humid and is thought to result from immature or dysfunctional thermoregulatory mechanisms. clinical signs of increased respiratory rate and rectal temperature develop within a few days of birth and may persist for several weeks. treatment involves moving the foal to a cooler environment, body clipping, and provision of cool water or alcohol baths. these foals frequently are treated with broad-spectrum antimicrobial drugs until infectious pneumonia can be ruled out. a syndrome of bronchointerstitial pneumonia and acute respiratory distress has been described in older foals and appears to be a distinct entity from acute respiratory distress syndrome in neonatal foals in association with sepsis. 331 the underlying cause has not been identified, but the genesis is probably multifactorial with several potential pathogens being implicated. affected foals have acute respiratory distress with significant tachypnea, dyspnea, nostril flare, and increased inspiratory and expiratory effort. auscultation reveals a cacophony of abnormal sounds including crackles and polyphonic wheezes in all lung fields. loud bronchial sounds are audible over central airways, and bronchovesicular sounds are lost peripherally. affected foals are cyanotic, febrile, and unwilling to move or eat. foals may be found acutely dead. laboratory abnormalities include leukocytosis, hyperfibrinogenemia, and hypoxemia with hypercapneic acidosis. foals can be dehydrated severely and have coagulation changes consistent with disseminated intravascular coagulation. hypoxic injury to other organs, primarily the kidneys and liver, can occur. chest radiographs reveal a prominent interstitial pattern overlying a bronchoalveolar pattern that is distributed diffusely throughout the lung. this syndrome is a respiratory emergency. treatment is broad-based and includes administration of oxygen, nonsteroidal antiinflammatory agents, broad-spectrum antimicrobial therapy, nebulization, judicious intravenous fluid therapy, nutritional support, and corticosteroid therapy. one must manage hyperthermia in the foal. corticosteroid therapy appears to have been lifesaving in most of the reported surviving foals. because this syndrome is associated with high environmental temperatures in some areas, prevention involves control of ambient temperatures, not transporting foals during hot weather, and keeping foals out of direct sun on hot days, particularly foals being treated with erythromycin for suspected or confirmed r. equi infection. 332 uroperitoneum has been recognized as a syndrome in foals for more than 50 years. 333, 334 classically, affected foals are 24 to 36 hours old at the time clinical signs first are recognized. [334] [335] [336] previous reports had a proportionately larger affected male than female population. 334, 335, 337 the hypothesis was that colts were more at risk because their long, narrow, high-resistance urethra was less likely to allow bladder emptying, resulting in rupture of a full bladder during parturition when high pressures were applied focally or circumferentially around the bladder. 333 more recent reports suggest that such extreme sex bias may have been an artifact of small case numbers in the early reports. rupture or disruption of any structure of the urinary tract can occur. the dorsal wall of the bladder has been reported to be a frequent disruption site, with the ventral wall less likely to be involved. 336 the urachus appears to be the next most commonly affected structure. a few cases of ureteral and urethral defects have been reported. 336, 337 sepsis does not appear to favor one site over the others. 338 the pathophysiology of uroperitoneum is not yet understood fully. the high pressure exerted on a full bladder during parturition once was thought to be the main cause. full bladder and obstruction caused by a partial umbilical cord at parturition, strenuous exercise, and external trauma have been reported as causes. 339 a few reports describe smooth and noninflamed edges of torn tissue, suggesting the possibility of congenital bladder wall defects. 338, 340, 341 sepsis leading to urinary tract rupture and uroperitoneum may occur in foals hospitalized for a variety of unrelated problems. the onset of clinical signs of uroperitoneum may be insidious in these foals, and diagnosis may be less obvious. 338 clinical signs associated with uroperitoneum in the neonatal foal typically include straining to urinate, dribbling urine, and a stretched-out stance. weakness, tachycardia, tachypnea, and not sucking well are also common. a distended abdomen may be evident, and one may feel a fluid wave on ballottement of the abdomen. occasionally, urine accumulates in the scrotum and should not be confused with hernia. foals also may show signs of sepsis, including fever, injected mucous membranes, diarrhea, and disease of other body systems. laboratory findings vary depending on the duration of the uroperitoneum and on the presence and severity of sepsis. classic findings include hyperkalemia, hyponatremia, and hypochloremia arising from equilibration of urine electrolytes and water with blood across the peritoneal membrane. [335] [336] [337] the usual foal diet of milk, which is high in potassium and low in sodium, promotes the electrolyte abnormalities. foals that develop uroperitoneum while receiving intravenous fluids may not have classic electrolyte imbalances at the time clinical signs are recognized. 338 increased serum creatinine concentration is often present, whereas blood urea nitrogen concentrations occasionally, but not consistently, are increased. [335] [336] [337] metabolic acidosis and hypoxemia may be present. some patients also have serum hypoosmolality. 335 one should test foals for failure of passive transfer. one of the most sensitive laboratory tests for uroperitoneum is the ratio of peritoneal to serum creatinine. a ratio greater than or equal to 2:1 is considered diagnostic of uroperitoneum. one should collect peritoneal fluid and test it for creatinine concentration, as well as for cytologic findings, culture, and sensitivity. cytologic evaluation of peritoneal fluid is necessary to identify concurrent peritonitis or other gastrointestinal compromise. one should perform an electrocardiogram on initial evaluation of a foal with suspected uroperitoneum because hyperkalemia may result in bradycardia, increased duration of the qrs complex, a shortened q-t interval, increased p-wave duration, prolonged p-r interval, or atrioventricular conduction disturbances. other possible cardiac sequelae to hyperkalemia include cardiac arrest, third-degree atrioventricular block, ventricular premature contractions, and ventricular fibrillation. 337, 340 for any foal exhibiting signs of dypsnea, tachypnea, or hypoxemia, one should have thoracic radiographs taken before induction of anesthesia to rule out pleural effusion, pneumonia, or acute respiratory distress syndrome, which could complicate ventilation and oxygenation during anesthesia and the postoperative period. ultrasonography has become the tool of choice in the diagnosis of uroperitoneum and is a useful tool available to the practitioner. 342 one can image free peritoneal fluid readily, and tears within the bladder are readily visible. the empty bladder with a significant defect, in a fluid-filled abdomen, will collapse on itself and often have a u shape. one also can visualize urachal and urethral lesions. six of eight foals in one study had urinary tract lesions identified sonographically, and all 31 foals of another study underwent sonographic evaluation, and a significant correlation between ultrasonographic findings and location of the lesion at surgery existed. 336, 338 initial treatment aims to stabilize the patient and correct any electrolyte and acid-base abnormalities and provide fluid volume replacement. one should use 0.9% or 0.45% saline with 5% dextrose until laboratory data are available. a potassium concentration of greater than 5.5 meq/l can be life threatening. one can manage hyperkalemia by peritoneal drainage to decrease whole-body potassium stores using teat cannulae, foley catheters, large-gauge (16 or 14) intravenous catheters, or human peritoneal dialysis catheters. fluid replacement at least should equal the amount of fluid removed from the abdomen to prevent acute hypotension caused by expansion of previously collapsed capillary beds. abdominal drainage also helps ventilation and decreases the work of breathing by decreasing pressure on the diaphragm. one may administer calcium gluconate, glucose, sodium bicarbonate, or insulin intravenously to decrease serum potassium concentrations. these maneuvers do not correct the whole-body potassium overload, however, and once therapy is discontinued, hyperkalemia can reappear until the urine is removed from the abdomen. one should correct hyponatremia slowly. because of the real possibility of concurrent sepsis, one should obtain blood cultures before preoperative administration of antimicrobials. broad-spectrum coverage (penicillin and amikacin or ceftiofur sodium) is recommended until culture results become available. one should perform therapeutic drug monitoring when using aminoglycoside therapy. however, the peak value may be depressed because of the increased volume of distribution represented by the volume of urine in the abdomen, so one should not make dose adjustment based on a low peak until obtaining a new peak after surgical correction of the uroperitoneum. one should treat foals with failure of passive transfer with adequate volumes of intravenously administered plasma. after one has addressed the metabolic abnormalities, one may consider surgical management. medical management using an indwelling foley catheter has been described. 343 preoperative medical stabilization reduces anesthetic risk. safer inhalant agents such as isoflurane also have decreased risk. removal of the internal umbilical remnant at the time of surgery is usual. one should consider culturing any removed umbilical remnant and submitting the remnant for histopathologic evaluation. recurrence of urinary tract rupture can occur. sepsis, hypoxemia, pneumonia, peritonitis, and acute respiratory distress syndrome complicate the management of uroperitoneum. many affected foals are persistently oxygen dependent for several days following surgical correction, and one should perform serial arterial blood gas analyses before discontinuing intranasal oxygen supplementation. prognosis is associated closely with concurrent illness, especially septicemia. uncomplicated uroperitoneum from a defect in the bladder has a good prognosis. if the location of the lesion is other than the bladder, the prognosis is not as favorable. 337 foals with septicemia have a much poorer prognosis. 338, 339 acute renal failure most often occurs as a complication of prenatal asphyxial syndrome, sepsis, or aminoglycoside therapy. acute renal failure also has been reported following oxytetracycline administration in foals. 344 the dose of oxytetracycline commonly used to treat flexural deformities in foals is approximately 10 times the antimicrobial dose. many foals treated in this manner also have suffered some degree of perinatal asphxia, which also damages the kidney, because of prolonged parturition precipitated in part by the flexural deformity. evaluation of renal function in these foals before the administration of the first dose of oxytetracycline and continued monitoring of serum creatinine concentrations before administering subsequent doses of this nephrotoxic compound would seem reasonable. hemodialysis has been used as therapy in one of these cases, but prevention is important because these foals may fail to respond to usual therapy for oliguric renal failure and are euthanized. 344 the most commonly reported congenital deformity of the kidney of the foal is renal hypoplasia and dysplasia, which may have a heritable component. 345, 346 renal arteriovenous malformations have been reported also. 347 ectopic ureters and fenestrated ureters have been described in the foal. [348] [349] [350] congenital renal defects, among others, were reported in three weak, recumbent neonatal foals born to mares being treated for equine protozoal myeloencephalitis. 351 mares received sulfadiazine or sulfamethoxazoletrimethoprim, pyrimethamine, folic acid, and vitamin e orally. the foals were anemic, leukopenic, azotemic, hyponatremic, and hyperkalemic. serum folate concentrations were lower than those reported in the literature for clinically normal brood mares. treatment was unsuccessful. necropsy revealed lobulated kidneys with thin cortices and a pale medulla. the authors postulated that oral administration of sulfonamides, 2,4-diaminopyrimidines (pyrimethamine with or without trimethoprim), and folic acid to mares during pregnancy is related to congenital defects in newborn foals. the umbilicus serves as the conduit for nutrition and gas exchange between the dam and the fetal foal. the urine from the foal is expelled via this structure into the allantoic cavity. the author has recognized cases of in utero bladder distention in the fetus that were associated with multiple twists decreasing urine flow or focal stenosis creating the same effect. foals born with this condition did not have bladder rupture associated with parturition but did have other severe abnormalities that eventually resulted in their demise, primarily premature delivery with failure to adapt to extrauterine life (p.a. wilkins, j.e. palmer, and f.t. bain, unpublished data). at birth the umbilicus breaks, leaving a small external remnant and a large internal remnant. the umbilicus long has been regarded as the primary site of entry of pathogens into the neonate, although this has been challenged recently. treatment of the umbilicus after birth involves dipping it (preferably just the most distal component) with various caustic compounds. the most current recommendation is to treat the umbilicus with dilute chlorhexidine, povidone-iodine, or dilute iodine solutions for just a few times following birth. exhuberant treatment of the umbilical stump with caustic solutions can lead to scalding of the ventral abdomen and may promote patency of the urachus. the ultrasonographic appearance and measurements of the umbilical arteries, urachus, and umbilical vein of foals from 6 hours to 4 weeks of age have been described in detail. 342 a 7.5-mhz sector scanner transducer placed across the midline of the ventral portion of the abdominal wall of the foal works best because of the superficial location of these structures. the mean (â± sd) diameter of the umbilical vein was 0.61 â± 0.20 cm immediately cranial to the umbilical stalk, 0.52 â± 0.19 cm midway between the umbilicus and liver, and 0.6 â± 0.19 cm at the liver. the urachus and umbilical arteries of normal foals have a mean total diameter of 1.75 â± 0.37 cm at the bladder apex. the umbilical arteries scanned along either side of the bladder have a mean diameter of 0.85 â± 0.21 cm. one can use these measurements and the ultrasonographic appearance of the internal umbilical structures from clinically normal foals as references to diagnose abnormalities of the umbilical structures in neonatal foals. 352, 353 the most common abnormalities of these structures are focal abscess formation, hematoma, and urachal tear. herniae traditionally have been thought to develop from failure of closure at the umbilical stump after birth. however, the closure of the body wall defect at the umbilicus was studied in relation to the development of umbilical herniae in a large group of normal foals followed from birth until 5 months of age or from birth until 11 months of age. 354 at birth, approximately half of these foals had a defect in the body wall at the umbilicus that was termed a palpable umbilical ring. in 18 foals this defect disappeared within 4 days, but in one foal the ring did not close and a hernial sac with abdominal contents was palpable. this foal was considered to be the only foal to have a truly congenital umbilical hernia. twelve foals developed an umbilical hernia between 5 and 8 weeks of age. the prevalence of umbilical herniae was much higher than in other studies, possibly because of the prospective nature of the study. based on this study, the large majority of umbilical herniae would appear not to result from failure of closure but rather to be acquired after birth. one should consider the palpable ring structure within the body wall at the umbilicus a variant of normal in the foal and should not call it a hernia until the foal is at least 1 month of age. in one study of 147 horses treated for umbilical herniae over a 13 1 / 2 -year period, only 8.8% developed complications in association with umbilical defects. 355 six horses had intestinal incarceration; the incarceration was reduced manually in 3 horses before admission and resolved without treatment in 2 others. the hernia was surgically reduced in 1 horse. herniorrhaphy was performed on 4 of the 5 horses in which the incarceration did not require surgical reduction, and the fifth was managed conservatively. the study confirmed that complications of umbilical herniae are rare in horses; however, when they do develop, they may be one of various forms, some of which are insidious in onset. the primary differential diagnosis for an external swelling in the umbilical stump region is an external abdominal abscess, which will be firm, variably painful, warm, and nonreducible. ultrasonographic evaluation readily can confirm either possibility. one report describes a 3-day-old foal that died from intestinal strangulation caused by a remnant of vitelline vein that extended between the umbilicus and the portal vein. 356 patent urachus frequently is recognized in the abnormal neonate, probably because of the increased recumbency and decreased movement of these patients. cauterization of a patent urachus is no longer recommended except in cases that persist for long periods of time (>1 month) after the foal becomes more active. surgical resection may provide relief in some foals, but most cases resolve without treatment if given enough time. foals with a patent urachus may posture and strain frequently to urinate, some of this may be associated with irritation or local infection of the urachus. one can alleviate this by administration of broad-spectrum antimicrobial therapy such that the drug has a high concentration in the urine (e.g., trimethoprim-sulfa drug combinations) and by oral administration of phenazopyridine hydrochloride (pyridium), a dye that anesthetizes the urinary tract epithelial surfaces (see table 19 -7). this dye turns the urine orange and stains everything yellow-orange that it or the urine touches but can provide a great deal of relief to foals with this problem. the umbilicus has been considered the traditional point of entry of bacteria into the septic neonate, and septic foals have been referred to as having "navel ill" and "joint ill" in the past. although current thought suggests that the gastrointestinal tract may be the route of entry in most septic neonates, infection of the umbilicus-termed omphalitis, or omphalophlebitis if the vessels are involved-still occurs as a single focus of infection or along with more generalized infection. external signs, such as swelling, heat, pain, ventral edema, or purulent discharge may be present in some foals, but more usually external signs are minimal and one suspects infection because of infection in another site (e.g., an infected joint), fever, or otherwise unexplained increased blood fibrinogen concentration. one confirms the diagnosis by ultrasonographic evaluation of the internal umbilical remnant. any of the umbilical structures may be involved. a complete description of the evaluation is available within the relevant veterinary literature, but the examination is performed best with the foal standing using a 7.5-mhz probe with a standoff. 353 the usual finding is that the affected structure is larger than expected. a fluid-filled core and echogeneic shadows consistent with gas may be apparent in some cases. interpretation requires some experience, and the examiner should be familiar with variants of normal, such as gas shadows associated with a patent urachus and enlarged vessels caused by hematoma formation, so that treatment is not initiated inappropriately. two options for treatment are surgical and medical. medical treatment is preferable in cases in which the lesion is well localized and small and in foals with a medical condition that is not amenable to anesthesia and surgical intervention. one should institute broad-spectrum antimicrobial therapy, and one may need to continue therapy for 2 to 3 weeks. most affected foals respond to medical therapy. frequent reevaluation of the abnormality is necessary, every 5 to 7 days initially, and one should measure blood fibrinogen concentrations at reevaluation because they should stabilize and decrease with effective treatment. failure to respond to therapy within 10 days to 2 weeks suggests that an empiric change in the antimicrobial used may be necessary. in foals that are refractory to medical management or where the lesion is large, surgical excision of the entire umbilical remnant may be desirable. colic in the foal can be difficult to diagnose accurately because one cannot perform an examination per rectum. however, many diagnostic aids, most importantly ultrasonography, are available to help differentiate medical from surgical causes of abdominal discomfort in the foal. intestinal accidents of all types described in adult horses, with the possible exception of enteroliths, occur in foals. intussusception, volvulus, displacement, diaphragmatic hernia, and intra-and extraluminal obstruction have been reported in foals. abdominal ultrasonographic and radiographic evaluation greatly aids diagnosis. treatment is primarily surgical. foals with pas and intestinal dysmotility are at increased risk of intussusception and displacement, and miniature breed foals appear to be at increased risk for fecolith and enterolith formation. meconium retention or impaction is a common cause of abdominal discomfort in newborn foals. most foals defecate shortly after their first meal. the usual practice for most owners or veterinarians attending the birth of a foal is to administer an enema to aid this process. in the past, phosphate-based commercially available enemata (fleet) were used frequently, but if used excessively these types of enemata can create problems of their own, including rectal irritation and hyperphosphatemia. the best enema is warm soapy water made with a mild soap such as liquid ivory soap that can be administered through soft rubber tubing using gravity flow. foals with significant meconium retention become colicky within the first few hours of life as gas accumulates within their bowel. frequently, one can palpate the meconium through the abdominal wall. additional diagnostics can include abdominal ultrasonography and radiography, particularly if one must rule out other, more serious types of colic. these foals assume a classic stance with an arched back. one must differentiate this stance from the stance assumed by foals with uroperitoneum, which is more extended. foals with meconium retention have had simultaneous ruptured bladder, however, so the clinician must be sure to evaluate the foal fully for both problems. foals that do not respond rapidly to enema administration need additional treatment, which can include giving mineral oil (2 to 4 ounces) by nasogastric tube. one can treat persistent meconium retention resulting in significant abdominal distention by muzzling the foal to prevent further milk intake and administering intravenous fluids at an appropriate maintenance rate. if continuous rate infusion is possible, 5% to 10% dextrose is the preferred fluid to use to provide calories to the foal. one should not use dextrose as a bolus fluid. more aggressive treatment would include administration of retention enemata made using acetylcysteine, which serves as an irritant and increases secretion. extreme cases of meconium retention may require surgical intervention, but this is usually not necessary and most cases resolve with medical management alone within 12 to 24 hours. some foals require pain managment. one should avoid nonsteroidal antiinflammatory drugs in the neonate because of their effects on renal function and gastric mucosal blood flow (see gastric ulcers). many foals respond well to butorphanol administered intramuscularly at a dose of 3 to 5 mg to an average 50-kg foal. intranasal oxygen insufflation is beneficial in foals with significant abdominal distention. one should evaluate foals with meconium impaction/ retention for evidence of pas because intestinal dysmotility is common in pas. colostrum is a laxative, and these foals also may suffer from failure of passive transfer, with meconium retention resulting from the lack of adequate colostrum. these foals are also at risk of sepsis because the mucosal intestinal barrier probably has been disrupted and translocation of bacteria can occur. one should obtain blood cultures on these foals and should monitor them closely for signs of sepsis. atresia within the gastrointestinal system of the foal occurs infrequently, but clinical signs are characteristic. 357 acute colic occurs within the first few hours and is accompanied by abdominal distention similar to meconium retention. three primary types of atresia are described in the foal: membrane atresia, cord atresia, and blind-end atresia. antemortem diagnosis of atresia, short of abdominal exploratory surgery, is aided by the lack of meconium staining of the rectum or any administered enema fluids. additional diagnostic tests may include administration of a barium enema for a radiographic study, colonoscopy, and abdominal ultrasonography. abdominocentesis is usually normal until bowel rupture is imminent or has occurred. one can make affected foals more comfortable by muzzling them to prevent further milk intake and by supplying them with fluids and nutrition intravenously. if one attempts surgical correction, one first should initiate broad-spectrum antimicrobial therapy and determine passive transfer status. frequently, these foals are hypoxemic because of the abdominal distention, and oxygen supplementation is desirable. solid white foals born to overo-overo matings of american paint horses may suffer from congential aganglionosis of the ileum, cecum, and colon. these foals present similarly to foals with meconium impaction or atresia in that colic develops shortly after birth and involves progressive abdominal distention with feeding. the inherited defect is in the endothelin receptor gene. [358] [359] [360] [361] no effective treatment exists, but the clinician should be aware that not all white foals of this mating are affected, and some simply may have meconium retention, so a short period of treatment may be warranted. necrotizing enterocolitis is considered the most common acquired gastrointestinal emergency of human infants. 362, 363 the 1500 to 2000 infants that die every year from this disease in the united states and the large number of infants who develop short gut syndrome from this disease only represent the tip of the iceberg of the problems necrotizing enterocolitis causes. the widespread fear of necrotizing enterocolitis among neonatologists and pediatric surgeons has contributed in large part to the use of the intravenous route rather than the gastrointestinal tract for nourishing these infants for long periods. the pathogenesis of necrotizing enterocolitis is unknown but may result from a disturbance of the delicate balance among gastrointestinal perfusion, enteric organisms, and enteral feeding. risk factors for necrotizing enterocolitis in human infants include prematurity, hypoxic-ischemic insult, and formula or breast milk feedings. the clinical spectrum of necrotizing enterocolitis is multifactoral and ranges from temperature instability, apnea, lethargy, abdominal distention, bilious residuals, septic shock, disseminated intravascular coagulation, and death. medical management is usually adequate treatment for necrotizing enterocolitis. in the neonatal foal, necrotizing enterocolitis is probably one of the most underrecognized causes of gastrointestinal dysfunction and in the past has been attributed only to infection with anaerobic organisms including clostridium perfringens type c and c. difficile. 364 although a specific form of enteritis is associated with intestinal infection by these organisms, most necrotizing enterocolitis is associated with prematurity or pas in the infant and the foal. one should suspect necrotizing enterocolitis in any foal that is having difficulty tolerating oral feeding, demonstrating signs of ileus, or having episodes of colic and in any foal with occult blood or frank blood in the stool. foals exhibiting any of these clinical signs should not be fed orally if possible and should receive parenteral nutrition until gastrointestinal function returns to near normal. the mucosal barrier of the intestine is unlikely to be fully intact, and these foals are at risk for sepsis from bacterial translocation. one should institute broadspectrum antimicrobial therapy in these foals and, if any evidence of coordinated gastrointestinal motility is apparent, should administer sucralfate orally as a protectant. gastric ulcer disease has been recognized in foals, and lesions vary in anatomic distribution, severity, and cause. in clinically normal neonatal foals (<30 days of age), gastric ulcers and mucosal desquamation have been documented. [365] [366] [367] [368] because of these reports and other early reports of death following ruptured clinically silent ulcers in neonatal foals, for years many clinicians felt it necessary to treat critically ill neonates with antiulcer medication prophylactically. [369] [370] [371] recently, this paradigm has been challenged. the pathophysiology of gastric ulcer disease is described most reasonably as an imbalance in protective and aggressive factors. [372] [373] [374] these protective factors are responsible for maintaining a healthy gastrointestinal tract by promoting adequate mucosal blood flow, adequate mucus and bicarbonate production, prostaglandin e 2 production, epithelial growth factor production, gastric afferent innervation, epithelial cell restitution, and gastroduodenal motility. probably the most important factor is maintenance of mucosal blood flow. hypoxia, no, prostaglandins, and gastric afferent innervation influence mucosal blood flow. the aggressive factors include gastric acid, bile salts, pepsin, and enzymes. few specific causes have been found for gastric ulcer disease in foals. excessive administration of nonsteroidal antiinflammatory drugs can result in ulceration of the glandular and squamous epithelium because of an inhibition of prostaglandin production, which leads to a decrease in mucosal blood flow and an increase in acid production. nonsteroidal antiinflammatory drugs also can impair the healing of lesions and rarely are indicated in neonatal equine medicine. 372, 373 in the critically ill neonate the suspected cause of gastric ulcers has shifted away from an excessive amount of intraluminal gastric acid toward gastric mucosal ischemia caused by hypoxia, low blood flow conditions, or both. 375 perforating gastric ulcers are more likely a manifestation of necrotizing enterocolitis than of excessive gastric acid. shock, sepsis, or trauma can result in gastric mucosal ischemia, allowing for the disruption of epithelial cell integrity and permitting damage by aggressive factors or providing an environment suitable for the establishment of bacteria colonization. 375,376 impairment of mucosal blood flow also may result in reperfusion injury, allowing the formation of gastric ulcers. in the sick neonatal foal (<7 days of age) a wide variability in the intragastric ph has been documented depending on the type of disease, severity, and milk intake frequency and volume, suggesting that in the critically ill equine neonate, ulcer prophylaxis using histamine antagonists or proton pump inhibitors is not only unnecessary but unlikely to work. 377 clinically significant gastric ulcers can occur in the squamous, glandular, or both portions of the stomach as a primary problem or resulting from another problem. clinical signs include diarrhea, abdominal pain, restlessness, rolling, lying in dorsal recumbency, excessive salivation, and bruxism. in the neonatal foal the only clinical signs present may be depression or partial anorexia until a more catastrophic event, such as perforation, occurs. some lesions in the gastric mucosa extend from the pylorus into the proximal duodenum and can result in stricture of the pylorus and proximal duodenum. these foals are usually older (>1 month of age) and have a greater volume of reflux. bruxism and ptyalism are also more prominent in these older foals. the most sensitive and specific method for diagnosing gastric ulcers is visualization by endoscopic examination. 365 unfortunately, the use of gastric endoscopy has led to recognition of relative nonlesions and ulcers resulting from other problems and of clinically significant disease states. the clinician should not stop simply when ulceration of the stomach is recognized with endoscopy but should examine that patient fully for other potential sources of the clinical signs. other diagnostic tests may help in determining the severity of the ulcers, including fecal occult blood or gastric blood assessments, contrast radiography, abdominal ultrasound, and abdominocentesis. endoscopy of the foal stomach carries an additional risk of exacerbating colic in the short term, unless the examiner ensures that as much introduced air as possible is evacuated from the stomach at the end of the procedure. the presence of a brown gastric reflux fluid may indicate the presence of bleeding ulcers. blood in the feces of the neonate is more consistent with a diagnosis of necrotizing enterocolitis, which can be associated with gastric ulcers. contrast radiography is useful if one suspsects delayed gastric emptying or pyloric or duodenal stricture in older foals. if a stricture has occurred, one will note a delay in complete emptying of barium from the stomach (>2 hours). 367 abdominal ultrasound may be useful to visualize free abdominal fluid and gastric or small intestinal distention if one suspects a perforation. one can visualize portions of the descending duodenum, and a thickened duodenum should increase the index of suspicion for duondenal stricture. abdominocentesis also may confirm perforation. traditional therapy for gastric ulceration includes mucosal adherents, histamine type 2 receptor antagonists, proton pump inhibitors, and antacids. 378 the most widely used mucosal adherent is sucralfate, which is a hydroxy aluminum salt of sucrose. the main therapeutic action of sucralfate is to bind to the negatively charged particles in the ulcer crater. 378, 379 at a ph less than 2, sucralfate is converted to a sticky viscous gel, which adheres to the ulcer crater and remains adhered for 6 hours, but at a higher ph, sucralfate remains in a suspension. sucralfate is still effective because it inhibits pepsin and buffers hydrogen ions. other important actions of sucralfate include stimulating production of prostaglandin e, which maintains mucosal blood flow; increasing bicarbonate secretion; stimulating mucous secretion; decreasing peptic activity; and binding epidermal growth factor. the histamine type 2 receptor antagonists include cimetidine, ranitidine, and famotidine. these compounds block the interaction of histamine with the histamine type 2 receptor on the parietal cell, resulting in inhibition of gastric acid secretion. clinically normal neonatal foals have a highly acidic gastric fluid that is influenced by sucking. intravenous and oral administration of ranitidine increases intragastric ph in normal foals but critically ill neonatal foals have a blunted response to ranitidine administration. 377, 380 one possible conclusion reached from these studies is that in critically ill neonatal foals, gastric ulcers may not be caused by an increased intraluminal gastric acidity. the most commonly used proton pump inhibitor is omeprazole. this drug has not as yet been approved for use in foals under 30 days of age. omeprazole inhibits the secretion of hydrogen ions at the parietal cell by irreversibly binding to the h + ,k + -atpase proton pump of the cell. most of the lesions in older foals were healed after daily administration of omeprazole for 28 days according to one report. 381 table 19 -9 summarizes the therapeutic agents for treating gastric ulcers in foals. prophylactic treatment of critically ill neonates for gastric ulcers has been standard therapy for years because of the evidence of clinically silent ulcers. this approach may not be appropriate for several reasons. an increased incidence of nosocomial pneumonia and systemic sepsis is associated with high gastric ph in human patients in intensive care. [382] [383] [384] patients in intensive care units treated prophylactically with histamine type 2 receptor antagonists are more likely to develop pneumonia during ventilation therapy and gastric colonization with potentially pathogenic bacteria or yeast. 382, 385 an acidic environment appears to protect against airway colonization by bacteria of intestinal origin and bacteria translocated across the gastrointestinal tract. pathogenesis of ulcers in the neonatal foal most likely does not involve increased intraluminal gastric acid but instead may be caused by decreased mucosal perfusion associated with shock, hypoxia, and hypoxic/ischemic insult to the gastric mucosa. a recent report revealed that gastric ulcer disease in equine nicu patients is independent of pharmacologic prophylaxis. 386 in this study, despite decreased treatment, the incidence of gastric ulcers found in these foals at necropsy had decreased significantly. the decrease was attributed to overall improvement in management of these cases. similarly, in a human intensive care unit, the incidence of stress ulcers decreased independent of the use of prophylaxis. 375, 387 early treatment of sepsis, sufficient oxygenation, improved monitoring, institution of enteral feedings, and improved nursing care may contribute to the reduction in gastric ulcers in the neonatal patient. use of histamine type 2 receptor antagonist and proton pump inhibitors apparently may not be necessary; however, in some instances sucralfate may be useful. sucralfate reduced the rate of bacterial translocation in a rat model during hemorrhagic shock and also may prohibit the generation of acute gastric mucosal injury and progression to ulcer formation induced by ischemia-reperfusion. 388, 389 in a human medical intensive care unit, airway colonization by new pathogens occurred more frequently in patients receiving agents that increased gastric ph than in those receiving sucralfate. 382, 390 in the critically ill neonatal foal, risk factors for gastric ulceration have not been identified clearly, although foals treated routinely with nonsteroidal antiinflammatory drugs may be at increased risk for gastric lesions. prophylactic treatment for gastric ulcers in critically ill neonates may not be necessary, and one should consider carefully the pros and cons of their use before their administration. foal heat diarrhea is a mild, self-limiting form of diarrhea that occurs in foals between 5 and 14 days of age, about the time of the "foal heat" in the dam. the definitive cause of foal heat diarrhea has yet to be described, but the condition may be associated with dietary changes or changes in gastrointestinal function that occur around that time. this form of diarrhea is not caused by stongyloides westeri infestation as previously thought. 391 foals with foal heat diarrhea are not systemically ill and should not require therapy. one should evaluate fully any foals with diarrhea at this time for other possible causes of diarrhea, particularly if they are unwell or exhibit anorexia or dehydration. viral diarrhea occurs most commonly in large groups of mares and foals that are housed together. rotavirus is an isolate from the feces of up to 40% of foals with diarrhea worldwide, alone or with another pathogen. 392, 393 the virus infects and denudes the microvilli, resulting in increased secretion combined with decreased absorption. the virus interferes with disaccharidase function and alters the function of the intestinal sodium-glucose cotransport proteins. the initial clinical signs are anorexia and depression, with profuse watery diarrhea occurring shortly thereafter. severely affected foals may become significantly dehydrated and have electrolyte abnormalities, primarily hyponatremia and hypochloremia with metabolic acidosis. these foals generally require intravenous fluid support, whereas less severely affected foals may require only symptomatic therapy. definitive diagnosis is by detection of the virus in the feces of foals with diarrhea. however, none of the available tests are particularly sensitive, and the virus also may be found with other intestinal pathogens. recently, vaccination of pregnant mares has been suggested as a means of prevention, with preliminary results suggesting efficacy. 394,395 although a definitive role for adenovirus has not been established in the foal, adenovirus is a common co-isolate from foals with rotaviral diarrhea. 396 a specific equine coronavirus recently has been identified from an immunocompetent foal with diarrhea, and a second report of cornavirus diarrhea was published recently. 397,398 one case report suggests a parvovirus caused diarrhea in the foal. 399 treatment of viral diarrhea in foals is primarily supportive. intravenous fluid and parenteral nutritional support may be necessary in severe cases. very young foals may benefit from intravenous plasma administration and broad-spectrum antimicrobial coverage to limit bacterial translocation. one can administer sucralfate orally in these cases as a gastrointestinal protectant and to discourage bacterial translocation. foals with moderate to severe metabolic acidosis may benefit from sodium bicarbonate administration if their ventilatory function is normal. one administers sodium bicarbonate at half the calculated deficit (0.5 ã� standard base excess ã� body mass in kilograms) as an isotonic solution at the maintenance fluid rate. one should reevaluate sodium and bicarbonate (or standard base excess) concentrations regularly. nonspecific therapy of diarrhea is discussed elsewhere in this text. diarrhea is frequently the primary presenting complaint in foals with sepsis, so one should rule out this differential diagnosis in foals less than 1 week of age. one should evaluate all neonatal foals with diarrhea for possible sepsis and should include a blood culture whenever possible. clostridium perfringens and c. difficile are recognized increasingly as serious pathogens of the foal. 400-403 foals with either pathogen generally have abdominal pain, dehydration, and profuse watery diarrhea. some foals may have red-tinged or frankly bloody feces, which carries a poorer prognosis. most foals with this type of diarrhea require intensive care or, at the minimum, intravenous fluid administration. outbreaks of this type of diarrhea on farms occasionally occur, and the suggestion is that the dam has a role in transmission of the bacteria. diagnosis is by recognition of the offending organism by gram stain of the feces, by bacterial isolation from the feces, and by detecting the presence of toxins associated with the organisms. specific treatment includes oral administration of metronidazole and broad-spectrum antimicrobial coverage as prophylaxis for bacterial translocation associated sepsis in younger foals. foals with severe blood loss in their feces may require transfusion of whole blood. salmonella spp., escherichia coli, bacteroides fragilis, and aeromonas hydrophila have been implicated in diarrhea in foals. salmonella generally is associated with septicemia in foals, and although some convincing evidence exists for a role for e. coli in foal diarrheal disease, the extent of e. coli as a pathogen of the gastrointestinal tract in foals has yet to be described fully. 371, [404] [405] [406] [407] proliferative enteropathy is a transmissible enteric disease caused by lawsonia intracellulare. 408,409 most foals have been weaned before the appearance of clinical signs of depression, rapid and significant weight loss, subcutaneous edema, diarrhea, and colic. poor body condition with a rough hair coat and a pot-bellied appearance are common in affected foals. clinicopathologic abnormalities included hypoproteinemia, leukocytosis, anemia, and increased serum creatine kinase concentration. postmortem reveals characteristic intracellular bacteria within the apical cytoplasm of proliferating crypt epithelial cells of the intestinal mucosa. antemortem diagnosis of equine proliferative enteropathy is based on clinical signs, hypoproteinemia, and the exclusion of other common enteric pathogens. fecal polymerase chain reaction analysis may be positive for the presence of l. intracellulare, and affected foals develop antibodies against l. intracellulare. 410 treatment with erythromycin estolate alone or combined with rifampin for a minimum of 21 days is recommended with additional symptomatic treatment when indicated. cryptosporidium spp. cause gastroenteritis and diarrhea in many animal species and are not host-specific. cryptosporidium has been implicated as the casual agent of diarrhea in foals, but the organism is isolated from the feces of diarrheic foals and normal foals with the same frequency and concentration, making a clear role for the organism difficult to elucidate. 411-413 diarrhea caused by cryptosporidium in other species and that described for foals is generally self-limiting, with a clinical course of between 5 to 14 days. immunosuppressed patients, including foals compromised by concurrent disease, are thought to be at increased risk for complications resulting from infection with this organism. 411,412 treatment is symptomatic. cryptosporidiosis is a disease with zoonotic potential, and one should take appropriate precautions, including use of gloves and frequent hand washing, if organisms are identified in the feces of any patients so as to prevent spread to other patients and personnel. eimeria leukarti, trichomonas equi, and giardia equi have been identified in the feces of normal horses and horses with diarrhea. transmission studies have failed to produce reliable clinical signs, and the prevalence and significance of these organisms in the genesis of foal diarrhea remain unknown. strongyloides westeri is a common parasitic infection of foals. 392, 414 transmission is transmammary, and patent infection is recognizable in the foal by 8 to 12 days of age. this nematode previously was associated anecdotally with foal heat diarrhea, but the association has not been demonstrated clearly. the diarrhea is generally mild and is treated effectively by deworming with benzimidazole or ivermectin anthelmintics. 391 strongylus vulgaris fourth-stage larvae cause diarrhea in young foals during migration through the arterioles of the cecum and descending colon. clinical signs may resemble thromboembolic colic. 414 the prepatent period is about 6 months, and diagnosis is based on clinical examination, clinicopathologic changes, and farm deworming history. patients with diarrhea associated with this parasite may have peripheral leukocytosis, neutrophilia, eosinophilia, and hypoproteinemia. appropriate deworming with ivermectin (label dose), fenbendazole (10 mg/kg/day orally for 5 days), or thiabendazole (440 mg/kg/day orally for 2 days) is recommended, with the last two drug dosages being larger than the label dose. cyathostomiasis, or diarrhea resulting from the sudden emergence of encysted cyathostome larvae, is an unusual cause of diarrhea in the foal. the clinician managing critically ill neonates must recognize that intravenous fluid therapy simply cannot be scaled down from adult management approaches. fluid management of the ill neonate, particularly over the first few days of life, must take into consideration that the neonate is undergoing a large transition from the fetal to the neonatal state and that important physiologic changes are taking place. 166 these transitions include shifts in renal handling of free water and sodium and increased insensible losses because of evaporation from the body surface area and the respiratory tract. the newborn kidney has a limited ability to excrete excess free water and sodium, and the barrier between the vascular and interstitial space is more porous than that of adults. water and sodium overload, particularly in the first few days of life, can have disastrous long-term consequences for the neonate. 416, 417 in the equine neonate, excess fluid administration frequently manifests as generalized edema formation and excessive weight gain, frequently equivalent to the volume of excess fluid administered intravenously. in cases in which antidiuretic hormone secretion is inappropriate, as in some foals with pas, generalized edema may not form, but the excess free water is maintained in the vascular space. this syndrome of inappropriate antidiuretic hormone secretion is recognized in the foal that gains excessive weight not manifested as edema generally, with decreased urine output and electrolyte abnormalities such as hyponatremia and hypochloremia. 418 the foal manifests neurologic abnormalities associated with hyponatremia. the serum creatinine concentration varies in these cases, but urine always is concentrated compared with the normally dilute, copious amounts of urine produced by foals more than 24 hours of age on a milk diet. if measured, serum osmolarity is less than urine osmolarity. the treatment for this disorder is fluid restriction until weight loss occurs, electrolyte abnormalities normalize, and urine concentration decreases. if the clinician is unaware of this differential diagnosis, the neonate can be assumed mistakenly to be in renal failure, and the condition can be exacerbated by excessive intravenous fluid administration in an attempt to produce diuresis. the problem of appropriate fluid management in critically ill neonates has been recognized by medical physicians for years and has resulted in changes in fluid management of these patients. the approach taken has been one of fluid restriction, in particular sodium restriction but also free water restriction, and has resulted in improved outcome and fewer complications, such as patent ductus arteriosus and necrotizing enterocolitis. 416, 417 the calculations used for maintenance intravenous fluid support in these patients takes into consideration the ratio of surface area to volume and partially compensates for insensible water losses. maintenance fluids are provided as 5% dextrose to limit sodium overload and provide sufficient free water to restore intracellular and interstitial requirements. the calculation for maintenance fluid administration is as follows: first 10 kg body mass 100 ml/kg/day second 10 kg body mass 50 ml/kg/day all additional kilograms of body mass 25 ml/kg/day as an example, the average 50-kg foal would receive 1000 ml/day for the first 10 kg of body mass, 500 ml/day for the next 10 kg of body mass, and 750 ml/day for the remaining 30 kg of body mass for a total of 2250 ml/day. this translates to an hourly fluid rate of about 94 ml/hr. one should adjust the fluid and sodium requirements for ongoing losses exceeding the maintenance requirements. these losses can take the form of diarrheal losses and excessive urine output, such as those with glucose diuresis and renal damage resulting in an increased fractional excretion of sodium. the normal fractional excretion of sodium in neonatal foals is less than that of adult horses, usually less than 1% (j.e. palmer, unpublished data). in the critically ill foal the sodium requirement can be met with as little as 140 meq of sodium per day, about that administered in a single liter of normal equine plasma. one can address sodium deficits by separate infusion of sodium-containing fluids, although this may not be necessary if one considers the sodium being administered in other forms, including drugs administered as sodium salts and any constant rate infusions (pressors, inotropes, etc.) that are being provided as solutions made with 0.9% sodium chloride. the author has used this approach to fluid therapy in her nicu for the last few years and believes that the percentage of foals suffering from generalized edema and related problems has decreased. if one takes this approach to fluid therapy, one should take the weight of the patient once daily, or even twice daily, and monitor the fluid intake and output as closely as practical. one should evaluate any larger than anticipated weight gains or losses. one should not expect urine output to approach the reported normal of 300 ml/hr for a 50-kg foal because the free water administered is limited, unless the patient is experiencing diuresis (glucosuria, resolution of the syndrome of inappropriate antidiuretic hormone secretion, resolution of previous edematous state, renal disease). one should obtain the urine specific gravity several times daily and should determine fractional excretion of sodium at regular intervals. if the volume of urine produced by the patient is measured accurately, one can determine sodium losses accurately and can obtain creatinine clearance values. one should obtain blood pressure measurements at regular intervals throughout the day because hypotension can be a problem in these patients, particularly in septic foals and foals suffering from pas, and one may need to increase fluid therapy to maintain adequate vascular volume. patients with hypotension may need inotrope and pressor support. inotrope and pressor therapy generally is restricted to referral centers where these drugs can be administered as constant rate infusions and blood pressure can be monitored closely. blood pressure can be monitored directly or indirectly by the use of cuffs placed on the base of the tail. both techniques have advantages and disadvantages. although direct blood pressure measurements are considered the gold standard and are generally more accurate, the difficulty in placing and maintaining arterial catheters and lines in these patients severely restricts the utility of this method. indirect techniques can be inaccurate and are affected by cuff size and placement. however, indirect techniques are easier to use in the nicu and can be useful if trained staff are using the equipment. in the author's nicu, once practitioners identify the appropriate cuff size, they dedicate that cuff to that patient for the duration of the hospitalization to decrease variability caused by using different cuffs. one should monitor the blood pressure of all recumbent patients at regular intervals, and trends upward or downward should prompt the clinician to make necessary adjustments. foals suffering from pas and sepsis are the patients most at risk for significant hypotension and perfusion abnormalities. perfusion is maintained by supporting cardiac output and blood pressure with judicious use of intravenous fluid support and inotrope/pressor support. the author does not aim for any specific target systolic, mean, or diastolic pressure. instead the author monitors urine output, mentation, limb perfusion, gastrointestinal function, and respiratory function as indicators that perfusion is acceptable. for nicu patients to require inotrope and pressor therapy is not unusual, but in some cases hypoxic and septic damage is sufficiently severe to blunt the response of the patient to the drugs. one must approach each patient as an individual, and no single inotrope/pressor protocol will suffice for all patients. dobutamine is a î²-adrenergic inotrope that is frequently used as first choice therapy in nicu patients. its effects are î² 1 at the lower dose range. neonates have a limited ability to increase stroke volume in an effort to maintain cardiac output, and one may observe tachycardia in these patients as heart rate increases to maintain cardiac output and vascular pressure. dobutamine is useful after patients are volume replete for support of cardiac output. the dose range is between 2 to 20 âµg/kg/min provided as a constant rate infusion. dopamine has dopaminergic activity at low doses, î² 1 and î² 2 activity at moderate doses, and î± 1 activity at high doses. dopamine causes norepinephrine release, which has lead to the suggestion that this is its major mode of action at higher doses. at doses greater than 20 âµg/kg/min, intrapulmonary shunting, pulmonary venous vasoconstriction, and reduced splanchic perfusion may occur. dopamine also produces natriuresis at lower doses through a direct effect on renal tubules. for these reasons, dopamine has fallen out of favor at some referral institutions. norepinephrine has î± 1 and î² 1 activity but variable î² 2 activity, resulting in potent vasopressor effects; it has inotropic and chronotropic effects, but its chronotropic effect usually is blunted by vagal reflexes slowing the heart rate induced by the increase in blood pressure. in many critical care units, norepinephrine has become a pressor of choice and frequently is used along with dobutamine. evidence suggests that splanchic perfusion is maintained better with norepinephrine than with some other pressors. 419 the dose range is 0.2 to 2.0 âµg/kg/min, although larger doses have been used when necessary in certain patients. epinephrine has î± 1 , î± 2 , î² 1 , and î² 2 activity; î² activity predominates and results in increased cardiac output and decreased peripheral resistance at low doses. epinephrine has been associated with hyperglycemia, hypokalemia, lipolysis, increased lactate concentration, and increased platelet aggregation. the effect on renal function is controversial. use of epinephrine usually is limited to those patients not responding to other pressors. vasopressin (antidiuretic hormone) is a pressor gaining a great deal of attention in the critical care literature. vasopressin appears to be depleted from the neurohypophysis in septic shock, 420 and short-term administration of vasopressin spares conventional vasopressor use, in addition to improving some measures of renal function. 421 low-dose vasopressin infusion increases mean arterial pressure, systemic vascular resistance, and urine output in patients with vasodilatory septic shock that are hyporesponsive to catecholamines. these data indicate that low-dose vasopressin infusions may be useful in treating hypotension in patients with septic shock. 422 the author has been using low-dose vasopressin in patients in her nicu for the past few years and has the clinical impression that blood pressure is defended more readily using this agent in concert with other management strategies. the author commonly uses low-dose vasopressin constant rate infusion with dobutamine constant rate infusion as the initial inotrope/pressor therapy in cases requiring pressure defense, although no prospective studies are yet available regarding this drug in veterinary medicine. 20 for quality health care for animals, advances in medical science, and in some breeds the increasing value of the juvenile equine athlete. equine veterinarians that encounter pediatric orthopedic problems are only beginning to get the information needed to make appropriate treatment decisions. the equine neonate has specific differences in structure and physiology from adults that one must consider when designing an optimal therapeutic or management strategy. few investigations have focused on the equine neonatal musculoskeletal system, 1-6 but a large body of clinical information exists, and one can make cautious extrapolations from work in other species. 7 neonatal equine bones have accelerated modeling and remodeling processes 5 that result in accelerated fracture healing and an increased susceptibility to deformation caused by excessive loading. contralateral limb varus deformities of the growth centers (most commonly distal radius and metacarpus/ metatarsus) are common in overloaded limbs. the increased plasticity of the skeletal structure also is mirrored in the soft tissue support system, for these units become flaccid within 2 weeks of immobilization. 4 this laxity is important, because it further compromises the use of the fractured limb and can last as long as the coaptation was in place. additional divergences from adult physiology include musculoskeletal immaturity (generalized or focal) and immune system differences. finally, foals are lighter and can tolerate and will assume recumbency more readily than adults. the net results of these differences are that one must consider the use of external coaptation carefully, fractures heal quickly, one must consider damage to the contralateral limb from overstress, reducing weight bearing is possible, and infection is always lurking. stresses can affect the musculoskeletal system of the foal at any time, including in utero. although rare, reports describe in utero fractures (k. sprayberry, personal communication, 2003) that result in foal locomotor problems and even maternal uterine damage from sharp bone ends. the cause is presumably from vigorous muscular activity of the foal, but one cannot rule out direct trauma. the fractures result in foal lameness and can increase the likelihood of dystocia and caused colic in one mare when the broken bones damaged the uterus. treatment depends on how long the fracture has been present and on the fracture location and configuration, but if the fracture is repairable, internal fixation probably is necessary. fractures occurring during foaling result from aggressive obstetric manipulation (mandibles) or the advances in medical care of equine neonates in the last 20 years have resulted in the survival of many foals that previously would have died from sepsis, asphyxia, and prematurity; and the successful management of their musculoskeletal system can be a major challenge. major factors adding to the challenge are the immaturity of components of the musculoskeletal system and the demands placed on them by a growing and active foal. additional pressures to treat orthopedic conditions in foals have come from an overall increase in the demand chest compression. one should stabilize unstable mandibular fractures. appendicular fractures usually do not occur during parturition because of the robust character of the bones of the foal. after birth, foals are susceptible to external trauma from many sources. the dilemma is that younger foals with fractures are more likely to heal but also are more likely to develop contralateral limb problems because of excessive weight bearing and affected limb flexor tendon laxity if the limb is immobilized fully. as a result, internal fixation is often the best choice for neonatal fractures to keep the fractured limb in use. proximal sesamoid bone fractures result from hyperextension of the fetlock joint. foals are lame after the fracture, but the lameness can be mild and often diminishes quickly. soft tissue swelling occurs over the sesamoids. fractures are usually simple, can occur uniaxially or biaxially, and can be apical, midbody, or basilar. fractures can occur in any joint and can affect multiple sesamoids in one foal. however, they most commonly are single forelimb fractures 8 and in thoroughbreds are most frequent in the left front medial proximal sesamoid (j.p. morehead, personal communication, 2003). of particular interest to neonatologists is that proximal sesamoids fractures often occur in recovered neonatal patients that are allowed too much exercise too soon. foals from the nicu need a gradual introduction to pasture turnout to allow their musculoskeletal system to adjust. mares are often in need of turnout, but in the interest of their foals, they must wait. treatment of proximal sesamoid fractures in foals is stall confinement with support bandaging. healing occurs, albeit with some distortion of the shape of the sesamoid. severely displaced fragments result in large and misshapen sesamoids, and surgery may be considered for these foals, because restriction of fetlock flexion can occur after conservative therapy. third phalangeal fractures are also common in foals. these foals have a lameness that worsens with hoof compression. hoof abscesses are uncommon in young foals but should be considered. most commonly, radiographs reveal nonarticular small fractures on the wings on the third phalanx. the fractures are associated with hard ground and exercise. the fractures heal with stall confinement, and unlike adults, leave no discernable radiographic fibrous union. avulsion fractures of the proximal insertion of the peroneus tertius and the origin of the long digital extensor tendon have been reported. 9,10 both soft tissue structures attach to the extensor fossa of the distal femur. the two affected foals had lameness of a hindlimb associated with swelling, pain, and crepitation. radiographs revealed multiple avulsion fractures of the extensor fossa. because of the intraarticular fragments in the femoropatellar joint, and the fear of later degenerative joint disease, fragments were removed arthroscopically. both foals were juveniles at last follow-up; one foal was considered normal, and one had a mild residual lameness. tendon and ligament damage is uncommon in neonates probably because of their low body weight. extensor tendon damage following flexural deformities is the most common tendon problem and is discussed in congential flexural deformities of foals. gastrocnemius ruptures are one of the most devastating problems and have occurred after forced extraction because of a breech presentation, severe flexor tendon laxity, and tarsal contracture. loss of gastrocnemius function usually results in a non-weight-bearing limb, although an intact superficial digital flexor tendon may make some weight bearing possible. complete loss of support is difficult to treat successfully. coaptation of the limb is logical but difficult to obtain. schroeder-thomas splints have been used but are difficult to manage. tube casts also are used but must be changed frequently, and cast sores are inevitable (l.r. bramlage, personal communication, 2003) . the prognosis for athletic function is guarded. treatment for ligamentous injuries is usually some form of coaptation, although surgical repairs have been performed when coaptation was unworkable. 11 coaptation in proper limb alignment allows the ligaments to heal and should be used if the injury will destabilize a joint and cause damage to growing epiphyses or cuboidal bones. one can achieve coaptation with casts or splints under a bandage. casts are initially a greater expense, and cast sores and their resulting white hairs are a risk, but the rigid immobilization and the lack of the requirement for daily adjustment makes them preferable. important to musculotendinous health is some measure of weight bearing to avoid laxity after coaptation removal, which one can achieve by using tube casts and splints that allow weight bearing. following coaptation, bandaging and a gradual return to exercise are recommended for ligamentous injuries. patellar luxation can affect foals in one or both hindlimbs, and the luxation can vary from a laxity in the medial attachments to complete luxations that cannot be replaced in the patellar groove of the distal femur. 12, 13 medial luxations have not been reported. clinical signs vary from a slight discontinuous motion during stifle flexion to an inability to stand. many foals have a crouching stance on the affected limb because of an inability to extend the stifle. the pathophysiology of patellar luxations is unknown. congenital bilateral luxations are common in miniature horse foals and are believed to be genetic. luxations are rarer in other breeds and are occasionally traumatic. the affected limbs are usually not grossly abnormal except for effusion of the femoropatellar joint and the luxation. a shallow trochlear groove has been reported to be a cause of patellar luxation, but objective evidence is lacking. one should evaluate foals for the ability to stand. once the appropriate supportive care is provided, if a foal cannot stand, euthanasia is recommended. most bilateral luxations in horses fit in this category. however, miniature horse foals often can stand sufficiently to nurse despite bilateral luxations, and one may consider treatment. treatment consists of replacing and stabilizing the patella and sometimes surgically deepening the patellar groove. delaying surgical repair until the foal is approximately 30 days old is recommended to avoid neonatal problems, allow the musculoskeletal system to mature, and provide good anchors for suture. some surgeons worry that delay may cause further femoropatellar developmental abnormalities, but in a small number of cases, this has not been an issue. the prognosis for miniature horse foals appears to be good because of their low body weights and modest performance expectations. too few reports about the correction of unilateral luxations in light horses exist to make a definitive statement about prognosis except that success and failure have been experienced. 12, 13 congenital flexural deformities in foals can be classified as severe (rarely correctable), moderate (correctable with therapy), or mild (self-correctable). examples of severe flexural deformities include arthrogryposis (deformities of multiple limbs and often the head and neck), severe carpal deformities (flexor angle of the carpus less than 90 degrees), and tarsal contractures (rare). extraordinary methods have been used to correct severe deformities 14 but are often unsuccessful. mild flexural deformities are those that result in an upright conformation to the limb, but the foal can bear weight on the limb and load the flexor structures. these foals require no specific treatment and will self-correct with controlled exercise. moderate flexural deformities are those that make bearing weight on the limb and loading the flexor structures and ligaments difficult for the foal. when these deformities occur bilaterally (most common), the foals cannot rise to suckle or does so with great difficulty, and the lack of weight bearing worsens the flexural deformity. examples of moderate flexural deformities include carpal and forelimb fetlock flexural deformities that usually occur together, hindlimb fetlock flexural deformities with coronopedal flexion or hyperextension, and the uncommon coronopedal flexural deformity alone. treatment of moderate flexural deformities aims to place the solar surface of the foot on the ground so that the weight of the foal can stretch the flexor structures. splints are useful for restoring the limb to normal orientation but require attention to detail because the splints often exert an extreme amount of tension on the soft tissues, and the skin of the foal is thin. pressure sores are easy to create and at a minimum result in an extended convalescence. the first step in splint application is to apply a separate heavy bandage to the limb, which should be reapplied as necessary because the bandage can slip and cause focal constriction. commercial gauze over cotton bandage material works better than sheet cotton as a bandage. the splint is made of polyvinyl chloride pipe cut in half or thirds. using 50% of the diameter of the pipe results in less splint rotation but is bulkier and leaves more splint exposed to cause trauma. one cuts off the corners of the splint and pads the ends with gauze or roll cotton covered with tape. palmar or plantar placement of the splint is preferable, but severe deformities may require initial dorsal placement. as the limb straightens, one can bend the splint to tape the fetlock into the bend to extend it. one can tape the splint tightly to the limb over the bandage with nonelastic (white or duct) tape. this procedure requires at least two persons, one to extend the limb firmly and hold the limb and one to tape. one should leave the splint on for 8 to 12 hours and then remove it for 8 to 12 hours. one can reapply splints as necessary. in addition to splints, some medications are of value for treating flexural deformities. oxytetracycline (40 to 50 mg/kg) given intravenously appears to relax the soft tissues. 15 the mechanism of action is unknown, and the drug is most efficacious when given in the first 3 days of life. this dose is high but appears to be safe for healthy foals and can be repeated at 24-hour intervals. foals should be normovolemic during tetracycline administration. one should use the drug with caution in foals with renal impairment. foals should be urinating and have reasonable urinary parameters (serum urea nitrogen, creatinine, and urinalysis) before tetracycline use. diarrhea is an uncommon sequela to tetracycline use. one should monitor the unaffected limbs closely because all limbs experience a relaxation of the palmar/plantar support. 15, 16 discontinuation of tetracycline therapy before affected limbs are normal but after they can bear weight is common because of worsening laxity in the "normal" limbs. one also can use phenylbutazone (4 mg/kg) for a short time when the splints are used. some analgesia appears to help the foals use the limbs and stretch the soft tissues. one should not use phenylbutazone for long periods of time because of the potential of inducing gastric ulcers. surgical treatment of congenital flexural deformities rarely is indicated. severely affected foals rarely respond favorably to surgery, and mildly affected foals do not need it. surgery is most appropriate for foals with moderate flexural deformities that are neglected or have not responded to splinting and tetracycline. the most common surgical therapy performed for congenital flexural deformities is the inferior check ligament desmotomy for fetlock or coronopedal flexural deformities. ruptures of the extensor tendons commonly occur with congenital flexural deformities and result from the foal overloading the extensor tendons. no specific therapy for the ruptures is necessary. if the rupture is extensive, it can interfere with the ability to extend the fetlock and to place the foot flat. these foals then tend to knuckle over, even after correction of the flexural deformity. a firm fetlock bandage extends the digit and assists in foot placement until the extensor tendons heal. foals commonly are born with hyperextension deformities of the fetlock of varying degrees of severity. all but the worst deformities self-correct as muscle tone improves. a deeply bedded stall is all that is usually necessary to protect the soft tissues, but one can apply a light bandage to the coronary band and pastern if trauma is a problem. severe deformities are more problematic but rare, so therapeutic recommendations are not available. hyperextension of the carpus occasionally occurs and usually is treated conservatively. however, a tube cast to align the limb may be necessary to protect the dorsal surface of developing carpal bones. neonatal foals exhibit three categories of forelimb conformational deviations: angulation, rotation, and carpal offset. angular deviations most commonly are centered in the metaphysis and epiphysis, but their location is described by the closest joint, usually the carpus and fetlock. when the deviation of the distal limb is lateral to the long axis, the deviation is valgus, and when the deviation is medial, the deviation is varus. more than one joint can be affected, and although rare in neonates, valgus and varus can occur in different joints in one limb. rotational deformities appear to originate most commonly in the diaphysis or metaphysis of the radius or the metacarpus. in neonates the direction of rotation of the distal limb at both sites is almost exclusively outward. associated angular and rotational deviations occur. 17 in neonates, limb deviations occur in foals with narrower chests and less developed pectoral muscles than in straight foals, and they appear to have an initial greater overall weakness in the musculoskeletal system because it first interacts with gravity, body mass, and ground reaction forces. however, after the first few days of life, the asymmetric loading of the growth centers does affect limb deviations. angulation results from a compressive load that is asymmetric in a frontal plane but is uniform in the sagittal plane, and rotation occurs when the compressive load is asymmetric in both planes and the limb develops around an overloaded axis point. considered this way, valgus and outward rotation deviations in young foals are coupled, as are varus and inward rotation in older foals. the loading asymmetry for valgus/outward rotation foals is accentuated as foals assume a base-wide posture that is more stable side-to-side but promotes a lateralization of the limb load. the specific effects of intermittent versus static loads, strain magnitude versus strain rate, and shear and hydrostatic stress on growing bones is only beginning to be understood. however, clinical experience supports the general observation that excessive cartilage compression is deleterious to bone growth. offset carpal conformation describes a joint that appears to deviate outwardly and then inwardly, all within the carpus. the deformity is thought to be centered at the radiocarpal joint, but the specific structural cause of offset has not been determined. this conformation is more common in older foals but occasionally occurs in neonates. the deviation is particularly common when incomplete ossification of the carpal bones is present. the causes of conformational deviations are a matter of some debate. as always, the major factors are genetics or environment. genetic influences include the assortment of alleles that controls bone form and growth and the assortment that modulates bone remodeling. many in the horse industry believe that genetics is a strong determiner of limb conformation. environmental influences are many and include the intrauterine environment, the postnatal limb load, nutrition, and bad luck. suffice to say, the situation is complex, but one must consider biologic and mechanicobiologic influences when evaluating the growth of long bones. 18 several factors may contribute to the common occurrence of deviations in the carpus. first, the carpus is in the middle of the limb and is subject to the greatest bending forces. second, the carpal anatomy is complex and perhaps is not understood completely. the carpus has seven cuboidal bones, two long bones, and two epiphyses (distal radial and lateral styloid); and cartilage surrounds all. the ligamentous support includes collateral ligaments, innumerable intracarpal ligaments, and a palmar carpal soft tissue ligament. the distal radial physis is not flat transversely, but undulates in the frontal and sagittal planes. 3 a separate center of ossification for the lateral styloid process is found at its palmar-lateral aspect. because of this separate center of ossification, more cartilage and less bone are in the lateral aspect of the distal radial growth center, suggesting it may be more susceptible to growth alterations from load. less common conformation deformities in young foals include hindlimb deformities, windswept conformation, diaphyseal deviations (usually of the metacarpus/ metatarsus), gross congenital malformations such as agenesis and polydactyly, and acquired varus deformities of the carpus and fetlock. hindlimb conformational deviations can manifest as tarsal and fetlock angular deformities and external limb rotation, usually centered above the tarsus. windswept foals have limbs (usually both forelimb or both hindlimbs) that are curved in the same direction in the frontal plane. diaphyseal deviations, agenesis, and polydactyly are rare and have various presentations. acquired varus deformities are caused by excessive loading, which appears to be focused medially on the growth plates. one should evaluate the limbs to determine the location, extent, and potential cause of the deviation. evaluation consists of observation and then palpation for heat, swelling, or ligament laxity. ligamentous laxity of the medial carpal ligaments is an important cause of carpal valgus and should be evaluated carefully. lameness is not a characteristic of uncomplicated angular limb deformities and suggests further evaluations are necessary. radiography is indicated for foals with severe deviations (all tarsal valgus), ligamentous laxity, lameness, or joint effusions. ultrasonography may be valuable for selected soft tissue evaluations. conservative therapy is by far the most commonly used therapy in foals less than 30 days of age. 19 mild to moderate carpal valgus and external rotation of the carpus and fetlock are common and normal in neonates, particularly light breed horses. most congenital limb deviations improve with age, if the developing musculoskeletal system is protected from overuse and abnormal loads. approximately 90% of thoroughbred foals with congenital carpal valgus self-correct. those foals that do not most often have abnormal bone (incomplete ossification) with normal stress or normal bone with abnormal stress (ligamentous laxity or contralateral limb lameness). correction continues for several months, and on average, foals reach their straightest conformation (regarding angulation) at approximately 10 months of age (e.m. santschi, unpublished data). determination of the appropriate treatment for foals with angular limb deformities is based on the age of the foal, the severity and location of the deviation, and its causes. one must evaluate the entire foal and the affected limb. if the carpal collateral ligaments have no laxity and carpal incomplete ossification is not suspected, one may use an exercise program such as in table 19 -10, assuming that the foal has no contradicting additional problems. exercise is essential for the robust development of almost every body system for neonates, and fresh air and good ventilation reduce the occurrence of respiratory disease. appropriate limb loading along with growth and maturity is what straightens limbs, but excessive amounts of loading can be deleterious. for example, one should use exercise cautiously in foals with very asymmetric deviations. when one limb is much more deviated than the other, it appears to be loaded excessively and compromised more than if both limbs were affected similarly. and finally, limb deviations are additive. foals with external rotation and carpal valgus improve more slowly than those with one type of deviation. incomplete ossification of cuboidal bones and focal ligamentous laxity are complicating matters of great potential impact on adult conformation. they generally manifest as a moderate to severe limb deviation. physical examination indicates laxity because angular limb deviations are reducible. radiographs are the best way to evaluate the extent of carpal bone ossification. incomplete ossification of the cuboidal bones can be focal or widespread. focal immaturity is not common but can result in severe angulation. generalized immaturity is more frequent and initially often manifests as an offset conformation with valgus angulation. when the foal becomes heavier, assumes a base-wide stance, and is allowed exercise, crushing of the bones of the lateral carpus (usually the lateral styloid process of the radius, the ulnar, the fourth and the intermediate facet of the third carpal bone) results in a permanent intracarpal valgus deviation. the same result occurs when significant medial carpal ligament laxity goes untreated. in the forelimb, foals with collateral ligamentous laxity and moderate to severely immature cuboidal bones should have external coaptation placed on the affected limb to maintain axial orientation. tube casts that allow weight bearing on the digit are preferred to splints. ligamentous laxity in the carpus usually responds to tube casting for 7 to 10 days followed by bandaging and cautious exercise. the duration of similar coaptation necessary for immature carpal bones depends on the degree of immaturity and the speed with which the bones mature. because casts cannot be left on neonatal limbs for more than 7 to 10 days because of their fast growth, more than one cast may be necessary. treatment of tarsal valgus and rotational deformities is much less common than in the forelimbs because deviations are less common than in the forelimb, because some breeds prefer an outward position to the hindlimb, and perhaps because owners recognize it less frequently. 20 hindlimbs generally are unaffected by ligamentous laxity, but tarsal incomplete ossification is common and often is associated with tarsal valgus. treatment of tarsal incomplete ossification is important because tarsal crushing results in an unfavorable prognosis for athletic performance. 20, 21 hindlimbs require a slightly different approach to coaptation than forelimbs because of their anatomy. foals can rise to stand if their forelimbs are fixed in extension but cannot do so if their hindlimbs are extended. the multiple bony protuberances of the hock make cast sores more likely than in the forelimb, so casts are problematic. gutter splints are not useful because of the angle of the hock. severely limiting exercise is part of allowing the tarsus to mature without cartilage crushing, but foals cannot always be recumbent. extra small articulated anterior cruciate ligament splints for human beings (playmaker wraparound, dj orthopedics, vista, california) have given the best results. for small foals, a padded bandage is necessary under the splint, which is reversed to conform to the angle of the hock. the splints allow enough flexion in the hock for the foal to rise but appear sufficient when combined with stall rest to protect the cartilage from crushing. splints are left on the hocks until the cuboidal bones have ossified as shown by radiography. fetlock conformational deviations in neonates that are treated best conservatively are rare. outward rotation is the most common deviation but is thought to have minimal effect on the performance and improves with maturity. the only therapy used is to rasp the toe square to promote central breakover. severe outward rotation can promote a fetlock valgus conformation, so one can use a medial hoof wall extension of epoxy to bring the limb load medially. the most commonly treated fetlock deviations are inward but usually occur in foals older than 30 days. however, if the deviation is noticed in neonates, one can use small lateral hoof wall extensions that generally are made of epoxy with fiberglass cloth embedded to prevent chipping. windswept foals are born with multiple deviations. evaluating the foal as a whole is best rather than focusing on individual joints. most of these foals become straight over time with conservative therapy. no surgical procedures are commonly accepted for direct treatment of rotational or carpal offset deviations, so angular deviations are described. surgical procedures to correct carpal and fetlock valgus include periosteal transection and elevation and transphyseal bridging. periosteal elevation is thought to accelerate growth on the concave side of the metaphysis, and transphyseal bridging is used to restrict the growth on the convex side of the physis. studies indicate an approximately 80% improvement of carpal valgus foals after periosteal transection and elevation, but unfortunately they do not compare foals that had surgery with controls that did not. 22, 23 recently, some have suggested that most of the correction was unrelated to the surgery, 24 and one experimental study supports that conclusion. 25 as a result, at this time making firm recommendations about the indications for periosteal transection and elevation is difficult. however, periosteal transection and elevation has a low likelihood of complications and may be effective. the procedure is inexpensive and can be done in the field and therefore may be an option for clients with foals with carpal valgus in which a transphyseal bridging is undesirable or unnecessary. one indication is the very young foal born with a notably asymmetric epiphysis that results in a severe carpal valgus. this distal radial appearance is not particularly common, but the lack of ossification in the epiphysis can make a firm hold with a transphyseal bridging difficult to achieve. however, one can use distolateral radial periosteal elevation at an early age in an attempt to accelerate correction of the valgus and protect developing carpal bones. often a degree of anxiety exists about correction of fetlock angulations because of the much shorter time period for physeal growth. most fetlocks are in their final conformation by 60 days of age, so correction is best accomplished with earlier treatment, usually by 4 weeks of age. one can perform periosteal elevation on the medial (for varus deviations) or lateral (for valgus deviations) aspect of the distal metacarpus/metatarsus. the definitive treatment of limb angulation at a growth plate is transphyseal bridging. one should consider using the procedure at about 3 weeks of age for all moderate to severe fetlock deviations, at about 4 weeks for severe carpal deviations, and 6 to 8 weeks for mild fetlock deviations, moderate carpal deviations, and any worsening angular deformities. one must perform bridge removal when the limb straightens to prevent overcorrection. diaphyseal deviations are rare but can occur in varying degrees of severity. if the foal can bear weight on the limb, a conservative approach is indicated. one can consider periosteal elevation of the length of the concave surface of the long bone. if the foal cannot bear weight on the limb because of the severity of deviation, euthanasia is probably the best option. however, a revision osteotomy and internal fixation may be appropriate for selected foals. 26 polydactyly is also rare and sometimes can be corrected surgically. the outcome is based on the degree of articular involvement. bacteria may invade the foal musculoskeletal system and cause orthopedic infection after delivery by the circulation, by direct extension from another system, or by direct inoculation. hematogenous delivery is by far the most common and results in infection of synovial structures (joints, tendon sheaths, bursae) and bone. extension from another site without hematogenous delivery is rare. direct inoculation almost exclusively results from traumatic rather than surgical wounds. much is still to be learned about the pathophysiology of orthopedic infection, including the source of the infecting bacteria. the umbilicus commonly is accepted as a possible source of bacteria, 27 but many believe that the gastrointestinal and respiratory tracts are at least equally responsible. associated conditions in foals with septic arthritis include failure of passive transfer, pneumonia, and enteritis. 28 the classification of orthopedic sepsis in foals into infection of bones and joints is probably irrelevant because most foals with septic arthritis also have infectious osteitis or osteomyelitis. 27, 29 septic arthritis is more readily recognizable because the reactivity of the synovium to the bacteria causes joint effusion and lameness and because early radiographic signs of bone infection in foals are equivocal. also unclear are the reasons for the apparent site predilection for orthopedic infection in foals. the femoropatellar joint and the tarsocrural joint are affected most frequently, followed by the carpal and fetlock joints, and finally an assortment of miscellaneous joints such as the elbow, shoulder, and hip. 28 the common association of osteomyelitis of the distal femoral, tibial, and metacarpal/metatarsal physes with a newly recognized septic arthritis suggests that the infection in that area started at the growth center (epiphysis, physis, or metaphysis). the localization of the apparent initial site of infection to the growth center has been suggested to result from "looping" metaphyseal vessels with sluggish blood flow that allow pathogens more time to escape the circulation. 29, 30 however, transmission electron microscopy indicates that osteogenic cells and the vascular endothelium are a continuous network in developing embryos, 31 indicating that the relationship between circulation and bone is more intimate than previously suspected. a possible association between osteomyelitis and thickened or traumatized cartilage exists. focal osteomyelitis lesions occur commonly at the bone cartilage junction 27, 29 and particularly in areas where cartilage is attached at an angle to the long axis or where thickened. 29 an association also exists between incomplete ossification of the central and third tarsal bones and osteomyelitis. 32 trauma to the metaphysis is a known predisposing cause of osteomyelitis in young bacteremic rabbits. 33 a trend exists for foals with more than one joint affected to be affected bilaterally in the same joint, rather than in random joints. this trend suggests that a "window" exists when a joint may be more susceptible to infection and that trauma to the developing cartilage may be a contributing factor. in neonates, cartilage is vascular, 34 and possibly small traumatic cartilage lesions with associated hemorrhage and exposure of bacterial binding sites might be the inciting cause for the location of infection. the pathogens most commonly associated with septic arthritis in young foals are also those that frequently are implicated in neonatal sepsis. the most commonly isolated gram-negative organisms are escherichia coli and other enterobacteriaceae, actinobacillus equuli, and salmonella spp. frequently isolated gram-positive organisms include streptococcus spp., staphylococcus spp., and rhodococcus equi. 28 anaerobic bacteria and fungi are rare but should be considered in refractory cases. the diagnosis of orthopedic sepsis can be challenging. the most common clinical sign is lameness, followed by swelling around a joint or metaphysis. joint effusion alone may cause the swelling, but edema is also common, especially if metaphyseal osteomyelitis is present. but effusion and edema can be difficult to detect because of the tissue surrounding the focus of infection in the shoulder, elbow, hip, and coffin joints. one should evaluate lame foals carefully by palpation to localize pain and swelling. if one can find no pain or swelling, one should obtain a complete blood count and fibrinogen level. although a complete blood count is not always abnormal in foals with septic arthritis, abnormalities should raise the index of suspicion of infection. elevations in fibrinogen are fairly common in septic arthritis, 28 and fibrinogen almost always is elevated if the infection involves bone. if hematologic values are normal, the lameness could be caused by trauma, but the foal should be monitored closely for improvement, and closer evaluation is indicated if improvement is not rapid. an arthrocentesis is the diagnostic test of choice for confirmation of septic arthritis. one should perform joint puncture in a sterile fashion, and sedation is indicated to get an atraumatic tap. short-term anesthesia is preferable when joints have effusion because one may perform joint lavage at the same time. normal joint fluid should be clear to slightly yellow, should be viscous, and should contain less than 2500 nucleated cells per deciliter. the cell ratio should be roughly 50:50 polymorphonuclear and mononuclear. the total protein content should be less than 2.5 mg/dl. one should consider joints to be infected if the nucleated cell count is greater than 10,000 cells/dl. for joints falling between 2500 and 10,000 cells/dl, if the polymorphonuclear cell count is >90%, one should consider the joints infected. cytologists are often reluctant to diagnose infection when nuclear degeneration or bacteria are not visible. this is overly conservative and results in delay in treating infections because bacteria and nuclear degeneration are rare in early cases of joint infection. out of an abundance of caution, one should treat lame foals with suspicious joints as infected unless they are clearly normal. one should always culture joint fluid in an attempt to identify the offending organisms, but because of difficulties in culturing pathogens from joint fluid samples, absence of growth does not mean absence of infection. one obtains the best culture results if the foal has not been treated with antimicrobial agents beforehand. one should obtain as much joint fluid as possible for culture and should incubate it overnight in blood culture media before plate inoculation. as always in potentially septic foals, blood culture may assist in the isolation of the organism. other orthopedic infections that do not involve the joint may be more difficult to detect. often these are not apparent until infection breeches the joint and causes lameness. however, astute caretakers may notice early clinical signs such as mild lameness, fever, or edema centered at a growth center. radiography and advanced imaging modalities such as magnetic resonance imaging are the best diagnostic tools for the localization of areas of osteitis and osteomyelitis. one should examine the area of concern carefully, giving particular attention to the growth centers and subchondral bone. interpretation of radiographs may be difficult because these areas are complex and normally have irregular bone margins in the growing foal. if a normal contralateral joint is available, comparison radiographs may be useful. because of the high metabolic turnover in growing foal bone, changes occur faster than with adults, so radiographs at the earliest sign of potential infection of bone and joint are recommended. if evidence of osteolysis is clear, aspiration of the area may yield material for culture. the goals of treatment are to eliminate infection immediately and then resolve inflammation. bacteria and products of inflammation elicited by infection are responsible for destruction of bone and cartilage. the ultimate aim of treatment is to protect the structures critical to athletic performance such as subchondral bone and cartilage in weight-bearing areas. advances in the treatment of sepsis have resulted in hospital discharge rates of 78% for foals with septic arthritis, but their rate of high performers is 30%, 28 indicating a need for improvement. equine veterinarians cannot replace what has been destroyed, so early identification and aggressive therapies are presently the best methods to improve performance rates. one achieves the goals of treatment by physical removal of bacteria, products of inflammation, and debris and by medications to kill the bacteria and reduce inflammation. one should optimize the physiology and general health of the foal to assist this process; one should include other treatments and supportive therapies for septic foals, especially treatment of failure of passive transfer, in the therapeutic plan. intravenous administration of antimicrobials (see chapter 4) is the cornerstone of treatment of orthopedic infection, and if the drug is administered early in the course of infection and bacteria are susceptible, intravenous administration may be sufficient to eliminate the organisms. however, treatment of many foals does not begin until disease is advanced. if treatment begins after bacteria have had a chance to establish themselves, one should bring all appropriate methods to bear to end the infection. additional therapies for septic arthritis include joint lavage, arthrotomy (for drainage), 35,36 debridement (arthroscopically or arthrotomy), 37 intraarticular administration of antimicrobials, intravenous regional perfusion, 38 and antimicrobial beads. 39, 40 one can use any sterile isotonic solution to flush a joint, and additives do not appear to give significant additional benefit. if radiographs do not indicate osteomyelitis, lavage, intraarticular antibiotics, and if possible, regional perfusion are recommended. if osteitis or osteomyelitis is present, debridement is indicated arthroscopically or via arthrotomy (one should culture the debris if the pathogen is unknown). if the joint is closed, one may use antibiotics intraarticularly. if the joint is left open to drain, regional perfusion is useful. antimicrobial beads theoretically are best to use if the wound is closed, but they appear to give benefit even if the wound is open under a bandage. because of concerns about the use of beads in a joint, 41 beads often are used in tissue defects and the surrounding tissues. the major goal is to remove material that is compromising healthy tissues and to obtain high concentrations of antimicrobials in infected tissues. high antimicrobial concentrations are necessary because adhered bacteria are difficult to kill and may require many times the in vitro bacterial minimum inhibitory concentration. intraarticular administration of antimicrobials has been used for many years and has great value. 35 regional perfusion of diluted antimicrobials recently has come into use and may be administered intraosseously 42 or intravenously. intravenous perfusion is preferable because no special equipment is needed, but intraosseous perfusion may be valuable where intravenous access is impossible. the concept behind both procedures is to fill the venous vasculature in the area of the infection with antimicrobials diluted by a sterile balanced electrolyte solution. one isolates the anatomic area of interest using one or two tourniquets. the perfusate diffuses into all tissues and achieves much higher concentrations than are possible using intravenous therapy. this technique has shown excellent results as an adjunct therapy for orthopedic infection. 43 for foals, 12 to 20 ml total of perfusate containing 250 mg amikacin is useful for most single joint sites. amikacin has given consistently good results without complication and is a good choice based on its concentration-dependent activity. one may use a higher volume for the stifle, but the thigh musculature makes an effective tourniquet difficult to achieve. because of concerns that perfusion might dislodge bacteria and renew systemic sepsis, high concentrations of systemic antimicrobials are recommended at the time of the perfusion. if joint lavage and intraarticular administration of antimicrobials are not sufficient to resolve infection, one may perform arthrotomy to assist the joint to drain. passive and active drains add foreign material and so are not useful. maintaining the joint under a sterile bandage is critical and can be difficult to do in proximal joints such as the stifle and elbow. tie-over bandages can be useful in this application. the best measure of success is the resolution of lameness and local inflammation. radiographs may be helpful, but the most common sign of success is a failure of the infection to progress, rather than radiographic healing. one should continue intravenously administered antimicrobials for at least 1 week after the resolution of lameness. if an appropriate drug is available, one should give foals antimicrobials orally for at least 2 weeks more. a total of at least 4 weeks of antimicrobials is recommended for most foals with orthopedic infection. treatment failures usually result from an inability to kill bacteria adhered to isolated tissue (usually dead bone). sometimes this failure is caused by incomplete debridement or an inability to access a known site of infection, but more frequently it is because infection has flourished in an unknown site. for this reason, multiple imaging modalities (radiographs, ultrasound, computed tomography, and magnetic resonance imaging) used multiple times are recommended for all refractory cases of septic arthritis. osteomyelitis not associated with a joint still involves a growth center. the ideal treatment for these infections is surgical debridement, systemic antimicrobial therapy, and some form of local antibiotic delivery. 44, 45 even in the face of large initial osseous defects, infection may resolve, the defect may heal, and the foal may regain normal limb anatomy and 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gentamicin-impregnated polymethylmethacrylate beads use of antibioticimpregnated polymethyl-methacrylate in horses with open or infected fractures or joints: 19 cases (1987-1995) the effect of implanting gentamicin-impregnated polymethylmethacrylate beads in the tarsocrural joint of the horse regional perfusion of the equine carpus for antibiotic delivery how to perform equine digital intravascular perfusion surgical management of rhodococcus equi metaphysitis in a foal intraosseous regional perfusion for treatment of septic physitis in a 2-week-old foal key: cord-262843-i0cy7467 authors: suzumoto, masaki; hotomi, muneki; billal, dewan s.; fujihara, keiji; harabuchi, yasuaki; yamanaka, noboru title: a scoring system for management of acute pharyngo-tonsillitis in adults date: 2008-09-05 journal: auris nasus larynx doi: 10.1016/j.anl.2008.07.001 sha: doc_id: 262843 cord_uid: i0cy7467 objectives: the aim of this study was to develop and evaluate a scoring system for the management of acute pharyngo-tonsillitis. methods: we conducted a prospective study between may 2004 and june 2005. patients with acute pharyngo-tonsillitis were evaluated for causative pathogens and were assessed clinical symptoms and pharyngo-tonsillar finding by a clinical scoring system. results: a total 214 adult patients were enrolled in this study. streptococcus pyogenes were identified at 13.6%. thirty-one viruses were also identified by pcr. they were adenovirus (4.8%), influenza virus (1.0%), rs virus (6.3%), and human metapneumovirus (2.9%). numbers of total white blood cells and levels of c-reactive protein showed a significant positive correlation with clinical scores (p < 0.001) and were also higher in cases with s. pyogenes. the clinical scores rapidly improved after the antimicrobial treatments in moderate cases and severe cases. conclusion: the current study strongly suggested that the clinical scoring system reflected disease severity well and would be very useful for evaluating clinical course and decision making for the antimicrobial treatment of acute pharyngo-tonisllitis. sore throat is one of the commonest respiratory symptoms in general practice and the vast majority of adults presenting sore throat have acute pharyngitis. acute tonsillitis also accompanies acute pharyngitis and is obvious from typical appearances of tonsils as crypts studded with purulent material or purulent exudations covering palatine tonsils [26, 27] . the management of acute pharyngo-tonsillitis is an important issue for quality of care because this infectious disease is frequent in outpatients setting. most of cases are caused by viral infections and are self-limiting by only symptomatic treatments. approximately 5-15% of cases in adults are caused by streptococcus pyogenes (s. pyogenes) and prescribed antimicrobial agents [3, 5, 6, 10, [19] [20] [21] . in contrast to the rationale of managements for pharyngotonsillitis, antibiotics are actually prescribed to a majority of adult patients at approximately 75% [1, 16] . the best way to manage adult patients with pharyngo-tonsillitis has still been controversial among countries [8, 12, [23] [24] [25] 34] . optimal management depends on both the clinical likelihood of infections with s. pyogenes and the relative importance assigned to the criteria to avoid over-use and/or under-use of antibiotics with preventing complications. it is important to develop a clinical scoring system easy to use and to assess accurate clinical features of acute pharyngo-tonsillitis with special emphasis on infections with s. pyogenes in adults [7, 9] . we organized a nationwide prospective surveillance study group (pharyngo-tonsillitis study group: phatons) in japan during [2004] [2005] pharyngo-tonsillitis in comparison with clinical features. an appropriate scoring system was also developed and applied for evaluating severities and clinical course of acute pharyngo-tonsillitis. adult outpatients with acute pharyngo-tonsillitis between ages of 15 and 80 years old, irrespective of gender, were eligible and were enrolled in this prospective study. the diagnostic criteria for acute pharyngo-tonsillitis included sore throat, histories of fever, erythema of pharyngotonsillar mucosa, and, if any, tonsillar exudates. exclusion criteria included cases with complications that reduce antimicrobial treatments, antibiotics in preceding month, pregnancy, and immune deficiency including immunosuppressive medications. we designed the study as a prospective trial organized by a nationwide study groups (pharyngo-tonsillitis study group: phatons) during may 2004-june 2005. adult patients with pharyngo-tonsillitis were prospectively enrolled in this study. the severity and clinical courses of the disease were evaluated by a clinical scoring system (table 1) . swabs from tonsillar crypts for identifying pathogens and blood examinations were performed at the first visit (day 0). the patients were treated with or without antibiotics according to the severity of illness. briefly, the mild cases were treated with oral antibiotics or symptomatic management without antibiotics, the moderate cases were treated with oral antibiotics, and the severe cases were treated with oral or parenteral antibiotics. for the evaluation of relationship between doctors' habit of using and selecting antimicrobial agents and the severity of illness, antimicrobial agents were selected and used by physician's own decision. informed consent approved by the institutional review broad was obtained from the patients at the time of enrollment in the study. we assessed the severity and clinical course of the disease using a scoring system consisting of symptoms and pharyngo-tonsillar findings (table 1) . we evaluated difficulties in a daily life, sore throat, and fever as symptoms and scored erythema and swelling of pharyngo-tonsillar mucosa and the presence of exudates or plugs in tonsils grading from 0 (none) to 2 (marked). severities of the disease were classified into three groups according to total scores. patients with total scores !9, 4-8, and 3 were assigned into severe group, moderate group and mild group, respectively. standard laboratory methods were performed to identify pathogenic bacteria according to the manual of clinical microbiology (8th edition). briefly, swabs from tonsillar crypts were cultured on sheep blood agar, chocolate agar and macconkey agar plates overnight at 37 8c in 5% co 2 . haemophilus influenzae (h. influenzae) were determined by growth in chocolate but not in blood agar plates, catalase test, and requirement of x and v factor. haemophilus haemolyticus (h. haemolyticus) were differentiated from h. influenzae by haemolysis on blood agar plates. streptococcus pneumoniae (s. pneumoniae) were identified by optochin susceptibility and bile solubility. s. pyogenes were confirmed by latex agglutination with commercially available latex reagen (biomerieux, marcy l'etoile, france) and bacitracin susceptibility. suspected staphylococcus aureus (s. aureus) were identified by use of dnase testing and a staphaurex latex test (remel, lenexa, usa). the growth of bacteria was graded from 0 to +4. we applied pcr to identify adenovirus and rt-pcr to identify human metapneumo virus (hmpv), influenza virus a and b, and respiratory syncytial (rs) virus a and b. swabs from tonsillar crypts were suspended into minimum essential medium (mem) with penicillin and streptomycin. nucleic acid including rna and dna were purified using high pure viral nucleic acid purification kit (roche, basel, switzerland). the final amplified products were separated by electrophoresis on 2% agarose gels and visualized by ethidium bromide. statistical analysis of data was performed using nonparametric test. comparisons between two groups were assessed by tukey-kramer analysis. comparisons of clinical outcomes of the disease were assessed by wilcoxon signed-rank test. correlation between clinical scores and numbers of wbc or levels of crp were assessed pearson regression analysis. statistical tests were based on a level of significance of p-value less than 0.05. calculations were performed using the statistical software package jmp6.0.3 (sas institute, inc., cary, nc, usa). a total 236 adult patients with pharyngo-tonsillitis were enrolled in this study. during a study 22 patients were dropped out for incomplete follow-up and 214 patients (89.4%) were finally evaluated for causative pathogens and clinical outcomes of the disease. they were 114 males and 100 females, ranging in ages between 16 and 79 years old (mean 33.9 years old). acute pharyngitis is a painful inflammation of the mucosa of the pharynx. acute pharyngitis includes a sore throat and is characterize by signs of erythema of pharyngeal mucosa. acute tonsillitis is an infectious inflammation of the pharyngeal tonsils. acute tonsillitis accompanying acute pharyngitis includes a severe sore throat, painful and difficult swallowing, fever and chills and is characterize by signs of red, swollen tonsils which have a purulent exudative coating of white pus. the characteristics of illness in this study were classified in 165 cases with acute tonsillitis and 49 cases with acute pharyngitis (table 2) . a total 234 pathogenic bacteria were identified in 157 (73.4%) out of a total 214 patients. the organisms were s. pyogenes (29 isolates, 13.6%), hemolytic streptococci (35 isolates, 16.4%), h. influenzae (52 isolates, 24.3%), h. haemolyticus (23 isolates, 10.7%), s. aureus (71 isolates, 33.2%), s. pneumoniae (11 isolates, 5.1%), m. catarrhalis (8 isolates, 3.7%), and others (13 isolates, 6.1%) ( table 3 ). there were no significant differences in distribution of bacteria between acute tonsillitis and pharyngitis. thirty-one viruses were identified by pcr. they were adenovirus (10 out of 205 cases, 4.8%), influenza virus (6 out of 205 cases, 2.9%), rs virus (2 out of 191 cases, 1.0%), and hmpv (13 out of 206 cases, 6.3%) ( table 3) . among 206 cases in which both bacterial culture and virus pcr were performed, bacteria alone were identified in 128 cases (62.1%), virus alone were identified in 7 cases (3.4%), both bacteria and virus were identified in 23 cases (11.2%). in 48 cases (23.3%) neither bacteria nor virus was identified. both severities of disease and inflammatory parameters were compared with pathogens. although s. pyogenes together with hemolytic streptococci, h. influenzae, h. haemolyticus, s. aureus, s. pneumoniae, m. catarrhalis were frequently identified among patients with acute pharyngotonsillitis, the clinical scores were not different among those (fig. 1a) . on the other hands, the numbers of total wbc at the first visit were significantly higher in cases with s. pyogenes than cases with other pathogens (fig. 1b) . the levels of crp were significantly higher in cases with s. pyogenes than in cases with s. aureus and m. catarrhalis ( p < 0.05) (fig. 1c) . patients were classified into 33 (15.4%) mild cases, 121 (56.5%) moderate cases, and 60 (28.0%) severe cases according to the criteria by clinical scores. the ratio of acute tonsillitis and pharyngitis according to the severities were 51.4% and 48.6% in mild cases, 73.7% and 26.3% in moderate cases, and 98.4% and 1.6% in sever cases, respectively. total numbers of wbc at the first visit showed a positive correlation with clinical scores (r = 0.482, p < 0.001) (fig. 2) . the mean ae s.d. of wbc in mild cases, moderate cases, and severe cases were 7937 ae 2585 cells/mm 3 , 9578 ae 3790 cells/mm 3 , and 12,727 ae 4082 cells/mm 3 , respectively. the levels of crp at the first visit were also showed a positive correlation with clinical scores (r = 0.571, p < 0.001) (fig. 3) . the mean ae s.d. of crp in mild cases, moderate cases, and severe cases were 0.6 ae 0.8 mg/dl, 3.6 ae 4.1 mg/dl, and 8.5 ae 7.0 mg/dl, respectively. the frequencies of isolations of pathogenic microorganisms did not differ regarding the severities of the disease. the clinical outcomes were evaluated by a scoring system according to the severities of the disease (fig. 4a and b) . in 33 mild cases, 21 (63.6%) patients followed up without antibiotics and improved scores gradually whereas 12 (36.4%) patients were treated with oral antibiotics (ampc: 12.1%, lvfx: 15.2%, cfpn: 9.1%). in 121 moderate cases, 120 (99.2%) patients were treated with antibiotics and 87 patients (71.9%) were treated with ampc (66 patients, 54.5%) or lvfx (21 patients, 17.4%). all severe cases were treated with antibiotics. seven patients (11.7%) were treated with ampc and 14 patients (23.3%) were treated with lvfx. in the severe cases, 22 patients (36.7%) were treated with parenteral antibiotics. among those 22 patients, 12 patients (20.0%) were treated with ctrx. the clinical scores of moderate and severe cases were significantly improved after antimicrobial treatments ( p < 0.01). because of a wide range of illness with sore throat, diagnosis of acute pharyngitis is still troublesome for primary care physicians. in the current study, we defined causative pathogens and the severity of acute pharyngotonsillitis by a clinical scoring system in adult patients. most of acute pharyngo-tonsillitis were reported to be caused by viruses such as adenovirus, rhinovirus, corona virus, parainfluenza virus, coxackie virus, influenza virus, herpes virus, and cytomegalovirus and were considered to be selflimiting [4, 19] . in this study, the frequencies of viruses in adult acute pharyngo-tonsillitis were lower rather than those reported in children, when we applied pcr/rt-pcr to identify four important viruses such as rs virus, adenovirus, influenza virus, and hmpv from pharyngeal swab. the implication of viral infections might be low in adult acute pharyngo-tonsillitis [29, 31] . bacteria were identified in 73.3% of patients studied herein. s. pyogenes that had been reported as an important causative pathogen responsible for acute pharyngo-tonsillitis were identified at 13.6% [15, 28, 32] . other hemolytic streptococci were also frequently identified from the patients with acute pharyngotonsillitis. however, the pathogenic roles of group c or g streptococci in the upper respiratory tract infections have not been completely studied. the haemophilus spp. and staphylococcus spp. are more controversial. isolation of s. pyogenes was closely related with the high value of inflammatory parameters such as white blood cells and creactive protein compared to isolation of other pathogens. determinations of infections due to s. pyogenes have been an important issue for studying acute pharyngotonsillitis [2, 14, 17, 22] . several clinical findings have the discriminative value in distinguishing s. pyogenes from other causes of acute pharyngo-tonsillitis. the ability of experienced physicians to predict positive throat cultures of s. pyogenes is moderate with estimated sensitivity and specificity ranging from 55 to 74% and 58 to 76%, respectively. in an attempt to improve clinical sensitivity and specificity, investigators have developed clinical decision rules based on constellation of physical signs and symptoms [13, 30, 33] . the centor score has been the most reliable predictors for estimating the likelihood of infections of s. pyogenes in a patients presenting with a sore throat [9] . the score is calculated by determining how many of the following four clinical features are present: history of fever, tonsillar exudates, anterior cervical adenopathy, and absence of cough. at the usual clinical setting, the majority of primary care physicians prescribe antimicrobial agents and pain-killers based on the severity of illness [18] . although the center score is useful to infer s. pyogenes, the score is not valuable for diagnosis of the severity of the illness. a rapid antigen detection kit for s. pyogenes using a latex agglutination method also applied to determine infections with s. pyogenes. the test showed negative predicting value at 95% and relatively lower positive predicting value at 62% [37] . there has been a general consensus that negative rapid antigen tests for s. pyogenes should be confirmed by the culture test [17] . however, recent guidelines have suggested that confirmation of negative rapid antigen test results for s. pyogenes in adults is either not necessary at all or only if the sensitivity of the rapid antigen test is <80% [11, 28] . the rapid antigen tests has the lower sensitivity compared to a well-performed culture. therefore, the importance of rapid identification of s. pyogenes is still controversial. we applied a scoring system based on symptoms and clinical findings to diagnose the severity of acute pharyngotonsillitis in this study. the scoring system reflected severities of the illness correlated well with numbers of wbc and levels of crp. although we could not found any correlations between identification of s. pyogenes and severity of the disease, identification of s. pyogenes clearly correlated with numbers of wbc and levels of crp. regarding to antibiotic treatment, it is important to discriminate causative agents such as bacterial and/or virus infection in acute pharyngo-tonsillitis. however, it is sometimes difficult to discriminate them in the usual clinical setting. the current study was also designed to evaluate correlation among clinical parameters such as clinical scores, wbc, and crp. viruses were identified in only 21 (9.8%) patients and there were no correlation between identification of viruses and numbers of wbc or levels of crp. in contrast, the numbers of total wbc and the levels of crp at the first visit were significantly higher in cases with s. pyogenes indicationg the importance of s. pyogenes as the causative pathogen for acute pharyngotonsillitis. thus, the clinical scoring system together with blood test could discriminate the possible bacterial infections from virus infections. we further confirmed the usefulness of the clinical scoring system to evaluate the efficacy of antimicrobial treatments on acute pharyngo-tonsillitis. the study on the difference of treatment outcomes among various age groups reported that group a b-hemolytic streptococcus required antibiotic therapy [35, 36] . in this study, a marked reduction of clinical scores after antimicrobial treatments in severe and moderate cases indicated high efficacy of them for the illness with higher severity. on the other hand, mild cases showed decrease of scores regardless of antimicrobial treatments. thus, the current study strongly suggested that the clinical scoring system reflected disease severity well and would be very useful for evaluating clinical course and decision making for the antimicrobial treatment of acute pharyngo-tonisllitis. practice guidelines for the diagnosis and management of group a streptococcal pharyngitis diagnosis and management of group a streptococcal pharyngitis: a practice 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patient have strep throat role of beta-hemolytic group c streptococci in pharyngitis: incidence and biochemical characteristics of streptococcus equisimilis and streptococcus anginosus in patients and healthy controls principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods the prevalence of bhaemolytic streptococci in throat specimens from healthy children and adults, implications for the clinical value of throat cultures a randomized controlled trial of antibiotics on symptom resolution in patients presenting to their general practitioner with a sore throat pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms susceptibility of group a beta-hemolytic streptococci to thirteen antibiotics: examination of 301 strains isolated in the united states between detection of group a streptococci in the laboratory or physician's office. culture vs antibody methods suitability of throat culture procedures for detection of group a streptococci and as reference standards for evaluation of streptococcal antigen detection kits streptococcal pharyngitis. placebo-controlled double-blind evaluation of clinical response to penicillin therapy antibiotic treatment of adults with sore throat by community primary care physicians: a national survey clinical and psychosocial predictors of illness duration from randomized controlled trial of prescribing strategies for sore throat reattendance and complications in a randomized trial of prescribing strategies for sore throat; the medicalizing effect of prescribing antibiotics open randomized trial of prescribing strategies in managing sore throat sore throat management in general practice molecular assays for detection of human metapneumovirus a clinical score to reduce unnecessary antibiotic use in patients with sore throat role of metapneumovirus in viral respiratory infections in young children the accuracy of experienced physicians' probability estimates for patients with sore throat. implications for decision making optimal management of adults with pharyngitis-a multi-criteria decision analysis principles of appropriate antibiotic use for acute pharyngitis in adults diagnosis of pharyngitis: clinical and epidemiological features perplexity and precision in the diagnosis of streptococcal pharyngitis use of a high-sensitivity rapid strep test without culture confirmation of negative results: 2 years' experience we greatly thank to prof. edward l. kaplan, m.d. (department of pediatrics, the university of minneapolis, usa) for his suggestion to this paper. these works were organized by a nationwide surveillance group for adult acute pharyngo-tonisllitis (pharyngo-tonsillitis study group: phatons). we greatly thank to all members of phatons. we also express our hearty thanks to miss yuki tatsumi for her technical assistances. this study was supported for funding by daiichi pharmaceutical co., ltd. (presently daiichi-sankyo, post-merger). key: cord-283545-vu8lt3w6 authors: brabb, thea; newsome, denise; burich, andrew; hanes, martha title: infectious diseases date: 2011-12-16 journal: the laboratory rabbit, guinea pig, hamster, and other rodents doi: 10.1016/b978-0-12-380920-9.00023-7 sha: doc_id: 283545 cord_uid: vu8lt3w6 although guinea pigs are sensitive and susceptible to the development of lesions from a wide range of viruses, bacteria, protozoa, and parasites, only a small number of organisms cause natural infection and only a portion of that group cause clinical disease. this chapter discusses naturally occurring diseases of guinea pigs, although some data from experimental infections have also been covered as they relate to the pathogenesis of the disease. the material presented includes background, etiology, epizootiology/pathogenesis, clinical manifestations, pathology, diagnosis, prevention, and therapy. the diseases are discussed in an alphabetical order based on the taxonomic groups to which the organisms belong and are independent of the order of perceived importance of the various diseases. the federation of european laboratory animal science associations recommends monitoring for guinea pig adenovirus, guinea pig cytomegalovirus, sendai virus, ectoparasites, endoparasites, e. cunniculi, and a variety of bacteria including bordetella bronchiseptica, chlamydia psittaci, corynebacterium kutscheri, dermatophytes, pasteurellaceae, salmonella, streptobacillus moniliformis, streptococcus, yersinia pseudotuberculosis, and clostridium piliforme. virus-associated necrotizing ronchopneumonia in guinea pigs is a spontaneous multifactorial disease that has low morbidity, high mortality, and a worldwide distribution. although guinea pigs are sensitive and susceptible to the development of lesions from a wide range of viruses, bacteria, protozoa, and parasites, only a small number of organisms cause natural infection and only a portion of that group cause clinical disease. the intent of this chapter is to discuss naturally occurring diseases of guinea pigs, although some data from experimental infections may be covered as they relate to the pathogenesis of the disease. the material is presented under the following headings: background, etiology, epizootiology/pathogenesis, clinical manifestations, pathology, diagnosis, prevention, and therapy. the diseases are discussed in an alphabetical order based on the taxonomic groups to which the organisms belong and are independent of the order of perceived importance of the various diseases. in laboratory colonies, routine surveillance of guinea pigs is conducted monthly, quarterly, or yearly as required. the federation of european laboratory animal science associations (felasa) recommendations include monitoring for guinea pig adenovirus, guinea pig cytomegalovirus, sendai virus, ectoparasites, endoparasites, e. cunniculi, and a variety of bacteria including bordetella bronchiseptica, chlamydia psittaci, corynebacterium kutscheri, dermatophytes, pasteurellaceae, salmonella spp., streptobacillus moniliformis, streptococcus spp., yersinia pseudotuberculosis, and clostridium piliforme. most laboratories also monitor for these additional viruses, simian virus-5 (sv5), pneumonia virus of mice (pvm), reovirus, lymphocytic choriomeningitis virus (lcmv), and parainfluenza virus-3 (piv-3). these viruses are routinely monitored both to minimize the risk of transference to mouse and rat colonies (pvm, reovirus, sendai virus, lcmv) and to identify infections that are zoonotic (lcmv, piv-3). the viral taxonomy used follows the recommendations of the viiith international committee on taxonomy of viruses (fauquet, 2005) , but well-established common names for viruses are used when appropriate. historically, pvm, parainfluenza viruses, cytomegalovirus, and reovirus have been commonly found in guinea pig colonies. from 1984 to 1988 serologic investigations of laboratory animal colonies originating from ten different european countries found seropositivity for four viral infections in guinea pig stocks; reovirus, pvm, sendai virus, and sv5 (see paramyxoviridae section for discussion of serological specificity of sendai virus and sv5) (kraft and meyer, 1990) . in a 2004 study guinea pigs reared conventionally were positive serologically for sendai virus, pvm, and reovirus (park et al., 2006) . adenoviridae: guinea pig adenovirus (gpadv) background virus-associated necrotizing bronchopneumonia in guinea pigs is a spontaneous multifactorial disease that has low morbidity, high mortality, and a worldwide distribution (percy and barthold, 2007) . after the first description in germany and experimental reproduction of the disease (kunstyr et al., 1984; naumann et al., 1981) , sporadic spontaneous cases were reported from the united states, australia, and switzerland (brennecke et al., 1983) . a 10-year endemic "in-house" occurrence of adenovirus-associated disease was reported in a british pharmaceutical research facility. in all described spontaneous cases, some additional stress factors were involved (pring-akerblom et al., 1997) . etiology gpadv is a member of the adenoviridae, genus mastadenovirus that contains canine and bovine adenoviruses as well (fauquet, 2005) . a portion of the hexon gene was cloned and sequenced and found to be eimeria 666 giardia duodenalis 667 klossiella cobayae 667 leishmania enrietti 668 toxoplasma gondii 668 tritrichomonas caviae 669 trypanosoma cruzi 669 prevention and therapy animals with gpadv are not appropriate for guinea pig pulmonary research projects. rederivation of infected colonies with aseptic hysterectomy or embryo transfer should eliminate the virus. in addition, there could be a concern that natural infection with gpadv would interfere with the use of adenovirus gene vectors. this was examined in a study of gpadv naturally infected guinea pigs that were used as recipients of a human adenoviral vector carrying the gene for green fluorescent protein (hankenson et al., 2010) . in this model system, no difference in transfection-efficiency was seen in guinea pigs naturally infected with gpadv or gpadv-free. three members of the family herpesviridae that specifically infect guinea pigs are catalogued in the eighth report of the international committee on the taxonomy of viruses (fauquet, 2005) ; caviid herpes virus 2 (commonly known as guinea pig cytomegalovirus and in some publications as caviid herpesvirus 1 (staczek, 1990) ), caviid herpes virus 1 (also known as guinea pig herpes-like virus or hsiung-kaplow herpesvirus, or in some publications as caviid herpesvirus 2 (staczek, 1990) ), and caviid herpes virus 3 (also known as guinea pig x virus) (fauquet, 2005) . in addition, equid herpes virus 1, a virus of horses, has been shown to cause severe disease in guinea pigs in one outbreak in a zoo (wohlsein et al., 2010) . of these viruses, guinea pig cytomegalovirus is the most commonly isolated herpes virus from guinea pigs and serological reactivity to this virus in colonies is not unusual. guinea pig cytomegalovirus is used extensively in research as an animal model for human cytomegalovirus. is consistently recovered from the blood and many other tissues including lung, spleen, and kidney during a 10-day period beginning at day 2 post-inoculation . viral clearance from the blood and most tissues occurs by 10 days post-infection, but virus remains consistently detectable in the urine and salivary gland during the chronic phase of infection (bia et al., 1979; hsiung et al., 1980) . less consistently, virus is found in splenic macrophages, b lymphocytes, kidneys, spleen, pancreas, and cervix of infected animals during this chronic phase. pregnancy can lead to more severe disease and changes in viral load following experimental gpcmv infection griffith and hsiung, 1980; griffith et al., 1983) . pregnant guinea pigs may develop interstitial pneumonia, splenomegaly, and necrosis of the liver, kidney, thymus, pancreas, and bone marrow (griffith et al., 1983) . the mortality rate for pregnant animals during an acute viremic episode following experimental infection is significantly greater than for non-pregnant females. although the fetus is susceptible to gpcmv infection at any time throughout gestation, transplacental transmission occurs most readily during the acute phase of maternal infection. the frequency of stillbirths and viral infection in neonates is highest in animals infected late in gestation. in neonates, brain lesions are observed and virus can be recovered from the salivary glands and, to a lesser extent, from the brain, lungs, pancreas, and liver of the neonates. in some cases, lesions are detected in the salivary glands of offspring up to 14 weeks postpartum. placental infection may be detected after maternal clearance of viremia and maintained despite the presence of significant levels of gpcmv neutralizing antibody. the site of infection is localized at the transitional zone between the capillarized labyrinth and the noncapillarized interlobrium of the placenta. whenever infection of the fetus is demonstrated, the placenta is invariably infected; however, infected placentas may be associated with uninfected fetuses. the status of maternal immunity before pregnancy can favorably affect the outcome of maternal or fetal infections with virulent gpcmv strains (staczek, 1990) . clinical manifestations natural infection with gpcmv causes a latent, persistent infection in the salivary gland generally without serious disease in animals in the vivarium (staczek, 1990; van hoosier and robinette, 1976) . however, the death of a sow and fetuses (motzel and wagner, 1989) and disseminated infection, including pneumonia, in guinea pigs that were not being manipulated experimentally have been reported (van hoosier et al., 1985) . illness is more likely when associated with pre-existent immune suppression or pregnancy (percy and barthold, 2007) . transient increase in mononuclear cells is seen as well as histopathological evidence of lymphoid hyperplasia of the spleen in both the t cell and b cell zones, although no changes were noted in the cervical and mesenteric lymph nodes (dowler et al., 1984) . intranuclear inclusions in tissues have not been noted in vivo, although they are evident in tissue culture cells (dowler et al., 1984; hsiung et al., 1971a hsiung et al., , 1971b van hoosier and robinette, 1976) . virus can be recovered from the lymph nodes and spleen of infected animals well after clinicopathological signs of infection end. serologically, this virus is distinct from gpcmv and gpxv and can be differentiated from these viruses both morphologically and serologically . prevention and therapy gphlv is not a clinically important disease of guinea pigs, but could be a complicating factor in research either through interaction with other viruses or cytopathological effects on cultured cells. herpesviridae (fauquet, 2005) . it was originally isolated from leukocytes of strain 2 guinea pigs that were free of gphlv and gpcmv . in one study of 112 hartley and strain 2 guinea pigs tested serologically for gpxv, 38% were found to be positive. inoculation of gpxv into hartley guinea pigs caused viremia which persisted for at least 3 weeks . virus could be recovered 5-6 months after inoculation suggesting a persistent infection. in this study, 50% of the animals died between 6 and 11 weeks postinoculation. hepatic necrosis was the only consistent lesion seen. gpxv is both morphologically and serologically distinct from gpcmv and gphlv. prevention and therapy natural disease from gpxv is unknown, but similar to gphlv, this virus may be a complicating factor in research. background and etiology ehv1 is an equine pathogen that causes a persistent infection in horses with a variety of clinical presentations including respiratory disease, abortion, neonatal death, and neurologic disease (reed and toribio, 2004) . ehv1 is a species in the genus varicellovirus of the alphaherpesvirinae subfamily (fauquet, 2005) . other members of this genus include the type species human herpesvirus 3 (varicella-zoster virus or chickenpox) and bovine herpesvirus 1 (infectious bovine rhinotracheitis virus). one recent report describes infection with ehv1 resulting in hindlimb paralysis, ataxia, abortion, or stillbirth in 18 of 80 guinea pigs at a european zoo (wohlsein et al., 2010) . in this outbreak, thomson gazelles (equus thomsoni) kept in the same building as the guinea pigs were first affected and suffered a short course of fatal neurologic disease. the source of the virus was unclear, although a similar strain of virus was isolated 6 months earlier from affected black bears (ursus americanus) and clinically unaffected onagers (equus hemionus kulan). in the second outbreak, a similar strain of virus was also recovered from clinically unaffected zebra (equius quagga boehmi) housed in the same building as the guinea pigs and gazelles. pathology lympho-histiocytic meningoencephalitis was seen predominantly in the olfactory bulb and the frontal cortical regions of the brain with neuronal and glial necrosis, gliosis, and intranuclear inclusion bodies (wohlsein et al., 2010) . ehv1 antigen was demonstrated in the neurons, neuronal processes and glial cells by immunohistochemistry and encapsulated herpes viral particles of 120-150 nm were detected by electron microscopy. diagnosis differentiation from other members of the herpesviridae is important for diagnosis. immunohistochemistry, virus isolation, pcr, and dna sequencing were used in this report to identify the virus involved (wohlsein et al., 2010) . prevention and therapy ehv1 infection of guinea pigs is an example of the severe disease seen when members of the alphaherpesvirinae infect unusual hosts similar to human herpes virus i (herpes simplex virus) which has been shown to infect guinea pigs experimentally (wohlsein et al., 2010) and has also been reported to cause naturally acquired clinical disease in rabbits (weissenbock et al., 1997) and chinchillas (wohlsein et al., 2002) . separation of species, control of fomites, and use of appropriate personal protective equipment can be used to prevent transmission of members of the alphaherpesvirinae subfamily of viruses to aberrant hosts such as guinea pigs. there has been one report of pox-like virus particles obtained from tissue culture samples of fibrovascular proliferations involving the rear limb of half of a colony of guinea pigs (hampton et al., 1968) . particles resembling pox viruses were observed by electron microscopy. arenaviridae: lymphocytic choriomeningitis virus (lcmv) background the first identified arenavirus, lcmv, was isolated in 1933 and shown to cause aseptic meningitis in humans and was named for its ability to cause lymphocytic choriomeningitis in mice and monkeys upon intracerebral injection (amman et al., 2007; charrel and de lamballerie, 2010; percy and barthold, 2007; van hoosier and robinette, 1976) . lcmv is a rodent-borne zoonotic arenavirus endemic in housemice (mus musculus) worldwide. infection by lcmv in people is known to cause acute central nervous system disease and congenital malformations. etiology the viral genus arenavirus includes 22 viral species, the type species is lcmv (fauquet, 2005) . like other arenaviruses, lcmv is a non-cytopathic, enveloped, single-stranded rna virus. epizootiology and pathogenesis lcmv is uncommon to rare in guinea pigs (fox, 2002; percy and barthold, 2007) . in may 2005, the centers for disease control and prevention reported a cluster of lcmv infections among four solid organ recipients in rhode island and massachusetts who received organs from a single apparently asymptomatic donor (centers for disease control and prevention [cdc], 2005a) . recipients became gravely ill shortly after transplantation; three subsequently died. lcmv was identified as the etiologic agent. viral sequences from the organ recipients were identical to those from a pet hamster acquired by the donor's household 17 days before organ donation. sequence and phylogenetic data provided strong support for the presence of the same lcmv lineage in hamsters and guinea pigs in the rhode island pet store and the ohio distribution center (amman et al., 2007; cdc, 2005b) . clinical manifestations clinical signs of lcmv are uncommon in the guinea pig, however meningitis with hind limb paralysis has been reported (van hoosier and robinette, 1976) . pathology lcmv in guinea pigs results in lesions involving the brain including lymphocytic infiltrates in meninges, choroid plexus, and ependyma (percy and barthold, 2007) . lymphocytic infiltrates are also seen in the liver, adrenal, and lungs. experimentally, neutrophilic destruction of the splenic red pulp, focal bone marrow necrosis, lymphopenia, and death occur following infection with the more virulent (we) strain (djavani et al., 1998) . diagnosis diagnosis is typically by pcr, ifa, elisa, or mfia (charrel and de lamballerie, 2010; fox, iii. guinea pigs 2002; percy and barthold, 2007) . detection of viral antigen in tissue or section via immunohistochemistry is also feasible. immunity to lcmv is primarily cellular, but virus-specific antibody is produced. prevention and therapy lymphocytic choriomeningitis is a zoonotic disease of concern with rodents kept as pets (pickering et al., 2008) . human infection occurs most commonly through exposure to secretions or excretions of infected animals. in addition, lcmv can contaminate transplantable tumor or cultured cell lines from mouse, hamster, and guinea pig, and viral stocks (ilar, 1991; percy and barthold, 2007) . in mice, lcmv has been shown to limit tumor induction by polyomavirus, mouse mammary tumor virus, and transplantable guinea pig leukemia, delay tumor rejection, and alter sensitivity to endotoxins (ilar, 1991) . natural infections would be expected to interfere with research studies involving enterohepatic, lymphoid, musculoskeletal, nervous, respiratory, and urinary systems. coronavirus-like particles were found in the feces of young guinea pigs that developed wasting, anorexia, and diarrhea with low morbidity and mortality (jaax et al., 1990) . at necropsy, there were large amounts of mucoid material throughout the small intestine. histologically, the primary lesion was acute to subacute necrotizing enteritis involving the distal ileum with blunting and fusion of the affected villi, necrosis and loss of enterocytes, and mucosal syncytial cells were evident. by electron microscopy, viral particles consistent with coronavirus were demonstrated in fecal matter from affected animals. coronavirus shedding was also noted in the feces of clinically normal guinea pigs (marshall and doultree, 1996) . the virus has not been isolated. paramyxoviridae is composed of pleomorphic, enveloped, linear, negative-sense single-stranded rna viruses occurring worldwide in animals and humans, often associated with subclinical infections of the respiratory tract (fauquet, 2005; simmons et al., 2002) . the family is split into two subfamilies, paramyxovirinae and pneumovirinae (fauquet, 2005) . in guinea pigs, three distinct members of the paramyxovirinae have been described; human parainfluenza virus 3 (including human parainfluenza virus 3, cavian parainfluenza virus 3, and guinea pig parainfluenza virus 3), sendai virus, and simian virus 5 (sv5). in addition, murine pneumonia virus, a member of the pneumovirinae, has been described in guinea pigs. (fauquet, 2005) . sequence analysis of a guineapig parainfluenza virus 3 isolated in 1998 from a colony of guinea pigs in japan indicates that it has 95.6-97.9% nucleotide identity to human parainfluenza 3 virus and 71.0-79.6% to bovine parainfluenza virus 3 suggesting this virus was introduced into guinea pigs from a human with human parainfluenza virus 3 (ohsawa et al., 1998) . a novel paramyxovirus (cavian parainfluenza virus 3) was isolated in 2002 from a colony of guinea pigs (simmons et al., 2002) . this virus has 94% nucleotide identity to guinea-pig parainfluenza virus 3 and human parainfluenza virus 3 and 80% nucleotide identity to bovine parainfluenza virus 3. epizootiology and pathogenesis seroconversion in endemic parainfluenza-3-positive breeding colony was studied in 2002 (blomqvist et al., 2002) and indicated that pups become infected from 2 weeks to 8 weeks of age. the virus did not persist as sentinels exposed to 4-5-month-old seropositive animals did not seroconvert. experimental infections indicate that seroconversion in naã¯ve animals occurs approximately 10 days following infection (graziano et al., 1989) . in an infection study guinea pigs inoculated with cavian parainfluenza virus 3, sendai virus, simian virus 5 (sv-5), murine pneumonia virus, or bovine parainfluenza virus developed no clinical signs of disease or lesions during the eightweek course of the study although they developed robust homologous or heterologous serologic responses to the majority of the antigens (simmons et al., 2002) . the serologic response, using an elisa, of those inoculated with sv-5 was modest or equivocal. in addition, sv-5 elisa resulted in the highest degree of non-specific reactivity among all of the paramyxovirus assays. in one study, no clinical signs or lesions were seen when guinea pigs were infected with cavian parainfluenza virus 3 (simmons et al., 2002) . in a separate study, guinea pigs were shown to be susceptible to human parainfluenza virus 3, developing peribronchiolar and interstitial lesions (clyde, 1980) . diagnosis identification of the virus via pcr and sequencing is ideal as cross-reactive serological results make interpretation of serology difficult (simmons et al., 2002) . it is apparent that human parainfluenza virus 3 can be transmitted to guinea pigs and infection-control measures such as the use of face masks, gloves, and laminar flow hoods to prevent transmission in laboratory settings is prudent. it isn't known whether human or cavian parainfluenza virus 3 can be transmitted to humans from guinea pigs. etiology sendai virus, also known as murine parainfluenza virus, is the type species in the genus respirovirus, which also contains the species human parainfluenza virus 3, bovine parainfluenza virus 3, and human parainfluenza virus 1 (fauquet, 2005) . numerous studies have reported seropositivity to sendai virus, including a publication in 1978 which describes seropositive reactions by hi or cf in seven out of 16 colonies tested over a 13-year period in the united states (parker et al., 1978) . in addition, there is one report of isolation of sendai virus from guinea pigs associated with mice (van hoosier and robinette, 1976) , although no clinical signs were reported. more recently, five of 15 european guinea pig colonies were seropositive to either sendai virus, human parainfluenza virus 3, or both (schoondermarkvan de ven et al., 2006) . inoculation of guinea pigs with sendai virus in one report resulted in no clinical signs of disease or lesions (simmons et al., 2002) . diagnosis as with the other paramyxoviridae, lack of specificity can result in false-positive results with routine serological testing (simmons et al., 2002) . in one study, sendai elisa-positive samples were seen in guinea pigs infected with pneumonia virus of mice and bovine parainfluenzavirus 3. guinea pigs were also positive by ifat in the case of bovine parainfluenza virus 3 infection. the importance of sendai virus infections in guinea pigs is unclear. however since it is a significant disease of mice housed in laboratory animal colonies, guinea pigs should be maintained free of sendai virus. in addition, sendai virus is used as a vector in research and natural infection or sero-reactivity may interfere with such uses (baker, 1998) . sv5 is a species of the genus rubulavirus which also contains mumps virus and human parainfluenza virus 4 (fauquet, 2005) . sv5 was initially isolated from simian kidney cell cultures and has also been shown to infect guinea pig cells in vitro (zakstelskaya et al., 1976) . serological reactivity to sv5 has been reported in guinea pig colonies (kraft and meyer, 1990) . seropositve guinea pigs show no clinical signs or lesions and inoculation with sv5 results in seroconversion, but not clinical signs of disease (simmons et al., 2002) . infection of guinea pigs with sendai virus, pneumonia virus of mice, or human parainfluenza virus 3 can result in positive sv5 elisa results which were negative by indirect fluorescent antibody test, indicating low specificity of the sv5 elisa (simmons et al., 2002) . etiology pvm is a member of the genus pneumovirus, species murine pneumonia virus (fauquet, 2005) . other members of the genus pneumovirus include the human and bovine respiratory syncytial viruses. the complete genomes of two strains of this virus were sequenced in 2005 (thorpe and easton, 2005) . pvm is most often subclinical in immunocompetent mice although in immunodeficient mice, it can cause chronic wasting with cyanosis and dyspnea (percy and barthold, 2007) . seropositive reactions to pvm have been seen historically in guinea pig colonies in animals without apparent disease (van hoosier and robinette, 1976) . inoculation of guinea pigs with a strain of pvm that caused mortality in immunocompetent and immunodeficient mice resulted in no clinical signs, although the guinea pigs seroconverted within 11 days after inoculation (griffith et al., 1997) . prevention and therapy transmission of pvm from guinea pigs to mice, or vice versa, appears to be possible and similar in this regard to sendai virus. in laboratory colonies, it is important to keep guinea pigs free of pvm in order to minimize potential transmission to mice. it is unclear whether laboratory guinea pigs may harbor a poliovirus which, in 1911, was described as the cause of a disease called guinea pig lameness (hansen et al., 1997; van hoosier and robinette, 1976) . a similar disease was described by rohrer in 1958 (van hoosier and robinette, 1976) . in these investigations, sera from affected guinea pigs reacted positively to theiler's murine encephalomyelitis virus (tmev) antigens. clinical signs involved a flaccid paralysis and weight loss with an incubation period of 9-23 days, and a duration of 1-2 weeks. affected animals had meningomyeloencephalitis. more recently, two pet shop guinea pigs were reported to suffer from rear limb paresis and generalized debilitation. the guinea pigs had extremely high titers against "poliovirus", while healthy guinea pigs from the same pet shop were negative (hansen et al., 1997) . the diseased guinea pigs recovered iii. guinea pigs fully after treatment with vitamin c in the drinking water. further testing of other guinea pig colonies by the same authors demonstrated antibody responses to tmev in 35 out of 152 laboratory guinea pig sera. positive results were found in two out of six breeding centers, and in three out of three experimental units, all of which purchased guinea pigs from one of the seropositive breeding colonies. guinea pig sera from some of the breeding units were also positive serologically for other infections; adenovirus, pvm, reovirus type 3, sendai virus, sv5 and encephalitozoon cuniculi. in experimental studies of susceptibility of laboratory animals to six strains of human poliovirus, newborn guinea pigs were the only species of laboratory animals in which multiplication of any of the viruses could not be detected (koroleva et al., 1975) . naturally occurring antibodies to reovirus have been detected in laboratory guinea pig colonies by ifa, elisa, and mfia (percy and barthold, 2007; van hoosier and robinette, 1976) . no clinical signs or lesions have been described. experimentally guinea pigs have been exposed to a reovirus associated with the sars coronavirus (liang et al., 2005) . background cavian leukemia was first described in 1954 by congdon and lorenz as being caused by a retrovirus, however herpes viral inclusions have also been seen in leukemic guinea pigs (jungeblut and opler, 1967; opler, 1969; percy and barthold, 2007; van hoosier and robinette, 1976) . etiology type c retrovirus particles have been seen in cases of cavian leukemia van hoosier and robinette, 1976 ). an endogenous guinea pig retrovirus was induced by bromodeoxyuridine (michalides et al., 1975; nayak, 1974) . molecular hybridization techniques were used to show that guinea pig virus nucleotide sequences are endogenous to both domestic (cavia porcellus) and indigenous (cavia aperea) guinea pigs, but cannot be detected in the dna of other mammals tested (dahlberg et al., 1980) . in 1982, a transplantable leukemia (ksl) of unknown etiology, that had the characteristics of a b cell tumor, was found in a female sewall-wright strain 2 guinea pig. ksl leukemia was also shown to be distinct from another guinea pig lymphatic leukemia (l2c) with respect to cell morphology, antigenicity, and in vivo growth rate (key, et al., 1983) . a c-type virus was reported in the urine of diabetic guinea pigs (lee et al., 1978) . clinical manifestations clinical signs of cavian leukemia include lethargy, pale mucous membranes, secondary infections, peripheral lymph node enlargement, and death (van hoosier and robinette, 1976) . leukocyte counts may vary from 25 000-250 000, with the preponderance of cells being lymphoblastic. peripheral lymphadenopathy is generally evident. pathology enlarged lymph nodes in the cervical, axillary, mediastinal, retroperitoneal, and inguinal areas are seen in cavian leukemia with splenomegaly and hepatomegaly (van hoosier and robinette, 1976) . there is a moderate infiltration of leukemic cells in all organs including the spleen, liver, bone marrow, lung, thymus, gastrointestinal associated lymphoid tissue (galt), heart, eyes, and adrenals (opler, 1969) . treatment and control there is no described treatment. rabies has been reported in a pet guinea pig associated with a bite from a raccoon (eidson et al., 2005) . most clostridia are large, spore-forming, grampositive, anaerobic rods. the one exception is c. piliforme which is gram negative and is discussed in the section covering gram-negative organisms below. two species of clostridia are discussed here, c. difficile and c. perfringens. background severe profuse diarrhea, associated with clostridium difficile in guinea pigs treated with antibiotics, is an important and preventable disease process. etiology clostridium difficile is most commonly associated with antibiotic-induced typhilitis in guinea pigs, although other organisms including escherichia coli, clostridium perfringens, c. sordelli, c. histolyticum, and bacillus pumilis have been implicated in different studies (boot et al., 1989; brophy and knoop, 1982; knoop, 1979; lowe et al., 1980; pakes, 1981, 1982; rehg et al., 1980; . c. difficile is a common anaerobic, spore-forming, fecal-borne, gram-positive, rod-shaped organism that generally produces both an enterotoxin (toxin a) and a cytotoxin (toxin b) that are crucial in the pathogenesis of disease (greenwood, 2007) . pathogenesis normal guinea pigs may carry low resident populations of c. difficile in the intestines and toxins can be identified in normal cecal contents (boot et al., 1989) . in one study, c. difficile was recovered by culture in one out of eight normal guinea pigs and 18 out of 34 guinea pigs with typhilitis. oral or parenteral antibiotic administration, including penicillin, ampicillin, streptomycin, clindamycin, lincomycin, spiramycin, aureomycin, erythromycin, and bacitracin, have all been implicated in causing antibiotic-associated typhilitis by permitting an overgrowth of primarily gram-negative organisms including toxinproducing clostridium such as c. difficile (young et al., 1987) . the enteric flora of guinea pigs is primarily grampositive and those antibiotics that target gram-positive organisms preferentially are of greatest risk to cause this disease (farrar and kent, 1965) . one study demonstrated that in the 24-48 hours post-administration of penicillin, there was a significant increase in gram-negative anaerobic and aerobic (coliforms predominantly) bacteria bringing the levels of coliform bacteria from less than 100 organisms per gram to 10 8 -10 9 organisms per gram. this shift in the normal gut flora allows bacteria such as c. difficile, which is generally nearly undetectable, to predominate (farrar and kent, 1965; fox, 2002; percy and barthold, 2007) . other gram-negative organisms, e. coli in particular, and other clostridium spp. also can contribute to disease. clostridium difficile (toxin)-associated typhilitis has also been diagnosed in guinea pigs not treated with antibiotics that had been rederived by caesarian section and were exposed to mice as a source of anaerobic flora (boot et al., 1989) . two years after rederivation, an outbreak of typhilitis was investigated. young guinea pigs 2-4 weeks old and a few adults were affected. clostridium difficile was isolated from half of the animals tested and the cytotoxin was identified in cecal contents from 95% of the affected animals. co-infection with c. perfringens and encephalitozoon cuniculi was present. the authors speculate that the anaerobic flora that the animals were exposed to was not sufficient to protect guinea pigs from c. difficile infection. this same flora has been shown to be unsuitable for rats and rabbits. clinical manifestations generally, affected guinea pigs have weight loss, rough hair coats, anorexia, dehydration, decreased activity, and hypothermia beginning 24-48 hours after antibiotic administration (farrar and kent, 1965; fox, 2002; knoop, 1979; . some animals have no stool, while others have diarrhea and acute death has been reported. pathology at necropsy, the cecum is often gasfilled and dilated with hemorrhage evident in the cecal mucosa. histopathologically, there is usually hyperplasia of the ileal mucosa as well as ulceration, edema, and degeneration of the cecal epithelium with leukocytic infiltration. diagnosis c. difficile can be isolated from cecal contents via anaerobic culture (boot et al., 1989; greenwood, 2007) . detection of toxin in cecal contents, tissue, or feces via an enzyme immunoassay, cytotoxin activity in cell culture, serum neutralization assay, or pcr are considered the gold standard, however, false positives and false negatives are not uncommon (greenwood, 2007; houser et al., 2010; songer, 1996) . prevention and therapy antibiotic-associated diarrhea is usually treated symptomatically. in humans, administration of metronidazole or vancomycin is standard (greenwood, 2007; rupnik et al., 2009; songer, 1996) . anecdotal information suggests that administration of yogurt or other lactobacillus-containing products in conjunction with antimicrobial agents will prevent or minimize the effects of antibiotic-associated enteritis. a recent study attempted to induce antibiotic-associated enteritis by a single subcutaneous injection of clindamycin . c. difficile and other enteric pathogens were not isolated, however, several guinea pigs that received clindamycin developed enteritis. in affected animals, administration of antibiotics with the oral lactobacillus preparation did not result in any clinical improvement over those animals receiving antibiotics alone. certain pcr ribotypes of c. difficile are found in both human and animal populations, suggesting that this can be a zoonotic disease, although most of these studies are concerned with c. difficile found in food animals rather than guinea pigs (rupnik et al., 2009) . clostridium perfringens is a ubiquitous gram-positive anaerobic spore-forming bacterium that is the primary cause of enterotoxemia in domestic animals. c. perfringens strains produce a variety of toxins, as many as 17 exotoxins, although four major toxins are associated with typing of the bacteria; alpha, beta, episilon, and iota. infections typically occur via contaminated food, water, bedding, or soil and primarily affect sheep, pigs, and cattle. confirmed c. perfringens infections have been reported in germ-free guinea pigs in 1970 and, more recently, in a conventionally housed guinea pig (feldman et al., 1997; madden et al., 1970; songer, 1996) . clinical signs seen in the conventionally housed guinea pig were lethargy and anorexia. at necropsy, there were fibrinous adhesions involving the small intestine and liver (feldman et al., 1997) . the ileum and cecum had ecchymotic hemorrhages. histopathology revealed acute, multifocal, severe, necrotizing, ulcerative typhlitis and ileitis as well as focal, severe, necrotizing, centrilobular vascular thrombosis of the liver with infarction and coagulative necrosis of the adjacent hepatocyes. pcr was used iii. guinea pigs to identify the toxins of c. perfringens both in the intestine and the liver. corynebacterium etiology corynebacterium spp., members of the family corynebacteriaceae, are gram-positive, non-sporeforming, non-motile, aerobic, pleomorphic rods with coccoid or club-shaped appearance that are catalase-positive and non-acid-fast (boone et al., 2001; greenwood, 2007) . pathology corynebacterium spp. can cause disease in guinea pigs, but are also part of the normal flora. specifically, they are commonly isolated from guinea pig conjunctiva. in one study, 27 out of 30 clinically normal pet guinea pigs grew corynebacterium spp. from conjunctival cultures (coster et al., 2008) . spontaneous disease of guinea pigs associated with corynebacterial infections has rarely been reported, but have involved numerous different species of corynebacterium. in one report, corynebacterium pyogenes was isolated from a guinea pig with septicemia (ganaway, 1976) . further research with that agent demonstrated it was pathogenic when administered ip to other guinea pigs, but not if it was given orally or intranasally. in another report, c. kutscheri was isolated from the lung of a guinea pig during an epizootic of group c, beta-hemolytic streptococcal disease. further research with this isolate was similar to c. pyogenes, in that intraperitoneal administration resulted in disease while intranasal administration did not. the organism was also given intravenously in this case and was rapidly fatal. in a retrospective study of urinary bladder calculi in guinea pigs, it was reported that corynebacterium renale was the most common isolate from urine and bladder samples (hawkins et al., 2009) . of the 44 cases submitted for bacterial culture, 77% were negative. the most common pure culture isolate was c. renale, which was also commonly found in mixed infections with staphylococcus and streptococcus spp. diagnosis diagnosis is made by recovering the organism using aerobic culture conditions, generally on blood agar plates with standard biochemical tests to differentiate corynebacterium from other species (greenwood, 2007) . pcr and sequencing has been used for further identification (greenwood, 2007; hawkins et al., 2009) . prevention and therapy many corynebacterium spp. have significant resistance to a number of antibiotics and this may be true of some organisms in guinea pigs as well (greenwood, 2007) . in the study isolating c. renale from the urine and bladder wall, many of those animals were already on antibiotics when those isolates were obtained (hawkins et al., 2009 ). in addition, the corynebacterium spp. recovered from the normal conjunctiva of guinea pigs, demonstrated some bacterial resistance with six out of nine isolates resistant to oxytetracycline, four out of nine resistant to polymyxin b, two out of nine resistant to bacitracin, and one out of nine resistant to erythromycin, gentamicin, amikacin, and ciprofloxacin (coster et al., 2008) . guinea pigs are highly susceptible to m. tuberculosis. natural infection has rarely been reported in the literature, but in those cases, the sources of the infections were believed to be from contact with human cases (van hoosier and robinette, 1976) . background markham and markham (1966) studied the prevalence of staphylococcal organisms in various animal species. a 42% incidence of coagulasepositive staphylococcus was noted in the nasal passages of guinea pigs. this was the greatest incidence of staphylococcal infection of any species tested, including humans. all of the guinea pigs cultured appeared clinically normal. etiology the staphylococcus genus, members of the staphylococcaceae family, are common inhabitants of the skin, oral cavity, respiratory system, and intestine, and cause suppurative lesions and septicemia in all species (songer and post, 2005) . these gram-positive cocci are coagulase-positive, catalase-positive, oxidasenegative, non-spore-forming and facultative anaerobic organisms (harkness and wagner, 1995; songer and post, 2005) . in guinea pigs, staphylococcus aureus has been isolated from cases of ulcerative pododermatitis and exfoliative dermatitis (percy and barthold, 2007) . pathogenesis despite the existence of speciesspecific serotypes and biotypes, human staphylococcus aureus phage types have been recovered from animals, and human-animal contact is one means of transmission of s. aureus (harkness and wagner, 1995) . additionally, direct contact with an infected animal or contaminated surface, as well as spread via aerosol can result in the dissemination of infection. ulcerative pododermatitis, or dermatitis of the footpad, is also known as "bumblefoot". trauma to the footpad from fighting, a sharp cage edge, or abrasive flooring creates a site of entry for bacteria (harkness and wagner, 1995) . obese guinea pigs, as well as any other natural or experimental cause that results in a sedentary lifestyle, can predispose an animal to bumblefoot, since perfusion is decreased and the pressure on the feet is increased (brown and donnelly, 2008; harkness and wagner, 1995) . exfoliative, or acute staphylococcal, dermatitis has also been associated with s. aureus in guinea pigs. strain 13 guinea pigs are reported with this condition more frequently than other strains, and mortality rates due to this condition are higher in young animals, especially if born to an affected dam that is too painful to nurse (ishihara, 1980; percy and barthold, 2007) . clinical manifestations swollen, erythemic paws and lameness are noted with bumblefoot (brown and donnelly, 2008) . paws will often have erosions or ulcerations on the palmar or plantar surfaces. osteoarthritis or osteomyelitis may result, and animals that develop such sequela have a poorer prognosis. alopecia and erythema of the ventral abdomen, leading to cracking and scabbing of the epidermis, are often observed with exfoliative dermatitis (fox, 2002; ishihara, 1980; percy and barthold, 2007) . in addition to its association with ulcerative pododermatitis and exfoliative dermatitis, pneumonia, mastitis, conjunctivitis, cheilitis, and osteoarthritis have been attributed to s. aureus infection in guinea pigs (fox, 2002) . systemic amyloidosis can develop secondary to chronic s. aureus infection (brown and donnelly, 2008; fox, 2002; percy and barthold, 2007) . pathology hypertrophy of the stratum corneum with a minimal inflammatory response is noted histologically in cases of dermatitis associated with s. aureus (percy and barthold, 2007) . diffuse cellulitis is the primary lesion associated with ulcerative pododermatitis (brown and donnelly, 2008) . in cases that progress to amyloidosis, amyloid may be noted in the liver, spleen, adrenal glands, and pancreatic islets (ganaway, 1976) . diagnosis stained impression smears of lesions can demonstrate clumps of gram-positive cocci (harkness and wagner, 1995) . s. aureus can often be cultured directly from affected tissues and from the upper respiratory tract and pharynx of affected animals (percy and barthold, 2007) . blood agar or selective mediums, such as mannitol salt or staph 110 agar, can be used for primary culture (songer and post, 2005) . s. aureus colonies often present with a golden pigmentation. prevention and therapy prevention of ulcerative pododermatitis and exfoliative dermatitis is easier than treatment. preventing cutaneous wounds by providing sturdy, smooth flooring to guinea pigs, offering non-abrasive feedstuff, and preventing obesity are highly effective in minimizing infection with s. aureus. pododermatitis and exfoliative dermatitis are not usually conditions conducive to lesion drainage and surgical removal (brown and donnelly, 2008) . lesions can be cleaned, but the possibility of causing greater trauma to the affected area must be considered. also, disinfectants that dry out the skin or agents that are cytotoxic to fibroblasts and reduce white blood cell viability and phagocytic efficiency, such as povidone-iodine or chlorhexidine, should be avoided. long-term antibiotic treatment is necessary, and enrofloxaxin or ciprofloxacin administered twice a day for 2-6 months has been reported in the treatment of ulcerative pododermatitis. use of an analgesic agent, especially a non-steroidal antiinflammatory drug such as meloxicam, is also recommended. low-level laser therapy, or phototherapy, has been reported as successful in treating bumblefoot by accelerating angiogenesis and stimulating vasodilatation, although such therapy can only be used after the infection is first controlled. two strains of streptococcus cause disease in guinea pigs. streptococcus pneumoniae can lead to severe pneumonia and streptococcus equi subsp. zooepidemicus is associated with the development of chronic lymphadenitis . infections due to s. equi subsp. zooepidemicus are more prevalent in guinea pigs than are pneumococcal infections. members of the streptococcus genus are part of the streptococcaceae family and consist of gram-positive, catalase-negative, facultative anaerobic bacteria that are non-spore-forming and non-motile (songer and post, 2005) . background streptococcus pneumoniae was first recognized in guinea pigs in europe in the late 1800s . homberger et al. (1945) are credited with the first report of this organism in guinea pigs in the united states; the animals were from a colony in massachusetts and presented with signs of respiratory infection. etiology streptococcus pneumoniae is an oval-to lancet-shaped, encapsulated coccus that presents in pairs (diplococcus) or short chains (fox, 2002; percy and barthold, 2007) . s. pneumoniae is an î±-hemolytic streptococcus that ferments trehalose and is optochin-sensitive (harkness and wagner, 1995; keyhani and naghshineh, 1974; songer and post, 2005) . additionally, it is not categorized according to one of the lancefield groupings (songer and post, 2005) . serovars of pneumococci are differentiated according to their capsular polysaccharide content, and serovars 4 and 19 are the two most often recovered from guinea pigs (fox, 2002; percy and barthold, 2007) . asymptomatic guinea pigs can carry pneumococci in the upper respiratory passages; the carrier rate for laboratory colonies can be as high as 50-55% (fox, 2002; percy and barthold, 2007) . while iii. guinea pigs pneumonia epidemics due to s. pneumoniae seldom occur in well-managed facilities, stressors which may predispose to infection include poor husbandry, pregnancy, sudden or prolonged changes in temperature, poor ventilation, shipping, inadequate nutrition, concurrent infections, and experimental procedures (nakagawa et al., 1986; percy and barthold, 2007) . transmission of s. pneumoniae is by aerosol or via direct contact with abraided skin or oral mucosa (fox, 2002; percy and barthold, 2007; wagner et al., 1976) . infection can also be passed at the time of parturition by an infected dam. abortions and stillbirths can accompany a high mortality rate during an epizootic outbreak in a guinea pig colony (percy and barthold, 2007) . in 1974, a spontaneous epizootic of respiratory infection involving 2400 guinea pigs was caused by s. pneumoniae type 19 (keyhani and naghshineh, 1974) . during this outbreak, 450 guinea pigs died within 33 days of infection, and a short course of listlessness and failure to thrive were the only noted clinical signs prior to death. in less acute cases of s. pneumoniae, guinea pigs display depression and lethargy, anorexia, and have ruffled fur. they may have a wet nose, nasal or ocular discharge (rhinitis, conjunctivitis), sneezing, coughing, dyspnea, or torticollis (head tilt due to otitis media) (fox, 2002; wagner et al., 1976) . wagner, owens, kusewitt, and corley reported that otitis media occurred in 177 of 1373 guinea pigs necropsied during a 6-year period in the 1970s . streptococcus pneumoniae was noted in 20% of these cases, and was the most common bacteria isolated. gupta et al. (1970) , reported mastitis caused by s. pneumoniae in two guinea pigs. pathology acute bronchopneumonia is most often associated with s. pneumoniae infections. fibrinous exudate, a polymorphonuclear cell infiltrate and thrombosis of the pulmonary vessels may be observed in the lung (fox, 2002; keyhani and naghshineh, 1974; percy and barthold, 2007) . other pyogenic processes noted in infected animals include pericarditis, peritonitis, otitis media, arthritis, endometritis, and suppurative meningitis (fox, 2002; percy and barthold, 2007) . additionally, splenitis, fibrinopurulent meningitis, metritis, and lymphadenitis with focal hepatic and ovarian abscessation have been reported (percy and barthold, 2007) . pneumococci are readily demonstrated on impression smears and in stained tissue sections . diagnosis culture of nasal washings is an antemortem means of diagnosing s. pneumoniae (homburger et al., 1945) , as is culture of the nasal passages (harkness and wagner, 1995) . post-mortem, direct smears and culture of inflammatory exudates can be performed. s. pneumoniae is a fastidious bacterium that grows best when incubated under 5-10% co 2 on blood agar or enrichment media (fox, 2002; percy and barthold, 2007) . serological diagnosis via elisa has been reported (matsubara et al., 1988) . prevention and therapy antibiotic treatment of a clinical animal usually results in reversion to a sub-clinical carrier state, so elimination of clinical animals is recommended whenever possible (fox, 2002) . chloramphenicol, trimethoprim-sulfa combinations, and tetracycline have been used during epizootic outbreaks (harkness and wagner, 1995; homburger et al., 1945; keyhani and naghshineh, 1974) . prevention should focus on good husbandry, adequate diet, early isolation of streptococcal carrier animals, and reduction of environmental stressors. the same s. pneumoniae serovars commonly detected in guinea pigs have been isolated from humans (songer and post, 2005) . s. pneumoniae can lead to respiratory and neurological disease in humans, especially in older and immune-compromised individuals. to date, interspecies transmission of s. pneumonia has not been reported (harkness and wagner, 1995; percy and barthold, 2007) . charles boxmeyer (1907) described his findings of epizootic lymphadentitis in over 3000 guinea pigs in 1907. cunningham (1929) reported on 20 guinea pigs from a colony of 150 that had "lumps," and from which "the same unusual type of mucoid hemolytic streptococcus was isolated". cunningham noted a 3:1 female to male ratio among the animals with chronic lymphadenitis. etiology streptococcus equi. subsp. zooepidemicus is a lancefield group c streptococcus that is betahemolytic, encapsulated, and ferments sorbitol (percy and barthold, 2007; songer and post, 2005) . s. equi subsp. zooepidemicus has a high degree of dna homology with s. equi subsp. equi. s. equi subsp. zooepidemicus has been recovered from human infections, while s. equi subsp. equi has not (songer and post, 2005) . pathogenesis guinea pigs can carry s. equi subsp. zooepidemicus asymptomatically in the nasopharynx and conjunctiva (percy and barthold, 2007) , but compared to s. pneumonia, clinical disease is more often noted in guinea pigs infected with s. equi subsp. zooepidemicus. as noted by cunningham, females are indeed more susceptible to disease than males (cunningham, 1929; fox, 2002; percy and barthold, 2007) . strain 2 guinea pigs also appear to be more sensitive than other strains (fox, 2002; percy and barthold, 2007; wagner et al., 1976) . transmission is via aerosol, as well as direct contact with abraded skin or oral mucosa (harkness and wagnerl 1995; fox, 2002; percy and barthold, 2007) . the organism can be transmitted via bite wounds and secondary to abrasion by rough foodstuff (ganaway, 1976) . while this is likely the route of entry for most natural infections, murphy et al. (1991) showed that the oral mucosa does not need to be abraded in order for entry of the bacterium. the female genital tract can be infected during farrowing (percy and barthold, 2007) . after initial entrance, the organism travels to the draining lymph node and replicates (harkness and wagner, 1995) . cervical lymphadenitis is commonly noted in guinea pigs when the point of entry for infection is via the conjunctiva or nasal mucosa (harkness and wagner, 1995) . clinical manifestations clinical disease associated with s. equi subsp. zooepidemicus is colloquially referred to as "lumps," due to the pyogenic nature of the bacteria and its propensity to travel to and replicate in the lymph nodes (fox, 2002; percy and barthold, 2007) . while the cerival lymph nodes are the most common site of s. equi subsp. zooepidemicus replication and abscessation, any lymph node, and practically any organ, can be affected (harkness and wagner, 1995) . a common presentation for infection with this organism is an animal that appears in good condition except for a swelling in the neck at the position of the cervical lymph node (fox, 2002) . the swelling is often soft to firm, pus-filled, non-fluctuant and freely moveable (percy and barthold, 2007) . cunningham's (1929) observations were that "in some cases, one or two nodes were greatly enlarged; in others, as in one animal with cervical node involvement, several plum-sized encapsulated abscesses formed a collar across the front and side of the neck". depending on what additional organs are affected, torticollis (if middle ear involvement), dyspnea and cyanosis or nasal and ocular discharge (if respiratory involvement), or hematuria and hemoglobinuria (if septic) may be noted (fox, 2002; harkness and wagner, 1995) . abortions, stillbirths and unexpected deaths are possible (fox, 2002) . during epizootic outbreaks, septicemia, acute pneumonia, and high mortality can occur (harkness and wagner, 1995) . pathology the most common finding at necropsy is that of an abscessed, encapsulated cervical lymph node (fox, 2002) . the node architecture is often destroyed by central necrosis and peripheral fibrosis, and a thick pustular exudate is present (cunningham, 1929; fox, 2002; percy and barthold, 2007) . smears of the exudate reveal numerous gram-positive cocci in short chains (cunningham, 1929) . a generalized lymphadenitis may be noted, as may retroorbital abcessation, otitis media, pneumonia, pleuritis, pericarditis, or hepatitis (cunningham, 1929; fox, 2002; percy and barthold, 2007) . diagnosis s. equi subsp. zooepidemicus can be cultured from affected tissues or heart blood (harkness and wagner, 1995; percy and barthold, 2007; quesenberry and carpenter, 2004; wagner et al., 1976) . culture requires blood agar, on which after 24 hours, a clear zone of hemolysis is observed (harkness and wagner, 1995) . trimming of teeth, elimination of sharp edges to feeders, and feeding nonabrasive feed may assist in prevention of s. equi subsp. zooepidemicus infection (fox, 2002) . infected animals should be isolated from the colony. surgical removal of abscess contents and capsule can be done with creation of drainage and lavage. antibiotic therapy is required. in epizootic cases, depopulation of affected animals and disinfection of the environment is advised. enzootic disease represents significant potential for research complications. disease-free replacement stock should be obtained and is available from commercial vendors. vaccines are typically type-specific and do not provide reliable protection (fox, 2002; mayora et al., 1978) . actinobacillus actinobacillus lignieresii and actinobacillus equuli have been noted in laboratory guinea pigs (songer and post, 2005) . the genus actinobacillus is a member of the pasteurellaceae family (boone et al., 2001) . these organisms are pleomorphic gram-negative rods that on gram stain, can have a "morse code" appearance (songer and post, 2005) . actinobacillus lignieresii and actinobacillus equuli were cultured from 36 guinea pigs, rats and mice during a 6-month period at the university of missouri research animal diagnostic and investigative laboratory (lentsch and wagner, 1980) . organisms grew on blood agar inoculated with swabs from the posterior nasopharynx, conjunctiva, and middle ear. conjunctivitis was noted in one animal and otitis media was noted in six. background tartakowsky is credited with one of the first accounts of bordetella infection in guinea pigs in the late 1880s (mccartney and olitsky, 1923; smith, 1913) . woolfrey and moody (1991) in their review of this organism stated "ferry, using the name bacillus bronchisepticus; mcgowan, using the term bacillus bronchicanis; and torrey and rahe, using ferry's epithet, independently observed the association of a small gram-negative coccobacillus with outbreaks of "canine distemper" and respiratory tract illness in laboratory animals such as the cat, rabbit, and guinea pig". in the early 1970s, b. bronchiseptica was still considered to be the primary cause of acute pneumonia in guinea pigs and while it is not often noted in modern laboratory facilities, it continues to be a major cause of respiratory disease in pet guinea pigs and this species is thought to be quite susceptible to infection (percy and barthold, 2007; rigby, 1976) . etiology bordetella bronchiseptica is a short, gramnegative rod or coccobacillus, that is aerobic, motile, and non-spore-forming (fox, 2002; percy and barthold, 2007) . b. bronchiseptica is oxidase, catalase, and urease positive, as well as positive for citrate utilization and nitrate reduction (songer and post, 2005; woolfrey and moody, 1991) . b. bronchiseptica is considered a commensal organism in the guinea pig, as well as many other mammalian species, including humans (fox, 2002; percy and barthold, 2007; woolfrey and moody, 1991) . the bordetella genus is a member of the alcaligenaceae family (songer and post, 2005) . epizootiology and pathogenesis b. bronchiseptica is carried by guinea pigs in the nasal cavity and trachea, and up to 20% of non-clinical animals in a colony can be carriers (ganaway, 1976) . stressful events, such as transport or pregnancy, may trigger an acute fatal pneumonia in carriers or animals with previously inapparent infections. transmission of b. bronchiseptica is via aerosol spread, direct contact, direct contact with respiratory secretions of infected animals, or fomites (fox, 2002; ganaway, 1976) . b. bronchiseptica adheres to ciliated respiratory epithelium and causes ciliary paralysis (fox, 2002) . pathogenic b. bronchiseptica produce adhesion and cytolytic toxins that lead to an inflammatory response, antiphagocytic activity, and dermo necrosis. while not explicitly described in the guinea pig, the impairment in mucociliary clearance caused by the binding of bordetella is known to reduce the clearance of additional respiratory pathogens in other animal species. the incubation period is 5-7 days (ganaway, 1976) . the highest levels of morbidity and mortality due to b. bronchiseptica have been noted in young guinea pigs, as well as strain 2 animals (fox, 2002; ganaway, 1976) . it is possible for infected animals to develop immunity and clear the organism. yoda et al. (1972) , noted that within 6-54 weeks of initial infection, 69 of 79 naturally infected guinea pigs completely recovered from infection. clinical manifestations infection with b. bronchiseptica is often subclinical in nature (fox, 2002) . it has been suggested that the clinical signs associated with bordetella in the past have actually been due to infections with a secondary invader, such as guinea pig adenovirus, which has not been recognized as an infectious agent of the guinea pig for as long as b. bronchiseptica. during an epizootic outbreak, death may follow respiratory disease and septicemica within a 24-72-hour period (fox, 2002) . abortion and stillbirths can occur in pregnant dams (percy and barthold, 2007) . in an enzootically infected colony, sporadic deaths may occur throughout the year, with highest levels during the winter months. inappetance, depression, nasal discharge, dyspnea, and cyanosis may also be observed (fox, 2002) . pathology at necropsy, cranioventral pulmonary consolidation is seen, and whole lobes or individual lobules will present as dark red to red-gray in color (ganaway, 1976; percy and barthold, 2007) . a bloodtinged froth is noted in the trachea. mucopurulent exudates may be noted in affected airways. pleuritis and otitis media may be observed. suppurative bronchopneumonia is noted histologically, with an influx of heterophils and mononuclear cells. uterine infections may result in dead fetuses or pyosalpinx. diagnosis b. bronchiseptica can be cultured on blood or macconkey's agar from nasal or other respiratory secretions (songer and post, 2005) . in cases of otitis media, b. bronchiseptica can be isolated from the middle ear, and in cases of metritis, from the uterus (fox, 2002; yoda et al., 1972) at 35-37â°c (songer and post, 2005) . smith and baskerville medium selects for b. bronchiseptica, and is another option for culture (songer and post, 2005) . elisa and ifa tests have been developed for the detection of guinea pig bordetella, and have been noted as equally successful in identifying infected animals as cultures of the respiratory tract (boot et al., 1993a; wullenweber and boot, 1994) . purchasing bordetellafree animals is the best means of control in laboratory colonies of guinea pigs. it is recommended that rabbits and guinea pigs not be co-housed since guinea pigs are highly susceptible to disease and rabbits are frequently sub-clinical carriers of b. bronchiseptica (charles river laboratories, 2011) . rats and other rodents can be additional sources of infection (rigby, 1976) . antibiotic treatment with fluroquinolones or trimethoprimsulfonamides may successfully resolve clinical signs, but elimination of infection is rare, with animals often reverting to the sub-clinical state. if infection is suspected in a colony, restocking, test and cull, or rederivation may be more beneficial than treatment (fox, 2002) . the efficacy of canine, porcine, human, and autogenous bordetella vaccines and bacterins has been evaluated by several individuals; reports suggest that these vaccines do not completely protect guinea pigs from infection, but a decrease in the incidence and severity of clinical disease has been noted in experimentally challenged animals (matherne et al., 1987; stephenson et al., 1989) . b. bronchiseptica apparently does not cause epidemic disease in man, but it can cause a whooping cough-like syndrome in immune-competent children or respiratory tract infections in immune-suppressed individuals (songer and post, 2005) . endocarditis, meningitis, and peritonitis have also been associated with b. bronchiseptica infections in humans. the ease of transmission between guinea pigs and humans in unknown. background and etiology spirochetes of the genus brachyspira (formerly serpulina) have been associated with diarrhea and colitis in a variety of animals including birds and mammals. brachyspira contains seven distinct species. of these, two species have been implicated in guinea pigs, either in natural infections or as an animal model; b. hyodysenteriae, the primary cause of swine dysentery, and b. pilosicoli, a zoonotic agent associated with disease in chickens, pigs, and humans. spirochetes have been associated with disease in guinea pigs in several publications, although purposeful infection to demonstrate causality has not been done and in many cases, identification of the species involved has also not been accomplished (duhamel, 2001) . guinea pigs have been used as an animal model for b. hyodysenteriae infection. two reports in the 1970s describing tyzzer's disease in guinea pigs also report observing spirochetes on histopathology (mcleod et al., 1977; zwicker et al., 1978) . the significance of the spirochete infections in the progression of the disease seen is unclear. a subsequent report describes a series of cases submitted for necropsy between 1992 and 1996 in belgium (vanrobaeys et al., 1998) . in 29 of 33 cases when spirochetes were identified, the presenting complaints were either sudden death or a short course of diarrhea followed by sudden death. flagellated parasites were seen in 12 animals and lesions consistent with vitamin c deficiency in six cases. gross necropsy of affected animals most commonly demonstrated liquid, occasionally mucoid or hemorrhagic large intestinal contents, and dilation of the cecum and colon. histologically, the cecum was characterized by hyperemia, mucosal infiltration of neutrophils, a mixed inflammatory infiltrate in the lamina propria, and occasionally, necrosis of crypt epithelium. lesions involving other organs were present in 30 of the 37 animals identified, suggesting multifactorial disease processes. in a report of a single pet guinea pig, clinical signs of tenesmus, tachycardia, pale mucous membranes, and dehydration were associated with acute rectal prolapse (helie et al., 2000) . histopathology identified superficial mucosal necrosis and ulceration and congestion with hemorrhage in the intussuscepted segment. although spirochetes and organisms consistent with eimeria spp. were seen in the rest of the intestinal tract, no other lesions were noted. b. pilosicoli was identified by pcr. diagnosis diagnosis can be made by identifying typical organisms on histopathology. pcr of intestinal contents is diagnostic (helie et al., 2000) . prevention and therapy treatment with ranidazole stopped the spread of the disease in some cases as described by vanrobaeys et al. (1998) , although cessation of treatment resulted in resumption of disease. as the majority of reports describe co-pathogens, controlling copathogens may be the most effective prevention. brucella spp. are zoonotic, gram-negative, strictly aerobic, intracellular, non-motile coccobacilli, which infect a variety of species, including guinea pigs (martirosyan et al., 2011; pappas, 2010; van hoosier and robinette, 1976) . natural infections in guinea pigs have been described likely associated with contaminated food, bedding, or other biological materials (van hoosier and robinette, 1976) . in these outbreaks, guinea pigs developed disease similar to that seen in other species including testicular and joint swelling as well as abscesses in the liver and pancreas. modern husbandry practices should limit transmission of brucella spp. to guinea pigs. campylobacter jejuni is a species of curved, rod-shaped, non-spore-forming, gram-negative, microaerophilic, bacteria that naturally colonize the digestive track of birds and numerous other species, including domestic farm animals, dogs, cats, various wildlife, and rodents (horrocks et al., 2009 ). it is a common cause of human gastroenteritis worldwide primarily from contamination of food. it was isolated from laboratory animal guinea pigs in one report where the prevalence of c. jejuni in a multispecies laboratory animal facility was investigated (meanger and marshall, 1989) . in this report, no clinical signs were seen in any of the animals involved and pathological analysis was not done. guinea pigs have been used as an animal model of c. jejuni infection (burrough et al., 2009; coid et al., 1987) . background and etiology guinea pig inclusion conjunctivitis was first described in 1964 associated with an experiment to examine the correlation between vitamin deficiency and the development of trachoma virus (murray, 1964) . the organism was identified as a type of chlamydia psittaci, a member of the psittacosis-lymphogranuloma-trachoma group, first thought to be protozoa, then viruses because they could pass through a 450-nm filter, and finally in 1966 recognized as bacteria (longbottom and coulter, 2003; moulder, 1966; songer and post, 2005) . as members of the family chlamydiaceae, they are iii. guinea pigs gram-negative, obligate intracellular pathogens that infect a variety of animals, including amoeba, birds, sheep, humans, and guinea pigs (greenwood, 2007) . recently they have been divided into two genera: chlamydia and chlamydophila. chlamydophila species include c. caviae as well as c. pneumoniae (humans, horses, koalas) and c. psittaci (birds) (everett et al., 1999; murray, 1964) . unlike most bacteria, the cell walls of chlamydiaceae do not have a peptidoglycan layer, but they do have a major outer-membrane protein, which is the determinant for serologic classification (greenwood, 2007; songer and post, 2005) . they also have a unique life cycle which consists of two forms; a small infectious elementary body which is more similar to a spore in that it is environmentally resistant and not metabolically active and a larger metabolically active, non-infectious reticulate body that is responsible for division within the host cell. epizootiology and pathogenesis generally, c. caviae infection is thought to be endemic in guinea pig colonies (percy and barthold, 2007) , although its detection in colonies has been variable. in a survey done in 1964 of five herds of guinea pigs, conjunctival staining revealed the organism in four out of five herds, although not in any guinea pigs less than 4 weeks of age (murray, 1964) . in 2006, two breeding facilities of conventional guinea pigs in korea were examined by conjunctival staining and no positive organisms were seen (park et al., 2006) . a survey of pet guinea pigs with normal conjunctiva, also revealed no positive staining (coster et al., 2008) , which may reflect the sensitivity of the test used or the actual prevalence of c. caviae. in a study using real-time pcr for diagnosis, c. caviae was detected in 12 out of 12 guinea pigs tested, four out of four rabbits, and one dog from samples obtained from a diagnostic laboratory (pantchev et al., 2010) . c. caviae in a second report was identified via pcr from conjunctival swabs from a rabbit, cat, and human that lived in the same household as infected guinea pigs (lutz-wohlgroth et al., 2006) . also utilizing pcr and dna sequencing, c. caviae was detected in foals with conjunctivitis, rhinitis, and coughing, indicating the host range of the species of chlamydiaceae may continue to be refined as new diagnostic tests are utilized (gaede et al., 2010) . one study identified acanthamoebae spp. via pcr from two guinea pigs with conjunctivitis that were also pcr positive for c. caviae (lutz-wohlgroth et al., 2006) . their role in the disease process is unclear. urogenital disease has been reported in natural infections with c. caviae and has been reproduced in experimental models (lutz-wohlgroth et al., 2006; mount et al., 1973) . in experimental infections, inoculation with c. caviae in the lower genital tract of female guinea pigs causes a self-limiting infection lasting 3-4 weeks. typically, the infection involves the epithelium of the cervix with very little inflammation. however, in 80% of the animals, the infection progresses to involve the oviducts, with half of the animals developing pathologic changes in the oviducts including inflammation and fibrosis rank and sanders, 1992) . infection can be transferred from infected male animals to females during sexual intercourse and vertically from dam to pups (padilla-carlin et al., 2008; miyairi et al., 2010) . in experimental infections, both cell-mediated and humoral immunity are important in recovery and resistance to re-infection (miyairi et al., 2010) . early infection is characterized by influx of polymorphonuclear cells while later in infection, lymphocytes predominate. t-cell depletion results in chronic infection and delayed clearance of the organisms. decreased antibody response also correlates with delayed clearance of the organisms (miyairi et al., 2010; rank et al., 1979) . clinical manifestations c. caviae has been primarily associated with conjunctivitis. guinea pigs have reddened, swollen conjunctiva with serous to purulent discharge, follicular hypertrophy, and pannus (deeb et al., 1989; lutz-wohlgroth et al., 2006; murray, 1964; padilla-carlin et al., 2008; strik et al., 2005) . generally the conjunctivitis resolves in 3-4 weeks. occasionally, conjunctivitis is accompanied by rhinitis. in one study, nasal discharge was present in 31 of 39 of the animals with ocular discharge (lutz-wohlgroth et al., 2006) . vaginal discharge was seen in 25% (ten of 39) of the animals although the organism could not be recovered by pcr from either the nose or the vagina. abortion was recorded in two animals. an early study also reported rhinitis, bronchopneumonia and abortions, although this study was complicated by infection with streptococcus pneumonia and bordetella bronchiseptica (schmeer et al., 1985) . pathology histological evaluation of the eyes and surrounding tissue reveals a mixed inflammatory response and congestion beneath the conjunctival epithelium (deeb et al., 1989; lutz-wohlgroth et al., 2006) . histological examination of the urogenital tract has primarily been described following experimental infection and consists of inflammation of the endometrium, mesosalpinx, and oviduct with a mixed inflammatory infiltrate and fibrosis rank and sanders, 1992) . diagnosis diagnosis is by cytology, pcr, culture, tissue assays, and serology (songer and post, 2005) . giemsa, gimenez, or macchiavello stains on cytologic preparations reveal inclusions in the cytoplasm. inclusions are a dark purple with giemsa and red with gimenez or macchiavello stains. cytology can be insensitive hence pcr can be used in addition (pantchev et al., 2010; strik et al., 2005) . in one study, 31 samples were tested via cytology and pcr (lutz-wohlgroth et al., 2006) . twenty-one were positive by pcr for c. caviae, however, no samples were positive by cytology. as c. caviae is an obligate intracellular pathogen, it cannot be cultured in cell-free media, but only on specific cell lines (songer and post, 2005) . this is an insensitive and difficult process that is not typically used for diagnosis. direct fluorescent antibody test and enzyme immunoassays can be used to detect antigens in cytology samples or tissues (percy and barthold, 2007; songer and post, 2005) . prevention and therapy generally, the disease is self-limiting and treatment is not required (percy and barthold, 2007; quesenberry and carpenter 2004) . no current vaccine prevents chlamydial infection, although vaccination studies have demonstrated a decrease in the intensity of the disease following vaccination (padilla-carlin et al., 2008) . recognition that zoonotic transmission is a possibility should guide appropriate personal protective equipment choices (lutz-wohlgroth et al., 2006) . citrobacter is a genus of gram-negative coliform bacteria of the family enterobacteriacae (boone et al., 2001) . in the 1960s and 1970s, a disease eventually named transmissible murine colonic hyperplasia caused by coliform bacteria of the genus citrobacter was recognized (mundy et al., 2005; percy and barthold, 2007; petty et al., 2010) . originally described as unusual biotypes of citrobacter freundii, these organisms were eventually separated into their own species, citrobacter rodentium, on the basis of dna sequencing studies (luperchio et al., 2000; petty et al., 2010) . whether the organisms that caused severe septicemia and death in guinea pigs in 1988 (ocholi et al., 1988) and other disease syndromes in hysterectomy-rederived guinea pigs (boot and walvoort, 1986) are c. freundii as originally indicated or c. rodentium is unclear. pathology there are two reports of disease associated with citrobacter spp. in guinea pigs (boot and walvoort, 1986; ocholi et al., 1988) . first, citrobacter spp. were isolated from germ-free guinea pigs that were exposed to defined flora from gnotobiotic mice (boot and walvoort, 1986) . citrobacter spp. were isolated from the middle ear, spleen, mammary gland, and kidney of some animals as well as the intestinal tract, suggesting an ability to cause varied disease in guinea pigs that are not populated with normal flora. second, an epizootic of citrobacter spp. septicemia in a large colony of conventional guinea pigs was reported (ocholi et al., 1988) . animals presented with diarrhea, dyspnea, and decreased appetite. mortality in weanlings and breeders was 115 of 1300 animals. gross necropsy revealed lung consolidation with pleural adhesions as well as enteritis and thickening of the intestinal wall. fibrinous pneumonia and septic thrombi in the capillaries of the lung, liver, and spleen were seen histopathologically. citrobacter spp. were consistently isolated in pure culture from the lung, liver, spleen, and intestine. diagnosis culture is the traditional method of detecting citrobacter spp. which grow well on normal media, are aerobic or facultative anaerobic, ferment glucose, produce catalase, but not oxidase, and are generally lactose-negative or later lactose-fermenting (greenwood, 2007) . however, pcr is more sensitive than bacterial culture for detection of c. rodentium in feces from mice (mckeel et al., 2002) . prevention and therapy c. freundii strains utilize a number of methods to encode resistance to ampicillin and cephalosporins (pfeifer et al., 2010) . enrofloxacin has been successful in treating mice infected with c. rodentium (maggio-price et al., 1998) . prevention would include eliminating contact with c. rodentium-infected mice and other rodents. clostridium piliforme (tyzzer's disease) background clostridium piliforme, first described in 1917 (tyzzer, 1917) , causes severe disease in many laboratory animals as well as other mammals (percy and barthold, 2007) . although rare in modern colonies, outbreaks in mice, rats, rabbits, and guinea pigs have been reported and c. piliforme is found in both wild (wobeser et al., 2009 ) and domestic mammals (borchers et al., 2006; ikegami et al., 1999) . while tyzzer's disease is not generally considered zoonotic, infection of an hivpositive patient has been reported (smith et al., 1996) . etiology clostridium piliforme (formerly bacillus piliformis) is a gram-negative, spore-forming, anaerobic rod that can survive for as long as five years in the environment (percy and barthold, 2007; songer and post, 2005) . pathogenesis c. piliforme is thought to be transmitted via fecal-oral transmission. in experimental models, oral inoculation was successful when other routes of inoculation did not result in disease (waggie et al., 1987) . vertical transmission has been reported in one case of hysterectomy-rederived guinea pigs (boot and walvoort, 1984) . in outbreaks of tyzzer's disease in other species, usually predisposing factors such as stress, overcrowding, poor sanitation, or immunemodulating treatments contribute to the development of disease (percy and barthold, 2007 (boot and walvoort, 1984; mcleod et al., 1977; zwicker et al., 1978) typically seen in weanlings. subclinical infections have been noted (boot and walvoort, 1984) . pathology lesions are usually found only in the gastrointestinal tract in young guinea pigs, although liver lesions have been reported in some animals (sparrow, 1978; waggie et al., 1987) . grossly, pinpoint gray foci occur on the ileum, cecum, and colon as well as enlarged, reddened mesenteric and colonic lymph nodes (mcleod et al., 1977; sparrow, 1978; waggie et al., 1987; zwicker et al., 1978) . white to tan pinpoint foci are also observed on the liver. microscopically, foci of necrosis occur in the mucosa of the ileum, cecum, and colon as well as foci of periportal coagulative hepatocellular necrosis when the liver is involved. clusters of intracellular organisms can be observed via silver stain or giemsa stain in affected enterocytes and hepatocytes. in two reports, affected animals have also had large numbers of spirochetes evident at necropsy (mcleod et al., 1977; zwicker et al., 1978) . diagnosis c. piliforme cannot be cultured using standard media, although it can be isolated by inoculation of cell lines, embryonated hen's eggs, and primary mouse or chick embryo cell cultures (niepceron and licoism, 2010; percy and barthold, 2007) . therefore, diagnosis typically relies on characteristic lesions and organisms observed on histopathology using a warthin-starry silver stain or giemsa stain (percy and barthold, 2007) . pcr has been used to detect c. piliforme in feces from rats (furukawa et al., 2002) . nested pcr was developed to increase the specificity of detection in tissues, better separating c. piliforme from other closely related organisms used conserved regions of 16s ribosomal rna (niepceron and licois, 2010). serology to detect antibodies has been used to monitor colonies for this organism (boot and walvoort, 1984; kraft and meyer, 1990) . treatment and control treatment of individual animals has not been reported. tyzzer's disease affects a wide variety of animals and immune-compromised people. prevention entails modern husbandry and sanitation practices, preventing contamination of food and bedding, and separation of species. escherichia coli are aerobic, straight gram-negative rods and are part of the normal intestinal flora of most vertebrates, including guinea pigs (crecelius and rettger, 1943; songer and post, 2005) . several pathotypes have been reported (e.g. epec-enteropathogenic strains), some which produce cytotoxins. diarrhea, rough hair coats, wasting and death have been reported to be associated with e. coli infection in conjunction with other environmental stressors (ganaway, 1976) . in addition, there is one report of a compilation of cases of mastitis in guinea pigs from a diagnostic lab over a four year period (kinkler et al., 1976) . of the 26 cases where cultures were taken, e. coli was found in 17 cases with the next most common isolate being klebsiella pneumonia in six cases. diagnosis may be obtained by culture of affected organs on macconkey agar and differentiation from other enteric gram-negative bacteria by a number of biochemical reactions such as indole production and utilization of certain sugars (greenwood, 2007) . background perkins (1901) described an epizootic outbreak in 25 laboratory guinea pigs that resulted in the death of all but two animals 18-24 hours after the onset of disease. a short bacillus, often paired, was isolated in the blood, spleen, liver, and peritoneal exudates. disease was reproduced in naã¯ve guinea pigs subsequently administered the bacterium by the intraperitoneal route. perkins' findings were similar to those of howard (1899), who inoculated dogs, rabbits, mice, pigeons, and guinea pigs with a bacillus organism isolated from human patients. etiology klebsiella pneumoniae is a gram-negative, rod-shaped bacillus from the genus klebsiella and family enterobacteriaceae (boone et al., 2001) . k. pneumoniae is facultatively anaerobic, oxidase-negative, and produces acid and gas from lactose. it is an enteric bacterium, noted in the intestinal tract of 5% of healthy humans (ganaway, 1976) . it can also reside in the skin and mouth. k. pneumoniae causes pneumonia in guinea pigs of both sexes and all ages, although there are few reports of natural infections of this animal species with this organism. clinical manifestations in the epizoonotic outbreak described by perkins, animals presented as anorexic and ungroomed, and their illness escalated in severity until, in some animals, a comatose condition ensued (perkins, 1901) . animals usually died 18-24 hours after the onset of clinical signs. in other epizootic outbreaks, dyspnea has been reported prior to reaching the comatose state (ganaway, 1976) . less severely infected animals may be able to recover from disease and develop immunity to re-infection (perkins, 1901) . otitis media and other signs consistent with a state of septicemia have been associated with clinical disease (fox, 2002; ganaway, 1976; kohn, 1974) . pathology seropurulent or serofibrinous peritonitis is noted at necropsy (fox, 2002; ganaway, 1976; perkins, 1901) . additionally, such exudates may be observed in the pleural cavity and pericardial sac. congestion of the liver, spleen, and kidney has been noted, as has hepatic coagulative necrosis and degeneration of the renal tubule cells. an acute, necrotizing bronchopneumonia may be observed. diagnosis diagnosis of k. pneumonia is usually via culture of the upper respiratory tract. the bacterium has been isolated from blood, spleen, liver, peritoneal exudate, and cerebrospinal fluid (fox, 2002; ganaway, 1976; perkins, 1901) . k. pneumoniae can be differentiated from k. oxytoca, another klebsiella spp. frequently recovered in animals, by the fact that it is indole-negative and does not grow at 10â°c, while k. oxytoca is indolepositive and does grow at 10â°c. antibiotic treatment for klebsiella infection should be based on sensitivity of culture isolates. ceftriaxone and cefodizime were found effective at clearing k. pneumoniae in experimentally infected guinea pigs (drago et al., 1999) , although generally, chloramphenicol, enrofloxacin, trimethoprimsulfa, and aminoglycoside drugs are considered the safest antibiotic choices for use in guinea pigs. background and etiology proliferative enteritis associated with campylobacter-like organisms has been reported in many species including pigs, hamsters, rats, rabbits, foals, nhps, ferrets, and deer (lawson and gebhart, 2000) . in the early 1990s, molecular techniques resulted in the identification of lawsonia intracellularis as the causative agent of many of these syndromes. since that time, diagnostics, including pcr, have enabled the diagnosis of l. intracellularis infection (collins et al., 2011) . pathology there have been two reports of disease in guinea pigs associated with campylobacter-like organisms, both prior to the identification of l. intracellularis. in 1981, one 3.5-month-old guinea pig, treated with steroids for 90 days as part of a study, displayed no clinical signs of disease but on necropsy had marked duodenal mucosal hyperplasia with intracellular warthin-starry stained argyrophilic bacteria in affected epithelial cells (elwell et al., 1981) . two cagemates of this guinea pig, that had the same steroid treatment, died at days 13 and 30. one had diarrhea for two days prior to death. histopathology revealed acute enteritis with mucosal erosions without mucosal hyperplasia in both animals. bacteria similar to that seen in the first case were found in the epithelial cells. the authors noted this organism was very similar to the organism associated with transmissible mucosal hyperplasia of hamsters (subsequently identified as l. intracellularis). in 1983, two dams and five young guinea pigs in a laboratory in japan developed diarrhea, anorexia, weight loss, and dehydration. two young animals died 5-7 days post-onset of clinical signs. grossly, there was thickened jejunum and ileum. histopathologically, there was hyperplasia and proliferation of the epithelial cells and dilation of the glands primarily in the ileum and the distal part of the jejunum. immature epithelial cells contained various numbers of intracytoplasmic, non-membrane-bound, curved organisms resembling campylobacter spp. bacteria. diagnosis characteristic histopathological lesions, immunohistochemistry, and pcr are diagnostic (collins et al., 2011; lawson and gebhart, 2000) . antibiotics have been used to treat a similar proliferative enteritis in swine with success (lawson and gebhart, 2000) . care should be taken to avoid penicillins and other antibiotics implicated in antibiotic-associated dysbacteriosis (percy and barthold, 2007) . background and etiology leptospira are tightly coiled, aerobic, gram-negative, flagellated spirochetes belonging to the genera leptospira, family leptospiraceae, phylum, spirochaetes (boone et al., 2001) . before 1989, the genus, leptospira, was divided into two species, l. interrogans (pathogenic) and l. biflexa (non-pathogenic) which each contained strains separated into numerous serovars (levett, 2001) . more recently, dna analysis has identified 20 species of leptospira and revisions of these taxonomic groups are ongoing (galloway and levett, 2010; levett, 2001) . leptospira are zoonotic organisms with a world-wide distribution that infect a variety of mammals, including mice, rats, carnivores, and ruminants (ko et al., 2009; levett, 2001; percy and barthold, 2007) . wild guinea pigs in south america (cavia porcellus apera), infected with leptospira spp., have been implicated as the natural reservoir responsible for transmitting the disease to domestic cattle (blood et al., 1963) . in domestic guinea pigs, there have been only a few reports of natural infection, although the guinea pig infection models have been used extensively in leptospira research (ko et al., 2009; van hoosier and robinette, 1976) . data from research models and infections in other species indicate that transmission occurs from direct contact with infected urine, soil, or water as leptospira are excreted in the urine (ko et al., 2009; lourdault et al., 2009 ). a report from 1937 describes a natural infection where one out of 12 guinea pigs died from leptospirosis (ganaway, 1976) . pathological findings include jaundice, petechial hemorrhages in the skin, fascia, and muscles, and ecchymosis in the lung. a more recent report of a case of leptospirosis in a 21-year-old man, described 20 out of 50 guinea pigs that died on his farm in germany. three of the remaining guinea pigs were tested and were serologically positive for leptospira serovar bratislava similar to the man. no necropsies of affected animals were described. diagnosis direct examination of infected tissue, urine, or blood with dark-field microscopy, immunoflourescence, or light microscopy with special stains is useful for diagnosis (greenwood, 2007; levett, 2001) . culture and pcr are additional diagnostic tools. growth in culture can be slow. generally, antibody detection is used to demonstrate previous infection. antimicrobial treatment of individual animals is generally successful in other species (pischke et al., 2010; van de maele et al., 2008) , although in guinea pigs, care must be taken to avoid antibiotic-associated dysbacteriosis (percy and barthold, 2007) . prevention includes preventing exposure to wild rodents and leptospira-infected food, bedding, soil, or water. background listeria monocytogenes was first discovered in 1926 by murray et al. (1926) , who isolated it from laboratory rabbits and guinea pigs. since that time, few cases have been reported in guinea pigs, although guinea pigs are very susceptible and have been used extensively to model the pathogenesis of listeriosis (cossart, 2007; disson et al., 2009; fox, 2002) . etiology listeria monocytogenes is a facultative intracellular, non-spore-forming, zoonotic, food, soil-, and silage-borne bacterium which causes disease in birds and many mammals. pathology in spontaneous infections of guinea pig colonies, l. monocytogenes infection has been correlated with acute death, reproductive disorders such as abortions and still births, as well as conjunctivitis (chukwu et al., 2006; colgin et al., 1995; fox, 2002) . in an outbreak associated with feeding infected greens to a colony of 80 guinea pigs, the mortality rate was reported to be 80-100% with lung and liver lesions predominating (chukwu et al., 2006) . conjunctivitis was reported in one outbreak affecting 11 out of 49 newly arrived guinea pigs (colgin et al., 1995) . l. monocytogenes was cultured from 10 of 12 specimens submitted. the animals presented with unilateral or bilateral serous to purulent discharge with hyperemic conjunctiva. histologically, there was corneal ulceration, stromal edema, and vascular proliferation. the conjunctiva contained an inflammatory infiltrate and the lacrimal gland had multifocal areas of inflammation and necrosis. intracytoplasmic gram-positive rods were seen in the conjunctival epithelium and no chlamydial organisms were identified on conjunctival scrapings or by histopathology. experimentally, guinea pigs have been shown to be susceptible to listeriainduced conjunctivitis. pasteurella multocida background pasteurellosis is rare in presentday guinea pig laboratory colonies. reports of epizootic outbreaks due to gram-negative coccobacilli were reported in europe in the late 1800s (wright, 1936) . etiology pasteurella multocida, a gram-negative, non-spore-forming and non-motile rod is a member of the pasteurella genus and the pasteurellaceae family (songer and post, 2005) . spp. are mucosal commensal organisms of the oropharynx and gastrointestinal tract of many species, including man (songer and post, 2005) . when stressed, the animal's immune system can be overwhelmed and, in guinea pigs, pneumonia may result. p. multocida can be transmitted to man via contact with infected saliva, which is likely to occur as a result of a bite wound or scratch. clinical manifestations wright detailed an outbreak of pasteurellosis that killed 600 guinea pigs over a 1-year period (wright, 1936) . clinical signs were not noted prior to death. p. multocida has been isolated from cases of conjunctivitis (percy and barthold, 2007) . pathology fibrinopurulent serositis is present in cases of guinea pig pasteurellosis (fox, 2002; ganaway, 1976; wright, 1936) . such serositis has been noted in the pericardium, pleura, and peritoneum. lung consolidation may also be observed (fox, 2002) . diagnosis pasteurella infection is diagnosed via culture. the bacteria do not reliably grow well on macconkey agar, therefore blood agar is routinely used for isolation (ganaway, 1976; songer and post, 2005) . plates should be incubated at 3-5% co 2 at 37â°c for 24-48 hours (songer and post, 2005) . in animal tissue or fluids, p. multocida appears as a bipolar rod after aniline dye staining, but in a smear taken from culture, it stains evenly (ganaway, 1976) . unlike p. pneumotropica, p. multocida is o-nitrophenyl-ã�-d-galactoside (onpg) and urease-negative (songer and post, 2005) . p. pneumotropica is also positive for the fermentation of mannose, while p. multocida is negative. an elisa-based assay has been developed to monitor antibodies to the sp group of pasteurellaceae, which is one of five serologically distinct groups of pasteurellaceae in guinea pigs (boot et al., 1995) . prevention and therapy antibiotic treatment of p. multocida should be based on culture sensitivities. antimicrobial therapy will eliminate clinical signs, but will not eliminate the organism from the colony (songer and post, 2005) . background scherago (1937) reported on a fatal epizootic septicemia in a colony of young guinea pigs received from a local breeder. animals died within 5-6 hours after showing clinical signs and "gram-negative, non-spore-forming encapsulated rods with rounded ends and straight sides appearing singly and occasionally in pairs end to end" were found on smears from the peritoneal cavities of all examined animals. the route of infection was not determined in this colony, but scherago did complete the required steps to fulfill koch's postulates and demonstrated that the infection was due to pseudomonas caviae. p. caviae has since been reclassified as aeromonas caviae, of the aeromonadaceae family. pseudomonas aeruginosa was noted as the cause of pulmonary botryomycosis in two guinea pigs (bostrom et al., 1969) . etiology p. aeruginosa, a member of the genus pseudomonas, is part of the pseudomonadaceae family (songer and post, 2005) . pseudomonas spp. are gramnegative rods that are aerobic, non-spore-forming, oxidase-positive, and non-fermentative. pseudomonas organisms thrive in aqueous environments (songer and post, 2005) . additionally, they are ubiquitous in soil, decaying organic matter, and vegetation. pseudomonas spp. are opportunistic pathogens of both humans and animals, yet, there are few reports of infections caused by these agents in guinea pigs (fox, 2002) . bostrum et al. (1969) , did not describe the clinical signs associated with the epizootic outbreak of pulmonary botryomycosis. otitis media, conjunctivitis, and an inflamed prostate gland are signs that have been associated with pseudomonas in other reports of guinea pig infection (fox, 2002) . pathology a focal, necrotizing bronchopneumonia, along with pulmonary consolidation has been described in cases of guinea pig pseudomonas infection (bostrom et al., 1969; fox, 2002; ganaway, 1976; percy and barthold, 2007) . bostrum noted atypical "sulfur granules", resembling the spherules of coccidioides immitis, in the lungs of affected animals (bostrom et al., 1969) . diagnosis p. aeruginosa can be cultured from infected tissues (songer and post, 2005) . p. aeruginosa grows well on macconkey agar and trypticase soy agar. additionally, cetrimide agar, a commercial formulation, selectively isolates p. aeruginosa. the best means of controlling pseudomonas is to reduce possible sources of infection, such as damp bedding or stagnant water. animal drinking water should be monitored for p. aeruginosa, and in some situations, water may be chlorinated to eliminate contamination (songer and post, 2005) . reducing stressors, such as overcrowding and concurrent infection, also aids in control. pseudomonas spp. have an inherent resistance to many antimicrobials. salmonella background some of the earliest reports of salmonellosis in guinea pigs date back to the 1800s (nelson and smith, 1927) . multiple outbreaks of natural infections in guinea pig colonies in the united states were documented throughout the early 1900s (holman, 1916; nelson and smith, 1927) . since this period of time, as laboratory standards have grown more stringent and general hygiene and sanitation have improved, the occurrence of salmonellosis in laboratory guinea pigs has declined greatly (fox, 2002; harkness and wagner, 1995; percy and barthold, 2007) . etiology members of the genus salmonella are gram-negative, non-spore-forming bacilli that are facultative anaerobes. salmonella other than s. typhi or s. paratyphi produce hydrogen sulfide, as well as acid and gas from glucose, but not lactose (ganaway, 1976; songer and post, 2005) . salmonella is a member of the enterobacteriaceae family. while multiple serovars have been recovered from guinea pigs, the most frequently isolated are s. typhimurium and s. enteritidis (fox, 2002; ganaway, 1976; harkness and wagner, 1995; quesenberry and carpenter, 2004; percy and barthold, 2007) . humans are susceptible to disease from the same serovars and phage types as guinea pigs (fish et al., 1968; percy and barthold, 2007; rigby, 1976 ). pathogenesis guinea pigs are extremely susceptible to salmonella (fox, 2002) . transmission of salmonella is primarily fecal-oral or via ingestion of contaminated feed (contaminated with feces of infected guinea pig or a wild rodent) (fox, 2002; harkness and wagner, 1995; percy and barthold, 2007; quesenberry and carpenter, 2004) . entry via the conjunctiva has also been reported in guinea pig epizootics (iijima et al., 1987; moore, 1957) . additionally, ingestion of contaminated blood or tissue can transmit salmonella (fox, 2002) . stressed animals, due to conditions such as weaning, parturition, old age or poor nutrition, are more susceptible to infection (quesenberry and carpenter, 2004) . recovered animals can develop an asymptomatic carrier state with intermittent shedding in the feces, making elimination of this bacterium from a colony difficult (fox, 2002; harkness and wagner, 1995; percy and barthold, 2007) . the incubation time for salmonella is 5-7 days and epizootic or enzootic patterns of infection are possible (fox, 2002; ganaway 1976) . salmonella occurs as peracute septicemia or acute, subacute, or chronic enteritis (songer and post, 2005) . acute disease is characterized by high morbidity and low to moderate mortality. clinical signs include depression, weakness, and fever. dehydration and electrolyte imbalance may be severe. infection spreads rapidly within a colony. conjunctivitis and abortions have also been noted (percy and barthold, 2007) . although weight loss is present, diarrhea may or may not occur in guinea pigs. in an epizootic outbreak, young guinea pigs may die suddenly without prior signs of illness. pathology in acute and peracute cases, there may be no lesions seen at necropsy (harkness and wagner, 1995; percy and barthold, 2007) . splenomegaly may be observed in subacute and chronic infections. minute white foci and/or yellowish-white nodules, up to several millimeters in diameter, may occur in the spleen, liver, or other lymph nodes. similar foci or nodules may also occur in the lung, pleura, peritoneum, and in the wall of the uterus. rupture of the nodules may result in a suppurative pleuritis, peritonitis, and/or pericarditis. gas may be observed in the small and large intestine, along with catarrhal enteritis (fish et al., 1968) . on histopathology, lesions support bacterial invasion, with subsequent necrosis and abscess formation (ganaway, 1976) . nodules are noted to be "typhoidlike" granulomas, with areas of central necrosis, surrounded by histiocytes. polymorphonuclear leukocytes and histiocytes are present in the peyer's patches of the ileum and jejunum. diagnosis salmonella can be isolated from blood, feces, and affected organs (most commonly from the spleen) (fox, 2002) . recovery requires special conditions: enrichment in a broth such as selenite-f or tetracycline and culture at 37â°c on macconkey's or brilliant green agar (fox, 2002; songer and post, 2005) . (harkness and wagner, 1995; rigby, 1976) . all fresh fruit and vegetables should be thoroughly washed and stored in airtight containers. since so many species of mammals are potential carriers, the exclusion of wild rodents, birds, and other vermin is essential. when increased colony mortality is apparent and a chronic case is recognized at necropsy, salmonella infection is likely widespread and well established in the colony. in situations such as this, it is reasonable to depopulate the colony, sanitize the premises, and restock with salmonella-free guinea pigs. treatment on an individual basis will include the appropriate antibiotics with fluid therapy. animals that become asymptomatic after treatment may become carriers, a problem with zoonotic potential. antimicrobial resistance is expanding; 90% of salmonella isolates from domestic animals demonstrate multi-drug resistance (songer and post, 2005) . background streptobacillus moniliformis is one of the causative agents of rat bite fever, a significant worldwide, zoonotic, systemic infection of humans associated with contact with rats (gaastra et al., 2009; khatchadourian et al., 2010) . it was described in early recorded history in india and was recognized in the us as early as 1839 as a syndrome that developed following contact with rats (gaastra et al., 2009) . s. moniliformis also causes haverhill fever, a systemic infection of those who eat food contaminated with rat urine or feces (abdulaziz et al., 2006; mcevoy et al., 1987; shanson et al., 1983) . etiology streptobacillus moniliformis, a facultative anaerobic, non-motile, non-capsulate, pleomorphic, gram-negative rod, is the type species of the genera, streptobacillus, family leptotrichiaceae within the phylum fusobacteria (greenwood, 2007; nolan et al., 2009) . its genome has been completely sequenced (nolan et al., 2009) . epizootiology and pathogenesis s. moniliformis is commonly found in the nasopharynx of wild and pet rats (gaastra et al., 2009; wullenweber, 1995) , although typically excluded from modern spf laboratory animal facilities (nicklas et al., 2002; pritchett-corning et al., 2009) . the organism has also been found in carnivores, calves, pigs, turkeys, and a variety of rodents including guinea pigs presumably following contact with infected rats (gaastra et al., 2009; wullenweber, 1995) . most commonly, s. moniliformis in guinea pigs has been associated with cervical lymphadenitis and other localized abscesses (aldred et al., 1974; fleming, 1976; percy and barthold, 2007; van hoosier and robinette, 1976; wullenweber, 1995) . severe necrotizing bronchopneumonia with pyogranuloma formation was reported in one guinea pig by kirchner et al. (1992) . no clinical signs of disease were noted in their report. diagnosis gram stain of smears can be suggestive of infection by demonstrating short bacilli in chains or long filaments followed by bacterial culture and isolation (greenwood, 2007; kirchner et al., 1992; wullenweber, 1995) although because of the fastidious nature of s. moniliformis, pcr is more commonly used for detection . if culture is attempted, samples must be cultured on a media containing serum, blood or ascitic fluid, such as loeffler's serum medium (greenwood, 2007) . cross-reactive sequences between leptotrichia spp. and s. moniliformis have been demonstrated and can result in false positives when pcr is used for diagnosis (boot et al., 2008; wouters et al., 2008) . sequence of the amplicon can differentiate these outcomes. as the entire sequence of s. moniliformis has recently been completed (nolan et al., 2009) , new primers for diagnosis may be forthcoming. antibodies to s. moniliformis can be demonstrated by elisa (boot et al., 1993b (boot et al., , 2006 . because the organism is not spread easily, outbreaks can be controlled by culling affected guinea pigs (van hoosier and robinette, 1976) . treatment of individual animals with antibiotics is effective in other species (gaastra et al., 2009; wullenweber, 1995) , although treatment should be approached with caution because of the zoonotic potential of this organism. prevention of contact with infected rats, other animals that contact wild or infected rats, or infected food and/or bedding should eliminate introduction of this organism (van hoosier and robinette, 1976) . yersinia pseudotuberculosis background ganaway states that "one of the earliest recognized bacterial disease of the guinea pig was caused by yersinia pseudotuberculosis" (ganaway, 1976) . in present day colonies of laboratory guinea pigs, natural outbreaks of pseudotuberculosis are rare (fox, 2002; percy and barthold, 2007) . etiology yersinia pseudotuberculosis, an ubiquitous enteropathogen, is a gram-negative, non-spore-forming, facultative anaerobic rod that is oxidase-negative and catalase-positive (ganaway, 1976) . it is non-hemolytic and produces both exotoxin and enzyme (fox, 2002) . growth is optimal at 20-30â°c (fox, 2002; ganaway, 1976) . the genus yersinia is part of the family enterobacteriaceae and, in addition to guinea pigs, it causes pseudotuberculosis in other rodents, cats, and turkeys (songer and post, 2005) . epizootiology and pathogenesis y. pseudotuberculosis can result in clinical disease or a sub-clinical carrier state. guinea pigs are very susceptible to infection with this bacterium (fox, 2002; ganaway, 1976) . y. pseudotuberculosis is shed in feces, therefore ingestion of food contaminated with feces from a carrier guinea pig, wild rodent, or bird can transmit the organism, as can aerosol spread, or entry via a bite wound or skin laceration (fox, 2002; ganaway, 1976; rigby, 1976) . dams can pass infection to their pups (fox, 2002) . orally absorbed organisms disseminate from the intestinal tract to the mesenteric lymph nodes. acute and chronic forms of disease have been described (ganaway, 1976; rigby, 1976 ). an acute septicemic form of infection can lead to mortality in 24-48 hours. a chronic infection that often lasts several weeks to months and ultimately results in death is the more classic pseudotuberculosis presentation. the classic clinical presentation associated with y. pseudotuberculosis is that of wasting and lymphadenitis, sometimes with accompanying diarrhea, and frequently resulting in death about a month after initial infection (obwolo, 1977; sebesteny, 1976) . the acute form of the disease can present with no clinical signs or consist of one to two days of coughing and respiratory distress prior to death (rigby, 1976) . pathology necropsy of animals chronically or subacutely infected with yersinia pseudotuberculosis reveals nodules throughout the body, including the regional lymph nodes, spleen, liver, lung, and bone marrow (fox, 2002; percy and barthold, 2007) . the grayish-white spherical nodules vary from miliary pinpoint to 2-3 cm in diameter and may contain creamy to caseous exudate. in acute cases, nodules are noted in the intestinal wall, especially at the location of the terminal ileum and cecum, and often with accompanying mucosal ulceration and acute enteritis (percy and barthold, 2007) . lung congestion may be seen in acute cases (rigby, 1976) . yersinia nodules often have a central area of necrosis with neutrophilic infiltration; foamy macrophages are often noted in the periphery (fox, 2002; ganaway, 1976 ). blood vessels within the nodule may contain bacterial emboli. in chronic lesions, fibroblasts and epithelial cells proliferate and nodules may become granulomatous, but do not calcify. diagnosis y. pseudotuberculosis can be cultured from abscesses (rigby, 1976) . direct smears may also iii. guinea pigs be beneficial. in acute septicemic cases, yersinia may be cultured from the blood (ganaway, 1976) . yersina spp. can be cultured on standard media and y. pseudotuberculosis can be differentiated from y. pestis, the causative agent of plague, by the fact that it is urease, and rhamnose-positive, while y. pestis is negative for both of these growth conditions (songer and post, 2005) . treatment and control euthanasia of infected animals is advised due to the fact that antibiotic treatment can result in a carrier state, which, due to its zoonotic potential, puts human handlers and staff at risk. a killed vaccine has been unsuccessful at protecting guinea pigs from infection, but a more recent live vaccine has produced promising results (quintard et al., 2010) . background dermatophytosis, also known as ringworm or tinea, indicates infection with pathogenic fungi in the phylum ascomycota that cause the bulk of superficial fungal infections in humans and animals (ameen, 2010; howard et al., 2003) . the fungi are keratinolytic and keratinophilic and infection is usually limited to cornified layers of the skin, hair, or nails (howard et al., 2003; weitzman and summerbell, 1995) . their importance as pathogens is clear in that the majority of dermatophytes infecting animals are zoonotic (chermette et al., 2008) . originally, the dermatophytes were organized into three anamorphic, or asexual, genera, microsporum, trichophyton, and epidermophyton. the primary structure associated with asexual reproduction is the conidium and classification into these genera was based on the morphology of the macroconidia in culture. subsequent studies revealed sexual reproduction in certain microsporum and trichophyton spp. that occurs by means of an ascospore found within an ascus. the dermatophyte sexual states (teleomorphs) are classified in the genus, arthroderma (weitzman and summerbell, 1995) . recent efforts at phylogenetic analysis and identification of dermatophytes have been achieved by sequencing 28s ribosomal dna (rdna) and internal transcribed spacer (its) regions flanking 5.8s rdna (drouot et al., 2009; frealle et al., 2007; symoens et al., 2011) . dermatophyte species can also be divided into three groups determined by their adaptation to a certain habitat. humanassociated dermatophytes are anthropophilic (e.g. trichophyton rubrum), those primarily found on animals and occasionally infecting humans are zoophilic (e.g. trichophyton mentagrophytes), and species persisting in the soil are termed geophilic (e.g. microsporum gypseum) (weitzman and summerbell, 1995) , however some overlap does occur. zoophilic and geophilic dermatophytes infecting humans cause a more intense inflammatory reaction than anthropophilic species (weitzman and summerbell, 1995) . etiology dermatophytosis in animals is most often caused by the anamorph species microsporum and trichophyton, however the infecting species can vary with the geographic region (bond, 2010) . of these genera, trichophyton mentagrophytes is the most common cause (aho, 1980; balsari et al., 1981; drouot et al., 2009; feuerman et al., 1975; lopez-martinez et al., 1984; mcaleer, 1980a mcaleer, , 1980b papini et al., 1997; pombier and kim, 1975; stenwig, 1985; vangeel et al., 2000) . t. mentagrophytes is a species complex with several variants including both anthropophilic and zoophilic pathogens. pollock (2003) considered t. mentagrophytes var mentagrophytes as the most common variant infecting rodents, however the specific variant is not always reported in the literature. the teleomorphs are known for the t. mentagrophytes complex and there are two, arthroderma benhamiae and a. vanbreuseghemii. the a. benhamiae genome has been sequenced (burmester et al., 2011) . the different variants and sexual states of the t. mentagrophytes complex coupled with more recent phylogenetic analyses presents confusion about proper nomenclature and species assignment (drouot et al., 2009; fumeaux et al., 2004) . infection with either m. canis or m. gypseum has also been reported in the guinea pig but less frequently (feuerman et al., 1975; papini et al., 1997) . guinea pigs, and other animals, are infected by direct exposure to an infected animal, contaminated environments, or fomites. arthroconidium produced by septation of hyphae are infectious and persist in the environment for months to years (bond, 2010; weitzman and summerbell, 1995) . hyphae invade the stratum corneum eventually colonizing the hair follicles. the sequenced genome of a. benhamiae revealed numerous predicted protease-encoding genes and their secretion was confirmed experimentally in a keratin digestion assay indicating an important role in invasion and pathogenesis (burmester et al., 2011) . young guinea pigs appear to be more susceptible to disease and other predisposing and susceptibility factors include pregnancy, high temperature and humidity, health status, and genetics (pollock, 2003; pombier and kim, 1975) . surveys of dermatophytosis in guinea pigs have been reported from around the world, with prevalence ranging from 1.3-56% (balsari et al., 1981; drouot et al., 2009; feuerman et al., 1975; lopez-martinez et al., 1984; papini et al., 1997; vangeel et al., 2000) . clinical manifestations infected guinea pigs are most often asymptomatic but can exhibit lesions typical of dermatophytosis. when present, lesions are most common on the head and appear to begin on the nose or muzzle and then can spread over the body to the trunk and limbs (figure 23 .2). circumscribed or irregular lesions with combinations of alopecia, scale, crust, erythema, and ulceration develop, with or without pruritis, and spontaneous remission is possible (drouot et al., 2009; mcaleer, 1980a; pollock, 2003; pombier and kim, 1975) . pustules may be associated with the lesions due to secondary bacterial infections. furthermore, in one outbreak of t. mentagrophytes, affected animals were in poor body condition and there was approximately 50% mortality in young guinea pigs (pombier and kim, 1975) . onychomycosis is rare in the guinea pig (drouot et al., 2009) . pathology microscopic analysis of affected epidermis and adnexa can include acanthosis, vascular congestion, dermal lymphocytic infiltration, folliculitis, perivascular, and interstitial dermatitis, and intra-epidermal pustules (chermette et al., 2008; pombier and kim, 1975) . diagnosis microscopy and culture are the primary means of diagnosing dermatophytosis. wood's lamp can be used as a screening tool for m. canis and infected hairs will fluoresce with an apple-green color. however, false negatives can occur (chermette et al., 2008) . hairs are plucked or the skin scraped from the periphery of an active lesion or from the whole lesion if there is no evidence of inflammation and samples placed in 10% potassium hydroxide to remove keratin. the samples are then examined for hair or skin invasion with hyphae and/or arthroconidia. to increase sensitivity, fluorescent microscopy with calcofluor white and congo red can be used (bond, 2010; robert and pihet, 2008) . geimsa staining will also identify arthroconidia. all the dermatophytes infecting guinea pigs will have ectothrix hair shaft involvement. prior to obtaining a skin or hair sample for culture, the area should be wiped with alcohol to reduce contamination. saprophytic fungi contamination of the fur may hinder isolation of dermatophytes (aho, 1983) . hair, skin, or crusts are collected using a sterile toothbrush, swab, forceps, scalpel blade, or surgical scrub brush and placed onto culture medium. sabouraud's dextrose agar supplemented with cyclohexamide and chloramphenicol is commonly used. dermatophyte test medium is available, however contamination can cause both false-positive and falsenegative results (robert and pihet, 2008) . if the animal is simply a mechanical carrier, results of repeated testing will vary (chermette et al., 2008) . biopsy samples can be stained with periodic acid-schiff or silver stains to detect arthroconidia and hyphae (figure 23 .3) (chermette et al., 2008) . as mentioned earlier, polymerase chain reaction (pcr) amplification and sequencing of its and 28s ribosomal dna (drouot et al., 2009; fumeaux et al., 2004; symoens et al., 2011) will identify isolates, and mating experiments can be performed (hironaga et al., 1981) . reducing exposure to infected animals and contaminated environments is critical in preventing dermatophytosis. assuring a wellmanaged facility with no overcrowding, parasite control, and proper temperature and humidity regulation are important preventive components (pollock, 2003; iii. guinea pigs pombier and kim, 1975) . infected animals should be removed, the environment thoroughly decontaminated and any items that cannot be disinfected should be discarded. animal care staff should wear proper personal protective equipment when handling potentially contaminated items or bedding since zoonosis is a concern (mcaleer, 1980a). dilute bleach, benzalkonium chloride, and glutaraldehyde are effective surface disinfectants (pollock, 2003) . in a laboratory setting, it is doubtful that animals will be treated for ringworm. readers are referred to other summaries of available topical and systemic treatments (pollock, 2003) . background the microsporidia (members of the phylum microspora) are a group of single-celled intracellular spore-forming eukaryotic parasites that infect a wide range of animals, from insects to mammals. the defining and unique feature of the phylum is the presence of a polar filament (tube) in the mature spore . the microsporidia also have one of the smallest genomes of any eukaryote and lack several key features, such as typical mitochondria. long thought to be protozoa, certain characteristics indicated that these organisms were fungi-like such as presence of a chitinous spore wall, genes for trehalose metabolism, and intranuclear division (brosson et al., 2006; dunn and smith, 2001) . recently, lee et al. (2008) concluded that microsporidia are true fungi related to zygomycetes. of the microsporidial species infecting humans, enterocytozoon bieneusi is the most common with lesser, but still significant, numbers of cases due to the encephalitozoon spp. the majority of patients are immunocompromised as a result of hiv infection, aids, or are organ transplant recipients. however, healthy immunecompetent persons are also susceptible to disease (didier and weiss, 2006; mathis et al., 2005) . animals are hosts for those common species strongly supporting their zoonotic potential. etiology the primary agent of microsporidiosis in guinea pigs is encephalitozoon cuniculi (syn. nosema). e. cuniculi was first reported in the rabbit as the cause of "infectious motor paralysis" (percy and barthold, 2007) and subsequently has been identified in a wide range of animal species . katinka et al. (2001) have sequenced the 11 chromosomes of the approximately 2.9-mb genome, highlighting the genome compaction and shortened protein sequences that reflect its intracellular location and host dependence. provide an informative summary of the mammalian microsporidian life cycle. environmentally resistant spores are shed in feces, urine, and mucus and then ingested or inhaled. transplacental transmission has been documented in the rabbit (baneux and pognan, 2003) and has been claimed in the guinea pig (boot et al., 1988) . predictably, primary sites of infection commonly include the small intestine, respiratory tract, and placenta. an unknown signal triggers the polar filament (tube) to be extruded from the spore and infectious sporoplasm is injected into the host cell cytoplasm. the sporoplasm then divides into meronts (merogony) that differentiate through intermediary forms before becoming mature spores (sporogony). for e. cuniculi and other encephalitozoon spp., developing spores are packaged in a parasitophorous vacuole. the host cell ruptures releasing spores that commonly disseminate to the kidney, liver, and brain. host protection from infection is primarily achieved by cell-mediated immunity with lesser contributions from the humoral immune system (khan et al., 2001) . from serologic surveys, prevalence of encephalitozoonosis in guinea pig colonies has ranged from 13%-63%. this variability may be due to differences in housing and husbandry for the particular colony and diagnostic methodology (boot et al., 1988; gannon, 1980) . clinical manifestations encephalitozoonosis is subclinical in the guinea pig (boot et al., 1988; gannon, 1980; illanes et al., 1993; moffatt and schiefer, 1973; wan et al., 1996) . pathology gross lesions of encephalitozoonosis in the guinea pig are not consistently found and when present have only been described in the kidney. infected animals may have pale kidneys and/or pitting of the renal cortex (gannon, 1980; moffatt and schiefer, 1973) . histologic lesions are found primarily in the brain and kidney. focal to multifocal granulomatous encephalitis may be evident in different regions of the brain, with or without associated necrosis, and perivascular and meningeal mononuclear cell infiltrate (moffatt and schiefer, 1973; wan et al., 1996) . organisms approximately 1-1.5 âµm in width î�³ 1.5-2.5 âµm in diameter (illanes et al., 1993; can be found within or adjacent to lesions or free in the tissue with no associated inflammation. in the kidney, interstitial nephritis and necrosis, fibrosis, perivascular cuffing and tubular ectasia have all been described (boot et al., 1988; gannon, 1980; moffatt and schiefer, 1973) . here, organisms may occasionally be visualized in renal epithelial cells and collecting tubule lumens. absence of typical lesions in the brain or kidney in a seropositive animal may be due to the multifocal nature of the lesions and insufficient sections being analyzed (gannon, 1980; wan et al., 1996) . other lesions reported include necrotic liver foci and interstitial pneumonia with perivascular and peribronchial lymphoid accumulation. diagnosis serology tests including carbon immunoassay, ifa, elisa, multiplex fluorescent immunoassay, and western blot have all been or currently are being used for colony monitoring (percy and barthold, 2007; . presence of typical histopathologic lesions and special stains confirm the infection. while indistinct with hematoxylin and eosin staining, spores are periodic acid-schiff, gram, and modified trichrome positive (figure 23.4) . chemofluorescent agents such as calcofluor white can also be used (garcia, 2002) and spores are birefringent (tiner, 1988) . pcr primers are available (baneux and pognan, 2003; ghosh and weiss, 2009 ) providing a fast and easily interpretable means of diagnosis and the genome for e. cuniculi has recently been sequenced providing further opportunities for novel molecular diagnostic strategies (katinka et al., 2001) . urine, brain, and kidney are optimal specimens for testing by pcr. electron microscopy is the gold standard for diagnostic confirmation and offers species identification which is particularly important for human infections (garcia, 2002) . prevention and therapy e. cuniculi-free guinea pigs are commercially available and therefore, protection from contaminated animals or environments is the primary means of prevention (gannon, 1980) . faced with contamination, eradication may be successful through serological analysis and euthanasia of seropositive animals (baker, 2007) coupled with environmental decontamination. e. cuniculi spores are environmentally stable for days to weeks depending on the temperature and humidity, but are susceptible to common disinfectants (jordan et al., 2006; waller, 1979) . vertical transmission is thought to occur in guinea pigs (boot et al., 1988) , so hysterectomy rederivation should be used with caution and offspring extensively tested. it is unlikely that laboratory guinea pigs would be treated for encephalitozoonosis. two of four laboratory-bred guinea pigs were found dead several days to two weeks after adoption (kunstyr et al., 1980) . diarrhea was noted in one animal prior to death and each had gross evidence of enteritis at necropsy which was confirmed histologically. the yeast candida pintolopesii, a normal inhabitant of the gut, was isolated from the small intestine, lung, and ascitic fluid of one animal. the authors hypothesized that a change in social structure, diet, and environment precipitated disease. cryptococcus neoformans is a basidiomycetous yeast causing serious infections of the lungs and central nervous system in immunocompromised persons (boekhout and guã©ho, 2003) . betty (1977) reported chronic, subclinical cryptococcal meningitis in laboratory-reared dunkin hartley guinea pigs with no evidence of generalized infection. the source of infection was not identified. van herck et al. (1988) described dermal cryptococcosis of an adult male pet guinea pig. histopathologic analysis of a large ulcerative lesion on the dorsal aspect of the nose showed extensive focal ulcerative dermatitis with infiltrating neutrophils, plasma cells, lymphocytes, and macrophages with edema and ovoid organisms. dermal and subcutaneous tissue also contained large numbers of these thick-walled organisms that were positive by periodic acid-schiff staining. enterocytozoon bieneusi is a significant cause of intestinal microsporidiosis in immunocompromised persons and has been identified in many mammalian and nonmammalian hosts (mathis et al., 2005) . microsporidian spores were found in the feces of a two-year-old male entered into a prospective study of pediatric enteric parasites in peru. to investigate the source of infection, stool was analyzed from animals in the household, including guinea pigs, chickens, dogs, and cats. seven of eight asymptomatic guinea pigs were positive for spores, whereas all the other animals were negative. polymerase chain reaction and sequence analysis confirmed that both the child and guinea pigs were infected with e. bieneusi and with the same genotype. furthermore, this specific genotype was found in guinea pigs from other unrelated iii. guinea pigs households suggesting that guinea pigs are the natural host and there is zoonotic potential for this organism. there is a single report from brazil of a naturally occurring histoplasmosis outbreak in laboratory guinea pigs (correa and pacheco, 1967) . clinical signs of disease in adults included progressive emaciation and hindlimb dysfunction before death. young animals exhibited a hunched back, ruffled fur, and conjunctivitis with discharge before dying at two months of age. gross and histologic lesions were numerous; however, for these authors a characteristic lesion of colitis with the wall expanded by numerous lymphocytes, macrophages, epithelioid and giant cells with basophilic organisms free or inside macrophages and culture results established the diagnosis. there may have been a link between this outbreak and histoplasmosis diagnosed in a cow on a farm from which the grass used to feed the guinea pigs was sourced. hortaea werneckii, the causative agent of tinea nigra in people, was diagnosed in a household guinea pig in japan (sharmin et al., 2002) . lesions included a focal area of ulceration and alopecia on the back and black pigmentation on the palmar aspect of the right forepaw. h. werneckii was detected by mycologic culture of the back lesion and dna sequencing of an amplified region of large subunit ribosomal dna. the authors hypothesized that the animal contracted the infection from the environment, but could not definitively rule out contamination with the fungus rather than a real infection. paecilomyces spp. are occasional opportunists in humans and animals (summerbell, 2003) . this fungus was identified during routine monitoring from a single conventionally housed laboratory guinea pig with no apparent clinical signs . paecilomyces spp. were most commonly identified in specific pathogenfree rats from one particular animal facility with the trachea and lungs being the most common site of infection in all animals analyzed. mild dermatitis was noted in a group of hairless mice; however, the vast majority of animals had no clinical or histologic evidence of disease. a hairless mutant arose in a closed colony of hartley guinea pigs. in addition to abnormal haircoat development, affected guinea pigs were smaller than their haired siblings and died early due to infections otherwise associated with an abnormal immune system such as systemic cytomegalovirus and balantidiasis, and pneumocystis pneumonia (reed and o'donoghue, 1979) . abnormal thymic and lymphoid follicle morphology and agammaglobulinemia confirmed the immunodeficiency. protozoa rarely cause disease in guinea pigs and intestinal protozoa are often considered part of the normal flora. in this review, the more frequently reported protozoa of domestic guinea pigs will be discussed. the reader is referred to parasites of laboratory animals (baker, 2007) and morphology and taxonomy of the intestinal protozoa of the guinea pig (nie, 1950) for a more detailed description of the protozoa of this species. the nomenclature used in this section is in accordance with the 2007 reference. amoebiasis etiology endolimax caviae and entamoeba caviae (syn. entamoeba cobayae) are the causative agents of amoebiasis in guinea pigs (levine, 1985) . nie (1950) reported the incidence of endolimax caviae to be 18% and the incidence of entamoeba caviae to be 14% in a colony of guinea pigs studied at the university of pennsylvania. pathogenesis endolimax caviae and entamoeba caviae are observed in the cecum of the guinea pig (nie, 1950) . both of these organisms are thought to feed upon the fecal material and microflora of the host intestine, without invasion of tissue or consumption of blood. transmission is via ingestion of cysts passed in the feces. clinical manifestations infection with either organism does not generally result in clinical signs (levine, 1985) . pathology entamoeba and endolimax are usually non-pathogenic (baker, 2007; levine, 1985) . diagnosis trophozoites can be observed in a smear of intestinal contents (baker, 2007; levine, 1985) . cysts are detected by zinc sulfate float. endolimax cavieae trophozoites are smaller than those of entamoeba caviae, with an average diameter of 1.6 âµm and 14.4 âµm, respectively (nie, 1950) . the cyst forms of either organism have rarely been observed, and little detail has been recorded on their appearances. prevention and therapy generally, treatment is not necessary for guinea pig amoebiasis. balantidia caviae background upon initial description, controversy developed over whether b. caviae was the same organism as b. coli in swine (vetterling, 1976) . morphological descriptions and infection studies have since proved that the two species are distinct. etiology balantidium caviae is the causative organism. pathogenesis b. caviae transmission is via ingestion of cysts in the feces (baker, 2007) . clinical manifestations if the mucosal barrier of the intestine is compromised, b. caviae can become invasive and result in enteritis; otherwise infection is non-pathogenic (baker, 2007) . pathology b. caviae may be observed in the walls of the cecum and colon, but penetration can occur postmortem, a consideration that should be made when diagnosing infection at the time of necropsy (baker, 2007; nie, 1950) . if invasion is ante-mortem, intestinal inflammation should be present; more often, though, b. caviae is considered a commensal protozoan. diagnosis in addition to diagnosing b. caviae in histologic sections of the cecum or colon, ciliated organisms with micro-and macro-nuclei can be observed in fresh fecal smears (baker, 2007; fox, 2002) . proper hygiene is most important in controlling b. caviae infection in guinea pigs (baker, 2007) . tetracyclines have been used to treat balantidiasis in other species. background c. wrairi is named after the walter reed army institute of research where the organism was first identified in a colony of laboratory guinea pigs (vetterling et al., 1971) . etiology cryptosporidium wrairi is the causative organism. pathogenesis the route of infection for c. wrairi is likely fecal-oral, with ingestion of oocysts in feces (baker, 2007; fox, 2002) . experimental infection has shown that the duration of infection for animals older than 16 weeks is usually short, lasting as little as 1-2 weeks, after which the organism is cleared (chrisp et al., 1990) . younger animals have a longer duration of infection. recovered animals appear to be refractory to subsequent infection. clinical manifestations clinical signs are more likely to be seen in young animals, with weight loss noted most commonly (baker, 2007; fox, 2002) . if infection is severe, anorexia, a potbellied appearance and a greasy hair coat may be observed with or without accompanying diarrhea (baker, 2007) . morbidity and mortality, especially in young animals, can reach levels of 50% during an outbreak (harkness and wagner, 1995; percy and barthold, 2007) . echinococcus coli has been associated with clinical cases of c. wrairi, but the significance of this infection is unknown (percy and barthold, 2007) . subclinical infections with c. wrairi are thought to be possible (baker, 2007; fox, 2002) . pathology erosion, hyperemia, and inflammation of the small intestine have been observed with c. wrairi infection (baker, 2007; chrisp et al., 1992; harkness and wagner, 1995) . edema of the lamina propria and hyperplasia of the crypt epithelium occurs. in chronic infections, villous atrophy and bridging, metaplasia of the mucosal epithelium, and lymphocyte infiltration of the lamina propria have been noted. developmental stages of c. wrairi can be seen throughout the intestine, with highest concentrations of the organism noted in the brush border of the ileum. diagnosis oocysts can be seen in fecal floats (gressler et al., 2010; percy and barthold, 2007) . kinyoun staining of fecal smears and microscopic examination of mucosal scrapings or histological sections are also diagnostic options. prevention and therapy prevention is the best means of control for c. wrairi. oocysts are resistant to many disinfectants or require high concentrations and/or long contact times before being rendered noninfectious. heating above 65â°c for greater than 5 minutes has been described to be successful for the destruction of cryptosporidium organisms, as has exposure to temperatures below 0â°c (baker, 2007; harkness and wagner, 1995) . successful treatment with sulfonamides has been reported, but the efficacy of this treatment has been questioned (fox, 2002; percy and barthold, 2007; sebesteny, 1976) . harkness suggests the "extra-label" use of high doses of the coccidiostat, decoquinate, to treat cryptosporidiosis (harkness and wagner, 1995) . while c. wrairi is not known to infect humans, the genus has a general lack of specificity and precautions should be taken to prevent zoonotic transmission (baker, 2007; harkness and wagner, 1995) . eimeria background reports of coccidia in guinea pigs date back to the late 1800s, although the observed organisms were initially thought to be a variety of rabbit coccidian (vetterling, 1976) . in the early 1920s, bugge and heinke showed that coccidia noted in the guinea pig were indeed distinct from those of the rabbit and in 1924 sheather named the guinea pig coccidia e. caviae. iii. guinea pigs etiology eimeria caviae is the causative organism. pathogenesis transmission of e. caviae is fecaloral, with ingestion of oocysts in feces (baker, 2007) . clinical manifestations clinical signs due to e. caviae are noted in severe infections and include diarrhea, anorexia and a rough hair coat (baker, 2007; ellis and wright, 1961; rigby, 1976) . the first appearance of diarrhea is often 10-11 days after initial infection (baker, 2007; elsheikha et al., 2009; percy and barthold, 2007) . watery, pasty, and hemorrhagic forms of diarrhea have all been reported (baker, 2007; elsheikha et al., 2009; fox, 2002; percy and barthold, 2007) . severe infections can result in death (baker, 2007; fox, 2002) . in mild infections or infections of older animals, diarrhea is likely to resolve in 4-7 days (baker, 2007; fox, 2002) , after which constipation may follow (fox, 2002) . stress, such as a diet change or transport, may exacerbate an otherwise nonpathogenic infection of e. caviae in the guinea pig (ellis and wright, 1961; elsheikha et al., 2009; rigby, 1976) . pathology the large intestine is most affected by e. caviae, with organisms most often settling in the proximal colon (baker, 2007; elsheikha et al., 2009) . hyperemia, edema, and petechial hemorrhage of the colonic mucosa may be seen (baker, 2007) . white or yellow plaques may be present in the colon or cecum. watery intestinal contents can contain blood (baker, 2007; percy and barthold, 2007) . dilated cystic crypts of liekberkuhn may be observed (baker, 2007) . developmental stages of e. caviae can be seen in intact epithelial cells or free in the intestinal lumen. enterocytes may slough and an infiltration of polymorphonuclear and mononuclear cells is possible (baker, 2007; percy and barthold, 2007) . microgametocytes and macrogametocytes may be present in the cecal and colonic mucosa (percy and barthold, 2007) . diagnosis oocysts are seen on fecal float (baker, 2007; fox, 2002; percy and barthold, 2007) . fox et al. (2002) recommend using a flotation medium of 1.33 specific gravity. the prepatent period of e. caviae is 11-12 days, yet diarrhea may occur before day 11; therefore, a fecal float performed at the beginning of diarrhea may result in a false-negative finding. multiple floats performed every 4 or 5 days for several weeks is recommended (vetterling, 1976) . organisms may also be identified on mucosal scrapings or histopathology sections (baker, 2007; fox, 2002; percy and barthold, 2007) . sulfonamides are recommended for treatment. minimizing stress and providing an adequate level of vitamin c help to prevent clinical infection. oocysts in the feces take 6 days to become infective, therefore regular cleaning of pans will help to minimize the spread of infection (rigby, 1976) . ammonia, followed by a thorough rinsing, has been used to clean cages and pans of infected animals (elsheikha et al., 2009 ). steam has also been used to clean enclosures. calhoon notes that eimeria-free colonies can be achieved via cesarean rederivation (calhoon and matthews, 1964) . etiology the causative agent of guinea pig giardiasis is giardia duodenalis, formally referred to as as g. caviae (baker, 2007; vetterling, 1976) . pathogenesis giardia duodenalis is a flagellate of guinea pigs that is transmitted by the fecal-oral route or via ingestion of contaminated food or water (baker, 2007) . clinical manifestations overt signs of infection, such as diarrhea, are rare, although some animals are severely infected and may present as weak and moribund (baker, 2007) . pathology the small intestine, primarily the duodenum, is colonized by trophozoites (baker, 2007) . colonization may result in mild inflammatory lesions, decreased villar height, and cystic enlargement of duodenal crypts. diagnosis diagnosis of g. duodenalis is via direct fecal smear, where trophozoites or cysts may be observed (baker, 2007) . only trophozoites, and not cysts, are found in diarrheic feces (vetterling, 1976) . shedding of g. duodenalis is intermittent, so unless multiple fecal smears are performed, there is a high likelihood of obtaining a falsenegative result. felasa recommends including giardia spp. on guinea pig breeding colony health monitoring reports (rehbinder et al., 1996) . prevention and therapy metronidazole and fenbendazole are treatment options for guinea pig giardiasis (baker, 2007) . infection can be prevented by thorough environmental sanitation using a quaternary ammonium product or sodium hypocholorite. hot temperatures will destroy cysts. cysts thrive in moist areas, so environments must be kept dry. the zoonotic potential of g. duodenalis of guinea pigs is unknown, but the possibility of transmission between guinea pigs and humans is suspected. klossiella cobayae background k. cobayae is also known as klassia caviae, as it was described and named simultaneously by two individuals, pearce and sangiori (respectively) working independently of each other (vetterling, 1976) . occurrence in modern laboratory guinea pigs is rare (percy and barthold, 2007) . etiology klossiella cobayae is the causative organism. pathogenesis k. cobayae is a parasite of the epithelial cells of the renal tubules, as well as the endothelial cells associated with glomerular capillaries and other organs, such as the spleen and lungs (griffiths, 1971; van andel et al., 1995; vetterling, 1976) . transmission is via ingestion of sporocysts in urine (baker, 2007) . (baker, 2007; sebesteny, 1976) . heavy infection can lead to an irregular surface and a gray mottled appearance of the kidney (baker, 2007; fox, 2002) . interstitial and perivascular lymphocytic and histiocytic infiltration may occur (baker, 2007) . a large number of interstitial fibroblasts may also be observed. diagnosis sporocysts are passed in the urine, yet observation of this stage in the urine is difficult (baker, 2007) . most often, diagnosis is made at the time of necropsy by identifying the different developmental stages of k. cobayae in glomerular capillaries or in the cytoplasm of epithelial cells lining the renal tubules (baker, 2007; percy and barthold, 2007) . felasa recommends including klossiella spp. as part of a health monitoring report for guinea pig breeding colonies (rehbinder et al., 1996) . prevention and therapy control of k. cobayae is best achieved through prevention. contamination of food and bedding with infective urine should be minimized (baker, 2007) . sulfonamides might be effective forms of treatment. background leishmania enrietti was first noted in laboratory guinea pigs in 1948 in brazil (medina, 1946) . according to the review by machado et al., this flagellate was next reported in 1967 in a guinea pig captured from the outskirts of curitiba (machado et al., 1994) . the sandfly, lutzomyia monticola, which is frequently noted on the trunks of curitibia pine trees, was proposed as a possible vector. etiology leishmania enrietti is the causative organism. pathogenesis little is known about the lifecycle of l. enrietta, but other members of the genus leishmania have indirect lifecycles and sandfly vectors (baker, 1998 (baker, , 2007 nie, 1950) . l. enrietta results in cutaneous infection. an infected guinea pig may present with a cutaneous nodule at the site of entry 1-2 weeks after infection (baker, 2007) . additionally, ulcers can develop on the feet, ears, nose, and genitalia of infected animals. ulcers will go through a series of pathologic changes, such as necrosis of surrounding macrophages 4-5 weeks after initial infection (especially in naive animals), followed by an infiltrate of giant cells, plasma cells, and lymphocytes at the periphery of the ulcer. by 7 weeks, giant cells are gone and fibroblasts appear, indicating resolution. resolution is usually complete by 10 weeks post-infection. hematogenous spread of the organism can occur and l. enrietti may be observed in the lymph nodes. diagnosis detection is via identification of amastigotes in lesion histology or via culture of the organism (baker, 2007) . control is achieved by elimination of vectors. treatment with meglumine antimoniate has been attempted, with inconsistent success (thomaz-soccol et al., 1996) . contact with possible sandfly vectors should be avoided. background this organism was first reported in brazil by carini and migliano (vetterling, 1976) . in early reports, t. gondii was mistaken for sarcocystis in the guinea pig (kean and grocott, 1945) . etiology toxoplasma gondii is the causative organism. pathogenesis cats are the definitive hosts of t. gondii (baker, 2007) . oocysts are released in cat feces and are ingested by guinea pigs which act as intermediate hosts for t. gondii. cysts can remain viable in a guinea pig for up to five years before ingestion by the definitive host. in addition to the guinea pig, a large number of mammalian and avian species are intermediate hosts to t. gondii, including humans. ingestion of contaminated biological material and transplacental transmission are alternative routes of transmission for the guinea pig (baker, 2007; percy and barthold, 2007) . clinical manifestations t. gondii infection in guinea pigs is often asymptomatic and, therefore, frequently goes undiagnosed (baker, 2007; griffiths, 1971; percy and barthold, 2007) . infection in pregnant sows can result in vulvar bleeding and abortion (fox, 2002) . in a case of spontaneous toxoplasma encephalitis in a guinea pig, spastic paralysis, opisthotonos, and loss of urethral and anal sphincter control were reported (markham, 1937) . pathology hepatitis, pneumonia, encephalitis, and uterine infection (possibly blood-filled), have been noted in infected animals, as have cysts in both the myocardium and central nervous system (baker, 2007; fox, 2002; percy and barthold, 2007) . in spontaneously infected animals that develop toxoplasma encephalitis, congested blood vessels of the meninges were noted and were surrounded by mononuclear leukocytes (markham, 1937) . diagnosis serology is often used for diagnosis in guinea pigs (baker, 2007) . cysts can be observed on histology. mice or hamsters can be inoculated with tissue homogenate from suspected positives and act as sentinels of infection. felasa recommends including toxoplasma gondii on guinea pig breeding colony health monitoring reports (rehbinder et al., 1996) . sulfadiazine and pyrimethamine are reported treatment options for clinical cases of t. gondii, yet the effectiveness of such treatments is questionable (baker, 2007; fox, 2002) . temperatures above 60â°c kill oocysts (baker, 2007) . strict sanitation and periodic colony monitoring are necessary for t. gondii control. background tritrichomonas caviae has also been referred to as trichomonas caviae and t. flagelliphora (tanabe, 1925) . etiology tritrichomonas caviae is one of the largest intestinal flagellates of the guinea pig, measuring an average of 16 î¼m long by 8.5 î¼m wide (baker, 2007) . no cyst stage is known. pathogenesis transmission of t. caviae is fecaloral (baker, 2007) . clinical manifestations tritrichomonas caviae is a non-pathogenic flagellate of guinea pigs (baker, 2007) . pathology t. caviae is most often noted in the cecum, although it has been observed in the duodenum, jejunum and lower ileum as well (baker, 2007) . although rare, tissue invasion and cecal or colonic ulceration are possible. diagnosis diagnosis of t. caviae is via direct fecal smear (tanabe, 1925) . prevention and therapy t. cavaie does not usually result in clinical signs or pertinent pathology and does not routinely require treatment (baker, 2007) . guinea pigs, among other mammals, are reservoirs for the flagellate t. cruzi (baker, 2007; vetterling, 1976) . reduviid bugs act as vectors, becoming infected after a blood meal from a positive animal. t. cruzi mature and reproduce within the vector. the bugs then go on to deposit t. cruzi-containing feces on humans during another blood meal. the organism enters human skin through a wound (potentially the bug bite) or contact with mucous membranes. chagas disease may result in humans. in the guinea pig, t. cruzi can encyst in multiple organs, including the skin and cardiac muscule. t. cruzi has been noted in domesticated guinea pigs of south america exposed to reduviid vectors. clinical and pathological signs are not described. the reader is once again directed to flynn's parasites of laboratory animals for further discussion on many of the parasites discussed below, including anatomical appearances and detailed life cycles (baker, 2007) . the nomenclature used in this section is also in accordance with this reference. note: the common names of arthropod organisms have been used in place of the name of the resulting condition (e.g. flies instead of myiasis). ctenocephalides felis has been noted on pet guinea pigs living in a household with cats and/or dogs. infected guinea pigs presented with pruritus, alopecia, dermal crusts, and anemia (white et al., 2003) . aqueous-based pyrethrin sprays have been recommended as the safest treatment option for such infection. nosopsyllus fasciatus, the northern rat flea, can also inhabit guinea pigs, although similarly to c. felis, infection of laboratory guinea pigs is rare (fox, 2002) . it has been stated that "fatal myiasis involving at least three species of flies, lucilia sericata, calliphora vicina and calliphora vomitoris, have been reported in guinea pigs" (baker, 2007) . eggs are deposited on the skin of a guinea pig by an adult fly, where larvae will develop and then feed on living or necrotic animal tissue (baker, 2007) . (baker, 2007) . g. porcelli, the most commonly observed of the three, is known as the "slender louse" due to its general appearance, especially when compared to g. ovalis or the "oval louse" (baker, 2007; harkness and wagner, 1995; kim et al., 2008) . several species of sucking lice (order anoplura) have been noted on wild guinea pigs in south america: pterophtirus alata and polyplax spinulosa (dittmar, 2002) . these later lice are listed in table 23 .1, but not discussed here in detail. pathogenesis biting lice attach to hair shafts and abrade the skin to ingest cutaneous fluids (fox, 2002; kim et al., 2008) . transmission is via direct contact (harkness and wagner, 1995; kim et al., 2008) . the life cycles of guinea pig lice are not specifically described, but in general, biting lice go through the following stages: egg, three nymphal stages, and adult (baker, 2007) . clinical manifestations g. ovalis, g. porcelli or t. hispidium infection of a guinea pig can be asymptomatic or may result in pruritus and a rough hair coat or alopecia (baker, 2007; coman et al., 2009; harkness and wagner, 1995; kim et al., 2008; percy and barthold, 2007; rigby, 1976) . scabs and crusts are sometimes noted secondary to scratching, especially around the ears (harkness and wagner, 1995) . pathology signs of louse infection are usually superficial. dermatitis may be noted grossly. diagnosis lice (adults or nits) can be seen on the haircoat of an infected animal, with or without the aid of a magnifying lens (figure 23 .6) (baker, 2007; griffiths, 1971 ). on a dead animal, lice will migrate to the warm tips of the hair as the skin cools (griffiths, 1971) . tape tests and flea combing can also be used to diagnose louse infestation (coman et al., 2009) . as stated previously, g. porcelli is slender in appearance (1.0-1.5 mm î�³ 0.3-0.4 mm), compared to g. ovalis (1.0-1.2 mm î�³ 0.5 mm) (figure 23 .7) (huerkamp et al., 1996) . t. hispidum's dimensions are similar to those of g. ovalis, yet can be differentiated by the fact that t. hispidum has five abdominal segments as compared to g. ovalis' eight. in reports of successful control of guinea pig louse infestations, both infected animals and the environment have been treated (harkness and wagner, 1995; kim et al., 2008) . systemic ivermectin (baker, 2007; white et al., 2003) , carbamate or pyrethrin-based powders (baker, 2007; griffiths, 1971) , romavermectin b1 (coman et al., 2009 ) and a combination of imidacloprid and moxidectin (kim et al., 2008) have been noted as effective drug choices for treating infected guinea pigs. hypochlorite bleach has been used for environmental decontamination (kim et al., 2008) . guinea pigs are susceptible to infection with several species of mites, some occurring more commonly than others. chirodiscoides caviae and trixacarus caviae are the most commonly noted infectious mites in guinea pigs, with demodex caviae, myocoptes musculinus, sarcoptes scabies and notoedres muris reported less frequently (baker, 2007; fox, 2002; white et al., 2003) . infection with the astigmatic mite, acarus farris, was described in a case report of two guinea pigs (linek and bourdeau, 2005) . psocoptes cuniculi has been described on a pet guinea pig in close contact with a pet rabbit (yeatts, 1994) . white et al. (2003) note cheyletiella parasitivorax as a cause of pruritus and scaling along the dorsum of guinea pigs. the more commonly noted mites, c. caviae and t. cavaie, will be discussed below. the first reports and illustrations of c. caviae were by stanley hirst in the early 1900s (hirst 1922 ). hirst noted this mite attached to the hairs of the back of the guinea pig. etiology chirodiscoides caviae is the causative organism (figure 23.8 ). pathogenesis c. caviae is a species-specific fur mite that tends to concentrate in the lumbar area and the lateral aspects of the hindquarters (harkness and wagner, 1995; percy and barthold, 2007; schonfelder et al., 2010) . c. caviae feed on the scales of hair shafts (hirsjarvi and phyala, 1995) and transmission is via direct contact with an infected animal (fox, 2002; schonfelder et al., 2010) or with infected cage debris or bedding (fox, 2002) . the life cycle of c. caviae has not been specifically described, although mites in general commonly go through egg, larval, nymphal, and adult stages (baker, 2007) . concurrent infection with lice is not uncommon (white et al., 2003) , and mixed infection with demodex caviae (detected via deep skin scrapping) has also been reported (schonfelder et al., 2010) . clinical manifestations infection with c. caviae can be asymptomatic or, if infestation is heavy, pruritis, alopecia, hyperemia, and dermal crusts may be seen (coman et al., 2009; fox, 2002; hirsjarvi and iii. guinea pigs phyala, 1995; lumeij and cremers, 1986; schonfelder et al., 2010) . anorexia may result secondary to grooming pruritic areas (schonfelder et al., 2010) . the appearance of c. caviae mites themselves is the major pathologic finding (fox, 2002) . mites and ova are located on the hair shafts of the guinea pigs, not burrowed into the skin. diagnosis mites may be seen with the unaided eye, hand lens or dissecting microscope. c. caviae can also be found on a superficial scrape (harkness and wagner, 1995; percy and barthold, 2007; schonfelder et al., 2010) . combing, hair plucking, and cellophane tape testing can aid in isolating mites for observation (white et al., 2003) . prevention and therapy many treatment options have been described in the literature for c. caviae. dilute ivermectin (diluted in aqua/propylene glycol) sprays have been successful, especially for treating large colonies of infected animals (baker, 2007; hirsjarvi and phyala, 1995; white et al., 2003) . selamectin, 12-15 mg/ kg, applied twice at 2-week intervals has also eliminated infection (baker, 2007; fox, 2002; schonfelder et al., 2010) . pyrethrin sprays and powders have been used to rid the environment of c. caviae (harkness and wagner, 1995; hirsjarvi and phyala, 1995) . 1% virkon s â® was used to treat an automatic watering system (hirsjarvi and phyala, 1995) . older successful treatments include the use of dichlorvos vapors (henderson, 1973) as well as immersion of shaved animals in 0.15% trichlorfon (lumeij and cremers, 1986 ) . background t. caviae was discovered in a colony of albino guinea pigs in the early 1970s by fain and was described as a disease very similar in appearance to sarcoptic mange in other animals (dorrestein and vanbronswijk, 1979; fain et al., 1972) . the first report of t. caviae in north america was in 1980 at davis, california (mcdonald and lavoipierre, 1980) . etiology trixacarus caviae is the causative organism (figure 23 .8). trixacarus caviae is a species-specific sarcoptic mite that most commonly affects guinea pigs that are 1-3 years of age (dorrestein and vanbronswijk, 1979) . if left untreated, the parasite load peaks 1 month post-infection, after which it slowly regresses (fuentealba and hanna, 1996) . the life cycle of t. caviae includes an egg, larval, two nymphal, and a final adult stage, all of which inhabit the host guinea pig (baker, 2007) . transmission is by direct contact, with nymphal or larval stages indicated in establishing new infestations (baker, 2007; rothwell et al., 1991) . within 72 hours, pups born to an infected guinea pig dam will show clinical signs consistent with t. caviae infestation (beck et al., 2007; kummel et al., 1980) . humans have been reported to develop transient pruritic, papulovesicular dermatitis after contact with infected animals, although mites appear to be incapable of persisting on human skin (fuentealba and hanna, 1996; kummel et al., 1980; mederle and indre, 2009) . t. caviae may be asymptomatic and result in non-clinical carrier animals, t. caviae has been reported as the most common and important cause of dermatitis in guinea pigs (dorrestein and vanbronswijk, 1979; fuentealba and hanna, 1996; percy and barthold, 2007; white et al., 2003) . severe pruritis and excoriation along with erythema and alopecia can accompany dermatitis in some animals (ackerman, 1987; beck et al., 2007; dorrestein and vanbronswijk, 1979) . in those guinea pigs that are clinical, grayish to yellow or white crusts may be present on the skin and can be dry or slightly greasy (ackerman, 1987; dorrestein and vanbronswijk, 1979) . secondary bacterial infections of infected skin areas are possible (fuentealba and hanna, 1996) . infection usually starts on the face and ears, spreading to the lumbar regions and lateral aspects of the legs (dorrestein and vanbronswijk, 1979; percy and barthold, 2007) . the intense pruritic response in some guinea pigs is reported to be due to an initial allergic reaction to mite antigen (fox, 2002) . extreme restlessness and emaciation have been noted in affected animals, especially in those that seemingly scratch uncontrollably (beck et al., 2007) . this constant scratching can lead to "fits" of muscular spasms or sporadic epileptiform seizures (ackerman, 1987; beck et al., 2007; dorrestein and vanbronswijk, 1979; kummel et al., 1980) caused by generalized pruritus-induced hyperesthesia (baker, 2007) . pathology orthokeratotic hyperkeratosis and acanthosis have been noted in animals showing clinical signs of t. caviae infection (ackerman, 1987; dorrestein and vanbronswijk, 1979; fuentealba and hanna, 1996; zenoble and greve, 1980) . a polymorphonuclear leucocytic infiltrate is present in the dermis (dorrestein and vanbronswijk, 1979; percy and barthold, 2007; rothwell et al., 1991; zenoble and greve, 1980) . adult mites may be noted in "tunnels" or burrows located in the hyperkeratotic areas (dorrestein and vanbronswijk, 1979; zenoble and greve, 1980) . such tunnels approach the epidermis perpendicularly, with some entering the mouth of hair follicles (zenoble and greve, 1980) . eggs may also be present in tunnels (dorrestein and vanbronswijk, 1979) . t. caviae mites have sharp spines on the cuticle of their dorsums (zenoble and greve, 1980) , which differentiates them from notoedres (ackerman, 1987) . the anus of the female t. caviae mite is located dorsally, while this structure is located terminally on s. scabiei (ackerman, 1987; baker, 2007; fuentealba and hanna, 1996) . diagnosis deep skin scrapes of crusted areas with 10% koh reveal t. caviae (dorrestein and vanbronswijk, 1979; fain et al., 1972; fuentealba and hanna, 1996; mederle and indre, 2009 ). zajac et al. (1980) report that live mites could be demonstrated for 5 days postmortem from deep skin scrapings taken from a guinea pig held at 4â°c after death. prevention and therapy treatment of both affected animals and the environment has been employed to rid guinea pig colonies of t. cavaie. multiple treatment regimens have been reported as successful over the years, including lindane baths (dorrestein and vanbronswijk, 1979; zajac et al., 1980) , weekly lime sulfur dips (ackerman, 1987; mcdonald and lavoipierre, 1980; zenoble and greve, 1980) , ivermectin injections (white et al., 2003) , and monthly spot-on treatment with 10% imidacloprid and 1% moxidectin (beck et al., 2007) . dilute lime sulfur can also be used to treat the environment (white et al., 2003) . valium has been used to control seizure-like activity related to t. cavaie infection by some, whereas others suggest that treating the mite infection alone eliminates this sequela to infection (beck et al., 2007; white et al., 2003) . according to harkness and wagner (1995) , tapeworms rarely infect guinea pigs. anoplocephala spp. and monoecocestus parcitesticulatus (table 23 .1) have been reported in the intestines of south american guinea pigs (baker, 2007; sardella and fugassa, 2009 ). etiology baylisascaris procyonis is the causative organism. pathogenesis guinea pigs are paratenic hosts of b. procyonis and contract infection by ingesting eggs in raccoon feces (baker, 2007) . once ingested, larvae will hatch and penetrate the small intestine of the guinea pig, migrate through the liver to the lungs and disseminate throughout the body via the circulatory system. larvae then encapsulate where they remain until ingested by a raccoon. clinical manifestations no signs are present in the guinea pig due to b. procyonis unless organisms migrate to the brain. migration can result in lethargy, head tilt and ataxia, which may progress to cachexia, stupor, hyperexcitability, lateral recumbency, torticollis, or opisthotonos (van andel et al., 1995) . pathology in cases were b. procyonis migrates to the brain, multifocal eosinophilic granulomatous inflammation and neutrophilic infiltration is seen, along with perivascular lymphoid cuffing and malacia (van andel et al., 1995) . eosinophilic granulomata have been noted in the lungs of some infected animals. diagnosis histology is diagnostic for b. procyonis (baker, 2007) . the baermann extraction technique can be used to extract organisms from the cerebral tissue of clinical animals (van andel et al., 1995) . prevention and therapy prevention, rather than treatment, is the most logical approach for b. procyonis control, as clinical signs are often not noted until the end stage of infection and diagnosis relies on histopathology. contamination of bedding or food with raccoon feces must be avoided. ova can be viable for years in soil and weeks to months in straw and are resistant to most disinfectants (fox, 2002) . removal of contaminated bedding and the autoclaving of caging may be required (baker, 2007) . humans, similarly to guinea pigs, can contract infection by ingesting raccoon feces, but transmission from guinea pigs to humans is not feasible (fox, 2002) . etiology paraspidodera uncinata is the causative organism. epizootiology and pathogenesis p. uncinata is the cecal worm of guinea pigs and the most common nematode infecting this species (griffiths, 1971) . the prevalence of p. uncinata in wild guinea pigs of south america was found to be 37%, while the prevalence was noted as 23.8% in a laboratory colony of guinea pigs (coman et al., 2009; dittmar, 2002) . transmission is via ingestion of an embyronated egg in feces (baker, 2007; fox, 2002) . eggs become infectious 3-5 days after they are initially shed (fox, 2002) . the life cycle is not well described (baker, 2007) . clinical manifestations infections are normally asymptomatic, but with heavy parasitic loads weight loss, diarrhea, and disability are possible (fox, 2002) . pathology infection can, and often does, occur without pathologic changes (baker, 2007; percy and iii. guinea pigs barthold, 2007; rigby, 1976) . if cecal worms migrate through the intestinal mucosa, a hemorrhagic typhlitis may be seen along with capillary ectasis in the submucosa (coman et al., 2009 ). diagnosis adult worms may be seen in the cecum at necropsy and eggs may be observed in feces ( figure 23 .9) (baker, 2007; rigby 1976) . prevention and therapy levimasole administered at 25 mg/kg, either orally or subcutaneously, has most often been reported as an effective treatment for p. uncinata in the guinea pig (baker, 2007; eliazian et al., 1975) . other reported treatment regimens include oral mebendazole at 50 mg/kg (baker, 2007) and romavermectin b1 given subcutaneously at a dose of 0.2 mg/kg twice at a three-week interval (coman et al., 2009) . etiology pelodera strongyloides is the causative organism. pathogenesis p. strongyloides organisms are usually found in damp soil or vegetation (white et al., 2003) . bedding can be a possible source of infection. clinical manifestations while typically nonpathogenic, if p. strongyloides invade hair follicles dermatitis can result (baker, 2007; white et al., 2003) . pathology organisms may be found in hair follicles of clinically infected animals. the observation of larvae in skin scrapings or biopsies signifies infection (white et al., 2003) . adults may be observed in the bedding. prevention and therapy cages should be kept dry, as organisms thrive in moist environments (white et al., 2003) . the bedding of any positive animal should be replaced. a 1-2% chlorhexadine bath has been recommended for infected animals as a means of preventing secondary infections. trichinellosis due to trichinella spiralis is possible in guinea pigs, but rare, especially in laboratory animals that seldom come in contact with infected material (raw or undercooked meat) (sebesteny, 1976) . enteritis could develop in infected animals if t. spiralis organisms migrate through the intestinal wall. fasciola background infection in present laboratoryhoused guinea pigs is rare, but when fasciola organisms are noted it is often in conjunction with recent diet supplementation of a leafy vegetable carrying encysted trematodes (baker, 2007; fox, 2002) . etiology two fasciola species are noted in guinea pigs, fasciola hepatica and fasciola gigantica (baker, 2007) . f. gigantica is slightly larger in size than f. hepatica, although f. gigantica rarely reach patency in guinea pigs. pathogenesis guinea pigs ingest encysted fasicola metacercariae on vegetation (baker, 2007; fox, 2002) . once ingested, metacercariae hatch in the small intestine and migrate through the wall to the peritoneal cavity and the liver. juvenile flukes develop in the liver and, once mature, burrow in the bile ducts. eggs are shed and enter the gut, where they pass in the feces. a snail intermediate host is necessary for maturation from cercariae to infectious metacercariae. metacercariae encyst on leafy vegetation. clinical manifestations emaciation and anemia have been associated with fasciola infection (sebesteny, 1976) . posterior paresis was noted in animals that developed cysts in the lumbar musculature after aberrant fluke migration (baker, 2007) . pathology hepatic congestion and hemorrhage, especially around portal vessels, central veins and sinusoids is possible (baker, 2007) . fibronecrotic tracks and granulomas may also be observed in the liver. other pathology due to fluke infection is often the result of aberrant migration, resulting in cysts in areas such as the kidney, the peritoneal cavity and the pelvic cavity. cysts often contain coffee-brown-colored material. diagnosis fasciola spp. can be observed on fecal flotation (baker, 2007) . prevention and therapy prevention is best achieved by limiting the amount of leafy vegetation supplemented in a guinea pig's diet; if supplemented, do not feed vegetation from fluke-endemic locations. fasciola in ruminants is treated with albendazole and clorsulon (baker, 2007) . haverhill fever with spine involvement trixacarus caviae infestation in a guinea pig studies on fungal flora in hair from domestic and laboratory animals suspected of dermatophytosis. i. dematophytes saprophytic fungi isolated from the hair of domestic and laboratory animals with suspected dermatophytosis the isolation of streptobacillus moniliformis from cervical abscesses of guinea-pigs epidemiology of superficial fungal infections pet rodents and fatal lymphocytic choriomeningitis in transplant patients flynn's parasites of laboratory animals natural pathogens of laboratory mice, rats, and rabbits and their effects on research dermatophytes in clinically healthy laboratory animals in utero transmission of encephalitozoon cuniculi strain type i in rabbits target tissues associated with genital infection of female guinea pigs by the chlamydial agent of guinea pig inclusion conjunctivitis scratching, hyperkeratosis and ectoparasites in a guinea pig spontaneous cryptococcal meningitis in a group of guinea pigs caused by a hyphae-producing strain cytomegalovirus infection in guinea pigs. iii. persistent viruria, blood transmission, and viral interference new endogenous herpesvirus of guinea pigs: biological and molecular characterization transmission pattern of parainfluenza 3 virus in guinea pig breeding herds infection caused by leptospira pomona in pampas guinea pigs (cavia pamparum). i. existence in a natural population basidiomycetous yeasts superficial veterinary mycoses bergey's manual of systematic bacteriology clostridium difficileassociated typhlitis in specific pathogen free guineapigs in the absence of antimicrobial treatment an enzymelinked immunosorbent assay (elisa) for monitoring guineapigs and rabbits for bordetella bronchiseptica antibodies an enzyme-linked immunosorbent assay (elisa) for monitoring rodent colonies for streptobacillus moniliformis antibodies pcr for the detection of streptobacillus moniliformis an enzymelinked immunosorbent assay (elisa) for monitoring antibodies to sp group pasteurellaceae in guineapigs positive streptobacillus moniliformis pcr in guinea pigs likely due to leptotrichia spp detection of antibodies to streptobacillus moniliformis in rats by an immunoblot procedure serological evidence for encephalitozoon cuniculi infection (nosemiasis) in gnotobiotic guineapigs vertical transmission of bacillus piliformis infection (tyzzer's disease) in a guinea pig: case report opportunistic infections in hysterectomyderived, barrier-maintained guinea pigs successful treatment and polymerase chain reaction (pcr) confirmation of tyzzer's disease in a foal and clinical and pathologic characteristics of 6 additional foals atypical fatal pulmonary botryomycosis in two guinea pigs due to pseudomonas aeruginosa epizootic lymphadenitis -a new disease of guinea pigs naturally occurring virus-associated respiratory disease in two guinea pigs bacillus pumilus in the induction of clindamycin-associated enterocolitis in guinea pigs proteomic analysis of the eukaryotic parasite encephalitozoon cuniculi (microsporidia): a reference map for proteins expressed in late sporogonial stages treatment of pododermatitis in the guinea pig comparative and functional genomics provide insights into the pathogenicity of dermatophytic fungi pathogenicity of an emergent, ovine abortifacient campylobacter jejuni clone orally inoculated into pregnant guinea pigs a method for initiating a colony of specific pathogen-free guinea pigs update: interim guidance for minimizing risk for human lymphocytic choriomeningitis virus infection associated with pet rodents on-line) technical sheet: "bordetella bronchiseptica zoonotic aspects of arenavirus infections dermatophytoses in animals cytomegalovirus infection in guinea pigs. ii. transplacental and horizontal transmission cryptosporidiosis in guinea pigs: an animal model comparison of the host ranges and antigenicity of cryptosporidium parvum and cryptosporidium wrairi from guinea pigs epidemiological evidence of listeriosis in guinea pigs fed with cabbage (brassica oleracea) in nigeria experimental models for study of common respiratory viruses variations in the virulence, for pregnant guinea pigs, of campylobacters isolated from man a filterable virus present in the submaxillary glands of guinea pigs case report of listerial keratoconjunctivitis in hairless guinea pigs colonisation and shedding of lawsonia intracellularis in experimentally inoculated rodents and in wild rodents on pig farms aspects of the parasitary infestations of guinea pigs reared in intensive system naturally occurring histoplasmosis in guinea pigs listeriology (1926-2007): the rise of a model pathogen results of diagnostic ophthalmic testing in healthy guinea pigs the intestinal flora of the guinea pig asymptomatic adenoviral respiratory tract infection in guinea pigs epizootic lymphadenitis in guinea-pigs due to an encapsulated mucoid hemolytic streptococcus immunological relationships of an endogenous guinea pig retrovirus with prototype mammalian type b and type d retroviruses guineapig inclusion conjunctivitis (gpic) in a commercial colony microsporidiosis: current status modeling human listeriosis in natural and genetically engineered animals arthropod and helminth parasites of the wild guinea pig, cavia aperea, from the andes and the cordillera in peru, south america sequence comparison of the large genomic rna segments of two strains of lymphocytic choriomeningitis virus differing in pathogenic potential for guinea pigs trixacarus-caviae fain, howell and hyatt 1972 (acari, sarcoptidae) as a cause of mange in guinea-pigs and papular urticaria in man lymphoproliferative changes induced by infection with a lymphotropic herpesvirus of guinea pigs evaluation of antibacterial activity of cefodizime, ceftriaxone and cefonicid in klebsiella pneumoniae-infected guinea pigs pets as the main source of two zoonotic species of the trichophyton mentagrophytes complex in switzerland, arthroderma vanbreuseghemii and arthroderma benhamiae comparative pathology and pathogenesis of naturally acquired and experimentally induced colonic spirochetosis microsporidian life cycles and diversity: the relationship between virulence and transmission naturally developing virus-induced lethal pneumonia in two guinea pigs (cavia porcellus) rabies virus infection in a pet guinea pig and seven pet rabbits control of paraspidodera unicinata in guinea-pigs with levamisole coccidiosis in guinea-pigs death and diarrhea in guinea pigs (cavia porcellus) duodenal hyperplasia in a guinea pig emended description of the order chlamydiales, proposal of parachlamydiaceae fam. nov. and simkaniaceae fam. nov., each containing one monotypic genus, revised taxonomy of the family chlamydiaceae, including a new genus and five new species, and standards for the identification of organisms a new sarcoptid mite producing mange in albino guinea-pigs enteritis and coliform bacteremia in guinea pigs given penicillin virus taxonomy: classification and nomenclature of viruses: eighth report of the international committee on taxonomy of viruses comparison of the deduced amino acid sequence of guinea pig adenovirus hexon protein with that of other mastadenoviruses multifocal necrotizing enteritis with hepatic and splenic infarction associated with clostridium perfringens type a in a guinea pig raised in a conventional environment saprophytic occurrence of trichophyton mentagrophytes and microsporum gypseum in the coats of healthy laboratory animals adenovirus pneumonia in guinea pigs family outbreak of salmonellosis due to contact with guinea pigs streptobacillus moniliformis isolations from cervical abscesses of guinea-pigs laboratory animal medicine phylogenetic analysis of trichophyton mentagrophytes human and animal isolates based on mnsod and its sequence comparison mange induced by trixacarus caviae in a guinea pig detection by pcr of the tyzzer's disease organism (clostridium piliforme) in feces rat bite fever detection of chlamydophila caviae and streptococcus equi subsp. zooepidemicus in horses with signs of rhinitis and conjunctivitis application and validation of pfge for serovar identification of leptospira clinical isolates the biology of the guinea pig a survey of encephalitozoon cuniculi in laboratory animal colonies in the united kingdom laboratory identification of the microsporidia molecular diagnostic tests for microsporidia the effect of parainfluenza 3 infection on guinea pig basophil and lung mast cell histamine release medical microbiology : a guide to microbial infections: pathogenesis, immunity, laboratory diagnosis, and control gastrointestinal parasites of cavy (cavia aperea aperea) in southern brazil cytomegalovirus infection in guinea pigs. iv. maternal infection at different stages of gestation enhancement of cytomegalovirus infection during pregnancy in guinea pig experimental pneumonia virus of mice infection of guineapigs spontaneously infected with bordetella bronchiseptica some common parasites of small laboratory animals mastitis in guinea pigs virus-like particles in a fibrovascular growth in guinea pigs guinea pig adenovirus infection does not inhibit cochlear transfection with human adenoviral vectors in a model of hearing loss a serological indication of the existence of a guineapig poliovirus the biology and medicine of rabbits and rodents composition and characteristics of urinary calculi from guinea pigs intestinal spirochetosis in a guinea pig with colorectal prolapse treatment of cutaneous acariasis in the guinea pig trichophyton mentagrophytes skin infections in laboratory animals as a cause of zoonosis ivermectin treatment of a colony of guineapigs infested with fur mite (chirodiscoides caviae) mites injurious to domestic animals. order of the trustees of the british museum spontaneous infection in the guinea-pig an epizootic of pneumococcus type 19 infections in guinea pigs incidence and ecology of campylobacter jejuni and coli in animals real-time multiplex polymerase chain reaction assay for rapid detection of clostridium difficile toxin-encoding strains haemorrhagic septicemia in man due to capsulated bacilli onygenales, arthrodermataceae. pathogenic fungi in humans and animals viruses of guinea pigs: considerations for biomedical research cytomegalovirus infection in guinea pigs. i. viremia during acute primary and chronic persistent infection guinea pig leukocytes: in vivo and in vitro infection with a herpes-like virus herpeslike virus isolated from spontaneously degenerated tissue culture derived from leukemiasusceptible guinea pigs herpesvirus infection of guinea pigs. i. isolation, characterization and pathogenicity guinea pigs epizootiological studies of salmonella typhimurium infection in guinea pigs naturally occurring tyzzer's disease in a calf committee on infectious diseases of mice and rats. and national cancer institute an exfoliative skin disease in guinea pigs due to staphylococcus aureus coronavirus-like virions associated with a wasting syndrome in guinea pigs an intracellular protozoan parasite of the ducts of the salivary glands of the guinea-pig activity of bleach, ethanol and two commercial disinfectants against spores of encephalitozoon cuniculi on the pathogenesis of cavian leukemia genome sequence and gene compaction of the eukaryote parasite encephalitozoon cuniculi sarcosporidiosis or toxoplasmosis in man and guinea-pig development of a model of chronic lymphocytic leukemia in inbred strain 2 guinea pigs spontaneous epizootic of pneumococcus infection in guinea-pigs immune response to encephalitozoon cuniculi infection the rise of the rats: a growing paediatric issue use of a formulation containing imidacloprid and moxidectin in the treatment of lice infestation in guinea pigs bacterial mastitis in guinea pigs isolation of streptobacillus moniliformis from a guinea pig with granulomatous pneumonia clindamycin-associated enterocolitis in guinea pigs: evidence for a bacterial toxin leptospira: the dawn of the molecular genetics era for an emerging zoonotic pathogen bacterial otitis media in the guinea pig development of poliovirus infection in laboratory animals of different species seromonitoring in small laboratory animal colonies. a five year survey: 1984-1988 trixacarus caviae infestation of guinea pigs fungus paecilomyces: a new agent in laboratory animals adenovirus pneumonia in guineapigs: an experimental reproduction of the disease torulopsis pintolopesii -an opportunistic pathogen in guineapigs? proliferative enteropathy isolation of virus-like particles from the urine of guinea pigs (cavia porcellus) with spontaneous diabetes mellitus microsporidia evolved from ancestral sexual fungi isolation of actinobacillus lignieresii and actinobacillus equuli from laboratory rodents veterinary protozoology pathology of guinea pigs experimentally infected with a novel reovirus and coronavirus isolated from sars patients alopecia in two guinea pigs due to hypopodes of acarus farris (acaridae: astigmata) animal chlamydioses and zoonotic implications dermatophytes isolated from laboratory animals use of quantitative real-time pcr for studying the dissemination of leptospira interrogans in the guinea pig infection model of leptospirosis clostridium difficile-associated cecitis in guinea pigs exposed to penicillin citrobacter rodentium, the causative agent of transmissible murine colonic hyperplasia, exhibits clonality: synonymy of c. rodentium and mouse-pathogenic escherichia coli chlamydiales in guineapigs and their zoonotic potential naturally acquired infections with leishmania enriettii muniz and medina 1948 in guinea-pigs from sao paulo spontaneous infection in ex-germfree guinea pigs due to clostridium perfringens diminished reproduction, failure to thrive, and altered immunologic function in a colony of t-cell receptor transgenic mice: possible role of citrobacter rodentium spontaneous toxoplasma encephalitis in the guinea pig staphylococci in man and animals. distribution and characteristics of strains chronic excretion of coronaviruslike particles in laboratory guinea pigs an evolutionary strategy for a stealthy intracellular brucella pathogen efficacy of commercial vaccines for protecting guinea pigs against bordetella bronchiseptica pneumonia zoonotic potential of the microsporidia serodiagnosis of streptococcus pneumoniae infection in guinea pigs by an enzyme-linked immunosorbent assay prevention of cervical lymphadenitis in guinea pigs by vaccination an epizootic in laboratory guinea pigs due to trichophyton mentagrophytes keratinophilic fungi on four animal groups studies on the etiology of snuffles in stock rabbits: paranasal sinusitis, a factor in the interpretation of experimental results trixacarus caviae infestation in two guinea pigs outbreak of fever caused by streptobacillus moniliformis molecular, biological, and in vivo characterization of the guinea pig cytomegalovirus (cmv) homologs of the human cmv matrix proteins pp71 (ul82) and pp65 (ul83) comparison of an espb gene fecal polymerase chain reaction assay with bacteriologic isolation for detection of citrobacter rodentium infection in mice intestinal tyzzer's disease and spirochetosis in a guinea pig campylobacter jejuni infection within a laboratory animal production unit trixacarus caviae infestation in guinea pigs, case report. lucrari stiintifice medicina veterinara xlii estudos sobre leishmaniose: i. primeiros casos de leishmaniose espontã¢nea observados em cobã¡ios biochemical properties of the bromodeoxyuridine-induced guinea pig virus duration of untreated chlamydial genital infection and factors associated with clearance: review of animal studies microsporidiosis (encephalitozoonosis) in the guinea pig observations pointing to the conjunctiva as the portal of entry in salmonella infection of guinea-pigs diagnostic exercise: fetal death in guinea pigs the relation of the psittacosis group (chlamydiae) to bacteria and viruses experimental genital infection of male guinea pigs with the agent of guinea pig inclusion conjunctivitis and transmission to females citrobacter rodentium of mice and man cervical lymphadenitis in guinea pigs: infection via intact ocular and nasal mucosa by streptococcus zooepidemicus a disease of rabbits characterised by a large mononuclear leucocytosis guinea pig inclusion conjunctivitis virus. i. isolation and identification as a member of the psittacosis-lymphogranuloma-trachoma group a survey of streptococcus pneumoniae, streptococcus zooepidemicus, salmonella spp., bordetella bronchiseptica and sendai virus in guinea pig colonies in japan lethal pneumonia in guinea pigs associated with a virus endogenous guinea pig virus: equability of virusspecific dna in normal, leukemic, and virus-producing cells studies on paratyphoid infection in guinea pigs: i. report of a natural outbreak of paratyphoid in a guinea pig population recommendations for the health monitoring of rodent and rabbit colonies in breeding and experimental units morphology and taxonomy of the intestinal protozoa of the guinea-pig, cavia-porcella development of a high-sensitivity nested pcr assay for the detection of clostridium piliforme in clinical samples complete genome sequence of streptobacillus moniliformis type strain (9901) the pathology of experimental yersiniosis in guinea pigs an epizootic infection of citrobacter freundii in a guineapig colony: short communication genetic characterization of parainfluenza virus 3 derived from guinea pigs morphology of cavian leukemia the guinea pig as a model of infectious diseases detection of all chlamydophila and chlamydia spp. of veterinary interest using species-specific real-time pcr assays survey of dermatophytes isolated from the coats of laboratory animals in italy the changing brucella ecology: novel reservoirs, new threats microbiological monitoring of guinea pigs reared conventionally at two breeding facilities in korea susceptibility of inbred and outbred mouse strains to sendai virus and prevalence of infection in laboratory rodents pathology of laboratory rodents and rabbits report of a laboratory epizootic among guineapigs, associated with gaseous emphysema of the liver, spleen, and kidneys, due to bacillus mucosus oapsulatus the citrobacter rodentium genome sequence reveals convergent evolution with human pathogenic escherichia coli resistance to cephalosporins and carbapenems in gram-negative bacterial pathogens exposure to nontraditional pets at home and to animals in public settings: risks to children of guinea pigs and men--an unusual case of jaundice fungal diseases of laboratory rodents an epizootic outbreak of ringworm in a guinea-pig colony caused by trichophyton mentagrophytes polymerase chain reaction for detection of guinea pig adenovirus contemporary prevalence of infectious agents in laboratory mice and rats ferrets, rabbits, and rodents: clinical medicine and surgery efficacy of an oral live vaccine for veterinary use against pseudotuberculosis pathogenesis of endometritis and salpingitis in a guinea pig model of chlamydial genital infection humoral immunity in the resolution of genital infection in female guinea pigs infected with the agent of guinea pig inclusion conjunctivitis a new guinea pig mutant with abnormal hair production and immunodeficiency equine herpesvirus 1 and 4 report of the federation of european laboratory animal science associations (felasa) working group on animal health accepted by the felasa board of management clostridium difficile antitoxin neutralization of cecal toxin(s) from guinea pigs with penicillin-associated colitis implication of clostridium difficile and clostridium perfringens iota toxins in experimental lincomycinassociated colitis of rabbits toxicity of cecal filtrates from guinea pigs with penicillin-associated colitis natural infections of guinea-pigs conventional methods for the diagnosis of dermatophytosis haematological and pathological responses to experimental trixacarus caviae infection in guinea pigs clostridium difficile infection: new developments in epidemiology and pathogenesis paleoparasitological analysis of rodent coprolites in holocenic samples from patagonia an epizootic septicemia of young guinea pigs caused by pseudomonas caviae animal models of congenital cytomegalovirus infection: an overview of progress in the characterization of guinea pig cytomegalovirus (gpcmv) quantitative-competitive pcr monitoring of viral load following experimental guinea pig cytomegalovirus infection analysis of the nucleotide sequence of the guinea pig cytomegalovirus (gpcmv) genome course of chlamydia-induced inclusion conjunctivitis in the guinea pig in experimental animal husbandry concureent infesation of demodex caviae and chirodiscoides caviae in a guinea pig; a case report prevalence of naturally occurring viral infections, mycoplasma pulmonis and clostridium piliforme in laboratory rodents in western europe screened from diseases of guinea-pigs streptobacillus moniliformis isolated from blood in four cases of haverhill fever the first isolation of hortaea werneckii from a household guinea pig characterization of a novel parainfluenza virus, caviid parainfluenza virus 3, from laboratory guinea pigs (cavia porcellus) bacillus piliformis infection (tyzzer's disease) in a patient infected with hiv-1: confirmation with 16s ribosomal rna sequence analysis some bacteriological and environmental factors in the pneumonias of lower animals with special reference to the guineapig clostridial enteric diseases of domestic animals veterinary microbiology: bacterial and fungal agents of animal disease naturally occurring tyzzer's disease in guinea pigs animal cytomegaloviruses isolation of dermatophytes from domestic animals in norway efficacy of a commercial bacterin in protecting strain 13 guineapigs against bordetella bronchiseptica pneumonia conjunctival swab cytology from a guinea pig: it's elementary! ascomycetes, apergillus, fusarium, sporothrix, piedraia, and their relatives molecular analysis and mating behaviour of the trichophyton mentagrophytes species complex a study of trichomonas from the guinea-pig new isolation of leishmania enriettii muniz and medina, 1948 in paranastate, brazil, 50 years after the first description, and isoenzymatic polymorphism of the l. enriettii taxon genome sequence of the non-pathogenic strain 15 of pneumonia virus of mice and comparison with the genome of the pathogenic strain j3666 birefringent spores differentiate encephalitozoon and other microsporidia from coccidia a fatal disease of the japanese waltzing mouse caused by a spore-bearing bacillus (bacillus piliformis cerebrospinal larva migrans due to baylisascaris procyonis in a guinea pig colony leptospirosis in dogs: a review with emphasis on clinical aspects dermal cryptococcosis in a guinea pig disseminated cytomegalovirus disease in the guinea pig viral and chlamydial diseases prevalence of dermatophytes in asymptomatic guinea pigs and rabbits typhlitis caused by intestinal serpulina-like bacteria in domestic guinea pigs (cavia porcellus) the biology of the guinea pig cryptosporidium wrairi sp. n. from the guinea pig cavia porcellus, with an emendation of the genus lesions of experimentally induced tyzzer's disease in syrian hamsters, guineapigs, mice and rats otitis media of guinea pigs sensitivity of encephalitozoon cuniculi to various temperatures, disinfectants and drugs diagnostic exercise: granulomatous encephalitis in guinea pigs therapeutic efficacy of oral lactobacillus preparation for antibiotic-associated enteritis in guinea pigs mammalian microsporidiosis naturally occurring herpes simplex encephalitis in a domestic rabbit (oryctolagus cuniculus) the dermatophytes dermatologic problems in guinea pigs tularemia, plague, yersiniosis, and tyzzer's disease in wild rodents and lagomorphs in canada: a review fatal epizootic equine herpesvirus 1 infections in new and unnatural hosts spontaneous human herpes virus type 1 infection in a chinchilla (chinchilla lanigera f. dom.) human infections associated with bordetella bronchiseptica dogs as vectors of streptobacillus moniliformis infection an epidemic of pasteurella infection in a guinea-pig stock streptobacillus moniliformis -a zoonotic pathogen. taxonomic considerations, host species, diagnosis, therapy, geographical distribution interlaboratory comparison of enzyme-linked immunosorbent assay (elisa) and indirect immunofluorescence (iif) for detection of bordetella bronchiseptica antibodies in guinea pigs rabbit mite infestation development of resistance to reinfection of bordetella bronchiseptica in guinea pigs recovered from natural infection an evaluation of ampicillin pharmacokinetics and toxicity in guinea pigs mange caused by trixacarus caviae in guinea pigs persistent sv5 virus infection in continuous cell cultures sarcoptid mite infestation in a colony of guinea pigs naturally occurring tyzzer's disease and intestinal spirochetosis in guinea pigs key: cord-253295-82ydczid authors: funkhouser, william k. title: pathology: the clinical description of human disease date: 2020-07-24 journal: essential concepts in molecular pathology doi: 10.1016/b978-0-12-813257-9.00011-5 sha: doc_id: 253295 cord_uid: 82ydczid pathology is that field of science and medicine concerned with the study of diseases, specifically their initial causes (etiologies), their step-wise progressions (pathogenesis), and their effects on normal structure and function. this chapter will consider the history of relevant discoveries and technologies that have led to our current understanding of diseases, as well as the pathologist’s current role in the diagnosis, prognosis, and prediction of response of human diseases. this chapter will discuss the fundamental concepts, terminology, and practice of pathology as the discipline dedicated to the understanding of causes, mechanisms, and effects of diseases. a section on key terms, definitions, and concepts is followed by sections on historical human approaches to diseases, an overview of current diagnostic practice, and a vision for new interface with applied molecular biology. pathology (from the greek word pathologı´a, meaning the study of suffering) refers to the specialty of medical science concerned with the cause, development, structural/functional changes, and natural history associated with diseases. disease refers to a definable deviation from a normal phenotype (observable characteristics due to genome and environment), evident via patient complaints (symptoms), and/or the measurements of a careful observer (signs). the cause of the disease is referred to as its etiology (from the greek word meaning the study of cause). one disease entity can have more than one etiology, and one etiology can lead to more than one disease. each disease entity develops through a series of mechanistic chemical and cellular steps. this stepwise process of disease development is referred to as its pathogenesis (from the greek word meaning generation of suffering). pathogenesis can refer to the changes in the structure or function of an organism at the gross/clinical level, and it can refer to the stepwise molecular abnormalities leading to changes in cellular and tissue function. the presentation of a disease to a clinician is in the form of a human patient with variably specific complaints (symptoms), to which the examining physicians can add diagnostic sensitivity and specificity by making observations (screening for signs of diseases). these phenotypic (measurable characteristic) abnormalities reflect the interaction of the genotype (cytogenetic and nucleic acid sequence/expression) of the patient and his/her environment. patient workup uses present illness history with reference to past medical history, review of other organ systems for other abnormalities, review of family history, physical examination, radiographic studies, clinical laboratory studies (for example, peripheral blood or csf specimens), and anatomic pathology laboratory studies (for example, tissue biopsy or pleural fluid cytology specimens). as you will see from other chapters in this book, the ability to rapidly and inexpensively screen for chromosomal translocations, copy number variation, genetic variation, and abundance of mrna and mirna is adding substantial molecular correlative information to the workup of diseases. the differential diagnosis represents the set of possible diagnoses that could account for symptoms and signs associated with the condition of the patient. the conclusion of the workup generally results in a specific diagnosis which meets a set of diagnostic criteria, and which explains the patient's symptoms and phenotypic abnormalities. obviously, arrival at the correct diagnosis is a function of the examining physician and pathologist (fund of knowledge, experience, alertness), the prevalence of the disease in question in the particular patient (age, race, sex, site), and the sensitivity/ specificity of the screening tests used (physical exam, vital signs, blood solutes, tissue stains, genetic assays). the pathologic diagnosis represents the best estimate currently possible of the disease entity affecting the patient, and is the basis for downstream follow-up and treatment decisions. the diagnosis implies a natural history (course of disease, including chronicity, functional impairment, and survival) that most patients with this disease are expected to follow. be aware that not all patients with a given disease will naturally follow the same disease course, so differences in patient outcome do not necessarily correspond to incorrect diagnosis. variables that independently correlate with clinical outcome differences are called independent prognostic variables , and are routinely assessed in an effort to predict the natural history of the disease in the patient. it is also important to note that medical therapies for specific diseases do not always work. variables that independently correlate with (predict) responses to therapy are called independent predictive variables. diagnosis of a disease and development of an effective therapy for that disease do not require knowledge of the underlying etiology or pathogenesis. for example, granulomatous polyangiitis (née wegener's granulomatosis) was understood by morphology and outcomes to be a lethal disease without treatment, yet responsive to cyclophosphamide and corticosteroids, before it was found to be an autoimmune disease targeting neutrophil cytoplasmic protein pr3 ( fig. 11.1 ). however, understanding the molecular and cellular pathogenesis of a disease allows development of screening methods to determine risk for clinically unaffected individuals, as well as mechanistic approaches to specific therapy. the pathologist is that physician or clinical scientist who specializes in the art and science of medical risk estimation and disease diagnosis, using observations at the clinical, gross, body fluid, light microscopic, immunophenotypic, ultrastructural, cytogenetic, and molecular levels. clearly, the pathologist has a duty to master any new concepts, factual knowledge, and technology that can aid in the estimation of risk for unaffected individuals, the statement of accurate and timely diagnosis, accurate prognosis, and accurate prediction of response to therapy for affected individuals. the ability of h. sapiens to adapt and thrive has been due in part to the ability of humans to remember the past, respect tradition, recognize the value of new observations, develop tools/symbols, manipulate the environment, anticipate the future, and role-specialize in a social structure. the history of human understanding of diseases has progressed at variable rates, depending on the good and bad aspects of these human characteristics. our understanding of ancient attitudes toward diseases is limited by the historical written record. thus, the start point for written medical history corresponds to around 1700 bce for mesopotamian rules in the code of hammurabi, and around 1550 bce for the analogous egyptian rules in the ebers papyrus. by definition, these philosophers, theologians, and physicians had access and assets to allow a written record, and materials and storage sufficient for the written records to survive. the mesopotamian records indicate a deity-driven, demon-driven theory and empirical practice by recognized professional physicians. in this context, the prevailing thought was that "disease was caused by sprit invasion, sorcery, malice, or the breaking of taboos; sickness was both judgment and punishment . . ." the greek medical community evolved a theory of disease related to natural causes and effects, with less emphasis on deity-driven theory. the hippocratic corpus includes "on the sacred disease" (circa 400 bce), which rejected a divine origin for diseases, and postulated a natural rather than supernatural basis for disease etiology (". . . nowise more divine nor more sacred than other diseases, but has a natural cause . . . like other affections. . ."). aristotle (384à322 bce) wrote broadly on topics including logic, biology, physics, metaphysics, and psychology. to aristotle, observations led to a description of causes, or first principles, which in turn could be used logically in syllogisms to predict future observations. we would agree with these basic notions of induction and deduction. however, there was a different background philosophical construct regarding the nature of matter and causality (four elements, four humors, and four causes, including a final or teleological purpose). we would recognize aristotle's "efficient" cause of a disease as its etiology. alexander the great's conquest of egypt in the 4th century bc led to greek (ptolemaic) leadership of egypt from 305 bce to 30 bce, with development of the alexandrian library and university. faculty such as euclid developed geometric models of vision (optica), and herophilus described human anatomy by direct dissection and observation (greek medicine apparently allowed dissection in alexandria, including vivisection of the condemned). during the roman imperial era, galen (129à207 ce) used dissection and observation of other animals such as the macaque (human dissection was illegal) to extrapolate to human anatomy and physiology. like aristotle's approach, galen's approach to patients, diseases, and treatments was guided by philosophical constructs of four humors (blood, phlegm, yellow bile, and black bile) and the resulting temperaments (buoyant, sluggish, quick-tempered, and melancholic) due to humoral imbalances. it is thought that many of galen's texts were destroyed with the alexandrian library before the 7th century ad, but a subset was preserved and translated by middle eastern scholars. these ancient classic texts were then retranslated into latin and greek when printing houses developed in the 15th century (for instance, hippocrates'de natura hominis, circa 1480 ce, and galen's therapeutica, circa 1500 ce). the historical picture of the greco-roman understanding of disease is one of empirical approaches to diseases based on inaccurate understanding of anatomy, physiology, and organ/cellular pathology. greek medicine became less superstitious and more natural cause-and-effect oriented, yet philosophy still trumped direct observation, such that evidence was constrained to fit the classic philosophical constructs. some of the concepts sound familiar; for example, normal represents equilibrium and disease represents disequilibrium. however, we would differ on what variables are in disequilibrium (the historical humors, numbers, and opposites versus contemporary chemical and kinetic equilibria). following the collapse of the western roman empire in 476 ce, the classic texts of aristotle, hippocrates, and galen were protected, translated, and built upon in the byzantine and arab societies of the near east, and in spain during the muslim/moorish period through the 11th century. during these middle ages for western europe outside spain, there was apparently a retreat to pre-hellenistic beliefs in supernatural forces that intervened in human affairs, with protecting saints and relics for disease prevention and therapy. centers of medical learning following the spanish muslim model developed in montpellier, france, and in salerno, italy, beginning in the 11th century. aristotle's concept of induction from particulars to general first principles, then use of syllogistic logic to predict particulars, evolved into the scientific method during the renaissance. ibn alhazen's (al-haitham's) work on the physics of optics in the 11th century challenged euclid's concepts of vision from the alexandrian era. (euclid thought that the eye generated the image, rather than light reflected from the object being received by the eye). in the 13th century, roger bacon reinforced this use of observation, hypothesis, and experimentation. the printing press (gutenberg, 1440 ce) allowed document standardization and reproduction, such that multiple parallel university and city libraries could afford to have similar collections of critical texts, facilitating scholarly publications in journals. access to publications in libraries and universities led to a system of review, demonstration, discussion, and consensus regarding new scientific findings. the concept of the body as an elegant machine was captured by not only 15th and 16th century renaissance artists like da vinci and michelangelo, but also by anatomists and pathologists interested in the structure/function of health and disease. the ancient models of aristotle and galen had become sacrosanct, and newer, evidence-based models were considered heretical to some degree. so it was somewhat revolutionary when vesalius dissected corpses, compared them with galenic descriptions, and published de humani corporis fabrica libri septem (1543 ce; "seven books on the structure of the human body"; the fabrica), challenging and correcting 16th century understanding of normal human anatomy. vesalius's successors (colombo, fallopius, and eustachius) further improved the accuracy of human anatomic detail. thus, correction of galen's anatomical inaccuracies (including the rete mirabile at the base of the brain, blood vasculature, the five lobed liver, and curved humerus) required at least 13 centuries for challenge, scientific disproof, and eventual medical community acceptance. the scientific revolution describes the progressive change in attitude of scientists and physicians toward understanding of the natural world, health, and disease. this revolution began circa 1543 ce, when copernicus published arguments for a heliocentric universe and vesalius published the fabrica series on human anatomy. by the 17th century, galileo, kepler, newton, harvey, and others had used this observation-based, matter-based, and mathematical law-based perspective to develop a scientific approach similar to our own modern approach of testing hypotheses with experimental data and statistics. in human biology, the investigation of structure led to studies of function, initially of human cardiovascular physiology, for example, harvey's anatomical exercise concerning the motion of the heart and blood in animals (1628). whereas galen conceived of parallel but unconnected arteries and veins, with continuous blood production in the liver and continuous blood consumption in the periphery, harvey demonstrated that blood was pumped by the heart through arteries, through tissue capillaries, to veins, and then back to the heart in a circle (circulation). correction of these and other galenic physiological inaccuracies (such as nasal secretions representing the filtrate of cerebral ventricle fluid) thus required at least 14 centuries before challenge, scientific disproof, and eventual medical community acceptance. the scientific method facilitates empirical, rational, and skeptical approaches to observational data, and minimizes human dependence on non-evidence-based traditional models. in spite of the scientific method, physicians are still human, and the medical community still shows an inertial reluctance to adapt to new information when it disrupts traditional paradigms. recent examples would include reluctance to accept an etiologic role for the h. pylori bacterium in peptic ulcer disease, and reluctance to offer less than radical mastectomy for primary breast carcinoma. before the use of lenses to magnify objects, it was physically impossible to make observations on objects smaller than the resolving limit of the human eye (about 0.1à0.25 mm). thus, prokaryotic and eukaryotic cells, tissue architecture, and comparisons of normal and disease microanatomy were philosophical speculation until description of the mathematics of optics and lens design. in a real sense, optical technology was rate-limiting for the development of the fields of tissue anatomy, cellular biology, and microbiology. concepts of optics were written as early as 300 bce in alexandria (optica, euclid). clear glass (crystallo) was developed in venice in the 15th century. a compound microscope was invented by janssen in 1590 ce. microanatomy and structural terminology was begun by malpighi (1661 ce), who examined capillaries in frog lung, trachea tubes for airflow in silkworms, and stomata in plant leaves. robert hooke used a compound microscope to describe common objects in micrographia (1665 ce). antony van leeuwenhoek used self-made simple magnifying lenses to count the threads in cloth in a dutch dry-goods store, then later published descriptions of bacteria (termed animalcules), yeast, and algae, beginning in 1673 ce. yet the relevance of these observations in microanatomy and microbiology to human diseases required changes in conceptual understanding of the etiology and pathogenesis of diseases. for example, it was 200 years after van leeuwenhoek that a streptococcus sp. was recognized by koch and pasteur as the likely etiologic agent of puerperal fever in post-partum women. the relevance of microanatomy and microbiology to human disease required expansion of conceptual understanding to include morphologic changes in diseased cells and tissues, as well as recognition of an etiologic role for microorganisms. rokitansky's gross correlates with clinical disease (a manual of pathological anatomy, 1846), paget's surgical perspective on gross pathology, and virchow's morphologic correlates with clinical disease were critical to the development of clinico-pathologic correlation, and served to create a role for pathologists to specialize in autopsy and tissue diagnosis. virchow's description of necrotizing granulomatous inflammation, the morphologic correlate of infections caused by mycobacteria such as tb and leprosy, preceded the discovery of the etiologic agents years later by hansen (m. leprae, 1873) and koch (m. tuberculosis, 1882). the causal relationship between microorganisms and clinical disease required scientific demonstration and logical proof before medical community acceptance. for example, identification of the cause-and-effect relationship between streptococcus sp. and puerperal fever required an initial recognition of unusual clinical outcomes (clusters of postpartum deaths), then correlation of puerperal fever clusters with obstetrician habits, then semmelweiss's experimental demonstration in 1847 that hand-washing reduced the incidence of puerperal fever, then the demonstration that particular bacteria (streptococci) are regularly associated with the clinical disease (koch, circa 1870), and finally by culture of the organism from the blood of patients with the disease (pasteur, 1879) . 'germ theory' articulates this causal relationship between microorganisms and clinical diseases in animals and humans. technical improvements in microscopes (abbe condenser, apochromatic lenses, oil immersion lenses), the development of culture media, and the development of histochemical stains no doubt made it possible for koch to identify m. tuberculosis in 1882. to be emphasized is the process of recognition, first of all of the variables associated with the clinical disease, then the scientific demonstration of a causal relationship between one or more of these variables with the clinical disease. this latter step was enunciated as koch's postulates (1890): (i) the bacteria must be present in every case of the disease, (ii) the bacteria must be isolated from a diseased individual and grown in pure culture, (iii) the specific disease must be reproduced when a pure culture is inoculated into a healthy susceptible host, and (iv) the same bacteria must be recoverable from the experimentally infected host. viruses, like bacteria, were understood and manipulated clinically prior to their isolation. manipulation of viruses as vaccines is traced to description of smallpox variolation in turkey by at least 1718 (described by lady montagu). smallpox variolation was used in the us continental army in the 1770s. local availability of cowpox, a non-lethal poxvirus, allowed jenner to demonstrate (cross-) vaccination against smallpox (1796). vaccination against smallpox was used in napolean's army in 1812, and was mandated for massachusetts schoolchildren by 1855. the success of these vaccination programs prompted development of vaccines against other human viruses through the 19th and 20th centuries, including rabies ( prior to 1828, organic (carbon-containing) compounds were thought to derive from living organisms, and it was thought that they could never be synthesized from nonliving (inorganic) material. this concept ('vitalism') was disproven by the in vitro synthesis of urea by f. wohler in 1828. work from this era initiated the field of organic chemistry. predictable rules for in vitro and in vivo organic reactions, structural theory, modeling, separation technologies, and accurate measurement subsequently allowed the chemical description of natural products, and the chemical synthesis of both natural products and synthetic compounds. in addition to setting the stage for a systematic understanding of cellular biochemistry and physiology, organic chemistry set the stage for laboratory synthesis of natural products, such as dyes, vitamins, hormones, proteins, and nucleic acids. in that era, the textile industry was the main consumer of dyes. access to imported natural product dyes from plants was predictable for seafaring nations, but not for landlocked nations. in parallel with natural product extraction and purification was the recognition that aniline from coal (perkin, 1856) could be modified to generate a spectrum of colors, catalyzing the development of the german dye industry in the last half of the 19th century. some of these synthetic dyes were found useful for histochemical staining. morphologic diagnosis requires thin (3à5 μm), contrast-rich (requiring dyes) sections of chemically fixed (cross-linked or precipitated) tissue. thin sections allow the passage of light through the tissue, but reduce overlapping of cells in the light path. thus, technologies had to develop for cutting and staining of thin fixed tissue sections. work leading to our current technique for tissue solidification in paraffin wax was first described by klebs in 1869. prototypes of our current mechanical microtome for making thin (~5 μm thick) tissue sections was developed by minot in 1885. precursor work leading to our current technique for tissue fixation with diluted formalin was first described by blum in 1893. histochemical stains developed in parallel with dye technology for the textile industry. botanists used carmine as a stain in 1849, and subsequently gerlack applied carmine to stain brain tissue in 1858. the current hematoxylin dye used in tissue histochemistry was originally extracted from logwood trees from central america for the dye industry (to compete with indigo). metallic ion mordants made oxidized hematoxylin (hematein) colorfast in textiles, and a protocol for tissue staining was published by boehmer in 1865. similar to the hematoxylin story, semisynthetic analine dye technology was adapted by histochemists from 1850 to 1900. many of these dyes are still routinely used for recognition of tissue structure, peripheral blood cells, and microorganisms, including hematoxylin, eosin, methylene blue, ziehl-neelsen, gram, van gieson, mallory trichrome, and congo red. the most commonly used stains for general tissue diagnosis are the hematoxylin and eosin (h&e) stains, which provide a wealth of nuclear and cytoplasmic detail not visible in an unstained section. supplemental histochemical stains demonstrate specific structures and organisms: collagen and muscle (trichome), elastin (verhoff-von giessen), glycogen/mucin (periodic acid-schiff, pas), mucin (pas diastase, mucicarmine, alcian blue), fungi (gemori methenamine silver, gms), mycobacteria (ziehl-neelsen, fite), and bacteria (gram, warthin-starry). each of these stains is inexpensive ($10à$50), fast (minutes to hours), and automatable, making them extremely valuable for service diagnostic pathology use. light microscopy lens technology matured during the last half of the 19th century. critical were abbe's introductions of the apochromatic lens system to eliminate chromatic aberration (different focal lengths for different wavelengths of visible light) in 1868, a novel condenser for compound microscopes (to provide better illumination at high magnification) in 1870, and an oil immersion lens in 1878. by 1900, maturation of tissue fixation chemistry, histochemical stain protocols, and light microscope technology had evolved into the workhorse technique for evaluation of morphologic abnormalities in tissue examination in anatomic pathology labs, and for the evaluation of morphologic features of microorganisms in microbiology labs. the scope of this chapter is limited to pathology, but it should be clear to the reader that the momentous discoveries of deep general anesthetics (long, 1841; morton, 1846), commercial electricity (edison, 1882), and radiography (roentgen, 1895) also contributed to the development of the modern medical specialties of diagnostic pathology and laboratory medicine. the development of antisera in the 20th century for therapeutic purposes (for instance, treatment of diptheria) led to progressive understanding of the antibody, the efferent arm of the humoral immune response. similarly, tissue transplantation experiments led to the recognition of cellular rejection due to thymus-derived t-cells. antibodies and t-cells cooperate to react to foreign (non-self) molecules, common examples being allergic responses, viral infections, and organ transplants. antibodies were found to be made by b-cells and plasma cells, and were found to be exquisitely specific for binding to their particular antigens (ligands) either in solid phase or in solution. the analogous t-cell receptor (tcr) recognizes a ligand made up of a 15à20mer peptide presented by self mhc (hla in human) molecules on the surface of antigen-presenting cells (macrophages, dendritic cells, activated b-cells). b-cell and t-cells activate and proliferate when exposed to non-self proteins, but not to self proteins, attesting to tolerance to self. when b-cell and t-cell self-tolerance breaks down, autoimmune diseases can result (including myasthenia gravis, grave's disease, and lupus erythematosus). antibodies (immunoglobulins) were found to be heterodimers of 50 kd heavy chains and 25 kd light chains, folded together so that a highly variable portion defines the antigen-binding site, and a constant portion defines the isotype (igm, igd, igg, ige, or iga). similarly, t-cell receptors were found to be heterodimers of immunoglobulinlike molecules with a highly variable portion for ligand binding, and a constant portion, but without different isotypes. the range of antigen-binding specificities in a normal mammal is extensive, perhaps infinite, subtracting out only those self proteins to which the animal is tolerant. the genes encoding immunoglobulins and t-cell receptors were sequenced and, surprisingly, the extensive variation of specificities was due to a unique system of gene rearrangements of polymorphic v, d, and j gene segments with random nucleotide addition at the junctions. this system allows generation of literally billions of different ig and tcr binding specificities. although the ig and tcr molecules define the specificity of antigen (ligand) binding, we now understand that the probability of t lymphocyte activation is adjustable, based on activating (e.g. cd28:b7) or inhibitory (e.g. pd-1:pd-l1) receptor:ligand interactions. polyclonal antibodies raised in other species (goat, mouse, rabbit) against an antigen can be used to detect the antigen in diffusion gels (ochterlony, western blot), in solution (elisa), and in tissue sections. use of fluorescent-tagged antibodies for frozen section immunohistochemistry was developed first, and immunofluorescence (if) is still routinely used in renal pathology and dermatopathology. peroxidase-tagged secondary antibodies and dab chemistry were developed to generate a stable chromogen in the tissue, and this is now the primary method for detecting antigens in formalin-fixed tissue sections. improved antibody binding specificity and industrial production required monoclonal antibodies, which in turn required the development of mouse plasmacytomas/myelomas and cell fusion protocols. the net result is that commercial antibodies are now available for antigens of both clinical and research interest, including antibodies specific enough to distinguish minimally modified variant antigens (for instance, phosphorylated proteins or proteins with single amino acid substitutions). natural product chemistry and the rise of clinical laboratories diseases due to dietary deficiencies (like scurvy) and hormonal imbalances (like diabetes mellitus) were described clinically long before they were understood pathologically. dietary deficiency diseases prompted searches for the critical metabolic cofactors, so-called 'vital amines' (vitamins). xerophthalmia was linked to retinol (vitamin a) deficiency in 1917 (mccollum). rickets was linked to calcitriol (vitamin d) deficiency in 1926. beri-beri was linked to a deficiency of thiamine (vitamin b1) in 1926. scurvy was linked to ascorbic acid (vitamin c) deficiency in 1927. pellagra in the united states was linked to niacin deficiency in 1937. pernicious anemia was linked to cobalamin (vitamin b12) deficiency in 1948. it is currently unusual to see morphologic features of these diseases in this country. diseases due to non-dietary physiologic imbalances prompted isolation of circulating molecules with systemic effects, i.e. the hormones. parathyroid hormone was isolated (berman, collip) in the 1920s. thyroxine and cortisone were isolated (kendall) in 1915, and table salt was iodized starting in 1917. insulin was isolated (banting, best) in 1921, non-human insulin was industrially purified and marketed soon thereafter, and recombinant human insulin was marketed starting in 1982. these examples highlight the ability of 20th century chemists to fractionate, purify, synthesize, measure bioactivity, and manufacture these compounds for safe use by humans. study of diseases due to deficiencies and excesses of single molecule function led to a mechanistic understanding of biochemistry and physiology, with resultant interconnected reaction pathways of byzantine complexity (now referred to as systems biology). clinical demand for body fluid levels of ions (such as sodium, potassium chloride, and bicarbonate), glucose, creatinine, hormones (such as thyroxine and parathyroid hormone), albumin, enzymes (related to liver and cardiac function), and antibodies (reactive to aso, rh, abo, and hla antigens) led to the development of clinical laboratories in chemistry, endocrinology, immunopathology, and blood banking. functional assays for coagulation cascade status were developed, as were methods for estimating blood cell concentration and differential, leading to coagulation and hematology laboratories. serologic and cell activation assays to define hla haplotype led to hla laboratories screening donors and recipients in anticipation of bone marrow and solid organ transplants. culture medium-based screening for infectious agents led to dedicated clinical microbiology laboratories, which are beginning to incorporate nucleic acid screening technologies for speciation and prediction of treatment response. the clinical laboratories now play a critical, specialized role in inpatient and outpatient management, and their high test volumes (a 700-bed hospital may perform 5 million tests per year) have catalyzed computer databases for central record-keeping of results. the previous vignettes indicate a scientific approach to natural products of the steroid and protein types, but do not indicate how proteins are encoded, what accounts for variation in the same protein in the population, or how inherited diseases are inherited. it turns out that the instruction set for protein sequence is defined by dna sequence. the role of nucleoproteins as a genetic substance was alluded to by miescher in 1871, and was shown by avery to be the pneumococcal transforming principle in 1944. the discovery of x-ray crystallography in 1912 made it possible for franklin, wilkins, and gosling to study dna crystal structure, and led to the description of the antiparallel double helix of dna by watson and crick in 1953 . this seminal event in history facilitated dissection of the instruction set for an organism, with recognition that 3-base codons specified amino acids in 1961, and description of the particular codons encoding each amino acid in 1966. demonstration of in situ hybridization in 1969 made it possible to localize specific dna or rna sequences within the cells of interest. recognition and purification of restriction endonucleases and dna ligases, and the development of cloning vectors, made it possible to clone individual sequences, leading to methods for synthesis of natural products (such as recombinant human insulin in 1978). chemical methods were developed for sequencing dna, initially with radioisotope-tagged nucleotide detection in plate gels, then with fluorescent nucleotide detection in 1986. subsequent conversion to capillary electrophoresis and computer scoring of sequence output allowed high throughput protocols which generated the human genome sequence by 2001. the development of polymerase chain reaction (pcr) chemistry in 1986 has made it possible to quickly screen for length polymorphisms of microsatellite (identity testing, donor:recipient ratio after bone marrow transplant, and microsatellite instability), coding sequence abnormalities in genes (translocations, rearrangements, insertions, deletions, substitutions), and epigenetic control of transcription (promoter methylation) in a targeted fashion. quantitative pcr methods using fluorescent detection of amplicons has made it possible to study dna and rna copy number, and to mimic northern blots/oligo microarrays in estimating rna transcript abundance for cluster analysis. massively parallel solid-state ("next-generation") sequencing chemistries now allow rapid alignment of hundreds of independent sequencing reactions, facilitating rapid comparison of germline and somatic sequence, as well as identification of low-abundance mutations. diseases can be distinguished from each other based on differences at the molecular, cellular, tissue, fluid chemistry, and/or individual organism level. one hundred and sixty years of attention to the morphologic and clinical correlates of diseases has led to sets of diagnostic criteria for the recognized diseases, as well as a reproducible nomenclature for rapid description of the changes associated with newly discovered diseases. sets of genotypic and phenotypic abnormalities in the patient are used to determine a diagnosis, which then implies a predictable natural history and can be used to optimize therapy by comparison of outcomes among similarly afflicted individuals. the disease diagnosis becomes the management variable in clinical medicine, and management of the clinical manifestations of diseases is the basis for day-to-day activities in clinics and hospitals nationwide. the pathologist is responsible for integration of the data obtained at the clinical, gross, morphologic, and molecular levels, and for issuing a clear and logical statement of diagnosis. clinically, diseases present to front-line physicians as patients with sets of signs and symptoms. symptoms are the patient's complaints of perceived abnormalities. signs are detected by examination of the patient. the clinical team, including the pathologist, will work up the patient based on the possible causes of the signs and symptoms (the differential diagnosis). depending on the differential diagnosis, the workup typically involves history-taking, physical examination, radiographic examination, fluid tests (blood, urine, sputum, stool), and possibly tissue biopsy. radiographically, abnormalities in abundance, density or chemical microenvironment of tissues allow distinction from surrounding normal tissues. traditionally, the absorption of electromagnetic waves by tissues led to summation differences in exposure of silver salt photographic film. tomographic approaches such as computerized tomography (ct, 1972) and nuclear magnetic resonance (nmr, mri, 1973) complemented summation radiology, allowing finely detailed visualization of internal anatomy in any plane of section. in the same era, ultrasound technology allowed visualization of tissue with density differences, such as a developing fetus or gallbladder stones. more recently, physiology of neoplasms can be screened with positron emission tomography (pet, 1977) for decay of short half-life isotopes such as fluorodeoxyglucose. neoplasms with high metabolism can be distinguished physiologically from adjacent lowmetabolism tissues, and can be localized with respect to normal tissues by pairing pet with standard ct. the result is an astonishingly useful means of identifying and localizing new space-occupying masses, assigning a risk for malignant behavior and, if malignant, screening for metastases in distant sites. this technique is revolutionizing the preoperative decision-making of clinical teams, and improves the likelihood that patients undergo resections of new mass lesions only when at risk for morbidity from malignant behavior or interference with normal function. pathologically, disease is diagnosed by determining whether the morphologic features match the set of diagnostic criteria previously described for each disease. multivolume texts are devoted to the gross and microscopic diagnostic criteria used for diagnosis, prognosis, and prediction of response to therapy. pathologists diagnose disease by generating a differential diagnosis, then finding the best fit for the clinical presentation, the radiographic appearance, and the pathologic (both clinical lab and morphologic) findings. logically, the venn diagram of the clinical, radiologic, and pathologic differential diagnoses should overlap. unexpected features expand the differential diagnosis and may raise the possibility of previously undescribed diseases. for example, legionnaire's disease, human immunodeficiency virus (hiv), hantavirus pneumonia, and severe acute respiratory syndrome (sars) are examples of newly described diagnoses during the last 40 years. the mental construct of etiology (cause), pathogenesis (progression), natural history (clinical outcome), and response to therapy is the standard approach for pathologists thinking about a disease. a disease may have one or more etiologies (initial causes, including agents, toxins, mutagens, drugs, allergens, trauma, or genetic mutations). a disease is expected to follow a particular series of events in its development (pathogenesis), and to follow a particular clinical course (natural history). disease can result in a temporary or lasting change in normal function, including patient death. multiple diseases of different etiologies can affect a single organ, for example, infectious and neoplastic diseases involving the lung. different diseases can derive from a single etiology, for example, emphysema, chronic bronchitis, and small cell lung carcinoma in long-term smokers. the same disease (for instance, emphysema of the lung) can derive from different etiologies (emphysema from α-1-antitrypsin deficiency or cigarette smoke). modern surgical pathology practice hinges on morphologic diagnosis, supplemented by special stains, immunohistochemical stains, cytogenetic/molecular data, and other clinical laboratory findings, as well as on the clinical and radiographic findings. findings that meet all of these criteria are diagnostic for the disease. if some, but not all, of the criteria are present to make a definitive diagnosis, the pathologist must either equivocate or make an alternate diagnosis. thus, a firm grasp of the diagnostic criteria, and the instincts to rapidly create and sort through the differential diagnosis, must be possessed by the service pathologist. the tissue diagnosis has to make sense, not only from the morphologic perspective, but from the clinical and radiographic vantage points as well. it is both legally risky and professionally erosive to make a clinically and pathologically impossible diagnosis. in the recent past, limited computer networking meant numerous phone calls to gather the relevant clinical and radiographic information to make an informed morphologic diagnosis. for example, certain diseases such as squamous and small cell carcinomas of the lung are extremely rare in non-smokers. thus, a small cell carcinoma in the lung of a non-smoker merits screening for a non-pulmonary primary site. fortunately for pathologists, computing and networking technologies now allow access to preoperative clinical workups, radiographs/reports, clinical laboratory data, and prior pathology reports. all of these data protect pathologists by providing them with the relevant clinical and radiographic information, and protect patients by improving diagnostic accuracy. just as research scientists ". . . ignore the literature at their peril . . .", diagnostic pathologists ". . . ignore the presentation, past history, workup, prior biopsies, and radiographs at their peril. . ." there are limitations to morphologic diagnosis by h&e stains. first, lineage of certain classes of neoplasms (including small round blue cell tumors, clear cell neoplasms, spindle cell neoplasms, and undifferentiated malignant neoplasms) is usually clarified by immunohistochemistry, frequently by cytogenetics (when performed), and sometimes by electron microscopy. second, there are limitations inherent in a snapshot biopsy or resection. thus, the etiology and pathogenesis can be obscure or indeterminate, and rates of growth, invasion, or timing of metastasis cannot be inferred. third, the morphologic changes may not be specific for the underlying molecular abnormalities, particularly the ratelimiting (therapeutic target) step in the pathogenesis of a neoplasm. for example, ret gain of function mutations in a medullary thyroid carcinoma will require dna level screening to determine germline involvement, familial risk, and presence or absence of a therapeutic target. fourth, the same morphologic appearance may be identical for two different diseases, each of which would be treated differently. for example, there is no morphologic evidence by h&e stain alone to distinguish host lymphoid response to hepatitis c viral (hcv) antigens from host lymphoid response to allo-hla antigens in a liver allograft. this is obviously a major diagnostic challenge when the transplant was done for hcv-related cirrhosis, and when the probability of recurrent hcv infection in the liver allograft is high. paraffin section immunohistochemistry has proven invaluable in neoplasm diagnosis for clarifying lineage, improving diagnostic accuracy, and guiding customized therapy. if neoplasms are poorly differentiated or undifferentiated, the lineage of the neoplasm may not be clear. for example, sheets of undifferentiated malignant neoplasm with prominent nucleoli could represent carcinoma, lymphoma, or melanoma. to clarify lineage, a panel of immunostains is performed for proteins that are expressed in some of the neoplasms, but not in others. relative probabilities are then used to lend support (rule in) or exclude (rule out) particular diagnoses in the differential diagnosis of these several morphologically similar undifferentiated neoplasms. the second role is to make critical distinctions in diagnosis that cannot be accurately made by h&e alone. examples of this would include demonstration of myoepithelial cell loss in invasive breast carcinoma but not in its mimic, sclerosing adenosis ( fig. 11.2 prostatic adenocarcinoma (fig. 11.3) . the third role of immunohistochemistry is to identify particular proteins, such as nuclear estrogen receptor (er) (fig. 11.4 ) or the plasma membrane her2 proteins (fig. 11 .5), both of which can be targeted with inhibitors rather than generalized systemic chemotherapy. morphology remains the gold standard in this diagnostic process, such that immunohistochemical data support or fail to support the h&e findings, not vice versa. probability and statistics are regular considerations in immunohistochemical interpretation, since very few antigens are tissue-specific or lineage-specific. cytokeratin is positive in carcinomas, but also in synovial and epithelioid sarcomas. this example may imply aspects of the lineage of these two sarcomas that may be helpful in our categorization of these neoplasms. another example would be the diagnosis of small cell carcinoma in the lung of a nonsmoker. because lung primary small cell carcinoma is extremely uncommon, in non-smokers, this diagnosis would prompt the pathologist to inquire about screening results for other, non-pulmonary, sites. likewise, immunohistochemistry results are always put into the context of the morphologic, clinical, and radiographic findings. for example, an undifferentiated cd30+ neoplasm of the testis supports embryonal carcinoma primary in the testis, whereas a lymph node effaced by sclerotic bands with admixed cd30+ reed-sternberg cells supports nodular sclerosing hodgkin's disease. demand for both diagnostic accuracy and report promptness has increased as hospitals come under increasing financial pressure to minimize length of patient stay. hospitals now manage all but the sickest patients as outpatients. minimally invasive approaches for the acquisition of tissue samples for diagnosis use flexible endoscopic biotomes or hollow needles that sample 1à2 mm diameter tissue specimens. multidisciplinary conferences function almost realtime with respect to the initial biopsies. together, these changes have forced modern pathologists to make critical diagnoses on progressively smaller biopsy specimens, sometimes bordering on the amounts seen in cytopathology aspirates, and to do this in a timely fashion. this requires a clear understanding of the limitations to development of an accurate diagnosis, and a willingness on the part of the pathologist to request repeat biopsy for additional tissue when it is necessary for accurate diagnosis. diagnostic criteria involving electron microscopic ultrastructure found relevance for the evaluation of neoplasms described as small round blue cell tumors, spindle cell tumors, melanocytic tumors, and neuroendocrine/neuroblastic tumors, as well as delineation of ciliary ultrastructural abnormalities in primary ciliary dyskinesia. current approaches to these neoplasms are now generally approached using paraffin section immunohistochemistry. electron microscopy is now currently used mainly for nephropathology, platelet morphology, ciliary axoneme morphology, and for rare cases where immunohistochemistry is not diagnostic and where demonstration of premelanosomes, neuroendocrine granules, or amyloid is diagnostic. adequate sampling of a lesion is critical to making an accurate diagnosis. undercall diagnostic discrepancies are frequently due to sampling of a small portion of a large lesion that is not representative of the most abnormal portion of the lesion. insufficient sampling can result in an equivocal diagnosis or, worse, an inaccurate diagnosis. empirical rules have been adopted over the decades to ensure statistically adequate sampling of masses and organs, e.g. transurethral resections of prostate, soft tissue sarcomas, and heart allograft biopsies. in spite of the limitations and statistical uncertainties relating to morphologic diagnosis, a wealth of information is conveyed to a service pathologist in a tried-and-true h&e section. analogous to the fact that a plain chest x-ray is the sum total of all densities in the beam path, the morphologic changes in diseased cells and tissues are the morphologic sum total of all of the disequilibria in the abnormal cells. for most neoplastic diseases, morphologic criteria are sufficient to predict the risk of invasion and metastasis (the malignant potential), the pattern of metastases, and the likely clinical outcomes. for example, the etiology and pathogenesis in small cell lung carcinoma can be inferred (cigarette smoking, with carcinogen-induced genetic mutations) and the outcome predicted (early metastasis to regional nodes and distant organs, with high probability of death within 5 years of diagnosis). new molecular data for both neoplastic and non-neoplastic diseases will most likely benefit unaffected individuals by estimating disease risk, and will most likely benefit patients by defining the molecular subset for morphologically defined diagnostic entities, thus guiding individualized therapy. diagnostic pathology will continue to use morphology and complementary data from protein (immunohistochemical) and nucleic acid (cytogenetic, in situ hybridization, dna sequence, epigenetic, and rna abundance) screening assays. improvements in current technologies should improve current test performance, reduce test cost, and shorten turnaround time. development of new technologies will lead to better diagnostic algorithms, improved diagnostic accuracy and prognosis, improved patient assignment to prospective randomized clinical trials, improved prediction of response to customized therapy, and improved sensitivity for measurement of residual subclinical disease. for transplant candidates, major histocompatability complex (mhc, hla in human) screening is evolving from cellular assays and serology toward sequencing of the alleles of the class i and ii hla loci. rapid sequencing of these alleles in newborn cord blood would allow creation of a database of the population's haplotypes, facilitating perfect matches for required bone marrow or solid organ transplants. current uses of in situ hybridization to screen for viruses (such as ebv), light chain restriction (in b lymphomas), and copy number variation (for instance, her2 gene amplification) demonstrate the benefit of in situ nucleic acid hybridization assays. interphase in situ hybridization with fluorescent probes (fish) is now being used in the initial diagnostic workup for certain diseases, e.g. sarcoma-specific translocations, ploidy analysis in hydatidiform moles, and copy number variation analysis for detection of locus amplification and deletion. rapid dna sequence, rna sequence, and rna abundance screening current uses of dna screening for bcr-abl translocation, donor:recipient ratios after allogeneic bone marrow transplant, microsatellite instability, quantitative viral load (e.g. ebv, bk, cmv), single gene mutations (e.g. cftr, factor 2, serpina1 (α-1-antitrypsin), hfe), and promoter methylation (e.g. mlh1, mgmt) demonstrate the benefit of nucleic acid screening in diagnosis and management. it is likely that each new malignant neoplasm will be promptly inventoried for chromosomal ploidy, gene translocations, gene copy number variation, dna base substitutions/insertions/deletions, annotation of non-synonymous coding sequence and splice-site changes as either benign polymorphisms or pathogenic mutations, local and global promoter methylation status, and rna expression cluster subset. this inventory at the time of initial diagnosis, prior to therapy, should allow molecular subgrouping, individualized therapy, and targeted residual disease screening. as the cost of genome sequencing approaches the $1000 mark, sequencing of newborns for germline mutations that predispose to subsequent developmental or neoplastic diseases now seems practical for the purposes of early diagnosis, prompt management, and routine follow-up. current uses of morphology, immunohistochemistry, and molecular pathology demonstrate their benefit through improved diagnostic accuracy. however, diagnosis, extent of disease, and molecular subsets are currently imperfect estimators of prognosis and response to therapy. relational databases which correlate an individual's demographic data, family history, and concurrent diseases with the neoplasm's morphologic features, immunophenotype, and molecular subset, and which integrate disease prevalence by age, sex, and ethnicity using bayesian probabilities, should improve accuracy of prognosis and prediction of response to therapy. as risk correlates are developed, it is possible that healthy individuals can be screened and given risk estimates for development of different diseases, as desired. it is worth noting here that unaffected patients in inherited-disease kindreds such as huntington's disease may prefer not to know what the future holds with respect to the disease that runs in their extended family, so germline screening should hinge on pre test patient consent. current uses of normal ranges for serum chemistry assume similar bell-curve distributions across ages, sexes, and ethnicity. this may not be true for all analytes, so normal ranges should be measured and compared, with publication of analytes whose normal ranges differ by age, sex, or ethnic group. computer reference databases facilitate this sort of normal range database, stratified by age/sex/ethnicity of individual patients. similarly, familial risk for an inherited disease may vary by ethnic group, and this variation may be used in bayesian calculations to define risk for unaffected atrisk family members. current uses of liver and renal impairment to guide drug dosage demonstrate the benefit of using patient physiology to customize therapy. we are now starting to use gene haplotype data for specific genes that encode specific drugmetabolizing enzymes, so as to guide starting doses for particular drugs (e.g. warfarin, tamoxifen, or clopidogrel/ plavix) prior to treatment initiation. current uses of prostate specific antigen (psa) to screen for prostate carcinoma and its recurrence demonstrate the benefit of serum biomarkers in common neoplasms. it is likely that high-sensitivity screening for single and clustered serum analytes using proteomic and metabolomic technologies will lead to improved methods for early detection of neoplasms, autoimmune diseases, and infections. residual disease testing for malignancies with clonal mutations or translocations can now be performed via assays based on circulating tumor cells or circulating cell-free tumor dna (so-called liquid biopsies). similar high-sensitivity testing for disease-specific analytes may also improve diagnosis, treatment, and residual disease testing for autoimmune diseases, and infections. treatment by pathway, rather than by tissue diagnosis traditional medical oncology chemotherapy strategies for malignant neoplasms hinged on the tissue diagnosis and the organ of origin. this is changing, as current knowledge of signaling pathway disruption by gain-of-function mutations, e.g. egfr or braf, points to specific treatment targets. the pharmaceutical industry is able to create small-molecule inhibitors and humanized antibodies that allow specific treatment of specific mutant enzyme isoforms. current data suggests that many, if not most, patients with driver gain-of-function mutations treated with specific inhibitors will show an initial brisk response, although later recurrence is possible due to outgrowth of subclones with different driver mutations. the challenge for the next generation of scientists and oncologists is how to rescue homozygous loss-of-function mutations that are etiologic in human diseases, e.g. cftr or p53. pathologists consider each disease to have a natural, mechanical, physicochemical basis. each disease has an etiology (initial cause), a pathogenesis (stepwise progression), and a natural history with effects on normal function (clinical outcome). pathologists collect the data needed to answer patients' and clinicians' questions, simply phrased as "what is it?" (diagnosis), "how it going to behave?" (prognosis), and "how do i treat it?" (prediction of response to therapy). instincts and diagnostic criteria, as well as the optical, mechanical, chemical, and computing technologies described previously, are the basis for modern service pathology. as the human genome is deciphered, and as the complex interactions of cellular biochemistry are refined, risk of disease in unaffected individuals will be calculable, disease diagnosis will be increasingly accurate and prognostic, and molecular subsets of morphologically defined disease entities will be used to guide customized therapy for individual patients. it is a great time in history to be a pathologist. g clinically, diseases present to front-line physicians as patients with sets of signs and symptoms. symptoms are the patient's complaints of perceived abnormalities. signs are detected by examination of the patient. the clinical team (including the pathologist) evaluate the patient based on the possible causes of the signs and symptoms (the differential diagnosis). g pathologically, disease is diagnosed by determining whether the morphologic features match the g set of diagnostic criteria previously described for each disease. pathologists diagnose disease by generating a differential diagnosis, then finding the best fit for the clinical presentation, the radiographic appearance, and the pathologic (both clinical lab and morphologic) findings. g etiology describes the causes of a disease. one disease entity can have more than one etiology, and a single etiology can lead to more than one disease. for example, emphysema, chronic bronchitis, and small cell lung carcinoma can all occur in long-term smokers (different diseases derived from a single etiology). likewise, the same disease (for instance, emphysema of the lung) can derive from different etiologies (emphysema from a-1-antitrypsin deficiency or cigarette smoke). g the pathogenesis of a disease describes its stepwise progression after initiation in response to a specific etiologic factor (or factors). pathogenesis can refer to the changes in the structure or function of an organism at the gross/clinical level, and it can refer to the stepwise molecular abnormalities leading to changes in cellular and tissue function. g the natural history of a disease describes the expected course of disease, including chronicity, functional impairment, and survival. however, not all patients with a given disease will naturally follow the same disease course, so differences in patient outcome do not necessarily correspond to incorrect diagnosis. variables that independently correlate with clinical outcome differences are called independent prognostic variables, and are assessed routinely in an effort to predict the natural history of the disease in the patient. g variables that independently correlate with response to therapy are called independent predictive variables, and are assessed routinely in an effort to optimize therapeutic response for each patient. suggested readings the greatest benefit to mankind: a medical history of humanity unidentified curved bacilli in the stomach of patients with gastritis and peptic ulceration the legacy of karl rokitansky lectures on surgical pathology. london: brown, green, and longmans cellular pathology investigations concerning the etiology of leprosy die ä etiologie der tuberkulose (the etiology of tuberculosis) rudolf virchow-father of cellular pathology contagiousness of puerperal fever oliver wendell holmes (1809à1894) and his essay on puerperal fever ignac semmelweis and the etiology of fetal and neonatal sepsis on the germ theory ueber kunstliche bildung des harnstoffs in search of the origins of modern surgical pathology the immunology of transplantation an immunoglobulin heavy chain variable region gene is generated from three segments of dna: vh, d and jh recombination events that activate, diversify, and delete immunoglobulin genes emerging paradigms of t-cell co-stimulation localization of antigen in tissue cells; improvements in a method for the detection of antigen by means of fluorescent antibody continuous cultures of fused cells secreting antibody of predefined specificity molecular structure of deoxypentose nucleic acids molecular configuration in sodium thymonucleate molecular structure of nucleic acids; a structure for deoxyribose nucleic acid general nature of the genetic code for proteins the rna code and protein synthesis formation and detection of rna-dna hybrid molecules in cytological preparations molecular hybridization of radioactive dna to the dna of cytological preparations expression in escherichia coli of chemically synthesized genes for human insulin dna sequencing with chain-terminating inhibitors a new method for sequencing dna fluorescence detection in automated dna sequence analysis initial sequencing and analysis of the human genome the sequence of the human genome specific enzymatic amplification of dna in vitro: the polymerase chain reaction sternberg's diagnostic surgical pathology. philadelphia: lippincott diagnostic histopathology of tumors. churchill livingstone the continuing role of morphology in the molecular age key: cord-346539-kxnrf5g5 authors: riggioni, carmen; comberiati, pasquale; giovannini, mattia; agache, ioana; akdis, mübeccel; alves‐correia, magna; antó, josep m.; arcolaci, alessandra; kursat azkur, ahmet; azkur, dilek; beken, burcin; boccabella, cristina; bousquet, jean; breiteneder, heimo; carvalho, daniela; de las vecillas, leticia; diamant, zuzana; eguiluz‐gracia, ibon; eiwegger, thomas; eyerich, stefanie; fokkens, wytske; gao, ya‐dong; hannachi, farah; johnston, sebastian l.; jutel, marek; karavelia, aspasia; klimek, ludger; moya, beatriz; nadeau, kari; o'hehir, robyn; o'mahony, liam; pfaar, oliver; sanak, marek; schwarze, jürgen; sokolowska, milena; torres, maría j.; van de veen, willem; van zelm, menno c.; wang, de yun; zhang, luo; jiménez‐saiz, rodrigo; akdis, cezmi a. title: a compendium answering 150 questions on covid‐19 and sars‐cov‐2 date: 2020-06-14 journal: allergy doi: 10.1111/all.14449 sha: doc_id: 346539 cord_uid: kxnrf5g5 in december 2019, china reported the first cases of the coronavirus disease 2019 (covid‐19). this disease, caused by the severe acute respiratory syndrome‐related coronavirus 2 (sars‐cov‐2), has developed into a pandemic. to date it has resulted in ~6.5 million confirmed cases and caused almost 400,000 related deaths worldwide. unequivocally, the covid‐19 pandemic is the gravest health and socio‐economic crisis of our time. in this context, numerous questions have emerged in demand of basic scientific information and evidence‐based medical advice on sars‐cov‐2 and covid‐19. although the majority of the patients show a very mild, self‐limiting viral respiratory disease, many clinical manifestations in severe patients are unique to covid‐19, such as severe lymphopenia and eosinopenia, extensive pneumonia, a “cytokine storm” leading to acute respiratory distress syndrome, endothelitis, thrombo‐embolic complications and multiorgan failure. the epidemiologic features of covid‐19 are distinctive and have changed throughout the pandemic. vaccine and drug development studies and clinical trials are rapidly growing at an unprecedented speed. however, basic and clinical research on covid‐19‐related topics should be based on more coordinated high‐quality studies. this paper answers pressing questions, formulated by young clinicians and scientists, on sars‐cov‐2, covid‐19 and allergy, focusing on the following topics: virology, immunology, diagnosis, management of patients with allergic disease and asthma, treatment, clinical trials, drug discovery, vaccine development and epidemiology. over 140 questions were answered by experts in the field providing a comprehensive and practical overview of covid‐19 and allergic disease. the first cases of the coronavirus disease 2019 (covid19) , caused by the novel severe acute respiratory syndrome-related coronavirus 2 (sars-cov-2), were reported in china in december 2019 1 and rapidly led to pandemic. currently, ~6.8 million confirmed cases of covid-19 and near 400,00 covid-19-related deaths have been reported globally. 2 these numbers, which are still rising, likely underestimate the cumulative incidence of covid-19 due to several factors; these include limitations of current diagnostic tests, the extent of population testing and reporting, and the type and timing of community mitigation strategies adopted by each country, among others. 3 covid-19 shows a complex clinical profile with many different presentations. like in many other viral infections, subclinical, mild, moderate, or severe cases (10-20% of patients require hospitalization and 2-4% intensive care unit, icu) presenting with or without pneumonia are observed. asymptomatic cases are common but, to date, there is a lack of epidemiological surveys that provide a clear percentage of asymptomatic cases. 4, 5 the covid-19 pandemic is the world's gravest public health crisis of the 21st century, and there is an urgent need for reliable and updated scientific and clinical information. covid-19 is a zoonosis to cd147 (known as basigin or extracellular matrix metalloproteinase inducer), which is expressed in human airway and kidney epithelium, as well as in innate cells and lymphocytes, 14 and to tmprss4, which is highly expressed in intestinal epithelial cells. 15 in addition, antibody-dependent enhancement of sars-cov-2 cell entry may also contribute to infection as reported for sars-cov. 16 sars-cov-2 may use receptors that have been reported for other coronaviruses, such as cd26, aminopeptidase n and glutamyl aminopeptidase for cell invasion. 13, 17, 18 among these, cd26 (encoded by dpp4) has emerged as a putative receptor for sars-cov-2 because structural analyses predict that the spike protein of sars-cov-2 binds to cd26. 19 this receptor has been shown to be expressed in the human epithelium and immune cells. 14 there is limited evidence about covid-19-associated polymorphisms. ace might be one of the candidate genes that influences pneumonia progression in sars. it is conceivable that the d allele influences the renin-angiotensin system via elevation of serum or local ace levels, which may damage the endothelium or epithelium of the lungs. 20 the variance in covid-19 prevalence and mortality cannot be explained by an ace insertion or deletion polymorphism alone, or one polymorphism of any single gene. however, polymorphisms in genes of toll-like receptors, inflammasome, intracellular molecular sensors, interferons (ifns) 21 and interleukins (ils) may contribute. structural proteins of sars-cov-2 virions, such as the spike glycoprotein, envelope, membrane and nucleocapsid, are the main immunogenic molecules (figure 1) . 22 ,23 sars-cov-2 adaptive responses develop mainly to the spike protein, and immunodominant t and b cell epitopes have been reported. 24 intracellularly, the viral rna replicase complex, and non-structural and translated proteins, activate innate immune pathways. this leads to an ifn type i response, nf-kb activation in epithelial cells, as well as activation of nlrp3 and other inflammasomes, in macrophages and dendritic cells. 23 this article is protected by copyright. all rights reserved the spike protein of sars-cov-2 has a receptor-binding domain that binds ace2 with higher affinity than sars-cov. 8 in addition, the sars-cov-2 spike protein harbors a polybasic furin cleavage site (prrar) with an insertion of 4 amino acid residues, which is distinct from that found in sars-cov and other sars-like viruses. this allows effective cleavage by furin and other proteases and determines viral infectivity and host range. 6 the severe lymphopenia observed in covid-19 25 is similar to that reported in hiv infection and acquired immune deficiency syndrome. the latter is characterized by cd4+ t cell lymphopenia, whereas covid-19 causes general lymphopenia. however, severe lymphopenia development in covid-19 happens in weeks, whereas hiv-induced lymphopenia takes years. 26 hiv and sars-cov-2 are both rna viruses and share some similarities in their replication pathways; hence certain rna replication drugs may work in both diseases (figure 1) . 27 there are 2 strains of sars-cov-2 that are clinically relevant. genome analysis of sars-cov-2 from human samples shows high rates of mutation and deletion in several viral genes, including the spike-glycoprotein gene. 28 covid-19 treatments, including future vaccination against sars-cov-2, may drive the genetic evolution of the virus affecting virulence and pathogenicity. for example, a report on a 382-nt deletion in orf8 (figure 1 ) of sars-cov2 isolated from patients in singapore implied that mutations may arise as a result of human adaptation and could be associated with attenuation. 29 nevertheless, the emergence of a sars-cov-3 is possible as long as there is close contact between humans and living animals that harbor coronaviruses. data from 96 covid-19 patients in china show sars-cov-2 detection in respiratory samples for a median of 18 days (13-29 days) . in this study, sputum and saliva were not analyzed separately. viral shedding was significantly longer in patients with severe disease, with a median of 21 days (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) days), compared to mild disease, 14 days (10-21 days). furthermore, glucocorticoids treatment this article is protected by copyright. all rights reserved longer than 10 days significantly extended the duration of sars-cov-2 shedding. 30 viral load differed significantly by sample type, with respiratory samples showing the highest, followed by stool samples, and serum samples showing the lowest (figure 2) . 30 another study of 78 patients with covid-19 (33 asymptomatic vs 42 symptomatic) has estimated that the duration of viral shedding from nasopharynx swabs was 8 days (3-12 days) for asymptomatic vs 19 days (16-24 days) for symptomatic patients. 31 the viral load range from 1.34 × 10 11 copies per ml to 7.52 × 10 5 in sputum of patients who died or survived, respectively. 32 tmprss2 and tmprss4 promote sars-cov-2 infection of ace-expressing human enterocytes 15 causing diarrhea in adults and children. 33,34 sars-cov-2 has been detected in stool samples by reverse transcription polymerase chain reaction (rt-pcr) (figure 2) . the median duration of the virus in stool samples (22 days, interquartile range 17-31 days) was significantly longer than in respiratory samples (18 days, 13-29 days) . 30 however, sars-cov-2 released into the intestinal lumen was inactivated by simulated human colonic fluid, and infectious virus was not recovered from the stool specimens of patients with covid-19. therefore, the intestine is a potential site of sars-cov-2 replication, which may contribute to local and systemic illness and overall disease progression but unlikely to contribute to the spreading of covid19. 15 section 2: immunology of covid-19 from previous sars studies, it is known that the median seroconversion time for detectable igg was 17 days after infection. 35 detectable levels of sars-specific igg and neutralizing antibodies persisted for up to 720 days. this suggests that there is antibody-mediated protection from sars-cov recurrent infection for up to 2 years. 36 there are inconsistent reports on the humoral response to sars-cov-2. one study with 285 covid-19 patients reported that sars-cov-2 virus-specific igg and igm peaked 17-19 days and 20-22 days after symptom onset, respectively. 37 on the other hand, another study of 26 hospitalized covid-19 patients showed that seroconversion could take up accepted article to 50 days. 38 these discrepancies may be related to the time of sars-cov-2 diagnosis or the clinical characteristics of each cohort and warrant additional studies. systemic iga responses may play a relevant role in the pathogenesis of covid-19. 39 mucosal iga likely exerts a protective role by preventing sars-cov-2 adherence to epithelial cells. circulatory iga may also contribute to sars-cov-2 neutralization. in addition, iga has the ability to either promote inflammation, through the formation of immune complexes, or to dampen it via fc-mediated inhibitory itam-signaling. 40, 41 a seroconversion study in covid-19 patients has found and association between disease severity and sars-cov-2-specific iga levels. these were significantly higher than sars-cov-2-specific-igm and -igg levels in critically ill covid-19 patients. 39 whether this association, previously unseen in sars-cov infection, 42 is due to a protective or detrimental role of iga in covid-19 remains to be elucidated. preliminary findings indicate that asymptomatic and mild cases of covid-19 can generate detectable levels of sars-cov-2-specific antibodies in serum. however, seroconversion is observed less frequently in asymptomatic compared to mild or severe cases, and many asymptomatic cases yield undetectable sars-cov-2-specific antibody responses. 37, [43] [44] [45] so far, no robust data are available on the qualitative differences in humoral responses between asymptomatic and symptomatic covid-19 patients. it is not clear which molecular mechanisms underlie the milder symptoms of covid-19 in children as compared to adults. children may mount a sars-cov-2 antibody response characterized by more efficient production of the so-called natural antibodies, which arise from activated igm+ memory b cells. 46 these cells, which are more prevalent in children than in adults, presumably produce broadly neutralizing antibodies early during the infection. this article is protected by copyright. all rights reserved b cell receptor-sequencing has been conducted in the blood of covid-19 patients. naive b cells exhibited little clonal expansion, whereas cd27+cd38+ memory b cells showed the highest expansion levels among diverse b cell subsets. covid-19 patients significantly expanded specific bcell receptor clones compared to those in the healthy controls. these findings suggest that b cells experience unique clonal variable, diversity, and joining gene segment rearrangements upon sars-cov-2 infection. 47 the lifespan and functionality of these b cells remain to be elucidated. the term "herd immunity" refers to the generation of population immunity that protects a region, or country, from infection. 48 the number of confirmed covid-19 cases has reached approximately 6.5 million. 2 the world population is estimated to be 7.8 billion. to ascertain the extent of herd immunity, it is pivotal to define the prevalence of sars-cov-2-exposed humans. it is thought that 67% is the minimum percentage of symptomatic or asymptomatic covid-19 population required for herd immunity. 48 that is to say that worldwide herd immunity may occur when ⁓5 billion humans have a protective immune response against sars-cov-2. to date, there are no reliable data, particularly on the number of asymptomatic individuals that show seroconversion, to determine the degree of herd immunity. 49 il-4 is pleiotropic and could theoretically cause negative effects on immune responses. however, based on phase ii and iii studies with dupilumab (an il-4rα-specific monoclonal antibody that blocks il-4 and il-13 signaling) in the context of atopic dermatitis, chronic rhinosinusitis with nasal polyps and asthma, no increased risk of infections to viral or bacterial pathogens have been documented. 50 furthermore, dupilumab had no impact on responses to non-live vaccines. 51 this article is protected by copyright. all rights reserved allergic airway disease patients appear to be underrepresented among covid-19 patients. 52-54 this could be partly attributed to the low ace2 expression detected in allergic patients, with or without concomitant asthma. 55 furthermore, allergen challenge, which induces t helper (th)-2 inflammation, 56 has been shown to reduce ace2 expression in a murine model of asthma, and ace2 expression was inversely associated with type 2 biomarkers (il-13, ige, exhaled nitric oxide fraction). 57 these results are in line with previous work showing that decreased ace expression in the airway epithelium of asthmatic subjects was associated with eosinophilic inflammation. 58 on the other hand, the analysis of nasal airway transcriptome data from 695 children identified that tmprss2 is highly upregulated by type 2 inflammation through the action of il-13. therefore, the reduced ace2 expression seen in asthmatic patients may be compensated by an increase in tmprss2 production. 59 eosinopenia has been reported in ⁓50-70% of severe covid-19 patients. a minority of covid-19 patients present with eosinophilic inflammation. 25,60 the th1/th2 cytokine balance may play a role, particularly as it pertains to il-5, which promotes eosinophilopoiesis and eosinophil survival and activation. eosinophilic inflammation suggests the dominance of type 2 inflammation, which may play a protective role against sars-cov-2. on the other hand, it may be the result of a hypersensitivity reaction to drugs used to treat covid-19. 61-63 anti-il-5 treatment, which induces eosinophil deficiency, results in a higher viral load in influenza and rhinovirus infection. this might be due to the ability of eosinophils to bind and inactivate the influenza a virus and respiratory syncytial virus (rsv). 64 a similar role seems possible in sars-cov-2 infection, where type-2 asthma patients potentially benefit from antiviral eosinophil responses. on the other hand, covid-19 post-mortems did not show lung eosinophilia 62 , which argues against its local protective role in sars-cov-2 infection, although it is important to control for glucocorticoid-driven eosinophil reduction in these studies. 61 this article is protected by copyright. all rights reserved eosinopenia is commonly reported in severe covid-19. 65, 66 the underlying mechanisms are largely unknown and most likely multifactorial. a number of possible explanations have been proposed: decreased eosinophilopoiesis; defective eosinophil egression from the bone marrow; and eosinophil apoptosis induced by type 1 ifn released during the acute infection. 61 also, increased eosinophil migration and retention within inflamed tissues has been described, 67 but disputed for the aforementioned reasons. 62 there is no evidence for an enhanced susceptibility of patients on anti-il-5/il-5r treatment to develop viral infections. observational studies in covid-19 patients reported elevated eosinophil counts with a favorable outcome, whereas eosinopenia was observed in more severe cases. 25, 68 neither was there proof of causation nor evidence for enhanced tissue presence in lungs of covid-19 patients. 69 there is neither evidence for a protective effect of these biologicals nor a negative effect regarding sars-cov-2 infection. importantly, maintaining proper asthma control is imperative and so is to follow up on severe asthmatics during the covid-19 pandemic, for example via telemedicine. 50 more than 1 billion people worldwide are infected with helminths, with those living in resource-poor tropical areas being disproportionately affected. helminth co-infection has been shown to influence the severity of viral infection in mice. for example, murid herpesvirus 4 respiratory infection, prior infection with schistosoma mansoni, reduced disease severity. 70 however, immune responses to pulmonary coronaviruses and murid herpesvirus 4 are different and therefore the impact of helminth co-infection is yet to be determined. this is particularly important as the pandemic is now spreading through the helminth-endemic regions of the word. 71 this article is protected by copyright. all rights reserved sars-cov-2 infects human t cells via cd147-binding. 72 t cells are severely affected by sars-cov-2, which reduces t cell counts nearly 2 times below the reference limit. this effect is more pronounced in critically ill covid-19 patients. 60, 73, 74 in addition to the reduction in t cell numbers, a recent study found that cd4+ and cd8+ t cells as well as natural killer cells displayed reduced antiviral cytokine production in covid-19 patients. a reduced cytotoxic potential was identified in covid-19 patients, particularly in those that required icu, and was associated with high il-6 serum levels. 75 circulating sars-cov-2−specific cd8+ and cd4+ t cells have been reported in ∼70% and 100% of covid-19 convalescent patients, respectively. 76 cd4+ t cell responses to the spike protein were robust and correlated with sars-cov-2-specific-igg and -iga titers. the m, spike and n proteins each accounted for 11-27% of the total cd4+ response, with additional responses commonly targeting nsp3, nsp4, orf3a and orf8, among others. for cd8+ t cells, spike and m proteins were recognized, with at least 8 sars-cov-2 orfs targeted. interestingly, sars-cov-2−reactive cd4+ t cells were detected in ∼40-60% of unexposed individuals, which indicate cross-reactive t cell recognition between circulating 'common cold' coronaviruses and sars-cov-2. 76 three sars-recovered individuals, 9-and 11-years post-infection, were analyzed for t-cell responses against 550 sars-cov peptides that may share homology with mers-cov. sarsspecific memory t cells persisted at 9 and 11 years post-sars infection in the absence of antigen exposure. 77 based on these data, it is likely that specific sars-cov-2 epitopes elicit a persistent t cell response, which may also confer protection against other 'common cold' coronaviruses. 76 however, long-term studies on the natural history of sars-cov-2 infection are pending. different mechanisms have been proposed for lymphopenia: 1) t cell exhaustion. the expression of programmed cell death-1 marker (also known as pd-1), which is associated with t-cell exhaustion, was higher in t cells from covid-19 patients than in healthy controls; the expression of pd-1 and tim-3 (another exhaustion marker) increased as covid-19 progressed. 78 2) activation of p53 signaling in lymphocytes, which suggests a role for apoptosis for in lymphopenia. 3 this article is protected by copyright. all rights reserved pyroptosis, which induces lymphopenia and may be proinflammatory. 79 cov-2, which may also cause a cytopathic effect on infected t cells. 5) other mechanisms of lymphopenia that remain to be studied are bone marrow suppression during cytokine storm syndrome (css; see below) and sequestration in the lungs during extensive bilateral pneumonia. 60 lymphopenia can be used as an early predictor of severity and clinical outcome. a significant reduction in lymphocyte counts was common in severe and critically ill covid-19 patients. a continuing or gradual decrease of lymphocyte counts was indicative of poor prognosis and usually required icu admission ( table 1) 60 . in agreement with this, a number of studies have identified lymphopenia as an independent risk factor for mortality in covid-19. 25,80 in covid-19 patients, decreases were observed in total lymphocytes, cd4+ and cd8+ t cells, b cells and natural killer cells. t cell and natural killer cell counts were below normal levels, while b cell counts were at the low end of the normal range. a reduction in specific subsets of lymphocytes, such as cd16+cd56+ natural killer cells and regulatory t cells, was reported in severe covid-19 patients. 60 css is associated with a wide variety of diseases, both infectious and noninfectious. it is a complex cascade of multicellular activation events that leads to an excessive or uncontrolled release of proinflammatory cytokines. css-associated inflammation begins at a local site and spreads throughout the body via the systemic circulation and can cause multi-organ failure and hyperferritinemia. 60,81 css encompasses the activation of large numbers of blood cells, including b cells, natural killer cells, macrophages, dendritic cells, neutrophils, monocytes, resident tissue cells and epithelial and endothelial cells. their activation cause a massive release of pro-inflammatory cytokines, which this article is protected by copyright. all rights reserved drives pathology. 82 the cells involved in css during covid-19 have not been fully determined yet. were the most important cell types releasing a large amount of proinflammatory cytokines. 60, 83 which cytokines are most elevated during css? multiple proinflammatory cytokines and inflammasome activation may contribute to css pathogenesis. 60 elevated serum ferritin, il-6, il-1β, ifn-γ , cxcl10 (known as ip-10) and ccl2 immunosuppression is a double-edged sword in viral infections. 86 this article is protected by copyright. all rights reserved primary immunodeficient patients are a high-risk group in the current pandemic, but to date it is unknown if a particular immunodeficiency poses a higher risk of severe disease. international primary immunodeficiency monitoring is being carried out and few cases have been documented. patients at higher risk are those with complications resulting from their primary immunodeficiency and strict follow-up must be done in those cases. a consensus has been established that baseline chronic treatment should be continued in those patients if they are asymptomatic or mildly symptomatic. furthermore, recommendations regarding primary immunodeficient patients adhere to individual national guidelines emphasizing social distancing and strict hygiene measures. systematic testing of primary immunodeficient patients is not advised, however recommendations may change as the pandemic evolves. 89 there are no longitudinal studies analyzing t regulatory cells in covid19 systemic dysregulation of metabolism, such as that seen in obesity and diabetes is a risk factor of sars-cov-1 and sars-cov-2 infection and of covid-19 severity 69 . these diseases lead to chronic systemic inflammation, upregulation of sars-cov-2 receptors in the lungs and the periphery, and they disturb the glucose and lipid metabolism of tissues and immune cells. 14, 91, 92 ards is an acute life-threatening inflammation of the lung due to infection, trauma, or inflammatory conditions. excessive inflammation leads to alveolar damage and increased permeability of endothelial and epithelial cells. this results in protein-rich fluid accumulation in the interstitium and the air space, which causes impaired gas exchange and hypoxemia. reactive oxygen species, leukocyte proteases, chemokines, and cytokines also contribute to lung injury. the barrier impairment of the lung microvascular barrier is central to the pathogenesis of ards. 93 in covid-19 patients, ards is more common in the elderly, those with multiple comorbidities, and those with continuing or gradually progressing neutrophilia and lymphopenia, and a higher level of creactive protein, lactate dehydrogenase, d-dimer and procalcitonin. 60, 88 there are at least 2 clinical phenotypes of ards: 1) near normal pulmonary compliance with isolated viral pneumonia; 2) decreased pulmonary compliance. 95, 96 what specific therapies can be suggested for ards? different treatments were suggested for ards. corticosteroid treatment is generally not recommended, although widely used in critically ill patients. convalescent plasma (cp) was administered to a small number of patients and was associated with virus clearance and clinical improvement ( table 2) . low tidal mechanical ventilation, positive end-expiratory pressure, prone positioning ventilation, and fluid management guidelines were associated with improved outcomes. extracorporeal membrane oxygenation could be used according to the inclusion and exclusion criteria of the eolia trial. other potential therapies such as mesenchymal stem cell therapy and cytokine inhibitors are still in trials and without definite results. 60,97 bcg is a live attenuated vaccine that was developed against tuberculosis at the beginning of the 20th century. bcg vaccination induces metabolic and epigenetic modifications by enhancing trained immunity (innate immunity to subsequent infections). 98 it was hypothesized that general bcg vaccination policies adopted by different countries might have impacted the transmission patterns and/or covid-19-associated morbidity and mortality. 99 the mechanisms underlying kawasaki disease -a generalized vasculitis, in young children, of unknown, potentially post-viral etiology-are poorly understood. the rare covid-19-associated inflammatory syndrome also features vasculitic changes, affects older children too and is often only associated with positive sars-cov-2 serology, but not viral shedding. its mechanisms need to be elucidated and may include post-infectious, antibody and immune-complex mediated pathology. in adults, there are occasional cases of covid-19-associated cutaneous vasculitis, possibly a localized manifestation of the disease that leads to severe generalized vasculitis in some children. [104] [105] [106] interestingly kawasaki-like disease was not reported in chinese cases and the first months of european cases. the season of the disease and environmental factors should be considered. the chinese epidemic was mainly from january to march whereas the usa epidemic started in mid-march and is still ongoing. initial results of acute phase reactants such as c-reactive protein, alanine transaminase, lactate dehydrogenase, d-dimer, procalcitonin, serum ferritin and il-6 on admission were used to evaluate the severity and predict the mortality. however, dynamic changes of these variables will be more precise in predicting the recovery or progression of covid-19. continuing or progressively increasing levels of c-reactive protein, procalcitonin, d-dimer and lactate dehydrogenase were shown to be associated with a high risk of death in severe covid-19 patients. 25,60,107 patients with acute respiratory illness (i.e., fever and at least one sign/symptom of respiratory disease such as cough or shortness of breath) and a history of contact with a confirmed or probable covid-19 case during the 14 days before symptom onset. patients with any acute respiratory illness in the context of a pandemic should have sars-cov-2 infection in their differential diagnosis. special attention should be given to patients with sudden onset of anosmia, loss of taste, gastrointestinal symptoms or skin lesions without respiratory symptoms who also have epidemiological links. 5,25,108 smell loss is now a well-established diagnostic symptom of covid-19 and can be present in otherwise asymptomatic patients, making it a useful tool in initial diagnosis. 109 this has resulted in anosmia to be included in the list of symptoms used in early screening tools for possible covid-19 in many international bodies. 109 rapidly progressive respiratory failure and sepsis, elevated serum proinflammatory cytokine levels, elevated acute phase reactants (e.g. c-reactive protein), cell-free-hemoglobin-leukopenia and markers of disseminated intravascular coagulation. 110 rt-pcr to generate cdna from sars-cov-2 rna extracted from respiratory samples, followed by quantitative pcr (figure 2 ). 111 common gene targets for sars-cov-2 include the envelope, nucleocapsid, spike, rna-dependent rna polymerase, and orf1 genes. it is recommended to include in the analysis, at least, 2 target genes. 112 nasopharyngeal and oropharyngeal (throat) swabs are the primary specimens for sars-cov-2 rt-pcr testing. lower respiratory tract specimens (i.e. sputum, endotracheal aspirate or bronchoalveolar lavage) may have higher viral loads and be more likely to yield positive tests ( figure 2 ). however, these locations carry a high risk of aerosolization and therefore should be reserved for severe patients with a negative test on an upper respiratory tract specimen and high suspicion for lower respiratory tract sars-cov-2 infection. 113, 114 serology is useful to determine prior exposure to sars-cov-2 within a given period of time (the length of time following infection that one remains positive is unknown) (figure 2) . detection of this article is protected by copyright. all rights reserved antibodies specific to the receptor binding domain of the spike protein indicates neutralization capacity, hence informing better about the development of protective immunity. 37, 111, 115 the antibody response occurs later than initiation of symptoms as well as of the detection of viral rna by rt-pcr in respiratory tract specimens, which usually peaks within the first week of symptom onset (figure 2) . although antibodies to sars-cov-2 have been detected as early as the first week after symptom onset, igm, iga and igg seroconversion commonly occurs between the 2 nd and 3 rd week of clinical illness onset. thereafter, igm starts to decline, reaching low levels by week 5 and almost disappears by week 7, while iga and igg persist beyond this period. 37, 39, 111, 116 the main approaches include nucleic acid amplification on respiratory samples using mobile devices (rt-pcr or isothermal nucleic acid amplification) and viral antigens or host antibodies (viral protein fragments) detection using immunoassays. 117 however, individual tests need validation in large populations before use and their sensitivity, specificity, positive and negative predictive values have to be accurately ascertained. otherwise, they may lead to covid-19 under or over diagnosis, thus undermining the public health efforts to control the disease. 118 a high rate of false negatives with antigen point-of-care assays may be due to the fact that the majority of patients produce antibodies against sars-cov-2 only after the second week after of infection ( figure 2 ). 119 furthermore, an effective antibody response is connected with several determinants, comprising severity of the disease, age and nutritional status of the patient, medications administered and concomitant infections. 118 nucleic acid amplification using rt-pcr directly targeting the virus is not affected by the above-mentioned limitations. 120 this article is protected by copyright. all rights reserved positive by the fifth and final test. 121 patients with an initial positive sars-cov-2 result had an increased risk of progressing to severe cases. altogether, these findings underscore how the timing of the immune response influences rt-pcr tests for sars-cov-2, and the importance of combining rt-pcr and seroconversion data for covid-19 diagnosis. the decision to discontinue home isolation/quarantine should be adapted to specific groups of patients based on factors such as symptom severity, healthcare systems´ capacity, laboratory diagnostic resources and local epidemic status. patients with suspected or confirmed symptomatic covid-19 can discontinue self-isolation/quarantine if all the following 4 conditions are met: a) resolution of fever (without the use of fever-reducing medications) for at least 3 days; b) clinical improvement in respiratory symptoms (e.g., cough, shortness of breath) for at least 3 days; c) at least 8 days have passed since the onset of symptoms for mild cases or at least 14 days for severe cases and immunocompromised patients; d) 2 negative rt-pcr tests from respiratory specimens taken 24 hours apart. if there is limited or no testing capacity, the combined symptom/test-based strategy should be reserved to hospitalized covid-19 cases and healthcare workers, whereas for mild or asymptomatic covid-19 cases (suspected or confirmed) the symptom-based strategy (condition a) and b) and c)) without lab testing is considered acceptable to end the self-isolation period. 122 pandemic strategies for risk minimization should be elaborated, harmonized and followed as such in allergy clinics, centers and practices. 123 in the eaaci/aria position paper by pfaar et al. 124 experts in the field have developed practical recommendations for optimizing allergic patients 'care whilst ensuring the safety of all health care professionals (figure 3) . general guidance from national health authorities should be strictly followed (i.e., world health organization, who; european centre for disease prevention). in-person consultations should be minimized to the lowest necessary level and triaged by telemedicine whenever possible (figure 4 ). 125 special attention should be paid to dataprotection in adherence to national data-security and -protection laws. non-delayable diagnostic and therapeutic measures should strictly follow reasonable preventive measures. several specific considerations regarding diagnostic and therapeutic measures are important in different allergic diseases ( figure 5) . moreover, socio-psychological aspects play a fundamental role in the care of allergic patients during the current pandemic and should be especially recognized and followed. stress caused by isolation and stigmatization due to allergic symptoms may amplify the development of allergic symptoms. 126 virtual doctor consultations have been regarded as an alternative to on-site clinical encounters and are increasing during the covid-19 pandemic. 124 initially, pre-visit telephonic communication is helpful to screen for patients with potential sars-cov-2 infection. 127 the epidemiological history should be investigated to determine if patients have fever or respiratory symptoms. in addition, previsit specific triage improves the efficiency of the patient's visit, thus reducing the length of stay in the hospital. to reduce face-to-face meetings, physicians can train some patients to self-treat at home based on the diagnosis obtained through a telephone consultation (figure 4) . a strict screening protocol is needed to identify sars-cov-2 infected patients (figure 4) . ideally, only sars-cov-2 negative patients (diagnosed via rt-pcr and/or rapid test) should come to the clinic. in places where systematic testing is unavailable, at least, normal temperature and negative epidemiological history should be mandatory to proceed to the outpatient departments. patients with a body temperature higher than 37.3ºc should have additional screening examinations, including routine blood tests, chest computed tomography scanning and even throat swabs for sars-cov-2 rt-pcr testing. 128 the indication and urgency of the tests for diagnosis should be considered. contraindications for skin, provocation and lung function tests can be explained beforehand to the patient, which helps to accepted article avoid unnecessary in-person consultations. 124 any test generating aerosol particles should be avoided because it is considered high risk (figure 4) . personal protective equipment (ppe) must be used when collecting biological samples. biological samples collected on-site from suspected or confirmed covid-19 patients (e.g. antibody assays, rna isolation, flow cytometry) should be processed following bsl-2 practices. during and after the covid-19 pandemic, the usage of bsl-2 facilities is mandatory for all newly arriving patient samples to prevent spreading the disease. research procedures involving sars-cov-2 isolation or culture should be conducted in a bsl-3 facility. 124,129 patients with common allergic diseases do not develop distinct symptoms or severe outcomes. allergic children show a mild course similar to non-allergic children 5 . in a recent study of 182 hospitalized children, 43 of them were reported with allergies. allergic rhinitis was the most prevalent allergic disease (83.7%), followed by drug allergy, atopic dermatitis, food allergy and asthma. in this study, allergic children showed a reduced increase in acute phase reactants, procalcitonin, d-dimer and aspartate aminotransferase levels compared to all patients. there were no deaths in allergic children in that study. 130 clinical history is very helpful to identify seasonality-and exposure-related symptoms driving the diagnosis of pollen-induced allergic rhinitis. an atopy test (in vivo or in vitro) reinforces the diagnosis. however, covid-19 can be superimposed on allergic rhinitis symptoms. 124 symptoms such as fever, fatigue and sudden loss of smell, are suggestive of covid-19 and should be closely monitored. pandemic? this article is protected by copyright. all rights reserved n95 facial masks have been proven useful in reducing allergen exposure by blocking pollen access to nose and mouth. on the other hand, surgical masks do not protect against inhalation of small airborne contaminants and are not designed to seal tightly against the user´s face, hence the contaminated air can pass through the gaps. 131 there are no conclusive data on the impact of allergic rhinitis on covid-19 susceptibility 132 . a recent study with 24 allergic rhinitis patients demonstrated a reduction of ace2 expression in nasal brush samples following an allergen challenge. 55 also, this study reported lower ace2-expression in the epithelium of asthmatic patients. on the other hand, tmprss2 is highly upregulated by type 2 inflammation through the action of il-13. 59 therefore, further studies are necessary to determine if allergic rhinitis patients have an altered risk of sars-cov-2 infection as compared to non-allergic individuals. although limited, the available evidence suggests that, compared to non-allergic individuals, allergic there is no scientific evidence that treatments for allergic rhinitis either increase susceptibility to sars-cov-2 infection or the severity of covid-19. therefore, allergen avoidance measures, nasal saline douches, and background controller therapies recommended by current guidelines for allergic rhinitis, such as nasal corticosteroids or second-generation h1-blockers, should be continued as prescribed, both in non-infected and covid-19 diagnosed patients. 124 the loss of smell in chronic rhinosinusitis is caused by type-2 inflammation of the olfactory epithelium. 135 in covid-19, the exact mechanism of potential olfactory neuropathy is still unclear. 136 however, a study found that sustentacular cells of the olfactory epithelium express ace2 and tmprss2, which enable sars-cov-2 entry and may subsequently impair the sense of smell. 137 a considerable percentage of covid-19 patients experience loss of smell as an early sign of the disease. 109 in many patients smell recovers in 1-2 weeks and there is no indication that intranasal corticosteroid treatment has a positive impact on the recovery. 138 on the other hand, there is no evidence suggesting that this treatment has a negative impact on symptomatology and/or accepted article development of covid-19. consequently, it is recommended to continue regular intranasal corticosteroid treatment for chronic rhinosinusitis (figure 5) . 124 an asthma exacerbation is difficult to differentiate from covid-19 ards or pneumonia by the patient, especially if it is triggered by rhinovirus, or other common respiratory viruses, because both conditions have dry cough and dyspnea. the british thoracic society advises patients with asthma experiencing fever, fatigue and loss of taste or smell to alert their physician as these are indicative of covid-19. 144 the distinction can be made by the physician based on the presence of wheeze, which is generally (but not always) absent in covid-19 pneumonia, as well as high-resolution chest tomography and viral diagnostic tests. 124 patients with controlled asthma are not at higher risk of severe infection than the general population. 53,54 ace2 expression was shown to be decreased in patients with allergic asthma 55 and in those receiving inhaled corticosteroids. 145 on the other hand, ace2 expression in asthmatic patients was increased in african-americans, in males and associated with diabetes, 55 and type 2 inflammation in children is associated with increased expression of tmprss2. 59 it is clear though that uncontrolled asthma is a risk factor of severe covid-19, thus all efforts should be focused on treating asthma by regular use of controller medication, including inhaled corticosteroids and biologicals. 53,146,147 there is no evidence available that patients on inhaled corticosteroids are at higher risk of covid-19 infection or of more severe symptoms than the general population. it is strongly advised by international scientific societies that patients continue with their routine control medication including inhaled corticosteroids during the pandemic (figure 5) . 132,148 this article is protected by copyright. all rights reserved recent evidence indicates that inhaled corticosteroid treatment reduces the expression of viral membrane receptors used to infect the human airways in a dose-dependent manner. 145 on the other hand, the immune suppression exerted by corticosteroids may impair anti-viral responses. 141 however, there are no clinical studies investigating the effect of inhaled corticosteroid on sars-cov-2 infection rates. spirometry is essential for the diagnosis of new asthma cases as stated by the global initiative for asthma guidelines. therefore, it should be conducted, but under special conditions (negative pressure chamber, etc.) and only in areas with low sars-cov-2 infection incidence. healthcare providers performing lung function testing need to wear maximum ppe (filtering face-piece particles 2 or 3 face mask, goggles, or disposable face shield covering the front and sides of the face, clean gloves, and clean isolation gowns), and the spirometer devices should be properly disinfected between patients (figure 3) . 149 an alternative, less precise, is monitoring morning and evening peak expiratory flow variability over a week. 150, 151 the global initiative for asthma guidelines state that routine spirometry should be avoided, especially in high-risk areas of covid-19 transmission. if spirometry needs to be performed, maximum ppe should be used (figures 3 and 4) . 148 the treatment of asthmatic patients can be monitored using personal devices measuring forced expiratory volume and peak expiratory flow. many of these devices are equipped with remote transmission functions and thus are amenable for the telemedicine management of patients. 152 pandemic? this article is protected by copyright. all rights reserved there is no evidence suggesting that the current approach to treat asthmatic patients during an exacerbation should change during the covid-19 pandemic. moreover, there is no proof that a short course of systemic corticosteroids impacts the evolution of covid-19. thus, oral corticosteroids should be given as usual for the treatment of an asthma exacerbation ( figure 5) . 144, 148 in the few cases in which patients are treated with long-term oral corticosteroids in addition to their high dose inhaled corticosteroids this should be continued in the lowest dose possible to prevent exacerbations. 148 the cause of the asthma exacerbation should be studied thoroughly to rule out potential exacerbations due to viral infections. 89 the preferred treatment is a pressurized metered-dose inhaler with a spacer. each patient should have an individual spacer, and this should not be shared at home. the use of nebulizers should be avoided when possible because they increase the risk of disseminating viral particles, which could affect other patients and healthcare personnel. 148 anti-ige treatment with omalizumab (or other biologics indicated for asthma) should be continued in non-infected patients. self-administration devices at home, whenever this option is available, are preferred, to minimize face-to-face contact in the clinic. in infected patients, omalizumab administration should be delayed until complete clinical recovery and viral clearance is achieved ( figure 5) . 50,153 endotype is associated with severe asthma in obese patients, are obese asthmatic patients more likely to develop severe covid-19? obesity, as part of the metabolic syndrome, increases the risk of severe covid-19. this is due to the pre-existent systemic low-grade inflammation and increased expression of sars-cov-2 entry receptors (ace2, tmprss2 and cd147). 154, 155 obese patients tend to have worse asthma control, increased hospitalizations and suboptimal response to standard controller therapy. thus, both difficult-to-control asthma and underlying metabolic syndrome are risk factors for severe covid-19. this article is protected by copyright. all rights reserved the il-6/th17 endotype encountered in late-onset obese asthma might be an additional risk factor. 156,157 the dermatological manifestations of covid-19 range from an un-specific macular erythematous rash, urticarial lesions, chickenpox-like vesicles and acro-ischemic lesions. 158, 159 they can result from local inflammation due to circulating immune complexes or from systemic manifestations leading to vasculitis and thrombosis. 160 these patients are also at increased risk of drug hypersensitivity lesions ( figure 6 ). 161 there is no evidence that patients with barrier defects such as atopic eczema have a higher risk for sars-cov-2 infection or skin complications during covid-19. however, patients with atopic dermatitis are often on systemic immunosuppressants and should be monitored closely. optimal topical treatment regime should also be encouraged in all patients. 162 hand hygiene procedures are pivotal to prevent self-infection and virus spreading. however, extensive water contact enhances dry skin, disturbs the commensal microbiota and leads to barrier disruption in healthy individuals. moreover, it exacerbates diseases with an intrinsic barrier defect such as atopic dermatitis. 163, 164 effective skin-care after hand hygiene is therefore essential to prevent barrier disruption and sensitization events. here, emollients containing hyaluronic acid, vitamin e, ceramide or urea are recommended. 165 dupilumab is approved for the treatment of moderate-to-severe atopic dermatitis. first data from italy on dupilumab-treated non-infected in high epidemic areas, and current evidence from dupilumab trials, suggest no negative effect of dupilumab regarding viral infections 166 with reports on a reduced number of herpes simplex superinfections and less bacterial superinfections. [167] [168] [169] accepted article this article is protected by copyright. all rights reserved the current eaaci statement on the usage of biologicals in the context of covid-19 advices no change of therapy in non-infected individuals and to withhold/delay the application of biologicals for a minimum of two weeks or the resolution of the disease in case of sars-cov-2 infection (figure 5) . 50 this is based on expert opinion in the light of missing data and may be adapted if more information becomes available. acro-ischemic lesions on toes and fingers have been identified in a subgroup of covid-19 patients. 25, 170 the data available are scarce and it is unclear if preventive or active anticoagulation should be initiated. however, acro-ischemic lesions could predate other sars-cov-2 symptoms in children and young adults. covid-19-induced skin lesions can be related to thrombovascular events (i.e. petechiae, acroischemia, dry gangrene) or to typical viral infections (i.e. erythematous rash, urticaria, maculopapular exanthema). 161 drug hypersensitivity has to be considered as a differential diagnosis, mainly in the second group, being a distinction difficult during the acute phase. diagnosis relies mostly on clinical observations. in that regard, an accurate chronology of the reaction and the drug exposure timeline is very informative 63 . laboratory and histopathological findings may also help. immunomodulatory drugs (including azithromycin), hydroxychloroquine/chloroquine and ifns, are the ones most frequently involved in hypersensitivity reactions. most reactions are non-immediate and further studies are required to clarify whether this increased frequency is caused by the drug immunogenicity or simply derives from a greater consumption as compared to other treatments. 161 this article is protected by copyright. all rights reserved drug provocation tests are not recommended because reactions can occur during the tests, including the generation and spreading of virus-containing aerosols. however, they may be considered after careful risk-benefit assessment in cases of urgent need, such as chemotherapy in cancer patients, perioperative drugs and radiocontrast media in subjects needing urgent procedures, and antibiotics if no effective alternative drug is available. 124 most ait products authorized for use in europe indicate that ait should be discontinued in case of infection; the same principle will apply to the covid-19 pandemic. patients on subcutaneous or sublingual ait, who are diagnosed with covid-19, those suspected of sars-cov-2 infection or symptomatic patients with a positive contact to sars-cov-2 individuals, ait should be interrupted until the patient has recovered. in patients not infected or who have recovered from the infection, ait could be continued ( table 3) . these recommendations are conditional and could change as clinical data evolve. 124 ,134 ait should continue in non-infected patients or those recovered from covid-19 ( figure 5 ). this is especially important in patients with life-threatening conditions such as venom allergy. it is possible to extend the intervals between vaccines during subcutaneous ait, as done for inhalant allergens, to minimize visits to the allergy clinic. if venom ait was stopped due to sars-cov-2 infection, it is unclear when it should be re-initiated because data from convalescent patients is scarce. 134 in patients diagnosed with covid-19 or cases with suspected sars-cov-2 infection, oral immunotherapy dosing should continue as indicated in the dosing plan and in coordination with the treating physician. oral immunotherapy can be continued in non-infected patients and those who have recovered from covid-19 ( figure 5 ). in areas with high level of sars-cov-2 community transmission, visits to the allergy clinic for oral immunotherapy up-dosing should be postponed. 124, 134 accepted article this article is protected by copyright. all rights reserved these patients are generally on symptomatic treatment. they need to look out for symptoms suggesting hypoxia or pneumonia, such as shortness of breath, deep shallow breathing, chest pains or persistent tachycardia. special attention needs to be given to those with risk factors for disease progression, such as patients older than 65 years, cardiac or pulmonary comorbidities and immunosuppression. 171, 172 prophylactic low molecular weight heparin, or heparin, has been recommended by the who in severe to critically ill covid-19 patients. 141 however, the international society on thrombosis and haemostasis recommended that all hospitalized covid-19 patients, not just those in icu, should receive prophylactic low molecular weight heparin in the absence of contraindications. 173 during the sars outbreak in 2003, corticosteroids did not change the course of the viral infection and delayed viral clearance. 174 on the other hand, a retrospective study on sars patients in hong kong suggested a better survival rate in patients treated with prednisolone for milder pneumonia or methylprednisolone in more severe cases. 175 recently, chinese experts stated that, in covid-19 patients, systemic corticosteroids should be considered on individual indications in a low-to-moderate dose and for no longer than a week. 176 the national institutes of health in their covid-19 treatment guidelines advises against the use of systemic corticosteroids in non-critically ill patients. 177 there are over 170 clinical trials on covid-19 treatment registered now in the international databases and very few have been completed. currently promoted pharmacological treatments are, at the most, based on anecdotic data collected in small numbers of covid-19 patients. these studies did not satisfy evidence-based medicine criteria, but caught general attention through news media, for example hydroxychloroquine (see below). tocilizumab is a humanized monoclonal antibody specific for il-6r, and it is approved for the treatment of rheumatoid arthritis. a positive response to tocilizumab points towards an imbalanced innate immune response in severe covid-19. luo et al. 178 reported that of the 15 patients treated with tocilizumab, 7 of them critically ill, 11 of the patients recovered within a week. prompt resolution of symptoms and encouraging results have also been reported in uncontrolled or retrospective trials. [179] [180] [181] [182] [183] [184] [185] [186] [187] [188] [189] [190] these zoonotic beta-coronaviruses share structural and genomic similarities that are useful to patients? this article is protected by copyright. all rights reserved fang et al. 192 suggested that there is ace2 overexpression upon treatment with ace inhibitors, thiazolidinediones and ibuprofen. there were concerns pertaining to the use of nonsteroidal antiinflammatory drugs in covid-19 patients. the european medicines agency clarified that no scientific evidence established a link between ibuprofen, or other nonsteroidal anti-inflammatory drugs, and a risk to worsen covid19. 193 section 7: clinical trials and drug discovery in covid-19 adaptations for clinical trials during the pandemic must include all concerned parties such as there are drugs that interfere with ace2 and tmprss2, which are molecules used by the virus to enter the cell. 9, 195 for example, camostat mesylate is a clinically proven serine protease inhibitor with affinity for tmprss2. it has shown activity against sars-cov-2 in human lung calu-3 cells. 9 several drugs that target virus internalization are being investigated, including chloroquine phosphate and hydroxychloroquine, which have shown limited efficacy in humans and raised concerns due to side effects (see below). 196 drugs designed to inhibit the viral replication machinery may be effective against sars-cov-2. for example, remdesivir inhibits viral rna polymerases, which prevents sars-cov-2 replication (see below). it is uncertain whether lopinavir-boosted ritonavir and other antiretrovirals improve clinical outcomes or prophylaxis among patients at high risk of sars-cov-2 infection. 200 additional potential candidates include other broad-spectrum antiviral drugs such as arbidol and favipiravir and phytochemicals with anti-viral activity such as resveratrol ( figure. 1) . 197 in a cohort of severe covid-19 patients, compassionate-use of remdesivir showed clinical improvement in 68% of patients (36 out of 53). 201 of note, a double-blind, randomized, placebocontrolled trial of intravenous remdesivir was conducted in 1,063 adults hospitalized with covid-19 with evidence of lower respiratory tract involvement; remdesivir was superior to placebo in shortening the time to recovery in adults hospitalized with covid-19 and evidence of lower respiratory tract infection. 202 furthermore, in a study of 5 hiv-positive hospitalized patients with severe covid-19, three of them were given lopinavir-boosted ritonavir and 2 darunavir-boosted cobicistat for 14 days. four patients recovered and 1 remained hospitalized. 203 meplazumab is a cd147-specific humanized monoclonal antibody that has been shown to prevent sars-cov-2 infection of fibroblasts (veroe6 cells). 72 currently, there is insufficient evidence to draw any conclusions on the benefits of meplazumab for the therapy of covid-19 patients. in an observational chinese study, adults hospitalized with covid-19 pneumonia (n=17) who were treated with an intravenous infusion of meplazumab as an add-on therapy showed a higher recovery rate compared to controls (n=11). 198 however, these results should be interpreted with caution because they were generated in a non-randomized, non-stratified study, with a small sample size. large-scale studies are needed to assess the effectiveness and safety profile of meplazumab as a potential therapy for covid-19. cp therapy for covid-19 treatment has yielded promising results. for example, in a trial of 10 severe covid-19 patients, 205 cp therapy was well tolerated and improved the clinical outcomes. the viral load was undetectable after cp transfusion in 7 patients who had viremia. no severe adverse effects were observed. other clinical trials have shown the beneficial effect of cp therapy in covid-19 patients and ongoing clinical trials will provide additional data on its efficacy, safety and optimal timing for treatment ( table 2) . in this regard, it is unclear whether in patients with a high viral load, such as severely ill patients, cp therapy may drive tissue pathology through immune complexes or complement activation. baricitinib, fedratinib, and ruxolitinib are potent and selective jak-stat signaling inhibitors approved for indications such as rheumatoid arthritis and myelofibrosis. these drugs are powerful antiinflammatory medications that may reduce the systemic levels of cytokines associated with covid-19. 206 indeed, in a pilot study of 12 covid-19 patients, baricitinib limited the css and was beneficial for the patients. 207 the use of jak inhibitors has been associated with a higher risk of opportunistic viral infections, such as herpes zoster, which suggests that the reduced inflammation caused by jak inhibitors may limit, to some extent, anti-viral responses. 208 this article is protected by copyright. all rights reserved ivermectin (avermectin b1a and avermectin b1b) is an anti-parasitic drug that has shown broadspectrum anti-viral activity in vitro. in sars-cov-2-infected fibroblasts (vero-hslam cells), a single addition of ivermectin at 2 h post-infection reduced viral rna ~5000-fold at 48 hours. 209 however, plasma concentrations of total and unbound ivermectin did not reach the ic50 determined in vitro, even at a 10-times higher dose than approved by the food and drug administration (usa). 210 consequently, the likelihood of a successful clinical trial using ivermectin is low. in an observational study of 1,446 covid-19 patients, 811 received hydroxychloroquine treatment, which did not change the risk of intubation or death. 211 furthermore, in a brazilian randomized control study evaluating 2 different doses of chloroquine in covid-19 patients with severe respiratory symptoms, mortality was 2.5 times higher in the high-dose chloroquine arm. 212 moreover, pre-published results from us veterans health administration hospitals did not support any advantages of hydroxychloroquine administered alone or with azithromycin. 213 in addition, the results of a clinical study conducted in 821 individuals showed that hydroxychloroquine did not prevent illness compatible with covid-19 or confirmed infection when used as postexposure prophylaxis within 4 days after exposure. 214 however, because of the retraction of two main papers on hydroxychloroquine treatment for covid-19 patients, this area requires further attention by the european medicines agency and the food and drug administration. mesenchymal stem cells may exert antiviral mechanisms in the context of sars-cov-2 infection. the basal ifn-stimulated gene expression of mesenchymal stem cells is high, which enhances their responsiveness to ifn signaling, potentially inducing broad viral resistance. mesenchymal stem cell therapy may potentiate the low ifn-i and -iii levels and moderate ifn-stimulated gene response reported in sars-cov-2-infected ferrets and covid-19 patients. 215 it is is being used in some centers but its efficacy in covid-19 has not been proven. data available are mainly experimental with few records in humans and no reports on its efficacy in randomized clinical trials. 216 common anti-hypertensive drugs inhibit ace, but not ace2. importantly, ace2 opposes ace actions and lowers blood pressure by converting angiotensin-ii (a vasoconstrictor peptide) into its metabolites-angiotensin (1-7) (vasodilators). 217 other common related antihypertensive drugs are angiotensin-2 receptors blockers, which block at-1, a receptor for angiotensin-ii, through which it exerts its vasoconstrictor effect. however, at-1 is not known to be used by sars-cov-2 to infect cells. it was shown in animal models that ace inhibitors might increase ace2 expression, thus increasing susceptibility to infection. it has not been proven in humans but it raised the concerns during the covid-19 pandemic. 217 based on the data available to date, antihypertensive treatment with these medications should be continued. 218 at the moment, the animal model that resembles more closely human covid-19 is the rhesus macaque, whose ace2 receptor is identical to that in humans. this model recently showed that sars-cov-2 reinfection was hampered due to infection-acquired immunity and demonstrated the therapeutic effect of remdesivir in covid-19 prior use in human clinical trials. 219, 220 the murine ace2 receptor is different from humans, hence humanized murine models with recombinant human ace2 are necessary. 221 previous vaccine research for sars/mers facilitates rapid translation. 222 in the who vaccine single-domain antibodies have been investigated as potential therapeutics for influenza, rsv and hiv in addition to coronaviruses. sars-cov-2 mainly targets the respiratory tract, hence the development of vaccines directed to the respiratory epithelia and lung parenchyma using a nebulizer has been considered to maximize bioavailability and function. 229 although active research against respiratory viruses has focused on aerosolized plasmid dna vaccines, other forms of vaccine administration are currently further advanced in clinical trials. 222 veterinary medicine commonly uses aerosolized coronavirus vaccines for chicken farms. 230 a novel vaccine platform requires careful evaluation and should ideally include toxicological studies in valid animal models. early progress towards sars vaccines has facilitated a "running start" but standards of care and safety must be maintained. acceleration rather than omission of clinical trials is key. preliminary data from oxford university is anticipated by mid-2020. 222 of note, a doseescalation, single-center, open-label, non-randomized, phase 1 was conducted in 108 healthy individuals that received an ad5 vectored covid-19 vaccine. the vaccine was tolerable and this article is protected by copyright. all rights reserved immunogenic at 28 days post-vaccination. sars-cov-2-specific antibodies peaked at day 28 postvaccination and specific t-cell responses were detected from day 14 post-vaccination. 231 an important aspect is that covid-19-associated mortality is very high, almost unavoidable when the pandemic control fails. this is due to rapid community spread, high community virus, especially in the elderly and co-morbid, but also in younger non-comorbid persons, including healthcare workers, young adults and children. the covid-19 pandemic also seems to be characterized by a significant level of asymptomatic spread. [232] [233] [234] the iceberg of covid-19: are there asymptomatic cases below the surface? the the differences are almost entirely due to the timing and effectiveness of public health interventions. countries that failed to control did too little, too late, and allowed sars-cov-2 to rip through their population, with catastrophic outcomes. those that intervened early effectively stopped the disease transmission. 235 this article is protected by copyright. all rights reserved it is difficult to determine as it varies greatly from country to country, depending on how well countries control their epidemics with widespread testing, case isolation and vigorous contact tracing, testing and isolation if positive. in countries that do this well, the r0 can be very low indeed. in countries that fail to control the spread of the virus, the r0 is high but unknown as sars-cov-2 spreads untested and therefore undetected. it has been estimated to be ~2.2. 236 sars-cov-2 transmits more readily than either sars-cov or mers-cov. the r0 of sars-cov-2 is controversial but if left unchecked it is likely to be greater than 3-4. however, the r0 number cannot be precisely defined as no country has left it to spread completely unchecked. in any case, even when preventative measures are taken, the r0 of sars-cov-2 is higher than that of sars-cov (1.7-1.9) and mers-cov (<1). 237 there is a considerable frequency of very mild covid-19 patients as well as asymptomatic sars-cov-2-infected people. this makes transmission control more challenging than either sars-cov or mers-cov, where illness is frequently more severe. children are at low risk of severe covid-19 outcomes. 238, 239 most patients in pediatric age with sars-cov2 infection presented with no or mild clinical manifestations, including fever, fatigue and dry cough. they were typically managed with supportive treatments only and they had generally a favorable prognosis with a recovery within 2 weeks. [240] [241] [242] young children also frequently carry other respiratory viruses, which potentially limit sars-cov-2 infection, as reported for other viral infections. 243 differences between children and adults in the regulation of ace2 expression may also play a role. 46 ace2 mrna expression was high in type i and ii alveolar epithelial cells, in nasal and oral mucosa and nasopharynx, in smooth muscle cells and endothelium of vessels from the stomach, small intestine, colon, and in the kidney of human adults (mean age 52±22). 244 interestingly, a recent study demonstrated age-dependent ace2 gene expression in the nasal epithelium, which was lowest in younger children and increased with age. 245 in addition, cd147, cd26 and their molecular interaction proteins seem to be differently expressed in peripheral blood mononuclear cells and t cells in children in comparison with adults. 14 many children remain asymptomatic, even when they have radiologic pneumonia detected on screening. 238 given that children are effective transmitters of other respiratory viruses, 246 it is expected that they will be just as good at transmitting sars-cov-2. bats are likely the natural reservoir of sarsseverity (see questions below). data on ethnicity and covid-19 are scarce and further research on ethnicity and covid-19 outcomes is needed. 250 however, the data available show a disproportionate number of covid-19 deaths in black, asian and minority ethnic backgrounds. in fact, one third of uk icu admissions are reportedly from them. 251 in the usa, african americans had more covid-19 diagnoses and deaths, after adjusting for age, poverty, comorbidities, and epidemic duration. these disparities are also seen in the hispanic and asian communities. 252 pregnant women may be at a higher risk of poorer covid-19 outcomes because they have deficient ifn-α and ifn-λ responses to viral infections. 253 however, reported pregnancy outcomes in covid-19 are reassuring as they appear similar to non-pregnant adult females. 254 this article is protected by copyright. all rights reserved testing treatments is problematic because pregnant women are excluded from most trials. 255 it is known that azithromycin doubles innate ifn production from virus-infected lung cells. 256 it is safe for all trimesters of pregnancy 257 and has been shown effective in high-quality clinical trials of virusinduced lung disease. 258, 259 given that the human ace2 protein is encoded on the x chromosome, this may be relevant for malefemale differences in outcomes. particularly in males with rare ace2 coding variants as they will express those variants in all ace2-expressing cells compared to a mosaic pattern of expression in females. 260 males may also have differences in certain innate antiviral responses compared to female counterparts. 261 there is reasonably robust data of covid-19 deaths in hospitals because most people who die in hospital are tested. deaths outside hospitals are likely underestimated as people are dying in care homes where mortality approaches ~40%, 267 and may die without being tested and diagnosed. it is difficult to determine prevalence as testing practices vary so much from country to country. seroprevalence studies will help to collect these data. covid-19 was introduced rapidly to many industrialized countries as a result of air travel. 268 most of europe and the usa probably did not react in a timely and efficient manner, resulting in the rapid spread and subsequent high mortality rates. in light of the devastating situation in many european countries and the usa, less industrialized countries had a little more time to better prepare to control the pandemic. 269 an important factor for prevalence studies is the percentage of the population that has undergone a diagnostic test, which seems to be at lower levels in developing countries. this article is protected by copyright. all rights reserved respiratory viruses spread less readily in summer than in winter for reasons that are not well understood. dry air and higher temperatures are slowing down the spread of respiratory viruses. absence of school attendance, more time outdoors, greater household ventilation, warmer temperatures facilitating virus inactivation and higher vitamin d levels are all likely to play a part. although social distancing measures are implemented, the summer weather should play a role in hampering the spread of covid-19. however, based on the analogy of previous influenza pandemic, it is unlikely that summer, on its own, could stop transmission of sars-cov-2. [270] [271] [272] it largely depends on the sars-cov-2 seroprevalence developed in each country, which is still unknown. countries that have had widespread transmission may be hit by a second wave, but presumably with less severe consequences. countries that effectively controlled the pandemic are at a higher risk of second wave of covid-19 if those effective controls are relaxed due to the limited viral transmission and lack of active immunization. sars-cov-2 has spread worldwide in humans, causing mild or no disease in many cases. it will continue circulating similar to other human coronaviruses (229e, hku1, nl63, oc43), and it may well become an endemic, seasonal virus. 273 the main route of sars-cov-2 transmission is via respiratory droplets and aerosols. [274] [275] [276] avoidance of high virus loads, acquired through aerosol and droplet transmission, is paramount to prevent severe outcomes. consequently, social distancing, masks and hand sanitation are undoubtedly effective because they prevent the droplet and surface contact-associated initial high virus load and the increased risk of severe disease. [277] [278] [279] what is the evidence supporting social distancing and face mask to prevent sars-cov-2 infection? this article is protected by copyright. all rights reserved a systematic review and meta-analysis has found that transmission of viruses was lower with physical distancing of 1 m or more, compared with a distance of less than 1 (or 0.18) and protection was increased as distance was lengthened. in addition, face mask use could result in a large reduction in risk of infection (or 0.15), with stronger associations with n95 or similar respirators compared with disposable surgical masks or similar. eye protection also was associated with less infection (or 0.22). 280 therefore, the covid-19 pandemic can be controlled if social distancing is combined with widespread testing, case isolation, vigorous contact tracing and personal protection. indeed, severe and critical illness among chinese healthcare workers before january 10 th was 45%, a time when personal protection equipment and infectious control measures were likely not implemented. after february 1 st , when personal protection measures were in place, the percentage of severe and critically ill chinese healthcare workers dropped to 8.7%. 281 sars-cov-2 remained viable in aerosols for 3 h with a ~10-fold reduction in infectious titre. 282 sars-cov-2 was more stable on plastic and stainless steel than on copper and cardboard; viable virus was detected up to 3 days after application to plastic and 2 days to stainless steel, on each surface the virus titer was reduced nearly ~100-fold. 282 importantly, sunlight exposure inactivated 98% of infectious sars-cov-2 every 6.8 minutes in simulated saliva and every 14.3 minutes in culture media. this study suggests that persistence, and subsequently exposure risk, may vary significantly between indoor and outdoor environments. 272 therefore, it is convenient to minimize contact with surfaces touched by others (even before sars-cov-2 existed), particularly at indoor environments, for example when using public transportation. in 248 covi̇d-19 patients, the estimated median time from symptom onset to viral clearance in the nasal swabs was 11 days, while in asymptomatic cases it was 2 days. 283 in patients that recovered, the median duration of viral shedding was ⁓20 days, while in non-survivors it was detected until death. the longest duration of viral shedding in survivors was 37 days. 110 accepted article and found that a slow viral clearance is associated with an increased risk of high disease severity with a 1% mortality rate. 285 the individual variation in the transmission of an infection is described by a factor called "dispersion factor or k". the lower "k" value, the more transmission comes from a small proportion of individuals acting like superspreaders. superspreading clusters have been observed in past coronavirus outbreaks (sars/mers), where a small number of infected individuals was responsible for a large proportion of secondary transmissions, with an estimated "k" of about 0.16 for sars and 0.25 for mers. 286 it is unclear whether superspreading clusters have contributed to the covid-19 outbreak. a simulation of early outbreak trajectories estimated that "k" for covid-19 is higher than for sars and mers. 286 however, in a recent preprint study, the estimate of "k" for sars-cov-2 was around 0.1, suggesting that around 10% of infected patients may have been responsible for 80% of secondary transmissions. 287 individual variation in infectiousness is difficult to measure, as it is mostly empirical, but the identification of any sars-cov-2 superspreading will be of primary importance for pandemic control. the designation of covid-19-dedicated wards and personnel within hospitals is useful to limit nosocomial sars-cov-2 infections. 124 it also allows other non-covid-19 conditions to be treated using routine healthcare resources more safely and effectively. maintaining such separation requires intensive sars-cov-2 testing in view of the high asymptomatic infection rate. 288 community-based strategies are effective at controlling the transmission of sars-cov-2. australia, hong kong, japan, singapore, south korea, and new zealand have all controlled effectively. their cumulative covid-19 mortality is >100-fold less than that in belgium, france, italy, spain and the uk, countries which have had difficulties to adequately control the pandemic. 147, 289, 290 it is important to implement measures to contain the spread of the virus, such as developing models to predict sars-cov-2-related mortality. 291 closing live animal markets is likely to reduce the risk of future viral outbreaks although this is not a practical way to prevent viral outbreaks for multiple reasons including social and economic. lifestyle factors that may influence sars-cov-2 infection susceptibility and covid-19 severity include smoking, stress, diet and alcohol intake, among others. for example, smoking has been shown to increase the susceptibility to respiratory tract infections and its severity, 294 and it is a risk factor for severe covid-19. 295 moreover, alcohol consumption may impair anti-viral immunity; 296 in vitro studies with human monocytes have shown that both acute and prolonged alcohol exposures inhibit type i ifn induction upon toll-like receptor-8 and -4 stimulation 297 . dietary habits may also play a role as obese patients have been shown to have a higher risk of developing severe covid-19. 298 furthermore, there are bioactive food compounds with antiviral activity, such as resveratrol, 299 although the amount of them obtained through the diet is unlikely to play a relevant role in covidit is known that respiratory virus infection causes perturbations in the gut microbiota and that germfree mice are more susceptible to viral infections, which intimates a role for the microbiota in covid19 . 300 however, the impact of the commensal microbiota on sars-cov-2 infection susceptibility and covid-19 severity is unknown. 301 an essential step is identifying the bacterial species interacting with sars-cov-2. this is rather challenging given the large number of bacterial species in the lung and respiratory tract, 302 and especially in the gut. however, a number of lung metagenomic studies have reported an abundance of prevotella in the lung of sars-cov-2 infected patients 303 . while in accepted article silico analysis have revealed that prevotella proteins may promote viral infection 304 , prospective studies are necessary to ascertain if this is a consequence of the infection or a risk factor for it. it is well-established that epithelial barrier defects and/or damage favor the development of th2 immunity. 305, 306 increased hygiene, in general, as well as overexposure to epithelial barrier opening molecules, such as detergents, can promote the onset of allergic disease. 307 to date, there is no evidence linking the covid-19 protective measures (gloves, hand-sanitizers, etc.) with increased allergy prevalence. in this regard, multifactorial epidemiological studies are needed. these studies should consider the impact on allergic diseases of virus-specific type 1 responses and psychosocial and environmental changes caused by the pandemic and efforts to contain it. although there has been a significant change in pollution parameters, unfortunately this reduction in pollution is transient and consequently unlikely to be significant. the exposome-related allergy and asthma risk is multifactorial. it includes climate change, biodiversity, the microbiome and nutrition among others, which have not changed during the pandemic. 308 in addition, although pollution levels have dropped, climate change still occurs at an accelerated pace. lifestyle changes during the lockdown 309 , weight gain and increased exposure to indoor allergens and pollutants may even increase the incidence of allergic diseases in the long-run. with the rapid spread of covid-19 at a pandemic scale, we are overwhelmed and drowned with a wealth of information. a global fight to contain the pandemic has started in which we need international solidarity and prompt sharing of accurate scientific information. we strongly support the this article is protected by copyright. all rights reserved continue scit or slit: non-infected individuals this article is protected by copyright. all rights reserved hypersensitivity reactions to drugs may occur more often during the pandemic due to the increased use of drugs and drug interactions, which can result in morbilliform rash, erythroderma, early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia effect of changing case definitions for covid-19 on the epidemic curve and transmission parameters in mainland china: a modelling study presumed asymptomatic carrier transmission of covid-19 eleven faces of coronavirus disease 2019 the proximal origin of sars-cov-2 phylogenetic network analysis of sars-cov-2 genomes structural 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antiretroviral drugs against sars, mers or covid-19: initial assessment compassionate use of remdesivir for patients with severe covid-19 remdesivir for the treatment of covid-19 -preliminary report covid-19 in patients with hiv: clinical case series a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 effectiveness of convalescent plasma therapy in severe covid-19 patients covid-19: combining antiviral and anti-inflammatory treatments accepted article this article is protected by copyright. all rights reserved baricitinib therapy in covid-19: a pilot study on safety and clinical impact growing evidence of the safety of jak inhibitors in patients with rheumatoid arthritis the fda-approved drug ivermectin inhibits the replication of sars-cov-2 in vitro the approved dose of ivermectin alone is not the ideal dose for the treatment of covid-19 observational study of hydroxychloroquine in hospitalized patients with covid-19 effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection: a randomized clinical trial outcomes of hydroxychloroquine usage in united states veterans hospitalized with covid-19. medrxiv a randomized trial of hydroxychloroquine as postexposure prophylaxis for covid-19 imbalanced host response to sars-cov-2 drives development of covid-19 current status of cell-based therapies for respiratory virus infections: applicability to covid-19 angiotensin-converting enzyme 2 (ace2) as a sars-cov-2 receptor: molecular mechanisms and potential therapeutic target covid-19 and the use of angiotensin-converting enzyme inhibitors and receptor blockers lack of reinfection in rhesus macaques infected with sars-cov-2 clinical benefit of remdesivir in rhesus macaques infected with sars-cov-2 on the way from sars-covsensitive mice to murine covid-19 model the covid-19 vaccine development landscape structures of human antibodies bound to sars-cov-2 spike reveal common epitopes and recurrent features of antibodies human neutralizing antibodies elicited by sars-cov-2 infection a human neutralizing antibody targets the receptor binding site of sars-cov-2 structural basis for potent neutralization of betacoronaviruses by single-domain camelid antibodies a human monoclonal antibody blocking sars-cov-2 infection delivery of alx-0171 by inhalation greatly reduces respiratory syncytial virus disease in newborn lambs vaccine efficacy against ontario isolates of infectious bronchitis virus safety, tolerability, and immunogenicity of a recombinant adenovirus type-5 vectored covid-19 vaccine: a dose-escalation, open-label, nonrandomised, first-in-human trial presymptomatic sars-cov-2 infections and transmission in a skilled nursing facility accepted article this article is protected by copyright. all rights reserved asymptomatic transmission, the achilles' heel of current strategies to control covid-19 asymptomatic seroconversion of immunoglobulins to sars-cov-2 in a pediatric dialysis unit suppressing the epidemic in new south wales covid-19 -navigating the uncharted covid-19, sars and mers: are they closely related? sars-cov-2 infection in children epidemiology of covid-19 among children in china coronavirus infection in pediatric emergency departments research g. children with covid-19 in pediatric emergency departments in italy severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection in children and adolescents: a systematic review multicentre italian study of sars-cov-2 infection in children and adolescents, preliminary data as at 10 virus-virus interactions impact the population dynamics of influenza and the common cold tissue distribution of ace2 protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis nasal gene expression of angiotensin-converting enzyme 2 in children and adults the september epidemic of asthma hospitalization: school children as disease vectors susceptibility of ferrets, cats, dogs, and other domesticated animals to sars-coronavirus 2 coronavirus disease 2019 (covid-19) in italy patients with diabetes are at higher risk for severe illness from covid-19 ethnicity and covid-19: an urgent public health research priority is ethnicity linked to incidence or outcomes of covid-19? assessing differential impacts of covid-19 on black communities impaired type i and iii interferon response to rhinovirus infection during pregnancy and asthma coronavirus disease 2019 in pregnancy consider pregnancy in covid-19 therapeutic drug and vaccine trials azithromycin induces anti-viral responses in bronchial epithelial cells azithromycin plus chloroquine: combination therapy for protection against malaria and sexually transmitted infections in pregnancy early administration of azithromycin and prevention of severe lower respiratory tract illnesses in preschool children with a history of such illnesses: a randomized clinical trial effect of azithromycin on asthma exacerbations and quality of life in adults with persistent uncontrolled asthma (amazes): a randomised, doubleblind, placebo-controlled trial accepted article this article is protected by copyright. all rights reserved ace 2 coding variants: a potential x-linked risk factor for covid-19 disease tlr7 ligands induce higher ifn-alpha production in females baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region risk factors for severity and mortality in adult covid-19 inpatients in wuhan spread of sars-cov-2 in the icelandic population updates by select demographic and geographic characteristics clinical characteristics of patients who died of coronavirus disease 2019 in china epidemiology of covid-19 in a long-term care facility in king county, washington coast-to-coast spread of sars-cov-2 during the early epidemic in the united states outbreak dynamics of covid-19 in europe and the effect of travel restrictions absolute humidity and pandemic versus epidemic influenza the signature features of influenza pandemics--implications for policy simulated sunlight rapidly inactivates sars-cov-2 on surfaces potential impact of seasonal forcing on a sars-cov-2 pandemic accepted article this article is protected by copyright. all rights reserved high sars-cov-2 attack rate following exposure at a choir practice airborne transmission of severe acute respiratory syndrome coronavirus-2 to healthcare workers: a narrative review aerodynamic analysis of sars-cov-2 in two wuhan hospitals changes in contact patterns shape the dynamics of the covid-19 outbreak in china evaluating the effectiveness of social distancing interventions to delay or flatten the epidemic curve of coronavirus disease social network-based distancing strategies to flatten the covid-19 curve in a post-lockdown world physical distancing, face masks, and eye protection to prevent person-to-person transmission of sars-cov-2 and covid-19: a systematic review and meta-analysis. the lancet epidemiology working group for ncip epidemic response ccfdc, prevention aerosol and surface stability of sars-cov-2 as compared with sars-cov-1 clinical progression of patients with covid-19 in shanghai distinct regulation of tonsillar immune response in virus infection covid-19 in a designated infectious diseases hospital outside hubei province pattern of early human-to-human transmission of wuhan estimating the overdispersion in covid-19 transmission using outbreak sizes outside china disease control, civil liberties, and mass testing -calibrating restrictions during the covid-19 pandemic evaluation of the effectiveness of surveillance and containment measures for the first 100 patients with covid-19 in singapore a dynamic residential community-based quarantine strategy: china's experience in fighting covid-19 advanced forecasting of sars-cov-2-related deaths in italy peer-to-peer contact tracing: development of a privacy-preserving smartphone app ethics of instantaneous contact tracing using mobile phone apps in the control of the covid-19 pandemic how cigarette smoke skews immune responses to promote infection, lung disease and cancer smoking is associated with covid-19 progression: a meta-analysis. medrxiv alcohol's effect on host defense inhibition of tlr8-and tlr4-induced type i ifn induction by alcohol is different from its effects on inflammatory cytokine production in monocytes high prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (sars-cov-2) requiring invasive mechanical ventilation antiviral activity of resveratrol gut microbiota and covid-19-possible link and implications considering the effects of microbiome and diet on sars-cov-2 infection: nanotechnology roles the microbiome and the respiratory tract a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster covid-2019 associated overexpressed prevotella proteins mediated hostpathogen interactions and their role in coronavirus outbreak the initiation of th2 immunity towards food allergens igg1(+) b-cell immunity predates ige responses in epicutaneous sensitization to foods laundry detergents and detergent residue after rinsing directly disrupt tight junction barrier integrity in human bronchial epithelial cells emerging concepts and challenges in implementing the exposome paradigm in allergic diseases and asthma: a practall document will changes in alcohol and tobacco use be seen during the covid-19 lockdown? treatment of 5 critically ill patients with covid-19 with convalescent plasma treatment with convalescent plasma for critically ill patients with severe acute respiratory syndrome coronavirus 2 infection use of convalescent plasma therapy in two covid-19 patients with acute respiratory distress syndrome in korea treatment with convalescent plasma for covid-19 patients in wuhan effect of convalescent plasma therapy on viral shedding and survival in covid-19 patients treatment of covid-19 patients with convalescent plasma the authors thank the european academy of allergy and clinical immunology this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved this article is protected by copyright. all rights reserved key: cord-260993-udajtsmm authors: youssef, mohanad; hussein, mohammad; attia, abdallah s; elshazli, rami; omar, mahmoud; zora, ghassan; farhoud, ashraf; elnahla, ahmad; shihabi, areej; toraih, eman; fawzy, manal; kandil, emad title: covid‐19 and liver dysfunction: a systematic review and meta‐analysis of retrospective studies date: 2020-05-23 journal: j med virol doi: 10.1002/jmv.26055 sha: doc_id: 260993 cord_uid: udajtsmm background: recently, coronavirus disease 2019 (covid‐19) pandemic is the most significant global health crisis. in this study, we conducted a meta‐analysis to find the association between liver injuries and the severity of covid‐19 disease. methods: online databases, including pubmed, web of science, scopus, and science direct, were searched to detect relevant publications up to april 16, 2020. depending on the heterogeneity between studies, a fixed‐ or random‐effects model was applied to pool data. publication bias egger's test was also performed. results: meta‐analysis of 20 retrospective studies (3428 patients), identified that patients with a severe manifestation of covid‐19 exhibited significantly higher levels of alanine aminotransferase, aspartate aminotransferase, and bilirubin values with prolonged prothrombin time. furthermore, lower albumin level was associated with a severe presentation of covid‐19. conclusion: liver dysfunction was associated with a severe outcome of covid‐19 disease. close monitoring of the occurrence of liver dysfunction is beneficial in early warning of unfavorable outcomes. this article is protected by copyright. all rights reserved. data extraction was conducted by four authors (my, gz, aa, and af). the process included using a two-step approach: firstly, we screened titles and abstracts for eligibility according to the study objective, and secondly, we screened the full-text article of relevant abstracts. the newcastle-ottawa scale was used for assessing the quality of eligible manuscripts. publication bias was assessed with the newcastle-ottawa quality assessment scale cohort studies. 17 the pooled estimates were extracted using revman version 5.3. descriptive summary statistics in the form of mean, standard deviation, and range for continuous parametric measures were tabulated. pairwise comparison between mild and severe covid-19 patients was performed. overall pooled odds ratio (or) or standardized mean difference (smd) with 95% confidence intervals (ci) were estimated for categorical accepted article and quantitative variables, respectively. a fixed-effects model was employed unless significant heterogeneity was detected. in this case, the random-effects model has applied. 18 heterogeneity was considered significant if the i-square value exceeds 50%, or its p-value was less than 0.1. subgroup analyses by the location of the patients, publication date, sample size, and quality score were performed. sensitivity analysis was carried out by removing one study each time, to reflect its effect size on the overall or. publication bias was assessed via begg's funnel plot and egger's linear regression approach using comprehensive meta-analysis software. 19 an asymmetric funnelshape or a p-value <0.1 indicated significant bias. 20 meta-regression analysis was employed using openmeta analyst software, taking into consideration the following study characteristics; sample size, mean age of patients, percentage of males, city of the hospital, publication date, and quality score. to evaluate the reliability of statistical appraisal of this meta-analysis study, we used tsa software (version 0.9.5.10 beta) by merging several available sample sizes of applicable studies with the threshold of statistical influence to reduce the unintentional miscalculations and improve the strength of anticipations. we used twoside trials and type i error with a calculated power of 5% and 80%. if the cumulative z-curve crosses the monitoring boundaries, no additional trials would be required. on the contrary, if the z-curve did not accomplish the boundary levels, the necessary threshold requires additional records to achieve a prominent significance. this article is protected by copyright. all rights reserved. following the removal of duplicates (n=1,870), our database search identified 2,582 unique citations, of which 186 full-text articles were assessed. a total of 20 eligible retrospective cohort studies, including 3428 positively confirmed covid-19 patients, were enrolled in the current meta-analysis. the workflow of the process of study selection is demonstrated in figure 1 . all articles were published during the period between january 30 and april 16, 2020. most of them were from wuhan city (13), three from zhejiang, one from guangdong, one from hubei, one from guangdong, and one from anhui. as depicted in table 1 , the sample size of studies ranged from 21 to 651 cohorts. the mean age of patients was 53.8 years, and 57.8% were men. in the included studies, the severe disease was detected in 36.2% of patients and the average survival rate was 72.18%. all studies except for three scored more than five on the scale. two studies scored a three, and one study scored a two. (figure s1 ). apart from alt data, significant heterogeneity was detected in laboratory results. subgroup analysis by the origin of the hospital, publication date, sample size, and quality score of the studies failed to resolve the obvious heterogeneity. this article is protected by copyright. all rights reserved. figure s2 ). apart of cardiovascular disease, homogeneity between studies was detected. a total of 17 studies reported treatment to be administered to covid-19 patients. on comparison between the two groups, severe patients were nearly three times more likely to receive steroids (or = 3.17, 95%ci = 3.02-4.97, p <0.001) and immunoglobulins (or = 2.75, 95%ci = 1.09-6.94, p = 0.032). sensitivity analysis revealed that the studies of wang 31 and zhang 24 contributed in the significant heterogeneity observed in treatment results ( table 2) . figure s3 ). considerable heterogeneity was observed for the outcomes. meta-regression analysis for study characteristics showed higher odds of mortality in articles involving wuhun hospitals (coefficient = 4.30, 95%ci = 3.07-5.54, p <0.001) (supporting information materials table s1 ). the funnel plot of laboratory and clinical parameters is shown in figure s4 . egger's test showed no publication bias for all variables (p >0.1) except for two; cardiovascular and cerebrovascular diseases (p = 0.061 and 0.041) ( table 2) . we applied tsa on mortality rate available among all eligible articles of covid-19 patients with a mild and severe exhibition and indicated that the cumulative z-curve transverses the monitoring boundaries before reaching the required sample size and achieving considerable significant and so no further studies are necessary (figure 2 ). our meta-analysis including 3428 subjects from 20 retrospective studies explored the potential relationship between liver injury and the severity of covid-19 disease. we found that liver dysfunction seemed to be higher in patients with severe outcomes from covid-19 infection. our results were in agreement with a previous study review. 21 previously, liver injury has been reported as an important risk factor for severe outcome and death in sars accepted article and middle east respiratory syndrome. [22] [23] [24] [25] patients in our study who had severe presentations of covid-19 disease had higher levels of ast, alt, bilirubin, and lower albumin levels. our results are consistent with recent studies on covid-19 disease that showed that the incidence of liver injury ranged from 58% to 78%, mainly indicated by elevated ast, alt, and total bilirubin levels accompanied by slightly decreased albumin levels. 26, 27 in a recent study, guan et al. documented that higher serum levels of ast were observed in nearly 18% of patients with non-severe covid-19 disease and approximately 56% of patients with severe covid-19 infection. 28 moreover, in that study, higher serum levels of alt were also observed in nearly 20% of patients with non-severe covid-19 presentation, and approximately 28% of patients with severe covid manifestation. 28 similar findings in huang et al. were also observed, where patients with severe covid-19 features had an increased incidence of liver injury. postmortem liver biopsies specimens were observed in deceased covid-19 patients. the findings showed mild lobular and portal activity along with microvascular stenosis, indicating the injury could have been caused by either covid-19 disease or drug-induced liver injury. 3 similar to the treatment of sars, steroids, antivirals, and antibiotics are widely used for the treatment of covid-19. [29] [30] [31] these drugs are all potential causes of liver injury during covid-19 treatment but have not yet been evident. 32 a recent study reported that the liver injury observed in covid-19 patients might be caused by lopinavir, which is used as an antiviral for the treatment of sars-cov-2 infection. 33 it is worth noting that the specific underlying causes of liver injury and elevated levels of liver enzymes in covid-19 patients are still limited. however, collectively the proposed mechanisms might include "hyperactivated immune this article is protected by copyright. all rights reserved. responses and cytokine storm-related systemic inflammation, psychological stress, drug toxicity, and progression of pre-existing liver diseases" as detailed by li and fan. 46 further studies are needed to investigate the mechanisms of liver dysfunction in covid-19 disease as a direct outcome of infection and the possible effects that treatment has on the liver. limitations of our study include the following; firstly, all the studies included in this meta-analysis used a case-control or cohort design, which are susceptible to recall and selection biases. secondly, we could not distinguish if the liver dysfunction in covid-19 patients was an acute liver injury or exacerbated chronic liver disease. lastly, the enrolled studies focused on chinese patients, which restricted a more precise estimation of liver dysfunction in the context of other races. in this meta-analysis, we comprehensively analyzed liver dysfunction in accordance with the severity of clinical outcomes in covid-19 patients. liver dysfunction was associated with severe covid-19 infection. patients presented with abnormal liver function tests are at higher risk of severe clinical outcomes. close monitoring of the presence of liver dysfunction may be beneficial as an early indicator of worse outcomes. this may serve to better prepare the treatment of patients. none. this article is protected by copyright. all rights reserved. all authors declare no conflict of interest. this article is protected by copyright. all rights reserved. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study coronavirus disease 2019 (covid-19) situation report -84. world heal organ pathological findings of covid-19 associated with acute respiratory distress syndrome clinical features of patients infected with 2019 novel coronavirus in wuhan coronavirus as a possible cause of severe acute respiratory syndrome a novel coronavirus from patients with pneumonia in china the novel coronavirus 2019 (2019-ncov) uses the sarscoronavirus receptor ace2 and the cellular protease tmprss2 for entry into target cells specific ace2 expression in cholangiocytes may cause liver damage after 2019-ncov infection cholangiocyte pathobiology clinical characteristics of refractory covid-19 pneumonia in wuhan, china diagnostic utility of clinical laboratory data this article is protected by copyright. all rights reserved. accepted article determinations for patients with the severe covid-19 clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study clinical and immunologic features in severe and moderate coronavirus disease risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease epidemiological, clinical characteristics of cases of sars-cov-2 infection with abnormal imaging findings preferred reporting items for systematic reviews and meta-analyses: the prisma statement critical evaluation of the newcastle-ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses hematological and biochemical factors predicting sars fatality in taiwan clinical characteristics of 36 non-survivors with covid-19 in wuhan, china. medrxiv clinical characteristics of 82 death cases with covid-19 clinical characteristics of coronavirus disease 2019 in china covid-19: combining antiviral and antiinflammatory treatments non-steroidal anti-inflammatory drugs and covid-19 the antiviral compound remdesivir potently inhibits rnadependent rna polymerase from middle east respiratory syndrome coronavirus clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a single-centered, this article is protected by copyright. all rights reserved platelet-to-lymphocyte ratio is associated with prognosis in patients with coronavirus disease-19 clinical characteristics of fatal and recovered cases of coronavirus disease 2019 (covid-19) in wuhan, china: a retrospective study clinical features and treatment of covid-19 patients in northeast chongqing epidemiological, clinical and virological characteristics of 74 cases of coronavirus-infected disease 2019 (covid-19) with gastrointestinal symptoms clinical characteristics of covid-19 patients with digestive symptoms in hubei, china: a descriptive, cross-sectional, multicenter study the clinical characteristics of myocardial injury in severe and very severe patients with 2019 novel coronavirus disease characteristics and mechanism of liver injury in 2019 coronavirus disease key: cord-029547-9ei1ram3 authors: li, jingwei; shao, jun; wang, chengdi; li, weimin title: the epidemiology and therapeutic options for the covid-19 date: 2020-05-28 journal: precis clin med doi: 10.1093/pcmedi/pbaa017 sha: doc_id: 29547 cord_uid: 9ei1ram3 an outbreak of coronavirus disease 2019 (covid-19), a disease caused by a novel pneumonia virus, has affected over 200 countries and regions worldwide. with the increasing number of patients and deaths, who have declared it as a global pandemic currently, indicating a third large-scale epidemic coronavirus has appeared since the emergence of severe acute respiratory syndrome coronavirus (sars) and middle-east respiratory syndrome (mers) in the twenty-first century. considering the great harm it has caused, researchers throughout the world have been chasing to exploit the pathophysiology, characteristics, and potential remedies for covid-19 to better battle the outbreak. therefore, the current study revisits advances of the virology, epidemiology, clinical features, therapeutic options, and prevention of covid-19. the features of asymptomatic carriers are also been explored. at the end of 2019, a sudden outbreak of pneumonia occurred in wuhan, china, which was later confirmed to be caused by a coronavirus, severe acute respiratory syndrome coronavirus 2 (sars-cov-2). 1,2 soon after, the virus spread rapidly around the world and affected human health as well as causing huge economic losses to society. [3] [4] [5] on 12 february 2020, this novel disease was named coronavirus disease 2019 (covid-19) by who. 6 since then, medical experts around the world have been trying to find the control measures and treatment for it. because covid-19 is highly contagious, the number of patients has increased rapidly. thus, realizing its basic characteristics and finding appropriate methods to detect and cure covid-19 is necessary for outbreak control. the detection and rehabilitation judgment of covid-19 are mainly through reverse transcriptionpolymerase chain reaction (rt-pcr), 7 but experts have pointed out the low sensitivity will lead to missed diagnosis. so a combination of rt-pcr and other clinical features of covid-19 is important for diagnosis. 8 the treatments for covid-19 are still unclear and mainly contain administration of oxygen, drug therapy, and emergency treatments such as ecmo. 9 ,10 as we know, few studies have summarized and classified therapies for covid-19 systematically. therefore, we review basic characteristics such as virology and epidemiology of covid-19 and classified explore antiviral therapy, symptomatic treatment, and traditional chinese medicines for curing covid-19. considering no licensed vaccine exists for covid-19, we also summarize the research and development of its vaccine. notice that the recent emergence of asymptomatic carriers has brought great difficulties for prevention and control of this disease, 11 we highlight the characteristics of asymptomatic carriers and how to reduce their impact on the development of the covid-19 pandemic. in january 2020, after the outbreak of covid-19, scientists identified its pathogen and immediately confirmed it to be a novel coronavirus, which is found to be a β coronavirus of group 2b and was named 2019-ncov by who initially. 2 because 70% of its genetic sequences are similar to the sars-cov, it was later renamed sars-cov-2. 12 the origin of sars-cov-2 is unclear and is thought to be related to bat coronaviruses. zhou et al. compared gene sequence of sars-cov-2 with ratg13, a bat coronavirus, and found the whole-genome sequence of sars-cov-2 is 96.2% similar to ratg13, indicating that sars-cov-2 may originate from a bat coronavirus. 13 at the same time, wu and colleagues reported that the genome sequence of sars-cov-2 was closely linked with sl-covzc45, another bat coronavirus, with 82.3% similarity. 14 however, despite the high similarity of sars-cov-2 to the virus from bats, the genetic differences will take at least a few decades of evolution to make up. 15 thus, bats are unlikely to be the definitive hosts of it, and there may exist other intermediate hosts which brought the virus into humans. 16 the relative synonymous codon usage analysis of viruses found sars-cov-2 used the translation machinery of several snakes effectively. therefore, snakes are a potential reservoir of the novel virus. 17 apart from this, pangolins are thought to be the potential intermediate host of sars-cov-2 due to the sequence similarity of their spike receptor binding domains. 18 furthermore, liu et al. declared that turtles were another possible host of sars-cov-2. 19 thus, more studies are necessary for confirming the intermediate host of sars-cov-2. the pathogenic mechanism of sars-cov-2 is still unclear and thought to be closely related to viral sepsis, 20 but structural biology has explained how viruses enter cells. angiotensin converting enzyme ii (ace2) has been demonstrated to be the only receptor for sars-cov-2. 13 the s protein on the surface of coronavirus was confirmed to mediate virus entry, 21 which contains proteins s1 and s2 subunits. the receptor-binding domain (rbd) of s1 is responsible for the recognition of ace2 on the surface of human cells to complete the binding of viruses to cells. the s2 subunit mediates the fusion of the virus envelope and human cell membrane to complete the invasion process. there are two important conserved repeated amino acid sequences, hr1 and hr2, in the s2 subunit of sars-cov-2. together, they form a spiral structure called 6-hb, which is the key for the fusion of a coronavirus envelope with cell membrane. 22 the serine protease tmprss2 triggers the s protein and promotes its fusion with the cell membrane. 23 after that, the rna of the virus is released into the cytoplasm to complete its biosynthesis. sars-cov-2 is more contagious, although it has a similar structure of s protein to sars-cov, so virus-receptor-binding affinity is now being conducted in further studies. goh et al. found the rigidity and stability of sars-cov-2 shell are apparently higher than sars-cov, 24 which increase its adaption to the environment. moreover, the structural difference of hr1 contributes to the higher structural stability for the 6-hb of sars-cov-2, which has caused the better membrane fusion capacity of sars-cov-2. 22 thus, sars-cov-2 has a stronger infectious ability. it is worth noting that the expressions of ace2 in patients with some diseases such as diabetes are notably higher than those in healthy people, 25 indicating that people with underlying diseases are more likely to be infected. on 31 december 2019, wuhan municipal health commission reported that 27 pneumonia patients were associated with a south china seafood market, which was the earliest discovery of covid-19. 26 then, the quantity of covid-19 patients increased rapidly after chinese new year. up to 16 may 2020, covid-19 had affected more than 200 countries and regions, and the quantity of confirmed patients had reached 4 425 485 globally. 27 after the breakthrough of covid-19, experts began to predict the incubation stage of the sars-cov-2. according to the data collected in january 2020, the incubation stage of covid-19 patients ranges between 2 and 14 days, and its average is about 5 days (95% credible interval: 4.2-6.0) when implementing the best-fit lognormal distribution. thus, experts recommended that suspected patients are quarantined for at least 14 days. 28 the mode of sars-cov-2 transmission is also an important part of epidemiological investigation. it is clear that humanto-human transmission of covid-19 occurs mainly via droplet respiratory particles, 29 but whether sars-cov-2 can be transmitted via the eyes is still unclear. 30 it should be noted that several studies have showed that chief complaint of some covid-19 patients were digestive symptoms, and nucleic acids of sars-cov-2 were even found in fecal samples or anal swabs of some patients, demonstrating the possibility of an oralfecal route. [31] [32] [33] furthermore, mother-to-child transmission is also a potential route of covid-19. 34, 35 luckily, infection rates of children are relatively low, and most inpatient children only have mild symptoms even if they are infected, [36] [37] [38] thus less damage would occur to them. up until now, the largest case series data of china has shown that 86.6% of covid-19 patients were aged 30-79 years, 1% were aged under 1 year old, 1% aged 10-19 years, and 3% were aged above 80 years. among all patients, males account for 51%, and females account for 49%. furthermore, 4% of them are medical workers. 39 in the united states, the elderly (aged over 65) account for 31% of total covid-19 cases, 45% of inpatients, 53% of icu patients, and 80% of death cases. 40 in terms of epidemiology, the basic reproductive number and mortality rate are indispensable. basic reproductive number (r0) is thought to be an important index for predicting the development of an outbreak. the main method of calculating r0 is using the data of infected people, such as serial interval distribution and latent period, to build a proper mathematical model for predicting the trend of the epidemic. a big epidemiological data of 425 confirmed covid-19 patients reported that the basic reproductive number of sars-cov-2 was 2.2, which means each patient could infect 2.2 other people. 1 however, more recent research estimated that basic reproductive number was 5.8. 41 it is obvious that distinctions of r0 exist in these studies, and they result in data and model differences. the incubation period and serial interval distribution of former research are calculated only through 10 confirmed cases and six pairs of cases in clusters, respectively. 1 furthermore, the model of the former research is made merely on the basis of one region, 1 thus its r0 distinctly lacks universality. by contrast, the latter study gathered the information of incubation period, serial interval, and infectious period from the individual cases reported throughout china and designed two models to infer the growth rate of the outbreak in different perspectives. 41 so, its r0 better reflects the epidemic situation of china. similarly, the r0 of around 3.87 reported by imperial college covid-19 response team only represented the situation in europe. 42 according to the data analysis of the chinese center for disease control and prevention, the overall mortality of covid-19 patients was approximately 2.3%, 43 which is obviously lower than severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers). 44 however, because of the lager quantity of covid-19 patients, the number of covid-19 deaths is still high. furthermore, the data from the epidemic area indicated that people aged 30-59 years had the highest death rate of any age group, and the risk of symptomatic infection increased year by year. 45 like most respiratory illnesses, covid-19 has many typical respiratory clinical symptoms. data from 1099 confirmed covid-19 patients have shown that 88.7% had a fever, 67.8% developed a cough, and 2.3% received invasive mechanical ventilation, 46 which is consistent with other studies. 47 for some severe patients, acute respiratory distress syndrome (ards), shock, and arrhythmia are common complications. 48, 49 apart from these symptoms, covid-19 patients sometimes have other non-respiratory symptoms such as fatigue, myalgia, headache, and digestive tract symptoms. 48, 50 moreover, the main changes in laboratory results of covid-19 are decreases in lymphocytes and eosinophils as well as increases in d-dimer, c-reactive protein, prothrombin time, and procalcitonin. 48, 51 computed tomography (ct) is one of the most efficient techniques for evaluating severity and differential diagnosis of pulmonary diseases, thus the ct characteristics ( fig. 1 ) of covid-19 are another important clinical feature. this clinical evidence indicates that ground glass opacity (ggo), consolidation, and interlobular septal thickening are the most common ct characteristics of covid-19, which occurs mainly in the posterior lung area and middle and lower lung regions. 52, 53 compared to patients with mild symptoms, signs such as consolidation, thickened bronchial wall, linear opacities, extrapulmonary lesions, and higher ct scores are marked ct features of critically ill patients. 54 therefore, ct is potentially used to diagnose and predict the prognosis of covid-19 patients. clinical symptoms are often used as indicators of clinically suspected cases. thus, when it comes to the clinical features above, it is easy to think about clinical diagnosis of covid-19 (table 2and fig. 2 ). according to the diagnosis and treatment program of novel coronavirus pneumonia, only a suspected case has one of the pieces of evidence of etiology or serology, such as positive nucleic acid, confirmation of gene sequencing, and virus specific antibody, to be confirmed to be covid-19 patient, 55 and the suspected cases were identified by a comprehensive analysis of epidemiological history and clinical manifestations. 56 however, there are also many problems with this program. the most obvious problem is that rt-pcr patients have any epidemiological history and conform to at least two clinical manifestations, or patients without clear epidemiological history conform to three clinical manifestations. epidemiological history: i. travel or residence history of an affected area or close contact with a suspected or confirmed case within 14 days before onset ii. have contact with covid-19 cases (nucleic acid positive) within 14 days prior to onset iii. have contact with patients with fever or respiratory symptoms from an affected area, or from communities with covid-19 cases iv. cluster onset (two or more cases of fever and/or respiratory symptoms within 2 weeks in a small area such as home, office, school, and class) clinical manifestations: i. fever and/or respiratory symptoms ii. with covid-19 imaging characteristics iii. normal or reduced number of white blood cells and/or lymphocytes in early covid-19 the suspected cases have at least one of the following etiological or serological evidences. i. the real-time fluorescent rt-pcr for specimens with a positive result of sars-cov-2 rna ii. virus gene sequences are highly homologous to sars-cov-2 iii. positive sars-cov-2 specific igm antibody and igg antibody in serum; the serum sars-cov-2 specific igg antibody changes from negative to positive or is four times higher in the recovery period than in the acute phase is the most common method for nucleic acid testing, but its sensitivity is not as high as expected, 57 thus it possibly causes misdiagnosis of covid-19. furthermore, although viral gene sequencing is an accurate diagnostic method and used on a small scale, 58 its complex operation and time-consuming process make it difficult for wider clinical use. sars-cov-2 specific antibody detection is a simple detection method with higher sensitivity than rt-pcr, 59 but its high sensitivity is only reflected after 5.5 days of symptom onset, 60 so it is just a supplementary means to rt-pcr. luckily, the fast and convenient method, ct, was found to have a higher diagnostic sensitivity for covid-19 than other diagnostic methods such as rt-pcr and can predict the prognosis of patients, 57,61 thus it is meaningful for the initial screening. zhang et al. developed a deep learning system for image recognition of covid-19 patients. they collected ct images from 4154 patients for validation and found this system precisely identified the covid-19 and other forms of pneumonia, and it also divided these patients into high-and low-risk groups correctly, 62 so rational use of artificial intelligence such as this may be better able to screen covid-19 patients and give them timely interventions to ensure a better prognosis. in addition, a crispr-cas12-based technique was confirmed to be a faster test for covid-19 with higher sensitivity, 63 thus it is possibly a replacement for the rt-pcr assay. the therapeutic schedule issued by the general office of national health committee of china on 3 march has shown that therapy of covid-19 should be combined with etiological treatment and symptomatic treatment, and symptomatic treatment is especially important for severe and critical patients. furthermore, traditional chinese medicine can be also used for the whole treatment cycle of covid-19 patients. 55 in the processes of covid-19 therapy, drugs and bioproducts play important roles (table 3) . here, we summarize the main treatments of novel pneumonia. the etiological treatment for covid-19 means antiviral therapy for it, which depends on antiviral drugs and bioproducts. the processes of virus infection could be described as attachment, penetration, uncoating, biosynthesis, assembly, and release. after that, the virus complete its proliferation and causes damage to host cells. similarly, the mechanism of antiviral therapy is through disturbing these processes. thus, the medicines for antiviral treatment of covid-19 are divided into penetration and uncoating inhibitors, biosynthesis inhibitors, and assembly inhibitors. penetration and uncoating inhibitors of sars-cov-2 mainly include chloroquine, arbidol, and camostat mesilate. chloroquine is an efficient drug for treatment of malaria as well as autoimmune rheumatic diseases. wang and colleagues treated vero e6 cells that were infected by sars-cov-2 with several drugs in vitro and found a low half-maximal effective concentration at 1.13 μmol and a high selectivity index of chloroquine, indicating that chloroquine probably inhibits the viral infection. 64 there have been tens of clinical trials to confirm the safety and efficiency of chloroquine in treating covid-19 patients, and its mechanism can be described as interfering with the glycosylation of ace2 or alkalizing the phagolysosome to inhibit viral replication, 65, 66 which prevents the sars-cov-2 entering the host cells. the in vitro study indicated that chloroquine only had an antiviral effect under high doses. however, the clinical data of chloroquine showed the mortality of highdosage group was apparently higher than the low-dosage group, but there was no significant difference in efficacy, 67 and the qt interval of some covid-19 patients was prolonged after hydroxychloroquine/azithromycin treatment, 68 thus it might not be an effective medicine for covid-19. arbidol is the other penetration inhibitor that suppresses the fusion of the virus lipid membrane and host cells to block the replication of the virus. arbidol also has the function of interferon (ifn) inducement, thus it has been widely used to treat a and b influenza viruses. it is promising that several studies of arbidol have shown a significant therapeutic effect for curing covid-19 patients. wang and colleagues found arbidol reduced the mortality and improved discharging rate by analysis of 67 discharged covid-19 patients. 69 furthermore, the other study compared the treatment effects between combination of arbidol and lopinavir/ritonavir, and simple lopinavir/ritonavir, finding that their ct scan improvement rates are 69% and 29%, and viral rna decrement rates are 75% and 35%, respectively. 70 thus, arbidol perhaps serves as a specific treatment for covid-19. however, another clinical report pointed out arbidol could not improve the symptoms or accelerate the clearance of sars-cov-2. 71 thus, further studies are needed to validate its antiviral efficiency. camostat mesylate is a specific drug for inhibiting tmprss2, a protease used for s protein priming to promote the entry of sars-cov-2, thus it is another potential penetration inhibitor. 23 however, there is still lack of clinical evidence to prove its effectiveness. the biosynthesis inhibitors for sars-cov-2 chiefly contain remdesivir, sofosbuvir, ribavirin, and lopinavir/ritonavir. remdesivir is as kind of broad spectrum antiviral medicine that suppresses the virus replication through inhibiting the activity of rnadependent rna polymerase, 72, 73 and its efficiency has been widely confirmed in coronaviruses such as sars-cov and mers-cov. recently, remdesivir has been found to be a potential drug to treat covid-19. a previous study showed that half-maximal effective concentration of remdesivir was 0.77 in an in vitro test treating covid-19 with a high selectivity index, demonstrating its therapeutic effect. 64 there, the first covid-19 case of america was reported to be cured completely after intravenous injection of remdesivir, 74 and clinical data showed that remdesivir dramatically alleviated clinical symptoms and reduced mortality for severe patients, 75 which demonstrated it is a potential drug for treating novel pneumonia. however, a patient died of hypotension and cardiac arrest after remdesivir treatment in a randomized controlled trial of ebola virus (ebov) treatment, 76 and 60% covid-19 patients had side effects after using remdesivir, 75 which indicated its security is worthy of further confirmation. up to now, several agencies have published conflicting clinical results from remdesivir. 77, 78 thus, more research should be conducted to verify its curative efficacy. furthermore, in vitro tests showed that other broad-spectrum antiviral medicines such as sofosbuvir and ribavirin interacted with rna-dependent rna polymerase of sars-cov-2, which prevents the replication of virus, thus they can also serve as antiviral drugs for covid-19. 79 lopinavir and ritonavir are suppressors of 3-chymotrypsin-like protease, a protease of coronavirus. furthermore, ritonavir suppresses the activity of cytochrome p450 isoenzymes and thus elevates plasma concentration of other medicines. therefore, combining lopinavir and ritonavir has a good inhibitory effect on virus biosynthesis, which was confirmed in the treatment of sars-cov and mers-cov. 80 recently, many covid-19 patients have received lopinavir/ritonavir therapy and to good effect. 81 moreover, the first report of the lopinavir/ritonavir clinical trial results have been published on 19 march 2020. in that study, 99 patients were assigned to the lopinavir/ritonavir group and 100 patients were treated with the routine therapy, and the median time of clinical improvement was advanced by 1 day when given the lopinavir/ritonavir treatment. 82 but it failed to accelerate clinical improvement significantly, and reduce mortality and viral rna detected in the throat. 82 similarly, the clinical trial in severe covid-19 patients indicated lopinavir/ritonavir was of no benefit compared to standard care. 83 therefore, further studies are needed to identify or exclude the possible benefits of lopinavir/ritonavir-based therapies. the most common antiviral products are ifns, which induce cells to synthesize antiviral proteins and thus inhibit all processes of the viral replication cycle. furthermore, it could also enhance immunity of patients, so it is widely used for therapy for multiple viruses such as mers-cov. 84 in this outbreak, ifns combined with antiviral drugs were recommended to treat covid-19, 85 which has achieved good clinical therapeutic effect. xu et al. reported that the combination of ifns and arbidol or lopinavir/ritonavir cured 62 covid-19 patients in the zhejiang province. 50 in addition, a combination use of ifn beta-1b, ribavirin, and lopinavir-ritonavir was found to be more effective than pure lopinavir-ritonavir. 86 these therapies have been initiated into multiple clinical trials. convalescent plasma therapy (cpt) is based on the principle of using a certain titer of viral-specific antibodies in the recovered plasma to obtain passive immunity, neutralize specific pathogens, and eventually clear the pathogens in blood circulation, thus achieving the treatment expectation. 87 luckily, key indicators of laboratory testing, clinical signs, and symptoms of several covid-19 patients were confirmed to improve significantly after cpt, 88 so cpt is recommended for covid-19 treatment. currently, clinical trials are under way to further evaluate the efficiency and safety of cpt to covid-19. the monoclonal antibody is a highly uniform antibody that is produced by a single b cell and specific to target the antigen epitopes, which have been confirmed to suppress viruses entering host cells extracellularly for many coronaviruses including sars-cov-2. 89 like most diseases, the main treatments of the complications of covid-19 are to strengthen supportive treatment, ensure adequate energy, and pay attention to water and electrolyte balance to maintain internal environment homeostasis. 55 for covid-19, hypoxia is a typical clinical symptom of covid-19, thus oxygen inhalation is the essential treatment for both mild and severe patients. 92, 93 it is worth noting that severe cases of covid-19 often develop severe inflammation, shock, combination of bacterial infection, and severe kidney damage as well as acute respiratory distress syndrome (ards), which often result in death. 94 thus, timely complications treatment is necessary for critical patients. glucocorticoids such as methylprednisolone and dexamethasone have strong anti-inflammatory as well as antishock effects, so they are usually used to save critical patients, especially patients with ards. 95 however, they suppress immunity, cause femoral head necrosis of patients, and cannot save patients with shock who have increased intrathoracic pressure, thus who did not recommend using glucocorticoids initially. 96 for these situations, physicians suggested that short-term administration of glucocorticoids should be adopted to decrease the side effects. 97 moreover, considering the immunosuppressive action, immune boosters such as α-ifn and thymosin are important for use in avoiding adverse events. for severe cytokine storms, simple glucocorticoids cannot suppress the inflammation efficiently, so potent blood purification measures such as an artificial liver system are essential. 98 the processes of urgent antishock therapy mainly contain complements of blood volume, improving cardiac contractility and vascular activity, thus vasoactive agents and positive inotropic drugs such as epinephrine, dopamine, and norepinephrine 99 are necessary for first aid of critical covid-19 patients. for patients with severe kidney damage, we should actively search for the primary cause and pay attention to the water, electrolyte, and acid-base balance. when homeostasis is decompensated and/or multiple organ failure occurs, continuous renal replacement therapy (crrt) should be adopted for treatment. 100 ards is one of most critical complications for patients, which is known for its high mortality rate, especially for pregnant patients. 101 for its therapy, ecmo is usually recommended and has a certain curative effect. 102 however, its complex operation and low cure rate make it difficult to perform in a primary hospital. luckily, stem cells and their extracellular vesicles are able to repair the damage and relieve lung symptoms, thus they have been used to cure ards. 103 currently, some covid-19 patients have been treated with umbilical cord mesenchymal stem cells and achieved good effects. 104 therefore, stem cells may be the hope for the treatment of severe covid-19 patients. tens of clinical trials of stem cell treatment have been registered in chinese clinical trial registry. recently, many covid-19 patients were found to have thrombotic risk, 105 therefore, antithrombotic treatments have potential application value in the treatment of covid-19. furthermore, patients with underlying diseases such as hypertension, diabetes, and cardiovascular disease have a potential bad prognosis, 106-108 so care should be taken to cure these basic diseases during treatment. covid-19 patients with low immunity are susceptible to hospital-acquired bacterial infections, 109 therefore, antibiotics such as amoxicillin are another symptomatic treatment medicine for covid-19. traditional chinese medicine has been confirmed to play a vital role in treating many respiratory viruses such as sars-cov. furthermore, the general office of national health committee pointed out that chinese medicines such as qingfei paidu decoction, qingfei touxie fuzheng recipe, and sheganmahuang decoction could be used for the whole therapeutic process of covid-19, 55 thus they are widely used for covid-19 treatment currently. the present clinical evidence has shown that a combination of western and chinese medicines apparently improved curative effect. 110 for example, wan et al. treated 124 patients with multiple traditional chinese medicines such as suhuang zhike capsule and xuebijing, and found their respiratory symptoms were significantly improved in a shorter time. 109 furthermore, four cases treated with antiviral drugs and shufeng jiedu capsule had an obvious improvement both in symptoms and blood biochemical indexes. 111 however, lack of a control group means these results are not reliable enough. although treatment based on syndrome differentiation and lack of scientific evidence on mechanisms are typical characteristics of traditional chinese medicines, many of them are gradually found to have antiviral potential for sars-cov-2. theaflavin is conventional ingredient of chinese medicine, which was found to have hydrogen bonds to rna-dependent rna polymerase with a binding energy of −8.8 kcal/mol, 112 thus it possibly inhibits the proliferation of sars-cov-2. lianhuaqingwen was also confirmed to significantly inhibit the replication of sars-cov-2 and suppress the inflammatory factors tnf-α, il-6, ccl-2/mcp-1, and cxcl-10/ip-10 in vero e6 cells, 113 so it is potentially a specific medicine for covid-19 both etiologically and symptomatically. the prevention and control of covid-19 can be divided into controlling the source of infection, cutting off the transmission route, and protecting susceptible people. controlling the source of infection in this outbreak mainly refers to timely isolation of suspected and confirmed cases, which greatly depends on wireless communication data. 114 isolation of convalescent patients is also necessary, because some of them have a positive rt-pcr test even after 13 days of recovery. 115 cutting off the transmission route includes sterilizing and wearing suitable masks such as n95, kn95, and medical surgical masks. 116 protecting susceptible people means self-segregation, improving constitution, and prophylactic vaccination. considering the strong infectivity of covid-19, the secondary outbreak of covid-19 can be prevented only if the public has immunity to sars-cov-2, thus vaccine is the key area among all prevention measures. therefore, scientists all over the world are working on the vaccine for sars-cov-2, aiming to completely control the outbreak. after a long period of effort, the vaccine targets of the virus had been found and shared with the world. 117, 118 soon afterward, medical institutions around the world adapted joint research and identified five development approaches, including a live attenuated vaccine, inactivated whole-virus vaccine, nucleic acid vaccine, protein vaccine, and viral vector-based vaccine (table 4 ), 119 and most of them used the s protein of sars-cov-2 as the main inducer of neutralizing antibodies directly, or inducing the expression of the whole s protein or receptor-binding domain of the s protein indirectly. 120 by interaction of the s protein and ace2 of host cells, uncoating and penetration of sars-cov-2 are induced. 23 thus, s-protein-based vaccines potentially inhibit the uncoating and penetration of the virus. whole-virus vaccines are conventional strategies to develop a vaccine for most viruses. by injecting artificially attenuated or inactivated viruses, pathogens trigger the body's immune response without causing disease. compared to other vaccines, these keep the inherent immunogenicity of sars-cov-2 and stimulate the body's innate immunity such as releasing toll-like receptors. however, live viruses have the potential to cause disease. furthermore, it has been reported that patients were more easily infected by sars-cov after immunization with a live attenuated vaccine or inactivated wholevirus vaccine. 121 thus, sufficient experiments are necessary to verify their safety. currently, three inactivated novel coronavirus pneumonia vaccines have entered the phase i/ii clinical trials. [122] [123] [124] nucleic acid vaccine nucleic acid vaccines, including dna vaccines and mrna vaccines, are to directly deliver foreign genes encoding antigenic proteins into host cells and synthesize the antigenic proteins by host cells to induce the immunity of hosts. nucleic acid vaccines of covid-19 mainly aim to induce the whole s protein or receptorbinding domain of s protein expression, and several of them have entered clinical trials. 125 for example, researchers of inovio pharmaceuticals are conducting the clinical trial of a dna vaccine. 126 in the meantime, the national institute of allergy and infectious diseases have developed a mrna vaccine, mrna-1273, which uses lipid nanoparticles to encapsulate the mrna encoding s protein of sars-cov-2. 127 interestingly, symvivo corporation have developed an oral dna vaccine to avoid invasive injection. it consists of live bifidobacterium longum, which contain the synthetic dna encoding s protein. 128 although patients with typical symptoms are easily diagnosed and isolated, we still need to pay attention to asymptomatic carriers. 135 in january 2020, a family cluster of three covid-19 patients with one symptomatic and two asymptomatic carriers drew great attention. 11 because any one of them could have the first one to transmit the virus to others, there may exist asymptomatic patients with high infectivity who have not been detected. at the same time, another family cluster of five patients was found to have contact with an asymptomatic carrier before onset of their symptoms. 136 according to time sequence, it is obvious that the virus was transmitted by an asymptomatic carrier. hereafter, the phenomenon of asymptomatic infection has been reported in several articles. 137, 138 on the basis of virology of sars-cov-2, quantity of shedding sars-cov-2 from pharyngeal sources is very high in the first week of symptoms, and they also replicate actively during this time, thus the first week after onset of symptoms is when the patients have the highest infectivity. 139 but in this time period, some patients only have mild symptoms or even no symptoms, so they might be invisible sources of infection. therefore, people who have traveled to endemic areas or had contact with patients should be isolated, monitored, and screened strictly, even if they are asymptomatic, to rule out the possibility of infection. covid-19, a disease that seriously endanger the safety of human life and properties, is caused by sars-cov-2, which attacks host cells through ace2. the spread of covid-19 mainly depends on airborne and droplet transmission. some researchers pointed out the possibility of fecal-oral transmission and vertical transmission, but these opinions need further confirmation. an accurate diagnosis of covid-19 is essential for containing disease, thus combnation of rt-pcr and clinical characteristics is widely used for its detection currently. the typical clinical features of covid-19 patients include fever, cough, and dyspnea. moreover, ggo, consolidation, and interlobular septal thickening are also typical ct signals of covid-19. using artificial intelligence to screen covid-19 early on is likely to be the future diagnostic directions of it. good treatment is necessary to reduce mortality, and drug therapy is the main treatment of covid-19. thus, we summarize the chief medicines and bioproducts for its treatment. according to the current reports, combined use of the drugs and bioproducts to treat covid-19 both etiologically and symptomatically has received great clinical effect. however, not all antiviral drugs for covid-19 have passed the clinical trials. a few clinical trial reports demonstrated that lopinavir-ritonavir, chloroquine, and remdesivir did not work as well as expected, 67, 75, 82 which reflects the fact that many antiviral drugs have gone through many extensive clinical trials with currently only modest effect. instead, some bioproducts such as monoclonal antibodies and stem cells are more likely to play important roles in treatment of severely affected patients in the future. furthermore, we should also focus on vaccine research and artificial intelligence-based studies for fighting the outbreak, both of which play vital roles in controlling the it. although antiviral effects of many drugs and vaccines have been obtained in vitro, it remains to be seen as to whether they have comparable activity in vivo. therefore, establishing efficient animal models as soon as possible is important for virology research, drug, and vaccine development. currently, rhesus macaques models have been established to study the transmission and distribution of sars-cov-2 as well as effects of viral infection on host prognosis, 140, 141 which is meaningful for virology study. furthermore, hace2 transgenic mice have been found to own typical covid-19 clinical symptoms, which could not be found in wild-type mice, 142 indicating this model may be used for development of 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immunogenicity study of 2019-ncov vaccine (inactivated) for prophylaxis sars cov nct04352608?term = vaccine&cond = covid-19&draw = 2&rank = henan provincial center for disease control and prevention. a phase i/ii clinical trial for inactivated novel coronavirus (2019-cov) vaccine (vero cells study to describe the safety, tolerability, immunogenicity, and potential efficacy of rna vaccine candidates against covid-19 in healthy adults tolerability and immunogenicity of ino-4800 for covid-19 in healthy volunteers safety and immunogenicity study of 2019-ncov vaccine (mrna-1273) for prophylaxis sars cov-2 infection (covid-19) evaluating the safety, tolerability and immunogenicity of bactrl-spike vaccine for prevention of covid-19 vaccines/vaxart-announces-initiation-of-cor onavirus-vaccine-program.html, accessed date evaluation of the safety and immunogenicity of a sars-cov-2 rs (covid-19) nanoparticle vaccine with/without matrix-m adjuvant ct04313127?term = vaccine&cond = covid-19&draw = 1&r ank = 8, accessed date academy of military medical sciences, pla of china. a phase ii clinical trial to evaluate the recombinant novel coronavirus vaccine (adenovirus vector) (ctii-ncov immune medical institute. safety and immunity of covid-19 aapc vaccine immunity and safety of covid-19 synthetic minigene vaccine covid-19: four fifths of cases are asymptomatic, china figures indicate presumed asymptomatic carrier transmission of covid-19 transmission of 2019-ncov infection from an asymptomatic contact in germany evidence of sars-cov-2 infection in returning travelers from wuhan, china virological assessment of hospitalized patients with covid-2019 respiratory disease in rhesus macaques inoculated with sars-cov-2 sars-cov-2 receptor ace2 is an interferon-stimulated gene in human airway epithelial cells and is detected in specific cell subsets across tissues the pathogenicity of sars-cov-2 in hace2 transgenic mice this work was supported by the national natural science all authors declared that they had no conflict of interest. key: cord-007331-wccmeaep authors: orcutt, connie j. title: emergency and critical care of ferrets date: 2017-04-20 journal: vet clin north am exot anim pract doi: 10.1016/s1094-9194(17)30157-3 sha: doc_id: 7331 cord_uid: wccmeaep ferrets are becoming increasingly popular as pets in the united states. emergency situations involving ferrets are most often caused by gastrointestinal disease, neoplasia, cardiac disease, or endocrinopathy. hospitalization and supportive care of the critically ill ferret, emergency treatment techniques, and diagnostic procedures are discussed. diseases most commonly involved in critical presentations are reviewed along with treatment protocols. localities mandate euthanasia of the animal for rabies testing? if the ferret is active yet tractable, support the body vertically under the forelimbs for examination. with more energetic ferrets or those prone to biting, scruffing and holding the patient vertically elicits relaxation and a yawning reflex. distraction is afforded by offering nutri-cal (evsco pharmaceuticals, buena, nj) or ferretone (8-in-l pet products, hauppauge, ny), but avoid sugary treats in ferrets suspected of insulinoma. fractious ferrets can be scruffed in lateral or sternal recumbency with one hand while placing the other hand cranial to the pelvis and stretching the body slightly? awareness of specific anatomic, physiologic, and behavioral characteristics of the ferret is important for accurate clinical assessment. modify the extent of the physical examination based on the ferret's status. dyspneic animals may tolerate only brief periods of handling without oxygen supplementation. bruxism, ptyalism, or pawing at the mouth most often indicates gastrointestinal discomfort or nausea resulting from hypoglycemia or other causes. hypoglycemic ferrets may also appear dazed. posterior paresis in the ferret can be a manifestation of hypoglycemia, neurologic disease, or weakness of any cause. the ferret's normal body temperature is 100° to 103° f. 42 testing the hydration status of a ferret by tenting the skin can be inaccurate, and evaluating mucus membrane capillary refill time is generally a more reliable method. the normal heart rate of 180 to 250 beats / min often varies greatly due to the ferret's normal respiratory sinus arrhythmiay the thorax is long relative to the total body length of a ferret, and the entire area must be ausculted for murmurs or abnormal arrhythmias. splenomegaly is a common finding in many ferrets, but pronounced splenomegaly or abnormal splenic texture may indicate pathology. most pet ferrets in the united states originate from large breeding facilities in which kits are neutered at 5 to 6 weeks of age, and a tattoo is placed inside the right pinna. although this makes disease involving the reproductive tract less likely, it does not preclude the presence of a reproductive remnant. a swollen vulva in a female ferret may indicate adrenal disease (most commonly, especially in middle-to older-aged animals),42 an intact female in estrus, or the presence of an ovarian or uterine remnant. male ferrets have an os penis, and the prepuce is located on the ventral abdomen. the critically ill ferret is optimally hospitalized in a quiet area separate from dogs and cats. isolation areas must be available for pa-tients suspected of having infectious disease (for example, canine distemper virus or epizootic catarrhal enteritis). hospital personnel with influenza should avoid contact with ferrets. the ferret requiring supplemental oxygen or heat can be hospitalized in the same type of oxygen cage or incubator used for a dog or cat. alternatively, ferrets can be placed in acrylic intensive care cages designed for birds. 42 monitor ferrets in incubators carefully to prevent hyperthermia. the normothermic, eupneic ferret hospitalized in a wellventilated cage must also be monitored closely to prevent hypothermia. placing a towel or disposable diaper in the cage discourages the ferret from expending energy while attempting to burrow under cage paper. anorectic ferrets are at risk of developing hepatic lipidosis or hypoglycemia. enteral feeding is recommended whenever possible. debilitated ferrets refusing their regular food often accept syringe feeding or soft foods offered on a tongue depressor. aid diet (hills pet products, topeka, ks) provides an easily digestible diet accepted by most ferrets. syringe feeding is dosed at 2-5 ml three to four times daily. 42 supplements such as nutri-cal or deliver 2.0 (mead johnson, evansville, il) provide additional calories when added to syringe-fed foods, but these sources are not nutritionally complete for ferrets and should not be fed as their sole diet for extended periods. 42 nutri-cal and other sugarcontaining formulations can cause rebound hypoglycemia in ferrets that have insulinoma and should be avoided in those animals. raw meat or eggs that may contain bacterial pathogens are also not recommended. pharyngostomy tube placement in ferrets has been described? the technique is identical to that described for cats and utilizes an 8 to 10 fr pediatric feeding tube. in cases of protracted diarrhea or vomiting, gastrointestinal ulceration, or resistance to syringe feeding, a total nutrient admixture (tna) has been used successfully to provide parenteral nutrition (pn) to more than 10 ferrets in the author's clinical practice. if a veterinary practice does not have the capability to compound parenteral solutions, some human hospitals mix pn solutions in their own pharmacies and will formulate a bag of tna for a veterinarian when provided with a prescription (table 1) . a mixture of lipid and dextrose provides the ferret's resting energy requirement (rebecca remillard, phd, dvm, acvn, angell memorial animal hospital, boston, ma, personal communication, november 1997). this mixture is supplemented with amino acids, electrolytes, water-soluble vitamins, and minerals, and fluid is added so the total solution meets daily fluid volume requirements. such all-in-one solutions can be refrigerated for at least 7 days. a silicone elastomer or polyurethane jugular catheter (cook veterinary products, bloomington, il) is recommended for delivery of the solution by infusion pump. hospitalized ferrets eating voluntarily and without special dietary requirements are optimally provided with their regular diet. otherwise, offer a premium-quality dry cat, kitten, or ferret food . ferrets have high fat and animal protein requirements and metabolize fat more efficiently for energy than carbohydrates. 7 if a ferret requires fasting before surgery for the evaluation of blood glucose or for radiographic examination of the gastrointestinal tract, do not withhold food for more than 6 hours. 6 ferrets with insulinoma are especially at risk for developing profound hypoglycemia during extended periods of fasting. the critically ill ferret should be stabilized before pursuing extensive diagnostics. however, even severely compromised ferrets usually toler-ate the sampling of a small volume of blood from a peripheral vein for estimated blood glucose (bg), total protein (tp), packed cell volume (pcv), and blood urea nitrogen (bun) measurements. use an insulin syringe with a 28-gauge needle for collecting small volumes of blood «0.5 ml) from either the lateral saphenous or cephalic vein. visualization of peripheral veins is facilitated by using a 1/ 4-in. penrose drain as a tourniquet. for larger volumes of blood, the jugular vein or anterior vena cava are preferred sites of venipuncture. a healthy ferret's blood volume is approximately 5% to 6% of its body weight? as much as 10% of the blood volume can be safely withdrawn in a healthy ferret?42 determine the ferret's initial pcv and level of hydration before withdrawing substantial volumes of blood. for jugular venipuncture, use a 25-gauge needle on a tuberculin or 3-ml syringe. hold the ferret at a table's edge or in lateral recumbency as for a cat, or alternatively, wrap the ferret in a towel and restrain in dorsal recumbency? the ferret's jugular vein lies more lateral than that in a dog or cat?-42 venipuncture of the anterior vena cava for ferrets has been described. 42 this procedure can be performed without sedation in a debilitated ferret. however, if the patient resists restraint or the practitioner is inexperienced with this technique, anesthesia may be required. restrain the ferret in dorsal recumbency while one assistant extends the forelimbs caudally and a second assistant stretches the body with gentle traction applied cranial to the pelvis (fig. 1) . palpate a slight depression at the thoracic inlet lateral to either side of the manubrium and cranial to the first rib. approach the site at a 45° angle to the skin while aiming toward the opposite hip. insert a 25-gauge needle attached to a 3-ml syringe up to the needle hub. apply negative pressure, and slowly withdraw the needle until blood begins to fill the syringe. withdraw the needle if the ferret struggles. it is not necessary to apply pressure to the venipuncture site after the sample is collected. a method for obtaining volumes of as much as 1.0 to 1.5 ml of blood from the ventral tail artery of ferrets has been described? this procedure is painful to perform in the unanesthetized patient. restrain the ferret in dorsal recumbency. insert a 22-gauge needle attached to a syringe along the ventral midline of the tail, 2 to 5 cm distal to the tail base. direct the needle at a shallow angle toward the body while gently aspirating. peripheral catheterization can be performed in the awake debilitated ferret, but more active ferrets often require anesthesia. use a 22-or 24gauge peripheral catheter for placement in the lateral saphenous or cephalic vein. to facilitate intravenous (iv) catheter placement, first puncture the skin overlying or adjacent to the vein with a 20-or 22gauge needle while being careful to avoid the vein. secure the catheter with sterile tissue glue or a tape butterfly sutured to the skin before bandaging the leg. for jugular catheterization, the author most often uses a 22-gauge, 8-in. through-the-needle catheter on a 19-9auge needle (intracath, becton dickinson vascular access, sandy, ut). a cutdown procedure may be necessary to access the vein. ferrets often act depressed with a jugular catheter and neck bandaging in place. access to the vascular system for more than several days can be achieved with a subcutaneously placed vascular access system (vascular-access-port, access technologies, skokie, il). 44 an intraosseous (10) catheter can be placed in the humerus, femur, or tibia, with the femur being the site least likely to impede the ferret's movement,4,7 use a 20-or 22-gauge, 1.5-in. spinal needle or a 20-or 22gauge hypodermic needle with a sterile surgical wire inserted into the lumen as a stylet to prevent occlusion of the needle with a plug of bone. 7 , 42 placement of the catheter is done with the ferret under anesthesia unless the animal is very debilitated. alternatively, the soft tissues and the periosteum can be blocked with local anesthetic. 4 the technique for catheter placement is the same as that described for a cat. 10 catheters can be left in place for several days during which time prophylactic use of parenteral antibiotics is recommended? maintenance fluid requirement for the ferret is estimated at 70 ml/kg / 24 h ? calculate additional fluid requirements for correction of dehydration and compensation for ongoing losses following protocols used for small animals. iv or 10 fluid delivery is recommended in severely debilitated ferrets requiring dextrose supplementation. continuous delivery of fluids using an infusion pump is recommended. alternatively, a buretrol device (baxter healthcare, deerfield, il) can be used to deliver small fluid volumes. 42 monitor the ferret carefully for overhydration, which may first be evident by auscultation of harsh lung sounds or a heart murmur. ferrets with cardiac disease are especially at risk of overhydration. debilitated, anorectic animals may require fluids supplemented with dextrose, vitamin b, and potassium following the protocols used for small animals. 42 in cases of protracted anorexia, a tna delivered iv can be substituted for this fluid mix. use only small volumes of heparinized saline when flushing any catheter in the ferret to prevent heparin overdosage. antibiotics and most other medications are administered at dosages used with cats on a per kilogram basis.42 when an indwelling catheter is not in place, use a 25-gauge butterfly catheter for iv medications. most medications given intravenously, with the exception of some chemotherapeutic drugs, can alternatively be administered via an 10 catheter? limit the use of intramuscular (1m) medications in ferrets owing to their reduced muscle mass. 42 this author prefers the quadriceps for 1m injections because of its increased mass and the reduced risk of iatrogenic nerve damage at this site compared with the caudal thigh. administer subcutaneous injections as for a dog or cat. oral medications are best administered in liquid form, because pill administration is difficult in ferrets.42 most tablets can be crushed and compounded into a suspension with a vehicle such as ora-plus (paddock laboratories, inc., minneapolis, mn), flavoring, and water in a 1:1:2 ratio. 51 refrigerate the medication and shake well before using. there is no guarantee of stability.51 transfusion in the ferret has been recommended when the pcv drops below 12% to 15%, depending on whether the anemia is acute or has developed gradually.42 blood groups have not been demonstrated in ferrets, and there is little risk of a transfusion reaction even without crossmatching and after using a variety of donors?' 33, 42 estimation of the blood volume required by the recipient can be calculated as for a cat. 3d . . rcv desired -fcv of recipient anticoagulated blood volume (ml) = body welght (kg) x 70 x fcv f d . . i o onor ill anhcoagu ant place a 22-gauge jugular catheter or a 20-gauge 10 catheter for transfusion delivery. the author treats the recipient 15 minutes before transfusion with a slow iv bolus of a short-acting corticosteroid (prednisolone sodium succinate at 22 mg/kg or dexamethasone sodium phosphate at 6-to 8-mg/kg)y choose a clinically normal ferret (pc v at least 44%) as a donor.42 the author collects a maximum blood volume (milliliter) equivalent to 0.6% of the donor's body weight. use a 21-gauge butterfly catheter on a 6-to 12-ml syringe for blood collection. an acid-citrate-dextrose (acd) solution is used as an anticoagulant. flush the needle, tubing, and syringe with acd before collection, and use 1.0 ml acd per 6.0 ml whole blood collected from the anesthetized donor ferret. 42 whole blood can be transfused immediately with a slow bolus or with a syringe pump?' 33, 42 sedation is recommended for cystocentesis in all but very debilitated ferrets, because the bladder wall is thin and can be easily lacerated if the patient struggles? use a 25-or 28-gauge needle for cystocentesis. urethral catheterization requires anesthesia even with depressed patients. most cases of urethral obstruction involve male ferrets and are the result of cystic calculi or hyperplastic prostatic-like tissue at the neck of the bladder? catheterization of the male is complicated by the jshaped os penis as well as the very small diameter of the penile urethra. place the male in dorsal recumbency, and aseptically prepare the prepuce. if the prepuce or tip of the penis is swollen, a small incision can be made in the preputial opening to exteriorize the penis. 7 the tissue covering the os penis is very thin. a surgicalloupe aids visualization of the small penile urethral opening lying on the ventral surface of the penis several millimeters proximal to the tip of the os. a 24-gauge pediatric catheter with the stylet removed can be used to localize the urethral orifice (fig. 2) . flush the catheter with sterile saline if resistance is met while catheterizing the urethra. in some cases, a 3.5-fr rubber feeding tube can be used as an indwelling catheter, but this will be too large in many ferrets. the author most often uses a 20-or 22-gauge, 8-in. jugular catheter with the stylet removed (see the section on iv catheterization). the stylet can be left in place with the end retracted to provide support around the pelvic flexure, but exercise extreme caution to avoid perforation of the urethra. suture the catheter to the skin using tape butterflies, and tape the administration port of the catheter to a tongue depressor to prevent kinking. place a padded bandage taped to the skin, and attach the catheter to a closed urinary collection system. monitor the ferret carefully, because many animals attempt to remove the bandage and catheter. the ferret with an indwelling urinary catheter should be treated empirically with a broad spectrum antibiotic (see the section on cystitis). for catheterization of the female ferret, place the anesthetized patient in ventral recumbency, elevate the hindquarters, and aseptically prepare the vulva and perivulvar area. use a small vaginal speculum or otoscope cone to locate the urethral opening on the ventral floor of the vaginal vestivule, approximately 1 to 1.5 cm cranial to the clitoral fossa?' 42 use a catheter as described above for the male ferret. in some instances of pneumothorax or pleural effusion, placement of a chest tube may be required. the author has performed this technique as described for a cat by using, as a chest tube, an 8-fr rubber feeding tube with a kirschner wire stylet. once sutured in place, the tube is capped for intermittent suction. the author has successfully used continuous suction at 13 to 15 cm h20-negative pressure in one case of a ferret with a continuous spontaneous pneumothorax. isoflurane provides the safest means of anesthesia in the critically ill ferret. avoid the use of injectable agents in debilitated animals. 35 ideally, a ferret should be fasted for 4 to 6 hours before induction. an induction chamber is recommended, because ferrets often violently resist induction by face mask. many ferrets hypersalivate during isoflurane induction, but because this is usually a transient behavior, atropine is generally not necessary? ferrets are not prone to laryngospasm, and intubation is relatively easy with a 2.0 to 4.0 mm endotracheal tube. 35 , 37 deliver anesthesia via a nonrebreathing circuit. to prevent hypothermia, place the ferret on a circulating warm water heating pad for any procedure lasting more than a few minutes. administer iv fluids to debilitated patients, taking care to avoid overhydration, especially in patients suspected of having cardiac disease, administer 2.5% to 5% dextrose-containing fluids to hypoglycemic ferrets during prolonged surgical procedures?' 35 monitor anesthesia with a pulse oximeter or a doppler ultrasound blood pressure monitor. 35 a rectal probe may increase the usefulness of the pulse oximeter in small animals ,35 clinical signs of pain in ferrets include lethargy, anorexia, vocalization, stiff movements, reluctance to curl up in a sleeping position, and squinting? buprenorphine (0,01 to 0.03 mg/kg iv, 1m, or sc q8 to 12 h) or butorphanol (0.1 to 0.5 mg/kg 1m or sc q12 h) is well-tolerated by ferrets ?' 13 monitor carefully for signs of significant depression, hypothermia, or hyperthermia. if necessary, naloxone (0.04 mg/kg iv, 1m, or sc) can be administered as a reversal agent? the pcv of ferrets is high relative to that of other species, and normal values have been reported to range from 46% to 61 %. 42 the normal leukocyte range of 2.8 to 8 x 10 3 , with clinically normal ferrets often having white blood cell counts of 3 to 4 x 10 3 , is generally lower than that of other species,29 there is no evidence that ferrets demonstrate a leukocytosis with stress? the ferret's normal differential parallels that of the cat. isoflurane administered for 15 minutes has been shown to result in significant decreases in hematocrit, hemoglobin, and plasma protein as well as red and white blood cell counts. 34 coagulation profiles have not been standardized for ferrets, but the normal mean prothrombin time has been reported to be 14.4 to 165 seconds, 42 in contrast to the cat and the dog, bun values in the ferret appear to be more sensitive than creatinine in the evaluation of renal status. in cases of renal failure, bun levels are often drastically elevated compared with relatively less significant increases in creatinine. 24 , 29 however, an elevated bun is not specific for a renal disorder. other significant clinicopathologic findings with renal disease in the ferret include hyperphosphatemia, hypocalcemia, hyperkalemia, and acidosis. 29 the cardiac silhouette of a normal ferret may appear slightly elevated from the sternum on lateral radiographs as a result of fat accumulation surrounding the ligament extending from the heart to the sternum,6 and this finding alone should not be interpreted as a pneumothorax. normal ferrets should have only a small amount of gas in the gastrointestinal tract. 55 variations from this norm may indicate an obstructive pattern or ileus. the spleen is often pronounced in radiographs of even clinically normal ferrets. cardiopulmonary resuscitation in the ferret is based on protocols published for cats. establish an airway by intubation with a 2.0 to 4.0 mm endotracheal tube, and ventilate the ferret at a rate of 20 to 30 breaths/min taking care not to overinflate the lungs. evaluate the cardiac rhythm with an electrocardiogram. in cases of asystole, place the ferret in lateral recumbency, and gently perform cardiac massage at a rate of 100/min. evaluate the femoral pulse frequently. if external massage alone does not stimulate a heart beat, administer epinephrine (0.2 to 0.4 mg/kg diluted with sterile water delivered intratracheally, or 0.2 mg/ kg via an intracardiac, iv, or 10 route). 16 establish an iv line, and administer fluids at a rate of 70 ml/kg/h. if mechanical systole returns but the ferret is bradycardic, administer atropine at a dose of 0.05 mg/ kg intravenously or 0.10 mg/kg intratracheally.16 continue to monitor the electrocardiogram for treatment of specific arrhythmias. differential diagnoses for the ferret in respiratory distress include pleural effusion (cardiac disease, neoplasia, infection, heartworm disease, hypoproteinemia, metabolic disease); pulmonary edema (cardiac disease, hypoproteinemia, metabolic disease, electrical cord bite); anterior mediastinal mass; pneumonia; pneumothorax; diaphragmatic hernia; tracheal obstruction; metabolic disease (acidosis); and profound weakness (circulatory collapse, hypoglycemia, anemia).21,36 hyperthermia or pain may also manifest as dyspnea in ferrets. the dyspneic ferret often requires oxygen supplementation before pursuing extensive diagnostics. evaluate the initial pcv, bg, tp, and bun if the ferret is insufficiently stable to collect blood for an initial complete blood count (cbq and serum chemistry. if cardiac disease is suspected, administer furosemide (see the section on cardiac disease). obtain whole body radiographs as soon as the animal tolerates further handling. perform thoracocentesis in cases of pronounced pleural effusion or pneumothorax, and submit fluid collected for cytology and a gram's stain as well as culture and sensitivity if indicated. cardiac disease is seen most frequently in middle-to older-aged ferrets. the most common form of cardiac disease in the ferret is dilated cardiomyopathy (dcm), with hypertrophic cardiomyopathy occurring less frequently.54 historical abnormalities include lethargy, anorexia, weight loss, exercise intolerance, and periods of dyspnea, tachypnea, or coughing. tachycardia, murmurs, irregular arrhythmias, moist rales, muffled heart and lung sounds, rear limb weakness, and hypothermia are possible physical examination findings. 54 radiographs may reveal an enlarged cardiac silhouette, pleural effusion, pulmonary edema, ascites, hepatomegaly, or splenomegaly. 54 electrocardiography is recommended if abnormal arrhythmias are ausculted. isoflurane anesthesia is usually needed to obtain an electrocardiogram (ecg). the ferret ecg normally contains small p waves but large r waves. 54 echocardiography is ultimately the most informative aspect of the cardiac workup in the ferret and should be performed as soon as possible. use feline dosages on a per kilogram basis for cardiac drugs when uncertain of specific dosing in the ferreu 4 furosemide for treatment of pulmonary edema is dosed at 1 to 4 mg/kg iv, sc, 1m, or po q8 to 12hy,54 although the iv route is most direct in cases of fulminant heart failure, the ferret in severe respiratory distress may only tolerate 1m injection. digoxin is used as a positive inotrope in cases of dcm or to depress av nodal conduction of supraventricular tachyarrhythmias at a dose of 0.01 mg/kg po q24h dosed on lean body weight (estimating a normal 15% body fat).54 balanced vasodilators used to decrease afterload in cases of dcm include enalapril (0.5 mg/kg po q48h) or captopril (1/8 of a 12.5-mg tablet/ferret po q48h),b, 54 monitor the ferret closely for hypotension, decreasing the frequency of dosing to once every third day if the ferret becomes lethargic. 54 alternatively, during the initial management of heart failure, one can use a venous vasodilator such as 2% nitroglycerin ointment (1/8 in. applied to the skin or inner pinna q12 to 24h).54 monitor the patient for signs of hypotension. beta-adrenergic blockers (atenolol, 6.25 mg/ferret po q24h) or calcium channel antagonists (diltiazem, 3.75 to 7.5 mg/ferret po q12h) are most commonly used to relax the myocardium and to improve diastolic filling in cases of hypertrophic cardiomyopathy.l3, 54 administer fluid therapy judiciously in ferrets with cardiac disease to avoid fluid overload and subsequent development of pulmonary edema. prednisone and diazoxide, medications often used to treat insulinoma, can also increase preload on the heart. 49 lymphosarcoma (lsa) is one of the most common forms of neoplasia reported in the ferreu dyspnea can result from an anterior mediastinal mass, pleural effusion, pulmonary metastasis, or profound weakness. mediastinal masses and pleural effusion are most common in ferrets less than 1 year of agey in young animals, acute onset of clinical signs or sudden death are typical with the rapidly progressive mediastinal form of lsa.2. 17 other clinical signs may include anorexia, weight loss, vomiting, depression, dehydration, or signs associated with secondary infections. accompanying physical examination findings may be referable to any body system but most commonly include hepatomegaly, splenomegaly, and lymphadenopathy. lo diagnosis of mediastinal lymphoma is generally made by cytologic examination of pleural fluid. ultrasound-guided aspiration of an anterior mediastinal mass can be used to collect samples for cytology.j5 ferrets that have mediastinal lsa have been reported by some authors to respond favorably to chemotherapeutic protocols described in the references.9. 10. 15 infection with the canine heartworm (dirofilaria immitis) is uncommon in ferrets, but the risk increases in heartworm endemic areas and when the ferret is housed outside. 25 signs include lethargy, coughing, dyspnea, ascites, heart murmur, pulmonary congestion, or sudden death. 9 . 54 the presence of even one adult worm in the small heart of a ferret can be fatal, 54 peripheral microfilaremia is uncommon in ferrets with dirofilariasis, so testing for the dirofilaria antigen may be inconclusive. 9 • 25. 54 antibody tests used for feline patients are species specific and are not applicable to ferrets (karen rosenthal, ms, dvm, abvp-avian, personal communication, october 1997). radiographic changes with dirofilariasis include cardiomegaly, pulmonary congestion, pleural effusion, and ascitesy· 25 a peripheral eosinophilia may be evident on the cbc. 9 the test of choice for diagnosing dirofilariasis in ferrets is echo cardiography, which images the parasite in the heart (karen rosenthal, ms, dvm, abvp-avian, personal communication, october 1997). in some cases, angiography has been used to confirm the presence of adult worms. 56 treatment protocols have been reported, but results are inconsistent. 9 • 54 pneumothorax pneumothorax can occur as a result of trauma, primary pulmonary disease, or esophageal perforation. the author has treated two ferrets with spontaneous pneumothorax. thoracocentesis is performed using protocols described for other small animals. if pleural air continues to accumulate, perform a tube thoracostomy. in uncommon cases of severe pneumothorax, resolution can be rapid when managed by continuous underwater suction if pressure is carefully monitored. 4o perform diagnostics as indicated to reveal the primary pathology, and treat as indicated. pneumonia is uncommon in ferrets and is most commonly associated with severe influenza virus or canine distemper virus (cdv) infections. 50 coughing is not as prominent a sign of pneumonia in ferrets as in dogs. 9 clinical signs of influenza include sneezing, epiphora, serous ocular discharge, rhinitis, anorexia, lethargy, and pyrexia. 9 ,5o influenza is usually mild and self-limiting in adult ferrets but can be fatal in neonates. 9 because ferrets are susceptible to human influenza viruses, affected caretakers should avoid contact with ferrets. ferrets with cdv may initially present with clinical signs similar to influenza but go on to develop a severe crusting dermatitis on the face and other areas of the body as well as marked hyperkeratosis of the footpads. 52 ferrets that have advanced cdv infection may also present with neurologic signs. 53 bacterial pneumonia is occasionally seen in ferrets. pulmonary mycosis is uncommonly reported. 9 , 50 radiographs and a cbc are often the most helpful initial diagnostic tests in cases of pneumonia. 9 a neutrophilic leukocytosis with a left shift may be pronounced. 9 ,5o radiographs demonstrate an interstitial pattern progressing to an alveolar pattern if the pneumonia worsens. 50 aspiration pneumonia primarily involves the dependent lung lobes. if the ferret is stable, a tracheal wash to collect samples for cytology as well as bacterial and fungal cultures is important in guiding treatment. diagnosis of cdv is generally made on the basis of clinical signs, but viral inclusion bodies may be visualized or fluorescent antibody tests performed on conjunctival or mucus membrane scrapings. 52 treatment for influenza consists of supportive care. antihistamines used to control sneezing or to improve appetite include chlorpheniramine (1 to 2 mg / kg po q8 to 12h) or diphenhydramine (0.5 to 2.0 mg/ kg po q8 to 12h).9, 13 use antibiotics only if a secondary bacterial infection is suspected. euthanasia is recommended for ferrets with cdy'9,62 antibiotic treatment of bacterial pneumonia is based on culture and sensitivity results. empirical broad-spectrum antibiotics to consider while awaiting culture results include trimethoprim / sulfonamide (30 mg/kg of combined drug po qi2h), cephalexin (15 mg / kg po qi2h), or amoxicillin / clavulanate (22 mg/kg po q8h).9, 13, 50 parenteral antibiotics used with cats more rapidly achieve therapeutic blood levels in severe cases. nebulization with gentocin may be useful in young animals. 9 clinical signs of gastrointestinal (gi) discomfort in ferrets are often not specific: collapse; lethargy; anorexia; dehydration; nausea evident by bruxism, ptyalism, pawing at the mouth, or frequent swallowing; retching or gagging; diarrhea; or vomiting. a number of the gi diseases affecting ferrets can have similar clinical presentations. profuse diarrhea can rapidly produce severe dehydration in the ferret. in contrast to the canine patient, diarrhea in the ferret is difficult to classify as being small intestinal or large intestinal in character.26 differential diagnoses for diarrhea include gi foreign body or trichobezoar, dietary indiscretion, helicobacter mustelae gastritis, eosinophilic gastroenteritis or other inflammatory bowel disease, neoplasia, metabolic disease (i.e., hepatopathy), clostridial overgrowth subsequent to prolonged antibiotic administration, influenza, rotavirus (usually in very young, unweaned ferrets), edv (generally accompanied by respiratory signs and a crusting dermatitis), epizootic catarrhal enteritis ("green slime disease"), gi parasitism (i.e., coccidiosis, giardiasis), and proliferative bowel disease. 21 , 26, 36 less common entities associated with diarrhea in pet ferrets include salmonellosis, aleutian disease, and mycobacteriosis. 21 , 26, 36 frank blood in the stool may be evident with proliferative bowel disease, salmonellosis, or clostridial overgrowth. 3 ,26 differential diagnoses for melena in the ferret include h. mustelae gastritis, toxin ingestion, gi foreign body or trichobezoar, hemorrhaging gi polyps, neoplasia, uremic ulceration, iatrogenic causes (i.e., nonsteroidal inflammatory drug induced), and aleutian disease (uncommon in pet ferrets).3, 36 . vomiting is not as common in ferrets as in dogs or cats and must be distinguished from regurgitation. 26 the most common differential diagnoses for true vomiting in . ferrets include gi foreign body, h. mustelae gastritis, or inflammatory gastroenteritis (including eosinophilic gastroenteritis).25 vomiting is not commonly seen with metabolic disease (i.e., azotemia or hepatic disease) in ferrets.25 regurgitation or gagging may be caused by esophageal foreign body or megaesophagus. initial treatment of dehydration and electrolyte imbalances is critical while pursuing diagnostics. evaluate the pev, bg, tp, and bun before treatment, and submit a ebe and serum chemistry. obtain initial survey radiographs. additional imaging diagnostics may include ultrasonography, endoscopy, or colonoscopy. evaluate a fecal sample wet mount and flotation as well as a fecal gram's stain. in cases of hematochezia or if the ferret is febrile, culture the stool for campylobacter jejuni or salmonella spp.26 rubber, latex, or cloth objects are the most common gi foreign bodies in ferrets under 1 to 2 years of age, whereas trichobezoars are more common in older ferrets. 9 , 26, 38 in contrast to cats, linear foreign bodies are uncommonly ingested by ferrets. 26, 38 clinical signs of gi foreign bodies vary greatly. in cases of total gastric or intestinal obstruction, the ferret may present recumbent, dehydrated, and in circulatory collapse. in general, vomiting is an infrequent finding with gi foreign bodies in ferrets. 9 , 26, 38 diarrhea or melena may be a part of the history with trichobezoars or other foreign bodies. in some cases, gastric foreign bodies may not be totally obstructive and instead act as chronic ball valves, causing intermittent nausea, vomiting, melena, gagging, anorexia, and weight loss. esophageal foreign bodies, though uncommon, can elicit regurgitation, gagging, or pawing at the mouth. 26 on physical examination, the ferret may be dehydrated with tacky mucus membranes and a delayed capillary refill time. ferrets often resist abdominal palpation or grind their teeth as a sign of gi pain, especially with small intestinal foreign bodies. 26 a gas-or fluid-dilated stomach or bowel may be palpable, and in some cases, the foreign body may be localized as well. radiographs are often diagnostic with abnormal findings including segmental ileus, gaseous distension of the stomach, and occasionally a visible object or trichobezoar. 26 the ferret's normal gi transit time is 3 to 4 hours? include the esophagus in the film for evaluation. barium studies are rarely needed to confirm the diagnosis of a gi foreign body. 26 obtain a pcv, tp, bg, and bun as a minimum database on admission, and submit blood for a cbc and serum chemistry. with ferrets in circulatory collapse, begin fluid therapy immediately via an iv or 10 catheter. administer a broad-spectrum antibiotic with severely compromised animals or those with melena. consider removal of a gi foreign body a surgical emergency when accompanied with signs of obstruction. 38 an esophageal foreign body, if devoid of sharp edges, may be removable with a small diameter endoscope, or alternatively, can be pushed into the stomach where it can be retrieved by way of gastrotomy.l1 if surgery is not an option in cases of suspected obstruction, fluid therapy and administration of a cat hairball remedy may facilitate passage of small objects. 25 h. mustelae naturally colonizes the stomach and the pyloric duodenum of many ferrets and may be clinically silent or can cause mild to severe gastritis, gastric and duodenal ulceration, and gastric adenocarcinoma. 3 , 18, 19, 27, 41 pathology may be exacerbated by environmental stress owing to environment or additional disease. 3 , 27 clinical signs include bruxism, ptyalism, abdominal pain, chronic vomiting, anorexia, weight loss, and melena, which can cause significant anemia. while clinical disease is reported to be most common in ferrets 12 to 20 weeks of age,3 this author has seen ferrets of all ages affected. assessment of the initial pcv and tp is especially important in cases of severe melena. a cbc, serum chemistry, and radiographs are part of the initial database. once the patient is stabilized, definitive diagnosis includes biopsy of the gastric mucosa via an endoscopic or surgical approach. administer fluids to correct hydration. supportive care includes parenteral nutrition in cases of severe ulcerative gastroenteritis. treatment for h. mustelae gastritis has centered on a three-drug combination: amoxicillin (20 mg/kg po q12h), metronidazole (20 mg/kg po q12h), and bismuth subsalicylate (1 ml/kg po q12h) administered for 3 to 4 weeks.3, 28 a combination of omeprazole (a proton-pump inhibitor), amoxicillin, and clarithromycin has shown a notable success rate in the eradication of helicobacter pyloru 8 however, omeprazole capsules supplied in timed-release form should not be opened before administration, therefore dosing is difficult in the ferret. epizootic catarrhal enteritis (ece) is a highly infectious diarrheal disease that affects ferrets and that can rapidly cause severe dehydration. this syndrome has been called /i green slime disease" by the lay community because of the profuse green diarrhea that is its most pronounced clinical manifestation. however, green mucoid diarrhea can be seen in a variety of malabsorptive syndromes affecting ferrets and is not pathognomonic for ece. although the etiology of ece has not been identified, histologic findings appear to be similar to those caused by rotavirus or corona virus. 26 ferrets most commonly affected are those recently exposed to new ferrets, that is, at fairs, pet stores, or as recent additions to the household. incubation appears to be only several days before the onset of clinical signs that may include a brief period of vomiting followed by anorexia, profuse diarrhea that often lasts from days to weeks, and subsequent pronounced dehydration. morbidity is high, but mortality is low with the most severely affected individuals being those having underlying disease. diagnosis is presumptive based on the ferret's history and clinical signs. the pcv and tp may be drastically elevated due to dehydration. profound leukopenia is generally not evident. radiographs may demonstrate segmental ileus, which can be confused with an obstructive pattern. hospitalized ferrets must be isolated from other ferrets, and personnel should be made aware of possible viral transmission by fomites. treatment consists of aggressive supportive care aimed at correcting dehydration and providing nutritional support. antibiotic use appears to be of little use unless indicated with accompanying disease. the author has noted significant improvement in persistent cases after administration of prednisone at anti-inflammatory doses. eosinophilic gastroenteritis (ege) is an uncommon disease of ferrets generally seen in animals older than 6 months. 3 the cause is unknown, but some authors suggest an allergic or immunologic response to foods or parasites as an initiating factor.3 clinical signs include vomiting, diarrhea, anorexia, melena, lethargy, and weight loss. thickened abdominalloops or enlarged mesenteric lymph nodes may be evident on palpation. ege is suspected when clinical signs are accompanied by a peripheral eosinophilia (equal to or greater than 1000/mm3); however, not all cases demonstrate an abnormal differentia1. 9 histopathologic demonstration of an eosinophilic infiltration of intestine, lymph node, or other tissues provides the definitive diagnosisy, 31 initiate supportive care with fluids and nutritional supplementation. although this author has successfully treated the majority of diagnosed cases with prednisone, treatment may be unreliable because the underlying cause is unknown. 27 adjust the dose of prednisone (0.25 to 1.0 mg/ kg sq or po ql2h) to control clinical signs. 9 resolution of signs is most often evident within 7 days, but treatment is recommended for an additional month before tapering the dose of corticosteroid. 9 in some cases, treatment may be lifelong. lymphoplasmacytic gastroenteritis is a similar clinical syndrome. histopathology provides the definitive diagnosis, and treatment is similar to that for ege. primary neoplasia of the gi tract is uncommon in ferrets. 26 lsa can affect any area of the ferret's digestive tract. 1o ,26 pyloric adenocarcinoma has been associated with chronic h. mustelae-associated gastritis in the ferreu 8 affected animals may have clinical signs similar to those seen with a gi foreign body. palpation and radiographs may demonstrate a fluid-distended stomach. lo , 18, 45 definitive diagnosis is made on biopsy, but abdominal ultrasonography may aid localization of pathology. critical care is supportive until the animal is stable for abdominal exploratory. surgical resection of the pyloric mass in a ferret followed by a bilroth i gastroduodenostomy was reported to be successful in one case of gastric adenocarcinoma. 18 lsa involving the intestine or liver typically responds poorly to chemotherapy.9, 10, 17 hepatopathies can present as acute or chronic conditions in the ferret. differential diagnoses include hepatic lipidosis, toxin ingestion, primary or metastatic neoplasia, bacterial infection, and inflammatory disease. other than neoplasia, primary hepatopathies appear to be rare in ferrets. 26 hepatic lipidosis is a common result of chronic anorexia. steroid hepatopathies are very rare, and to date, vascular shunts have not been reported in the ferret. 26 clinical signs of hepatic disease include lethargy, anorexia, weight loss, diarrhea, vomiting, melena, anemia, and icterus (in advanced stages).9. 26 the most consistent diagnostic abnormality with hepatic disease is an often drastic elevation of alanine aminotransferase (alt).9.29 alkaline phosphatase may be elevated as well, and in severe cases, total bilirubin levels may increase. abdominal ultrasound is recommended, but this author does not encourage ultrasound-guided liver biopsy, because coagulation panels, useful to assess risk of hemorrhage, have not been standardized for ferrets. definitive diagnosis requires biopsy of the liver. although bacterial hepatitis is not commonly reported for the ferret, in cases of persistent elevation of liver enzymes, submission of tissue for culture and sensitivity is recommended. institute supportive care while determining the definitive diagnosis of hepatopathy. nutritional supplementation is important in the treatment of hepatic lipidosis. once anorexia has resolved, hepatic lipidosis commonly requires no further treatment in the ferret. in cases of suspected bacterial hepatitis, empirical antibiotic choices pending culture and sensitivity include enrofloxacin (5 mg/kg po ql2h) or amoxicillin (20 mg/kg po ql2h) in combination with metronidazole (20 mg/kg po qi2h).9 administer vitamin k at the feline dosage on a per kilogram basis in cases of suspected coagulopathy. lactulose (0.15 to 0.75 mg/ kg po q8-12h)13 is indicated with hepatic encephalopathy. definitive treatment of hepatic neoplasia is unrewarding unless a small portion of the liver is involved and can be resected. although acquired megaesophagus is a chronic condition in the ferret, complications of the disease can lead to a critical situation. the cause of megaesophagus in the ferret is unknown. clinical signs include lethargy, anorexia, dysphagia, regurgitation, coughing or gagging, and weight 10ss.26 aspiration pneumonia is a common complication. diagnosis relies on history, clinical signs, and radiographic evidence of a dilated esophagus. aerophagia or aspiration pneumonia may also be apparent on radiographs. an esophagram may delineate esophageal abnormalities, and fluoroscopy can illustrate abnormal esophageal motility. 9 management of megaesophagus is generally less successful in fer-rets than in dogs, and the prognosis is very poor. 26 motility modifiers (metoclopramide at a dose of 0.2 to 1 mg/kg po or sc q6 to 8h, or cisapride at a dose of 0.5 mg/kg po q8 to 24h) may be useful.2 6 treat aspiration pneumonia with protocols described in the section on cardiorespiratory emergencies. rectal prolapse is not common in ferrets but can occur in some cases of proliferative bowel disease (pbd), coccidiosis, or neoplasia. 3 ,9, 10,26 pbd, uncommonly seen in the author's practice, generally affects ferrets less than 14 months of age. 3 , 9 clinical signs, in addition to rectal prolapse, include chronic liquid or mucoid diarrhea sometimes with frank blood, tenesmus, anorexia, and cachexia, pbd may be exacerbated by environmental stress,9 and affected ferrets may be more susceptible to other diseases, an affected ferret may be moderately to severely dehydrated with thickened bowel loops evident on abdominal palpation. initial diagnostics include a fecal direct wet mount and flotation, radiographs, a cbc, and serum chemistry. definitive diagnosis is made on biopsy of intestinal mucosa, rectal prolapse can initially be repaired with a pursestring suture. chloramphenicol (50 mg/kg 1m, sc, or po q12h for 14 to 21 days) is the treatment of choice for pbd.3,9 resolution of the prolapse may occur spontaneously as the colon heals. 3 coccidiosis is treated with feline protocols, urethral obstruction most commonly affects male ferrets, clinical signs include stranguria, lethargy, and anorexia. male ferrets may have a palpable mass caudodorsal to the bladder.37 ferrets with accompanying adrenal disease may also be pruritic with bilaterally symmetrical or diffuse alopecia. in the author's experience, the most common differential diagnoses for urinary obstruction include prostatic enlargement associated with adrenocortical disease in males, urolithiasis, and cystitis. less frequently, bladder neoplasia has also been reported as a cause of dysuria. 19 initial treatment for urinary obstruction is urethral catheterization. place an indwelling catheter while determining the origin of the obstruction. if a urinary catheter cannot be passed, a 25-or 28-gauge needle can be used to perform cystocentesis as an emergency measure. submit urine collected for urinalysis and culture and sensitivity. a cystostomy allows catheterization of the bladder directly from the body wall if passage of a catheter via the urethra is obstructed. submit blood for a cbc and serum chemistry. place an iv catheter and begin fluid diuresis concentrating on correction of dehydration and electrolyte imbalances. empirical broad-spectrum antibiotic therapy is recommended once a urine culture has been submitted and a urinary catheter placed (refer to the section on cystitis). further diagnostics to determine the cause of the obstruction include radiographs and abdominal ultrasound. along with ultrasonographic evaluation of the bladder, areas of special interest include the urethra, periurethral region, and adrenal glands. partial or complete urethral obstruction by hypertrophied prostatic tissue accompanies some cases of adrenocortical disease in male ferrets, and prostatic disease may be the most common cause of stranguria in male ferrets over 3 years of age. s , 47, 53 androgens of adrenal gland origin are hypothesized to cause hyperplasia or cystic changes of prostatic tissue, which subsequently presses on the urethra. 47 ,53 in some cases, prostatic tissue may become abscessed with a resultant thick purulent discharge from the prepuce. abdominal ultrasound may reveal unilateral or bilateral adrenomegaly, but not all cases of adrenal disease can be reliably diagnosed with this method. although studies of adrenal gland ultrasonography in ferrets have been published,39 diagnosis of adrenomegaly may be difficult for the ultrasonographer with little experience imaging ferrets. elevated plasma androgen and estrogen levels have been shown to be useful in diagnosing adrenal disease in ferrets,4s,53 but test results are often not available soon enough to be useful in an acute situation. removal of the diseased adrenal gland generally results in rapid dissipation of prostatic hypertrophy.37,53 cystotomy may be necessary to remove accumulation of purulent material,b and if a prostatic abscess is involved, surgical resection of the involved tissue is recommended after a sample has been retrieved for culture and sensitivity.9 this author maintains an indwelling urethral catheter for at least 2 to 3 days after surgery. persistent obstruction by prostatic tissue may be a result of infection or neoplastic changes or may be stimulated by remaining abnormal adrenal tissue. s , 53 the prognosis with prostatic abscessation may be poor because it is difficult to remove all affected tissue, and response to antibiotics is uncertain.s,9 magnesium ammonium phosphate (struvite) uroliths are the most common type of calculi reported in ferrets. 24 the incidence of struvite urolithiasis in ferrets has been less frequent with the introduction of higher-quality, animal protein-based diets that produce a more acidic urine than do plant protein-based foods. s ,24 diagnosis and treatment are similar to procedures used with cats and dogs. the practitioner can treat cases of severe or persistent urolithiasis with prescrotal urethrostomy using a technique similar to that described for the dog. 37 although primary cystitis is reported to be rare in the ferret,8, 24 purulent material in the bladder can be thick enough to cause a complete urethral obstructiony what appears to be cystitis in some male ferrets may actually be discharge from a prostatic abscess. 8 submit a urinalysis and a urinary culture and sensitivity obtained by cystocentesis. in cases of urethral obstruction, place a urinary catheter and stabilize the ferret. obtain radiographs and an abdominal ultrasound to evaluate the bladder, urethra, and adrenal glands. while awaiting culture and sensitivity results, begin treatment with a broad-spectrum antibiotic: trimethoprim/sulfonamide (30 mg/kg of combined drug po q12h), amoxicillin (20 mg/kg po q12h), or amoxicillin/ clavulanate (22 mg/kg po q8h).13 severe cases of cystitis may require treatment for 2 months or longer. clinical signs of renal failure may be nonspecific and include collapse, depression, lethargy, dehydration, anorexia, weight loss, rear limb weakness, polydipsia or polyuria, anemia, melena, oral ulcerations, or an azotemic odor to the breathy, 24 differential diagnoses for renal failure in the ferret include chronic interstitial nephritis, pyelonephritis, neoplasia, toxins, and glomerulonephropathy secondary to other causes such as aleutian disease (rarely seen in the clinical setting with pet ferrets). 24 diagnostics include a cbc, serum chemistries, urinalysis, urine culture and sensitivity, and radiographs. abdominal ultrasound is helpful in evaluating renal cysts, urinary tract calculi, or abnormal renal parenchyma. an ultrasound-guided renal aspirate may yield diagnostic information. initial treatment consists of iv fluid support geared toward correction of dehydration and electrolyte imbalances. an active urinary sediment indicates the need for a broad-spectrum antibiotic while awaiting results of a urine culture. the most common cause of hypoglycemia in pet ferrets in the united states is insulinoma (pancreatic islet cell neoplasia). additional differential diagnoses for hypoglycemia include anorexia or starvation, sepsis, neoplasia, hepatopathy, and other metabolic disease. 1 insulinoma affects ferrets ranging in age from 2 to 7 yearsy initial signs may be insidious and attributed by the owner to geriatric changes in their ferret. 49 the history may include episodes of collapse with hypersalivation or extreme weakness lasting from minutes to hours that typically resolve after administration of sugar-containing solutions. 43 other common clinical signs include depression, rear limb weakness (which may be apparent as posterior paresis or ataxia), gagging, pawing at the mouth, or a dazed appearance. occasionally severely hypoglycemic ferrets appear dyspneic. signs are often intermittent and may not be apparent on clinical presentation. although hypoglycemic seizures are the most common clinical sign of insulinoma in the dog, they are rare in ferretsy when a ferret over the age of 2 years presents collapsed or exhibiting any of the clinical signs described, immediately evaluate the bg level. initial evaluation can be performed with glucose measurement strips or a digital glucometer. 43 for more accurate evaluation of bg levels, submit blood in a sodium fluoride (gray top) tube. a bg glucose level less than 70 mg/ dl with accompanying clinical signs is suspicious for insulinoma, and ferrets presenting collapsed or comatose often have bg levels lower than 40 mg/dl.9, 43 an elevated serum insulin concentration (using an assay that has been validated for ferrets) concurrent with hypoglycemia is diagnostic for insulinoma, in cases of hypoglycemic collapse, administer a slow iv bolus of 50% dextrose (0.5 to 2 ml) to response, 43 the goal of treatment is stabilization and not the complete reversal of hypoglycemia. if dextrose is administered too rapidly, the tumor will be stimulated to release large amounts of insulin, resulting in rebound hypoglycemia, place an iv catheter and begin infusion of fluids supplemented with 5% dextrose, control rare persistent seizures with diazepam (refer to the section on seizures). administer prednisone (0.5 to 2 mg/kg sq) to inhibit peripheral tissue uptake of glucose and stimulate gluconeogenesis. 43 begin with the lowest dose needed to maintain adequate bg levels (i,e" > 70 mg/ dl), continue to monitor clinical signs along with bg concentrations q12h, and increase dextrose supplementation if necessary. once the ferret is stable, administer prednisone orally. in cases of persistent hypoglycemia, concurrently administer diazoxide, which acts to inhibit insulin release from pancreatic beta cells, beginning at the low end of the dose range (5 to 30 mg/kg po q12h).43 once clinical signs have resolved, gradually discontinue dextrose supplementation while monitoring the bg level, and adjust medications accordingly, prednisone doses can often be lowered with concurrent administration of diazoxide. offer a meatbased, high-protein ferret or feline diet while avoiding foods high in sugar or carbohydrate. in a minority of cases, hypoglycemic seizures or collapse may recur in spite of medications once iv dextrose supplementation is discontinued, these ferrets, once stabilized, may require surgical debulking of the tumors to allow further management. ongoing medical and surgical management of insulinoma is well described in the references. 9 , 43, 49 spontaneous diabetes mellitus (dm) is uncommon in ferrets. 47 most cases of hyperglycemia develop secondary to surgery for insulinoma. 47 clinical signs are similar to those seen in other small animals with dm. dm is suspected when the bg concentration is consistently greater than 400 mg/ dl in conjunction with glycosuria. 47 in cases of ketoacidosis, ketones are detected in the urine. a low insulin concentration concurrent with hyperglycemia confirms the diagnosis of dm. 47 for the initial treatment of ketoacidotic dm, follow protocols used with cats to stabilize metabolic derangements. tight regulation of bg levels in ferrets with dm can be difficult. one protocol suggests initiation of treatment with insulin when the bg level is consistently greater than 300 mg/ dl.47 neutral protamine hagedorn (nph) insulin is administered at an empirical dose of 0.1 unit per ferret twice daily with serial bg concentrations to dictate dosagey once the ferret is stabilized with a bg concentration less than 200 mg / dl, treatment is continued with either nph or ultralente insulin (which only requires once daily dosing). the owner is instructed to use dipsticks to check for the presence of glucose and ketones in the ferret's urine. the same dose of insulin is administered if only trace amounts of glucose are present in the urine. if no glucose is detected, insulin is not administered, and if the glucose concentration is elevated, the insulin dose is increasedy in cases of transient dm secondary to debulking of pancreatic tumors, hyperglycemia usually resolves within several days to 2 weeks after surgery.9, 47 ferrets with ongoing hyperglycemia are often very difficult to regulate. the differential diagnoses for anemia are broadly divided on the basis of regenerative versus nonregenerative processes. differentials for regenerative anemia in ferrets include blood loss (i.e. gi bleeding, trauma, flea infestation) and hemolytic anemia potentially caused by heavy metal toxicosis or immune-mediated disease. 22 causes of nonregenerative anemia include estrogen toxicosis of the bone marrow secondary to persistent estrus in an intact female, ovarian remnant(s), or adrenocortical disease; neoplastic infiltration of the bone marrow; or anemia of chronic disease. 22 immune-mediated hemolytic anemia has not been identified in ferrets owing to the lack of reagents specific for ferret antibodies. 22 aleutian disease, an immune-mediated disease caused by a parvovirus is uncommon in pet ferrets. although estrogen-induced bone marrow suppression was once a serious and common cause of nonregenerative anemia involving intact female ferrets, this form of pancytopenia is rarely seen owing to the current practice of spaying females at 5 to 6 weeks of age. 22 rarely, an ovarian remnant may secrete estrogen with similar results. 20 increased levels of estrogen may infrequently be associated with adrenocortical disease either as a result of estradiol secretion from an adrenocortical tumor or subsequent to conversion of tumor-secreted androgens to estrogen in peripheral tissues. 48 , 57 resultant pancytopenia has been reported,57 but this syndrome is uncommon in spite of markedly increased serum estrogen concentrations in some ferrets with adrenocortical disease. 32 clinical signs observed with pancytopenia of any cause include petechiation, ecchymosis, gi bleeding, infection, and sepsis. obtain an initial pcv from the critically anemic ferret before collecting a larger volume of blood for a cbc, platelet count, reticulocyte count, and serum chemistries. avoid anterior vena cava venipuncture in cases of suspected pancytopenia. normal mean reticulocyte counts for female and male albino ferrets have been reported as 5.3% and 4%, respectively.22 pursue further diagnostics as indicated. if the pcv is less than 15%, transfuse whole blood. if an 10 catheter is used, obtain a bone marrow sample before transfusion. if an ovarian remnant is suspected, administer human chorionic gonadotropin (hcg) (100 iu per ferret) to stimulate ovulation. 24 administration of hcg has no effect on hyperestrogenism secondary to adrenocortical disease. if the pcv remains below 15%, the prognosis is poor, and multiple transfusions along with b complex vitamins, an anabolic steroid (stanazolol, 0.5 mg/kg po, sc q12h),b iron supplementation, fluid therapy, and nutritional support may be required. 9 , 24 pursue surgical treatment for adrenocortical disease, a retained ovary, or bleeding gi masses once the patient is stabilized. anecdotal reports of reactions following canine distemper vaccination in ferrets describe clinical signs ranging from diarrhea, gagging, vomiting, fever, or erythematous skin to circulatory collapsey although many of these reactions happen within 30 minutes after vaccination, less severe signs can be noted up to several hours later. in cases of postvaccination collapse, administer diphenydramine hydrochloride (0.5 to 2.0 mg/kg iv or im),42 epinephrine (20 j-lg/kg iv, 1m, sc, or intratracheally),42 and a slow iv bolus of a short-acting corticosteroid (22 mg/kg of prednisolone sodium succinate or 6 to 8 mg/kg of dexamethasone sodium phosphate).b administer iv fluids, and provide supportive care following treatment protocols for small animals. seizures are uncommon in ferrets with the most common cause arguably being insulinoma-induced hypoglycemia. l additional differential diagnoses include hypoglycemia from other causes; trauma; toxin ingestion; ens infection (including rabies or canine distemper), inflammation, or neoplasia; renal failure; hepatopathy; or other metabolic derangements. 1 evaluate the bg level on presentation, and treat hypoglycemia as described above (refer to the section on hypoglycemia). administer diazepam (1 to 2 mg iv to effect), and treat supportively using protocols applied to other small animals. pursue diagnostics as indicated. lumbar cerebrospinal fluid tap has been described in the ferret. l gastrointestinal disease, neoplasia, cardiac disease, and endocrinopathy are among the most common syndromes affecting the ferret that presents in an emergency situation. knowledge of these and other disease processes, indicated diagnostic testing, and immediate treatment protocols are critical to provide efficient and effective care to the ferret in crisis. musculoskeletal and neurologic diseases a cluster of cases of juvenile mediastinal lymphoma in a ferret colony helicobacter muste/ae gastritis, proliferative bowel disease, and eosinophilic gastroenteritis intraosseous catheters in small mammals biology and medicine of the ferret ferrets: basic anatomy, physiology, and husbandry (of the ferret) clinical techniques in domestic ferrets stranguria in a castrated male ferret a practitioner's guide to rabbits and ferrets ferrets, rabbits, and rodents: clinical medicine and surgery. philadelphia, wb saunders medical and surgical management of esophageal foreign body in a ferret diagnosis and treatment of insulin-secreting pancreatic islet cell tumors in ferrets: 57 cases (1986-1994) exotic animal formulary s. pet ownership and pet populations chemotherapeutical remission of multicentric lymphosarcoma in a ferret (mustela putorius juro) cardiac emergencies clinical and pathologic findings in ferrets with lymphoma: 60 cases (1982-1994) helicobacter mustelae-associated gastric adenocarcinoma in ferrets (mustela putorius jura) gastric colonization of the ferret with helicobacter species: natural and experimental infections cystic ovarian remnant in a ferret critical care of ferrets, rabbits, and rodents ferrets, rabbits, and rodents gastrointestinal diseases of ferrets (mustela putorius juro! urogenital diseases cardiac disease in ferrets gastrointestinal diseases gastrointestinal diseases of ferrets helicobacter infection normal parameters and laboratory interpretation of disease states in the domestic ferret blood transfusions multisystemic eosinophilic complex in a ferret (mustela putorius juro) estradiol-17j3-secreting adrenocortical tumor in a ferret lack of detectable blood groups in domestic ferrets: implications for transfusion effect of isoflurane on hematologic variables in ferrets anesthesia, analgesia, and sedation for small mammals differential diagnoses for common clinical problems in ferrets soft tissue surgery gastrointestinal foreign body in ferrets: 25 cases ultrasonography of adrenal glands in normal ferrets pleura and pleural space helicobacter mustelae-associated hypergastrinemia in ferrets (mustela putorius jura) basic approach to veterinary care endocrine diseases: insulinoma use of a vascular access system for administration of chemotherapeutic agents to a ferret with lymphoma pyloric adenocarcinoma in a ferret the collapsed ferret endocrine diseases: adrenal gland disease, d iabetes mellitus, and thyroid disease evaluation of plasma androgen and estrogen concentrations in ferrets with hyperadrenocorticism proceedings of the north american veterinary conference ferret respiratory disease diagnosis new therapeutics in small mammals respiratory diseases stranguria in a castrated male ferret cardiovascular diseases: cardiac disease small mammal radiology radiographic and angiographic evaluations of ferrets experimentally infected with dirofilaria immitis estrogen induced bone marrow depression in a ferret (mus tela putorius juro) with adrenal gland tumors key: cord-023165-f6o6owg3 authors: navarre, christine b.; pugh, d.g. title: diseases of the gastrointestinal system date: 2009-05-21 journal: sheep & goat medicine doi: 10.1016/b0-72-169052-1/50006-5 sha: doc_id: 23165 cord_uid: f6o6owg3 nan the gastrointestinal system is, arguably, more prone to disease than any other part of the sheep or goat. gastrointestinal parasitism alone is the most significant cause of production and animal losses in much of north america. 1, 2 there is no substitute for a thorough physical examination when trying to determine the affected body systems of a sick animal; this is especially true in diseases of the gastrointestinal system. a complete physical examination should include palpation for body condition, assessment of abdominal shape and rumen motility, observation of the consistency of the stool, and evaluation for the presence of bloat. however, because rectal palpation cannot be performed in sheep and goats, diagnosis of disease in a particular segment of the gastrointestinal system can be difficult. therefore, the clinician may have to perform ancillary diagnostic procedures to characterize gastrointestinal diseases properly. clinicopathologic data consisting of a complete blood count (cbc), serum biochemical evaluation (sbe), and urinalysis can be helpful in differentiating gastrointestinal diseases, developing a prognosis and plan for treatment, and monitoring treatment. a cbc rarely identifies a specific disease, but it can be helpful in evaluating the severity of dehydration, anemia, and hypoproteinemia. the clinician must take care to interpret the packed cell volume (pcv) and total protein in light of the hydration status of the animal as noted on physical examination. an anemic or dehydrated hypoproteinemic animal may have normal pcv and total protein values. both the cbc and sbe can be helpful in characterizing the presence and severity of an inflammatory disease process. changes in the total and differential white blood cell count indicate acute or chronic inflammation; increases in globulins or fibrinogen suggest a chronic inflammatory disease. low protein levels, especially albumin, can point to chronic blood loss from intestinal parasitism or infiltrative bowel disease. liver disease should be suspected if liver enzymes or bilirubin are elevated. however, liver enzymes can be normal in chronic liver disease. also, albumin levels rarely drop in ruminants with liver disease, as they do in other species. 3 changes in electrolytes can occur with gastrointestinal disease, especially if the animals are anorexic. electrolyte measurements also are helpful in formulating a treatment plan. hypochloremia and metabolic alkalosis occasionally occur in abomasal disease. a mild hypocalcemia may be encountered in some small ruminants with gastrointestinal atony. because many animals with gastrointestinal disease are dehydrated and therefore azotemic and possibly hypoproteinemic, urinalysis is helpful to eliminate urinary disease as a cause of these pathologies. normal ranges for clinicopathologic values are included in this textbook (see appendix iii) and also have been published in several other textbooks. [4] [5] [6] [7] however, clinicians would do well to learn the normal values, especially serum biochemistry values, established by the laboratory most commonly used for analysis. 7 analysis of rumen fluid can help differentiate diseases of the forestomachs. an appropriately sized orogastric tube can be passed through the oral cavity for fluid collection (figure 4-1) . the clinician must properly restrain the animal, using a mouth speculum (figure 4 -2) to prevent tube chewing. if the tube is chewed, its roughened surface may damage the esophagus; parts of a broken tube can be swallowed. rumen fluid also can be collected using percutaneous rumenocentesis 4, [8] [9] [10] [11] [12] (figure 4 the clinician then aspirates fluid with a syringe. local anesthesia and sedation of the animal may be necessary. this technique avoids the saliva contamination that can occur during collection with an orogastric tube, and it appears to be less stressful. rumenocentesis presents a slight risk of peritonitis, but this risk can be minimized with proper restraint. percutaneous rumenocentesis should not be performed on pregnant females. after the fluid is collected, it can be analyzed for color, odor, ph, protozoal species and motility, methylene blue reduction time (mbr), gram's staining characteristics, and chloride levels. normal values are listed in table 4 -1. anorexia may cause the fluid to appear darker, the ph to increase, and the number and motility of protozoa to decrease. a gray color, low ph, and dead or no protozoa are seen in rumen acidosis from grain overload. the mbr is prolonged with any type of indigestion. large numbers of gram-positive rods (lactobacillus species) also may be seen in rumen acidosis. elevated rumen chloride indicates an abomasal or proximal small intestinal obstruction (either functional or mechanical). the most important reason for examining feces in sheep and goats is to determine the presence and relative number of nematode parasites infesting an animal or flock. the quantitative technique for determining eggs per gram of feces (epg) is shown in box 4-1. fecal epg values of more than 500 to 1000 indicate serious infestation and the need for intervention. fecal occult blood testing and acid-fast staining of fecal smears also can be performed. fecal occult blood tests can detect microscopic amounts of blood in the feces. however, they cannot indicate which part of the gastrointestinal tract is bleeding. acid-fast stains of fecal smears that reveal clumps of acid-fast rods usually indicate infection with mycobacterium paratuberculosis ( johne's disease). generally, individual acid-fast rods found on fecal examination are nonpathogenic. abdominocentesis is useful in discerning the causes of fluid distention in the abdomen. two methods can be used. the first technique involves tapping the lowest point of the abdomen slightly to the right of midline; it is useful in ruling out a ruptured bladder as the cause of general ascites (figure 4-4) . 4, 13 the clinician should take care to avoid the prepuce in males. the second technique is useful if peritonitis is suspected. because localized peritonitis is more common than generalized peritonitis, four sites are tapped. 14 the two cranial sites are slightly caudal to the xyphoid and medial to the milk veins on the left and right sides. the two caudal sites are slightly cranial to the mammary gland and to the left and right of midline. for either technique, manual restraint with sedation is recommended; the use of real-time ultrasonography may help locate fluid pockets. a 20-gauge needle or teat cannula can be used for fluid collection. 13 the clinician should prepare the site using sterile technique and provide local anesthesia when employing a teat cannula. fluid should be collected in a small ethylenediamine tetra-acetic acid (edta) tube for analysis and a sterile tube for culture. abdominal fluid can be difficult to obtain because of the small amounts normally present in both sheep and goats. the clinician should minimize the ratio of edta to fluid because edta can falsely elevate protein levels. using edta tubes made for small animals or shaking excess edta out of large tubes resolves this problem. normal culture values are similar to those for cattle (clear, colorless to slightly yellow, 1 to 5 g/dl protein, less than 10,000 cells). 14 cytologic examination 1 . weigh 2 g of feces and thoroughly mix with 28 ml of water. this is the preferred method. however, if a gram scale is not available, feces can be added to the 28 ml of water until the water level indicates 30 ml. this approximates 2 g of feces. 2. remove 1 ml of well-mixed fecal-water suspension, add to 1 ml of sheather's solution,* and mix well. is needed to characterize the cell population and assess for the presence of phagocytized bacteria. radiography of the abdomen can be performed in small ruminants using small animal techniques. in adults, the rumen normally fills the entire abdomen. radiography can detect gas distention of the small intestine, abdominal fluid, and foreign bodies. 14, 15 contrast techniques are useful for diagnosing atresia of the rectum or colon. unlike in other small animals, contrast techniques are not practical for characterizing small intestinal problems in sheep and goats because the rumen dilutes and slows passage of the contrast media. 16 ultrasonography ultrasonography can be used to provide better characterization of abdominal distention, internal and external abdominal masses, and gross lesions of the liver. ascites may be differentiated from fluid in the intestinal tract, and gas distention of the intestines can be differentiated from fluid distention. normal ultrasonographic examination of the liver in sheep has been described. 17 the liver can be viewed on the right side from the seventh or eighth rib caudally to the thirteenth rib ( . ultrasonography can be used to perform biopsies of organs or masses and to locate pockets of fluid. laparoscopy is more commonly used as a reproductive tool, but it also can be used diagnostically as an alternative to exploratory laparotomy in small ruminants. 18, 19 general anesthesia is recommended. the technique for laparoscopic exploration of the abdomen used for cattle can be modified for use in sheep and goats. 20 the clinician inserts a cannula in the caudal abdomen and carefully inflates the abdomen with carbon dioxide (co 2 ). with the animal restrained in dorsal recumbency and either sedated or anesthetized, the clinician places the cannula in the inguinal area as described for laparoscopic insemination in chapter 6. entrance on the right side allows visualization of most of the abdominal organs. the clinician should avoid the rumen when introducing the laparoscope into the abdomen. this procedure may be enhanced by lowering the head or rear of the animal, allowing better visualization of the entire abdomen. animals should be properly ventilated during this procedure because inflation of the abdomen and lowering of the head can put pressure on the diaphragm. exploratory laparotomy can be a valuable diagnostic tool in evaluating gastrointestinal diseases when other tests indicate abdominal disease. in some cases, therapeutic surgical techniques can be performed at the same time. the technique of exploratory laparotomy used in cattle can be adopted for sheep and goats as long as the clinician keeps in mind that these animals are more likely to lie down during surgery and standing surgery should only rarely be attempted. 21 small ruminants should be heavily sedated or placed under general anesthesia during this procedure. they may show signs of postoperative pain, anorexia, and depression and should be treated accordingly with a nonsteroidal antiinflammatory drug (nsaid) (flunixin meglumine 1.1 to 2.2 mg/kg intravenously [iv] ). 14 the decision to use perioperative and postoperative antimicrobial agents should be based on the conditions under which the surgery is performed and the diagnosis made at surgery. sheep the area should be clipped, but in goats alcohol can be applied to the overlying hair and skin. if the area is clipped, the clinician should apply a bland coupling material (e.g., methyl cellulose, vegetable oil) between the skin and the transducer. liver biopsy in sheep and goats is performed using the same technique and instruments as in cattle. 12 however, sedation and ultrasound guidance are recommended. 22 the biopsy can be performed in the ninth to tenth intercostal space slightly above an imaginary line from the tuber coxae to the point of the elbow (figure 4-7) . the site should be surgically prepared, and a local anesthetic (2% lidocaine hydrochloride) infused subcutaneously. a small scalpel blade is used to make a stab incision through the skin. a 14-gauge, 11.5-cm liver biopsy instrument is inserted through the incision and the intercostal muscles and into the liver. the biopsy instrument should be directed toward the opposite elbow in most cases, but the use of real-time ultrasonography can help determine the direction and depth needed (2 to 4 cm). the clinician should avoid the vessels along the caudal border of the ribs. on reaching the liver, the clinician will note a slight increase in resistance. samples can be submitted for culture (in a sterile plastic or glass vial or tube), histopathology (in formalin at a 10ϻ1 ratio of formalin to tissue); and/or mineral analysis (in a plastic tube). when performing a liver biopsy for mineral analysis, the clinician should rinse the biopsy site with distilled and deionized water after sterile preparation to minimize sample contamination. samples for mineral analysis should not be placed in formalin. the skin incision can be sutured, and aseptically prepared, the surgeon makes a stab incision in the skin and introduces a 14-gauge biopsy needle. bloat is less common in small ruminants than in cattle, with goats having the condition less commonly than sheep. bloat is the accumulation of either free gas or froth in the rumen, which causes rumen distention. the causes of bloat can be divided into three categories 1,2 : 1. frothy bloat-caused by diets that promote the formation of stable froth 2. free gas bloat-caused by diets that promote excessive free gas production 3. free gas bloat-caused by failure to eructate pathogenesis. frothy bloat is usually associated with the ingestion of legume forages or hay (particularly alfalfa) and with grazing on lush cereal grain pastures, but it also may occur with high-grain diets. 3 in the case of frothy bloat from a finely ground diet (usually corn), mucoprotein released from rumen protozoa stabilizes the foam at a low ph. in legume-associated frothy bloat, plant chloroplasts released into the rumen trap gas bubbles. regardless of the form of frothy bloat, the small bubbles fill much of the rumen, preventing clearance of the rumen's cardia and resulting in a cessation of eructation. free gas bloat also occurs with grain diets, especially if the animals are not adapted to the diet. failure to eructate has a variety of causes. physical obstructions of the esophagus such as choke or swollen mediastinal lymph nodes can cause free gas bloat. any disease of the rumen wall can interfere with rumen contractions and eructation. hypocalcemia, endotoxemia, pain, peritonitis, and some pharmaceutical agents (especially xylazine) can all interfere with rumen function and eructation. 1, 2, 4, 5 clinical signs. clinical signs of frothy bloat and free gas bloat from either food intake or physical obstruction of the esophagus are usually more severe and immediately life-threatening than bloat seen from rumen wall diseases and systemic influences. abdominal enlargement occurs, particularly in the dorsal left paralumbar fossa. this may be subtle in sheep or angora goats with full fleece. signs of colic and anxiety are common. the rumen may be either hypomotile or hypermotile. respiratory distress is evident, with some animals breathing through their mouths; death can ensue if the bloat is not treated. 3 this condition is a medical emergency, and therefore diagnosis and treatment should occur almost simultaneously. if the animal is not in immediate danger of dying, an orogastric tube can be passed. most cases of free gas bloat are relieved with passage of the tube. a clinician should then take a thorough history and perform a complete physical examination to find the cause of the bloat. if the bloat is not relieved with an orogastric tube, the tube should be removed and examined for evidence of froth. frothy bloat can be treated with poloxalene (44 mg/kg) or dioctyl sodium sulfosuccinate (dss) (28 cc [1 oz]) delivered by orogastric tube. the froth encountered in frothy bloat caused by the ingestion of finely ground grain has a ph of less than 5.5. if frothy bloat occurs while animals are being fed concentrates, mineral oil (100 ml) may work better. peanut oil (20 to 50 mg/kg), vegetable oil (100 to 200 ml), and hand soap (10 ml) also have been recommended in emergency situations. 3 if the animal is in severe respiratory distress, the clinician should insert a trocar or large needle into the rumen at the paralumbar fossa. if gas does not escape, or froth is seen coming out of the trocar, an emergency rumenotomy should be performed (see the rumenotomy section of this chapter). 3 if several cases of bloat are encountered in a group of pastured animals, the entire group should be removed from the pasture and reintroduced slowly after gradual acclimation. if only one or two cases of bloat are encountered, the healthy animals can remain on the offending pasture, but grazing should be limited to ensure gradual acclimation. prevention. prevention of frothy bloat involves limiting access to offending pastures or feedstuffs; providing supplemental feed and providing poloxalene in mineral supplements; and adding ionophores to the ration or supplement. when grazing or consuming legumes as "greenchop," animals should be introduced to the feed or pasture slowly, preferably over 2 to 3 weeks. animals should be closely monitored after a frost and during the rapid growth phase of plants because legumes, particularly alfalfa, may be more likely to cause bloat at this time. certain varieties of legumes that are designed for intensive grazing systems (e.g., alfagraze) should be planted and managed in a manner that decreases the incidence of bloat (limited or creep grazing). feeding dry, stemmy hay for 1 to 2 hours before allowing access to the legume pasture also may help minimize bloat. grass-legume pastures in which legumes are limited to less than 50% of the forage are safer but can still pose a problem for animals that are selective grazers. grazing legumes with high leaf tannin concentrations (e.g., arrowleaf clover, kudzu) is usually safer because tannins help break down rumen foam. the inclusion of poloxalene (10 to 20 mg/kg daily) in the feed or mineral supplement is useful in preventing frothy bloat. if poloxalene supplements are used, keepers should feed them for 1 to 2 weeks before moving animals onto a problem pasture. free gas bloat from concentrate feeds can be controlled by slow introduction to these feeds to allow for rumen adaptation and by the inclusion of ionophores in the diet. 1 monensin (15 mg/head/day in ewes, 1 mg/kg/day in goats) and lasalocid (0.5 to 1 mg/kg/day in sheep and goats) both decrease the formation of free ruminal gas. by enhancing propionic acid formation, these drugs not only reduce the amount of methane produced in the rumen, they also improve the efficiency of nutrient assimilation from feedstuffs. bloat in lambs and kids can have the same causes as in adults but also can be caused by improper milk feeding. overfeeding, feeding of large infrequent meals, and feeding spoiled or cold milk have all been associated with bloat in lambs and kids. 6 rapid overdistention of the abomasum and improper chemical or physical composition of milk replacers inhibit rumen motility, leading to bloat. even though the feeding of cold milk has been associated with bloat, the practice can be used effectively in orphan feeding programs. lambs and kids tend to limit their intake of cold milk after they have become accustomed to cold milk in a free-choice feeding system. milk is usually placed in the rumen when animals are tube-fed; this may result in milk spoilage. 1, 6 simple indigestion is a mild form of upset of the reticulorumen caused by a change in feeding routine. it can be caused by an alteration in the type of feed or in the amount of feed offered. the most common causes of simple indigestion are the addition of grain to the diet, an increase in the amount of grain fed, and an increase in the energy density of the diet. examples of such dietary changes are replacing oats with corn or changing from whole to ground corn. if the changes are drastic, rumen acidosis can occur (see the following section). other common causes are changes in hay or pasture, consumption of moldy hay, and ingestion of weeds and toxic plants after overgrazing or droughts. clinical signs include mild anorexia that lasts for 1 to 2 days. mild diarrhea and bloat also may occur. rumen fluid ph can be unchanged, increased, or decreased depending on the inciting cause. most animals improve with no treatment. 1 pathogenesis. rumen acidosis is caused by the rapid rumen fermentation of highly digestible carbohydrates that are ingested in excessive amounts. although corn is commonly implicated, other cereal grains (oats, wheat, barley) may be involved, particularly if they are finely ground. the smaller the particle size, the more quickly rumen bacteria are able to ferment the carbohydrates contained in the feed. the common name of this condition is "grain overload," but breads, candy, apples and other fruits, beets, and potatoes also can cause this condi-tion. rumen acidosis usually occurs in animals that have been fed predominantly forage-based rations and are suddenly given access to large amounts of highly fermentable concentrates or concentrated forms of energy. it also can occur in animals that have been receiving concentrates previously, if the amount is suddenly and drastically increased; if access is denied for a time, then suddenly returned (e.g., during weather changes and alterations in water availability); or if ration mixing errors occur (e.g., leaving out monensin and rumen buffers) as highly digestible carbohydrates are fermented, rumen ph drops. lactobacillus species, which are lactic acid producers, proliferate in the acidic rumen environment and further lower rumen ph. as the rumen ph drops, rumen protozoa and many of the lactate users begin to die. lactic acid production causes the osmotic pressure in the rumen to increase. fluid is drawn from the systemic circulation into the rumen, resulting in dehydration and possibly hypovolemic shock. lactate concentrations increase in the blood and may cause systemic lactic acidosis. the lactic acid in the rumen also is toxic to the rumen epithelium. damage to the epithelium can result in leakage of bacteria and toxins into the portal and systemic circulation. chronic sequelae to rumen acidosis include fungal rumenitis and occasionally liver abscesses. 1, 7 liver abscesses are less commonly encountered in sheep and goats than in cattle. laminitis also can occur, but may be more of a problem in sheep than in goats. 8 the severity of the disease depends on the composition of the feed, particle size, amount of feed consumed, and the period of adaptation to the diet. clinical signs. clinical signs vary with the amount and type of feed ingested and the time since ingestion. signs first appear 12 to 36 hours after ingestion of the offending feed; they vary from anorexia, depression, and weakness to a down animal suffering from severe circulatory shock. dehydration is usually severe and evidence of toxemia is present (e.g., injected mucous membranes, increased scleral injection). colic, bilateral ventral abdominal distention, rumen stasis, and a "splashy" feel to the rumen also may be present. diarrhea can develop, adding to dehydration. 1, 8, 9 the diarrhea can range from a pastelike feces to very watery droppings with foam and occasionally pieces of grain easily recognized. dehydration, lactic acidosis, and toxemia result in neurologic signs, including ataxia, head pressing, opisthotonos, and seizures. the body temperature is initially elevated but may drop as the condition worsens or the animal becomes toxic. some animals develop polioencephalomalacia and appear blind. diagnosis. the rumen fluid ph may fall below 5.5. the fluid itself is milky gray and particles of the inciting feed may be noticed. protozoa are usually reduced in number or absent, and large gram-positive rods (lactobacillus species) may be seen on gram's stain. 9 clinicopathology is consistent with dehydration (increased pcv and total protein, prerenal azotemia) and metabolic acidosis. 9 liver enzymes (gamma-glutamyl transpeptidase [ggt], aspartate aminotransferase [ast], lactate dehydrogenase [ldh]) may be elevated on serum biochemical analysis. 1, 10 the leukogram can vary from normal to a degenerative left shift, depending on the severity of the case. urinalysis reveals an increased specific gravity. treatment. treatment is aimed at correcting cardiovascular shock, dehydration, acidosis, and toxemia and removing or neutralizing the offending feedstuffs. iv fluids containing 5% sodium bicarbonate should be administered. 1, 11 oral fluids are contraindicated because they cannot be absorbed and may increase the rumen distention and discomfort of the animal. nsaids are indicated for toxemia (flunixin meglumine, 1.1 to 2.2 mg/kg iv). 1, 11 oral administration of magnesium hydroxide and magnesium oxide (1 g/kg) may neutralize the acidic ph and is sufficient in mild cases. however, if much of the feed is still in the rumen, these two alkalinizing agents will only work temporarily. oral antibiotics have been recommended to kill rumen microflora and stop fermentation. however, the authors of this chapter feel they are contraindicated because the gram-negative anaerobes that need to flourish to reestablish normal rumen microflora are susceptible to most antimicrobials effective against lactobacillus species. removing the substrate for the lactobacillus species is more effective. because orogastric tubes with large enough bores to reflux feedstuffs are too large for sheep and goats, rumenotomy is indicated in severe cases to remove the feed (see the section on rumenotomy in this chapter). after the rumen ph is cor-rected, transfaunation of the rumen microflora with about 1 qt of rumen fluid from a small ruminant is beneficial (box 4-2). thiamine supplementation (vitamin b 1 , 5 mg/lb subcutaneously [sc] three times a day [tid] to four times a day [qid]) is indicated until rumen function returns. 11 in certain instances, calcium may be indicated and can be included in the iv fluids (calcium gluconate). the clinician should avoid mixing calcium salts and sodium bicarbonate. bacterial leakage into the rumen wall, liver, and systemic circulation makes antimicrobial therapy necessary. the systemic antimicrobial agent of choice is penicillin (procaine penicillin g, 22,000 iu/kg im bid) because anaerobes are the most likely offending organisms. if treated aggressively, the prognosis for immediate survival is good. feed (grass hay only) and water should be limited until rumen contractions return to prevent overdistention of the rumen. the chronic sequelae discussed previously influence long-term survival. prevention. prevention involves introducing concentrate feeds slowly to allow rumen microflora adaptation. dietary change from a lower to a higher fermentable energy concentration should occur slowly and preferably over a 2-to 3-week period. in the case of animals being fed high-grain rations (e.g., club lambs, feedlot lambs, dairy goats), buffering agents can be added to the diet. rumen buffers may improve milk production, increase feed intake, and increase rate of gain. the crude fiber content should comprise a minimum of 20% of the diet's total digestible nutrients (tdn). for example, the tdn is 75%, the minimum acceptable crude fiber is 15%. crude fiber levels lower than this can be fed for short periods if the rumen is properly adapted, but problems may nevertheless occur. sodium bicarbonate is probably the most commonly used buffer; it can be offered free choice or included in the diet as 1% of dry matter intake. calcium carbonate or limestone (which both have low can be collected through a weighted orogastric tube. alternatively, fluid can be collected from any normal ruminant at slaughter. handling rumen contents collected from a fistulated cow or at slaughter can be strained through gauze or cheesecloth to separate the fluid from the fibrous contents. fluid collected through a weighted tube should be ready for storage. rumen fluid should ideally be administered immediately. however, it can be stored for 24 to 48 hours. the surface of the fluid should be covered with a layer of mineral oil to maintain an anaerobic environment and stored at refrigerator temperature. caution: do not store rumen fluid in a closed container because it may explode. rumen solubility) and magnesium oxide (which has poor palatability) also can be included in the feed. magnesium oxide should be limited to 0.5% to 0.8% of the dry matter intake. pathogenesis. reticulitis and rumenitis can result from chemical or mechanical damage to the mucosal lining of the reticulorumen. the most common cause of chemical damage is rumen acidosis. however, ingestion of caustic toxins also can damage the mucosa. mechanical damage can occur from ingested foreign bodies or the formation of rumen bezoars. in cattle, some viruses such as the ones that cause bovine virus diarrhea and infectious bovine rhinotracheitis can infect the rumen wall. similar viruses have yet to be identified in sheep and goats. after the mucosa has been damaged, secondary infection by bacteria or fungi can occur. 12 previous treatment with oral antibiotics may predispose to fungal infections of the rumen wall, especially if the mucosa is already damaged. actinobacillosis, actinomycosis, and tuberculosis rarely affect the rumen wall. tumors of the rumen wall also have been reported. 1, 13 not all of these causes of reticulitis and rumenitis have been reported in sheep and goats, but all are potential problems. clinical signs. the clinical signs of these diseases are vague. anorexia and forestomach hypomotility may be the only clinical signs. confirming a diagnosis also may prove difficult. samples of rumen fluid may only show changes associated with anorexia (alkaline ph, decreased numbers and motility of protozoa, prolonged mbr time; see table 4 -1 for normal values). occasionally fungal organisms may be seen on diff quik stained slides of rumen fluid. in these cases a diagnosis of fungal rumenitis should be made. an exploratory laparotomy and rumenotomy may be required to diagnose foreign bodies or masses. rumen parakeratosis is characterized by dark, thickened, and clumped rumen papillae. it is seen mainly in feedlot lambs that consume finely ground or pelleted rations. 14 the parakeratotic rumen papillae are fragile and predisposed to damage, which can increase the chances of rumenitis. 1 treatment and prevention. treatment depends on the inciting cause. dietary changes should be made to decrease energy density and increase fiber intake. mild rumenitis may improve with time and supportive care (transfaunation, fluid support, high-quality feed). fungal rumenitis can be treated with thiabendazole (25 mg/kg orally). 15 severe changes may lead to scarring and permanent impairment of rumen function. traumatic reticuloperitonitis is not as common in small ruminants as in cattle, but it has been reported. goats are affected more commonly than sheep. this is probably because of the dietary habits of small ruminants; they tend to be selective grazers and do not "vacuum" the ground as cattle do. offending foreign bodies that cause traumatic reticuloperitonitis include pieces of wire and needles. 16, 17 the clinical signs are identical to those in cattle and may include anorexia, depression, colic, signs of heart failure, and evidence of draining tracts from the chest cavity. treatment is usually difficult. rumen impaction can occur after dehydration, blockage of the omasal orifice by a foreign body, sand ingestion, or consumption of diets high in fiber and low in digestibility. 18 clinical signs are nonspecific, but the firm rumen can usually be palpated in the left flank. the feces may be scant and dry. oral fluids containing magnesium sulfate (60 g) may loosen impactions, but a rumenotomy is required in severe cases. 18 to reduce rumen fill, sheep or goats should ideally have feed withheld for 24 hours before rumenotomy. however, this is usually impossible because in most cases rumenotomy is an emergency procedure. the perioperative administration of antimicrobial agents is essential because even with meticulous technique some contamination of the incision site and possibly the peritoneal cavity is inevitable. because the rumen microflora is predominantly composed of anaerobic bacteria, penicillin (22,000 iu/kg) is the antimicrobial agent of choice and should be administered 2 to 4 hours before surgery. if the rumenotomy is being performed in an emergency situation, penicillin salts (potassium or sodium) that can be given iv provide therapeutic concentrations more rapidly than procaine penicillin. nsaids (flunixin meglumine, 1.1 to 2.2 mg/kg iv) also are recommended before surgery. if necessary, treatment of cardiovascular shock and dehydration with iv fluids also should begin before surgery and continue until the animal is rehydrated and in stable condition (see appendix ii). general anesthesia is recommended, but heavy sedation and local anesthetic infiltration of the incision site can be efficiently used (see chapter 16) . the clinician should clip and surgically prepare a square area from 5 cm in front of the last rib to the tuber coxae, and from the dorsal midline to the lower abdomen, encompassing the entire left paralumbar fossa. the surgeon makes a skin incision approximately 5 cm longer than the width of the hand 5 cm caudal and parallel to the last rib. the incision is continued through the muscle layers into the abdomen. because the abdominal wall is relatively thin, the surgeon should take care not to enter the rumen or bowel. the surgeon grasps the rumen wall and pulls it through the incision; suturing it to the skin with a simple continuous circular pattern around the entire incision. this forms a seal that minimizes rumen content contamination of the deep layers of the incision and peritoneal cavity. the rumen wall is then incised inside the circle of sutures. the incision in the rumen wall should be large enough for the surgeon to put his or her hand inside the rumen without traumatizing the rumen wall. after the rumen has been explored and emptied and the primary reason for doing the procedure has been completed, the surgeon closes the rumen wall in a continuous inverting pattern (cushing, lembert, or guard's rumen stitch) with absorbable suture (0 catgut). the area should be rinsed with copious amounts of sterile isotonic fluids, and a new set of sterile instruments, sterile gloves, and surgical attire should be used for the remainder of the surgery. the surgeon then removes the suture securing the rumen to the skin and rinses the area again before performing routine closure of the abdominal muscles and subcutaneous layers with absorbable suture (0 catgut) in simple continuous patterns, taking care to close dead space between layers. the skin is closed with a continuous pattern (ford interlocking) using a nonabsorbable suture material. the sheep or goat should be observed closely by the clinician for signs of complications, including peritonitis, incisional dehiscence, incisional hematoma, abscess, and hernia formation. penicillin therapy (procaine penicillin g, 22,000 iu/kg bid) should continue for at least 5 days. the skin sutures can be removed 10 to 14 days after surgery. abomasitis and abomasal ulcers in adult sheep and goats are associated with rumen acidosis or chronic rumenitis but also can be caused by infections. [1] [2] [3] [4] finely ground feeds, pelleted rations, systemic stress, and feeding lush forages have all been implicated. anecdotal associations with mineral deficiency (copper) have gone unproved. clinical signs and diagnosis. this disease often goes unnoticed in mild cases, and the most common signs are anorexia and colic. no definitive antemortem diagnostic tests are available. fecal occult blood is often absent. occasionally dark stool, altered appetite (wood chewing), and bruxism are seen. therefore other causes of colic should be eliminated. diagnosis is based on clinical signs. effective therapy can be difficult. oral medications such as coating agents must first pass through the rumen, and therefore arrive at the abomasum diluted. iv (not oral) ranitidine (15 mg/kg once a day [sid]) may be beneficial. 5 herd problems of rumen acidosis may be addressed with buffers in the feed. a syndrome of abomasal hemorrhage, bloat, and ulceration is seen in lambs and kids 2 to 10 weeks of age. sarcina-like bacteria, clostridium falax, clostridium sordelli, and clostridium septicum have been isolated from many of these cases. [6] [7] [8] [9] c. septicum infections of the abomasum are commonly called braxy. 1 the feeding of milk replacer free choice, iron deficiency, and bezoars have been implicated as predisposing factors. 10, 11 clinical signs. the signs of this syndrome are severe, acute abdominal distention; colic; and death. [6] [7] [8] [9] diagnosis and treatment. the diagnosis of this condition is by postmortem examination. treatment in suspected antemortem cases is unsuccessful. prevention. adding formalin to milk replacers and vaccinating for clostridial diseases may decrease the occurrence of this disease. 10, 12 lambs or kids on problem farms can be vaccinated for clostridium species during the first week of life with multivalent bacterins. similar to rumen impaction, abomasal impaction usually occurs when poor-quality roughage is fed, but it also can be seen with foreign body obstruction of the pylorus. 4, 13, 14 goats appear to be more commonly affected than sheep, and boer goats are more commonly affected than angora goats. 15 pregnant animals may be more prone to this condition. clinical signs and diagnosis. affected animals are usually anorexic. they have mild distention of the ventral abdomen, and in some cases the firm abomasum can be palpated through the abdominal wall on the right side. 16 weight loss may be apparent. clinicopathologic evaluation may be normal, or mild hypochloremic metabolic alkalosis may be present, with elevated rumen chloride concentrations (more than 50 meq/l). 16 treatment. diet changes and mineral oil by mouth (po) are the most commonly employed treatments. abomasotomy can be attempted, but it has rarely been reported in small ruminants and does not usually improve the animals' long-term prognosis. when attempting abomasotomy, the clinician should perform the procedure with the animal in dorsal recumbency and under general anesthesia. the abomasum can best be visualized through an incision parallel and to the right of midline, caudal to the xyphoid process. the prognosis is poor. 13 prevention. dietary manipulation to improve feed or forage quality is the best mode of prevention. abomasal emptying defect is a disease that presents similarly to abomasal impaction but is recognized only in suffolk sheep. the underlying cause is unknown. unlike abomasal impaction, this disease is associated with concentrate feeding and often occurs around lambing time. the clinical signs are chronic weight loss, abdominal distention, and anorexia. clinical pathology and rumen chloride levels are the same as described for abomasal impaction. on necropsy the abomasum is greatly distended, and the contents may be liquid or dry. treatment with laxatives, cathartics, motility modifiers, and abomasotomy has been mostly unsuccessful. [17] [18] [19] azalea, laurel, and rhododendron toxicity members of the azalea, laurel, and rhododendron plant group produce andromedotoxins that alter sodium metabolism, resulting in prolonged nerve depolarization. these plants are cardiotoxic, but affected animals generally exhibit acute gastrointestinal upset. these evergreen shrubs produce thick, dark green leaves. they also have five-lobed, white to pink, saucer-shaped flowers that bloom around july. some of these plants are grown as ornamental shrubbery around homes, whereas others grow wild along streams, cliffs, and rocky slopes. they can be short or tall (as large as 10 m) and can form thickets. all parts of these plants are toxic. clinical signs. animals browsing a new area, those fed clippings from trimmed azalea hedges, and underfed, hungry animals given access to these plants are likely candidates for intoxication. animals that ingest as few as two or three leaves may show signs of salivation, grinding teeth, nasal discharge, colic, epiphora, and acute digestive upset within 6 hours of ingestion. as the intoxication progresses, animals become depressed and exhibit projectile vomiting, frequent defecation, and a slowed pulse. terminally intoxicated animals become paralyzed and comatose. some sheep and goats develop aspiration pneumonia secondary to intoxication. diagnosis. the diagnosis of this condition is usually based on clinical signs coupled with a history of ingestion of one of these plants and/or the discovery of these plants in the gastrointestinal tract. treatment. intoxicated animals may recover in 1 to 2 days without any therapy if the offending plants are removed from the diet. however, the administration of charcoal (2 to 9 g/kg po), atropine (0.06 to 0.1 mg/kg iv), other antiarrhythmic drugs, and iv fluids all may be indicated. to manage the aspiration pneumonia, the administration of antibiotics (penicillin 22,000 units/kg bid im) and oral magnesium hydroxide also may be beneficial. obviously, any existing dehydration should be corrected (see appendix ii). mountainous or hilly areas should be fenced. feeding shrubbery clippings is discouraged. diarrhea in lambs and kids is a complex, multifactorial disease involving the animal, the environment, nutrition, and infectious agents. decades of research have been devoted to the study of the pathophysiology of infectious diarrhea of calves; the pathology in lambs and kids is quite similar. despite improvements in management practices and prevention and treatment strategies, diarrhea is still the most common and costly disease affecting neonatal ruminants. [1] [2] [3] [4] some general preventive measures (e.g., improved sanitation) decrease disease no matter the cause. however, specific control measures such as vaccination require the definition of a specific cause of diarrhea. table 4 -2 lists the agents most likely to cause diarrhea in lambs and kids, tissues or other samples required for diagnosis, and commonly employed test methods. the color and consistency of the feces and any gross lesions can appear similar no matter the cause. therefore laboratory identification of infectious agents and tissue histopathology are key to establishing a diagnosis. because autolysis and secondary bacterial invasion of the gut begins within minutes of death, necropsy samples taken immediately from euthanized lambs and kids yield the most reliable diagnostic material. mixed infections with two or more pathogens are common, and pathogens that are a problem on a farm change from year to year. 3, 5, 6 in some cases an underlying nutritional deficiency or excess may occur concurrently with an infectious agent. therefore the clinician should be careful to take a variety of samples to ensure that all pathogens and predisposing factors involved are recognized; continued reevaluation of the causes of diarrhea is crucial. examination of several cases, with a focus on those in the acute phases, is important. although examination of antemortem fecal samples can be diagnostic, laboratory testing of tissue samples may yield better results. treatment and preventive measures specific to a particular disease are discussed with that disease in the following paragraphs. general supportive treatment and control measures are covered at the end of this section. four major pathogens cause diarrhea in lambs and kids during the first month of life: enterotoxigenic escherichia coli (etec), rotavirus, cryptosporidium species, and salmonella species. the relative prevalence of these infectious agents varies greatly among studies. this variance most likely results from differences in location, season, diagnostic techniques, and the occurrence of mixed infections. other, less common causes of diarrhea in neonates are giardia infections and nutritional diarrhea. pathogenesis. etec employs two virulence factors to cause disease. the first is the ability to attach and colonize the intestinal villi, which is accomplished via fimbria or pili. the most important fimbria in lambs are k99 and f41. 7, 8 the fimbrial antigens can be recognized from samples sent to most diagnostic laboratories and are important in diagnosing this agent as a cause of diarrhea. after the organism attaches to the villi, it produces the second virulence factor, enterotoxin. enterotoxin interferes with the normal physiology of the gut, with resultant diarrhea. 8 calves have an age-associated resistance, most likely related to the blocking of fimbrial attachment to the gut, so etec occurs mainly in calves less than a week old. 9, 10 the mode of infection is fecal-oral. clinical signs. etec is seen in lambs and kids less than 10 days of age but is most common at 1 to 4 days of age, so age-related resistance also may occur in these animals. 3, 7 it usually presents as an outbreak in lambs and kids between 12 and 48 hours of age. because etec causes a "secretory" diarrhea, bicarbonate loss in the diarrhea leads to severe acidosis, with lambs and kids quickly becoming dehydrated and recumbent. however, many infected animals die before developing diarrhea. affected neonates are depressed, stop nursing, and may show excessive salivation. fluid sequestration in the abomasum causes a "splashing" sound on movement.this condition results in high mortality if animals are not treated promptly. 7 diagnosis. fecal culture and serotyping for the k99 and f41 fimbrial antigens are the basis for diagnosis. because many nonpathogenic e. coli are normal gut inhabitants, simply culturing this organism is usually insignificant. 8 occasionally the bacteria do not express the fimbrial antigens in culture, so etec cannot be ruled out if the culture is negative for k99 and f41. 11 histologic evidence of colonization of the small intestine can support a diagnosis. treatment. supportive care consisting of fluid therapy with either oral, iv, or sc administration of a polyionic solution is the mainstay of therapy. the use of oral antimicrobial agents is controversial. although antibiotics may kill the etec, they also may interfere with normal gut flora. if fluid support is provided, the diarrhea usually subsides without antibiotic treatment. still, oral neomycin (10 to 12 mg/kg bid) or trimethoprim sulfa (30 mg/kg po) and systemic ampicillin (10 to 20 mg/kg im bid) or amoxicillin (10 to 20 mg/kg im tid) may be beneficial. nsaids are indicated to decrease inflammation of the gut and provide some analgesia. the use of flunixin meglumine (1 to 2 mg/kg im) has been shown to decrease fecal output in etec infections in calves 12 and appears to be beneficial in lambs. prevention. it is recommended that clinicians vaccinate ewes and does with bovine etec vaccine before they give birth to increase passive immunity. 3, 4, 8 monoclonal and polyclonal antibody products for calves may be beneficial during an outbreak if it can be given to lambs or kids within the first 12 hours of life. the use of neomycin (10 to 12 mg/kg po bid) in lambs that appear normal may help stop the progression of an outbreak. shearing ewes prepartum to minimize fecal ingestion by neonates and ensuring that newborns ingest adequate colostrum both help decrease the incidence of this disease. making sure that ewes and does give birth at a 2.5 to 3.5 body condition score increases the chance of adequate colostrum manufacture by the dam. pathogenesis. lambs and kids are infected with group b rotaviruses, whereas most other animals and human beings are infected with group a rotaviruses. 13 rotaviruses infect villus tip cells of the small intestine, which results in villus atrophy and malabsorptive diarrhea. 14 clinical signs. rotavirus generally causes diarrhea in lambs and kids 2 to 14 days old, but older animals also can be affected. young animals can become very depressed and dehydrated. 3, 13, 15, 16 diagnosis. detection of the organism by electron microscopy of fecal or colonic samples or by immunologic techniques on feces or tissue sections is the basis of diagnosis. 13, 16 because these organisms are sloughed with the villus tip cells they infect, and viral antigens are complexed with the lambs' and kids' antibodies, tissue samples from acutely infected animals are best. 17 rotavirus has been detected in animals without diarrhea, so other causes of diarrhea should be investigated as well. 4, 5 treatment and prevention. rotavirus is treated with supportive care. prevention by vaccination of ewes and does with bovine rotavirus vaccines before they give birth is recommended to increase passive immunity. 3 clinical signs. cryptosporidia can cause diarrhea in lambs and kids 5 to 10 days of age. 4, 19, 20 affected animals are often active, alert, and nursing. the diarrhea is usually very liquid and yellow. diarrhea can vary from mild and self-limiting to severe, especially with mixed infections. 4, 5, 19, 21 relapses are quite common, and this organism usually occurs as a component of mixed infections. diagnosis. acid-fast staining of air-dried fecal smears is a quick and easy method of diagnosis. examination under 40ϫ to 100ϫ magnification reveals round protozoa that have taken up the red color of the carbol fuchsin portions of the stain on a green background (figure 4-9 ). although they can be diagnosed by fecal flotation, their very small size (4-6 mm) makes this method difficult and subject to false negative results. 22, 23 both immunologic and polymerase chain reaction (pcr) techniques have been developed to improve detection limits. 22, 24 cryptosporidia also can be identified with histology. cryptosporidiosis is a zoonotic disease, and people can easily become infected from handling infected animals or feces. 18 prevention. no consistently effective treatment for cryptosporidiosis in ruminants has been identified. anecdotal reports suggest that decoquinate and monensin sodium may be useful in control of cryptosporosis. decoquinate (2.5 mg/kg po) may be very useful in prevention of cryptospirosis in goats and possibly kids. during an outbreak affected animals should be isolated from the rest of the flock. no new animals should be added to a pen in which the disease has been diagnosed. keepers should depopulate pens in which the disease has been diagnosed and attempt to clean the environment. cryptosporidiosis can be particularly difficult to control because of the organisms' persistence in the environment and resistance to most chemical disinfectants. however, ammonia (5% to 10%) and formalin (10%) seem to be most effective. 19, 25 feeders should be constructed to minimize fecal contamination. studies are currently underway to develop a vaccine for cryptosporidiosis in cattle. early results are favorable, and this may prove the best way to control the disease in the future. 26 this is potentially a zoonotic disease, and therefore clinicians and keepers should exercise great caution when handling affected animals. pathogenesis. the bacterial genus salmonella has thousands of serotypes, and all can potentially cause diarrhea in animals. salmonella can cause diarrhea in lambs and kids of any age. 3, 4 the microbes produce enterotoxins, are invasive, and cause severe inflammatory disease and necrosis of the lining of the small and large intestines. clinical signs. animals less than 1 week old are more likely to die acutely without clinical signs, whereas animals older than 1 week are more likely to have diarrhea. 4, 7, 27 an acute onset of fever, depression, tenesmus, and shock is occasionally observed. salmonella-induced diarrhea is more likely to contain blood. 4 this also is a zoonotic disease that warrants protective measures. a diagnosis of this condition is based on culture of the organism in feces or tissues and histologic examination of the small and large intestine. 28 more sensitive pcr techniques for identifying salmonella species in feces are being developed. 29 the diarrhea may occa-sionally contain fibrin, but many animals die before this is observed. clinicians may note leukopenia or leukocytosis in the cbc results. treatment. therapy for salmonella-induced diarrhea involves supportive care and possibly parenteral antimicrobial therapy. the use of antimicrobial agents is controversial and probably does not influence the gastrointestinal infection. however, because this is an invasive organism, parenteral use of antimicrobial agents may be beneficial in preventing septicemia. antimicrobial susceptibility patterns are difficult to predict for salmonella species, so antimicrobial therapy should be based on culture and sensitivity results. ceftiofur sodium (1.1 to 2.2 mg/kg im bid) or trimethoprim sulfadiazine (15 mg/kg sc sid) can be administered until antimicrobial sensitivity results are known. prevention. latent carriers of salmonella can potentially shed organisms to other animals, particularly when they are stressed. 4 newly introduced animals should be isolated for 1 month, and fecal culture should be considered. 4 bleach is an effective disinfectant to use during an outbreak. identification of carrier animals by fecal culture is recommended for herd problems. vaccine efficacy is questionable, and to date its effects have not been thoroughly evaluated in sheep and goats. giardia: giardia-induced diarrhea is more commonly seen in but not limited to 2-to 4-week-old lambs and kids. 4, 30 the diarrhea is usually transient, but infected animals can continue to shed cysts for many weeks, even when they are clinically normal. 22 ,31,32 therefore simply finding the agent in feces does not mean it is the cause of diarrhea, especially in older animals. however, these animals may be a source of infection for other animals and possibly humans. 22, 30 iodine-stained wet mounts of feces or tissue is the classic method of diagnosing giardiasis, but more sensitive immunologic techniques are now available. 22, 30 infected animals can be treated effectively with fenbendazole (5 to 10 mg/kg bid for 3 days or sid for 5 days). 22 giardia has historically been treated with metronidazole (50 mg/kg po sid for 5 days). however, use of this drug class in food animals is currently illegal in the united states.this is potentially a zoonotic condition. infectious agents are not the only cause of diarrhea in neonates. nutritional problems can result in diarrhea, but these causes are overshadowed in the literature because the resulting diarrhea is usually mild and subsides without treatment. nutritional diarrhea is most common in orphaned animals as a result of keepers offering poorquality milk replacers, making mixing errors, or feeding large amounts infrequently (see chapter 2) . diarrhea resulting from consumption of lush pasture or high-energy rations is a common occurrence. in most cases such diarrhea is self-limiting. the incidence of this form of gastric upset can be minimized by a slow introduction (over 2 to 3 weeks) to energy-dense diets. calves with infectious diarrhea that develop maldigestion or malabsorption can have secondary nutritional diarrhea from an inability to digest carbohydrates (lactose, xylose). 33,34 this has been reported in goats, and also is probably a cause of diarrhea in lambs. 35 diarrhea resulting from primary lactose deficiency also has been reported in calves. 36 calves on poor-quality milk replacers can develop an overgrowth of normal enteric e. coli, resulting in diarrhea. 37 if lactose intolerance is suspected, decreasing the amount of lactose fed and using commercially available lactose enzymes may alleviate signs. the most common cause of diarrhea in older lambs and kids is nematode infestation. this condition is discussed later in this chapter in the section on causes of adult diarrhea. other major causes of diarrhea in older lambs and kids are c. perfringens and coccidiosis. c. perfringens types a, b, c, and d can all cause diarrhea in lambs and kids, but type d is the most common agent. 4, 7, 38 pathogenesis. the disease occurs in peracute, acute, and chronic forms and is commonly called enterotoxemia or overeating disease. in the case of type c infection, a beta-toxin can cause acute hemorrhagic enteritis. type c infection is seen mostly in lambs or kids younger than 3 weeks of age. an epsilon-toxin is responsible for pathology in type d infections. enterotoxemia is usually seen in rapidly growing feedlot lambs on high concentrate rations. it also is associated with other feeding changes, including changes in type of pasture. however, it occasionally occurs with no reported dietary changes, particularly in goats. 4, 7, 39 this disease usually occurs in the fastest-growing and most well-conditioned animals. it can occur in vaccinated herds (again, more commonly in goats) so it should not be ruled out if a history of previous vaccination is present. 4 clinical signs. the peracute form of clostridial infection is characterized by the rapid onset of severe depression; abdominal pain; profuse, bloody diarrhea; and neurologic signs. death occurs within hours of the onset of signs. sudden death may occur without signs of diarrhea. the onset of neurologic signs followed by sudden death is more common in sheep, whereas goats are more likely to show signs of diarrhea before death. 4 similar but less severe signs are seen in the acute form of the disease. the chronic form occurs more commonly in goats. 4, 39 diagnosis. antemortem diagnosis is based on clinical signs. at necropsy, c. perfringens can be cultured from intestinal tissue samples. however, the significance of a positive culture can be difficult to interpret because these organisms can be present in the gut normally and then proliferate after death. histologic examination of sections of the gut can be helpful. identification of the toxins (namely the epsilon-toxin) in intestinal contents is required for a definitive diagnosis. 4, 7 because the toxin degrades within several hours of death, not finding the toxin does not preclude enterotoxemia as a diagnosis. 38 treatment. treatment is rarely effective but consists mainly of aggressive supportive care. c. perfringens type d antitoxins (15 to 20 ml sc) can be administered to animals during an outbreak of enterotoxemia if clinical signs are noted before death. the antitoxin may be more effectively used as a preventive in the face of an outbreak. during an outbreak any animals that have not been vaccinated should be given the antitoxin and vaccinated with the toxoid simultaneously; those previously vaccinated should receive a booster vaccination. prevention. routine vaccination should start at 4 to 6 weeks of age and be followed by a booster 3 to 4 weeks later. however, on farms where the disease has become endemic, lambs or kids can be vaccinated and given antitoxin during the first week of life. yearly vaccination, preferably a few weeks before the ewes and dams give birth increases colostral immunity in neonates and improves prevention programs. goats may not respond as well to vaccination as sheep, so biannual or triannual vaccination is recommended, especially in problem herds. 4, 38 vaccination with only c. perfringens types c and d and tetanus is superior to the use of more polyvalent clostridial vaccines. 4 reducing the energy density of the diet and avoiding sudden dietary changes or alterations of the feeding routine are crucial to prevention. reducing internal parasites, particularly tapeworms, may further reduce the incidence of these disorders. pathogenesis. coccidiosis is a protozoan parasitic disease that is a common cause of diarrhea in lambs and kids. it also may cause subclinical production losses. 19 clinical disease is often seen when some form of stress (e.g., dietary change, weather changes, parturition, weaning) is occurring on the farm or in the flock. eimeria species cause the disease in sheep and goats; each is infested with its own host-specific species. unlike cryptosporidium, which can be shed in feces in the infective stage, coccidia must sporulate outside the host to become infective. sporulation occurs under moderate temperatures and high moisture conditions. the nonsporulated and sporulated oocysts can survive a wide range of temperatures and may survive for years under certain conditions. clinical signs. lambs and kids are most susceptible to the problem at approximately 1 to 4 months of age, although younger animals may become infected. clinical disease is common after the stress of weaning, feed changes, or shipping. crowded conditions result in excessive manure and urine contamination, which is ideal for the buildup and sporulation of the oocysts. under these conditions, animals may be exposed to high numbers of infective organisms and develop diarrhea.the diarrhea in lambs and kids is usually not bloody, but it can contain blood or mucus and be very watery. anorexia, dehydration, weakness, rough hair coat, and death all may occur. 19 weight loss is common, and constant straining can result in rectal prolapse. in severe cases the disease becomes protracted because of necrosis of the mucosal lining. even if these animals are treated appropriately, the diarrhea continues until the intestinal mucosa heals, which can take several days to weeks. permanent scarring can result in chronic poor development, even if the diarrhea subsides. 19, [40] [41] [42] diagnosis. acute coccidiosis can be easily diagnosed from a direct smear or flotation of feces (figure 4-10) . in the chronic stages, most of the organisms have been shed and very low numbers are seen on fecal examination. because normal animals can shed small numbers of pathogenic species or large numbers of nonpathogenic species, interpretation of fecal examinations in the chronic stages of coccidiosis or in animals with diarrhea from other causes can be difficult. [40] [41] [42] in these cases the clinician should rule out other diseases before making a diagnosis of coccidiosis. blood analysis may show both anemia and hypoproteinemia. treatment. treatment of affected animals with clinical signs includes supportive care and administration of coccidiostats. all animals in the group should be treated during an outbreak. the use of coccidiostats has little effect on the existing infection, but it does prevent the spread of the disease from continued exposure to infective organisms. 40 many coccidiostats inhibit coccidia development and prevent disease if given prophylactically. 40 they are of little value if they are given after the onset of clinical disease. sulfa drugs appear to be clinically beneficial, but they may simply decrease secondary or concurrent bacteria-induced diarrhea. 40 because coccidia develop some resistance to coccidiostats, these drugs should be administered only before stressful events (e.g., shipping, weaning, parturition). 40 the drugs listed in table 4 -3 and trimethoprim sulfa (15 mg/kg orally sid for 5 days) are approved for use in the united states. 7, 41 prevention. control involves improved sanitation and possibly the use of coccidiostats. preventing overcrowding decreases the buildup of manure and infective oocysts. exposure to sunlight and desiccation are two of the most effective means of killing the organisms. minimizing stress and optimizing nutritional intake also are important. coccidiostats available in the united states are shown in table 4 -3 and appendix i. to avoid toxicity in growing animals, the clinician or keeper must carefully adjust dosages to the changing levels of feed intake as animals grow. all agents except amprolium should be fed for at least 4 weeks. 19, 40 this allows exposure and subsequent development of immunity to occur while preventing the detrimental effects of clinical disease. however, coccidia can become resistant to coccidiostats; fecal samples should be periodically evaluated after prolonged use of a particular product. anecdotal reports suggest amprolium resistance may occur on some farms. moreover, if amprolium is offered with a creep feed rich in thiamine, its ability to act as a thiamine antagonist may be compromised. year-round use of coccidiostats increases the potential for resistance. therefore they should be fed only during times of expected risk. 40 the inclusion of lasalocid (1 kg of 6% premix) or decoquinate (1 kg of 13% premix) in 22 kg of trace mineralized salt fed as the only source of salt for 30 days prepartum can reduce the number of oocysts shed in ewe or dam feces. this practice can reduce the coccidia contamination of pasture and thereby remove a source of infection for kids and lambs. the benefits of administering lasalocid and monensin beyond coccidia control include increased feed efficiency, enhanced growth rate, and decreased incidence of free gas bloat. however, if coccidiostats are included in either mineral or feed supplements, inconsistent or depressed intake may result in subtherapeutic drug dosing. lambs are resistant to infection in the first few weeks of life. exposure to the protozoa during this time confers immunity and resistance to later infections. 40,42 adenovirus, caprine herpesvirus, coronavirus, campylobacter jejuni, yersinia species, and strongyloides papillosus can cause diarrhea in lambs and kids of various ages. 2, 4, 6 enterohemorrhagic e. coli (ehec) and enteropathogenic e. coli (epec) also have been isolated in the feces of kids with diarrhea. 43,44 these e. coli types are k99and f41-negative. culture and serotyping of these organisms from feces and tissue samples with typical histopathologic lesions is diagnostic. although etec is not zoonotic, ehec and epec can potentially affect humans. although some causes of diarrhea have specific treatments, many animals need to be treated for dehydration and metabolic acidosis regardless of the inciting cause. animals with only mild diarrhea, especially mild nutritional diarrhea, may not require therapy unless they become dehydrated. if kids or lambs become less than 8% dehydrated and are only mildly depressed but still willing to nurse, they can be treated with oral electrolytes designed for calves. fluids can be administered by bottle or by tube if the animal will not nurse. the keeper or clinician should carefully adjust the amount of fluids for lambs and kids (250 to 500 ml, or 8 to 16 oz, as opposed to 4 l in a calf ). because most electrolyte solutions designed for calves contain glucose, after they have been mixed they should be refrigerated and any leftovers discarded within 24 hours. iv fluids may be needed to treat more severe dehydration. if the lamb or kid is too weak to stand, iv fluids are indicated. isotonic fluids containing electrolytes should be given to replenish losses. glucose can be added to fluids to make a 1% to 2.5% solution. sodium bicarbonate also may be administered, especially if the dehydration is severe. a rule of thumb is to give one fourth of the calculated fluid need (see appendix ii) as isotonic bicarbonate (1.3%). extra potassium (10 to 20 meq/l) can be added to fluids because most animals are severely dehydrated from diarrhea and depleted in potassium, even though their blood potassium levels may be elevated. if extra potassium is added, acidosis must be corrected concurrently. after correcting the dehydration, the keeper or clinician can offer oral electrolyte-enriched fluids to replace ongoing losses caused by continued diarrhea. removing milk or milk replacer from the diet is not recommended. young animals need nutrients, and even high-energy, glucose-containing electrolyte solutions are no substitute for milk. animals should continue to receive milk replacer in normal amounts or be allowed to nurse; they can be supplemented with oral electrolytes if necessary. animals being hand fed should be offered small amounts frequently to help minimize problems. electrolytes should never be mixed with milk, but should instead be given in separate feedings. if lactose deficiency is suspected, lactase drops or capsules (available in health food stores) can be added to milk or milk replacer. 35 nsaids (flunixin meglumine, 1.1 to 2.2 mg/kg iv; ketoprofen, 2.2 to 4.4 mg/kg iv) are beneficial, especially if toxemia is involved, as in etec, enterotoxemia, and salmonellosis. it is the authors' opinion that antimicrobial agents should be reserved for proven outbreaks of salmonellosis and for animals with other causes of diarrhea that do not respond to fluid therapy and nsaids; these drugs should only be administered parenterally. the use of oral coating agents and antacids is popular, but it has not been shown to be beneficial and is not therapeutically logical in light of the pathogenesis of these diseases. probiotics may be beneficial in reestablishing the normal flora of the small intestine. the authors' rule of thumb is that nothing should be given orally except milk, oral electrolytes, and probiotics. ensuring adequate intake of high-quality colostrum and minimizing stress are important for prevention of all neonatal diseases. a normal lamb or kid will stand and nurse within 45 minutes to 1 hour of birth. the ingestion of colostrum within 2 to 3 hours is essential in preventing hypothermia and hypoglycemia and decreasing the incidence of various diseases. lambs or kids born as twins or triplets, weak or injured neonates, those born during severe weather, those born from a dam with dystocia, and those delivered by cesarean section are all candidates for colostrum supplementation. if supplemental colostrum is provided, it should be good-quality colostrum from females that have tested negative for johne's disease, ovine progressive pneumonia (opp), and caprine arthritis-encephalitis (cae). mixing colostrum from several cows decreases the incidence of the "cow colostrum-associated" hemolytic disease sometimes seen in lambs. if the lamb or kid is unable to nurse, it should be tube fed 50 ml/kg of colostrum. the veterinarian or animal handler can sit comfortably holding the lamb or kid in sternal recumbency in the lap. a 12 to 14 french soft feeding tube is then lubricated, inserted into the side of the mouth, and passed slowly. if the tube is placed in the trachea, the lamb or kid will become uncomfortable and may shake and cough. the tube may be palpated on the left side of the throat. after the tube has been slowly passed to the thoracic inlet, colostrum can be administered by gravity flow (see chapter 6) . prepartum shearing of the dam may decrease the ingestion of feces by lambs. good sanitation of lambing and kidding areas is paramount in management programs that stress prevention. the presence of organic matter interferes with the effectiveness of many disinfectants, so removal and proper disposal of feces, carcasses, and placentas are essential. when disposing of waste material containing either cryptosporidium or giardia, the keeper should be careful to avoid contaminating water sources. infected animals should be isolated to prevent spread of the infection throughout the flock. in general, infected animals should remain in the environment where the infection was first diagnosed, because it is already contaminated. removing pregnant ewes or dams to a clean area before lambing or kidding helps minimize the continued spread of disease. if possible, lambs and kids already born but not showing clinical signs should be removed to a third area. if "safe" pastures are maintained for internal nematode control, they are ideal for use in an emergency situation to control these diseases. although some animals may appear normal, they may be incubating and possibly shedding the infective agents of a disease. if such animals are moved with pregnant females, they can be a source of contamination in a clean area. if healthy lambs and kids cannot be moved to a third, relatively safe area, they should be left with the clinically infected animals because they have already been exposed. 11 . schultheiss p: diarrheal disease in calves, large anim vet 47 (2) the differential diagnosis list for acute and chronic diarrhea in small ruminants is very long. 1 the most common cause of diarrhea in adult sheep and goats is parasitism; another major cause is johne's disease. both of these diseases are discussed in the following sections. other causes of acute diarrhea include rumen acidosis, peritonitis, endotoxemia, and ingestion of toxins. the list of toxins that cause diarrhea also is very long, and often the diarrhea is not the primary clinical sign. some of the more common toxins that produce diarrhea are arsenic, toxic amounts of salt, levamisole, copper, oak, selenium, and pyrrolizidine alkaloids. 1 salmonella species and chronic enterotoxemia can cause diarrhea in adult animals. coccidiosis can occur in adults under severe stress or in animals that possess limited immunity because of lack of exposure. hepatic and renal disease and copper deficiency are sometimes accompanied by chronic diarrhea, but weight loss is a more common sign in adults. etiology and pathogenesis. sheep and goats are infested with many of the same gastrointestinal nematode parasites as cattle, but these parasites tend to either be species-specific or have some amount of host specificity. sheep and goats are susceptible to the same nematodes and tend to share resistance to those that infect cattle and horses. the major gastrointestinal nematodes that parasitize pastured sheep and goats are haemonchus, ostertagia, trichostrongylus, cooperia, nematodirus, oesophagostomum, and bunostomum species. the acronym hotc comes from the first letter of each of the first four genera of parasites listed. the specific parasites that produce disease vary from flock to flock. climate usually determines which parasites are of clinical significance on a farm, and the weather determines when the parasites will be transmitted and infective. in much of the united states, haemonchus is the most significant parasite with respect to both clinical disease and anthelmintic resistance. most of these parasites affect the abomasum or small intestine of young, recently weaned animals and occasionally adult animals. sheep (and, to a lesser extent, goats) that are older than 18 months may be less susceptible. overcrowding and overgrazing with concurrent pasture mismanagement and malnutrition usually increase susceptibility to these parasites. inadequate nutrient or protein intake may result in greater susceptibility. 2 the life cycle appears to be similar in most of these parasite species. adults lay eggs that are passed in the feces; except for nematodirus species, the eggs hatch under favorable environmental conditions. the larvae go through several free-living developmental stages becoming infective. when the infective larvae are ingested by the host, the parasite completes its life cycle as an adult. trichuris eggs are the infective stage and can survive for extended periods in dry lots or barns. 4 however, trichuris is associated with minimal pathology. during dry environmental conditions, fecal pellets tend to trap the nematode larvae, whereas in wet conditions, larvae are released onto the pasture. therefore drought conditions followed by rain can result in devastatingly high rates of pasture contamination as larvae that have remained in fecal pellets are released. 2 very high environmental temperatures result in shorter survivability of some stages of infective larvae. most of the larvae have adapted the ability to over-winter, but can survive only for short periods outside the host during spring. nematodirus is an exception in that the developmental stages leading to infective larvae occur while the microbe is still encapsulated in the egg. however, compared with other species of parasite, nematodirus is of minor importance. nematodirus battus may pose a threat to young, newly weaned and therefore immunologically naive grazing lambs. the hookworm bunostomum also is different, as it may infect the host by either oral ingestion or percutaneous penetration. with the exception of the small intestinal parasite strongyloides, lambs or kids fed indoors or in dry pens tend to be free of parasites. clinical signs. all intestinal nematode infections produce similar signs, although infection with the more rarely encountered bunostomum may perhaps result in more profound anemia. if they infest the animal in sufficient numbers, all nematodes may cause poor growth, decreased feed conversion, decreased milk production, weight loss, diarrhea, anemia, ventral edema (bottle jaw), midline edema, and death. again, all these parasites can potentially result in disease, but haemonchus is the most devastating, particularly in more temperate regions. 2 diagnosis. antemortem diagnosis of nematode infestation is made by examining the feces for nematode eggs. although a direct fecal smear can be examined, the mere presence of parasite eggs is not helpful in determining the parasite load of an animal or animals. quantifying of the epg of feces is the best way of estimating parasite loads. the quantitative mcmaster's technique for determining the epg of feces is shown in box 4-1. common nematode eggs are shown in figure 4 -10. treatment and control program. after taking a thorough history of the previous parasite control program used on a farm and determining its effectiveness, the clinician can design and implement a new control program. 2,3 however, before deciding to implement a deworming program, the clinician should decide which parasites are in need of control and whether control of these parasites is cost effective in a particular flock. whenever possible, a dewormer that can reduce epg counts on the farm by 90% should be identified and used for at least a year. of all the parasite prevention programs, strategic deworming or a combination of strategic and tactical programs appear to produce the best results. 2, 4, 5 strategic deworming is used when most of the parasites are inside the animals and not on the pasture. 2 in northern climates, strategic deworming can best be carried out during the winter, when the nematode parasites are in a hypobiotic state. when environmental conditions are inhospitable for the survival of the infective larvae, some of the most pathogenic nematodes (e.g., haemonchus) may become hypobiotic; that is, they assume a state of arrested development. they may then mature to the adult stage when environmental conditions become conducive for the survival of their eggs or larvae. preventing or decreasing the numbers of maturing adults by killing the larvae before the periparturient rise in parasite egg production and pasture contamination is an excellent management tool. 4, 6, 7 unfortunately, in warmer, more temperate to subtropical environments, this method is less effective because larvae can survive the environment for longer periods. the addition of a protein supplement overlapping the expected periparturient rise has been shown to decrease the number of parasite eggs shed around the time of parturition. however, the cost of the protein supplement may outweigh its benefits. 8 a strategic program entails the use of an anthelmintic agent that is capable of killing encysted larvae. animals are then moved to parasite-free or safe pastures-areas in which the level of parasite contamination is too low to result in infection of grazing animals. examples of safe pastures include pastures where sheep or goats have not grazed for 3 to 6 months in the spring or fall, respectively (and depending on the climate); pastures used for hay production; new pastures (i.e., those used for corn, cotton, or other crops); and pastures grazed by horses or cattle. the use of safe pastures is paramount in any de-worming program. rotating pastures after less than 3 months during the warm part of the year or less than 6 months during cooler months is ineffective. 3 however, if pastures are tilled and replanted, by the time new grazeable forage is available, infective parasite larvae will be dead or significantly decreased. 3 an alternative to pasture rotation is to perform an initial strategic deworming before lambing or kidding and follow it with two to four more dewormings at 3week intervals throughout the lambing and kidding period. [9] [10] [11] treating lambs or kids at weaning and moving them to a safe pasture is a form of strategic deworming. 4 in lambs or kids to be sold at an early age, the administration of a single anthelmintic treatment followed by a move to a safe pasture may be all that is required. a "double treat and move" system is required for lambs kept for 12 to 18 weeks after weaning, particularly during the summer. 12, 13 this form of strategic deworming requires two treatments 6 to 8 weeks apart as well as two safe pastures. in northern climates where animals are moved to a dry lot or barn for the winter, a strategic anthelmintic administration as animals are moved off pasture can help reduce the parasite burden through the winter. 14 if this deworming is followed by minimal or no exposure to grazing areas and another dewormer is administered before the spring rise in fecal egg counts, the total parasite burden on spring pasture can be drastically reduced, effectively controlling parasites until summer or fall. tactical deworming programs are used to remove parasites from their hosts before they enter their reproductive phase and can contaminate the pasture. 4 an example of tactical deworming is treating animals 10 to 14 days after a rain, particularly if the rain has followed a drought. parasite transmission is worse in most flocks during this time as pastures become heavily contaminated. mcmaster's counts of more than 1000 epg in the spring or more than 2000 epg in the fall warrant tactical deworming. 2, 4, 7 opportunistic deworming and salvage deworming are usually less effective in long-term flock management. many times salvage deworming programs are used to save the lives of heavily parasitized animals. 4 if animals are dewormed only after showing signs of parasitism (e.g., bottle jaw, anemia), animal and flock productivity have already been depressed. deworming during handling for other procedures (e.g., castration, vaccination, shearing) is an example of an opportunistic program. it is convenient but is not conducive to long-term flock health. flock work should be scheduled around parasite management programs, not vice versa. 2, 14 suppressive deworming programs entail the use of anthelmintics at regular intervals, usually every 2 to 4 weeks. suppressive programs are labor-intensive, tend to be very expensive, fail to identify animals with superior immunity to parasites, and ultimately result in anthelmintic resistance despite initial effectiveness. 2, 4 as a general rule, the more frequently deworming occurs, the more quickly resistance is attained to anthelmintics. after deworming, only resistant parasites remain to infect the animal and they are able to reproduce freely, resulting in proliferation of resistant strains. 2, 4 using drugs that remain in tissues at inappropriately low concentrations and treating and retaining immunocompromised animals encourage the development of anthelmintic resistance. practices that ensure adequate dosages, proper treatment techniques, and appropriate types of anthelmintics should be emphasized. 2, 13 the clinician should do everything in his or her power to minimize the incidence of anthelmintic resistance, both through their own actions and by counseling owners in proper use of deworming drugs. the product development market for anthelmintics is the cattle industry. the small sheep and goat markets simply use drugs made available for cattle. because most available anthelmintics are highly effective in controlling parasites, anthelmintic resistance in sheep and goats must be avoided. the anthelmintics that have been used previously on a flock, the route of administration (e.g., po, sc, im, pour-on), and the length of use should be determined. few dewormers are approved for use in sheep and goats, but many approved for use in cattle and horses may be effective. 2, 7 if sheep graze with goats that harbor anthelmintic-resistant parasites, the sheep also may become infected. 4 however, if sheep are allowed to graze while the goats browse and the two groups rarely mingle, less parasite movement will occur between these species. resistance to macrolides (e.g., ivermectin, doramectin, moxidectin) does occur. resistant worms are generally not very tolerant of cold temperatures and therefore resistance to this drug class in northern environments is not as large a problem as it is in more temperate or subtropical zones. 15 although moxidectin is not approved for use in sheep and goats in the united states, it has been shown to be effective in cases where ivermectin resistance is encountered. 2 still, this drug should be avoided until all other anthelmintics have failed. craig 3, 4 has suggested that clinicians refrain from injecting or using pour-on macrolide preparations designed for cattle in small ruminants. this practice may enhance the development of resistant strains of some internal parasites because of inappropriately low drug absorption (with pour-on use) or long-term subtherapeutic levels (with injection). 4 if resistance to tetrahydropyrimidines (e.g., morantel, pyrantel) occurs in a flock, levamisole also may be ineffective. morantel and levamisole resistance in parasites appears to be sex-linked. therefore if animals are not exposed to these drugs for several years, reversion to susceptibility can occur. 3, 4 if resistance to one of the benzimidazole dewormers has been documented in a flock, some resistance to all members of that class is likely. 4 benzimidazole-resistant haemonchus species appear to be more virulent, produce more eggs, cause greater environmental contamination, and survive in the environment as free-living larvae for longer periods. benzimidazole-resistant parasites apparently do not revert to susceptible forms, even over long periods. therefore the clinician or keeper should exercise caution to minimize resistance. 4 benzimidazole efficacy can be improved by increasing dosages, dividing dosages into two treatments administered at 12-hour intervals, and instituting pretreatment fasting. 2 if resistance to numerous classes of anthelmintics occurs on a farm, combining two of the resistant classes of dewormers (fenbendazole and levamisole) has proven effective. 16 when using combined dewormers, the clinician should administer the full therapeutic dosage of each. anthelmintics are metabolized at different rates by sheep and goats. goats may require larger dosages of some dewormers than sheep. 7 craig 4 has suggested that if no dose rate is known for a particular anthelmintic for sheep or goats, the animals should be treated at twice the suggested cow dosage. pour-on anthelmintics designed for cattle tend to be of limited value when used topically on either goats or sheep. 2 table 17 -3. to maximize a parasite control program, anthelmintics that appear effective should be used for only 1 year before a new class of deworming drug is used. more frequent rotation (after less than 1 year) of anthelmintic agents hastens resistance and should be avoided whenever possible. whenever a flock is dewormed, animals should be treated based on the heaviest animal in the group and not on the group's average weight. underdosing can hasten the formation of parasitic resistance and therefore should be avoided. 4 holding the sheep or goats in a dry lot overnight or feeding only dry hay for 12 to 24 hours before and 12 hours after deworming appears to improve the efficacy of some orally administered anthelmintic agents (benzimidazole). limiting feed intake before deworming slows the rate of passage of ingesta through the bowel, enhancing drug effectiveness. 2, 13, 14 feed should never be withheld from sick or debilitated animals or late-term females. 2, 13, 14 most dewormers may effectively control adult or larval parasites but are ineffective against eggs. therefore animals should be kept on a dry lot for as long as 3 days after deworming, then moved to a safe pasture. use of this procedure minimizes parasite egg contamination of the new pasture because most of the egg-contaminated feces is voided within 72 hours of deworming. if more than one dosage appears on the drug label, the larvacidal dose should be used (fenbendazole at 10 mg/kg rather than 5 mg/kg). 2 anthelmintic effectiveness can be determined by comparing a mcmaster's fecal epg on the day of deworming with one taken 7 to 14 days later. if less than a 90% drop in epg is found, anthelmintic resistance exists and the animals should be switched to another class of dewormer. 2 although it is a controversial method, the authors have used this technique to identify anthelmintic effectiveness for many years and on many farms and ranches. 2, 14 the authors randomly collect feces from 5% to 10% (or a minimum of 10 animals) of the sheep or goats on the farm. a composite sample is prepared by combining equal amounts of stool from all animals. craig 3 has suggested that combining stool samples from many animals alters the accuracy of the tests because great individual variation in fecal egg counts occurs among animals. composite egg counts more accurately reflect parasite burdens in groups of young animals, and individual fecal examinations are more accurate in adults. 2, 4 still, the authors prefer to use composite samples unless obvious differences in stool character or body condition score exist among the sampled animals. anthelmintic resistance can be minimized by using drugs that reduce fecal egg counts by 90%. pre-and postdeworming changes in epg should be evaluated yearly or whenever resistance is suspected. 4 in vitro methods of assessing flock parasite resistance also are available at some diagnostic laboratories. in most in vitro tests, larvae are hatched from collected feces and the sensitivity of different anthelmintics is determined by larval exposure. these tests are very accurate but tend to be quite expensive. the most effective method to prevent anthelmintic resistance is to not use deworming drugs at all. 4 one of the most overlooked management procedures is the identification and selection of parasite-resistant sheep and goats. 2 some breeds or familial lines within breeds have excellent parasite resistance (e.g., gulf coast native and barbados sheep, some strains of spanish, pygmy, and tennessee myotonic-fainting goats). 2 one study 17 comparing boercrossed goats with non-boer crosses found that the boer crosses had significantly more parasite infestations. only a small number of flock members contribute the greatest amount of environmental parasite contamination because susceptible animals shed the most eggs in their feces. animals with the lowest epg in a flock may be those that possess the most parasite resistance. 4 salvage deworming programs should generally be avoided, but they may be used as aggressive selection criteria. that is, animals that do well with little or no deworming, particularly those grazing heavily contaminated pastures, should be identified and retained in the breeding flock. those that become infected should be dewormed to salvage them or save their lives and then sold when possible. proper record keeping and identification of all animals is paramount in selecting for parasite resistance. 2, 14 this aggressive approach can yield excellent results if it is carefully implemented, but devastating losses can occur if it is poorly managed. when introducing new animals to a flock, keepers should have biosecurity programs in place to limit the introduction of new or potentially anthelmintic-resistant parasites. new flock additions should be kept in a dry lot for 3 weeks and dewormed at least twice with two different classes of dewormers during this period. the effectiveness of the anthelmintic agent used should be deter-mined by fecal examination before the animal is allowed contact with the rest of the flock. 2 other nontraditional chemical methods of parasite control are used by some owners. some appear to be worthless (e.g., diatomaceous earth), but others (e.g., nematophagous fungi, herbal dewormers) may prove effective in some situations. pathogenesis. the most common gastrointestinal tapeworm of sheep and goats seen in north america belongs to the genus moniezia. cestodes (tapeworms) are usually of more concern to owners than clinicians, who generally consider them only incidental low-grade pathogens, particularly in adult animals. still, several 10to 20-foot-long tapeworms can compete with the host for nutrients, hinder normal gut motility, and excrete some toxic wastes into the host's gastrointestinal tract. mature tapeworm eggs are passed in the feces individually or protected in proglottides, which are usually visible to the owner. the eggs embryonate and infect a mite, a small pasture-living arthropod that serves as the intermediate host. a sheep or goat ingests the mite while grazing, allowing the tapeworm to complete its life cycle. clinical signs. tapeworms may rarely cause disease in lambs and kids less than 6 months of age. anecdotal reports suggest a cause-effect relationship between heavy tapeworm infestation and an increased incidence of c. perfringens enteritis, digestive disturbances (e.g., diarrhea, constipation), poor condition, and anemia. ulceration at the site of attachment may be seen on necropsy. rarely species of trypanosoma, the fringed tapeworm, may cause liver condemnation. a presumptive diagnosis can be made by finding proglottides in the stool, eggs on direct smears, or eggs on fecal flotations (see figure 4 -10).treatment with albendazole (15 mg/kg), fenbendazole (20 to 25 mg/kg), or praziquantel (10 to 15 mg/kg) may be effective either with a single treatment or with daily therapy (e.g., fenbendazole daily for 3 to 5 days). because of the free-living nature of the arthropod intermediate host, animals are readily reinfected after treatment, which may give rise to the false assumption that the therapy was ineffective. again, tapeworm infestation may result in disease, but often it is easier to blame the tapeworm segment seen in the stool as a cause of disease than to implicate the unseen thousands of hotc complex parasites in the abomasum and small intestine of the animal. 3, 14 johne's disease johne's disease (also called paratuberculosis) is a chronic wasting and diarrheal disease caused by the bacteria my-cobacterium avium subspecies paratuberculosis. transmission of the organism is primarily by the fecal-oral route. young animals are more susceptible to infection than adults. it can be transmitted through milk and placenta. pathogenesis. bacterial shedding in feces and milk and transplacental transmission is more common in animals showing clinical signs. [18] [19] [20] therefore the offspring of infected animals and especially the offspring of animals showing clinical signs are most likely to acquire the infection. after an animal is exposed, it will either clear the organism or develop a chronic, persistent infection. the infection is most commonly isolated to the ileal regions of the small intestine, where it causes granulomatous thickening of the intestine and subsequent malabsorptive diarrhea. infected animals may be asymptomatic for years. clinical signs. morbidity rates are low (approximately 5%), but for every animal with clinical signs, several exist in the subclinical state, and may be a source of both horizontal and vertical transmission. 18 both sheep and goats appear to remain asymptomatic until 2 to 7 years of age. the most consistent clinical sign in sheep and goats is chronic weight loss. chronic diarrhea occurs in approximately 20% of cases. 18 signs may appear with or be exacerbated by stress, especially after parturition. 18, 19 hypoproteinemia and chronic mild anemia are the only consistent clinicopathologic findings. because of their low protein levels, infected animals can develop submandibular edema. diagnosis is by culture of the organism from feces. unfortunately, this testing takes between 8 and 14 weeks, but it can detect 40% to 60% of clinically infected goats. sheep strains of johne's disease and some goat variant strains seem to be more difficult to culture in media used to identify cattle strains of the disease.therefore fecal culture in sheep and goats appears to be of limited benefit. 19, 20 a relatively inexpensive and easily performed method of identifying approximately 50% of all clinically infected animals is acid-fast staining of fecal smears. 18, 19 a pcr test of feces also is available, but its sensitivity is lower than that of fecal culture. good diagnostic results can be obtained with serologic testing for antibodies (e.g., agar gel immunodiffusion [agid], enzyme-linked immunospecific assay [elisa], complement fixation) in animals showing clinical signs. the specificity of all the serologic tests is greater than 95% in sheep and goats with signs of clinical disease, although the sensitivity is not as high. [19] [20] [21] therefore a positive serologic test in an animal showing clinical signs indicates that the animal has johne's disease. however, the disease cannot be ruled out with a negative test. sheep and goats appear to respond differently in regard to the formation of antibodies. sheep tend to develop antibodies in the later stages of the disease, whereas antibodies may be detected much earlier in the goat. the agid test appears to be the best serologic test currently available. 22, 23 the elisa and complement fixation tests can cross-react with corynebacterium pseudotuberculosis, making them of limited value in flocks with caseous lymphadenitis infections. 19, 24 necropsy diagnosis is based on the finding of thickened, corrugated intestines, especially in the area of the ileum. acid-fast staining of impression smears (taken from the ileum and ileocecal lymph nodes) can help yield a quick diagnosis. the staining of numerous clumps of acid-fast rods is highly suggestive of johne's disease. prevention. johne's disease has no effective treatment, so prevention and control are imperative. however, preventing the introduction of johne's disease into a herd can be difficult. because animals with subclinical infection may not shed the organism or may shed only small quantities of it, fecal culture is helpful only if a positive culture is obtained. the sensitivity of serologic tests of animals with subclinical disease is low and variable among flocks. 19, 20 negative test results in subclinically infected animals are common. however, the specificity of serologic tests remains high, and therefore a positive test is a valid reason to not purchase an animal. 19 because johne's disease also occurs in cattle, supplemental colostrum supplies should come only from dairy herds with no history of johne's disease. after johne's disease is diagnosed in a herd, several control measures can be taken. sanitation is important because the organism is highly resistant in the environment (able to survive more than 1 year under most conditions). 20 reduced stocking rates, frequent cleaning of pens, and use of automatic waterers decrease fecal transmission. keepers should cull the offspring of infected animals. culling animals based on the results of agid tests or fecal culture of the flock is recommended. animals should be tested at least once a year. more frequent testing as resources allow speeds the identification of infected animals. a vaccine for cattle is only available in some locales and clinicians or keepers may require official permission to use it. vaccine use does not eliminate infection, but it can decrease herd prevalence, delay the onset of clinical signs, and decrease cross-transmission by infective bacterial shedding in the feces. any cause of intestinal obstruction that occurs in other ruminants may occur in sheep and goats. most of these diseases produce abdominal discomfort and occasionally abdominal distention. diagnosis can be difficult because rectal palpation cannot be performed on small ruminants. abdominal radiographs and ultrasonography may help differentiate these diseases, but exploratory surgery may be required to obtain a definitive diagnosis and select appropriate treatment. intussusception is more common in young animals, but it can occur in adults. it occurs when one segment of the intestine telescopes into an adjacent segment. any portion of the intestine can intussuscept, but the ileum and ileocecal junction are the most common areas involved. when intussusception occurs, the lumen of the intestine narrows to the point of obstruction. the initiating cause is not always known. 1,2 it is associated with an intestinal mass in adults and enteritis in young animals. 1 oesophagostomum infestations have been implicated as a cause in sheep. 1 clinical signs. the initial complaint is colic (manifested as kicking at the abdomen, repeated rising and lying down, and vocalization) followed by low-grade pain. true colic signs are variable in lambs and kids. in some cases, after the initial colic episode subsides, animals show no evidence of pain until the abdomen becomes distended. the time between the initial intussusception and abdominal distention depends on where the blockage occurs. intussusception of the ileal area may take several days to cause bilaterally symmetric abdominal distention. fecal output is scant, and what little there is may be dark or tarry, or may contain mucus. dehydration becomes evident, hypochloremic metabolic alkalosis may develop and rumen chloride levels may increase with obstructions of the duodenum. diagnosis. abdominocentesis may yield fluid compatible with a transudate (increased protein concentration and leukocyte numbers). 1 radiography and ultrasonography reveal fluid-distended intestinal loops. occasionally the intussusception itself can be visualized with ultrasonography or palpable through the abdominal wall. if the disease is not treated, intestinal rupture and peritonitis can occur. treatment. surgical correction is required. if the intussusception is corrected early, the prognosis is good in the absence of peritonitis. fluid support is needed to correct dehydration and metabolic abnormalities. fluids should be administered iv until rumen function returns. ringer's solution with added calcium (approximately 25 ml calcium borogluconate per liter) and potassium (10 to 20 meq/l) is a good choice for fluid therapy. ingested foreign bodies or bezoars can obstruct portions of the intestines. 3, 4 the signs are similar to those of obstruction caused by intussusception and depend on the part of the intestine that is blocked. in some cases the obstructing body can be seen with radiography or ultrasonography. surgical removal is required for treatment. cecal volvulus and torsion of the root of the mesentery occur sporadically in sheep and goats. 1,3 extreme abdominal pain, rapid abdominal distention, and circulatory collapse are typical signs. immediate surgical correction and circulatory support are needed. atresia of the colon, rectum, and anus can all occur as congenital problems. the clinical sign of progressive abdominal distention usually is noted in the first week of life. atresia of the anus can be diagnosed on physical examination, but atresia of the colon and rectum may require contrast radiography for a definitive diagnosis. surgical establishment of anal patency can be performed for atresia ani. a permanent colostomy may be required for atresia of the colon and rectum. atresia of the anus and rectum are considered heritable in cattle. 1 in the authors' experience, atresia ani is more common in sheep than in goats. if surgical correction of atresia ani is attempted, the animal should be neutered or kept out of the breeding program because of the potential genetic basis for this condition. occasionally a slight bulge in the skin may occur where the anus should be located, especially in male lambs. ultrasonography can be used to locate a fecesfilled rectum. for surgical correction, the clinician should locate the area where the anus should be, prepare it with sterile technique, and infiltrate it with a local anesthetic. the surgeon then makes a circumferential incision to remove the overlying skin covering the rectum. an alternative is to make an x-shaped incision into the rectum. treated animals should be given mineral oil, dss, or stool softeners as needed. ileus of the small intestine is a pseudo-obstruction that occurs when there is an absence of intestinal motility. the animal's failure to pass ingesta leads to signs similar to intussusception. the cause of ileus is usually unclear, but it often occurs secondary to systemic diseases. the same elements that cause rumen stasis may potentially result in intestinal stasis and ileus. symptomatic treatment with nsaids for pain and inflammation and fluids for dehydration is usually curative. 1 however, if signs persist, surgical exploration is indicated to rule out true obstructive diseases. pathogenesis. infection of the peritoneal lining of the abdominal cavity may lead to septic peritonitis. common causes include uterine tears; rupture of the rumen or abomasum secondary to rumenitis, abomasitis, or abomasal ulcers; trocarization of the rumen for bloat; and rupture of the intestine secondary to obstruction. clinical signs. signs depend on the severity of the condition. abdominal discomfort and distention, dehydration, injected mucous membranes, depression, and death can all occur in cases of peritonitis. the presence of a fever is variable, both heart rate and respiration rate are usually elevated, and respiratory effort may be guarded. animals may be febrile early, but have a normal to low body temperature as the condition progresses. abdominal ultrasound can be useful in locating pockets of fluid for abdominocentesis, which usually yields fluid with increased protein concentration and leukocyte numbers. on occasion, intracellular bacteria are observed on cytologic examination. the presence of extracellular bacteria is not diagnostic because accidental enterocentesis can occur. culture of abdominal fluid and subsequent antimicrobial sensitivity tests are indicated for the implementation of proper treatment. the causative organisms vary depending on the source of the bacteria. rumen bacteria are typically gram-negative anaerobes, and e. coli and other enteric bacteria are common if the intestine is the source of infection. exploratory surgery may be required to diagnose a gastrointestinal rupture. the cbc can be normal but often shows an inflammatory leukogram and, in severe cases, a degenerative left shift. treatment. treatment includes the prescription of appropriate antimicrobial agents, the administration of nsaids for pain and endotoxemia, and fluid support for dehydration. the prognosis is guarded, especially if an intestinal rupture has occurred. pathogenesis, clinical signs, and diagnosis. rectal prolapse is more common in sheep than in goats. this evagination of the rectal mucosa and rectal structures (and possibly the descending colon) is usually associated with excessive straining. straining is seen in lambs with diarrhea caused by coccidiosis, salmonella, or dietary imbalances, in ewes or ewe lambs with vaginal prolapse, in males with urolithiasis, and in animals grazing lush forage (particularly legumes such as alfalfa and clover). it also can occur secondary to chronic coughing, short tail docking, and the use of growth implants. [5] [6] [7] rabies also can cause chronic straining and rectal prolapse. [5] [6] [7] [8] [9] regardless of the cause, after the rectal mucosa becomes everted and exposed, irritation of the mucosa causes further straining, which exacerbates the problem. venous drainage of the prolapse may be compromised, but the arterial supply usually remains intact and contributes to the swelling. rectal prolapses are graded as type i to iv, based on the portion of rectum and distal colon that is everted. 5 a description of these grades in shown in table 4 -4. treatment. correction may be cost prohibitive for feedlot lambs, and immediate slaughter is recommended. in more valuable animals, very mild, early cases can be treated with frequent application of hemorrhoidal ointment designed for humans and manual replacement of the prolapsed mucosa into the anus. the authors try to avoid applying purse-string sutures in the anus because they tend to serve as a nidus and result in further straining. however, if less aggressive therapies do not relieve the problem in 24 hours, a purse-string suture may become necessary, particularly in type i and ii prolapse. in all cases and modes of treatment, restricting feed for 24 to 48 hours and administering mineral oil is recommended. dusty feedstuffs (concentrates, pellets, hay) should be avoided because they may contribute to coughing, which exacerbates this condition. adding molasses to feeds and lightly wetting hay may help reduce problems with dust. purse-string suture is easily performed. the prolapsed tissue and perineal area are washed with mild soap and lubricated with petroleum jelly or hemorrhoidal ointment before the prolapse is replaced. 5, 9 after replacing the prolapsed mucosa, the clinician inserts a tubular object (syringe case, wooden dowel, gloved finger) into the rectum. he or she then places a purse-string suture of nonabsorbable suture material (3-5 nylon) in the skin around the anus, tightens it around the tubular object, and ties it off. the suture should be placed around the anus using a cutting needle, and entering and exiting at the 12 o'clock position. tying the knot above the anus ensures that less fecal soiling of the suture will occur. the clinician should tie the suture in a bow knot to allow easy identification over the next few days and then remove the tubular object. the suture should be tight enough to prevent prolapse but loose enough to allow feces to pass. the clinician should regularly reevaluate the animal and if possible loosen the purse-string suture at 24-hour intervals until no tension exists. after a full day of no tension, the suture can be removed. if animals continue to strain, an epidural anesthetic can be administered. petroleum jelly and hemorrhoid gels should be placed on the anus daily. 5, 9 the injection of counterirritants around the rectum (1 ml or less of lugol's iodine) either alone or in conjunction with anal purse-string suturing is a quick and inexpensive treatment. 5, 6, 9 the clinician inserts an 18-gauge needle (5 cm) deeply into the skin around the anus at 12, 3, and 9 o'clock. an injection at the 6 o'clock position should be avoided because swelling around the urethra can result in obstruction. for more severe cases, submucosal resection or rectal amputation of tissue may be necessary. 5, 9 rectal amputation can be performed with a prolapse ring or suture technique. 7 prolapse ring usage is a salvage technique. the clinician inserts the prolapse ring into the rectum and places an elastrator band or suture around the area to be amputated to induce vascular compromise and necrosis of tissue. if a ligature is used, it should be tightened to allow purchase on the tube or ring. a fibrosis is induced just proximal to the band or suture, and mucosa subsequently grow across the areas. 5 strictures, peritonitis, and abscesses are possible complications, but this technique may be useful as a field procedure. submucosal resection can be performed under epidural analgesia after the prolapse and the perineal area have been surgically prepared. the clinician places two spinal needles (9 to 10 cm) at 90-degree angles to each other 2 to 4 mm distal to the anal sphincter and through the entire prolapse. 5 a circular incision is made 2 to 4 mm distal to the spinal needles through the mucosa and around the outside of the anus. another circular incision is made just distal to the caudal extent of the prolapse into the point where the mucosa reflects on itself on the innerside of the prolapse. the clinician connects these two incisions with a longitudinal incision parallel to the prolapse and dissects the mucosa between the circumferential incisions. 5 the mucosal edges are then sutured with a simple interrupted pattern using a suitable absorbable suture material. after completely suturing the mucosal surfaces, the clinician removes the two spinal needles and places a purse-string suture in the anal sphincter. placement of the suture and follow-up care are the same as described for the purse-string suture technique. submucosal resection decreases the incidence of both peritonitis and stricture formation compared with other surgical techniques, but it is expensive. 5 in all of these techniques, a caudal epidural anesthetic (2% lidocaine, 0.5 ml per 45 kg) is recommended to decrease straining and ease pain from the procedures. 6,7 a xylazine epidural (0.01 to 0.03 mg/kg as sufficient [qs] to 2 ml with 2% lidocaine) may give longer relief (approximately 4 to 6 hours) from straining than lidocaine. an alcohol epidural also may prevent straining for extended periods. either isopropyl alcohol or ethanol can be used to demyelinate the motor and sensory nerves. 5 this type type i small, circular amount of submucosal swelling good prognosis if there is no damage to mucosa; protrudes through anus; probing reveals a pocket purse-string suture, iodine injection, submucosal or fornix just inside anus resection type ii slightly more circular submucosal and mucosal good prognosis if treated quickly and no mucosal swelling, possibly containing retroperitoneal rectal damage; purse-string suture, iodine injection, tissue from anus; probing reveals a pocket just submucosal resection, rectal amputation inside anus type iii complete prolapse containing part of the if there is vascular injury to the descending colon, retroperitoneal structures of the rectum and the prognosis is guarded to poor; submucosal descending colon; probing reveals a fornix just resection or rectal amputation are the methods of inside anus; the affected portion of the descending choice colon does not prolapse through the anus type iv the descending colon appears as a tube, and has if there is vascular injury to the descending colon, intussuscepted through the rectum and anus; prognosis is poor; abdominal exploration may unlike the previous types, in this case a probe be required to determine the extent of damage to or finger can be inserted into the prolapse through the descending colon the anal sphincter for a distance of 5 to 10 cm of anesthesia can be permanent and therefore should be used only for animals intended for slaughter. because of the potential for some loss of sciatic nerve function, the clinician should perform a test injection of a local anesthetic (2% lidocaine) before using alcohol. if the epidural appears effective and no ataxia or muscle weakness of the rear limbs occurs, the clinician can inject a mixture of equal parts of lidocaine and alcohol into the sites where the test epidural was performed. possible problems with alcohol epidural anesthesia include injection site necrosis, sciatic nerve dysfunction, and the inability to void feces. 5 regardless of the type of epidural used, the clinician clips, washes, and dries the area before placing a small needle (20-to 21-gauge [2.6 cm]) in the most cranial yet moveable intracaudal vertebral space-usually c1 to c2 or c2 to c3. the needle is placed on the dorsal midline, with the needle 90 degrees to the skin and the hub moved slightly caudal, and then slowly advanced. liver abscesses usually occur as a result of chronic rumenitis in cattle, but they are rare in sheep and goats. they can occur in feedlot lambs and kids and other animals fed rations high in grain. in lambs and kids, septicemia or extension of an umbilical vein infection can cause liver abscesses. 1 in most cases, however, liver abscesses are an incidental finding. weight loss, anorexia, depression, and decreased production (growth, milk) may occur. in adults, corynebacterium pseudotuberculosis is the most common cause. actinomyces pyogenes and fusobacterium necrophorum also are cultured from abscesses. [1] [2] [3] liver enzymes may or may not be elevated. diagnostic ultrasonography of the liver may help detect abscesses, especially if they are numerous and widespread. however, no specific treatment or control measure is available. many of the preventive protocols used for feeder cattle apply to the control of abscesses in sheep and goats. these include slowly introducing concentrates into the diet, offering long-stemmed hay free choice, and including rumen buffers (alkalinizing agents) and antimicrobial agents in the feed. pathogenesis. fatty liver occurs in conjunction with pregnancy toxemia in ewes and does during the last month of gestation. it is most common in thin or obese ewes or does with a single large fetus, twins, or triplets. 1 during late gestation, particularly in obese females, the abdominal space is filled with accumulated fat and an ever-expanding uterus. because of the lack of rumen space, these females have difficulty consuming enough feedstuffs to satisfy energy requirements. in most management systems, late gestation occurs during the winter months, when less pasture is available and poorer-quality feedstuffs are offered. energy requirements for ewes and does carrying twins or triplets is greatly increased during the final 2 months of gestation because 70% to 80% of fetal growth occurs during this time. ewes with twins require 180% more energy, and those with triplets need 200% to 250% more dietary energy. pregnancy toxemia also occurs in association with anorexia caused by other diseases (foot rot, opp, cae) or sudden stresses (feed or weather changes, predator attacks, hauling). whatever the initiating cause, a period of anorexia and lack of sufficient energy intake result in a negative energy balance. these animals begin to mobilize body stores of fat and transport them to the liver. in the liver, fat is catabolized to glycerol and free fatty acids (ffas). ffas can be used in the citric acid cycle (krebs cycle) as an energy source, but not in the direct formation of glucose. anorexic animals have less ruminal substrate available for production of the glucose precursor propionic acid. however, oxaloacetate, which is an integral part of the citric acid cycle, is removed from the cycle and converted into glucose. depletion of oxaloacetate inhibits the normal citric acid cycle's function, inhibiting the use of ffas. as the pool of ffas increases, they are converted to ketone bodies or repackaged into lipoproteins. because ruminants are not efficient at transporting lipoproteins out of the liver and back to the adipose stores, the lipoproteins overwhelm the liver's ability to handle this massive buildup, resulting in a fatty liver. because less substrate is available for glucose formation, more oxaloacetate is "cannibalized" from the citric acid cycle, further inhibiting the body's ability to use ffas. this in turn causes the continued accumulation of ketone bodies. hypoglycemia, hy-perketonemia, and potentially uremia and death can occur. clinical signs. animals suffering from fatty liver or pregnancy toxemia become anorexic and depressed, display altered behavior, and become recumbent. some are constipated, grind their teeth, have a ketone smell to their breath, and suffer from dystocia. neurologic signs include blindness, circling, incoordination, star-gazing, tremors, and convulsions. 4, 5 death can occur if the condition is left untreated. in the case of in-utero fetal death, maternal septicemia-endotoxemia and death are common sequelae. diagnosis. diagnosis is based on clinical signs, the presence of multiple fetuses, and typical clinicopathologic findings. cbc results may be normal or show an eosinophilia, neutropenia, and lymphocytosis. these animals may or may not be hypoglycemic, but ketoacidosis, hypocalcemia, and hypokalemia are common. 2, 4 liver enzymes are usually within normal limits but occasionally may be increased. azotemia, both from dehydration and secondary renal disease, is a common finding, and a fatal uremia may occur. blood concentrations of ß-hydroxybutyric acid greater than 7 mmol/l are consistent with pregnancy toxemia. urinalysis will be positive for both ketones and protein. urine is collected from sheep by holding the nares and from does by frightening them and then allowing them a perceived escape when they stop, squat, and void. although not commonly performed, liver biopsy can help determine the extent of fatty infiltration. this syndrome must be differentiated from hypocalcemia, hypomagnesemia, polioencephalomalacia, encephalitis, lead toxicity, and cerebral abscesses. treatment. very early cases (before the animal exhibits recumbency) may be treated with oral or iv glucose. a balanced electrolyte solution with extra calcium (25 ml of a 23% calcium borogluconate per liter), potassium (10 to 20 meq/l), and 5% dextrose is needed. in some cases, sodium bicarbonate is valuable in treating acidosis (see appendix ii). energy intake must be increased, and propylene glycol can be administered (15 to 30 ml every 12 hours) as a glucose precursor. rumen transfaunation and supplementation with vitamin b complex (including vitamin b 12 , biotin, niacin, and thiamine) also are recommended. after females become recumbent, treatment must be very aggressive. removal of the fetuses is crucial in these cases. chemically inducing parturition (by administering 2.5 to 10 mg of prostaglandin f 2a or 0.75 mg/45 kg of cloprostenol in does and 15 to 20 mg of dexamethasone in ewes) and giving the ewe or doe medical support (fluids, b vitamins, glucose) while waiting is a useful protocol in some cases. unfortunately, during the time before parturition, endotoxemia from dead fetuses further compromises the female. for this reason, the authors recommend immediate cesarean section on depressed moribund animals (see chapters 6 and 16) . the owner should be forewarned of the poor prognosis for animals already in a moribund state. fluid support during and after surgery is crucial. regardless of the therapeutic plan, the animal should be offered a palatable, energy-rich, highly digestible feedstuff. the keeper and clinician should take care to minimize the risk of a confounding disease during convalescence (e.g., lactic acidosis, polioencephalomalacia). prevention. fatty liver and pregnancy toxemia can be prevented through proper nutrition. maintaining animals in proper body condition throughout the year and making sure energy and protein levels are adequate in late gestation (see chapter 2) are two key preventive measures. 2, 4 the owner/manager should be taught to assess body condition in individual animals and should maintain emergency stores of feed in case of severe weather or natural disasters. the requirement for energy may be one and a half to two times maintenance for single fetuses and two to three times maintenance for multiple fetuses. prevention of concurrent disease that may further increase energy demands or cause anorexia (e.g., intestinal parasitism, foot rot) is crucial. the keeper should take care to increase the grain portion of the diet slowly because anorexia from rumen upset can lead to this disease. 2 ewes should be offered 0.5 to 1 kg of a cereal grain (corn, oats, barley, or a combination) every day during the final months of gestation; does can be offered 1 ⁄2 to 1 kg of grain. keepers should maintain ewes and does at a body condition score of 2.5 to 3 (see chapter 2) throughout gestation and evaluate the animals' energy every 2 to 4 weeks. ultrasonography can help identify females with multiple fetuses. these animals should be separated into groups and fed accordingly. ultrasonographic determination of fetal numbers is best accomplished between days 45 and 90 after breeding with a 3.5 mhz transducer; a 5 mhz transducer produces better results between days 45 to 50. either type of transducer may be of value and these windows of time may be expanded by the ability of the operator (see chapter 6) . determination of fetal numbers may be enhanced by shearing the hair or fiber in front of the udder, applying a coupling substance to the skin, and viewing as much of the abdomen as possible, building a mental image of its structures and the number of fetuses while systematically moving from one side of the posterior abdomen to the other. keepers and clinicians should ensure that ewes are healthy and free of chronic diseases (e.g., opp, cae, foot rot, chronic parasitism) and that a good-quality trace mineral salt mixture is available free choice. the addition of lasalocid (0.5 to 1 mg/kg/day) or monensin (1 mg/kg/day) to the feed or mineral mixture enhances the formation of the glucose precursor propionic acid and improves the efficiency of feed use. however, monensin should be used with caution because toxicity may occur; the agent should comprise no more than 30 ppm of the complete diet. the inclusion of niacin (1 g/head/day) in a feed supplement or mineral mixture helps prevent pregnancy toxemia. supplementation with lasalocid, monensin, or niacin should begin 2 to 4 weeks before the females give birth. shearing in the last trimester also is recommended in ewes. 5 many sheep producers routinely clip the wool around the vulva. if complete body shearing is performed, the incidence of fatty liver or pregnancy toxemia may be decreased. sheared sheep require less energy to walk and graze. sheared ewes also tend to shiver on cold days, exercising the enzyme systems that promote the more efficient use of ffas as energy substrate. these ewes tend to seek shelter during cold weather, which may decrease lamb losses resulting from hypothermia. obviously, if ewes are to be shorn, keepers should make adequate shelter available. keepers should avoid hauling or moving females during late gestation. proper predator control measures should be maintained. good hoof care programs should be in place on farms or ranches where grazing is the predominant form of nutrient intake. sheep and goats should have their teeth checked to ensure good dentition before the breeding season. animals with poor teeth should be culled. measuring serum b-hydroxybutyric acid concentrations is useful in assessing energy status in ewes. values of 0.8 to 1.6 mmol/l suggest a negative energy balance. keepers should take steps to correct the problem by feeding better-quality, more digestible feedstuffs. white liver disease is a form of fatty liver disease reported only in angora and angora-cross goats and sheep. it is associated with cobalt deficiency. pathogenesis. cobalt is needed by rumen microflora to produce cyanocobalamin, or vitamin b 12 , which is a coenzyme for methylmalonyl-coa mutase. in turn, this enzyme is needed to convert propionate to glucose through the krebs cycle. cobalt deficiency leads to the accumulation of methylmalonyl-coa, or methylmalonic acid, which is converted to branched chain fatty acids that accumulate in the liver. 2, 6 high-grain diets that are fermented to propionate coupled with deficient or marginal cobalt intake may predispose to this condition. 2, 6 white liver disease has not been reported in the united states, but ill thrift from cobalt deficiency has been observed. it is therefore possible that the disease goes unrecognized. 1 clinical signs. signs are most commonly seen in young animals, and include ill thrift, anorexia, and diar-rhea; sheep may exhibit photosensitization. clinicopathologic findings include a macrocytic, normochromic anemia and hypoproteinemia. 1, 2 diagnosis. abnormal serum or liver concentrations of vitamin b 12 or liver cobalt are the basis of diagnosis. liver cobalt concentrations on a dry matter basis of 0.08 ϯ 0.02 ppm were reported in goats with white liver disease, compared with 0.53 ϯ 0.11 ppm in controls. 6 treatment and prevention. sheep can be treated with oral cobalt (1 mg/head/day) or vitamin b 12 injections. the condition can be prevented by including cobalt in the ration by feeding a good-quality trace mineral salt. 2 both fasciola hepatica and fascioloides magna can infest sheep and goats. the disease occurs along the gulf coast and in the pacific northwest and great lakes areas. clinical signs. f. hepatica infestation usually causes acute disease in sheep and goats but can present as a chronic condition. chronic disease is the result of the mature flukes in the bile ducts and is manifested in depressed growth and milk production. acute disease occurs when large numbers of immature flukes migrate at once, particularly in animals with limited immunity to flukes. signs include anorexia, depression, weakness, dyspnea, anemia, ascites, colic-like signs, dry feces, and sudden death. the clinical signs are identical to those of nematode infestations (i.e., chronic weight loss, ill thrift, diarrhea, anemia, hypoproteinemia). similar but more severe signs occur with f. magna infection, which is usually fatal. 2, 5, 8 diagnosis. antemortem diagnosis of fluke infestation can be difficult. finding eggs in feces is diagnostic for f. hepatica. eggs are only produced by adults and not in great numbers, so a negative fecal test cannot preclude acute or chronic fascioliasis. fluke eggs do not float in routine fecal flotation methods used for nematode diagnosis; a sedimentation technique should be used for suspected fluke infestations. to perform a sedimentation test, the clinician mixes 2 to 3 g of feces with 200 ml of tap water and strains the mixture through a tea strainer into a beaker. the sediment can be examined 15 minutes later under a dissecting microscope. eggs are light yellow to golden and have an operculum at one end (see figure 4 -10). f. magna does not mature, so eggs are not produced and fecal examination is of no value. most fluke infestations are discovered by finding the flukes at necropsy or slaughter. an elisa test may be available in the future. 2, 5, 8 cbcs of affected animals may indicate eosinophilia and anemia. increased liver enzymes and hypoalbuminemia also are occasional findings. because antemortem diagnosis is difficult, the clinician should institute fluke treatment after ruling out other differential diagnoses if the possibility of fascioliasis exists. if fascioliasis is diagnosed at necropsy, the remaining animals in the herd should be treated. because flukicides available in the united states are highly effective only against mature flukes, the timing of treatment is important. in the southern portions of north america the snails are ingested in the spring and the flukes migrate in the summer and mature in the fall. in cooler, northern climates, snails may remain active during summer, so flukes can mature in the fall and into the winter. clinicians should begin treatment in the southern united states in the late summer or early fall. a single treatment in late winter or early spring is commonly used in the northern climates of north america. albendazole (15-20 mg/kg orally) and clorsulon (7 mg/kg orally, 2 mg/kg sc) are very effective against adult f. hepatica. 2, 9, 10 clorsulon has no efficacy against nematode parasites but is highly efficacious against both adult and late-stage immature flukes. albendazole (15 mg/kg orally) is somewhat useful in controlling f. magna at 8 weeks after infestation, and clorsulon is effective only at very high dosages. [11] [12] [13] unfortunately, neither agent can kill 100% of f. magna, and only a few remaining flukes can be fatal. control of fluke infestations is difficult, although timely treatment of animals can decrease infec-tions in successive years. decreasing exposure is the key to control. eliminating the snail is impractical, but fencing off low-lying areas may prevent ingestion. depending on local fluke life cycles, keepers should avoid grazing animals on areas with high fluke populations during peak infection times. areas where water stands or flows over grazing pastures, streams, and irrigation ditches (particularly those with clay soil) are high-risk zones. cysticercus tenuicollis is the larval stage of the dog tapeworm taenia hydatigena, of which sheep and goats are intermediate hosts. the larval stage migrates through the liver, then attaches to the liver or other abdominal organs and causes black, winding tracts and cysts in the liver. acute disease occurs only with large numbers of cysticerci and is characterized by depression and weakness resulting from liver damage. the chronic cystic stage is usually asymptomatic. no treatment is available and control is problematic because it requires treating infestation in dogs and preventing contact with dogs. 1,2,5 pathogenesis. copper (cu) toxicosis is more common in sheep than in goats. goats appear closer to cattle than sheep in their ability to store and handle cu and resist toxicosis. toxicity results from chronic accumulation in the liver from the ingestion of excess cu in relation to molybdenum (mo) or sulfate in the diet. in sheep, a cuto-mo ratio greater than 10ϻ1 leads to the accumulation of excess cu. the most common sources of excess cu in sheep and goats are trace mineral mixtures and feeds formulated for cattle or horses. clinical signs are often absent during the chronic accumulation phase. acute disease is seen when cu is suddenly released from the liver in large amounts. stress usually precipitates this acute phase. acute release and subsequent high blood cu concentrations cause an acute hemolytic crisis, resulting in anemia, hemoglobinuria, and acute renal failure. existing hepatic disease (such as that caused by liver flukes) may predispose animals to this condition. some breeds seem to be prone to cu absorption and storage problems (merino sheep), whereas others tend to be more resistant and prone to deficiency (pygmy goats) (see chapters 2 and 3). clinical signs. anorexia, depression, diarrhea, and weakness are all signs of cu toxicity. many affected animals are found dead with hemolysis and icterus. signs of abdominal pain and diarrhea are sometimes present. port wine-colored urine is evidence of hemoglobinuria. hemoglobinemia produces icterus of the mucosal membranes and fever. diagnosis. on clinicopathologic examination, anemia, hemoglobinemia, hyperbilirubinemia, increased liver enzymes, and azotemia are present. urinalysis reveals hemoglobinuria and isosthenuria. the combination of azotemia and isosthenuria indicates acute renal failure. definitive diagnosis of acute disease requires measurement of cu concentrations in serum. normal blood cu concentrations are approximately 50 to 200 mg/dl in sheep and goats. 2, 5, 14 these concentrations increase 10to 20-fold with an acute hemolytic crisis. 5 on necropsy, kidney cu concentrations are the most diagnostic because liver concentrations may be normal from release into the bloodstream. generally kidney concentrations greater than 100 ppm and liver concentrations greater than 350 ppm on a dry matter basis are diagnostic. 2, 5 if tissue copper is reported in wet weight, the conversion to dry tissue weight can be estimated by multiplying the tissue concentration by a factor of 3.5 treatment. treatment of acutely affected animals is often futile. it consists of supportive therapy for the acute renal failure and anemia and attempts to lower liver cu stores. fluid therapy for the acute renal failure (see appendix ii) is of therapeutic value, and a blood transfusion may be needed if the pcv drops precipitously. ammonium tetrathiomolybdate (1.7 mg/kg iv or 3.4 mg/kg sc on alternate days for three treatments) is the most economical agent for treatment for acute cases. in valuable animals, d-penicillamine (26 to 50 mg/kg bid or 52 mg/kg sid po for 6 days) increases urinary cu excretion. trientine is used in human beings, but has shown variable results in sheep. 15 treatment of the remainder of the flock should include the administration of ammonium molybdate (50 to 500 mg/head/day po) and sodium thiosulfate (300 to 1000 mg/head/day po) for 3 weeks. 15 stress should be minimized, so keepers and clinicians should delay routine maintenance procedures such as deworming and hoof trimming until after treatment. the offending source of cu should be eliminated. prevention. avoiding high dietary cu (more than 10 ppm), a high cu-to-mo ratio (greater than 10ϻ1) in the feed, cu-containing foot baths, and other sources of cu is crucial. including supplemental mo in the diet to lower the cu-to-mo ratio to 6ϻ1 to 8ϻ1 is beneficial. this requires 2 to 6 ppm of mo in many instances. often too much emphasis is placed on the trace mineral component of the diet. the clinician should be aware that even if no cu is added to the trace mineral mixture and the element does not appear on the product label, the mineral mixture may still contain cu. many components of mineral mixes are contaminated with cu (zinc sulfate may contain 400 ppm of cu, dicalcium phosphate may contain more than 30 ppm of cu). therefore the clinician needs to perform a dietary analysis to find and correct the problem. pathogenesis. the liver is vulnerable to toxic insult because one of its major functions is detoxification. the most common plants that are gastrointestinal and liver toxins are shown in table 4 -5. clinical signs depend on the cause. acute, severe toxicity is more common with chemical toxicosis, whereas plant toxins usually cause chronic disease. a thorough history is important and in many cases inspection of the animals' environment is required. clinical signs. the clinical signs of toxic hepatitis can be vague. animals may only show anorexia and depression. icterus is more common with hemolytic diseases and is not always seen with liver disease. photosensitivity is a common clinical feature in ruminants and hepatoencephalopathy also can occur. clinicopathologic data are more helpful in diagnosing acute toxicity. serum ast and ldh levels can increase with hepatocellular necrosis but are not liverspecific, so muscle injury and disease must be ruled out. these enzymes also increase if serum is not separated from a blood clot in a timely fashion. 1 increased levels of alkaline phosphatase (ap) and ggt indicate biliary stasis. ap also is not liver-specific, but increased serum levels of ggt are very specific for liver disease. ggt also increases in some hepatocellular diseases, so testing for its normal concentrations is important. 15 unfortunately, all of these enzymes can be normal with liver disease, especially if it is chronic. hyperbilirubinemia, hypoglycemia, low blood urea nitrogen (bun), and hypoalbuminemia are not always evident as classically taught. if hepatoencephalopathy is suspected, blood ammonia concentrations may be elevated. blood ammonia analysis may be impractical in the field because the blood should be kept on ice, and the test should be performed within 30 minutes of collection. to enhance the accuracy of blood ammonia analysis, the clinician should collect blood from a normal control animal for comparison. ammonia concentrations three times those of the control animal are diagnostic. 16 liver biopsy remains the most valuable tool in diagnosing liver disease. although clotting dysfunction may occur in liver disease, it is an uncommon complication in ruminants and should not discourage the clinician from performing a liver biopsy. treatment. if the intoxication is caught in the acute stage, activated charcoal (500 g per adult animal) can be given. supportive care, especially fluid support with dextrose solutions, is the mainstay of therapy. low-protein diets may suppress ammonia production temporarily, but they can be detrimental over time depending on the production status of the animal. if photosensitization occurs, animals should be housed indoors if possible, and broad-spectrum (systemic or topical) antibiotics may be necessary to control secondary bacterial dermatitis. corticosteroids (dexamethasone 0.1 to 1 mg/kg iv or im) may be indicated in early cases of photosensitization to decrease inflammation. neurologic signs can be controlled with phenobarbital (initial dose: 10 to 20 mg/kg iv diluted in saline and administered over 30 minutes; subsequent doses: 1 to 9 mg/kg iv diluted in saline, as needed up to tid). diazepam (valium) is contraindicated in hepatoencephalopathy because it may worsen signs. 17 congenital hyperbilirubinemia, or black liver disease, occurs in mutant corriedale sheep (dublin-johnson syn-drome). 1 this is a genetically recessive condition. it is characterized by an abnormality in the excretion of conjugated bilirubin and phylloerythrin and is often seen in animals consuming green forage. clinical signs include anorexia, photodermatitis, and icterus. liver biopsy of affected animals reveals dark to black granules in otherwise normal hepatocytes. the syndrome first manifests itself in lambs around 5 months of age. 18 a similar condition occurs in southdown lambs around 6 months of age (gilbert's syndrome). this too is a recessive condition that causes decreased hepatic uptake of phylloerythrin and bilirubin, with concurrent renal failure. 18 signs include icterus, photodermatitis, and ulceration around the ears and mouth. a liver biopsy reveals normal hepatic tissue. in both of these conditions, animals should be kept out of sunlight and fed minimal various tumors of the liver, including fibrosarcoma, lymphosarcoma, and cholangiocellular carcinoma, have been reported. 17, 18 the use of ultrasonography and ultrasound-guided liver biopsy may aid in diagnosis. the umbilicus is an opening in the ventral abdominal wall that allows passage of the umbilical vessels and allantoic stalks. this opening should close within a few day of birth. the failure of this opening to close properly is termed umbilical hernia. the hernial sac has an inner peritoneal layer and an outer layer of skin. these hernias are probably of genetic origin but may occur as sequelae to umbilical remnant infection. the opening in the abdominal wall is perceived as a ring on palpation. if the clinician can insert more than one finger into the hernial ring or if the hernia persists for more than 3 to 4 weeks, surgical intervention is indicated. penning. clamps or rubber bands may be of value for closing small hernias (those less than 4 cm in diameter). the clinician should either lightly sedate the animal or infiltrate the skin around the hernia with a local anesthetic (2% lidocaine). the animal should be placed on its back and held by a technician-helper. any viscera prolapsing into the hernial sac should be replaced into the abdomen. the clinician then inserts two metal pins (baby diaper pins can be used) through the skin and on opposite sides of the hernial ring, just on the edge of the linea alba. the pins should be placed deep enough to sit next to the abdominal wall. slight tension is placed on the skin in the center of the umbilical sac, pulling it away from the abdomen. when the clinician is confident that all viscera have been cleared from the hernial sac, he or she places an elastrator band between the pins and the abdominal wall. this results in ischemic necrosis of the skin. the skin will slough and the abdominal defect will heal in 7 to 14 days. lambs should be given tetanus prophylaxis. this procedure and other clamping techniques are useful in females and some males. however, urine scalding of the skin may occur in some males. clinicians should closely monitor animals that have undergone clamping. surgical resection. in cases in which the hernial ring is larger than 5 cm, surgical intervention should be carried out. animals can be sedated and then infiltrated with a local anesthetic or placed under general anesthesia. the area around the hernia is clipped and surgically prepared. the clinician opens the hernial sac and introduces a finger into the abdomen to ensure that no viscera have adhered to the inner lining of the ring and that no enlarged or infected umbilical remnants are present. he or she then carefully excises the ring and closes the defect in the abdominal wall. this closure can be made by simply opposing the abdominal wall with a horizontal mattress pattern stitch (absorbable suture). an alternate closure of the abdominal wall is to suture the peritoneal lining in a separate pattern and close the abdominal wall defect so one side of the defect is pulled to overlap the other side. the upper free edge is sutured to the opposite wall with a near-far-far-near pattern. the authors choose not to employ surgical techniques that slow this procedure. the subcutaneous tissue can be closed with simple interrupted pattern using absorbable suture and the skin should be closed with whatever pattern the clinician prefers. animals should be given tetanus prophylaxis and antibiotics. they should be closely monitored for signs of sepsis and surgical failure. exercise should be limited for 7 to 14 days after surgery. infections of the umbilical arteries (omphaloarteritis) and veins (omphalophlebitis) and urachal disease can occur because of failure or partial failure of passive transfer of colostral antibodies and subsequent sepsis. contamination of the umbilicus, retracting of these structures after stretching and breaking, and chemical damage (from strong tincture of iodine) to the amniotic remnants are other possible causes. 1,2,3 dipping the umbilicus with iodine or iodine-chloriodine substances is a common practice. aggressive use of these chemicals may precipitate serious inflammation of the cord. excessive torsion of the umbilical cord, distention of the proximal urachus, and some genetic factors may all be associated with patent urachus, which also may occur as a sequela to omphaloarteritis or omphalophlebitis. clinical signs and diagnosis. the clinical signs include umbilical swelling, pain, and occasionally drainage or discharge of the umbilical stump. palpation and transabdominal ultrasonographic evaluation reveal an enlarged cord-like structure ascending from the umbilicus cranially (umbilical vein) or caudally (urachus or um-bilical artery). ultrasonographic evaluation may indicate an abscess or thickened tissue. patent urachus is associated with dermatitis, urine scalding of the ventral abdomen, and urine dribbling. if the urachus becomes infected it may leak urine intraperitoneally or subcutaneously. both of these developments may be identified with abdominal palpation, ballottement, ultrasonographic evaluation, and, when indicated, paracentesis. 1 the cbc may indicate neutrophilia. blood culture is indicated if sepsis occurs simultaneously. occasionally infection of the internal structures may occur with no outward umbilical swelling. deep abdominal palpation and/or the use of real-time ultrasound are necessary to attain a diagnosis. animals with umbilical infections also may have signs of septicemia, anorexia, depression, joint distention, and fever. treatment. if a patent urachus occurs without inflammation of the associated tissues, it can be cauterized daily with iodine or silver nitrate. however, if it remains patent for more than 5 days, it should be surgically closed. the animal should be placed under general anesthesia (see chapter 16) . the area around the umbilicus should be clipped and surgically prepared, and the animal should be placed on a broad-spectrum antimicrobial agent 2 to 4 hours before surgery. the clinician opens the abdomen lateral to the umbilicus and digitally explores the adjacent area for adhesion formation. the urachus should be identified and followed to the urinary bladder. after this, the clinician should amputate the urachal attachment to the bladder and close the bladder with a double-layered inverting pattern (cushing). the abdominal wall, subcutaneous tissue, and skin are closed as described for umbilical hernia repair. on occasion some cases of omphalophlebitis-omphaloarteritis can be treated medically. prolonged antibiotic therapy with a broad-spectrum antimicrobial agent (ceftiofur 2.2 mg/kg sid or oxytetracycline 20 mg/kg sc every 72 hours) may be attempted. however, if medical therapy is ineffective, the infected umbilical remnants should be marsupialized or excised. the authors prefer more aggressive, surgical removal of the umbilical rem-nants. as with urachal surgery, the abdomen should be opened lateral to the umbilicus. depending on the severity of infection and the amount of tissue involved, the clinician may need to perform extensive dissection of necrotic tissue and possibly intestinal resection. 3 if the infection of the umbilical vein extends to and involves the liver, marsupialization of the umbilical vein is an effective method of therapy. 2, 3 the clinician can pull the vein to the most cranial portion of the abdominal incision and suture it to the muscle layers and skin before closing the abdomen as described for umbilical hernia repair. however, a preferable method is to close the abdominal wall, pull the transected umbilical vein through, and suture it to a separate stab incision. this may help minimize the incidence of abdominal wall herniation. only monofilament, absorbable, non-gut suture material should be used. 3 the venous stump should be flushed daily with antiseptic solution (1% chlorhexidine, 0.1% povidone iodine), and the animal should be maintained on antibiotics for more than 14 days. the venous stump usually closes within a month. 3 prevention. umbilical infections can be prevented or drastically reduced by ensuring adequate intake of goodquality colostrum. lambs and kids also should be only minimally stressed (particularly during the first 2 to 3 days of life) to enhance colostral absorption. in some management scenarios, proper dipping of the navel with non-caustic materials also helps reduce the incidence of this disease. indigestion in ruminants bloat or ruminal tympany diseases of the goat on the effect of xylazine on forestomach motility in sheep anorexia during febrile conditions in dwarf goats: the effect of diazepam, flurbiprofen and naloxone bloat in kids experimentally induced lactic acidosis in nubian goats: clinical, biochemical, and pathological investigations diagnosis of enteric disease in small ruminants ruminal lactic acidosis in sheep and goats biochemical alterations in serum and cerebrospinal fluid in experimental acidosis in goats commonly encountered diseases of goats generalized aspergillosis in dairy sheep rumen papillomas in sheep effect of monensin on development of ruminal parakeratosis in fattening lambs, zentralblatt fur veterinarmedizin lactic acidosis foreign body syndrome in goats-a report of five cases traumatic gastritis in sheep and goats goat medicine references 1. sherman dm: causes of kid morbidity and mortality: an overview, proceedings of the fourth international conference on goats enteric infections in young goats and their control enteritis and diarrhea goat medicine infectious gastrointestinal diseases of young goats occurrence of cryptosporidia, rotaviruses, coronavirus-like particles and k99 ϩ escherichia coli in goat kids and lambs jensen and swift's diseases of sheep escherichia coli in domestic animals and humans development of resistance with host age to adhesion of k99 ϩ escherichia coli to isolated intestinal epithelial cells references 1. smith bp: alterations in alimentary and hepatic function control programs for gastrointestinal nematodes in sheep and goats epidemiology of internal parasites: effects of climate and host reproductive cycles on parasite survival anthelmintic resistance: the selection and successful breeding of superior parasites control and prevention of specific diseases of sheep and goats herd rp: control of periparturient rise in worm egg counts of lambing ewes production medicine and health programs for goats the effects of dietary protein on establishment and maturation of nematode populations in adult sheep nematode infections-cattle, sheep, goats, swine parasites affecting goats in the southeast, proceedings of goat production and marketing opportunities in the south grazing management strategies for the control of parasitic diseases in intensive sheep production systems goat medicine helminth parasites of the gastrointestinal tract. nematode infections in cattle, sheep, goats, and swine parasite control programs in sheep and goats epidemiology and control of trematodes in small ruminants use of anthelmintic combinations against multiple resistant haemonchus contortus in angora goats preliminary investigation of anthelmintic efficacy against gi nematodes of goats and susceptibility of goat kids to gastrointestinal nematode infection johne's disease in sheep and goats paratuberculosis in small ruminants, proceedings of the small ruminants for the mixed animal practitioner, western veterinary conference paratuberculosis in small ruminants, deer, and south american camelids comparison of the absorbed elisa and agar gel immunodiffusion test with clinicopathologic findings in ovine clinical paratuberculosis paratuberculosis in a large goat herd serodiagnosis of paratuberculosis in sheep by use of agar gel immunodiffusion corynebacterium pseudotuberculosis infection in sheep and the complement fixation test for paratuberculosis obstructive intestinal diseases intussusception in goats goat medicine duodenal obstruction by a phytobezoar in a goat general surgical techniques for small ruminants: part ii, proceedings of the small ruminants for the mixed animal practitioner, western veterinary conference rectal prolapse in ruminants and horses jensen and swift's diseases of sheep rectal prolapse in food animals. part 1: cause and conservative management rectal prolapse in food animals. part ii: surgical options, comp cont ed pract vet 14:554, 1992. references 1. fetcher a: liver diseases of sheep and goats goat medicine a retrospective study of hepatic abscesses in goats: pathological and microbiological findings hepatic lipidosis jensen and swift's diseases of sheep hepatic lipidosis associated with cobalt deficiency in omani goats epidemiology of internal parasites: effects of climate and host reproductive cycle on parasite survival epidemiology and control of trematodes in small ruminants efficacy and safety of albendazole against experimentally induced fasciola hepatica infections in goats efficacy of an injectable ivermectin/clorsulon combination against fasciola hepatica in sheep albendazole treatment of experimentally induced fascioloides magna infection in goats efficacy of clorsulon against fascioloides magna infection in sheep evaluation of clorsulon against fascioloides magna in cattle and sheep clinical biochemistry of domestic animals metals and other inorganic compounds interpreting a bovine serum chemistry profile: part i large animal internal medicine large animal internal medicine neonatal conditions, with emphasis on equine neonate umbilical hernia, umbilical abscess, and auricle fistula general surgical techniques for small ruminants: part ii, proceedings of the small ruminants for the mixed animal practitioner, western veterinary conference key: cord-310205-j57x9ke6 authors: alcaide, maria l.; bisno, alan l. title: pharyngitis and epiglottitis date: 2007-06-08 journal: infect dis clin north am doi: 10.1016/j.idc.2007.03.001 sha: doc_id: 310205 cord_uid: j57x9ke6 acute pharyngitis is one of the most common illnesses for which patients visit primary care physicians. most cases are of viral origin, and with few exceptions these illnesses are both benign and self-limited. the most important bacterial cause is the beta-hemolytic group a streptococcus. there are other uncommon or rare types of pharyngitis. for some of these treatment is required or available, and some may be life threatening. among those discussed in this article are diphtheria, gonorrhea, hiv infection, peritonsillar abscess, and epiglottitis. sore throat accounts for 1% to 2% of all patient visits to office-based primary care practitioners, hospital outpatient departments, and emergency departments in the united states [1] . data from the national medical care survey indicate approximately 7.3 million annual visits for children [2] and 6.7 such visits for adults [3] . thus, familiarity with the principles of diagnosis and management of this disorder is essential for primary care physicians seeing patients of all ages. the hallmarks of acute pharyngitis are sore throat of varying degrees of clinical severity, pharyngeal erythema, and fever. most cases of pharyngitis are of viral origin, and with few exceptions these illnesses are both benign and self-limited. a large proportion of cases of pharyngitis is associated with rhinovirus [4] and coronavirus colds or with influenza. the most important cause of bacterial pharyngitis is the beta-hemolytic group a streptococcus (streptococcus pyogenes, gas). there are other uncommon or rare types of pharyngitis, and for some of these treatment is also required or available. the recognized microbial causes of pharyngitis are listed in table 1 , which shows the syndromes of respiratory illness caused by the various agents [5] [6] [7] [8] [9] [10] . it still is not possible to determine the cause in a sizable proportion of cases. a major task of the primary care physician is to identify those patients with acute pharyngitis who require specific antimicrobial therapy and to avoid unnecessary and potentially deleterious treatment in the great majority who suffer from a benign, self-limited, usually viral infection. in most cases this distinction can be made easily by attention to the epidemiologic setting, history, and physical findings augmented by performance of a few simple and readily available laboratory studies. the results of epidemiologic investigations are influenced by the season of the year, the age of the population, the severity of illness, and the diagnostic methods used to detect cases. most cases of pharyngitis occur during the colder months of the year, during the respiratory disease season. viral agents such as rhinoviruses tend to have annual periods of peak prevalence in the fall and spring; coronaviruses have been found most often in the winter. influenza appears in epidemics, which in the united states usually occur between december and april. in military recruits, adenoviruses cause the syndrome of acute respiratory disease during the colder months. in civilians, acute respiratory disease occurs in the winter, and epidemics of pharyngoconjunctival fever occur in the summer. streptococcal pharyngitis occurs during the respiratory disease season, with peak rates of infection in winter and early spring. spread among family members in the home is a prominent feature of the epidemiologic behavior of most of these agents, with children being the major reservoir of infection [11] . as shown in table 1 , a number of bacteria may cause acute pharyngitis, but most of these are rare or unusual causes of the syndrome. moreover, the benefit of antimicrobial therapy for some of these agents (ie, arcanobacterium haemolyticum, non-group a beta hemolytic streptococci) is unclear. thus, gas is the only commonly occurring cause of sore throat for which antimicrobial therapy is definitely indicated. gas is estimated to be the cause of 15% to 30% of cases of acute tonsillopharyngitis occurring during the cooler months of the year in schoolaged children [12] and of approximately 10% of cases in adults [13, 14] , but there is considerable variability from study to study [15] . nationally, however, approximately 53% of children [2] and 73% of adults [3] who have sore throat receive antimicrobial agents, and a substantial proportion receives antimicrobial agents not recommended as treatments of choice for gas pharyngitis. the following discussion provides recommendations by which such unnecessary and/or inappropriate therapy may be minimized. the characteristic clinical findings are summarized in table 2 . the presence of marked odynophagia, exudative tonsillopharyngitis ( fig. 1) , anterior cervical adenitis, fever, and leukocytosis is highly suggestive of gas pharyngitis. none of the signs and symptoms listed in the table is specific for ''strep throat,'' however. moreover, patients vary widely in the severity of their symptoms. many cases are milder and nonexudative. only approximately half of children presenting with sore throats and positive throat cultures have tonsillar or pharyngeal exudates [12] . patients who have had a tonsillectomy may have milder symptoms. children less than 3 years of age may have coryza and crusting of the nares; exudative pharyngitis caused by gas is rare in this age group. on the other hand, the presence of cough, coryza (in children older than 3 years), hoarseness, diarrhea, conjunctivitis, and/or anterior stomatitis is highly indicative of viral rather than streptococcal infection. scarlet fever results from infection with a streptococcal strain that elaborates streptococcal pyrogenic exotoxins (erythrogenic toxins) to which the patient is not immune. although this disease usually is associated with pharyngeal infections, it may follow streptococcal infections at other sites such as wound infections or puerperal sepsis. nowadays, the clinical syndrome is similar in most respects to that associated with nontoxigenic strains, save for the scarlatinal rash. the latter must be differentiated from those of viral exanthems, drug eruptions, staphylococcal and streptococcal toxic shock syndrome, and kawasaki disease. when confronted with a patient who has acute pharyngitis, the clinician must decide whether the likelihood of gas infection is high enough to warrant a confirmatory diagnostic test. patients lacking the suggestive clinical and epidemiologic findings or manifesting signs and symptoms indicative of viral pharyngitis (see table 2 ) need not be tested or treated with antimicrobial agents. attempts have been made to incorporate clinical and epidemiologic features of acute pharyngitis into scoring systems that attempt to predict the probability that a particular illness is caused by gas [14, [16] [17] [18] [19] . these clinical scoring systems are helpful in identifying patients at such low risk of streptococcal infection that further testing is usually unnecessary. selective use of diagnostic studies for gas will increase the proportion of positive test results and also the percentage of patients with positive tests who are truly infected rather than merely streptococcal carriers. the signs and symptoms of streptococcal and nonstreptococcal pharyngitis overlap too broadly, however, to allow the requisite diagnostic precision on clinical grounds alone. although some have suggested otherwise [1, 20] , empiric antimicrobial treatment based on clinical and epidemiologic grounds alone has been found suboptimal in cost effectiveness [21] and by prospective analyses [18] . therefore, if the clinician is unable to rule out strep throat on clinical and epidemiologic grounds, further testing is required (see later discussion) [22] . a properly performed and interpreted throat culture is the gold standard for the diagnosis of gas pharyngitis. it has a sensitivity of 90% or higher, as judged by studies employing duplicate throat cultures. obtaining definitive results of the throat culture takes 18 to 48 hours. in the minority of patients who are severely ill or toxic at presentation and in whom clinical and epidemiologic evidence leads to a high index of suspicion, oral antimicrobial therapy may be initiated while awaiting the results of the throat culture. if oral therapy is prescribed, the throat culture serves as a guide to the necessity of completion of a full antimicrobial course or, alternatively, of recalling the patient for an injection of penicillin g benzathine. early initiation of antimicrobial therapy results in faster resolution of the signs and symptoms, but two facts should be kept in mind. first, gas pharyngitis usually is a self-limited disease; fever and constitutional symptoms are markedly diminished within 3 or 4 days after onset even without antimicrobial therapy. thus, antimicrobial therapy initiated within the first 48 hours of onset will hasten symptomatic improvement only modestly. second, it has been shown that therapy can be postponed safely up to 9 days after the onset of symptoms and still prevent the occurrence of the major nonsuppurative sequela, acute rheumatic fever [23] . the issues alluded to in the previous discussion may be obviated in part by the use of rapid antigen detection tests (radt), which can confirm the presence of gas carbohydrate antigen on a throat swab in a matter of minutes. currently available commercial test kits yield results that are highly specific for the presence of gas. thus, a positive radt can be considered equivalent to a positive throat culture, and therapy may be initiated without further microbiologic confirmation. unfortunately, the sensitivity of most of these tests ranges between 70% and 90% when compared with the blood agar plate culture [24] . for this reason it is necessary to back up negative radts with a conventional throat culture. one possible exception to the need for such backup relates to adults, in whom the prevalence of gas pharyngitis is relatively low and the risk of a first attack of acute rheumatic fever in north america is minimal [25, 26] . a positive radt or throat culture does not differentiate between the presence of acute streptococcal infection and chronic gas carriage [27] . in the appropriate clinical setting, however, a positive test should be considered as confirmatory of strep throat. follow-up throat cultures are not indicated routinely for asymptomatic patients who have received a complete course of therapy for gas pharyngitis, because most such patients are streptococcal carriers. exceptions include patients who have a history of rheumatic fever, patients who develop acute pharyngitis during outbreaks of either acute rheumatic fever or poststreptococcal acute glomerulonephritis, and outbreaks of gas pharyngitis in closed or semiclosed communities. follow-up throat cultures also may be indicated when ''ping-pong'' spread of gas has been occurring within a family. treatment of gas pharyngitis is recommended to prevent acute rheumatic fever, prevent suppurative complications [28] , shorten the clinical course (although only modestly) [28] , and reduce transmission of the infection in family and school units. there is no definitive evidence that such therapy can prevent acute glomerulonephritis. a number of antibiotics have been shown to be effective in therapy of gas pharyngitis. these include penicillin and its congeners (such as ampicillin and amoxicillin), numerous cephalosporins, macrolides, and clindamycin. penicillin, however, remains the treatment of choice because of its proven efficacy, safety, narrow spectrum, and low cost. amoxicillin often is used in place of oral penicillin v in young children; the efficacy appears equal, and this choice is related primarily to superior palatability of the suspension. erythromycin is a suitable alternative for patients allergic to penicillin, although increases in gas resistance to this agent have been reported in certain localized areas of the united states. first-generation cephalosporins also are acceptable for penicillin-allergic patients who do not manifest immediate-type hypersensitivity to beta-lactam antibiotics. there is debate regarding the relative efficacy of cephalosporins vis-a-vis penicillin [29] in eradicating gas from the pharynx and about the utility of shorter courses of certain antimicrobial agents in treating strep throat. for a further discussion of this topic, the reader is referred to the infectious diseases society of america (idsa) practice guideline [25] . penicillin, however, remains the preferred therapy according to guidelines published by the american heart association [30] , american academy of pediatrics [31] , and idsa (table 3 ) [25] . the idsa guideline also offers guidance in management of patients who have recurrent episodes of culture-or radtpositive acute gas pharyngitis. preliminary investigations have demonstrated that once-daily amoxicillin therapy is effective in the treatment of group a beta hemolytic streptococcus pharyngitis [32] [33] [34] . in the most careful of these studies, feder and colleagues [32] randomly assigned 152 children to receive amoxicillin, 750 mg once daily, or penicillin v, 250 mg three times daily. compliance was monitored by urine antimicrobial activity, and serotyping was performed to distinguish treatment failures from new acquisitions. the two regimens a although shorter courses of azithromycin and some cephalosporins have been reported to be effective for treating group a streptococcal upper respiratory tract infections, evidence is not sufficient to recommend these shorter courses for routine therapy at this time. b amoxicillin often is used in place of oral penicillin v for young children; efficacy seems to be equal. the choice is related primarily to acceptance of the taste of the suspension. c for patients who weigh ! 27 kg. d dose should be determined on basis of the benzathine component. for example, mixtures of 9 â 10 5 u of benzathine penicillin g and 3 â 10 5 u of procaine penicillin g contain less benzathine penicillin g than is recommended for treatment of adolescents or adults. e available as stearate, ethyl succinate, estolate, or base. cholestatic hepatitis, rarely, may occur in patients, primarily adults, receiving erythromycin estolate; the incidence is greater among pregnant women, who should not receive this formulation. f these agents should not be used to treat patients with immediate-type hypersensitivity to beta-lactam antibiotics. were equally effective in eradicating gas from the pharynx. if additional investigations confirm these results, once-daily amoxicillin therapy, because of its low cost and relatively narrow spectrum, could become an alternative regimen for the treatment of group a beta-hemolytic streptococcal pharyngitis. suppurative complications of gas pharyngitis include peritonsillar infection, retropharyngeal abscess, cervical lymphadenitis, mastoiditis, lemierre syndrome, sinusitis, and otitis media. such complications have become relatively rare since the advent of effective chemotherapy. peritonsillar infection may take the form of cellulitis or abscess (quinsy) and is the most common form of deep oropharyngeal infection. although peritonsillar abscesses may occur as complications of gas pharyngitis, the abscesses themselves frequently contain a variety of other oral flora including anaerobes, with or without gas [35] [36] [37] . they occur more frequently in adolescents and adults than in young children. pharyngeal pain is usually severe, and dysphagia is common. on examination, there is inflammation and swelling of the peritonsillar area with medial displacement of the tonsil, and patients speak with a ''hot potato'' voice. trismus may be present. peritonsillar cellulitis may be treated with antibiotics alone, but abscesses require drainage by direct aspiration or by incision and drainage. given the polymicrobial nature of these infections, parenteral antibiotics such as clindamycin, penicillin with metronidazole, or ampicillin-sulbactam are frequently employed. their superiority over penicillin has not been demonstrated definitively, however. lemierre syndrome (postanginal septicemia) is caused by an acute oropharyngeal infection with secondary septic thrombophlebitis of the internal jugular vein and, often, bacteremic spread to lungs or elsewhere [38] . the most common causative organism is fusobacterium necrophorum. the clinical findings include acute presentation with fever, swelling and tenderness at the angle of the jaw, and neck rigidity. dysphagia and dysphonia can occur. the peritonsillar area is inflamed only early in the disease. emergency medical treatment with intravenous antibiotics such as clindamycin, penicillin with metronidazole or ampicillin-sulbactam is usually sufficient, but at times ligation of the internal jugular vein is required. acute rheumatic fever and poststreptococcal acute glomerulonephritis are the delayed nonsuppurative sequelae of gas pharyngitis. although the former occurs only after gas upper respiratory infection, the latter may occur after infection of the throat or skin (streptococcal pyoderma). discussion of these entities is beyond the scope of this article. non-group a beta-hemolytic streptococci are classified biochemically by species. for clinical purposes, however, they usually are identified by their expression of the lancefield cell-wall antigens. certain of these strains clearly are capable of causing acute pharyngitis when ingested in high inocula. streptococci of serogroup g have been linked to common-source outbreaks of pharyngitis, usually related to a food product. one unusual species of group c organisms, streptococcus equi subspecies zooepidemicus, has given rise to common-source epidemics of pharyngitis, usually caused by consumption of unpasteurized dairy products. several of these outbreaks have been associated with poststreptococcal acute glomerulonephritis [39] . groups c and g streptococci are common commensals of the human pharynx. they form large colonies similar to those of gas and belong to the species streptococcus dysgalactiae subspecies equisimilis. physicians who do not back up negative radts with throat cultures will not identify these organisms. the extent to which they cause sporadically occurring episodes of true acute pharyngitis is unclear, but several careful studies suggest that group c streptococci may cause episodes of pharyngitis that mimic gas infection [40, 41] . moreover, a community-wide outbreak of group g streptococcal pharyngitis occurred in connecticut during the winter of 1986-1987 [42] . because of the difficulty in differentiating benign colonization from true infection with groups c or g streptococci, the benefit, if any, of antimicrobial therapy in sporadically occurring cases is unknown. should therapy be elected, agents listed in table 3 would be appropriate, but probably for a shorter duration, because non-group a streptococci never have been shown to cause acute rheumatic fever. arcanobacterium haemolyticum. arcanobacterium (formerly corynebacterium) haemolyticum is a gram-positive bacillus that is a relatively uncommon cause of acute pharyngitis and tonsillitis. symptomatic infection with this organism closely mimics acute streptococcal pharyngitis. rarely, a haemolyticum produces a membranous pharyngitis that can be confused with diphtheria. two features of pharyngeal infection with this organism are notable. it has a predilection for adolescents and young adults, and it frequently provokes a generalized rash that may resemble that of scarlet fever [43] [44] [45] . the organism is detected more readily on human-than sheep-blood agar plates and thus may not be identified in the routine throat culture. thus, the clinician should suspect a haemolyticum infection in a teenager or young adult who has an acute pharyngitis and scarlatiniform rash but a negative culture or radt for gas. should antimicrobial therapy of a patient who has a haemolyticum pharyngitis be elected, a macrolide or, alternatively, a betalactam antimicrobial agent may be prescribed. neisseria gonorrhoeae. neisseria gonorrhoeae is an uncommon, sexually transmitted cause of acute pharyngitis seen in persons who practice receptive oral sex. the risk of acquisition by this means is highest in men who have sex with men (msm). rates of pharyngeal gonorrhea in msm have been reported as being as high as 15%. a recent study in san francisco found n gonorrhoeae in the pharynx of 5.5% of msm and concluded that the pharynx was the most common site of infection in this population [46] . because of this high prevalence, the united states centers for disease control and prevention (cdc) guidelines for sexually transmitted diseases recommend a yearly pharyngeal test for n gonorrhoeae in msm who receive oral intercourse [47] . although the presence of gonorrhea in the pharynx is common, the occurrence of symptomatic pharyngitis is rare. in the abovementioned san francisco study, there was no association between the presence of n gonorrhoeae and pharyngeal symptoms. when symptomatic oral infection does occur, pharyngitis and tonsillitis are the most common manifestations. sore throat with an erythematous pharynx, bilateral tonsillar enlargement, at times with grayish-yellowish exudate, and occasionally with cervical lymphadenopathy have been reported [48] . gingivitis and glossitis also have been described. the diagnosis should be confirmed by culture on thayer-martin medium. currently, ceftriaxone (125 mg in a singular intramuscular dose) is the only cdc recommended therapy for uncomplicated pharyngeal gonorrhea. concomitant therapy for chlamydia is recommended if this infection has not been ruled out. corynebacterium diphtheriae. pharyngeal diphtheria is caused by corynebacterium diphtheriae. humans are the only reservoir of the organism. asymptomatic carriers account for 3% to 5% of the population in endemic areas, and transmission occurs through respiratory secretions. although diphtheria has become extremely rare in the united states and other developed countries with effective childhood immunization programs, there are reasons for the primary care physician and infectious disease specialist to be familiar with this disease. first, there have been a few indigenous cases in the united states in the last 10 years in unimmunized or underimmunized individuals in the lower socioeconomic groups [49] . second, a large proportion of adults in north america and western europe lack protective serum levels of antitoxic immunity and are at risk for acquiring the infection when traveling to endemic areas. in 2003, a fatal case occurred in a pennsylvania resident who traveled to haiti to assist in building a church [50] . epidemics of diphtheria involving thousands of cases occurred in the 1990s among residents of the newly independent countries of the former soviet union. third, early diagnosis and treatment are important predictors of ultimate prognosis. respiratory diphtheria is typically caused by toxin-producing (''toxigenic'') strains of c diphtheriae and rarely by toxigenic strains of corynebacterium ulcerans. the main pathogenic factor is an exotoxin capable of producing a severe local reaction of the respiratory mucosa with the formation of a dense necrotic coagulum and pseudomembranes. these pseudomembranes can lead to airway obstruction resulting in suffocation and death. the toxin is also responsible for severe cardiac and neurologic complications [51] . the incubation period of 2 to 4 days is followed by malaise, sore throat, and low-grade fever. the most notable physical finding is the grayish-brown diphtheritic pseudomembrane that may involve one or both tonsils or may extend widely to involve the nares, uvula, soft palate, pharynx, larynx, and tracheobronchial tree. it is firmly adherent to the mucosa, and its removal provokes bleeding. in severe cases, there is swelling of the soft tissues of the neck (''bull neck''), cervical adenopathy, profound malaise, prostration, and stridor. cardiac complications manifested as myocarditis with cardiac dysfunction occur in 10% to 25% of cases, usually when the pharyngeal manifestations are improving. neurologic complications can occur also and are related directly to the severity of the primary infection, the immunization history, and the time between the onset of symptoms and institution of treatment. the diagnosis of diphtheria requires a high index of suspicion and specific laboratory techniques. diagnosis should be suspected on epidemiologic grounds and in the presence of pharyngitis with pseudomembranes, especially if extending to the uvula and soft palate and bleeding when dislodged. plating on loeffler's or tindale's selective media can identify black colonies with metachromatic granules, but definitive diagnosis requires demonstration of toxin production by immunoprecipitation, polymerase chain reaction (pcr), or immunochromatography. because successful treatment is inversely related to the duration of the disease, therapy should be started once the diagnosis seems likely on clinical grounds and while awaiting laboratory confirmation. treatment of diphtheria includes diphtheria antitoxin and antibiotics. equine diphtheria antitoxin is only available through the national immunization program of the cdc. the therapeutic dose and mode of administration are recommended by the american academy of pediatrics according to the duration and extension of the disease [52] . antibiotics are effective in decreasing local infection, decreasing toxin production, and decreasing spread. intramuscular penicillin g, switched to oral penicillin v once the patient is able to swallow, and erythromycin are the antibiotics of choice. respiratory diphtheria (in contrast to cutaneous diphtheria) does not induce protective immunity, so diphtheria toxoid should be administered to patients during convalescence. prevention of transmission is crucial and is accomplished by strict isolation. close contacts should be cultured and started on prophylactic antibiotics while awaiting culture results; if not fully immunized, they should receive diptheria toxoid. both penicillin and erythromycin are efficacious in eradicating the carrier state, but erythromycin has been shown to be superior in some reports. c ulcerans is an animal pathogen that causes bovine mastitis but can be transmitted to humans through the consumption of raw milk. it can produce diphtheritic toxin and a clinical disease undistinguishable from c diphtheriae. mycoplasma pneumoniae and chlamydophila pneumoniae are known causes of lower respiratory tract infections; they also can be found in the throats of patients who have symptomatic pharyngitis and of asymptomatic carriers. although these agents probably cause some cases of acute pharyngitis, either as primary pathogens or copathogens, the frequency with which this occurs is still unclear. the pharyngeal manifestations that have been described include erythema, tonsillar enlargement, and, less often, exudate with cervical lymphadenopathy. in a recent italian study, 133 children who had acute tonsillopharyngitis were tested for m pneumoniae and c pneumoniae with acute-and convalescent-phase titers and pcr on nasopharyngeal aspirates. thirty-six of the children (27%) had serologically confirmed acute m pneumoniae infection, and 10 (7.5%) had serologically confirmed c pneumoniae infection. five of the latter also had a positive nasopharyngeal pcr for this organism [53] . the children were assigned randomly to receive azithromycin plus symptomatic treatment or symptomatic treatment alone and were followed for 6 months. in the short term, there was no difference in the outcomes of children with or without atypical infection. a significantly decreased rate of recurrent upper and lower respiratory infections occurred in patients with atypical infections who were randomized to azithromycin, however. these results require confirmation. infectious mononucleosis clinical manifestations. infectious mononucleosis (im) or ''glandular fever'' is caused by the epstein-barr virus (ebv). the virus is present in the oropharyngeal secretions of patients who have im and is spread by personto-person contact. infection with ebv is frequent in childhood but usually is asymptomatic. clinical manifestations are more common when the infection is acquired in adolescence or young adulthood. thus, most cases of im occur between ages 15 and 24 years. symptoms develop after an incubation period of 4 to 7 weeks. following a 2-to 5-day prodromal period of chills, sweats, feverishness, and malaise, the disease presents with the classic triad of severe sore throat accompanied by fever as high as 38 c to 40 c and lymphadenopathy. pharyngitis with associated tonsillitis occurs in 70% to 90% of the patients. tonsillar exudates are present in approximately one third of cases, and palatal petechiae may also be present lymphadenopathy is bilateral, particularly posterior cervical, but can involve axillary and inguinal areas. about 10% of patients have a rash of variable morphology, but administration of ampicillin or amoxicillin provokes a pruritic maculopapular eruption in 90% of patients. hepatomegaly is present in 10% to 15% of patients who have im, and splenomegaly occurs in almost half of the patients. this classic clinical presentation of im occurs in most of the children and young adults. older adults may not exhibit pharyngitis or lymphadenopathy, and disease can be manifested only with fever and more prominent hepatic abnormalities (typhoidal presentation) [54] . ebv infection can be complicated by a variety of neurologic and oncologic conditions that are beyond the scope of this article. the hematologic findings include leukocytosis with 60% to 70% lymphocytosis and thrombocytopenia that usually is mild but occasionally may be severe. the lymphocytosis usually is found at presentation and peaks 2 to 3 weeks after onset of the disease. the presence of more than 10% atypical lymphocytes in peripheral blood is one of the characteristic features of im and supports the diagnosis. the differential diagnosis at initial presentation includes gas pharyngitis, other respiratory viral infections (see table 1 ), cytomegalovirus infection, and, if suggested by epidemiologic history, the acute retroviral syndrome (see later discussion). rarely, entities such as toxoplasmosis, hepatitis a, human herpesvirus 6, and rubella must be considered. in most cases, the diagnosis is readily confirmed if suspected. initial diagnostic studies should include throat culture or radt for gas and a serologic test for the presence of heterophile antibodies. the latter are antibodies directed against antigens in erythrocytes from different animal species. they are present in approximately 90% of affected adolescents and adults within the first 1 to 3 weeks of illness and may persist for up to 1 year. spot and slide tests that use horse or purified bovine erythrocytes and allow rapid screening are commercially available. when combined with a compatible clinical presentation, a positive rapid test for heterophile antibodies can be considered diagnostic of im. false-negative tests can occur in up to 10% of patients, however, especially in children and older adults and in the early stages of the disease. approximately 10% of patients who have a classic mononucleosis syndrome have negative tests for heterophile antibodies. in such patients, ebv-specific antibodies should be assayed. the most useful of these for general clinical purposes is the igm antibody to viral capsid antigen. this test is present at clinical presentation and persists for 4 to 8 weeks. antibody to epstein-barr nuclear antigen first appears 3 to 4 weeks after onset and persists for life [55] . many patients who have heterophile-negative im are found by the aforementioned tests to be infected with ebv. in the majority of the remainder, serologic studies confirm infection with cytomegalovirus, which can produce a syndrome closely mimicking that induced by ebv. im is predominantly a self-limited disease, and studies have failed to detect any benefit of using antiviral agents. most symptoms resolve within 3 weeks of onset. physical activity is tailored to patient tolerance. because of the risk of splenic rupture, contact sports and heavy lifting should be avoided until the spleen returns to normal size, usually in approximately 3 to 4 weeks. the use of corticosteroids has been studied in clinical trials, but no clear benefit has been demonstrated [56, 57] . steroids, however, may be useful in the management of severe complications such as airway obstruction, hemolytic anemia, severe thrombocytopenia, and aplastic anemia. within days to weeks after initial infection with hiv type 1, 50% to 90% of patients develop a constellation of symptoms known as the ''acute retroviral syndrome.'' fever, sore throat, lymphadenopathy, maculopapular rash, myalgia, arthralgias, and mucocutaneous ulcerations are the landmarks of the syndrome [58] [59] [60] [61] . a nonexudative pharyngitis is present in 50% to 70% of patients. other oropharyngeal findings include ulcers and thrush. oral ulcers, which occur in 10% to 20% of the patients, appear in the first days of the illness and last for approximately 1 week. their distribution is usually in the inner lips and in the floor of the mouth, but tonsils, soft palate, and uvula also can be involved. fever occurs in almost 100% of patients who have acute retroviral syndrome, and it is usually high. lymphadenopathy occurs in 40% to 70% of the patients, is nontender, usually develops after 1 week of illness, and involves cervical, axillary, and inguinal regions. skin rash, which occurs in 40% to 50% of patients, usually is maculopapular, disseminated, and almost invariably involves the neck and upper trunk. the rash usually spares the distal extremities, although palms and soles can be affected. the clinical findings of fever, pharyngitis, and lymphadenopathy may simulate im. atypical lymphocytosis, although infrequent, also could lead to a misdiagnosis of mononucleosis. acute retroviral syndrome can be differentiated from mononucleosis, however, by its more acute onset, the absence of exudate or prominent tonsillar hypertrophy, the frequent occurrence of rash (rare in mononucleosis except after treatment with ampicillin or amoxicillin), and the presence of oral ulcerations (table 4 ) [62] . it is important for the clinician to recognize that the elisa commonly used to diagnose hiv-1 infection are negative in the first 3 to 4 weeks after infection and therefore are not useful in this setting. tests for p24 antigen or, preferably, quantitative assays for plasma hiv rna by branched chain dna or pcr should be performed. the viral load can be anticipated to be very high during this acute phase of infection. an hiv antibody test always should be performed later in time to confirm the diagnosis. treatment of acute retroviral syndrome with highly active antiretroviral medication has been controversial, current recommendations consider the use of antiretroviral medications in the setting of acute hiv infection to be optional [63] . potential benefits of antiretroviral therapy in acute hiv would be to decrease the severity of acute disease and to decrease viral replication. studies have demonstrated improvement of laboratory markers of disease progression when highly active antiretroviral therapy is used in acute hiv infection [64, 65] . these results would suggest a decrease in progression and transmission of the disease. treating acute hiv infection, however, also can have potential risks, including known side effects to medications, possible development of resistance, and adverse effects on quality of life. if the patient and clinician elect to start antiretroviral medications, the goal should be suppression of viral replication. whereas most respiratory viruses can cause symptoms indistinguishable from the common cold or acute pharyngitis, some viruses may produce more distinctive clinical syndromes. adenovirus. adenovirus is a common cause of viral pharyngitis. it is manifested clinically as an upper respiratory infection with fever, cough, rhinorrhea, and sore throat, usually more pronounced than in the common cold. the pharynx is erythematous and frequently may have exudates that mimic streptococcal pharyngitis [66] . a distinctive syndrome associated with adenovirus infection in children is pharyngoconjunctival fever. the disease occurs in outbreaks and is characterized by conjunctivitis, pharyngitis, rhinitis, cervical adenitis, and high fever. although adenoviral infections commonly occur in winter months, pharyngoconjuntival fever has been implicated in outbreaks in summer camps [67] and associated with contaminated swimming pools and ponds. several types of adenovirus also have been implicated in outbreaks of influenza-like illnesses with sore throat, rhinorrhea, and tracheobronchitis, known as acute respiratory disease of army recruits [68, 69] . these infections are self limited, and symptomatic treatment alone is recommended. coxsackie virus. most enteroviral infections occur in the summer and fall and present as febrile illnesses with sore throat, cough, or coryza. distinctive manifestations of enteroviral infection are herpangina and hand-footand-mouth disease. herpangina most often is caused by coxsackie a and is most frequent in infants or young children. it usually presents acutely with fever, sore throat, odynophagia, diffuse pharyngeal erythema, and a vesicular enanthem. headache and vomiting can be preceding symptoms. the oral lesions consist of 1-to 2-mm gray-white papulovesicles that progress to ulcers on an erythematous base and may be present on the soft palate, uvula, and anterior tonsillar pillars [70] . they are moderately painful and usually number less than a dozen. hand-foot-and-mouth disease also is caused by coxsackie a. it is characterized by a febrile vesicular stomatitis with associated exanthema. the oral findings include small, painful vesicles in the buccal mucosa and tongue that can coalesce and form ulcerative bullae. the lesions are similar to those seen in herpangina, but there is an associated peripheral rash involving hands and feet that can extend proximally. these coxsackie diseases are self limited, and treatment is symptomatic. herpes simplex virus. several studies have documented primary human herpes simplex (hsv) type 1 infection as a cause of pharyngitis in college students [71, 72] . hsv2 occasionally can cause a similar illness as a consequence of oral-genital contact [73] . this form of pharyngitis represents primary infection in immunocompetent patients but can occur as a reactivation of latent virus in immunocompromised hosts. although the characteristic presentation consists of small vesicles and ulcerations in the posterior pharynx and tonsils, hsv also may produce pharyngeal erythema and exudates at times indistinguishable from strep throat. lesions may extend to the palate, gingiva, tongue, lip, and face. general symptoms include fever, malaise, inability to eat, and cervical lymphadenopathy. treatment of hsv oral infection with antiherpetic medication is efficacious in reducing the duration of signs and symptoms as well as viral shedding. acyclovir, valcyclovir, and famciclovir are all useful in treating hsv infection. acetaminophen or nonsteroidal anti-inflammatory drugs are effective analgesics and antipyretics. treatment should be started as soon as symptoms develop and is useful in both viral and bacterial diseases. oral hydration and gargles with salt water may help alleviate the pharyngeal complaints. oral cough suppressants, decongestants, and antihistamines are helpful, depending on the symptoms present. lozenges containing local anesthetics are widely available over the counter and seem to provide temporary relief of sore throat [74, 75] . several authors have reported that adjuvant therapy with dexamethasone decreases the duration of throat pain in patients who have severe odynophagia [76] [77] [78] . the regimens used and the magnitude of the effect varied among the studies. no adverse effects have been reported, but duration of follow-up often has been limited. one randomized, double-blind, placebo-controlled trial of adjuvant dexamethasone therapy in children found efficacy only in patients who had radt-positive pharyngitis, and the benefit was judged to be only ''of marginal clinical importance'' [79] . the authors do not recommend use of corticosteroids in the therapy of gas pharyngitis. acute epiglottitis or supraglottitis is an inflammatory process of the epiglottis and adjacent structures that can lead to life-threatening acute respiratory obstruction. in the past, epiglottitis occurred most frequently in children between 2 and 4 years of age and was associated mainly with haemophilus influenzae type b (hib) infection. since the initiation of the childhood vaccination programs, epiglottitis caused by this organism is much less common. nevertheless, there are still cases of hib epiglottitis in both immunized and nonimmunized children, and the possibility of an infection with this pathogen cannot be excluded completely in vaccinated patients [80, 81] . bacteria associated with epiglottitis nowadays include streptococcus pneumoniae, staphylococcus aureus, and beta hemolytic streptococci. multiple agents including other bacteria, viruses, and fungi have been implicated in rare cases. the typical presentation in children includes fever, irritability, sore throat, and rapidly progressive stridor with respiratory distress. the affected child adopts a forward-leaning position, drooling oral secretions while trying to breathe. adults usually present with sore throat and a milder disease, although airway compromise can occur also. physical examination of patients suspected of having epiglottitis requires careful inspection of the oropharyngeal and suprapharyngeal area. the diagnosis requires direct visualization of an erythematous and swollen epiglottis under laryngoscopy. because of the risk of airway obstruction, this procedure should be performed in children only when skilled personnel and equipment to secure the airway are available [82] . once the airway has been secured, culture of the surface of the epiglottis along with blood cultures should be obtained to guide antibiotic therapy. management focuses on two important aspects: close monitoring of the airway with intubation if necessary and treatment with intravenous antibiotics. because of the aforementioned possibility of failure of vaccination, antibiotics should be directed against hib in every patient regardless of immunization status. cefotaxime, ceftriaxone, or ampicillin/sulbactam are appropriate choices. steroids are used commonly in the management of acute epiglottitis although no randomized trial has been done to support this practice. when a case of hib epiglottitis is diagnosed, the american academy of pediatrics recommends that postexposure prophylaxis with rifampin be given to household contacts when there is at least one child in the household younger than 4 years of age, a child in the household younger than 12 months of age who has not received the primary series of hib vaccine, or an immunosuppressed child, regardless of that child's hib immunization status [83] . acute pharyngitis is an extremely common disorder that usually runs a benign course. in almost all cases, the primary care physician must discriminate between a viral sore throat, which requires only symptomatic management, and gas pharyngitis, which requires specific antimicrobial therapy. this distinction is important so that gas pharyngitis can be treated appropriately to minimize the risk of suppurative and nonsuppurative complications. equally important is minimizing unnecessary and potentially deleterious overtreatment of viral infections with antimicrobial agents. this article has outlined the epidemiologic, clinical, and laboratory findings that assist in decision making. the clinician also must be alert to the occurrence of rare but serious upper respiratory infections that may be life threatening and require special forms of therapy (eg, diphtheria, parapharyngeal suppurative processes, acute epiglottitis). principles of appropriate antibiotic use of acute pharyngitis in adults antibiotic treatment of children with sore throat antibiotic treatment of adults with sore throat by community primary care physicians: a national survey clinical significance and pathogenesis of viral respiratory infections a collaborative study of the aetiology of acute respiratory infection in britain 1961-4. a report of the medical research council working party on acute respiratory virus infections virology of middle ear virologic studies of acute respiratory disease in young adults. iv. virus isolations during four years of surveillance acute respiratory illness in an american community. the tecumseh study acute pharyngitis and tonsillitis in university of wisconsin students group a streptococci, mycoplasmas, and viruses associated with acute pharyngitis principles and practice of infectious diseases diagnosis of streptococcal pharyngitis: differentiation of active infection from the carrier state in the symptomatic child a clinical score to reduce unnecessary antibiotic use in patients with sore throat the prediction of streptococcal pharyngitis in adults group a streptococcal pharyngitis in adults the diagnosis of strep throat in adults in the emergency room a streptococcal score card revisited empirical validation of guidelines for the management of pharyngitis in children and adults streptococcal pharyngitis: evaluation of clinical syndromes in diagnosis principles of appropriate antibiotic use for acute pharyngitis in adults: background a cost-effectiveness analysis of diagnosis and management of adults with pharyngitis diagnosing strep throat in the adult patient: do clinical criteria really suffice? the role of streptococcus in the pathogenesis of rheumatic fever rapid diagnosis of pharyngitis caused by group a streptococci practice guidelines for the diagnosis and management of group a streptococcal pharyngitis management of acute pharyngitis in adults: reliability of rapid streptococcal tests and clinical findings treatment failures and carriers: perception or problems? antibiotics for sore throat are cephalosporins superior to penicillin for treatment of acute streptococcal pharyngitis? treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: a statement for health professionals. committee on rheumatic fever, endocarditis, and kawasaki disease of the council on cardiovascular disease in the young, the american heart association committee on infectious diseases. group a streptococcal infections once-daily therapy for streptococcal pharyngitis with amoxicillin randomized, single-blinded comparative study of the efficacy of amoxicillin (40 mg/kg/day) versus standard-dose penicillin v in the treatment of group a streptococcal pharyngitis in children treatment of streptococcal pharyngitis with amoxycillin once a day microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses peritonsillitis: abscess of cellulitis? the microbiology of peritonsillar sepsis the evolution of lemierre syndrome: report of 2 cases and review of the literature group c and group g streptococcal infections: epidemiologic and clinical aspects epidemiologic evidence for lancefield group c beta-hemolytic streptococci as a cause of exudative pharyngitis in college students clinical and microbiological evidence for endemic pharyngitis among adults due to group c streptococci community-wide outbreak of group g streptococcal pharyngitis arcanobacterium haemolyticum in children with presumed streptococcal pharyngotonsillitis or scarlet fever incidence and pathogenicity of arcanobacterium haemolyticum during a 2-year study in ottawa corynebacterium hemolyticum as a cause of pharyngitis and scarlatiniform rash in young adults prevalence and incidence of pharyngeal gonorrhea in a longitudinal sample of men who have sex with men: the explore study sexually transmitted diseases treatment guidelines gonococcal tonsillar infection-a case report and literature review status report on the childhood immunization initiative: reported cases of selected vaccine-preventable diseases-united states fatal respiratory diphtheria in a u.s. traveler to haiti-pennsylvania principles and practice of infectious diseases red book: 2006 report of the committee on infectious diseases. elk grove (il): american academy of pediatrics acute tonsillopharyngitis associated with atypical bacterial infection in children: natural history and impact of macrolide therapy infectious mononucleosis in middle age epstein-barr virus (infectious mononucleosis) epstein-barr virus infections: biology, pathogenesis, and management steroids for symptom control in infectious mononucleosis acute human immunodeficiency virus type 1 infection acute aids retrovirus infection. definition of a clinical illness associated with seroconversion primary hiv infection clinical presentations and virologic characteristics of primary human immunodeficiency virus type-1 infection in a university hospital in taiwan clinical picture of hiv infection presenting as a glandular-fever-like illness is antiretroviral treatment of primary hiv infection clinically justified on the basis of current evidence? highly active antiretroviral treatment initiated early in the course of symptomatic primary hiv-1 infection: results of the anrs 053 trial effect of combination antiretroviral therapy on t-cell immunity in acute human immunodeficiency virus type 1 infection clinical presentation and characteristics of pharyngeal adenovirus infections outbreak of pharyngoconjunctival fever at a summer camp-north carolina large, persistent epidemic of adenovirus type 4-associated acute respiratory disease in u.s. army trainees large epidemic of adenovirus type 4 infection among military trainees: epidemiological, clinical, and laboratory studies viral exanthems pharyngitis associated with herpes simplex virus in college students acute respiratory disease of university students with special reference to the etiologic role of herpesvirus hominis acute pharyngotonsillitis caused by herpesvirus type 2 efficacy and tolerability of ambroxol hydrochloride lozenges in sore throat. randomised, double-blind, placebo-controlled trials regarding the local anaesthetic properties demonstration of dose response of flurbiprofen lozenges with the sore throat pain model efficacy of single-dose dexamethasone as adjuvant therapy for acute pharyngitis effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children a pilot study of 1 versus 3 days of dexamethasone as add-on therapy in children with streptococcal pharyngitis oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial epiglottitis and haemophilus influenzae immunization: the pittsburgh experience-a five-year review paediatric acute epiglottitis: not a disappearing entity airway infectious disease emergencies red book: 2006 report of the committee on infectious diseases key: cord-018335-4l7scdqk authors: kiechle, frederick l.; arcenas, rodney c. title: utilization management in a large community hospital date: 2016-12-01 journal: utilization management in the clinical laboratory and other ancillary services doi: 10.1007/978-3-319-34199-6_14 sha: doc_id: 18335 cord_uid: 4l7scdqk the utilization management of laboratory tests in a large community hospital is similar to academic and smaller community hospitals. there are numerous factors that influence laboratory utilization. outside influences like hospitals buying physician practices, increasing numbers of hospitalists, and hospital consolidation will influence the number and complexity of the test menu that will need to be monitored for over and/or under utilization in the central laboratory and reference laboratory. clia’88 outlines the four test categories including point-of-care testing (waived) and provider-performed microscopy that need laboratory test utilization management. incremental cost analysis is the most efficient method for evaluating utilization reduction cost savings. economies of scale define reduced unit cost per test as test volume increases. outreach programs in large community hospitals provide additional laboratory tests from non-patients in physician offices, nursing homes, and other hospitals. disruptive innovations are changing the present paradigms in clinical diagnostics, like wearable sensors, maldi-tof, multiplex infectious disease panels, cell-free dna, and others. obsolete tests need to be universally defined and accepted by manufacturers, physicians, laboratories, and hospitals, to eliminate access to their reagents and testing platforms. this chapter will review the numerous factors that infl uence laboratory test utilization in a large community hospital (table 14 .1 ). assessment of laboratory test utilization usually relies on data compiled after a utilization review or analysis of the necessity, appropriateness, and effi ciency of laboratory tests on a concurrent and/or retrospective basis. most laboratory utilization studies have been reported from academic medical centers [ 1 -8 ] , however, there are often common fi ndings in large community hospital settings [ 9 -13 ] . the major difference between an academic center and community healthcare system is usually the number of hospital-employed physicians versus independent physicians with their own offi ce practices. some large community hospitals have only employed physicians on their medical staff like kaiser permanente, henry ford hospital, and others. generally, it will be easier to assemble a group of specialists to convene a laboratory utilization committee meeting, if the physicians are accustomed to leaving their practice responsibilities and going to a hospital-oriented committee meeting in the middle of the day. since the focus of this committee is to review the evidence-based evaluation of a new or old laboratory test to rule in or out a specifi c disease, attendance and the quality of participation will vary depending on the physician's commitment to the project. in a large community hospital, it may "save time" during these meetings if homework is assigned beforehand. "this includes what do people need to read, think about, bring with them, or come prepared to discuss so the meeting will be more productive" [ 14 ] . one of the authors (flk) has worked for 23 years directing the clinical laboratory and outreach laboratory at a large community hospital (william beaumont hospital) in royal oak, mi and for the past 9 years at a six hospital county healthcare system (memorial healthcare system) in hollywood, fl with the co-author (rca). we will review several of the issues listed in table 14 .1 . in preparation for the shift from fee-for-service to a valuebased payment system [ 15 ] large community hospitals have been actively engaged in three enterprises which will impact laboratory test utilization: buying physician practices, increasing the use of hospitalists and consolidation of hospitals. in the early 1990s during the initiation of health maintenance organizations (hmos) , hospitals purchased physician practices. in general, at that time, hospitals had a diffi cult time managing the physicians and their practices. during this second more recent phase of buying, contracts are designed to enhance physician productivity [ 16 -19 ] . the "key motivation for hospital acquisition of physician practices is the ability to gain market share for inpatient admissions and outpatient services by capturing referrals from physicians employed by the owned practices" [ 16 ] . carlin et al. [ 16 ] documented a shift in inpatient admissions, outpatient ct scans and mri procedures from three large multispecialty clinic systems to a two hospital-owned integrated delivery system (ids) after the ids purchased them. this same shift of referral patterns to the new hospital owner will also be true for laboratory tests ordered by newly acquired physician practices. in the usa 57 % of physicians were independent in 2000 compared to 39 % in 2012 [ 19 ] and 36 % of male and 23 % of female physicians in 2015 [ 17 ] . in 2004, 11 % of physicians were employed by hospitals compared to 64 % in 2014 [ 18 ] . a downside of this trend is the fi nding that hospitals charge more when the doctors work for them attributing the cause to higher overall costs [ 19 ] . this current trend should drive more laboratory testing from new hospitalbased physicians to the hospital central laboratory with the consequence of potential utilization issues. the hospitalist model of inpatient care is one of the most rapidly growing forms of medical practice in the usa since its introduction in the mid-1990s [ 20 , 21 ] . in 2006, there were more than 12,000 hospitalists in the usa [ 20 ] which has increased to 34,000 in 2014 [ 21 ] . most hospitalists practice in hospitals with greater than 200 beds [ 20 , 21 ] . their average starting salary was greater than that for internal medicine or family practice physicians in 2014 [ 18 ] . hospitalists work strictly in the hospital and oversee the care of complex patients with the goal of reducing the need of transferring patients from one physician to another [ 22 ] . most large community hospitals use a voluntary hospitalist system in which primary care physicians can choose to admit to a hospitalist service or attend to their own patients [ 23 ] . large community hospitals are more likely to adopt a hospitalist model if their case mix complexity was greater than the national average for medicare's diagnosis rated group index, while high health maintenance organization market share resulted in lower interest in this model [ 22 ] . the hypothesis that the hospitalist model will lead to a reduction in the patient's length of stay and total hospital costs has been demonstrated [ 20 , 22 -24 ] . hospitalists may order excessive diagnostic tests secondary to their lack of previous knowledge of the patient [ 20 ] . the choosing wisely campaign sponsored by the american board of internal medicine foundation, consumer reports, and more than 60 specialty societies have recommended reduction or elimination of inappropriate use of radiologic, laboratory, and therapeutic procedures [ 12 , 25 -27 ] . the fi rst 25 societies provided fi ve selections each, of which 12 % were related to laboratory tests or pathology [ 27 ] . one of these lists from the society of hospital medicine recommended reducing the use of repetitive common laboratory testing when the patient is clinically stable [ 26 ] . in a quality improvement project focused on hospitalists, an effort was made through education to reduce the repetitive use of complete blood counts and basic metabolic panels [ 25 ] . these panels are often embedded in order sets established for specifi c diseases or for specifi c physicians to simplify computerized physician order entry [ 28 ] . there was a 10-month baseline period before the intervention followed by a 7-month intervention period [ 25 ] . the intervention resulted in a 10 % reduction of these two panels ordered per patient day associated with decreased direct costs of $16.19 per patient and annualized savings of $151,682 [ 25 ] . this study illustrates how a small segment of laboratory test ordering physicians can impact expenses through overutilization and by analogy underutilization of laboratory tests. like the fi rst round of hospitals buying physician practices started in the early 1990s, so did the consolidation or mergers of hospitals [ 29 ] . there has been a recent increase in both horizontal and vertical consolidation [ 29 , 30 ] . horizontal consolidation involves hospitals merging with other hospitals that supply similar services in geographic proximity [ 29 , 30 ] . these mergers are most likely to be investigated for antitrust violations [ 29 ] . vertical consolidations involve hospitals consolidating with other health care provider entities [ 16 , 29 ] . from 2007 to 2012, 432 hospital mergers and acquisitions were announced involving 835 hospitals [ 30 ] . sixty percent of hospitals are now part of health systems. the downside to these mergers has been a 10-40 % increase in prices secondary to increased market share [ 30 ] . strategies have been suggested for avoiding this market disequilibrium [ 30 , 31 ] . no us hospital markets were rated highly competitive [ 30 ] while the german market is competitive and the number of hospital systems decreased by 18 % from 2000 to 2007 [ 32 ] . there are myths associated with the latest hospital merger activity. the fi rst myth is that consolidation is equivalent to integration [ 33 ] . the second is that higher quality is associated with size rather than leadership and competition [ 33 , 34 ] . evidence supports the suggestion that hospitals in competitive markets tend to have better administrative management [ 33 ] . the combination of hospital mergers and increased hospital-employed physicians [ 35 ] will lead to increase in laboratory test volumes and the need for robust utilization management practices. the clinical laboratory improvement amendment of 1988 (clia'88) went into effect september 1, 1992. the regulations categorize laboratory procedures based on test complexity using well-defi ned criteria: waived, moderately complex, and highly complex or provider-performed microscopy . these regulations defi ne the universe of tests that a large community hospital laboratory is directly or indirectly responsible for their utilization management. there are a variety of clia-tests that have been classifi ed as waived by the fda and a list of them from 2000 to present can be found at www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfclia/ testswaived.cfm . the implementation of point-of-care testing (poct) usually involves a desire to decrease the total turn-around time for an analytical test and improve patient outcome [ 36 ] . however, decreased turn-around time does not always equal improved patient outcome [ 37 , 38 ] . two prospective studies analyzed the effect of the poct i-stat device (abbott, abbott park, il) on length of stay in the emergency department after a control period when the central laboratory was used. the i-stat cartridge that analyzed sodium, potassium, chloride, urea, glucose and calculated hemoglobin was used. neither study revealed any change in the length of stay or clinical outcome for emergency department patients, although both showed a decrease in time required to obtain laboratory results for the six tests on the cartridge when the istat was used. the blood test was not the rate-limiting step in the patient's length of stay [ 38 ] . in a similar study using fi ve different testing cartridges for the istat (inr, lactate, brain natriuretic peptide, troponin t and chemistry with hemoglobin and hematocrit), singer et al. [ 39 ] reported a reduced turn-around time for poct compared to the central laboratory which translated into a reduction in time to completion of iv contrast ct and the length of stay of those specifi c patients. it is not clear whether relocating poct tests to the patient's bedside increases [ 40 , 41 ] or decreases [ 42 ] the test volume of that test in the central laboratory. it has been reported in both adult and newborn intensive-care units that patients with indwelling arterial lines have more blood drawn for laboratory studies than patients without arterial lines [ 43 , 44 ] . the blood loss may be great enough to require a transfusion [ 43 ] . certainly, utilization management of poct programs will require investigations to determine the relationship between total laboratory turn-around time for results, patient outcome and hospital costs using cost effectiveness analyses [ 36 ] . there are at least 17 different sources of body fl uids in a human [ 45 ] . some of these are laboratory specimens that are examined under the bright-fi eld or phase contrast microscope and are classifi ed as provider-performed microscopy (ppm) by clia'88 [ 46 , 47 ] . a separate cms license is available for sites performing these assays which include koh preparation, pinworm detection, fern test, microscope urinalysis, semen analysis for presence of sperm and motility, and eosinophils in nasal smears [ 46 , 47 ] . it is wise for the laboratory poct administrative committee to assist in the initiation of a ppm testing program in collaboration with the ppm license holder for that clinically defi ned program, like fern testing in the labor and delivery area under the direction of a staff ob/gyn physician. in this model, training and utilization management is not under the direction of the hospital poct administrative committee [ 46 , 47 ] . in order to audit laboratory test utilization year to year it is "essential to understand how test volumes are actually counted" [ 1 ] . are test panels bundled and counted as one test or are the test panels unbundled and each test in the panel counted separately. in an evaluation of the total inpatient test volumes from 1978 to 2000 for the department of clinical pathology at william beaumont hospital, royal oak, mi, it was determined that the method for counting inpatient tests changed in 1992 and 1996 [ 36 , there are two categories for cost reductions : "hard" cost savings and "soft" cost avoidance. tangible "hard" cost savings are often achieved by bringing reference laboratory tests inhouse to the clinical laboratory (or eliminating the reference laboratory test altogether) [ 4 , 11 ] . the more intangible "soft" cost avoidance includes such things as decreases costs associated with the introduction of a new laboratory test with the intent to decrease costs in the future. it also can occur when a cost is lower than the original expense that would have otherwise been required if the cost avoidance exercise had not been undertaken. since processes consume overhead and overheard costs money, any signifi cant process improvement could represent signifi cant cost avoidance for an organization. total cost includes direct and indirect costs [ 48 ] . direct cost includes personnel time to prepare and perform the test, reagents, quality control, profi ciency testing, and equipment depreciation. indirect costs including reporting costs (computer) and hospital overhead. incremental or marginal costs include only variable direct costs and not the indirect costs [ 48 -50 ] . therefore, incremental costs demonstrate what it would cost to perform one more laboratory test, assuming the equipment and facility are already available. neither total cost analysis nor incremental cost analysis includes an analysis of the defect rate or failure to achieve established goals, like turn-around time [ 50 ] . they are defi ned as internal or external failure rates. internal failure costs are incurred by the testing center as a consequence of a defect in the testing system. the receiver of the test results incurs the external failure costs. over utilization of laboratory tests incurs both internal and external failure costs in the excess time spent in the laboratory to generate the result and then excess insurance charges to the patient and nursing/physician time to evaluate the results. to illustrate cost avoidance , consider the presentation of potential enterovirus meningitis in the emergency department. children and adults with detectable enterovirus in the cerebrospinal fl uid (csf) may exhibit symptoms of meningitis including photophobia, stiff neck, acousticophobia , severe headache with vomiting, confusion, diffi culty concentrating, seizure and sleepiness. a molecular test for enterovirus detection will alter the patient's length of stay in the emergency department. if the patient is positive for enterovirus in the csf specimen, the patient will be discharged for home care until the viral meningitis resolves (table 14. 2 ). if the patient does not have enterovirus in the csf, they will need further hospitalization to rule out a bac-terial source for the meningitis with culture and sensitivity studies (table 14. 2 ). romero [ 51 ] has demonstrated the cost range for hospitalization related to enterovirus testing/care of infection to be $4476-4921 with an average length of stay of 3-4 days. we used $4476 for the calculation in table 14 .2 , which illustrates a cost avoidance of $187,992 for 20 patients with or without enteroviral detection by molecular methods. "cost per unit went down if you could make longer and longer runs of identical products. this gave rise to the theory of economies of scale " [ 52 ] . the laboratory achieves economies of scale and lower unit costs per test by expanding the volume of laboratory tests it analyzes. in the early 1990s, the number of inpatient laboratory tests at william beaumont hospital began to decrease. to fi ll the gap, after a 3-year preparation period, we initiated an outreach program (beaumont reference laboratory) expanding our laboratory testing services to non-patients from physician offi ces, nursing homes, and other hospitals [ 53 , 54 ] . several years later (1992) beaumont reference laboratory joined a regional laboratory network of other hospital-based laboratory outreach programs in michigan, joint venture hospital laboratories , to accommodate the wide geographic coverage required by third party payers [ 53 , 54 ] . the participating laboratories are independently owned and operated. a central network administrator coordinates negotiations for managed care contracts. the volume of brl specimens grew to half of the total volume of clinical pathology procedures of six million tests in 2004. this increased volume permitted an expansion of the test menu in each laboratory section. in 2002, we reviewed 2,976,494 procedures ordered by 2806 physicians in nine subspecialty areas (family practice, pediatrics , internal medicine, cardiology, endocrinology, gastroenterology, nursing home, ob/gyn, and urology). the requisitions for physician, procedures per requisition and procedures/physician were calculated for each of the nine groups of physicians [ 54 ] . family practice (464 physicians) and internal medicine (831) ordered the greatest number of total procedures as well as procedures/physician while urology (126) ordered the least of these two categories [ 54 ] . the tests ordered by each of the nine groups were counted in seven laboratory sections. all nine groups ordered more chemistry tests than any other category but the percent varied from 34.5 % for ob/gyn to 90.2 % for internal medicine. the most popular individual tests in fi ve laboratory sections (chemistry, hematology, immunology, microbiology, and molecular diagnostics) were calculated as an average number of a specifi c test ordered per physician per month. using this data, a laboratory section could prepare themselves for the increased utilization from a six-member internal medicine group that the beaumont reference laboratory sales force just signed up as a new client. this type of deep dive into specifi c physician specialty ordering patterns is an invaluable resource for managing a growing outreach business [ 54 ] . the 20 million requests for chemistry, hematology, and microbiology tests were included for all physicians in calgary, canada who ordered a test in fi scal year 2013-2014 [ 55 ] . the physicians were divided into 30 subspecialties and the average yearly cost per group and average yearly cost per physician in each of the 30 groups was calculated. family practice and internal medicine had the greatest average yearly cost per group while hematology and nephrology had the highest average yearly cost per physician per group secondary to utilization of more expensive laboratory tests [ 55 ] . this cost-based approach to utilization review requires the calculation of an average median cost for each test which in the usa would be much less than the price listed on the hospital's charge master. there was a synergistic relationship between the growth of beaumont reference laboratory and test mix complexity in each laboratory section. in the molecular diagnostics laboratory started in 1992, chlamydia trachomatis (ct) nisseria gonorrhoeae (ng) were performed in urine using the ligase chain reaction in 1996 and pcr in 2002 [ 56 , 57 ] . more than 75 % of the requests for these two assays are from brl clients (table 14. 3 ). the increased volume of these two assays helped turn the molecular diagnostic section into a profi t center in 4 years. annual utilization review revealed that the outreach program contributed 33,019/43,814 = 75 % of the volume, hospital a (8624/43,814 = 20 %) and hospital b (2181/43,814 = 5 %). the multiplex assay using primarily urine specimens made a margin of $72.00 per assay billed (at that time) based on an average medicare reimbursement ($83.00) and cost/test of $11.00. why was there an exceptionally low ng volume from hospital b? after an investigation it was learned that hospital b chose to do the less sensitive ng culture assay [ 56 ] to retain laboratory test volume which was encouraged by their hospital administration. also, a myth existed at hospital b that ng would not survive the transport time (40-60 min) to hospital a. the ordering physicians at hospital b prevailed and the request for molecular detection of ng at hospital b was followed. this case illustrates just how complex problem solving in utilization management issues can be in a large community hospital. some new technologies are defi ned as disruptive innovations , when they offer new paradigms in diagnostics (table 14 .4 ) [ 12 , 83 , 84 ] . all seven of the technologies listed in table 14 .4 share similar issues including clarifi cation of the best applications for routine clinical use, paucity of evidence-based outcome literature to review, education of practitioners and physician users of the clinical information generated and software to convert big databases the method generates into useful information. the references in table 14 .4 will direct attention to these issues for the seven disruptive innovations [ 58 -82 ] . as the paradigm shifts and these strategies become incorporated into daily clinical practice, the debate about appropriate utilization will diminish. this next section will devote time to describing the impact of current changes in microbiology ( mass spectrometry for bacterial identifi cation [ 12 , 68 , 69 ] and multiplex molecular panels for infectious agent detection for respiratory viral panels and gastric pathogen panels) and future changes ( microscopy for antibacterial drug sensitivity). traditionally, the laboratory diagnosis of most infectious disease pathogens has relied on culturing and in vitro growth of the causative agent. once culture growth has been achieved, then automated and/or manual biochemical tests can be performed to identify the microbial organism(s). these methodologies are dependent on skilled medical technologists to perform the manual tasks required to determine the bacterial identifi cation (id). the approach to id and antimicrobial susceptibility testing (ast) has been dependent on testing a single pathogen at a time, regardless if the culture [ 81 , 82 ] growth yielded multiple, signifi cant pathogens. although automated id and ast systems can run multiple isolates to help streamline the workfl ow and maximize throughput, the basic testing is still individually performed for each isolate being analyzed. another limiting factor for culture based detection methods is that some bacteria do not grow well or at all in vitro adding to the potential of missing a signifi cant organism(s). viral cultures are time-consuming because cytopathic effects (cpe) must be observed before other methods can be used to determine the viral identifi cation [ 85 -87 ] . the development of viral antigen based testing [direct fl uorescence antigen (dfa) and other rapid antigen testing devices] directly from the sample shortened the culture time to obtain a faster diagnosis. however, the reliable performance of the viral antigen based testing is highly dependent on the quality of the sample collected and is less sensitive than viral cultures [ 85 ] . a suboptimal specimen could lead to a false negative antigen/dfa result. are viral cultures and antigen based testing truly needed in a clinical microbiology/virology laboratory since molecular methods are becoming the new gold standard? [ 85 -87 ] . many routine clinical microbiology/ virology laboratories do not have the capabilities to perform viral cultures lacking the physical space and expertise to interpret the cpe [ 88 ] . as technology advances, the traditionally " agrarian society " of the laboratory is becoming more industrialized with the implementation of automation, molecular based testing, and use of mass spectrometry ( maldi-tof -matrix-assisted laser desorption ionization-time of flight). many of these advances are revolutionizing how microbiology testing is performed and disrupting how traditional clinical microbiology workfl ows and processes are set up. however, all of these technological advances are shortening the time for a laboratory diagnosis and ultimately maximizing the impact to patient care and how physicians at a large community hospital will utilize the more rapid microbiology laboratory services. there is a trend in clinical microbiology to develop syndromic panels using molecular techniques. for example, positive blood culture panels have been developed to reduce time to start the most appropriate antibiotics in the patient. once a blood culture bottle is fl agged as positive, a gram stained smear is prepared to determine the presence of bacteria (and potentially yeast) in the patient's blood sample. if any organism(s) are seen, a call is made to the patient's healthcare provider so that broad-spectrum antimicrobial therapy can be initiated until the confi rmed microbiological id is resulted. a caveat for the clinician is that s/he must make their best educated guess for determining which antibiotic treatment to use. clinical microbiology laboratories typically publish an antibiogram so that clinicians and hospital pharmacists know the prevalence of susceptible and resistant phenotypes for their most common bacteria isolated. although this provides a good start and useful reference, there is a heavy emphasis on antimicrobial stewardship and tailoring therapy as soon as possible so that there is less pressure for the development of antimicrobial resistance . many institutions have developed or are in the process of developing formal antibiotic stewardship programs/committees in an effort to improve the utilization of antimicrobial treatments. molecular methods have been developed that will, within one test, identify a number of pathogens from a positive blood culture sample. these methods have decreased the amount of time to provide a more defi nitive id and an abbreviated antimicrobial resistance genetic profi le. advandx/ biomerieux, inc. utilizes pna-fish (peptide nucleic acidfl uorescent in situ hybridization) and detection of a positive fl uorescent signal directly from a positive blood culture . gram stained smear fi ndings typically are resulted as "gram positive cocci in clusters" or "gram negative rods" (table 14 .5 ). this information is useful in deciding broadspectrum therapy, but a more focused therapy is the ultimate goal to ensure that the pathogen is adequately treated. the pna-fish assays offer four basic assays [ staphylococcus (gram positive), enterococcus (gram positive), gram negative, and candida ] that complements the gram stain result so that clinicians at least have a presumptive genus identifi cation. additional pna-fish probes do have the ability to separate s. aureus /coagulase-negative staphylococcus and a meca probe for the identifi cation of mrsa. use of these pna-fish assays requires a fl uorescent microscope to visualize the results. a number of studies have shown the clinical benefi ts of pna-fish implementation as part of the blood culture workup before the confi rmatory culture growth and potentially identifying methicillin resistance genotype, in the example of s. aureus , before the full antibiotic susceptibilities can be performed [ 89 -93 ] . antibiotic therapy can, therefore, be tailored or deescalated as appropriate. similar to the pna-fish scenario, when utilizing cepheid's xpert mrsa/sa blood culture test the gram stained smear prepared from the positive blood culture smear will determine whether cepheid's assay should be run. cepheid's methodology is real-time pcr based and does not require any subjective interpretation of the results by the laboratory staff. the cartridge for the xpert mrsa/sa test houses all the reagents and is compartmentalized to accommodate the nucleic acid extraction, pcr amplifi cation, and detection in one device. the testing is automated once the sample is loaded into the test cartridge and the software analyzes the pcr amplifi cation curves to determine if a patient's blood sample is positive or negative for mrsa or mssa [ 94 -97 ] . the cepheid and advandx tests must be added to the already existing workfl ow, and serves as another laboratory tool to more quickly determine the pathogen identifi cation and a preliminary ast profi le. nanosphere, inc. and biofire diagnostics, inc. approach testing from positive blood culture bottles by targeting the most common pathogens (bacteria or yeast) that can cause sepsis. this is a unique approach due to the overlap in patient symptoms for a specifi c syndrome or condition. when the symptoms overlap, clinicians have diffi culty defi ning the causative pathogen(s) infecting their patient solely from the clinical picture, and delaying specifi c pathogen-based therapy. use of these syndromic multiplex molecular panels streamlines the testing process to more of a "one-and-done" approach. nanosphere offers different panels: (1) gram positive ( bc-gp panel ); (2) gram negative ( bc-gn panel ); and (3) yeast ( bc-y panel ) and the organism(s) observed from the gram stained smear will determine which panel(s) to run. additional testing with the gram positive and gram negative panels also includes testing for certain antibiotic resistance genes encoding for methicillin ( meca ) and vancomycin ( vana and vanb ) resistance (table 14 .5 ). there are many studies showing overall good performance for the bc-gp panel [ 98 -104 ] , gram negative species and candida spp. panels [ 105 , 106 ] . there are limitations with molecular testing as observed by buchan et al. [ 101 ] . a positive meca target was not able to be assigned due to the presence of a mixed infection. in this case the full antibiotic sensitivity testing is still recommended because the traditional methods test each bacterial pathogen individually. beal et al. [ 102 ] noted that when blood culture infections were caused by one pathogen, there was good performance of the multiplex molecular assays. when polymicrobial blood culture infections were noted, there was only 33 % agreement with the routine cultures. mestas et al. [ 103 ] also noticed a lower percentage agreement for polymicrobial infections when compared to monomicrobial infections. polymicrobial bacteremia is relatively rare, but can potentially be severe [ 107 ] . again, cultures are still required to identify the full antibiotic susceptibility profi le, and to identify pathogens that are not included in the multiplex molecular panels. the filmarray blood culture identifi cation panel (bcid) is another comprehensive panel that covers gram positive, gram negative, and yeast pathogens (table 14 .5 ) and a gram stain is not required. however, it is still good routine practice to perform the gram stain to correlate results with the molecular panel results and the eventual culture testing and antibiotic susceptibility testing. altum et al. [ 105 ] observed that certain pathogens were detected in routine cultures that were not detected in the filmarray panel because those pathogens were not in the molecular panel. so although the comprehensive panel covers the most common pathogens, clinical intuition is still ultimately needed especially when clinical symptoms and other laboratory data point to a bacteremic process in the setting of a negative filmarray panel. overall, these assays show the potential for a decreased tat and a preliminary susceptibility profi le based on the antibiotic resistance genes tested [ 104 , 105 , 108 , 109 ] . the ability to have a more rapid answer that is technically more sensitive and specifi c will have positive downstream effects on patient care and antibiotic stewardship. the impact of these rapid pcr blood culture assays on the clinical end users (infection control, pharmacy, length of stay, and overall hospital costs) is not well defi ned. one study by bauer et al. [ 95 ] demonstrated clinical benefi t after implementing the cepheid xpert mrsa/sa assay for positive blood cultures. a 4-month pre-pcr period was evaluated followed by a 4-month post-pcr period. there was an overall shorter length of stay (6.2 days shorter) and mean hospital costs were $21,387 less than what was observed in the pre-pcr period. infectious disease pharmacists were more effective in deescalating or changing to more specifi c antibiotic therapies compared to the pre-pcr period. benefi ts were gained by having a more rapid and sensitive test. when adopting newer molecular methods, the laboratory must work with their clinical counterparts to determine the clinical utility of a more rapid test. the cost and potential benefi ts of the newer tests may not be warranted if the clinical staff is not able to effectively utilize this information in their workfl ow. even though the downstream benefi ts have been documented and are almost inarguable from a clinical perspective, there are fi nancial and workfl ow impacts to the microbiology/molecular laboratories that implement these assays. as mentioned prior, the gram stain results from the positive blood cultures will help drive the culture workup. thus, there is the time required for a blood culture bottle to alarm as positive, and then the culture time waiting for growth on the culture plates. the use of these molecular methods must be introduced into the workfl ow and will add additional work because culture id and ast methods still must be performed. in the setting of having a continual decrease of incoming medical technologist graduates and an increasing number of laboratorians retiring, this puts the burden of additional testing on the existing staff. another example of a clinically benefi cial, but disruptive test within the laboratory is the development of respiratory pathogen panels. molecular multiplex panels have been developed to target the general syndrome of a respiratory illness. table 14 .6 shows that there are a variety of fda-approved assays available with a varying number of pathogens offered within their respective multiplex assay. each assay also requires varying levels of hands-on-involvement and molecular expertise required by the medical technologist. prior to the implementation of a respiratory virus panel (rvp) in our institution, the only viral testing offered were the rapid antigen immunochromatographic devices for infl uenza a/b and respiratory syncytial virus (rsv). with the addition of offering rvp testing, we are now able to provide our clinicians with a more comprehensive answer of which virus(es) are occurring in their patient. this benefi ts transplant, immunocompromised, and oncology patients who have more frequent respiratory viral infections [ 110 -112 ] . we had serendipitously brought in the rvp before the 2009 h1n1-infl uenza a outbreak which demonstrated the poor performance of the rapid antigen testing [ 113 ] . because of this observation, many laboratories have discontinued their rapid antigen test offerings and now only offer molecular tests. in our laboratory, we have observed a decline in rapid infl uenza and rsa antigen testing (fig. 14.1 ) . the spike in volumes in 2008-2009 was related to the 2009 h1n1 infl uenza a outbreak. we will eliminate these rapid antigen tests in favor of a rapid molecular test for infl uenza and rsv. an algorithm will refl ex a negative rapid molecular infl uenza a/b and rsv test to a more comprehensive viral and/or bacterial panel. when compared to the dfa and/or shell vial culture, a molecular multiplex respiratory virus panel saved time and lowered costs to the patient [ 114 , 115 ] . despite the clinical benefi ts observed, a limitation of molecular based methodologies is that they are batched and can take hours to perform in the laboratory. for example, in our laboratory the testing time is 6-7 h as compared to the 20-min it takes to run the rapid antigen testing. that trade off in time to result is offset by the increase in sensitivity, specifi city, and breadth of viral pathogens discovered. this can be a challenge for clinicians because many times they will want a fast answer for the purposes of triaging or taking action on a patient. however, the question that should be asked of them is whether they want a bad quality, rapid answer or a good quality, not-so-fast answer. biofire diagnostics, inc. has attempted to solve the testing time problem by offering a comprehensive respiratory pathogen panel that tests directly from the respiratory specimen. only one patient can be run on one instrument and the assay time is approximately 1 h. there will be certain institutional settings where this technology will have benefi ts such as an urgent care clinic, smaller community hospital, or within a laboratory that has minimal molecular testing experience. however, for those institutions with a higher volume where batch testing is more optimal, the biofire may not be the best solution. there are other commercial panels that differ in the number of pathogens offered as well as various levels of medical technologist involvement (table 14 .6 ). the decision to implement one of these panels is driven by a myriad of factors such as cost, workfl ow, physician demand, and the technical capabilities of the laboratory staff. whatever respiratory pathogen panel is introduced, remember that the sample testing volume is highly dependent on seasonal variations. figure 14. 2 shows a graph of our volumes over two respiratory virus seasons (august 2013 through april 2015) with our peak volumes occurring over the winter months. this variability can have a signifi cant impact to how microbiology/molecular laboratories are staffed. physician demand, coupled with an increase in testing volumes, may be high enough to warrant increasing the number of runs per day as the staffi ng levels allow, potentially leading to an increase in employee overtime hours. interestingly during fig. 14.1 the decline in the rapid antigen infl uenza and rsv testing volumes in response to the introduction of rvp testing in conjunction with the 2009 h1n1/infl uenza a outbreak the 2014 respiratory virus season, amidst reports of the infl uenza vaccine having suboptimal effi cacy [ 116 ] , we observed a large increase in rvp testing volumes compared to the prior season. thus, one factor that is virtually impossible to control is the antigenic drift/shift of the infl uenza a virus affecting the effectiveness of the current vaccine in use. assay performance may also be affected due to genetic mutations being introduced into the pcr targeted gene regions. with the limitations of culture and antigen based testing , co-infections were greatly under-appreciated for respiratory viral infections. one can expect an increased incidence of co-infections with multiplex molecular panels. figures 14.3 and 14 .4 show our experiences with co-infections among pediatric and adult patients. the clinical signifi cance of these co-infections is not completely understood in relationship to modulation of disease severity [ 117 -119 ] . research is needed to fully understand virus-virus and bacteria-virus co-infections and their interactions with the other pathogens present as well as the pathogen-host interactions . every respiratory virus season, our laboratory publishes a " virogram " that shows the prevalence of viruses currently circulating among the patient population (fig. 14.5a, b ) . infectious gastrointestinal illness is another syndrome targeted by commercial vendors. as of this writing, there are a number of fda-approved assays from luminex, inc. , biofire diagnostics, inc. , becton dickinson diagnostics, inc. , nanosphere, inc. , and genprobe-prodesse (table 14.7 ) . clinicians are often unaware of what pathogens are actually included when they order a stool culture and ova & parasite (o&p) testing [ 120 ] . similar to respiratory illness symptoms, the symptoms of an infectious gastrointestinal (gi) illness overlap also making it diffi cult to ascertain the true pathogen(s) causing the disease. the development of an infectious gi panel that targets bacterial , viral , and parasitic pathogens , provides a more effi cient approach to diagnosis compared to standard practices. the appeal to the clinical microbiology laboratory is the consolidation of culture, antigen, biochemical, and single-molecular analyte testing into one comprehensive panel. the implications to the state and public health laboratories that rely on culture isolates for epidemiological typing and characterization may not be immediately recognized when considering these molecular stool panel tests. because of the improved ability to detect a pathogen(s) with molecular methods as compared to culture, there will be scenarios when the molecular test is positive and the culture growth is negative. it is imperative that clinical laboratories communicate with their state/public health laboratory counterparts to come up with an amenable solution given that there will be discordant molecular and culture results if an isolate is required to be sent to the state/public health laboratory. similar to respiratory co-infections , gi co-infections are also an under-appreciated aspect of disease and pathogenicity. what potentially makes gi co-infections more confusing and would require some additional clinical scrutiny is that some bacteria can be colonizers (i.e., c. diffi cile ) and so the burden of determining clinical signifi cance is left to the clinician. maldi-tof is another technology that shortens the time to result for determining the microbial identifi cation of clinically signifi cant pathogens. the reader is referred to a number of reference review articles on the technology itself [ 121 -126 ] . recently, maldi-tof systems have been made commercially available for use in the clinical microbiology laboratory. how this technology compares with the currently available testing (culture/biochemical and dna sequencing) is outside the scope of this chapter [ 127 -132 ] . maldi-tof does outperform the conventional methods in overall accuracy and time to result. our laboratory has implemented maldi-tof as an identifi cation tool. results are available in approximately 1 day earlier when compared to our traditional culture based testing. branda et al. [ 88 ] found that maldi-tof reduced turn-around time by 1.45 days compared with their traditional testing. a side effect that we have observed is an increased number of calls from clinicians asking for the antimicrobial susceptibility results. these results are available the next day from our automated ast system. in addition laboratories will need to adapt their workfl ow processes when maldi-tof testing is implemented. the upfront cost of instrumentation is high (approximately $200,000), resulting in delayed implementation in some clinical microbiology laboratories. the fi nancial savings are realized in the cost per isolate of running the maldi-tof compared to the cost per isolate for a traditional work-up [ 127 , 133 , 134 ] . there can be reductions in the reagent and laboratory costs when compared to culture/ biochemical methodologies [ 134 , 135 ] . despite the initial capital expenditure to obtain the instrumentation, there are cost-savings after maldi-tof is implemented. if the organism is not in the maldi-tof database, it will need to be confi rmed by traditional methods and/or dna sequencing . another potential limitation is that the defi nitive speciation by maldi-tof can confuse clinician end users when they see a new bacterial genus/species name that they do not readily recognize and may pose challenges in deciding what antibiotics to prescribe. this new defi nitive identifi cation is a result of technological advancements that have a greater ability to further speciate bacteria when only a genus answer may have been given with traditional techniques (i.e., coagulase-negative staphylococcus or enterobacter cloacae complexes). from the laboratory perspective, changes in nomenclature must be updated in the laboratory information system as appropriate when microorganisms undergo taxonomic reclassifi cations. future advancements with maldi-tof technology also will affect the clinical microbiology laboratory workfl ow. studies have preliminarily shown the ability to detect the pathogen directly from a patient sample (i.e., positive blood cultures [ 92 , 135 , 136 ] and urines [ 137 -139 ] ), bypassing the current requirement for testing on a culture isolate. however, it should be stressed that direct sample testing is in the very early stages of development. antibiotic susceptibility testing has also been examined and hrabak et al. [ 140 ] provide an in-depth review of using maldi-tof for these purposes. interestingly, this technology has also been described in identifying the species of ticks potentially minimizing the ectoparasite experience normally required [ 141 ] . technological advancements are focused on shortening the time of pathogen detection so that clinical action can be taken much more quickly. two relatively new companies have been working on methodologies that will further disrupt clinical microbiology practices. t2 biosystems, inc. has recently received fda approval for the detection of fi ve candida species ( c. albicans , c. tropicalis , c. parapsilosis , c. krusei , and c. glaboratoryrata ) direct from the patient's blood sample without prior incubation within a blood culture bottle. the t2 biosystems assay claims to detect these candida species within 5 h. this technology shortens start time for appropriate candidemia treatment. patient mortality is decreased, the earlier treatment is started [ 142 ] . having the ability to identify the particular candida species is critical since c. glaboratoryrata and c. krusei have signifi cant rates of azole resistance [ 143 , 144 ] . similar to the other blood culture tests mentioned above, this technology will not eliminate the need for culture/pcr and antimicrobial susceptibility testing after a blood culture bottle becomes positive. the technology allows for processing of the whole blood sample, since a thermostable mutated dna polymerase that is not affected by inhibitors in whole blood detection is used to amplify dna. detection of any pcr product is done via t2 magnetic resonance technology. ( www.t2biosystems.com ). clinical trials data show an overall sensitivity of 91.1 % with a mean time of 4.4 h for detection and species identifi cation [ 144 ] . the limit of other studies have demonstrated earlier detection and its effect on antimicrobial stewardship [ 145 , 146 ] . because this is a relatively new technology, hospitals and other healthcare institutions are currently determining the most optimal and cost effective way to utilize this technology. this test is not intended as a screening tool, but should be used in a more targeted patient population where candidemia is more signifi cant and more likely to occur. accelerate diagnostics, inc. has developed a methodology for both rapid pathogen identifi cation and antimicrobial susceptibility testing that can purportedly be performed within 5 h ( www.accerlatediagnostics.com ). the company is conducting clinical trials on blood culture pathogen panel at the time of this writing. the technology utilizes fish dna probes to identify the panel pathogens that may be present. the antimicrobial susceptibility testing results are determined by single-cell microbiological analysis via time-lapse computerized images of the pathogen's growth characteristics in the presence of a particular antibiotic. the blood culture pathogen panel assay is intended to be the company's fi rst fda-approved assay with other sample type panels in their assay pipeline. automation in the microbiology laboratory has been a slow to make an impact unlike the other laboratory sections (i.e., chemistry, urinalysis, etc.) attributable to the inherent manual process of specimen preparation required. vendors are developing automated plate streakers for more consistent yields with culture plating. also, companies are developing automated specimen processors that can be programmed to inoculate a battery of plates. one can imagine the advantages to be gained with high volume sections of the laboratory such as urine cultures [ 147 -153 ] . the implementation of microbiology automation is in its infancy and there is debate on the utility of automation and its widespread adoption. the potential is there for a large impact on the manual workfl ow and disruption of how clinical microbiology laboratories function. obviously, there is a fi nancial aspect to the implementation of automation and the estimated total cost of a total automated microbiology solution can be in the millions of dollars [ 149 ] . it is not out of the realm of possibilities for further advancements for a total microbiology laboratory automated technological solution where clinical microbiologists may be able to function from a "virtual" bench able to work up cultures and set-ups for other downstream tests from a computer touchscreen/tablet eliminating the potential hazard of being exposed to pathogenic and/or bioterrorism organisms. the arrival of new equipment in a large community hospital laboratory, chemistry automation [ 154 ] for example, creates a lot of stress on the staff to complete the performance verifi cation of the new quantitative analytical systems [ 155 , 156 ] . the practicing physician and healthcare system depend on this equipment to perform well. the assays will require verifi cation of calibration , linearity , analytic measurement ranges, accuracy, precision, appropriateness of the reference range and quality control requirements [ 155 -157 ] . a variety of poct and main chemistry laboratory methods for hba1c have been evaluated to see if that meets the total allowable error goal set by the cap proficiency testing program and the national glycohemoglobin standardization program (ngsp) [ 158 -160 ] . "clearly, many methods, including a few poc methods, do perform well in laboratories, as seen by data from the cap proficiency surveys" [ 160 ] , our new system was not one of those good performers. we replaced immunoassays for hba1c (roche diagnostics method, siemens medical solutions diagnostics-potential new method) with a capillary electrophoresis method (sebia) [ 161 -163 ] . during the evaluation of these three hba1c methods, the roche immunoassay reported hba1c values (3.7-4.8 %) for four patients with no hba but had hbsc. during the screening of 231 random patients, 13 % had homozygous or heterozygous variants [ 163 ] . hb n-baltimore comigrates with hba1c on capillary electrophoresis while hb silver spring and 17 other hb variants did not [ 162 ] . in this case, a method for hba1c had to be quickly evaluated to replace the immunoassay originally planned for implementation to prevent repeated profi ciency testing failures and potential discontinuation of the hba1c assay. an obsolete test is a test that is no longer in use or no longer useful (table 14 .8 ) [ 12 , 164 -171 ] . an effective way to evaluate whether a test has become obsolete is to review it at the laboratory utilization committee that is responsible for the laboratory formulary [ 172 ] . the formulary concept comes from the play book of the pharmacy and therapeutics committee that approve medication for use by medical providers and under what circumstances. when a newer more effective drug is fda approved it may replace an older less effective drug in the formulary. in the laboratory, the perfect obsolete test cannot be ordered by a medical provider because the reagents are no longer provided by the in vitro diagnostics industry. for example, protein bound iodine (pbi) [ 169 ] is no longer available at any reference laboratory because the test reagents are no longer manufactured. however, t3 uptake is just as obsolete and useless; however, its reagents are still manufactured by many vendors and still offered by reference laboratories [ 12 ] . in a utilization review of our hospital's send out test volume, it was asked by the reference laboratory why physicians ordered so many t3 uptake assays from them. i said it is not on our formulary just like ck mb [ 164 -166 ] , but both of these obsolete tests and others are still ordered and performed by your reference laboratory. the response was "we offer the test because physicians order the test," however, if the reagents were not available from the manufacturer, it is unlikely the reference laboratory would develop a laboratory developed test to support obsolescence. the workaround for removal of the obsolete tests from the hospital laboratory formulary usually involves the use of an emr that has reference laboratory test ordering built for the convenience of the medical providers. if this feature is not inactivated for inpatients the hospital laboratory formulary develops a leak from which a fl ood of abuse can originate. until locally defi ned obsolete tests are universally accepted and eliminated from the test lists of hospitals, manufacturers, and reference laboratories, the discovery of ingenious work-arounds will occupy the time of the medical providers who by habit are accustomed to having the obsolete test results by their side. the utilization management of laboratory tests in a large community hospital is similar to academic and smaller community hospitals. there are numerous factors that infl uence laboratory utilization (table 14 .1 ). outside infl uences like hospitals buying physician practices, increase in the placement of hospitalists and hospital consolidation will infl uence the number and complexity of test menu that will need to be monitored for over and under utilization in the central laboratory and reference laboratory. the laboratory utilization committee and laboratory formulary stewardship are key to a successful beginning. there are numerous excellent suggestions and reports of the successful implementation of remedies that have been reviewed and arranged in generic toolkits or tool boxes [ 1 , 173 , 174 ] or with solutions for specifi c laboratory sections like microbiology [ 12 , 88 ] , toxicology [ 5 ] , chemistry [ 175 ] , transfusion medicine [ 176 ] , and molecular diagnostics [ 177 -180 ] . this useful approach provides a resource for the exploration of laboratory test utilization management issues and their potential resolution using a method that is successful in your local geographical environment. 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principles and practice of point-of-care testing principles and practice of point-of-care testing reverse-transcription polymerase chain reaction detection of the enteroviruses. overview and clinical utility in pediatric enteroviral infections creating a new civilization: the politics of the third wave hospital laboratory outreach program builds success through affi liation with a laboratory network outreach implementation requirement: a case study yearly clinical laboratory tests expenditures for different medical specialties in a major canadian city recommendations for the laboratory-based detection of chlamydia trachomatis and neisseria gonorrhoeae -2014 accuracy of results obtained by performing a second ligase chain reaction assay and pcr analysis on urine samples with positive or near-cutoff results in the lcx test for chlamydia trachomatis newborn screening: adapting to advancements in whole-genome sequencing design of a genomics curriculum. competencies for practicing pathologists standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the american college of medical genetics and genomics and the association for molecular pathology molecular diagnostic profi ling of lung cancer specimens with a semiconductor-based massive parallel sequencing approach. feasibility, costs, and performance compared with conventional sequencing a variant detection pipeline for inherited cardiomyopathy-associated genes using next-generation sequencing non-invasive prenatal rhd genotyping using cell-free fetal dna from maternal plasma: an italian experience society for maternal-fetal medicine. cell-free dna for fetal aneuploidy. committee opinion number 640 dna sequencing versus standard prenatal aneuploidy screening noninvasive prenatal testing and incidental detection of occult maternal malignancies circulating cell-free tumour dna in the management of cancer maldi-tof mass spectrometry for microorganism identifi cation beyond identifi cation. emerging and future uses for maldi-tof mass spectrometry in the clinical microbiology laboratory disposable platform provides visual and color-based point-of-care anemia self testing a smartphone dongle for diagnosis of infectious disease at the point of care new quick and cheap bedside test for cortisol uses smartphone can hospital rounds with pocket ultrasound by cardiologists reduce standard echocardiology? point-of-care ultrasound in medical education-stop listening and look defi ning digital medicine tattoo-bases non-invasive glucose monitoring: a proof-ofconcept study all-organic optoelectronic sensor for pulse oximetry bioinformatics for beginners. genes, genomes, molecular evolution, databases and analytical tools. london: academic computational solutions for omics data confi rming variants in next-generation sequencing panel testing by sanger sequencing digital imaging in pathology guideline from the college of american pathologists pathology and laboratory quality center why disruptive innovations matter in laboratory diagnostics pathology resident and fellow education in a time of disruptive technologies role of cell culture for virus detection in the age of technology replacement of biologic by molecular techniques in diagnostic virology: thirty years after the advent of pcr technology-do we still need conventional methods? detection of respiratory viruses by molecular methods utilization management in microbiology impact upon clinical outcomes of translation of pna fish-generated laboratory data from the clinical microbiology bench to bedside in real time rapid diagnosis of staphylococcus aureus bacteremia using s. aureus pna fish an evaluation of the advandx staphylococcus aureus /cns pna fish assay emerging technologies for rapid identifi cation of bloodstream pathogens clinical consequences of using pna-fish in staphylococcal bacteraemia impact of an assay that enables rapid determination of staphylococcus species and their drug susceptibility on the treatment of patients with positive blood culture results an antimicrobial stewardship program impact with rapid polymerase chain reaction methicillin-resistant staphylococcus aureus / s. aureus blood culture test in patients with s. aureus bacteremia impact of rapid methicillin resistant staphylococcus aureus polymerase chain reaction testing on mortality and cost effectiveness in hospitalized patients with bacteraemia: a decision model le interest of realtime pcr xpert mrsa/sa on genexpert(®) dx system in the investigation of staphylococcal bacteremia evaluation of the verigene gram-positive blood culture nucleic acid test for rapid detection of bacteria and resistance determinants rapid detection of gram-positive organisms by use of the verigene gram-positive blood culture nucleic acid test and the bact/alert pediatric fan system in a multicenter pediatric evaluation evaluation of a microarray-based assay for rapid identifi cation of gram-positive organisms and resistance markers in positive blood cultures multiplex identifi cation of gram-positive bacteria and resistance determinants directly from positive blood culture broths: evaluation of an automated microarray-based nucleic acid test evaluation of the nanosphere verigene gram-positive blood culture assay with the versatrek blood culture system and assessment of possible impact on selected patients performance of the verigene gram-positive blood culture assay for direct detection of gram-positive organisms and resistance markers in a pediatric hospital evaluation of filmarray and verigene systems for rapid identifi cation of positive blood cultures clinical evaluation of the filmarray blood culture identifi cation panel in identifi cation of bacteria and yeasts from positive blood culture bottles discrimination of candida albicans from candida dubliniensis by use of the biofire filmarray blood culture identifi cation panel clinical signifi cance and outcomes of polymicrobial staphylococcus aureus prospective assessment of filmarray technology for the rapid identifi cation of yeasts isolated from blood cultures rapid identifi cation of pathogens from positive blood cultures by multiplex polymerase chain reaction using the filmarray system community respiratory virus infections in immunocomprised patients: hematopoietic stem cell and solid organ transplant recipients, and individuals with human immunodefi ciency virus infection viral diagnostics and antiviral therapy in hematopoietic stem cell transplantation respiratory viral infections in transplant recipients evaluation of multiple test methods for the detection of the novel 2009 infl uenza a (h1n1) during the new york city outbreak cost analysis of multiplex pcr testing for diagnosing respiratory virus infections implementation of filmarray respiratory viral panel in a core laboratory improves testing turnaround time and patient care early estimates of seasonal infl uenza vaccine effectiveness. united states co-infections with infl uenza and other respiratory viruses coronavirus causes lower respiratory infections less frequently than rsv in hospitalized norwegian children identifi cation of viral and atypical bacterial pathogens in children hospitalized with acute respiratory infections in hong kong by multiplex pcr assays survey of physician diagnostic practices for patients with acute diarrhea: clinical and public health implications what is new in clinical microbiology: microbial identifi cation by maldi-tof mass spectrometry application of maldi-tof mass spectrometry in clinical diagnostic microbiology applications of maldi-tof mass spectrometry in clinical diagnostic microbiology maldi-tof mass spectrometry applications in clinical microbiology matrix-assisted laser desorption ionization-time of fl ight mass spectrometry: a fundamental shift in the routine practice of clinical microbiology maldi-tof mass spectrometry for microorganism identifi cation comparison of two matrix-assisted laser desorption ionization-time of fl ight mass spectrometry methods with conventional phenotypic identifi cation of bacteria to the species level performance of the vitek ms matrix-assisted laser desorption ionization-time of fl ight mass spectrometry system for rapid identifi cation of bacteria in routine clinical microbiology high-throughput identifi cation of bacteria and yeast by matrix-assisted laser desorption ionization-time of fl ight mass spectrometry in conventional medical microbiology laboratories performance of matrix-assisted laser desorption ionization-time of fl ight mass spectrometry of identifi cation of bacterial strains routinely isolated in a clinical microbiology laboratory prospective evaluation of a matrix-assisted laser desorption ionization-time of fl ight mass spectrometry system in a hospital clinical microbiology laboratory for identifi cation of bacteria and yeasts: a bench-by-bench study of assessing the impact on time to identifi cation and cost-effectiveness matrix-assisted laser desorption ionization-time of fl ight mass spectrometry for identifi cation of clinically signifi cant bacteria that are diffi cult to identify in clinical laboratories performance and cost analysis of matrix-assisted laser desorption ionization-time of fl ight mass spectrometry for routine identifi cation of yeasts for the diagnosis of infectious diseases direct identifi cation of bacteria in positive blood cultures: comparison of two rapid methods, filmarray and mass spectrometry evaluation of three rapid diagnostic methods for direct identifi cation of microorganisms in positive blood cultures direct identifi cation of bacteria causing urinary tract infections by combining matrix-assisted laser desorption ionization-time of fl ight mass spectrometry with uf-1000i urine fl ow cytometry procedure for microbial identifi cation based on matrix-assisted laser desorption ionization-time of fl ight mass spectrometry from screening-positive urine samples direct identifi cation of urinary tract pathogens from urine samples by matrix-assisted laser desorption ionization-time of fl ight matrix-assisted laser desorption ionization-time of fl ight (maldi-tof) mass spectrometry for detection of antibiotic resistance mechanisms: from research to routine diagnosis matrix-assisted laser desorption ionization-time of fl ight mass spectrometry for rapid identifi cation of tick vectors mechanism of fl uconazole resistance in candida krusei clinical practice guidelines for the management of candidiasis: 2009 update by the infectious diseases society of america t2 magnetic resonance assay for the rapid diagnosis of candidemia in whole blood: a clinical trial t2 magnetic resonance: a diagnostic platform for studying integrated hemostasis in whole blood-proof of concept comparison of the t2dx instrument with t2candida assay and automated blood culture in the detection of candida species using seeded blood samples automation in clinical microbiology point-counterpoint: the automated clinical microbiology laboratory: fact of fantasy? automation in the clinical microbiology laboratory emerging technologies for the clinical microbiology laboratory laboratory automation in clinical microbiology: a quiet revolution automation in clinical bacteriology: what system to choose? the future of diagnostic bacteriology the william beaumont hospital experience with total laboratory automation verifi cation of method performance for clinical laboratories verifying performance characteristics of quantitative analytical systems satisfying regulatory and accreditation requirements for quality control three of 7 hemoglobin a1c point-of-care instruments do not meet generally accepted analytical performance criteria utilization of assay performance characteristics to estimate hemoglobin a1c result reliability performance of hemoglobin a1c assay methods: good enough? evaluation of the sebia capillarys 2 fl ex piercing for the measurement of hb a1c on venous and capillary blood samples effects of 49 rare hb variants on hb a1c measurements in eight methods hemoglobin a1c: evaluation of 4 methods antiquated tests within the clinical pathology laboratory requiem for a heavyweight: the demise of creatine kinase-mb creatine kinase-mg. the journey to obsolescence should the qualitative serum pregnancy test be considered obsolete? aetna clinical policy bulletin: obsolete and unreliable tests and procedures the interpretation of the serum protein-bound iodine: a review cerebrospinal fl uid myelin basic protein is frequently ordered but has little value. a test utilization study acg clinical guidelines: diagnosis and management of celiac disease laboratory formularies the laboratory test utilization management toolbox reducing unnecessary laboratory testing using health informatics applications. a case study in a tertiary care hospital effect of population-based interventions on laboratory utilization. a time series analysis utilization management in the blood transfusion service clinical requests for molecular tests. the 3-step evidence check improving molecular genetic test utilization through order restriction, test review, and guidance genetic counselor review of genetic test orders in a reference laboratory reduces unnecessary testing differences in brca counseling and testing practices based on ordering provider type key: cord-255746-ir73lpi8 authors: sirimaturos, michael; gotur, deepa b.; patel, samir j.; dreucean, diane; jakowenko, nicholas; cooper, megan h.; brahmbhatt, nishal; graviss, edward a.; nguyen, duc t.; pingali, sai ravi; lin, jiejian; musick, william l. title: clinical outcomes following tocilizumab administration in mechanically ventilated coronavirus disease 2019 patients date: 2020-10-01 journal: crit care explor doi: 10.1097/cce.0000000000000232 sha: doc_id: 255746 cord_uid: ir73lpi8 effective treatments for the critically ill patient with novel coronavirus disease 2019 are desperately needed. given the role of cytokine release syndrome in the pathogenesis of coronavirus disease 2019-associated respiratory distress, therapies aimed at mitigating cytokine release, such as the interleukin-6 receptor-inhibiting monoclonal antibody tocilizumab, represent potential treatment strategies. therefore, we examined the outcomes of critically ill coronavirus disease 2019 patients treated with tocilizumab and factors associated with clinical improvement. design: a retrospective cohort analysis of 21-day outcomes for consecutive mechanically ventilated patients treated with tocilizumab from march 24, 2020, to may 4, 2020. setting: nine icus at six hospitals within a hospital system in houston, texas, united states. patients: the first 62 coronavirus disease 2019 patients on invasive mechanical ventilation who were treated with tocilizumab, which was considered for all patients with severe disease. interventions: tocilizumab was administered either at a weight-based dose of 4–8 mg/kg or at a flat dose of 400 mg, with repeat administration in some patients at the physician’s discretion. measurements and main results: the primary outcomes were mortality and clinical improvement, defined as extubation. by day 21 post-tocilizumab, clinical improvement occurred in 36 patients (58%) and 13 patients (21%) died. in both univariable and multivariable analyses, age less than 60 years was associated with clinical improvement. transient transaminitis was the most common adverse reaction, occurring in 25 patients (40%). conclusions: based on clinical outcomes and mortality rates seen in previous reports of mechanically ventilated patients, tocilizumab, as part of the management strategy for severe coronavirus disease 2019, represents a promising option. these findings support the need for evaluation of tocilizumab in a randomized controlled trial. t he clinical presentation of severe acute respiratory syndrome coronavirus 2 (sars-cov-2) associated coronavirus disease 2019 (covid-19) varies widely, and acute respiratory distress syndrome (ards) represents a severe manifestation of the disease and ultimately may result in death (1, 2) . preliminary reports from china were highly discouraging, indicating mortality rates of 81-97% in those with severe ards requiring invasive mechanical ventilation (1, 2) . in the united states, mortality rates of 24-67% have been observed in critically ill cohorts (3) (4) (5) . patients with greater disease severity have been shown to express elevated concentrations of proinflammatory cytokines, implicating cytokine release syndrome (crs) or cytokine storm in the pathogenesis of covid-19 induced ards (2, 6-8). thus, among the numerous treatment modalities being evaluated, those targeting cytokine dysregulation are of major interest as a management strategy for covid-19 (9) . the level of interleukin (il)-6 expression is thought to have a prominent role in distinguishing between patients with severe disease and a high likelihood of mortality, compared with those with milder disease (9) . tocilizumab is a recombinant humanized monoclonal antibody against the il-6 receptor, inhibiting subsequent il-6-mediated signaling and thereby potentially mitigating crs. tocilizumab is food and drug administration (fda) approved for the treatment of several conditions including severe chimeric antigen receptor t cell-induced crs (10) . therefore, tocilizumab may be a suitable therapy for the management of critically ill covid-19 patients. based on the potential role of tocilizumab in modulating crs as well as its established clinical and safety profile, our center included tocilizumab as part of its covid-19 treatment algorithm since early march 2020. while several reports on tocilizumab treatment in covid-19 patients now exist, data pertaining specifically to tocilizumab use in a large cohort of critically ill patients on invasive ventilation is lacking (11, 12) . thus, in this report, we describe the 21-day outcomes of mechanically ventilated patients with severe covid-19 who received tocilizumab as part of their management strategy. this retrospective review of covid-19 patients managed within the houston methodist hospital system from march 24, 2020, to may 4, 2020, used data from electronic medical records and the institution's clinical surveillance program. patients were critically ill (i.e., requiring invasive mechanical ventilation) and received tocilizumab after intubation or within 24 hours before intubation. sars-cov-2 infection was confirmed by reverse transcriptase polymerase chain reaction assay performed on nasopharyngeal or sputum specimens. retrospective review was approved by the institutional review board of the houston methodist research institute. beginning early march 2020, a consensus treatment algorithm for the management of hospitalized covid-19 patients was developed at the institution level. the algorithm used a disease severity classification to guide supportive measures and pharmacologic treatment. management consisted of supportive care only for patients with mild disease, consideration of hydroxychloroquine for patients with moderate disease, and consideration of hydroxychloroquine with or without ribavirin for patients with severe disease (defined as oxygen saturation < 94%, respiratory rate > 30 breaths per minute, > 4 l of oxygen by nasal cannula, or imminent respiratory failure). all patients were screened for inclusion in ongoing industry-sponsored clinical trials or compassionate use programs for investigational antiviral agents. given the rapidity of the spread of the virus as well as emerging data regarding potential treatment options, additional off-label or investigational agents were administered at the medical team's discretion. tocilizumab administration was considered in patients with moderate disease and risk factors for worse covid-19 outcomes and in all patients with severe disease, according to the institutional algorithm. all patients receiving tocilizumab were screened for contraindications prior to administration. initially, tocilizumab (genentech, san francisco, ca) was administered intravenously at a dose of 4-8 mg/kg. during evolution of the treatment algorithm, a flat dose of 400 mg was adopted to prevent medication shortage within the hospital system. a repeat dose was administered at the discretion of the treating physician. the primary outcomes of interest were mortality and clinical improvement, defined as extubation, at 21 days post-tocilizumab administration. additional outcomes included changes in inflammatory markers (il-6, c-reactive protein [crp], lactate dehydrogenase [ldh], and ferritin) and respiratory markers (ratio of the pao 2 /fio 2 and positive end-expiratory pressure [peep]) in those who remained ventilated over the first week post-tocilizumab. in addition, radiographic assessment of the quality of lung edema (rale) score was calculated daily over the first week and at days 10, 14, and 21 when available. hospital discharge status and serious adverse events potentially associated with tocilizumab according to the product labeling were also collected (13) . patient characteristics were reported as frequency and proportion for categorical variables and as median and interquartile range or mean and sd for continuous variables. differences across groups were determined by chi-square or fisher exact tests for categorical variables and wilcoxon rank-sum test or t test for continuous variables as appropriate. the distribution of markers was depicted by box plots and the mean change over time assessed by linear mixed modeling. post hoc marginal pairwise comparisons were performed to determine the adjusted means and 95% cis of the changes in each continuous variable. cox regression analyses were used to determine the characteristics associated with clinical improvement. variables for the multivariable models were selected based on clinical importance and stata's lasso technique with the cross-validation selection option. model performance was determined by the c-statistic. good calibration was determined by a nonsignificant hosmer-lemeshow goodness-of-fit test. the likelihood ratio test was used to reduce model subsets. analyses were performed on stata version 16.1 (statacorp llc, college station, tx). a p value of less than 0.05 was considered statistically significant. a total of 69 patients who initially presented to six different hospitals within the hospital system received at least one dose of tocilizumab. of these, seven patients were excluded from the analysis as they were not critically ill. baseline characteristics and tocilizumab dosing for the first 62 consecutive patients with severe disease who required invasive ventilation and received tocilizumab are shown in table 1 . the cohort was primarily male (59.7%), had a mean age of 59.7 years (± 13.9 yr), and 63% were obese. the median times from symptom onset to hospital admission and from hospital admission to intubation were 6 days (3-9 d) and 1.5 days (0-3 d), respectively. thirty-two patients (51.6%) underwent prone ventilation and eight (12.9%) required venovenous extracorporeal membrane oxygenation (ecmo) prior to tocilizumab administration. laboratory markers and indicators of respiratory status are shown in table 2 . median il-6 and crp values pre-tocilizumab were 82 pg/ml (22-221 pg/ml) and 25.1 mg/dl (15.7-36.8 mg/ dl), respectively. baseline mean pao 2 /fio 2 , peep, and rale scores were 181.5 (± 89), 12.1 cm h 2 o (± 3.2 cm h 2 o), and 20.3 (± 9.3), respectively. sixty-nine percent of patients received corticosteroids, and nearly all patients (95%) received additional off-label or investigational viral-directed therapy ( table s1 , supplemental digital content, http://links.lww.com/ccx/a368). the mean weight-based tocilizumab dose was 4.8 mg/kg (± 0.9 mg/kg) and 24% of patients received a repeat infusion. the median time from symptom onset to tocilizumab administration was 9 days (7-14 d), and the time from hospital admission to tocilizumab administration was 3.5 days (2-6 d). of the 62 patients, clinical improvement occurred in 36 patients (58%) by 21 days post-tocilizumab. twenty of these patients were figure 1a . thirteen out of the 62 patients (21%) remained intubated 21 days following tocilizumab administration. by day 21 post-tocilizumab, 13 patients (21%) died. time to death is shown by kaplan-meier analysis in figure 1b . in 11 patients, life support measures were withdrawn in the presence of irreversible hypoxemic respiratory failure and concomitant multisystem organ failure. in one case, resuscitation was performed in a patient with severe bradycardia and subsequent pulseless electrical activity. in another case, life support was withdrawn following intraventricular hemorrhage in a patient on venovenous ecmo. factors associated with clinical improvement or mortality were evaluated using logistic regression. age less than 60 years was significantly associated with clinical improvement at 21 days, whereas hypertension and history of cancer were associated with lack of clinical improvement ( table 3) . male gender and ribavirin administration approached significance (p < 0.2) and were therefore included in the multivariable model. of these, only age less than 60 years remained significantly associated with clinical improvement in multivariable analysis (odds ratio, 3.56; 95% ci, 1.02-12.34; p = 0.045). several factors were associated with mortality by univariable analysis (table s2 , supplemental digital content, http://links. lww.com/ccx/a368). these included age, male gender, hypertension, smoking history, cancer history, lower absolute lymphocyte count at baseline, and higher sequential organ failure assessment score. azithromycin administration was the only pharmacologic similarly, only one out of 11 patients who received convalescent plasma with tocilizumab died during the same period. in all patients, il-6 increased beginning on day 1 post-tocilizumab as expected and remained elevated throughout the first week (mean increase of 1,166 pg/ml; p = 0.054; fig. 2a) . crp decreased by a mean of 50% (± 40) of the pre-tocilizumab value by day 2 and by 80% (± 20) by day 3 post-tocilizumab. overall, crp decreased significantly in all patients from baseline to day 7 posttocilizumab (mean decrease of 24.6 mg/dl; p < 0.001; fig. 2b ). ferritin, ldh, and pao 2 /fio 2 did not change significantly over the 7 days post-tocilizumab ( fig. 2c-e) , whereas peep decreased slightly (mean decrease 1.7 cm h 2 o; fig. 2f ). overall, there were no differences in inflammatory markers, pao 2 /fio 2 , or peep over the 7 days post-tocilizumab therapy based on clinical outcomes (figs. s1 and s2, supplemental digital content, http://links.lww.com/ccx/a368). however, slight improvements in pao 2 /fio 2 and peep were seen at the end of the period in those with better outcomes. since crs could lead to abnormalities in alveolar-capillary permeability and cause infiltrations on the chest radiograph, a rale score was calculated to quantify trends in pulmonary edema in gender was evaluated in the initial model; however, it was not significant and had some confounding effect on age. further evaluation between models with and without gender suggested no difference in the performance, which indicated by a nonsignificant p of the likelihood ratio test. given the number of covariates needing to be kept at minimum, gender was not included in the final model. days 0-7, then at days 10, 14, and 21 following tocilizumab administration. as shown in figure s3 (supplemental digital content, http://links.lww.com/ccx/a368), the scores did not change significantly over the follow-up period, nor did they differ significantly based on 21-day clinical improvement status. the most common adverse event following tocilizumab administration was new-onset elevation in transaminases to greater than three times the upper limit of normal, which occurred in 25 patients (40%). this was transient in 23 patients, while two patients had persistence/reoccurrence of transaminitis. transaminase levels peaked at a mean of 6.2 ± 3.9 days post-tocilizumab. five patients (8%) developed serious infections following tocilizumab administration, including two with bloodstream infections and three with bacterial pneumonia. no fungal or secondary viral infections were detected in the 21-day follow-up period. four patients (6.5%) experienced severe thrombocytopenia (< 50,000 per mm 3 ) . no patient experienced severe neutropenia (< 500 per mm 3 ) or gastrointestinal perforations. one patient experienced an anaphylactic reaction with a probable association to tocilizumab. during the infusion, a 74-yearold male became hypotensive and required discontinuation of the infusion, vasopressor therapy, diphenhydramine, and hydrocortisone. the patient recovered from the anaphylactic reaction but continued to deteriorate clinically due to ongoing multiple organ dysfunction over the following 6 days and eventually succumbed to multiple organ system failure. at nearly 800,000 deaths globally related to covid-19 reported thus far and the lack of an effective treatment for critically ill patients, there remains an urgent need to evaluate both investigational and commercially available off-label therapies for the management of covid-19. based on descriptions of the role of crs in the pathogenesis of covid-19 pneumonia, as well as the devastating outcomes initially described in critically ill patients, our center adopted the use of tocilizumab to mitigate the hyperinflammatory response thought to contribute to ards and mortality. patients with severe covid-19 reviewed here were not only mechanically ventilated, but also had several risk factors for poor outcomes following covid-19, including a high prevalence of patients with hypertension, diabetes, obesity, and smoking history. our report of tocilizumab in patients exclusively receiving invasive mechanical ventilation demonstrates a 21-day mortality of 21% and clinical improvement at day 21 in 58% of patients with severe disease. mortality rates among critically ill patients with severe covid-19 are difficult to ascertain due to geographic variation and differences in follow-up duration. staggering mortality rates of 81-97% in mechanically ventilated patients were initially observed in chinese cohorts (1, 2), whereas u.s. experiences describe rates of 24-67% (3) (4) (5) . reports on tocilizumab, specifically in critically ill populations, are limited. some include patients of moderate to severe disease, with smaller numbers of patients requiring invasive ventilation (11) (12) (13) . in a series from qatar, of 21 patients who required invasive ventilation prior to tocilizumab, seven remained on ventilation at 14 days post-tocilizumab administration (14) . another larger series from italy found that among 43 patients requiring invasive ventilation, 77% improved and 24% died after 10 days after tocilizumab administration (15) . in a cohort from yale, 14-day survival among 42 mechanically ventilated patients with severe disease was 74% (16) . finally, a recent study of 78 patients receiving tocilizumab showed lower mortality when compared with 76 patients who did not receive tocilizumab (18% vs 36%) at 28 days (17) . on the contrary, a news article cited tocilizumab as failing to reduce severe respiratory symptoms, icu visits, and deaths compared with standard care in a nonrandomized trial (18) , while release of phase iii data noted tocilizumab did not meet its endpoints of improved clinical status or reduced mortality (19) . importantly, details of these studies, which also included patients at earlier stages of the disease and outcomes specifically in the most severe patients have not been described. therefore, mortality and clinical improvement rates in our tocilizumab cohort appear to be at least comparable if not more favorable than those in similar populations previously reported. interestingly, mortality and clinical improvement in our cohort closely resemble those seen in mechanically ventilated patients from the compassionate use experience with remdesivir (20) . in those patients, grein et al (20) reported mortality of 18% and improvement in 56% with a median follow-up of 18 days. preliminary data from the placebo-controlled trial of remdesivir, which subsequently led to its emergency use authorization by the fda for treatment of severe covid-19, do not demonstrate differences in recovery or mortality rates between the remdesivir and placebo groups among patients on invasive ventilation (21) . thus, it is still crucial to identify effective therapies, particularly in critically ill patients. it is noteworthy that in our cohort, mortality appeared to be lower in those who received either remdesivir or convalescent plasma with tocilizumab (9.1%) compared with tocilizumab without these therapies (23.5%). hence, future studies may consider the use of combination therapies to combat covid-19 in critically ill patients. to identify early indicators of clinical improvement or mortality, we evaluated daily inflammatory markers as well as indicators of respiratory status and oxygenation support during the first 7 days post-tocilizumab. while crp changed significantly over this time, no differences were seen in crp, il-6, ferritin, or ldh in relation to clinical improvement or survival status. other studies that evaluated biomarkers later in the disease progression after 7 days have demonstrated reductions in inflammatory markers among recovering patients (22) . therefore, it is possible that monitoring of inflammatory markers immediately post-tocilizumab may not aid in identification of patients with poor prognosis, particularly among those who have already reached ards. information on radiographic scoring in the setting of covid-19 is limited. a study using modified rale scoring found that chest radiograph consolidation peaked at 10-12 days from symptom onset (23) , which was consistent with the time from symptom onset to tocilizumab administration in our cohort. however, no significant change was seen in rale scores during the 21-day period following tocilizumab administration. this could be attributed to other confounders such as fluid balance, peep management, or radiographic lag time compared with clinical improvement. given the severity of illness and presence of concomitant diagnoses in this cohort, we limited our safety analysis to serious potential complications associated with tocilizumab. tocilizumab had an acceptable safety profile for most patients, with transient transaminitis being the most common side effect and a low rate of new-onset infections. a probable case of anaphylaxis occurred, which has been reported in less than 1% of patients (24) . further study comparing tocilizumab use against a control group is vital to adequately evaluate the safety in this setting. the primary limitations of this study are its retrospective nature, relatively small sample size, and lack of a control group, which prevents any assertion of the effectiveness of tocilizumab. the dosing of tocilizumab also varied among patients, with a flat dose used in most cases. furthermore, in the setting of rapidly progressing respiratory distress and without known effective therapies against covid-19, a myriad of off-label and experimental agents were used in this cohort, which may have confounded the true impact of tocilizumab. this includes the frequent use (69%) of corticosteroids, which has been shown in a large cohort of mechanically ventilated patients to reduce mortality (25) . finally, although our multivariate logistic regression model has a ratio of events per covariate slightly lest that the ratio of 10 events per predictor as suggested by harrell et al (26) , there is a growing number of more recent publications recommended that the rule of "10 events for one covariate" can be relaxed. specifically, in their large factorial simulation study, vittinghoff and mcculloch (27) suggested that models with 5-9 events per covariate are usually comparable to those with 10-16 events per covariate (28) . several strengths of the current report should be noted as well. our experience represents one of the largest series of tocilizumab-treated patients on invasive mechanical ventilation. the population is diverse, with nearly 30% of the cohort being african american or hispanic/latino. the data offer insights into early trends in inflammatory markers and respiratory status and is the first to evaluate rale scores assessing changes in chest radiographs in a cohort of its kind. finally, these results may inform certain plausible combinations of therapies, such as tocilizumab with remdesivir or convalescent plasma, for the management of critically ill covid-19 patients. since the release of preliminary phase iii data, we have removed tocilizumab from the covid-19 treatment algorithm, but continue to consider its use or the use of other immunomodulatory agents on a case-by-case basis pending further analyses. in conclusion, mortality and clinical improvement rates reported here appear to be better than initial reports in similar critically ill cohorts, and comparable to reports on emerging treatment modalities. while recent reports cite tocilizumab as failing to improve clinical outcomes in covid-19 positive patients, it is important to note that our cohort was focused on a high-risk cohort of patients already exhibiting severe respiratory distress and on invasive mechanical ventilation. our experience, therefore, supports the need for continued evaluation of the il-6 inhibitor tocilizumab in a randomized controlled trial for treatment of covid-19, particularly in invasively ventilated patients. clinical course and outcomes of critically ill patients with sars-cov-2 pneumonia in wuhan, china: a singlecentered, retrospective, observational study clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study and the northwell covid-19 research consortium: presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area characteristics and outcomes of 21 critically ill patients with covid-19 in washington state covid-19 in critically ill patients in the seattle region -case series detectable serum sars-cov-2 viral load (rnaaemia) is closely correlated with drastically elevated interleukin 6 (il-6) level in critically ill covid-19 patients epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study longitudinal characteristics of lymphocyte responses and cytokine profiles in the peripheral blood of sars-cov-2 infected patients cytokine release syndrome in severe covid-19: interleukin-6 receptor antagonist tocilizumab may be the key to reduce mortality fda approval summary: tocilizumab for treatment of chimeric antigen receptor t cell-induced severe or lifethreatening cytokine release syndrome effective treatment of severe covid-19 patients with tocilizumab tocilizumab treatment in covid-19: a single center experience pilot prospective open, single-arm multicentre study on off-label use of tocilizumab in patients with severe covid-19 tocilizumab for the treatment of severe coronavirus disease 2019 tocilizumab for the treatment of severe covid-19 pneumonia with hyperinflammatory syndrome and acute respiratory failure: a single center study of 100 patients in tocilizumab treatment for cytokine release syndrome in hospitalized covid-19 patients: survival and clinical outcomes tocilizumab for treatment of mechanically ventilated patients with covid-19 rheumatoid arthritis drug fails to help covid-19 patients in italian study. 2020. reuters health news roche provides an update on the phase iii covacta trial of actemra/roactemra in hospitalised patients with severe compassionate use of remdesivir for patients with severe covid-19 remdesivir for the treatment of covid-19 -preliminary report the role of interleukin-6 in monitoring severe case of coronavirus disease 2019 frequency and distribution of chest radiographic findings in covid-19 positive patients recovery collaborative group: dexamethasone in hospitalized patients with covid-19 -preliminary report multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors relaxing the rule of ten events per variable in logistic and cox regression no rationale for 1 variable per 10 events criterion for binary logistic regression analysis we thank amanda weiskoff, phd (office of strategic research initiatives, houston methodist) for scientific writing and editing assistance, ray black for generation of reports from clinical surveillance programs, the houston methodist pharmacy department for providing support for data collection, and the houston methodist coronavirus disease 2019 algorithm workgroup.supplemental digital content is available for this article. direct url citations appear in the printed text and are provided in the html and pdf versions of this article on the journal's website (http://journals.lww.com/ccejournal).the authors have disclosed that they do not have any potential conflicts of interest.for information regarding this article, e-mail: mwsirimaturos@houstonmethodist.org key: cord-021453-vf8xbaug authors: dysko, robert c.; nemzek, jean a.; levin, stephen i.; demarco, george j.; moalli, maria r. title: biology and diseases of dogs date: 2007-09-02 journal: laboratory animal medicine doi: 10.1016/b978-012263951-7/50014-4 sha: doc_id: 21453 cord_uid: vf8xbaug nan status as a cooperative companion animal of reasonable size. dogs were used in the mid-1600s by william harvey to study cardiac movement, by marcello malpighi to understand basic lung anatomy and function, and by sir christopher wren to demonstrate the feasibility of intravenous delivery of medications (gay, 1984) . the use of dogs continued as biomedical research advanced, and they were featured in many noteworthy studies, including those by pavlov to observe and document the conditioned reflex response and by banting and best to identify the role of insulin in diabetes mellitus. for a comprehensive but concise review of the use of the dog as a research subject, the readers are directed to the manuscript by gay (1984) . the breed of dog most commonly bred for use in biomedical research is the beagle. some commercial facilities also breed foxhounds or other larger-breed dogs for use in surgical research studies. some specific breeds with congenital or spontaneous disorders are also maintained by research institutions (see specific examples below). random-source dogs used in research are most frequently mongrels or larger-breed dogs (e.g., german shepherd, doberman pinscher, labrador and golden retrievers) that are used for surgical research and/or training. according to a computerized literature search for beagle for the years 1998-1999, approximately 40% of the biomedical scientific publications identified were in the fields of pharmacology or toxicology. especially common were studies focusing on pharmacokinetics, alternative drug delivery systems, and cardiovascular pharmacology. the next most common areas of research using beagles were dental and periodontal disease and surgery (12% of publications), orthopedic surgery and skeletal physiology (7%), and radiation oncology (4%). other research areas that utilized beagles included canine infectious disease, surgery, imaging, prostatic urology, and ophthalmology. most large-sized dogs (either purpose-bred or randomsource) are used in biomedical research because of their suitability for surgical procedures. anesthetic protocols and systems for dogs are well established, and the organs of larger-breed dogs are often an appropriate size for trials of potential pediatric surgical procedures. surgical canine models have been used extensively in cardiovascular, orthopedic, and transplantation research. there are also some unique spontaneous conditions for which dogs have proven to be valuable animal models. a colony of gray collies is maintained at the university of washington (seattle) for the study of cyclic hematopoiesis. this condition is manifested by periodic fluctuations of the cellular components of blood, most notably the neutrophil population. these dogs are used to study the basic regulatory mechanisms involved with hematopoiesis, as well as possible treatments for both the human and the canine conditions (brabb et al., 1995) . golden retrievers affected with muscular dystrophy have been used as models of duchenne muscular dystrophy in human children. duchenne muscular dystrophy is caused by an absence of the muscle protein dystrophin, inherited in an x-linked recessive manner. the dystrophy in golden retrievers is caused by absence of the same protein and is inherited in the same way. the clinical signs (such as debilitating limb contracture) are also similar between the canine and human conditions (kornegay et al., 1994) . bedlington terriers have been used to study copper storage diseases (such as wilson's disease), and the development of spontaneous diabetes mellitus and hypothyroidism in a variety of dogs has also been studied for comparisons with the human conditions. although historically the dog has been a common laboratory animal, the use of dogs in research has been waning over the past few years. according to the u.s. department of agriculture (1998) , the number of dogs used in research has declined from a high use of 211,104 in 1979 211,104 in to only 75,429 in 1997 . this decrease was caused by a variety of factors, including (but not limited to) increased cost, decreased availability, local restrictive regulations, conversion to other animal models (such as livestock or rodents), and shift in scientific interest from pathophysiology to molecular biology and genetics. dogs used for research are generally segregated into two classes: purpose-bred and random-source. purpose-bred dogs are those produced specifically for use in biomedical research; they are intended for use in long-term research projects and/or pharmacologic studies in which illness or medication would require removal from the study. usually these dogs are either beagles or mongrel foxhounds, although other breeds may be available. purpose-bred dogs typically receive veterinary care throughout their stay at the breeding facility. they are usually vaccinated against canine distemper virus, parvovirus, adenovirus type 2, parainfluenza virus, leptospira serovars canicola and icterohemorrhagiae, and bordetella bronchiseptica. rabies virus vaccination may also be included. purpose-bred dogs are also usually treated prophylactically for helminths and ectoparasites, intestinal coccidia, and bacterial ear infections (r. scipioni and j. ball, personal communication, 1999) . random-source dogs are not bred specifically for use in research. they may be dogs bred for another purpose (e.g., hunting), retired racing dogs, or stray dogs collected at pounds or shelters. the health status of these dogs can be the same quality as purpose-bred dogs, or it can be an unknown entity. randomsource dogs that have been treated and vaccinated in preparation for use in research are termed conditioned dogs. these dogs are then suitable for long-term studies or terminal preparations that require unperturbed physiologic parameters. conditioned dogs are often tested for heartworm antigen because of the implications that infestations can have on cardiovascular status and surgical risk. nonconditioned random-source dogs are useful only in a limited number of research studies, such as nonsurvival surgical training preparations. options for procurement of dogs for biomedical research typically include purchase from a u.s. department of agriculturedesignated class a or class b licensed dealer or directly from a municipal pound. the requirements for usda licensure are detailed in code of federal regulations (cfr), title 9, chapter 1 (1-1-92 edition), subchapter a, animal welfare, 1.1, definitions, and 2.1, requirements and application. briefly, class a licensees are breeders who raise all animals on their premises from a closed colony (suppliers of purpose-bred dogs are typically class a dealers). class b licensees purchase the dogs from other individuals (including unadopted animals from municipal pounds) and then resell them to research facilities. there are additional regulations that apply to class b dealers (such as holding periods and recordkeeping documentation) because of the public concern that stolen pets could enter biomedical research facilities in this manner. regulations regarding the sale of pound dogs to research facilities or class b dealers vary from state to state and include some bans on this practice. the best resource for identification of possible vendors is the "buyer's guide" issue of the periodical lab animal. typically the last issue of each year, the "buyer's guide" lists sources for both purpose-bred and random-source dogs and denotes such features as pathogen-free status, documentation of health status, and availability of specific breeds and timed pregnant females. some suppliers also have separate advertisements within that issue of the journal. welfare act (7 cfr 2.17, 2.51, and 371.2[g] ) are described in 9 cfr chapter 1 (1-1-92 edition), subchapter a, animal welfare. regulations pertaining specifically to the care of dogs used in research are found in subpart a, specifications for the humane handling, care, treatment, and transportation of dogs and cats, of part 3 (standards) of subchapter a. particular attention should be paid to section 3.6c (primary enclosures--additional requirements for dogs), because the space required for housing dogs is calculated using the length of the dog rather than the body weight (which is used for other species and also for dogs, according to national research council (nrc) guidelines). section 3.8 (exercise for dogs) describes the requirements that dealers, exhibitors, and facilities must follow in order to provide dogs with sufficient exercise. the institute of laboratory animal research (ilar) has written the "guide for the care and use of laboratory animals" (seventh edition, 1996) . the "guide" is the primary document used by institutional animal research programs to develop and design their programs, as well as by the association for assessment and accreditation of laboratory animal care international (aaalac international) and other animal care evaluation groups to facilitate site visits and inspections. the ilar committee on dogs has also written "dogs: laboratory animal management " (1994) . this publication describes "features of housing, management, and care that are related to the expanded use of dogs as models of human diseases" and includes "an interpretive summary of the animal welfare regulations and the requirements of the public health service policy on humane care and use of laboratory animals." the reader is encouraged to use these publications to obtain further information on care and husbandry of dogs in the biomedical research setting. growth data for beagles from a purpose-bred dog breeding facility are provided in table i . table ii features hematology data from beagles from the same commercial facility. table iii lists serum and urine chemical data for beagles. normal physiologic data for dogs (no breed specified) are provided in table iv . the information presented in the tables represents a range of normal values that can vary, depending on the analytical method and equipment used as well as the age, breed, gender, and reproductive status of the animal. federal regulations promulgated by the animal and plant health inspection service, usda, in response to the animal good nutrition and a sound, balanced diet are essential to the health, performance, and well-being of the animal. the basic nutrient requirements for dogs have been compiled by the nrc and represent the average amounts of nutrients that a group of animals should consume over time to maintain growth and prevent deficiencies (national research council, 1985) . the reader is referred to these guidelines for useful reference points for management of an animal's diet during various physiologic states (e.g., gestation, lactation, maturational age). most commercially available balanced dog diets are "closedformula" diets, in which the labeled specific minimum requirements for protein and fat, and the maximum values for ash and fiber, are met. these diets do not necessarily provide the identical composition of ingredients from batch to batch. ingredient composition varies, depending on the cost relationships of the various ingredients as the manufacturer attempts to achieve the label requirements at the lowest ingredient cost. an "openformula" (or "fixed-formula") diet provides more precise dietary control. in these diets the ingredients are specified, and the percentage of each ingredient is kept constant from batch to batch. "semipurified" diets provide for the strictest control of ingredients and are formulated from the purified components: amino acids, lipids, carbohydrates, vitamins, and minerals. the animal care provider should be aware of the manufacture date of the diet, which should be clearly visible on the bag. as a general rule, diets are generally safe for consumption up to 6 months following the manufacture date when stored at room temperature. refrigeration may prolong the shelf life, but the best strategy is to use each lot based on the date of manufacture in order to prevent food from expiring and to ensure that only fresh diets are fed. specifications for feeding and watering of dogs are provided in the regulations of the animal welfare act. recommendations for feeding the appropriate amount of diet are determined by the dog's metabolic requirements. the basal metabolic rate, or basal energy requirement (ber), refers to the amount of energy expended following sleep, 12-18 hours after food consumption, and during thermoneutral conditions (kleiber, 1975; lewis et al., 1987) . the maintenance energy requirement (mer) is the amount of energy used by a moderately active adult animal in a thermoneutral environment, which in the dog is approximately twice the ber (lewis et al., 1987) . for dogs weighing greater than 2 kg, the mer may be calculated using this simplified linear equation: mer (metabolizable kcal/day) = 2(30 weightkg + 70) (national research council, 1985; lewis et al., 1987) . the quantity of a correctly balanced diet to be fed to each dog can then be determined by dividing the mer by the energy density of the diet. fat provides three major dietary functions, including absorption of fat-soluble vitamins (a, d, e, and k), enhancement of palatability, and provision of essential (unsaturated) fatty acids. dietary fat is an excellent, highly digestible energy source, providing 2.25 times more energy on a per weight basis than either soluble carbohydrates or proteins (lewis et al., 1987) . however, fats are not needed for this purpose when adequate carbohydrate and protein are present. consumption of fat in excess of an animal's ability to metabolize it results in steatorrhea and has been related to the development of acute pancreatitis, whereas lack of dietary fat may lead to a fatty acid/energy deficiency. fatty acid deficiency is associated with poor growth, poor physical performance, reduced reproductive performance, and weight loss. dogs are considered to be "easy keepers," because they do not have as many absolute nutritional requirements as their domestic counterpart, the cat. however, they do possess a unique requirement for certain polyunsaturated fatty acids, a deficiency of which may predispose them to decreased growth rates and dermatologic abnormalities, such as "hot spots." dogs require linoleic (f2-6) acid, an essential fatty acid (national research council, 1985) , and more recently it has been demonstrated that the f2-3 fatty acids may play a role in maintaining healthy skin (logas and kunkle, 1994) . supplementation with a balanced essential fatty acid product (e.g., derm caps) may alleviate allergy-related dermatoses such as flea-bite dermatitis and pyoderma (logas and kunkle, 1994; miller, 1989) . essential fatty acid deficiency can occur in dogs receiving low-fat dry dog food that has been stored too long, particularly under warm, humid conditions (lewis et al., 1987) . there are 22 a-amino acids, 10 of which cannot be synthesized in sufficient quantity to meet a dog's normal metabolic demands for growth and maintenance. hence, as their name implies, these essential amino acids are required by all dogs and must be provided in the diet. the essential amino acids and the minimal requirements for growth are listed elsewhere (lewis et al., 1987) . chronic excessive protein intake may be detrimental to the kidney by contributing to accelerated renal aging and subsequent glomerulosclerosis (lewis et al., 1987) . conversely, inadequate protein intake results in retardation of growth and adata graciously provided by r. scipioni and j. ball of marshall farms usa, inc., north rose, new york. beagles tested for period 2/28/99-9/01/99. b s.d., standard deviation; wbc, white blood cells; rbc, red blood cells; hgb, hemoglobin; hct, hematocrit; mcv, mean corpuscular volume; mch, mean corpuscular hemoglobin; mchc, mean corpuscular hemoglobin concentration; rdw, red cell distribution width; hdw, hemoglobin distribution width; plt, platelets; mpv, mean platelet volume; neut, neutrophils; lymp, lymphocytes; mono, monocytes; eos, eosinophils; baso, basophils; luc, large unstained cells; li, lobularity index; mpxi, mean peroxidase activity index reduction in production and/or performance. protein deficiency, a potential consequence of decreased food intake, results in decreased energy intake. as a compensatory mechanism for a lack of fat or carbohydrate, body protein catabolism ensues in order to meet energy demands, thus exacerbating the negative protein balance and contributing to the clinical signs of edema/ascites, unkempt appearance, lethargy, and weight loss. thus, caloric needs must be met before protein needs (lewis et al., 1987) , an important concept to bear in mind in the event of research experiments that may predispose to anorexia. in general, providing a good quality commercial diet that supplies the required amount of amino acids and caloric requirements of the animal, while avoiding excess protein, will ensure nutritional stability and promote longevity. appropriate mineral balance in the diet is very important. the best approach in the laboratory setting is to feed a commercial diet that has been formulated with the proper amount and balance of minerals for normal growth. the recommended amount of dietary minerals and the major causes and clinical signs of deficiencies are published elsewhere (lewis, 1987) . determining the specific mineral involved in an imbalance can be a diagnostic challenge, because the clinical signs for several excesses/ 2.0 (basal) 12.6 (anestrus) 2.0 c <0.5 c 20-100 c 4-73 r (continues) deficiencies are similar and nonspecific. a definitive diagnosis is often made only after the diet has undergone analysis of the mineral components. once the imbalance has been identified, the safest resolution to the problem is to discard the entire lot of misformulated diet. attempting to correct the imbalance through oral supplementation is likely to be more harmful than beneficial, and it risks intensifying the problem by creating additional mineral imbalances. vitamins function as enzymes that regulate a wide variety of physiologic processes. they are divided into two groups based on their solubility. the fat-soluble vitamins include a, d, e, and k, whereas the rest are water-soluble. a list of the vitamins, their requirements, and clinical signs associated with deficiencies and toxicities is published elsewhere (lewis et al., 1987) . cases of dietary deficiency are rarely encountered in the research setting, because laboratory dog chows are fortified with vitamins. additional vitamin supplementation may occasionally be required during prolonged clinical illnesses, such as polyuria or diarrhea, which predispose to loss of water-soluble vitamins (b complex and c) (lewis et al., 1987) . however, as with minerals, routine supplementation of vitamins may induce inadvertent toxicity and exacerbation of an imbalance. management of a breeding colony requires broad knowledge of the dog's anatomy, reproductive physiology, and behavioral needs during breeding, gestation, and parturition. although a comprehensive discussion of the biology of canine reproduction is beyond the scope of this chapter, essential features of the broad topics noted above are presented. this section is largely based on information assimilated from texts such as "miller's anatomy of the dog" (evans and christensen, 1993) , "veterinary reproduction and obstetrics" (arthur et al., 1989) , and an issue of veterinary clinics of north america: small animal practice devoted to pediatrics of puppies and kittens (hoskins, 1999) . the ovaries of the bitch are attached to the dorsolateral walls of the abdominal cavity caudal to the kidneys by the broad ligaments and are not palpable abdominally. the uterus consists of the cervix, uterine body, and uterine horns. the cervix is an abdominal organ, located approximately halfway between the birchard and sherding (1994) . ovaries and the vulva. when the bitch is in proestrus and estrus, the cervix can be distinguished during abdominal palpation as an enlarged, turgid, walnut-shaped structure. catheterization of the cervix is usually not possible in the normal bitch at any stage of the reproductive cycle, except during or immediately following parturition. thus, semen is deposited at the external cervical os during natural or artificial insemination. the vagina is a long musculomembranous canal that extends from the uterus to the vulva. when the vagina is examined, the gloved finger or examination instrument should be introduced through the dorsal commissure of the vulva so as to avoid the deep ventral clitoral fossa. examination should proceed at an angle of approximately 60 ~ until the instrument or fingertip has passed over the ischial arch, after which it can be directed further craniad toward the cervix. the bitch has a monoestrous cycle, with clinical estrus occurring predominantly in january or february and again in july or august (although it can occur at any time of year). the estrous cycle consists of four stages: proestrus, estrus, diestrus, and anestrus. the average duration of proestrus is 9 days. during this stage the vulva is enlarged, turgid, and firm, and a sanguinous vaginal discharge is present. endocrinologically, proestrus is the follicular stage of the cycle, and estrogen levels peak at this time. estrus generally lasts 9 days, and the vulva is softer and smaller than in proestrus. a vaginal discharge persists during estrus and may remain serosanguinous or become straw-colored. the endocrine feature of estrus is the luteinizing hormone (lh) surge, followed by ovulation within 24-72 hours. diestrus begins approximately 9 days after the onset of standing heat. the end of this stage is 60 days later, which would be coincident with whelping if the bitch had become pregnant. serum progesterone levels peak during diestrus. the duration of anestrus is approximately 4 months. anestrus is the stage of reproductive quiescence, characterized by an absence of ovarian activity and serum progesterone levels of less than 1 ng/ml. components of the canine spermatic cord include the ductus deferens, the testicular artery and vein, the lymphatics and nerves, and the cremaster muscle. the cremaster muscle and pampiniform plexus aid in thermoregulation of the testicles, which are maintained at 2~176 lower than basal body temperature. sweat glands in the scrotum assist in lowering the scrotal temperature through evaporation. the penis is a continuation of the muscular pelvic urethra and is attached to the ischiatic arch by two fibrous crura. it is composed of fibrous tissue and three cavernous sinuses: corpus cavernosum, corpus spongiosum penis, and corpus spongiosum glandis. the accessory sex glands of the dog consist of only a well-encapsulated prostate gland that surrounds the pelvic urethra, and ampullary glands at the termination of the vas deferens in the urethra. the dog does not have seminal vesicles or bulbourethral glands. the onset of puberty ranges from 5 to 12 months of age and is affected by breed, season, and nutritional and disease status. testicular growth is rapid at this time, and the seminiferous tubules begin to differentiate. the sertoli cells form the bloodtestis barrier, the tubules become hollow, and spermatogenesis commences. this process is initiated by the secretion of lh from the anterior pituitary, which stimulates the production of testosterone by the interstitial, or leydig's, cells. secretion of follicle-stimulating hormone (fsh) by the anterior pituitary stimulates the production of other key hormones by the sertoli cells, including inhibin, androgen binding protein, and estrogen. fsh stimulates spermatogenesis in the presence of testosterone, while inhibin and estrogen play a role in a feedback loop on the pituitary gland to decrease fsh production. spermatogenesis in the dog is completed in 45 days, with subsequent maturation of sperm occurring in the epididymis for approximately 15 days. thus, the entire process from initiation of spermatogonial mitosis to delivery of mature sperm to the ejaculate is 60 days. a breeding soundness exam should be conducted to assess the probability of a male dog's successful production of offspring. factors affecting male fertility include libido, ability to copulate, testicular size, and quality and number of sperm produced. problems with libido may occur in dogs due to early weaning, isolation, or inherited abnormalities that suppress sexual behavior. animals with poor hindlimb conformation or with trauma to the back or hindlimbs may be unable to properly mount the female. there is a positive correlation with the size of the testicles as measured by scrotal circumference and the number of sperm produced. finally, parameters used to assess the quality of sperm include motility, morphology, volume, and concentration. an ejaculate (5 ml) that contains approximately 500 million progressively motile sperm without significant morphological abnormalities (such as a kinked tail) is a good indicator of normal male fertility. in general, erection, which involves muscular contractions and increased arterial blood flow to the penis, is controlled by the parasympathetic nervous system, whereas ejaculation is under sympathetic control. on mounting, the initial thrusting and ejaculation of semen last about 1 minute. the bulbus glandis becomes enlarged, which lodges the penis in the female reproductive tract. the male then dismounts and brings one hindleg over the female, and the two continue to be joined "rear to rear," a position classically termed "the tie." ejaculation of the accessory gland fluid continues for 5-30 minutes. the continued expulsion of prostatic fluid during the "tie" may serve to propel the semen from the vagina through the cervix into the uterus. fertilization occurs in the oviduct and may occur as late as 8 days after coitus, because of the long life span of sperm in the dog. however, once ovulated, oocytes generally remain viable for only 12-24 hours. therefore, the bitch should be bred prior to ovulation to ensure the presence of sperm for fertilization of live oocytes. cells of the vaginal epithelium mature to keratinized squamous epithelium under the influence of estrogen. because of the rise in estrogen throughout proestrus, with peak levels occurring just prior to the onset of standing heat, the vaginal smear can be used as an indicator of the bitch's readiness for breeding. the smear will not confirm the presence of ovulation, nor is it of prognostic value in normal bitches during anestrus. the percentage of vaginal epithelial cell cornification is an index of estrogen secretion by the ovarian follicles. as cornification of vaginal epithelial cells proceeds, the cells become larger, with more angular borders. the nuclear-cytoplasmic ratio decreases until the nuclei reach a point where they no longer take up stain (coincident with the onset of estrus). the cells appear "anuclear" and are classified as "cornified" or "anuclear squames." cornification occurs approximately 2 days prior to the estrogen peak and 4 days prior to standing heat. the percentage of cornified cells (of the total number of epithelial cells) decreases gradually to zero after the onset of diestrus. the vaginal cytology smear of the bitch changes from predominantly cornified to noncornified 6 days after ovulation. the day of this change is the first day of diestrus. other epithelial cell types noted on vaginal cytology include superficial cells (large, angular cells with small nuclei); intermediate cells (round or oval cells with abundant cytoplasm and large, vesicular nuclei); and parabasal cells (small round or elongated cells with large, well-stained nuclei, and a high nuclear-cytoplasmic ratio). based on vaginal cytology, the estrous cycle is classified as follows: although vaginal cytology is a useful tool, it is not a substitute for observation of behavioral estrus, which is the best criterion to use in breeding management. during proestrus the male is attracted to the bitch and will investigate her hindquarters, but she will not accept breeding. the behavioral hallmark of estrus is standing receptivity toward the male. during this stage the bitch will exhibit "flagging," or elevation of her tail with muscular elevation of the vulva to facilitate penetration by the male. in order to maximize the conception rate, and the number of pups whelped per egg ovulated, it is recommended to breed the bitch on days 1, 3, and 5 of the standing heat. fertilization is completed in the mid-to distal oviduct. implantation is evident by areas of local endometrial edema 17-18 days after breeding. there is no correlation between the number of corpora lutea and the number of fetuses in the corresponding uterine horn, suggesting transuterine migration of embryos. the dog has endotheliochorial placentation. the endothelium of uterine vessels lies adjacent to the fetal chorion, mesenchymal, and endothelial tissues, so that maternal and fetal blood are separated by four layers. the canine placenta is also classified as zonary and deciduate, indicating that the placental villi are arranged in a belt and that maternal decidual cells are shed with fetal placentas at parturition. the length of gestation is 59-63 days. luteal progesterone is responsible for maintaining pregnancy, and canine corpora lutea retain their structural development throughout gestation. serum progesterone rises from less than 1 ng/ml in late proestrus to a peak of 30-60 ng/ml during gestation, then declines to 4-5 ng/ml just prior to parturition. progesterone is essential for endometrial gland growth, secretion of uterine milk, attachment of the placentas, and inhibition of uterine motility. pregnancy detection can be performed by abdominal palpation of the uterus 28 days after breeding. the embryos and chorioallantoic vesicles form a series of ovoid swellings in the early gravid uterus. they are approximately 2 inches in length at 28-30 days, the time at which pregnancy is most easily and accurately diagnosed. by day 35 the uterus begins to enlarge diffusely, so that the vesicles (and, therefore, pregnancy) are difficult to identify by palpation. fetal skeletons become calcified and are radiographically evident by day 42. bitches in which a difficult whelping is anticipated should be radiographed in late pregnancy to determine the litter size and to evaluate the size of the fetal skulls in relation to the bony maternal birth canal. real-time ultrasound can be utilized for pregnancy detection of vesicles as early as 25-28 days. an abrupt drop in body temperature to less than 100~ indicates impending parturition within 18-24 hours. the process of parturition has been divided into three stages, stage 1 of labor lasts 6-12 hours and is characterized by uterine contractions and cervical dilation. during this stage, the bitch may appear restless, nervous, and anorexic. other common clinical signs include hard panting and increased pulse and respiration rates. fetal expulsion occurs during stage 2, which lasts approximately 3-6 hours. as the fetus engages the cervix, the neuroendocrine system induces the release of oxytocin; this is referred to as the ferguson reflex. oxytocin strengthens the uterine contractions and may elicit voluntary abdominal contractions as well. the bitch is usually recumbent during stage 2 but is able to inhibit this stage if labor if disturbed. the chorioallantois ruptures either during passage of each neonate through the birth canal or by the bitch's teeth at birth. interestingly, posterior presentation is common in dogs but does not predispose to dystocia. the time interval between delivery of each pup is irregular, but the average time lapse is less than 1 hour between pups until parturition is complete. veterinary assistance is necessary if the bitch remains in stage 2 for more than 5 hours without delivering the first pup, or for more than 2 hours before delivering subsequent pups. the placentas are expelled during stage 3 of labor, immediately following delivery of a pup, or up to 15 minutes thereafter. if two pups are delivered from alternate uterine horns, then the birth of both puppies may precede expulsion of the respective placentas. the bitch will lick the newborn vigorously to remove the membranes from its head and to promote respiration. she will also sever the umbilical cord. the bitch may ingest the placentas, although they confer no known nutritional benefit and may induce a transient diarrhea. thermal support should be provided prior to parturition. dogs housed on grated flooring should be provided with mats, and those on solid floors would benefit from blankets placed in a corner of the primary enclosure. shavings are discouraged as they have the potential to coat the umbilical cord, which may predispose to ascending infections. heat lamps may be placed 24 hours prior to parturition and remain until all neonates dem-onstrate vigorous and successful suckling behavior. however, the use of heat lamps necessitates strict supervision in order to prevent thermal burns. if possible, whelping bitches should be housed in a quiet corridor in order to decrease periparturient stress, especially in primiparous or young mothers. thus, monitoring of parturition is important, but human intervention should be minimal in order to prevent stress-induced cannibalism. weak or debilitated puppies may be cannibalized by the bitch before the research staff recognizes the need for veterinary attention. the postpartum use of oxytocin is required only in the event of uterine inertia, stillbirths, or agalactia. in these cases, 5-20 units of oxytocin may be administered intramuscularly. uterine involution occurs during anestrus within 4-5 weeks of parturition. during this time a greenish to red-brown vaginal discharge, or lochia, may be noted. although lochia is normal, the presence of an odiferous, purulent discharge, accompanied by systemic signs of illness, indicates metritis or pyometra. desquamation of the endometrium begins by the sixth postpartum week, with complete repair by 3 months. newborn puppies are easily sexed by examination of the anogenital distance. in female puppies the vulva is evident a short distance from the anus, whereas the prepuce of male puppies is nearly adjacent to the umbilicus. eyes are open at approximately 12 days, and ears are patent at approximately 12-20 days. solid food can be introduced between 4.5 and 6 weeks of age, and puppies can be weaned at 6-8 weeks. artificial insemination (ai) is indicated when the male is physically incapable of mounting or penetrating the bitch, when there are vaginal abnormalities such as strictures, or when the bitch refuses to stand for breeding. semen for ai is collected using a plastic centrifuge tube and rubber latex artificial vagina. the male is introduced to the bitch's scent and manually stimulated. after collection of the first two fractions, a sufficient amount of the third fraction, which consists predominantly of prostatic fluid, is collected to bring the total semen volume to 4-6 ml. the semen is then drawn into a sterile 10 or 12 ml syringe attached to a sterile disposable insemination pipette. the bitch is inseminated either standing or with raised hindquarters. a gloved index finger is inserted into the dorsal commissure of the vulva and directed craniodorsally until it is over the ischial arch. the tip of the insemination pipette is introduced and guided by the gloved finger toward the external cervical os. the semen is injected, and 2-3 ml of air are then flushed through the syringe and pipette. the pipette is withdrawn, and the gloved finger is used to feather the ceiling of the vagina until contractions of the vaginal musculature are palpable. the bitch's hindquarters are subsequently elevated to promote pooling of semen around the external cervical os. as with natural breeding, ai should be performed on days 1, 3, and 5 of standing heat, or on the days of maximal vaginal cornification. the bitch should be palpated for pregnancy approximately 4 weeks after the first insemination. false pregnancy (pseudocyesis), a stage of mammary gland development and lactation associated with nesting or mothering behavior, is common in the bitch. the condition occurs after the decline in serum progesterone toward the end of diestrus. there is no age or breed predisposition. pseudopregnancy does not predispose the bitch to reproductive disease or infertility. however, in the event of extreme discomfort due to mammary gland enlargement, bitches may be treated with mibolerone (cheque drops) at an oral dose of 16 ~tg/kg q24 hr for 3-5 days (brown, 1984) . reproductive performance in the bitch is optimal prior to 4 years of age. although normal cycle lengths are reported to occur up to the ages of 5-7 years, the interestrous interval tends to increase by 4 years of age. cycling does not completely cease; however, after 8 years of age, bitches demonstrate significant decreases in conception rate and number of live pups whelped. by 8-9 years of age, pathologic conditions of the uterus, such as cysts, hyperplasia, atrophy, and neoplasia are extremely common. beagles have been a popular animal model because of their docile nature. they are easily handled and for the most part respond favorably to repetitive manipulations such as body weight measurements, physical examination, electrocardiogram (ecg) recordings, oral gavage, and venipuncture. dogs are sexually mature by 6-9 months of age, but they are not socially mature until 18-36 months of age. the socialization process should begin early during development, when puppies are receptive to conspecific and human contact. for example, from 3-8 weeks of age, puppies are most capable of learning about how to interact with other dogs. between weeks 5 and 12, puppies are most capable of learning how to interact with people. by 10-12 weeks of age dogs voluntarily wander and explore new environments. thus, early handling and mild stress (such as vaccination) appear to be extremely beneficial components of a dog's social exposure. the extent to which breed affects behavior has been the subject of popular speculation but is difficult to prove. in general, breed-specific patterns do tend to emerge. for example, it appears that beagle pups are very motivated by food reward (overall, 1997 ). this is not surprising, because the breed was selected to work with its nose, and this may be a useful attribute for laboratory investigations that are predicated on food restriction. canid social systems use signals and displays that minimize the probability of outright aggression. these behavior patterns are most likely elicited during distressful situations, such as strange environments, being handled by strange people, or encountering new animals. an excellent, illustrated discussion of normal canine behavior patterns can be found in the third chapter of "clinical behavioral medicine for small animals" (overall, 1997). by virtue of the dog's status as a companion animal, there are many veterinary publications and reference texts on the diagnosis, medical management, pathology, and epidemiology of the disorders that can affect this species. the authors of this chapter have chosen to emphasize those diseases that are more frequently encountered in the research setting. especially noted in this chapter are infectious diseases associated with the use of random-source dogs that have unknown vaccination history and have had intensive contact with other similar animals at pounds and/or shelters, or conditions seen frequently in the beagle, the most common breed used in biomedical research. for more thorough and detailed discussion of these diseases, as well as those not discussed in this chapter, the reader should consult standard veterinary textbooks, such as the "current veterinary therapy" series (j. d. bonagura and r. w. kirk, eds.), "veterinary internal medicine" (s. j. ettinger and e. c. feldman, eds.), and "infectious diseases of the dog and cat" (c. e. greene, ed.) . full citations of some chapters from these texts are listed in the references (w. b. saunders co. of philadelphia publishes all three texts.) canine infectious tracheobronchitis (kennel cough complex) etiology. infectious tracheobronchitis (itb) is a highly contagious illness of the canine respiratory tract that usually manifests as an acute but self-limiting disease. several organisms have been incriminated as causative for this condition: bordetella bronchiseptica; canine parainfluenza virus (cpiv); canine adenovirus types 1 and 2 (cav-1, cav-2); canine herpesvirus; canine reovirus types 1, 2, and 3; and mycoplasms and ureaplasms. clinical signs. clinical infectious tracheobronchitis can be subdivided into mild or severe forms. the mild form is the more common presentation and is characterized by an acute onset of a loud, dry, hacking cough. increased formation of mucus sometimes results in a productive cough, followed by gagging or retching motions. cough is easily elicited by tracheal palpation and may be more frequent with excitement or exercise. otherwise the dog is typically asymptomatic, with normal body temperature, attitude, and appetite. mild tracheobronchitis usually lasts 7-14 days, even if left untreated. the severe form of tracheobronchitis generally results from mixed infections complicated by poor general health, immunosuppression, or lack of vaccination. secondary bronchopneumonia can occur and may be the determinant of severity (sherding, 1994) . animals are clinically ill and may be febrile, anorexic, and depressed. productive cough and mucopurulent naso-ocular discharge are more common than in the mild form. these cases require more aggressive treatment and may be fatal. bordetella bronchiseptica is considered to be the respiratory tract of infected animals (bemis, 1992) . this bacterium is very easily spread by aerosol and direct contact, and fomite transmission is also possible (bemis, 1992) . transmission is favored by confined housing of multiple animals. in experimental studies, b. bronchiseptica transmission to susceptible individuals was 100% (thompson et al., 1976; mccandlish et al., 1978) . the incubation period is 3-10 days. cpiv and cav-2 are also spread by aerosols. of these two viruses, cav-2 is the most persistent, lasting for up to several months in the environment, whereas cpiv is fairly labile (hoskins, 2000a) . both viruses can be destroyed by quaternary ammonium disenfectants. pathogenesis. the most common clinical isolates are cpiv and bordetella bronchiseptica. however, b. bronchiseptica may be a commensal organism, and it is often recovered from asymptomatic animals. in cases of clinical infection, b. bronchiseptica attaches to the cilia on the mucosal surface of the upper airway epithelium, causing suppurative tracheobronchitis and bronchiolitis. infections with cpiv or cav-2 alone are usually subclinical; coinfections with b. bronchiseptica or other microbes may result in clinical itb (keil and fenwick, 1998; wagener et al., 1994) . the characteristic lesion from cpiv or cav-2 infection is necrotizing tracheobronchiolitis (dungworth, 1985) . pathogenic infection of the upper airways typically results in inflammation and ciliary dysfunction. diagnosis and differential diagnosis. diagnosis of infectious tracheobronchitis is often based on clinical signs. isolation of bordetella bronchiseptica or mycoplasma by nasal swabs allows only a presumptive diagnosis. viral isolation or paired serology can be done but is often impractical and expensive. if cough persists for more than 14 days, other disease conditions should be considered. canine distemper virus infection, pneumonia, heartworm disease, tracheal collapse, and mycotic infections are differential diagnoses for dogs with similar signs. bronchial compression as a result of left atrial enlargement, hilar lymphadenopathy, or neoplasia may also elicit a nonproductive cough (johnson, 2000) and should be considered as a differential for itb. prevention. prevention is best achieved by avoiding exposure to infected animals, but this is oftentimes not practical. dogs should be vaccinated prior to, or at the time of, admission to the animal research facility. intranasal vaccine combinations for bordetella bronchiseptica and cpiv are preferred. intranasal vaccines protect against both infection and disease, can be given to dogs as young as 2 weeks of age, and can produce immunity within 4 days. control. sanitation and ventilation are critical for control. the animal care staff must practice proper hygiene to prevent fomite transmission. symptomatic animals should be isolated, and animal-to-animal contact avoided. kennels should be disinfected with agents such as bleach, chlorhexidine (nolvasan) or quaternary ammonium chloride (roccal-d). proper ventilation and humidity are important in controlling spread of these infectious agents; 15-20 air changes per hour at 50% relative humidity are recommended (sherding, 1994) . no specific treatment is available for viral infections. bordetella bronchiseptica is typically sensitive to potentiated sulfas, chloramphenicol, quinolones, tetracyclines, gentamicin, and kanamycin. use of antibiotics is indicated when severe or persistent clinical signs occur, and it should be continued for 14 days. use of empirical antibiotic treatment in mild cases may hasten the resolution of clinical signs. for severe or unresponsive infection, treatment should be based on bacterial culture sensitivity patterns; nebulized gentamicin may be helpful. cough suppressants (e.g., dextromethorphan) should be avoided if the cough is bringing up mucus (productive); however, their use is indicated if coughing is causing discomfort or interfering with sleep. bronchodilators such as aminophylline, theophylline, or terbutaline can be helpful in reducing reflex bronchoconstriction and minimizing discomfort. tis results in altered respiratory tract histology and impaired mucociliary clearance, infected animals should not be used for pulmonary studies. animals with clinical disease would also be poor surgical candidates. etiology. [3-hemolytic lancefield's group c streptococcus (streptococcus zooepidemicus) is a gram-positive non-spore-forming coccus and an etiologic agent for pneumonia and septicemia in dogs. clinical signs. clinical signs vary based on the organ system affected. pneumonic disease is typically associated with coughing, weakness, fever, dyspnea, and hematemesis. peracute death without clinical signs has been reported in a previously healthy research dog (bergdall et al., 1996) , and conjunctivitis can also be caused by this organism (murphy et al., 1978) . epizootiology and transmission. lancefield's group c streptococci have been isolated as commensal flora in the upper respiratory tract and the vagina of clinically normal dogs (olson et al., 1973) . epizootics have been reported in both racing greyhounds and research colonies (sundberg et al., 1981; garnett et al., 1982) . in these epizootics, and in the reported case of peracute death (bergdall et al., 1996) , recent transportation (within 7 days) was associated with the disease. as such, lancefield's group c streptococcus may be an opportunistic pathogen in dogs. pathologic findings. in the peracute case reported (bergdall et al., 1996) , hemorrhage from the mouth and nose and within the pleural cavity was the most striking lesion. ecchymotic and petechial hemorrhages were seen on other organ surfaces. the lungs were heavy and wet, and blood oozed from cut surfaces. "bull's-eye" lesions were observed on the pleural surface of affected lung lobes, similar to ischemic lesions seen with fungal infections (fig. 2) . histologically, the lungs were characterized by areas of hemorrhage surrounding foci of degenerative neutrophils, blood, and necrotic debris. gram-positive cocci were seen in both the lung and the tonsils. pathogenesis. the pathogenesis for disease caused by lancefield's group c streptococcus is unclear. strain variation with respect to virulence and host immune factors is probably significant. diagnosis and differential diagnosis. definitive diagnosis is made based on bacterial culture and identification. any cause of pneumonia and/or peracute death in dogs needs to be considered as a differential diagnosis. bacterial pneumonias or septicemias can be caused by other pathogenic streptococcus spp., staphylococcus spp., escherichia coli, pasteurella multocida, pseudomonas spp., klebsiella pneumoniae, and bordetella bronchiseptica. nonbacterial causes include rodenticide intoxication, coagulopathies, heartworm disease, pulmonary thromboembolism, ruptured aneurysm, and left-sided congestive heart failure. prevention and control. too little is known about the pathogenesis of lancefield's group c streptococcus to make any recommendations about prevention and control. treatment. antibiotic therapy should be provided, based on culture and sensitivity. intravenous fluids are indicated for febrile or systemically ill patients. for dyspneic patients, oxygen therapy and strict activity restriction are required. research complications. clearly, dogs with severe hemorrhagic pneumonia or septicemia are not appropriate for any research study. the association between epizootics of this disease and transportation shipment supports the philosophy of providing acclimation periods to animals upon arrival at research facilities to evaluate health status and enable the animals to normalize physiologically. etiology. serovars of the spirochete leptospira interrogans sensu lato cause canine leptospirosis. disease in dogs is primarily due to serovars canicola, icterohemorrhagiae, grippotyphosa, pomona, and bratislava. clinical signs. leptospirosis may present as either an acute or a chronic problem. clinical signs are nonspecific and include lethargy, depression, abdominal discomfort, stiffness, anorexia, and vomiting. animals may be febrile and may be reluctant to move, because of muscle or renal pain or meningitis. icterus, congested mucous membranes, or signs referable to disseminated intravascular coagulation (petechial/ecchymotic hemorrhages, melena, epistaxis, or hematemesis) are also possible. animals with peracute leptospirosis are characterized by septicemia, shock, vascular collapse, andrapid death. uveitis, abortions, and stillbirths have also been associated with leptospirosis. epizootiology and transmission. vaccination and reduced exposure to reservoir hosts have markedly decreased the prevalence of leptospirosis over the past 30 years. wild animals, cattle, and rodents are reservoirs for leptospira. the epidemiology of the disease is not static, and recent changes have been observed. serovars pomona, grippotyphosa, and bratislava are becoming more common causes of canine disease, with canicola and icterohemorrhagiae becoming less common. this may be due to vaccination practices and increased movement of wildlife reservoirs (raccoons, skunks, and opossums) into urban/suburban areas. rats have been implicated as important in the transmission of serovars canicola and icterohemorrhagiae (rentko et al., 1992; brown et al., 1996; kalin et al., 1999) . transmission occurs primarily by environmental contact, and not directly from animal to animal. infected hosts shed leptospires in urine, thereby contaminating the environment; naive animals are infected when the organisms contact mucous membranes or abraded skin. recovered animals may shed organisms in their urine for months to years. the organisms are actually labile in the environment; moisture, moderate temperatures, and alkaline soil favor survival and subsequent transmission. close contact, bites, ingestion of infected meat, and transplacental and venereal transmission are also possible. leptospirosis is a zoonotic disease. pathologic findings. the kidneys consistently have gross and microscopic lesions. in the acute phase of the infection, kidneys are swollen and have subcapsular and cortical ecchymotic hemorrhages. petechial or ecchymotic hemorrhages and swelling of the lungs and liver may also be noted. hepatic lesions during the acute phase consist of diffuse hemorrhage and focal areas of necrosis (searcy, 1995) . in chronic stages of leptospirosis the kidneys become small and fibrotic. endothelial cell degeneration and focal to diffuse lymphocytic-plasmacytic interstitial nephritis are the characteristic histopathological findings. pathogenesis. infection occurs after the leptospires penetrate a mucous membrane or abraded skin. the organisms then invade the vascular space and multiply rapidly. several days postinfection the renal tubular epithelium (and, to a variable extent, the liver) is colonized. the hematogenous phase lasts 4-14 days. acute renal failure or progressive renal failure leading to oliguria or anuria may occur. the most common clinical syndrome is chronic or subclinical infections after recovery from the acute phase (greene, 2000) . the nephritis may or may not be accompanied by hepatitis, uveitis, and meningitis. icterus, if it develops, is most common in the acute phase. the combination of azotemia and icterus should alert the clinician to the possibility of leptospirosis. disseminated intravascular coagulation is often a secondary complication. the severity and course of leptospirosis depend on the causative serovar and the age and immune status of the patient. diagnosis and differential diagnosis. zinc toxicity in dogs most closely mimics the clinical syndrome of leptospirosis. other causes of acute and chronic renal failure, icterus, and acute hepatic failure must also be considered. paired serology is the most reliable means of definitive diagnosis; however, seroconversion may not occur until after the first week of infection. prevention and control. vaccination for leptospirosis is standard veterinary practice. bivalent inactivated bacterins for serovars of l. interrogans canicola and serovars of l. interrogans icterohemorrhagiae are commercially available. however, immunization does not prevent development of the carrier state or protect against other serovars. for outdoor-housed dogs, an effective program to prevent contact with wildlife reservoirs is important. control requires identification and either treatment or elimination of carrier animals. treatment. penicillins are the drugs of choice for treating leptospiremia, and prompt use reduces fatal complications. aggressive fluid therapy and supportive care may also be needed. elimination of renal colonization and the carrier state can be accomplished with dihydrostreptomycin or doxycycline administration. should not be used in research studies because of the effects of the disease on renal and hepatic function. etiology. campylobacteriosis in dogs is caused by campylobacter jejuni, a thin, curved or spiral, microaerophilic, thermophilic motile gram-negative rod. clinical signs. most adult animals infected with c. jejuni are asymptomatic carriers; clinical signs are most commonly noted in dogs that are less than 6 months of age (greene, 2000; burnens et al., 1992) . in cases of clinical illness, small volumes of mucoid or watery diarrhea, with or without frank blood, are most commonly noted. these signs are usually mild, may be intermittent, and typically last 5-21 days. tenesmus, inappetance, vomiting, and a mild fever may accompany the diarrhea. epizootiology and transmission. the role of c. jejuni as a primary pathogen has been questioned; it may require a coenteropathy to produce disease (sherding and johnson, 1994) . clinical signs of disease most often occur in dogs less than 6 months of age, although any age may be affected. stress or immunosuppression may make animals more susceptible to clinical disease. pound and shelter populations have the highest rates of fecal excretion of c. jejuni (sherding and johnson, 1994) . transmission is via the fecal-oral route, mostly through fecally contaminated food or water. unpasteurized milk, poultry, and meat are other sources of infection. campylobacter jejuni can be zoonotic; children and immunocompromised individuals are at the greatest risk. pathologic findings. the actual lesions observed depend upon the mechanism of the enteropathy (van kruiningen, 1995) . enterotoxin production results in dilated fluid-filled bowel loops, with little or no histopathologic alteration. in cytotoxin-mediated disease, hyperemia and a friable, hemorrhagic mucosal surface are noted. on histopathology the mucosal surface is irregular and ulcerated, and a lymphocytic-plasmacytic ileitis or colitis may be seen. when translocation occurs, the lamina propria becomes edematous and congested, with focal accumulation of granulocytes in the crypts and lamina propria. focal areas of epithelial hyperplasia and decreased numbers of goblet cells are also noted. with warthin-starry silver staining, c. jejuni may be seen between enterocytes but only rarely inside them. pathogenesis. clinical disease may be produced by several different mechanisms after the campylobacter has populated the intestinal tract (van kruiningen, 1995) . after colonization of the enterocyte surface, c. jejuni can produce an enterotoxin that causes a secretory diarrhea. campylobacterjejuni can also cause an erosive enterocolitis by invasion of the ileal and colonic epithelium along with production of a cytotoxic agent; this may be the mechanism that causes hematochezia. in addition, c. jejuni can produce illness by translocation, i.e., multiplication in the lamina propria and transportation to regional lymph nodes by macrophages. this causes mesenteric lymphadenitis. diagnosis and differential diagnosis. fresh feces (per rectum) are best for ensuring an adequate diagnostic sample. presumptive diagnosis may be made by demonstration of highly motile curved or spiral organisms with dark-field or phase-contrast microscopy. gram-stained c. jejuni appear as gull-winged rods. definitive diagnosis requires isolation of the organism (sherding and . culture requires selective isolation media, and growth is favored by reduced oxygen tension and a temperature of 42~ any disorder that can cause diarrhea in dogs should be considered as a differential diagnosis, including canine parvovirus, coronavirus, distemper virus, giardia, and salmonella infections; helminth infestations; and hemorrhagic gastroenteritis. clinical signs. based on experimental infections in dogs, three phases to the disease have been described: acute, subclinical, and chronic. clinical signs observed vary with the phase of the disease, and the acute and subclinical phases are often missed or misdiagnosed (c. g. couto, personal communication, 1993; waddle and littman, 1988; woody and mcdonald, 1985) . a history of tick exposure may be noted prior to onset of signs. in the acute phase, clinical signs range from mild to severe and may last 1-2 weeks. they include inappetance, lethargy, fever, generalized lymphadenopathy, hepatosplenomegaly, exercise intolerance or dyspnea, petechial or ecchymotic hemorrhages, and peripheral edema. central nervous system (cns) signs may also be present such as hyperaesthesia, myoclonus, and cranial nerve deficits. clinical laboratory abnormalities noted during the acute phase include thrombocytopenia, anemia, neutropenia or neutrophilia, and bicytopenia or pancytopenia. hyperplastic bone marrow, mild hyperglobulinemia, and elevated hepatic enzymes may be noted during this phase (kuehn and gaunt, 1985) . clinical signs are generally absent during the subclinical phase. mild thrombocytopenia, anemia, or leukopenia may be seen. the chronic phase develops 1-4 months after the initial infection, and signs may be subclinical to severe. an extremely varied clinical picture can emerge during this time and can mimic several other clinical syndromes. the following constellation of clinical signs may be observed: chronic lethargy, weight loss, inappetance or anorexia, fever, generalized lymphadenopathy, hepatosplenomegaly, petechial or ecchymotic hemorrhages, epistaxis, hematuria, melena, pallor, anterior or posterior uveitis, chorioretinitis, peripheral edema, ataxia, upper and lower motor neuron deficits, altered mentation, cranial nerve deficits, and seizures. persistent thrombocytopenia is the most consistent laboratory abnormality noted for all three stages. many other hematologic abnormalites may be found, such as regenerative or nonregenerative anemia (more frequently the latter), positive coombs' test, bicytopenia or pancytopenia, and splenic plasmacytosis or lymphocytosis. on bone marrow evaluation, plasmacytosis along with hypoplasia of erythroid, myeloid, and/or megakaryocyte lines may be seen. hyperglobulinemia as a result of polyclonal or occasionally monoclonal gammopathy has been noted in 50-100% of e. canis seropositive or infected dogs (kuehn and gaunt, 1985; breitschwerdt et al., 1987; shimon et al., 1996) . proteinuria and/or hypoalbuminemia have also been seen. epizootiology and transmission. ehrlichia canis is an obligate intracellular parasite that infects mononuclear cells. the definitive hosts are arthropods; domestic and wild canids are parasitized secondarily. the primary vector and reservoir is the brown dog tick, rhipicephalus sanguineus. ehrlichia canis is found worldwide and follows the distribution of the vector. infection in dogs is most prevalent in tropical and subtropical areas (greene, 1991) . in the united states, cases are concentrated in the southeastern and southwestern states but have been reported in almost every state (breitschwerdt, 2000) . transmission is primarily by tick bites, but it can also occur via blood transfusions from dogs infected for as long as 5 years. ticks become infected by feeding on an infected dog that is in the first 10-15 days of an acute infection (lewis et al., 1977) , and ticks can shed the organisms for up to 5 months. within the tick population, e. canis is transmitted transstadially (within developmental stages) but not transovarially (from female to offspring) (groves et al., 1977) . pathogenesis. in experimental infections, the incubation period prior to the onset of the acute phase is 7-21 days. during the acute phase, which can last from 2-4 weeks, the bacteria replicate within circulating and tissue monocytes, resulting in lymphoreticular hyperplasia in affected tissues. infected monocytes then spread hematogenously to other organs in the body, in particular the lungs, kidney, and meninges. infected cells adhere to the vascular endothelium and induce vasculitis, which is the primary mechanism whereby the organism causes disease. the thrombocytopenia during the acute phase is due to both sequestration and destruction, and the development of anemia is a result of red blood cell destruction and suppression of erythrocyte production. the subclinical phase of the disease occurs 6-9 weeks after initial infection. during this stage, dogs that can mount an effective immune response clear the infection. those that cannot mount such a response progress to the chronic stage. infection does not confer protective immunity in dogs that recover. german shepherds and doberman pinschers seem to be more severely affected than other breeds. pathologic findings. gross lesions are varied and change, depending on the phase of the disease. the most common findings are petechial and ecchymotic hemorrhages and edema of dependent tissues (woody and hoskins, 2000) . the most common histologic abnormality noted is lymphocytic-plasmacytic inflammation of numerous organs. mononuclear phagocytic system hyperplasia, extramedullary hematopoiesis, and splenic erythrophagocytosis may also be seen. diagnosis and differential diagnosis. the most sensitive, specific, and commonly employed method for diagnosing e. canis infections is the indirect fluorescent antibody (ifa) test. antibodies can be detected as early as 7 days postinfection, although some dogs may not seroconvert until 28 days postinfection (buhles et al., 1974) . cross-reaction may occur between e. canis, e. chaffeensis, and e. ewingii. titers greater than 1:10 are considered positive and indicative of infection and may persist for up to 1 year. effective treatment typically produces seronegative results in 6-9 months. in some cases, asymptomatic dogs may remain seropositive for years after treatment or may be seropositive with a persistent hematologic abnormality (bartsch and greene, 1996) . the exact mechanism for this finding has not been elucidated. ehrlichia canis morulae can be demonstrated in circulating monocytes of giemsa-stained blood smears. however, this method is labor-intensive and has low sensitivity, as morulae are present transiently and in low numbers. using buffy coat smears from capillary blood may increase the diagnostic yield. polymerase chain reaction (pcr) assays are also available to identify e. canis. differential diagnoses include immune-mediated hemolytic anemia/thrombocytopenia, multiple myeloma, chronic lymphocytic leukemia, and lymphoma. prevention. preventing laboratory animals from contacting ticks is the primary means to avoid monocytic ehrlichiosis in research dogs. avoid exercising dogs in areas infested with ticks. use topical acaricides to prevent tick infestations. keep kennel areas tick-free. dogs used as blood donors and dogs from unproven sources should be tested for e. canis. treatment. doxycycline is the drug of choice for treating monocytic ehrlichiosis. oral doses of either 2.5-5 mg/kg q12 hr or 10 mg/kg q24 hr for 21 days are very effective at eliminating the organism. tetracycline, chloramphenicol, and enrofloxacin are also effective antibiotics; however, chloramphenicol should not be used in animals with cytopenias. in chronic cases, antibiotic treatment should be extended for an additional 1-2 weeks. research complications. the most significant research complication is the thrombocytopenia that persists for all stages of the disease. additionally, there is probable alteration in immune function and increased susceptibility to infectious agents. for these reasons, dogs positive for antibodies to e. canis should not be used in research. etiology. this disease, caused by ehrlichia platys, was first described as cyclic thrombocytopenia by harvey et al. in 1978 . clinical signs. in most cases, infection with e. platys results in subclinical disease. a generalized lymphadenopathy may be noted. epizootiology and transmission. the vector for e. platys is assumed to be a tick; however, this mode of transmission has not been established. experimental studies by simpson et al. ( 1991) failed to demonstrate rhipicephalus sanguineus as a vector for e. platys. coinfection with e. canis has been reported, which suggests a common vector for both organisms (french and harvey, 1983; kordick et al., 1999) . dogs have been experimentally infected by inoculation with infected blood or infected platelets from other dogs (harvey et al., 1978; gaunt et al., 1990) . the geographic distribution of thrombocytic ehrlichiosis is assumed to follow that of other ehrlichia organisms. the highest concentration of cases seems to be in southeastern states, but isolated cases have been reported as far north as michigan and as far west as oklahoma (wilson, 1992; mathew et al, 1997) . the prevalence of seropositive dogs can be high in some parts of the country. a study by bradfield et al. (1996) reported that 74% of the dogs entering a research institute's quarantine facility from sources in eastern north carolina were seropositive for e. platys. hoskins et al. (1988) reported a 54.2% seropositive prevalence in healthy dogs from kennels in louisiana. pathologic findings. gross and histopathologic findings during experimental e. platys infection in dogs have been described by baker et al. (1987) . generalized lymphadenopathy was the only gross lesion noted. follicular hyperplasia and plasmacytosis were the predominate findings in lymphoreticular tissues. all dogs also had extramedullary hematopoiesis, erythrophagocytosis, and crescent-shaped hemorrhages in the spleen. multifocal kupffer's cell hyperplasia was noted in the liver, and mild multifocal lymphocytic-plasmacytic interstitial inflammation was seen in the kidneys. pathogenesis. the pathogenesis of e. platys in dogs has primarily been determined through experimental infection (harvey et al., 1978) . after inoculation the organism directly infects platelets. thrombocytopenia occurs by day 10-14 and fluctu-ates, along with parasitemia, at 10 to 14 day intervals. in some cases the rebound may be within the normal range for thrombocyte counts. the nadir can be lower than 20,000 platelets/~d. concurrent with low platelet counts is the development of megakaryocytic hyperplasia in the bone marrow. interestingly, despite extremely low platelet counts, spontaneous bleeding has not been reported in cases of e. platys infection. the mechanism responsible for the cyclic nature of the infection has not been elucidated. diagnosis and differential diagnosis. ehrlichia platys infection may be diagnosed on stained blood smears by visualization of the organisms within platelets. however, this method is very unreliable due to the cyclic nature of the parasitemia and the low numbers of infected thrombocytes. available ifa assays are much more sensitive and specific, and there is reportedly no serologic cross-reaction with other ehrlichia species. dogs usually develop detectable titers 2-3 weeks postinfection. pcr assays for e. platys have now been developed as well (chang and pan, 1996; mathew et al., 1997) . differential diagnoses for thrombocytic ehrlichiosis include e. canis infection, immunemediated thrombocytopenia, and disseminated intravascular coagulation (dic). platys is the same as described for e. canis, above. research complications. ehrlichia platys infection may increase the risk of bleeding during surgical or traumatic procedures. coinfection with e. platys may potentiate the pathogenicity of other infectious agents, in particular e. canis (breitschwerdt, 2000) . etiology. lyme disease is caused by borrelia burgdorferi sensu lato, a microaerophilic spirochete that is primarily an extracellular pathogen. clinical signs. clinical signs may be highly variable; lameness due to polyarthritis has been reported as the most common sign. the onset of lameness may be acute or chronic, shift from limb to limb, and be accompanied by swelling and joint pain. synovial fluid analysis from affected joints is consistent with a diagnosis of suppurative arthritis. other clinical signs include fever, anorexia, lethargy, lymphadenopathy, and weight loss. over the course of the disease, signs may wax and wane over a period of weeks to months. dogs rarely develop erythema chronicum migrans (the characteristic rash seen in infected people) and do not exhibit the severe arthritis and neurologic sequelae seen in human beings (greene, 1991; manley, 1994) . hematologic and biochemical profiles are generally unremarkable. lyme disease is thought to be the most common arthropod-borne disease of human beings (and possibly of dogs) in the united states. it affects humans and dogs worldwide. the geographic distribution of canine borreliosis is assumed to follow that of the human disease and is related to the range of the arthropod vectors. three major endemic foci that have been identified in the united states account for 94% of reported human cases (appel and jacobson, 1995). the distribution of these cases is as follows: northeast/mid-atlantic focus, 85%; midwestern focus (michigan, wisconsin, minnesota, iowa, illinois, and missouri), 10%; and california and oregon, 4%. for the most part, dogs in the remainder of the country are not at risk for contracting lyme disease. borrelia burgdorferi is transmitted exclusively by ixodes ticks. other arthropod hosts may carry the organism but have not as yet been implicated in the transmission of disease. ixodes scapularis, a three-host tick with a 2 to 3 year life cycle, is the prototypical vector for north america. the spirochetes are spread by tick bites from both nymphs and adults. ticks become infected by feeding on an infected mammal and by transstadial transmission (transovarial passage is rare). in endemic areas, 50-80% of adult ticks may be infected (appel and jacobson, 1995) . the primary reservoir for the organism is the whitefooted deer mouse, peromyscus ieucopus, which can carry spirochetes for its life span without becoming ill. evidence also indicates that the eastern chipmunk, tamias striatus, is an important reservoir (slajchert et al., 1997) , and birds may also be a significant reservoir. deer, however, serve only as hosts for the tick vectors and not as a reservoir for the spirochete. pathogenesis. the pathogenesis of lyme disease is poorly understood, primarily because of a lack of good animal models and the chronic nature of the disease. infection can be induced experimentally by the bite of a single infected tick. clinical signs develop 60-90 days postinfection. some evidence points to the host's inflammatory response to the organism as etiologic for disease (pershing et al, 1994; greene, 1991) . seroconversion in dogs occurs 4-6 weeks after infection with b. burgdorferi. antibody titers may remain extremely elevated for at least 18 months. igm titers also remain elevated for several months and are indicative of neither acute nor active infection (appel and jacobson, 1995) . because antibiotic treatment may not eliminate the organism, persistent infections in dogs (treated for 30 days with antibiotics) can be reactivated by steroid treatment up to 420 days postinfection (straubinger et al., 1998) . diagnosis and differential diagnosis. appel and jacobson (1995) recommend that three of the following four criteria be met to establish a diagnosis of lyme disease in dogs: (1) history of exposure to ixodes ticks in an endemic area, (2) characteristic clinical signs, (3) positive serology, and (4) rapid resolution of clinical signs with antibiotic therapy. ifa or elisa tests for borrelia antibodies are the assays of choice. it should be re-membered, however, that a positive titer in an endemic area indicates exposure and not necessarily disease and that vaccinated dogs will also have a positive titer. responses to vaccine versus infection may be distinguished by western blot. culture or identification of the organism provides a definitive diagnosis but is very difficult to perform. differential diagnoses include immune-mediated polyarthritis and septic arthritis from other etiologic agents. prevention and control. prevention and control are the same as for the other tick-borne diseases (see discussion of monocytic ehrlichiosis, section iii,a,l,e above). a vaccine against b. burgdorferi is available but should not be necessary in a research setting. treatment. doxycycline is the drug of choice for treating lyme borelliosis. a typical dosing regimen is 10 mg/kg q12 hr for 3-4 weeks. amoxicillin, tetracycline, and the quinolones are also effective. of significant note is that antibiotic treatment results in resolution of clinical signs but may not result in elimination of the organism. (fox and lee, 1997) . "helicobacter heilmannii" and h. bizzozeronii are thought be the same species, with the latter being the updated nomenclature. this species, as well as h. rappini and h. canis, is considered to be zoonotic (fox and lee, 1997) . clinical infections may present with vomiting, diarrhea, fever, and anorexia, pica, or polyphagia. epizootiology and transmission. the epizootiology and transmission of helicobacter spp. in the dog remains to be elucidated. the prevalence of canine helicobacter infections in colony or shelter situations has been reported to range from 82% to almost 100% (fox, 1995; hermanns et al., 1995) . both oral-oral and fecal-oral routes for transmission have been suggested. pathologic findings. no gross lesions are noted; the primary lesion is that of histologic gastritis. this is typically characterized by reduced mucus content of the surface epithelium; vacu-olation, swelling, karyolysis, and karyorrhexis of parietal cells; and multifocal infiltrates of plasma cells and neutrophils into the subepithelium, primarily around blood vessels and between the gastric pits (hermanns et al., 1995) . focal areas of lymphocytic inflammation and lymphoid follicles may also be seen. pathogenesis. some helicobacter spp. colonize the gastric epithelium exclusively and other species colonize lower parts of the gastrointestinal tract. helicobacter felis and "h. heilmannii" infections have been linked to gastric lesions in laboratoryraised beagles (fox and lee, 1997) . the mechanism by which these organisms cause disease may be related to the host's inflammatory response to colonization and the helicobacter's ability to produce urease. urease splits urea into ammonia and bicarbonate; ammonia is toxic for the epithelial cells, and bicarbonate may help the organism survive the acidic environment (marshall et al., 1990; shimoyama and crabtree, 1998 ). diagnosis and differential diagnosis. any of the numerous causes of acute or chronic vomiting and diarrhea in the dog (including canine distemper, viral or bacterial gastroenteritis, and ingested toxicants) should be considered as differential diagnoses. definitive diagnosis for dogs requires either endoscopic or surgical biopsy. confirmation of infection with helicobacter spp. requires demonstration of the organism in biopsy samples by histopathology, culture, or recognition by pcr. a positive urease test on a biopsy sample may give a presumptive diagnosis, but only for those species that produce urease. the use of warthin-starry silver stain may increase the sensitivity for histopathologic diagnosis. prevention and control. until more is known about the epizootiology and transmission of helicobacter spp. in the dog, specific recommendations cannot be made about prevention and control in this species. treatment. combination therapy has proven to be the most effective method for treating helicobacter spp. infections in dogs. combination therapy of amoxicillin (10 mg/kg q12 hr), metronidazole (30 mg/kg q24 hr), and sucralfate (0.25-0.5 mg/kg q8 hr) for 21 days has been suggested for dogs (hall and simpson, 2000) . replacing the sucralfate with famotidine (0.5 mg/kg q24 hr), omeprazole (0.3 mg/kg q24 hr), or bismuth subsalicylate (0.2 ml/kg q4-6 hr) may also be effective (marks, 1997; jenkins and bassett, 1997; denovo and magne, 1995) . the benefits of antimicrobial therapy in dogs still need to be established by controlled therapeutic studies. research complications. helicobacter spp. infections could result in altered gastrointestinal responses to drugs and toxic or carcinogenic compounds. therefore, dogs used in gastric physiology or oral pharmacology studies should be free from helicobacteriosis. clinical signs. clinical signs of canine parvovirus usually appear 5 days after inoculation by the fecal-oral route and are characterized by anorexia, fever, depression, and vomiting. profuse, intractable diarrhea ensues, which may become hemorrhagic. approximately 85% of affected dogs develop severe leukopenia, with a total granulocyte/lymphocyte count ranging from 500-2000 wbc/~d or less. repeated hemograms may provide prognostic value, because rebounds in leukocyte counts are indicative of impending recovery. terminally ill dogs may develop hypothermia, icterus, or disseminated intravascular coagulation due to endotoxemia. parvovirus can infect dogs of any age, but puppies between 6 and 20 weeks of age appear to be particularly susceptible. puppies less than 6 weeks of age are generally protected from infection by passive maternal antibody. adult dogs probably incur mild or inapparent infections that result in seroconversion. pathogenesis. canine parvovirus has an affinity for rapidly dividing cells of the intestine and causes an acute, highly contagious enteritis with intestinal crypt necrosis and villus atrophy. the virus also has tropism for the bone marrow and lymphoid tissues; thus leukopenia and lymphoid depletion accompany the intestinal destruction. diagnosis and differential diagnosis. parvovirus can be detected in fecal samples with a commercially available elisa from cite. at necropsy, diagnosis is based on gross and histopathologic evidence of necrosis and dilatation of intestinal crypt cells with secondary villous collapse. other lesions include myeloid degeneration and widespread lymphoid depletion. parvovirus can also be demonstrated in frozen sections by fluorescent antibody techniques. differential diagnoses should include other viral enteritides, salmonellosis, and small intestinal obstruction. prevention and control. prevention of transmission begins with isolation of affected animals and quarantine for 1 week after full recovery. disinfection of potentially infected kennel and diagnostic areas with diluted bleach (1:30) or commercially prepared disinfectant (such as kennesol, available from alphatech, lexington, massachusetts) is essential for elimination of the virus. six-week-old puppies should be vaccinated every 2-4 weeks with a commercially available modified live vaccine until 16-18 weeks of age. young rottweilers and doberman pinschers appear to be predisposed to parvoviral enteritis and should be vaccinated every 3 weeks (5 times) from 6-18 weeks of age. treatment. treatment is largely supportive and is aimed primarily at restoring fluid and electrolyte balance. research complications. infection with parvovirus obviously precludes the use of a particular dog in an experimental protocol. given the potential for significant discomfort of the affected animal, and the cost of therapy, humane euthanasia is usually the option chosen in a research setting. canine coronavirus infection is usually inapparent or causes minimal illness. this epitheliotropic virus preferentially invades the enterocytes of the villous tips, resulting in destruction, atrophy, and fusion and subsequent diarrhea of varying severity. subclinical infections are most common, but abrupt gastrointestinal upset accompanied by soft to watery, yelloworange feces is possible. definitive diagnosis by virus isolation or paired sera is usually not made, because supportive therapy generally results in rapid resolution of the diarrhea. inactivated coronavirus is present in commercially available combination vaccines, which are administered immunoprophylactically at 6 -8, 10 -12, and 12-14 weeks of age and then annually thereafter. the role of these vaccines in protection from coronaviral infection is unknown, because the virus typically causes inapparent or mild illness (hoskins, 1998) . etiology. canine distemper virus (cdv) belongs to the family paramyxoviridae, within the genus morbillivirus, which includes human measles virus and rinderpest virus of ruminants. although there is only one serotype of cdv, there is a wide difference in strain virulence and tissue tropism. some strains produce mild clinical signs that are similar to tracheobronchitis, whereas other strains cause generalized infections of the gastrointestinal tract, integument, and central nervous system, resulting in enteritis, digital hyperkeratosis, and encephalitis, respectively. other factors contributing to the severity and progression of clinical signs include environmental conditions, immune status, and age of the host. a transient subclinical fever and leukopenia occur 4-7 days after exposure, with a subsequent fever spike 7-14 days later, accompanied by conjunctivitis and rhinitis. other clinical signs associated with acute distemper include coughing, diarrhea, vomiting, anorexia, dehydration, and weight loss. secondary bacterial infections can cause progression to mucopurulent oculonasal discharge and pneumonia. an immune-mediated pustular dermatitis may develop on the abdomen; this is usually a favorable prognostic sign (greene and appel, 1998) , because dogs that develop skin lesions often recover. neurologic complications of distemper infection may occur weeks to months after recovery from an acute infection. dogs that develop late-onset disease are usually immunocompetent hosts, suggesting that the virus may have escaped complete elimination by the immune system, possibly because of protective effects by the blood-brain barrier. classic neurologic signs that may occur in acute or chronic cdv infection include ataxia, incoordination, vocalization, "chewing gum" seizures, and myoclonus with or without paresis of the affected limb. canine distemper is the most common cause of seizures in dogs less than 6 months of age. dogs with extensive neurologic involvement often have residual clinical deficits, including flexor spasm and olfactory dysfunction. cdv has also been associated with two forms of chronic encephalitis in mature dogs: multifocal encephalitis and "old dog encephalitis." epizootiology and transmission. the virus is highly prevalent and contagious to dogs and other carnivores, especially at the age of 3-6 months, coincident with the waning of maternal antibody. transmission is primarily by aerosolization of infective droplets from body secretions of infected animals. pathologic findings. the predominant histopathologic lesion in neurologic forms of distemper is demyelination, which may .. be accompanied by gliosis, necrosis, edema, and macrophage infiltration. acidophilic cytoplasmic inclusions can be found in epithelial cells of mucous membranes, reticulum cells, leukocytes, glia, and neurons, while intranuclear inclusions are often present in lining or glandular epithelium and ganglion cells. diagnosis and differential diagnosis. diagnosis of cdv is based on history of exposure and clinical signs. young dogs who have not received routine immunoprophylaxis (or similarly, mature dogs with a questionable vaccination history) and present with rhinitis, mucopurulent oculonasal discharge, plus or minus hyperkeratosis of the footpads and neurologic signs, are highly likely to have cdv. ophthalmologic examination may reveal chorioretinitis with acute disease or retinal atrophy in chronic cases. definitive diagnosis of acute infection can be made by fluorescent antibody testing of intact epithelial cells from conjunctival and mucous membranes. attenuated strains of cdv, found in modified live vaccines, are not disseminated from lymphoid tissue to epithelial cells and thus are not detected by the fluorescent antibody. serologic testing is usually not useful, because dogs frequently fail to mount a measurable immunologic response. because of the variety of clinical signs, there are many differential diagnoses for canine distemper. an important differential diagnosis for respiratory illness is infectious tracheobronchitis (kennel cough). bacterial, viral, and protozoal causes of gastroenteritis must be considered for cases presenting with vomiting and diarrhea, and rabies, pseudorabies, bacterial meningitis, and poisonings are differential diagnoses for dogs with central nervous system disorder. prevention and treatment. a series of three immunizations from 6 to 14 weeks of age, followed by yearly boosters, is a recommended preventative. treatment is largely supportive, but because of the profound immunologic effects and significant morbidity of cdv, humane euthanasia is usually undertaken in the research setting. etiology. canine herpesvirus (chv) infection causes a generalized hemorrhagic disease with a high mortality rate in newborn puppies less than 2 weeks of age. in adult dogs, chv causes a persistent, latent infection of the reproductive tract with recrudescence and shedding during periods of physiologic stress. clinical signs. clinically affected puppies do not suckle, cry persistently, become depressed and weak, and fail to thrive. petechial hemorrhages of the mucous membranes and erythema of sparsely haired regions such as the caudal abdomen and inguinal area are evident. older puppies, aged 3-5 weeks, develop less severe clinical signs and are likely to survive with neurologic sequelae such as ataxia and blindness resulting from reactivation of latent infection. infection in adult dogs may result in stillbirths, abortions, and infertility. lesions in adult bitches include raised vesicular foci in the vaginal mucosa, accompanied by mild vaginitis. adult males have preputial discharge due to vesicular lesions at the base of the penis and on the preputial mucosa. passage of puppies through the birth canal or venereally in adult dogs. puppies can also be horizontally infected by littermates. entire primiparous litters may be lost, with subsequent litters protected by colostral antibody. pathologic findings. pathologic findings include multifocal ecchymotic hemorrhages of the kidneys, liver, lungs, and gastrointestinal tract. basophilic intranuclear inclusions in necrotic areas of parenchymal organs are characteristic findings. diagnosis and differential diagnosis. diagnosis of canine herpesvirus infection in adult dogs is based on a history of reproductive infertility and the presence of genital vesicular lesions. differential diagnoses for stillbirths, abortions, and infertility include canine brucellosis, canine distemper virus and parvovirus infections, and pyometra. the diagnosis in infected puppies is usually made based on clinical history and characteristic lesions (multifocal systemic hemorrhages) (carmichael and greene, 1998) . differential diagnoses for the disease in neonates would include canine ehrlichiosis and causes of disseminated intravascular coagulation, including bacterial endotoxemia. there is no effective curative treatment. supportive therapy is unrewarding, and death usually ensues within 48 hours in in-fected neonates. in general, adult bitches that have multiple abortions, stillbirths, or persistent infertility should be culled from the breeding colony. examination of these animals may reveal raised vesicular lesions on the vaginal mucosa. adult male dogs that have vesicular lesions on the base of the penis and preputial mucosa should be similarly culled. adult dogs would obviously interfere with production operations, and affected animals should be culled based on the criteria noted above in the discussion of prevention and treatment. because of the severity of clinical illness in puppies, such animals should be humanely euthanatized. etiology. rabies virus is a member of the rhabdovirus family and is essentially contagious to all species of warm-blooded animals. clinical signs. clinical progression of neurologic disease occurs in three stages. the first, or prodromal, stage is characterized by a change in species-typical behavior. the loss of the instinctive fear of humans by a wild animal is a classic sign of impending rabies. in the second, or furious, stage animals are easily excited or hyperreactive to external stimuli and will readily snap at inanimate objects. the third, or paralytic, stage is characterized by incoordination and ascending ataxia of the hindlimbs due to viral-induced damage of motor neurons. death usually occurs within 2-7 days of the onset of clinical signs, due to respiratory failure. epizootiology and transmission. wild animals such as raccoons, skunks, and bats are common reservoirs of infection for domestic animals, which in turn are the principal source of infection for humans. transmission occurs primarily by contact of infected saliva from a rabid to a naive animal (or human), usually via bite wounds. pathogenesis. the incubation period for rabies is generally 3-8 weeks from the time of exposure to the onset of clinical signs but can range from 1 week to 1 year. bites of the head and neck typically result in shorter incubation periods because of the proximity to the brain. following infection, the virus migrates centripetally via peripheral nerve fibers to the central nervous system and eventually to neurons within the brain, resuiting in neurologic dysfunction. on reaching the brain, the virus migrates centrifugally to the salivary glands, thus enabling shedding and subsequent transmission. diagnosis and differential diagnosis. diagnosis of rabies is based on clinical signs; differential diagnoses include pseudorabies, canine distemper, bacterial meningitis, and toxicants that affect neurologic function. definitive diagnosis is based on fluorescent antibody demonstration of the virus in negri bodies of hippocampal cells. prevention and treatment. puppies should be vaccinated at 4-6 months of age, "boostered" in 1 year, then vaccinated annually or triennially, depending on state and local laws and which vaccine product is used. treatment of rabies is not recommended, because of the risk of human exposure. research complications. in a research setting, dogs are often not vaccinated for rabies, because of the low incidence of exposure to wild-animal reservoirs. a healthy, purpose-bred dog that bites a human in a research facility should be quarantined for 10 days and observed for signs of rabies. this quarantine interval is based on the knowledge that dogs do not shed rabies in the saliva for more than a few days before the onset of neurologic disease. a random-source dog with an unknown vaccination history that bites a human should be immediately euthanized. the brain should be examined for rabies virus to determine if the dog was infected, and if the test is positive, postexposure immunization should be initiated for the human patient. a rabies vaccine licensed for use in humans is available, and immunoprophylaxis is recommended for animal care and research personnel who may have high work-related risks of exposure. a. protozoa i. giardiasis etiology. giardiasis is a small-intestinal disease of the dog caused by giardia duodenalis (lamblia), a binucleate flagellate protozoan. clinical signs. most giardia infections are subclinical. when dogs are clinically affected, diarrhea is the most prominent sign. the diarrhea is a result of intestinal malabsorption and is often characterized as voluminous, light-colored, foul-smelling, and soft to watery. weight loss has also been associated with clinical infection. clinical illness is more often seen in young animals. epizootiology and transmission. giardia has a direct life cycle. dogs (and people) typically become infected when they consume water (or food) contaminated with giardia cysts. the ph change from the stomach (acid) to duodenum (neutral) causes excystation. trophozoites migrate to the distal duodenum and proximal jejunum and attach to the villus surface. eventually the trophozoites encyst and pass in the feces to perpetuate the life cycle. pathologic findings. giardiasis is rarely fatal. on histopathology of duodenal or jejunal specimens, giardia trophozoites can be seen attached to enterocytes. mucosal inflammation and ulceration, and villous atrophy, have been observed. pathogenesis. the exact pathogenesis of giardia-induced illness is unknown. it is thought that tissue invasion, although occasionally observed, is unimportant for pathogenesis. it is suspected that illness is caused by physical obstruction of enteric absorption, enterotoxicity, competition for nutrients, excess mucus production, and/or secondary bacterial overgrowth. diagnosis and differential diagnosis. definitive diagnosis requires observation of the organism in fecal or intestinal samples. direct fecal smears are considered best for observing trophozoites, and zinc sulfate flotation is preferred for detection of cysts. commercial elisa kits and direct immunofluorescent tests are available to detect fecal giardia antigens, but the diagnostic specificity and/or sensitivity of these tests may not be sufficient to warrant substitution for the less expensive direct fecal examination or zinc sulfate preparation (barr, 1998) . differential diagnoses for giardiasis include bacterial and protozoal enteritis, coccidiosis, and whipworm infestation. prevention. high-quality water sources will eliminate the possibility of infection developing within an animal research facility. use of dogs with a known husbandry and medical background will minimize the chances of giardiasis developing in a research colony. control. once giardiasis has been diagnosed in a canine population, segregation of infected animals will help to reduce further infection (provided other dogs were not preinfected at the same source location as the signal case). disinfection with quaternary ammonium compounds, bleach, or steam is usually successful in eradication of giardia cysts. treatment. the most common treatment for giardiasis is metronidazole (flagyl) at 25-30 mg/kg per os twice per day for 5-10 days. quinacrine hydrochloride (atabrine) at 9 mg/kg per os once per day for 6 days, furazolidone (furoxone) at 4 mg/kg per os twice per day for 7-10 days, and the anthelmintics albendazole and fenbendazole have been proposed for use against metronidazole-resistant strains of giardia. a1bendazole is recommended at 25 mg/kg per os q12 hr for 2 days, and fenbendazole at 50 mg/kg per os q24 hr for 3 days. fenbendazole was thought to be safer for both puppies and pregnant females (nonteratogenic) (barr, 1998) . research complications. typical asymptomatic infections probably have no consequence on research protocols, with the exception of intestinal physiology or immunology studies. clinical diarrhea would clearly need to be treated before a dog could be used as a research subject. ii. coccidiosis etiology. intestinal coccidia that have been associated with enteropathy in dogs include cystoisospora canis, c. ohioensis, c. burrowsi, and c. neorivolta. clinical signs. dogs are typically asymptomatic when infected with intestinal coccidia, and oocysts are an incidental finding on fecal flotation or direct smear. dogs that are clinically infected usually develop diarrhea, which can vary from soft to watery and may contain blood or mucus. vomiting, dehydration, lethargy, and weight loss can also be seen. epizootiology and transmission. cystoisospora oocysts are typically spread by fecal-oral transmission, usually by ingestion of fecal-contaminated food or other objects in the environment. an indirect form of transmission is also possible, whereby the dog consumes a rodent or other animal that is serving as a transport host. once inside the small intestine, the cyst releases sporozoites that infect enteric epithelium. several generations of asexual reproduction can occur in the enterocyte before sexual reproduction produces gamonts. the gamonts fuse to become a zygote, which encysts, ruptures the enterocyte, and passes in the feces. once in the environment the cyst sporulates and is now an infective stage for ingestion by another host. pathologic findings. dogs with coccidiosis may have hyperemia or fluid retention at affected intestinal segments. the mucosa may appear normal, raised, or ulcerated. histologically, there may be necrosis of enterocytes, hyperemia, and submucosal inflammation. the oocysts are usually readily apparent within the epithelial cells (van kruiningen, 1995) . pathogenesis. intestinal coccidia are opportunistic organisms; they do not typically cause illness unless other predisposing factors are present. such factors include immunodeficiency, malnutrition, and/or concurrent disease. overcrowding and unsanitary conditions can also promote clinical coccidiosis by providing a high population of infective oocysts to stressed animals. diagnosis and differential diagnosis. diagnosis is somewhat difficult, as coccidian oocysts (of both cystoisospora and non-cystoisospora spp.) can be seen on fecal examinations of clinically healthy dogs, as well as animals with diarrhea. other causes for diarrhea (e.g., parvovirus, roundworms, giardia spp., campylobacter jejuni, and inflammatory bowel disease) should be excluded before a coccidial etiology is implicated. prevention. clinical coccidiosis can be readily prevented by adhering to proper sanitation guidelines, reducing any over-crowding, and providing as stress-free an environment as possible. treatment. treatment for the presence of coccidial oocysts may often not be necessary, because cystoisospora infections are typically self-limiting and clinically insignificant. treatment may, however, help to limit the number of oocysts shed in a kennel housing situation and may be necessary in cases of protracted clinical illness. possible choices for treatment include daily administration of sulfadimethoxine (25-30 mg/lb per os for 10 days), trimethoprim sulfa (15 mg/lb per os for 10 days), or quinacrine (5 mg/lb per os for 5 days). amprolium, which is not labeled for dogs, can also be used as a coccidiostat. it can be given in gelatin capsules for 7-12 days at a daily dose of 100 mg for small-breed pups and 200 mg for larger breeds. research complications. as with any enteric disease, the presence of clinical coccidiosis can cause aberrations in gastrointestinal physiological parameters. dogs used in intestinal pharmacokinetic studies should be confirmed to be free of cystoisospora infections. b. nematodes i. ascarids etiology. the most common ascarid of dogs is toxocara canis. toxascaris leonina can also infect both dogs and cats. clinical signs. ascarid infestations are most commonly subclinical. however, large worm burdens can cause diarrhea, vomiting, dehydration, and abdominal discomfort with vocalization. puppies may have a classical "potbellied" appearance and dull hair coat. heavy infestations can cause intussusception and/or intestinal obstruction, in which case the young dogs may be found dead. visceral larval migrans caused by toxocara canis can cause pneumonia. epizootiology and transmission. toxocara canis typically infects puppies. in fact, a unique characteristic of t. canis is its ability to infect prenatal puppies by transplacental migration, and neonatal puppies by transmammary migration. ingestion of infective eggs that have been shed in the feces is another common route of transmission, and infection by ingestion of a transport or intermediate host is also possible. pathologic findings. puppies that die from ascarid infestations typically have large worm populations in the lumen of the small intestine. such populations can cause intestinal obstruction and may also result in intussusception or intestinal perforation. puppies that experience lung migrations of large larval worm populations can have severe pulmonary parenchymal damage and develop fatal pneumonia. pathogenesis. the infective stage of t. canis is the third-stage larva (l3). infections initiated by ingestion of infective eggs have three possibilities for larval migration: liver-lung migration (which leads to intestinal infection), somatic tissue migration, and intestinal wall migration. older dogs that become infected typically have an age-related resistance to liver-lung migration and instead experience the other two migratory patterns. these larval migrations are often asymptomatic, and progression of the l3 larvae is arrested in the tissues. it is these larvae that become reactivated in a pregnant bitch, thus establishing the transplacental and transmammary routes of transmission. if the source of infection is transplacental, puppies may be born with l3 larvae in their lungs, because larval migration is already in progress (sherding, 1989 ). diagnosis and differential diagnosis. the characteristic large (70-85 ~tm in diameter) and relatively round ascarid eggs can be readily diagnosed by standard fecal flotation methods. prevention and control. monthly administration of milbemycin or ivermectin plus pyrantel pamoate (heartgard plus) is recommended for prevention and control of canine ascarid infestation (hall and simpson, 2000) . treatment. most anthelmintics are effective for treatment of ascariasis. pyrantel pamoate (nemex) and fenbendazole (panacur) are commonly used. treatment should be started early in puppies (2, 4, 6, and 8 weeks) because of the possibility of prenatal or neonatal infection. pyrantel pamoate, dosed at 5 mg/kg per os, is safe for puppies and is also effective in treatment of hookworms (see section iii,a,3,b,ii). in breeding colonies in which ascarid infestation is a known problem, treatment of the pregnant and nursing bitch may be advantageous. extended fenbendazole therapy (50 mg/kg per os twice per day for 14 days or once per day from day 40 of gestation through day 14 of lactation) has been shown to be experimentally safe and effective in decreasing ascarid burdens in puppies. research complications. puppies with large worm burdens make poor research subjects and should be treated aggressively before placement on an experimental study. ii. hookworms etiology. the most common and most pathogenic hookworm of dogs is ancylostoma caninum. other, less pathogenic canine hookworms found in north america are a. braziliense, which can be found in the american tropics and southern united states, and uncinaria stenocephala, which is distributed in the northern united states and canada. clinical signs. only a. caninum infestation typically results in clinical illness, because of the amount of blood that it con-sumes. puppies with a. caninum infestations are typically pale and weak (from anemia), with bloody diarrhea or melena. other clinical signs include lethargy, anorexia, dehydration, vomiting, and poor weight gain. epizootiology and transmission. infective larvae (l3) are typically ingested by puppies and develop directly in the intestinal tract. ingestion can be from the bitch's milk (transmammary migration occurs with a. caninum), from food or objects contaminated with infective larvae, or from ingestion of a paratenic host. transplacental migration does occur with a. caninum, but to a much lesser extent than is seen with toxocara canis. larvae can also penetrate intact skin, migrate to the lung via somatic or circulatory routes, and be coughed and swallowed to reach the intestine. the prepatent period is 3 weeks. pathologic findings. infected puppies often have severe anemia and eosinophilia. the anemia can be from acute blood loss or can also be an iron-deficiency anemia caused by chronic blood loss coupled with limited iron reserves. on gross necropsy, the small-intestinal tract contains worms admixed with intestinal contents containing fresh or digested blood (fig. 3a) . ulcerative enteritis caused by hookworm attachment is evident on histopathologic examination, and worms with mouthparts embedded in the mucosa can be identified in some sections (fig. 3b) . pathogenesis. the severe pathogenicity of a. caninum is a direct result of its voracious consumption of blood and body fluids. each adult hookworm can consume 0.01-0.2 ml of blood; thus an extensive infection could deplete a puppy of 20 ml of blood per day, which is approximately 15% of the blood volume of a 2.0 kg animal. in contrast, a. braziliense and u. stenocephala consume 0.001 and 0.0003 ml per worm, respectively. diagnosis and differential diagnosis. diagnosis of ancylostomiasis is made by identification of eggs or larvae from fecal samples by either flotation or direct smear. parvovirus should be considered for puppies with bloody diarrhea, and autoimmune hemolytic anemia should be considered in the diagnosis of a young dog with anemia. prevention and control. purchase of purpose-bred animals will limit the exposure to hookworm larvae, and effective sanitation programs will easily eradicate the infective larvae. unlike ascarid eggs, hookworm eggs are readily killed by drying, sunlight, or cold; however, they do survive readily in warm, moist environments. monthly administration of milbemycin or ivermectin plus pyrantel pamoate (heartgard plus) is recommended for prevention and control of canine ascarid infestation (hall and simpson, 2000) . treatment. pyrantel pamoate (nemex) is the anthelmintic of choice because it is safest in young ill animals and is also effective against ascarids and other enteric helminths. because of the possibility of transplacental or milk-borne infection, puppies should be treated every 2 weeks from weeks 2-8. a follow-up treatment at 11 weeks is recommended to kill any larvae that have migrated and matured since the initial therapy. severely ill puppies may require supportive fluid therapy and possibly whole blood transfusions and iron supplementation. research complications. anemic puppies with large worm burdens make poor research subjects and should be treated aggressively before placement on an experimental study. iii. strongyloides etiology. strongyloides stercoralis is a small strongyle that can cause hemorrhagic enteritis in puppies. it is found in warm, humid climates such as the southeastern united states. fects dogs and other animals by third-stage larval penetration of the skin or mucous membranes. larvae migrate via the circulatory system to the lung and then are coughed and swallowed to initiate the intestinal parasitism. the eggs of s. stercoralis hatch within the gut lumen, and so it is the first-stage larvae that pass in the feces and need to be identified by diagnostic examination. once passed, the larvae can either develop into the infectious third-stage larvae or mature into free-living, nonparasitic adults. diagnosis and differential diagnosis. the baermann procedure is usually performed on fresh feces in order to detect the motile first-stage larva (280-310 ~tm x 30-80 ~tm). the larvae must be distinguished from larva of filaroides hirthi and hatched ancylostoma caninum. treatment. the usual treatment for s. stercoralis is fenbendazole (panacur) at 50 mg/kg per day for 5 days. iv. whipworms etiology. trichuris vulpis, the canine whipworm, can cause acute or chronic large-intestinal diarrhea. the adult whipworm typically resides in the cecum or ascending colon. clinical signs. most whipworm infections are subclinical. in symptomatic cases, the typical clinical sign is diarrhea with blood and/or mucus. abdominal pain, anorexia, and weight loss are also seen. dogs may have eosinophilia, anemia, and/or hypoproteinemia on clinical hematology. severe dehydration with electrolyte imbalance has occurred occasionally as an acute crisis episode. life cycle. adult worms residing in the canine large intestine intermittently release eggs that pass in the feces. the eggs are very hardy and can persist for years. in optimal conditions, the eggs develop into an infective embryo within 10 days. after ingestion by a dog, the larvae hatch in the small intestine, burrow into the small-intestinal mucosa, and then reemerge several days later to travel and burrow into the cecal and colonic mucosa. the prepatent period is typically 2-3 months long. pathologic findings. dogs do not typically die from whipworm infestations. lesions seen as incidental findings feature adult worms embedded into the colonic and cecal mucosae, causing local granulomatous inflammatory reactions and mucosal hyperplasia. pathogenesis. the penetration of the adult worm into the enteric mucosa, and the associated inflammation, can lead to the clinical development of diarrhea. factors that influence the possible.development of clinical symptoms are the number and location of adult whipworms; the severity of inflammation, anemia, or hypoproteinemia in the host; and the overall condition of the host. diagnosis and differential diagnosis. whipworm infestation is diagnosed by the presence of characteristic trichurid eggs on fecal flotation. these eggs are barrel-shaped, with thick walls and bipolar plugs. because of the intermittent release of eggs by the adult female worms, negative fecal flotation does not exclude the possibility of clinical whipworm infection. adult worms can be seen on colonoscopy (jergens and willard, 2000) . differential diagnoses for whipworm infestation include giardiasis, coccidiosis, and bacterial enteritis. prevention and control. trichuris eggs are resistant to disinfection, making control difficult. dessication or incineration is the only completely effective means to eradicate whipworm eggs from the environment. treatment. fenbendazole, oxibendazole, and milbemycin have all been recommended for treatment of whipworms. treatment for whipworm infestation should be at monthly intervals for 3 months (jergens and willard, 2000) . treatment is also suggested in cases wherein whipworm infestation is suspected but not confirmed by multiple fecal flotation. rapid response to treatment would be indicative of a correct diagnosis; lack of response should prompt further diagnostic efforts. research complications. whipworm infestation has not been documented to interfere with research protocols, although one would anticpate that aberrations in local enteric immune function and absorptive functions of the large intestine could result from trichuriasis. etiology. heartworm disease of dogs is caused by the filarial worm, dirofilaria immitis. adult heartworms reside in the pulmonary artery; severe infestations can result in the presence of worms in the right ventricle and atrium. microfilariae, the immature worms produced by the adults, circulate in the bloodstream until a mosquito (intermediate host) ingests them. clinical signs. most heartworm infestations are asymptomatic. the most common clinical signs observed are coughing and dyspnea. clinical signs of exercise intolerance and rightsided heart failure can be seen in severe infestations. epizootiology and transmission. successful heartworm transmission requires the presence of mosquitoes. for this reason, random-source dogs or dogs housed in outdoor kennels are much more likely to have heartworm infestations than indoor, purpose-bred dogs. mosquitoes become infested with heartworm microfilariae when they take a blood meal from the dog. the microfilaria progress through several larval stages within the mosquito, eventually terminating at the third stage. this stage is then returned to the canine bloodstream during feeding. this stage matures within the dog's circulatory system, and the adults reside in the pulmonary artery. male and female heartworms will then sexually reproduce to create more microfilariae and propagate the parasitic life cycle. in the united states, transmission of heartworm by mosquitoes occurs over a 6month or shorter period, except for the southeastern and gulf coast states. here, climatic conditions enable longer survival of the mosquitoes (possibly year-round), thus resulting in the highest prevalence of heartworm infestation (knight, 2000) . pathologic findings. on necropsy, the small, slender worms can be seen in the pulmonary artery, right ventricle, and/or right atrium (fig. 4a ). there may be no histologic abnormalities associated with a minor worm burden, although typically the arterial endothelium in these areas is hyperplastic (fig. 4b) . endothelial cell hyperplasia, vascular smooth muscle hyperplasia, inflammation, and thrombosis of the pulmonary arteries and arterioles characterize more significant infestations. severe infestations can lead to right-sided heart failure and its pathologic sequelae of ascites, pleural effusion, hepatomegaly, and right heart and pulmonary artery enlargement. verminous pulmonary embolism can result from treatment of dogs with anthelmintics when a worm burden is present. immune responses to circulating microfilariae can cause pathologic lesions, most commonly glomerulonephritis. pathogenesis. the physical presence of the worms in the pulmonary artery is partially responsible for clinical signs observed in severe cases. however, the host immunologic response to this infestation, coupled with secretion by the heart-worms of physiomodulative factors, contributes significantly to the complications seen with this disease. endothelial cell proliferation, damage, and sloughing stimulates periarteritis and proliferation of the vascular media of pulmonary arteries and arterioles. these changes lead to thrombosis of these vessels and the arterial truncation that can be seen radiographically in severe infestations. the heartworms also release circulating factors that affect vascular tone and can promote bronchoconstriction (dillon, 2000) . these factors are discussed in more detail below, under "research complications." diagnosis and differential diagnosis. for dogs used in biomedical research, diagnosis of asymptomatic heartworm disease is important, especially if the dogs are used in cardiovascular, pulmonary, or long-term studies. a diagnosis of dirofilariasis is typically made by detection of adult heartworm antigens in a blood sample. use of adult heartworm antigen tests has virtually eliminated the historical status of "occult" heartworm disease, which was caused by infestation of adult worms without corresponding microfilarial circulation. commercial test kits that assay for the presence of adult heartworm antigens, and designed for use by veterinary practitioners, are readily available. false-negative results can occur during the prepatent period after initial infection (first 6-7 months), and when the adult worm burden is light or predominantly male. infections consisting of more than three mature female worms are usually detected by antigenic serology (knight, 2000) . a significant feature of these tests for circulating antigen is that they have a very high specificity (low rate of false-positive resuits). if a dog were negative on initial testing because of prepatency or small worm burden, it will more than likely be detected on a follow-up test 7 months later. examination for circulating microfilariae could be used to confirm an antigenic diagnosis of dirofilariasis or to establish that microfilarial production had occurred. microfilarial detection can be done by microscopic examination of the buffy coat of a microhematocrit tube or by concentration techniques, such as the modified knott test and filter tests. tests that examine for microfilariae have the inherent problem of false positives caused by microfilariae of dipetalonema reconditum, a nonpathogenic filarial worm. other serologic diagnostic tests that were more common historically, and that may still be useful, include detection of antibodies to either adult heartworm antigens or microfilarial antigens. these same techniques can be used to diagnose clinical heartworm disease. additional diagnostic tests that can augment a diagnosis of clinical heartworm disease include thoracic radiography (pulmonary artery and right-heart enlargement), electrocardiography (right-heart enlargement), and hematology (eosinophilia). differential diagnoses for symptomatic heartworm disease (coughing, dyspnea, and exercise intolerance) include canine distemper, canine infectious tracheobronchitis (complicated), streptococcal or other bacterial pneumonia, nocardiosis, and congestive heart failure. prevention and control. for dogs used in biomedical research, prevention is primarily via insect control and housing of the dogs in a controlled, indoor environment. purpose-bred dogs reared in such an environment are usually free from dirofilariasis. however, any dog (random-source or purposebred) exposed to mosquitoes could become inoculated with infective larvae and, if untreated, could develop adult heartworm disease. there are many commercial anthelmintic preparations used to prevent heartworm infestation by killing the larval stages in the canine bloodstream before they become adult worms (e.g., ivermectin, milbemycin, and diethylcarbamazine). these could be used in a research setting in which heartwormnegative dogs are housed outdoors and thus could potentially be infected through mosquito bites. if a research facility is conditioning random-source dogs for long-term use, the presence of circulating adult heartworm antigen should disqualify an animal from the conditioning program. treatment. treatment for eradication of heartworms (adults, juveniles, and microfilaria) is a long process that can pose a significant risk to the patient with regard to both drug side effects (hoskins, 1989) and immunologic reactions to dead worms lodged in the pulmonary vasculature. for this reason, medical treatment of heartworm disease is not usually attempted in research dogs. in a rare instance when such treatment was in the best interest of a long-term canine experiment, thiacetarsamide (caparsolate) and ivermectin (ivomec) were used to eradicate adults and microfilariae, respectively (authors' personal experience). alternative choices include melarsomine (immiticide) as an adulticide and milbemycin (interceptor), levamisole (levasol), or fenthion (spotton) as microfilaricidal agents. dosing regimens for these agents are detailed in dillon (2000) . research complications. the physiomodulative properties of heartworm infection have been studied. such studies have looked at factors released by adult heartworms, as well as changes in the function of host tissues in response to the worm presence. probably the most consistent finding is that endothelial cell-dependent relaxation of pulmonary arterial smooth muscle is depressed in heartworm-infected dogs as compared with control dogs, indicative of alterations in local endothelial cell behavior (maksimowich et al., 1997; matsukura et al., 1997; mupanomunda et al., 1997) . the extension of this effect on peripheral arteries (in vivo and in vitro) has been supported in some studies (kaiser et al., 1992) but refuted in others (tithof et al., 1994) . it is thought that the endothelium is perturbed by a factor released from the adult dirofilaria, possibly a cyclooxygenase product such as prostaglandin d2 (kaiser et al., 1990 (kaiser et al., , 1992 . these products have also been demonstrated to cause constriction in in vitro rat tracheal ring preparations (collins et al., 1994) , suggesting that bronchoconstriction could be an aspect of the pathogenesis of the infestation. platelet reactivity was also been found to be enhanced in dogs naturally infected with dirofilaria, when compared with uninfected controis (boudreaux and dillon, 1991) . based on these data, dogs that are positive for adult heartworm antigen should be considered inappropriate for use as research subjects and, if used, should be restricted to nonsurvival preparations that do not require physiological measurements. etiology. several species of cestodes (tapeworms) parasitize the small intestine of dogs. the most common is dipylidium caninum. other species include taenia pisiformis and, more rarely, echinococcus granulosus, multiceps spp., mesocestoides spp., and spirometra spp. clinical signs. most cestode infestations are subclinical. severe infestations with dipylidium can be associated with diarrhea, weight loss, and poor growth. epizootiology and transmission. the cestode life cycle requires an intermediate host. for dipylidium caninum, the intermediate hosts are fleas and lice. thus this species of tapeworm can be readily transmitted by ingestion of arthropods that are canine parasites in and of themselves. taenia pisiformis requires small ruminants, rabbits, or rodents for intermediate hosts, so spread is less likely, especially in a research setting. echinococcus granulosus uses not only sheep as an intermediate host but also human beings, and thus the zoonotic potential of this cestode must be considered. pathologic findings. adult cestodes in the small intestine are usually an incidental finding at necropsy. diagnosis and differential diagnosis. definitive diagnosis is usually made by the identification of egg capsules or proglottids (tapeworm segments) on the surface of the feces or around the anus. dipylidium egg packets are large (100 x 150 bm) and contain 1-63 eggs per packet (hall and simpson, 2000) . prevention and control. the most significant means to limit cestode infestation is to control the population of fleas and/or lice infesting the colony. see the sections on these ectoparasites for effective means to treat infested dogs and kennels. treatment. praziquantel at 5-12.5 mg/kg orally or subcutaneously is the standard treatment for cestodiasis, especially taenia or echinococcus species. fenbendazole, mebendazole, or oxfendazole may also be effective against dipylidium caninum (hall and simpson, 2000) . clinical signs. most lung fluke infestations are inapparent, but coughing can develop in cases that prompt a strong inflammatory response. pneumothorax has been a sequela of cyst rupture, in which case dyspnea with reduced lung sounds would be the typical presentation. epizootiology and transmission. the lung fluke life cycle requires two intermediate hosts: a snail and then a crayfish. dogs become infested after eating crayfish, which essentially limits this disease to random-source dogs. on ingestion, the immature flukes (metacercariae) migrate to the lungs and encyst in the pulmonary parenchyma. eggs produced by adult flukes are passed into the bronchioles, coughed up, swallowed, and passed in the feces to complete the life cycle. pathologic findings. grossly, the trematode cysts containing adult flukes can be seen in the lung parenchyma. areas of eosinophilic inflammation surround the cysts, and eosinophilic granulomas can also be seen encircling released eggs. pleural hemorrhages may also be caused by the migrating metacercariae (lopez, 1995) . pathogenesis. clinical illness is usually a result of a severe eosinophilic inflammatory response, pneumothorax caused by cyst rupture, or secondary bacterial pneumonia. diagnosis and differential diagnosis. definitive diagnosis of paragonimus infestation requires identification of the characteristic ovoid eggs (80-115 ~tm long) with a single operculum in either the feces or a transtracheal wash. identification from fecal samples requires sedimentation techniques. other causes of coughing in dogs (e.g., infectious tracheobronchitis, dirofilariasis, congestive heart failure) need to be considered. radiographically, the appearance of (multi)focal densities within the air-filled lung field needs to be differentiated from pulmonary neoplasia (primary or metastatic) or systemic fungal pneumonias. prevention. use of purpose-bred dogs virtually eliminates the chance of pulmonary trematodiasis in a research animal. treatment. praziquantel (at 25 mg/kg q8 hr x 3 days) or fenbendazole (25-50 mg/kg q12 hr x 10-14 days) are recommended for treatment of canine paragonimus infestation (hawkins, 2000) . effectiveness is monitored by fecal sedimentation tests for eggs and resolution of radiographic lesions (which may never resolve entirely). early diagnosis of pulmonary trematodiasis should warrant discontinuation of a dog from a long-term study because of the possibility of more serious clinical sequelae, such as pneumothorax. research complications. experimental studies involving the immune system, especially eosinophilic or local pulmonary responses, would be significantly affected by even minor infestations. clinical illness would complicate almost any research project and makes dogs poor anesthetic risks. radiographic lesions may confound diagnostic evaluation for pulmonary metastasis of tumors. e. mites i. demodicosis etiology. canine demodicosis is caused by demodex canis, a commensal mite that lives in the hair follicles. it is considered to be normal fauna of dog skin, but certain conditions (i.e., immunosuppression) cause development of clinical illness. clinical signs. demodex canis infestation is typically asymptomatic. clinical demodicosis presents with variable and nonspecific clinical signs, such as alopecia, erythema, pruritus, crusts, and hyperpigmentation. it can occur anywhere on the body but is often seen on the feet and the face and around the ears (demanuelle, 2000a). secondary bacterial pyoderma is a common complication. epizootiology and transmission. demodex canis mites pass to nursing pups from the dam. they live their entire lives on one dog and are not considered contagious to other dogs or humans. certain breeds are predisposed to the generalized form of demodex dermatitis (see "pathogenesis," below). beagles are among the predisposed breeds, as are german shepherds, doberman pinschers, old english sheepdogs, collies, boxers, and shorthair brachycephalic breeds (muller et al., 1983) . pathologic findings. histologically, demodex infections are characterized by perifolliculitis and folliculitis with mites and keratin debris visible in the hair follicles. cases with generalized demodicosis (see "pathogenesis," below) may have a minimal cellular response with no eosinophils, indicative of severe immunosuppression . pathogenesis. when clinical demodicosis develops, it is classified into "localized" or "generalized" (e.g., more than one foot affected, or five or more small areas, or one large body area). localized demodicosis is typically seen in juvenile dogs (< 18 months) and usually resolves without treatment as natural immunological control develops. generalized demodicosis can develop in juvenile or adult populations. juvenile-onset generalized demodicosis occurs in dogs with a genetic predisposition, thought to be an inherited t-lymphocyte dysfunction. adult-onset generalized demodicosis is usually indicative of an underlying endocrine (hyperadrenocorticism, diabetes mellitus, hypothyroidism) or neoplastic disorder or can develop as a result of immunosuppressive therapy (such as corticosteroid administration). diagnosis and differential diagnosis. demodex is readily identified from deep skin scrapings of lesioned areas (campbell, 2000; noli, 2000) . demodex canis has a characteristic "cigar shape," with short, stubby legs on a body 100-400 ~tm long. differential diagnoses for local demodicosis include dermatophytosis, allergic contact dermatitis, and seborrheic dermatitis. the primary differential diagnosis for generalized demodicosis is primary bacterial pyoderma; remember, however, that bacterial pyoderma is a common secondary complication of the generalized form of this parasitism. prevention and control. dogs with generalized demodicosis should not be maintained in a breeding colony. treatment: ivermectin (ivomec) at 200-600 ~tg/kg and oral milbemycin (interceptor) at 1-2 mg/kg/day have been found to be effective treatments. these parasiticides are probably the most practical to use in a research setting, although they are not labeled for treatment of demodex canis. amitraz (mitaban) dips (250 ppm every 14 days) can be used for more problematic cases. treatment duration can be extensive and must be accompanied by repeated skin scrapings. research complications. dogs with generalized demodicosis should not be used in research studies, because this disease is indicative of another underlying disorder (endocrine or immunological). dogs that receive immunosuppressive agents or paradigms could develop generalized demodicosis as an unexpected consequence of the experimentation. ii. sarcoptic mange etiology. canine sarcoptic mange is caused by sarcoptes scabiei var. canis. clinical signs. the most common clinical sign is an intense pruritus, usually beginning at sparsely furred areas such as the ear pinnae, elbows, and ventral thorax and abdomen. lesions are characterized by alopecia and yellowish dry crusts with a macular papular eruption. these lesions may be exacerbated by excoriation due to the pruritic nature of the condition. epizootiology and transmission. sarcoptes mites live their entire lives in the stratum corneum of the host animal; however, they can survive for 1-3 weeks away from the host, and it is this ability that enables them to spread from dog to dog. sarcoptes scabiei var. canis can also infect cats and humans. pathologic findings. histologic examination can be unrewarding because mites are rarely seen on tissue sections, and the associated dermatitis is nondiagnostic: perivascular and interstitial dermatitis with hyperkeratosis, with or without eosinophilic infiltration. suggestive histopathologic lesions are epidermal "nibbles," small foci of edema, exocytosis, degeneration, and necrosis . pathogenesis. lesions and illness are a result of the female mites burrowing through the epidermal layers to deposit eggs, and the larvae migrating back to the surface. the typical locations of mange lesions are a result of the mite's preference for relatively hairless areas. diagnosis and differential diagnosis. sarcoptic mange can be difficult to diagnose because multiple skin scrapings can yield negative results with this parasitic disorder. hopefully, adult mites, mite eggs, or mite feces can be observed on superficial skin scrapings. even if scrapings are negative, however, a therapeutic trial should be initiated if the clinical signs and history suggest a sarcoptes etiology. demonstration of anti-mite ige in either the serum or via an intradermal antigen test can be used as a diagnostic aid (campbell, 2000 ). an important differential diagnosis is flea allergy dermatitis; in contrast, mange is nonseasonal and contagious. prevention and control. use of purpose-bred dogs limits the possibility of having research animals with sarcoptic mange. for random-source dogs, an ectoparasite control program should be in place to limit possible infestations. many institutions use ivermectin as a means to control both endoparasites and ectoparasites. treatment. unless treatment would interfere with research objectives, all dogs with sarcoptic mange (no matter how minor the lesions) and their kennel mates should be treated because of the contagious nature of the disease and its zoonotic potential. in research colonies, the usual means of treatment is either ivermectin (ivomec) at 200-400 ~tg/kg q14 days or milbemycin (interceptor) at 3 oral doses of 2 mg/kg q7 days . neither of these agents is approved for treatment of sarcoptic mange, but they are considered to be effective. acaricidal dips (e.g., lime sulfur, organophosphates, amitraz) can also be used. research complications. the local skin inflammation and systemic immune response to sarcoptic mange probably make infected dogs poor subjects for dermatologic and immunologic studies. f lice and ticks i. lice etiology. dogs can be infested by one species of sucking louse (linognathus setosus) and two species of biting lice (trichodectes canis and heterodoxus spiniger). clinical signs. mild cases of pediculosis may be asymptomatic or may cause pruritic areas of dry skin. more severe infestations can cause significant pruritus and produce alopecia, papules, and crusts. these lesions lead to excoriation and secondary bacterial dermatitis. severe linognathus infestations could cause anemia, because this species feeds on blood. epizootiology and transmission. louse infestations are uncommon in both pet animal practice and the research setting. they would most likely be seen in random-source dogs that were obtained from a pound or shelter. transmission is usually by direct contact, for lice spend their entire lives on the host species. lice are host-specific and not zoonotic. pathogenesis. the biting lice usually cause more local irritation than the sucking louse and therefore are more apt to induce clinical dermatologic signs. trichodectes canis can serve as vector for the canine tapeworm dipylidium caninum. the most severe complication of infestations by the sucking louse is the potential anemia. diagnosis and differential diagnosis. pediculosis is diagnosed by direct observation of the lice or nits (eggs) on the dog's skin. cellophane tape can be used to pick up surface debris from skin lesions, which may include nits or immobilized lice (muller et al., 1983) . differential diagnoses include dermal acariasis, flea allergy dermatitis, and seborrhea. prevention. use of high-quality conditioned dogs for research should prevent pediculosis from ever being seen within a research facility. random-source dogs should be shampooed or treated prophylactically with topical insecticide before being permitted to enter the research colony. treatment. most commercially available insecticide shampoos and dips readily treat louse infestations. treatment should be repeated in 10-14 days, because any nits that were not killed would have hatched by that time (muller et al., 1983) . there is probably minimal interference with research, unless severe linognathus infestations cause anemia. ii. ticks etiology. ticks are obligate arachnid parasites that require vertebrate blood as their sole food source. except for the brown dog tick (rhipicephalus sanguineus), ticks have a wide host range and are not especially host-specific; so any number of tick genera and species can be found on dogs. genera that more commonly infest dogs in the united states include species of rhipicephalus, dermacentor, and ixodes. the primary significance of tick infestation is the tick's ability to be a vector for many other infectious diseases, including rocky mountain spotted fever (caused by rickettsia rickettsii), lyme disease (borrelia burgdorferi), and the canine forms of ehrlichiosis (ehrlichia canis and e. platys), babesiosis (babesia canis), haemobartonellosis (haemobartonella canis), and hepatozoonosis (hepatozoon canis). clinical signs. as an entity unto itself, tick infestation causes minimal clinical signs. most infestations are subclinical, although some dogs may lick and bite at the site, aggravating the local lesion. some dogs can develop a hypersensitivity reaction after several tick bites; these dogs develop a more granulomatous response at the location of the bite (merchant and taboada, 1991) . some species of ticks (primarily dermacentor andersoni and d. variabilis) produce a salivary neurotoxin that can cause an ascending flaccid paralysis (malik and farrow, 1991) . the paralysis develops within 5-9 days of tick attachment and can result from a single tick. this paralysis is fatal once the respiratory musculature is affected. epizootiology and transmission. in dogs used for biomedical research, tick infestation may occasionally be seen in randomsource dogs, because these dogs are more likely to have been in tick habitats than purpose-bred dogs. ticks commonly reside in wooded areas until they contact a suitable host for a blood meal. the brown dog tick may reside within kennels (attics, bedding, wall insulation) (garris, 1991) . pathologic findings. under most circumstances, tick infestation will be an incidental finding on necropsy (unless tick paralysis was the cause of death). pathogenesis. tick-bite paralysis is caused by the presence of a salivary neurotoxin released by female ticks of certain genera (e.g., dermacentor) while consuming a blood meal (malik and farrow, 1991) . interestingly, dogs seem to be most affected by this condition, whereas cats appear to be resistant. the primary dysfunction appears to be at the neuromuscular junction, as stimulation of the motor nerves fails to elicit a response, but direct stimulation of the muscle tissue results in contractions. tick bites can also transmit pathogen microorganisms to the dog, because ticks serve as vectors for several infectious diseases, including lyme borreliosis, ehrlichiosis, babesiosis, and rocky mountain spotted fever. diagnosis and differential diagnosis. for uncomplicated tick bites and tick-bite paralysis, definitive diagnosis is made by identification of the offending arachnid (and improvement of paralysis after removal). differential diagnoses for tick-bite paralysis include botulism, snakebite, polyradiculoneuritis, and idiopathic polyneuropathy (malik and farrow, 1991) . prevention. purpose-bred dogs should be free from all ectoparasites, but ticks can occasionally be seen on randomsource animals. research dogs should not be exercised in outdoor areas infested with ticks, and kennels must be cleaned properly and regularly so as to remain free of ticks and other parasites. treatment. removal of the offending tick is the primary treatment for both local inflammation as well as tick-bite paralysis. dogs with tick-bite paralysis usually show improvement within 24 hr, with complete recovery within 72 hr (malik and farrow, 1991) to remove an attached tick from a dog, forceps should be used to grasp the tick as close to the dog's skin as possible. the tick should not be grabbed by the body, as this may cause the parasite to either rupture or inject its body contents into the dog. the tick should be pulled away from the dog with steady pressure. many of the diseases transmitted by ticks are zoonotic so precautions, such as wearing gloves, should be taken. use of topical acaricide/insecticides on newly arrived random-source dogs should help to limit infestations. probably have minimal impact on research variables. the significant concern for tick infestation is the possible development of tick-bite paralysis or of any one of a number of systemic diseases spread by ticks (see sections iii,a,l,e-g). g. other i. flea infestation etiology. fleas are laterally flattened wingless insects that feed on animal blood. the most common flea to infest dogs is ctenocephalides felis, the cat flea. other fleas that can affect dogs are ctenocephalides canis, pulex irritans, and echidnophaga gallinacea. the fleas are speciated by the shape of their head and by the presence or absence of ctenidae (spiny combs on or behind the head) (campbell, 2000) . clinical signs. flea infestations usually cause foci of alopecia and pruritus. dogs that are hypersensitive to antigenic proteins in flea saliva develop the more severe "flea allergy dermatitis," which features papules and crusting. acute moist dermatitis ("hot spots") can also be seen in these cases, and secondary pyoderma or seborrhea can develop. lesions from flea allergy dermatitis generally appear in the dorsal lumbosacral region, as well as the flanks, thighs, and abdomen (muller et al., 1983) . the lesions are typically worse in the summer and autumn months and are progressively more severe as the dog ages. epizootiology and transmission. fleas are readily transmitted between animals and even between host species. they move readily between the host and the environment, making transmission easy and control difficult. because fleas require host blood for food, they can survive off of a host for only 1-2 months (muller et al., 1983) . pathologic findings. biopsy samples are usually nondiagnostic in cases of flea allergy dermatitis. lesions are typically characterized by perivascular eosinophilic inflammation and may feature pustules and folliculitis if secondary pyoderma develops (muller et al., 1983) . pathogenesis. fleas are parasites that require animal blood for their meals. when they bite host animals, they inject some saliva into the host's skin. if the host develops an allergic response to the flea saliva, it will develop the more pruritic flea allergy dermatitis. fleas can also transmit or serve as vectors for other pathogens (e.g., dipylidium tapeworms). flea allergy dermatitis are definitively diagnosed by observing the fleas on the host's skin. given that this may be difficult because of the mobility of the flea and the majority of the time it spends off of the host, diagnosis is often based on clinical signs, history, and lesion distribution. sometimes the presence of flea excrement ("flea dirt") on the dog's skin can support a presumptive diagnosis (demanuelle, 2000b) . circulating eosinophilia is seen in some dogs with flea allergy dermatitis. differential diagnoses include mite and louse infestations, bacterial folliculitis, and allergic or atopic conditions that present with skin lesions in dogs (e.g., food, drug, or contact hypersensitivity). prevention. most dogs obtained from high-quality purposebred facilities should be free from flea infestations. dogs received from pounds, shelters, or licensed dealers would be more likely to be affected by fleas (or any ectoparasitism). thorough knowledge of prevention, control, and treatment measures at these facilities should be obtained, and dogs from sources where proper prevention and/or therapy are not practiced should be evaluated and/or empirically treated upon arrival at the facility. control. thorough cleaning of the dog's housing environment should remove the risk of perpetuating or transmitting flea infestation in the colony. treatment. treatment for fleas needs to address treatment of both the dog and the environment. many insecticide formulations such as shampoos, sprays, dips, powders, and oral systemics can be used for initial treatment of the individual dog. the active ingredients include pyrethrins, pyrethroids, carbamates, and organophosphates. flea control in the kennel may need to include outdoor areas in warm climates. typically combinations of adult insecticides and juvenile growth regulators are used for environmental treatment. directed sprays are the most effective means of treating housing areas, because flea "bombs" or foggers do not penetrate adequately into tight areas where fleas might hide (demanuelle, 2000b) . in addition to insecticide therapy, dogs with flea allergy dermatitis may also require anti-inflammatory medication to relieve clinical signs. oral prednisone or prednisolone at 0.5 mg/kg q12 hr for 5-7 days has been proposed as a starting therapy (muller et al., 1983) . the use of hyposensitization with flea-bite antigens is controversial and not practical for the research setting. research complications. mild flea infestation probably has minimal impact on most research protocols, and treatment measures may in fact be more detrimental to the experimental objective than the actual ectoparasitism. in a research setting, the residual effects of insecticides may preclude their use in experimental animals. such treatments should be used judiciously to ensure that experimental results are not more seriously affected by the therapy rather than the infestation. dogs with flea-allergy dermatitis are more severely affected by the flea infestation and should be treated apigropriately; however, systemic corticosteroids may also interfere with experimental objectives, especially in studies involving functions of the immune system. the ability of fleas to transmit other parasitic diseases must also be considered. etiology. dermatophytoses ("ringworm") are fungal skin infections, which in dogs in the united states are usually caused by either microsporum canis, m. gypseum, or trichophyton mentagrophytes (muller et al., 1983) . clinical signs. uncomplicated superficial dermatophytoses are characterized by circumscribed circular areas of alopecia, usually with minimal to no inflammation. these skin lesions are usually seen around the face, neck, and forelimbs but can be found anywhere on the body. secondary bacterial infections can develop; these lesions are called kerions and are selflimiting, for the fungus cannot survive in inflamed skin (muller et al., 1983) . ep&ootiology and transmission. the fungi that cause skin infections are very contagious and readily transmissible between dogs and other species (including human beings), but they can also be obtained from the soil. pathologic findings. on close inspection of skin samples, broken hair shafts (and not complete hair loss) would be seen with uncomplicated dermatophytosis. histologically, fungal elements can be seen within the stratum corneum or in and around the hair and hair follicles (muller et al., 1983) . stains that facilitate visualization of fungal elements include periodic acid-schiff (pas) or gomori methenamine-silver. the pattern of inflammation in the affected foci is very variable and can feature folliculitis, perivascular dermatitis, hyperkeratosis, and/or vesicular dermatitis. pathogenesis. the dermatophytes typically infect the hair shaft itself, the hair follicle, and possibly the skin around the affected hair. the hair follicle is not destroyed (unless by secondary bacterial infection), but the hair itself becomes brittle and breaks. this causes short stubbly hair to be seen within the lesion. as the lesion progresses, the hairs in the center recover from the infection, thus leading to the classic "ringworm" appearance of the alopecic areas. it is postulated that the inflammatory process produces an environment that is unfavorable for dermatophyte survival, whereas the periphery of the lesion still enables continued fungal growth (muller et al., 1983) . diagnosis and differential diagnosis. diagnosis of dermal fungal infection is typically made by scraping the affected area to obtain hair and superficial epidermal cells. these scrapings are then digested with potassium hydroxide to facilitate observation of fungal elements. fungal elements can also be seen on skin biopsy samples. for speciation of a fungus, skin scrapings can also be inoculated onto agars that promote fungal growth, such as sabouraud's medium or dermatophyte test medium (dtm). incubation should be at 30~ with 30% humidity for 14-30 days. lesions caused by m. canis may fluoresce when inspected using a wood's (253.7 nm ultraviolet) light. unfortunately, some strains of m. canis do not fluoresce, and neither does m. gypseum or t. mentagrophytes. differential diagnoses for dermatomycosis include seborrhea, localized demodecosis, folliculitis, histiocytoma, and acral lick dermatitis (muller et al., 1983) . prevention. purpose-bred dogs are typically free of infectious dermatophytes, but ringworm may be diagnosed on randomsource animals. control. in cases of dermatophytosis, isolation of the affected animal(s) is prudent, because the fungi are easily spread to other dogs, as well as to people. treatment, if acceptable, should be started immediately. treatment. topical antifungal therapy is most commonly used. shampoos, rinses, and creams containing miconazole, ketoconazole, enilconazole, or chlorhexidine are commercially available to treat ringworm (stannard et al., 2000) . severe cases may require systemic therapy with griseofulvin, ketoconazole, itraconazole, or fluconazole. however, these systemic antifungal agents may have considerable side effects (such as vomiting and teratogenicity with griseofulvin). many of the newer agents are also expensive and not labeled for use in dogs. impact on most research applications for dogs. unfortunately, the zoonotic implications of dermatophytoses force the issue of aggressive treatment, and many antifungal agents may not be compatible with biomedical research studies. systemic fungal infections disseminate to multiple organ systems from a single mode of entry (usually through the respiratory tract). dogs are susceptible to several fungi that characteristically cause systemic mycosis, including blastomyces dermatitidis, histoplasma capsulatum, coccidioides immitis, and cryptococcus neoformans var. neoformans. these diseases are not typically seen in the research setting, because of the low overall incidence and noncontagious nature of these disorders and because of the use of purpose-bred animals. these conditions could, however, present in the rare random-source dog that was subclinical at its point of origin, especially if the animal becomes immunosuppressed (either naturally or by virtue of experimental manipulation). typical clinical signs include weight loss, fever, lymphadenopathy, and cough and dyspnea (if the lungs are affected). the reader is advised to read veterinary medical text chapters (e.g., taboada, 2000) for more complete information on these disorders and their possible treatments. although the incidence of hypothyroidism in the canine population is not high (kemppainen and clark, 1994) , deficiency in thyroid hormone can significantly affect basal metabolism and immune function. because these factors are important in many biomedical research studies, it is imperative that laboratory animal veterinarians be able to recognize, diagnose, and treat this problem. etiology. the majority of cases of canine hypothyroidism are due to lymphocytic thyroiditis, an autoimmune disorder, or idiopathic atrophy of the thyroid gland. both of these causes result in a gradual loss of functional thyroid tissue (kemppainen and clark, 1994) . lymphocytic thyroiditis is the major cause of hypothyroidism in laboratory beagles and appears to be familial in that breed (tucker, 1962; beierwaltes and nishiyama, 1968; manning 1979) . rarely, congenital defects or nonfunctional tumors may cause hypothyroidism (peterson and ferguson, 1989; kemppainen and clark, 1994) . clinical signs. because it affects metabolism in general, hypothyroidism can produce a large number of clinical signs referable to many organ systems. an individual dog with hypothyroidism may have one or any combination of clinical signs. hypothyroidism reduces the dog's metabolic rate, which then produces such signs as obesity, lethargy, cold intolerance, and constipation. additionally, hypothyroidism can produce several dermatologic abnormalities, including alopecia, hyperpigmentation, seborrhea, and pyoderma (peterson and ferguson, 1989; panciera, 1994) . several clinicopathologic abnormalities have also been reported in a large percentage of hypothyroid dogs. these aberrations include increased serum cholesterol and triglycerides due to a decrease in lipolysis and decreased numbers of low-density lipopolysaccharide receptors (peterson and ferguson, 1989; panciera, 1994) . normocytic normochromic nonregenerative anemia and increased serum alkaline phosphatase and creatine kinase have also been reported in a significant number of hypothyroid dogs (peterson and ferguson, 1989; panciera 1994) . neurologic signs of hypothyroidism, which include lameness, foot dragging, and paresis, may be caused by several mechanisms such as segmental nerve demyelination or nerve entrapment secondary to myxedema (peterson and ferguson, 1989) . mental impairment and dullness have also been reported in hypothyroid dogs, secondary to atherosclerosis and cerebral myxedema (peterson and ferguson, 1989) . hypothyroidism has been implicated in other neurological abnormalities such as horner's syndrome, facial nerve paralysis, megaesophagus, and laryngeal paralysis; however, these conditions do not always resolve with treatment (bischel et al., 1988; panciera, 1994) , and so the relationship between hypothyroidism and these problems has not been completely defined (panciera, 1994) . myopathies associated with hypothyroidism are caused by metabolic dysfunction and atrophy of type ii muscle fibers and can present with signs similar to neurological disease (peterson and ferguson, 1989) . hypothyroidism can also cause bradycardia as a result of decreased myocardial conductivity. abnormalities that may be detected by ecg include a decrease in p and r wave amplitude (peterson and ferguson, 1989) and inverted t waves (panciera, 1994) . these electrocardiographic abnormalities are caused by lowered activity of atpases and calcium channel function. several reports have suggested that hypothyroidism is associated with von willebrand's disease and bleeding abnormalities. however, the relationship is probably one of shared breed predilection and not a true correlation. it has been demonstrated that dogs with hypothyroidism are not deficient in von willebrand's factor when compared with other dogs. in addition, the replacement of thyroid hormone in dogs did not increase the levels of vwf:ag in naturally occurring (panciera and johnson, 1994) or experimentally induced (panciera and johnson, 1996) hypothyroidism. epizootiology. the prevalence of hypothyroidism in the general canine population has been reported to be less than 1% (panciera, 1994) . the disorder occurs most often in large-breed dogs but has been reported in several other breeds as well as mongrels. doberman pinschers and golden retrievers appear to have a higher incidence of hypothyroidism when compared with other breeds (panciera, 1994; peterson and ferguson, 1989; scarlett, 1994) . there have been several reports about hypothyroidism in laboratory colonies of beagles (manning, 1979; tucker, 1962; beierwaltes and nishiyama, 1968) . in general, the problem is usually recognized in middle-aged animals, and some reports state that there is a higher incidence of hypothyroidism in spayed female dogs (panciera, 1994; peterson and ferguson, 1989 ). diagnosis and differential diagnosis. because of the large number of clinical manifestations in dogs, the recognition of hypothyroidism is not always straightforward. likewise, the diagnosis of hypothyroidism can be difficult because of the lack of definitive diagnostic tests available for the dog. the tests currently available and in popular use will be discussed further. however, a complete understanding of the diagnosis of hypothyroidism requires a familiarity with thyroid hormone metabolism and function that is beyond the scope of this writing. for additional information, the reader is referred to one of several manuscripts available (peterson and ferguson, 1989; ferguson, 1994) . currently, the ability to diagnose hypothyroidism relies heavily on the measurement of serum total t 4 (thyroxine) and free t 4 (peterson and ferguson, 1989; ferguson, 1994) . t 4 serves primarily as a precursor for t 3 in the body and is heavily proteinbound. free t4 represents the unbound fraction that is available to the tissues (peterson and ferguson, 1989) . using the measurement of serum total t 4 and free t4, hypothyroidism can usually be ruled out if the values are within the normal range or higher. if both hormone concentrations are low, it is highly likely that the patient has hypothyroidism, and a therapeutic trial is in order (peterson and ferguson, 1989) . however, it must be noted that nonthyroidal illnesses and some drugs (e.g., glucocorticoids, anticonvulsants, phenylbutazone, salicylates) can falsely lower these values (peterson and ferguson, 1989; ferguson, 1994) . therefore, low values do not always indicate that hypothyroidism is present, and animals should not be treated solely on the basis of serum hormone levels if clinical signs are absent. if the clinical signs are equivocal or if only total t 4 or free t 4 is decreased, further diagnostic testing is warranted (peterson and ferguson, 1989) . although t 3 is the most biologically active form of thyroid hormone in the body, the measurement of serum t 3 levels is an unreliable indicator of hypothy-roidism (peterson and ferguson, 1989; ferguson, 1994) . like t4, serum t 3 can be falsely lowered by many nonthyroidal illnesses and many drugs (see above). in addition, t 3 may be preferentially released, and conversion of t 4 to t 3 may be enhanced in the hypothyroid dog (peterson and ferguson, 1989; ferguson, 1994) . t 3 was within normal limits in 15% of the hypothyroid dogs in one study (panciera, 1994) . autoantibodies can be responsible for false elevations in the concentrations of t 3 and t 4 found in these respective assays. it has been recommended that free t4, measured by equilibrium dialysis, be assayed in dogs that are suspected of hypothyroidism and have autoantibodies with normal or high t 3 and t 4. autoantibodies have been found in less than 1% of the samples submitted to one laboratory (kemppainen and behrend, 2000) . other means of diagnosing hypothyroidism have been described. in humans, endogenous tsh (thyroid-stimulating hormone) levels provide reliable information on thyroid status, and an assay for endogenous tsh is now available in dogs. however, tsh levels can be normal in some dogs with hypothyroidism, and high tsh levels have been noted in normal dogs. therefore, it is recommended that tsh levels be considered along with other information (clinical signs, t4) prior to diagnosis and treatment (kemppainen and behrend, 2000) . tsh stimulation testing using exogenous bovine tsh provides a good and reliable method for establishing a diagnosis. unfortunately, the availability and expense of tsh limit the use of this diagnostic tool (peterson and ferguson, 1989; ferguson, 1994) . another drawback of tsh testing is that the test must be postponed for 4 weeks if thyroid supplementation has been given (peterson and ferguson, 1989) . when tsh is available for testing, there are several recommendations for dosage, routes of administration, and sampling times. one recommendation is 0.045 u of tsh per pound of body weight (up to a maximum of 5 u) to be administered iv. for this protocol, blood samples are taken prior to administration of tsh and 6 hours after. a normal response to the administration of tsh should create an increase of t 4 levels at least 2 ktg/dl above the baseline levels or an absolute level that exceeds 3 ~tg/dl (peterson and ferguson, 1989; wheeler et al., 1985) . treatment. the treatment of choice for hypothyroidism in the dog is l-thyroxine (sodium levothyroxine). a recommended dosing regimen is 0.02 mg/kg once a day or 0.05 mg/m 2 (body surface area)/day for very small or very large dogs. if drugs that decrease thyroxine levels are being administered concurrently, it may be necessary to divide the thyroxine dose for twice daily administration. after the supplementation has begun, the thyroid hormone level should be rechecked in 6-8 weeks, and blood samples should be drawn 4-8 hours after the morning pill. a clinical response is usually seen in 6-8 weeks and would include weight loss, hair regrowth, and resolution of other signs (panciera, 1994) . ecg abnormalities also return to normal (peterson and ferguson, 1989) . for dogs with neurologic signs, the prognosis is guarded, because the signs do not always resolve with supplementation (panciera, 1994) . weight gain and eventual obesity are also frequent findings in dogs in the research environment. because obesity can adversely affect several body systems as well as general metabolism, the laboratory animal veterinarian must be aware of the development of obesity and the potential effect that it can have on research. etiology. obesity is defined as a body weight 20-25% over the ideal. in general, obesity occurs when the intake of calories exceeds the expenditure of energy. excessive caloric intake resuits from overeating or eating an unbalanced diet. overeating is a common cause of obesity in pet dogs and may be triggered by boredom, nervousness, or conditioning (macewen, 1992) . in addition, pet animals are often subjected to unbalanced diets supplemented with high-fat treats. in the laboratory animal setting, overeating is less likely than in a household, because access to food is more restricted and diets are usually a commercially prepared balanced ration. however, obesity can still be a problem if specific guidelines for energy requirements are not followed. in addition, the necessary caging of dogs in the research environment and thus the limitation to exercise reduces energy expenditure and predisposes dogs to weight gain. it is also important to realize that other factors may predispose dogs to obesity, even when guidelines for caloric intake and energy expenditure are followed (butterwick and hawthorne,. 1998 ). as in humans, genetics plays an important role in the development of obesity in dogs. it has been established that certain breeds are more predisposed toward obesity. in a study of dogs visiting veterinary clinics in the united kingdom, labrador retrievers were most likely to be obese. other breeds affected included cairn terriers, dachshunds, basset hounds, golden retrievers, and cocker spaniels. the beagle was also listed as a breed predisposed to obesity in the household environment (edney and smith, 1986) . in addition to genetics, several metabolic or hormonal changes are associated with obesity. it has been well established that neutering promotes weight gain. in one study, spayed female dogs were twice as likely to be obese when compared with intact females (macewen, 1992) . the authors proposed that the absence of estrogen promotes an increase in food consumption. a similar trend toward obesity was found in castrated male dogs (edney and smith, 1986) . in addition, hypothyroidism and hyperadrenocorticism may present with obesity as one of the clinical signs (macewen, 1992) . epizootiology. ewen, 1992) . obesity affects up to 40% of pet dogs (mac-diagnosis and differential diagnosis. the diagnosis of obesity is somewhat subjective and relies on an estimate of ideal body weight. the ideal body condition for dogs is considered to be achieved when the ribs are barely visible but easily palpated beneath the skin surface. when the ribs are not easily palpated and/or the dog's normal function is impaired by its weight, the animal is considered obese. there are few objective, quantifiable methods for establishing this diagnosis. ultrasound has been evaluated for measurement of subcutaneous fat in dogs, and measurements taken from the lumbar area can be used to reliably predict total body fat (wilkinson and mcewan, 1991) . after a diagnosis of obesity has been made, additional diagnostic tests should be performed to determine if there is an underlying cause for the problem. a complete physical exam should be performed to look for signs of concurrent disease and to establish if obesity has adversely affected the individual. serum thyroid hormones should be evaluated (see section iii,b,l,a), and serum chemistry may reveal an increased alkaline phosphatase associated with hyperadrenocorticism. treatment. restricting food intake readily treats obesity, and this is easily done in the research setting. it has been suggested that a good weight loss program involves restriction of intake to 60% of the calculated energy requirement to maintain ideal body weight. it has been shown that restriction of calories down to 50% produces no adverse health effects. however, t 3 levels will decrease in direct proportion with caloric intake. ideally, weight loss will occur at a rate of 1-2% of body weight per week (laflamme et al., 1997) . with more severe calorie restriction and more rapid weight loss, the individual is more likely to rebound and gain weight after restrictions are relaxed. there has been agreat deal of attention in humans as to the correct diet to be fed to encourage weight loss. likewise, the type of diet fed to dogs has been examined. as mentioned above, the restriction of calories is most important, and feeding less of an existing diet can do this. alternatively, several diet dog foods are available, and there is some evidence that these diets are superior to simple volume restriction (macewen, 1992) . there has been much concern about the addition of fiber to the diet in both humans and animals as a method for reducing caloric intake while maintaining the volume fed. studies in dogs have examined the addition of both soluble and insoluble fibers to calorierestricted diets. these studies have shown that the addition of fiber does not have an effect on satiety in dogs and therefore does not have a beneficial effect in weight loss protocols (butterwick and thorne, 1994; butterwick and thorne, 1997) . it is important to control weight gain in research animals, because of the association of obesity and several metabolic changes. although an association between obesity and reproductive, dermatologic, and neoplastic problems has been reported (macewen, 1992) , this relationship is not consistently apparent (edney and smith, 1986) . obesity in dogs over 10 years of age appears to be related to an increase in cardiovascular problems (edney and smith, 1986) , and obesity has been linked to hypertension. joint problems including osteoarthritis and hip dysplasia have also been related to obesity (macewen, 1992; kealy et al., 1997) . in addition, diabetes mellitus has been linked to obesity, and obesity induces hyperinsulinism in several experimental models (macewen, 1992) . in the laboratory setting, the majority of traumatic wounds will be small in size. in facilities with good husbandry practices and a diligent staff, traumatic wounds will generally be observed quickly and attended to promptly. under these conditions, proper initial treatment will lead to uncomplicated wound healing. complications such as infection and delayed healing arise when wounds are not noticed immediately or. when the basic principles of wound management are not followed. to aid in the description of wounds and in decision making about wound therapy, several classification systems have been developed for traumatic injuries. at one time, decisions about wound therapy were largely based upon the length of time since wounding, or the concept of a "golden period." it is now recognized that several factors must be considered prior to initiating wound care, including (but not limited to) the type and size of the wound, the degree of wound contamination, and the capability of the host's defense systems (swaim, 1980; waldron and trevor, 1993) . one of the most widely used classification systems is based upon wound contamination and categorizes wounds as either clean, clean-contaminated, contaminated, or dirty (see table v ). the vast majority of the wounds seen in the laboratory setting will fall into the clean and clean-contaminated categories. these wounds may be treated with the basic wound care described below and primary closure of the wound. contaminated and dirty wounds, which are seen infrequently in the laboratory setting, require more aggressive therapy. dirty wounds can occur as postsurgical infections or complications of initial wound therapy. when one is in doubt as to the classification of a wound, the worst category should be presumed in order to provide optimal therapy and reduce the chance for complications. the initial treatment of a wound is the same regardless of the wound's classification. when first recognized, the wound should be covered' with a sterile dressing until definitive treatment is rendered. bleeding should be controlled with direct waldron and trevor (1993) . pressure; tourniquets are discouraged because of the complications that may arise with inappropriate placement (swaim, 1980) . it is best to avoid using topical disinfectants in the wound until further wound treatment (culture, debridement, lavage) has been performed (swaim, 1980) . when the treatment of a wound begins, anesthesia or analgesia may be necessary, and the choice of anesthetic regimen will depend on the size and location of the wound as well as the preference of the clinician. if the wound is contaminated or dirty, bacterial cultures, both aerobic and anaerobic, should be performed at this time. then a water-soluble lubricant gel may be applied directly to the wound. a wide margin of hair should then be clipped from around the wound, using a #40 blade. after the clipping, a surgical scrub is performed around the edges of the wound. povidone-iodine alternating with alcohol or chlorhexidine gluconate scrub alternating with water is most often recommended for surgical preparation of the skin surface (osuna et al., 1990a,b) . simple abrasions that involve only a partial thickness of the skin do not generally require further treatment. full-thickness wounds require further attention, including irrigation with large quantities of a solution delivered under pressure. two solutions, 0.05% chlorhexidine diacetate in water (lozier et al., 1992) and 1% povidone-iodine in saline, are most often recommended for wound lavage (waldron and trevor, 1993) . the chlorhexidine solution may offer the advantage of greater bactericidal activity but does not significantly alter wound healing when compared with povidone-iodine (sanchez et al., 1988) . actually, the type of solution chosen may not be as important to wound care as the volume and pressure at which the solution is delivered. it has been suggested that 8 psi is required to obtain adequate tissue irrigation, and this may be achieved by using a 35 ml syringe and an 18-or 19gauge needle (waldron and trevor, 1993) . for wounds that are contaminated or dirty, debridement is an important part of initial therapy. debridement usually proceeds from superficial to deeper layers. skin that is obviously necrotic should be removed. although it is often recommended to remove skin back to the point at which it bleeds, this may not be feasible with large wounds on the limbs. in addition, other factors such as edema or hypovolemia may reduce bleeding in otherwise viable skin (waldron and trevor, 1993) . if one is unsure about tissue viability in areas that are devoid of extra skin, the tissue may be left (swaim, 1980; waldron and trevor, 1993) , and nonviable areas will demarcate within 2-3 days (waldron and trevor, 1993) . necrotic fat should be resected liberally, because it does not have a large blood supply and will provide an environment for infection. often, resection of subcutaneous fat is necessary to remove debris and hair that could not be removed during wound irrigation. damaged muscle should also be liberally resected (swaim, 1980) . the wound should be irrigated several times during debridement and again after completion. after initial wound treatment, the options concerning wound closure must be weighed. the principles of basic surgery are discussed in several good texts, and readers are encouraged to pursue additional information. primary wound closure is defined as closure of the wound at the time of initial wound therapy and is the treatment of choice for clean and clean-contaminated wounds. closure is performed in two or more layers, carefully apposing tissues and obliterating dead space. if dead space will remain in the wound, a drain should be place d. subcutaneous closure should be performed with absorbable suture such as polydioxanone (pds), polyglactin 910 (vicryl), or polyglycolic acid (dexon). it is best to use interrupted sutures and avoid leaving excess suture material in the wound. it may be necessary to choose tension-relieving suture patterns, such as horizontal mattress. skin closure is generally performed with nylon (3-0 or 4-0). in situations where gross contamination cannot be completely removed, closure of the wound should be delayed or avoided. after debridement and irrigation, the wound should be bandaged. initially, the wound can be covered by gauze sponges soaked in saline or chlorhexidine to create a wet-to-dry bandage. when the sponges are later pulled from the wound, dried exudates will also be removed. when the wound appears clean, the layer in contact with the wound may be changed to a nonadherent dressing such as vaseline-impregnated gauze (swaim, 1980) . the contact layer is covered by cotton padding, and the entire bandage is covered by a supportive and protective layer. the bandages should be changed once or twice daily, depending upon the amount of discharge coming from the wound. wound closure within 3-5 days of wounding (prior to the formation of granulation tissue) is considered delayed primary closure. when the wound is closed after 5 days, this is considered secondary closure (waldron and trevor, 1993) . secondintention healing involves allowing the wound to heal without surgical intervention. this type of healing is often used on limbs when there is an insufficient amount of skin to allow complete closure (swaim, 1980) . it is important to note that second-intention healing will take longer than surgical repair of a wound, and in the case of large wounds it will be more expensive because of the cost of bandaging materials. several factors must be weighed concerning the use of antibiotics in traumatic wounds, including the classification and site of the wound, host defenses, and concurrent research use of the animal. when wounds are clean or clean-contaminated, antibiotics are seldom necessary unless the individual is at high risk for infection. when wounds have been severely contaminated or are dirty, antibiotics are indicated, and the type of antibiotic will ultimately depend on culture and sensitivity results. until such results are available, the choice of antibiotic is based on the most likely organism to be encountered. in skin wounds, staphylococcus spp. are generally of concern, whereas pasteurella multocida should be considered in bite wounds. cephalosporins, amoxicillin-clavulanate, and trimethoprim sulfas are often recommended for initial antibiotic therapy (waldron and trevor, 1993) . etiology. pressure sores (decubital ulcers) can be a problem in long-term studies that require extended periods of recumbency. decubital ulcers usually develop due to continuous pressure from a hard surface contacting a bony prominence such as the elbow, the tuber ischii, tarsus, or carpus. the compression of the soft tissues between the hard surfaces results in vascular occlusion, ischemia, and ultimately tissue death (swaim and angarano, 1990) . several factors that increase pressure at the site and/or affect the integrity of the skin will predispose an individual to develop pressure sores. these factors include poor hygiene, self-trauma, low-protein diet, preexisting tissue damage, muscle wasting, inadequate bedding, and ill-fitting casts or bandages (swaim and angarano, 1990) . clinical signs. at first, the skin at the developing site will appear red and irritated. over time, constant trauma can result in full-thickness skin wounds and can progress to necrosis of underlying structures such as bone. the severity of the sores may be graded from i to iv, according to the depth of the wound and the tissues involved, from superficial skin irritation to bone necrosis. epizootiology. the problem usually occurs in large-breed dogs, but any type of dog can be affected. prevention and control. minimizing or eliminating those factors that can predispose to decubital ulcers is important to both the prevention and the control of this condition. if the dogs are going to experience long periods of recumbency, adequate bedding or padding must be provided. skin hygiene is of the utmost importance when trying to prevent or treat pressure sores. the skin should be kept clean and dry at all times. if urine scalding is a problem, the affected area should be clipped, bathed, and dried thoroughly at least once or twice daily. finally, an appropriate diet to maintain good flesh and adequate healing is also important (swaim and angarano, 1990) . treatment. the treatment of pressure sores must involve care of the wound and attention to the factors causing the wound. the extent of initial wound management will largely depend on the depth of the wound. for simple abrasions and small wounds involving the skin only, simple wound cleansing and openwound management provide adequate treatment. when wounds involve deeper tissues, including fat, fascia, or bone, more aggressive therapy must be performed. the affected area should be radiographed to assess bone involvement, and the wound should be cultured. all of the damaged tissue should be debrided, and wound management guidelines should be followed (see section iii,c,1). when a healthy granulation bed has formed over the entire wound, a delayed closure over a drain may be performed (swaim and angarano, 1990) . with extensive lesions, reconstruction with skin flaps may be necessary. bandaging should be performed on all full-thickness wounds; however, it is important to remember that ill-fitting or inadequately padded bandages or casts may worsen the problem. the area over the wound itself should not be heavily padded, because this will increase the pressure over the wound. the wounded area should be lightly covered and then a doughnut, created from rolled gauze or towel, should be fitted around the wound. this will displace the forces acting on the wound over a larger area and over healthier tissue. then the doughnut is incorporated into the bandage. if a cast has been applied to the area for treatment or for research purposes, a hole can be cut over the wound to reduce pressure in that area and allow treatment of the wound (swaim and angarano, 1990 ). bandages should be removed at least once or twice a day to allow wound care. after wound care has been initiated the causative factors for the pressure sore must be addressed (see "prevention and control," above). recumbent animals should be moved frequently to prevent continuous compression on the wound. if the dog tends to favor a position that aggravates the problem, splinting the body part to reduce contact with hard surfaces may be necessary. etiology. acral lick granuloma is a psychodermatosis, a skin lesion caused by self-trauma. in a few cases, self-trauma begins because of identifiable neurologic or orthopedic causes (tarvin and prata, 1988) . however, the majority of the cases begin because of repetitive licking by dogs that are confined and lack external stimuli (swaim and angarano, 1990) . it has been theorized that the self-trauma promotes the release of endogenous endorphins, which act as a reward for the abnormal behavior (dodman et al., 1988) . the laboratory setting is an environment that could promote this abnormal behavior and lead to acral lick granuloma. epizootiology. the lesions associated with acral lick granuloma are seen most often in large-breed dogs, but any type of dog can be affected (walton, 1986) . clinical signs. at first, lesions appear as irritated, hairless areas usually found on the distal extremities (swaim and angarano, 1990 ). the predilection for the limbs may be due to accessibility or possibly may be caused by a lower threshold for pruritus in these areas. as the lesions progress, the skin becomes ulcerated, and the wound has a hyperpigmented edge. the wounds may partially heal and then be aggravated again when licking resumes. diagnosis and differential diagnosis. acral lick granulomas must be differentiated from several other conditions, including bacterial or fungal infection, foreign bodies, and pressure sores. in addition, mast-cell tumors and other forms of neoplasia can mimic the appearance of acral lick granuloma. many of these problems can be ruled out by the history of the animal. when in doubt, a biopsy should be taken. an uncomplicated acral lick granuloma would feature hyperplasia, ulceration, and fibrosis without evidence of infection or neoplasia (walton, 1986) . prevention and control. behavior modification and relief of boredom are important aspects of preventing (and treating) acral lick granuloma. the environment of a dog with this problem can be enriched with exercise and the introduction of toys. in addition, the relief of boredom or anxiety can be attempted through the use of drugs such as phenobarbital, megestrol acetate, and progestins. these drugs may produce side effects, however (swaim and angarano, 1990) , and may interfere with experimental results. treatment. several treatments have been reported for acral lick granuloma, and none of them have been proven to be successful in ah cases. one of the most important aspects of treatment is to break the cycle of self-trauma. mechanical restraint with an elizabethan collar is one of the easiest methods to accomplish this goal. several direct treatments have been examined, including intralesional and topical steroids, perilesional cobra venom, acupuncture, radiation, and surgery (swaim and angarano, 1990; walton, 1986) . opioid antagonists have been used in an attempt to treat acral lick granuloma by blocking endogenous opioids. in one study, either naltrexone (1 mg/kg sq) or nalmefene (1-4 mg/kg sq) successfully reduced the excessive licking behavior in 7 of 11 dogs; however, lesions returned after the drug was discontinued (dodman et al., 1988) . the use of a mixture of flunixin meglumine, steroid, and dimethyl sulfoxide (3 ml of banamine [schering] mixed with 8ml of synotic [diamond laboratories]) applied topically twice daily has also been shown to be effective (walton, 1986) . the prognosis for acral lick granuloma should be considered guarded, because the lesions often recur or new lesions develop when treatment is discontinued. etiology. hygromas are fluid-filled sacs that develop as a result of repeated trauma over a bony prominence. the area over the olecranon is most frequently affected, but hygromas have been reported in association with the tuber calcis, greater trochanter, and stifle (newton et al., 1974) . epizootiology. elbow hygromas are most frequently reported in large and giant breeds of dogs around 6-18 months of age (johnston, 1975; bellah, 1993) . elbow hygromas are seen infrequently in the laboratory animal setting because the commonly affected breeds are seldom used in research. however, the housing environment for research dogs predisposes them to hygromas, because these animals spend a large amount of time on hard surfaces such as cage bottoms or cement runs. for this reason, laboratory animal veterinary and husbandry staff should be familiar with this condition. clinical signs. a dog with an elbow hygroma presents with a unilateral or bilateral, painless, fluctuant swelling over the point of the elbow. the animals are not usually lame. over a long period of time, elbow hygromas may become inflamed and ulcerated. if the hygroma is secondarily infected, the animal may exhibit pain and fever (johnston, 1975; bellah, 1993) . pathology. the fluid-filled cavity in the hygroma is lined by granulation and fibrous tissue. hygromas lack an epithelial lining and therefore are not true cysts. the fluid within the cavity is yellow or red and is a serous transudate. this fluid is less viscous than joint fluid, and elbow hygromas do not communicate with the joint (johnston, 1975) . treatment. the treatment of elbow hygromas should be conservative whenever possible, and surgical options should be reserved for complicated or refractory cases. conservative management of the elbow hygroma is aimed at relieving pressure at the point of the elbow by providing a padded cage surface and/or bandaging the elbow in a manner similar to that used to treat pressure sores (see section iii,c,2). more aggressive therapy, including needle drainage and the injection of corticosteroid into the hygroma, has been described but is not recommended, because infection is a serious complication of this treatment (johnston, 1975) . likewise, simple surgical excision of elbow hygromas can be associated with complications such as wound dehiscence and ulceration (johnston, 1975) . a technique that has been used successfully involves placement of multiple penrose drains. the drains are kept in place for 2-3 weeks, and the limb remains bandaged for 4 weeks with this technique (bellah, 1993) . another technique has been described that involves the removal of a crescent-shaped piece of the skin and capsule. the remaining dead space is closed with mattress sutures over stents, and then the wound is closed in a routine fashion. the stents are removed in 5-7 days, and the wound is bandaged until suture removal in 10-14 days (newton et al., 1974) . regardless of the method used to treat an elbow hygroma, recurrence of the problem is likely unless the predisposing factors are identified and relieved. etiology. in the research environment, corneal ulcers are most often associated with either direct trauma, contact with irritating chemicals, or exposure to the drying effects of air during long periods of anesthesia. chronic or recurrent corneal ulcers may also be associated with infection or hereditary causes in some breeds of dogs; however, these cases would be rare in the laboratory setting. clinical signs. the signs of corneal ulceration are blepharospasm, epiphora, and photophobia. the eye may appear irritated and inflamed. in minor cases, the cornea may not appear abnormal; however, in cases of deeper ulceration, the cornea may appear roughened or may have an obvious defect. in addition, the periocular tissues may be swollen and inflamed because of self-inflicted trauma from rubbing at the eye. a tentative diagnosis of corneal ulcer or abrasion may be based on the clinical signs. a definitive diagnosis of corneal ulcers may be made by the green appearance of the cornea when stained with fluorescein dye. when a corneal ulcer has been diagnosed, the eye should be inspected for underlying causes such as foreign bodies or abnormal eyelids or cilia. treatment. the treatment of corneal ulcers will depend on the depth and size of the affected area. deep ulcers may require debridement and primary repair. in such cases, a third eyelid or conjunctival flap may be applied to the eye until experienced help can be obtained. superficial abrasions are generally treated with topical application of antibiotics. a triple antibiotic ointment that does not contain steroids given 3 times a day for 2-3 days usually provides adequate treatment. ointments are preferred over drops, because use of the former requires less frequent. simple corneal ulcers are restained with fluorescein after 3 days and should show complete healing at that time. if the ulcer is not healed, this may indicate that the ulcer has an undermined edge impeding proper healing. topical anesthetic should be applied to the eye, and a cotton-tipped applicator can be rolled over the surface of the ulcer toward its edge. this will remove the unattached edge of the cornea and healing should progress normally after debridement. in all cases, an elizabethan collar or other restraint may be necessary to prevent additional trauma to the eye. indwelling intravascular catheters, including intracaths and vascular access ports, often play a vital role in research protocols. the catheters are most often placed in a central vein or artery where they may be used for repeated blood sampling, administration of anesthetics and experimental compounds, or measurement of hemodynamic parameters. although catheters vary in composition, number of ports, and port placement, the basic principles of their implantation and maintenance are similar. it is important that the laboratory animal veterinarian be familiar with these principles and the potential complications of catheter use. when appropriately maintained, indwelling catheters may remain functional for months without serious complication. the actual incidence of complications associated with indwelling vascular catheters in dogs is unknown. this is due largely to the fact that many of the problems may be incidental findings or related to a particular research protocol. one study (hysell and abrams, 1967 ) examined the lesions found at necropsy in animals with chronic indwelling catheters (exact vascular locations not specified). the lesions found were categorized as traumatic cardiac lesions, visceral infarcts, and fatal hemorrhages. the traumatic cardiac lesions consisted primarily of masses of fibrin and inflammatory cells on the heart valves. the visceral infarcts were noted in the spleen, kidney (fig. 5) , and brain and resulted from fibrin embolization from either the valvular lesions or the catheter tip. fatal hemorrhages were most often found in animals with experimentally induced hypertension. these animals developed clinical signs of sepsis and later ruptured a major vessel associated with mycotic infection and aneurysm. etiology. the leading complication associated with the use of indwelling vascular catheters is infection, either systemic or local at the point of entry through the skin. septicemia may develop from bacterial colonization of either the tract around the catheter or the catheter lumen. clinical signs. the signs and treatment of systemic infection are covered in section iii,d,3. problems with the skin defect associated with the catheter port vary from mild skin irritation to obvious infection. the signs may include redness and swelling of the skin around the external port, discharge from the skin wound, or even abscess formation. prevention. because indwelling catheters play an important role in many research protocols, it is highly desirable to prevent catheter complications that may result in loss of the device. the catheter should be made of nonthrombogenic material. in addition, it is recommended that catheters be as simple as possible. a catheter with extra ports or multiple lumens requires additional management and supplies more routes for infection. the use of vascular access ports that lie entirely under the skin eliminates many problems with infection. it has also been found that a long extension of tubing connected to the port may actually reduce the potential for infection of the catheter (ringler and peter, 1984) . the initial placement of an indwelling catheter must be done under aseptic conditions by individuals who are familiar with the procedure. the placement of the catheter should be verified by radiography. catheters that are used for delivery of drugs or blood sampling should be positioned in the vena cava and not in the right atrium, thereby minimizing trauma to the tricuspid valve. after catheter placement, the animals should be observed daily for signs of either local or systemic infection. the catheter entry site should be disinfected, coated with antibiotic ointment, and rebandaged every other day. once a month, the catheter line may be disinfected with chlorine dioxide, as described below (see "treatment"). throughout the life of the catheter, injections into and withdrawals from the catheter should be done in a sterile manner, and the number of breaks in the line should be kept to a minimum. treatment. the treatment of catheter infections almost invariably involves removal of the catheter, as demonstrated in both dogs and monkeys (ringler and peter, 1984; darif and rush, 1983) . superficial wound irritation or infection may be treated locally with antibiotic ointment, sterile dressing changes and efforts to minimize catheter movement; however, more extensive problems require aggressive therapy. systemic antibiotic therapy should be initiated for a 10-day period. the choice of drug will ultimately be based on previous experience and culture results. aerobic and anaerobic cultures of blood and locally infected sites should be performed (ringler and peter, 1984) . localized abscesses or sinus tracts may be managed by establishing drainage and flushing with chlorhexidine. again, the catheter should be removed. if retention of a catheter is important, the catheter lumen may be disinfected by filling with chlorine dioxide solution. it has been shown that there are no adverse effects from the use of chlorine dioxide in catheters (dennis et al., 1989) . the solution is removed after 15 min and replaced with heparinized saline. all of the extension lines and fluids used in the catheter should be discarded. the blood cultures should be repeated 3 days after the antibiotic therapy has ceased. if bacteria are still cultured, the catheter must be removed. intestinal access ports have been used to study the pharmacokinetics of drugs at various levels in the intestinal tract. these catheters are usually vascular access ports with several modifications to allow secure placement in bowel (meunier et al., 1993) . when placed and managed correctly, these ports may remain in place for months without complications. the most frequently reported complication associated with these catheters is infection around the port site (meunier et al., 1993 , kwei et al., 1995 . these infections lead to removal of the catheters despite treatment with local lavage and systemic antibiotics. there have also been reports of catheters dislodging from the intestinal tract and resulting in peritonitis. this complication has largely been eliminated with the improved security afforded by a synthetic cuff added to the end of the catheter (meunier et al., 1993) . the chapter authors have also seen migration of the catheter end within the lumen of the intestine (caused by peristaltic motion to egest the catheter), extensive intra-abdominal adhesions, and intestinal torsion (figs. 6a,b) as complications of intestinal access ports. the procedures for placement and maintenance of the catheters are similar to those outlined previously for indwelling vascular catheters. it is important that the catheters be firmly secured to the intestine to prevent migration or dislodgment. an omental patch placed over the site of entry may help form a firm adhesion. in addition, it is important to place the proper length of catheter within the peritoneal cavity; excess catheter length can promote adhesion formation, whereas insufficient catheter length to account for visceral organ motion can result in detachment. the placement and patency of the catheters can be verified periodically by contrast radiography using iodinated contrast material or by fecal occult blood testing after a small amount of blood has been injected through the catheter (meunier et al., 1993) . etiology. sepsis is defined as the systemic response to infection. most often, sepsis is a result of infection with gramnegative bacteria; however, sepsis may also be associated with gram-positive bacteria and fungi. in laboratory animals, sepsis is seen as a complication of surgical procedures or associated with chronic implants. sepsis may also be seen as a complication of infectious diseases such as parvovirus. clinical signs. the signs of sepsis can vary, depending on the source of the infection and the stage of the disease. early in the course of sepsis, dogs will present with signs of a hyperdynamic response, including an increased heart rate, increased respiratory rate, red mucous membranes, and a normal to increased capillary refill time. systemic blood pressure and cardiac output will be increased or within the normal range. the animals will often be febrile. later in the course of the syndrome, the animals will show the classic signs of septic shock, including decreased temperature, pale mucous membranes, and a prolonged capillary refill time. cardiac output and blood pressure are decreased as shock progresses. peripheral edema and mental confusion have also been reported (hauptman and chaudry, 1993) . pathogenesis. the pathophysiology of sepsis is complex and is mediated by immune responses involving mediators such ~ as cytokines, eicosinoids, complement, superoxide radicals, and nitric oxide. the body responds to overwhelming infection with an attempt to optimize metabolic processes and maximize oxygen delivery to tissues. however, if inflammation is left unchecked, the system may be unable to compensate, and the result is cardiovascular collapse. diagnosis. in general, a presumptive diagnosis of sepsis is made based on the occurrence of several in a group of signs, including altered body temperature, increased respiratory and/or heart rate, increased or decreased white blood cell count, increased number of immature neutrophils, decreased platelet count, decreased blood pressure, hypoxemia, and altered cardiac output. however, extreme inflammation without infection (e.g., pancreatitis, trauma) may create similar signs. one study examined the diagnosis of sepsis in canine patients at a veterinary hospital based on easily obtainable physical and laboratory findings. that study found that septic individuals had higher temperatures, wbc counts, and percentage of bands than nonseptic individuals, whereas platelet counts were lower in the septic dogs. there were no differences in respiratory rate or glucose levels between the groups. using these criteria, the results had a high sensitivity and a tendency to overdiagnose sepsis (hauptman et al., 1997) . ultimately, the presence of a septic focus simplifies diagnosis greatly; however, the focus may not be obvious. if the signs of sepsis are evident but the focus is not, several systems should be evaluated for infection, including urinary tract, reproductive tract, abdominal cavity, respiratory tract, teeth, and heart valves (kirby, 1995) . treatment. the treatment of sepsis has three aims. the first aim is to support the cardiovascular system. all septic animals should be treated with fluids to replace deficits and to maximize cardiac output. crystalloids are most frequently used to maintain vascular volume, primarily because of their low cost. colloids offer the advantage of maintaining volume without fluid overload and may have other positive effects on the cardiovascular system. acid-base and electrolyte imbalances should also be addressed. after the animal has stabilized, the treatment of sepsis should be aimed at removing the septic focus. obvious sources of infection should be drained or surgically removed. if an implant is associated with the source of infection, the implant should be removed. antibiotic therapy should also be instituted. the choice of antibiotic will ultimately depend upon the results of culture; however, the initial choice of antibiotics is based on previous experience, source of infection, and gram stains. the organisms associated with sepsis are often gram-negative bacteria of gastrointestinal origin or are previously encountered nosocomial infections. ideally, the antibiotic chosen for initial therapy should be a broad-spectrum, bactericidal drug that can be administered intravenously. second-or third-generation cephalosporins provide good coverage, as does combination therapy with enrofloxacin plus metronidazole or penicillin. finally, the treatment of sepsis is aimed at blocking the mediators of the systemic response. several studies have examined the effects of steroids, nonsteroidal anti-inflammatory drugs, and antibodies directed against endotoxin, cytokines, or other mediators of the inflammatory response; however, none of these treatments have proven greatly effective in clinical trials. consequently, there is no "magic bullet" for the treatment of sepsis at this time. successful therapy remains dependent on aggressive supportive care coupled with identification and elimination of the inciting infection. etiology. in research animals, aspiration into the lungs may occur accidentally during the oral administration of various substances or by the misplacement of gastric tubes. aspiration of gastric contents may also occur as a complication of anesthesia. in pet animals, aspiration is often seen as a result of metabolic and anatomical abnormalities; however, such occurrence would be rare in the research setting. clinical signs. the signs of aspiration lung injury may include cough, increased respiratory rate, pronounced respiratory effort, and fever. when respiration is severely affected, the oxygen saturation of blood will be decreased. the diagnosis of this problem is based on a history consistent with aspiration and the physical findings. classically, radiographs of the thorax demonstrate a bronchoalveolar pattern in the cranioventral lung fields. however, these lesions may not appear for several hours after the incident of aspiration. in addition, the location of the lesions may be variable, depending on the orientation of the animal at the time of aspiration. pathogenesis. aspiration of gastric contents or other compounds can create lung injury of variable severity, depending upon the ph, osmolality, and volume of the substance. the compounds aspirated can produce direct injury to lung tissue, but more importantly, the aspiration provokes an inflammatory response probably mediated by cytokines. the result is a rapid influx of neutrophils into the lung parenchyma and alveolar spaces. the inflammation leads to increased vascular permeability with leakage of fluid into the alveolar spaces and can eventually lead to alveolar collapse. if the condition is severe, it may result in adult respiratory distress syndrome and respiratory failure. it should be noted that infection is not present in the early stages of this condition but may complicate the problem after 24-48 hr. treatment. the treatment of aspiration lung injury is largely supportive and depends upon the severity of the inflammation and the clinical signs. in cases in which a small amount of a relatively innocuous substance (e.g., barium) has been aspirated, treatment may not be necessary. when severe inflammation is present, systemic fluid therapy should be instituted. support of the cardiovascular system should be performed judiciously; fluid overload could lead to an increase in pulmonary edema. the use of colloids is controversial because of the increase in vascular permeability that occurs in the lungs. oxygen therapy is also controversial, because it may increase lung injury if administered at high concentrations for long periods of time (nader-djahal et al., 1997) . several studies have addressed the use of anti-inflammatory agents to reduce lung injury associated with aspiration; however, none are used clinically in human or veterinary medicine at this time. in humans, antibiotics are reserved for use in cases with confirmed infection, in order to prevent the development of antibiotic-resistant pneumonia. it has been suggested that dogs should be treated with antibiotics immediately when the aspirated material is either not acidic or has potentially been contaminated by oral bacteria associated with severe dental disease. amoxicillin-clavulanate has been recommended as a first line of defense, reserving enrofloxacin for resistant cases (hawkins, 2000) . the presence of pneumonia should be verified by tracheal wash and cultures. etiology. in laboratory animals, accidental burns usually result from thermal injury (heating pads, water bottles) or harsh chemicals (strong alkalis, acids, disinfectants). the insult to the skin results in desiccation of the tissue and coagulation of proteins. in addition, the severely injured area is surrounded by a zone of vascular stasis, which promotes additional tissue damage. even small burns can result in significant inflammation that could affect the outcome of some research investigations and cause considerable discomfort to the animal. the proper and immediate treatment of burn wounds can reduce the effects of the injury on both the individual and the research. clinical signs. the clinical signs vary with the type and degree of burn injury. initially, the injury may not be noticed. the first signs may be oozing from the skin and matting of the overlying hair. within a couple of days, progressive hair and skin loss may be observed (johnston, 1993) . the wounds may vary in severity from very superficial (involving only the epidermis) to those in which the epidermis and dermis are completely destroyed. superficial wounds appear as red, inflamed skin similar to sunburn in humans. the pain associated with these injuries usually subsides in 2-3 days, and the wound reepithelializes without complications in 3-5 days. deeper burns develop a thick covering, or eschar, composed of the coagulated proteins and desiccated tissue fluid. the wound heals by granulation under the eschar, which eventually sloughs or is removed to allow further healing by contraction and reepithelialization. within 2-3 days of injury, the burn wound will be colonized by grampositive bacteria that rapidly cover the entire wound. several days later, gram-negative organisms can appear in the burn wound (johnston, 1993) . at this point, signs of wound infection and sepsis may occur (see section iii,d,3). treatment. appropriate and timely treatment of a burn wound will reduce the extent of the injury. thermal injuries should be immediately cooled to reduce edema and pain (demling and lalonde, 1989) . chemical burns should be thoroughly lavaged for 60 min after wounding. the damaged tissues may be unable to mount appropriate responses to changes in temperature; therefore, the lavage should be performed with warm water to prevent hypothermia. after the initial treatment, all burn wounds should be gently cleansed 2-3 times a day (demling and lalonde, 1989) . burns involving the epidermis and part of the dermis can be extremely painful, and analgesia should be addressed throughout the treatment period. systemic antibiotics are unable to penetrate eschar and are not adequately distributed through the abnormal blood supply of burned tissues. therefore, topical wound dressings are recommended in the early stages of treatment. a thin film of a water-soluble broad-spectrum antibiotic ointment should be applied to the wound surface after each cleaning. silver sulfadiazine has a broad spectrum, penetrates eschar well, and is often the preparation of choice for burn wound therapy. povidone-iodine ointment will also penetrate thin eschar and provides a broad spectrum. mafenide has a good spectrum that covers gram-negative organisms well and is often used to treat infected wounds, although it is associated with pain upon application (demling and lalonde, 1989) . when signs of wound or systemic infection are present, systemic antibiotics should be employed, and their ultimate selection should be based on culture and sensitivity results. after the topical antibiotic has been applied, a nonadherent dressing should be placed on the wound. burn wounds covered in such a manner tend to epithelialize more rapidly and are less painful than uncovered wounds. when the eschar over a burn wound has formed and become fully defined, a small or moderately sized wound may be completely resected. prevention. obviously, prevention of burn wounds is preferable to a long course of treatment. care should be taken to prevent direct exposure to harsh chemicals. tables, floors, and other surfaces should be rinsed thoroughly after chemical use, prior to allowing any animal contact. electric heating pads should be avoided, and only heated water blankets or circulating warm-air devices should be used to provide warmth to the animals. in rare instances, heated water blankets have also caused burns; therefore these devices should be carefully monitored. as a precaution, a thin towel may be placed between the animal and the water blanket. etiology. research and/or anesthetic protocols may require the intravenous injection of various solutions. when these substances have a ph or osmolarity significantly different from that of the surrounding tissues, the accidental perivascular extravasation of the solutions may result in tissue damage. several drugs have been shown to cause problems when injected perivascularly, including pentobarbital, thiamylal, thiopental, thiacetarsemide, vincristine, vinblastine, and doxorubicin (swaim and angarano, 1990; waldron and trevor, 1993) . clinical signs. the immediate signs of perivascular injection are swelling at the injection site and withdrawal of the limb or other signs of discomfort. later, the area may appear red, swollen, and painful as inflammation progresses. often there will be eventual necrosis of the skin around the injection site. in cases of doxorubicin extravasation, signs may develop up to a week after the injection, and the affected area may progressively enlarge over a 1 to 4 month period. this is because the drug is released over time from the dying cells (swaim and angarano, 1990) . prevention. because the degree of injury and extensive treatment associated with perivascular extravasation of a drug can be detrimental to research protocols and can cause severe discomfort to the dog, prevention of these injuries is preferred. prior to the use of any substance, the investigator should be aware of its chemical composition and the potential for problems. if a potentially caustic compound is to be used in a fractious subject, sedation of the dog is warranted if this will not interfere with the research protocol. whenever possible, insertion of an indwelling catheter is extremely important. access to a central vessel such as the cranial or caudal vena cava is preferred over the use of peripheral vessels. when peripheral catheters are used, the injection should be followed by a vigorous amount of flushing with saline or other physiological solution and removal of the catheter. additional injections are best given through newly placed catheters in previously unused vessels. the repeated use of an indwelling peripheral catheter should be approached cautiously and done only out of necessity. prior to use, the catheter should be checked repeatedly for patency by withdrawal of blood and injection of saline. any swelling at the catheter site or discomfort by the subject indicates that the catheter should not be used. treatment. the treatment of perivascular injections will depend on the amount and type of substance injected. in most cases, dilution of the drug with subcutaneous injections of saline is recommended. in addition, steroids may be infiltrated locally to reduce inflammation. topical application of dimethyl sulfoxide (dmso) may also be helpful in reducing the immediate inflammation and avoiding the development of chronic lesions (swaim and angarano, 1990 ). the addition of lidocaine to subcutaneous injections of saline has been used in cases of thiacetarsemide injection (hoskins, 1989) , and local infiltration of hyaluronidase accompanied by warm compresses has been suggested for use in cases of vinblastine injection (waldron and trevor, 1993) . despite these treatments, necrosis of skin may be observed and would require serial debridement of tissues with secondary wound closure or skin grafting. in cases of doxorubicin extravasation, early excision of affected tissues is advocated to prevent the progressive sloughing caused by sustained release of the drug from dying tissues (swaim and angarano, 1990) . in all cases, the condition can be painful, and analgesia should be addressed. etiology. hepatic encephalopathy is the result of the derangements in metabolism associated with abnormal liver function. this condition may be seen in young dogs with congenital portosystemic shunting of blood flow. however, in the research setting, encephalopathy occurs more often in canine models of hepatic disease that lead to liver failure. a well-developed knowledge of the pathophysiology of liver disease is necessary for the initial treatment and long-term management of hepatic encephalopathy. pathogenesis. when the liver function is severely impaired because of either portosystemic shunting of blood flow or loss of metabolically active hepatic tissue, the result is an accumulation of ammonia, toxic amines, aromatic amino acids, and short-chain fatty acids (hardy, 1989; center, 1998) . these compounds have several toxic effects that result in a decrease in cerebral energy metabolism and a decrease in excitatory neurotransmitter synthesis. concurrently, there is an increase in the concentration of false neurotransmitters and the inhibitory substance 7-aminobutyric acid (gaba). clinical signs. the signs of hepatic encephalopathy include lethargy, depression, muscle tremors, and convulsions. diagnosis and differential diagnosis. a presumptive diagnosis of hepatic encephalopathy may be based on the appearance of clinical signs following experimental manipulation of the liver. additional diagnostic tests to verify the loss of liver function can be performed to confirm the diagnosis. serum glucose and protein levels may be low if hepatic function is severely impaired. a low serum urea nitrogen level suggests that the normal hepatic metabolism of ammonia into urea has been impaired. elevated levels of serum bile acids and blood ammonia also verify the loss of liver function (hardy, 1989) . measurement of serum hepatic leakage enzymes are nondiagnostic, because they can be low, high, or normal. treatment. because of the severity of hepatic encephalopathy, treatment may be initiated based on a presumptive diagnosis. during initial treatment, supportive care with fluids and electrolytes should be instituted, based on the results of serum chemistry and blood gas analysis. the majority of animals with hepatic dysfunction will be hypokalemic, alkalotic, and hypernatremic; therefore, either 0.45% sodium chloride or 0.45% sodium chloride with 2.5% dextrose, supplemented with potassium chloride, is recommended (hardy, 1989) . the type of drug to be used for seizure control is controversial. the short halflife of diazepam makes it an attractive choice compared with barbiturates, which have prolonged metabolism when hepatic function is impaired (maddison, 1995) . however, endogenous benzodiazepines mediate some of the cns signs seen with hepatic encephalopathy. therefore, the use of diazepam has been discouraged in favor of phenobarbital (johnson, 2000) . the drug selected for seizure control should be titrated carefully, given the altered liver metabolism. most importantly, the treatment of dogs with hepatic encephalopathy must be aimed at reducing the levels of toxic metabolites in the bloodstream. because protein metabolism is a major source of ammonia, all oral food intake should cease until the signs of hepatic encephalopathy have abated. because gastrointestinal bleeding may occur in individuals with liver failure and this is also a source of protein, the use of h2 blockers such as cimetidine or ranitidine is suggested (swalec, 1993) . in addition, lactulose retention enemas should be performed (10-15 ml/lb of a 30% solution in water, retained for 20-30 min) (hardy, 1989) . lactulose is an indigestible semisynthetic sugar that is metabolized in the gut to lactic and other acids. the decrease in colonic ph reduces ammonia levels in the bloodstream by converting intestinal ammonia into less diffusible ammonium ions. lactulose will also cause an osmotic diarrhea. antibiotics such as neomycin (10 mg/lb, 3-4 times/ day) or metronidazole (9 mg/lb, 3 times/day) should also be used to reduce the intestinal load of urease-producing bacteria responsible for splitting urea into ammonia (hardy, 1989) . when the signs of hepatic encephalopathy have resolved, the dog may be fed a low-protein diet. diets suitable for dogs with renal insufficiency are recommended initially. this type of diet is not suitable for long-term use, however, because it appears that individuals with some types of hepatic disease actually have increased protein requirements. these requirements may be met by slowly increasing protein in the diet as long as signs of hepatic encephalopathy do not recur. to maintain the appropriate balance of aromatic and branched-chain amino acids, the diet should be based on vegetable and dairy protein instead of meat or fish protein (center, 1998) . in addition, the antibiotics suggested above should be continued to reduce the effects of increasing dietary protein levels. the prevalence of cancer in the general canine population has increased over the years (dorn, 1976) . this can be attributed to the longer life spans resulting from improvements in nutrition, disease control, and therapeutic medicine. because of these changes, cancer has become a major cause of death in dogs (bronson, 1982) . in a lifetime cancer mortality study of intact beagles of both sexes, albert et al. (1994) found death rates similar to the death rate of the at-large dog population (bronson, 1982) . approximately 22% of the male beagles died of cancer. the majority of the tumors were lymphomas (32%) and sarcomas (29%), including hemangiosarcomas of the skin and fibrosarcomas. of the female beagles dying of cancer (26% of the population studied), three-quarters had either mammary cancer (40%), lymphomas (18%), or sarcomas (15%). of the sarcomas in females, one-third were mast cell tumors. in addition to these tumors that cause mortality, the beagle is also at risk for thyroid neoplasia (hayes and fraumeni, 1975; benjamin et al., 1996) . because of the popularity of the beagle as a laboratory animal, discussion of specific neoplasms will focus on the tumors for which this breed is at risk, as well as tumors that are common in the general canine population. fine-needle aspirates are generally the first diagnostic option for palpable masses, because they can easily be performed in awake, cooperative patients. this technique allows for rapid differentiation of benign and neoplastic processes. in cases where cytologic results from fine-needle aspirates are not definitive, more invasive techniques must be used. needle-punch or core biopsies can also be performed in awake patients but typically require local anesthesia. an instrument such as a tru-cut needle (travenol laboratories, inc., deerfield, illinois) is used to obtain a 1 mm x 1 to 1.5 cm biopsy of a solid mass. a definitive diagnosis may be limited by the size of the sample acquired using this technique. incisional and excisional biopsies are utilized when less invasive techniques fail to yield diagnostic results. excisional biopsies are the treatment of choice when surgery is necessary, because the entire mass is removed. surgical margins should extend at least 1 cm around the tumor, and 3 cm if mast cell tumors are suspected (morrison et al., 1993) . incisional biopsies are performed when large soft-tissue tumors are encountered and/or when complete excision would be surgically difficult or life-threatening. when performing an incisional biopsy, always select tissue from the margin of the lesion and include normal tissue in the submission. etiology. lymphomas are a diverse group of neoplasms that originate from lymphoreticular cells. whereas retroviral etiologies have been demonstrated in a number of species (e.g., cat, mouse, chicken), conclusive evidence of a viral etiology has not been established in the dog. in humans, data implicate the herbicide 2,4-dichlorophenoxyacetic acid (2,4-d) as a cause of non-hodgkin's lymphoma, but studies in dogs with similar conclusions have come under scrutiny (macewen and young, 1991) . clinical signs. multicentric and alimentary lymphomas account for most cases of canine lymphoma. in multicentric lymphoma, animals usually present with enlarged lymph nodes and nonspecific signs such as anorexia, weight loss, polyuria, polydypsia, and lethargy. when the liver and spleen are involved, generalized organomegaly may be felt on abdominal palpation. alimentary lymphoma is associated with vomiting and diarrhea, in addition to previous clinical signs. less commonly, dogs develop mediastinal, cutaneous, and extranodal lymphomas. dogs with mediastinal lymphoma often present with respiratory signs secondary to pleural effusion. hypercalcemia is most frequently associated with this form of lymphoma and may result in weakness. cutaneous lymphoma varies in presentation from solitary to generalized and may mimic any of a number of other skin disorders. the tumors may occur as nodules, plaques, ulcers, or dermatitis. approximately half of the cases are pruritic. a number of extranodal forms of lymphoma have been reported, including tumors affecting the eyes, central nervous system, kidneys, or nasal cavity. clinical presentation varies, depending on the site of involvement. epizootiology. the incidence of lymphoma is highest in dogs 5-11 years old, accounting for 80% of cases. although the neoplasm generally affects dogs older than 1 year, cases in puppies as young as 4 months have been reported (dorn et al., 1967) . pathologic findings. enlarged neoplastic lymph nodes vary in diameter from 1 to 9 cm and are moderately firm. some may have areas of central necrosis and are soft to partially liquefied. the demarcation between cortex and medulla is generally lost, and on cut section, the surface is homogenous. the spleen may have multiple small nodular masses or diffuse involvement with generalized enlargement. the enlarged liver may have disseminated pale foci or multiple large, pale nodules. in the gastrointestinal tract, both nodular and diffuse growths are observed. these masses may invade through the stomach and intestinal walls. histologically, the most common lymphomas are classified as intermediate to high grade and of large-cell (histiocytic) origin. the neoplastic lymphocytes typically obliterate the normal architecture of the lymph nodes and may involve the capsule and perinodal areas. pathogenesis. all lymphomas regardless of location should be considered malignant. a system for staging lymphoma has been established by the world health organization. the average survival time for dogs without treatment is 4-6 weeks. survival of animals undergoing chemotherapy is dependent on the treatment regimen as well as the form and stage of lymphoma (macewen and young, 1991) . hypercalcemia is a paraneoplastic syndrome frequently associated with lymphoma. the pathogenesis of this phenomenon is not fully understood but may be a result of a parathormone-like substance produced by the neoplastic lymphocytes. diagnosis and differential diagnosis. differential diagnoses for multicentric lymphoma include systemic mycosis; salmonpoisoning and other rickettsial infections; lymph node hyperplasia from viral, bacterial, and/or immunologic causes; and dermatopathic lymphadenopathy. alimentary lymphoma must be distinguished from other gastrointestinal tumors, foreign bodies, and lymphocytic-plasmacytic enteritis. in order to make a definitive diagnosis, whole lymph node biopsies and full-thickness intestinal sections are frequently needed. treatment. therapy for lymphoma typically consists of one or a combination of several chemotherapeutic agents. the treatment regimen is based on the staging of the disease, the presence of paraneoplastic syndromes, and the overall condition of the patient. macewen and young (1991) provide a thorough discussion of therapeutic options for the treatment of lymphomas in the dog. research complications. given the grave prognosis for lymphoma with or without treatment, euthanasia should be considered for research animals with signifcant clinical illness. etiology. the fibrosarcoma group of tumors encompasses not only malignant tumors of fibroblasts but also a number of indistinguishable tumors, all of which are capable of collagen production (pulley and stannard, 1990) . frequently classified in this group are undifferentiated leiomyosarcomas, liposarcomas, malignant melanomas, and malignant schwannomas. clinical signs. although these neoplasms can arise throughout the body, they are most commonly found in the skin, subcutaneous tissues, and oral cavity. fibrosarcomas are extremely variable in size and can grow to be quite large. in general, they are irregular and nodular, poorly demarcated, and nonencapsulated, and they frequently invade deeper tissues. epizootiology. most fibrosarcomas develop in adult and aged animals but can affect dogs as young as 6 months or less. pathogenesis. fibrosarcomas exhibit rapid, invasive growth, recurring frequently after excision. metastasis occurs in only one-fourth of cases, usually by the bloodstream to the lungs. less frequently, spread to local lymph nodes is observed. diagnosis and differential diagnosis. differential diagnoses for fibrosarcomas vary with the location of the tumor. histopathologic exam should be used to distinguish these tumors from round cell tumors (mast cell tumors, histiocytomas, transmissible venereal tumors), papillomas, and other neoplasms. treatment. treatment of any soft-tissue sarcoma would begin with wide surgical excision. if the tissue margins indicate incomplete resection, radiotherapy could be used. for any highgrade tumors, adjuvant chemotherapy would be recommended (see macewen and withrow, 1991a , for a complete discussion). research complications. because fibrosarcomas are locally invasive and often recur, dogs with these neoplasms should not be considered good subjects for long-term studies. etiology. neoplasms of lipocytes and lipoblasts are welldifferentiated tumors referred to as lipomas. clinical signs. these growths can be found as single or multiple round, ovoid, or discoid masses in the subcutaneous tissues of the lateral and ventral thorax, abdomen, and upper limbs. generally they are well circumscribed, encapsulated, and soft on palpation. further, the skin is freely movable over the tumor. epizootiology. lipomas occur principally in aged animals (average 8 years), and the incidence increases with age (pulley and stannard, 1990) . the tumors are most commonly seen in overweight female dogs, but no breed predisposition is observed. pathologic findings. histologically, lipomas are indistinguishable from normal adipose tissue except when a fibrous capsule is present. pathogenesis: lipomas are typically slow-growing and do not recur after complete surgical excision. diagnosis and differential diagnosis. lipomas are not frequently confused with other tumors but can sometimes be difficult to distinguish from normal adipose tissue. generally, the distinction can be made from the clinical history. treatment. treatment for lipomas is not usually necessary unless the mass is causing problems with normal ambulation. in such cases, surgical excision is usually curative. research complications. lipomas usually do not complicate research studies unless they are interfering with other systemic functions or ambulation. etiology. histiocytomas are benign skin growths that arise from the monocyte-macrophage cells in the skin. some debate exists as to whether this growth is actually a neoplasm or a focal inflammatory lesion (pulley and stannard, 1990) . clinical signs. the most frequent sites for histiocytomas are the head (especially the pinna) and the skin of the distal forelegs and feet. the masses are usually domelike or buttonlike (often referred to as "button tumors") and usually measure 1-2 cm in diameter. epizootiology. histiocytomas are the most common tumors of young dogs, mostly occurring in dogs less than 2 years of age. pathologic findings. histologically, these tumors contain round to ovoid cells with pale cytoplasm and large nuclei. the cells infiltrate the dermis and subcutis, displacing collagen fibers and skin adnexa. despite being benign lesions, histiocytomas characteristically have a high mitotic index. pathogenesis. this tumor typically exhibits rapid growth (1-4 weeks) but does not spread. most histiocytomas will spontaneously regress in less than 3 months. diagnosis and differential diagnosis. histiocytomas must be distinguished from potentially metastatic mast cell tumors. this is accomplished by staining with toluidine blue, which would stain the cytoplasmic granules of mast cells red or purple. treatment. although most histiocytomas will spontaneously resolve, conservative surgery or cryosurgery will provide an expeditious resolution. research complications. histiocytomas should not interfere with most studies. etiology. neoplastic proliferations of mast cells are the most commonly observed skin tumor of the dog (bostock, 1986) . mast cells are normally found in the connective tissue beneath serous surfaces and mucous membranes, and within the skin. clinical signs. well-differentiated mast cell tumors are typically solitary, well-circumscribed, slow-growing, 1 to 10 cm nodules in the skin. alopecia may be observed, but ulceration is not usual. poorly differentiated tumors grow rapidly, may ulcerate, and may cause irritation, inflammation, and edema. mast cell tumors can be found on any portion of the dog's skin but frequently affect the hindquarters, especially the thigh and in-guinal and scrotal areas. mast cell tumors usually appear to be discrete masses, but they frequently extend deep into surrounding tissues. epizootiology. these tumors tend to affect middle-aged dogs but have been observed in dogs ranging from 4 months to 18 years (pulley and stannard, 1990 ). pathologic findings. because of the substantial variation in histologic appearance of mast cell tumors, a classification and grading system described by patnaik et al. (1986) has become widely accepted. in this system, grade i has the best prognosis, and grade iii the worst prognosis. grade i tumors are well differentiated, with round to ovoid uniform cells. the nuclei are regular, the cytoplasm is packed with large granules that stain deeply, and mitotic figures are rare to absent. grade ii (intermediately differentiated) mast cell tumors have indistinct cytoplasmic boundaries with higher nuclear-cytoplasmic ratios, fewer granules, and occasional mitotic figures. grade iii (anaplastic or undifferentiated) mast cell tumors have large, irregular nuclei with multiple prominent nucleoli. the cytoplasmic granules are few, but mitotic figures are much more frequent. in addition to skin lesions, mast cell tumors have been associated with gastric ulcers. these lesions are most likely secondary to tumor production of histamine. histamine stimulates the h2 receptors of the gastric parietal cells, causing increased acid secretion. gastric ulcers have been observed in large numbers (>75%) of dogs with mast cell tumors (howard et al., 1969) . the ulcers can be found in the fundus, pylorus, and/or proximal duodenum. although all mast cell tumors should be considered potentially malignant, the outcome in individual cases can be correlated with the histologic grading of the tumor. grade iii tumors are most likely to disseminate internally. this spread is usually to regional lymph nodes, spleen, and liver and less frequently to the kidneys, lungs, and heart. diagnosis and differential diagnosis. mast cell tumors can be distinguished histologically from other round cell tumors (such as histiocytomas and cutaneous lymphomas) by using toluidine blue, which metachromatically stains the cytoplasmic granules of the mast cells red or purple. treatment. initial treatment for mast cell tumors is generally wide surgical excision (1 to 3 cm margins). even with wide surgical margins, approximately 50% of mast cell tumors may recur. if the site is not amenable to wide surgical excision, debulking surgery and radiation therapy may be used. other alternatives include amputation (if on a limb) or radiation therapy alone. as an adjunct to surgery, grier et al. (1990 grier et al. ( , 1995 found that deionized water injected into surgical margins reduced tumor recurrence by hypo-osmotically lysing any mast cells left behind. this technique has recently been refuted by jaffe et al. (2000) . for systemic mastocytosis, and nonresectable or incompletely excised mast cell tumors, chemotherapy can be used. treatment options would include oral prednisolone, intralesional triamcinalone, and the combination of cyclophosphamide, vincristine, and prednisolone (graham and o'keefe, 1994) . research complications. because of the possibility of systemic histamine release and tumor recurrence, dogs with mast cell tumors are not good candidates for research studies. grade i mast cell tumors may be excised, allowing dogs to continue on study; however, monitoring for local recurrence should be performed on a regular basis (monthly). grade ii tumors are variable; animals that undergo treatment should be monitored for recurrence monthly, and evaluation of the buffy coat should be performed every 3-6 months for detection of systemic mastocytosis. because of the poor prognosis for grade iii tumors, treatment is unwarranted in the research setting. etiology. hemangiosarcomas are malignant tumors that originate from endothelial cells. clinical signs. these tumors may arise in the subcutis but are more commonly found in the spleen and the right atrium. clinical signs are associated with the site of involvement. vascular collapse is frequently observed secondary to rupture and hemorrhage from splenic masses. heart failure can be observed secondary to tumor burden or hemopericardium. when found in the skin, hemangiosarcomas are poorly circumscribed, reddish black masses that range in size from 1 to 10 cm in diameter. the most common cutaneous sites are the ventral abdomen, the prepuce, and the scrotum. epizootiology: hemangiosarcomas occur most frequently in 8-to 13-year-old dogs. the german shepherd dog is most commonly affected. pathologic findings. grossly, splenic hemangiosarcomas resemble nodular hyperplasia or hematomas (fig. 7) . the masses are spherical and reddish black and can range in size up to 15-20 cm in diameter. on cut section the masses may appear reddish gray or black and have cavernous areas of clotted blood. when the masses are found in the heart, the endocardium may be covered by a thrombus, giving the 2 to 5 cm tumors a reddish gray or yellow appearance. histologically, hemangiosarcomas are composed of immature endothelial cells that form vascular channels or clefts. these spaces may be filled with blood or thrombi. the neoplastic cells are elongated with round to ovoid, hyperchromatic nuclei and frequent mitotic figures. pathogenesis. hemangiosarcomas can be found in one or many sites. in cases where multiple sites are involved, it may be impossible to identify the primary tumor. this neoplasia is highly malignant and spreads easily. metastasis occurs most frequently to the lungs but can be found in any tissue. diagnosis and differential diagnosis. splenic hemangiosarcoma may resemble nodular hyperplasia or some manifestations of lymphoma. when the heart is affected, other causes of heart failure must be ruled out. echocardiography is a valuable tool for identifying the primary lesion. histopathology should be used to differentiate dermal hemangiosarcoma from hemangiomas and other well-vascularized tumors. treatment. surgery is generally the first choice of treatment for hemangiosarcoma. dermal tumors are treated with radical resection, splenic tumors by total splenectomy, and heart tumors by debulking and pericardiectomy. because of the high likelihood of metastasis, adjunct chemotherapy should always be considered. research complications. dogs with dermal hemangiosarcoma may be cured after complete resection with margins, but monitoring should be done regularly for recurrence. the other forms of hemangiosarcoma have a much poorer long-term prognosis, and treatment is typically unwarranted in the research setting. etiology. also known as infectious or venereal granuloma, sticker tumor, transmissible sarcoma, and contagious venereal tumor, the transmissible venereal tumor is transmitted to the genitals by coitus (nielsen and kennedy, 1990) . the origin of this tumor is still unknown but has been described as a tumor of lymphocytes, histiocytes, and reticuloendothelial cells. although this tumor has been reported in most parts of the world, it is most prevalent in temperate climates (macewen, 1991) . clinical signs. the tumors are usually cauliflower-like masses on the external genitalia, but they can also be pedunculated, nodular, papillary, or multilobulated. these friable masses vary in size up to 10 cm, and hemorrhage is frequently observed. in male dogs, the lesions are found on the caudal part of the penis from the crura to the bulbus glandis or on the glans penis (fig. 8) . less frequently, the tumor is found on the prepuce. females typically have lesions in the posterior vagina at the junction of the vestibule and vagina. when located around the urethral orifice, the mass may protrude from the vulva. these tumors have also been reported in the oral cavity, skin, and eyes. epizootiology and transmission. transmissible venereal tumors are most commonly observed in young, sexually active dogs. transmission takes place during coitus when injury to the genitalia allows for transplantation of the tumor. genital to oral to genital transmission has also been documented (nielsen and kennedy, 1990) . extragenital lesions are believed to be a result of trauma prior to exposure to the tumor. pathogenesis. tumor growth is rapid after implantation but later slows. metastasis is rare (<5% of cases) but may involve the superficial inguinal and external iliac lymph nodes as well as distant sites. diagnosis and differential diagnosis. transmissible venereal tumors have been confused with lymphomas, histiocytomas, mast cell tumors, and amelanotic melanomas. cytology may be of benefit in making a definitive diagnosis, so impression smears should be made prior to processing for histopathology. prevention. thorough physical examinations prior to bringing new animals into a breeding program should prevent introduction of this tumor into a colony. control. removing affected individuals from a breeding program should stop further spread through the colony. treatment. surgery and radiation can be used for treatment, but chemotherapy is the most effective. vincristine (0.5-0.7 mg/m 2) iv once weekly for 4 -6 treatments will induce remission and cure in greater than 90% of the cases (macewen, 1991). research complications. experimental implantation of transmissible venereal tumors has been shown to elicit formation of tumor-specific igg (cohen, 1972) . this response may occur in natural infections and could possibly interfere with immunologic studies. etiology. dogs are susceptible to a wide variety of mammary gland neoplasms, most of which are influenced by circulating reproductive steroidal hormones. clinical signs. single nodules are found in approximately 75% of the cases of canine mammary tumors. the nodules can be found in the glandular tissue or associated with the nipple. masses in the two most caudal glands (fourth and fifth) account for a majority of the tumors. benign tumors tend to be small, well circumscribed, and firm, whereas malignant tumors are larger and invasive and coalesce with adjacent tissues. epizootiology. mammary tumors are uncommon in dogs under 5 years of age with the incidence rising sharply after that. median age at diagnosis is 10-11 years. mammary tumors occur almost exclusively in female dogs, with most reports in male dogs being associated with endocrine abnormalities, such as estrogen-secreting sertoli cell tumors. pathologic findings. based on histologic classification of mammary gland tumors, approximately half of the reported tumors are benign (fibroadenomas, simple adenomas, and benign mesenchymal tumors), and half are malignant (solid carcinomas, tubular adenocarcinomas, papillary adenocarcinomas, anaplastic carcinomas, sarcomas, and carcinosarcomas) (bostock, 1977) . extensive discussions of classification, staging, and histopathologic correlations can be found in macewen and withrow (199 lb) and moulton (1990) . pathogenesis. mammary tumors of the dog develop under the influence of hormones. receptors for both estrogen and progesterone can be found in 60-70% of tumors. futher, schneider et al. (1969) showed that the risk of developing mammary tumors increased greatly after the first and second estrus cycles. dogs spayed prior to the first estrus had a risk of 0.8%, whereas dogs spayed after the first and second estrus had risks of 8% and 26%, respectively. malignant mammary tumors typically spread through the lymphatic vessels. metastasis from the first, second, and third mammary glands is to the ipsilateral axillary or anterior sternal lymph nodes. the fourth and fifth mammary glands drain to the superficial inguinal lymph nodes where metastasis can be found. many mammary carcinomas will eventually metastasize to the lungs. diagnosis and differential diagnosis. both benign and malignant mammary tumors must be distinguished from mammary hyperplasia and mastitis. prevention. mammary tumors can effectively be prevented by spaying bitches prior to the first estrus. this is commonly done in the general pet population at 6 months of age. recently, the topic of spaying sexually immature dogs (8-16 weeks of age) has received much attention for the control of the pet population. kustritz (1999) reviewed the techniques for anesthesia and surgery, as well as possible pros and cons of spaying at this young age. treatment. surgery is the treatment of choice for mammary tumors, because chemotherapy and radiation therapy have not been reported to be effective. the extent of the surgery is dependent on the area involved. lumpectomy or nodulectomy should be elected in the case of small discrete masses, while mammectomy and regional or total mastectomies are reserved for more aggressive tumors. at the time of surgery, axillary lymph nodes are removed only if enlarged or positive on cytology for metastasis. inguinal lymph nodes should be removed any time the fourth and fifth glands are excised (macewen and withrow, 199 lb). research complications. because 50% of mammary tumors are benign, treatment may be rewarding, allowing dogs to con-tinue on study. if removed early enough, malignant masses could yield the same results. all dogs should be monitored regularly for recurrence and new mammary tumors. etiology. beagles are among the breeds with the highest prevalence of thyroid carcinomas. benjamin et al. (1996) reported a correlation between lymphocytic thyroiditis, hypothyroidism, and thyroid neoplasia in the beagle. clinical signs. thyroid carcinomas generally present as palpable cervical masses. affected animals may experience dysphagia, dyspnea, and vocalization changes. precaval syndrome resulting in facial edema is also observed in some cases. epizootiology and transmission. the mean age of dogs presented with thyroid carcinomas is 9 years, with equal distribution of cases between the sexes. pathologic findings. grossly, thyroid carcinomas are multinodular masses, frequently with large areas of hemorrhage and necrosis. they tend to be poorly encapsulated and invade local structures such as the trachea, esophagus, larynx, nerves, and vessels. the masses are unilateral twice as often as bilateral (capen, 1990) . histologically, thyroid carcinomasare divided into follicular, papillary, and compact cellular (solid) types (see capen, 1990 , for complete discussion). pathogenesis. thyroid carcinomas tend to grow rapidly and invade local structures. early metastasis is common and occurs to the lungs by invasion of branches of the thyroid vein. diagnosis and differential diagnosis. nonpainful cervical swellings such as seen with thyroid tumors are also consistent with abscesses, granulomas, salivary mucoceles, and lymphomas. often a preliminary diagnosis can be made by fineneedle aspirate. treatment. surgery is the treatment of choice for thyroid carcinomas that have not metastasized. when the tumor is freely movable, surgery may be curative. surgical excision may be difficult for tumors that adhere to local structures, requiring excision of the jugular vein, carotid artery, and associated nerves. when bilateral tumors are observed, preservation of the parathyroid glands may not be possible. in such cases, treatment for hypoparathyroidism will be necessary. both chemotherapy and radiation therapy have been suggested for extensive bilateral tumors and/or after incomplete excision, but no controlled trials have been performed (ogilvie, 1991) . in the research setting, treatment of this tumor may not be rewarding. only freely movable tumors can be practically treated without seriously affecting research efforts. euthanasia is warranted in the more advanced cases when clinical illness is apparent. beagles are subject to many of the inherited and/or congenital disorders that affect dogs in general. in a reference table on the congenital defects of dogs (hoskins, 2000b) , disorders for which beagles are specifically mentioned include brachyury (short tail), spina bifida, pulmonic stenosis, cleft palate-cleft lip complex, deafness, cataracts, glaucoma, microphthalmos, optic nerve hypoplasia, retinal dysplasia, tapetal hypoplasia, factor vii deficiency, pyruvate kinase deficiency, pancreatic hypoplasia, epilepsy, gm1 gangliosidosis, globoid cell leukodystrophy, xx sex reversal, and cutaneous asthenia (ehlers-danlos syndrome). in addition, there are defects that affect so many breeds that the author simply lists "many breeds" for the breeds affected by those disorders. thus these defects could also affect beagles and include pectus excavatum, polydactyly, radial and ulnar dysplasia, hypoadrenocorticism, entropion, lens coloboma, factor viii deficiency (von willebrand's disease), renal agenesis or ectopia, and developmental defects of the reproductive and lower urinary tracts. at a commercial breeder of purpose-bred beagles, the most common birth defects were umbilical hernia (1.82% of births) and open fontanelle (1.44% of births) (r. scipioni and j. ball, personal communication, 1999) . other defects observed include cleft palate and cleft lip, cryptorchidism, monorchidism, limb deformity, inguinal hernia, diaphragmatic hernia, hydrocephaly, and fetal anasarca. each of these other congenital defects occurred at less than 1.0% incidence. etiology. cataract is an opacification of the lens or the lens capsule. it is the pathologic response of the lens to illness or injury, because the lens has no blood supply. cataracts can be caused by metabolic, inflammatory, infectious, or toxic causes and can be congenital, juvenile, or degenerative. nuclear sclerosis is an apparent opacification of the lens caused by the compression of older lens fibers in the center of the lens (nucleus) as a consequence of the production of new fibers. because the nucleus increases in size as the animal ages, the sclerosis is more apparent in older animals and may be mistaken as a senile cataract. the ability to see the fundus during ophthalmoscopy persists with nuclear sclerosis but is obstructed by a true cataract. clinical signs. the first clinical sign is typically the ability to visualize the opaque lens through the pupil of the dog's eye. dogs have an impressive ability to tolerate bilateral lens opacity (especially when development is gradual), and often visual impairment is detected late in the development of the condition (helper, 1989) . moderate vision loss may cause the dog to be hesitant in moving in new surroundings or unable to locate movable objects (such as a toy). rapid cataract development can result in a sudden vision loss, such as can occur with diabetic cataracts. epizootiology and transmission. certain dog breeds can be predisposed to the development of juvenile or senile cataracts or to metabolic disorders that result in cataract development, such as diabetes mellitus. dogs in studies for diabetes mellitus should be observed regularly for cataract development. toxicological studies may also induce formation of cataracts. pathogenesis. lens fibers respond to all biological or chemical insults by necrosis and liquefaction (render and carlton, 1995) , because they have no blood supply with which to recruit an inflammatory and repair process. disruption of these fibers by any means, therefore, leads to opacification. the exact processes by which the varieties of congenital and juvenile cataracts are produced have not been determined. in diabetic cataracts, the excess glucose is metabolized to sorbitol and fructose. as these alcohols and sugars accumulate in the lenticular cells, they produce an osmotic imbalance, which brings fluid into the cells, causing swelling and degeneration of lens fibers and resultant opacity (capen, 1995) . diagnosis and differential diagnosis. the ability to visualize the retina and fundus during ophthalmoscopy differentiates true cataracts from nuclear sclerosis. dogs with cataracts should be evaluated for possible causes, especially diabetes mellitus. diabetes mellitus will typically affect middle-aged dogs and feature rapid cataract formation, whereas juvenile and senile cataracts are slow to develop and affect younger and older dogs, respectively. progressive retinal atrophy can also cause secondary cataract formation; pupillary light response is maintained with primary cataracts (even if the lens is completely opaque), whereas this reflex is obtunded by retinopathy. prevention. most forms of cataracts cannot be prevented, for their exact etiologic pathogenesis is unknown. diabetic cataracts, however, can be prevented by proper regulation of blood glucose concentrations with insulin therapy and proper diet. treatment. because dogs do not need to focus visual images as accurately as human beings, proper lens clarity and function are not necessary for an adequate quality of life. many dogs adjust quite well to the visual impairment caused by persistent cataracts. lens removal can be performed for dogs seriously affected by cataracts, but this would not be anticipated for dogs in the research setting. information on surgical lens extraction procedures can be found in helper (1989) or other veterinary ophthalmology textbooks. research complications. research complications would be minimal with cataracts, unless the dogs were intended for use in ophthalmologic or visual acuity-based studies. etiology. hip dysplasia is a degenerative disease of the coxofemoral joint. a specific etiology is unknown, but the development of hip dysplasia has a strong genetic component (pedersen et al., 2000) , modified by age, weight, size, gender, conformation, rate of growth, muscle mass, and nutrition (smith et al., 1995) . clinical signs. the initial clinical abnormality caused by hip dysplasia is laxity of the coxofemoral joint. this may present as a gait abnormality without any indication of lameness or stiffness. eventually, affected dogs will have periods of lameness and, in protracted cases, will be rendered immobile by severe pain. epizootiology and transmission. hip dysplasia has been seen in most dog breeds, but it typically affects larger breeds of dogs. in the research setting, it is primarily a condition of randomsource large-breed dogs used for surgical research. diagnosis and differential diagnosis. hip dysplasia is classically diagnosed by radiography of the pelvis and hip joints. radiographic abnormalities consistent with hip dysplasia include shallow acetabula with remodeling of the acetabular rim, flattening of the femoral head, subchondral bone sclerosis (caused by erosion of articular cartilage and exposure of underlying bone), and osteophyte production around the joint (pedersen et al., 2000) . hip dysplasia needs to be differentiated from other musculoskeletal or neurological conditions that can cause unusual gaits and/or lameness. this may be somewhat difficult, because clinical signs of hip dysplasia may develop before radiographic abnormalities. radiographic calculation of the distraction index (di) to measure joint laxity has proven to be a good means to predict future hip dysplasia before other radiographic changes are evident (smith et al., 1995) . prevention. because of the genetic component, dogs with hip dysplasia should not be used in breeding colonies. dogs should be provided a good plane of nutrition but not be allowed to become overweight. dogs that were limit-fed at 75% of the food amount eaten by ad libitum-fed dogs had lower body weights and decreased severity of radiographic lesions of hip dysplasia (kealy et al, 1997) . treatment. in the stages when clinical signs are episodic, cage rest and analgesics for several days can be used to treat the symptoms. more advanced cases may require continuous analgesia. sectioning of the pectineus muscle or tendon may provide some pain relief but does not affect the progression of the disease (pedersen et al., 2000) . surgical treatments for hip dysplasia include femoral head ostectomy and total hip replacement. neither surgical treatment is likely in a research setting. research complications. long-term studies using large-breed dogs may be affected by the eventual development of hip dysplasia. in studies where hip dysplasia would be a serious complication or confounding variable (e.g., orthopedic research), dogs should be radiographed upon arrival to assess possibility of early coxofemoral joint degeneration and suitability for use in the study. etiology. benign prostatic hyperplasia (bph) is an agerelated condition in intact male dogs. the hyperplasia of prostatic glandular tissue is a response to the presence of both testosterone and estrogen. clinical signs. bph is often subclinical. straining to defecate (tenesmus) may be seen because the enlarged gland impinges on the rectum as it passes through the pelvic canal. urethral discharge (yellow to red) and hematuria can also be presenting clinical signs for bph. epizootiology and transmission. bph typically affects older dogs (>4 years), although it has been seen as early as 2 years of age. pathologic findings. in its early stages, canine b ph is hyperplasia of the prostatic glandular tissue. this is in contrast to human bph, which is primarily stromal in origin. eventually, the hyperplasia tends to be cystic, with the cysts containing a clear to yellow fluid. the prostate becomes more vascular (resulting in hematuria or hemorrhagic urethral discharge), and bph may be accompanied by mild chronic inflammation. pathogenesis. bph occurs in older intact male dogs because increased production of estrogens (estrone and estradiol), combined with decreased secretion of androgens, sensitizes prostatic androgen receptors to dihydrotestosterone. the presence of estrogens may also increase the number of androgen receptors, and hyperplastic prostate glands also have an increased ability to metabolize testosterone to 5a-dihydrotestosterone (kustritz and klausner, 2000) . diagnosis and differential diagnosis. bph is diagnosed in cases of nonpainful symmetrical swelling of the prostate gland in intact male dogs, with normal hematologic profiles and urinalysis characterized by hemorrhage, at most. differential diagnoses include squamous metaplasia of the prostate, paraprostatic cysts, bacterial prostatitis, prostatic abscessation, and prostatic neoplasia (primarily adenocarcinoma). these differential diagnoses also increase in frequency with age and, except for squamous metaplasia, can also occur in castrated dogs. as such, these conditions do not necessarily abate or resolve when castration is used for treatment of prostatic enlargement. prevention. castration is the primary means for prevention of benign prostatic hyperplasia. treatment. the first and foremost treatment for b ph is castration. in pure cases of b ph, castration results in involution of the prostate gland detectable by rectal palpation within 7-10 days. for most dogs in research studies this is a viable option to rapidly improve the animal's condition. the alternative to castration is hormonal therapy, primarily with estrogens. this may be applicable in cases in which the dog is a valuable breeding male (e.g., genetic diseases), and semen collection is necessary. if the research study concerns steroidal hormone functions, then neither the condition nor the treatment is compatible. newer drugs marketed for human males have also shown promise in treating canine bph. finasteride (proscar) is a 5a-reductase inhibitor that limits metabolism of testosterone to 5a-dihydrotestosterone. treatment at daily doses of 1-5 mg/kg has been effective in causing prostatic atrophy without affecting testicular spermatogenesis (kustritz and klausner, 2000) . dogs given 1.0 mg/kg were proven to still be fertile. there are also indications that lower doses may be effective in relieving b ph. androgen receptor antagonists (flutamide and hydroxyflutamide) have also been studied in the dog and found to be effective for treatment of bph while maintaining libido and fertility (kustritz and klausner, 2000) . unfortunately, both the 5areductase inhibitors and the androgen receptor antagonists are not presently labeled for use in male dogs in the united states. research complications. bph can cause complications to steroidal hormone studies, in that the condition may be indicative of abnormal steroidal hormone metabolism, and neither castration nor estrogen therapy is compatible with study continuation. it is presently unknown whether the use of the newer antihyperplastic agents systemically alters physiologic parameters outside of the prostate itself. the development of tenesmus as a clinical sign may also affect studies of colorectal or anal function. etiology. juvenile polyarteritis syndrome (jps) is a painful disorder seen in young beagles (occasionally reported in other breeds). the lesion consistent with the syndrome is systemic necrotizing vasculitis. the cause of the vasculitis has not been established, but it appears to have an autoimmune-mediated component and may have a hereditary predisposition. clinical signs. clinical signs of jps include fever, anorexia, lethargy, and reluctance to move the head and neck. the dogs tend to extend the neck ventrally. most dogs seem to be in pain when touched, especially in the neck region. the syndrome typically has a course of remissions and relapses characterized by 3-7 days of illness and 2-4 weeks of remission (scott-moncrieff et al., 1992) . there may be a component of this condition that is subclinical, given that a vasculitis has been diagnosed postmortem in beagles that had no presenting signs. epizootiology and transmission. jps typically affects young beagles (6-40 months), with no sex predilection. pathologic findings. on gross necropsy, foci of hemorrhage can be seen in the coronary grooves of the heart, cranial mediastinum, and cervical spinal cord meninges (snyder et al., 1995) . local lymph nodes may be enlarged and hemorrhagic. histologically, necrotizing vasculitis and perivasculitis of small to medium-sized arteries are seen. these lesions are most noticeable in the three locations where gross lesions are observed, but they may be seen in other visceral locations. the perivasculitis often results in nodules of inflammatory cells that eccentrically surround the arteries (fig. 9a) . the cellular composition of these nodules is predominantly neutrophils, but it can also consist of lymphocytes, plasma cells, or macrophages (snyder et al., 1995) . fibrinous thrombosis of the affected arteries is also seen (fig. 9b) . a subclinical vasculitis has also been diagnosed in beagles postmortem; it is not known whether this subclinical condition is a different disorder or part of a jps continuum. this subclinical vasculitis often affects the coronary arteries (with or without other sites). pathogenesis. the initiating factors for jps are unknown. it was once presumed to be a reaction to test compounds by laboratory beagles, but this may have been coincident to the fact that the beagle is the breed most often affected with jps. immune mediation of jps is strongly suspected, because the clinical signs have a cyclical nature and respond to treatment with corticosteroids, and the affected dogs have elevated a2-globulin fractions and abnormal immunologic responses. there may be hereditary predisposition, given that pedigree analysis of some affected dogs has indicated that the offspring of certain sires are more likely to be affected, and breeding of two affected dogs resuited in 1/7 affected pups (scott-moncrieff et al., 1992) . diagnosis and differential diagnosis. differential diagnoses include encephalitis, meningitis, injury or degeneration of the cervical vertebrae or disks, and arthritis. in the research facility, the disorder may be readily confused with complications secondary to the experimental procedure, or with postsurgical pain. beagles with jps that were in an orthopedic research study were evaluated for postsurgical complications and skeletal abnormalities prior to the postmortem diagnosis of systemic vasculitis (authors' personal experience). are known at this time. no prevention and control measures brane (third eyelid). this is not considered a congenital anomaly, but there is breed disposition for this condition, including beagles. a specific etiology is not known. clinical signs. the glandular tissue of the nictitating membrane protrudes beyond the membrane's edge and appears as a reddish mass in the ventromedial aspect of the orbit (fig. 10) . excessive tearing to mucoid discharge can result, and severe cases can be associated with corneal erosion. treatment. clinical signs can be abated by administration of corticosteroids. prednisone administered orally at 1.1 mg/kg, q12 hr, was associated with rapid relief of clinical symptoms. maintenance of treatment at an alternate-day regimen of 0.25-0.5 mg/kg was shown to relieve symptoms for several months. however, withdrawal of corticosteroid therapy led to the return of clinical illness within weeks. pathologic findings. typically the glandular tissue is hyperplastic, possibly with inflammation. rarely is the tissue neoplastic. pathogenesis. prolapse of the gland may be a result of a congenital weakness of the connective tissue band between the gland and the cartilage of the third eyelid (helper, 1989) . research complications. because of the potentially severe clinical signs and the need for immunosuppressive treatment, jps is often incompatible with use of the animal as a research subject. it is unknown whether subclinical necrotizing vasculitis causes sufficient aberrations to measurably alter immunologic responses. etiology. "cherry eye" is a commonly used slang term for hyperplasia and/or prolapse of the gland of the nictitating mem-prevention. hyperplasia of the third eyelid cannot be prevented, but dogs that develop this condition unilaterally should have the other eye evaluated for potential glandular prolapse. preventative surgical measures might be warranted. treatment. corticosteroid treatment (topical or systemic) can be used to try to reduce the glandular swelling. however, surgical reduction or excision of the affected gland is typically required to resolve the condition. in the reduction procedure, the prolapsed gland is sutured to fibrous tissue deep to the fornix of the conjunctiva (helper, 1989 ). if reduction is not possible (as with deformed nictitating cartilage) or is unsuccessful, removal of the gland can be performed. such excision is fairly straightforward and can be done without removal of the nictitating membrane itself. the gland of the third eyelid is important in tear production; although the rest of the lacrimal glands should be sufficient for adequate tear production, keratoconjunctivitis sicca is a possible consequence after removal of the gland of the nictitating membrane. research complications. in most cases, research complications would be minimal, especially if treated adequately. either the presence of the hyperplastic gland, or its removal, might compromise ophthalmologic studies. etiology. interdigital cysts are chronic inflammatory lesions (not true cysts) that develop in the webbing between the toes (fig. 11 ). the cause for most interdigital cysts is usually not identified unless a foreign body is present. bacteria may be isolated from the site, but the lesions may also be sterile (hence the synonym "sterile pyogranuloma complex"). clinical signs. dogs with interdigital cysts are usually lame on the affected foot, with licking and chewing at the interdigital space. exudation may be noticed at the site of the lesion. the lesion appears as a cutaneous ulcer, usually beneath matted hair, with possible development of sinus tracts and purulent exudate. epizootiology and transmission. interdigital cysts are common in a variety of canine breeds, including german shepherds. beagles have been affected in the research setting. interdigital cysts usually occur in the third and fourth interdigital spaces (bellah, 1993) . pathologic findings. histopathologically, interdigital cysts are sites of chronic inflammation, typically described as pyogranulomatous. pathogenesis. initial development of the cysts is unknown, except for those cases in which a foreign body can be identified. diagnosis and differential diagnosis. bacterial culture swabs and radiographs should be taken of the cysts to rule out bacterial infection, and radiopaque foreign bodies or bony lesions, respectively. a biopsy should be taken if neoplasia is suspected. treatment. if a foreign body is associated with the lesion, then removal is the first order of treatment. if biopsy of the site provides a diagnosis of sterile pyogranuloma complex, then systemic corticosteroid therapy (e.g., prednisolone at 1 mg/kg ql2h) can be initiated and then tapered once the lesion heals. interdigital cysts that are refractory to medical therapy require fig. 11 . interdigital cyst between the third and fourth digits of the forelimb of a research beagle. surgical removal. excision includes removal of the lesion and the interdigital web, and a two-layer closure of the adjacent skin and soft tissues is recommended (bellah, 1993) . the foot should be put in a padded bandage and a tape hobble placed around the toes to reduce tension when the foot is weightbearing. the prognosis for idiopathic interdigital cysts is guarded, because the cysts tend to recur (bellah, 1993) . research complications from the cysts are minimal, unless the dogs need to be weight-bearing for biomechanic or orthopedic studies. treatment with systemic steroids could be contraindicated with some 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thyroid gland and arterial lesions of beagles with familial hypothyroidism and hypedipoproteinemia bacterial gastroenteritis in dogs and cats: more common than you think urea protects helicobacter (campylobacter) pylori from the bactericidal effect of acid characterization of a new isolate of ehrlichia platys using electron microscopy and polymerase chain reaction decreased pulmonary arterial endothelium-dependent relaxation in heartworm-infected dogs with pulmonary hypertension vaccination against canine bordetellosis: protection from contact challenge dermatologic aspects of tick bites and tick-transmitted diseases a chronic access port model for direct delivery of drugs into the intestine of conscious dogs clinical trial of dvm derm caps in the treatment of allergic diseases in dogs: a nonblinded study diagnosis of neoplasia tumors of the mammary gland dirofilaria immitis: heartworm infection alters pulmonary artery endothelial cell behavior survey of conjunctival flora in dogs with clinical signs of external eye disease hyperoxia exacerbates microvascular injury following acid aspiration nutrient requirements of dogs surgical closure of elbow hygroma in the dog tumors of the genital system practical laboratory methods for the diagnosis of dermatologic diseases walker's mammals of the world tumors of the endocrine system beta hemolytic streptococcus isolated from the canine vagina comparison of three skin preparation techniques in the dog comparison of three skin preparation techniques in the dog. part 2: clinical trial in 100 dogs clinical behavioral medicine for small animals hypothyroidism in dogs: 66 cases (1987-1992) plasma von willebrand factor antigen concentration in dogs with hypothyroidism plasma von willebrand factor antigen concentration and bleeding time in dogs with experimental hypothyroidism canine cutaneous mast cell tumor: morphologic grading and survival time in 83 dogs joint diseases of dogs and cats target imbalance: disparity of borrelia burgdorferi genetic material in synovial fluid from lyme arthritis patients textbook of veterinary internal medicine tumors of the skin and soft tissue thomson's special veterinary pathology canine leptospirosis: a retrospective study of 17 cases dogs and cats as laboratory animals effects of chlorhexidine diacetate and povidoneiodine on wound healing in dogs epidemiology of thyroid diseases of dogs and cats factors influencing canine mammary cancer development and postsurgical survival muller and kirk's small animal dermatology systemic necrotizing vasculitis in nine young beagles thomson's special veterinary pathology textbook of veterinary internal medicine canine infectious tracheobronchitis (kennel cough complex) saunders manual of small animal practice serum protein alterations in canine erhlichiosis bacterial factors and immune pathogenesis in helicobacter pylori evaluation of rhipicephalus sanguineus as a potential biologic vector of ehrlichia platys role of the eastern chipmunk (tamias striatus) in the epizootiology of lyme borreliosis in northwestern illinois evaluation of risk factors for degenerative joint disease associated with hip dysplasia in dogs pathologic features of naturally occurring juvenile polyarteritis in beagle dogs textbook of veterinary internal medicine clinical manifestations, pathogenesis, and effect of antibiotic treatment on lyme borreliosis in dogs streptococcus zooepidemicus as the cause of septicemia in racing greyhounds trauma to the skin and subcutaneous tissues of dogs and cats chronic problem wounds of dog limbs portosystemic shunts textbook of veterinary internal medicine lumbosacral stenosis in dogs experimental respiratory disease in dogs due to bordetella bronchiseptica dirofilaria immitis: depression of endothelium-dependent relaxation of canine femoral artery seen in vivo does not persist in vitro thyroiditis in a group of laboratory dogs: a study of 167 beagles of agriculture, animal and plant health inspection service thomson's special veterinary pathology a retrospective study of 27 cases of naturally occurring canine ehrlichiosis role of canine parainfluenza virus and bortedella bronchiseptica in kennel cough management of superficial skin wounds serum concentrations of thyroxine and 3,5,3'-triiodothyronine before and after intravenous or intramuscular thyrotropin administration in dogs use of ultrasound in the measurement of subcutaneous fat and prediction of total body fat in dogs ehrlichia platys in a michigan dog ehrlichial diseases of dogs canine ehrlichiosis. miss albert, r. e., benjamin, s. a., and shukla, r. (1994). life span and cancer mortality in the beagle dog and human. key: cord-023367-ujflw19b authors: newcomer, benjamin w.; cebra, chris; chamorro, manuel f.; reppert, emily; cebra, margaret; edmondson, misty a. title: diseases of the hematologic, immunologic, and lymphatic systems (multisystem diseases) [image: see text] date: 2020-04-17 journal: sheep, goat, and cervid medicine doi: 10.1016/b978-0-323-62463-3.00025-6 sha: doc_id: 23367 cord_uid: ujflw19b nan in this chapter, multisystemic diseases are discussed in small ruminants (sheep, goats, and cervids). these include diseases of the hematologic, immunologic, and lymphatic systems. in general, species will be discussed together, but when pertinent data are available, each species will be considered separately. the terms "cervid" and "deer" have been used interchangeably in parts of this chapter by the authors. an adequate volume of blood for hematologic and biochemical analysis is best obtained from the jugular vein. a docile animal may be restrained in a standing position or tipped up (sheep only) with the head turned away from the jugular vein to be used. wilder ones, such as some cervids, may require restraint devices or chemical sedation. ideally, the animal should be restrained by someone other than the blood collector, although the same person may be able to both restrain a sheep and collect blood if the animal is tipped up or a halter is used (see chapter 1) . the animal should be at rest, with minimal excitement. the collector parts or clips the wool or hair to visualize the jugular vein and then uses the hand not holding the needle to apply digital pressure proximally just above the thoracic inlet to block blood movement through the vein. the vessel may take a second or more to distend after pressure is applied. the collector may then use the needlebearing hand to "strum" the vessel and cause the blood to oscillate. if in doubt about whether the distended vessel is the jugular vein, the collector can release the hand placing pressure on the vessel and observe whether the distended vessel disappears; if it does, the distended vessel was probably the jugular vein. the collector should avoid vessels that pulsate because these are likely to be the carotid arteries. the area should be cleaned with alcohol or other disinfectant, water, or a clean, dry gauze sponge. an 18-or 20-gauge, 1-to 1.5-inch needle is usually adequate to collect blood from an adult, whereas a 22-gauge needle may be used in a neonate. the skin of adults or males may be thicker and more difficult to penetrate with the needle. a syringe or evacuated tube attached to a vacutainer (becton dickinson inc., rutherford, nj) can be used to collect blood. the needle should be plunged through the skin into the vein at an approximate 30-degree angle. the blood should not come out of the vessel in pulsatile waves; this is suggestive of an arterial stick. after aseptically obtaining an adequate volume of blood, the collector removes the needle and releases the pressure on the vessel near the thoracic inlet. pressure should be applied to the site of puncture for a minute or more to prevent extravascular leakage of blood and hematoma formation. the blood should be carefully transferred to a vial containing the appropriate anticoagulant to prevent red blood cell (rbc) rupture. goat erythrocytes are small and particularly prone to hemolysis. to minimize this problem, goat blood should be collected with a needle and syringe, not a vacutainer. white blood cell (wbc) differential distribution, individual blood cell staining characteristics, and morphology may be assessed by microscopic examination of a stained blood film. the differential distribution provides more information than total wbc count because inflammatory conditions in artiodactyls often result in a shift in neutrophil populations toward more degenerate, toxic, or immature forms without changing the overall wbc count. 1 the preferred anticoagulant for a complete blood count (cbc) is ethylenediaminetetraacetate (edta), and tubes should be filled to ensure the proper blood-to-anticoagulant ratio. blood samples should be processed as soon as possible after collection. if a delay is anticipated, the blood sample should be refrigerated (4° c) and an air-dried blood smear should be made because prolonged contact of blood with edta causes changes in wbc morphology and the separation of some rbc parasites. blood can be refrigerated for 24 hours and still yield an accurate cbc. a reference range for hematologic data for sheep and goats is provided in table 16.1 (see appendix 2, tables 1 and 2) . goats tend to have a low mean corpuscular volume (mcv) because of their small erythrocytes. sheep and goats younger than 6 months old tend to have lower hematocrit, rbc count, hemoglobin, and plasma protein concentrations, as well as a higher total wbc count. neonates often have a high hematocrit at birth that decreases with colostral ingestion. lactating animals may have decreased hematocrits, rbc counts, and hemoglobin concentrations. animals grazing at high altitude (mountain goats and bighorn sheep) tend to have increased rbc counts, hematocrits, and hemoglobin concentrations. interpreting hematologic changes in cervids is more complex. restraint method affects a variety of parameters in non-acclimated individuals. physical restraint yields red cell counts and hematocrit and hemoglobin concentrations that are 20 to 40% higher than animals immobilized chemically. 2, 3 neutrophil, lymphocyte, monocyte, and total white cell counts are also 70 to 100% higher in physically restrained cervids (see appendix 2, tables 1 and 2) . adult deer also have seasonal variations in their hemogram. red cell numbers and related values are highest during midsummer and late winter. 3 white cells, especially neutrophils, are also highest in midsummer, and platelet counts are highest in spring and fall. these changes may relate to diet or to seasonal activities, such as antler growth and rutting conflicts, which increase the chance of trauma. red cell stickling has also been reported in a variety of deer species. this appears to relate to a mutation in hemoglobin's b-globin component, similar to the disorder in people, but no pathologic role has been described. 4 bone marrow aspirates and core biopsy samples taken from sites of active erythropoiesis can be useful to evaluate erythrocyte production and determine the cause of anemia and other hemogram abnormalities. the sites of biopsy include the sternebrae, femur, and ileum. the procedure should be done under chemical sedation or anesthesia (see chapter 18) . the area over the biopsy site is clipped and surgically prepared; the sampler should wear sterile gloves to maintain asepsis. aspirates can be obtained by inserting a sterile needle attached to a 3-or 6-cc syringe containing one or two drops of edta through the bone and into the bone marrow. drawing back on the syringe plunger several times may aid in the procurement of an acceptable sample; such a sample may consist of as little as 0.5 ml of bone marrow. if the sample is going to be processed immediately, no anticoagulant is required. core biopsies are obtained using a jamshidi or westerman-jensen biopsy needle. the skin is incised with a scalpel and the biopsy needle is inserted into the bone and turned several times to obtain a core sample. more than one site may be used. the sampler then closes the skin with sutures or staples. biopsy samples are preserved by placing them in 10% neutral buffered formalin solution. impression smears can be made from these samples by gently rolling them on a clean glass slide before placing them in the formalin solution. information obtained from bone marrow samples includes subjective data regarding cell density, megakaryocyte numbers, abnormal cells, maturation patterns of rbcs and wbcs, and the ratio of erythroid to myeloid cells. prussian blue stain can be used on bone marrow to demonstrate iron stores. bone marrow aspirates and biopsies are painful and invasive procedures. therefore, animals should be placed on antibiotics and antiinflammatory drugs prophylactically. blood cultures can be useful in diagnosing bacteremia in an intermittently or persistently febrile animal or one with numerous sites of organ infection. ideally, the clinician should obtain the sample before instituting antimicrobial therapy. however, if this is impossible, antimicrobial therapy should be discontinued 48 to 72 hours before sampling. samples should be taken before and during febrile episodes. the jugular vein is most commonly used to attain a blood culture. as described previously, the skin over the jugular vein should be clipped and surgically prepared. the person collecting the blood sample should wear sterile gloves and use a sterile needle and syringe. blood samples should be placed immediately in a blood culture flask. the chances of attaining a positive culture from bacteremic animals increase with the size of the sample up to about 30 ml, but adding more than the recommended amount to any single culture vial may overwhelm the capacity of the specialized antibiotic-absorbing resins within the flasks. the clinician should change the needle on the sample syringe after collecting the blood and before putting the sample in the culture medium. samples should be refrigerated until they can be sent to a diagnostic laboratory, where aerobic and sometimes anaerobic cultures are made. as an alternative to hematologic testing, comparing conjunctival color to swatches on a standardized famacha chart has been used as a rapid and inexpensive assessment of anemia in whole flocks, primarily to assess the impact of haemonchus contortus and other blood-sucking parasites. 5, 6 results from a number of trials have yielded fair to good sensitivity to packed cell volume and h. contortus load in both sheep and goats. similar to body condition scoring systems, it is essential to calibrate assessors to ensure consistency when using this system. 7 also, some breeds hematocrit (%) 27-45 22-36 hemoglobin (g/dl) 9-15.8 [8] [9] [10] [11] [12] red blood cell count (310 6 /ml) 9-17.5 [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] mean corpuscular volume (fl) 28-40 15-26 mean corpuscular hemoglobin concentration (g/dl) 31-34 [29] [30] [31] [32] [33] [34] [35] platelet count (310 5 /ml) 2.4-7.0 2.8-6.4 total white blood cell count (/ml) 4000-12,000 4000-13,000 segmented neutrophils (/ml) 1500-9000 1400-8000 band neutrophils (/ml) 0 0 lymphocytes (/ml) 2000-9000 2000-9000 monocytes (/ml) 0-600 0-500 eosinophils (/ml) 0-1000 0-900 basophils (/ml) 0-300 0-100 total plasma protein (g/dl) 6.2-7.5 6.0-7.5 fibrinogen (mg/dl) 100-600 read differently on the cards, and use of an electronic color analyzer, while more expensive and less field-friendly, may detect anemia earlier (see chapter 6, figure 6 .4a, b, and chapter 19) . 8 easy use of this technique in deer is limited by their intractability and has not been reported. the most common and significant abnormality of the hemogram is anemia. anemia occurs most commonly after blood loss, hemolysis, or chronic disease. blood loss is usually covert and commonly caused by gastrointestinal or external parasites. overt blood loss is usually caused by major trauma such as that caused by dog bites, severe lacerations, male rivalry fighting, or complications of castration or dehorning. cbc values appear normal immediately after acute blood loss. however, after a few hours of fluid redistribution, anemia and hypoproteinemia are evident. evidence of red cell regeneration (macrocytosis, reticulocytosis, and nucleated red cells) should appear within a day or two of the blood loss. hemolysis occurs most commonly after ingestion of toxic plants, rbc parasitism, intravenous (iv) injection of hypotonic or hypertonic agents, contact with bacterial toxins, water intoxication, or immune-mediated destruction of opsonized erythrocytes. ingested toxins include sulfur compounds from onions and brassica plants (kale and canola), [9] [10] [11] [12] nitrates, nitrites, and copper. [13] [14] [15] [16] except for that caused by copper, hemolysis usually occurs within a day or two after ingestion. copper toxicosis can occur after acute overingestion but more commonly is seen in animals that are chronically overfed copper and suffer some stressful event. goats are more tolerant of excess copper than sheep are, and certain breeds of sheep, particularly the suffolk, are highly sensitive to copper toxicosis (see chapters 2 and 5) . hemolytic bacterial toxins include those from clostridium perfringens type a, clostridium haemolyticum, and leptospira interrogans. 17, 18 intraerythrocytic parasites include anaplasma species, mycoplasma (eperythrozoon) species, and babesia species. [19] [20] [21] [22] [23] immune-mediated rbc destruction is very uncommon except with parasitemia, the administration of certain drugs (penicillin), or bovine colostrum to small ruminant neonates. 24 rapid reduction of plasma osmolality can lead to osmotic lysis of erythrocytes. this can occur locally as a sequela to rapid iv injection of hypotonic substances or after ingestion of a large quantity of water following a period of water deprivation and dehydration (water intoxication). selenium and copper deficiency have also been associated with heinz body anemia. 25 parasite infestation, opsonization, and ingestion of toxic plants typically cause extravascular hemolysis. in these cases, damaged erythrocytes are removed by cells of the reticuloendothelial system, resulting in anemia, pallor, weakness, depression, icterus, and dark urine. bacterial toxins, changes in plasma osmolality, and copper toxicosis cause intravascular hemolysis, resulting in the additional signs of hemoglobinemia and hemoglobinuria. other signs such as fever, neurologic symptoms, and sudden death may be seen with specific diseases. signs of regeneration should be seen on the hemogram 1 to 2 days after the onset of hemolysis. anemia that is not related to the loss or destruction of erythrocytes usually results from a lack of production and thus are nonregenerative. although mild forms may exist in pregnant sheep and goats and those deficient in vital minerals (e.g., iron, selenium, copper, and zinc), the most common cause of nonregenerative anemia is chronic disease. under these conditions, iron is sequestered in an unusable form in the bone marrow; staining a marrow sample with prussian blue stain reveals large iron stores, differentiating this disease from iron-deficiency anemia. the causes of anemia of chronic disease are numerous and include infectious conditions (e.g., pneumonia, foot rot, and caseous lymphadenitis), malnutrition, and environmental stressors. 1 most anemia does not require treatment. unless loss of rbc mass is rapid and severe, the animal is usually able to compensate to the decreased oxygen-carrying capacity by decreasing activity. it is important to remember in this regard that anemia often first becomes apparent to the manager of a flock or herd when animals appear overly stressed or die during movement or handling. if possible, the cause of the anemia should be addressed. this can involve trying to control internal and external parasites, changing the diet, and treating infectious diseases. maintaining adequate hydration is essential in animals with intravascular hemolysis to avoid hemoglobin-induced renal tubular damage. specialty compounds such as molybdenum salts, such as ammonium molybdate, and sulfur or penicillamine for copper toxicosis 16 and methylene blue (15 mg/kg in a 4% solution in 5% dextrose or normal saline intravenously) for nitrate toxicity are usually too expensive or difficult to be used on a flock-wide basis but may be useful in valuable individual animals. veterinarians should be aware that methylene blue is no longer approved for use in food-producing animals. animals with severe acute blood loss or hemolysis may benefit from a whole blood transfusion. because transfusion reactions are rare and strong erythrocyte antigens have not been identified in small ruminants (including cervids), almost any donor of the same species is acceptable for a first transfusion. cross-matching can be done to ensure compatibility, which becomes more important if the animal receives more than one transfusion. blood should be withdrawn aseptically from the donor and collected by a bleeding trocar into an open flask or by a catheter into a special collection bag. blood should be mixed at a 7.5:1 ratio with acid-citrate dextrose, or 9:1 with 2% sodium citrate, or another suitable anticoagulant and administered through a filtered blood administration set. if the jugular vein is not accessible, blood may be infused into the peritoneal cavity, but the slower absorption from that site makes it less effective for treating acute blood loss. the first 15 to 30 minutes of administration should be slow. if no reaction is seen (fever, tenesmus, tachypnea, tachycardia, and shaking), the rate may be increased. transfused erythrocytes may only survive a few days, and therefore, the original cause of the anemia must be addressed. 1 peripheral wbcs include granulocytes (neutrophils, eosinophils, and basophils) and mononuclear cells (lymphocytes and monocytes). immature forms of neutrophils and lymphocytes may be seen during severe inflammatory diseases. abnormalities of the neutrophil line are usually the best cellular evidence of inflammation in small ruminants, and inflammation is almost always a sequela of infection. an increase in neutrophil numbers and their proportional contribution to the total wbc count is usually seen in mild gram positive, subacute, or chronic bacterial infections. animals with more severe disease may exhibit high or normal counts, but a greater proportion of the neutrophils will have toxic changes or be immature forms (band cells, metamyelocytes, or myelocytes). in severe, acute inflammation and many diseases caused by gram negative bacteria, a temporary reduction in neutrophil numbers is observed, often with a concurrent shift toward more toxic or immature forms. if the animal survives the peracute disease, neutropenia should resolve over 3 to 4 days, first through an increase in immature cells, and later through a mature neutrophilic response. another important cause of increased total and relative neutrophil counts is stress (or glucocorticoid administration), which inhibits neutrophil margination and extravasation and thereby increases the number of these cells in the midstream blood. increases in eosinophil counts are usually related to exposure to eukaryotic parasites. decreases are rarely of clinical significance and may be part of the stress response. idiopathic allergic-type reactions also are indicators of pathology but are very rare. increases in basophils are rarely clinically significant. increases in lymphocyte counts often reflect chronic inflammatory disease such as that seen with internal abscesses. in rare cases, lymphocytosis may consist of abnormal, blast-type cells and indicate a lymphoproliferative neoplasm. lymphopenia is an important part of the stress response; nevertheless, the clinician must keep in mind that many diseases stimulate a stress response. therefore, lymphopenia and neutrophilia may represent either stress or inflammation, and an examination of neutrophil morphology and plasma fibrinogen concentrations may be useful in distinguishing the two situations. a high fibrinogen concentration, toxic changes, and high counts of immature neutrophils indicate inflammation under those circumstances. blood monocyte counts also may indicate stress or chronic inflammation. the difficulties in interpreting individual cell count abnormalities highlight the importance of obtaining a differential wbc count and description of cellular morphology in assessing sick sheep and goats. leukogram abnormalities are rarely given specific treatment. it is far more common and useful to use the information from the leukogram to develop a plan to treat the disease responsible for the abnormality. palpation of external lymph nodes is part of the thorough physical examination. lymph nodes that can be found in normal sheep and goats include the submandibular, prescapular, and prefemoral nodes. none of these should be prominent or painful on palpation. additional nodes that may be palpated occasionally in normal animals include the parotid, retropharyngeal, supramammary, perirectal, and popliteal nodes. internal lymph nodes that may be identified during specialized diagnostic procedures include the mediastinal, mesenteric, and other abdominal nodes. enlargement of lymph nodes may be focal, multifocal, or generalized. identification of a single enlarged superficial node does not always rule out a multifocal or generalized disorder because the status of the internal nodes often cannot be determined. enlargement generally indicates either inflammation or neoplasia. inflammatory enlargement is generally related to an associated disease with an infectious component. small ruminants are particularly sensitive to lymph node-based infections (e.g., caseous lymphadenitis), so the search often does not extend beyond aspirating or draining the lymph node itself. neoplastic enlargement almost always results from lymphosarcoma. lymphosarcoma pathogenesis. neoplastic transformation of a member of the lymphocyte cell line leads to unregulated clonal expansion of that cell. the cause of transformation is usually unknown; in rare cases, especially in flock outbreaks in sheep, it can be linked to exposure to the bovine leukemia virus, which has occurred experimentally and as a result of the administration of whole blood anaplasma vaccines. whether the bovine leukemia virus can induce lymphosarcoma in goats and cervids is still unclear. multicentric lymphosarcoma has been reported sporadically in white-tailed deer (odocoileus virginiatus) and other deer, but bovine leukemia virus infection has not been diagnosed in cervids. 26 in one study of neoplastic diseases affecting goats from 1987 to 2011, lymphoma was identified as the most common neoplasm, accounting for 17.7% of the assessed tumors. 27 in contrast to other species such as cattle, sheep, and horses, lymphomas in goats are predominantly t-cell lymphomas affecting the mediastinum. a recent study attempted to classify the type of lymphoma affecting 15 goats. using immunohistochemistry (ihc), it was determined that 73% (n 5 11) of affected goats had t-cell lymphoma and only 27% (n 5 4) had b-cell lymphoma. 28 proliferation of t or b lymphocytes leads to mass lesions and infiltration of viscera. these changes cause physical obstruction (to breathing, blood flow, urination, defecation, etc.), ulceration of mucosal surfaces (blood loss, bacterial invasion), immune system dysfunction, organ failure, and generalized malaise and cachexia. tissue masses may be internal or visible on external examination. clinical signs. clinical signs in affected animals vary according to the type of lymphoma (t-or b-cell) and the location of the masses. t-cell lymphomas in goats are usually localized in the thoracic cavity and/or neck, suggesting thymic origin or homing. 27 in contrast, b-cell lymphomas tend to have a multicentric distribution. 27 lymphoma in small ruminants usually presents with non-specific signs that can mimic other respiratory or gastrointestinal conditions. slowly progressive weight loss is the most common finding. in some cases, generalized peripheral lymphadenopathy and expansile masses are noted 29 ; at first, they usually are presumed to be caseous lymphadenitis abscesses. progressive chemosis and exophthalmos have been reported in a sheep and a goat with multicentric b-cell lymphoma. 29, 30 most masses form at the sites of internal or external lymph nodes. in sheep, masses in the brain, skin, joint, and lymphoid tissue have been reported. 30 leukemia is rare. the most common abnormalities are those of chronic disease and cachexia and include nonregenerative anemia and hypoalbuminemia. bone marrow examination may reveal clonal expansion of lymphoid precursor cells. in cervids, lymphadenopathy and multifocal masses affecting the heart, blood vessels, kidney, urinary bladder, and peritoneum have been reported. 31 a more recent report described a subcutaneous maxillary mass in a 13-year-old captive-born, female whitetailed deer. 26 the mass was diagnosed as focal lymphosarcoma with local metastasis. diagnosis. history and clinical signs are important in the diagnosis of lymphoma in small ruminants. age of affected animals ranges from 2 to 18 years and no gender or breed predisposition has been reported. 29 final diagnosis of affected animals is achieved through necropsy, histopathology, and ihc. lesions seen at necropsy include homogeneous white to tan masses that bulge on the cut surface. they may be small or large. less commonly, diffuse paleness of the reticuloendothelial organs is noted. microscopic examination of these tissues reveals infiltrates of abnormal cells of the lymphocyte line. prevention. avoiding exposure to the bovine leukemia virus and restricting the use of instruments to one animal between cleaning procedures may help prevent the spread of lymphosarcoma. in most animals, however, this neoplasm appears to develop spontaneously. pathogenesis. lambs, kids, and fawns are born with functional lymphocytes that can produce endogenous immunoglobulin. these cells develop the ability to respond to foreign antigens in the fetus during mid to late gestation. because of a lack of in utero exposure, however, basal concentrations of immunoglobulin are very low at birth. these cells therefore are naïve to foreign antigens and unable to develop protective immunity through specific cellmediated and immunoglobulin production. additionally, as with other ruminants, no transplacental passage of maternal immunoglobulin to fetal sheep, goats, and fawns occurs. lambs, kids, and fawns depend exclusively on intestinal absorption of maternally derived colostral antibodies, immune cells (t-lymphocytes), and other immune factors to provide a ready supply of specific immunity and allow opsonization of pathogens for the first months of life. adequate passive transfer requires delivery of a sufficient quantity of good-quality colostrum (immunoglobulin g [igg] concentration in mg/ml) into the gastrointestinal tract, as well as adequate absorption of antibodies (timely) from the colostrum into the blood. however, the amount of maternal colostrum produced by the dam, and its composition, as well as the ability of the newborn to stand and nurse in a timely manner, can be affected by several factors. colostrum igg concentration and volume of production can be influenced by breed, age, nutrition, body condition score (bcs) at parturition, and vaccination status of the dam. the igg concentration in colostrum samples from ewes of different breeds can vary between 60 and 125 mg/ml. 32 one study demonstrated that primiparous ewes with low bcs (, 2.75) at lambing produced less colostrum compared with multiparous ewes with similar bcs. additionally, ewes with higher bcs (. 2.75) tended to produce higher volumes of colostrum compared with ewes with lower bcs. 32 another study suggested that undernutrition of ewes during late gestation can affect colostrum quality and immune development and function in newborn lambs. 33 it has been suggested that at least 30 g of total igg should be fed to newborn lambs and kids during the first 24 hours of life to reach adequate transfer of passive immunity. adequate transfer of passive immunity in small ruminant neonates has been suggested as serum igg levels at 24 hours of life of  15 mg/ml. one study indicated that lambs that nurse low-quality colostrum (igg , 30 mg/ml) had lower serum igg concentrations compared with lambs that that nurse colostrum of higher quality (igg . 110 mg/ml), indicating that the concentration of igg in colostrum is a determining factor for the presentation of failure in the transfer of passive immunity. 34 other factors such as pregnancy toxemia, gastrointestinal parasitism, excess of iodine intake during pregnancy, and inadequate vaccination of the dam can result in poor colostrum synthesis and quality. 35 timely consumption of maternal colostrum during the first hours of life is essential to achieve adequate transfer of passive immunity. in small ruminants, cells of the small intestine are able to internalize and transfer igg into the blood during the first 24 hours of life; however, the absorption efficiency of igg is higher during the first 6 to 12 hours of life. 32, 36 factors associated with the neonate, such as weakness, inability to stand, and congenital abnormalities, will prevent timely nursing of maternal colostrum and lead to failure of passive transfer (fpt). litter size and body weight (bw) of the kid(s) have also been correlated with inadequate absorption of igg from colostrum. one study demonstrated that litter sizes of three light goat kids (, 2.8 kg bw) or more had significantly lower mean serum igg levels at 24 hours of life when compared with litter sizes of one or two heavier kids (9.85 versus 18.30 mg/ml, respectively). 37 this suggests that special attention and monitoring should be paid to multiple fetus gestation as the risk of fpt under these circumstances at kidding is higher; however, the quality of colostrum, amount ingested, and adequacy of absorption are rarely monitored by small ruminant producers in natural or artificial rearing systems. the use of monitoring tools to evaluate colostrum quality and igg absorption is common in modern dairy cattle operations, and these tools are readily available for small ruminant production systems. recent reports have presented the use of %brix in maternal colostrum and neonate serum and its positive correlation with serum total proteins (stps) at 24 hours as effective monitoring tools of fpt in lambs and goat kids. [38] [39] [40] the use of stp has also been used to monitor colostrum deficiency intake in mule deer fawns 41 ; however, adequate values of serum igg for cervid neonates have not been established yet. inadequate colostrum intake and low serum igg at 24 to 48 hours of life have been consistently associated with higher morbidity and mortality rates in lambs, goat kids, and fawns. one study reported that 46% of lamb mortality between 24 hours and 5 weeks of age can be attributed to fpt. 42 another study suggested that colostrum deficiency and low serum igg in goat kids resulted in higher mortality rates at weeks 10 and 12 of life due to chronic infections with pasteurella multocida and escherichia coli. 43 other reports demonstrated that 45% of lambs with a serum igg of , 6 mg/ml at 24 hours died before 3 weeks of age compared with only 5% of the lambs with a serum igg of . 6 mg/ml at 24 hours. 34 in a previous report, mule deer (odocoileus hemionus) fawns with a stp of # 5 g/dl between days 1 and 7 of age developed diarrhea and died before 17 days of age compared with fawns with stp . 5 g/dl. 41 in a more recent report, a 7-day-old formosan sambar deer (rusa unicolor swinhoei) with a history of colostrum deprivation died due to severe suppurative meningitis caused by e. coli infection. 44 in addition to immunoglobulins, colostrum also contains large quantities of fat-soluble vitamins that do not cross the placenta. the most important of these are vitamins a, d, and e, which are important in bone development and the immune or inflammatory response. neonates that have not ingested enough colostrum are likely to be deficient in these vitamins. diagnosis. history of dam dystocia, inadequate colostrum nursing, complete colostrum deprivation, and signs of undernourishment or sepsis in the first few days after birth are usually a presumptive indication of failure in the transfer of passive immunity. a high prevalence of diarrhea and respiratory disease in neonates should prompt investigation and evaluation of passive transfer of immunity in affected herds or flocks. owners occasionally evaluate lambs or kids for adequate intake by picking up the animal and holding it at ear level, while carefully cradling the head and neck, and then shaking the abdomen to hear milk in the abomasum; however, this is not a reliable indication of adequate transfer of passive immunity. a definitive diagnosis of fpt can be made by direct laboratory measurement (single radial immunodiffusion [srid]) of igg in serum at 24 hours of life. although some practitioners use the value of igg used in dairy calves (10 mg/ml), others have suggested an igg value , 15 mg/ml to establish the presence of fpt in small ruminants. 45 numerous semiquantitative methods of estimating igg are available and are easy to use in sheep, goats, and cervids. the most common is the measurement of serum total solids or stp values at 24 hours of life through an optical refractometer. the stp at 24 hours of life in a well-hydrated animal has demonstrated correlation with serum igg in calves, lambs, and goat kids. studies in goat kids indicated that an stp between 5.3 and 5.4 g/dl was associated with adequate transfer of passive immunity. 39, 40 another study demonstrated fpt in lambs with stp values , 4.5 g/dl at 24 hours of life. 32 a study in mule deer suggested that fawns with an stp # 5 g/dl had inadequate colostrum intake and fpt. recently, the measurement of %brix in maternal colostrum and serum with a digital brix refractometer has become an alternative method to evaluate colostrum quality and fpt in dairy operations. colostrum %brix . 22% and serum %brix . 8.4% have been associated with adequate transfer of igg in calves and goat kids. 39 other qualitative methods to assess the transfer of passive immunity in large animals include various agglutination (glutaraldehyde), precipitate assays (sodium sulfate), and measurement of g-glutamyl transferase (ggt) in serum. these methods may be relied on to give an overall flock assessment of adequacy of passive transfer, but they are rarely accurate enough to provide definitive information on individual animals. treatment. fpt is not in itself pathologic, but it greatly increases the neonate's susceptibility to infectious diseases. the amount of colostrum absorbed across the gut decreases with time, especially in animals that have been ingesting other proteins (e.g., the casein in milk); it also decreases with illnesses that decrease gastrointestinal function. neonatal small ruminants should receive at least 4 g of igg/kg of bw or ideally 30 g of total mass of igg from a good-quality colostrum source (. 50 mg/ml of igg) during the first hours of life. 32 other authors recommend an intake of 180 to 210 ml of colostrum/kg during the first 18 hours of life. 46 in artificial rearing systems or lamb feedlots, feeding of colostrum every 6 hours until 24 hours of life is recommended. 47 when same species' maternal colostrum is unavailable, goat colostrum or bovine colostrum/colostrum replacers or are a good alternative; however, hemolysis has been reported in lambs receiving cattle colostrum. 48 one study demonstrated that there was no difference in serum igg levels of lambs that received the same volume of sheep or goat colostrum at birth. 47 another study demonstrated that lambs that received 250 ml of a bovine colostrum replacer at birth in addition to 250 ml of stored sheep colostrum at 6 hours of life had higher serum %brix values at 24 hours and had less incidence of disease during the preweaning period compared with lambs that received the same volume of stored sheep colostrum at birth and at 6 hours of life. 38 since igg absorption cannot be extended more than 24 hours after birth, administration of an oral colostrum source is the best treatment in the immediate postpartum period in still-healthy neonates. after the window for immunoglobulin absorption has closed, plasma, serum, or whole blood administered by the iv or intra-peritoneal route is the best way to raise the neonate's blood immunoglobulin concentrations. adult donor plasma contains approximately 2.5 to 3.5 g of immunoglobulin/dl, so administration of a volume equivalent to 10% of bw or a dose of 20 to 40 ml/kg has been recommended for the treatment of large animal neonates. if plasma is used instead of colostrum, administration of vitamins a, d, and e also may be beneficial. if colostrum and plasma are unavailable or cost-prohibitive, "closing" the gut as quickly as possible with milk, maintaining high standards of hygiene, and possibly administering prophylactic antibiotics offer the greatest prospects for preventing infectious disease. vaccination of the neonate or the administration of antitoxin hyperimmune serum should not be considered protective but may be of value. prevention. prevention of fpt should be based on the establishment of an adequate colostrum program managing the previously mentioned factors that affect production, quality, and absorption of maternal colostrum components in lambs, goat kids, and fawns. ensuring colostral quality is best done through good nutrition, health care, and vaccination of dam (see chapters 2 and 19) . administration of vaccines 6 weeks before parturition, followed in 2 weeks with a booster, provides the highest quantity of protective immunoglobulin in the colostrum. antepartum leakage is rarely the problem in small ruminants that it is in horses and cattle. however, in a flock or herd environment, still-pregnant dams may steal babies from other sheep or goats. to prevent such theft and the resultant loss of colostrum by the "adopted" neonate, owners may choose to keep pregnant animals separate from those that have already delivered. if complete separation is not possible, the dam and her offspring should be allowed to bond with each other in a private pen ("jug" or "crate") for at least 24 hours before being placed back with the flock. clipping excessive wool or mohair from around the perineal area and udder before lambing or kidding, expressing the teats to ensure they are not plugged, and having extra colostrum available when pregnant females are placed in jugs or crates are other good preventive measures. etiology and pathogenesis. uncomplicated diarrhea in lambs, goat kids, and fawns may be caused by infectious agents such as viruses, bacteria, and protozoa. in goat kids and elk calves, metabolic causes of diarrhea have been described. 49, 50 group b and a rotavirus, enterotoxigenic e. coli k99, cryptosporidium parvum, and other cryptosporidium spp. have been commonly identified as causal agents of diarrhea in small ruminant neonates. [51] [52] [53] [54] with recent advances in diagnostics and metagenomics of the enteric environment of large animals, novel viruses have been identified as potential causal agents of diarrhea in lambs and goat kids. adenovirus, astrovirus, calicivirus, coronavirus, and picornavirus have been identified in feces of diarrheic lambs and goat kids 55 ; however, their role in the pathogenesis of neonatal diarrhea is still uncertain. these organisms differ from the agents of complicated diarrhea in that they do not invade beyond the gut wall or result in systemic toxemia (see chapter 5) . additional causes of diarrhea reported in goat kids and elk include lactose intolerance and hypernatremia, respectively. 49, 50 less frequently, bacteria such as c. perfringens, clostridium difficile, and attaching and effacing e. coli have been associated with complicated diarrhea in small ruminant neonates. 54, 56 the net result of such an infection is that a large volume of water and electrolytes are lost into the bowel due to malabsorptive, hypersecretory, or hyperosmolar processes. if enough fluid and electrolytes are lost, dehydration and metabolic acidosis arise, inducing systemic clinical signs of depression and weakness in association with diarrhea. in goats, this clinical entity is one component of the floppy kid syndrome. clinical signs. profuse, watery, yellowish-green to brown diarrhea without fever is the hallmark clinical sign. with severe dehydration and acidosis, affected lambs, kids, and fawns become weak and dull and lack appetite. [50] [51] [52] excessive salivation and loss of suckle reflex have also been reported in affected lambs and kids. 51, 52 mucous membranes become tacky, and skin tenting times are prolonged. shock signs may develop. physical assessment often must take the place of clinicopathologic analysis in affected neonates. mild, nonclinically complicated diarrhea is characterized by profuse diarrhea with minimal systemic signs. the affected animal is bright and alert, with minimal skin tenting, and can stand and eat readily, with a strong suckle reflex. it is less than 5% dehydrated, with a blood ph of 7.35 to 7.50, and bicarbonate deficit is minimal. moderate uncomplicated diarrhea is characterized by profuse diarrhea in a dull but responsive animal. skin tenting is prolonged, but eye luster is normal. the affected animal is able to stand and eat but eats slowly and has a weak suckle reflex. the head typically is held down. it is 5 to 7% dehydrated, with a blood ph of 7.10 to 7.25 and a bicarbonate deficit of 5 to 8 meq/l. severe uncomplicated diarrhea is characterized by profuse diarrhea. the affected animal is dull and minimally responsive, with a very long skin tent time and dull, sunken eyes. it can stand only with assistance and prefers to stay in sternal recumbency with its head up. the animal eats very slowly, if at all, and has a minimal suckle reflex. it is 8 to 10% dehydrated, with a blood ph of 6.90 to 7.10 and a bicarbonate deficit of 10 meq/l. very severe uncomplicated diarrhea is characterized by profuse diarrhea and profound weakness. the animal's skin remains tented for more than 1 minute, and its eyes are very sunken and dull. it is nonresponsive with no suckle response. it is unable to maintain sternal recumbency, lying on its side instead. the animal is 10 to 12% dehydrated, with a blood ph of 6.8 to 7.0 and a bicarbonate deficiency of 15 to 20 meq/l. epidemiology. morbidity and mortality of uncomplicated diarrhea in small ruminants and fawns vary depending on the cause. reports of rotaviral diarrhea in newborn lambs indicate morbidity rates between 50% and 100% and mortality rates between 0 and 10% 51,52 ; however, one study reported a 50% case fatality rate in lambs affected with types b and a rotavirus diarrhea. 52 another study reported mortality rates between 10% and 30% in lambs and kids affected with c. parvum diarrhea. 57 most of infectious agents associated with uncomplicated neonatal diarrhea in small ruminants are shed by adult animals and older lambs/kids around stressful events such as lambing/kidding and extreme weather conditions. one study reported that pregnant does shed 7 to 10 times more oocysts during the 3 weeks around kidding compared with other time periods. 58 additionally, poor husbandry/hygiene of lambing/kidding sheds, fecal soiling, flock size (. 200 animals), lambing/kidding season (winter/spring), and the presence of c. perfringens type a in feces have been suggested as potential risk factors for uncomplicated diarrhea in small ruminant neonates. [58] [59] [60] clinical pathology. the leukogram should be normal or show abnormalities compatible with stress. serum biochemical or blood gas analysis may reveal evidence of intestinal malabsorption, electrolyte loss, metabolic acidosis (hypoglycemia, hyponatremia, hypochloremia, hyperkalemia, low bicarbonate, and increased anion gap), and dehydration (hyperalbuminemia and increased blood urea nitrogen [bun] and creatinine). in contrast with the common leukogram and biochemical abnormalities found in calves, lambs, and goat kids with uncomplicated diarrhea, elk calves with diarrhea develop leukocytosis, hyperchloremia, and hypernatremia (serum na . 153 meq/l). 50 additionally, increased anion gap, bun, creatinine, and albumin concentrations have been reported in affected elk calves. 50 a presumptive diagnosis may be based on the characteristic history and clinical signs. response to conservative treatment also is supportive of this diagnosis. identification of the specific causative agent is less important than proper treatment of affected animals; however, feces or intestinal contents from affected animals can be submitted for electron microscopy, reverse-transcription polymerase chain reaction (pcr), and cell culture immunofluorescent assays to identify viruses. [51] [52] [53] additionally, intestinal tissue can be submitted for ihc for rotavirus and c. parvum. 53, 57 feces of affected animals can also be submitted for enzyme-linked immunosorbent assay (elisa), ziehl-neelsen staining technique, light or fluorescence microscopy, sugar flotation, and auramine or fluorescent antibody staining for the diagnosis of c. parvum infection. 60 fecal culture to determine a bacterial cause is recommended. treatment. the immediate goals of treatment are rehydration, replacement of lost electrolytes, and restoration of acid-base balance as these are usually the leading causes of death in affected neonates. less immediate goals are provision of nutrition and replacement of ongoing losses. the aggressiveness of treatment is dictated by the severity of the condition, as well as economic considerations. 61 1. rehydration: calculate the percent dehydration and use to calculate fluid requirements for a 24-hour period. example: 10% dehydration in a 3-kg lamb: dehydration: 0.1 3 3 kg 3 1 kg/l 5 0.3 l or 300 ml. maintenance: 100 ml/kg/day 5 0.3 l or 300 ml. total fluids to replace in 24 hours 5 0.6 l or 600 ml fluid loss due to dehydration (300 ml in this case) should be replaced during the first 4 hours and the rest can be replaced in the next 20 hours. 2. replace lost electrolytes: sodium, chloride, and bicarbonate are lost roughly in proportion to extracellular fluid (ecf) in the acute phase of diarrhea (1-2 days) in untreated animals. potassium tends to be increased in this phase due to the presence of metabolic acidosis and care should be taken when selecting fluids containing potassium to treat affected animals at this time. in chronic cases of diarrhea, and especially in cases where the owner/producer has given oral milk replacer or electrolyte supplements/replacements to affected animals before veterinary evaluation, the serum concentration of sodium, potassium, and bicarbonate might be variable or increased. special care should be taken in these cases when selecting fluids to treat affected animals as the risk of causing hypernatremia is higher. 61 in cases of diarrhea in elk calves, hypernatremia is common, and fluids should be selected accordingly. 50 in the majority of cases, initial replacement of sodium, chloride, and bicarbonate with fluids containing proper composition is recommended. 61 example: assessment suggests a bicarbonate deficit of 16 meq bicarbonate in a 3-kg, comatose lamb with prolonged skin tenting (0.6 is the multiplier for ecf in a neonate): 0.6 3 (16 meq) 3 3 kg 5 29 meq bicarbonate. commercial iv 8.4% sodium bicarbonate solutions contain 1 meq of bicarbonate per milliliter and could be added directly to iv fluids in severely dehydrated and acidotic animals. 61 therefore, the immediate goal is to provide 300 ml of fluid and 29 meq of bicarbonate to this lamb in a formulation that resembles normal ecf. fluids can be given by various routes. selection of route of administration of fluids depends on degree of dehydration, presence or not of a strong suckle reflex, and degree of depression. neonates with advanced degrees of dehydration, depression, and absence of suckle reflex will benefit from iv fluid therapy. in contrast, neonates with mild dehydration and active suckle reflex can be effectively treated with oral electrolytes 61 ; however, if oral fluids have not produced an improvement within 2 to 4 hours, iv treatment should be strongly considered. other routes such as subcutaneous, intra-peritoneal, and intra-osseous can also be used for fluid administration to neonates. • advantages: oral fluids are inexpensive (nonsterile) and easy to give. they are less likely to cause fatal arrhythmias or neurologic disease than iv fluids. • disadvantages: an animal receives a maximum of its gastric volume (5% of bw), and good gastric motility is required. oral fluids may not be well absorbed by a damaged gut. absorption also is slow. intravenous • advantage: this method allows rapid correction of all deficits, even in moribund animals. • disadvantages: it is expensive (sterile), requires venous access, and can rapidly lead to overcorrection. subcutaneous • advantages: this method does not require venous access or good gut motility. • disadvantages: it is expensive (sterile), and the fluids may not be well absorbed in very dehydrated animals. absorption is not as quick as by iv administration. animals should be given only hypotonic or isotonic fluids. intra-peritoneal • advantages: this method does not require venous access or gut motility. fluids are absorbed quickly by this route. • disadvantages: it is expensive (sterile) and can cause peritonitis. isotonic fluids are best used in this route. only a limited volume can be given. many commercial oral electrolyte solutions for neonatal ruminants are available; however, not all of them fulfill the requirements to adequately replace fluids and electrolytes in neonatal ruminants with diarrhea. oral electrolyte solutions must contain enough sodium , provide agents that increase absorption of water (glycine, glucose, and acetate), provide an alkalinizing agent (bicarbonate, propionate, acetate, and citrate; acetate has demonstrated best results), and an energy source (glucose). 61 the amount of carbohydrates might vary and is usually higher in "high-energy" solutions specifically used for severely affected neonates that are not eating and develop negative energy balance. less carbohydrate is needed in less severely affected animals because they are usually eating some and are less likely to have severe negative energy balance. fluids to be avoided include medicated milk replacers and unbuffered saline solutions. iv treatment should be provided with a sterile commercial product. such preparations typically contain 25 to 30 meq/l of base. additional sodium bicarbonate solution or sterile powder can be added to fluid therapy based on the bicarbonate deficit (1 meq/ml of 8.4% solution and 12 meq of bicarbonate/g of powder, respectively). the bicarbonate deficit should be over the first 4 hours. after deficits are replaced, the following continued treatments and adjuncts may be considered: 1. continued administration of fluids (oral rather than iv, if possible) to replace ongoing losses: • oral electrolytes at a volume equal to 5% of the bw per feeding can be given; the number of feedings can be increased from two (normal) to three to six per day. • iv fluids can be continued at twice the maintenance fluid rate until appetite is restored. • more bicarbonate may be necessary. 2. consideration of addition of milk to the treatment regimen: • milk or milk replacers should be added to the therapy of neonates with diarrhea. they provide nutrition to the affected neonate, preventing negative energy balance and promoting intestinal healing. • care should be taken to not mix oral electrolyte solutions with milk or milk replacers in the same container as the concentration of sodium and overall osmolarity of the solution can dramatically increase, leading to hypernatremia or other metabolic abnormalities. • milk or milk replacers should be given in small volumes (,20% of total requirements) but at a higher frequency (every 3-6 hours) to avoid overloading the abomasum and intestine of affected animals. lambs fed milk lose less weight with scours. • free water helps prevent hypernatremia. • milk is a good potassium source (see chapter 3). elk deer calves. elk deer calves commonly develop diarrhea with hypernatremia (serum na . 153 meq/l) compared with other large animal neonates, where hyponatremia is more common. 50 therefore, administration of oral electrolyte solutions designed for other ruminants (calves, lambs, and kids) should be avoided in these animals. a dilution (1:2 or 1:4) of commercially available bovine calf electrolyte solutions to reduce sodium content is recommended for the treatment of elk calf diarrhea. 50 the use of lactated ringer's solution, which has a low sodium concentration in addition to a very low reduction rate of serum sodium (, 1.7 meq/l/hour) has been advocated in the fluid therapy of hypernatremic elk calves with diarrhea. 50 additional therapy. dextrose (2.5-5%) solutions can be added to the fluid therapy of hypoglycemic animals. the use of nonsteroidal antiinflammatory drugs (nsaids) in neonatal ruminants with diarrhea is controversial due to the risk of renal damage and abomasal ulceration; however, in cases of diarrhea complicated by septicemia or endotoxemia, nsaids should be used to reduce the effects of systemic inflammation. flunixin meglumine at a dose of 1.1 to 2.2 mg/kg is the only nsaid approved for food animal use. similarly, the use of oral or systemic antibiotics in cases of uncomplicated diarrhea is controversial due to its potential effect on the intestinal microbiota and development of bacterial resistance; however, their use is warranted in the presence of septicemia or endotoxemia in addition to diarrhea. in these cases, b-lactams such as oral amoxicillin or systemic ceftiofur are usually good choices. the effect of mucosal protectants and probiotics in cases of diarrhea is unknown in small ruminant neonates, and their use is left to practitioners based on their own experiences (see appendix 1) . prevention. prevention of uncomplicated diarrhea in small ruminant neonates is based primarily on the timely feeding of adequate amounts of good quality maternal colostrum or colostrum replacer (see "failure of passive transfer" section). vaccination of dams with antigens of common infectious agents associated with uncomplicated neonatal diarrhea before parturition has demonstrated to be effective increasing colostrum immunity and prevention of diarrhea in lambs. 62 maintenance of adequate husbandry and hygiene conditions in lambing/kidding sheds or barns is necessary to reduce neonatal exposure to infectious agents normally shed in feces of dams during parturition such as rotavirus and c. parvum. ruling out infectious causes of depression and weakness is difficult, and clinicians often do well to assume that an infectious disease is contributing to clinical signs when making treatment decisions. however, several noninfectious systemic disturbances also can depress neurologic and muscular function. successful treatment often requires identification and correction of each of these disturbances. among the more common abnormalities leading to depression in neonates are hypoxemia, metabolic or respiratory acidosis, hypothermia, hyperthermia, hypoglycemia, dehydration, azotemia, and some electrolyte imbalances. hypothermia and hyperthermia can easily be diagnosed by measuring body temperature with a rectal thermometer. hypothermia is far more common and can result from weakness, shock, and environmental stress. cold, windy weather or tube feeding with cold milk replacer or fluids can lead to a rapid drop in core body temperature, especially in neonates that are small or weak or have been inadequately licked off or were rejected by their dams. strong, vigorous neonates usually are protected by heat produced during muscular activity and are able to seek food and shelter. clinical signs appear when the rectal temperature drops to 98° f (36.7° c) or below. protection from wind and cold such as with an individual ewe jug or pen, heat lamps (positioned far enough away so as not to burn the neonate), hot water bottles, blankets, and administration of warm fluids is helpful in treating and preventing hypothermia. shearing the ewe before lambing is of value because it forces the ewe to seek shelter. if this management technique is used, care should be taken to avoid inducing severe hypothermia in the dam. environmental hyperthermia is much less common than fever in neonates. therefore, treatment for infectious diseases in young animals with high temperatures usually is warranted. providing cool shelter with good ventilation, minimizing stressful events, ensuring adequate fluid intake, and shearing the adults are the best defenses against environmental heat stress. hypoglycemia also is easy to diagnose with the aid of an inexpensive, portable glucose meter. lambs and kids typically develop hypoglycemia under the same circumstances as those leading to hypothermia. administering 50 ml/kg of dextrose (approximately 3.5 fl oz/lb, or 5% of bw) in warm milk replacer or 1 ml/kg of 50% dextrose, by either the iv or oral route (diluted to 5% dextrose), should provide ample energy to correct hypoglycemia. iv administration may be necessary if gut motility is absent. follow-up treatment may be necessary if the neonate does not regain its appetite. except during severe conditions, normal lambs and kids should be able to maintain normal body core temperature. they should therefore be examined for an underlying disorder if they exhibit signs of hypothermia or hyperthermia. clinicians and owners should not assume that warming and feeding a cold, weak neonate will always correct the problem. hypoxemia is much more difficult to diagnose. portable blood gas meters for arterial analysis and radiography units for thoracic imaging are available but are still not in common use in small ruminant practice. for those reasons, hypoxemia usually is underdiagnosed. hypoxemia can result from prematurity or dysmaturity, infection, depression or weakness (decreased ventilation), meconium aspiration, bullous emphysema, hernias, and other thoracic fluid or tissue masses. it is likely to be a contributing factor in illness and death in most weak neonates younger than 3 days of age. such animals benefit from the provision of supplemental oxygen, either through a nasal insufflation tube or by oxygen tent. in addition to its direct effect on general wellbeing and behavior/ attitude, hypoxemia at birth leads to poor gut function and subsequent poor colostral absorption. many animals that exhibit fpt and subsequent sepsis had a previous bout of hypoxemia. azotemia, metabolic acidosis, and electrolyte imbalances are difficult to diagnose without clinicopathologic analysis. therefore, these problems are best treated in animals showing signs of dehydration with the administration of a balanced, physiologic electrolyte solution. metabolic acidosis usually is accompanied by either obvious evidence of bicarbonate loss (diarrhea) or severe dehydration. however, neither of these conditions is present with floppy kid syndrome. this descriptive title is applied to muscle weakness, anorexia, and depression in kids observed in the first 2 weeks of life. by its strictest definition, floppy kid syndrome refers to metabolic acidosis with a high anion gap without dehydration or any known cause in young kids that were normal at birth. a variety of disorders and conditions have been proposed as the cause of metabolic acidosis without dehydration, including intestinal fermentation of milk in well-fed kids with subsequent absorption of volatile fatty acids, transient neonatal renal tubular acidosis, and lactic acidosis secondary to toxic impairment of cardiovascular function. overgrowth of c. perfringens type a often is suggested as a source of the toxin. with a high anion gap, a pathologic condition that leads to overproduction of an organic acid is more likely than one that leads to bicarbonate loss. the disease can occur in individual animals or in outbreaks; although parity of the dam and number of offspring have not been associated with this metabolic disturbance, aggressively feeding kids are more likely to suffer from milk fermentation or clostridial overgrowth. an infectious etiology appears to be more likely in herds displaying an increased incidence of this metabolic disturbances as the kidding season progresses. the disease also is reported to be more common in meat goats than in dairy goats. the prevalence can vary tremendously from year to year in a single flock or region. a similar disease has been reported in calves and llama crias, and lambs are likely to be susceptible under the right conditions. because blood gas analysis and exclusion of other diseases often are impractical, the term floppy kid syndrome frequently is used by owners to refer to any kid that is weak and does not have an overt, organ-specific sign (e.g., diarrhea). different pathologic processes are grouped together by their common clinical endpoint (as with "thin ewe syndrome"), and the veterinarian is charged with determining the etiology in a specific flock. most possible causes are found in the previous list of conditions that cause weakness and depression in neonates. among these entities, sepsis and hypoxemia are the most important items and therefore must also be considered possible causes of floppy kid syndrome. treatment and prevention of floppy kid syndrome currently follow the same lines as for treatment and prevention of neonatal sepsis or enteritis. spontaneous recovery of animals with floppy kid syndrome may occur. however, in valuable kids, quick assessment of blood chemistry and base deficits will allow requisite correction of electrolyte and blood ph abnormalities with 1.3% sodium bicarbonate. 63 tissue-invading clostridia are large, straight, gram positive rods that are 3 to 10 mm in length. c. perfringens and c. haemolyticum are smaller bacteria, and clostridium novyi, clostridium chauvoei, and clostridium septicum are larger. the bacteria grow best under anaerobic conditions and produce waste gases. clostridia bear spores, which may be the only viable form in the environment (soil and decomposed organic matter). identification of these spores within bacteria on microscopic examination is useful to identify clostridia, but it is not diagnostic of disease. spores in c. perfringens are central and do not affect the shape, whereas most other species have the spore toward one end and appear slightly club shaped. clostridia cause infectious, noncontagious disease. the bacteria inhabit the intestinal tract and are present in the feces of ruminants. small numbers of organisms in their dormant spore form also may reside in tissues such as liver and skeletal muscle. they can be isolated from soil, where most are thought to have short life spans. soil concentrations are highest in locations recently contaminated with ruminant feces, especially crowded, overused facilities such as feedlots and lambing sheds. environmental contaminations are associated with cool, damp times of the year such as late winter and spring. the concentration of organisms and their toxins found in the feces, gut contents, and internal organs of most adult ruminants usually is small. competition and peristalsis prevent overgrowth in the gut, and aerobic conditions prevent overgrowth in other tissues in live animals. however, rapid overgrowth and tissue invasion ensue after death, making rapid postmortem examination essential to ascertain whether clostridial organisms are responsible for the death. pathogenic clostridial organisms all produce heat-labile protein exotoxins. most make a variety of toxins, and the relative contribution of each toxin to the disease state is not known. c. perfringens is a normal commensal of the intestinal tract of clinically healthy large animals, including cervids; however, the number of bacteria and their toxin production within the intestine usually remain low due to peristalsis and normal homeostasis. 64 c. perfringens is classified into five biotypes (a, b, c, d, and e) based on the production of four major exotoxins, namely alpha (cpa), beta (cpb), epsilon (etx), and iota (itx); however, the production of more than 16 different exotoxins in various combinations has been associated with these bacteria, including perfringolysin o (pfo), enterotoxin (cpe), and beta2 toxin (cpb2). 64 the different biotypes of c. perfringens cause different diseases in relation with the exotoxins they produce. the major effect of the phospholipase/ sphingomyelinase cpa, produced by all c. perfringens biotypes, is cell lysis and hemolysis, and its role on intestinal disease of large animals is not well understood. however, this toxin has been associated with hemolytic disease and hemorrhagic enteritis in large animals; cpb, produced by c. perfringens types b and c, is a trypsinlabile toxin associated with necrotizing enteritis and enterotoxemia in large animal neonates; etx, produced by c. perfringens types d and b, is a trypsin-activated necrotizing toxin associated to vasculitis, edema, and necrosis of the cns and enterotoxemia; and itx, another trypsin-activated necrotizing toxin produced by c. perfringens type e, has also been associated to intestinal disease in small ruminants. 64,65 c. perfringens types c and d are considered the most important types in veterinary medicine as they can cause disease in most farm animals. 66 severe clinical disease due to bacteria sporulation and massive toxin production only occurs when the normal intestinal environment and microbial balance are disrupted in affected individuals. decreased peristalsis and poor ruminal and abomasal function have also been proposed as factors that contribute to disease presentation. weather and handling stresses, feed changes, and an overabundance of high-energy feeds such as milk, bakery products, and cereal grains might promote bacteria overgrowth and exotoxin synthesis and release. additionally, other enteric infections that disrupt the mucosal border may increase systemic absorption of toxins and promote severe disease. c. perfringens type a is a normal inhabitant of the intestinal tract of large animals and is ubiquitous in the environment (soil). one study reported c. perfringens type a as the most common isolate among other clostridia from healthy young lambs. 67 c. perfringens type a has been associated with a fatal hemolytic syndrome in younger lambs and cattle but not goats ("yellow lamb disease"), 66, 68 acute hemorrhagic enteritis and hemolytic enterotoxemia in cattle (hemorrhagic bowel/jejunal syndrome) and goats, 66, 69, 70 and intestinal hemorrhage and splenomegaly in farmed deer. 71, 72 risk factors for infection have not been established; however, high soluble carbohydrate diets and high bcss have been associated with clinical disease. 69, 70, 72 this disease occurs most commonly in lambs 2 to 6 months old. under favorable conditions, the organisms proliferate and cause a corresponding increase in alpha toxin production. the alpha toxin (cpa), in synergy with the beta2 toxin (cpb2), is responsible for hemolytic crisis, vasculitis, and gastrointestinal lesions. the clinical course usually is less than 24 hours. clinical signs. in most cases, sudden death or history of found dead is common. clinical signs observed usually include weakness, depression, fever or hypothermia, icterus, anemia, hemoglobinuria, tachypnea, colic, hemorrhagic diarrhea or absence of feces, and terminal recumbency. 66, 69, [70] [71] [72] adult animals also are susceptible to hemolytic disease and vasculitis caused by c. perfringens type a infection. 66 fatal abomasitis and rumenitis in neonates and juveniles also have been blamed on c. perfringens type a, but the rapid postmortem proliferation of the organism makes substantiation of this claim difficult. 73 morbidity in a flock is lower than for many of the other enteric clostridial diseases, but the mortality rate is very high. diagnosis. the most characteristic clinicopathologic change is neutrophilic leukocytosis with a left shift. other evidence of systemic toxemia (metabolic acidosis, azotemia, and increases in liver and muscle enzymes) also may be seen. laboratory evaluation reveals evidence of intravascular hemolysis. necropsy in sheep, goats, and cervids usually reveals evidence of hemolysis, pallor, jaundice, hemoglobinuria, hyperemic and edematous intestines, splenomegaly, gastrointestinal serosal and mucosal hemorrhage, and multifocal internal petechial hemorrhages. 66, 69, [70] [71] [72] the isolation of c. perfringens type a from necropsied animals is not itself diagnostic. definitive diagnosis can be made based on identification of the alpha toxin and the absence of other toxins by elisas or older, live animal assays. more recently, multiplex pcr techniques are replacing immunodiffusion assays for the identification of a specific toxin-producing gene isolate, typing of bacteria, and demonstration of toxins or toxin genes. 74 gut content and intestinal samples collected from freshly dead animals make the most meaningful samples for diagnosis. 74 treatment. administration of high doses (. 30,000 iu/kg bid) of penicillin and clostridium antitoxin (10-20 ml subcutaneously [sc] or orally [po] ) is the mainstay of treatment, although animals may die acutely before therapies can be instituted. prevention. a conditionally licensed toxoid against the clostridial alpha toxin is available for cattle in the united states. a recent report demonstrated that a new vaccine including recombinant cpa, cpb, and etx was effective at inducing protective antibodies to c. perfringens biotypes in cattle, sheep, and goats. this could be an alternative for the prevention of morbidity and mortality caused by c. perfringens type a. prevention efforts should focus on environmental hygiene and avoiding gut conditions favorable for proliferation of the organism (high content of soluble carbohydrates in the diet). because this type appears to survive better in soil than other types, preventing ingestion of soil may be important in preventing disease. c. perfringens types b and c occur in the soil and the animals' housing environment and can be shed by asymptomatic individuals. the reported geographic range of both diseases is limited (type b to the united kingdom and south africa and type c to the united kingdom, australia, and north america), even though infection with c. perfringens type c appears to occur worldwide. these organisms cause very similar diseases called lamb dysentery and hemorrhagic enterotoxemia, respectively. very young lambs and kids (1-4 days to 2-3 weeks of age) are usually affected due to the presence of trypsin inhibitors in colostrum. 75 older animals may become susceptible as a result of overwhelming infection or trypsin inhibition by some soy and sweet potato products or temporary suppression of pancreatic trypsin production (struck in adult sheep). with both diseases, the beta toxin (cpb) is a required pathophysiologic factor, and inactivation of this toxin after maturation of pancreatic trypsinogen secretion is what commonly limits the susceptible population to neonatal animals. the cytolytic and necrotizing effects of the beta toxin (cpb), in synergy with the beta2 toxin (cpb2), cause necrosis and ulceration of the intestinal mucosa and are translocated into circulation, causing severe toxemia and death. 75 the diseases initially affect lambs and kids younger than 3 days of age, with illness occasionally occurring in older lambs. the incidence of disease in lambs and kids can be around 15 to 30%, with a case fatality rate of 100%. high stocking density in lambing areas, cold weather, single-born lambs, and high milk production of dams have been suggested as potential risk factors for type b and c enterotoxemia. 76 because of management practices in young animals and age-related vulnerability, fecal contamination of teats, hands, and equipment that enter the mouths of the neonates (orogastric tubes and nipples) is a major cause of infection. clinical signs. severely affected animals or those at the beginning of an outbreak usually are found dead. less acutely affected animals expel initially yellow, fluid feces that progressively become brownish and/or hemorrhagic. feces may also contain flecks of blood and show splinting of the abdomen, especially when handled, along with signs of colic and feed refusal. the clinical course usually is short, and the disease is almost always fatal. one study reported acute abdominal pain, hemorrhagic diarrhea, and death within 24 hours of experimental oral inoculation of three goat kids with a field strain of c. perfringens type c. 75 dehydration, anemia, and severe weakness are also common clinical signs in affected animals. terminal convulsions and coma occasionally are noted, especially in outbreaks in the united states. c. perfringens type c in older sheep causes the disease known as "struck." affected animals usually are found dead or with signs of toxemia. specific antemortem signs of gastrointestinal disease are rare. specific antemortem signs of gastrointestinal disease are rare. clinical pathology changes observed in these animals include neutrophilic leukocytosis with a left shift. additional evidence of systemic toxemia (metabolic acidosis, azotemia, and increases in liver and muscle enzymes) also may be seen. necropsy findings. postmortem examination reveals focal hemorrhagic ulcers (up to 2.5 cm in diameter) in the small intestine (mostly in the ileum) with type b infection and diffuse reddening with hemorrhage and necrosis of the abomasum and the entire segments of the intestine with type c infection. type c infections in ruminants can also present with generalized peritonitis, subendocardial and subepicardial hemorrhages, and hemorrhagic lymph nodes. animals that die very rapidly may exhibit minimal or no gross abnormalities of the intestine. a similar syndrome of type c enterotoxemia has been previously reported in a sika deer (cervus nippon). 72 sudden death, severe hemorrhagic gastritis including forestomach and abomasum, and catarrhal enteritis was observed in the affected animal. diagnosis. diagnosis of these diseases is made by identification of characteristic history, clinical signs, postmortem lesions, and positive toxin assays. because the beta toxin is very labile, negative toxin assays are less significant than negative assays for presence of other tissue-invading clostridia. the isolation of c. perfringens type b or c from necropsied animals is not itself diagnostic. immunodiffusion assays or multiplex pcr of intestinal contents for specific isolate and beta toxin (cpb) identification are recommended to obtain final diagnosis (see "diagnosis" in "c. perfringens type a" section). treatment. if the infection is identified early in the disease course, high doses of oral and parenteral penicillin and c. perfringens c and d antitoxin may be of benefit. iv fluids and antiinflammatory agents may be indicated as well. usually, the condition is not recognized early enough, and animals are found dead or dying. prevention. a beta toxoid is available in the united states and other countries. it usually is packaged with an epsilon toxoid. the best protection is achieved by vaccinating pregnant dams twice, with the second dose administered approximately 3 to 4 weeks before lambing or kidding and annual booster. deer does should receive double the dose of sheep as low antibody responses to clostridia have been reported in these animals. 77, 78 vaccination of pregnant dams is directed to increase specific colostrum antibodies to protect neonates. juveniles also should be vaccinated twice or three times at 2 months, 3 months, and 4 months. adults, including males, should receive an annual booster. in the face of an outbreak, the lambing area should be moved to a different place. additionally, vaccination of dams and newborns with a beta toxoid and administration of c. perfringens c and d antitoxin can be carried out in the face of an outbreak to reduce morbidity and mortality. c. perfringens type d produces epsilon toxin (etx), which is responsible for causing type d enterotoxemia in sheep, goats, calves, and deer. 79, 80 other common names for the disease include "overeating disease" or "pulpy kidney disease." the disease has a worldwide distribution and occurs primarily in suckling lambs of 1 to 10 weeks of age, although it has also been reported in weaned lambs up to 10 months of age and adult sheep. the disease is also common in grazing goats and deer. the prevalence of disease has been reported from 1.49 to 3.14%, with a 100% case fatality rate in feedlot lambs. 81 one study on proportional distribution of goatherd mortality in the province of quebec, canada, reported a 17.1% mortality of goats to c. perfringens type d enterotoxemia. 82 the disease is more common in feedlot lambs after they enter the lot. tail docking, castration, and other management interventions are thought to decrease the incidence of this disease by temporarily decreasing appetite. the disease also affects unvaccinated adult sheep, even without any history of stressors or feed changes. sudden changes in the diet are the main predisposing factor in goats. the disease can occur in vaccinated goats, as vaccination has not demonstrated to be completely protective in this species. 83, 84 c. perfringens type d is normally found in the gastrointestinal tract of healthy ruminants, but the acid environment of the abomasum and continuous peristalsis help to keep numbers of bacteria and levels of toxin production low. however, under specific conditions such as overingestion of high-energy feeds (milk, grain, and lush pasture), excess of fermentable starches in the intestine, and intestinal stasis, the organism proliferates rapidly, producing lethal quantities of epsilon toxin. these conditions are usually triggered in well-conditioned, fast-growing animals that are on a highly nutritious diet. the epsilon toxin, once produced, acts locally, causing increasing gut permeability and widespread tissue damage. epsilon toxin and other exotoxins are then absorbed through the intestinal tract into systemic circulation and transported to the brain, lungs, and kidneys, causing increased endothelial permeability, perivascular edema, and generalized necrosis. 79, 83 the characteristic increased vascular permeability and perivascular edema in the kidney and brain are responsible for the name of "pulpy kidney disease" and "focal symmetric encephalomalacia." clinical signs. the course of the disease is usually very short (0.5-12 hours), so sudden or spontaneous death is a common clinical sign across affected small ruminant species. 80,84-86 natural disease caused by c. perfringens type d differs between sheep and goats, possibly because of a difference in relative local and systemic actions of the epsilon toxin, although experimental models have demonstrated that both species develop similar lesions. 84, 87, 88 in sheep, systemic actions of the toxin leads to mostly neurological signs such as dullness, depression, ataxia, trembling, stiff limbs, opisthotonus, convulsions, frothy mouth, and rapid death. in goats, actions of the toxin appear to be more localized to the intestinal tract, causing enterocolitis, colic, diarrhea, dehydration, and occasional neurological signs. 85, 86 necropsy findings. postmortem findings in sheep are characterized by edema of the brain, lungs, and heart in addition to hydropericardium. 89 edema of the kidneys (pulpy kidney lesion) is inconsistent. sheep usually demonstrated minor and inconsistent intestinal changes. 89 other lesions reported in cattle and deer include hemorrhages on the epicardium, thymus, and diaphragm and petechial hemorrhages in the jejunal mucosa. 80, 90 necropsy lesions reported in goats include pseudomembranous enterocolitis with mucosal ulceration, as well as fibrin, blood clots, and watery contents in the bowel lumen. evidence of systemic toxemia, including multifocal petechial and ecchymotic hemorrhage, proteinaceous exudates in body cavities, pulmonary edema, hydropericardium, and cerebral malacia with perivascular cuffing, have also been reported in goats and affected deer. 80, 84, 87, 88, 91 clinical pathology. characteristic clinicopathological changes include pronounced hyperglycemia and glucosuria, which are considered a hallmark of c. perfringens d enterotoxemia. 86 additionally, neutrophilic leukocytosis with a left shift and evidence of systemic toxemia (metabolic acidosis, azotemia, and increases in liver and muscle enzymes) also may be seen. treatment. in general, the course of disease is too acute for the establishment of any treatment. however, as with infections with types b and c, if the disease is identified early in the disease course, high doses of oral and parenteral penicillin in addition to clostridium c and d antitoxin may be of benefit. iv fluids and antiinflammatory agents may be indicated as well. prevention. vaccination of pregnant ewes with two doses of toxoid, with the second dose given 3 to 4 weeks before lambing, and adequate ingestion of colostrum are the best methods of protecting newborn lambs. vaccination of older lambs should occur before exposure to diets rich in carbohydrates (grain-feedlot settings) or lush pastures. in these cases, lambs should be vaccinated twice or three times around 2, 3, and 4 months of age. males and adult females that are not part of the breeding program may be vaccinated annually. vaccination has been shown to protect goats from experimental disease, but clinical evidence suggests that well-vaccinated goats are still susceptible to developing clostridial enteritis. the toxoids may not protect against local action of the toxins in the goat, which appears to play a greater role in their disease than it does in the sheep. 84, 87, 88 more frequent vaccination (every 6 months) in goats is suggested to increase protection. the adjuvant present in some multivalent clostridial vaccines may cause subcutaneous reactions that may lead to abscess formation. in the face of an outbreak, immediate mass administration of c and d antitoxin (200 iu/kg) in addition to vaccination is recommended. 92 nonenteric clostridial infections c. novyi, c. septicum, c. chauvoei, and c. sordelli have been identified as causal agents of severe muscle, liver, and abomasal necrosis in small ruminants and cervid species. 66, [93] [94] [95] these organisms are usually present in the soil and environment and in the gastrointestinal tract and liver of healthy ruminants. 66 pathogenesis is usually facilitated by trauma of affected tissues, local multiplication of the organism, local and systemic damage by exotoxin production, and ultimately death. 66, 96 four types of c. novyi have been described, a, b, c, and d. c. novyi type c is considered nontoxigenic and therefore is not associated with disease. c. novyi type a produces alpha toxin and is associated with wound infections and myonecrosis in cases of "bighead" and "malignant edema." c. novyi type b produces alpha and beta toxins and is associated with infectious necrotic hepatitis or "black disease." 97, 98 the temporal and geographic distributions of black disease resemble those of fascioliasis, with the highest incidence of disease in milder, moister months in many countries. black disease is less common in sheep than in cattle and is rare in goats. 66, 96 c. novyi type d (c. haemolyticum) produces beta toxin and is associated with bacillary hemoglobinuria (red water disease). c. septicum produces alpha toxin and is associated with malignant edema and necrotic abomasitis (braxy). c. chauvoei produces alpha and beta toxins and is associated with severe myonecrosis observed in blackleg and c. sordelli produces a hemolytic toxin associated with myonecrosis in cases of malignant edema and blackleg. 96, 97 pathogenesis. spores of the organism shed in feces of carrier animals contaminate the environment and are ingested with feed/ grass and stored within kupffer cells. 97, 98 liver damage caused by migrating liver fluke larvae (fasciola hepatica, fasciola gigantica, and cysticercus tenuicollis) create perfect ischemic conditions that induce germination of c. novyi type b spores and toxin synthesis and production. 97, 98, 99 the alpha toxin is necrotoxic and causes liver necrosis and diffuse damage of the vascular system. 98 the beta toxin is produced in smaller amounts and contributes to vascular damage and systemic toxemia. infective organisms also may be brought into the liver by the flukes. clinical signs. the course of disease from first illness to death is short and never lasts more than a few hours in sheep. therefore, peracute or sudden death is not uncommon in this species. wellnourished adult sheep between 2 and 4 years are more commonly affected. the disease course is a little longer (1-2 days) in cattle and deer. 66, 95 affected sheep are debilitated, fail to keep up with the flock, and exhibit generalized weakness, sternal recumbency, separation, and anorexia. tachypnea and tachycardia may be seen; high fever (105-107° f) occurs early in the disease. clinical signs observed in cattle, goats, and deer are similar and may include severe depression, anorexia, abdominal distention, colic, ruminal stasis, and lateral recumbency. 66, 94, 95, 99, 100, 101 a report of black disease in a forest reindeer (rangifer tarandus fennicus) described serosanguinous discharge from mucocutaneous orifices (nostrils and anus), periorbital edema, and nystagmus in addition to other clinical signs. 95 necropsy findings. necropsy might be difficult due to rapid autolysis of tissues in affected animals. severe venous congestion usually darkens the underside of the skin of affected animals, giving this disease its common name of "black disease." fluid in the pericardial sac, pleural space, and peritoneal cavity is usually present. 66 endocardial and epicardial hemorrhages are a common finding. the liver is swollen and congested and on its diaphragmatic surface presents pale foci of coagulation necrosis; however, solid organs such as liver and kidneys could be in an advanced state of autolysis. characteristic lesions of black disease in the liver are single or multiple yellow to white areas (1-2 cm in diameter) of necrosis surrounded by a bright hyperemic zone. 102 a recent report of black disease in a reindeer described moderate amounts of dark red thoracic and pericardial fluid, edema of the lungs and upper respiratory tract, swollen spleen, and several well-circumscribed areas of black discoloration in the liver. 95 diagnosis. the most characteristic clinicopathological change is neutrophilic leukocytosis with a left shift. additional evidence of systemic toxemia (metabolic acidosis, azotemia, and increases in liver and muscle enzymes) also may be seen; however, diagnosis of black disease is based on characteristic history (endemic liver fluke areas), clinical signs, and postmortem findings and testing. an impression smear of the margins of the liver might reveal large numbers of gram positive rods, but this is not definitively diagnostic. anaerobic culture of c. novyi from typical liver lesions, in addition to demonstration of the alpha/beta toxins from peritoneal fluid or liver (fresh-refrigerated), through elisa or pcr is required to establish final diagnosis. 98, 100 the use of fluorescent antibody and ihc for the identification of c. novyi on liver impression smear samples or other liver (formalin-fixed) samples have also been described. 95, 100 treatment and prevention. treatment is rarely possible because of the fulminant clinical course of the disease; however, if treatment is attempted, high doses of penicillin g sodium (20,000-40,000 iu/kg) iv every 6 hours or oxytetracycline 10 mg/kg iv every 12 hours should be initiated. supportive care, including iv fluids, nutritional support, and stress reduction, may be beneficial. in the face of an outbreak, vaccination of the whole herd/flock should be initiated immediately. efforts to control fluke infestation constitute the most effective approach to prevention of this disease. administration of multivalent clostridial vaccines containing c. novyi is highly effective. animals should be vaccinated every 6 months starting around 2 to 3 months of age and before parturition as protective immunity is short lived. in flocks at high risk for developing this disorder, a booster vaccine given 1 month before expected fluke exposure may provide additional protection. 99, 100 deer should be vaccinated in the same fashion as sheep but double the vaccine dose for sheep should be used for these animals as they do not develop a strong antibody response to commercially available multivalent vaccines. 77, 78 efforts to eliminate the organism from soil and environment are usually unrewarding but carcasses of animals dying from the disease should be burned, deeply buried, or removed from the premises. pathogenesis. c. novyi type d (c. haemolyticum) is the etiologic agent associated with red water disease. c. haemolyticum is similar to other clostridial species in its life cycle and appears to thrive on alkaline soils and pastures with standing water. the disease tends to be seasonal occurring at times of high larval fluke migration. similar to c. novyi b, c. haemolyticum colonizes the livers of healthy animals and proliferates after liver damage, including damage caused by migrating flukes (f. hepatica, fascioloides magna, dicrocoelium dendriticum, and c. tenuicollis), liver abscessation (fusobacterium necrophorum or trueperella pyogenes), or damage incurred during liver biopsy. 100, 103 under ischemic conditions of the liver, spores of c. haemolyticum germinate and produce high amounts of beta toxin. the beta toxin causes localized hepatic necrosis and after reaching circulation induces severe intravascular hemolysis and damage of the capillary endothelium. 103 intravascular hemolysis leads to rapid anemia and death due to anoxia. the disease is seen worldwide and is more commonly reported in sheep than in goats. bacillary hemoglobinuria has been reported in a free-ranging elk calf (cervus elaphus roosevelti) found dead in the southwest of the state of washington, united states. 104 clinical signs. bacillary hemoglobinuria usually affects wellnourished animals older than 1 year of age. 105, 106 in most cases, the disease is per-acute and sudden dead or found dead is the only sign. 103 in cases where signs are recognized antemortem, affected animals appear weak, depressed, and febrile (104-106° f); blood or blood-tinged froth may be present in the nostrils; rectal bleeding and bloody feces may be present; and severe hemoglobinuria (dark red, port wine-colored urine) is usually observed. 105, 106 blood appears thin and watery and mucous membranes are pale and icteric. heart and respiratory rates are high and become much higher with any sort of effort or stress. other terminal signs include bloat and the presence of blood in the nostrils, mouth, vagina, and rectum. death occurs within hours to a few days after onset of clinical signs. 100 necropsy findings. gross lesions include jaundice of mucous membranes and tissues and subcutaneous petechial/ecchymotic hemorrhages, edema, and emphysema. marked autolysis of internal organs might prevent identification of typical lesions. dark red urine is present in the bladder. 102 lymph nodes and spleen are congested and hemorrhagic. hemorrhagic abomasitis and enteritis might occur, as well as the presence of hemoglobin-stained transudate in pleural and peritoneal cavities and pericardial sac. pulmonary edema is common. the pathognomonic lesion is the ischemic hepatic infarcts ranging from 5 to 30 cm in diameter with a hyperemic interface with healthy liver tissue. 100, 102 diagnosis. clinicopathological abnormalities usually include anemia, leukocytosis with mature neutrophilia, and degenerative left shift (immature forms of neutrophils and toxic changes) often is present. 106, 107 serum biochemical evaluation may reveal increased levels of liver enzymes such as sorbitol dehydrogenase, ggt, aspartate aminotransferase, and increased indirect total serum bilirubin. [105] [106] [107] presumptive diagnosis can be made on history, clinical sigs, clinicopathological abnormalities, and postmortem findings; however, similar to black disease, final diagnosis should be based on anaerobic culture of c. novyi from typical liver lesions in addition to demonstration of the beta toxins from peritoneal fluid or liver (fresh-refrigerated) through elisa or pcr techniques. 98, 100, 104, 106 the use of fluorescent antibody and ihc for the identification of c. novyi on liver impression smears or other liver (formalin-fixed) samples has also been described. 95, 100 more recently, a pcr assay for the detection of c. novyi type d in cattle has been reported. 107 treatment and prevention. treatment is rarely possible because of the fulminant clinical course of the disease; however, if treatment is attempted, high doses of penicillin g sodium (20,000-40,000 iu/kg) iv every 6 hours or oxytetracycline 10 mg/kg iv every 12 hours should be initiated. supportive therapy should include the administration of iv fluids, blood transfusions, and antiinflammatory agents. efforts to control liver flukes and prevent other causes of liver damage are most important. administration of multivalent clostridial vaccines containing c. novyi is highly effective. animals should be vaccinated every 6 months starting around 2 to 3 months of age and before parturition as protective immunity is short lived. in flocks at high risk for developing this disorder, a booster vaccine given 1 month before expected fluke exposure may provide additional protection. 100 deer should be vaccinated in the same fashion as sheep, but double the vaccine dose for sheep should be used as these animals as they do not develop a strong antibody response to commercially available multivalent vaccines. 77, 78 efforts to eliminate the organism from soil and environment are usually unrewarding but carcasses of animals dying from the disease should be burned, deeply buried, or removed from the premises. pathogenesis and clinical signs. fecal and soil contamination of wounds received during fighting (head-butting) or dehorning (disbudding) leads to proliferation of c. novyi type a in damaged head and neck tissues. 100 accumulation of secreted toxins leads to swelling, edema, serohemorrhagic exudates, and local tissue necrosis. wounds appear and smell gangrenous. systemic toxemia may affect internal organs, leading to the death of the animal. c. sordelli causes identical disease. diagnosis. laboratory analysis may reveal an increase in enzymes of muscle or liver origin as well as neutrophilic leukocytosis with many immature and toxic neutrophils. postmortem findings include local necrosis around the injury site. diagnosis usually is made by characteristic clinical signs and lesions. treatment. wound management (disinfection, debridement) and administration of high doses of penicillin g sodium (20,000-40,000 iu/kg) iv every 6 hours are important treatment considerations. prevention. ram management may aid in the prevention of head-butting wounds. vaccination with multivalent clostridial toxoids starting around weaning time (3-6 months of age) and with annual boosters also may be helpful. in flocks with a high prevalence of this disorder, a booster vaccine given to rams 1 month before the breeding season and to ewes/does before parturition may provide additional protection. 100 pathogenesis. c. septicum is the most important agent in the pathogenesis of malignant edema and braxy. in the case of malignant edema, other tissue-invasive clostridia (c. chauvoei, c. sordelli, and c. perfringens a) have also been associated with this disease, and mixed infections are common. the pathogenesis of infection is often similar to that seen with bighead and blackleg: soil or fecal clostridial invasion of a contaminated wound. in sheep and goats, this disease has been reported following lambing/kidding, after shearing of tail docking. 100 c. septicum can also invade the abomasal lining of lambs, causing severe hemorrhagic, necrotic abomasitis known as braxy. 108 activation of dormant bacteria in previously damaged tissue (myositis/abomasitis) similar to that seen in clostridial necrotic hepatitis also occurs. 108 in both cases (malignant edema and braxy), bacterial toxins precipitate local tissue necrosis and systemic toxemia. the alpha, beta, gamma, and delta toxins produced by c. septicum are lecithinase, deoxyribonuclease, hyaluronidase, and hemolysin, respectively. commonly affected sites of malignant edema include castration, dehorning, and injection sites; the umbilicus; and the postpartum uterus. 100 factors that promote braxy have not been identified, although it usually affects weaned and yearling lambs in the winter after ingestion of frozen feedstuffs implicated as initial causes of abomasitis. 100, 108 both forms of the disease have worldwide distribution and are described more in sheep than in goats. 100, 108 clinical signs. malignant edema is characterized by local lesion (wound) or regional pain characterized by swelling and edema that progressively becomes tense and dark (skin). high fever, signs of shock/toxemia, and frothy exudation of the wound are usually present. evidence of subcutaneous gas production is less common in this infection than in blackleg. uterine infection may cause a fetid vaginal discharge. death occurs within hours to a few days after onset of clinical signs. 100 braxy usually causes death before any abnormalities are noted. on rare occasions, signs of sudden onset of illness with high fever, abdominal distention, depression, colic, and recumbency may be seen before death. 100 diagnosis. characteristic clinicopathologic changes include neutrophilic leukocytosis with a left shift. a decrease in wbc and rbc counts also is possible because of the leukocidal and hemolytic effects of the toxins. additional evidence of systemic toxemia (metabolic acidosis, azotemia, and increases in liver and muscle enzymes) also may be seen. examination of a gram-stained smear from the edematous swelling(s) or wound swabs could give an early diagnosis. one study reported the successful use of a pcr assay for the identification of bacteria associated with malignant edema in cattle, sheep, and other ruminants. 109 postmortem changes with malignant edema include dark red, swollen muscle filled with hemorrhagic, proteinaceous exudate and little or no gas. with braxy, the abomasal wall is hemorrhagic and necrotic. both diseases are associated with rapid postmortem decomposition of the carcass. treatment and prevention. wound management and the rapid administration of high doses of penicillin (penicillin g sodium at 20,000-40,000 iu/kg iv every 6 hours) are important in treating malignant edema. local treatment consists of surgical incision of the affected area to provide drainage and irrigation with peroxide. injection of penicillin directly into or in the periphery of the lesions may help. ancillary treatments such as iv fluids, antiinflammatory agents (e.g., flunixin meglumine, 2 mg/kg iv), and nutritional support may be necessary. maintenance of good hygiene during procedures such as lambing, tail docking, shearing, castration, obstetric manipulation, and administering injections is helpful in preventing malignant edema. multivalent clostridial toxoids may provide some protection and should be given annually to animals at risk for the disorder. 110 pathogenesis. several species of clostridial organisms can cause myonecrosis in small ruminants. 93, 111, 112 the disease is acute to per-acute, has a short course of duration, and is usually fatal. c. chauvoei, c. septicum, and c. sordelli are commonly involved with clostridial myonecrosis in ruminants. [111] [112] [113] blackleg can be enzootic in some areas or farms because of increased bacterial contamination and occurs more commonly in the warm months of the year. [113] [114] [115] animals between 4 months and 3 years of age can be affected. 111, 112 c. chauvoei is the most important cause of blackleg. c. sordelli tends to be involved in the myonecrosis of older feedlot animals. 112 these organisms are found in the soil and can gain access to muscles after translocation from the gastrointestinal tract and liver into systemic circulation. additionally, direct inoculation of the organisms by penetrating wounds or intramuscular injections has been suggested. local tissue trauma, wounds, unsanitary procedures (i.e., shearing, tail docking, and castration), umbilical infection (neonates), or vaginal trauma from lambing can create perfect conditions for the germination of clostridial spores inducing rapid toxin synthesis and production. 113 in some cases, bacterial proliferation appears to occur in a site distant from the original wound (i.e., fetal infections after shearing of a ewe and myocardial necrosis in cattle and sheep). 113 bacterial toxins cause severe local tissue necrosis, systemic toxemia, and ultimately death. as with braxy, several other strains of tissue-invasive clostridia can cause this disease and mixed infections are common. clinical signs. clostridial myonecrosis usually progresses rapidly and sudden death or history of found dead is not uncommon. [111] [112] [113] clinical signs in animals who are still alive include local to regional painful, edematous swelling most commonly in the limbs or trunk muscles. skin of the affected area can become discolored and crepitus; however, in affected sheep, subcutaneous edema and gaseous crepitation are uncommon and cannot be felt before death. 111 other signs might include stiff gait, lameness, fever, and signs of shock. in cases where the infection occurred through a wound, there is extensive local damage and malodorous serosanguinous fluid discharge. c. chauvoei also causes uterine infection and severe gangrenous mastitis in postparturient ewes. 111, 113 in these cases, uterine and mammary infections may cause fetid vaginal and mammary discharge, respectively. death often occurs within 12 to 36 hours after onset of clinical signs. necropsy findings. rapid tissue autolysis is not uncommon in animals that succumb to clostridial myonecrosis. bloodstained fluid and froth can be observed discharging from nostrils and anus. in small ruminants and especially sheep, affected muscle areas are more localized and deeper, brown to black discoloration is present, the subcutaneous edema is not as severe, and, although there is gas present, is not in such large amounts as in cattle. in cases of infection from skin wounds, the area demonstrates subcutaneous edema, swelling, and underlying muscle discoloration. in cases of infection through the urogenital tract, typical lesions are found in the perineal area, vagina, uterus, and fetus. lung congestion, fibrinohemorrhagic pleuritis, pericarditis, myocardial damage, and bloat are also common findings. 111, 112 diagnosis. it is rarely possible to obtain samples for clinicopathological analysis due to the per-acute course of the disease. if samples can be obtained, common findings include neutrophilic leukocytosis with a left shift. a decrease in wbc and rbc counts also is possible because of the leukocidal and hemolytic effects of the toxins. additional evidence of systemic toxemia-metabolic acidosis, azotemia, and increases in liver and muscle enzymesalso may be seen. presumptive diagnosis can be made from history, characteristic clinical signs, and gross pathology findings; however, aspirates or tissue specimens from affected muscles for direct smear examination, fluorescent antibody testing, or anaerobic culture are required for definitive diagnosis. 111, 112 a multiplex pcr is available for identification of pathogenic clostridia on fluid and tissue samples. 109 treatment and prevention. aggressive antibiotic therapy (e.g., penicillin g sodium or potassium penicillin at 20,000-40,000 iu/kg iv every 6 hours), in combination with surgical debridement of affected tissues (fasciotomy), and supportive care (nutritional support, iv fluids, and antiinflammatory agents) are important within the treatment plan for clostridial myositis. prognosis for treatment of all types of clostridial myositis cases is usually guarded to poor and depends on the duration and extension of the lesions. maintaining excellent hygiene during invasive procedures such as castration, obstetric manipulation, shearing, tail docking, and administering injections is helpful in preventing blackleg. multivalent clostridial toxoids may provide some protection and should be given to all animals starting at weaning time, before parturition, and annually. 114, 115 both tetanus and botulism are important diseases in small ruminant medicine. these two diseases are covered elsewhere in this book (see chapters 5, 11, 13, 19, and 20) . older animals are generally more resistant to sepsis than neonates because they have larger amounts of circulating antibodies. however, this resistance can be overwhelmed by aggressive bacteria, or loss of immune function can allow invasion by opportunistic bacteria. malnutrition, parasitism, transport, overcrowding, other diseases, extreme weather conditions, and other stressors are the major causes of immune suppression. sepsis may produce peracute, acute, or chronic disease signs. peracute signs include fever, injected mucous membranes (including the sclera), tachycardia, tachypnea, dyspnea, swollen joints, lameness, splinting of the abdomen, weakness, depression, anorexia, recumbency, seizures, coma, and sudden death. acute signs are similar, except that they persist for a longer period and therefore are more likely to be noticed. chronic signs usually result from the partial clearance of infection after an acute episode, which may be clinical or inapparent. pathogenesis. gram negative bacteria and their toxins gain access to the blood from a site of proliferation or destruction. the most important toxin is endotoxin, a group of lipopolysaccharide molecules that reside within the wall of the bacteria. bacteria or endotoxins incite a systemic inflammatory response, chiefly through activation of host macrophages and stimulation of host cytokine release. these cytokines cause inflammation, produce leukocyte recruitment, increase capillary permeability, induce fever through stimulation of the hypothalamus, and have regional or diffuse vasomotor effects. because the ruminant gut has a plentiful population of gram negative bacteria, it is implicated as the source of most cases of gram negative sepsis. grain overload causes a die-off of the normal gram negative ruminal flora, ulcerative enteric disease allows invasion of bacteria or absorption of their toxins, and ingestion of pathogens provides a suitable place for proliferation and route for invasion of the body. gram negative sepsis caused by opportunistic organisms is best recognized in immunocompromised neonates but also can be seen in stressed or immunocompromised animals of all ages. e. coli is commonly found in fecal material, klebsiella pneumoniae is found in feces and wood products, f. necrophorum lives in the gastrointestinal tract and in soil and invades through compromised gastric mucosa or foot-rot lesions, and pseudomonas aeruginosa is commonly found in water and wash solutions. primary pathogens are most common in adults. although some coliform bacteria may fit into this category, by far, the most important genus is salmonella. sources of salmonella infection are numerous and include carrier animals of the same species, cattle, rodents, birds, other animals, environmental contamination, and possibly feedstuffs. only one serotype of salmonella is specifically adapted to sheep (salmonella abortus ovis), and it is not found in north america. no strain is known to be host-adapted to goats or cervids. therefore, all infections in sheep, goats, and cervids have the potential to spread to and from other species, including humans. serotypes of salmonella that have caused important infections in sheep or goats include salmonella typhimurium, salmonella dublin, and salmonella montevideo. most of these infections lead to bacteremia with mild systemic signs, followed by abortion. s. dublin and s. typhimurium tend to cause more illness in adults because of fibrinonecrotic enteritis. clinical signs. affected animals can exhibit anything, from mild depression with a low-grade fever to shock. common signs include fever, tachycardia, tachypnea, depression with slow or absent eating and drinking, weakness or recumbency, and injection or cyanosis of mucous membranes. organ-specific signs may betray the source or at least the primary location of the infection. fetid discharge may be seen with metritis or abortion; dyspnea and abnormal lung sounds may be seen with pulmonary infection; and bloat, ruminal atony, abdominal distention, and diarrhea may be seen with gastrointestinal infections. diagnosis. the most common abnormality identified on a cbc with peracute gram negative sepsis is panleukopenia. over the course of several days, this condition may resolve, first through an increase in immature neutrophils and later through an increase in mature neutrophils and restoration of lymphocyte counts. very immature cells, severe toxic changes, and persistence of neutropenia suggest a poor prognosis. serum biochemical changes often reflect the severity of the condition. the greater the evidence of shock or tissue damage, the worse the prognosis. metabolic acidosis with a large anion gap and azotemia suggest advanced disease. necropsy findings include diffuse evidence of inflammation, including pulmonary congestion, and polyserositis with body cavity exudates. hemorrhagic pneumonia or fibrinonecrotic enteritis may be seen and reflect the source of bacterial invasion. in all cases, diagnosis is best confirmed by bacteriologic culture of body tissues or fluids. in the live animal, culture of blood, feces, or tracheal fluid yields the best results. when several animals are infected, environmental samples (including feed, water, and bedding) should be tested for the presence of the bacteria. bacteriologic culture of aborted fetuses or placentas frequently yields heavy growth of the organism. prevention. maintaining overall good health and hygiene is the best means of preventing gram negative sepsis. antiendotoxin bacterins are available for cattle in the united states, but their use in small ruminants has been too limited to assess their efficacy. during a flock outbreak, the use of autogenous bacterin may help prevent the spread of disease on a farm. actinobacillus seminis is a gram negative bacillus or coccobacillus that affects primarily the male and female reproductive tracts. infection causes posthitis, epididymitis, and orchitis in rams and metritis and abortion in ewes. other sites of infection, including rare occurrences of chronic sepsis, also are possible. serologic tests are much more useful for identifying infected flocks than infected individuals within flocks. definitive diagnosis depends on bacteriologic culture of the organism and differentiation of it from brucella ovis. the bacillus is common in sheep in some parts of the world but is uncommon in north american sheep and goats. t. pyogenes is best known as an abscess-forming bacterium because of the thick pus formed in response to infection by it and the fibrinous response it elicits. it occasionally also causes sepsis. its association with chronic sepsis lends credence to the belief that trueperella is often a secondary invader that colonizes tissues damaged by another bacterium (see chapter 10) . bacillus anthracis is a large, gram positive, anaerobic bacillus that causes anthrax. it forms spores under aerobic conditions (such as on culture plates) but rarely does so when oxygen tensions are low, as in carcasses. the organism affects most mammals, with herbivores being most susceptible. it is usually carried from one area to another by shedding or dying animals and also can multiply in alkaline, nitrogenous soils. periods of heat and intermittent flooding promote overgrowth of the organism. b. anthracis spores may be inhaled or ingested; in rare cases, the bacillus itself may be spread by biting flies. after local replication, the organism gains access to the blood, where it multiples readily. large numbers of the organisms colonize the spleen. b. anthracis secretes a holotoxin made of edema factor), protective antigen, and lethal factor. this toxin impairs phagocytosis, increases capillary permeability, and inhibits clotting. splenic engorgement, generalized edema, circulatory shock, and bleeding diathesis are the most common lesions and signs of anthrax. generalized infection should be considered uniformly fatal. death may occur before or within hours of initial recognition that the animal is sick. prophylactic antibiotic treatment of healthy animals (oxytetracycline 10 mg/kg iv sid) may decrease spread and mortality during outbreaks. the disease is reportable in many areas. local forms of anthrax also occur, most commonly after transmission through a skin wound or fly bite. local heat, pain, swelling, and necrosis are seen first, and the generalized syndrome often follows. bacterial organisms are rarely identified before important treatment decisions must be made. therefore, treatment should follow general principles and have a wide spectrum of efficacy. antimicrobial drugs are the cornerstone of treatment. in meat-or milkproducing animals, the veterinarian must be careful to use drugs within label directions or have a rational plan for extra-label drug use. the issue of extra-label drug use is especially important in small ruminants and cervids because very few pharmaceutical products have been licensed for them in north america. unless a specific organism is suspected (clostridiosis or anaplasmosis), a single antibiotic or combination of antimicrobial drugs to provide a broad spectrum of coverage should be selected. penicillins, macrolides, tetracyclines, and cephalosporins all provide effective coverage against gram positive pathogens. the newer third-generation cephalosporins are effective against many systemic and enteric gram negative pathogens. the gram negative pathogens of the respiratory tract are often sensitive to other classes of antibiotics. macrolides and tetracyclines also are effective against mycoplasma species and rickettsial organisms. nsaids are almost always beneficial in severe infectious conditions because of their antiinflammatory, antipyretic, and antiendotoxic effects. they are likely to be more effective than corticosteroids because they provide benefits without suppressing the immune response. all such drug use should be considered extralabel and administered accordingly with appropriate withdrawal times established. specific antisera are available for some of the clostridial diseases and may be beneficial if given before widespread tissue necrosis has occurred. severely compromised animals should be treated with fluids for shock (see chapter 3). the most common zoonotic disease risk posed by exposure to small ruminants is orf, also known as contagious ecthyma in animals (see chapter 10) . the disease is caused by an epitheliotropic poxvirus and is transmitted to humans by direct contact with infected animals. skin trauma is a significant risk factor for transmission in both humans and animals. in humans, erythematous macules or papules appear at the site of infection 2 to 3 days following exposure. the infection is generally self-limiting in immunocompetent individuals with complete healing occurring within 8 weeks. brucella melitensis. apart from contagious ecthyma, the greatest risk of zoonotic disease from small ruminants is due to pathogens typically found in the reproductive tract that are transmitted to humans through contact with aborted fetuses, the placenta, or birthing fluids or through the consumption of raw or improperly pasteurized dairy products. b. melitensis is more common in goats than sheep (see chapter 8) . swine, cattle, and other ruminants are common hosts. infection in animals usually causes inapparent mammary infection and abortions; infection in humans is characterized by undulant fever, myalgia, and fatigue. coxiella burnetii. c. burnetii is a rickettsial organism that is an important cause of abortion in sheep and goats (see chapter 8) . wildlife and farm-raised deer may serve as reservoir hosts for infection in other ruminants and humans. 116 infection is a documented cause of reproductive failure in farmed deer and prolonged shedding of the organism is an important source of environmental contamination. 117 in addition to abortion, newly infected sheep and goats occasionally have mild, transient fevers. c. burnetii is far more important as the cause of q fever in humans, who become infected after inhaling particles, handling contaminated animals, or coming into contact with contaminated body fluids (uterine fluid, milk) from infected animals. infection in humans may be asymptomatic, present with flu-like symptoms, or, in the chronic form, present as granulomatous hepatitis, osteomyelitis, or bacterial endocarditis. chlamydophila spp. chlamydophila abortus (previously chlamydia psittaci) is an obligate intracellular parasite and the cause of enzootic abortion of small ruminants (see chapter 8) . chlamydophila pecorum may cause polyarthritis and keratoconjunctivitis (see chapter 14) in sheep and goats. transmission between animals and to humans most commonly occurs through direct contact with infected tissues or materials. infection in humans results in an acute febrile syndrome or respiratory symptoms. chlamydial diseases are more commonly reported in sheep than in goats. chlamydial diseases are suspected to cause disease in other species, including deer. recent serologic evaluation of wild ungulates identified multiple species of deer with antibodies against several chlamydial species. 118 the clinical significance of serological infection in these species remains undetermined. francisella tularensis. f. tularensis is more common in sheep than goats. the organism has many hosts, of which the most important are wild rabbits and rodents. it can contaminate water sources. transmission to sheep is usually through biting arthropods that have previously fed on an infected wild mammal. acute or chronic sepsis may be seen, with more widespread and severe disease occurring in sheep with poor immune function. at necropsy, the disease is characterized by military foci of necrosis in the liver, and less commonly in the lymph nodes, spleen, and lungs. most cases in humans result in acute onset of flu-like symptoms a few days after exposure. l. interrogans. pathogenesis. leptospira spp. are spirochete bacteria that live in moist environments. their survival time outside of hosts is usually short, so their most important reservoirs are the kidneys of infected animals, especially rodents. infected animals shed the organisms through urine and most other body fluids. organisms enter new hosts through mucous membranes and skin breaks and cause bacteremia. signs of sepsis range from inapparent to severe, with more severe signs predominating in neonates. intravascular hemolysis may result. in animals that survive the acute stage, infection may localize in sites such as the kidneys, eyes, and fetoplacental unit. abortion may occur a month or more after acute signs first become evident while renal shedding may occur for several months. leptospirosis is zoonotic. in most cases, infections in humans are asymptomatic and selflimiting. however, in approximately 10% of cases, severe, and potentially fatal, systemic disease may develop, including jaundice, renal failure, and pulmonary hemorrhage. clinical signs acute leptospirosis causes signs of sepsis, including fever, depression, dyspnea, exercise intolerance, weakness, and death (see chapter 12) . additionally, many affected animals show signs of intravascular hemolysis such as anemia, icterus, and hemoglobinuria. diagnosis evidence of intravascular hemolysis such as anemia, hyperbilirubinemia, hemoglobinuria, and hemoglobinemia is suggestive of this disease. in chronic infection, non-specific inflammatory changes and azotemia may be seen. animals dying in the acute hemolytic stage are likely to have dark, discolored urine, bladder, and kidneys. spirochetes can be identified on dark-field microscopy of fresh urine or plasma from infected animals and may be cultured with special techniques. in animals with less severe infection, a rise in antibody titers can be used to support a diagnosis of leptospirosis. prevention numerous vaccines are available for sheep. because protection is serotype specific, it is important to vaccinate against common serotypes in the area. leptospira pomona is the most consistent isolate from sheep and goats; leptospira hardjobovis is the predominate serovar in deer. 119 vaccination immunity is thought to be short lived; boosters should be given at least twice a year in endemic areas. vaccination of deer against serovars hardjobovis and pomona has been associated with decreased urine shedding and increased growth rate in young animals. 120 pathogenesis. l. monocytogenes causes disease with similar frequency in sheep and goats (see chapter 13) . the organism is a common soil and fecal contaminant. it also proliferates in silage that is not properly acidified and in rotting, woody debris. risk of exposure depends on the feed and environment of the animals. environmental and fecal contamination is a more common source than silage in small ruminants overall because most sheep and goats throughout the world are not fed silage. infection in humans almost always results from ingestion of contaminated food products or unpasteurized milk. clinical signs. nervous system dysfunction and abortion are the most common manifestations of the disease. animals with the brainstem form of the disease display signs reflective of cranial nerve dysfunction, including drooped ears or eyelids, decreased facial sensation, and deviated nasal septum. a head tilt and circling may be present; in advanced cases of the disease, the animal is recumbent. clinical signs are mainly unilateral, occasionally bilateral, according to the nerve nuclei affected. diagnosis. antemortem diagnosis of listeriosis is difficult. a presumptive diagnosis is made based on history, clinical signs, and potential response to treatment. histopathologic identification of microabscesses in the brainstem and culture of the organism from affected tissues can be used to confirm the diagnosis. pathogenesis. p. multocida is a small, gram negative, bipolar, ovoid rod that inhabits the pharynx of healthy ruminants. it can survive in soil and water for varying amounts of time after contamination with ruminant nasal secretions. healthy ruminants shed p. multocida much more frequently than mannheimia haemolytica. disease occurs when bacteria colonize the lower respiratory tract or enter the blood. risk factors for pulmonary and systemic infection include viral or mycoplasmal respiratory diseases, temperature extremes, respiratory tract irritants, transport, overcrowding, changes to higher-energy feeds, and handling stress. these factors are thought to both increase bacterial replication in the airway and suppress mechanisms to clear the infection. pasteurellosis is a major problem in feedlot sheep but less common in small breeding or hobby flocks. pasteurellosis also is a significant disease in certain wild small ruminants such as bighorn sheep. direct spread of the organism between animals occurs with nasal contact, and indirect spread occurs after contact with infected nasal secretions. the organism persists in the environment for longer periods during warm, moist weather. p. multocida produces a polysaccharide capsule that inhibits phagocytosis and an endotoxin that contributes to clinical signs. the major disease caused by p. multocida is pneumonia (see chapter 7). however, pasteurella spp. also are capable of entering the blood to cause septicemia in young lambs and hemorrhagic septicemia in adults. occasionally, focal infections such as septic arthritis and mastitis are found. clinical signs. clinical signs of pneumonic and septicemic pasteurellosis include severe depression, bilateral purulent nasal discharge, coughing, diarrhea, anorexia, high fever, and edema of the head, neck, and brisket. the disease course can be short with septicemic pasteurellosis and is usually more insidious with p. multocida pneumonia. pasteurella mastitis is characterized by the bluebag condition or gangrene of the udder. diagnosis. inflammatory changes in the leukogram and hyperfibrinogenemia are the most frequent abnormalities. with severe disease and in the septicemic form, immature neutrophils may predominate over mature cells. inflammation of the intestine and abomasum also may be seen. hemorrhage and fibrin are usually absent or less prominent than in pneumonia caused by m. haemolytica. samples for bacteriologic culture are usually obtained postmortem. blood or tracheal fluid may be obtained before death if the value of the animal warrants it. m. haemolytica is a gram negative rod that is a common commensal inhabitant of the tonsils of young animals. disease is much more frequently described in sheep than in goats and occurs when the organism gains access to the lower respiratory tract. clinical signs and diagnosis. the most common syndrome is enzootic pneumonia, which is seen in young lambs and their dams (see chapter 7) . hemorrhagic bronchopneumonia is the major lesion and respiratory signs predominate. gangrenous mastitis (bluebag) is seen in some of the dams, presumably after they have been nursed by infected offspring. factors that promote respiratory disease, including viral infections, airborne irritants, high stocking density, and stress, are thought to promote invasion of the lower airway by these bacteria. b. trehalosi is a gram negative rod that is a commensal inhabitant of the upper respiratory tract (see chapter 7) . disease is much more frequently described in sheep than in goats and occurs when the organism gains access to the lung or blood. replication occurs in the lung and systemic toxemia or bacteremia resulting in septicemic pasteurellosis. septicemic pasteurellosis is a significant cause of mortality in young lambs and in some farms is the leading cause of death in the age group. clinical signs. septicemic pasteurellosis occurs most commonly in weaned lambs, often following some form of stress such as transport, marketing, or weaning itself. the course of the disease is relatively rapid, and animals may be found dead within 6 hours without showing premonitory clinical signs. when observed, clinical signs include depression, recumbency, and signs of toxemia. diagnosis. septicemic pasteurellosis should be suspected when presented with a dead, recently weaned, sheep with a recent history of stress. diagnosis is best confirmed by typical lesions at necropsy and culture of the organism from bodily tissues. demonstration of b. trehalosi in nasal swabs is of limited value due to the high prevalence of upper respiratory tract colonization in healthy lambs. at necropsy, there may be no evidence of pneumonia, but blood-stained foam can be found in the upper respiratory tract. ulceration of the pharynx and esophagus is commonly present as is subcutaneous hemorrhage of the neck and thorax. prevention. treatment is difficult due to the rapid course of disease. efforts should be made to minimize stressors, particularly during and following weaning, and to manage management factors that may contribute to the disease. vaccination with pasteurella bacterins is rarely effective at controlling natural outbreaks of disease. pathophysiology. abscess-forming bacteria are usually able to survive phagocytosis and thereby avoid destruction by cells of the immune system. alternatively, they invoke such an inflammatory response that the host body "walls off" the entire region with fibrous tissue. abscesses may occur locally, frequently after a wound infection, or at numerous or distant sites from the point of infection. for abscesses to occur at the latter sites, the organism must travel either by way of the blood or within leukocytes. disease characterized by multifocal or internal abscesses usually results from a low-grade, transient event of bacteremia. the best known and most important abscess-forming bacterium in small ruminants is corynebacterium pseudotuberculosis, the gram positive, facultative anaerobic coccobacillus that causes caseous lymphadenitis. infection is usually maintained in a flock by infected animals that spread the organism to others through purulent material draining from open abscesses. the organism is very hardy, so infection can occur through direct contact or indirect contact with contaminated common instruments and facilities. infection is usually introduced into a flock through acquisition of an infected animal, although it also can occur when a naive flock is moved into a contaminated area. horses, cattle, and humans also are minor hosts. infection is thought to occur after ingestion, inhalation, or wound contamination. except for lower respiratory tract invasion, a surface break is thought to be necessary. contaminated shears, tail-docking knives, and emasculators readily spread the organisms through a flock. abscesses can form at the site of invasion or more commonly at the site of the local lymph node. clinical signs. clinical signs of external abscesses include surface swellings and draining lesions. drainage may be intermittent and usually consists of thick, yellow-white purulent material. internal abscesses are more difficult to diagnose. thoracic masses may cause inspiratory dyspnea or occlude venous return to the heart. abdominal lesions may cause tenesmus, stranguria, and occasionally colic. the most common sign of internal abscesses is weight loss with or without intermittent fever. common external sites include the submandibular or retromandibular space and the preinguinal, prefemoral, and supramammary lymph nodes. head and neck lesions are more common in goats, whereas sheep have a more even distribution of cranial and caudal lesions, presumably as a result of shearing wounds. external infections rarely cause clinical illness beyond the draining abscess, although some degree of cachexia may be present. diagnosis. diagnosis is often made by the characteristic lesions with their thick, nonmalodorous pus. bacteriologic culture provides a definitive diagnosis, which may be important for flock management. serologic tests have been developed to identify carrier animals and may be useful if the manager wishes to eliminate infection from the flock. treatment. treatment is often unrewarding: antibiotic sensitivity profiles do not reflect the degree of protection afforded the organisms within the abscesses. long-term treatment with antibiotics and drainage of any compromising masses may lead to some degree of resolution, but internal abscesses are likely to persist. prevention. prevention through the use of vaccines has been attempted. vaccines appear to reduce the severity of the disease but do not completely prevent infection. moreover, live attenuated bacterins lead to de facto infection of all vaccinated animals and therefore should not be used in naïve flocks. 121 other abscess-forming bacteria are most important as differential diagnoses for caseous lymphadenitis. t. pyogenes is another wound contaminant that affects focal areas or regional external lymph nodes. it also commonly colonizes damaged internal tissues such as postpneumonic lungs, postacidotic livers, and damaged feet and heart valves. it is thought to be ubiquitous and poorly invasive in ruminants and therefore does not have the same flock significance as c. pseudotuberculosis. flocks with outbreaks of this infection often have suboptimal management. f. necrophorum causes similar disease and often coinfects with t. pyogenes. it is generally more necrotizing and leads to greater systemic signs of acute illness, including death. f. necrophorum also produces fetid pus, whereas t. pyogenes usually does not. rhodococcus equi is a rare cause of pulmonary abscesses in sheep. numerous small, coalescent, nodular skin abscesses may result from pseudomonas pseudomallei infection (melioidosis). infection usually occurs after the sheep or goat is bitten by an insect that previously fed on an infected rodent. this organism is found in many subtropical regions, including the caribbean, but is not reported in north america. f. necrophorum causes or is associated with a variety of diseases in sheep and is likely to cause many similar diseases in goats. it is best known as a cause of foot rot and hepatic abscesses and appears to be important in lip-leg ulceration. it is an enteric gram negative anaerobe and as such can cause gram negative sepsis after entrance of the bacteria or its toxins into the circulation. f. necrophorum has a poor ability to invade healthy tissue. however, it readily colonizes regions damaged by trauma, persistent moisture, and infection. in addition to endotoxin, the bacterium produces leukocidal and cytolytic toxins that form zones of necrosis around bacterial colonies. this tissue necrosis and the foul-smelling waste gases produced by the bacteria are characteristic of necrobacillosis, or f. necrophorum infection. clinical signs include necrotic, fetid lesions, usually of the mouth or feet, that can cause ingestion or lameness problems. efforts to maintain good hygiene are helpful in preventing fecal contamination. additionally, preventing trauma to foot and mouth tissues through good surface choices and proper pasture drainage is important. pathogenesis. yersinia spp. are gram negative bacteria. yersinia enterocolitica and yersinia pseudotuberculosis both have many mammalian and avian hosts, including humans, and cause clostridial enteritis-like disease in goats. rodent and bird hosts may be important reservoir populations for infections in domestic animals. kids younger than 6 months develop enteritis, bacteremia, and diarrhea that is watery but not bloody. severe toxemia and sudden death can occur. older kids and flocks with chronic exposure tend to have less severe acute disease. instead, chronic diarrhea and weight loss are seen, usually in association with gut wall and abdominal abscesses. sheep, deer, and wild ungulates are rarely affected. clinical signs. signs of enteritis or sepsis predominate in acute disease, whereas signs of wasting are more common in chronic disease. diagnosis. evidence of acute or chronic inflammation is provided by blood work. characteristic necropsy lesions include numerous microabscesses in the gut wall and mesenteric lymph nodes, as well as other evidence of enteritis or sepsis. culture of lesions and demonstration of a rising antibody titer are diagnostic. prevention. avoiding exposure to sources and maintaining overall flock health are helpful in preventing losses due to yersiniosis. pathogenesis. mycobacteria are small, aerobic, straight or curved pleomorphic rods with thick lipid cell walls. they can be stained with acid-fast stains and are usually gram positive. the bacteria live within infected animals of many mammalian species and survive for several years in warm, moist environments. infection occurs after ingestion or inhalation. an identifying characteristic of the mechanism of infection by mycobacteria is the bacteria's ability to survive within macrophages by preventing fusion of phagosomes and lysosomes. the organisms are carried to local lymphatic vessels or lymph nodes, where they form granulomas. as they enlarge, granulomas may develop necrotic or mineralized centers surrounded by macrophages and giant cells. disease can be local, regional, or generalized, depending on the distance the organism is carried from the original site of infection. granulomatous pneumonia, enterocolitis, and lymphadenitis are the most common local and regional forms of the disease. organisms from ruptured granulomas may be spread in contaminated respiratory secretions and feces. mycobacterial infections of all types are uncommon in north american sheep, goats, and cervids, and these species are considered to be relatively resistant to infection. mycobacterium bovis is the most common organism associated with ovine tuberculosis in other countries (see chapter 7), but mycobacterium avium is more common in the united states. the most common mycobacterial infection is johne's disease (paratuberculosis) caused by the etiologic agent m. avium subsp. paratuberculosis (see chapter 5) . mycobacterium tuberculosis is rare in the united states. mycobacterial infections are reportable in most parts of the united states. some debate is ongoing about human susceptibility to m. avium subsp. paratuberculosis; the other organisms are known to be pathogenic in people. clinical signs. the most common clinical sign is emaciation. diarrhea may be seen terminally in both tuberculosis and paratuberculosis. the disease is insidious, with signs becoming more apparent over several weeks to months. respiratory signs may be seen, especially with infection by m. bovis or m. avium subsp. diagnosis. reports of clinicopathologic abnormalities are rare. hypoalbuminemia and hypoproteinemia are likely to be common with chronic enterocolitis caused by either tuberculosis or paratuberculosis. the most common necropsy lesions seen in tuberculosis are nodular lesions of the lung, liver, lymph nodes, spleen, and intestines. histologic evaluation reveals the nodules to be granulomas with giant cells and acid-fast organisms. frequently, the center of the lesion is necrotic and mineralized. intestinal lesions appear to be more common than pulmonary lesions in goats. the lesions of paratuberculosis are centered around the ileocecocolic junction and the adjacent mesentery. the regions may appear normal or be notably thickened. thickening of bowel or nodular infiltrates of lung or liver may be detected antemortem using imaging modalities, such as ultrasonography or computed tomography. postmortem diagnosis is made by identifying characteristic lesions and culturing the organisms. antemortem diagnosis of tuberculosis is best achieved by observing the reaction to intradermal injection of tuberculin with or without comparative injection of purified protein derivatives of m. bovis and m. avium subsp. paratuberculosis. all tuberculosis testing should be done in accordance with local regulations. antemortem diagnosis of johne's disease can be achieved by fecal culture of the organism, but this test takes several weeks to months to complete and is far less reliable in sheep or goats than cattle, with a sensitivity as low as 0.08. serologic tests (e.g., elisa) appear to be sensitive and specific for johne's disease in animals demonstrating clinical disease rather than preclinical infection. serologic detection of clinical johne's disease in cervids has been shown to be highly sensitive and specific while the sensitivity of fecal culture is low in both sheep and goats. the recommended organism detection method in both species is fecal pcr. 122 fecal or milk pcr can be used on pooled samples for flock identification and to type the organism. prevention. tuberculosis should not be endemic in flocks in the united states because positive animals are quarantined or destroyed. preventing exposure to wild ruminants and other possible sources is crucial. except in goat flocks raised for the production of milk that is to be sold unpasteurized, testing is uncommon, so animals are usually not identified until they develop overt disease. paratuberculosis is much more common and may be maintained in flocks by carrier animals. no effective treatment is available for either disease, nor should any be encouraged because efforts should be concentrated on eliminating infection from the flock or herd. vaccination of sheep is used extensively in australia to control paratuberculosis. prolonged vaccination has been shown to decrease fecal shedding in infected animals over time. 123 pathogenesis. mycoplasma spp. are very small, simple bacteria that parasitize cells of higher species. they are common inhabitants of mucous membranes and can have either a commensal or pathogenic relationship with the host. transmission between animals is most likely through direct or indirect contact with body fluids from infected animals, inhalation of respiratory droplets, and arthropod vectors. common sites for superficial infection include the ocular membranes, lung, mammary gland, and female reproductive tract. the organisms can also enter the blood and cause septicemia, abortion, pleuritis, and polyarthritis. flare-ups often occur during times of crowding and during parturition, when neonates can spread the organisms from the mother's mouth to her udder and in turn become infected by ingesting contaminated milk. the most important mycoplasma species in the united states are mycoplasma conjunctivae, mycoplasma capricolum, and the less pathogenic mycoplasma ovipneumoniae. they are most commonly associated with keratoconjunctivitis, acute or chronic sepsis, and pneumonia, respectively. m. conjunctivae and c. abortus are the most common causes of pinkeye in north american small ruminants. mycoplasma spp. are thought to inhibit tracheal ciliary function and thus may have a role similar to viruses in "shipping fever pneumonia" in facilitating lower respiratory tract invasion by primary bacterial pathogens. many of the major pathogenic serotypes found in other countries (some of which cause severe pleuropneumonia without the participation of another bacteria), including mycoplasma mycoides subsp. mycoides, mycoplasma mycoides subsp. capri, mycoplasma agalactiae, and strain f38, are not found in or have been eradicated from north america clinical signs. keratoconjunctivitis, mastitis, exudative vulvovaginitis, fever, cough, dyspnea, exercise intolerance, abortion, lameness, swollen joints, neonatal death, and depression may all be seen with mycoplasma infections. diagnosis. no specific clinical pathologic findings occur with these diseases. mycoplasma infection should be suspected in sheep and goats with severe exudative pleuropneumonia in some parts of the world. mycoplasma can be identified by bacteriologic culture or staining of exudates. examiners must take care in interpreting positive cultures from body surfaces because nonpathogenic mycoplasma are common. prevention. vaccines against mycoplasmal infections are available in some parts of the world, but not in the united states. providing fly control, preventing stress and overcrowding, and isolating sick animals from healthy ones may help prevent the spread of disease. anaplasma ovis, mycoplasma ovis, and babesia spp. a. ovis and m. ovis are small bacteria that lack cells walls and parasitize erythrocytes. these and similar organisms have undergone recent reclassification following molecular analysis. other species of hemotropic mycoplasmas may affect sheep and cervids. 116 the organisms are spread from animal to animal by insect or mechanical vectors. known arthropod vectors for a. ovis include ticks and horseflies; other biting flies may be more important with m. ovis infection. hypodermic needles and equipment used for tail-docking, castrating, or disbudding animals may be important in iatrogenic transmission. after being introduced into a naive host, the organisms proliferate, and the number of red cells infected increases rapidly until an effective immune response begins 1 to 2 weeks later. a similar proliferation of organisms may occur in chronically infected animals after temporary immune suppression. the humoral and cellular immune responses against a. ovis lead to opsonization of parasitized erythrocytes and their removal by cells of the reticuloendothelial system; m. ovis infection is thought to cause more intravascular hemolysis. the result in both cases is hemolytic anemia. 117 the protozoon parasites babesia ovis and babesia motasi have similar life cycles and cause similar diseases, but they have been eradicated and are reportable in the united states. babesia spp. affecting small ruminants are generally less pathogenic than are their bovine counterparts. animals surviving acute hemolytic crisis reduce the parasites to low numbers but rarely clear the infection completely; they serve as sources of infection for other animals. sheep and goats are susceptible to infection by either organism; goats generally appear to be more resistant to the development of severe parasitemia and clinical signs. clinical signs. signs present during hemolytic crises include fever, weakness, pale mucous membranes, and pigmenturia. urine discoloration results from increased amounts of bilirubin in most cases, although hemoglobinuria may be seen in some sheep with m. ovis infection. icterus is usually present only after the acute hemolytic crisis. clinical signs are exacerbated during times of stress, and infection is often first noted when the animals are moved or handled. chronically infected animals may appear clinically normal, may have recrudescence of infection after stress, or may display signs of ill-thrift such as poor body condition and fleece. babesiosis occasionally causes concurrent central neurologic signs. diagnosis. the major clinical laboratory finding is regenerative anemia with detection of the intraerythrocytic bodies. chronically infected sheep often have high counts of nucleated erythrocytes. because m. ovis consumes glucose, hypoglycemia and metabolic acidosis may be detected, especially in blood samples that are not processed immediately. diagnosis is by identification of the organisms on blood smears. special stains are available to make the organisms more visible. postmortem lesions include pallor or icterus of membranes and splenomegaly. some evidence of vasculitis, including edema or exudates in body tissues or cavities, may be seen with m. ovis infection. treatment. mycoplasma spp. and anaplasma spp. are sensitive to tetracycline antibiotics. babesiosis is more difficult to treat. effective drugs include diminazene, pentamidine, and imidocarb dipropionate. supportive care for all blood parasite infections includes whole blood transfusions, nutritional support, and administration of fluids. prevention. prevention in most cases involves maintaining low levels of parasites rather than eliminating them entirely. this method ensures continual stimulation of the immune response, whereas eradication often leaves the animal susceptible to another bout of acute infection. vector control can also be important in management of the disease. pathogenesis. two organisms belonging to the anaplasmataceae family, ehrlichia ovis and anaplasma phagocytophilum, infect ovine wbcs, causing fever, immune suppression, and some organ damage. a. phagocytophilum is the causative agent of tick borne fever in sheep and granulocytic anaplasmosis in horses, dogs, and humans. the organism is transmitted by ticks (ixodes spp.) and maintained in the environment by asymptomatic carrier animals. the distribution and incidence of disease is seasonal with the life cycle of the tick. the organism infects cells of the granulocytic lineage, leading to severe persistent neutropenia and acute lymphopenia. fever occurs 1 to 2 weeks after infection, lasts as long as 2 weeks, and occasionally relapses. chronic infection is common. spleen, lung, liver, and kidney tissue may show some damage because of immune destruction of infected cells, but organ-specific signs are usually the result of secondary infection. secondary bacterial joint infections in lambs infected with a. phagocytophilum develop debilitating lameness known as tick pyemia. e. ovis causes fever (benign ehrlichiosis) 1 to 2 weeks after infection. because of this organism's predilection for mononuclear cells, the degree of immunosuppression and subsequent importance of this disease are much less than for a. phagocytophilum infection. diagnosis. specific diagnosis is best made by identifying darkly stained bodies at the periphery of granulocytic cells, as well as occasional large bodies deep within the cytoplasm of some cells. stained bodies also can be seen on the periphery of mononuclear cells from a blood smear during the acute febrile stage or in tissues during chronic infection. serologic tests are available for detection of anaplasmosis. the available celisa is incapable of distinguishing species of anaplasma and serologic results must be interpreted appropriately, and the species confirmed by pcr. both infections affect sheep and goats (a. phagocytophilum also affects many other ruminants, including white-tailed deer), but neither has been reported in north america. a recent study demonstrated that sheep are capable of being experimentally infected with a human isolate a. phagocytophilum. interestingly, the sheep did not develop clinical disease. 118 such findings suggest that sheep could serve as asymptomatic carriers and potential reservoirs for humans. a. phagocytophilum is widespread in northwestern europe, including the united kingdom, scandinavia, and india, and e. ovis is found mainly in countries bordering the indian ocean. in spite of documented seropositive status of animals, there have been no reports of sheep or goats naturally infected with a. phagocytophilum in the united states developing clinical disease. treatment and prevention. treatment and prevention efforts should focus on reducing vectors and bacterial counts during vector season. both organisms are susceptible to treatment with tetracycline. people and animals can become infected with trypanosome protozoa. the trypanosomes can complete their developmental cycle only in tsetse flies (glossina species). trypanosomes multiply in blood, tissues, and body fluids of their vertebrate hosts and are transmitted between vertebrate hosts in the saliva of blood-sucking flies as they feed. the trypanosome species that are known to infect goats and sheep include trypanosoma congolense, trypanosoma vivax, trypanosoma brucei subsp. brucei, trypanosoma evansi, and trypanosoma simiae. pathogenesis. after entering through the skin, trypanosomes reach the bloodstream by way of the lymphatic system. the parasites multiply, and the prepatent period lasts for 10 to 14 days after infection. the infection is characterized by periods of parasitemia, followed by the absence of parasites. this pattern of infection occurs because of antigenic variation: trypanosomes vary the antigenic nature of their glycoprotein surface coat to evade the host's immune system. this immune system-evasive maneuver prolongs infection and is responsible for chronic disease. some trypanosomes tend to invade extravascular spaces, such as the ocular aqueous humor and cerebrospinal fluid. the pathogenicity of trypanosomes varies with the different host species. trypanosomes may produce a hemolysin early in the course of the disease that causes anemia in the host. later, increased phagocytic activity results in massive erythrocyte destruction. clinical signs. the clinical signs are variable and non-specific and depend on the speed of onset of anemia and the degree of organ impairment. entire herds may be affected. all aspects of production are impaired-fertility, birth weight, lactation, weaning weight, growth, and survival. trypanosomiasis may predispose the animal to the development of other diseases that mask the underlying trypanosome infection. trypanosomiasis may be acute, subacute, or chronic, with chronic infection occurring most commonly. acute disease often causes abortion. dairy goats may show a sudden drop in milk production. depression, anorexia, and a stiff gait may be present. physical examination reveals tachycardia, tachypnea, and a slight fever. hyperemic mucous membranes and excessive lacrimation may be noted. affected animals often become recumbent and anorexic and die within 1 to 3 weeks of onset of clinical signs. if the animal survives, progression to the subacute phase, characterized by listlessness, weight loss, enlargement of superficial lymph nodes, and a dull, dry hair coat, may occur. in such cases, auscultation findings are similar to those in other forms of acute cardiac disease, as well as pale mucous membranes and a pronounced jugular pulse. the animal may linger for several weeks or months, or the chronic form of the disease may develop. affected animals show ill-thrift: dull and dry hair coat, inelastic skin, lethargy, emaciation, peripheral lymphadenopathy, pale mucous membranes, and exercise and stress intolerance. death may occur many months or even years after infection and usually results from congestive heart failure. subclinical trypanosomiasis causes acute episodes when animals are stressed by inadequate nutrition, increased production demands, or concurrent disease. diagnosis. diagnosis is difficult because the parasitemia is intermittent, clinical signs are non-specific, and infection is not always synonymous with disease. a pcr assay is gaining acceptance as the most sensitive diagnostic modality, but not all infected animals exhibit clinical disease. although a tentative diagnosis of pathologic trypanosomiasis can be made on the basis of history, clinical signs, and the presence of appropriate vectors, a definitive diagnosis requires identification of trypanosomes on a fresh blood smear, a giemsa-stained blood smear, or less commonly, a lymph smear. examination of the buffy coat of centrifuged blood with darkfield phase-contrast spore illumination is the most sensitive direct microscopic method and is useful when parasite numbers are low. pathogenic trypanosomes must be distinguished from more ubiquitous, nonpathogenic species particularly common in cattle, such as trypanosoma theileri. repeated blood sampling in individual animals often is necessary, because as noted, parasitemia is intermittent. the diagnosis is supported by evidence of anemia on a cbc. indirect diagnostic methods include an indirect fluorescent antibody test and the elisa. these tests are less helpful for diagnosis of a single clinical case but are useful in assessment for herd infection. both t. congolense and t. brucei readily infect rats and mice, and detection of these pathogens can be used to diagnose the infection indirectly. treatment. treatment consists of the use of trypanocidal agents and supportive care. animals with acute, subacute, and subclinical disease respond better to treatment than those with chronic disease because of the irreversible damage to hematopoiesis associated with chronic infection. with most trypanocides, the therapeutic index is low and varies with the host species. trypanocide efficacy also varies with the species of trypanosome present; resistance to agents is common. some trypanocides are irritating to the skin and may cause severe inflammation at the injection site. in sheep and goats with t. brucei infection, the trypanocide of choice is diminazene aceturate, which should be used at a higher dosage rate (7 mg/kg given intramuscularly [im] or sc) than that recommended for cattle. protection after trypanocide use usually lasts 2 to 4 months, depending on the season. animals must be rested before and after treatment. supportive care consists of providing fluids, an environment conducive to rest, good nutrition, and possibly blood transfusions. prevention. vector control, stress and nutrition management, and selection of trypanosome-tolerant breeds of sheep and goats all help control or prevent trypanosomiasis. no vaccine is available. animals can be treated with insecticides (pyrethroids) to prevent bites by tsetse flies and other flies. control is accomplished by strategic use of trypanocides during the peak season. continued parasitologic and clinical surveillance is essential to determine the efficacy of control measures. pathogenesis. sarcocystis spp. are protozoon parasites that have a two-host life cycle. sexual reproduction occurs in the bowel of a carnivore (mainly dogs and wild canids) after the carnivore ingests cysts in the muscles of sheep, goats, and cervids. sporocysts are passed in the carnivore's feces and later ingested by a sheep, goat or cervid. the sporocysts hatch in the ruminant gut and invade the vascular endothelium during three phases of asexual reproduction. after the third phase (approximately 8 to 10 weeks after ingestion), merozoites enter the ruminant's muscle tissue and encyst. clinical signs are uncommon but can occur during the stages of reproduction and muscle invasion of the host. n. caninum has a similar life cycle and causes similar disease, except that it appears more likely to cause abortion and affect the central nervous system. clinical signs. most infections are asymptomatic. however, if a large number of sporocysts are ingested, tissue damage may occur during the intestinal, vascular, and muscle stages of the sarcocystis life cycle. fever, lameness or a stiff gait, reluctance to move, and diarrhea may be seen. central neurologic signs (blindness, changes in mentation, and seizures) may occur if the organisms invade the brain or interrupt blood flow to it. abortion can occur as early as 4 weeks after ingestion. with severe chronic infections, emaciation and anorexia are seen. diagnosis. the most characteristic abnormality is an increase in muscle enzyme activity in the blood. anemia is common and may result from extravascular hemolysis. cerebrospinal fluid may show mild mononuclear pleocytosis or may appear normal. on necropsy, muscles may display pale streaks or macroscopic cysts throughout. other evidence of vasculitis includes hemorrhagic serosal surfaces, body cavity fluids, and lymphadenopathy. microscopic or ultrastructural examination of affected tissues should reveal the presence of organisms. specific antibody tests are available and do not cross-react with t. gondii antibodies. blood antibody titers often peak around the onset of clinical signs and should be markedly higher than baseline values. antibody preparations also are available for identification of organisms in tissue preparations. treatment. sheep infected with sarcocystis species can be treated with salinomycin (200 ppm in complete feed), monensin (0.5-1 mg/kg po), or amprolium (25-40 mg/kg po). drugs such as sulfadiazine or trimethoprim (25-44 mg/kg im sid), pyrimethamine (0.5-1 mg/kg po sid), and clindamycin have shown some success in treating neospora infections. these treatments are off-label and thus are governed by regulations regarding extra-label drug use. prevention. preventing contamination of feedstuffs with the feces of infected carnivores and preventing ingestion of raw meat by carnivores are most important, but these measures may not be possible in flocks handled with dogs or those living on range land. anticoccidial drugs appear to decrease the chance of clinical disease. 119 pathogenesis. t. gondii is a protozoon parasite with a life cycle very similar to sarcocystis, except that the definitive host is the cat and that a wider range of mammalian and avian species, including humans, appear to be capable of acting as intermediate hosts. sporocysts are infective a few days after passage in cat feces, and most ruminants are infected by eating feed contaminated with cat feces. people can become infected by ingesting raw meat or milk from infected animals. abortion, stillbirth, and neonatal death are the most common forms of clinical disease in sheep and goats, and toxoplasma should be considered one of the most common causes of perinatal losses in small ruminants (see chapter 8) . abortion usually occurs during the final month of pregnancy. fever, vasculitis-induced disease, and neurologic disease are less common manifestations. clinical signs. beyond abortion, clinical disease is rare in adults and resembles systemic sarcocystosis. clinical signs include fever, dyspnea, depression, and anorexia. neurologic signs are more common than with sarcocystis infection, especially in lambs and kids infected in utero. diagnosis. no specific laboratory abnormalities are associated with toxoplasmosis. nodular lesions similar to sarcocysts may be seen in various tissues, including the brain. aborted or stillborn fetuses may appear normal except for histologic lesions in the brain, liver, or lung, but more commonly fetuses are macerated. the placenta is usually abnormal, with gross and microscopic evidence of necrosis of the cotyledons. microscopic identification of the organism in body tissues is the most common means of diagnosis. serologic tests also are available. treatment and prevention. drugs similar to those used to treat neospora may be effective against toxoplasma. preventing contamination of feeds with cat feces and preventing ingestion of dead animals by cats are the most important ways of stemming the spread of this organism. both methods are likely to be difficult in most flocks. direct spread from one animal to another is rare. clinical signs. bluetongue disease has two different manifestations-reproductive problems (see chapter 8) and acute vasculitis of several organ systems. with vasculitis, a spiked fever often precedes depression, anorexia, and rapid weight loss. leukopenia is present. affected animals may develop edema of the lips, tongue, throat, ears, and brisket. other signs include excessive salivation and hyperemia or cyanosis of the oral mucosa, including the tongue (hence the name bluetongue). affected sheep often produce profuse serous nasal discharge that soon becomes mucopurulent and produces crusts and excoriations around the nose and muzzle. oral lesions progress to petechial hemorrhages, erosions, and ulcers. pulmonary edema is often severe, and pneumonia may develop. skin lesions can progress to localized dermatitis. affected sheep may exhibit stiffness or lameness because of muscular changes and laminitis. cyanosis or hemorrhagic changes of the skin of the coronet can extend into the horny tissue. after recovery, a definite ridge in the horn of the hoof may be present for many months. in severe cases, the hoof sloughs. mortality varies widely. in africa, the virus is much more virulent than in the united states, and mortality ranges from 2 to 30%. the reproductive or teratogenic form of the disease varies greatly with strain, host, and environmental factors. teratogenic effects include abortions, stillbirths, and weak, live "dummy lambs." congenital defects may include hydranencephaly. diagnosis. in parts of the world where the disease is common, the diagnosis is usually based on clinical signs alone. the virus can be isolated from blood, semen, or tissues (spleen and brain from aborted fetuses). viral isolation from blood obtained during the viremic state is the most definitive means of diagnosis. serologic evaluation involves two types of viral antigen groups called p7 and p2. the former is found in all bluetongue viruses, and the latter determines the serotype. sera are commonly tested with complement fixation, agar gel immunodiffusion (agid), or one of several elisa tests. a competitive elisa is considered the best serologic test for detecting group antibodies to bluetongue virus. a direct fluorescent antibody test is available. molecular tests (e.g., pcr) for bluetongue have recently become available and are extremely sensitive and specific. they can be useful for distinguishing serotypes. other clinicopathologic signs that aid in diagnosis include leukopenia during the early febrile stage of the disease and an increase in serum ck corresponding to the latter phase of muscle stiffness and lameness. treatment. treatment is non-specific and consists of nursing care. because of the reluctance of animals to eat, they should be fed a gruel of alfalfa pellets by stomach tube or encouraged to eat soft feeds and green grass. broad-spectrum antimicrobials are often used to treat secondary pneumonia and dermatitis. animals should be kept on soft bedding with good footing. water and shade should be readily available. nsaids are commonly used. prevention. the culicoides vector is difficult to eliminate, so animals should be kept indoors during periods of peak gnat activity (dusk and early evening). owners should attempt to eliminate gnat breeding grounds such as overflowing watering troughs and shallow septic systems and should limit exposure of sheep to gnats with the use of repellent sprays. modified live vaccines based on local strains and serotypes are available in some parts of the world. some cross-protection among serotypes does occur. the vaccine should be administered at least 2 weeks before breeding season to prevent teratogenic effects. vaccinated breeding rams may have a slight risk of decreased fertility. lambs can be vaccinated in the face of an outbreak. pregnant animals cannot be vaccinated with modified live vaccines. sheep that have recovered from an attack of bluetongue are solidly resistant for months to infection by the same viral strain and to some other viral types. active immunity in sheep requires both humoral and cellular immunity. etiology. epizootic hemorrhagic disease virus (ehdv) is an orbivirus belonging to the family reoviridae. the virus is structurally related to bluetongue virus, and the pathogenesis and clinical signs of disease resulting from these two viral infections are very similar. at least seven distinct serotypes of ehdv are recognized, although formal classification of serotypes has yet to be finalized. only two serotypes (ehdv1 and ehdv2) have historically circulated throughout north america, and those serotypes are largely considered to be endemic in almost all areas of the united states, with the exception of the northeast and arid areas of the southwest. however, in 2006, ehdv6 was isolated from surveillance efforts in dead white-tailed deer. 124 since then, ehdv6 has been increasingly identified from both surveillance samples and clinical cases and is also believed to be endemic in several regions. 125 pathogenesis. epizootic hemorrhagic disease (ehd) is a noncontagious disease that is transmitted by the culicoides biting midges. culicoides sonorensis is the primary vector of ehdv in the united states, although other species are also suspected to transmit the disease based on the geographic distribution of clinical cases, although this has yet to be formally shown. due to the vector-borne route of transmission, peak incidence of the disease is closely associated with peak vector population, namely, in the late summer and fall of the year. although capable of infecting a wide range of wild and domestic ruminants, ehdv is largely a pathogen of wild cervids, particularly white-tailed deer. episodes of clinical disease are less common in mule deer, pronghorn antelope, and bighorn sheep and have lower morbidity and mortality. sheep are only rarely infected with the virus and goats appear to be resistant to the virus. cattle are commonly infected based on seroprevalence surveys, but overt clinical disease is uncommon. as a rule, infection in livestock is usually asymptomatic except for periodic epidemics. the last major ehd epidemic in the united states occurred in 2012 and affected a variety of captive and wild ruminant species. 126 in endemic areas, seroprevalence in cervids and other ruminants is high, but clinical disease is not commonly seen. conversely, where seroprevalence is low, introduction of the virus results in widespread infection, where morbidity and mortality can reach 90% and 60%, respectively. following transmission of the virus by biting midges, ehdv replicates in the endothelial cells of the lymphatics surrounding the site of the bite. a primary viremia allows for systemic spread of the virus and secondary replication in lymph nodes throughout the body and the spleen. viremia is important for disease propagation and generally lasts no more than 3 weeks following infection, although the virus can occasionally be isolated from deer infected 50 days previously. antibodies to ehdv are first detected 10 to 14 days following infection but are not always capable of completely neutralizing the infection. thus, it is possible to find both neutralizing antibodies and live virus in the same animal. passive antibodies in fawns can be found up to approximately 4 months of age. as in adults, antibodies in fawns may not protect from infection but generally protect from severe clinical signs. clinical signs. clinical disease in white-tailed deer can be peracute, acute, or chronic. the course of the peracute syndrome of diseaseis relatively short, with death often occurring within 36 hours of infection, with or without the presence of clinical signs. when present, clinical signs include severe edema of the head and neck, swelling of the tongue and conjunctiva, anorexia, fever, weakness, and respiratory distress. hemorrhagic diatheses are not present antemortem but may occur after death. in contrast, in the acute form of the disease, the clinical signs of the peracute form are accompanied with bleeding throughout body tissues (figure 16.1a, b) . ulcers may be evident in the oral cavity and throughout the upper gastrointestinal tract, forestomachs, and abomasum. case fatality rates are high for both the peracute and acute forms. deer that recover after several weeks of illness are said to suffer from the chronic form of the disease. signs of previous illness may include breaks or rings in the hoof horn due to interrupted growth and synthesis leading to lameness, sometimes severe. ulceration and scarring of the rumen and gastrointestinal tract may result in loss of body condition despite a seemingly normal appetite and ample nutrition. widespread evidence of vasculitis may be observed histopathologically. diagnosis. the gold standard for ehdv diagnosis is virus isolation. demonstration of neutralizing antibodies to ehdv reference strains is evidence of previous infection but may be of limited value in endemic areas where seroprevalence levels are expected to be high. also, all potentially suspected serotypes must be used when testing the sample, thereby increasing the time and cost involved with the test. continued research and refinement of molecular techniques, including pcr, are ongoing and are attractive due to the short turnaround times and the potential for high throughput of samples. however, it is important to remember that a positive result using molecular techniques does not equate to the presence of infectious virus, and thus, interpretation of results must be done with caution. control. control of ehd is difficult and relies on a combination of disease surveillance, vector control, and potentially, vaccination. eradication of vector-borne diseases from endemic areas is difficult and time-consuming, and thus, disease control is likely more attainable than strict eradication. vector control is more important in the late fall and summer, when populations are at peak levels and viral transmission is more likely. midge-proofed housing and the treatment of animals with pyrethroid insecticides have been attempted but may be logistically challenging and have yet to have been demonstrated efficacious. vaccine availability in north america is limited, but inactivated autogenous vaccines have been developed from isolates obtained from ill or recently diseased animals. autogenous vaccines are tested for purity but not necessarily for efficacy. vaccine usage must be approved by the u.s. department of agriculture prior to administration. etiology. peste des petits ruminants (ppr) is an acute or peracute, febrile, often fatal disease of ruminants caused by a virus in the family paramyxoviridae and genus morbillivirus. sheep are less susceptible than goats and white-tailed deer. cattle are only subclinically infected, and some wild ungulates, as well as camels, appear to suffer the occasional epizootic. the virus (pprv) is serologically related to the virus that causes rinderpest. geographically, the virus is found throughout northern africa, the middle east, and adjacent regions of asia, with possible movement into southern africa and europe noted. pathogenesis. the main route of infection is respiratory, and ppr is spread by airborne droplets. all secretions and excretions of infected animals are contagious throughout the course of the disease, but no carrier state exists. the virus targets lymphoid tissue. lymphocytes are destroyed in germinal centers in lymph nodes, peyer's patches, tonsils, splenic corpuscles, and cecal lymphoid tissue. immunosuppression results from lymphoid destruction. lymphocytes are partially replaced by plasma cells, macrophages, an eosinophilic acellular matrix, and occasionally neutrophils. the epithelial lining of the mouth and digestive tract is highly vulnerable to the pprv. with the loss of the alimentary tract mucosa, weight loss and diarrhea become severe. the incubation period is usually 2 to 6 days, with up to 10 days possible. clinical signs. the clinical disease produced by pprv in sheep and goats closely resembles that of rinderpest, but the course is much more rapid. with the acute form, sheep and goats typically display an abrupt rise in temperature to 104° to 106° f (40°-41° c). within a few days, infected animals develop nasal and lacrimal discharge, depression, thirst, anorexia, and leukopenia. congestion of the conjunctival and other mucous membranes occurs, followed by serous and mucopurulent exudates. sheep and goats develop oral erosions with necrotic foci, which results in excessive salivation. diarrhea that may be profuse but rarely hemorrhagic develops within 2 to 3 days and is accompanied by abdominal pain, tachypnea, emaciation, and severe dehydration. bronchopneumonia, particularly that caused by pasteurella spp., may be a terminal • fig. 16.1 a. the lungs of the adult pen-raised, white-tailed deer, have been retracted to reveal to ecchymoses on the ventral surface of the "ribcage." petechiae and ecchymoses can occur anywhere within the carcass in cases of epizootic hemorrhagic disease (ehd), but common locations are on the epicardium, on the pleural surface the ribs, subcutaneously, and on the surface of the spleen. b. ecchymoses over the surface of the reticulum (bottom right of photo) and the surface of the rumen (left side of photo). in addition to ehd, this deer also had bronchopneumonia (fibrin overlying consolidated lung can be seen in the far right of photo). (courtesy dr. kelley steury, auburn, al.) a b sequela. death usually occurs 5 to 10 days after the onset of fever. pregnant sheep or goats with ppr may abort. diagnosis. a presumptive diagnosis of ppr can be made on the basis of clinical, pathologic, and epizootiologic findings. the diagnosis can be confirmed by isolating the virus from blood or tissues, including lymph nodes, tonsils, spleen, and lung. immunocapture elisa or pcr may be used to detect infection several days before the development of clinical disease. most serologic tests (complement fixation or agid) cannot differentiate between ppr and rinderpest. characteristic postmortem findings include necrotic stomatitis that is generally confined to the inside of the lower lip and adjacent gum, the cheeks near the commissures, and the ventral surface of the free portion of the tongue. abomasal erosions are often present. in the small intestine, peyer's patches are markedly affected, particularly in the first portion of the duodenum and terminal ileum. the large intestine may be severely affected. lesions occurring near the ileocecal valve, at the cecocolic junction, and in the rectum are often described as zebra stripes that indicate areas of congestion along the folds of the mucosa. treatment and prevention. infection with pprv has no specific treatment. mortality can be reduced by supportive care, including the administration of antimicrobial and antiinflammatory agents, as well as nutritional support. in the united states, state and federal veterinarians should be notified if pprv is suspected. methods used to eradicate rinderpest are useful in the eradication and control of ppr. all sick sheep and goats and those exposed should be slaughtered and disposed of by burning, burying, or rendering. the premises should be decontaminated, and the area quarantined. sheep and goats can be protected against ppr by immunization with rinderpest vaccines or by the simultaneous administration of ppr hyperimmune bovine serum and virulent pprv. 127 pathogenesis. louping ill is a tickborne disease caused by a flavivirus. it affects mainly lambs but occasionally also affects other livestock species and infrequently affects deer, camelids, and humans. transmission is most common during tick season, and ixodes ricinus is thought to be the most important infective host. many sheep clear the infection after a few days of fever and viremia, but others develop severe, fatal viral encephalitis. the virus is shed in many secretions, including milk, which is an important source of infection for other animals (and humans). the severity of the disease depends on herd immunity because previous exposure gives long-lasting immunity. colostrum from immune females is protective for the neonate. high antibody titers also appear to shorten the duration and level of viremia and thereby prevent invasion of the central nervous system. naïve flocks may have fatality rates as high as 60%. clinical signs. high biphasic fever, anorexia, and depression are seen in most infected sheep. lambs may die quickly before illness is noted. some sheep also develop central neurologic signs, including hyperexcitability, muscle tremors, and rigidity. abnormal coordination and muscle activity may cause sheep to move with a bounding gait (hence the name louping ill). diagnosis. the condition has no characteristic gross lesions. microscopic examination of animals with neurologic signs reveals evidence of viral meningoencephalitis. diagnosis is made by history (based on location, signs, and time of year), the identification of characteristic lesions, virus isolation, or fluorescent antibody staining of fresh brain tissue. a demonstrated increase in specific antibody titers in survivors strongly suggests the presence of this infection. prevention. vaccines are available in endemic areas to control infection. vector control during tick season also is important. lambing season should also be timed so that lambs have high colostral antibody protection at the time of exposure to ticks. pathogenesis. foot-and-mouth disease is caused by a highly contagious picornavirus and has been eradicated from the united states. vesicular stomatitis is caused by a rhabdovirus and is intermittently eradicated from the united states. both diseases are highly contagious, nearly indistinguishable from each other clinically, and reportable. foot-and-mouth disease has a broad host range that includes most hoof stock (including pigs but not horses) and several other mammalian species. vesicular stomatitis also affects many species of hoof stock, including both pigs and horses. sheep and goats are relatively less susceptible than cattle, particularly to vesicular stomatitis. the viruses are spread by aerosol and mechanical vectors and primarily colonize skin or mucous membranes. milking machines, flies, birds, and humans all may be important mechanical vectors. vesicular stomatitis tends to remain at the site of infection, and colonization is facilitated by damage to the skin. oral mucous membranes, coronary bands and interdigital skin, and teat-end skin are common sites of lesions. vesicular stomatitis outbreaks in the united states tend to occur in the summer or fall and end with the first killing frost. viremia plays more of a role with foot-and-mouth disease. the virus is present in most body tissues and fluids in infected animals and can be transmitted through milk, meat, bone, and hide products; semen; equipment that pierces the skin; and biting arthropods. it also tends to spread through the circulation from the site of infection to other susceptible tissues, including the sites of vesicular stomatitis, as well as to the nasal cavity, mammary glandular epithelium, and ruminal pillars. the basic lesion for both diseases are the vesicles that form in the oral cavity and on the teats and coronary band. the vesicles quickly rupture and may not be visualized before forming erosions. ruptured vesicles leave deep erosions on the skin or mucous membranes and appear to cause pain. tissue damage and inflammation are often compounded by secondary bacterial infection, which can cause greater morbidity and mortality than the original viral infection. morbidity is related to feed refusal, increased recumbency, and secondary infections of the mouth, udder, and feet. clinical signs. sheep and goats usually develop minor lesions, if any, and are more important in many outbreaks as transport or multiplying hosts than as primary clinical cases. however, identification of lesions should raise suspicion of this disorder. in the worst cases, vesicles, erosions, and ulcers are seen at target sites. they may appear mildly inflamed and erythematous; if they are infected, they may appear severely inflamed with hemorrhage and necrosis. other signs vary according to the location and severity of the lesions. lingual and buccal lesions cause salivation, dysphagia, and feed refusal. foot lesions, which are the most common clinical manifestation in small ruminants, cause lameness and recumbency. teat lesions cause reluctance to be milked or nursed and a decrease in production. fever also may be seen early in the disease, when vesicles are most apparent. the fever then usually abates, and vesicles are replaced by erosions or ulcers. abortion may occur, especially with foot-and-mouth disease, and is probably related to the fever rather than to fetal infection. the disease is usually self-limiting; most animals recover within 2 to 3 weeks. shedding of the virus causing vesicular stomatitis is thought to subside soon after healing of lesions. foot-and-mouth disease virus may be shed for as long as 6 months, and all body secretions and tissues should be considered contagious, including milk, semen, meat, and offal. both viruses have zoonotic potential and cause a disease in humans that resembles mild influenza. the diseases are self-limiting, but people can shed the viruses in sufficient quantities to infect other animals. diagnosis. no characteristic clinicopathologic changes are reported for either virus. gross lesions resemble those seen before death and include vesicular, erosive, and ulcerative lesions of the mouth, feet, and teat ends; foot-and-mouth disease also causes lesions of the mammary gland and ruminal epithelium. microscopic findings include hydropic degeneration of cells of the stratum spinosum of the epidermis without inclusion bodies. secondary bacterial infection may lead to deeper ulcers and complicate identification of the viral etiology of these lesions. myocarditis lesions may be seen with some forms of foot-and-mouth disease. a presumptive diagnosis may be made by identifying characteristic lesions during a season and in an area at risk for one of these infections. in north america, bluetongue should be considered as an important differential diagnosis for ulcerative oral lesions in sheep. a confirmed diagnosis of foot-and-mouth disease is achieved by a combination of virus isolation (from vesicles), ihc, and serology by regulatory officials. identifying the source of infection also is very important. diagnosis of vesicular stomatitis is achieved by complement fixation or fluorescent antibody staining of virus in vesicular fluid or detection of a rise in antibody titers. flocks with either of these diseases in the united states are subject to quarantine and possible destruction (especially for foot-and-mouth disease). prevention. meticulous personal hygiene and avoidance of contact with new animals are important during outbreaks to prevent spread between flocks. vaccines against foot-and-mouth disease are available in many parts of the world, but not in the united states. most nations slaughter or quarantine affected animals. vaccines against vesicular stomatitis are available and are most commonly used if the risk of outbreak is high, but vaccination does not prevent infection or shedding. good hoof and teat care and soft feeds may help prevent spread of the virus by providing a healthy, intact barrier against invasion. pathogenesis. sheep and goat pox are caused by two closely related poxviruses. some strains are infective to both sheep and goats; most are species specific. they are maintained in populations by infected animals, and transmission occurs by aerosol or direct or indirect contact. flies may play an important role as mechanical vectors in some flocks. viruses remain infective in the environment for as long as 6 months. after infection, viremia and inflammation of the oral, nasal, and ocular mucous membranes occur. erythematous papular pox lesions appear a few days later. severity varies according to strain pathogenicity, breed susceptibility, and immune status. mild infections are characterized by lesions concentrated in the non-wooled or hairless regions of the skin. severe infections produce lesions throughout the oral cavity, respiratory tract, and peritoneal cavity. secondary infection is common with the severe form and mortality is high. if the animal survives, lesions heal in 3 to 4 weeks. both diseases have been eradicated from the united states and are reportable. people can develop mild disease on exposure to these viruses. clinical signs. fever, inappetence, conjunctivitis, and upper respiratory signs are seen in the initial stages. pox lesions are visible shortly thereafter. secondary infection can lead to a variety of more serious signs indicative of respiratory disease, sepsis, and shock. diagnosis. characteristic pox lesions are highly suggestive of this disease. microscopic analysis reveals eosinophilic intracytoplasmic inclusion bodies, acantholysis, and pustule formation within the epidermis and occasionally the dermis. viral particles may be seen on ultrastructural examination. gross and microscopic lesions are characteristic with the severe form, but mild disease may produce mild lesions that are difficult to differentiate from other viral diseases that cause oral proliferative or ulcerative lesions. virus can be isolated from blood or tissues (mainly skin) during the acute viremic stage and identified by antibody staining of more chronic lesions. serologic tests are available to detect rising titers in convalescent animals. treatment and prevention. no specific treatment is available for sheep or goat pox. antibacterial drugs may be useful to treat secondary infection. judicious use of insecticides and confinement of affected animals may prevent spread. vaccines are available in some countries, but not in the united states. infected flocks are placed under quarantine or destroyed in regions where the diseases are not endemic. these viruses are difficult to eradicate from flocks because of their environmental persistence and the constant supply of susceptible hosts. caprine arthritis-encephalitis virus (caev) is an enveloped, singlestranded retrovirus in the lentivirus genus. like other retroviruses, caev integrates into the host chromosomal dna before replicating. the virus is able to remain latent or undergo sporadic bouts of productive viral replication. caev is closely related to ovine lentiviruses. clinical signs. clinical disease may be evident in only 10% of goats from a caev-infected herd at any given time. as many as 85% of seropositive goats may be clinically normal. caev produces four clinical syndromes: encephalomyelitis, arthritis, interstitial pneumonia, and indurative mastitis. the pattern of disease usually varies with age. arthritis is generally seen in sexually mature goats, whereas encephalomyelitis is generally seen in kids 2 to 4 months old. interstitial pneumonia and indurative mastitis are more common in adult goats. some goats suffer from a wasting disorder characterized by poor body condition and rough hair coat. diagnosis. a presumptive diagnosis of caev can be made on the basis of history and clinical signs suggestive of one or more of the syndromes. in general, elisa tests are better for detecting disease in an individual animal because the sensitivity of the test is higher than that of the agid, whereas the agid is better for herd screening that requires high specificity. with the agid test, false negatives may occur in goats that have not yet seroconverted to recent infection. individual goats may take months or years to seroconvert or may never do so. parturition or advanced stages of disease also may contribute to a false-negative result. false positives may occur in goats younger than 90 days old that have colostral antibodies. for this reason, it is often suggested that kids be at least 6 months old before they are tested. pcr testing has high specificity and sensitivity and can detect infection within a day of exposure. other less commonly used tests include a western blot to detect antibodies and a northern blot to look for mitochondrial rna. because of the limitations in interpreting serologic results, caev-induced disease can only be definitively diagnosed by identification of characteristic lesions from examination of biopsy specimens or postmortem viral isolation. treatment. no specific treatments are available for any of the syndromes associated with caev. young goats suffering from encephalomyelitis may benefit from physical therapy if they are recumbent, and bottle feeding may help maintain hydration and caloric intake. antibiotics may be beneficial to goats affected with interstitial pneumonia or mastitis if secondary bacterial infection is present. generally, the prognosis is poor for the encephalitic form and guarded for the other forms. prevention. prevention of caev is crucial because infection is lifelong. infected colostrum and milk are the most important sources of infection. newborn kids should be prevented from ingesting colostrum from infected does and should instead be fed pasteurized goat's milk or milk from caev-negative goats. all goats in a herd should undergo serologic testing twice yearly; seropositive goats should be segregated or culled to prevent direct contact between infected and uninfected animals. ovine progressive pneumonia (opp) is an ultimately fatal retroviral disease that causes chronic, progressive, debilitating inflammatory conditions of the lungs (united states) and central nervous system (other parts of the world). it also is called maedi-(maeði is icelandic for "shortness of breath") visna (meaning "wasting"). the virus is a member of the lentivirus genus of retroviruses and is closely related to caev. recombination between opp and cae viruses has been observed. 128 the virus primarily affects sheep and rarely goats and has been identified worldwide, except in australia and new zealand. the disease has a long incubation period and protracted clinical course. pathogenesis. only sheep older than 2 years of age are affected by opp virus (oppv). the virus is spread by direct contact, probably in respiratory and salivary secretions, and by excretion in the milk and colostrum. transplacental transfer is of minor importance. virus is excreted by animals that exhibit clinical signs and asymptomatic animals. infection is established in the monocyte and macrophage cell line and spread by these cells to the lungs, lymph nodes, choroid plexus, spleen, bone marrow, mammary gland, and kidneys. like caev, oppv evades the cellular and humoral immune system of the host by incorporation of its provirus in host dna, low-grade replication of virus only when monocytes differentiate into macrophages (restricted replication), and production of antigenic variants that are not neutralized by existing antibodies. continual antigenic stimulation of the host by low-grade replication of oppv results in chronic inflammation and resultant lymphoid proliferation in various target tissues. the virus may prevent b lymphocytes from differentiating into plasma cells in lymph nodes and may thereby impair immunoregulation. seroconversion occurs within 2 to 3 weeks after infection. clinical signs. in the united states, serologic surveys reveal infection rates of between 30 and 67% but rarely is more than 5% of a flock lost to oppv. icelandic, texel, border leicester, and finnish landrace appear to be susceptible sheep breeds. more resistant sheep breeds include rambouillet, suffolk, and columbia. various clinical syndromes are associated with oppv and include wasting (thin ewe syndrome), dyspnea occasionally with a dry cough, pneumonia, mastitis ("hard bag"), posterior paresis, arthritis, and vasculitis. in north america, pneumonia and indurative aseptic mastitis are common sequelae of infection. coinfection with the jaagsiekte virus (the cause of pulmonary adenomatosis) worsens respiratory signs. visna, the neurologic form, is more common in goats. over the course of up to a year, subtle signs such as a head tilt or hindlimb weakness progress to gross incoordination, whole body tremors, and rarely more profound cranial nerve signs. diagnosis. a presumptive diagnosis can be made on the basis of clinical signs, poor response to treatment, characteristic postmortem findings, and serologic testing. definitive diagnosis requires pcr or isolation of the virus from wbcs (buffy coat of whole blood sample) or tissues. less expensive and faster serologic tests include agid, elisa, and an indirect immunofluorescence test. the agid test is frequently used as a flock screening test, but the elisa is more sensitive on an individual basis and can detect antibodies earlier in the course of the disease. as with caev, false negatives and false positives are possible. characteristic postmortem lesions include generalized wasting and firm, noncollapsing lung or firm, mottled mammary glands, both with regional lymphadenopathy. microscopic evaluation of those tissues reveals interstitial non-septic, mononuclear cell infiltrates, although these may be complicated by secondary infections. histopathology of nervous tissue reveals meningoleukoencephalitis. treatment. no effective treatment is available for oppv. supportive therapy that includes appropriate husbandry and control of secondary infection with antibiotics may prolong life for a few weeks or months but, ultimately, the disease is fatal. because of the poor prognosis and risk of exposure of naive animals to clinical disease, long-term treatment is not recommended. prevention. the only known method of preventing oppv infection in a flock is to prevent exposure to the virus. management practices that help decrease the incidence of horizontal transmission include disinfection of milking equipment, dehorning instruments, and tail docking and castration tools before use and between animals. contaminated feed and water also are potential routes of infection and should not be shared among infected and uninfected animals. serologic testing and separation or culling of seropositive animals may help reduce infection. although oppv can readily be isolated from ewe colostrum, colostral transmission of oppv has not been definitively established. however, many prevention guidelines recommend that offspring from infected dams be separated from the dam before they nurse and then be fed cow colostrum and artificially reared. quarantine and serologic testing of flock additions before placing them with the current flock and purchase of sheep only from oppv-free flocks are important to prevent the introduction of new infections. because of the potential cross-species spread, all precautions taken for sheep also apply to contact goats. serologic testing should be performed at least annually in a flock until two consecutive negative test results are obtained. border disease virus (bdv) is in the genus pestivirus and family flaviviridae, which also includes the two genotypes of bovine viral diarrhea virus (bvdv) and classical swine fever virus. it rarely causes disease in adults and is most important as a cause of in utero infection of lambs and kids. the condition gets its name from the fact that it was first reported in sheep along the welsh border of the united kingdom. other names such as "hairy shakers" and "fuzzy lamb disease" refer to some of the clinical signs seen in affected newborns. it is important to recognize that although bdv is genetically distinct from the two types of bvdv, sheep and goats also are susceptible to some strains of bvd. pathogenesis. horizontal transmission of bdv occurs through contact with secretions and excretions of body fluids and tissues from infected animals. the virus crosses intact mucous membranes and can spread rapidly through a flock. the major reservoir is the persistently infected sheep or goat. these reservoirs are usually asymptomatic, congenitally infected, and often seronegative animals that shed large quantities of virus. these may be residents of a flock with an ongoing problem or bought in as replacement animals to a naïve flock. some cross-infection from other species is possible, particularly from cattle. adult, immunocompetent sheep rarely show any signs of acute infection. however, if a pregnant ewe or doe is infected, the virus may be transmitted vertically to the embryo or fetus. depending on the stage of gestation, embryonic or fetal infection may have different outcomes ranging from embryonic reabsorption to normal birth. these infections are the most important aspect of border disease. the major organ system targeted by bdv is the fetal central nervous system. the hallmark lesion is hypomyelination, or degeneration of oligodendroglial cells. three factors contribute to this lesion. the first is direct viral damage. the second is viral-induced inhibition of the thyroid gland that causes decreased secretion of thyroid hormones. in the absence of these hormones, a resultant lowered concentration of a specific nucleotide in the central nervous system also contributes to the hypomyelination. the third factor is altered immune function. the virus causes the host to produce a virus-specific delayed hypersensitivity reaction that causes inflammation in the central nervous system. it also causes immunosuppression. death often results from opportunistic conditions such as parasitism, diarrhea, and bronchopneumonia. clinical signs. clinical signs depend on the time during gestation when the fetus or embryo is exposed to the virus. clinical signs also may vary in severity from animal to animal because different fetuses develop competent immune systems at different times. if the fetus or embryo is exposed to the virus within 45 days of conception, it dies and is resorbed or aborted. these losses are not usually noticed by the flock manager. the principal manifestation in the flock is a large number of open ewes and a small lamb crop. infection of the fetus between days 45 and 80 of gestation causes damage to rapidly growing systems such as the skin and nervous, lymphoid, thyroid, and skeletal systems. congenital malformations are seen at birth. lambs have abnormal fleece characteristics (hairy rather than woolly in consistency), small stature, domed heads, shortened legs, and dark pigmentation of the skin, particularly on the dorsal aspect of the neck. the lamb may exhibit tonic-clonic tremors ("hairy shakers") when awake, which may prevent standing or suckling. most of these lambs die within a few days of birth. if they survive, the hair changes disappear in 9 to 12 weeks and the central nervous system signs resolve by 20 weeks. goats infected at this time have similar symptoms except that they rarely exhibit hair coat changes. if kids are infected before day 80 of gestation and are still viable, they may become persistently infected and immunologically compromised. they are small at birth and generally weak. typical outbreaks of border disease cause abortions and birth of weak lambs in the first year as the virus rapidly spreads throughout a susceptible flock and then insignificant losses in the succeeding years as adult sheep develop immunity. however, if new naïve ewes are introduced in the flock, substantial losses may occur in perpetuity. diagnosis. border disease viral antigens can be demonstrated in abomasum, pancreas, kidney, thyroid, skin, and testicle tissues from aborted fetuses and persistently infected animals using fluorescent antibody tests. however, ihc on ear notch samples is not considered as reliable for detecting persistently infected small ruminants as it is for cattle. the virus can be isolated, or viral antigen detected by elisa, from serum, heparinized whole blood, and tissue taken from brain, spinal cord, spleen, and bone marrow from affected lambs. whole blood is better than serum if colostral antibodies are likely to be high; serum is an adequate sample in neonates and juveniles that have not suckled. antibodies to the virus may be quantified by serum neutralization, agid, and complement fixation with hyperimmune bvd antiserum. serologic tests are useful to detect exposure in lategestation (after day 80) neonates and unvaccinated animals but may be confounded by colostral antibodies in suckling neonates, previous exposure, and vaccination in older animals. any titer in a presuckling neonate indicates in utero exposure, whereas a serum neutralization titer of 1:20 to 1:320 suggests infection in adults. the presence of specific antibodies in the cerebral spinal fluid suggests bdv infection. negative presuckling serologic tests do not rule out exposure because persistently infected lambs tend to be immunotolerant to the bdv and therefore are born without an antibody titer. these animals may subsequently develop a titer that is indistinguishable from that of a normal animal. although persistently infected animals do not respond immunologically to the strain of the virus they carry, they may respond to other strains of the virus, including vaccine strains. as with bvd, pcr assays are gaining popularity for the detection of bdv in fluids and tissue samples. these assays appear to be superior to other techniques, except in autolyzed tissues. realtime pcr may also be used to differentiate bdv from bvd and to type isolates. gross postmortem findings include hydranencephaly, porencephaly, microcephaly, cerebellar hypoplasia, abnormal rib curvature, brachygnathia, doming of the frontal bones of the skull, narrowing of the distance between the orbits, shortening the crown-to-rump length, shortening of the diaphyseal length, retention of secondary hair fibers, and abnormal skin pigmentation. the major histopathologic changes include hypomyelination and hypercellularity of the white matter. glial cells appear normal. treatment. no treatment is available for border disease infection. supportive care may include assistance in nursing and standing for affected lambs, provision of good bedding and solid footing, and treatment of secondary opportunistic infection. prevention. control is primarily achieved by eliminating persistently infected carrier animals from the flock and preventing the addition of new carrier animals. this is easiest in a closed flock but especially difficult in small ruminant flocks because of the frequent desire to import new genetics. to identify carriers, virus isolation must be performed on every animal in the flock; carrier animals must be culled. additionally, all unborn animals must be considered potential carriers and should be tested at birth. an alternative solution in hobby flocks is to arrest breeding activity until all animals have been shown to be free of infection. new animals should be quarantined and tested before admission to the flock. herd screening with the ear skin biopsy test using fluorescent antibody staining to detect virus is less expensive and more convenient than the whole blood virus isolation test. the role of vaccination in preventing infection is still unclear. no vaccine against bdv is available, but some reports suggest that bvdv vaccines for cattle may be helpful for sheep at risk. however, these vaccines have proven to be more effective at preventing clinical disease in vaccinated animals than in preventing in utero infection because they do not prevent transient viremia. vaccination decreases viremia and fetal infection but does not eliminate them. therefore, vaccines play a role in decreasing economic loss but do not replace culling of carrier animals as the major method of control. another member of the slow infection group of diseases of small ruminants is scrapie. it is an afebrile, chronic, progressive degenerative disorder of the central nervous system of sheep and occasionally of goats (see chapter 13) . scrapie is caused by a prion and, as such, is one of the transmissible spongiform encephalopathies. sheep (and goats and mouflon to a lesser degree) are the natural hosts for scrapie. clinical signs often do not usually appear until animals are 2 years old, and animals as old as 5 years may exhibit clinical disease. both vertical and horizontal transmission have been demonstrated experimentally in sheep and goats. abnormal scrapie protein has been identified in milk, urine, and seminal plasma of sheep up to 20 months prior to the development of clinical signs. also, new evidence from deer with chronic wasting disease, a similar disorder, suggests that infective prions are excreted in the saliva and feces well before the development of clinical signs. these new revelations may help explain horizontal transmission of infection. clinical signs. the onset of scrapie is insidious. initially, sheep show subtle changes in behavior such as mild apprehension, staring or fixed gaze, failure to respond to herding dogs, and boldness around humans. several months later, the animals become intolerant of exercise and develop a clumsy, unsteady gait and floppy ears. later, the sheep develop itchy skin that causes them to rub themselves excessively against firm, immobile objects (origin of the name scrapie). this leads to excoriations and wool damage. there is a general decline in body condition and coordination. diagnosis. histologically, the only consistent lesions are degenerative changes in the central nervous system consisting of bilaterally symmetric vacuolation of the neurons in the brainstem and spinal cord with accompanying spongy degeneration. as a preclinical test, ihc may be performed in lymphoid tissue from the tonsils, third eyelid, or rectoanal mucosa, but none of these methods is foolproof. cwd is discussed in chapters 13, 19, and 20. testing for clinical anaemia caused by haemonchus spp. in goats farmed under resource-poor conditions in south africa using an eye colour chart developed for sheep validation of the fama-cha eye color chart for detecting clinical anemia in sheep and goats on farms in the southern united states validation of the famacha © eye colour chart using sensitivity/ specificity analysis on two south african sheep farms is the famacha chart suitable for every breed? 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suppurative abomasitis associated with clostridium septicum infection clostridial myocarditis in lambs outbreak of clostridial myocarditis in calves clostridial myositis in cattle: bacteriology and gross pathology clostridial vaccination efficacy on stimulating and maintaining an immune response in beef cows and calves failure of clostridium chauvoei vaccines to protect against blackleg prevalence of coxiella burnetti infection in wild and farmed ungulates coxiella burnetii shedding by farmed red deer (cervus elaphus) high prevalence of antibodies against chlamydiaceae and chlamydophila abortus in wild ungulates using two regional seroprevalence of leptospirosis on deer farms in new zealand growth response and shedding of leptospira spp. in urine following vaccination for leptospirosis in young farmed deer corynebacterium pseudotuberculosis paratuberculosis (johne's disease) in cattle and other susceptible species efficacy of a killed vaccine for the control of paratuberculosis in australian sheep flocks detection of a novel reassortant epizootic hemorrhagic disease virus (ehdv) in the usa containing rna segments derived from both exotic (ehdv-6) and endemic (ehdv-2) serotypes the first 10 years (2006-15) of epizootic hemorrhagic disease virus serotype 6 in the usa review of the 2012 epizootic hemorrhagic disease outbreak in domestic ruminants in the united states peste des petits ruminants demonstration of coinfection with and recombination by caprine arthritis-encephalitis virus and maedi-visna virus in naturally infected goats key: cord-023913-pnjhi8cu authors: foreman, stephen; kilsdonk, joseph; boggs, kelly; mouradian, wendy e.; boulter, suzanne; casamassimo, paul; powell, valerie j. h.; piraino, beth; shoemaker, wells; kovarik, jessica; waxman, evan(jake); cheriyan, biju; hood, henry; farman, allan g.; holder, matthew; torres-urquidy, miguel humberto; walji, muhammad f.; acharya, amit; mahnke, andrea; chyou, po-huang; din, franklin m.; schrodi, steven j. title: broader considerations of medical and dental data integration date: 2011-10-08 journal: integration of medical and dental care and patient data doi: 10.1007/978-1-4471-2185-5_4 sha: doc_id: 23913 cord_uid: pnjhi8cu dental health insurance coverage in the united states is either nonexistent (medicare and the uninsured), spotty (medicaid) and limited (most employer-based private benefit plans). perhaps as a result, dental health in the united states is not good. what public policy makers may not appreciate is that this may well be impacting medical care costs in a way that improved dental benefits would produce a substantial return to investment in expanded dental insurance coverage. have been rising at double digit rates. most employers have been dropping health care coverage rather than expanding it ( kaiser family foundation 2010 ) . medicare trust funds are bankrupt (social security and medicare boards of trustees 2011 ). adding coverage would exacerbate an already alarming problem. medicaid funding is a major source of state government defi cits. many states are slashing medicaid coverage during this time of crisis (wolf 2010). improving medicaid dental coverage during times of budget crisis would meet substantial political resistance. strikingly, strong and increasing evidence suggests relationships between oral health and a range of chronic illnesses. for example, recent fi ndings show relationships between periodontal infl ammatory conditions and diabetes, myocardial infarction, coronary artery disease, stroke, preeclampsia and rheumatoid arthritis. this suggests that improved oral health may well have the potential to reduce the incidence of chronic diseases as well as their complications. if chronic disease incidence is reduced it may be possible to avoid medical care costs related to treating them. it would be important to know more about the extent to which improved oral health could reduce health care costs and improve lives. there are few, if any, studies of the costs of providing medicare dental benefi ts, the costs of improving the medicaid dental benefi t or the cost of providing dental insurance to the uninsured. there are a few studies that indicate that periodontitis increases medical care costs, perhaps by as much as 20% (ide et al. 2007; albert et al. 2006) . 1 ideally there should be a controlled study to assess the benefi t of providing dental coverage through a government payer system. for a preliminary inquiry we can consider work already done and using some cost and benefi t estimates, determine whether it is possible that benefi ts of extending dental coverage may outweigh costs. the failure of medicare to cover dental care has engendered some (albeit not much) public debate. in 2003, congress enacted the medicare prescription drug, improvement, and modernization act (medicare part d). by 2009 medicare provided $56.6 billion in benefi t payments for outpatient prescription drugs and medicaid paid 15.7 billion for outpatient prescription drugs (center for medicare and medicaid services 2010 ) . benefi ciaries provided billions more in the form of monthly part d premiums. the expense of the medicare prescription drug program and the controversy surrounding its enactment may well have eroded public support for increased medicare coverage. so while there has been no shortage of effort paid to improving medicare, the one common theme in all of the recent initiatives is that dental care has been conspicuously 1 a new study by hedlund, jeffcoat, genco and tanna funded by cigna of patients with type ii diabetes and periodontal disease found that medical costs of patients who received maintenance therapy were $2483.51 per year lower than patients who did not. cigna, research from cigna supports potential association between treated gum disease and reduced medical costs for people with diabetes, http://newsroom.cigna.com/newsreleases/research-from-cigna-supports-potential-association-between-treated-gum-disease-and-reduced-medical-costs-for-people-with-diabetes. omitted. as a result, 43 million medicare recipients in 2009 (us census bureau 2011 ) continue to have no dental insurance coverage through medicare. 2 medicaid dental coverage is an optional benefi t that states may or may not elect to provide. in medicaid, both the state and the federal government provide funds to cover healthcare services to eligible patients. the bulk of the money comes from the federal government. because the medicaid dollars are limited and coverage for systemic diseases has precedence, medicaid coverage of dental care has been spotty. even where it has been provided, payments to dental providers have been so low as to make it diffi cult or impossible for medicaid benefi ciaries to obtain adequate dental care (broadwater 2009 ) . the 2008 recession increased the number of medicaid eligible individuals nationwide. further, the federal budget defi cits of the past few years have reduced the federal contribution to state medicaid programs. the combination of increases in the number of benefi ciaries and diminished revenues has caused a number of states to eliminate or curtail medicaid dental coverage (ehow 2011 ; mullins et al. 2004 ) . the result, 49 million medicaid benefi ciaries in the us (us census bureau 2011 ) in 2009 either had no dental insurance coverage or inadequate coverage. approximately 52 million people in the united states do not have health insurance (kaiser family foundation 2010 ) . presumably, they have no dental insurance either. further, not every employer provides dental insurance. a 1995 cdc survey found that 44.3% of adults do not have dental insurance coverage (centers for disease control 1997 ) . a 2006 montana survey found that 53% of employers who offer health insurance do not offer dental insurance coverage (montana business journal 2006 ) . in 2009 there were approximately 202 million people enrolled in health insurance plans (us census bureau 2011 ) . if half (a rough combination of the cdc and montana percentages) of them do not have dental insurance it is likely that an additional 101 million (nonelderly, non-poor) people in the us do not have dental insurance coverage. finally, the term "dental insurance" is actually a misnomer. 3 dental policies cover routine treatments, offer discounts for more complex treatment and impose a low yearly on total payments. in fact, it has been called "part insurance, part prepayment and part large volume discount" (manski 2001 ) . effectively, many (if not most) people who have dental insurance fi nd it coverage to be quite restrictive. for example, many impose a small yearly cap ($1,500 is common) or large coinsurance amounts (50% for orthodontia, for example) (rubenstein 2005 ) . even with discounts it is easy for many people to exceed the annual limit. given the lack of dental insurance coverage it is not surprising that the status of oral health in the us is not particularly good. in 2002 approximately 26.5% of adults between the ages of 35 and 44 had untreated caries, 42% had decayed, missing and fi lled tooth surfaces and more than one-half of adults had gingival bleeding (dental, oral and craniofacial data resource center of the national institute of dental and craniofacial research 2002 ) . three fourths of adults in the us have gingivitis and 35% have periodontitis (mealey and rose 2008 ) . if these levels of untreated disease were applied to most systemic diseases, there would be public outcry. over the past decade evidence has been building that there is a relationship between dental disease, particularly periodontal disease, and chronic illnesses. mealey and rose note that there is strong evidence that "diabetes is a risk factor for gingivitis and periodontitis and that the level of glycemic control appears to be an important determinant in this relationship" (mealey and rose 2008 ) . moreover, diabetics have a six times greater risk for worsening of glycemic control over time compared to those without periodontitis and, periodontitis is associated with an increased risk for diabetic complications. for example, in one study more than 80% of diabetics with periodontitis experienced one or more major cardiovascular, cerebrovascular or peripheral vascular events compared to 21% of the diabetic subjects without periodontitis (thorstensson et al. 1996 ) . also, a longitudinal study of 600 type 2 diabetics found that the death rate from ischemic heart disease was 2.3 times higher in subjects with severe periodontitis and the death rate from diabetic nephropathy was 8.5 times higher (saremi et al. 2005 ) . clinical trials have demonstrated that treatment of periodontal disease improved glycemic control in diabetics (miller et al. 1992 ) . moreover, investigations have found an association between periodontal disease and the development of glucose intolerance in non-diabetics (saito et al. 2004 ) . while it is diffi cult to establish causality and it is possible that other factors infl uence periodontal disease and medical complications, these studies suggest that treatment of periodontitis substantially improves health and greatly reduces medical complications related to diabetes. similarly, periodontitis is associated with cardiovascular disease and its complications including ischemia, atherosclerosis, myocardial infarction and stroke. a study by slade and colleagues found both a relationship between periodontitis and elevated serum c-reactive protein levels (systemic marker of infl ammation and documented risk factor for cardiovascular disease) as well as a relationship among body mass index, periodontitis and crp concentrations (slade et al. 2003 ) . hung and colleagues evaluated the association between baseline number of teeth and incident tooth loss and peripheral arterial disease. they determined that incident tooth loss was signifi cantly associated with pad, particularly among men with periodontal disease potentially implying an oral infection-infl ammation pathway (hund et al. 2003 ) . the same group of researchers used the population enrolled in the health professionals' follow-up study (41,000 men free of cardiovascular disease and diabetes at baseline) to assess the relationship between tooth loss and periodontal disease and ischemic stroke. controlling for a wide range of factors including smoking, obesity, and dietary factors, the researchers found a "modest" association between baseline periodontal disease history and ischemic stroke . as early as 1993 destefano and colleagues found that among 9760 subjects, those with periodontitis had a 25% increased risk of coronary heart disease relative to those without. the association was particularly high among young men. the authors questioned whether the association was causal or not, suggesting that it might be a more general indicator of personal hygiene and possibly health care practices (destefano et al. 1993 ) . in 2000 wu and colleagues used data from the first national health and nutrition examination survey and its epidemiologic follow-up study to examine the association between periodontal disease and cerebrovascular accidents. the study found that periodontitis was a signifi cant risk factor for total cva, in particular, for non-hemorrhagic stroke (wu et al. 2000 ) . in addition to diabetes and coronary artery disease, associations have been found between periodontal disease and rheumatoid arthritis and respiratory disease. this is not surprising given the role of periodontal disease in the production of infl ammation related proteins. dissick and colleagues conducted a pilot study of the associate ion between periodontitis and rheumatoid arthritis using multivariate regression and chi square tests. they found that periodontitis was more prevalent in patients with rheumatoid arthritis than in the control group and that patients who were seropositive for rheumatoid factor were more likely to have moderate to severe periodontitis than patients who were rf negative and also that patients who were positive for anti-cyclic citrullinated peptide antibodies were more likely to have moderate to severe periodontitis (redman et al. 2010 ) . paju and scannapeico investigated the association among oral biofi lms, periodontitis and pulmonary infections. they noted that periodontitis seems to infl uence the incidence of pulmonary infections, particularly nosocomial pneumonia in high-risk subjects and that improved oral hygiene has been shown to reduce the occurrence of nosocomial pneumonia. they found that oral colonization by potential respiratory pathogens, for possibly fostered by periodontitis and possibly by bacteria specifi c to the oral cavity contribute to pulmonary infections (paju and scannapeico 2007 ) . the implications for these fi ndings are profound. professionally, they suggest that managing patients with chronic illness and periodontal disease will require teamwork and a deeper knowledge base for dentists and for physicians (mealey and rose 2008 ) . dentists will need to be alert for early signs of chronic illness among their patients and physicians will need to be alert for signs of dental disease. both will need to consider wider treatment options than their specialty indicates. dentistry and medicine have operated as professional silos in the past. the relationship between dental disease and chronic medical conditions suggests that continued separation is detrimental to patient centered care. beyond treatment implications, there are extremely important health policy concerns. if treatment of periodontitis and other dental problems leads to reduced incidence of chronic illness, fewer complications from chronic diseases and reduced morbidity among chronically ill patients, increased access to dental services could signifi cantly reduce health care costs. the diseases associated with periodontitis are among the most common illnesses, the fastest growing and the most expensive diseases that we treat. a recent robert wood johnson report notes that approximately 141 million americans have one or more chronic conditions, that the number of people with chronic conditions is expected to increase by 1% per year for the foreseeable future and that the most common chronic conditions include hypertension, disorders of lipid metabolism, upper respiratory disease, joint disorders, heart disease, diabetes, cardiovascular disorders, asthma and chronic respiratory infections (anderson 2010 ) (see fig . 4 .1 ). one in four americans has multiple chronic conditions. ninety-one percent of adults aged 65 and older have at least one chronic condition and 73% have two or more of them (anderson 2010 ) . people with chronic conditions account for 84% of all healthcare spending. seventy eight percent of private health insurance spending is attributable to the 48% of privately insured persons with chronic conditions. seventy three percent of healthcare spending for the uninsured is for care received by the one third of uninsured people who have chronic conditions. seventy nine percent of medicaid spending goes to care for the 40% of non-institutionalized benefi ciaries who have chronic conditions (anderson 2010 ) (see fig. 4 .2 ). further, health care spending increases with the number of chronic conditions (anderson 2010 ) (see fig. 4 .3 ). more than three fi fths of healthcare spending (two thirds of medicare spending) goes to care for people with multiple chronic conditions. those with multiple chronic conditions are more likely to be hospitalized, fi ll more prescriptions, and have more physician visits (anderson 2010 ) . in 2002 the american diabetes association estimated direct medical expenditures for diabetes at $91.8 billion: $23.2 billion for diabetes care, $24.6 billion for chronic complications and $44.1 billion for excess prevalence of general medical conditions. approximately 52% of direct medical expenditures were incurred by people over 65. indirect expenditures included lost workdays, restricted productivity mortality and permanent disability -a total of $39.8 billion. all told, diabetes was found to be responsible for $160 billion of $865 billion in total expenditures. per capita medical expenditures totaled $13,000 annually for people with diabetes and $2600 for people without diabetes (hogan et al. 2002 ) . more recently, dall and colleagues estimated that the us national economic burden of prediabetes and diabetes had reached $218 billion in 2007, $153 million in higher medical costs and $65 billion in reduced productivity. annual cost per case was estimated at $2,900 for undiagnosed diabetes and 10,000 for type 2 diabetes (dall et al. 2010 ) . the costs of caring for people with diabetes have risen both because the numbers of diabetics has been increasing and because the per capita costs of care have increased. the number of diabetics increased from 5.8 million on 1980 to 14.7 million in 2004 (ashkenazy and abrahamson 2006 ) . a recent report by the unitedhealth group center for health reform & modernization provides a dire estimation -that more than 50% of adult americans could have diabetes (15%) or prediabetes (37%) by 2020 at a cost of $3.35 trillion over the decade. this compares with current estimates of 12% of the population with diabetes and 28% with prediabetes, or 40%. these estimates conclude that diabetes and prediabetes will account for 10% of total healthcare spending in 2020 at an annual cost of $500 billion, up from an estimated $194 billion in 2010 (unitedhealth center for health reform and modernization 2010 ) . average annual spending over the next decade by payer type is $103 billion for private health insurance, $204 billion for medicare, $11 billion for medicaid and $16.6 billion for the uninsured. what about cardiovascular disease and rheumatoid arthritis? among the top ten health conditions requiring treatment for medicare benefi ciaries in 2006 approximately 50% of benefi ciaries suffered from hypertension, 25% from heart conditions, 33% had hyperlipidemia 24% had copd, 23% had osteoarthritis and 22% had diabetes (thorpe et al. 2010 ) . the american heart association estimates the 2010 cost of cardiovascular disease and stroke to be $324 billion in direct expenditures and $41.7 billion for productivity losses due to morbidity and $137.4 billion in lost productivity due to mortality (present value of lost wages at 3%) (lloyd) . the centers for disease control estimates that during 2007-2009 50 million americans had selfreported doctor diagnosed arthritis, 21 million of them with activity limitations (cheng et al. 2010 ) . cisternas and colleagues estimated that total expenditures by us adults with arthritis increased from $252 billion in 1997 to $353 billion in 2005. most of the increase was attributable to people who had co-occurring chronic conditions (cisternas et al. 2009 ) . the cisternas study appears to aggregate all medical care expenditures by people with arthritis (which would include expenditures to treat diabetes and cardiovascular disease). an earlier cdc study focused on the direct and indirect costs in 2003 attributable to arthritis that estimated $80.8 billion in direct costs (medical expenditures) and $47 billion in indirect costs (lost earnings) (yelin et al. 2007 ) . in short, current cost estimates for direct health care expenditures (excluding productivity losses) related to diabetes are approximately $190 billion, for cardiovascular treatment, $324 billion, and for rheumatoid arthritis, approximately $111 billion (estimating that the $80.8 billion in 2003 costs have grown approximately 6% per year), a total of $625 billion of the $2.6 trillion that will be spent in the us in 2010. moreover, given current growth in the prevalence of diabetes, the unitedhealth estimate of $500 million in 2020 spending for diabetes alone is not unreasonable. if health care costs attributable to diabetes, cardiovascular disease and rheumatoid arthritis only increase by 100% over the next decade (even given added demand produced by the aging baby boomer population), annual costs of these chronic diseases will exceed $1.2 trillion in 2020. if we use the unitedhealth estimates for the proportions of diabetes costs paid by private insurance (48%), medicare (38%), medicaid (6%) and the uninsured (8%) and estimate total costs based on the 2010 studies projecting a 50% increase in 5 years and a 100% increase in 10 years we can obtain an estimate of future costs for treating diabetes, cardiovascular disease and arthritis. table 4 .1 set forth below, summarizes these cost estimates. by 2020 medicare costs for these chronic illnesses would be approximately $475 billion. the estimated costs to medicaid will be approximately $75 billion. the costs for the uninsured will be approximately $100 billion. any intervention that has the potential to substantially reduce these costs will produce meaningful results. unfortunately, even though there had been a substantial numbers of studies that show relationships between dental disease and chronic illness that are have been very few studies that actually test whether improved dental treatment reduces the incidence of chronic illness and complications due to chronic illness. the potential for large health care cost savings through an active and aggressive program of dental care is so large that such studies are clearly indicated. suppose, for example, that 10% of all medical care costs required to treat diabetes, cardiovascular disease and arthritis could be avoided through an active aggressive program of dental care. 4 what this would mean is that in 2020 private health insurers could see a $60 billion reduction in healthcare costs, medicare would see a $47.5 billion reduction and medicaid pay $7.5 billion reduction. recent health reform has provided for the issuance of health insurance to the uninsured by state exchanges. aggressive dental care that saved 10% of costs attributable to diabetes, cardiovascular disease and arthritis could save the exchanges $10 billion per year. and, if greater proportions of costs can be saved or if the 2020 estimates of costs are low, potential benefi ts will be even larger. once again, it would be important to know whether aggressive dental care could produce such savings and how much. ide and colleagues found that people who were treated for periodontitis incurred 21% higher health care costs than those who were free of periodontal disease (ide et al. 2007) . similarly, albert, et al., found medical costs associated with diabetes, cardiovascular disease and cerebrovascular disease were signifi cantly higher for enrollees who were treated for periodontitis than for other dental conditions (albert et al. 2006) . additional studies of this nature would be important to support a measured approach to expanding dental coverage. so what do we mean by an aggressive dental treatment plan? suppose we were to provide dental insurance to all medicare benefi ciaries at the level of current private dental insurance coverage and strongly encourage benefi ciaries to receive dental treatment. suppose we were to provide for medicaid payment for all benefi ciaries at the level of current private dental insurance coverage. suppose health care insurers provided dental coverage in order to reduce their costs and that such coverage was consistent with current private dental insurance coverage. suppose health insurance companies, understanding the benefi ts from dental care, were to require their private employer customers to cover the costs of dental care. how much would all of this cost? how would it compare to the benefi ts that may be available? in order to estimate the potential costs of providing enhanced coverage for dental care we start use the cms estimates of national health care spending for dental services and statistical abstract of the us estimates for medicare enrollment, medicaid enrollment, private health insurance enrollment and uninsured persons. based on the estimate that half of private employers with health insurance provided dental insurance coverage we estimate that of the private health insurance enrollment one half would have dental insurance coverage and one half would not. table 4 .2 sets forth the national health care expenditures for dental services in millions and enrollment in private dental plans, medicare, medicaid, the uninsured without health insurance and dental insurance, the uninsured with health insurance and dual eligibles. from this we derive a cost per enrollee for private dental insurance, medicare dental benefi ts and medicaid dental benefi ts. in order to estimate the annual cost of providing full dental coverage to medicare benefi ciaries we subtracted dual eligibles (who receive some dental insurance) from total medicare enrollees to determine the number of persons who would need coverage. in our 2009 example there were 43 million medicare benefi ciaries including 9 million dual eligibles. accordingly, the estimates would cover the 34 million medicare benefi ciaries that are not dual eligible at a cost equal to the per capita cost of private dental insurance ($494.66) less amounts that medicare is already paying for dental services ($6.73 per person). the result provides an estimate of the cost of covering all medicare benefi ciaries for dental services at a level equivalent to private health insurance. using the 2009 example the cost of providing full dental insurance coverage to medicare benefi ciaries would have been $16.6 billion. in addition, we used the cms national health expenditure fi gures to determine administrative costs for private health insurance, medicare and medicaid as a percentage of program expenditures for medical care. we found that the administrative costs of the medicare program were 6.2% on average for 1966-2009. in order to fully estimate the cost of medicare dental coverage we added 6.2% to the cost health insurers will be in the same position as medicare and medicaid regarding dental coverage. if quality dental coverage saves health care costs attributable to diabetes, cardiovascular disease and rheumatoid arthritis then the exchanges will have an incentive to provide quality dental coverage to reduce costs. accordingly, we estimated the cost of providing dental coverage equivalent to private dental insurance coverage through the exchanges. again we assume that the costs of such coverage will be equivalent to the number of uninsured persons multiplied by the annual per capita cost of coverage. 5 for the 2009 example, this would refl ect coverage for 52 million people at $494.66 per person, a total of $24.9 billion. with administrative costs, the cost of providing dental insurance coverage to the uninsured at a level equivalent to private dental coverage would be $26.8 billion. finally, given the evidence that improved dental care has the potential to reduce health care costs private health insurers may wish to expand health insurance to cover dental care. 6 here, we estimate the cost of providing dental insurance to the 50% of the workforce whose employers currently do not provide dental insurance benefi ts. once again, we multiply the number of covered lives by the estimated annual per capita cost. for the 2009 example we estimate 101 million adults will receive dental coverage at $495 per person: $50 billion for dental services and $3.8 billion for administrative costs or a total of $53.8 billion. of course, as noted a number of times above, these estimates are based on providing full "universal" dental insurance coverage at levels equivalent to current benefi t levels for private dental insurance. it may be that an appropriate package of dental services that deals specifi cally with periodontitis can be provided for less than the full cost of private dental insurance. once again, further research should provide better information. 7 5 the health reform law does not attempt to provide coverage to all 52 million people without health insurance. estimates are that only 31 million people will be covered by the bill. even though this is the case we prepare our estimates using all 52 million uninsured americans. 6 indeed, the failure of 50% of employers to cover dental services may well constitute a classic externality in the market for health insurance. internalizing this externality may well provide better effi ciency. 7 it is also possible that dental care for persons with greater incidence of chronic illness as is the case with medicare benefi ciaries may require even higher levels of spending per benefi ciary. again, it would be good to know scientifi cally if this is the case. as noted in sect. 6 above, 2010 costs for diabetes, cardiovascular disease and arthritis will be $300 billion for private health insurance, $238 billion for medicare, $38 billion for medicaid and $50 billion for the uninsured. costs of providing "full" dental coverage will be $17.6 billion for medicare, $18.2 billion for medicaid, $26.8 billion for the uninsured and $53.8 billion for private health insurance. given this, if 7.4% or more of the medicare costs can be "saved" through improved dental care, medicaid dental insurance will pay for itself and will provide a positive return on investment. see table 4 .3 . similarly, private health insurers could justify providing dental insurance coverage to employees who do not have it so long as they spend 17.9% or more of their chronic care costs for diabetes, cardiovascular disease and arthritis. on the other hand, it would appear that medicaid expansion would require cost savings of approximately 48% and that health care insurance coverage of the uninsured would require savings of approximately 54% in order to justify coverage. while it is possible, it may not be likely that full dental coverage would be justifi ed for these programs. of course, these estimates do not consider indirect costs in the form of lost wages or premature death. these costs are externalities to the health insurance programs. to the extent that they represent a social benefi t that a national dental insurance program might internalize, it would be appropriate to consider their impact in the cost-benefi t analysis. in any event, better understanding of the potential for deriving savings in health insurance costs related to chronic diseases like diabetes, cardiovascular disease and arthritis would be crucial to any determination whether to expand insurance coverage for dental care. heretofore the case for expanding medicare coverage to include dental care has taken the form of "benefi t" to patients rather than benefi t to health insurance programs and society and has been cast in emotional and political terms. for example, oral health america grades "america's commitment to providing oral health access to the elderly" (oral health america 2003 ) . in truth, there is no american commitment to providing oral health access to any age group, much less the elderly. rubenstein notes that "at least one commentator has suggested that the dental profession should join with senior citizen groups when the time is right to ask congress to expand medicare to cover oral health" (rubenstein 2005 ) . rubenstein emphasizes that "calls for action" are "mere words" unless they are accompanied by political actions that health policy professionals and the dental profession must help promote (rubenstein 2005 ) . another commentator has suggested that "as soon as the debate over medicare prescription drug coverage and, the debate to provide dental care coverage for the elderly may soon begin" (manski 2001 ) . rubenstein, again suggests that "the dental community must convince americans, and particularly aging boomers, that oral health is integral to all health, and for that reason, retiree dental benefi ts are an important issue". in truth, a decade of defi cit spending and public distaste for out of control program costs in the medicare and medicaid programs as well as the unpopularity of the process that was used to provide medicare prescription drug coverage (with perceived abuses by the health insurance and drug lobbies) and national health reform makes it unlikely that the public would be willing to approve expansions in insurance coverage for dental care "for its own sake" or "as the right thing" or to "benefi t seniors." what this political climate has produced is an arena in which a good idea that could provide appropriate return on investment for society might well be rejected out of hand based on political history of health insurance coverage. as a result, it is incumbent on policymakers, medical and dental research scientists and health economists to investigate and confi rm the potential savings that expansion of dental insurance coverage has the potential to produce and to develop hard evidence regarding potential costs of the expansion prior to, not as a part of, political efforts aimed at dental coverage expansion. a responsible, well informed effort to expand dental coverage may well go far to restore public confi dence in the health policy process. joseph kilsdonk and kelly boggs the adage of "putting your money where your mouth is" is often referenced when being challenged about public statements or claims. in this instance, we use it literally. in 2008 health care costs in us were $2.2 trillion. there have been numerous reports on health disparities, the burden of chronic diseases, increasing healthcare costs and the need for change. long-term economic benefi ts associated with the cost of care are dependent upon integrating oral health with medicine. this is particularly true as it relates to the management of those conditions which impact the economics of healthcare the most. as examples, 96% of medicare costs and 83% of medicaid costs are in managing chronic health conditions (partnership for solutions national program offi ce 2004 ) . more than 40% of the u.s. population has one or more chronic condition (cartwright-smith 2011 ) and in 2006, 76% of medicare spending was on patients with fi ve or more chronic diseases (swartz 2011 ) . effective management of health care resources and information are critical to the economic well-being of our healthcare system. we can no longer afford to manage care in isolation. integration of care between medicine and dentistry holds much promise in terms of reducing the cost of care and an integrated medical-dental electronic healthcare record (iehr) is the vehicle that will lead to downstream cost savings. in the united states the center for medicare & medicaid services (cms) has conducted demonstration projects around chronic disease management. section 121 of the benefi ts improvement and protection act of 2000 mandated cms to conduct a disease management demonstration project. april 1, 2005, as an effort to reduce the cost of care and improve quality associated with chronic diseases, cms partnered with ten premier health systems to effectively manage chronic diseases in a medicare physician group practice demonstration (pgp). it was the fi rst pay-for-performance initiative for physicians under the medicare program (center for medicare and medicaid services 2010 ) . it involved giving additional payments to providers based on practice effi ciency and improved management of chronically ill patients. participants included ten multispecialty group practices nationwide, with a total of more than 5,000 physicians, who care for more than 200,000 medicare benefi ciaries (frieden 2006 ) . the chronic diseases that were targeted were based on occurrence in the population and included diabetes, heart failure, coronary artery disease, and hypertension (frieden 2006 under the pgp, physician groups continued to be paid under regular medicare fee schedules and had the opportunity to share in savings from enhancements in patient care management. physician groups could earn performance payments which were divided between cost effi ciency for generating savings and performance on 32 quality measures phased in during the demonstration as follows: year 1, 10 measures, year 2, 27 measures and years 3 and 4 having 32 quality measures. for each of the 4 years only the university of michigan faculty group practice and marshfi eld clinic, earned performance payments for improving the quality and cost effi ciency of care. a large part of the success of this project was attributed to being able to extract, evaluate, and monitor key clinical data associated with the specifi c disease and to manage that data through an electronic health record (table 4 .4 ). during the third year of the demonstration project marshfi eld clinic, using a robust electronic health record succeeded in saving cms $23 million dollars; that's one clinic system in 1 year. as a result of such demonstration projects and as of this writing, cms is looking to establish accountable care organization's as the medical front runners to new care delivery methods for quality and cost control. accountable care organization (aco) is a term used to describe partnerships between healthcare providers to establish accountability and improved outcomes for the patients. in a cms workshop on october 5, 2010, don berwick, the administrator of cms, stated "an aco will put the patient and family at the center of all its activitiesâ�¦" an emerging model of an aco is the patient-centered medical home (pcmh). pcmh is at the center of many demonstration projects. acos were derived from studies piloted by cms. since funds provided by cms, do not cover routine dental care as part of the patient management or quality and cost objectives cms aco studies are limited if they become models for the pcmh, due to the exclusion of dental. more recently, organizations representing the major primary care specialtiesthe american academy of family practice, the american academy of pediatrics, the american osteopathic association, and the american college of physicianshave worked together to develop and endorse the concept of the "patient-centered medical home," a practice model that would more effectively support the core functions of primary care and the management of chronic disease (fisher 2008 ) . in 2011 geisinger health system, kaiser permanente, mayo clinic, intermountain healthcare and group health cooperative announced they will be creating a project called the care connectivity consortium. this project is intended to exchange patient information. although progressive in their approach their project does not include dental. these benefi ts however, are yet to be adapted in the arena of oral health. as of this writing, dentistry remains largely separate from medical reimbursement mechanisms such as shared billing, integrated consults, diagnosis, shared problem lists, and government coverage. for example, cms does not cover routine dental care. dentistry is also working to establish its own "dental home" with patients. however to reap the economic benefi ts of integrated care, a primary care "medical-dental" home is what needs to be created. according to an institute of oral health report ( 2010 ) it is widely accepted across the dental profession that oral health has a direct impact on systemic health, and increasingly, medical and dental care providers are building to bridge relationships that create treatment solutions. the case for medical and dental professionals' comanaging patients has been suggested for almost the past century, in 1926 william gies reported that "the frequency of periodic examination gives dentists exceptional opportunity to note early signs of many types of illnesses outside the domain of dentistry" (gies 1926 ) . as described by dr. richard nagelberg, dds "the convergence of dental and medical care is underway. our patients will be the benefi ciaries of this trend. for too long, we have provided dental care in a bubble, practicing -to a large degree -apart from other health-care providers. even when we consulted with our medical colleagues, it was to fi nd out if premedication was necessary, get clearance for treatment of a medically compromised patient, or fi nd out the hba1c level of a diabetic individual, rather than providing true patient co-management. we have made diagnoses and provided treatments without the benefi t of tests, reports, metrics, and other information that predict the likelihood of disease development and progression, as well as favorable treatment outcomes. we have practiced in this manner not due to negligence, but because of the limitations of tools that were available to us" (nagelberg 2011 ) . integrated medical/dental records need to be a tool in a providers' toolbox. in the case of marshfi eld clinic, dental was not included in their past cms demonstration project as dental is not a cms covered benefi t, and thus not part of the demonstration. however, as a leader in healthcare, the marshfi eld clinic recognizes the importance of data integration for both increased quality and cost savings. "marshfi eld clinic believes the best health care comes from an integrated dental/medical approach," said michael murphy, director, business development for cattails software. integration enhances communication between providers and can ultimately lead to better management of complex diseases with oral-systemic connection, avoidance of medical errors, and improved public health. while the cms pgp and other demonstration projects along with independent studies have shown to improve quality and reduce costs through integration, greater results may be afforded if studies are not done in isolation from dental data. in fact, if healthcare does not fi nd a way to manage the systemic nature of the 120 pathogens known to the oral cavity the economic impact and cost savings around chronic disease management will hit a ceiling. the economic opportunity of having clinical data for integrated decision making is readily identifi ed by the insurance industry. the effective management of clinical data around chronic and systemic oral and medical disease as part of an iehr is the greatest healthcare cost savings opportunity associated with such a tool. the insurance industry sustains itself through risk management [obtaining best outcomes] using actuarial analysis [data] and controlling costs [reduction of costs] in order to ensure coverage [profi tability]. as such they have pursued the economic and outcome benefi ts of integrated medical -dental clinical decision making. as an example, in 2009 there was a study conducted by the university of michigan, commissioned by the blue cross blue shield of michigan foundation ( 2009 ) , the study included 21,000 blue cross blue shield of michigan members diagnosed with diabetes who had access to dental care, and had continuous coverage for at least 1 year. with regular periodontal care, it was observed diabetes related medical costs were reduced by 10%. when compounding chronic health complications were also examined, the study showed a 20% reduction in cost related to the treatment of cardiovascular disease in patients with diabetes and heart disease. a 30% reduction in cost related to treatment of kidney disease for patients with diabetes and kidney disease. and a 40% reduction in costs related to treating congestive heart failure for patients with diabetes and congestive heart failure. according to a joint statement by lead researchers, and blue cross blue shield of michigan executives, "our results are consistent with an emerging body of evidence that periodontal diseaseâ�¦it addresses quality of care and health care costs for all michigan residents." also, at the institute for oral health conference in november 2007 joseph errante, d.d.s., vice president, blue cross blue shield of ma reported that 2003 blue cross blue shield of massachusetts claims data showed medical costs for diabetics who accessed dental care for prevention and periodontal services averaged $558/month, while medical costs for diabetics who didn't get dental care were about $702/month (errante 2007 ) . similarly insured individuals with cardiovascular diseases who accessed dental care had lower medical costs, $238/month lower than people who did not seek dental treatment (errante 2007 ) . the cost is $144 less per visit for those diabetics who accessed prevention and periodontal services. those savings could be translated into access to care or additional benefi ts for more individuals. in the case of neonatal health there is similar research. over 12% of all births in the u.s. are delivered preterm, with many infants at risk of birth defects ( martin et al. 2009 ) . according to a january 2006 statement issued by cigna, announcing their cigna oral health maternity program, "the program was launched in response to mounting research indicating an increased probability of preterm birth for those with gum disease. these research-based, value-added programs are designed to help improve outcomes and reduce expense" (cigna 2006 ) . the program was initially designed to offer extended dental benefi ts free of charge to members who were expecting mothers, citing "research supporting the negative and costly impact periodontal disease has on both mother and baby." according to research cited by cigna, expecting mothers with chronic periodontal disease during the second trimester are seven times more likely to deliver preterm (before 37th week), and the costs associated with treating premature newborns is an average of 15 times more during their fi rst year, and premature newborns have dramatically more healthcare challenges throughout their life. cigna also cited the correlation between periodontal disease and low birth weight, pre-eclampsia, gestational diabetes as additional rationale to support extended dental benefi ts to expecting mothers. six months later cigna initiated well aware for better health, an extended benefi ts free of charge program for diabetic and cardiovascular disease patients aimed at "turning evidence into action by enhancing dental benefi ts for participants in disease management" programs. it is interesting to note, not only does cigna offer extended dental benefi t to targeted groups, they also reimburse members for any out-of-pocket expenses associated to their dental care (co-pays, etc.) in 2006, columbia university researchers conducted a 2-year retrospective study of 116,306 aetna ppo members with continuous medical and dental insurance, exhibiting one of three chronic conditions (diabetes mellitus, coronary artery disease, and cerebrovascular disease) (aetna 2008 ) . researchers found members who received periodontal treatments incurred higher initial per member per month medical costs, but ultimately achieved signifi cantly lower health screening (episode risk group/erg) risk scores than peers receiving little or no dental care. convinced by the data and understanding lower risk scores ultimately leads to healthier people and cost savings, aetna initiated the dental/medical integration (dmi) program in 2006. aetna's dmi program offers enhanced benefi ts in the form of free-of-charge extended benefi t dental care to aetna's 37.2 million indemnity, ppo and managed choice medical plan members, specifi cally targeting members deemed at-risk, including those who are pregnant, diabetic, and/or have cardiovascular disease and have not been to a dentist in 1 year as a result of various outreach methods during the pilot, 63% of at-risk members who had not been to a dentist in the previous 12 months, sought dental care (aetna 2008 ) . "the fi ndings from this latest study we conducted continue to show that members with certain conditions who are engaged in seeking preventive care, such as regular dental visits, can improve their overall health and quality of life," said alan hirschberg, head of aetna dental (aetna 2008 ) . delta dental of wisconsin understands the connection between oral and systemic health and has created a program that is designed to offer members with certain chronic health conditions the opportunity to gain additional benefi ts. more than 2,000 groups now offer delta dental of wisconsin's evidence-based integrated care plan (ebicp) option (delta dental of wisconsin 2011 ) . ebicp provides expanded benefi ts for persons with diseases and medical conditions that have oral health implications. these benefi ts include increased frequency of cleanings and/or applications of topical fl uoride. they address the unique oral health challenges faced by persons with these conditions, and can also play an important role in the management of an individual's medical condition. ebicp offers additional cleanings and topical fl uoride application for persons who are undergoing cancer treatment involving radiation and/or chemotherapy, persons with prior surgical or nonsurgical treatment of periodontal disease and persons with suppressed immune systems. the ebic offers additional cleanings for persons with diabetes and those with risk factors for ie, persons with kidney failure or who are on dialysis and for women who are pregnant. the iehr provides the insurance industry in partnership with the healthcare industry an integrated tool to facilitate these health and subsequently economic outcomes across medicine and dentistry. in addition to the anticipated savings through better outcomes using integrated clinical data, an example of a positive economic outcome associated with an integrated record as related to increased effi ciency and patient safety is found in the united states veterans administration (va) hospitals and clinics. the va is one of the few institutions that have implemented the shared electronic medical-dental record successfully. the va has the ability to be the "one stop shop" for their patients. an april 2010 press release published on the department of veterans affairs website highlighted the success of va's health information technology in terms of cost reductions and "improvements in quality, safety, and patient satisfaction" (department of veterans affairs 2010 ) . the press release spotlighted a recent study conducted by the public health journal, health affairs, which focused on va's health it investment from 1997 to 2007. the study confi rmed that while va has spent $4 billion on their technology initiative, a conservative estimate of cost savings was more than $7 billion. after subtracting the expense of the it investment, there was a net savings of $3 billion for the va during the 10 years covered by the study (mcbride 2011 ) . furthermore, the study estimated that "more than 86 percent of the savings were due to eliminating duplicated tests and reducing medical errors. the rest of the savings came from lower operating expenses and reduced workload." independent studies show that the va system does better on many measures, especially preventive services and chronic care, than the private sector and medicare. va offi cials say "its [integrated] technology has helped cut down hospitalizations and helped patients live longer" (zhang 2009 ) . recently, the journal of obstetrics and gynecology reported on a tragic loss of life due to the systemic nature of oral health. a study found oral bacteria called fusobacterium nucleatum was the likely culprit in infecting a 35-year-old woman's fetus through her bloodstream (carroll 2010 ) . the doctors determined that the same strain of oral bacteria found in the woman's mouth was in the deceased baby's stomach and lungs. integrated records would provide critical data to the obstetrician including oral health issues and when the patient had her last dental exam. how does one measure the economic impact of a life not lived and another derailed by such tragedy? in a randomized controlled study, lopez et al. ( 2005 ) determined that periodontal therapy provided during pregnancy to women with periodontitis or gingivitis reduced the incidence of preterm and of low birth weight. the institute of medicine and national academies estimate that preterm births cost society at least $23billion annually . data integration of the iehr enables the effective management between the dentist and obstetrician to ensure proper periodontal therapy has been provided during pregnancy. such management based on the lopez et al. study, will have direct impact in reducing the prevalence per preterm births leading to reduced health care costs. there have also been studies indicating a correlation between poorer oral hygiene or defi cient denture hygiene and pneumonia or respiratory tract infection among elderly people in nursing homes or hospitals (rosenblum 2010 ; ghezzi and ship 2000 ; scannapieco 2006 ) . one such study of 141 elderly persons in two nursing homes in japan (adachi et al. 2002 ) concluded that "the number of bacteria silently aspirating into the lower respiratory tract was lower in the group who received professional oral care, which resulted in less fatal aspiration pneumonia in that group." over the 24 month period of the study, of the 77 patients receiving professional oral care, 5% died of pneumonia versus 16.7% of the 64 patients that died of the same cause who maintained their own oral hygiene. lack of access is certainly a key factor to consider. however, lack of available data respective to the interrelationship between oral health and systemic health also contributed to the apathy in these cases. as identifi ed above, complications are correlated to cost. as conditions compound, costs go up. marshfi eld clinic, as part of their iehr is creating a shared problem list that identifi es both oral and medical conditions and history to recent visits and medication lists for monitoring at point of care [be it a medical or dental visit], such cross access to clinical data and care management milestones serves as a tool to prevent conditions from compounding and escalating costs such as those described above. several other areas of economic impact will be seen as iehr's become broadly deployed. some of these are listed as follows: medication management. a great deal of provider and allied support time is â�¢ spent obtaining medication information between dentistry and medicine [and vice versa] including current medications, contraindications, tolerances, etc. marshfi eld clinic cattails software has created a dashboard that readily identifi es this for both the medical and dental providers. not is time saved but chances for complications or escalation of conditions is reduced [both of which impact cost]. for example an integrated record allows medical providers treating respiratory infections to include or exclude oral fl ora as the possible source of the infection which would lead to more knowledgeable prescribing decision on the antibiotic used. coordination of care has a direct impact on cost for the system and the patient. â�¢ for example, in 2008 55.6% of the us population aged 2 years and older that was diagnosed diabetes had been to the dentist in the past year (healthy people 2020 (2010 )). the us government's program healthy people 2020 includes an initiative to increase the proportion of people with diagnosed diabetes who have at least an annual dental examination. the american diabetes association recommends that diabetic patients be seen semi-annually and more if bleeding gums or other oral issues are present. the american diabetes association also recommends the consultation between the dentist and doctor to decide about possible adjustments to diabetes medicines, or to decide if an antibiotic is needed before surgery to prevent infection. the target from the healthy people 2020 is a 10% improvement at 61.2%. integrated medical/dental records could allow for the coordination of efforts between providers to include communication of treatment plan and services leading to quicker resolution, increased patient compliance, and less patient time away from work or home and potentially less travel. similarly, integrated records also create a platform to integrate clinical appointing â�¢ between medicine and dentistry. as such, combative patients or severely disabled patients needing anesthesia in order for care to be delivered can be treated with one hospital sedation vs. multiple sedations. family health center of marshfi eld, inc. (fhc) dental clinics shares an iehr with marshfi eld clinic and uses it integrated scheduling feature to complete dental care, lab work, ent care, woman's health, preventive studies, all in one visit. follow up care management can be more focused and coordinated. for example, â�¢ without the knowledge or dental conditions, medical providers could spend months attempting to control diabetes with periodontal disease. however, with access to an iehr, the practitioner or allied care manager can determine patient's oral health status immediately to determine possible infl uence of periodontal disease. similarly an iehr with a shared patient data dashboard brings to light history â�¢ and physical examination data without having to have patients be the historian to their physician on their last dental visit or for the dentist to have to rely on the patient's recall of medications or medical diagnosis. for example, if an integrated record saved providers 5 min per hour of patient care, that would be 40 min per day. imagine giving a physician or dentist 40 min more a day. in a capitated system, this allows for more patients to be seen in a day for roughly the same amount of expenditure. in a production based clinic this allows more patients to be seen and more charges per day. in either case, the investment into informatics is covered. in an underserved area, more patients get care quicker, which creates the opportunity for quicker resolution, which can lead to a healthier society, which in turn may lead them back to a productive livelihood sooner. an iehr results in one system for acquisition, orientation, training and support. â�¢ pc based owners who also own a mac and mac owners who also have to operate a pc can relate. need we say more? imagine if your pc function just like a mac [or your mac function just a pc]. no cross learning of software quirks. not having to purchase two separate units to begin with. reduced costs, increased space. not having to jump from one computer to the other computer to get data from one data from another to create a report. not having to call two separate computer companies for service or updates. third party coordination. having an iehr creates a platform for interfacing â�¢ with third party payers. a common system and language for timely reimbursement. in part, the result of an iehr is driving the diagnostic coding for dentistry. such an integrated interface provides a tool to bridge with healthcare payors that historically kept payment as segregated as the oral and medical health professions. the iehr overcomes that limitation. timely payment, consolidation of payment, expansion of covered patient and provider benefi ts based on clinical integration, and a viable system for interfacing are all potential economic benefi ts of iehr clinical data. the iehr creates new horizons for research that will lead to cost saving discov-â�¢ eries. as example, knowing the benefi ts of research, marshfi eld clinic research foundation (mcrf) has created an oral and systemic health research project (oshrp). the creation of oshrp, led by dr. murray brilliant, will allow mcrf to capitalize on its existing and growing strengths in the areas of complex disease interactions and personalized health care (phc) to advance oral health and the health of the rest of the body. the oshrp has three specifi c goals: understand the connections between oral and systemic health (diabetes, heart disease, pre-term births) understand the causes of oral diseases and determine the effect of genetics, diet, water source (well/city + fl uoridation) and microbiome. understand how improving oral health aids systemic health (comparative effectiveness) and bring personalized health care (phc) to the dental arena. the oshrp research resource will be unique in the nation. as mcrf has done â�¢ with other projects, it will share this resource with qualifi ed investigators at other academic institutions both within and outside of wisconsin. oshrp will advance scientifi c knowledge, improve healthcare and prevention, reduce the cost of oral healthcare, and create new economic opportunities. such knowledge will have a direct economic impact on the cost of care and care management. the iehr creates an ability to have an integrated patient portal to comprehen-â�¢ sively maintain their health. portals are becoming more and more popular in the healthcare industry as a means to helping maintain compliance with care management recommendations and preventative procedures. portals provide patents a tool to stay up to date on their care and recommendations. portals can take iehr clinical data, adapt it through programming, and provide creative visual reinforcement for patients as they monitor their health status. the more patients engage in owning their health status, the more preventative services are followed through with. the more medicine and dentistry can leverage the prevention potential [which insurance companies have come to realize] the more likely costly conditions can be avoided. the link between oral health and systemic health is well documented. the separation of dental and medical is not a sustainable model in modern healthcare delivery. a new model of integrated care is necessary. aristotle said, "the whole is greater than the sum of its parts." increased access to combined medical and dental histories and diagnosis at the providers' fi ngertips makes vital information available. shared diagnosis between physicians and dentists could aid in formulating interventions and to accelerate decision making abilities by allowing for prioritizing of medical/ dental procedures. clinical management and treatment of the patient would be expedited with immediate access to both records. quality could be improved through a complete picture of the patient through the dashboard. all of which have a direct or indirect economic benefi t. the iehr will be the tool that facilitates such delivery and the studies and scenarios described in these pages point to signifi cant economic benefi ts to patients, payors, and providers. if increased access, multi-provider monitoring, shared problems lists with enhanced decision making abilities from iehr could reduce healthcare costs. the greatest cost reduction will be with using the iehr to manage chronic disease. a combined dental-medical electronic record with a shared data informatics platform is most likely to yield the best long-term economic solution while maintaining or enhancing positive patient outcomes. this section reveals viewpoints from a variety of medical and dental providers. one section focuses on optimal use of ophthalmic imaging, which should show how that the challenges of clinical data integration go beyond those encountered in the effort to bring oral health and systemic health together. wendy e. mouradian , suzanne boulter , paul casamassimo , and valerie j. harvey powell oral health is an important but often neglected part of overall health. historically separate systems of education, financing and practice in medicine and dentistry fuel this neglect, contributing to poorer health outcomes for vulnerable populations such as children, while increasing costs and chances for medical error for all patients. advances in understanding the impact of oral health on children's overall health, changing disease patterns and demographic trends strengthen the mandate for greater integration of oral and overall healthcare, as reviewed in two recent institute of medicine reports (iom 2011a, b ) . the pediatric population could realize substantial benefit from oral disease prevention strategies under a coordinated system of care enhanced by integrated electronic health records (ehr). this approach would benefit all children but especially young children and those from low socioeconomic, minority and other disadvantaged groups who are at higher risk for oral disease and difficulties accessing dental care. this section focuses on the pediatric population and the need for close collaboration of pediatric medical and dental providers. first we consider how a child's developmental position and their parents' level of understanding might affect oral health outcomes. next we address the importance of children's oral health and the urgency of seizing missed opportunities to prevent disease. we then briefl y outlines some steps to preventing early childhood oral disease utilizing some of the many health providers that interact with families. finally we examine one pediatric hospital's approach to choosing an integrated ehr technology. children have unique characteristics which distinguish their needs from those of adults. children's developmental immaturities may increase their risks for poor oral health outcomes ( fig. 4 all children, but especially young children, are limited in their ability to care for their own health and must depend upon adults. a child's parent/caregiver may also lack basic oral health knowledge and an awareness of their child's oral health needs, and/or suffer from poor oral health themselves. low oral health literacy is prevalent among patients and health professionals alike in america; individuals of low socioeconomic status or from ethnically diverse backgrounds may be at particular risk for low oral health literacy (iom 2011a ) . without appropriate education, a parentâ�¦. may not correctly interpret a child's symptoms or signs of oral disease â�¢ may not know that caries is an infectious disease that can be spread to a child by â�¢ sharing spoons, for example, may not know the potential value of chewing gum with xylitol, â�¢ may not fully grasp the importance of good oral health hygiene habits, â�¢ may not grasp the consequences of a child consuming quantities of sugared â�¢ foods or beverages, may have diffi culty controlling the child's consumption of sugared foods or bev-â�¢ erages in or out of the home, may not realize the consequences of chronic use of sugared medications, â�¢ may not know the potential for systemic spread of disease from a toothache, or â�¢ for liver damage due to overuse of acetaminophen or other analgesics, may not grasp the long-term consequences of early childhood caries, â�¢ may live in a community without fl uoride in the tap water and not know about â�¢ alternative sources of fl uoride, may overlook oral health due to the stress of living in poverty, â�¢ may be fearful of dentists or oral health care due to their own experiences, â�¢ may have diffi culty locating a dental provider accepting public insurance, or â�¢ have other problems navigating the health care system. parents in turn depend on access to medical and dental providers with current understanding of the most effective ways to prevent caries and promote the child's oral and overall health. an important element in helping families is the provision of culturally-sensitive care to a diverse population. children are the most diverse segment of the population with 44% from minority backgrounds compared with 34% of the overall population (us census bureau 2010 ) . the separation of medical and dental systems and the lack of shared information can create additional barriers for families, especially for those with low health literacy or facing linguistic or cultural barriers. all pediatric health professionals have increased ethical and legal responsibilities to promote children's health, including advocacy for them at the system level (mouradian 1999 ) . although many factors can infl uence children's oral health outcomes, caries is largely a preventable disease. despite this, national trends and other data on 4 broader considerations of medical and dental data integration children's oral health attest to this persistent national problem ) . some important facts include the followingâ�¦. caries is the most prevalent chronic disease of childhood, â�¢ caries is a preventable disease unlike many chronic diseases of childhood, â�¢ yet according to (nicdr 2011) 42% of children 2-11 have had dental caries in â�¢ their primary teeth; 23% of children 2-11 have untreated dental caries. further, "21% of children 6-11 have had dental caries in their permanent teeth; 8% of children 6-11 have untreated decay." overall "[c]hildren 2-11 have an average of 1.6 decayed primary teeth and 3.6 decayed primary surfaces," the latest epidemiologic evidence shows increasing rates of caries for young-â�¢ est children, reverse from the healthy people 2010 goal of decreasing caries. according to (nicdr 2011), overall "dental caries in the baby teeth of children 2-11 declined from the early 1970s until the mid 1990s. from the mid 1990s until the most recent (1999) (2000) (2001) (2002) (2003) (2004) ) national health and nutrition examination survey, this trend has reversed: a small but signifi cant increase in primary decay was found. this trend reversal was more severe in younger children." disparities in children's oral health and access to care persist by age, income â�¢ level, race and ethnicity, and parental education level (edelstein and chinn 2009 ) . of concern, the latest increase was actually in a traditionally low-risk group of young children (dye and thornton-evans 2010 ) . the human and economic costs of early childhood caries are substantial â�¢ (casamassimo et al. 2009 ) . according to catalanotto ( 2010 ) , health consequences includeâ�¦ extreme pain, spread of infection/facial cellulitis, even death (otto 2007 ) diffi culty chewing, poor weight gain falling off the growth curve (acs et al. 1999 ) risk of dental decay in adult teeth (broadbent et al. 2005 ; li and wang 2002 ) crooked bite (malocclusion) -children with special health care needs (cshcn) may be at higher risk for oral â�¢ disease and diffi culties accessing care. analyzing data from the national survey of children with special health care needs, (lewis 2009 ) found that "cshcn are more likely to be insured and to receive preventive dental care at equal or higher rates than children without special health care needs. nevertheless, cshcn, particularly lower income and severely affected, are more likely to report unmet dental care need compared with unaffected children." children who were both low-income and severely affected had 13.4 times the likelihood of unmet dental care needs, dental care is the highest unmet health care need of children; 4.6 million children â�¢ had unmet dental care needs because families could not afford care compared with 2.8 million with unmet medical needs for the same reasons (cdc 2008 ) , according to the national survey of children's health, children are 2.6 times as â�¢ likely to lack dental as medical insurance (lewis et al. 2007 ) , there is evidence that children who get referred to a dentist early may have lower â�¢ costs of care and disease. savage et al. ( 2004 ) reported that children "who had their fi rst preventive visit by age 1 were more likely to have subsequent preventive visits but were not more likely to have subsequent restorative or emergency visits" and concluded that preschool "children who used early preventive dental care incurred fewer dentally related costs," ramosgomez and shepherd ( â�¢ 1999 ) , in their "cost-effectiveness model for prevention of early childhood caries," conclude that preventive ecc interventions could reduce ecc by 40-80% for a particularly vulnerable population of children, and that part of the costs of interventions will be offset by savings in treatment costs. as these facts convey, and the deaths of more than one child from consequences of untreated caries make painfully clear, there is an urgent need for more attention to the oral health needs of children. a more coordinated system for oral health care including integrated ehr would be an important advance. a glance at table 4 .5 , an ideal model, reveals that intervention should begin before birth and that a range of medical and oral health professionals can contribute to the child's oral health. early intervention is necessary because of the transmissibility of cariogenic bacteria from mother/caregiver to infant, and importance of oral health practice in preventing disease. the following professionals may be involved: â�¢ pediatric medical provider family physician pediatrician pediatric nurse nurse practitioner in pediatric/family practice physician assistant in pediatric /family practice other appropriate allied health professionals â�¢ the availability of some of these professionals can be affected socioeconomic status, health insurance, place of residence, or by a child's special health care need. one obvious limitation on developing a "relay" as in table 4 .5 , with a "hand-off" from family care to obstetric care to pediatric care is the education of the medical providers. as part of pre-conception and perinatal healthcare, providers should address oral health, but may lack the knowledge to do so. additionally, as noted by ressler-maerlaender et al. ( 2005 ) , "some women may believe that they or their table 4 .5 timeline of some oral health interventions to prevent early childhood caries (ecc) -birth to 3 years age (marrs et al. 2011 ; lannon et al. 2008 ; han et al. 2010 ; ezer et al. 2010 ; aap 2008 ; mouradian et al. 2000 ) child's age intervening professional(s) planning conception, prenatal and perinatal family physician the physician and/or obstetric provider educates mother-to-be about good maternal oral hygiene and infant oral health issues, including transmissibility of caries. mother's dentist assesses and treats caries, gingivitis or other oral health problems and educates the mother-to-be obstetrician/nurse midwife obstetric nurse general dentist obstetric nurse obstetric nurse advises new mother to chew xylitol gum, limit salivary contact between mother and infant, and help child avoid sugar intake (exposure) while asleep and from common sugar sources (medicines, sugared water, bottle feeding on demand at night with fl uid other than water -following tooth eruption, certain foods), and to schedule dental exam at 1 year age 6 months pediatric medical provider first dental examination recommended by aapd when the fi rst tooth comes in, usually between 6 to 12 months pediatric/general dentist educate mother about optimal fl uoride levels 1. assess the woman's oral health status, oral health practices, and access to a dental home; 2. discuss with the woman how oral health affects general health; 3. offer referrals to oral health professionals for treatment; 4. educate the woman about oral health during pregnancy, including expected physiological changes in the mouth and interventions to prevent and relieve discomfort; and 5. educate the woman about diet and oral hygiene for infants and children and encourage breastfeeding a combination of anticipatory guidance, with continuity from prenatal and perinatal care to pediatric care, can help move infant oral health from "missed opportunities" to "seized opportunities." others who may be of assistance to families in closing these gaps are professionals at the women, infants and children's (wic) supplemental nutrition program, early head start/head start and neurodevelopmental/birth to three programs. together medical, dental and community professionals can help create a system of care to improve maternal and child oral health. for the envisioned model in table 4 .5 to be realized, the mother requires access to a general dentist with accurate information on her oral health during pregnancy and on her infant's oral health, including the need for an early dental visit. the mother and child then need access to a pediatric medical provider who will provide oral health screening/counseling, and who will guide the family to establishing the child's dental home by age 1. success in dental referral requires access to a pediatric or general dentist willing and able to provide infant oral health. (dela cruz et al. 2004) , in a discussion of the referral process mentioned that among the factors in assessing the likelihood of a dental referral were the medical providers' "level of oral health knowledge, and their opinions about the importance of oral health and preventive dental care." since young children are much more likely to access medical than dental care, the medical provider plays an important role in promoting children's oral health. (catalanotto 2010 ) recommends, as part of a pediatric well child checkup: an oral screening examination, â�¢ a risk assessment, including assessment of the mother's/caregiver's oral health, â�¢ application of fl uoride varnish â�¢ anticipatory guidance (parental education) including dietary and oral hygiene â�¢ information, attempted referral to a dental home. â�¢ the aap recommends that child healthcare providers be trained to perform an oral health risk assessment and triage all infants and children beginning by 6 months of age to identify known risk factors for early childhood caries (ecc). the oral health component of pediatric care is integrated into the aap's "recommendations for preventive pediatric health care (periodicity schedule)" (aap 2008 ) . to what extent are medical and dental and providers aware of recommendations for a fi rst dental visit for a child by age one, as recommended by the aap, the american academy of pediatric dentistry (aapd), and the american dental association? (wolfe et al. 2006 ) reported that 76% of licensed general dentists in iowa were familiar with the aapd age 1 dental visit recommendation and that most obtained the information through continuing education; 11% believed that the fi rst dental visit should occur between 0 and 11 months of age. however, according to (caspary et al. 2008 ) , when pediatric medical residents were asked the age for the fi rst dental visit, the average response was 2.4 years, while 35% reported received no oral health training during residency. in a national survey of pediatricians ) reported that less than 25% of had received oral health education in medical school, residency, or continuing education. finally (ferullo et al. 2010 ) surveyed allopathic and osteopathic schools of medicine and found that 69.3% reported offering less than 5 h of oral health curriculum, while 10.2% offered no curriculum at all. other workforce considerations relevant to preventing early childhood caries include the training of dentists in pediatric oral health (seale et al. 2009 ) , the number and diversity of the dental workforce, the number of pediatric dentists, and the use of alternative providers such as dental therapists, expanded function dental assistants and dental hygienists (mertz and mouradian 2009 ; nash 2009 ) . examples of integrated care models do exist, such as that presented by (heuer 2007 ) involving school-linked and school-based clinics with an "innovative health infrastructure." according to heuer, "neighborhood outreach action for health (noah)" is staffed by two nurse practitioners and a part-time physician to provide "primary medical services to more than 3,200 uninsured patients each year" in scottsdale, arizona. heuer counts caries among the "top ten" diagnoses every year. mabry and mosca ( 2006 ) described community public health training of dental hygiene students for children with neurodevelopmental/intellectual disabilities. they mentioned that the dental hygiene students had worked together with school nurses and "felt they had impacted the school nurses' knowledge of oral disease and care." the decision to acquire an integrated ehr as pediatric clinicians (both medical and dental) work more closely together, they require appropriate ehr systems that integrate a patient's medical and dental records. following is a set of local "best practices" from nationwide children's hospital in columbus, ohio, which may help other children's hospitals in planning acquisition of an integrated pediatric ehr system. integrated (medical-dental) ehr technologies are becoming more widely available outside the federal government sector (see integrated models e1 and e2 in fig. 1.3 ). nationwide children's 'drivers' for the acquisition process were, in 2011: 1. minimize registration and dual databases . patient registration takes time and requiring both a stand-alone dental and a medical patient registration inhibits cost-effective fl ow of services. integration allows for the use of single demographics information for all clinics in the comprehensive care system serving the patient. clinicians always have an updated health history on patients, if they have been a patient of record. if not, and for a dental clinic that sees walk-ins, a brief "critical" dental health history can be completed on paper by a parent and scanned into the emr. in designing an integrated medical-dental record for patients of record, the system can sort essential health history elements into a brief focused dental history without the detail needed by other medical specialty clinics. kioskdriven electronic health histories for those children who are new to clinic similar to those used in airline travel could be considered if feasible in busy clinics. 2. for charting, no more key/mouse strokes than with paper . some commercial dental record products try to accomplish too much. moving from paper to electronics should be driven in part by effi ciencies. the tooth chart, which is an essential part of any dental record, must be such that examination fi ndings can be transferred quickly and accurately to either paper or electronic capture. a helpful exercise is visualization of the functionality of the charting process, including both the different types of entries (caries, existing restorations and pathology) and how these are entered in the paper world. if charting will be able to be used for research the system should be able to translate pictures to numerical values, often a complex programming function. dental practitioners and faculty may want to use drawings of teeth or graphics of surfaces because that is their current comfort level. a true digital charting is possible with no images of teeth, but some habits are hard to change. 3. maximizing drop downs with drop down building possible . duplication of paper chart entries using drop downs which can be upgraded as more clinical entities are found is a staple of an emr. the paper process usually relies on a clinician's wealth of medical-dental terms since inclusion of every possible, or even the most common fi ndings, is prohibitive on a paper chart. the emr drop down requires front-end loading of the most common clinical fi ndings with opportunity for free-hand additions. being able to add terms to any drop down is a needed capability. 4. don't design a system for uncommon contingencies, but for your bulk of work . a pediatric dental record should be primarily designed around dental caries, with secondary emphases on oral-facial development (orthodontics) and a lesser capability to record traumatic injuries and periodontal fi ndings. these second and third level characteristics can be hot-buttoned and should not drive the design of the basic system which is caries charting for 98% of our patients. sadly in most dental schools, the chart is slave to every teaching form, few of which ever exit with the dds into practice! these forms may have little relationship to patient care and only create "signature black holes" that need to be addressed, usually after treatment is completed. 5. progress notes should be designed for the routine entries with free-hand modification possible . student learners tend to write too much and a carefully crafted progress note format with standard entries in required fi elds helps patient fl ow and record completion. in federally funded clinics and residencies, attending reconciliation of student/resident service delivery is a compliance requirement. a well-designed emr system can "stack" required co-signing tasks on a computer screen, offer standard entries as well as free-hand options, and create a process far faster than paper records for an attending's validation (same as reconciliation?). 6. tie examination results to treatment planning and treatment planning into billing . a good system allows easy transfer of clinical fi ndings needing treatment into some problem "basket" and ideally in a tabulated format. an alternative is a split screen that allows a clinician to visualize clinical fi ndings, radiographic fi ndings while compiling a treatment plan. again, in clinical settings where compliance to medicaid/medicare regulations is required, the design of the record should give attention to auditing principles and security. a good emr system allows portals of entry for billing and compliance personnel. 7. plan for users of different skill levels and different periods of exposure . the teaching hospital or dental school environment often involves learners and attendings with varying skill levels and computer experience who may be there for brief periods of time. this reality adds signifi cant security and userfriendliness issues. some medical record systems are far too complex for shortterm or casual users. a well-integrated medical-dental emr allows navigation of the depths of the medical side should a user want to explore, but should focus on the dental portion. some suggestions in design: initial opening or logging into the dental portion for dental users, rather than â�¢ opening into the medical portion, clearly indicated options for exploration of medical portions, â�¢ orientation of major dental component (examination, radiographs, treatment â�¢ plan) in a logical dental treatment fl ow to replicate the way dentistry works rather than trying to reshape dentistry's normal fl ow to the record, minimization of seldom-used functions on the main dental screen, such as â�¢ specialty medical clinics, old laboratory tests and hyperfunctionalities like letter writing, clear identifi cation of existing non-caries dental portions like orthodontics or â�¢ trauma, so a novice user need not randomly search to see if a patient has any of these records. unfortunately, many pediatric hospitals do not yet have an ehr system that supports convenient communication among a pediatric patient's medical and dental providers. evidence of this state of affairs was provided unintentionally by (fiks et al. 2011 ) . some pediatric hospitals may have an awkward mix of systems serving physicians, dentists, and orthodontists and their shared patients. this section demonstrates how closely medical and dental professionals must collaborate to deliver appropriate oral health care for infants and children. such collaboration is especially important given the developmental vulnerabilities of children and the urgency of the oral health needs of many children, especially those from underserved populations. collaboration is made more diffi cult by the long-standing separation of medical and dental systems and poor oral health literacy of parents and medical professionals alike. teamwork in the delivery of pediatric care requires appropriate electronic patient record technology to facilitate sharing of patient information, to avoid patient record discrepancies between systems, and to create effi ciencies by maintaining only a single repository for patient demographics. only comparatively recently have appropriate integrated systems become available to support a range of clinical sites from pediatric special needs clinics to the largest children's hospitals. nationwide children's has given practical examples of effi cient decision-making in identifying an integrated system to acquire. much more work will be needed to develop the means to move towards integrating offi ce and community-based care for children through the sharing of electronic health records. oral health is an oft neglected area in the care of patients who have chronic kidney disease. furthermore, the provision of care by dentists and physicians to the same patient is fragmented as communication between the two health care providers is scant. emerging data suggesting the periodontal disease is closely linked to chronic kidney disease highlights the importance of proper oral health and the importance of communication between dentists and physicians in the care of the patient. investigators used data from nhanes iii, including information on 11, 211 adults who had an oral examination by a dentist who categorized each patient as having no periodontal disease, periodontal disease or edentulous to examine the relationship between numerous risk factors for moderate to severe chronic kidney disease, as determined by calculation of estimated gfr through use of the mdrd formula (fisher et al. 2011 ) . no chronic kidney disease was defi ned as an estimated gfr of 60 ml per min per 1.73 m 2 . three percent of the patients had ckd, 22.5% were hypertension and 4.4% had diabetes (2.4% with glycated hemoglobin of 7% or higher). four models were constructed to examine the potential relationship between periodontal disease and ckd. in model one adults with either periodontal disease or edentulous had an adjusted odds ratio of 1.83 (with 95% confi dence intervals of 1.31-2.55) of having ckd, independent of the other risk factors for ckd including of age above 60 years, ethnicity, hypertension, smoking status, female gender and c-reactive protein elevation. the fourth model contained 15 potential risk factors including the periodontal disease score and for every 1-unit increase in the score, the risk of having ckd increased by 1% controlling for the other risk factors. the authors hypothesized from their results that the relationship between periodontal disease and ckd was bidirectional in that ckd may increase the risk of periodontal disease which in turn increases the risk of ckd. grubbs et al. ( 2011 ) also used nhanes data to look more closely at the relationship between periodontal disease and ckd, using dental examinations obtained from 2001 to 2004 (n = 6,199 adults, 21-75 years) (grubbs v, et al. 2011 ) . in this analysis edentulous subjects were excluded and those with albuminuria were included in the defi nition of ckd. in the entire population ckd was present in 10.6%, but in those with moderate to severe periodontal disease this increased to 21.6%. other associations with moderate to severe periodontal disease were being older, male, nonwhite, less educated and poor. there was a strong relationship between periodontal disease and ckd (2.5 unadjusted odds ratio). when adjusted for age, gender, tobacco use, hypertension, diabetes, ethnicity, poverty and educational attainment, the odds ratio for the association of periodontal disease and ckd was still signifi cant (1.55). in some groups (mexican american, poor, and poorly educated) dental care was not received on an annual basis in the majority of this segment of the population. periodontal disease has been associated with an increased risk of death in hemodialysis patients (kshirsagar et al. 2009 ). this relationship has been poorly studied in peritoneal dialysis patients. this requires further study but it appears possible that periodontal disease might hasten loss of residual kidney function and perhaps contribute to atherosclerosis in dialysis patients and therefore, contribute to the high mortality in this population. patients who desire a kidney transplant are required to undergo a thorough evaluation beforehand including an oral examination by a dentist. some patients on dialysis have inadequate insurance which does not cover dental care, leading to a situation in which a kidney transplant is denied because the patient cannot afford the dental examination. communications between dentists and physicians in the care of the patient is scant. if oral surgery is required in a dialysis patient, the surgeon generally requires a brief summary from the nephrologist with recommendations. these might include suggestions for prophylactic antibiotics, avoidance of vasoconstrictor agents to an excess locally (which can elevate blood pressure) and the increased risk of bleeding of a dialysis patient. for more routine dental examinations no information is requested which could potentially lead to drug interactions or a dangerous situation. most nephrologists and health care providers in the dialysis unit do not inquire of the patient concerning dental health and examination of the mouth is quite uncommon. although the dialysis patient is seen monthly at a minimum, there is little conversation or documentation of oral health. connecting the electronic health records of in-patient care, the out-patient dialysis unit and the dentists' offi ce could potentially have a large impact in improving the care of those with end stage kidney disease. integrating medical and dental records in ehr's may or may not be the "golden ring." first, we need to integrate the clinical thinkingâ�¦something we both realize is important, but not likely to be solved by an inert computer. i also think that integrated records will be very cumbersome, given the fact that the language used by the separate disciplines is so different, and the kind of detail required to support good decisions and good work is so different. it could be doneâ�¦but for many professionals on either "side," they would never open the other module. to me, a more sensible solution may be to have a condensed "nugget" of information that could cross populate. "moderate periodontal disease" may be what the medical doctor needs to know, plus know what a treatment plan may include. she won't need to know the number of the teeth with the deepest pockets and erosions but will need to support the patient's determination to follow through. on the other hand, if the patient has shown remarkable initiative in gum care and has successfully migrated to a lower severity index, that would be important for congratulation and reinforcementâ�¦and also to encourage similar diligence in managing, let's say, the hypertension that is not optimally controlled. in the other direction, the dentist should know that a patient has been erratic in clinical follow up, does not self-test blood glucose, uses hypoglycemic drugs only intermittently, and has failed several appointments for eye exams. this would lead to a rather different set of approaches from a highly motivated grandmother who is enrolled in a community cultural center's senior exercise club, and is learning to become a lay community teacher for diabetes. right now, i don't think even this superfi cial degree of information is exchanged. we need to support each other's efforts, but we probably do not need to share minute details. the benefi ts of an electronic health record are well described. ehrs allow for legible standardized documentation and easier sharing of patient data between providers at multiple locations. they are less prone to loss and require much less space to store. they have the potential to result in a reduction in the cost of health care. a distinct disadvantage of the ehr, in its current confi guration, is the problem of information overload. simply put, there is often too much information presented in a way that is diffi cult to review and digest. the ehr equivalent of thumbing through a chart quickly is not yet available. as a result we frequently see practitioners look only at the last note or two as they review a patient's history. we require a way to communicate information directly relevant to patient diagnosis, treatment and prognosis among subspecialists and primary care providers. we require a way to identify subclinical cerebrovascular disease in a patient, independent of blood pressure and other traditional risk factors. we require a way to recognize which patients with cerebrovascular disease are two to four times more likely than average to develop a stroke in the next 3 years. we have a way -retinal imaging. the eye is the one place in the body we can directly observe arteries, veins and a cranial nerve in a noninvasive manner. routine imaging of the retina and optic nerve could allow primary care providers to assess retinal, and by proxy systemic, end organ damage from atherosclerosis in an effi cient manner. the key to optimal use of the medical record and effi cient yet effective communication among providers may lie with the familiar adage; a picture is worth a 1,000 words. traditionally, when ophthalmologists communicate with primary care providers they send brief letters regarding the fi ndings seen during a yearly dilated examination and the presence, absence or progression of diabetic retinopathy. these letters end by exhorting the virtues of improved blood sugar, blood pressure and lipid control, a sentiment that the primary care provider likely shares. this system of communication does not provide particularly useful information for the primary care provider, except to serve as a notice that the standard of care screening guidelines have been met. the box has been checked. if primary care providers, cardiologists, nephrologists had access to routine ophthalmic imaging, they would be able to directly visualize the effect that suboptimal blood sugar control is having on their diabetic patients. as importantly, they would be equipped with information directly predictive of congestive heart failure, stroke, and cardiovascular mortality for their patient with hypertension, hyperlipidemia and for those who smoke. large clinical studies have shown that assessment of retinal vascular changes such as retinal hemorrhages, microaneurysms and cotton wool spots provides important information for vasculopathy risk stratifi cation. as an example, wong et al. showed that the presence of retinopathy indicates susceptibility to and onset of preclinical systemic vascular disease, independent of and qualitatively different from measuring blood pressure or lipids (wong and mcintosh 2005 ) . in the atherosclerosis risk in communities (aric) study, individuals with hypertensive retinopathy signs such as cotton wool spots, retinal hemorrhages and microaneurysms were two to four times more likely to develop a stroke within 3 years, even when controlling for the effects of blood pressure, hyperlipidemia, cigarette smoking and other risk factors (wong et al. 2001 ) . in a recent study by werther et al., patients with retinal vein occlusions were found to have a two-fold increased risk of stroke compared to controls (werther et al. 2011 ) . in addition, the aric study group reported that individuals with retinopathy were twice as likely to develop congestive heart failure as individuals without retinopathy, even after controlling for pre-existing risk factors (wong et al. 2005a ) . interestingly, even among individuals without pre-existing coronary artery disease, diabetes or hypertension, the presence of hypertensive retinopathy was associated with a three-fold increased risk of congestive heart failure events (wong et al. 2005a ) . in the beaver dam eye study, cardiovascular mortality was almost twice as high among individuals with retinal microaneurysms and retinal hemorrhages as those without these signs ( wong et al. 2003a, b ) . the aric and beaver dam eye studies have also shown that, independent of other risk factors, generalized retinal arteriolar narrowing predicts the incidence of type ii diabetes among individuals initially free of the disease (wong et al. 2002a (wong et al. , 2005b . a primary care provider with access to patients' retinal photographs may therefore have the evidence needed to suggest which patient with either established systemic vascular disease or preclinical systemic vascular disease requires a more aggressive treatment and risk factor modifi cation. they could do this without wading through the electronic equivalent of piles of records. one photograph could refl ect both acute changes in blood pressure (retinal hemorrhages, microaneurysms and cotton wool spots) and chronic changes resulting from cumulative damage from hypertension (av nicking and generalized arteriolar narrowing) (sharrett et al. 1999 ; wong et al. 2002a ; leung et al. 2004 ) . in brown et al. 23 out of 24 patients, excluding those with known diabetes, that presented with a single cotton wool spot or a predominance of cotton wool spots on examination of the retina were found to have underlying systemic disease (brown et al. 1985 ) . systemic work-up revealed diagnoses including previously undiagnosed diabetes, hypertension, cardiac valvular disease, severe carotid artery obstruction, leukemia, metastatic carcinoma, systemic lupus erythematosus, aids and giant cell arteritis (brown et al. 1985 ) . these fi ndings illustrate the importance of retinal fi ndings on a systemic level. the utilization and integration of ophthalmic imaging may serve to achieve more effective communication among subspecialists and primary care providers and ultimately to provide improved diagnosis and treatment for delivery of optimal quality of patient care. moreover, the improved integration and maximal use of resources may serve to reduce overall health care cost and perhaps decrease provider frustration with the electronic health record (fig. 4 .5 ). there are cotton wool spots, exudates, intraretinal dot-blot hemorrhages and microaneurysms. av nicking is also present especially along the superior arcade just as the vessel leaves the optic nerve ( fig. 4.6 ) . av nicking, tortuosity of vessels, intraretinal hemorrhages and dry exudates are seen ( fig. 4.7 ) . there is edema of the optic nerve head, with cotton wool spots and fl ame shaped hemorrhage along the disc margin. there are several cotton wool spots along the vascular arcades and scattered dot hemorrhages throughout the posterior pole and periphery ( fig. 4.8 ) . notice the cholesterol plaque in the vessel just as it exits the optic nerve head and the pallor in the superior macula corresponding to retinal ischemia and edema ( fig. 4.9 ). the cholesterol embolus has resulted in lack of blood fl ow to the superior arcade ( fig. 4.10 ) . there is pooling of subretinal blood just superior to the optic disc with a central fi brin clot and associated vitreous hemorrhage (fig. 4.11 ) . optic disc edema, fl ame hemorrhages and venous congestion are seen in a patient with severe hypertension. biju cheriyan in clinical practice, an otolaryngologist often needs a dental consult not only because of the topographically adjacent nature of the structures but also because most structures are supplied by the same neurovascular bundle and therefore there is overlapping of symptoms. the converse scenario can also apply. apart from this, there are many systemic medical conditions (for example: bleeding diatheses, diabetes) a hypertensive optic neuropathy dentist encounters throughout his or her practice which can determine the outcome of a successful treatment. sometimes, providers may observe a cluster of diagnostic criteria which may have to a single source. in the sections below, i will explore a few of these scenarios and conditions, and indicate where and how an integrated electronic health record (ehr) could optimize delivery of health care by dentists and otolaryngologists. cleft palate/cleft lip : cleft lip and cleft palate (cl/cp) are congenital conditions that require multidisciplinary management by dentists, oral and maxillofacial surgeons, orthodontists, otolaryngologists, speech pathologists and plastic surgeons a number of studies report that a multidisciplinary approach is essential for better treatment outcomes (wangsrimongkol and jansawang 2010 ) and for post operative rehabilitation (furr et al. 2011 ). these multidisciplinary approaches may lead to new ways to manage and treat cl/cp patients (salyer et al. 2009 ). hutchinson's teeth : notching of the upper two incisors is typically seen in individuals infl icted with congenital syphilis. macroglossia refers to enlarged tongue in relation to oral cavity. macroglossia is an important sign. it can indicate important systemic diseases like systemic amyloidosis, congenital hypothyroidism, acromegaly, or down syndrome. a common complaint that dentists and otolaryngologists encounter in their practice is the common headache. because of the special nature of the neurovascular bundle of the head and neck this symptom can be presented to both dentists and otolaryngologists (ram et al. 2009 ). any sinus pathology can present as a headache to an otolaryngology practice. since the maxillary sinus fl oor is in close proximity to the maxillary premolars and molars, it is imperative to obtain a dental evaluation in persistent cases of headache. there are a number of causes for headache from the dental and otolaryngology perspective. a mal-aligned denture patient with chronic headache, whom i saw in my practice was shuttled between departments and an array of investigations only to fi nd at the end that an ill-fi tting denture caused the intractable headache. in these cases, an integration of fi ndings is extremely important in providing quality treatment to the patient and also saves money and time for the whole health care system. hence it is important to have an integrated patient record for this particular symptom alone. trigeminal neuralgia is facial pain of neurogenic origin experienced along the distribution of the trigeminal nerve(fi fth cranial nerve). it can present as a dental pain and can also be triggered by brushing teeth among other trigger factors. as a result, patients with dental pain without obvious causes are required to have a physicians' consultation to rule out this obscure condition. sometimes it is diagnosed by omission (aggarwal et al. 2011 ; rodriguez-lozano et al. 2010 ; spencer et al. 2008 ). any tumor of the nasal sinuses (specifi cally maxillary and ethmoids) can erode the lower bony wall and present in the oral cavity (usually the maxillary arch) as dental pain, loose tooth, etc. therefore, these are areas of interest to both dentists and otolaryngologists. such tumors most commonly present fi rst to a dentist or could also be an accidental fi nding. cancers of the naso/oro/laryngo pharynx can also present as toothache to a dentist as these structures have a common nerve supply from cranial nerves 5,7 and 9. therefore, an integration of the patient record may even help in early diagnosis of the tumor. the same principle applies to all oral tumors, tumors of the nasopharynx, the oropharynx etc. this is especially true of malignant lesions of the oral cavity as these may help in early detection and treatment of cancer. in these cases, an early biopsy and histopathology can save the life of the patient. therefore, it is imperative to say that a collaborative patient record can save patients' lives. ulcers of the oral cavity from aphthous ulcers to carcinomas can present both to a dentist and an otolaryngologist. oral ulcers can be of dental origin. contact ulcers from sharp edges of a mal-aligned tooth can result in intractable ulcers, where a simple smoothing of sharp edges may eradicate the ulcer and terminate it as a chronic condition and can even prevent the ulcer turning into a malignancy. if you have an integrated electronic health record (ehr) these problems are immediately addressed and managed. otherwise, the condition will consume valuable time of both the patient and the physician concerned. in addition to this, there are a few conditions which require special attention: aphthous stomatitis (canker sore), which may indicate oral manifestation of defi ciencies of iron, vitamin b12, folate deficiency and oral candidiasis, which can be a sign of diabetes mellitus or of an immunocompromised patient (e.g. aids). temperomandibular joint (tmj) disorders can present in a variety of symptoms to both dentists and otolaryngologists. they can present as a headache, earache, toothache, or as facial pain. there can be a number of causes for this including osteoarthritis of the tmj, recurrent dislocation, bruxism, or even an ill fi tting denture. there have been cases where patients have been subjected to removal of teeth for chronic toothache only to discover at the end that the symptom was a referred pain from tmj! therefore, an integrated ehr can prevent misdiagnoses and resulting impairment or disability to patients. trismus (lock jaw) can indicate important diagnoses such as tetanus and rabies.it is due to a spasm of muscles of mastication, which is an important oral manifestation of widespread muscle spasm. apart from these conditions, other causes of trismus are peritonsillar abscesses, and scleroderma. other problems dentists and otolaryngologists encounter in clinical practice are concurrent systemic diseases (patients with multiple problems): patients with bleeding diatheses, diabetes mellitus and a hidden primary malignancy. a non-healing ulcer in the oral cavity may hide a primary malignancy behind it. in these cases, you have to look for it specifi cally. similarly, one has to be aware of oral manifestations of internal pathology. some of them are crohn's disease, ulcerative colitis and gastro-intestinal tract malignancies. often dentists see patients after a tooth extraction with intractable bleeding to fi nd that they have a bleeding diathesis. so, this may be the fi rst presentation of these patients' bleeding disorder. when this patient undergoes any elective procedure in future, it will be a great help to surgeons to be aware of this information to prevent any inadvertent complications. therefore an integrated ehr can prevent unwanted complications where a patient's life may be in jeopardy. the source of otalgia or earache can be from a number of sites other than ear itself. technically ear lobe and ear canal are supplied by four different cranial nerve branches (5th, 7th, 9th, 10th). therefore, an area with a common nerve supply can present as earache. common dental problems which present as referred otalgia are (1) dental caries (2) oro-dental diseases or abscesses (3) an impacted molar tooth (which is a common cause) (4) malocclusion (5) benign and malignant lesions of oral cavity and tongue (kim et al. 2007 ) . therefore, it is essential these two departments collaborate with each other in diagnosing and treating these diseases, and one way of facilitating it is through an integrated ehr system. there is a lot of overlap between dentists and otolaryngologists in the diagnosis and treatment of patients with halitosis (delanghe et al. 1999 ; bollen et al. 1999 ) . poor oral hygiene is the most common cause for this common complaint. oral causes include tooth caries, oral ulcers, periodontal diseases, unhealthy mucosa of the oral cavity. it is interesting to note that a simple oral ulcer can form an abcess eroding the fl oor of mouth and becoming a life-threatening oral cellulitis (ludwig angina). once the cellulitis has developed, it becomes a medical emergency. therefore, it is essential to prevent it before it can progress into a life-threatening condition, which of course is possible. causes pertaining to otolaryngologists include: chronic sinusitis or mucociliary disorder, chronic laryngitis or pharyngitis, pharyngeal pouches-related pathology, tumors or ulcers of naso/oro/laryngopharynx, diseases or conditions that impair normal fl ow of saliva such as salivary gland diseases or stones preventing fl ow of saliva, medications which cause dryness of mouth: antihistamines, antidepressants; local manifestation of systemic disorders: auto immune disorders, sjã¶gren syndrome, dehydration from any cause, diabetes mellitus and gastro esophageal refl ux disorder (gerd). gerd is caused by improper neuro-autonomy of the lower esophageal sphincter (les). the les does not close tightly after food intake which causes gastric content to enter the esophagus. over time this can erode mucosa and cause various diseases even becoming cancerous (friedenberg et al. 2010 ). this disorder is attributed to life style. fast food consumption habits (oily fried foods) and eating habits (swallowing food without properly chewing) are partly responsible for this disorder (lukic et al. 2010 ; al-humayed et al. 2010 ) . here again an early diagnosis can manage the disease process before it is fully developed. at present there are no integrated ehr systems serving these specialties (dentistry and otolaryngology). an integrated ehr would facilitate effi cient communication between a dentist and an otolaryngologist who are providing care to the same patient and addressing a problem with a shared focus between the two disciplines. such integrated communication, may only require consulting the available medical or dental record of the patient, based on the particular circumstance. even enabling this simple communication would avoid duplication of effort, clarify the context of certain symptoms and reduce stress endured by the patient. it also has the potential to reduce healthcare delivery costs, and in some cases, even contribute to saving the patient's life. henry hood, allan g. farman, and matthew holder in this chapter, the authors attempt to put forth a justifi cation for precisely this kind of collaborative approach through a summary and discussion of a series of actual clinical cases. the protocols discussed in the management of each of these clinical cases illustrate the value in providing whole-person, interdisciplinary health care to this complex patient population. there is arguably no single patient population for whom the provision of collaborative, interdisciplinary health care is more challenging than for patients with neurodevelopmental disorders and intellectual disabilities (nd/id). in planning and delivering the generally-accepted standard of health care to this unique population, myriad biomedical, psychosocial and sociopolitical realities converge to create a landscape that is, at best, daunting for patients with these disorders, and for the clinicians who are charged with their care. anecdotal and scientifi c evidence suggest that this landscape has produced a paucity of physicians and dentists who are willing and able to provide care to patients with nd/id, and that american medical and dental schools are providing little training focused on their care (holder et al. 2009 ; wolff et al. 2004 ) . in february of 2002, 16th surgeon general david satcher issued a report, which documented that americans with nd/id experience great diffi culty accessing quality health care (thompson 2002) . in that same report, former health and human services secretary tommy thompson said, "americans with mental retardation and their families face enormous obstacles in seeking the kind of basic health care that many of us take for granted." (thompson 2002) the disparities identifi ed by dr. satcher and secretary thompson require that physicians and dentists approach this population in a spirit of collaboration, compassion, and teamwork in order to produce positive health outcomes for them. perhaps, an even greater imperative driving the need for collaboration between medicine and dentistry in this arena is the fact that many patients with intellectual disabilities have developed this cognitive impairment as the result of an underlying neurodevelopmental disorder that is often undiagnosed. and it is this neurodevelopmental illness and the constellation of potentially devastating complications associated with that illness that create a biomedical fragility and a vulnerability that neither begins nor ends at the oral cavity, and that leaves these patients at risk in almost every aspect of their daily lives. when, for example, patients with nd/id are dependent upon publicly-funded programs for their health care, and when these systems fail to provide the health services that biomedically complex cases require because they fail to account for and accommodate the link between medical and dental pathologies, the risk of a negative outcome is greatly enhanced. such was the case for an intellectually disabled woman in michigan who, in october of 2010, was unable to access dental services through the state's public medical assistance program, and who fatally succumbed to a systemic bacteremia resulting from an untreated periodontal disease (mich. dent. assoc. 2009 ). the american academy of developmental medicine and dentistry (aadmd) defi nes a neurodevelopmental disorder as a disorder involving injury to the brain that occurs at some point between the time of conception and neurological maturationapproximately age 21 or 22 (zelenski et al. 2008 ). examples of frequently-encountered neurodevelopmental disorders would include fragile x syndrome, a genetically acquired neurodevelopmental disorder caused by a mutation at the distal end of the long arm of the x chromosome (see fig. 4 .12 ), trisomy 21, another genetic disorder, which features extra genetic material at the chromosome 21 site (see fig. 4 .13 ), and cerebral palsy, a prenatal or perinatal, acquired neurodevelopmental disorder (see fig. 4 .14 ). patients with neurodevelopmental disorders tend to present clinically with one or more of fi ve frequently-encountered, objective symptom complexes or primary complications. these fi ve, classic primary complications include intellectual disability (aka: mental retardation), neuromotor impairment, seizure disorders, behavioral disturbances, and sensory impairment (aadmd). additionally, multiple secondary health consequences can derive from the fi ve primary complications; and any one of these secondary health consequences, or a combination of them, can produce profound morbidity. an example of a common secondary health consequence seen in patients with nd/id, which is derived from intellectual disability and / or neuromotor impairment, is the patient who is unable to care for his or her own mouth, and who develops ubiquitous caries and advanced periodontal disease as a result (see: fig. 4.15 ). another example would be the patient who suffers from the secondary health consequence of gastroesophageal refl ux disease (gerd) as a result of the neuromotor impairment associated with multiple neurodevelopmental disorders; and whose tooth enamel and dentinal tissues become chemically eroded as a result of the chronic intraoral acidity produced by gerd (see: fig. 4.16 ) . the diagnosis and management of these secondary health consequences provide dentists and physicians with a unique opportunity to work together to improve the quality of health and quality of life for their patients by implementing a team approach, which crosses the traditional interdisciplinary lines of communication, and which expands each clinician's ability to make meaningful treatment options available. indeed, it is often the case that quality primary care provided in one discipline will provide potentially valuable information to an attending clinician from another discipline. such is the case with the patients featured in figs. 4.16 and 4.17 . the patient whose intraoral photograph is featured in fig. 4.14 is a 19 year-old male patient who presented to a special needs dental clinic accompanied by his mother. the mother indicated that her son was exhibiting hand-mouthing behaviors that she believed suggested he was experiencing mouth pain. a comprehensive radiographic and intraoral exam revealed, among other maladies, notched incisors, multiple diastemas, grossly decayed mulberry molars, and advanced periodontal disease. the patient also exhibited moderate to severe intellectual disability. these fi ndings were all consistent with a diagnosis of congenital syphilis. 6 however, in developing the medical history with the mother, it was learned that no previous diagnosis of syphilis had been discussed with the mother, nor was it included in the health history. in cases like this, a comprehensive dental treatment plan should always include consultation with the primary care physician for purposes of moving forward with confi rmation of the clinical diagnosis by serologic testing, and consultation with a cardiologist to assist in the management of potential cardiovascular sequelae. as the dental treatment plan is being developed, consideration should also be given to human immunodefi ciency virus (hiv) testing for this patient, as coinfection is a common fi nding 7 . this issue could easily be attended to by a primary care physician, an internist or an infectious disease specialist. in the absence of any of these team members, the dentist should feel entirely comfortable ordering hiv testing. the primary care physician and the developmental dentist should continue to advise each other and their respective consultant specialists of any signifi cant developments or new information, which could in any way impact either the medical or the dental treatment plan. as treatment progresses, both the physician and the dentist should expect improvement in the patient's periodontal status, which will likely be refl ected in a decrease in the frequency of immune-related illnesses, and in the maladaptive behaviors produced by chronic oral pain. it is quite often the case in this patient population that, with a reduction in maladaptive behaviors, comes a reduction of the use of psychotropic medications prescribed in a frequently futile attempt to manage behaviors that were born of an undiagnosed medical or dental illness. gerd is defi ned as the refl ux of gastric contents into the esophagus. gerd is primarily associated with incompetence of the lower esophageal sphincter; however there are numerous co-contributors, which may predispose a patient to gerd or exacerbate an existing refl ux problem. these co-contributors include a diet high in fat, neuromotor impairment associated with functional abnormalities such as dysphagia, neuromotor impairment associated with impaired ambulation and prolonged periods of recumbence, and the use of multiple medications including anxiolytics, calcium channel blockers, and anticholinergics. gerd is thought to affect approximately 25-35% of the general us population. it has been established in the literature that the incidence of gerd in patients with intellectual disabilities is signifi cantly higher than in the neurotypical population, and that the relative number of unreported cases of gerd is much higher in patients with a neurodevelopmental diagnosis, as well. patients who have gastric refl ux as a function of a neurodevelopmentally-derived neuromotor impairment and a coexisting intellectual disability are impaired in their ability to voice the complaint that would, in the neurotypical patient, commonly lead to an encounter with either a family physician or a gastroenterologist and, ultimately, to a diagnosis. this inability to voice a complaint can be problematic in that, left untreated, gerd can produce maladaptive and sometimes aggressive behaviors in this population. and, of even greater concern, is the fact that undiagnosed esophageal refl ux can lead to more complex conditions that can produce signifi cant morbidity or even mortality -maladies such as barrett's esophagus or adenocarcinoma of the esophagus. chronic gerd can also produce an acidic intraoral environment, which can lead to the chemical erosion of the enamel and dentinal tissues of the teeth. ali et al. have established a link between erosion of the enamel and dentinal tissues of the teeth and gerd. there is additional anecdotal evidence suggesting a link between tooth enamel erosion and gerd, and related maladies. a special needs dental clinic in the eastern united states serving 1,000 patients with nd/id, has reported that, of nine patients referred to gastroenterology who presented for dental exam with a fi nding of either tooth enamel erosion or ubiquitous caries, two cases were diagnosed with gerd, two with barrett's esophagus, three with gastritis, and one with duodenitis. in all cases, medical treatment was required. in light of all that is known about the incidence of gerd and of the gerdrelated risks unique to this patient population; and in light of the link between tooth enamel erosion and gerd, it is incumbent upon any dentist encountering tooth enamel erosion in a patient with an intellectual disability to immediately refer that patient to gastroenterology for a work up, which should include esophagogastroduodenoscopy (egd) and ph monitoring. a dentist encountering gerd in a patient with an intellectual disability must be aware that he or she may be the fi rst and only link between that patient and the diagnosis of a potentially life-threatening illness. phenytoin-induced gingival enlargement can appear as either an infl ammatory lesion or a more dense, fi brotic hyperplastic lesion. the infl ammatory lesion is one in which the gingival tissues are swollen and bleeding, and in which pain is often a component. this type of gingival enlargement is the more acute lesion, frequently seen in patients who are currently taking phenytoin. in advanced cases of infl ammatory gingival enlargement, the tissues can appear botryoid, with a characteristic grape-cluster appearance. in advanced cases of phenytoin-induced gingival enlargement, the lesion can sometimes shroud entire sections of the dentition. phenytoin has long been a common medication used to treat seizure disorders in patients with neurodevelopmental disorders and intellectual disabilities. however, the gingival enlargement it produces, and the obstacle this lesion can pose to effective oral hygiene -especially in a population in which oral hygiene is typically compromised -can, over time, lead to periodontal disease, edentulism, and in advanced cases, systemic bacteremias. gingivectomy performed to reduce phenytoin-induced gingival enlargement will typically fail unless the patient is weaned off the offending medication, and another anti-seizure medication is titrated to effect. multiple alternative anti-seizure medications are currently available, which do not have the side effect profi le of phenytoin, and most patients who are weaned off phenytoin will demonstrate a virtual 100% resolution of the infl ammatory lesion within a matter of 3 or 4 months. the image in fig. 4 .18 is of a 22 year-old, microcephalic african-american male with intellectual disability, neuromotor impairment, and a seizure disorder. figure 4 .17 illustrates the appearance of this patient's gingival tissues while he was currently on phenytoin. figure 4 .18 features the same patient 4 months after being weaned off phenytoin and placed on topiramate. these images illustrate the dramatic result that can be achieved when a dentist and a physician work in collaboration in the best interests of the patient. it is worth noting that this particular collaboration required only one intervention to achieve this result: the patient was weaned off phenytoin and was placed on a safer alternate anti-seizure medication. any dentist caring for a patient with an intellectual disability who presents with phenytoin induced gingival enlargement should immediately contact either the primary care physician or neurologist managing the patient's seizure disorder, and strongly urge that the patient be weaned off phenytoin and placed on a safer alternative anti-seizure medication. edentulism and bacteremia need not be a side-effect of a seizure management protocol. the patient seen in fig. 4 .19 is a 20 year old male patient with idiopathic intellectual disability who presented to an outpatient dental clinic for comprehensive dental evaluation and treatment. he was accompanied by his father. his father was referred to the clinic by the staff at his son's day program workshop. the day program staff had observed hand-mouthing behaviors, and they had voiced concern that the patient may be in pain. in the waiting room, the patient exhibited behaviors consistent with neurodevelopmental dysfunction. he was non-communicative, and his gaze aversion and tactile defensiveness were suggestive of autism. he was resistant and somewhat combative when directed to the dental chair, and effective behavior management in both the waiting room and operatory required the combined efforts of his father and two staff fig. 4.19 the adult patient suspected of having fragile x syndrome members. the patient's health history was positive for attention defi cit hyperactivity disorder (adhd), and there was no history of seizure or neuromotor impairment. the father indicated that, at age ten, the patient was admitted to an inpatient psychiatric unit for evaluation of his uncontrollable behavior. the following day, the parents were told that managing the patient's behavior was beyond the ability of the psychiatric unit staff, and the parents were asked to take the child home. the father also indicated that the psychiatric unit staff described the child's behavior as overwhelming. the patient was last seen by a dentist 12 years prior to presentation; examination and treatment at that time were carried out in the operating room under general anesthesia. effective oral examination of this patient required utilization of papoose board and molt mouth prop. multiple options for behavior management, including utilization of general anesthesia in the operating room, were discussed with the father, and informed consent to utilize medical immobilization techniques for purposes of this examination was obtained and documented prior to taking the patient into the operatory. in the operatory a dental examination was performed, and a baseline panel of digital radiographs was obtained. the head and facial features of this patient were suggestive of fragile x syndrome (see: fig. 4.20 ) . the body of the mandible was somewhat elongated; the nose was prominent; the head had somewhat of a triangular shape, and the patient readily averted his gaze. upon further inquiry, the father reported that the patient also exhibited macroorchidism, although he indicated that no physician or dentist had ever suggested a work up for fragile x. fragile x syndrome is a disorder with which many clinicians are unfamiliar. yet it is the second leading genetic cause of intellectual disability in the united states, and it is the leading known cause of autism in the u.s. in addition to the phenotypic fi ndings noted in this case, there are other frequently-encountered physical characteristics consistent with fragile x that may move a clinician toward this diagnosis. they include pectus excavatum or funnel chest (see fig. 4 .21 ) and joint laxity (see fig. 4.22 ) . gaze aversion, as previously mentioned, is a typical fi nding in autism and in fragile x syndrome. indeed, in conjunction with non-verbal behaviors, gaze aversion is often the fi nding that initially alerts the clinician to the possibility of a neurodevelopmental diagnosis featuring autism as a complication. figure 4 .22 features a photograph of fi ve children at a school for children with special needs. four of the children have been diagnosed with autism, and a fi fth child is a neurotypical child who was visiting his brother on the day the photograph was taken. the reader is left to decide which child is the neurotypical child. any physician or dentist who encounters a patient with an obvious intellectual disability, who does not have an established underlying neurodevelopmental diagnosis, and who presents with additional fi ndings, which may include gaze aversion, shyness, a prominent chin, pectus excavatum, a large nose or large ears, should suspect a possible fragile x diagnosis. the primary care clinician -physician or dentist -should discuss with the guardian or family member the importance of establishing a neurodevelopmental diagnosis. the family member or guardian should be informed that genetic counseling should be made available to all members of the extended family, since fragile x syndrome is a genetic disorder that can be passed from parents to offspring. once this discussion has taken place, a referral to a geneticist for a complete genetic work up is indicated. both the dentist and physician should feel entirely comfortable making this referral. in remote areas where the services of a geneticist may not be available, the attending physician or dentist may order a high resolution chromosomal analysis and a fragile x dna test, and have those results sent to a remote location for interpretation by a geneticist. consultation with a psychiatrist or a clinical psychologist may also be advisable, as patients with fragile x can sometimes experience enhanced social integration as a benefi t of behavioral therapy. the healthcare access problem for americans with neurodevelopmental disorders and intellectual disabilities is, at its core, a healthcare education problem -an education problem resulting from a long-standing defi ciency in professional training focused on the care of this patient population. and it is clear that the medical and dental professions share equally in responsibility for these defi ciencies. eighty-one percent of america's medical students will graduate without ever having rendered clinical care to a single patient with a neurodevelopmental disorder or intellectual disability; and the graduates of 90% of america's medical residency programs will graduate from those residencies having had no formal training whatsoever -didactic or clinical -in the care of this patient population. 1 additionally, 50% of graduating dentists have never treated a single patient with a disability. 2 it is no wonder that patients like those whose cases were discussed in earlier sections of this chapter have such diffi culty accessing quality health care. as robert uchin, dean of nova southeastern university college of dental medicine observed in a speech in 2003 to his faculty, "not only do we not have enough doctors to care for these patients; we don't have enough teachers to teach them how to care for them." as a result of these defi ciencies in professional education, few clinicians with any expertise in developmental medicine or developmental dentistry are to be found in communities across america. the experts in developmental medicine and dentistry, for the most part, tend to be physicians and dentists who work at the few remaining intermediate care facilities, and at special needs outpatient clinics, psychiatric hospitals, and nursing homes. these physicians and dentists possess the knowledge and expertise in these disciplines because they are the physicians and dentists with the clinical experience. unfortunately for the patients with neurodevelopmental disorders who are clamoring for quality care, there are too few of these clinicians. national experts in developmental medicine and dentistry, however, have begun to collaborate in the creation of patient care protocols; and they have produced multidisciplinary curricula in both dvd and online format. the aadmd has made available 9 hours of online curriculum in developmental medicine, developmental dentistry, and developmental psychiatry (see: list of urls). the curriculum program is entitled, the continuum of quality care , and it teaches collaborative patient care in three disciplines through an interdisciplinary format. the aadmd, through a grant from the wal mart foundation and the north carolina developmental disabilities council, and in collaboration with the north carolina mountain area health education center and the family medicine education consortium, has also established the national curriculum initiative in developmental medicine. this initiative, which is scheduled for completion in 2012, will develop curriculum standards for physicians in the primary care of adults with nd/id. the curriculum stresses the importance of a collaborative approach, which includes medicine, dentistry, podiatry, optometry, and multiple ancillary health professions. if the disparities in access to healthcare for americans with nd/id are to be resolved, physicians and dentists must be willing to cross professional boundaries and work together to plan and deliver whole-person healthcare to their patients with nd/id. interdisciplinary protocols in the diagnosis of neurodevelopmental disorders and in the management of the secondary health consequences associated with these disorders must be established. additionally, clinicians with expertise in these arenas must be willing to work and teach in our nation's medical and dental schools. the clinicians with expertise must be willing to develop predoctoral and postdoctoral curricula, and the deans of america's professional schools must be willing to include these curricula as part of their larger programs in primary and specialized care. the clinicians with expertise in developmental medicine and dentistry must also be willing to conduct patient-focused, interdisciplinary, clinical research in an effort to solve the myriad problems that create obstacles to the delivery of the standard of care for patients with nd/id. they must be willing to obtain institutional review board approval for this research, and they must be willing to make this research available to their colleagues through publication in peer-reviewed journals and text books, and in professional lecture forums. the patient featured in figs. 4.23 and 4.24 is a man named james. he is a 48 year old patient with idiopathic intellectual disability who presented to a dental clinic for evaluation of a painful facial swelling. a comprehensive intraoral exam revealed a cellulitis resulting from multiple grossly decayed teeth, and a generalized advanced periodontitis. no fewer than fi ve clinicians became involved in this patient's care. they included a general dentist, two oral surgeons, a family practice physician, and a geneticist. over the course of several months, as the treatment plan was completed, and as the chronic dental and periodontal infections were eliminated, james experienced signifi cant improvement in his overall state of health. a comparison of these two photographs reveals not only signifi cant improvement in his aesthetic appearance, but also in his skin turgor and color. these improvements in the patient's health translated to improvements in his daily life. he found gainful employment, and his caregivers now report that he smiles constantly -at work and at home. these photographs were entered into evidence in 2007 before a congressional subcommittee investigating the death of a young african-american boy who died as a result of an untreated dental abscess. the photographs were intended to make the point that patients with intellectual disabilities need not die as a result of medical illnesses derived from untreated dental disease. this patient's case illustrates that, when physicians and dentists are willing to work together toward a common goal of whole-person health for their patients, profoundly positive outcomes can be achieved. in a larger context, if our nation's medical and dental professions are willing to commit to a shared agenda, one which promotes the idea of collaborative, interdisciplinary care as a foundational concept, signifi cant improvements in quality of health and quality of life can be realized, not just for americans with neurodevelopmental disorders, but for every patient seeking quality care. in light of the events of 2001, bioterrorism has become subject of increased attention from all members of society. government agencies, professional associations, academia, etc. have expressed their determination to wage war on such threats by all means available. dentists can also participate in this effort by providing assistance at interested groups and the general public (flores et al. 2003 ) . in this chapter we will examine the elements and components that may play a role in the establishment of an electronic network for the dental profession for supporting the fi ght against bioterrorism. in this section we review the threats, the public health system, current electronic surveillance systems, regulations and ethical issues, the computerization of dentistry, and how dentistry can serve in improving biosurveillance efforts. the aftermath of september 11 and the anthrax incidents in october 2001 ( lane and fauci 2003 ) , made the us government reorganize its priorities and reform its current structure (white house offi ce of the press secretary 2003 ) . in response to these incidents, president bush proposed the "health security initiative" (white house letter 2002 ) in february 2nd of 2003. this effort labeled the "bioshield initiative," (white house letter 2002 ) has the purpose to stimulate research and development of medical countermeasures against bioterrorism attacks. however, despite all these efforts, terrorist attacks are likely to happen in the future and even the best work from intelligence and security agencies will be unable to prevent such events (betts and richard 2002 ; council on foreign relations 2003; baker and koplan 2002 ) . to cope with this threat, a report published by an independent task force sponsored by the council on foreign relations "america-still unprepared, still in danger" (council on foreign relations 2003 ) , suggested a series of steps to assist the government in preparing to better protect the country. one of these suggestions is the bolstering of the "public health systems". baker et al. defi ne the u.s. public health system as a system that consists of a broad range of organizations and partnerships needed to carry out the essential public health services, such as hospitals, voluntary health organizations, other non-governmental organizations and the business community (baker and koplan 2002 ) which can collaborate with local, state and federal public health entities. after the unfortunate incidents in 2001 the public health system was revisited and the realization that "the nation's public health infrastructure is not fully prepared to meet this growing challenge" (frist 2002 ) became clear. to address this need, congress and president bush enacted the public law (p.l.) 107-188 titled "public health security and bioterrorism preparedness and response act of 2002" (frist 2002 ; 107th congress 2002 ) . the main purpose of this law was to improve the public health capacity by means of increasing funding and fostering other measures. frist ( 2002 ) , described the law as a "good start" and that "to be prepared for bioterrorism, it is imperative that we develop a cohesive and comprehensive system of ongoing surveillance and case investigations for early detection". in this way, several early detection systems have been implemented with different levels of success among different geographic regions in the us. one of the most important initiatives over the years has been the establishment of the national electronic disease surveillance system (nedss) (baker and koplan 2002 ; nedss 2001 ) . the national electronic disease surveillance working group establishes that the "nedss is a broad initiative focused on the use of data and information systems standards to advance the development of effi cient, integrated, and interoperable surveillance systems at the state and local levels. the long-term objectives for nedss are the ongoing automatic capture and analyses of data needed for public health surveillance". the purpose of this system is to take into consideration and integrate the information of current public health systems implemented at different health department levels: county, state and fi nally at the centers for disease control and prevention (cdc). another initiative spearheaded by the cdc is biosense (looks 2004 ) . the purpose of this program is to develop advance detection capabilities of health related events including disease outbreaks. in addition, its emphasis is to improve situational awareness by integrating advanced analytics to process data generated by different health providers and other entities in the us. now that we have examined the general aspects, we will continue our background review focusing on the aspects that pertain to the specifi cs of the dental profession. this section will provide some perspective of the structure of the dental profession in comparison with its medical counterpart. "there are approximately 150,000 active dentists in the united states" (mertz and o'neil 2002 ) . in 1990 the dentistto-population ratio was of 60-100,000. and it is expected that by the year 2020 the ratio will be 52.7, which translates into one dentist for every 1,898 people. " in contrast, the physician-to-population ratio has been increasing for the past 40 years and now stands at 286 per 100,000, about one physician for every 349 people." eighty percent of the dentists are in general practice. during march 27 and 28 of 2003, the american dental association and the us public health service sponsored the conference "dentistry's role in responding to bioterrorism and other catastrophic events" (palmer 2003 ; national institute of dental and craniofacial research 2004 ) . this meeting reviewed several aspects of bioterrorism and the dental profession: the nature of biological pathogens and its oral manifestations, what needed to be communicated, how dentists should participate, etc. dr. michael c. alfano described the diffi culties that biological pathogens create for clinicians because "they are so insidious." while discussing the anthrax mailings after september 11th he pointed out that: "â�¦ early symptoms appeared so they resembled the aches, fever, and malaise of fl u so those affected delayed seeking treatment, a delay that has proven fatal in some cases". lieutenant colonel ross h. pastel of the us army medical research institute of infectious disease (usamriid) listed the "category a" pathogens as defi ned by the centers for disease control and prevention, and those are: smallpox, anthrax, plague, botulinum toxin, tularemia and viral hemorrhagic fever. he also described an outbreak of smallpox in yugoslavia in 1972 and the measure that had to be taken to control it. dr. michael glick described the oral manifestations of smallpox showing "signs 24 hours before skin rash. these oral signs include tongue swelling, multiple mucosa vesicles, ulceration, and mucosal hemorrhaging. oral signs are also evident in inhalation and gastro-intestinal anthrax. in oropharyngeal anthrax the mucosa appears edematous and congested; there may be neck swelling, fever, and sore throat" . dr. ed thompson, deputy director of the centers for disease control and prevention mentioned that "none of the new counter-bioterrorism measures can be effective unless local health practitioners are vigilant in observing and reporting a possible disease outbreak. such surveillance-knowing what to look for and whom to report to-is critical and applies not only to suspected bioterrorist agents, but to a list of reportable diseases which has grown to include such entities as west nile virus and sever acute respiratory syndrome (sars)." dr. sigurs o. krolls presented the response at the local level and he "stressed the importance of communication and the need for redundant systems", "to keep all the parties informed". he also posed the question "can dentists recognize signs and systems of contagious diseases?", and emphasized that education can be essential. dr. louis depaola made several connotations that can be key in the scope of this paper by saying "dentists can contribute to bioterrorism surveillance by being alert to clues that might indicate a bioterrorism attack. such surveillance would note if there is an infl ux of people seeking medical attention with non-traumatic conditions and fl ulike or possibly neurological or paralytic symptomsâ�¦ or even specifi c signs of a bioterrorist agent. patterns of school of work absence, appointment cancellations or failures to appear, could also be indicators." dr. depaola made clear that in cases of limited release of bioterrorist agents, dentists "have little to offer" but "a widespread attack can certainly tap into dental professional skills in recognition, isolation and management". in addition, dr. guay ( 2002 ) lists all the possible roles in which dentists can participate including "education, risk communication, diagnosis, surveillance and notifi cation, treatment, distribution of medications, decontamination, sample collection and forensic dentistry." dental informatics must pay attention to these and other recommendations, in order to develop integrated systems that take these recommendations into consideration. it is also important to understand that informatics has to work with technologies already in place like the computer-based oral health record and current standards. the fi nal recommendation from the meeting stated that to play an important role in biodefense, a serious amount of coordination and preparation will be required, not only from dentists but from other groups, most likely requiring medical and dental data integration. the cohr as described by rhodes ( 1996 ) "can provide a structure for documentation that goes beyond the concept of a blank form on a page, it includes a glossary of dental terminology for the entire content of the form as well as knowledge bases and expert systems that can enhance the practitioner's diagnostic and treatment planning decisions". he also acknowledges that one of the advantages of this type of documentation is that it "is much more transportable". he also recognizes the need for standardized methods for collecting information from dentists. schleyer and eisner ( 1997 ) defi ned several scenarios where the cohr is used in a "shared" environment where several healthcare providers interact and information is seamless communicated, improving the decisions made by clinicians. delrose and steinberg ( 2000 ) discuss how the "digital patient record" enhances clinical practice by providing "better quality information" to the clinician. although all of these benefi ts sound promising and encouraging some still express concern of the lack of standards among different information systems, which translates in communication breakdowns (schleyer 2003 ) . on the other hand, heid and colleagues ( 2002 ) mention a list all the steps that are currently being taken by different organizations such as the ada in order to produce a standardized cohr. other examples of standardization can be found in a paper presented by narcisi ( 1996 ) where ada's participation as a voting member in the american national standards institute has allowed edi or the cohr to be discussed and improved at a national level. additional infl uences in the standardization of the cohr are the security regulations mandated by hipaa, the health insurance portability and accountability act of 1996. dentists are required to "adopt practices necessary for compliance" (sfi kas 2003 ; chasteen et al. 2003 ) . these and other regulations (szekely et al. 1996 ) will encourage the homogeny among different system vendors. computer ownership, on the other hand, has increased steadily during the last 25 years. according to schleyer et al. ( 2003 ) in 1976 only 1% of dental professionals used computers in their practices compared to 85% in the year 2000. additionally similar trends in internet connectivity where described. the issues mentioned above describe the issues that have to be considered in order to create surveillance system against bioterrorism for the dental profession. this review has tried to be inclusive by covering different aspects starting with the current state of affairs and environment, treats, technology, law, etc. next we present a blueprint for developing a biosurveillance system. the purpose of developing an electronic health surveillance system is to gather information from patients directly ( wagner et al. 2006 ) by detecting signs and/or symptoms, or indirectly by obtaining other types of information such as over the counter medication sales, patients' no-shows, usage of internet search engines keywords, etc. in this particular case, the proximity of contact between the dentist and the patient is equivalent to a medical inspection in terms of immediacy and/or closeness. such signs and symptoms can be easily detected if the dentist is properly prompted to search for them. this is just one example of ways how a system could provide assistance in the detection of a bioterrorism incident. but, before describing our proposed system, it would be important to address the fact that current syndromic surveillance systems have certain advantages in terms of its particular technological implementation . the rods laboratory obtains data directly from chief complains in the emergency departments from hospitals. the advantage of this surveillance system is that the implementation has to be made with only a limited number of parties (hospitals, clinics, health systems, etc.). on the other hand, our system would have to deal with thousands of different implementations (one in each dental offi ce). this and other challenges have to be considered when designing the proposed system: the proposed system should work at multiple levels: the system would have to provide a mechanism to alert the dentist if there is â�¢ suspicion that a bioterrorist attack may be happening. the mechanism would increase the dentist's awareness in case of fi nding suspicious signs or symptoms in a patient. this can be triggered by the patient's characteristics such as geographic location of residence, etc. automated collection of information from the patient's oral health record. the â�¢ system would report to a central database signs or symptoms of interest. the aggregation of this data could generate information that would eventually identify the presence of patterns that may lead to the early detection of such events. collection of additional information, which combined with other sources, can be â�¢ useful in terms of detecting or tracing some incident. patients' "no-shows" is the primary example, that, if combined with others such as work or school absenteeism can provide a relevant pattern for public health offi cials. dr. x, who practices in a community 20 min away from capitol city, installed a new clinical management system 2 months ago. among the features that were included in this new clinical management system (cms), a bioterrorism detection module was added. she felt curious because of recent news she read in the newspaper about possible attacks against the us and decided to install such feature. he read about how the module would work in combination with the cms she just bought. the educational information provided with the software instructed dr. x, that in case that a patient victim of a bioterrorism attack happens to be seen in her practice, the software would collect information and would send it to public health offi cials. when installing the software, dr. x was asked if she agreed to share such information with authorities. she was provided the option to receive notifi cation in case some information was sent but she decided not to enforce it. during the last week a patient walked into dr. x's dental offi ce. the patient presented some signs that indicated the presence of a disease; still its origin was not clear. an epidemiologic study later would show that the patient was present at the football stadium when an infectious agent was released (fig. 4.25 ) . although, at that time his medical history showed no indication of a systemic disease, the presence of multiple oral vesicles prompted the dentist to make an annotation into the cohr. the system, by using a natural language processing engine, detected such sign and sent this information to a central database. the patient was discharged and instructed to take some support medication to treat the oral ulcers. the next day, the central database pinpointed the presence of an out of the ordinary increase in the number of cases with the same signs and symptoms around that region. when the presence of this peak was detected, the central server sent a request to the dentist computer for additional information. one of the requested elements was if there was any use of medication for treating oral ulcers. fortunately this information was available. the central database crossed this with the information of other surveillance systems together with the information from other patients that happen to have similar clinical signs and/or symptoms. dr. x received an email from a public health offi cial asking her to communicate to the local health department to discuss information about one her patients. the case depicted above simulates the release of smallpox during a football game. in the case of smallpox oral symptoms include tongue swelling, multiple oral mucosal vesicles, ulceration, and mucosal hemorrhaging (national institute of dental and craniofacial research 2004 ) . dentists could be alerted by an electronic system to search for such signs or they can be detected automatically. in case of a high incidence within a group of patients, in a confi ned area, public health offi cials get to be notifi ed. in our hypothetical case there are issues that need to be addressed in order to make such detection system feasible: as described by schleyer et al. ( 2006 ) , 85% of dentists in the us use a computer in their practices. this fi gure would generate an estimate of 127,500 computers in dental practices. this prevalence of computers represents an opportunity for public health data collection. the creation of a software application for surveillance purposes must rely on existing technology. currently there are approximately 20 major clinical management software packages in the market (dentistry today 2003 ) . out of these 20, 17 clearly permit direct database manipulation. this characteristic can easily allow the creation of a "querying" application that would look for specifi c information within the data stored by those packages. additionally, a natural language processing engine could be embedded into the application in order to detect variations in data input on the computer oral health record. nevertheless, it is necessary to obtain a detailed list of the oral manifestations of diseases that are likely to be found on patients. successful implementations of similar systems have been shown to work successfully (chapman et al. 2001 ; ivanov et al. 2002 ) and using the same approach for our system seems technically feasible. this collected information later would be send to a central server in order to be analyzed and interpreted. the components of our system would be as follows (fig. 4.26 ) : thin client: a software application distributed for data collection. it would be â�¢ conformed of a "querying" mechanism, combined with a natural language processing engine and a communication module. this software client should be as thin as possible to reduce the work load on the dentist's equipment and should be embedded as a plug-in for current clinical management systems. vendors should be contacted to ask for their collaboration in the development of such application to ensure maximum compatibility and integrity of data collection. central servers: server software in charge of integrating all the data collected â�¢ from dental offi ces. it has to be capable of handling simultaneous requests from multiple users. this server would integrate all the data and would perform an analysis with the intention of detecting anomalies. it would be recommended that redundant servers should be located in different data centers with mirroring capabilities to guarantee their survivability in case of technical diffi culties. communication network: the transmission of information should be done using â�¢ the internet. this, of course, would essentially depend on the practitioner's current connectivity. if that is not available, backup connection to the central servers should be established. dentistry uses several standards for transmission of health related information. clinical management systems use standard-based technology to transmit information (narcisi 1996 ; chasteen et al. 2003 ; szekely et al. 1996 ; dentrix dental systems 2011 ) . dentists are aware of these standards and use them in a day-to-day basis to transmit information to insurers. additionally, in order to interact with other surveillance systems such as the nedss, our application should rely on the same standards. the software both client and server should be thoroughly verifi ed to be secure in terms of being safe against hacker attacks. on the server side, redundancy should be provided so downtime is reduced from design. the system should be developed so mirrored servers are always up and running. data integrity mechanism should also be considered. privacy and confi dentiality are important issues that need to be incorporated as part of a robust biosurveillance system and distinct regulations such as hipaa require protecting patient information (frist 2002 ; chasteen et al. 2003 ; bayer and colgrove 2002 ; etzioni 2002 ; ivanov et al. 2002 ) . in our hypothetical case we describe the use of several sources of information for detecting a bioterrorist attack. we described how syndromic information is transmitted to a central database which initially should be de-identifi ed. later, after the suspicion a bioterrorist attack more information is requested (medications) and more inferences are made. this, although technically possible, would require changing our processes and also the will to share clinical information. this leads to the discussion mentioned in the background section about "individual rights" vs. "common good". although hipaa addresses public health , some other implications may arise and the health professionals including dentists, physicians, public health offi cials and patients should discuss and address such issues. as discussed earlier, legislators face a diffi cult task in terms of determining what is best on behalf of the individuals they were asked to represent. legislation may have to be passed in order to guarantee the functioning of such a system. individual freedom and privacy are important values which may pose a confl ict when collecting individuals' information even for their own good. in any case, careful consideration has to be given to which information is required to detect a bioterrorist attack and also, by keeping in mind that it is always important to reduce, as much as possible, the collection and transmission of patients' information over the internet or any other network. a detection algorithm has to be created or adapted in order to determine the presence of a bioterrorist attack. some algorithms have proven their effectiveness (wong et al. 2003a, b ) and it is likely that from these, a new analysis should be done in order to select or create one that addresses the particular needs of our system. a study was conducted to assess the feasibility of using oral manifestations in order to detect disease outbreaks (torres-urquidy et al. 2009 ) . it was found that for diseases such as botulism and smallpox it would be feasible to gather data that contains oral manifestations that would allow creating a detection signal using natural language processing followed by the use of statistical methods such as moving average to serve as part of a detection algorithm. the system should also be thoroughly evaluated, before and after implementation. to perform the evaluation before the system implementation computer simulation can be used to assess the effectiveness and likelihood of detection. simulation and modeling techniques (reshetin and regens 2003 ) have been used to estimate the effects of a bioterrorist attack. the same techniques can be used to evaluate our system. in case of the study by torres-urquidy ( 2009 ) , the investigators utilized synthetic outbreaks to test the performance of different signals. from their evaluation process, they learned, for instance, how many cases would be necessary to occur for the system to reach certain detection thresholds. several dental organizations have shown publicly their support of measures against bioterrorism. the american dental association and the national institute of dental and craniofacial research are two organizations who could play an important role in the development, deployment and ongoing support for our system. local dental societies also would also play an important role in the deployment of the proposed system. similarly, local, state and federal public health agencies should engage in activities that could make these mechanisms for health surveillance feasible. if dentists want to play an active role in the fi ght against bioterrorism, they should commit to collaborate with public health entities as well as to seek a way to integrate their information with the rest of electronic biosurveillance systems. professional organizations such as the american dental association can also participate by endorsing such efforts and by collaborating in the educational process of the dental professionals and their patients. as mentioned by dr. depaola (national institute of dental and craniofacial research 2004 ) dentists "have little to offer" in the current biosurveillance state of affairs. however, the integration of different technologies can change this perception. goldenberg et al. ( 2002 ) described over-the-counter medication sales as a technique for discovering disease outbreaks and stated that their approach may be "more timely" than traditional medical or public health approaches. medical cases that result from bioterrorism attacks do not produce symptoms until they have fully developed, so it is likely that different patterns can be detected before the patients start reaching the emergency department. as stated earlier (torres-urquidy et al. 2009 ) , it may be possible to have dentists participating of biosurveillance efforts, if we solve the proper organizational and technical challenges. dr. john r. lumpkin ( 2001 ) states that "hippocrates noted the health of the community was dependent on characteristics of a community and the habits of the people who lived there." dr. krolls (nidcr 2003) in his fi nal remarks during his presentation at the dentistry's role conference against bioterrorism, said, "dentists may pick up telltale information about what is happening in the community. after all, dentists spend more time with their patients than any other health specialty". kass-hout t, zhang x. biosurveillance: methods and case studies. muhammad f. walji maintaining patient records are essential for both clinical care and research. clinical research often occurs in the context of also providing patient care, yet the systems that are used for each are different and often cannot exchange data. the lack of data exchange between systems pose signifi cant barriers to effi ciently treating patient and conducting clinical research in dentistry. the purpose of this section is to review the benefi ts and challenges of integrating electronic health record (ehr) used for patient care and electronic data capture (edc) which is used for clinical research such as clinical trials. an increasing number of dentists routinely use ehrs (schleyer et al. 2006 ) . most dental schools in north america also use ehrs. benefi ts of using ehrs include increased legibility, portability, and improved patient safety (buntin et al. 2011) . recent federal incentives, although not directly benefi cial to dentists, will also likely spur the adoption of ehr (blumenthal and tavenner 2010 ) . clinical researchers, especially those conducting clinical trials, are also discovering benefi ts of using electronic data capture compared to paper. a clinical trial is a process in which new treatments, medications and other innovations are tested to evaluate safety and effi cacy. a standard part of health care, clinical trials are often lengthy and costly due to myriads of regulatory oversight. recent estimates set the cost of drug development in excess of $800 million (grabowski et al. 2002 ) . accurately documenting data with suffi cient detail is critical for providing patient care and conducting clinical research. while the medical record is the foundation for patient care, the case report form is the foundation in a clinical trial. not all clinical research is clinical trials. clinical trials whose data will be submitted to the fda as a new therapy or device have additional requirements relating to the collection and transmission of the data. similarly for patient care data, ehrs need to meet the privacy and security requirements of hipaa. case report forms (crf) are a medium in which research study sites collect subject data in pre-defi ned formats for communication with clinical trial sponsors (rondel and webb 2000 ) many clinical trials data are collected on paper (rondel and webb 2000 ) . data measurement, collection, and recording are considered the "most crucial stage" in the data management process (hosking et al. 1995 ) . traditionally, study coordinators often record information in a case report form and subsequently mail or fax the crf to the centralized coordinating center. there, data entry staff, sometimes with the aid of optical character recognition systems, input crf data into a computer. errors made during this second data entry process are diffi cult to detect and correct (hosking et al. 1995 ) . lengthy guidelines in literature discuss methods for developing paper case report forms to reduce data entry mistakes (hosking 1995 ) . a well-designed crf may allow a user to effi ciently collect and record pertinent data. however, forms are often revised and redesigned during a clinical trial due to changes in protocol, unforeseen outcomes, or oversight (singer and meinert 1995 ) . there has been a recent drive to use electronic case report forms (ecrf). direct data entry at a study site shortens time to analysis and provides opportunities to audit data at time of entry. this could reduce data errors that might otherwise be caught weeks after submission. for quality control purposes, some studies require double data entry using computers and paper (day et al. 1998 ) , though alternative solutions have been explored including the use of data sampling (king and lashley 2000 ) and probability statistics to select only those forms likely to contain errors (kleinman 2001 ) . ecrfs may also facilitate data collection from existing electronic information systems such as lab systems. however, ecrfs are almost always reside in a separate system that is not linked to a patients record. although many clinical research studies are still being conducted using paper, an increasing number of studies are using ecrfs and electronic data capture (edc). for example, a review of canadian clinical trials found that 40% use edc (el emam et al. 2009 ). studies that are sponsored by a pharmaceutical company and are multicenter appear to use edc at a higher rate than those sponsored by government or a university. the cost of a commercial edc is substantial. recently a freely available edc has become popular amongst universities called redcap. a tool originally developed at vanderbilt university, it is now being used at over a 100 institutions worldwide (harris et al. 2009 ). however, such tools are generally not integrated with the institutions ehr. although moving from paper to electronic will afford benefi ts there is a great need to allow data exchange between the patient care and clinical research components of information systems. although ehr and edc are similar, several challenges remain unresolved that prevent integration. one of the major barriers is likely to be different workfl ows for patient care purposes and to collect data for research. research is needed in defi ning an optimal workfl ow that can streamline the tasks associated with patient care and research, while at the same time providing a unifi ed information system that support these activities. also, the data that are collected for care and research are likely to differ. a researcher may require far more granularity of an oral health measurement than a clinician seeking to provide care. in cases when conducting a double blind placebo controlled clinical trial, the investigator may not even know the type of treatment that has been delivered to the patient. due to complexities of each domain, and large differences in goals, to date mutually exclusive workfl ows have arisen. a clinician investigator who sees a patient for both care and research, will likely need to enter data on this same patient twice; once in the ehr and once in the edc system. despite the availability of electronic systems, a major barrier is the integration and compatibility of disparate health information systems to converse with one another. the languages are important because they can help data sharing. clinical trials are not usually conducted in isolation, but are part of conventional medical care. therefore sharing data by clinical trials, patient care and laboratory systems becomes especially important with the adoption of ehrs in dentistry. in biomedical informatics, standardized terminologies are recognized as a critically important area to help better represent and share data for use in electronic systems (cimino 2000 ) . the systematized nomenclature of medicine clinical terms (snomed-ct), developed by the college of american pathologists, is the most comprehensive medical terminology (strang et al. 2002 ; chute et al. 1996 ) and is used in a number of health informatics applications. the us department of health and human services ( 2010 ) has also licensed snomed-ct, allowing access throughout the us at no charge. therefore snomed-ct is even more likely to be the vocabulary used in electronic formats of patient records in the future. the medical dictionary for regulatory activities (meddra) is terminology used by the fda and drug development industry to classify, retrieve, present, and communicate medical information throughout the medical product regulatory cycle (brown et al. 1999 ) . in particular it is used to record and report adverse drug event data. therefore standard languages are essential in sharing clinical trials data between sites, and also with regulatory agencies. no one single terminology is suited for all tasks. snomed-ct is likely to be more comprehensive to code clinical encounters, while meddra is more suited to help adverse event reporting. however, it is important that terminologies are widely adopted and used for similar purposes. even when standard terminologies are agreed upon, such information needs to be interchanged in standard formats. health level 7 (hl7) is an important organization whose standards are widely adopted in healthcare to exchange information between computer systems. the clinical data interchange standards consortium (cdisc) is also an important group that helps to defi ne different data standards specifi cally for clinical trials research, such as clinical trials or regulatory submissions. one particular challenge in oral health has been the lack of a standardized terminology to describe diagnoses. although icd contains oral health concepts, they are often not granular enough to be useful for some patient care or research purposes. recently a dental diagnostic terminology has been developed by a group of dental schools, and has already been adopted by several institutions and used within dental ehrs (kalenderian et al. 2010 ) . the american dental association (ada) has also been developing snodent, but is not yet publically available for clinical use (goldberg et al. 2005 ). another link between ehr data and clinical research is the potential to fi nd human subjects. recruiting suffi cient numbers of patients that meet eligibility requirements within an allotted time frame for clinical trials is challenging. as ehrs contain detailed information about patients, they can be used to fi nd patients that meet specifi c inclusion and exclusion criteria. informatics for integrating biology and the bedside (i2b2), an open source data warehousing platform, has been found to be a useful tool for cohort selection especially if the source data from an ehr is represented in a structured format (deshmukh et al. 2009 ). further, with health information increasingly available to patients through the internet, it is possible interested patients will be more effective in fi nding clinical trials than investigators looking for patients. many clinical trial registers are now available online. the national institutes of health (nih) have made available their database of nih funded research (mccray 2000 ) . there is currently no single repository for patients to fi nd all trials studying a health condition. a recent study assessed the comprehensiveness of online trial databases concerning prostate and colon cancer and found that online trial registries are incomplete, especially for industry-sponsored trials (manheimer and anderson 2002 ) . a more collaborative effort between government and industry-sponsored research groups to compile and standardize information may be a mutually benefi cial effort. it is not clear how many patients now enroll in clinical trials through online discovery. ehr data originally collected for patient purposes can be potentially used for research. aggregating data from multiple sources can provide a large dataset that could otherwise not be available. electronic health records (ehr) contain a wealth of information and are a promising source to conduct research. data extracted from ehrs differ from other sources such as population surveys or data obtained from payers, as they provide a more detailed and longitudinal view of patients, symptoms, diseases, treatments, outcomes, and differences among providers. therefore ehr data in dentistry can potentially provide valuable insight into oral health diseases, and treatments performed on a large cohort of subjects. ehrs also play an important role in enhancing evidence-based decision-making in dentistry (ebd) and improving clinical effectiveness through decision support (atkinson et al. 2002 ; walji et al. 2007 ; valenza and walji 2007 ; taylor et al. 2007 ; spence et al. 2007 ; chambers et al. 2007 ; langabeer 2nd et al. 2008 ; walji mf et al. 2009 ). the consortium of oral health related informatics (cohri) provides an example of how dental ehrs are used for research purposes (schleyer et al. 2006; stark et al. 2010 ) . cohri was formed in 2007 by a group of dental schools who used the same ehr platform and who are interested in sharing clinical and education data. through funding from the national library of medicine, four dental schools are participating in a pilot project to develop an inter-university oral health research database by extracting and integrating data from ehrs. one promising area where data repositories derived from ehr data can be used for new discoveries is in the area of comparative effectiveness research. comparative effectiveness research is defi ned as "a rigorous evaluation of the impact of different options that are available for treating a given medical condition for a particular set of patients." (congressional budget offi ce 2007 ) further, such research includes focusing on the clinical benefi ts and risks of each option (clinical effectiveness), and an analysis on the costs and benefi ts (cost effectiveness analysis). comparative effectiveness research (cer) is also likely to reduce costs of dental care and increase access to the majority of the population who currently receive no dental care. unfortunately many recent systematic reviews focusing on cer questions in dentistry have been inconclusive due to the lack of existing evidence in the scientifi c literature. secondary analysis of the data that reside in dental electronic health records (ehr) is a particularly appealing approach to facilitate cer and generate new knowledge. ehr data has the potential to provide a comprehensive picture of patients' histories, treatments, and outcomes, and if integrated with similar data from other dental clinics can include a large and diverse set of patients. however, numerous challenges must be solved before ehrs can be used for cer. first, data suitable for cer must actually be collected from ehr systems. second, this data, which often resides in proprietary systems, must be accessible and retrievable. and lastly, this data should be structured in a format that can be integrated with data from other sources or institutions. practice-based research networks (pbrn) are groups of primary care clinicians and practices working together to answer community-based health care questions and translate research fi ndings into practice. pbrns engage clinicians in quality improvement activities and an evidence-based culture in primary care practice to improve the health of all americans. in 2005, the national institute of dental craniofacial research funded three such research networks. the dental pbrn's to date have been conducting both prospective and retrospective research. for example, barasch et al. conducted a case controlled study to investigate risk factors associated with osteonecrosis of the jaws . many prospective studies conducted as part of pbrns still require separate data collection systems for the research data. ehr data contained in practices as part of pbrns are beginning to be used for secondary purposes. for example fellows et al. conducted a retrospective analysis of data contained in electronic health records to estimate incidence rates of osteonecrosis of the jaws ( fellows et al. 2011 ) . pbrns provide great promise of how ehr and clinical research data can be used effectively to promote both patient care and new discoveries. another area that intersects both the patient care and research realm are patient registries. patient registries are ways to track groups of patients who have had specifi c diseases or have had certain treatments. while ehr data would contain information on all types of patients, their diseases, and treatments, registries would allow focus on specifi c diseases or treatments of interest. registries would not be as costly in terms of resource requirements like a traditional clinical trial, but would require specifi c eligibility criteria, informed consents, and collection addition to that collected as part of routing care. dentistry has lagged far behind in forming data registries, primarily because dentistry is practiced in small offi ces and not in large hospitals making the process of integrating data very diffi culty. however, dental schools which themselves house large clinical operations are ideally positioned to create disease specifi c registries that can potentially use data collected for patient care and extend for research purposes. there is great potential for providing new insight in oral health by the integration of patient records and clinical research from both a workfl ow and information systems perspective. the technology challenges of developing systems that can exchange data, and use standardized terminologies appear solvable. however, the socio-technical issues such as determining how to incorporate optimal workfl ows for conducing both patient care and research with minimal additional overhead appear to be the greatest challenge before widespread adoption. similarly, there appears to be great potential in using ehr data originally collected for patient care for the secondary use of research and discovery. this will require collaboration between patients, providers and researchers from all healthcare disciples, and institutions with friendly policies for sharing data to improve both patient care and drive new discoveries. amit acharya , andrea mahnke , po-huang chyou , and franklin m. din more recently there has been a strong push from the united states federal government for the adoption of the electronic health record (ehr) within the healthcare industry. as a result, $19.2 billion is made available to incentivize the physicians, dentists and hospitals for the adoption of the ehr through the health information technology for economic and clinical health (hitech) act. as the nation head towards adoption of the ehrs, there has also been a growing interest with the majority of the u.s. dental schools to implement ehrs within the educational setting. fifty of the fi fty-six u.s. dental schools, as well as dental schools in canada and europe, are either using or in the process of adopting some aspects of a common dental ehr framework (white et al. 2011 ) . a group of dental schools known as consortium for oral health-related informatics (cohri) was formed in 2007 which used this common dental ehr framework -axium (stark et al. 2010 ) . currently there are about 20 dental schools within cohri. the ehr will not only support clinical care, but will also result in training the next generation dental students and to conduct innovative research that was not possible earlier. however, not much is known about how many of these dental schools' electronic dental records are integrated with their respective university's electronic medical record. a common medical-dental ehr model at healthcare universities would enable a holistic approach to providing patient care and provide the much needed electronic infrastructure to study interrelationship between the various oral-systemic diseases. recently a group of researchers from marshfi eld clinic in wisconsin, us conducted a survey to investigate the current states of health information technology and informatics within the dental school in the us. list of us dental schools were identifi ed through the american dental education association (adea) web site. dental schools were contacted to determine who the most appropriate person to take the survey would be. once the list of contact was developed from each dental school, an email was sent to 55 us dental schools with a link to a survey created in surveymonkey. the survey was administered on tuesday march 1, 2011. reminder survey emails were sent to all recipients on march 9 and march 17. the survey was closed on march 31. the anonymous survey was at most 23 questions, depending on how questions were answered. the survey focused on topics such as presence of dental informaticians within the dental schools, use of fi nancial and clinical information systems, interest in federal stimulus support for ehr adoption provided through american recovery and reinvestment act and meaningful use of ehr, relationships with health care entities and bidirectional nature of the dental and medical ehrs. the study was approved as exempt from the marshfi eld clinic institutional review board under section 45 cfr 46.101(b) and waived requirement for an authorization. thirty out of the fi fty fi ve dental schools responded to the survey (response rate of 55%). however, fi ve of the thirty dental schools representative did not complete the survey and hence their response was not included in the analysis. regarding the question about the presence of a dedicated department or a center for information technology (it) or informatics within the dental school in us, 80% (n = 20) of the responding dental schools had a dedicated it/informatics department or center (p-value of 0.0027). the it or the informatics department size (in terms of the number of personnel) at the 20 dental schools is illustrated in fig. 4 .27 . thirty fi ve percent (n = 7) of the us dental schools that housed an it / informatics departments had personnel with not only it training but also dental informatics training. while 40% (n = 8) of the dental schools were considering integration of dental informatics personnel within their department or center. twenty fi ve percent (n = 5) of the dental schools did not have any plans of integrating personnel with dental informatics personnel within their department or center (see fig. 4 .28 ). partial responses to additional questions in the section 1 of the survey is provided under table 4.6 . the majority of the responding dental schools were currently using financial electronic systems (fes) (p-value of <0.0001) and electronic dental records (edr) (p-value of 0.0001). the use of fes outnumbered the use of edrs in the dental schools (see fig 4.29 ) . about 77% of the dental schools that were currently utilizing the edrs used it in all the clinical modules (p-value of 0.0105), while 23% of the dental schools used the edrs in some of the clinical modules. when asked about the commercial edr system that the dental schools were using, axium (exan group, canada) was by far the most implemented edr system. two dental schools had salud (two-ten health limited, ireland) implemented and two dental schools had gsd academic (general systems design group, iowa, us) implemented. combinations of two ehr systems (home grown and dentrix) were implemented at two dental schools. one school had a dentrix only implementation, while another had developed its own edr system (home grown) (see fig. 4 .30 ). there were 13 dental schools which had implemented an edr fi ve or more years ago, 3 dental schools 3-4 years ago, 4 dental schools 1-2 years ago and 2 dental schools less than a year ago (see fig. 4 .31 ) (p value of 0.0029). when the dental schools were asked the question as to whether they were expecting to apply for the medicaid meaningful use incentive program, majority (52%) of the dental schools did not know and only 28% of the dental schools were expecting to apply within the next 4 years (fig. 4 .32 ) (p-value of 0.0044). challenges or barriers identifi ed by some of the dental schools in complying with the meaningful use objectives were (a). lack of certifi ed edr and information regarding it, (b). issues with getting auxium certifi ed and (c). qualifi cations of the edr as many of the meaningful use objectives do not apply to dentistry and lack of specifi c information about it. only 44% of the responded dental schools were part of a health system. fifty two percent (n = 13) of the responded dental schools had a formal relationship with other health care delivery entities in terms of sharing facilities, patient transfer, training programs. some of the types of relationship mentioned by the dental schools that had a formal relationship with other health care delivery entities included: (a). a gpr program and an emergency dental unit in the hospital, (b). affi liated hospital, (c). affi liation agreements, (d). oral and maxillofacial surgery (omfs), anesthesia and pedodontics all have some portion of education in medical health center, (e). omfs residents are also residents of medical health center, (f). residents providing care under contract with area hospitals, (g). sharing patients wand facilities with the health center, (h). students rotating in the community health centers and (i) collaborative grand programs. eighty fi ve percent of the dental schools that had a formal relationship with the health care delivery entities had routine interaction with them because of their existing relationship (p-value of 0.0015). their usual method for exchanging information was through informal medium such as phones, emails and faxes and formal medium such as memorandums, letters and contracts. when the dental schools were asked about the communication between the health systems' emr and the school's edr, majority of the dental schools did not have any communication (60%) or did not know is such a communication existed (25%) (p-value of <0.0001) (see fig. 4 .33 ). out of the 60% (n = 15) of the responded dental schools who's edr did not communicate with the health system's emr, 47% (n = 7) of the dental schools stated that they did not need to exchange patient information electronically as a reason for the non-communication, while 33% (n = 5) dental schools states that they would like to exchange patient information electronically but there were barriers that prevent them from doing so. some of the barriers identifi ed by these dental schools were (a). the hospitals and the dental school are not part of the same medial system and hipaa concerns prevent sharing data, (b). the dental school currently neither did have an edr nor the infrastructure to support one and (c). hospital is not interested and has high and perhaps unrealistic security standards. the remaining 20% (n = 3) of the dental schools expected to exchange patient information electronically in the near future (next 5 years). some of the information categories that were shared between the edr and emr in the small number of dental schools are illustrated in fig 4. 34 . finally when asked about any research projects under way in their dental school to investigate discrepancies between medical and dental records for the same patient, only 1 (4%) dental school was currently undertaking such project. in all common diseases, including those that affect the oral cavity, both the environment and genetics are pathogenic conspirators. unfortunately, we currently know little about the specifi c mechanisms underlying any common disease; and oral diseases are among the least understood. elucidating the etiology of chronic oral diseases will involve a synthesis of results from careful experiments of environmental exposures such as diet and tobacco use, the oral microbiome, co-morbidities, largescale, well-designed genetic studies, and the various interaction effects. with regard to genetics, the past few decades have witnessed transformative developments in our ability to interrogate the entire genome for genes that contribute to disease. while dramatic advances in experimental designs, statistical approaches, and clinical insights have greatly aided this scientifi c campaign, the central driver of this progress has been the development of high-throughput, inexpensive genetic technologies. following initial molecular studies using variant forms of enzymes, or allozymes, a major breakthrough was the use of highly informative dna-based markers throughout the genome (botstein et al. 1980 ) . this idea of directly assaying existing dna variation to conduct linkage and association studies in genetics began a revolution in disease gene mapping. recent interest from commercial entities has produced a feverish pace of technological innovation, markedly reducing cost and expanding the depth of inquiry. previously unfathomable, the testing of over one million single nucleotide polymorphisms (snps) in thousands of patients and controls is now commonplace (wellcome trust case control consortium 2007 ; schaefer et al. 2010 ) ; and very recently, next generation sequencing technologies have progressed to the point where sequencing of the entire protein-coding portion of the genome (exome) or even the entire genome is a costeffective method to examine disease traits across the entire spectrum of genetic variants in small numbers of affected individuals (ng et al. 2010 ) . there is little doubt that soon whole genome sequencing will be applied to nuclear family-based designs, studies among distantly-related affected individuals in extended pedigrees, and case/control studies involving thousands of individuals. this unprecedented scope of inquiry made possible by large-scale genetics, has begun to yield fascinating resulting into predisposition to oral cancers, caries, and periodontal disease that will molecularly redefi ne these pathologies, explicate unique biological connections with related diseases, give impetus to the development of directed therapeutics, and indeed personalize medicine. still, much more genetic focus on oral disease phenotypes is required if we are to realize this medical impact in a timely fashion. as genetic technologies have allowed the progression of interrogating single protein variants to single dna markers to entire genes to markers across the genome, and now to the entire genome sequence, the promises of these large-scale genetic studies have understandably undergone monumental expansion. it may be reasonable to expect the results from whole genome sequencing to decidedly revolutionize medicine within the next two decades. however, this new scientifi c capacity comes at a cost. as genetics, and biology in general, transitions to a data-rich science, practitioners have found themselves woefully unprepared to store and analyze the volume of data generated. once analyzed, interpretation and integration of these abundant and multifaceted results into medical practice will also be an appreciable challenge. insuffi cient assimilation of genetic fi ndings into merged dental and medical records will severely limit the ability of clinicians to appropriately treat patients. inadequately addressing these informatics issues will severely derail efforts in the basic sciences efforts as well as the translational and clinical sciences. this chapter explores the current state of genomics studies, what we have learned from genetic investigations into oral diseases, and where we may be headed. genetic studies have much to offer investigations of disease etiology. why do some acquire diseases and others do not? for those affected, why do some progress more rapidly than others? what causes some patients to respond to therapies, while others suffer from adverse reactions? these are all fundamental questions in both biology and medicine, whether the focus is on the gastrointestinal tract, the hippocampus, the lymphatic system, metabolic disorders, or oral diseases. speaking generally across disease areas, a portion of the answers to these questions often lies in described environmental effects. in numerous chronic diseases, infectious agents are likely contributors to the disease process -periodontitis, for example, is initiated by gram negative anaerobes in susceptible individuals (holt and ebersole 2005 ) . surely, unique and latent environmental exposures provide a random component to common disease susceptibility and progression. through twin studies, studies of risk in close relatives, and quantitative traits experiments, it is well-understood that heritable factors, including but not limited to dna variation, are typically responsible for 30-90% of the phenotype variability for common diseases. this section will attempt to cover, at least at a cursory level, the major salient developments affecting genetic insights into chronic and aggressive periodontitis, with some comment on genetic factors infl uencing susceptibility to caries and oral cancers. while it would be extremely naã¯ve to view genetic studies as an immediate panacea for our ills, the discovery of disease-causing genes does illuminate hitherto unknown biological pathways and molecular mechanisms, draws unforeseen connections with other traits, may improve prognostic models applicable for individuals, and suggests specifi c therapeutics. industrialization has brought forth increased lifespan and wellness through vaccination, modern sanitation practices, public health policies, and advances in medical science translated into practice. however, the accompanying physical inactivity coupled with a high calorie diet are probable contributors to an extremely common, chronically infl amed metabolic syndrome (hotamisligil 2006 ) that is thought to give rise to a multitude of intimately related disease traits: insulin resistance, compromised insulin signaling, hyperglycemia, obesity, dyslipidemia, hypertension, impaired kidney function, elevated liver enzymes and steatohepatitis, poor wound healing, neurodegeneration, vascular disease, pregnancy complications, accelerated immunosenescence, and periodontal disease (ford et al. 2002 ; ferrannini et al. 1991 ; eaton et al. 1994 ; holvoet et al. 2008 ; speliotes et al. 2010 ; eckel et al. 2005 ; d'aiuto et al. 2008 ) . these diseases often co-occur within the same patient and could be considered variable expression complications arising from a state of aberrant caloric fl ux that induces metabolic dysfunction and chronic, systemic infl ammation. these features constitute a disruption in a fundamental homeostatic mechanism with intensifying pathogenic consequences. the rapidly increasing incidence and decreasing age of onset for this pathophysiological state have generated a major source of mortality and morbidity in modern cultures (ford et al. 2002 ; ferrannini et al. 1991 ; weiss et al. 2004 ) . it is becoming increasing clear that many chronic diseases have an infectious component. there is relatively convincing evidence that many systemic, t-cell mediated autoimmune disorders may be initiated by infections. for example, from archaeological data, it is believed that an infectious agent -currently unknown -is necessary for rheumatoid arthritis (firestein 2003 ) , and both guillain-barre syndrome and rheumatic fever have well-described pathogeneses triggered by specifi c infections in susceptible individuals (bach 2005 ) . in many instances, oncogenesis and tumor progression can be traced to pro-infl ammatory responses at the site of chronic infection (coussens and werb 2002 ) , although it is not known whether these effects are mediated through the actions of the immune system, the infectious agents, or a combination thereof. several cancers fall into this category including gastric adenocarcinoma (uemura et al. 2001 ) , cervical cancer (walboomers et al. 1999 ) , hepatocellular carcinoma (saito et al. 1990 ) , and kaposi's sarcoma (dictor 1997 ) , all having unequivocal infectious agent etiologies. recent fi ndings of antiinfl ammatory pharmaceuticals, particularly those that inhibit cox-1 and cox-2, reduce the incidence of certain classes of cancers are consistent with this view (dannenberg and subbaramaiah 2003 , rothwell rothwell et al. 2010 ) . in addition, there is moderate evidence that several bacteria -the most studied is chlamydia pneumoniae -play a role in atherosclerosis and myocardial infarction (saikku et al. 1988 ; watson and alp 2008 ) , however the studies are not conclusive and antibiotic treatment does not appear to be effective (andraws et al. 2005 ) . chronic periodontal disease is fi rmly footed at the intersection of infection, chronic infl ammation, and metabolic dysfunction. chronic periodontitis is characterized by infl ammation of the periodontal membrane, slowly causing gingival recession and eventual bone loss. the proximate cause of periodontitis is the virulent oral microbiome. the involvement of gram negative anaerobes has been fi rmly established for the disease. aside from the known oral pathogenic species p. gingivalis , t. denticola , and t. forsythensis , the so-called "red complex" (holt and ebersole 2005 ) , new bacterial species associated with chronic periodontitis have also been described (kumar et al. 2003 ) . the advent of an extensive database covering the oral microbiome will surely propel such investigations . numerous studies have shown that periodontal disease covaries with many diseases, presumably due to overlapping molecular etiologies. compelling meta-analyses demonstrate a highly signifi cant synchronicity of obesity and periodontal disease (chaffee and weston 2010 ) . in addition, the correlation between periodontal diseases/ alveolar bone loss and frank metabolic syndrome is repetitively observed (nesbitt et al. 2010 ; andriankaja et al. 2010 ) . extensive work has also shown a strong role for both infl ammation-related genes and circulating infl ammatory markers in periodontal disease (nikolopoulos et al. 2008 ; bretz et al. 2005a, b ) . treatment studies further support the link between periodontal disease and immuno-metabolic syndrome. these experiments have demonstrated a signifi cant improvement in intermediate molecular markers of infl ammation when chronic periodontitis in the presence of metabolic syndrome (acharya et al. 2010 ) or type 2 diabetes (iwamoto et al. 2001 ) was treated. conversely, treatment of periodontal disease with reduction of bacterial load leads to greater glycemic control among diabetic patients (simpson et al. 2010 ; stewart et al. 2001 ) . given the high prevalence of periodontitis and the co-morbidity of metabolic syndrome with periodontal disease, these treatment experiments appear to suggest that the virulent oral microbiome could play an important role in the pathogenesis of systemic infl ammatory metabolic syndrome, and is exacerbated by the syndrome. certainly, further studies are needed to defi nitively answer this question. as chronic periodontal disease seems to be a critical feature of sustained, systemic dysfunction of both metabolic and infl ammatory networks, uncovering the genetic variants carried by susceptible individuals would not only provide much needed insight into the molecular pathogenesis of chronic periodontal disease, but would also markedly aid our understanding of the infl ammatory metabolic syndrome and how it drives related co-morbidities. such genetic studies may also shed light on the specifi c mechanisms that appear to improve cardiovascular, infl ammatory, and diabetic outcomes when periodontal disease is treated, potentially leading to therapies and medical/dental intervention with greater effectiveness. such studies may also provide clues to which subsets of individuals respond more effectively than others and why they do so. periodontal disease can also present in a rapid manner with aggressive bone loss and early-onset. this is termed aggressive periodontitis (lang et al. 1999 ) . in contrast to chronic periodontitis, there is often a greater degree of familial aggregation with aggressive periodontitis, and it is hypothesized that most aggressive cases may affl ict individuals with one or more defective immune genes (zhang et al. 2003 ; amer et al. 1988 ; machulla et al. 2002 ; carvalho et al. 2010 ; toomes et al. 1999 ; hart et al. 2000 ; hewitt et al. 2004 ) . mutations in the lysosomal protease, cathepsin c, have been shown to be responsible for some forms of aggressive periodontitis, along with complications associated with other infl ammatory diseases (laine and busch-petersen 2010 ) . the specifi c hla variants thought to play a role in aggressive periodontitis, are also involved in infectious disease susceptibility and autoimmunity; and, interestingly, two of the non-mhc-linked regions, fam5c and a locus on chromosome 9p21, have been implicated in myocardial infarction (connelly et al. 2008 ) and may have action as a tumor suppressor in tongue squamous cell carcinoma (kuroiwa et al. 2009 ) . as with chronic periodontal disease, an infectious microbiome is heavily involved. however, in general, microbiome differences could not explain the presence of chronic versus aggressive forms of the disease, although in some aggressive periodontitis patients, a highly leukotoxic a. actinomycetemcomitans strain may contribute to the disease process (mombelli et al. 2002 ) . we currently do not fully know the differences between the genetic susceptibility factors for the chronic and aggressive forms of the disease. the most prevalent chronic disease in both children and adults is dental caries (national institute of dental and craniofacial research) . caries formation is a complex disease with several interacting components form the environment and host genetics. similar to gingivitis and periodontitis, caries have an infection-initiating etiology with acidifi cation leading to localized demineralization. epidemiological studies have long shown that diet is a strong predictor of caries formation; and the reduction in ph is exacerbated by high consumption of carbohydrates. the principal pathobacterial species are streptococcus mutans and lactobacillus ( van houte 1994 ) . there are also several reports of positive correlations of caries with infl ammatory diseases, although the association is not always repeatable. it is also not clear what proportion of the putative association with infl ammatory disease is due to innate upregulation of immune networks in contrast to the immuno-modulating pharmaceuticals prescribed to those with infl ammatory disease (steinbacher and glick 2001 ) . much of the effect is reported to result from lack of saliva volume (steinbacher and glick 2001 ) . interestingly, the presence of epilepsy may be associated with higher caries rates (anjomshoaa et al. 2009 ) . fluoride is an effective antimicrobial agent that interferes with bacterial growth and metabolism (wiegand et al. 2007 ) . hence, topical fl uoride administration as well as ingestion of fl uoridated water inhibits cariogenesis and caries progression (ripa 1993 ) . amelogenesis is a key process involved in modifying the rate of caries formation. both common variation and rare mutations in enamel formation genes such as amelogenin and enamelin are involved in caries rates (patir et al. 2008 ; kim et al. 2004 ; crawford et al. 2007 ) , the molecular actions of which are beginning to be revealed (lakshminarayanan et al. 2010 ) . over 35,000 new cases of cancers affecting the oral cavity and pharynx were expected in the united states for 2009, with deaths numbering 11,000 (jemal et al. 2009 ) . the majority of these malignancies involved solid tumors originating from cancerous changes in squamous cells of the mouth. again, oral cancers have a complex etiology existing of entangled genetic, epigenetic, infectious, and dietary causes, further modifi ed by tobacco, alcohol and other environmental exposures. as with most cancers, it is reasonable to expect that both germline and somatic genetic changes will be involved in carcinogenesis, tumor growth, and metastasis. promoter hypermethylation of genes central to cellular growth, differentiation, dna fi delity, apoptosis, and metabolic stability is an important facet of these cancers (poage et al. 2010 ) . indeed, methylation-mediated silencing of genes involved in tumor suppression (e.g. the cyclin-dependent kinase inhibitor 2a), detoxifi cation (e.g. mgmt ), and apoptosis (e.g. the death-associated protein kinase-1) are commonly found in oral squamous cell carcinoma samples (ha and califano 2006 ) . to quantify the proportion of the variance in a phenotypic trait that is due to variance in genetic factors, population geneticists defi ned the concept of heritability (visscher et al. 2008 ; falconer and mackay 1996 ) . researchers subsequently developed several methods for estimating heritabilities using the measure of a trait (e.g. occurrence of disease/not-disease) in combinations of relatives (e.g. parentoffspring, or monozygotic-dizygotic twins). in general, the higher the measured heritability of a variable phenotype, the larger the contribution of genetic factors is in comparison to environmental effects. it is fallacious to assume that the heritable variation is composed entirely of alleles residing in the dna sequence, for heritability studies simply examine the covariance between relatives without comment on specifi c molecular mechanisms. hence, any heritable variation such as methylation patterns, vertically-transmitted infectious agents, as well as dna variation can contribute to the heritability measure. heritability results are important because they not only give a rough estimate of the collective effects of heritable factors, but also can provide a measure to quantify how much of the total genetic effect is accounted for by specifi c loci examined. for periodontal disease, four twin-based studies of heritability have been performed (michalowicz et al. 1991 ; corey et al. 1993 ; michalowicz et al. 2000 ; mucci et al. 2005 ) . although varying in sample size and methodological details, all four arrived at consistent results, with 30-50% of the variance in periodontal disease being attributed to genetic variability for chronic periodontitis. given the segregation patterns described in the literature, it is reasonable to assume that aggressive periodontal disease exhibits a higher heritability. therefore, given the prevalence of periodontal disease, heritable factors within the population at large are likely appreciable. using 314 twin pairs, bretz and colleagues reported substantial heritability values for multiple traits related to caries ranging from 30% to 56% (bretz et al. 2005a, b ) . lastly, mutagen sensitivity studies of head and neck cancer patients suggest a signifi cant effect of genetic factors for the carcinogenesis of oral cancers (cloos et al. 1996 ) . hence, there is every reason to believe that a sizable pool of genetic and/or epigenetic factors await discovery for oral diseases. once the development of pcr (saiki et al. 1985 ) was applied to the idea of using naturally-occurring dna variation (botstein et al. 1980 ) , large-scale dna-based studies of disease underwent a substantial acceleration (schlotterer 2004 ) . genotyping of short, tandem repeated sequences (weber and may 1989 ) -microsatellites -spurred on a wave of genome-wide linkage studies, which evaluate the co-segregation of disease state with microsatellite markers, for both rare mendelian disorders as well as more common diseases with complex inheritance patterns. while the rarer traits with more coherent transmission patterns generally relinquished their genetic secrets to linkage analysis, more common diseases did not. in the mid-to late 1990s, several theoretical studies had shown that the power to detect disease-causing alleles is higher with association-based designs such as a case/control experiment or association in the presence of a linkage signal as in the transmission/disequilibrium test if the frequency of those alleles is high and the effects are moderate (kaplan et al. 1995 ; risch and merikangas 1996 ; jones 1998 ; long and langley 1999 ) . however, to conduct genomewide association studies presented an ominous obstacle for the genetic technologies at the time. the number of markers required to effectively cover the genome was prohibitively large as the chromosomal blocks in population-based samples used in association designs were expected to be small. even within large extended families, the limited number of recombination events generates substantial chromosomal blocks passed through the pedigree, but researchers had both theoretical and empirical evidence that the blocks in population-based samples were on the order of 50 k base pairs for most large human populations. as the reader can imagine, the mean length of blocks that are shared by descent is inversely related to the product of recombination rate, the number of affected individuals and the number of meioses separating the affected individuals. in practice, even very large extended families segregate regions shared by affected members on the order of several million base pairs in length. however, once geneticists seriously considered large-scale studies using a case/control design where individuals are separated by say 5,000 meioses, it became clear that to adequately cover the much smaller shared regions across the entire genome, hundreds of thousands of markers would be required (kruglyak 1999 ) . utilizing the human genome sequence (venter et al. 2001 ; lander et al. 2001 ) , a number of studies at celera diagnostics provided an intermediate solution, where approximately 30,000 putative functional snps primarily located in genes were assayed through allelespecifi c pcr in a number of common diseases using a staged case/control design. these studies were successful in identifying several gene-centric polymorphisms associated with common diseases (begovich et al. 2004 ; cargill et al. 2007 ) (fig. 4.35 ) . concurrently, several groups had performed extensive sequencing and genotyping across the genome to produce a genome-wide map of haplotype structure (hinds et al. 2005 ) , useful in linkage disequilibrium mapping. within 2 years, technology for snp hybridization arrays had advanced so as to enable genome-wide association studies capable of capturing most of the common genetic variation in the genome either through direct genotyping or indirect interrogation using linkage disequilibrium -the term linkage disequilibrium is a measure of the correlation of alleles at closely-linked sites (see fig. 4 .36 ). these investigations were met with numerous successes (klein et al. 2005 ; kathiresan et al. 2008 ; graham et al. 2008 ; gudmundsson et al. 2009 ) . inexpensive genotyping platforms and urging from theoreticians ensured that these genome-wide association studies were, in general, highly powered to detect all but very mild effects from high frequency alleles. these efforts, led by large academic consortia such as the wellcome trust, the international multiple sclerosis genetics consortium, and the broad institute and commercial entities such as decode genetics and perlegen have greatly expanded our understanding of the basic biology of common diseases: we now know, for example, that (i) autophagy-related genes are involved in crohn's disease (rioux et al. 2007 ) , (ii) there are a number of genes such as the protein tyrosine phosphatase, ptpn22 and the interleukin-23 receptor, il23r , that exhibit ample pleiotropic effects among autoimmune conditions (lopez-escamez 2010 ; safrany and melegh 2009 ) , (iii) in the case of age-related macular degeneration, predictive models using the genetic results enable fairly accurate prognosis of individuals who are at high risk of disease (seddon et al. 2008 transcription factor tcf7l2 plays a role in type 2 diabetes (grant et al. 2006 ) , and (v) aberrant il-7 signaling likely contributes to multiple sclerosis susceptibility (gregory et al. 2007 ) . the plot shows the tremendous progress in genotyping technology where, a decade ago, very little of the genome was accessible for disease studies using association designs through the current wave of viable sequencing-based whole exome studies (2010) (2011) and whole genome studies (2012) (2013) . in fig. 4 .37 , the average distance between adjacent genetic markers is plotted as a function of year of introduction to the disease mapping community. impressively, the total number of genetic markers has increased a million-fold over the past decade. although successful in uncovering numerous pathogenic pathways for common diseases, results from the current wave of genome-wide association studies, with a few exceptions, explain little of existing disease heritability. the reasons for this are cryptic and the subject of heavy debate (manolio et al. 2009 ) . multiple rare sequence variants generating high levels of allelic heterogeneity, functional de novo mutations, structural mutations such as copy number variants and large deletions, and epigenetic effects constitute four of several possible disease models that could account for the heritability discrepancy. the answer will almost certainly consist of a conglomeration of these and other effects. bringing forth the new genome-wide technologies that illuminate these previously non-or under-interrogated properties of the genome to bear on this enigma is a reasonable next step for all complex traits including oral diseases. the most commonly used measure of ld in a sample of chromosomes is linkage disequilibrium (ld) is a measure of the correlation between alleles at two sites in a sample of chromosomes. for two biallelic sites, if the a1 allele is always paired with the b1 allele, and the a2 allele is always on the same haplotype as the b2 allele, then the two sites are said to be in perfect ld. successive recombination diminishes ld. interrogating one site for disease association allows investigators to indirectly interrogate other sites in sufficiently high ld with the interrogated site. a key feature explicitly studied in molecular population genetics and implicitly used in disease gene mapping studies is the site frequency spectrum; that is, the distribution of allele frequencies at single sites in the genome that vary in the human population studied. from both diffusion models (kimura 1970 ) and coalescent theory (hudson 1991 ) in theoretical population genetics, we know that the vast majority of realistic models generate many more rare variants compared to common polymorphisms. this is particularly true for expanding populations. are these rare variants the source of much of the missing heritability? recently, with the application of high-throughput sequencing technology to human studies over the past decade, empirical studies have clearly verifi ed these predictions -the large majority of variants have low frequencies (the international hapmap 3 consortium 2010 ) . the distribution of deletions appears to be skewed toward more rare frequencies, presumably due to the deleterious effects of such variants. individual mutations appearing de novo typically are extremely rare events per locus, but collectively are numerous. other types of genetic variability, such as copy number repeats, span both ends of the frequency spectrum with the preponderance of the markers being rare. thus, there is a sizable pool of low-frequency variants in human populations that have yet to be thoroughly investigated. over the past few years it has become increasingly clear that structural variants exist in the human genome at a far higher rate than previously thought. structural variants can exist in a multitude of forms including deletions, copy number variants, and inversions among others. due to the nature of these genetic changes, many are considered to be highly disruptive of molecular function if they lie in functional motifs. indeed, there are several mendelian diseases are caused by fully-penetrant structural variants impacting a chromosomal region (lupski 2007 ) . numerous structural variants have recently been reported to be associated with common diseases, particularly in the neurological fi eld (sebat et al. 2007 ; stefansson et al. 2008 ; elia et al. 2010 ) , infectious disease susceptibility (gonzalez et al. 2005 ) , and drug metabolism (zackrisson et al. 2010 ) . although they have improved dramatically over the past few years, algorithms using snp-based data from hybridization arrays to infer copy number variants have had high error rates, perhaps explaining the rather low rates of replication of structural variation association results for common diseases. nevertheless, given the high frequency of structural variants, their pathogenic potential, and that we are on the precipice of a sequencing revolution in genome-wide studies, examination of these variants should be a high priority for new sequencing-based studies in oral disease susceptibility, progression, and related pharmacogenetic applications. as different technologies examine different portions of the site frequency spectrum (i.e. genome-wide snp scans interrogate variation that is common in the hapmap populations, whereas sequencing-based studies typically interrogate the entire frequency spectrum), where one believes genetic causation is harbored should infl uence the selection of genotyping technology. if common genetic variation contains the vast majority of heritable effects on disease phenotypes, then an investigator would be wise to employ a snp-based experimental design. if, however, there is reason to believe that a signifi cant portion of the genetic load of the disease studied exists in the highly populated portion of the distribution -the rare variants -then a sequencing-based study may be better suited to unravel causative alleles. the studies of heritability discussed previously show that there is heritable variation underlying a substantial portion of the variance observed in oral diseases. as discussed above, sequencing technologies may address many aspects of dna variation including copy number loci, rare haplotypes, inversions, and insertions/deletions, but it is also worthwhile to repeat that the molecular mechanisms for disease heritability are not necessarily limited to variation at the dna level. for a disease state, the covariance between relatives could be driven by co-inherited chromosomal regions or other phenomena. chief alternative heritable mechanisms include dna methylation (hammoud et al. 2009 ) , modifi cations to the histones (bestor 2000 ) , complex rna zygotic transfer (rassoulzadegan et al. 2006 ) , and vertical transmission of infectious agents. additionally, transgenerational effects offer an intriguing class of epigenetic mechanisms (nadeau 2009 ) . in a thorough review on epigenetics and periodontitis, gomez et al. make a strong argument for consideration of both cpg dinucleotide methylation and deacetylation actions on cytokine expression as a credible avenue for further investigation in periodontal disease etiology (gomez et al. 2009 ) . genome-wide epigenetic studies have been successfully conducted for oral cancers (poage et al. 2010 ) . the scale of this study on head and neck squamous cell carcinomas allowed these researchers to show a global pattern of tumor copy number changes signifi cantly correlated with methylation profi les that was not detectable at the individual gene promoter level. with advanced chromatin immunoprecipitation and new methods to study dna methylation, efforts to apply highthroughput epigenetic methods to oral diseases should be accelerated. numerous studies have been conducted in oral disease traits using a candidate gene approach. there are two large reviews of the existing candidate gene results (nikolopoulos et al. 2008 ; ) . laine and colleagues have recently put together a comprehensive review article covering gene polymorphisms. there are some suggestive fi ndings for cyclooxygenase-2 gene, cox-2 , the cytokineencoding genes, il6 and il1b , the vitamin d receptor, vdr , a polymorphism immediately upstream of cd14 , and the matrix metalloproteinase-1 gene, mmp1 . however, these initial results will require further confi rmation, for the association patterns are inconsistent across independent studies, the statistical signifi cance is moderate, and the posterior probability of disease is decidedly bland. the striking pattern that emerges from the laine et al. summary data is the lack of coherent replication of genetic association for the vast majority of polymorphisms examined. the situation is reminiscent of genetic association studies prior to large-scale snp studies where poor repeatability of results plagued the fi eld. in a pivotal study from 2002, hirschhorn and colleagues (hirschhorn et al. 2002 ) examined the state of genetic association studies, fi nding that "of the 166 putative associations that had been studied three or more times, only six have been consistently replicated." the dearth of robust results was largely remedied when large-scale genetic studies were applied to very substantial numbers of well-characterized patients and geneticallymatched controls and stringent statistical criteria enforced. one can only suspect that a similar state of affairs is operating in genetic studies of chronic periodontitis. perhaps efforts to (1) reduce the heterogeneity of the disease state through detailed clinical and laboratory assessments, (2) drastically increase sample sizes, and (3) expand the scope of inquiry to larger numbers of genes/regions, and examine a more comprehensive set of variants/epigenetic effects will improve the current situation. the second large study is a meta-analysis of 53 studies, where nikolopoulos and colleagues analyzed six cytokine polymorphisms linked to il1a , il1b , il6 , and tnf-alpha (nikolopoulos et al. 2008 ) . two of these, an upstream snp in il1a and a snp in il1b , exhibited signifi cant association with chronic periodontal disease risk. although the results were not particularly strong, as is typical with complex diseases, the results do suggest the importance of infl ammation-response variability in chronic periodontitis predisposition. perhaps the strongest, most replicable genetic association fi nding with coronary heart disease and myocardial infarction is centered on the short arm of chromosome 9 (9p21.3) (mcpherson et al. 2007 ; helgadottir et al. 2007 ) . two studies of periodontal disease showed that the same alleles at the 9p21.3 locus confer risk for aggressive periodontitis (schaefer et al. 2009 ; ernst et al. 2010 ) . the discovery of such a pleiotropic locus may explain a portion of the aggregation of periodontal disease with other co-morbid conditions. further studies investigating overlapping genetic susceptibility factors between periodontitis and cardiovascular disease, diabetes mellitus, metabolic syndrome, rheumatoid arthritis, and other related diseases may be a fruitful strategy for honing in on shared genes affecting these immuno-metabolic disorders. using patients from 46 families from the philippines, the fi rst genome-wide linkage study for caries was completed in 2008 (vieira et al. 2008 ) . the study identifi ed fi ve loci which exhibit suggestive statistical evidence (lod scores exceeding 2.0): 5q13.3, 14q11.2, xq27.1, 13q31.1, and 14q24.3. the latter of which overlapped with a quantitative trait locus discovered from mapping work in the mouse. further work is necessary to refi ne these signals and localize the variants that may be driving these linkage signals. aggressive periodontal disease and rarer dental diseases have also been subjected to linkage analysis. results from linkage studies for dentinogenesis imperfecta type i, for example, have gone on to produce the novel gene fi ndings of the dentin sialophosphoprotein-encoding gene on 4q21.3 being responsible (song et al. 2008 ; crosby et al. 1995 ) . a linkage study in african american families examining localized aggressive periodontitis found a strong linkage signal in a region covering approximately 26 megabases on chromosome 1 (li et al. 2004 ) . several interesting genes are in this region. in a study earlier this year further mapping from carvalho et al. in brazilian families identifi ed haplotypes in this region on 1q in fam5c which were associated with aggressive periodontitis (carvalho et al. 2010 ) . the function of the fam5c protein is not fully understood. fam5c is localized in the mitochondria and it appears to play a role in vascular plaque dynamics and risk of myocardial infarction (laass et al. 1997 ) . it should also be noted here that other types of mapping analyses such as homozygosity mapping to identify have yielded gene discoveries. for example, the lysosomal protease cathepsin c gene for the recessively-inherited papillon-lefevre syndrome which is characterized by aggressive and progressive periodontitis was effectively mapped using homozygosity mapping (fischer et al. 1997 ; connelly et al. 2008 ) . cathepsin c is highly expressed in leukocytes and macrophages and is a key coordinating molecule in natural killer cells (rao et al. 1997 ; meade et al. 2006 ) . although sparse, these linkage results are undoubtedly encouraging. employing very large extended families subjected to genome-wide genotyping or sequencing will surely shed much needed light on chromosomal regions and genes relevant to oral disease research (fig. 4.38 ). for periodontitis, a single study has employed a genome-wide association design in an effort to uncover aggressive periodontal variants (schaefer et al. 2010 ) . this study by schaefer and colleagues discovered and replicated an intronic snp, rs1537415, in the glycosyltransferase glt6d1 which is signifi cantly correlated with aggressive periodontal disease in both german and dutch samples. often, seemingly signifi cant results from large studies are due to the effect of reporting the top result from a great many statistical tests -this is called the multiple testing problem. in this situation, the strength of the fi nding, along with the replication across three case/control studies, argues for true association with aggressive periodontal susceptibility. the snp may modulate the binding affi nity of gata-3. the association with glt6d1 is currently one of strongest genetic associations for aggressive periodontal disease, testifying to the power of genome-wide studies to generate novel, relevant molecular pathophysiology for complex diseases. it seems unlikely that glt6d1 would be extremely high on a candidate gene list, and it was only through a genome-wide scan that it appeared. like many excellent studies, the fi nding by schaefer et al. raises more questions than it answers and will undoubtedly provide fertile ground for ensuing molecular work. after a somewhat sluggish start, due to a lack of critical mass of investigators aiming to collect large numbers of patient samples and bring high throughput genetic technologies to caries susceptibility, gingivitis, and periodontal disease traits, the future of genetic studies in oral health is bright. scientifi c progress in revealing the molecular pathogenesis of oral diseases is dependent on genome-wide genetic studies; and i have argued that progress in related immuno-metabolic diseases is also dependent on these large-scale genetic studies in periodontal disease. to study sporadic disease, substantial patient collection efforts are required for the application of these technologies. this may involve a combination of new recruitment and consortiumrelationships with existing collections. the beginning of such a collection for sporadic aggressive periodontitis in europe has shown extremely intriguing initial results, but more patients are needed to examine rare variants of moderate effect. both the german/dutch collection of aggressive periodontitis and the brazilian collection have begun to revolutionize the study of periodontal disease susceptibility with the discovery of glt6d1 snps and fam5c -linked haplotypes. there is little doubt that subsequent molecular work on these two genes will uncover novel mechanisms for the predisposition to aggressive periodontal disease. focus should also be placed on the collection of extended families segregating these diseases. applying sequencing technologies to large pedigrees can be an effective method of identifying rare variants and structural variants in a highly-refi ned phenotype. furthermore, applying these methods to the entire genome would make for a comprehensive genetic study. several trends in large-scale genomics science hold promise to signifi cantly advance our understanding of oral disease pathogenesis: the sociology of biological sciences has changed over the past 15 years so as to â�¢ become more collaborative. essential for association-based designs, consortiumbased genetic research has blossomed over that time period, increasing sample sizes and therefore the power to detect disease-causing variants. there currently is consortium-based research in periodontal disease and oral cancer. further expanding these efforts will enhance subsequent studies, particularly those investigating rare alleles and/or rare epigenetic effects. through over a century of laboratory work, the collective knowledge of bio-â�¢ chemical pathways, signal transduction, cell physiology, regulatory mechanisms, and structural biochemistry is weighty. incorporation of this information into etiological models may substantially advance oral disease work as well as the fi eld of complex disease genetics in general. sophisticated analysis techniques are needed to perform this task. recent advances merging results from network science with probability theory within the context of computer science have produced the fi eld of machine learning. this rigorous framework can be used to identify those factors responsible for disease status and can also be used to develop robust predictive models using known biological networks and genetic data. the output from such models, typically the probability of disease, an estimate of disease progression rate, or a probability of adverse reaction, can be used by physicians and dentists to personalize medical care. until relatively recently, population genetics did not contribute a great deal to â�¢ human genetics research. that has changed in the past decade where effort spent on association studies surpassed that spent on family-based studies. those investigating disease gene mapping began to collaborate with population geneticists and population geneticists took up a wide-spread interest in fi nding disease alleles. incorporation of population genetics theory into such studies markedly improved association studies on several levels: confounding by population stratifi cation was effectively treated using population genetics, linkage disequilibrium patterns. use of population genetics theory in large-scale oral disease mapping studies may accelerate discoveries. sequencing technology has rapidly progressed over the past decade. currently, â�¢ sequencing studies across the exome can be accomplished at reasonable cost and yield data for all known genes in the genome. within the next few years, sequencing costs will depreciate to a point where whole-genome sequencing studies will be commonplace, using both family-based and population designs. application of these technologies to oral disease studies is imperative for comprehensive studies of etiology. high-throughput dna methylation and chromatin immunoprecipitation studies â�¢ will enable large-scale epigenetic studies in oral diseases (meade et al. 2006 ; ehrich et al. 2005 ; bibikova et al. 2006 ; ren et al. 2000 ; pokholok et al. 2005 ) . these have already started to play an important role in delineating mechanisms responsible for oral cancers (poage et al. 2010 ) . additional application of these techniques to studies of gingivitis, caries, and periodontal diseases may generate novel fi ndings. molecular biologists and pharmacologists have increasingly become able to â�¢ develop and evaluate highly targeted pharmaceuticals based on genetic discoveries. the use of such genetic information may improve the chances of developing effi cacious therapies. geneticists and disease researchers are beginning to realize that oral diseases â�¢ both impact and are intrinsically tied to susceptibility and progression of other common diseases. a synthesis of genetic fi ndings from immuno-metaboliclinked disorders would seem to greatly increase the knowledge of these diseases and better pinpoint their respective etiologies. as the new high-throughput genomics and epigenomics technologies become â�¢ implemented in oral disease research, the storage, management, analysis, and interpretation of the ensuing colossal amounts of data will be critical to enable clinicians to use these results in daily practice. advances in dental and medical informatics will facilitate these steps. we are in exciting times where advances in genetic technologies will uncover the genetic causes of diseases, including those that affect the oral cavity. with more focus in the area of oral disease genomics and the harnessing of new high-throughput sequencing and epigenetic technologies, novel insights into the pathways driving these diseases are imminent. these discoveries will, in turn, motivate directed therapies, aid in illuminating the molecular etiology of related disorders such as diabetes, and increase the level of personalized medicine. joseph kilsdonk the title of this section reinforces a 1995 institute of medicine (iom) report titled "dental education: at the crossroads." to quote yogi berra, a baseball sage: "when you come to a fork in the road, take it." the implication being that dental education must take action and move beyond its crossroads. these crossroads are described in the fi rst third of the section. it includes a summary and recommendations of the iom report and three transitional reports that followed: the 2000 surgeon general's report identifying oral health as a silent epidemic, the josiah macy foundation report, and a "pipeline" study funded by both the robert wood johnson and the california foundations. having been at the crossroads for a decade or so, the middle portion of the section highlights educational models that may lead to a more promising future. the later third of this section describes an alternative path of action for dental education which emphasizes the central roles of clinic-based education and dental informatics in dental education curriculum. it is unknown how traditional dental educators may view this model; however, it is effectively a logical conclusion and responsive to the reports. in 1995 the institute of medicine (iom) published "dental education at the crossroads" (field 1995 ) . the title was apropos as the authors' analysis concluded: (1) economics surrounding dental education were unsustainable ; (2) student service learning opportunities and access to care for patients were limited; and (3) new dental schools were not replacing those forced to close due to the economic climate. the iom report additionally proposed key recommendations to reform dental education and service delivery. fifteen years later, we remain at "the crossroads" as these issues remain largely unresolved. furthermore, these recommendations have retained their validity. their implementation would directly impact structures and services for contemporary models of dental education in the future. the following iom recommendations (field 1995 ) are intrinsic to the proposed dental education reform: recommendation 2 : to increase access to care and improve the oral health status of underserved populationsâ�¦ recommendation 3 : to improve the availability of dental care in underserved areas and to limit the negative effects of high student debtâ�¦ recommendation 5 : to prepare future practitioners for more medically based modes of oral health care and more medically complicated patients, dental educators should work with their colleagues in medical schools and academic health centers to: move toward integrated basic science education for dental and medical â�¢ students; require and provide for dental students at least one rotation, clerkship or â�¢ equivalent experience in relevant areas of medicine and offer opportunities for additional elective experience in hospitals, nursing homes, ambulatory care clinics and other settings; continue and expand experiments with combined md-dds programs and â�¢ similar programs for interested students and residents; increase the experience of dental faculty in clinical medicine so that they, â�¢ and not just physicians, can impart medical knowledge to dental students and serve as role models for them. recommendation 6 : to prepare students and faculty for an environment that will demand increasing effi ciency, accountability, and evidence of effectiveness, the committee recommends that dental students and faculty participate in effi ciently managed clinics and faculty practices in which the following occurs: patient-centered, comprehensive care is the norm; â�¢ patients' preferences and their social, economic, and emotional circumstances â�¢ are sensitively considered; teamwork and cost-effective use of well-trained allied dental personnel are â�¢ stressed; evaluations of practice patterns and of the outcomes of care guide actions to â�¢ improve both the quality and the effi ciency of such care; general dentists serve as role models in the appropriate treatment and referral â�¢ of patients needing advanced therapies; larger numbers of patients, including those with more diverse characteristics â�¢ and clinical problems, are served. recommendation 17 : because no single fi nancing strategy exists, the committee recommends that dental schools individually and, when appropriate collectively evaluate and implement a mix of actions to reduce costs and increase revenues. potential strategies, each of which needs to be guided by solid fi nancial information and projections as well as educational and other considerations, include the following: increasing the productivity, quality, effi ciency, and profi tability of faculty â�¢ practice plans, student clinics, and other patient care activities; pursuing fi nancial support at the federal, state, and local levels for patient-â�¢ centered predoctoral and postdoctoral dental education, including adequate reimbursement of services for medicaid and indigent populations and contractual or other arrangements for states without dental schools to support the education of some of their students in states with dental schools; rethinking basic models of dental education and experimenting with less â�¢ costly alternatives; raising tuition for in or out-of-state students if current tuition and fees are low â�¢ compared to similar schools; developing high-quality, competitive research and continuing education â�¢ programs; consolidating or merging courses, departments, programs, and even entire â�¢ schools. in summary, the iom report identifi ed that: (1) an outdated curriculum continues to be retained which refl ects past dental practice rather than current and emerging practice and knowledge; (2) clinical education does not suffi ciently incorporate the goal of comprehensive care, with instruction focusing too heavily on procedures; (3) medical care and dentistry are not integrated; and (4) the curriculum is crowded with redundant material, often taught in disciplinary silos. the 1995 iom's report was followed by the surgeon general's report on oral health in 2000 and a subsequent supplement by the surgeon general in 2003 called "the national call to action" (u.s. department of health and human services 2003 ) . five signifi cant fi ndings and recommendations from the surgeon general's report(s) that have implications pertaining to the envisioned structure and services of new models for dental education include: changing the perception of oral health so that it will no longer be considered â�¢ separate from general health; improving oral health care delivery by reducing disparities associated with popu-â�¢ lations whose access to dental treatment is compromised by poverty, limited education or language skills, geographic isolation, age, gender, disability, or an existing medical condition; encouraging oral health research, expanding preventive and early detection pro-â�¢ grams, and facilitating the transfer of knowledge about them to the general population; increasing oral health workforce diversity, capacity, and fl exibility to overcome â�¢ the underrepresentation of specifi c racial and ethnic groups in the dental profession. in this regard, the national call to action urged the development of dental school recruitment programs to correct these disparities and to encourage parttime dental service in community clinics in areas of oral health shortage; increasing collaboration between the private sector and the public sector to cre-â�¢ ate the kind of cross-disciplinary, culturally sensitive, community-based, and community-wide efforts to expand initiatives for oral health promotion and dental disease prevention. spurred by the 1995 iom report and the 2000 surgeon general's report, the josiah macy foundation ( 2004 ) conducted a study entitled "new models of dental education." the study was prompted by concerns about declines in dental school budgets and the diffi culties experienced by schools in meeting their educational, research, and service missions. the macy study concluded that: financial problems of dental schools are real and certain to increase. â�¢ current responses of schools to these economic challenges are not adequate. â�¢ most promising solutions require new models of clinical dental education. â�¢ macy study lead researcher dr howard bailit, and his team recently concluded in reference to points one and two above, that: "if current trends (to aforementioned) continue for the next 10 years, there is little doubt that the term crisis will describe the situation faced by dental schools. further, assuming that it will take at least ten or even more years to address and resolve these fi nancial problems, now is the time for dental educators, practitioners, and other interested parties from the private and public sectors to come to a consensus on how to deal with the coming crisis. clearly, these fi nancial problems will not be solved by minor adjustments to the curriculum, modest improvements in the clinical productivity of students or faculty, or even signifi cant increases in contributions from alumni. the solutions 'must involve basic structural changes in the way dental education is fi nanced and organized' (bailit et al. 2008 ) ." this statement is supported by the fact that in the past 25 years more dental schools have closed than opened. specifi cally eight schools have closed, whereas to date a couple has opened and a handful is pending. curriculum relevance was also a focus of the study. findings concluded that "changing the curriculums in dental schools to allow students to spend more time in community venues would be highly benefi cial to both society and student. society benefi ted from having underserved patients cared for while students were assessed as being fi ve to ten times more productive, more profi cient, more confi dent, more technically skilled and more competent in treating and interacting with minority patients" (brodeur 2008 ) . macy study (formicola et al. 2005 ) outcomes represented signifi cant and foundational guideposts for assessing and planning any future models for dental education. their report led to the robert wood johnson foundation pipeline study ( 2007 ) , a major research study funded by the robert wood johnson foundation and the california endowment (tce). the goal of the dental pipeline program was to reduce disparities in access to dental care. the pipeline study provided over $30 million for the start up or expansion of 15 schools and student clinical programs that incorporated services to underserved extramural clinical settings (primarily community health centers). the following recommendations from the surgeon general's report structured â�¢ the goals of the pipeline's initiative: increase the number of under-represented minority and low-income students enrolled in the dental schools participating in the pipeline program so that there would be a voice of minority and low-income students at all the funded schools. provide dental students with courses and clinical experience that would prepare â�¢ them for treating disadvantaged patients in community sites. have senior dental students spend an average of 60 days in community clinics â�¢ and practices treating underserved patients. increasing the community experience of dental students was expected to have an immediate impact on increasing care to underserved patients (brodeur 2008 ) . this third point is pivotal to future success of dental curricula and dental education economics. recently published in a supplemental volume to the journal of dental education , february, 2009, the pipeline study reported the following outcomes: minority recruitment of low-income students increased by 27%; â�¢ the rate of recruitment for under-represented populations was almost twice that â�¢ of non-pipeline schools; the length of time dental students spent in extramural rotations increased from a â�¢ mean of 16 days to a mean of 39 days over a period of 4 years. procedural profi ciency increased compared to that of their non-extramural peers. of the 15 pipeline-funded programs, only four schools achieved the goal of â�¢ 60 days of extramural rotations; through extra funding from tce, the four schools extended extramural rotations to an average of 198 days; based on this publication, it appears that only a handful of pipeline schools defi -â�¢ nitely plan to sustain their extended extramural rotations. financial concerns were highlighted as the major problem in sustaining future recruitment and placement of students beyond the timeframe of the study; a survey of program seniors indicated a mean of 26% [range of 14-60% by â�¢ school] were planning to devote â³ 25% of their practice to serving minority patients. only 9% [range of 3-22% by school] were planning to practice at community clinics. in the context of these outcomes, discussion indicated that the unwillingness of students to practice in underserved settings was based on several factors: students that participated were already enrolled in traditional programs and were â�¢ not necessarily seeking a pipeline experience or a future in community service. concern over future reimbursement as a provider in a community setting; â�¢ limited time spent in underserved settings; â�¢ limited loan forgiveness scholarship opportunities. â�¢ the fact that the large majority of pipelines were unsustainable was attributed to lack of productivity in the school clinics while the students were on rotation at community based clinics. schools generate meager, yet necessary revenue streams on intramural student clinical activity to support the costly clinical and faculty infrastructure. currently, similar economic constraints involved with outsourcing students to serving rural and underserved populations impacts the ability of tradition dental schools to participate in sustained outreach programs. most recently, the pew center on the states national academy for health policy ( 2009 ) released "help wanted: a policy makers guide to new dental providers". this report provided an excellent summary outlining workforce needs, access issues, and strategies for dental-related services to help states and institutions develop creative ways to solve oral health access and care issues. the guide proposes the following relevant components and trends for consideration in development of future sustainable school models: dental colleges are willing to bear a large and disproportionate share of the burden â�¢ in terms of access to care, particularly during a time of incredibly scarce resources. expanded, extensive, and/or creative extramural rotations have been developed â�¢ in recent years under the conceptual umbrella of service-learning. these often involve clinics providing direct or indirect payment to dental schools or clinics managed in some way by dental schools. dental education has certain obligations. first, education must adhere to accreditation standards with the goal of producing competent practitioners. second, education must remain responsive and impact the societal need for care. lastly, the delivery of dental education must be economically sustainable. the macy, rwjf, and iom reports note that improved oral health, sustainable dental education economic models, and competent workforce pipelines converge around community health centers (chc). university of michigan researchers fitzgerald and piskorowski ( 2009 ) reaffi rm this conclusion in an evaluation of an ongoing 7-year program, stating that: (the chc model) is self-sustaining and can be used to increase service to the underserved and increase the value of students' clinical educational experiences without requiring grant or school funding, thus improving the value of dental education without increased cost. self-sustaining contracts with seven federally qualifi ed health centers (fqhcs) have resulted in win-win-win-win outcomes: win for the underserved communities, which experienced increased access to care; win for the fqhcs, which experienced increased and more consistent productivity; win for the students, who increased their clinical skills and broadened their experience base; and win for the school in the form of predictable and continuing full coverage of all program costs (fitzgerald and piskorowski 2009 ) (fig. 4.39 ). however, unlike medicine that outsources their students to clinical sites, dental education programs retain the majority of the student time within their own "clinical laboratories" as documented by the aforementioned studies, this limits students' exposure to extramural experiences. costs to operate such intramural clinical programs are ever increasing and many schools' clinical operations run defi cits. if that component can be outsourced to community-based resources such as a chc, then the burden of cost is shifted away from the school. an example would be a.t. still university's arizona school of dentistry and oral health (asdoh) which matriculated its fi rst class in 2003. at the prompting of the state's community based clinics, asdoh designed a program that placed students into community-based settings for up to 6 months, an unprecedented length of time for an extramural rotation. they also saw this as an opportunity to use an adjunct centric faculty that signifi cantly reduced traditional education overhead. through this innovation, the school was able to develop a program that was sustained by "fair market" value tuition and trained students where community needs were greatest for up to 6 months (which was then unprecedented). conversely, if the chc can rely on student service-learning to care for patients, the cost of care is reduced. other schools are also advancing with innovative education and care delivery. adea's charting progress (valachovic 2009 ) fig. 4.39 the synergy between access to care, student competency, and fi nancially sustainable dental education converge around chc/fqhcs little rock, arkansas; and the university of southern nevada in south jordan, utah. western university is planning placement of 50% of their fourth year class in community health centers, while east carolina is seeking to set up rural clinical campuses as well as clinical partnerships with the state's fqhc. at the time of this publication, several existing schools are expanding or looking to expand including the university of north carolina, marquette university, midwestern university in downer's grove, il. such expansions will contribute to solving the existent access supply and demand issues. however, it was observed even with all the start ups and expansions, graduation numbers will not approach the output of schools in the late 1970s and early 1980s. these creative models establish the foundation for a sustainable clinic structure by generating self-sustaining revenue through student service-learning, which, unlike medical student services, are billable. simultaneously these new models provide access to care for the needy while student exposure to clinical experiences that are often not available in academic patient pools. these models also shift some of the cost of providing clinical education from the dental college to community-based clinics. however, this innovation is not without criticism. schools are dependent on the success of their clinics and clinic partnerships. one author cautions: "however, these creative models also may present potential political strategic risk or confl ict: private practitioners may organize and protest higher than normal reimbursement schemes. potentially, such protests could even jeopardize the very existence of such models (dunning et al. 2009 ) ." notably, community health centers have historically received strong bipartisan support. for example, during the bush administration, fqhc funding was doubled and most recently expanded through health reform legislation by the obama administration. according to the institute for oral health, "the group practice of the future is the dentist working with the physician" (ryan 2007 ) . the ada reported "multidisciplinary education must become the norm and represent the meaning and purposes of primary care as it applies to dentistry. educational sequences should include rotation strategies across discipline specialties in medicine and dentistry, clerkships and hospital rotations, and experience in faculty and residency clinics." (barnett and brown 2000 ) the models alluded to, were school-based attempts at improving educational outcomes. perhaps the proverbial fork in the road regarding the future of dental education leaves two paths for consideration. is it better to travel down a road that leads a school to develop and operate a clinic? or is the road less traveled, where a clinic becomes a school, the better of the two options? the answer, perhaps, is that a combination of both will accomplish the desired outcome. for example, didactic knowledge is measured by examination whereas competency as a practitioner is measured by clinical demonstration. at a minimum, the result must achieve learner competency, quality, and sustainability. however, the road less traveled has not been taken yet. william gies, in his revered report written 85 years ago on the state of american dental education, wrote "dental faculties should show the needâ�¦. for integrated instruction in the general principles of clinical dentistry and in its correlations with clinical medicine" (gies 1926 ) . basic sciences aside, could a clinicalbased educational training center have an advantage over a school-based clinical center? soon-to-be-implemented new commission on dental accreditation (coda) standards will require schools to demonstrate competency in patient-centered care (valachovic 2010 ) . might an enterprise profi cient at running a successful clinical business model have an advantage running a professional, patient-centered clinical training program as compared to a pedagogical business model attempting to run a clinical training model? these questions should challenge us to reexamine why our thinking about educational models should be limited to schools being the starting point for the development of a profession that demands clinical competency, patientcenteredness, and integration as outcomes. the clinic based model may serve as an equivalent starting point and, have some distinct advantages for achieving responsiveness to recommendations and directions cited in this section. beginning in november 2002 through august 2010, the family health center (fhc) of marshfi eld, inc, marshfi eld, wisconsin, launched of a broad network of developing dental clinics, targeting dental professional shortage areas with the provision of dental services to the underserved communities whose dental needs were not being adequately met by the existing infrastructure. fhc-marshfi eld is a federally qualifi ed health center (fqhc). as an fqhc, fhc receives cost-based reimbursement for its dental services to medicaid populations. along with the cost-based reimbursement, fqhcs are obligated to provide care to anyone regardless of their ability to pay. presently, fhc is the nation's largest federally qualifi ed dental health center. to date, this network of dental clinics has served over 58,000 unique patients, 85% of whom were under 200% of poverty. notably, service was provided to a signifi cant number of cognitively and developmentally disabled patients in special stations developed for serving patients with special needs. these patients frequently travel the furthest to get to our dental centers for care. beginning in 2008, fhc stepped up the pace of dental clinic expansion, constructing two new dental centers in 2009, two in 2010, and two more are slated to open in 2011. when fully operational, this will establish capacity to serve 66,000 patients annually. each site has proactively included dedicated clinical and classroom training space for dental residents or students, thus laying the framework for clinic-based training of new dental professionals. the plan is to continue to stand up new dental centers until they have the capacity to serve 158,000 patients annually or approximately 50% of the 300,000 underserved patients in the rural service area. in addition to the capacity for training residents and students, a dental post-baccalaureate program is being considered in partnership with regional 4 year under graduate campuses. the post-baccalaureate program is aimed at preparing students from rural and underserved areas who desire to practice in rural and underserved areas for acceptance and success in dental schools. presently fhc in partnership with marshfi eld clinic is moving forward with plans to develop dental residencies at these sites and a dental post baccalaureate training program to better prepare pre-doctoral students from rural and/or underserved backgrounds to be successful in dental school as a means to create a dental academic infrastructure responsive to rural environments which have been classically underserved. marshfi eld clinic has a long-standing history in medical student education and multiple medical residency programs. creating access for the underserved population was the major motivational force driving the establishment of the dental clinic network back in 2002. the fi ndings of the iom, macy, and rwjf reports became the foundational framework for developing the vision of a dental education model that would realize the major recommendations found in the reports. by establishing clinical campuses in regional underserved dental health professional shortage areas, access to care where care is needed most was provided. sustainment of a work force for provision of care across the dental clinic network is accomplished by schools contracting with fqhc's for service learning, thus circumventing challenges associated with releasing dental students at traditional dental schools to distant extramural training sites as discussed previously. this model is however not without its own set of challenges including calibration of faculty, supervision and evaluation of students in training, and achieving accreditation acceptance. however, through video connectivity and iehr technology curriculum, learning plans, competency assessment, progression, performance, faculty development, and learner evaluations can be centrally calibrated. additionally, this dental service-learning model based in a community health center setting offers students unique state-of-the-art exposures to alternative access models, cutting-edge informatics (including access to a combined dental-medical record) and a quality-based outcomes-driven practice. given the novelty of such an extended extramural dental clinical training model, there is limited data on the success of rural placement leading to retention to practice in a rural setting. the pipeline study piloted a model for getting students into underserved communities. however, that experiment was limited to 60-day rotations. outcome driven programs may provide a predictive surrogate for purposes of comparative analysis. for example, the rural medical education "rmed" program of the university of illinois medical school at rockford, has sustained a longstanding program in illinois. over 17 years in duration with over 200 student participants of whom 70% have been retained as primary care medicine practitioners in rural illinois. rabinowitz et al. ( 2008a ) further reinforced that medical school rural programs have been highly successful in increasing the supply of rural physicians, with an average of 53-64% of graduates choosing to practice in rural areas. they also noted rural retention rates of 79-87% among the programs (rabinowitz et al. 2008 a) . recently, the university of wisconsin school of medicine and public health (uwsmph) launched the wisconsin academy for rural medicine (warm program). the warm program places medical students in rural academic medical centers during their third and fourth years in medical school. marshfi eld clinic is one of those sites. warm students affi liating with marshfi eld clinic's system would ultimately share learning experiences with dental students, clinical rotations, team-based rounding, lectures, and exposure to a combined medical-dental patient record. in an analogous manner, the marshfi eld clinic dental education model will incorporate a curriculum that embeds students in rural clinical practice for up to 2 years. a secondary but not insignifi cant outcome of placing residents and students in clinical campuses focused on developing competency and providing care where needs are often greatest is the cost savings to taxpayers associated with the public care of patients. these savings are accomplished through the "service-learning" of the student. for example, in the model described where clinical training is embedded within the fhc clinics, the stipend resident or unpaid student learner provides the patient care as part of their service learning training while requiring oversight from one paid faculty per four to six learners. as a result, an academic based clinical partnership creates a model that reduces the cost for care provided to underserved patients. an additional benefi t to the community based clinic might be realized through tuition assistance by the academic program to help support patient procedures that develop learner competencies. in educational quality and infl uence, dental schools should equal medical schools, for their responsibilities are similar and their tasks analogous (william gies 1926 ) . the commission on dental accreditation (coda) notes that one of the learning objectives of an advanced education general dentistry (aegd) residency is to have the graduate function as a "primary care provider". to function competently in this role, the graduate needs to have a strong academic linkage to primary care medicine. at a 2010 dental deans forum, 84 years after the gies report, dr polverini made the statement "dentistry has never been linked to the medical network but unless dentistry becomes part of the solution to the challenge of providing comprehensive patient care, it will be looked on as part of the problem, and ultimately, all dental schools will be called into question." (polverini 2010 ) the use of dental informatics and an integrated record are elements essential to this competency. on april 1, 2010, fhc and marshfi eld clinic successfully transitioned all of their dental centers to a new practice management and electronic health record system that fully integrates medical and dental; one of the fi rst such systems in the nation. along with the benefi ts derived in fig. 4 .39 , chc placement also exposes students to an integrated medical-dental care setting where learners can develop skills in system-based practice to include the interdependence of health professionals, systems, and the coordination of care. on the administrative side, dental and medical appointments can be coordinated to enhance convenience for patients and improve compliance with preventive dental visits. in 2009, marshfi eld clinic's research foundation biomedical informatics research center hired their fi rst dental informatician, dr. amit acharya, bds, ms, phd. with dedicated biomedical informatics and research resource centers, the marshfi eld clinic has laid the groundwork for true medical/dental integration with appropriate electronic health record decision support and is positioned to develop a dental education curriculum capable of implementing the iom recommendations. downstream benefi ts of using such a curriculum are the ability of future practitioners to use informatics to improve quality of care and reduce the burden of disease. according to an institute of oral health report ( 2010 ) it is widely accepted across the dental profession that oral health has a direct impact on systemic health, and increasingly, medical and dental care providers are building to bridge relationships to create treatment solutions. as early as 1926, william gies recognized that "the frequency of periodic examination gives dentists exceptional opportunity to note early signs of many types of illnesses outside the domain of dentistry" (gies 1926 ) . the following examples show how integration of dental and medical care can impact patient outcomes, underlining the importance of this concept in dental curriculum design. a 2009 study of 21,000 blue cross blue shield of michigan (bcbs) members with diabetes, who had access to dental care lead researchers, and bcbs executives to conclude that treatment of periodontal disease signifi cantly impacts outcomes related to diabetes care and related costs (blue cross blue shield of michigan 2009 ) . another example is found in the context of preterm delivery and miscarriage. according to research cited by cigna ( 2006 ) , expecting mothers with chronic periodontal disease during the second trimester are seven times more likely to deliver preterm (before 37th week), and have dramatically more healthcare challenges throughout their life. cigna also cites the correlation between periodontal disease and low birth weights, pre-eclampsia, gestational diabetes. equally important is the opportunity to develop and implement the team-based curriculum that trains future dentists and physicians in the management of chronic disease as an accountable care organization (aco) in a patient-centered environment. as an example, joseph errante, d.d.s., vice president, blue cross blue shield of ma, reported that medical costs for diabetics who accessed dental care for prevention and periodontal services were signifi cantly lower than those who didn't get dental care (errante 2007 ) . these data suggest that team based case management of prevalent chronic health conditions have considerable cost savings opportunities for government payers, third party payers, employers and employees (errante 2007 ) . these economic benefi ts to integration as it relates to the iehr are discussed elsewhere in this book, but begin with the ability of providers to function in a team based environment and as such, underscore the importance of training in such an environment. dentists trained in a fqhc iehr integrated educational model will be well positioned to function successfully within an aco model. an aco is a system where providers are accountable for the outcomes and expenditures of the insured population of patients they serve. the providers within the system are charged with collectively improving care around cost and quality targets set by the payor. within this system, care must be delivered in a patient-centered environment. the patient-centered environment according to the national committee for quality assurance (ncqa), is a health care setting that cultivates partnerships between individual patients and their personal physicians and, when appropriate, the patient's family. care is facilitated by registries, information technology, health information exchange and other means to assure that patients receive defi ned, timely and appropriate care while remaining cognizant of cultural, linguistic and literacy needs of the patient being served. the model includes the opportunity to deliver patient care that is patient-centric, incorporates the patient in the care planning, considers the patient's beliefs and views, and incorporates the patient's families as needed. the model allows providers to deliver care that is inclusive of needs, attentive, and accessible. the model equips payers to purchase high quality and coordinated care among teams of providers across healthcare settings. while this describes the medical home, most dental practices also follow this process. many dental practices function in this regard with insured populations and refl ect elements of the model that medicine is creating. william gies would be proud. training in the delivery of accountable and patient-centered medical-dental care must be done purposefully. commenting on the inadequate training relative to the integration of medical and dental education, baum ( 2007 ) stated that "we need to design new curricula with meaningful core competencies for the next generation of dentists rather than apply patches to our existing ones." while this statement was made in reference to the basic sciences, the same holds true for patient-centered system-based practice competencies. utilizing state-of-the-art electronic medical records as a tool and the fhc infrastructure as the service venue, meaningful patient-centered system-based practice core competencies achievement becomes possible in a manner highly responsive to societal needs. by defi nition, fqhcs must provide primary medical care, dental care, and behavioral health. fqhc have also historically been utilized as healthcare workforce training centers and the affordable care act of 2010 reinforced their role as healthcare training centers. specifi cally, this legislation serves to promote fqhcs as the entity through which the primary care workforce (including dental) will be developed and expanded. in combination, fqhcs and primary care centers are positioned to be the front runners in a medical/-dental home training model which will be essential to preparing future practitioners for practice in an aco. critical to this success is the ability to train these practitioners on an integrated medical-dental record and informatics platform. use of this platform imprints most strongly during the learner's formative years of training; instructing and guiding disease management, decision making, patient care coordination, prevention, and both outcome-based and comprehensive care. training in this hybrid academically orientated clinically integrated setting moves dental education off its crossroads and creates the highway to its future. concerns with the new models extend to their ability to integrate medical and dental disciplines at the clinical and informatics level. while the 1995 iom report identifi ed the need to integrate medical and dental curriculum, success at the curricular and technological level within schools, has been limited. three major factors have contributed to the limited progress: access priorities. creating access to care has outranked the need to integrate â�¢ care. in part, this refl ects societal need for care and public demand to reduce the burden of the "silent epidemic." schools play an important role as a safety net to care for the uninsured and underinsured through intramural clinical service learning. even though "dental colleges seem to be willing to bearing a large and disproportionate share of the burden in terms of access to care" (dunning et al. 2009 ) , schools were challenged as part of iom, surgeon general, and macy reports, to expand that role. while these reports have prompted creative educational solutions to increase access, the reports understate the tremendous opportunity, quality and cost benefi ts that could result from an integration of medicine and dentistry. it is diffi cult to change the culture and structure of existing schools. this is not â�¢ unique to dentistry. however, the 1995 iom report specifi cally recommended that schools "eliminate marginally useful and redundant courses and design an integrated basic and clinical science curriculum". the challenges with this are many. examples include: some schools may not have other disciplines to draw from to create an inte-grated curriculum; a number of schools use a faculty senate to determine curriculum. this can result in curriculum that preserves the current faculty structure; changing curriculum is associated with expense and can be fi nancially pro-hibitive to some schools physical changes may be needed and represent an expense and/or may, in some instances, may not be practicable based on structure of existing facilities. public school programs may direct the fi nal curriculum, as boards or regent's one or two steps removed from the curriculum often have fi nal authority conversely, private schools may specify business or mission objectives that determine fi nal design. perhaps most germane to this text is the lack of a common technology plat-â�¢ form between disciplines in a learning environment. an integrated curriculum requires an integrated platform to accomplish delivery and evaluation. this is particularly essential to clinical management of the patient by professionals in training as part of a healthcare delivery team. some progress in establishing shared basic sciences curricula has been documented in the literature. to date, no single integrated electronic health (medical-dental) record has been meaningfully adapted for educational purposes, including incorporation of assessment of the learner relative to integrated competencies, integrated case-based and problem-based curriculum, and integrated evaluation and assessment. another concern with new educational programs emerging in response to these reports and relative to creating a transformational integrated curriculum is that some of the programs are focusing primarily on creating clinicians with no value or emphasis on integrating training with research and/or scholarly activity. integrated training models counter such concerns. research will be fundamental to measuring the relative benefi ts and outcomes associated with treatment of patients in a shared curriculum setting and will be the catalyst for the development of integrated medical-dental informatics incorporating educational capabilities. additionally, accreditation will also need to evaluate its response to such models. presently it is unclear how accrediting bodies will view an integrated crossdisciplinary curriculum. further, due to its integrated nature, such a curriculum would lie outside of the expertise of a single traditional accrediting body focused on one particular discipline. it has yet to be determined how accrediting bodies will review and appraise such cross-disciplinary competencies. lastly, it is important to recognize that a successful education model with innovative informatics is only successful if its focus is patient care. graduating learners with competency only in the use of informatics will be limited unless adapted to training and delivery programs that result in patient centric care. research and reports over the past 15 years support the need to reform dental education. first steps have been taken and lead the way for continued innovation around clinic-based education and integrated curriculum. the models identifi ed point to a strong partnership and interrelationship with chcs for creative, cost saving, effective and sustainable delivery methods. moreover, chc's must be more involved in a training curriculum integrated with informatics. chcs, in turn, benefi t from residents and students through service-learning to help meet a societal and workforce need, while the learners benefi t from increased competency. in order to train an evidence-based, patient-centered, medical-dental workforce, it is imperative that medical and dental data and record accessibility be incorporated into these training and care delivery initiatives. in order to keep moving away from the 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of the medical team in preventing early childhood caries trends in oral health by poverty status as measured by hp 2010 objectives update on disparities in oral health and access to dental care for america's children early childhood caries: the dental disease of infants teaching oral health in u.s. medical schools: results of a national survey electronic medical record use in pediatric primary care term stillbirth caused by oral fusobacterium nucleatum integrated medical and dental health in primary care advancing oral health in america improving access to oral health care for vulnerable and underserved populations the bright futures training project: implementing systems to support preventive and developmental services in practice dental care and children with special health care needs: a population-based perspective preventive dental care for children in the us: a national perspective oral health and pediatricians: results of a national survey predicting caries in permanent teeth 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and costs dental education's role in improving children's oral health and access to care survey of iowa general dentists regarding the age 1 dental visit integration of patient records and clinical research: lack of integration as a barrier to needed research electronic patient records for dental school clinics: more than paperless systems risk factors for osteonecrosis of the jaws: a case-control study from the condor dental pbrn the "meaningful use" regulation for electronic health records the medical dictionary for regulatory activities (meddra) the benefi ts of health information technology: a review of the recent literature shows predominantly positive results assessing user perceptions of an electronic patient record (epr) before implementation the content coverage of clinical classifi cations. for the computer-based patient record institute's work group on codes & structures from data to knowledge through concept-oriented terminologies: experience with the medical entities 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quality care series, american academy of developmental medicine and dentistry key: cord-022520-ebj51v9o authors: marini, robert p.; otto, glen; erdman, susan; palley, lori; fox, james g. title: biology and diseases of ferrets date: 2007-09-02 journal: laboratory animal medicine doi: 10.1016/b978-012263951-7/50016-8 sha: doc_id: 22520 cord_uid: ebj51v9o nan ferrets (mustela putorius furo) belong to the ancient family mustelidae, which is believed to date back to the eocene period, some 40 million years ago. the taxonomic groups in the family mustelidae, as recognized by corbet and hill (1980) , include 67 species from north, central, and south america, eurasia, and africa. no other carnivore shows such diversity of adaptation, being found in a wide variety of ecosystems ranging from earlier references to ferrets are probably the basis of the belief that ferrets originated in north africa (thomson, 1951) . evidently they were bred specifically for rabbiting (rabbit hunting) and were muzzled before being sent into rabbit burrows. this practice was later introduced into europe, asia, and the british isles, where the sport is still practiced today. although the ferret has been historically used for hunting, more recently it has been increasingly used in biomedical research and is popular in north america as a pet. it is most likely a domesticated version of the wild european ferret or polecat (m. putorius or m. furo) (thomson, 1951) . alternatively, it may be related to the steppe polecat (m. eversmanni), which it closely resembles in skull morphology (walton, 1977) . the domesticated ferret, although introduced to north america by the early english settlers some 300 years ago, has not established feral colonies on this continent. the ferret was not recognized as having potential as an animal model for biomedical research until the 1900s. early studies utilized the ferret in classic experiments with influenza virus pathogenesis (pyle, 1940) . its use was cited infrequently; an article published in 1940, detailing the use of ferrets in research, cited only 26 publications (pyle, 1940) . literature reviews undertaken in 1967, 1969, 1973, and 1985 , however, revealed an increasing appreciation for the ferret's usefulness and versatility in the study of human physiologic, anatomic, and disease mechanisms (hahn and wester, 1969; marshall and marshall, 1973; shump et al., 1974; frederick and babish, 1985) . in 1991, a bibliography containing "selected" literature citations on the ferret and its use in biomedical research was published (clingerman et al., 1991) . the document was designed to serve as a reference tool for individuals involved in the care or use of ferrets in the laboratory setting. although not comprehensive, the document provides extensive coverage of ferret biology, diseases, and use as an animal model. the domesticated ferret has been and continues to be used extensively in studies involving virology, reproductive physiology, anatomy, and endocrinology, as well as other areas of biomedical research (morgan and travers, 1998) . the ferret is also being used to replace the cat in some types of neuroendocrinology, neuroanatomy, and cardiology experiments. the ferret's increasing popularity in research and as a pet is mainly a result of large-scale commercial production. for example, commercial farms have been raising ferrets for almost 50 years. biomedical researchers in the united states can request animals of a specific sex, weight, and age for individual experiments. investigators in other countries may acquire fer-rets from fur operations or may make arrangements with commercial vendors in the united states. even though the ferret is nonstandardized with regard to exact genotype and pedigree, its routine availability in a clinically healthy state has aided immeasurably its acceptance as a research animal. readily available commercial stocks, based on coat color, are albino, sable (or fitch), siamese, silver mitt, and siamese-silver mitt (siamese with white chest and feet) (mclain et al., 1985) . the fitch or so-called wild coat color is the most common, recognized by yellow-buff fur with patches of black or dark brown, particularly on the tail and limbs (andrews and illman, 1987) . the production of ferrets by large commercial operations has raised concern by some that inbreeding of these animals has made the ferret more susceptible to diseases, e.g., endocrinerelated disorders. this topic is covered in more detail in chapter 21. housing of ferrets in a research facility is similar to that of other small carnivores such as cats (fox, 1998c) . ferrets tolerate low temperatures well and high temperatures poorly; the recommended temperature range for juvenile and adult animals is 4-18~ (hammond and chesterman, 1972) . ferrets less than 6 weeks of age should be housed at > 15 ~ c. kits under this age require a heat source if separated from the dam; older kits that are group-housed do not. elevated temperatures (>30~ cannot be tolerated by ferrets, because they have poorly developed sweat glands and are susceptible to heat prostration. signs of hyperthermia include panting, flaccidity, and vomiting. the preferred humidity is 40-65%. for nonbreeding animals that will remain in the facility for a short time, a conventional dark-light cycle at 12:12 hr is adequate. lighting may be altered to control breeding cycles. breeding and lactating jills should be exposed to 16 hr of light daily. ferrets that are maintained for breeding or for use beyond 6 months should be exposed to "winter" lightw6 weeks per year of 14 hr of dark dailywto maintain physiologic normalcy. it is also essential that researchers receiving time-pregnant jills preserve the photoperiod to which jills were exposed prior to shipment. failure to do so may cause inappetence, with subsequent negative energy balance and pregnancy toxemia. similar to other laboratory animal species, ferrets should be housed with 10-15 air changes per hour (usdhhs, 1996) . it is important to use nonrecirculated air because of the strong odor of ferrets and the susceptibility to respiratory tract infections. the ferret odor should not overlap into any rodent housing areas, because rodents have an instinctive fear of ferrets, and the ferret scent can disrupt rodent breeding and physiology (fox, 1998c) . female ferrets can be housed singly or in groups, but estrous females that are cohoused may become pseudopregnant (beck et al., 1976) . males should be housed individually after 12 weeks of age. molded plastic caging used to house rabbits works very well for ferrets. the solid bottom is perforated with holes and is readily sanitizable. an absorbable paper liner may be used in the pan beneath the cage to facilitate daily disposal of urine and feces. in a research setting, the plastic caging should be washed weekly to avoid excessive soiling. the spacing of grid walls should be 1.0 x 0.5 inches apart, or 0.25 inch if using wire mesh. ferrets like to lick and bite at their enclosures, so sharp edges and galvanized metal should be avoided. zinc toxicosis has been reported from licking galvanized bars from which metals had leached during steam sterilization (straube and walden, 1981) (table i) . ferrets can be trained to use a litter box because they repeatedly urinate or defecate in one corner of the cage. clay litters have been reported to cause chronic upper respiratory irritation parameter (jenkins and brown, 1993) . ferrets prefer sleeping in a soft isolated area, and in a research facility this can be accomplished by providing a washable "snooze tube" (fox, 1998c) . the thorax of the ferret is narrow and elongated, and as a result the trachea is proportionally long. this makes the ferret an ideal species for studies of tracheal physiology. the tracheal size and laryngeal anatomy make endotracheal intubation somewhat challenging, and as a result the ferret has been advocated as a species suitable for use in pediatric intubation training (powell et al., 1991) . the lungs are relatively large, and the total lung capacity is nearly 3 times that which would be predicted based on body size, as compared with other mammals. this characteristic, together with a higher degree of bronchiolar branching and more extensive bronchial submucosal glands (as compared with the dog), makes the ferret an attractive model for pulmonary research studies (vinegar et al., 1985) . although a previous report (willis and barrow, 1971) commented that the carotid arterial branching pattern in the ferret is unusual, it is actually typical for a carnivore. as is the case in the dog and the cat, the paired common carotid arteries arise from the brachiocephalic trunk (sometimes called the innominate artery) at the level of the thoracic inlet (andrews et al., 1979b) . the ferret's gastrointestinal tract is specialized to fit its carnivorous nature. the simple monogastric stomach is similar to that of the dog. there is no cecum present, and the indistinct ileocecal transition makes it difficult to identify the junction of the small and large intestines during a gross examination. the overall length of the alimentary tract is very short relative to the body size, resulting in a gastrointestinal transit time as short as 3 hr (bleavins and aulerich, 1981) . as in other mustelids, the paired anal scent glands of the ferret are well developed. although not as potent as those of the skunk, the secretions of the ferret are sufficiently odoriferous that many pet or research ferrets are descented. surgical techniques for this procedure have been described (creed and kainer, 1981; mullen, 1997) . ferrets, especially intact males and estrous jills, may possess a distinctive musky odor even after a successful descenting, because of normal sebaceous secretions. ferrets lack well-developed sweat glands for use in thermal regulation, and as a result they are predisposed to heat prostration when ambient temperatures reach 32~ (90 ~ f) (ryland et al., 1983) . extramedullary hematopoiesis is commonly found during histological examination of the spleen, and in some cases it may result in a grossly evident splenomegaly (erdman et al., 1998) . this must be differentiated from splenomegaly that can arise from a variety of pathologic conditions or from isoflurane administration (see section iii,e). experimental evidence suggests that ferrets have no naturally occurring antibodies against unmatched erythrocyte antigens, and that none develop even in the face of repeated transfusions . ferrets are seasonal breeders, and the resulting pronounced physiological variations in body weight, behavior, and gametogenesis are utilized in scientific studies of photoperiod responses and neuroendocrine control. prolonged estrus in unbred females can cause an aplastic anemia, an effect that can be reproduced with exogenous estrogen administration . the male has a radiographically evident os penis, and, contrary to some earlier reports, a prostate gland is present in males (evans and an, 1998) . newborn ferret kits weigh 6-12 gm at birth and will grow to 400 gm by the time they are weaned at 6-8 weeks (shump and shump, 1978) . in sexually intact populations, males (1.0-2.0 kg) can be twice the size of females (0.5-1.0 kg). the adult weight of nonobese male and female ferrets that have been gonadectomized prior to weaning and raised in captivity will generally fall between 0.8 and 1.2 kg (brown, 1997a) . adult animals (especially those that are sexually intact) may be subject to seasonal fluctuations in body fat percentage, which can cause body weight to fluctuate by 30-40% (fox and bell, 1998) . the approximate life span for the ferret is 6-8 years, but on rare occasions they may live as long as 11 years (table ii) . normal hematology and serum chemistry values have been reported for the ferret (thornton et al., 1979; lee et al., 1982; fox, 1998e) . these values are not greatly dissimilar from those of other domestic carnivores. one distinctive hematological characteristic of the ferret is the presence of a relatively robust erythron, characterized by hematocrit, hemoglobin, and total erythrocyte and reticulocyte counts that are generally higher than those of the dog or cat. reported neutrophil-lymphocyte ratios range from 1.7:1 to 0.7:1. representative hematology and chemistry ranges from one of our studies (fox et al., 1986b) are shown in tables iii and iv, but for diagnostic purposes any laboratory that evaluates ferret samples should develop its own set of specific normal ranges. a low-grade proteinuria may be identified by urinalysis in normal, healthy ferrets (thornton et al., 1979) (table v) . ferret diets have been formulated both empirically and based upon the nutrient requirements of other mustelids (fox and mclain, 1998) . specific requirements for various life-cycle stages have not been determined experimentally. available commercial diets are certainly capable of supporting growth, reproduction, and maintenance in conventional settings. in the (fox et al., 1986b) . bfour-to 8-month-old ferrets (loeb and quimby, 1999) . cnd, not done. absence of careful analysis, however, it is uncertain whether the proportion and quantity of ingredients in these diets is optimal. ferrets are strict carnivores with a high requirement for dietary fat and protein. their short digestive tract and rapid gastrointestinal transit time (3-4 hr) require protein to be readily digestible. there is general agreement that ferrets should not be given diets high in complex carbohydrates or fiber. diets that are high in fish products are also not recommended for ferrets (fox and mclain, 1998) . the use of any raw chicken, beef, or other meats is strongly discouraged because of the potential contamination by campylobacter, salmonella, listeria, mycobacterium, and streptococcus (fox, 1998a) . daily maintenance energy consumption for ferrets is 200-300 kcal/kg body weight. calorie-percent protein ratios have been determined for mink (mustela vison) kits up to and after 16 weeks of age (sinclair et al., 1962; allen et al., 1964) . a ratio of 13 and a caloric density of 550 kcal/100 gm of feed, corresponding to 42% protein, provided optimum growth for male kits up to 16 weeks. after 16 weeks, ratios of 17 and 21, corresponding to 36% and 26% protein, respectively, were recommended. diets containing 9-28% fat and 22-42% carbohydrate have been used successfully to maintain ferrets. one author recommends 30-40% protein and 18-20% fat for adult, nonbreeding animals and a minimum of 35% protein and 25% fat for reproductively active animals and those that have notreached sexualmaturity (brown, 1997a) . the long-term impact of diets containing high levels of fat and protein are unknown. ferrets have been used to investigate the absorption, metabolism, and interaction of the dietary micronutrients [3-carotene and vitamin e. ferrets, like humans, convert [3-carotene to vitamin a in the gut and absorb ~-carotene intact (fox and mclain, 1998) . in intestinal perfusion experiments in ferrets, it was demonstrated that [3-carotene, retinol, and retinyl esters are absorbed intact into lymph and that cleavage products, including [3-apo-12'-carotenal, [3-apo-10'-carotenal, and retinoids, accumulate in the intestinal mucosa (wang et al., 1992) . the intestinal mucosa is capable of converting [3-carotene into retinoic acid and other polar metabolites, which are then transported via the portal vein to the liver (wang et al., 1993) . [3-carotene absorption is enhanced by co-perfusion with a-tocopherol, and the perfusion of the latter is unaltered by the presence of [3-carotene. the conversion of [3-carotene into retinol is also enhanced by the presence of a-tocopherol (wang et al., 1995) . these and other findings have established the ferret as an important model for the study of these antioxidants. adult ferrets drink 75-100 ml of water daily, depending on the dry-matter content of the feed (andrews and illman, 1987) . fresh water can be provided ad libitum in stainless steel bowls or water bottles with sipper tubes. ferrets are playful and will overturn bowls or water bottles that are not well secured. features of ferret reproduction may be found in table vi for males, corresponding temporally to increasing day length. ferrets born in the late spring or early summer and maintained under natural lighting will not assume an adult pattern of gonadal activity (i.e., puberty) until the following season (baum, 1998) . under artificial illumination, jills that are maintained at 8 hr light-16 hr dark reach puberty at 10-12 months. stimulatory photoperiods may be used, however, in the laboratory or intensive production setting, as a method of breeding ferrets out of the natural season. however, the transfer from short to long photoperiods should not occur prior to 90 days of age, because jills that are prematurely transferred will remain anestrous (hammond and chesterman, 1972) . management practices in one breeding facility are such that jills commence breeding at 7-10 months, average 3.7 litters a year, and are cycled out of reproduction after 6 litters. in another strategy, ferrets are exposed to a 16:8 hr photoperiod at 12 weeks of age, are bred at 16 weeks during their first estrus, and whelp at 5v2 months. vulvar swelling is the hallmark of estrus in jills. the ease with which estrus is detected in the ferret, as well as the size of the ferret and ease of its maintenance in captivity have made the ferret a model for study of neuroendocrine events and their gonadal correlates. along with the hamster, the ferret has contributed extensively to an understanding of the photoperiodic influences on the hypothalamic-pituitary-gonadal axis (baum, 1998) . as in females of other species, estradiol concentrations are responsible for controlling the development of the female reproductive tract and secondary sexual characteristics, and the tonic inhibition of luteinizing hormone (lh) secretion by the anterior pituitary during both prepubertal life and anestrus. the sensitivity of the hypothalamic gonadostat to negative feedback inhibition by estradiol changes at the time of puberty, and under the influence of increasing light exposure, lh levels rise despite estradiol (ryan, 1984) . similarly, age differences in the sensitivity of negative feedback inhibition of the hypothalamic secretion of gonadotropin-releasing hormone (gnrh) by testosterone, or to estrogenic compounds derived from the aromatization of testosterone, appear to be essential in determining puberty and seasonality of reproduction in the male (baum, 1998) . estrus in jills is characterized by dramatic vulvar swelling from an anestrous diameter of 5-16 mm to an estrous diameter of 17-33 mm. changes in vaginal cytology have also been described for the ferret and other mustelid species, but these changes are seldom used to determine onset of estrus or to schedule breeding (williams et al., 1992) . after a 2-to 3-week proestrus, estrus occurs. estrus onset is not associated with elevated serum fsh in the ferret, as it is in the rodent. once estrus has occurred, it may terminate in coitus-induced ovulation and pregnancy, pseudopregnancy after infertile mating, pharmacologic termination (by injection of human chorionic gonadotropin (hcg) or gnrh), death due to estrogen-induced aplastic anemia, or spontaneous remission and anestrus due to reduced photoperiod. waves of follicular development occur in estrus, and 5-13 ova are ovulated approximately 30-40 hr after coitus. female ferrets are brought to the male approximately 14 days after vulvar enlargement. females and males copulate many times and for prolonged periods of time; they are typically left together for 2 days. both intromission and neck restraint by the male are apparently required for induction of ovulation (baum, 1998 ). an lh surge accompanies coitus in females, but the same is not true of males (carroll et al., 1987) . implantation occurs 12 days after mating; both a functional corpus luteum and the anterior pituitary are required for implantation and maintenance of pregnancy. placentation is typical of carnivores and is zonary and endotheliochorial (morrow, 1980) . pregnancy may be detected by ultrasonographic demonstration of 3-5 discrete nonechogenic structures as early as day 12 (peter et al., 1990) , by palpation as early as day 14, or by radiographic demonstra-tion of calcified fetal skeletons at approximately 30 days of gestation. jills within 2 weeks of parturition should be singly housed and provided with a secluded place in which to deliver their kits. when rabbit cages are used for housing, nest boxes may take the form of polypropylene rat cages or other plastic boxes (cat litter box or dishpan). nest boxes should have bedding provided for warmth and comfort. materials suitable for bedding include pieces of fabric (towels), ripped cageboard, shredded paper, or cotton batting. the nest box should be at least 6 inches deep and should prevent the kits from wandering from the jill. entrance to the nest box should be smooth, to avoid injury to the teats and mammary gland. at our institution, jills are provided a stainless steel rectangular box with a smooth-surfaced plastic entrance ( fig. 1) . a retractable steel roof panel and a guillotine side panel exposing a plexiglas sidewall allow access to the jill and permit observation with minimal disturbance. one major supplier of ferrets uses sunken tubs filled with bedding to promote a sense of security and isolation of the jill. most jills will leave the nest box to eat and drink. if the jill will not leave, however, low-sided food bowls should be placed within the nest box. parturition occurs rapidly in ferrets and may last as little as 2 -3 hr. primiparous jills typically deliver on day 41 of gestation whereas multiparous jills deliver on day 42. there are few signs of impending parturition, although abdominal enlargement and mammary development do occur in the last week or two. small litters (fewer than three) may result in inadequate stimulus for parturition. jills that pass their due date without delivery should be palpated for fetuses. kits remaining in utero beyond the 43rd day typically die; kits with congenital malformations such as cyclopia and exencephaly may also delay the initiation of labor. dystocia is common in ferrets because of positional abnormalities and fetal oversize and should be treated by cesarean section. jills tolerate cesareans well and will nurse kits delivered in this way. if small littel: size is responsible for delayed parturition, prostaglandins (0.5-1.0 mg lutalyse) may be used, followed by 0.3 ml oxytocin (6 u) after 3 hr (fox and bell, 1998) . failure to deliver within 8 hr of administration of prostaglandin is an indication for cesarean section. jills should be provided heat, energy, hydration, and analgesia following cesarean. kits will attempt to nurse soon after parturition, but jills experiencing difficult labor may not allow them to nurse until all kits are delivered. jills that are not attentive to their kits should be palpated for the presence of additional, undelivered kits. oxytocin may be used to facilitate delivery of remaining kits. offering the jill regular chow mixed with warm water may promote maternal acceptance. kits should be kept warm pending acceptance by the jill. jills should be left undisturbed for the first several days postpartum to avoid their cannibalizing the litter. cross-fostering to other jills may be successfully accomplished, provided that the kits are warm and that the foster jill has kits of similar age. kits to be fostered should be allowed to mingle with the foster jill's own kits while their dam is absent so that rejection due to olfaction will not occur. kits are born in an altricial state, covered by lanugo hair and with their eyes closed. by 3 days of age, albino ferrets retain their white hair whereas pigmented ferrets acquire a gray coat. they are completely dependent on the jill for the first 3 weeks of life. defecation and urination are stimulated by jills through anogenital licking of the kits. kits are born weighing 6-12 gm, double their weight in 5 days, and triple it in 10 days to a weight of 30 gm. the 3-week-old male kit should weigh at least 100 gm. sexual dimorphism in size is apparent by week 7 and persists into adulthood. developmental landmarks include ability to hear at 32 days, opening of the eyes at 34 days, eruption of deciduous teeth at 14 days, eruption of permanent canines at 47-52 days, and displacement of deciduous canines by 56-70 days (fox and bell, 1998) . gender may be distinguished in neonatal ferrets, as in other species, by anogenital distance, with the distance being much shorter in females than in males. in males, the urogenital opening is seen just caudal to the umbilicus. the prominent midline raphe penis overlying the palpable os penis is also a distinctive feature in the male. ferrets are typically weaned at 6 weeks of age. early weaning may be encouraged by making a slurry of the jill's chow available at 3-4 weeks; fat may be added to achieve a fat content of 30%. the fatty acid supplement linatone (lambert kay, cranberry, new jersey) is recommended by one author (brown, 1997a) . the diet should contain approximately 30% fat and 40% protein. the slurry should be fed twice daily for a restricted time and then removed to avoid having kits walking through and defecating in the diet. unthrifty kits over 14 days of age may be supplemented with canine or feline milk replacers administered per os by tygon-tipped pasteur pipette . weaned ferrets are best housed in groups until sexually mature. males over 12 weeks old may begin to fight if exposed to greater than 12 hr light per day. jills may return to estrus during the second or third week of lactation if they have fewer than 5 kits or 2 weeks after weaning if the litter is of normal size. jills should be rebred or administered hcg to terminate estrus, even if still lactating. a highquality, calorie-dense diet is required for lactation and to maintain pregnancy. if maintained on a stimulatory photoperiod and adequate nutrition, jills may have 2-3 liters of 6 or more kits yearly until they are 5 years old (fox and bell, 1998) . a nonstimulatory photoperiod should be used 6 weeks per year to rest the ferret and preserve maximum fertility; a maintenance diet can be given at this time. jills return to estrus approximately 3 weeks after reinstitution of the longer photoperiod. artificial insemination is not commonly performed in ferrets but has been studied in the context of providing strategies for species perpetuation of the endangered black-footed ferret (wildt et al., 1989) . synchronization of estrus as practiced in rodent production is not used as a tool of reproductive management in the ferret. synchronization ofjills may be approximated, however, by manipulation of photoperiod. with natural illumination in outdoor housing, jills all come into estrus within a 1-to 2-week period (baum, 1998) . in the laboratory setting, when jills are maintained in a nonstimulatory photoperiod (8 hr light-16 hr dark) for 6-8 weeks, followed by reversal of the cycle (16 hr light-8 hr dark), estrus will follow in 4 weeks (immature jills) or 3 weeks (mature jills) after the change (carroll et al., 1985) . this correlates with follicular development and increased plasma estradiol. the occurrence of infectious disease affects animal health and well-being and may complicate research efforts. a program combining good animal husbandry, optimal nutrition, health monitoring practices, and clinical care is essential to maintaining a healthy ferret colony. etiology. the etiologic agent is clostridium perfringens type a (clostridium welchii). epizootiology and transmission. clostridium perfringens is ubiquitous and is present in the intestinal contents of humans and animals. clostridium perfringens type a has been associated with the occurrence of acute abdominal distension, dyspnea, and cyanosis in weanling ferrets (field and laboratory service veterinary staff, 1984) and an outbreak of gastroenteritis in weanling black-footed ferrets (schulman et al., 1993) . the exact cause of these conditions is uncertain, but predisposing factors such as overeating, sudden changes in diet, the prolifer-ation of c. perfringens type a, and the production of overwhelming amounts of toxins are suspected (field and laboratory service veterinary staff, 1984; schulman et al., 1993) . the alpha toxin is the principal lethal toxin. it is hemolytic and necrotizing and possesses the ability to split lecithin or lecithinprotein complexes, leading to destruction of cell membranes and subsequent necrosis. reported cases have involved weanling animals exclusively. clinical signs. ferrets may present with acute abdominal distension, dyspnea, and cyanosis or may be found dead and bloated (field and laboratory service veterinary staff, 1984; schulman et al., 1993) . diagnosis. isolation of c. perfringens type a from gastric and small-intestinal contents is required. toxin identification may be performed by the use of a mouse protection assay (smith, 1975) . necropsy findings. gross findings include markedly distended stomachs and intestines containing a large amount of gas and a moderate amount of brown, semiliquid ingesta, and subcutaneous emphysema with minimal or no putrefaction (field and laboratory service veterinary staff, 1984; schulman et al, 1993) . histologic findings observed in weanling black-footed ferret cases included the observation of abundant gram-positive bacilli in smears of gastric and intestinal contents. other findings included varying degrees of gastrointestinal mucosal necrosis, numerous gram-positive bacilli lining the denuded mucosal surface and extending into the gastric glands and intestinal crypts; lymphoid necrosis of lymph nodes, spleen, and thymus; mild to moderate dilatation of central hepatic sinusoids with mild, acute, centrilobular hepatocellular dissociation and multifocal aggregates of small numbers of necrotic neutrophils within portal areas (schulman et al., 1993) . and feeding practices is the primary means of control. in the reported cases of c. perfringens type a-associated gastroenteritis in black-footed ferret weanlings, supportive care and gastric trocharization were unrewarding. the occurrence of the condition was eliminated by restricting feeding of weanlings to twice a day instead of 3 times daily. etiology. campylobacteriosis is caused by infection with campylobacter jejuni. epizootiology and transmission. campylobacter jejuni is a gram-negative, spirally curved microaerophilic bacterium that is recognized as a significant cause of human enteritis and is as-sociated with diarrheic illness in several animal species, including dogs, cats, cows, goats, pigs, mink, ferrets, and sheep (carter et al., 1995) . it also known to cause mastitis in cows, infectious hepatitis of chickens, and abortion in cattle, sheep, goats, dogs, and mink (carter et al., 1995) . the organism may also be cultured from the feces of normal asymptomatic dogs, cats, and ferrets carter et al., 1995) . transmission occurs by ingestion of organisms through direct contact with feces or contaminated food and water (carter et al., 1995) . there have been reports linking the disease in humans to pets. many of these outbreaks were associated with dogs, puppies, and kittens recently obtained from animal shelters or pounds and displaying diarrhea before the human illness occurred . isolation of campylobacter jejuni from asymptomatic ferrets also implies a potential for zoonotic transmission (fox et al., 1982 . clinical signs. experimental oral inoculation of ferret kits with various strains of c. jejuni produced a self-limiting diarrhea that ranged in character from very mild to watery manning, 1990a, 1991) . the presence of mucus and/or blood was also noted in the feces of affected animals. anorexia, dehydration, and tenesmus with watery diarrhea were also observed. intravenous inoculation of 4 pregnant mink and 7 pregnant ferrets resulted in reproductive failure, ranging from fetal resorption to expulsion of dead or premature living kits . oral inoculation resulted in abortion in a majority of the infected animals . diagnosis. diagnosis is based on history, clinical signs, and culture of affected animals. reports of spontaneous cases in ferrets require diagnostic confirmation and differentiation from cases of proliferative bowel disease and other infectious and noninfectious causes of diarrhea. campylobacter jejuni grows slowly and has specific culture requirements that involve the use of selective media or filtration techniques, and a requirement for thermophilic (42~176 and microaerophilic conditions (fox, 1998a) . cultures should be examined every 48 hours for round, raised, translucent, and sometimes mucoid colonies (fox, 1998a) . campylobacter jejuni revealed small focal neutrophilic infiltrates in the lamina propria of the colon of relatively few infected animals . bell and manning (1991) noted mild to moderate enterocolitis with neutrophilic infiltration of the lamina propria, which was most severe in kits with concurrent cryptosporidiosis. placentitis was the most notable histologic finding in pregnant ferrets and mink after experimental inoculation of a strain of an abortion storm-associated isolate of c. jejuni . erythromycin is the drug of choice for treatment of human campylobacteriosis (fox, 1998a) . in a study to eliminate the carrier state in ferrets, erythromycin was ineffective even though in vitro isolates of c. jejuni were sensitive to the antibiotic . according to the author, reasons for therapeutic failure included dose selection, interspecies differences in pharmacokinetics and possible reinfection. supportive care should be instituted, and choice of antibiotic therapy in confirmed diarrheic cases should be based on culture and sensitivity. in addition, because of its zoonotic potential, isolation of affected animals and good hygienic practices are recommended. reculture of animals after treatment to ensure elimination of the organism is recommended. epizootiology and transmission. in 1985, a gastric helicobacter-like organism was isolated from the margins of a duodenal ulcer of a ferret and named helicobacter mustelae (fox et al., 1986a (fox et al., , 1989a . subsequently, in the united states, gastritis and peptic ulcers have been routinely reported in ferrets colonized with h. mustelae (fox et al., 1988b (fox et al., , 1991a . every ferret with chronic gastritis is infected with h. mustelae, whereas specific pathogen-free (spf) ferrets not infected with h. mustelae do not have gastritis, gastric ulcers, or detectable igg antibody to the organism (fox et al., , 1991a . helicobacter mustelae has also been isolated from the stomachs of ferrets living in england, canada, australia and, most recently, from ferrets in new zealand (forester et al., 2000; tompkins et al., 1988) . koch's postulates have been fulfilled: by oral inoculation of h. mustelae into naive ferrets uninfected with h. mustelae, the infection induced a chronic, persistent gastritis similar to that observed in ferrets naturally infected with h. mustelae (fox et al., 1991b) . it is now known that h. mustelae colonizes nearly 100% of ferrets shortly after weaning. feces from weanling and adult ferrets have been screened for the presence of h. mustelae to determine whether fecal transmission could explain the 100% prevalence observed in weanling and older ferrets (fox et al., 1988b (fox et al., , 1992b . helicobacter mustelae was isolated from the feces of 8 of 74 nine-week-old and 3 of 8 eight-month-old ferrets. ferrets placed on proton pump inhibitors, which raise gastric ph, have a statistically higher recovery of h. mustelae from feces when compared with age-matched untreated control ferrets . clinial signs and pathology. helicobacter mustelae-infected ferrets examined in our laboratory are usually asymptomatic. ferrets with gastric or duodenal ulcers can be recognized clinically by vomiting, melena, chronic weight loss, and lowered hematocrit. clinical signs in ferrets with h. mustelae-associated gastric adenocarcinoma have consisted of vomiting, anorexia, and weight loss, signs that may be confused with gastric foreign body. diagnosis. gastric and duodenal ulcers are observable endoscopically. it is interesting that the ferret is the only domesticated animal to date that has naturally occurring helicobacterassociated ulcer disease. the h. mustelae isolated from ferrets has similar but not identical biochemical features to those of h. pylori, particularly in regard to the production of large amounts of urease. gastric samples collected by endoscopy or necropsy are minced with sterile scalpel blades and inoculated onto blood agar plates supplemented with trimethoprim, vancomycin, and polymixin b (remel, lenexa, kansas). the plates are incubated at 37~ or 42~ in a microaerobic atmosphere (80% n2, 10% h2, and 10% co2) in vented jars for 3-7 days. bacteria are identified as h. mustelae on the basis of gram-stain morphology; production of urease, catalase, and oxidase; resistance to cephalothin; and sensitivity to nalidixic acid. necropsy and findings. the histopathological changes occurring in the stomach closely coincided in topography with the presence of h. mustelae . a superficial gastritis present in the body of the stomach showed that h. mustelae was located on the surface of the mucosa but not in the crypts. inflammation occupied the full thickness of the distal antral mucosa, the so-called diffuse antral gastritis described in humans (fig. 2a,b) . in this location, h. mustelae was seen at the surface, in the pits, and on the superficial portion of the glands. in the proximal antrum and the transitional mucosa, focal glandular atrophy, a precancerous lesion, and regeneration were present, in addition to those lesions seen in the distal antrum. also, deep colonization of h. mustelae was observed focally in the affected antral glands. animals infected with helicobacter spp. may also be susceptible to gastric cancer yu et al., 1995) . there is recent documentation of the presence of argyrophilic bacteria, compatible in location and morphology to h. mustelae, within the pyloric mucosa of 2 male ferrets with pyloric adenocarcinoma . in humans, epidemiologic data strongly support the association between h. pylori and development of gastric adenocarcinoma. similarly, we have recently documented a series of h. mustelae-infected ferrets with gastric mucosa-associated lymphoid tissue (malt) lymphoma that parallels the same syndi'ome found in humans. lymphoma was diagnosed in the wall of the lesser curvature of the pyloric antrum, corresponding to the predominant focus ofh. mustelaeinduced gastritis in ferrets. gastric lymphomas demonstrated characteristic lymphoepithelial lesions, and the lymphoid cells were igg positive in all ferrets (erdman et al., 1997) . these findings and their parallels in h. pylori-infected humans implicate the involvement of h. mustelae in the pathogenesis of gastric cancer in ferrets. treatment. studies in ferrets indicate that triple therapy consisting of oral amoxicillin (30 mg/kg), metronidazole (20 mg/ kg), and bismuth subsalicylate (17.5 mg/kg) (pepto-bismol original formula, procter and gamble) 3 times a day for 3-4 weeks has successfully eradicated h. mustelae . clinical improvement, including increased appetite and resolution of melena, may occur within 48 hr of initiation of triple therapy. a new treatment regimen being used to eradicate h. pylori in humans has also been used successfully for eradication of h. mustelae from ferrets . ferrets received 24 mg/kg ranitidine bismuth and 12.5 mg/kg clarithromycin per os 3 times daily for 2 weeks. culture of tissue collected by gastric endoscopic biopsy at 16, 32, and 43 weeks after termination of treatment indicated that long-term eradication was achieved in all 6 ferrets. eradication was associated with decrease in anti-h, mustelae igg antibody titers, results that are consistent with findings in humans after h. pylori eradication. omeprazole in ferrets at an oral dose of 0.7 mg/kg once daily effectively induces hypochlorhydria and may be used in conjunction with antibiotics to treat h. mustelae-associated duodenal or gastric ulcers. cimetidine at 10 mg/kg tid per os can also be used to suppress acid secretion. acute bleeding ulcers must be treated as emergencies, and fluid and blood transfusions are essential. etiology. proliferative bowel disease is caused by intracellular campylobacter-like organisms, closely related to desulfovibrio spp., that are now classified as lawsonia intracellularis in proliferative enteropathy of swine (fox, 1998a) . the organisms are gram-negative, comma-to spiral-shaped bacteria. epizootiology and transmission. proliferative bowel disease is a common clinical disease observed in young ferrets. fecaloral spread is suspected. the disease typically involves the large bowel, although it has been observed to affect the small bowel (rosenthal, 1994) . campylobacter species, coccidia, and chlamydia have been isolated from some cases of proliferative bowel disease in ferrets (li et al., 1996b) . the role, if any, of copathogens in this disease is unclear. clinical signs. clinical signs include chronic diarrhea, lethargy, anorexia, weight loss (which is often marked), and dehydration. diarrhea may be blood-tinged, may contain mucus, and is often green in color. rectal prolapse may be observed in affected animals. ataxia and muscle tremors have also been observed (fox et al., 1982) . diagnosis. diagnosis is based on clinical signs, a palpably thickened colon, and colonic biopsy. it is important to rule out other causes of diarrhea and weight loss through diagnostic tests that include but are not limited to a complete blood count, chemistry profile, radiographs, and fecal analysis and culture. necropsy findings. gross findings include a segmented, thickened lower bowel, usually the terminal colon but occasionally including the ileum and rectum (fox et al., 1982; fox, 1998a) . histologic examination consistently reveals marked mucosal proliferation and intracytoplasmic l. intracellularis demonstrated with silver stain within the apical portion of epithelial cells in the hyperplastic epithelial cells (fox et al., 1982; fox, 1998a) (fig. 3a,b) . other common histologic changes observed include the presence of a mixed inflammatory infiltrate that is variable in severity, reduced goblet cell production, hyperplasia of the glandular epithelium, glandular irregularity with penetration of the mucosal glands through the muscularis mucosa, and an increase in thickness of the tunica muscularis (fox et al., 1982; fox, 1998a) . translocation of proliferating glandular tissue to extraintestinal sites, including regional lymph nodes and liver, has been described in two ferrets (fox et al., 1989b) . differential diagnosis. proliferative bowel disease should be differentiated from other diseases that may cause diarrhea and wasting, including dietary changes, eosinophilic gastroenteritis, gastric foreign bodies, lymphoma, aleutian disease, and gastric ulcers (bell, 1997b) . a complete physical exam that includes palpation of the abdomen should reveal a palpably thickened intestine in cases of proliferative bowel disease. treatment and control. supportive care, including fluid therapy and nutritional support, should be provided. treatment with chloramphenicol (50 mg/kg bid po, sq, im) or metronidazole (20 m/kg bid po) for 2 weeks is reported to be effective (krueger et al., 1989; bell, 1997b) . clinical improvement may be apparent within 48 hr. etiology. tuberculosis can be caused by a variety of mycobacteria, including mycobacterium bovis, m. avium, and m. tuberculosis. epizootiology and transmission. mycobacteria are aerobic, gram-positive, nonbranching, non-spore-forming, acid-fast rods. natural infections with mycobacterium bovis and m. avium have been reported in the ferret. ferrets are also susceptible to experimental infection with human tubercle bacillus. most reports of tuberculosis in ferrets are in animals that were used for research in england and the rest of europe between the years of 1929 to 1953 and were likely related to the feeding of raw poultry, raw meat, and unpasteurized milk to ferrets during this time (fox, 1998a) . the feeding of commercially prepared diets and widespread tuberculosis testing and elimination in livestock and poultry have resulted in the reduced incidence of the disease in ferrets. mycobacterium avium-infected wild clinical signs and necropsy findings. clinical signs and lesions are dependent on the infective strain. systemic infection with the bovine strain in ferrets results in disseminated disease with weight loss, anorexia, lethargy, death, and miliary lesions involving the lungs and other viscera (fox, 1998a) . progressive paralysis has also been reported in a case of spontaneously occurring bovine tuberculosis in a ferret (symmers and thomson, 1953) . mycobacterium bovis lesions contain numerous acid-fast bacilli within macrophages with little cellular reaction (fox, 1998a) . in contrast, infection of ferrets with the human tubercle bacilli results in localized infection, often confined to the site of injection and adjacent lymph nodes; microscopically few organisms are observed. an impaired cell-mediated response may account for the large number of organisms observed in m. bovis lesions. vomiting, diarrhea, anorexia, and weight loss were observed in a pet ferret with granulomatous enteritis caused by m. avium (schultheiss and dolginow, 1994) . granulomatous inflammation characterized by large numbers of epithelioid macrophages containing numerous acid-fast bacilli were present in the lamina propria and submucosa of the jejunum and pylorus. other sites of granulomatous inflammation included peripancreatic adipose tissue, mesenteric lymph nodes, spleen, and liver. a source of infection was not identified in this report. pulmonary infection with m. avium has also been reported in 3 ferrets in a zoo in france (viallier et al., 1983) . diagnosis. definitive diagnosis of tuberculosis requires isolation and identification of the organism from suspect tissue specimens. great care should be exercised in handling suspect clinical specimens, and an appropriately equipped laboratory should be identified for culture and identification of the organism. although there has been some experimental work in the area of the intradermal tuberculin skin-test response in ferrets and its apparent use in controlling tuberculosis in a breeding colony of ferrets, a tuberculin skin-testing regimen, including dose and type, has not been definitively characterized for clinical use in ferrets (kauffman, 1981) . treatment and control. because of the zoonotic risk, ferrets infected with m. bovis and m. tuberculosis should be euthanized (fox, 1998a) . recurrent m. bovis infection involving the palmar aspect of the wrist of a 63-year-old man, which developed after he was bitten by a ferret at the age of 12, was reported and demonstrates the zoonotic potential (jones et al., 1993) . mycobacterium avium infection is not reportable but may pose a risk to immunocompromised patients (fox, 1998a) . personnel at risk should be followed up by a physician for appropriate diagnostic testing (fox, 1998a) . etiology. salmonellosis is caused by infection with organisms of the genus salmonella. epizootiology and transmission. salmonella is a gram-negative, non-spore-forming, facultative anaerobic rod in the family enterobacteriaceae (carter et al., 1995) . infection is by the oral route. transmission may be direct from infected carrier animals or humans or through contaminated food products or water (carter et al., 1995) . several salmonella serovars have been isolated from mink with gastroenteritis and abortion (gorham et al., 1949) . contaminated raw meat products were suspected as the source in one outbreak. salmonella typhimurium was isolated in ferrets in an outbreak of clinical disease (coburn and morris, 1949) and several serotypes including s. hadar, s. enteritidis, s. kentucky, and s. typhimurium were isolated from the feces of ferrets surveyed in a research colony (fox et al., 1988a) . clinical signs and necropsy findings. clinical signs of an outbreak of s. typhimurium in ferrets included conjunctivitis, rapid weight loss, tarry stools, and febrile temperature fluctuations (coburn and morris, 1949) . gross findings in 2 ferrets 10 days after inoculation with s. typhimurium of ferret origin included marked tissue pallor, petechiae in the gastric mucosa, and the presence of melena in one and a dark-colored fibrinous exudate in the large intestine of the other ferret (coburn and morris, 1949) . studies involving experimental inoculation with s. enteritidis, s. newport, and s. choleraesuis via the oral route to healthy, distemper-infected, and feed-depleted ferrets and mink showed a fairly high resistance to infection (gorham et al., 1949) . only 2 animals of 29 in the diet-restricted group--1 ferret and 1 minknshowed clinical signs of infection after feeding s. newport culture. signs included lethargy, anorexia, trembling, and fecal blood. the gastrointestinal tract showed a large amount of mucus containing red blood cells; bits of desquamated epithelium and few mononuclear cells overlying the gastric mucosa; an exudate in the small intestine consisting of mu-coid material, red blood cells, and desquamated small intestinal villi; edematous villi in the ileum; and a diffuse infiltrate of the small intestinal mucosa with lymphocytes and macrophages. necrotic foci in the liver, spleen, and, less commonly, the kidney, as well as splenomegaly and visceral lymphadenopathy, were observed in chronic fatal infections (coburn and morris, 1949) . abortion and gastroenteritis have been reported in mink (gorham et al., 1949) . diagnosis. diagnosis is based on history, clinical signs, and isolation of the organism. the organism can be cultured on enrichment and selective media and then characterized serologically. samples of blood, feces, exudates, tissues, and intestinal material may be cultured. treatment and control. coburn and morris (1949) treated 6 of 12 ferrets experimentally infected with s. typhimurium with sulfathalidine in the feed (coburn and morris, 1949) . salmonella typhimurium was isolated in 4 of 6 control animals and none of the treated animals 3 days after the administration of the last dose. sulfathalidine was administered by the same authors to a colony of 77 ferrets in which an outbreak of salmonella occurred. the group was surveyed 2 days after sulfathalidine treatment and showed weight gain, improvement in condition, and a reduction in the number of salmonella-infected ferrets (coburn and morris, 1949) . salmonella spp. isolated from ferrets may show resistance to a number of antibiotics (fox, 1998a) . treatment includes appropriate use of antimicrobials and supportive care, which may include fluid therapy, nutritional support, maintenance of electrolyte balance, treatment of concurrent diseases, recognition of and attention to shock, and reduction of stress (fox, 1998a) . etiology. streptococcus zooepidemicus and other group c and g streptococci, escherichia coli, klebsiella pneumoniae, pseudomonas aeruginosa, and bordetella bronchiseptica have been reported as primary and secondary bacterial pathogens in pneumonia in ferrets (fox, 1998a) . epizootiology and transmission. bacterial pneumonia may occur secondary to megaesophagus in the ferret. an influenza virus-bacteria synergism has been the subject of several studies in ferrets (fox, 1998a) . debilitated and immunosuppressed animals and animals with concurrent diseases such as influenza may be more susceptible to bacterial pneumonias (fox, 1998a) . clinical signs. clinical signs may include nasal discharge, dyspnea, lethargy, anorexia, increased lung sounds, cyanosis, and fever (rosenthal, 1997) . fulminant pneumonia may progress to sepsis and death (fox, 1998a) . diagnosis. diagnosis is based on history, clinical findings, a complete blood count, culture and cytology of a tracheal wash or lung wash, and radiographs (rosenthal, 1997) . differential diagnosis. diagnostic rule-outs include dilatative cardimyopathy, heartworm disease, mycotic pneumonia, pneumocystis pneumonia in immunosuppressed animals, neoplasia, and influenza. treatment and control. treatment should consist of appropriate antimicrobial therapy and supportive care, which may include the administration of oxygen, fluid therapy, and force feeding (rosenthal, 1997) . etiology. a variety of bacteria have been associated with abscesses and localized infection of the lung, liver, uterus, vulva, skin, mammary glands, and oral cavity. these include staphylococcus spp., streptococcus spp., corynebacterium spp., pasteurella, actinomyces, hemolytic escherichia coli, and aeromonas spp. (fox, 1998a) . epizootiology and transmission. abscesses in ferrets may result from wounds that are inflicted secondary to biting during fighting, playing, mating, or chewing sharp objects. clinical signs. localized or subcutaneous abscesses present as swellings with or without draining tracts. the swelling may be fluctuant. in most cases, the abscess is walled off and does not result in systemic signs (fox, 1998a) . abscesses or infection involving visceral organs may give rise to organ-specific and/or systemic signs. diagnosis. cytologic and gram staining of an aspirate of a suspect subcutaneous swelling will aid in the definitive diagnosis. culture and sensitivity of the aspirate should also be performed to identify the causative organism and guide appropriate antibiotic therapy. differential diagnosis. differential diagnosis of a subcutaneous swelling in a ferret should include myiasis, granuloma, hematoma, and neoplasia. treatment and control. prevention of ferrets from exposure to sharp objects in the cage and feed, and limiting the exposure of male and female during breeding, can minimize the occurrence of abscesses. treatment of localized abscesses should include appropriate antibiotic therapy and establishment of drainage and debridement if necessary. bacterial culture and sensitivity of the exudate should be performed. a broad-spectrum antimi-crobial may be used pending results of culture and sensitivity (orcutt, 1997) . etiology. gram-positive cocci such as streptococcus spp., staphylococcus aureus, and coliforms such as hemolytic e. coli are the most frequently associated organisms (bernard et al., 1984; bell, 1997a) . although the exact pathogenesis of mastitis in ferrets is not clear, a number of factors may play a role and include the stress of lactation, injury to mammary glands by the kits' teeth, environmental contamination, and the virulence of the organism. in one report, the causative organism, hemolytic e. coli, was cultured from the feces of mastitic and healthy ferrets and the oral cavity of suckling kits (liberson et al., 1983) . the high level of perineal contamination and the presence of the organism in the oral cavity of suckling kits may enhance transmission and introduction of this organism into mammary tissue. in another outbreak, the causative organisms were cultured from bovine meat fed prior to the outbreak, and the meat was suspected as a possible source. clinical signs. mastitis occurs in nursing jills and has been characterized as acute or chronic (bell, 1997a) . the acute form is reported to occur soon after parturition or after the third week of lactation. examination of affected jills reveals swollen, firm, red or purple, and painful glands. affected glands may quickly become gangrenous. the chronic form, which may occur when kits are 3 weeks old or as a sequela to the acute form, is characterized by glands that are firm but not painful or discolored. diagnosis. diagnosis is based on history, clinical signs, physical examination findings, and isolation of the causative organism. necropsy findings. in acute mastitis, grossly affected glands are swollen, and the skin overlying the gland may be discolored. surgical biopsies and necropsies of 8 ferrets with mastitis caused by hemolytic e. coli (liberson et al., 1983) revealed extensive edema, hemorrhage, and coagulative and liquefactive necrosis involving the glandular tissue as well as surrounding subcutaneous tissue. other findings included the presence of a mixed leukocytic infiltrate composed primarily of polymorphonuclear leukocytes; large numbers of bacteria; and thrombosis and necrosis of vessels within and immediately adjacent to areas of inflammation (liberson et al., 1983) . in an outbreak of mastitis in mink due to staphylococcus aureus and escherichia coli, histologic examination of affected glands revealed an acute suppurative mastitis with desquamation of alveolar epithelium, edema of the connective tissue stroma, alveoli filled with neutrophils and cellular debris, and lactiferous ducts filled with purulent exudate and mats of bacteria within lobules (trautwein and helmboldt, 1966) . treatment. broad-spectrum antibiotic therapy may be instituted pending culture and sensitivity results of the milk. enrofloxacin (2.5 mg/kg bid po after a loading dose of 5.0 mg/kg im) is often effective. jills may require aggressive care, because acute mastitis may progress rapidly and animals may become septicemic and moribund (liberson et al., 1983) . oral antibiotic administration to kits nursing affected jills is recommended (bell, 1997a) . surgical resection and debridement of affected glands and supportive care may be necessary for jills with acute mastitis. supplementation of kits with milk replacer may also be necessary, because jills with acute mastitis are reluctant to nurse, and jills with the chronic form have diminished lactation as milk-producing tissue is replaced by scar tissue (bell, 1997a) . maintaining thorough personal hygiene practices when handling affected jills is important in minimizing spread to other lactating jills. cross-fostering kits may be required; however, kits may spread infection to healthy jills. it is reported that jills with the chronic form of mastitis should be culled (bell, 1997a ). etiology. canine distemper (cd) is caused by a paramyxovirus of genus morbillivirus that is related to measles and rinderpest (budd, 1981) . there are several strains, including a ferret-adapted strain of canine distemper virus (cdv), that vary in incubation, clinical signs, and duration . the virus can be inactivated by heat, light, and various chemicals, including phenol, roccal, sodium hydroxide, and formalin (shen and gorham, 1980; budd, 1981) . infectious virions have been recovered from fomites after 20 min at room temperature. canine distemper is the most serious viral infection of ferrets. mortality approaches 100%, making appropriate husbandry and vaccination imperative. the disease has a catarrhal phase and a neurological, or central nervous system (cns), phase. the catarrhal phase is 7-10 days postinfection and involves anorexia, pyrexia, photosensitivity, and serous nasal discharge. an erythematous pruritic rash spreads from the chin to the inguinal region. it is suspected that the rash results from cell-mediated immunity to infected endothelial cells, similar to the response seen in humans with measles (norrby and oxman, 1990) . hyperkeratosis of footpads, called hard pad, is an inconsistent feature. secondary bacterial infections result in mucopurulent ocular and nasal discharge and possibly bacterial pneumonia. the cns phase, with ataxia, tremors, and paralysis, may or may not be preceded by the catarrhal phase. death occurs in 12-16 days from ferret strains of cdv and up to 35 days with canine strains. infection is uniformly fatal. epizootiology and transmission. virus is shed from infected hosts from conjunctival, nasal, and oral exudates, urine, feces, and sloughed skin (gorham and brandly, 1953) . transplacental infection is not reported in ferrets. attenuated cdv vaccine strains have not been recovered from the body secretions of ferrets following vaccination (shen et al., 1981) . unvaccinated dogs and other canids, mustelids, and procyonids may serve as reservoirs of infection. viremia is detectable 2 days postinfection and persists until the ferret dies or mounts a neutralizing antibody response (liu and coffin, 1957) . the primary site of replication is the respiratory and lymphatic systems, and cdv has been recovered from the nasal secretions of ferrets 5-13 days postinfection. a decrease in lymphocyte subsets is detectable 5-30 days postinfection. clinical signs and necropsy findings. histologically, intracytoplasmic and intranuclear inclusion bodies may be observed in tracheal, bronchial, epithelia, and bile duct as well as transitional epithelium in the bladder (liu and coffin, 1957) (fig. 4) . the eosinophilic (hematoxylin-eosin) inclusions appear orange using pollack's trichrome stain. diagnosis and differential diagnoses. presumptive diagnosis is based on clinical observation, questionable vaccination history, and exposure. a fluorescent antibody test can be used on peripheral blood and conjunctival mononuclear cells to detect infection. reverse transcriptase-polymerase chain reaction (rt-pcr) has also been used to detect experimental infection (stephensen et al., 1997) . differential diagnoses should include infection with influenza virus or bordetella bronchiseptica. influenza does not rapidly progress to mucopurulent ocular and nasal discharge as cd does. during an outbreak, clinically affected ferrets should be isolated and the remainder of the colony vaccinated. distemper infection can be prevented by vaccination with modified live vaccine of chicken embryo tissue culture origin (cetco) administered subcutaneously or intramuscularly. kits should be vaccinated every 2-3 weeks, starting at age 6 weeks, until 14 weeks and annually thereafter . it is important to adhere to the prescribed vaccination protocol, because ferret deaths have been reported following double-dose vaccination (carpenter et al., 1976) . inactivated distemper vaccines do not elicit consistent, effective immunity and are not recommended. it is important to know the vaccination schedule of your ferret supplier and to vaccinate supplementally as appropriate. new ferrets should be held in quarantine for 2 weeks prior to introduction into the resident colony. ferrets have been experimentally infected with feline panleukopenia, canine parvovirus, canine parainfluenza virus, mink enteritis virus, respiratory syncytial virus, transmissible mink encephalopathy, and pseudorabies, but natural infection with these viruses has not been reported . etiology. aleutian disease virus (adv) is a parvovirus with strains of varying virulence and immunogenicity. mink-derived strains are more virulent to mink than are ferret-derived strains . epizootiology and transmission. aleutian disease (ad) is a chronic progressive illness that was first described in mink (oxenham, 1990) . it was originally named hypergammaglobulinemia (hgg) because of this remarkable finding. infection may be subclinical for years. because the immunomodulation associated with adv infection is disruptive to biomedical research, it is important to seek sources of adv-free ferrets . transmission between ferrets may be direct or via aerosol of urine, saliva, blood, feces, and fomites (kenyon et al., 1963; gorham et al., 1964) . vertical transmission is established in mink but is unproven in ferrets. clinical signs. ferrets infected with adv as adults develop persistent infection but rarely disease, although chronic progressive weight loss, cachexia, malaise, and melena have been described (porter et al., 1982) . ad may also cause ataxia, paral-ysis, tremors, and convulsions (oxenham, 1990; welchman et al., 1993) . the lesions are typically immune-mediated, and there is elevation of the gammaglobulins to generally greater than 20% of the total proteins (porter et al., 1982; fig. 5 ). the precise mechanism of immunomodulation is unknown, but in mink there is depression of b-and t-cell responses. necropsy. ferrets may have no lesions upon necropsy, or infrequently they may have hepatosplenomegaly and lymphadenopathy. the most consistent histological finding is periportal lymphocytic infiltrates (fig. 6 ). bile duct hyperplasia and periportal fibrosis have also been reported. membranous glomerulonephritis has been described (ohshima et al., 1978) . although lesions are subtle, use of adv-infected ferrets in biomedical research is contraindicated because histological lesions interfere with the interpretation of study results . diagnosis and differential diagnoses. presumptive diagnosis is based on hgg and chronic weight loss. diagnosis is confirmed by immunofluorescent antibody (ifa) or counterimmunoelectrophoresis (ciep) for antibody to adv antigen (palley et al., 1992) . pcr-based assays have also been used (erdman et al., 1996b; saifuddin and fox, 1996; erdman et al., 1997) . differential diagnoses include the neurotropic form of cd, as well as chronic wasting diseases such as neoplasia, malabsorption, maldigestion, and bacterial enteritis . vaccination against adv would be contraindicated because of the immune-mediated reaction, and a vaccine is not available. chemical disinfection may be achieved tp -10.6 g/dl 9 /globulin = 5.75 g% , .. with formalin, sodium hydroxide, and phenolics (shen et al, 1981) . there is no treatment for ad, and infected ferrets should be culled from the colony. etiology. influenza is caused by an orthomyxovirus that is transmissible from humans to ferrets and ferrets to humans (smith and stuart-harris, 1936) . human influenza viruses a and b are pathogenic to ferrets . ferrets are also susceptible to avian, phocine, equine, and swine influenza, although only porcine influenza causes clinical signs. because the viruses can be readily transmitted from humans to ferrets, handling precautions such as wearing masks and gloves should be in place to minimize transmission. epizootiology, transmission, and clinical signs. influenza virus generally remains localized in nasal epithelium in ferrets but may cause pneumonia. clinical signs appear 48 hr postinfection and include anorexia, fever, sneezing, and serous nasal discharge. conjunctivitis, photosensitivity, and otitis are also sometimes seen . secondary bacterial infection by streptococcus sp. and occasionally bordetella bronchiseptica may prolong recovery. transmission occurs via aerosol and direct contact. diagnosis. diagnosis is based on typical clinical presentation and recovery within 4 days, unlike with cd, which progresses to more severe disease and death. hemagglutination inhibition antibody titers on acute and convalescent sera are rarely needed. treatment and control. antibiotic therapy may be instituted to preclude secondary bacterial infection. animal technicians and investigators suffering from influenza should avoid contact with ferrets. ferrets have been used extensively as a model for influenza research because the biological response to infection is similar to that in humans . ferrets have been used in influenza a research to study pathogenesis, to investigate reye's syndrome, and to evaluate vaccine trials (deshmukh, 1987; sweet et al., 1987) . etiology. rabies is caused by a rhabdovirus. rabies infection is infrequently reported in ferrets, and until recently, research on rabies in ferrets was lacking . ferrets in a well-managed facility would have low risk of exposure to rabies virus. a usda-approved, killed rabies vaccine given subcutaneously at ages 3 months and 1 year and annually thereafter is recommended to protect ferrets against rabies (rupprecht et al., 1990) . modified live vaccine (mlv) is not recommended, because there is at least one case of rabies in a ferret that was vaccinated with mlv rabies vaccine . there is no treatment for rabies. clinical signs and pathogenesis. clinical signs of rabies infection in ferrets may include anxiety, lethargy, and posterior paresis. in one experimental infection, 11 of 40 ferrets died, and negri bodies were seen in the brain of only 2 of the 11 (blancou et al., 1982) . there is conflicting data on the isolation of rabies virus from the salivary glands following experimental infection. in one study using raccoon variant of rabies for infection, more than half of the ferrets had rabies isolated from the salivary glands . ferrets at risk for exposure to rabies virus that bite or scratch a human should be placed under quarantine for not less than 10 days of observation. veterinarians and facility managers should seek assistance from state public health officials. diagnosis and differential diagnoses. differential diagnosis includes the neurotropic form of cd. diagnosis is based on direct ifa of brain tissue. because rabies in ferrets is poorly understood, the head from ferrets that exhibit signs compatible with rabies and that have exposure histories that raise concerns about rabies should be shipped to the state public health authority for confirmation. etiology. rotaviruses cause diarrhea in young of many species, including humans, calves, pigs, sheep, and rats. diarrhea in ferret kits is thought to be caused by a poorly characterized, atypical rotavirus that has not been cultivated in vitro (torres-medina, 1987) . atypical rotaviruses lack the rotavirus common antigen. epizootiology, transmission and clinical signs. clinical disease may occur in kits as young as 1-4 days old or in older animals up to 6 weeks of age. diarrhea soils the perineum and possibly the fur and nest material. mortality rates are agedependent, with high mortality occurring in young kits and lower mortality occurring in kits over 10 days of age (bell, 1997a; fox et al., 1998b) . secondary bacterial infection may influence the severity of diarrhea. necropsy andpathogenesis. lesions are restricted to the gastrointestinal tract. yellow-green liquid or mucous feces may be seen in the terminal colon on necropsy. subtle small-intestinal villous atrophy and epithelial cell vacuolation are detectable histologically. diagnosis and differential diagnoses. clinical diagnosis can be confirmed by using clarified and ultracentrifuged fecal pel-lets for electron microscopy. the ferret rotavirus does not crossreact with commercially available enzyme immunoassays (torres-medina, 1987) . it is desirable to avoid sources that are known to be infected with ferret rotavirus. affected kits may be supplemented with kitten milk replacer, using a medicine dropper. mortality is reduced if the kits continue nursing. treatment of secondary bacterial infections may reduce severity of the diarrhea, and supportive care, including subcutaneous fluid administration for young kits, may be required . jills develop immunity to rotavirus infection, and subsequent litters are protected. infectious bovine rhinotracheitis (ibr) was isolated from the liver, spleen, and lung of clinically normal ferrets (porter et al., 1975) . raw beef was suspected as the source of infection, reinforcing the need to exclude raw meat products from the diet of ferrets used for research. ibr does cause significant respiratory pathology in experimentally infected ferrets (porter et al., 1975) . a transmissible diarrhea, referred to as epizootic catarrhal enteritis, has been observed in adult ferrets several days after direct contact and fomite exposure to affected ferrets . clinically the diarrhea is green and bile-tinged, and the ferrets become rapidly dehydrated. mortality is low. some ferrets develop elevated liver enzymes. treatment involves aggressive oral and systemic fluid therapy. a recent study implicates a coronavirus as the cause of this disease (williams et al., 2000) . a. protozoa i. enteric coccidiosis etiology. three species of the genera isospora and eimeria have been reported to infect the ferret: isospora laidlawi, eimeria furonis, and e. ictidea (blankenship-paris et al., 1993) . tion of sporulated oocysts. clinical signs. coccidiosis in ferrets is usually subclinical but has been reported to be associated with diarrhea, lethargy, and dehydration in one ferret (blankenship-paris et al., 1993) . clinical signs are often seen in young, newly acquired ferrets and are more common after a stressful event (rosenthal, 1994) . rectal prolapse can also develop in association with coccidial infection (rosenthal, 1994) . diagnosis. diagnosis is generally made by any of the fecal flotation methods commonly used in veterinary practice or by direct wet mount of feces and microscopic examination for sporulated or unsporulated oocysts. because coccidial oocysts are small, slides should be examined under higher magnification. necropsy findings. diagnosis is usually performed antemortem. pathologic lesions associated with enteric coccidiosis in a laboratory-reared ferret that was euthanized were described in one published report (blankenship-paris et al., 1993) . microscopic lesions were confined to the jejunum and ileum and consisted of villous and epithelial thickening. parasitic cysts and microorganisms within epithelium, and a mild granulomatous inflammation in the villar lamina propria, were also observed. a recent report documents clinical and anatomic pathology associated with biliary coccidiosis in a weanling ferret (williams et al., 1996) . differential diagnosis. diarrhea may be observed in ferrets that present with gastroenteritis secondary to gastrointestinal foreign bodies and dietary indiscretion, as well as other nutritional, inflammatory, infectious, or other systemic diseases. infectious causes such as proliferative colitis, salmonellosis, giardiasis, rotavirus, and campylobacteriosis should be considered. diarrhea may also be seen in eosinophilic gastroenteritis, an uncommonly reported condition in ferrets. good husbandry practices that include sanitation and frequent disposal of feces reduce the number of oocysts in the environment. cleaning cages with a strong ammonium hydroxide solution is reported to be effective (kirkpatrick and dubey, 1987) . heat treatment of surfaces and utensils may also be effective (kirkpatrick and dubey, 1987) . treatment of ferrets with sulfadimethoxine at 50 mg/kg orally once and then 25 mg/kg orally every 24 hr for 9 days is recommended (rosenthal, 1994) . as in dogs and cats, the complete elimination of a coccidial infection requires an immunocompetent host. ii. cryptosporidiosis etiology. cryptosporidiosis is caused by infection with cryptosporidium spp. epizootiology and transmission. cryptosporidium is a protozoan in the class sporozoa, subclass coccidia, that inhabits the respiratory and intestinal epithelium of birds, reptiles, mammals, and fish (regh et al., 1988) . it is known to cause gastrointestinal tract disease in many species, including rodents, dogs, cats, calves, and people (hill and lappin, 1995) . it has a life cycle similar to other coccidian parasites and is transmitted by ingestion of sporulated oocysts. autoinfection is also a characteristic of the life cycle. transmission may occur through consumption of contaminated food or water. cattle, dogs, and cats, shedding oocysts, are reported to be potential sources of human infection (hill and lappin, 1995; fox, 1998g) . immunosuppressed people are at greatest risk of developing severe fulminating gastrointestinal disease (hill and lappin, 1995) . the finding of cryptosporidiosis in two ferrets that died from unrelated causes in one animal facility resulted in a survey of the existing ferret population and new arrivals into the facility to determine the prevalence and incidence of infection (regh et al., 1988) . findings indicated that 40% of the resident population and 38-100% of new arrivals had oocysts in their feces but showed no clinical signs. clinical signs. only subclinical infection has been reported in both immunocompetent and immunosuppressed ferrets (regh et al., 1988) . diagnosis. diagnosis is based on the identification of the organism in feces. the oocysts are small when compared with other coccidia and may be overlooked or mistaken for yeasts (kirkpatrick and dubey, 1987) . yeasts are oval, whereas cryptosporidium oocysts are spherical or ellipsoidal. additionally, yeasts will stain with iodine and are not acid-fast, whereas cryptosporidium has the opposite staining characteristics. the oocyst residuum is seen as a refractive dot under phase-contrast microscopy, a structure lacking in yeast (kirkpatrick and dubey, 1987) . sugar-solution centrifugation and fecal sedimentation using formalin-ether or formalin-ethyl acetate are effective di-agnostic concentration techniques (hill and lappin, 1995) . oocysts may then be viewed with phase-contrast or bright-field microscopy of specimens stained with an acid-fast method. a direct fecal smear may be methanol-or heat-fixed and stained with an acid-fast method (hill and lappin, 1995) . necropsy findings. histologic evaluation reveals the presence of organisl3ns, spherical to ovoid in shape and from 2 to 5 ~tm in diameter, associated with the brush border of the villi. a mild eosinophilic infiltrate was observed in the lamina propria of the small intestine in most animals. the ileum was the most common and heavily infected section of small intestine (regh et al., 1988) . there is no known definitive treatment for cryptosporidiosis (fox, 1998g) . supportive and symptomatic care should be provided in clinical cryptosporidiosis. infections are self-limiting in immunocompetent patients (fox, 1998g) . control is aimed at eliminating or reducing infective oocysts in the environment and avoidance of contact with known sources. because of the potential for zoonotic transmission, restricting contact of children and immunosuppressed individuals with infected ferrets and practicing good hygiene may help reduce the potential for infection. drying, freeze-thawing, and steam cleaning inactivate the organism (hill and lappin, 1995) . there are few effective commercial disinfectants. i. sarcoptic mange etiology. sarcoptic mange is caused by infection with sarcoptes scabiei. epizootiology and transmission. transmission occurs through direct contact with infected hosts or contact with fomites. this parasitic infection is rare under research conditions. clinical signs. infection of ferrets with s. scabiei may occur in a generalized or a pedal form (bernard et al., 1984) . in the generalized form, lesions consist of focal or generalized alopecia with intense pruritus. in the pedal form, lesions are confined to the toes and feet, which become swollen and encrusted with scabs. nails may be deformed or lost if the condition is left untreated. diagnosis. diagnosis is made by finding the mites in skin scrapings or removing crusts, breaking them up, and clearing with 10% koh for microscopic examination (phillips et al., 1987) . false-negative results are possible; multiple scrapings may be necessary. differential diagnosis. differential diagnosis should include other pruritic external parasitic conditions, including flea infes-tation. demodicosis has been reported to cause mild pruritus and alopecia in ferrets (noli et al., 1996) . in the pedal form, treatment consists of trimming the claws and removing the scabs after softening them in warm water (bernard et al., 1984) . treatments that have been used include ivermectin, 0.2-0.4 mg/kg, administered subcutaneously and repeated every 7-14 days until mites are gone; shampoos or soaks to reduce the pruritus; and topical or systemic antibiotic administration for treatment of secondary bacterial dermatitis (hillyer and quesenberry, 1997b) . alternatively, weekly dips in 2% lime sulfur until 2 weeks after clinical cure have been shown to be effective (fox, 1998a) . treatment of all affected animals as well as contact animals, and decontamination of enclosures and bedding, are recommended. ii. demodicosis etiology. demodicosis is caused by infection by demodex spp. epizootiology and transmission. the parasite is found in normal skin of almost all dogs and is not considered contagious. predisposing factors such as immunologic or genetic conditions have been suggested (kwochka, 1986) . one clinical report describes demodicosis in two adult ferrets that had been treated with an ear ointment containing triamcinolone acetonide for recurrent ear infections daily for 3 periods of 3 months each during the course of a year (noli et al., 1996) . clinical signs. in the report mentioned above, the ferrets presented with alopecia, pruritus, and orange discoloration of the skin behind the ears and on the ventral surface of the abdomen and an accompanying seborrhea (noli et al., 1996) . diagnosis. deep skin scrapings should be performed to demonstrate mites. finding a large number of live adult mites or immature forms and eggs is necessary to confirm the diagnosis. in very chronic cases, the skin may be so thickened that scrapings may be unrewarding. in these cases, a skin biopsy may be diagnostic (kwochka, 1986) . necropsy findings. histologic evaluation of skin biopsies obtained in the case report described above revealed mites with a short, blunted abdomen similar to that of demodex criceti and located in the infundibulum of hairs. the epidermis was slightly hypertrophic, and there was a mild superficial orthokefatotic hyperkeratosis. a very mild superficial and perivascular mixed cellular infiltrate was also observed in the dermis. differential diagnosis. generalized demodicosis should be differentiated from sarcoptic mange and flea infestation. primary or secondary bacterial dermatitis or pyoderma should also be considered. treatment and control. the ferrets in the above-mentioned clinical report were treated initially with a suspension of 0.0125% amitraz applied as a dip 3 times at 7-day intervals for 3 treatments. two drops of the same solution were applied in each ear every other day. after the initial treatment, the ferrets were reexamined, and treatment was continued with the same concentration of solution applied once every 5 days, while the tail was washed with a higher concentration of amitraz (0.025%) once every other day. thereafter, 3 final treatments with 0.0375% amitraz every 5 days for the body, and every other day for the ears and tail, were administered. the ferrets were evaluated and skin scrapings were performed regularly during treatment and posttreatment to monitor response to therapy. treatment of any associated pyodermas, systemic illnesses, or management problems should also be included as part of the therapeutic regimen. iii. ear mites etiology. the ear mite, otodectes cynotis, which commonly infects dogs and cats, is also a common clinical problem in ferrets (fox, 1998g) . epizootiology and transmission. ear mites are transmitted through direct contact with infested ferrets, dogs, or cats (fox, 1998g) . the entire life cycle is completed in 3 weeks. clinical signs. ear mite infestation in the ferret is usually asymptomatic (orcutt, 1997) . however, clinical signs may include head shaking; mild to severe pruritus with inflammation and excoriation; secondary otitis interna with ataxia; circling; torticollis; and horner's syndrome (orcutt, 1997; fox, 1998g) . a brownish black waxy discharge is often present. diagnosis. diagnosis is based on direct observation of mites via otoscopic examination or microscopic identification of the ear mite or any of the life-cycle stages of the mite in exudate from the ear canal. treatment and control. several treatment regimens, including topical and injectable mitocidal treatments, have been recommended (orcutt, 1997; fox, 1998g) . a recent study using three treatment regimens--two topical and one injectable--revealed that topical treatments were more efficacious than the injectable in reducing or eradicating ear mites (patterson et al., 1999) . efficacy was evaluated by microscopic evidence of ear mites in debris from aural swabs taken weekly for an 8-week period. topical 1% ivermectin (ivomec, merck agvet division, rahway, new jersey), diluted 1" 10 in propylene glycol at a dosage of 400 ~tg/kg body weight divided equally between the two ear canals and administered on days 1 and 14 of the study, was the most effective treatment. all susceptible animals in a household should be treated. ears should be gently cleaned prior to initiating treatment (orcutt, 1997) . high doses of injectable iver-mectin (0.2 ml of 1% ivermectin) administered to jills at 2-4 weeks of gestation resulted in high rates of congenital defects (orcutt, 1997) . iv. fleas etiology. ctenocephalides species can infest ferrets. epizootiology and transmission. transmission requires direct contact with another infested animal or a flea-infested environment. clinical signs. flea infestation may be asymptomatic or may cause mild to intense pruritus and alopecia of the dorsal thorax and neck (timm, 1988) . differential diagnosis. sarcoptic and demodectic mange should be included in the differential diagnosis of pruritic skin disease in the ferret. close examination of the pelage for fleas or flea excrement should be performed. skin scrapings may be indicated. as with flea infestation in dogs and cats, concurrent treatment of the environment, as well as all animals in the household, is essential for effective flea control. compounds approved for flea control in cats such as rotenone or pyrethrin powders or sprays may be used in ferrets (hillyer and quesenberry, 1997a) . ferrets may develop systemic disease from blastomyces, coccidioides, cryptococcus, and histoplasma. the reservoir of most of these fungi is the soil, however, making infection unlikely in a research facility. in production facilities, exposure can be minimized through careful selection of source animals, appropriate sanitation, and control of pests, particularly birds. pneumocystis carinii has been recently reclassified as a fungus. although p. carinii inhabits the lungs of many different species, recent transmission studies suggest that these fungi are highly species-specific (gigliotti et al., 1993; fox et al., 1998b) . clinical disease is evident only in immunocompromised ferrets and can be induced using high doses of exogenous steroids (stokes et al., 1987) . lesions include interstitial pneumonitis with mononuclear cell infiltrates; cysts and trophozooites are evident with gomori methanamine-silver nitrate and giemsa on bronchoalveolar lavage. treatment with trimethoprim sul-famethoxazole probably controls but does not eliminate infection . ferrets are susceptible to secondary fungal infection of the outer ear canal with absida corymbifera or malassezia spp. (dinsdale and rest, 1995; fox, 1998d) . the fungi are widespread in the environment and will cause a secondary fungal infection in the ears of ferrets infested with otodectes cynotis. the yeasts can be visualized by impressions of ear exudates. treatment involves eradication of the underlying mite infestation followed by oral and topical ketoconazole, miconazole, and polymyxin b. dermatomycoses in ferrets are caused by microsporum canis and trichophyton mentagrophytes. dermatophytes are transmissible to humans and are a zoonosis; thus affected animals should be quarantined and removed from the facility to minimize risk (dinsdale and rest, 1995; scott et al., 1995; fox et al., 1998b) . control of infection includes general disinfection and destruction of contaminated bedding. lesions are circumscribed areas of alopecia and inflammation, which begin as small papules that spread peripherally in a scaly inflamed ring. the yellow-green fluorescence of m. canis under ultraviolet light helps distinguish it from t. mentagrophytes. skin scrapings digested with 10% potassium hydroxide reveal characteristic arthrospores. treatment with griseofulvin causes clinical remission but may not clear infection. other ectoparasitic infections observed to occur in ferrets include cutaneous myiasis and tick infestation. granulomatous masses in the cervical region caused by the larval stage of hypoderma bovis have been reported in ferrets (fox, 1998g) . cuterebra larvae, although uncommonly observed in ferrets, may cause subdermal cysts found in the subcutis of the neck (orcutt, 1997) . infestation with the flesh fly has been reported as a problem in commercially reared mink and ferrets housed outdoors (fox, 1998g) . ticks may be found on ferrets housed outdoors or on those used for hunting rabbits (fox, 1998g) . ticks should be removed carefully with hemostats or tweezers, ensuring that the entire head and mouthparts are removed from the skin. appropriate caution should be exercised in tick removal, because ticks are responsible for transmission of various zoonotic pathogens; gloves should be worn. etiology. the ferret is susceptible to natural and experimental infection with dirofilaria immitis. epizootiology and transmission. dirofilaria immitis is a filarial parasite that is transmitted by mosquitoes, which serve as the intermediate host and vector. microfilaria are ingested by mosquitoes and, after two molts, become infective third-stage larvae. infective larvae are deposited onto the skin when mosquitoes feed, and larvae find their way into the body of the final host through the bite wound and migrate subcutaneously to the thorax and eventually to the heart (knight, 1987) . the primary reservoir of infection is dogs, but heartworm may be found in a variety of mammals, including humans. all other species except wild and domestic canids, domestic felines, ferrets, and the california sea lion are considered aberrant hosts (knight, 1987) . clinical signs. the following clinical signs have been reported in clinical reports describing cases of d. immitis in the ferret: weakness, lethargy, depression, dyspnea, cyanosis, anorexia, dehydration, cough, and pale mucous membranes (miller and merton, 1982; parrott et al., 1984; moreland et al., 1986) . moist lung sounds and/or muffled heart sounds were revealed by thoracic auscultation in many of these cases. pleura/or abdominal effusion may be observed radiologically. the ferrets described in these cases were housed outdoors and either died or were euthanized. diagnosis. diagnosis of heartworm is based on clinical signs, radiographic findings, and testing for circulating microfilariae and heartworm antigen. microfilaremia is not consistently observed in naturally occurring and experimental cases of heartworm infection in ferrets (fox, 1998g) . testing for heartworm antigen appears to be more diagnostically useful (stamoulis et al., 1997) . in a study to determine the minimum oral dose of ivermectin needed for monthly heartworm prophylaxis in ferrets, the use of an antigen test (uni-tec canine heartworm test, pitman-moore co., mundelein, illinois) detected infection in more untreated control animals than did the modified knott test for detection of circulating microfilaria in the same ferrets (supakorndej et al., 1992) . necropsy findings. cardiomegaly, pleural and/or abdominal fluid, and pulmonary congestion are common findings at necropsy. grossly, adult worms have been observed in the right atrium, right ventricle, pulmonary artery, and cranial and caudal vena cava. microscopically, microfilaria may be seen in small and large vessels of the lung. differential diagnosis. differential diagnosis should include primary cardiac diseases, such as dilatative cardiomyopathy, and other systemic or pulmonary diseases. control is best directed at prevention through the administration of heartworm preventative and it is recommended that ferrets in heartworm-endemic areas receive monthly oral ivermectin throughout the year (stamoulis et al., 1997; fox, 1998g) . the dosage recommended for ferrets by the american heartworm society is 0.006 mg/kg body weight monthly (fox, 1998g) . housing ferrets indoors, particularly during the mosquito season, would help minimize exposure. successful adulticide treatment in ferrets has been described and includes the administration of thiacetarsemide, with the same precautions used in dogs: antithrombotic therapy, treatment for heart failure, and strict cage confinement (stamoulis et al., 1997) . one should follow up with heartworm antigen tests until negative and resume heartworm prevention 1 month after adulticide treatment (stamoulis et al., 1997) . ferrets are also susceptible to infection with the following nematodes: toxascaris leonina; toxocara cati; ancylostoma spp.; dipylidium caninum; mesocestoides spp.; atriotaenia procyonis; trichinella spiralis; filaroides martis; and spiroptera nasicola (rosenthal, 1994; fox, 1998g) . a day of their due date should include cesarean section and intensive postoperative support, including force-feeding a gruel of high-quality cat food and ferret chow, nutritive pastes, intravenous fluids containing glucose, and supplemental heat. cesarean section should be performed under isoflurane anesthesia because hepatic dysfunction prolongs the metabolism of injectable agents. agalactia is common after cesarean section, and kits may require hand feeding with kitten or puppy milk replacers, administered per os by fine-tipped syringe 6 times daily for the first 24 hr. cross fostering is an effective method of enhancing kit survival; hand rearing of kits if the jill fails to nurse within a day postoperatively is energy-consuming and generally unrewarding. for jills that develop pregnancy toxemia before day 40 of gestation, fluids and nutritional support must be provided until viable kits can be delivered by cesarean. pregnancy toxemia may be avoided by close monitoring of appetite of jills in late gestation, provision of a highly palatable diet with >20% fat and > 35 % crude protein, and avoidance of stress and dietary change. water should be made available in both bowls and water bottles, and food should be provided ad libitum in several bowls. pregnancy toxemia in the ferret occurs predominantly in primiparous jills carrying large litters. an inadvertent fast in late gestation is sometimes implicated. at least 75 % of jills carrying more than 8 kits will develop pregnancy toxemia if subjected to 24 hr of food withdrawal in late gestation (bell, 1997a; batchelder et al., 1999) . any jill with 15 or more kits may develop pregnancy toxemia because abdominal space is not adequate for both the gravid uterus and the volume of food required to support it. pregnancy toxemia of the ferret is of the metabolic type and shares features with similar conditions in pregnant sheep, obese cattle, pregnant camelids, obese guinea pigs, and starved pregnant rats, as well as with the condition feline idiopathic hepatic lipidosis. it is characterized by abnormal energy metabolism with consequent hyperlipidemia, hypoglycemia, ketosis, and hepatic lipidosis. in this condition, energy demand exceeds intake, leading to excessive mobilization of free fatty acids and a chain of metabolic events that culminates in a shift from fatty acid metabolism and export to ketosis and hepatic lipidosis. clinical signs include anorexia, lethargy, melena, dehydration, and easily epilated hair. differentials include dystocia, metritis, pyometra, septicemia, renal failure, and helicobacter mustelae-induced gastric ulcer. in a recent study of ferrets with pregnancy toxemia, consistent clinical chemistry abnormalities included azotemia (100%), hypocalcemia (83 %), hypoproteinemia (70%), and elevated liver enzymes (100%) (batchelder et al., 1999) . anemia was found in 50% of ferrets tested. necropsy findings include tan or yellow discolored liver, gastric hemorrhage, and gravid uterus. treatment forjills within ferrets are induced ovulators and may remain in persistent estrus if they are not bred or if estrus is not terminated chemically or via ovariohysterectomy (bell, 1997a) . jills that remain in estrus for more than 1 month are at risk for developing estrogeninduced anemia. hyperestrogenism from persistent estrus causes bone marrow hypoplasia of all cell lines in approximately half of ferrets in prolonged estrus (ryland et al., 1983) . clinical signs include vulvar enlargement, bilaterally symmetric alopecia of the tail and abdomen, weakness, anorexia, depression, lethargy, weight loss, bacterial infection, and mucopurulent vaginal discharge. hematology findings may vary from an initial neutrophilia and thrombocytosis early in the disease course to lymphopenia, thrombocytopenia, neutropenia, and anemia. the anemia begins as normocytic normochromic but progresses to macrocytic hypochromic (sherrill and gorham, 1985) . coagulopathy associated with hepatic dysfunction and thrombocytopenia combine to produce extensive manifestations of bleeding, pallor, melena, petechiation or ecchymosis, subdural hematoma, and hematomyelia (hart, 1985; fox and bell, 1998) . at necropsy, tissue pallor, light tan to pale pink bone marrow, hemorrhage, bronchopneumonia, hydrometra, pyometra, and mucopurulent vaginitis may be seen. histopathology may reveal cystic endometrial hypoplasia, hemosiderosis, diminished splenic extramedullary hematopoiesis, and mild to moderate hepatic lipidosis (sherrill and gorham, 1985; bell, 1997a) . treatment consists of terminating estrus while supporting the animal with antibiotics, blood transfusion, b vitamins, and nutritional supplementation. estrus may be terminated by injection with 50-100 iu of human chorionic gonadotropin (hcg) or 20 ~tg of gonadotropin-releasing hormone (gnrh), repeated 1 week after initial injection if required. ovariohysterectomy may be considered for ferrets that are stable and have adequate numbers of platelets and red cells. ferrets with a packed cell volume (pcv) of 25% or greater have a good prognosis and require only termination of estrus for resolution of aplastic anemia. jills with a pcv of 15-25% may require blood transfusions and have a guarded prognosis. ferrets with a pcv of less than 15% have a poor prognosis and require aggressive therapy with multiple transfusions. the lack of identifiable blood groups in ferrets makes multiple transfusions uncomplicated by potential transfusion reactions . estrogen-induced anemia may be avoided by ovariohysterectomy. of nonbreeding females, use of vasectomized hobs, or pharmacologic termination of estrus initiated 10 days after estrus onset. a 40-to 45-day pseudopregnancy then follows, except in the case of ovariohysterectomy. repeated administration of hcg may result in sensitization and anaphylaxis. after several administrations, hcg is unlikely to be effective in termination of estrus. anaphylaxis is manifest as incoordination, tremor, vomiting, and diarrhea and may be reversed by prompt administration of diphenhydramine. arginine-free diets are unlikely to be fed in the laboratory setting, but administration of such a diet to young ferrets fasted for 16 hr leads to hyperammonemia and encephalopathy within 2-3 hr (thomas and desmukh, 1986) . exacerbation of signs may be achieved by challenging young ferrets with influenza virus and aspirin (desmukh et al., 1985) and constitutes a model of reye's syndrome in children. lethargy and aggressiveness yield to prostration, coma, and death in affected ferrets. hyperammonemia presumably occurs because of the inability of ferrets to produce adequate amounts of ornithine from non-arginine precursors. detoxification of ammonia is thereby compromised. ferrets more than 18 months old are unaffected by arginine-free diets. ferrets of all ages are susceptible to zinc toxicosis, and the condition has been documented in two ferret farms in new zealand (straube and walden, 1981) . leaching of zinc from steam-sterilized galvanized food and water bowls was implicated. clinical signs included pallor, posterior weakness, and lethargy. definitive diagnosis requires demonstration of elevated concentrations of zinc in kidney and liver. at necropsy, kidneys are enlarged, pale, and soft; livers are orange, and gastric hemorrhage may be seen. histopathology reveals glomerular collapse, tubular dilation, tubular proteinaceous debris, focal cortical fibrosis, hepatic periacinar infiltration, and depression of the erythroid series. avoidance of galvanized materials precludes the development of zinc toxicosis. umbilical entanglement may occur in ferrets on the day of parturition and has been associated with fine-particle bedding, large litters, and short kit-birth intervals (bell, 1997a; fox et al., 1998a) . jills may neglect to clean placentas from their kits, or kits may be born so rapidly that there is not adequate time for the jill to clean the kits of placental membranes, thereby predisposing to entanglement. entangled kits may succumb to dehydration, hypothermia, and hypoglycemia because they are unable to nurse and the jill cannot curl around them. detailed dissection with fine scissors and forceps under a heat lamp or on a heated surface can free the kits. occasionally, kits may need to be rotated on their umbilical pedicle to achieve adequate clearance to cut the cord; cords should be cut as far from the umbilicus as possible. the use of warm saline or water may help soften the mass. some kits in the tangle may present with dark, swollen extremities or prolapsed umbilical cords and may require euthanasia. parturition should be supervised, if possible, to avoid umbilical entanglement. hydronephrosis may occasionally occur in the ferret and is most commonly associated with inadvertent ligation of the ureter during ovariohysterectomy. ovarian remnants are another potential sequela to ovariohysterectomy. ovarian remnants in ferrets may be associated with estrus, vulvar enlargement, and alopecia. appropriate diagnostic procedures include ultrasonography and plain and contrast radiography for hydronephrosis and ultrasonography and serum hormone concentrations for ovarian remnants. exploratory celiotomy confirms the diagnosis, and unilateral nephrectomy or ovariectomy is indicated if the remaining kidney is normal and the ferret is otherwise healthy. over the last few decades, increasing numbers of ferrets have been used in research or kept as pets, and as these animals have received veterinary care, it has become evident that ferrets are subject to a wide variety of neoplastic conditions . however, four categories of cancer account for the majority of ferret neoplasms: pancreatic islet cell tumors, adrenocortical cell tumors, lymphoma, and skin cancers. functional pancreatic islet cell tumors (insulinomas) are the most common neoplasm diagnosed in ferrets . disease may be evident in ferrets as young as 2 years old, but later onset (at 4-5 years of age) is typical (caplan et al., 1996; ehrhart et al., 1996) . nonspecific presenting signs include weight loss, vomiting, and ataxia. weakness is often evident, ranging from lethargy to posterior paresis or outright collapse (caplan et al., 1996) . hypoglycemia caused by excess production of insulin by neoplastic 13 cells may cause tremors, disorientation, or seizures (fox and marini, 1998) . excessive salivation (ptyalism) or pawing at the mouth is a frequent finding. clinical signs are often intermittent or episodic. other common findings include splenomegaly and lymphocytosis. presumptive diagnosis is made based on clinical signs in conjunction with the demonstration of hypoglycemia. blood glucose determinations for the diagnosis of insulinoma are most useful when taken after a 4 hr fasting period. fasting glucose concentrations below 60 may be diagnostic for the condition (quesenberry and rosenthal, 1997) , whereas values between 60 and 85 are suspect and the test should be repeated (fox and marini, 1998) . other potential causes for hypoglycemia should be ruled out, including anorexia, starvation, hepatic disease, sepsis, and nonpancreatic neoplasia (antinoff, 1997) . demonstration of concurrent hyperinsulinemia aids the diagnosis (caplan et al., 1996) . medical management using prednisone and/or diazoxide along with dietary modification such as frequent feeding of high-protein meals can minimize or control clinical signs but will not affect the underlying tumor (quesenberry and rosenthai, 1997) . surgical exploration of the pancreas and tumor excision are recommended for animals that are healthy enough to be subjected to anesthesia and surgery. histological examination of the tissue removed can provide a definitive diagnosis, and although the effect may be transient, clinical signs are often reduced or eliminated after surgical debulking (figs. 7 and 8) (ehrhart et al., 1996) . histologically, these tumors reveal ma-lignant proliferation of pancreatic 13 cells, and local recurrence or metastasis to lymph nodes, mesentery, spleen, or liver may occur (caplan et al., 1996) . adrenocortical cell tumor is the second most common type of neoplasia in ferrets and is generally diagnosed between 3 and 6 years of age. if clinical signs are present, they often include weight loss and a bilateral, symmetric alopecia. pruritus is a variable finding (quesenberry and rosenthal, 1997) . although ferrets with this syndrome have been called "cushingoid," it is rare to diagnose elevated resting levels of glucocorticoids or an abnormal response to adrenocorticotropic hormone (acth) stimulation or dexamethasone suppression testing. elevation of adrenal sex hormones (e.g., androstenedione, 17-hydroxyprogesterone, and/or estradiol) is more likely, and these may lead to characteristic changes such as estruslike vulvar swelling in spayed females and prostatic changes in males coleman et al., 1998) . rule-outs for enlarged vulva include estrus in an intact female or functional ovarian remnants in a spayed female. abdominal palpation may reveal cranial abdominal masses, and ultrasound may be useful (barthez et al., 1998) . serum assay for abnormal levels of the sex hormones listed above should be considered (lipman et al., 1993; wagner and dorn, 1994; rosenthal and peterson, 1996) . in many cases the alopecia begins as a seasonally intermittent partial hair loss that becomes more severe as time goes on (fig. 9) . even severe manifestations of this endocrine alopecia can spontaneously reverse in the absence of specific therapy, as demonstrated in a group of 5 ferrets referred to our facility for diagnostic workup. in each of these 5 ferrets, near total alopecia resolved within a few months of being housed in a research environment. despite being asymptomatic at the end of the study, all 5 were shown to have histologic evidence of adrenocortical neoplasia. although this phenomenon is mediated by hormonal effects, anecdotal reports such as this suggest that the alopecia may be significantly modulated by environmental factors (e.g., photoperiod or diet). surgical exploration and removal of enlarged adrenals are commonly performed to establish the diagnosis and to remove hyperfunctional tissue. unilateral adrenalectomy early in the disease may be curative, but because bilateral neoplastic involvement is not uncommon, full or partial removal of both glands may be required. adrenolytic agents such as mitotane have been used with limited success (quesenberry and rosenthai, 1997) . histologically, adrenocortical adenomas are generally 1 cm or less in diameter and are composed of well-differentiated cells with a granular or vacuolated cytoplasm. adrenal cell carcinomas are less commonly found and are larger, with a more pleomorphic and invasive character . metastasis to nearby tissues can occur. in our experience, adrenal cortical hyperplasia with or without neoplasia is an extremely common finding in aging ferrets, even in those not showing clinical signs. in one retrospective survey of our necropsy records it was found that more than 90% of ferrets greater than 4 years of age had hyperplastic or neoplastic adrenal changes when examined (data not shown). for this reason, careful considerations of other possible disease processes should be made before attributing clinical signs solely to adrenal enlargement. lymphoma can affect ferrets of almost any age. ferrets younger than 2 years of age often present with mediastinal lymphoma and/or leukemia, whereas those older than 3 years of age often develop multicentric solid tumors . the early age of onset in some ferrets and reports of case clustering have led to investigation into potential infectious etiologies for lymphoma in the ferret (erdman et al., 1996b) . earlier reports of feline leukemia virus (felv) seroconversion in affected animals have not been substantiated. however, experimental and epidemiological evidence suggests that a retrovirus that is distinct from felv may be involved . in one study, whole or filtered lymphoma cells from a 3-year-old ferret with spontaneous lymphoma were injected ip into 6 recipient ferrets . two of the 6 ferrets were euthanized after 14 months, but the remaining 4 developed splenomegaly, lymphocytosis, and lymphoma. one ferret that received cell-free materials developed multicentric lymphoma with prominent cutaneous lymphoma nodules. elevated reverse transcriptase activity and retrovirus-like particles evident by electron microscopy were seen in the donor and all of the affected recipient ferrets. other potential etiologies that have been considered include two infectious agents that are known to cause chronic immune stimulation in affected ferrets, the aleutian disease virus (adv) and helicobacter mustelae. a link with adv has not been proven, but h. mustelae seems to be responsible for the development of a very specific type of gastric b-cell lymphoma (erdman et al., 1997) . affected ferrets may exhibit localizing signs (e.g., dyspnea in a ferret with mediastinal involvement or peripheral lymphadenopathy in an animal with a multicentric distribution) but as is the case in many species, lymphoma is a "masquerader," and affected ferrets often present with chronic, nonspecific signs. weight loss, anorexia, and lethargy are often reported. splenic and/or hepatic enlargement may be evident. cutaneous involvement has been documented (li et al., 1995; rosenbaum et al., 1996) . although hematological examination typically reveals anemia and lymphopenia, lymphocytosis may be found, especially in younger ferrets. atypical lymphocytes are identified in the circulation in some cases. antemortem definitive diagnosis of lymphoma can be made by cytological examination of specimens obtained via fine-needle aspiration or excisional biopsy. tan-colored masses involving lymph nodes, spleen, liver, or other organs are commonly found at necropsy (fig. 10) . diffuse involvement may lead to uniform enlargement of these organs or to a thickening of the wall of the stomach or intestines. as in other species, histological evaluation reveals neoplastic lymphocytes in affected tissues, generally evident as a monomorphic population (fig. 11) . although surgery and radiation therapy may be useful in certain cases, most attempts to treat ferret lymphoma have utilized chemotherapeutic regimens with dosages extrapolated from other domestic animals or humans. treatment generally results in a remission that may last from 3 months to 5 years (brown, 1997b; erdman et al., 1998) . mast cell tumors are among the most commonly reported integumentary tumors in ferrets (parker and picut, 1993; . cutaneous mastocytomas may occur anywhere on the body and present as firm, nodular skin lesions 2-10 mm in size that are often associated with alopecia or crusty ulceration of the overlying skin. pruritis is common (stauber et al., 1990) . histologically, they are composed of well-differentiated mast cells with metachromatic cytoplasmic granules that may be difficult to detect in sections stained with hematoxylin-eosin, but are more evident in toluidine bluestained sections. a variety of tumors of epithelial origin occur in ferrets, and they can appear at any site on the body. the most common are the basal cell tumors, which present as firm plaques or pedunculated nodules that are white or pink (parker and picut, 1993) . they may grow rapidly and become ulcerated. the percentage of basiloid cells present in these tumors, and the degree of associated squamous or sebaceous differentiation can vary, resulting in a spectrum of tumor subtypes and associated histological diagnoses (orcutt, 1997) . however, as is the case with mastocytomas, most are benign and will not recur after excision. resected tumors should be examined histologically to rule out less common tumors that might have a more guarded prognosis, such as squamous cell carcinoma or apocrine gland adenocarcinoma. chordomas are not epithelial tumors, but they often present as readily evident firm masses on the tail that may cause ulceration of the overlying skin. these neoplasms arise along the axial skeleton from notochord remnants and are typically slow-growing (dunn et al., 1991) . tumors involving the tail generally do not recur after amputation of the affected region, but a wide surgical margin should be maintained by removing several vertebrae proximal to the tumor. the prognosis is guarded for those rare chordomas that arise in the cervical region, and metastasis has been documented (williams et al., 1993) . congenital defects identified in ferrets include a variety of neural tube defects, gastroschisis, cleft palate, amelia, corneal dermoids, cataracts, and supernumerary incisors (willis and barrow, 1971; ryland and gorham, 1978; mclain et al., 1985; besch-williford, 1987) . cystic or polycystic kidneys have been observed (andrews et al., 1979a; dillberger, 1985) . cystic genitourinary anomalies associated with the prostate, bladder, and/or proximal urethra most likely develop secondary to aberrant hormone secretion by adrenocortical tumors coleman et al., 1998) . newborn ferrets are normally born with a closed orbital fissure and are prone to developing subpalpebral conjunctival abscesses. treatment involves surgically opening the lids (a minor procedure) to establish drainage and to allow topical antibiotics to be administered (bell, 1997a) . cardiomyopathy is a common cause of disease in aging ferrets. the dilatative form of disease is most commonly diagnosed. affected animals commonly present with lethargy, weight loss, and anorexia. physical examination may reveal signs of congestive heart failure such as hypothermia, tachycardia, cyanosis, jugular distension, and respiratory distress (lipman et al., 1987) . auscultation may reveal a heart murmur and/or muffled cardiac sounds. hepatomegaly and splenomegaly are often identified. radiographs may reveal an enlarged cardiac silhouette and evidence of pulmonary edema or pleural effusion (greenlee and stephens, 1984) . electrocardiography and echocardiography can help make the definitive diagnosis. medical therapy (supportive care, diuretics, and inotropic drugs) may relieve clinical signs and improve the qual-ity of life for a period of months (stamoulis et al., 1997) . the long-term prognosis for survival is guarded to poor. splenomegaly is a common finding in ferrets. in many cases the enlarged spleen appears to be a secondary manifestation of another disease (e.g., insulinoma, cardiomyopathy, or adrenal tumor) and is of unknown significance (stamoulis et al., 1997) . histologic examination of affected organs has revealed that the most common cause for splenic enlargement (in the absence of a neoplastic infiltrate) is extramedullary hematopoiesis (emh) (erdman et al., 1998) . this may be an incidental finding, but it has been suggested that in some cases a pathologically enlarged spleen may play a role in chronic anemia that may respond to splenectomy, a syndrome known as hypersplenism (ferguson, 1985) . splenomegaly can also be commonly found in conjunction with lymphoma, with or without intrasplenic neoplastic lymphoid accumulations. in anesthetized ferrets, splenomegaly may be caused by splenic sequestration of erythrocytes (marini et al., 1994 (marini et al., , 1997 . because this is a transient effect, the normalization of splenic size upon recovery from anesthesia can help in the differentiation of anesthetic-induced splenomegaly from that due to other causes. eosinophilic gastroenteritis is an idiopathic disorder characterized by peripheral eosinophilia (10-35% of circulating leukocytes), hypoalbuminemia, and diffuse infiltration of the gastrointestinal tract with eosinophils (fox et al., 1992a) . presenting signs for this syndrome generally include chronic weight loss, anorexia, diarrhea, and occasionally vomiting. eosinophilic granulomas have been found in the mesenteric lymph nodes of most affected ferrets, and in some cases other organs (e.g., lung or liver) may be involved. an interesting finding in many ferrets is the presence of splendore-hoeppli material in the inflamed lymph nodes, a histological phenomenon that has been associated in other species with helminths, bacteria, fungi, and foreign bodies (fig. 12 ). an etiological agent has not been identified; consequently, therapy consists largely of supportive care to treat the chronic enteritis (fox, 1998b) . based on the biology of eosinophils, however, the use of corticosteroids or ivermectin has been attempted and may be beneficial (bell, 1997b) . megaesophagus has been diagnosed in ferrets presenting with a variety of signs, including weight loss, anorexia, difficulty in eating, or repeated regurgitation. the cause is generally unknown, and the prognosis is poor, despite efforts at supportive care (blanco et al., 1994) . gray, yellow, or white small raised lesions may be found on the surface of ferret lungs at gross examination. histologically, these lesions are composed of a superficial thickening of the lung tissue with mononuclear cell infiltration and 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with killed influenza a virus vaccines observations on tuberculosis in the ferret (mustela furo l.) effect of arginine-free diet on ammonia metabolism in young and adult ferrets the ferret, mustela putoriusfuro, as a new species in toxicology pruritis in rabbits, rodents, and ferrets the characterization and pathological significance of gastric campyiobacter-like organisms in the ferret: a model of chronic gastritis? isolation of atypical rotavirus causing diarrhea in neonatal ferrets mastitis in mink due to staphylococcus aureus and escherichia coli guide for the care and use of laboratory animals place de mycobacterium avium dans l'epidemiologies mycobacterienne actuelle chez les animaux domestiques et savages. sci pulmonary physiology as a model for inhalation toxicology evaluation of serum estradiol concentrations in alopecic ferrets with adrenal gland tumors the ferret intestinal uptake and lymphatic absorption of [3-carotene in ferrets: a model for human [3-carotene metabolism intestinal perfusion of [3-carotene in the ferret raised retinoic acid level in portal blood vitamin e enhances the lymphatic transport of [3-carotene and its conversion to vitamin a in the ferret aleutian disease in domestic ferrets: diagnostic findings and survey results semen characteristics and testosterone profiles in ferrets kept in a long-day photoperiod, and the influence of hcg timing and sperm dilution medium on pregnancy rate after laporoscopic insemination biliary coccidiosis in a ferret (mustela putoriusfuro) cervical chordoma in two ferrets (mustela putorius furo) coronavirus-associated epizootic catarrhal enteritis in ferrets comparative vaginal cytology of the estrous cycle of black-footed ferrets (mustela nigripes) the ferret (mustela putorius furo) as a laboratory animal effect of helicobacter mustelae infection on epithelial cell proliferation in ferret gastric tissues key: cord-315598-qwh72inx authors: mendoza, jose luis accini; estrada, victor hugo nieto; lópez, nelly beltrán; bolaños, elisabeth ramos; franco, daniel molano; castell, carmelo dueñas; moreno, albert alexander valencia; amaya, iván camilo alarcón; flórez, john serna; valencia, bladimir alejandro gil; camilo pizarro, g; polo, yulieth maría zabaleta; meza, carmen lucia chica title: actualizacion de la declaración de consenso en medicina critica para la atención multidisciplinaria del paciente con sospecha o confirmación diagnóstica de covid-19 date: 2020-10-06 journal: nan doi: 10.1016/j.acci.2020.09.004 sha: doc_id: 315598 cord_uid: qwh72inx antecedentes y objetivos: la enfermedad por coronavirus de 2019 (covid-19) es una enfermedad ocasionada por el nuevo coronavirus del síndrome respiratorio agudo grave (sars-cov-2). se identificó por primera vez en diciembre de 2019 en la ciudad de wuhan, en los meses siguientes se expandió rápidamente a todos los continentes y la organización mundial de la salud (oms), la reconoció como una pandemia global el 11 de marzo de 2020. la mayoría de los individuos son asintomáticos pero una baja proporción ingresan a cuidados intensivos con una alta morbilidad y mortalidad. este consenso tiene como objetivo actualizar la declaratoria inicial emitida por la asociación colombiana de medicina crítica (amci) para el manejo del paciente críticamente enfermo con covid-19 dentro de las áreas críticas de las instituciones de salud. métodos: este estudio utilizó dos técnicas de consenso formal para construir las recomendaciones finales: delphi modificada y grupos nominales. se construyeron preguntas por la estrategia pico. 10 grupos nominales desarrollaron recomendaciones para cada unidad temática. el producto del consenso fue evaluado y calificado en una ronda delphi y se discutió de forma virtual por los relatores de cada núcleo y los representantes de sociedades médicas científicas afines al manejo del paciente con coid-19. resultados: 80 expertos nacionales participaron en la actualización del consenso amci, especialistas en medicina critica y cuidados intensivos, nefrología, neurología, neumología, bioeticistas, medicina interna, anestesia, cirugía general, cirugía de cabeza y cuello, cuidados paliativos, enfermeras especialistas en medicina crítica, terapeutas respiratorias especialistas en medicina crítica y fisioterapia, con experiencia clínica en la atención del paciente críticamente enfermo. la declaratoria emite recomendaciones en los ámbitos más relevantes para la atención en salud de los casos de covid-19 al interior de las unidades de cuidados intensivos en el contexto nacional de colombia. conclusiones: un grupo significativo multidisciplinario de profesionales expertos en medicina crítica emiten mediante técnicas de consenso formal recomendaciones sobre la mejor práctica para la atención del paciente críticamente enfermo con covid-19. las recomendaciones deben ser adaptadas a las condiciones específicas, administrativas y estructurales de las distintas unidades de cuidados intensivos del país. background and objectives: the 2019 coronavirus disease (covid-19) is caused by the new severe acute respiratory syndrome coronavirus (sars-cov-2). it was first identified in december 2019 in wuhan, china. in the following months it spread quickly to all continents and was recognised as a global pandemic by the world health organization (who) on march 11th, 2020. most cases of infection remain asymptomatic, while a low proportion require intensive care, experiencing high morbidity and mortality. this consensus aims to update the initial statement issued by the colombian association of critical medicine (amci) for the management of the critically ill patient with covid-19 within the critical areas of health institutions. methods: this study used two formal consensus techniques to construct the final recommendations: modified delphi and nominal groups. questions were constructed using the pico strategy. recommendations for each thematic unit were developed by 10 nominal groups. the consensus product was evaluated and qualified in a delphi round, and was discussed virtually by the speaker of each nucleus, as well as the representatives of scientific medical societies related to the management of the patient with covid-19. results: a total of 80 national experts participated in the update of the amci consensus, all specialists in critical and intensive care medicine, nephrologists, neurologists, chest physician, bioethicists, internal medicine specialists, anaesthetists, general surgeons, head and neck surgery, palliative care, nurses specialised in critical medicine, respiratory therapists specialised in critical medicine and physiotherapy, with clinical experience in the care of critically ill patients. this update issues recommendations in the most relevant areas for health care of covid-19 patients within the intensive care units, contextualised for colombia. conclusions: a significant multidisciplinary group of professionals, who are experts in critical medicine, reviewed and issued recommendations on best practice for the care of critically ill patients with covid-19 through formal consensus techniques. recommendations must be adapted to the specific, administrative, and structural conditions of the different intensive care units in the country. para la actualización de la declaratoria se utilizaron dos técnicas para el desarrollo de consensos de tipo formal, técnica delphi modificada y grupos nominales. un consenso formal permite integrar las opiniones de un colectivo de expertos que están expuestos a un tema específico (experto afectado) con la mejor evidencia científica disponible, utilizando técnicas que permitan reducir los sesgos de subjetividad. la técnica delphi es una metodología que plantea enviar cuestionarios a un grupo de expertos, para que califiquen una serie de recomendaciones en rondas reiteradas con retroalimentación de los resultados y respuestas anónimas, la técnica delphi empleada fue modificada, variante a la versión original propuesta por la corporación rand en 1948, pero se mantuvo las ventajas de la técnica, la iteración y retroalimentación para reflexión de las propias opiniones. los grupos nominales es una técnica que reúne a un grupo de expertos bajo la coordinación de un facilitador para evaluar y calificar información o preguntas (1, 2) . para la actualización se convocó 10 grupos nominales con 50 expertos multidisciplinarios cada uno con un líder o jefe de núcleo. los grupos construyeron las preguntas por metodología pico y desarrollaron progresivamente las recomendaciones hasta las versiones finales. el proyecto se desarrolló en 3 fases, fase 1: formulación del problema y socialización; fase 2: elaboración de las preguntas, fase 3: formulación de las recomendaciones y ronda de calificación. las estrategias de búsqueda se desarrollaron en bases de datos especializadas (medline, embase, lilacs, central), en las circunstancias donde no se encontró evidencia directa, se utilizó y se adaptó evidencia indirecta del tópico relevante en el paciente críticamente enfermo general. 80 expertos con un promedio de 15 años de experiencia en la atención del paciente crítico evaluaron y calificación las recomendaciones en la metodología delphi mediante un cuestionario distribuido por medio de correo electrónico, respetando la política de privacidad de datos vigente. recomendación se recomienda que los prestadores de servicios de acuerdo con su infraestructura física y la disponibilidad de recursos (tecnológico, humano, de interdependencia y apoyo) definan su modelo de atención para pacientes con covid-19 en estado crítico basado en principios de factibilidad, efectividad, seguridad y la relación entre la demanda (momento epidemiológico) y capacidad/capacidades de respuesta:  modelo 1. atención de pacientes con sospecha o confirmación diagnóstica covid19 . este enfoque permite concentrar, optimizar y racionalizar recursos y reducir el riesgo potencial de contagio al equipo de atención, de apoyo y de pacientes.  modelo 2. atención mixta, de pacientes con y sin diagnóstico de covid-19, en escenarios que cuentan con unidades de aislamiento normatizados (presión negativa y >12-renovaciones completas de aire por hora) soportado en el documento institucional de gestión organizacional y operativo del servicio de cuidados intensivos, descrito en los procesos prioritarios. amci ® menos accidentalidad y violencia). la reducción de procedimientos quirúrgicos complejos electivos es una opción razonable condicionado a las posibilidades del paciente. sin embargo, situaciones como la progresión y descompensación de las patologías crónicas asociadas a las medidas de restricción social puede plantear un efecto bumerang con mayor demanda de camas de uci. con base en las predicciones simuladas de las tasas esperadas de ingreso a uci de pacientes con covid-19 contrastado con el déficit de servicios y camas de cuidados críticos en el país a partir de la capacidad instalada se han planteado 4 fases de desarrollo cuyas características en términos de servicios, recursos y cronología se aprecian en la ilustración 1 y 2.  fase 1 (para el gobierno nacional: ampliación de la capacidad instalada*). parte de la liberación de camas de cuidados intensivos destinadas para atención covid-19 bajo el modelo 1 y/o 2. la liberación de camas y servicios con mínima adaptación es la fase más inmediata y resolutiva que debe acogerse a la exigencia normativa (resolución 3100 de 2019), en la que se espera menos mortalidad, morbilidad y tasa de complicaciones asociados con la atención de pacientes con covid-19 en estado crítico.  fase 2 (optimización para el gobierno nacional*) representan el reordenamiento de las camas de cuidados intermedios adultos en camas de cuidados intensivos y de hospitalización en intermedio. de adultos. el gobierno nacional toma en cuenta la ampliación de la capacidad instalada hospitalaria descrita en el plan territorial. para esta fase se necesitan equipos de ventilación mecánica (excluidos por la norma de estos servicios), monitoreo básico y avanzado y un número mayor de talento humano multidisciplinario competente. amci ® acuerdo con las etapas (1-3) y los perfiles requeridos priorizados como primera, segunda y tercera línea de respuesta*. en la ilustración 1 podemos observar que avanzar de las fases 1 a 4 se va a necesitar mayor intervención en términos de organización, planeación operativa, formación por competencias y apoyo por telesalud (teleapoyo o teleexperticia). el personal no especializado o especializado de servicios hospitalarios diferente a urgencia, quirófano o uci pueden constituir grupos de apoyo para la gestión administrativa y de índole humanitaria (líneas de respuesta) la integración de estos requerimientos adaptativos se ha puesto de manifiesto en la experiencia del centro médico new york -presbyterian weill en la ciudad de nueva york, en donde la demanda de camas de unidades de cuidados intensivos (uci) y ventilación mecánica excedió su capacidad.(3) se recurrió a los quirófanos y de recuperación las cuales no estaban en uso porque los procedimientos electivos habían sido pospuestos. se hicieron adecuaciones físicas para garantizar la vigilancia continua de los pacientes y la seguridad del equipo de atención. se capacito a todo el personal de cuidado perioperatorio disponible y fueron distribuidos en las áreas recién configuradas. las enfermeras familiarizadas con las máquinas de anestesia asumieron como terapeutas respiratorios y los intensivistas de anestesia supervisaban estas unidades. recomendación se recomienda la adopción de un modelo simulado de predicción (basado en el cociente de fatalidad, tasa de ingreso a uci y el número de reproducción ro) para proyectar, de manera anticipada las necesidades de recurso físico, tecnológico y humano de cuidados críticos en fase de preparación de la pandemia por covid-19. las tomas de decisiones relacionadas con el fortalecimiento de la capacidad/capacidades de la oferta de cuidados críticos (habilitadas o adaptadas) pueden deducirse mediante la aplicación de modelos matemáticos que intentan, desde la dinámica epidemiológica, establecer el efecto simulado de las medidas de mitigación o supresión adoptadas sobre la tasa de contagio a través del tiempo. con ello se busca planear el uso de recursos e implementar acciones de prevención y de distanciamiento social más eficientes, así como establecer las necesidades en materia de cama de cuidados críticos (intensivos e intermedios) habilitadas o adaptadas en áreas de expansión y con ello los recursos resolutivos como tecnologías, interdependencias y talento humano capacitado. la capacidad predictiva del modelo resulta de establecer: la información en términos de casos proyectados (población susceptible), el modelo de transmisión, el impacto de las amci ® intervenciones no farmacológicas (mitigación y supresión) para lograr disminuir el número de reproducción r (tasa de contagio), la distribución de la gravedad de la enfermedad y con ello el porcentaje esperado de casos críticos el decreto 417 del 17.03.20 (4) , por el cual se declara un estado de emergencia económica, social y ecológica en todo el territorio nacional proyectó para una tasa de contagio de 2.68 y cerca de 4 millones de casos, la ocurrencia de 187 mil casos de pacientes con covid-19 en estado crítico (4.7%) y la necesidad de incrementar las camas de cuidados intensivos en un 10% que con una estancia promedio de 14 días tendría un costo de 200 mil millones de pesos. colombia cuenta con cerca de 8500 camas de cuidados intensivos (1/3 parte son intermedio) de las cuales el 60% podría ser utilizada para la atención de pacientes covid-19 (5100). con base en el modelo matemático ha proyectado la necesidad de 9500 camas de uci indicando por deducción la necesidad de 4400 camas a partir de un plan adaptativo de expansión y extensión. colombia reporta a la fecha actual 113,389 casos confirmados y 3984 nuevos casos de covid-19 confirmados y cerca del 4% ocupan una cama de cuidados intensivos (esta cifra es mayor si se tomaran en cuenta los casos sospechosos). de este modo, los modelos matemáticos permiten predecir el comportamiento epidemiológico de la enfermedad y con esto anticiparse a proyectar el plan de fortalecimiento hospitalario (incluyendo camas, tecnologías, talento humano) y los recursos financieros para respaldar la expansión del cuidado críticos. estos modelos deben ser predictivos y no reactivos al comportamiento epidemiológico de la enfermedad y solo debe des escalarse hasta después de reducirse a menos de 1.0 el índice ro. (5-10) recomendación se sugiere la implementación de una estrategia de telesalud (teleapoyo o teleexperticia) en el marco de la pandemia covid-19, cuando no se cuente con un intensivista presencial, que, mediante una tecnología adecuada complemente la atención en las áreas de cuidados críticos realizado por personal capacitado. aún cuando es considerada ventajosa sus implicaciones en términos de resultados clínicos, económicos y de riesgos legales no se ha demostrado. en situaciones donde se declara una pandemia los sistemas de salud pueden tener dificultades para hacer frente a una demanda exponencial y fuera de control. esto puede ser así en el marco pandemia covid-19 que prevé un 5% de pacientes en condición crítica y que amerita reorganización y/o adaptación de su capacidad de respuesta. incrementar la disponibilidad de camas y servicios de cuidados críticos mediante una estrategia de expansión supone retos asociados a la insuficiencia que se puede presentar en talento humano especializado específicamente de especialistas en medicina crítica y cuidado amci ® intensivo, escenario que se puede complicar en la medida que intensivistas sean separados o aislados en el curso de la epidemia. en este contexto se hace necesaria la implementación de modelos ágiles de telesalud (ts) para el acompañamiento de las unidades de cuidado crítico en expansión y de instituciones prestadoras de servicios de salud de baja y mediana complejidad para la regulación con los equipos de referencia y contrarreferencia de pacientes que pueden necesitar atención en cuidados intensivos. (11) (12) (13) (14) (15) (16) el decreto ley 538 de 2020 (17) plantea la adopción de medidas en el sector salud para garantizar la prestación de los servicios de salud y para facilitar la implementación de modelos de atención que incluyan la telesalud y la prestación de los servicios en la modalidad de telemedicina se determinan algunas medidas temporales para: i) adecuar temporalmente un lugar no destinado a la prestación de servicios de salud, intra o extra mural. ii) prestar servicios en modalidades o complejidades diferentes a las habilitadas dentro de las cuales puede estar la telemedicina iii) prestar servicios de salud no habilitados. en este decreto también se establecen condiciones temporales para la implementación de plataformas tecnológicas para la telesalud. en complemento, la resolución 3100 de 2019(18) (estándares de habilitación) plantea la modalidad de la telemedicina (prestador remisor-prestador de referencia) para las unidades de cuidado intermedio e intensivo. la telesalud se puede prestar de dos maneras: teleapoyo y teleexperticia. tabla 2. teleapoyo (ta) soporte solicitado por un profesional de la salud a otro profesional de la salud a través de tic siendo responsable de la conducta quién solicita el apoyo. no requiere habilitación y por tanto no requiere autorización transitoria relación a distancia con comunicación sincrónica o asincrónica utilizando tic entre dos profesionales de la salud, uno de los cuales atiende presencialmente al usuario y otro atiende a distancia. el primero es responsable de las decisiones/recomendaciones entregadas al paciente y el segundo es responsable de la calidad de la opinión que entrega y debe especificar las condiciones en las que se da dicha opinión, lo cual debe consignarse en la historia clínica. requiere autorización transitoria (decreto 358 2020) (17) la telesalud y la prestación de servicios de salud en esta modalidad son estrategias seguras y efectivas para guiar, a distancia, el diagnóstico y el tratamiento del paciente hospitalizado y en estado crítico. sus ventajas generales se presentan en la tabla 3. 14 asociación colombiana de medicina crítica y cuidados intensivos. amci ® tabla 2. ventajas generales de la telesalud decreto legislativo 538 de 2020.  facilita la viabilidad de aplicación modelos organizativos que favorecen la continuidad y la integridad asistencial y la atención centrada al entorno del paciente, aplicando conceptos de globalidad e interoperabilidad a las organizaciones sanitarias, dando lugar a nuevas formas de organización y trabajo en red.  mejora de la calidad asistencial, ya que facilitan el acceso y la disponibilidad de servicios asistenciales en condiciones de calidad.  mejora calidad de vida del paciente por la disminución de desplazamientos para la atención ya que permite la atención o monitorización remota con tic en su domicilio.  mejora la oportunidad y la resolutividad de la atención.  facilita la equidad en el acceso a los servicios de salud independientemente de la localización geográfica (acerca la atención especializada a toda la población).  mejora la atención integral y seguimiento tanto de los pacientes crónicos, como los de las enfermedades de baja prevalencia.  reduce los tiempos de espera (tanto en la realización del diagnóstico como en el tratamiento), evitando complicaciones por no atención oportuna.  posibilita realizar atención remota de mediana y alta complejidad en la baja complejidad, reduciendo el número de remisiones.  disminuye la posibilidad de infección cruzada entre usuarios de los servicios de salud y el personal de salud.  incide en la formación y competencia del talento humano en salud.  facilita la educación de pacientes en medicina preventiva y salud pública.  descongestiona servicios de urgencias y consulta externa.  contribuye a la reducción de movilidad de personas en la ciudad.  responde a las necesidades inmediatas en salud de la comunidad.  es un medio de racionalización de costos en salud. puede abarcar otros servicios de gestión administrativa como entrega de fórmulas o facturación. amci ® se recomienda la implementación de un modelo de cuidados críticos covid-19 liderado por intensivistas, en áreas habilitadas o adaptadas, con el beneficio preponderante de disminuir la mortalidad, tiempo de estancia y optimización de recursos. se recomienda una cobertura por intensivistas de al menos 12 horas diarias y un cociente intensivista/paciente cercano a 1 intensivista por cada 8-10 pacientes, basado en la alta complejidad de la enfermedad critica covid-19 con un alto porcentaje de pacientes en ventilación mecánica, largos tiempos de estancia y alto riesgo de mortalidad. fuerte a favor fundamento un intensivista es un profesional médico capacitado en medicina crítica y de cuidados intensivos conforme a los estándares establecidos por una institución de educación superior debidamente reconocida ante el ministerio de salud. este especialista debe liderar y tomar todas las decisiones con respecto al cuidado de los pacientes críticos, incluyendo admisiones y egresos, qué médicos consultar, estándares de atención, gestión de la calidad y seguridad, gestión humana y ética, interacción con la familia e implementación de un programa de investigación y de formación continua para mejorar capacidades y competencias del equipo de atención, control de conflictos, entre otras.(20) existe una enorme validez conceptual y una preponderancia de evidencia que sugiere que ser atendido por un especialista en cuidados críticos (intensivista) es "bueno" para los pacientes de la uci. la mayoría de los estudios demuestran el impacto positivo de un uci dirigida por intensivistas los modelos de personal médico de la uci más ampliamente estudiados difieren en el nivel al cual los intensivistas están involucrados en el manejo de los pacientes. las uci de alta intensidad son aquellas donde un intensivista de tiempo completo u obligatorio maneja a la mayoría de los pacientes diariamente. las uci de baja intensidad no tienen participación intensivista u ofrecen consultas intensivistas electivas. un metaanálisis mostró que un modelo de alta intensidad en comparación con uno de baja intensidad estuvo asociado con una menor mortalidad en la uci, menor mortalidad hospitalaria, y una reducción significativa en la duración de la estancia hospitalaria. un modelo de alta intensidad por la noche se asoció con menor mortalidad solo cuando durante el día era de baja intensidad. (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (36) 17 asociación amci ® forzosa" por condición de riesgo siempre en consonancia con los términos establecidos en el decreto ley 588 de 2020 (39). según la normatividad vigente todo miembro del equipo de atención, especialista no intensivista o no especialista (enfermeras, fisioterapeutas/terapeutas respiratorias) y auxiliares de enfermería deben tener constancia de asistencia a acciones de formación continua y/o capacitación en atención covid-19 en cuidados críticos las cual puede ser parte de un programa institucional de capacitación liderado por el intensivista coordinador o titular del servicio o a partir de cursos respaldados por instituciones académicas acreditadas o los ofrecidos por la asociación colombiana de medicina crítica y cuidados intensivos (amci). las tablas 5 y 6 nos muestra como dentro de este proceso adaptativo por estado de emergencia y atribuido a un desequilibrio entre la oferta y la demanda, otras especialidades, profesionales de la salud y personal en formación pueden hacer parte de los equipos de atención bajo las siguientes premisas: 1. la supervisión, coordinación y liderazgo del intensivista es necesaria y 2. el intensivista establece los roles y competencias del th no intensivista y no normatizado, de acuerdo a sus perfiles, y delegada acciones asistenciales (vía aérea, accesos vasculares, reanimación cardiopulmonar, pronación), administrativas (ordenes médicas, notas clínicas) o de naturaleza humanitaria (comunicación con la familia, apoyo emocional al th, etc.). es necesario considerar los roles de las especialidades que formarán parte de la gestión asistencial y/o administrativa de pacientes con covid-19 en áreas críticas habilitadas o adaptadas de manera transitoria en colombia tabla 7. integridad de interdependencia (norma3100/10) integralidad e interdependencia (adaptiva) gfa integridad de interdependencia (norma3100/10) integralidad e interdependencia (norma 3100/10) integridad de interdependencia (norma3100/10) obligatorio en gestión asistencial integralidad e interdependencia(norma 3100/10) obligatorio gestión asistencial apoyo a tomas de decisiones(gfa) apoyo a tomas de decisiones (gfa) a:formacion continua + covid-19 (curso virtual); b: requiere capacitación covid-19 (curso virtual); c: gfa: grupo focal asistencial, sistema alerta-acción, rcp, pronación, accesos vasculares, ingreso a uci. d: gfad: grupo focal administrativo: consentimiento, notas de evolución. ts: telesalud. se recomienda la aplicación de la escala news-2 por parte de un equipo de respuesta rápida, para establecer el lugar de atención de pacientes con diagnóstico definitivo o sospecha de infección por covid-19 que encuentran en los servicios de urgencias o de hospitalización. se recomiendan escalas como el qsofa y el curb-65 para apoyar la decisión tomada con base en la escala news-2. sin embargo, un qsofa mayor o igual a 2 puntos (mínimo 2/3) y un crb-65 mayor o igual 2 puntos tienen baja sensibilidad (alta incidencia de falsos negativos) para identificar pacientes que puedan requerir ingreso a uci. se recomienda el score de riesgo covid-19-gram para identificar el riesgo de desarrollar un estado de la enfermedad crítico en pacientes con covid-19 y como herramienta complementaria a la escala news-2 en escenarios de alta demanda y escasez de recursos, de manera que la decisión de ingreso a uci se haga sobre aquellos pacientes que realmente se beneficiarán de la misma en términos de vidas salvadas y número de años salvados. la escala news fue construida y validada en paciente con infección por el virus de la influenza a/h7n9 y se recomienda como una herramienta objetiva para decidir nivel de atención, incluyendo ingreso a uci o situaciones terminales que requieren acompañamiento familiar y medidas de cuidado paliativo. esta escala incluye 6 variables fisiológicas que son: frecuencia respiratoria, saturación arterial de oxígeno (spo2), uso de oxígeno suplementario, presión arterial sistólica, frecuencia cardiaca (pulso), temperatura y nivel de conciencia. es de mencionar que esta escala no contempla la edad del paciente. en 2007 un reporte del acute medicine task force of the royal college, london, uk, recomendó la utilización de la escala news en los servicios de urgencias (41) . un estudio que evaluó una base de datos con 198.755 signos vitales obtenidos de 35.585 pacientes demostró que esta escala tiene una buena capacidad para discriminar pacientes en riesgo para un desenlace combinado de paro cardiaco, ingreso no anticipado a uci o muerte dentro de las primeras 24 horas de atención; de esta manera genera una gran oportunidad para el establecimiento temprano de una intervención clínica que cambie el pronóstico del paciente (42) . la escala news-2 tampoco contempla la edad, pero sí incluye la presencia de hipercapnia bajo diferentes niveles de spo2 y oxígeno suplementario. esta escala es la que ha sido estudiada como herramienta para identificar pacientes en riesgo de desarrollar un estado de enfermedad crítica por covid-19 con un valor ≥ 5 puntos (5/20) (43) . con base en la escala news-2 se establece el grado de riesgo, el tipo de alerta, y la intensidad de monitoreo requerido; y de acuerdo con el puntaje arrojado, se define claramente el nivel de atención que requiere el paciente con diagnóstico de infección por covid-19, incluso ingreso a uci (tabla 7). esto se establece a través de una escala de puntuación así: -score 0 puntos: manejo domiciliario bajo aislamiento y signos de alarma. -score 1 punto: manejo domiciliario y seguimiento clínico en casa. -score 2-4 puntos: manejo en salas de hospitalización. -score 5-7 puntos: manejo en uci, área covid-19. -score ≥ 7 puntos sin condición extremadamente grave o irreversible y con alta posibilidad de recuperación: traslado a uci, área covid-19. amci ® -score ≥ 7 puntos con condición extremadamente grave y con datos de irreversibilidad o enfermedad terminal: no ingresa a uci y se traslada a salas de hospitalización con acompañamiento familiar y consulta a experto en bioética y cuidados paliativos. la ilustración 4 establece un flujograma de conductas basado en el puntaje del news-2. tabla 6. news-2 score. el qsofa con un valor ≥ 2 puntos es otra herramienta recomendada para decidir qué pacientes que ingresan a uci. esta herramienta fue recomendada por la tercera definición de consenso (sepsis-3) para identificar pacientes con alto riesgo de muerte o estadía prolongada en uci entre aquellos con sospecha de infección (44) . en este score, un punto es asignado para 3 variables así: frecuencia respiratoria ≥ 22/min, presión arterial sistólica ≤ 100 mmhg y escala de coma de glasgow (ecg) < 15. el score curb-65 y su versión simplificada, el crb-65 se utilizan para evaluar la severidad de enfermedad en personas hospitalizadas con neumonía adquirida en comunidad (nac). ambos scores han sido adoptados por la sociedad británica de tórax para predecir la necesidad de soporte respiratorio o vasopresor intensivo (srvi) en pacientes con covid-19 (40) . el score crb-65 asigna un punto para 4 variables así: confusión de reciente inicio, frecuencia respiratoria ≥ 30/min, presión arterial sistólica < 90 mmhg o presión arterial diastólica ≤ 60 mmhg y edad ≥ 65 años. pacientes con un score ≥ 2 puntos necesitan hospitalización (43) . en un estudio clínico observacional realizado sobre los primeros 42 pacientes ingresados en un hospital de noruega con diagnóstico confirmado de covid-19, se evaluó la utilización de 4 sistemas de score clínicos al momento del ingreso: news-2, qsofa, crb-65 y sirs, con los puntos de corte previamente mencionados (43) . la enfermedad se clasificó como enfermedad severa y enfermedad crítica. solo 9 pacientes (21%) se clasificaron como enfermedad crítica. al evaluar los scores con sus puntos de corte, 2 pacientes presentaron un qsofa ≥ 2 [1 con enfermedad severa (3%) y 1 con enfermedad crítica (11%)], solo 7 pacientes presentaron un crb-65 ≥ 2 [6 con enfermedad severa (18%) y 1 con enfermedad crítica (11%)] y 19 pacientes presentaron un news-2 ≥ 5 [(11 con enfermedad severa (33%) y 8 con enfermedad crítica (89%)]. la mediana del score news-2 para pacientes con enfermedad severa fue de 3.3 [riq: 3-9] vs 7.6 [riq: 8.4 -10] para pacientes con enfermedad crítica. los autores concluyen que el qsofa y el crb-65 se comportan similar y con una baja capacidad para la identificación de enfermedad crónica en pacientes con covid-19; por otro lado, los datos indican que el news-2 podría ser una herramienta más útil para identificar pacientes con riesgo de un curso más agresivo de la enfermedad (33% vs. 89%) (43) . amci ® un estudio de cohorte retrospectivo realizado en un hospital en liverpool (uk), el puntaje qsofa se comportó como el más específico (79%; 95% ic: 77% -81%) pero el menos sensible (37%; 95% ic: 31% -43%) en comparación al puntaje sirs y la escala news como predictor de mortalidad hospitalaria en un grupo de 1818 paciente admitidos por sepsis al servicio de emergencias (45) . otro estudio retrospectivo de un único centro comparó el rendimiento de 3 sistemas de score, qsofa, curb-65 y crb-65 para predecir la necesidad de soporte vasopresor o respiratorio intensivo (svri) en 116 pacientes ingresados con diagnóstico confirmado de covid-19 a un hospital de wuhan (china) (40) . un total de 25 pacientes (21.6%) necesitaron svri durante su estadía en el hospital. la tasa de mortalidad hospitalaria en esta cohorte fue de 9 pacientes (7.8%). se evalúo el rendimiento de las escalas con análisis de curva roc (auc), puntos de corte óptimo, sensibilidad, especificidad y valores predictivos. el punto de corte óptimo del crb-65 para predicción de srvi fue de 2 puntos, con una sensibilidad del 64% y una especificidad del 93.4%. el valor auc del score crb-65 para predecir la necesidad de svri fue significativamente más alto que el del qsofa (0.81 ± 0.05 vs. 0.70 ± 0.06, p= 0.02). los valores de auc fueron similares entre crb-65 y curb-65 para predecir svri (0.81 ± 0.05 vs. 0.85 ± 0.05, p= 0.08). los autores concluyen que el crb-65 podría ser mejor que el qsofa para identificar paciente con covid-19 en riesgo de necesitar svri. su et al consideran que fue la inclusión de la edad ≥ 65 años dentro del score crb-65 lo que le dio un mayor grado de superioridad sobre el qsofa (40) . el crb-65 puede ser una herramienta de puntuación útil para covid-19 debido a su simplicidad en la aplicación, especialmente en emergencias y condiciones de escasez de recursos. finalmente, el score de riesgo covid-19-gram fue descrito por un grupo de investigadores en covid-19 quienes reunieron datos de 1590 pacientes en 575 hospitales en china (46) . esta fue una cohorte retrospectiva multicéntrico en la que se recogieron un total de 72 variables entre demográficas, médicas, clínicas (signos y síntomas), imagenológicas y de resultados de laboratorios. utilizando la metodología de regresión lasso (least absolute shrinkage and selection operator) construyen un modelo de regresión multivariable resultando en un score de riesgo predictivo para desarrollar enfermedad critica en pacientes con covid-19 confirmado al momento de la admisión. de las 72 variables iniciales 10 fueron predictores independientes estadísticamente significativos para el desarrollo de enfermedad crítica. estas variables fueron: anormalidad en los rx tx (or: 3.39; 95%ic: 2. 14 -5.38 recomendación se recomienda la aplicación de un algoritmo basado en una evaluación dinámica del score news 2 que involucre una escala de evaluación funcional, para priorizar el ingreso a uci con transparencia científica y ética con equidad social, y de ser posible respaldado por un comité de priorización clínica (cpc) integrado por expertos de cuidado intensivo y un representante del comité de ética hospitalaria durante la pandemia por covid-19. se recomienda un modelo determinado por 4 prioridades para definir criterios de ingreso a uci, permite establecer rápidamente qué pacientes se benefician de ingreso uci y qué pacientes deben permanecer en servicios de hospitalización, o con acompañamiento familiar y cuales con medidas de cuidado paliativo. fuerte a favor page amci ® fundamento la pandemia covid-19 nos ha enseñado que la disponibilidad de camas de uci puede ser insuficiente y el plan estratégico diseñado para ampliar la capacidad de respuesta debe ir de la mano con la implementación rigurosa de un protocolo de triaje y de priorización de ingreso a cuidados intensivos, como medida extraordinaria para optimizar los recursos, mitigar y controlar los efectos de la pandemia sobre el balance oferta (efectiva y resolutiva) y la demanda. los protocolos de triaje y priorización están diseñados para asignar los limitados recursos de una manera justa y transparente donde, por definición, algunas personas serán excluidas del acceso a la atención orientado a aumentar la disponibilidad de camas de cuidados intensivos. sin embargo, es necesario enfatizar que la disponibilidad de camas no es un fin en sí mismo. la intención implícita y explícita de los protocolos de clasificación debiera ser el «bien público» de maximizar la supervivencia de la población. pero es incorrecto suponer que este bien público se logra al maximizar la supervivencia entre los que reciben cuidados intensivos. si bien muchos protocolos de triaje reconocen esto al tratar de excluir a los pacientes que no lo necesitan absolutamente (el «demasiado sanos») y los que tienen menos probabilidades de beneficiarse (él «demasiado enfermo»), no prestan suficiente atención a las diferencias entre grupos en términos de la duración de los cuidados intensivos necesarios para lograr resultados. si el objetivo del triage es mejorar la supervivencia de la población con un recurso escaso, entonces el recurso escaso no son camas, sino días de cama; no son ventiladores, sino tiempo de ventilación. de ello se deduce que el triaje no será efectivo si en la valoración, no se discrimina adecuadamente y se considera de manera equívoca que la gran mayoría de las personas que requieren cuidados intensivos tienen una probabilidad similar de supervivencia y una duración de estadía anticipada similar. (47) de este modo, el ingreso a uci debe acogerse a los criterios habituales, científicos y éticos, bajo el rigor de "idoneidad clínica" tomando en cuenta parámetros como la gravedad de la enfermedad, la presencia de comorbilidades (severidad, clase funcional), potencial de recuperabilidad, deseo del paciente (o la familia), de equidad distributiva y el uso de las escalas validadas de severidad y de predicción de ingreso a cuidados intensivos. los pacientes con covid-19 tienden a progresar después del inicio de los síntomas dentro de los 7 a 12 días a una forma grave con síndrome de dificultad respiratoria aguda (sdra) o falla multiorgánica órgano. la identificación temprana y simple de pacientes que requieren respiración intensiva o el soporte vasopresor sería de gran valor durante el brote covid-19. (48) (49) (50) (51) la implementación de un algoritmo "dinámico" que vincule uno o más de las escalas fisiológicas (news con o sin qsofa y/o crb-65 ≥2), una escala de predicción de ingreso a uci (covid-19-gram) y un puntaje de fragilidad (vipi) puede informarnos sobre el estado actual y evolutivo de la enfermedad y a priorizar el ingreso de pacientes a uci permitiendo un uso óptimo de los recursos y tomar decisiones éticas, transparentes y centradas en la dignidad de los pacientes y el bien público ilustración 4-5. se recomienda no usar escalas de severidad de enfermedad (criterios objetivos) para definir el traslado de pacientes de uci hacia un nivel de menos complejidad de atención, ya que estas escalas no han sido validadas para este uso. se recomienda en la atención por covid-19 en cuidados intensivos utilizar los mismos criterios de egreso que se emplean para el traslado desde uci hacia una unidad de menor complejidad de pacientes sin infección por covid-19. se recomienda contar con áreas de bajo nivel de complejidad asignadas solo a la atención de paciente con infección por covid-19, las cuales serán las áreas hacia donde se realiza el de-escalamiento gradual de los pacientes basado en su evolución clínica. cuando se habla de criterios objetivos, se hace referencia a escalas de severidad de enfermedad que ayuden a tomar decisiones más racionales y no basadas en consideraciones tradicionales de resolución de cuadros clínicos. no hay una recomendación definida sobre el uso de escalas de severidad de enfermedad para definir el de-escalamiento de la atención para pacientes críticos. los sistemas de evaluación de severidad de enfermedad generales y específicos pueden identificar una población específica de pacientes en alto riesgo de deterioro clínico luego del traslado fuera de la uci(53); sin embargo, su valor para evaluar que tan preparado está un paciente individual para ser trasladado a un nivel inferior de cuidado no ha sido evaluado(53). los criterios que recomienda el colegio americano de cuidado intensivo(53) para definir el traslado desde uci a un nivel de menor complejidad (unidad de cuidados intermedios o sala de hospitalización) se basan en 3 principios:  cuando el estado fisiológico del paciente se ha estabilizado y ya no es necesario monitoreo y tratamiento en uci.  cuando el paciente cumpla con los criterios de admisión del nivel de menor complejidad, teniendo en cuenta la disponibilidad actual del recurso, el pronóstico del paciente y la presencia de intervenciones activas en curso. específicamente para los pacientes con alto riesgo de muerte y reingreso a uci en quienes se decide no hacer intervenciones adicionales (alta severidad de enfermedad, inestabilidad fisiológica, soporte orgánico), el colegio americano de cuidado intensivo(53) siguiere pasarlos a una unidad de menor nivel de atención o a un hospital de cuidado agudo de largo plazo; siempre con un formato escrito donde se deje claro la decisión para reducir la tasa de reingreso a uci(53). específicamente en situaciones de pandemia y escasez de recursos, la sociedad española de medicina intensiva, crítica y unidades coronarias (semicyuc) recomienda la realización de la escala sofa al menos cada 48 horas para identificar pacientes con evolución tórpida y progresiva a un fallo multiorgánico luego de la iniciación de tratamientos de soporte vital. esto permitirá la adecuación y reorientación de medidas terapéuticas a un objetivo más paliativo, incluyendo la transferencia del paciente a un nivel más bajo de complejidad y la consulta al servicio de cuidado paliativo para que brinde la atención respectiva(52). finalmente, se debe mencionar que no se ha establecido una diferencia en los criterios de egreso de pacientes con covid-19 para su traslado desde uci hacia una unidad de menos complejidad, con respecto a los utilizados para pacientes sin infección por covid-19(54). todo paciente hospitalizado en uci sea covid-19 o no, debe ser valorado diariamente para establecer en qué momento su condición clínica permite que sea trasladado fuera de la uci hacia una unidad de menor complejidad. en caso de tratarse de pacientes con sospecha o diagnóstico de covid-19, este traslado puede hacerse a una unidad de cuidados intermedios dispuesta como área covid-19 o una sala de hospitalización con igual asignación(54); esto es lo que se conoce como de-escalamiento gradual de la atención hasta el final egreso del paciente a casa. se recomienda para pacientes con covid-19 que evolucionan hacia la mejoría, utilizar los criterios clásicos de de-escalamiento del nivel de atención (unidad de cuidados intermedios o sala de hospitalización) que propone el colegio americano de cuidado intensivo(53) . se recomienda aplicar la escala sofa al menos cada 48 horas sumado al criterio de fragilidad y años de vida saludables salvados estos criterios podrían ser válidos en pacientes con fallo terapéutico a las medidas óptimas y orientar decisiones de deescalamiento de medidas y de nivel de complejidad de atención cuando la demanda potencial supera la oferta (capacidad y capacidades), estas decisiones deben ser tomadas idealmente en junta médica. amci ® se recomienda generar procesos administrativos más eficientes para el traslado de pacientes fuera de la uci hacia niveles de menor complejidad, estos ayudarán a liberar recursos para otros pacientes. se recomienda no utilizar el resultado de la rt-pcr positiva para decidir el egreso de la unidad de cuidados intensivos. la literatura no ha definido unos criterios de flexibilidad en uci para el traslado de pacientes con sospecha o diagnóstico confirmado de covid-19; y los criterios que definen la posibilidad de egreso de uci y que aplican a todos los pacientes, incluso aquellos ingresados por una condición crítica en relación con infección por covid-19, están claramente definidos por el colegio americano de cuidado intensivo en su documento-guía del 2016.(53). los principios fundamentales han sido revisados en los fundamentos de la pregunta 8. es importante implementar una estrategia de identificación temprana para aquellos pacientes con soporte vital avanzado que evolucionan progresivamente a fallo multiorgánico y pocas probabilidades de recuperación; el de-escalamiento de medidas y su posterior traslado fuera de la uci, liberará espacio para otros pacientes en situaciones de desborde de la demanda. la sociedad española de medicina intensiva, crítica y unidades coronarias (semicyuc) recomienda que en caso de complicaciones o que se prevea una mala evolución tanto clínica como funcional, se plantee el retiro terapéutico por futilidad y se inicie un manejo con medidas de soporte paliativo, tal como ha sido considerado en los fundamentos de la pregunta 8 (55) . para el grupo español es claro que, adecuar procesos administrativos más eficientes para traslado de pacientes fuera de la uci a los usualmente utilizados en condiciones normales de práctica clínica, ayudaría a ser más eficientes en la gestión de la demanda (55) . finalmente, la persistencia de una rt-pcr positiva no es una contraindicación para el traslado del paciente fuera de la uci siempre y cuando se aseguren condiciones de aislamiento por contacto y aerosol en aquellas áreas de menor complejidad de atención; estas incluyen zonas de expansión o área del hospital específicamente acondicionadas para el manejo de pacientes estables o pacientes con limitación de esfuerzo y manejo paliativo de su condición (55). recomendación se recomienda que la disposición final de cadáveres de personas con sospecha o diagnóstico de covid-19 se haga preferiblemente por cremación. en tal caso, las cenizas pueden ser objeto de manipulación sin que suponga ningún riesgo. amci ® se recomienda que la disposición final del cadáver se haga por inhumación en sepultura o bóveda individualizada cuando no se cuente con instalaciones para cremación en el territorio donde ocurrió el deceso o la disponibilidad de esta tecnología desborda la capacidad económica de las personas. se recomienda realizar siempre el aislamiento del cadáver en el lugar del deceso, siguiendo las recomendaciones del ministerio de salud y la protección social (msps). se recomienda que en los casos que se requiera necropsia médico legal y estuviese indicada la cremación, esta deberá contar con la orden del fiscal del caso. se recomienda que la institución establezca en sus procesos prioritarios un protocolo humanizado de despedida bajo estrictos criterios de bioseguridad. no existe una evidencia fuerte que recomiende hacer una disposición de cadáveres de pacientes fallecidos con sospecha o diagnóstico confirmado de covid-19 con un acto de cremación o con inhumación y sepultura en féretro; sin embargo, siempre y cuando la manipulación y manejo del cadáver hasta su disposición final se haga manteniendo todas las medidas de precaución para evitar la diseminación del virus y siguiendo la normatividad legal vigente, ambas formas son aceptadas. la infección por covid-19 es una enfermedad con gran variabilidad en presentación clínica, alta tasa de contagio y para la cual no existe en el momento un tratamiento definido. el riesgo de contagio al personal que ejecuta autopsias o procedimientos de tanatopraxia y la probabilidad de diseminación de la enfermedad por la manipulación de cadáveres no se conoce, pero se considera que puede ser alto, teniendo en cuenta que, en ausencia de la aplicación de un método de diagnóstico masivo, todo caso debe considerarse potencialmente positivo. por tanto, el manejo de cuerpos de personas fallecidas con diagnóstico confirmado, sospechoso o probable de sars-cov-2 (covid-19), debe realizarse con la mínima manipulación posible(56). el cadáver debe ser transferido lo antes posible al depósito y entregado al servicio funerario antes de 24 horas luego del fallecimiento(57). el transporte, la cremación o inhumación, según sea el caso, se efectuará en el menor tiempo posible, con el fin de prevenir la exposición de los trabajadores y comunidad general al virus sars-cov-2 (covid-19). se debe evitar la realización de rituales fúnebres que conlleven reuniones o aglomeraciones de personas(56). el alistamiento del cadáver será realizado en el ámbito hospitalario del mismo sitio del deceso. las personas que accedan a la habitación donde se encuentre el cadáver, deben tomar las precauciones de transmisión por contacto y gotas, y para ello deben contar con todos los elementos de protección personal (epp) y seguir los procedimientos de amci ® bioseguridad de acuerdo con lo establecido en el protocolo del msps.(58) para hacer el alistamiento del cadáver, se debe cubrir todos los orificios naturales con algodón impregnado de solución desinfectante y se deberá envolver en su totalidad sin retirar catéteres, sondas o tubos que puedan contener los fluidos del cadáver, en tela antifluido o sábana; luego se deberá envolver en dos bolsas plásticas biodegradables que cumplan con las características técnico-sanitarias de impermeabilidad y resistencia a la presión de gases en su interior(57). se debe rociar el interior y el exterior de ambas bolsas con solución desinfectante de hipoclorito sódico que contenga 5.000 ppm de cloro activo(57) (exceptuando los casos asociados de covid-19 y muerte violenta). una vez el cadáver esté adecuadamente dispuesto en las bolsas, se podrá movilizar sin riesgo hacia el depósito de cadáveres siguiendo la ruta intrahospitalaria dispuesta para este traslado. luego el cadáver podrá será entregado al personal del servicio funerario para su depósito en ataúd o contenedor de cremación o inhumación y posterior traslado al sitio de destino final (horno crematorio y/o cementerio), luego de completar toda la documentación necesaria. cuando deba practicarse necropsia médico legal, el cuerpo será entregado a los servidores del sistema judicial quienes asumirán la custodia(56). si se han seguido correctamente todas estas indicaciones, se asume que no hay ninguna diferencia entre disponer del cuerpo enviándolo al crematorio o colocarlo en ataúd para llevarlo al tanatorio y realizar el entierro. si se opta por lo primero, las cenizas pueden ser objeto de manipulación sin que supongan ningún riesgo.(57) se recomienda que el trabajador de la salud conozca a través de la institución donde labora, los riesgos éticos, de salud y seguridad a que se expone por la atención en el paciente covid-19, evitando así conflictos e incertidumbres que afecten la atención. se recomienda que las instituciones prestadoras de salud a través de los líderes de atención médica, guíen y orienten a los trabajadores, para ofrecer una mejor atención médica y menor daño emocional durante la pandemia. se recomienda dar a conocer las directrices institucionales sobre el nivel de atención (uci vs. sala médica); inicio del tratamiento de soporte vital (incluyendo rcp y soporte de ventilación); retirada del tratamiento de soporte vital; y derivación a cuidados paliativos (centrados en la comodidad) en la atención médica de los pacientes durante la pandemia, esto genera una atención caracterizada por alivio del sufrimiento, no abandono, respeto a amci ® los derechos y preferencias de los pacientes, igualdad moral de las personas y la equidad en la distribución de riesgos y beneficios en la sociedad. el apoyo de la práctica ética es necesario integrarlo al cuidado de la salud y al bienestar de la fuerza laboral del cuidado en salud. reconociendo los desafíos especiales a que se enfrentan al responder al covid-19. esto forma parte del liderazgo en la atención médica y del servicio del deber cívico. berlinger n. el 29 de abril del 2020. en su artículo "respondiendo a covid-19 como un desafío regional de salud pública pautas preliminares para la colaboración regional que involucra hospitales". refiere que los trabajadores del equipo médico tienen el deber de conocer la gestión asistencial de los "desafíos éticos" previsibles durante la emergencia de salud pública (pandemia covid-19). que los desafíos éticos surgen cuando existe incertidumbre acerca de cómo "hacer lo correcto" es cuando los deberes o valores en los trabajadores entran en conflicto. estos desafíos afectan a la fuerza laboral (carga moral y emocional ante una decisión no prevista) en la atención médica. así como la operatividad en la atención médica (falta de epp y recursos que pueden limitar el buen desempeño por temor a infectarse).(59) los líderes de atención médica tienen el deber de guiar a los trabajadores de atención médica que experimentan condiciones laborales exigentes, mayor riesgo de daños ocupacionales, incertidumbre ética y angustia moral durante una emergencia de salud pública.(60) chih chen a, t. el 6 de abril del 2020. en su editorial ¿cómo deben prepararse los sistemas de salud para la evolución de la pandemia de covid-19? sugiere un apoyo emocional adecuado para el personal y horas razonables de exposición al riesgo para evitar el agotamiento, ya que los profesionales de la salud luchan por cuidar a los pacientes y proteger sus vidas y sus familias. se refiere que a medida que aumenta el número de casos, los médicos y los trabajadores de la salud en la primera línea deben reducir al mínimo su carga de trabajo clínico. las instituciones de atención médica deben reasignar al personal realizar tareas no clínicas, incluidos el papeleo y la recopilación de datos, tanto como sea posible. los hospitales deben tomarse su tiempo para capacitar al personal para implementar eficazmente las precauciones de contacto y los procesos de flujo. (61) jick j.l. el 5 de marzo del 2020. en relación con la obligación de planificar la atención médica, considera que: los líderes de atención médica tienen el deber de planificar la gestión de los desafíos éticos previsibles durante una emergencia de salud pública. la planificación de los desafíos éticos previsibles incluye la identificación de posibles decisiones de triage, herramientas y procesos. en una emergencia de salud pública que presenta una enfermedad respiratoria grave, es posible que se deban tomar decisiones de clasificación sobre el nivel de atención (uci vs. sala médica); inicio del tratamiento de soporte vital (incluyendo rcp y soporte de ventilación); retirada del tratamiento de soporte vital; y derivación a cuidados paliativos (centrados en la comodidad) si el tratamiento de soporte vital no se iniciará o se suspenderá. es posible que también se deban tomar decisiones de clasificación en relación con la escasez de personal, espacio y suministros. el deber de cuidado fundamental requiere fidelidad al paciente (no abandono como una obligación ética y legal), alivio del sufrimiento y respeto a los derechos y preferencias de los amci ® pacientes. el deber de cuidado y sus ramificaciones son el enfoque principal de la ética clínica, a través de los servicios de consulta de ética clínica a pie de cama, el desarrollo de políticas institucionales y la educación y capacitación en ética para los médicos. deberes de promover la igualdad moral de las personas y la equidad (justicia en relación con la necesidad) en la distribución de riesgos y beneficios en la sociedad. estos deberes generan deberes subsidiarios para promover la seguridad pública, proteger la salud de la comunidad y asignar de manera justa recursos limitados, entre otras actividades. estos deberes y sus ramificaciones son el foco principal de la ética de la salud pública. no se puede emitir una recomendación a favor o en contra acerca del uso de los medicamentos y dispositivos "prototipos" utilizados en el manejo del covid-19 denominados de uso compasivo o fuera de etiqueta, se considera sin embargo que no pueden ser utilizados por fuera de ensayos clínicos o protocolos institucionales estandarizados de evaluación del perfil de riesgo/beneficio y bajo la aplicación de consentimiento informado. se entiende como uso compasivo la utilización, en pacientes aislados y al margen de un ensayo clínico. dichos medicamentos experimentales no han sido aprobados aún por la fda, (64) y no se ha demostrado su seguridad y eficacia. es importante recordar que el medicamento médico puede tener efectos secundarios inesperados y graves, y que los pacientes deben considerar los posibles riesgos cuando procuran acceder a un producto médico experimental. hay que tener en cuenta que, para utilizar un medicamento bajo las condiciones de uso compasivo, se requerirá el consentimiento informado por escrito del paciente o de su representante legal, un informe clínico en el que el médico justifique la necesidad de dicho tratamiento. la regulación de la utilización de medicamentos por la vía del uso compasivo se ha realizado dentro de un texto legal sobre la realización de ensayos clínicos. una interpretación común del uso no indicado en la etiqueta y el uso compasivo de medicamentos es que, si el paciente murió, murió de la enfermedad, pero si el paciente sobrevivió, sobrevivió debido al medicamento administrado. recomendación se recomienda en la comunicación inicial con los familiares del paciente adulto con sospecha o diagnóstico de covid-19 críticamente enfermo incluir de forma clara y transparente los aspectos relacionados con el derecho al final de la vida que incluye: proporcionalidad en el tratamiento, adecuación del esfuerzo terapéutico, documento de voluntad anticipada, adecuación del esfuerzo terapéutico y la atención paliativa. situaciones estas que se pueden presentar durante la evolución hospitalaria y que requieren de una decisión conjunta entre el médico y el familiar del paciente. se recomienda dar una información específica, y adecuada a los familiares del paciente con sospecha o diagnóstico de covid-19, para que firmen el consentimiento informado, generando esta información confianza y comprensión en el familiar. la información del consentimiento que recibe el familiar debe constar dentro de la historia clínica. fundamento el ministerio de salud y protección social del 23 de marzo del 2020 a través del documento de "recomendaciones generales para la toma de decisiones éticas en los servicios de salud durante la pandemia covid-19". ante la posible circunstancia de pacientes sin capacidad para la toma de decisiones, por deterioro del estado general o requerimiento de aislamiento, en el cual no se puede contactar a su representante, conduzca la toma de decisiones teniendo en cuenta la prioridad de no hacer daño y la modificación en las condiciones de disponibilidad de los recursos en caso de presentarse deterioro. recuerde que esta situación debe preverse y debe ser informada a los representantes desde la admisión del paciente". durante toda la atención debe darse información sobre la posibilidad de que se presenten limitaciones de acceso a los soportes necesarios incluido al personal de salud , lo anterior puede limitar los derechos individuales o preferencias, esto debe ser informado al paciente y su familia, para que les permita entender que bajo la emergencia, puede presentarse una circunstancia que en condiciones habituales pudiera ser reversible de ser tratada pero en el contexto actual los recursos pueden verse trágicamente limitados, sin que esto implique abandono en el cuidado. el documento se refiere a la información que debe recibir el paciente o su familiar sustituto durante su evolución o fallecimiento. (65)la información durante la evolución también debe incluir: la información sobre el ejercicio de derechos al final de la vida incluyendo la adecuación de los esfuerzos terapéuticos y la suscripción de documentos de voluntad anticipada la consulta y revisión de existencia de este en todos los casos. se recomienda tener un consentimiento informado al ingreso hospitalario del paciente covid-19, se deben tener en cuenta las circunstancias del paciente al ingreso hospitalario, si la capacidad para la toma de decisiones está limitada por su estado clínico o incapacidad mental. de ser estas las circunstancias se dará la información al familiar en primera línea de consanguinidad quien asume por el paciente el consentimiento de la información (consentimiento sustituto). se recomienda tener el consentimiento informado en situaciones de excepción o urgencia ante la pandemia por covid-19, debe ser universal, en el que se informe el ingreso a la uci, o a cualquier otra área hospitalaria, realización de procedimientos, administración de tratamientos, posibles riesgos, beneficios durante su hospitalización. con esto se respeta el derecho a la autonomía personal en el paciente competente. en caso contrario el familiar tomará la información y asume el consentimiento a la información dada. es importante que el familiar esté informado de las decisiones que se vayan tomando durante la evolución hospitalaria (realización de procedimientos, inicios o cambios de tratamientos, movilización dentro del área hospitalaria. etc.) fuerte a favor fundamento el ministerio de salud y protección social, el 25 de marzo del 2020 ha elaborado un formato de "consentimiento informado para acompañante de casos probable/confirmado de covid-19". en que se expresa: "que de manera detallada se me ha suministrado información completa, suficiente, con un lenguaje sencillo y claro. el profesional de la salud me ha explicado la naturaleza de la enfermedad, acerca del significado de caso sospechoso o confirmado del coronavirus covid-19 en cuanto a su presentación clínica, modo de contagio, medidas para contenerla, posibilidad de sufrir la enfermedad, complicaciones o muerte, mientras permanezca como acompañante del paciente". este documento se firma al ingreso por el acompañante o familiar quien asume las decisiones durante su estancia hospitalaria. (67) el consentimiento informado en los pacientes covid-19 será un consentimiento sustituto para su ingreso a la uci y para los procedimientos que en la uci se realicen (colocación de tubo orotraqueal, diálisis, colocación de catéteres, reanimación cardiopulmonar, ecmo, etc.). previa información y autorización del familiar. en circunstancias normales el consentimiento debe ser firmado por el paciente quien en su autonomía acepta la información sobre su manejo y tratamiento. feld ad. recomendación se sugiere ante la pandemia del covid-19, si es posible, que el grupo de expertos en bioética y/o comité de ética institucional sean consultados y estén informados por el médico responsable para la orientación o consejo en la toma de directrices ante decisiones difíciles. se sugiere en lo posible que el médico tratante no asuma solo la responsabilidad moral de la decisión y que la decisión sea institucional y documentada en la historia clínica e informada a los familiares. en caso de no contar con un comité de bioética y/o ética hospitalaria el médico responsable podrá tomar la decisión fundamentada en principios éticos y derechos del paciente o convocar a una junta médica u otro comité relacionado con su dilema o consultar un apoyo externo en bioética. débil a favor fundamento el ministerio de salud y protección social. (65) el 23 de marzo del 2020 en el documento "recomendaciones generales para la toma de decisiones éticas en los servicios de salud durante la pandemia covid-19 establece: "que en caso de que la institución cuente con un comité de bioética y/o ética, con el servicio de bioética o ética clínica, o consultoría clínico-ética, se debe definir una ruta de consulta para los casos que de forma concreta puedan superar las recomendaciones generales. de igual forma establece que en las circunstancias actuales que se viven el actuar ético es parte integral del profesionalismo del cuidado. teniendo en cuenta que los profesionales de la medicina serán los llamados a tomar decisiones de alto estrés moral, al tener que adherirse y promover conductas concretas basados en las circunstancias que les rodean para dar o retirar tratamientos de las personas infectadas, quienes esperan confirmación del diagnóstico y de las personas que acuden a la atención en salud por razones diferentes a la infección por covid-19. partiendo de lo antes referenciado, se recomienda que las acciones emprendidas, busquen siempre poder responder a: a. no hacer daño b. beneficiar c. actuar con justicia sobre la persona en el contexto de la emergencia frente a la justicia sanitaria de la población d. mantener la integridad profesional" el comité de bioética y/o comité de ética institucional en tiempos normales o en tiempos de pandemia deberá mantener actualizadas las directrices de toma de decisiones. que apoyaran al médico responsable en la decisión. de no contar el médico con dicho comité o directrices institucionales y deba tomar una decisión que no permite interconsultar, deberá justificar en la historia clínica fundamentado en los principios éticos y derechos del paciente las razones que lo llevaron a tomar la decisión e informar y dialogar con los familiares del hecho. esto es importante que siempre quede documentado en la historia clínica la acción moral y ética de la decisión y el diálogo con la familia. en caso de que el médico responsable no cuente con un comité de bioética y/o comité de ética institucional, ni con el apoyo externo de expertos en bioética. y no quiera tomar la amci ® decisión a título personal podrá consultar a otro médico de la institución su decisión y entre ambos definir la acción a seguir. esta decisión conjunta debe ser documentada en la historia clínica e informada al grupo de trabajo y a los familiares como junta médica. si los familiares después de recibir la información no quedan satisfechos ellos tienen el derecho a la segunda opinión. los comités de bioética y/o comités de ética hospitalaria son entes administrativos, consultores, orientadores, asesores y consejeros de las situaciones que tienen que ver con el respeto y cumplimiento de los principios éticos, deberes y derechos de los pacientes, sus recomendaciones no son vinculantes, apoyan y orientan la decisión médica. aconsejando la mejor decisión ante una situación que genera un dilema moral o ético en el médico responsable. las decisiones médicas son tomadas por el consultor en bioética, quien es médico. los comités institucionales fuera de un comité de bioética y/o ética que podría dar apoyo al médico responsable y que serían otras instancias consultivas serian el comité de humanización, comité de historias clínicas, comité de bioseguridad, comité de infectología, comité de mortalidad hospitalaria, comité de paliativos o un comité de gerencia. pues todos los mencionados tiene que ver con el bienestar del paciente y la seguridad del médico ante una decisión. las decisiones especiales deben ser tomadas inicialmente a través de la realización de un comité (pueden ser los mencionados), en su defecto una junta médica. una vez se tenga la decisión esta debe ser consultada a la familia como una decisión institucional respaldada por el comité o junta médica realizada. se recomienda que todo ensayo clínico que se realice en la institución debe ser presentado, revisado y aceptado por un comité de investigación local o un comité de investigación externo nacional o internacional. se recomienda que todo paciente que se incluya en un ensayo clínico debe contar con un consentimiento informado el cual garantiza la aceptación voluntaria a participar y la comprensión de los objetivos, riesgos, beneficios, derechos y responsabilidades que tiene dentro de la investigación. se recomienda el consentimiento informado en todo ensayo clínico, el cual debe ser debe ser individual en tiempos de normalidad como en tiempos de pandemia por covid-19. solo el comité de ética en investigación podrá establecer en tiempos de normalidad o de pandemia las condiciones de dispensa o excepción al requisito de obtener el consentimiento informado. refiere que el consentimiento informado tiene sus raíces en el código de núremberg de 1947 y la declaración de helsinki de 1964 y ahora es un principio rector para la conducta en la investigación médica. en el consentimiento informado para investigaciones clínicas es claro que los participantes deben entender ampliamente los componentes del consentimiento. (69) thanh tam, n. et al. el 22 de enero 2015. mediante una revisión sistemática de pubmed, scopus y google scholar y revisando manualmente las listas de referencias para publicaciones hasta octubre de 2013. realizó un metaanálisis de los resultados del estudio utilizando un modelo de efectos aleatorios para tener en cuenta la heterogeneidad. evaluó la proporción de participantes en ensayos clínicos que entienden los diferentes componentes del consentimiento informado. encontrando que los participantes en ensayos clínicos deben comprender los componentes fundamentales del consentimiento informado como: la naturaleza y los beneficios del estudio, la libertad de retirarse en cualquier momento y la naturaleza voluntaria de la participación, así como la comprensión de otros componentes, como la aleatorización y el placebo. la proporción de participantes en ensayos clínicos que comprendieron diferentes componentes del consentimiento informado varió de 52.1% a 75.8%. esto asegura que la toma de decisiones de los participantes es significativa y que sus intereses están protegidos. (70) la red de américa latina y el caribe de cnb-unesco, (26 de marzo de 2020) que agrupa a las comisiones y consejos nacionales de bioética cuya finalidad es la de asesorar sobre los problemas éticos relativos a las ciencias de la vida y la salud humana expresa su preocupación ante la realización de investigaciones biomédicas en relación con la pandemia de enfermedad infecciosa por coronavirus covid-19. reconociendo lo siguiente en relación con el consentimiento informado: que la investigación con seres humanos durante las emergencias debe contar con garantías éticas mayores, no menores, que en las situaciones ordinarias. que en situación de excepción o emergencia los participantes deben seleccionarse en forma justa y proporcionar una justificación adecuada cuando se escogen o excluyen determinadas poblaciones, distribuyendo en forma equitativa las posibles cargas y beneficios de participar en esa investigación. "que se debe obtener el consentimiento informado individual de los participantes incluso en una situación de excepción o alarma, a menos que se cumplan las condiciones para la dispensa del consentimiento informado. las cuales el comité de revisión ética solo puede decidir dar la dispensa al requisito de obtener consentimiento informado: a) si no es factible obtenerlo; y si además los estudios: b) tienen un importante valor social y científico, c) solo suponen riesgos mínimos para los participantes, d) no implican agravio comparativo con otros grupos en situación o no de vulnerabilidad; y si e) se garantiza que no se privará a la población investigada de acceder en forma preferencial al beneficio derivado. de otorgarse un consentimiento informado amplio, éste debería ser única y exclusivamente para los procesos asociados con covid-19".(71) amci ® se recomienda considerar la transición del cuidado intensivo al cuidado paliativo en todo paciente con sospecha o diagnóstico de covid-19 sin mejoría a pesar de las intervenciones óptimas, con empeoramiento progresivo de su pronóstico vital y ante un evidente deterioro; aplicando medidas generales en control de síntomas ( manejo de secreciones -tratamiento del dolor -tratamiento de la disnea -sedación paliativa), así como apoyo espiritual, siempre acompañando al paciente y nunca abandonarlo en el final de la vida. fuerte a favor fundamento la sociedad española de anestesiología, reanimación y terapéutica del dolor en su documento: "marco ético pandemia covid-19" madrid, 20 de marzo de 2020 refiere: la sedación paliativa en pacientes hipóxicos con progresión de la enfermedad no subsidiaria de tratamiento debe considerarse como una expresión de buena práctica clínica y debe seguir las recomendaciones existentes. si se prevé un período agónico no corto, se debe proporcionar una transferencia a un entorno no intensivo.(71) se recomienda la utilización de guías establecidas previamente a la pandemia por el ministerio de salud y sociedades científicas para orientar las decisiones que se tomen al final de la vida en pacientes con sospecha o diagnóstico de covid-19. estas guías deben ser divulgadas al equipo de atención y aplicadas en los pacientes en casos de: adecuación del esfuerzo terapéutico (aet), orden de no reanimar (onr), consentimiento sustituto, voluntades anticipadas, cuidados paliativos. se recomienda fundamentar las decisiones del final de la vida individualizadas a cada paciente y a cada situación sin llegar a tomar decisiones apresuradas sin fundamento científico o ético, solicitando de ser posible una valoración por medicina paliativa para el manejo de síntomas. se recomienda indagar durante la hospitalización de todo paciente con sospecha o diagnóstico de covid-19, si en tiempos de salud hizo válida su autonomía y realizó un documento de voluntad anticipada, teniendo en cuenta que esta será equivalente al consentimiento informado. amci ® terapéuticos y la suscripción de documentos de voluntad anticipada.(72) el inicio de sedación paliativa con reubicación del pacientede ser necesario el des escalonamiento por deterioro clínico. en situación de pandemia covid-19 cuando se refiere a situaciones del final de la vida se relaciona a la adecuación del esfuerzo terapéutico, la sedación paliativa la cual será la maniobra terapéutica que se utilizará en pacientes no recuperables y que no son candidatos a cuidados intensivos por covid-19,(73) que evolucionan desfavorablemente y tienen mal pronóstico a corto plazo, así como la disnea refractaria y la limitación del esfuerzo terapéutico. el delirium o síndrome confusional por fallo cerebral agudo, es un problema habitual en situaciones de alteración orgánica severa, y ha sido descrito como uno de los síntomas neurológicos presente en los pacientes que sufren infección por el covid-19(74). wilson c. 24 de abril del 2020. en su artículo "la crisis golpea al final de la vida" se refiere a que el brote de coronavirus está obligando a las personas a enfrentar dilemas en torno a la cantidad de atención médica que se debe brindar al final de la vida y apresurar decisiones controvertidas sobre rechazar ciertos tratamientos. dicen los expertos que esto ha alentado a más personas a tomar decisiones de tratamiento anticipadas relacionadas con la rcp y la ventilación,(75) haesen s. el 16 de mayo de 2018. en su artículo "dirigir a los ciudadanos a crear directivas anticipadas" las voluntades o directrices anticipadas son para las personas que quieran asumir plenamente su papel de ciudadanos responsables tomando decisiones proactivas. la decisión de redactar directivas anticipadas marca un cambio del enfoque actual de "aceptación" a un escenario de "exclusión voluntaria".(76)al emitir una directiva de tratamiento anticipado, una persona autónoma puede expresar formalmente qué tipo de tratamiento desea y no desea recibir en caso de que se enferme o se lastime y no pueda decidir de manera autónoma sobre su tratamiento. (77) ministerio de salud y protección social en su documento de voluntades anticipadas que es el documento en el que toda persona capaz, sana o en estado de enfermedad, en pleno uso de sus facultades legales y mentales y como previsión de no poder tomar decisiones en el futuro, declara, de forma libre, consciente e informada su voluntad sobre las preferencias al final de la vida que sean relevantes para su marco de valores personales.(72) se recomienda que el paciente crítico con covid-19 que no es candidato para ingresar o continuar recibiendo cuidados intensivos y que presente deterioro rápido con mal pronóstico a corto plazo, se le brinde una adecuación del esfuerzo terapéutico orientada a acompañamiento al final de la vida, alivio del sufrimiento y control de síntomas. dependiendo de la disponibilidad de recursos se sugiere dentro del plan de atención hospitalaria contar con un área destinada a la atención del final de vida con el recurso físico, humano y de procesos necesario. marzo 13 del 2020. refiere: en situación de adecuación terapéutica, retirada de medidas y/o mala evolución es adecuado derivar al paciente a un área de menor complejidad para establecer el plan de cuidados paliativos. consultar al servicio de cuidados paliativos para procurar la continuidad de cuidados de los pacientes en los que se haya acordado la limitación de tratamientos y aliviar su sufrimiento, incluyendo la sedación paliativa en los casos en los que sea precisa.(71) schmidhauser tf. el 8 de abril 2020. considera en su publicación que: los cuidados paliativos durante la pandemia de covid-19 deben adaptarse a un estilo de" cuidados paliativos de emergencia" ya que los pacientes pueden deteriorarse rápidamente y requieren decisiones rápidas y planes de tratamiento claros. estos deben ser seguidos fácilmente por los miembros del personal de salud que atienden a estos pacientes. además, los cuidados paliativos deben estar a la vanguardia para ayudar a tomar las mejores decisiones, atender a las familias y ofrecer apoyo espiritual.(71) se recomienda como estrategia de protección personal en las unidades de cuidado intensivo sin presión negativa y cubículos abiertos utilizar de forma continua el respirador n95 o fpp2, adicional a otros elementos de protección para prevención del contagio por covid-19. la atención segura en áreas crítica para todas las modalidades de atención se fortalece a través de las medidas de precauciones estándar en el manejo de todos los pacientes, establecidos en el "manual de medidas básicas para control de infecciones en prestador servicios de salud" ley 9 de 1979, por la cual se dictan medidas sanitarias. resolución 4445 de 1996, numeral 3 y numeral 4.3 epp. el respirador, n95 o fpp2, puede utilizarse de manera continua por 8 a 12 horas, o desecharlo antes si está visiblemente contaminada o si está húmeda. luego de colocar la n95 se debe verificar prueba de ajuste antes de ingresar a la unidad para atención de pacientes con covid-19 de la siguiente manera: mascarillas sin válvula de exhalación: cubra la totalidad de la mascarilla con ambas manos y exhale con fuerza. si nota fugas de aire por sus bordes, reajuste la posición del respirador. mascarillas con válvula de exhalación: cubra el respirador con ambas manos e inhale con energía. deberá sentir una presión negativa dentro de la mascarilla. si detecta alguna pérdida de presión o entrada de aire, reajuste la posición del respirador. no se puede emitir una recomendación a favor o en contra acerca de la efectividad de bioseguridad del uso extendido, continuo o intermitente de los respiradores n95 ó ffp2. sin embargo, se considera que puede ser una alternativa, bajo la adopción de un protocolo riguroso, cuando se debe optimizar el uso de los epp en el contexto de un acceso limitado. el reúso no está permitido en colombia. la duración máxima del uso continuo de la n95 es de 8 a 12 horas, siguiendo las recomendaciones del manual de medidas básicas para control de infecciones en ips de minsalud. pero en la vida real, ningún trabajador tolera 8 a 12 horas continuas con un respirador. por esto, su uso continuo en el sitio de trabajo dependerá de la necesidad de pausar para comer, para ir al baño, etc. en este caso, se guardará en una bolsa de papel para su nueva colocación, si tiene menos de 12 horas, o desechará si está visiblemente contaminada o se torna húmeda. el reúso de la n95 dependerá de la casa del fabricante, de si contiene o no celulosa en su estructura del respirador. por ejemplo, la recomendación de desinfección para los respiradores sin celulosa es con peróxido de hidrógeno vaporizado al 58% por 28 minutos (tabla 9 y 10). los respiradores n95 de uso industrial tienen mayor contenido de celulosa que los de uso médico por lo tanto para procesos de esterilización, solo los n95 de uso médico podrán ser esterilizados mediante de peróxido de hidrógeno vaporizado (sterrad®) (84-88) 22. ¿existe superioridad en términos de protección personal para el personal sanitario y de apoyo dentro de las unidades de cuidados intensivos con la utilización del overol frente a la bata manga larga con antifluido durante la atención del paciente con covid-19? no se puede emitir una recomendación a favor o en contra si los overoles ofrecen mayor protección por cobertura corporal frente a otros elementos como vestidos largos, batas y delantales. resulta intuitivo que su uso genera una mayor protección en especial en servicios cohortizados. sin embargo, su uso está asociado con una mayor dificultad para su colocación y retiro, lo que puede potencializar el contagio del usuario, la utilización debe hacerse bajo un protocolo supervisado y chequeado. las batas modificadas para ajustarse firmemente en el cuello pueden reducir la contaminación. en estudios ya descritos el uso de un respirador eléctrico purificador de aire con overol puede proteger contra el riesgo de contaminación mejor que una máscara n95 y una bata con un rr: 0.27, intervalo de confianza (ic) del 95%: 0.17 a 0.43 pero fue más difícil su retiro con rr 7.5, ic del 95% 1.81 a 31.1. en un eca (59 participantes), las personas con una bata larga tenían menos contaminación que aquellas con un overol. las batas pueden proteger mejor contra la contaminación que los delantales.(89-92) los epp como batas y overoles deberían estar hechos de un material que cumpla con los requisitos mínimos de la asociación americana de químicos textiles:  tipo a: buena repelencia al agua, resistente a la penetración, pero mala permeabilidad al aire.  tipo b: buena repelencia al agua, buena permeabilidad al aire, pero poca resistencia a la penetración del agua.  tipo c: bata quirúrgica que tiene poca repelencia al agua y resistencia a la penetración de agua.  tipo d: hecho de fibras de polietileno de alta densidad, tela no tejida (tyvek®), tiene buena repelencia y resistencia al agua, mala permeabilidad al aire. no se puede emitir una recomendación a favor o en contra para el uso de respiradores elastoméricos como elementos de protección personal dentro de las unidades de cuidados amci ® intensivos. no hay evidencia que soporte la superioridad de los respiradores elastoméricos frente a los n95, son más costosos, difíciles de utilizar y pueden implicar algún riesgo para el paciente. por tanto, su uso sólo debería considerarse frente a un desabastecimiento de los n95 y bajo la adopción de un protocolo institucional riguroso y bajo chequeo. los respiradores elastoméricos son respiradores ajustados a media cara o cara completa, esta última otorga protección ocular. su filtración está determinada por el filtro que se utilice, estos van desde partículas de nivel n95 a p100. están hechos de material sintético o de goma que les permite desinfectarse, limpiarse y reutilizarse repetidamente. están equipados con cartuchos de filtro reemplazables. al igual que los respiradores n95, los respiradores elastoméricos requiere entrenamiento adecuado para su correcta colocación y retiro. por eso es muy importante revisar el manual del usuario antes de su uso. los respiradores elastoméricos no deberían utilizarse en entornos quirúrgicos, debido al riesgo potencial de contaminación del campo quirúrgico, con el aire que sale de la válvula de exhalación. como recomendación de buena práctica, aprobado por la fda, debe colocarse una máscara quirúrgica encima de la válvula de exhalación para evitar este riesgo. solo se debe permitir el uso del respirador elastoméricos por clínica para evitar infecciones cruzadas, esto permitirá una protección esencial contra agentes infecciosos y la auto contaminación. aunque los cartuchos de filtro son finalmente desechables, están destinados a ser reutilizados hasta que ya no se puede respirar o se vuelven visiblemente sucio. generalmente se recomienda, en la mayoría de los casos, hacer recambios cada 30 días. deben tener procedimientos de limpieza/desinfección actualizados y aprobados por su manufacturador.(78, 93-110) recomendación se recomienda realizar la limpieza y desinfección de equipos biomédicos y de superficies las veces que sean necesarias y en el momento de egreso del paciente siguiendo los protocolos de cada institución. el desinfectante para este proceso debe ser de nivel intermedio o alto para superficies y equipos biomédicos y cumplir con las recomendaciones del fabricante según lo aprobado en el registro sanitario. fuerte a favor fundamento para la desinfección de las superficies ambientales hospitalarias y domiciliarias, la oms recomienda emplear un desinfectante que sea efectivo contra virus cubiertos (el coronavirus pertenece a esta categoría), específicamente, recomienda emplear alcohol etílico para la desinfección de algunos equipos biomédicos reusables (p. ej.: termómetros) y para las superficies, el hipoclorito de sodio o precursores de sodio como el dicloroisocianurato de sodio (nadcc) que tiene la ventaja de la estabilidad, la facilidad en la dilución y que no es corrosivo.(87) (tabla 11). page se recomienda que el ingreso de un paciente a uci debe hacerse bajo un procedimiento estandarizado que incluya la coordinación y comunicación de los servicios vinculados, adecuación de la unidad de atención a las necesidades del paciente y la garantía de la bioseguridad del equipo multidisciplinario. se recomienda que cada institución establezca en sus procesos prioritarios el circuito del traslado que incluye el itinerario del traslado, el uso de ascensor, el número y la organización de los intervinientes sanitarios y no sanitarios (celadores, seguridad, limpieza), las medidas de protección empleadas por los mismos (epp, limpieza) y los recursos materiales necesarios durante el traslado. el traslado de pacientes con casos sospechosos o confirmados de covid-19 se puede presentar entre servicios a nivel hospitalario o entre instituciones con diferentes niveles de atención y deben tenerse las precauciones universales de un traslado seguro. una posición responsable es evitar el traslado de estos pacientes el máximo posible, a menos que sea imprescindible, teniendo en cuenta el riesgo/beneficio. considerar evitar traslados interinstitucionales solo por temas administrativos. el personal sanitario que realice el traslado debe contar con todos los epp, considerando este traslado como de alto riesgo de transmisión vírica. se debe utilizar mascarilla quirúrgica o n-95, de acuerdo con el riesgo amci ® de aerosolización. hasta que la rt-pcr para sars-cov-2 este negativo se podrían retomar las prácticas habituales de traslado de los pacientes . (111) (112) (113) capítulo 2. abordaje diagnóstico y covid-19 se recomienda en pacientes con diagnóstico o sospecha de infección por sars-cov-2 clasificar la enfermedad en leve, severo o paciente crítico, teniendo en cuenta los criterios de la clasificación por las fases y estadios de la enfermedad. se recomienda en pacientes con diagnóstico o sospecha de infección por sars-cov-2, clasificados como críticos y que requieren de intubación orotraqueal realizar la clasificación por fenotipos (1 o 2), con el fin de proyectar una estrategia de ventilación mecánica. el covid-19, es una enfermedad con una presentación clínica diversa, desde formas leves hasta presentaciones graves que incluyen el sdra, la mediana del período de incubación desde la exposición hasta el inicio de los síntomas es de aproximadamente 4 a 5 días, y el 97.5% de los pacientes sintomáticos tendrán síntomas dentro de los 11.5 días después de la infección (114) , que incluye fiebre, tos, disfagia, malestar general, mialgias, anorexia, náuseas, diarrea, anosmia y ageusia; la disnea se presentó entre los 5 y 13 días (115) y puede representar progresión a covid-19 severo, que se manifiesta con hipoxemia, disfunción orgánica múltiple, documentación de arritmias cardíacas, rabdomiólisis, coagulopatía y choque (116) . dentro del espectro de enfermedad, siddiki et al, proponen un enfoque estructurado por fases expresados en tres estadios (historia natural de la enfermedad), siendo el primero donde la patogenicidad viral es dominante, se incluye el periodo de incubación, síntomas leves, con multiplicación del sars-cov-2 centrándose principalmente en el sistema respiratorio gracias a la unión del virus con el receptor de la enzima convertidora de angiotensina 2 (ace2), el hemograma puede revelar linfopenia y neutrofilia sin otras anormalidades significativas. el estadio 2 es la enfermedad pulmonar establecida, neumonía viral, tos, fiebre con progresión en algunos casos a hipoxia con trastorno de los índices de oxigenación (pao2/fio2 menor 300 mmhg), hallazgos en imágenes de tórax (radiografía y/o tomografía) de infiltrados alveolares o vidrio esmerilado, mayor linfopenia y elevación de transaminasas (2a: sin hipoxemia, 2b: con hipoxemia). el estadio 3 o fase de híper inflamación sistémica extrapulmonar se caracteriza por elevación de biomarcadores inflamatorios y estado protrombótico (il -2, il-6, il-7, ftn -α, proteína c reactiva, ferritina y el dímero d), con presencia en las formas más graves de disfunción orgánica múltiple, lesión miocárdica (troponina y péptido natriurético de tipo b elevados), con fenómenos trombóticos, progresión a sdra y choque (117) . amci ® la neumonía por sars-cov-2, se característica por disociación entre la severidad de la hipoxemia y el mantenimiento relativamente bueno de la mecánica respiratoria, con compliance del sistema respiratorio en promedio de 50 ml / cmh2o; gattinoni, marini et al, proponen dos fenotipos de presentación de la insuficiencia respiratoria; el primero (tipo 1) con una mecánica pulmonar adecuada, con baja probabilidad de reclutabilidad y con hipoxemia, relacionado al desbalance entre la perfusión y la ventilación; el segundo (tipo 2) más acorde a las definiciones de sdra (csdra "covid-19 patient with sdra"), con una compliance pulmonar baja y reclutabilidad potencial(118, 119) (120). se propone la siguiente clasificación clínica del covid-19. (121, 122 , y pacientes críticos de 5%, con tasa global de mortalidad de 2,3%, siendo mayor entre los pacientes de 70 a 79 años con 8% y entre los mayores de 80 años con 14.8%, dentro del grupo de pacientes clasificado como crítico la mortalidad descrita fue del 49%(121). recomendación se recomienda en cuidado intensivo, realizar el diagnóstico de covid-19 del paciente sospechoso por medio de rt-pcr conociendo su alta especificidad, su variabilidad en relación con el tiempo y pérdida de rendimiento diagnóstico luego de la primera semana de inicio de los síntomas. se recomienda tomar la primera muestra para rt-pcr de hisopo nasofaríngeo o de cornete medio sobre hisopado oro faríngeo o de saliva, de ser negativo se puede repetir la prueba de 24 a 48 horas preferiblemente de tracto respiratorio inferior, esputo no inducido o en aspirado traqueal en paciente intubado. se recomienda el uso conjunto de rt-pcr e igm por elisa en pacientes con sospecha de covid-19, primera rt-pcr negativa, que se encuentren entre la segunda y tercera semana desde el inicio de los síntomas, con el objetivo de mejorar la sensibilidad en la identificación de infección por sars-cov-2. en cuidado intensivo, el diagnóstico de covid-19 se fundamenta con base en la presentación clínica compatible y factores epidemiológicos asociados con probabilidad de infección; el diagnóstico definitivo se realiza con pruebas de amplificación de ácido nucleico del virus (naat), la detección del genoma viral del sars-cov-2 se realiza por medio de reacción en cadena de la polimerasa por transcriptasa reversa (rt-pcr) dado a su especificidad del 100% (123, 124) ; por lo cual todo paciente que cumple con la definición de caso sospechoso se le debe realizar rt-pcr, sars-cov-2 independientemente de si se encuentra otro patógeno respiratorio (124) . las muestras para el diagnóstico por rt pcr se recolecta de las vías respiratorias superiores, nasofaringe, cornete medio u orofaringe; todos con alta especificidad. sin embargo, se sugiere recolectar los hisopos nasofaríngeos o de cornete medio por tener mayor sensibilidad (125 (17/34) . en pacientes con neumonía severa a quienes se le realizó lavado broncoalveolar (bal) y rt-pcr entre los días 8 y 14 el 100% de las muestras fueron positivos, en pacientes no intubados con esputo no inducido el 83% de las muestras fueron positivas (126, 127). wang et al, en un estudio de 205 pacientes con covid-19, las rt-pcr con tasas positivas más altas fue en muestras extraídas por bal (95%; 14 de 15 muestras) y esputo 72% (72 de 104 muestras) (128) . para la detección del sars-cov-2 por rt-pcr en pacientes en cuidado intensivo, teniendo en cuenta la rigurosidad de aspectos de bioseguridad y aerosolización, se debe tomar la primera muestras en nasofaringe o cornete medio, si esta prueba es negativa se puede repetir en 24 a 48 horas, si este es el caso o existe más de 8 días desde el inicio de los síntomas se prefiere una muestra del tracto respiratorio inferior, por esputo no inducido por personal de salud o por aspirado traqueal en pacientes intubados (126, 129), aunque el rendimiento diagnóstico del bal es alto por lo general, se debe evitar la broncoscopia para minimizar la exposición de los trabajadores de la salud (130) . la probabilidad de detección del arn de sars-cov-2 puede variar según la fase de la enfermedad, si bien una rt-pcr positiva confirma el diagnóstico de covid-19, los reportes falsos negativos y la sensibilidad se ve influenciado por el tiempo desde la exposición e inicio de síntomas. kucirka et al, en un análisis de siete estudios evaluaron el rendimiento diagnóstico de la rt-pcr en relación con el tiempo desde el inicio de los síntomas o la exposición, con resultados expresados en tasa estimada de falsos negativos, siendo del 100% el día de la exposición, del 38% el día 5 (estimado como primer día de síntomas, ic: 18% a 65%), 20% en el día 8 (día 3 desde el inicio de síntomas, ic: 12% a 30%) luego comenzó a aumentar nuevamente de 21% en el día 9 (ic: 13 a 31%) a 66% en el día 21 (ic: 54 a 77%) (131) . la precisión y los valores predictivos de rt-pcr para sars-cov-2 no se han evaluado sistemáticamente, la sensibilidad de las pruebas moleculares está influenciada por múltiples factores como sitio y calidad de la muestra, técnica de procesamiento; probablemente las menores tasas de falsos negativos (sensibilidad entre 65 y 80%) está entre el día 3 y 10 luego de inicio de los síntomas (131) . a partir de aquí el rendimiento diagnóstico disminuye, por lo tanto, es importante que el intensivista valore estas consideraciones en el momento de tomar conductas, en cuanto tipo de aislamiento, tratamiento y pronóstico. amci ® las pruebas serológicas detectan anticuerpos contra el sars-cov-2 y ayudan a identificar pacientes que han tenido la enfermedad y algunos con la enfermedad activa, la seroconversión se ha descrito entre el día 13 y 21, sin embargo, hay incertidumbre en la incidencia de la seroconversión (132) . estas pruebas se usan principalmente en tamizaje poblacional y estudios de seroprevalencia; en cuidado intensivo el análisis de la igm por elisa contribuye a la detección de pacientes con infección reciente, además con el análisis conjunto con la igg se clasifica el estado de infección en agudo o convaleciente. las pruebas serológicas se realizan por diferentes técnicas como la inmunocromatográfica de flujo lateral, la inmunofluorescencia indirecta (ifi) y el ensayo de inmunoadsorción ligado a enzima (elisa) (133, 134) . las pruebas serológicas no deben usarse como la única prueba para diagnosticar o excluir la infección activa por sars-cov-2. la sensibilidad y la especificidad de muchas de estas pruebas serológicas son inciertas, así como su valor predictivo positivo. los anticuerpos detectables generalmente tardan varios días en desarrollarse. guo et al, documenta niveles de anticuerpos por elisa, con una mediana de detección de anticuerpos igm e iga de 5 días (iqr, 3-6) y de igg de 14 días (iqr, 10-18) después del inicio de los síntomas, con una probabilidad de resultados positivos de 85.4%, 92.7% y 77.9 % respectivamente; es probable que el rendimiento diagnóstico de igm por elisa sea mayor que la de rt-pcr después del quinto día luego de inicio de síntomas; cuando se combinan estas técnicas (elisa igm con rt-pcr) la tasa de detección positiva es del 98.6% (135) . zaho et al, en un estudio de 173 pacientes con covid-19, donde el 18,5% estaba en condición crítica, la mediana del tiempo desde el inicio de los síntomas hasta la detección de anticuerpos (técnica elisa) fue de 12 días para igm y 14 días para igg; dentro de los primeros 7 días desde el inicio de los síntomas solo el 38.3% tenía anticuerpos detectables, entre los días 8 a 14 la sensibilidad de igm fue 73.3% e igg de 54.1%, luego de los 15 días la sensibilidad igm e igg fue de 94.3% y 79.8% respectivamente; el uso combinado de rt-pcr y elisa igm presentó una sensibilidad del 78% entre los días 1 a 7 y del 97% entre los días 8 a 14. (136) la rt-pcr tiene especificidad del 100%, con adecuado rendimiento diagnóstico entre los días 3 y 10 luego del inicio de los síntomas con sensibilidad que varía entre el 65 y 80%, con presencia ascendente de falsos negativos luego del día 9, por lo cual el diagnóstico debe tener consistencias epidemiológicas y clínicas (síntomas y hallazgos radiológicos compatibles con covid-19) donde una rt pcr negativa no excluye la enfermedad; la precisión y el tiempo para la detección de anticuerpos varían con la técnica utilizada, su uso es limitado en cuidado intensivo, sin embargo su identificación por técnica elisa en conjunto con rt-pcr mejora la sensibilidad y la probabilidad de falsos negativos, especialmente entre los días 3 y 14 desde el inicio de síntomas. faltan estudios que evalúen el rendimiento diagnóstico de las diferentes pruebas. amci ® se recomienda la medición de marcadores de severidad al ingreso a uci del paciente críticamente enfermo por covid-19 (hemograma, transaminasas, ldh, ferritina, troponina, dímero d y pcr) los cuales se han asociado con peor pronóstico en la enfermedad por covid-19, logrando ofrecer intervenciones más tempranas. se recomienda no utilizar una periodicidad de rutina para la medición de seguimiento de biomarcadores de severidad en el paciente con sospecha o diagnóstico de covid-19. en un estudio cohorte retrospectivo que evaluó 140 pacientes diagnosticados con covid-19 desde el 18 de enero de 2020 hasta el 12 de marzo de 2020, fang liu y colaboradores encontraron correlación en la elevación de il-6 y pcr con la gravedad clínica, lo que sugiere podrían usarse como factores independientes para predecir la severidad del cuadro, los pacientes con il-6> 32.1 pg./ml o pcr> 41.8 mg/l tenían más probabilidades de tener complicaciones graves (137) , así mismo en otro estudio multicéntrico retrospectivo de 150 pacientes infectados se identificó resultados de laboratorio con diferencias significativas con elevación de glóbulos blancos, valores absolutos de linfocitos, plaquetas, albúmina, bilirrubinas, función renal, transaminasas, troponina, proteína c reactiva e interleucina (il 6) en el grupo con desenlace de mortalidad contra los dados de alta (138) . entre otros marcadores la troponina como lesión cardiaca (elevación de troponina por encima del percentil 99 límite de referencia superior) se ha reportado en 7% a 23% de los pacientes con covid-19 en wuhan, china, en dos estudios retrospectivos por xiabo yang y colaboradores (37, 139) . en una revisión sistemática de mayo 2020, kermali m. y colaboradores exponen que existe evidencia a favor de los valores bajos de linfocitos y plaquetas y valores elevados de los biomarcadores il-6, pcr, troponina, ldh, ferritina, proteína amiloidea a y dímero d, pueden relacionarse con la gravedad de la infección por covid-19 y su fuerte asociación con la mortalidad (140) . estos resultados pueden usarse como un complemento en la práctica clínica para guiar a los médicos a identificar pacientes con mal pronóstico y la rápida implementación de medidas de soporte, monitorización y reanimación en la evolución de los pacientes críticos en la unidad de cuidados intensivos. solo en 1 estudio, karmali et al, en 2002, determinan en promedio entre 48 a 72 horas, la periodicidad en el seguimiento de estos, sin embargo, no se discrimina entre pacientes críticos y no críticos. consideramos que el seguimiento de estas pruebas debe estar ajustado al juicio clínico del médico intensivista tratante, según la evolución de los pacientes. se muestran el comportamiento de los biomarcadores mas frecuentes en la tabla 12. tabla 11. biomarcadores en pacientes críticos con sospecha o diagnóstico de covid-19. tendencia de biomarcador en relación con la gravedad covid-19 pcr aumentada recomendación se recomienda la no medición de marcadores de inflamación o de severidad de forma rutinaria solo con el objetivo de iniciar un tratamiento específico o algoritmos terapéuticos en la enfermedad por covid-19 en pacientes críticos. el síndrome de liberación de citocinas o denominado "tormenta de citocinas" parece asociarse en pacientes con afecciones graves por covid-19. la citocina proinflamatoria il-6 es la citocina mejor documentada en covid-19 correlacionada con la gravedad, el estado crítico del paciente, la carga viral y el pronóstico (138, 141, 142) . se han descrito mayores niveles de citoquinas proinflamatorias (il-2, il-6, il-7, factor estimulante de colonias de granulocitos, factor de necrosis tumoral e interferón gamma) asociadas a compromiso pulmonar severo en pacientes con infección por coronavirus, determinado por la rápida replicación del virus, infiltración masiva de células inflamatorias y trastorno severo de la inflamación (143, 144) . igualmente, está asociada la presencia de linfopenia como biomarcador de mal pronóstico para covid-19 (145) . hallazgos similares se encontraron en la pandemia de influenza a (h1n1) de 2009 sin ser especificó su valor (146) . las manifestaciones clínicas de la tormenta de citocinas incluyen síndrome de respuesta inflamatoria sistémica, hipotensión, síndrome de fuga capilar, insuficiencia renal, sdra, miocarditis, entre otras (116) , algunos autores han determinado este cuadro como un síndrome de linfohistiocitosis hemofagocitica secundaria. es razonable pensar que, en pacientes con sospecha de tormenta de citocinas basado en los hallazgos de laboratorio, el manejo con inmunomoduladores puede resultar beneficioso, sin embargo, los resultados del manejo de la hiperinflación basado en pruebas diagnósticas han tenido resultados encontrados en pacientes con covid-19. el uso de esteroides, inmunoglobulina endovenosa, inhibidores del receptor de citoquinas (tocilizumab) o inhibidores de janus kinasa, han disminuido los valores de los biomarcadores, días de hospitalización (147) o necesidad de fracciones elevadas de oxígeno (148) , sin embargo no han demostrado beneficio sobre la mortalidad y en algunos casos, si un aumento en la incidencia de infecciones bacterianas o fúngicas sobreagregadas (116) . se recomienda realizar radiografía simple de tórax para todos los pacientes con sospecha o diagnóstico de covid-19 en uci. se recomienda realizar tac de tórax según disponibilidad de tecnología institucional, ante la incertidumbre diagnostica, teniendo en cuenta las condiciones clínicas, la tolerancia del paciente al traslado y los protocolos administrativos de seguridad. fuerte a favor fundamento se reconoce como el gold estándar diagnóstico de infección pulmonar por covid-19 a los estudios moleculares, sin embargo, estos presentan limitaciones: a) contaminación de las muestras b) errores en la técnica de la toma, c) muestra insuficiente para ampliación genética favoreciendo falsos negativos d) demora de reporte de los resultados. por lo anterior, se recomienda imágenes diagnósticas en la aproximación de paciente con sospechas de infección pulmonar por covid-19 (149, 150) .  radiografía simple de tórax: ventajas: mayor accesibilidad que la tac de tórax y realización de la prueba a la cabecera del enfermo desventaja: baja sensibilidad en estadio temprano, después del día 9 de inicio de los síntomas presenta aumento en el rendimiento diagnóstico  tac de tórax: ventaja: es ampliamente recomendada. alta sensibilidad en estadios tempranos. permite describir extensión, distribución, localización, densidades parenquimatosas, aplicables en clasificaciones y puntajes diagnósticos, pronósticos y de seguimiento en permanente evolución y mejoría. algunas asociaciones referentes como asociación china de radiología, en su recomendación de expertos propone clasificación tomografía en 4 estadios 1 temprana 2 avanzada 3 severo 4 disipación desventaja: traslado del paciente hasta el tomógrafo (no todos los enfermos toleran el transporte) y tecnología no disponible en todos los niveles de atención page no se puede emitir una recomendación a favor o en contra para el uso de ecografía pulmonar a la cabecera del paciente crítico como herramienta diagnóstica o de pronóstico en con covid-19. se puede considerar como una alternativa para la valoración imagenológica pulmonar en el paciente crítico con covid-19 cuando las condiciones del paciente no permitan su traslado. no se sugiere la utilización de la ecografía pulmonar para el seguimiento de lesiones pulmonares agudas en el enfoque del paciente crítico con covid-19. puede utilizarse para determinar complicaciones asociadas a la enfermedad o en la inserción de dispositivos invasivos. en general los estudios de imágenes no representan un papel concluyente para el diagnóstico de covid-19. la ultrasonografía en específico requiere estudios de validación, un programa de entrenamiento es operador dependiente, y se le atribuido limitaciones en la capacidad de discriminación en la cronicidad de las lesiones pulmonares. la ultrasonografía pulmonar puede servir como herramienta a la cabecera del paciente para mejorar la evaluación del compromiso pulmonar y reducir el uso de radiografías de tórax y tomografía computarizada (151) , sin embargo no debe usarse para el diagnóstico inicial, pues éste se compone de criterios clínicos, radiográficos y microbiológicos que actualmente son el estándar de oro; la ecografía no los reemplaza debido a la baja especificidad en relación con el virus, se sugiere su uso como complemento en la valoración diaria del paciente, ojalá realizada por el mismo observador. la ecografía pulmonar es altamente sensible y puede revisar de forma rápida y precisa la condición pulmonar, creando un potencial para evaluar los cambios o la resolución con el tiempo, especialmente en la uci, escenario en el que cada vez se usa más para la detección de múltiples patologías pulmonares que se pueden demostrar junto con covid-19, sin embargo, hasta la fecha no hay hallazgos específicos, ni patognomónicos que se relacionen con covid-19 en el examen ecográfico del paciente (152) . la adopción de ultrasonido pulmonar puede reducir la necesidad de exposición a la radiación ionizante y, a su vez, reducir la cantidad de radiografías necesarias para la evaluación rutinaria del paciente, disminuyendo también la exposición de personal asistencial adicional como el uso de elementos de protección personal (153) . es bien conocido el beneficio de la ecografía durante y después de la colocación de accesos venosos centrales para establecer la presencia o no de complicaciones inmediatas como neumotórax. a la fecha no hay publicaciones acerca de la utilidad del ultrasonido como herramienta para establecer pronóstico. se necesitan más estudios para evaluar la utilidad de la ecografía pulmonar en el diagnóstico y manejo de covid-19 (153) . se recomienda no establecer un punto de corte en el valor de dímero d para el inicio rutinario de anticoagulación plena en el contexto de infección por covid-19. se recomienda la administración de profilaxis antitrombótica según protocolo institucional independiente de niveles de dímero d en el paciente críticamente enfermo por covid-19. los fenómenos inflamatorios inherentes a procesos infecciosos son considerados desde décadas previas, factores protrombóticos, no siendo una excepción la infección por covid-19. en algunas publicaciones se hallan asociaciones con desenlaces cardiovasculares negativos (154) y sugieren asociación entre niveles elevados de dímero d ( marcador de estado de trombosis ) y riesgo de embolismo pulmonar con or crecientes or de 1.7 a los 3 días hasta 2.4 a los 9 días de seguimiento (155) . de igual manera, zhou et al, reportan asociación de dímero d mayor a 1 mcg/ml y mortalidad (37) sin embargo los estudios presentan limitaciones en su diseño, a pesar de ello algunos autores proponen anticoagulación como factor de protección en mortalidad sin precisar precisión en la dosis, tipo de heparina y selección de enfermos (156) . finalmente la european heart journal en su entrega de farmacología cardiovascular desarrolla una propuesta en la cual combina un puntaje previo de riesgo de cid en uci a niveles de fibrinógeno; esta pudiera ser una herramienta para selección de pacientes a recibir anticoagulación sin embargo aún está en proceso de validación (157) . por estos motivos, hasta el momento, no se tiene suficiente cuerpo de evidencia que permita hacer una recomendación basado en los niveles de dímero d como variable aislada para administración de anticoagulación terapéutica. se recomienda no utilizar de rutina la procalcitonina en un algoritmo diagnóstico, para diferenciar entre neumonía viral vs bacteriana o confirmar la presencia de una sobreinfección bacteriana en el paciente con sospecha o diagnóstico de covid-19. se recomienda no medir de forma rutinaria la procalcitonina en pacientes con sospecha o diagnóstico de covid-19 como factor pronóstico. la procalcitonina es un biomarcador que ha sido incluido en algoritmos de diagnóstico y pronóstico durante los últimos años. schuetz et al, en 2017, concluyen en una revisión sistemática de 26 estudios, que la procalcitonina es segura dentro de un algoritmo, para guiar a los médicos tratantes entre iniciar o suspender antibióticos en neumonía adquirida en la comunidad; sin embargo en una revisión sistemática más reciente, kamat et al, reportaron una sensibilidad 55% [ic 95% 37%-71%; i2 = 95.5%], especificidad 76% [95% ic, 62%-86%; i2 = 94,1%]) para el inicio de tratamiento antibiótico para neumonía bacteriana, lo cual nos determina que la prueba es inespecífica para diferenciar entre infecciones virales vs bacterianas. en neumonía por sars-cov-2, se han publicado algunos artículos evaluando el uso de la procalcitonina como prueba asociada al pronóstico de los pacientes. liu et al encontraron que la procalcitonina se asoció a mayor severidad de los cuadros de neumonía. hr, 4.908; 95% ci, 1.797-13.402; p=0.002. en este estudio también se tuvo un resultado similar con la proteína c reactiva y la il-6. plebani et al, publican un metaanálisis, donde sugiere que los niveles elevados de procalcitonina se asocian a mayor severidad de la infección. (or, 4.76; 95% ci, 2.74-8.29). es importante mencionar, que en estos estudios se evaluaron otros biomarcadores de inflamación como interleucina 6, proteína c reactiva y ferritina; presentando todos ellos, aumento en sus valores y asociándose a severidad de la enfermedad; por tanto, se considera que, en particular, la procalcitonina elevada, no representa una diferencia en el pronóstico, comparado con otros biomarcadores de inflamación. hasta el momento no se han publicado estudios en infección por sars-cov-2 donde se evalué el papel de prueba diagnóstica para confirmar sobreinfección bacteriana o diferenciar entre neumonía viral vs bacteriana. (137, (158) (159) (160) se recomienda no usar de forma rutinaria el uso de pruebas clínicas de laboratorios clínicos para determinar la resolución de la enfermedad crítica por covid-19. se recomienda considerar la ausencia de dificultad respiratoria y fiebre por más de 72 horas, requerimiento de oxígeno a baja concentración y bajo flujo, como indicadores clínicos de resolución de la fase crítica de la enfermedad por covid-19. se recomienda no utilizar de forma rutinaria el uso de pruebas microbiológicas de erradicación viral, para determinar la resolución de la enfermedad en pacientes en uci con covid-19. amci ® enfermedad está asociado tanto a la carga viral como a la respuesta hiperinflamatoria del huésped a la infección viral. en cuanto a la carga viral, en pacientes que tienen un curso leve de infección, el pico de la carga viral en muestras nasales y orofaríngeas ocurre durante los primeros 5-6 días tras el inicio de síntomas y prácticamente desaparece al día 10, mientras que en los que cursan con neumonía severa en uci, la carga viral es 60 veces mayor y puede persistir la excreción viral hasta el día 21 a 28 (161) . por esta razón, consideramos que en los pacientes en uci no es necesario confirmar la erradicación del virus o su negativización en muestra respiratorias, orina o heces, para determinar la mejoría clínica, curación o para el egreso del paciente crítico (162) . en el contexto clínico, el pronóstico se ha asociado a la presencia de marcadores bioquímicos elevados, sin embargo, no existe evidencia que el seguimiento con estos marcadores iniciales de inflamación determine el momento exacto de la resolución de la enfermedad. varias organizaciones internacionales como el cdc de usa y el european centre for disease prevention and control (10 mar 2020) (162, 163), national centre for infectious diseases (ncid) singapore (164), world health organization (13 de marzo de 2020)(165), han establecido criterios para resolución clínica y egreso hospitalario de los pacientes. estos criterios incluyen: ausencia de fiebre mayor a 72 horas sin antipiréticos, mejoría de los síntomas respiratorios, ausencia de requerimiento de hospitalización por otras patologías, el resultado de dos (2) rt-pcr para sars-cov-2 negativas, con intervalo de muestra mayor a 24 horas. la utilidad de dichos criterios no ha sido evaluada en pacientes en cuidado intensivo. en uci, huang et al (115) , describieron en 28 pacientes a quienes se dio egreso, la ausencia de fiebre por 10 días, mejoría radiológica y evidencia de erradicación viral, como criterios de alta. sin embargo, consideramos que deben primar los criterios clínicos sobre los paraclínicos, en el momento de definir el egreso de un paciente de cuidado intensivo, teniendo como principal indicador la ausencia de dificultad respiratoria y la mejoría en los índices de oxigenación, con requerimiento de oxígeno suplementario a bajos flujos y concentración (166) . se recomienda la cánula de alto flujo, donde esté disponible, en pacientes con covid-19 a nivel del mar con hipoxemia leve (pao2/fio2<300 y >200 o sao2/fio2<300 y>200). en alturas superiores a los 2000 mts por encima del nivel del mar esta terapia se puede considerar en pacientes que no tengan hipoxemia severa (pafi< 100). amci ® se recomienda en pacientes críticos por covid-19 el uso de la cánula de alto flujo en salas de presión negativa, donde estén disponibles, que garanticen la seguridad del recurso humano. si no se dispone de habitación con presión negativa se puede optar por habitación individual cerrada. se debe contar con todo el equipo de protección personal necesario para el personal sanitario y de apoyo. se recomienda colocar mascarilla quirúrgica por encima de la cánula nasal en el paciente con sospecha o diagnóstico de covid-19 y mantener una distancia mínima de 2 metros con otros pacientes. se recomienda la intubación inmediata en pacientes críticamente enfermos con sospecha o diagnóstico covid-19 con índice de rox ([spo2/fio2] / frecuencia respiratoria) < 3 a las 2 horas de iniciada la oxigenación con cánula de alto flujo teniendo en cuenta que el retraso en la intubación aumenta la mortalidad. se recomienda considerar la cánula de alto flujo en caso de agotamiento de ventiladores mecánicos. la cánula de alto flujo ofrece flujos de hasta 60 litros/minuto, que aportan una fracción inspirada de oxígeno (fio2) constante que reduce el espacio muerto y produce una presión positiva que genera reclutamiento alveolar y puede redistribuir el líquido alveolar (167) (168) (169) . se ha reportado que al generar aerosoles, aumenta el riesgo de contagio para el personal de salud (167, (170) (171) (172) . hasta el punto de que se ha recomendado su uso en salas con presión negativa (167) . recientes publicaciones han establecido que la cánula de alto flujo genera una corta distancia de dispersión de aerosoles con lo cual las medidas de distanciamiento, un adecuado equipo de protección personal y donde estén disponibles, realizarla en salas de presión negativa darían seguridad al uso de la cánula de alto flujo (167, 173) . a pesar de que la experiencia en la actual pandemia ha sido escasa, basada en series de casos, estudios retrospectivos y de metodología limitada, ha resultado ser promisoria en cuanto a la mejoría en la oxigenación y la tolerancia por el paciente (37, 121, 139, 166, 167, (174) (175) (176) (177) (178) . sin embargo, hasta el momento no se ha establecido que la cánula de alto flujo evite la intubación. la caf podría convertirse en un alto riesgo de mortalidad al prolongar la decisión de intubación y al favorecer la lesión pulmonar autoinducida (p-sili) por aumento del esfuerzo inspiratorio. por todo ello es necesario un estricto y estrecho monitoreo del paciente durante una o dos horas para definir si ha habido mejoría o no mientras se realizan estudios que demuestren que evita la intubación y genera desenlaces clínicos importantes como menor estancia en uci, menor estancia hospitalaria y menos días de ventilación mecánica. la terapia de oxígeno de caf podría ser considerada para pacientes atendidos en altitudes mayor a 2000 mts, que no tienen hipoxemia severa (pafi < 100), la respuesta debe evaluar dentro de los 30 a 60 minutos posteriores a su inicio y los pacientes que no mejoran amci ® significativamente y progresa la dificultad respiratoria no deben mantenerse con esta terapia. el monitoreo del paciente con caf para la toma de decisión de éxito o fracaso de esta estrategia y considerar la posibilidad de intubación incluye la evaluación gasométrica, la oximetría de pulso, así como considerar los criterios para intubación: frecuencia respiratoria >30 por minuto, deterioro de conciencia, inestabilidad hemodinámica, pao2/fio2<150 (a nivel del mar), sao2/fio2<150, índice de rox<2,85, spo2<93% (119, 166-169, 175-177, 179,180) . se recomienda crear o ajustar protocolos institucionales de sedoanalgesia basado en objetivos con escalas validadas. se recomienda el uso de analgesia multimodal que incluya analgésicos opioides, no opioides y bloqueos regionales en el paciente crítico por sospecha o diagnóstico de covid-19. se recomienda sedación profunda con agentes como midazolam o propofol para mantener rass entre -4 y -5 en pacientes covid-19 con sdra severo, necesidad de uso de relajantes neuromusculares o posición prona. se puede considerar en planos de sedación superficial agentes como propofol o dexmedetomidina (coadyuvante) para mantener rass entre 0 y -3 en pacientes seleccionados con sospecha o diagnóstico de covid-19 con sdra no severo. en la actualidad no se encuentra evidencia de alta calidad proveniente de ensayos clínicos, sino editoriales, series, reportes de casos y artículos de revisión de expertos (180) (181) (182) . la creación y aplicación de protocolos de sedoanalgesia adaptados a cada institución ha mostrado disminución del tiempo en la uci y menores complicaciones (183, 184) . es importante definir objetivos guiados por escalas, recomendándose sedación profunda o completa en situaciones especiales como ventilación mecánica invasiva por sdra severo, disincronía ventilatoria persistente, posición prona y bloqueo neuromuscular (bnm), como puede observarse en pacientes covid-19 con compromiso pulmonar severo. mientras que se debe procurar sedación ligera, cooperativa o no sedación en pacientes en ventilación mecánica invasiva en pacientes con sdra no severo, ventilación no invasiva y en el retiro de la ventilación (185, 186) . los opioides han sido el pilar de la analgesia en dolor moderado a severo. el fentanilo es actualmente el más usado; el remifentanilo reduce el tiempo en ventilación en pacientes amci ® renales, hepáticos, ancianos y neurológicos; la hidromorfona se prefiere en el retiro de la ventilación y en pacientes extubados; y la metadona ha mostrado disminuir la tolerancia a opioides (187) . se propone el uso de estrategias de analgesia multimodal asociando medicamentos no opioides como el paracetamol, ketamina a dosis analgésicas (<0,5 mg/kg) en dolor somático, lidocaína en dolor visceral, y pregabalina en dolor neuropático (188) . la sedación ligera o cooperativa son mejores con propofol en cuanto a tiempo de despertar y con dexmedetomidina para preservar funciones cognitivas y el impulso respiratorio, con menor desacondicionamiento (189) . en sedación profunda, el propofol ha mostrado más fácil titulación y menos acumulación que el midazolam; sin embargo, su uso se ve limitado hasta 48 horas y a dosis < 3,0 mg/kg/h, ante el riesgo de pris (síndrome relacionado con la infusión de propofol). el midazolam, sin dosis techo ni tiempo límite y de bajo costo, ha sido el más utilizado de los sedantes, disminuyendo su uso por su asociación con delirium y de retraso en los tiempos en ventilación; sin embargo, la pandemia covid-19 ha vuelto a aumentar su uso. la dexmedetomidina ha sido utilizada como adyuvante en sedación profunda, disminuyendo el consumo de sedantes, con menos efectos secundarios (190, 191) . se muestran los medicamentos para sedoanalgesia y relajación neuromuscular que se pueden utilizar en los pacientes con covid-19 en la tabla 13. se recomienda iniciar una estrategia individualizada de ventilación mecánica ajustadas a las condiciones específicas de severidad en el paciente crítico con covid-19. amci ® se recomienda la ventilación protectora en modos controlados por volumen o por presión que garanticen un volumen corriente < 8 cc/kg de peso predicho teniendo como metas una presión meseta < 30 cm h2o y una presión de conducción < 15 cm h2o. se recomienda emplear fracciones inspiradas de oxígeno para lograr metas de saturación de acuerdo con la pao2/fio2 entre 88 y 92% en el paciente con sospecha o diagnóstico de covid-19. en la paciente embarazada entre 92 y 95%. se recomienda en el paciente crítico por covid-19 iniciar con peep individualizado a la severidad del compromiso pulmonar y ajustar el nivel de peep de acuerdo con la tabla de fio2/peep. el estudio arma (192) demostró que la ventilación con bajos volúmenes corrientes (vt) se asocia con reducción de: mortalidad (p=0.007), en días libres de ventilación mecánica (p=0.007) y días libres de falla orgánica (p= 0.006). una revisión sistemática posterior confirmó que el uso de bajos volúmenes se asocia con menor progresión a sdra (193) . un metaanálisis que revisó 159 estudios y 29 meta-análisis en uci confirmó que la ventilación protectora era una de las tres intervenciones que mejora la sobrevida en pacientes con sdra (194) . esto fue confirmado por landoni en un análisis de estudios multicéntricos con impacto en mortalidad en uci (195) . recientes publicaciones han sugerido que en covid-19 puede haber dos fenotipos que se diferencian en la distensibilidad (119, 196) . sin embargo, el mismo estudio arma demostró que "el beneficio de ventilación con vt más bajo fue independiente de la distensibilidad de las vías respiratorias, lo que sugiere que el vt más bajo fue ventajoso independientemente de la distensibilidad pulmonar". más aún, el uso de bajos vt se asoció con una reducción en las concentraciones de interleuquina 6 lo cual explicaría el mayor número de días sin falla orgánica múltiple y sugeriría una reducida respuesta inflamatoria asociada a la ventilación protectora (192) . con el tiempo la evidencia ha demostrado que la ventilación protectora, además de vt y presión meseta bajos, debe incluir presiones de conducción menores de 15 cm h2o (197) (198) (199) . existe suficiente evidencia que demuestra que fio2 y pao altas se asocian con aumento en la morbimortalidad (200) (201) (202) . en sdra el estudio arma y una más reciente publicación demostraron que el tener metas conservadoras de pao2 se asocia con mayor sobrevida (192, 203) . hasta el momento, la literatura en ventilación mecánica ha demostrado que la mejor estrategia para ajustar el nivel de peep en sdra es la tabla de fio2/peep (192, 204) . amci ® se recomienda la ventilación mecánica protectora en sdra por covid-19 independiente del fenotipo de presentación. se recomienda la clasificación de fenotipos en sdra para pacientes con covid-19 para ajustar la toma de decisiones de manera individualizada en ventilación mecánica. el manejo ventilatorio en covid-19 tiene los mismos principios generales de los pacientes con sdra (205) . sin embargo, la identificación de fenotipos podría impactar en la evolución y pronóstico (206) . gattinoni ha postulado el desarrollo de un sdra típico (fenotipo h: con alta elastancia, alto cortocircuito, alto peso pulmonar) o una presentación atípica (fenotipo l: caracterizado por baja elastancia, bajo shunt, bajo peso pulmonar). (207) . pelosi et al sugiere clasificar los pacientes con tres fenotipos similares (208) . con base en tales fenotipos se han propuesto estrategias ventilatorias diferenciales para minimizar el daño inducido por el ventilador (vili) (209): 1. el primer paso, en el fenotipo l, es revertir la hipoxemia aumentando la fio2. 2. en el tipo l, hay varias opciones no invasivas: cánula nasal de flujo alto, presión positiva continua en la vía aérea (cpap) o ventilación no invasiva (niv). se debe evaluar el esfuerzo inspiratorio y, de estar disponible, medir la presión esofágica. la peep alta puede disminuir los cambios de presión pleural y detener el ciclo vicioso que exacerba la lesión pulmonar. sin embargo, la peep alta, en pacientes con distensibilidad normal, puede tener efectos hemodinámicos perjudiciales. en cualquier caso, las opciones no invasivas son cuestionables, ya que pueden asociarse con altas tasas de fracaso y retraso de la intubación. 3. la magnitud de las presiones pleurales inspiratorias puede determinar la transición del tipo l al h. la presión esofágica > 15 cmh2o aumenta el riesgo de vili y, por lo tanto, la intubación debe realizarse lo antes posible. los tipo l, si son hipercápnicos, pueden ser ventilados con volúmenes > 6 ml / kg (hasta 8 ml / kg). la posición prona debe ser usada solo en último caso, ya que las condiciones pulmonares son buenas. la peep debe reducirse a 8-10 cm h2o, dado que la capacidad de reclutamiento es baja y el riesgo de falla hemodinámica aumenta. la intubación puede evitar la transición al fenotipo tipo h. 4. los pacientes tipo h deben ser tratados como sdra grave, incluyendo mayor peep, si es compatible con la hemodinamia, posición en pronación y soporte extracorpóreo. en el fenotipo 3 se deben aplicar las estrategias de ventilación protectora convencional (208, 209) . amci ® se recomienda en paciente con covid-19 considerar hipoxemia refractaria cuando no se obtienen las metas de oxígeno propuestas, a pesar de las maniobras ventilatorias recomendadas y cumple con los siguientes parámetros: pafi < 150, fio2 > 0,6 y peep apropiado, considerando la altitud. se recomienda considerar la utilización de ecmo, en sitios donde esté disponible y con alta experiencia para obtener resultados aceptables, en pacientes con hipoxemia refractaria luego de haber implementado ventilación protectora, relajación neuromuscular y posición prona. se recomienda administrar tromboprofilaxis en todos los pacientes con covid-19 con hipoxemia refractaria que no presenten contraindicaciones. la hipoxemia refractaria no es un concepto estático y absoluto, según la definición de berlín del sdra, se clasifica el sdra en leve, moderado y severo de acuerdo con la relación pao2 y fracción inspirada de oxígeno, con peep mayor de 5 cms de h2o. la hipoxemia severa es aquella que cuenta con una pafi menor de 100 (210) (211) (212) . la hipoxemia refractaria hace referencia a un estado de hipoxemia severa que a pesar de las diferentes estrategias ventilatorias no aumenta la pafi y tiene consecuencias en el estado ácido básico y metabolismo celular permitiendo una anaerobiosis (213, 214) . para definir la hipoxemia refractaria deben coincidir varios escenarios , una pafi menor de 150, una fracción inspirada de oxígeno mayor de 0.6, a pesar de un peep apropiado no se tiene en cuenta en la definición el ph ni la paco2 ni el tiempo transcurrido (122) . algunas de las medidas terapéuticas no ventilatorias que se han empleado en sdra y covid-19 con hipoxemia refractarias son la oxigenación con membrana extracorpórea (ecmo) y la tromboprofilaxis o anticoagulación de rutina. la oxigenación extracorpórea a través de una membrana ha sido una estrategia controvertida en pacientes con hipoxemia refractaria de diferentes orígenes, en la epidemia de la influenza por el virus h1n1 fue usada en pacientes con hipoxemia refractaria teniendo resultados aceptables (215) . en el estudio eolia los resultados no mostraron mejoría en la supervivencia, aunque hay diferentes posiciones y estudios post hoc de este ensayo clínico con beneficios, su uso se limita a casos muy restringidos y en sitios de alta experiencia para obtener resultados aceptables (216) . en sdra por covid-19 el ecmo se ha usado en hipoxemia refractaria entre un 4 a 11.5% en diferentes series con resultados variables (205, 217, 218) . un tipo de pacientes hipoxémicos y con ventilación mecánica han presentado cuadros tromboembólicos pulmonares en estos casos la trombólisis de rescate con activador de plasminógeno tisular rtpa (alteplase) se ha recomendado con resultados alentadores en serie de casos, pero su evidencia es muy débil para ser recomendada(219-223). dada la alta frecuencia de enfermedad tromboembólica reportada en covid-19 se ha reportado la utilidad de la tromboprofilaxis, especialmente en casos de dímero d o índice de sic elevado (156) . amci ® se recomienda monitorizar sistemáticamente la oxigenación con los índices: pao2/fio2 y sao2/fio2, y en donde esté disponible el monitoreo continuo con capnografía. se recomienda monitorizar de forma rutinaria la presión meseta y la presión de conducción como estrategia al pie de la cama para verificar la ventilación protectora. el sdra y covid-19, es una condición dinámica que apenas se está caracterizando, hay varias presentaciones que no cumplen con todos los criterios de berlín (209, 211) . gattinoni ha caracterizado en dos presentaciones el sdra en los pacientes con neumonía por coronavirus sars-cov-2, una con alta compliance, mínima reclutabilidad; la otra con baja compliance, pulmones pesados y reclutabilidad, tal vez esta presentación sea el verdadero sdra (118, 224, 225) . los pacientes que requieren ventilación mecánica por falla ventilatoria en covid-19, son los que mayor mortalidad tienen al parecer por la lesión pulmonar inducida por la intubación tardía y el gran esfuerzo respiratorio con presiones transpulmonares oscilantes y muy negativas (212, 213, 226) . la monitoria de estos pacientes soportados con ventilación mecánica tiene dos objetivos: el primero detectar el deterioro clínico para sugerir estrategias más avanzadas como el ecmo, y el segundo es evitar el daño pulmonar inducido por la ventilación mecánica. se debe tener presente la mayor posibilidad de contagio con el número de manipulaciones en el paciente, por esto nunca olvidar el perfecto uso de los elementos de protección personal y disminuir el número de contacto con el paciente. las metas que se buscan con la ventilación mecánica en el paciente con sdra por covid-19 son mantener una oxigenación adecuada teniendo en cuenta la altura sobre el nivel del mar con pao2 entre 70 y 80 mmh20 y metas de saturaciones reportadas entre 89 y 92% a 90 y 95% , mantener una ventilación adecuada evitando el espacio muerto , disminuir el trabajo respiratorio y protegiendo el pulmón del daño ocasionado por la ventilación mecánica y las repercusiones hemodinámicas (214) .  el confort de los pacientes en ventilación mecánica es la principal señal de un uso adecuado del modo ventilatorio y los parámetros ventilatorios apropiados para la patología y demanda del paciente (214) .  las curvas y bucles son herramientas indispensables para valorar la mecánica respiratoria del paciente soportado con ventilación mecánica, se puede diagnosticar amci ® las asincronías del paciente y el ventilador, el origen, tipo y frecuencia además de la respuesta al manejo. también se evalúa la resistencia de la vía aérea (214) . variables fisiológicas:  es importante valorar la oxigenación del paciente, la literatura actual sugiere el monitoreo de la pafi es el más representativo y sencillo test para valorar la oxigenación y representa el shunt pulmonar, se debe hacer mínimo diariamente, o cuando se haga una intervención en el ventilador o paciente; en sdra por covid-19 la hipoxemia se relaciona directamente con mortalidad, debe mejorar con la ventilación mecánica (214, 227) .  la medición de la paco2 indica la de la ventilación, la hipercapnia tiene relación directa con el espacio muerto en el paciente con sdra, y varios estudios la relacionan con la mortalidad. puede evaluarse directamente en los gases arteriales o relacionarla con el pco2 expirado por medios de la capnografía, gattinoni propone una forma de evaluarla al lado de la cama del paciente relacionando el etco2/paco2, cuando es < de 1 sugiere un shunt elevado y mayor espacio muerto; áreas de pulmón ventiladas y no aireadas. otras tecnologías incluidas en el ventilador moderno como la capnografía volumétrica se está validando para evaluar el espacio muerto, la reclutabilidad y la titulación de peep (214, 228) .  la saturación venosa mixta svo2 , refleja de manera subrogada la función ventricular, no todos los pacientes tienen catéter de arteria pulmonar para su medición por lo que se está reemplazando con el ultrasonido en la cabecera del paciente; recordar que el 30% de los pacientes con sdra cursan con falla ventricular derecha (214) . monitoria de mecánica ventilatoria y protección pulmonar:  para evitar el daño pulmonar debe propender por un volumen corriente bajo (4-8 ml/kg de peso predicho) y presión plateau menor de 30 cms h20, para garantizar la ventilación con protección pulmonar (192, 229) .  driving pressure ( presión cambiante de la vía aérea, presión diferencial o presión de conducción) es la presión plateau (presión pico en ventilación controlada por presión) menos peep, debe ser menor de 15 cm h20, está relacionado con aumento en la mortalidad en pacientes ventilados por que representa una medición indirecta del strain pulmonar porque relaciona el volumen corriente con la compliance del sistema respiratorio y este a su vez se relaciona con el volumen espiratorio pulmonar final (198) .  la medición de la compliance del sistema respiratorio es necesaria y nos clasifica el paciente de acuerdo con su fenotipo para trazar el plan de manejo ventilatorio, cuando la compliance es baja, esto se puede hacer al lado de la cama del paciente con los ventiladores modernos (214, 225) .  la construcción de la curva presión/volumen aún es una herramienta útil para ubicar el área de ventilación segura del paciente, evitando el atelectrauma y la sobredistensión pulmonar(estrés) , el peep se calcula dos puntos por encima del punto de inflexión inferior y el punto de inflexión superior nos indica hasta dónde podemos aumentar el volumen corriente este punto debe estar por debajo de 30 cms h20 para evitar la sobre distensión, con los ventiladores modernos se puede construir esta curva (214, 229) . amci ®  las curvas presión tiempo en pacientes ventilados con modos volumétricos pueden monitorizar la resistencia de la vía aérea, la compliance pulmonar, el trabajo respiratorio, las curvas de flujo puede también indicar si se presenta autopeep, resistencia aumentada de la vía aérea entre otras (214) .  presión transpulmonar, en casos más complicados donde es más difícil obtener la meta de oxigenación a pesar del peep en aumento una opción es el catéter esofágico, para medir la presión transpulmonar en la inspiración y espiración y calcular así el stress pulmonar y evitar las presiones oscilatorias y sobre todo negativas para evitar el daño pulmonar. esta herramienta también ayuda a evaluar el trabajo respiratorio, y el diagnóstico de las asincronías que se presenten en el paciente ventilado (214, 230) . se recomienda no utilizar de forma rutinaria la relajación neuromuscular en el paciente crítico con covid-19 con sdra. se recomienda utilizar la relajación neuromuscular en pacientes en posición supino o prono, que están fuera de parámetros de protección pulmonar (presión de conducción mayor 15 y presión plateau mayor a 30) con pafi menor 150 y cuando ya no es posible limitar el volumen corriente. se debe considerar la utilización de protocolos estandarizados con el fin de disminuir la variabilidad, y según disponibilidad seleccionar el cisatracurio como primera opción, en caso de escasez se pueden utilizar otras opciones teniendo en cuenta su farmacodinamia y farmacocinética. el 13 de marzo de 2020, la organización mundial de la salud emite una serie de orientaciones para el manejo de la infección respiratoria aguda grave (irag) en pacientes con sospecha o diagnóstico de covid-19. en el paciente críticamente enfermo con sdra moderado o grave (pao2/fio2 <150) por covid-19 no está indicado de forma sistemática el bloqueo neuromuscular mediante infusión continua debido a que no se cuenta con evidencia suficiente que sustente mejoría en la supervivencia con respecto a una estrategia de sedación ligera sin bloqueo neuromuscular, se debe considerar su uso cuando se evidencia asincronía paciente-ventilador a pesar de la sedación, hasta el punto de que no se pueda limitar el volumen corriente de forma fiable, hipoxemia o hipercapnia que no mejoran con el tratamiento (231) . recomendación se recomienda no utilizar de forma rutinaria oni en pacientes adultos que presenten sdra e infección por sars-cov-2. fuerte en contra fundamento a la fecha (mayo 18 de 2020) no contamos con estudios sobre el uso de óxido nítrico inhalado (oni) como tratamiento de pacientes con infección covid-19. existe evidencia indirecta sobre el uso de oni en el síndrome de dificultad respiratoria aguda (sars-cov), y la infección por coronavirus en el síndrome respiratorio de oriente medio (mers-cov) (233) . en 2016 cochrane realizó una revisión sistemática que incluyó 14 ensayos de calidad moderada con 1275 pacientes adultos con sdra tratados con óxido nítrico inhalado. los resultados no mostraron ningún efecto estadísticamente significativo sobre la mortalidad (rr 1.04, 95% ci 0.9 -1.19). se mostró mejora transitoria en el índice de oxigenación a las 24 horas (md (diferencia media) -2,31, ic del 95% -2,73 a -1,89) y mejoría en pao2/fio2 a las 24 horas (md 15,91, ic del 95% 8,25 a 23,56). no se identificó diferencia significativa en los días libres de ventilación y finalmente se presentó aumento estadísticamente significativo en la incidencia de insuficiencia renal en pacientes con óxido nítrico inhalado (rr 1,59, ic del 95% 1,17)(234). amci ® en 2014 se realizó un estudio observacional que incluyó 14 pacientes tratados de dos hospitales de beijing con oni como tratamiento para sars (235) . en comparación con ningún tratamiento, oni mejoró la saturación arterial de oxígeno (spo2) de 93% a 99% (p<0.05); se asoció a menor necesidad de oxígeno suplementario (p< 0.05) y menor necesidad y retiro de cpap y bial (p < 0.05). los cambios en radiografía de tórax mejoraron en 5 de los 6 pacientes que recibieron oni. sin embargo, debido a problemas graves de validez por pequeño tamaño de la muestra (n= 16, oni=6, control=8), no aleatorización y no enmascaramiento en la asignación, se considera que este estudio cuenta con baja calidad metodológica, lo cual limita la interpretación de los resultados. en un estudio retrospectivo multicéntrico que incluyó 330 pacientes con mers-cov en condición crítica en arabia saudita, se mostró que el manejo con ventilación no invasiva (niv) tenía mayor probabilidad de requerir óxido nítrico en comparación con los pacientes con ventilación mecánica invasiva (20,0% vs 11,7%, p a 0,05) (236) . en una serie de casos en la que participaron 12 pacientes con infección por mers-cov confirmada o probable, 6 pacientes recibieron oni debido a hipoxemia refractaria. en el seguimiento a 90 días, cinco de los pacientes continuaron vivos (237) . los estudios sobre mers-cov se limitaron a una serie de casos y una cohorte retrospectiva con baja calidad de evidencia. en ambos estudios, los pacientes recibieron otras terapias de rescate (relajación neuromuscular, ventilación oscilatoria de alta frecuencia, ecmo y posición en prono), por lo tanto, se desconoce el efecto terapéutico clínico del oni en el tratamiento de la infección por mers-cov. a la fecha (18 de mayo de 2020) tres ensayos clínicos evalúan el papel del óxido nítrico inhalado en pacientes con covid-19 y sdra leve/moderado, y como profilaxis para los trabajadores de la salud covid-19(tabla 14). tabla 13. comparación de ensayos clínicos que evalúan el papel del óxido nítrico inhalado en pacientes con covid-19 y sdra leve/moderado, y como profilaxis para los trabajadores de la salud covid-19. no se cuenta con evidencia por el momento que respalde el uso de óxido nítrico inhalado en pacientes con covid-19. los resultados de los ensayos en curso, así como ensayos clínicos de alta calidad son necesarios para apoyar su uso. sólo evidencia indirecta metodológicamente limitada de óxido nítrico en pacientes con sras mostró una mejor oxigenación, una menor necesidad de oxígeno suplementario y mejoría en la radiografía de tórax. en pacientes con sdra y mers-cov, no mostró un beneficio claro e incluso mostró un mayor riesgo de insuficiencia renal (238) . otros estudios han evaluado el efecto tóxico asociado a su uso documentando metahemoglobinemia(239), inhibición de la agregación plaquetaria y formación de dióxido de nitrógeno (240) . razones por la cuales guías recientemente publicada no recomienda su uso de forma rutinaria(205). recomendación se recomienda el uso temprano de la ventilación en posición prona, por al menos 16 horas continuas, en pacientes con sdra por covid-19 con pao2/fio2<150 mmhg. la ventilación en posición prono como estrategia ventilatoria propuesta desde los años 70 (241), cuenta con evidencia que demuestra resultados positivos en cuanto a mejoría de mortalidad, mejoría en el trastorno de oxigenación y el reclutamiento alveolar en pacientes con sdra. los mecanismos por los cuales la posición prona conduce a la mejoría en el trastorno de oxigenación y del reclutamiento alveolar en los pacientes con sdra, incluyen (242) (243) (244) (245) : amci ®  mejoría de la relación ventilación/perfusión y mayor homogeneidad en la distribución de aire en los pulmones.  aumento del volumen de fin de espiración.  disminución del efecto compresivo del corazón en los pulmones.  mejoría del drenaje de las secreciones.  optimización del reclutamiento alveolar, con mejoría de la distribución del volumen corriente, a su vez, limita el desarrollo del daño alveolar pulmonar. los estudios coinciden en el efecto benéfico que esta terapia tiene en la mejoría de la oxigenación, el objetivo se centrará en evaluar las recomendaciones con respecto a:  beneficio de la terapia con respecto a la mortalidad al día 28, al día 90 y a los 6 meses.  beneficio de la terapia según el grado de severidad de sdra con respecto la relación pao2/fio2.  tiempo de terapia en posición prono con mayor beneficio.  número de sesiones de la terapia en posición prono.  recomendaciones según balance riesgo/beneficio en lo que respecta a los efectos adversos: retiro o desplazamiento no planeado de catéteres, obstrucción de tubo endotraqueal, neumonía asociada a ventilador, lesiones de presión. se eligieron 8 artículos que con las características metodológicas consistentes (246) (247) (248) (249) (250) (251) (252) (253) . de estos ocho artículos se excluyó uno por corresponder a pacientes pediátricos (253) . al evaluar los escritos de forma cronológica, se puede apreciar en los primeros artículos (246, 247) , la dificultad para lograr enrolar (reclutar) el suficiente número de pacientes, de tal manera que algunos estudios fueron detenidos de forma prematura (246, 247, 251, 252) . era entonces esperable que los resultados no fueran concluyentes, y que no lograran ser robustos, al no alcanzar el tamaño de muestra deseado, comprometiéndose la confiabilidad, el poder y corriendo el riesgo de obtener resultados falsamente negativos. sin embargo, se podía percibir en los diferentes estudios, una notoria mejoría en la oxigenación, sin repercusión en la mortalidad (246) (247) (248) (249) (250) (251) . por otro lado, es necesario tener en cuenta que los estudios iniciales (246) (247) (248) (249) no se realizaron con el uso de ventilación protectora asociada a la pronación. esto es un elemento pertinente, pues la ventilación protectora puede per se, brindar un efecto adicional en la mejoría de la oxigenación. otro efecto importante que debe analizarse es el bloqueo neuromuscular, cuya evidencia hoy sugiere su uso en criterios ya mencionados (254) . con el tiempo y según la experiencia de cada centro, se fue utilizando con menor dificultad (255) . sin embargo, no se tenía aún claro qué tipo de pacientes obtenían el mayor beneficio de la terapia, además que el tiempo de la terapia en posición prona, seguía siendo una incógnita. la evidencia reflejaba hasta el momento que los pacientes con sdra más severos y la terapia aplicada por más tiempo se asociaban con una tendencia a la reducción en mortalidad. para dirimir qué tipo de pacientes se beneficiarían más de la terapia, se tomó como base, la severidad del sdra según la relación pao2/fio2 (210) . a pesar de que los estudios iniciales(246-250) enfrentaban el reducido tamaño de muestra, algunos análisis identifican beneficio de la mortalidad (246) en pacientes con sdra más severo, constituyendo un probable umbral de beneficio cercano y por debajo de 140-150 mmhg (256) . amci ® antes del estudio proseva (252) en totalidad 2 estudios reportan mortalidad al día 28 (247, 251) , un estudio mortalidad al día 30 (246) , uno estudio mortalidad al día 60 (250)y uno mortalidad al día 90 (248) . sin embargo, al tomar todos los estudios, aún no se alcanzaba suficiente significancia estadística para reducir la mortalidad a los 28 días y 6 meses. con el estudio proseva -guerin et als -en el año 2013 (252) , se alcanza más poder estadístico, demostrando un beneficio importante en pacientes con pao2/fio2 menor de 150 mmhg, ventilados con bloqueo neuromuscular y ventilación protectora en su totalidad, y logrando una reducción de la mortalidad al día 28 y mantenida hasta el día 90 con respecto al grupo control (16.0% (38 de 237 participantes) versus 32.8% (75 de 229) (p<0.001). de tal manera que, según la evidencia disponible, en lo que al trastorno de oxigenación se refiere (según la relación pao2/fio2), sugiere que el mejor candidato para esta estrategia ventilatoria es el paciente con sdra severo con una pao2/fio2 menor de 150 mmhg. es de primordial importancia detenerse a considerar por otra parte, el número de horas que se implementaría la terapia. el estudio inicial realizado por gattinoni et al. (246) , llevó a los pacientes a un período corto de 6 horas, sin encontrar resultados positivos en mortalidad. (resultados que no se pueden solamente atribuir a la calidad del estudio, sino también, al reducido número de horas de la ventilación en posición prono). mancebo et als (la abreviación latina para "otros "es et al.), y fernández et al. (249, 250) por su parte, optan por ventilar un mayor número de horas (18-20 horas) obteniendo resultados (que sugieren una reducción en mortalidad) con tendencia a disminuir mortalidad. si bien diferentes metaanálisis sugieren no (la ausencia de beneficio) beneficio de la ventilación en prono (256, 257) , los resultados son diferentes cuando se aborda la terapia con períodos mayores a 12 horas (256) . teniendo en cuenta, que el estudio con más poder estadístico (252) postula 16 horas de terapia en posición prono, la recomendación es la pronación por un tiempo mayor a 16 horas, contemplando hasta las 20 horas por sesión. otra pregunta que surge con frecuencia es el número de veces que se puede implementar la terapia. existen diferentes estudios en los cuales se indica el número de veces en promedio en que se llevó el paciente a posición prono (247, 248) , otro protocolo en donde se estipula un número límite de días en los que se llevó a cabo la terapia(249), y otro estudios en los cuales no se precisó el número de sesiones de la terapia (246, 250) . se podría entonces recomendar con respecto a la mayor evidencia disponible (252) , pronar a los pacientes en varias sesiones (4 en promedio) (depende de los criterios para continuar o suspender el prono que deben ser individualizados para cada paciente, en cada zona geográfica y en cada unidad de cuidados intensivos, es difícil saber si 4 es el promedio para todos), y considerarla más veces si es necesario. en lo que respecta a los efectos adversos, tres estudios reportaron barotrauma y neumonía asociada a ventilador (247, 249, 250) ; dos estudios desplazamiento de catéter central (246, 251) y siete estudios reportaron extubación (246) (247) (248) (249) (250) (251) (252) . sin embargo, los efectos adversos no alcanzaron significancia estadística para proscribir la terapia (256) . recientemente fue publicado el consenso colombiano de sdra(204) en el cual se hace referencia a las recomendaciones para realización de ventilación prono. se presenta la lista de chequeo, y medidas que deben ser realizadas en la maniobra para lo cual se cuenta con la participación de terapia respiratoria, enfermería y médico. se recomienda implementar un protocolo de retiro de ventilación mecánica basado en la prueba de respiración espontánea y articulado con un protocolo de sedación y analgesia en el paciente críticamente enfermo por sospecha o diagnóstico de covid-19. desde diciembre de 2019, un número de casos de neumonía por síndrome respiratorio agudo severo sars-cov2/covid-19 en wuhan china se identificaron, como causa de insuficiencia respiratoria aguda(258). el síndrome de dificultad respiratoria aguda (sdra) ocurre en el 20% de los 138 pacientes hospitalizados y en el 61% de los 36 pacientes admitidos a la unidad de cuidados intensivos (uci) en wuhan (174) . mientras la ventilación mecánica es una intervención que potencialmente salva la vida, esta puede llevar a múltiples complicaciones y contribuir a la lesión pulmonar (259) . es por todo esto que el retraso en el retiro de la ventilación mecánica puede aumentar el riesgo de amci ® infecciones, aumenta la sedación innecesaria, el trauma de la vía aérea y aumento en el costo de la atención de estos pacientes (260) . el retiro de la ventilación mecánica es un proceso de tres pasos, el primero es conocido como preparación la cual depende de variables fisiológicas, criterios clínicos y predictores de weaning (destete), el segundo paso es el propio weaning, el cual consiste en la disminución del soporte ventilatorio entregado al paciente, con el objetivo de llevar al último paso que es la extubación(261), ilustración 7. por todo lo anterior, se recomienda realizar un proceso de retiro de ventilación mecánica invasiva adoptando un protocolo, seleccionando adecuadamente a los pacientes, ya que evidencia sugiere que la adecuada selección de los pacientes disminuye los días de ventilación mecánica, disminuye la estancia hospitalaria y la estancia en uci (262) . se recomienda realizar el retiro de la ventilación mecánica siguiendo los pasos antes mencionados, iniciando con la preparación, la cual consiste en: preparación 1. asegurarse que la lesión pulmonar que llevó a la falla respiratoria esté resuelta. 2. adecuado intercambio de gas, definido como adecuados índices de oxigenación con peep (presión positiva al final de la expiración) 5 a 8 cmh2o, y fio2 (fracción inspirada de oxígeno) < 0.5. al igual que el proceso de intubación, es un proceso que genera aerosoles por lo cual se recomienda la aplicación de lidocaína dosis de 0,5 a 1,5 mg por kilogramo de peso, 1 a 5 minutos antes la extubación con el objetivo de disminuir el reflejo de tos (266) y la exposición del personal de salud. se recomienda en el paciente con sospecha o diagnóstico de covid-19 a quien se considera realizar vmni, utilizarla en salas de presión negativa, donde estén disponibles, que garanticen la seguridad del recurso humano, con todo el equipo de protección personal necesario. se recomienda considerar la vmni en pacientes con covid-19 con hipoxemia leve (pao2/fio2<300 y >200 o sao2/fio2<300 y>200) en salas de presión negativas, donde estén disponibles que garanticen la seguridad del recurso humano, con todo el equipo de protección personal necesario. fuerte a favor se recomienda considerar la vmni en pacientes con covid-19 con hipoxemia leve (pao2/fio2<300 y >200 o sao2/fio2<300 y>200) y con historia de epoc o cuadro de edema pulmonar agudo asociado en salas de presión negativas, donde estén disponibles que garanticen la seguridad del recurso humano, con todo el equipo de protección personal necesario. se recomienda colocar doble filtro en el circuito del ventilador para reducir el riesgo de generación de aerosoles en vmni del paciente crítico con sospecha o diagnóstico de covid-19. se recomienda la intubación inmediata en pacientes críticamente enfermos por covid-19 si se evidencia respiración toraco-abdominal, uso de músculos accesorios, frecuencia respiratoria > 30, hipoxemia (pao2/fio2<200 o sao2/fio2 <200), fracaso ventilatorio (ph<7.35 con paco2>45 mmhg), hacor>5. existe suficiente evidencia que demuestra que la vmni es una estrategia que reduce la mortalidad en pacientes críticos (195, 267, 268) . además, reduce la necesidad de intubación. los números de casos necesarios a tratar (nnt) son: ocho para salvar una vida y 5 para evitar una intubación (268) . estos desenlaces son fundamentalmente en pacientes con epoc y edema pulmonar agudo (268) (269) (270) ; también hay evidencia a favor, aunque menos fuerte, en pacientes inmunosuprimidos (259, 271) . se ha planteado mayores tasas de éxito con interfaces faciales totales o con helmet (195, (267) (268) (269) (270) (271) . por el contrario, en falla respiratoria hipoxémica hay evidencia en contra del uso de vmni (272) . la experiencia previa con h1n1, sars y mers no apoya el uso de la vmni en falla respiratoria hipoxémica de origen viral (273) (274) (275) (276) (277) (278) . además, se ha cuestionado el uso de vmni en covid-19 por el riesgo de contagio al generar aerosoles (279) . recientemente se demostró que la distancia de dispersión de aerosoles era menor de un metro (280) . por otro lado, el fracaso de la vmni se ha asociado con alta morbimortalidad (281) (282) (283) . ello obliga a evaluar estrictamente la posibilidad de éxito o fracaso. así, en falla respiratoria amci ® hipoxémica la escala hacor ha sido validada para este fin y un puntaje>5 contraindicaría la vmni (284) . adicionalmente si se emplea la vmni el prolongar la decisión de intubación puede aumentar la mortalidad y es por ello necesario monitorizar estrictamente al paciente y evaluarlo para establecer, ojalá antes de dos horas, si el paciente responde a la vmni (167, 285, 286) . las indicaciones para intubación en este caso son respiración toracoabdominal, uso de músculos accesorios, frecuencia respiratoria mayor de 30, hipoxemia (pao2/fio2<200 o sao2/fio2 <200), fracaso ventilatorio (ph<7.35 con paco2>45 mmhg), hacor>5 o índice de rox (spo2/fio2)/frecuencia respiratoria) < 3 (119, 167, 179, 180, 285, 286) . recomendación se sugiere el uso de posición prono en pacientes no ventilados críticamente enfermos por covid-19 que no responden a la oxigenoterapia convencional de acuerdo con los protocolos institucionales, las condiciones de cada servicio y la tolerancia individual de cada paciente. débil a favor fundamento los pacientes con enfermedad por coronavirus 2019 (covid-19) están en riesgo de desarrollar un síndrome de dificultad respiratoria aguda (sdra) (287) . en pacientes intubados con síndrome de dificultad respiratoria aguda grave, la posición prona (pp) temprana y prolongada (al menos 16 horas diarias) mejora la oxigenación y disminuye la mortalidad (252, 288) .debido a que las unidades de cuidados intensivos (uci) están sobrecargadas con pacientes con covid-19, la pp en paciente despierto con respiración espontánea puede ser útil para mejorar la oxigenación y prevenir las transferencias hacia uci. un estudio describió la viabilidad del uso de la ventilación no invasiva y la cánula de alto flujo asociado a la pp estableciendo su tolerancia y su seguridad en pacientes con sdra moderado y severo(289); la pronación puede reclutar todas las regiones pulmonares y favorecer el drenaje de secreciones de la vía respiratoria, mejorando el intercambio gaseoso y la supervivencia en el síndrome de dificultad respiratoria (sdra) (252) . en una comunicación corta proveniente de italia en el cual se incluyeron 15 pacientes que son sometidos al pp asociada con el uso de ventilación no invasiva, se concluye que proporcionar niv en la posición prona a los pacientes con covid-19 y sdra en salas generales en un hospital en italia era factible. la frecuencia respiratoria disminuyó durante su implementación y la oxigenación mejoró durante una pronación posterior a su línea de base. si la intubación se evitó o se retrasó, queda por determinar (290) . en otro reporte de caso, publicado recientemente por un grupo francés(291) de pacientes con covid-19 e insuficiencia respiratoria hipoxémica manejados fuera de la uci, el 63% amci ® fue capaz de tolerar pp durante más de 3 horas. sin embargo, la oxigenación aumentó durante el pp solo un 25% y no se mantuvo en la mitad de los pacientes después del regreso a la posición supina. estos resultados son consistentes con los hallazgos de pequeños estudios previos de pp en pacientes no intubados (289) . un ensayo clínico controlado que evalúe el uso del pp en pacientes no intubados puede ser un mecanismo para seleccionar pacientes que bien puedan beneficiarse de esta estrategia terapéutica. dada la evidencia débil que soporta el uso del pp en pacientes no intubados en términos de la disminución de la necesidad de entubación o ingreso a cuidados intensivos y la duda razonable de aumentar desenlaces deletéreos en aquellos pacientes en los cuales se retarde el tiempo de intubación, no se emite recomendación, a favor o en contra, del empleo de esta estrategia de manera rutinaria. en situaciones en las cuales hay limitación de recursos y de disponibilidad de camas en cuidados intensivos el uso de la pp asociada a vni o cánula de alto flujo podría ser una estrategia útil para mejorar la oxigenación en pacientes infectados con covid-19 e hipoxemia. se recomienda considerar la elevación de biomarcadores como la troponina i o t y el nt-pro-bnp en el paciente con covid-19 como indicadores de injuria miocárdica aguda, sin embargo, no reemplazan la ecocardiografía en el enfoque del paciente con sospecha de disfunción miocárdica. fuerte a favor fundamento la injuria miocárdica aguda asociada a covid-19 se reporta con frecuencia teniendo en cuenta los cambios en biomarcadores como la troponina y cambios electrocardiográficos, pero su impacto en la función cardíaca se desconoce y mucho menos su correlación con los cambios ecocardiográficos. los pacientes con covid-19 pueden desarrollar una serie de complicaciones cardiacas desde injuria miocárdica, arritmias, infarto, hasta miocarditis fulminante con falla cardiaca aguda y shock cardiogénico (292) . la troponina i, se ha encontrado más elevada en pacientes con curso fatal por covid-19 (37) . los niveles de nt-pro-bnp han sido reportados con elevación severa en pacientes con miocarditis y disfunción sistólica, con una disminución progresiva en relación a la mejoría de los pacientes, pero no parece tener un correlación significativa con el cambio de la fracción de eyección (fevi) (293) . la evidencia clínica sugiere que la elevación de los biomarcadores es más relacionada al compromiso sistémico que el daño miocárdico directo, q. deng y colaboradores en un análisis retrospectivo de 112 pacientes, reportaron niveles iniciales de troponinas normales casi en la mayoría, en el 37,5% de los casos los niveles incrementaron significativamente, principalmente en los que fallecieron y solo 6 pacientes tenían fevi menor al 50% y ninguno inferior al 40%, lo cual no sugiere una asociación entre las dos amci ® pruebas (294) . en una publicación donde se compara el fenotipo de 18 pacientes con covid-19 con un histórico de 23 pacientes con sdra por influenza (295) , se encontró que los primeros tenían mayor elevación de troponinas 73% vs 53%, pero en los parámetros ecocardiográficos contrario a lo que se esperaría los índices de rendimiento ventricular fueron mayores para el grupo de covid-19: índice cardiaco 3.1 vs 2.5 l/m/m 2 ; fevi 52 vs 44%; tapse 25 vs 18mm, nuevamente aunque no fue uno de los objetivos del estudio, parece no encontrarse correlación entre los biomarcadores que sugieren injuria miocárdica y los parámetros ecocardiográficos, el cual constituye uno de los pilares de la exploración cardiaca. se recomienda considerar como marcadores iniciales de mal pronóstico en el paciente crítico con covid-19 con sospecha de disfunción miocárdica aguda la elevación persistente de troponina i, mioglobina o creatin kinasa; independiente de la fracción de eyección del ventrículo izquierdo evaluada mediante ecocardiografía. fundamento los pacientes con covid-19 admitidos a la unidad de cuidados intensivos presentan con frecuencia disfunción cardiaca primaria, que puede corresponder a cardiomiopatía por estrés o miocarditis viral, pero también pueden ser consecuencia del compromiso sistémico (294, 296) . aunque parece que en los fenotipos cardiovasculares estudiados, el compromiso hemodinámico severo de la función sistólica izquierda y derecha es menor (295) . en el estudio de deng y colaboradores con 112 pacientes con covid-19, la fiebre, la disnea, hipoxemia, la obesidad y niveles elevados de cpk, troponina y nt-pro-bnp se relacionaron significativamente con mayor severidad (294) . en el subgrupo de pacientes con miocarditis frente a controles, el perfil clínico se describe con mayor edad, niveles de temperatura más elevados (38.8 ± 0.8 vs 38.2 ± 1.0; p:0.03), mayor proporción de disnea (92,8 vs 51%), y de dolor torácico (92,8 vs 61,2%). en los 14 pacientes fallecidos el 100% tuvieron picos de elevación de troponina i y de nt-pro-bnp dentro la semana que precedió la muerte, el 78% presentaron alteraciones electrocardiográficas y solo el 28% presentaron fracción de eyección menor o igual al 45% (294) . shi y colaboradores, enrolaron 671 pacientes para describir el significado clínico del compromiso miocardio de pacientes con covid-19 en wuhan, 62 pacientes fallecieron, de los cuales el 75% presentaron injuria miocárdica aguda (297) . el área bajo la curva (auc) de la troponina i inicial para predecir muerte intrahospitalaria fue de 0,92 (ic 95%, de 0,87-0,96) con una sensibilidad y especificidad del 86%, el auc para mioglobina fue de 0.88 y para cpk-mb fue de 0,87(297). un punto de corte para el pico más alto de troponina i de 4.5, tuvo un hazard ratio para mortalidad de 1.25 (ic 95%, 1.07-1.46; p= 0.004). en un análisis multivariado la edad avanzada, la respuesta inflamatoria y las enfermedades cardiovasculares subyacentes se asociaron con mayor riesgo de lesión miocárdica en pacientes con covid-19. con la información disponible parece que los biomarcadores de lesión miocárdica aguda elevados amci ® al ingreso y de forma persistente pueden predecir el riesgo de mortalidad intrahospitalaria en los pacientes con sospecha o diagnóstico de covid-19 con afectación cardiovascular. se recomienda no realizar de forma rutinaria ecocardiografía en pacientes críticos con covid-19. se debe practicar ecocardiografía en pacientes con sospecha o diagnóstico de covid-19 si presenta alguna de las siguientes condiciones: 1. síntomas y signos de insuficiencia cardíaca aguda de novo. 2. shock o deterioro súbito hemodinámico refractario a líquidos y/o vasoactivos con sospecha de origen cardiogénico. 3. sospecha de infarto agudo de miocardio o embolismo pulmonar para determinar intervenciones terapéuticas con un beneficio clínico. 4. cambios en el electrocardiograma, arritmias ventriculares o paro cardiorrespiratorio no explicados por otra causa. para nuestro conocimiento, en el momento no existe estudios clínicos que evalúen los criterios para realización de ecocardiograma en el paciente con covid-19. las sociedades de ecocardiografía han recomendado realizar el ecocardiograma en el contexto clínico en el cual, la información obtenida proporcione un cambio en la conducta o se espere un beneficio clínico al realizar este procedimiento (298) (299) (300) (301) . igualmente, se recomienda realizar el examen a la cabecera del paciente y el escaneo debe ser dirigido a contestar preguntas específicas según el contexto clínico del paciente (298) (299) (300) (301) (302) . ward et al, en su publicación describe cómo el uso del ecocardiograma limitado (dirigido) en la university of chicago medicine (ucm), aumentó significativamente durante la pandemia (15% frente a 34%, p <0.001), posterior a la implementación de recomendaciones sobre el uso apropiado de la ecocardiografía en tiempos de pandemia (303) . los pacientes con infección por sars -cov-2 pueden presentarse con comorbilidades cardiovasculares que potencialmente estén descompensadas y/o compromiso cardiovascular por covid-19. en este último, podemos encontrar alguno de los siguientes fenotipos: falla cardiaca aguda en el marco de compromiso directo viral o secundario al estrés metabólico y liberación de citoquinas, síndrome coronario agudo, cor-pulmonar secundario a tep o por compromiso secundario al sdra (299, 300, 304, 305) . las manifestaciones cardiovascular puede sospecharse en el marco de choque que no esté explicado por causas extracardiacas evidentes que no responde a líquidos, dolor torácico con clínica de síndrome coronario agudo, cambios electrocardiográficos y elevación de biomarcadores de lesión miocárdica, signos de falla cardiaca descompensada, deterioro súbito de la oxigenación, arritmias o paro cardiorrespiratorio (301, 304, 305) . ante estas manifestaciones, el ecocardiograma podría ser útil para entender el origen de la descompensación aguda, al estar enfocado a amci ® responder preguntas acerca de la función ventricular global y segmentaria (en el abordaje de síndrome coronario agudo), compromiso del ventrículo derecho, alteraciones valvulares, derrame pericárdico, si existe una contribución cardiovascular al compromiso pulmonar, si en el marco del choque existe evidencia de componente cardiogénico y cómo podría guiarse/optimizarse el soporte hemodinámico de estos pacientes(300-304). se sugiere en pacientes críticamente enfermos con covid-19 que cursan con shock y sdom, ajustar la monitoria a las condiciones clínicas del paciente y recursos disponibles. se puede considerar el cap para el monitoreo del gasto cardiaco, la valoración de la perfusión y orientar los elementos hemodinámicos del tipo de shock, el cap de gasto cardiaco continuo puede disminuir la exposición del personal de salud frente al catéter de medición convencional. se sugiere la utilización de la tdtp dependiendo de la disponibilidad del recurso para orientar el diagnóstico diferencial del sdra versus edema pulmonar cardiogénico en los pacientes con covid-19. fundamento los pacientes con infección severa por sars-cov-2, cursan con alto riesgo de falla renal y cardiovascular, con necesidad de un manejo restrictivo de líquidos, lo que justifica la monitoria estricta en uci (306, 307) . el catéter venoso central es útil para la monitoria inicial de estos pacientes, sin embargo, su predicción a respuesta a volumen está limitada (306) (307) (308) . la monitoría no invasiva tiene limitaciones en casos severos de inestabilidad hemodinámica, ventilación espontánea y en presencia de peep alto, lo que limita su uso para el cálculo de gasto cardiaco y la predicción de respuesta a líquidos (308, 309) . la monitoria con cap puede ser considerada en pacientes con covid-19 que cursan con choque y doms, con el objetivo de realizar un diagnóstico definitivo de los componentes del choque, valorar la hipoperfusión, la función cardiaca y el estado de volemia (307, 308) . igualmente, los pacientes con sospecha tep o compromiso del ventrículo derecho pueden beneficiarse de esta monitoria(308). richard et al, en su estudio determinaron los desenlaces asociados al uso de cap vs cvc en pacientes con shock, sdra, o ambos, sin evidenciar diferencias en mortalidad (49.9% vs 51.3% p =.70) o estancia hospitalaria. el uso de cap no garantiza la mejoría de desenlaces en pacientes con covid-19, sin embargo, la presencia de una monitoria continua ayudaría a optimizar los recursos y disminuiría la interacción con el paciente, con menor exposición del equipo médico (310) . la monitoria por tdtp puede utilizarse en pacientes con covid-19 que cursan con choque, buscando optimizar el manejo hídrico, valorar el agua extravascular pulmonar (evlw) y el índice de permeabilidad vascular pulmonar (pvpi) con el fin de establecer el diagnóstico amci ® definitivo del edema pulmonar: sdra vs cardiogénico (311) (312) (313) . hu et al, en su estudio evaluaron los desenlaces del uso de evlw y la presión de cuña de la arteria pulmonar (pawp) como estrategias para el manejo de líquidos en pacientes sdra, no encontraron diferencias significativas en las tasas de supervivencia (p = 0,542). no obstante, en el grupo de evlw la duración de la ventilación mecánica y la estancia en la uci fueron significativamente menor (p <0,05), al igual que el balance hídrico (p <0.05), con mejoría significativa en los índices de oxigenación (p = 0.006)(314). no se puede emitir una recomendación a favor o en contra para la utilización de un protocolo de ultrasonido rutinario a la cabecera del paciente (pocus). sin embargo, se podría considerar el uso en pacientes seleccionados, con los adecuados epp y desinfección de los equipos; donde el pocus pueda tener ventajas sobre otras modalidades de monitoria o en pacientes con limitaciones para monitoria invasiva que requieren evaluación del estado hemodinámico o determinación de severidad del compromiso pulmonar. las recomendaciones sobre la utilidad de pocus en pacientes con covid-19 están enfocadas principalmente en la evaluación de la severidad/progresión de la lesión pulmonar, diagnóstico de manifestaciones cardiovasculares, monitoria hemodinámica y en la guía de fluidoterapia (302, (315) (316) (317) . en la valoración del compromiso pulmonar por covid-19, el pocus ofrece una ventaja sobre otras modalidades de monitoreo, debido a la capacidad de enmarcar el compromiso pulmonar en una línea de tiempo según sus hallazgos: desde la aparición de un patrón de "líneas b", consolidaciones subpleurales con evolución a consolidaciones multilobares, irregularidades en el artefacto de la línea pleural y finalmente aparición de patrón de "líneas a" una vez inicie la recuperación, con adecuada correlación tomográfica (318) (319) (320) (321) . en la diferenciación del origen del choque, el pocus ha demostrado superioridad versus el concepto clínico al evaluar: función ventricular (incluyendo ventrículo derecho), vena cava inferior, líquido libre abdominal, lesiones aórticas, compromiso pulmonar y búsqueda de trombosis venosa profunda identificando tep (322, 323) . en cuanto a la monitoria hemodinámica de pacientes con covid-19, adicional a la función y gasto cardíacos, se recomienda variables dinámicas de respuesta a líquidos y ultrasonido pulmonar en el diagnóstico de sobrecarga hídrica (205) . la variabilidad de gasto cardiaco calculado por pocus durante la elevación pasiva de miembros inferiores, identifica los respondedores a líquidos con sensibilidad del 88% y un lr (-): 0.13 [95%ci, 0.07-0.22]) (324) . la variabilidad de la vena cava inferior muestra limitaciones en pacientes con aumento de presiones de cavidades derechas y respiración espontánea (325) . en cuanto a otras modalidades de monitoría no invasiva, es importante conocer las limitaciones en el marco de compromiso hemodinámico severo, ventilación espontánea, alteraciones valvulares aórticas, entre otras (309) . marik (326) . el ultrasonido tiene limitaciones específicas como la necesidad de un operador experimentado y la adecuada calidad de las imágenes. adicionalmente, en los pacientes con covid-19, esta modalidad de monitoreo requiere una mayor interacción con el paciente, mayor uso de epp en comparación con otras modalidades el pac(307). se recomienda perseguir al inicio de la reanimación del paciente críticamente enfermo con covid-19, metas clínicas de fácil medición, como la presión arterial media (entre 60 y 65 mmhg) o el gasto urinario (mayor a 0,5 cc/k/h) y metas de perfusión como el lactato en sangre arterial (menor a 2 mmol), la saturación venosa central de oxígeno (entre 65 y 70%) y la diferencia veno arterial de co2 (menor a 6 mmhg). se han reportado casos de disfunción ventricular como causa de choque asociado a covid-19, sin embargo, no se ha descrito un manejo específico o cambios en las metas de reanimación para estos pacientes, las manifestaciones de hipoperfusión tisular son: alteración de la conciencia, oliguria, piel fría y moteada y pulso débil. a nivel de gases sanguíneos las metas de reanimación pueden ser globales como el lactato (en sangre arterial vn< 2 mmol) y la diferencia veno arterial de co2(pv-aco2 vn < 6 mmhg) o regionales como la saturación venosa central de oxígeno medida en la sangre venosa tomada de un catéter central (vn: 65-70%). se puede optimizar la perfusión, interviniendo los principales determinantes: fluidos para aumentar el volumen intravascular, inotrópicos para aumentar la fuerza de contractilidad, vasopresores para recuperar la presión de perfusión y transfusión de glóbulos rojos para aumentar la hemoglobina como transportador de oxígeno (44) , las recomendaciones dadas en el documento anterior siguen siendo válidas e incluyen entre otras que todo paciente con covid-19 en estado de shock debe ser ingresado de forma inmediata a la unidad de cuidados intensivos, garantizando el aislamiento indicado, procurando recuperar la presión arterial media a valores > 65 mmhg, para ello la utilización de un catéter venoso central en los pacientes que no responden al manejo inicial y el procedimiento debe ser realizado por el médico con mayor entrenamiento, idealmente guiado por ecografía si hay disponibilidad y las competencias, así mismo las estrategia de control estricto de fluidos para no generar efectos deletéreos relacionados a la sobrecarga de volumen, es lo más indicado. se recomienda en la reanimación inicial de pacientes en estado de shock con sospecha o amci ® diagnóstico de covid-19, guiar la fluidoterapia con el uso de índices clínicos como el tiempo de llenado capilar, temperatura de la piel y depuración de lactato; en fases avanzadas donde el monitoreo clínico es insuficiente utilizar medidas dinámicas como la variabilidad de presión de pulso (vpp), la variabilidad de volumen sistólico (vvs), la respuesta a la maniobra de elevación pasiva de piernas o la prueba de oclusión teleespiratoria de acuerdo a los recursos disponibles y la experiencia. fuerte a favor fundamento sobre los objetivos de intervención y el tipo de agente vasoactivo a utilizar en pacientes con covid-19 y shock no existe una evidencia directa y las recomendaciones se basarán en evidencia indirecta de pacientes críticos con diversos tipos de shock en especial el séptico y vasopléjico. la falla circulatoria aguda asociado a sdra en covid-19 se presenta con una frecuencia del 6-30% y en la admisión a urgencias la hipotensión y un lactato ≥2 es infrecuente(38, 327). la baja sensibilidad del qsofa y crb-65 para predecir la severidad del covid-19 y la necesidad de intervenciones de terapia intensiva refleja lo infrecuente del shock en esta condición. factores como la vasoplejia, fuga capilar asociada al estado hiperinflamatorio, altos requerimientos de peep y disfunción cardiaca pueden ser generadores o contribuyentes del shock y deben ser considerados en el abordaje diagnóstico, en su interpretación para lograr tomas de decisiones adecuadas. en pacientes con sdra, una reanimación óptima de líquidos debe tomar en cuenta aspectos como tiempo (oportunidad), tipo (cristaloides balanceados y/o no balanceados o coloides) y volumen (ni mucho, ni poco) con el objetivo de disminuir la mortalidad, el tiempo de vm y de cuidados intensivos, sin que ello afecte los índices de oxigenación, de perfusión tisular y la morbilidad asociada con su uso inadecuado. la administración agresiva de líquidos puede empeorar la oxigenación y la disfunción ventricular, lo que potencializa un mayor tiempo de ventilación mecánica e incluso la mortalidad. la evidencia ha demostrado que una estrategia conservadora de fluidos (balance -136+/amci ® en una revisión sistemática y un metaanálisis de 7 rct (n = 1.301) una terapia dirigida al aclaramiento temprano de lactato frente a una terapia guiada por la saturación venosa central de oxígeno (svo2), se asoció con una reducción significativa de la mortalidad (rr 0,68), menor estadía en la uci (dm 1,64 días), y menor duración de la ventilación mecánica (dm -10,22 horas). pero se debe resaltar que un nivel alto de lactato no siempre indica hipovolemia; también puede ser causada por uso de adrenalina, agonistas beta o por disfunción mitocondrial, insuficiencia hepática e isquemia mesentérica (331) . por otra parte, el llenado capilar (crt), una prueba técnicamente fácil y accesible, realizada cada 30 minutos se asoció con una reducción no significativa de la mortalidad (hr 0,75) en comparación con la medición de lactato sérico cada 2 horas. dado el potencial beneficio sobre mortalidad, duración de estancia en uci y la duración de la ventilación mecánica, así como su accesibilidad, sugerimos utilizar parámetros dinámicos de temperatura de la piel, tiempo de llenado capilar y / o medición de lactato sobre parámetros estáticos para evaluar la capacidad de respuesta a la fluidoterapia en pacientes con covid-19 y shock(332). se recomienda en pacientes adultos con covid-19 y estado de shock, escoger la norepinefrina como el vasopresor de primera línea y a la vasopresina el de segunda. si no se cuenta con norepinefrina el uso de vasopresina o epinefrina serían la primera elección; la dopamina no se recomienda por el mayor riesgo de arritmias. se recomienda iniciar dobutamina frente al aumento de la dosis de norepinefrina en pacientes en estado de shock con evidencia de disfunción cardíaca e hipoperfusión persistente a pesar de la reanimación inicial. fuerte a favor fundamento sobre los objetivos de intervención y el tipo de agente vasoactivo a utilizar en pacientes con covid-19 y shock no existe una evidencia directa y las recomendaciones solo pueden basarse en evidencia indirecta de pacientes críticos con sepsis y sdra. en pacientes en shock séptico los agentes vasoactivos para alcanzar una pam de 60-65 es un objetivo razonable. una presión media más alta puede incrementar 2.5 veces el riesgo de arritmias cardiacas y no está exento de riesgo de isquemia en las extremidades (333) . para aproximarnos a la escogencia de los vasoactivos en shock séptico, basados en su perfil de riesgo/beneficio, la guía scandinavian society of anaesthesiology and intensive care medicine (ssai ) task force for acute circulatory failure(334), la revisión sistemática de cochrane database 2 con 28 rct con un n:3497 (335) y el ensayo clínico controlado de honarmand k et al con un n:3,737 (336) amci ®  la noradrenalina es el agente vasoactivo más ampliamente estudiado con el menor riesgo a priori de efectos no deseados, razón por la cual se sugiere usar como el agente vasoactivo de primera línea en pacientes con covid-19 y shock.  si la noradrenalina no está disponible la vasopresina o epinefrina se muestran como la mejor alternativa. los factores que determinan la elección entre vasopresina y epinefrina pueden incluir disponibilidad y el perfil de seguridad de estos agentes. con la vasopresina, la isquemia digital puede ser una preocupación y con epinefrina, la taquicardia, la isquemia miocárdica y el exceso de producción de lactato.  el uso de dopamina se ha asociado un 2.5 veces mayor de riesgo de aparición de arritmias frente a la norepinefrina y un posible aumento del riesgo de mortalidad. por ello la dopamina no debe utilizarse en pacientes con covid-19 y shock donde haya disponible de norepinefrina o las alternativas señaladas  en shock distributivo la adición de vasopresina a las catecolaminas evidenció baja certeza de reducción de la mortalidad (rr 0,91; ic del 95%: 0,85 a 0,99), alta certeza de una reducción de la fibrilación auricular (rr 0,77; ic del 95%: 0,67 a 0,88) y certeza moderada de un mayor riesgo de isquemia digital (rr 2,56; ic del 95%: 1,24 a 5,25). en vista de estos hallazgos se plantea la vasopresina como un agente vasoactivo de segunda línea a ser utilizado si la pam objetivo no se ha alcanzado con norepinefrina en pacientes con covid-19 y shock. no existe evidencia directa en pacientes con covid-19 y shock, para establecer una recomendación sobre cuál es el agente inotrópico óptimo. en una guía de práctica clínica de 2018 que evalúa el agente inotrópico óptimo en pacientes con insuficiencia circulatoria aguda (shock), no se identificaron rct que comparen dobutamina versus placebo o ningún tratamiento. con base en una justificación fisiopatológica, sugerimos agregar dobutamina, más que no suministrar ningún tratamiento, en pacientes con covid-19 y shock con evidencia de disfunción cardíaca e hipoperfusión persistente a pesar de la reanimación con líquidos y altas dosis de norepinefrina. el uso de dobutamina en estado de shock, incluso en pacientes con covid-19 con shock, debe ser investigado. recomendación se recomienda no suspender la medicación estándar para falla cardiaca en pacientes con sospecha o diagnóstico de covid-19, especialmente los iecas, ara-ii, y b-bloqueadores, si la condición clínica permite continuar el uso de esta medicación, ya que no se ha podido confirmar una asociación nociva. amci ® previos alrededor de la relación independiente de la edad avanzada, enfermedad cardiovascular subyacente (enfermedad coronaria, insuficiencia cardíaca y arritmias), tabaquismo activo y epoc con muerte por covid-19 (337) (338) (339) ; esos mismos reportes sugieren que las mujeres son proporcionalmente más propensas a sobrevivir a la infección por covid-19 que los hombre; existen además consideraciones especiales desde el punto de vista cardiovascular, que se deben tener en cuenta al decidir cualquier terapia en paciente afectados por covid-19 y existe la hipótesis de un efecto nocivo de la terapia estándar para falla cardiaca en estos pacientes (338) . en un estudio observacional que incluye 8910 paciente con infección por covid-19, se evaluó la relación entre la enfermedad cardiovascular subyacente, y la asociación entre la terapia farmacológica cardiovascular y la mortalidad (337); respecto a los factores de riesgo cardiovascular, el 30.5% de los pacientes tenían hiperlipidemia, el 26.3% tenía hipertensión, el 14.3% tenía diabetes mellitus, y en relación a los medicamentos, los sobrevivientes usaron más comúnmente ieca y las estatinas que los no sobrevivientes, mientras que no se encontró asociación entre la supervivencia y el uso de ara ii; respecto a los otros medicamentos incluidos b-bloqueadores, antiplaquetarios e insulina no se encontraron diferencias significativas; sin embargo, y teniendo en cuenta el impacto sobre mortalidad del uso de betabloqueadores en la falla cardiaca, consideremos que la decisión de continuar su uso debe basarse en el análisis clínico de cada paciente y su estabilidad clínica. se recomienda establecer un protocolo de reanimación ajustado al contexto del paciente con covid-19 con una organización administrativa ajustada a la pandemia que incluya las siguientes estrategias:  desarrollar una estrategia de prevención del paro cardiorrespiratorio en el paciente con sospecha o diagnóstico de covid-19 basada en la detección oportuna.  formar un equipo multidisciplinar formado en rcp con líderes médicos, de en enfermería y en terapia respiratoria, los cuales deben educar a todo el equipo de trabajo en la identificación de signos de alerta temprana, cambios abruptos de variables clínicas, técnicas de monitoreo, interpretación de paraclínicos y de alarmas de monitoreo.  entrenamiento del personal sanitario a través del uso de la simulación clínica en manejo de crisis, epp, y procesos de atención fundamentales en la atención del paro cardiaco en el paciente con sospecha o diagnóstico de covid-19  promover la comunicación asertiva, planeación y retroalimentación de las intervenciones realizadas antes y después de un evento de paro cardiaco (briefing y debriefing), con el fin de establecer modificaciones que conllevarán a mejoras en la atención de futuros eventos. amci ® el pronóstico y sobrevida de un paciente con sospecha o diagnóstico de covid-19 que presenta paro cardiaco depende de la prevención a través del reconocimiento oportuno de las causas reversibles de éste, la no presencialidad y un ritmo de paro no desfibrilable lo hacen de mal pronóstico. la prevención va a depender del nivel de entrenamiento del equipo previamente, y en época de pico de pandemia cuando el talento humano especializado disminuya, se hace necesario que en los equipos de trabajo estén liderados por especialistas en la disciplina para que puedan guiar al equipo. los nuevos procesos de atención del paciente, la alta contagiosidad del virus, y el uso de nuevos medicamentos hacen que se requiera un entrenamiento del personal para estandarizar los procesos y disminuir el error médico. la crisis de covid-19 está ejerciendo una presión sin precedentes sobre las personas, los equipos y los sistemas organizacionales, conllevando a errores médicos que van desde la infección cruzada por el personal sanitario con la posibilidad de cometer errores en la atención. cada día trae nuevos desafíos: picos en volumen y gravedad, escasez de equipos y estrés en los médicos sobrecargados, que se manifiesta según la experiencia de wuhan en insomnio y depresión. se propone implementar una estrategia antes, durante y después del trabajo clínico, denominada circle up covid-19 desarrollada por center of medical simulation dirigida a convertir equipos de trabajo muchas veces insustituibles , en eficientes , seguros, fuertes y que se apoyan mutuamente incluyendo en mejora de la salud psicológica . impactando en el rendimiento del equipo , y promoviendo el bienestar y la resiliencia(340-342) se recomienda establecer un protocolo de reanimación ajustado al contexto clínico del paciente con covid-19 que incluya las siguientes modificaciones:  implementar criterios de selección e inicio de maniobras de rcp en la atención del paro cardíaco basados en la bioética y en el pronóstico de supervivencia a corto y largo plazo de los pacientes.  promover la prevención del paro cardiaco mediante la detección oportuna del riesgo y definir intubaciones programadas.  asegurar la correcta protección con los epp necesarios al abordar el paro cardiaco y la intubación que son procedimientos generadores de aerosoles.  priorizar el manejo de la vía aérea antes del inicio de las compresiones torácicas, haciendo énfasis en la reducción de la exposición de aerosoles (código azul protegido).  utilizar filtro de alta eficiencia contra virus para todas las estrategias de ventilación (bolsa mascarilla con cierre hermético y en el circuito del ventilador).  promover la realización de la intubación por el operador de mayor experticia con uso de videolaringoscopio si está disponible y considerar el acceso supraglótico solo si el intento de intubación es fallido. amci ®  en caso de parada cardiaca en ventilación mecánica iniciar el masaje cardiaco evitando las desconexiones del circuito del respirador.  en caso de paro en posición prono si el paciente se encuentra vigil retornar rápidamente a la posición supino y si está en ventilación mecánica es razonable realizar compresiones en la espalda. fuerte a favor fundamento se hace necesario el entrenamiento en el manejo de los procedimientos generadores de aerosoles y se sugiere que el que realiza la intubación orotraqueal debe ser el más experto. el riesgo de aerosolización es de 6.6 en el proceso de intubación orotraqueal, el de compresiones torácicas es de 4,5, ventilación mecánica no invasiva de 3,1, ventilación manual pre-intubación de 2,8, succión después de intubación 1,3. se ha descrito que si no se ha capacitado previamente en el retiro de los epp existe más riesgo de auto contaminación y aumenta ésta sin un líder supervisor al retirarlo. según revisión de cochrane sobre ropa y equipo de protección para los trabajadores sanitarios para evitar que se contagien con el coronavirus y otras enfermedades altamente infecciosas da a conocer que la capacitación presencial, la simulación por ordenador y la capacitación por vídeo dieron lugar a menos errores a la hora de quitarse el epp que la capacitación impartida solo como material escrito o una conferencia tradicional (343) (344) (345) (346) (347) (348) . se recomienda no considerar la existencia de manifestaciones neurológicas específicas o típicas atribuidas a la infección por sars-cov-2. se recomienda realizar la valoración neurológica integral del paciente con diagnóstico o sospecha de sars-cov-2 teniendo en cuenta manifestaciones frecuentes relacionadas a covid-19: disgeusia, anosmia, cefalea, vértigo, confusión, delirium, alteración de estado de consciencia, eventos cerebrovasculares, ataxia, polineuropatías inflamatorias y convulsiones. una revisión sistemática realizada por asadi-pooya et al. entre diciembre y marzo de 2020 mostró que el 25% de los pacientes con covid-19 presentaron sintomatología neurológica. analizaron cinco artículos (n=765) donde 4 eran retrospectivos, y 1 era prospectivo, encontrando cefalea entre el 6 y el 13%, vértigo entre el 9 y el 17%, confusión en el 9%, alteración del estado de consciencia en el 8%, eventos cerebrovasculares en un 3%, ataxia en un 0,5% y convulsiones en un 0,5% (349) . amci ® menor a 1000 participantes donde recolectarán información sobre el compromiso neurológico en pacientes con covid-19 con un seguimiento hasta febrero de 2021 (350) . la hiposmia y la disgeusia de aparición súbita son manifestaciones clínicas muy prevalentes en pacientes con covid-19 evidentes aun en ausencia de sintomatología respiratoria alta. lechien et al publicaron un estudio multicéntrico que incluyeron 12 hospitales europeos reclutando 412 pacientes infectados con covid-19 levemoderado donde 85,6% presentaron alteraciones relacionadas con el olfato y 88,5% presentaron alteraciones relacionadas con el gusto, donde la anosmia se presentaba antes que cualquier otro síntoma en el 11,8% de los casos y el 18,2% de los casos no presentaba rinorrea u obstrucción nasal, la recuperación del olfato fue presente en el 44% de los pacientes y las mujeres fue el grupo poblacional más afectado (p=0,001) (351) . otras manifestaciones clínicas son las alteraciones de la agudeza visual, y dolor tipo neuralgia (352) . respecto a las patologías psiquiátricas; la serie de mao comenta que el 7,5% de los pacientes tiene clínica de alteración del estado de consciencia, concepto que se aproxima a la defunción de delirium. severance et al. encontraron que 106 pacientes con sintomatología psicótica aguda presentaron niveles elevados de inmunoglobulina g para coronavirus del tipo hku1, nl63 y oc43 con diferencias estadísticamente significativas respecto a los individuos controles (n=106) (p<0,001). donde la respuesta inmune para nl63 fue asociado con el espectro-esquizofrenia (or: 3.10, ci 5 1.27-7.58, p= 0.013) pero no se correlaciona con desórdenes afectivos (353) . aún no se ha descrito una correlación directa de este trastorno psicótico con covid-19. los síntomas musculares se han observado en pacientes infectados por covid-19 incluyendo la miopatía del paciente en estado crítico (miopatía difusa no necrotizante con degeneración grasa de fibras musculares), la miopatía necrotizante (ligada a falla orgánica múltiple) y la miopatía de filamentos gruesos(354). se recomienda considerar como predictores clínicos neurológicos de alerta para sospechar covid-19: anosmia, disgeusia, delirium y alteraciones neuromusculares inespecíficas sin otra causa aparente de explicación. se recomienda no establecer de rutina predictores neurológicos específicos de mal pronóstico en el paciente críticamente enfermo con covid-19. se deben tener en cuenta los factores de riesgos generales de mal pronóstico para la población general como la edad avanzada, las comorbilidades cardiovasculares y el tabaquismo. page la proteína spike (s) del covid-19 es reconocida por la enzima convertidora de antígenos 2 (eca2) de la célula huésped cuyo papel es el punto de entrada molecular a tejidos pulmonares, gastrointestinales y neuronales (355) . la forma como el covid-19 ingresa al sistema nervioso central es desconocido, pero se especula que inicialmente invade terminales nerviosas periféricas y después llega al sistema nervioso central a través de una ruta guiada por sinapsis nerviosas con un patrón ascendente (ruta dada por el coronavirus hev67 y el oc-43) (352, 356) . en modelos de roedores el covid-19 ingresaría al cerebro a través del nervio olfatorio, atravesando la lámina cribiforme propagándose por el tálamo y el tallo cerebral; explicándose por la expresión de los receptores de la enzima convertidora de antígenos (eca2) en la superficie de las mucosas nasales, las neuronas y la glía (352, 357, 358) . una segunda forma de ingreso es a través de la vía hematológica mediante arterias cerebrales atravesando la barrera hemato-encefálica utilizando las células inflamatorias como un modelo similar al del caballo de troya (352, 359, 360) logrando una ubicación definitiva en células neuronales y endoteliales del lóbulo frontal como lo demostraron en estudios post-mortem descritos por paniz -mondolfi et al, lo que explicaría los cambios comportamentales de paciente (360) . la tercera forma de acceso al sistema nervioso central es mediante el drenaje del sistema linfático cerebral invadiendo ganglios linfáticos hiliares y mesentéricos con sintomatología gastrointestinal asociada (361) . una vez ha logrado ingresar tiene la capacidad de infectar macrófagos, microglía, y astroglía los cuales secretan factores proinflamatorios como interleuquina 12, interleuquina 15, y factor de necrosis tumoral alfa (362) . esta condición se exacerba con el desencadenamiento de la tormenta de citoquinas liderada por la interleuquina 6, interleuquina 2, interleuquina 7 e interferón gamma (355) . de esta forma los coronavirus siendo neurotrópicos ocasionan múltiples manifestaciones clínicas ya mencionadas, así como encefalitis, parálisis flácida, incluyendo la asociación con guillain-barré (357) . los síntomas que harían sospechar la presencia de neurocovid-19 son la náusea, el vómito y la anorexia, estos síntomas pueden ser el reflejo del compromiso del virus en el área postrema del piso del cuarto ventrículo que hace parte del complejo vagal dorsal de la médula oblonga. sin embargo, estos síntomas pueden enmascararse como una respuesta inespecífica relacionada con un compromiso gastrointestinal (363) . como se mencionó previamente la anosmia y la disgeusia son síntomas significativos para sospechar en covid-19 (358) ; esto es debido a una lesión directa sobre el nervio olfatorio (i par craneal), y la lesión de alguno de los tres nervios encargados de registrar el sentido del gusto como lo son el vii, ix y x pares craneales, así como el compromiso del núcleo solitario y del tálamo como zona de relevo; de hecho el núcleo del tracto solitario es muy cercano al centro respiratorio que podría ocasionar disnea de origen central (361) , otros núcleos como el núcleo dorsal motor del vago y el núcleo ambiguo están relacionados con funciones cardiovasculares a tener en cuenta (364) . respecto a los factores de riesgo destaca el tabaquismo el cual aumenta la posibilidad de neuroinfección debido a interacciones funcionales entre el receptor nicotínico de acetilcolina y el receptor eca2 el cual está sobreexpresado en pacientes fumadores (365) . amci ® en pacientes con infecciones severas vs infecciones no severas (45.5% vs 30.2%, p = 0.02), incluyendo eventos cerebrovasculares (5,7% vs 0,8% p=0,03), alteración del estado de consciencia (14.8% vs 2.4%; p<0.001) y lesiones musculoesqueléticas (19,3% vs 4,8% p< 0001) (366) . la encefalopatía que se manifiesta como una alteración aguda o subaguda del estado de consciencia presentándose en pacientes con comorbilidades, factores de riesgo cardiovasculares, edad avanzada y deterioro cognitivo previo (362, 366, 367) . así como aquellos individuos con hipoxemia la cual induce metabolitos anaerobios en el sistema nervioso central, edema celular, intersticial e isquemia (362) . los eventos cerebrovasculares pueden ser desencadenados por cuadros de hipoxia, inmovilización, un incremento de la respuesta proinflamatoria o por predisposición a la hipercoagulabilidad (359) . respecto a este último rubro tanto la edad (hazard ratio 1,05/por año 95% ic 1,004 -1,01) y la coagulopatía definida como como un tiempo de protrombina mayor a 3 segundos, o tiempo de tromboplastina mayor a 5 segundos (hr 4,1 95% ic 1,9 -9,1) fueron considerados predictores independientes de complicaciones trombóticas (352) ; otros trabajos reportan incremento del conteo plaquetario y niveles elevados de dímero d (352) . de hecho, un scoping review realizado por wilson y jack muestra que la presencia de eventos cerebro vasculares es un factor de riesgo de mal pronóstico para pacientes infectados por covid-19 (368) . mao et al. reportaron 14 eventos cerebro vasculares en 214 pacientes con covid-19, los factores de riesgo más relevantes fueron los clásicos factores de riesgo cardiovasculares (diabetes, hipertensión y edad avanzada), así como una presentación sistémica severa, teniendo como un denominador común el compromiso estructural de grandes vasos (366) . la presencia de convulsiones (clínicas o subclínicas) puede ser una manifestación de eventos cerebro vasculares, meningoencefalitis o hipoxia cerebral. siendo los factores de riesgo más importantes en su exacerbación las alteraciones electrolíticas como hipocalcemia, las reacciones adversas a medicamentos y la epilepsia como comorbilidad de base (359, 368) . otros tipos de coronavirus como lo son el 229e, 293, y oc43 se han aislado de líquido cefalorraquídeo (lcr) de pacientes con esclerosis múltiple sugiriendo posiblemente sean agentes etiológicos en la exacerbación de brotes de esta patología sin embargo aún no se ha documentado la asociación entre covid-19 y ésta condición (356) . otras patologías en las cuales se ha asociado la presencia de esta familia de microorganismos es la enfermedad de parkinson, la esclerosis lateral amiotrofia, la neuritis óptica y la encefalitis aguda diseminada (356, 362) . múltiples trabajos han documentado la asociación entre polineuropatía y coronavirus. la mayoría de ellos consideran que existe una estrecha relación entre una polineuropatía autoinmune exacerbada por la infección por coronavirus o bien un compromiso nervioso periférico inducido por bloqueo neuromuscular, alteraciones hidroelectrolíticas o disvitaminosis(356). amci ® se recomienda que todo paciente con acv isquémico se considere sospechoso de infección por covid-19 si presenta: sintomatología asociada sospechosa de infección por covid-19, contacto cercano con individuos con sintomatología infecciosa, allegados con viajes recientes, si la historia clínica es atípica, si la información suministrada no es clara, si presenta deterioro del estado de alerta inexplicable, y si al examen físico presenta hallazgos compatibles con una infección por covid-19. se recomienda que todo paciente con acv isquémico de quien no se pueda recibir información se considere sospechoso de covid-19 ya que el evento cerebro vascular es una complicación que se ha reportado en pacientes con infección por covid-19. hay una gran evidencia que correlaciona la presencia de infección por covid-19 con factores de riesgo cardiovasculares. esto se demostró en un metaanálisis que incluyó 7 estudios de china (n=1576) donde las comorbilidades más frecuentes fueron hipertensión (21,1%, 95% ic: 13 -27,2%), diabetes (9,7%, 95% ic 7,2 -12,2%), enfermedad cardiovascular (8.4%, 95% ic: 3.8-13.8) y patologías respiratorias (1.5%, 95% ic: 0.9-2.1%). al comparar severidad vs no severidad la presencia de hipertensión tuvo un or de 2.36 (95% ci: 1.46-3.83), y la enfermedad cardiovascular un or de 3.42 (95% ci: 1.88-6.22) respectivamente (369) . existieron pocos casos de hipercoagulabilidad en pacientes sin factores de riesgo cardiovasculares (356) . la cohorte de wuhan (n=138) publicada por wang et al. mostró otros factores de riesgo que podrían eventualmente estar asociados a estado de embolia y trombosis como shock en 8,7%, arritmias 16,7% y miocarditis en un 7,2%. situaciones que conllevarían a hipercoagulabilidad, lesión endotelial y eventualmente la aparición de acv. (174) . en este orden de ideas existe una estrecha correlación entre la presencia de factores de riesgo cardiovasculares que ocasionarían acv y que podrían eventualmente estar relacionados con la patogenia de covid-19. ante esta inquietud khosravani et al. publicaron en stroke un informe especial donde realizan ciertas recomendaciones para el abordaje de los pacientes con acv en el contexto de la pandemia por covid-19 de una forma rápida, eficaz y segura para los diferentes profesionales de la salud. surge así el código stroke protegido el cual consiste en:  usar elementos de protección personal y una mascarilla al paciente  ejecutar protocolo de aislamiento de contacto y gotas  ejecutar protocolo de aerosoles si el paciente está sometido a ventilación mecánica no invasiva, manejo de aspiración de secreciones o maniobras de reanimación cardiopulmonar básica y avanzada  si el paciente presenta deterioro del estado de alerta con necesidad de soporte ventilatorio alto con fracción inspirada de o2 mayor a 50% se recomienda intubar temprano y proceder con el transporte. se debe proceder con el código stroke protegido si el paciente presenta alguna de las siguientes condiciones:  si el paciente presenta sintomatología sospechosa de covid-19 (fiebre, tos, dolor torácico, disnea, cefalea, mialgias, emesis)  si existe algún contacto cercano con sintomatología infecciosa  si el paciente o alguno de sus allegados ha presentado viajes recientes amci ®  si el paciente es covid-19 positivo  si refiere al interrogatorio una historia clínica atípica o poco clara  si el paciente o alguno de sus acudientes es incapaz de suministrar información  si el paciente presenta deterioro del estado de alerta  si al examen físico se encuentran signos compatibles con patologías diferentes a covid19 por último, estas son las recomendaciones en el momento de realizar el traslado a saber:  no apresurarse dentro de la sala de reanimación o dentro de la unidad de cuidados intensivos y mantener la calma  designar un líder para el traslado del paciente y para supervisar el uso adecuado de los elementos de protección personal  limitar el número de personas encargadas del transporte  evitar la contaminación con otras áreas del hospital(370). se recomienda no realizar neuroimagen de rutina en pacientes críticos por covid-19 con cefalea y anosmia, dado que no existe una evidencia concluyente que demuestre una estrecha correlación entre estos síntomas y hallazgos imagenológicos. fuerte en contra fundamento en la mayoría de los casos la cefalea es un síntoma no específico que no es característico de irritación meníngea la ocurrencia de cefaleas aisladas en ausencia de otros síntomas sugiere un mecanismo benigno más que un compromiso de sistema nervioso central (356) . sin embargo, el covid-19 al tener una capacidad neuroinvasiva, se han reportado casos de encefalitis virales con o sin necrosis hemorrágicas de compromiso temporal mesial y talámico que ameritarían estudio de imagen diagnóstica (368) . un estudio retrospectivo publicado por kandenmirli et al. evaluó 749 pacientes en 8 hospitales infectados con covid-19 de los cuales 235 requirieron manejo en uci donde el 21% de ellos (n=50) presentaron sintomatología neurológica. la resonancia magnética cerebral fue realizada en 54% (n=27) de estos pacientes. el 44% tuvieron hallazgos agudos, el 37% tuvieron alteraciones corticales de la captación de señal en el modo flair, 3 pacientes tuvieron anormalidades en la señal flair en la sustancia blanca profunda y subcortical, 4 pacientes con lesiones en el lóbulo frontal, 3 en el lóbulo parietal, 4 en el lóbulo occipital, 1 en el lóbulo temporal, 3 en la corteza de la ínsula, y 3 en el giro cingular (371) . amci ® un paciente presentó trombosis de seno venoso y otro presentó un infarto en el tercio medio del territorio de la arteria cerebral media. en 56% de los pacientes no se encontraron hallazgos que sugieran compromiso intracraneal de covid-19. una correspondencia escrita por helms et al. reportaron 58 pacientes con sdra y covid-19 en dos unidades de cuidados intensivos en francia entre marzo y abril del 2020, el 84% presentaron signos neurológicos como delirium evaluados mediante cam-icu (65%), agitación (69%), signos del tracto cortico espinal (67%), síndrome disejecutivo (36%). de ellos se realiza resonancia magnética en 13 pacientes encontrando alteraciones en la perfusión en un 100%, un realce de leptomeninges en un 62%, y un acv isquémico en un 23%; dos pacientes asintomáticos presentaron áreas isquémicas con hiperintensidad focal (372) . ante estos hallazgos los principales diagnósticos diferenciales son las patologías autoinmunes, encefalitis, convulsiones e hipoglucemia. los pacientes con compromiso frontal bilateral poseen hipoxemia que ocasionan hipoperfusión fronto temporal. las microhemorragias corticales (y no) son consecuentes de la ruptura de la membrana hematoencefálica resultando en este patrón mencionado. el estado postictal muestra un compromiso simétrico de la sustancia blanca. de esta forma hay que considerar otras condiciones como las comorbilidades cardiovasculares, las reacciones adversas a los medicamentos, e hipoxia inducida por sdra que ocasionarían patrones imagenológicos de confusión, que ponen en duda la estrecha relación entre covid-19 y hallazgos de resonancia magnética (371) . en este orden de ideas necesitamos más datos para determinar cuáles son los hallazgos imagenológicos relacionados con neurotropismo y qué patrones pueden encontrarse directamente relacionados con la presencia de convulsiones, hipoxia o el desencadenamiento de una tormenta de citoquinas(362, 371, 372). se recomienda la valoración neurológica completa en los pacientes con sospecha o infección por covid-19. se recomienda la monitorización electroencefalográfica continua por al menos 24h o según la consideración del especialista en neurociencias en el paciente en estado crítico con sospecha o infección por covid-19 en quien se sospeche crisis epilépticas o estatus no convulsivo. las manifestaciones neurológicas en pacientes con infección por covid-19 pueden estar presentes en el 36% de los casos (366, 373, 374) . en el paciente en estado crítico con infección por covid-19 se han observado complicaciones vasculares que puede causar ataque cerebrovascular agudo isquémico o hemorrágico con tazas de entre el 5 al 6% por lo que el examen neurológico debe realizarse para documentar la presencia de déficit amci ® neurológico focal que haga sospechar esta patología (366, 375, 376) . es conocido que los pacientes en unidades de cuidado crítico tienen patologías que aumenta el riesgo de crisis o estado epiléptico, entre las cuales se encuentran (377) (378) (379) (380) :  pacientes sin patologías neurológicas hospitalizados en unidad de cuidado intensivo  hemorragia subaracnoidea  hemorragia intracraneal  trauma cráneo encefálico moderado a severo  infección del sistema nervioso central  tumor cerebral  encefalopatía hipóxico-isquémica algunas de estas patologías se presentan más frecuentemente en pacientes por covid-19 por lo que la monitorización electroencefalográfica continuar es requerida en este grupo de pacientes. el virus puede producir descompensación de paciente con epilepsia conocida, crisis por fiebre, crisis producidas por el estado crítico del paciente o las patologías subsecuentes que se han observado en esta infección (381) . el tiempo de monitorización requerido debe ser entre 12 a 24 horas para lograr una sensibilidad de 82 a 88%(380, 381). se recomienda realizar tomografía cerebral simple ante las manifestaciones neurológicas focales que nos hagan sospechar ataque cerebrovascular isquémico o hemorrágico. la resonancia cerebral puede ser necesaria como estudio complementario para determinar otros diagnósticos diferenciales en los pacientes con sospecha o infección por covid-19. las manifestaciones neurológicas en pacientes con infección por covid-19 pueden estar presentes en el 36% de los casos (366, 373, 374) . en el paciente en estado crítico con infección por covid-19 se han observado complicaciones vasculares que puede causar ataque cerebrovascular agudo isquémico o hemorrágico con tazas de entre el 5 al 6% por lo que el examen neurológico debe realizarse para documentar la presencia de déficit neurológico focal que haga sospechar esta patología (366, 375, 376) . la tomografía cerebral hace parte de la valoración inicial del ataque cerebrovascular isquémico y del estudio para determinar la presencia de otros diagnósticos diferenciales como ataque cerebro vascular hemorrágico en paciente con dicha patología puede ser necesario realizar angiotac con extensión a tórax en caso de sospecha de oclusión proximal o estudios endovasculares en pacientes que sea indicado (382) . la realización de resonancia cerebral usualmente documenta alteraciones en los pacientes con covid-19 en el 37 -62 % de los casos evaluados no relacionada con el acv. se recomienda la realización de punción lumbar en el paciente con sospecha o diagnóstico de covid-19 con base en los reportes de casos disponibles:  paciente con crisis epilépticas de novo.  paciente con alteración del estado de conciencia persistente a pesar de encontrarse metabólicamente compensado, descartado ataque cerebrovascular u otra causa de encefalopatía.  paciente con manifestaciones como mielitis, neuropatía craneal múltiple o sospecha de polineuropatía desmielinizante aguda. las capacidades neurotrópicas de los coronavirus en general han sido expuestas desde la infección por sarscov. en cuanto al sars-cov-2, asadi-pooya y colaboradores(383), han descrito, la posibilidad de ingreso al sistema nervioso central tras el ingreso por la mucosa nasal o por una gran viremia en el torrente sanguíneo. se han descrito procesos inflamatorios asociados (encefalitis) y en previamente con el sars y el mers hasta lesiones desmielinizantes (encefalomielitis aguda diseminada). estas primeras manifestaciones en 2002 con el sars fueron presencia de crisis epilépticas de novo, en quienes excluyendo otras causas tanto por neuroimagen además de pruebas microbiológicas en lcr, les fue descubierto el sars cov mediante pcr rt. en la presente pandemia, takeshi moriguchi y colaboradores (384) describieron el primer caso de encefalitis asociado a sars-cov-2, en un hombre joven en japón, que, tras 7 días de clínica respiratoria, desarrollo crisis epilépticas y alteración del estado de conciencia, sin antecedente conocido de epilepsia. se realizo imagen por resonancia cerebral, demostrando hiperintensidades a nivel temporal y lcr que mostró pleocitosis linfocitaria, se descartaron otros virus ( herpes, herpes zoster) y se le realizó pcr rt para sars-cov-2 siendo positiva. inclusive en este paciente los primeros hisopados faríngeos fueron negativos, pero los hallazgos en tomografía de tórax hicieron sospechar la infección por sars-cov-2. otro caso descrito de encefalitis hemorrágica aguda, fue también descrito en la revisión de ahmad y colaboradores (385) . donde una mujer joven presentó cuadro respiratorio de fiebre de 3 días de evolución y compromiso del estado de conciencia. en esta paciente se aisló el sars-cov-2 en hisopado faríngeo y ante el compromiso severo del estado de conciencia, se realizó resonancia que mostró compromiso hemorrágico bitalámico, en regiones temporales e ínsula, apoyando que se tratara de una diseminación tras neuronal probablemente con puerta de entrada mucosa olfatoria y siguiendo la diseminación por el los tractos del primer nervio hasta la corteza entorrinal, que es la vía propuesta de infección descrita inclusive por grupos como el de montalvan (356) y natoli (386) . amci ® precisamente, en la revisión sistemática de montalvan (356) se describen 1 caso de mielitis en contexto de paciente con infección por sars-cov-2, en quien se documentó la infección en lcr. se recomienda la medición de ácidos nucleicos por rt-pcr para sars-cov-2 en líquido cefalorraquídeo en los pacientes con sospecha o confirmación de infección por sars-cov-2 que realice crisis epilépticas de novo, en quien se descarte otras causas de estructuralidad (acv, tumores) o causas metabólicas (alteraciones hidroelectrolíticas, hipoglicemia, uremia etc.). se recomienda la medición de ácidos nucleicos por rt-pcr para sars-cov-2 en líquido cefalorraquídeo en pacientes con sospecha o confirmación de infección por sars-cov-2 con alteración franca del estado de conciencia, en quien se haya descartado como causante hipoxia, ataque cerebrovascular, alteración hidroelectrolítica o estatus no convulsivo mediante imágenes y electroencefalograma. se recomienda la medición de ácidos nucleicos por rt-pcr para sars-cov-2 en líquido cefalorraquídeo en pacientes con sospecha de encefalitis, mielitis o síndrome de guillain barré. en pacientes críticos, se ha recomendado búsqueda activa de compromiso del snc por sars-cov-2, sobre todo en pacientes con crisis epilépticas que no sean sintomáticas a trastornos metabólicos, además de hallazgos imagenológicos y curso clínico. las descripciones hechas por asadi y takeshi (383, 384) , muestran pacientes con cursos tórpidos, en los que el común denominador es una alteración del estado de conciencia persistente a pesar que otras variables (metabólicas, vasculares e infecciosas diferentes al sars-cov-2). de igual forma pacientes que realicen en contexto de la enfermedad, un cuadro de debilidad generalizada aguda, con arreflexia e incluso compromiso de nervios craneales como los descritos por zahra sedaghat(387). page amci ® se recomienda en los pacientes críticos con compromiso pulmonar por covid-19, un manejo orientado de fluidos frente a una estrategia liberal, ajustando el balance de fluidos de acuerdo con la evaluación clínica y/o a la capacidad de respuesta a volumen para garantizar la perfusión renal. se recomienda ajustar la intensidad de la monitoria en el paciente crítico con covid-19 al grado de severidad de la enfermedad para alcanzar tempranamente metas de reanimación que se reflejen en menor riesgo de lesión renal aguda. se recomienda evitar el uso de medicamentos nefrotóxicos teniendo en cuenta la farmacocinética y farmacodinamia individual, así como las interacciones farmacológicas en el paciente crítico con covid-19. el manejo de la volemia en los pacientes críticos ha cambiado considerablemente en las últimas décadas orientándose a un manejo titulado, evitando la administración empírica de altos volúmenes de líquidos durante la fase de reanimación de los pacientes siendo el flujo sanguíneo el determinante primordial del aporte tisular de oxígeno; los principales componentes de este deben optimizarse y balancearse para evitar la disoxia tisular. en estados de bajo flujo, los mecanismos compensadores neurohumorales producen una redistribución del flujo a lechos no esplácnicos y a nivel renal una redistribución corticomedular convirtiendo el tejido medular renal en una zona vulnerable a la lesión. de igual forma, el flujo sanguíneo renal se ve reducido de forma refleja en presencia de hipoxemia y/o hipercapnia. diversas fuentes de información nos han indicado cómo orientar adecuadamente el manejo del estado de perfusión tisular en los pacientes críticos con o sin una condición de shock, siendo la estimación aproximada del estado de volumen del paciente el pilar fundamental sobre el cual se basará toda la estrategia de restablecimiento o mantenimiento de la volemia del paciente con el fin de mantener la perfusión adecuada. aunque históricamente se prioriza la normalización del volumen en la reanimación de un paciente inestable, hemos comprendido la importancia que tiene el tiempo para lograr las metas en el pronóstico general del paciente y evidencias como el trabajo de ospina y cols. soportan el uso temprano de vasopresores para lograr de forma temprana metas de perfusión mientras buscamos la normovolemia. los pacientes con enfermedad pulmonar asociada a covid-19 deben mantenerse normovolémicos para preservar el flujo sanguíneo renal siendo la evaluación del estado de volumen un verdadero reto clínico. la fiebre, el aumento de pérdidas insensibles, la baja ingesta o las pérdidas por el tracto digestivo, pueden hacer que un paciente con covid-19 tenga hipovolemia, situación que puede desencadenar daño renal de no ser revertida apropiadamente y a tiempo. del otro lado del espectro, la administración liberal de líquidos además del potencial de empeorar la lesión pulmonar en presencia de una membrana alveolo capilar seguramente alterada, puede producir por sí misma un incremento en el riesgo de desarrollar lesión renal como lo demostró el estudio de grissom. desde el punto de vista de las metas amci ® hemodinámicas que se deben tener con un paciente con covid-19, se recomienda seguir los lineamientos de la campaña sobreviviendo a la sepsis, orientadas a mantener un óptimo estado de volumen, unas presiones de perfusión en un rango que permita la regulación de los flujos regionales en los distintos órganos y un gasto cardíaco dentro de unos rangos establecidos para una perfusión sistémica óptima. el examen clínico sigue teniendo vigencia absoluta para una adecuada aproximación al paciente, por ello debemos buscar los indicadores clínicos tradicionales de hidratación (piel, mucosas, enoftalmos, edema, etc.), el llenado capilar como lo describe hernández y cols en el estudio andrómeda-shock, el estado de alerta, las funciones cognitivas y la rata urinaria son entre otros unos marcadores aceptables para hacernos una idea del estado de adecuación de la perfusión periférica. la oliguria como marcador de perfusión renal está presente en 1/4 parte de los pacientes al ingreso a uci sin tener en sí sola una implicación pronóstica, sin embargo, la persistencia de esta en el tiempo es un indicador de alerta y obliga a una evaluación más detallada de las diversas variables que pudieran ocasionarla. debemos recordar que la administración de cargas de líquidos solamente está justificada cuando hay una respuesta cardiovascular a dicha administración, situación que se puede prever con una prueba de elevación pasiva de las piernas o con métodos más invasivos como la variabilidad de la onda de pulso, del volumen sistólico y/o del gasto cardíaco, entre otros. el esfuerzo respiratorio del paciente, los volúmenes utilizados en las estrategias de ventilación protectora y las arritmias frecuentemente presentes en los pacientes con compromiso pulmonar limitan el rendimiento diagnóstico de diversos dispositivos utilizados para la evaluación del estado de volumen y el gasto cardíaco, situación que debemos conocer y manejar(332, 388-394). se recomienda no utilizar de forma rutinaria la administración de tratamientos específicos antivirales para el paciente crítico con covid-19, con lesión renal aguda o crónica se recomienda no utilizar de rutina remdesivir en los pacientes con falla renal crónica y debe suspenderse en los pacientes que desarrollan lesión renal aguda con tfg < 30 ml/min. las intervenciones farmacológicas en los ensayos clínicos deben ajustarse a la farmacocinética y farmacodinamia específicas de cada molécula. la incidencia de falla renal reportada por criterios de kdigo, en los estudios chinos fue de 0.5% de los pacientes críticamente enfermos y de 4.7% en los pacientes con covid-19 y amci ® sdra. sin embargo, otros estudios han demostrado que hasta un 40%de pacientes con covid-19 que ingresan a la uci pueden presentar falla renal aguda. la falla renal en los pacientes con covid-19 es multifactorial como se ha descrito en preguntas anteriores por lo que se recomienda la toma diaria de creatinina sérica y el seguimiento continuo del gasto urinario y otros parámetros de la función renal como hematuria, proteinuria, tasa de filtrado glomerular, nitrógeno ureico en sangre, dímero d. los medicamentos que se emplean en el manejo de la infección covid-19 que actualmente incluyen oseltamivir, lopinavir/ritonavir, ribavirina, y la cloroquina o hidroxicloroquina son metabolizados principalmente en el hígado, aunque en la orina se encuentran metabolitos derivados de oseltamivir, ribavirina y de la hidroxicloroquina. por esto en ninguno de los estudios realizados en torno a la infección por sars-cov-2 se ha realizado ninguna recomendación en cuanto a la modificación de su dosis. la hidroxicloroquina por su parte se metaboliza a cloroquina, que a su vez se metaboliza a monodesetilcloroquina y a bisdesetilcloroquina. este medicamento no es dializable en las diálisis intermitentes y la única recomendación en los pacientes con falla renal, es hacer seguimiento electrocardiográfico estrecho para vigilar la prolongación del qtc. el favipiravir es un inhibidor de la polimerasa dependiente de rna que se encuentra en fase experimental para el tratamiento de la infección por sars-cov-2. la eliminación de este medicamento se realiza por vía renal y en los pacientes con falla renal en estadios leves a moderados se ha encontrado una concentración dos veces mayor en el riñón que sus niveles en sangre; sin embargo, esto no se ha asociado con ningún evento adverso por lo que la recomendación actual es no disminuir la dosis en pacientes con falla renal. el remdesivir se elimina por vía renal por lo cual no se recomienda administrar en pacientes con falla renal y los pacientes que desarrollan falla renal con el medicamento durante los estudios han sido retirados de los ensayos clínicos. no se cuenta con estudios que evalúen el remdesivir en una tfg <30 ml/min. en la tabla 15 se describen algunas intervenciones farmacológicas propuestas en medio de la pandemia para el manejo del covid-19 y su relación con la tasa de filtración según tfg. recientemente , izzedine et al publicaron una carta editorial en el kidney international may 21, 2020 donde alertan sobre el posible efecto nocivo de la hidroxicloroquina en la aparición de falla renal aguda al inhibir la autofagia celular que es un proceso importante en la remodelación de los túbulos renales, siendo estas células de alto recambio, pudiendo todo esto contribuir a la aparición de falla renal aguda(166, 327, 395-398) se recomienda aplicar las indicaciones tradicionales de terapia de soporte renal en pacientes críticamente enfermos con covid-19. se recomienda el inicio de terapia de soporte renal en pacientes críticos con covid-19 con hipercalemia severa o acidosis metabólica severa, refractarias a pesar del manejo médico óptimo o cuando el balance positivo de fluidos es deletéreo, con mayor requerimiento de oxígeno suplementario y que no responde a diuréticos. se recomienda el inicio temprano de terapia de soporte renal dentro de las primeras 24 horas de una indicación absoluta, asegurando previamente una adecuada reanimación de la perfusión tisular. en ausencia de trastornos hidro-electrolíticos y severa sobrecarga de volumen, el tiempo de inicio de diálisis es controversial. amci ® se recomienda en pacientes críticos con covid-19 que requieren soporte renal, las modalidades de terapia continua o extendida si cursa con inestabilidad cardiovascular, de acuerdo con la disponibilidad institucional. se debe considerar en pacientes críticos con covid-19, que requieren inicio de soporte renal preferir la vía femoral para inicio de la terapia para disminuir el riesgo de contaminación por proximidad, la siguiente vía se establecerá de acuerdo con la evolución y condiciones del paciente. en pacientes diagnosticados con covid-19 se puede presentar la insuficiencia renal aguda como parte de su enfermedad. en estudios observacionales de usa y china la ira se reportó entre un 3 y 37% de los pacientes. la enfermedad renal en pacientes con covid-19 se puede manifestar como ira, hematuria o proteinuria, y conllevan un mayor riesgo de mortalidad. la ira se asocia con cambios hemodinámicos y liberación de citocinas, pero no se descarta citotoxicidad directa por el virus. en un estudio realizado en nueva york con 5450 pacientes covid-19 positivos se diagnosticó lesión renal aguda en 37% de ellos, siendo leve con aumento de creatinina dos veces por encima del nivel basal en 47% de los pacientes, moderada en 22% de los pacientes, y severa con más del triple de la creatinina basal en 31%. hubo hematuria en el 46% de los pacientes y proteinuria en el 42%. se requirió terapia dialítica en el 15% de todos los pacientes con diagnóstico de ira, y el 97% de los pacientes que requirieron diálisis estaban en ventilación mecánica. la ira fue notada dentro de las primeras 24 horas de admisión a uci en el 33% de los pacientes y se relaciona con la severidad de la enfermedad. existen además predictores independientes: edad, raza negra, diabetes, hipertensión, enfermedad cardiovascular, ventilación mecánica, y uso de vasopresores. la terapia dialítica debe instaurarse precozmente una vez realizado el diagnóstico, idealmente dentro de las primeras 24 horas, después de asegurado que se ha completado el proceso de reanimación correspondiente. las indicaciones te trr en pacientes críticos con ira en covid-19 no difieren del paciente crítico general y se debe considerar ante: manifestaciones severas de uremia, sobrecarga de volumen, trastornos ácidos básico, refractarios, hipercalemia severa con manifestaciones cardiovasculares. pero no hay datos clínicos que respalden el inicio temprano vs tardío en esta población particular. pero un planteamiento válido es que la sobrecarga de volumen en pacientes que desarrollan sdra es perjudicial, dificultando el soporte ventilatorio óptimo, por lo cual se puede considerar un umbral más bajo para el inicio de trr con esta indicación específica: sdra + sobrecarga de volumen + infección covid-19 (399) . amci ® el paciente debe ser dializado en el cubículo de cuidado intensivo o en la habitación de aislamiento en los casos en que esté disponible y siempre evitar traslado a unidades con otros pacientes. la crrt es la modalidad preferida para este tipo de pacientes, pero debe quedar claro que esto depende de las facilidades de la institución que albergue al paciente y de la experticia de los profesionales. el acceso vascular en el paciente crítico general debe ser en su orden: vena yugular interna derecha, venas femorales comunes, vena yugular interna izquierda, y debe ser colocado por el médico encargado del paciente si está capacitado para ello, para evitar exposiciones innecesarias del personal de la salud. sin embargo, por precaución por el riesgo de contaminación, recomendaciones de expertos basadas en seguridad sugieren la utilización el catéter femoral. el tipo de catéter recomendado es un catéter doble lumen transitorio. sería ideal el monitoreo a través de cámaras del procedimiento para evitar el contacto prolongado del personal de enfermería durante el procedimiento de diálisis. en algunos casos específicos y de acuerdo con la disponibilidad, la diálisis peritoneal puede ser una alternativa. en los casos de crrt el líquido efluente no es contaminante para el personal de la salud. para terminar, es importante hacer énfasis en que en algunos hospitales ha habido escasez de insumos y esto puede llegar a convertirse en un serio problema. se recomienda para casos de fuerza mayor:  un litro de solución salina al 0.9% con cloruro de potasio a necesidad  un litro de dextrosa al 5% en agua con 150 meq de bicarbonato de sodio  un litro de solución salina al 0.9% con 1 gr de cloruro de magnesio  un litro de solución salina al 0.9% con 1 gr de cloruro de calcio esto nos da una solución de cuatro litros que contienen: 153 meq/l de sodio, 37.5 meq/l de bicarbonato, 2.6 mmol/l de magnesio y 2.25 mmol/l de calcio, más una cantidad variable de potasio. esta solución se puede usar como líquido dializante en pacientes en terapias de reemplazo renal continuo. especial cuidado se debe tener en el proceso de anticoagulación, pudiéndose usar heparina no fraccionada, hbpm, y citrato en los centros donde se tenga experiencia (139, 339, (400) (401) (402) (403) (404) (405) (406) (407) (408) (409) (410) (411) . se sugiere no utilizar de rutina la trrc más hemoperfusión en el paciente crítico con covid-19. débil en contra page amci ® se puede considerar en el paciente crítico con covid-19 con lesión renal aguda en quien se considere inicio de trrc, considerar la utilización de filtros de fibra hueca con propiedades adsortivas o asociado con cartuchos para hemoperfusión directa. el síndrome de liberación de citocinas (tormenta de citocinas) es un importante determinante en la transformación de infección por covid-19 de leve a moderado y progresión de la lesión de un órgano como el pulmón con neumonía y sdra a compromiso sistémico con inestabilidad hemodinámica, cid y fom. los pacientes afectados de tormenta de citocinas se encuentran con niveles altos de il-6 especialmente, además de il-10, tnf, que se relacionan con pobres pronósticos y mayor mortalidad. la asociación entre la lesión alveolar y renal (eje pulmón-riñón) es evidenciada en estudio del 2019 por panitchote y cols con 357 pacientes con sdra secundaria a neumonía y sin enfermedad renal preexistente que desarrollaron lesión renal aguda en el 68% con aki 3 en el 50% de ellos. recientemente en estudio en china zhou, con 191 pacientes afectados de covid-19 se encontraron como indicadores de mal pronóstico pacientes con altos niveles de dímero d, il-6, troponina i, dhl, ferritina y choque séptico. las terapias de depuración extracorpórea han sido utilizadas como tratamiento en pacientes con lesión severa por covid-19; dentro de estas se cuentan la crrt, hemoperfusión aislada, intercambio plasmático (tpe), plasmafiltración y adsorción (cpfa) y crrt + hemoperfusión. dentro de los beneficios de la crrt se cuentan la estabilidad hemodinámica, estabilidad del medio interno, depuración de toxinas pequeñas y medianas, incluidos mediadores inflamatorios, cuando se utiliza terapia convectiva, además de permitir soporte nutricional. la asociación de este procedimiento con membranas especiales (an69 + metilsulfonato y polietilamina oxiris) permiten hacer adsorción de citocinas (il-6) y endotoxinas, por periodos de 24h por 2 días consecutivos para manejo de tormenta de citocinas. la hemoperfusión aislada o asociada a crrt, también permite la remoción de il-6, utilizando cartuchos ha330, con procedimientos de 2 a 4 horas de duración por 3 días consecutivos (37, (412) (413) (414) (415) (416) (417) . no se puede emitir una recomendación a favor o en contra sobre el uso rutinario de la plasmaféresis como opción terapéutica en la fase de inflamación del paciente con covid-19. amci ® el coronavirus covid-19 puede inducir el síndrome respiratorio agudo severo (sars), que conduce a la disfunción inmune, la liberación excesiva de citoquinas inflamatorias, y a una serie de reacciones en cascada de activación de citoquinas, que resultan en lesiones alveolares difusas, formación de membrana hialina, exudación de fibrina y otras manifestaciones de lesión del pulmón. en casos severos, la tormenta de citoquinas sistémicas invade el sistema circulatorio, lo que lleva a una inestabilidad hemodinámica, shock y mods (418) . los niveles de il-6, il-10, tnf-a y otras citoquinas inflamatorias en pacientes con covid-19 grave son significativamente más altos, lo que puede estar relacionado con un mal pronóstico (419) . por lo tanto, la plasmaféresis se puede usar con seguridad y efectividad en pacientes con covid-19 grave, para eliminar mediadores inflamatorios de gran peso molecular. la seguridad depende como todas las terapias extracorpóreas de un personal de la uci entrenado, preparado y capacitado para aplicar las intervenciones en forma óptimas (420) . las terapias extracorpóreas de soporte de órganos pueden representar una parte importante de la respuesta y los médicos y otros profesionales de la salud deben estar familiarizados con estas terapias sofisticadas. se debe hacer un llamado a la acción, para crear conciencia sobre las diferentes técnicas extracorpóreas, cada una con criterios específicos y modalidades de prescripción, entrega y monitoreo(421, 422). se recomienda no utilizar de forma rutinaria el uso de un tratamiento específico dirigido a pacientes con infección por sars-cov-2/covid-19 comparado con el manejo estándar para mejorar desenlaces clínicos fuertes. actualmente no existe una terapia dirigida que se a efectiva para el manejo del virus; un número alto de estudios han surgido en los últimos dos meses, la mayoría sin el rigor metodológico suficiente para tomar decisiones adecuadas con respecto al manejo del amci ® paciente con infección por sars-cov-2. el conocimiento en la estructura del virus y el mejor entendimiento en la fisiopatología de la enfermedad genera un sinnúmero de potenciales fármacos que han sido ensayados para el manejo de la enfermedad. en tiempos de pandemia, con una patología catastrófica en términos de vidas humanas y costos hospitalarios; es importante encontrar soluciones a desenlaces importantes como mortalidad, días de estancia en uci y en el hospital, aumento en los días libres del ventilador, disminución de complicaciones mayores debido a la enfermedad entre otros. hasta el momento no se ha documentado ninguna terapia específica que pueda impactar sobre estos desenlaces; pero la calidad de los trabajos, tampoco dejan claro sin él no usar ningún tratamiento específico mejora los desenlaces al menos al disminuir el número de complicaciones. este nuevo beta-coronavirus es similar al coronavirus del síndrome respiratorio agudo severa (sars-cov) y del síndrome respiratorio del medio este (mers-cov); por lo tanto, varias moléculas que habían sido evaluadas en este tipo de enfermedad rápidamente se abrieron paso a ensayos clínicos en paciente con covid-19. estos ensayos principalmente observacionales, aleatorios pero abiertos con un número pequeño de pacientes no han permitido sacar adecuadas conclusiones y es frecuente como ver las diferentes guías de las principales sociedades del mundo cambiar de forma frecuente sus recomendaciones; no existes evidencia de estudios clínicos aleatorios y controlados que midan desenlaces fuertes, la premura de un tratamiento efectivo ha sacrificado el rigor metodológico que una investigación requiere. una estructura viral y replicación conocidas generan posibles dianas para que diferentes fármacos puedan ser investigados, antivirales tipo arbidol el cual inhibe la fusión de la membrana en la envoltura viral a algunos receptores; antimaláricos como la hidroxicloroquina y la cloroquina, las cuales inhiben la entrada viral y endocitosis por múltiples mecanismos, así como los efectos inmunomoduladores demostrados en el huésped; antivirales que impiden la replicación como el lopinavir o darunavir inhibiendo las proteasas o la ribavirina, el remdesivir o el favipiravir que actúan como análogos de nucleótidos o fármacos que actúan modulando la respuesta específica del huésped como el tocilizumab el cual se une al receptor de la il-6 inhibiendo el punto de acción de esta; los corticosteroides con múltiples efectos en la modulación del sistema inmunológico del paciente o los fármacos para evitar la respuesta secundaria a esta cascada inflamatoria como son los anticoagulantes. por último, se han buscado estrategias con el fin de mejorar la inmunización pasiva del huésped en el uso del plasma de pacientes convalecientes o el uso de inmunoglobulinas enriquecidas entre otros tratamientos propuestos para esta enfermedad. como vamos a ver más adelante, actualmente no existe un tratamiento específico con el nivel de evidencia suficiente para recomendar de manera generalizada; tampoco existe suficiente evidencia del manejo del soporte básico sin el uso de fármacos dirigidos, que demuestre que esta estrategia se deba implementar de manera sistemática en todos los pacientes; por lo tanto, a continuación trataremos de resolver las inquietudes con respecto a los diferentes medicamentos que han sido usados en la pandemia del sars-cov-2/covid-19. se recomienda no utilizar antimaláricos tipo hidroxicloroquina (hcq) o cloroquina (cq) para el manejo de pacientes con infección por sars-cov-2/covid-19. para la fecha no hay un adecuado sustento bibliográfico que soporte el uso de antimaláricos en la prevención o manejo de pacientes con infección por sars-cov-2 tanto leve, moderada como severa. los mayores estudios no muestran utilidad clínica y tendencia a mayores eventos cardiovasculares con el uso de antimaláricos en pacientes con infección por covid-19 comparado con no darlo. su utilidad se deriva principalmente de resultados en estudios preclínicos e in vitro; como los presentados por wang y cols donde evaluaron 7 medicamentos de manera in vitro contra el covid-19, siendo el remdesivir y la cq efectivos de manera in vitro contra el nuevo coronavirus(424); liu y cols, donde la hcq fue efectiva en inhibir la infección por sars-cov-2 in vitro que junto con su potencial antiinflamatorio tenía potencial para el uso clínico (425) y yao y cols, donde la hcq fue más potente que la cq para inhibir el sars-cov-2 in vitro y fue recomendado para el uso en humanos en dosis de 400 mg dos veces al día por el primer día, seguido de 200 mg dos veces al día por 4 días más mantendría la concentración efectiva del fármaco en el tejido pulmonar (426) . los pocos estudios clínicos, son de baja calidad y no han mostrado mejoría ni eficacia en el uso de antimaláricos para el manejo de paciente adultos con covid-19, algunos estudios iniciales con pocos pacientes con resultados favorables (427) e incluso con recomendaciones para uso en las primeras versiones de guías internacionales para la amci ® hcq y cq, encontrando superioridad en estudios observacionales, de pocos pacientes, sin comparadores para inhibir la exacerbación de la neumonía, hallazgos de las imágenes pulmonares, promover una conversión negativa al virus y acortar el curso de la enfermedad; la cq tuvo un efecto notable tanto en términos de resultado clínico como de eliminación viral (428) ; considerando la hcq y la cq como un tratamiento costo efectivo (429) . estudios posteriores con un mayor número de pacientes no han logrado reproducir los estudios preclínicos iniciales; mahévas y cols, evaluaron la efectividad de la hcq en 181 pacientes admitidos a cuatro hospitales en francia, con neumonía por covid-19 quienes requieren oxígeno, pero no se encontraban en uci, comparado con una población con manejo estándar; la hcq se usó a dosis de 600 mg día en las primeras 48 horas a la admisión, este estudio no soporte el uso de la hcq en pacientes admitidos al hospital con covid-19 que requieren oxígeno al no reducir de forma significativa la admisión a la uci, el sdra o muerte en el día 7 después del ingreso (430) ; por el contrario, se han reportado efectos secundarios frecuentes (prolongación del intervalo qt, hipoglucemia, cambios en el estado mental, alteraciones gastrointestinales y retinopatía); silvia borda y cols, evaluó la seguridad y eficacia de dos dosis de cq en pacientes con covid-19 severo en un estudio aleatorizado, doble ciego fase iib en 81 pacientes adultos hospitalizados con infección por sars-cov-2, los pacientes fueron expuestos a dosis altas de cq (600 mg dos veces al día por 10 días) o dosis bajas (450 mg dos veces al día en el día 1 y una vez al día por 4 días), los hallazgos preliminares de este estudio sugieren que la dosis más alta de cq no debe recomendarse para pacientes críticos con covid-19 debido a sus posibles riesgos de seguridad, especialmente cuando se toman simultáneamente con azitromicina y oseltamivir; estos hallazgos no pueden extrapolarse a pacientes con covid-19 no severo (431); tang y cols, evaluaron la eficacia y seguridad de la hcq con el manejo estándar en un estudio multicéntrico, abierto, aleatorio y controlado en china, 150 pacientes con covid-19 positivo se incluyeron en el análisis de intención a tratar (75 en el grupo de hcq y 75 en el grupo estándar), la hcq fue administrada a dosis de 1200 mg día por tres días y mantenimiento con dosis de 800 mg día (duración del tratamiento: dos a tres semanas en pacientes con enfermedad leve a moderada o enfermedad severa respectivamente); la administración de hcq no resultó en una significativa mayor probabilidad de conversión negativa comparado con el tratamiento estándar, los efectos adversos fueron mayores en el grupo de hcq (432) . con todo esto la hcq y la cq, si se usan deberá ser bajo estudios experimentales aprobados con una estricta monitorización y vigilancia clínica de la frecuencia cardíaca y el intervalo qt, los niveles de glucosa, la función hepática y renal, y el cribado clínico de trastornos mentales y visuales en pacientes que reciben estos fármacos. debe evitarse hcq/cq en pacientes con enfermedades cardiovasculares subyacentes. nuevas evidencias con un mayor número de pacientes podrían sacar la hcq y la cq inclusive de estudios clínicos; barbosa y cols, evaluaron en un estudio cuasialeatorio comparativo el uso fuera de registro de la hcq en pacientes positivos por el sars-cov-2, el pronóstico primario fue la necesidad de escalar el soporte ventilatorio, cambio en el conteo de linfocitos o cambio en el índice de neutrófilos/linfocitos, un total de 63 pacientes fueron incluidos, 32 en el brazo de hcq. la administración de hcq fue asociada con la necesidad de aumentar el nivel del soporte ventilatorio comparado con aquellos que no recibieron hcq al día 5 del estudio, no hubo beneficios en la mortalidad, reconstitución inmunológica y riesgo de intubación (433) . el estudio con un mayor número de pacientes proviene de la ciudad de new york; geleris y cols, examinaron la asociación entre el uso hcq y la intubación o muerte en un centro médico de ny, se analizaron 1. amci ® estaban más enfermos en términos de oxigenación, en este estudio observacional la administración de hcq no fue asociada con una disminución en el riesgo compuesto de intubación o muerte (434) . se recomienda no utilizar antimaláricos tipo hidroxicloroquina (hcq) o cloroquina (cq) en combinación con azitromicina (az) para el manejo de pacientes con infección por sars -cov-2/covid-19. fundamento para la fecha la evidencia no favorece el uso combinado de los antimaláricos en combinación con la azitromicina; por el contrario, la combinación de estos dos medicamentos puede ser deletérea, inclusive con un aumento reportado en la mortalidad y la aparición de arritmias ventriculares de novo; estudios iniciales fueron promisorios, gautret y cols, evaluaron inicialmente el efecto de la hcq en la carga viral respiratoria en conjunto con el uso de azitromicina, la presencia del virus al día 6 fue el pronóstico primario; 20 pacientes con tratamiento mostraron una significativa reducción en la carga viral al día 6 de la inclusión comparado con los controles; la azitromicina adicionada a la hcq fue significativamente más eficiente en la eliminación viral (435) ; nuevamente gautret y cols, realizaron un estudio observacional, no controlado, no comparativo de 80 pacientes tratados con la combinación de hcq más azitromicina, presentando una mejoría significativa en disminución de la carga nasofaríngea del virus y una menor tiempo de enfermedad (436) ; luego million y cols, evaluaron la combinación de hcq y az en un estudio retrospectivo de 1.061 pacientes con sars-cov-2 tratados con hcq (200 mg tres veces al día por 10 días) + az (500 mg en el día 1, seguido de 250 mg al día por los próximos 4 días), el pronóstico fue mortalidad, empeoramiento clínico (ingreso a uci) o persistencia viral; la administración de hcq+az en combinación antes de que aparecieran las complicaciones del covid-19 es segura y asociada a una baja mortalidad en los pacientes (437) ; soportado además por estudios in vitro que demuestran que la combinación de hcq y az tienen efectos sinérgicos para el sars-cov-2 a concentraciones compatibles con las que se obtienen en pulmones humanos (438) . otros estudios por el contrario no han encontrado resultados positivos, es así como, magagnoli y cols, en un análisis retrospectivo de pacientes confirmados con infección por sars-cov-2 en centros de veteranos de los eeuu, un total de 368 pacientes fueron evaluados (hcq, n=97; hcq+az, n=113; no hcq, n=158), en este estudio no hubo evidencia que el uso de la hcq tanto sola o en combinación con la az, redujo el riesgo de ventilación mecánica en pacientes hospitalizados con covid-19; una asociación con un aumento en la mortalidad fue identificada en pacientes tratados con hcq sola (439) . nuevamente los estudios con un mayor número de pacientes se encuentran en la ciudad de new york; rosenberg y col, describieron la asociación entre hcq, con o sin az en el pronóstico de pacientes hospitalizados con covid-19; un estudio de cohorte multicéntrico retrospectivo en pacientes hospitalizados con covid-19 en 25 hospitales de ny, los pacientes recibieron ; en pacientes hospitalizados en el área metropolitana de ny con covid-19, el tratamiento con hcq, az o ambos, comparado con ningún tratamiento, fue no significativamente asociado con diferencias en la mortalidad hospitalaria (440) . recomendación se recomienda no utilizar de forma rutinaria el uso rutinario del lopinavir/ritonavir para el manejo de pacientes con infección por sars-cov-2/covid-19. en la actualidad no existe evidencia a favor o en contra en el uso del tratamiento con antirretrovirales con lopinavir/ritonavir en el manejo de pacientes adultos hospitalizados con covid-19; no se observó ningún beneficio con lopinavir/ritonavir más allá de la atención estándar. se está en espera de cierre de diferentes ensayos futuros que confirme o excluyan el uso de lopinavir/ritonavir en el paciente covid-19. en diciembre de 2019, un nuevo coronavirus, designado sars-cov-2, ha causado una pandemia (115, 142, 174, 441) ; cuando hablamos de enfermedad producida por covid-19 hablamos de enfermedades que van desde las enfermedades leves autolimitantes del tracto respiratorio hasta neumonía rápidamente progresiva, neumonía grave, falla multiorgánica y muerte. hasta este momento no existen agentes terapéuticos específicos para las infecciones por coronavirus. después de la aparición del síndrome respiratorio agudo grave (sars) en 2003, entre los fármacos aprobados se identificó lopinavir, un inhibidor del aspartato proteasa tipo 1 del virus de inmunodeficiencia humana (vih), que tiene actividad inhibitoria in vitro contra el sras-cov, el virus que causa el sars en los seres humanos y el ritonavir combinado con lopinavir para aumentar su vida media plasmática a través de la inhibición del citocromo p450 (442) . se comenzaron estudios evaluando la respuesta antiviral in vitro de la combinación de lopinavir/ritonavir y ribavirina en 41 pacientes con sars; comparados con 111 pacientes tratados con ribavirina sola, que sirvieron como controles históricos; el pronóstico adverso (sdra o muerte) fue significativamente más bajo en el grupo de tratamiento comparado con los controles históricos (2.4% vs 28.8%, p = 0.001) al día 21 del inicio de los síntomas; una reducción adicional en el uso de esteroides y de infecciones nosocomiales fue vista en el grupo de tratamiento con una disminución en la carga viral y aumento en el conteo de linfocitos (443) ; del mismo modo, el lopinavir tiene actividad, tanto in vitro como en modelo animal, contra el coronavirus del síndrome respiratorio de oriente medio (mers-cov) (444) . estos estudios previos son el soporte inicial para el uso del lopinavir/ritonavir en la epidemia del covid-19; cao y cols, en mayo de 2020 publicaron en china, un estudio controlado, aleatorizado en pacientes hospitalizados con prueba ; los efectos adversos gastrointestinales fueron más comunes con el lopinavir-ritonavir, pero los eventos adversos serios fueron más común con el grupo control; el tratamiento con lopinavir-ritonavir fue suspendido en 13 pacientes (13.8%) secundario a los eventos adversos (445) . otro estudio hung y cols, en hong kong, evaluaron en un trabajo multicéntrico, prospectivo, aleatorizado, fase 2 la eficacia y seguridad de la terapia combinada por 14 días de lopinavir 400 mg y ritonavir 100 mg cada 12 h, ribavirina 400 mg cada 12 h y tres dosis de 8 millones de ui de interferón beta-1b en días alternos en pacientes con covid-19 comparado con lopinavir/ritonavir cada 12 h (grupo control); el resultado primario fue tiempo en la negativización de la pcr viral en el hisopado nasofaríngeo en paciente con covid-19; 127 pacientes fueron ingresados, 86 en el grupo de combinación y 41 en el grupo control; en el grupo de intervención de forma significativa se negativizo la prueba de pcr de forma más rápida (7 días [iqr 5-11]) que el grupo control (12 días [8] [9] [10] [11] [12] [13] [14] [15] ; hr 4.37 [ic 95% 1.86-10.24], p = 0.0010); los eventos adversos fueron similares entre los grupos; ningún paciente murió durante el estudio (446) . por último, un pequeño estudio de zhu y cols en china, con 50 pacientes con sars-cov-2; evaluaron de forma retrospectiva los efectos antivirales y seguridad del lopinavir/ritonavir y el arbidol (antiviral aprobado en china y rusia para el sasr y la influenza), 34 pacientes en el grupo de lopinavir/ritonavir y 16 en el grupo de arbidol; los pacientes lopinavir/ritonavir presentaron un mayor tiempo para la negativización de la prueba de pcr viral (p < 0.01)(447). se recomienda no utilizar de forma rutinaria remdesivir como antiviral para el manejo de pacientes con infección por sars-cov-2/covid-19. se debe considerar su uso en escenarios de estudios de investigación clínica aprobados. actualmente no hay disponibilidad del medicamento en el país (colombia) por lo cual no se incluye en los protocolos de manejo de paciente con covid-19. en estados unidos el primer paciente con covid-19 mostró una mejoría significativa de sus síntomas con 24 horas de tratamiento con remdesivir (448) , lo que abrió la puerta a un nuevo tratamiento para el sars-cov-2; el remdesivir (gs-5734) es un análogo de los nucleótidos que inhibe la rna polimerasa; con un amplio espectro antiviral, puede inhibir la replicación de múltiples coronavirus en las células epiteliales del sistema respiratorio (449) ; estudiado (451) . por último, un estudio publicado por antinori y cols, en milán, italia; de manera prospectiva (compasional) incluyó pacientes con neumonía por sars-cov-2 mayores a 18 años bajo ventilación mecánica o con una saturación de oxígeno ≤ 94% al aire ambiente o un puntaje del national early warning score 2 ≥ 4; el pronóstico primario en cambio en el estado clínico en una escala ordinal de 7 categorías (1 = no hospitalizado de regreso a sus actividades diarias normales; 7 = muerte); de los 35 paciente ingresados, 18 se encontraban en uci y 17 en un piso de hospitalización de enfermedades infecciosas; un curso de 10 días de remdesivir fue completado por 22 pacientes (63%) y suspendido en 13, de os cuales 8 (22.8%) se descontinuo por eventos adversos; a los 28 días, 14 (82.3%) pacientes de piso fueron egresados, 2 permanecían hospitalizados y uno murió (5.9%), en la icu 6 (33.3%) fueron egresados, 8 (44.4%) pacientes murieron, 3 (16.7%) aún se encontraban en ventilación mecánica y 1 (5.6%) estaba con mejoría pero aún hospitalizado; la hipertransaminasemia y la injuria renal aguda fueron los eventos adversos más frecuentes reportados (42.8% y 22.8%, respectivamente); los datos sugieren que el remdesivir puede beneficiar a pacientes con neumonía por sars-cov-2 hospitalizados por fuera de la unidad de cuidado intensivo (452). page se recomienda no utilizar de rutina la ivermectina para el manejo de pacientes con infección por sars-cov-2/covid-19. para la fecha no se cuenta con la suficiente evidencia para emitir una recomendación para el uso de la ivermectina en pacientes con covid-19, en estudios iniciales in vitro, caly y cols, demostró como la ivermectina, una droga autorizada por la fda como antiparasitario tiene un efecto antiviral de amplio espectro de manera in vitro, con una reducción significativa de la replicación viral en modelos experimentales (453) , un estudio aún sin publicar, observacional multicéntrico de casos y controles (n: 704 casos y n: 704 controles), realizado entre el 1 de enero y 31 de marzo de 2020, incluyó pacientes diagnosticados con covid-19 confirmados por laboratorio, la dosis fue de 150 mcg/kg de ivermectina más la terapia médica de soporte en comparación con terapia médica sin ivermectina, el resultado principal fue la medición de supervivencia; en pacientes que requirieron ventilación mecánica, la mortalidad fue menor en el grupo de ivermectina (7,3% y 21,3% respectivamente) y las tasas de mortalidad global fueron más bajas con ivermectina ( no se puede emitir una recomendación a favor o en contra sobre el uso compasivo o rutinario de tocilizumab en pacientes con infección por sars-cov-2/covid-19. en pacientes individualizados se ha reportado desenlaces clínicos favorables. se puede considerar su uso en pacientes que cumplan con todos los siguientes criterios: ver tabla 16. el tocilizumab (tcz) un anticuerpo monoclonal humanizado igg1k, el cual se puede unir de manera específica a los receptores solubles de membrana para la il-6 (sil-6r and mil-6r) y ha sido ampliamente usado en el tratamiento de enfermedades autoinmunes, tales como la artritis reumatoide, la enfermedad de still del adulto o vasculitis de grandes vasos (459) . un primer estudio de xiaoling xu y cols, describió en china, 21 pacientes tratados con tocilizumab, se documentó una mejoría en los síntomas, en los requerimientos de oxígeno y en los hallazgos imagenológicos de la tomografía de tórax; los niveles promedio de il-6 antes de la terapia fueron de 132.38 pg./ml; todos los pacientes recibieron lopinavir y metilprednisolona antes de la terapia. se trata de una serie con una muestra pequeña de pacientes en donde solo 4 (19%) pacientes estaban en condición crítica (148) . posteriormente luo y cols, en china, reportan el uso de tocilizumab en 15 pacientes, con mejoría en el aumento de la pcr en todos los pacientes, excepto uno, y una disminución de la il6. el nivel sérico de il-6 tendió a aumentar inicialmente y luego disminuyó en 10 pacientes. los niveles medios de il-6 antes de la terapia fueron de 111.05 pg./ml; 53% de los pacientes recibieron metilprednisolona; el 20 % fallecieron. es otra serie pequeña, con 7 pacientes (46,6%) en condición crítica (147) . roumier y cols, en francia, estudiaron 30 pacientes que recibieron tcz, observando que se redujo la necesidad de ventilación mecánica en comparación con los controles ( amci ® 0.001); en este estudio, no hubo diferencias en la reducción de la mortalidad y 7 pacientes (23%) se encontraban en uci (460) . klopfenstein y cols, también en francia, en un estudio retrospectivo de casos y controles, encontraron que pacientes que recibieron tcz (n=20), a pesar de tener más requerimiento de oxígeno, con resultados biológicos más pobres (mayor linfopenia y un nivel de pcr superior) al inicio del estudio que los pacientes sin tcz (n = 25), presentaron el objetivo combinado (ingreso a uci y mortalidad) menor que los pacientes sin la terapia (25% vs 72%, p = 0.002); es otra serie, que disminuye la necesidad de ventilación mecánica (0% vs 32%, p = 0.006) de manera significativa (461) . luego rimland ca y cols informan los primeros datos de 11 pacientes con covid-19 tratados con tcz en los estados unidos, 9 de ellos en ventilación mecánica; la pcr y el fibrinógeno mejoraron rápidamente, pero no hubo mejoría en otros marcadores o resultados clínicos. sólo a seis pacientes les tomaron niveles previos de il 6 y de ellos dos tenían niveles bajos (462) . en otro estudio mikulska y cols, próximo a salir en jama, en pacientes con sdra moderado a severo, hay mayor disminución de la mortalidad con el tratamiento combinado de tocilizumab y esteroides, en relación con cada una de estas terapias. por último, no todos los estudios han mostrado resultados positivos; kimmig y cols, de chicago (eeuu), en 28 de los 60 pacientes críticos con covid-19, que recibieron tcz, se asoció con una mayor incidencia de infecciones bacterianas secundarias, incluida la neumonía asociada al ventilador (64.3% vs. 31.3% p = 0.010) (463) . posterior a la recomendación hay nueva evidencia publicada y estudios aún sin publicar que puede soportar el uso de los inhibidores de la il-6 en pacientes con sars-cov-2/covid-19; morena y col, en un estudio de tocilizumab como uso "off-label" en el tratamiento de neumonía por sars-cov-2 en milán, italia, este estudio abierto, prospectivo, describe las características clínicas y el pronóstico de 51 pacientes con covid-19 confirmado y severo tratados con tcz iv, todos los pacientes, presentan niveles plasmáticos elevados de il-6 (> 40 pg/ml) y saturación de oxígeno < 93% al aire ambiente, 45 pacientes (88%) se encontraban con sistema de alto flujo de oxígeno y 6 en ventilación invasiva, a los 7 días luego del tratamiento se observa una caída dramática en la temperatura corporal y la pcr, con un incremento significativo en el conteo de linfocitos (p < 0.001); a los 34 días del tratamiento, 34 pacientes (67%) mostraron una mejoría en la severidad del cuadro; 31 fueron dados de alta; 17 (33%) mostraron empeoramiento de su cuadro clínico y de estos, 14 murieron (27%). la mortalidad fue significativamente asociada con el uso de ventilación mecánica al inicio (83.3% vs 20% de los pacientes en soporte de oxígeno no invasivo, p = 0.0001), el efecto adverso más frecuente reportado fue la elevación de las enzimas hepáticas (29%), trombocitopenia (14%) e infecciones bacterianas serias e infecciones fúngicas en un (27%); los autores concluyen que el tcz ejerce un rápido beneficio sobre los marcadores inflamatorios y la fiebre, aunque no se consiguió un impacto clínico sobre el pronóstico, el riesgo aumentado de infecciones severas no es despreciable (464) . capra y col, describieron 85 pacientes en un hospital de italia con neumonía por covid-19 y falla respiratoria sin soporte ventilatorio y al menos uno de los siguientes: frecuencia respiratoria ≥ 30 respiraciones/min, saturación ≤ 93% o pao2/fio2 <= 300 mmhg, los pacientes recibieron la terapia estándar para el momento (hidroxicloroquina, lopinavir y ritonavir) y fueron considerados el control; 62 pacientes recibieron tzc con 4 días de la admisión más el manejo estándar, los pacientes en el grupo de tratamiento mostraron de manera significativa una mayor sobrevida comparado con los pacientes control (hr para muerte, 0.035; 95% ic], 0.004 a 0.347; p = 0.004), ajustado para las características clínicas de base; 2 de 62 pacientes en el grupo de tcz y 11 de 23 en el grupo control murieron; 92% y 42.1% de los pacientes que se dieron de alta en el grupo de tcz y en el control se recuperaron; la función respiratoria mejoró en el 64.8% de los amci ® pacientes con tcz que aún se mantenía hospitalizados, donde el 100% de los controles empeoro y requirieron ventilación mecánica, dando al tcz un espectro positivo en términos de curso clínico y sobrevida en pacientes con covid (465). guaraldi y col; evaluaron el papel del tcz en reducir el riesgo de ventilación mecánica invasiva en pacientes con neumonía severa por covid-19 quienes recibían tratamiento estándar para el momento (hidroxicloroquina, azitromicina, antirretrovirales y heparinas de bajo peso molecular) en un estudio retrospectivo, observacional en bologna, reggio emilia y módena, italia; el tcz fue dado a dosis de 8 mg/kg de peso corporal de forma iv (con un máximo de 800 mg) en dos infusiones separadas 12 h o 162 mg sc administradas en dos dosis simultáneas, una en cada muslo (324 mg en total), cuando la formulación iv no se encontraba disponible; el pronóstico primario fue la combinación de ventilación mecánica invasiva o muerte; de 1351 pacientes ingresados, 544 (40%) tenían neumonía severa por covid-19 y fueron incluidos, 57 (16%) de 365 pacientes en el grupo estándar requirieron ventilación mecánica, comparados con 33 (18%) de 179 pacientes tratados con tcz (p = 0·41; 16 [18%] de 88 pacientes tratados iv y 17 [19%] de 91 pacientes tratados sc); 73 (20%) pacientes en el grupo estándar murieron, comparado con 13 (7%; p < 0.0001) pacientes con tcz (6 [7%] del grupo iv y 7 [8%] sc); luego de ajustar para sexo, edad, centro de reclutamiento, duración de los síntomas y puntaje de sofa, el tratamiento con tcz fue asociado con una reducción en el riesgo de ventilación mecánica invasiva o muerte (hr 0.61, 95% ic 0.40-0.92; p = 0.020); 24 (13%) de 179 pacientes tratados con tcz fueron diagnosticados con nuevas infecciones en comparación con 14 (4%) de 365 pacientes en el grupo estándar (p < 0.0001) (466) . campochiaro y col, en un solo centro evaluó la eficacia y seguridad del tcz en pacientes con covid-19 severo, se diseñó un estudio retrospectivo en pacientes con características de hiper-inflamación (definida como una elevación tanto en la pcr, ≥ 100 mg/l, normal <6 mg/l o ferritina ≥ 900 ng/ml, normal <400 ng/ml en presencia de un incremento en la dhl > 220 u/l), acompañado de un compromiso respiratorio severo, definido como hallazgos típicos en la radiografía y/o tomografía, la presencia de una saturación de oxígeno ≤ 92% al aire ambiente o una pao2:fio2 ≤ 300 mmhg ingresados a la uci, comparando pacientes con tcz iv al manejo estándar, 65 pacientes fueron incluidos de los cuales 32 fueron tratados con tcz; los pacientes se encontraban con alto flujo o ventilación mecánica no invasiva, a 28 días de seguimiento, 69% de los pacientes con tcz experimentaron mejoría clínica comparado con un 61%del tratamiento estándar (p = 0.61); la mortalidad fue 15% en el grupo de tcz y 33% en el grupo estándar (p = 0.15); la incidencia de infección y trombosis pulmonar fue similar en ambos grupos (467); somers y col, evaluaron un estudio observacional en pacientes con neumonía por covid-19 severo que se encontraban en ventilación mecánica, evaluando como pronóstico la probabilidad de sobrevida posterior a la extubación; 154 pacientes fueron incluidos, 78 recibieron tcz y 76 no; en los modelos ajustados, el tcz, fue asociado con una reducción del 45% en el riesgo de muerte [hr 0.55 95% ic 0.33 a 0.90]; aunque el tcz, fue asociado con un incremento en la proporción de pacientes con superinfecciones (54% vs. 26%; p < 0.001), no hubo diferencias en la mortalidad a 28 días entre los pacientes tratados con tcz con o sin superinfecciones [22% vs. 15%; p=0.42] (468). price y col, también publicaron un estudio observacional de pacientes hospitalizados con covid-19, los pacientes recibieron tcz si cumplían criterios del síndrome de liberación de citoquinas, se evaluaron 239 pacientes; de los cuales 153 (64%) recibieron tcz, estos pacientes que recibieron ventilación mecánica la sobrevida fue del 75% (95% ic, 64-89), luego del tcz pocos eventos adversos fueron reportados y tanto la oxigenación como los biomarcadores de inflamación mejoraron (469) y por último, en un estudio preliminar con datos aún sin publicar perrone y col, evaluaron la eficacia del tcz en pacientes con neumonía por covid-19, en un estudio amci ® multicéntrico fase 2 en italia; se utilizó tcz, a dosis de 8 mg/kg iv, una o dos administraciones con 12 horas de diferencia; 301 y 920 casos fueron disponibles para un análisis de intención a tratar, 67 pacientes murieron; las tasas de letalidad fueron de 18.4% (97.5% ic, 13.6-24.0, p = 0.52) y 22.4% (97.5% ic, 17.2-28.3, p < 0.001) a 14 y 30 días; el tcz redujo la tasa de letalidad a 30 días pero no a 14 días comparado con las esperadas sin presentar una toxicidad significativa; la eficacia fue más evidente en los paciente que no requerían ventilación mecánica (469). recomendación se recomienda no utilizar de rutina bloqueadores de interleuquina-1 (anakinra) en pacientes con infección por sars-cov-2/covid-19. aunque su ventaja está en el perfil de seguridad, su vida media corta (3 horas) y porque las infecciones oportunistas son raras ,no hay suficiente evidencia para emitir una recomendación sobre el uso de este medicamento; cavalli y cols, de milán, italia, realizaron un estudio de cohorte retrospectivo en pacientes con sdra moderado a severo con hiperinflamación (pcr ≥ 10 mg/dl, ferritina ≥ 900 ng/ml o ambos), manejados con ventilación mecánica no invasiva fuera de la uci y que recibieron tratamiento con hidroxicloroquina y lopinavir, los pacientes que recibieron anakinra, 5 mg/kg dos veces al día intravenosa (n= 29, dosis alta) o 100 mg dos veces al día subcutánea (n= 7 pacientes, dosis baja) fueron comparados con una cohorte retrospectiva que no recibió anakinra (tratamiento estándar); la duración del tratamiento se prolongó hasta el beneficio clínico sostenido (reducción del 75% en la pcr, y una pafi > 200, durante al menos 2 días consecutivos) o hasta la muerte, bacteriemia, o efectos secundarios (alt > 3 veces valores de referencia); el tratamiento con anakinra a bajas dosis se interrumpió después de 7 días debido a la escasez de efectos sobre la pcr y el estado clínico. a los 21 días, el tratamiento con dosis altas de anakinra se asoció con una reducción en la pcr y mejoría en la función respiratoria en 21 de 29 pacientes (72%); en el grupo estándar, ocho de 16 pacientes (50%) mostraron mejoría respiratoria a los 21 días. en 21 días de seguimiento, la sobrevida fue del 90% en el grupo de dosis altas de anakinra y del 56% en el grupo estándar (p = 0.009). se trata del primer estudio que demuestra seguridad y mejoría en los pacientes covid-19, pero en el contexto fuera de la uci (470) . huet y cols, de parís, francia, realizaron el estudio llamado ana-covid-19 en el que compararon 52 pacientes tratados con anakinra subcutánea 100 mg dos veces al día durante 72 h, luego 100 mg diarios durante 7 días, con 44 pacientes históricos; su criterio de inclusión fue tener una saturación de oxígeno del 93% o menos con un soporte de mínimo de 6 l / min de oxígeno. la admisión a la uci por ventilación mecánica invasiva o muerte se produjo en 13 (25%) pacientes en el grupo de anakinra y 32 (73%) pacientes en el grupo histórico (hr 0. amci ® pacientes en el grupo histórico tuvieron un aumento en las aminotransferasas hepáticas (471). recomendación se sugiere que la terapia con interferón sólo sea considerada en pacientes con formas graves de infección por covid-19 en el marco de un estudio clínico. estudios preliminares muestran que el virus del covid-19 induce una expresión muy débil de interferones en las células infectadas, lo que obstaculiza la respuesta inmune innata temprana a la infección y sugiere que el uso de interferón (ifn) exógeno para estimular la inmunidad antiviral (473) . zhou q y col, en china, en un estudio observacional de 70 pacientes con covid-19 con gravedad mixta proporcionó evidencia de muy baja calidad que la adición de interferón-α a la terapia con umifenovir no afecta el tiempo de eliminación viral o la duración en la estancia hospitalaria cuando se comparó con el umifenovir solo (474) . hung if y cols, de hong kong, realizaron un ensayo multicéntrico, en adultos con covid-19, en los que 86 pacientes recibieron una combinación de lopinavir/ritonavir y tres dosis de 8 millones de unidades internacionales (0·25 mg) de interferón beta-1b en días alternos (grupo de combinación) y 41 pacientes recibieron lopinavir/ritonavir (grupo control); la terapia de combinación fue segura y superior al control, para aliviar los síntomas y acortar la duración de la eliminación del virus y la estancia hospitalaria; se trata de un estudio fase 2, en pacientes con covid-19 leve a moderado (ningún paciente con ventilación en el grupo de combinación), en el que el ifn se administró en los primeros 7 días de inicio de los síntomas y con el uso de un análogo de nucleósido oral (ribavirina), que no está en nuestras guías (446) . se necesitan estudios de ifn solo o combinado en pacientes críticos con covid-19. los efectos adversos de los ifn tipo i pueden limitar su uso para una intervención generalizada, como se propone en el brazo ifn-β con lopinavir/ritonavir del ensayo solidaridad de la oms. la administración por inhalación de vapor que se realiza actualmente en china ofrece la ventaja de acceso rápido al tracto respiratorio; sin embargo, la farmacodinamia y la farmacocinética de este modo de administración nunca se han evaluado. se sugiere no utilizar de rutina corticoides en el tratamiento de pacientes con sospecha o diagnóstico de covid-19. no se puede considerar su uso profiláctico ni en pacientes con enfermedad leve sin requerimiento de oxígeno. débil en contra page en diciembre de 2019, una serie de casos de neumonía de causa desconocida surgió en wuhan, hubei, china, con presentaciones clínicas muy parecidas a una neumonía viral; los análisis de secuenciación profunda de muestras del tracto respiratorio inferior indicaron un nuevo coronavirus, que se denominó novel coronavirus 2019 (covid-19-2019) (115) . en la actualidad, en ausencia de terapia preventiva para sars-cov-2, la piedra angular de atención para pacientes con covid-19 sigue siendo el manejo de apoyo, que va desde el tratamiento ambulatorio sintomático hasta el tratamiento intensivo completo con medidas de soporte en cuidados intensivos (475) . dentro del manejo farmacológico se ha planteado la opción del uso de corticoides, la justificación estaría basada en la disminución de la respuesta inflamatoria del huésped a nivel pulmonar; es decir, un efecto inmunomodulador, ya que esta infección puede conducir a un síndrome de distrés respiratorio agudo (sdra); sin embargo, el beneficio puede verse superado por los efectos adversos, incluido el retraso en el aclaramiento viral y mayor riesgo de infección secundaria. a pesar de que la evidencia directa de corticoides en covid-19 es limitada, revisiones de los resultados en otras neumonías virales nos podrían orientar en principio en esta actual situación (476) . teniendo en cuenta lo anterior; stockman y cols, en el 2.006, realizaron una revisión sistemática sobre ensayos en pacientes con sars; quince ensayos examinan el uso de corticoides con diez o más pacientes en tratamiento; 13 ensayos también recibían ribavirina; trece de estos estudios no fueron concluyentes; dos estudios describen un daño potencial con el uso de esteroides; en la literatura china estos autores encontraron catorce estudios con uso de esteroides en sars; doce fueron suspendidos por posible daño, la mayoría de estos ensayos se realizaron con muestras pequeñas de pacientes y de manera retrospectiva (477) . arabi y cols, en noviembre 21 de 2.017, realizaron un estudio multicéntrico de cohorte retrospectivo en 14 hospitales de atención terciaria de arabia saudita, donde se incluyeron 309 pacientes; el uso de corticoides en pacientes con mers no se asoció con un cambio significativo a los 90 días en la mortalidad y se documentó un retraso en la eliminación del arn de mers-cov (478) . en cuanto hace referencia a la situación actual de pandemia por sars-cov-2 y compromiso pulmonar; wu y cols, en marzo de 2.020 realizaron un estudio retrospectivo de 201 pacientes con covid-19 en china; para aquellos pacientes que desarrollaron sdra, el tratamiento con metilprednisolona estuvo asociado con una disminución del riesgo de muerte (23/50 [46%] con esteroides vs 21/34 [62%] sin esteroides; hr, 0.38 [ic 95%, 0.20-0.72]), con las limitaciones de los estudios retrospectivo, de un solo centro, con un limitado número de pacientes (400). zha y cols, en marzo de 2.020, describen el uso de corticosteroides en el tratamiento de pacientes con covid-19; no hallaron asociación entre la terapia con esteroides y el pronóstico de los pacientes sin sdra, siendo un estudio con una serie muy pequeña de pacientes (479) . yang y cols, en marzo de 2.020, en una revisión sistemática y meta-análisis que incluyó 5.270 pacientes de 15 estudios, describen como el tratamiento con corticoides estuvo asociado con una mayor mortalidad (rr = 2.11, ic 95% = 1.13-3.94, p = 0,019), mayor estancia (wmd = 6.31, ic 95% 5.26-7.37, p = <0,001) y una mayor tasa de infección bacteriana (rr = 2.08, ic 95% 1.54-2.81, p = <0.001); con algunas limitaciones en este metaanálisis, la mayoría de los estudios incluidos son estudios de cohorte retrospectivos, controles históricos, con un bajo nivel de evidencia y una falta de ensayos controlados aleatorizados con buen diseño, sin un estándar uniforme para el tiempo y la dosis de los corticoides utilizado en los estudios; los efectos de los corticosteroides pueden ser influenciado también por otras opciones terapéuticas, como los medicamentos antivirales (480) . por último, li y cols, en mayo de 2.020, en otra revisión sistemática y metaanálisis, con respecto al uso de corticosteroides en sujetos con amci ® infecciones por sars-cov-2, sars cov y mers-cov, se determinó que hubo retraso en la eliminación del virus sin mejoría en la supervivencia, reducción en la duración de la hospitalización o tasa de admisión en la uci y/o uso de ventilación mecánica; presentándose varios efectos adversos. debido a la preponderancia de los estudios observacionales en el conjunto de datos y los sesgos de selección y publicación, se concluye especialmente con respecto al sars-cov-2, que se necesita mayor investigación con ensayos clínicos aleatorizados. internamente en este meta-análisis sugiere precaución al usar esteroides en pacientes con covid-19 (481). horby y col en una rama del ensayo de evaluación aleatorizada de la terapia covid-19 (recovery), estudio aleatorizado, controlado, abierto que compara una gama de posibles tratamientos con la atención habitual en pacientes hospitalizados con covid-19, compararon el uso de la dexametasona a dosis de 6 mg día (oral o intravenosa) una vez al día por 10 días o el alta según lo que ocurriera primero contra el manejo habitual; en 2104 pacientes aleatorizados que recibieron dexametasona se compararon con 4321 pacientes en manejo estándar; 454 (21.6%) pacientes en el grupo de dexametasona y 1065 (24.6%) pacientes en el grupo control murieron a los 28 días, con un riesgo relativo ajustado para la edad (rr 0.83; 95% ic 0.74 a 0.92; p < 0.001). la mortalidad relativa y absoluta variaron significativamente en relación al soporte ventilatorio al momento de la aleatorización; la dexametasona redujo las muertes en una tercera parte de los pacientes que recibieron ventilación mecánica invasiva (29.0% vs. 40.7%, rr 0.65, 95% ic 0.51 a 0.82; p < 0.001), y una quinta parte en los pacientes que reciben oxígeno sin ventilación mecánica invasiva (21.5% vs. 25.0%, rr 0.80, 95% ic 0.70 a 0.92; p = 0.002), pero sin reducir la mortalidad en paciente que no recibieron soporte respiratorio al momento de la aleatorización (17.0% vs. 13.2%, rr 1.22, 95% ic 0.93 a 1.61]; p = 0.14) (482). se recomienda no utilizar plasma convaleciente como tratamiento de rutina en paciente con sars-cov2 -covid-19. se debe considerar su uso en el marco de un ensayo clínico y con alguno de los dos escenarios siguientes: escenario a (enfermedad severa), definida como uno o más de los siguientes: disnea, frecuencia respiratoria > 30/min, spo2 < 93%, pao2/fio2 < 300 o empeoramiento radiológico con aumento > 50% de los infiltrados pulmonares en 24 -48 horas. escenario b (enfermedad que amenaza la vida), definida como uno o más de los siguientes: falla respiratoria, choque séptico, o disfunción multiorgánica. se recomienda no utilizar plasma convaleciente para profilaxis clínica de rutina contra la infección por sars-cov-2, solo se debe considerar en el marco de un ensayo clínico. (485) . una revisión sistemática y meta-análisis exploratorio realizado en 2014 identificó 32 estudios de infección por coronavirus sars e influenza severa, el estudio reveló una reducción de la mortalidad, especialmente si el plasma convaleciente se emplea en la fase temprana de la enfermedad cuando se comparó con placebo o no tratamiento (or 0.25; ic del 95% 0.14 -0.45); sin embargo, hay que tener presente que los estudios son de baja calidad, carecen de grupos control y puede tener riesgo moderado a alto de sesgo (486) . se ha sugerido que el plasma convaleciente de pacientes que se han recuperado de covid-19 puede ser una terapia potencial, proporcionando inmunidad pasiva de los anticuerpos específicos contra sars-cov-2 y podría servir para prevenir y tratar la enfermedad (487) . las personas que se han recuperado de la infección por sars-cov-2 pueden generar anticuerpos neutralizantes (488, 489) que podrían tener aplicación en la prevención de infección en ciertos escenarios, como las personas con comorbilidades subyacentes que predisponen a enfermedad grave y aquellas con exposición de alto riesgo como los trabajadores de la salud y los expuestos a casos confirmados de covid-19. existen algunos riesgos asociados con el uso de plasma convaleciente, unos conocidos y otros teóricos; los riesgos conocidos son aquellos asociados con la transfusión de hemocomponentes, incluida la transmisión de virus (ej. vih, vhb, vhc, entre otros) (490); riesgo muy bajo, con los estándares de calidad actuales de los bancos de sangre; también se pueden presentar complicaciones no infecciosas, como las reacciones alérgicas, anafilaxia, reacción febril a la transfusión, lesión pulmonar aguda relacionada con la transfusión (trali), sobrecarga cardiaca asociada a transfusión (taco) y hemólisis si se administra plasma abo incompatible (491) . los riesgos teóricos incluyen el empeoramiento de la infección dependiente de anticuerpos (antibody-dependent enhancement of infection -ade); el ade puede ocurrir en varias enfermedades virales e implica una respuesta inflamatoria exagerada ante la presencia de ciertos anticuerpos (492) . otro riesgo teórico es que la administración de anticuerpos a las personas expuestas al sars-cov-2 puede evitar la enfermedad, pero modifica la respuesta inmune de tal manera que esos individuos monten respuestas inmunes atenuadas, lo que los haría vulnerables a la reinfección posterior, si se comprueba que este riesgo es real estos individuos podrían ser vacunados contra covid-19 cuando exista una vacuna disponible (487) . durante el brote actual en china, se utilizó plasma convaleciente en algunos pacientes con covid-19 (493), desde esta publicación se identificaron 9 publicaciones relacionadas con el tema, entre todos los estudios fueron tratados con plasma convaleciente un total de 5063 pacientes(494-502) (tabla 17). shen y cols en marzo 2020 describieron en china el primer reporte en el cual el plasma convaleciente puede ser una opción de tratamiento en pacientes con covid-19; reportaron una serie de casos de 5 pacientes críticamente enfermos con covid-19 y síndrome de dificultad respiratoria aguda (sdra), todos en ventilación mecánica, a quienes se les administró plasma convaleciente con anticuerpos neutralizantes [10 a 22 días después del inicio de la enfermedad (ddie)], todos ellos posteriormente mostraron mejoría clínica, la carga viral de los pacientes disminuyó y fueron negativas en los 12 días posteriores a la intervención (494) . de forma similar, duan y cols en mazo 2020 en china reportaron mejoría clínica en una serie prospectiva de 10 casos de paciente severamente enfermos con covid-19, que recibieron plasma convaleciente con un tiempo medio de 16.5 ddie (11 a 20 días) después del inicio de los síntomas, e hicieron amci ® una comparación con un grupo control histórico comparables en edad, género y severidad de la enfermedad (495) . zhang y cols en mazo 2020, en china reportaron una serie de 4 casos de pacientes con covid-19 críticamente enfermos, 3 en falla respiratoria con ventilación mecánica y dos de ellos con ecmo (membrana de oxigenación extracorpórea), a quienes se les dio tratamiento con plasma convaleciente en un tiempo medio 15.5 ddie, posteriormente todos tuvieron mejoría clínica (496) . posteriormente ahn y cols en abril 2020 en corea, describieron una serie de dos casos de paciente con covid-19 severamente enfermos, en falla respiratoria y con ventilación mecánica, quienes además de recibir hidroxicloroquina, lopinavir/ritonavir y metilprednisolona, fueron tratados con plasma convaleciente entre 6 -10 ddie, ambos pacientes se recuperaron y fueron liberados de la ventilación mecánica, uno fue dado de alta al momento del reporte (497) . ye y cols en abril 2020 en china, describieron una serie de 6 pacientes con covid-19 con anormalidades imagenológicas y deterioro clínico a pesar del tratamiento estándar y con pcr para sars -cov-2 persistentemente positiva, aunque no estuvieron en falla respiratoria o con ventilación mecánica, de hecho, una de las pacientes era portadora asintomática; todos recibieron plasma convaleciente entre 32 a 49 ddie, en todos los pacientes, excepto 1, hubo resolución de los cambios de vidrio esmerilado y consolidación, todos mejoraron y fueron dados de alta (498) . zeng y cols en abril 2020 en china, reportaron una serie de 6 casos con covid-19 en falla respiratoria y se compararon con 21 controles que no recibieron plasma convaleciente por limitación en la disponibilidad y compatibilidad abo; a este grupo de paciente, se les administró plasma convaleciente en promedio 21.5 ddie, en todos los casos se negativizó la pcr para sars-cov-2 a los 3 días después del tratamiento; sin embargo, contrario a los reportes de los 5 estudios previos, en este grupo se murieron 5 pacientes (83% vs 93%, p = 0.184), pero tuvieron mayor porcentaje de aclaramiento del virus (pcr sars-cov-2 negativa 100% vs 21.4%, p = 0.005) antes de la muerte e incluso el tiempo de sobrevida fue mayor en el grupo de tratamiento (p = 0.029) (499) . salazar y cols en mayo 2020, en houston, texas, reportaron una serie de 25 pacientes con covid-19 severa o amenazante para la vida, el desenlace primario fue seguridad y el secundario fue el estado clínico de los pacientes al día 14 luego de la transfusión; al día 7 posttransfusión, 9 pacientes (36%) mejoraron con relación a su estado clínico basal, 13 (52%) no tuvieron cambios y 3 pacientes tuvieron deterioro clínico. siete de los nueve pacientes que mejoraron (28%) habían sido dados de alta; para el día 14 post-transfusión, 19 (76%) de los pacientes presentaron mejoría y 4 pacientes más, habían sido dados de alta; tres pacientes permanecían sin cambios, 3 pacientes se deterioraron y uno murió por una condición no relacionada con el plasma; el promedio de estancia hospitalaria fue de 14.3 días y la estancia hospitalaria luego de la transfusión fue en promedio 11 días; hubo una disminución de los valores promedio de pcr desde 14.66 mg/dl el día 0, a 2,9 mg/dl y 0.45 mg/dl los días 7 y 14 respectivamente; al momento de la publicación del artículo, solo permanecían intubados 2 pacientes; todos los pacientes que requirieron ecmo ya se habían liberado y 20 (80%) fueron dados de alta (500) . también en texas, estados unidos, ramachandruni y col en mayo 2020, reportaron una serie de 5 casos con covid-19 severa, falla respiratoria y en ventilación mecánica o pao2/fio2 < 100, todos con comorbilidades; a los cuales les administraron metilprednisolona y posteriormente plasma convaleciente; compararon los valores basales de pao2/fio2 y posterior a la intervención; encontrando, mejoría de la pao2/fio2 en 48% luego del tratamiento con esteroides y en 26% luego de la administración de plasma convaleciente (501) . finalmente, en respuesta al brote de covid-19 en los eeuu y las tasas de mortalidad reportadas, la fda en colaboración con la mayo clinic y la comunidad nacional de bancos de sangre desarrollaron un programa nacional de acceso ampliado para recolectar y distribuir plasma convaleciente donado por amci ® individuos que se han recuperado de covid-19; entre abril 3 y mayo 11, 2020; fueron incluidos 14.288 pacientes con covid-19 severa o potencialmente mortal o con riesgo alto de progresión a covid-19 severa o potencialmente mortal en el programa nacional de acceso ampliado; en ese tiempo, un total de 8.932 pacientes inscritos recibieron transfusión de plasma convaleciente covid-19. en una publicación reciente, joyner y cols en mayo 2020, en estados unidos, hicieron un análisis de seguridad después de la transfusión de plasma convaleciente covid-19 humano con compatibilidad abo en 5.000 adultos hospitalizados con covid-19 grave o potencialmente mortal, 66% de los cuales se encontraban en uci; la incidencia de eventos adversos serios (eas) durante las 4 horas siguientes a la transfusión de plasma convaleciente fue < 1%, incluyendo mortalidad (0.3%); de los 36 eas reportados, hubo 25 incidentes reportados como eas relacionados, incluyendo 4 muertes, 7 eventos de taco, 11 trali y 3 reacciones alérgicas graves asociadas a la transfusión; sin embargo, solo 2 (de 36) eas fueron considerados definitivamente relacionados con la transfusión de plasma convaleciente por el médico tratante; en este grupo de pacientes, la tasa de mortalidad a los siete días luego de la administración del plasma convaleciente, fue del 14,9% (502) . a pesar que la tasa general de letalidad para la covid-19 parece ser aproximadamente 6.4% (503), la tasa de mortalidad reportada parece no ser excesiva si la comparamos con los informes de wuhan que sugieren tasas de letalidad del 14% para los pacientes hospitalizados (504) y 57% entre los pacientes en unidad de cuidados intensivos (139) . los nueve estudios mostraron mejoría en muchos aspectos, incluyendo el aclaramiento del virus, la disminución del suplemento de oxígeno y la ventilación mecánica, la normalización de los valores de laboratorio, y la recuperación en los hallazgos pulmonares radiológicos. todos los estudios, reportaron que no se presentaron eventos de seguridad o reacciones adversas serias relacionadas con la administración de plasma convaleciente en pacientes con covid-19, excepto en 2 casos relacionados, según criterio de los médicos tratantes, en el estudio publicado por joyner y cols (502) . esta serie de estudios son alentadores; sin embargo, la mayoría de los reportes de casos tienen limitaciones significativas: carecen de los ajustes para factores de confusión críticos, incluidos los co-tratamientos, las características basales, la gravedad de la enfermedad y el momento de administración del plasma y deben ser seguidas de investigaciones adicionales. para establecer mejor el papel del plasma convaleciente es necesario realizar estudios dirigidos a los siguientes escenarios: 1. el uso como profilaxis post-exposición 2. evaluar si el plasma convaleciente es útil en paciente con enfermedad leve 3. el efecto del plasma convaleciente en pacientes con enfermedad moderada 4. el tratamiento de rescate con plasma convaleciente en pacientes que requieren ventilación mecánica debido a covid-19 5. finalmente, trabajos que evalúen la seguridad y farmacocinética del plasma convaleciente en los pacientes pediátricos con alto riesgo. actualmente están en curso varios estudios para evaluar el tratamiento de pacientes infectados con sars-cov-2 con plasma convaleciente. una búsqueda realizada el 23 de mayo de 2020 en clinicaltrials.gov con los términos "plasma convaleciente y covid-19" mostró 82 ensayos en curso sobre el uso de plasma convaleciente en pacientes con amci ® covid-19, que nos ayudarán a resolver las inquietudes relacionadas con esta intervención (505) . page se recomienda no utilizar de rutina las las inmunoglobulinas hiperinmunes en pacientes con infección por sars-cov-2/covid-19. la inmunoglobulina hiperinmune (h-igiv) se deriva de individuos con altos títulos de anticuerpos contra patógenos específicos y se ha utilizado con éxito en el tratamiento de infecciones, como el citomegalovirus y la gripe h1n1 (506) . se propone que la inmunoglobulina hiperinmune combinada con medicamentos antivirales puede ser efectiva en el tratamiento de pacientes con covid-19, estos anticuerpos (ac) recogidos de los pacientes recuperados serán específicos contra covid-19 al aumentar la respuesta inmune en pacientes recién infectados (507) . existe evidencia más sólida para el uso de h-igiv en el tratamiento de enfermedades virales. cheng y cols en enero de 2005, realizaron una revisión retrospectiva en hong kong, que reveló que el plasma convaleciente de los sobrevivientes de sars-cov administrados a pacientes con sars-cov que tenían enfermedad progresiva resultó en tasas de alta significativamente más altas en el día 22 y tasas de mortalidad más bajas, en comparación con los controles históricos (485) . hung y cols en febrero de 2011, realizaron un estudio de cohorte prospectivo sobre la efectividad del plasma convaleciente de los sobrevivientes de h1n1 con un título de ≥ 1:160 ofrecido a pacientes de la uci con infección grave por h1n1; los pacientes que rechazaron las infusiones de plasma convalecientes fueron controles; veinte de los 93 pacientes recibieron sueros convalecientes, el tratamiento con plasma convaleciente condujo a una reducción significativa de la carga viral respiratoria, los niveles séricos de citocinas (il-6, il-10, tnfα) y la mortalidad (484) . posteriormente hung y cols en agosto de 2013, publicaron un estudio multicéntrico prospectivo, doble ciego, aleatorizado y controlado en el que compararon la efectividad de la inmunoglobulina hiperinmune (h-igiv) del plasma convaleciente de los sobrevivientes de h1n1 versus la inmunoglobulina iv (igiv) normal, en pacientes con h1n1 en uci con soporte respiratorio y recibiendo oseltamivir; este estudio mostró, una reducción de la carga viral y una mayor supervivencia en el grupo que recibió h-igiv dentro de los 5 días posteriores al inicio de los síntomas, demostrando la superioridad de la inmunoglobulina hiperinmune sobre la igiv en el tratamiento de la infección grave por h1n1(508). el uso de inmunoglobulina hiperinmune ha demostrado una clara efectividad en el tratamiento de la gripe y el sars-cov; sin embargo, el plasma se debe recolectar y procesar de pacientes convalecientes y verificar que tenga títulos adecuados. según la experiencia con el sars-cov, lo ideal es recolectar plasma de pacientes con un curso de enfermedad más leve (506) . poco se sabe sobre la seguridad de la inmunoglobulina hiperinmune cuando se usa para el tratamiento de infecciones por coronavirus, los riesgos incluyen la exacerbación de la infección dependiente de anticuerpos (antibody-dependent enhancement of infection -ade)(509); el ade puede ocurrir en varias enfermedades virales, e implica una respuesta inflamatoria exagerada ante la presencia de ciertos anticuerpos; sin embargo, los estudios en sars y mers no proveen información suficiente para extrapolarse a la infección por sars-cov-2. no se encontraron estudios con inmunoglobulina hiperinmune en el tratamiento de pacientes con covid-19. no se puede emitir una recomendación a favor o en contra para el uso de la inmunoglobulina intravenosa como tratamiento adyuvante en pacientes con covid-19 severo. se debe considerar la inmunoglobulina intravenosa como tratamiento adyuvante en pacientes con covid-19 severo, en el contexto de estudios clínicos en los siguientes escenarios. escenario a (enfermedad severa), definida como uno o más de los siguientes: disnea, frecuencia respiratoria > 30/min, spo2 < 93%, pao2/fio2 < 300 o empeoramiento radiológico con aumento > 50% de los infiltrados pulmonares en 24 -48 horas. escenario b (enfermedad que amenaza la vida), definida como uno o más de los siguientes: falla respiratoria, choque séptico, o disfunción multiorgánica. en las enfermedades virales, los anticuerpos ejercen su efecto por neutralización viral (bloqueo de la entrada de células virales y, por lo tanto, replicación), activación del complemento, opsonización y mediación de citotoxicidad celular dependiente de anticuerpos. la neutralización viral es específica de antígeno; otras actividades antivirales son antígeno-inespecíficas y se realizan en parte a través de interacciones fc: fc receptor. en la infección por sars-cov-2, el principal antígeno objetivo asociado con la neutralización es la proteína spike, que es responsable de la unión del sars-cov-2 a las células epiteliales, incluidos los neumocitos; los anticuerpos en las inmunoterapias pasivas covid-19 son de naturaleza policlonal, con múltiples epítopos contra los paratopes de sars-cov-2, incluido el dominio de unión al receptor en la proteína spike (509) . la inmunoglobulina intravenosa (igiv) es un producto derivado del plasma de miles de donantes utilizados para el tratamiento de inmunodeficiencias primarias y secundarias, afecciones autoinmunes/inflamatorias, trastornos neuroinmunológicos y secuelas relacionadas con infecciones; la igiv proporciona protección inmune pasiva contra una amplia gama de patógenos; actualmente, la experiencia con el uso de igiv en el tratamiento de la infección por sars-cov-2 es muy limitada; sin embargo, la justificación del uso de ivig en la infección por sars-cov-2 es la modulación de la inflamación (506) . la igiv se ha usado en el tratamiento de otros coronavirus, incluido el sars cov. stockam y cols, en septiembre de 2006, en respuesta a una petición de "the world health organization -who", realizaron una revisión sistemática de los efectos del tratamiento en los pacientes con síndrome respiratorio agudo, incluida la igiv o el plasma convaleciente; se evaluaron cinco estudios sobre el uso de igiv o plasma convaleciente administrado además de corticosteroides y ribavirina, se consideró que estos estudios no fueron concluyentes ya que los efectos de la igiv o el plasma convaleciente no podían distinguirse de otros factores que incluían comorbilidades, estadio de la enfermedad o el efecto de otros tratamientos (477) . wnag y cols, en mayo 2004, hicieron un estudio prospectivo, en un solo centro, de infección por sars en taiwán, se administró igiv si el paciente tenía leucopenia amci ® o trombocitopenia, o si había progresión rápida de la enfermedad en la radiografía; un total de 40 pacientes recibieron igiv, de los cuales 22 tenían citopenias graves, uno de ellos tenía evidencia de síndrome hemofagocítico y 18 paciente tuvieron progresión radiológica de la enfermedad; el estudio sugiere que la igiv condujo a una mejora significativa en el recuento de leucocitos y plaquetas, pero reconoce que no había un grupo de control para evaluar objetivamente las respuestas (510) . lew y cols, en julio 2003, reportaron un estudio retrospectivo de un solo centro en singapur, se encontró que los pacientes adultos con sars tratados con un régimen de pulso de metilprednisolona (400 mg) e igiv (0.4 mg/kg) diariamente durante tres días consecutivos tuvieron una hazard ratio ajustada de 0.41 para mortalidad en comparación con el grupo no tratado, con una tendencia hacia una recuperación más temprana; sin embargo, este hallazgo no fue estadísticamente significativo (ic del 95%: 0.14 a 1.23; p = 0.11); además, este resultado tuvo como factor de confusión el uso concurrente de esteroides (511) . aunque algunas de las preparaciones de igiv comercializadas actualmente (gamunex-c y flebogamma) contienen anticuerpos que reaccionan de forma cruzada contra el sars-cov-2 y otros antígenos de virus, in vitro(512), hasta la fecha, ningún ensayo clínico de alta calidad ha demostrado eficacia y seguridad convincentes de igiv en epidemias de coronavirus. a pesar de que los datos para el uso de igiv en la infección por sars y mers son débiles, la dosis alta de ivig puede ser útil en la infección grave por sars-cov-2 a través de la modulación inmune, saturando fcγr y reduciendo ade (506) . en general, la inmunoglobulina intravenosa es bien tolerada y el perfil de seguridad es bien conocido. las reacciones adversas comunes son leves y autolimitadas, pero se sabe que en pacientes de alto riesgo se producen efectos adversos graves, como trombosis, disfunción renal y muerte. en cuanto la evidencia (tabla 18); xie y cols en abril, en wuhan, china, realizaron un estudio retrospectivo, revisando 58 casos de covid-19 severa (disnea, fr > 30/min, spo2 < 93% en reposo, pao2/fio2 < 300, progresión imagenológica > 50% en 24 -48 horas) o críticamente enfermos (falla respiratoria con ventilación mecánica, choque, disfunción orgánica múltiple) en el cual evaluaron la mortalidad a 28 días como desenlace primario y como desenlace secundario evaluaron la mortalidad a 14 días, días de estancia hospitalaria, de uci y la necesidad de ventilación mecánica; reportaron que el tratamiento con igiv dentro de las 48 horas posteriores al ingreso no sólo redujo el uso de la ventilación mecánica comparado con el tratamiento luego de 48 horas del ingreso (6.67% vs 32.14%, p = 0.016), sino que también redujo la duración de la estancia en el hospital (11.50 ± 1.030 vs 16.96 ± 1.620 días, p = 0.0055) y la uci (9.533 ± 1.089 vs 13.50 ± 1.632 días, p = 0.0453); mejorando en última instancia la mortalidad a los 28 días (p = 0.0215); concluyen, que el estudio demostró que el tratamiento con igiv en pacientes con covid-19 con neumonía grave puede mejorar los indicadores en poco tiempo y mejorar la eficiencia del tratamiento de los pacientes con alta efectividad (513) . el tratamiento con dosis altas de igiv (25 g/día durante 5 días) al inicio del distrés respiratorio, sumado al tratamiento de soporte y en un caso combinados con antivirales (lopinavir/ritonavir) y metilprednisolona en covid-19 grave publicado por cao y cols en marzo, en wuhan, china (514), demostró la elevación de los recuentos de linfocitos, disminución de los marcadores inflamatorios, recuperación de la oxigenación, resolución parcial/completa de las alteraciones radiológicas pulmonares y las pruebas de hisopos nasales y orofaríngeos negativos dentro de unos pocos días después del inicio tratamiento (< 6 días). lanza y cols en mayo 2020, reportaron en nápoles, italia, el caso de una mujer de 42 años que tenía covid-19 severa y que venía con deterioro clínico a la cual se le venía dando tratamiento con hidroxicloroquina más azitromicina, no se le administraron amci ® esteroides por el riesgo de disminuir la depuración de la viremia, a quién se le administró igiv el día 16 después de iniciados los síntomas con mejoría clínica rápida, normalización de los gases arteriales y disminución marcada de los infiltrados pulmonares al día 5 y 8 respectivamente; como evento adverso, reportaron hipotensión durante el inicio de la infusión que se mejoró al disminuir la velocidad de infusión. la paciente finalmente se recuperó, negativizó rt-pcr sars-cov-2 y fue dada de alta (515) . se recomienda la tromboprofilaxis farmacológica en todos los pacientes confirmados o sospechosos de covid-19 severo, a menos que está contraindicada, en cuyo caso es razonable la implementación de profilaxis no farmacológica. en términos generales se reconoce que los pacientes hospitalizados con enfermedad médica aguda, incluidas infecciones como la neumonía, tienen un mayor riesgo de eventos tromboembólicos (516) . tang y cols, en china describieron múltiples trastornos de la coagulación en pacientes con covid-19, aquellos pacientes que no sobrevivieron tenían significativamente mayores niveles de dímero-d y productos de degradación de la fibrina y con tiempos de coagulación convencionales más alargados al ingreso (p < 0.05); 71.4% de los no sobrevivientes y 0.6% de los sobrevivientes cumplían criterios para coagulación intravascular diseminada(517); este mismo grupo realizó un estudio con 449 pacientes con covid-19 severo, pacientes con coagulopatía asociada a covid-19 (cac), definida por un sic score ≥4 la utilización de tromboprofilaxis redujo de manera significativa la mortalidad a 28 días (40.0% vs 64.2%, p = 0.029) así como también en aquellos con un se recomienda no utilizar de rutina antiagregación en pacientes con covid-19 severo con el fin de prevenir desenlaces neurológicos adversos. no se encuentran estudios en la literatura para el uso de antiagregantes para el manejo específico del covid-19; el manejo de los eventos cardiovasculares en pacientes covid-19 no difiere de la población general sin la enfermedad. no se establecen diferencias en los estudios descritos, ni en las publicaciones hasta la fecha de la revisión (518) . no se puede emitir una recomendación a favor o en contra sobre el uso de la anticoagulación terapéutica de rutina con heparinas de bajo peso molecular o heparina no fraccionada en pacientes con bajo riesgo de sangrado y con un curso clínico grave o crítico, que además tengan elevación del dímero d mayor a 1 mcg/ml (1000 ng/ml) y/o fibrinógeno mayor a 900 mg/dl. diferentes publicaciones describen como una estrategia de tratamiento basada en profilaxis con heparina de bajo peso molecular (hbpm) para tratar la coagulopatía grave por covid-19 podría no ser suficiente. especialmente porque estos pacientes tienen dentro de su coagulopatía, una predisposición mayor a la presencia de trombosis que al sangrado. además, los bajos niveles de antitrombina que se han descrito en estos pacientes, los hace más resistentes a la heparina, lo que sugiere que las dosis profilácticas ya sea de heparina no fraccionada o hbpm pueden ser inadecuadas(519-521). 135 asociación colombiana de medicina crítica y cuidados intensivos. amci ® no se puede emitir una recomendación a favor o en contra sobre la anticoagulación terapéutica de rutina con heparinas de bajo peso molecular en pacientes con covid-19 en estado crítico, que presenten elevación del dímero d mayor a 1 mcg/ml (1000 ng/ml). tang y cols, en china con un estudio retrospectivo donde se incluyeron 449 pacientes con covid-19 severo, se evaluó la presencia de trombosis como desenlace asociado. este estudio describe como niveles de dímero d por encima de 1500 ng/ml estaban asociados a una mayor probabilidad de muerte y en estos pacientes el tratamiento anticoagulante reduce de manera significativa la mortalidad (0.44, ic 95% 0.22-0.86) (156, 521) . no se puede emitir una recomendación a favor o en contra para la medición rutinaria de niveles de anti xa en pacientes con covid-19 en los que se decide hacer anticoagulación terapéutica con hbpm. se puede considerar la medición de niveles anti xa si se cuenta con la disponibilidad del recurso. harr y cols, en un estudio en donde se incluyeron pacientes con hiperfibrinogenemia relacionada a trauma, se evidenció como los niveles de fibrinógeno se correlacionaron significativamente con la consistencia del coágulo y adicionalmente como se genera una relación inversa entre los niveles de fibrinógeno y la actividad de las hbpm, lo que sugeriría una potencial resistencia a la heparina. basados en que los pacientes covid-19 presentan niveles de fibrinógeno en muchas ocasiones con niveles > 700 mg/dl e incluso >900 mg/dl lo que hace razonable considerar que aquellos pacientes covid-19 que requieren dosis terapéuticas de hbpm y es posible evaluar los niveles de anti xa, hacer ajustes y monitoreo del nivel de anticoagulación sería una opción razonable (522) . se recomienda el uso de hbpm o hnf para la anticoagulación terapéutica en pacientes con una indicación específica con diagnóstico de covid-19. amci ® como previamente se describió, una revisión sistemática comparó las dosis fijas de hbpm subcutánea con dosis ajustadas de hnf intravenosa o subcutánea en personas con clínica sugestiva de tep, esta revisión demostró que la incidencia de tep recurrente fue menor con hbpm que en los participantes con hnf (or 0.71, ic 95% 0.56 a 0,90), también se asoció con una reducción en el tamaño del trombo (or 0.71, ic 95% 0.61 a 0.82), evidencia de baja calidad. sin embargo, no hubo diferencias en la mortalidad general entre los participantes tratados con hbpm y los tratados con ufh (or 0.84, ic 95% 0.70 a 1.01). por otra parte, los protocolos de manejo en escenarios de coagulación intravascular diseminada (cid), proponen el uso de hnf por encima de la hbpm en pacientes en los que se indica la anticoagulación. más aún, la presencia de falla renal aguda es común en los pacientes con covid-19, por lo que la opción de tratamiento con hnf tiene también escenarios en donde podrían ser de elección (519, 523) . capítulo 8. procedimientos y covid-19 recomendación se recomienda realizar la preoxigenación en pacientes con sospecha o diagnóstico de covid-19, cuando estén disponibles, en áreas de presión negativa con mínimo 12 recambios de aire por hora o en instalaciones con ventilación natural o que tengan un recambio de aire de mínimo 160 l/seg si están disponibles. se recomienda como complemento opcional durante la preoxigenación en el paciente crítico con diagnóstico o sospecha de covid-19 la caja de acrílico para protección durante la intubación, la caja no protege contra la generación de aerosoles fuera de esta y requiere para su uso, entrenamiento previo. si es difícil su uso retírela inmediatamente. se recomienda utilizar en la mascarilla quirúrgica sobre la mascarilla de oxigenación en el paciente crítico con sospecha o diagnóstico de covid-19. se recomienda utilizar filtros hpfa entre la máscara y el dispositivo disponible para la preoxigenación en el paciente crítico con sospecha o diagnóstico de covid-19. se recomienda en el paciente con sospecha o diagnóstico de covid-19 preoxigenación por 3 a 5 min, si el paciente luego de 3 minutos no tiene incremento en la mejoría inicie la administración de medicamentos. se recomienda en caso de compromiso hemodinámico considerar ventilación a dos manos con cierre hermético de la máscara sobre la cara del paciente con frecuencias altas (>25 por minuto y baja presión). amci ® fundamento el manejo de la vía aérea es un procedimiento considerado generador de aerosoles, la enfermedad covid-19 tiene una alta tasa de transmisión y el personal de salud requiere el uso estricto del epp (524, 525) , revise el enunciado para epp recomendado en esta guía. la posibilidad de permanencia del virus en algunos ambientes puede durar hasta 4 horas, por esto una estrategia para proteger al equipo de salud y otros pacientes podrías ser estar en áreas con presión negativa, lo cual no es fácil de encontrar en nuestro contexto o que tenga un adecuado recambio de aire(526). como medidas complementarias se pueden utilizar opciones como las cajas acrílicas para intubación, esta disminuye el riesgo de contaminación por gotas, pero no elimina los aerosoles, es necesario previo entrenamiento. en caso de que la caja sea una limitante retírela inmediatamente (527) . los pacientes covid-19 , clásicamente se presentan con tos, esto es un factor de riesgo para quienes manipulan la vía aérea, la utilización de mascarilla por parte del paciente debajo del dispositivo bolsa mascarilla , la cual también deberá tener un filtro de alta eficiencia para disminuir el número de partículas que pueden estar en el ambiente durante la preoxigenación y posible ventilación, ésta última la cual será evitada al máximo (524, 526, 528) . la preoxigenación es una técnica que pretende barrer el nitrógeno y aumentar la disponibilidad de oxígeno para que cuando el paciente presente apnea por los medicamentos para la intubación o por su condición clínica, se disponga de un tiempo mayor sin desaturación crítica y riesgo de colapso cardio-respiratorio. considere que los pacientes con formas moderadas y severas de covid-19, pueden tener más comprometida esta reserva respiratoria y puede no ser efectiva la preoxigenación y cuando inicia la apnea, la desaturación será más precoz. si después de 3 minutos de preoxigenación no hay mejoría de la saturación arterial, considere fallida esta maniobra y considere mayor riesgo de hipoxemia severa con probabilidad de bradicardia extrema y paro cardiorrespiratorio. en caso de requerir ventilación por disminución rápida de la saturación de oxígeno arterial y considere necesario ventilación manual bolsa mascarilla a dos manos no debe ser vigorosa y debe utilizar filtros hpfa, estos reducirán los aerosoles en el ambiente(526, 529). se recomienda la utilización de cajas de acrílico para intubación del paciente con sospecha o diagnóstico de covid-19 como complemento durante la intubación para disminuir el riesgo de contaminación por gotas, sin embargo, no protege 100 % la generación de aerosoles y si ésta hace más difícil la intubación retírela inmediatamente. amci ® se recomienda minimizar los intentos de intubación orotraqueal en el paciente con sospecha o diagnóstico de covid-19, el primer intento debe procurar ser realizado por el más experimentado en el manejo de la vía aérea. se recomienda la intubación con videolaringoscopio en pacientes con covid-19 teniendo en cuenta disponibilidad y entrenamiento); esta alternativa puede ofrecer ventajas frente a la laringoscopia tradicional. se recomienda administrar medicamentos para asegurar la vía aérea en secuencia de inducción rápida, para obtener en el menor tiempo posible condiciones para la intubación (45 a 60 s). se recomienda en caso de intubación fallida por personal experto, considerar dispositivos supraglóticos como las máscaras laríngeas como medida de rescate con el riesgo de generación de aerosoles. se recomienda contar con disponibilidad de vasopresor y atropina en el sitio donde se realizará la intubación. en caso de contar con lidocaína se recomienda utilizar a dosis de 1 mg/kg sin epinefrina. administrada 3 minutos antes de la intubación. como se describió en el aparte de preoxigenación, se deben garantizar todas las medidas basadas en bioseguridad y protección adecuada para el personal de la salud, ubicación en áreas que cuenten con presión negativa o salas con un óptimo recambio de aire pueden ayudar a disminuir el riesgo de contagio. las medidas complementarias como la caja de taiwán o caja de intubación puede complementar de forma opcional estas medidas durante el proceso de aseguramiento definitivo de la vía aérea pero no garantiza 100 % la eliminación de aerosoles, pudiendo ser un obstáculo para quien realiza la intubación, de ser así, se deberá retirar inmediatamente, por eso sólo es un complemento al epp, que es la verdadera protección en estos escenarios (se debe incluir máscaras n95 o ffp2 fpp3) (524, 527) . el paciente críticamente enfermo puede tener comprometida de forma significativa su reserva respiratoria y hemodinámica por su cuadro clínico y puede empeorar por los medicamentos utilizados durante la intubación orotraqueal. las complicaciones en el manejo de la vía aérea se presentan cuando se realiza más de un intento dentro de los cuales están el traumatismo, desaturación e hipoxemia (530) . es por esto por lo que se debe procurar que el primer intento sea realizado por el más experimentado en el manejo de la vía aérea e idealmente se logre la intubación en el primer intento con la menor hipoxemia secundaria (166, 526, (531) (532) (533) . basado en el planteamiento anterior y considerando la ventaja de intubar pacientes críticamente enfermos en el primer intento dadas sus condiciones clínicas, la revisión de amci ® demandas asociadas a manejo de vía aérea en los estados unidos sigue siendo preocupante al considerar posibles causas la falta de entrenamiento y falta de aplicación de las guías y recomendaciones de manejo así como en la utilización de equipos adecuados para pacientes específicos (534) ; se ha planteado especialmente en los pacientes covid-19 los cuales tienen un importante compromiso pulmonar y alto riesgo de desaturación, la posibilidad de encontrar una vía aérea difícil no predicha y dificultades en su manejo(526, 533). es por esto que se requiere del mejor dispositivo para manejo de vía aérea invasiva disponible, siempre y cuando se cuente con el adecuado entrenamiento previo en su uso, la ventaja de los videolaringoscopio se debe a la superioridad al compararla con la laringoscopia convencional, siendo en algunos grupos la primera opción para intubaciones electivas (535, 536) . como se ha mencionado, el riesgo de una rápida desaturación en pacientes con enfermedad pulmonar, así como en pacientes con covid-19, se debe utilizar la inducción de secuencia rápida la cual se utiliza para pacientes con estómago lleno en los cuales se quiere lograr condiciones de inconciencia y de intubación óptimas en el menor tiempo posible para disminuir el riesgo de broncoaspiración. en estos casos de falla respiratoria con tan mala reserva se quiere aprovechar la ventaja que ofrece esa técnica para tener en poco tiempo al paciente intubado con menor riesgo de desaturación. es así como los medicamentos en una inducción de secuencia rápida incluyen el opioide, hipnótico y relajante, estos dos últimos administrados simultáneamente y lavados con un bolo de 20 cc. la opción del opioide en nuestro contexto suele ser fentanilo a dosis de 2 a 5 mcg / kg iv, dando 2 a 3 minutos de latencia para su efecto, luego el hipnótico que puede ser propofol entre 1 y 1,5 mg / kg si la estabilidad hemodinámica lo permite o considera usar vasopresor simultáneo. en caso de preferir evitar la hipotensión la ketamina a dosis de 1 a 1, 5 mg / kg es una opción más estable hemodinámicamente. con relación al relajante neuromuscular la succinilcolina es la clásicamente utilizada dosis de 1 a 1,5 mg/kg pero debido a sus efectos secundarios como hiperpotasemia, fasciculaciones, mialgias y un importante riesgo de hipertermia maligna algunos grupos no lo consideran, el rocuronio a dosis de 1,2 mg/kg ha demostrado lograr tiempos y condiciones de intubación similar a la succinilcolina sin los efectos secundarios de esta (533, 535) algunos grupos han considerado no utilizarlos si la condición clínica del paciente es crítica pues éste período de latencia puede ser acompañado de una hipoxemia severa y paro cardíaco, por lo tanto sólo usan hipnótico y relajante neuromuscular. ante una vía aérea difícil no predicha en la cual no se logre la intubación, considere los dispositivos supraglóticos como las máscaras laríngeas los cuales son más fáciles de insertar en comparación con la técnica de intubación orotraqueal, y deben estar dentro del planeamiento y organización de elementos para manejo de la vía aérea invasiva. al lograr ventilar con este dispositivo se logrará una recuperación del paciente, pero se pueden generar aerosoles pues este mecanismo de cierre puede permitir escape de aire y macropartículas durante el ciclo respiratorio ya sea manual o mecánico (535, 536) . el cuadro clínico de pacientes críticos y particularmente covid-19, puede asociarse a inestabilidad hemodinámica y requerimiento de soporte vasopresor. la adición de medicamentos como los opioides o hipnóticos pueden asociarse a hipotensión la cual puede no responder a volumen, es necesario evitar episodios de hipotensión en especial en pacientes ancianos, con enfermedades cardiovasculares de base las cuales pueden tolerar menos estos cuadros de hipotensión, así como también pueden favorecer amci ® desbalance en la relación ventilación/perfusión a nivel pulmonar empeorando los cuadros de hipoxemia. la hipoxemia puede acompañarse de bradicardia y si no se corrige la ventilación o la bradicardia es muy probable que el paciente presente paro cardiorrespiratorio, por lo cual se recomienda utilizar una dosis de atropina para corregir la bradicardia, no mejorará la oxigenación, pero tendrá un tiempo adicional para recuperar la oxigenación y ventilación del paciente. en estos casos debe tener disponibles vasopresores y atropina desde el planeamiento de los medicamentos necesarios para el manejo de la vía aérea (166) . se recomienda la intubación orotraqueal oportuna y no retrasar el inicio de la ventilación mecánica invasiva en los pacientes con sdra severo por covid-19 debido a mayor riesgo de desenlaces adversos. fundamento definir el momento de la intubación en esta población es un reto. la mayoría de los autores recomiendan el inicio "temprano" de la ventilación mecánica, sin embargo, la definición de cuando es temprano no es clara. este punto es motivo de análisis dado que a la luz de la evidencia actual la utilización de métodos no invasivos como la ventilación no invasiva y la cánula de alto flujo, para manejo inicial de pacientes con algún grado de hipoxemia es controvertido entre otras por el riesgo que supone al personal sanitario al ser un procedimiento generador de aerosoles. en el 2015 un estudio mostró que la intubación retrasada después de la falla al utilizar cánula de alto flujo o la ventilación no invasiva para pacientes con insuficiencia respiratoria moderada y grave se asoció con una mayor mortalidad. publicaciones recientes muestran que solo la quinta parte de los pacientes que murieron por covid-19 recibieron ventilación mecánica invasiva y soporte respiratorio más agresivo antes de la muerte, lo que indica que en muchos pacientes se habría retrasado la intubación. de los pacientes fallecidos solo el 27% recibieron tratamiento de oxígeno nasal o con mascarilla facial antes de su muerte. esta baja proporción puede tener varias explicaciones. primero, algunos pacientes con hipoxemia severa no tenían otros síntomas, como dificultad para respirar o disnea, es decir, desarrollaron una especie de hipoxemia silenciosa. en segundo lugar, la falta de suficientes ventiladores mecánicos invasivos es una razón importante que evitaría que los pacientes reciban intubación. tercero, el manejo de estos pacientes por un equipo de médicos no intensivistas; por lo tanto, pueden no estar seguros del momento en que un paciente requiere intubación. la serie de casos de la epidemia de covid-19 en wuhan mostró que la intubación tardía era común en la etapa inicial de la epidemia, mostrando que una de esas posibles razones del retraso incluía falta de ventiladores mecánicos invasivos y falta de capacitación clínica específica para el soporte respiratorio. recomendación se recomienda tomar la decisión de intubación orotraqueal en el paciente crítico con sospecha o diagnóstico de covid-19 utilizando una combinación de variables clínicas, gasométricas y hemodinámicas. tabla la intubación orotraqueal (iot) efectiva y segura, programada debe prevenir el colapso respiratorio y hemodinámico. siempre es necesario asegurar la escena del procedimiento de intubación con las consideraciones técnicas y de protección personal adecuadas. conocer los pasos para la realización del procedimiento de intubación orotraqueal (iot) contextualizados al paciente covid-19, reduce los riesgos innecesarios. la iot es un procedimiento generador de aerosoles por lo tanto lo ideal es realizarlo en una habitación con presión negativa, sin embargo, la baja disponibilidad en el país obliga a utilizar otras alternativas de seguridad. una habitación de presión negativa es un cuarto que tiene una presión más baja que las áreas adyacentes, lo que mantiene el flujo de aire fuera de la habitación y hacía habitaciones o áreas contiguas. las puertas de la sala deben mantenerse cerradas, excepto al entrar o salir de la sala, y la entrada y la salida deben minimizarse. la intubación en el paciente crítico con covid-19 es de los procedimientos que mayor riesgo de aerosolización tiene, por lo tanto, se debe adoptar una posición de intervención oportuna, pero también segura, para evitar desenlaces desfavorables en el paciente y disminuir el riesgo de contaminación en el personal de salud, se recomienda individualizar cada caso mediante la combinación y análisis de los criterios clínicos, gasométricos y hemodinámicos de cada paciente. (533, (537) (538) (539) se recomienda no realizar de rutina broncoscopia en los pacientes con sospecha o diagnóstico de covid-19, debido al riesgo de generación de aerosoles. se puede considerar en atelectasias masivas con compromiso significativo de la oxigenación adicional a la lesión pulmonar per sé y la hemorragia alveolar para control local directo. en general la realización de broncoscopia en pacientes con sospecha o confirmación de covid-19 debe ser evitada y realizarse sólo con indicación de emergencia como cuerpo extraño en la vía aérea, hemoptisis masiva, obstrucción grave de la vía aérea central o atelectasia lobar o pulmonar completa(540). esto debido a la alta carga viral en la mucosa nasal y faríngea de los pacientes con infección por sars-cov-2 (102) y la alta producción de aerosoles infecciosos que se generan durante este procedimiento. en caso de ser necesaria su realización, deberá ser llevada a cabo por el operador con mayor experiencia amci ® minimizando el tiempo de exploración y el personal expuesto en la sala. es mandatorio utilizar epp completo que incluya respirador fpp2 o fpp3, bajo protocolo supervisado de donning y doffing (541) . son de elección los broncoscopios desechables de un solo uso, pero de no ser posible se prefiere el uso de un broncoscopio flexible por encima de uno rígido por la más fácil manipulación de este. idealmente el procedimiento se llevará a cabo en el mismo cubículo del paciente que deberá contar con presión negativa y recambio de aire de 12 a 15 veces por hora. recomendación se recomienda no realizar de rutina la broncoscopia para la recolección de muestras para el diagnóstico de covid-19 en el paciente críticamente enfermo. la broncoscopia es una prueba de segunda elección para la toma de muestras respiratorias en los pacientes con sospecha o confirmación de covid-19 (542) . la toma de muestras del tracto respiratorio superior por hisopado nasofaríngeo u orofaríngeo es el método primario y de elección para determinar la infección por sars-cov-2. solo si resultaran dos pruebas negativas y persistiera una alta sospecha diagnóstica estaría indicado tomar muestras del tracto respiratorio inferior por broncoscopia, ya sea aspirado endotraqueal (bas) o lavado bronco alveolar (bal) (543), prefiriendo la realización de minibal para la recolección de muestras (540). las muestras deberán ser recogidas en un recipiente estéril, e introducidas en una bolsa con autocierre. deben manejarse con cuidado extremo evitando manipulaciones innecesarias y bajo protocolos de protección para el personal que las maneja, y trasladarse al laboratorio para su análisis. pueden almacenarse a 2-8ºc las primeras 72 h de su recolección; si se demorara más el análisis, precisa almacenarse a temperatura de -70ºc (124) . en una serie china la sensibilidad del bal fue de 93% frente a 72% en muestra de esputo (no recomendada) y 63% en hisopado nasofaríngeo (128) por lo que el especialista que realiza el procedimiento deberá sopesar el riesgo de este procedimiento en cada caso, valorando que se beneficiarán aquellos pacientes que tengan una indicación adicional para su realización. se recomienda la realización de la traqueostomía cuando está indicada, en los pacientes covid-19 sospechosos y confirmados con pronóstico razonable de vida, después del 5 o 7 día de ventilación , previa valoración y consenso por el equipo quirúrgico y de cuidado intensivo, asegurando que las condiciones clínicas, ventilatorias y hemodinámicas se encuentran controlada. en el contexto de pacientes hospitalizados en cuidado intensivo, la traqueostomía se realiza para facilitar el destete de la ventilación mecánica, mejorar la limpieza de la vía aérea y el manejo de las secreciones, aumentar la comodidad de los pacientes y la movilización y disminuir la probabilidad de complicaciones como la estenosis traqueal; sin embargo no hay una clara disminución en la mortalidad (544) (545) (546) . la infección actual por sars-cov2, tiene diferentes estadios de gravedad, uno de ellos es el compromiso pulmonar el cual se caracteriza por un síndrome de dificultad respiratorio agudo (sdra). de acuerdo con el comportamiento de la covid-19, entre un 10% a un 15% de los pacientes requieren ventilación mecánica (115, 121) , este grupo de pacientes con manifestación grave del compromiso pulmonar requiere estrategias de protección pulmonar en la ventilación mecánica, sedación profunda y posiblemente parálisis muscular y puede tener una mortalidad entre el 30% y el 50% (48, 547) . una de las principales características en éste grupo de pacientes es la mortalidad temprana, definida ésta como aquella que se produce en menos de 14 días; de acuerdo a la experiencia en wuhan, china; leung (548), reporta que la mortalidad se presenta en los primeros cinco días luego de la admisión hospitalaria y de acuerdo a lo referido por graselli et al (287) , en la región de lombardía, italia, la mediana de mortalidad se presenta al día siete después del ingreso. con estas consideraciones, al principio de la pandemia y en las aproximaciones iniciales no se recomendaba realizar la traqueostomía en los primeros 14 días posteriores a la intubación orotraqueal. sin embargo, con el conocimiento de la fisiopatología y las experiencias en otras series, como medida para facilitar la liberación de la ventilación mecánica, se ha podido realizar el procedimiento después de la primera semana de inicio de la ventilación. de acuerdo con el curso natural de la enfermedad, el paciente en promedio se intuba al día 10 a 12 de iniciado los síntomas, una semana posterior a la intubación para la traqueostomía, estaríamos alrededor del día 21 de la enfermedad, donde los pacientes ya tendrán una disminución de la carga viral. esto sin embargo no evita la utilización de los epp necesarios. esta medida en específico fue discutida y consensuada entre la sociedad de medicina critica amci y la asociación colombiana de cirugía. no existe evidencia que permita evaluar el riesgo real de infección del personal asistencial de los pacientes con sospecha o diagnóstico de covid-19 en la realización de traqueostomías. se debe considerar en la traqueostomía y la realización de ésta como un procedimiento generador de aerosoles (organización mundial de la salud). se recomienda que los epp requeridos para la realización del procedimiento, deben incluir máscaras ffp3 o n95, protección ocular, vestido antifluido idealmente desechable y amci ® guantes; este nivel de protección representa el mayor nivel de seguridad para realizar el procedimiento en el paciente con sospecha o diagnóstico de covid-19. no existe actualmente artículos que permitan evaluar cual es el riesgo real de infección del personal asistencial en la realización de traqueostomías en pacientes con covid-19; quizás el ejemplo más cercano, es una serie de casos, reportada durante la epidemia del síndrome respiratorio agudo grave en el 2004 (549), en el cual se realizaron 23 traqueostomías sin ninguna infección del personal, en este reporte se aseguró un adecuado uso del equipo de protección personal (epp), el cual incluía las medidas de barrera, máscaras ffp3 y cuando existía la disponibilidad, respiradores con suministro de aire purificado. la traqueostomía y la realización de ésta es considerada por la organización mundial de la salud (oms) un procedimiento generador de aerosoles, bajo esta perspectiva, el epp requerido para la realización del procedimiento, debe incluir máscaras ffp3 o n95, protección ocular, vestido antifluido idealmente desechable y guantes; este nivel de protección representa el mayor nivel de seguridad para realizar el procedimiento mencionado. es obligatorio, que todo el personal reciba el entrenamiento para la postura, el uso y el retiro de los epp, si estos pasos no se realizan de la forma adecuada, representan una fuente de contaminación(550). se recomiendan no esperar la negativización de la pcr para sars-cov2 para realizar la traqueostomía en el paciente con diagnóstico de covid-19. fuerte en contra fundamento los estudios de zou et al y lescure et al (102, 551) , muestran que la carga viral de los hisopados nasales y faríngeos es elevada en la primera fase de la enfermedad, con una disminución entre el día nueve al quince, pero esta puede permanecer detectable hasta por tres semanas (37) . existen recomendaciones acerca de la necesidad de realizar la traqueostomía una vez la pcr para sars-cov2 sea negativa (552, 553) ;aunque este esquema suena lógico, es importante tener presentes las siguientes consideraciones. la sensibilidad de una sola muestra para ruta-pcr puede ser sólo del 70%(554) y es posible que sea necesario realizar una segunda prueba para minimizar el riesgo para quien realiza el procedimiento, aunque esta aproximación no siempre puede ser viable desde el punto de vista clínico, epidemiológico y administrativo. amci ® recomendamos que la mejor estrategia es diferir la realización de la traqueostomía hasta 5 7 días luego de la intubación cuando esta indicada, con el conocimiento acerca de la evolución natural de la enfermedad, en ese momento en la mayoría de los pacientes, lo más probable es que la condición ya se encuentre en la tercera semana desde el inicio de los síntomas, en cuyo caso lo más probable es que ya exista una disminución de la carga viral; este hecho no evita que se deba utilizar de la forma correcta los epp. recomendación se recomienda escoger la técnica teniendo en cuenta la experticia que tenga en el grupo tratante y la anatomía del paciente para la decisión de la técnica. se recomienda la guía ecográfica para disminuir la probabilidad de complicaciones del procedimiento si la anatomía es desfavorable para la realización de traqueostomía percutánea. se recomienda la traqueostomía quirúrgica en pacientes de riesgo elevado de complicaciones donde se requiere un control más rápido y seguro de la vía aérea. se recomienda no utilizar de forma rutinaria la utilización de broncoscopia para la realización de traqueostomía por vía percutánea. no hay evidencia directa hasta la fecha de publicación del consenso si existe superioridad entre las dos técnicas en el paciente con sospecha o diagnóstico covid-19. en pacientes críticos no existen diferencia en los desenlaces cuando se evalúa el rendimiento de la técnica percutánea y la técnica quirúrgica, la elección de uno u otro método está dado por la anatomía del paciente, el entrenamiento de los profesionales y la disponibilidad de los diferentes insumos y técnicas. tampoco se ha logrado hasta la fecha evaluar durante la pandemia de covid-19 si existe una diferencia entre las dos técnicas y por lo tanto no es posible acercarse a una recomendación basada en la literatura. sin embargo, es importante que para la decisión de la técnica a utilizar se considere la anatomía del paciente y los siguientes aspectos:  no se recomienda la utilización de broncoscopia para la realización de traqueostomía por vía percutánea, ésta aumenta la generación de aerosoles y el número de personas expuestas a estos (555, 556) . amci ®  si la anatomía es desfavorable para la realización de traqueostomía percutánea, la guía ecográfica puede disminuir la probabilidad de complicaciones del procedimiento (557) .  la traqueostomía quirúrgica es una alternativa para la realización del procedimiento en las unidades de cuidado intensivo en momentos de sobrecarga laboral y adicionalmente puede tener un mejor y más rápido control de la vía aérea, especialmente en pacientes con riesgo elevado de complicaciones (549) . recomendación se recomienda el uso de la terapia ecmo en sdra severo refractario por covid-19 (pao2/fio2 < 150, posición prona, requerimiento de relajantes neuromusculares en algunos casos vasodilatadores pulmonares y maniobras de reclutamientos) sin respuesta clínica manifestado por:  pao2/fio2 < 60 mmhg por mas de 6 horas  pao2/fio2 < 50 mmhg por mas de 3 horas  ph < 7.20 + paco2 > 80 mmhg por mas de 6 horas además del criterio anterior, se recomienda tener en cuenta la edad, las comorbilidades y la expectativa de sobrevida del paciente con buena calidad de vida y en circunstancias donde no exista limitación de recursos. no hay estudios clínicos aleatorizados sobre el uso del ecmo en pacientes con covid-19 (166, 558) . existe el estudio eolia (216) , el cual fue detenido durante su realización, y de acuerdo a un análisis bayesiano posterior puede interpretarse como una disminución de la mortalidad en los pacientes en ecmo con sdra severo (211, 216, (559) (560) (561) (562) . de igual manera debe considerarse la racionalización de los recursos y el estado de prevalencia de la pandemia en un lugar determinado. el inicio de la terapia puede evaluarse en función de la cantidad de pacientes en falla respiratoria y la disponibilidad de personal y otros recursos; si el hospital debe comprometer todos los recursos en proveer medidas básicas de cuidado intensivo no debe utilizar el ecmo (563, 564) . los pacientes jóvenes sin comorbilidades son considerados de alta prioridad al igual que los trabajadores de la salud (565, 566) . amci ® se recomienda no desarrollar nuevos centros de ecmo en época de pandemia, sobre todo en situaciones con limitación de recursos. fuerte en contra fundamento actualmente se recomienda el uso del ecmo con las mismas indicaciones para sdra basado en la capacidad de las instituciones de salud para iniciar éste tipo de terapias (567) . en épocas de crisis la capacidad de los hospitales está saturada y obliga a la reubicación y optimización de los recursos (568, 569) . los centros que ofrecen la terapia en ecmo deben ser centros con resultados favorables y tiempos de soporte de pacientes relativamente cortos (570) . cuando estamos en tiempos de capacidad hospitalaria convencional y existe disponibilidad de camas de cuidado intensivo se pueden ofrecer los servicios de ecmo vv, va, e-cpr inclusive a pacientes no covid-19, cuando estamos en contingencia y capacidad nivel 1 se debe hacer un triage respecto a pacientes jóvenes y ofrecer ecmo vv, va, escoger muy bien los casos para pacientes no covid-19 y no ofrecer e-cpr, cuando estamos en contingencia y capacidad nivel 2 es porque ya se están usando sitios de expansión y están casi saturados se restringe el ecmo a todas las indicaciones y se prioriza a pacientes con indicaciones no covid-19 con mayor riesgo de sobrevida, el ecmo vv queda para pacientes jóvenes, con disfunción de 1 órgano y covid-19 positivo, no se ofrecerá ecmo va o e-cpr y cuando estamos en capacidad de crisis es porque la capacidad total hospitalaria está sobresaturada y no es posible realizar ecmo tanto en pacientes covid-19 como en los no covid-19 (564, 571) . se recomienda practicar e implementar medidas de capacitación y vigilancia continua para mejorar la higiene de manos, evaluando la adherencia a protocolos establecidos en los trabajadores de la salud mediante listas de chequeo y supervisión para evitar infecciones cruzadas en el entorno del paciente con sospecha o diagnóstico de covid-19. se recomienda establecer protocolos específicos para reducir el riesgo de infecciones que se deriven de la interacción y el cuidado del paciente crítico con sospecha o diagnóstico de covid-19. amci ® se recomienda implementar prácticas de cuidado para la prevención de contagio de covid-19. se debe utilizar el equipo de protección personal (epp) para la prevención de enfermedades de componente infeccioso asociado a exposición con fluidos corporales derivados del paciente crítico con sospecha o diagnóstico de covid-19. las infecciones relacionadas con la atención sanitaria (iras) son definidas por la organización mundial de la salud como aquellas "infecciones que se presentan en un paciente durante el proceso de atención en un hospital u otro centro sanitario que no estaban presentes o no se estaban incubando en el momento del ingreso; se incluyen las infecciones contraídas en el hospital pero que se manifiestan tras el alta hospitalaria y también las infecciones profesionales entre el personal del centro sanitario". las iras representan una importante carga de enfermedad que se asocia a un impacto negativo en la economía del paciente y del sistema sanitario. la organización mundial de la salud plantea la higiene de manos como la principal medida necesaria para reducir y prevenir las iras; por esta razón establece directrices sobre la higiene de manos en la atención sanitaria y basada en esta propone la estrategia multimodal para la mejora de higiene de manos. las estrategias mencionadas anteriormente han demostrado el incremento en el cumplimiento de higiene de manos y disminución en las infecciones relacionadas con la atención en salud. la estrategia multimodal se articula a través de cinco componentes: cambio del sistema, formación, evaluación/ retroalimentación, recordatorios en el lugar de trabajo clima institucional. a través de estos componentes, se garantiza que el centro sanitario cuenta con la infraestructura necesaria para practicar adecuadamente el lavado de manos incluyendo dentro de este el acceso a un suministro seguro continuo de agua, jabón, preparado alcohólico y toallas; a su vez se proporciona educación, evaluación y retroalimentación con regularidad a todos los profesionales sanitarios (572 se recomienda realizar un plan de cuidados organizado y específico en paciente crítico con sospecha o diagnóstico de covid-19, ofreciendo el uso óptimo de recursos e intervenciones. se recomienda evitar el uso de excesivo de papelería relacionada con los registros usados para gestión de insumos y atención de los pacientes. se recomienda realizar intervenciones educativas enfocadas a mejorar la adherencia y adecuado uso de los epp. se debe procurar el cuidado de los elementos de protección personal bajo un protocolo que conserve las condiciones de integridad de estos. la actual reserva de elementos de protección personal (epp) es insuficiente debido al aumento de la demanda global, por el incremento de casos de covid-19 y por la información errónea que ha conllevado a compras de pánico y almacenamiento. por esta razón la organización mundial de la salud a través de su guía: uso racional del equipo de protección personal para la enfermedad por covid-19 ha implementado las siguientes estrategias para optimizar la disponibilidad de (epp): usar los (epp) adecuadamente, minimizar la necesidad de (epp) y coordinar el suministro adecuado de (epp). (574) la duración máxima del uso continuo de la n95 es de 8 a 12 horas, siguiendo las recomendaciones del manual de medidas básicas para control de infecciones en ips de minsalud. pero en lo cotidiano, ningún trabajador tolera 8 a 12 horas continuas con un respirador. por esto, su uso continuo en el sitio de trabajo dependerá de la necesidad de pausar para comer, para ir al baño, etc. en este caso, se guardará en una bolsa de papel para su nueva colocación, si tiene menos de 12 horas, se desechará si está visiblemente contaminada o se torna húmeda. el reusó de la n95 dependerá de la casa del fabricante, de si contiene o no celulosa en su estructura del respirador. por ejemplo, la recomendación del consenso colombiano acin sobre la desinfección para los respiradores sin celulosa es con peróxido de hidrógeno vaporizado al 58% por 28 minutos. los respiradores n95 de uso industrial tienen mayor contenido de celulosa que los de uso médico por lo tanto para procesos de esterilización, solo los n95 de uso médico podrán ser esterilizados mediante de peróxido de hidrógeno vaporizado (sterrad®)(84-88). amci ® se recomienda elaborar el protocolo de pronación del paciente críticamente enfermo por covid-19, garantizando el entrenamiento al personal de salud, organizando el recurso humano, dispositivos de apoyo y tiempo establecido para cambios de posición para prevenir las lesiones por presión en el paciente. fuerte a favor fundamento la estrategia de pronación es una alternativa eficiente en el manejo del síndrome de dificultad respiratoria en pacientes críticos y es fundamental la gestión del profesional de enfermería en la prevención de complicaciones y eventos adversos, lo cual aportará significativamente a la calidad del cuidado ofrecido favoreciendo las mejoras en la oxigenación. es importante optimizar los cuidados de enfermería en torno de los cuidados de piel en los pacientes en ventilación mecánica en decúbito prono, los estudios han demostrado como principal complicación las lesiones de presión con una incidencia hasta de 25.7%, siendo las más frecuentes las grado 1 y 2(573). una lesión se puede producir si se supera una presión en el tejido capilar arterial de 32 mmhg denominándose interfaz de presión. basándose en lo anteriormente mencionado, el cambio de posición es un componente integral de la prevención y el tratamiento de las upp, con una justificación sólida y de amplia recomendación en la práctica de enfermería (575) . el uso de superficies especiales para el manejo de la presión (semp) a partir del estudio de defloor (576), se determinó un antes y un después en el uso de las semp en conjunción de los cambios posturales. este realizo un importante aporte para reducir la incidencia de lesiones por presión comparado con los colchones de estándar. se recomienda promover actividades para controlar el nivel de estrés en el personal durante las jornadas de trabajo: identificar y reconocer los propios límites, buscar o proponer ayuda psicológica profesional cuando sea requerido, promover estilos de vida saludables, y organizar los turnos de trabajo asegurando periodos de descanso. se recomienda compartir las emociones con pares y superiores, analizar objetivamente las situaciones adversas, manejar fuentes de información objetivas y científicas, realizar pausas activas durante el turno y brindar espacios grupales para expresar emociones, miedos e incentivar al equipo de trabajo reconociendo su labor. amci ® se recomienda utilizar recursos de salud mental ocupacional, apoyo por enfermedad y licencia familiar, además de garantizar una adecuada dotación de personal. los estilos de superación personal y el crecimiento psicológico desempeñan un papel importante en el mantenimiento de la salud mental de las enfermeras. es razonable suponer que los niveles de ansiedad y estrés entre los profesionales de la salud son proporcionalmente más altos que los de la población general debido al contacto directo con pacientes infectados. esto puede explicar por qué las enfermeras de primera línea son excepcionalmente vulnerables a la fatiga y al agotamiento (wang, okoli, et al.2020) , agotamiento mental, falta de moral del personal, control / autonomía de decisión, menor calidad de vida y baja satisfacción laboral (cheung y yip, 2015). (577) . una investigación reciente realizada en china continental menciona el impacto negativo de la pandemia de covid-19 en los trabajadores de atención médica de primera línea, incluidos los mayores niveles de ansiedad (shanafelt, ripp y trockel, 2020 ), depresión (xiang et al. 2020 ), estrés postraumático síntomas, soledad e impotencia (xiang et al.2020) (577, 578) . los aspectos traumáticos y estresantes de la participación en una pandemia también ponen en riesgo el daño psicológico a los médicos (579) . la experiencia psicológica de las enfermeras que atienden a pacientes con covid-19 se puede resumir en 4 temas: primero, las emociones negativas presentes en la etapa inicial consisten en fatiga, incomodidad e impotencia que fue causado por el trabajo de alta intensidad, el miedo y la ansiedad, y la preocupación por los pacientes y sus familiares. segundo, los estilos de auto afrontamiento incluyeron ajustes psicológicos y de vida, actos altruistas, apoyo de equipo y coordinación racional. tercero, encontramos crecimiento bajo presión, que incluía un mayor afecto y agradecimiento, desarrollo de posición de responsabilidad profesional y autorreflexión. finalmente, encontraron que las emociones positivas ocurrieron simultáneamente con emociones negativas(580). se recomienda ofrecer mecanismos de apoyo para amortiguar el estrés relacionado con la pandemia por covid-19. esto incluye intervenciones para pacientes y familias ofreciendo recursos de salud mental y educación al egreso, previo a este reforzar visitas virtuales. se recomienda anticipar las necesidades de salud mental de los pacientes, el personal y las familias para ofrecer una respuesta integral de salud pública. se debe incluir atención psicológica en la hospitalización para pacientes, familiares y personal afectado por covid-19. se recomienda proporcionar atención de salud mental en las comunidades, mientras que se requiere distanciamiento social y los recursos del sistema de salud son limitados. amci ® se recomienda mantener una estrategia de comunicación asertiva con la familia, teniendo en cuenta la formación del personal sobre las estrategias para comunicar malas noticias. ser solidarios con el duelo de las familias y acompañar el proceso de afrontamiento aún en la distancia, identificando factores de riesgo para patología mental o duelo complicado, utilizando los recursos institucionales de salud mental para mejorar las intervenciones. la pandemia tiene el potencial de crear una crisis secundaria de angustia psicológica y desbordamiento del sistema de salud mental. los miembros de la familia pueden experimentar angustia, miedo o ansiedad por la hospitalización de un ser querido, particularmente cuando las medidas de control de infecciones restringen las visitas. la telesalud (incluida la cobertura de seguro para la telesalud), el suministro extendido de medicamentos, el aumento de la capacitación en salud mental del proveedor, el apoyo virtual de pares y los grupos virtuales de apoyo al uso de sustancias pueden ayudar a garantizar que se satisfagan las necesidades de salud mental de la comunidad (581). el sistema de salud y los líderes de enfermería deben asegurarse de que su personal de enfermería clínica esté protegido y respaldado para que puedan proporcionar esta dimensión crucial de la atención de covid-19. se recomienda crear grupos centralizados y definidos para atención de pacientes con sospecha o diagnóstico de covid-19 que se encarguen de elaboración, socialización e implementación de protocolos. estos deben incluir los aspectos de infraestructura, áreas delimitadas, utilización de epp, listas de chequeo, observadores, insumos y recursos que permitan atención integral. se recomienda organizar el plan de atención del paciente con sospecha o diagnóstico de covid-19 de enfermería con la asignación de actividades, número de personas según escalas que midan escalas de carga laboral para definir el número adecuado de los miembros del equipo de trabajo, tiempo de atención, gestión de recursos, gestión de riesgo y un líder por turno que garantice el cumplimiento fuerte a favor fundamento la implementación de estrategias de gestión en contingencias genera un trabajo organizado, enfocado en la prevención y tratamiento centralizado, elaboración y socialización de protocolos claros, áreas específicas, delimitadas y asignadas, con un uso racional del recurso humano que se despliega en fases, desde el inicio de la emergencia considerado como detección temprana hasta la atención directa de pacientes con sospecha amci ® o confirmación de sars-cov-2. dentro de las fases tempranas, se busca la gestión de los recursos necesarios para la atención de estos pacientes, con una asignación de zonas o servicios y unas condiciones particulares, tratamientos específicos y actividades de atención especiales para las cuales se discriminan medicamentos, dispositivos e insumos necesarios para el cuidado de enfermería. los grupos de atención deben contar con capacitación, gestión y supervisión, apoyo logístico, apoyo psicológico y retroalimentación (573, 580) . el plan de atención de enfermería debe tener presente la minimización de exposición, la prevención de infecciones en el personal y cuidados especiales derivados de la condición clínica de los pacientes con esta infección, altamente contagiosa y con síntomas o necesidades que rompe el modo operacional convencional y que requiere implementación basada en la práctica clínica. por lo tanto, el plan debe ser centralizado oportuno, ordenado, seguro y eficiente e incluye: relación enfermería/paciente de acuerdo a criticidad, capacitaciones y entrenamiento al personal de enfermería de línea de frente en el área crítica de aislamiento mediante videos, infografías y procesos prácticos (el contenido de capacitación incluye el uso de elementos de protección personal, higiene de manos, desinfección de áreas, manejo de residuos y esterilización de dispositivos de atención al paciente y manejo de exposición ocupacional), asignación de actividades clínicas (atención directa) y administrativas (supervisión, observador, líderes, gestión de recurso humano y medicamentos), soporte y contratación de personal adicional ante la contingencia con preparación académica o inducción, asignación de turnos razonables con períodos de descanso (alimentación, eliminación), coordinación con otros departamentos y optimización de flujos de trabajo, estrategias de control de infecciones y trabajo en equipo (577, 579) . se recomienda que las muestras clínicas tomadas para el diagnóstico de covid-19 deben conservarse a temperatura entre -2 a 8°c, y luego de las 48 horas deben permanecer congeladas a una temperatura de -70°c. se recomienda que se realice el envío al laboratorio de salud pública de referencia dentro de las 48 horas posteriores a la toma de la muestra del paciente. se recomienda que el transporte de las muestras debe realizarse con geles o pilas congeladas. se recomienda considerar que las muestras del tracto respiratorio bajo presentan la mejor certeza diagnóstica en pacientes con neumonía para adultos intubados y ventilados mecánicamente con sospecha de covid-19. se recomienda contar con elementos de protección personal de acuerdo con las precauciones establecidas para el paciente con sospecha o diagnóstico por covid-19 para evitar la transmisión a profesionales de la salud. se debe evitar perder el circuito cerrado en los pacientes ventilados mecánicamente y valorar el riesgo de las acciones en pacientes con peep alta. se recomienda realizar la toma de muestra post mortem no invasiva por hisopado nasofaríngeo dentro de las primeras seis (6) horas posteriores al fallecimiento, para que esta sea útil para su análisis. las muestras clínicas tomadas para el diagnóstico de coronavirus deben conservarse a temperatura entre -2 a 8°c, y luego de las 48 horas deben permanecer congeladas a una temperatura de -70°c. sin embargo, la muestra puede conservarse en un tiempo máximo de refrigeración por 72 horas. no obstante, se sugiere que se realice el envío al laboratorio de salud pública de referencia dentro de las 48 horas posteriores a la toma. si no se conserva la cadena de frío adecuada, la muestra puede ser inviable. el transporte de las muestras debe realizarse con geles o pilas congeladas (128, 582, 583) .se debe tener en cuenta que no conservar la cadena de frío durante el transporte de la muestra, degradan la partícula viral, obteniéndose falsos negativos (583) . las muestras del tracto respiratorio bajo presentan la mejor certeza diagnóstica en pacientes con neumonía. para adultos intubados y ventilados mecánicamente con sospecha de covid-19 en comparación al tracto respiratorio superior (nasofaríngeo u orofaríngeo). en el caso de aspirado traqueal, es importante considerar que para la obtención de las muestras para el diagnóstico de covid-19 se deben contar con elementos de protección personal de acuerdo a las precauciones estándar para evitar la transmisión a profesionales de la salud, circuito cerrado y valorar su realización en aquellos pacientes con peep alta (128) . la toma de muestra post mortem no invasiva por hisopado nasofaríngeo se debe hacer antes de seis (6) horas post mortem, para que esta sea útil para su análisis(166, 582-585). se recomienda en los pacientes con diagnóstico covid-19, monitorizar continuamente la oxigenación mediante saturación arterial de oxígeno con pulso oxímetro y la aparición temprana de signos clínicos de dificultad respiratoria durante la monitorización (aleteo nasal, cianosis, tirajes intercostales). se recomienda no suministrar de forma rutinaria suministrar oxígeno si la saturación de oxígeno (spo2) está por encima de 94%, y no se evidencian signos clínicos de dificultad respiratoria durante la monitorización continua del patrón respiratorio. se recomienda como parámetro importante para evaluar la oxigenación y guiar el suministro de oxígeno mediante los diferentes dispositivos la transferencia de oxígeno, medida por la pao2/ fio2 o sao2/fio2. se propone iniciar la oxigenoterapia por cánulas de bajo flujo y ajustar el flujo (máximo 5 l) hasta alcanzar la spo2 objetivo ≥ 94%; si el paciente se encuentra en estado crítico iniciar con mascarilla con bolsa de reserva (a 10-15 l / min). una vez que el paciente esté estable, el objetivo de oxigenación es mantener niveles de spo2 entre 88 y 92% en pacientes no embarazadas y entre 92-95% en pacientes embarazadas. se recomienda no utilizar de forma rutinaria el uso de dispositivos que generan aerosoles durante la administración de oxígeno (dispositivos venturi o nebulizador de alto flujo o jet) en pacientes con sospecha o diagnóstico covid-19. en las diferentes guías publicadas para manejo de pacientes positivos para covid-19 las metas de oxigenación durante la terapia de oxígeno en adultos recomiendan iniciar la oxigenoterapia a 5 l / min y ajustar el flujo hasta alcanzar la spo2 objetivo ≥ 94% durante la reanimación; o use mascarilla con bolsa de reserva (a 10-15 l / min) si el paciente está en estado crítico. una vez que el paciente esté estable, el objetivo de oxigenación es > 90% de spo2 en pacientes, no embarazadas y ≥ 92-95% en pacientes embarazadas(165). los dispositivos para la oxigenoterapia se pueden dividir en dos grupos, dependiendo de si cubren la totalidad o una parte de los requerimientos respiratorios del paciente. unos son de bajo flujo o para esfuerzos mínimos del paciente, estos dispositivos completan su ventilación con aire ambiente y los sistemas de alto flujo cubren la totalidad de los requerimientos inspiratorios del paciente. escalones terapéuticos: oxigenoterapia convencional a diferentes concentraciones de bajo flujo (son las cánulas nasales, las mascarillas simples y las mascarillas con reservorio), es el primer escalón terapéutico ante cualquier paciente que presente una situación de hipoxemia (spo2) < 90% respirando aire ambiente. el objetivo debe ser ajustar la fio2 (hasta 0.4) para mantener un nivel de oxigenación adecuado, considerado este como una spo2 > 91%. la administración de oxígeno se considera un procedimiento generador de aerosoles de riesgo bajo y por lo tanto es adecuado para pacientes covid-19 positivos(586). b. en adultos con signos de emergencia (respiración obstruida o ausente, dificultad respiratoria severa, cianosis central, shock, coma y / o convulsiones) deben recibir vía aérea amci ® de emergencia manejo y oxigenoterapia durante la reanimación para apuntar a spo2 ≥ 94%. una vez el paciente está estable, objetivo> 90% de spo2 en adultos no embarazadas y ≥ 92-95% en mujeres embarazadas. c. para el manejo del paciente con covid-19 la máscara de no re inhalación se considera como la opción de preferencia para escalar el paciente antes de la intubación y considerar la transferencia a uci; esto se debe a que puede proporcionar altas fracciones inspiradas de oxígeno (587) . d. los dispositivos que generan aerosoles durante la administración de oxígeno (dispositivos venturi o nebulizador de alto flujo o jet), no están indicados para manejo de covid-19 (588). se recomienda aplicar las estrategias de retiro de la ventilación mecánica habituales para pacientes adultos críticos en general, hasta el momento no se ha construido una evidencia contundente para el destete en covid-19. se recomienda en el paciente críticamente enfermo por covid-19 un descenso de la presión de soporte (psv) según tolerancia clínica, de esta forma el paciente podrá ser sometido a la realización de prueba de respiración espontánea con una presión de soporte de entre 5-8 cm h2o. se recomienda que el destete automatizado puede ser considerado como una herramienta útil según disponibilidad de equipos para realizarlo. se recomienda no utilizar las maniobras que incrementan la aerosolización como la prueba de respiración espontánea en pieza en t o el cuff-leak test en el momento de realizar la medición de los predictores de éxito en el destete. fuerte en contra fundamento la realización de las pruebas de respiración espontánea sigue siendo un factor predictor importante en el éxito en el retiro del soporte ventilatorio mecánico y la indicación de tiempo de duración sigue siendo de 30 a 120 minutos debido a que las intubaciones realizadas en el mismo periodo de tiempo no han tenido diferencias significativas en el éxito del destete (589, 590) . en los pacientes que han sido ventilados por más de 24 horas y que el motivo por el cual fueron llevados a ventilación mecánica ya ha sido superado se debe establecer un protocolo de destete que debe incluir una prueba diaria de respiración espontánea y la minimización o retiro de la sedación (si no existe alguna contraindicación)(165, 591). la movilización temprana como factor coadyuvante en el éxito de la liberación mecánica ya se ha documentado en otros escenarios similares, razón por la cual la implementación amci ® temprana de este tipo de estrategias será un punto de vital importancia para recuperar la funcionalidad de los pacientes con covid-19 (121) . se recomienda que la extubación de los pacientes críticamente enfermos por covid-19 se debe realizar con los elementos de protección personal requeridos para el riesgo de aerosoles. se recomienda no estimular la tos y el esputo inducido en los pacientes con sospecha o diagnóstico de covid-19 posterior a la extubación inmediata. se recomienda no utilizar de forma rutinaria la vmni en la falla respiratoria post extubación en pacientes críticos que no tengan una enfermedad concomitante que sea respondedora a la vmni como el epoc o edema pulmonar de origen cardiogénico en pacientes con sospecha o diagnóstico de covid-19. fuerte en contra se recomienda mantener un umbral bajo para decidir intubación en caso de sospecha de fallo en la extubación en el paciente con sospecha o diagnóstico de covid-19. la estricta monitoria y manejo del paciente posterior a la extubación surgen como un reto insoslayable para el personal de cuidado intensivo, enfocando todos sus esfuerzos en evitar la re-intubación, lo que se traducirá en un descenso significativo de la morbilidad y la mortalidad que supone una re-intubación (592), la cual se puede definir como el no requerimiento de re intubación en las primeras 72 horas post extubación (593, 594) . en los últimos años la cánula nasal de alto flujo (caf) se ha convertido en una herramienta útil en el soporte de oxigenoterapia en los pacientes extubados que presenten riesgo de reintubación (595, 596), y a la vez no presenten hipercapnia (597) . la utilización de ventilación mecánica no invasiva de manera profiláctica en la falla respiratoria post extubación no ha demostrado tener éxito evitando la re-intubación en las primeras 48 horas (598, 599) excepto en las situaciones donde el paciente presente una enfermedad pulmonar o alteración cardiaca concomitante que sea respondedora a el manejo con vmni como lo son la enfermedad pulmonar obstructiva crónica (epoc) y el edema pulmonar de origen cardiogénico (267, 600) . los pacientes extubados en los que se halla documentado epoc, se sugiere posterior a la extubación la implementación de una estrategia de niv de manera protocolaria (600, 601), con una intensidad de 1 hora cada 3 horas durante un período mínimo de 48 horas (602). se recomienda utilizar en los pacientes con extubación reciente que no expresen predictores de riesgo de fracaso, sistemas de oxigenoterapia convencionales de bajo flujo que generen menos riesgo de aerosolización, fuerte a favor se podría considerar cánulas de alto flujo de oxígeno y/o la ventilación mecánica no invasiva (con una máscara facial adecuadamente ajustada y ramas inspiratorias y espiratorias separadas) como terapia de puente después de la extubación, pero se deben brindar las condiciones estructurales necesarias (habitaciones de presión negativa o habitaciones aisladas de puertas cerradas) y con epp estrictos para el personal sanitario. fuerte a favor fundamento las pautas de anzics establecen que la caf y/o la ventilación no invasiva (con una máscara facial bien ajustada y ramas inspiratorias y espiratorias separadas) pueden considerarse como terapia de puente después de la extubación, pero deben proporcionarse epp estricto en el aire. la terapia cpap o bipap (con alta presión espiratoria final) podría ser útil para prevenir la eliminación del reclutamiento en estos pacientes. en el momento de la extubación, los pacientes a menudo han estado enfermos durante más de una semana. es probable que su carga viral disminuya en ese punto, por lo que el riesgo de transmisión del virus puede ser menor (en comparación con la intubación inicial) (603) . de no contar con predictores de que nos indiquen que podría fracasar la extubación se deben utilizar entonces sistemas de oxigenoterapia convencionales de bajo flujo que generen menos riesgo de aerosolización(604). se recomienda limpiar y desinfectar con frecuencia el área de retiro de epp, incluso después de que se haya completado cada procedimiento de eliminación. se debe limpiar esta zona, pasando de las áreas más limpias a las más sucias, antes de ingresar a la habitación del paciente y realizar el manejo y disposición final de residuos. se recomienda realizar la limpieza de superficies con un desinfectante adecuado o con una solución de hipoclorito sódico que contenga 5000 ppm de cloro activo (por ejemplo, un producto con hipoclorito en una concentración de 40-50 gr/litro, se hará una dilución 1:10 en el momento de su utilización). amci ® se recomienda que los recipientes que contengan los residuos deberán quedar en el lugar designado a tal efecto, que permanecerá cerrado hasta que, según el procedimiento de gestión de residuos de la institución sean retirados. los circuitos, filtros, succión cerrada y tot deben ser dispuestos en bolsas de color rojo las cuales deben ser de polietileno de alta densidad de 1.6 milésimas de pulgada y deben contar con un rótulo donde se indiquen: el nombre del generador, las palabras residuos biológicos (covid19 2019) . una vez dispuesto, apretar y asegurar con nudo la bolsa de residuos y remover la bolsa de residuos del recipiente de residuos. posteriormente, desinfectar el exterior de la bolsa con solución desinfectante. luego colocar la bolsa de residuos en otra bolsa adicional de residuos y apretar y asegurar con nudo la bolsa de residuo. finalmente desinfectar la exterior bolsa de residuos con solución desinfectante. una vez terminada la disposición de los residuos de extubación, desinfectar los guantes con que manipuló los residuos con solución desinfectante y ubicar la bolsa de residuos dentro del vehículo de recolección interna de residuos. finalmente desinfectar el exterior de la bolsa de residuos con solución desinfectante. una vez terminada la disposición de los residuos de extubación, desinfectar los guantes con que manipuló los residuos con solución desinfectante y ubicar la bolsa dentro del vehículo de recolección interna. acogerse a la ruta sanitaria que asegure el menor riesgo de contaminación en el traslado interno de los residuos en la habitación del paciente (zona limpia) y zona sucia, se debe garantizar la ubicación de recipiente plástico de color rojo, liviano, resistente a los golpes, en material rígido impermeable, de fácil limpieza, y resistentes a la corrosión. los recipientes deberán ser lavados y desinfectados de acuerdo con los procedimientos establecidos por el prestador de servicios de salud(605-608). se recomienda utilizar un ajuste de peep del paciente crítico por covid-19, basado adicional a la tabla de peep, en las condiciones clínicas del paciente, en los índices de oxigenación, en la mecánica respiratoria del paciente y en los métodos de monitoreo disponibles. se recomienda titular la peep más alta que mantenga o mejore la relación safi y permita una presión plateau ≤ 30 cmh2o. se recomienda utilizar otras estrategias de titulación de peep probadas y con las cuales el equipo de trabajo esté familiarizado, dependiendo de la disponibilidad del recurso: ensayo peep decremental precedido por una maniobra de reclutamiento; titulación mediante la amci ® estimación de la presión transpulmonar con catéter esofágico o tomografía de impedancia eléctrica. fuerte a favor fundamento la titulación de la peep debe hacerse en función de la distensibilidad, oxigenación, espacio muerto y estado hemodinámico. puede titularse la peep mediante la estimación de la presión transpulmonar con catéter esofágico o tomografía de impedancia eléctrica. podría también titularse a partir de la fórmula (dp=plateau-peep) teniendo en cuenta que sea lógico el acoplamiento matemático fisiológico (lo que resultaría en una peep de 15 cmh2o si la presión plateau es de 30 cmh2o). la titulación de la peep requiere consideración de los beneficios (reducción de atelectrauma y mejora del reclutamiento alveolar) frente a los riesgos (sobre distensión inspiratoria final que conduce a lesión pulmonar y mayor resistencia vascular pulmonar)(165, 609, 610). se recomienda aplicar los protocolos de rehabilitación física como estrategia beneficiosa en el tratamiento respiratorio y físico de pacientes críticamente enfermos por covid-19. se recomienda realizar la movilización precoz del paciente críticamente enfermo por covid-19 durante el curso de la enfermedad siempre que sea posible hacerlo de forma segura, asegurando la protección personal del personal sanitario. derivado del tratamiento médico intensivo para algunos pacientes con covid-19, incluida la ventilación pulmonar protectora prolongada, la sedación y el uso de agentes bloqueantes neuromusculares, los pacientes con covid-19 que ingresan en la uci pueden presentar un elevado riesgo de desarrollar debilidad adquirida en la uci empeorando su morbilidad y mortalidad. por lo tanto, es esencial la rehabilitación temprana después de la fase aguda del síndrome de distrés respiratorio agudo (sdra) para limitar la gravedad de la debilidad adquirida en uci y promover la recuperación funcional. según la guía de la oms y la ops, enfatizan extremar el uso de los elementos de protección personal (epp) durante las intervenciones de rehabilitación física. la rehabilitación física proporciona intervenciones a través de movilizaciones, ejercicio terapéutico y programas individualizados a las personas que superan la enfermedad crítica asociada con covid-19 durante la ventilación mecánica y luego de esta, con el fin de permitir un retorno al hogar con funcionalidad. la prescripción de la movilización y ejercicio terapéutico debe de ser considera cuidadosamente en función del estado del paciente teniendo en cuenta, la estabilidad hemodinámica y clínica de la función respiratoria. cuando las movilizaciones, ejercicio terapéutico o programas de rehabilitación están indicados, debe realizarse una correcta planeación teniendo en cuenta amci ® la identificación/uso del personal mínimo necesario para realizar la actividad de manera segura. y el aseguramiento de todo el material que requerido esté a la mano y funcione correctamente y esté perfectamente limpio y desinfectado. si el material/equipo tiene que ser compartido con otros pacientes, límpielo y desinféctelo después de cada uso, entre paciente y paciente. se requiere personal entrenado específicamente para la limpieza y desinfección de los equipos, en una habitación aislada. y siempre que sea posible, evitar el traslado del material entre las áreas infectadas y no infectadas del hospital, manteniendo el equipamiento en las zonas aisladas (611) (612) (613) (614) (615) . ( basados en un estudio preliminar aún sin publicar, se podría sugerir el uso de dexametasona a dosis de 6 mg (oral o venosos) por 10 días o hasta el alta si ocurre primero en pacientes hospitalizados con sospecha o diagnóstico de covid-19 que requieren suplencia de oxígeno, incluyendo aquellos con ventilación mecánica, que sean menores de 70 años y con más de 7 días de síntomas. amci ® actualmente no existe una terapia dirigida que se a efectiva para el manejo del virus; un número alto de estudios han surgido en los últimos dos meses, la mayoría sin el rigor metodológico suficiente para tomar decisiones adecuadas con respecto al manejo del paciente con infección por sars-cov-2. el conocimiento en la estructura del virus y el mejor entendimiento en la fisiopatología de la enfermedad genera un sinnúmero de potenciales fármacos que han sido ensayados para el manejo de la enfermedad. en tiempos de pandemia, con una patología catastrófica en términos de vidas humanas y costos hospitalarios; es importante encontrar soluciones a desenlaces importantes como mortalidad, días de estancia en uci y en el hospital, aumento en los días libres del ventilador, disminución de complicaciones mayores debido a la enfermedad entre otros. hasta el momento no se ha documentado ninguna terapia específica que pueda impactar sobre estos desenlaces; pero la calidad de los trabajos, tampoco dejan claro sin él no usar ningún tratamiento específico mejora los desenlaces al menos al disminuir el número de complicaciones. este nuevo beta-coronavirus es similar al coronavirus del síndrome respiratorio agudo severa (sars-cov) y del síndrome respiratorio del medio este (mers-cov); por lo tanto, varias moléculas que habían sido evaluadas en este tipo de enfermedad rápidamente se abrieron paso a ensayos clínicos en paciente con covid-19. estos ensayos principalmente observacionales, aleatorios pero abiertos con un número pequeño de pacientes no han permitido sacar adecuadas conclusiones y es frecuente como ver las diferentes guías de las principales sociedades del mundo cambiar de forma frecuente sus recomendaciones; no existes evidencia de estudios clínicos aleatorios y controlados que midan desenlaces fuertes, la premura de un tratamiento efectivo ha sacrificado el rigor metodológico que una investigación requiere. una estructura viral y replicación conocidas generan posibles dianas para que diferentes fármacos puedan ser investigados, antivirales tipo arbidol el cual inhibe la fusión de la membrana en la envoltura viral a algunos receptores; antimaláricos como la hidroxicloroquina y la cloroquina, las cuales inhiben la entrada viral y endocitosis por múltiples mecanismos, así como los efectos inmunomoduladores demostrados en el huésped; antivirales que impiden la replicación como el lopinavir o darunavir inhibiendo las proteasas o la ribavirina, el remdesivir o el favipiravir que actúan como análogos de nucleótidos o fármacos que actúan modulando la respuesta específica del huésped como el tocilizumab el cual se une al receptor de la il-6 inhibiendo el punto de acción de esta; los corticosteroides con múltiples efectos en la modulación del sistema inmunológico del paciente o los fármacos para evitar la respuesta secundaria a esta cascada inflamatoria como son los anticoagulantes. por último, se han buscado estrategias con el fin de mejorar la inmunización pasiva del huésped en el uso del plasma de pacientes convalecientes o el uso de inmunoglobulinas enriquecidas entre otros tratamientos propuestos para esta enfermedad. amci ® a los diferentes medicamentos que han sido usados en la pandemia del sars-cov-2/covid-19. de manera reciente en datos preliminares aún sin publicar horby y col en una rama del ensayo de evaluación aleatorizada de la terapia covid-19 (recovery), estudio aleatorizado, controlado, abierto que compara una gama de posibles tratamientos con la atención habitual en pacientes hospitalizados con covid-19, compararon el uso de la dexametasona a dosis de 6 mg día (oral o intravenosa) una vez al día por 10 días o el alta según lo que ocurriera primero contra el manejo habitual; en 2104 pacientes aleatorizados que recibieron dexametasona se compararon con 4321 pacientes en manejo estándar; 454 (21.6%) pacientes en el grupo de dexametasona y 1065 (24.6%) pacientes en el grupo control murieron a los 28 días, con un riesgo relativo ajustado para la edad (rr 0.83; 95% ic 0.74 a 0.92; p < 0.001). la mortalidad relativa y absoluta variaron significativamente en relación al soporte ventilatorio al momento de la aleatorización; la dexametasona redujo las muertes en una tercera parte de los pacientes que recibieron ventilación mecánica invasiva (29.0% vs. 40.7%, rr 0.65, 95% ic 0.51 a 0.82; p < 0.001), y una quinta parte en los pacientes que reciben oxígeno sin ventilación mecánica invasiva (21.5% vs. 25.0%, rr 0.80, 95% ic 0.70 a 0.92; p = 0.002), pero sin reducir la mortalidad en paciente que no recibieron soporte respiratorio al momento de la aleatorización (17.0% vs. 13.2%, rr 1.22, 95% ic 0.93 a 1.61]; p = 0.14) (423) . no se emite recomendación a favor ni en contra para el inhibidor de la janus quinasa (baricitinib) en los pacientes con sospecha clínica o diagnóstico de covid-19 severo. uno de los reguladores conocidos de la endocitosis es la proteína quinasa 1 asociada a ap2 (aak1); la interrupción de aak1 podría, a su vez, interrumpir el paso del virus a las células y también el ensamblaje intracelular de partículas del virus. uno de los seis fármacos de unión a aak1 de alta afinidad es el inhibidor de la janus quinasa (jak1 y jak2), llamado baricitinib, que también se une a la quinasa asociada a la ciclina g, otro regulador de la endocitosis (23) . el baricitinib alcanza concentraciones plasmáticas suficientes para inhibir aak1 con 2 mg o 4 mg una vez al día; por su baja unión a proteínas plasmáticas y a su mínima interacción con las enzimas cyp, permite combinarlo con los antivirales. sin embargo, algunos piensan que el bloqueo de la señal jak-stat por baricitinib puede producir un deterioro de la respuesta antiviral mediada por interferón, con un posible efecto facilitador sobre la evolución de la infección por sars-cov-2; otras limitantes son la linfopenia (no dar si < 500 cel./ mm 3 ) y el aumento de la cpk. (24, 25) . cantini y cols, en abril 2020, en italia, administraron baricitinib a 4 mg/día vía oral por 2 semanas a 12 pacientes con covid-19 moderado y los compararon con un grupo control; la terapia mejoró significativamente los parámetros clínicos, respiratorios y de laboratorio (pcr); ninguno de los pacientes requirió uci vs 33% del grupo control, sin eventos adversos. se amci ® trata de un estudio piloto de seguridad e impacto clínico en pacientes que no estaban en uci (472) . ¿en pacientes hospitalizados con sospecha o diagnóstico de covid-19 el uso de n-acetil cisteína modifica el curso clínico de la enfermedad o genera beneficios en desenlaces clínicos de interés? basados en evidencia indirecta para el manejo del sdra y resultados observaciones en covid-19, se podría utilizar el uso de n-acetil cisteina a dosis de 200mg/kg/día durante los primeros cinco días del sdra, aunque no se ha demostrado impacto en la mortalidad, su utilización parece relacionarse con una disminución significativa en la estancia en la unidad de cuidados intensivos y con disminución de los marcadores inflamatorios en pacientes con covid-19 . la severidad de la infección en covid-19, en gran parte depende de la respuesta inmunológica de cada persona, sin embargo, se encuentran 3 mecanismos fisiopatológicos de relevancia. sobreproducción de moco en vía aérea superior e inferior, que en parte explica la dificultad en la mecánica ventilatoria y los retos de ventilación en estos pacientes, la descarga desmedida de citoquinas proinflamatorias que se asocian a la falla multiorgánica y la coagulopatía asociada a la disfunción endotelial. esto mecanismos fisiopatológicos son comunes en el sdra, incluido los casos asociados a covid-19(616). amci ® enfermo con falla respiratoria aguda, la cual engloba falla respiratoria hipóxica (tipo 1), falla respiratoria hipercápnica aguda (tipo 2), sdra y lesión pulmonar aguda, se revisaron 13 ensayos clínicos, más de 1712 pacientes. el análisis del grupo de n acetilcisteína intravenoso mostró una reducción de estancia en uci, de 4.7 días, con una heterogeneidad muy baja del 25%, con valoración de la evidencia calificada como de alta calidad y baja probabilidad de sesgo (621) . en covid-19, fue utilizada con recuperación completa en un caso severo de un paciente con déficit de glucosa 6 fosfato deshidrogenasa (g6pd), con control de la hemolisis y resolución del compromiso pulmonar. en pacientes sin déficit de g6pd, también ha sido asociada a mejoría clínica y disminución significativa de los niveles de pcr y ferritina (622) . en una revisión de costo efectividad nacional, se identificaron 222 referencias, 3 de ellos era revisiones sistemáticas de la literatura, dos de las cuales incluían metaanálisis (lu 2019 y zhang 2017), y fueron incluidos en la evaluación. estos estudios incluyeron información de ensayos clínicos que comparaban la aplicación de nac intravenosa frente a placebo o cuidado usual en pacientes con sdra. los tres estudios reportan como resultado de mortalidad rr de 0.83 con ic al 95% de 0.62 a 1.11 (lu 2019), rr de 0.64 con ic al 95% de 0.32 a 1.30 (lewis 2019) y rr de 0.73 con ic al 95% de 0.50 a 1.07 (zhang 2017) . para el tiempo de estancia en uci solo las revisiones con metaanálisis reportaron resultados, encontrando una diferencia de promedio de días de estancia de -4.47 días con ic al 95% de -8.79 a -0.14 (lu 2019) y de -4.56 días con ic al 95% de -7.32 a -1.80 (zhang 2017). una de las revisiones reportó que en ninguno de los estudios analizados se presentaron eventos adversos. no se encontraron resultados para los desenlaces de infección, sobreinfección, ni uso y tipo de antibiótico utilizado. en el análisis se encontró una reducción estadísticamente significativa de los días de estancia en uci de los pacientes que recibieron tratamiento con n-acetilcisteína intravenosa con dosis entre 150 y 200 mg/kg/día durante los primeros cinco días del sdra, en comparación con los pacientes que recibieron placebo o manejo usual. no se reportó diferencia estadísticamente significativa en la reducción de la mortalidad de los pacientes que recibieron nac. (623) calidad de vida 1. ¿cómo podemos medir la calidad de vida, en los pacientes con covid-19 que egresan de la uci? se recomienda utilizar los marcadores disponibles de severidad y del riesgo de mortalidad por covid-19 en los pacientes internados en la uci. amci ® las secuelas inmediatas en los pacientes víctimas del devastador ataque sistémico del covid-19 durante su estancia en la uci son valorables, pero no se dispone de herramientas que permita medir el grado de afectación de la calidad de vida de estos pacientes posterior al egreso de la uci o de alta hospitalaria, por lo tanto, se sugiere realizar estudios de creación, validación y utilización de instrumentos de valoración de la calidad de vida en pacientes con covid-19 posteriores al alta hospitalaria. parte importante de los pacientes con diagnóstico de covid-19 que ingresan a la uci, evolucionan tórpidamente presentando deterioro progresivo de los diferentes órganos llegando en pocos días a una falla multiorgánica (327) , estos pacientes presentan características clínicas y de laboratorio que se relacionan de manera significativa con mayor severidad y riesgo de mortalidad (294, 624) . a pesar de conocer con alguna precisión el riesgo de severidad y mortalidad de los pacientes que ingresan a la uci, no disponemos de un score que nos permita evaluar y predecir el grado de afectación en la calidad de vida de los pacientes que logran sobrevivir. aproximadamente un 6,1% del total de pacientes con enfermedad por covid-19 ingresan a uci, y de estos 2,3% sometidos a ventilación mecánica (327); lamentablemente los pacientes con enfermedad severa que logran sobrevivir y recuperarse han sido sometidos a una larga estancia en la uci y a ventilación mecánica invasiva con una intubación prolongada, que puede producir disfunción en la deglución impidiendo a la persona alimentarse de forma correcta y segura. es importante diagnosticar esta disfagia en los pacientes que se están recuperando del covid-19 y tratarla correctamente desde el principio para evitar complicaciones importantes como la malnutrición y la deshidratación, así como el riesgo de neumonía aspirativa. además de la disfagia, la fibrosis pulmonar y el riesgo de trombos son los problemas más frecuentes, pero no los únicos. una de las características de la enfermedad severa por covid-19 es que el virus provoca una enfermedad multiorgánica, con un amplio y heterogéneo abanico de secuelas cuyo alcance todavía se desconoce y aunque el órgano más afectado es el pulmón, puede afectar también otros órganos o sistemas incluido el snc, que en los casos más graves puede presentar encefalitis, delirios, desorientación y confusión, síntomas que pueden persistir tras el alta de la uci. otra secuela frecuente son las polineuropatías, esta afectación suele comenzar con una sensación de hormigueo en las extremidades y en los pacientes con covid-19 se presenta además con un cuadro de miositis que provoca debilidad y cansancio al caminar, a veces incluso en reposo; en algunos pacientes se presenta tal debilidad que dificulta llevar el alimento a la boca e incluso deglutirlo. sin embargo, la primera y más frecuente de las manifestaciones neurológicas del covid-19 es la pérdida del olfato, que a veces perdura como secuela tiempo después del alta. un estudio en 900 pacientes ingresados en el hospital clínico san carlos de madrid revela que el 70% había sufrido anosmia en mayor o menor grado. la importancia de este síntoma radica en que las fosas nasales pueden ser la vía de acceso del virus al sistema nervioso central. amci ® otras posibles secuelas neurológicas asociadas a la infección por covid-19 son la ageusia, la cefalea y amnesia a corto y mediano plazo. también son importantes las secuelas que afectan al sistema cardiovascular. un estudio publicado en la journal o the american medical association advierte que un 20% de los pacientes presenta una elevación de las enzimas que indican daño en el miocardio. la inflamación que provoca el virus puede provocar directamente ese daño y también puede agravar el estado de pacientes que ya tengan una patología cardiovascular de base, muchas miocarditis son reversibles, pero hay una parte importante que deja como secuela una pérdida de la función contráctil. todavía se desconoce el alcance y es difícil medir el impacto de la enfermedad sobre el corazón porque en algunos casos, los síntomas de insuficiencia cardíaca se confunden con los de la neumonía. otra de las complicaciones más frecuentes, y potencialmente más grave, afecta al mecanismo de coagulación de la sangre. durante el ingreso hospitalario se han visto numerosos casos de ictus. la secuela más importante es el riesgo de que se formen trombos, que pueden ir al pulmón o al cerebro, y si se producen en las arterias, pueden dar lugar a un infarto, aunque este efecto es mucho menos frecuente. eso explica que algunos pacientes de covid-19 dados de alta hayan tenido que volver a ingresar por trombosis. finalmente es importante tener presente que a las afectaciones que haya podido producir el virus, hay que sumar las secuelas neurológicas propias de una estancia prolongada en una unidad de cuidados intensivos que también pueden ser graves y a veces no se distinguen bien unas de otras. debilidad muscular, desorientación, depresión y problemas psicológicos son secuelas muy habituales entre los pacientes que salen de la uci por enfermedades diferentes. por la anterior razón es difícil, por ahora, saber qué es efecto directo del virus y que puede derivarse del proceso de hospitalización. aún es difícil decir si los daños a largo plazo dependen del propio virus o de los efectos adversos del proceso tratante. sin embargo, este análisis de las posibles secuelas del covid-19 en el cuerpo, se presenta con más dudas que certezas. como es habitual en medicina, las causas pueden ser múltiples y muchas veces reflejan la participación de varias complicaciones que se han podido dar durante el proceso infeccioso directo o por la hospitalización, la información sobre los mecanismos de invasión del sars-cov-2 en todos los órganos sigue siendo, por ahora, escasa. y también lo es nuestro conocimiento sobre los efectos adversos de los medicamentos, muchos de ellos experimentales, que se han utilizado durante esta crisis. gran parte de lo que conocemos actualmente sobre los efectos de este virus proviene de la experiencia clínica de otros colegas y de las historias de pacientes que han sufrido la enfermedad, quedando todavía mucho por descubrir. dado el actual panorama, diferentes hospitales e instituciones de salud se preparan en torno a la rehabilitación, habilitando ya unidades multidisciplinares poscovid-19 para el seguimiento de estos pacientes y algunos centros están contactando con los pacientes dados de alta para evaluar su estado y hacer un seguimiento a su salud. también están en marcha varios estudios multicéntricos para evaluar el alcance de las secuelas, prácticamente todos los centros sanitarios deberán tener pautas de seguimiento y control para los pacientes ya dados de alta, creándose necesario la utilización simultánea de amci ® instrumentos de medición de calidad de vida, que en nuestro país colombia, ya se han utilizado previamente con este fin (625, 626) . con este instrumento de medición de la calidad de vida se realizaron algunos estudios piloto tanto en pacientes crónicos como en la población general con el fin de determinar la comprensión del instrumento y factibilidad de aplicación del mismo en cuanto a la consistencia interna, la revisión realizada por vilagut y cols demostró que la aplicación de la escala arrojó en diversos estudios un alfa de cronbach igual o superior a 0.7 en todas las escalas excepto en función social (626) . y aunque un número cada vez mayor de estudios mide los resultados físicos, cognitivos, de salud mental y de calidad de vida relacionada con la salud (cvrs) en los sobrevivientes adultos de la uci, los datos sobre las propiedades de medición de tales instrumentos son escasos y, en general, de calidad deficiente a justa. se necesitan análisis empíricos que evalúen el rendimiento de los instrumentos en adultos sobrevivientes de la uci para avanzar en la investigación en este campo (627) . finalmente, el conocimiento de las secuelas y complicaciones dejadas por la infección del covid-19, permitirá identificar importantes variables clínicas que acompañan a esta enfermedad y que afectan de manera importante la calidad de vida de los pacientes que padecen la enfermedad severa en la unidad de cuidados intensivos. en la actualidad no existen estudios para evaluar el riesgo de malnutrición aguda en pacientes hospitalizados por sars-cov-2. experiencias con otras infecciones virales por influenza, se han identificado como factores asociados con mortalidad, la presencia de malnutrición, la adquisición de infección intrahospitalarias, la falla respiratoria y la presencia de infiltrados en la radiografía de tórax (628) . las guías espen 2020 recomiendan utilizar el must o el nrs-2002(2), para la tamización del riesgo nutricional, estos puntajes de tamización previamente han sido validados en múltiples patologías y contextos clínicos; sin embargo, existen otros puntajes útiles desde la perspectiva clínica como la valoración global subjetiva, mini-nutritional asessment(629), puntaje nutric (630) y la global leadership initiative on malnutrition (glim) (631) . el proceso de diagnóstico nutricional debe involucrar, dos componentes: la identificación del riesgo con la utilización de alguno de los puntajes previamente validados en otros contextos y posteriormente el diagnóstico de los pacientes con malnutrición y la valoración de la gravedad de ésta; en este último paso es importante la valoración del índice de masa corporal, los hábitos de consumo calórico y proteico, la presencia de inflamación, los trastornos gastrointestinales, las enfermedades de base y siempre que sea factible el cálculo de la masa muscular. tabla 20. en vista del riesgo de infección al personal de salud, no siempre será necesario la visita nutricional al paciente, ésta podría ayudarse con entrevista al familiar, interrogatorio vía amci ® telefónica y sólo en caso necesario el examen del paciente para lo cual se requiere el uso de equipo de protección personal completo. esta estrategia de interrogatorio al familiar o al paciente por vía remota o telefónica puede ayudar a identificar los patrones de consumo y los hábitos nutricionales de riesgo y en caso de ser necesario la valoración nutricional disminuye el tiempo de exposición a un ambiente contaminado. para la atención presencial de pacientes en el ámbito de cuidado intensivo, es necesario definir cuál es el riesgo que existe de infección para el personal de salud, para aclarar esta pregunta se debe definir si hay un riesgo de generación de aerosoles(88). aunque no existen pautas específicas para la nutrición en pacientes con covid-19, las diferentes sociedades científicas han desarrollado guías de pauta clínica para la nutrición de pacientes con esta enfermedad (632, 633) . idealmente la nutrición debe ser iniciada de forma temprana, esto se refiere al inicio en las primeras 24 a 36 horas del ingreso a cuidado intensivo o en las primeras 12 horas luego de la intubación y el inicio de la ventilación mecánica(633) y se prefiere la vía enteral. aunque no existen estudios para evaluar el momento del inicio de la nutrición en pacientes con infección por sars-cov2, el inicio temprano de la nutrición ha mostrado beneficios en términos de mortalidad y reducción de infecciones con dicha estrategia (634, 635) . adicionalmente es importante, evaluar el riesgo de morbilidad y mortalidad asociado a la malnutrición aguda en el ámbito del paciente crítico, en los pacientes que no se alcance la meta de aporte calórico y proteico por vía enteral o que exista contraindicación para ésta, se debe considerar el inicio de nutrición por vía parenteral, especialmente cuando su riesgo nutricional agudo sea elevado (puntaje nutric ≥5, nrs ≥5) (636) (637) . el choque no es una contraindicación para la utilización de nutrición enteral (638) y no es una indicación para el uso de nutrición parenteral, quizás la mejor estrategia, es vigilar la presencia de disfunción gastrointestinal, en combinación con la presencia de intolerancia a la nutrición enteral, especialmente en pacientes con acidosis láctica en progreso y cuando sea necesario escalar la dosis de vasopresores o exista incapacidad para la reducción de éstos. no es necesario medir el residuo gástrico de rutina, es preferible iniciar procinéticos de forma rutinaria. la sonda debe colocarse con cuidado de evitar riesgo de contaminación, preferiblemente al entubar al paciente. algunos pacientes pueden presentar diarrea, ya que se ha descubierto la presencia de la proteína ace2 (receptor del virus sars-cov-2) en células del esófago, estómago, duodeno y recto. no existe evidencia que indique que la nutrición enteral durante la posición prono aumente el riesgo de complicaciones. sugerimos no suspender nutrición enteral al durante la pronación, se debe iniciar con dosis trófica de 20 ml/h. amci ® se recomienda una estrecha monitorización de la tolerancia a la nutrición enteral para pacientes en posición prono. se recomienda para aumentar la tolerancia de la ne a los pacientes en posición prona, una elevación del tórax entre 10-25º (posición de trendelenburg inversa) no realizar endoscopias digestivas para ubicación de sondas avanzadas recomendaciones de nutrición parenteral los pacientes con covid-19 pueden requerir niveles significativos de sedación y bloqueo neuromuscular, lo que puede aumentar la incidencia de intolerancia gastrointestinal. la nutrición parenteral (np) debe utilizarse donde la alimentación enteral no está disponible o no logra completar el 60% de los requerimientos. si existen limitaciones para la ruta enteral, se podría recomendar nutrición 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disease requiring icu care guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: society of critical care medicine (sccm) and american society for parenteral and enteral nutrition guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: society of critical care medicine (sccm) and american society for parenteral and enteral nutrition espen guideline on clinical nutrition in the intensive care unit safety and outcomes of early enteral nutrition in circulatory shock gastrointestinal function in intensive care patients: terminology, definitions and management. recommendations of the esicm working group on abdominal problems key: cord-022555-a7ie82fs authors: nan title: digestive system, liver, and abdominal cavity date: 2011-12-05 journal: the cat doi: 10.1016/b978-1-4377-0660-4.00023-5 sha: doc_id: 22555 cord_uid: a7ie82fs nan these complex pathways highlight the need to consider the whole cat and not just the cat's gastrointestinal vomiting can be defined as the ejection of part or all of the contents of the stomach and/or upper intestine through the mouth, usually in a series of involuntary spasmodic movements. the disturbances in gastrointestinal (gi) motility are coordinated with respiratory and abdominal muscle contractions and mediated by the central nervous system (cns). vomiting begins with retching, a series of brief negative intrathoracic pressure pulses that coincide with positive abdominal contractions. these pressure changes occur as a result of repeated herniations of the abdominal esophagus and cardiac portion of the stomach into the esophagus. during retching, food freely moves back and forth in the esophagus, which is now dilated because of the ingesta. ultimately, the diaphragm rapidly moves cranially, resulting in positive intrathoracic pressure that leads to expulsion of these contents. 12 vomiting is such an active process that it seems to involve the whole cat, and so it is little wonder that it concerns owners so much. since vomiting is mediated by the cns with input and influence from just about anywhere in the body, it is important to summarize this physiology so it can be appreciated when managing clinical cases. vomiting results from stimulation of the "vomiting center," which is located in the brainstem; there are four main pathways that stimulate the vomiting center, 12 and these are summarized below and in figure 23 (though not all older cats have grown out of this habit). some extragastrointestinal problems, such as hyperthyroidism and renal disease are more likely to occur in older cats. most texts and references instruct clinicians to distinguish between vomiting and regurgitation, with the latter noted as being quite passive. 3, 11, 12 in practice, it can be hard to make this distinction, because it is the author's experience that cats with esophageal disease can have quite forceful, spasmodic movements when ejecting ingesta by regurgitation-although it is also possible for regurgitation to be a passive process. given that the physiology of vomiting, as described above, results in ingesta being forced to and then evacuated from the esophagus, it is hardly surprising that it can resemble regurgitation. fortunately, regurgitation and esophageal disease do vary from vomiting in other ways! vomiting 3. blood and urine testing 4. imaging (radiography, ultrasonography) 5. biopsy samples 6. treat and manage underlying problem the decision to proceed to steps 4 and 5 is based on the assumption that the prior steps have narrowed down the underlying cause as gastrointestinal, pancreatic, or hepatic in origin. the important aspects of the clinical history are given in chronic kidney disease. the author has found that some cats with dental disease can gorge their food, resulting in vomiting; so, paying attention to the state of the teeth and gums is important. of course, some cats have multiple problems, and correction of dental disease may not resolve vomiting if there is another process. in the examination, it is also important to note consequences of both the underlying process and the vomiting itself; these include the demeanor of the cat, hydration status, and abdominal pain. the physical examination findings, together with the clinical history, help determine the next appropriate steps. well cats that are not continually vomiting and are appropriately hydrated, with no other specific signs, may be treated as outpatients by fasting them for 24 hours, then returning to food with a bland diet, such as plain cooked chicken or commercial, low-residue prescription diets designed for this purpose. follow-up is important to ensure signs do not progress. cats with nonspecific signs may require supportive care with subcutaneous or intravenous fluids and perhaps analgesia (with opioids). if clinical signs do not resolve, the pursuit of a specific diagnosis should be attempted. the practitioner must ask the following important questions: • are ancillary tests appropriate? • is supportive care necessary? • are any medications required? routine serum/plasma biochemistries, hematology, urinalysis, and total thyroxine (t 4 ) (for older cats) testing is not only important to distinguish primary from secondary gastrointestinal disease but to look for consequences of vomiting that may need to be addressed, such as hydration status and electrolyte abnormalities. careful interpretations should be made. severe azotemia, even with hyperphosphatemia, can occur as a result of primary gastrointestinal disease, and the distinction from renal disease usually requires an assessment of urine specific gravity. cobalamin, folate, feline trypsin-like immunoreactivity (ftli), and feline pancreatic lipase immunoreactivity (fpli) tests are useful markers of intestinal and pancreatic disease, 7, 8, 9, 10 but it is important to note that they mostly do not give a precise diagnosis. more detail about the utility of these tests is noted below in the section approach to the cat with diarrhea. is usually preceded by the cat licking its lips, salivating, or making attempts to swallow. regurgitated ingesta is often in a tubelike structure and if undigested can be covered with frothy saliva. partially digested food suggests vomitus, and the presence of bile or digested blood confirms this. it is important to determine if the cat vomits regularly. many owners have seen their cats vomit on a regular basis with no evidence of the cat being unwell, and this is noted frequently in the veterinary literature. 3, 12 hairballs can cause gastric irritation, and it may be that eating quickly also stimulates the peripheral sensory receptors that contribute to vomiting. if a cat does vomit regularly, it is important to assess if the cat is presenting for a change in the vomiting pattern (e.g., frequency or timing in relation to eating) and if the cat is unwell in any way, such as anorexia or weight loss. the pattern of vomiting is important in all cases, because cats presenting with acute gastritis usually have a sudden onset of frequent vomiting compared with those with chronic disease processes that may vomit every few days. the timing in relation to eating can be helpful, because the stomach should empty by 6 to 8 hours after a meal; so, vomiting longer than 8 hours after a meal can suggest motility or retention disorders. the description of the vomitus can be helpful. if bile is present, the pylorus is not obstructed; the presence of blood (digested or fresh) indicates ulceration. hair in the vomitus can indicate hairball gastritis, and the possibility of trichobezoar obstruction should be considered. access to foreign bodies or toxins is an important aspect of the clinical history. has the cat been seen playing with an insect, mouse, or other prey? are there any medications unaccounted for (e.g., a dropped aspirin tablet)? are lilies present in the house? vomiting is the major sign of gastric disease, but given the number of potential organ systems that can be involved, a thorough physical examination should be undertaken. because linear foreign bodies are a common cause of vomiting, all cats presenting for anorexia or vomiting should have the underside of the tongue evaluated for the presence of string caught there. applying gentle pressure with a thumb in the intermandibular space to elevate the tongue is an effective way to visualize lesions or foreign bodies in the sublingual area (see . a thorough examination may reveal specific signs, such as a palpable thyroid nodule and tachycardia in the case of hyperthyroidism or palpably small kidneys with and analgesia, many cats recover uneventfully. one survey assessed that 83% of cats undergoing exploratory laparotomy survived the hospitalization, and although complications occurred in 26% of cats, these were more likely to be associated with the underlying disease process and not surgery or anesthesia. 4 laparoscopy is not readily available in all veterinary clinics. this alternative is less invasive and allows exploration of the abdomen but not as thoroughly as with laparotomy. organs are usually exteriorized for biopsy. there is the possibility of anesthetic complications associated with insufflating the abdomen. endoscopy is the least invasive procedure and is the only alternative that allows examination of the intestinal lumen. this option limits the parts of the gastrointestinal tract that can be biopsied; it does not allow examination or sampling of any other part of the gastrointestinal tract and does not enable full-thickness biopsy samples. one study found that, of cats investigated for gastrointestinal disease, 9 of 33 cats (27%) had no pathology recognized proximal to the jejunum (i.e., the effective length of diagnostic endoscopes would have precluded diagnosis), and other organs were affected in 9 of 10 cats with inflammatory bowel diseases and 7 of 8 cats with intestinal small cell lymphoma. 1 careful case selection for endoscopy from survey ultrasonography can reduce the number of missed diagnoses from endoscopy, but the possibility still remains. the quality of endoscopically obtained biopsy samples varies greatly with the skill of the endoscopist. it has been stated that "it is exceedingly easy to take inadequate tissue samples with a flexible endoscope." 5 in an assessment of endoscopically obtained biopsy samples, two laboratories were compared, one that received samples from any practitioner and the other that received samples only from practitioners trained to take, mount, and submit endoscopy samples. all slides were reviewed by three pathologists who found that, of samples from the first laboratory, 15% of the slides were considered inadequate for diagnosis, 71% were considered questionable, and only 14% were adequate. by comparison, in the second laboratory (with samples from experienced practitioners) 0% of slides were inadequate, 21% were questionable, and 79% were considered adequate for diagnosis. 13 in the case of distinguishing between lymphocytic intestinal infiltrates (commonly known as inflammatory bowel disease) and lymphocytic neoplasia (small cell lymphoma), endoscopically obtained samples can give an incorrect diagnosis. 2 many of these problems can be minimized with experienced operators and careful case selection from prior ultrasonography. radiography is most useful for identifying foreign bodies or signs of intestinal obstruction from other causes. the major findings are noted below in the section intestinal obstruction. contrast radiography can aid the diagnosis for both discrete and linear foreign bodies but should be used with caution, because intestinal perforation may be present. nonionic iodinated agents that are typically used for myelography (such as iopamidol or iohexol) should be used, since barium irritates the peritoneum and oral iodine compounds are hypertonic. hypertonic compounds may draw fluid into the stomach and intestines after oral administration, with the potential of creating further fluid and electrolyte imbalances in an already compromised patient. 6 ultrasonography is a useful diagnostic adjunct and helps to detect and characterize localized thickening of the stomach or intestinal wall, lymphadenopathy, radiolucent foreign bodies, and changes in the size and echogenicity of the pancreas, liver, kidneys, or spleen. abdominal effusions can be assessed and sampled. ultrasound-guided fine-needle aspiration can be used to sample masses, bile, or peritoneal fluid. it should be recognized that in most cases of gastrointestinal disease, imaging will not give a definitive diagnosis and biopsy will be required, usually using either endoscopy or laparotomy. ultrasonography can be a considered as a means to "survey the field," assessing • the nature of the underlying disease, such as • thickened intestines with or without discrete layers • lymph node involvement • other organ involvement • the location of disease, for example, • diffuse or focal • proximal duodenum (reachable by endoscope) versus distal ileum these factors may be used to assess the appropriateness of endoscopy versus laparotomy to obtain diagnostic samples. most commonly used antiemetics all control vomiting by different mechanisms and include mirtazapine, metoclopramide, dolasetron/ondansetron, maropitant, and the phenothiazines (tables 23-2 and 23-3) . metoclopramide functions both as an antiemetic and prokinetic in cats, while cisapride functions solely as a prokinetic. mirtazapine, a piperazinoazepine, antagonizes the presynaptic alpha 2 -adrenergic receptor, increasing noradrenergic and serotonergic neurotransmission; the primary mechanism targeted for its use is as an antidepressant in humans. mirtazapine is also a potent antagonist of the postsynaptic serotonergic receptors (5-ht 2 and 5-ht 3 ) and histamine h 1 receptors. because of its antiserotonergic and antihistaminic effects, mirtazapine is used as an entiemetic and appetite stimulant in cats. anorexia is a common clinical problem in ill cats, and in some anorexic or partially anorexic cats the use of an appetite stimulant as adjunctive therapy to nutritional support (i.e. feeding tubes) may be of clinical benefit. prior to the development of mirtazapine, cyproheptadine was used as an appetite stimulant in cats, with variable clinical results. recently, the pharmacokinetics and pharmacodynamics of mirtazapine have been reported in cats. in a group of healthy cats, mirtazapine was found to be an effective appetite stimulant, with a shorter half-life than that reported in humans. the recommended oral dose is 1.88 mg/cat every 48 hours. 55a in humans, age and kidney and liver dysfunction affect mirtazapine metabolism (hepatic cyp 450 enzymes) and clearance (excreted in urine and feces), suggesting that dose adjustment may be necessary. 69a side effects reported in cats treated with mirtazapine include behavior changes (vocalization and interaction), tremors, muscle twitching, and hyperactivity. 9a,55a metoclopramide is both an antiemetic and prokinetic drug that acts peripherally on the gastrointestinal tract and centrally within the central nervous system (cns). at low doses metoclopramide inhibits dopaminergic (d 2 ) transmission, and at higher doses it inhibits serotonergic 5-ht 3 receptors in the chemoreceptor trigger zone (crtz). 15, 23 metoclopramide also acts peripherally as a prokinetic at the level of the gastrointestinal smooth muscle of the stomach and duodenum, triggering gastric emptying and duodenal contractions. multiple mechanisms mediate metoclopramide's prokinetic activity, including augmentation of acetylcholine release and increased smooth muscle sensitivity to cholinergic neurotransmission, which may in part be because of antagonism of dopamine, but more recently, serotonergic 5ht 4 receptor activation has been suggested. 23, 56 metoclopramide has been reported to increase the lower esophageal sphincter tone in humans, 20 although in cats metoclopramide's affect on the lower esophageal sphincter is reported to be weak. 32 adverse central nervous system, extrapyramidal signs occur secondary to dopamine (d 2 ) antagonism, including excitement and behavior changes. extrapyramidal signs are most often seen at the higher doses needed to block 5-ht 3 receptors. because of metoclopramide's prokinetic properties, an intestinal obstruction should be ruled out prior to its use. dopamine is a less important neurotransmitter in the chemoreceptor trigger zone of cats than alpha 2adre nergic and 5-ht 3 -serotonergic receptors, suggesting that d 2 -dopaminergic antagonist may be a less effective antiemetic in cats. clinically metoclopramide commonly controls vomiting in cats, although this clinical response may be secondary to 5-ht 3 antagonism and/ or its prokinetic effects. 32, 44 extrapolated from the short elimination half-life of metoclopramide in dogs (90 minutes), frequent be clinically significant side effects. phenothiazines have the potential to lower the seizure threshold; their use is not recommended in patients with a known seizure history. other cns-associated side effects linked to d 2 antagonism occur at higher doses and produce extrapyramidal signs, including rigidity, tremors, weakness, and restlessness. antagonism of the histaminergic receptors carries the risk of sedation. because of the need for frequent dosing (0.2 to 0.4 mg/ kg subcutaneously every 8 hours) and the risk of hypotension and sedation, the clinical use of phenothiazine antiemetics is limited to hospitalized patients with refractory vomiting and should be avoided in patients who are dehydrated or hypotensive. cisapride is a serotonergic 5-ht 4 agonist that increases propulsive gastrointestinal motility from the lower esophageal sphincter to the colon. cisapride binds serotonergic 5-ht 4 receptors in the myenteric plexus, increasing the release of acetylcholine in gastrointestinal smooth muscle. in dogs cisapride has greater prokinetic activity in the stomach relative to metoclopramide. 29 cisapride has no direct antiemetic effect, although it is indicated in a vomiting cat with colonic dysmotility secondary to megacolon. colonic distention can trigger the vomiting reflex in cats. cisapride induces colonic smooth muscle contractions in cats with megacolon that is dependent on the influx of extracellular calcium and is only partially cholinergic dependent. 30 other potential indications include refractory generalized ileus or gastroesophageal reflux. dosage recommendations based on the pharmacokinetics in healthy cats is 1.5 mg/kg orally every 12 hours. 41 prior to the use of cisapride, an intestinal obstruction should be ruled out because of its strong prokinetic effects. side effects reported in humans are cramping and diarrhea. potentially life-threatening side effects include qt prolongation and ventricular arrhythmias, the primary concern in humans that led to cisapride's removal from the market in the united states. 47 in cats qt prolongation associated with cisapride administration requires 20 times the therapeutic dose. 37 because of the risk of prolongation of the qt interval and ventricular arrhythmias, the concurrent use of cisapride and dolasetron is not recommended. 14 other potential drug interactions associated with cisapride include concurrent therapy with azole antifungals (ketoconazole and itraconazole), because of their inhibition of hepatic cyp3a isoenzyme system and the inhibition of cisapride metabolism. 47 diet trials are commonly used in cats with idiopathic gastrointestinal signs or in cats with suspected or known intermittent dosing or delivery by a constant rate infusion (cri) is necessary. empirical dosing in cats is 0.2 to 0.4 mg/kg subcutaneously or orally every 8 hours or 1 to 2 mg/kg/day as a cri. approximately 25% of metoclopramide is excreted in the urine, thus dose reduction is recommended in cats with underlying renal azotemia. 42 dolasetron and ondansetron are selective serotonin antagonists that inhibit central and peripheral 5-ht 3 receptors. their main antiemetic effect is through antagonism of the peripheral 5-ht 3 receptors in the gastrointestinal tract. in cats 5-ht 3 antagonism of the crzt is also likely important in the antiemetic effect of dolasetron and ondansetron. dolasetron and ondansetron were originally used for vomiting secondary to chemotherapy because of their superior clinical efficacy. the clinical use of dolasetron and ondansetron in cats has not been associated with reported side effects, and experimental studies report minimal toxicity in animals at doses 30 times the antiemetic dose. 15 side effects reported in humans include headaches, elevated liver enzymes, rare hypersensitivity reactions, prolongation of the qt interval, and arrhythmias. 14, 24 dolasetron is commonly used for parenteral administration and ondansetron for oral administration, dictated primarily based on the tablet sizes available and cost. recommended dosing of dolasetron is 0.5 to 1 mg/kg intravenously every 24 hours and ondansetron 0.5 mg/ kg orally every 12 hours. maropitant is a neurokinin-1 (nk-1) receptor antagonist, blocking the binding of substance p to the nk-1 receptors located in the emetic center, crtz, and the enteric plexus. 55 in cats maropitant has been reported to be efficacious in treating xylazine-induced vomiting and motion sickness. 31 recommended dosing in cats is 1 mg/ kg intravenously, subcutaneously or orally every 24 hours for up to 5 days. 31 maropitant is reported to be well tolerated in cats. prochlorperazine and chlorpromazine are considered broad-spectrum antiemetics by antagonism of d 2dopaminergic, histaminergic (h 1 and h 2 ), and cholinergic (muscarinic) receptors within the crtz and, at high doses, the alpha-adrenergic receptors (alpha 1 and alpha 2 ) within the vomiting center. in cats alpha 2 -receptors play a key role in emesis (recall xylazine is the emetic of choice in cats), suggesting cats may be more sensitive to the antiemetic effects of the phenothiazines. prochlorperazine and chlorpromazine produce an antiemetic effect at relatively low doses, thus avoiding profound sedation; although, because of antagonism of the alpha-receptors, vasodilation and hypotension can hyperacidity alone is not considered a common cause for vomiting in cats, but famotidine is effective in treating vomiting in cats associated with gastric ulcers or gastritis. recommended dosage in cats is 0.5 mg/kg every 12 to 24 hours. ranitidine is also a competitive inhibitor of the h 2 receptor associated with gastric parietal cells. in addition, ranitidine increases lower esophageal sphincter tone and functions as a prokinetic agent (increasing gastric emptying and stimulating intestinal motility, including colonic motility), because of its anticholinesterase food hypersensitivities. dietary strategies used to control vomiting in cats focus on either a highly digestible diet or an elimination (novel protein/carbohydrate or hydrolyzed protein) diet. 72 the empirical use of elimination diets in cats is reported to be relatively successful, with approximately 50% of cats with idiopathic gastrointestinal signs responsive to a novel protein/carbohydrate diets within 2 to 3 days. 28 interestingly, traditional diet trials are recommended for a minimum of 8 to 12 weeks, but in this group of diet-responsive cats with chronic gastrointestinal disease, clinical improvement was reported within days. 28 thus if a cat is going to be diet responsive, clinical improvement to a diet trial should be noted relatively early. highly digestible diets enable more effective absorption and assimilation of nutrients in the face of a compromised digestive tract. these diets contain highly digestible proteins and carbohydrates, moderate to low fat, soluble fiber but low concentrations of insoluble fiber, and are supplemented with omega-3 fatty acids. these diets are recommended when food allergy or intolerance is suspected. these diets contain a single highly digestible novel carbohydrate source and novel protein source. alternatively, diets formulated with hydrolyzed proteins can be used as an alternative to novel protein/carbohydrate diets. see tables 23-4 and 23-5 for information on gastrointestinal ulcers. famotidine has no direct antiemetic effect but is a competitive inhibitor of the histamine (h 2 ) receptors associated with the gastric parietal cells. the h 2 -receptor is the dominant receptor involved in gastric acid secretion. h 2receptor antagonism is reported to result in a 70% to 90% reduction in acid production. 13 famotidine is more effective at suppressing gastric acid secretion relative to ranitidine. famotidine is well tolerated, although, with chronic therapy, there is the potential for hypoacidity and gastric bacterial overgrowth. in humans dose reduction is recommended in association with renal dysfunction. 21 famotidine is not an inhibitor of the hepatic microsomal cytochrome p-450 enzyme system, therefore significant drug interactions are not anticipated. activity. 40, 54 significant drug interactions associated with hepatic microsomal cytochrome p-450 enzyme system inhibition are not a clinical concern with ranitidine. 46 an adverse effect to be aware of in cats treated with ranitidine is transient hypotension associated with ranitidine administered as an iv bolus. 19 in humans dose reduction is recommended in patients with renal azotemia. 39 ranitidine is effective in decreasing gastric acid in cats. 22 ranitidine would be a logical choice in a cat with gastrointestinal ulceration and/or atony. the reported dosage recommendation for ranitidine in cats is 3.5 mg/ kg orally every 12 hours or 2.5 mg/kg intravenous every 12 hours. 19 omeprazole omeprazole is a proton pump inhibitor that targets the h + /k + atpase pump on the luminal surface of partial cells. omeprazole is effective at suppressing parietal cell acid secretion, and its effects persist for ≈24 hours after drug withdrawal because of drug accumulation in the parietal cell (by ion trapping). indications for omeprazole therapy are for the treatment and prevention of nonsteroidal antiinflammatory drug (nsaid)-induced ulcers. 9 omeprazole is enteric coated to prevent its degradation by gastric acid; therefore oral formulations should not be crushed. based on human studies, omeprazole is a hepatic microsomal cytochrome p-450 enzyme inhibitor with known drug interactions with diazepam. 2 the extent of clinically significant drug interactions in cats has yet to be studied. omeprazole is reported to be effective in reducing gastric acid secretion in cats. 22 the recommended empirical dosage in cats is 0.5 to 1 mg/kg orally once daily. long-term use in humans 33 and dogs 11 is associated with gastric polyps and parietal cell hyperplasia, respectively, but the effect of long-term use in cats is currently unknown. sucralfate is a disaccharide complexed with aluminum that dissociates to sucrose octasulfate and aluminum hydroxide upon exposure to gastric acid. the sucrose octasulfate spontaneously polymerizes, producing a viscous material capable of binding ulcerative lesions in the gastric mucosa. once bound to the exposed mucosa, it prevents back diffusion of h + , inactivates pepsin, absorbs bile acids, and increases mucosal prostaglandin synthesis, collectively supporting ulcer healing. sucralfate is not systemically absorbed but does prevent the absorption of drugs capable of chelating with aluminum, including fluoroquinolones, tetracyclines, and digoxin. if sucralfate is indicated in a cat being treated concurrently with fluoroquinolones, tetracyclines, or digoxin, the recommendation is to administer the other drug 2 hours prior to the administration of sucralfate to optimize drug absorption. clinical indications for the use of sucralfate in cats are for the treatment of gastric ulcers and esophagitis. 36 dosage recommendation in cats is 250 mg orally every 12 hours. sucralfate can be crushed, suspended in water, and administered as slurry. diet trials are used in some cats with diarrhea if the underlying cause is from known or suspected food hypersensitivities. dietary management includes either a highly digestible diet, an elimination (novel protein/ carbohydrate or hydrolyzed protein) diet (see above for both), or a diet high in fiber. 72 high-fiber diets contain a mixture of both soluble and insoluble fiber that can be beneficial in patients with signs of large bowel diarrhea. insoluble fiber, such as cellulose, functions to increase the bulk of the stool, bind fluid, and regulate intestinal motility. soluble fiber, including fruit and vegetable pectins and beet pulp, functions as a source of butyric acid that can be used by the colonic mucosa and decreases proinflammatory cytokines. 69, 72 cobalamin cobalamin (vitamin b 12 ) is an essential vitamin needed by a number of different enzymes, including key enzymes involved in methionine metabolism and the conversion of methylfolate to tetrahydrofolate needed for dna synthesis. cobalamin and folate are intimately linked, and hypocobalaminemia can lead to a functional deficiency of folate. 57 ingested cobalamin requires intrinsic factor binding for enterocyte absorption at the level of the ileum. hypocobalaminemia is commonly associated with distal small intestine diseases in cats, including inflammatory bowel disease. in addition, low cobalamin has a negative impact on enterocyte function; therefore in many cats with intestinal disease and hypocobalaminemia, cobalamin supplementation is necessary for resolution of clinical signs. 60, 64 quantification of serum cobalamin levels is recommended in cats with clinical signs of small bowel diarrhea, ones suspected to have an infiltrative disease of the small intestine (inflammatory bowel disease or gastrointestinal lymphoma), or ones with pancreatic dysfunction. when hypocobalaminemia is identified, supplementation is recommended mannanoligosaccharides, inulin, chicory, and lactosucrose. 72 reports on the use of prebiotics in cats are limited to their use in healthy cats; healthy cats fed fructooligosaccharides were reported to have a trend toward an increase in fecal concentrations of lactobacilli and a decrease in concentration of c. perfringens and e. coli relative to the controls. 65 to date no reports are available on the use of prebiotics in cats with gastrointestinal disease. probiotics and prebiotics potentially have a supportive role in the treatment of gastrointestinal disease in cats. the important clinical consideration in the use of probiotics as an adjunctive therapy is to ensure the use of live nonpathogenic microorganisms that have been documented to colonize the intestinal tract of cats. gastrointestinal flora co-evolve with their host. gastrointestinal microorganism colonization varies among species and within each individual animal. the distribution of fecal microflora for a given individual is considered unique but stable over time. 68 antimicrobial and antiparasitic therapies for the treatment of feline diarrhea are indicated based on the specific diagnosis of infectious diarrhea, bacterial enteritis, or as adjunctive therapy for inflammatory bowel disease. infectious pathogens more commonly associated with feline diarrhea include bacterial enteropathies (clostridium, campylobacter), protozoal enteropathies (tritrichomonas foetus, giardia spp.), and helminthic enteropathies associated with ascarids, hookworms, whipworms, and tapeworms. only the more common anthelminthic, antimicrobial, and antiprotozoal therapies are discussed below (tables 23-6 and 23-7) . more information about antimicrobials and antiparasitics is found under specific infections in the discussions of infectious enteritis and gastrointestinal parasites. fenbendazole is an anthelmintic used to treat common helminth infections, including ascarids, hookworms, whipworms, and a single species of tapeworm, taenia pisiformis. giardia spp. are also considered susceptible to fenbendazole. fenbendazole binds beta-tubulin subunits of microtubules, interfering with their polymerization. side effects include vomiting and diarrhea, although both are considered rare. fenbendazole is not approved for use in cats in north america but is commonly used clinically, and an empirical dosage of 50 mg/kg (250 µg/cat every 7 days) while the underlying cause of cat's malabsorption is being investigated and at initiation of targeted therapy. probiotics probiotics are ingested live microorganisms intended to benefit the host, specifically to support the microflora environment of the gastrointestinal tract as well as to provide an overall benefit to the body's immune function by immunomodulation. 8, 18, 51 probiotics chemically modify ingesta and intestinal mucus, as well as affect immune cells, enterocytes, and goblet cells within the intestinal mucosa through direct receptor interactions and indirectly through the action of cytokines. the microorganisms commonly used are nonpathogenic bacteria and yeast that have a vital role in gastrointestinal health, including lactobacillus spp., enterococcus faecium, bifidobacterium spp., and saccharomyces spp. for example, lactobacilli synthesize b vitamins, digestive enzymes, and folate coenzymes. 63 clinical indications for the use of probiotics are diverse, including primary gastrointestinal disease, chronic renal disease, and pancreatitis. 71 the rational use of probiotics in the treatment of gastrointestinal diseases include their ability to modulate gastrointestinal flora, minimize colonization by pathogenic bacteria, and decrease the likelihood of bacterial translocation. 17 in healthy cats, lactobacillus acidophilus is reported to reduce fecal clostridium counts. 45 when lactobacillus acidophilus was used adjunctively with antimicrobial therapy, fecal shedding of campylobacter was reduced in cats with campylobacter-induced diarrhea relative to cats treated with antimicrobials alone. 3 specifically, in cats with gastrointestinal disease, available research supports the probiotic enterococcus faecium as clinically beneficial in resolving diarrhea in kittens. 16 relative to the control group, the kittens treated with probiotics had increased fecal bifidobacteria and blood iga concentrations and decreased fecal counts of clostridium perfringens. prebiotics are dietary supplements used to select for the more beneficial enteric flora, support gastrointestinal function, and prevent the overgrowth of pathogenic bacteria, including salmonella, escherichia coli, clostridium, or campylobacter. for a food additive to be considered a prebiotic, it must be nondigestible by the gastrointestinal tract (resistant to gastric acidity, gastrointestinal hydrolysis and absorption), yet fermentable by gastrointestinal microflora to short-chain fatty acids to stimulate the growth of "good" intestinal bacterial. 72 prebiotics include nondigestible oligosaccharidescommonly, oligofructose, fructo-oligosaccharides, pyrantel pamoate is a nicotinic anthelmintic used primarily for the treatment of ascarids, but its spectrum of activity also includes hookworms and the stomach worm, physaloptera spp. pyrantel is toxic to susceptible parasites through its selective action on their nicotinic acetylcholine receptors, resulting in depolarization and spastic paralysis. pyrantel is not approved for use in cats but is considered safe in cats and is commonly used clinically. the dosage recommendation in cats is 5 mg/ kg orally once, repeat in 3 weeks, and finally repeated in 3 months. metronidazole is a nitroimidazole antibiotic with an anaerobic antibacterial spectrum with antiprotozoal activity against giardia spp. in an anaerobic environment, metronidazole is converted to unstable intermediates (nitroso free radicals) that disrupt bacterial dna synthesis. immunomodulatory properties capable of inhibiting cell-mediated immunity have been described for metronidazole, although its immunomodulatory properties are reported at dosages well beyond what is recommended for clinical use, 62 raising questions about the clinical use of metronidazole as an adjunctive therapy for treating inflammatory bowel disease. 34, 43 resistance to metronidazole is considered rare. 43 the most common adverse reaction is gastrointestinal upset, including inappetence, anorexia, nausea, and vomiting. profuse salivation can occur in cats after oral administration of metronidazole base (formulation used in standard tablets), which has lead to the use of metronidazole benzoate (a compounded formulation not approved by the food and drug administration) in some cats because of its better oral palatability. 61 at high doses (>200 mg/ kg/day) benzoic acid is reported to be neurotoxic in cats, but with appropriate clinical dosing of metronidazole benzoate benzoic acid toxicity is unlikely. 6 dose-related metronidazole toxicity in cats results in cerebellovestibular ataxia secondary to gamma-aminobutyric acid (gaba) inhibition at dosages greater than or equal to 58 mg/kg/day 12, 52 ; clinical signs include nystagmus, head tilt, ataxia, seizures, and obtundation. in cats with inflammatory bowel disease, the dosage recommendation for the metronidazole base is 10 to 15 mg/kg/day. metronidazole benzoate contains approximately 60% metronidazole base by weight, translating to an empirical dosage of 20 mg/kg/day of metronidazole benzoate (equivalent to 12.4 mg/kg/day of metronidazole base). 61 little is known about the safety of chronic metronidazole use in cats, but oral metronidazole has been reported to disrupt dna within feline peripheral mononuclear cells following 7 days of therapy. 61 this metronidazole-induced genotoxicity is reversible and is no longer detected 6 days after antibiotic therapy is discontinued. ronidazole is a nitroimidazole antibiotic (similar to metronidazole) and available as a powder-on-feed antibiotic. ronidazole is not approved for use in cats but has immunosuppressive therapies used in cats with inflammatory bowel disease include glucocorticoids, cyclosporine, and chlorambucil (tables 23-8 and 23-9 ). more information on the treatment of inflammatory bowel disease is found elsewhere in this chapter. glucocorticoids are considered first-line therapy in the treatment of cats with inflammatory bowel disease. glucocorticoids bind their intracellular glucocorticoid receptors, modifying the expression of genes with glucocorticoid response elements. immunomodulation is achieved through inhibition of cytokine release and response, including decreasing leukocyte phagocytosis, chemotaxis, and antigen expression. the more common side effects in cats include gastrointestinal ulceration, opportunistic infections (e.g., urinary tract infections), pancreatitis, and diabetes mellitus. cats are less susceptible to iatrogenic hyperadrenocorticism than dogs. initial therapy is usually with oral prednisone or prednisolone. prednisone is a prodrug that is metabolized to its active form prednisolone. cats are reported to be less efficient in the conversion of prednisone to prednisolone 27 ; therefore prednisolone may be preferred in cats, especially in cats refractory to prednisone therapy. been used off-label to effectively treat tritrichomoniasis in naturally and experimentally infected cats (30 mg/kg orally every 12 hours for 14 days). 25 t. foetus reduces nitroimidazoles to their nitroso free radicals. ronidazole has been reported to have better in vitro and 10-fold higher in vivo activity against t. foetus relative to metronidazole. 25, 35, 49 ronidazole resistance is beginning to be reported in t. foetus isolates from cats with diarrhea. 26 side effects include hepatoxicity and neurotoxicity. neurotoxicity is associated with high doses and has been reported in cats. 59 the use of ronidazole is recommended only for confirmed cases of t. foetus, and dosing should not exceed 30 mg/kg once daily in cats, especially in cats at risk for neurotoxicity. ronidazole is not registered for human or veterinary use in the united states; therefore its use in cats requires owner informed consent and client education of the potential human hazards. immunosuppressive therapies are considered the standard of care for cats with gastrointestinal biopsies consistent with inflammatory bowel disease (lymphoplasmacytic or eosinophilic inflammation). the common alternative forms of glucocorticoids can be considered in specific patient populations. in patients with severe malabsorption, injectable dexamethasone may provide improved bioavailability and clinical response. also dexamethasone maybe preferred in patients with a history of heart failure, fluid retention, or hypertension because of its lack of mineralocorticoid activity relative to prednisone/prednisolone. dexamethasone's potency is 4 to 10 times that of prednisolone; therefore a dose reduction is necessary when prescribing dexamethasone (the dexamethasone dose is one seventh that of prednisolone). 4, 10 budesonide is an oral, locally active, highpotency glucocorticoid that is formulated to be released in the distal gastrointestinal tract (based on the ph differential between the proximal and distal small intestine), where it is absorbed and is locally immunomodulating at the level of the enterocyte. the amount of systemically absorbed budesonide is minimized, because 80% to 90% of the budesonide absorbed from the gastrointestinal tract undergoes first-pass metabolism in the liver. some systemic absorption does occur, as evidenced by a blunted adrenocorticotropic hormone (acth) stimulation test in dogs treated with budesonide at 3 mg/m 2 for 30 days. 66, 70 the use of budesonide in cats remains anecdotal, with a suggestive empirical dose of 0.5 to 1 mg/cat/day. initial glucocorticoid therapy for cats with inflammatory bowel disease consists of antiinflammatory (0.5 to 1 mg/kg/day) to immunosuppressive (2 to 4 mg/kg/ day) dosages, with dosages based on the potency of prednisone/prednisolone. the goal of therapy is to achieve clinical remission and slowly taper the dose of glucocorticoids to the lowest dose that will control the cat's clinical signs. 67 some cats may be completely weaned off therapy, while others require long-term lowdose therapy. the tapering of therapy should be slow, with a 25% to 50% dose reduction every 3 to 4 weeks. cyclosporine is considered a second-tier immunosuppressive drug used to treat inflammatory bowel disease in cats. use of cyclosporine in the treatment of diarrhea associated with inflammatory bowel disease in cats is extrapolated from its use in dogs to treat glucocorticoid refractory inflammatory bowel diarrhea. 1 cyclosporine suppresses t-lymphocyte-mediated inflammation in the gastrointestinal tract secondary to suppression of inflammatory cytokines. specifically, cyclosporine attenuates t-lymphocyte activation and proliferation through the inhibition of interleukin-2 (il-2) production. side effects of cyclosporine in cats include dose-dependent inappetence and vomiting, which may occur at the onset of therapy and are generally responsive to dose reduction. other less common side effects reported in cats are opportunistic infections, including toxoplasmosis 5 and hepatoxicity. the microemulsion formulation of cyclosporine has higher oral bioavailability and less variable pharmacokinetics. 58 a suggested initial dosage of cyclosporine is 4 mg/kg every 12 or 24 hours. serum cyclosporine levels can be used to monitor for excessive trough plasma concentration (>400 ng/ml) as determined using a highperformance liquid chromotography (hplc) analytical method. 53 chlorambucil is a slow-acting nitrogen mustard that alkylates and effectively cross links dna, leading to altered protein production. the immunosuppressive effects of chlorambucil are the result of its cytotoxic effect on lymphocytes, similar to other nitrogen mustards. bone marrow suppression is considered mild to moderate and is rapidly reversible. neurotoxicity and myoclonus has been reported in a cat accidently overdosed with chlorambucil. 7 chlorambucil is used as a second-tier drug in cats to treat immune-mediated disorders, in part because of ease of administration and its low risk of myelosuppression. for the treatment of inflammatory bowel disease, the recommended dosing in cats is 2 mg/cat every 48 hours in cats greater than 4 kg and 2 mg/cat every 72 hours in cats less than 4 kg. 50 chlorambucil is commonly used in combination with glucocorticoids in the treatment of immune-mediated diseases, including inflammatory bowel disease, 48 overlooked. awareness about feline esophageal diseases is low, the clinical signs are often not specific, and imaging beyond survey radiographs may be required for diagnosis. the esophagus is composed of four layers (from inner to outer): mucosa, submucosa, muscularis, and adventitia (there is no serosal layer). in the dog, the muscle layer is entirely composed of skeletal muscle, but in cats, the distal third of the esophagus is composed of smooth muscle. the upper esophageal sphincter prevents reflux of esophageal contents into the pharynx and minimizes aerophagia. the lower esophageal sphincter prevents gastroesophageal reflux and relaxes during swallowing to allow food and fluid to enter the stomach. clinical signs of esophageal disease include drooling, dysphagia, pain on swallowing (odynophagia), and, most classically, regurgitation. weight loss may occur secondary to inadequate food intake when disease is severe or chronic. other clinical signs, such as anorexia, cough, dyspnea, and fever, may occur if complications such as aspiration pneumonia or esophageal perforation occur. regurgitation is passive expulsion of food or fluid from the esophagus. the food is undigested and often accompanied by mucus and saliva. mucosal erosions may produce frank blood in the regurgitated material. regurgitation must be differentiated from vomiting (table 23 esophageal disease is uncommon in the cat when compared with dogs, but it is also likely that problems such as esophagitis and esophageal strictures are often salivation, retching, and abdominal contractions. the vomitus consists of partially digested food from the stomach and/or intestines and may be mixed with bilestained fluid. some cats will have both vomiting and regurgitation. expectoration may also be confused with vomiting or regurgitation. expectoration is associated with coughing, but cats that cough excessively may also stimulate vomition so that a careful history is needed to characterize the clinical signs correctly. coughing may also occur in cats that have aspirated as a result of regurgitation. drooling, dysphagia, and odynophagia are most commonly seen with conditions of the oropharynx and/or proximal esophagus. odynophagia is most commonly associated with esophagitis and foreign bodies. dysphagia and regurgitation together most commonly indicate oral or pharyngeal dysfunction; if regurgitation is not accompanied by dysphagia, esophageal dysfunction is likely. 55 regurgitation in cats with esophageal disease is caused by obstruction or muscular dysfunction. causes of obstruction include vascular ring anomaly, foreign object, stricture, and neoplasia. causes of muscular dysfunction include congenital disease, esophagitis, myopathies, neuropathies, and dysautonomia. regurgitation may occur immediately after eating if the lesion is in the proximal esophagus. however, a dilated esophagus provides a reservoir for food and fluid so that regurgitation may not be associated in time with eating. young cats with signs of esophageal disease should be suspected of congenital defects, such as vascular ring anomaly, or a foreign body. adult cats with esophageal disease may have a recent history of general anesthesia, administration of certain oral medications, or ingestion of irritant chemicals. acute onset of clinical signs may suggest a foreign body, while chronic, slowly worsening signs may indicate a stricture or tumor. all cats suspected of esophageal disease should have a minimum database as part of the diagnostic plan (complete blood cell count, serum chemistries, urinalysis, and other tests as indicated by age or concurrent diseases, such as serum total t 4 and blood pressure measurement). an important part of diagnosis is observation of the cat while eating food, to localize the location of the dysfunction. if the cat is unwilling to eat while in the veterinary clinic, the owner can make a video of the cat eating at home for the clinician to view. the general diagnostic approach to regurgitation in cats is found in figure 23 -3. plain and contrast radiography and endoscopy are important diagnostic tools for esophageal disease. fluoroscopy is valuable for the diagnosis of motility disorders, but availability is limited to universities and referral centers because of the cost of equipment. ultrasonography is limited to evaluation of * references 1, 8, 11, 15, 38, 43. the cervical esophagus and a small segment of abdominal esophagus between the cardia of the stomach and the diaphragm. the entire esophagus should be evaluated with cervical and thoracic radiographs. thoracic radiographs may also show evidence of complications such as aspiration pneumonia or esophageal perforation. the normal esophagus is not visualized on plain radiographs, but may be seen if food or fluid are retained or a foreign body or mass is present. radiographic contrast agents useful for esophagrams in cats include liquid or paste barium. a water-soluble iodinated contrast agent (e.g., iohexol, gastrografin) is preferred if there is any risk the esophagus is perforated, because these agents are less irritating and more rapidly reabsorbed. esophagrams are most useful for diagnosis of luminal obstructions, extraluminal compression, mucosal irregularities, and possibly alterations in motility. dilute liquid barium can be administered with a syringe or it may be mixed with canned food, especially if a motility disorder or stricture is suspected. multiple lateral radiographs are taken rapidly, starting within 10 seconds of swallowing the contrast agent. contrast is rapidly cleared from the normal esophagus by peristalsis. if the contrast in the esophagus terminates abruptly, an obstruction is likely. if the contrast is retained throughout the esophagus, muscular dysfunction is suspected. some conditions, such as esophagitis, are difficult to diagnose radiographically, because contrast agents may or may not adhere to ulcerated mucosa. flexible endoscopy is a noninvasive diagnostic tool for esophageal disorders and is often used if plain and contrast radiographs have failed to establish a diagnosis. it is most sensitive for diagnosis of masses, ulcers, perforations, and obstructions. in addition, it is often possible to retrieve foreign bodies using endoscopy as well as to assist with dilatation of strictures or placement of gastrostomy feeding tubes if required. biopsy of the esophageal mucosa is more difficult than biopsy of gastric or intestinal mucosa and is not commonly performed with the exception of mass lesions. esophagitis may result from various causes of inflammation, such as contact irritation from foreign bodies (including trichobezoars lodged in the esophagus), chemical irritants or caustic medications, gastroesophageal reflux, persistent vomiting, hiatal hernia, or general anesthesia. inflammation disrupts the esophageal mucosa and exposes the submucosa. an important part of the treatment plan is identification and treatment of the underlying cause. clinical signs include dysphagia, regurgitation, salivation, and repeated swallowing, although signs may be absent in cats with mild esophagitis. cats with odynophagia may repeatedly extend the head and neck while swallowing. if the esophagitis or underlying disease is severe, weight loss and dehydration may occur secondary to anorexia. if the submucosa and muscularis are damaged, strictures may form as a result of the production of fibrous connective tissue and compromise the esophageal lumen. 54 neoplasia is an important cause of esophageal stricture in humans, but not in cats. most cases have single strictures, but multiple strictures are possible. in two studies, the mean stricture diameter was reported as 5 mm. 26, 32 most strictures are less than 1 cm in length. clinical signs associated with strictures appear 5 to 14 days after the esophageal injury and may be present for weeks before definitive treatment is pursued. regurgitation typically occurs immediately after eating, although if the stricture is long standing, a pouch may form cranial to the lesion where food accumulates. survey radiographs may be normal in cats with esophagitis and strictures, but are useful to rule out other causes for the clinical signs, such as a foreign body, or to detect related problems, such as aspiration pneumonia. in some patients, dilation of the esophagus with fluid or air may be seen. 45 a contrast esophagram may disclose irregularities of the mucosa in cats with severe esophagitis. segmental dilation may occur with severe inflammation. strictures may be diagnosed with an esophagram (figure 23-4) ; however, in some cases, it may be difficult to differentiate a stricture from intramural thickening (e.g., because of neoplasia). endoscopy is useful for diagnosis of esophagitis; findings include mucosal erythema, hemorrhage, and erosions or ulcerations. if gastroesophageal reflux is present, the lesions will be most severe in the distal esophagus, and the lower esophageal sphincter may be dilated. endoscopy is often used for definitive diagnosis of esophageal stricture as well as to visualize the lesion during treatment by bougienage or balloon catheter dilation. strictures appear as a ring of white fibrous tissue that narrows the esophageal lumen. if endoscopy is performed after a barium esophagram, 24 hours should be allowed to elapse between the procedures or the barium will obscure visualization with the endoscope. 19 general anesthesia is an important cause of esophagitis (sometimes leading to stricture formation) in cats, probably because gastroesophageal reflux appears to occur commonly in anesthetized cats.* for example, in a series of seven cats with benign esophageal stricture, recent anesthesia for ovariohysterectomy was the suspected cause in five cases. 1 clinical signs appeared up to 21 days after anesthesia. abnormal esophageal tissue was performed in two cases. the authors noted that the esophageal mucosa may appear grossly normal, but submucosal inflammation may be found on histopathologic examination of biopsies. a consequence of chronic severe gerd in humans is the development of metaplastic columnar epithelium (barrett esophagus) that replaces the normal squamous epithelium. one case series reported on barrett-like esophagus in three cats. 23 two cases were associated with hiatal hernia and one with cardial incompetence. drug-induced esophageal damage and stricture formation is well known in humans and cats (see . in humans over 70 drugs have been implicated, and most are antibacterials or nsaids. 30 implicated drugs in the cat include tetracycline, doxycycline, and clindamycin in tablet or capsule form administered without a food or water bolus. 4, 17, 32, 36, 37 clinical signs (dysphagia, regurgitation, salivation, anorexia) appear 3 to 16 days after drug treatment is started. strictures commonly form in the midcervical esophagus or over the heart base in the thoracic esophagus. doxycycline hyclate is most commonly associated with esophageal strictures in cats, and the principle reason for its irritating properties is an acidic ph. the monohydrate salt of doxycycline is less irritating and is marketed as tablets and a palatable paste licensed for use in dogs and cats in some countries. 48 in humans esophageal ulceration after doxycycline therapy is more common than stricture formation. although the development of strictures in cats would appear to be uncommon, it seems possible the incidence of esophagitis is underestimated, because the clinical signs (e.g., odynophagia, chest pain) may go unrecognized. esophageal transit studies of normal cats have shown that the passage time of dry-swallowed tablets and capsules is often prolonged (longer than 30 seconds). 20, 53 complete entrapment (retention for more than 4 minutes) in the midcervical region occurs commonly. however, a small bolus of food or water is sufficient to ensure immediate passage of the medication into the stomach. 20, 53 the risk of esophageal retention can also be lessened by coating a tablet or capsule with butter or a gel dietary supplement (nutri-cal; vétoquinol, fort worth, tex.). 21 one study determined that tablets or capsules administered using a one-step pill gun with flavored liquid (flavorx pill glide; flavorx, columbia, md.) or a pill delivery treat (greenies pill pockets; nutro products, franklin, tenn.) ensured an average transit time of 60 seconds or less. 6 delayed esophageal transit of medications allows tablets and capsules to disintegrate within the esophagus, exposing the mucosa to irritating chemicals. cats may be at risk of delayed esophageal transit, because they do not typically drink water with medication, and they do not have an upright posture. in addition, medications are often given to sick or dehydrated patients many preanesthetic drugs and induction agents reduce lower esophageal sphincter pressure. 27, 28 other predisposing factors may be intraabdominal surgery and a head-down position on the surgery table. reflux fluid with a ph less than 4 is likely to cause esophageal mucosal damage, as is prolonged contact time. esophageal defense mechanisms include clearance of the reflux fluid by peristalsis and neutralization of the acidic ph by the bicarbonate present in saliva. in a study of 40 kittens less than 15 weeks of age, risk of gastroesophageal reflux during anesthesia was evaluated with use of a laryngeal airway mask versus endotracheal intubation. 47 gastroesophageal reflux was observed in 50% of kittens with use of the laryngeal airway mask but more importantly in 22% of kittens with endotracheal intubation. the reflux episodes occurred shortly after anesthesia induction. in a study of 50 cats anesthetized with thiopentone or propofol, gastroesophageal reflux occurred in 14%. 16 reflux also occurred shortly after anesthesia was induced and lasted for a mean of 23 minutes. it is unknown why esophageal strictures form only in a small number of cats that experience gastroesophageal reflux during anesthesia. gastroesophageal reflux disease (gerd) is a commonly reported cause of esophagitis in humans, but it is rarely reported in cats when not associated with general anesthesia. 24, 33 the true incidence is unknown, and diagnosis may be hampered by scant knowledge about the clinical presentation and diagnosis. clinical signs and diagnostic procedures are as for other causes of esophagitis. in one case series of three cats, diagnosis of gerd was based on clinical signs, contrast radiography, and endoscopic findings. 24 biopsy and histopathology of obtained from a compounding pharmacy in most countries and can only be given orally. h 2 -receptor antagonists are competitive inhibitors that block parietal h 2 receptors and decrease the amount of gastric acid produced. proton pump inhibitors are noncompetitive inhibitors that act on the h + /k + atpase enzyme system at the secretory surface of gastric parietal cells. they are considered superior for decreasing gastric acid secretion and are therefore the first choice, despite their greater cost. 45 a drawback of proton pump inhibitors is that they must be administered orally. sucralfate may be beneficial for reflux esophagitis, because it binds to mucosal erosions in an acid environment and provides a protective barrier. it is given as oral slurry, ideally separate from meals or other medications. antibiotics are not commonly recommended unless aspiration pneumonia is present or the eroded mucosa is at risk of bacterial infection in a patient with severe disease or a compromised immune system. corticosteroids are often recommended for cats with esophagitis to reduce esophageal inflammation and impair the formation of fibrous connective tissue. however, the benefit of corticosteroids in cats with esophagitis has not been investigated and administration must be weighed against potential adverse effects, especially in patients with aspiration pneumonia. treatment of esophageal stricture typically requires dilation with either bougienage or a balloon catheter; both are used with endoscopic visualization under general anesthesia. appropriate analgesia should be provided, because dilating the stricture is painful. it does not appear that placement of a gastrostomy feeding tube is specifically required to recover from dilation procedures, although a tube may be placed in some anorexic cats to ensure nutritional intake and administer oral medications. a bougie is a long, narrow, oblong, mechanical dilator available in various sizes (typically 9-to 12-mm sizes are used in cats) that is gently passed through the stricture, usually over a guide wire. established criteria for selection of bougie diameter and dilation end points are not available. in one study, the initial bougie chosen was approximately the same size as the estimated diameter of the stricture, or no more than 2 mm larger. 8 once the first bougie is passed, subsequent bougies of increasing diameter are employed. two to four bougies of increasing size may be passed in a single session, with the goal of dilating the stricture without causing esophageal tear or perforation. determining when dilation should be stopped is a matter of clinical judgment. the procedure may be repeated as needed to maintain improvement; the total number of procedures required is variable. in one retrospective case series of eight cats treated with bougienage, the median number of procedures was 4.5, and a good outcome was achieved in 75% of the cases. 8 in some cases, the endoscope tip itself has been used for that may be at greater risk of esophageal retention of medication. all oral medication given to cats in tablet or capsule form should be followed with food or a liquid. mild esophagitis will resolve on its own, especially if an underlying cause can be removed or treated. frequent meals of canned food should be provided. cats with moderate to severe esophagitis will require medical therapy, and those with difficulty eating or weight loss may also require gastrostomy tube feeding. esophagostomy or pharyngostomy feeding tubes should be avoided in these patients. treatment is provided to control inflammation and promote healing while reducing gastric acid secretion and increasing lower esophageal sphincter tone. the length of medical treatment will vary from about one week to several weeks, depending on the underlying cause and severity of disease. medications indicated for esophagitis include prokinetics, h 2 -receptor antagonists, proton pump inhibitors, and sucralfate (table 23-11) . prokinetic drugs enhance gastric emptying and increase lower esophageal sphincter tone. metoclopramide also has antiemetic effects, which may be beneficial in patients with chronic vomiting. it can be administered by the subcutaneous (sc) route, an advantage in a vomiting or regurgitating patient. cisapride may be more effective at enhancing both gastric emptying and lower esophageal sphincter tone, but it must be stent placement has recently been described in cats with esophageal strictures with variable results. a 1-year-old cat presented with a 4-week history of dysphagia and regurgitation caused by a single cervical esophageal stricture after treatment with oral clindamycin. 18 guided balloon dilation was performed 6 times over a period of 3 weeks, but stricture formation always recurred. a self-expanding metal stent was placed using endoscopy and fluoroscopy after another dilation procedure. the cat did well eating a canned diet from an elevated position for 10 months, but by 12 months, the cat was no longer able to eat even liquid food and was euthanized. on necropsy, the stent had migrated and was obstructed by swallowed hair. in another case, a biodegradable self-expanding stent was used to successfully treat an 11-year-old cat that presented with a stricture in the cervical esophagus after anesthesia for dentistry. 3 balloon dilation was performed twice, but regurgitation recurred 5 days after the last procedure. the stricture was dilated a third time with a balloon catheter, and a tubular selfexpanding polydioxanone stent was placed with fluoroscopic guidance. the life span of the stent was estimated to be 10 to 12 weeks, sufficient time to allow healing of the esophagus. foreign bodies are less commonly found in the esophagus of the cat than in other gastrointestinal locations. reported foreign bodies include string, needles, fish hooks, and bones. trichobezoars may cause obstruction when they become lodged in the esophagus during vomiting ( figure 23 -5). recurrent esophageal trichobezoars have been infrequently reported in the literature. 12, 51 it is not known if an esophageal motility disorder is the underlying cause for recurrent obstructions. in one case, an esophageal diverticulum developed in association with recurrent trichobezoars. 12 treatment for recurrent trichobezoars includes prokinetic drug therapy (e.g., cisapride), moderate to high-fiber diets, and shaving of long-haired cats. common areas for foreign bodies to lodge include the thoracic inlet, the heart base, and the esophageal hiatus in the diaphragm. 5 obstruction of the esophageal lumen may be complete or partial. clinical signs include acute onset of gagging, salivation, repeated swallowing, dysphagia, and regurgitation. however, chronic esophageal foreign bodies have been reported in cats with dysphagia, intermittent regurgitation, and weight loss over a period of weeks or months. 2 bougienage when bougies or balloon catheters were not available. balloon catheter dilation has become a popular method in recent years. 26, 32, 38 although some clinicians feel this is a safer procedure than bougienage, there is no data in the literature to support this assumption. the catheter can be placed through the endoscope biopsy channel, alongside the endoscope, or with the aid of a preplaced guide wire. as for bougienage, established criteria for selection of balloon diameter and dilation end points are not available, and the clinician's best judgment must be used. various balloon sizes are available; in one study, the size was selected so that the inflated diameter was 4 mm larger than the stricture diameter. 32 the balloon is passed into the stricture with endoscopic guidance. it is then inflated to a predetermined pressure for 1 to 2 minutes to stretch the stricture, usually with saline, but contrast agents may also be used if fluoroscopy is used. as for bougienage, some cases may require more than one dilation procedure (typically two to four). cuffed endotracheal tubes are not appropriate substitutes for balloon catheters. regardless of the method used, after the dilation procedure, the endoscope should be used to look for other strictures and should be passed into the stomach to look for potential causes, such as causes of chronic vomiting. after treatment, medical management to decrease ongoing gastroesophageal reflux, resolve inflammation, and prevent further stricture formation should be instituted (as described previously). most cats are able to eat the day following the dilation procedure. corticosteroid treatment after dilation is controversial, and no controlled studies in animals are available. antibiotics are not routinely recommended. the prognosis for cats undergoing esophageal dilation is generally good based on the ability to eat canned food with minimal episodes of regurgitation. however, published studies show 10% to 30% of cats died or were euthanized despite multiple episodes of dilation, and up to 30% could only be fed liquid diets. 1, 8, 32, 38 even among cats with good outcomes, a return to a dry kibble diet may not be possible. the dilation technique employed may be dictated by the clinician's experience, the equipment available, and the cost. potential complications of both methods include esophageal tear or perforation, hemorrhage, infection, and aspiration. esophageal tears or perforations may lead to pneumothorax or pneumomediastinum. repeated stricture formation is also possible, leaving only less desirable treatment options, such as long-term percutaneous gastrostomy tube feeding or surgery. esophageal surgery is generally avoided whenever possible, because it is difficult and invasive (requiring a thoracotomy), with risk of serious complications, such as failure of anastomosis, necrosis, and stricture formation. closure of incisions in the esophagus is following uncomplicated foreign body removal, the esophagus should be carefully inspected for lesions and bleeding before the endoscope is withdrawn. food and water should be withheld for 24 to 48 hours. supportive care includes fluid therapy and analgesia; a gastrostomy feeding tube may be required in selected cases for nutritional support. broad-spectrum antibiotics are administered to control bacterial infection and therapy for esophagitis should be instituted as described previously. careful follow-up should include evaluation for stricture formation. if an esophageal perforation has occurred, conservative management may be sufficient if the defect is small. a broad-spectrum antibiotic should be administered along with other supportive care, such as fluid therapy and analgesia. feeding through a gastrostomy tube for several days is recommended as well as close monitoring for complications such as pleuritis. large perforations require thoracotomy for surgical repair. megaesophagus is a diffuse hypomotility disorder that may be classified as congenital versus acquired or idiopathic versus secondary to other diseases. it is uncommon in cats compared with dogs. at least two dog breeds have been identified with heritable congenital megaesophagus. a heritable form of megaesophagus has been suggested for cats, particularly for siamese cats, although no detailed studies have been performed. 13, 29 it is often frustrating to determine the underlying cause of acquired megaesophagus. megaesophagus may be a manifestation of neuromuscular diseases, such as dysautonomia or myasthenia gravis (see chapter 27) . megaesophagus may also develop secondary to esophagitis from chronic vomiting or gerd. 24, 43 other uncommon causes of megaesophagus are found in the literature. one case report describes a young cat with megaesophagus secondary to a large nasopharyngeal polyp that extended into the cervical esophagus. 10 megaesophagus resolved once the polyp was removed. in another report, a young cat with diaphragmatic hernia was diagnosed with megaesophagus and gastric dilation. 31 megaesophagus resolved with medical treatment and surgical correction of the diaphragmatic defect. clinical signs are typically those of esophageal dysfunction; regurgitation is the most consistently found sign. regurgitation may not be closely related in time to eating if the esophagus is markedly distended and holds food. cats with long-standing disease may suffer from weight loss or secondary rhinitis. the appetite is typically normal or increased. additional signs may occur if systemic neuromuscular disease is present. aspiration pneumonia may cause fever, dyspnea, and cough. two case reports describe cats with idiopathic cough, mucopurulent nasal discharge, and fever may be found if aspiration has occurred. trauma to the esophagus may cause esophagitis and even esophageal stricture. perforation of the esophagus by the foreign body may lead to pneumothorax, pneumomediastinum, or pyothorax with signs of depression, anorexia, fever, and dyspnea. if the perforation occurs in the cervical esophagus, swelling, cellulitis, and drainage of serous or purulent material may be noted. many foreign bodies are readily diagnosed with survey radiographs, especially if they are radiopaque. other radiographic findings include an esophagus dilated with fluid or air. radiolucent objects may be detected with an esophagram. care must be taken when performing esophagrams on cats that may have an obstruction, because aspiration is a concern. if abnormalities that could be consistent with an esophageal perforation (e.g., periesophageal gas or fluid, pleural effusion) are detected on survey radiographs, an aqueous iodine contrast solution should be used. removal of esophageal foreign bodies should be performed as soon as possible to minimize esophageal trauma and pressure necrosis. endoscopy can be used to confirm the diagnosis and often to remove the object. both rigid and flexible endoscopes may be used along with accessories such as various forceps and foley catheters. care should be taken to remove the object as atraumatically as possible, especially if the object is sharp or pointed. if the object is in the caudal esophagus and it cannot be grasped and removed, an attempt should be made to gently push it into the stomach, where it can be retrieved using laparotomy and gastrotomy. if esophageal perforation has occurred, esophagotomy is recommended and is described elsewhere. 5, 14 removal of fish hooks may require a combination of surgery and endoscopy. 5, 39 a surgical approach to the esophagus is made, but the esophagus is not incised; rather, the portion of the hook protruding through the esophagus is cut and removed, and the endoscope is used to retrieve the remainder. clinical sign is regurgitation, and most patients are underweight. a distended cervical esophagus may be palpated, and secondary aspiration pneumonia may occur. a history of regurgitation since weaning is very suggestive of a vascular ring anomaly, but other causes of regurgitation must be ruled out. survey radiographs show a dilated esophagus cranial to the heart, while the caudal esophagus is usually normal. the bulge of the aortic arch normally seen on a ventrodorsal radiographic view is absent. an esophagram is used to confirm the location of the obstruction and the severity of disease. definitive treatment is surgical repair of the vascular defect (i.e., ligation and transection of the ligamentosum arteriosum). some patients will require nutritional support through gastrostomy tube feeding and treatment for aspiration pneumonia before surgery. early diagnosis and surgical intervention brings the best prognosis for return of normal esophageal function. some affected cats are left with residual esophageal hypomotility, which is managed as for idiopathic megaesophagus. esophageal neoplasia is rare in the cat as in the dog. although parasitic granulomas caused by spirocerca lupi are associated with esophageal neoplasia in dogs, this parasite does not infect cats. both primary and metastatic esophageal tumors can occur in the cat. squamous cell carcinoma is the most common primary esophageal tumor in cats and is often found in the caudal two thirds of the esophagus. 7, 22, 25, 46 affected cats are middle aged or older. clinical signs are typically those associated with esophageal obstruction, such as regurgitation, dysphagia, odynophagia, and salivation. patients with advanced disease may suffer anorexia, depression, and weight loss. on physical examination, an esophageal mass may or may not be palpable. survey and contrast radiographs reveal esophageal dilation, a soft tissue mass, or periesophageal lesions that displace the esophagus. computed tomography is useful to identify periesophageal or intraluminal masses. definitive diagnosis is made with endoscopy and biopsy. mucosal biopsies are difficult to obtain, because the esophageal mucosa is tough; exfoliative cytology may also be helpful. treatment is rarely undertaken, because disease is often advanced at the time of diagnosis, and many patients have complications such as aspiration pneumonia. palliation may be attempted with chemotherapy or radiation, although data on efficacy is unavailable. in general, squamous cell carcinomas in other anatomic locations respond poorly to treatment. surgical resection may be attempted if anastomosis can be accomplished without excessive tension. megaesophagus and chronic vomiting associated with intermittent gastroesophageal intussusception. 35, 50 survey and contrast radiographs may identify a dilated esophagus (figure 23-6), but contrast fluoroscopy is the diagnostic tool of choice when available, because it allows for assessment of peristalsis. care must be taken with contrast studies because of the risk of aspiration. treatment of megaesophagus is largely symptomatic and supportive unless an underlying disorder can be identified and treated. frequent small meals are offered with the cat feeding in an upright position. the upright position should be maintained for at least 10 minutes after eating to allow for gravity-assisted passage of food into the stomach. this is best accomplished by having the owner hold the cat over their shoulder so that the esophagus is in a vertical position. 44 different types of diets should be offered to determine which is best for the individual patient; calorically dense diets may be beneficial for patients with weight loss. prokinetic drugs, such as cisapride, stimulate smooth muscle, but since most of the esophagus is skeletal muscle, the efficacy of such drugs is questionable for treatment of megaesophagus. prokinetic drugs also increase lower esophageal sphincter tone and may increase esophageal transit time, neither of which is desirable in patients with megaesophagus. vascular ring anomalies are congenital malformations of the great vessels that entrap the thoracic esophagus and cause obstruction. the most commonly reported anomaly is persistent right aortic arch. the esophagus is entrapped by the aorta on the right, the ligamentum arteriosum and the pulmonary trunk on the left, and the heart base ventrally. other vascular anomalies are rarely described in cats, such as a double aortic arch described in a siamese cat. 56 onset of clinical signs occurs around the time of weaning to solid food so that most affected cats are presented at less than 6 months of age. the most common surgery. 34 surgery is the treatment of choice for large defects, especially in young cats with congenital disease or cats that have failed medical management. various reconstructive surgical techniques have been described. 14 disorders of the hiatus are rare in cats. hiatal hernia is protrusion of the distal esophagus and stomach through the esophageal hiatus of the diaphragm into the thoracic cavity; the protrusion may be intermittent ("sliding") or persistent. other organs are occasionally involved, such as the omentum. 40 this is distinct from a gastroesophageal intussusception where the stomach is prolapsed into the lumen of the distal esophagus. 35, 49 both congenital and traumatic hiatal hernias have been described in cats. 9, 23, 41, 42, 52 congenital hernias appear to be more common than acquired hernias, and affected cats typically present with clinical signs before 1 year of age. it is suspected that increased inspiratory effort associated with upper airway obstruction, such as a nasopharyngeal polyp, may also lead to development of hiatal hernia. 23 hiatal herniation reduces lower esophageal sphincter pressure. clinical signs associated with hiatal hernia, such as intermittent vomiting and regurgitation, may be because of reflux esophagitis, hypomotility, or obstruction. large hernias and secondary aspiration pneumonia may be associated with respiratory distress. survey radiographs may reveal a gas-filled soft tissue density in the caudal dorsal mediastinum. an esophagram will show the gastroesophageal junction and gastric rugae cranial to the diaphragm (figure 23-7) . both fluoroscopy and endoscopy may be useful for diagnosis but are not typically necessary. the prognosis for cats with hiatal hernia is considered to be good. a trial of medical management (as for reflux esophagitis) for 1 month has been recommended before the stomach is a frequent site for gastrointestinal problems in cats, and the most common gastric problems are described in this chapter. some conditions such as gastric dilatation-volvulus are often reported in dogs but rarely reported in cats. in one report of three feline cases, all were associated with diaphragmatic hernia. 15 gastric parasites, the diagnostic approach to the vomiting cat, the gastric emptying time of normal cats is shorter than that of other mammals. in one study, the gastric emptying half-time for solid food in normal cats was 1.4 to 3.6 hours. 53 this implies prolonged fasting (longer than 8 hours) in preparation for anesthesia and surgery is unnecessary. the main clinical sign of gastric disease is vomiting, but it is important to note that vomiting is also associated with many nongastric problems, including concurrent intestinal disease, such as enteritis or colitis. vomiting patients therefore require a thorough physical examination and diagnostic plan to determine the cause. vomiting must be distinguished from regurgitation, which is primarily associated with esophageal disease (see table 23 -10). vomitus often contains food, hair, refluxed bile, and therapeutics for vomiting are covered elsewhere in this chapter. the anatomy of the feline stomach is similar to that of other mammals having a simple glandular stomach. most of the stomach is situated on the left side of the abdominal cavity. it has five regions, starting from the lower esophageal sphincter: cardia, fundus, body, antrum, and pylorus ( figure 23-8) . the pylorus of the cat is unique compared with other species in that it is narrow and has high resistance in order to maintain a tight seal ( figure 23 involve a wide variety of objects, including linear objects (e.g., dental floss, thread with or without a needle, tinsel, string). the owner may or may not be aware of the ingestion. ingestion of multiple foreign bodies may be seen in cats with pica ( figure 23-12 ). in one case report, a young domestic shorthair cat required gastrotomy for removal of 32 copper pennies. 43 some patients require multiple surgeries, because of repeated foreign body ingestion. 22 in such cases, a behavioral diagnosis should be sought and treatment instituted (see chapter 13) . trichobezoars (large masses of hair) also represent a type of foreign object. both long-and shorthaired cats may be affected. hair is normally ingested during grooming and is eliminated in vomitus and feces. cats lack the strong peristaltic contractions ("housekeeper" contractions) that clear the stomach of undigested contents normally found in other species. this may explain why cats seem to be susceptible to gastric trichobezoars. gastric motility dysfunction is suspected to cause repeated gastric trichobezoars in some cats. intestinal 3, 22 and esophageal 14, 59 obstruction with trichobezoars has also been documented. traditional treatments for cats with recurrent trichobezoars include regular grooming, shaving the hair coat of long-haired cats, flea control, or blood. fresh blood may appear as large or small clots. older blood clots have a brown "coffee ground" appearance. gastric bleeding may also cause melena. other clinical signs may be associated with gastric disease, such as anorexia, weight loss, pain, lethargy, bloating, and nausea. gastritis may be acute or chronic in nature, and this distinction may be useful in assessing the potential cause. for example, cats with acute gastritis may be suspected of foreign body or plant ingestion, drug or toxin exposure (see chapter 31), or dietary indiscretion. cats with chronic gastritis may be suspected of parasitism, helicobacter spp. infection, or dietary intolerance or hypersensitivity (see chapter 17) . chronic lymphocytic plasmacytic gastritis of unknown etiology is also a common cause of chronic vomiting. whenever possible, a specific underlying cause should be sought and treated. patients with sudden onset of vomiting may have an obvious cause in the history (e.g., dietary indiscretion), but in many cases, the cause is not apparent. abdominal radiographs should be taken if foreign body ingestion is possible, especially in a young cat. if the patient is systemically well, further diagnostic testing may be postponed pending response to therapy. treatment for uncomplicated acute gastritis is symptomatic and supportive. clinical signs are expected to resolve in 24 to 48 hours; if signs persist, re-evaluation and further investigation is warranted. subcutaneous fluid therapy using an isotonic balanced electrolyte solution may be used to correct mild fluid deficits (<5%). oral intake of fluids and food should be discontinued for up to 24 hours. a highly digestible diet, either commercial or homemade, is introduced with a gradual transition back to the normal diet over the next several days. antiemetic therapy may be indicated for acute uncomplicated gastritis if the vomiting is frequent or the cat has signs of nausea (see table 23 -3). protectants, such as kaolin and pectin, are difficult to administer to cats and are without proven efficacy. bismuth subsalicylate is controversial; it is considered contraindicated by some experts, because of the cat's sensitivity to salicylates, 39 yet is commonly used in clinical practice. cats ingest foreign bodies less commonly than dogs. in one study of 208 cases of gastrointestinal foreign body ingestion, only 12% were in cats. 22 foreign body ingestion is most likely to be seen in young cats and may a b taken just before surgery to ensure the object has not moved further down the gastrointestinal tract. postoperative management after gastrotomy includes maintenance of hydration and electrolyte balance. hypokalemia is common with anorexia and vomiting and should be treated by supplementation of iv fluids with 20 to 40 meq/l potassium chloride (not to exceed 0.5 meq/kg/hour). refractory vomiting should be treated with an antiemetic. a highly digestible diet can be introduced the day after surgery. in general, the prognosis for recovery is good. in one study, 88% of cats with gastrointestinal foreign bodies survived to discharge. 22 those cats that did not survive had linear foreign bodies of long-standing duration with subsequent peritonitis. helicobacter are spiral or curved gram-negative bacteria that inhabit the glands, parietal cells, and mucus of the gastric antrum and fundus. helicobacter contain large amounts of urease, which alters the ph in the vicinity of the bacteria and allows for colonization of the acidic environment of the stomach. in the early 1980s, the discovery of the association of helicobacter pylori with gastric disease (gastritis, peptic ulcers, and neoplasia) in humans revolutionized treatment of those diseases. since then, helicobacter spp. have been associated with gastric disease in various veterinary species, including cats and dogs. several helicobacter spp. (e.g., h. heilmannii, h. bizzozeronii, h. felis) have been identified in cats, some of which have the potential to infect humans, although transmission is thought to be rare. 19, 48 the prevalence of helicobacter infection in cats varies geographically and may be very high (>40%) in some locations. 1, 27, 37, 47, 58 the importance of helicobacter as a cause of gastric disease is cats is unclear; the bacteria may be found in the stomach of both clinically normal cats and cats with gastritis. the prevalence of helicobacter infection is not higher in cats with gastritis compared with normal cats. 61 determination of the role of helicobacter is also hampered by the paucity of controlled clinical trials that evaluate eradication of gastritis and clinical signs in infected cats. an immune response to infection characterized by gastric lymphoid hyperplasia is common, although the local immune response in cats is generally less severe than the response in humans infected with h. pylori. to date gastrointestinal ulcers have not been associated with helicobacter infection in cats. recent studies have suggested a possible association between helicobacter infection and gastric lymphoma in cats, although more research is needed to confirm the association and understand the pathogenesis. 7, 32 helicobacter spp. may be commensal in most cats, and perhaps loss of tolerance explains the development of gastritis in some individuals. 49 another possibility is that the inflammatory response is normally well managed and disease may treatment of underlying dermatologic disorders, and administration of semisolid petroleum laxatives. more recently, commercial diets have been formulated for control of trichobezoars. cats with recurrent trichobezoars causing illness and suspected motility disorders may benefit from treatment with prokinetic drugs such as cisapride. clinical signs of gastric foreign bodies are variable but typically involve intermittent or persistent vomiting because of gastric outflow obstruction, distention, and mucosal irritation. gastric obstruction may be partial or total. patients with complete obstruction will present with more dramatic signs, including anorexia and depression. the base of the tongue should always be examined, because linear foreign bodies are sometimes anchored either in this location, or they may be lodged in the pylorus, causing intestinal plication. gastric foreign bodies may also be asymptomatic and found incidentally. 5 physical examination may be unremarkable or may reveal dehydration or abdominal pain. if the stomach is markedly distended, the foreign body may be palpable in some patients. survey radiographs are always indicated when foreign body ingestion is suspected. radiopaque foreign bodies may be readily diagnosed, although some, along with radiolucent objects, will require a contrast study for diagnosis ( figure 23-13) . barium is commonly used as a contrast agent, although if gastric perforation is suspected, an aqueous iodinated agent is preferred. ultrasonography is also useful for detection of gastrointestinal foreign bodies. 56 removal of some foreign bodies can be attempted endoscopically, particularly if the object does not have sharp edges and is not too large. successful removal of fish hooks, particularly single-barb hooks, using endoscopy has been described. 35 otherwise, foreign objects are best removed using gastrotomy through a ventral midline laparotomy. a radiograph should always be to know when treatment should be attempted. one expert recommends treating only patients with clinical signs of gastritis that have biopsy-confirmed helicobacter infection with a treatment regimen of amoxicillin (20 mg/kg, every 12 hours, po), clarithromycin (7.5 mg/ kg, every 12 hours, po) and metronidazole (10 mg/kg, every 12 hours, po) for 14 days. 49 a common dilemma would be determining the treatment of choice for patients with lymphoplasmacytic inflammation of the stomach and small intestine and confirmed helicobacter infection. are such patients best treated for inflammatory bowel disease, helicobacter infection, or both? currently, guidelines for determining the best treatment approach are lacking. also, few studies on the efficacy of combination therapy have been conducted in cats. long-term eradication of infection may be difficult, and histopathologic resolution of gastritis may not be possible, which raises the question of whether helicobacter is the true underlying cause. 38, 41 in one study, two cats with clinical gastritis and helicobacter infection were treated with oral metronidazole, amoxicillin, and bismuth subsalicylate for 3 weeks and were also fed a commercial elimination diet. 25 posttreatment gastric biopsies were obtained a mean of 7 weeks after the cessation of treatment. resolution of clinical signs occurred rapidly, and clearance of helicobacter spp. was achieved at that time point, but gastric inflammation persisted in post-treatment biopsies. in another study, 13 cats with asymptomatic helicobacter infection were treated with oral omeprazole, amoxicillin, metronidazole, and clarithromycin for 14 days. 26 treatment failed to eradicate infection in 4 of the cats based on molecular analysis of post-treatment gastric biopsies. it is unclear if treatment failure is because of recrudescence or reinfection. the reader is referred to excellent reviews of helicobacter in cats for more information. 27, 38, 48 chronic gastritis chronic gastritis is common in cats with chronic intermittent vomiting. ollulanus tricuspis is a worm that infects the stomach of cats, causing chronic gastritis, and it is difficult to diagnose (see below, gastrointestinal parasites). the worm is occasionally found on histologic examination of gastric biopsy samples. 9 it is reasonable to treat empirically (fenbendazole 10 mg/kg, once daily, po × 2 days) for this parasite when the cause of gastritis is not apparent. 49 the frequency of vomiting in cats with chronic gastritis is highly variable, ranging from once or twice per week (and not necessarily every week) to more than once daily. most patients are otherwise well, although other clinical signs (inappetence, anorexia, depression, or weight loss) are possible depending on disease severity. results of routine laboratory testing are typically normal but may show neutrophilic leukocytosis, result when there is an abnormality of the immunoregulatory system. 21 the most commonly used methods for diagnosis of helicobacter infection in cats are based on gastric specimens obtained during endoscopy (or laparotomy): exfoliative cytology, histopathologic examination of biopsy specimens, and rapid urease testing of biopsy specimens. 28 however, it is important to note that even when helicobacter organisms are identified, the infection may not be the cause of the patient's clinical signs, and other causes of vomiting should always be evaluated. exfoliative cytology is the least expensive and most easily performed diagnostic test. in one study, it was also the most sensitive diagnostic method when compared with urease testing and histologic examination. 20 brush cytology samples gathered during endoscopy are airdried on microscope slides and stained with wright's stain. the slide is examined at 100× magnification under oil immersion. spiral bacteria are readily seen if present. at least 10 oil-immersion fields on two slides should be examined before determining a specimen is negative for helicobacter-like organisms. 28 since helicobacter produce abundant urease, a rapid urease test (e.g., clotest, ballard medical products, draper, utah) may be used for diagnosis. 38 the kit consists of an agar gel impregnated with urea and a ph indicator. a gastric biopsy sample is applied to the gel, and if urease is present, ammonia will form and change the ph (and thus the color) of the gel. the gel may change color rapidly (within 30 minutes), but 24 hours must elapse before the test can be considered negative. 28 the more rapidly the color changes, the higher the bacterial load. both false-positive and false-negative results are possible with rapid urease testing for various reasons, giving the test a sensitivity of 70% to 90%. 28, 37 histopathologic examination of gastric biopsy samples using hemotoxylin and eosin (h&e) or silver stains is highly sensitive and specific in human studies for detection of helicobacter-like organisms. the organisms are not equally distributed; so, examination of biopsy specimens from multiple sites will increase sensitivity. the bacteria may be seen in mucus on the surface epithelium as well as in the gastric pits, glandular lumen, and parietal cells. organisms may also be seen submucosally within gastric lymphoid follicles. 46 histopathologic examination of biopsy samples also allows for assessment of other abnormalities. mild to severe lymphocytic-plasmacytic or lymphocytic gastritis may be present. in humans combination therapy with antibiotics and antisecretory drugs is recommended to reduce the risk of gastric ulcers and cancer from h. pylori infection. treatment is highly successful at eradicating both clinical signs and histologic changes in the gastric mucosa. since helicobacter infection is common in cats, yet no clear pathogenic role has been established, it is difficult cases. 29 depending on the underlying cause and severity of disease, abdominal pain, anorexia, lethargy, pale mucous membranes, and drooling may also be seen. cats with neoplastic disease may have prolonged clinical signs and are more likely to present with anorexia and weight loss. 29 cats with perforated ulcers may or may not present with signs of shock. diagnosis may be problematic because the clinical signs and physical examination findings are often not specific, even in cats with perforated ulcerations. 8 the causes of gastric ulceration in cats are not well characterized. in dogs the most common cause is the administration of ulcerogenic drugs, particularly nsaids, either alone or in combination with corticosteroids. several cases of nsaid-induced gastroduodenal ulceration or perforation have been reported in cats. 8, 34, 45 additional cases may be reported in the future, because long-term administration of these drugs is gaining in popularity for treatment of chronic diseases such as osteoarthritis. nsaids cause direct mucosal damage and interfere with prostaglandin synthesis. although inhibition of the cox-1 enzyme is thought to be the cause of adverse effects, such as gastric ulceration, even cox-2-selective drugs have been associated with adverse effects, and safety in sick cats is not well evaluated. recently, guidelines for the long-term use of nsaids in cats were published by the international society of feline medicine and the american association of feline practitioners. 51 the recommendations include administering nsaids either with or shortly after food, withholding therapy if inappetence or anorexia develops, determining dose based on lean body weight, and titrating to the lowest effective dose. neoplastic causes of gastric ulceration include systemic mastocytosis, mast cell tumor, lymphosarcoma, adenocarcinoma, and gastrinoma (zollinger-ellison syndrome). cats with chronic renal disease may suffer mucosal damage from uremic toxins and increased gastric acid production secondary to hypergastrinemia (because of decreased renal metabolism of gastrin). 18 hepatic disease is a cause of gastric ulceration in dogs but is uncommonly reported in cats. 23 recent anesthesia and surgery have been implicated as a cause of gastric ulceration and perforation, perhaps through hypovolemia, hypoperfusion, or stress. 8, 29 other non-neoplastic causes reported for gastric or gastroduodenal ulceration in cats include parasites (e.g., ollulanus tricuspis, toxocara cati, aonchotheca putorii, gnathostoma spp.), bacterial infections, toxins, inflammatory bowel disease, and foreign bodies. one case report describes a cat with severe gastric ulceration caused by intoxication with dieffenbachia leaves. 36 in some case reports, the cause for the gastric ulcerations could not be determined. a minimum database should be collected for cats suspected of gastric ulceration, to identify underlying diseases. anemia, usually regenerative, may be present. eosinophilia, or hypoproteinemia. survey and contrast radiographs are often normal. the most common finding on histopathologic examination of biopsy samples is lymphocytic plasmacytic (lp) gastritis ( figure 23-14) . some patients will also have concurrent evidence of lp inflammation in the small intestine, pancreas, and/or liver. such patients will be treated for their concurrent problem; treatment of inflammatory bowel disease, pancreatitis, and cholangiohepatitis is covered elsewhere in this chapter. some cats with chronic lp gastritis respond to treatment for dietary intolerance or hypersensitivity with a limited antigen diet (see chapter 17) . patients with moderate to severe lp gastritis may be best treated with a limited antigen diet and immunosuppressive therapy (prednisolone 1 to 2 mg/kg/day, po tapering to every other day at the lowest dose that controls clinical signs). patients that fail this initial treatment approach may require additional immunosuppressive therapy, such as chlorambucil (see table 23-9) . occasionally, cats with chronic gastritis are diagnosed with eosinophilic inflammation on histopathologic examination of biopsy specimens. treatment is similar to that for lp gastritis, although such patients should be evaluated for evidence of hypereosinophilic syndrome and eosinophilic enteritis. eosinophilic fibrosing gastritis was suspected to be caused by toxoplasmosis in one case report. 33 gastric or gastroduodenal ulcerations are uncommon in the cat compared with the dog and may be caused by a variety of disorders, both gastric and nongastric. 29 classical clinical signs include vomiting, hematemesis, and melena. however, in one review of eight cats, hematemesis and melena were present in less than one third of suturing of the ulcer site as well as collection of biopsy samples for histopathologic examination. the prognosis for recovery was excellent in two studies, particularly for cats with non-neoplastic causes of gastric or gastroduodenal ulceration. 8, 29 in one study of seven cats with perforated gastric or duodenal ulcers, the survival rate was low (14%). 23 disorders of gastric motility are better characterized in dogs than in cats. the most common clinical sign is vomiting of undigested food 8 hours or more after a meal. if outflow obstruction is present, vomiting may be projectile. there may also be a history of recurrent trichobezoars. various disorders are associated with impaired gastric motility, such as chronic gastritis, drug therapy (e.g., anticholinergic and narcotic drugs), dysautonomia, gastric neoplasia, metabolic disorders (e.g., hypokalemia), and temporary postsurgical gastroparesis. in some cases of chronic motility dysfunction, no cause can be identified. outflow obstruction may be caused by neoplasia, foreign bodies, and extragastric masses. pyloric stenosis is infrequently documented in young cats, often siamese cats. 4, 40, 55 since the range of underlying disorders is diverse, the diagnostic approach should allow for detection of both gastric and nongastric disorders. a minimum database (cbc, serum chemistries, urinalysis, feline leukemia virus [felv] and feline immunodeficiency virus [fiv] serology) is used to establish overall health status. radiographs are used to confirm presence of food in the stomach for longer than 8 hours. ultrasonography may detect gastric lesions, such as masses. endoscopy is used to identify outflow obstruction as well as other lesions, such as ulcers, and evidence of gastritis. assessment of gastric emptying using nuclear scintigraphy is the most accurate method but is limited to referral centers. gastric emptying times for liquids, canned food, and dry diets have been established using nuclear scintigraphy. 11, 16, 17 however, emptying times are variable, depending on the amount and type of diet fed as well as the amount of water ingested. even the shape of kibble affects emptying time. 2 radiographic contrast series are widely used, but gastric emptying times are variable for barium in either liquid form or mixed with canned food. contrast radiography using liquid barium (8 to 10 ml/kg) is performed in a fasted patient. radiographs are taken immediately after administration of the barium and again at 15 and 30 minutes, in some cases, also at 1 and 3 hours. liquid barium is expected to enter the duodenum no more than 30 minutes after administration, and the stomach should be completely empty of barium within 3 hours. the clinician should be aware that some cats with gastric motility disorders will have other findings will be dependent on the presence of underlying diseases; for example, azotemia and isosthenuria may indicate renal disease. electrolyte and acidbase abnormalities may be because of chronic vomiting and anorexia. survey and contrast radiographs and ultrasonography are primarily useful to rule out other causes for the clinical signs, such as foreign bodies. cats with perforated ulcers may have evidence of pneumoperitoneum (sometimes severe) on plain radiographs or ultrasonographs, and this is an indication for surgical exploration. 6, 8, 24, 31, 34 evidence of peritonitis on imaging studies should be followed with peritoneal fluid analysis. a definitive diagnosis may be made using endoscopy, which allows direct visualization of lesions and collection of biopsy samples. however, some cats with gastric ulceration present in poor condition, which may preclude the use of endoscopy because of anesthetic risk and risk of ulcer perforation. 29 the location of ulcers is typically pyloroantral or fundic in cats with nonneoplastic disease. 8, 29 areas of erosion may appear pale or hemorrhagic; the mucosa is often friable and bleeds easily. fresh or clotted blood may be seen in the stomach lumen. in some cases, mucosal ulceration must be distinguished from ulcerated tumors. nsaid-induced ulcers are typically found in the antrum and do not have marked mucosal thickening; ulcerated tumors frequently have thickened edges and surrounding mucosa. 49 biopsy samples should be taken at the periphery of the ulcer to avoid perforation. treatment should be directed at any underlying disorder. treatment for nsaid toxicity is described in chapter 31. general supportive measures include fluid therapy and electrolyte replacement; blood transfusion may also be required (see chapter 25) . gastric acid production can be decreased with the use of h 2 -receptor blockers or proton pump inhibitors, and sucralfate is used as a mucosal protectant (see table 23 -5). sucralfate may inhibit absorption of other oral medications and should be given 2 hours apart from other drugs. if vomiting is severe or persistent, antiemetic therapy is warranted (see table 23 -3). analgesia should be provided for painful patients; a good choice is the opioid buprenorphine (see table 6 -1). broad-spectrum antibiotic therapy is indicated for patients with significant mucosal barrier dysfunction, perforation, leukopenia and/or neutrophilia, fever, and melena. surgical intervention is warranted for patients with life-threatening hemorrhage, failure to respond to medical management, or evidence of perforation. 29 the entire abdominal cavity and gastrointestinal tract should be thoroughly explored to locate extragastrointestinal lesions, non-perforated ulcers, and multiple ulcers. in one case series, nonperforated ulcers were detected at laparotomy by association with adhesions or a gastric mass. 29 surgical management includes débridement and months. physical examination findings are nonspecific, although occasionally a gastric mass or gastric thickening may be palpated if the stomach is markedly enlarged. results of routine diagnostic testing are generally nonspecific; anemia may be associated with ulceration. survey or contrast radiography may reveal a mass ( figure 23 -15, a); other findings include delayed gastric emptying, impaired motility, and mucosal ulceration. ultrasonography is also useful for diagnosis and can be used to guide needle aspirates of masses ( figure 23-15 , b). endoscopy allows for visualization of lesions as well as the ability to obtain partial thickness biopsy samples. problems with interpretation of endoscopic biopsy samples include detection of necrosis, inflammation, and ulceration rather than the primary lesion. in dogs some neoplastic lesions are submucosal, making it very difficult to obtain diagnostic samples by endoscopy. therefore several biopsies should be taken and masses should be biopsied multiple times in the same place to sample deeper tissues. the center of ulcerated lesions should not be biopsied. surgical biopsies are more reliable for diagnosis. a normal gastric emptying time with liquid barium. barium can also be mixed with canned food and fed as a meal; retention of barium-containing food in the stomach for more than 8 to 12 hours is abnormal. gastric emptying time may also be established with the use of barium impregnated polyspheres (bips; med i.d. systems, grand rapids, mich.) and radiography. gastric emptying times for bips have been established in healthy fasted and fed cats as well as in sedated cats, 10,52 but the values do not correlate well with scintigraphic studies. 17 a mixture of small (1.5 mm) and large (5 mm) spheres are administered with food, and two to four radiographs are taken over the next 24 hours. the small spheres are intended to mimic liquid transit time and the large spheres solid transit time. however, studies assessing the clinical relevance of this method are lacking. one review concluded that bips are probably sufficiently sensitive to detect grossly delayed gastric emptying. 60 treatment of gastric emptying disorders is directed at identifiable causes. treatment for gastric ulcers, chronic gastritis, and foreign bodies is described elsewhere in this chapter. pyloric stenosis is managed surgically. if no outflow obstruction exists, treatment with prokinetic agents, such as metoclopramide or cisapride, may be beneficial (see table 23 -3). gastric tumors account for less than 1% of malignancies in dogs and cats. 30 benign gastric tumors are even less common than gastric malignancies. gastric smooth muscle hamartoma has been reported in one 11-year-old cat. 50 although adenocarcinoma is the most common gastric cancer of the dog, lymphoma is the most common gastric cancer in the cat. feline gastrointestinal lymphoma occurs as two major types: small cell (lymphocytic) and the more aggressive large cell (lymphoblastic) form. small cell lymphomas are more frequently enteric. 57 in one study of 12 cats with gastric lymphoma, diffuse large b-lymphocyte tumors of immunoblastic nuclear type predominated. 42 gastric lymphoma is not associated with felv, and the role of helicobacter in the development of gastric lymphoma in cats requires investigation. 7 adenocarcinoma, 12,13,54 plasmacytoma, 62 and gastric carcinoid 44 have also been described. the siamese cat may be predisposed to adenocarcinoma. 12, 54 as would be expected, most cats with gastric neoplasia are older cats. as for most gastric diseases, vomiting is the most common clinical sign of neoplasia. the vomitus may contain blood and melena may be present. other clinical signs include anorexia, weight loss, bloating, and depression. perforation of the tumor may occur, leading to pneumoperitoneum or septic peritonitis. clinical signs present gradually and are often present for weeks to surgical resection is the most common treatment for gastric neoplasia other than lymphoma ( figure 23 -16). the prognosis for most patients is poor, typically because of debilitation, concurrent diseases, and recurrent or metastatic disease. 30 the success of chemotherapy for lymphoma depends on cell type, with small cell tumors carrying a better prognosis than large cell tumors. in diarrhea can be defined as increased volume and/or increased frequency of defecation of stools with increased water content. approaches to diarrhea, as for any clinical sign, need to take into account the individual animal. for example, neoplasia is much less likely to occur in a kitten than in a geriatric cat. in many cases, the precise diagnosis of gastrointestinal disease cannot be reached without biopsy samples. the decision to obtain biopsy samples should follow a logical pathway that is appropriate to the cat's condition. these are summarized in figure 23 -17. for example, many cases of acute diarrhea in a well cat can resolve with limited or no intervention, and so do not require a precise diagnosis. the diagnostic steps are 1. signalment and clinical history 2. physical examination 3. fecal assessment 4. blood and urine testing 5. imaging (radiography, ultrasonography) 6. biopsy samples these steps do not include treatment/diet trials or other empiric therapies that are appropriate in many cases. steps 3 and 4 are often undertaken at the same time, and there is no definite order for these steps. they are divided here for reasons of clarity. in a younger cat, where infectious causes are more likely, thorough fecal testing is more important; in an older cat, extragastrointestinal diseases, such as hyperthyroidism, are more likely; so, blood and urine testing is more important, but fecal assessment should not be neglected. the decision to proceed to step 4 (and each subsequent step) should take into account several considerations. the main considerations in assessing and managing a cat with diarrhea are • is there an acute onset or a chronic time course? • are there any dietary changes or indiscretion? 36 consider treatment trials: antibiotics (e.g., amoxicillin/ clavulanate ؉ metronidazole). food trials with novel proteins (e.g., rabbit, kangaroo, venison). • is the cat well or unwell? • is there primary or secondary gastrointestinal disease? • is there small or large bowel diarrhea? the components of the clinical history for cats with diarrhea are detailed in table 23 -12. after establishing the cat's age, breed, vaccination, and deworming history, it is important to establish the duration and nature of the diarrhea. chronic diarrhea is usually defined as greater than 3 weeks in duration and mostly warrants at least some degree of a diagnostic workup, whereas acute diarrhea is often self-limiting in a well cat. a description of the feces helps determine whether the diarrhea is small or large bowel in origin (table 23 -13); this will affect how any investigations might proceed. important questions to ask concern frequency of defecation (and how this compares with the normal state), tenesmus (straining usually indicates large bowel diarrhea, since an irritated colon leads to urgency), volume of feces (smaller volumes are typical of large bowel diarrhea; larger volumes are more typical of small onset and duration of diarrhea acute versus chronic? acute diarrheas are abrupt in onset and of short duration, and generally they are self-limiting. chronic diarrheas persist usually longer than 3 weeks and fail to respond to symptomatic therapy. appearance of diarrhea quantity and quality of the stool (color, consistency, character, presence of blood or mucus)? loose to watery feces that contain fat droplets, undigested food, melena, and variable colors suggests small intestinal disease. the volume is always increased with small intestinal disease. loose to semisolid feces containing excess mucus and fresh blood (hematochezia) indicates large intestinal disease. the volume may be normal to slightly decreased with large intestinal disease. description of defecation process tenesmus (straining) and dyschezia (painful defecation)? these are hallmarks of large intestinal disease (e.g., inflammatory or obstructive lesions of the colon, rectum, or anus). frequency is normal to slightly increased with small bowel disease, but greatly increased with large bowel disease. associated physical signs vomiting, anorexia, weight loss, and dyschezia may help localize the disorder to a specific part of the gastrointestinal tract. clinical signs relating to problems in other organs or body systems should be noted and may suggest a more generalized disease. vomiting may occur as a consequence of small intestinal inflammation in some cats with diarrhea. weight loss may result from decreased caloric intake (anorexia), decreased nutrient assimilation (maldigestion/malabsorption), or excessive caloric loss (protein-losing enteropathy or nephropathy). weight loss is observed uncommonly with large bowel disease. in many cases, the answers to these questions are obvious. for example, a cat may seem well but has had access to lilies (the author has seen diarrhea as a primary presenting sign for this!) or has a palpable abdominal mass. substantial weight loss is an indicator that further investigations are warranted sooner rather than later. if the decision is made for empiric management and outpatient care, it is vital to follow up either by scheduling a recheck visit or calling the client, because simple acute problems can turn into complicated chronic problems. if the diarrhea has been present for less than a week and the cat has no weight loss, dehydration, fever, or palpable abdominal abnormalities, it is appropriate to manage the cat as an outpatient. even in the absence of fecal testing, it is appropriate to deworm the cat (see the section gastrointestinal parasites). the cat should be fasted for 24 hours (12 hours, if less than 4 months old) and then fed a bland diet (such as plain, cooked, skinless chicken, or low-residue prescription diets designed for cats with gastrointestinal problems). it is appropriate to maintain the cat on the low-residue diet for at least 7 to 10 days and then slowly reintroduce the regular diet. fecal assessment is mostly used to assess infectious agents, such as parasite-associated diarrhea, but the importance of assessing feces, even when parasitic or bacterial infections are not suspected, should not be underestimated. gross examination of feces can determine if melena or fresh blood or mucus are present to help distinguish large from small bowel disease when the owner's observations may be misleading. occult fecal blood can be an indicator of gastrointestinal inflammation in cases of subtle disease, and undigested starches and fats can indicate maldigestion or malabsorption. 8 for assessment of feces for parasites, the fecal sample should ideally be fresh (<1 hour old). refrigeration (for no longer than one week) can preserve ova, oocysts, and cysts but not protozoal trophozoites. feces should be assessed by a. to assess for trophozoites bowel), how formed the stool is (from soft stool to cow-pat consistency to liquid tea; usually more watery stool relates to small intestinal disease), color (darker indicates digested blood), and presence of any mucus or blood (presence relates to large bowel). most household toxins, such as plants, cause signs additional to diarrhea such vomiting or neurological signs, 11 but it is important to ascertain if the cat has had access to anything unusual. likewise, it is important to find out if the cat has had any possible exposure to dietary indiscretions; this can include if the cat has been seen with or is known to hunt prey including insects. cockroaches carry pathogenic bacteria 12, 18 and other prey such as birds and rats can carry salmonella; salmonellosis in cats has been dubbed songbird fever. 6 simple causes of self-limiting diarrhea include dietary change (either a new flavor or a new style of food, such as dry food for the first time); so, the owner must also be quizzed if anything new has been offered, either new cat food or treats (such as greasy fish or chicken). although the physical examination will usually determine how unwell a cat is, the owner's impressions are also important, because cats can hide signs from strangers, particularly in a practice setting. lethargy and inappetence are important signs, as ill cats typically do not eat well. the cat's general demeanor can be an indicator of how unwell a cat is and therefore dictate the extent of diagnostic testing required. this can be noted by assessing how interested the cat is in its surroundings or any behavior changes from previous visits, such as if a normally difficult-to-handle cat is placid. body weight should be assessed and, if possible, compared with that of previous visits (even those noted on a clinical record from another veterinarian). the body condition score (bcs) should also be assessed and can be very important when there is no prior weight information. dehydration is usually a sign that a cat needs more involved management. abdominal palpation should be performed to assess pain (where?), any masses (foreign bodies, lymph nodes, or even focally thickened intestines, such as with neoplasia), or turgid intestines. fever often indicates infection but can also reflect neoplasia or other inflammatory changes. a thorough examination of all body systems should always be performed, no matter what a cat presents for. in the case of diarrhea, extragastrointestinal signs can be of vital importance, such as a palpable thyroid and tachycardia suggesting hyperthyroidism. after the clinical history has been taken and the physical examination performed, the veterinarian must make the important decisions of whether any interventions are required and whether the patient should be factors affecting interpretation include whether the growth is a heavy and pure growth of a known pathogen, such as salmonella, campylobacter, yersinia, or clostridium difficile. further information about the relevance of culture and pcr results is contained below in the section infectious enteritis. investigations begin by assessing if the diarrhea is the result of primary gastrointestinal disease or secondary to another process, by performing routine serum/plasma biochemistries, hematology, urinalysis, and total t 4 (for older cats). in most cases of secondary gastrointestinal disease, diarrhea is not usually the primary presenting complaint, but since the approach to investigations and management diverge so much, this is an important step to take. biochemistry and urine tests may also show the consequences of diarrhea, such as dehydration and electrolyte abnormalities. a. can aid in the visualization of internal structures of some protozoa 3. fecal flotation (preferably with centrifugation) a. to find cysts, oocysts, and ova fecal culture should be undertaken with the understanding that bacteria will be cultured; so, interpretation is based on the relevance of the positive culture result. used to evaluate the smear for the presence of trophozoites, such as giardia spp. and tritrichomonas foetus. 1. place peppercorn size amount of feces on a warm slide and mix with a drop of 0.9% saline (smear must not be too thick, because trophozoites will be easily missed). 2. apply coverslip. 3. evaluate systematically for motile organisms using the 10× magnification. 4. confirmation at 40× magnification. adding iodine to a wet mount through the edge of the coverslip can aid in the visualization of internal structures of some protozoa. the direct wet preparation must be examined without any stain for motility first, because staining the preparation kills the organism. methylene blue is useful for identifying trophozoites, particularly those of entamoeba histolytica. this method has little to no diagnostic value for the diagnosis of bacterial-associated diarrhea. used to find cysts, oocysts, and ova in feces. standing (gravitational) flotation methods are easier and quicker but have much poorer sensitivity than centrifugation methods. 2 solutions used in centrifugation flotation methods include zinc sulfate and sheather sugar. 1. weigh out 2 to 5 g of feces. 2. mix feces with approximately 10 ml of flotation solution. 3. pour mixture through a tea strainer into a beaker or fecal cup. 4. pour strained solution into a 15-ml centrifuge tube. 5. fill tube with flotation solution so that a slight positive meniscus forms, being sure not to overfill the tube. 6. place a coverslip on the tube, and put the tube in the centrifuge. 7. make sure the centrifuge is balanced. 8. centrifuge at 1200 rpm (280× g) for 5 minutes. 9. remove the tube and let stand 10 minutes. 10. remove the coverslip, and place it on a glass slide. systematically examine the entire area under the coverslip at 100× magnification (i.e., 10× objective). you may wish to use the 40× objective lens to confirm your diagnosis and make measurements; however, with practice, most parasites can be identified using the 10× objective (100× magnification). (fpli) are useful markers of intestinal and pancreatic disease, [14] [15] [16] [17] but it is important to note that they typically do not give a precise diagnosis. cobalamin and folate are water-soluble vitamins and are readily found in commercial cat foods so that dietary insufficiency is rare, and decreased levels are almost always because of gi disease. these vitamins are taken up by specific receptors in different areas of the small intestine. chronic inflammatory gastrointestinal disease may damage the receptors and lead to decreased serum concentrations of one or both vitamins, provided the disease process is severe and long standing enough to deplete body stores. serum cobalamin and folate concentrations may also be decreased in cats with exocrine pancreatic insufficiency (epi). trypsin-like immunoreactivity is a pancreasspecific marker, and assessment of serum tli is used for diagnosis of epi and pancreatitis in the cat, although the sensitivity of the assay for pancreatitis is low. pli is a marker for pancreatic inflammation and is more sensitive than tli for the diagnosis of pancreatitis. since inflammation of the small intestine may be seen concurrently with pancreatitis, serum tli and pli are useful adjunctive tests in the diagnosis of diarrhea. tli, pli, and cobalamin are stable in serum at room temperature for several days, but folate is unstable so that samples for cobalamin/folate analysis should be frozen (table 23-14) . samples submitted for folate concentration should not be hemolyzed, because red blood cells contain high levels of folate. in addition, folate is light-sensitive, and samples should be wrapped to exclude light. severe lipemia may interfere with common assays for tli and pli. the main utility of these tests are to indicate that further investigation of gastrointestinal disease is warranted. when a cat presents for weight loss with no overt signs of gi disease, decreased cobalamin or folate can indicate that further investigations with imaging and, ultimately, biopsy sampling are warranted. many clients are more willing to proceed with hematology can be normal in some cats, with changes expected, and so should not be used to rule out any condition. it can be useful, for example, if there is a left shift neutrophilia, indicating acute infection, or eosinophilia, reflecting parasitism. monocytosis can suggest chronic disease that was not suggested by the clinical history. in the case of acute onset diarrhea, the cat may be unwell as a consequence of the diarrhea (e.g., from dehydration) and not because of the cause of the diarrhea. if rehydration is required (with intravenous or subcutaneous fluids, depending on severity of illness), then it is important that biochemistry tests are performed before fluid administration so that any diagnostic clues are not lost by alteration of the profile from the fluid therapy. fever and neutrophilia may indicate the need for antibiotic therapy. if infection is suspected, fecal sampling (see step 4) should occur before starting antibiotics. if a cat is unwell from dehydration, then further testing may not be warranted. the clinician should be alert that linear foreign bodies can result in diarrhea (see the section intestinal obstruction). diarrhea of chronic duration (greater than 3 weeks) does require a more thorough investigation at the outset. however, if clinically well, the cat can be managed as an outpatient in the first instance, at least while waiting for results of diagnostic testing. a diet trial with a novel protein is appropriate for a well cat with stable weight. as with any patient managed as an outpatient, follow-up is vital and, in this scenario, includes scheduling revisits. cobalamin, folate, feline trypsin-like immunoreactivity (ftli), and feline pancreatic lipase immunoreactivity invasive diagnostics when a specific marker of the disease in the organ involved has been recognized. caution should be exercised, because either cobalamin or folate may not be reduced with gi disease. in one study of small cell lymphoma, only 78% of cats were hypocobalaminemic, 7 meaning that if this was the only instigating factor to investigate, nearly one fourth of cats would not have been investigated further. also, cobalamin may be reduced in nonalimentary illness. 1 2. to detect hypocobalaminemia that may indicate the need for supplementation for clinical improvement. 13 to recognize pancreatic pathology when fpli is increased. 17 it is important to note that an elevated value gives no indication of the nature of the pancreatic pathology. 4. to make a diagnosis of epi when the ftli is low. 15 it should be noted that epi can result from other pathology that may require further investigations. veterinarians if the patient is new to the practice) are usually helpful. body condition scoring (using a 5-point or 9-point scale) for every cat seen is helpful in recognizing those that are underweight. weight loss often occurs with loss of muscle mass in cats, and muscle mass can be assessed over the ribs and pelvis as well as scapulae and nuchal crest. thickened intestines are also a subjective finding; it is the author's opinion that thickened intestines are actually intestines with increased turgidity, since differences between normal intestines and those with inflammatory infiltrates can be as little as 0.5 mm. perhaps more important during the history taking and physical examination are those signs that can point to extragastrointestinal disease. when confronted with a cat showing weight loss or vomiting or diarrhea (or a combination of signs), the clinician should start with trying to distinguish the signs as being either primary gastrointestinal or secondary signs. examples of clues pointing to extragastrointestinal diseases include tachycardia and palpable thyroid nodule, indicating hyperthyroidism, or polydipsia/polyuria, which has a variety of causes but is not typical of primary intestinal disease. inflammatory bowel disease has traditionally been considered an immune-mediated disease. the local immune system of the intestinal mucosa no doubt plays an important role, but recent work has also shown the importance of the normal bacterial population in perpetuating and, perhaps, even initiating pathology. it is known for certain that ibds are an expression of an overanxious immune response, with a recent study 104 indicating increases in inflammatory (il-6), type-1 immunity (il-12 p40), and immunomodulatory (transforming growth factor [tgf]-beta, il-10) cytokines. other researchers have found an association with bacterial counts (enterobacteriaceae, e. coli, and clostridium spp.) and abnormalities in mucosal architecture, indicating that mucosal bacteria are involved in the etiopathogenesis. 65 we can summarize these theories by saying that ibds are likely to be a consequence of hypersensitivity reactions to antigens from the intestinal lumen (e.g., bacterial, parasitic, or dietary antigens). this hypersensitivity may occur because of failed immunoregulation (suppressive function) of the gut-associated lymphoid tissue (galt). it is known that granulomatous colitis in boxer dogs is associated with infection, 143 and pathogens may well be found in at least some cases of ibd in cats that cause the immune response and subsequent inflammatory infiltrate of the lamina propria typically seen. although not described specifically in cats, chronic intestinal inflammatory change can impair motility. inflammatory bowel disease (ibd) refers to intestinal inflammatory infiltrates of the small or large intestine (or both) of unknown etiology. the term ibd should strictly be applied to mean idiopathic ibd, thus excluding inflammatory enteritis because of food sensitivities, although common usage has led to ibd referring to intestinal inflammatory infiltrates of both known and unknown causes. ibd is not a diagnostic end point but a description of a series of intestinal diseases that have similar histopathology. recent efforts by the world small animal veterinary association (wsava) gastrointestinal standardization group have led to both diagnostic and classification guidelines 35, 168 ,169 that encompass chronicity, nonresponse to symptomatic treatment, no specific cause found, as well as histologic confirmation of non-neoplastic intestinal inflammatory changes. there are no obvious breed or gender predispositions, and although cats of any age can be affected, inflammatory intestinal diseases are more likely to occur in middle-aged to older cats (5 to 10 years of age or older) than in younger cats. presenting clinical signs include vomiting, diarrhea, and weight loss with increased or decreased appetite. these signs can occur in isolation or together. weight loss without vomiting or diarrhea deserves special mention because not only have several studies 38, 58 shown this to be the most common presenting sign for ibd, but many veterinarians do not consider primary intestinal disease without the presence of vomiting or diarrhea. weight loss despite normal to increased caloric intake can represent poor absorption of food because of small intestinal disease, although it can also represent maldigestion associated with exocrine pancreatic insufficiency or increased metabolism associated with hyperthyroidism, or even lack of energy utilization associated with diabetes mellitus. conversely, appetite may be reduced, most likely because of nausea. if the large bowel is affected, signs are typically discomfort when defecating, resulting in frequent small volumes of diarrhea, often with mucus and blood; if the large bowel alone is affected, there may be no weight loss. physical examination findings are often nonspecific, but the most consistent findings for small intestinal disease are weight loss (or being underweight in a cat not seen previously) and palpably "thickened" intestines. noting a cat as underweight can be subjective, and prior recorded weights (even from previous paper has suggested that ultrasonographic thickening of the muscularis layer is more likely in cats with intestinal small cell lymphoma than those with ibd, but this change was also seen in 12% of cats with normal small intestine. 177 inflammatory bowel diseases require histologic findings obtained from biopsy samples for diagnosis, but diagnosis should not be made solely on these findings. the wsava international gastrointestinal standardization group has proposed "an all encompassing definition of inflammatory bowel disease" that comprises clinical criteria, imaging criteria, as well as pathophysiologic criteria. 169 the clinical criteria for the diagnosis of ibd include there are no typical laboratory findings in ibd, and many cats may have entirely normal results from routine biochemical and hematologic investigations. moderate liver enzyme elevations may be seen 5,38,58,66 even in the absence of recognizable hepatic pathology, and this may reflect subclinical secondary hepatic disease, secondary cholestasis, or showering of the liver with inflammatory cells from the small intestine through the portal circulation. 66 other changes can reflect consequences of the intestinal disease, such as azotemia or hemoconcentration reflecting dehydration, 58 or hypokalemia reflecting inappetance. 38 the chronic inflammation may be reflected by neutrophilia, monocytosis, 5, 38, 58, 66 or hyperglobulinaemia. 38 hypocobalaminemia can reflect ileal inflammation, and low serum folate can reflect proximal small intestinal inflammation. 149 typical ultrasonographic findings consistent with ibd are focal or diffuse intestinal wall thickening ( figure 23-19) ; normal wall thickness is less than or equal to 2.8 mm for the duodenum and less than or equal to 3.2 mm for the ileum, 50 and large mesenteric lymph nodes with hypoechoic changes may be seen. one study found that ultrasonographic findings correlated with histologic grade of ibd. 5 there is no clear distinction between ultrasonographic changes from ibd and those from small cell lymphoma. one recent therapeutic trial, follow-up visits are vitally important. many cats with small intestinal disease may show initial improvement simply because of the diet having lower residue, since there is decreased substrate for intestinal bacteria to digest and lower osmotic potential. the corollary of this is that failure of one novel protein diet does not mean that all novel protein diets will fail. when food sensitivities are responsible for gastrointestinal clinical signs in cats, the responsible food ingredient is usually a dietary staple. commonly incriminated ingredients are beef, fish, wheat, and corn gluten. 55 a careful dietary history is therefore important. large bowel inflammation typically improves with higherfiber diets, 38, 58 and attempting a trial with such a diet is certainly appropriate. immune suppressive therapy is the mainstay of ibd treatment, and glucocorticoids, such as prednisolone, are most commonly used. sulfasalazine use for large bowel signs has not been critically evaluated but seems safe and effective. in cats with substantial weight loss or severe clinical signs, such as chronic diarrhea, the author prefers to start with corticosteroid therapy, even if dietary causes have not yet been ruled out. the diet should also be changed to one containing a novel protein, and, if and when clinical signs resolve, an attempt is made to wean the cat from corticosteroid therapy, hopefully to the point of being discontinued. a diet challenge can then be used to confirm the diagnosis of food sensitivity. there are no universal guidelines for doses of corticosteroids. the author prefers the use of orally administered prednisolone to reduce the chance of side effects and will choose the starting dose based on the severity of disease. the starting dose is usually 2 mg/kg, once daily, po (10 mg/cat/day for most cats) starting 10 days after biopsies have been obtained to allow time for the mucosa to heal. if there is an improvement noted after a recheck at 2 weeks, the higher dose is maintained for a further 2 to 4 weeks, at which point, many cats are back to their normal weight and are not exhibiting clinical signs. if this is the case, the corticosteroid dose can be weaned down to 1 mg/kg, po (often 5 mg/cat/day) for several months, with continued rechecks scheduled to assess weight, clinical signs, and diet. the goal is to wean down to the lowest effective dose. if hypocobalaminemia is present, cobalamin supplementation may be required. 144 cobalamin is administered parenterally at 250 µg/cat subcutaneously weekly for 6 weeks, then every second week for 6 weeks, then monthly. owners can be shown how to inject their cats (as practitioners routinely do with diabetics). clinicians often consider the assessment of histologic samples to be out of their hands; however, it is important to work with the pathologist by providing good quality samples and a good clinical history, as well as having an open dialogue if the findings are not within expectations. for example, with lymphocytic/plasmacytic infiltrations, the pathologist has the difficult task of distinguishing diseased from normal tissue in a site that is laden with lymphocytes in the healthy state. once deciding the tissue has pathology, the pathologist's next task is distinguishing inflammatory infiltrate from neoplastic infiltrate with normal, mature lymphocytes (as seen in small cell lymphoma). inflammatory change also results in changes to normal tissue architecture, with thickened villi, edema, or erosion of the epithelium being typical changes. clinicians should expect morphologic descriptions as well as assessments of degree and type of inflammation. these difficulties are further compounded with the recognition that histologic grading of mild, moderate, or severe does not necessarily correlate with severity of clinical signs. this means that a cat with severe clinical signs of weight loss and vomiting or diarrhea may have only mild histologic changes (and vice versa). concurrent inflammation of the pancreas and liver with intestinal inflammation was first described in the mid-1990s, 171 and despite constant reference to this phenomenon at conferences and veterinary websites, there has been little description since then, though one study found 70% of ibd cases had liver inflammation and 30% had pancreatic inflammation. 6 the term "triaditis" has frequently been used, but the author prefers to spell this "tri-iditis" to distinguish it from inflammation of the hepatic portal triads. there has been no assessment of prognosis when the pancreas and/or liver are involved, but the author has found no difference in prognosis. many cases diagnosed with intestinal inflammatory infiltrates have these changes because of dietary sensitivity. in one study, 29% of cats with histologic gastrointestinal changes improved with dietary elimination therapy alone. interestingly, improvement was noted within 4 days compared with the longer duration of 8 weeks often recommended for improvement of dermatologic manifestations of food sensitivities. this careful study made note of the cat's prior diets and likely dietary causes of sensitivities. 55 another study found dietary therapy to be unsuccessful in 52 of 60 cats but no specifics of diets tried are noted. 58 as with any national cancer institute working formulation (nci wf) system. 116 for most veterinarians in practice, the most important distinction is the histologic grade, because low-grade (lymphocytic or small cell) lymphoma has a much better prognosis (and requires different treatment) compared with high-grade (often lymphoblastic) or intermediategrade lymphoma. for the purposes of simplicity and practicality, only small cell lymphoma and high-grade lymphoma will be addressed here. the prognosis and treatment for intermediate-grade intestinal lymphoma should be considered as for high-grade lymphoma. small cell lymphoma was first described in human pathology in 1966. 122 earlier, small lymphocytes were considered end-stage cells without the ability to divide. in cats small cell lymphoma is most commonly associated with the gastrointestinal tract or skin. 163 small cell neoplasia can be a confusing concept, since our traditional ideas of malignant neoplasia focus on rapidly dividing cells. the confusion is compounded by various terms used in the literature, such as lymphocytic lymphoma, low-grade lymphoma, well-differentiated lymphoma, or diffuse lymphoma; another term, epitheliotropic malignant lymphoma predominantly applies to small cell lymphoma, and other papers fail to distinguish these lymphomas from lymphoblastic lymphosarcoma (the traditional, aggressive form). "small cell lymphoma" seems to be most widely used term, though the author prefers "lymphocytic lymphosarcoma," since it is more descriptive. intestinal small cell lymphoma can be considered as a severe lymphocytic intestinal infiltrate, the most common form of which is commonly called ibd. not only is lymphocytic ibd hard to distinguish histologically from lymphocytic lymphosarcoma, but the approaches and treatments are similar. several reports have suggested a relationship between the two conditions in that inflammatory infiltrates may become neoplastic over time. 27, 43, 90 prevalence the true prevalence of intestinal small cell lymphoma is unknown, but several recent studies have indicated similar rates to inflammatory bowel diseases, with kleinschmidt et al noting 10 small cell lymphoma cats compared with 14 with intestinal lymphocytic infiltrates, 74 evans et al reporting 10 cases compared with 12 with ibds 40 , and baral et al diagnosing 8 cases compared with 10 with ibds. 6 traditionally, 90% of feline lymphosarcoma is regarded as intermediate or high grade, 163 but this may not be the case within the gastrointestinal tract. fondacaro et al found 75% of gastrointestinal lymphoma to be lymphocytic 43 ; a more recent paper found some cats seem resistant to conventional therapy. if this is the case, the diagnostic findings should be re-assessed to ensure no steps were missed or findings disregarded; the cat should be reexamined to look for emergence of other signs; and the pathologist who reads the histology should be contacted to recheck the findings. some cases of apparently resistant ibd are actually food sensitive, but it can be difficult to find the incriminating diet source, and commercial diets are not always effective. if underlying infectious causes have been entirely ruled out and the practitioner is certain of the diagnosis of idiopathic disease, immune suppressive therapy can be increased by either increasing the dose of prednisolone or using other agents, such as chlorambucil, typically at 2 mg/cat, po, every second day. it has been suggested that cats with eosinophilic inflammation may be more likely to be refractory to standard therapy. side effects of immunosuppressive therapy are rare but include inducing diabetes mellitus, immune suppression, delayed healing, and gastrointestinal ulceration. reported doses of sulfasalazine to manage large bowel ibd are 10 to 20 mg/kg, po, once daily for 7 to 10 days. 174 because this drug is usually only available as 500 mg tablets, one eighth of a tablet, providing a dose of 62.5 mg, is usually appropriate for most cats. in some countries, it is possible to have a compounding pharmacist formulate the drug into more convenient tablet sizes or as an oral suspension. cats are generally regarded as susceptible to salicylates, and possible side effects include vomiting or diarrhea, or anemia. the exact pharmacodynamics of this drug are not known; so, caution for extended use should be exercised and the drug withdrawn if any possible adverse signs are noted, but there are anecdotal reports of extended use of this drug without adverse consequences. a survey of the online veterinary cancer registry (http://www.vetcancerregistry.com) identified 6% of all submitted feline tumors to be intestinal tumors. approximately 74% of reported feline small intestinal tumors were lymphomas. adenocarcinomas accounted for 17%, and other tumor types reported included mast cell tumors and leiomyosarcomas. 135 "lymphoma in veterinary medicine: no longer a oneword diagnosis" was the title of an editorial in a recent issue of the veterinary clinical pathology journal, 95 and this is nowhere truer than in the feline gastrointestinal tract! a recent study classified 50 cases of feline gastrointestinal lymphoma both histologically and immunophenotypically, and it found eight different categories according to the revised european and american lymphoma/world health organization (real/who) classification system and six categories according to the approximately equal numbers of high-grade and lowgrade gastrointestinal lymphoma. 84 older cats are more at risk of small cell lymphoma, with mean or median ages reported from 9 to 13 years. younger cats with the disease have, however, been recognized. 40, 43, 73, 84 no breed or gender predispositions have been definitively recognized. two larger studies have suggested a skew to males with 28 males compared with 22 females in one report, 43 and 24 males compared with 17 females in the other 73 ; most other studies looking at gender and breed did not clearly distinguish between lymphoblastic and lymphocytic neoplasia. clinically, it is impossible to distinguish cats with ibds from cats with small cell lymphoma. this is hardly surprising when even histologic distinction can be difficult! therefore cats will present with weight loss or vomiting or diarrhea at a similar frequency to those with ibd. weight loss has been recognized as a presenting sign in 82% to 100% of cases, diarrhea in 25% to 60% of cases, and vomiting in 25% to 73% of cases, with various combinations of these signs also possible. other variable signs are lethargy and inappetence or, conversely, polyphagia. 40, 43, 73, 84 these findings can be summarized by stating that cats with gastrointestinal small cell lymphoma can present with any combination of signs relating to the gastrointestinal tract. intestinal small cell lymphoma is typically a diffuse disease, and therefore multiple areas of the alimentary tract are usually affected. in studies where different locations of the small intestine were assessed, the jejunum was most commonly affected (100%), with the ileum frequently affected (93% to 100%), and duodenal pathology slightly less prevalent (83% to 90%). 40, 84 although the numbers of cats assessed in these studies are small, the important fact that the duodenum is not always affected needs to be recognized, which has important implications for how biopsy samples are obtained, because lesions beyond the duodenum are likely to be beyond the reach of an endoscope. further difficulties in precise diagnosis may arise, since non-neoplastic lymphocytic infiltrates (e.g., ibd) are often found in other locations along the intestinal tract. 27, 40, 84 the stomach is also affected in 14% to 40% of small cell lymphoma cases. 40, 43, 84 although not fully assessed, involvement of the colon appears rare. 84 local lymph node involvement is common, being noted in up to 59% of cases. 84 this percentage may be even higher, because many studies assessed lymph node cytology from ultrasound-guided fine-needle aspirates, which may miss spread to the lymph node, because the population of neoplastic lymphocytic cells is indistinguishable from the normal population of lymph node cells. histology is required to assess changes in lymph node architecture. liver involvement is not uncommon but not thoroughly assessed. one study noted liver lymphocytic neoplasia in 8 of 38 cats with small intestinal lymphocytic neoplasia, 73 another found 5 of 15 affected cats in which the liver was biopsied, 84 another noted 2 of 4 cats had liver involvement, 27 and a further study detected neoplasia "in the lymph nodes, liver, or both" in all 10 cats with intestinal small cell lymphoma. 40 the pancreas may also be involved. 73, 84 this may be akin to the noted association of lymphocytic inflammation of intestine, pancreas, and liver 171 that has been dubbed tri-iditis. ultrasound findings may not suggest extragastrointestinal involvement. in the case of liver pathology, ultrasonography may show no changes in as many as 75% to 80% of cases. 40, 84 focal nodular changes and he patomegaly have been recognized as ultrasonographic signs of hepatic small cell lymphoma. 7 both lymphocytic ibd and lymphocytic neoplasia are often recognized simultaneously in the same cat, 40, 84 and numerous authors have suggested that lymphocytic ibd may be a precursor to intestinal lymphoid neoplasia. 90, 125 if this is the case, then antigenic factors, such as bacterial population changes or food sensitivities, could be considered primary initiating factors for small cell lymphoma since they are potential underlying etiologies of ibds. 79 however, neoplasia also requires genetic mutations to occur (often affecting regulation of cell death and cell survival), and these may be initiated by the inciting antigenic factors or the ongoing inflammatory changes. 154 as opposed to other feline lymphoid neoplasia, no association has been made with felv infection. 27, 43, 73, 125 intestinal lymphocytic lymphosarcoma begins in the superficial mucosa and progresses to involve the entire mucosa and submucosa; then advancing in a perivascular pattern into the tunica muscularis, eventually infiltrating all four intestinal tunics. 43 lymph node and other organ (such as liver or pancreas) involvement likely represent metastasis through lymphatics and perhaps hematogenously. more distant metastasis is not reported. serum or plasma biochemistry and hematologic findings are typically nonspecific. however, this testing is important as part of the diagnostic workup to rule out extra-gi disease, such as hyperthyroidism or diabetes mellitus. common biochemistry findings are mild to moderate increase of liver enzymes, such as alanine aminotransferase (alt), aspartate aminotransferase (ast), and/or alkaline phosphatase (alp). 27, 40, 43, 84 as with ibds, these liver enzyme changes may or may not represent overt hepatic disease. 67 albumin may be reduced 43 but is normal in most cases 27, 43, 84 ; azotemia may be present and may be of prerenal origin or represent concurrent renal disease. in one study, 25 of 32 cats were hypocobalaminemic; 1 of 27 cats had low folate, but 10 of 27 had elevated folate; and 12 of 16 cats had increased ftli. 73 hematologically, a mature neutrophilia with or without monocytosis is sometimes present, representing the inflammatory response; lymphopenia may be present as a stress response. anemia may be present and may occur as a result of chronic slow gi blood loss, and in some cases, ulceration, or it may be because of chronic disease; hemoconcentration is also possible, reflecting dehydration. 27, 40, 43, 84 palpable or ultrasonographically visible thickened intestines (30% to 41% of cases) 27, 40, 43, 84 or mesenteric lymph nodes (20% to 50% of cases) 27, 40, 43, 84 are no more or less likely to be present in comparison with ibds. there are no defined ultrasound guidelines for cats with intestinal small cell lymphoma, because most prior papers do not distinguish between small cell and lymphoblastic neoplasia. 54 ,113 a more recent paper found 9 of 15 cats undergoing ultrasound examination had diffuse small intestinal wall thickening, with a mean of 4.3 mm (range, 3.4 to 5.0 mm; median, 4.5 mm), and focal mural thickening of 20 mm was noted in one cat. 84 in many cases, against expectations, intestinal wall layering was preserved. these findings also mean that 5 of 15 cats had ultrasonographically normal intestinal wall thickness (≤2.8 mm for the duodenum and ≤3.2 mm for the ileum). 50 if affected, jejunal lymph nodes may appear as hypoechoic and enlarged; in the same study, 12 of 15 cats had lymph node changes with a mean diameter of 15.9 mm (range, 6.5 to 30 mm; median, 10 mm) 84 compared with the normal diameter of less than or equal to 5.0 mm. 132 none of these findings can definitively distinguish small cell lymphoma from ibds; although one recent paper has suggested that ultrasonographic thickening of the muscularis layer is more likely in cats with intestinal small cell lymphoma (figure 23 -20) than those with ibd, this change was also seen in 12% of cats with a normal small intestine. however, thickening of the muscularis layer together with lymphadenopathy was recognized in 26% of those cats with small cell lymphoma compared with 4% of those with ibd and 2% of cats with no small intestinal pathology. 177 biopsy samples and histopathology are required for definitive diagnosis. an example of jejunal and mesenteric lymph node appearance at laparotomy is shown in figure 23 it is difficult to distinguish between lymphocytic inflammation and small cell lymphocytic neoplasia in any location; some histopathologic features that might help in differentiating the ends of the spectrum may include therefore become known as the fondacaro protocol. this consists of a combination of prednisolone and chlorambucil given orally by the client at home (table 23-15 ). the rationale is that a slow alkylating agent, such as chlorambucil, is more appropriate to use for the slowly dividing, well-differentiated lymphocytes that cause disease. this can be contrasted to the aggressive chemotherapeutic agents required for the rapidly proliferating cells in lymphoblastic neoplasia that is typically associated with lymphosarcoma. reported response rates to this protocol are excellent, with 59% to 76% of cats achieving complete clinical remission, reported median survival times ranging from 20 to 30 months for those cats responding to therapy, and reports of individual cats surviving as long as 76 months. 43, 73, 84 the original reported protocol comprised prednisolone (10 mg/cat, po or 2 mg/kg, po) given daily with chlorambucil pulsed by administration of 15 mg/m 2 for 4 days every 3 weeks. a more recent study 73 dosed prednisolone similarly, but chlorambucil was given as continuous therapy of 2 mg/cat, po every second or third day. no mucosal congestion, edema, or fibrosis in lymphocytic neoplasia, 43 compared with ibd 4. epitheliotropism, or homing of neoplastic t lymphocytes to the mucosal epithelium in lymphocytic neoplasia 27 these features can be seen in figure 23 -22. each of these criteria may be useful but are unlikely to be definitive. further studies that may not be routinely available but which may be helpful are immunophenotyping; most reports have found purely t lymphocytes in most cases of intestinal small cell lymphoma 27, 73, 84, 116 (figure 23-23 ). 2. clonality; the detection of a clonal population of cells, as recently described for intestinal lymphocytic lymphosarcoma, 101 would be closest to providing the basis for definitive diagnosis. effective treatment of feline intestinal small cell lymphoma was brought to light by fondacaro et al 43 and has cat to be weaned off corticosteroids, with chlorambucil continued as monotherapy (as is often the case with humans). iatrogenic diabetes mellitus usually needs to be managed with insulin therapy, at least initially (see chapter 24) . high-grade lymphoma or lymphosarcoma is the traditional style of aggressive, rapidly dividing lymphoid neoplasia that carries a much poorer prognosis than small cell lymphoma. most early studies do not distinguish grade of neoplasia; so, the prevalence of low-grade and high-grade alimentary lymphoma are difficult to assess. several recent studies found a similar prevalence of each, 84 ,116 but the seminal paper describing small cell lymphoma found only 17 cases of lymphoblastic lymphoma compared with 50 cases of small cell lymphoma. 43 this ratio of approximately one high-grade gi lymphoma case for every three low-grade cases more closely approximates the rate found in the author's practice. the reported median ages of affected cats range from 10 to 12 years, but cats as young as 1 year old have been diagnosed. most papers note that males are overrepresented, and siamese cats may also be overrepresented although most affected cats are domestic shorthairs. 43, 49, 90, 116, 176 precise signalment is difficult to determine from the literature, because many papers assess all anatomic locations of lymphoma without necessarily breaking down epidemiologic data for each anatomic site. also, there are few comparisons to a reference population. the association of lymphoma with felv infection is well established and documented 139 and is covered in chapter 28; fiv has also been shown to be lymphomagenic. 12, 139 since the control of felv through vaccination began in the 1980s, nonretroviral-associated lymphoid neoplasia has become more common, and the rates of intestinal lymphoma have, in fact, increased since felv infection rates have decreased. 86 the underlying causes for this increase are not known. the association with inflammation from ibds was noted for small cell lymphomas, and perhaps there is a spectrum from lymphocytic ibd to small cell lymphoma to high-grade lymphoma. that some cats are more likely to have inflammatory changes become neoplastic is suggested by a paper noting higher lymphoma rates in cats with vaccine-associated sarcomas (a neoplastic condition where the role of chronic inflammation is well noted). 89 similar protocols are used in humans with both lowgrade (i.e., lymphocytic) lymphosarcoma and chronic lymphocytic leukemia. 117,151 some studies with humans have indicated that continuous therapy with chlorambucil results in prolonged survival, 64 although metaanalyses have not been able to determine optimum dosing and scheduling of administration of chlorambucil or other alkylating agents in these conditions in humans. 20, 72 although we do not have enough data to critically compare pulsed therapy to continuous dosing, the study assessing continuous dosing appeared to have a lower number of cats completely responding, although those cats that did respond had a longer median survival 73 than those in the studies assessing pulsed chlorambucil dosing. 43, 84 the differences may also relate to the definitions used for complete response. the chlorambucil dose of 2 mg/cat, po every second day (or third day) is often chosen because of the ready availability of 2 mg coated tablets, the breaking of which can expose the owner to these cytotoxic medications. chlorambucil can be compounded into smaller doses, thus allowing daily dosing of 1 mg capsules. the author has used this dose to apparent good effect, but there has been no critical assessment. it is unknown whether involvement of lymph nodes or other organs, such as the liver, affects prognosis. the only study of substantial size to include extra-gi locations found anatomic location was not prognostic for response or survival time. 73 in another study, of the five cats with liver involvement, two cats did not survive more than 5 months, yet the other three lived longer than 2 1 2 years, with two surviving longer than 4 1 2 years. 84 a study of hepatic small cell lymphoma suggests the density of neoplastic lymphocytes may influence survival, and density may relate to the stage of the disease when diagnosis occurs. 7 adverse effects of chlorambucil are rare, but gastrointestinal signs, myelosuppression, and myoclonus have all been reported. gastrointestinal signs, such as vomiting, diarrhea, or inappetence, can be difficult to distinguish from continuation of the gastrointestinal disease diagnosed. these signs are usually self limiting. myelosuppression is also possible with thrombocytopenia reported. 57, 84 monoclonus has been reported on one occasion. 17 it is ideal to check hematologic parameters every 2 months for cats receiving chlorambucil. continuous therapy using lower doses of chlorambucil may be less likely to lead to these adverse effects. high doses of corticosteroids can induce diabetes mellitus, and thus blood glucose should be checked regularly. if diabetes occurs, the author has found that budesonide (1 mg budesonide is generally considered to be equivalent of 5 mg prednisolone) can be substituted for prednisolone, since it has reputed lower systemic effects (though no assessments of this drug's effectiveness in cats have been made). an alternative is for the of distinction of intestinal layering as shown in figure 23 -24. the area of lymphomatous infiltration is hypoechoic, because it contains a uniform cell population without much reactionary fibrous tissue. mesenteric lymphadenomegaly is common (figure 23-25) , as are changes in other organs, such as kidney, liver, or pancreas. ascites may also be seen. 54, 113 although ultrasonographic distinctions predominate, there is considerable overlap between ultrasonographic findings with small cell lymphoma and high-grade lymphoma. the clinician must not lose sight of the fact that microscopic distinctions are required to diagnose either condition. cytologic diagnosis of high-grade lymphoma from fine-needle aspirates (fna) is much more likely than with small cell lymphoma. this is because there is usually a focal lesion, and the neoplastic cells are a monomorphic population of large, immature cells (i.e., that are not normally seen in tissue). sometimes, mixed lymphoid whether the underlying cause is retroviral or chronic inflammation or anything else, the pathogenesis of highgrade intestinal lymphoma, as with small cell lymphoma and other neoplasia, depends on chromosomal changes that affect regulation of cell growth and death, resulting in malignant transformation and clonal expansion of immature lymphocytes. 152 metastasis can occur in one third to two thirds of cases, 90,92 with involvement of mesenteric lymph nodes most commonly noted, but spread to liver, spleen, kidneys, and thorax is also possible. 90 a recent survey of gastrointestinal lymphoma found that most cases (37 of 50) involved the small intestine (including 3 that also involved the stomach and 4 that also involved the large intestine), and 4 of 50 cases involved the large intestine only. 116 cats with high-grade alimentary lymphoma often present similarly to those with other gastrointestinal diseases. typical clinical signs are weight loss, anorexia, lethargy, vomiting, diarrhea, or a combination of these signs. repeated studies have found cats with no vomiting or diarrhea; in one study, 13 of 28 cats had only anorexia or weight loss on presentation. 90 cats with large bowel pathology usually present, as with other causes of colitis, with increased urgency, and small, frequent amounts of diarrhea, often with blood or mucus. cats with large bowel neoplasia of any form can present for constipation caused by intestinal obstruction. palpation of an abdominal mass has been recognized in 59% to 85% of cases, 43, 90 but the corollary of this is that 15% to 41% of cases did not have a palpable mass. it is also important to note that up to 50% of cats with intestinal small cell lymphoma, and a number with ibds, have palpable mesenteric lymph nodes; so, a palpable abdominal mass is not a specific indication of high-grade neoplasia. many cats have palpably thickened bowel loops. 124 hematology and plasma or serum biochemistry findings are also nonspecific. increased liver enzymes may or may not indicate liver involvement. anemia may be recognized and can be non-regenerative, reflecting chronic disease or slow blood loss, or regenerative if there is more substantial blood loss associated with mucosal ulceration. hypoalbuminemia can be because of blood loss or intestinal protein loss. hypercalcemia of malignancy is a possibility but not commonly reported. despite nonspecific signs, laboratory testing is important to rule out extra-gi diseases and help manage consequences of enteric disease, as with small cell lymphoma and ibds. ultrasonography commonly shows a focal intestinal thickening (of 5 to 25 mm) with partial or complete loss although noted as the next most common intestinal neoplasia, after the various forms of lymphoma, adenocarcinoma is seen relatively infrequently in practice. most cats are more than 10 years old, 32,76,126 males may be overrepresented, and several studies have recognized a distinct overrepresentation of siamese cats. 32, 76 three distinct forms have been described 140 : cats typically present with nonspecific signs of gastrointestinal disease but can present with obstructive signs. cats with large bowel neoplasia can present for tenesmus or hematochezia and even constipation, if the lesion is obstructive (or partially obstructive). on physical examination, an abdominal mass is palpable in approximately 50% of cases, but other findings are usually nonspecific. anemia can be found if mucosal ulceration has occurred, but there are no distinctive laboratory findings. lesions can occur anywhere along the intestinal tract. one study of 100 cases found 40% of feline intestinal adenocarcinoma lesions were present at the ileum or ileocolic junction. 32 twenty-five to 50 percent of cases have metastasis at the time of the diagnosis, and this is a poor prognostic indicator. 32, 76, 145 radiology may show a mass lesion or intestinal obstruction, and ultrasonography can localize lesions to an intestinal origin. the ultrasonographic appearance of the proliferative, circumferential, outwardly expansile populations (of immature lymphoblasts and mature lymphocytes) are seen if a germinal lymphoid follicle is aspirated, and precise diagnosis may be difficult if there are a large number of lymphoblasts. 160 fna samples are best obtained with ultrasound guidance. the cytologic sample quality is greatly improved by not aspirating when the needle is visualized in the mass but merely "pecked" into the mass so that the needle is merely acting to finely "core" the mass. on removing the syringe and needle, the hub of the needle is removed before drawing air into the syringe, the hub is replaced, and the sample within the needle is expressed onto a slide. usually, the decision to diagnose by cytology from fna is based on the ultrasonographic appearance of a mass. since there is substantial crossover of ultrasonographic appearance of intestinal masses, laparotomy for excision is often performed with the affected bowel submitted for histology. except when intestinal obstruction has resulted, there is no therapeutic benefit of excising a gastrointestinal lymphoma (which requires excision and anastomosis), but there is minimal room for doubt when a histologic diagnosis is achieved. the response to therapy for high-grade intestinal lymphoma is significantly worse than that for small cell lymphoma. 43, 124 further, response to therapy for highgrade intestinal lymphoma appears to be worse than for lymphoma in other anatomic locations. 142 precise remission rates and survival times are difficult to quantify, because many studies assess lymphoma from multiple locations and do not necessarily differentiate response of gastrointestinal lymphoma or report the grade of lymphoma. with remission rates reported from 18% to 80% 43,92,176 and a median survival time of up to 41 weeks (range, 4 to 120 weeks), 176 it can be said with some certainty that some cats respond to therapy for reasonable durations. multiple authors have noted that the best prognostic indicator is response to an initial treatment cycle, 92,100,176 which should prompt clinicians to encourage owners to start therapy and decide whether to continue based on the cat's response. there are several published chemotherapeutic protocols, 43 ,92,100,142,176 but all follow the same principles of using medications to target specific phases of the cell division cycle (such as l-asparaginase and vincristine) with other medications that interrupt multiple phases of the cell cycle (cyclophosphamide and doxorubicin). targeting the cancer cell in different ways enables more cells to be killed, reduces the toxicity of the individual drug used, and reduces the likelihood of resistance to a specific drug. several authors have noted increased success with the addition of l-asparaginase and doxorubicin to protocols. 92, 162, 176 chemotherapy for lymphoma is covered in more detail in chapter 28, oncology. look promising, but only two cats assessed had gastrointestinal mast cell neoplasia. lomustine was used unsuccessfully in one cat with sclerosing mct; another cat with sclerosing mct received eight treatments of vinblastine and had a survival time of greater than 4 years. 56 adenomatous polyps have been reported in the duodenum 87 and ileum 106 and can result in intussusception. 133 cats of asian ancestry, predominantly siamese, are greatly overrepresented, and most reported cases have been males. 87 cats usually present for vomiting or hematemesis that, surprisingly, can be very acute in onset; complete intestinal obstruction may result. 87, 106, 133 resection is curative, with survival times of more than 4 years reported. 87 eosinophilic sclerosing fibroplasia has recently been described in a series of 25 cases and is not strictly neoplasia. 29 the ulcerating mass lesions that can occur anywhere from the stomach to the colon are often grossly and histologically mistaken for neoplasia. there appears to be no breed predisposition or age predisposition (with ages ranging from 14 weeks to 16 years), but 18 of 25 cases (72%) were castrated males cats compared with 7 of 25 (28%) female spayed cats. eighty-four percent of cats presented for vomiting, 68% presented for weight loss, and 7 of 12 (58%) cats had peripheral eosinophilia. all cases had a palpable abdominal mass. the pyloric sphincter was the most common site, and lesions in this location were mostly considered unresectable. fourteen of 25 cats (56%) had bacterial colonies within microabscesses and necrotic foci within the lesion. the bacteria recognized were predominantly gram-negative rods, but antibiotics did not seem to be clinically effective. the bacteria are suspected to initiate the lesions, having been embedded after foreign body penetration. there are no specific treatment recommendations, but excision, where possible, would be prudent; corticosteroids appear to be helpful adjunctive therapy. survival times are difficult to estimate since many cats were euthanized because neoplasia was suspected and follow-up times were short (up to 6 months) for the remaining cats. 29 there are very few reports of intestinal leiomyosarcomas in cats, 8, 159 which have been reclassified as gastrointestinal stromal tumors. 99 these tumors may be more likely to arise from the ileocecocolic junction. resection, if possible, is usually recommended, with survival times of 3 to 4 months reported before recurrence. the author owns a cat with this tumor where resection was not form is better described than the annular, constrictingband form with minimal outward enlargement. in these cases, sonographically, a solitary segmental intestinal mural mass is present and characterized by circumferential bowel wall thickening with transmural loss of normal sonographic wall layers. the thickening can vary in echogenicity but may be hypoechoic and may be symmetric or asymmetric. there is no definitive distinction, however, from lymphosarcoma, mast cell tumor, smooth muscle origin tumors, or even segmental benign inflammatory bowel disease. 126 surgical resection is the treatment of choice. there seem to be two distinct groups in terms of survival time postresection: 1. short-duration survival (euthanasia or death within 2 weeks of surgery) 2. long-duration survival (mean survival time of 15 months, 76 with a number of cats surviving greater than 2 years) 76, 109 because clean margins improve prognosis, for large bowel adenocarcinoma, subtotal colectomy may be required for complete excision. 145 because of the potential for success after resection, it is recommended to excise unidentified masses at the time of surgery. 145 other forms of intestinal neoplasia are recognized infrequently, and include intestinal mast cell tumors, adenomatous polyps, eosinophilic sclerosing fibroplasia, gastrointestinal stromal tumors (leiomyosarcoma), and hemangiosarcoma. mast cell tumors (mct) are often cited as the third most common form of feline gastrointestinal tumor, 85 but the intestines are a far less common site than cutaneous, splenic, or hepatic mast cell neoplasia. 85, 124 masses are usually segmental nodular thickenings that occur in older cats. 140 the masses are indistinguishable ultrasonographically from other tumors, such as lymphoblastic lymphosarcoma. 126 a recent series of 50 cases described a variant of feline intestinal mast cell tumor, dubbed sclerosing mast cell tumor, for which neoplastic cells form a trabecular pattern with dense stromal collagen. additionally, eosinophilic infiltrates were moderate to marked in most cases. these cases can be confused histologically with eosinophilic enteritis, gastrointestinal stromal tumor, or fibrosarcoma. 56 surgical resection is recommended, but lesions are commonly infiltrative or metastasize widely, and there are few reports of successful treatment. lomustine (dosed 50 to 60 mg/m 2 , po every 4 to 6 weeks) has recently been assessed as adjunctive chemotherapy for mast cell neoplasia in various locations, 123 and results recognized in that many intestinal bacteria can be found in healthy animals. 70 further antibiotic administration can result in increase of other bacteria. 69 fungal causes of diarrhea are usually recognized from histology of biopsy samples. it remains to be seen whether the recent ready availability of pcr panels looking at a number of infectious causes of diarrhea will be beneficial for recognizing pathogens that had previously been misdiagnosed or a hindrance for readily recognizing commensal organisms not necessarily causative of the clinical signs being investigated. the most common viral, bacterial, and mycotic causes of diarrhea in cats are described below. parasitic gastrointestinal diseases are covered later in this chapter. viral causes of diarrhea are not usually specifically diagnosed, since, with the exception of the canine fecal elisa possible, and the cat appears healthy 24 months past diagnosis (figure 23-27 ). cats with intestinal hemangiosarcoma often present with anemia, and the disease appears to be highly metastatic. 33 the intestines appear grossly thickened by dark red tissue. 138 the small and large intestines seem to be affected with similar frequency. removal of macroscopic disease is recommended, but often the full extent of the severity is only recognized at surgery. 33 the prognosis is poor. suspicions of infectious causes of diarrhea should be aroused in younger cats, cats from shelters, or cats with immune suppression. when considering infectious causes of diarrhea, clinicians should assess whether the diarrhea is large bowel or small bowel in origin and correlate this with specific pathogens that are likely to cause clinical signs as shown in table 23 -16. to increase the diagnostic yield of fecal examination for parasitic causes of diarrhea, wet smears and appropriate fecal flotations should be performed on fresh fecal samples (<1 hour old). it is appropriate to administer broad-spectrum anthelminthics, even if fecal tests are negative. bacterial and viral causes of diarrhea should be considered when the cat is systemically unwell with fever. fecal culture should be performed in these circumstances, but the limitations of this testing need to be yersinia enterocolitica current theory of fip pathogenesis involves initial infection with fecv and then mutation to fipcv in small numbers of susceptible individuals. 112,165 routine serologic testing for fecv in cats with diarrhea would neither prove correlation with the clinical signs nor affect how the disease is managed and so is not recommended. cats with fecv diarrhea should be managed with symptomatic therapy of fasting, then reintroducing a bland diet and supportive care with fluid therapy if necessary. other viruses, such as astrovirus, reovirus, rotavirus, and torovirus-like agent, have been recognized to cause diarrhea in cats, but their roles as pathogens are unclear. they are not routinely recognized in practice, since electron microscopy of fecal samples is necessary for diagnosis and is not routinely performed. management is supportive care with appropriate fasting, then reintroduction of bland diets and fluid and electrolyte replacement if necessary. 51 successful identification of a known bacterial pathogen from a fecal sample does not necessarily mean that the agent found is the cause of disease in the cat. although a number of bacterial pathogens have been demonstrated to cause diseases when specific pathogen-free (spf) cats are experimentally infected, 42 these same organisms can be found in healthy cats. 93 the differences between healthy and diarrheic cats that have bacteria found in their feces may relate to virulence factors of the organism, or host factors (local or systemic immunity) of the cat. there is no definitive answer for this quandary. the author's opinion is that • if a diarrheic cat is systemically unwell and has a fever, then feces should be cultured. • if an organism is isolated that is known to cause signs consistent with those the cat is showing, the cat should be treated appropriately. campylobacter diarrhea is usually caused by c. jejuni. clinical signs of infection are poorly documented, but most cats are asymptomatic. younger cats are more likely to have clinical signs and hemorrhagic, mucoid diarrhea has been reported. diagnosis can be from culture of feces or swabs, and the organism is quite hardy; so, it usually survives transport to the laboratory. 28 in individual cases, the organism has not been cultured after antibiotic treatment, 45,46 but it is not definitively proven that antibiotic therapy affects the natural course of the disease. antibiotics that can be used are amoxicillin-clavulanate (15 mg/kg, every 12 hours, po) for parvovirus, routine definitive tests are not available. clinical signs of panleukopenia (feline parvovirus infection) are more likely to occur in kittens, with the highest morbidity and mortality occurring between 3 and 5 months of age. subclinical cases in older (susceptible) cats probably go unrecognized. the organism is very stable in most environments, and infections mostly occur from environmental contact. peracute cases can result in death within 12 hours, with little or no warning signs. acute cases often have fever, depression, and anorexia, with signs beginning approximately 3 to 4 days before presentation. vomiting is usually bile tinged and unrelated to eating. diarrhea does not always occur, and when it does, it is usually later in the course of the illness. leukopenia is not pathognomonic, because this can also occur with acute bacterial infection (e.g., salmonellosis can present identically). 53 commercially available elisa tests for canine parvovirus antigen in feces can detect feline parvovirus; however, shedding may have ceased by the time clinical signs occur, and vaccination can result in positive test results for up to 2 weeks. 111 aggressive fluid therapy, usually at twice maintenance rates, is usually required. broad-spectrum antibiotic coverage is used to prevent or treat secondary bacterial infection from viral injury of intestinal mucosa. parenteral antibiotics are preferred to prevent the possibility of further gastrointestinal irritation. the author recommends calculating iv doses and introducing appropriate amounts of antibiotics to the fluids bag to create a constant rate infusion (cri); cefazolin can be used in this way at 100 mg/kg/24 hours, and betalactam cris are commonly used in human medicine. 127 aminoglycosides or fluoroquinolones can be used concurrently at routine doses if fever persists after 24 hours or the cat is moribund on presentation, but care must be used with these agents. aminoglycosides are potentially nephrotoxic, and fluoroquinolones have been reported to result in cartilage damage in growing animals, although this has not been demonstrated clinically in cats. 134 fluoroquinolone retinal toxicity has been seen in all animals. cats that survive the first week usually recover, and prior infection imparts lifelong immunity. 28 vaccinations are highly effective for disease prevention. feline enteric coronavirus (fecv) mostly causes mild, self-limiting diarrhea and must be distinguished from feline infectious peritonitis coronavirus (fipcv), which is essentially always fatal and for which diarrhea is not a typical sign (but is possible). the most widely accepted or fluoroquinolones, such as enrofloxacin (5 mg/kg, once daily, po) for durations of 14 to 21 days. 44 macrolides, such as erythromycin (10 to 15 mg/kg, every 8 hours, po), are regarded as the drug of choice for humans but can cause gastrointestinal side effects. 93 clostridium difficile has been recognized in up to 5% of diarrheic cats. 93 clinical signs are typically acute onset watery diarrhea and anorexia. diagnosis has been made with detection of toxin a or toxin b in fecal samples using elisa. although these tests have not yet been validated for cats, they may prove to be a useful aid to diagnosis 94 and are available for testing of equine feces at some commercial laboratories. nontoxigenic strains exist; so, positive culture alone does not ensure diagnosis. metronidazole (10 mg/kg, every 12 hours, po) for approximately 7 days is the treatment of choice. 93 clostridium perfringens typically results in large bowel diarrhea with tenesmus, mucus, and hematochezia, but small bowel signs can also be seen. 42 pcr testing for enterotoxin a is commercially available and may prove to be a useful adjunct in diagnosis. antibiotics that can be used include metronidazole (10 mg/kg, every 12 hours, po), tylosin (10 to 20 mg/kg, twice daily, po), or amoxicillin-clavulanate (22 mg/kg, every 12 hours, po) for 7 days. 94 escherichia coli is a ubiquitous organism within the feline intestinal tract, and it would be unusual not to successfully culture e. coli from the feces of both healthy and unwell cats. when e. coli is associated with clinical signs of gastrointestinal disease, it is mostly as an opportunistic pathogen, with overgrowth resulting from changed environmental conditions, such as inflammation from other pathology or another pathogen. there are also specific strains of e. coli that are true pathogens because of virulence factors not present in commensal e. coli; these include enteropathogenic e. coli and enterotoxigenic e. coli, which both induce a watery diarrhea, and enterohemorrhagic e. coli, which produces a diarrheal syndrome with copious bloody discharge and no fever. 77 pcr testing is commercially available to identify pathogenic strains of e. coli 16,148 ; although not offered at routine veterinary laboratories, this testing is available to veterinarians, and laboratories offering these services can readily be found online. diagnosis should also document histologic lesions corresponding to the strain of e. coli identified. 77 there is emerging resistance to e. coli worldwide in all species of animals, including humans. this includes the typical therapies for gram-negative bacteria of beta-lactamenhanced penicillins and fluoroquinolones. 167 a major risk factor is prior antibiotic usage, because commensal organisms are exposed to antibiotics. pcr testing does not enable antibiotic sensitivity testing, and fecal culture may not be able to distinguish pathogenic from nonpathogenic strains; so, sensitivities may not be an accurate reflection of the pathogenic organism. pcr testing for genes that impart resistance to e. coli have recently been described but are not yet commercially available. 34 in some circumstances, supportive care with fluid and electrolyte replacement may be all that is required while the cat's immune system combats the infection. empiric therapy could include beta-lactam-enhanced penicillins (such as amoxicillin-clavulanate at 20 mg/kg, every 12 hours, po), fluoroquinolones (such as enrofloxacin at 5 mg/kg, once daily, po), or cefovecin (8 mg/kg, every 2 weeks, sc), but the clinician must be aware of possible drug resistance. salmonella typhimurium infection is possible from ingestion of infected prey, infected food sources, or from a contaminated environment, including the veterinary hospital. the resulting clinical signs depend on the number of infecting organisms, the immune status of the cat, and the presence of concurrent diseases. infection rates in cats (and humans) have been correlated with seasonal bird migrations, 153 and the illness has been dubbed songbird fever, 52 but there is no distinction between this and other salmonella infections. clinical signs usually begin 3 to 5 days after exposure, starting with fever (often >40° c [104° f]), malaise and anorexia, and progressing to diarrhea, vomiting, and abdominal pain. hematology can show leukopenia with a left shift and nonregenerative anemia, and biochemistry results are usually nonspecific. diagnosis is based on isolation of the organism by culture or identification with pcr, but care should be taken to correlate pathogen identification with clinical signs since, as with most gi pathogens, the organism can be isolated from healthy animals. 147 as with e. coli, antibiotic resistance is widespread, 120 with one united kingdom survey finding the multiple drugresistant strain dt104 to be the most frequent bacteriophage type identified. 115 treatment should be reserved only for those cats showing systemic signs, because routine antibiotic use in treating salmonellosis induces drug-resistant strains and prolongs the convalescent excretion period. 52 antibiotic choice should be based solely on sensitivity findings, since resistances are so widespread and unpredictable. 98 this means that if the organism has been identified by pcr, then culture of feces must also be undertaken. the duration of treatment must be long enough to eliminate fecal excretion of the organism, prevent the chance of relapse, and reduce the chance of resistance developing; up to 28 days has been advocated. 4, 164 these cautions are particularly important because of the zoonotic potential of salmonellosis. linear foreign bodies have traditionally been considered more common than discrete foreign bodies in cats, 10,14,41 but a study from a primary care facility indicated only 33% of foreign body cases were because of linear foreign bodies. 60 the larger case load of linear foreign bodies at referral institutions noted in earlier studies may indicate the abilities of primary care practitioners to recognize and effectively deal with discrete foreign body obstructions. most studies have found that cats with intestinal foreign bodies are generally younger (mean, 1.0 to 2.7 years), with a notable exception being obstruction from trichobezoars where three of five cats in one study were 10 years or older; the greatest risk factor appears to be length of hair coat. 9 no specific breed predispositions have been described but siamese and siamese-related cats have been noted to have oral fixations 13 and so may be expected to be overrepresented with intestinal foreign bodies. clinical signs will vary depending on the type of foreign body (linear or discrete), the position of obstruction, and the time since obstruction. most cats present for anorexia or vomiting. partial obstruction can result in diarrhea (which can be bloody). foreign body obstruction is typically considered an acute condition, with duration of obstruction because of a linear foreign body, measured from the onset of clinical signs to diagnosis, reported to range from 1 to 10 days. 10,41,60 however, one paper demonstrated chronic, intermittent, gastrointestinal disease from a linear foreign body of a 1-month duration 175 demonstrating that partial obstruction can result in a chronic course. physical examination may or may not reveal abdominal pain, palpable abdominal mass (or plication), dehydration, or fever. all cats presenting for anorexia or vomiting should have the underside of the tongue evaluated for the presence of a linear foreign body. applying gentle pressure with a thumb in the intermandibular space to elevate the tongue is an effective way to visualize lesions or foreign bodies in the sublingual area (see figure 3-8) . life-threatening consequences can result from the interactions of local and systemic factors that arise from intestinal obstruction. locally, damage to the mucosa from traction and pressure of the foreign object can cause hemorrhage, ischemia, and necrosis. systemically, hypovolemia, toxemia, and acid-base and electrolyte imbalances can ensue. complete intestinal obstruction by discrete masses results in gas and fluid distention of the lumen proximal other bacterial causes of diarrhea have been reported in cats, such as yersinia enterocolitica, 48 yersinia pseudotuberculosis, 63 clostridium piliforme (tyzzer's disease), 71 and anaerobiospirillum sp. 36 specific diagnosis of these (and other bacterial infections) may be found in the course of investigation. management follows the principles of supportive care and appropriate antibiosis based on sensitivity testing. small intestinal bacterial overgrowth (sibo) has not been specifically described in cats. the criteria defined for dogs is a fasting bacterial count in duodenal juice of greater than 10 5 organisms/ml 11 and is often recognized with other chronic gastrointestinal diseases. 130 healthy cats appear to have at least this number of upper intestinal bacterial with a range of 10 5 to 10 8 /ml recognized. 68 bacterial overgrowth could potentially occur with ileus or intestinal inflammation of any underlying cause. foul-smelling small bowel diarrhea with no specific pathogen recognized may be an indicator of this condition, as could an increase in bacterial metabolites, such as folate. if suspected, it is appropriate to manage with broad-spectrum antibiotics, such as metronidazole (10 to 15 mg/kg, every 12 hours, po) or amoxicillin (10 mg/ kg, every 12 hours, po) for an extended duration such as 21 to 28 days. alterations in intestinal flora have been recognized after such treatment 69 ; however, any advice for this "condition" is entirely empirical. all efforts should be directed at identifying a precise underlying cause. mycotic and other infectious agents are only rarely recognized as intestinal pathogens in cats. diagnosis is made by histologic and microbial analysis of samples obtained at biopsy. possible agents include histoplasma capsulatum, 24 aspergillus spp., candida albicans, 140 and pythium insidiosum. 119 intestinal obstructions arise most commonly as a result of neoplasia in older cats and foreign body ingestion predominantly in younger cats. 10, 41, 60 less common causes include intussusception 83 and granulomatous inflammation (e.g., from fip) 59 ; tapeworm infection, with greater than 30 worms acting as a linear foreign body, has also been reported. 173 other listed causes are volvulus, intestinal torsion, incarceration of bowel in a hernia, adhesions or stricture, intramural abscess or hematoma, and congenital malformations. 140 may not occur if the obstruction is partial or intermittent, or if vomiting results in less fluid present. since most foreign body obstructions in cats are proximal, identifiable dilatation may not be recognized for this reason. 78 linear foreign bodies present further challenges for radiographic recognition; the following typical radiographic signs 129,137 may or may not be present: to the obstruction. most gas accumulation is a result of swallowed air, which is predominantly nitrogen that cannot be absorbed by the intestinal mucosa. gas also arises from bacterial fermentation. fluid accumulates as a result of increased secretions (saliva, bile, and secretions of gastric, pancreatic, and small intestinal origin) and retention of fluid already ingested, and it can be augmented by local hemorrhage. 39 since most intestinal obstructions in cats do not reach the midjejunum, 60 reabsorption of fluids that normally occurs at the jejunum and ileum is impaired. 39 linear foreign bodies, such as string, dental floss, or elastic toys, require proximal anchoring, usually under the tongue or in the pylorus (for example, by part of a toy attached to elastic). peristalsis moves the free end of the "string" through the intestinal tract, resulting in pleats of intestines around the foreign body. as the foreign body is forced against the intestinal mucosa, the mucosa becomes edematous, and even partial penetration affects mucosal integrity, allowing systemic entry of bacteria. intraluminal bacterial populations increase for both discrete and linear foreign bodies as a result of stasis. mucosal permeability can be affected by prolonged luminal distention, allowing entry of bacteria and toxins systemically or into the peritoneal cavity. direct entry of bacteria to the peritoneal cavity, causing septic peritonitis, can result from perforation of the intestinal wall from linear foreign bodies or sharp discrete foreign bodies, such as toothpicks or plastic toys. definitive diagnosis requires identification of the foreign body retrieved at surgery or in some cases, by endoscopy. this may be aided greatly prior to surgery by diagnostic imaging. however, imaging findings, particularly in the case of partial obstructions, may be subtle enough that obstruction of no identifiable cause is recognized or no overt signs are apparent. laboratory findings are not helpful in the precise diagnosis but are important to assess fluid and electrolyte balances that must be corrected. cats rarely help practitioners by ingesting radiopaque objects, but on the rare occasions that they do, these can be observed easily on plain radiographs. nonopaque foreign bodies depend on dilatation of the intestine from gas and fluid accumulation proximal to the obstruction for radiographic recognition (figure 23-28) . one study has suggested that if the jejunal diameter is greater than 2.5 times the length of the cranial end plate of the second lumbar vertebra, then intestinal obstruction is the most likely abnormality. care must be taken that the jejunal and not duodenal diameter is measured and that the radiographs must be positioned strictly lateral, because an oblique view can alter the measurement of the lumbar vertebra. 1 however, dilatation of an obstructed intestine successful treatment of foreign body obstruction requires evacuation or removal of the foreign body as well as correction of any bacteremia or endotoxemia, acid-base or fluid imbalances. discrete foreign body obstruction requires surgery or endoscopy to remove the object. in some specific circumstances, linear foreign body obstruction may be managed conservatively by cutting the anchor point below the tongue and allowing the cat to pass the foreign body by peristalsis. however, the decision to manage a cat conservatively must be done with the cat hospitalized, with fluid therapy and antibiotic coverage and a clear recognition on behalf of the practitioner and the owner that surgery may subsequently be required. cutting a sublingual linear foreign body may be achieved in a conscious cat by applying pressure with the thumb of one hand in the intermandibular space to elevate the tongue and gently grasping it using gauze with the other hand while a second person cuts the line with a suture cutter. there is a chance of a small nick on the sublingual surface. if the cat will not tolerate the procedure, sedation is appropriate. when cutting the line, the nature of the linear foreign body should be assessed (i.e., is it more or less likely to cut mucosa). in one study, 10 19 cats with linear foreign bodies were managed conservatively with 10 cats subsequently requiring surgery. the authors of that paper created guidelines that will be adapted here. conservative management should be attempted if the cat • is presented acutely (within 2 days) after known ingestion of a linear foreign body • has a sublingually fixed linear foreign body that can be cut • has no overt signs of peritonitis • altered gas pattern with luminal gas collecting in small bubbles instead of normal curved tubular columns. this can be subtle when there is only minimal involvement of the intestine but overt when involving the entire small intestine. commashaped gas patterns are more likely to occur with linear foreign bodies. 1 contrast radiography can aid diagnosis for both discrete and linear foreign bodies but should be used with caution because intestinal perforation may be present. nonionic iodinated agents that are typically used for myelography (such as iopamidol or iohexol) should be used, since barium is irritating to the peritoneum and oral iodine compounds are hypertonic. hypertonic compounds may draw fluid into the stomach and intestines after oral administration, with the potential of creating further fluid and electrolyte imbalances in an already compromised patient. 137 ultrasonography is a very useful diagnostic tool, particularly for discrete foreign bodies, where, in most cases, there is overt distention of the small intestines with intraluminal fluid apparent (figure 23-31) . this modality has not been extensively assessed as an adjunct to diagnosis of foreign body intestinal obstruction in cats specifically, although there are several papers assessing dogs and small numbers of cats that agree with its utility. 114,156,161 linear foreign bodies are more difficult to assess ultrasonographically, but plicated bowel can be recognized, sometimes with the foreign body seen as a hyperechoic line centrally. 156 si a technique has been described for removal of linear foreign bodies by making a single enterotomy incision proximally and passing a red rubber catheter over the linear foreign body aborally, milking the foreign body within the catheter through the colon for retrieval from the cat's anus by an assistant. 2 this technique is not always effective, because it can be hampered if the foreign body is knotted or does not run smoothly through the red rubber catheter. 102 if the affected bowel segment demonstrates evidence of necrosis or perforation on the mesenteric border of the intestine, resection and anastomosis should be performed. necrosis is indicated by dark discoloration, thin intestinal wall, poor arterial pulsation, poor capillary bleeding, or lack of peristalsis. end-to-end anastomosis can be accomplished using a simple interrupted appositional pattern or a modified simple continuous appositional pattern with the same type of suture material used for enterotomy closure. 14,88 intraabdominal masses causing intestinal obstruction are often presumed to be neoplastic but can also be of infectious origin. resection, where possible, is always recommended, because resection of neoplasia (if no metastasis) can offer a good prognosis, 76, 87, 109, 145 and infectious causes may be managed with adjunctive therapy after definitive diagnosis. intestinal obstruction in older cats is more likely to be secondary to neoplasia. any neoplasia can cause obstruction, but adenocarcinoma 32,76 and adenomatous polyps 88, 106 are reported to cause obstruction more often surgical intervention is mandatory if • clinical signs (e.g., vomiting or anorexia) persist or deterioration occurs with conservative management • the cat has overt signs of peritonitis • the linear foreign body is fixed at the pylorus some authors disagree with attempting conservative management, since a perforated intestine from a linear foreign body reportedly carries a 50% mortality rate, 41, 88 and early surgical intervention is never an incorrect decision. this should be balanced with the observation that cats can carry a linear intestinal foreign body, such as an elastic cord for a 1-month duration without intestinal perforation. 175 however, fishing line, for example, would not be so forgiving! surgery to remove an intestinal foreign body (figures 23-32 and 23-33) should be considered an exploratory laparotomy. that is, the aim of the surgery is not only to remove the foreign body but to assess the entire intestinal tract and abdomen for other foreign bodies or pathology. enterotomy to remove discrete foreign bodies should always be distal to the obstruction, because the intestine is likely to be compromised proximal to as well as overlying the obstruction, thus delaying healing and creating the potential for surgical dehiscence. linear foreign bodies require multiple enterotomy incisions, since pulling the object out through a single incision could create iatrogenic intestinal perforation. the anchor point (either sublingual or pylorus by gastrotomy) must be released in the first instance. enterotomy incisions are closed with 5/0 synthetic, monofilament, absorbable suture material, such as polydioxyanone (pds) or equivalent, in either a simple interrupted or simple continuous pattern. 14,88 removal of a discrete foreign body (a piece of leather) at laparotomy. enterotomy to remove discrete foreign bodies should always be distal to the obstruction, because the intestine is likely to be compromised proximal to as well as overlying the obstruction. this is the same cat as in the radiology image in figure 23 -28. affected bowel is required, with anastomosis of the healthy tissue. there appears to be no benefit to enteroplication, which can result in significant ileus. there is no benefit to performing resection-anastomosis if the intussusception does reduce manually. 15, 25 the prognosis depends on the underlying disease process and the chronicity of the intussusception, and therefore how debilitated the cat is at presentation, however, prognosis is mostly good, with survival reported in up to 80% of cases, though recurrence can occur in some cats with idiopathic disease, often at different locations of the intestinal tract. 15 constipation is defined as infrequent or difficult defecation associated with retention of feces within the colon and rectum. prolonged constipation results in harder than other types of neoplasia. please refer to the sections on intestinal neoplasia earlier in this chapter for more details. granulomatous inflammation causing a single focal intestinal lesion can lead to obstruction in the same way that neoplastic change can. feline infectious peritonitis (fip) can present as focal lesions, 59 often in the colon or ileocecocolic junction. in the case of fip, the focal lesion is usually an indicator of multisystemic disease; so, resection does not help prognosis. the fungus-like organism, pythium insidiosum has also been reported to cause granulomatous lesions, resulting in intestinal obstruction 119 from large extraluminal masses that are approximately fist sized. resection with adjunctive itraconazole (10 mg/kg) for 2 months after surgery was a successful treatment. intussusception refers to invagination or prolapse of one portion of the intestine into the part of the tract that either precedes or follows it. there is a bimodal age distribution with intussusceptions in older cats, most likely associated with neoplasia (or ibd in some cases) 25 ; underlying causes for younger cats are ill defined and may be idiopathic in many cases, 15,25 but associations with parasitism and, in one case, a linear foreign body, have been made. siamese and burmese cats seem to be overrepresented. the most common locations are the ileocolic region and the jejunum. 15, 25, 83, 110 affected cats present with nonspecific signs of gastrointestinal disease, such as anorexia and lethargy. vomiting is not necessarily a presenting sign; diarrhea may occur. abdominal palpation reveals a mass in most cases. plain and contrast radiography only show evidence of obstruction and usually do not help define that the bowel has intussuscepted. 15, 25, 83, 110 ultrasonography is very useful for diagnosis, because a distinctive pattern of alternating hypoechoic and hyperechoic concentric rings (figure 23-34) is present in transverse sections. 25, 110 sometimes, the target lesion seen can be hard to distinguish from the pathology of other intraabdominal masses, such as lymph nodes, and in these cases, the size of the lesions can help, because the width will always be greater than 11 mm with an intussusception (because the sum of at least four intestinal wall widths cannot be less) and is often greater than16 mm. 110 surgical correction is always required, and manual reduction is typically not possible because there is usually significant venous infarction, edema, and congestion (figure 23 -35) as well as adhesions from fibrin and effusions from the affected bowel. 15, 25 if the intussusception does not reduce manually, resection of the and drier feces that become impacted, and this is known as obstipation. 140 chronic, recurrent constipation and obstipation can result in megacolon, which refers to persistent increased bowel diameter that is not responsive to therapy. megacolon is not a specific disease entity; it may be considered the most advanced stage in the spectrum of chronic constipation. 18 in most cases, constipation can be managed quite simply if the underlying cause is determined and dealt with. a comprehensive list of causes of constipation is noted in table 23 of course, multiple factors can interact. for example, an older cat may have renal disease and so will be dehydrated to some degree and have arthritic hips and so be reticent to squat. the presenting signs of constipation are usually evident to owners and include straining in the litter box and producing hard dry feces, if at all. sometimes, however, owners can misinterpret signs. cats can strain because of lower urinary tract problems, and, if no urine is produced, some owners assume the problem is because of constipation. some constipated cats can intermittently have diarrhea because of direct colonic irritation from hard dry feces and so may present for diarrhea and not constipation. cats can also present for less specific signs, such as anorexia, lethargy, weight loss, and even vomiting. 140,170 vomiting can occur because of colonic receptors stimulating vagal afferent endings, which, in turn, can stimulate the chemoreceptor trigger zone. 61 sometimes owners are concerned that their cat is defecating less, but the cat has just changed its diet to a much lower-residue diet and so is producing less feces. a full dietary history is an important aspect of the initial assessment. physical examination should confirm presence of feces in the colon and assess the degree of impaction. the presence of feces can usually be confirmed by abdominal palpation. in constipated cats, the colon is often palpated as a long firm tube extending cranially; sometimes, feces can be palpated to and around the colic flexure. alternatively, the feces may be palpated as large, discrete fecal concretions (that can sometimes be hard to distinguish from intraabdominal masses such as lymph nodes). if there is any doubt of the presence or degree of fecal impaction, survey abdominal radiographs should be taken. a lateral view taken in a conscious cat should be adequate to confirm the diagnosis. the physical examination should also assess for contributing causes, including musculoskeletal conditions. any recent trauma should be taken into account. the hips and lumbosacral region should be assessed for pain. the degree of flexion and extension of the hips should be gently assessed. the lumbosacral spine can be assessed by running two fingers on either side of the spinous processes. the cat will flinch in painful areas. any arthritic change is magnified in an underweight cat, since there may be less muscle mass and the joints may bear a heavier load. any suspicions of underlying musculoskeletal abnormalities can be confirmed with radiographs. neurologic assessment should also be performed. subtle changes just affecting colonic innervation will not be apparent on physical examination alone. however, an assessment of proprioception, placing reflexes, and gait should at least be performed to assess for lumbosacral spinal cord disease. anorectal abnormalities or lesions should be evaluated. impacted or infected anal sacs can lead to reticence to defecate; and therefore anal sacs should be assessed and expressed. because this is painful for most cats, the cat should be held by an experienced assistant. the author prefers expressing one anal sac at a time with well-lubricated gloves and the index finger within the rectum and the thumb positioned externally. a rectal exam can be performed with a well-lubricated (gloved!) middle finger, feeling over the pelvic rim for masses as well as assessing if the colon closes over (squeezes) the finger. if the colon feels open around the finger, this can be an indicator of impaired colonic innervation but does not imply that this is a permanent change. if there are impacted feces continuing to the anus, rectal examination is not possible until this has been cleared. if a cat finds anal gland expression or rectal examination too painful to tolerate (based on the clinician's judgment), these procedures should be done under sedation. hydration and electrolyte status are also important factors in the constipated cat. chronic renal disease is defined by azotemia (in conjunction with inadequately concentrated urine), which means the cat must be dehydrated to some degree. plasma or serum biochemistry and urinalysis can be used to diagnose renal disease, assess degree of renal disease, or recognize prerenal dehydration. electrolyte changes including hypokalemia and hypocalcemia may also contribute to reduced colonic smooth muscle function. 140 in young to middleaged cats of apparent good health and hydration, blood difficulty defecating and pass hard, dry stools but do not have fecal impaction at the time of examination. after the obstructing feces have been removed, steps must be taken to ensure colonic motility and smooth passing of feces. medical management of constipation traditionally involves laxatives and prokinetic agents. these may not be required in straightforward cases. as long as there is no obstructive lesion, cisapride at 2.5 mg/ cat, every 12 hours, po 82 is very safe and can be instituted with a view to reducing the dose to once daily after 10 to 14 days and discontinuing if signs remain abated. doses of up to 7.5 mg/cat, every 8 hours, po have been reported. cisapride is only available from compounding agencies in most countries. an osmotic or lubricant laxative (table 23 -18) may be used concurrently at reduced doses as necessary. reducing the fecal bulk produced is an important part of long-term management. traditional dietary recommendations are to increase the amount of fiber. 18, 26, 140, 170 increased dietary fiber results in production of shortchain fatty acids, which have been demonstrated to stimulate feline colonic smooth muscle contractions. 128 however, dietary fiber is also classified as a bulk laxative and so, by definition, will increase fecal bulk. in humans dietary fiber has been considered a mainstay of therapy for constipation, but a recent review concluded that many patients with more severe constipation have worsening symptoms when increasing dietary fiber intake. 103 because megacolon is believed to be the end result of chronic dilatation, 140,170 it is the author's firm belief that initial dietary efforts should be directed to reducing fecal bulk and thus introducing a low-residue diet. reduced dry matter intake reduces stool volume, 31 and the author has found that recurrence rates of constipation reduce greatly when cats are transitioned to entirely wet food diets. wet food diets also help ensure adequate water and urine assessments are usually not required at an initial presentation for constipation. in all cases, the same principles of management apply: 1. ensure removal of obstructing feces 2. ensure colonic motility and smooth passage of feces 3. reduce fecal bulk 4. ensure adequate hydration 5. manage underlying problems the first step is to ensure obstructing feces are removed. in simple cases, the cat will evacuate feces after use of a glycerin or sorbitol pediatric rectal suppository. another option is administration of a microenema, such as microlax (mcneil consumer healthcare, fort washington, pa.), which contains 5 ml of sodium lauryl sulfoacetate. these products act to lubricate the colon wall and therefore facilitate the passage of feces. the author prefers to use one or two of these within the consult room to observe the cat defecating (the cat must be provided with a litter tray!). the outside tube should be lubricated with the suppository contents before carefully inserting and then expressing the rest of the contents. there are also stimulant laxatives (containing bisacodyl) and emollient laxatives (containing sodium docusate) that have reportedly been used. 140 if a rectal suppository vial cannot easily be inserted because hardened fecal content obstructs its entry, a more substantive enema will be required (sometimes requiring sedation or anesthesia), and this is covered in the next section on management. some cats present for the abdominal wall with the other hand, but great care must be taken with this maneuver, because the devitalized colon can be perforated more easily. 140,170 enemas as described are painful for the cat, and opioid analgesia is recommended at the time of anesthesia. opioids can reduce peristalsis in humans, 96 but having evacuated the bowel, the pain relief is more important than this transient effect. an alternative to enemas is administration of an oral polyethylene glycol (peg 3350) solution (e.g., colyte, golytely). a nasoesophageal tube is placed and the solution is given as a slow trickle (6 to 10 ml/kg/hour) over 4 to 18 hours. defecation usually results in 6 to 12 hours. in a retrospective study of 9 cats, median time to defecation was 8 hours and the median total dose of peg 3350 was 80 ml/kg. 26a no adverse effects were noted. a cat that has been obstipated needs supportive therapy when discharged. there are no controlled comparisons of the various therapies noted in table 23-21; the author prefers cisapride 2.5 mg, every 12 hours to every 8 hours, po 82 (first thing in the morning, when the owner returns from work, when the owner goes to bed), and lactulose syrup 2 ml/cat, every 12 hours, po. a cat that has been so severely obstipated that an enema under anesthesia is required can be expected to continue these medications lifelong. to reduce fecal bulk and decrease the opportunity for recurrence, low-residue canned foods (or sachets) are preferred for cats that have become obstipated. some cats may benefit from high-fiber diets. as with simple initial episodes, canned food helps maintain adequate hydration, and at home subcutaneous fluids may be used additionally in cats with chronic kidney disease. with repeat episodes or severe obstipation, investigations for an underlying cause should be thorough and include evaluation for colonic mass obstructions. a review of published cases indicated that 96% of cases of megacolon are accounted for by idiopathic megacolon (62%), pelvic canal stenosis (23%), nerve injury (6%), or manx sacral spinal cord deformity (5%). 170 although most cases are idiopathic, an attempt should be made to identify and treat any specific underlying causes. megacolon is not specifically defined in cats. it has been described as "generalized colonic dysfunction manifesting as severe colonic dilation and fecal impaction," or a "severely and irreversibly dilated and hypomotile" colon 140 and "a subjective evaluation of the diameter of the colon, usually based on radiographic assessment." 18 there are specific radiographic guidelines for humans with megacolon, in that a colonic diameter of more than 6.5 cm at the level of the pelvic brim is considered diagnostic. 118 intake and therefore help maintain hydration. however, increased dietary fiber is beneficial for some cats, and trial and error may be required to determine whether a high-fiber or low-residue diet will be of benefit to each individual cat. in one report, 15 cats with recurrent constipation refractory to traditional medical and dietary management were successfully treated with a psylliumenriched dry extruded diet. 48a after 1 month on the diet, 14 cats had no clinical signs of constipation. the remaining cat was clinically normal after 2 months on the diet. improvement was noted in 10 of 15 cats after only 7 days of dietary therapy. measures should be taken to ensure adequate hydration. maintaining adequate hydration is particularly relevant for cats with chronic kidney disease that have impaired ability to conserve water. changing to wet food diets helps increase water intake. some cats with chronic kidney disease may need additional fluid support, such as subcutaneous fluids administered by the owner at home on a regular basis. underlying problems may be minor and simple to manage, such as an anal gland abscess, or more involved, such as reduced pelvic outflow, as a result of prior trauma. arthritis is a common underlying factor in many older cats and may be managed with prudent use of nonsteroidal agents (see chapter 26) . in cases of obstipation, the cat is more likely to be debilitated to some degree; so, laboratory investigations to assess plasma or serum biochemistry parameters as well as hematology and urinalysis are ideal. any hydration deficit or electrolyte abnormalities should be corrected before the anesthesia that is often required to remove the obstructing feces. rectal suppositories and microenemas are usually ineffective in obstipated cats. enemas are often required to remove impacted feces in such circumstances. the enema solution must be warmed and introduced slowly to avoid vomiting. the typical volume required is 5 to 10 ml/kg (so, up to approximately 50 ml/cat). the enema solution can be an isotonic electrolyte solution or tap water, and mild soap can be added (but any soap used must not contain hexachlorophene, which is neurotoxic if absorbed); mineral oil can be used (5 to 10 ml/cat) as a lubricant or docusate as an emollient (5 to 10 ml/cat), but the two agents must not be used together since docusate promotes mucosal absorption. sodium phosphate-containing enemas must not be used, because they can induce severe hypernatremia, hyperphosphatemia, and hypocalcemia in cats. often, the enema solution alone is insufficient to reduce the fecal mass, and manual manipulation of the feces by abdominal palpation is required. sometimes the feces must be broken down by a gloved finger perrectum while the colon is massaged manually through radiographically, in the lateral view, the normal colon should be approximately the same diameter as the length of the body of the second lumbar vertebra. 81 in cats, however, "there are no published guidelines for determining megacolon, so, diagnosis of abnormal colonic dilatation is subjective." 75 however, one author has suggested that "as a rule of thumb, the diameter of the colon should be less than the length of the body of the seventh lumbar vertebra (l7)." 105 this author continues, "enlargement of the diameter of the colon beyond 1 1 2 times the length of the body of l7 is indicative of chronic large bowel dysfunction and an explanation must be sought." 105 a recent paper found that 15 of 20 cats with no gastrointestinal disease had a colon diameter greater than the length of l7; however, no assessment of constipated cats was made. 1 in practice, many cats with megacolon have a colonic diameter far exceeding this guideline ( figure 23 -36). one study of 11 cats with megacolon found the mean diameter of the colon was 2.7 times greater than the length of the seventh lumbar vertebra (median, 2.4; range, 1.8 to 3.3), 107 but in general, objective descriptions of this condition are lacking in the veterinary literature. the definition of megacolon in cats should include functional as well as radiographic guidelines. in the absence of broadly recognized radiographic recommendations, the author proposes that the o'brien rule-ofthumb guidelines 105 (as noted above) be introduced until a more comprehensive study can establish other radiographic diagnostic criteria (or confirm these). the author therefore proposes to define megacolon as dilatation of the colon, to more than 1.5 times the length of the seventh lumbar vertebra, which is refractory to medical and dietary management. practitioners can expect the radiographic assessment of colonic dilatation to exceed this guideline in cats with megacolon and, conversely, there are likely to be cats having colonic distention greater than this amount that will respond to medical and dietary management and can therefore not be defined as having megacolon. by the definition used above, megacolon is refractory to medical and dietary therapy; so, to be defined as having megacolon, a cat may have had several episodes of obstipation managed by enema as well as dietary trials (with both low-residue and high-fiber diets) and medical therapy with cisapride and an osmotic or emollient laxative; yet the cat will still obstruct with feces. in these circumstances, the only possible therapy is subtotal colectomy. subtotal colectomy refers to surgical excision of 95% to 98% of the colon, whether it is grossly diseased or not with preservation of the ileocolic junction (icj). this approach has resulted in a more favorable clinical response than when the icj is also excised. 22, 170 when preserving the icj, it has been noted that, in some rare cases, it can be difficult to join the proximal segment of colon to the distal piece of descending colon because of the tethering effect of the ileocecocolic blood vessels. in these cases, sacrificing these vessels and removing the icj (i.e., total colectomy) is recommended to facilitate approximation of the ileum to the distal colonic segment. 21 a recently described technique using a biofragmentable anastomosis ring, compared with sutured anastomoses, showed no discernible effect on prognosis. 131 prognosis following subtotal colectomy is generally good. a review of multiple papers, totaling over 100 cats that had undergone subtotal colectomy, found the most commonly reported perioperative complication was diarrhea or loose stools immediately after surgery. in the majority of individuals, stool consistency improves without further treatment so that within 1 to 6 weeks of the surgery soft, formed stools are developed. diarrhea can persist in a small number of cases. in the longer term, in some cats, constipation can eventually return, but this can usually be managed by dietary and medical therapies. 172 pathology of the rectum or anus is relatively rare in cats and therefore poorly described in the veterinary literature. consequently, published information is often not referenced, suggesting it expresses the authors' opinions. readers are directed to surgical texts for details and approaches about surgical corrections. the anal sacs are paired cutaneous evaginations situated between the internal and external sphincter muscles. these sacs store secretions from alveolar and sebaceous glands that reside within the sacs. each anal gland has an associated duct that opens to the skin surface just lateral to the anus. 136,155 normal anal gland secretions have only very recently been described 47 and vary markedly; the color can be white, brown, orange, yellow, tan or gray, and consistency can range from watery to thick and creamy, with two thirds of cats having solid portions within the secretion. on microscopic examination, epithelial cells are commonly seen, with most cats having some neutrophils present. bacteria are commonly recognized as are, on some occasions, yeasts. bacteria seen in this study were mainly gram-positive cocci (63%) or gram-negative cocci (30%). gram-negative or grampositive rods were also seen but were rarely the dominant bacterial population. 47 with such a wide range of normal secretions, it is difficult to diagnose any pathology from the nature of the secretion alone. however, blood is infrequently recognized, and neutrophils are typically present in only small numbers in normal secretions. anal sac diseases described in cats include impaction, inflammation (sacculitis), infection, abscessation, and neoplasia (essentially the same as in dogs). 140,155 it has been contended in dogs that sacculitis and abscessation are an extension of impaction. it is not known in dogs or cats what the predisposing causes are, but suggested underlying reasons are loose stools (that are less effective at expressing the sac during defecation), local swelling or edema occluding the duct, and obesity. 155 the author's observations have also indicated that constipation can result in anal sac impaction because of less frequent expulsion of the sac contents; the resultant pain of the anal sac impaction can lead to further constipation, thus establishing a cycle. the retention of secretions may predispose to sacculitis, but impacted anal sacs do not always result in inflammation. abscessation is a likely sequel to sacculitis. 155 cats usually present for licking, scratching, or biting at the perineal area and can present for scooting (or dragging their anus) as dogs do. other presenting signs can be inability to sit or settle, a lump seen by the owner, or a generally unwell state. expression is the only management required for impacted (and not infected) anal sacs. the author prefers expressing one anal sac at a time with well-lubricated gloves and the index finger within the rectum and the thumb externally. this is painful for most cats; so, the cat should be held by an experienced assistant, and it is sometimes not possible without some degree of sedation. with frequent episodes, underlying causes should be investigated. sometimes, trial-and-error diet change to manipulate the nature of the feces to either more (highfiber diets) or less (low-residue diets) bulk help reduce the frequency of episodes. obesity should be managed by reduced caloric intake, but dietary management for this should also take into account the nature of the feces. overt infection may be recognized by pus secretion from the anal sacs, which will have a high numbers of neutrophils. this can be managed by broad-spectrum antibiotics, such as amoxicillin/clavulanate or cephalosporins. a single treatment with a nonsteroidal antiinflammatory drug, such as meloxicam, can be given in animals with appropriate hydration and without other illness. anal sac abscesses often present already open and draining. many heal well by secondary intention with antibiotic treatment until they are closed over; so rechecks are required before the completion of an antibiotic course. large abscesses may require surgical drainage with the insertion of a penrose drain and management as for a cat fight abscess. it must be remembered that wounds in this area are easily re-infected by fecal contamination. recurrent impaction, sacculitis, or infection may require anal sacculectomy (as in dogs). this procedure should be delayed until infection is cleared. the procedure is similar to that performed in dogs. reports of anal sac/gland neoplasia were confined to sporadic case reports, 97,108 until a large case series was recently published. 141 in this study, 64 cases of anal gland carcinoma were recognized at a private diagnostic laboratory during a 12-year period, with submissions from 62 practices. this indicates that, for most practices, this condition will be seen, at most, once every 12 years. affected cats ranged in age from 6 to 17 years (median and mean, 12 years); female (mostly spayed) cats were overrepresented (61% of cases), and siamese cats may have been over-represented (7.8% of cases). the number of siamese cats with anal sac neoplasia was 3 times greater than the number of siamese cats in the laboratory reference population. affected cats presented for dyschezia, recurrent constipation, change in the nature or volume of feces, b). a low-residue wet diet is recommended to reduce fecal bulk during the healing period. rectal prolapse occurs as a result of a disease process that causes chronic straining, such as intestinal conditions that result in diarrhea and tenesmus 2. conditions that result in constipation or other intestinal obstruction 3. lower urinary tract diseases 4. dystocia and/or perineal swelling or ulceration, sometimes with purulent or hemorrhagic discharge. most tumors were originally interpreted as and initially managed as anal sac abscess. presumptive metastasis in liver, lung, or abdominal lymph nodes was recognized by physical examination or radiography in six cats; one cat was hypercalcemic. excision appeared to be curative (with a 3-to 4-year follow-up period) in 3 of 29 cats undergoing surgery for resection or debulking (others had only incisional biopsy performed). for the remaining 36 cats with known postsurgical outcome, median survival was only 3 months, with a 19% 1-year survival rate (with none of these cats surviving to 2 years). 141 atresia ani is a developmental defect of the anal opening or terminal rectum (see figure 41 -4). kittens usually present within days or weeks of birth with abdominal distention, discomfort, tenesmus, restlessness, vomiting, and/or loss of appetite. there are several anatomic variations 22 : • type i: a membrane over the anal opening remains, with the rectum ending as a blind pouch just cranial to the closed anus. • type ii: the anus is closed as in type i, but the rectal pouch is located somewhat cranial to the membrane overlying the anus. • type iii: the rectum ends as a blind pouch cranially within the pelvic canal (rectal atresia), whereas the terminal rectum and anus are normal. • type iv: occurs in females and atresia ani exists with a persistent communication between the rectum and the vagina (rectovaginal fistula). this fistula can occur with a normal anal opening as well. most reported cases have been type iv, 23, 146, 150, 158, 166 and this has also been recognized with concurrent sacrococcygeal agenesis. 3 surgical correction has been described for type ii 157 and type iv 19,91 atresia ani in cats. the reader should consult these references for surgical advice; possible complications include megacolon after prolonged obstruction, postsurgical anal stricture, and fecal incontinence because of sphincter dysfunction. foreign bodies in cats rarely obstruct the gastrointestinal tract distal to the jejunum 60 ; however, large fecal balls resulting from constipation can, additional to constipation or obstipation, cause distention of the anus. this distention can result in inflammation of the anal sphincter with loss of tone ( figure 23-37, a) , which, in the author's experience, is temporary with correction of the underlying cause of constipation. it can take some weeks for the dilated anus to return to normal (figure 23 -37, with antibiotics, such as cephalosporins, and regular cleansing. prolapses are usually classified in three ways. 62 first degree: prolapse of only mucous membrane 2. second degree: prolapse of full rectal wall thickness 3. third degree: prolapse is sufficient to bring mesorectum outside the anus the prolapsed rectum is obvious but must be differentiated from ileocolic intussusceptions, which have been described with neoplasia. 37 this distinction can be made by inserting a thermometer through the anus alongside the prolapsed mass. insertion will not be possible for an intussusception but will be for an anorectal prolapse. the prolapsed tissue must be assessed for viability, and management must include determining and managing the underlying cause as well as management of the prolapse. in simple cases where the mucosa is viable, the prolapse can be reduced with lubrication and gentle pressure. a temporary purse-string suture may be required to prevent recurrence. perineal dermatitis is often confused with gastrointestinal or urogenital disease, because there are often copious sebaceous secretions that can mimic fecal or urinary secretions. perineal dermatitis can result from flea or other allergies but also fecal or urine scalding associated with diarrhea or urinary incontinence, respectively. skin fold dermatitis can also occur in obese cats ( figure 23-38 ). episioplasty has been described to correct this, 121 but the author has found that stringent dieting can result in improvement while managing the skin fold dermatitis these populations. 48 the reported prevalence for each parasite varies greatly with the population studied, the geographic location of the population, and the sensitivity of the diagnostic test used to study that population. 48 the presence or absence of diarrhea is not a reliable predictor of whether a particular cat is infected with or shedding a parasite. 42 in fact, most cats with diarrhea do not harbor enteric protozoa. 48 on the other hand, most cats with diarrhea because of enteric pathogens will shed those organisms, often intermittently. it is important to remember that infection with most gastrointestinal parasites may not cause clinical signs. therefore detection of a pathogenic parasite in a cat with diarrhea does not necessarily prove causation. 48 a search should always be undertaken to identify other causes of diarrhea prior to convicting a cat of having diarrhea because of a particular parasite. in addition, co-infections or the presence of other noninfectious causes of diarrhea can result in more severe diarrhea that is often refractory to treatment for the parasite. treatment will be more rewarding if all potential causes of diarrhea are identified in the patient. enteric parasites with zoonotic potential occur commonly enough that cats, particularly those with diarrhea and who are owned by immunocompromised persons, should be evaluated for those pathogens. 26, 27 the following is a discussion of the most common enteric parasites found in cats. for more on parasite prevention and control, see chapter 8, and for more on zoonotic enteric parasites, see chapter 34. ollulanus tricuspis is an almost microscopic nematode worm infecting the stomach of domestic and wild cats. 5 the worm measures less than 1 mm long. 3 the larvae of o. tricuspis develop and hatch within the uterus of the female worm. they develop to maturity in the stomach of the cat where it is capable of re-infecting the host. 3 the worm is transmitted to other cats that ingest the vomitus of an infected cat. 41 clinical signs shown by infected cats include vomiting, anorexia, and weight loss. 2, 5 histologic findings in infected cats include lymphocytic-plasmacytic gastritis, lymphoid hyperplasia, and mucosal fibrosis. gross lesions may be absent, or the cat may develop nodular gastritis. 41 one report suggested the parasite may have been a contributing factor in the carcinogenesis of a gastric adenocarcinoma in an infected cat. 10 160. a common theme when discussing the prevalence of most gastrointestinal parasites in cats is that they occur more commonly in younger cats and in cats housed in crowded conditions, such as catteries and shelters. it is likely an increased chance for transmission exists in lungs. after further development in the lungs, the parasite migrates up the trachea and is swallowed. adult s. felis and s. planiceps burrow into the wall of the small intestine, while adult s. tumefaciens lives in the colonic mucosa. ova may be shed in the feces or hatch in the intestinal tract. autoinfection occurs if larvae become infective and penetrate the intestinal wall before being shed. ova and larvae that are shed develop into freeliving adult worms. 11 the prepatent period is between 7 and 10 days. 1, 11 clinical signs and diagnosis signs of a strongyloides spp. infection are usually absent. 1, 40 lung migration may cause cough or respiratory distress. the presence of the parasite in the intestinal tract may result in diarrhea and weight loss. 11 strongyloides tumefaciens is associated with the formation of small, worm-filled nodules in the colon. 40 identification of strongyloides spp. larvae using the baermann fecal concentration technique is required to diagnose most infections. unless the infection is heavy, examination of a fresh fecal smear is insensitive for identification of these larvae. 1 the nodules formed by s. tumefaciens infection can be visualized during colonoscopy. histopathology of the biopsied nodules should reveal many adult worms. 40 infection with strongyloides spp. can be treated with fenbendazole, 11 pyrantel pamoate, 40 thiabendazole, 1,11 or ivermectin. 3 to evaluate efficacy, repeat a fecal examination 2 to 3 days after the treatment ends. because of the presence of free-living adult worms in the environment and the ability of larvae to cause infection by penetrating intact skin, prevention is difficult. keeping cats indoors in warm, humid climates may be an owner's only means of preventing infection with strongyloides spp. parasites. infections with trichuris vulpis rarely occur in cats and are considered to be clinically unimportant. 3, 14 the two species of roundworms commonly infecting cats are toxocara cati (figure 23-39) and toxascaris leonina (figure 23-40) . the latter also has the ability to infect dogs. 14 cats are infected with t. cati in several ways. most commonly, infection is by ingestion of contaminated food, water, or infected paratenic hosts such as rodents. transuterine transmission has not been reported. 14 the diagnosis of infection with o. tricuspis is difficult, because ova are not shed in the feces; rather, the vomitus must be examined for worms or larvae. the worms may also appear in gastric mucosal biopsy samples. 41 a report of 131 cats undergoing endoscopic examinations found the parasite in gastric biopsy samples from 4 cats. 5 fenbendazole may be effective in treating infections with o. tricuspis. 41 preparations with febantel may also be expected to successfully treat these infections. transmission can be prevented by appropriately treating infected cats. other cats should not be allowed to ingest infected vomit. this parasite is of no zoonotic concern. physaloptera another parasite rarely inhabiting the stomach in cats is in the genus physaloptera. larger than ollulanus tricuspis, this blood-sucking worm infects cats that have ingested intermediate hosts, such as cockroaches, crickets, or flour beetles. 11 preying on transport hosts, such as mice that have eaten an intermediate host, is another way cats become infected with this parasite. clinical signs of infection with physaloptera spp. include vomiting, anorexia, and melena. a diagnosis of physaloptera infection can be made after identifying the ova in the patient's feces or adult worms in the vomitus. occasionally, the worms may be seen during gastroscopy. the adult worms must be differentiated from ascarids. 11 infection can be treated with ivermectin, pyrantel pamoate, or fenbendazole. 3 because there is no migratory phase of the life cycle, the treatment does not need to be repeated. 11 three species of strongyloides infect cats. strongyloides felis infects cats in india and tropical australia, 1,43 s. tumefaciens is a rare parasite of cats in the southeastern united states, 3 and s. planiceps is found in cats in malaya and japan. 1 strongyloides stercoralis, found in dogs and humans, produces experimental infections in cats, but natural infection with this species has not been observed. 1 feline infection with strongyloides spp. is considered by most to be rare. however, one report from australia identified s. felis in 169 of 504 necropsied cats. 43 infection with strongyloides spp. occurs after ingestion of infective larvae. infection can also take place after the larvae penetrate the skin of the cat. 11 ingested larvae penetrate the intestinal wall and migrate through the diaphragm into the lungs. after cutaneous penetration, the larvae enter the venous circulation and enter the clinical illness because of roundworm infection is uncommon. illness, when it does happen, most often occurs in kittens 26 signs may be mild and can include vomiting, 14 diarrhea, weight loss, poor growth, and a "pot belly." 26 a heavy infection with t. cati can result in catarrhal enteritis. severe infections can lead to intestinal obstruction and, possibly, perforation. 26 much less dramatic changes arise after infection with t. leonina, although enteritis may occur. 14 roundworms are frequently diagnosed with a fecal floatation. the centrifugal floatation technique is more sensitive than the simple fecal floatation technique many hospitals use. 14 occasionally, adult worms will be passed with the feces. the goals of treating roundworms include disease prevention in an individual cat or kitten, prevention of environmental contamination by cats defecating outside, and the prevention of zoonotic infections. many effective and safe anthelmintics are available (table 23-19) . benzimidazoles, such as fenbendazole, act on the parasite's microtubular structure, leading to disintegration of the worm's intestines, muscular layer, and hypodermis. 14 pyrantel in the pamoate formulation is poorly absorbed and causes paralytic parasite death. macrocyclic lactones, such as milbemycin, also lead to paralytic parasite death. these compounds act on the parasite's gamma-aminobutyric acid (gaba)-and glutamate-controlled ion channels. these channels are lacking in tapeworms, accounting for the lack of efficacy against these parasites. 14 lastly, emodepside (a cyclic octadepsipeptide) has been combined with praziquantel in the product profender (bayer animal health). this topical parasiticide has been shown to be both safe and effective. 14 these drugs appear to be so safe that overdosing is almost impossible. 14 kittens can be dewormed starting at two weeks of age and again at 4, 6, 8, 12, and 16 weeks. 26 older kittens and adults can be dewormed every month to 4 months. 14 because of the safety of these drugs, the possibility of false-negative tests and, more importantly, the zoonotic potential of these infections, perhaps all kittens should be dewormed, not just those testing positive. roundworm ova are very hardy and can remain infective for years. 14 they survive sewage treatment and composting, and there is no practical means of decreasing the ova population once the environment is contaminated. thus it is best to attempt to prevent contamination in the first place. when practical, keeping cats indoors allows appropriate control of potentially transmammary infection occurs, but only if the queen is acutely infected late in pregnancy. chronically infected queens do not pass t. cati ova in their milk. 14 after ingestion, t. cati larvae migrate through the small intestinal wall, into the liver, and then to the lungs where they are coughed up and swallowed. these larvae then infect the small intestine. some of the migrating larvae become encysted in the cat's muscle tissue. larvae from ova ingested through the milk tend not to undergo migration and mature directly in the small intestine. 14 the prepatent period is approximately 8 weeks. infection with t. leonina occurs after ingestion of infective ova or an infected paratenic host. unlike t. cati, very few t. leonina larvae migrate through the cat's tissues. most develop in the wall of the small intestine. the prepatent period is 7 to 10 weeks. toxascaris leonina ova can become infective within 8 days of being passed in the feces when the ambient temperature is 27° c but normally require 3 to 4 weeks. 14 lungs, and kidneys. ocular larval migrans results in granulomatous retinitis that is often misdiagnosed as retinoblastoma in older children. 3 this can lead to unnecessary enucleation. toxocara cati appears, however, to be less important than t. canis as an infection in humans. 3 the species of hookworms that infect cats are ancylostoma tubaeforme and ancylostoma braziliense (see figure 23 -39). they are reported to be an uncommon infection in cats. 26, 34 ancylostoma braziliense can also infect dogs. hookworm infections occur after ingesting food or water contaminated with hookworm larvae or eating contaminated fecal material. if the pet cat is allowed outdoors, attempts at preventing hunting may reduce the possibility of infection. keep children's play areas, such as sand boxes, inaccessible to cats when children are not at play. feeding only well-cooked food can prevent infection by contaminated food. finally, empirical, preventative deworming for cats that go outdoors should be performed 3 to 4 times yearly. any less frequently does not lead to an appreciable decrease in the prevalence of the parasite. 7 roundworms easily infect humans who ingest the ova, particularly children. visceral larval migrans occurs after infection with toxocara canis in humans. infection can lead to the formation of nodules in the brain, liver, tapeworm infections are well tolerated by the cat. usually there are no signs of infection other than finding segments on the feces or attached to perianal hair. because both d. latum and spirometra tapeworms absorb vitamin b 12 across the cuticle, megaloblastic anemia is possible, but unlikely. 11 tapeworm infections are diagnosed by identifying the typical appearance of the segments 8 or the egg packets within the segments. 26 the segments of t. taeniaeformis are flat, while those of d. caninum have been described as appearing like a grain of rice. the segments should be handled carefully, because they are friable and rupture may result in exposure of the handler. 8 the operculated ova of d. latum and spirometra spp. must be differentiated from trematode ova. even though tapeworm infections are well tolerated, cats should be treated for reasons of owner discomfort and public health concerns (see table 23 -19) . these infections are easily treated, because drug treatment is highly effective. re-infection must be controlled using preventative measures, especially flea control to prevent re-infection with d. caninum. praziquantel and infected paratenic hosts. the larvae can survive for months in the tissues of paratenic hosts. 14 infection also occurs after larval migration through the skin. in either case, the worm matures in the small intestine. 14 unlike dogs, transmammary infection has not been reported in cats. 3, 14 the prepatent period is between 19 and 28 days, depending on the route of infection. the time to patency after transcutaneous infection is longer than for direct colonization. infective l3 larva develop 2 to 7 days after the ova are passed. 3 developing larvae attach to the mucosa of the small intestine where they ingest copious amounts of blood. because the worms can remove a significant volume of blood from kittens, weakness from iron-deficiency anemia 34 or blood-loss anemia may be noted. 14 melena and diarrhea may also be recognized. signs are uncommon in adult cats. identification and treatment of hookworm infections are similar to that for roundworm infections (see table 23 -19) . hookworm larvae are not as hardy as roundworm eggs. soil contamination may be a temporary problem in areas that experience a hard frost. 3 hookworm larvae will not develop in temperatures less then 15° c or greater than 37° c. frequent, appropriate disposal of feces, cleaning surfaces with a 1% bleach solution, and deterring hunting may prevent infections. migration through the skin of persons coming into contact with the larvae of a. braziliense is the most common cause of cutaneous larval migrans, particularly in the southeastern united states. 3 this is an erythematous, pruritic skin eruption often found on the soles of the feet of infected children. the tapeworms most commonly found in cats are dipylidium caninum and taenia taeniaeformis. diphyllobothrium latum, spirometra spp., and echinococcus multilocularis occasionally infect cats. the latter is important, because it can lead to alveolar echinococcosis in humans. 8 spirometra tapeworms are found in north america (s. mansonoides) and far-east asia (s. mansoni and erinacei), while d. latum prefers temperate climates. 11 unnoticed, but the cat may cough or experience hemoptysis. 3 diagnosis involves demonstration of fluke ova in the feces. although therapy may be unnecessary, 11 praziquantel or epsiprantel are effective in eliminating the intestinal population of the fluke. platynosomum spp. are flukes living in the gall bladder, bile ducts, 46 and pancreatic ducts. 3 these flukes are most prevalent in the southeast united states and caribbean islands 3 and require two intermediate hosts. the first host is a snail, while the second intermediate host is a lizard, toad, gecko, or skink. 46 cats become infected with this fluke after ingesting an infected second intermediate host. the prepatent period for the fluke is 8 weeks. 46 most infections are subclinical. if clinical signs do occur, they may include weight loss, vomiting, diarrhea, icterus, hepatomegaly, or abdominal distention. diagnosis involves identification of ova shed in the feces using a fecal sedimentation method 46 or by finding adult flukes in the gall bladder or bile ducts during abdominal surgery. treatment involves administering praziquantel (20 mg/kg, q24h, po for 3 to 5 days) and/or surgical removal of the flukes. 3 two species of coccidians are the most common to infect cats, isospora felis and isospora rivolta (figure 23-41) . the genus isospora may be renamed cystoisospora. these are epsiprantel are safe and effective. fenbendazole is effective against t. taeniaeformis, but not d. caninum. without controlling exposure to intermediate hosts, tapeworm infections are difficult to eliminate. flea control is imperative in eradicating infections with d. caninum. controlling predation helps prevent ingestion of t. taeniaeformis-infected rodents. infection with d. caninum occurs in young children who are most likely to eat fleas. infection results in only minimal signs of illness. 8 the larval stage of t. taeniaeformis is of little zoonotic importance. 3 although cats are uncommonly infected with echinococcus multilocularis, potentially life-threatening alveolar damage occurs in north american humans infected with this tapeworm. 8 plerocercoids of spirometra spp. can penetrate the mucous membranes or open skin wounds of humans and migrate around the subcutaneous connective tissue, forming nodules, a condition called sparganosis. 3 megaloblastic anemia, as a result of vitamin b 12 deficiency, may occur in humans infected with d. latum or spirometra spp. tapeworms. 11 alaria marcianae flukes reside in the intestinal tract of cats and the mammary glands of lactating queens. miracidia hatch underwater from ova shed in the feces and penetrate the skin of a snail. after further development, cercariae penetrate the skin of leopard frog tadpoles and are able to survive the metamorphosis to the adult frog. 3 if the tadpole is eaten by a snake, bird, or mammal, the parasite enters the host's tissues but does not undergo further development. after a male or nonlactating female cat ingests the infected intermediate host, the parasite penetrates the wall of the small intestine, passes through the diaphragm, and enters the lungs for further development. finally, the parasite is coughed up and swallowed to complete maturation and reproduce in the small intestine. if, however, an infected host is ingested by a lactating queen, the parasite migrates through the tissues to the mammary glands, rather than the lungs. 3 once shed in the milk, the parasites develop into mature adults in the kittens. some of the mesocercariae remain in the mammary glands to infect future litters. clinical signs associated with worms in the small intestine are uncommon. 11 migration through the lungs often goes species-specific obligate intracellular parasites. 4, 13 they are able to survive in the environment for months. 13 a detailed description of the coccidial life cycle can be found elsewhere. 4, 13 simply put, direct transmission is by ingesting oocyst-contaminated food or water or by grooming contaminated body parts. indirect transmission occurs after ingesting a mechanical vector or the infected tissues of paratenic hosts. 39 after ingestion by a cat, the oocyst excysts in the small intestine and enters the enterocyte where further development occurs. 26 the parasite may also migrate through the intestinal wall to form cysts in mesenteric lymph nodes. these cysts may serve as a source for reinfection. 4, 13 the prepatent period is 4 to 11 days 26 and the shed oocyst becomes infective after several days of exposure to warmth and moisture. 13 infection with isospora spp. is usually subclinical. 26 signs, if they occur, range from mild, transient watery diarrhea to severe mucohemorrhagic diarrhea with vomiting and resultant dehydration and weight loss. 4, 13 signs are most commonly recognized in severely infected neonatal kittens, 26 particularly those with concurrent illness, and arise because of small intestinal congestion, mucosal erosion, or villus atrophy. 39 signs may also be noted in immunosuppressed adult cats. 26 isospora species are readily found in fecal floatation or wet-mount examinations. shedding can be intermittent, but most cats with diarrhea caused by coccidial infection shed large numbers of oocsyts. 39 fortunately, in most cats, the diarrhea from isospora spp. infection is self-limiting. 26 in fact, if a kitten is persistently shedding oocysts despite appropriate treatment 13 or the parasite is identified in an adult cat with chronic diarrhea, attempts should be made to identify co-infections or other diseases that may cause diarrhea. 39 anticoccidial drugs are either coccidiostatic or coccidiocidal (table 2320) . coccidiostatic drugs are the most commonly used drugs for individual pet cats. trimethoprim-augmented sulfadiazine (tribrissen; intervet/schering-plough animal health, summit, nj) or another sulfa-containing antibiotic, sulfadimethoxine (albon; pfizer animal health, madison, nj), can be used. supportive care for severely affected kittens, such as parenteral rehydration, should be used as needed. coccidiocidal drugs are often reserved for use in densely populated situations such as catteries or shelters. 26 however, many veterinarians are now using them as a first-line defense against isospora spp. infection. 13 ponazuril (marquis oral paste; bayer animal health, shawnee mission, kan.), formulated for horses, is effective and can be safely administered to cats. for more on the use of ponazuril in cats, see chapter 46. a related drug, diclazuril, is also available and may be administered once at 25 mg/kg po. 13 while not available in north america, toltrazuril (baycox, bayer animal health) may be administered once at 30 mg/kg po or 15 mg/kg po once daily for 3 days. 32a a second course of therapy 10 days later may be required to completely eliminate the oocysts. sanitation is very important, because the oocyst requires several days to become infective. frequent removal of feces, preferably daily, is recommended to prevent re-infection and transmission to other cats. 39 controlling a cat's ability to hunt reduces the chance of ingesting an isospora-infected rodent. control of mechanical vectors, such as cockroaches and flies, is also useful. 13 since a cat can become infected after grooming an infected cat's perineum, consideration should be given to treating all cats in contact with the patient. 39 in addition, catteries and shelters should ensure all food is well cooked, litter boxes are cleaned daily, and surfaces are well cleaned with steam 13 or 10% ammonia. 39 where recurrent isospora spp. infections are a problem, prophylactic treatment of all 2-to 3-week-old kittens with ponazuril should be considered. 13 despite all wellintentioned efforts at hygiene and treatment, isospora spp. infection can still be transmitted to other cats. 13 because these are species-specific parasites, transmission of i. felis and i. rivolta from cats to humans does not occur. the flagellated protozoal parasite, giardia duodenalis, has seven microscopically indistinguishable genotypes or assemblages. 26 assemblages a and b infect humans, while assemblage f is harbored by cats. cats will occasionally harbor assemblages a and b. 39 infection with g. duodenalis occurs after ingesting cystcontaminated feces, by grooming an infected cat or from contaminated fomites. 37 re-infection may occur by selfgrooming. only a small number of cysts need be ingested to establish an infection. in humans as few as 10 cysts are required to cause infection. 37 after ingestion of infective cysts, trophozoites begin to excyst in the stomach. 37 this process is completed in the proximal duodenum. 26 the trophozoites adhere to enterocytes along the length of the small intestine using the ventral suction disk. intermittent shedding of immediately infective cysts begins 5 to 16 days after infection. 28 proteins released during encystment of the trophozoites are detected by the fecal antigen tests. 37 cysts may adhere to the perianal region, facilitating re-infection by self-grooming. 28 occasionally, trophozoites are found in examinations of fresh, watery feces. these do not survive for long and are not infective. 4 the mechanisms of disease induced by g. duodenalis are still unclear. after the trophozoite attaches to the brush border of the enterocyte, the tight junction between cells is disrupted, increasing intestinal permeability. 37 the brush border becomes attenuated, further exacerbating malabsorption of water, electrolytes, and other nutrients. 39 the alteration in intercellular adhesion results in t-lymphocyte activation and mucosal cell injury. 37 infection also promotes mucosal cell apoptosis (preprogrammed cell death). 28 in addition, small intestinal bacterial overgrowth may accompany g. duodenalis infections, resulting in more severe clinical signs. 39 fortunately, most cats infected with g. duodenalis show no clinical signs. 28, 39 the most common sign is acute, transient, small bowel diarrhea 28 without systemic illness, such as fever or vomiting. 39 less commonly, a cat might have profuse, watery malodorous diarrhea 37 with mucus. 39 also possible, but uncommon, is weight loss 26, 28 or abdominal pain. 37 the severity of clinical signs exhibited in an individual cat depends on the age and general health of the cat. 37 cats co-infected with cryptosporidium felis or tritrichomonas foetus may have more severe diarrhea that is more difficult to control, 39 as will the presence of bacterial overgrowth. the diagnosis of g. duodenalis requires demonstration of trophozoites or cysts in a fecal examination, or detection of encystment proteins or giardial dna in a fecal sample. a reliable diagnosis may be difficult to obtain for several reasons. cysts are small, easily missed, and must be differentiated from plant debris or yeast. 37 trophozoites are short lived outside the body and can only be found in very fresh, watery feces or, better yet, in diarrheic feces collected directly from the cat's rectum. 37 shedding of cysts is usually intermittent, and the intensity of shedding varies greatly. 28, 37 because of these difficulties, the absence of the organism in a fecal sample does not eliminate it as the cause of diarrhea. it is often necessary to test multiple fecal samples, using at least two different techniques in order to find the organism. 37, 39 the easiest test to perform is a fecal smear or wet mount examination to identify trophozoites or cysts (figures 23-42 and 23-43 ). the sample examined should be very fresh, warm, diarrheic feces. 39 one drop of feces is placed on a slide along with a drop of 0.9% saline or lugol iodine. 28 trophozoites are identified by their characteristic structure (table 2321) . the motile trophozoites have a motion described as appearing like the back and forth rolling motion of a falling leaf. since lugol iodine stain kills the trophozoite, there will be no motion to detect. 28 this test is not very sensitive; however, with trained examiners, the test has a high specificity. increased sensitivity can be gained by performing a centrifugal flotation using zinc sulfate. the sample should be warm, fresh feces or feces refrigerated for no more than 2 days. 28 the processed sample is examined for the same structures as the wet mount. the sensitivity of examining one sample is 70% 28 and increases as more samples are examined. the sensitivity of looking at three samples is 95% 26, 28 ; therefore the test is not considered negative until three specimens have been found free of the organism. 39 a fecal antigen test that identifies the encystment protein is available. the snap giardia antigen test (idexx laboratories) uses fresh or frozen feces, or feces refrigerated for less than 7 days. 34 since the antigen is continuously shed, this test avoids the problem of intermittent shedding of the whole organism. 28 the sensitivity of the test is 85%, with a specificity of 100%. 35 by combining the antigen test with a zinc sulfate fecal centrifugal flotation, the sensitivity improves to 97.8%. 11 it is unknown how long the antigen remains in the feces after treatment. thus a zinc sulfate centrifugal flotation examination should be used to evaluate therapeutic efficacy. 28, 39 the use of this test in cats without diarrhea is controversial, because these cats are unlikely to shed cysts. the zoonotic significance of a positive antigen test in a cat not shedding cysts is unknown and may cause confusion. 39 polymerase chain reaction detection of giardia dna is available, but the test has not been standardized across all diagnostic laboratories. one needs to ensure the laboratory performing the test has validated it for assemblage f. the test may also be used to identify cats harboring the zoonotic assemblages a and b. the sensitivity of this test is unknown. 39 two commonly available drugs are used most frequently to treat infections with g. duodenalis (see table 23 -20) . fenbendazole may be effective and can be used in pregnant queens 28 and in cats co-infected with roundworms, hookworms, and taenia spp. tapeworms. 39 however, in one small study, only four of eight cats infected with both g. duodenalis and cryptosporidium felis stopped shedding giardia permanently after receiving fenbendazole. 29 febantel, in the combination product drontal plus (bayer animal health), is converted to fenbendazole. when six experimentally infected cats received 56.5 mg/ kg of febantel q24h po for 5 days, four of them stopped shedding g. duodenalis cysts. 39 metronidazole has been the traditional drug used to treat g. duodenalis in pets. 28 the drug is also useful for treating concurrent small intestinal bacterial overgrowth and clostridial infections. 39 the administration of metronidazole may eliminate shedding in 67% of cats. 26 neurologic side effects may occur at the dose recommended for treatment of giardia (see above, therapeutics for vomiting and diarrhea). the use of a giardia vaccine was ineffective in clearing infection by itself. 44 the combination of fenbendazole and metronidazole has been suggested as the initial treatment of choice for g. duodenalis infections. 39 although controlled studies are lacking, they may work synergistically by acting on two different targets within the parasite. 28 febantel would be expected to have the same synergism with metronidazole. drug therapy may not be necessary in cats without diarrhea that are infected with g. duodenalis, 37 because it is uncommon for a cat to carry the assemblages required to infect humans. the veterinarian may be obligated to treat a healthy cat if the owner wants to treat, the owner is immunocompromised, or the goal is eradication of an infection from a multicat home or prevention of parasite transmission to giardia-naïve cats is attempted. 28 what may appear to be treatment failure is more likely to be re-infection. in addition to drug therapy, steps should be taken to prevent re-infection. all cats with diarrhea positive for g. duodenalis should be treated along with their housemates. 37 sanitation is imperative in the fight against re-infection and transmission of g. duodenalis. dispose of old litter pans and scoops and use disposable litter boxes during treatment. when the infection is eliminated, not just controlled, new litter boxes and scoops may be purchased. bathe all cats during treatment to remove cysts from the hair coat. since giardia spp. cysts are susceptible to desiccation, 28 blowdry all cats using a warm air blower, paying particular attention to the perineal area. disinfect bowls, housing, and other utensils with bleach. 28 in addition to antiprotozoal drugs and sanitation, supportive care may become necessary. probiotics and a highly digestible, bland diet may be offered to cats with small bowel diarrhea, while a high-fiber diet may be useful for those few cats with large bowel diarrhea. 39 where required, hydration and electrolyte imbalances must be corrected and antiemetics used to control vomiting. therapy can be evaluated by retesting feces with a zinc sulfate centrifugal flotation examination 1 to 3 days after the end of treatment and again 3 weeks later. a positive test immediately posttreatment is most likely because of therapeutic failure. if the cat is negative immediately after treatment ends, but is positive 3 weeks later, re-infection is likely. 28 since the fecal antigen test may remain positive long after the infection is eradicated, this test is inappropriate for evaluating therapy. 28, 39 re-treatment of fecal flotation-positive, recovered cats may be handled in a manner similar to the positive healthy cat mentioned above. 28 cats with diarrhea that continue to shed cysts may be re-treated for g. duodenalis infection along with dietary modification and empirical treatment for other common intestinal parasites. however, serious consideration should be given to investigation into other potential causes of diarrhea. 28 the giardia vaccine has been found to be ineffective in preventing infection 37 and production has been discontinued. 39 this means prevention of giardia infection involves avoiding exposure, stress and re-infections. providing a clean environment, feeding only processed foods, and controlling potential transport hosts will help reduce the chances of exposure. isolation of cats with diarrhea may be important, too. 39 municipal sanitation control is difficult as the cyst survives for weeks in cool, moist environments. 28 cysts are also able to survive water treatment and can pass through attempts at water filtration. 37 giardiasis is associated with debilitating diarrhea in some humans, particularly those who are immunocompromised. 35 however, cats do not commonly carry the assemblages needed to infect humans. transmission of g. duodenalis from cats to humans is rare and unproven. 28 still, it seems prudent to consider the owner's health when contemplating management of giardial infections in cats. to avoid human health risks, cats with diarrhea that test positive for g. duodenalis should be treated with the goal of controlling the diarrhea. 39 since no treatment for g. duodenalis is completely effective or 100% safe, treatment of positive cats without diarrhea should only begin after a discussion of the benefits and risks of the treatment with the owner. 39 tritrichomonas foetus is best known for causing bovine reproductive infections. it is an obligate anaerobic parasite 26 that also colonizes the lower intestinal tract of cats. there are enough differences between the two isolates that the feline isolate does not cause disease in heifers and vice versa. 39 the parasite depends on the host's normal intestinal flora and secretions for obtaining nutrition. 7 a report from the united states of purebred cats tested at an international cat show found t. foetus in 36 of the 117 cats tested, a prevalence of 31%. 23 this parasite seems to have a higher prevalence in purebred cats than nonpurebred cats. a study of pet cats visiting veterinary hospitals across the united states reported 12 of 32 purebred cats were positive for t. foetus, while only 5 of 141 nonpurebred cats were positive. in this same study, 12 of the 17 positive tests were from purebred cats. 45 a study from the united kingdom of diarrheic fecal samples sent to a veterinary diagnostic laboratory reported similar results. purebred cats represented 14 of the 16 cats testing positive for t. foetus. the u.k. study also found the siamese and bengal breeds each represented 6 of 14 positive cats; only two other breeds tested positive. 25 transmission like most other protozoal parasites, t. foetus is transmitted by ingestion of the parasite, in this case, the trophozoite. unlike most of the other parasites, t. foetus does not form cysts and only survives up to 3 days outside the body in moist feces. 47 a cat becomes infected through the use of a shared litter box with an infected cat. after walking into the box, the parasite is transferred from the infected feces of one cat to the paws of the other. infection then occurs through ingestion of the trophozoites during grooming. 47 after infection, t. foetus colonizes the distal ileum and colon, 15 followed by shedding of infective trophozoites 2 to 7 days later. 19 there are several mechanisms by which t. foetus causes diarrhea. these include alteration of the cat's normal bacterial flora population, increases in local inflammatory cytokine concentrations, production of enzymes, and direct mucosal injury. the resulting injury leads to plasmacytic-lymphocytic 49 and neutrophilic colitis. 37 although most infections involve only the mucosa of the colon, one study reported two of seven cats with diarrhea and t. foetus infections as having trophozoites in deeper layers of the colonic wall. 49 co-infection with cryptosporidium felis 17 or giardia duodenalis 39 can be associated with increased numbers of t. foetus trophozoites and increased severity of diarrhea. signs of infection are most frequent in kittens and young cats, although infections without clinical signs can occur. 39 adult cats, however, may also show signs of t. foetus infection. the most common sign is a foulsmelling large bowel diarrhea with increased frequency of defecation, 39 mucus, blood, 15 and flatulence. 37 the consistency of the diarrhea may wax and wane, but the presence of diarrhea does not. 47 cats with diarrhea are otherwise in good health and maintain their body condition. 15, 39 severe diarrhea can result in anal swelling and fecal incontinence. 39 diarrhea may respond to the use of antibiotics because of changes in the cat's intestinal microbial flora. however, it always returns at the cessation of therapy. 39, 47 many cats experience a spontaneous resolution of the diarrhea within 2 years of diagnosis. 15, 38 since t. foetus causes reproductive infections in heifers and bulls, there is speculation the parasite also infects the reproductive tract in cats. tritrichomonas foetus was found in the uterus of a queen with pyometra. 9 however, in a study of 60 breeding male and female cats from 33 catteries, no cytologic or molecular evidence of t. foetus was found in the reproductive tract. the authors reported colonic infection with t. foetus in 15 of the 60 cats representing 22 of the 33 catteries. 24 detection of the trophozoites in a sample of feces is the most expedient means of diagnosing an infection with t. foetus (figure 23-44 ). an index of suspicion is required, because the clinical presentation of t. foetus infection is often mistaken for infection with giardia duodenalis. if a cat is not responding to treatment for that parasite, consider t. foetus as a cause of the diarrhea. the sample required for the diagnosis of t. foetus is a fresh, nonrefrigerated sample of watery feces. refrigeration kills the trophozoites, and they are not found in normal feces. 34 the sample may be freshly passed diarrhea, feces collected using a wire loop passed into the colon, or collected by a colonic flush using a red rubber catheter and 10 ml of saline. 47 a wet mount or smear examination of the feces should be performed on all cats with diarrhea. examination of multiple samples may be required to find the t. foetus trophozoites with this technique because it is insensitive. 39 the trophozoites must be differentiated from giardia duodenalis based on structural differences and motility patterns (see table 23 -21). the trophozoites of t. foetus can be cultured using the inpouch tf system (biomed diagnostics). this test is more sensitive than the fecal wet mount examination and detects 1000 trophozoites per sample. 15 the number of parasites shed by a cat with diarrhea is high enough to be routinely detected with this method. 18 the test should be performed in-house, because the parasite is unlikely to survive the trip to the laboratory. 47 the test pouch is inoculated with 50 µg of freshly collected feces, about the size of a peppercorn. 18 any more than this increases the chances of bacterial overgrowth. 15 the pouch is incubated at 25° c and examined under the microscope for motile trophozoites every other day for 12 days. the pouch should be tapped gently to dislodge the parasites, which tend to collect along the seams. 15 the test is considered negative if parasites are not found after 12 days. one benefit of this system is that it does not support growth of giardia duodenalis or pentatrichomonas hominis. 18 if a fecal wet mount examination and culture are both negative and infection with t. foetus is still under consideration, a pcr test can be performed. this test detects dna from live or dead trophozoites, but is more expensive than other diagnostic methods. 47 this test is more sensitive than the other two methods and can detect 10 parasites per sample. 16 the sample size is 200 mg of feces not contaminated by litter preserved in 3 to 5 ml of rubbing alcohol shipped at room temperature. 15 trophozoites of t. foetus are sometimes found in colonic biopsy samples adhered to the surface or in the lumen of crypts. 15 the most effective drug for the treatment of t. foetus in cats is ronidazole. 17 the drug has a bitter taste and should be compounded into capsules. veterinary staff and owners should use gloves when handling ronidazole. 15 if a confirmed relapse occurs, another course of treatment may eliminate the parasite. 39 diarrhea may take several weeks to resolve after elimination of the parasite, because significant colitis is often present. 47 effectiveness of treatment can be evaluated by performing fecal pcr tests 2 and 20 weeks after the end of treatment. 15 apparent treatment failures may occur because of re-infection, co-infection with giardia duodenalis or cryptosporidium felis, or the presence of another concurrent diarrhea-causing disorder. a more worrisome cause for treatment failure is a recent report of parasite resistance to ronidazole in two cats. 22 fortunately, diarrhea ultimately resolved in both cats despite the continued presence of the parasite. if the cat retests negative and the diarrhea is not improving after 2 weeks, consider the possibility that another disease may exist. nonspecific treatment for diarrhea is unhelpful 37 and may prolong the duration of diarrhea. 15 diarrhea may respond to antibiotics as they alter the intestinal flora population; however, once treatment is stopped, the diarrhea will return. 47 an important and potentially serious adverse effect of ronidazole administration in cats is a reversible neurotoxicity. onset of signs often begins within 1 week of the onset of therapy and may last between 1 and 4 weeks after cessation of therapy. 38 these signs can include depression, ataxia, seizures, 47 behavioral changes, weakness, hyperesthesia, and trembling. 38 neurotoxicosis usually requires only supportive care along with discontinuation of the drug. the neurologically affected cat should be retested for the parasite, because it may have been eliminated. 38 because of the potential for neurotoxicity, the use of ronidazole should be restricted to cats with confirmed infections with t. foetus. 47 crowded conditions should be avoided, because transmission of t. foetus trophozoites is more efficient in these settings. 39 cats testing positive should be isolated from other cats during treatment. 37 providing a clean environment will help prevent transmission of trophozoites. although there is a report of an infection in one immunocompromised person, transmission of t. foetus trophozoites from cats to healthy humans has not been reported. 39 still, prudence dictates handling feces infected with t. foetus trophozoites carefully. recent genetic evaluations have shown that most feline infections with cryptosporidium spp. are with c. felis; not, as previously thought, with c. parvum. 36 cryptosporidium parvum seems to be limited to farm animals. 4 cryptosporidium felis is an obligate intracellular parasite infecting the small intestine. 4 infective oocysts are ingested from contaminated feces during self-grooming of contaminated body parts and from contaminated food and water. 32, 39 after infection, the parasite attaches to the brush border of the enterocyte. the prepatent period is 3 to 6 days, 39 and the oocysts are infective as soon as they are shed, making this a very contagious disease. 20 like most intestinal parasites, shedding is often intermittent. the pathogenic effects of c. felis infections are not well understood. direct cytotoxicity and inflammation causes villus atrophy and decreased surface area for absorption of water, electrolytes, and other nutrients. 20, 32 apoptosis (preprogrammed cell death) of the mucosal cells may be accelerated, adding to the malabsorption. 20 most infections with c. felis are subclinical. 39 signs, if present, range from a mild, self-limiting small bowel diarrhea 33 to chronic intermittent small bowel diarrhea. 32 severe diarrhea with weight loss and anorexia may also occur. 32, 33 clinically apparent infections are most common in kittens, adult cats with concurrent gastrointestinal diseases, and cats co-infected with giardia duodenalis or tritrichomonas foetus. 39 cats with co-infections may experience more severe clinical signs. 32 a fecal flotation, which should be performed on all cats with diarrhea, may reveal c. felis if there are large numbers of oocysts (figure 23-45) . the fecal floatation test, however, is often negative 39 because of intermittent shedding. the parasite is small and floats in a higher plane than helminth ova; the high-power lens and appropriate adjustment of the microscope stage is required to find the parasite. 32 the small size of the oocyst makes identification difficult, particularly if the examiner is not specifically looking for them. 34 a modified ziehl-neelsen stain of a thin fecal smear may help in the identification of the oocysts. 39 this technique works well in humans with large numbers of oocysts. 33 once signs resolve or the oocyst numbers decline, a single examination of a stained smear becomes insensitive. when only one sample is available, testing for c. felis antigen is a good choice. 34 the prospect microplate assay (alexon biomedical, sunnyvale, calif.) is more sensitive and specific for the diagnosis of c. felis than is the examination of a stained smear. 6 immunofluorescent antibody testing is available from some laboratories. fecal c. felis dna can be detected using pcr testing. this test is available at many veterinary diagnostic laboratories; however, at present, there is no test standardization among laboratories. 39 the clinical and zoonotic significance of a positive pcr test combined with an oocyst negative test is unknown. 39 therefore a positive pcr test in a cat without diarrhea presents a confusing situation for the attending veterinarian with regard to recommendations for the owner. unfortunately, there are no completely effective and safe treatment protocols available for c. felis. 32, 39 a concerted attempt to find other causes of diarrhea should take place prior to convicting a cat of having diarrhea solely from c. felis infection. most reports on therapy for c. felis are uncontrolled and anecdotal. a number of drugs have been discussed. azithromycin for at least 10 days appears safe but produces variable results. 39 paromomycin, an oral aminoglycoside, may be effective. however, one study reported acute renal failure in 4 of 32 cats receiving the drug. deafness also occurred in three of those four cats. 21 nitazoxanide is a drug approved for treating humans with diarrhea caused by cryptosporidium spp. infections. the administration of nitazoxanide to cats at 25 mg/kg q12h po for at least 5 days 39 up to 28 days 32 may be effective. however, nitazoxanide is a gastrointestinal irritant and commonly results in vomiting and foul-smelling diarrhea. co-infections with giardia duodenalis and/or tritrichomonas foetus are more difficult to control. if diarrhea from c. felis infection improves but does not resolve at the end of therapy, the duration of treatment may be prolonged. 39 additional diagnostic testing should also be performed to ensure the only cause of the diarrhea is infection with c. felis. environmental control of c. felis is difficult, because it is extremely hardy. it is resistant to chlorination and most disinfectants. 32 oocysts remain viable at temperatures above freezing up to 65° c. 4 the parasite is difficult to filter and survives treatment at municipal water treatment facilities. 20 steam-cleaned housing and utensils may be beneficial in controlling parasite numbers, and they are susceptible to 5% ammonia solutions; however, the required contact time is 18 hours. 39 cryptosporidium spp. are relatively species specific, and there are no reports of waterborne outbreaks of human cryptosporidiosis associated with c. felis. 32 cryptosporidiosis can cause life-threatening diarrhea in hivpositive persons. 20 fortunately, humans are rarely infected with c. felis. 39 in fact, the zoonotic species most commonly found in humans (often veterinary students), is c. parvum found in young heifers. 4 regardless of a person's health, feces from a cat with diarrhea should be handled carefully. if a cat infected with cryptosporidium spp. is owned by an immunocompromised person, a pcr test may be useful in determining the species of the parasite and its zoonotic risk. like other coccidians, toxoplasma gondii is an obligate intracellular parasite. 12 domestic cats and other felids are the only animals that shed oocysts. any warmblooded animal, including humans, can be infected with this parasite. toxoplasma gondii can be transmitted by ingestion of infective oocysts in fecally contaminated food or water after ingestion of tissue cysts through carnivorism, or by transplacental or trans-mammary transmission of the parasite. the parasite enters into one of two cycles, depending on the host species. the enteroepithelial cycle only occurs in cats and results in shedding of oocysts after sexual reproduction of the parasite. after a cat ingests an infective oocyst or a tissue cyst, the parasite enters the mucosal cells of the small intestine, where it may undergo development and sexual reproduction, after which oocysts are shed. 12 the prepatent period after ingesting an infective oocyst is 19 to 48 days, while shedding after ingesting tissue cysts starts in 3 to 10 days. 4 fecal shedding, which occurs only after initial infection, lasts for 2 to 3 weeks 4,31 and the oocysts become infective 1 to 5 days after they are shed. 12 the extraintestinal cycle occurs in any animal, including cats. after ingestion, the parasite penetrates the cells of the small intestine and rapidly replicates in the enterocytes and associated lymph nodes into tachyzoites. after hematogenous and lymphatic spread, tachyzoites infect cells in all tissues of the body. 4 tissues most commonly infected include the brain, liver, pancreas, and lungs. 30 if a pregnant queen becomes infected, tachyzoites cause placentitis, after which they infect the fetus. 13 in 3 weeks, the host's immune response slows parasite replication, and the resultant bradyzoites form tissue cysts 30 in the brain, striated muscle, and liver, and they remain viable for the life of the animal. 4 immunosuppressive drugs or disease may dull the suppression of parasite division by the host immune system and allow the slowly dividing bradyzoites in tissue cysts to begin rapid division, thereby reactivating the infection with tachyzoites. 30 none of the forms of t. gondii produces a toxin. rapid replication of tachyzoites within a cell leads to rupture of the cell and necrosis of the tissue in which they are located. 12 the most commonly injured tissues are the brain, lungs, liver, and pancreas. prenatal infection leads to more severe illness, because the immature immune system is unable to slow down replication by tachyzoites, allowing continued damage to tissues. prenatal infection is more likely to result in ocular infections, and neonatal death is usually caused by pulmonary or hepatic infection. 30 type ii and iv hypersensitivities may be involved in the pathogenesis of chronic disease from bradyzoites in tissue cysts. 30 kittens infected perinatally can be stillborn or die shortly after birth. they may also suffer from hepatomegaly and ascites, central nervous system signs resulting from encephalitis, respiratory distress, or uveitis. 12, 13 clinical signs of infection in healthy adult cats are uncommon (box 23-2). 31 diarrhea from enteroepithelial development of the parasite is rare. 39 cats that develop clinical disease often have an episodic course with vague signs 30 that depend on the body system affected. onset of illness may be acute or chronic, and the most commonly affected organs include the brain, lungs, liver, heart, pancreas, and the eyes. 13 signs are the result of spread of tachyzoites after initial infection or after reactivation of tissue cysts. cats suffering from uveitis may develop lens luxation and glaucoma. the best way to identify a cat shedding t. gondii oocysts is to demonstrate them with a centrifugal fecal flotation technique using sheather sugar solution. the oocysts are about a quarter of the size of isospora felis oocysts ( figure 23-46 ). 12 oocysts of t. gondii are morphologically indistinguishable from hammondia or besnoitia spp. oocysts. 13 detection of fecal t. gondii dna using a pcr test can be used to definitively differentiate t. gondii oocysts from similar coccidians. 31 it is probably best, however, to assume suspicious oocysts are those of t. gondii until proven otherwise. proving infection with t. gondii is responsible for a cat's systemic illness is also difficult. finding tachyzoites in cytology samples is uncommon. they are most likely to be identified from body cavity effusions. 13 the most common method of identifying an infected cat is by detecting t. gondii-associated immunoglobulins using immunofluorescent antibody or elisa techniques. since cats are infected for life, a seropositive cat has been infected at some point in its life. however, use of serology alone is insufficient to diagnose an active t. gondii infection. serum immunoglobulin m (igm) is produced within 1 to 2 weeks after infection, but increased igm titers may persist for months to years. serum immunoglobulin g (igg) begins to rise later; in some cats, igg may not be detectable for 4 to 6 weeks. 12 by the time igg is detectable, shedding will have ceased. maternally acquired igg persists in kittens for 8 to 12 weeks. 13 a rising igg titer is associated with an active infection, but the degree of increase is not associated with the severity of the clinical signs. if a cat becomes seronegative, it is more likely the titer has fallen below the sensitivity of the test rather than the parasite has been eliminated from the body. 31 because of the vague nature of the clinical signs, many cats are presented later in the course of the disease. by this time, they may have switched from igm to igg production or passed the time of maximal igg production. thus a negative igm titer or a lack of rising igg titer does not rule out t. gondii infection. 30 also, reactivation of tissue cysts is rarely associated with rising igg titers. 31 ultimately, the diagnosis of an active systemic t. gondii infection requires demonstration of an igm titer greater than 1 : 64 or a fourfold increase in igg titers over a 2-to 3-week period along with signs consistent with toxoplasmosis, the exclusion of other disorders that may cause the clinical signs, and response to appropriate anti-t. gondii treatment. 31 although serum igm titers may be increased in otherwise healthy cats, increased igm titers in cerebrospinal fluid or aqueous humor only occurs in cats with active cns or ocular infections. 30 the goals of treating a cat infected with t. gondii are to reduce shedding of oocysts and to control the clinical signs in sick cats. shedding can be reduced by using ponazuril, 13 toltrazuril, or high doses of clindamycin. the drug options for treating a sick cat include clindamycin, trimethoprim-augmented sulfadiazine, or azithromycin for at least 4 weeks (see table 23 -20) . recurrences are more common if the cat is treated for less than 4 weeks. 13, 30 the antifolate drug pyrimethamine may be more effective than trimethoprim, but megaloblastic anemia develops in many cats. supplementation with folinic acid (5 mg/cat, once daily, po) or brewer's yeast (100 mg/kg, once daily, po) may prevent or reverse the anemia. 12 no drug clears all of the tissue cysts; so, cats remain infected for life. if uveitis is also present, use appropriate topical, oral, or parenteral corticosteroids. for a cat with proven t. gondii-associated uveitis alone, a topical ocular glucocorticosteroid is the only required treatment; no antibiotics are necessary unless the uveitis is persistent or recurrent. 31 • wash hands after handling cats, especially if you are pregnant or immunocompromised. • remove fecal material from the home environment daily, since shed oocysts require a minimum of 24 hours to become infective. • do not have immunocompromised persons clean the litter box. if they must clean the litter box, they should wear gloves and wash hands thoroughly when finished. • use litter box liners, and periodically wash the litter box with scalding water and detergent. • wear gloves when gardening, and wash hands thoroughly when finished. • cover children's sandboxes when not in use to avoid fecal contamination by outdoor cats. • only feed cats cooked or commercially processed food. • control potential transport hosts, such as flies and cockroaches, that may bring the organism into the home. • filter or boil water from sources in the environment. • cook meat for human consumption to 80° c for 15 minutes minimum (because of uneven heating, microwave cooking does not kill all t. gondii 12 ). • freeze meat at −12° c for 24 hours. 12 • wear gloves when handling meat, and wash hands thoroughly with soap and water when finished. clinical signs such as malaise, fever, and muscle pain should begin to resolve in 2 to 3 days. 30 if there is no response within 7 days, switch to or add another drug. 31 if there is still no response, search for another condition that may cause the observed clinical signs. however, ocular and cns signs resolve more slowly and thoracic radiographic changes may take weeks to resolve. 30 some cns changes may never completely resolve. cats co-infected with feline immunodeficiency virus (fiv) do not respond to anti-t. gondii treatment as well as fivnegative cats respond. 12 feeding cats commercially processed cat food and avoiding undercooked or raw meat can prevent exposure to t. gondii. controlling hunting reduces access to paratenic hosts with infective tissue cysts. access to mechanical carriers of t. gondii, such as earthworms or cockroaches, should be minimized. human infection with t. gondii is common, more so in warm, humid climates where the prevalence of t. gondii seropositive persons approaches 100%. the number of persons seropositive for t. gondii is estimated to be around 500,000,000 worldwide. 12 infective oocysts are hardy and may remain viable in the environment for up to 18 months. 12 human infection most often occurs after eating raw or undercooked meat infected with tissue cysts or by transplacental infection. 31 seropositive cats are finished shedding and are unlikely to resume shedding even if the infection becomes reactivated. 31 cats found to be shedding oocysts should be quarantined at a veterinary hospital until shedding ends. oocysts of t. gondii have not been found on the hair coat 13 ; so, transmission of toxoplasmosis does not occur after touching a cat. 31 pregnant women infected with t. gondii for the first time, or chronically infected women who are also hiv positive, can transmit the parasite to their unborn child. transplacental infection can result in stillbirths, cns, or ocular disease. 30 more severe fetal disease may occur if the infection happens in the first half of the woman's pregnancy. 12 toxoplasma gondii infection of immunocompetent humans usually results in a self-limiting fever and malaise. 30 steps useful in preventing transmission of t. gondii to humans can be found in box 23-3. pancreatitis refers to inflammation of the pancreas only, with no implication of the underlying cause or pathology. for example, acute necrotizing pancreatitis (anp) with pancreatic auto-digestion, requiring predominantly supportive care by maintaining fluid and electrolyte balances and pain relief, must not be confused with chronic pancreatitis (cp) caused by lymphocytic infiltration, and commonly associated with lymphocytic inflammatory bowel disease (ibd), and often requires corticosteroids to manage. these two conditions (and others) can only be definitively distinguished histologically. in many cases, the clinical signs of cats with acute pancreatitis will resolve with supportive care before a precise diagnosis is reached and will thus remain undiagnosed. there are no formal classifications for feline pancreatitis, but most authors 78, 89, 90 use the terms • acute pancreatitis • acute necrotizing pancreatitis, characterized by severe peri-pancreatic fat necrosis • acute suppurative pancreatitis, characterized by neutrophilic infiltration • chronic pancreatitis, characterized by lymphocytic infiltration the exact prevalence of feline pancreatitis is unknown. necropsy studies from the 1970s to 1990s reported prevalence of feline pancreatitis ranging from 0.45% to 2.4%. 21,67 a more recent study 17 found 67% of 115 cats had evidence of pancreatitis. however, this included pancreatic pathology in 45% of apparently healthy cats, which suggests that mild pathology is unlikely to cause clinical signs. these studies all show lymphocytic pancreatitis to be significantly more prevalent than acute pancreatitis. this may underestimate the true prevalence of acute pancreatitis, since it is understood that no permanent histopathologic changes are present after resolution of acute pancreatitis. 89 it is also possible that studies assessing pathology in necropsy cases do not reflect clinical practice. there are no specific age, breed, or sex predispositions. although one study reported siamese cats to be at increased risk of acute pancreatitis, 33 subsequent studies have recognized the majority of cases are domestic shorthair cats, suggesting no specific breed predispositions. 22, 29, 60, 71 most studies have indicated older cats (8 to 10 years of age) are more likely to be affected, 22, 29, 60, 71 but these studies most likely underrepresent cats with less severe clinical disease for which definitive diagnosis may not be reached and which may be younger. no association has been made with a high-fat diet or obesity. in most cases of both acute and chronic pancreatitis, no specific cause is found, and the disease is primarily considered to be idiopathic. 22, 90 there are, however, some specific underlying causes that are sporadically recognized. these include infections with herpesvirus, 75 calicivirus, 37,49 feline infectious peritonitis (fip), 44 liver fluke 58 and pancreatic fluke, 26, 77 and toxoplasmosis. 20 however, a recent paper found no association between serum feline pancreatic lipase immunoreactivity (fpli) concentrations and toxoplasma gondii serology. 8 pancreatitis has also been recognized subsequent to trauma 81 and organophosphate poisoning. 33 the association of pancreatitis with inflammatory bowel disease and cholangitis is frequently mentioned (triaditis) but poorly described in the literature. 80 one study found 30% of ibd cases to have histologic evidence of pancreatic involvement, 6 and another found fpli concentrations were elevated in 70% of cases with histologically confirmed ibd. 3 it is the author's experience that many cases of pancreatitis recognized with ibd have no specific clinical signs attributable to pancreatitis and should therefore be diagnosed and treated as intestinal disease. diabetes mellitus is a recognized co-morbidity of pancreatitis in cats. a recent study found fpli concentrations were significantly higher in 29 diabetic cats compared with 23 non-diabetics. no association could be made between fpli concentrations and the degree of diabetic control. 23 one study found 5 of 13 cats (38%) histologically diagnosed with hepatic lipidosis were also histologically diagnosed with acute pancreatitis. it is not known if pancreatitis is a cause, consequence, or coincident disease of hepatic lipidosis. for example, anorexia associated with acute pancreatitis could predispose to fatty infiltration of the liver. however, the high rate of concurrent disease has important implications for ensuring cats with pancreatitis receive adequate caloric intake. 1 ongoing or recurrent pancreatitis may lead to pancreatic cysts 10 or exocrine pancreatic insufficiency, 74 which are both covered later in this chapter. although pancreatitis has been experimentally induced in cats, 18, 41, 56 the pathophysiology of spontaneous pancreatitis remains unknown. acute pancreatitis is initiated by an increase in secretion of pancreatic enzymes that leads to inappropriate cellular activation of trypsin and subsequently other digestive zymogens. these activated digestive enzymes lead to local effects including inflammation, hemorrhage, acinar cell necrosis, and peripancreatic fat necrosis. 43, 78, 86 chronic pancreatitis may result from any of several underlying processes: ongoing, low-grade acute pancreatitis episodes may instigate chronicity; chronic pancreatitis, with a predominance of lymphocytic inflammation has been induced experimentally within 5 weeks by narrowing the main pancreatic duct to approximately 25% of its normal diameter 18 ; and the association with ibd 80 may suggest an immune-mediated cause. the clinical signs of pancreatitis in cats are nonspecific. a review of eight prior series totaling 159 cases of acute pancreatitis in cats found anorexia (87% of cases) and lethargy (81%) to be the most common historical findings. 78 vomiting was recognized in 46% of cases, diarrhea in 12%, and weight loss in 47%. physical examination findings were similarly nonspecific with dehydration (54%) being the major finding; fever was recognized in only 25% of cases and abdominal pain in 19%. it is important to note that vomiting and abdominal pain, key features of pancreatitis in dogs, are not consistently recognized in cats. similar, nonspecific findings indistinguishable from ibd are recognized in cats with chronic pancreatitis. 3, 6 diagnosis because the presenting signs and physical examination findings are nonspecific, the diagnosis of pancreatitis can be challenging, requiring not only clinical suspicion but a combination of diagnostic modalities. for the most part, hematology and plasma biochemistry findings are unremarkable, although a combination of findings may increase clinical suspicion. for example, moderate elevations in liver enzymes, bilirubin, and glucose are present in approximately 50% of cases and hypocalcemia in approximately two of three of cases; hypocalcemia infers a poorer prognosis. hypoalbuminemia is seen in approximately one of three of cases and has important implications for fluid therapy. 78 amylase and lipase elevations are not reflective of pancreatitis in cats. 47 feline trypsinlike immunoreactivity (ftli) is the diagnostic test of choice of exocrine pancreatic insufficiency, but elevations in pancreatitis are not seen consistently enough to warrant use of this test for this purpose. 29, 47, 71 the biggest recent advance in feline pancreatic diagnostics has been the characterization of feline pancreatic lipase, 69 leading to the development of a radioimmunoassay for the measurement of feline pancreatic lipase immunoreactivity (fpli). 70 it must be remembered, however, that an increase in fpli only tells the clinician that pancreatic pathology is present, but not the cause of pathology, which may be, for example, neutrophilic or lymphocytic pancreatitis or neoplasia, and it may or may not involve the intestines or liver. fpli should therefore be used as a screening test, with elevated results not suggesting a diagnostic end point. further, the high interassay variability of this test 70 would suggest that mild cases may be missed as shown in one study 24 and that the test may not be appropriate for serial monitoring. fpli is currently available as "spec fpl" from commercial laboratories and has a sensitivity of 79% and a specificity of 82% when 5.4 µg/l is used as the diagnostic cut off 25 compared with 3.5 µg/l, which is the listed reference range high point. in an acutely unwell cat (less than 2 days) with only mild to moderate signs of disease, further diagnostics may not be warranted, and many cats will improve with supportive therapy of balancing fluid and electrolytes, pain relief, and antinausea/vomiting therapy. cats with chronic duration of signs and acutely unwell cats that do not improve with supportive therapy warrant further diagnostics. the underlying disease process cannot be assumed from an elevated fpli; in one study of 63 cases, acute necrotizing pancreatitis could not be distinguished from chronic nonsuppurative pancreatitis by signalment, duration of signs, or clinical findings. 22 the major utility of diagnostic imaging is to rule out other differential diagnoses, such as an intestinal foreign body, and perhaps confirm that the pancreas is affected. radiography is non-specific for diagnosis of pancreatitis, but findings may include decreased abdominal detail (sometimes associated with ascites), soft tissue density in the right cranial quadrant of the abdomen, hepatomegaly, or gas-filled intestines 22,60,64 (see . additionally, thoracic radiographs may show pleural effusion. one study found 5 of 20 cats with pancreatic necrosis had such a change 60 ; the mechanisms resulting in pleural effusion are not precisely defined. ultrasonography has high specificity (>85%) but low sensitivity (<35%) for recognizing pancreatitis in cats, 22, 29, 60, 71 with findings dependent on operator skills, quality of equipment, and severity of lesions. typical findings are hypoechogenicity of the pancreas, which may be enlarged or irregular; hyperechogenicity of the peripancreatic fat; the possible presence of abdominal effusion; and abnormal findings with other organs, such as liver or intestine, may add to the clinical picture 22, 60, 64, . one study indicated that contrast-enhanced doppler ultrasonography can provide further diagnostic insights. 54 a recent study suggested that endosonography may be useful in cases where transabdominal ultrasonography is difficult, for example, because of obesity, hyperechoic mesentery, or excessive intestinal gas. 61 for more than 20 years, computed tomography (ct) has been a commonly used modality to confirm pancreatitis in humans, 55 but this reliability has not been demonstrated in cats, where sensitivity may be as low as 20%. 24, 29 definitive diagnosis of pancreatitis, including differentiation of the inflammatory process, can only be made by cytologic assessment of pancreatic tissue. in most cases, ultrasound-guided fine-needle aspiration (fna) of the pancreas is technically difficult because of the small dimension of the feline pancreas; there appears to be no assessment of feline pancreatic fna findings in the literature. gross inspection of the pancreas and samples for histologic assessment can be obtained during laparotomy 22, 64 (see or laparoscopy. 16, 79 because pancreatitis often occurs concurrently with pathology of other organs, 22 thorough evaluation of the abdomen by ultrasonography or gross inspection is recommended, as are multiple biopsies of, for example, intestines, liver, and mesenteric lymph nodes, where appropriate. clinicians may be reluctant to biopsy the pancreas because of perceived risks of deleterious effects. studies of pancreatic biopsy in healthy cats dispel the concern that the pancreas is unforgiving to mild manipulation and biopsy 16,42a and the author's clinical experience is consistent with these findings. supportive care comprising correction of fluid/ electrolyte imbalances, pain management, and nutritional support are the mainstay of therapy for cats with figure 23-49 gross appearance of pancreas at laparotomy; this was histologically diagnosed as chronic pancreatitis (i.e., lymphocytic infiltration was recognized). gross appearance of pancreas at laparotomy; this pancreas was found to be histologically normal. it does look smaller than is typically seen; pancreatic atrophy can look similar to this, grossly. pancreatitis. 78, 86, 89 specific underlying causes, when diagnosed, should be managed, as should concurrent diseases. follow-up evaluation is determined on a case-by-case basis; reduction or resolution of clinical signs is the main criterion for success of therapy. serial fpli values may be monitored when initial results are extremely high but are of limited value for mild increases because of assay variability. dehydration, acid-base and electrolyte abnormalities should be corrected during the first 12 to 24 hours. hypocalcemia, if present, should be treated with a calcium gluconate infusion of 50 to 150 mg/kg during 12 to 24 hours, with continued assessment of plasma calcium concentrations. plasma transfusions can be considered in cats with hypoalbuminemia. 78, 86, 90 although abdominal pain is not commonly described in cats with pancreatitis, it is likely to be present in most cases and may contribute to anorexia. historical concern about exacerbation of pancreatitis with opioids is no longer accepted, and this class of drugs is considered appropriate. meperidine (1 to 2 mg/kg sc or im) every 1 to 2 hours, butorphanol (0.2 to 0.4 mg/kg sc) every 6 hours, or sustained-release buprenorphine (120 µg/kg sc) every 72 hours are alternatives. 67, 78, 86 the author uses one dose of methadone (0.1 to 0.2 mg/kg sc, im, or iv) initially and places a fentanyl patch for longer-term pain management. the traditional recommendation for management of pancreatitis across all species has been nil per os for several days. this recommendation is appropriate for cats with severe vomiting, but there is no evidence to support this approach in cats that are not vomiting and that are eating normally. further, nutritional support is vital for those cats with concurrent hepatic lipidosis. if the cat is not eating voluntarily, nutritional support by tube feeding is often warranted. 67,78,86 a recent paper found nasogastric tube feeding of cats with pancreatitis was tolerated well and resulted in few clinically significant complications. 42 other reported nutritional strategies for cats with pancreatitis incorporate partial parenteral nutrition (ppn; 8.5% amino acids, 20% lipids), or total parenteral nutrition (tpn; 6% amino acids, 20% lipids, 50% dextrose), or both instead of enteral feeding. 14,39,53 cats do not seem to benefit from feeding of specially formulated low-fat diets; commercially available, veterinary liquefied diets appear to be well tolerated despite their high-fat contents. 86 other therapy may be appropriate in individual cases. all cats with pancreatitis that are vomiting should be treated with antiemetics. examples of drugs that can be used are 5-ht 3 antagonists, such as dolasetron (0.5 to 1.0 mg/kg iv or po, once to twice daily); ondansetron (0.1 to 0.2 mg/kg iv every 6 to 12 hours); and maropitant, an nk 1 -inhibitor (0.5 to 1.0 mg/kg sc once daily). these drugs are covered in detail earlier in this chapter under therapeutics for vomiting and diarrhea. dopaminergic antagonists, such as metoclopramide, are less effective antiemetic agents in cats than the other choices mentioned. 78, 89 in most cases, pancreatitis begins as a sterile process, and antibiotic therapy is controversial. pancreatic necrosis and inflammation may predispose to bacterial colonization of the pancreas as demonstrated in experimental models. 82, 84 this has not been demonstrated in spontaneous disease, and no comparison of outcomes has been made of cats with pancreatitis treated with or without antibiotics. cefotaxime (20 to 80 mg/kg iv, im) has been used to prevent bacterial colonization in experimental models. 83 other broad-spectrum cephalosporins or ampicillin may act similarly. antibiotic considerations are possibly more important for acute pancreatitis than for treatment of chronic disease. cats with demonstrated lymphocytic pancreatitis, with or without concurrent ibd or lymphocytic cholangitis, should be treated with corticosteroids (e.g., prednisolone, 1 to 2 mg/kg once to twice daily) with tapering to the lowest effective dose. there is no justification for use of corticosteroids in cats with acute necrotizing or acute suppurative pancreatitis, or cats for which the cause of pancreatitis has not been diagnosed histologically. use of corticosteroids in cats with pancreatic disease creates a risk of iatrogenic diabetes mellitus. surgical intervention is warranted to relieve any bile duct obstruction that may result or for the débridement of pancreatic abscesses or necrotic tissue; in many cases, cats will survive multiple years after such corrective surgery. 65 pancreatic cysts, pseudocysts, and bladders have been described sporadically in cats.* pancreatic cysts are lined by a single layer of cuboidal epithelium and do not communicate with the pancreatic duct; pseudocysts are enclosed by a wall of fibrous tissue, lacking the epithelial lining characteristic of true cysts and can form secondary to pancreatic inflammation; cystic dilations of the pancreatic duct are referred to as pancreatic bladder. true pancreatic cysts have been described in three cats 9,10,15 ; a congenital pancreatic cyst with associated inflammation was described as an incidental finding in an adult cat 15 ; multiple pancreatic cysts were described in a cat with concurrent polycystic disease in the kidney and liver 9 ; and a another cat had multiple recurrent pancreatic cysts with concurrent mild pancreatic inflammation and atrophy associated a with rapid clinical course resulting in diabetes mellitus. 10 cysts, pseudocysts, and bladders may be identified ultrasonographically or by ct. they may be benign, but the associated pancreatic inflammation and other sequelae, such as diabetes mellitus, may need to be managed. pancreatic bladders may result in biliary obstruction, and surgical correction may be required. pancreatic nodular hyperplasia is recognized quite frequently as an incidental finding in older cats or at necropsy. 45 neoplasia of the exocrine pancreas is rare in cats. its frequency was assessed in the 1970s when one study estimated 12.6 cases per 100,000 patients per year at risk, 52 and another found pancreatic tumors in 5 of 800 feline necropsies. 45 a more recent study recognized, from 15,764 feline admissions over a 20-year study period, only two cats with pancreatic adenomas (0.013% of admissions) and eight with pancreatic adenocarcinomas (0.05% of admissions). 62 adenomas appear as small, solitary or multifocal nodules and are not typically associated with adjacent pancreatic inflammation. they do not cause clinical signs, unless large, when any clinical signs result from the physical size and are usually an incidental finding. 45, 86 few generalities can be made about the presentation for pancreatic adenocarcinoma. the age range is large (4 to 20 years), there is no sex predisposition, and no clear breed predispositions are present. 62, 86 only cytology or histopathology can distinguish pancreatitis from pancreatic carcinoma in cats antemortem, yet it is important to differentiate the two conditions, because, in contrast to adenomas, pancreatic adenocarcinoma is associated with a grave prognosis. the presence of lesions consistent with metastases on radiography or ultrasonography may suggest malignancy, but one study could not distinguish neoplasia from pancreatic nodular hyperplasia ultrasonographically based on the appearance of the pancreas alone 32 (figures 23-53 and 23-54) . pancreatic adenocarcinomas in cats can result in a paraneoplastic dermatologic condition consisting of nonpruritic, symmetric alopecia affecting the face, ventral body, and medial aspect of the limbs of cats. the skin is usually glistening but not fragile, and there can be crusty lesions on the footpads.* the pathogenesis of this dermatologic disease is unknown. in one case, surgical excision of the pancreatic carcinoma resulted in resolution of dermatologic disease, indicating that the process is reversible (although signs recurred as the tumor re-emerged). 73 diabetes mellitus is a recognized complication of pancreatic adenocarcinoma. the mechanism is unknown and may simply be secondary to compression or invasion of islet cells by the tumor. in some cats, diabetes is recognized ahead of pancreatic neoplasia. 31, 40, 62 obstructive jaundice has also been described with pancreatic adenocarcinoma. 13 most cases of pancreatic adenocarcinoma in cats have metastasized by the time of diagnosis, and most reported cases die or are euthanized within 7 days of diagnosis. 62 surgical excision is a potential option if neoplasia is confined to one limb of the pancreas, but recurrence is possible even if there is no evidence of metastasis and excision seems complete at the time of surgery. 73 exocrine pancreatic insufficiency (epi) is a condition caused by insufficient synthesis and secretion of pancreatic digestive enzymes from the exocrine portion of the pancreas. 66 in humans it has been reported that 90% of pancreatic acinar cells must be lost before clinical signs of epi are seen. 19 epi is considered rare in cats but is perhaps being recognized more frequently because of increased awareness. there are less than fifty cases described in the veterinary literature* with one of these papers describing only 16 cases from five institutions, with prevalence described as 0.01% to 0.1% of cats seen over a 15-year period. 74 in contrast to this, the gastrointestinal laboratory at texas a&m university recognized 1342 samples with serum ftli concentrations at or less than 8.0 µg/l, which is diagnostic for epi, out of 84,523 submissions, 66 which equates to 1.6% of cats with known or suspected gastrointestinal disease. all studies indicate a wide age range of cats can be affected, from kittens less than 6 months of age to cats more than 15 years old, with a median age of approximately 7 years. there is no apparent breed predisposition. 66, 68, 74 one paper recognized 10 of 16 (62.5%) cats to be male, 74 and another recognized 15 of 20 (75%) male cats, 68 suggesting a possible sex predisposition. chronic pancreatitis is believed to be the most common cause of epi in cats, 66 acinar atrophy (paa) is recognized as the most common cause of epi in dogs, and has been definitively described in two feline cases 74 and mentioned as a cause for three other cases. 85 other potential causes of epi include disruption of pancreatic enzyme flow at the duodenal papilla following duodenal resection 72 and pancreatic fluke infection (eurytrema procyonis), 2,26 and amyloid deposition and neoplasia are other possible causes of pancreatic cell damage that have not definitively been described in cats. 66 congenital pancreatic hypoplasia or aplasia has not definitively been reported in cats, but reports of epi in cats as young as 3 months of age 63, 74 suggest this possibility. since chronic pancreatitis is a common cause of epi and chronic pancreatitis has a strong association with ibd, many cats may have concurrent lymphocytic pancreatitis and enteritis. 66, 74, 85 therefore cats failing to respond to therapy for epi may require further diagnostics and management of an underlying condition. further, destruction of functional exocrine pancreatic tissue can also affect pancreatic endocrine tissue, resulting in concurrent diabetes mellitus. 35 several studies have indicated that all cats with epi will have weight loss when diagnosed, unless a kitten, in which case ill-thrift is recognized. 68, 74 diarrhea is not necessarily present, being described in 50% to 75% of cats; the nature of feces can vary from voluminous, malodorous stools that can be discolored (yellow or pale), sometimes with steatorrhea, to normal feces in other cats. increased frequency of defecation and the presence of mucus in the feces of some cats can lead to the diarrhea being characterized as large bowel. only about 20% to 30% of cats are polyphagic, some described as having a ravenous appetite; conversely, some cats present with anorexia. vomiting has also been described. since cats with epi often have concurrent disorders, such as ibd, the clinical signs recognized may reflect the concurrent disease and not necessarily epi alone. physical examination findings are similarly nonspecific, with thin/ emaciated body condition being the most common finding. hematologic findings are non-specific, but a mild nonregenerative, normocytic, normochromic anemia may be recognized as well as lymphopenia or neutrophilia. plasma biochemistry results may show a mild to moderate increase in alanine aminotransferase (alt) and a mild increase in alkaline phosphatase in some cats. mild to moderate hyperglycemia may be seen, as may mild hypoglycemia or normoglycemia. 66, 68, 74 hypocobalaminemia is recognized in nearly all cats with epi. 66, 68, 74, 85, 87 this may be because of insufficient production of intrinsic factor, a cobalamin-binding protein only produced by the pancreas in cats and necessary for ileal absorption of cobalamin 27 ; it may also be because of failure of pancreatic enzymes to liberate cobalamin from binding by r protein in the duodenum or small intestinal bacterial overgrowth (sibo), not yet specifically described in cats. 74 folate concentrations may be reduced (because of concurrent intestinal malab sorption), 68 normal, 68, 74 or increased, 74 which may relate to reduced pancreatic bicarbonate secretion, secondary to severe hypocobalaminemia, 59 or associated with sibo. 7 none of these presenting complaints, physical examination findings, or routine testing results are specific to epi. therefore epi requires a degree of clinical suspicion and/or thorough diagnostics to ensure the diagnosis is not missed. a low level of serum ftli is diagnostic for epi. 66, 68, 74 samples can be sent to the gastrointestinal laboratory at texas a&m university from anywhere worldwide (with instructions about sample handling requirements on their website: http://vetmed.tamu.edu/gilab/). the reference range for serum ftli is 12 to 82 µg/l, with concentrations at or less than 8.0 µg/l diagnostic for epi. since the clinical signs and routine laboratory findings are nonspecific for epi, it is ideal to test serum for ftli in any cat with weight loss or ill-thrift. the texas a & m gastrointestinal panel also includes testing for levels of cobalamin, folate, and fpli, ensuring concurrent hypocobalaminemia will not be missed and potentially providing indications of other gastrointestinal disease. conversely, although a low level of serum ftli confirms a diagnosis of epi, it is not necessarily a diagnostic end point, since epi is so often recognized concurrently with other gastrointestinal disease. failure to respond to therapy should prompt the clinician to consider and investigate further for concurrent processes. most cats with epi can be successfully managed with dietary supplementation of pancreatic enzymes. commercial products (e.g., viokase [axcan pharma, birmingham, ala.], pancrezyme [virbac, fort worth, tex.], and creon [abbott laboratories, abbott park, ill.]) are available, and powder is considered more effective than tablets or capsules (some capsules can be opened and the contents sprinkled onto food, like powder). the required dose can vary quite substantially from cat to cat. it is appropriate to start with one teaspoon of powder with food twice daily, and adjustments can be made depending on the response; most cats accept the powder readily if it is mixed thoroughly through canned food, but other flavors (e.g., fish oil or brine from canned tuna) can be used to disguise the taste if necessary. raw pancreas (e.g., from beef or pork) may also be used, with 30 to 60 g twice daily an appropriate starting dose. 66 since most cats with epi are hypocobalaminemic, supplementation by subcutaneous injection is required (oral supplementation is not effective since cobalamin deficiency leads to cobalamin malabsorption). an appropriate dose for most cats is 250 µg, and it is usually given weekly for 6 weeks, then every second week for a further six doses; it is appropriate to continue dosing every month beyond that. owners can be taught to inject their cats at home (as owners of diabetic animals are taught to do with insulin). 66 because some cats may have sibo, antibiotics such as metronidazole (15 to 25 mg/kg po every 12 hours for 14 days) may be warranted. an elevation of folate may arouse suspicion of sibo, but it is appropriate to try antibiotics in a cat failing to respond to enzyme and cobalamin supplementation. concurrent diseases, such as lymphocytic, chronic pancreatitis, or ibd may need to be managed with corticosteroids, or diabetes mellitus with insulin. no studies have assessed specific dietary requirements in cats with epi. most cats respond to appropriate treatment, with a return to normal weight and normal feces. with ongoing therapy, cats can lead normal lives for a full life span. 83 the feline liver is a large, complex organ involved in a variety of essential metabolic, functional, and detoxification processes that can be affected, individually or collectively, by disease or dysfunction. cats have a unique set of liver diseases that occur more commonly in this species compared with the typical diseases that occur in dogs, and these include hepatic lipidosis, feline cholangitis syndrome, and infectious hepatopathies (e.g., fip, flukes, histoplasmosis, toxoplasmosis). 2, 15, 34, 58, 61 nevertheless, these conditions often present with characteristic clinical, laboratory, and histopathologic changes that are necessary for proper diagnosis and management. the goal of this section is to review the interpretation of clinical and laboratory changes that occur in these feline liver diseases, provide an approach for separating the more common diseases by their clinical footprint, and then discuss therapy of each liver disease based on our current level of understanding of hepatoprotectants, antioxidants, and drugs used for specific therapeutic purposes. the clinical signs of liver disease in cats are often vague and nonspecific; however, recognition of certain clinical and laboratory abnormalities and their association with liver disease can greatly aid the diagnostic process. the most common early clinical signs observed in cats with liver disease are anorexia, lethargy, and weight loss, which are signs present in many (if not most!) feline diseases. 2, 15 because these early indicators of disease do not point specifically toward liver disease, a delay in diagnosis will occur unless the clinician carefully considers all possibilities and performs other tests to further evaluate the situation. for example, feline hepatic lipidosis is the most common form of liver disease in cats in the united states, united kingdom, japan, and western europe, occurring with a prevalence of nearly 16% in one study. 2 however, the most common, and often only, clinical sign associated with onset of this condition is anorexia; the signs of serious hepatic disease (especially jaundice and vomiting) do not occur until later (days or weeks) in the course of the disease. 2, 21 recognition that anorexia in a cat, even for a few days, is a risk factor for development of hepatic lipidosis is essential, and this risk is increased in obese cats. 11, 21 further, the clinical signs of liver failure develop much more slowly; many cats with hepatic lipidosis present alert and responsive until much later in the course of the disease, thus delaying onset of appropriate therapy. a similar clinical situation exists for the second most common form of liver disease in cats, feline cholangitis syndrome. 15, 28, 58 this complex of diseases in the cat can be associated with signs ranging from anorexia and lethargy to vomiting and jaundice, and these signs can vary in severity and prevalence. the key point is that except for development of jaundice, there is no constellation of clinical signs that are classic clinical indicators of liver disease in cats. 15, 28 as with many feline diseases, the subtle clinical signs of anorexia, lethargy, or inactivity are often the only signs of illness and should be further investigated. there are few changes that occur in the complete blood count that are specific indicators of primary liver disease in cats. the most common finding is the presence of poikilocytes, which are red blood cells with an irregular shape, speculated to be caused by changes in membrane lipids as a result of liver dysfunction. 14 other abnormalities may occur, such as anemia of chronic disease or neutrophilia, but these findings are nonspecific and occur with variable frequency. perhaps the most important reason for obtaining a hemogram is in icteric cats, because this test is essential to help rule out hemolysis as the cause of the hyperbilirubinemia. the serum chemistry profile can be very helpful, but there are several critical points in interpretation of these values that are important to review. the hepatic transaminases (alanine aminotransferase [alt] and aspartate aminotransferase [ast]) are leakage enzymes but do not discriminate among hepatobiliary disorders, nor do they provide an indicator of severity or disease origin. thus although increases in alt may be noted in cats with liver disease, they are also present in a variety of other systemic infectious, inflammatory, neoplastic, and and protein-losing nephropathies can also cause loss of albumin and affect cholesterol, it is essential to evaluate the cat for these problems when interpreting these results. finally, bilirubin metabolism is a critical function of the liver, but interpretation of hyperbilirubinemia requires a careful consideration of bilirubin disposition. hyperbilirubinemia develps because of one of three possible causes: (1) excessive hemolysis of red blood cells (rbc) (also known as prehepatic icterus)-high bilirubin in the blood stream occurs because of an overload of the mononuclear/phagocyte system with heme pigments from rbc destruction, (2) hepatic parenchymal disease or insufficiency (also known as hepatic icterus)-resulting in lack of normal bilirubin metabolism in hepatocytes and regurgitation of the pigments into the blood stream when they are not taken up into cells and excreted in bile, and (3) disease of gall bladder, biliary tract, or pancreatic duct (also known as posthepatic icterus)resulting in obstruction of the bile ducts or loss of bile into the abdomen (duct or gall bladder rupture and bile peritonitis). 41 the bottom line is that in any cat with hyperbilirubinemia, an assessment of the packed cell volume and rbc morphology should be completed to determine whether icterus is caused by hemolysis. once hemolysis is ruled out, then assessment of primary endocrine diseases, including hyperthyroidism, feline heartworm disease, fip, and neoplasia.* alternatively, the cholestatic membrane-associated enzymes alkaline phosphatase (alp) and gamma glutamyltransferase (ggt) are especially useful for recognizing disorders involving biliary or pancreatic ductal components. unlike the dog, these enzymes will only increase modestly in cats, even in severe disease, and there is no glucocorticosteroid or drug induction of the enzymes to influence interpretation. 14, 37 thus increases in alp in the adult cat represent a release of enzyme from the hepatobiliary tree and should be considered clinically important. both alp and ggt are produced in other tissues than the liver, with the highest ggt activity present in the kidney and pancreas; however, sources other than the liver do not contribute to the activity of these enzymes in health. recent studies of the effects on these enzymes in cats with pancreatitis, cholangitis, extrahepatic bile duct obstruction (ehbdo), and hepatic lipidosis reveal some important characteristics in interpreting increases in these enzymes. 14 first, both alp and ggt are increased in cats with pancreatitis, cholangitis, or ehbdo, because inflammation in the biliary tree also affects the pancreatic ducts (and vice versa, figure 23-55) , and if the fold increases in these enzymes are similar, the diagnosis is likely one of the three. 15 conversely, in cats with hepatic lipidosis (without concurrent inflammatory disease of the biliary or pancreatic duct system), large increases in alp are observed, but ggt will remain normal or only slightly increased. thus if the increase in alp is 5 to 10 times, while ggt is not increased or is only increased 1 to 2 times, then the likely diagnosis is hepatic lipidosis. [14] [15] [16] other than enzymes on the biochemistry panel, which are of limited value for assessing liver function, there are several key tests that can be used to help assess liver function cats with elevated liver enzymes. these five tests found on most routine biochemistry panels are helpful functional indicators: cholesterol, bilirubin, glucose, albumin, and urea nitrogen (bun). however, none are immune to outside influences on their interpretation, including bilirubin and cholesterol, which are the most liver specific. in cats with severe liver disease or failure, bilirubin levels tend to be quite elevated, while bun, albumin, cholesterol, and glucose concentrations tend to be significantly decreased, reflecting inability to metabolize urea (lack of arginine), inability to produce albumin or cholesterol, and abnormal metabolization of glucose. however, these changes represent severe loss of liver function and thus are not sensitive indicators of liver function because the changes occur quite late in the course of the disease. nevertheless, in cats with elevated liver enzymes and clinical signs of liver disease, these values should be carefully assessed. because gi disease of hepatic failure. in nonicteric cats with severe liver disease or in young cats suspected of having a portosystemic shunt, serum bile acids are the more reliable indicator of hepatic insufficiency. 18 the measurement of serum bile acid concentrations, preprandially and postprandially, is the most reliable, readily available, and sensitive test of hepatic function in nonicteric cats. 5, 14 that being said, although increases in bile acids are accurate indicators of hepatic insufficiency, the levels cannot be used to assess severity of disease or the type of dysfunction. further, bile acid assays are most effective when paired samples (preprandial-and postprandial) are compared, because single, fasting, or random bile acid samples can result in a falsenegative (normal) result. however, cats will often not eat in the hospital or when they are sick, and this prevents collection of a postprandial sample. however, this does not invalidate the results, because if the result of the single bile acid sample is abnormal, it does reliably indicate liver dysfunction. an alternative to using serum for testing bile acids in cats is urine bile acid analysis. healthy cats excrete a small percentage of conjugated bile acids in the urine 14 ; however, in cats with liver disorders that cause increased serum bile acids (and especially cholestatic liver diseases) a significant increase in urine bile acid excretion occurs. when urine bile acids (uba) were collected 4 to 8 hours after a meal and measured (normalizing the value with urine creatinine: uba/ucr) and compared with serum bile acids in a study of 54 cats with hepatic disease, 17 cats with nonhepatic disease, and 8 normal cats, the results were highly correlated. 47 the utility of the urine bile acid test is that it does not require a paired sample (postprandial test), and it is not as affected as the serum test is by hemolysis or lipemia of the blood sample. normal cats will have an uba/ucr of less than 4.4 µmol/mg, while values greater than 4.4 are considered evidence of significant hepatic dysfunction. 47 it is well known that the liver plays a central role in coagulation homeostasis and is the single site of synthesis of many coagulation proteins, anticoagulant proteins, and fibrinolytic factors. vitamin k is one of the most common factors found to be inactive or deficient in cats with liver dysfunction, and it is essential for normal functioning of factors ii, vii, ix, and x; protein c and s; and thrombin. insufficient or inactive vitamin k can occur for a variety of reasons, including dietary restriction (e.g., anorexia or diet deficiency), disruption of the enteric microflora that synthesize vitamin k (e.g., chronic antibiotic therapy), diseases causing fat malabsorption (e.g., ibd, exocrine pancreatic insufficiency), ingestion of vitamin k antagonists, or liver dysfunction. 20 for example, in cats with hepatic lipidosis, approximately 25% will have an increased prothrombin time (pt), 35% will have an increased partial thromboplastin time (ptt), but 60% of cats will have increased pivka parenchymal disease versus disease of the biliary tree is completed by evaluating the clinical presentation, laboratory values, and imaging of the biliary tree and abdomen for possible evidence of biliary or pancreatic disease. a urinalysis is also an important part of the minimum database, and it is no different in a sick cat with suspected liver disease. in cats the presence of hyperbilirubinuria is abnormal at any urine concentration, because they do not conjugate bilirubin in their renal tubules. 14 however, like bilirubinemia, presence of bilirubin in the urine can occur because of any of the three possible causes of hyperbilirubinemia: prehepatic, hepatic, and posthepatic; thus further evaluation is necessary once bilirubin is detected. ammonium biurate crystalluria suggests the presence of hyperammonemia, which in the cat is either because of a congenital portosystemic shunt (less common in cats than in dogs) or because of severe, end-stage liver disease resulting in portal hypertension, which is typically caused by cirrhosis or advanced polycystic liver disease. 6, 41 the most common feline liver diseases are hepatic lipidosis and feline cholangitis syndrome, which are two diseases that often result in development of clinical or biochemical icterus. thus because hyperbilirubinemia is a more sensitive indicator of liver function than bile acids or other liver function tests, the need for further testing is moot. however, there will be circumstances when further assessment of liver function is indicated, and for this, serum bile acids, blood ammonia levels, and urine bile acids may be needed. there are several situations where liver function testing may be indicated, but the most common indications for additional testing would be a cat with persistently elevated liver enzymes of unknown origin, a cat that develops urethral obstruction because of urate stones (suggestive of portosystemic shunting) or a cat with possible polycystic liver disease. 5 one of the oldest tests of liver function, because of its association with development of hepatoencephalopathy, is measurement of blood ammonia levels. 38 however, although this test is the only practical way to diagnose hepatoencephalopathy in dogs, the test has a number of limitations, including differences in ammonia levels between arterial and venous (lower) samples and significant sample handling issues (ammonia is labile and results are affected by improper sample handling or lack of immediate measurement) that make its use difficult in practice. 43 in cats hyperammonemia is even less common than in dogs likely because of their highfunctioning urea cycle pathways 14 ; the assays have not been validated for feline blood in most laboratories, and as such, the test is not recommended as the sole indicator uncommon in cats, the most common causes are neoplasia (primarily of the pancreas, but cholangiocarcinomas can occur) or chronic pancreatitis, which can occur concurrently with cholangitis in cats, resulting in both intrahepatic and extrahepatic cholestasis in some cats. 23, 41 the bile ducts are affected in cats with chronic pancreatitis, because the feline biliary system and pancreatic duct system merge at the level of the pancreas to form a single duct that empties into the duodenum. thus in cats with either pancreatitis or biliary disease, recent evidence has shown that the inflammation affects both organs. 54, 59 further, in chronic pancreatitis, either persistent inflammation or development of fibrosis can result in dilation or obstruction of the common bile duct. 33 in cats with chronic ehbdo, the common bile duct will become widely dilated and tortuous, a finding easily seen on abdominal ultrasonography but a problem not easily managed (figures 23-56 and 23-57) . interestingly, the gallbladder is often not enlarged, and may in fact be small in cats with this condition, because the remaining fluid in the gallbladder is white bile (highly concentrated mucinous bile from which the pigment has been resorbed). 41 in addition, variable filling of the gall bladder is a normal phenomenon; thus gallbladder size is not an indicator of ehbdo. (proteins induced by vitamin k antagonists or absence). 20 nevertheless, although pivka is a very sensitive test for abnormalities of vitamin k function, most cats with liver disease that have a normal pt/ptt, but abnormal pivka do not represent clinical evidence of bleeding. in any case, abnormalities in the clotting cascade related to vitamin k deficiency in cats with liver disease are common, whether or not they show evidence of active bleeding. and because the balance of the coagulation system in a cat with liver disease can be disrupted by a procedure that initiates small amounts of bleeding (e.g., a biopsy), all cats with liver disease should be given vitamin k as a precautionary measure before and after invasive procedures, even if the clotting times (pt and ptt) are normal. this may be especially important in cats with hepatic lipidosis, because their vitamin k clotting status is likely to be even more affected by the concurrent anorexia and disruption of enteric microflora. 14 the dose of vitamin k 1 (phytonadione, aquame-phyton [merck, west point, pa.]) used prophylactically is 2.5 mg sc, im, or po q12h for 3 to 5 days, then weekly until recovered. see box 23-4 for a summary of the causes of icterus. cholestasis is the reduction of bile flow, which can occur at any point along the biliary tree; bile production occurs in hepatocytes, and flow is connected to the distal concentrating components (gallbladder and common bile duct) by the bile ductules. thus cholestasis can occur inside the liver's biliary tree (intrahepatic cholestasis) or outside the liver in the gallbladder and common bile duct (extrahepatic cholestasis). intrahepatic cholestasis most often occurs in diseases involving hepatocellular damage, leakage, or swelling, such as infections (e.g., bacterial cholangiohepatitis, toxoplasmosis, fip, or other diseases causing inflammation), infiltrative diseases (e.g., lymphoma), metabolic diseases (e.g., hepatic lipidosis), or diseases causing disruption of architecture (e.g., cirrhosis or severe polycystic disease). 41 intrahepatic cholestasis occurs in zone 1 of the liver lobules (periportal zone); at the level of hepatocytes, canaliculi or bile ductules; and is damaging to cells because of the emulsifying properties of lipid on membrane lipids. however, because the liver has a large reserve capacity, clinical icterus (e.g., jaundice) only occurs in the most severe cases when the liver is affected diffusely. thus severe or persistent intrahepatic cholestasis can serve to perpetuate the inflammation and cell damage if it is not corrected. extrahepatic cholestasis or extrahepatic bile duct obstruction (ehbdo) is less common than intrahepatic cholestasis and is most commonly associated with obstruction of the common bile duct. since gallstones are icterus is the result of cholestasis, and the underlying cause can be either hemolysis or hepatobiliary disease, for which further clinical examination will be needed to determine if rbc destruction or liver disease is occurring. in most hepatobiliary diseases of cats, cholestasis is occurring, but there may be no clinically apparent icterus because the degree of hyperbilirubinemia must be at least 2 to 3 times greater than the normal values to exceed the capacity of the liver to process the excess bilirubin. in cats with hyperbilirubinemia not caused by hemolysis, whether it is clinical or subclinical, there is no need for further evaluation of liver function (e.g., bile acid assays), because bilirubin is a more sensitive indicator of liver function than bile acids. the degree of hyperbilirubinemia does not suggest differentiation of intrahepatic versus extrahepatic cholestasis; however, the presence of acholic feces (white feces) is diagnostic for extrahepatic bile duct obstruction (ehbdo), because lack of stercobilinogen (the brown/black pigment in feces) is only found in cats with complete obstruction of the bile duct. finally, the presence of intrahepatic cholestasis and clinical icterus in a cat indicates a diffuse hepatobiliary disease, such as cholangitis or hepatic lipidosis, as focal liver disease, even if severe, will not cause clinical hyperbilirubinemia because of the tremendous reserve capacity of the liver for bilirubin uptake. portal hypertension is an abnormally high venous pressure in the portal system and is typically caused by increased resistance to portal blood flow. there are potentially three regional causes of portal hypertension: prehepatic (disease in the portal vein itself), hepatic (intrahepatic diseases causing compression or decreased flow), and posthepatic (diseases of the caudal vena cava, right heart or pulmonary vasculature). the most common cause of portal hypertension in the cat is cirrhosis or portal venous thrombosis, because portal vein hypoplasia (formerly known as microvascular dysplasia) is known to occur only in the dog, and the other causes of portal hypertension (budd-chiari syndrome, heartworm caval syndrome, pulmonary hypertension) are rare and more likely to occur in the dog. 41, 44 in any case, the clinically recognizable effects of portal hypertension are development of ascites (unusual in the cat), acquired portosystemic shunting (reported in cats), and development of hepatic encephalopathy (less common in cats than in dogs, because of their profound ability to handle protein wastes). 5, 36, 41 most cats and dogs that develop hepatic encephalopathy (he) secondarily to portal hypertension do so because of reduced liver function (because of portosystemic vascular shunting [pss] or cirrhosis and the acquired shunting that develops). cats can develop another form of chronic he because of hepatic lipidosis, but this is believed to be because of the combination of liver failure and prolonged fasting, resulting in arginine deficiency and impaired ammonia detoxification. 2 portosystemic vascular anomalies, also called portosystemic shunts or portovenous shunts (pss), although less common than in dogs, also occur in cats. these vascular anomalies can be either congenital or acquired, single or multiple in number, and occur as extrahepatic vascular shunts or within the liver itself (intrahepatic shunts). 5 the shunting of blood around the liver is the cause of hepatic atrophy and reduced hepatic function that results in an accumulation of toxins, particularly ammonia that leads to the development of hepatoencephalopathy. the two most common veins that serve as the connection point for the shunting portal venous blood are the caudal vena cava and the azygous. 5 in cats a single, extrahepatic, portocaval shunt is the most commonly reported form, and occurs in 75% of cats with pss. 5 as in dogs, specific breeds of cats may have pss more commonly, and these include domestic shorthair cats, burmese, siamese, persian, and himalayan breeds. 5 in contrast to dogs, males may be more predisposed to pss than females, but the clinical signs relate to the three body systems most affected: the central nervous system, gi tract, and urinary tract. the most common presenting complaints in cats are weight loss or poor/stunted growth, and dull, bizarre or lethargic behavior, especially after eating. signs of gi disease common in dogs, such as vomiting, diarrhea, or inappetence, are less common in cats, but in one report, 75% of cats with pss drooled. 5 finally, cats with pss often present with signs of lower urinary tract disease (e.g., hematuria, stranguria, or even obstruction) because of the development of urate uroliths (which are radiolucent, thus difficult to detect). 5 because the most common signs of he are apathy, listlessness, and decreased mental alertness, they are often not recognized specifically as indicative of brain dysfunction but as part of the constellation of signs of the liver disease. however, with progression of the has not been reported. the clinical presentation is typically nonspecific (the most common signs are vomiting, lethargy, and anorexia), and there are no laboratory changes that are suggestive of hepatic neoplasia. thus the diagnosis must be made by identification of disease, other signs will develop, including ataxia, salivation, stupor, or coma. the best and only practical diagnostic test for he is plasma measurement of ammonia levels. 43 however, as previously noted, the test has many technical issues that make its clinical utility in the practice setting difficult at best, and there are few laboratories that have validated ammonia measurement in the cat. cancer of the liver can occur as a primary disease (table 2322) or as a result of metastasis of neoplastic disease occurring elsewhere and, most typically, the abdominal cavity. the most common neoplastic infiltration of the liver that is not a primary liver tumor is lymphoma (figures 23-58 and 23-59), followed by visceral mastocytosis. 4 as with many other types of cancer, hepatobiliary neoplasia is most common in middle-aged to older cats, and it is relatively rare, with a reported incidence of 1.5% to 2.3%. 4 benign tumors, such as biliary cystadenoma ( figure 23-60) , carry a good prognosis if they are amenable to surgical resection. the incidence of metastatic neoplasia (including lymphoma and mast cell tumors) the most common clinical signs are related to spontaneous rupture of the enlarged and friable liver. affected cats may present with lethargy, anorexia, pale mucous membranes, and a heart murmur secondary to anemia. clinical signs of liver disease are usually absent. hepatomegaly and hypotension may also be found. results of routine laboratory testing (mild to marked increases in alt and globulins while alp and ggt are typically normal) and ultrasonographic examination (hepatomegaly, generalized increase in hepatic parenchymal echogenicity) 4a of the liver may be supportive, but definitive diagnosis relies on histopathologic examination of a liver biopsy. fna of the liver is not helpful because amyloid is rarely detected with this method. hemostasis should be evaluated carefully before any biopsy procedure is planned. the most important differential diagnoses are fip, hepatic lipidosis, and hepatic lymphoma. scintigraphic imaging using i-123 serum amyloid p component has potential as a noninvasive test. 39a there is no specific treatment for amyloidosis in cats, so therapy is primarily supportive care (antioxidants, vitamin k, blood transfusion). attention should be paid to identification and control of any underlying chronic inflammatory disease. unfortunately, the long-term prognosis is poor as most affected cats die of intra-abdominal bleeding. survey abdominal radiography is the simplest and most readily available imaging modality to assess structures in the abdominal cavity. radiographs are most useful to assess liver size, will reveal large hepatic masses, and provide evidence of radiopaque masses or other abnormalities in the abdomen. however, the preferred imaging modality used to assess hepatic structures in cats with suspected liver disease is abdominal ultrasonography (aus). the reasons why ultrasonography is a more useful tool for assessment of the liver in cats are numerous, but because feline liver diseases are primarily diffuse, infiltrative, or metabolic diseases that also affect the biliary tree, ultrasonography is the only imaging tool that will give reliable diagnostic information. this widely available diagnostic tool can be helpful in determining liver size and parenchymal echogenicity, in identifying mass lesions, evaluating the biliary tree and gallbladder, quantifying flow (doppler techniques), and identifying vascular anomalies. 29 as with all diagnostic modalities, the skill and experience of the operator is vital to accurate procurement and interpretation of the images. further, it is important to remember that although ultrasonographic images are extremely useful in the clinical evaluation of a cat with possible liver disease, the images themselves do not represent a histologic diagnosis. structural abnormalities by hepatobiliary imaging and subsequent examination of the tissue either by fna or biopsy techniques. historically, amyloidosis has been recognized as primarily a renal disease, especially in abyssinian cats. more recently, cases of hepatic amyloidosis without renal involvement have been diagnosed in siamese and related breeds, as well as in nonpedigreed cats. 4a,10a,30a the majority of cases have been described in australia, the united kingdom, and europe. amyloid a is deposited in the liver, probably in response to chronic inflammation in another organ. in the siamese breed, a genetic component may contribute. 48a the amyloid a protein occurring in the siamese breed differs from that known in the abyssinian breed. 48a contraindicated in cats, because they may cause a lethal shock reaction. 40 a similar reaction may be seen with penetration of the larger bile ducts or gallbladder with a large-bore biopsy needle, because these tissues have a significant autonomic innervation in the cat that may result in bradycardia and shock following the procedure. 40, 48, 54 it is particularly important to recognize this as a risk in cats with ehdbo or dilated bile ducts, and this risk factor reiterates the need for ultrasound examination of the liver prior to making biopsy decisions. nonetheless, owners should be informed of these potential risks, in addition to the risk of bleeding from biopsy sites in any cat undergoing liver sampling. 7, 48 biopsy techniques liver biopsies, whether they are obtained by needle, laparoscopy, or surgical means, should be taken from a location that represents the primary liver pathology, handled appropriately to ensure accurate interpretation of the sample, and the histopathologic description should be interpreted according to the guidelines set by the wsava standards for clinical and histologic diagnosis of canine and feline liver disease. 42, 61 guidelines for obtaining and handling surgical biopsies of the liver are reviewed elsewhere 27 and will not be further discussed. because needle aspirates/biopsies, tru-cuttype biopsies, and laparoscopic biopsies are commonly used to obtain liver tissue in cats, the benefits and limitations of each of these techniques will be discussed. as a general rule, the more tissue that can be obtained, the better the pathologist's interpretation of the tissue abnormalities will be. for example, most pathologists believe that at least six portal areas are necessary to make a diagnosis of inflammation liver disease in cats. 42 this will require either a 16-or 18-gauge needle size or larger piece of tissue than is obtained with smaller needles or an aspirate. the amount of tissues required to view at least six portal areas is approximately 15 mg, and 5 mg will be required for culture of the tissue. 42 if other analyses of the tissues are considered (e.g., metal analysis), approximately 20 to 40 mg of liver is needed. 42 a typical laparoscopic cup biopsy forceps will provide 45 mg of liver tissue, a 14-g tru-cut-type biopsy needle provides 15 to 20 mg, and an 18-g needle biopsy provides only 3 to 5 mg of liver tissue. 42 thus, depending on the clinical circumstances and considered differentials, the best approach for obtaining the needed tissue must be considered prior to planning the procedure. fine-needle aspiration to obtain liver tissue for cytologic examination is commonly performed in cats with liver disease for good reason. the procedure is inexpensive, easy to do, is relatively low risk, and often requires only sedation to complete. 57 further, samples obtained by this method can be diagnostic for hepatic lipidosis, hepatic lymphoma or other round cell tumors, and in for the most common liver diseases of cats (hepatic lipidosis, feline cholangitis syndrome, and neoplasia/ lymphoma), aus examination provides a useful means of obtaining clinical clues and tissue to support or refute the differentials. for example, in cats with hepatic lipidosis, the liver is quite enlarged and typically diffusely hyperechoic, while in cholangitis or other inflammatory diseases, the liver is more often diffusely hypochoic. 29 however, these sonographic findings are very nonspecific and can easily lead to errors in diagnosis if the tissue is not subsequently sampled for confirmation. 24, 35 thus one of the most important utilities of the aus is the ability to obtain liver tissue (either by aspiration or guided-needle biopsy) and for aspiration of the gallbladder to obtain bile for culture. 24, 49 these techniques alone have made the aus an extremely important diagnostic tool in the evaluation of liver disease in cats. the diagnosis of most liver diseases requires a histopathologic sample of liver tissue, and this is particularly true in the most common feline liver diseases, which tend to be diffuse diseases affecting the entire liver. cats with one of these diffuse diseases can be sampled randomly using any one of these commonly employed techniques: ultrasound-guided fine-needle aspirates (fna), ultrasound-guided needle biopsy, laparoscopic biopsies, or biopsies obtained surgically. some types of neoplasia (particularly round cell tumors) and vacuolar hepatopathies (hepatic lipidosis) can often be diagnosed by cytology using fna techniques. however, differentiation of liver cell tumors (adenomas and carcinomas) and inflammatory diseases of the liver cannot be diagnosed without a larger sample of tissue and histopathologic examination. 30, 50 further, even in cats with classic hepatic lipidosis changes, concurrent diseases such as cholangitis or lymphoma can be missed if only fna techniques are employed. 60 thus it is essential to consider that in many liver diseases the lesions, although typically diffuse, may also have focal components; for example, inflammation may be throughout the liver, but fibrosis will be present only in focal areas. thus the results of fna or tru-cut needle biopsies should always be considered in the light of the clinical, laboratory, and ultrasonographic evidence. prior to scheduling a cat for a biopsy, the risk-tobenefit ratio of performing a liver biopsy should always be considered. this is primarily because heavy sedation or anesthesia will be essential in most cats undergoing a liver fna, and for all cats undergoing a liver biopsy (needle or otherwise). in addition to anesthesia risks, the use of automatic spring-loaded biopsy guns to obtain ultrasound-guided biopsies of liver tissue is equipment, the interested reader is referred to several recent reviews on the subject. 48, 54 to maximize the histopathologic accuracy, biopsies taken at laparoscopy or surgically should be taken from both normal-appearing and abnormal areas in the liver. further, if there is a need to obtain samples from the deeper tissues, the laparoscope can be used to direct a tru-cut needle biopsy to the best location for sampling. one of the major advantages of the laparoscopic technique is that it allows the operator to observe the biopsy sites for excessive bleeding, which is unusual, but if observed can be staunched by using pressure on the site, gelatin coagulation material placement, or electrocautery. with experienced operators, the complication rate for laparoscopy is very low (less than 2%), and most complications were because of anesthesia, bleeding, or air embolism. 48 finally, although not necessary to have direct visualization to obtain an aspirate of gallbladder bile, laparoscopy allows easy sampling of bile for culture, which is important in all cats with suspected inflammatory liver disease or hepatobiliary disease. once a diagnosis of liver disease is made in the cat, specific therapy for the cause (if available) should be instituted; however, for many feline liver diseases, no specific therapy is available, and thus hepatoprotective therapy is used concurrently to aid in the recovery of the liver from the insult. in this section, therapy of two of the most common diseases of the feline liver will be considered, with a special emphasis on nutritional aspects of treatment, nutraceutical therapy, and the unique needs of cats. the most common liver disease of cats is idiopathic hepatic lipidosis (figures 23-61 and 23-62) , a disease that results in liver failure because of a combination of factors including hepatic lipid accumulation, insulin resistance, fasting, and protein (especially arginine) deficiency. 2, 8, 9, 11 thus, unlike many diseases of the liver, the primary focus of therapy and the essential component for recovery is nutritional support. as in any patient with serious liver disease, initial therapy is always aimed at correction of any fluid or electrolyte abnormalities that may exist, because these may be profound if the cat has been vomiting. in addition, normalization of electrolytes is particularly important in cats that have been anorexic for an especially long time (1 to 2 weeks), because refeeding syndrome may be triggered with the initiation of feeding, resulting in sudden drops in potassium, phosphate, and magnesium. 1 although this phenomenon is less common and usually less profound in cats fed enterally versus areas where appropriate, definitive diagnosis of certain infectious diseases (e.g., histoplasmosis). 57 however, even with these relatively straightforward diseases, fna of liver tissue has significant limitations, the most important of which is the failure to accurately identify the primary disease. for example, although it is easy to make a diagnosis of hepatic lipidosis using this technique, a paper recently showed four cats that were incorrectly diagnosed with hepatic lipidosis instead of lymphoma because the fna samples were obtained from areas that did not have lymphoma infiltration. 60 in another study, reviewing the agreement between fna cytologic samples of liver and the histopathologic diagnosis, only 51% of the cases had overall agreement. 50 thus although cytology of fna samples of liver tissue in cats with diffuse hepatic disease remains a useful first step, it is important for the clinician to carefully interpret the results and discuss the potential limitations of this technique with owners. there are several needle biopsy techniques available for sampling liver tissue, but not all are suitable or safe for use in cats. the menghini technique is one such approach that is not suitable for use in cats, because it is a blind procedure using a large-bore needle that cannot be used with ultrasound guidance. 42 the second option among the needle biopsy techniques that is not recommended for cats is the biopsy gun device. tru-cut biopsy guns are operated by a triggering device that can result in the induction of a lethal vagotonic shock reaction in the cat immediately following the procedure. 40 for most ultrasound-guided liver biopsy procedures, either the manual or, preferably, the semiautomatic tru-cut device is recommended for use in obtaining needle biopsies from cats. as a general rule, the tru-cut device will advance into the liver to a depth of 2 cm; so, it is essential to carefully note the amount of liver tissue available during the ultrasound assessment before advancing the needle for tissue collection. properly obtained tru-cut needle biopsies are a valuable technique for obtaining a representative sample of liver tissue 61 ; however, because of the risk for bleeding or liver fracture with any movement, it is essential that cats be anesthetized for this procedure. laparoscopy is an intermediate step between needle biopsy and surgical laparotomy for obtaining liver tissue for histopathology in cats. 48, 54 this technique is becoming more widely used as more specialists are trained for this procedure that allows visualization of tissues to be biopsied without opening the entire abdomen. although this technique does require general anesthesia, the limited degree of invasiveness, the large biopsy sample size, and rapid patient recovery make laparoscopy a valuable tool for obtaining liver tissue, 48 and it can be used to obtain biopsies from the spleen, pancreas, kidneys, lymph nodes, or to aspirate the gallbladder. for a detailed discussion of laparoscopic techniques and lipidosis. the echogenicity of the parenchyma is uniformly increased, which is more apparent when compared with other ultrasonographic images presented in this chapter. additionally, the gall bladder is distended. hepatic lipidosis in this cat was secondary to anorexia associated with primary intestinal disease. (courtesy dr. randolph baral.) liver gb figure 23-62 gross appearance of liver from a cat with hepatic lipidosis. note the pale tan and exaggerated reticular pattern. in most cases, the edges appear more rounded than is evident here. hepatic lipidosis in this cat was secondary to anorexia associated with primary intestinal disease (same cat as in figure 23-61) . (courtesy dr. randolph baral.) those started on intravenous nutrition, it can be a significant source of morbidity if electrolyte replacement and monitoring are not carefully attended. once the cat is hemodynamically stable, the next step in treatment planning in cats with hepatic lipidosis is re-introduction of nutrition, which must include placement of a feeding tube (box 23-5). however, because many of these cats are extremely ill and are not good candidates for anesthesia, placement of a nasoesophageal (ne) tube to allow initiation of enteral feeding is often the most appropriate step for the first few days. when administering food through a feeding tube, there are several important points: 1. the food should be room temperature (not too hot or cold). 2. the tube should be flushed with water following feeding, to remove any particles of food or medication that may cause the tube to clog. 3. if the cat is volume sensitive, it is important to carefully calculate how much water is used for flushing the tube, because a significant volume of fluid can be infused, creating a potential fluid overload. if the cat is fluid sensitive, the total amount of fluids (amount in the food, amount added to food if blenderized, and amount of flush) must be determined, and the amount of fluid used in flushes or food preparation may have to be reduced. force feeding is to be strongly discouraged in these sick cats for several reasons: • it is highly stressful and will further increase the stress response and insulin resistance phenomena that are perpetuating the hepatic lipidosis. • it can be dangerous to the cat (aspiration) or operator (scratches/biting). • it is rarely able to meet the necessary nutritional goals set for the patient. • it may induce food aversion, a phenomenon unique to cats, but creating a profound aversion to the chosen food that can be lifelong. 12 although ne tubes are excellent choices for short-term feeding of cats unwilling to eat, there are several disadvantages to their long-term use, including the nasal irritation that occurs, the relative ease with which cats can (and will) remove them, and the need to use liquid enteral diets. 62 thus once the cat is deemed stable enough for general anesthesia, a long-term feeding tube solution is needed, and this typically is either an esophageal (e) tube ( figure 23 -63) or percutaneous endoscopic gastrostomy (peg) tube. 22, 62 both feeding options are generally well tolerated methods for providing long-term feeding, but e tubes have the advantage of being placed without the need for any specialized equipment, and if complications occur, they are generally easily addressed, because the most common complications are infection at the tube site or premature removal of the tube by the cat. placement of a peg tube, although relatively easy to learn to place, requires having the appropriate endoscopic equipment, and if complications occur as a result of infection or tube removal, more significant morbidity can result. because there is no advantage to placement of peg tubes easiest to use, and are an acceptable choice in most situations. finally, because many cat stomachs are volume sensitive with initiation of feeding, it is very important to start conservatively with small-volume feeding on a more frequent schedule. with prolonged fasting, the stomach volume of a cat with hepatic lipidosis may be reduced dramatically, preventing normal expansion and limiting intake to as little as 10% of normal. thus to avoid vomiting when feeding, the starting volume may have to be as small as 10 to 15 ml every 2 to 3 hours. a good rule of thumb is to start with estimation of resting energy requirement (rer) (40 to 50 kcal/kg is a good estimate of rer), and then attempt to meet 25% of rer the first day. if no problems are encountered, increase the amount to 50% of rer the second day, and so on, but during this period, keep the frequency as high as possible (feed four to six meals per day) so that the volume remains relatively small at each meal. once full rer has been achieved with multiple meals per day, the frequency of feeding can be gradually reduced to three to four meals per day. most cats will eventually tolerate three meals per day well, and some can tolerate two meals per day, but this is quite variable and should not be attempted during the first weeks of feeding. in general, most cats with hepatic lipidosis will require tube feeding for a minimum of 3 to 6 weeks before they will show interest in food and begin eating again on their own. the tube should be retained until the cat has been eating on his or her own for at least 1 week or longer and can be maintained for a longer duration if it is being used to administer medications, because cats can eat normally with the e tube in place. the other therapeutic considerations for cats diagnosed with hepatic lipidosis are directed toward dealing with the complications of the disease and reducing the oxidative stress on the liver with hepatoprotective therapy (table 2323) . in cats that are vomiting, in cats versus e tubes, placement of e tubes is advocated as the best approach for most practice situations. interested readers are referred to several recent reviews on tube placement for specific details on each method and to chapter 18. 22, 62 diet selection is the next step in treatment planning for cats with hepatic lipidosis. in contrast to the belief that animals in liver failure need lower quantities of protein to reduce the workload on the liver, cats with hepatic lipidosis actually need protein to recover. in fact, the work of biourge and coworkers showed that protein was the essential nutrient in reducing hepatic lipid accumulation, was essential to eliminate the negative nitrogen balance, and also appeared to minimize muscle catabolism. 9 further, diets high in protein can improve insulin sensitivity and assist weight loss in recovery from obesity. 8, 11 conversely, although carbohydrates are a readily available energy source, they are often associated with gastrointestinal distress (diarrhea, abdominal cramping) and hyperglycemia (secondary to the insulin resistance in place as a result of obesity and hepatic lipidosis). 2 thus diets selected for cats with hepatic lipidosis should ideally be high in protein (>40% metabolizable energy [me]) and have lower amounts of carbohydrates (<20% me), with the remaining calories coming from fat. the diets that best fit this profile are the diets formulated for diabetic cats; however, kitten food, many adult cat foods, and some of the enteral recovery diets have this high protein/low carbohydrate profile. many of the intestinal diets are not higher protein and are higher in carbohydrates, and so would not be the ideal choice. the key to using any of the foods that are not designed for use in a feeding tube is to blenderize them (and if necessary, strain the food) so that the food will easily go through the 14-or 16-g feeding tube without clogging it. enteral diets designed for use in feeding tubes are the because the primary starting point of the inflammatory disease in cats is the bile ducts (cholangitis), with inflammation extending to the hepatic parenchyma (cholangiohepatitis) only with time and severity, the term cholangitis syndrome has become the preferred terminology. the disease syndrome has been further classified by the wsava liver diseases group into one of three primary types: neutrophilic or suppurative, chronic lymphoplasmacytic (figures 23-64 and 23-65) , and lymphocytic (non-suppurative). 61 each of the forms appears to behave quite differently clinically as well as in their progression and outcome. in general, cats with the suppurative form of cch typically have an acute onset of illness, which often includes fever, anorexia, and vomiting, and they may become icteric quite quickly (figure 23-66) . 28, 52 the nonsuppurative form of cch (lymphocytic form) tends to be a more chronic condition, with affected cats showing nonspecific signs of illness that may include partial anorexia and lethargy, but the signs may wax and wane or are non-progressive. 28, 52 because of the feline pancreatic and bile duct anatomy, it is common for cats with cch to have pancreatitis and vice versa, and in some cases, cats will also have concurrent ibd; the constellation of the three conditions occurring together is called triaditis. 59 this combination is increasingly recognized in cats, and recent reports suggest from 50% to 85% of cats with one syndrome have all three diseases. 25, 51, 54, 59 at this time, the etiology of each of these syndromes and the pathogenesis is not well understood; however, the enteric microflora are presumed to play an important role in the suppurative form, and immune mechanisms are presumed to be the cause of the chronic inflammation found in the chronic nonsuppurative antiemetic therapy is beneficial, because it is imperative that the cat continues to receive some food, and vomiting will complicate this. metoclopramide is often used in cats because of its ready availability and low cost, but it is a very weak antiemetic in cats and thus may not be the best choice. in most cats, the novel nk-1 receptor antagonist maropitant has been a safe and effective choice. 32 the most commonly used antiemetics in the author's feline practice are maropitant (1 mg/kg iv, sc or through the e tube q24h), ondansetron (0.22 mg/kg iv q8-12h), or dolasetron (0.5 mg/kg iv, sc q24h). in addition to control of vomiting, all cats with hepatic lipidosis should be given vitamin k 1 (2.5 mg/cat po, sc) daily for a week, then weekly until the cat has recovered, and vitamin b 12 (cobalamin) (250 µg/cat sc) weekly for 6 weeks, then monthly until blood values are normal. 46 other vitamins may become deficient, such as some of the b vitamins and vitamin e; however, feeding is likely to rapidly replenish these deficiencies if they exist. this is also likely true of amino acid deficiencies, but supplementation of l-carnitine (250 mg/day po) may be beneficial by improving fatty acid oxidation. 10 finally, hepatoprotectant and antioxidant therapy with s-adenosylmethionine (same) (20 mg/kg po q24h) has been advocated to increase glutathione and may be beneficial in cats with hepatic lipidosis. 13, 19, 56 it is important to note that if same is given through the tube (and thus the tablets must be crushed), the dose must be increased by approximately 50% to allow for the loss of absorption from loss of the enteric coating. because drug metabolism is often impaired in cats with hepatic lipidosis, appetite stimulants, such as mirtazapine, cyproheptadine, and clonazepam, should not be used in cats because dosing and side effects can be unpredictable. benzodiazepine agonist drugs (e.g., diazepam) should be completely avoided in cats with possible lipidosis-induced hepatoencephalopathy, because they will exacerbate the signs and may cause fulminant liver failure. 2, 14 fortunately, most cats with idiopathic hepatic lipidosis that receive immediate and aggressive therapy and feeding for their disease will recover completely. cats that develop hepatic lipidosis secondary to other serious diseases (e.g., lymphoma) have a much lower chance of complete recovery and often die of their disease or its complications. the most common inflammatory liver disease in the cat is a complex syndrome with multiple subgroups of disease previously termed cholangitis/cholan giohepatitis complex (cch) but currently recognized under the terminology feline cholangitis syndrome. 61 this disease is quite variable in both its presentation and severity, and it may occur as a primary process or secondary to/ concurrent with other diseases (e.g., pancreatitis, ibd). ultrasonographic appearance of liver with lymphocytic/plasmacytic inflammation. note the varying echogenicity throughout the hepatic parenchyma; areas of hypoechogenicity likely reflect inflammatory cell infiltration. the gall bladder is distended; its shape is distorted by pressure from the transducer. (courtesy dr. randolph baral.) liver gb [10 mg/kg po q24h]), and if pancreatitis is concurrent, pain control with opioid pain relievers (e.g., buprenorphine 0.05 to 0.1 mg/kg po, sq q8-12h). 52 if culture is not possible, combination therapy with enrofloxacin (4 mg/kg po q24h) and metronidazole (5 mg/kg po q12h) is reasonable. in cats with chronic lymphoplasmacytic forms of cholangitis, management must be tailored to the individual situation and often requires therapy with either immunosuppressive doses of prednisolone (2 to 4 mg/kg po q24h) or chlorambucil (4 mg/m 2 po q2d), along with the hepatoprotectants and cholerectics, and concurrent treatment of other diseases (pancreatitis or ibd) that may be occurring. 52 the lymphocytic or lymphoplasmacytic forms of cholangitis may wax and wane in intensity over time, and may require long-term continuous or intermittent therapy to control the disease. there is no specific diet that is recommended for cats with inflammatory liver disease, but protein restriction should not be initiated unless the cat has clear evidence of severe hepatoencephalopathy. the diet should be selected based on other conditions (such as ibd), for which the diet may be more critical in the management. monitoring of serum chemistry values (especially glucose), clotting times, cobalamin levels, and pli/tli concentrations are recommended every few months, as well as careful monitoring of the cbc for all cats on chlorambucil. in all cats with chronic inflammatory liver disease, prior to initiation of immunosuppressive therapy, a careful assessment of the cat for other possible causes of inflammation should be completed (box 23-6). as in dogs, if a cat with pss can have surgical closure of the shunting vessel (ligation, placement of an ameroid constrictor, intravenous coiling), the long-term forms. however, whether or not these syndromes are related, a continuum of disease or completely different diseases remains undetermined. once a definitive diagnosis is obtained by histopathology of the liver tissue and culture of bile, treatment can be tailored to needs of the cat. cats with the more aggressive suppurative form of cholangitis often require intravenous fluid therapy, antibiotic therapy (based on results of culture whenever possible), and supportive therapy (antiemetics, vitamin k 1 , hepatoprotectants such as same [ important antioxidant and stabilizes membrane functions • n-acetylcysteine-a precursor to glutathione and antioxidant, also improves tissues oxygen delivery • ursodeoxycholic acid (tertiary bile acid)-used to replace hepatotoxic, hydrophobic bile acids and increase bile flow • silymarin (milk thistle)-a free radical scavenger and anti-inflammatory/antifibrotic agent • vitamin e-an antioxidant and antiinflammatory vitamin* although few clinical trials of these nutraceuticals have been performed in feline liver disease, a few studies have recently appeared showing that same, ursodeoxycholic acid, silymarin, and n-acetylcysteine all are hepatoprotective, have few adverse side effects, and may be beneficial in many types of liver disease in cats. 3, 26, 39, 53, 55 feline liver disease is a common problem that requires careful consideration of the presenting complaint, clinicopathologic findings, imaging results, and, if available, histopathologic interpretation to be able to provide an accurate diagnostic and therapeutic plan. a variety of insults can be responsible for liver dysfunction or failure, but hepatic lipidosis and feline cholangitis syndrome remain the most common reasons for cats to present prognosis for function and quality of life is generally very good. 5 however, even if surgical correction is anticipated, and especially if surgical correction is impossible or not completely successful, medical management of he is indicated. see table 23 -24 for the basic therapeutic approach to medical management of cats with he resulting from pss. because hepatocytes, by their position in the body between the gi tract and rest of the body, as well as their critical role in metabolism and detoxification, are uniquely susceptible to oxidative injury and reactive intermediates of metabolism, they must be able to protect themselves. the natural defenses of the liver include superoxide dismutase and glutathione, free-radical scavengers such as vitamin e and ascorbate, and other prosurvival signaling pathways that are controlled by hormones and growth factors. 56 however, in injury or overwhelming infection or inflammation, the natural defenses of the liver can be overwhelmed, and then it is essential for medicines and nutraceutical therapy to be included in the treatment plan to help reduce inflammation and fibrosis, protect against oxidant injury, and enhance bile flow. the cytoprotective agents most commonly used in liver diseases to assist in these processes (table 23 -25) are: • s-adenosylmethionine (same)-a precursor in the synthesis of glutathione and an important methyl donor to dna and proteins, is an with icterus or liver failure. therapy must be tailored to the individual, but nutritional support is critical in the management of hepatic lipidosis, and appropriate supportive therapy with hepatoprotectants may be crucial to treatment success. resorption from that space. effusion accumulation is therefore correlated to increased capillary hydrostatic pressure, widening of the oncotic pressure gradient, increased endothelial permeability, increased interstitial hydrostatic pressure, or loss of effective lymphatic drainage or a combination of these factors. 10, 23, 32 peritonitis of any cause results in vascular dilation, increased capillary permeability, and the migration of inflammatory cells into the peritoneum in response to immunomodulatory mediators. the inflamed peritoneum becomes a freely diffusible membrane, allowing a massive outpouring of fluid and plasma proteins from the circulation. 5, 30 ascites is not commonly seen in practice; one study recognized ascites in only three cats out of 1000 admissions to an american veterinary teaching hospital, 34 but the prevalence may be greater in primary care practice. in that study, dilated cardiomyopathy (dcm) was the most common disease associated with peritoneal effusion; however, dcm was diagnosed in most of these cats before 1987, when taurine deficiency was found to be a primary cause of this form of cardiomyopathy in cats. neoplasia was the most common cause after 1987. 34 feline infectious peritonitis (fip) was by far the most common cause of feline ascites diagnosed over a 10-year period at the feline centre at the university of bristol, comprising 50% of all cats with recognized ascites. 32 cats with ascites usually present with nonspecific clinical signs, such as anorexia or lethargy. the owners may present the cat because they recognize abdominal enlargement ( figure 23-67 ), but in many cases, owners perceive this as weight gain. clinicians should be aware that sudden weight gain in a chronically underweight cat may be because of fluid accumulation (which can be intrathoracic fluid if ascites is not present), particularly if muscle mass seems reduced. ascitic cats presenting subsequent to trauma may have intraabdominal hemorrhage or urinary tract rupture. fever in a young ascitic cat will often suggest fip, and cats with fip may or may not be jaundiced. presence of jugular distention or even a jugular pulse can suggest right-sided heart failure. a palpable fluid thrill can help to distinguish ascites from other causes of abdominal enlargement, such as organomegaly, abdominal masses, bladder distention, abdominal wall weakness, obesity or, occasionally, accumulations of gas within the abdominal cavity 27 (table 23-26) . recognizing a fluid thrill involves gently tapping one side of the abdominal wall with the fingers of one hand while feeling for a sensation of fluid movement the peritoneum is the serous membrane lining the abdominal cavity, as well as covering the organs of the abdomen. it comprises a single layer of squamous mesothelial cells resting on a deeper layer of loose connective tissue. the layer of peritoneum that lines the inner surface of the abdomen is called parietal peritoneum; the abdominal organs are lined by visceral peritoneum. the total surface area of the peritoneum is one to one-and-ahalf times that of the total cutaneous area of the body. 5, 30 the peritoneal cavity contains a small amount of fluid (less than 1 ml/kg body weight) that reduces friction between the abdominal organs as they slide over each other. the fluid is a pure transudate and contains solutes in the same concentration as serum (box 23-7). this fluid is absorbed from the abdominal cavity predominantly through lymphatic vessels lying beneath the mesothelial basement membrane on the surface of the diaphragm. lymphatic drainage occurs predominantly to the sternal lymph nodes. 5, 30 ascites is the abnormal effusion and accumulation of fluid in the abdominal cavity. fluid exchange across the capillary bed is determined by starling forces, that is, the balance between hydrostatic pressure, which causes transudation of fluid out of blood vessels, and the colloid osmotic pressure, which acts to retain fluid within blood vessels. the amount of peritoneal fluid is therefore determined by the balance of these, as well as vascular permeability, with excess fluid drained by the lymphatic system. accumulation of fluid within a body cavity results when the rate of filtration of fluid into a space is greater than the rate of fluid routine laboratory findings are usually nonspecific but may provide clues to the underlying cause of ascites. for example, neutrophilia may point towards septic peritonitis but can also occur with fip; most cats with hemoperitoneum are anemic at presentation 8 ; uroperitoneum often results in azotemia and electrolyte abnormalities; hypoglycemia may reflect sepsis with septic peritonitis, and a recent study recognized 83% of cases of septic peritonitis had ionized hypocalcemia 17 ; elevated liver enzymes may be associated with inflammatory, infectious or neoplastic hepatopathies including fip; elevation of serum globulins occurs in many cats with fip but can also be associated with neoplasia or septic peritonitis; and a finding of hypoalbuminemia (which can cause a pure transudate) should prompt for an assessment of urine protein : creatinine ratio to assess if there is renal protein loss. imaging may be required to confirm the presence of fluid as well as to aid in diagnosis of the underlying cause. radiographic findings can vary greatly depending on the amount of abdominal fluid present and the underlying etiology. loss of normal detail or presence of a "ground glass" appearance to the abdominal cavity is suggestive of the presence of fluid (figures 23-68 and 23-69). very young, thin or dehydrated cats may also have a loss of detail that can mimic the presence of fluid. ultrasonography of the abdomen (figures 23-70 and if a large volume effusion causes discomfort because of abdominal distention, a three-way stopcock may be used so large volumes can be drained from one puncture (figure 23-72) . however, removal of large volumes of ascitic fluid can be detrimental, because it may prevent the subsequent reabsorption of valuable protein and/or red blood cells; the resulting reduction in intraabdominal pressure may encourage further accumulation of fluid; and rapid removal of large volumes can lead to fluid shifts causing cardiovascular collapse. 32 fluid can be collected into ethylenediaminetetraacetic acid (edta) tubes (for total nucleated cell count, packed cell volume, total protein, and cytology), serum tubes (for biochemistry, such as albumin, bilirubin, creatinine, potassium, triglyceride, glucose, lactate, and lipase), sterile tubes for culture, and/or other tubes for effusion-specific tests such as pcr. samples should be prioritized according to the volume of fluid available and to the suspected underlying disease process. 10 initial assessment of fluid retrieved is made on the basis of color and protein concentration, and much information can be gleaned from this simple assessment, even before cell numbers and types are assessed. although this brief, initial assessment is useful to refine the differential diagnoses, a thorough assessment based on underlying etiology and pathophysiology is required for definitive diagnosis and therefore appropriate management (table 23-27) . ascitic fluid, classified according to its pathophysiologic cause, can be divided into transudates, modified transudates, exudates (septic or nonseptic), or effusions (chylous or hemorrhagic). 10,23 can allow the detection of even very small volumes of fluid. it also enables evaluation of the size and structure of intraabdominal organs, such as the liver and spleen, which can help determine the underlying cause of ascites. abdominocentesis confirms the presence of abdominal fluid (in cases of low-volume effusion) and assessment of the fluid is required to diagnose the underlying cause of ascites. most cats tolerate abdominocentesis without sedation and the cat can be held in a standing position or in lateral recumbency (whichever is more comfortable for the cat and familiar to the clinician). the abdomen is clipped and aseptically prepared. a 20-to 22-gauge butterfly needle may be used with a 5-to 10-ml syringe. in cases with low-volume effusion, ultrasonography can help to guide fine needle aspiration from small pockets of abdominal fluid. diagnostic peritoneal lavage can be used if ultrasound-guided aspiration is unsuccessful. for this procedure, 10 to 20 ml/kg of warmed, sterile fluid is infused into the abdomen over 2 to 5 minutes after aseptic preparation of the site. the cat is gently rolled from side to side or allowed to stand; gentle massage of the abdomen also helps distribute the fluid. the fluid is allowed to dwell for a minimum of 2 to 5 minutes before aseptic preparation is repeated before paracentesis. no attempt is made to remove all the fluid. it must be remembered that, since the recovered fluid has been diluted by this procedure, cell counts and biochemical analyses will be affected. 33 transudates are a consequence of altered fluid dynamics. protein-poor transudates (commonly referred to as pure transudates) form predominantly as a result of severe hypoalbuminemia, which causes a lowered colloid osmotic pressure. since there is no change in endothelial or mesothelial permeability, as fluid accumulates, there is no concurrent cell leakage; so, there is a decrease in the cell count through a dilutional effect. consequently, transudative effusions are typically clear and colorless. 10, 23, 32 other pathologic causes of proteinpoor transudates include cirrhosis, lymphatic obstruction, and noncirrhotic portal hypertension (presinusoidal and sinusoidal). since hypoalbuminemia is the most common cause of transudates, serum albumin concentrations must be measured to guide further diagnostics. if the serum albumin concentration is normal (or only minimally decreased), then radiographs, abdominal ultrasonography, and/or echocardiography are indicated to assess cardiac function and for urinary bladder rupture. 10 one review of feline ascitic cases found 24% of effusions were protein-poor transudates, of which 82% were the result of hepatic failure or primary renal disease. 34 modified transudates can result from increased hydrostatic pressure within the postsinusoidal vessels of the liver secondary to right-sided congestive heart failure (e.g., tricuspid insufficiency) or potentially from mass lesions (such as neoplastic masses) obstructing blood flow from the hepatic vein or caudal vena cava into the right side of the heart. the increase in hydrostatic pressure within the vessels of the liver causes a protein-rich fluid to leach out of the liver into the abdominal cavity. since cell membrane permeability does not change, cells do not accumulate in the effusion. 10 modified transudates can also result from increased vascular permeability in the early stages of an inflammatory process, in which case cellularity will be increased. modified transudates were described as the most common type of ascitic effusion identified in cats in one study, with most being resulting from neoplasia and congestive cardiac failure; however, this study partially included cases prior to 1987, when right-sided heart failure associated with dilated cardiomyopathy (dcm) was prevalent. 34 the recognition of the role of taurine deficiency in this condition and the subsequent addition of this amino acid to feline diets now means that right-sided heart failure is only rarely encountered as a cause of ascites in cats. exudates are a consequence of altered mesothelial and/ or endothelial permeability. this permeability results from a cytokine-mediated inflammatory response of any underlying cause (e.g., infectious, neoplastic, immune mediated). exudates have high protein and moderate to high cell concentrations and are classified as nonseptic or septic. exudates are often primarily composed of neutrophils. nondegenerate neutrophils (and the absence of organisms) points to a nonseptic exudate (mostly fip but also neoplasia). fip is the most common cause of exudative effusion in cats and was the most common cause of feline ascites diagnosed over a 10-year period at the feline centre at the university of bristol. 32 the presence of neoplastic cells rules in neoplasia, but the absence of such cells does not rule out this diagnosis since many cases of neoplastic ascites are not associated with exfoliated neoplastic cells. other causes of nonseptic exudates include pancreatitis, lymphocytic cholangitis, and viscus rupture, such as the gall bladder or urinary bladder. degenerate neutrophils typify septic exudates (i.e., septic peritonitis), and their presence should instigate investigation for causes of infection (mostly leakage of gastrointestinal contents). 34 chylous effusions appear as milky or pink opaque fluid, and small mature lymphocytes initially predominate in cell counts. after drainage, more macrophages and nondegenerate neutrophils may be found. chyle is typically classified as an exudate, but its physical characteristics can be consistent with a modified transudate (protein content between 25 and 40 g/l); biochemical analysis of triglyceride and cholesterol levels in the fluid are required to confirm the diagnosis. pseudochylous effusions resemble true chyle both in appearance and cytology but do not contain fat. similar conditions result in both chylous and pseudochylous effusions. chylous abdominal effusions are rarely reported in the cat and only accounted for 7% of cases of ascites in one study. 34 the described causes of chylous ascites in cats are predominantly neoplastic. in a series of nine cats, chylous ascites was associated with nonresectable abdominal neoplasia in four cases (i.e., hemangiosarcoma and paraganglioma), with intestinal and mesenteric lymphoma in two cases and lymphangiosarcoma of the abdominal wall in another. 13 one described case in a 10-year-old cat was thought to be because of fip. 28 figure 23 -71 shows an ultrasonographic image of a cat with chylous abdominal effusion associated with pancreatitis. other potential causes include right-sided congestive cardiac failure, steatitis (inflammation of fat), biliary cirrhosis, and lymphangiectasia. hemoperitoneum in companion animals is categorized as traumatic or spontaneous. traumatic hemoperitoneum is further divided into blunt causes of trauma (i.e., motor vehicle accidents and high-rise falls) and penetrating trauma (i.e., gunshot wounds and bite wounds). 8, 21 inadvertent splenic aspiration, venipuncture, or acute severe hemorrhage should be suspected if the cytology is consistent with peripheral blood including platelets but without erythrophagocytosis or if the blood clots readily. when there is no history of trauma, coagulopathy or spontaneous rupture of a vascular neoplasm should be considered. in one study of 16 feline cases of spontaneous hemoperitoneum, 12 cases (75%) were associated with hepatic pathology such as neoplasia, necrosis, and amyloidosis. 21 in another study of 65 cases of spontaneous hemoperitoneum, 46% (30 of 65) of cats had abdominal neoplasia, and 54% (35 of 65) had non-neoplastic conditions. cats with neoplasia were significantly older and had significantly lower packed cell volumes (pcvs) than cats with non-neoplastic disease. hemangiosarcoma was the most often diagnosed neoplasm (18 of 30, 60%), and the spleen was the most common location for neoplasia (11 of 30, 37%). coagulopathies (8 of 35, 23%) and hepatic necrosis (8 of 35, 23%) were the most common causes of non-neoplastic hemoperitoneum. 8 other nonneoplastic causes of hemoperitoneum include ruptured bladder, hepatic rupture secondary to hepatic amyloidosis, gastric/duodenal ulcer, hepatic hematoma, hepatitis, perinephric pseudocyst, feline infectious peritonitisinduced liver rupture, and feline infectious peritonitisinduced nephritis. 8, 21 the prognosis of cats with spontaneous hemoperitoneum is poor. in two studies, only approximately 12% of cases survived to be discharged from hospital. 8, 21 median survival time for cats that were discharged in one of those studies was 54 days (range, 5 to 1825 days). 8 feline infectious peritonitis (fip) comprised 50% of cats with recognized ascites over a 10-year period at the feline centre at the university of bristol, 32 and, as a rule of thumb, when ascites is recognized in a younger cat, fip should be considered the major rule-out. the abdominal effusion found with fip is typically straw to golden yellow (although the color can be very variable, for example, chyle may be present), may contain fibrin clots, and has a high protein concentration. the total protein content is greater than 35 g/l and often greater than 45 g/l, with globulins comprising 50% or more. 31 one study described an effusion with total protein greater than 80 g/l as 90% specific, 55% sensitive, and having a 0.78 positive predictive value to diagnose fip. 31 the rivalta test evaluates the fluid's globulin content, and was found to be very sensitive but only 80% specific; this test is performed by adding one drop of acetic acid (98%) to 5 ml of distilled water. this fluid is mixed thoroughly, and then one drop of effusion is gently placed on the surface of the mixture. if the drop stays at the top of the fluid or slowly floats to the bottom, the test is considered to be positive. this test can give inaccurate results if inappropriate technique is used or if there is a significant temperature difference between the fluid sample and the acetic acid solution. a positive rivalta test can result from lymphosarcoma, septic, or fip effusions; these can be distinguished by cytology and culture. immunofluorescence staining of coronavirus antigen in macrophages had a positive predictive value of 1.00 but a negative predictive value of 0.57. 15 the potential clinical presentations, diagnosis, and management of fip are covered in detail in chapter 33. one study found neoplasia to be the most common cause of ascites in cats, 34 and neoplasia should be considered the major rule-out in older cats with ascites. the effusion from cats with ascites resulting from neoplasia may be a modified transudate, resulting from compression of hepatic veins or the caudal vena cava, or metastases to the peritoneum; hemorrhage from neoplasia can cause hemoperitoneum; chylous effusions may result from reduced lymphatic drainage or rupture of lymphatic vessels; and raised vascular permeability caused by neoplastic infiltration can result in an exudative effusion. carcinomas, mesotheliomas, and discrete (round) cell neoplasms (e.g., lymphoma, mast cell tumors, malignant histiocytosis) exfoliate cells into effusions more readily than sarcomas, and of these, lymphosarcoma is the most common malignancy of cats. cytology of ascitic fluid reveals neoplastic cells in less than a quarter of cases; so the absence of such cells does not rule out a diagnosis of neoplasia. in these circumstances, the diagnosis may be achieved by ultrasound-guided fine-needle aspiration of affected organs, or even biopsy samples obtained at laparotomy. the specific approaches will depend on the specific neoplasia diagnosed. exudates caused by septic inflammation usually result from bacterial contamination of the peritoneal cavity secondary to gastrointestinal tract leakage or penetrating wounds associated with trauma. gastrointestinal tract leakage may occur as a result of ulceration associated with neoplasia or inflammatory disease or as a result of penetration of a sharp object ingested (such as a toothpick), it can also occur subsequent to prior abdominal surgery. 7, 9, 17, 24 primary septic peritonitis in which no apparent cause can be identified has also been described in cats. 26 septic exudates are usually yellow to tan in color, with yellow particulate matter and are foul-smelling. microscopically, the fluid is characterized by the presence of degenerate neutrophils and bacteria. bacteria are often seen intracellularly within neutrophils. the condition is associated with high morbidity and mortality rates, with survival rates reported between 32% and 80%. 7, 9, 17, 24, 26 the history and clinical signs are often vague and nonspecific but can include abdominal pain, vomiting, lethargy/depression, and anorexia. abdominal pain is an inconsistent finding, being recognized in only 62% of cats in one study 7 and 43% in another. 24 some cats may have an inappropriately low heart rate. 7, 26 hematologic and serum biochemistry findings are also inconsistent; neutrophilia with a left shift may be present, as may neutropenia or a normal neutrophil count. similarly, cats may be hypoglycemic, hyperglycemic, or normoglycemic, and they may be hypoalbuminemic. 7, 24, 26 one study recognized ionized hypocalcemia in 89% of cats with septic peritonitis at the time of diagnosis, 17 and another suggested hyperlactatemia, when present, may be associated with a poorer prognosis. 24 radiographic findings are usually typical of ascites of any cause, but presence of pneumoperitoneum in a cat that has not undergone recent surgery may suggest the presence of gas-forming bacteria or rupture of an abdominal viscus and warrants immediate surgical intervention. ultrasonography does not directly aid the diagnosis of septic peritonitis. 7 exploratory laparotomy to determine and correct an underlying problem, such as full-thickness gastrointestinal perforation (often requiring partial resection) is required, as is copious abdominal lavage with sterile, warmed fluids ( figure 23-73 ). there are no statistically significant survival differences between postsurgical primary closure, open peritoneal drainage, or closed suction drainage postsurgical lavage; however, a trend toward a higher survival rate has been seen in cats treated with primary closure. 24, 26 treatment also involves antibiotics, initially parenterally, based on culture and sensitivity findings. consistent with intestinal contents, most bacteria recognized are gram-negative aerobes, such as e. coli or enterobacter spp., but mixed infections are usually found. 7, 24 anaerobes seem more common in cats with primary septic peritonitis, 26 which perhaps suggests these cases may result from healed over-bite wounds into the abdomen. amoxicillin/ clavulanate would be an appropriate empirical choice of figure 23-73 fulminant peritonitis associated with gastrointestinal perforation. in this case, the effusion volume was low but the high degree of serosal inflammation is evident. antibiotics while awaiting sensitivity results. there are no definitive guidelines for duration of antibiotic treatment; the author uses extended treatment courses of 4 to 6 weeks. supportive care with intravenous fluids to maintain fluid and electrolyte balances is also required perioperatively. bile peritonitis is infrequently reported in cats but has been recognized in association with gunshot 20 or motor vehicle 2 trauma, with biliary obstruction from gall stones 2,22 and subsequent to percutaneous ultrasoundguided cholecystocentesis in a cat with infectious cholangitis. 4 concurrent bacterial infection was recognized in each case; this increases severity of inflammation and worsens the prognosis, although full recovery was achieved in most reported cases. 2, 4, 20 bile peritonitis has the potential to result in small-volume effusions; so, if abdominocentesis does not yield a sample of effusion but bile peritonitis is high on the differential list, then diagnostic peritoneal lavage is appropriate. since repair of or removal of the gall bladder and abdominal lavage are required, exploratory laparotomy is an appropriate means to diagnose this condition. management should be considered as for septic peritonitis of other causes. trauma, including blunt abdominal trauma, urethral catheterization, and bladder expression, is the most common cause of uroperitoneum in cats. 1 it is also recognized as a complication of ureteral surgery. 18 the bladder is the most frequent site of urine leakage after blunt abdominal trauma, whereas the urethra is most commonly injured following catheterization. cats with ruptured bladders may still have a palpable bladder and the ability to urinate. common historical complaints are anuria (53.8%) and vomiting (50%). azotemia is a common finding, and hyperkalemia is seen in around 50% of cases. drainage of urine from the peritoneal cavity seems to improve patient stabilization. morbidity and mortality depended largely on the severity of associated injuries. 1 regardless of the site of injury or the cause of uroabdomen, the first goal of treatment is patient stabilization. isotonic replacement fluids are used for initial resuscitation. treatment of hypovolemic shock, if present, is the first order of fluid therapy. after fluid resuscitation, drainage of urine from the abdomen should be established. continuous passive drainage of the urine is necessary for stabilization and allows effective diuresis to occur. indwelling catheterization of the urinary bladder is recommended to keep the bladder decompressed and reduce urine flow into the abdominal cavity in patients with bladder and proximal urethral injury. if the urethra is traumatized and a catheter cannot be placed, prepubic tube cystostomy may be necessary to achieve temporary urinary diversion. the decision to treat the uroabdomen patient surgically or conservatively should be based on the location and severity of the underlying injury, the condition of the patient at presentation, and the patient's response to initial stabilization. 1, 12 congestive heart failure has become an uncommon cause of ascites in cats since the late 1980s/early 1990s, from which time dilated cardiomyopathy has been largely eradicated. 32, 34 ascites does still result from rightsided congestive heart failure in conditions such as tricuspid insufficiency, 6 arrhythmogenic right ventricular cardiomyopathy, 16 myocardial fibrofatty infiltration, 14 or restrictive cardiomyopathy. 29, 34 concurrent pleural effusion or pulmonary edema is often, but not necessarily, present with cardiac induced ascites. a heart murmur is not necessarily noted. noting a jugular pulse or thrill is helpful diagnostically, if present. the ascitic fluid is typically a modified transudate, but a chylous effusion is also possible. cardiac diseases are covered in chapter 20. in some cases, hepatic lipidosis has been reported to cause ascites, particularly in association with pancreatitis. these cats are often hypoalbuminemic, with the possibility of intravenous fluid therapy contributing to the ascites by raising hydrostatic pressure. 11 other liver diseases which can result in ascites include lymphocytic cholangitis, 19, 25 neutrophilic cholangitis, cirrhosis, 13 necrosis, neoplasia, and suppurative cholangiohepatitis. 34 portosystemic shunts in cats rarely result in ascites, compared with dogs. 3 hypoalbuminemia and hepatic failure result in transudates; portal hypertension and cirrhosis cause higher protein ascites because of raised capillary hydrostatic pressure causing leakage of high protein lymph. hepatopathies are covered in detail elsewhere in this chapter. gold references 1. adamama-moraitou kk, rallis ts, prassinos nn et al: benign esophageal stricture in the dog and cat: a retrospective study of 20 cases chronic oesophageal foreign body in a cat use of a biodegradable self-expanding stent in the management of a benign oesophageal stricture in a cat suspected clindamycinassociated oesophageal injury in cats: five cases feline gastrointestinal foreign bodies a comparative study evaluating the esophageal transit time of eight healthy cats when pilled with the flavorx pill glide versus pill delivery treats primary esophageal squamous cell carcinoma in a cat risk factors and outcome of bougienage for treatment of benign esophageal strictures in dogs and cats: 28 cases hiatus hernia in a cat megaesophagus in a 6-monthold cat secondary to a nasopharyngeal polyp post anaesthetic oesophageal stricture in the cat helicobacter species detection and histopathological changes in stray cats from niterói, brazil gastric emptying in cats using foods varying in fiber content and kibble shapes intestinal obstruction by trichobezoars in five cats feline gastrointestinal foreign bodies ultrasonographic findings references association of intestinal disorders in cats with findings of abdominal radiography single enterotomy removal of gastrointestinal linear foreign bodies sacrococcygeal agenesis association and anal atresia in mixed breed cats quinolone antibiotics in the treatment of salmonella infections radiographic, ultrasonographic, and endoscopic findings in cats with inflammatory bowel disease of the stomach and small intestine: 33 cases (1990-1997) laparotomy for gastro-intestinal biopsies hepatic small cell lymphosarcoma in four cats intestinal leiomyosarcoma in a cat intestinal obstruction by trichobezoars in five cats conservative versus surgical management of gastrointestinal linear foreign bodies in the cat bacterial overgrowth associated with a naturally occurring enteropathy in the german shepherd dog feline immunodeficiency virus integration in b-cell lymphoma identifies a candidate tumor suppressor gene on human chromosome 15q15 beaver bv: disorders of behavior feline gastrointestinal foreign bodies intussusception in 12 cats rapid detection of enterohemorrhagic escherichia coli by real-time pcr with fluorescent hybridization probes chlorambucilinduced myoclonus in a cat with lymphoma megacolon in the cat recto-vaginal fistula and anal imperforation in a cat: surgical treatment a systematic overview of chemotherapy effects in indolent non-hodgkin's lymphoma bright rm: gi surgery surgery of the digestive system atresia ani and urethrorectal fistula in a kitten idiopathic inflammatory bowel disease in dogs and cats: 84 cases an unexpected bacterial flora in the proximal small intestine of normal cats effects of oral administration of metronidazole on small intestinal bacteria and nutrients of cats comparison of the bacterial flora of the duodenum in healthy cats and cats with signs of gastrointestinal tract disease tyzzer's disease a systematic overview of chemotherapy effects in b-cell chronic lymphocytic leukaemia outcome of cats with low-grade lymphocytic lymphoma: 41 cases chronic inflammatory and non-inflammatory diseases of the gastrointestinal tract in cats: diagnostic advantages of full-thickness intestinal and extraintestinal biopsies radiology and sonography of the digestive system small intestinal adenocarcinoma in cats: 32 cases (1978-1985) gram-negative bacterial infections radiological identification of nonopaque intestinal foreign bodies chronic inflammatory bowel diseases, etiopathogeny, diagnosis, bull acad vét contribution to the study of feline inflammatory bowel disease: 51 cases (1991-1994) normal parameters in abdominal radiology of the dog and cat pharmacokinetics and suggested oral dosing regimen of cisapride: a study in healthy cats intussusception in dogs and cats: a review of thirty-six cases low-grade alimentary lymphoma: clinicopathological findings and response to treatment in 17 cases characterisation of the signalment, clinical and survival characteristics of 41 cats with mast cell neoplasia feline lymphoma in the post-feline leukemia virus era adenomatous polyps of the duodenum in cats: 18 cases gastrointestinal obstruction vaccine site-associated sarcoma and malignant lymphoma in cats: a report of six cases strongyloides species diagnostic parasitology georgis' parasitology for veterinarians georgis' parasitology for veterinarians demonstration of ollulanus tricuspis in the stomach of domestic cats by biopsy comparison of conventional coproscopical methods and commercial coproantigen elisa kits for the detection of giardia and cryptosporidium infections in dogs and cats recent investigation on the prevalence of gastrointestinal nematodes in cats from france and germany cestodes of dogs and cats in north america first record of natural tritrichomonas foetus infection of the feline uterus gastric adenocarcinoma and chronic gastritis in two related persian cats helminth and noncoccidial protozoan parasites of the gastrointestinal tract toxoplasmosis and neosporosis toxoplasmosis and other intestinal coccidial infections in cats and dogs intestinal nematodes: biology and control kirk's current veterinary therapy xiv single-tube nested pcr for detection of tritrichomonas foetus in feline feces efficacy of ronidazole for treatment of feline tritrichomonas foetus infection use of a commercially available culture system for diagnosis of tritrichomonas foetus infection in cats experimental infection of cats with tritrichomonas foetus host responses to cryptosporidium infection acute renal failure in four cats treated with paromomycin documentation of in vivo and in vitro aerobic resistance of feline tritrichomonas foetus isolates to ronidazole prevalence of and risk factors for feline tritrichomonas foetus and giardia infection assessment of reproductive tract disease in cats at risk for tritrichomonas foetus infection prevalence of tritrichomonas foetus infection in cats with diarrhoea in the uk diseases of the small intestine prevalence of enteric zoonotic organisms in cats giardia infection in cats evaluation of fenbendazole for treatment of giardia infection in cats concurrently infected with cryptosporidium parvum kirk's current veterinary therapy xiv update on the diagnosis and management of toxoplasma gondii infection in cats cryptosporidium infections in cats and dogs activity of toltrazuril and diclazuril against isospora species in kittens and puppies comparison of direct immunofluorescence, modified acid-fast staining, and enzyme immunoassay techniques for detection of cryptosporidium spp in naturally exposed kittens diarrhea in kittens comparison of direct immunofluorescence, immunoassays, and fecal flotation for detection of cryptosporidium spp. and giardia spp. in naturally exposed cats in 4 northern california animal shelters determining the zoonotic significance of giardia and cryptosporidium in australian dogs and cats the biology and control of giardia spp and tritrichomonas foetus neurotoxicosis in 4 cats receiving ronidazole gastrointestinal protozoal infections diseases of the intestines diseases of the stomach prevalence of enteric zoonotic agents in cats less than 1 year old in central new york state survey of cats for strongyloides felis efficacy of giardia vaccination in the treatment of giardiasis in cats tritrichomonas foetus infections in surveyed pet cats the cat: diseases and clinical management tritrichomonas foetus: a new agent of feline diarrhea prevalence of cryptosporidium, giardia and isospora species infections in pet cats with clinical signs of gastrointestinal disease histologic features associated with tritrichomonas foetus-induced colitis in domestic cats acute pancreatitis in cats with hepatic lipidosis pancreatic atrophy and fibrosis associated with eurytrema procyonis in a domestic cat comparisons between cats with normal and increased fpli concentrations in cats diagnosed with inflammatory bowel disease pancreatolithiasis and pancreatic pseudobladder associated with pancreatitis in a cat acinar cell carcinoma of the pancreas in a cat laparotomy for gastro-intestinal biopsies enteric bacteria: friend or foe? serum feline pancreatic lipase immunoreactivity concentration and seroprevalences of antibodies against toxoplasma gondii and bartonella species in client-owned cats polycystic kidney and liver disease in cats multiple recurrent pancreatic cysts with associated pancreatic inflammation and atrophy in a cat pancreatic paraneoplastic alopecia in three cats exocrine pancreatic insufficiency in a cat cholecystoenterostomy for treatment of extrahepatic biliary tract obstruction in cats: 22 cases retrospective evaluation of partial parenteral nutrition in dogs and cats pancreatic cyst in a cat prospective evaluation of laparoscopic pancreatic biopsies in 11 healthy cats prevalence and histopathologic characteristics of pancreatitis in cats differential effects of experimentally induced chronic pancreatitis on neuropeptide immunoreactivities in the feline pancreas relations between pancreatic enzyme outputs and malabsorption in severe pancreatic insufficiency histologically confirmed clinical toxoplasmosis in cats: 100 cases (1952-1990) some aspects of pancreatic disease in the cat clinical differentiation of acute necrotizing from chronic nonsuppurative pancreatitis in cats: 63 cases determination of serum fpli concentrations in cats with diabetes mellitus evaluation of serum feline pancreatic lipase immunoreactivity and helical computed tomography versus conventional testing for the diagnosis of feline pancreatitis evaluation of feline pancreas-specific lipase (spec fpltm) for the diagnosis of feline pancreatitis [abstract pancreatic function in domestic cats with pancreatic fluke infection feline intrinsic factor (if) is pancreatic in origin and mediates ileal cobalamin (cbl) absorption [abstract feline pancreatic disease comparison of the sensitivity of different diagnostic tests for pancreatitis in cats a case of feline paraneoplastic alopecia with secondary malassezia-associated dermatitis response to insulin treatment and survival in 104 cats with diabetes mellitus (1985-1995) imaging findings in pancreatic neoplasia and nodular hyperplasia in 19 cats acute necrotizing pancreatitis and acute suppurative pancreatitis in the cat pancreatic pseudocyst associated with chronic-active necrotizing pancreatitis in a cat pancreatic insufficiency and diabetes mellitus in a cat feline pancreatic insufficiency an outbreak of virulent systemic feline calicivirus disease jaundice in the cat associated with inflammation of the biliary tract and pancreas placement of jejunal feeding tubes for post-gastric feeding diabetes mellitus and exocrine pancreatic neoplasia in two cats with hyperadrenocorticism clinical and pathologic changes in experimentally induced acute pancreatitis in cats nasogastric tube feeding in cats with suspected acute pancreatitis: 55 cases pancreatic biopsy in normal cats review of feline pancreatitis part one: the normal feline pancreas, the pathophysiology, classification, prevalence and aetiologies of pancreatitis extraperitoneal lesions in feline infectious peritonitis pancreatic disease in the cat d-lactic acidosis secondary to exocrine pancreatic insufficiency in a cat paraneoplastic alopecia associated with internal malignancies in the cat an isolated epizootic of hemorrhagic-like fever in cats caused by a novel and highly virulent strain of feline calicivirus carriage of malassezia spp. yeasts in cats with diabetes mellitus, hyperthyroidism and neoplasia exocrine pancreatic insufficiency with associated coagulopathy in a cat data from eleven united states and canadian colleges of veterinary medicine on pancreatic carcinoma in domestic animals evaluation of complications and prognostic factors associated with administration of total parenteral nutrition in cats: 75 cases contrast-enhanced power and color doppler ultrasonography of the pancreas in healthy and diseased cats diagnostic standards for acute pancreatitis ethanol-mediated neutrophil extravasation in feline pancreas diabetes mellitus associated with pancreatic endocrine insufficiency in a kitten liver cirrhosis and pancreatitis in a cat infected with amphimerus pseudofelineus early biochemical and clinical responses to cobalamin supplementation in cats with signs of gastrointestinal disease and severe hypocobalaminemia ultrasonographic findings in cats with clinical, gross pathologic, and histologic evidence of acute pancreatic necrosis: 20 cases evaluation of endosonography as a new diagnostic tool for feline pancreatitis exocrine pancreatic neoplasia in the cat: a case series ante mortem diagnosis of pancreatitis in four cats retrospective study: surgical intervention in the management of severe acute pancreatitis in cats: 8 cases exocrine pancreatic insufficiency feline exocrine pancreatic disorders serum feline trypsin-like immunoreactivity in cats with exocrine pancreatic insufficiency purification and partial characterization of feline classical pancreatic lipase development and analytical validation of a radioimmunoassay for the measurement of feline pancreatic lipase immunoreactivity in serum evaluation of serum feline trypsin-like immunoreactivity for the diagnosis of pancreatitis in cats complications associated with proximal duodenal resection and cholecystoduodenostomy in two cats resolution of paraneoplastic alopecia following surgical removal of a pancreatic carcinoma in a cat feline exocrine pancreatic insufficiency: 16 cases pancreatitis associated with a feline herpesvirus infection pancreatic pseudocysts in 4 dogs and 2 cats: ultrasonographic and clinicopathologic findings eurytrema procyonis and pancreatitis in a cat acute necrotizing pancreatitis laparoscopic diagnosis of pancreatic disease in dogs and cats relationship between inflammatory hepatic disease and inflammatory bowel disease, pancreatitis, and nephritis in cats traumatic pancreatic injury in a cat: a case history management of prolonged food deprivation, hypothermia, and refeeding syndrome in a cat hepatic lipidosis in cats evaluation of prophylactic and therapeutic effects of silymarin and n-acetylcysteine in acetaminophen-induced hepatotoxicity in cats hepatobiliary neoplasia in dogs and cats spontaneous hepatic rupture in six cats with systemic amyloidosis portosystemic vascular anomalies acquired portal collateral circulation in dogs and cats correlation between coagulation profile findings and bleeding complications after ultrasound guided biopsy: 434 cases (1993-1996) effect of weight gain and subsequent weight loss on glucose tolerance and insulin response in healthy cats effects of protein, lipid or carbohydrate supplementation on hepatic lipid accumulation during rapid weight loss in obese cats dietary l-carnitine supplementation in obese cats alters carnitine metabolism and decreases ketosis during fasting and induced hepatic lipidosis generalized amyloidosis and acute liver haemorrhage in four cats metabolic and hormonal alterations in cats with hepatic lipidosis effects of nutritional support on hospital outcomes in dogs and cats metabolic, antioxidant, nutraceutical, probiotic, and herbal therapy relating to the management of hepatobiliary disorders current considerations for evaluating liver function in the cat diseases of the gallbladder and biliary tree diagnostic value of serum gamma glutamyl transferase and alkaline phosphatase in hepatobiliary disease in the cat: 1975-1990 retrospective study of 77 cats with severe hepatic lipidosis: 1975-1990 measurement of serum bile acids concentrations for diagnosis of hepatobiliary disease in cats role of i-123 serum amyloid protein in the detection of familial amyloidosis in oriental cats high complication rate of an automatic tru-cut biopsy gun device for liver biopsy in cats important clinical syndromes associated with liver disease liver biopsy techniques arterial and venous ammonia concentrations in the diagnosis of canine hepatoencephalopathy portal vein thrombosis in cats: 6 cases hepatic abscesses in cats: 14 cases subnormal concentrations of serum cobalamin (vitamin b12) in cats with gastrointestinal disease urine sulfated and nonsulfated bile acids as a diagnostic test for liver disease in cats mosby, p 44. 48a. van der linde-sipman j, niewold t, tooten p et al: generalized aa-amyloidosis in siamese and oriental cats bacterial culture results from liver, gallbladder, or bile in 248 dogs and cats evaluated for hepatobiliary disease accuracy of ultrasound guided fine needle aspirate of the liver and cytologic finding in dogs and cats: 97 cases acute necrotizing pancreatitis feline cholangitis syndrome oxidative stress and neutrophil function following oral supplementation of a silibininphophatidylcholine complex in cats laparoscopic diagnosis of pancreatic disease in dogs and cats s-adenosylmethionine in a feline acetominophen model of oxidative injury therapeutic use of cytoprotective agents in canine and feline hepatobiliary disease liver cytology inflammatory liver disease relationship between feline inflammatory liver disease and inflammatory bowel disease, pancreatitis, and nephritis fine needle aspiration cytology suggests hepatic lipidosis in 4 cats with infiltrative hepatic disease wsava standards for clinical and histological diagnosis of canine and feline liver diseases nutrition for anorectic, critically ill or injured cats the effects of s-adenosylmethionine on clinical pathology and redox potential in the red blood cell, liver and bile of normal cats proteins invoked by vitamin k absence in clotting times in clinically ill cats liver glutathione concentrations in dogs and cats with naturally occurring liver disease critical care nutrition extrahepatic biliary tract obstruction, a retrospective study of 45 cases (1983-1993) statistical relevance of ultrasound criteria in the assessment of different liver diseases in dogs and cats clinical differentiation of acute and chronic feline pancreatitis milk thistle (silybum marianum) for the therapy of liver disease surgery of the liver clinical features of inflammatory liver disease in cats: 41 cases (1983-1993) update on hepatobiliary imaging sensitivity of tru-cut and fine needle aspirate biopsies of liver and kidney for the diagnosis of feline infectious peritonitis generalised amyloidosis in two siamese cats: spontaneous liver haemorrhage and chronic renal failure severe cholestatic liver disease secondary to liver fluke (platynosomum concinnum) infection in three cats safety, pharmacokinetics and use of the novel nk-1 antagonist maropitant (cerenia) for the prevention of emesis and motion sickness in cats pancreatic ductal and interstitial pressures in cats with chronic pancreatitis infectious hepatopathies in dogs and cats abdominal ultrasonographic findings associated with feline infectious peritonitis: a retrospective review of 16 cases complications and longterm outcomes of the ligation of congenital portosystemic shunts in 49 cats clinical, clinicopathological, and histological changes observed in 14 cats treated with glucocorticoids hepatic encephalopathy. current concepts of the pathogenesis effects of oral ursodeoxycholic acids in healthy cats on clinicopathological parameters, serum bile acids and light microscopic and ultrastructural features of the liver uroperitoneum in cats: 26 cases (1986-1995) extrahepatic biliary tract surgery in the cat: a case series and review congenital portosystemic shunts in the cat: a report of nine cases feline cholecystitis and acute neutrophilic cholangitis: clinical findings, bacterial isolates and response to treatment in six cases diagnosis and management of peritonitis in small animals traumatic tricuspid insufficiency in a kitten underlying cause, pathophysiologic abnormalities, and response to treatment in cats with septic peritonitis: 51 cases spontaneous hemoperitoneum in cats: 65 cases primary bacterial peritonitis in dogs and cats: 24 cases a review of the pathophysiology, classification, and analysis of canine and feline cavitary effusions feline hepatic lipidosis uroabdomen in dogs and cats chylous ascites in cats: nine cases congestive heart failure and atrial fibrillation in a cat with myocardial fibrofatty infiltration comparison of different tests to diagnose feline infectious peritonitis arrhythmogenic right ventricular cardiomyopathy in two cats retrospective study: ionized calcium concentrations in cats with septic peritonitis: 55 cases management and outcome of cats with ureteral calculi: 153 cases progressive lymphocytic cholangitis in the cat surgical treatment of bile peritonitis in 24 dogs and 2 cats: a retrospective study feline hemoperitoneum 16 cases (1986-1993) duplex gall bladder associated with choledocholithiasis, cholecystitis, gall bladder rupture and septic peritonitis in a cat the cytologic examination of body cavity fluids a retrospective study of surgically treated cases of septic peritonitis in the cat chronic lymphocytic cholangitis in three cats primary bacterial septic peritonitis in cats: 13 cases pneumoperitoneum in dogs and cats: 39 cases chylous abdominal effusion in a cat with feline infectious peritonitis restrictive cardiomyopathy in a cat with hypereosinophilic syndrome kirk's current veterinary therapy xii: small animal practice feline infectious peritonitis: a review of clinicopathological changes in 65 cases, and a critical assessment of their diagnostic value differential diagnosis of ascites in cats abdominal paracentesis and diagnostic peritoneal lavage peritoneal effusion in cats: 65 cases (1981-1997) *when present for any length of time, a pure transudate will become modified. this is particularly true of transudates that develop slowly, such as those associated with congestive heart failure or portal hypertension. modified transudates are therefore more common than pure transudates. adapted from tasker s, gunn-moore d: differential diagnosis of ascites in cats, in practice 22:472, 2000. key: cord-011282-hgzneooy authors: david, yadin; judd, thomas title: evidence-based impact by clinical engineers on global patients outcomes date: 2019-07-02 journal: health technol (berl) doi: 10.1007/s12553-019-00345-0 sha: doc_id: 11282 cord_uid: hgzneooy the intersection of technological changes and societal evolution has transformed every aspect of human life. technological advancements are transforming how healthcare knowledge is expanding and accelerating the outreach of critical medical services delivery (jamal et al. in health information management journal 38(3):26–37, 2009). while this transformation facilitates new opportunities simultaneously it also introduces challenges (jacobzone and oxley, 2001). appropriate health technology (ht) is vital to new and existing global health care programs. therefore, qualified professionals who can safely guide the development, evaluation, installation, integration, performance assurance, and risk mitigation of ht must be in position to lead. trained clinical engineers (ce) and biomedical engineers (be) have been recognized by the world health organization (who) as the essential practitioners to providing this critically needed guidance. over the past four years, a senior professional group participated in an international project that seeks evidence for the hypothesis that the engagement of ce and be in guiding ht impacts positively on patient outcomes, while the alternative is that there is no difference. the group collected published data that was subjected to peer review screening; additional data qualification conditions are described in this paper. the project was initiated at the global ce summit during the first international clinical engineering and health technology management congress (icehtmc) in hangzhou, china in october 2015 (global clinical engineering summit at the first international clinical engineering and health technology management congress, 2015). following the adoption of a resolution to investigate ce contributions to the improvement of world health status, an international survey and literature survey were initiated. during the first two years of this project 150 case studies from 90 countries were identified covering the previous ten years. the results of this survey were presented to health leaders at the world health organization (who) world health assembly in 2016. last year, 250 case studies were added including 35 more countries covering the 2016–2017 period. the combined project contains 400 qualified submissions from 125 countries. the conclusion was that engagement of ce and bme is critical for successful investment in ht and for achieving intended patient outcomes. this paper describes the project’s plan, the results of the literature review performed, and the evidence identified during the process. the intersection of technological changes and social evolution has transformed every aspect of human life [1] . this transformation is expansive and most obvious in the changes that has been occurring over the past fifty years in the provisioning of healthcare services [2] . the dependence of health, rehabilitation, and wellness programs on technology for the delivery of services has never been greater [3] . therefore, it is essential that health technology (ht) be strategically guided and optimally managed [4] . guidance can only be provided by educated and experienced professionals who can safely lead the full life cycle of the technology, starting with innovation and progressing to development, regulatory compliance, evaluation, installation, training, integration, performance assurance, and risk mitigation. however, these professionals must be familiar with the relationship between contributions from ht and their impact on patient outcomes. the understanding of this relationship is a fundamental requirement for achieving optimal return on investment and improvement of outcomes. such practitioners are critical members of the healthcare team and should be in position to facilitate technology-related plans. beyond the ongoing healthcare burdens of population growth, political and economic instability, disease management, disasters, refugees, accidents, terror attacks, and increasing dependence level on technology, our world of healthcare systems is facing enormous challenges to manage its resources in the twenty-first century. the flood of scientific and technological innovation is radically redefining the nature of healthcare in virtually every dimension, from vascular nanoengineered interventions and predictive diagnostic tests to image guided surgery and remote telehealth-based services at the national and global levels. however, most healthcare systems are not adequately staffed to safely and effectively manage these forces of change. most systems are structured around vertically-expert professions (medical doctors, medical physicists, nurses, administrators), but lack the "horizontal expertise" that trained biomedical and clinical engineers (be&ce) provide. for example, the expertise in assessing and managing the integration and the performance of complex smart systems that have varying areas of service, durations of technological lifecycle [5] , hardware and software platforms, and middleware in support of integrated medical and surgical services. disproving the myth -that there is a lack of evidence to qualify how much the dependency of ht is well-guided by ce expertise and best practice methodologyled to our examination of published literature and formal presentations of case studies in which ces, bes, and those in similar roles have participated. this allowed us to answer the question whether their participation contributed to improvement in overall healthcare outcomes. in the field of ht management and ce, the incentives to publish studies are lower than it should be, resulting in limited volume of resources to develop best practice measures. despite these perceived limitations, our results were recently published [3] . in this paper, the focus is on the process used for the selection of data sources and the methodology to qualify their inclusion, described in the methodology section of this paper. on the other hand, over the past 50 years, concerns were expressed that there is a lack of knowledge by government agencies and key stakeholders, coupled with limited recognition for those contributions for the practitioners that guide the deployment, creation and safe deployment of health technology. our data answers these concerns. if the knowledge and the expertise of the global ce community does have a critical role in optimal guidance of ht deployment, how can that expertise be best demonstrated. the collection of the case studies (that were later called success stories) from all over the world can facilitate the determination if there is competency unique to ces around the world that leads the development and optimal management of these technology life cycles. having this knowledge can help to reach better understanding of the required strategy to achieve desired patient outcomes when technology is used in care and rehabilitation management. the ebola virus disease crisis [6] has demonstrated that multidisciplinary team expertise and collaboration are keys to success. low resources countries in particular face a challenge of improving their health services because, in addition to the above stated challenges, they also have scarce availability of professional expertise trained to address technology-related issues [7] . varied availability and state of infrastructure and human resources place higher demand on adequate management of ht innovation and deployment. the effective health workforce of the twenty-first century consists of more individual practitioners caring for complex health-issues and thus charged with deploying the most optimal benefits from medical technology, such as proper selection, effectiveness, timely access, and affordable. in academia, government, and industry, teams of be&ce translate design innovations and integrate knowledge of science, engineering, standards and regulations with clinical strategy to create new tools that save and improve lives while building more quality into patient outcomes. in hospitals, be&ce practitioners ensure that proper acquisition, installation, integration and operation of devices and systems are safe and efficient. with the increasing role of technology in the delivery health care services, professional competency of the entire span of the technology lifecycleacross systems and sectorsis critical to achieving the full benefits and best outcomes clinically, economically, and operationally. following the resolution adopted at the first international clinical engineering and health technology management congress [8] that took place in hangzhou, china, in october 2015, senior members from the ce profession from around the world who participated in the global ce summit [9] initiated the international project seeking evidence to the hypothesis that the engagement of ce and be in guiding ht deployment positively impacts patient outcomes while the null hypothesis was that there is no difference. the group identified the volume of published data that and developed criteria for inclusion pertinent and qualified publications. the rules are shown in fig. 1 below. several conditions were placed on the total volume of publications and formal presentations that were found. only sources that responded positive to the challenge of the criteria were included in the final examination. to begin with, the source must be subjected to peer-review screening. secondly, the source must include care-related outcomes in the body of the manuscript, thirdly the source had to be published in ifmbe [10] sponsored publication or event (meeting) proceedings, fourthly, the source must describe how ce or bme practices led to the second criterion of outcomes, and the fifth criterion limit the source inclusion to specific window of time. this window was defined as 2005-2015 for the first phase of this examination, and 2016-2017 for the second phase. during the first two years of the project 150 case studies from 90 countries were identified and satisfied the criteria described in fig. 1 . searching through the time span over a period of previous ten years (2005) (2006) (2007) (2008) (2009) (2010) (2011) (2012) (2013) (2014) (2015) . the results of the initial review were presented to health leaders from member countries at the who world health assembly in 2016. the interest generated in the project helped to sustain its work and as a result of the continuation of data analysis the team identified and qualified additional 250 case studies from a total of 125 countries covering the period of the 2016-2017. the combined project's two stages examine and qualified over 400 qualified submissions from 125 countries. next, we looked at the methodology of putting together peer recognized clinical engineering experts from around the world, all members of the ifmbe clinical engineering division and issued a call for collections of papers from around the world, that will demonstrate what is the involvement and what is the contribution of individual programs from around the world in the ce arena. within 6 months, in 2016, we were able to collect a vast volume of evidence that was qualified and filter into 150 specific studies from 90 countries. the literature sources and the results of the examination are presented, grouped into six categories of outcomes impact. the resulting qualified volume of sources were categories into groups. the six groups were created to facilitate decision if sufficient evidence has been accumulated to support conclusion of outcomes. while the six categories were reviewed independently the significant overall commonality is that they all address different aspects of ht technology's impact on outcomes. data collected that met the inclusion criteria was grouped into six categories as follows: through provision of new ht solutions, adaptation of existing, or a combination to address several issues. ease in reaching ht-related health services or facilities in terms of location, time, and ease of approach. positive impact from more efficient and effective deployment of ht at national or policy level. ht's positive impact on health services safety or quality outcomes, or through ht human resource development. establishing or improving htm methodology resulting in improved population health or wellness. improvements achieved due to deployment of internet-based ht tools.following phases of the technology life cycle the analysis of the data began with the group that starts the cycle -with the innovation phase. innovation and the provision of new solutions to existing problems. the next group, reasonable progression to health services. where the question to address was the possible existence of evidence to demonstrate that the access to health care services has increased because of technology management programs. or, did the ht management program established methodologies that improve the overall finance and/or wellness of the population. after that, review of data was conducted with regard to overall impact on national or regional systems or multi-hospital health systems. safety and quality services that dependent on complex technological systems is critical for outcomes and therefore identified with its own group of data technology management group was the next category to be reviewed where ce/bme contributions to organized, integrate, manage, and improve safe and efficient sustainable ht. finally, in a way of looking forward the future, the group of e-technology where telemedicine, image guided interventions, informatics and disaster response operation were grouped together. making assumption that with the introduction of complex technological systems improvements in patient care safety and the quality of services receive were evident. with review of data in these six categories this study was able to cover major activities that are technology-dependent in health. successful source (or submission) was defined as satisfying objective measures developed by the investigators: timeliness, cost saving, deployment or adoption by care providers, impact on services, and overall projection for success. each success metric was evaluated using 3-point scale against a statement representing the success construct (1 = strongly disagree; 3 = strongly agree). timeliness refers to whether the project/submission was implemented in timely manner. this was measure by the statement "the submission will impact outcomes on present time." the cost measure was evaluated on whether the submission's overall costs were within budget constraints and reasonable for the conditions in the region. this was assessed by the statement, "the submission cost objectives can be met in the region." the final two metrics were combined into the statements "the submission will be deployed by its intended users" and "the submission will have a positive impact on those who will adopt it." finally, overall submission success was assessed with the statement "all things considered, the submission will be a success." success was determined when the source received overall rating of 2 or above. sources for data collection included the following: ifmbe/ clinical engineering division (ced) 2016 health technologies resources [11] document provided to the world health assembly, who in may 2016, the 2nd and 3rd global forums on medical devices [12] organized by the world health organization ifmbe/ ced's china and brazil icehtmc [12] october 2015 and september 2017 respectively, others [13] ifmbe journals proceedings and published sources from the period 2016-2017. the results containing criteria inclusive and qualified data were tabulated and categorized into six categories that are described in tables below. the tables provide detailed information about the category of the submission, the region summitted it, the submission title and authors identification. each of submission is accompanied by hot link facilitating further data and evidence details that the reader is welcome to pursue. the data in these tables with the accompanied links demonstrates that evidence exists for benefit registered in each of the six categories from every region around the world. overall this review identified evidence from 400 case studies received from 125 countries where management of medical devices (as main component of health technologies) made a positive difference over the past twelve years. the results of first phase of the literature survey were incorporated into a document that in may of 2016 was successfully presented to the world health assembly consisting of member country delegations of ministry of health from around the world to who in geneva switzerland [14] . data collection and analysis was conducted over three years period employing the same selection factors as shown in fig. 1 . the analysis shows that volume of evidence exists in the literature to demonstrate the important and critical contributions of ce and bme to the initiation of new and improvement of present care outcomes. these contributions are evident on every continent and every day of the year. not just randomly but continuously 24x7x365 days. after the completion of the two phases of this literature survey 400 publications from 125 countries document evidence and showing the success of clinical engineering competency serving on the healthcare delivery team (tables 1, 2, 3, 4, 5 and 6). the case studies are actually ht success stories demonstrating, in a limited resource environment, that it is desirable to include professional ht expertise, such as clinical engineers, in national decision-making in order to maximize health systems' services. case studies from the links on the following pages demonstrate these benefits: & access: the ministry of health ht unit-led project in albania that doubled access to critical diagnostic services, such as computed tomography scanners, magnetic resonance and angiography imaging, while reducing equipment downtime to zero, and significantly reducing cost. & health systems: improved coordination between multiple stakeholders in the national laboratory and its satellites in colombia, led by the ministry of health and clinical engineers who partner with experts from academia and industry. & quality & safety: a clinical engineer-led 122-hospital program in the shanghai region that cooperates with officials, industry, and academic entities, resulting in improved device user satisfaction, tracking of emerging technologies, and closer partnerships with industry. & table 1 innovation & table 2 access & table 3 management & table 4 health systems & table 5 e-technology & table 6 quality & safety in all of the above mentioned topics, data collection, review and validation continued throughout the project period as access to ifmbe sponsored events and related publications was secured in phases. during 2017 and 2018 we added more evidence that was qualified by our criteria. 250 additional stories from additional of 35 countries, were now increasing the overall count to 400 publications from 125 countries. all with evidence, showing the success from ce involvement in the relationship to improving patient outcomes, and the derived benefits from ht creation, management, and deployment. involvement that is documented through services provided over 365 days a year, 24 h a day, 7 days a week. to be included in the project evidence database, shown in the tables above, each entry must comply with conditions for inclusion and with performance parameters described earlier of timeliness, costsaving, extent of deployment or adoption by care providers, impact on overall services and estimated projection for the entry success. the timeliness parameter complied if an impact has been described in the entry as immediate as in present tense. other parameters were similarly considered similarly. all entries included can be viewed through the on-line links provided in the tables. the hot links to all the resources the task force reviewed and qualified were validated. the tables are color coded to facilitate ease readers interest of seeking additional details for a specific technology category. examples of entries from the table above describe details as follow: in the innovation category, for example, anne-louise smith from adelaide, australia, with a team of clinicians identified a need for solution to specific clinical problem related to retrieval to transfusion of fluids of patients who maybe in a shock. no device was able to meet the need of fulfilling the task without external power source. the entry -bme development of non-electric portable blood/fluid warmer for roadside trauma, describe the critical contribution of ce to create solution, test it, identify and resolve usability barriers and bring it to commercialization. transferring of patients in rural areas is now safer and having better patient outcomes. the engineering expertise and the collaboration with physicians were key factors for the success evident in this entry. in the health systems category: bilal beceren, from turkey, affiliated with ministry of health (moh) of turkey practices at the national ht management program, involved 800 public hospitals. prior to 2013 there was no moh based program and knowledge of the medical technology assets deployed. they embarked on national project in 2015 that built information about medical assets purchasing, commissioning and facilitated better performance support. ce training was initiated, and maintenance support has increased. the outcomes show that medical technology has been acquired under better terms, more efficiently maintained, the uptime of 95% for covered inventory now was reachable facilitating better patient care. annual audits conducted since show that from unknown level prior to 2013 the program in 2015 reached coverage of 88% of the inventory in the country. national health technology management system for public hospitals in turkey improve the performance and cost efficiency of the technology that patient management is dependent upon. in the access category: ledina picari from the moh in albania, a clinical engineer by training identified concern about the access to diagnostic services. diagnostic imaging technology was not properly maintained and equipment up time did not meet patients' need. in 2014 a collaborative national project was initiated to examine the state of equipment management and identify opportunities for increasing access to diagnostic services, to increase clinical availability of diagnostic technology at the local level, and to increase efficient and effective use of public funds. the evidence provided shows that in 2015 the volume of ct examinations more than doubled from 3157 to 6602 exams while the equipment downtime was reduced from almost four months a year down to near 0 days. this is important achievement that in addition delivered the benefit of reducing the maintenance costs from about 10 to 12% before the project was initiated down to 8% of the purchase price per annum afterwards. diagnostic technology availability significantly improves patient's outcome. a second example in the access to health services category that bridges to e-technology and specifically a telemedicine program was initiated with ce guidance (yadin david) in houston, texas. the project aimed at connecting rural community in central america village in the safety and quality category, li bin, a ce from shanghai, china, identified the need for having better technology quality control as there was not clear measure in the management of the technology in large network of care providers before 2005. network of care providers facilities in community of 23 million population, 122 hospitals above grade two, and about 1000 ce & bme in the region. as result of this project in 2016 they changed the conditions from lack of quality standards in purchasing and servicing of diagnostic technology they implemented enhanced management program with collaboration of industry. data sharing and benchmarking information led to better cooperation between the parties, improve service personnel training, the initiation of annual quality improvement reporting and to sustain readiness of technology to serve clinical objectives. they now know that there are 26 billion yuan of medical equipment assets, this is about 4 billion dollars usd that due to ce management improved outcomes for both financial investment in technology and clinical services to patients. the e-technology category has another example of how be & ce contributed to better outcomes, specifically during the devastating earthquake in port-au-prince, haiti. in that occasion, article of new england journal of medicine, march 2010, describes how 109 support staff, including ce, arrived at haiti and within two days after the earthquake, established a field hospital that was able to treat 1100 patients, performed 320 surgeries, and delivered 16 babies. the first baby born there was named by his mother 'israel'after the group origin that came to establish the field hospital there. finally, in the ht management category, in brazilian rainforest, we found another evidence for how ce expertise has helped to achieve better patient outcomes and improving care. ryan pinto ferreira from university of campinas, optimal transportation method and assembly all the medical devices that clinicians needed. they transport it over the challenge of difficult route, to be placed in a highly humid rainforest environment. they assembled, commissioned, and operated the equipment and provided support for clinical services that those patients needed. at the who, in the health systems category, adriana velasquez have implemented many technology-based patient care programs that have far reach all over the world. her collaborative efforts perhaps best known through assembling networking of international stake holders during the successful series of global forums on medical devices. another successful contribution she achieved has been the development and dissemination of international publication and resources [65] for addressing ht issues such as creating a resource for global atlas of medical devices, global model for regulatory framework, medical device policies, compendium of new and emerging health technologies, human resources ht is vital to health and the dependence of health, rehabilitation, and wellness programs that rely on ht for the delivery of their services has never been greater. beyond the ongoing healthcare burdens of population growth, political and economic instability, disease management, disasters, the refugee crisis, accidents, and terror attacks, world healthcare technological systems are facing enormous challenges to be innovative and optimally managed. the transition into health programs for the 21st century requires the employment of trained competent ce professionals. disease prevention, treatment, and rehabilitation is more efficient and effective when health services are provided with appropriate tools. along with world health organization (who) [66] , the international it is critical, therefore, that with limited availability of resources, ht must be professionally managed and its creation and deployment over its life-cycle be appropriately guided. this paper describes the extensive study of published data on the vast contributions by ce that positively impact patient outcomes. this finding of this study shows that every region of the world including lowresource regions face a challenge of improving health services while facing varied levels of infrastructure and human resources capacity challenges. ces play vital roles in all stages of healthcare technology life-cycle management. from creation to planning, and from commissioning to utilization and integration; technology-based systems must and can be managed for optimal performance. in each of the technology life-cycle stages the requirement for trained and competent ce input makes critical difference as evidence show in the analyzed data reviewed above. it is our hope that government agencies and other interested parties will have better understanding of ces role and thus will support their inclusion in the healthcare team of professionals. the identified and qualified 400 case studies shown in this manuscript support the need to expand the reach of ce community in order to provide competent guide to management of healthcare technologies around the world. case studiesgrouped in 6 categoriescan assist to formulate national strategies and plans on how to improve the creation and deployment of ht while improving quality of care and efficient use of scares funding. in several countries, case studies demonstrated, this has best been achieved by developing a ht unit at the level of ministry of health that engages the ce community. these studies provide evidence that ht is beneficial; however, at times, deployment of such complex systems when it is not effectively guided and managed may not realize intended outcomes for optimal impact. the 2007 who wha resolution 60.29 urges member states to create national ht management plans in collaboration with clinical and biomedical engineers. who further clarified the definition of these personnel in 2017-2018 as part of a global survey [67] in coordination with ifmbe/ced. "trained and qualified biomedical engineering professionals are required to design, evaluate, regulate, maintain and manage medical devices, and train on their safe use in health systems around the world.5" these occupations have various names in different countries like clinical engineers, medical engineers, … and related professionals and technicians." we encourage the dissemination of survey tools as describe here to better understand the need for and monitoring of progress towards safe, appropriate and optimal quality care outcomes. the authors express gratitude for the intense work invested by members of the project task force and for kallirroi stavrianou for creating and validating all of evidence links on the tables above. conflict of interest the authors declare that they have no conflict of interest. ethical approval this article does not contain any studies with human participants or animals performed by any of the authors. informed consent informed consent was not obtained since there were individual participants included in the study. using technology to advance global health, proceedings of a workshop, forum on public-private partnerships for global health and safety a systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation making a difference -global health technology success stories: overview of over 400 submissions from 125 health technology assessment task group, advisory committee on information and emerging technologies managing medical devices within a regulatory framework ebola virus disease, infection prevention and control recommendations for hospitalized patients under investigation (puis) for ebola virus disease (evd) in u.s. hospitals, center for disease control and prevention (cdc) defining the medical imaging requirements for a rural health center, health technology task group (httg) of the international union of physical and engineering sciences in medicine (iupesm) clinical engineering/ health technology management 2015 global update invitation letter for the global ce summit, advisory group who -third who global forum on medical devices, medical devices model fitting and simulation of the respiratory control system under incremental exercise and altitude in healthy subjects modeling and simulation of ciprofloxacin pharmacokinetics: electric circuits approach autoregressive models of electrocardiographic signal contaminated with motion artifacts: benchmark for biomedical signal processing studies parametric modeling of kinetic-kinematic polycentric mechanical knee motion artifacts recognition in electrocardiographic signals through artificial neural networks and support vector machines for personalized health monitoring optimization of spectral analysis of electrophysiological recordings of the subthalamic nucleus in parkinson's disease: a retrospective study three dimensional reconstruction and airflow simulation in a realistic model of the human respiratory airways permanent magnets to enable highly-targeted drug delivery applications: a computational and experimental study brain functional connectivity in parkinson's disease -eeg resting analysis supporting diabetic patients with a remote patient monitoring systems impedance-based monitoring for tissue engineering applications current and future trends in the hta of medical devices hta of a large tablet system in digital pathology survey of prolonged mechanical ventilation in intensive care units in mainland china (eds) international conference on advancements of medicine and health care through technology; 12th -15th telemedicine and mhealth system for complex management in t1dm and t2dm patients: results of 6 months study testing of dialysis machines in healthcare institutions in bosnia and herzegovina health technology assessment applied to health technology management through clinical engineering estimation of the optimal maintenance frequency of medical devices: a monte carlo simulation approach teaching maintenance of medical devices in simulation centers: a pilot study clinical engineering online courses for africa a novel approach to improve the technical maintenance of biomedical equipment the benefit of in-hospital clinical engineer services for medical devices maintenance medical equipment maintenance personnel and training in zambia the potential power of sub-saharan africa professional associations for biomedical/clinical engineering professionals status of biomedical engineering education in the asia pacific cost estimate methodology in procurement processes of me study of medical device purchasing cycles through temporal series analysis rios cuartas i, identifying the needs in the integration of disciplines in the hospital infrastructure management in colombia trading barriers in the medical devices industry. are these barriers hindering the development of this sector in cuba hospital based hta -implementation for the czech republic ifmbe/clinical engineering division projects for the advancement of the profession of clinical engineering the potential role of ifmbe in improving the state of medical equipment in developing countries assessing the impact of a cis/pacs technology for a cardiology department using qfd methodology the status of bme programs in latin america medical devices management strategy in the republic of moldova a comprehensive system for healthcare technology management htm how clinical engineers will solve the billion dollar healthcare funding gap indicators for evaluating and measuring the impact of healthcare infrastructure and technology management on investments, service delivery and quality of care becoming of ubiquitous sensors for ubiquitous healthcare study on medical equipment location systems that use rfid technology (eds) international conference on advancements of medicine and health care through technology; 12th -15th integrating an electronic health record graphical user interface into nanoelectronic-based biosensor technology camacua: low cost real time risk alert and location system for healthcare environments assessing risk in the kaiser permanente clinical technology program intelligent system for identification of patients in healthcare design of a web-based medical equipment management system for clinical engineering technological surveillance and integrity monitoring of infusion systems implementation of six sigma on corrective maintenance case study at the directorate of biomedical engineering in the jordanian ministry of health human resources for medical devices, the role of biomedical engineers, who, medical devices the impact of health information technology on the quality of medical and health care: a systematic review healthcare expenditure a future in question 0 1 5 + & f o r m = e d g h p t & q s = h s & c v i d = & r e f i g = 228dd87718b544a99098c75f7cf91781&cc=us&setlang=en-us&plvar=0&pc=dcts publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord-258281-gxwk8jq9 authors: wenling, yao; junchao, qiu; xiao, zhirong; ouyang, shi title: pregnancy and covid-19: management and challenges date: 2020-08-31 journal: revista do instituto de medicina tropical de sao paulo doi: 10.1590/s1678-9946202062062 sha: doc_id: 258281 cord_uid: gxwk8jq9 the consequences of covid-19 infecting pregnant women and the potential risks of vertical transmission have become a major issue. since little is currently known about covid-19 in pregnancy, the understanding of covid-19 in this particular group will be updated in time, and a comprehensive review will be useful to evaluate the impact of covid-19 in pregnancy. based on recently published literature and official documents, this review provides an introduction to the pathogenesis, pathology, and clinical features of covid-19 and has focused on the current researches on clinical features, pregnancy outcomes and placental histopathological analysis from pregnant women infected with sars-cov-2 in comparison with sars-cov and mers-cov. these viruses trigger a cytokine storm in the body, produce a series of immune responses, and cause changes in peripheral leukocytes and immune system cells leading to pregnancy complications that may be associated with viral infections. the expression of ace2 receptors in the vascular endothelium may explain the histological changes of placentas from pregnant women infected by sars-cov-2. pregnant women with covid-19 pneumonia show similar clinical characteristics compared with non-pregnant counterparts. although there is no unequivocal evidence to support the fetal infection by intrauterine vertical transmission of sars, mers and sars-cov-2 so far, more and more articles began to report maternal deaths due to covid-19. in particular, from february 26, 2020 (date of the first covid-19 case reported in brazil) until june 18, 2020, brazil reported 124 maternal deaths. therefore, pregnant women and neonates require special attention regarding the prevention, diagnosis and management of covid-19. a series of a new coronavirus pneumonia (ncp), whose pathogen is the novel 2019 coronavirus (2019 -ncov) was officially recognized by the world health organization on february 11, 2020 and the disease was called covid-19. meanwhile, the international committee on taxonomy of viruses named the 2019 novel coronavirus as sars-cov-2. at 10:00 a.m. on march 30, 2020, a total of 82,447 confirmed cases and 3,310 deaths had been reported in china, with a case fatality rate of 4.0%, while there were 693,224 confirmed cases and 33,106 deaths worldwide, with a case fatality rate of about 4.8% 1 . furthermore, the epidemic had a tendency to spread around the world. therefore, the who has raised the global risk of the covid-19 epidemic to the highest level (very high). together with the other two highly pathogenic coronaviruses, the sars-cov and mers-cov, sars-cov-2 poses a global threat to public health. pregnant women are particularly vulnerable to respiratory pathogens and severe pneumonia due to physiological and immunological changes, such as altered t lymphocyte immunity, increased oxygen consumption, decreased functional residual capacity and decreased chest compliance, which may result in higher maternal and fetal morbidity and mortality 2 . furthermore, pregnant women with pneumonia have a significantly higher risk of giving birth to low birth weight, as well as preterm and, small for gestational age infants, with low apgar scores, born by cesarean section, whose mothers presented with preeclampsia/ eclampsia more often than uninfected women 3 . however, there is still insufficient data to evaluate the impact of covid-19 on pregnant women. considering that sars-cov-2, sars-cov, and mers-cov are all β-coronaviruses, and their genomes, pathogenesis and clinical symptoms have certain similarities, this article draws lessons from previous studies on sars-cov and mers-cov infecting pregnant women to predict the impact of sars-cov-2 on pregnant women and fetuses and make some suggestions. the functional receptor for sars-cov is the angiotensin-converting enzyme 2 (ace2) 4 , which is abundantly present in lung alveolar epithelial cells and enterocytes of the small intestine, as well as in arterial and venous endothelial cells and arterial smooth muscle cells in virtually all of the organs 5 . in contrast, mers-cov uses the dipeptidyl peptidase 4 (dpp4) as its receptor 6 . dpp4 is widely expressed on epithelial cells in the kidney, alveoli, small intestine, liver, prostate and activated leukocytes 7 . sars-cov-2 is a novel β-coronavirus from the subgenus sarbecovirus, genetically similar to sars-cov (about 79%) and mers-cov (about 50%) 8 . like in sars-cov infections, ace2 is the cell receptor for sars-cov-2 9 . the spike proteins of these viruses bind with cellular receptors of sensitive cells to mediate the infection of their target cells, after which viral replication begins in the cell cytoplasm. sars-cov and mers-cov were both found to be able to show extremely high and early replication rates, infecting dendritic cells, macrophages and t cells 10-13 , using several strategies to avoid the host innate immune response 11, 14 , and resulting in a robust and sustained production of proinflammatory cytokines and chemokines 11, 12, 15, 16 17 . il6 (interleukin 6) levels in patients with severe covid-19 were also significantly higher than in patients with milder infections 18 . these results suggest that the cytokine storm may also play a relevant role in the development of covid-19. the pathological features of covid-19 greatly resemble those seen in sars and mers coronavirus infections [19] [20] [21] [22] [23] . diffuse alveolar damage is the predominant pulmonary histological pattern. other changes included hyaline membrane formation, alveolar hemorrhage, desquamation of pneumocytes, extensive infiltration of neutrophils and macrophages in the interstice and alveoli. an interesting report showed the pathological characteristics of a patient who died from a severe infection by sars-cov-2 and underwent postmortem biopsies 23 . both lungs showed diffuse alveolar damage with cellular fibromyxoid exudates and interstitial mononuclear inflammatory infiltrates, with predominance of lymphocytes. the right lung showed evident desquamation of pneumocytes and hyaline membrane formation and the left lung showed a pulmonary edema with hyaline membrane formation, related to the acute respiratory distress syndrome (ards). a recent study reported that the lung histopathology in the early phase of covid-19 pneumonia include edema, proteinaceous exudate, focal reactive hyperplasia of pneumocytes with patchy inflammatory cellular infiltration, and multinucleated giant cells 24 . diffuse alveolar damage with hyaline membranes and pulmonary edema play important roles in ards. pregnant women with ards are more prone to hypoxia, their oxygen consumption is increased by 20% and their functional residual pulmonary capacity is decreased during pregnancy, rendering the woman intolerant to hypoxia. severe pneumonia is characterized by hypoxemia, which subsequently leads to placental hypoxia. the hypoxic placenta releases antiangiogenic and proinflammatory factors that converge to the maternal endothelium, inducing endothelial dysfunction, hypertension, and organ damage 25 . women with pneumonia during pregnancy have a significantly higher risk of adverse pregnancy outcomes, such as preterm delivery, pre-eclampsia, low birth weight and small-for-gestational-age infants 2,3,26 . therefore, severe maternal respiratory distress syndrome may affect the fetal oxygen supply and endanger the fetus. in a study of the placental histopathology of mothers with sars 27 , a total of seven placentas were studied. two placentas from women recovering from sars in the first trimester were normal. three placentas from women that gave birth during the acute stage of sars showed an increase in intervillous and subchorionic fibrin, and these findings may be related to disturbances in maternal placental blood flow due to hypoxia. two placentas from women recovering from sars in the third trimester of pregnancy were found to have an extensive thrombotic vasculopathy on the fetal side (ftv). the etiology of ftv may be related to the tendency to thrombosis due to sars and/ or placental hypoxia. these two pregnancies were also accompanied by intrauterine growth restriction, oligohydramnios and small for gestation newborns. a recent study analyzed the placental histopathology of three pregnant women who were infected by sars-cov-2 in the third trimester of pregnancy, and all of them presented with mild disease 28 . in one of the placentas a chorioangioma was evidenced, and another placenta showed multifocal infarctions. all three cases had varying degrees of increment of intervillous or subchorionic fibrin associated with increased syncytial nodules. no villitis or chorioamnionitis were found. whether these changes were caused by placental ischemia due to 2019-ncov infection still needs to be further investigated by enlarging the sample size. in humans, maternal viral infections caused by ah1n1, dengue and hiv have been associated with impaired maternal and fetal hemodynamics and abnormal placental villous architecture. a healthy functioning placenta relies on a proper vascularization and perfusion of the placenta. early studies indicated that systemic maternal infection and consequent inflammation can disrupt the placental vasculogenesis and angiogenesis and the alterations in placental hemodynamics may contribute to adverse pregnancy outcomes including preeclampsia, preterm delivery, small-for-gestational-age, low birth weight infants and stillbirths. in addition, it is believed that placental ischemia/ hypoxia can trigger an increased production of inflammatory biomarkers, such as il6 and tnfα, which contribute to endothelial dysfunction in preeclampsia 29 . the clinical features of sars-cov and mers-cov infections are similar but patients with mers have a higher incidence of acute respiratory distress syndrome, which may explain why the fatality rate of sars is about 10%, while in mers it is about 36%. the major clinical features of sars-cov infections include persistent fever, chills or rigor, myalgia, dry cough, headache, malaise and dyspnea. sore throat, rhinorrhea, sputum production, nausea, vomiting and dizziness were less common. in contrast, sars and mers-cov infections usually start with fever, cough, chills, sore throat, myalgia and arthralgia, progressing with dyspnea and a rapid development of pneumonia within the first week, usually requiring respiratory support and ventilation, as well as other supportive measures 30 . in comparison with sars, patients with mers are older, with male predominance, a higher incidence of comorbidities and relatively lower human-to-human transmission potential 31 . pregnant women infected with mers may develop severe disease with fatal consequences, including stillbirths [32] [33] [34] [35] . the transmission route of covid-19 is similar to the ones of sars and mers, mainly spread by respiratory droplets and direct contact. it is unclear if covid-19 can be transmitted by the fecal-oral route, given that sars-cov-2 has been identified in stool specimens 36 . sars-cov-2 can also infect the lower respiratory tract and cause pneumonia, but its symptoms seem to be milder than in sars and mers 37 . among all covid-19 cases, severe manifestations accounted for 18.1% 38 . data suggest an incubation period of about 5 days (range 2-14 days). fever, cough, myalgia, fatigue and dyspnea were the most common clinical manifestations, whereas diarrhea, hemoptysis, headache, sore throat and shock only occur in a small number of patients 17,38-41 . bilateral ground-glass or patchy opacities were the most common signs of radiological abnormalities 17,38-41 . lymphopenia and eosinopenia were observed in most patients 17, [40] [41] [42] . the viral load of 2019-ncov detected from the patients' respiratory tract was positively correlated with the lung disease severity 42 . complications of covid-19 included the acute respiratory distress syndrome, anemia, acute cardiac injury, and exuberant secondary infections 17 . the majority of patients were older than 50 years 39-41 . sars-cov-2 is more likely to affect elderly men suffering from chronic comorbidities that may lead to serious and even fatal respiratory failure 41, 43 . the case fatality rate of patients with 2019-ncov infection is lower than those of sars and mers. twelve pregnant women were diagnosed with sars in hong kong between february 1 and july 31, 2003 44 . all patients had high fever (>38 °c) and most presented with chills, rigor, malaise, myalgia and lymphopenia. only 33% of the pregnant patients presented with shortness of breathe. six (50%) were admitted to intensive care units because of hypoxemia. four (33%) required mechanical ventilation, three of whom, died from respiratory failure or nosocomial infection. among seven pregnant women in the first trimester, four had spontaneous miscarriages, two underwent termination of pregnancy due to social reasons and one had an uncomplicated ongoing pregnancy. all five newborns in the second and third trimester groups survived and four of them were delivered by cesarean section. four newborns (80%) were preterm and three of them were delivered by emergency cesarean sections due to the deterioration of maternal respiratory conditions. among the live newborn infants, none had clinical or laboratory evidence of sars-cov2 infection. zhang et al. 45 reported five primigravidas with sars (including 2 twin pregnancies) from guangzhou, china. two were infected in the 2 nd trimester while the other three in the 3 rd trimester. two presented with hospital-acquired infections and the other three had community-acquired infections. all five pregnant women had fever and abnormal chest x-ray. other symptoms included cough (n=4), hypoalbuminemia(n=4), chills or rigor (n=3), elevated alanine aminotransferase (n=3), decreased lymphocytes (n=2) and decreased platelet count (n=2). all five pregnant women were cured with one of them required intensive care hospitalization. in a twin-pregnancy, one of the fetuses evolved to intrauterine death. the five neonates were followed-up and none had evidence of sars. there were no cases of vertical transmission identified among pregnant women infected with sars 44-49 so far, but sars during pregnancy is associated with high incidences of spontaneous miscarriage, preterm delivery, intrauterine growth restriction, endotracheal intubation and admission to the neonatal intensive care unit [44] [45] [46] . there are limited data on the clinical features of mers-cov during pregnancy. only 11 cases of mers-cov in pregnancy have been documented [32] [33] [34] [35] 50, 51 . the clinical presentations of pregnant women with mers were variable and ranged from asymptomatic presentations to shortness of breathe, fever, cough, myalgia and even fatal cases. seven (63.6%) patients required icu hospitalization and three (27%) patients died during the hospital stay. regarding the infants, three (27%) infants died. only one case resulted in both maternal and fetal death: the infant died four hours after birth and the mother died of severe refractory hypoxia and cardiac arrest 24 days after delivery. there were other two cases of intrauterine fetal demise, one maternal death for septic shock eight days after delivery, and one maternal death due to multiple organs failure 19 days after delivery. few studies documented mers-cov testing in infants, except one report of an infant whose blood sample did not contain any igg, igm, or iga antibodies raised to mers-cov 52 . although data are limited, they also indicate that mers infections may cause unfavorable clinical outcomes in pregnancy. chen et al. 53 performed a retrospective review of medical records from nine pregnant women with covid-19 pneumonia in the zhongnan hospital, wuhan university, from january 20 to 31, 2020. none of the nine patients developed severe pneumonia requiring mechanical ventilation or died of covid-19 pneumonia (february 4, 2020). seven of the nine patients presented with fever but none had high fever (> 39°c). other symptoms, including cough (n=4), myalgia (n=3), sore throat (n=2), malaise (n=2), lymphopenia (n=5), and elevated crp (n=6) were also observed. all nine patients had cesarean sections during the third trimester and nine live births were recorded. one infant had a slightly increase in myocardial enzymes but without any clinical symptoms nine days after birth. none of the newborns needed special pediatric treatment. neonatal throat swabs, amniotic fluid, cord blood and breast milk from six patients were tested, all of them were negative for sars-cov-2. zhu et al. 54 retrospectively analyzed the clinical features and outcomes of 10 neonates, including two twins, whose mothers had covid-19 and were hospitalized in five hospitals of hubei, from january 20 to february 5, 2020. among these nine pregnant women, the initial symptoms were fever and cough, one patient also had diarrhea. there were some prenatal complications including prematurity (5 to 7 hours before the onset of the true labor), intrauterine distress (n=6), abnormal amniotic fluid (n=2), rupture of membranes (n=3), abnormal umbilical cord (n=2), and abnormal placenta (placenta previa) (n=1). among these 10 newborns only four were full-term infants and the other six were preterm infants; and one was a large-forgestational-age (lga) infant, while two were small-forgestational-age (sga). the newborns' symptoms were mainly short of breathe (n=6), digestive tract symptoms (n=4), fever (n=2), abnormal liver enzymes accompanied by thrombocytopenia (n=2), neonatal respiratory distress syndrome (nrds) (n=2), increased heart rate (n=1) and vomiting (n=1). until this article was published, five neonates had been cured and discharged from hospital, four neonates were still hospitalized in stable conditions and one died. pharyngeal swab specimens were collected 1-9 days after birth, from nine of the 10 neonates, and none of them were positive to sras-cov-2. on february 5, 2020, one newborn whose mother had confirmed covid-19, was admitted at the wuhan children's hospital of hubei province presenting with stable vital signs, no fever or cough, normal liver function, absence of respiratory symptoms and normal chest x-ray. throat swabs collected from the newborn 30 hours after birth were positive to sars-cov-2 but there was no direct evidence of intrauterine-acquired infection. unfortunately, amniotic fluid, umbilical cord blood and placenta were not tested, thus one cannot conclude if this is a case of vertical transmission or a perinatal transmission by close contact with the infected mother. in the same hospital, another newborn had confirmed covid-19 infection 17 days after birth and a history of close contact with two confirmed cases 55 , the infant's mother and the maternity matron. in this case, there is no reliable evidence to support the vertical transmission of covid-19. one mother tested positive for sars-cov-2 two days after delivery 56 . she was admitted to the hospital due to elevation of her liver enzymes and had no fever or digestive tract symptoms when admitted to the hospital. covid-19 was confirmed after delivery, and the prenatal infection cannot be ruled out. no sars-cov-2 was detected in the blood, urine, breast milk and in the throat swab of the newborn. there was no neonatal asphyxia, but the cardiac myoglobin and ck-mb enzymes were increased in the newborn, suggesting that a myocardial injury might exist. liu et al. 57 reported 13 pregnant patients with laboratoryconfirmed sars-cov-2 infection admitted to hospitals outside of wuhan between december 8, 2019, and february 25, 2020. ten patients (77%) presented with fever (range 37.3-39.0 °c), mostly accompanied by fatigue. three patients (23%) complained of dyspnea and one patient (7.6%) developed severe pneumonia with multiple organs dysfunction syndrome requiring icu hospitalization in the third trimester. three patients (23%) improved after treatment and were discharged with an ongoing pregnancy. the other 10 patients (77%) underwent caesarean sections. five out of 10 (50%) patients had pregnancy complications including fetal distress (n=3), premature rupture of the membranes (n=1) and a stillbirth (n=1) and six patients (60%) had preterm infants. no severe neonatal asphyxia was observed in the nine live births and no vertical transmission was found. yu et al. 58 reported seven pregnant women with covid-19 admitted to tongji hospital in wuhan, china. six patients (86%) had fever, one patient (14%) had cough, one patient (14%) had shortness of breathe and one patient (14%) had diarrhea. chest tomography (ct) revealed that six patients (86%) had bilateral pneumonia and one patient (14%) had unilateral pneumonia. no one needed icu hospitalization and the outcomes of these pregnant women were favorable. among three infants tested for sars-cov-2, one was positive to sars-cov-2 in a throat swab 36 h after birth. this infant had a mild pulmonary infection and mild shortness of breathe, no fever or cough. in addition, the placenta and cord blood of this infant were negative for sars-cov-2 by rt-pcr so that intrauterine vertical transmission may not have occurred. since ahmed et al. 59 reported the first maternal death of a 29-year-old pakistani woman was reported in the heart zone hospital in birmingham, uk on april 8, 2020, more and more articles began to report maternal deaths due to covid-19. in particular, from february 26, 2020 (date of the first covid-19 reported case in brazil) until june 18, 2020, brazil had already reported 124 maternal deaths, in the same period mexico had reported seven maternal deaths 60 . brazil's elevated covid-19 mortality rate in pregnancy might have several explanations. firstly, a possible shortage of healthcare providers and lack of intensive care resources are some of the chronic challenges in brazilian health care. secondly, brazil has a higher cesarean section rate than most countries firstly hit by covid-19 60 . a comparison of pregnant women from the above described studies is shown in table 1 . this is a review on pregnant women infected by sars-cov-2, sars, and mers, including their pathogenesis, clinical manifestations and pregnancy outcomes. these viruses mainly spread through the respiratory mucosa and infect other target cells, triggering a cytokine storm in the body, producing a series of immune responses and causing changes in peripheral leukocytes and immune system cells such as lymphocytes, which might be an important pathological pathway that inhibits the body's cellular immune function, leading to the deterioration of the patient's condition. the angiotensin-converting enzyme 2 (ace2) has been identified as the functional receptor for sars-cov-2 and sars-cov. the fact that ace2 is abundantly present in the epithelia of the lungs and small intestine, provides a possible explanation for the pathological lung and gastrointestinal symptoms. the abundant expression of ace2 in alveolar cells may cause a rapid viral expansion and destruction of the alveolar wall, resulting in a rapid progression of extensive pulmonary consolidations and diffuse alveolar damage with hyaline membrane formation. its presence in the vascular endothelium might also provide a step forward in understanding the histological changes of placentas from pregnant women infected by sars-cov-2. the clinical manifestations of covid-19 infection also show great similarities with sars and mers. however, covid-19 has affected more people in a shorter period of time compared to sars and mers, although with a lower fatality rate than sars and mers. pregnant women with covid-19 pneumonia showed a similar pattern in comparison with non-pregnant counterparts, including fever, cough, myalgia, fatigue, shortness of breathe or asymptomatic presentation. it is worth noting that there is currently no evidence that pregnant women with covid-19 are at higher risk of severe illness. however, sars and mers were found to be greatly associated with severe maternal illness, spontaneous abortion and even maternal death and intrauterine fetal demise. some pregnancy complications have occurred in pregnant women with covid-19, such as fetal distress, premature rupture of membranes, preterm deliveries and stillbirths. furthermore, these pregnancy complications might be closely related to the cytokine storm, lung injury and placental ischemia/ hypoxia caused by sars-cov-2 infections. although there is currently no evidence to support the fetal infection by intrauterine vertical transmission of sars, mers, and covid-19, more and more articles began to report maternal deaths due to covid-19. in particular, from february 26, 2020 (date of the first covid-19 case in brazil) until june 18, 2020, brazil had already reported 124 maternal deaths. thus, we should be alert that these diseases may follow the same trend of greater severity and poorer prognosis in pregnant women. therefore, pregnant women and newborns require special attention in the prevention, diagnosis and management of covid-19. the maternal physiological and immune function changes in pregnancy make pregnant women more susceptible to covid-19. furthermore, considering that pregnant women with covid-19 may not have typical symptoms such as fever, we suggest that pregnant women with any symptoms suggestive of covid-19 should undergo careful examination to prevent adverse pregnancy outcomes. covid-19 infection itself is not an indication for cesarean section deliveries. the timing and mode of delivery should be individualized based on the disease severity, pre-existing maternal comorbidities, obstetric history, gestational age and fetal conditions. newborns from women with suspected or confirmed covid-19 should undergo a careful examination, and have the body temperature, respiratory rate and heart rate closely monitored, as well as digestive tract symptoms. so far, breast milk samples were negative for sars-cov-2 and this virus is mainly transmitted by respiratory droplets and close contact. furthermore, the protective effect of breastfeeding on newborns is particularly strong. precautions should be taken to enable infected mothers to breastfeed, including respiratory hygiene, hand hygiene and disinfection, the use of n-95 masks by the mother while breastfeeding in cases in which mothers or newborns are suspected of or have confirmed covid-19. personal protection must be taken in order to minimize the risk of contracting the virus. future researches should cover different pregnant stages of covid-19 as much as possible. it is recommended that the placenta and other tissues of pregnant women with 2019-ncov infection should be evaluated by histopathological examinations, to provide more detailed pathological analyses. the epidemic situation of covid-19 is still spreading, and this review has limitations. thus, further investigation is needed to elucidate how covid-19 affects pregnant women and fetuses, as well as the exact impact of covid-19 on pregnant women themself and on pregnancy outcomes. yao w, qiu j and xiao z had the idea for the article and performed the literature search and data analysis. the first draft of the manuscript was written by yao w and all authors critically revised the previous versions of the manuscript. all authors read and approved the final manuscript. world health organization. coronavirus disease 2019 (covid-19): situation report -70 characteristics and pregnancy outcomes of patients with severe pneumonia complicating pregnancy: a retrospective study of 12 cases and a literature review pneumonia and pregnancy outcomes: a nationwide population-based study angiotensin-converting enzyme 2 is a functional receptor for the sars coronavirus tissue distribution of ace2 protein, the functional receptor for sars coronavirus: a first step in understanding sars pathogenesis dipeptidyl peptidase 4 is a functional receptor for the emerging human coronavirus-emc differential expression of the middle east respiratory syndrome coronavirus receptor in the upper respiratory tracts of humans and dromedary camels genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding a pneumonia outbreak associated with a new coronavirus of probable bat origin interaction of severe acute respiratory syndrome-associated coronavirus with dendritic cells productive replication of middle east respiratory syndrome 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epidemiological, demographic, and clinical characteristics of 47 cases of middle east respiratory syndrome coronavirus disease from saudi arabia: a descriptive study severe acute respiratory syndrome vs. the middle east respiratory syndrome middle east respiratory syndrome coronavirus infection during pregnancy: a report of 5 cases from saudi arabia impact of middle east respiratory syndrome coronavirus (mers-cov) on pregnancy and perinatal outcome middle east respiratory syndrome coronavirus during pregnancy stillbirth during infection with middle east respiratory syndrome coronavirus first case of 2019 novel coronavirus in the united states emerging coronaviruses: genome structure, replication, and pathogenesis clinical characteristics of hospitalized patients with sars-cov-2 infection: a single arm meta-analysis epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study clinical characteristics of 140 patients infected with sars-cov-2 in wuhan, china clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in wuhan clinical and biochemical indexes from 2019-ncov infected patients linked to viral loads and lung injury early transmission dynamics in wuhan, china, of novel coronavirusinfected pneumonia pregnancy and perinatal outcomes of women with severe acute respiratory syndrome clinical analysis of pregnancy in second and third trimesters complicated severe acute respiratory syndrome sars during pregnancy, united states 225-management guidelines for obstetric patients and neonates born to mothers with suspected or probable severe acute respiratory syndrome (sars) sars and pregnancy: a case report middle east respiratory syndrome coronavirus (mers-cov) infection during pregnancy: report of two cases & review of the literature emergency cesarean section in an epidemic of the middle east respiratory syndrome: a case report e62 pregnancy and covid-19: management and challenges page mers-cov infection in a pregnant woman in korea clinical characteristics and intrauterine vertical transmission potential of covid-19 infection in nine pregnant women: a retrospective review of medical records clinical analysis of 10 neonates born to mothers with 2019-ncov pneumonia neonatal coronavirus expert confirmed at 30 hours of birth: vertical transmission from mother to infant perinatal covid-19: a case report clinical manifestations and outcome of sars-cov-2 infection during pregnancy clinical features and obstetric and neonatal outcomes of pregnant patients with covid-19 in wuhan, china: a retrospective, single-centre, descriptive study first covid-19 maternal mortality in the uk associated with thrombotic complications in brazil: 124 maternal deaths and counting we declare no conflict of interests. this work was supported by the national natural science foundation of china, grant nº 81803884 key: cord-326331-g4o3forj authors: rai, ansaar t; leslie-mazwi, thabele m; fargen, kyle m; pandey, aditya s; dabus, guilherme; hassan, ameer e; fraser, justin f; hirsch, joshua a; gupta, rishi; hanel, ricardo; yoo, albert j; bozorgchami, hormozd; fiorella, david; mocco, j; arthur, adam s; zaidat, osama; siddiqui, adnan h title: neuroendovascular clinical trials disruptions due to covid-19 potential future challenges and opportunities date: 2020-06-30 journal: j neurointerv surg doi: 10.1136/neurintsurg-2020-016502 sha: doc_id: 326331 cord_uid: g4o3forj to assess the impact of covid-19 on neurovascular research and deal with the challenges imposed by the pandemic. methods: a survey-based study focused on randomized controlled trials (rcts) and single-arm studies for acute ischemic stroke and cerebral aneurysms was developed by a group of senior neurointerventionalists and sent to sites identified through the clinical trials website (https://clinicaltrials.gov/), study sponsors, and physician investigators. results: the survey was sent to 101 institutions, with 65 responding (64%). stroke rcts were being conducted at 40 (62%) sites, aneurysm rcts at 22 (34%) sites, stroke single-arm studies at 37 (57%) sites, and aneurysm single-arm studies at 43 (66%) sites. following covid-19, enrollment was suspended at 51 (78%) sites—completely at 21 (32%) and partially at 30 (46%) sites. missed trial-related clinics and imaging follow-ups and protocol deviations were reported by 27 (42%), 24 (37%), and 27 (42%) sites, respectively. negative reimbursements were reported at 17 (26%) sites. the majority of sites, 49 (75%), had put new trials on hold. of the coordinators, 41 (63%) worked from home and 20 (31%) reported a personal financial impact. remote consent was possible for some studies at 34 (52%) sites and for all studies at 5 (8%) sites. at sites with suspended trials (n=51), endovascular treatment without enrollment occurred at 31 (61%) sites for stroke and 23 (45%) sites for aneurysms. a total of 277 patients with acute ischemic stroke and 184 with cerebral aneurysms were treated without consideration for trial enrollment. conclusion: widespread disruption of neuroendovascular trials occurred because of covid-19. as sites resume clinical research, steps to mitigate similar challenges in the future should be considered. the neurovascular community has had to date a relatively homogeneous response to the covid-19 pandemic with regards to clinical care. measures including elective case suspension and modifications for emergency treatment and safety procedures to accommodate patients with covid-19 have been widely adopted. societal guidelines containing overlapping recommendations, based on evidence in the literature and expert consensus, were published to codify this. [1] [2] [3] by contrast, the impact of covid-19 on clinical research efforts has been less clear. the food and drug administration (fda) published its guidance on the 'conduct of clinical trials of medical products during covid19 pandemic' for the industry, investigators, and institutional review boards in march 2020 and updated these on april 2, 2020 (https://www. fda. gov/ media/ 136238/ download). this guidance is expected to remain in effect until the public health emergency related to the pandemic is lifted by the department of health and human services. the fda document is comprehensive and recognizes the challenges due to quarantines, suspension of trials, and interruption of supply chains. it also recognizes that protocol deviations are likely and that trial modifications may be required. similar guidelines were issued by the european medicines agency on the management of clinical trials during the covid-19 pandemic on april 28, 2020 (https:// ec. europa. eu/ health/ sites/ health/ files/ files/ eudralex/ vol-10/ guid ance clin ical trials_ covid19_ en. pdf). disruption of clinical research infrastructure has implications for patient enrollment, study timing, sponsorship, and advances in clinical care and disease understanding. at the time of writing, fears of resurgent or re-emergent disease remain prominent. 4 the impetus of this study was clinical trial suspension and challenges in patient monitoring experienced by several physician investigators and enrolling sites. this led to formulation of a hypothesis and study design which aimed to evaluate the impact of covid-19 on neurovascular research studies and had a goal of better understanding the implications for existing and future trials. institutional review board approval was not obtained as the survey did not involve study of human subjects. a survey writing group committee, comprising 12 neurointerventional physicians (four neuroradiologists, five neurosurgeons, and three standards neurologists) each with 10 or more years of experience in clinical practice, was assembled. all were involved in neurovascular clinical trials as site principal investigators and six were leading clinical trials as national principal investigators. the writing group was tasked with composing a concise survey, limited to fewer than 20 questions, to be completed by institutional research coordinators to explore the effect of covid-19 on neurointerventional research and clinical trials (full survey can be found in online supplementary materials a). the survey focused on endovascular trials for acute ischemic stroke and cerebral aneurysms, including both randomized clinical trials (rcts) and single-arm studies. the specific trial names or study sponsors were not recorded to protect confidentiality. the site name was only logged to assure one response from each site. no compensation was offered to participants. no requests to complete the survey were placed on public social media platforms. the questions were intended to explore key aspects of managing clinical trials in a restricted environment as imposed by the pandemic. these were identified by the writing group and fell into four categories: general disruption caused by trial suspensions and missed opportunities of enrollment, compromised trial quality due to inability of timely clinical and imaging follow-up, inability to enroll neurologically debilitated patients because legally authorized representatives were not at hand for face to face consent and dated remote consent procedures did not apply and, finally, personal effect of compensation or working conditions on study staff. the question about remote consent related to existing operating procedures for ongoing trials. the suspension of clinical trials was divided into partial or complete suspension based on whether some or all neuroendovascular trials were suspended. in cases of partial suspension, the question did not give details of the criteria for suspending some trials and not others. the survey also did not seek information on the size of the program, case volume, or association with a research consortium. this was partly to ensure that the brevity of the survey was maintained, and partly to maintain broad applicability of the survey regardless of program size, academic affiliation, or geographic location. the final questionnaire was also reviewed by three industry sponsors of clinical trials, two of which agreed to disclose their names (stryker neurovascular; fremont, california, usa and cerenovus; miami, florida, usa). the survey sample was identified by creating a list of participants from the federal repository website ( clinicaltrials. gov). the website allows combinations of search terms to identify clinical trials. the search terms used included 'stroke', 'thrombectomy', and 'brain aneurysms' with the geographic localizer of clinical trials in the 'united states'. the results were filtered for recruiting trials. the website provided contact details for each study. in a separate process, various study sponsors and principal investigators of ongoing clinical trials were approached by members of the writing group and asked to provide lists of participating sites. the accumulated sites were cross referenced with the list generated from clinicaltrials. gov to eliminate duplicates and when site information was missing, physician investigators localized by state were identified and invited individually through the society of neurointerventional surgery senior physician membership (https://www. snisonline. org/). the final sample resulted in a total of 101 institutions identified for potential participation. the finalized survey was prepared on qualtrics (https://www. qualtrics. com) using an institutional license. the survey was distributed to the identified sites by email and was open for a 4-week period from april 21, 2020 to may 21, 2020. to boost the response rate, a digital link to the survey and a printable version (pdf, word document) were emailed to the physician investigators and study coordinators midway through the 4-week period as a prompt. surveys were completed voluntarily by a research coordinator at each institution with the help of the physician investigator as required. each center was permitted only one response. the survey is presented as descriptive statistics. the survey was sent to study coordinators at 101 institutions with 65 responding (64%). all responding sites were actively involved in neurovascular trials before the covid-19 pandemic. of the returned forms, the only missing responses related to entry of the date of clinical trial suspension (if applicable). an evaluation of endovascular studies showed that a majority of sites were conducting stroke-related rcts or single-arm studies. most sites were also conducting single-arm aneurysm trials while a minority were participating in aneurysm-related rcts ( figure 1a) . during the pandemic, the majority of the sites either partially or completely suspended enrollment in clinical trials (figure 1b), with the suspension occurring between the middle to the end of march 2020. there was no correlation between site trial suspension and geographic location or academic affiliation. suspension of sites by state showed a heterogeneity of response, with different sites in same state having different responses (figure 2). no correlation was found between trial suspension and the intensity of the pandemic. endovascular stroke care continued in sites where enrollment had been suspended (n=51), and most of these sites treated patients with acute ischemic stroke without enrollment. almost half of the sites treated patients with an aneurysm (figure 3a). a total of 277 patients with endovascular stroke and 184 with endovascular aneurysm were treated without consideration for enrollment following suspension of clinical trials. effects were also observed on patients already enrolled in trials. forty-two percent of sites missed clinical follow-up visits, and 37% missed imaging follow-up. under half of the sites (42%) reported protocol deviations because of the pandemic and a quarter reported loss of reimbursements possibly due to delayed or missed milestones or inability to enroll patients ( figure 3b ). almost all (61/65, 94%) sites had developed alternative mechanisms such as telemedicine for clinical visits. most of the sites had received institutional review board guidance for the conduct of clinical trials (n=57, 88%) and most had received guidance from sponsors for either all (n=31, 48%) or some (n=30, 46%) of the clinical trials. over half of the sites allowed electronic or phone consent for enrollment ( figure 4 ). there were widespread challenges for study staff, with the majority of the study coordinators working from home (n=41, 63%) or a combination of home and office (n=18, 28%) and almost a third (n=20, 31%) reporting being personally affected by the pandemic either due to loss of pay, paid time off, or loss of benefits. the majority of the sites (n=49, 75%) had placed new trials on hold, with the number of postponed trials per site ranging from one to seven. two sites reported a diagnosis of covid-19 among the enrolled patients. this study identified widespread disruptions to neurovascular clinical trial networks, most notably due to a suspension or postponement of trial enrollment, interruptions in scheduled patient follow-up, and challenges with study staff routines. cessation of ongoing trials was nearly uniform, which may have downstream effects on trial validity and solvency. understanding the effect of covid-19 on clinical trials during the early months of the pandemic is especially important given the uncertainty about the future and potential need for subsequent lockdowns should widespread infection recur after resumption of elective procedures and relaxation of social distancing measures. one previous letter has been published, documenting decreased enrollment related to the pandemic in cancer-related clinical trials, 5 and another systematic review on cancer research during covid-19. 6 the federation of italian cooperative oncology group issued a brief commentary and practice indications for drug studies. 7 other publications have included clinical trials for alzheimer's research, 8 and a review for guidance in head and neck research. 9 at the time of writing, no published studies measuring the comprehensive impact of covid-19 on research are available, and while this study focuses specifically on neurovascular research and trials, disruptions captured may well be generalizable to united states clinical trials in other medical specialties. a prominent source of disruption identified by this survey was the complete or partial suspension of trial enrollment. many sites with suspended enrollment treated potentially eligible patients with stroke and aneurysm. a total of 277 patients with stroke and 184 with an aneurysm reportedly underwent endovascular therapy at these sites during the period in which the survey was conducted and thus could not be considered for enrollment owing to the suspension of clinical research. in view of the number of sites that did not respond to the survey, this number may be even higher. unlike the 'clinical deficit', which is expected to be gradually overcome by returning case volume and case rescheduling, no similar option exists for research enrollment deficits. the most likely means of compensating for missed enrollments is to extend trial enrollment timelines. such extension has implications for funding, compounded by potential contraction of funding following the wider economic impact of the global pandemic. beyond enrollment alone, trial quality was compromised. many patients missed clinical and imaging follow-up milestones, and many sites reported protocol deviations due to the pandemic. these may increase as pandemic effects continue and could affect the veracity of overall trial data. site trial infrastructure will have to adjust to new realities of reduced funding for many centers, with just over a quarter reporting a negative impact on reimbursements. human trial expertise has also been affected by the covid-19 pandemic. sites could experience reassignment, furloughing, or termination of study coordinators. one-third of responding coordinators reported a direct personal effect through loss of pay, time off, or benefits. as operations gradually return, this human expertise may need to be rebuilt. trialists and staff will also need ongoing protection from potential infectious exposures. 10 failure to do so could affect a site's ability to perform existing and future trials unless alternative mechanisms are developed. as clinical research activities resume with lifting of mandated lockdowns, this survey highlights several opportunities to update the conduct of clinical trials in accordance with the virtual care revolution brought about by the covid-19 pandemic. 11 12 in this survey, 40% of the responding sites did not have any protocols in place for remote consent. challenges to the traditional consent process could persist into the foreseeable future as hospital visitor restrictions are likely to remain in place for some time. study sponsors, local institutional review boards, and federal authorities regulating these trials will have to demonstrate creativity in modernizing these procedures. harnessing emerging virtual technologies that allow for face-to-face interactions with legally authorized representatives, electronic exchange of documents, and digital signatures, represents a clear opportunity. it is possible to comply with the ethical principles governing informed consent while updating these procedures to meet the current and future needs of operating with restricted visits. 13 in the recovery phase there are calls in both public and medical circles for our healthcare infrastructure to focus on broadly improving our approaches, not simply returning to the prior state of normalcy. 14 for acute trials in particular this could have broad positive implications for enrollment. further, there are opportunities to enhance virtual capabilities to conduct trials, with reduced reliance on in-person monitoring and reporting forms. based on existing data about telehealth, 15 this may expand the trial footprint, decrease trial costs, and potentially increase trial efficiency. trial reorganization into adaptive designs like platform trials may allow us to respond more rapidly to design changes and randomize more effectively as new questions arise. 16 early efforts are underway to develop a neurovascular platform trial infrastructure, and this should remain a focus for the neurointerventional community. another important consideration is how to handle potential trial candidates regarding covid-19 exposure. in this survey, a small number (two sites) reported a positive covid-19 diagnosis in enrolled patients. there is current uncertainty about how to process patients with covid-19 in neurovascular trials or whether to screen based on symptoms or exposures. the direct effect of sars-cov-2 on cerebrovascular disease remains largely unknown, but early evidence suggests endothelial involvement 17 and a range of syndromes 18-20 that could confound the natural history of the disease or treatment response. this may be particularly relevant for studies of cerebrovascular conditions where patient outcomes may be directly influenced apart from the interventions being studied. how patients with covid-19 should be handled by trials that are not focused on that disease specifically, is unknown. testing all potential enrollees for covid-19 and excluding all positive patients a priori seems reasonable, but this could result in unnecessary delays in enrollment or exclusion of patients who are covid false positive or who have recovered from covid. this larger question will probably be answered as we learn more about the virus. as more data are collected on the impact of the pandemic on clinical trials it may be possible to crystallize strategies for operating in a restrictive environment due to lingering concerns of outbreaks. this study has several important limitations. as a survey study, this study is subject to the inherent limitations of survey methodology, including recall and selection bias. the potential for selection bias is strong as those most affected by the pandemic may be more likely to complete the surveys. additionally, centers with furloughed or terminated coordinators were unable to provide responses. a number of potentially important research or practice-specific questions, such as region or the prevalence of covid-19 in the population, were not included in the survey by the writing group to improve participation rates. questions were intentionally generated to assess a broad overview of research as opposed to specifically focus on individual trial statistics. the survey questions were purposely kept under 20, and therefore details that might have been helpful in further exploring some responses were not obtained. for example, the criteria for choosing to keep some trials open and others suspended are not known. likewise, details of the causes of loss of trial-related reimbursements were not obtained. additionally, implications for neurovascular basic or laboratorybased research, or for research in other domains, were similarly not assessed. the questions used were not previously validated and were designed specifically for the ni research coordinators involved in clinical trials, which may limit their generalizability to other specialties and make comparison with data from other surveys challenging. lastly, since this type of pandemic has never occurred in modern history, there is no previously developed, validated survey instrument to study the effects of a global pandemic on research. this is the first study comprehensively evaluating the effect of covid-19 on clinical trials. respondents indicated widespread disruption of neurovascular clinical research and research infrastructure during the covid-19 pandemic. it has also revealed opportunities for increased infrastructural strength and pliability, including the increased use of virtual access for consent and follow-up, and the benefits of platform trial design at times when flexibility and responsiveness are key advantages. many questions remain to be answered, including how we should incorporate covid-19 screening into trial criteria. it should be expected that disruptions due to covid-19 will continue, based on expert predictions of the disease course. trial conduct in this restrictive environment will need to evolve. decisions about how to maintain enrollment during the current pandemic and in the event of future similar disruptions 21 must be prioritized. society of neurointerventional surgery recommendations for the care of emergent neurointerventional patients in the setting of covid-19 letter: considerations for performing emergent neurointerventional procedures in a covid-19 environment preserving access: a review of stroke thrombectomy during the covid-19 pandemic how will country-based mitigation measures influence the course of the covid-19 epidemic? association of the coronavirus disease 2019 (covid-19) outbreak with enrollment in cancer clinical trials cancer patients and research during covid-19 pandemic: a systematic review of current evidence indications regarding the management of interventional clinical trials with drugs during the current covid-19 emergency in italy clinical trials and tribulations in the covid-19 era clinical trials during covid-19 risk factors of healthcare workers with corona virus disease 2019: a retrospective cohort study in a designated hospital of wuhan in china a digital embrace to blunt the curve of covid19 pandemic virtually perfect? telemedicine for covid-19 a rationale and framework for seeking remote electronic or phone consent approval in endovascular stroke trials -special relevance in the covid-19 environment and beyond what the coronavirus crisis reveals about american medicine. the new yorker patient and clinician experiences with telehealth for patient follow-up care this is a platform alteration: a trial management perspective on the operational aspects of adaptive and platform and umbrella protocols endothelial cell infection and endotheliitis in covid-19 characteristics of ischaemic stroke associated with covid-19 covid-19-related stroke large-vessel stroke as a presenting feature of covid-19 in the young innovation for pandemics key: cord-282131-wap7lo05 authors: chen, haixia; ai, li; lu, hong; li, hongjun title: clinical and imaging features of covid-19 date: 2020-04-27 journal: radiol infect dis doi: 10.1016/j.jrid.2020.04.003 sha: doc_id: 282131 cord_uid: wap7lo05 since december 2019, multiple cases of 2019 coronavirus disease (covid-19) have been reported in wuhan in china's hubei province, a disease which has subsequently spread rapidly across the entire country. highly infectious, covid-19 has numerous transmission channels and humans are highly susceptible to infection. the main clinical symptoms of covid-19 are fever, fatigue, and a dry cough. laboratory examination in the early stage of the disease shows a normal or decreased white blood cell count, and a decreased lymphocyte count. while ct examination serves as the screening and diagnostic basis for covid-19, its accuracy is limited. the nucleic acid testing is the gold standard for the diagnosis of covid-19, but has a low sensitivity is low. there is clearly a divide between the two means of examination. this paper reviews the published literature, guidelines and consensus, and summarizes the clinical and imaging characteristics of covid-19, in order to provide a reliable basis for early diagnosis and treatment. since december 2019, multiple cases of unexplained pneumonia have been reported in wuhan, in china's hubei province. as the disease has spread, cases of covid-19 have also been found across the whole of china and overseas. nucleic acid detection of a patient's respiratory secretions identified the source of infection to be a new type of coronavirus, which was been defined as 2019 novel coronavirus (2019-ncov) [1] . on 11 february 2020, the who officially named the disease caused by the novel coronavirus (2019-ncov) as coronavirus disease 2019 (covid-19) [2] . on february 22, 2020, china's national health commission announced the designation of the new coronavirus pneumonia as coronavirus disease. the disease is a new type b infectious disease (in accordance with the class a management, infectious disease prevention and control law). although there is considerable overlap between imaging manifestations of different viral pneumonia, comprehensive analysis of clinical features, epidemiology and laboratory examination results are of significance in improving the diagnosis of covid-19. coronaviruses form a large rna virus family. the surface of virus particles is covered in many spines, and the virus particles as a whole resemble a crown, which is the origin of the name "coronavirus". six subtypes have been found; of these, four are less pathogenic and generally lead to mild symptoms after infection; two subtypes can cause severe infections. the novel coronavirus is a new-type coronavirus that has not been previously been found in humans being. it is now considered to be a seventh subtype, but its genes have more than 85% homology with a sars-like virus in bats. it has been speculated that the pathogenic mechanism of the virus may be that because the 2019-ncov receptor and sars-cov receptor binding region (rbd) structure domain between the amino acid sequence and the prediction of protein structure are highly similar, 2019-ncov can effectively use angiotensinconverting enzyme 2(ace2) on alveolar type ii epithelial cells as the receptor to invade cells, thus entering the bronchial epithelial cells to replicate and cause disease [3, 4] . current epidemiological investigations show the incubation period of covid-19 to range from one to fourteen days, and in most cases to be three to seven days. the main source of infection is patients infected with the novel coronavirus infection. patients with asymptomatic infection (incubation period) can also be a source of infection. infection is mainly spread by respiratory droplets and contact. exposed mucus membranes and unprotected eyes increase the risk of infection, and the detection of the virus in stool and urine samples from patients also suggests the possibility of fecal-oral transmission. there is a possibility of aerosol transmission under the condition of prolonged exposure to high concentrations of aerosols in a relatively closed environment [5e7]. at present, there are no reports of vertical transmission from mother to child. covid-19 lacks specificity in both clinical manifestations and laboratory tests. the main clinical manifestations of the disease are fever, fatigue, and a dry cough, and in severe cases, multiple organ failure [7e9]. its atypical symptoms may include myalgia and diarrhea. laboratory tests have shown that the total number of white blood cells in early peripheral blood is normal or has decreased, and the lymphocyte count has progressively decreased; c-reactive protein and serum sedimentation rates were increased in most patients [7e9]. covid-19 was confirmed by viral nucleic acid detection with strong specificity and poor sensitivity [10] . in order to improve the rate of positive nucleic acid detection, it is recommended to retain sputum and lower respiratory secretions as far as possible and promptly submit them for examination [7] . ct examination serves as the screening and diagnostic basis for covid-19: chest imaging in the early stage shows multiple plaque shadows and interstitial changes, mostly seen in the peripheral lung and subpleural, and then developed into multiple ground glass shadows and infiltration shadows in both lungs. in severe cases, lung consolidation can occur, presenting as "white lung", with rare pleural effusion and mediastinal lymph node enlargement [6, 7] . since the outbreak of the covid-19 epidemic in december 2019, the "diagnosis and treatment scheme for coronavirus disease (trial version 5)" [6] recommended that suspected cases with pulmonary imaging characteristics be included for the first time in "clinical diagnosis" in hubei province. pulmonary imaging is mainly performed by chest ct (particularly hrct), supplemented by x-ray chest radiographs [10, 11] . ct examination is the main screening and diagnosis basis for covid-19. the image changes basically reflect the inflammatory pathological process of lung tissue-exudation, proliferation, and metamorphism [12] . ggo is a slightly higher density blurred image in the lungs, where the pulmonary blood vessels are visible. the pathological change of ggo is that the virus invades the bronchioles and alveolar epithelium, and replicates in the epithelial cells, causing the alveolar cavity to leak, and the alveolar wall or the alveolar space to become inflamed or thickened, with a distribution mainly around the lung and under the pleura [13, 14] . as inflammation progresses, there is extensive involvement of alveoli and mucosal ulcers, followed by consolidation; when the body reacts strongly as to an inflammatory storm, large exudation occurs in the alveoli of both lungs, showing a "white lung" performance. air bronchus sign refers to the phenomenon of dendritic low-density shadowing of air-containing bronchus in the consolidation of lung tissue, which is more common in the progress of the disease. the pathological basis is that the pathogen invades epithelial cells, causing inflammatory thickening and swelling of the bronchial wall, but without obstructing the bronchioles [15] . on high-resolution ct, the lobular interval thickening and interlobular interval line shadows are superimposed on a ground glass-like opaque background. they are called paving stones due to the resemblance of the forms to irregularly shaped paving stones. the pathological changes are lobular intervals and interlobular interstitial thickening, suggesting interstitial changes. during repair and healing of chronic inflammation or hyperplasia of the lung, fibrous components gradually replace the normal cellular components to form scars. fibrous lesions can cause distracted bronchi or bronchiectasis and distorted travel. thickening vessels can be seen at the edge or the center of the lesion, and are observable at various stages of the disease. the density of the lesion is slightly higher at the center and slightly lower at the edges. a thin circle of cloud-like ground glass shadow, which varies in thickness and changes like a halo surrounds the lesion. pathological changes may be virus replication in epithelial cells [16] . in "diagnosis and treatment scheme for coronavirus disease (trial version 6)", infection is classified according to its clinical symptoms and imaging manifestations [7] . there is a one-to-one correspondence between the imaging stage (early, advanced, and severe) and clinical classification (mild, general, and severe) in most patients with covid-19. ① early-stage and mild type (mild patients have mild clinical symptoms and no significant imaging findings such as pneumonia performance). ② progressive stage and common type (general type patients have fever, respiratory tract symptoms, and imaging shows pneumonia). ③ severe stage and severe type (patients with shortness of breath and hypoxemia. the images mainly show diffuse lung lesions, some of which manifest "white lung" changes; the range of lesions within 24e48 h significantly progresses >50% [7] ). there are, however, some cases which do not comply to the above oneto-one correspondence. ① some cases have obvious imaging manifestations, but the clinical symptoms are atypical (fig. 1) . among the close-contact cases diagnosed through screening as having covid-19, most patients had no obvious clinical symptoms at the initial diagnosis, and the corresponding clinical symptoms appeared after a period of time; a few patients showed no obvious clinical symptoms for a long period, with the infection becoming "invisible ". however, the images of the above cases did show pneumonia at the time of screening, the signs of which were mainly ground glass and patchy shadows under the pleura or outside the lungs [17, 18] . ② the clinical manifestations of some cases are typical, and no obvious manifestations of pneumonia were found on imaging examination (fig. 2) . this may relate to the virus being mainly located in the upper respiratory tract and not causing exudative lesions in the lung. such patients should be diagnosed, isolated, and treated early to prevent transmission of the virus. ③ in some cases, the clinical symptoms are relieved, and the imaging manifestations have progressed (fig. 3 ) [19] . the mismatch between clinical and imaging manifestations becomes a difficult problem for covid-19 diagnosis. therefore, comprehensive analysis of clinical data, epidemiology and imaging performance is more helpful for the diagnosis of covid-19. the gold standard for diagnosis of covid-19 is a positive nucleic acid test with high specificity, and a low sensitivity of 30e50% [20] . it is common in clinical work to find that clinical and imaging findings support the diagnosis of covid-19 while multiple consecutive nucleic acid tests are negative (fig. 4) . it has been reported that up to eight nucleic acid tests have been negative in infected patients before covid-19 was finally diagnosed. over-reliance on nucleic acid tests may lead to the misdiagnosis of patients who do in fact have covid-19. this is not conducive to the control of the epidemic. preliminary data from a designated virus hospital in wuhan showed that the ct positive rate of clinically highly suspected cases was 90%, while the positive rate of nucleic acid tests was about 40%. this is due to the many factors which affect the nucleic acid test such as the course of infection, viral load, sampling method, detection reagents, and interpretation standards. reagents in particular greatly affect the detection effect [21] . therefore, nucleic acid test cannot be a factor in restricting the accurate diagnosis and treatment of diseases. the director of the radiology department of a hospital in wuhan strongly recommends ct scan as the main diagnostic and screening basis for covid-19. the "diagnosis and treatment scheme for coronavirus disease (trial version 5)" [6] specifically formulated clinical diagnosis standards for patients in hubei province, and defined suspected cases with pneumonia imaging manifestations as "clinical diagnostic cases", which reduced the risk of further spread. with the exception of the above cases, some mild cases had no obvious imaging changes of pneumonia, but the nucleic acid test was negative (fig. 5) . the use of imaging pneumonia as a prerequisite for the diagnosis of covid-19 may lead to clinicians focusing solely on patients with pneumonia and missing the diagnosis of infected patients who show no changes in pneumonia. the "diagnosis and treatment scheme for coronavirus disease (trial version 4)" stipulates that [22] jrid198_proof ■ 26 april 2020 ■ 3/ 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 a patient who meets any one of the epidemiological history criteria and any two of the clinical manifestations can be included in suspected cases, and that an etiological test then be conducted. such an approach is conducive to the detection of patients with covid-19 [6, 7] . chest radiographs are suitable for primary hospitals which do not have ct machines, and for the bedside examination of critically ill patients. ct tomography, especially highresolution ct, has no overlapping structural interference and can detect small lesions early. the value of a ct scan for covid-19 lies in it being: the key technology for detecting the presence of lesions in the lungs; the important basis for the diagnosis and differential diagnosis of covid-19; detecting important warning signals for patients with negative virus nucleic acid test; an important means to monitor covid-19 treatment outcome (progression, stability, absorption); an early detection of other complications; the best follow-up method for patients following discharge [23] . as mentioned above, the ct scan occupies an important position in the diagnosis of covid-19; in clinical work, however, we must perform ct examinations without affecting the premise of diagnosis, and we must not over-examine. therefore, based on the observation of existing cases and combined with clinical experience, we recommend the following ct examination time window: ① newly diagnosed patients with typical clinical manifestations and positive nucleic acid tests, with a negative chest ct scan at the initial diagnosis, and a review of chest ct scan within 3e5 days; ② clinical diagnosis cases with atypical clinical manifestations and viral pneumonia characteristics. in addition to repeated nucleic acid tests, a chest ct is recommended for 5e7 days; ③ non-critical confirmed cases: a chest ct scan is recommended at 5e7 days [24] . the differential diagnosis of covid-19 in "diagnosis and treatment scheme for coronavirus disease (trial version 6)" primarily includes [7] : the need to distinguish mild manifestations from other respiratory infections caused by other viruses such as influenza viruses, adenoviruses, respiratory syncytial virus and other known viral pneumonia and mycoplasma pneumoniae infections. they should also be distinguished from non-infectious diseases such as vasculitis, dermatomyositis, and organizing pneumonia. the imaging manifestations of viral pneumonia were mainly pulmonary interstitial changes accompanied by alveolar wall edema, while the ct manifestations were ggo, with consolidation, thickening of interlobular septa, mesenchymal shadow, central lobular nodules, tree buds, air retention, and fiber cable shadow. there is significant overlap between the imaging manifestations of different viral pneumonia, so the final diagnosis should be combined with clinical data, epidemiology and laboratory results. diagnosis depends on the detection of etiology. unilateral or bilateral multiple ggo, with or without consolidation, located in the bronchovascular bundle or subpleural (fig. 6) [25, 26] . it is difficult to distinguish the image from the new type of coronavirus pneumonia. however, the early stage of the new coronavirus pneumonia can be manifested as a small ground glass density shadow, or a small flake of ground glass density shadow can be seen in the thickened blood vessel shadow. this may be helpful for the early identification of h1n1 lesions. common in children. multifocal ggo in both lungs with patchy consolidation, present a multisegmental pulmonary distribution trend (fig. 7) . atelectasis can occur in children. it can sometimes be difficult to distinguish it from bacterial pneumonia [25, 26] . a common cause of seasonal respiratory infections. imaging findings are varied, and include multiple peribronchial nodules, consolidation of ggo and aerated bronchi (fig. 8 ) [25, 26] . the central distribution of the lesion is different from the characteristic subpleural distribution of new coronavirus pneumonia. common in infants, congenital defects, immunosuppression and chronic lung disease. the central lobular nodule is the most characteristic image, and its occurrence rate is up to 50% (fig. 9) , which can be distinguished from the new coronavirus pneumonia. in addition, air consolidation (35%), ggo (30%), and bronchial wall thickening (30%) are seen. it is distributed in the central or surrounding area of the lung and presented bilateral asymmetric distribution [25, 26] . common in children and adolescents, image presenting as central lobular nodules, ground-glass opacity, consolidation, with thickening of bronchial wall, bronchiole tree buds, hilar and mediastinal lymph node enlargement [27] . laboratory tests are positive for the mycoplasma antibody. there are no prodromal symptoms of upper respiratory tract infection, cough purulent sputum, bloody sputum or rusth. chen et al. / radiology of infectious diseases xxx (xxxx) xxx colored sputum, laboratory examination of increased white blood cell count, imaging features of single leaf segment or sub segment consolidation shadow. treatment with antibiotics is good. 5.3.1. mechanical pneumonia typical manifestations are bilateral subpleural patchy ground-glass opacity or consolidation, the air bronchi sign. in some lesions, the central ground-glass opacity, marginal ring or crescent shape consolidation presents an "anti-halo" sign, hilum and, mediastinal lymph node enlargement, as well as pleural effusion in a small number of cases [28] . diffuse ground-glass opacities in both lungs. central lobe nodules with fuzzy edges, mosaics perfusion and air retention in expiratory phase, lung field in chronic stage shows fine mesh shape shadow and stretch extension. the patient usually has a history of bird breeding or of occupational exposure [29] . the manifestations are multiple nodules with cavitation, nodules connected to pulmonary vessels (nourishing vascular signs), halo or anti-halo signs, multiple consolidation, fiber cord shadow and ground glass density shadow diffuse distribution, the subpleural area is rare. it occurs mostly in the middle of the band with diffuse alveolar hemorrhage. clinical manifestations can be hemoptysis, and pleural effusion is common [30] . a laboratory test of positive canca antibody is helpful in diagnosis. covid-19 is highly contagious and humans are generally susceptible to infection. while clinical and ct scans do share certain characteristics, there is some separation between a ct scan and a nucleic acid detection in some cases. therefore, comprehensive analysis of the patient's epidemiological history, laboratory test results, clinical symptoms and imaging manifestations is necessary in order to effect early prevention, early detection, early diagnosis, early isolation, and early treatment. written informed consent was obtained from the patients for the publication of this report and any accompanying images. world health organization. who director-general's remarks at the media briefing on sars coronavirus entry into host cells through a novel clathrin and caveolae independent endocytic pathway a crucial role of angiotensin converting enzyme 2 (ace2) in sars coronavirus-induced lung injury a new coronavirus associated with human respiratory disease in china the national health commission. diagnosis and treatment scheme for coronavirus disease 2019 (trial version 5), 2.8 the national health commission. diagnosis and treatment scheme for coronavirus disease 2019 (trial version 6), 2.18 epidemiologic and clinical characteristics of novel coronavirus infections involving 13 patients outside wuhan, china first case of 2019 novel coronavirus in the united states clinical features of patients infected with 2019 novel coronavirus in wuhan, china outbreak of pneumonia of unknown etiology in wuhan china: the mystery and the miracle radiographic and ct features of viral pneumonia clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (covid-19): a multi-center study in wenzhou city chest radiographic and ct findings of the 2019 novel coronavirus disease (covid-19): analysis of nine patients treated in korea guideline for medical imaging in auxiliary diagnosis of coronavirus disease 2019 emerging 2019 novel coronavirus (2019-ncov) pneumonia early transmission dynamics in wuhan, hubei, of novel coronaviruseinfected pneumonia updated understanding of the outbreak of 2019 novel coronavirus (2019-ncov) in wuhan ct imaging of two cases of one family cluster 2019 novel coronavirus (2019-ncov) pneumonia: inconsistency between clinical symptoms amelioration and imaging sign progression thinking about the hot issues in the diagnosis and treatment of novel coronavirus pneumonia a novel coronavirus from patients with pneumonia in china the national health commission. diagnosis and treatment scheme for coronavirus disease 2019 (trial version 4), 1.27 identification of novel coronavirus pneumonia coronavirus disease 2019 (covid-19): role of chest ct in diagnosis and management imaging of pulmonary viral pneumonia radiographic and ct features of viral pneumonia1 mycoplasma pneumoniae: a potentially severe infection cryptogenic organizing pneumonia spectrum of high-resolution ct and pathologic findings when to suspect pulmonary vasculitis: radiologic and clinical clues key: cord-017331-ru7mvfc0 authors: samanta, indranil; bandyopadhyay, samiran title: infectious diseases date: 2017-02-25 journal: pet bird diseases and care doi: 10.1007/978-981-10-3674-3_2 sha: doc_id: 17331 cord_uid: ru7mvfc0 the chapter describes bacerial, viral, parasitic and fungal infections commonly detected in pet birds. the chapter includes history, etiology, susceptible hosts, transmission, pathogenesis, clinical symptoms, lesion, diagnosis, zoonosis, treatment and control strategy of tuberculosis, salmonellosis, chlamydiosis, campylobacteriosis, lyme disease, other bacterial infection, newcastle disease, avian influenza infection, west nile virus infection, usutu virus infection, avian borna virus infection, beak and feather disease, other viral infection, toxoplasmosis, giardiasis, cryptosporidiosis, other parasitic infection, cryptococcosis, aspergillosis, other fungal infections. indranil samanta and samiran bandyopadhyay 2.1 bacterial diseases 2.1.1 tuberculosis 2.1.1.1 history tuberculosis (mycobacteriosis) is an ancient or 'heritage' disease which was observed even before the neolithic age and in egyptian mummies. in 1882, robert koch first isolated mycobacterium, stained with alkaline methylene blue and vesuvin and established its etiologic relationship with tuberculosis. koch described that the same human or bovine type mycobacterium may cause avian tuberculosis. strauss and gamaleia (1891) and maffucci (1892) cited in cobbett (1917) illustrated that the etiological mycobacterium of avian tuberculosis was different from human or bovine type. hinshaw (1933) and ackermann et al. (1974) reported occurrence of tuberculosis in amazon parrot (amazona farinosa). coyle et al. (1992) proposed a new mycobacterial species (mycobacterium genavense) isolated from human patients with aids. simultaneously in 1993, mycobacterium genavense was reported from pet birds in europe (hoop et al. 1993 ). mycobacterium is gram positive, straight or slightly curved rod with occasional coccobacillary, club and branched form. in the tissues, it measures 1-4 µm in length and 0.2-0.3 µm in width. it occurs singly, in pair or in bundle. it is difficult to demonstrate their gram positive nature due to high lipid content of the cell wall. the stains are relatively impermeable to the bacterial cell. they can be easily stained by ziehl-neelsen (zn) or acid fast staining technique. the genus mycobacterium (actinomycetes family) contains more than 100 species. some are pathogenic for man and animals which grow slowly in artificial media in laboratory (slow growers) than the fast growers (m. smegmatis). previously, slow growing mycobacterium was sub divided into three types based on their host specificity i.e. human type, bovine type and avian type. recent classification reveals that slow growing mycobacterium is composed of several species. the most common species are mycobacterium tuberculosis complex and m. avium-intracellulare complex (mac) . mycobacterium tuberculosis complex is comprised of m. tuberculosis, m. bovis, m. caprae, m. microrti, m. africanum and m. canettii. mac is composed of two major species-m. avium and m. intracellulare. m. avium is subdivided into four subspecies (ssp.) i.e. ssp. avium (maa), ssp. paratuberculosis (map), ssp. silvaticum and recently added ssp. hominissuis. mac is considered as 'atypical mycobacteria' and members of this group are highly resistant against environmental changes such as high and low temperatures, dryness, extreme ph and common disinfectants. there are total 28 serotypes of mac and the serotypes 1-6, 8-11 and 21 belonged to m. avium ssp. avium. mycobacterium genavense forms a deep branch of mycobacterial phylogentic tree with other members such as m. interjectum and m. simiae. this group is characterized by slow growth albeit contains the signature molecule of fast growers (short helix 18). m. genavense can be distinguished from other slow growers by their fastidious growth and preference for liquid medium. m. genavense was first reported from human aids patients with disseminated infections (hirschel et al. 1990 ). among psittacine birds, grey-cheeked parakeets (brotogeris pyrrophterus), amazons (amazona spp.), budgerigars (melopsittacus undulatus) and pinous parrots (pionus spp.) are the most commonly affected species with tuberculosis. other psittacines such as green-winged macaws (ara chloroptera), cockatoos (cacatua spp.), conures (aratinga auricapillus, cyanoliseus patagonus) and red-crowned parakeet (cyanoramphus novaezelandieae) are also detected to be infected with m. genavense and m. tuberculosis. m. avium subsp. avium is reported to cause infection in cockatiels (nymphicus hollandicus). the non-cultivable mycobacterium is detected in blue and yellow macaw (ara ararauna) and grey-cheeked parakeet (brotogeris pyrrhopterus). the common parrots (african grey parrot, senegal parrot) are not considered as natural host of m. tuberculosis although infection in african grey parrot is reported which was transmitted from human. m. bovis can produce natural infection in parrots and the budgerigars are experimentally infected with m. bovis producing clinical syndrome within 70 days. among non-psittacine group of birds, canary (serinus canaria), gouldian finch (chloebia gouldiae) and zebra finch (poephila guttata castanotis) are commonly infected with m. genavense. synergistic infection of m. genavense and avian polyoma virus was detected in european goldfinch (carduelis carduelis). occasionally canaries are also infected with m. tuberculosis. avian tuberculosis is a disease of adult birds although occasionally detected in young (<1 year old) canaries. mac is transmitted in birds chiefly by ingestion, inhalation and rarely through arthropods. m. avium ssp. avium is excreated through faeces of infected birds and survive in soil (up to 4 years), sawdust (8 months at 37°c) and water for a long period. bird to bird transmission in aviaries may occur through infected faeces or rarely by cannibalism. occasionally skin abrasion acts as a route of mycobacterial infection in pet birds. ingestion is considered as a potential route of transmission of m. genavense infection in pet birds. the environment specially drinking water is an identified source of m. genavense infection. lung involvement in pet birds suggests inhalation as an additional route of transmission. birds may act as reservoir of m. genavense. bird to bird transmission of m. genavense is rare although the possibility could not be excluded entirely. immunosuppression plays a role in transmission of m. genavense in human but whether the same condition facilitates the transmission in pet birds is obscure. transmission of m. tuberculosis in pet birds (green-winged macaws, blue-fronted amazon) from human is observed due to close contact with owners suffering from tuberculosis and feeding the birds with pre-chewed food. m. avium subsp. avium mac enters the host chiefly through ingestion route of transmission and become present in the intestine. the waxy cell wall of the bacteria protects it from gastric acids and enzymes. several pathogen associated molecular patterns (pamps) are expressed by virulent mycobacterium which can recruit 'microbicidal' macrophages through toll like receptor (tlr) mediated signaling. during m. tuberculosis infection in human, these pamps in the bacterial surface are masked with a lipid, namely phthiocerol dimycoceroserate (pdim). the pamps are not recognized by the host immune system and the bacteria can avoid the reactive nitrogen species (rns) generated by 'microbicidal' macrophages. mac (m. avium subsp. avium) does not contain pdim in their surface but use a different strategy (still unexplored) to resist rns. mac is benefited with these rns as commensal present in the gut are sensitive to it. commensal mediated competitive inhibition is thus excluded and probably mac enters m-cells like host adopted salmonella to invade the underlying blood monocytes. the m-cells are specialized cells of the follicle associated epithelium and the region is relatively free from commensal mediated competitive inhibition. the invasion of monocytes is followed by bacterimia and subsequent haematogenous spread to liver, spleen and other organs. mac enters the macrophages (histiocytes) of periarteriolar lymphoid sheath (pals) zone in spleen within 10 days post infection in birds. mycobacterium has several virulence factors which promote their survival within macrophages using different strategies such as acid resistance, avoidance of acidification etc. mac (m. avium subsp. avium) specifically restricts vacuole maturation and prevents the fusion of phagosome and lysosome for their survival within macrophages. haematogenous spread of the organism leads to infection of bone marrow, lungs, air sacs, gonads and rarely, kidney and pancreas. the organs become enlarged due to accumulation of macrophages within organ parenchyma. granuloma formation is an attempt of host tissue to localize the infection, although mycobacterium exploits it for their multiplication and further dissemination. the growth of mycobacterium occurs in the macrophages present in a granuloma. the infected macrophages undergo apoptosis and leave the encased bacteria which are engulfed by newly recruited macrophages. this process of apoptosis and re-phagocytosis within a granuloma is regulated by a mycobacterial secreation system (esx-1/esat6) detected in m. tuberculosis but absent in m. avium subsp. avium. typical tuberculous granulomas in different organs are not frequent in m. avium subsp. avium infection, although observed in lungs and periocular region of parrots. granulomas in different organs (liver, kidney, intestine, muscle and subcutaneous tissues) are observed in red-crowned parakeet (cyanoramphus novaezelandiae) and green-winged macaw (ara chloroptera) infected with m. tuberculosis. m. genevense infection in pet birds mostly occurs through the oral route like mac. there is every possibility that they follow the same pattern of pathogenesis although still unexplored. m. genevense causes non-tuberculoid form of mycobacteriosis in pet birds albeit occurrence of granulomas are observed in glottis of amazon parrot (amazona ochracephala), aorta of cockatiel (nymphicus hollandicus), small intestine of canary-winged parakeet (brotogeris versicolurus) and brain of spectacled amazon parrot (amazona albifrons). incubation period of mycobacteriosis in pet birds is 6 months to 4 years. clinical syndrome in psittacine birds varies widely. in acute form, sudden death without any symptom is common. in chronic form, constant loss of weight along with diarrhoea ( fig. 2.1 ), frequent micturition with excessively large quantity and low specific gravity of urine, depression, laboured breathing, distension of abdomen and poor feathering primarily suggests about mycobacteriosis. the condition fails to respond to common antibiotics. cutaneous masses are sometimes observed in skin and conjunctiva. inflammation of feather follicles (folliculitis) is occasionally observed which includes perifollicular swelling, erythema, pruritus and pain, restlessness, shivering and feather damaging behaviour. the liver and spleen are enlarged, mottled and whitish. miliary abscess in liver are observed in budgerigars experimentally inoculated with m. avium subsp. avium. the intestine becomes tubular, thickened and tan coloured. typical tuberculous granulomas in different organs are not frequent in m. avium subsp. avium infection, albeit observed in lungs and periocular region of parrots, pericardium of gang gang cockatoo (callocephalon fimbriatum) and cervical esophagus of blue-fronted parrots (amazona aestiva) occluding the lumen. involvement of lung is rare in pet birds affected with mycobacteriosis. some post mortem findings in canary (serinus canarius), eurasian goldfinch (carduelis carduelis) and the red siskin (spinus cucullatus) reported the occurrence of lung lesions. in a rare case of m. genevense infection in an amazon parrot (amazona albifrons), perivascular cuffs of macrophages in the grey and white matter of the brain and spinal cord, gliosis and mild vacuolation of white matter were observed. clinical specimens blood/sera, cloacal swabs, tracheal swabs, biopsies from organs can be collected as ante-mortem samples for diagnosis of mycobacteriosis in the laboratory. post-mortem samples include vital organs such as liver, spleen, intestine, heart, lung and bone marrow. all the specimens should be immediately sent to the laboratory following the standard regulations for sending biohazardous substances. if there is delay in sending, refrigeration of the samples should be done to prevent the growth of contaminants. addition of 0.5% boric acid may preserve the samples for 1 week. (a) clinical signs and history of direct contact with owner and other birds suffering from tuberculosis give a tentative diagnosis (b) haematological parameters: following haematological changes can be correlated with tuberculosis in pet birds although these changes are non-specific and are observed in other inflammatory and chronic infections also. • moderate to marked increases in white blood cell numbers (heterophilia, monocytosis, lymphocytosis) • decreased packed cell volume (pcv) (except during early stage of infection) • increased enzyme concentration (alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase) (c) demonstration of acid-fast organisms: demonstration of the organisms can be done in the smears prepared from ante-mortem samples by acid-fast (or zn) staining. mycobacterium appears as red coloured slender rods singly or in bundle ( fig. 2. 2). fluorescent acid fast stain may be used for better detection. in post mortem specimens, cytoplasm of infected cells is laden with acid-fast organisms. (d) gross and histopathology: enlarged liver, thickened intestinal loop, increased opacity in endosteal bone in the humerus, tibia, ulna, femur in advanced cases is suggestive for tuberculosis. presence of visible granuloma is not a constant feature although may be detected in lungs. in decomposed carcasses bone marrow is the best specimen. histopathogical findings such as presence of acid-fast bacilli in inflammatory cells can also tentatively diagnose mycobacteriosis. (e) isolation of organism: this is considered as gold standard method for confirmatory diagnosis of mycobacterium. to isolate the organism, the tissue sample must be processed in proper way. tissue samples are homogenized in pestle and mortar after keeping in the solution of hypochlorite (1:1000) for 4-16 h. it is decontaminated by the addition of acid (5% oxalic acid), alkali (2-4% sodium hydroxide) or detergent (0.375-0.75% hexadecylpyridiniumchloride, hpc). the acid or alkali mixture is neutralized, centrifuged and the sediment is used for culture. m. avium subsp. avium can be isolated in dorset egg medium, lowenstein-jensen (lj), herrold's and middlebrook's (7h10,7h11) medium containing pyruvate. glycerol and 'mycobactin' is also added as growth enhancer. mycobactin extracted from the environmental mycobacteria, acts as siderophore helping in acquisition of iron. mycobactin is produced by all cultivable mycobacteria except m. avium subsp. avium and m. avium subsp. paratuberculosis. incubation period is 8 week at 40°c. even it can grow at 42-43°c. it produces smooth or rough type of colonies. in liquid culture a radiometric method using 14 c labelled substrate can be used for rapid detection (bactec system). m. genavense isolation is difficult although can be done on special media with prolonged incubation for 2-9 months. conventionally, after decontamination of the samples with 2(n) naoh, the samples can be inoculated in herrold's egg yolk medium with and without mycobactin j and sula's liquid medium and incubated at 37°c. the growth is periodically checked in every two weeks. the successful isolation of m. genavense from blue headed parrot (pionus menstruus) was observed in herrold's egg yolk medium without mycobactin j after 270 days of incubation. in specialized laboratories, newly developed liquid culture systems [manual mycobacteria growth indicator tube (m-mgit), bactec system) are used for confirmatory isolation of m. genavense. subsp. avium in birds. however elisa produces variable results in different species of birds. immunological or serological tests for detection of mycobacteriosis in pet birds are not routinely followed. (g) molecular biology: polymerase chain reaction (pcr) can detect mycobacterium from fresh samples, faeces and paraffin-blocked tissues. the species-specific pcr targets is901 and hsp65 genes for detection of m. avium subsp. avium and m. genavense, respectively. differentiation of both the species can be done by sequencing of the 16srrna gene. a nested polymerase chain reaction (pcr) from the consensus sequences of the hsp65 gene, followed by analysis with restriction enzymes can also differentiate m. avium and m. genavense. real-time taqman pcr assay is developed to detect hsp65 gene of m. genavense and mac subsp. other recent technologies such as genotype assay and dna microarrays can be used for diagnosis of avian tuberculosis. for detection of genetic diversity among the strains of m. avium subsp. avium, mycobacterial interspersed repetitive units-variable-number tandem-repeat markers (miru-vntr) typing can be successfully used. 2.1.1.9 zoonosis m. avium subsp. avium is considered as a potential zoonotic risk in the immunocompromised persons albeit majority of human infection is caused by another member of m. avium group (m. avium subsp. hominissuis). m. genavense is associated with gastrointestinal or pulmonary mycobacteriosis in immunosuppressed patients associated with aids. other species of mycobacteria associated with pet bird causes opportunistic and sporadic infections in human. the cases of reverse zoonosis (anthroponosis) are also reported where m. tuberculosis was transmitted from the infected owners to their pet birds (green-winged macaws, blue-fronted amazon). successful treatment of pet birds is reported with various combinations of anti-tuberculous drugs at highest tolerable dose for a prolonged period (9 months or more). single anti-tuberculous drug is not preferred due to possibility of resistance development. emergence of multidrug-resistant tuberculosis (mdr-tb; resistant to isoniazid and rifampicin) and extremely drug-resistant tuberculosis (xdr-tb; in addition to being multidrug-resistant the bacteria are resistant to fluoroquinolone and 1 of 3 antibiotics such as capreomycin, kanamycin and amikacin) is a global problem now a days. in most of the cases, dose is fixed on the basis of human paediatric studies because pharmacokinetic properties of anti-tuberculous drugs in pet birds are still unknown. the anti-tuberculous drugs and antibiotics used against m. avium infections in pet birds are isoniazid, rifampin, rifabutin, ethambutol, clofazimine, ciprofloxacin, enrofloxacin, streptomycin and amikacin. successful therapy of m. genavense infections with combinations of moxifloxacin, clarythromycin, ethambutol and amikacin in humans has been reported but there is no specific drug recommended for m. genavense infection. treatment with clarithromycin, rifampin, and ethambutolm against m. marinum infection in a blue-fronted amazon parrot was not successful. experimentally, different combinations of anti-tuberculous drugs and antibiotics such as isoniazid (30 mg/kg) + ethambutol (30 mg/kg) + rifampin (45 mg/kg) for 12-18 months, clofazimine (6 mg/kg) + ethambutol (30 mg/kg) + rifampin (45 mg/kg) for 9-18 months, ciprofloxacin (80 mg/kg) + ethambutol (30 mg/kg) + rifampin (45 mg/kg) for 9-12 months was used successfully against confirmed cases of tuberculosis in different pet birds (grey-cheeked parakeet, double yellow-headed amazon, lilac-crowned amazon). although combination of azithromycin (43 mg/kg), rifampin (45 mg/kg), and ethambutol (30 mg/kg) administered orally once daily for 180 days in ring-neck doves (streptopelia risoria) naturally infected with m. avium subsp. avium failed to eradicate the infection. further, treatment with combination of clarithromycin (61 mg/kg bw), moxifloxacin (25 mg/kg bw) and ethambutol (60 mg/kg bw) administered in budgerigars experimentally infected with m. avium subsp. avium by crop gavage every 12 h for 18 weeks significantly improved the situation but failed to recover completely. combination of minocycline (10 mg/kg p.o. b.i.d.) and clarithromycin (10 mg/kg p.o. s.i.d.) significantly reduced oral plaques in blue penguins (eudyptula minor) naturally infected with m. intracellulare. due to zoonotic potential specially for children and elderly persons and immunocompromised patients, prolonged treatment and poor success rate, difficulty of drug administration to avian patients maintaining proper doses, natural and acquired antimicrobial resistance, poor owner compliance and moreover, lack of a proper treatment schedule, the debate exists regarding advice of treating pet birds against tuberculosis. nevertheless, euthanasia is the preferred measure in the prevention of tuberculosis in pet birds in relation to human health. for prevention of further transmission, removal of all organic matter and debris from cages, washing the cages and surroundings properly with disinfectants and maintenance of biosecurity measures are required. chlorohexidine and quaternary ammonium compounds can act as mycobacteriostatic disinfectants. 2.1.2 salmonellosis 2.1.2.1 history d.e. salmon (1885) first isolated salmonella from the infected pigs. it was considered as a cause of 'hog cholera' until the discovery of the etiological virus. the nomenclature of the bacteria ('salmonella') was done in memory of salmon. in 1889, klein (united kingdom) first isolated salmonella gallinarum from chickens with 'fowl typhoid'. loeffler first described salmonella typhimurium from a natural outbreak of typhoid like infection in mice. among the pet birds, salmonellosis was first described in ducks (vandervort 1954; keymer 1958) , and parakeets (kaye et al. 1961; madewell and mcchesney 1975) . the genus salmonella is classified under the family enterobacteriaceae that belongs to the order enterobacteriales. there are two major species under the genus salmonella i.e. s. enterica (>2440 serovars) and s. bongori (20 serovars). a third proposed species is s. subterranea, yet to be recognized as a true species. salmonella enterica is considered as type species of the genus at present. s. enterica has 6 subspecies (ssp.): salamae, arizonae, diarizonae, houtenae, indica, enterica. most of the pathogenic salmonella are designated as 'serovar' under the s. enterica ssp. enterica. virulent serovars are: typhi, typhimurium, dublin, choleraesuis, pullorum, gallinarum, abortusovis. salmonella typhimurium (var. copenhagen) is the most frequently isolated serovar from different outbreaks in psittacine birds. in passerine birds (perching/song birds), s. typhimurium phage types dt40, dt41, dt56, dt160 are adapted. it acts as either a primary pathogen or it causes sub-clinical infection in young and immunocompromised birds. if the density of flock is high and the quantity of available feed is low, most of the birds become debilitated and are susceptible to s. typhimurium infection. other sub-species and serovars of salmonella isolated from pet birds include s. houtenae, s. arizonae, s. rissen, s. enteritidis, s. pullorum, s. gallinarum, s. newport, s. panama, s. rublislaw, s. aberdeen, s. thompson and s. wasenaar. among them, s. gallinarum can infect canaries, ring dove, pheasants, peacocks and peafowl. a novel salmonella serovar (s. pajala) was isolated from peregrine falcon (falco peregrinus) nestlings. clinical outbreaks of salmonellosis are frequently detected in passerine and psittacine birds. among passerine birds, finches (fringillidae) and sparrows (passeridae) seem to be particularly susceptible to salmonella spp. infection. salmonellosis is reported from canary (serinus canaria), eurasian siskin (carduelis spinus), zebra finch (taeniopygia guttata), bengalese finch (lonchura striata domestica) and picoplat (sporophila intermedia). fatal outbreaks with high mortality were reported in psittacine birds such as lories and lorikeets (trichoglossus, lorius, eos spp.), budgerigars (melopsittacus undulatus), parakeets (psephotus spp., psittacula spp.), and sulphur crested cockatoo (cacatua galerita galerita). the birds with caecum [e.g. macaw (ara sp.), amazon parrot (amazona sp.)] can asymptomatically carry salmonella spp. like poultry. both free-ranging and captive blue-fronted amazon parrots (amazona aestiva) are detected to carry salmonella spp. although, lilac-crowned amazon parrots (amazona finschi schlater) was found died due to s. enteritidis infection. moreover, s. typhimurium is detected as a primary pathogen causing death of blue and gold macaws (ara ararauna). occasionally, raptors or hunter birds (e.g. falcon, red kite), game birds [e.g. red-legged partridge (alectoris rufa)], free-ranging sparrow (passer domesticus), gull (laridae), wild birds such as temminck's seedeater (sporophila falcirostris), chestnut-capped blackbird (chrysomus ruficapillus), brown-headed cowbirds (molothrus ater), white-throated sparrows (zonotrichia albicollis) can also harbour salmonella spp. infected pet birds, rodents, reptiles, wild birds, contaminated water, feed and eggs act as source of salmonella spp. when the pet birds are gathered in an exhibition the healthy birds come in direct contact to the infected birds. the rodents, reptiles and wild birds having access to the open-air aviary can contaminate the place. the bacteria can survive for extensive periods on wood and dust and can live for 28 months in avian faeces. the contaminated places become a constant source of infection. in a pet shop, iguana (iguana iguana) was identified as a source of salmonella spp. infection in a cockatoo. ingestion of contaminated feed and drinking water is the major route of transmission in pet birds. sometimes, the infection is also transmitted by owners or attendants through their contaminated hands, feet and clothes. trans-ovarian transmission is common in poultry, although, is not frequently observed in pet birds. salmonella typhimurium following oral route of transmission, salmonella is deposited in the intestine, where they invade enterocytes. the bacteria can invade the epithelial cells throughout the intestine, although, caeca and ileocaecal junction are the preferred site. in the intestine, low ph, peristalsis, intestinal mucus, lysozyme in secreations and moreover normal microbial flora try to destabilize the bacterial colonization. normal microflora in adults prevents the salmonella colonization by occupying their receptors, known as 'competitive exclusion'. young are more susceptible as their intestinal microfloral range is not fully developed. bacterial fimbriae, lipopolysaccharide (lps), pathogenicity island (sp-1-t3ss associated proteins) help in adherence with the enterocytes. the interaction between the t3ss proteins (sipa, sipc) with the actin cytoskeleton of the enterocytes causes cytoskeletal rearrangements to generate an uneven surface (membrane ruffle). the organisms are trapped within the ruffled membrane and are internalized by the enterocytes. within the enterocytes, the bacteria reside in a membrane bound vacuole i.e. salmonella containing vacuoles (scv). as the scv matures, it migrates from the luminal border of the enterocyte to the basal membrane. in the basal membrane, the scv enter the macrophages associated with peyer's patches in the sub mucosal space. the scv never fuses with lysosome within macrophages and thus avoid phago-lysosome fusion which is necessary to kill the bacteria. additional factors such as sp-2-t3ss (sipc protein), sp-3 associated proteins also help in intracellular survival. the formation of salmonella induced fibrils (sif) help in bacterial replication in an unknown way. it is evident that major portion of the infection is cleared by the macrophages, only certain part can survive leading to chronic infection or carrier state with persistent faecal shedding. sometimes, invasion of salmonella takes place beyond the intestine which causes bacterimia, survival and replication of the bacteria in reticulo-endothelial cells of liver and spleen. in passerine birds (canary, finch and starling), esophagus and crop are the preferred site for bacterial colonization after bacterimia. acute and chronic form of salmonellosis is detected in pet birds. in acute form, huge mortality without any prior cardinal signs was observed in a flock of canaries. a s. typhimurium infected macaw (ara ararauna) showed depression, anorexia, delay in the emptying of crops (ingluvies), laboured breathing and diarrhoea for 3-4 days before death. greenish-yellow diarrhoea was observed in adult budgerigers (melopsittacus undulatus) infected with s. gallinarum. the chronic form shows numerous general symptoms such as anorexia, diarrhoea, dyspnoea, lethargy, cachexia, ruffled feathers, subcutaneous granuloma, crop stasis, conjunctivitis, arthritis and panophthalmitis. adult budgerigars with chronic salmonellosis showed loss of condition, unwillingness to fly, inability to perch, and gathering in the bottom of the cage (fig. 2. 3). drop in egg production and increased embryonic mortality rate was observed. in pigeons, in addition to the general syndrome, polyuria, arthritis of the joint, nervous symptoms and dermatitis followed by death was detected. stress associated with environment, season, change of diet and housing, transport, breeding, concurrent infection, and introduction of new birds without quarantine are the major predisposing factors for salmonellosis in pet birds. in acute form of salmonellosis in pet birds, no specific gross lesion is observed. in chronic infection, congestion of lung and intestine, spleenomegaly, hepatomegaly, liver with necrotic foci is observed (fig. 2.4) . the passerines birds infected with s. typhimurium shows the granulomatous lesions like pseudotuberculosis. esophagitis and ingluvitis with necrotic plaques in esophagus and crop, respectively, are consistently detected in wild or free-range passerine birds. in european goldfinch (carduelis carduelis), instead of esophagus lesions are sometimes developed in the subcutaneous tissues. in canaries, congestion of vital organs and necrotic foci on the liver with a nodular and miliary appearance is detected. intestinal content become dark in colour due to haemorrhagic diasthesis. in lories and lorikeets, petechial hemorrhages on the serosal surface of the proventriculus, ventriculus, and cardiac muscle along with atrial dilation are observed. sometimes, bacterial emboli occur in liver, spleen, lung, kidney, and proventriculus. in s. typhimurium infected macaws, pectoral muscle atrophy, fibrinous exudate on intestinal mucosa, white-greyish nodules on intestinal serosa, myocardium, lungs and ingluvies mucosa are commonly observed. in young budgerigars, fibrin deposit is observed as a white, thick layer on the pericardium. petechial haemorrhages are detected on the surfaces of pericardium, myocardium, gizzard, duodenum and ileo-caecum. in garden birds infected with s. typhimurium, esophageal ulcers, granulomata in soft tissues, hepatomegaly and spleenomegaly are observed. microscopic inspection of histopathological sections shows necrosis of parenchymatous organs specially the liver with granulocyte infiltration and fibrin deposition. in young and adult budgerigars, the blood vessel walls become hyalinized in appearance with various-sized microthrombi. the chronic cases are characterized by formation of a granuloma. a typical granuloma consists a necrotic centre which is surrounded by granulocytes and macrophages containing salmonella spp. multinucleated giant cells are found in chronic infection. in passerine birds, epithelial surface of the esophagus is ulcerated and it forms a thick layer of necrotic cellular debris composed of degenerated and intact leukocytes with gram-negative bacteria. infiltration of heterophils, lymphocytes and plasma cells occur into the underlying sub-mucosa. clinical samples include faeces or cloacal swabs, blood/serum of live birds and affected tissues, such as liver, spleen, heart, intestine/caeca, lung, esophagus/crop, brain and kidney in 10% buffered formalin. before collection of cloacal swabs, pericloacal asepsis with iodized alcohol is performed. blood samples are collected from jugular, wing or ulnar vein. the environmental samples, such as pooled faeces, litter and dust from the cages, feed and drinking water should be examined to know about an outbreak, if any. specimens should be collected before antibiotic treatment of the birds. after death, the collection should be done immediately from fresh carcasses. for 'pre-enrichment', swabs should be collected in buffered peptone water. pre-enrichment in buffered peptone water helps in survival of salmonella from freezing, heating and desiccation. the cold chain (4-5°c) should be maintained during transportation of the samples to the laboratory. (a) clinical signs and lesions after necropsy, history of direct contact with infected birds give a tentative diagnosis (b) direct examination: an impression smear prepared from clinical samples such as cloacal swab/faeces/tissues, is stained by gram's method. salmonella appears as gram negative small rods with no distinct characteristics. the tissue samples of heart, lung, liver, spleen, kidney, and intestine are fixed in 10% buffered formalin, embedded in paraffin, sectioned at 3 mm, and stained with hematoxylin-eosin and periodic acid-schiff for direct examination of the bacteria. zoonotic transmission of salmonella spp. to human from parakeet kept as a pet was documented. a salmonellosis outbreak associated with dissection of an owl was reported among the elementary school children. the possibility of children infection (below 5 years age) is more in those families who rear a pet bird (odd ratio: 2.7) or a lizard (odd ratio: 3). in open air aviaries and children's zoos, the transmission of salmonella spp. was reported between wild birds, pet birds and human. special care for designing such aviaries should be adopted. antibiotics against salmonella spp. in infected pet birds can be administered after doing the sensitivity of the bacterial isolates. antimicrobial resistance of salmonella spp. is a global concern at present. successful treatment of infected canaries with 10% (w/v) enrofloxacin solution provided as 200 mg/l in drinking water for 5-7 days was observed. treatment with kanamycin, gentamicin, trimethoprim/sulfamethoxazole suspension along with anti-diarrhoeals such as daolin and pectin combination is recommended. general control and prevention strategies such as isolation of diseased birds from the rest of the flock, cleaning and disinfection of cages, water and feed utensils with 10% (v/v) solution of sodium hypochlorite or commercial disinfectants are recommended. if the feedstuffs are suspected it should be replaced with new batch immediately. 2.1.3 chlamydiosis 2.1.3.1 history halberstaedter and von prowazek (1907) , a czech zoologist, first described chlamydia, although it was actively infecting people for centuries before its discovery. first description of chlamydia associated trachoma in human was found in the ebers papyrus dated around 1550 b.c. in modern times, ritter (1879) first described chlamydia psittaci infection in human acquired from parrots. during 1890-1930, numerous outbreaks of human psittacosis occurred in europe, north and south america, associated with parrots and other pet birds. in 1929-30, pandemic psittacosis outbreaks in human were reported due to import of infected psittacine birds from south america to europe and north america. in 1930, levinthal, coles, and lillie, independently described the properties of the pathogen, and accordingly chlamydia was known as levinthal-coles-lillie (lcl) agent. moulder (1962) first revealed the structural and chemical composition of c. psittaci. hatch (1975) demonstrated the requirement of adenosine-triphosphate (atp) supplementation for growth of chlamydia. in literatures, first description of chlamydiosis in parakeets was reported from germany (strauch and rott 1958) . further study after few years also revealed the presence of chlamydia in parrots and other parakeets in germany (schmittdiel 1966) . human psittacosis outbreaks specially in persons associated with poultry, turkey and duck industry were reported from united states and european countries during 1980-90. all the chlamydiae are placed under the order chlamydiales, and family chlamydiaceae. based on cluster analysis of 16s and 23s rrna genes, the family chlamydiaceae was divided into two genera i.e. chlamydia and chlamydophila. recent genome comparison study of the two genera proposed to unite the chlamydia in a single genus. the latest edition of the bergey's manual of systematic bacteriology also described the single genus of chlamydia. pathogenic species under the genus chlamydia are c. psittaci, c. trachomatis, c. suis, c. muridarum, c. abortus, c. caviae, c. felis, c. pecorum and c. pneumoniae. among the pathogenic species, c. psittaci is mostly associated with avian chlamydiosis (psittacosis) in pet birds, ornithosis in poultry, and zoonotic infection in human. the 16s rrna gene based phylogenetic study indicates the presence of a distinct cluster of c. psittaci strains which are associated with chlamydiosis in psittaciformes (cockatoos, parrots, parakeets, lories etc.) and columbiformes (pigeons) birds. although, other chlamydial species such as c. abortus, c. trachomatis and c. pecorum are occasionally detected in brown skua, parrots, parakeets, and pigeons. three new avian species of chlamydia, namely c. ibidis sp. nov., c. avium sp. nov., and c. gallinacea sp. nov. are proposed. among them, c. ibidis and c. avium are isolated from feral sacred ibis (threskiornis aethiopicus), psittacines, and pigeons. earlier, avian isolates of c. psittaci was divided into six serovars (serotypes) which can infect different species of birds (a-f, table 2 .1). based on major outer membrane protein (ompa) sequence, c. psittaci is currently divided into 15 genotypes. among them, nine genotypes (a-f, e/b, m56, wc) are associated with different species of birds and mammals (table 2 .1). avian strains of c. psittaci are detected in more than 460 species of birds under 30 orders. the pet birds belonged to the order psittaciformes (cockatoos, parrots, parakeets, lories etc.) and columbiformes (pigeons) are most susceptible to c. psittaci infection. in parrots, the worldwide prevalence of c. psittaci varies from 16-81%. the infection in pet birds is reported from europe, brazil, africa, usa, iran and india. free ranging galapagos doves (zenaida galapagoensis) and rock doves (columba livia) in spain; monk parakeets (myiopsitta monachus), amazon parrots, red-tailed amazon (amazona brasiliensis) in brazil; ring necked parakeet (psittacula krameri), alexandrine parakeet (psittacula eupatria), african grey parrot (psittacus erithacus), timneh grey parrot (psittacus erithacus timneh) in iran were reported to be infected with c. psittaci. in india, c. psittaci was isolated from pigeons (columba livh), parrots (psittacula krameri) and crows (corvus splendens). infection of passeriformes birds is not common, although, canaries were detected to be infected with c. psittaci in croatia. c. psittaci was also detected in healthy asymptomatic birds such as in ara macao, and amazona ochrocephala in costarica, and free-living hyacinth macaw (anodorhynchus hyacinthinus) and blue-fronted parrot (amazona aestiva) in brazil. the syndrome was not expressed either due to infection with low virulent strain or resistance of some bird species. the seroprervalence studies revealed the presence of c. psittaci antibodies in macaws (ara macao, ara ambigua), hyacinth macaws (anodorhynchus hyacinthinus), budgerigars (melopsittacus undulatus), lovebirds (agapornis sp.), cockatiels (nymphicus hollandicus), alexandrine parakeets (psittacula eupatria), eurasian siskins (carduelis spinus), oriental skylarks (alauda arvensis), and black-tailed grosbeaks (coccothraustes migratorius) in different countries. the presence of c. psittaci antibodies indicates the exposure of the birds to the organism. in a study in china, highest seroprevalence was observed in cockatiel which was followed by alexandrine parakeets, lovebirds, and budgerigars. it seems that lovebirds and budgerigars among the psittacine birds are relatively resistant against c. psittaci infection, although, the reason is unexplored. among the wild predator birds, white-tailed sea eagle (haliaeetus albicilla) and the peregrine falcon (falco peregrinus) are detected to be infected with c. psittaci. inhalation of contaminated dust, airborne particles from the feathers and ingestion are major ways of c. psittaci transmission in the birds. direct contact during close proximity with the infected birds also helps in transmission. throughout the breeding season, specially during incubation of eggs, male psittacine birds prefer to feed the females by regurgitation. in this process the feeds are often mixed with secreations of the crop, pharynx and nasal cavity. transmission of c. psittaci is observed from parent birds to their nestlings during feeding. asymptomatic carrier birds infected with c. psittaci, excreate the organisms through faeces, nasal and lacrimal discharge, oropharyngeal mucus, crop milk and other secreations. shedding is increased during coexisting infections and stress conditions such as shipment, breeding, crowding, chilling and nutritional deficiencies. when the excreated faecal material dries, the organisms are aerosolized. elementary bodies (infections form) of c. psittaci survive in the dried faeces for several months, in the contaminated feed for up to two months, on glass for 15 days, and in straw for 20 days. mechanical transmission of c. psittaci by biting arthropods such as flies, mites and lice are observed. vertical transmission is infrequently observed in parakeets, seagulls, snow geese and poultry. zoonotic transmission of c. psittaci in human occurs mostly through inhalation of contaminated dust, feathers and aerosolized excreations. direct contact with infected pet birds or their cages, utensils, beddings contaminated with discharges can transmit the bacteria. sometimes, biting of the infected birds also helps in transmission. person to person spread is rarely reported although possible through inhalation. chlamydia follows a unique life cycle with tri-phasic developmental stages. the infectious form (elementary body, eb) is extremely small (250-350 nm in diameter), pear to spherical shaped particle with electron dense irregular nucleoid. it has rigid cell wall with disulphide cross linkage among the cysteine rich amino acids of outer membrane proteins (omp). this form can survive for a prolonged period in the environment. after transmission, infection starts with the attachment of elementary bodies to the host cell membrane. in birds, apical surface of columnar epithelial cells in intestine acts as preferred site for attachment of c. psittaci. primary attachment of eb takes place by electrostatic interactions, most likely with glycosaminoglycan (gag) moieties on the host cell surface. this reversible binding is followed by receptor mediated irreversible attachment. protein disulfide isomerase (pdi), present in the host cell membranes and causing disulphide reduction, helps in attachment of ebs. chlamydial major outer membrane protein (momp) mostly acts as adhesin to bind with the host cellular receptor. following receptor mediated attachment, the eb enters the cell via endocytosis [microfilament dependent/independent process (clathrin mediated)]. some chlamydial strains enter the host cells through cholesterol-rich lipid raft domains. among different pathways, c. psittaci strains prefer to use clathrin-coated vesicles for cellular entry. c. psittaci elementary bodies contain rosette like long projections (matsumoto's projection) on their surface which acts as type three secreation system (t3ss). c. psittaci-t3ss helps in introduction of chlamydial proteins into the host cell cytoplasm. these t3ss-injected proteins interact with host cellular proteins and cause modulation of host cell function. after cellular entry, vesicles containing ebs escape the lysosomes in the host cell cytoplasm and reach near the nucleus within 8-12 h after entry. in c. psittaci infection, incb proteins (t3ss-effector protein) interact with host cell proteins (dynein motor proteins) for intracellular transport of vesicles with ebs into the nuclear zone. the eb is converted into reticulate bodies (rb) in this nuclear zone. the eb loses its electron dense dna core and its cell wall loses its rigidity due to break of disulphide bridges. the reticulate bodies are non-infectious form, larger in size (500-2000 nm diameter) and metabolically active. rbs multiply by binary fission and start genus specific protein synthesis. the structural reorientation started and rbs are transformed into intermediate bodies (ib, 300-1000 nm in diameter). a central electron-dense core with radially arranged nucleoid fibres surrounding the core is observed in the ibs. the ibs are converted into progeny ebs within a vesicle after 30 h of the entry of initial ebs. chlamydial micro colony with 100-500 ebs within the vesicle is called 'inclusion body' and it is generated after 48-50 h. the inclusion bodies move to the golgi apparatus region with the help of host dynein proteins. eb is released to attack new cells by rupturing the vesicles and the cycle is repeated. the signal for release of ebs is yet unknown but it is associated with host cellular apoptosis. suppression of host cellular apoptosis can induce persistent chlamydial infection. intracellular survival of ebs depends on escape from the lysosomal breakdown process. the ebs can induce delayed maturation of lysosomes as an escape mechanism. the intracellular inclusion bodies are covered with a mesh of host cytoskeletal filaments which prevent the exit of the content and consequent activation of the host immune system. close attachment of c. psittaci inclusions with the mitochondria helps in acquisition of atp because they cannot synthesize it. moreover, intracellular survival of the inclusions depends on acquisition of lipids such as sphingomyelin, phosphatidylinositol and phosphatidylcholine. golgi apparatus of the host cells act as major source of lipids for the inclusions and often the golgi apparatus are fragmented to provide the lipid. some non-replicating reticulate bodies persist within the host cytoplasm and produce latent infection. the growth cycle of chlamydia within the body of the host is disrupted due to nutritional deprivation, treatment with antibiotic and activated immune system. in disrupted growth cycle, reticulate bodies are converted into enlarged pleiotrophic 'aberrant' rbs. the aberrant rb contains chromosome but the genes associated with growth (genes encoding membrane proteins, transcription regulators, cell division factors, eb-rb differentiation factors) are not expressed. further, the genes encoding chlamydia protein associated with death domains (cadd) are down regulated which causes suppression of host cell apoptosis and persistence of infection. interaction of host cellular protein (g3bp1) and chlamydial inca (t3ss-effector protein) also suppress host cellular apoptosis. when the inducers of the disrupted growth cycle (antibiotic, immune system products) are removed, the aberrant rb is again converted into normal rb and they can complete the growth cycle. in birds, chlamydiosis has an incubation period of 3-10 days. clinical symptoms are not specific. general syndrome such as loss of condition, anorexia, fever, diarrhoea, respiratory problems, nasal and ocular discharges are observed. expression of syndrome and associated mortality (up to 80%) depends on virulence of c. psittaci strains, age, species, nutritional and immune status of the pet birds. occasionally, sub-clinical c. psittaci infection without visible syndrome is observed in birds. during stress conditions, the sub-clinical infection is activated with increased shedding of c. psittaci. the pet birds with avian chlamydiosis do not show any pathognomonic gross lesion. conjunctivitis, lateral nasal adenitis, sinusitis, fibrinous airsacculitis, lung congestion, fibrinous pneumonia, pericarditis with presence of fibrinous cover, peritonitis, hepatitis with multifocal necrosis and splenitis are observed (figs. 2.5 and 2.6). in pigeons, conjunctivitis, swollen eyelids, rhinitis, presence of fibrinous exudates over peritoneum, air sac and pericardium, enlarged, soft and dark coloured liver and spleen are observed. the budgerigars, infected with c. psittaci and reovirus, showed distinct cachexia, hepatomegaly and spleenomegaly. the livers become enlarged, mottled and tan-brown in colour. other lesions include uric acid atherosclerosis is considered as a well defined ailment specially in aged pet birds. african gray parrots, macaws and amazon parrots are most susceptible to this condition. sudden death without prior symptom is the cardinal sign of atherosclerosis. like human, the risk factors for atherosclerosis include high cholesterol and triglyceride concentrations, sex, age, species, obesity and inactivity, and moreover, c. psittaci infection. arteriosclerotic plaques are observed between the intima and internal elastic lamina of the blood vessels in many species of birds ( fig. 2.7) . the plaques are composed of fibrous tissues and are observed as pale yellowish areas at the thickened portion of intima. in severe cases, the plaques become circumferential lesion which cause narrowing of the lumen and reduced blood flow. clinical specimens from live birds, pharyngeal/choanal slit swabs, conjunctival swabs and nasal swabs can be collected aseptically as ante-mortem samples. faeces or cloacal swabs are less preferred because shedding of chlamydia is not consistent. post mortem samples collected from the dead birds include lungs, spleen, liver and air sacs. chlamydiae are relatively labile organisms and special precautions are required for their detection. samples should be maintained in cold chamber and processed immediately after collection. the tissue samples can be preserved at −80°c for prolonged period. dna extracted from the tissue samples can be stored in stabilization buffer. for successful isolation of chlamydia, the clinical samples should be collected in special chlamydia transport medium such as 2sp (0.2 m sucrose phosphate medium containing 10 lg/ml of gentamicin, 25 u of nystatin and 25 lg/ml of vancomycin) and spg (75 g of sucrose, 0.52 g of kh 2 po 4, 1.22 g of na 2 hpo 4 , 0.72 g of glutamic acid and water in 1litre, ph 7.4-7.6) supplemented with bovine serum albumin, streptomycin, vancomycin and nystatin. broad spectrum antibiotics like tetracycline, chloramphenicol, macrolides, sulphonamides, penicillin should not be added as they have anti-chlamydial effect. (a) direct examination: smears prepared from collected faecal samples, conjunctiva or impression smears of tissue samples can be stained with macchiavello, castaneda, giemsa, giménez, modified gimenez (pvk stain), stamp, modified z-n, and methylene blue for demonstration of chlamydial inclusion bodies. giemsa stain is more useful in the smears prepared from conjunctival scrapings. the inclusion bodies appear purple/blue with giemsa, castaneda and methylene blue stain and red with macchiavello, giménez, stamp, and modified z-n stains. (b) isolation of chlamydia from clinical samples: isolation of chlamydia can be done in the yolk sacs of embryonated hen eggs, laboratory animals and cell culture. fertile chicken eggs (6-8 days old) are inoculated through the yolk sac route. the embryo dying three or more days after incubation is examined for chlamydial inclusions. mice are ideal laboratory animal for isolation of chlamydia. the mice usually die within ten days of intranasal, intracerebral or intraperitoneal inoculation and the ebs can be isolated from viscera and peritoneal exudates. cell lines treated with a metabolic inhibitor (cycloheximide at 2 lg/ml) can be used for isolation of chlamydiae human psittacosis cases are reported in europe, usa, south america, japan and australia. other than the persons who rear the birds in their home, occupational risk groups such as veterinarians, pet shop workers, avian quarantine workers, poultry processing plant workers, bird breeders, and farm workers are most susceptible. even psittacosis outbreak was detected among custom officers in some countries due to their exposure to imported parakeets in the airport. incubation period in human is 5-14 days. clinical syndrome in human includes fever, chills, headache, pneumonia, renal disorders, and miscarriages in pregnant women. all the vital organs are affected with the progression of infection and endocarditis, hepatitis, myocarditis, arthritis and encephalitis are reported. ocular infection with follicular kerato-conjunctivitis is also observed. doxycycline, tetracycline and enrofloxacin were successfully used in budgerigars and psittacine birds to cure avian chlamydiosis. doxycycline is the drug of choice for the birds and the treatment should be continued for 45 days. it may induce toxicity in some bird species and produce signs of depression, inactivity, anorexia, greenish or yellowish urine. use of the drug in those birds should be stopped immediately and supportive symptomatic treatment should be started. recommended dose of doxycycline in feed is 300 mg/kg feed for 45 days. in drinking water, 400 mg of doxycycline hyclate/litre of water will maintain therapeutic concentration in psittacine birds. administration of the drug through the feed or drinking water is suitable for aviaries. for pet bird owners, oral administration of the capsule in individual bird is appropriate. recommended oral dose of the drug is 40-50 mg/kg body weight in every 24 h for cockatiels, senegal parrots, blue-fronted, orange-winged amazon parrots; 25 mg/kg body weight in every 24 h for african gray parrots, blue and gold macaws, green-winged macaws; and 25-50 mg/kg body weight in every 24 h for other psittacine birds. injectable doxycycline is administered at doses of 75-100 mg/kg body weight, intramuscularly (pectoral muscle), in every 5-7 days for the first 30 days and subsequently in every 5 days for the rest of the treatment period. long acting oxytetracycline can be injected sub-cutaneously at the dose of 75 mg/kg body weight in every 3 days in cockatoos, blue-fronted and orange-winged amazon parrots, and blue and gold macaws. the oxytetracycline injection causes irritation at the site. if tetracycline is orally administered or used in feed, dietary calcium sources (mineral block, oyster shell, supplemented pellets) should be reduced. to control the psittacosis infection in aviaries, general precautionary measures, such as quarantine of newly introduced birds for 30 days and periodical testing for c. psittaci infection, separation of birds after return from bird shows or fairs, rodent control, control of exposure to wild birds, regular disinfection of the cages and utensils, proper ventilation to reduce aerosol load within the unit should be followed. use of prophylactic antibiotic is not recommended as it may produce resistant bacteria. recommended disinfectants for c. psittaci infection are 1:1,000 dilution of quaternary ammonium compounds, 70% isopropyl alcohol, 1% lysol, and chlorophenols. use of vacuum cleaner in the aviaries is not preferred as it will aerosolize infectious particles. no vaccine is commercially available for the pet birds against c. psittaci infection. experimental dna vaccination in budgerigars with plasmid dna expressing momp of c. psittaci was found effective. were also carried out by smith in 1918 when similar organisms were isolated from aborted bovine foetuses. in this period, the bacteria were known as vibrio foetus. in 1963, due to certain differentiating characteristics, the bacteria were separated from vibrionaceae family and the new genus campylobacter ('curved rod') under campylobacteriaceae family was proposed. campylobacter spp. is gram negative, comma shaped rods specially in infected tissues and young cultures. when two bacterial cells are found together in a microscopic field, occasionally it looks like 's' or 'wing of gull' ('flying seagull'). they are motile by single unipolar/bipolar unsheathed flagella. motility is darting or corkscrew type, best observed by dark field microscopy. campylobacteriaceae family contains four genera namely campylobacter, arcobacter, sulfurospirillum and thiovulum. currently there are 18 species and 6 sub species of the genus campylobacter. important species and sub species of campylobacter are-campylobacter jejuni ssp. jejuni, c. jejuni ssp. doyeli, c. coli, c. lari, c. fetus ssp. venerealis, c. fetus ssp. fetus. thermotolerant campylobacter (c. jejuni ssp. jejuni, c. coli, c. lari, some strains of c. upsaliensis) is isolated from pet birds with or without clinical syndrome. the thermotolerant species requires higher temperature for their growth (42°c) which is provided by the pet birds due to high body temperature. other than thermotolerant campylobacter species, c. fetus and c. intestinalis have also isolated from parrots. the pet birds such as tropical finches (juvenile estrildidae), canaries, pigeons, parakeets [except red-crowned parakeet (cyanoramphus novaezelandiae), dusky-headed parakeet (aratinga weddellii), orange winged parrot (amazona amazonica), red bellied macaws (ara manilata)], emu, ostriches, waterfowls (mallard duck, shoveler duck, green-winged teal duck) are detected to harbour campylobacter spp. in a study in peruvian amazon, parrots (ara, brotogeris and pionites) were detected to be infected with campylobacter spp. wild and free-living birds, for instance, sparrows, crows, waders, black-headed gull (larus ridibundus), sparrow hawk (accipter nisus), jackdaw (corvus monedula), hooded crow (corvus cornix), dunnock (prunella modularis), yellowhammer (emberiza citrinella), white wagtail (motacilla alba), dunlin (calidris alpina), curlew sandpiper (calidris ferruguinea), bald ibis (geronticus eremita), little stint (calidris minuta), broad-billed sandpiper (limicola falcinellus), ruff (philomachus pugnax), wood sandpiper (tringa glareola), long-eared owl (asio otus), starling (sturnus vulgaris), reed warbler (acrocephalus scirpaceus), winter wren (troglodytes troglodytes), redwing (turdus iliacus), blackbird (turdus merula), song thrush (turdus philomelos), fieldfare (turdus pilaris), blackbirds (turdus merula), thrush (turdus viscivorus) can act as reservoir of c. jejuni in nature. certain clonal lineages of c. jejuni and species of wild birds are positively associated. among the raptors (birds of prey), only hawks were detected to carry c. jejuni in their gut. possession of campylobacter spp. in birds depends on feeding habits. gulls and crows have higher possession rate than the pigeons due to their preference for sewages. the shoveler ducks (spatula clypeata) have higher carriage rate than green-winged teal duck (anas acuta) because they prefer bottom sediments of aquatic environments containing molluscs as a feed. direct and indirect contact with infected birds and vectors (house flies, beetles, cockroaches, mealworms) are major ways of c. jejuni transmission in pet birds. c. jejuni is sensitive to oxygen and cannot grow below 31-32°c temperature. so, they cannot survive in feed and drinking water for a prolonged period. presence of c. jejuni in drinking water acts as an indicator for faecal contamination from wild birds or livestock. sometimes, campylobacter spp. can make a symbiosis with aquatic protozoa and survive in the environmental water. in human, major source of c. jejuni is contaminated poultry and its products, pork (with intact skin), beef, mutton and raw milk. consumption of undercooked meat, milk or their products and handling poultry are the key ways of transmission. direct or indirect contact with infected pet birds may play a role in zoonotic transmission of c. jejuni, although, not recorded in scientific literatures. in poultry, after transmission by faecal-oral route, c. jejuni colonizes at the mucous layer of caecal and cloacal crypts. the colonization is mediated by adhesin proteins like cadf (campylobacter adhesin to fibronectin), peb (periplasmic/ membrane-associated protein), capa (campylobacter adhesion protein a), jlpa (jejuni lipoprotein a), ciab (campylobacter invasin antigen b), flagella, and lipopolsaccharide (lps). occasional invasion of the intestinal epithelium takes place. no gross or microscopic lesions and clinical signs are produced in poultry during c. jejuni colonization or invasion. similar type of c. jejuni colonization takes place in psittacines and canaries and they mostly act as asymptomatic carriers. severe clinical signs and lesions are produced in tropical finches, especially in juvenile estrildidae. the precise mechanism of c. jejuni infection in pet birds is still unexplored. no clinical signs and lesions are detected in canaries, psittacines, free-living (migrating passerines) and wild birds, and they act as asymptomatic reservoir of c. jejuni. in finches [juvenile estrildidae, gouldian finch (chloebia gouldiae)], symptoms include sitting posture with its head under the wings, yellow droppings due to undigested starch (amylum), lethargy, and retarded moulting. high rate of mortality is observed among fledglings. in young ostriches, green coloured urination is the predominant sign. recent study indicates the possible synergistic role of c. jejuni in proventricular dilatation disease (pdd) in parrots caused by avian bornavirus. in tropical finches infected with c. jejuni, distinct cachexia, congestion in gastrointestinal tract, and presence of yellow coloured amylum or undigested seeds in gastrointestinal tract are the lesions. in sub-acute cases, hepatitis with focal necrosis and mucoid haemorrhagic enteritis is observed. fresh droppings (without urine) and cloacal swabs can be collected as clinical specimens. post mortem samples include intestine or intestinal contents and liver. infection with c. jejuni in human causes watery or bloody diarrhoea, elevated body temperature, abdominal pain, nausea, and vomition. septicaemia develops in a few diarrhoeic cases (0.15%) which may cause enlargement of the liver and spleen, endocarditis, arthritis, and meningitis. rarely, a complicated auto-immune response is developed as a sequel, known as guillain-barré syndrome. it is a demyelating disorder which results muscle weakness and neuromuscular paralysis. in mild infection, treatment with antibiotics is not recommended due to possibility of antibiotic resistance development. in severe cases, several antibiotics such as clindamycin, gentamicin, tetracyclines, erythromycin, cephalothin, and fluoroquinolones (nalidixic acid) can be used under the supervision of a qualified veterinarian. choice of antibiotic depends on sensitivity of the c. jejuni isolates, availability in suitable form, and species of the birds. in aviaries or personal collection, implementation of biosecurity practices such as regular cleaning and use of fly repellents in the cages is effective to prevent the introduction of campylobacter spp. no vaccine against campylobacter spp. is currently available for birds. 2.1.5 lyme disease 2.1.5.1 history lyme disease is a tick-borne, multi-system disorder of human and animals and it is characterized by swelling of joints, pain, lameness, fever, lethargy, anorexia, nephropathy with renal failure, myocarditis, cardiac arrest and cns involvement. the etiological agent is maintained in tick and several birds and animals. clinical description of lyme disease was first documented by arvid afzelius, a swedish dermatologist. the disease was first identified in 1975 (or 1976), among the people suffering with suspected juvenile rheumatoid arthritis in the area of lyme, connecticut, united states. hence it is known as 'lyme disease' or 'lyme borreliosis'. the causative agent, borrelia burgdorferi sensu lato (s.l.) was identified in 1982. borrelia spirochete is a gram negative, spiral organism with linear chromosome. the life cycle of borrelia requires arthropod vectors and mammalian hosts. it belongs to the family spirochetaceae under the order spirochaetales. borrelia spirochetes comprise three distinct species groups i.e. lyme borreliosis group (borrelia burgdorferi sensu lato; hard tick transmission), relapsing fever group (b. duttonii, b. hermsii; soft ticks transmission) and a third group phylogenetically similar with relapsing fever group but transmitted by hard ticks (b. theileri, b. lonestari, b. miyamotoi). lyme disease in human and animals (dogs, horses) is mostly caused by borrelia burgdorferi sensu lato (s.l.). borrelia miyamotoi is recently detected to produce lyme disease like syndrome in human. borrelia burgdorferi s.l. can be divided into 15 genomic groups or genospecies table 2 .2. borrelia burgdorferi is maintained in nature through a cycle. in the cycle, hard ticks (ixodes spp, haemaphysalis spp.) and small mammals (birds, rodents) act as vector and reservoir host, respectively (table 2 .2). the serum complement of the reservoir hosts determines host preference of b. burgdorferi. the bird associated genospecies are resistant to the bird complement but susceptible to the rodent complement. ixodes scapularis and i. pacificus in usa and canada, i. ricinus in europe and i. persulcatus in asia (japan) act as major vectors of borrelia burgdorferi s.l. occasionally, other species of ticks such as i. uriae, i. affinis, i. dammini, i. frontalis, i. angustus neumann, i. spinipalpis hadwen and nuttall, i. auritulus neumann, i. pacificus cooley and kohls are also associated. all of these ticks cannot parasitize human to transmit the spirochete, but, they can act as maintenance host (e.g. i. affinis, i. dentatus). ixodes persulcatus in japan and i. scapularis in usa was detected to act as vector of borrelia miyamotoi. different stages of ixodes ticks (larva, nymph and adult) can attach with three different hosts to take the blood meal and after engorgement they drop off the host in the environment. immatured ticks (larva or nymph) prefer to stay in moist areas such as vegetative mat of the forest floor or meadow. ground-feeding birds (passerines, game birds, sea birds), rodents, lizards act as preferred hosts of the imamatured ticks (table 2. 3). although, in comparison to rodents, tick infestation in migratory passerine birds is 20-30 times less, but the birds can transmit the infection for long distances. sometimes, reservoir birds generate mutant and more virulent strains of borrelia. passerine birds in mixed coniferous (evergreen) forest were more infected with b. burgdorferi s.l. than the birds in alder swamp forest. experimentally, mallard ducks (anas platyrhynchos platyrhynchos) are susceptible to b. burgdorferi infection and the ducks shed the organism in the droppings. they may transmit the infection without the help of tick vectors. the study indicated that psittacine birds such as yellow naped amazon parrots (amazona auropalliata) are generally not infected with b. burgdorferi s.l. more studies are needed to explore their resistance status against borrelia infection. the ticks normally attach with eyelid, head, neck and ventral feather of passerine birds during blood meal ( fig. 2 .8). the immature ticks take a blood meal for 2-4 days from their preferred hosts. in adult stage, the ticks attach with the tip of the grasses to get adhere with a large mammalian host. the adult ticks take a blood meal for 5-6 days. the ticks itself have less mobility but they can be carried by their hosts specially the migratory passerine birds across the countries. the seabird tick (i. uriae) is observed to disseminate borrelia burgdorferi s.l. from one hemisphere to another (trans-hemispheric transmission). in canada, passerine birds move northward during spring for breeding and nesting and they disseminate ticks with the pathogens. b. burgdorferi is transmitted to immatured ticks from infected birds, rodents and lizards along with the blood meal. the spirochete after transmission multiplies in the gut of the ticks. when the immature ticks molt into adult stage, the numbers of borrelia spirochete is decreased. during attachment of adult tick with large mammalian hosts, the multiplication of spirochete restarts and the number is increased. the expression of b. burgdorferi outer surface protein (osp) is also changed from ospa to ospc. the ospc helps in transmission of borrelia from the mid gut to the salivary glands of ticks. thus, b. burgdorferi is transmitted transstadially from larva to nymph and from nymph to adult. rarely, within the tick population, b. burgdorferi is transmitted transovarially. when the adult ticks bite a new host, the spirochetes are transmitted from the salivary glands. possibility of b. burgdorferi transmission by the adult ticks is more than the nymph and larvae, because the adult ticks have two blood meals in different hosts. sometimes, a single species of tick is infected with more than one numbers of borrelia genospecies (e.g. b. garinii and b. valaisiana) due to superinfection of the already infected ticks during their consecutive blood meals. occasionally, two different species of ticks (i. scapularis and i. affinis) may attach with the same borrelia burgdorferi infected host. co-transmission occurs between the infected and naive nymphs or larvae. infected larvae. occasionally, transmission of borrelia occurs from the infected ticks to uninfected ticks during their co-feeding from the same birds. the migratory birds not only import the infected ticks in a locality, but also, there is a possibility that local ticks get the infection during attachment with the birds. after a long journey, the birds prefer to take rest in some places for a few days. recently, role of cottontail rabbit in this transmission cycle is also explored. during carriage of b. burgdorferi most of the birds do not show any clinical symptom or lesion. experimental inoculation of b. burgdorferi in canary finches (serinus canaria) produced only a brief episode of diarrhoea. natural infestation of b burgdorferi infected tick (ixodes auritulus) results gasping, lameness and death in fledgling american robin (turdus migratorius). clinical specimens for collection of suspected ticks from the migratory birds, the birds are caught by mist nets and are observed carefully for the presence of ticks in head, neck, and beak by magnifying glasses. the ticks are collected by a blunt forcep and are placed in 70% ethanol. they should be labelled properly indicating species of bird and tick, and date of collection. for identification of bird and ticks up to the species level, expertise is needed. from the birds, suspected for b. burgdorferi infection, heparinized blood and tissues from liver, spleen, kidneys can be collected after post mortem. (a) direct examination: dark field microscopy or giemsa stain can directly demonstrate the borrelia spirochete in the blood film, liver/spleen smears. fat can be used for direct examination of the smears. (b) isolation of bacteria from clinical samples: isolation of borrelia is difficult due to its slow and fastidious growth and microaerophilic requirements. modified bsk (barbour-stoenner-kelly) medium is used for isolation of b. burgdorferi s.l. it is an enriched serum broth containing the antibiotics like kanamycin and 5-flurouracil. the media after inoculation is incubated at 33-34°c for 3 weeks. the collected heparinized blood sample (0.02 ml) or triturated tissue sample (0.1 ml) can be added in bsk medium (7-8 ml). (c) serological tests: elisa based kits for detection of total immunoglobulin, ig g, ig m against b. burgdorferi s.l is available for human. however, studies in animals (dogs), indicated that results of serological tests are inconclusive. the antibodies may be produced due to earlier exposure specially in those areas where infected tick bite is a common phenomenon. such kind of serological studies are not conducted in birds probably due to this uncertainty. (d) molecular biology: the whole blood samples collected from the birds can be used for dna extraction. whereas, from the ticks, dna is extracted by spin column technique. pcr for consensus flab gene of borrelia and the spacer region between the 5s and 23s rrna genes can be carried out to confirm borrelia burgdorferi s.l. zoonotic transmission of borrelia burgdorferi s.l. occurs from the bites of infected ticks. the persons during outdoor recreation, professionals such as wildlife and forest caretakers are at high risk. migratory birds passively maintain the infection in nature. no direct transmission of borrelia burgdorferi s.l. from the birds to human is evidenced. the infection in human initiates with a red coloured allergic pimple (erythema migrans), and it is followed by fever, headache, fatigue, muscle and joint pain. in severe cases, meningitis, unilateral facial nerve palsy and renal failure occur. products that kill or repel ticks (e.g. permethrin) can be used in the habitat to reduce the tick density. however, these acaricides may cause environmental hazard and they are only recommended during epidemic situation. 2.1.6 others 2.1.6.1 yersiniosis yersinia spp. was first isolated by alexandre yersin in 1894 in hongkong. he was sent by louis pasteur to investigate about plague outbreak there. in japan, s. kitasato also independently isolated the bacteria a few days later. previously, it was known as pasteurella pestis in honour of pasteur. later, in memory of yersin, the bacterium was renamed as yersinia pestis. in 1976, yersinia pseudotuberculosis was isolated from a sick palm dove (streptopelia senegalensis) in israel. yersinia enterocolitica was first detected in budgerigars in 1980. yersinia is gram negative, short rods or coccobacilli shaped bacteria. they show bipolar staining characteristics ('safety pin appearance') when stained with leishman's or wright or giemsa stain. the genus yersinia is classified under the family enterobacteriaceae that belongs to the order enterobacteriales. yersinia consists of 11 numbers of species. among them, y. pseudotuberculosis and y. enterocolitica are commonly associated with psittacine and passerine bird infection. mynahs are most susceptible to yersinia spp. infection. yersiniosis is also reported from canaries (serinus canaria), zebra finch (poephila guttata), kaka (nestor meriondalis), rainbow lorikeet (trichoglossus mollucanus), budgerigar (melopsittacus undulatus), new zealand wood pigeons (hemiphaga novaeseelandiae), blue-fronted amazon (amazona aestiva), yellow-headed amazon (amazona oratrix), eurasian collared dove (streptopelia decaocto) and cockatoo (cacatua alba). rodents and wild birds are major reservoir of infection and the feed and water are often contaminated with rodent urine or faeces. ingestion of contaminated feed and water is the key route of transmission. high mortality and non-specific clinical signs such as ruffling of feathers, depression, diarrhoea, and biliverdin in the urine are observed in the birds. the infection is acute and mostly enteric in passerine birds. chronic infection takes place in psittacines and pigeons, and it produces hepatitis, splenitis, pneumonia, nephritis and enteritis. the liver becomes dark, swollen and congested. yellow coloured foci (bacterial granulomata) are found in the liver, spleen, lungs, kidneys, intestines and heart ( fig. 2.9 ). microscopically, these foci are composed of necrosed hepatocytes and splenic pulp with fibrin and yersinia colonies. accumulation of iron in the liver (hepatic haemosiderosis) may act as a predisposing factor for systemic yersinia spp. infection. a smear can be prepared from the collected tissues of liver, spleen, kidney, intestine and stained by leishman's, wright, and giemsa stain. yersinia shows typical 'bipolar characteristics' (safety-pin appearance). yersinia can be isolated in blood agar, nutrient agar, macconkey's agar, brilliant green agar (y. enterocolitica). the selective medium is cin agar which contains antibiotics such as cefsulodin (15 mg/l), irgasin (4 mg/l) and novobiocin (2.5 mg/l). 'cold enrichment' method can be followed for primary isolation of y. pseudotuberculosis and y. enterocolitica from clinical samples. the samples are kept in sterile phosphate buffered saline (pbs) or nutrient broth at 4°c for 3 weeks. subculture in macconkey's or cin agar is done at weekly interval. amoxicillin in drinking water or soft food is the choice of treatment. in unresponsive cases, treatment should be carried out on the basis of antibiotic sensitivity test. albert bernhard frank (1889), a german biologist, first coined the term mycoplasma which is originated from the greek word mykes (fungus) and plasma (formed). earlier mycoplasma was known as pleuropneumonia-like organisms (pplo). adler (1957) first reported isolation of pplo from the air sac of a parakeet bird. mycoplasma is the smallest pathogenic bacteria (0.3-0.8 µm) and is pleomorphic in shape due to absence of the rigid cell wall. in stained smears, they appear as ring, globules, filaments or elementary bodies. the cell membrane is constituted of trilaminar structure enriched with phosphoprotein, lipoprotein, glycolipid, phospholipid and sterol moieties. mycoplasma belongs to the class mollicutes, order mycoplasmatales, and family mycoplasmataceae. the family comprises of two genera i.e. mycoplasma and ureaplasma. among different species under the genus mycoplasma, m. gallisepticum, m. iowae, and m. sturni are associated with pet bird infection. an epidemic of mycoplasmal conjunctivitis was noticed in house finches (carpodacus mexicanus) in usa in 1994. other birds such as budgerigars, cockatiel, canary, yellow-naped amazon parrot, pigeons, pea-fowls (pavo cristatus), fledgling cliff swallows, european starling (sturnus vulgaris), chukar partridges (alectoris chukar), ring-necked pheasants, purple finches (carpodacus purpureus), evening grosbeaks (coccothraustes vespertinus), pine grosbeaks (pinicola enucleator) are also reported to be infected. concomitant mycoplasmal infection with other bacteria and protozoa (cryptosporidium spp.) was detected in amazon parrots and fledgling cliff swallows. experimentally, american goldfinch (carduelis tristis) carried m. gallisepticum for prolonged period without showing any clinical sign. house sparrows (passer domesticus) are transiently infected experimentally with m. gallisepticum for a short period. in united states, tufted titmice (baeolophus bicolor) bird was reported as non-clinical carriers of m. gallisepticum. feeders or any focal point where the birds gather, act as a source of m. gallisepticum infection, because the infected birds excreate their droplets in the feeder. statistical correlation (multivariate analysis) was established between presence of tube style feeders, non-breeding period and low environmental temperature and m. gallisepticum infection in house finches. vertical way is a rare possibility of mycoplasmal transmission in birds. clinically the infected birds show variable symptoms ranging from serous nasal discharge, sinusitis, swollen eyes with discharge, conjunctivitis and blindness ( fig. 2.10 ). in fledgling cliff swallows and european starling (sturnus vulgaris) infected with m. sturni, bilateral conjunctivitis, episcleritis, epiphora, hyperaemia of palpebrae and nictitans are observed. gross lesions in birds include congestion of mucosa and accumulation of exudates in nasal sinus, trachea, bronchi, and air sacs. air sac congestion was also detected in budgerigars experimentally challenged with m. gallisepticum. histological investigation in birds reveals the presence of mucous gland hyperplasia and thickened mucous membrane of the respiratory tract with mononuclear cell infiltration. in european starling birds, ulceration of mucous membrane and absence of epithelial hyperplasia and lymphoplasmacytic infiltration was observed. in fledgling cliff swallows, lymphoplasmacytic conjunctivitis, rhinitis and infraorbital sinusitis with follicular lymphoid hyperplasia were detected. conjuntival swabs and head, lung, and spleen in 10% buffered formalin after post-mortem, can be collected as clinical samples from the suspected birds. the smears prepared from clinical specimens are stained with giemsa. m. gallisepticum appears as coccoid organisms having 0.25-0.5 lm in size. contrast phase microscopy, dark phase illumination techniques can be used for their direct visualization. m. gallisepticum can be isolated in specialized medium supplemented with 10-15% heat-inactivated avian, swine or horse serum. change in broth colour indicates positive growth after incubation at 37°c for 3-5 days. serum plate agglutination test is the rapid serological test for detection of m. gallisepticum antibodies in birds, although, sometimes it produces false positive result due to cross reaction. pcr targeting 16srrna gene and loop-mediated isothermal amplification (lamp) assay based on a gene within the pyruvate dehydrogenase complex (pdha) are developed for rapid detection of m. gallisepticum. in house finches, application of oral tylosin (1 mg/ml drinking water for 21 days) and ciprofloxacin eye drop (for 7 days) successfully treated conjunctivitis associated with m. gallisepticum. doxycycline (40-50 mg/kg body weight, orally) is also recommended for mycoplasmal infection in cockatiels and amazons. 2.1.6.3 pasteurella multocida, gallibacterium spp., volucribacter spp. bollinger (1878) first reported the isolation of pasteurella like organisms from cattle and wild animals. louis pasteur (1880) conducted more comprehensive studies on fowl cholera and its etiological agent. trevisan (1887) coined the name pasteurella for the bipolar organisms described earlier by pasteur and others. lignières (1900) proposed the specific name for each species of pasteurella according to their host preference, such as pasteurella aviseptica for fowls, p. suiseptica for pigs, p. boviseptica for bovines, p. oviseptica for ovines and p. leptiseptica for rabbits. rosenbusch and merchant (1939) proposed a single species pasteurella multocida and it is in use till date. miringa (1975) described pasteurellosis in african grey parrots. p. multocida is a gram-negative, non motile, non spore-forming short rod or coccobacillus bacterium. in fresh cultures and animal tissues, it produces typical bipolar staining characteristics, particularly with leishman or methylene blue stain. pasteurella belongs to the family pasteurellaceae. other avian pathogens such as gallibacterium (pasteurella anatis) and volucribacter are also members of the same family. p. multocida can be classified into 6 capsular types (a-f) and 16 somatic types (1-16). psittacines [parrots, red-fronted conure (aratinga wagleri)], passerine birds, owls, raptors and waterfowls (ducks) suffer from pasteurellosis. p. multocida is also isolated from eye swabs of healthy psittacine birds. unclassified members of the pasteurellaceae family were isolated from lesions in domestic goose (anser anser forma), fischer's lovebird (agapornis fischer), parrots (amazona spp.), macaws (ara macao), rock dove (columba livia), budgerigars (melanopsittacus undulates), and african gray parrot (psittacus erithacus). contaminated environment (e.g. water) is the major source of p. multocida infection. mechanical transmission by blood sucking arthropods and cat-bite is possible. in cat-bite cases, dermatitis and myositis develops rapidly and it is followed by septicaemia and death. in psittacine birds p. multocida serotype 3 and 4 are associated with septicaemia and cutaneous lesions, respectively. in african gray parrots, p. multocida produced obstruction of nares and dyspnoea, due to formation of intranasal caseous and fibrinous plugs along with other bacteria. in p. multocida infected budgerigars, crop inflammation and apathy was observed. gallibacterium melopsittaci are associated with septicaemia and salpingitis in budgerigars and parakeets. volucribacter psittacicida causes respiratory tract infections, septicaemia, crop inflammation, and diarrhoea in psittacine birds. a smear can be prepared from collected blood sample or the nasal swabs and it is stained by leishman or methylene blue or gram's stain. pasteurella appears as gram negative non-sporing coccobacilli with typical bipolar staining characteristics. p. multocida can be isolated in dextrose-starch agar, casein-sucrose-yeast (csy) medium with 5% blood (bovine or sheep). p. multocida specific pcr (pm-pcr) helps in rapid and confirmatory detection from clinical samples. treatment of avian pasteurellosis with ampicillin (150-200 mg/kg body weight for pigeons, amazon parrots) and tiamulin fumarate (25-50 mg/kg body weight, oral) are recommended. escherichia coli was first isolated by theodor escherich in 1885 from the faeces of human infants. it was named in honour of the german pediatrician and its major natural habitat i.e. colon. in 1978, e. coli was detected in faecal samples collected from psittacine birds. raphael and iverson (1980) described e. coli associated coligranuloma in amazon parrot along with psittacosis. e. coli is gram negative, short rods, varying form coccoid shape to long filamentous forms ( fig. 2.11 ). they occur singly, in pair or in short chain. they are non-spore forming and mostly motile by peritrichous flagella. the genus escherichia is classified under the family enterobacteriaceae that belongs to the order enterobacteriales. there are total 6 species under the genus escherichia. among them, escherichia coli are the important pathogen. the gastro-intestinal tract of all vertebrates including birds is the most common natural habitat of e. coli. the studies revealed that healthy parrots (31%), cockatoos (cacatua spp., 60%) and shore birds carried e. coli in their intestine. in healthy passerine birds, e. coli are not considered as a major intestinal flora. psittacines imported or illegally traded from other countries and shore birds act as source of e. coli. majority of these psittacine e. coli isolates possessed antimicrobial resistance due to the exposure of the birds to the prophylactic antibiotics after their capture. in pet birds, e. coli is transmitted by contaminated feed, drinking water, aerosols, and fomites. the stress conditions like transport, dietary change and extreme climate also help to establish the infection. in adult canaries and finches, e. coli are most common secondary pathogens associated with epizootic mortality. non-specific clinical signs and lesions such as lethargy, rhinitis and conjunctivitis are detected. e. coli as a primary pathogen is reported from a hyacinth macaw (anodorhynchus hyacinthinus), died due to septicaemia and enteritis with hemorrhages in different organs, and a kakapo (strigops habroptilus) with exudative cloacitis. recently, attaching-effacing e. coli is detected as a primary pathogen in a captive flock of budgerigars (melopsittacus undulatus). common lesions in budgerigars include hepatitis, enteritis, and attaching and effacing lesions along the intestinal tract. in nestlings of canaries and finches, e. coli is considered as most important cause of diarrhoea, dehydration, cachexia and mortality. appearance of young birds and their mothers became dirty, wet and yellowish ('sweating disease'). isolation of e. coli from the clinical samples is the major diagnostic technique. blood agar, macconkey's agar are choice of the medium for isolation. after overnight incubation in macconkey's agar, characteristic pink coloured colonies are transferred into eosine methylene blue (emb) agar for detection of 'metallic sheen' (fig. 2.12 ). the isolates are further confirmed by different biochemical tests. pathogenicity of the e. coli isolates from clinical samples should be confirmed as they are present as normal bacterial flora within the body. virulence of the isolates can be ascertained by ligated loop assay, cell culture cytotoxicity assay, typing and detection of toxin by serological or dna based methods. e. coli infections can be treated with ampicillin sodium, amoxicillin/clavulanate, cephalexin, oxytetracycline and spectinomycin. in unresponsive cases, antibiotic should be selected after sensitivity test of the etiological e. coli isolates. in nestlings, antibiotics are administered in drinking water and egg food from one day before hatching up to 6 days after hatching. extra drinking water should be provided to prevent dehydration. other bacterial infections of pet birds are described in table 2 .4. malbrant (1942) reported an outbreak in australian parrots and red-headed lovebirds (agaporius pullaria pullaria l.) in africa suspected to be suffered and died off newcastle disease. zuydam (1952) first isolated newcastle disease virus (ndv) from parakeet (psittacula krameri borealis nearn) and ospray birds (pandion haliaetus) in the netherlands. the first major outbreak of newcastle disease among grey parrots (psittacus erithacus l.) occurred in kenya in 1955 (scott et al. 1956 ). subsequently, in 1960, ndv was isolated from grey parrots (psittacus erithacus l.) in kenya (scott and winmill 1960) . in 1970s, pigeon paramyxovirus-1 (ppmv-1), a variant of ndv, was discovered in the middle east countries. ndv belongs to the avulavirus (avian paramyxovirus-1) genus within the paramyxoviridae family in the order mononegavirales. the virus is an enveloped, single-stranded, un-segmented, negative-sense rna virus. the virion has a genome of 15 kb in size and the genome comprises of the genes which encode nucleocapsid protein (np), phosphoprotein (p), matrix protein (m), fusion protein (f), hemagglutinin-neuraminidase (hn) and polymerase enzyme (l). on the basis of virulence, ndv can be classified into velogenic (highly virulent, icpi > 1.5), mesogenic (intermediate, icpi > 0.7 but 1.5) and lentogenic strains (non-pathogenic, icpi 0.7). intracerebral pathogenicity index (icpi) is oie recommended in vivo test for determination of ndv virulence. the strains differ in virulence also differ in amino acid sequence at the cleavage site of precursor fusion protein (f0). velogenic strains have more than two basic amino acids (arginine or lysine at positions 113-116) and phenylalanine at the position 117. on the basis of fusion protein (f) and polymerase enzyme (l) nucleotide sequence, ndv is classified into two major classes (class i and ii) with a single genotype under class i and 18 genotypes under class ii. distribution of ndv genotypes and sub-genotypes in different species of birds is described in table 2 .5. the virulence of class i ndv isolates is low (except one isolate from ireland) and they are mostly maintained by velogenic or mesogenic strains of ndv were detected in psittacine birds (cockatoos, budgerigars, macaw, lory, parrot, love bird, conure, yellow-headed amazon parrots, yellow-naped amazon parrots), pelicans, gulls, kestrels, falcons, white crested laughing thrush, pheasants, swans, robin, peafowl, whooper swan, spotted necked dove, white-cheeked starling, eurasian blackbird, wild little tern, wild village weaver, mynah (gracula religiosa), drongo (dicrurus spp.) and partridges (family phasianidae) ( table 2 .5). these wild and pet birds may act as reservoir or in pet birds, horizontal transmission through direct contact with infected birds or ingestion of contaminated feed and water are the major ways of ndv transmission. sometimes, infection of parrots occurs from live animal market during their direct contact with poultry. use of contaminated or improperly attenuated live vaccines in poultry against ndv is another possible source of infection in nature and pet birds. experimentally, yellow-headed amazon parrot was infected with velogenic ndv strain by nebulization. common houseflies (musca domestica) act as mechanical vector for ndv transmission, although, yet to be validated in pet birds. imported exotic birds including the psittacines may act as reservoir and they excreate the virus in the faecal matter for prolonged period without showing clinical signs. legally or illegally trafficked pet birds and migratory birds thus introduce the virus into the countries which produces a persistent risk for poultry. moreover, the study has also shown the possibility of spreading ndv in a native wildlife population through ndv contaminated illegal wildlife trade. after transmission of the virus into the susceptible host, cellular entry requires activation of fusion protein (f0) present in the viral envelope. the f0 is activated by post-translational cleavage by the host protease enzyme. the post-translational cleavage varies with the amino acid sequence present in the cleavage site and the type of host protease enzyme. in lentogenic ndv strains, cleavage site contains monobasic amino acid sequence at the c-terminus and leucine at the n-terminus ( 112 g-r/k-q-g-r-l 117 ). the cleavage site of velogenic and mesogenic strains contains multibasic amino acid sequence at the c-terminus and a phenylalanine at the n-terminus ( 112 r/g/kr-q/k-k/r-r-f 117 ). the cleavage site of lentogenic strains is cleaved by the protease present in respiratory and intestinal tract only. velogenic strains are cleaved by ubiquitous protease present in all vital organs. moreover, activation of hn (hn0) protein and other viral proteins such as v, np, p, and l also play role in pathogenesis. psittacine birds suffering with ndv mostly show respiratory signs (rhinitis, conjunctivitis), greenish watery diarrhea (green staining around the vent), lethargy, drooping of wing, torticollis, waving movement of head and neck and limb paralysis. experimental inoculation of six species of pet birds (budgerigar, yellow-headed amazon parrot, halfmoon conure, hill mynah, black-headed nun, canary) with velogenic ndv strain produced ruffled plumage, conjunctivitis, ataxia, wing tremors, paralysis of the extremities, and tremors of the head. neurological signs are more common in parakeets. mortality can reach as high as 100%, but typically ranges between 20-80% depending upon the virulence of the virus strain, host species, age, and immune status. petechial haemorrhages are often observed in viscera of pet birds suffering with newcastle disease. in naturally infected cockatiels and parrots, diffuse spongiosis of gray and white matter, neuronal necrosis, perivascular infiltration of mononuclear cells are detected. the lamina propria of the proventriculus shows infiltration of mononuclear cells and ulceration. accumulation of haemosiderin is detected in the cytoplasm of mononuclear cells. depletion of lymphoid cells is observed in spleen and bursa of fabricious. tracheal and cloacal swabs from live birds and the organs such as liver, brain, spleen, kidney after post mortem can be collected as clinical specimens. collection of cloacal swabs from small birds is a complicated process which may causes injury of the vent. fresh faeces collection is an alternative approach. during transport, the samples should be kept in isotonic phosphate buffered saline (ph 7.0-7.4) or brain heart infusion broth with antibiotics such as penicillin (2000 units/ml), streptomycin (2 mg/ml), gentamicin (50 lg/ml), and mycostatin (1000 units/ml). the samples can be preserved at 4°c for four days. (a) clinical signs and lesions after necropsy, history of direct contact with infected birds give a tentative diagnosis. (b) isolation of virus from clinical samples: the clinical samples collected in isotonic phosphate buffered saline with antibiotics are centrifuged (1000 g) and the supernatant fluid is inoculated into 9-11 days old embryonated hen's eggs (specific pathogen free) by allantoic sac route or the cell lines such as chicken embryo kidney (cek) cells, chicken embryo fibroblast (cef) cells. the inoculated eggs are incubated at 37°c for 4-5 days. after incubation, eggs are kept at 4°c. the embryo will die in positive samples and the allantoic fluids are collected to detect the haemagglutination activity of the viral isolate. the isolate is further confirmed by haemagglutination inhibition (hi) test. virulence of the isolate should be detected by intracerebral pathogenicity index (icpi) or amino acid sequencing of fusion protein to confirm a nd outbreak. (c) serological tests: virus neutralization test, plaque neutralization, hemagglutination-inhibition (hi), single radial immunodiffusion, agar gel immunodiffusion (agid), enzyme-linked immunosorbent assay (elisa) are employed for detection of ndv antibodies. however, these tests can not differentiate the infection caused by velogenic and lentogenic viral isolates. serological tests can give a tentative diagnosis of ndv exposure in the birds. (d) molecular biology: real-time reverse-transcriptase polymerase chain reaction (rrt-pcr) can be used for detection of fusion protein, matrix protein and rna-dependent rna polymerase enzyme either from the viral isolate or from the collected tissues and faeces of suspected birds. it can also confirm the virulence of the isolates. in conventional reverse-transcriptase polymerase chain reaction (rt-pcr), cloning and sequencing of pcr products will confirm the pathogenic potentiality of the isolate. zoonotic transmission of ndv is possible which causes acute conjunctivitis, malaise, and sinusitis in susceptible human. the flu like symptoms resolves automatically within 1-3 weeks. direct transmission of ndv into human from pet birds is still not documented possibly due to similarity of symptoms with common flu and its auto recovery. the pet birds as reservoir of ndv become a potential hazard for poultry population where the human may act as intermediate host. human to human transmission of ndv is not documented. no effective treatment for pet birds against ndv infection is documented. to control the infection in pet birds, exposure to live bird market, wild birds, and migratory birds should be restricted. infected birds should be kept separately and general hygiene practices should be followed to avoid the contamination of feed and drinking water. vaccination is an effective measure to control ndv infection in commercial and domestic poultry. vaccination in pet birds is not recommended because it cannot eliminate the carrier birds. vaccination with modified live virus may produce the infection in pet birds. however, experimental use of inactivated ndv vaccine produced a humoral response in wild house sparrows with doses above 0.05 ml per bird. the humoral response was produced within 4-6 weeks after experimental inoculation of the vaccine. in 1878, avian influenza (earlier known as fowl plague) was described for the first time in italy by perroncito. centanni and savonuzzi (1901) first observed the role of filterable agent (virus) as etiology of avian influenza. the definitive etiological correlation with influenzavirus a was established later (1955) . highly pathogenic avian influenza (h5 subtype) was first reported from chickens in scotland (1959) and common terns (sterna hirundo) in 1961 from south africa. during 1972-80, influenzavirus a was reported from exotic birds including budgerigars (melopsittacus undulatus), migratory ducks, and pelagic seabird (shearwater). avian influenza virus (aiv) belongs to the family orthomyxoviridae, genus influenzavirus a. the virions are sensitive to heat (56°c for 30 min exposure), acid (ph 3.0) and lipid solvents. so they are easily destroyed under common environmental conditions. the virions are enveloped and pleomorphic, spherical to filamentous in shape. the virion surface is covered with two types of glycoprotein projections, known as haemagglutinin (ha, rod shaped trimer protein) and neuraminidase (na, mushroom shaped tetramer protein). other constituent viral proteins are nucleoprotein (np), matrix proteins (m1, m2), polymerase basic (pb1, pb2), polymerase acidic (pa), and non structural proteins (ns2). the viral genome is linear, negative sense single stranded rna and it contains eight numbers of segments. during genetic reassortment, these segments are exchanged between two viral strains to generate a mutant one (antigenic shift). the point mutation in ha and na gene causes antigenic drift which can generate a new viral strain. on the basis of ha and na gene sequences, influenzavirus a has 16 ha (h1-16) and 9 na (n1-9) subtypes. genetic reassortment between the subtypes theoretically can produce 144 types of combinations. on the basis of pathogenicity, aiv can be further differentiated into two categories i.e. highly pathogenic avian influenza (hpai, e.g. h5 and h7 subtypes) and low pathogenic avian influenza (lpai, e.g. h9n2). hpai causes 90-100% mortality in birds and lpai infection is mostly restricted within the respiratory system. further molecular variations of ha gene can differentiate hpai (h5n1) into several clades (first order-fourth order clade). other than commercial and domestic poultry, birds belong to the order anseriformes (waterfowls) and charadriiformes (shorebirds, gulls, auks, terns, waders) are considered as major reservoir of avian influenza virus (table 2 .6). h3 and h6 subtypes are common in waterfowls (anseriformes), and h4, h9, h11, and h13 subtypes are widespread in charadriiformes. among the anseriformes, mallard (anas platyrhynchos) and northern pintail ducks (anas acuta) in united states and bar headed geese (anser indicus) in india are considered as major reservoirs. natural h5n1 outbreak among the migratory waterfowls such as bar-headed geese (anser indicus), great cormorants (phalacrocorax carbo), pallas's gulls (larus ichthyaetus), brown-headed gulls (larus brunnicephalus), ruddy shelducks (tadorna ferruginea) is also detected in china. role of passeriformes (canary, finch, starling, sparrow) as aiv reservoir is uncertain. a study in france with large numbers of wild passerine birds failed to detect aiv. although, wild passerine birds such as eurasian tree sparrow (passer montanus) in china and golden crowned kinglet (regulus satrapa), fox sparrow (passerella iliaca), western tanager (piranga ludoviciana), northern waterthrush (seiurus noveboracensis), cassin's finch (carpodacus cassinii) in united states, and flycatchers (family muscicapidae) in central africa is detected to possess aiv infection. experimentally, society finches (lonchura striata domestica), zebra finches (taeniopygia guttata), house sparrows (passer domesticus) and starlings are found susceptible to aiv (h5n1, h7n9, h7n7) . the sialic acid receptors for both avian influenza (a 2, 3) and human influenza (a 2, 6) viruses are present in house sparrows (passer domesticus) and starlings (sturnus vulgaris). in contrast, eurasian tree sparrows contain abundance of sialic acid receptors (a 2, 6) for aiv. detection of aiv is rare in psittacine birds and as such the psittacines are not considered as potential reservoir of aiv. limited reports of viral isolation such as h9n2 subtype from indian ring-necked parakeets and h5n2 subtype (mexican lineage) from red-lored amazon parrot is available (table 2.6). experimentally, parakeets (melopsittacus undulates) are found susceptible to human h7n9 isolate and after inoculation, development of clinical signs and shedding of the virus into water troughs is observed. on the other hand, psittacine isolate can also replicate in chicken, duck and turkeys and transmission into healthy cage mates is observed. water mediated transmission of aiv is possible in waterfowls and shorebirds due to their exposure to the contaminated water. lower temperature maintained in water bodies helps in survival of aiv for prolonged period. possibility of aiv transmission in waterfowl is more during their assembly in water bodies associated with post-breeding and pre-migratory molt. migratory shorebirds and other charadriiformes birds mostly transmit the infection when they congregate to feed and roost at places en route of migration. thus the migratory birds become a possible source of infection in pet birds living in open air aviaries. possibility of water mediated transmission is low in terrestrial and passerine birds. detection of aiv in passerines is possible, when the virus is maintained in local poultry population or the passerines share a common habitat with infected waterfowls. this kind of aiv transmission dynamics was observed during h5n1outbreaks (2005-10) in wild birds in china, russia and mongolia. consumption of infected bird carcass by raptors (bird of prey) is another possible way of transmission. in psittacine birds, aiv infection is transmitted by direct contact with infected birds if kept together after capture or during quarantine. international trade of exotic birds can transmit the aiv infection from one continent to another. further transmission of aiv from wild birds to local poultry population is possible. in hpai infection, most of the wild birds die except in h5n1-hpai (guangdong lineage) infection. the virus of guangdong lineage can persist in wild birds and is transmitted to the poultry. sometimes, lpai maintained in the wild birds is transmitted into poultry as observed during hpai outbreaks in poultry in united states. the source of the virus was confirmed as lpai from wild birds which undergo several mutations to generate hpai strain. pathogenesis of aiv in psittacine and passerine birds is still unexplored. experimental inoculation of hpai (h5n1) in finches, sparrows and budgerigars indicated the existence of variations in pathogenesis of aiv from the gallinaceous poultry. neurotropism of hpai in nongallinaceous birds is identified as the major cause of localization of virus is also detected in other tissues such as heart, pancreas, spleen, nasal epithelium, and reproductive organs of nongallinaceous birds. muti-organ failure or dysfunction is also identified as additional factor for mortality of the affected birds. non-specific clinical symptoms such as neurological signs (head between legs), depression, ruffled feathers, and standing at the bottom of the cage are observed in pet birds with aiv infection (fig. 2.13) . in a natural outbreak of lpai infection (h5n2) in a red-lored amazon parrot (amazona autumnalis autumnalis), lethargy, diarrhoea and dehydration are noted. sudden onset, depression, neurological symptoms are detected in finches and budgerigars experimentally inoculated with a chicken isolate of hpai (h5n1). in wild migratory passerine birds (blackcap, red-billed quelea) experimentally inoculated with hpai (h5n1), sudden death, ruffled feathers, lethargy, and neurological disorders (ataxia) are observed. in experimentally inoculated passerine and psittacine birds (zebra finches, house finches, budgerigars) with hpai (h5n1), carcass dehydration, spleenomegaly with mottling of parenchyma, accumulation of watery faeces in cloaca is observed. in house finches and budgerigars, vents are pasted with faeces and bile tinged urates. in wild migratory passerine birds (blackcap, red-billed quelea) experimentally inoculated with hpai (h5n1), lung congestion, pancreatic necrosis with multiple, white foci on pancreas are major gross lesions. cloacal swabs from live birds and tissue specimens from heart, pancreas, spleen, and brain after post-mortem can be collected as clinical specimens. the samples should be transported in isotonic phosphate-buffered-saline (pbs, ph 7.0-7.4) with antibiotics such as penicillin (2000 units/ml), streptomycin (2 mg/ml), gentamycin (50 lg/ml), mycostatin (1000 units/ml) and protein (5% cattle serum, 0.5% bovine albumen). the specimens can be preserved at 4°c for 4 days and at −80°c for extended period. the laboratory should have at least biocontainment level 3 facilities and official clearance from the concerned authority to handle the aiv suspected samples. in future, rapid isothermal nucleic acid detection assay-lateral flow (rida-lf) and immunoassay-based biosensors will be a better choice due to less dependence on instrumentation and rapid process of a good numbers of samples in less time, respectively. world health organization (who) has reported more than 600 human infections with hpai (h5n1) since 2003, of which 60% infected people died. transmission of h5n1 infection in human occurred during close contact with birds or contaminated environments. keeping pet birds in household also increased the seroconversion of the owners during a h7n7 outbreak. religious ceremonies, such as 'merit release' among buddhists, in which a passerine bird is purchased, kissed and released, may increase the transmission possibility of aiv among the human. no report of human to human transmission of aiv is reported so far. no effective treatment for pet birds against aiv infection is documented. to control the infection in pet birds, exposure to live bird market, wild birds, and migratory birds should be restricted. infected birds should be kept separately and general hygiene practices should be followed to avoid the contamination of feed and drinking water. the cages or aviaries should be cleaned with formaldehyde, gluteraldehyde, beta-propiolactone, binary ethylenimine, quaternary ammonium disinfectants, sodium hypochlorite, dilute acids, and hydroxylamine after an aiv outbreak. vaccination against aiv in birds is a controversial issue. due to high mutating capability of the virus, instead of control, vaccination with live virus may cause more damage to the birds. experimentally, inactivated recombinant h5n3 vaccine was used in several types of zoo birds (anseriformes, charadriiformes, ciconiiformes, columbiformes, coraciiformes, falconiformes, galliformes, gruiformes, passeriformes, psittaciformes) which produced strong antibody titer against h5 subtype in all the birds except in psittaciformes. prime-boost strategy of vaccination (priming with h5n9 and booster with h5n3) produced strong antibody titer in psittaciformes. west nile virus (wnv) was first isolated from a woman suffering with fever and other complications in uganda (1937) . in africa, middle east and european countries, wnv was mostly known to cause sub-clinical and self-limiting infections in horses and human during 1960s. later in 1990s, higher frequency of wnv infection was noticed among human, farm animals, pet animals and birds of prey. in 1999, a fatal outbreak of wnv was detected among birds, horses and human in new york, usa. during 2008-10, wnv was isolated from a clinically infected sun conure (aratinga solstitialis) and green-winged macaw (ara chloropterus) in united states. west nile virus is an arthropod-borne (arbovirus), enveloped virus which belongs to family flaviviridae and genus flavivirus. the virion is 50 nm in diameter with icosahedral symmetry. no spikes or peplomers are present on the virion surface. genome of the virus is positive sense single-stranded rna. the genome (11 kbp) encodes envelope protein (e), membrane precursor protein (prm), capsid protein (c) and non-structural proteins (ns1, ns2a, ns2b, ns3, ns4a, ns4b, ns5). the structural proteins help in formation of virion and the non-structural proteins help in viral replication and evasion of host immune response. seven lineages of wnv have identified and lineages 1 (clade ia and ib) and 2 are considered as major lineages. lineage 1is mostly distributed in europe (clade ia), america (clade ia), the middle east (clade ia), india, africa (clade ia) and australia (clade ib, kunjin virus). lineage 2 is widespread in south africa, madagascar and europe. both the lineages of wnv have neurotropism property, although, viruses belong to lineage 1 (clade ia) are more virulent than the clade ib and lineage 2 viruses. wnv is identified in 326 species of birds with or without clinical symptoms. the most susceptible birds to wnv infection are crows (corvus spp.), ravens (corvus corax), jays (garrulus spp.), magpies (pica spp.), owls (strigiformes spp.), and some raptors (spanish imperial eagle, goshawk, golden eagle, sparrow hawk, gyrfalcon). the passerine birds and the mosquitoes (culex spp.) are considered as major host and vector of wnv, respectively. crows are more exposed to wnv infection due to their communal roosting (perching) behaviour. after sunset, during the communal roosting, the mosquitoes (culex spp.) mostly feed on the birds. migratory passerines (american robins) can transmit the infection in distant places, whereas, resident passerines (house sparrows), crows [american crows (corvus brachyrhynchis)] and other birds act as local amplifying host of wnv. wnv is detected from resident birds such as columbiformes (columbina talpacoti), coraciiformes (melanerpes aurifrons), piciformes (cardinalis cardinalis, molothrus aeneus), and passeriformes (myiozetetes similis, sporophila torqueola, thamnophilus doliatus, tiaris olivaceus, tyrannus melancholicus). seroprevalence of wnv is observed among passerines such as northern cardinals (cardinalis cardinalis) and carolina wren (thryothorus ludovicianus). studies indicated that presence of non-passerine birds (enormous numbers) in a population can reduce the virus amplification and human transmission risk due to diversity of hosts (dilution effect). among the psittacine birds, seroprevalence of wnv is detected in budgerigars (melopsittacus undulatus), cockatiels (nymphicus hollandicus), cockatoos (cacatua spp.), macaws (ara spp.), parrots (amazona, rhynchopsitta, poichephalus, psittacus spp.), pacific parrotlets (forpus coelestis), canary-winged parakeet (brotogeris versicolurus), rosellas (platycercus spp.), lories and lorikeets (eos, lorius, pseudeos, trichoglossus spp.) and blue-crowned conure (thectocercus acuticaudata). red-legged partridges (alectoris rufa) are resistant to natural wnv infection, although they can be experimentally infected with the virus. other than birds, human, horses, sheep, alpacas, dogs, cats, white-tailed deer, reindeer, squirrels, chipmunks, bats, and alligators are susceptible to wnv. human and horses are dead-end-hosts of the virus as sufficient amount of virions are not maintained in the blood to infect the mosquitoes feeding on the hosts. maintenance of wnv throughout the world takes place by an enzootic cycle ('rural cycle'). the susceptible birds and mosquitoes (culex spp.) are two major components of the cycle. the birds maintain the virus by acting as reservoir and the mosquitoes act as vector and spread the virus into new hosts. microfilarial infection of mosquitoes can hasten viral replication and rapid transmission of the virus (microfilarial enhancement of arboviral transmission). when the mosquitoes introduce the virus into the human habitats, the 'urban cycle' begins. in endemic zones, urban cycle begins with mortality of wild birds (summer to autumn) and the cycle ends with human and horse infection (dead-end-hosts). in winter months, when the adult mosquitoes are mostly inactive, vertical transmission of the virus takes place to sustain in the vector population ('overwintering strategy'). sometimes, wnv is re-introduced into the vector population through migratory birds and rarely by human transport (mosquitoes on aeroplanes). other than mosquito bites, wnv is rarely transmitted by oral route (ingestion of infected prey, drinking water) and direct contact in birds, cats and other vertebrates. in psittacine birds, feathers are identified as an important source of wnv. association of testes in psittacine birds suggests the possibility of sexual transmission. following the wnv transmission through the mosquitoes in human and rodents, the virus primarily enters dendritic cells (langerhans cells) via receptor mediated endocytosis. the cell surface proteins (dc-sign, integrin) act as wnv receptors. the dendritic cells carry the virus into draining lymph nodes where viral multiplication occurs. following genomic replication and translation, the progeny virions are matured through er-golgi secreation pathway and are released by exocytosis into the blood circulation. transient viraemia develops and different vital organs such as liver, spleen, kidney are infected. neuroinvasion can take place through direct infection with or without breakdown of blood-brain barrier or virus transport along peripheral neurons. certain host proteins such as drak2 (death-associated protein-kinaserelated 2), icam-1 (intercellular adhesion molecule), mip (macrophage migration inhibitory factor) and mmp-9 (matrix metaloproeinase 9) help in altering blood-brain barrier permeability. sometimes, host innate immune response (tlr3) mediated up regulation of tumor necrosis factor alpha (tnfa) causes capillary leakage and increased permeability of blood-brain barrier. in contrast, in birds, viraemia develops within 30-45 min of mosquito bite without any local virus multiplication in the lymph nodes. positive correlation of peak viraemia and bird mortality is observed. in birds, wnv prefers to replicate primarily in spleen and mononuclear phagocytic cells and are disseminated into vital organs (liver, kidney, heart). different lineages (1 and 2) of wnv have different tissue tropism in avian hosts. lineage 1 virions prefer to infect liver and myocardium, whereas, lineage 2 of wnv mostly infect spleen, kidney and liver in goshawks. depending upon the viral load in blood wnv may infect central nervous system in birds. exact mechanism of neuroinvasion in birds is unexplored. role of endothelial cells and immune cells in neuroinvasion is predicted. death of the birds occurs due to wnv associated lesions and secondary infections with bacteria, fungi and parasites. pathogenicity of wnv infections in birds is influenced by route of viral transmission, host defense, age and species of birds. the virus can persist in different organs of birds such as spleen, kidney, eye, brain and skin. detection of wnv in a hawk (birds of prey) during winter months, when mostly the mosquitoes are inactive and unable to transmit the infection, revealed the possibility of persistent viral infection. experimentally, persistent wnv infection is produced in ducks, pigeons and immunocompromised mice. effect of persistent wnv infection in health status of the birds is indistinct. low level of wnv infection is detected in carcasses of rock pigeons (columba livia) and mourning doves (zenaida macroura), although, wnv is not confirmed as a cause of death. whereas, in a kea (nestor notabilis gould), a large mountain parrot, natural persistence of wnv in central nervous system for more than 6 years is detected. this persistence is associated with death of the bird after prolonged incubation period. non-specific clinical signs such as depression, anorexia, dehydration and ruffled feathers are observed in birds. in complicated cases, neurological signs, for instance, convulsions, ataxia, abnormal head postures and movements, tremors, paresis, and uncoordinated flight are detected. the neurological signs do not always correlate with the lesions in the brain (neuronal necrosis). partial or complete blindness develops in raptors and owls. sequelaes of viral neuroinvasion are observed in long-lived birds (e.g. raptors). in raptors, feather pulp abnormalities and abnormal molt can persist up to 4 years as sequelae of wnv infection. in naturally infected psittacine birds (rosellas, conures, lorikeets, cockatoos, caiques, parakeets), sudden death without any symptoms or non-specific signs like loss of weight, anorexia, lethargy, depression, and weakness are noted. specific neurological signs consisted of rolling over, legs stretched backward, stumbling and disorientation. no pathognomonic lesion of wnv infection is detected in birds. in highly susceptible birds (crows) sudden death without any gross lesion is observed. in passerines, necrosis and mild inflammation in the heart, spleen, liver, kidney, mild encephalitic lesions and absence of neuronal necrosis is detected. in naturally infected psittacines (rosellas, conures, lorikeets, cockatoos, caiques, parakeets), splenomegaly, hepatomegaly, mottled pale liver with multifocal petechiae, diffuse pallor in kidneys, myocardial pallor, petechiae on the gizzard serosa are observed. in long-lived birds (raptors) due to chronic wnv infection, hemorrhages, petechiae and congestion in vital organs, splenomegaly, hepatomegaly, myocardial pallor, pale mottling in the liver, spleen, kidney, cerebral atrophy and malacia are detected. in central nervous system, gliosis, perivascular cuffing and glial nodules are major microscopic findings. from the dead birds after post mortem, brain, heart, liver and kidney can be collected as clinical specimens for laboratory confirmation. the laboratories should have containment level 3 to handle the samples suspected for wnv infection diagnostic techniques real-time rt-pcr can be used for detection of wnv from avian tissues. sporadic outbreaks of wnv occurred in human in the mediterranean region, africa and europe before 1994. severe wnv outbreaks with neuroinvasion took place in human throughout the world after 1994. global warming associated increased temperature and prolonged rainfall helps in breeding of mosquitoes and spreading of arboviral diseases such as wnv. in human, wnv transmission can occur through biting of infected mosquitoes, blood transfusion, organ transplantation, breast milk, and intrauterine route. the clinical presentation ranges from asymptomatic (80% of infections) to encephalitis/paralysis and death (1% of infections). sometimes, flu like symptoms such as fever, headache, malaise, myalgia, fatigue, skin rash, lymphadenopathy, vomiting, and diarrhea are observed. no effective treatment for pet birds against wnv infection is documented. to control the infection in pet birds, exposure to mosquitoes should be restricted. maternal antibodies can protect the house sparrow chicks up to 3 days post hatch. no specific vaccine against wnv is available to use in birds. in some countries, equine vaccine is used, although not licensed. successful use of recombinant subunit wnv vaccine is reported from experimental geese. experimental vaccination in thick-billed parrots (rhynchopsitta pachyrhyncha) produced detectable antibody titer against wnv. usutu virus (usuv) was first detected in a mosquito (culex neavei) in 1959 in south africa. the isolated virus is currently considered as a reference strain of usuv (southafrica-1959) . subsequently, the virus was detected in different bird and mosquito species in africa. in recent decade, usuv was identified in passerine birds in austria (2001) usutu virus belongs to the genus flavivirus (japanese encephalitis serocomplex) under the family flaviviridae. different species of flavivirus such as usuv, west nile virus (wnv), japanese encephalitis virus (jev), murray valley encephalitis virus (mvev) and saint louis encephalitis virus are originated from same ancestral virus. nucleotide and amino acid sequencing revealed that mvev, among japanese encephalitis serocomplex, are the closest relative of usuv. usuv is a small (40-60 nm), spherical, enveloped virus with positive sense single stranded rna genome (11 kbp). the genome has a cap at 5′ end but no poly-a-tail at 3′ end. the genome can encode three structural proteins (core protein, pre-membrane and envelope protein) and eight non-structural (ns1, ns2a, ns2b, ns3, ns4a, 2k, ns4b, ns5) proteins. eurasian blackbirds (turdus merula) mostly suffer from usuv infection. several other families of birds (accipitriformes, anseriformes, caprimulgiformes, charadriiformes, ciconiiformes, columbiformes, coraciiformes, galliformes, passeriformes, piciformes, strigiformes) of different european countries are also susceptible to usuv infection (table 2 .7). migratory birds such as whitethroat (sylvia communis), lesser whitethroat (sylvia curruca), garden warbler (sylvia usuv is maintained in nature by a mosquito-bird cycle in which mosquitoes act as vector and the birds act as amplifying host. the mosquitoes occasionally spread the virus into other hosts (incidental) such as human, horses and rodents. usuv is detected in several mosquitoes such as culex pipiens, culex neavei, culex perexiguus, aedes albopictus, aedes caspius, anopheles maculipennis, culex perfuscus, coquillettidia aurites, mansonia africana. among them, c. pipiens and c. neavei are considered as competent vectors for usuv. although the migratory birds are sometimes infected with usuv the evidence of their role in transmission of infection is still missing. trematode infestation in blackbirds is detected as a predisposing factor for usuv infection. after introduction of usuv into the body of the host, viraemia lasts for a short period (2 days). the tissue tropism of the virus is almost similar to wnv infection. the virus is detected in brain, heart, liver, kidney, lungs, and intestinal tissues of laboratory mice and naturally infected birds. demyelination of neurons and formation of autophagosome are unique features of usuv infection. the process of autophagy helps in incorporation of host cellular components in viral replication. usuv infection in birds produces non specific clinical symptoms such as apathy, depression, anorexia, dehydration, ruffled feathers and moulting. in complicated cases, neurological signs, for instance, convulsions, ataxia, abnormal head postures and movements, tremors, paresis, torticollis and nystagmus are detected. neurological symptoms are often followed by death. the disease in birds is characterized by encephalitis, myocardial degeneration, and necrosis in liver and spleen. degeneration of purkinje cells, accumulation of glial nodules surrounding the degenerated purkinje cells ('glial shrubbery'), perivascular cuffing are characteristic findings in brain of affected birds. hepatomegaly, enlargement and discoloration of the kidneys, necrosis on the sheathed arteries of spleen are detected in great grey owls and boreal owls. in blackbirds, affected liver and spleen contains myriads of small (up to 1 mm) yellowish foci. enlarged gallbladder and intestine, hyperaemic meninges and brain are also found in blackbirds. clinical specimens blood or serum (paired sera collected in two weeks interval) from live bird and liver, spleen, lung, kidney, gizzard, and intestines are collected and fixed in 10% buffered formalin as post mortem specimens. igg-capture elisa is developed for human use. however, the serological tests often produce cross reactivity with other flavivirus infections such as wnv. prnt is more specific than other serological tests but requires specialized laboratory which can handle the virus. detection of acute infection is not possible by serological tests as the birds die before development of antibody titer. (f) molecular biology: reverse transcriptase-pcr can specifically detect usuv in tissues of suspected birds. recently real-time pcr is also developed for detection of usuv in human blood and cerebrospinal fluid samples which can be adapted in avian diagnostics. in 1981, in central african republic, a man with fever and rashes was diagnosed as a first human patient of usuv infection (car-1981) . in italy (2009), usuv infection was detected in two different patients of meningoencephalitis and orthotropic liver transplantation. both the patients were immunosuppressed and received blood transfusion before the infection. the common clinical symptoms were persistent fever, headache and neurological disorders. in 2012-13, a sero-surveillance program in germany and croatia detected low prevalence of usuv antibodies among the human population. no effective treatment for pet birds against usuv infection is documented. to control the infection in pet birds, exposure to mosquitoes should be restricted. water should not be stagnant in the vicinity of the aviaries or bird owner's houses. culex pipiens, the potent vector of usuv do not prefer to fly a long distance and lack of breeding site will significantly reduce their numbers. use of mosquito net (window and door) and repellants help to reduce the mosquito population. n, n-diethyl-meta-toluamide (ddet) is most effective repellant against culex pipiens. no specific vaccine against usuv is available to use in birds. vaccines against flavivirus (japanese encephalitis, yellow fever) are available for human use but no cross protection against usuv infection is reported. borna disease was first detected among animals (horse, sheep) in southeast germany during 19th century. it was named after the german district of borna around the town of borna in saxony where the infection remained endemic for prolonged period. the etiological correlation of borna disease with a virus was established in 1920. proventricular dilatation disease (pdd) was first reported from macaws and conures in usa during 1977. at that time, pdd was known as 'macaw wasting or fading syndrome' and 'gastric distension of macaws' as mostly macaws were associated with the syndrome. actual etiology of pdd remained uncertain for a considerable period. two independent research groups from israel and usa (honkavuori et al. 2008; kistler et al. 2008 ) identified a novel genus of the family bornaviridae, provisionally named as avian bornavirus (abv) as etiological agent of pdd. the virus was identified by molecular techniques such as panviral dna microarray and high throughput sequencing. avian bornavirus (abv) belongs to the family bornaviridae and order mononegavirales. the virion is enveloped, spherical, and 80-100 nm in diameter. the virions replicate in the nucleus of the host cells and use the host cellular splicing machineries for generation of mrnas. the genome is non-segmented, single stranded rna which encodes six major viral proteins such as nucleoprotein (n), regulatory protein (x), phosphoprotein (p), matrix protein (m), membrane-bound glycoprotein (g), and rna-dependent rna polymerase (l). after the discovery of avian bornavirus in psittacine birds, several types of bornavirus were detected in both psittacine and non-psittacine birds. recently it is proposed that the genus should include five species such as mammalian 1 bornavirus, psittaciform 1 bornavirus (avian/psittacine bornaviruses 1, 2, 3, 4, 7), passeriform 1 bornavirus (canary bornaviruses c1, c2, c3, ls), passeriform 2 bornavirus (estrildid finch bornavirus ef) and waterbird 1 bornavirus (avian bornavirus 062cg). till date, 14 abv genotypes have been detected in psittacine (abv-1, 2, 3, 4, 5, 6, 7) and non psittacine birds (abv-c1, abv-c2, abv-c3 in canaries; abv-cg in canada geese; abv-ef in estrildid finch; abv-bf in bengalese finch). avian borna viruses are detected in over 80 species of birds of which more than 70 species belongs to psittaciformes. the members of psittaciformes commonly infected with abv include cacatuidae (cockatoos, cockatiels) and psittacidae (lovebirds, macaws, parakeets, parrots, amazon parrots, conures) ( table 2 .8). among non-psittacine birds, canary, long-wattled umbrella bird, weaver finch, red-tailed hawk, falcon, canada geese, swan, duck, bald eagle are found naturally infected with abv (table 2 .8). pdd is reported from united states, australia, middle east, south america, south africa and japan. the studies suggest about faecal-oral or faecal-oronasal transmission of abv between the captive birds. in a bird with pdd, abv infected cells are detected in the intestinal villi from where they are excreated through the faeces. sometimes abv infected birds remain healthy and act as source of infection for other birds kept in the same aviary. it is observed that birds with high serum antibody titer against abv or viral rna load are prone to become clinically infected with pdd. overcrowding in aviaries, hand-feeding of parrot chicks are detected as predisposing factors for pdd. no gender based predisposition of pdd is observed. transmission route of abv in wild birds is still unexplored. irrespective of transmission route, classical borna disease virus enters central nervous system. in experimentally infected rats, centrifugal spread of virus into peripheral nerves and autonomic nerve fibers and ganglia are detected. in avian borna virus infection in birds, autonomous nervous system of the upper and middle digestive tract, including the esophagus, crop, proventriculus, ventriculus, and duodenum is chiefly infected. further spread of abv in extraneural tissues such as smooth or heart muscle fibers, liver, kidney, spleen, pancreas, lung, gonads, thyroid, and skin is observed. in mammalian borna virus infection, extraneural spread in hepatocytes, kidney epithelial cells, and myocytes of the intestine and heart is associated with immunosuppression of the host. the incubation period of abv infection in birds is highly variable (10 days-years). clinically the birds show gastrointestinal dysfunction or neurological signs or both. the symptoms of gastrointestinal dysfunction are impaction of proventriculus, dysphagia, polyuria, regurgitation, diarrhoea, presence of undigested food (seeds) in faeces, and crop stasis which leads to starvation and death. death due to circulatory collapse or food aspiration is also found. neurological signs are ataxia, seizure, blindness, tremor, abnormal gait, reduced proprioceptive skills, motor deficit and peripheral neuritis in sciatic, brachial and vagal nerves. no gross lesion is observed in sudden death of birds due to pdd. in majority of the birds suffering with pdd (70%), proventriculus is thin walled and distended with seeds. rupture of proventriculus wall releases the food particles and causes peritonitis. sometimes, enlargement of duodenum and adrenal glands, pale area on the epicardium is observed. microscopic lesions consist of lymphocytic infiltration along with plasma cells in the ganglia and nerve plexus (specially myenteric plexus supplying the digestive tract) of proventriculus, intestine, crop, esophagus, adrenal gland, conduction fibers of heart, central nervous system and spinal cord. perivascular cuffing by lymphocytes are detected in cerebral cortex, cerebellum, spinal cord and in peripheral nerves such as sciatic, brachial and vagus nerves. for intra vitam (ante-mortem) diagnosis of abv infection, faeces, blood, swabs of crop and cloaca, tissue biopsies from crops can be collected. left lateral sac of the crop (cranial portion) is preferred site for biopsy collection. the biopsy should be elliptical and it should contain a blood vessel so that the nerve sections can be visualized. after post-mortem, brain, crop, intestine and adrenal glands are collected. (a) clinical signs, haematology: clinical signs are mostly associated with gastrointestinal upset and/or neurological signs. non-regenerative anemia, leukocytosis, heterophilia, decreased total protein and albumin, increased level of muscle enzymes such as lactate dehydrogenase, creatine kinase, aspartate amino-transferase are detected in pdd infected birds. (b) radiography: distended proventriculus, ventriculus, crop and small intestine with ingesta and gas and prolonged gastrointestinal transit time are observed in infected birds by contrast radiography, contrast fluoroscopy and ultrasonography. spontaneous ruptures of the dilated proventriculus are rarely observed. although these findings are not specific for pdd. in healthy neonatal birds, distension of proventriculus and crop is also found. contrast radiography is performed in birds by introducing barium sulfate or iodine-based contrast media (@ 10-15 ml/kg) into the crop by gavage. barium sulfate produces better contrast but causes airway irritation. in psittacine birds, normal gastrointestinal transit time is 90 min-3 h. m and n genes of abv is developed. quantitative real time-pcr for detection of p gene is recently developed. brain, crop, intestine and adrenal glands collected after post-mortem and crop tissue, blood, cloacal swabs, and faeces can be used for abv-rna extraction. however, both false-positive (from asymptomatic bird) and false-negative results can be obtained by rt-pcr. zoonotic potentiality of abv is not established. pdd is a highly contagious infection and it spreads rapidly from one bird to another within a flock. decision to offer long term treatment or euthanasia of the affected bird is crucial. euthanasia is the best policy for management of pdd, although not preferred by most of the owners. management of inflammation, indigestion and secondary bacterial infections are currently considered as line of treatment for pdd. use of nonsteroidal anti-inflammatory drugs (nsaids, e.g. celicoxib, 20 mg/kg body weight, orally) along with antivirals (amantadine hydrochloride, 10 mg/kg po or 20 mg/kg with food) is recommended to treat pdd in birds. use of surfactants (for reduction of gas production), metoclopramide (0.5 mg/kg body weight, intramuscularly) and b complex vitamins are suitable supportive therapy. diet of the pdd infected birds should be easily digestible (preferably formulated diets), and in liquid or pelleted forms because the proventriculus and ventriculus function is adversely affected in pdd. addition of vegetables in the diet will increase intestinal motility. toys and cage accessories should be provided to the birds to avoid ingestion of foreign bodies. for prevention of pdd, new birds should be quarantined and checked for pdd before introduction into aviaries. maintenance of strict biosecurity and hygienic measures should be followed. overcrowding should be avoided in the aviaries. 2.2.6.1 history fist description of beak and feather disease (bfd) was observed in 1907 in an australian journal ('the emu') and the author described about wild red-rumped parrots (psephotus haematonotus) in the adelaide hills being unable to fly due to loss of feathers (ashby 1907) . in 1916, death of a captive sulphur-crested cockatoo (popular by its name 'cocky bennett') at the age of 120 years in sydney was published in local news paper. the bird was suspected for bfd due to loss of feather and presence of elongated beak. psittacine beak and feather disease (pbfd) was first scientifically documented in 1975 in sulfur-crested cockatoos, lovebirds, budgerigars and galahs in australia (pass and perry 1984) . beak and feather disease is caused by beak and feather disease virus (bfdv) which belonged to the genus circovirus and family circoviridae. circoviruses are icosahedral, non-enveloped and the smallest known autonomously replicating animal virus, measuring 15-26 nm in diameter. the viruses have an ambisense, circular, single-stranded dna genome (2000 nt) which can encode a replicase enzyme and capsid protein. the virus possesses highest mutation rate and genetic diversity although it is antigenically conserved. no serotype variation of circovirus is detected. the virus is considered as a model to study host parasite interaction due to its simple genome structure. it is also the representative of ancient viral form and circovirus sequences are detected in fossils of vertebrates, invertebrates, protozoa, plant, fungi, algae and bacteria. bfd virus mostly infects psittacine birds (more than 60 species) besides other bird families such as passeriformes, columbiformes and anseriformes (table 2 .9). a few susceptible bird species are enlisted as endangered or threatened by international union for conservation of nature (http://www.iucnredlist.org). bfdv infection is considered as a significant conservation threat. the infection is more fatal in young birds (0-3 years) due to poor development of immune system and the viral load is more prevalent in parental bird species than the hybrids. cockatoos mostly show chronic viral infection with excreation of virus through the faeces and dystrophic feathers. sometimes, cockatoos do not show any visible symptoms. occasionally, birds other than the common susceptible species are also infected with bfdv ('host switch over'). recently, bfdv infection is detected in rainbow bee-eaters (merops ornatus), a species of coraciiformes, unrelated to psittacine birds. mostly the bfd infection is detected in australia, new zealand, europe (poland, uk, denmark, portugal, germany, italy), united states, africa (zambia, zimbabwe) and asia (japan, china, taiwan, thailand). circumstantial evidence indicated that the infection was originated in australia. the virus was disseminated from australia in early 1970s to european countries with the imported parrots. from europe, the virus is further distributed to africa, new zealand, japan and united states during unregulated parrot trafficking. transmission of bfdv can take place by both horizontal and vertical means. horizontal route via direct contact with infected birds is the major mode of transmission in both wild and captive birds. the virus is excreated in high titers in the environment through feather dust, crop secreations, and faeces of infected birds. in aviaries, the virus once spread is difficult to control due to its high infectious and persistence nature. in the fomites, bfdv can persist for several years and after a long period, the fomites may act as a source of ancestral viral genotype in the host population. in forests, 'host switch over' is facilitated by horizontal transmission. the switch over mostly takes place in the unoccupied nests in the trees where competition exists between psittaciformes and other birds for reproductive opportunities. bfdv depends on host cell machineries for their replication and prefers the actively dividing cells such as basal follicular epithelium, lymphoid tissues, and intestinal epithelium. the virus causes necrosis of basal epithelium in the birds. the necrosis is found to be responsible for feather dystrophy and beak and claw deformities. bfdv also causes lymphoid depletion and associated immunosuppression. secondary infection with bacteria, fungi, parasite takes place due to immunosuppression and it is responsible for 70% bird mortality as observed in ducks, pigeons, geese, black-backed gull and other avian species. more experiments are needed to explore the pathogenesis of bfdv in pet birds. bfdv infection has three clinical forms in birds such as per acute, acute and chronic. sudden death without any symptom or mild symptom (feather dystrophy) occurs in per acute and acute forms, respectively. these forms are common in juvenile birds. in chronic form of the infection, weight loss, lethargy, anaemia, diarrhoea, shedding of developing feathers, abnormal development of new feathers is observed (figs. 2. 14, 2.15 and 2.16). mostly, contour, tail and down feathers are lost symmetrically and they are replaced with dystrophic feathers that fail to grow. deformities of beak and claws are not a constant feature. it depends on species of the bird and other predisposing factors. cockatoos are more susceptible to beak and claw deformities than other psittacine birds. beak elongation, transverse or longitudinal fractures, palatine necrosis are possible beak deformities observed (fig. 2.17) . chronic infection is not always fatal, the birds may survive for several years. sometimes death occurs due to secondary infection. gross lesions in feathers of bfdv infected birds are retention of sheaths, fracture of the proximal rachis, haemorrhage in pulp cavity, short clubbed feathers, curled feathers and circumferential constrictions. in naturally infected cockatoos, vane of feather is ragged with multiple fractures. hooklets, barbules and barbs are poorly developed and fractured ( fig. 2.18 ). hyperkeratotic sheaths are found in affected feathers which results terminal clubbing and mid-shaft constriction. in beaks of infected birds, abnormal elongation, palantine necrosis, transverse to longitudinal fractures is detected. histopathological examinations revealed basophilic intranuclear and/or intracytoplasmic inclusion bodies in feather epithelial cells, follicular epidermal cells and macrophages. clinical specimens feathers (newly grown quill portion is the best specimen), blood or serum, cloacal swabs, pharyngeal swabs can be collected as clinical specimens from the suspected birds. although, feathers produce low amount of viral dna because most of the fully grown feathers are separated from the blood supply. the blood should be collected from vein (not toenail) to avoid environmental contamination of bfdv. zoonotic potentiality of bfdv is not established. currently there is no known treatment for bfdv infection. secondary infection should be diagnosed and treated properly. avian gamma interferon injection (intramuscular) along with quaternary ammonium compound (as nebulizer) has shown success in treatment of bfd. no vaccine is commercially available to control bfdv infection. studies revealed that maternal antibodies against bfdv can protect the young birds. surviving birds sometimes develop long lasting immunity. the only way to control the disease is through maintenance of hygiene, strict isolation or culling of infected birds. pacheco and bier (1930) , a veterinarian from brazil first described an outbreak of acute, fatal hepatitis in psittacine birds. this syndrome became known as 'pacheco's disease'. later in 1975, psittacid herpesvirus type 1 (pshv-1) was confirmed as etiological agent. psittacid herpesvirus type 1 (pshv-1) is closely related with gallid herpesvirus-1 (infectious laryngotracheitis of chicken). pshv-1 has been classified into 4 genotypes (1-4) on the basis of variations in ul16 gene sequence. the genotypes of the virus have preference for different hosts (table 2 .10). pacheco's disease. the infection is common in united states, united kingdom, spain, south africa, kenya and japan. pshv-1 is transmitted by direct contact with the infected birds. persistently infected birds can shed the virus through faeces and pharyngeal secreation. in most of the cases, the infected birds die suddenly without showing any syndrome. if the birds survive, non-specific clinical signs such as depression, anorexia, diarrhoea, tremor and instability are observed. neurological disorder is followed by death. gross lesions are not distinct. intranuclear inclusion bodies (cowdry type a) are observed in liver, kidney, spleen, pancreas and small intestine. cloacal swabs, pharyngeal swabs, faeces, newly emerged feathers (blood/pin feather) can be collected from live bird as clinical specimens. after post-mortem, liver, spleen, kidney, lung, cerebellum can be used for detection of the virus. laboratory confirmation of pshv-1 infection depends on isolation of virus in cell lines, demonstration of virus in clinical samples by electron microscopy, detection of viral dna by pcr or real-time pcr. presence of intranuclear inclusion body in tissues is inconclusive because many other viruses (avian polyoma, psittacine adenovirus) also produce the same. use of antiviral (acyclovir, oral or intramuscular, intravenous injection) in early stage of infection can prevent the outbreak. an inactivated virus vaccine adjuvinated with oil is available for selected psittacine birds against pacheco's disease. the vaccine is recommended to use subcutaneously in smaller psittacines and subcutaneously or intramuscularly in larger psittacines (more than 100 g body weight). maintenance of strict hygiene, quarantine (30 days) of newly procured birds, and regular use of disinfectants in cages can prevent the pshv-1 infection. psittacine adenovirus (psadv) was first reported from senegal parrots (poicephalus senegalus) with acute infection. the virus was confirmed by amplification of hexon gene (l1 variable loop) by pcr (raue et al. 2005) . psittacine adenovirus belongs to the family adenoviridae and genus aviadenovirus. adenovirus is non-enveloped and has an icosahedral capsid with a diameter of 70 nm. the hexon protein is the major capsid protein and it has conserved pedestal regions (p1, p2) and the variable loops (l1-l4). adenovirus infection is reported from pet birds such as budgerigars, macaws, amazon parrots and cockatoos. aviadenoviruses are present in faeces, urine, tracheal and nasal secreations of infected birds. the virus is readily transmitted by horizontal mode. direct faecal contact and aerial spread are major ways of horizontal transmission. fomites, personnels and transport also contribute in horizontal transmission of aviadenovirus. in most of the cases, the infected birds die suddenly without showing any syndrome. if the birds survive, non-specific clinical signs such as depression, anorexia, diarrhoea, ruffled feathers are observed. gross lesions include hepatomegaly, splenomegaly, nephromegaly, dilatation of duodenum and , and congestion of lungs. the livers become enlarged, friable, haemorrhagic, pale or mottled. basophilic intranuclear inclusion bodies are observed. faeces from live birds and organs (kidney, liver, intestine) after post mortem are collected from the suspected birds for confirmatory diagnosis. psadv can be isolated in primary chicken embryo kidney (cek) or chicken embryo liver (cel) cell lines. embryonated chicken eggs can be inoculated by yolk sac, chorioallantoic membrane and allantoic cavity route. the eggs should be free of pathogen (spf) and antibodies against aviadenovirus. replication of the virus can be confirmed by death of embryos and gross microscopic lesions observed in hepatocytes. psittacine embryonated eggs are very expensive and are not readily available for diagnostic purpose. other diagnostic methods for detection of psadv in clinical samples are electron microscopy due to typical morphology of the virus and demonstration of basophilic or eosinophilic, intranuclear inclusion bodies in liver and intestinal epithelium by haematoxylin and eosin staining. psadv in clinical samples can be confirmed by pcr. no specific treatment for psadv infection is documented. secondary bacterial infection can be treated by broad spectrum antibiotics. aviadenoviruses are extremely resistant to the environment (heat, ph 3-9) and common disinfectants (ether, chloroform, trypsin, 50% alcohol) and they can persist for prolonged period in the cages or aviaries. treatment with formalin, aldehydes and iodophors for more than 1 h can inactivate the virus. poxvirus infection was reported for first time from lovebirds (agapornis personata, a. roseicollis) in germany (kraft and teufel 1971) . psittacine poxvirus belongs to the genus avipoxvirus, family poxviridae and subfamily chordopoxvirinae. the viral genome consists of double stranded dna (230-300 kbp). several psittacine and passerine birds, specially amazon and pionus parrots, lovebirds and canaries are susceptible to psittacine poxvirus infection. transmission of poxvirus from infected owners or caretakers is possible into the birds having skin injuries. mechanical transmission is also possible by mosquitoes and mites. in a contaminated cage or aviary, infected aerosols generated from dried scabs and feathers may act as source of infection. the infection in psittacine birds is characterized by ocular discharge, rhinitis, conjunctivitis and ulcerations on the eyelid. typical crusty lesions develop on the eyelid margins, lateral and medial canthi of the eyes and occasionally on face and feet (figs. 2.19 and 2.20) . persistent cutaneous lesion for a period of 13 months is detected in yellow-shafted flicker. diptheretic lesions develop in some birds which is associated with dyspnea and higher mortality rate. diphtheritic form produces necrotic lesions in the trachea, larynx and oral cavity. gross lesions include necrosis of heart, liver, air sac, lungs, peritoneum, and accumulation of necrotic debris on the surface of the alimentary tract. intracytoplasmic inclusion bodies (bollinger bodies) are observed in the mucosa of sinus, trachea, crop, esophagus and throat. presence of typical cutaneous lesions primarily suggests about poxvirus infection. vesicular fluid from cutaneous lesions, faeces and pharyngeal swabs can be collected as clinical specimens. the infection is confirmed by electron microscopy, detection of bollinger body in tissue samples and psittacine poxvirus specific-pcr. no specific treatment and vaccine is available to control psittacine poxvirus infection. infected birds should be separated from the healthy group. cages, fomites and utensils should be properly disinfected because the virus persists for prolonged period in the dried scabs and the aerosols generated from the infected scabs. among the pet birds, polyomavirus was detected for first time in young budgerigars (melopsittacus undulatus) in 1980. the virus was named as budgerigar fledgling disease polyomavirus which was renamed later as avian polyomavirus. the virus belongs to the family papovaviridae. the virion is icosahedral, non-enveloped with a diameter of 45-50 nm. the viral genome is a circular double-stranded dna and has two regions-early and late. the early region encodes tumour protein and the late region encodes four structural proteins (vp1, vp2, vp3, vp4). other than budgerigars, lovebirds, canaries, finches, macaws, eclectus parrots, conures, cockatoos and indian ringneck parakeets are also susceptible to avian polyoma virus infection. the infection is common in canada, china, australia, germany, slovakia and italy. direct contact with infected birds is the major way of transmission. contaminated cages, fomites, utensils, nestboxes, egg incubator may also act as source of infection as the virus is highly stable in the environment. the infection is more fatal in young birds of less than 16 weeks age. in fledgling and young budgerigars, death without symptom, or brief illness showing feather dystrophy, loss of down feathers, presence of 'filoplumes' (feather like projection with a thin rachis and few barbs, figs. 2.21 and 2.22) on head and neck, abdominal distension followed by death, are observed. it is known as 'french molt' or 'budgerigar and fledgling disease'. in cockatoos, two clinical forms i.e. acute death with haemorrhages in the feather shaft and pneumonia with gasping (in young (table 2 .11). gross lesions include distension of heart with hydropericardium, swollen liver, congested kidneys, and hemorrhage in the body cavity ( fig. 2.23 ). intranuclear and basophilic inclusion bodies are detected in spleen, liver and kidney. blood, cloacal swabs from live animals and tissues from spleen, liver and kidney can be collected as clinical specimens. the presence of avian polyomavirus in the clinical samples is confirmed by electron microscopy, virus neutralization test, immunofluorescent antibody staining, in situ hybridization, pcr and real-time pcr. no specific treatment for avian polyomavirus is documented for pet birds. an inactivated and oil adjuvinated vaccine is commercially available. a dose of 0.25 ml is recommended for birds below 200 g of body weight and larger dose (0.5 ml) is given to the birds with more than 200 g of body weight. primary vaccination is done at 5 weeks of age which should be followed by a booster after 2-3 weeks. annual vaccination is recommended. sometimes thickened skin at the vaccination site is observed as adverse reaction. papovavirus infection was detected in budgerigars (melopsittacus undulatus) and splendid parakeets (neophema splendida) which died suddenly without distinct clinical symptoms (graham and calnek 1987; pass et al. 1987) . psittacine papillomavirus belongs to papovaviridae family. pet birds such as amazon parrots, african grey parrots, macaws, finches, budgerigars, canaries and parakeets are most susceptible to psittacine papillomavirus infection. direct contact with infected bird is the major way of transmission. introduction of infected bird into aviary or cage rapidly transmit papillomavirus infection into other birds. the infection is characterized by reddish cauliflower like growth (papilloma) in oral (larynx, crop and upper gastrointestinal tract) and cloacal mucosa. presence of a large mass in larynx causes wheezing and change of voice. papillomas in oral mucosa hinder swallowing and digestion which causes anorexia, chronic weight loss and vomition. in clocal papillomatosis, raised, coalescing mass appears at the cloaca ( fig. 2.24) . presence of fresh blood is noted in the droppings. sometimes cloacal prolapse is detected. gross lesion is characterized by proliferation of epithelial cells on thin fibrovascular stalks. neoplastic growth of bile duct, pancreas and liver is also observed specially in amazon parrots and macaws. presence of typical cauliflower like growth in cloaca or oral mucosa primarily suggests about psittacine papillomavirus infection. tissue biopsy samples from cloaca can be collected by a sterile speculum, moistened cotton-tipped applicator or a gloved hand (fig. 2.25 ). histological examination of biopsy samples, in situ hybridization and pcr can confirm the infection. treatment of papillomas includes chemical cauterization with silver nitrate or surgical removal of the mass. in chemical cauterization, possibility of re-appearance of the papillomas is detected. use of interferon (50,000 iu/kg, intramuscular) in some species of birds can prevent the recurrence of growth. in a few countries, autogenous vaccine is used to prevent the infection. among the members of family reoviridae, orbivirus mostly causes pet bird infection. parrots, budgerigar, cockatiel, duck and american woodcock are susceptible to orbivirus infection. pheasants, pigeons and raptors mostly act as carriers. the carrier birds can shed the virus through faeces and contaminate the environment that can act as a source of infection. biting insects sometimes also help in transmission of infection. in psittacine birds, conjunctivitis, swollen eyelids, enteritis, emaciation, incoordination and other neurological signs are observed. in budgerigars and cockatiels, sudden death without clinical symptom is detected. stunted growth and feather deformity is observed in muscovy ducks. gross lesions include swollen liver, kidney and spleen with necrotic areas. accumulation of fluid in lungs and pericardium and myocarditis are often detected as gross lesions. cloacal swabs and tissues from liver, spleen, and kidney can be collected as clinical specimens. the virus can be isolated in chick embryo liver cells or chick kidney cells. the virus is confirmed by electron microscopy, immunofluorescence staining and pcr. psittacine birds (budgerigar, amazon parrot), pigeons, ostrich, rhea are sometimes infected with infectious bronchitis virus of coronaviridae family. respiratory signs, mucopharyngitis, ulcerated crop and esophagus, swollen kidney, egg peritonitis are commonly observed. in ostriches, thin walled and blood filled proventriculus is detected. nasal swabs, pharyngeal swabs can be collected as clinical specimens in 50% glycerol. the virus can be isolated in chicken embryo liver cells and primary embryo liver cells derived from blue and yellow macaw embryos. presence of virus can be confirmed by electron microscopy and pan-coronavirus reverse transcriptase-pcr. 2.3.1 toxoplasmosis 2.3.1.1 history splendore (1913, brazil) first observed toxoplasma like organisms in blood smear prepared from an infected rabbit. in the same year, nicole and manceaux detected the same organisms at gondi (tunisia) and described them as toxoplasma gondii. in pet birds (pigeons), carini (1911) first observed toxoplasma like parasites in smears prepared from liver and spleen in são paulo, brazil. based on phenotypical detection in smears prepared from blood and tissues, toxoplasma was described subsequently in different species of birds. catar (1974) detected the organisms in mistle thrush (turdus viscivorus), song thrush (turdus philomelos), robin toxoplasma gondii is an obligate intracellular protozoa and a member of suborder eimeriina, phylum apicomplexa. feral and domestic cats (felidae family) are the definitive host of the parasite. it has a wide range of intermediate hosts including different species of birds. t. gondii has three conventional clonal lineages (type i, ii, iii) which has different host preference and virulence pattern. most of the animal strains belong to type iii, whereas, type i and ii strains commonly infect human. occasionally, all the typical genotypes (i, ii and iii) and their variants are isolated from birds such as free-range chickens, raptors etc. progress in this area identified several other genotypes ('atypical') of t. gondii such as type bri, brii, briii, briv, type 12, africa 1 and chinese 1. a classification scheme is adopted to designate each genotype as 'toxo db-pcr-rflp genotype' followed by a specific number (table 2 .12). a total of 189 toxodb pcr-rflp genotypes is identified so far (2012). clinical toxoplasmosis is detected in birds belonged to passeriformes, psittaciformes, columbiformes, strigiformes, galliformes and anseriformes orders (table 2 .13). among the pet birds, passerines (canaries, finches, mynahs), pigeons and partridges are commonly infected with toxoplasma. clinical toxoplasmosis in pet birds is reported from different countries of europe, north america, south america and oceania (table 2 .13). apparently healthy wild and domestic birds belonged to different families (accipitriformes, anseriformes, galliformes, gruiformes, charadriiformes, columbiformes, strigiformes, passeriformes) can also harbour t. gondii without showing clinical symptoms. examples of carrier birds include goshawk (accipiter gentilis), common buzzard (buteo buteo), kestrel (falco tinnunculus), pallid harrier (circus macrourus), black vulture (aegypius monachus), red-tailed hawk (buteo jamaicensis), pheasant (phasianus colchicus), turkey (meleagris gallopavo), mallard duck (anas platyrhynchos), pintail duck (anas acuta), coot (fulica atra), blackheaded gull (larus ridibundus), common tern (sterna hirundo), collared dove (streptopelia decaocto), woodpigeon (columba palumbus), common pigeon (columba livia), ferruginous pygmy owl (glaucidium brasilianum), little owl (athene noctua), chaffinch (fringilla coelebs), house sparrow (passer domesticus), tree sparrow (passer montanus), yellowhammer (emberiza citrinella), starling (sturnus vulgaris), black bird (turdus merula), mistle thrush (turdus viscivorus), song thrush (turdus philomelos), robin (erithacus rubecula), great tit (parus major), treecreeper (certhia familiaris), jackdaw (corvus monedula), rook (corvus frugilegus). toxoplasma gondii has three stages in life cycle-oocyst (with sporozoites), tissue cyst with bradyzoites and rapidly multiplying form or tachyzoites. oocysts are infective stage of the protozoa present in cat faeces (definitive host) . the infected cats can shed millions of oocysts within 3-10 days of infection, regardless of the presence of clinical signs. the oocysts are activated within 1-5 days after faecal excreation and can survive in soil and water for prolonged period (up to 1 year). the feral cats bury the faeces into soil but earthworms and other soil associated focal discoloration of liver and heart, edematous lungs anseriformes hawaiian goose nene goslings (nesochen sandicensis) edematous, consolidated lungs and necrosis in liver, brain, heart and muscles apterygiformes north island brown kiwi (apteryx mantelli) hepatospleenomegaly and swollen lungs insects bring them into the top layer of soil. the oocysts are ingested by intermediate hosts (birds, rodents, sheep, marine mammals and human) from the soil or water. the parasite invades tissues of intermediate hosts and produce bradyzoites within tissue cyst. after ingestion of oocysts by the intermediate hosts, sporozoites prefer to invade most of the vital organs, with predilection for the reticuloendothelial and central nervous systems. the parasite enters the host cell by an active process. after intracellular multiplication, the progeny parasites go into the blood circulation by lysis of the infected cells and finally reach vital organs through the blood circulation. onset of clinical symptoms depends on type of organs invaded by the parasite. the parasitemia (presence of parasite in blood) declines after development of host immunity. the parasites localize and persist in the form of 'tissue cysts'. most of these tissue cysts are benign in nature and do not produce any clinical symptom during persistence. in immunosuppression due to stress, concurrent viral infection or immunosuppressive therapy, the tissue cysts are ruptured. granulomatous lesions develop with invading inflammatory cells into the surrounding tissues of the site where the cyst persisted. in canaries infected with toxoplasmosis, weight loss, diarrhoea, dyspnoea, crusty exudates around eye lids, collapsed eyeballs, inflammation of choroid with or without retinal involvement, cataracts and blindness, head twitch, walking in circles (due to encephalitis) are commonly observed. dull, visionless, closed eyes and encephalitis are consistent features in passerine birds (fig. 2.26) . in psittacine birds, non-specific clinical symptoms are observed. in lories, respiratory distress is distinct. in pigeons infected with t. gondii, anorexia, emaciation, high fever, weakness, conjunctivitis and convulsions are detected. in passerines (canaries), gross lesions include osseous replacement of eye globe, non-suppurative inflammation of optic nerve, anterior and posterior uveitis, swelling of the lenticular fibers in the lens, choroiditis, focal necrosis and detachment of retina and atrophy of periocular tissue (sunken appearance of eye). t. gondii tachyzoites are detected in choroid, retina (nerve fiber layer), vitreous and lens of the affected birds. histological evidence of pneumonia and non-suppurative encephalitis associated with tissue cysts is also observed. gross lesions observed in affected psittacine and other birds are enlisted in table 2 .13. clinical specimens blood, serum, eye suspensions from live birds and organs (spleen, liver, intestine, eye, brain, gizzard, proventriculus) collected after post mortem in buffered neutral 10% formalin can be used as clinical specimens. for bioassay (isolation), collected tissues are homogenized in 0.85% normal saline solution and brain tissue homogenates are digested with acidic pepsin before bioassay. (a) direct examination: preliminary diagnosis is made by demonstration of t. gondii tachyzoites in giemsa stained impression smears prepared from collected organs. in smears, tachyzoites are crescentic to globular in shape ( fig. 2.27 ). (b) histological examination: in formalin fixed tissues, globular to oval shaped t. gondii tachyzoites are detected which are smaller in size than their appearance in impression smear (fig. 2.28) . t. gondii 'tissue cysts' appear as a globular structure with a thin cyst wall and small, slender bradyzoites are present within it (50-500). the bradyzoites can be visualized by periodic acid schiff (pas) staining. immunohistochemical staining with polyclonal antibody raised against whole parasite can confirm the presence of t. gondii in formalin fixed tissues. (c) serological tests: modified agglutination test (mat) is a sensitive, specific and easy to do serological test for detection of t. gondii antibodies in different species of birds. elisa, indirect fat in tissues can also be performed. (d) bioassay: t. gondii can be isolated in laboratory mice by subcutaneous inoculation of eye suspensions or tissue homogenates (liver, brain) collected from suspected birds. in positive cases, inoculated mice will die and t. gondii tachyzoites or tissue cysts are detected from dead mice. (e) molecular biology: the parasite can be confirmed by t. gondii-specific pcr. nested pcr analysis based on t. gondii pppk-dhps gene is recently developed for confirmation. genotyping of t. gondii depends on restriction fragment length polymorphism of surface antigen 2 gene (sag2). human get the infection by ingestion of vegetables, fruits and other foods or water contaminated with t. gondii oocysts. direct transmission of t. gondii from pet birds to human is not documented. feral or domestic cats may ingest the t. gondii infected carcasses of pet birds disposed into the surroundings without proper measures. the cats may become infected with toxoplasmosis and start to shed oocysts into the environment. person to person transmission is rarely possible during organ transplantation or blood transfusion. most of the human infection is aymptomatic but sometimes cervical or occipital lymphadenopathy is observed. in immunosuppressed persons, encephalitis, chorioretinitis and pneumonitis are detected. in pregnant women, abortion and fetal infection causing congenital hydrocephalus, intracranial calcifications and mental retardation is documented. 2.3.1.10 treatment and control strategy pyrimethamine (0.5 mg/kg body weight, orally, 12 h interval) is recommended for treatment of clinical toxoplasmosis in birds. use of tiamulin fumarate (300-400 mg/kg feed for 7 days in different species of birds; 225-250 mg/l drinking water for 3-7 days in pigeons and poultry) and clindamycin (25 mg/kg body weight, oral, 48 h interval) is also observed. in canaries, treatment with trimethoprim (80 mg/ml) and sulfadiazine (400 mg/ml) in drinking water for 14 days was apparently successful. prophylactic use of coccidiostats (monensin, decoquinate) is recommended in calves and lambs to prevent toxoplasmosis. low acute toxicity of decoquinate is observed in avian species and no regulation or evidence is available regarding its prophylactic use. no vaccine is also available for birds to prevent toxoplasmosis. antony van leeuwenhoek (delft, netherlands, 1681) first observed giardia under his self made simple microscope during investigation of his own diarrhoeic stool. he described it as 'animalcule' with 'flattish belly' and 'sundry little paws' (flagella). under microscope, the organisms showed a slow and helical motion with occasional rapid movement by 'paws'. later (dobell 1932) it was concluded as trophozoite stage of giardia spp. in 1859, vilem dusan lambl (prague, czech republic) described the organism in more details and named it as cercomonas intestinalis. in 1915, charles wardell stiles coined the name giardia lamblia in honour of professor alfred mathieu giard (zoologist, france) and dr. vilem dusan lambl (czech) for their contribution in progress of giardia associated knowledge. leibovitz (1962) first described giardia infection in a budgerigar in united states with a history of chronic diarrhoea and debility. in 1977, jones and carroll also observed presence of giardia in the intestine of budgerigars in united kingdom. in 1978, giardia infection causing high mortality in parakeets was reported from united states which was successfully treated by dimetridazole (panigrahy et al. 1978 ). avian giardiasis is caused by giardia spp., an eukaryotic, multicellular, binucleate, flagellated protozoan belonged to sarcomastigophora phylum. six valid species of giardia are recognized based on morphological observations using light and electron microscopy. the valid species are giardia psittaci and g. ardeae in birds; g. duodenalis (syn. g. lamblia, g. intestinalis) in human, livestock and wildlife; g. microti and g. muris in rodents; and g. agilis in amphibians. g. duodenalis has eight identified genotypes (assemblages, a-h). assemblage a and b are common in both human and animals and assemblage c-h are restricted within animals only. giardia spp. has two stages in life cycle-motile 'trophozoite' and 'cyst' (fig. 2.29 ). the cysts are smaller than trophozoites (10 lm â 8 lm), dormant, resistant to adverse environmental condition (like bacterial spore) and infectious form of the protozoa. they are common in streams, lakes and ponds. they can survive for months in cold water also (8°c). after transmission of the cysts into the host, the cysts pass through acidic ph, increased co 2 level and slight alkaline ph (proximal small intestine) consecutively and excystation takes place. one trophozoite from each cyst emerges which undergoes cytoplasmic division to produce two trophozoites. trophozoites are pear shaped (pyriform) structure which measures 12-18 lm in length, 10 lm in breadth and 2-4 lm in thickness (fig. 2.30) . the trophozoites have a concave disc with a raised ridge at the ventral surface of anterior site (broad portion) and eight flagella arranged bilaterally. the trophozoites attach with enterocytes at duodenum and jejunum with the ventral disc ('sucker') for feeding on mucosal secreations. the colonization is followed by binary fission. some trophozoites detach from the enterocytes and move forward (tumbling and skipping) with their flagella to re-attach with a new enterocyte. a few of the trophozoites instead of re-attachment prefer to be excreated through the faeces as cyst. during the process of encystment, the trophozoites stop their active motility, become rounded in shape and covered with a cyst wall. nuclear division takes place and a quadrinucleate, matured cyst is excreated into the environment. giardia is identified in faecal samples of more than 20 species of birds specially in psittacines. giardia psittaci associated clinical infection is fatal in young budgerigars. avian giardiasis is also reported in cockatiels, lovebirds, finches, great blue herons, raptors and gray-cheeked parakeets throughout the world. some psittacines such as blue-fronted amazon (amazona aestiva), blue and yellow macaw (ara ararauna), scarlet macaw (ara macao) act as carrier (transport host) of giardia duodenalis (assemblage a) without showing clinical symptoms. the infection is transmitted by faeco-oral route through ingestion of the food or water contaminated with infective cysts. feeding or watering trough, cage materials, toys or other inanimate objects contaminated or soiled with faeces of the infected birds (captive or wild) may serve as a source of infection. asymptomatic birds generally shed the cyst intermittently and thus serve as a potential source of infection. giardia psittaci mostly reside in the duodenum with manifestation of diarrhoea and malabsorption syndrome in birds. the trophozoites adhere to the intestinal villi with ventral suckers. the adherence results inflammatory cell infiltration, villous atrophy, reduced villous to crypt ratio and reduction in disaccharidase enzymes (e.g. lactase). food absorption is hampered and the food particles are accumulated in the lumen which increases the osmotic pressure and causes diarrhoea. with inhibition of food absorption, chronic weight loss may be noticed in affected birds. there may be deficiency of vitamins and minerals due to absorption failure. unlike mammals where immunity has a direct relation with occurrence of giardiasis, avian immunity rarely shows such association. some risk factors are also noticed in birds for giardiasis such as overcrowding, unhygienic cage condition and inadequate nutrition. the studies revealed that giardiasis may be more common among heavily inbred population of birds. mucoid and persistent diarrhoea with loose, brown or pale coloured and foul smelling faeces, anorexia, depression, hypoproteinemia, weight loss, ruffled feathers are common clinical symptoms in birds infected with giardia spp. stunted growth and high mortality are observed in young budgerigars and cockatiels. in cockatiels, feather picking and pruritus are also detected. feather picking from wings, flanks and legs along with screaming is common. feather damage is sometimes observed in non-cockatiel birds also. secondary bacterial, viral or yeast infection are identified in birds with avian giardiasis. concurrent infection of g. psittaci and polyomavirus, cryptosporidium, chlamydia and macrorhabdus spp. (megabacterium) are observed in budgerigars. no gross lesion or sometimes distended small intestine with mucous, yellowish or creamy fluids is detected in most species of the birds. atrophy of villous, infiltration of inflammatory cells, hyperemia of intestinal mucosal layer and presence of numerous trophozoites throughout the entire length of villi are observed. in cockatiels, thickened skin, haemorrhage and areas of feather loss are observed in patagium (membranous structure that helps in flight) and axillary area. it may progress to squamous cell carcinoma. clinical specimens fresh faeces collected in saline from the suspected birds, blood or serum, intestine (duodenum) in 10% formalin can be used as clinical specimen. (a) direct examination: wet mount examination of collected faecal sample (mixed with warm saline, not tap water) or the content of duodenum can be performed for direct visualization of motile trophozoites (pear shaped) or cysts (fig. 2.31 ). the faecal sample can be concentrated with formalin-ethyl acetate or saf (sodium acetate, acetic acid, formaldehyde) and zinc sulphate. multiple fresh faecal samples (three consecutive samples) should be tested from a single suspected bird due to intermittent shedding of trophozoites and cysts. if the faecal sample is more than 10 min old, possibility of trophozoite visualization is low. if immediate processing is not possible, faecal samples may be preserved in polyvinyl alcohol for trichrome staining. the trophozoites are also destroyed in salt or sugar flotation solutions for faecal sample observation. faecal sample can be stained with lugol's iodine for visualization of giardia cysts. (b) molecular biology: for extraction of dna from giardia, oocysts present in faecal samples are concentrated. faecal suspension prepared with sterile distilled water is kept over sucrose solution (1 m) and is centrifuged at 400 g for 15 min at room temperature. the water-sucrose interface is removed with a pasteur pipette, washed in normal saline and centrifuged at 600 g for 10 min. dna is extracted from the sediment by a standard nucleic acid extraction kit. pcr targeting b-giardin gene, giardia elongation factor 1 alpha gene (ef1a) or giardia glutamate dehydrogenase gene (gdh) can be performed for confirmation. (c) antigen detection tests: elisa (antigen capture) and immunofluorescence tests are available for detection of giardia antigen in clinical samples. human giardiasis is caused by g. duodenalis and it has two phases i.e. acute and chronic. flatulence, belching, abdominal distension with cramps, frequent watery diarrhoea with offensive smell occurs in acute phase. in chronic phase, malabsorption syndrome takes place with chronic weight loss. the stools are usually pale or yellow, frequent and of small volume. the prevalence of giardiasis in developing countries is approximately 20% compared to about 5% in the developed world. transmission of giardia to humans can occur through ingestion of food and water contaminated with infectious cysts. waterborne transmission is associated with contaminated community water systems of municipality or corporation in urban area, and ponds, rivers and streams in rural area. contaminated swimming pool also plays a role in transmission of giardiasis. giardiasis is not specific for any human race and sex but it is more prevalent in children below 4 years of age. the cysts are excreated in the environment through the faeces of infected human, animals and birds. the studies revealed that psittacine birds (blue fronted amazon, blue and yellow macaw, scarlet macaw) can carry giardia duodenalis (assemblage a) cysts which may be disseminated into human. metronidazole (10-20 mg/kg body weight, oral, 12-24 h interval for two days for psittacines and pigeons) is the drug of choice in confirmed cases of avian giardiasis. necrosis at site of injection in all species of birds and toxicity in finches are adverse drug reactions of metronidazole. fenbendazole (50 mg/kg body weight, oral, 24 h interval for 3 days) is an alternative choice for effective treatment. other drugs such as tinidazole (20 mg/25 ml of drinking water for 7-14 days) or paromomycin (100 mg/kg twice daily for 7 days) are also used successfully against avian giardiasis in budgerigars and barred parakeets. in budgerigars, amphotericin b and metronidazole combination is indicated for synergistic infection of giardia, candida, megabacterium, trichomonas and other bacterial infections. with the discontinuation of therapy the infestation may relapse. it is necessary to properly rinse and dry the cage, feeding, watering and other in contact inanimate objects. cleaning and drying reduce both the number of cysts and their viability and helps to prevent reinfestation. feeding of boiled water in clean water bottles also helps to reduce the risk of infestation. dr. ernest edward tyzzer (1929, united states) first described cryptosporidiosis in bird (chicken) although cryptosporidium species was not identified. it resembled cryptosporidium muris as described in mice earlier by same worker (tyzzer 1907 (tyzzer , 1910 . c. meleagridis was first identified in turkeys by slavin (1955) . in 1986, current, upton and haynes isolated another species from chickens and coined the name c. baileyi. cryptosporidium is a protozoon under phylum apicomplexa, class sporozoasida, order eucoccidiorida, and family cryptosporidiidae. three cryptosporidium species such as c. meleagridis, c. baileyi, and c. galli are commonly associated with avian infection. recent molecular epidemiological studies have also identified several genotypes of cryptosporidium causing infection in birds. the genotypes are: avian genotypes (i-v), goose genotypes (i-iv), black duck genotype, and eurasian woodcock genotype. in addition, c. hominis, c. parvum, c. serpentis, c. muris and c. andersoni are detected in a number of birds due to accidental ingestion of cryptosporidial oocysts. among all these species and genotypes, c. baileyi is considered as the most common cause of avian infection. cryptosporidium has a direct life cycle which requires a single host. 'oocyst' with four sporozoites is the infectious form and it is shed in faeces and cough of infected birds, animals and human. the oocyst can enter a new host and after excystation the sporozoites penetrate to epithelial cells of the gastrointestinal or respiratory tract. the sporozoites undergo six developmental stages such as merogony (asexual multiplication), gametogony (gamete formation), fertilization, oocyst formation, and sporogonyv (sporozoite formation). the sporozoites of c. baileyi produce 3 types of meronts (type i, ii, iii) during merogony to generate merozoites. two types of oocysts (thin and thick walled) are observed in c. baileyi infection. thin-walled oocysts are not excreated and they excyst in situ within the host to begin auto-infection. whereas, thick walled (multilayered) oocysts are more resistant to environment and are excreated out to enter new hosts. sometimes, auto-infection takes place after excreation and the excreated oocysts may infect the same host. cryptosporidium is detected in more than 30 bird species (anseriformes, charadriiformes, columbiformes, galliformes, passeriformes, psittaciformes and struthiniformes) in different countries such as australia, argentina, canada, china, czech republic, denmark, egypt, germany, greece, hungary, japan, korea, the netherlands, romania, scotland, spain, south africa, taiwan, turkey, and united states (table 2 .14). avian cryptosporidiosis is transmitted by ingestion of contaminated food and water (faeco-oral) or inhalation of sporulated oocysts. feeding or watering trough, cage materials, toys or other inanimate objects contaminated with faeces of the infected birds may serve as a source of infection. in the same aviary or premises, transmission is possible from one avian species to another through contaminated equipments or personnel. once the oocyst enters the premises possiblity of large scale outbreak increases in the aviaries or zoos. following ingestion of oocysts by susceptible birds, it can enter salivary and esophageal glands, proventriculus, small intestine, caecum, colon, cloaca, and bursa of fabricius and developmental stages of cryptosporidium begins. the intracellular stages of the organism occur within a parasitophorous vacuole. detachment of enterocytes and villous atrophy in small intestine are common lesions which hamper the absorption of nutrients and causes osmotic diarrhoea and malabsorption syndrome. following inhalation of oocysts, primary colonization in upper respiratory tract (sinus) is followed by colonization in lower respiratory tract of the birds (trachea, bronchi, air sacs, lungs). mucoid exudates are detected in sinus, nasal passage, and trachea. the air sacs and lungs become cloudy and mottled grey-red, respectively. the site of predilection also varies with species of cryptosporidium infecting the birds. c. baileyi prefers to invade mucosal epithelium of a number of organs (small and large intestines, caeca, cloaca, trachea, air sacs, urinary system, bursa and conjunctiva), whereas c. meleagridis and c. galli are restricted within the intestine and proventriculus, respectively (table 2 .14). concurrent viral, bacterial or parasitic infections are observed in birds suffering with both clinical forms of cryptosporidiosis due to bursitis and impairment of immunity. escherichia coli and isospora sp. infection are common with c. galli infestation. two clinical forms such as respiratory and gastrointestinal cryptosporidiosis are observed in birds. in respiratory form, increased mortality, depression, lethargy, anorexia, unthriftines, coughing, sneezing, gurgling, dyspnoea, conjunctivitis and sinusitis are the common clinical symptoms. in gastrointestinal form, lethargy, decreased bodyweight gain, lower pigmentation, and diarrhoea with lime-green stool, chronic or intermittent regurgitation, lockjaw, aspiration pneumonia, seizure, egg binding are the common clinical observations. c. galli infection in passerine birds is characterized by chronic apathy and weight loss. in brazil in a cockatiel infected with c. galli lethargy for approximately 1 year before death was observed. lethargy and slow crop emptying was also detected in an indian ring-necked parrot infected with c. meleagridis. in peach-faced lovebirds infected with avian genotype iii, chronic vomiting and weight loss was detected. presence of too much mucoid exudates in conjunctival sacs, nasal passage, sinuses and trachea, chemosis, hyperemia, mucus gland distension or cystic hypertrophy/hyperplasia, mottled grey-red lungs, cloudy air sacs, bursal atrophy, hepatospleenomegaly are common gross lesions in respiratory form of cryptosporidiosis in birds. in gastrointestinal form, distended intestine filled with mucoid contents and gas, detachment of enterocytes, villous atrophy, bursal epithelial cell hypertrophy and hyperplasia and necrosis in the bursa are common gross and microscopic lesions in birds. histopathology demonstrates the presence of cryptosporidial oocysts adhered to the surface of intestinal brush border (fig. 2.32 ). in finches, purulent nephritis with enlarged and pale kidneys is detected. recently, visceral gout with renal and cloacal lesions is detected in mitchell's cockatoo infected with cryptosporidium sp. dilated proventriculus with thickened proventricular wall is common in lovebirds, cockatiels, red-faced aurora finch, australian diamond firetail finch and bronze mannikin finches. histopathology demonstrates the presence of cryptosporidial oocysts adhered to the surface of proventricular glandular epithelial cells along with hyperplasia and necrosis of epithelial cells. the organs affected by different cryptosporidium spp. are enlisted in table 2 .14. fresh faeces or cloacal swabs collected in potassium dichromate solution (2.5-5%) from the suspected birds, blood (collected from wing vein) or serum, and formalin fixed intestine, proventriculus can be used as clinical specimen. the cloacal swabs are filtered through wire mesh (0.3 mm) and the filtrate is centrifuged at room temperature at 1000 g for 10 min. after discarding the supernatant, the concentrated faecal sample is used for further analysis. the faecal samples can be preserved at 4°c in phosphate buffered saline solution (ph 7.2) with antibiotics and antifungals (streptomycin @ 100 mg/ml, penicillin g @100 iu/ml and amphotericin b @ 0.25 mg/ml). (a) direct examination: detection of cryptosporidial oocysts in clinical samples is the most common diagnostic technique used in laboratories. it is a low sensitive method which requires minimum 5000-50000 oocysts/g of faeces for detection. the oocysts are non-refractile, spherical (5-6 µm in diameter) in shape and are often confused with yeast cells. gram's stain, kinyoun acid-fast stains are used in light microscopy. in kinyoun stained smear, oocysts appear as red spherical bodies against blue background whereas yeast cells take blue stain. phase contrast microscopy provides better resolution and the oocysts appear as bright bodies with 1-4 dark granules (granules are absent in yeast cells). faecal samples can be concentrated by centrifugal flotation in high specific-gravity salt or sugar solutions (sheather's sugar flotation technique, discontinuous density sucrose gradient) for detection of oocysts. the sample after concentration should be used rapidly because in presence of sugar solutions oocysts are distorted or collapsed. in histologic sections stained with hematoxilin and eosin (h & e), cryptosporidia appear as basophilic bodies (fig. 2.33 ). (b) molecular biology: cryptosporidium is detected by means of pcr, followed by either restriction fragment length polymorphism (rflp) or sequencing of the amplified fragments. the gene commonly used for determining the species or genotype is 18s rrna. other target genes are actin, heat shock protein (hsp-70) and cryptosporidium oocyst wall protein (cowp). subtyping of c. meleagridis is based on 60-kda glycoprotein (gp60) gene. duplex-real-time pcr is recently developed for confirmation of c. galli and avian genotype iii. (c) serological tests: elisa can be used for detection of anti-cryptosporidium antibodies in serum samples. (d) antigen detection assays: capture enzyme-linked immunoassays (elisa), direct fluorescent antibody (dfa) assay using commercially available antibodies are used for detection of cryptosporidial antigen which is more sensitive and specific than staining. the detection of cryptopsordial species is not possible due to cross reactivity. cryptosporidial oocysts are excreated in the faeces of infected birds and animals which can be transmitted to human by faeco-oral route. human cryptosporidiosis is mostly caused by c. hominis, c. parvum and c. meleagridis. the pet birds and domestic chicken may act as source of c. parvum and c. meleagridis oocysts in the environment. watery diarrhoea, abdominal cramping, and increased gas production are common clinical signs of cryptosporidium infection in human. severe complications such as pancreatitis, cholangitis, respiratory distress and death are observed in immunosuppressed individuals. person to person transmission is possible. macrolide antibiotic (erythromycin) is used successfully against cryptosporidiosis in cliff swallow and owls. azithromycin (40-45 mg/kg body weight, 24 h interval, oral) is recommended for treatment of avian cryptosporidiosis in most of the bird species. united states food and drug administration (fda) have approved nitazoxanide for use in humans suffering with cryptosporidiosis. the cryptosporidial oocysts are highly resistant to common disinfectants used in aviaries and environmental stress such as temperature variation, desiccation, humidity and change of ph. maintenance of strict hygiene and biosecurity in the aviaries to reduce the possibility of oocyst contamination is the control strategy for avian cryptosporidiosis. other parasites affecting pet birds include protozoa, helminths (nematodes, cestodes, trematodes), and arthropods. captive birds kept in small and dirty cages are more susceptible to parasitic infestations. capability of a parasite to survive and reproduce in pet birds ('parasite fitness') depends on host immunity and nutrients for parasite available in the host body. the parasites may avoid the birds with good health condition due to strong immune response, but the parasites also avoid the birds with very poor health due to less possibility to obtain nutrients. the balance between immunity and nutrient availability is crucial for selection of host by the parasites. cockatoos, cockatiels, grey parrots can get the protozoon by the ingestion of insects with sarcocysts. three clinical forms such as acute pulmonary form, muscular form, and neurologic forms are observed in birds. in acute form, death without development of sarcocysts in the muscle occurs. in other two forms, clinical signs for instance dullness, weakness, respiratory signs, yellow urates are detected. pulmonary hemorrhage and edema are the cause of death. presence of sarcocysts in muscles of heart, breast, thigh, neck, and esophagus is the major lesion. hepatosplenomegaly, lung consolidation, pulmonary edema are also observed. diagnosis is usually based on visualization of sarcocysts in the muscles after post-mortem. ante-mortem diagnosis is possible by muscle biopsy, indirect immunofluorescent assay and pcr. successful treatment of birds can be done with pyrimethamine (0.5 mg/kg body weight, 12 h interval for 14-28 days) and sulphadiazine-trimethoprim (30 mg/kg body weight, 8-12 h interval). removal of insects from cages, maintenance of cleanliness, fencing of outdoor aviaries to prevent opossum access can prevent the occurrence of sarcocysticosis in birds. avian sarcocystosis is usually not considered to be a public health hazard. trichomonas sp. is a motile pear shaped protozoon which contains a central, longitudinal rod up to the posterior end (axostyle) and four flagella attached to the anterior end. an undulating membrane extending from the anterior to posterior end is present (fig. 2.34) . the membrane encloses a flagellum which does not have any free end. t. gallinae has direct life cycle without any intermediate hosts or/and vectors. they multiply by longitudinal binary fission. in budgerigars, finches, and cockatiels, transmission of t. gallinae occurs through ingestion of contaminated food and water. young domestic pigeons after entry through the oral route t. gallinae can invade the mucosal surface of the buccal cavity, sinuses, pharynx, esophagus, crop, proventriculus and conjunctiva (rare invasion) depending on the species of affected birds (figs. 2.35 and 2.36) . clinical signs include weight loss, hypersalivation, vomiting, and diarrhoea. death due to starvation occurs with progression of the infection. gross lesion includes formation of diphtheritic membrane or white plaques on gastrointestinal mucosa (oropharynx to esophagus), blockage of esophagus lumen with cheesy material and ingluvitis (inflammation of crop). solid, white to yellow circular masses appears in liver of affected pigeons (fig. 2.37) . buccal cavity and crop can be collected as clinical specimens after post-mortem of the bird. wet mount prepared from fresh crop wash with saline can be observed under microscope for detection of typical pear shaped trichomonas sp. in live birds, wet mount prepared from fresh faeces or crop swabs can be observed under microscope for detection of trichomonas sp. however, diagnosis of avian trichomoniasis is difficult in ante-mortem samples because the parasite is unstable in the environment due to lack of cyst formation capacity. metronidazole (10-20 mg/kg body weight, 12-24 h interval, for 2 days), ronidazole (6-10 mg/kg body weight, 24 h interval, for 6-10 days), carnidazole (100-200 mg/kg body weight, oral, once), dimetridazole [1 tea spoonful/gallon (4.5 l) drinking water] and ipronidazole (500 mg/galon drinking water for 7-30 days) are recommended for avian trichomoniasis. coccidia (eimeria spp., isospora spp.) eimeria spp. and isospora spp. belongs to phylum apicomplexa and they have a direct life cycle without any intermediate host or vector. sporulated oocysts are the infectious form and ingestion of food and water contaminated with oocysts is the major way of transmission. the oocyst wall is crushed in gizzard and the sporozoites are released. the sporozoites enter intestinal mucosa and undergo schizogony or merogony to produce progeny oocysts. the new oocysts leave intestinal mucosa and are excreated through the faeces. the direct life cycle requires 6-8 days time to complete. coccidiosis is common in mynahs, toucans, pigeons, lories, finches, budgerigars and canaries. clinical symptoms do not appear until the birds are immunosuppressed or infected with enormous numbers of coccidial oocysts. during schizogony in intestine, mucosa is damaged and enteritis is produced. lethargy, weight loss, severe haemorrhagic diarrhoea is detected as clinical symptoms within 4-6 days after infection. nonsporulated oocysts are shed with the faeces. diagnosis is made through examination of faeces and smears taken from the suspected lesion. the oocysts or macrogametes are detected in the smears in positive cases. the oocysts of eimeria contain four sporocysts each with two sporozoites, whereas, two sporocysts each with four sporozoites are present in oocysts of isospora. treatment with amprolium (50-100 mg/l drinking water for 5-7 days), trimethoprim and sulphamethoxazole (25 mg/kg body weight, 24 h interval, oral) are recommended for coccidiosis in pet birds. amprolium produces toxicity in falcons (@22 mg/kg body weight, 24 h interval) and trimethoprimsulphamethoxazole is recommended for toucans and mynahs. atoxoplasmosis is a dreadful disease caused by the protozoa atoxoplasma sp. causing significant mortality among the fledgling birds. although atoxoplasmosis is mostly asymptomatic among the adult birds, fatal infection with hepato-spleenomegaly may be noticed among the young birds of canaries and passeriformes. the infected birds usually shed the oocysts via faeces and the healthy one picks up the infection by consuming the oocysts. asymptomatic adults may also shed such oocysts and can be a potent but silent source of infection for the in-contact and prone young birds. interestingly, the atoxoplasma sp. from one host may not be infectious to other species of birds exhibiting certain degree of host specificity. infected birds may periodically shed large number of oocysts. in general, the birds were detected to shed the oocysts up to eight months of infection. the oocysts are environmentally stable and can persist for along period. birds of less than 1 year of age, usually exhibit clinical symptom and adults are usually asymptomatic. clinical findings are usually non-specific and include anorexia, depression, weight-loss, chronic diarrhoea, lethargy and depression. in few cases mortality may reach up to 80%. the enlarged liver, spleen and dilated intestinal loops can be palpated in few cases. during the period of parasitaemia, the protozoa a serini undergoes scizogony in the polymorphomononuclear cells (pmns) and spread throughout the body circulation. thereafter, the parasites reach out to their site of predilection reticuloendothelial cells (re cells) of vital internal organs like liver, spleen, pancreas and intestinal epithelial cells. during this process of multiplication and propagation, the parasite causes heavy damage to these organs resulting in hepatospleenomegaly and enteritis in young birds. when any adult bird is suspected as an asymptomatic carrier, microscopic examination of the fecal samples may confirm the presence of the oocysts (20.1 â 19.2 µm). in the height of severe infection, zoite form of the parasite may be detected in the lymphocytes following processing the buffy coat smear with romanowsky stain. reddish intracytoplasmic inclusion bodies are detected in the pmn cells when stained with giemsa. impression smear prepared from the enlarged liver, spleen or other affected organ may be helpful. pcr or nucleic acid detection method may give more confirmatory diagnosis. there is no effective therapy available for the disease. the birds may remain infected and continues to show periodic clinical symptoms even after therapy up to 4 months. primaquine has been recommended to suppress the tissue form of the parasite where as sulfachlorpyridazine can be used to decrease the faecal shedding of the oocysts. generally, toltrazuril is employed @ 12.5 mg/kg/day, orally for 14 days and sulfachlorpyridazine @ of 150-300 mg in one liter of drinking water. this sulfachlorpyridazine should be given for 5 days in a week for at least 2-3 weeks. ascaridia hermaphrodita, a. columbae, a. nymphii and a. galli have detected in hyacinth macaw, pigeon, australian parrots, budgerigar, cockatiel, and princess parrot. in some ground feeding species of birds (e.g. dove), baylisascaris procyonis (raccoon roundworm) and baylisascaris columnaris (skunk roundworm) infestation is observed due to occasional consumption of food, water and faeces contaminated with baylisascaris eggs. ingestion is the major route of transmission in pet birds for other ascarids also. clinical signs include lethargy, diarrhoea and death. engorgement of duodenal loop with roundworms is major necropsy finding. in baylisascaris procyonis infestation, considerable damage of central nervous system and subsequent ataxia, depression, head tilt, stumbling, recumbancy, torticollis, wing paralysis and death is common (fig. 2.38) . detection of thick shelled ascarid eggs in faecal sample is the major diagnostic approach. during necropsy, presence of roundworm in the intestine and larval stage in tissue section can aid in diagnosis. confirmation can be done by pcr targeting ribosomal dna, internal spacers (its-1, its-2), and mitochondrial gene (mtdna-cox2) of ascarids. treatment with fenbendazole (20-100 mg/kg body weight, once) is recommended for ascaridiasis in most of the birds except finches, marabou storks and vultures due to acute toxicity. the drug is contraindicated during growth of feathers also. other common anthelmentics such as piperazine dihydrochloride and mebendazole are also contraindicated in psittacines, pigeons, cormorants, pelicans, raptors, finches and ostriches due to toxicity and reported death. regular deworming of birds kept in crowded and unclean cages is needed to avoid ascaridiasis. other partasitic infections of pet birds are described in table 2 (sanfelice 1894 ) and subsequently, it was also isolated from a german patient (busse 1894) . two years later, an encapsulated bacilliform yeast, which was named saccharomyces subcutaneous tumefaciens, was detected from an apparently healthy man in france, later identified as cryptococcus gattii (curtis 1896) . vuillemin (1901) examined several of these cultures and due to lack of saccharomyces specific characteristics he placed these species in the genus cryptococcus. in 1905, von hansemann reported the first case of meningoencephalic cryptococcosis. in 1951, emmons isolated c. neoformans from pigeon nests and their droppings. disseminated cryptococcosis in a macaw was described later (clipsham and britt 1983) . cryptococcus belongs to the filobasidiella clade of the tremellales, under the order tremellomycetes, phylum basidiomycota. the genus cryptococcus includes over 37 species majority of which do not cause any infection in mammals. important pathogenic species are c. neoformans-c. gattii species complex, which includes c. neoformans var. neoformans, c. neoformans var. grubii, and c. gattii (c. bacillisporus). among them, c. neoformans var. neoformans and c. gattii are considered as primary pathogens in immunocompetent avian hosts. other cryptococcal species such as c. uniguttulatus, c. albidus and c. laurentii are occasionally detected in droppings and crops of pigeons and psittacine birds although clinical significance is uncertain. cryptococcus life cycle is predominantly divided into two phases i.e. vegetative and sexual growth phase. two major morphological forms (yeast and pseudohyphae) exist in the vegetative growth phase. the predominant form found in the environment and avian and animal hosts is unicellular budding yeast. the yeast cells are thin walled, spherical to oval with varying diameter (2-20 µm) and they reproduce by mitotic division. the buds are present at the narrow base ( fig. 2.45) . the morphological transition from the yeast phase to hyphal phase (pseudohyphae) is noticed during sexual mating. they are not considered as true dimorphic fungi probably due to their predominant existence as yeast form in the environment and hosts and the lack of involvement of this transition in the infection process. further, both at 25 and 37°c they can produce yeast like colonies in the isolation media. recently unusually large yeast like morphological form (30-100 µm) is also detected in clinical samples, known as 'giant' or 'titan' cells. another unique morphological feature of cryptococcus is the presence of capsule. the capsule can be best observed in fresh preparations by staining with diluted india ink or phase contrast microscopy ( fig. 2.46 ). giemsa can also partially stain the capsule. like other eukaryotic organism cryptococcus also possesses mitochondria which serves as source of energy, and is involved in processes of aging, calcium homeostasis, apoptosis, and regulation of virulence. presence of c. neoformans in the faeces of different avian species except raptors (table 2. 16.) is a saprobiotic phenomenon. avian faeces rich in creatine, urea, uric acid and protected from sunlight and ultraviolet light, high flock density and poor sanitary conditions create a microenvironment for c. neoformans. pigeons as mechanical carrier of c. neoformans in their feathers, feet and crop are mostly studied avian species. description of clinical cryptococcosis in birds is relatively rare although reported in pigeons, kiwis, major mitchell's cockatoo, moluccan cockatoos, thick-billed parrot, african grey parrot, green-winged macaw, papua lories, blackcapped lories, goldie's lorikeet, and ring necked parrot. cryptococcus is transmitted primarily through inhalation route in birds, animals and human. the basidiospores are major infectious particles, small in size (2-3 lm) which can easily invade the lung alveoli than the encapsulated yeast (10-60 lm). rarely ingestion of large number of organisms may cause the infection as observed during c. gattii infection of psittacine birds in brazil. psittacine birds have the habit of chewing wooden objects, such as the perches made of eucalyptus spp. in tropical countries, c. gattii is commonly associated with eucalyptus trees. the basidiospores lodge in the lung alveoli of the birds after inhalation. the capsule of the fungi helps in evasion of immune system and survival within the host. the capsule is constituted with mannan (polysaccharide) which is highly hydrophilic. it makes a gelatinous zone surrounding the yeasts that conceals the pattern recognition receptors (prr) of the yeast from the immune system. the capsule also prevents antibody binding and phagocytosis of the yeasts. c. gattii can produce extracellular fibrils which can prevent the phagocytosis by neutrophils and help to establish the primary pulmonary infection. after primary colonization in upper respiratory tract, haematogenous spread of yeast into different organs such as heart, liver, spleen, intestine, kidneys, and central nervous system is observed in different psittacine birds. occasionally, coelomic dissemination occurs between organs within close proximity. superficial colonization of yeast is detected in choanas, sinus, upper beak, and infraorbital sinus of african grey parrot, goldie's lorikeet and beccaris's crowned pigeon. minimal inflammatory response with epithelioid macrophages, multinucleated giant cells and heterophils or absence of inflammatory response is detected in different organs of psittacine birds. and blindness are also detected. in domestic pigeons (columba livia), rare report of clinical cases revealed the central nervous system signs, weight loss, dyspnoea, and infraorbital sinus mass. development of thick crust over the right naris is observed in major mitchell's cockatoo suffering with clinical cryptococcosis. gelatinous myxomatous mass (granulomata) in respiratory tract, abdominal cavity, sinuses and brain is the most common lesion observed in birds. in psittacines, hepatomegaly, multifocal hepatitis, yellow areas in the capsule and parenchyma of liver, congestion of lung, replacement of pulmonary parenchyma with yellow gelatinous material, thickened air sacs, sinuses filled with yellow coloured substance, nephromegaly, tubular and glomerular degeneration, splenomegaly, congested intestine with black coloured material in lumen are observed. cloacal/choanal swabs, dry faeces, blood/serum, aspiration biopsy of the gelatinous mass present in upper beak, infraorbital sinus and choana, visceras collected in 10% formalin after post mortem are considered as clinical specimens of avian cryptococcosis. dry faecal samples (2.5 gm) are suspended in 15 ml sodium chloride solution in tubes containing chloramphenicol (0.1 mg/ml). (a) direct examination: the smear can be prepared from the aspiration biopsy samples and is stained with india ink, nigrosin, or romanowski for demonstration of capsule. the romanowski stain produces clearer capsule against the lightly stained background. the tissue samples can be stained with periodic acid schiff base (pas)-haematoxylin stain which will outline the yeast cell and the capsule will appear as clear zone surrounding the cell (fig. 2.49 ). in mayer's mucicarmine stain, the capsule and cell wall appears as red. another characteristic feature of cryptococcus is narrow base budding ( fig. 2.45 ) in comparison to other yeasts (blastomyces) having broad based budding. sometimes false positive results are produced due to confusion with globules of myelin, lysed cells, lymphocytes and dead yeasts after successful treatment. (b) isolation of cryptococcus spp. from clinical samples: faecal suspension (dry faeces mixed with sodium chloride and chloramphenicol) of the suspected birds can be inoculated into corn meal agar, sabouraud's dextrose agar, blood agar, honey agar, brain heart infusion agar and malt agar. the specific medium is birdseed agar/staib medium (niger seed agar)/sunflower seed extract agar with antibiotics. the plates are incubated at 28-37°c for 2 days to 2 weeks. the colonies are initially small, convex, mucoid, creamy in colour, increases in diameter up to several centimeters after prolonged incubation. in birdseed agar the colonies appear as brown coloured in the center of the plate due to the production of melanin by the action of phenyl oxidase. the optimum capsule production is detected in chocolate agar after incubation at 37°c with 5% co 2 tension. the isolates are confirmed by api system or different biochemical tests such as urea hydrolysis, assimilation of inositol and creatinine, non-fermentation of carbohydrates, and melanin production. the l-canavanine glycine bromothymol blue media can differentiate c. neoformans and c. gattii by the formation of distinctive blue coloration with the growth of c. gattii. (c) detection of cryptococcal antigen: detection of cryptococcal antigen in clinical specimens can be performed by latex particles coated with polyclonal serum and antigen-capture elisa. the detection of antigen is possible from both live and dead organisms. during initial phase of therapy, disintegration of the yeast cells releases the capsule which produces high titer. so, the tests should not be done within 6-8 weeks after initiation of the therapy. the titer can be observed even after successful treatment as the dead organisms also have the intact capsule. (d) molecular biology: multiplex pcr and mating type-pcr are used for determination of molecular and mating types of c. neoformans var. neoformans and c. gattii isolates. in human the patients with suppressed immunity (suffering from aids, lymphoma, haematologic malignancy and using corticosteroids for prolonged period) are mostly susceptible to the cryptococcal infection. it causes meningitis, meningoencephalitis and death in human. inhalation of cryptococcal basidiospores is the major way of transmission in human. cryptococcal infection in patients after exposure to the birds is observed. it was first reported from united states in a renal transplanted patient who developed cryptococcal meningitis transmitted from her pet cockatoo (nosanchuk et al. 2000) . report of cryptococcal meningitis is also documented in immunocompetent patient who acquired the infection from her pet magpie, although, her contact with the bird was limited to passing by the cage when entering home (lagrou et al. 2005 ). fluconazole (5-15 mg/kg body weight, oral, 12 h interval for 15-60 days) and itraconazole (10 mg/kg body weight, oral, 24 h interval for 15-90 days with food) are recommended for treatment of avian cryptococcosis in pet birds. use of itraconazole is contraindicated in african grey parrots. proper ventilation, regular cleaning of droppings and organic debris from the cages can prevent the occurrence of avian cryptococcosis. in tropical countries, wooden perches made of eucalyptus tree should be avoided because psittacine birds like to chew the perches. in 1729, micheli first described aspergillus who found the similarity between the spore chain of the fungi with the brush ('aspergillium') used for sprinkling holy water in the churches. later in 1842, pathogenic aspergillus (a. candidus) was detected in air sac lesion of a bullfinch by rayer and montagene. whereas, a. fumigatus was first detected in lung of a great bustard (otis tardaga) in 1863 by fresenius, who was the first to use the term 'aspergillosis' for this respiratory infection. the major members of aflatoxins were first detected and its association with aspergillus flavus was established in 1961 during investigation of mysterious 'turkey-x disease' causing high mortality in turkey poults (sargeant et al. 1961) . in 1962, the name 'aflatoxin', using first letter from 'aspergillus' and the first 3 letters from 'flavus' was proposed. aspergillus is the fungus which belongs to trichocomaceae family under the order eurotiales and phylum ascomycota. the genus aspergillus contains more than 250 species grouped into sub genera and species complex. there are eight such sub genera i.e. aspergillus, fumigati, circumdati, candidi, terrei, nidulantes, warcupi, and ornati. the important species complexes are a. fumigatus, a. flavus, a. terreus, a. niger, a. nidulans, and a. ustus. among them, a. fumigatus is the most common cause of avian aspergillosis. other species complexes such as a. flavus, a. terreus, a. niger, and a. nidulans are occasionally associated with avian aspergillosis. a. fumigatus is the major cause probably due to smaller size of the spores than other species which helps in easy transmission. all species of domestic, pet and wild birds including chicken, duck, quail, and geese are susceptible to avian aspergillosis due to anatomic and physiologic characteristics of avian respiratory system (table 2 .17). among the wild birds, some species such as goshawks (accipiter gentilis), gyr falcons (falco rusticolus), penguins, and auk (alca torda) are more susceptible to respiratory fungal infections. diving birds (auk, penguin) are more susceptible due to air re-circulation during diving. inhalation of fungal spores (conidia) is the major way of aspergillus transmission in birds. in addition to inhalation route, ingestion of contaminated feed (seed mixture) with the fungal spores is another way of transmission. due to small non-expanding lung and presence of air sacs, the birds are more susceptible to aspergillus infection. primary colonization of the spores takes place in the air sacs because the inhaled air passes through the sacs to reach the lungs. other predisposing factors for aspergillus infection include higher body temperature which helps in fungal growth, lung injury, stress due to malnutrition and vitamin deficiency, use of immunosuppressive drugs, very young or old age and use of hay or straw contaminated with fungal spores in preparation of aviary litter. the conidia of aspergillus spp. reach the lung parenchyma through inhaled air. the conidia are trapped between atrium and infundibulum of parabronchus region of the lungs. conidial sialic acids act as ligand for adherence with the alveolar epithelial cells specially with fibrinogen and fibronectin, commonly found in the wounded epithelial surfaces. so, lung injury acts as major predisposing factor for causation of invasive aspergillosis. gliotoxin, fumagillin, and helvolic acid produced by the fungi causes damage in the respiratory mucosa and slow ciliary movement facilitating the attachment of the conidia. the conidial maturation begins which causes loss of hydrophobic layer and exposure of the inner cell wall. the cell wall is composed of galactomannan, chitin, and b glucan which act as ligand for the soluble and cell associated pattern recognition receptors (prr). the soluble receptors act as opsonin and can bind with fungal cell wall carbohydrate which enhances phagocytosis by the alveolar macrophages. most of the conidia are killed by reactive oxygen species (ros) or acidified phago-lysosome produced within the alveolar macrophages. in immunosuppressed birds having defective alveolar macrophage function the conidia are able to escape the phago-lysosome mediated killing. the conidia which survive the first line of defense can germinate. the germination involves conidial swelling (isotropic growth) followed by protrusion of germ tube (polar growth). they produce a necrotic focus (plaque) without a structured granuloma which can obstruct the trachea or bronchi and fill up the air sacs. hyphae with fruiting bodies can penetrate the air sacs or lungs and produce serositis. fungal growing hyphae also invade the endothelial cell lining of blood vessels (angioinvasion) from the albuminal side to the luminal side. dissemination of infection into vital organs occurs through the haematogenous route. avian aspergillosis is considered as an opportunistic infection in birds with immunosuppression. primary infection in immunocompetent hosts sometimes takes place when numerous spores are inhaled. acute and chronic types of aspergillosis may develop in affected birds. mostly young birds suffer with acute infection in which sudden death of birds occurs without prior symptoms probably due to hepatic damage by aflatoxins released by the fungi. if the birds are alive for a few days, general symptoms such as laboured breathing, anorexia, diarrhoea, polydypsia, and cyanosis develop. chronic aspergillosis is more common in adult birds. it produces non-specific syndrome such as fever, diarrhoea, respiratory distress, change in voice ('sore throat' sound due to tracheal and syringeal inflammation), change in behaviour, emaciation, cheesy deposit in conjuntival sac, and nares, development of rhinolith ('nose-stone') and facial swelling, neurological disorders, dermatitis, wing droop due to humerous involvement ( fig. 2.50 ). death occurs due to obstruction of airways and respiratory failure. congestion and yellow nodules in lungs, thickened air-sacs with small whitishyellow plaques are detected in acute aspergillosis (figs. 2.51 and 2.52). in chronic form, granulomatous lesions (nodules and plaques) are observed in periphery of lungs and air sacs which may occlude the trachea and bronchi. typical granulomas are also detected in kidneys, oviduct, and ovaries. whole blood, tracheal washings, air sac fluids, tissue biopsies from respiratory tract granuloma and vital organs such as lungs, air sacs, kidney, liver collected after post the tissues collected as clinical specimens should be cleared with 10% koh and are observed under microscope. histopathological staining can be performed with periodic acid schiff (pas), grocott's silver or methenamine silver stain for detection of tissue invasion. in the tissue section, aspergillus hyphae are narrow and septate which are not easily distinguishable from other fungi (fig. 2.53 ). different species of aspergillus has characteristic fruiting body structures which can be identified by an expert. confirmation of aspergillosis is also possible by immunohistochemistry. (c) isolation of aspergillus from clinical specimens: aspergillus can be isolated in sabouraud dextrose agar (sda) with or without chloramphenicol (0.05 gm/l) and other common bacteriological media such as blood agar. the cycloheximide can inhibit the growth. the plates are incubated at 37°c for 4-5 days. a. fumigatus is thermophilic which is able to grow at 55°c and can survive at more than 75°c. however, repeated isolation from the clinical specimen is required, along with correlation with history, clinical signs, histopathological observations for proper diagnosis of clinical aspergillosis. (d) blood biochemical tests and radiography: haematological parameters such as leukocytosis (20,000-100,000), heterophilia with a left shift (degenerative shift), monocytosis, lymphopenia, and change in b-globulin concentration indicate about occurrence of infection such as aspergillosis. radiographic changes of pneumonia and airsacculitis (lateral and ventrodorsal views) also suggests respiratory tract infection such as aspergillosis. both these biochemical tests and radiogrpahy cannot confirm the infection. (e) detection of aspergillus antigen: detection of aspergillus antigen is useful in acute infection. galactomannan (gm) is the predominant antigen released by a. fumigatus in the circulation during angioinvasion which can be detected by latex agglutination test, sandwich elisa in blood samples. the detection limit of both the tests is 15 ng/ml and 1 ng/ml, respectively. however, gm detection assay is not specific for aspergillus as it is cross-reacting with other fungi such as penicillium, fusarium, alternaria, and histoplasma. similarly, b-d-glucan (bdg) can be detected for identification of aspergillus. it is also produced by a lot of other fungi such as candida, fusarium, pneumocystis etc. so the test can predict the general fungal infection rather than specifically aspergillosis. (f) serological tests: serological tests such as counter-immunoelectrophoresis, agar gel immunodiffusion and enzyme-linked immunosorbent assays (elisa) can be employed as supportive diagnostic assays to detect the antibodies in chronic infection. in immunosuppressed birds production of antibody is undetectable. (g) molecular biology: confirmation of aspergillus spp. can be done by conventional pcr and real-time pcr from clinical samples. a. fumigatus isolates can be characterized by pcr-rflp using bcci, mspi and sau3ai restriction enzymes. a. fumigatus causes invasive aspergillosis in immunocompromised human which involves lung parenchyma, pleura, trachea and bronchi. it is common in the patients with haematological malignancy, prolonged antibiotic users or stem cell transplant recipients. transmission of clinical aspergillosis from pet birds is not documented so far. removal of granulomatous lesion is essential for effective treatment. it is difficult due to remote location of granuloma within respiratory tract, risk of surgical trauma and anaesthesia. in most of the confirmed cases, treatment is restricted with antifungals. nebulization, oral, intravenous, nasal or air sac flushing, surgical irrigation of the abdominal cavities are ways for drug application. antifungals used in avian aspergillosis with suitable dosage are described in table 2 .18. sometimes, immunostimulants, for example, levamisole and microbial products (b-glucans) can be used for boosting of the immune system. no vaccine is currently available against avian aspergillosis. maintenance of hygiene and nutrition, avoiding mouldy feeds, proper ventilation and spraying of fungistatic agents [nystatin, thiabendazole, copper sulphate (1 g per 2 l of water)] in large aviaries can prevent avian aspergillosis. candida spp. is a common inhabitant of avian enteric tract, although, it can cause infection in young, immunosuppressed and stressed birds and during prolonged use of antibiotics. candida albicans, c. krusei, and c. tropicalis are major cause of avian candidiasis. c. parapsilosis is rarely isolated from the crops of the birds. among the pet birds, clinical candidiasis is reported from peach-faced lovebirds, fisher's lovebirds, pigeons, cockatiels, amazon parakeets, budgerigars and peacocks. in eclectus parrot, concomitant infection of histoplasmosis and candidiasis is detected. healthy cockatiels and some other psittacines are also detected to act as carrier of candida spp. infected birds show whitish, pseudomembranous lesions in oral cavity, crop and esophagus. crop is the most suitable organ for fungal growth due to its pouch like structure and availability of nutrients. general symptoms such as anorexia, depression, delayed crop emptying, and regurgitation is sometimes observed. presence of thickened mucosa (pseudomembranes) and ulcers in oral cavity, esophagus and crop is the major necropsy findings. the smear prepared from the clinical specimens can be observed under microscope either by 10% koh preparation or by staining with gram's stain method. in the tissue section candida can be observed by pas-haematoxylin or methenamine silver stain. they appear as unicellular budding yeast or hyphae and pseudohyphae ( fig. 2.54 ). candida can be isolated in common fungal or bacteriological media such as sabouraud dextrose agar (with penicillin, streptomycin, chloramphenicol to prevent the bacterial growth), potato dextrose agar, blood agar and brain heart infusion agar. the plates are incubated at 25-30°c for 2-3 days. immunohistochemistry is also useful in detection of candida spp. in birds. several types of pcr such as semi nested and nested pcr, real time pcr, multiplex pcr followed by dna sequencing or pyrosequencing are developed for detection of candidal dna. the target gene includes rrna (5.8s, 18s, 28s) gene, internal transcribed spacer (its) and intergenic spacer (igs) region genes. treatment with nystatin (3,00,000-600,000 iu/kg body weight, 8-12 h interval for 7-14 days in psittacines; 1,000,000 iu/kg body weight, 12 h interval in raptors and pigeons) is recommended for pet birds in confirmed cases of avian candidiasis. the drug is not well absorbed from the gastro intestinal tract and it should be mixed with food for better absorption. except vomition in some species the drug is safe and cost-effective. infection) proventriculitis was originally described as megabacterium associated infection in aviaries. due to presence of a eukaryotic nucleus, mycotic staining properties, presence of chitin in cell wall, and finally phylogenetic analysis based on 18s rrna and 26s rrna gene, megabacterium is classified as yeast. it is renamed as macrorhabdus ornithogaster. the infection is reported from captive-bred budgerigars (melopsitticus undulatus), parrotlets (forpus spp.), canaries (serinus canaria), pheasants (phasianus colchicus), red-legged partridges (alectoris rufa), helmeted guinea fowl (numida meleagris) and gray partridges (perdix perdix) as primary pathogen or concomitant with other infections. faecal-oral route is the probable transmission route of macrorhabdus infection in birds. the yeast prefers to colonize isthmus of proventriculus or ventriculus in birds. the infection is chronic and it produces certain non-specific symptoms such as anorexia, continuous loss of body weight, depression, plumage disorder, regurgitation, diarrhoea and dehydration ( fig. 2.55 ). sudden death due to rupture of proventriculus is observed in budgerigars and parrots. swollen and hyperemic proventriculus, covering of isthmus with thick, transparent-to-white mucus, and mucosal erosions in gizzard are specific necropsy findings. fresh faecal samples from live birds and tissues from vital organs (esophagus, crop, proventriculus, gizzard, pancreas, liver etc.) can be collected in 10% buffered formalin after post-mortem. smears prepared from faecal samples can be stained by gram's method. the tissue sections are stained with periodic acid-schiff (pas), grocott's methenamine silver nitrate (gms) and mayer's hematoxylin and eosin. detection of typical gram-positive, large rod shaped organisms (20-60 µm long and 2-3 µm wide) suggests macrorhabdus infection (fig. 2.56) . isolation of macrorhabdus is difficult because it does not grow in commonly used solid media. it can be isolated only in liquid medium (minimum essential media) with 20% foetal bovine serum (fbs) and 5% sucrose and more than two weeks incubation. antifungals for instance nystatin and amphotericin-b can be used for the treatment (figs. 2.57, 2.58 and 2.59). other fungal infections of pet birds are described in table 2 .19. molecular characterization of giardia psittaci by multilocus sequence analysis ascaridia nymphii n. sp. 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diagnosis of avian borna disease virus infection of psittaciformes by protein analysis of feather calami and enzyme-linked immunosorbent assay of plasma antibodies avian psittacosis a case of aspergillosis in a bearded vulture (gypaetos barbatus) isolation of pacheco's disease herpesvirus in texas pasteurellosis in african grey parrots (psittacus erithacus l.) chlamydia in birds-occurrence, new species and zoonotic potential-a review detection of chlamydiosis in a shipment of pet birds, leading to recognition of an outbreak of clinically mild psittacosis in humans some basic properties of the psittacosislymphogranuloma venereum group of agents. structure and chemical composition of isolated particles necrotising ventriculitis due to combined infection with rhizopus microsporus var. chinensis and candida krusei in an eclectus parrot (eclectus roratus) diagnosis of gastric cryptosporidiosis in birds using a duplex real-time pcr assay an outbreak of avian mycobacteriosis caused by mycobacterium intracellulare in little blue penguins (eudyptula minor) aspergillosis in larus cachinnans micaellis: survey of eight cases passive immunity to west nile virus provides limited protection in a common passerine species experimental infection of european starlings (sturnus vulgaris) and house sparrows (passer domesticus) with pandemic 2009 h1n1 and swine h1n1 and h3n2 triple reassortant influenza viruses bird life in the national park a review of west nile and usutu virus co-circulation in europe: how much do transmission cycles overlap? living with avian flu-persistence of the h5n1 highly pathogenic avian influenza virus in egypt birds as reservoirs for borrelia burgdorferi s.l. in western europe: circulation of b. turdi and other genospecies in bird-tick cycles in portugal evidence of zoonotic transmission of cryptococcus neoformans from a pet cockatoo to an immunocompromised patient detection of chlamydophila psittaci by using sybr green real-time pcr avian malaria deaths in parrots canary finches (serinus canaria) as an avian infection model for lyme borreliosis no evidence of campylobacter, salmonella and yersinia in free-living populations of the red-crowned parakeet (cyanoramphus novaezelandiae) epizootie chex les perroquets du brésil. relations avec le psittacose disseminated aspergillus terreus infection in a caged pigeon pathology and immunohistochemical findings of west nile virus infection in psittaciformes avian mycobacteriosis in psittacines: a retrospective study of 123 cases role of birds in dispersal of etiologic agents of tick-borne zoonoses giardia infection in parakeets bacterial septicemias in two psittacine birds the pathology of psittacine beak and feather disease a papova-like virus infection of splendid parakeets (neophema splendida) sur les maladies virulentes et en particulier sur la maladie appele´e vulgairement chole´ra des poules detection and characterization of a distinct bornavirus lineage from healthy canada geese (branta canadensis) varied pathogenicity of a hong kong-origin h5n1 avian influenza virus in four passerine species and budgerigars mixed infection with reovirus and chlamydophila in a flock of budgerigars (melopsittacus undulatus) mycobacterium tuberculosis infection in a blue fronted amazon parrot (amazona aestiva aestiva) detection and identification of chlamydophila psittaci in asymptomatic parrots in poland pathogenicity and transmission studies of h5n2 parrot avian influenza virus of mexican lineage in different poultry species evaluation of chlamydophila psittaci infection and other risk factors for atherosclerosis in pet psittacine birds humans infected with relapsing fever spirochete borrelia miyamotoi mycobacteriosis caused by mycobacterium genavense in birds kept in a zoo: 11-year survey cryptosporidium spp. in pet birds: genetic diversity and potential public health significance disseminated histoplasmosis with concurrent oral candidiasis in an eclectus parrot (eclectus roratus) chronic rhinosinusitis and rhamphothecal destruction in a major mitchell's cockatoo (cacatua leadbeateri) due to cryptococcus neoformans var gattii coligranuloma and psittacosis in an amazon parrot chlamydophila psittaci infections in hyacinth macaws (anodorhynchus hyacinthinus) confiscated in brazil cryptococcosis outbreak in psittacine birds in brazil phylogenetic analysis of the hexon loop 1 region of an adenovirus from psittacine birds supports the existence of a new psittacine adenovirus (psadv) prevalence of borrelia burgdorferi sensu lato genospecies in ixodes ricinus ticks in europe: a metaanalysis gastrointestinal cryptosporidiosis in captive psittacine birds in the united states: a case review broad tissue and cell tropism of avian bornavirus in parrots with proventricular dilatation disease evidence for specificity of psittacine beak and feather disease viruses among avian hosts uber pneumotyphus, eine hausepidemie in uster encephalitozoon hellem infection in aviary passerine and psittacine birds in spain a study of the hemorrhagic septicemia pasteurellae campylobacter jejuni and proventricular dilatation disease in parrots: there may be a correlation? velogenic newcastle disease virus in captive wild birds epidemic of salmonellosis in passerine birds in switzerland with spillover to domestic cats evaluation of multidrug therapy with azithromycin, rifampin, and ethambutol for the treatment of mycobacterium avium subsp. avium in ring-neck doves (streptopelia risoria): an uncontrolled clinical study salmonella. in: samanta i (ed) veterinary bacteriology, 1st edn springer samanta i, joardar sn, das pk et al (2014) prevalence and antibiotic resistance profiles of salmonella serotypes isolated from backyard poultry flocks in west bengal cryptococcus neoformans (san felipe) vuillemin en aves confinadas y recintos hospitalarios de la región metropolitana (chile) the virus of hog cholera contributo alla morfologia e biologia dei blastomiceti che si sviluppano nei succhi de alcuni frutti toxicity associated with certain samples of groundnuts phylogeny of beak and feather disease virus in cockatoos demonstrates host generalism and multiple-variant infections with in psittaciformes evidence of a deep viral host switch event with beak and feather disease virus infection in rainbow bee-eaters molecular epidemiology of avian bornavirus from pet birds in japan origin of the pandemic 1957 h2 influenza-a virus and the persistence of its possible progenitors in the avian reservoir vergleichende sero-immunologische untersuchungen uber die viren der influenza unf klassichen geflugelpest studies of parrots, parakeets and their excrement to demonstrate the presence of the causative agent of psittacosis following treatment of the birds with chlortetracycline enteropathogenic escherichia coli in psittaciformes the reappearance of newcastle disease in kenya newcastle disease in the grey parrot (psittacus erithacus l.) detection of lyme disease spirochete, borrelia burgdorferi sensu lato, including three novel genotypes in ticks (acari: ixodidae) collected from songbirds (passeriformes) across canada investigation and control of an attaching and effacing escherichia coli outbreak in a colony of captive budgerigars (melopsittacus undulatus) isolation of avian serotype 3 paramyxoviruses from imported caged birds in israel first isolation of mycobacterium genavense in a blue headed parrot (pionus menstruus) imported from surinam (south america) to the czech republic: a case report a review on emerging diagnostic assay for viral detection: the case of avian influenza virus psittacine herpesvirus infection resembling pacheco's parrot disease leucocytozoon-like infection in parakeets, budgerigars and a common buzzard cryptosporidium meleagridis (sp. nov.) type-a influenza viruses isolated from wild free-flying ducks in california influenza type a isolated from imported exotic birds compendium of measures to control chlamydophila psittaci (formerly chlamydia psittaci) infection among humans (psittacosis) and pet birds outbreaks of salmonellosis at elementary schools associated with dissection of owl pellets a neurotropic virus isolated from the blood of a native of uganda rickettsiae of spotted fever group, borrelia valaisiana, and coxiella burnetii in ticks on passerine birds and mammals from the camargue in the south of france cryptosporidiosis in birds-a review avian bornavirus associated with fatal disease in psittacine bird emergence and establishment of usutu virus infection in wild and captive avian species in and around zurich, switzerland-genomic and pathologic comparison to other central european outbreaks possible human-avian transmission of mycobacterium tuberculosis in a green-winged macaw (ara chloroptera) west nile virus infection in a green-winged macaw (ara chloropterus) comparative studies on isolation of psittacosis virus from the parakeet with aid of the mouse experiment and cultivation in chick embryo neopsittaconirmus vendulae, a new species of louse (phthiraptera: philopteridae) from the cockatiel nymphicus hollandicus (psittaciformes: cacatuidae) phylogenetic analyses of chlamydia psittaci strains from birds based on 16s rrna gene sequence salmonella, campylobacter and chlamydophila in bald ibis (geronticus eremita) faeces in turkey thermotolerant campylobacter species isolated from psittaciformes in the peruvian amazon region sul micrococco della rabbia e sulla possibilità di riconoscere durante il periode d'incubazione, dall'esame del sangue della persona moricata, se ha contratta l'infezione rabbica histopathological survey of protozoa, helminths and acarids of imported and passerine local psittacine and birds in japan pathomorphological, immunohistochemical and bacteriological findings in budgerigars (melopsittacus undulatus) naturally infected with s. gallinarum a protozoan found in the peptic glands of the common mouse an extracellular coccidium cryptosporidium muris (gen. et sp. nov.) of the gastric glands of the common mouse west nile virus in the vertebrate world salmonella gastroenteritis; report of two cases ascribed to a pet duck usutu virus-potential risk of human disease in europe comprehensive serological analysis of two successive heterologous vaccines against h5n1 avian influenza virus in exotic birds in zoos isolation of salmonella typhimurium from dead blue and gold macaws (ara ararauna) les blastomycètes pathogènes does the roosting behavior of birds affect transmission dynamics of west nile virus? outbreak of salmonellosis in a zoologic collection of lorikeets and lories (trichoglossus, lorius, and eos spp.) mycobacterium tuberculosis infection in a green-winged macaw (ara chloroptera): report with public health implications isolation of yersinia (pasteurella) pseudotuberculosis from the palm dove (streptopelia senegalensis) usutu virus activity in austria emergence of usutu virus, an african mosquito borne flavivirus of the japanese encephalitis virus group exudative cloacitis in the kakapo (strigops habroptilus) potentially linked to escherichia coli infection the isolation of west nile virus from man and of usutu virus from the bird biting mosquito mansonia aurites (theobald) in the entebbe area of uganda die halb-acute gehirn-entzündung oder kopf-krankheit der pferde sarcocystis falcatula-associated encephalitis in a free-ranging great horned owl (bubo virginianus) molecular characterization of the cloacal microbiota of wild and captive parrots prevalence of campylobacter jejuni in selected domestic and wild birds in louisiana isolation of newcastle disease virus from the osprey and the parakeet key: cord-015334-8p124rwp authors: nan title: escp 36th european symposium on clinical pharmacy ‘implementing clinical pharmacy in community and hospital settings: sharing the experience’, istanbul, turkey 25–27 october 2007; abstracts date: 2008-06-11 journal: pharm world sci doi: 10.1007/s11096-008-9226-3 sha: doc_id: 15334 cord_uid: 8p124rwp nan pharmacy, groupe hospitalier pitié salpétrière, paris, france background and objective: strongyloides stercoralis infects each year millions of persons worldwide. in immunocompromised patients, this intestinal nematode can disseminate and cause a fulminant fatal illness: hyperinfection syndrome. oral ivermectin is the principal treatment. since one of the features of s. stercoralis hyperinfection is the development of an ileus and small bowel obstruction, the drug absorption is impaired and thus a reduced efficacy is noted. no parenteral antihelminthic drug is licensed for human use, but parenteral ivermectin is commonly used in veterinary medicine. we report two cases of s. stercoralis hyperinfection syndrome that were refractory to oral drugs and, as a life saving therapy, were treated with a veterinary formulation of parenteral ivermectin (ivomec ò , merial) after agreement from the french drug administration (afssaps). design: case report. setting: pneumology and neurochirurgical intensive care units, university hospital, paris, france. main outcome measures: case report. results: patient 1 a 44-year-old african man has been hospitalized in august 2006 for a degradation of his condition in neurosarcoidosis with hydrocephalus, associated with enterococcus faecalis meningitis. he underwent ventriculo-peritoneal shunt and was treated with corticosteroids (prednisone 65 mg/day). his condition worsened on september 2006, with the diagnosis of a disseminated strongyloidiasis with paralytic ileus. he was initially treated with ivermectin (12 mg bid) via the nasogastric tube. antibiotics were added on day 2 to control the sepsis. on day 5 albendazole (400 mg/day) was added. subcutaneous ivermectin was then obtained and administered on day 6 (200 lg/kg) in association with ivermectin via nasogastric tube while albendazole was discontinued. the patient's condition improved during the following days. he completed 8 days of ivomec ò and 30 days of oral ivermectin. he returned home 2 months later. patient 2 a 49-year-old african man was hospitalized in november 2006 because of a 30 kg weight loss. he was diagnosed with hiv, meningeal tuberculosis, urinary and pulmonary infections and s. stercoralis hyperinfection treated with oral ivermectin. on 29 january 2007 he was admitted in pneumology intensive care unit with melena on severe immunodepression. on 6 february he developed a septic shock with ards on an important bowel obstruction. therefore, among other antiinfectious therapies, a veterinary formulation of subcutaneous ivermectin was administered (200 lg/kg/day). the sepsis was controlled, but on 11 february he died of an acute haematological deterioration. conclusions: as the occurrence of malabsorption is a frequent complication of disseminated strongyloidiasis, a parenteral formulation of ivermectin would be really helpful, especially as the efficacy of the subcutaneous form has been proved in the literature. keywords: strongyloides stercoralis, hyperinfection, parenteral ivermectin • each pharmacy received three covert sp visits over six weeks. verbal and written feedback was provided to the pharmacy staff after each sp visit. no pharmacy was visited by the same sp more than once. each pharmacy was visited by the same pe throughout the study. background and objective: heart failure (hf) is a common disease with an estimated prevalence of 0.4 to 2% in europe. patients with hf have frequent episodes of exacerbation. non-compliance to medical and dietary advice is a significant clinical problem as is suboptimal treatment. one example of factors influencing the ability to comply with a treatment plan is impaired comprehension. the objectives were to construct a medication assessment tool and to establish face validity for its use in this project, to construct an interview schedule in order to identify non-compliance, poor patient comprehension and suboptimal treatment, to conduct a survey and to report the findings to the clinic. design: a cross-sectional study performed during april 2007-may 2007. setting: the emergency department and medical wards at malmö university hospital. main outcome measures: comparison of compliance, comprehension and optimal treatment on a population basis between men and women, younger (\75 years) and elderly ([75 years) patients, and patients in different new york heart association (nyha) classes, in order to assess if exacerbation could have been caused by any of these factors. results: of the 47 patients included, 60% reported high compliance. in the subgroup analysis, women and elderly patients reported a significant higher compliance than men and younger patients. comprehension on self-care was poor. only 30% weighed themselves regularly and 45% did not limit the amount of fluids. no more than 28% reported they would contact a health care provider in case of experiencing more symptoms. suboptimal treatment was also found to be a great concern with only 47% being treated with angiotensinconverting enzyme inhibitors (acei) or angiotensin ii receptor blocker (arb), 66% with beta blockers, and 51% with aldosterone receptor antagonists, but no consideration to other co-morbidities has been taken into account. the majority treated with recommended agents had not achieved target dose as recommended in guidelines. conclusions: poor patient compliance and comprehension as well as suboptimal treatment could contribute to hf exacerbation and efforts should be made to improve these factors in order to reduce hf exacerbation. keywords: heart failure, compliance, sub-optimal treatment background and objective: adherence with inhaled corticosteroids has repeatedly been reported to be poor. poor adherence could lead to inadequate control of asthma complaints. monitoring of repeat prescriptions by a pharmacist could offer an opportunity to reach concordance with the patient and improve adherence. the objective of this study is was to improve asthma control by optimizing use of asthma medicines. design: retrospective follow up study. all pharmacy dispensing records concerning respiratory medication (r03) from 1st october 2003 to 30th september 2006 were collected. between 1st october 2005 to 30th september 2006 monitoring of repeat medication was conducted by a pharmacist. pharmacists discussed asthma complaints and use of asthma medicines with all patients calling for repeat prescriptions. when indicated the pharmacist proposed adjustments of asthma medicines to the gp after this telephone consultation. setting: community pharmacy and one gp practice (5 gp's) in leiden, the netherlands, serving a community of 6.000 patients. main outcome measures: self-reported use of short-acting betaagonists (saba) by intervention patients. defined daily doses (ddds) of short-acting beta-agonists (saba), long-acting beta-agonists (laba) and inhaled corticosteroids (ics). results: 120 consultations were registered for 68 intervention patients. for 29 patients more than 1 consultation was registered. at the first consultation only 5 of 29 patients (17%) reported use of 1 pharmaceutical sciences, strathclyde institute of pharmacy and biomedical sciences, university of strathclyde, glasgow, united kingdom background and objective: to test a method to quantify adherence of medication use to clinical guideline recommendations in a primary care setting. design: retrospective survey to field-test a 51-item instrument (mat-cvd) based on earlier studies of quality of medication use in cardiovascular disease (cvd) 1 . setting: a database of 388 patients [45% male, mean (sd) aged 66 (14) years] coded with circulatory system disease (read code 'g*') was drawn from computerised records of all patients receiving care from a single community pharmacist and general medical practitioner (gp) collaboration (n = 1,703). the pharmacist worked as a supplementary prescriber and had remote access to the electronic records of the gp. patients had diagnoses of diabetes (n = 34), hypertension (htn; n = 250), ischaemic heart disease (ihd; n = 60), other ischaemic vascular disease (cerebrovascular n = 27; peripheral vascular n = 13), heart failure (hf; n = 12), atrial fibrillation (af; n = 28), were anticoagulated (warfarin, n = 19) or otherwise identified as potential candidates for primary prevention of cvd (n = 100). main outcome measures: adherence (%) to 51 criteria based on guideline recommendations on primary and secondary prevention of cvd, treatment of htn, ihd, hf, af and warfarin therapy; overall applicability of criteria and quantification of insufficient data; interrater agreement of application of individual mat-cvd criteria and of the overall tool (cohen's r) results: a total of 2473 criteria were applicable and for 131(5%) of these there was insufficient data to apply the standard. the guideline adherence (95% ci) overall was 74 (72-76)%. highest adherence was to 'primary/secondary prevention of cvd' [80 (77-82)% adherence, n = 11 criteria]. lowest adherence was to 'treatment of af' [43 (25-61)% adherence, n = 3 criteria]. non-adherences were found to at least one criterion in 259 (67%) and to c4 criteria in 49 (13%) patients. inter-rater agreement was assessed on the application of the tool to all patients by two independent raters. all six sections and the overall tool were found to have inter-rater agreement r [ 0.8 and a percentage agreement [90%. among the 31 (61%) of 51 individual mat criteria that were applicable to c10 patients 24 showed r [ 0.8. in two of the remaining seven criteria the base-rate problem 2 was responsible for r \ 0.8 and when taken into account the number of individual criteria with acceptable inter-rater agreement was 26 (84%). conclusions: the application of the mat-cvd to routine primary care records in a scottish primary care setting is feasible and reliable; the tool has potential use in continuous quality improvement of prescribing in primary care. pc-205 self-management of complications in diabetic patients: a pharmaceutical care program in community pharmacies 1 pharmacy, 2 general medicine unit, university medical outpatient clinic, lausanne, switzerland background and objective: seamless care refers to continuity of patient care in the health system across caregivers. the objectives of the present study were (1) to identify barriers to seamless information between a given hospital and an outpatient clinic in switzerland and (2) to propose tools for improving pharmaceutical seamless care. design: this is a retrospective study with a convenient sample of patients for mapping the information flow network. the inclusion criteria were: (1) at least one stay lasting more than 24 hours in the hospital in 2006, (2) regular checkups with a gp in the outpatient clinic and (3) medication delivered by the community pharmacy of the outpatient clinic 6 months prior to 6 months after the hospitalization. setting: both hospital and outpatient clinic are independent and run their own pharmacy. the hospital pharmacy is implied in drug production and distribution without generalized pharmaceutical care activities, and the community pharmacy delivers rx or otc medication for outpatients. geographic and computer proximity between both entities constitutes an ideal setting for seamless care projects. main outcome measures: (1) to map medical or administrative information between community pharmacy, gp and hospital and (2) to find opportunities to improve pharmaceutical seamless care. results: sixteen patients met inclusion criteria (5 women, 11 men, average 53 years, mean visits/patient/year with gp: 3, and with community pharmacist: 49, i.e. 16-time more with pharmacist than gp). we observed that administrative information is computerized on a common database for both hospital and outpatient clinic. in contrast, clinical information is mainly handwritten and difficult to share between hospital and outpatient clinic caregivers. patient medication database is managed by a community pharmacy software not linked to medical information. however administrative information flows in one direction from the administrative to the community pharmacy database. we identified 2 potential tools easily available to the community pharmacy to improve pharmaceutical seamless care in the center: (1) an alarm through the administrative database connection if a patient is hospitalized to allow pharmacist to contact hospital physician for medication history and (2) an access to patient discharge letter and lab results to improve rx validation process. conclusions: clinical information is not easily shared between caregivers of the hospital and the outpatient clinic. if global seamless care still remains a long term goal, initial actual steps promoted by community pharmacists can be easily implemented. keywords: seamless, information, community pk-145 implementation of a protocol for pharmacokinetic monitoring of high-dose methotrexate background and objective: to quantify the impact of the implementation of a protocol for the pharmacokinetic monitoring of patients receiving high-dose methotrexate. design: prospective experimental study, in which the hospital pharmacy department designed a specific protocol for the pharmacokinetics follow-up of these patients and for gathering the data required for a correct rescue. results were compared between three months before and three months after implementation of this new protocol. setting: 24-hr infusions of methotrexate at a dose of c1 g/m 2 were evaluated in adult patients admitted to the oncohaematological area of a tertiary level hospital. main outcome measures: number of infusions started at the correct time, number of missed blood extractions, number of missed leucovorin doses, calculation of the elimination half-life, and measurement of the urinary ph (dichotomous variables). degree of compliance with the leucovorin rescue dosage protocol was measured on a scale of 0-3 points, with all items carrying the same score (correct loading dose, dosage as function of body surface area, and dosage as function of the concentrations of methotrexate obtained). results: the number of infusions started at the correct time increased from 50% to 60%. the number of missed blood extractions fell from 1.6 to 0.4 extractions per course; and missed leucovorin doses dropped from 0.25 to 0 per course. the elimination half-life could be calculated in only 25% of courses in the first study period versus 100% of courses after protocol implementation. urinary ph changed from not being measured in any cycle to being measured in 100% of cycles. compliance with rescue dosage protocol was scored with 1.9 points before versus 2.8 points after implementation. background and objective: to quantitatively evaluate the safety of the current injectables medication process, from prescription to administration, in the paediatric and neonatal intensive care units. to compare the potential impact of safety measures on the risk. to classify these measures from a pharmacoeconomic point of view. design: assessment by a prospective risk analysis according to the failure modes, effects and criticality analysis (fmeca) method [1] by a multidisciplinary team: one physician, two nurses, three pharmacists. three drugs chosen as models (gentamicin; morphine; dopamine). failure modes (fm) defined during brainstorming and criticality indexes calculated on the basis of their likelihood of occurrence, potential severity for the patients and detectability. impact of ten safety measures on the criticality indexes of the selected three drugs, extrapolation to all drugs injected daily and calculation for each measure of the investment in euros per year to improve the safety by 1 quali (-1 point of criticality) per day. setting: university hospital, fifteen nicu beds and ten picu beds. main outcome measures: mean criticality indexes; gain in qualies per day; cost-efficacy ratios for each safety measure. results: in the current situation, the sum of mean criticality indexes of thirty-one identified fm was 4,540 for the selected three drugs. we gain 1,292 qualies (46,500 by extrapolation to all drugs injected daily) with civas (centralized intravenous additives services), 1,201 (72,060) with a clinical pharmacist, 996 (59,780) with double check by nurses, 984 (59,040) with cpoe (computerized physician order entry), 555 (23,296) with in-line filters, 457 (12, 348) with vial of dilution, 408 (17,122) with horizontal laminar airflow hood, 170 (4,590) with intermediate dilution, 144 (6, 192) with simple additional measures of asepsis and 98 (951) with a drug planer. the best cost-efficacy ratios were obtained by a clinical pharmacist (1 quali = 0.54 euros) or by double check by nurses (1 quali = 0.71 euros) or by civas (1 quali = 0.72 euros). the highest ratio was obtained with cpoe, due to the very high costs investment (1 quali = 22.47 euros). conclusions: the use of a prospective risk analysis allowed us to quantitatively evaluate the relationship between the medication process of injectables and the paediatric patient safety and to build a strategy for continuous quality improvement, by selecting the most appropriate evolutions. based on the results of the pharmacoeconomic analysis, development of clinical pharmacy and civas for some drugs will be discussed with the paediatric department background and objective: studies show that up to 38% of patients starting treatment with antidepressants fill only a single prescription at the pharmacy, apparently not accepting treatment. the aim of this study was to determine characteristics and reasons associated with non-acceptance of ssri treatment. design: retrospective questionnaire study. patients presenting a gp prescription for a newly started ssri treatment to a community pharmacy were selected. 'non-accepters' were defined as those patients filling only a single ssri prescription, and patients who received at least three prescriptions were defined as 'accepters'. setting: 37 community pharmacies in the netherlands. main outcome measures: characteristics evaluated included sociodemographic (e.g. level of education), disease (e.g. reason for use) and treatment (e.g. type of ssri) characteristics. 'non-accepters' were also asked for the reason not filling a second prescription. results: 57 'non-accepters' and 128 'accepters' were included in the analysis. 'non-acceptance' was more common among patients with a low level of education (or 2.6; ci 1. 1-5.9 ) and in patients who reported aspecific symptoms like fatigue, stress and restlessness as the reason for ssri use (or 2.7; ci 1. 4-5.5 ). in addition, there was a trend that 'non-acceptance' was more common among patients over 60 years of age (or 2.5; ci 0. 8-7.9) . of all 'non-accepters', 29.8% (n = 17) did not start ssri use, while 70.2% (n = 40) discontinued ssri use within two weeks. fear of side effects and the actual occurrence of side effects are main reasons for not accepting ssri treatment. in addition, a considerable number of 'non-accepters' indicated that they felt an aversion towards medicine use, were feeling better meanwhile or disagreed the gp's diagnosis. of the 'nonaccepters', 55.0% discontinued treatment without informing the gp. conclusions: acceptance of ssri treatment is a decisive moment in compliance to treatment initiated by gps, and deserves more attention. gps and pharmacists should address issues related to the use of ssris especially in groups who are at risk for non-acceptance. keywords: antidepressants, discontinuation, nonadherence edu-7 pharmaceutical interventions by pharmacists working within surgery and medicine departments julie prince 1 , stephanie diallo 1 , eric grandsire 1 , anne lecoeur 1 , caroline fijalkowski 1 , michelle lebas-certain 1 , franck le mercier 1 1 pharmacy, ambroise pare hospital ap-hp, boulogne-billancourt, france background and objective: since 1995, our pharmacy department set up a nominative daily drug distribution system without computarization. in each pharmaceutical unit localized in clinical departments, the prescriptions are screened daily by a pharmacist, then the drugs are delivered by a technician. our objective was to compare the frequency and content of pharmaceutical interventions in surgery and medicine departments. pharmacy, 2 haematology, 3 nurses' management, cancer centre henri becquerel, rouen, france background and objective: while several studies have evaluated the frequency and the consequences of medication errors, few have explored their causes. in particular, knowledge of nurses regarding treatment of their patients has been scarcely studied. this survey has been carried out to determine how nurses master medications prescribed to the patients they care for, and how often they access drugs database. design: this work is a prospective study carried out from february to april 2007. we have decided to focus on the clinical audit method, following french health authorities recommendations. a questionnaire has been elaborated and submitted to nurses during semistructured interviews. setting: french cancer centre: 9 nurses from an oncology department and 17 from a haematology department. main outcome measures: data collected were: nurses' profile (age, length of service, competencies' self-assessment), knowledge on drugs prescribed to their patients (usage, administration, side-effects, drug interactions…), use of existing tools (i.e. drugs database) and possible tools to be developed by the pharmacy ward to help them in their daily practice. results: twenty out of twenty six nurses (mean age: 27, mean length of service: 4 years) consider their medical knowledge as intermediate level. 54% of pharmaceutical classes are quite well known (95% of the indications are known). only 32% of drugs' inn are given and more than half of the generic drugs' names are not mastered. administration conditions and conservation are known for respectively 98% and 96% of the products. however, side-effects (48%), contraindications (37%) and drug-drug interactions (18%) are not acquired. in their daily routine, nurses face problems mainly related to: drug administration (20%), drug conservation (24%), and dealing with generic drugs and therapeutic equivalence (28%). 46% of nurses refer to a drug database several times a week when only 4% more than once a day. pharmacy ward is considered to give information on drugs on a 'regular' basis. three tools have been identified for their potential to help nurses: summarized data on drugs (card format), drugs administration and conservation tables. conclusions: this study has helped to define nurses' difficulties regarding patients' treatment, and their needs for information on drugs. it is also useful for the pharmacy ward to improve its relationships with clinical wards and feedback on treatments. training sessions will shortly be organised to improve the above results. results: the aim of the vita (vienna transdanubia aging) study is the early detection of alzheimer dementia and the discovery of its risk factors. at basic examination, dementia was diagnosed in 21 out of 606 patients (4%) at an age of 75 years. in 89% of these cases dementia was classified as alzheimer disease. in addition, a clinically relevant depression was diagnosed in 17% of patients at basic examination, but only 32% of them were treated accordingly. the first re-examination after 2.5 years included those patients, who showed no or only mild signs of cognitive disorders at basic examination. 19% of these patients developed dementia within the period of 2.5 years. the first reexamination also revealed a rapid increase of patients with depression (17% vs. 28%). the incidence for the development of dementia was 11% in patients, who have never suffered from depression. however, in patients with the diagnosis depression at basic examination, the risk for dementia was doubled. we aimed to prove whether there is a statistically significant correlation between long-term medication with selected drugs and the development of depression. eleven classes of drugs were investigated, including calcium channel blockers, beta-and alpha-blockers, corticoids, statines, non-steroidal anti-inflammatory drugs, h2-blockers, neuroleptic drugs, benzodiazepines, levodopa and opiates. medication was documented from those 285 patients pharm world sci (2008) 30:649-740 659 (122 male, 163 female) without dementia and depression at basic examination, and without dementia at first re-examination. at first reexamination 86 of them were depressive (26% male, 33% female), and 199 had no depression (control group). for each class of drug, patients were divided into 6 groups according to gender and duration of medication. a statistically significant (p \ 0.05) correlation was found between the treatment with benzodiazepines (c3 months) as well as beta-blockers (c30 months) and the development of depression in both male and female. conclusions: in elderly long-term therapy with benzodiazepines and beta-blockers can aggravate the development of depression. background and objective: pharmacogenomic studies aim to elucidate the genetic bases for interindividual differences and use such genetic information to predict the efficacy, response rate and safety of a selected drug. to date, the prognostic value of fccr polymorphisms as markers to predict treatment outcome in nhl is still being studied. our goal was to determine whether there is any correlation between fccriia polymorphisms and clinical response to rituximab in patients with nhl. design: in the present study we analysed fccriia polymorphisms in the genomic dna isolated from peripheral blood of 64 patients with nhl who have undergone immunotherapy with rituximab. genotype analysis was based on a polymerase chain reaction (pcr) method followed by a restriction fragment length polymorphism (rflp) study. data were analysed using the computer software spss for windows (version 13.0) and treatment outcomes of the patients were compared using chi-square or fisher's exact test. a cut-off p-value of 0.05 was adopted for all the statistical analysis. survival estimates were calculated using the kaplan-meier method. the curves were examined by the log-rank test. setting: unit of molecular oncology of instituto português de oncologia, porto, portugal. main outcome measures: the response to therapeutics with rituximab was evaluated according to physical examination and computed tomography images. responses were scored according to international working group consensus. overall response rate (orr) was considered as complete response (cr), unconfirmed complete response (cru) and partial response (pr). overall survival (os) duration was defined as the period of time between 1st treatment with rituximab and either death or the last clinical evaluation of the patient. event-free survival (efs) was defined as the time interval between 1st treatment with rituximab and the occurrence of an event (recurrence or death) or the time of the last clinical evaluation of the patient. results: the orr for hh genotype was 100% and for r allele was 87% (p = 0.251). however, our results demonstrate that all patients carrying the hh genotype had complete responses to rituximab therapy. complete response rate for hh genotype was 100% and for r allele was 63% (p = 0.028). when comparing the fccriia genotypes, hh genotype or r allele does not have a significant impact on os at 3-year (p = 0.338) or on efs at 3-year (p = 0.449). conclusions: this study demonstrates that fccriia polymorphism is predictive of complete response to regimens containing rituximab in nhl patients, but is not predictive of overall or event-free survival. based on the current observation, rituximab has in some way an fccriia-dependent mechanism of action which is ameliorated in patients with hh genotype. we hypothesize that hh genotype increases affinity of fccriia receptor not only for naturally occurring igg2, via antibody-dependent cellular cytotoxicity but also ameliorate connection with chimeric igg1 rituximab. keywords: non-hodgkin lymphoma, rituximab, pharmacogenomics pt-47 platinum salts, cancer and renal insufficiency. sub-group analysis of the irma study xavier pourrat 1 , nicolas janus 2 , stéphane oudard 3 , isabelle ray-coquard 4 , jean-philippe spano 5 , jospeh gligorov 6 , jean-françois morere 7 , philippe beuzeboc 8 , gilbert deray 2 , vincent launay-vacher 2 1 pharmacy, hôpital trousseau, tours, 2 nephrology, gh pitié-salpêtrière, 3 medical oncology, hôpital européen georges pompidou, paris, 4 medical oncology, centre léon bérard, lyon, 5 medical oncology, gh pitié-salpêtrière, 6 medical oncology, hôpital tenon, paris, 7 medical oncology, hôpital avicenne, bobigny, 8 medical oncology, institut curie, paris, france background and objective: the irma study reported the high prevalence of renal insufficiency (ri) in 4684 solid tumour patients: mean age 58.1, mean weight 67.8 kg (84.2% between 50 and 90 kg), glomerular filtration rate (gfr) \ 90 ml/min for 50-60% [1] . we present the results for irma patients who received a platinum salt (ps) as part of their chemotherapy. design: data were retrospectively collected for in and outpatients with cancer presenting over two periods in 2004 (february 1st-15th and october 1st-15th). setting: 15 anticancer centers in france. main outcome measures: subgroup analysis of irma patients who received ps. data collected: sex, age, weight, serum creatinine (scr), type of tumor and anticancer drugs. the prevalence of scr [ 110 lmol/l was assessed. gfr was estimated with cockcroft-gault (cg) [2] and amdrd [3] formulae. chi-square test was used to compare the prevalence of ri between patients who received ps and patients who did not. results: 990 patients were included: mean age 60.2 and weight 66 kg, 525 men. the prevalence of scr [ 110 lmol/l was 9.5%. gfr \ 90 ml/min was 63.1% with cg and 55% with amdrd. the prevalence of ri was significantly higher in patients who received ps as compared to patients who did not receive ps (p = 0.0005). there were 993 prescriptions: 38.1% carboplatin, 31.5% cisplatin and 30.4% oxaliplatin. 69.6% of patients received carboplatin or cisplatin, the two drugs of this class needing dosage adjustment and being nephrotoxic. conclusions: ri is highly frequent in cancer patients receiving ps. appropriate evaluation of renal function necessitates cg or amdrd calculation. in addition, two third of those patients with pre-existing ri are at risk for iatrogenic acute renal failure still receive nephrotoxic ps. consequently, appropriate methods for the nephrotoxicity prevention of those drugs should be used as recommended for cisplatin by the escp special interest group on cancer care [4] . [1] prevalence of renal insufficiency in cancer patients and implications for anticancer drugs management: the irma study. cancer 2007 (in press). [2] prediction of creatinine clearance from serum creatinine. nephron, 1976 ; 16: 31-41. [3] a simplified equation to predict glomerular filtration rate from serum creatinine [abstract] . j am soc nephrol 2000; 11: 828-828. 1 pharmacy, hospital la candelaria, tenerife, spain background and objective: to describe an quantify the pharmaceutical interventions in patients on total parenteral nutrition (tpn)and the drug related problems (drp)in patients on this type of nutritional support. to know the acceptance degree of the interventions and its relevance on patients' care and quality of life. design: prospective longitudinal study for four months (from january 2007 to april 2007). all patients on tpn were included. the registered data were: patients number, hospital departments, type of interventions and modifications on the tpn. setting: the pharmaceutical interventions were classified in: indication, effectiveness, safety and adherence according to the cipolle and cols methodology in order to identify de drp related to the tpn and/ or to the drugs. main outcome measures: all interventions were recorded both in the patient medical record and in a excel database in the pharmacy department. results: 135 patients were evaluated and 2190 interventions were recorded. that means an average of 16 interventions per patient and a duration average per nutrition of 7.5 ± 5.6 days. the drp were: indication 11.6%, safety 12.9%, effectiveness 58% and adherence 17.5%, being the drp5 the most representative. the drp were listed in: nutritional assessment (14.2%), monitoring (70.9%) and individualized tpn (14.9%). a total of 89 patients (65.9%) was favoured through some type of pharmaceutical intervention, being the most implicated hospital departments the neonatology and digestive surgery departments. a 90% of the interventions were focus on monitoring and optimization of nutritional support and 10% on drugs (diuretics, insulin, digoxine, enalaprile, and propofol). the acceptance degree of the interventions was 95%. conclusions: the individual monitoring of the patients with tpn represents an improvement of their clinical outcome and a lower incidence of drp. therefore, with this method we contribute to a lower hospital stay and it also may prevent the appearance of new adverse effects. main outcome measures: the number of interventions carried out and accepted, items concerned: regulation problems, nitrogenous and calorie intake, electrolytic intake, prescription omissions and eventually other fields. results: altogether, 569 parenteral nutrition prescriptions were analyzed for one month in five pediatric units. the pharmaceutical analysis, which consumes 2 hours a day for 2 pharmacists, generated 58 interventions for prescribers: 67% concerned electrolytic intake, more than half of which concerned potassium and sodium, the main dangerous electrolytes; 19% were prescriptions omissions; 7% about nitrogenous and calorie intake; 7% about other fields (weight error, incompatibility of lipids with divalent ions). of these 58 interventions, which concern exactly 54 prescriptions, 30 were accepted by prescribers, that is 52%, leading to prescription modifications. conclusions: putting in place a systematic pharmaceutical analysis of parenteral nutrition prescriptions has ensured the detection and the correction of prescription errors. these errors concern mainly non adjustment of electrolytes to the biological results of the child. pharmaceutical interventions are important for safety of the patient and represent a privileged way to communicate with prescribers and their acceptance is, on the whole, satisfactory. background and objective: the number of elderly intensively increases and the fact that they consume a great amount of pom and otc drugs makes them a significant group of patients that need pharmacy care. unfortunately pharmacists often find their interaction with elderly clients very difficult and determined by many factors such as the sensory and physical limitations that accompany the aging process. to test the readiness of the elderly patients to communicate with the pharmacist, to assess the barriers that hinder the proper communication process and to provide a communication skills training in order to be improved the communication process. design: an experimental design involving two stages -assessment and education. setting: setting: the elderly patient center (hospice) and 15 private community pharmacies both situated in the city of sofia, bulgaria. participants: 110 patients aged 65+ (80 community pharmacy patients and 30 patients from the elderly center). main outcome measures: an initial interview with the patients and questionnaire with the selected pharmacists to assess the level of communication and to clarify the hinders. communication skills training leaflets provided to the pharmacists. test of the newly received skills. final interview with the patients to be assessed the level of their satisfaction. results: the trained pharmacists that have passed the education process are more facilitated in providing pharmaceutical care that leads to the elderly patients' satisfaction (about 70%). additionally, the elderly patients obtained significantly more information from their pharmacists that leads to better care and avoidance of nearly half of the drug-related problems (drps) for this age. conclusions: pharmacist communication skills' training appears to be an effective means of enhancing the communication process in the pharmacy. background and objective: as the hospital has no pharmacists working in the multidisciplinary teams on the wards, we wanted to introduce and evaluate a clinical pharmacy service. design: a 14 month prospective pilot study with three aims: 1. identify drug related problems (drps) (data collecting period of eight months). 2. design drug related information sheets and teach nurses. 3. evaluate the service by questionnaire. suggest cost-effective measures. setting: paediatric ward with 16 beds, national university hospital. main outcome measures: the acceptance rate of the drps identified and suggested by the pharmacist, the number of drug information sheets introduced and lectures given to nurses. physicians' and nurses' views on the service. results: the pharmacist identified 162 drps in 121 (32%) of the 384 charts that was screened. immediate action was taken in 94 (59%) of the 162 cases, the physician considered 42 (26%) of the suggestion rational but no immediate action was taken due to various reasons, and 26 (16%) of the suggestions were not approved by the physician. the most commented drp was ''dosage'' (33%), which included too low or too high dose, non-optimal administration time or inappropriate formulation. the pharmacist designed six drug information sheets and gave five lectures. cost-effective measures were suggested for drug handling and specific drugs. seven out of eight physicians and all nurses (n = 15) considered the pharmacist a natural participant in the multidisciplinary team. conclusions: quality assurance of drug treatment may be performed by a clinical pharmacist, not only by the traditional way of identifying drps, but also by designing drug information sheets and teaching. the clinical pharmacist is also capable of suggesting cost-effective measures. physicians and nurses considered the clinical pharmacist a natural participant in the multidisciplinary team. as a result of this project, the clinical service will continue and also be introduced to one of the other paediatric wards. keywords: drp, paediatrics, quality assurance pc-44 iatrogeny and drug dispensations for outpatients: implication of a hospital pharmacy emilie degris 1 , isabelle peyranne 1 , anne laure sarda 1 , nadine malric 1 , brigitte bellon 1 1 pharmacie, hôpital paule de viguier, chu toulouse, toulouse cedex 9, france background and objective: in france, some drugs are not available in community and outpatients have to go to hospital to obtain their treatment. our objective was to assess the role of the pharmacist in prevention of iatrogeny when dispensing drugs, in particular medication errors at high risk for the patient. design: a 6 month retrospective study, from december 2006 to may 2007 setting: pharmacy of paule de viguier, teaching hospital of toulouse, france main outcome measures: each error encountered was recorded and analysed. first, we determined the number of errors avoided and the number of errors effective (divided into 2 groups: non avoided and created by pharmacy). then, we quantified the frequency (1 = once, 2 = from twice to ten times, 3 = more than ten times) and the severity (0 = no risk, 1 = weak, 2 = moderate, 3 = high) of each error. the multiplication of those two parameters gave us the level of the risk of error for the patient (0 = no risk, 1 to 3 = weak risk, 4 and 6 = moderate risk, 9 = high risk). finally, for each type of error we noted the actors. results: we made 6543 dispensations during the period of the study. we recorded 125 errors (1.9%): 92 (14 for 1000 dispensations) were avoided by the evaluation of the pharmacist, 8 were not avoided (1 for 1000 dispensations) and 25 were created (4 for 1000 dispensations). among the avoided errors, 36 (5.5 for 1000) were at high risk (9), 26 (4 for 1000) at moderate risk (6 or 4), 30 (4.5 for 1000) at weak risk (2 or 3). the actor of 87 of them was the prescriber (mainly lack of information on the prescription like no dosage). among the 33 effective errors, 24 (3.7 for 1000) were at moderate risk (6 or 4), 5 (0.7 for 1000) at weak risk (1 to 3), 4 (0.6 for 1000) had no risk (0). the actor of 31 of them was the pharmacy. conclusions: the errors for the activity ''retrocession'' are not numerous. the majority of them are stopped by the evaluation of the pharmacist, in particular those at high risk for the patient. we implemented curative and preventive measures to decrease the number of errors made both by prescribers and pharmacy. background and objective: despite improved treatments and guidelines, asthma control remains suboptimal. in a recent observational study, we described the asthma control test ò (act) as an easy tool to measure asthma control of patients presenting at community pharmacies (1) . the present randomised controlled trial was set up to study the hypothesis that a pharmacist intervention, focused on optimal use of asthma medication and tailor-made to the patient's current asthma control, would result in improved asthma control in adult patients. design: a 6-month randomised controlled trial in 201 asthma patients: 94 patients in the control group (c) and 107 patients in the intervention group (i). patients in the control group received usual care. patients in the intervention group received a protocol defined pharmacist intervention, mainly focusing on inhaler technique and adherence to controller medication. setting: 66 randomly selected community pharmacies in flanders (the dutch speaking part of belgium). main outcome measures: primary outcome was the level of asthma control, as measured by the asthma control test ò . secondary outcomes included rescue medication use, night-time awakenings due to asthma, patients' peak expiratory flow, inhalation technique, adherence to controller medication, quality of life, knowledge on asthma and smoking behaviour. results: mean act scores did not change from baseline for both study groups (act at baseline for c: 19.3, i: 19.7 -act at 6 months for c: 19.7, i: 20.3). however, a predefined subgroup analysis of patients having insufficiently controlled asthma at baseline showed that the intervention significantly increased act scores during the course of the study compared with usual care (p = 0.019). the intervention also significantly reduced reliever medication use (p = 0.012) and the frequency of night-time awakenings due to asthma (p = 0.044). inhalation technique (p = 0.004) and adherence to controller medication (p = 0.016) were significantly better in the intervention group. these findings suggest that the more effective use of asthma medication is responsible for the improvements in symptom control. there were no differences between control and intervention group in peak expiratory flow, quality of life, knowledge on asthma and smoking behaviour. conclusions: a pharmacist intervention can significantly improve outcomes for asthma patients (clinicaltrials.gov number nct00263159). background and objective: patients admitted to surgery departments receive multiple drugs before, during and after surgical procedures. drug-related problems (drp) are the most common cause of injury to hospitalized patients. in pharmacotherapeutic follow-up (ptf) a pharmacist is responsible for drug-related patient needs by detecting, preventing and solving drug-related problems (drp) aiming at specific results to improve patient quality of life. drp are pharmacotherapy negative outcomes leading to failed therapeutic goals or undesirable events. when a drp appears, it affects not only older hip fracture patient health, but also the effectiveness of hospital health care. the general objective of this study was to demonstrate that ptf improves the hip fracture assistential process quality, comparing some quality indicators of this process between patients in study group (sg) and control group (cg). design: cuasi-experimental study with control group. ptf was the intervention. setting: two traumatology wards in a large teaching hospital, ''hospital san cecilio'', granada, spain. the period of study was from january to july 2005 (sg) and the same period but in 2004 (cg). main outcome measures: incidence and types of drp; drp solved in sg; differences in lengh of stay, six-months mortality and threemonths readmissions between study and control groups. results: the incidence of drp was 74% in sg (n = 112) and 53.8% in cg (n = 119). in sg, more than 80% of drp were resolved. in sg and cg the 53% and 41% of drp were related to medication need, 26% and 50% to effectiveness, and 21% and 9% to safety, respectively. mean length of stay was 15 days in sg and 13.7 in cg. in general, patients with drp had a significative longer length of stay (15.6 d) than those without drp (12 6 d); but in sg, patients in which drp were solved had the same length of stay than those without drp. sixmonths mortality was 7.6% in sg and 11.7% in cg, and readmissions was 1.9% and 7.7% respectively. 13.3% (n = 4) of patients reported an aspirin allergy that triggers their asthma attacks. 26.6% (n = 8) had never used aspirin before and did not know whether they had any sensitivity to aspirin. 6.6% (n = 2) of subjects could correctly describe and distinguish between preventor and releiver drugs. 3.3% (n = 1) confused the terms, while 90.1% (n = 27) had no idea about these terms. 70% (n = 21) of asthmatics had received previous inhaler usage education from a specialist (doctor, nurse or pharmacist). 7 of these 21 patients had ineffective inhalator usage although they had ostensibly received education. the inhaler technique of the remaining 14 who had been previously educated was accepted as successful. 30% (n = 9) of the patients had never received inhaler usage education before a specialist. 2 of these 9 patients demonstrated successful technique but 7 of 9 failed. conclusions: the results of this pilot study indicate that some asthmatics are ignorant of their condition. in addition most of them seem to have no comprehension of the concepts of preventor or reliever therapy. despite prior education about half (n = 14) were unable to demonstrate successful technique. furthermore cigarette smoking may be a detremental factor to the lives of asthmatic patients. this results of this study suggest the potential benefit of an innovative pharmacist led patient education service among asthmatic patients in turkey. background and objective: according to a recent meta-analysis, drug-related morbidity leads to 3.7% of preventable hospital admissions causing enormous expenditures.1 in austria, there are only data on the incidence of adverse drug reactions (adrs) of psychiatric drugs. clinical pharmacy is not widely practised at hospital ward level. with this study, we aim to evaluate and document adrs leading to or occurring during hospital admissions. to improve the co-operation of doctors and pharmacists in an austrian hospital, to enhance doctors 0 sensitivity in detecting drug-related morbidity, to increase patient safety and lower costs by reducing hospital admissions. design: two study nurses especially instructed about typical symptoms of adrs identify and document these cases prospectively in cooperation with doctors on selected internal wards for a period of three months. these cases are evaluated by a clinical pharmacist by means of a computer tool and data-base specialised on detecting causality and severity of adrs. results and outcomes form the basis for structured feedback to doctors. setting: university teaching hospital. main outcome measures: quantity and quality of adrs connected with hospital admission. results: during the first six weeks, 958 patients were screened. sixty three adrs (41 female) were identified (6.6% of admissions). more than 50% of adrs occurred in patients more than 75 years old. reasons: polypharmacy (mean number of drugs on admission 8.5) and reduced renal function (mean creatinine clearance 48.6 ml/min). diuretics, oral anticoagulants, nsaids, digoxin and antibiotics were most frequently associated with drug-related problems. water-electrolyte imbalance, overantigoagulation with or without bleeding, gastrointestinal problems and bradycardia are some of the most common problems. results concerning the severity of adrs will be available in september 2007. conclusions: adrs are frequent in austria. incidences are comparable to numbers given in the literature. mainly older patients are affected. the impact on clinical practice is yet unknown. background and objective: adherence to cardiovascular treatment, particularly in the first year, is low and can result in serious complications. depression is associated with a 3 fold increased risk of nonadherence with medical treatment. therefore, our aim was to investigate whether illness and treatment perceptions were associated to depressive symptoms in patients starting treatment for cardiovascular diseases. design: cross-sectional study with mailed questionnaire. setting: patients, who were dispensed at least a first prescription for a cardiovascular disease (anti-thrombotics excluded), were selected from 5 pharmacies in the netherlands. main outcome measures: the questionnaire comprised the illness perception questionnaire-brief (ipq-b), beliefs about medicines questionnaire (bmq), the medication adherence report scale (mars) and the centre for epidemiological studies depression scale (ces-d). descriptive statistics and associations between depressive symptoms and the other study variables were assessed by bivariate correlations. results: sixty two (37.1%) of 167 eligible patients returned our questionnaire. the mean age was 62.9 yr ± 11.9 (range 40-90) and 51.6% was female. patients reported to have hypertension (51.6%), cardiac arrhythmia (21.0%) and hypercholestereamia (38.7%). the mean score on ces-d was 8.15 ± 6.7 and median self-reported adherence (mars) was 25. reports of depressive symptoms increased with emotional response (ipq-b emotional response, r = 0.51), the perceived consequences (ipq-b consequences, r = 0.38) and increased experience of symptoms (ipq-b identity, r = 0.49) attributed to their cardiovascular disease. depressive symptoms correlated with concerns about medication (bmq, r = 0.39), but not with self-reported adherence. adherence was relatively high, as 65.6% of the sample had the maximum mars score of 25. conclusions: in patients who started cardiovascular treatment, perceptions about cardiovascular disease and concerns about medication are associated with report of depressive symptoms. depressive symptoms did not correlate with self-reported adherence. the majority of patients reported excellent medication taking behaviour, which might reflect their awareness of the importance of adherence or reluctance to report deviant behaviour rather than their actual behaviour. further research is needed to clarify this finding. results: fifteen nurses completed the questionnaire. 93% of the nurses were aware of the purpose of controlled release formulations. pharmaceutical codes added to brand names such as uno, zok, la and ocas related to prolonged activity were not recognised in 47% of cases. in contrast, retard and cr were linked to slow release by 67% of the responders. the purpose of enteric coated (ec) drugs was only known by 26%. in general, the nursing staff did not pay a lot of attention towards the prevention of drug-nutrient and/or drug-tube interactions. the recommended time interval between administration of enteral feeding and drugs was not respected. 84% of the responders would crush drugs together (in the same mortar) when multiple drugs are prescribed. based on the results of the survey, an intervention plan has been developed. this consisted of information rounds, a poster related to the topic and implementation of the use of a website dedicated to crushing medication developed by the flemish association of hospital pharmacists. background and objective: the detection and solution of drugrelated problems is an important activity within pharmaceutical care. this study focused on drug-related problems (drps) detected during dispensing of new prescriptions in community pharmacies and aimed to explore frequency as well as nature and the pharmacist's management of them. design: during their pharmacy internships fifth-year pharmacy students collected consecutively 5 hospital discharge and 5 primary care prescriptions. after training, they documented drps and interventions on an adapted pcne classification form. inclusion criteria were: age over 18, at least one new medication, at least 2 prescribed drugs. setting: 64 swiss community pharmacies affording the opportunity of internships for fifth year pharmacy students. main outcome measures: prevalence, nature and management of drps in community pharmacies assessed with an adapted pcne classification form. results: the patient's median age was 56 years (iqr 32) and they received a median of 3 (iqr 2; range 2-19) different drugs. prescriptions of 618 patients (285 (43.9%) discharged from hospital) were analysed. in 129 (20.9%) of all prescriptions at least one drp was detected. the most frequent drps were potential interactions (28.7%), wrong/improper application or time of drug intake (17.1%), inappropriate drug (8.5%) or inappropriate drug form for indication (5.4%), no clear indication for drug use (7.8%) and too high or too low dosage (4.7%). these drps led to a total of 409 interventions (multiple answers): patient counselling (194); request of information from prescriber (56); change of drug (15; there from 1 after consultation with physician), drug form (10), dosage (15), instruction for application (17) or deliverable drug amount (16); drug stopped (7); start with new drug (2); referral to a physician (3); others (74). out of all interventions 78.7% could be managed by the pharmacist without any contact to the prescriber. there were no differences between hospital discharge and primary care prescriptions. conclusions: in the delivery process of new prescribed drugs drps are frequently observed prompting many interventions. most drps can be managed by the pharmacy. further studies are needed to analyse relevance of the problems and impact of according interventions. the main selection criteria were clinical relevancy (patient centred initiatives) reproducibility of clinical and economical outcome, outcome indicators and multidisciplinary approach. an approval by the hospital board and medical council must underline the willingness to integrate the clinical pharmacy in the patient care team. results: 80 projects has submitted (on a total of 112 hospitals). a total number of 28 hospitals were selected to receive funding for clinical pharmacy activities. 13 projects were quoted for a full time equivalent and 15 projects for a half time clinical pharmacist. the projects described different fields or a combination of different aspects of pharmaceutical care like e.g. the transfer of information on medication use on admission and discharge conclusions: the funding of the belgian health authorities triggered a very high response rate, which proves the increasing attitude from the belgian hospitals to the positive impact of clinical pharmacy. the funding was complementary to other national projects to improve overall safety of medical treatment. also, many hospital administrators took the opportunity to enhance more economical and rational use of drugs. financial support by the belgian authorities of clinical pharmacy and the results of the projects could trigger a further integration of the hospital pharmacies into a patient care team. background and objective: the task of assisting patients in selfmedication practice is an important component of pharmaceutical care in spain. in order to provide appropriate self-medication counselling pharmacist should be able to distinguish between a minor ailment and one that it is not, and should, consequently, refer patients as necessary to gps. nevertheless, there are no criteria for referral to gp in spain. the objectives were:(1)to identify the most relevant minor ailments, agreeing on the specific criteria for referral to the gp.(2)to select the non-prescription drugs, with evidence of safety and effectiveness, for the treatment of the identified minor ailments design: qualitative study with an expert panel which was made up of 2 primary care physician from semfyc and six community pharmacists (two members of sefac and four members of giaf-ugr). the expert panel held two meetings, of five hours each. it was established which minor ailments were considered most relevant within the framework of community pharmacy in spain. subsequently, the expert panel, reach an agreement on the general content that should be included in the protocols for the management of each selected minor ailment. finally, a working team composed of 4 gps and three community pharmacists prepared the protocols, which were compiled into a guide for self-medication counselling. setting: university of granada, spain during 2007. main outcome measures: identified minor ailments, content of the protocols for each minor ailment, non prescription drugs selected. results: it was selected 27 minor ailments, allocated as follows; respiratory (rhinitis, cough, cold, flu), pain (period pains, sore throat, headache, backache, toothache), gastrointestinal (heartburn, diarrhea, constipation, vomiting, hemorrhoids), skin and mucous membrane (aphthae, acne vulgaris, cutaneous wounds, burns, stings, urticaria, herpes labialis, eczema lesions) and others (vaginitis, varicose veins, fever, conjunctivitis, insomnia). the following sections were specified in each protocol: banal and serious reasons or conditions that can lead to the symptom (including drugs); referral criteria according to the duration of the symptom and associated signs; drug treatment and non-pharmacologic therapies. it was selected a total of 31 different non prescription drugs. conclusions: a total of 27 minor ailments were identified as the most frequently demanded in community pharmacies in spain. referral criteria were based mainly in the duration of the symptom and other associated symptoms that are indicative of illness. for the treatment of these minor ailments, 31 different non prescription drugs were selected. keywords: non-prescription drugs, minor ailment, community pharmacy services mareike kunkel 1 , matthias ganso 1 , irene kraemer 1 1 pharmacy, johannes-gutenberg-university hospital, mainz, germany background and objective: in 2004 clinical pharmacy service was implemented in three surgical clinics (inclusive icu). drug related problems (drp) were identified by medication review and discussed with the physicians. from january to june 2005 all pharmaceutical interventions (pi) from pharmacists (2 fte) were recorded (paper based) and classified according to drp (with the pi-doc ò -system, which was modified to comply the requirements for hospital use1), intervention type, outcome and clinical relevance. the pis were documented and evaluated with an access ò database. design: retrospective study of pis in surgical patients, identification of drp by medication review. setting: departments of neurosurgery, accident surgery and general/abdominal surgery (70, 73 and 71 beds, respectively), university hospital. main outcome measures: drp, intervention type, outcome, clinical relevance, drugs and admission diagnoses being at risk for drps. results: within six month 3679 patients were admitted. drps were identified in 17% (n = 610) of the patients. patients with drps were older (mean = 67 y sd ± 14 vs. 56 y sd ± 19) and had an increased length of stay (mean = 24 d sd ± 18 vs. 10 d sd ± 9). 970 pis were made. the acceptance by the physicians was 95.8%. 175 pis were classified to the outcome subcategory patient safety and clinical relevance was estimated as major (n = 6) or moderate (n = 169) by pharmacists. further data are based on these 175 pis. the most often addressed drps categories were overdose (34%), no or insufficient drug monitoring, when necessary (10%), untreated indication (7%) and increased risk of an adverse drug reaction (6%). the type of recommended intervention varied: change dose/time of application (34%), stop drug (26%) and conduct drug monitoring (15%). drps related with the outcome patient safety and at least moderate clinical relevance were caused by 185 drugs (100%). the most affected drugs were vancomycin (13%), diclofenac (8%), potassium (4%), acetaminophen (3%), digitoxin (3%), phenytoin (3%) and theophylline (3%). the incidence of the most frequently admission diagnoses of patients with relevant drp differed from the incidence of diagnoses of all admitted patients (incidence icd10 (cost-)effectiveness has started to emerge (1) . a literature review was carried out that a) summarized the findings of pharmaco-economic studies; b) evaluated the methodology employed by studies; and c) suggested how future research has to be designed to meet the requirements of a pharmaco-economic analysis. design: studies to be included are identified by searching electronic databases. due to limited relevance of older studies, the scope is limited to studies published between 1996 and 2006. mainly three techniques can be used to conduct an economic evaluation: costeffectiveness analysis, cost-utility analysis and cost-benefit analysis. (2) all studies are reviewed regarding results and methodological quality. nineteen out of 312 studies met our eligible criteria. setting: clinical pharmacy services provided in a hospital setting. main outcome measures: results were analyzed in terms of number of preventable adverse drug events (ade), length of stay (los) and financial savings. methodological quality was assessed with respect to perspective, scope and measurement of costs and consequences, sources of data on costs and consequences, and application of an incremental analysis. results: a) nearly all studies conclude a financial benefit based on direct cost saving and estimated cost avoidance as a measure of prevented ade or shortened los. b) methodologically there are a number of shortcomings: e.g. not including the wage of the personnel, lack of control groups, use of expert panels to estimate savings and costs, possible selection bias, no valorization of health effects. c) a methodology for conducting a prospective economic evaluation of an observational study is proposed. conclusions: it is not obvious to calculate the net savings of a clinical pharmacy program or to compare different programs because there are no common guidelines for this type of assessment. the ideal protocol is hard to achieve, so best practice will be more realistic. addition of direct cost saving, labor cost and economic value of prevented ade and shorter los results in a lucrative service. these savings are higher for specific inverventions (like preventing ade, switch therapy) or disciplines (e.g. intensive care unit versus geriatrics background and objective: the contribution of pharmacists to the delivery of public health in scotland is recognised in national pol-icy1,2. the new community pharmacy contract with its emphasis on public health will provide a new framework in which the contribution of community pharmacy to improving health in scotland can be delivered. the objective was to define the core public health competencies applicable to community pharmacy practise, using the 'skills for health public health practice competency framework'3. design: a web based delphi methodology4 was used to achieve consensus on which competencies, from the 'skills for health public health practice competency framework', should be met or aspired to by practising community pharmacists using a multidisciplinary group of expert stakeholders. two rounds took place. setting: primary and secondary healthcare and academia. main outcome measures: panel members rated their extent of agreement/disagreement that each community pharmacist should achieve or be striving to achieve that particular competency. consensus was defined as c90% rating a competency as strongly agree/ agree. results: ten organisations (83% of those invited) and 30 organisation members (88% of those invited) agreed to participate. responses were received from 25 (83%) individuals in round 1 and 22 (73%) in round 2. consensus was achieved for 25/68 (37%) competencies in round 1 and a further 8/68 (12%) in round 2. competencies achieving consensus predominantly focused on health improvement activities at individual and local community levels and ethical management of self, rather than those relating to surveillance and assessment, strategic leadership or research and development. conclusions: this research has identified that many of the competencies in the 'skills for health' document can be applied to community pharmacy. research has since been carried out, using focus group and questionnaire methodology, to investigate the views of practising community pharmacists. background and objective: in spain, off-label drug utilization (nonapproved indications, patient population, doses, administration route, association), must be derived to compassionate use, which requires a prior national health authorities (nha) approval and a monitoring plan and follow up information provided to them. request to nha includes circumstances of case and patient protection measures, including: physician assessment, informed consent and institutional clearance. the objective of this study is to analyse the strength of recommendation, strength of evidence and clinical efficacy of drugs prescribed outside the terms of product licence (off-label) in paediatric patients of our hospital. design: literature review to evaluate the evidence level: micromedex healthcare series, cochrane library, pub-med, embase, expert opinion or consensus. sample: 100% off-label drugs used in at least 2 paediatric patients (prior spanish nha treatment approval required for every patient). 10 years, retrospective observational study (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) . setting: paediatric hospital (300 beds) and pharmacy department (1 pharmacist) in a large general teaching hospital (1450 beds, 15 pharmacists). main outcome measures: categorisation of evidence-based medicine according to thomson ratings of recommendation (class i-iii), evidence (category a-c) and efficacy (class i-iii). results: 191 paediatric patients (3% total patients: adults and paediatrics) used 85 off-label drugs (27% total drugs: adults and paediatrics). out of this 85 off-label drugs, 48% (41/85) only approved for adults, 35% (30/85) outside of license in terms of indication for adults and paediatric patients and 17% (14/85) both causes. 26 off-label drugs for 29 indications were used in at least 2 paediatric patients: 17% anti-infective agents, 14% haematopoietic growth factors, 14% cytokines, 10% hormone therapy, 7% antiarrhythmics, 38% other 9 therapeutic groups. the categorisation according to evidence-based medicine was: a) strength of recommendation class: 3% i, 24% iia; 52% iib, 7% iii and 14% indeterminant; b) strength of evidence category: 7% a, 55% b, 28% c and 10% no evidence; c) clinical efficacy class: 2% i, 65% iia, 21% iib and 7% indeterminant. conclusions: a higher proportion of off-label prescriptions is observed among paediatric patients, most of them related to nonapproved indications in this population. there is a broad range of therapeutic groups involved. the evidence of most off-label therapies are based on meta-analyses of randomized controlled trials with conflicting conclusions, small numbers of patients or significant methodological flaws or nonrandomized studies and, although the weight of evidence favors efficacy of the treatment for a specific indication, the therapy may be useful and indicated in some, but not most, cases. keywords: medicine-based evidence, off-label, paediatrics background and objective: there is an increasing demand towards the involvement of the community pharmacists in health promotion. it has been reported that community pharmacists have a successful role in providing services, which help to improve and promote health with regard to smoking cessation, coronary heart disease, skin cancer prevention, drug misuse, sexual health, immunization, mental health, diabetes, nutrition and physical activity [1] . the aims of this study were to describe the current practice of community pharmacists with regard to their provision of health promotion activities, identify their willingness to participate in health promotion and identify the barriers that may limit their participation. design: a descriptive cross sectional study, which included 186 community pharmacies that selected via stratified and systematic random sampling. data were collected via face-to-face structured interview of the respondents using a pre-tested questionnaire. setting: community pharmacies in khartoum state. main outcome measures: the extent of the pharmacists' involvement in counselling patients about health promotion topics, their preparation to counsel patients in health promotion topics, and their success in changing the patients' health behaviour. results: the response rate was 88.2%. seventy five (45.7%) of the study participants were strongly involved in counselling patients on health promotion related to medications, but less involved in counseling them on the other personal health behaviours such as tobacco use (14.0%), alcohol use (9.1%) and exercise habits (7.9%). seventy two (43.9%) of the respondents perceived themselves as very prepared to counsel patients on taking drugs and less very prepared to counsel them on other personal health behaviours. fifty two (31.7%) claimed a high level of success in helping patients to change their behaviour with regard to medications, but not in relation to other personal health behaviours. ninety eight percent of respondents indicated their willingness to participate in continuing education programs to gain more knowledge and skills about health education and promotion. the main barriers facing the community pharmacists' participation in health promotion as perceived by respondents were lack of information and/or training (75.6%) and lack of pharmacists' time (27.9%). conclusions: community pharmacists reported to achieve considerable success in helping patients to change their behaviours in relation to medications, but were less successful of their ability to change personal health behaviours. the majority of the respondents have the interest and willingness to be a prime source of advice and support on health promotion. results: during the first study period, 502 inpatients were exposed to 567 major or moderate pddis. 419 (74%) of these pddis were judged clinically relevant by the pharmacist. 349 recommendations including pddi information, and 70 simply information leaflets were handed out to the physicians. 80% (278 of 349) of the recommendations were accepted. at hospital discharge, in 78% (47 of 60 reviewed instances, which were accepted) the drug changes due to the recommendations were implemented. during the second study period, 792 patients at hospital discharge were exposed to 392 major and moderate pddis. 258 (66%) pddis were assessed as clinically relevant by the pharmacist. 247 recommendations including pddi information, and 11 simply information leaflets were sent to the physicians. 73% (180 of 247) of the recommendations were accepted. one year after hospital discharge, 11 of 13 drug changes due to recommendations were still existent. overall, in 50% and 46%, respectively, of all major and moderate pddis detected by pharmavista, clinical management was adapted accordingly. conclusions: the management of clinically relevant pddis can be improved by physicians' advice of clinical pharmacists. changes in medication due to pddis were found to persist up to one year after hospital discharge. background and objective: current treatment options for metastatic renal cell carcinoma (mrcc) are limited and there is a need to identify novel and effective therapies. sunitinib is an oral multitargeted tyrosine kinasa inhibitor, which has shown activity in cytokinerefractory metastatic rcc patients. this agent inhibits vascular endothelial grown factor receptor and platelet derived growth factor receptor. the purpose of this study is to analyse the efficacy and safety profile of this agent in patients with mrcc. design: retrospective assessment in seven patients treated with sunitinib as second-line treatment in mrcc. data were obtained from clinical histories and informatic records from the oncology pharmacy department. setting: oncology and pharmacy department. la paz university hospital. madrid. spain. main outcome measures: assessment of clinical response and adverse events. results: seven patients were evaluated (4 men, 3 women), median age was 57 (41-77). six of them presented bone, lung, brain or liver metastases, all patients were treated with vinblastine and ifn-alpha as first-line therapy. patients received sunitinib at a starting dose of 50 mg per day in repeated 6-week cycles for 4 consecutive weeks followed by 2 weeks off treatment. they started therapy with sunitinib because of progressive disease in 3 patients and adverse events in 4 patients on previous therapy. sunitinib was discontinued in four of them, causes were: adverse events (1 patient), volunteered dropout (1 patient) and progressive disease (2 patients). the median progression-free survival was 6.2 months. the median number cycles received was six and 3 of the 7 patients are still in treatment at the time of data analysis. dosage was reduced 25 mg daily because of unacceptable toxicity: hand-foot syndrome(1 patient) and hypothyroidism (1 patient). the most common adverse events experienced were: asthenia (6 patients), diarrhea (3 patients), damaged nails(2 patients), insomnia (2 patients), dermatitis (3 patients)and dehydration (2 patients). conclusions: in our experience, sunitinib has demonstrated an acceptable efficacy and safety profile as a single agent in second-line therapy for patients with mrcc. (ii) validated questionnaire to guide discussion; (iii) fostering group interaction to generate data; (iv) post-interview analysis of verbatim transcripts with specialized software (qsr nvivo 1.2 for windows ò ), based on the grounded theory approach (classification of emerging themes). setting: 3 groups: prescribing physicians (7), nurses (10) , and laboratory technicians (6) , all involved in antibiotic tdm as performed in orthopaedic surgery, general surgery, neurosurgery, vascular surgery, haematology, and pulmonary wards in a 400 beds teaching hospital. main outcome measures: (i) issues causing poor antibiotic overall tdm performance, (ii) approaches for optimizing tdm performance supported by group consensus results: key identified issues: (i) nursing work overload; (ii) insufficient education to pharmacokinetics and lack of specific training; (iii) insufficient information communication and lack of coordination and involvement of all stakeholders; (iv) conflicting guidelines; (v) lack of perception of positive benefit/risk ratio. approaches for optimization (consensus): (i) continuous education of all stakeholders; (ii) daily multidisciplinary collaboration with infectious disease physicians and clinical pharmacists; (iii) simplification and uniformization of guidelines and procedures; (iv) implementation of a simpler administration scheme (v) increased staffing. conclusions: correct performance of tdm and its implementation in routine clinical care needs to be critically assessed and appears to be mainly dependent on non laboratory-related parameters. background and objective: new data published at the end of 2006 and the beginings of the 2007, suggest not to exceed a haemoglobin level of 12 g/dl to avoid cardiovascular morbility-mortality in patients with anaemia and chronic kidney disease (ckd) treated with recombinant human erythropoietin (rhuepo). before these evidences the optimal target haemoglobin levels was greater than 12 g/dl. our aim is to evalue if these new published evidences have changed the clinical practice in pre-dialysis ckd patients. design: retrospective observational study. all the pre-dialysis patients who received rhuepo were including. in order to evaluate the possible changes in clinical practice, we measured the levels of haemoglobin prior to the publication of evidences (march-may of 2006: group 1) and after the publication of these evidences (march-may of 2007: group 2). we made a descriptive analysis of independent data. setting: department of hospital pharmacy. main outcome measures: the main outcome measures were: age, sex, mean glomerular filtration rate (gfr), mean haemoglobin level, mean haematocrit and type of rhuepo used. results: we studied 196 patients (95 in group 1 and 101 in group 2). patients age ranging between 23 to 96 years (median = 73 years). the proportion of women was 61.2%. mean gfr for both years located around 25 ml/min and the most frequent stages of renal injury were 4 and 3. the most rhuepo used was darbepoetin alfa (71.4% of patients). mean haemoglobin level for group 1 was 11.25 g/dl (sd = 1.43) and 11.61 g/dl (sd = 1.43) for group 2. mean haematocrit was 34.98% (sd = 4.53) and 35.9% (sd = 4.42) for group 1 and 2, respectively. conclusions: our nephrologist are cautious about of prescribing rhuepo, not only after the publication of the new scientific evidences on this subject, but before this too. it 0 s worth questioning if clinical practice in ours hospital is different from the published evidences. background and objective: tacrolimus (tac)-based immunosuppression is effective in adult renal transplant patients with acute or chronic rejection or cyclosporin (cya)-related toxicity. the conversion from cya to tac resulted in improved cardiovascular risk profile and increased prevalence of post-transplant diabetes mellitus (ptdm)compared with treatment with cya. the aim of this study was to review clinical documents for renal transplant patients and assess patients' outcomes. design: a retrospective review of clinical data. excluded from the study were patients converted to tac less than 3 months posttransplantation. statistical analysis (one sample paired 2-tailed t test) was performed using microsoft office excel 2003. the graft survival was analysed with kaplan-maier survival curve using xl stat software. the study was approved by the northern ethics committee, auckland, new zealand. setting: tertiary care setting. main outcome measures: mean serum creatinine, incidence of ptdm, mean total cholesterol, hdl cholesterol, ldl cholesterol, total/hdl cholesterol ratio, mean blood pressure and antihypertensive scores, graft survival censored for death. results: forty-four patients were converted to tac more than 3 months post-transplantation from 1998 to june 2006. mean serum creatinine (scr) increased in the 3 months prior to conversion from 149 lmol/l (95% ci 143-155) to 167 lmol/l (95% ci 159-174) at 12 months post conversion to tac (p-value = 0.44). thirty-four patients were taking cya for more than 12 months. the mean scr increased from 143 lmol/l (95%ci 138-148) at the 12 months prior to conversion to 172 lmol/l (95%ci 164-180) at 12 months post conversion (p-value 0.04). if scr for seven patients who had an acute rejection episode were excluded, the mean scr did not show any change in slope after conversion and showed a tendency to gradually increase from 148 lmol/l (95%ci 142-153) to 159 lmol/l (95%ci 151-167) 12 months post conversion (p-value 0.32) eleven out of 44 patients were affected by diabetes mellitus. six patients were diabetic pre transplantation and remained diabetic post transplantation and post conversion to tac. two patients developed new onset ptdm post transplantation and two became glucose intolerant. after conversion to tac, glucose intolerance resolved in one patient and one patient (2%) developed new onset ptdm. in 34 patients converted to tac more than 12 months post transplantation, mean total cholesterol was reduced from 5.3 to 4.5 mmol/l (p-value 0.02) and mean ldl cholesterol from 2.9 to 2.5 mmol/l (p-value 0.004). in june 2006, 35/44 patients (79.5%) were taking tac with a mean scr of 158 +-56 lmol/l. four patients (9%) lost their grafts. mean graft survival time was 81.2 months. 5-year graft survival was 80.8%. conclusions: conversion from cya to tac was beneficial with respect to renal function and cardiovascular risk profile. the conversion had no added benefit on renal function in patients with stable renal function taking cya more than 12 months post transplantation. the reported incidence of ptdm was found to be low (2%). background and objective: most of the cancer patients suffer from severe pain especially during the terminal phase of the disease. it is essential to monitor these patients to achieve adequate and successive pain management, not just because of the importance of the effects, side effects and overdose problems; but also to improve quality of life. the aim of the study was to evaluate oncology pharmacist interventions on pain management. design: numeric pain scales was conducted prospectively among the 58 cancer patient who were over 18 years old and were selected randomly. patients were separated into two groups: 29 of the patients was control group, pharmacist had been effectively included to the rest 29 patient's pain management strategies, which was pharmacist intervention group. all of the patients had been evaluated by numeric pain scales (time 0). the patients who were on pharmacist intervention group were monitored by pharmacist on treatment effectiveness and side effect profile every three days during the study. after one month, numeric scales were repeated (time 1). the interventions that pharmacist done were pain evaluation, suggestion on appropriate pain reliever, dose management, patient education and patient monitoring. our therapy recommendations were made on the basis of the world health organization's analgesic ladder following the results of assessments. setting: oncology outpatient unit of a university hospital main outcome measures: the demographic and diagnostic information of the patients were collected. the results of the evaluations via numeric pain scales were calculated by using arithmetic mean value. results: the mean of pain intensity was significantly decreased in pharmacist intervention group when compared with control group (2.35 ± 1.85 vs. 4.04 ± 2.10, p = 0.003) and between time 0 and time 1 (3.68 ± 1.93 vs. 2.35 ± 1.85, p = 0.011). the mean of pain's effect on daily activity was significantly decreased in pharmacist intervention group when compared with control group (3.34 ± 2.79 vs. 6.00 ± 2.57, p = 0.010) and between time 0 and time 1 (5.23 ± 3.01 vs. 3.34 ± 2.79, p = 0.019). the mean of drug effectiveness was significantly increased in pharmacist intervention group when compared with control group (86.30 ± 16.4 vs. 73.52 ± 26.6, p = 0.040) and between time 0 and time 1 (58.45 ± 36.9 vs. 86.30 ± 16.4, p = 0.001). conclusions: the harmonious working of the pharmacist with the other health care staff working in oncology unit, helped patients to achieve more effective pain management. in this study; pain intensity was decreased, pain interfered less with daily activities was, and the reported effectiveness of drugs was increased in the pharmacist intervention group compared to the control group. all these outcomes show that the clinical pharmacists have an important role in oncology services, especially pain management. background and objective: to investigate and compare the frequency and nature of prescrbing errors requiring contact with the prescriber at community pharmacies in norway, estonia and sweden. design: a protocol, based on a scheme originally presented by rupp (1), revised and developed by kennedy (2) and translated and transformed to the nordic context by haavik (3), was used in all three settings. in norway the protocol was self-completed by the pharmacists; in sweden and estonia observers (trained students) recorded and classified the interventions. setting: norway -9 community pharmacies in southern and western norway; estonia -4 community pharmacies in three cities; sweden -6 community pharmacies in 6 swedish cities and 6 public pharmacies at 6 hospitals in sweden. main outcome measures: prescriptions with errors or ambiguities where the pharmacist decided to contact the prescriber to correct, clarify or complete the information on the prescription. results: the total numbers of dispensed prescriptions were: norway 69,315, estonia 13,221, sweden 49,657 (community pharmacies) and 36,840 (public pharmacies at hospitals). the proportion of handwritten prescriptions and prescriptions where pharmacists contacted the prescriber was higher in estonia than the other countries. administrative problems -reimbursement issues; prescriber data and distribution and licensing issues -were the reason for more than one third (34-43%) of all contacts with the prescribers in all settings. however, the patterns of prescription problems with potential clinical hazards varied -in estonia and norway, errors concerning strength, administration form and number of doses were the most common errors and constituted 31 and 24% of the problems. in sweden, errors concerning the prescribed dosage were the most common reasons. conclusions: the proportion of problem prescriptions requiring a clarifying contact with the prescriber was higher in estonia compared to norway and sweden. the main reason may be that most prescriptions in estonia were handwritten. administrative problems (reimbursement and availability of prescribed products) constituted a similar large portion in the three countries. however, prescription problems with potential clinical consequences for the patients, varied. , presenting with salmonella bacteremia and neurological deterioration due to cerebral toxoplasmosis was admitted to the intensive care unit. he was immediately intubated. to treat toxoplasmosis, cotrimoxazole was started in a dose of 1600 mg smx/ 320 mg tmp qd. 6 days later the patient developed leucopenia (absolute wbc count: 1.57 9 109/l, neutrophils: 1.4 9 109/l). folinic acid 15 mg od was associated to restore white blood cell count. neutrophils further dropped to attain its nadir (0.4 9 109/l) on day 8 of cotrimoxazole therapy. cotrimoxazole was stopped and clindamycin 600 mg td was used instead. neutrophil count restored, normalizing on day 2 after stopping cotrimoxazole. this event was attributed to the administration of cotrimoxazole. the time relation between the administration of cotrimoxazole and the onset of neutropenia as well as the normalisation of neutrophils was clear. other explanations, such as the contribution of concomitant medication (ranitidin, ceftriaxon, ethambutol, isoniazid, rifampicin, aciclovir, amphotericin b, enoxaparin)could be ruled out. the naranjo score, which estimates the probability of adverse drug reactions, is 6. the use of folinic acid as rescue therapy in association with cotrimoxazole is controversial, as it can theoretically antagonise the anti-infective action of cotrimoxazole. therapeutic failure in aids patients, receiving this combination for pneumocystis jiroveci pneumonia, has been reported. nevertheless, we decided to start folinic acid to further prevent nosocomial infections in this severe immunocompromised host. we don't know whether folinic acid contributed to quick recovery of neutrophil count in our patient. further studies are necessary to clarify its role as rescue agent during treatment with folic acid antagonists. conclusions: this case report illustrates that cotrimoxazole, frequently used in opportunistic infections, can be associated with agranulocytosis. this dangerous complication in immunocompromised patients with severe infections must be prevented, although the effectiveness of folinic acid as rescue therapy is still a matter of debate. background and objective: intravenous immunoglobulin (ivig) therapy is increasingly used in inflammatory and autoimmune disorders, because of its therapeutic benefit and its good safety profile. cutaneous adverse events are rare and include prurit, rash, alopecia and eczema. in the literature, about 40 cases of eczematous skin reactions have been reported. most of the cases were treated for a neurological or neuromuscular disease. erythematous eruptions on hands and feet have been notably reported after high-dose infusion. in most of the cases, the eruption was progressively extending to involve the entire body. when ivig were readministered, eruptions were more rapid and more intensive. we report an eczematous skin reaction of the palms after ivig infusion without extensive eruption, in spite of three administrations. design: case report. setting: neurology ward, university hospital, grenoble, france. main outcome measures: a 57-year-old man was treated with ivig (tegeline ò , lfb, france) for an inclusion body myositis. he developed a skin reaction, 8 days after the end of a 5 days ivig infusion (dose of 0.4 g/kg was given daily for 5 consecutive days). the eruption was a non-pruriginous erythematous maculopapulovesicular rash located on the palms. this reaction occurred 8th day after completing the second therapy and did not extend. the lesions regressed progressively with topical application of fatty ointment. three days after the third infusion, the same lesions reappeared, and regressed the same way. results: clinical pharmacist with the help of pharmacovigilance experts and doctor worked collaboratively: because of the chronology of exposure to other treatments, intrinsic imputability and recurrence on reintroduction, we ruled out an adverse drug reaction to any other medication. we decided not to interrupt the infusion. we advised the patient to continue fatty ointment application and to tell the healthcare team if the reaction became more serious. conclusions: dermatologic adverse reactions such as eczematous skin reactions are rare and usually mild. there is no reason to limit the use of ivig in a case like this one, as long as the treatment is effective. however, a narrow clinical and biological follow-up is required. if necessary, this adverse effect can be prevented by antihistamines or even steroids. anticoagulants must be monitored closely by physicians, because this products have a narrow therapeutic index. numerous interactions with herbs are documented, either increasing or decreasing the anticoagulant effect. our main objective is to identify this interactions in our surgery and if they are clinically significant. design: six months observational study; interviewing patients with their inr alterated about herbs that they were taking at that moment. literature review. setting: the anticoagulant oral treatment surgery. main outcome measures: the two oral anticoagulant drugs available in spain are acenocoumarol and warfarin. the international normalized ratio (inr) is the laboratory test used to measure therapeutic efficacy and safety of vitamin-k antagonists. a control test is done every four weeks and if necessary it can be done earlier. results: among 621 patients with inr [ 4, six of them were taking herbs at the same time, and we could relate the increase of the effect of oral anticoagulants to those products. one of this patients who was taking dandelion (tarxacum officinale) had a 4 inr. an other one who was taking chamomille (matricaria capensis) and passion flower (passiflora incarnata) had a 7.8 inr. all of these products have coumarins compounds. two patients who were taking equinacea (equinacea purpurea, equinacea angustifolia) also had their inr test altered: one had a 5.2 inr and the other one 4.9. an other one was taking bilberry (vaccinium myrtillus) and had a 16.16 inr. both, equinacea and bilberry inhibit different isoenzimes of cytochrome p450. the last patient was taking garlic oil (allium sativum) and had a 4 inr. garlic increases the anticoagulant effect. conclusions: it is commonly believed that herbal products are inofensive, that is the reason why mainly of the patients do not take medical advise before starting a treatment with them. however, there can appear interactions with the usual treatment. if we fix on the vitamin-k antagonists the risk resides on the hemorragic or strokes events. in conclusion, we believe that patients should be educated about the potential risk of using herbal products while being treated with vitamin-k antagonists. a 41 year-old man, treated with clopidogrel after coronary stenting, is hospitalized for aa (neutrophils: 0g/l (1.7-7g/l); haemoglobin: 10.8 g/dl (12-16 g/dl); platelets: 6g/l (150-450g/l)). his permanent medications were insulin, perindopril, omeprazole, atorvastatine, bisoprolol, and acetylsalicylic acid. clopidogrel (75 mg/d) was prescribed 3 weeks before aa occurence. clopidogrel is withdrawn and aa therapy is started, consisting in the sequential association of anti-thymocyte globulin therapy (15 mg/kg) and ciclosporin (5 mg/ kg/d) in a filtered-air room. but the severe co-morbidities lead to early stop ciclosporin, then relayed by androgen therapy (norethandrolone). finally, at 12 weeks from the diagnosis, the evolution ends to a resolution of aa, but with platelet-transfusion dependance. after the elimination of the other aetiologies, iatrogenic cause is envisaged. to blame clopidogrel is difficult with regard to the other drugs, especially perindopril and omeprazole known to induce bone marrow failures. four arguments lead to target clopidogrel: (i) the length of treatment by perindopril and omeprazole without complications, (ii) the timing between the onset of aa and the addition of clopidogrel to treatment, (iii) the resolution of aa whereas neither perindopril nor omeprazole were withdrawn, and (iv) the support of the literature. conclusions: clopidogrel seems to be responsible of this side effect. we unfortunately lack in specific biological tests to prove it. keywords: clopidogrel, side-effects, pharmacovigilance background and objective: informing patients on their medicines is a patient right. what does current information provision on antidepressants to patients with a depression admitted to a psychiatric hospital look like? what is the current practice of health care professionals? what are the experiences of patients? this study aims to explore current practice on drug information provision in psychiatric hospitals. design: a qualitative study consisting of semi-structured interviews with separate interview guides for health care professionals and for patients. interviews were tape recorded, verbatim transcribed and analyzed using nvivo7 software. setting: eight flemish psychiatric hospitals. main outcome measures: identification and evaluation of current approaches to drug information provision on antidepressants from the point of view of health care professionals as well as patients. results: patients get information on antidepressants, firstly, through psychiatrists and, secondly, through nurses. hospital pharmacists have a supporting role. the approach in giving information depends on patient characteristics and his/her mental state. information is provided mainly orally. leaflets are not frequently distributed to patients. patients also get information on antidepressants during psycho-educational sessions. on request, patients can read a package insert under supervision of a health care professional. health care professionals consider non-verbal cues of patients to verify if information has been understood. information is repeated when the first instruction was not clear for patients. there are no systematic interdisciplinary contacts on information interventions. patients as well as health care professionals are satisfied with current practice on information provision. health care professionals reported lack of time and lack of interdisciplinary contacts as negative aspects. patients indicated that health care professionals take too little initiative to give information about medicines. positive aspects reported by health care professionals are the hospitals' openness and the opportunity for patients to ask their questions to psychiatrists as well as nurses. suggestions for improving practice are: providing more medication information to patients, in particular on side-effects; enhancing the availability of easy readable information; and organizing continuing education for nurses on medicines. patients are informed about their antidepressants through various pathways. however, there seems to be room for improvement as a number of suggestions were formulated to support these pathways of drug information. keywords: medication information, antidepressant, psychiatry claire chapuis 1 , christine chevallier 1 , céline villier 2 , pierrick bedouch 1 , benoît allenet 1 , jean calop 1 , gérard besson 3 1 pharmacy, 2 pharmacovigilance, 3 neurology, university hospital, grenoble, france background and objective: the use of intravenous immunoglobulin (ivig) is expanding. the risk for adverse effects can be minimized by taking some precautions. there are yet no standardized practice guidelines for prevention and management of adverse effects occurring during the infusion, and there is a need for it. the purpose was to conduct a study of their knowledge among the nurse community and to make a review of the best practices. design: we search in medline and carried out a questionnaire for nurses. we evaluated knowledge and practices of 14 nurses in neurology, pneumology and haematology units, experienced in intravenous immunoglobulins administration, in order to define their role and the prescribers role in ensuring patients safety during therapy. we used all information and synthesized it in a table. for every type of adverse reaction, we indicated mechanism, frequency, seriousness, risk factors, practical guidelines of management and prevention and actor. the guidelines were reviewed by experts (pharmacist in charge of human derivative products, pharmacovigilance experts and neurologists). setting: university hospital, grenoble, france. main outcome measures: formalisation of practical guidelines on prevention and management of intravenous immunoglobulin adverse effects, for prescribers and nurses in the local hospital network and possibly other hospitals. results: nurses always checked the doses before administration (14/ 14), always prepared the product aseptically (14/14), warmed up the product until it reached room temperature (12/14), but only few recorded the patients tolerability during the infusion (9/14), and very few knew that most adverse events could be minimized first by slowing down the rate of infusion (4/14). all nurses called a doctor as an adverse effect appeared. conclusions: nurses must be involved in the management of adverse effects, even if the prescriber remains the one who makes the prevention by evaluating risk factors, co-medications, dosing and frequency of treatment and the one who makes the decision to interrupt the treatment if an adverse effect occurs. the clinical pharmacist in care units works collaboratively with both prescriber and nurse. he plays a central role for preventing drugs' adverse effects while counselling every member of the healthcare team background and objective: fludrocortisone tablets 10-50 lg (f) is mainly used in the treatment of adrenocortical insufficiency. it may also be used in treatment of orthostatic hypotension. f is manufactured by ageps (public special-order manufacturer) and dispensed to outpatients by hospital pharmacies, as a ''hospital preparation''. in order to follow gmp guidelines, a patient information leaflet for f was elaborated in our pharmacy outpatient unit. the leaflet was approved by our regulation unit. to evaluate the usefulness of this leaflet and to improve its quality, we performed a patient satisfaction survey. design: during 14 days, for every dispensation of f, a leaflet was presented to the patient and an anonymous satisfaction survey was performed. setting: pharmacy outpatient unit, agence générale des equipements et produits de santé (ageps) (ap-hp), paris, france. main outcome measures: the questionnaire consisted of three items: general information about patient and its treatment; patient's knowledge of f before reading the leaflet (uses, precautions, adverse events, storage); patient satisfaction of leaflet (general presentation, language simplicity, information volume, utility). results: 70 patients answered the questionnaire. the mean age was 47 years (3-88 years). mean f treatment duration was 17 years (2 months-43 years). 40% of patients were already informed about f: 96% by physicians and 4% by associations and internet. 97% knew the indication (90% adrenocortical insufficiency and 10% orthostatic hypotension).79% knew about precautions, 56% knew about side effects, and 76% knew about storage conditions. 4% of patients did not read the leaflet and had no opinion about satisfaction items. 96% were satisfied of general presentation. language was understandable for 94%, and non understandable for 2%. information volume was sufficient for 88%, insufficient for 4%, and too large for 4%. leaflet was useful for 93% of pts. patients who found the information insufficient suggested the following items: results of clinical trials, management of acute situations due to disease or f, and contacts of qualified centres in case of serious events. conclusions: nearly half of the patients were informed about f by their physicians, but information is communicated orally without written support. the majority of patients treated by f knew about precautions, side effects, and storage conditions. however, patients were satisfied of our information leaflet and find it useful. leaflet appears to be a good tool to communicate information from the pharmacist to the patient when not available in the packaging. of these 102 recommendations taken into account (63%), within a period of 2 days for most (n = 84), 53 involved the intervention of a pharmacy student, 33 were given only via the computer software, and 16 via a telephone call. conclusions: computerisation of prescriptions is an indispensable tool in order to make the pharmaceutical distribution circuit safer. however, its use as a vehicle for pharmaceutical interventions is limited, as shown by this study. it is impossible to analyse a nonresponse of our recommendations: is our advice even red, is it considered as inadequate? a discussion with the clinician (via pharmacy students or on the telephone) allowing a constructive exchange of knowledge, leads to a better transmission of recommendations. background and objective: in hospital setting, employees may be exposed to hazardous drugs. risks and protective measures needed when handling parenteral cytotoxic drugs are well described, whereas information related to drugs like monoclonal antibodies or antivirals are lacking. we developed a standardized method to evaluate drugs potential toxicity and occupational risks taking into account the pharmaceutical forms of the drugs to balance the risks. design: development of an algorithm for toxicity evaluation using material safety data sheet (risk and safety phrases), international agency for cancer research (iarc) classification and official manufacturers' data. 1. evaluation of chronic toxicity (mutagenicity, carcinogenicity), acute toxicity (sensitisation or irritation in contact with skin, eyes or by inhalation) and toxicity to reproduction 2. balancing of toxicity according to the pharmaceutical forms 3. assessment of protective measures (centralization of drug preparation in the pharmacy, wearing of mask, gloves and/or glasses) centralization of drug preparation in the pharmacy is recommended only in case of documented mutagenicity and carcinogenicity and when there is a risk of respiratory or cutaneous exposure related to the pharmaceutical form. setting: university hospital (2000 beds). main outcome measures: • chronic (r45, r46, r49 or iarc group 1, 2a or 2b), acute toxicity (r20-28, 34-38, 41-43; s22-28, 36-39) and toxicity to reproduction (r60-63; cat.d,x) • pharmaceutical forms associated with a risk of respiratory (e.g. tablets crushing), cutaneous (e.g. drug in solution) or ocular contact (e.g. inhalation) results: occupational risks of 14 parenteral monoclonal antibodies, 8 oral and 5 parenteral antivirals, 12 oral cytotoxics and 43 other drugs forms were analysed. according to our algorithm, crushing of 36% of the 33 tablets forms should be done in the pharmacy (e.g. valganciclovir). only 1 parenteral antiviral should be reconstituted at the pharmacy (ganciclovir). monoclonal antibodies were found not to be at risks of mutagenicity or carcinogenicity and only gloves will be recommended for their manipulation. no ''class-effect'' has been pointed out (e.g. only a few antivirals were found to be hazardous). 31 products were at risks for pregnant women. protective measures to be taken by pregnant nurses or those wishing to have a baby will be discussed institutionally. conclusions: toxicity evaluation of hazardous drugs handling in hospital should take the pharmaceutical forms into account as some toxic drugs may not be associated with occupational risks (e.g. coated tablets). our method allows a standardized way to evaluate whether a drug should be treated as hazardous or not. results will be discussed institutionally in order to implement applicable policies and procedures. results: lidocaine 1% injectable solution is indicated for tracheobronchial anesthesia, via bolus of 20 mg in adults, and 5 to 10 mg in children. the maximal dose is restricted to 9 mg/kg in adults and 5-7 mg/kg in children. epinephrine is indicated in hemorrhagic complications occurring during interventions; the solution is diluted to 1 mg/10 ml with nacl 0.9%; a 200 lg bolus is injected and can be repeated up to 1 mg. terlipressine can be used in heavy bleedings; the powder should be reconstituted with nacl 0.9%, at 1 mg/5 ml; 1 mg is injected, repeated if necessary. mesna is used to dissolve mucous plugs, especially in patients with cystic fibrosis. the solution is diluted to 30 mg/ml with nacl 0.9%; bolus of 10 ml are injected to allow visibility in the lower airways. there are no data available on the maximal dose. all preparations have to be compounded aseptically and extemporaneously by the nurse when requested by the physician, because of the lack of stability studies in those ranges of concentrations. conclusions: these guidelines are intended to standardize flexible bronchoscopy procedures between the different units, in order to minimize the occurrence of medication errors. almost half of the enquiries (49.7%) were about stability and incompatibility in intravenous (iv) admixtures. the frequency of these calls was significantly higher than the calls came from other health professionals (p \ 0.05). the following types of enquiries were about dosage (9.1%) and availability of pharmaceutical products (8.0%). while 76.5% of enquiries were answered by hizbim in less than 5 minutes, in 1% of all calls took more than 1 day to gather and tailor which requires more literature search. the mostly (50.0%) used references in retrieving information was general references followed by micromedex ccis inc. with 41.0%. • hizbim has been consulted by nurses in a rising pattern. this means that this service is of importance for them because of its rapidity, accuracy and currency • the preparing iv admixtures that has been left to nurses' responsibilities in practice in our country can be reconsidered by pharmacists since this service has been fulfilled by ''drug experts'', namely pharmacists in many countries. • drug information centers can provide not only emergent information for nurses but also education such as seminars and conferences in some topics they need. the establishment of drug information centers in hospital settings will be of use to stimulate the frequency of consultations by nurses and to improve patient care provided by them. background and objective: the concept of pharmaceutical care (pc) is capturing the attention of a growing number of pharmacists. the strategy followed by us to spread out the implementation of pc in pharmacies involves the utilization of internet tool as an innovation of traditional education. design: to do so, we designed an on line pc course with interactive cases. the specific goals of the course are: • the enhancement of the pharmacy practice. • the promotion of practice research. • the personal and professional development of pharmacists. the objective was to analyse the evolution of the program, whose pedagogical design was based in a process of teaching-learning in the field of the clinical pharmacy and pharmaceutical care that permit the training of the future pharmacists in the use of medicines. design: all the classes were designed with practical-theoretical modality including workshops, reading and analysis of the bibliography, discussion of cases and utilization of virtual simulators. setting: clinical pharmacy. department of biological sciences main outcome measures: students evaluation was carried out by tests of the general contents, degree of active participation during the workshops, resolution exposition and discussion of the cases. results: the development of clinical pharmacy education began in 2005. the students appreciated this experience and the 97% of them are satisfied with the process of teaching-learning employed. this teaching system improved them the adequate and rational use of the medicines. in these two years the 100% of the students has approved the examination. the students also realized two poster presentations during this period, namely: 1. ''comparative study of the information supplies in the leaflet of tablets of omeprazol 20 mg'', in 2005 and 2. ''study of the information supplied by the pharmaceutical laboratories in the television media'' in 2006. conclusions: we consider the importance of the incorporation of clinical pharmacy in the new pharmacy curricula, because the students have major task about the practical education involvement patients and related to their professional future. background and objective: clinical trials' managing and dispensation is one of the obligatory missions of a hospital pharmacy. the respect of good clinical practices is necessary to ensure proper trial performance and to be aware of errors in prescription and in drugs dispensation. the aim of our study was to analyse the nonconformities in the steps of prescription and dispensation and to evaluate their severity. design: the pharmacy department manages 240 clinical trials for all clinical wards with a pharmacist and a technician who change every four months. there is no specific computerized system but an excel software for data filing. we realized a retrospective study of ongoing 67 clinical trials. all the prescriptions were reviewed and we focussed on all the items required for the prescription (e.g., identification of the protocol, the patient, the investigator, the dosage) and for the dispensation (e.g., identification of the drug, the quantity dispensed, batch number, expiry date) setting: results: 57 gps participated to the survey. they agreed (median = 4, iqr = 5-4) that the following concepts are crucial in a patientcentred approach: the need of a specific training in counselling in under and post graduate education; the necessity of working with patients to develop mutually agreed-upon goals; the role of information in the decision making process, the ability to understand patients readiness to make change, and to identify barriers to change, the importance to recognize that patients are the experts when it comes to their own behaviour related issues. for only one item (time dedicated to the consultation) iqr changed (iqr = 4-2) indicating some difficulty in implementing this aspect in practice. conclusions: for benevento community gps, a patient-centred approach is a useful way to help change and promote behaviour. knowing how to support it is an important skill for all care professionals, but education is needed to shift from theory to practice. type ii and 6 gestationnal diabetes. the average age was 60 years and for the half of these patients, the pathology developed since more than 10 years. 27 patients were painful and 14 patients presented a positive score to dn4 questionnaire. symptoms frequently observed were: pins and needles, prickles, and numbness. among these 14 patients, 9 were treated by antidepressants (amytriptiline) or antiepileptics (clonazepam, gabapentine, tegretol, carbamazepine or pregabaline) or both. the average number of molecules received by patients was 2.44. the average number of lines of treatment was: 2.44. first intention treatment insisted of an anti-epileptic monotherapy in 7 patients. second line treatment involved the introduction of another anti-epileptic or an anti-depressant drug. the drugs have been well tolerated except a respiratory depression under clonazepam. among the 5 not-treated patients, only one benefitted from a treatment initiation. conclusions: patients are treated by ''old'' molecules with a large prescription of clonazepam but their efficacy is very variable. the physicians have been sensibilised to dn4 questionnaire and they concluded that it is easy to use. however there is a lack of physician's informations about the management of neuropathic pain; besides they are hesitant to initiate a treatment. the relationship between pharmacists and physicians and the development of clinical pharmacy seems important to optimize the management of this pain. background and objective: pharmacy education in the faculty of pharmacy and biochemistry of the university of buenos aires is taught as a product-oriented profession with a focus on the basic sciences. however in 1997 pharmaceutical care and clinical pharmacy was integrated as an optional course into the pharmacy curriculum by resolution cd 707/97. the object of the emphasis was on the students' ability to provide clinical pharmacy and pharmaceutical care upon graduation. hence, therapeutic plays a significant role in building students' knowledge and skills in preparation for clinical practice. design: theoretical education and program for students and collaborative implication in the hospital activity or in the community pharmacy. the development of the program is carried out in two phases. in the first phase the clinical activities of the pharmacists, the unidose drug distribution, the role of the drug information centers, pharmacoepidemiology and surveillance studies are explained. in the second phase the concept of pharmaceutical care is introduced and its implementation in different pathologies is developed. an active approach of the patient and contact with the treating physician was considered as tool in a strong learning environment. setting: undergraduate pharmacy students at university of buenos aires. main outcome measures: the students find them abilities to identify drug related problems and to assess patient care and follow-up. results: more than 300 students have attended pharmaceutical care and clinical pharmacy to: 97% passed and 3% failed. students option was that the strongest aspect are the case discussion and the weakest the very few number of hours not enough to discuss other important illnesses. they also say that many topics should be taught sooner in the career and it was not considered an emphasis an the clinical and patient oriented-aspects of the profession. conclusions: an approach to clinical pharmacy education in which the integration of teaching and learning are collaborative creates an atmosphere that is conducive to effective student learning. moreover the clinical pharmacy is a valued and important tool of the general practice team regarding quality improvement in drug therapy. all of the most popular cpd linked pharmacy activities were from the competency-'participation as a member of the multidisciplinary team'. telephone interview findings showed pharmacists cited 'priority for their service development' as the principle reason for cpd identification. no pharmacist identified a cpd need for: 'supporting patient/family motivation'; 'ecording problems in blood glucose control requiring balancing food intake and insulin dose'; 'sharing reflections of where your performance leaves room for improvement within a pharmacists group' and 'taking part in a local multi-disciplinary mentoring group.' conclusions: currently cpd workbooks appear not to be widely used within the pharmacy profession in the uk3 although there are examples of successful use of reflective portfolio.4,5 almost half of the participants chose the workbook as a means of support leading to a substantial number of identified cpd issues. for community pharmacists to deliver high quality care for diabetes, more attention is required to forms of training and to both uniprofessional and multiprofessional peer support. setting: we retrospectively reviewed all prescriptions of ivig issued from three infectious disease departments (50 beds) in a french 500bed university hospital. main outcome measures: for each ivig prescription, the following data were collected: patient identification, name of ivig product, quantity of ivig issued, date of ivig release, indication for treatment and level of relevance. these levels are determined as follows. level 1: indications approved by health authorities or for which comprehensive guidelines have been published (high level of proof). level 2: relevant indications based on scientific publications. level 3: off-label indications more difficult to prove on a scientific basis (few or no high quality randomized controlled clinical trials). results: during the studied period, 25 715 grams of ivig were administered for a total of 68 patients and 296 prescriptions. 88.9% ivig used saccharose as a stabilizing agent, other products contain either glucose (10.4%), or maltose (0.8%). the purpose of this study is to produce an evaluation focus on the risk profile and counselling activities concerning therapeutic and lifestyle change. design: descriptive study. individual measurements were recorded by pre graduation students on a standardized datasheet. blood pressure was measured using a digital wrist device. blood glucose monitoring systems of two different brands were used. setting: the screening was made in the street using passer-by volunteers. in the course of a single day in may 2007, a total of 293 subjects (48.8% males and 52.2% females, mean age 62.37 years, sd = 15.62) had glycaemia and blood pressure measured. main outcome measures: age, gender, medication taken, cigarette smoking, body mass index (bmi), blood pressure, capillary blood glucose results: 70.31% of the sample presented bmi [ 25kg/m. 53.24% had elevated systolic blood pressure values and 13.99% elevated diastolic blood pressure values. 11.95% had elevated occasional blood glucose. 12.30% are cigarette smokers. systolic (t = -1.97; p = .05) and diastolic (t = -2.09; p = .04) blood pressure values were significantly higher in smokers than in non-smokers. concerning patients taking diabetes medication, fewer patients with blood glucose controled and more patients blood glucose uncontrolled were found than those expected, suggesting either low compliance or lack of efficiency of medication (v 2 = 31.74; p \ .001). concerning the hypertension medication, similar results were found. more patients under therapy with blood pressure uncontrolled were found than expected. the concordance within the two measures of the blood glucose with different monitorizing system was found to be strong and significant (k = .86; p \ .001). positive and significant correlation between bmi and diastolic blood pressure was found. however, no significant correlation between bmi and systolic blood pressure was found. conclusions: events such as this screening improves the quality of education, as well as develops the interests and opinions of students. as well as it shows face to face were can be apply their knowledge of clinical pharmacy furthermore, events such as these are found by the students to be invaluable in acquiring training in similar-to-professional setting and expertise in field work. background and objective: nhs education for scotland (nes) has worked with the scottish executive health department (sehd) to develop training packages to support the use of validated needs assessment tools (nat) for several longterm conditions. consequently a specific training package was then developed to support and standardise needs assessment and pharmaceutical care delivery by palliative care pharmacists in the local networks set up in scotland. additional support materials (trainers package) was developed for representatives from the scottish palliative care pharmacists' association to deliver the training to their local network pharmacists in a consistent manner. design: development and evaluation of a training package and course for palliative care pharmacists. evaluation of the outcomes from using a nat for delivery of care. identification of issues 100%; relevance of questions 100%; time to complete nat 10-20 mins; barrier -time; benefits -care issues identified by nat; care issues -counselling and compliance issues, side-effects identified (nausea, dry mouth, constipation), pain relief not adequate. conclusions: nes are proactively supporting national policy and practice through a process of identifying and meeting the educational needs through direct and self-directed learning for continuing professional development (cpd). the needs of palliative care patients are seen as an appropriate target group for pharmaceutical care. the evaluation and feedback from the courses, training pack and outcomes from the use of the nat in practice have been very positive and amendments will be made for further implementation in scotland. background and objective: pharmacy students represent a broad spectrum of learning preferences and styles. this diversity presents a responsibility for the lecturers and instructors to meet the educational needs of all students. in order to develop appropriate learning approaches the instructors need to know the students learning preferences. therefore, the aim of this study was to identify the learning preferences of pharmacy students. design: the visual, auditory, reading/writing, kinesthetic (vark) questionnaire identifies student's preferences for particular modes of information presentation. the vark questionnaire is freeware that can be completed online. however, we administered the vark questionnaire as a hard copy at the end of the 'clinical pharmacy practices' final exam to the fourth-grade pharmacy students. setting: marmara university -faculty of pharmacy. main outcome measures: the frequency of students' preference for modes of information presentation. results: we administered the vark questionnaire to 108 students and 106 (98%) returned the completed questionnaire. almost half of the students (48.1%) preferred a single mode of information presentation. among these students, 2% preferred visual (learning from graphs, charts, and flow diagrams), 19.6% preferred auditory (learning from speech), and 29.4% preferred printed words (learning from reading and writing), and 49% preferred using all their senses (kinesthetics: learning from touch, hearing, smell, taste, and sight). the other half (51.9%) preferred multiple modes [2 modes (44.3%), 3 modes (4.8%), or 4 modes (2.8%)] of information presentation. a total of 63 (59.4%) students preferred 'kinesthetic' learning solely or in a multimodal combination. conclusions: the students represented a variety of learning styles. student motivation and performance improves when instruction is adapted to student learning preferences and styles; so, it is the responsibility of the instructor to address this diversity of learning styles and develop optimum learning approaches. escitalopram, fluoxetine and mirtazapine were rarely prescribed. the posology and taking plan were generally respected. however, some improvements in terms of treatment optimization could have been brought. they could have lead to 32 actions of clinical pharmacy within the framework of prospective study: 9 posology optimizations and 23 taking plan optimizations. nineteen patients (40%) had an adjustment in their antidepressant treatment: nature and dosage. for all the antidepressants, a sufficient duration was respected before increasing the doses. an average number of interactions by prescription were 4.8 but none was clinically significant. conclusions: therapeutic strategies corresponded to guidelines recommendations. the dosage adjustments and duration before increasing the doses respected the indication of antidepressants. in the future, to optimize the medicinal treatment, decision-making tools carried out could facilitate psychiatrists' prescriptions. the pharmaceutical validation of prescriptions will be facilitated by complying with them within the framework of clinical pharmacy activity. background and objective: al-amal hospital is a 51 bed oncology/ hematology hospital. al-amal hospital is now the first hospital in qatar to be accredited by the joint commission international (jci), the worldwide leader in improving the quality of healthcare. the objective is to implement clinical pharmacy services in al-amal hospital in the state of qatar by training the pharmacists about clinical pharmacy services. design: a pharmacist designed the training program and took the initiative and responsibility for training other pharmacists in aah about clinical pharmacy. the department of medical oncology/ hematology, the hospital administration and the pharmacy department agreed that the pharmacists should have central responsibility for antineoplastic agents and other drugs related problems. pharmacists for the program were selected from the existing staff. the healthcare team is consisting of two pharmacists rotating every 2 months. each pharmacist join 2 teams consisting of a pharmacists, a consultant, a specialist, a resident, a rotating resident, 2 nurses, a dietitian, physiotherapist, social worker and a psychologist. we used to have 3 oncology teams and 1 hematology team. both pharmacists participate in the medical rounds and morning report 3 days per week. the pharmacists provide clinical pharmacy services including chart review, pharmacy patient profile review, laboratory tests, therapeutic drug monitoring, antibiotics monitoring, interviews with patients and/or relatives. drug related problems were identified, resulting in interventions. setting: in patient wards, al-amal hospital, qatar. main outcome measures: to identify drug related problems, which well result in interventions and to help the medical team and the patients to reach their treatment goals. patient outcomes were evaluated by follow up with the medical team or by patient interview. we refer patients to the dietitian, physicians, the clinical psychologist as needed. results: more time is needed to evaluate the clinical pharmacy services provided by the pharmacists as the program was just started. patient and physicians were satisfied by starting the training program. conclusions: hematology/oncology setting provides an excellent opportunity to involve pharmacists. a. leads to encephalopathy and progressive neurodegeneration in the infant who is not treated. early diagnosis and dietary management can prevent complications and may allow for normal intellectual development. however, neurologic function may deteriorate rapidly at any age because of acute metabolic decompensation. these severe episodes are caused by catabolism of endogenous protein, which may be provoked by physiological stress (infections, post-surgery). during these crisis, the patient must have immediately intravenous glucose infusion and enteral nutrition free of b.c.a.a. design: case report. setting: department of pharmacy, hospital charles nicolle, rouen. main outcome measures: case report results: one patient with classical m.s.u.d. is followed in our establishment since many years. his disease has been diagnosed in neonatal period. a diet free of b.c.a.a. has been instaured. this diet is successful, now this patient is 34 years old and had a normal development except myalgia and hypoesthesy of the left leg. however, when the diet is not well followed or when he's infected, acute episode occurs (on average 3 or 4 times per years). as the crises starts, the patient is sleepy and confused. in order to be able to treat him very quickly, the medical staff decided to set up an emergency protocol, which include an adapted enteral nutrition formulation. the pharmacy is implicated in this protocol to prepare the mixture. the formula includes: m.s.u.d mix, dextrin maltose, oligoelements, ions, lipids (sunflower oil), vitamins and water. the pharmacy must be able to carried out the preparation at any time and the components must be always available. conclusions: because m.s.u.d is an unherited disease, published report of treatment are rare and they are no consensus for the treatment of acute decompensation. since 6 years, this protocol is successful: b.c.a.a. levels decrease between 2 to 4 days after the setting-up and the patient always recovered rapidly. this formula is administrated by nasogastric tube and avoid the use of hemodialysis which is the last solution to remove b.c.a.a. this is an example that a personnal follow-up program (with plan for clinical and metabolic evaluations) during common intercurrent illnesses can have optimal outcomes. keywords: leucinosis, metabolic decompensation, adapted enteral nutrition nutr-46 ensuring phosphorus adequacy of human-milk-fed preterm babies canadell laura 1 , cañete carmen 1 , pardo rocio 1 , albujar mar 2 , valldeperez cinta 2 , carretero juan 2 , gallart m jesus 1 , closa ricardo 2 1 pharmacy service, 2 neonatology, hospital universitari joan xxiii, tarragona, spain background and objective: human milk is the feed of choice for preterm infants both for nutritional and non-nutritional reasons. phosphorus levels in human milk are insufficient for most premature infants. this deficit is the major cause of osteopenia in prematurity. fortification with a commercial multinutrient product should only be considered after 2 weeks of mother's milk feeding, however, phosphorus supplement must be given initially. to describe a standardized scheme for early nutritional support with phosphorus of very preterm infants (\1250-1500 g)and describe the phosphorous oral solution we use as a supplement is the aim of this study. design: clinically relevant reports were reviewed to establish a standardized scheme for early nutritional support with phosphorus of the very preterm infants. a standardized formula of oral phosphorous was established to diminish the medical errors when the addition of this mineral is required. setting: pharmacy service and neonatology unit of a third level hospital. main outcome measures: to describe the scheme of adding phosphorous to human milk as well as the standardized formula we use, ''phosphorous oral solution'' (10 mg p/100 ml). results: phosphorous oral solution procedure: composition, stability and the scheme of addition to human milk to ensure the requirements for bone substrate needs in preterm infants to avoid osteopenia of prematurity. conclusions: various methods have been tested to decide when additional supplements must be given. individual adjustment is not possible due to the delay of laboratory results on milk analysis and the fast changes in infants' requirements. therefore, it is necessary to make a standard adjustment scheme on the dose of the fortifier that needs to be added. shortly to the pancreaticduodenectomy, total parenteral nutrition (tpn) was started (1500 kcal in progress until reaching his energy requirements). in addition to parenteral nutrition, supplementation enteral nutrition was delivered via jejunostomy along four postoperative days. on post day 8, transition to a complete enteral formula was achieved (standard formula, 1 ml = 1 kcal: 2000 kcal/d). on day 12, patient complained of colic pain in upper hemiabdomen. an emergency tc revealed presence of liquid in the abdominal cavity from anastomosis pancreatogastric. with the suspect of a leak from jejunostomy, the catheter was removed. tpn was reintroduced and kept as the only way of nutrition until 15 later when oral tolerance was started. during hospital stay (37 days) periodic blood controls were performed. main methabolic complication was high blood sugar, needing the administration of insuline. from day 2 to 28, mean plasma levels of albumin (2.4 vs 3.1 g/dl), total proteins (4.4 vs 6.2 g/dl), total serum cholesterol (88 vs 106 mg/dl), total lymphocite count (6.9 vs 12.9%) and prealbumin (10.5 vs 16.1 mg/dl) increased significantly conclusions: the leak of artificial nutrition to the abdominal space in patients with jejunal feeding is a frequent complication of ne. its incidence is probably related to the length of the tube inserted into the lumen. protocols are need to prevent complications like tube displacement and to encourage early enteral nutrition. increase in plasma concentrations of nutritional parameters suggests effective uptake admixtures might be either prescribed and made ''a la carte'' according to the newborn's needs or provided by pharmaceutical companies as standard formulations. the aim of the study is to review individual pn prescriptions in a neonatology care unit in order to assess the potential for using standardized pn instead. design: prospective study one day per week during 8 weeks. setting: neonatal intensive care unit, strasbourg university hospital. main outcome measures: the major criteria for the comparison are carbohydrate concentration and then amino acid intake. results: 57 prescriptions were analysed and compared with a standardized formulation, pediaven ò (fresenius kabi). the first point of comparison based on carbohydrate concentration resulted in an exclusion of 65% (37/57) of the total prescriptions because their carbohydrate concentration was less than 8 g/100 ml or more than 12 g/100 ml (pediaven ò glucose concentration, 10 g/10 ml). among the 20 prescriptions retained, only prescriptions whose amino acid concentration was less than 0.25 g/100 ml were included (pediaven ò : 0.2 g/100 ml background and objective: it is known that propofol protect myocardial tissue against global myocardial ischemic-reperfusion injury in the isolated rat heart model. the aim of this study was to investigate whether propofol, at a clinically relevant concentration infused during both preischemia and reperfusion (peri-ischemic) period, also provide protective effect against regional myocardial ischemic-reperfusion injury in vivo. design: mail sd rats weighing between 230 and 270 g were anesthetized with 50 mg/kg of ketamine and 3 mg/kg of xylazine. a haparinized 24 g catheter was placed in the left femoral vein. the trachea was intubated and then mechanically ventilated with room air using a volume-controlled rodent ventilator. a left thoracotomy was performed, and the pericardium was opened. for the ischemia-reperfusion experiments, a snare was passed around a left anterior coronary artery territory to induce regional myocardial ischemia. coronary occlusion was produced by pulling the snare and clamping it with a mosquito hemostat. reperfusion was produced by releasing the clamp. setting: rats were subjected to 25 minutes of coronary artery occlusion followed by 24 hours of reperfusion. propofol or intralipid was administrated during 35 minutes starting 5 minutes before the onset of ischemia until 5 minutes after the onset of reperfusion. main outcome measures: the micro-manometer catheter was advanced into the left ventricle via right internal carotid artery and hemodynamic function was checked after 24 hours of reperfusion. infarct size was determined by triphenyltetrazolium staining after 24 hours of reperfusion. results: propofol administration during both preischemia and reperfusion (peri-ischemic) period showed protective effects on myocardial function and infarct reduction. in the control group, the peak rate of ventricular pressure rise (+dp/dtmax) and the peak rate of intraventricular pressure decline (-dp/dtmin) significantly decreased than sham group. in the propofol group, the +dp/dtmax and -dp/dtmin significantly improved than conrol group. infarct size was 50.6% of the area at risk in control group, and was reduced markedly by administration of propofol during peri-ischemic period to 20.4% in the propofol group (p \ 0.001). infarct size of intralipid group was 43.8% of the area at risk, intralipid had no effect on infarct size compared with the control group. conclusions: propofol, at a clinically relevant concentration infused during peri-ischemic period, provided protective effect after regional myocardial ischemic-reperfusion injury at in vivo rat heart model. the results showed hemoglobin level of less than 10 g/dl in 52.2% of the subjects, transferrin saturation (tsat) of less than 20% in 77.2% of the hd patients, tsat \ 20% and ferritin \ 100 ng/ml in 7.6% of the patients, serum alb level of less than 4 g/dl in 37% of the patients, serum p level of more than 5.5 mg/dl in 57.6% of the subjects, ca 9 p product of more than 55 in 38% of the patients, parathyroid hormone (pth) \ 150 pg/ml (adynamic bone disease) in 23.9% of the subjects and serum pth concentration of more than 300 pg/ml (uncontrolled secondary hyperparathyroidism) in 48.9% of the subjects. the results showed that more than half of the hd patients need erythropoietin and ferrous dose adjustment or follow up for resistant anemia, more than half of the subjects need phosphate binders dose adjustment or replacement and about 20% of he patients need rocaltrol dose adjustment. we are planning to compare these results with the findings following the participation of a clinical pharmacist in this hd center rounds and monitoring of hd patients. since enough management of complications of crd patients and their drugs monitoring are necessary to improve quality of life of hd patients, clinical pharmacist may have a major role in hd centers. background and objective: computerization of our drug circuit has been deployed gradually to every hospitalisation units of our hospital since 2003. pharmacists coordinated the extension, the installation and the support for starting. they were the first interlocutors to analyze dysfunctions and to help solving them. difficulties encountered by nurses were often notified to head nurses and transmitted to pharmacists. the objective was to study as a whole difficulties of users and to bring a workable solution to their problems. design: a working subgroup depending on the drug commission was created. it was composed with 12 nurses from different departments (intensive care, infectious, pediatric and rehabilitation departments), 4 head nurses and 2 pharmacists. several meetings, organized between october and december 2006, made it possible to the participants to announce their difficulties. reports were written and diffused for validation. to evaluate the pharmacist -patient communication and the level of counseling for otc and prescription drugs dispense; to improve the professional relationship between the patient and the community pharmacist; to assess the effect of clinical pharmacist intervention over those parameters. design: interventional study (visits done by clinical pharmacists, especially employed for), repeated after 2 weeks and again after 6 months. setting: 37 chain pharmacies from bucharest, romania. main outcome measures: the investigation was conducted using a multiple sections protocol. the assessed parameters were: pharmacist's attitude toward the patients, his/her availability to communication and the level of counseling when otc or prescription medication is released. results: during the first visit, in sixteen pharmacies only (43%) the pharmacists greet the patients. two weeks later after the intervention, this number increased to 28 (75%), although after six moths it decreased to 23 pharmacies (62%). in more than 60% of the chain pharmacies, the professionals had a positive attitude toward the patients. as an example, an empathic approach has been encountered initially in 25 pharmacies (68%), then in 28 pharmacies (75%) and finally raised up to 30 pharmacies (81%) after 6 months. although the clinical pharmacist's intervention (therapeutic counseling) had positive impact, the extent of minimal counseling at otc or prescription drugs dispensing was found to be low at the first visit, since it increased from 7 to 12 pharmacies (20 to 32%) only, during the study period. the processed data showed a very low level of minimal counseling (32% at the end of surveillance period). by considering the patients benefits (quality of life, better control and management of chronic diseases, reduction of medication costs), the pharmacist interventions are imperatively needed in bucharest chain community pharmacies. background and objective: to compare the level of minimal consultation services in chain community pharmacies located in city center or district of bucharest (capital city) vs. independent pharmacy in a country town (cluj-napoca). design: prospective, 3 months, multicenter study. setting: 5 pharmacies accepted to fill in the study protocols. both shifts were covered, monday to friday (week-end days not included). main outcome measures: the investigation was conducted using a multiple sections protocol. the assessed parameters were: the level of minimal consultation when otc and prescription medications are dispensed and the extent of chronic medication release without a medical prescription. at the end of trial period, the results were centralized on weekly and monthly protocols. the interpretation of the collected data was done using percentile calculations. results: to evaluate the minimal consultation, the percentage of counseled patients from the monthly total was calculated, separately for otc and for prescription drugs dispense. the period of the study (from june 2006 to january 2007) was divided in various slices of 3 consecutive months, when certain pharmacies were compared. the level of otc medication counseling in the five studied pharmacies is different and varies from 25 to 70% (maximum level reached in the country town pharmacy). the counseling level for medication on prescription varied from 40 to 100%. by counting separately, the percentage of patients who requested chronic medication without presenting a prescription is as high as up to 30%. conclusions: the level of counseling, especially for otc drugs (recommended or auto-medication), was generally low in the studied pharmacies and may threat the health state of the patients, due to improper administration. as a third of patients come in pharmacy and request chronic medication without a physician's prescription, this commonly leads to complications which aren't discovered and treated in time. background and objective: the quality of medication use in nursing homes (nhs) is subject to growing concern. focus should not only be on appropriateness of prescribing, but also on correct pharm world sci (2008) 30:649-740 693 administration of the medication. the aim of this study was to investigate 1) the type and frequency of medication administration errors in nhs, 2) their clinical relevance and 3) whether a training session by a pharmacist on good medication administration practices can contribute to the prevention of the detected errors. design: the study had a pre-post design. during the first phase (pre), medication administration was observed during 5 days per ward by 2 pharmacists (barker method). phase 2 (intervention) consisted of a general information session on good medication administration principles provided by the 2 pharmacists to the nursing staff. moreover, the observed errors were discussed with the head nurse of each ward. phase 3 (post) took part one month after the intervention and consisted again of a 5-day observation on each ward. finally, in the last phase (phase 4), the clinical relevance of the detected errors was scored by an expert panel (geriatrician and clinical pharmacist). setting: 2 volunteering nhs with different medication distribution systems. in total, medication administration was observed for 122 residents. results: the number of detected errors was considerably lower in nh2 than in nh1. however, the type of errors did not differ. besides the unnecessary or forgotten preparation of medication, most problems occurred during the administration stage. 23.6% of crushed medications indeed were not suitable for crushing. the same applied to 43.5% of the opened capsules. moreover, the crushing hygiene was problematic: all medications for one resident were crushed together and the crushing device was not cleaned between different residents. inhalation techniques were inadequate in almost all cases (insufficient inhalation by the resident, coordination problems or expiration in the device). furthermore, specific administration moments were not taken into account. for example, the administration of alendronate (fosamax ò ) was observed in a horizontal position after breakfast, while it should be administered 30 minutes prior to breakfast in a vertical position. the nursing staff experienced the training course by the pharmacists as very interesting. 53.6% of the attendants found that the discussed topics were not sufficiently covered during their education. background and objective: the off-label use of intravitreal injection of bevacizumab (iib) for the treatment of macular edema (me) requires the approval of its use by health authorities. pharmacy department (pd) participates in that process, assessing each treatment request and preparing a sterile syringe for intravitreal administration. our aim is to evaluate the short term anatomic and visual acuity (va) response after iib in patients affected of me due to diabetic retinopathy or retinal vein thrombosis. the aim is to give an answer within 24 hours. setting: all three pharmacists are working in the virga jesse hospital, a large peripheral hospital of 600 beds in belgium. main outcome measures: implementation of the clinical helpline in the entire hospital. to make sure clinical pharmacy services are known by every physician and nurse and are easy to contact. results: we made an e-mail address and a schedule, so every day another clinical pharmacist is responsible for answering the questions. to let the physicians and nurses on the ward know we exist, we made flyers with the address and the explanation of the service. on a patient safety congress in the hospital, the clinical pharmacists presented a lecture concerning the advantages of clinical pharmacy services. the main aim is to explore other ways of delivering clinical pharmacy services. in belgium, the hospitals don't have a tradition of clinical pharmacy and there is no governmental support for this pharmaceutical function. with the clinical helpline we try to spread our services without having a clinical pharmacist on every ward. in the pharmacy we prepare the question thoroughly on paper. the clinical pharmacist has computerized access to all necessary medical information and pharmaceutical data. afterwards the pharmacist goes to the ward, to see the patient and to have a discussion with the physician. the physician can decide if he agrees with the given pharmaceutical advice or not. the clinical pharmacist has only an advisory function and doesn't do any therapeutic changes in the prescription. by collaboration of several caregivers, the patient receives a more complete and optimal therapy in our hospital. conclusions: by implementation of a clinical helpline, by an e-mail address, it is possible to spread our clinical pharmacy services over the entire hospital, without having a clinical pharmacist on every ward. the aim is to make an advice and go to the ward to discuss it with the doctor. not only physicians can use this e-mail address, also nurses can ask their questions. in this way we reach every caregiver. 67% of these pi was followed by modification of the prescription few days later. this study showed that 47% of the opinions were related to psychotropic drug overdose (often confirmed by psychiatrists after pi), especially neuroleptics, the most prescribed therapeutic class on the establishment. 21.1% of the pi was related to inappropriateness to available guidelines. we note an important proportion of no respect of correct use recommendations of long-acting rispéridone injection: no respect of posological equivalence, patients not stabilized by oral way, insufficient period of co-administration oral/im during the initialization of treatment… 2.16% of pi was guiding to drug management and to clinical and biological monitoring. drug related problems still under estimated without clinical and biological data accessible to pharmacists. however, pi may identify the risks related to therapeutic, to prevent potential problems, to reinforce the clinical and biological monitoring. comparison with a similar retrospectif study in 1998 shows that the number of prescriptions was increased (4030 in 1998 vs 5269), and number of pi doubled. however, nature and type of pi are virtually the same. conclusions: in order to reduce drp of overdose (the most frequent problem), an information strategy targeted to psychiatrists was developed and a updated list of maximal psychotrops posology was diffused and put on line. our study doesn't include problem of second -generation atypical antipsychotics association, this association still increasing despite fewer evidence and lucid guidelines; a second study will be soon conducted to identify pi having a significant clinical impact. conclusions: this study showed that clinical practices don't change even after reminding guidelines. information by fact sheet is not the best tool to spread guidelines. study's results will be submitted to an interactive presentation in medical staff, and clinical trials with iva are discussed and changed with acetaminophen oral route. the proportion of gp's that received, reviewed and returned the patient selection to the pharmacist, and the proportion of long-term users that received the informative letter. results: substantially more pharmacists in the intervention (77%) than in the control group (51%) handed over the patient selection to their gp's. 52% resp. 36% of the gp's received (n.s.), and 38% resp. 30% of the gp's reviewed and returned the list (n.s.). substantially more pharmacies in the intervention group got back any lists (70% vs 49%) and sent any letters (66% vs 40%). 20% and 13% of all longterm users received the informative letter in the intervention resp. control groep (n.s.). conclusions: the maximal implementation strategy was effective in getting the pharmacists started. the main outcome measures were not significantly different in both groups, though the realized effect on a large scale was relevant in practice. of the participants, total of 6.7% has heard of the term 'pharmacovigilance' in the period-1, which is entirely the academicians, while it is increased to 66.7% in the period-2 (chi-square test with yates correction, p \ 0.05), which are mainly expressed by the hospital (33.3%) and academician (23.3%) pharmacists. during the period-1, only 20% of the participants know where to report any adrs (13.3% academicians and 6.7% hospital pharmacists), whereas during the period-2, this figure is increased to 40% (13.3% academicians, 20% hospital and 6.7% community pharmacists) (p [ 0.05). the participants preferred to report any adrs mainly by the internet (66.7% vs 50%) and by the telephone (30% vs 46.7%) at the period-1 and the period-2, respectively (p [ 0.05). in terms of having reported any adrs among the participants, it is indicated that none of the pharmacists reported adrs at the period-1, but only three hospital pharmacists reported an adr at the period-2. conclusions: by the national regulations for pharmacovigilance, the pharmacists are entitled to report any adrs to the turkish pharmacovigilance centre. although this study is limited by the small number of pharmacists and location, it shows that there is an increased awareness and knowledge about pharmacovigilance. by the provision of pharmaceutical care, pharmacists' involvement in detecting and reporting adrs will improve, mainly in hospital and in community settings. background and objective: in france, global drug dispensing (gdd) is the common way to dispense drug inpatient. after an experience of implementation of individual drug dispensing (idd) the objective of the department of pharmacy was to prove the benefit offered by this system in comparing the clinical impact of the intercepted dispensing errors of both dispensing system. design: thirty days prospective study. setting: orthopaedic surgical care unit; department of pharmacy. main outcome measures: data related to drug preparation were collected by two pharm d students over a 30 days period and analysed. identified preparation errors were classified in four groups: discordance between prescription and drug administration, exceeding or missing treatment and, unidentified delivered drugs. then errors were classified in potential or effective errors. at last, pharmacist and prescriber have quote this errors. preparation errors were classified according to their clinical impact from 0 (no clinical impact) to 3 (life threatening). results: 1 631 drugs units were prepared with gdd vs 1 446 with idd. eighty effectives errors (4.90%) were observed with gdd and 11 (0.76%) with idd. clinical impact were 0 (34%), 1 (36%), 2 (30%) for gdd and 0 (90%), 1 (10%) and 2 (0%) for idd. a khi 2 test highlight a difference between the 2 dispensing system for clinical impact 0 and 2 (p \ 0.05). moreover, the mean value of weighting was about 0.95 with gdd vs 0.09 with idd (p \ 0.001). conclusions: this study shows the major benefit offered by idd versus gdd. errors weighting represent a relevant parameter for physicians. the results provided by this study highlight the role of the pharmacy staff, to reduce the incidence of medication errors and to promote a rational use of medicines. this work was the second step of our quality medication process; the next step will be the development of idd in several care unit by use and test automated process for preparing doses. for each prescription we collected information about the patient, the prescribed drug, the steps involved in its preparation and its administration. results: we collected 279 prescriptions (126 different drugs) concerning 77 children (average age: 6 years). sixty-two percent of medications were oral forms: 49% liquids, 25% tablets, 19% capsules. thirty-two percent of the tablets were cut; only 30% of those were authorized. due to the age, 44% of the tablets were crushed to facilitate administration whereas grinding was allowed in only 31% of the cases. most of the capsules were opened (71%) and 6% fractionated for an adapted dose. opening of capsules was possible in 92% of the cases. intravenous drugs represented 29%, the average injection was 71.5% of the vial; in 14%, less than a quarter was given. conclusions: about 20% of pediatric preparations were inappropriate. the results of this study highlight the need to provide drugs adapted to pediatric care, which is one of the main tasks of the pharmacy. we are thus developing more appropriate pharmaceutical formulations for children, such as oral suspensions. a comparative statement of solubilization rates in liquid of crushed tablets or capsules after opening has to be established. moreover if a pharmacist is present in the care units, most medication error will be avoided. background and objective: the world's population is aging. the elderly have many chronic disorders and consequently use more drugs than any other age group. safe, effective pharmacotherapy is one of the results: fifty patients received antibiotics according to several schemes. nineteen patients received prophylactic treatments during 3.3 days on average. the employed molecules were mostly part of beta-lactams' family (84.2%) including 87.5% of co-amoxiclav. the prophylactic treatment seemed to be effective in 73.7% of case because it wasn't followed by other treatment. thirty-one patients received probabilistic treatment: 19.3% of them received quadruple therapies, 22.6% received triple therapies, 35.5% bitherapies, and 22.5% monotherapies (only beta-lactams). the average duration of the probabilistic treatment was 3 days. twenty-three patients got curative treatment. compared with the probabilistic treatment or with the treatment at the entry, the curative treatment corresponded to a reduction of the spectrum in 75% of cases with mainly an arrest of the vancomycin (55%). monotherapy was the most prescribed (69.6%) and especially beta-lactams (68.2%). then came bitherapies (27.3%) and triple therapies (4.3%). the most frequent isolated germs were escherichia coli (12 cases), staphylococcus aureus (5 cases), pseudomonas aeruginosa (4 cases) and pneumococcus sp. (3 cases) alone or associated, including 8.7% of multiple-drugsresistant bacterias. the monitoring of aminosids and vancomycin was globally well carried out. only 17.6% of vancomycin's dosages and 22.2% of aminosides' dosages were not done. thirty-two patients increased their transaminases and/or their creatininemy. these increases were often physiopathological, related to multiviscérales failures or to septic shocks. the antibiotics could be clearly blamed in only one case. conclusions: in the surgical intensive care unit, antibioprophylaxy is longer than in recommendations. the probabilistic treatments used often associate active molecules on multiple-drugs-resistant bacterias. this can be explained by the gravity of infections, and the increased risk of bacteriologic resistances due to former treatments. moreover, bacteriological tests are systematically done, so antibiotics can quickly be adapt to the germs' resistances. background and objective: most of proton pump inhibitors (ppis) do not have legal mention for a paediatric use. however these drugs are largely prescribed to children. one disadvantage resides in the absence of liquid form which causes problems for their administration in nasogastric tubes. indeed, the absence of use recommendations involves many misuses responsible for inefficiency and/or tube obstruction. we tried to evaluate if ppis can be administered through paediatric nasogastric tubes. design: to quantify the transit of different ppis through paediatric nasogastric tubes and to optimise their modes of administration. setting: laboratory of clinical pharmacy and biotechnics. faculty of pharmacy. main outcome measures: we administered four ppis (mopral ò , ogast ò , inexium ò , ogastoro ò ) through nasogastric tubes by respecting their positioning in a child in a 30°elevation. for each ppi a study plan was drawn up to assess the influence of different variables: the volume of water to dissolve or put in suspension the ppis (2 or 5 ml), the rinse volume (2.5 or 10 ml), the length (50 or 125 cm) and the diameter (6 or 8 french) of the polyurethane tubes. for every tests (n = 134) we carried out an analysis of each active ingredient at the tube outlet by uv spectrometry. results: all 6 f tubes were obstructed by ppis. through 8 f tubes, we observed a mean recovery of active ingredient of 86% for ogastoro ò , 36.9% for inexium ò but only 7.1% for ogast ò and 3.9% for mopral ò . the length of the tubes had no significant influence on the loss of ppi at the outlet of the tube. a water volume of 5 ml instead of 2 ml increased only the final concentration of inexium ò (+26%). a rinse volume of 10 ml improved significantly the transit of mopral ò , ogast ò and ogastoro ò (+4.8%, +2.7%, +19.5% respectively). this rinse volume allowed to obtain a 94.5% recovery of lanzoprazole for ogastoro ò whatever the water volume employed for its administration. conclusions: the most satisfactory results were obtained with ogastoro ò : an administration volume of 5 ml and a rinse volume of 10 ml allowed a near-complete transit of lanzoprazole. under these conditions only 45% of inexium ò was recovered. it is disadvised using mopral ò and ogast ò through 8f nasogastric tubes because no condition ensure the transit of an efficient concentration of active ingredient. keywords: nasogastric tubes, proton pump inhibitors, children background and objective: feeding tube occlusion is a frequent problem. practices to make the clogging off are very varied and are not the subject of any consensus. no study have assessed the impact of the different products on the inner surface of the tubes. in this context, it seams to be important to evaluate if these products are safe in order to rationalize the practices. design: to study the inner surface of nasogastric feeding tubes after contact with various products used to unblock them. setting: laboratory of clinical pharmacy and biotechnics. faculty of pharmacy. main outcome measures: we have put in contact 12 f nasogastric tubes made of silicone or polyurethane with the following products: water, 1.4% sodium bicarbonate, orange juice, pineapple juice, cola, papain syrup, pancreatic enzymes. an analysis of the inner surface of the tubes was carried out after 7, 15 and 30 days by scanning electron microscopy (sem). photos of unexposed tubes were used as negative controls. photos of tubes exposed to heat, ether or sodium hydroxide were used as positive controls. results: the analysis by sem shows that the silicone tubes are not altered by the different products tested. on the other hand, the surface of polyurethane tubes is modified in the presence of 1.4% sodium bicarbonate and pancreatic enzymes. the papain syrup seems to settle on the surface of the tubes without altering it. water, fruit juices and cola do not modify the biomaterial whatever the exposure time. conclusions: 1.4% sodium bicarbonate, pancreatic enzymes and even papain syrup should not be used in practice to unblock the feeding tubes. the orange and pineapple juices as well as cola can be recommended because of their harmlessness with biomaterials. keywords: nasogastric feeding tubes, occlusion, scanning electron microscopy pc-118 assessment of administration practices of extemporaneous formulation pediatric capsule preparations helene richard 1 , anne jalabert 1 , sylvie hansel-esteller 1 1 pharmacy unit, lapeyronie and arnaud de villeuneuve hospitals, montpellier, france background and objective: to assess administration practices of pediatric capsules made as an extemporaneous formulation preparation by the laboratory of the pharmacy unit, in pediatric units. design: a questionnaire was designed and filled in by asking questions directly to nurses about their administration practices, from february to april 2007. setting: altogether, six pediatric units were consulted, corresponding to the units for which the laboratory carries out the most pediatric extemporaneous formulation preparations. main outcome measures: the questionnaire concerned the ten most made up pediatric preparations, which are: amiodarone, warfarine, captopril, propranolol, ursodesoxycholic acid, omeprazole, fludrocortisone, spironolactone, hydrocortisone and calcium carbonate. items filled in were: hygiene rules, the existence of administration procedures in units, preparation conservation, and practical administration details. results: in 3 months, 40 questionnaires were filled in. concerning hygiene rules, nurses wash their hands before every manipulation, 21% wear gloves, 10% wear a mask or a mobcap. no administration procedures were available in units and more than 80% of nurses would like to have one. in every unit, preparations were conserved at room temperature, in a dry place, and 87% in a light-free place. for amiodarone, propranolol, fludrocortisone, spironolactone and hydrocortisone capsules, nurses use sweetened water (g5%) to dilute capsule contents, sometimes milk (especially in newborns units). for the other drugs, the vehicules the most used were: sweetened water (55%), solid vehicules like yogurt, apple sauce, jam (17%), fruit juice or syrup (15%), milk (14%), and coca-cola (7%). the vehicule volume used fluctuates between 1 ml and 2 cl. nurses administer capsules by syringue into the mouth (38%), per os (33%), or by enteral nutrition (29%). conclusions: most of the administration practices of pediatric preparations are homogeneous in the different units (except the vehicule volume used). in the absence of administration procedures, the administration of preparations is more adapted to the child than to the drug. the aim of this study is to provide pediatric units with guidelines about good use of extemporaneous formulation pediatric preparations. services compared to a pharmaceutical care model. items pertaining to pharmacists' communication with the patient and the physician as well as the pharmacists potential to manage drug therapy were assessed. results: of the 1000 patients approached, 720 (72%) response rate was achieved. cronbach's alpha = 0.7084 (expectations) and 0.950 (satisfaction). females were 367 (51%), married (75%) and 52% had post-secondary education. some 83% expect accurate dispensing of their medications, 78% expect pharmacists to simplify their medications and 52% expect the pharmacist to spend as much time as possible with them. expectations were resolved into 3 components: humaneness, friendly attitude and professional competence. only 51% were satisfied with the professional appearance of the pharmacy, the rest of the items received dissatisfaction rating. two principal components of satisfaction were identified as humaneness and professional competence. marital status and level of education were associated with satisfaction scores. conclusions: patients' expectations of pharmaceutical care services were high but the satisfaction with current services compared to pharmaceutical care was below average. professional competence and humaneness were important dimensions of both patient expectations and satisfaction. there is a need to introduce pharmaceutical care. results: fourteen criteria were defined. a yes, no or not applicable answer has been given to each criterion according to the guidelines. drawing lots have been realised to set up a representative sample of twenty patients among those included in the study: six males, fourteen females, average age: 74.9 years old. two patients are below the average. the average mark of the patients is 56.3%. hemoglobin level of 40% patients is inferior to the targeted hemoglobin level (11 g/dl) at the end of the study. six criteria obtain a score superior or equal to 80%. five criteria obtain a score under 50%. the three criteria which obtain the best results concern the monitoring of the hemoglobin levels during correction phase and maintenance phase, and the maximum weekly dose of erythropoetin. the three criteria which obtain the lowest results concern the assessment of iron status before erythropoetin therapy starts (0%), the rate of increase in hemoglobin levels which should be 1-2 g/dl per month (25%) and the adjustment of total weekly erythropoetin dose. conclusions: the average grade obtained by the patients highlights the deviation from the guidelines. this indicates the needs of improving the anemia management in our haemodialysis unit. so it is necessary to make another time the team of doctors and nurses aware of the problem and to reinforce the pharmaceutic implication into the haemodialysis unit. a re-evaluation of practices (in the guise of clinical audit) must be planned in order to estimate the impact of the setting up of correctional measures. inclusion criteria were: oral and injectable drugs' prescriptions concerning patients who were present in the ward since more than 24 hours. results: 27 medical records were analyzed. patient age varied from 51 to 74 years old and the average duration of the hospitalisation from 4.5 to 13 days. omitted variables were: patient's weight in all cases, prescriber's quality in 93% of cases, prescription's hour in 63% and prescriber's signature in 59.3%. for each patient, all drugs prescribed since the beginning of the hospitalization in the unit was studied i.e. 334 lines of drugs. we have noted the inn was absent in 90% of the cases, pharmaceutical form in 74% and administration route in 57%. only one prescription had all variables. thus, the global rate of prescription conformity was 0%. in the 3 wards, nurses write the original prescriptions on a card-index (ci). then, drugs administrations are written on a temperature chart (tc) and on pharmacy's book (pb) for drugs order. we have compared documents one by one, for each drug. conformity rates are 60.5% (prescription/ci), 70.4% (ci/ tc) and 0% (ci/pb). the noted differences are multiple(modification of the administration or hour route, increase or dicrease of dosage…). the clinical relevance of non conformity was not studied. conclusions: from this study, it can be concluded that many prescriptions do not comply to the regulation and many retranscriptions are not identical to original prescriptions. it constitutes of course a potential iatrogenic impact. the development of computerized physician order entry (cpoe) in our hospital should be a corrective measure. the next stage will consist of realizing this study with cpoe and compared the 2 studies. anne-claire buire 1 , emilie prevost 1 , françois lebargy 2 , bertrand gourdier 1 1 pharmacy, 2 pneumology, reims teaching hospital, reims, france background and objective: assessment of antibacterial prescriptions regarding community-acquired lower respiratory tract infections and comparison with national guidelines. design: patients treated with antibiotics were included each day, during the analysis of the computerized prescriptions in the pharmacy. then, a report sheet was indicated in the unit with the prescribers for each patients with pneumonia or exacerbation of chronic obstructive lung disease. one month prospective study (in april 2007) included all patients hospitalised for pneumonia or exacerbation of chronic obstructive pulmonary disease (ecopd) in a unit of the pneumology department and treated with antibiotics. setting: pneumology department -reims university hospital. main outcome measures: for each patient the following data were assessed: age, hospitalization duration, diagnosis, severity factors, comorbidities and antibiotic prescriptions were analyzed. treatments were thought consistent when following the national guidelines [1; 2] . results: 63 new patients were hospitalized during this month. 44 (70%) were treated with antibiotics: 4 with no pulmonary pathology and 40 with pulmonary infection (19 patients with pneumonia, 4 with ecopd, 5 with pleurisy, 4 with exacerbation of asthma, 4 with chest secondary infection, 2 with acute respiratory infection, 2 with thoracic pain and 1 with cough). then, the study focused on 23 patients: 19 pneumonia and 4 ecopd (m/f = 13/10, mean age: 61 years old). hospitalization duration was about 10 days. 18 patients (78%) had at least one co-morbidities factor (the majority: 9 with pulmonary antecedents) and 13 (57%) a severity factor (the majority: 10 with an attack of the vital functions). 12 antibiotic treatments were initiated in the unit and 11 out (9 in emergency department and 2 by general practitioner). all treatments initiated in the unit were consistent with the recommendations and revaluated with the bacterial results (except one treatment) or changed because of bad tolerability. bacteriological documentation was always researched and the results were significant for 6 patients (26%): 3 streptococcus pneumoniae, 1 pseudomonas aeruginosa, 1 proteus mirabilis with morganella morganii and 1 haemophilus influenzae. when it was possible, per os relay was realized in the 24 at 48 hours, except for 2 patients (relay in the 3 days). conclusions: in this survey, the management of pneumonia and ecopd was globally consistent with the national guidelines. nevertheless, the bacterial documentation is poor and the antibiotics prescriptions for bronchopulmonary infections are difficult and need using molecules with large spectrum. collaborate with all of the health care professionals and patients and to identify causes of errors. the unique position and possibilities of a pharmacist enable him to follow up the errors, from a fact that he is an expert on medication properties and is basically the last in a row who deals with drugs before their administration to the patients. the aim of this study was to describe and evaluate the role of pharmacist in identification and dealing with medication errors in czech pharmacy. design: 30 pharmacists identified and recorded all medication errors over a period of six months of pharmaceutical care. basic characteristic of pharmacists: mean age 35.0 years; mean length of pharmaceutical practice 9.7 years; 16 of them worked in the hospital pharmacy. 19 of them got the first grade of attestation in pharmacy (by 4 years of working experience in pharmacy and by passing exams). pharmacists collected the following data: types and causes or errors, their interventions, drugs and time concerning errors, subjects making errors and patient's characteristics as age, gender, other drugs used and co-morbidities. all the data were processed by descriptive statistics. background and objective: there is no standard of care to prevent oral mucositis for patients with cancer treated by chemotherapy. most common treatment is local (mouthwashes). no commercial mouthwash solution is available. special preparations are compounded by clinical units. a new 1.4% sodium bicarbonate solution presentation was recently proposed for local treatment. our hospital drug committee decided to evaluate the clinical practices of oral mucositis prevention related to anti-neoplasic agents. design: an observational study conducted in pitié-salpétrière hospital. interview of nurses and physicians by pharmacy students about mouthwashes prescription and practice. data recorded on pre-established questionnaire and analyzed in pharmacy department using microsoft excel ò . setting: study performed in oncology, hematology and radiotherapy clinical departments and in clinical units with oncologic activity (gastroenterology…). during one year, more than 2600 patients received anticancer chemotherapy. main outcome measures: questionnaire items were: use of a specific mouthwash procedure within the service, use of a single agent or in combination. data collected from the nurse point of view were: preparation and administration practices; from the physicians' perspective: circumstances of prescription and duration of the treatment. results: 31 questionnaires were analyzed (nurses: 10, physicians: 21) from 7 clinical units. there was a standard written procedure in only one clinical unit. several formulations were used: each physician proposed his own, including antifungal prophylaxis (amphotericin b, nystatin), antimicrobial agents (povidone, chlorhexidine), mucosal surface protectant (sucralfate), alkalin solution (sodium bicarbonate), anti-inflammatory agent (aspirin), anaesthetic drugs (lidocaïn) and other agent (glycothymoline). preparations were not systematically labelled with patients name, formulation, date of preparation and stability duration. these were administered from 2 to 4 times daily regardless the stability compounding. for physicians, prescriptions of mouthwashes were done for patients with specific toxic anticancer drugs (5-fu, anthracyclin, capecitabin and sunitinib), were concomitant with chemotherapy and systematic after radiotherapy. conclusions: there are variations among clinical units in terms of mouth care regimen used. treatment efficacy was never evaluated. drug committee worked on guidelines in order to prescribe antifungal therapy only for curative aim or avoid anaesthetic drugs (swallowing difficulties). good practices included, before chemotherapy, dental hygiene. maintenance is realized by the patient himself (mouthrinses with alkalin solution or chlorhexidine). analgesics can be taken orally in case of mouth pain. design: the open, randomized, single-blind two-sequence, two-period crossover study design was performed. setting: under fasting conditions, each subject received a single oral dose of 10 mg olanzapine tablet as a test or reference formulation on 2 treatment days. the treatment periods were separated by a oneweek washout period. main outcome measures: the plasma concentrations of drug were analyzed by a rapid and sensitive hplc method with uv detection. results: the pharmacokinetic parameters included auc0-24 h, auc0-infinity, cmax, t1/2, and ke. the mean auc0-infinity of olanzapine was 570.76 and 558.66 ng h/ml for the test and reference formulation, respectively. the maximum plasma concentration (cmax) of olanzapine was on average 15.82 ng/ml for the test and 15.73 ng/ml for the reference product. no statistical differences were observed for cmax and the area under the plasma concentration-time curve for test and reference tablets. 90% confidence limits calculated for cmax and auc0-infinity of cefixime were included in the bioequivalence range (97.3-109.2%). conclusions: therefore, the two tablet formulations were considered to be bioequivalent. conclusions: clinical pharmacists effectively validate 43% of these prescriptions but one third of prescriptions will inevitably remain validated by pharmacist residents during night and week-ends. performance criteria must be proposed to measure impact of pharmaceutical improvement initiatives (validation procedures writing, continuous education for example). we suggest to test clinical pharmacy activities related to economic indicators and to medication events reduction. background and objective: education of patients with type 2 diabetes is a key point of non-medical management of that disease. thus objective was evaluation of patients' knowledge about their disease and its management for further development of pharmaceutical care protocols. design: prospective cohort control study. total 100 patients casually were divided in two equivalent groups: study group (n = 50), age 64.4 ± 8.93, diabetes duration 9.02 ± 6.74 who were questioned by face-to-face technique and received pharmaceutical care during the interview; control group (n = 50), age 61.6 ± 8.89, diabetes duration 6.97 ± 5.63 and filled in questionnaires without clinical pharmacist. inclusive criteria were: presence of type 2 diabetes mellitus, duration of the disease was not considered as criteria. patients were inquired once following standardized questionnaire. all included patients could read and write. two groups controlled their diabetes mostly by oral antidiabetics, only n = 6 in study group and n = 2 in control used insulin. setting: out-patient setting of lviv clinical hospital no4, endocrinologist's office. main outcome measures: assessment of patients' knowledge about diabetes and self-monitoring in study and control groups. results: only 32.0% and 30.0% of inquired patients in both groups respectively stated that they possess good knowledge about diabetes. but as it was shown by evaluation of their level of knowledge through assessment of keeping to diet, regular physical activity, self monitoring it didn't conform completely. diet was implemented by almost 70% of patients in two groups, while regular physical activity was declared only by 14.0% in study and 46% in control groups. smoking was reported by 14.0% and 16.0% respectively. next step was evaluation of self-monitoring. it has been revealed that only 12.0% and 10.0% of patients in two groups performed blood glucose monitoring at home; body weight was controlled by 58.0% and 50.0% respectively; blood pressure by 50.0% and 58.0% as well. target level of blood pressure was achieved by 42.9% of subjects in study group and in 40.9% -in control. in study group foot examination was performed everyday by 70.0% of patients when in control only by 18.0%. no one from both groups evaluated glycated haemoglobin regularly as it is recommended by american diabetes association, those they couldn't state their present or previous parameter. conclusions: it was estimated that knowledge about necessity of diet following, regular physical activity, and particularly -self-monitoring was very poor in diabetic patients, no regarding compliance which possibly also will be low. even if patients stated good knowledge about the disease they had problems with self-monitoring. it is obvious that patients of this out-patient setting require adequate education, which should be a component of pharmaceutical care program implemented by the clinical pharmacist. protocols of pharmaceutical care for these patients must be developed and include standard procedure of type 2 diabetes patients' education. pharmacy department, hospital universitari vall d'hebron, 2 pharmacy department, 3 pharmacy department, hospital universitari vall hebron, barcelona, spain background and objective: patients who are admitted for a programmed orthopedic surgery in a tertiary hospital are usually elderly and present high co-morbidity which makes therapy complexity increase. the objective is to evaluate whether a pharmaceutical care is necessary before patients hospital admission. design: we analysed the domiciliary treatment in 1000 patients who attended to a pre-surgery visit. a form designed by the pharmacy department and validated by anaesthesiology unit was delivered to the patient to fill in with domiciliary therapy. the average of prescribed drugs was 4.66 per patient, being this reduced to 3.9 drugs in patients younger than 65 and increased to 5.13 in patients older than 65. over one third of patients (340/1000) were taken orally nonsteroidal anti-inflammatory drugs (nsaids). from 495 ai, 122 would need a pharmacological evaluation in the preoperative. those were included in 1998 drugs, meaning the 42.8% of the different drugs prescriptions. this percentage belonged to 860 patients. conclusions: the fact that a high percentage of patients over 64 with an orthopedic pathology take a considerable amount of drugs at home makes it necessary to monitories the therapy in order to minimise the iatrogenic problems during the admission. we have seen that this situation is so frequently (86%) in our study, so the pharmacy department has established a collaborative job with anaesthesiologist unit to reduce as much as possible therapy problems. levation. through each tube, a 1500 ml nutritive solution was delivered on 24 h each day during one week. after dissolution in 5 ml water the ppis were administered once a day after stopping of the enteral nutrition and rinsing of the tube with 5 ml of water. the tubes were then rinsed with 10 ml of water and the nutrition was started again. during each administration of ppi the suspension was collected at the tube exit in order to quantify the ppi by uv-spectrometry. results: no tube was obstructed. the enteral nutrition mixture did not adversely affect the transit of lansoprazole through 8f nasogastric tubes. the transit of lansoprazole through the tube was complete and regular during the 7 days of the study (100.4 ± 4.2). for esomeprazole the mean recovery of active ingredient was of 79.2 ± 17.4 (coefficient of variation: 22%) this variability can be explained by the incomplete and inconstant dissolution of esomeprazole because of the low volume of water usable in paediatry. conclusions: orally disintegrating tablet of lansoprazole can be administered through 8f nasogastric tubes in a concomitant way to an enteral nutrition mixture. for esomeprazole there is a variability of the administered active ingredient. however enteral nutrition doesn't seem to affect the esomeprazole transit. low volumes of water used in paediatry seem to be responsible for the variability. results: we analyzed pharmacological treatment in 14 patients, with a mean age of 46 years old (27-77). the average of drugs per patients was 11 (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) . after checking the sources we detected 63 possible pi (4 severe, 40 moderate and 19 slight), observed 73 times. pi were detected in 9 of 14 patients and mean per patient was 5. 2 (0-19) . the following pi were described: increase of sedation (9 patients), risk of bleeding (2 patients), serum potassium levels alteration (3 patients), hypotension (1 patients), risk of hepatotoxicity (1 patients), increase of creatin kinase levels and risk of myopathy (1 patients). from all these, only two were observed: sedation which was observed in all patients and hypotension which permitted the reduction of patient antihypertensive treatment. conclusions: the most frequent pi was sedation which is considered beneficial in order to reduce anxiety in sci patients. arterial tension, electrolytic balance, hepatic and renal function, as well as risk of bleeding, are regularly controlled in the sci unit. this way, if one of these parameters was altered it would be easily detected. to conclude, it would be important to carry out regular checking to detect pi, especially for those drugs that are not usual and for those symptoms that are not controlled regularly in the sci unit. background and objective: pharmacists' individualized counselling of patients has positive impacts on the management of hyperlipidaemia, including improved compliance and better treatment endpoints. the objective was to evaluate patient knowledge on hypercholesterolemia and its treatment and to assess impact of pharmacist intervention at the lipid clinic. design: one hundred and fifty statin-treated patients were recruited by convenience sampling. following completion of a scored pre-intervention questionnaire, the pharmacist provided education on hypercholesterolaemia and the use of statins. a leaflet was prepared, evaluated and distributed to the patients. the patients completed again the same questionnaire after the intervention (post-intervention). results: patient demographics: 42% (63) were males, 58% (87) were females, mean age was 59 years (range 32-76 years). a response rate of 71% was achieved with 98 patients completing both questionnaires. following the educational intervention by the pharmacist, knowledge regarding the correct action to be taken if muscle pain or tenderness occur during statin therapy increased by 34% (p = 0). the awareness regarding the normal total blood cholesterol level increased by 22% (p = 0.0001) and the knowledge regarding the need for low-fat diet consumption during statin therapy increased by 27% (p = 0). face and content validity of the patients' leaflet were strong. the average gunning fog index obtained for the leaflet was 11.6 indicating good readability for individuals. the leaflet was endorsed by the local health promotion department and 10 000 copies were printed and distributed to patients. background and objective: in order to assess the performance of bayesian individualization of busulfan (bu) dosage regimens, venoocclusive disease (vod) rate was monitored for paediatric patients undergoing allogeneic bone marrow transplantation (bmt). design: consecutive patients undergoing allogeneic bmt with bu as conditioning regimen during five years period (january 2000 to febuary 2006) were retrospectively reviewed (66 patients). setting: vod was major outcome variable. preconditioning risk of vod was estimated for each patient using a scoring system that included type of transplant, recipient cmv-positive status and total parenteral nutrition provided pretransplantation. a risk-adjusted cumulative sum method was used to compare observed versus predicted outcome by assigning a risk score, based on log-likelihood ratios, to each patient. main outcome measures: the cumulative scores were sequentially plotted with preset control limits for ''signalling'' where results were substantially different than expected (doubling or halving of odds ratio). results: sixty-six children received bmt after oral busulfan-based conditioning regimen with median age 3.9 years, 63.6% of male. median preconditioning risk of vod was 0.34 range (0.23-0.84). observed vod rate was 16.7% (n = 11) which was 60.7% (17 patients) fewer than the expected number estimated by the risk score. the resulting risk-adjusted score for each patient was plotted sequentially. this plot adopted early a negative slope, crossing the lower control limit twice, after 27 and 66 patients, indicating improved results compared to those expected. background and objective: geriatric patients use numerous drugs; because they have several concurrent diseases. 85% of those 65 years old and over have at least one chronic disease, 30% have 3 or more chronic diseases (1) . the purpose of this study is to evaluate data on the geriatrics' drug usage, assess the appropriateness of their drug treatment and identify their pharmaceutical care requirements. design: patients, who were 65 years old and over and live in a nursing home in the anatolian part of istanbul, were included in our study. by interviewing the patients, individualized information was obtained regarding the drugs they used, dose and frequency of drugs, the purposes of medication use and side effects, and who suggested or prescribed the drug. the patients at risk of drug induced problems were defined and a risk map was developed. patients who have 4 or more risk factors were accepted as being in a high risk category. setting: a nursing home. main outcome measures: the demographic, clinical and drug data of the patients were recorded. the pills count that patients used daily and totally; side effects of the drugs; knowledge of patient's diseases and drugs; risk category of patients were assessed. results: polypharmacy was identified in 44% of those included in the study (total of 146 patients who take drug therapy). generally it was observed that the drugs were prescribed at an appropriate dosage and time; however 80% of the patients didn't know for what they were taking drugs. just 2 (1.4%) of the patients were aware of the conditions under which they should take drugs. 88 of the patients (60.3%) were not aware on how to and when they should receive their drugs. 24 patients (16.4%) were using their drugs by self-administration. the drugs of 122 patients (83.6%) were administered by their nurse. 8.75% of the patients were receiving no medication. mean of number of drug used by patients was 5.89 ± 3.61. 24.65% of patients were in a high risk category. conclusions: as a result, drug effects alter due to polypharmacy, physiological and psychological changes. drug treatment should be individualized and monitored in geriatrics. according to our results, patients have lack of knowledge on drug use and they have never been educated in this matter. it is necessary to begin meeting their factor analytical technique can be either exploratory or confirmatory. exploratory factor analysis (efa) remains one of the standard and most widely used methods to demonstrate construct validity of new instruments. it is used to help development of the instrument by revealing items that may be made redundant from the questionnaire because they contribute little to the presumed construct. the seip consists of 24 items in five domains and is scored on a four-to-fivepoint likert scale. the aim of the study was to assess further psychometric property of the seip using principal component factor analysis (pca). the strength of the inter-correlations among the items will be assessed by the presence of coefficients greater than 0.30 in the correlation matrix. if few correlations above this level are found, then factor analysis may not be appropriate. 193 issues were identified including 101 related to inr controls not performed and 27 due to a poor/no adjustement of the oat dosage. 91% of the issues resolved following the pharmacist recommandations conclusions: computerized follow-up system allows to check inrs at the right date and to reduce the loss of results. pharmacists' recommendations were well accepted by physicians. the impact of the follow-up on the reduction of the overdose incidence will have to be evaluated. indications were hip (n = 72) and knee (n = 24) total replacement, other orthopaedic surgery of lower limbs (n = 13) and pulmonary embolism treatment (n = 1). indications were ''off label'' for 7 patients with allergic reaction to heparine and 3 were not documented. at least one of the 3 haemorrhagic risks factors was identified in 42 patients (35%). conclusions: fondaparinux is mainly used in approved indications. within the 42 patients with haemorrhagic risks factors, no haemorrhagic accident was notified in the pharmacovigilance records of our hospital. nevertheless, fondaparinux has to be administred cautiously in this population of patients for whom the 1.5 mg dose will be necessary and hopefully available in a few month. diagnose group a streptococcal (gas) acute pharyngitis. this study aimed to evaluate the service; examine whether current clinical records were adequate; and test hypotheses investigating the association between clinical prediction rules (center criteria, cc), rapid antigen detection tests (radt) and antibiotic prescription. design: initially, a semi-structured interview was conducted to gain an insight into the service. data was retrospectively obtained from a standardised template (apef), completed by a pharmacist at the time of each patient visit. patient demographics and symptoms, radt results, cc scores and follow up rates were analysed. chi squared analyses were performed to investigate the aforementioned hypotheses. setting: jones pharmacy, spokane, washington dc. main outcome measures: establishing adequacy and effectiveness of clinical records and relationships between clinical prediction rules, radt and the antibiotic prescription. results: out of a total of 76 patients (mean age = 22; male = 33) there were 38 children (mean age = 9.9; male 16) and 38 adults (mean age = 33; male = 17). ten (47.6%) of the 21 negative radt results amongst children were referred to a primary healthcare provider. out of 72 patients, 58 (80.6%) needed a radt to be performed. only 25 (34.7%) out of 72 patients were followed up. significant association existed between radt outcomes and the prescription of antibiotics (p = 0.001, p \ 0.05). conclusions: the findings from this study indicate that pharmacists need to be educated on the importance of a comprehensive clinical record. inconsistent practices occur amongst pharmacists due to the conflict between us guidelines, particularly relating to the referral of children with negative radt results to a primary care provider. the template was an efficient tool for data collection. jones did not tailor their data collection for the purpose of the study: with improved data collection, jones can yield information demonstrating the value of this service in future studies. only 9% of the 67 rhophylac prescriptions. 100 lg of anti d ig were administered when natead was available, whereas 200 lg with rhophylac excepted 4 times where 300, 400 or 600 lg were administered. 5 times the pharmacist has induced a modification of the posology. however, none prescription was made according to the afssaps recommendations. 15 prescriptions were made for children in hematology unit concerning 4 boys and 2 girls. among 8 prescriptions of 100 lg natead, 100% were correct and 29% for the 7 rhophylac. the dose administered was not standard (200, 100 or 25 lg) and none prescription was conformed to the recommendations. conclusions: this study shows that since rhophylac was commercialized (more expensive than natead), the doses administered have doubled and the national recommendations (existent for adults only) are not followed. the reason is that hematologic patients may have a lot of transfusions so they want to protect them from any immunization, despite they are immunocompromised patients. new recommendations are needed, more applied to the practice and precising doses for children. the role of the pharmacist is then to remind physicians good practices of prescription. 1 pharmacy, chu bicêtre, le kremlin bicêtre, france background and objective: computerized prescriptions are settled in clinical wards of our hospital. as pharmacist we have to validate those prescriptions and make recommendations to change part of the prescription such as dose, drug drug interactions. the objective of this study is to evaluate what kind of pharmaceutical interventions physicians really pay attention to. design: the prescriptions had been analysed for three months in three medical care units by two pharmacists. one of them take part in the physician round in order to integrate particular medical practices. pharmacist's interventions were recorded and categorized. the ratio of accepted interventions by the physicians was assessed. setting: three medical care units: 2 internal medicine services (acute care unit: 10 beds and long term hospitalisation: 18 beds) and acute geriatric unit (12 beds) in a 1000-bed french university hospital. main outcome measures: description and analysis of pharmacist's interventions in clinical wards. results: we analysed 944 prescriptions. 104 interventions were performed and categorized. it should be noticed that 35% of pharmaceutical interventions were for misused of the new software: wrong selection of unit (75%) and redundant order (25%). the other 65% interventions were related to the prescription, our suggestions were as follow: time of administration (29%), adequate drug formulation (18%), dose adjustment (17%), therapeutic drug monitoring or biologic follow up (16%), to stop treatment (13%), route of administration (7%). among these recommendations, 32% were the consequence of drug-drug interaction. 57% of the interventions led to change in the prescription. 34% of the physicians maintained their prescription despite the recommendations, mainly for staggered administration to avoid drug interaction. background and objective: sliding scale insulin therapy (ssi) is a commonly used method of adjusting insulin in an attempt to control a patient's blood glucose levels. previous research investigating ssi use in the hospital setting has determined that ssi therapy leads to poor glycaemic control and poor patient outcomes. therefore, a corrective schedule for ssi therapy is recommended by the american diabetes association (ada). the aims of this study were therefore to determine, for the first time whether ssi recipients experience problems in the home care setting and whether ada guidelines on ssi use are being adhered to. design: eligible patients were identified through electronic records of patients admitted from 1st january to 31st december 2006. the list was utilised to obtain medical charts of the patients. relevant information including patient demographics, blood glucose readings and documented problems were recorded using a standardised data collection form. chi-squared statistical analysis was determined using spss version 14.0. setting: the visiting nurses association (vna) home care agency, spokane, washington state, usa. main outcome measures: use of 'traditional ssi therapy' versus 'corrective' version recommended by ada. results: of the total 117 (male = 45, female = 72; mean age = 67.37, age range = 34-96) patient medical records examined in this study, 36.75% (n = 43) had at least one problem documented with their insulin regimen. the most common problem that affected over a quarter of the population, 25.64% (n = 30) was 'lack of control' which included any hyper-and hypoglycemic events. more than a third of sliding scale recipients, 37.61% (n = 44) had preprandial blood glucose levels above 150 mg/dl. in total 70.94% (n = 83) of patients were prescribed the non-recommended traditional ssi therapy and only 29.06% (n = 34) were using the recommended corrective ssi therapy. conclusions: the findings of this study support previous concerns that ssi use is prone to problems and poor glycaemic control. furthermore, this study has established the lack of adherence to the ada recommended use of the corrective ssi schedule in the home care setting. it is hoped that this study will influence use of ssi in hospital and home care agencies as well as national and international guidelines. background and objective: prolonged (more than 48 hours) mechanical ventilation (mv) is the most important factor associated with nosocomial pneumonia (1) . nosocomial pneumonia (np) is differentiated in to ventilator-associated pneumonia (vap) if the process arose after the patient has been receiving at least 24 h of mv (2) . vap is defined as an inflamation of the lung parenchima caused by infectious agents not present or incubating at time mv was started (1). design: longitudinal, prospective and observational study. setting: we made a prospective evaluation of the clinical files of a patient population of 14 cases with vap diagnosed between april 2006 and december 2006, who were assisted in hospital garcia de orta. a total of 14 patients, 57% male and 43% female, aged 62 ± 15 years were diagnosed with vap. vap was defined as new positive respiratory culture after at least 24 hours of mv. main outcome measures: these data sugest that the increase of pcr for documented vap caused by pseudomonas aeruginosa ocurred more frequently with ceftazidim than other antibiotics. results: in all vap episodes, an aetiologic microrganism, was isolated from 26 hemocultures and 22 bronchic secretions. the gramnegative bacteria were the most commonly isolated microorganisms (68%). we collected pcr and leucocytes data of seven documented schedules (n = 7) for erradication of pseudomonas aeruginosa: (1) ceftazidime (2 g q8 h) + gentamicin (5 mg/kg qd), (2) ceftazidime (2 g q8 h) + ciprofloxacin (200 mg q12 h), (3) piperacillin-tazobactam (4 g/500 mg q6 h) + aztreonam (2 g q8 h), (4) piperacillintazobactam (4 g/500 mg q6 h) + gentamicin (5 mg/kg qd), (5) piperacillin-tazobactam (4 g/500 mg q6 h) + amikacin (15 mg/kg qd), (6) imipenem-cilastatine (500 mg q6 h) + gentamicin (5 mg/kg qd), (7) meropenem (1 g q8 h) + gentamicin (5 mg/kg qd). the mean duration of antibiotic therapy was 10 days. there was an increase of the pcr values of the patients who were scheduled with ceftazidim but in the other groups there was a decrease of this parameter. the number of leucocytes didn't have any impact of the pcr variation (p [ 0.05, t-test). considering the group of the 14 patients, 75% (6) of the positive cultures for pseudomonas aeruginosa which were sensitive to either ceftazidim or a carbapenem or piperacillin-tazobactam were treated with ceftazidim instead. conclusions: this approach provides useful information on the relation of host defenses and the clinical outcome. it is also useful to study the prevalence of acquired resistance to several antibiotics that may be used in documented antibiotherapy for pseudomonas aeruginosa. background and objective: rfviia is increasingly used as rescue therapy in uncontrolled bleeding, however little information is available regarding its safety and efficacy in this indication. -indication for use: massive bleeding when first-line treatment (surgical control of bleeding, use of blood products) has failed; -to achieve the correction of factors that may interfere with coagulation (hypothermia, severe acidosis, hypocalcemia); -before administration of rfviia the patient or his family should be informed about the treatment; -the prescription of fviia should be initialized by a referent physician -to conform the dose of 60 mu/kg in cardiac surgery patient. conclusions: several solutions have been proposed to the physicians to improve their professional practices: to develop an algorithm for use of rfviia, to fill in a checklist before administration of rfviia to be sure to follow the guidelines, … this study will be extended in others departments using rfviia as gastroenterology and traumatology. pharmacy, administração regional de saúde de lisboa, 2 pharmacy, administração regional de saúde de lisboa, lisboa, portugal background and objective: the pharmacist can contribute to the maintenance and recovery of population health conditions participating in patient house visit 0 s health teams. pharmaceutical care at this level may also have a real impact on the health system costs. the aim of this project is to establish a pathway at this care level in which all aspects of pharmaceutical care are explained and defined. design: program description. participation of the pharmacist in health care teams. definition of field areas, between the pharmaceutical hospital care and the community pharmacy and health care centers. articulation between the hospital pharmacist, the health care center pharmacist and this new ''home pharmacist''. definition of the different types of pharmaceutical care to be implemented in this setting. background and objective: hip fracture is a major public health problem with a high incidence and prevalence in people aged 65 years and older. changes in body composition and organ function, drug-drug interactions, and co-morbidities should be taken into account in the pharmaceutical care of this group of patients. the aim of this study is to analyse pharmacological treatment of elderly patients ongoing hip fracture in order to improve pharmaceutical care in this group of patients. design: a prospective pilot-study was performed during one month, (may-june 2007) in 14 patients admitted in a tertiary hospital ongoing hip fracture. these variables were recorded for each patient: sex, age, body mass index (bmi), diseases antecedents, serum creatinine and creatinine clearance estimated by cockroft-gault formula, serum albumin levels, lymphocytes count, sodium and potassium levels. drug treatment was recorded from pharmacy database. setting: patients with hip fracture admitted in a tertiary hospital. main outcome measures: prescription profile in elderly patients with hip fracture. results: of 14 patients, 9 were female. mean age was 80.4 years old (68-96). mean bmi was 27.6 (n = 10, range 21-35). albumin levels were lower than 3.4 g/dl in 10 patients. sodium levels were out of the normal range in 7 patients. five patients had creatinine clearance lower than 50 ml/min, 2 of them less than 30 ml/min. we analysed 119 prescriptions which included 50 drugs. they were classified in 5 categories: not adjustment required (16 drugs), adjustment required (12) , inappropriate based in beer's criteria (1), precaution in elderly people (10) and not enough information available in geriatric population (11) . mean number of drugs per patient was 9 (5-15). of 119 prescriptions revised, 22 required adjustment and 15 of them were correctly adjusted. of 24 prescriptions in precaution group 18 were correctly prescribed. conclusions: dosage adjustment or precaution was required in 40% of prescriptions. of these, 75% (33/46) needed dosage adjustment according to renal function. besides, 36% of patients had renal function alteration. thus, it is important to improve pharmaceutical care in this group of patients specially for those drugs that need dosage adjustment in renal failure. keywords: pharmaceutical care, hip fracture, elderly patients pc-282 hospital pharmacists and community pharmacists: an experiment of pharmaceutical information transmission carried out in an anticancer center anne lebreton 1 , erwin raingeard 1 , christelle audeval 1 , sophie rochard 1 1 anticancer center, centre rené gauducheau, nantes, france background and objective: to evaluate a programme of pharmaceutical information transmission from hospital pharmacists to the community pharmacists about drugs, particularly anticancer drugs, dispensed until then by hospital pharmacy and now distributed by them. design: while doing the last dispensation by the hospital pharmacy, an informative fax was sent to the community pharmacists indicating the name of the patient, prescribed drug and its posology, date and quantity dispensed, approximate date of the next dispensation and general information about the delivered drug. one month later a questionnaire was sent to the pharmacists to get their appreciation about this document. in the case of having no answer from them, the same questionnaire was re-sent. setting: pharmacy of french anticancer center, centre rené gauducheau, nantes. -appropriateness of the way of transmission -pertinence of information sent -efficiency of the programme results: out of 49 patients treated (11 vinorelbine oral, 10 erlotinib, 12 sorafenib, 16 sunitinib), 34 (69.4%) were registered in this study, involving 32 pharmacists. six pharmacists (18.8%) answered after the first sending of the questionnaire and 14 (43.8%) answered after they received the remainder. fourteen pharmacists (43.8%) did not answer. all the pharmacists were satisfied with the way of transmission. however, one of them suggested having the information sent by e-mail. seventeen professionals (85%) thought information was useful and 9 (45%) thought that it was sufficient for their practice. only 6 pharmacists (30%) encouraged us to continue the programme; the others did not express any opinion about its efficiency. moreover, none of them called us even though we suggested so. conclusions: this experiment seems to be interesting and to correspond to the needs of the pharmacists. it would also be an easy way to make dispensation safe. nevertheless, many problems appeared: much time spent and the difficulty making an exhaustive follow-up of all the patients thus limiting the application of this kind of programme to larger cohort. background and objective: to make a proposal of software that facilitates the analysis of clinical relevance of antiretroviral drug interactions, in the medical prescription, dispensation and dader methodology of pharmaceutical care study phase. design: pubmed and other databases evaluate revision. antiretroviral drug interactions were classified in four levels according to probability and severity of the interaction. the probability was grouped in 3 categories: defined, probable and possible. so, severity was grouped in 3 categories: serious, moderate, and slight. the levels are: level 1 (serious and defined or probable); level 2 (serious and possible, moderate and defined or probable); level 3 (moderate and possible, slight and defined or probable) and level 4 (slight and possible). we used the pubmed and database review for identified and organized the information to software elaboration. were by the enzymatic inhibition. antiarrhythmics, antihistaminics, ergot alkaloids, prokinetics, benzodiazepins, statines, calcium channels antagonists, phosphodiesterase inhibitors, azoles antifungics, selective serotonin reuptake inhibitors, opioid analgesic, immunosuppressants, macrolides, classic anticonvulsivants, and riphamicins were the most common drug therapeutic groups with anti-retroviral drug interactions. conclusions: 3694 interactions were classified, which 94% were drug-drug interactions; as well, 94.2% were pharmacokinetics interactions and in their majority (78.3%) were mediated by the enzymatic inhibition. about 36.7% of interactions were level 1 and 2, this levels of greater clinical relevance and whose the alert generated by software are contributions that help to analyze and take decisions with respect to the handling from the same ones. outcomes (e.g. mortality, morbidity, adverse drug reactions.); a profile of patients and clinical activities; an update of task description based on evidences and context. results: studies demonstrate that pharmacists have an impact on selected clinical outcomes following clinical pharmacy activities (e.g. drug therapy monitoring, pharmacokinetics and education for medical and paramedical professional). patients admitted in the intensive care unit have a higher level of complexity of care than average patients in the hospital, but a similar length of stay. for pharmacy services, their drug cost per admission is higher (503$cad vs 380$cad), as the number of pharmacist paid hours per admission (1.1 vs 0.88) and the number of pharmaceutical interventions per admission (2.05 vs 1.74). the approach helped us to identify solutions to problems like the nonparticipation to the cardiology patient's round, the absence of a medication reconciliation process or the inconstant documentation of interventions. a revised task description will be tested by both clinicians. conclusions: this study illustrates an approach for the evaluation of a pharmaceutical care model in a pediatric intensive care unit. background and objective: from 2005, an increase in the consumption of biological and synthetic glues was noted in the cardiac service of surgery. these are drugs and expensive medical devices, which represent an expenditure of more than 80 k€. the impact of their use was evaluated on the post-operative bleedings, the duration and the cost of stay by the way of a economic medical study. design: an observational exploratory study was carried out between january and march 2007. all the operated patients were included. setting: the computerized consultation of the patient files made it possible to identify the following criteria of judgement: indication, surgeon, type of glue used, catch of platelet aggregation inhibitors or oral anticoagulants, volume of drainage, number blood transfused, duration of hospitalization. the statistical analysis related to two groups of patients, treated or not by glues, with a stratification on the hemorrhagic factors of risk. main outcome measures: the comparison of the averages of the various parameters was carried out by tests of student, for the large samples presenting comparable variables, and of fisher in the other cases. the cost of each hospitalization was calculated from the numbers of stays. results: during the three months of study, 154 patients, whom average age was 70 years [35-90], were operated. the two principal indications were the valvular replacement (45.5%) and aorto-coronary bridging (39%). on all six surgeons, 70% of the interventions were dealt with by three. on the whole, 57 patients receive a glue (37%), of biological type with tissucol ò (32.5%), and synthetic with bioglue ò (4%), arista ò (2%) and the grf ò (1%). some patients received two types of glues (3.5%). no significant difference between the two groups appeared in the total analysis. among the 120 patients who received a pre-operative anticoagulant treatment (78%), only 37% were treated by a glue, for which the number of transfused globular bases and the duration of stay in reanimation were significantly lower (p \ 0.05; p \ 0.01), compared to untreated patients. conclusions: in general, the use of glues in cardiac surgery does not decrease the post-operative bleedings, but increases the cost of the stay. it however finds its utility with patients at the hemorrhagic risk. a standardization of the local practices of the surgeons is in progress because there is not any national consensus. these results should be confirmed by randomized studies on a large scale. although za is 5 times more expensive than pa, it seems more effective with a shortened administration time (20 minutes vs 2-4 hours). in respect of the contract of good use (cbu), our objective was to evaluate the real cost of a daily hospital (hdj) session per patient treated with bp, and to compare it with the one obtained from the national study of costs (enc) in order to determine if whether our hospital gained or loosed benefit from this new refunding status. design: retrospective study. setting: conception hospital, 147 bd baille, 13385 marseille ce-dex5, france. main outcome measures: for every hdj session, we accounted pharmacy direct expenditures (including implants, medical devices or drugs), medical technical acts, and structure and logistic supports costs. moreover, we evaluated matching of prescriptions with the cbu criteria. we analyzed data together with the public health and medical information ward and the department of management control. results: real costs of hdj session amounted to 327 € without bp, and increased to 368 € and 537 € with pa and za administration, respectively. according to enc results, each session including intravenous bp was refunded for 459.39 €. in 2005, on a total of 5242 hdj sessions (2085 patients), 712 sessions had bp administration (13.58%) and concerned 243 patients (11.65%). real costs of hdj were 302914 € (172960 € and 129954 €, for 470 and 242 hdj sessions with pa and za, respectively). if bp administrations were integrated in the ghs at this time, the 712 sessions would have been refunded for 327086 € (215913 € and 111172 € with pa and za, respectively) resulting in a profit of 24171 € for the hospital. among bp prescriptions, 32% matched approved indications, 4.6% were part of temporary protocol of use and 63.4% were medical publication-based. internal medicine ward initiated 37% of the prescriptions. conclusions: using pamidronic acid compensates the deficit generated by zoledronic acid use. in respect with the cbu, zoledronic acid use will be restrained to approved indications in outpatients and pamidronic acid will be preferred in all others indications. keywords: biphosphanate, refund, economy pec-127 evaluation of the implementation of automated medication-dispensing system in an intensive care ward gregory gaudillot 1 , marie antignac 1 , fabien heck 1 , nadine casimir 1 , robert farinotti 1 1 pharmacy, groupe hospitalier pitié-salpétrière, paris, france background and objective: the development of the implementation of automated medication-dispensing system in french hospitals is the main aim, defined in the ''good use'' contract voted in 2005. the purpose is to improve the safety around the drug dispensing by the nurses. the objective of this work was to evaluate this implementation in 3 thrusts: safety, economic and organization. design: comparison between two different organization ways: before the implementation (pharmacy order by nurses chief) and 6 months afterwards (automated order and arrangement by a chemist assistant). setting: surgery intensive care unit (8 beds) in the pitie-salpétrière hospital (ghps), a large teaching hospital. main outcome measures: study ''before and after'': follow up of prescribing and dispensing matches, analysis of time repartition between nurses and chemist assistants, follow up of line of emergency order, analysis of the results of a nurses satisfaction survey and costs study of drug consumption and drug storage. results: this study, performed over 50 days, showed very small differences between prescribing and administered medications (1% before versus 4% afterwards = no significant difference). organization: implementation of automated device allowed a better division of activities, the management by nurses chief of the pharmacy order decreased (from 9% to 2% of their weekly working time), because this part was attributed to the chemist assistant (15% of their weekly working time). satisfaction: 70% of nurses preferred the automated system and especially because they find that this system was safe. in the same time, 80% of them appreciate with the new relationship with the pharmacy department. costs study: a huge decrease of the storage: -34% of cost (14,819 € versus 9,806 €) and -13% of references number (296 versus 230). in the same time, over 2 months, the drug consumption of the unit has been reduced by 30% (-11,680 €). conclusions: even if the study did not demonstrate a decrease of the number of medication errors (due to the tiny number of them as much before than afterwards the implementation), this automated system allowed a safety access to the drugs (biometric system) and contributed to reduce the risk of medication errors. the other great interest is the real involvement of the pharmacy in the clinical wards. the presence of the chemist assistant ensures a better management of drug storage (decrease of emergency order), a direct follow up and allowed a contact with nurses. results: in 2007 in france, 5 intracranial stents with various technical characteristics are available (steel or nitinol, learning curve: 2 to 5 procedures, follow-up of patients is from 6 months to 2 years). stents with a hight radial force are used for intracranial artery angioplasty. more precisely, those devices are implanted in patients with recidive stroke, with an intracranial stenosis c50% and who had failed medical therapy. two stents are identified in this therapeutic use: wingspan ò (boston) and pharos ò (micrus). about 120 implantations are estimated for 2007 in france, whom 35 implantations (cost = 105,000 €) in paris hospitals. the need is not actually clearly identified: the number of eligible patients is not already known and not systematically searched by neuroradiologists. so number of implantations will evolve. 4 intracranial stents are used in combination with detachable coils embolization in patients with wide-necked cerebral aneurysms: léo ò (balt), neuroform 3 ò (boston), entreprise ò (cordis) and pharos ò (micrus, double therapeutic use). for 2007, about 230 to 300 implantations are estimated in france (10 to 25% of endovascular treatment of intracranial aneurysm), whom 40 implantations (cost = 116 000 €) in paris hospitals. those data might increase. indeed, there is evidence of the effectiveness of stent implantation in intracranial aneurysm which generates lower rate of aneurysm recanalisation. conclusions: 5 intracranial stents has been identified in 2 precise therapeutic uses. however, an exact quantitative assessment can not be realised: those medical devices are innovating and are actually changing the management of patients concerned. those quantitative results might evolve. further similar studies will be necessary in order to follow up those innovating therapeutic uses in neuroradiology departments and to estimate their cost impact, actually negligible. keywords: stent, intracranial angioplasty, intracranial aneurysm, implantable medical device, cost evaluation pec-216 feasibility of economical impact of management of cytotoxic remainders in a centralized cytotoxic unit hélène corneau 1 , déborah schlecht 1 , sébastien bauer 1 , sylvie froger 1 , jacqueline grassin 1 1 background and objective: the french law forecasts to reimburse the most expensive cytotoxic drugs to the real quantity administered to the patient. so to set up a secured procedure to use remainders of cytotoxic drugs in a centralized cytotoxic preparation unit in order to conform to the french law. design: prospective study. setting: clinic unit of oncologic pharmacy. main outcome measures: this procedure was tested during ten weeks and had concerned the three most expensive cytotoxic drugs used in digestive cancers. generated remaining quantities are conditioned inside isolator in radio-sterilized bags, and identified with the number of register of prescriptions, the drug's name, the remaining quantity, the conservation' conditions, the opening date, the duration of physico-chemical stability according to the data of the literature. bags are joined when they are gone out of the isolator. a theoretical differential is daily established between the doses which are prepared with or without management of remainders. results: the management of remainders involves that a rigorous manipulation during the conditioning and a daily management of the out-of-dates. the average of realized savings 800 € a week, that represents 41,600 € extrapolated to one year and a decrease of 7.5% of expenses for these three drugs. pharm world sci (2008) 30:649-740 713 our software of the preparations of drugs is adapted for the use of the remainders. but the invoice-software allows only one invoice for one flask, which involves with the management of the remainders an unequal invoicing system for the patients conclusions: the management of remainders generates a real financial profit. but the really administered quantity cannot be imputed to the patient because the software of inventory control and invoicing does not manage the fraction of flasks. nevertheless, according to the french law we must express under fractional shape the quantities of cytotoxics, which are administered by stay to the patients for the most expensive drugs. background and objective: since july 2006, financing of drugs in belgian hospitals is based on a lump-sump system. this decision favours efforts leading to more rational use of medication like for example the sequential treatment. efforts like posters, recommendation letters and information rounds were part of the strategy. since 01-11-2007 a clinical pharmacist puts also attention on this subject by contacting physicians and nurses regarding individual drug therapies. documenting the results of interventions suggested by a clinical pharmacist is often quite difficult. the number of ddd of intravenous administered drug versus the total amount of ddd [oral + iv] of the particular drug administered has been described. this parameter can be disturbed by the use of the oral form over a long period of time or by the early discharge of patients combined with a continuation of the therapy at home. to follow up the sequential treatment on the emergency department, this parameter seems to be accurate by the fact that the stay of the patient here is between 1 and 2 days. cost savings by sequential treatment of paracetamol and levofloxacin were 1274 euro and 2025 euro, calculated from the start of the activities the clinical pharmacist (for 8 months). old habits are difficult to change among them the administration of drugs by intravenous route. almost every medical and surgical patient admitted to the emergency department receives an intravenous line, so the threshold for intravenous administration is low. furthermore a wide variety in patients' medical conditions added to a rapidly changing timetable for technical examinations and surgery necessitates an individual approach of the most suitable route of drug administration. official letters and posters may be useful. however this report confirms the importance of a clinical pharmacists' permanent presence on the ward for maintaining awareness of sequential treatment. results: 303 applications for compassionate use treatment were processed (0.95 processings/1000 inhabitants). the higher number of applications has corresponded to gynecology unit, 154 processings of misoprostol to use in delayed curettage. secondly, botulinum toxin was processed in 81 cases, 96.3% of them corresponding to anaesthesic and reanimation unit for miofascial pain. active substance that has caused a higher impact on the hospital 0 s budget was inhalated tobramicin, processed for a total of 5 patients with bronchiectasias colonized by pseudomonas aeruginosa. the expenses for this indication has added up to 35,000 € during 2006. secondly, as regards to economic impact we found botulinum toxin which raised up to 26,300 €, expenses that were attributed in 95% to anaesthesic and reanimation unit. the highest cost/treatment by patient during 2006 corresponded to inhalated tobramicin that has increased up to 14,000 €, followed by infliximab approved for hydrosadenitis treatment which accounted for 11,000 €. total cost of treatments for compassionate use has involved approximately 0.7% of total consumption for drugs during 2006. conclusions: the higher number of processings in 2006 corresponds to misoprostol requested by gynecology unit although its economic impact on the consumption of medicinal products for compassionate use is very low. inhalated tobramicin utilization for colonized bronchiectasias involves the highest global cost and the highest cost/treatment on total medicinal products for compassionate use. the percentage accounted for medicinal products for compassionate use on total consumption of medicinal products is low. it would be interesting to perform a multicenter study in order to value economic impact in last years of medicinal products for compassionate use. the vacuum-assisted closure (vac) therapy: a 17-months medico-economic retrospective study stéphanie roche 1 , nathalie herment 2 , sandrine havet 2 , amélie pruvost 2 , willemin jean-claude 2 , frances carole 2 1 pharmacie, reims teaching hospital, reims, france, 2 background and objective: in the management of wounds care, spectacular results have been achieved through the application of negative pressure wound therapy. this approach known as vacuum-assisted closure (vac) involves the use of a defined controlled negative pressure (delivered by an ambulatory motor) over a polyurethane or polyvinyl sponge (which are considered as consumables) placed in the wound. in our hospital, this therapy was first introduced for acute traumatic wounds. in june 2005, the interdisciplinary wound and cicatrisation group decided to extend indications to chronic wounds. to improve management regarding this larger and complex use through all units, a specific prescription form associated with recommendations was set up. this document is available as well as paper or electronic form. the purpose of this study was to evaluate conditions of use and global costs of vac therapy. design: a 17-months retrospective study was based on the analysis of nominative prescriptions of vac consumables (canisters with gel, small, medium or large foam dressing kits and y connectors . the cost of consumables was estimated to 28.8 euros per day per patient. total cost over the study period amounted to 171366 euros, including the hiring of the vac system (52.73 euros per day). these data indicate that the use seems to be appropriate and optimized without overuse. conclusions: facing the high cost of this technical therapy, its use must be closely managed. this study suggests that the multidisciplinary collaboration in our hospital between medical staff and pharmacist unit contributes to guarantee the optimal use of this specific therapy. to analyze the effectiveness of an educational programme to increase the adrs reports during this period. design: clinically relevant events possibly caused by exposure to drugs have been analysed in a retrospective study for a period of five months. we analysed the prevalence of adrs reported, the medical conditions of the patients, the relationship between adr and the suspected drug using karch-lasagne algorithm and the severity of the reaction using who criteria. during this period, we implemented a pharmacovigilance programme in order to increase the reports and to estimate the prevalence of adr in this unit. setting: pharmacy service and critical care service of a general hospital main outcome measures: to evaluate prevalence, characteristics, nature and severity of adrs in uci. to measure the effectiveness of an educational programme to improve the awareness and detection of adrs. results: a total of 243 patients were hospitalized during this period, 24 adrs were detected (9.9%). severe sepsis and cardiac arrest were the most frequent diagnosis in this group of patients. 66.6% males and 33.3% females, 65.1 years in average. dermatologic effects as urticaria rashes and haematological effects as pancytopenia were the most frequently noted, with more than 20% each. therapies most often associated with the reported events were antibiotics (piperacillin/tazobactam, ertapenem, azitromicin) in 41.7% of cases and nitroglycerin in 8.3% of them. the adr reported were classified as low severity in 29.2% of cases, medium in 45.8% and high severity in 25% of them. level of causality more frequent was ''probable'' in a 62.5% of the reports followed by ''possible'' in 37.5% of them. since the implementation of the educational programme the number of reports of adr have increased from 3.2% to 13.7%. the high level severity of adrs reported has increased in this period from 0% to 41%. conclusions: communication and educational programmes should be implemented to promote detection, identification, reporting and evaluation of adrs. the analysis to determine the probability, causality and severity of adr is necessary to establish the measures needed to improve the security and the quality of health attention. background and objective: ace inhibitors are used for controlling blood pressure, treating heart failure and preventing kidney damage in people with hypertension or diabetes. although ace inhibitors are generally well-tolerated by the most individuals, they are not free of side effects. dry cough is one of the most common side effects seen in patients during ace inhibor therapy. in this study, we have evaluated the incidence of dry cough that appears during the ace inhibitors therapy and relationships with the other coughing factors and the other side effects that may appear. design: the questionnaire was applied on 304 ambulatory patients (144 m/160 f) who have used or been using ace inhibitors and 100 hypertension patients as control group who use also anti-hypertensive drugs except ace inhibitors. ace inhibitors, and the reactions against the dry cough were determined by pharmacist's questionnaire on the patients who come to the community pharmacy. results: dry cough was observed on the 65 patients out of 304, during their using of ace inhibitors (21%). 24% of male patients and 19% of female patients were having a cough. the 5 patients out of 100 (5%) from control group were having a cough. the incidence of dry cough that appears on the patients who use ace inhibitors were; silazopril 28%, ramipril 26%, lisinopril 21%, fosinopril 17%, qinapril 14%, perindopril 13%, enalapril 11% and trandolapril 10%. the treatments of 32 patients out of 65 who complain from coughing during the therapy of ace inhibitors were changed with angiotensin receptor antagonists and calcium antagonists by their physician. treatment changes were resulted in increasing in the cost by 382.08 ytl monthly if it was calculated on the base of generics. conclusions: as a conclusion, the incidence of dry cough from ace inhibitors was found to be 21% in the blacksea region of turkey. the pharmacist can play an important role in determining side effects such as dry cough and refer the these patients to physician. patient counselling and drug therapy monitoring in the community pharmacies will increase the compliance and provide better outcomes in many chronic diseases. setting: community in _ istanbul main outcome measures: visual analouge scale (vas) was used for assessment of pain. the universe of the study consisted of randomly selected 210 women and 190 men (n = 400). a pilot study was run on 15 individuals from different occupation groups to determine the validity and intelligibility of the questionnaire. results: the data were analyzed using a spss 10.0 program. the level of significance was accepted as p \ 0.05. the results show that women experience more intense pain than men; their mean vas score is higher than men (6 vs 4). headache is the most common type of pain (41.5%) and also its vas scores reached the highest level (9) (10) . this pain is especially caused by migraine and hypertension. in addition, 56% of questionees prefer to take an analgesic drug in order to manage their pain problem. it was recorded that especially non-steroidal antiinflammatory drugs (nsaids) and preparations containing paracetamol are the first choice in pain management. most respondees took analgesics when pain begun (37.5%), when pain increased (39.5%) or when was intolerable (20.5%). conclusions: the majority of those who participated in the study took their analgesic medication without consulting a health professional. this indicates a high level of self medication in our population. this gives rise to a number of potential drug problems such as nsaids usage in gastrointestinal disorders, hypertension and renal failure. although many participants used their drugs in a rondom and improper way, unfortunately the pharmacist was rated second to last as a drug consultant. background and objective: many patients visit the pharmacy for their oral problems like toothache and ask for appropriate pain relievers. the purpose of this study is to examine the attitude and role of pharmacists, dentists and non-health workers towards solving of dental and oral health (like management of toothache). design: 3 different questionnaires were applied randomly on 30 pharmacists, 30 dentists and 30 non-health workers. setting: canakkale -turkey. main outcome measures: dentists' and pharmacists' approach to patients with toothache, drug usage evaluation in dental problems, the type of information given by pharmacists, patient behaviors. results: 30% of non-health workers (n = 30) indicated that if they complain about toothache they choose their pharmacist as their consultant. 50% of non-health workers (n = 30) indicated that they use various medications without consulting a dentist (44% naproxen sodium, 21% paracetamol, 7% methimazole, 7% flurbiprofen, 7% amoxicillin, 7% carnation essence). the most common suggested antibiotics was amoxicillin (66%) by pharmacists and amoxicillinclavulanate (21%) by dentists. the most common suggested pain relievers were naproxen sodium by both pharmacists (59%) and dentists (36%). only 28% of dentists declared that they consult with a pharmacist about drug usage. 41% of dentists indicated the importance of consultation of patients by pharmacists. conclusions: according to our results; pharmacists must take an important role in prevention and management of oral and dental health problems including informing the patients about convenient drug usage. also collaboration between dental staff and pharmacists need to be improved. background and objective: in 1965 hibbard and smithells suggested a link between inadequate maternal intake of folic acid and neural tube defects in their offspring (1) . consequently, it has been recommended that all women planning to become pregnant should consume additional folic acid before conception and during the first 12 weeks of pregnancy. despite these recommendations, periconceptional intake of additional folic acid is still low in many developed countries and a substantial percentage of women are not aware of its benefits (2) . design: a questionnaire was used in a face-to-face encounter. setting: postnatal wards of a teaching and a private hospital in iran. main outcome measures: awareness of the effects of folic acid on the fetus was evaluated among 400 women. the questionnaire included questions about demographic information, folic acid supplementation before and during pregnancy, its effects and the most susceptible periods in pregnancy and the source of information regarding the drug's effects during pregnancy. results: the mean age of women was 26.4 (± 5.2) years old. the majority of the subjects had more than high-school education (53% vs.47%). out of 400 subjects, 359 (89.8%) took folic acid supplement before and during pregnancy. only 2.5% believed that its usage was unnecessary, 81.5% believed in its positive effects. in the subjects' opinion, the most important time for taking this supplement was the first trimester (32.5%), then prior to pregnancy (19.5%). the second and third trimester were noted important by 4.0%. 7.8% believed in the importance of this supplement during all nine months. the advisor for taking this supplement was doctors (74.4%), health visitor (23.3%), self-medication (2.7%), tv and radio (1.8%), family members and friends (1.8%) and pharmacist (0%). conclusions: awareness of the value of periconceptional folic acid was high among women of iranian nationality compare to similar studies (3) . the majority of the participants believed in the positive effects of folic acid. the advices provided by doctors and pharmacists had the greatest and least effect on the use of this medication. regarding the best time of usage of this supplement, the most emphasis was on the first trimester and next on prior to pregnancy. background and objective: diabetes mellitus type-ii is a metabolic disorder that is primarily characterized by insulin resistance, relative insulin deficiency, and hyperglycemia. before type ii diabetes stage, people almost always have ''pre-diabetes''; in which blood glucose levels are higher than normal but not yet high enough to be diagnosed as diabetes. while some people with type-ii diabetes have symptoms, the majority may go 7-10 years without apparent symptoms. because some of the symptoms for diabetes mimic other diseases or conditions, makes it harder to predict an precise diagnosis without any additional information. the purpose of this study is early diagnosis of pre-diabetes, prevention or delay of the complications with a collaboration of community pharmacists and patients. design: pharmacists used a structured questionnaire containing questions concerning demographic data and informations which indicate prediabetes symptoms. setting: four community pharmacies in istanbul. main outcome measures: data: age, gender, body mass index (bmi), genetic predisposition, blood pressure, pysical activity and hypoglycemia symptoms. results: one hundred people were screened for undiagnosed diabetes. and the risk for pre-diabetes is evaluated according fasting plasma glucose (fpg) and total oral glucose tolerance (ogtt) test results. blood glucose level between 100 and 125 mg/dl with the fpg test and 140 and 199 mg/dl with ogtt test are considered as pre-diabetes. conclusions: diagnosis of pre-diabetes can prevent the development of type ii diabetes and making changes in nutrition and increasing the level physical activity may even be able to return the elevated blood glucose levels to the normal levels. pepi-207 awareness among pregnant women of the effects of drugs on the fetus and mother maryam dilmaghanizadeh 1 , simin mashayekhi 1 , masoud naghizadeh 2 , zahra fardiazar 2 , roghaiieh bamdad moghaddam 2 1 pharmaceutics department, 2 the faculty of medicine, tabriz university of medical sciences, tabriz, iran (islamic republic of) background and objective: since the talidomide catastrophy [1] concern about the safety of drugs in pregnancy has been increasingly evident. studies have revealed that pregnant women continue to take considerable quantities of drugs. however, all pregnant women worry about whether to take any medications. because of an estimated 10% of birth defects resulted from maternal drug exposure [2] , this fear is well justified. little is known about the knowledge of pregnant women regarding the safety of medications during pregnancy. to our knowledge the present study is the first performed in iran. design: a questionnaire was used in a face-to-face encounter. setting: postnatal wards of a teaching and a private hospital in iran. main outcome measures: awareness of the safety of drug use during pregnancy among 400 women. the questionnaire included questions about demographic information, drugs use before and during pregnancy, information regarding the safety of drugs during pregnancy and the most susceptible periods in pregnancy, the source of information regarding drugs' safety during pregnancy. results: the mean age of women was 26.4 years old. only an 18.85% and 22.25% used conventional medications and herbal remedies during pregnancy, respectively. a great percentages (87.5%) believed in harmfulness of drugs during pregnancy, but only a 38.3% believed in harmfulness of herbal remedies. the first trimester and the second trimester were believed to be the most and the least susceptible period, respectively (60.8% vs. 3.0%). the sources of information for the subjects regarding the safety of medications was specialist doctors (53.8%), general practitioner (9.3%), pharmacist (5.8%), midwives (1.3%), health center (17.5%), media and books (9.5%) and friends and family member (1%). discussion: a common concern about the care of pregnant women involves the medications, which led us to establish a special initiative to review available knowledge among our general population. the present study highlights weakness of the role the pharmacists play in providing the information to this vulnerable and eligible group of people, who nourishing our next generation. conclusions: a common concern about the care of pregnant women involves the medications, which led us to establish a special initiative to review available knowledge among our general population. the present study highlights weakness of the role the pharmacists play in providing the information to this vulnerable and eligible group of people, who nourishing our next generation. ayce celiker 1 , nergiz nemutlu 1 , gulru ozkaya 1 1 hacettepe drug and poison information center, hacettepe university, ankara, turkey background and objective: poisoning casualties require be approached with utmost attention due to their ''medico-social emergency'' nature. children are more vulnerable because of their inherent interests for knowing the environment besides ignorance and carelessness of adults. drugs are among the leading offending agents in children poisonings. the services of drug and/or poison information centers have been regarded as one of the main challenge areas of clinical pharmacy practice. being a pioneer in turkey, hacettepe drug and poison information center (hizbim), has been run for 15 years in working hours basis. objective: the objective is to evaluate the demographic and epidemiological characteristics of drug poisonings in children, thus, to contribute to clarify the actual ''intoxication profile'' and identify necessary measures for the children in turkey. design: the data of childhood (aged \ 17 years) poisoning enquiries received by hizbim between january 1, 1996 and december 31, 2005 were collected retrospectively and analyzed with spss 11.5 ò setting: hizbim is affiliated to hacettepe university, faculty of pharmacy main outcome measures: categorization and comparison of data of children intoxicated with drugs during ten years results: children were involved in 54% of all poisoning cases and 63% of those cases were due to drugs. there was no gender difference among very young children, however, girls dominated as the age increases (p \ 0.05). 88% of the cases were accidental, and analgesics were involved in 40% of the accidental poisonings (p \ 0.05). while the most offending agent group was analgesics in children younger than 12 years (p \ 0.05), multiple drug ingestions were the main causes of the cases involved older children (p \ 0.05). multiple drugs were mostly encountered (63%) in suicidal attempts where the dominant gender was girls (75%) (p \ 0.05). the most frequently reported symptoms indicated central nervous system involvement almost in all intoxication cases and in all age groups. conclusions: pediatric poisonings are rather high in turkey like many other countries and drugs are accounted for mostly in those injuries whether accidental or suicidal exposures. some regulations, the attitudes of physicians, pharmacists, and parents and other care givers make contributions to that outcome. in the prevention of childhood drug intoxications it is essential to make cooperation between drug manufacturers, regulatory authorities, health professionals, and families, besides increasing social awareness. drug and/or poison information centers stimulate rational drug use through providing accurate and rapid information to health care providers, educating people directly, documenting current epidemiological data. recently, we noticed a great interest of pharmaceutical companies in drugs such as monoclonal antibodies or in diseases such as inflammatory rheumatism. the aim of this study is to put in evidence the orientations of biomedical research. we particularly analysed the pathologies concerned, the type and the target of the experimental drugs, and the aim of the biomedical researches. design: analysis of the protocols and of the investigator's brochures of the ongoing clinical trials in january 2007. setting: clinical trials sector of lapeyronie-arnaud de villeneuve hospital, montpellier. main outcome measures: methodological aspects were first analysed: aim of the study, phase, type of sponsor, type of binding, inclusion rate. then, we focused on the experimental drugs involved: type of drug, target, therapeutic area concerned. results: 84% of clinical trials are promoted by pharmaceutical companies. 68% are phase 3 trials, 56% are open-label trials. 5 objectives can be found: testing a new molecule on a new target (17%), testing a new molecule in an known pharmacological group (19%), testing a new formulation (7%), testing an known molecule in a new indication (24%), evaluating a therapeutic strategy (33%). 20% concern rheumatology, 20% pneumology, 11% infectiology, 8% haematology, and 8% nephrology. the most frequent pathologies concerned are inflamatory rheumatism (23%), malignancies (17%), asthma/cobp (10%), hiv infection (11%), and post renal transplantation immunosuppression (6%). the percentage of patients included (number of patients in the trials concerned/total number of included patients) and the inclusion rate (real number of inclusions/ number of expected inclusions)are respectively 16% and 126% in rheumatology, 32% and 174% in pneumology, 10% and 48% in haematology, 9% and 80% in infectiology and 19% and 113% in nephrology. 50% of experimental drugs are injectable. 54% are little molecules obtained by chemical synthesis, and 46% are issued from biotechnologies: monoclonal antibodies (34%), peptide (10%), and gene therapy (2%). the new targets (17% of clinical trials) are receptors (57%), enzymes (29%), gene transcription (9%), cytokines (5%). conclusions: this analysis gives an idea of the future commercialized drugs. it puts in evidence the development of drugs in therapeutic areas which concern a lot of patients and whose financial rentability is high. furthermore, only 17% of clinical trials concern new drugs and new targets. development of me-too and optimization of therapeutic strategies are the most frequent clinical trials. background and objective: the increasing use of performanceenhancing substances and methods in sport threatens not only the meaning and the ethical value of the sport itself, but also the health of the athletes. this study aims to assess the drug utilization profiles of the amateur football players, as well as their attitudes and knowledge on ''performance enhancing drugs''. design: this study was conducted on 62 male players of the amateur football league. the players were asked to fill in a standard questionnaire, where information about their drug utilization profiles as well as their attitudes and knowledge on ''performance enhancing drugs'' were sought through various questions. setting: various amateur football clubs in turkey. main outcome measures: drug consumption rates of the players. answers to the pre-prepared questions. results: the age of the players ranged between 16 and 30 years. forty-four (71%) players thought that drugs have a positive impact on sports performance; while 29% did not share this idea. the resource of this idea was a team-member for 45.2%, the trainer for 25.8%, sports magazines for 25.8% and a family-member for 3.2%. the players were asked to name the drugs that could be used for performance enhancement and 80.6% replied as vitamins, while 51.6% replied as central nervous system (cns) stimulants and 25.8% replied as anabolic steroids. thirty-six players (58.1%) reported that they use various drugs with the aim of performance enhancement. the drug utilization profile was as follows: vitamins were consumed by 54.8% of the players; where cns stimulants, anabolic steroids, diuretics and growth hormone were consumed by 48.4%, 16.1%, 12.9% and 6.5% of the players, respectively. the players reported the reasons referring them to drug-use as follows: 1. drugs always have a positive impact on sports performance (83.3% of the drug-users); 2. drugs are necessary in case of inadequate training (33.3% of the drug-users); 3. performance enhancement leads to individual success in the team and this brings prices and rewards in return (11.1% of the drug-users). about 40% of the players thought that cns stimulants have the main effects of increasing the heart rate, endurance and strength. the main potential adverse effects of the cns stimulants were reported as gastrointestinal problems, dependency and tachycardia. about 40% of the players thought that anabolic steroids increase muscle volume, endurance and strength. the main potential adverse effects of the anabolic steroids were reported as hypertension, hepatotoxicity and dependency. conclusions: the results of the questionnaire suggests that drug-use with the aim of performance-enhancement was common among the amateur football players; and the players were not adequately and properly informed on the effects and adverse effects of the (so called performance-enhancing) drugs. this reality yields new responsibilities in this challenging area of practice, for the clinical pharmacist. background and objective: psychiatric disorders and opiate misuse are associated with chronic pain syndromes, but their incidence in fibromyalgia (fms) is unknown. the aim of this study was to identify if the incidence of affective disorders, and opioid misuse, was more common in patients with fms than those with other forms of nonmalignant chronic pain. design: a prospective, cohort study was carried out involving 66 patients, who were internally referred to a chronic pain management program. subjects with a working diagnosis of fms were matched by age (mean = 53) and sex (82% female) and compared to a control group of patients with alternative forms of non-malignant chronic pain. individuals were compared using urine toxicological screens, drugrelated criminal convictions, diagnoses of affective disorders, and responses to the following inventories: screener and opioid assessment for patients in pain, the pain disability index, the personal health questionnaire and the fibromyalgia impact questionnaire. patients also underwent a standardised physical examination using american college of rheumatology (acr) guidelines to diagnose fms. setting: this was a quantitative, hypothesis-testing cohort study, conducted in an academic general internal medicine practice. main outcome measures: diagnosis of fibromyalgia, clinician's awareness of acr guidelines, pain intensity and impact of fibromyalgia on physical and psychosocial activity. results: response rate was 67% (n = 44; mean age = 53, median = 52, age range = 35-80; male = 8); the most common background and objective: the increase in the frequency of the metabolic syndrome and its implication, in the development of ischemic cardiovascular disease and type ii diabetes mellitus, represent a real public health problem and of much interest in the medical field. otherwise, the cardiovascular pathologies are twice more frequent among chronics psychotics patients, for that reason we were interested in the prevention of these pathologys. this phenomena have been accentuated with the arrival of second generation antipsychotic drugs which were associated with weight gain, disorders of glycemia and lipidemia. in the aim to elaborate recommendations, at first we proceeded to the assessment of biological and clinical follow-up of the patients hospitalized in the saint-egreves hospital. design: literature review, 6 months prospective study. setting: we asked 2 doctors of each unit (13) to answer 5 questionaries corresponding to 5 patient files. we worked out a general questionary to avoid revealing our objective. main outcome measures: blood pressure, body weight, height, abdominal perimeter, glycemia, total cholesterol, triglyceridemia, cholesterol's fractions(hdl and ldl). results: our results showed a good clinical follow-up but the frequency of biological control was not sufficient. the blood pressure and weight were evaluated respectively in 85 and 69% of the patients, the total cholesterol, glycemia and triglyceridemia were in 40% of patients. on the other hand, cholesterol's fractions (hdl and ldl) were rarely evaluated. as for the abdominal perimeter, where the increase is predictive of cardiovascular disease, is never measured. conclusions: it seems difficult to evaluate the risk of either cardiovascular disease or metabolic syndrome of these patients or to determine if there is any possible relationship between the nombre of cardiovascular risk factors and the apparition of this syndrome. these findings imply to identify these high risk subjects and to define the optimal preventive, or curative, management strategy of metabolic syndrome and this, through simple measurements to realize in clinical practice. background and objective: availability of a medicine in western markets can be delayed either due to differential submission strategies of companies or differences in review process between countries. the aim of this study was to examine delays in patient access to medicines for compounds approved by two or more authorities (us fda, eu emea, australian tga, health canada and swissmedic), by characterising potential drivers for new active substances (nas) approved between 1997 and 2006, from both a company and regulatory agency perspective. design: 310 nass approved by fda since 1997 were compared to nass approved by the other agencies. this data was analysed comparing the difference between submission and approval dates and characterised by; type of approval route, company size, and therapy area. setting: data on nas's approved by the authorities was collected from agencies and from public domain sources. main outcome measures: the difference in patient access to new medicines in different countries and factors influencing such differences. results: 170 nass have been approved by fda and one or more of the agencies studied. the median time ranged between submissions to fda and another authority from 20 days at emea to 99 days at tga. the difference between approval dates ranged from a median of 230 days at emea to 331 at health canada. however these differ depending on company size, therapy area and approval route. conclusions: availability of a new medicine is a mixture of company submission strategies and approval process, although therapeutic profile of submissions and company size are also influencing factors. in europe the main driver to patient access is review timelines rather than delay in submission by companies. main outcome measures: data on sex, age, origin of ppi prescription and indication were collected by a standardized questionnaire and were retrospectively analysed. results: 76 men and 84 women were reviewed. the median age was 68 years (range, 20-99). 54% of patients received ppi therapy by pantoprazole (available in our hospital) when hospitalized. 77% of patients received daily 40 mg of pantoprazole and 23% received 20 mg a day. 21% of the prescriptions were validated. the main off-label indications were prevention of hemorrhagic risk of antiplatelet agent (23%), hemoglobin decrease(16%), anticoagulant co-prescription(13%), steroids co-prescription(6%). conclusions: this prospective study confirms the large prescription of ppi therapy in a department of internal medicine. nevertheless, this study highlights the difficulties to interrupt this well tolerated therapy after the first prescription by family physicians. clinical pharmacist interventions in the department consist of explaining the difference of indications between pantoprazole 20 mg and pantoprazole 40 mg, he makes physicians aware of prescribing ppi therapy with a cautious reweighted cost/benefit consideration. background and objective: to develop and validate a system for regulatory authorities to provide feedback to companies on the quality of their submissions while companies report to authorities on the quality of the review. a standardised report format will allow performance comparisons within and across companies and agencies. design: draft scorecards were tested in a study on the same four compounds, each reviewed recently by the agencies in australia, canada and switzerland. the agencies provided feedback on the quality of submissions and sponsors, astrazeneca, gsk, novo nordisk and pfizer gave views on the conduct of reviews. background and objective: adherence with chronic medication such as inhaled corticosteroids (ics) has repeatedly been reported to be low. non-adherence could be related to inadequate knowledge of ics' actions and lack of ics' instructions on the use of inhalers. this has not been reported previously to our knowledge among new users of ics who discontinued ics treatment early. the aim of the study is therefore to describe, among new users of ics that discontinued, their knowledge of ics' actions and whether they were instructed on the use of their inhaler. design: a cross-sectional study among new users of ics that discontinued use. patients were interviewed by telephone and their gp received a mailed questionnaire. automated dispensing records of all patients were retrieved. setting: 15 community pharmacies in the netherlands. main outcome measures: by use of conditional logistic regression the association between knowledge and study variables was assessed. results: from 287 eligible patients, 230 (78.2%) were interviewed. the majority (83.5%) of these new users of ics who discontinued ics early was not aware of the anti-inflammatory actions of ics. most patients (79.6%) were instructed on the use of their inhaler, predominantly by the gp (27.8%). after adjusting for symptom experience by acq, asthma diagnosis, having persistend asthma or use of medication only age (or 1.03 95% ci 0.99-1.07) and male gender (or 0.04 95% ci 0.03-0.91) were associated with unawareness of anti-inflammatory actions. conclusions: this study shows that a substantial number of new patients that did not refill their ics prescriptions, were unaware of ics' inflammatory actions. surprisingly only age and gender seemed associated with awareness of ics actions. most patients were instructed on the use on their inhaler by a health care provider. physicians and pharmacists could cooperate in identifying and motivating these patients to continue ics use. background and objective: to assess the quality of antibiotic therapeutic drug monitoring (tdm) in routine hospital practice and establish baseline status for rationally defining future actions aimed at improving it (by implementation of clinical pharmacy services). design: 4 months prospective observational study with validated data collection form using predefined criteria for tdm quality assessment. descriptive statistics performed with spss 13.0 for windows ò . setting: orthopaedic surgery, general surgery, neurosurgery, vascular surgery, haematology and pulmonary wards of a 400 beds teaching hospital, using vancomycin twice daily and amikacin once daily administration schemes. main outcome measures: adherence to predefined criteria for sample timing, information transmission, and follow up of dose adjustment recommendations. criteria: (i) sampling time: less than ±15 min (amikacin) and ±30 min (vancomycin) deviation from preset time for peak levels; less than ±30 min for trough levels; (ii) information transmission: patient's full name, dose, schedule of administration, time of previous and current dose, actual time of peak and trough level sampling; (iii) quality of the analysis [internal and external controls]; (iv) acceptance of dose adjustment (more than 10%) recommendations. results: inclusion: 94 patients (46 vancomycin and 65 amikacin courses). correct sampling times: (i) peak levels: 39% (n = 15) for vancomycin and 11% (n = 9) for amikacin, (ii) trough levels: 63% (n = 51) for both antibiotics. correct information transmission: 55% (n = 83). no issue noted for the quality of the laboratory analyses. implementation of recommendations: 32% (n = 66) for vancomycin and 18% (n = 17) for amikacin. conclusions: incorrect sampling times and deficiencies in communication between the ward and the laboratory are key factors affecting the quality of tdm, leading to dosage adjustment recommendations that are only infrequently implemented. the companion abstract examines the underlying reasons for such poor performance of the tdm process using a qualitative approach. corresponding values of d were: background and objective: to evaluate the relation between vancomycin and amikacin pharmacokinetic (pk) parameters in an intensive care unit population. design: data from intensive care unit patients were collected over a 48-month period, through a retrospective review of medical records and therapeutic drug monitoring (tdm) reports. patients were included only if at least two blood samples, at steady state conditions, had been drawn. data were first evaluated for completeness and consistency of recorded sampling and dosing times. individual pk parameters were estimated (bayesian analysis) using a one-compartmental pk model for amikacin and a two-compartmental pk model for vancomycin (pks ò abbot). phase i of the study determined relationships between vancomycin and amikacin pharmacokinetic parameters, mainly clearance and volume of distribution. for that purpose, linear regression analysis of data from 63 out of 83 patients (analysis dataset) was performed. phase ii tested the predictability of the developed equations in an additional sample of 20 patients (validation dataset) by comparing predicted pk parameters from equations (predeq) to those estimated by bayesian analysis (predbay) . t-test between predeq and predbay from each antimicrobial was performed. bias and precision were evaluated calculating the mean prediction error (mpe) and mean absolute error (mape), respectively (s-plus 5). setting: intensive care units. tertiary university hospital. main outcome measures: patients demographics, clinical and tmd records, creatinine clearance by cockcroft-gault, vancomycin and amikacin blood levels and pk parameters. results: eighty-three critically ill patients (33 females, 48 males)were recruited for the study (mean values: age 59.30 yr, weight: 71.63 kg, cr: 0.92 mg/dl). a correlation between vancomycin and amikacin regarding their cl was found (clvancomycin = 0.5678 clamikacin + 0.7648; r = 0.811). however, no correlation was observed for vd (r = 0.114). concerning phase ii, differences in demographic data from both datasets were not statistically significant. no significant differences were observed when performing predeq versus predbay t-test. nevertheless, boxplot graphs for predeq and predbay residuals showed a wide variability of the values distribution and a lack of precision for both antimicrobials. conclusions: in our patient population this studied approach reveals an existing relation between amikacin and vancomycin pk parameters (or vice versa). however, the poor precision and large bias of residual values prevents us from recommending the use of these equations as pk parameters predictors (or regimen dose predictors) in intensive care patients. further studies with larger samples are definitely required in such an heterogeneous population. they were asked to identify which items of the ashp guidelines and gedefo they considered that must be filled in, in a prescription or in an identification label. consensus was defined as an agreement rate c66%. prescriptions/labels evaluation: all breast or colon intravenous chemotherapy prescriptions, from a central hospital, have been evaluated from january to december 2004 (n = 920), based on the parameters identified in the consensus document. a two month analysis of identification labels was performed. results: consensus document: a total of 49 hospital pharmacists (73.1%) completed the 2 rounds of the delphi. consensus was obtained for 84.6% of the prescription items and for 90.9% of the labels items. prescriptions/labels evaluation: more than 2/3 of the analysed prescriptions were for breast cancer (69%) and the rest for colon. none of the analysed prescriptions had all the consensus items filledin. information that allowed the validation of the prescription by the pharmacist (ex: height, weight, body surface or number of cycle) was present in less then 10% of the prescriptions. no one had the prescriptor telephone, or the justification for dose reduction (when appropriate). only 68.8% (110/160) of the labels mentioned the full identification of the solvent (96% miss the concentration) used and none of them stressed out the need for filter use when applicable. conclusions: consensus was obtained about a large number of items, which may constitute a difficulty in daily practice the evaluation of prescriptions highlights the lack of information that could allow confirmation by the pharmacist. labels do not seem to alert about special administration conditions. background and objective: background: the ministerial advisor on hepatitis c in catalonia has established a series of recommendations concerning hepatitis c treatment distinguishing between two groups: viral genotypes 1 and 4, and viral genotypes 2 and 3. in genotypes 1 and 4 it is necessary to evaluate treatment continuity after 12 and 24 weeks, depending on viral load and it is also necessary to prolong the treatment to 48 weeks if there is viral response. in genotypes 2 and 3 it has not to be longer than 24 weeks regardless of viral load. objective: to evaluate the adequacy of hepatitis c treatment and analytic monitoring, following the recommendations of the catalonian ministerial advisor. design: observational and retrospective study. setting: patients that started treatment with peg-interferon plus ribavirine in this hospital during 2005. the information obtained was: viral genotype, the beginning and the end of treatment, quantitative basal rna (in all genotypes), quantitative rna (12 weeks) and qualitative rna (24 weeks) in genotypes 1 and 4 and at the end of the treatment in all genotypes. main outcome measures: the application of global advices ranges from 59% to 100% according to viral genotype and established recommendation. results: the compliance degree in genotypes 1 and 4: 100% application of quantitative basal rna and 59% after 12 weeks. 60% of treatments were discontinued with quantitative rna positive after 12 weeks, 78% with qualitative rna positive after 24 weeks and 6% the treatment was continued longer than 48 weeks. in genotypes 2 and 3: 100% application of quantitative basal rna, 65% application of qualitative rna after 24 weeks and 20% the treatment was continued longer than 24 weeks. conclusions: following the recommendations on viral response evaluation after 12 and 24 weeks allows the early suspension of therapy in non-responsive patients. this leads to and improvement in patients' quality of life, a reduction in adverse side-effects and savings in medical care costs. treatment monitoring by hospital pharmacist provides medical decision support. in consequence these patients constitute a target group to establish pharmacy care programs focused on hospital outpatients. topical application of mitomycin 0.02% during two minutes and postoperative stenting for a period of four-ten weeks were used, no second application of mitomycin was used. the follow-up was 2 years in bilateral case and six months for the unilateral case. setting: pharmacy and otorhinolaryngology service. hospital universitari joan xxiii de tarragona. spain. main outcome measures: the success of the repair was measured according to the following items: endoscopic evaluation of the patency of the choanae, respiratory distress and nasal drainage. results: bilateral membranous choanal atresia was surgical repaired five days after birth, using transnasal endoscopic approach and topical mitomycin 0.02% during de proceeding. no operative complications occurred and stents were removed four weeks after repair. the choanae was inspected endoscopically to asses healing and no presence of re-estenosis was found. no clinical symptomatology. unilateral mixted atresia on the left side was diagnostic at six years old and surgical repaired because of association of respiratory distress and nasal mucus drainage symptomatology. no restenosis has appeared and syntomatology has improved. nome patient required surgical revision. conclusions: although, the exact role of the topical application of mitomycin 0.02% must to be further investigated, the use of this drug as an adjunct to the surgical repair of choanal atresia may offer decreased need for revision surgery due to re-estenosis. keywords: mitomycin 0.02%, choanal atresia pt-57 adherence to clinical guidelines for upper respiratory and ear infections in out-of-hours primary carea retrospective study sara claesson 1 1 biofarmaci, uppsala university, täby, sweden background and objective: infections in the upper airways and ears are a frequently occurring reason for patients to visit primary care settings. prescribing adherence to local guidelines for handling infections of ears and upper airways and antibiotic prescribing is of both local and national concern. increasing antibiotic resistance is one reason, cost and patient quality of care are others. the objective of this study was to investigate physician adherence to clinical guidelines at the out-of-hours primary care clinic in täby. design: a retrospective study. clinical case notes were scrutinised for all patients seeking care for problems with ear, nose, throat, fever, cough or cold between january 1 and march 31 2007. data was analysed for patients who were diagnosed with specified ear or upper respiratory infections. laboratory tests taken and antibiotic prescriptions were anonymously documented. antibiotic prescription filling dates were investigated. setting: husläkarjouren, the out-of-hours primary care clinic in täby. main outcome measures: adherence to and fulfillment of local therapeutic guidelines and professional quality criteria was defined with respect to immediate, delayed or no prescription, drug choice, dose and duration and the use of diagnostic tests. adherence was defined as complete or not, and deviations from the guidelines were separately analysed. prescription filling was analysed with respect to time from clinic visit to pharmacy visit. results: data from 1077 patient visits were analysed. adherence to local guidelines was disappointingly low. general treatment of infections was only according to guidelines in 44% of the cases and only laboratory testing met the quality criteria. adherence to antibiotic prescribing guidelines was even lower, only 22% of antibiotic prescriptions were completely according to local guidelines. 93% of all antibiotic prescriptions were filled within one day from the visit to the clinic. conclusions: communicating guidelines to prescribers and continuous follow up of prescribing behaviour is essential for improving patient care and decreasing the risk of antibiotic resistance in the community. this study exposes gaps in the quality of care that may not be picked up by traditional follow up measurments. studies with a wider scope and in depth analysis of reasons for nonadherence to guidelines are warranted if antibiotic use is to be improved. 3 .14 lines after other therapies. before bortezomib one patient received therapeutic with thalidomide/dexametasone, one vad, one cyclophosphamide (ctx), three followed by vad, one mp followed vad and followed ctx, and another with vad followed by ctx. the therapeutic selection followed the nccn guidelines in all patients. the average number of cycles with bortezomib has 4.14. from the 8 patients, 2 stopped, one had a generalized face oedema bortezomib related, although the disease was in remission, and another died by sepsis not related with this drug. in relation to bortezomib's effectiveness, 6 (75%) patients had a very good response, since the immunoglobulin decreased and three (25%) of these patients are actually at consolidation cycles (7th and 8th). conclusions: the use of bortezomib in our hospital was according the nccn guidelines and the experience was very positive. nevertheless, and considering also the high cost of this therapeutic, we consider very important to continue to follow up this group in order to evaluate the rate of response to bortezomib during time. pt-90 evaluation of the time interval between admission on the emergency department and administration of the first dose of antibiotics background and objective: when patients are admitted with a proven or suspected infection on the emergency department, adequate antibiotic treatment must be started as soon as possible. literature reveals that the time between admission and administration of the first dose of antibiotics can reach about 5 hours and this can influence the prognosis of the patient. international guidelines for community acquired pneumonia (cap) and bacterial meningitis define this time interval of 4 hours(1) and less than 2 hours(2) respectively. to evaluate the practice on the emergency department of our hospital, with an average daily admission of 136 patients, a study on this interval was carried out. 80.3% of all administered antibiotics is in adherence to the local guidelines; however this was only evaluated by the clinical pharmacist. a possible explanation for the relatively short time intervals could be that the antibiotics which are frequently used are available at the emergency department and that the guidelines are at all time available on our hospital intranet. the time intervals of cap and bacterial meningitis are shorter than the defined international guidelines.(1, 2) conclusions: the time interval, found in our study, between admission on the emergency department and administration of the first dose of antibiotics is short, compared with similar conducted studies.(3, 4) 1 pharmacy, 2 otolaryngology, 12 de octubre university hospital, madrid, spain background and objective: a woman diagnosed with laryngeal papillomatosis. treatment consisted of laser excision of the granulomatous lesions, followed by mitomycin c instillation over the surgical bed. description of the preparation and utilization of mitomycin c instillation over the surgical bed for the treatment of laryngeal papillomatosis. design: request by the ent service for compassionate use of mitomycin c. following authorization from the health authorities, a literature search was made. after determining the dose/day for the patient, elaboration was carried out according to the literature references. setting: vials of 10 mg of mitomycin c were used as starting material, with 1-ml syringes to facilitate instillation in the operating room. dilution was made to double the standard in our centre (20 ml). main outcome measures: two 1-ml syringes were prepared per cycle, with a mitomycin c solution of 0.5 mg/ml for instillation, though finally in all cases only one of them was used. stability was established as 24 hours at room temperature, without special considerations regarding light exposure, as specified by the literature. the entire procedure was carried out in a laminar flow chamber, in compliance with the specifications for manipulating cytostatic agents. results: the patient received a total of three cycles of mitomycin c, the last two being maintenance cycles. the patient has experienced no papilloma relapse, and only right vocal cord hyperaemia is observed, probably secondary to surgery. conclusions: collaboration between the service of pharmacy and the ent service allowed adequate treatment and recovery of the patient, without apparent adverse effects. swollen and tender joints over 28 joints evaluated, and the value of erythrocyte sedimentation rate, comparing the das28 from one patient on two different time points; eular response, that classifies patients in 3 groups according to treatment response, and decrease in mhaq (modified health assessment questionnaire), that indicates patient's awareness of disability. data were recollected at beginning and at 12 weeks of initiating treatment with rituximab. differences between b-lymphocyte count at beginning and at 2 weeks was of initiating treatment was used as a secondary variable. results: we collected data of 6 patients, all being females, 1 was rf positive and 5 were anti-ccp positive. at women) a 65.38% of patients received adjusted prophylaxis to their degree of risk (76.5% with heparin prescription and 23.5% without it) from all 11.53% of inadequate prescription (100% of the patients with lmwh prescription); 6 patients lost follow up. patients submitted to cancer surgery (30 surgeries, 17 men, 13 women), 40% received apropiate prophylaxis (83.3% with lmwh and 16.6% without it). same percentage of patients (40%) was not adapted to correct prophylaxis (100% patients with lmwh); 6 patients lost follow up. conclusions: there is a greater percentage of choledoco surgery patients with lmhw prescription in compliance with published guidelines than oncology surgery patients, however it will be necessary carry out a better implementation among healthy professionals in order to increase this percentage of patientes. results: 55 prescriptions of these broad-spectrum antibiotics were collected and analysed. 58% of the prescriptions were initiated by residents, 42% by senior physicians. vancomycin was the most prescribed antibiotic (53%), mainly in the orthopaedic surgery unit. the indications of antibiotics were osteomyelitis (31%), septic arthritis (15%), prosthetic joint infections (13%) and pneumonia (11%). only 13% of antibiotic doses were not correctly adapted to creatinine clearances or to plasmatic vancomycin rates. the initial choice of antibiotic was considered appropriate in 90% of cases. regarding bacteriological results (bacteria, antibiogram), the continuation of the treatement was acceptable in 80% of cases. however in 20% of prescriptions, an adjustment of therapy with a more narrow spectrum antibiotic could have been done. conclusions: these results have to be extended with further investigation (at least 3 months). were systematically reviewed to retrieve prospective trials describing esa doses in dialysis pts who converted from rhuepo to da. search words included: ''epoetin, darbepoetin, esrd, ckd, and dialysis.'' the inclusion criteria required a study to have dose data available during the evaluation period for both rhuepo and da. study selection and data extraction were performed by 2 independent reviewers and verified by a 3rd. relative doses and dose changes after conversion from rhuepo to da were estimated using an initial rhuepo:da 200:1 conversion ratio (aranesp ò eu label). study quality assessment was performed using the downs-black checklist, a standard method used to assess the quality of a study using ebm principles. setting: meta-analysis. main outcome measures: dose efficiency. results: the search yielded 34 studies meeting the inclusion criteria. upon further review, 19 studies were excluded (14 had unextractable data, 3 were retrospective analyses, and 2 had predialysis pts). the remaining 15 studies were analyzed: 3 rcts with parallel control groups, 3 cross-over trials, and 9 observational conversion studies (table) . the studies yielded data on 3,380 rhuepo and 3,164 da pts, with a mean treatment duration being 21 weeks. we found the average study quality was 70%, with rcts (n = 663) having a higher quality score (87%) than crossover (72%; n = 497) or observational (66%; n = 5384) studies. there was a notable dose efficiency observed when pts were converted to da from rhuepo. this effect was greater in the rcts (27.5%) than in crossover (19.1%) or observational (12.1%) studies. conclusions: we found a notable da dose efficiency (up to 27%) in pts who were converted from rhuepo to da using a 200:1 conversion ratio. additionally, studies with the highest quality scores (eg rcts) had the greatest observed dose efficiency while non controlled studies scored lowest in both quality and dose efficiency. background and objective: the purpose of this study is to evaluate the frequency of otitis media and the assessment of its relationship to patients' socio-demographic characteristics and determination of systemic and topical drug profiles in otitis media. design: this retrospective study included the assessment of patients diagnosed with otitis media, who admitted to the study hospital during a 3 months period (march-may 2006). demographic, clinical and prescription data of these patients were collected and analyzed. setting: the ear-nose-throat out-patient clinic of a states hospital. main outcome measures: the socio-demographic data of patients; the frequency of otitis media; type and percentage of prescribed drugs; the most used treatment regimens. results: 216 patients (122 women and 94 men), who were diagnosed with otitis media, were included in our study. patients were diagnosed as chronic otitis media or serous otitis media or acute otitis media or external otitis media at rates of 37.5%, 30.5%, 20.4%, and 11.6%; respectively. in children, the acute and serous otitis media were seen more often than in adults (p \ 0.05). however, chronic otitis media were seen more frequently in adults (p \ 0.05). all patients were administered drug therapy for their diseases. it was observed that antibiotics (oral and/or topical), analgesics, decongestants, and topical corticosteroids were prescribed at rates of 99.1%, 88.0%, 76.8%, and 7.4%; respectively. prescribed oral antibiotics were cephalosporins [cefixime (17.6%), cefuroxime axetil (15.6%) and cefaclor (8.3%)], amoxicillin-clavulanate, and floroquinolones [levofloxacin (10.7%) and ciprofloxacin (9.8%)] at rates of 41.5%, 38%, and 20.5% respectively. rifampin and ciprofloxacin were prescribed as topical antibiotics at rates of 87.5%, 12.5% respectively. when the number of drug used by the patients was evaluated, 38 were on quadri-therapy, 126 on tri-therapy, 46 on dualtherapy and 6 on mono-therapy. 89 patients were treated with the combination of antibiotic-analgesic-decongestants. conclusions: our study indicated that the most frequently prescribed drugs were antibiotics in otitis media. clinical pharmacists have a potential role in rational antibiotic use by providing clinical pharmacy services such as antibiotic selection, drug monitoring and patient education; so that they would reduce both antibiotic resistance and treatment costs. background and objective: the sampling method is crucial for the physical and chemical quality control of antineoplastic chemotherapies. this step acts upon the dosage correctness and may lead to risk of needle-stick or cytotoxic drug projection during its achievement. beyond, the sampling time must be as short as possible and the sample be directly placed on the analysis machine. this work evaluates a new and improved sampling method, specially worked out for this application. design: this study was designed to ensure the vial airtightness and the volume sampling. a cost and time study was also performed. setting: the vial is an hplc type, chromacol ò 2 ml, 12 9 32 mm dp = 500 hpa, (interchim ò , montluçon, 03). the vial is airtight thanks to a ptfe silicon septum set with an aluminium collar. the vials are vacuum-packed in a pvc bag (didop ò , compiègne, 60). a void test was led on unpacked vials up to 3 months, to ensure a maximum conservation, and showed a filling volume of 448 ± 90 ll, very close of the 500 ll target. main outcome measures: one week samples have been weighed to calculate the filling volume in real conditions of use. this volume is 747 ± 17 ll ranging from 220 to 1130 ll. since this sampling method has been set up, the percentage of refusal for insufficient volume is lower than 0.1%. this technique was compared to the previous method in terms of cost: vial, sampling adjuncts, handlingtime and waste. the vials are filled with a secured double-needle eclipse ò , 32 mm, 7/10 (becton-dickinson ò , le-pont-de-claix, 38). results: about 10,000 chemotherapies controls are made each year in the hospital. the vial and the sampling device costs are higher than the previous (1 € versus 0.25 €, and 0.29 € versus 0.05 €). on the contrary, the handling-time for sampling was estimated 1 minute lower (which corresponds to 0.388 € less per sample). furthermore, the waste weight is 1 gram lighter with the new devices, which costs 0.003 € less in the waste disposal. the total cost difference is 0.60 € higher per sample. an estimation of a needle-stick accident has been carried out, with the human cost (pharmacist technician's compensation and medical consulting) and the equipment including gloves, sterilization devices and post-sterilization check; the lowest estimation cost of an accident is 274.58 €. conclusions: the secured needle makes the sampling operation easier for the workers and it lowers the risk of needle-stick. besides, this closed system avoids completely the antineoplastic contact for the manipulators during the confection and the control. moreover, this system allows to secure the sample library. background and objective: the prevalence of diabetes mellitus in kuwait ranks amongst the highest in world at about 15%. diabetes is a well recognized independent risk factor for cardiovascular disease (cvd). the increased prevalence of several other known risk factors for cvd in kuwaiti diabetics further increases the risk. since cvd is the leading cause of death in kuwait, the high incidence of diabetes has major social and economic impact. diabetics aged 40 years or older have, in general, an increased 10-year risk of developing cvd compared to younger patients but there have been no audits involving this group of patients in kuwait. the objective of this study was therefore to audit achievement of cvd risk factor goals according to pt-188 pharmacotherapy of first-episode psychosis in the psychiatry clinics of the north estonia regional hospital (nerh) and the tartu university hospital (tuh) jana lass 1 , agnes männik 2 , simon j. bell 3 1 pharmacy department, north estonia regional hospital, tallinn, 2 institute of pharmacy, university of tartu, tartu, estonia, 3 faculty of pharmacy, university of helsinki, helsinki, finland background and objective: treatment guidelines provide recommendations for the evidence-based treatment of schizophrenia. adherence to these guidelines is often sub-optimal. our aim was to compare and contrast the pharmacotherapy of first-episode psychosis at the nerh and tuhs, with respect to both treatment location and evidence-based guidelines. design: retrospective study. case notes for consecutive patients with schizophrenia, schizotypal or delusional disorders (icd-10) admitted to the nerh and tuh between september 2005 and september 2006 were retrospectively reviewed. setting: psychiatry clinics of two tertiary care hospitals -nerh and tuh. main outcome measures: outcome measures included the choice and daily dose of antipsychotics, incidence of antipsychotic polypharmacy and reasons for changes in therapy plan. results: 113 patients form nerh and 29 from tuh were included in the final analyses. median age (sd) of the patients was 35 (13.8) in the nerh and 39(15.2) in the tuh patients were hospitalised for longer in the nerh than in the tuh, 31 (17.4) vs. 23(17.2). the most frequently prescribed antipsychotic was risperidone at both study locations -37% of prescriptions in the nerh and 57% in the tuh. conventional antipsychotics were administered twice often in the nerh than in the tuh. in the tuh olanzapine was administered in higher prescribed daily doses than in the nerh. the number of antipsychotics prescribed per patient was higher in the nerh than in the tuh -1.7 vs 1.3. the prevalence of antipsychotic polypharmacy was 13.3% among the patients in the nerh, whereas only one patient was treated with antipsychotic polypharmacy in the tuh. conclusions: analyses revealed significant differences in the pharmacotherapy of first episode psychosis at the nerh and the tuh. mechanisms to facilitate improved adherence to the evidence-based treatment guidelines should be investigated. 1 pharmacy, hospital universitario de getafe, getafe, spain background and objective: to analyze the use of tnf-alfa inhibitors in rheumatoid arthritis diagnosed patients in a 600 bed hospital. design: retrospective study of patients with anti-tnf-alfa during year 2006. the following data were compiled: age, sex and anti-tnfalfa prescription including dosage and duration of treatment. setting: hospital universitario de getafe. main outcome measures: dosage and duration of treatment. results: a total of 69 patients were included. 51 patients (73.91%) received just one anti-tnf-alfa drug, 17 (24.64%) needed two lines of treatment and 1 (1.45%) of them needed three. patients who were treated with just one drug had a median age of 46.5 years and those who required two lines of treatment had a median of 55.5 years. the first line drug was etanercept in 37.68%, infliximab in 31.19% and adalimumab in 30.43% of patients. second option was etanercept in 37.68%, adalimumab in 31.88% and infliximab in 30.43% of patients. the average duration of treatment with etanercept as forward edge was 463 days. the treatment was suspended in 42.31% of patients. when infliximab was used as first line, average duration was 578 days, and treatment was interrupted in 22.7%. with adalimumab, average duration was 435 days and treatment was interrupted in 33% of patients. conclusions: those of our patients who need an only one treatment line are younger than those who need 2 or 3, due to the chronic and progressive course of the disease. etanercept is used as much in first option (followed by infliximab) as in second one (followed of adalimumab), although these differences are not statistically significant and it would be necessary to make a study including more patients. the duration of treatment with infliximab is the longest, as this was the first drug available. regarding treatment failure, etanercept shows the greatest percentage. this should be taken into account when establishing first line treatment. background and objective: plantar warts are hyperkeratotic lesions on the plantar surface caused by infection with human papillomavirus. lesions caused by warts are commonly refractory to therapy and may become large and painful in immunodeficient patients. cidofovir is a cytidine analogue with activity against a broad spectrum of dna viruses. it is indicated for the treatment of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome and without renal dysfunction. we describe a case of plantar warts that was treated with topical cidofovir in a highly immunodeficient patient. design: case report, evaluation and discussion based in clinical chart and literature review. setting: pharmacy department, general teaching hospital. main outcome measures plantar warts regression, which was evaluated on the basis of change in overall surface area of the treated lesions compared with baseline. to evaluate the organoleptics properties of the galenic formulation. results: a 29 years old woman, who received kidney transplant in 1996, presenting plantar warts refractory to conventional therapy since last four years. she was treated with topical 3% cidofovir cream twice daily. the treatment was authorised as compassionate use by the national regulatory agency on drugs. the glomerular filtration rate (gfr) was monitored in order to detect nephrotoxicity due to cidofovir. the 3% cidofovir ointment was compounded as follows: -cidofovir 75 mg/ml 5 ml vial .…….. 20 ml -anhydrous lanolin ……………………….. 5 g -beeler base …..sufficient to produce 50 g it was packaged and labelled in a light-resistant containers and we assumed an expiration date of 3 months based on the duration of treatment and published studies. the quality controls of organoléptics properties were made according to the good manufacturing practice (gmp) after 10 weeks of therapy the patient did not show any improvement and developed severe local erosion, so treatment with cidofovir was withdrawn. two weeks later this local erosion disappeared spontaneously. no systemic side effects were observed. the colour, texture and smell organoleptics characters were complied with gmps. conclusions: there are not formal studies of optimal formulations or treatment regimens and further studies are needed to elucidate the role of cidofovir in treatment of plantar warts. the immunodeficiency of the patient and the large wart area could be related with the failure to the treatment. background and objective: hypersensitivity reactions (hr) to platinum salts can be serious and should lead to interrupt chemotherapy regimen. skin tests may be used to confirm diagnosis of hr. usually, these tests are prick tests and intradermal tests performed with diluted solutions of platinum salts. there is no standard solutions for these drugs, which local toxicity depends on concentration. the main objective of this study was to assess the safety of platinum salts skin tests performed in our hospital. the secondary objective was to assess their efficacy to verify the allergic nature of the reactions observed. design: pilot study of skin tests preparations between january 2004 and june 2007. these preparations were dilutions (1/10, 1/100, 1/1000) of a primary platinum salt solution, which concentration was roughly the one used in the chemotherapy regimen of most patients. the compatibility of platinum salts with dilution solvent was checked, and all solutions were prepared extemporaneously in a centralised cytotoxic drug preparation unit, in order to protect handlers. setting: allergology department and pharmacy department in a university hospital. main outcome measures: skin tests results: positive if a papule appeared, negative if there was no reaction, local toxicity if an irritative reaction happened. results: 11 patients with clinical symptoms of hr with a chemotherapy regimen containing platinum salts were explored by skin tests. drugs assessed were: oxaliplatin (9 patients), cisplatin (4), and carboplatin (1) . no patient developed local toxicity. tests results were positive in 5 cases (4 oxaliplatin and 1 cisplatin), and negative in 6 cases. 3 patients received both cisplatin and oxaliplatin skin tests: 2 patients had a single positive reaction with no cross reaction between the two drugs, and the third had no reaction. in 4 cases, tests results and clinical history of hypersensitivity mismatched. conclusions: this study shows that these skin test solutions were safe. their efficacy was judged correct: 5 positive reactions confirmed the diagnosis of hypersensibility for 5 patients. the main limit of the results is the absence of control subjects. these tests allowed to explore 11 patients' hr, and to help oncologists to choose the more appropriate treatment for them. stability studies are still needed to assess the pharmaceutical quality of these diluted solutions. these preparations have now been standardized in our hospital. background and objective: guidelines regarding appropriate use of prophylactic antibiotics have been implemented at university hospitals leuven. however, the degree of compliance with these guidelines is unknown. the aim of this study is to develop a method to quantify compliance with antibiotic prophylaxis guidelines and to apply this method to the clinical areas of appendectomy and heart valve surgery. design: a retrospective case series was carried out of all prophylaxis episodes related to appendectomy and heart valve surgery at university hospitals leuven between august 2001 and february 2007. four grades of compliance with antibiotic prophylaxis guidelines were identified: grade 1 compliance, reflecting administration of the antibiotic proposed by the guidelines in a dosage within 80-120% of the recommended dosage; grade 2 compliance, defined as the administration of the antibiotic proposed by the guidelines in a dosage outside 80-120% of the recommended dosage; grade 3 compliance, referring to the administration of an antibiotic equivalent to the antibiotic proposed, but not mentioned by the guidelines; and grade 4 compliance, representing any other antibiotic prophylaxis scheme. setting: divisions of abdominal and cardiac surgery, university hospitals leuven. main outcome measures: the percentage of prophylaxis episodes that satisfy each grade of compliance with antibiotic guidelines. results: prophylaxis guidelines relating to appendectomy (1, 191 episodes) recommend administration of three times cefazolin 2 g and a single dose of metronidazol 1.5 g. the proportion of episodes that satisfied grade 1, 2, 3 and 4 of compliance with guidelines amounted to 5%, 58%, 6%, and 30%, respectively. cefazolin 2 g and metronidazol 1.5 g was used in 257 episodes. prophylaxis guidelines applying to heart valve surgery (2,182 episodes) recommend administration of cefazolin 14 g. the proportion of episodes that satisfied grade 1, 2 and 4 of compliance amounted to 68%, 31% and 1%, respectively. grade 3 does not apply to heart valve surgery as no equivalent antibiotics were identified. the difference in compliance with prophylaxis guidelines between both surgical procedures could be explained by differences in infectious pathology, the peri-operative adaptation of the antibiotic regimen by the abdominal surgeon, and the use of a second regimen related to the severity of the appendicitis. a case can be made for combining grade 1-3 compliance with respect to appendectomy, resulting in a higher compliance rate. conclusions: our proposed method to measure compliance needs to be validated by future research. the method can be applied to different surgical procedures, thereby stimulating surgeons to explain differences in compliance between procedures and promoting the development of instruments to enhance compliance. closer interaction with surgeons is required to further develop the measurement of compliance with antibiotic prophylaxis. keywords: antibiotic prophylaxis, compliance, guidelines pt-240 non-specific immunoglobulins for immune neonatal thrombopenia nuria ibañ ez 1 , maria del pilar m. p. bautista 1 , ana maria a. m. iglesias 1 , roberto r. ortiz 2 , javier j. sanchez-rubio 1 , maria del carmen m. c. giron 1 , marta m. arteta 1 1 pharmacy, 2 pediatry, hospital universitario de getafe, madrid, spain background and objective: non-specific human immunoglobulins are being used at the moment in neonatal population for treatment of immune thrombopenia. the dosis commonly used varies between 400 mg/kg and 1 g/kg from one to five days. corticoids and platelet transfusions can be used jointly. to study the effectiveness and safety of non-specific human immunoglobulins in a neonatal unit for treatment of immune thrombopenia. design: retrospective study of neonatal patients diagnosed with immune thrombopenia during 2006 and treated with non-specific human immunoglobulins. a revision of clinical histories is made and following data are collected: sex, gestational age, born weight, age at the moment of infusion, administered dose and duration of treatment, use of corticoids and platelet transfusions, number of platelets/ll before infusion, at 24, at 48 hours of initiate the treatment and at discharge. possible adverse reactions is also considered. setting: hospital universitario de getafe. main outcome measures: the effectiveness and safety of nonspecific human immunoglobulins for treatment of immune neonatal thrombopenia. results: three children were included in the study, two of them were males. thrombopenia was diagnosed from probable alloimmune origin, including positive confirmation study in one of the cases. gestational ages ranged from 38 + 2 to 39 + 1 weeks. born weight ranged between 1.850 kg and 2.720 kg. immunoglobulin treatment was initiated between first and sixth day of life. administered dose varies between 400 mg/kg/day and 1 g/kg/day from two to five days. all children needed platelet transfusions, while only one of them was treated with corticoids. the number of platelets/ll before infusion of immunoglobulins, at 24 hours, at 48 hours and at discharge was: children 1: 41,000, 23,000, 81,000 and 116,000 platelets/ll. children 2: 34,000, 22,000, 18,000 and 303,000. children 3: 19,000 and 25,000 platelets/ll 24 hours after initiation of treatment, there were no analytical data at 48 hours, but number of platelets at discharge was 355,000. no adverse effects were observed in any children. conclusions: although eventually the three children recovered the number of platelets, it can not be concluded that this was due to immunoglobulin treatment, because it is overlapped with administration of platelet transfusions and corticoids. a higher number of patients is required to evaluate efficacy and safety of non-specific human immunoglobulins in treatment of neonatal thrombopenia. background and objective: pulmonary hypertension (ph) is one of the most difficult childhood disease to treat. in spain, oral sildenafil has recently been approved in adults to treat ph, but it 0 s an off-label drug for children (its utilization must be derived to ''compassionate use'', which requires a prior national health authorities approval for every children), and an oral suspension must be formulated at the pharmacy department for them. the objective of this study is to analyse the use of oral sildenafil for ph in paediatric patients. design: 4 years retrospective study. 100% paediatrics patients with oral sildenafil for ph. clinical data review. setting: paediatric cardiology unit and pharmacy department (1 pharmacist) in a paediatric hospital (300 beds), in a large general teaching hospital (1450 beds, 15 pharmacists). main outcome measures: patient data (diagnosis, age, weight). treatment description (dose, length of treatment). treatment effectiveness: peripheral arterial oxygen saturation and six-minute walk test. treatment security: side effects registered. results: 15 children (8 girls). age: 3 months to 17 years, median 7.3 years. diagnosis: 13/15 ph secondary to surgery due to congenital heart disease and 2/15 primary ph. sildenafil doses ranged from 0.3 mg/kg/8 h to 50 mg/8 h; median length of treatment was 19.5 months (1 month-4.3 years). 8 children have used the oral suspension formulated and monthly dispensed at the pharmacy department. other treatments: spironolactone (10), furosemide (8) , captopril (4), acenocoumarol (2), aspirin (2), ranitidine (2) and propranolol (1). 9 patients have experimented clinical improvement and are on treatment. sildenafil was withdrawn in 3 patients because it was indicated to ameliorate the effects of inhaled nitric oxide withdrawn. 2 patients died. no data available in 1 patient. only 1 patient experimented occasional headache. mensual treatment cost range from 40-624 €/patient. conclusions: oral sildenafilo seems to be a safe and effective therapy for paediatric patients with pulmonary hypertensión. due to the lack of an oral formulation for paediatrics patients, it should be elaborated at the pharmacy department. background and objective: we will describe the case of a bi-pulmonary transplant women who developed an invasive aspergillosis located in the lungs and the brain. she received intravenous voriconazole during 14 days. she was then diagnosed with an aspergillus endophthalmitis. even though a dual therapy consisting of caspofungin and posaconazole was initiated, the patient underwent a partial vitrectomy. this therapeutic failure could be explained by a late diagnosis and insufficient vitreous and aqueous humor penetration of the systemic drugs. design: a retrospective analysis of an endophthalmitis management. setting: clinical unit in a french teaching hospital main outcome measures: to secure a high ocular concentration, the ophtalmologist recommended voriconazole intravitreal injections. his prescription was based on several case reports. results: we found articles dealing with animal testing: one concluded that voriconazole was a safe intravitreal agent which may be injected in human eye. another study described the successfull use of intra-ocular voriconazole to treat a fungal endophthalmitis: it allowed a significant improvement in visual acuity and the patient's recovery. however, further studies are needed to assess the optimal dosage and frequency of administration. we prepared voriconazole syringes under a horizontal laminar air flow hood, as follows: -preparation of a 10 mg/ml solution with 19 ml of water for injection and dilution in 9 ml of water for injection, to obtain a 1 mg/ml solution pharm world sci (2008) 30:649-740 737 -we sampled 0.3 ml of this solution in a 1 ml syringe, which was closed with an occluder, labelled and refrigerated. since we had no data regarding stability, it was administrated extemporaneously. conclusions: intravitreal injections failed to prevent deterioration. had they been introduced precociously, they might have been more efficient. an early diagnosis and prompt management might improve the extremely poor visual prognosis of this devastating condition. were are currently studying the preparation stability. 1 pharmacy service, hospital universitario de getafe, getafe, spain background and objective: in 2003 professionals were alerted about an elevated frequency of early virological failure in patients treated with tenofovir (tdf) and didanosine (ddi) associated to lamivudine. in 2005 similar results related to the administration of tdf and ddi, in association with a non-nucleoside reverse transcriptase inhibitor (nnrti) were notified. therefore similar events can be observed when tdf and ddi are co-administered in combination with other antiretroviral classes, such as protease inhibitors (pi). subsequent pharmacokinetic studies have shown that tdf when co-administered with ddi increases ddi plasma concentrations leves by up to 40-60%, with a higher risk of didanosine-related adverse events, like pancreatitis and lactic acidosis. the administration of a reduced dose of didanosine (250 mg) to avoid over-exposure to didanosine may also contribute to a higher rate of virological failure and emergence of resistance at early stage. the objective of the study is to asses the rate of virological failure in patients treated with tdf and ddi associated to a pi. results: during the study period 27 patients had prescription for drotrecogin alfa for sepsis syndrome; 48.1% were male and the mean age was 58.7 years (range 16-83 years). all patients had proven infection: 66.7% had pneumonia (n = 18), 22.2% pyelonephritis(n = 6), 3.7% soft tissue infection(n = 1) and 7.4% abdominal infection(n = 2). the main isolated micro-organisms were klebsiella pneumonia(n = 3), escherichia coli(n = 2), pseudomonas aeruginosa(n = 1), enterococcus faecium(n = 1), staphylococcus aureus(n = 2), legionella pneumophila(n = 1), proteus vulgaris(n = 1), enterococcus faecium(n = 1), klebsiella oxytoca(n = 1). all patients started treatment within 24 h of the onset of severe sepsis. the treatment was not completed in one patient due to adverse events. contraindications were present in 4 patients: platelet count \30.000 9 106/l (n = 2), age under 18 years (n = 1) and major surgery (n = 1). the mean organ failures was 3.5 (range 2-5 organs). adverse reactions were present in 7 patients: thrombocytopenia (n = 3), pancytopenia (n = 1), bleeding (n = 1) and elevation of activated partial thromboplastin time (n = 1). mortality at 28 days was found to be 37% (n = 10). conclusions: despite the presence of some contraindications, in most patients drotrecogin alfa was used according to current guidelines. nevertheless, since apache ii score was not determined, the real risk of death is unknown and there can be no extrapolation to literature results. upon these findings, a systematic evaluation of apache ii score must be implemented in order to optimize patient selection and the risk-benefit ratio, improving the use of drotrecogin alfa. 1 pharmacy, 2 oncology, hôpital tenon aphp, paris, france background and objective: it is necessary to focus on side effects for pharmaceutical analysis. dosage reductions are commonly used in cancer chemotherapy. however, little is known concerning the way these reductions are performed in clinical practice. the objectives were to evaluate the incidence, the reason and the percentage of dosage reduction. design: prospective four-week study during which we analysed prescriptions with dosage reductions. setting: pharmacy and clinical oncology department in a paris university hospital. main outcome measures: we focused on prescriptions with dosage reduction and we recorded : -patient information -cancer localisation -chemotherapy regimen -dosage reduction characteristics (date, reduction percentage, reason) the toxicities were classified according to the nci-ctc criteria (grade 1 to 4). individual interviews were performed in order to assess how physicians decided the reduction ratio. results: 406 patients (53% women; mean age 57 years) have been treated during that period. diagnosis majority were breast (25%), colorectal (22%) and lung (16%) cancer. 66 patients required a dosage reduction (incidence 16%). hematological toxicities were the main cause of reductions (69%). the hematological toxicities observed were thrombopenia (35%), neutropenia (25%) and neutropenia-thrombopenia associations (40%). the toxicities observed were grade 3 (48%) or 4 (42%). the other major causes of reductions were neurological (7%) and gastrointestinal (5%). the average percentage of reductions was between 15% and 20%. the individual interviews have shown that physicians didn't base the dosage reductions on literature results (established criteria) but on their own clinical practice (experience). conclusions: 16% of the prescriptions showed a decrease of the regimen. even if there is few literature, clinical trials recommend a decrease of 25% of the usual dosage of the drugs. the percentage in practice is lower than the one defined by clinical trials. the choices of reduction percentage were not standardized. recommendations for dosage reductions are still needed. keywords: dosage reduction, anticancer chemotherapy, toxicity pt-294 interdisciplinary approach to dose adjustment in patients with renal impairment in secondary care liekweg a, hinnerkort a, ebeling g, braband s, dreischulte t, heilenkötter k, sander s, schiffmann s, schrimpff u, siems m, wagner k, weiland t, zeigermann g, melzer s hospital pharmacy of the asklepios kliniken hamburg gmbh background and objective: as part of a unit dose dispensing system, patient medication profiles are routinely entered in an electronic database. medication profile and laboratory data are accessible online by clinical pharmacists. the project was conducted in order to optimise pharmacotherapy in patients with renal impairment and to integrate the clinical pharmacist in the therapeutic team. setting: unit-dose supplied wards (n = 73) in four asklepios hopitals in hamburg with approximately 1800 patients per day. the project was conducted in cooperation with clinical pharmacists, physicians and the laboratory department over a period of 2.5 months (12/06-02/07). programm description: clinical pharmacists receive a list of all patients with an estimated glomerular filtration rate (egfr) \ 30 ml/ min/1,73 m 2 (mdrd) from the laboratory department on a daily basis. they screen medication profiles daily with regard to apparently inappropriate dosing of renally excreted drugs (q o \ 0.5). critical cases are reported to physicians by phone or entry in medical case notes. following an interdisciplinary discussion with the physician the drug dose or dosing interval is either adjusted, the medication is stopped or paused or an alternative is started. during the pilot phase the number of altered medications as a result of pharmacists' recommendations was documented. results: a prevalence of 5% of patients with a egfr \ 30 ml/min/ 1.73 m 2 was found in the examined setting. during the pilot phase 1088 of 5013 prescribed drugs (21%) were renally excreted or considered nephrotoxic. antibiotics (26%), antidiabetics (7%), diuretics (25%) or nsais (11%) were predominantly involved. overall, 225 of 318 pharmaceutical recommendations (71%) were accepted and acted upon by physicians. conclusion: the number of recommendations demonstrates the importance of this service in optimising pharmacotherapy. clinical pharmacists' contributions in matters of dose adjustment in patients with renal impairment is well received by physicians especially in non-nephrologic departments. the new service was found to be feasible in daily practice and has become part of the clinical routine. background and objective: the sources and availability of drug information for patients are growing, e.g. through the internet and official patient information leaflets (pils). however, the quality of the information on the internet might be questioned. furthermore, pils are not standardized, the layout is not reader friendly and the information covers all approved indications for the drug, some of them not relevant for rheumatic patients. also, over the years various information leaflets for drugs have been developed in the departments of rheumatology in norway. these are not standardized and the accessibility is limited. the objective was to develop a system for producing and maintaining reader friendly patient information leaflets about antirheumatic drugs, which takes the quality assurance aspect into account, and is easily accessible for the users. design: development project, consensus method. a national multidisciplinary project group was set up in december 2005, with members from the social leagues (two members), pharmacists' organization (four) and rheumatologists' organization (two). mandate and regulations were approved by the organizations, as well as a legal disclaimer. the pharmacists make a draft for each drug which is e-mailed to all the members of the group. based on the comments a revision is made followed by another hearing until consensus is reached. the rheumatologists approve the leaflet. setting: national multidisciplinary consensus including patients associations main outcome measures: establishment of a dedicated website. number of leaflets published. results: a web address for publication of the leaflets is set up on the home page of the norwegian society for rheumatology: www.legeforeningen.no/nrf. there is a link to this address on the home pages of the social leagues and the norwegian association of hospital pharmacists. during the first year 60 different drug leaflets have been developed and published on the web site. it is possible to search by trade name, generic name and groups of drugs such as ''antiinflammatory drugs'', so the numbers of hits adding up to 87. conclusions: this national multidisciplinary approach has made it possible to develop a system for making patient information leaflets about anti-rheumatic drugs, which are standardized and easily accessible. keywords: patient information leaflets, drugs in rheumatic diseases, multidisciplinary the need for pharmaceutical care in the prevention of coronary heart disease; an exploratory study in acute myocardial infarction patients the right medicine: a strategy for pharmaceutical care in scotland pharmacy for health: the way forward for pharmaceutical public health in scotland. glasgow: phis 2003. 3. the sector skills council for health. skills for health: public health practice competences qualitative research: consensus methods for medical and health services research prescribing problems and pharmacist intervention in community practice a dictation system for reporting prescribing errors in community pharmacies a competency framework for the care of a person with diabetes pharmaceutical care of the patient with type 2 diabetes mellitus: a consensus model for delivery of structured pharmaceutical care by community pharmacists in scotland development of a leadership course tailored for pharmacists in scotland pharmacy students attitudes and views about portfolio-based learning: a questionnaire survey using portfolios to learn about prescribing: qualitative insights into students experiences implementing clinical pharmacy services in an outpatient oncology clinic an evaluation of pharmacist contribution in oncology ward in a swedish hospital evaluation of clinical pharmacy services in a hematology/oncology outpatient setting rheumatic illness (ri): 27 (16.4%), multiple sclerosis (ms): 21 (12.7%), hepatitis c (hc): 14 (8.5%). 2005: cfk: 57 (27.4%), others: 51 (24.5%), ri: 37 (17.8%), hiv: 27 (13.0%), ms: 22 (10.6%), hc: 14 (6.74%). 2006: cfk: 52 (25.2%) total economic impact (tei): 926,399 € valorisation of clinical pharmacy activities: validation of a standard tool for routine interventions quotation in french hospitals keywords: drug related problems hiv-infected patients' perceived satisfaction with an outpatient pharmaceutical care unit (opcu) quality perceived by outpatients at the pharmaceutical care clinic antibiothérapie par voie générale en pratique courante au cours des infectons respiratoires basses de l'adulte et de l'enfant 15 éme conférence de consensus en thérapeutique anti-references simultaneous determination of olanzapine, clozapine and demethylated metabolites in serum by on-line column-switching comparative study and optimisation of the administration mode of three proton pump inhibitors by nasogastric tube is the administration of esomeprazole through a nasogastric tube modified by concomitant delivery of a nutrition mixture? gerontology and geriatric medicine the clinical implications of platelet transfusions associated with abo or rh(d) incompatibility platelet transfusion: products, indications anti-d ig pc-257 pharmacist's interventions in three medical care units: analysis and impact on the physicians' prescriptions ventilator-associated pneumonia epidemiology and outcomes of health-care-associated pneumonia keywords: pseudomonas aeruginosa, antibiotherapy, vap (ventilator-associated pneumonia) folic acid metabolism and human embryopathy folic acid in general medicine and dermatology folic acid awareness and intake survey in the united arab emirates keywords: pregnancy, folic acid, neural tube defects pepi-199 pre-diabetes screening program: a proactive study in istanbul community pharmacies www.diabetes.org keywords: type-ii diabetes 45 years later…where do we stand? over-the-counter medications in pregnancy north american association for the study of obesity. consensus development conference on antipsychotic drugs and obesity and diabetes second-generation (atypical) antipsychotics and metabolic effects. a comprehensive literature review keywords: metabolic syndrome, second-generation antipsychotic, biological and clinical follow-up references analysis of taurine in blood plasma of epileptic patients using an improved isocratic hplc method for amino acids cardiovascular actions of taurine pharmacokinetics and pharmacodynamics of the effects of taurine on human blood pressure and heart rate references criteris d'indicació en el tractament de les hepatitis víriques. direcció general de recursos sanitaris peginterferon-alpha2a and ribavirin combination therapy in chronic hepatitis c prevalence, incidence and predictors of severe anaemia with zidovudine-containing regimens in african adults with hiv infection within the dart trial the anemia prevalence study group. prevalence of anemia and correlation with biomarkers and specific antiretroviral regimens in 9690 human-immunodeficiency-virus-infected patients: findings of the anemia prevalence study clinical pharmacy and medication safety keywords: clinical pharmacist, chronic kidney disease, treatment safety reference nccn clinical practice guidelines in oncoloy for multiple myeloma a phase 2 study of bortezomib in relapsed 640 keywords: antibiotics, emergency department the use of mitomycin-c for respiratory papillomas: clinical, histologic and biochemical correlation mitomycin c: prevention and treatment of anterior glottic synechia preliminary results of intraoperative mitomycin-c in the treatment and prevention of glottic and subglottic stenosis airway complications from topical mitomycin c. otolaryngol head neck surg keywords: mitomycin c, laryngeal papillomatosis, papillomas pt-93 effectiveness of rituximab in rheumatoid arthritis background and objective: to assess the response to rituximab in patients with rheumatoid arthritis (ra) who were refractory to anti-tnf treatment. design: observational, cross-sectional study. performed on patients diagnosed of ra according to acr criteria the main variables used to assess clinical evolution were: decrease in das28-esr, considering the number of references noss eh et al. rituximab as therapy for refractory polymyositis and dermatomyositis treatment of early and refractory dermatomyositis with infliximab: a report of two cases keywords: dermatomyositis, rituximab, infliximab were included in the study. main outcome measures: percentage of patients achieving optimum and minimum audit standards for serum total cholesterol, ldl-c, glycosylated haemoglobin (hba1c), bp and take up of aspirin of these, optimum treatment standards for total cholesterol (\4 mmol/l) and ldl-c (\2 mmol/l) were achieved by 34.6% (n = 53) and 23.6% (n = 37), respectively. patients within the minimum audit goal for total cholesterol (\5 mmol/l) and ldl-c (\3 mmol/l) were 74 joint british societies' guidelines on prevention of cardiovascular disease in clinical practice pt-180 pediatric use of infliximab: retrospective study vanida brunie 1 reference french guidelines for assumption of responsibility of candida sp. and aspergillus sp. invasive infections. french society of anesthesia and reanimation keywords: assessment, antifungal agents comparisons of psychotropic drug prescribing patterns in acute psychiatric wards across europe to score personal risks factors (6 to 7: standard risk, 8 to 13: high risk) design of a therapeutic scheme following 2006 asco's guidelines, as follow. day 1: aprepitant 125 mg per os 1 h before chemotherapy ondansetron 8 mg iv 30 min before chemotherapy methylprednisolone (mp) 90 mg iv 30 min before chemotherapy days 2 and 3: aprepitant per os 80 mg methylprednisolone per os 12 mg b.i.d. for the beam strategy, this treatment is given on day 1 (carmustine) and on day 6 (melphalan). the course of corticosteroid was reduced on purpose for clinical oncology guideline for antiemetics in oncology: update 2006. kris and coll keywords: aprepitant, emesis, hematology pt-201 use of anti-tnf-alfa in rheumatoid arthritis intravitreal voriconazole for the treatment of endogenous aspergillus endophthalmitis intravitreal voriconazole for drug-resistant fungal endophthalmitis: case series fungal endophthalmitis caused by aspergillus ustus in a patient following cataract surgery intravitreal voriconazole: an electroretinographic and histopathologic study management of endogenous fungal endophthalmitis with voriconazole andcaspofungin histological examination of an eye with endogenous aspergillus endophthalmitis treated with oral voriconazole: a case report aspergillus endophthalmitis: an unusual complication of disseminated infection in renal transplant patients maria eugenia martínez nú ñ ez 1 , javier sánchez-rubio ferrández 1 , noelia garrido peño 1 , carolina apezteguía fernández 1 background and objective: zidovudine (zdv) is the first drug that approved for treatment of hiv infected patients and now has wide use in haart regimens. this drug can cause hypoproliferative anemia bone marrow toxicity. the object of this study is evaluation of incidence of anemia in iranian hiv positive patients that received zdv in haart regimens. design: in a prospective study, 162 hiv positive patients were referred to iranian hiv research center that start zdv in haart combination were entered the study and have followed for at least one year. baseline and monthly hematological parameters were recorded. setting: iranian hiv research center. main outcome measures: patients demographic parameters, route of infection exposure, stage of disease, cd4 counts, cbc, and hematological parameters. results: twenty nine (29) patients were excluded from the study because of impossible follow-up. from 133 patients, 77 of them have anemia (hemoglobin less than 12 g/dl for female and less than 13 g/dl for male). thirty there (33) patients have anemia before starting haart. thirty four (34) patients have showed anemia following received zdv. twenty (12) patients have improved anemia after were changed zdv to stavudine. conclusions: about 34% of hiv positive patients that were received zdv have experienced anemia.background and objective: in june 2007, the use of infliximab has been approved by emea for the treatment of severe active crohn's disease in pediatric patients aged 6 to 17 years old, who have not responded to conventional therapy (corticosteroid, immunomodulator and nutrition therapy). however, pediatricians were already using infliximab for patients with inflammatory bowel syndrome (ibd) such as crohn's disease (cd), ulcerative colitis (uc) and indeterminate colitis (ic). the goal of the study was to analyze infliximab prescriptions for children and to evaluate changes in prescriptions of corticosteroid due to the introduction of infliximab. design: retrospective study in 33 ibd patients in a pediatric teaching hospital. setting: gastroenterology unit and pharmacy department. main outcome measures: indications, infliximab dosage, anterior treatments, reason of therapeutic change (non-tolerance or inefficiency of anterior treatment and/or cortico-dependance), evolution of corticosteroid dosage 3 and 6 months after the introduction of infliximab. results: thirty-three children were treated by infliximab: 20 cd, 3 uc and 10 ic. age for diagnosis was an average of 11 years old (5.2-16.5) and 13.5 years old (7-17) for the beginning of infliximab. previous treatment to infliximab was immunomodulators, single therapy for 31 patients (azathioprine n = 23, mercaptopurine n = 3, methotrexate n = 5) or dual therapy (n = 2 azathioprine + methotrexate), with corticosteroids (n = 32) and/or mesalazine (n = 6). various etiologies justified infliximab administration: corticodependance (n = 31), corticoresistance (n = 1), non compliance to corticotherapy (n = 1), insufficient efficacy of previous treatment (n = 23), non tolerance to previous treatment (n = 2). at the beginning, dosage of infliximab was 5 mg/kg. dosages were increased (10 mg/kg) for 6 patients due to insufficient clinical results. one patient also had to be switched for adalimumab because he developed human antichimeric antibody (haca). among corticodependant patients (31), corticosteroids have been stopped after 3 or 6 months, 9 (29%) and 19 patients (61%) respectively. for 12 patients, corticosteroids were continued without reduction of dosages, six months after the introduction of infliximab. conclusions: infliximab is the only therapeutic alternative for children who are non tolerant or non respondent to conventional treatment. moreover, this treatment permits the use of decreased dosage of corticosteroids, limiting their side effects, especially on children growth. however, haca occurrence could limit its use in a long-term disease. keywords: infliximab, inflammatory bowel syndrome, pediatrics chemotherapy indication was autologous bone marrow transplant (bmt) (54%), leukaemia chemotherapy induction or consolidation (15%), leukaemia intensive chemotherapy (21%), myeloblastic allogeneic bmt (2%) and mini allogeneic bmt (8%).treatments were prophylactic (60%), empirical (13%) or curative (15% for aspergillus sp but no for candida sp infections); 8% of the prescriptions related to local candidosis and 4% remained unknown.although 66% of prescriptions were in accordance with internal guidelines concerned antifungal drug indication, 26% had wrong dosages e.g. no loading dose for voriconazole. moreover, only 22% of the prescriptions were in accordance with french recommendations: neither voriconazole is approved in prophylaxis of aspergillosis in patients with autologous bmt nor antifungal drugs associations (ten prescriptions). nevertheless, it may be a good way of medical management as hopeful patients outcomes have been obtained.conclusions: hematology department guidelines should be reviewed in accordance with french recommendations, department's ecology and the state-of-the-art about treatment of fungal infections in patients with haematological malignancies. the accordance to further recommendations should be regularly assessed as well as resistance emergence. background and objective: to evaluate the efficacy and safety of rituximab (rtx) for the treatment of refractory autoimmune cytopenia, including autoimmune hemolytic anemia (aha) and immunemediated thrombocytopenia (idiopathic thrombocytopenic purpura itp and thrombotic thrombocytopenic purpura ttp) design: descriptive, retrospective study based on rituximab prescriptions analysis. patients were identified through medical reports delivered by compassionate use program. data collection was made through the pharmaco-therapeutic profile and medical chart review setting: general teaching hospital (420 beds) main outcome measures: patients who received any course of rtx for refractory immune cytopenia from january 2004 to may 2007 were evaluated. data recorded included patients details, diagnosis, previous treatment, rtx schedule, number of courses and baseline hemoglobin (hb) and platelet count (pq) values. effectiveness and tolerance were also considered. response was evaluated according to criteria found in the literature: clinical symptoms resolution and a normal pq count of 100.000/mm 3 for itp/ttp or an hb level [10 g/ dl achieved and maintained for at least 3 months for aha. additional response criteria for aha was an hb increase [1.5 g/dl 1 month after the last dose of rtx. results: 11 patients (4 men), 54 doses rtx; average age 65 years (range 31-85). diagnosis: aha 7 (2 cases cold agglutinin disease), 3 itp and 1 ttp. in 3 patients cytopenia (aha) was associated with chronic lymphocytic leukemia. all patients had been previously treated with steroids and 8 had received 2 or more other treatment modalities (4 splenectomy, 7 immunosupressive agents, 7 intravenous immunoglobulin). patients received 4-6 rtx infusions at a standard dose of 375 mg/m 2 once per week, in combination with steroids therapy in 10 cases. no serious infusion-related effects occurred, but 2 patients reported hematologic toxicity (fever and infection). all patients with aha (7/7) and 2 patients with itp (2/3) responded to the first course of rtx. one patient aha had relapse after 29 months and responded to retreatment. itp responders achieved durable response (16 and 3 months) and were offered second course of rtx after relapse (1 patients did not respond to retreatment). after 28 months follow-up, patient with ttp remained with acceptable pq counts. hb levels increased by a median of 3.5 g/dl (range 2-7,6) among the aha responders. itp + ttp responders achieved a median increase in pq count of 172.500/mm 3 (range 67-188). only responders who reached a 3 months follow-up were considered for response duration assessment: 5 aha, 1 ttp, 3 itp (1 retreatment). median response duration was 17 months (range 4-29) for aha and 16 months (range 3-31) for itp + ttp conclusions: most of the literature findings for rtx in this setting were related to small series or isolated case descriptions. despite the common limitation of the number of patients, our results showed that rtx appears to be a promising agent for the treatment of refractory autoimmune cytopenia. key: cord-031188-btrc3k4c authors: shrestha, sunil; shakya, deepa; palaian, subish title: clinical pharmacy education and practice in nepal: a glimpse into present challenges and potential solutions date: 2020-08-14 journal: adv med educ pract doi: 10.2147/amep.s257351 sha: doc_id: 31188 cord_uid: btrc3k4c this commentary article highlights the challenges in providing clinical pharmacy education in nepal and suggests a few ways forward. contrary to other health care professions, clinical pharmacy practice is a new healthcare discipline in the country which is currently undergoing transition. the existing pharmacy curriculum and training in the country can provide competencies needed for pharmacists in industrial settings. considering the importance of clinical pharmacists in patient care, the government of nepal has implemented a policy recommending the recruitment of clinical pharmacists in hospitals. however, the education and training for pharmacists provided in the country are not sufficient enough for optimum patient care and for delivering clinical pharmacy services. international collaborations in terms of faculty and student exchanges, preceptor training, and accreditation by international organizations such as accreditation council for pharmacy education (acpe), establishment of need-based curriculum, incorporating clinical pharmacy department under the organizational structure of hospitals, etc., may be the right approaches to improve the current status of clinical pharmacy education in the country. the american college of clinical pharmacy (accp) defines clinical pharmacy as "a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, wellness, and disease prevention". 1 the primary work of clinical pharmacists is to collaborating with other healthcare professionals mainly with doctors and nurses, interviewing the patients for assessment, monitoring of drug therapy responses by patients, give drug information to patients or even to healthcare teams and make explicit therapeutic suggestions to patients. 2 currently, clinical pharmacy services are implemented in various countries. however, the area of clinical pharmacy practice is still primitive in the context of nepal and the nepalese pharmacy sector is experiencing changes related to clinical pharmacy education and practice. nepal is a south asian nation located between indian and china with a population of approximately 30 million. 3 health care system of nepal is managed by the ministry of health and population (mohp) of the government of nepal and is in authority for health policy development, planning, and healthcare delivery. 4 in the recent past, there has been an increase in the number of private hospitals with specialty services and more bed strengths. 5 the establishment of the hospitals inside the country has reduced the outflow of nepalese patients traveling to india or foreign countries seeking advanced health care services. these private hospitals and few government-run hospitals employ pharmacists and assistant pharmacists who often manage the hospital pharmacy. pharmacists working in hospital pharmacy are expected to provide clinical pharmacy services as well. however, in a lack of competency and expertise, they are unable to deliver appropriate clinical pharmacy services at their workplace. usually, the pharmacists in nepal complete their formal education on clinical pharmacy either within the country or from the nearby countries, india, pakistan, and bangladesh, where also the clinical pharmacy practice is not well established. in nepal, the quality delivery of pharmacy education is managed by the nepal pharmacy council (npc), through regular inspection visits and the npc is responsible for the registration of qualified pharmacists and assistant pharmacists. 6 a pharmacist and assistant pharmacist must register in the npc to have a professional license to practice pharmacy in the country. 6 even while a registered pharmacist from the country applies for a job abroad, the council provides verification services for foreign job applicants. as of 2020, there are 3761 pharmacists and 7162 pharmacy assistants registered with the npc. 6 nevertheless, the pharmacists with amaster in pharmacy (pharmaceutical care), master's degree in clinical pharmacy and doctor of pharmacy (post-baccalaureate), are not recognized as clinical pharmacists or hospital pharmacists, or other title or designation by the council as there is no provision and stringent policies for the subdivision of the pharmacists. also, though the theoretical and practical concept of clinical pharmacy is provided in the undergraduate and graduate study as per the requirement of the respective syllabus, the actual required skill and knowledge regarding the clinical pharmacy seem lacking among the pharmacy graduates. the emergence of clinical pharmacy services in the hospital lead pharmacists to be more patient-oriented in addition to the traditional dispensing services. clinical pharmacy practice was initially established in developed countries such as the united states (us) and most of the european countries. however, the situation is not the same in low-and middle-income nations, latin america, africa, asia, and the middle east. it is more likely to occur in the developing world where health care systems are also not well established/supported. currently, in developing countries such as nepal, pakistan, india and bangladesh, and many african countries clinical pharmacy is practiced in fewer hospitals, with varying success. 7, 8 clinical pharmacy service is provided by the pharmacist who possesses specialized advanced education and training and works in collaboration with other health care professionals. 9 the overall objective of clinical pharmacy practice is to provide an organized, complete and constant quality of facility to every single patient. 10 in nepal, majority of hospitals (including both private and government-run) have established hospital pharmacy services in the country. incorporating clinical pharmacy services. however, the clinical pharmacists engaged in these hospitals providing clinical pharmacy services are low in number. clinical pharmacists are also involved in activities such as procurement, distribution, store management and other activities predominantly related to hospital pharmacy services. in nepal, core clinical pharmacy services are either lacking or being provided with limited expertise to a limited number of patients or units in the hospital where the physicians voluntarily opt for it and encourage pharmacists to perform their clinical duties. the provision of the pharmaceutical care plan by pharmacists is nonexistent currently. in the year 2015, 'hospital pharmacy guideline 2072ʹ which was developed by the ministry of health and population (mohp), suggested that hospitals with 51-100 beds should have one clinical pharmacist to provide clinical pharmacy services, 12 which seemed to be a ray of hope for recognition of clinical pharmacy services in the country. however, this guideline has not been implemented effectively in all the hospitals within the country, more so common in the government-run hospitals. as the concept of clinical pharmacy is slowly being recognized in the country, there are fair chances of shaping the career of clinical pharmacists in government or private organizations. currently, pharmd graduates and m. pharm degree holders from different universities are working in hospital pharmacies as managers and faculty in medical and pharmacy institutes and rarely practicing as clinical pharmacists in private tertiary care hospitals. however, one must admit that the remuneration for the practicing clinical pharmacists is far too low and thus encouraging pharmacists either to look for a job in middle east countries or sectors other than clinical pharmacy wherein the salary is better at least. clinical pharmacy services witness several challenges despite their importance in improving patient outcomes. there are several problems which are associated with pharmacy education (curriculum content, manpower, and infrastructure 13 and issues related to the practice environment). challenges also arise from the poor awareness among the general public, attitude of pharmacists, and communication gaps between pharmacists. 14 besides these, lack of continuity of services, undefined roles and responsibilities of pharmacists in hospitals, poor recognition and unacceptance by other health care professionals are the challenges faced by the clinical pharmacist. the prospects and opinions of doctors towards the roles and responsibilities of pharmacists are the key factors that influence the development of clinical pharmacy services in hospitals. with increased in various general and specialty hospitals, there is an emerging scope for clinical pharmacy services in the country. pharmacists can play an important role in identifying, preventing, and mitigating drug therapyrelated problems and can stand as a pharmaceutical care providers for the patients. a few of the potential clinical pharmacy areas that can be focused by pharmacists in nepal are listed in table 1 . one of the key concerns associated with implementing clinical pharmacy services in hospitals of nepal is the de-prioritization by the government. however, only a few non-government hospitals in nepal have implemented clinical pharmacy services. however, there are a possible number of challenges in the implementation of clinical pharmacy services in every government and private hospitals in nepal. these factors are related to pharmacy policy, pharmacist and adoption by other healthcare professionals and hospital management related factors. 14 in 2003, npc has adopted guidelines for the accreditation of pharmacy degree programmes. 23 with the vision of setting pharmacy practice standards and uplifting the pharmacy professionals' structure, licensure examination for pharmacists and pharmacy assistants was then implemented by npc. 6 the pharmacists and pharmacy assistants are considered as registered, once they clear the licensure exam which is taken by npc. 14 unlike for pharmacist and assistant pharmacy, npc has not conducted licensure examination for the masters degree program (clinical pharmacy and industrial pharmacy). like any other developing country, pharmacy education in nepal was traditionally more product-oriented but it's focus is currently shifting towards direct patient care as well. though there have been attempts to convert pharmacy education to be patient-oriented, the transition is highly turbulent and had noticed several lacunae due to a lack of integration of practice standards across different there are poorly resourced drug information services in the country. pharmacists with skills in the provision of drug information services are needed. 16 drug-drug interactions (ddis) the clinical pharmacists can help identify potential ddis and prevent them from occurring in the patients. 17 drug utilization evaluation drug utilization research can improve drug use processes in hospitals and the community. 18 to begin with, clinical pharmacists can focus on drug utilization in hospitals and medicine use in specialty areas. emergency department service in nepal, there is no clinical pharmacist or pharmacist involved in the emergency departments of hospitals. this is an important section where the clinical pharmacist has a greater role to play. there are studies highlighting medication errors, adverse drug reactions (adrs) occurring in the country. there can be a great scope for pharmacists in providing medication reconciliation services to the patients. 19 medication error assessment there have been reports on the occurrence of medication errors. 20 the involvement of skilled clinical pharmacists in assessing and addressing medication errors can decrease its occurrence to a greater extent. oncology pharmacy practice pharmacists have been known to provide clinical pharmacy services in oncology departments. 21 additional clinical pharmacists are needed to enhance better patient outcomes. various studies have revealed the existence of patient counseling services in nepal. 16 however, this has not been endorsed by all the hospitals thereby creating a gap to be fulfilled by clinical pharmacists. the country has established national pharmacovigilance program and currently has 12 regional pharmacovigilance centers. 22 there is a scope for clinical pharmacy practitioners in adr reporting, causality assessment and other aspects at each regional pharmacovigilance centers. settings. 24 rather than a patient-oriented health care professional, pharmacists in nepal are more considered as drug sellers in commercial enterprises. the pharmacy graduates after completing their clinical pharmacy education either choose a job in pharmaceutical industries, try for foreign jobs or involve in other businesses that are not related to their educational qualifications. nepal, being a country with inadequate resources, lacks the infrastructure and manpower for effective pharmaceutical training and to maintain updated curricula. thereby, for the capacity building approaches, efficient management out frame facilitated by the effective directions and mentorship is very important. 25 national and international collaborations can be beneficial. the universities should also establish a memorandum of understanding (mous) with large hospitals having clinical pharmacy services in providing experiential learning for students. the institutions running the pharmacy programs should stimulate the proper utilization of funds and resources garnered by collaborating with the various interested contributors for the beneficial capacity building in the pharmacy field. 26 anderson c and futter b 27 have argued that a "need-based curriculum rather than focusing on adopting pharmd from developed countries without a proper preparation" is important. though pharmd was originally designed for north american practice settings it can be implemented with proper experiential learning centers and trained preceptors. 13 in nepal, outdated curriculum, and limited resources to explore clinical pharmacy practices remain the major pitfalls in pharmacy education. 13 also, pharmacy colleges (including those attached to university campuses) do not have their teaching hospital attached to it which directly influence the exposure of pharmacist to hospital settings. 28 some other challenges associated with pharmacy education in the country are mentioned below: with the advancement and complexity in health care technology, complicated patient cases, increasing prevalence of chronic disorders made the necessity of inclusion of more than one profession in their care. 29 the world health organization (who) has recognized that interprofessional education (ipe) is crucial to integrate care, strengthen the quality and improve patient safety. different countries such as the uk, us, germany, poland, australia had included ipe in pharmacy curricula. 30 ipe creates an optimal health care system. early incorporation of ipe into the curriculum may have the biggest impact on the health care system 31 as the students and faculties from different health care programs come together to explore the differences and similarities among the various programs. since ipe is rarely practiced, the graduates have less tendency to work together as a team with other health professionals. as multi-professional health care teams, clinical pharmacists play a significant role in the delivery of ipe and expanding their clinical roles. 32 ipe also provides an opportunity for each healthcare students to appreciate each other's strengths and establish a working relationship among these future health professionals. it also allows pharmacists to best communicate recommendations to other health professionals. for practicing as a pharmacist or a clinical pharmacist, the development of clinical pharmacy skills is essential. 33 the skills required for patient-oriented care includes clinical practice, critical thinking, decision-making, collaborative interpersonal practice, and these skills can be built with experiential training. experiential learning and clinical skills help to produce confident graduates. further, it makes students capable to assume their responsibilities towards patient care and apply their knowledge and skill in drug therapy management. 34 no skills lab provides physical assessment skills needed for clinical pharmacists, required for the ones working in ambulatory care centers and community pharmacies. knowledge of physical assessment is needed for clinical pharmacists to conduct complete and accurate patient evaluations. the pharmacy curriculum should be also revised by adding physical assessments in the current curriculum. it is important to have trained clinical preceptors who can oversee the experiential learning programs in the practice sites. these preceptors needed to be from hospitals as well as from community pharmacies. the presence of clinically competent preceptors enables students to shadow the preceptors and establish a "role model" for their future job responsibilities. however, currently, such an option is very far from reach in nepal. there are a very limited number of hospitals which provide clinical pharmacy services and providing clinical pharmacy training. despite the challenges, clinical pharmacy is one of the needed services in nepal. the center for the advancement of pharmacy education (cape) emphasizes the knowledge, skills, abilities, and attitudes are essential to becoming competent and qualified pharmacists in practice. 35, 36 cape outcomes are designed with four domains to guide the institutes in educating pharmacists. these four domains are further divided into 15 subdomains outcome; learner, caregiver, manager, promoter, provider, problem solver, educator, advocate, collaborator, communicator, self-aware, leader, innovator, and professional. these are constructed to identify what students should be capable of upon graduation from the pharm d program who are practice ready for the profession. 31 the findings from the study by alston et al stated that those applicants who did not possess the attributes of cape subdomains would not be hired for a job. 36 likewise, in nepal, rigid categories can be made (or the same of cape can be followed) which should be satisfied by all the professional pharmacists to be considered as a clinical pharmacist or community pharmacist because the existing pharmacy education and training do not impart all the skills to the future pharmacists. it has become utterly necessary to review and revise the clinical pharmacy curricula and link the course and program learning outcomes with the cape outcomes making sure that the students are provided with these essential skills needed for the pharmacists. clinical pharmacy-related national guidelines should be developed and executed by the ministry of health and population (mohp), 4 department of drug administration (dda) and npc 6 along with collaborating with all the universities giving clinical pharmacy education, pharmacy organizations of nepal, hospitals and related stakeholders. the pharmacy curriculum should be revised giving more emphasis the patient-centered pharmaceutical care delivery. awareness among other health care professionals and hospital management on the importance of clinical pharmacy services should be the starting point of change to achieve excellence in clinical pharmacy practice in nepal. the gap between pharmacy practice and academics which should full filled with introducing pharmacy practice-based teaching and learning modules, tying up with hospital and health sectors. 37 another major component of continuing professional development is through continuing education. this approach enables pharmacists to acquire the necessary skills and knowledge to remain updated and competent in their practice. few additional approaches to improve clinical pharmacy education and training are mentioned in table 2 . the recognition of clinical pharmacy services by the government of nepal indicates that it can be an integral part of health care services within the country. however, as pharmacy education in the country is more oriented towards industry and graduate pharmacists are unable to perform patient care and related clinical pharmacy services in the hospitals, it is a challenging task to uplift the fledgling clinical pharmacy services. the educational institutes should build their capacities for imparting skills to their students and for better experiential training opportunities through qualified and competent clinical preceptors. international collaborations and accreditation of the educational programs for the betterment of the clinical pharmacy may be the way forward. american college of clinical pharmacy. the definition of clinical pharmacy developing pharmacy practice: a focus on patient care: handbook. world health organization nepal population ministry of healhealth. nepal health facility survey the role of pharmacists in developing countries: the current scenario in pakistan current status, challenges and the way forward for clinical pharmacy service in ethiopian public hospitals clinical pharmacists: practitioners who are essential members of your clinical care team a text book of clinical pharmacy practice: essential concepts and skills history of pharmaceutical development in nepal kathmandu (nepal): government of nepal, ministry of health and population pharmd education in nepal: the challenges ahead pharmacy practice in nepal implementing antimicrobial stewardship in two community nepali hospitals. open forum infect dis overview, challenges and future prospects of drug information services in nepal: a reflective commentary a study of potential drug-drug interactions among hospitalized cardiac patients in a teaching hospital in western nepal can drug utilization help in promoting the more rational use of medicine? experiences from western nepal pattern of potential medication errors in a tertiary care hospital in nepal assessment of prescription pattern and prescription error in outpatient department at tertiary care district hospital, central nepal oncology pharmacy practice in a teaching hospital in nepal glimpse of pharmaceutical education in nepal the changing face of pharmacy practice and the need for a new model of pharmacy education individual capacity-building approaches in a global pharmaceutical systems strengthening program: a selected review capacity building in pharmacy education in resource-poor settings: an ethnographic case study of malawi pharmd or needs based education: which comes first? pharmacy practice in nepal world health organization. framework for action on interprofessional education and collaborative practice. world health organization interprofessional education (ipe) and pharmacy in the uk. a study on ipe activities across different schools of pharmacy interprofessional education: principles and application a framework for clinical pharmacy clinical pharmacy education in china experiential training for pharmacy students: time for a new approach center for the advancement of pharmacy education 2013 educational outcomes pharmacists' opinions of the value of cape outcomes in hiring decisions history and evolution of pharmaceutical education in nepal: education versus practice the authors of this manuscript would like to acknowledge ms. asmita priyadarshini khatiwada, nepal health research and innovation foundation, nepal for her assistance in revising the manuscript and recommending modifications. the authors received no funding. the authors declare no conflict of interest. advances in medical education and practice is an international, peerreviewed, open access journal that aims to present and publish research on medical education covering medical, dental, nursing and allied health care professional education. the journal covers undergraduate education, postgraduate training and continuing medical education including emerging trends and innovative models linking education, research, and health care services. the manuscript management system is completely online and includes a very quick and fair peer-review system. visit http://www.dovepress.com/testimonials.php to read real quotes from published authors. key: cord-009664-kb9fnbgy authors: nan title: oral presentations date: 2014-12-24 journal: clin microbiol infect doi: 10.1111/j.1469-0691.2009.02857.x sha: doc_id: 9664 cord_uid: kb9fnbgy nan [ primary immunodeficiency diseases are a heterogeneous group of disorders, caused by inherited defects in the immune system, and characterised by wide spectrum of clinical manifestations, particularly an increased susceptibility to infections and a predisposition to autoimmune diseases and malignancies. recurrent infections or infection with unusual organisms are the most commonly presentation of primary immunodeficiency diseases. although recurrent respiratory tract infections and gastrointestinal manifestations are the most common features of these diseases, especially in predominantly antibody deficiencies and combined immunodeficiencies, other organs can be involved as well. recurrent cutaneous abscesses with unusual organisms or deep abscesses may represent infections with an association with immunodeficiencies, particularly in phagocytes defects. meningococcal infections could have an association with complement deficiencies. meanwhile other bacterial infections, mainly streptococcus pneumoniae and staphylococcus aureus, as well as infections with viruses, fungi and parasites are also common in several primary immunodeficiency diseases. autoimmune diseases such as idiopathic thrombocytopenic purpura, autoimmune haemolytic anaemia, systemic lupus erythematosus, juvenile arthritis, sclerosing cholangitis, and vasculitis are common in primary immunodeficiency diseases. whilst some syndromic immunodeficiencies (e.g., wiskott aldrich syndrome, di george syndrome) have a strong association with autoimmunity, there are a group of disorders (e.g., alps, apeced, ipex) that the autoimmune manifestations are typically the first and most significant findings. malignancies are also common in some primary immunodeficiency diseases (e.g., cvid, alps, xlp, and dna repair defects). other manifestations such as dysmorphic features, associated anomalies, skeletal dysplasia, and oculocutaneous hypopigmentation can be unique characteristics of some cases with primary immunodeficiency diseases. the clinical manifestations of these diseases are often helpful in guiding the appropriate evaluation of the patients. prompt and precise diagnostic laboratory evaluation should be performed in the patients with such features, whereas early diagnosis and successful management of these patients prevent irreparable organ system damage and improve the prognosis. immunodeficiency specialists from all over europe have composed a multistage diagnostic protocol that is based on their expert opinion, in order to increase the awareness of pid among doctors working in different fields. the protocol starts from the clinical presentation of the patient; immunological skills are not needed for its use. a list of relevant symptoms and signs from the history and physical examination that should alert any physician to potential pid is given. these are grouped together to form eight typical clinical presentations of pid: recurrent ent and airway infections; failure to thrive from early infancy; recurrent pyogenic infections; unusual infections or unusually severe course of infections; recurrent infections with the same type of pathogen; autoimmune or chronic inflammatory disease, or lymphoproliferation; characteristic combinations of clinical features in eponymous syndromes; and angioneurotic edema. these presentations lead the user towards different algorithms, which in fact represent the traditional division into antibody, complement, lymphocyte, and phagocyte deficiencies, respectively. the algorithms each are comprised of several steps. this multistage design allows cost-effective screening for pid within the large pool of potential cases in all hospitals in the early phases, while more expensive tests are reserved for definitive classification in collaboration with an immunologist at a later stage. g. schmid°(geneva, ch) in 1986, articles suggesting that male circumcision (mc) decreased the risk of hiv infection appeared. over the next 15 years, studies of two epidemiologic types − ecologic and observational − increasingly supported this contention. ecologic studies showed strong correlations between prevalences of mc and hiv, e.g., tribes with low prevalences of mc had high prevalences of hiv infection. observational cross-sectional studies showed that uncircumcised men had higher rates of hiv than circumcised men. observational cohort studies confirmed these weaker study design findings. a systematic review of observational studies in 2000 found a relative risk (rr) of 0.42 (95% ci, 0.34−0.54), a 58% protective effect. in 2005 and 2007, results from three randomised controlled trials, all from sub-saharan africa, were reported. results were consistent, and the pooled rr of 0.42 (95% ci, 0.31−0.57) was identical to that of the observational studies. the protective effect in the three trials, found at about 21−24 months' follow-up, has been extended in one trial to a protective effect of 64% at 42 months of follow-up. who and unaids have strongly endorsed mc as an effective hiv prevention strategy in generalised hiv epidemics where mc is uncommon. what about europe? mc is uncommon with an adult male prevalence of <20%. hiv incidence is low enough that mc for hiv prevention purposes is unlikely to have much impact. no public health authority recommends routine neonatal circumcision. increasingly, however, data are showing benefits of mc in addition to hiv prevention. lessened risk of urinary tract infection in infants (rr 0.13, 95% ci 0.08−0.20) and lifetime avoidance of phimosis and associated conditions occur when mc is performed neonatally. other benefits occur in males circumcised at any age. mc protects against acquiring sexually transmitted infections characterised by genital ulcers-syphilis, chancroid and herpes-and possibly trichomoniasis. circumcised men may be less likely to acquire hpv and are more likely to clear the infection. through the protective effect against hpv, mc halves risk of penile cancer (rr 0.52, 95% ci 0.33−0.82) and partners of circumcised men are at lessened risk of cervical cancer. other issues must be considered in making public health decisions about mc. cultural objections may occur, but mc in the developing world is readily accepted in non-circumcising societies. studies of sexual pleasure and function have found no relationship to circumcision status. mc may be advised for subgroups, even if not for the entire population. and, surgical risk and cost must be considered. while many sub-saharan african countries are scaling up mc services to prevent hiv infection, public health agencies in many industrialised countries are reconsidering mc policies-the outcomes of both efforts are being followed with interest. acute otitis media (aom) is generally considered a bacterial infection that is treated with antibiotics. however, despite extensive use of broadspectrum antibiotics for this condition, the clinical response to the treatment is often poor. this fact, together with vast clinical experience connecting aom with viral respiratory infections, has prompted research into the role of viruses in aom. to date, ample evidence from studies ranging from animal experiments to large clinical trials supports a crucial role for respiratory viruses in the aetiology and pathogenesis of aom. in most cases, viral infection of the upper respiratory mucosa initiates the whole cascade of events that finally leads to the development of aom as a complication. the pathogenesis of aom involves a complex interplay between viruses, bacteria, and the host's inflammatory response. recent studies indicate that with sensitive techniques viruses can be found in the middle-ear fluid in most children with aom, either alone or together with bacteria. viruses appear to enhance the inflammatory process in the middle ear, and they may profoundly impair the resolution of otitis media. it is important to understand, however, that our increasing knowledge of the importance of viruses in the etiopathogenesis of aom does not diminish the central role of bacteria in aom. therefore, while viruses may explain many of the problems encountered in treating aom, the ultimate decision on whether or not to treat aom with antibiotics cannot be based solely on the degree of viral involvement in aom. the non-judicious use of antibiotics has lead to an epidemic in antimicrobial resistance. acute otitis media (aom) is the most common indication for use of antibiotics in children in the united states (us). despite available evidence that supports a wait and see approach, most us physicians immediately prescribe antibiotics for the treatment of aom. the american academy of pediatrics published a guideline in 2004 that addressed the diagnosis and treatment of aom. this guideline recommends the use of observation as a potential strategy for the treatment of aom. the key components of this published guideline will be discussed, as well as the evidence and rationale that supports the use of observation as an initial strategy to treat aom. otitis media (om) is the most common bacterial infection in children aged <5 years for which antibiotic treatment is prescribed worldwide. although most of the time this entity resolves spontaneously it is associated with morbidity, family dysfunction, antibiotic use and burden on the medical system. efforts to reduce the burden of om by vaccination have not been extremely rewarding, but some progress has been made. the first obvious step would be to reduce viral infections leading secondarily to om. in the modern era, the only viral vaccine with proven effect on aom is the influenza virus vaccine. both the inactivated and the live virus showed some effect, but since influenza virus has only a limited season yearly the effect on the overall om rate is far from being remarkable. haemophilus influenzae (hi) b vaccine did not reduce om since most hi causing om are nontypable (nthi) and not hib. the newly developed pneumococcal conjugate vaccines (pcvs) have all been shown to reduce >50% of the om caused by the serotypes included in the vaccines, but some replacement with serotypes not included in the vaccines and non pneumococcal organisms was demonstrated to reduce the overall effect of pneumococcal vaccines. the effect of pcv on the reduction of recurrent om, om with effusion, the need for ventilation tubes and frequent visits for aom has been suggested, and the real impact is still being studied. aiming with pcv at those with established recurrent om has proved disappointing. pcvs can reduce om caused by antibiotic-resistant s. pneumoniae but the continued overuse of antibiotics is responsible for the increase in antibiotic resistance in non-vaccine serotypes. a newly developed pcv with an outer membrane protein for hi (pnpd) is suggested to reduce also om caused by hi, but confirmation studies are needed. the expansion of the 7 serotypes included in the current licensed pcv to 10 or more serotypes may add to the prevention of om in the near future. in the next decade, om will continue to be an important disease in children. however, we can expect it to be modified in terms of bacteriologic aetiologies, antibiotic resistance and hopefully short and long term consequences. v. korten°(istanbul, tr) infectious consequences of an earthquake mainly involve several types of communicable diseases and crush related infections. water-borne and food-borne illnesses often result from the disruption of the public water and sewage systems and contamination of water supply. overcrowding, poor hygiene and sanitation in temporary shelters also may be factors. the type of infectious diseases are associated with the epidemiology of communicable diseases in the area where the earthquake occurred. the most common outbreaks associated with earthquakes are gastroenteritis, infectious hepatitis and pulmonary infections. in unvaccinated populations, there are reports of increased measles. tetanus can be seen in populations where vaccination coverage levels are low. the risk for diarrhoeal disease outbreaks following earthquakes is higher in developing countries than in industrialised countries. an outbreak of acute watery diarrhoea involved >750 cases occurred in a camp after the 2005 earthquake in pakistan. acute respiratory infections, hepatitis e clusters and measles (>400 clinical cases in the 6 months) also occurred among the displaced victims after the same earthquake. contamination of drinking water led to an outbreak of rotavirus after the 2005 earthquake in kashmir, india. an unusual outbreak of coccidiomycosis associated with exposure to increased levels of airborne dust occurred after the 1994 southern california earthquake. persons who have been trapped by rubble for several hours or days may develop compartment syndromes requiring fasciotomy or amputation. infectious complications were common in renal victims of the1999 marmara earthquake in turkey and were associated with increased mortality when complicated by sepsis. of 639 renal victims, 223 (34.9%) had infectious complications, mainly sepsis and wound infections. most of the infections were nosocomial in origin and caused by gram-negative aerobic bacteria and staphylococcus spp. multivariate analysis of the risk-factors for nosocomial infections revealed a significant association with fasciotomy and length of hospital stay in a back up university hospital. the most frequent pathogens isolated from pus and/or wounds culture in 2008 wenchuan earthquake survivors were s. aureus, e. coli, a. baumannii, e. cloacae, and p. aeruginosa. disaster-preparedness plans, focused on trauma and mass casualty management and also on health needs of the surviving affected populations may decrease the health impact of earthquakes. s16 infections in the disaster setting: famine. experience from darfour, sudan clinic malnutrition is a known risk factor for id worldwide. subsaharan africa and india is at higher risk due to vegetarian habits on absolute absence of animal meat proteins, resulting to depletion of micronutritients (zinc, iron, selenium), responsible for recovery of postmalarial anaemia. in addition, depletion of proteins results to immunoglobulinaemia and to delayed response to many bacterial pathogens causing id in topics (pneumococci, salmonella, etc.) . third problem is absence of vitamins dissolved in oil and fat, resulting to delayed phagocytic activity. therefore proteinocaloric malnutrition results to significant adverse outcome in hiv, tb (diarrhoea, pneumonia), the major killers of children under five. st. elizabeth university tropical programme runs 4 antimalnutrition centres: 1 in sudan, darfour and 2 in kenya amaong upcountry refugees from major conflict areas (sudan − turrana border) and 1 in uganda trying to rehabilitate malnourished children under 5 and helping them to combat disease, responsible for 12.5 million deaths in children mean 5 a year − malaria (1.2 mil), tb (1.1 mil), hiv (2.0 mil), pneumonia (7.5 mil) and diarrhoea (0.5 mil. children deaths approximately a year). h. giamarellou°(athens, gr) for the last six years greece has faced a large number of infections, mainly in the intensive care units (icu), due to carbapenemsresistant klebsiella pneumoniae. the proportion of imipenem-resistant k. pneumoniae has increased from less than 1% in 2001, to 23% in isolates from hospital wards and to 53% in isolates from icus in 2008. likewise, in 2002, these strains were identified in only three hospitals, whereas now they are isolated in at least 32 of the 40 hospitals participating in the greek surveillance system. until 2007 this situation was due to the spread of the blavim-1 cassette among the rapidly evolving multiresistant plasmids and multiresistant or even panresistant strains of mainly k. pneumoniae and also other enterobacterial species. however, the fact that most strains display mic values below or near the clsi resistance breakpoint create diagnostic and therapeutic problems, and possibly obstruct the assessment of the real incidence of these strains. as of 2007, the emergence of kpc-producing k. pneumoniae has been noted in icus of some greek hospitals and has now spread to most hospitals throughout the country creating a countywide outbreak in 2008. in attikon university hospital we recently described the icu outbreak of kpc-producing k. pneumoniae. twenty-nine patients (admitted from february to december 2008) were colonised mainly in gi tract. fifteen patients were male (52%) and the median apache ii was 19. patients had already long hospital stays preceding icu admission with a median of 25 (17−40) days. in twenty-two of these patients (76%) kpc-producing k. pneumoniae colonisation was definitely icuacquired while in 7 (24%) acquisition in other wards or other hospitals was hypothesized. five of these patients are still hospitalised in the icu and, of the remaining 24, 11 died (icu mortality 46%). ten of the 29 colonised patients were clinically infected. fifteen infections were documented, mostly bsi (11/15), followed by vap (2/15) and ssi (2/15). only 1 patient died from this infection (1/15, 6.7%). an evidence-based consensus on the therapeutic strategy for these infections has been reached by keelpno and the greek ministry of health which proposed the use of high dose meropenem (6−8 g/day) combined with an active aminoglycoside or colistin for strains with an mic 4 mg/ml whereas for strains with a higher mic the use of carbapenems is contraindicated and active alternatives (monotherapy with tigecycline, colistin, or an aminoglycoside or aztreonam-based combinations) could be used. antibiotic stewardship is of great importance in such a dismal situation but stringent adherence to infection control measures is probably of even greater importance for the effective containment of these pandrugresistant strains. the presentation of clostridium difficile infection (cdi) varies from mild diarrhoea to a potentially fatal pseudomembranous colitis. the recent emergence of types 027 and 078 of c. difficile has been associated with increased virulence. c. difficile takes advantage of disruption of the normal intestinal flora as caused by antibiotic therapy. the antibiotical class and the antimicrobial resistance pattern of c. difficile influence the development of disease. in the netherlands, significantly more patients with cdi due to type 027 used fluoroquinolones (or, 2.88; 95% ci, 1.01−8.20) compared with those who were infected with other pcr ribotypes. similar as type 027 cdi, patients infected with type 078 also more frequently received fluoroquinolones therapy (or, 2.17; . the risk to develop cdi due to type 027 was particularly high in persons receiving a combination of cephalosporin and fluoroquinolone (or 57.5, ). this association was also strongly dependent on the duration of therapy. the use of clindamycin was found as a protective factor. however, the recent detection of clindamycin-resistant c. difficile type 027 strains in other european countries is an important and worrying development. since the association of cdi with fluoroquinolones has only been investigated at patient level, a study was performed to investigate the relationship between cdi incidence and the preceding use of different antibiotic classes at hospital level in the netherlands. comparisons were made between hospitals where type 027 caused an epidemic, hospitals where only isolated cases of type 027 were observed and hospitals where no outbreak of cdi or type 027 were encountered. in the pre-epidemic period, the total use antibiotics was comparable between affected and unaffected hospitals. higher use of secondgeneration cephalosporins, macrolides and all other studied antibiotics were independently associated with a small increase in cdi incidence, but the effect was too small to predict which hospitals might be more prone to 027-associated outbreaks. despite the fact that the netherlands is known by its restrictive and conservative use of antibiotics, outbreaks of cdi due to new emerging types have been recognized. this is probably associated with the use of antibiotics at patient level and hospital department level rather than the use of antibiotics at the level of the healthcare institute. m. peiffer, j. bulitta, h.a. haeberle, m. kinzig-schippers, m. rodamer, v. jakob, b. nohé, f. sörgel, w.a. krueger°(trier, de; albany, us; tubingen, nuremberg, constance, de) piperacillin-tazobactam (pip-tazo) is a broad spectrum antibiotic, used for treatment of severe infections such as ventilator-associated pneumonia (vap). the effectiveness of betalactams is best predicted by the duration of free drug concentrations above the minimal inhibitory concentration (t > mic) of infecting pathogens [1] . animal experiments suggest that more than 50% of t > mic should be reached. continuous infusion (ci) of pip-tazo may enhance the therapeutic performance, but there is little data on pharmacokinetic/-dynamic (pk/pd) parameters, when ci is used in critically ill patients. objectives: the aim of our study was to determine concentrations of pip-tazo in plasma and broncho-alveolar epithelial lining fluid (elf) at steady state during ci. based on these results, the penetration ratio (plasma/elf) and pk/pd parameters for pip-tazo are derived. methods: after approval by the ethics committee, 16 mechanically ventilated critically ill patients were enrolled during treatment in 3 intensive care units. each patient received a loading dose of 4 g/0.5 g of pip-tazo, followed by ci of 12 g/1.5 g over 24 h. at steady state (67.8 + 39.5 h after loading dose), a total of 30 blood samples were drawn and bronchoalveolar lavage (bal) was simultaneously performed in 8 cases (1 sample discarded for technical reasons). samples were stored at −80ºc until analysis by liquid chromatography coupled with mass-spectrometry (lc-ms). elf-concentrations were calculated from bal-samples using the relation of ureaplasma:ureabal as dilution factor. results: plasma concentrations of pip and tazo (n = 30 in 16 pts.) amounted to 15.38+8.89 mg/ml, and 1.31+0.95 mg/ml, respectively. elflevels (n = 7) were 56.63+27.24 mg/ml, and 5.95+3.74 mg/ml. elf-levels were 368+236%, and 587+584% of corresponding plasma levels (n = 7) for pip and tazo, respectively. the ratio pip:tazo was 11.74:1 in plasma, and 9.52:1 in elf. conclusions: using advanced analytical techniques, elf concentrations were higher compared to traditional bolus administration [2] . ci yielded steady state plasma concentrations in excess of mics of susceptible bacteria (<8 mg/ml, according to eucast) in 76.6% of measurements, respectively, but elf levels exceeded 8 mg/ml in all cases. taken together, our data provide further arguments for ci being the preferred mode of administration for pip-tazo in critically ill patients with suspected vap. [ objectives: staphylococcus aureus is a potential pathogenic microorganism and a causative agent of~25% of infections in intensive care patients. an optimal empiric choice for the treatment of these infections will result in a reduction in morbidity and mortality. therefore, it is essential to provide the clinician with resistance data of the bacterial population to be treated. to optimise the empiric choice and to monitor the emergence of microbial resistance, a national surveillance program of the swab was started in the netherlands in 1996.this study describes the results of the resistance development of s. aureus from icu's of 14 hospitals all over the netherlands over a ten year period. methods: in the first 6 months of each year, the participating hospitals collected clinical isolates from among others blood and respiratory samples. in total 943 isolates were collected: 250 from 3 hospitals in the north, 187 from 2 in the east, 229 from five in the west and 280 from four in the south. the antimicrobial susceptibility was determined as a micro broth dilution method according to the clsi guidelines. results: an increase in resistance to ciprofloxacin was observed from 4% until 2002 to 14% from in 2005, which dropped again to 7% in 2006. the resistance to moxifloxacin was rather constant over time, i.e. 2%, only in 2003 8% resistance was found. resistance to clarithromycin increased to 10% in 2003, but decreased in 2006 to 6% the level before 2003. resistance to penicillin, clindamycin and tetracycline fluctuated over time at~75%, 4−8% and 2−10% respectively. during the study period seven methicillin resistant s. aureus were isolated, no resistance to vancomycin, teicoplanin and linezolid was observed. resistance to gentamicin and rifampicin was sporadicly found. regional differences were observed for ciprofloxacin, being the highest in the western and southern part and tetracycline being the lowest in the northern part. conclusion: during the 10 year study period only an increase in resistance to ciprofloxacin was observed. the data presented justify the empiric choice of flucloxacillin, (with rifampicin or gentamicin depending on the indication) in case of an infection in icu patients probably caused by s. aureus. j.j. lu°, p.r. hsueh, s.y. lee (taichung, taipei, tw) objectives: to investigate the prevalence of visa in hospitalised patients with mrsa infections or colonisations at a teaching hospital in taiwan and to evaluate the possible clonal spread of visa in the hospital. methods: from september 2001 to august 2002, 1500 consecutive mrsa isolates were collected from various clinical specimens of 637 patients hospitalised at a teaching hospital in taiwan. minimum inhibitory concentrations (mics) of vancomycin for all mrsa isolates were determined by the broth microdilution method in accordance with clsi guidelines. molecular characteristics and antimicrobial susceptibilities of visa isolates were investigated and pulsed-field gel electrophoresis was used to evaluate the clonality of the isolates. results: among the 1500 mrsa isolates, 43 (2.9%) were visa. of the 43 visa isolates, 35 had vancomycin mics of 4 microgram/ml and 8 had vancomycin mics of 8 microgram/ml. all isolates were inhibited by tigecycline at 0.5 microgram/ml, linezolid at 1 microgram/ml, and ceftobiprole at 2 microgram/ml. five (11.6%) isolates had reduced susceptibility to daptomycin (mics of 1−2 microgram/ml). six of the 43 visa isolates had decreased susceptibility to autolysis in 0.05% triton x-100. the 43 visa isolates were recovered from 21 patients; 13 of these patients had received glycopeptide treatment prior to the isolation of visa. five (23.8%) patients died despite vancomycin therapy. all 43 visa isolates carried sccmec type iii and agr group i but were negative for pvl gene (luks-lukf). none of the enterococcal van genes were detected in the 43 visa isolates. results of pfge analysis revealed that one major clone of visa isolates (90.5%, clone a exhibiting sccmec type iii, agr group i, and absence of pvl gene) had disseminated in the hospital. conclusion: this retrospective study demonstrated that clonal dissemination of visa had occurred in the hospital. rapid and correct detection of visa and proper use of antibiotics are the most effective approaches for preventing its emergence and spread. x. zheng°, c. qi, a. o'leary, m. arrieta, s. shulman (chicago, us) objectives: vancomycin remains one of the major options for treating methicillin-resistant s. aureus (mrsa) related infections. some but not all studies have shown an increase in prevalence of mrsa isolates with elevated vancomycin mic values among recent clinical isolates, so called "mic creep". although still within the susceptible range, higher mics may be associated with increased chance of treatment failure. because of the conflicting reports and lack of published data from paediatric patients, we sought to assess possible mic change over time and to compare results generated by using different methodologies including etest, agar dilution, and broth microdilution (microscan) methods. methods: we studied 318 mrsa isolates predominantly community acquired including all blood and normally sterile site isolates collected in our large children's hospital in 2000/2001, 2003, 2005, and 2007 molecular bacteriology o41 genome sequence of a virulent, methicillin-sensitive staphylococcus aureus clinical isolate that encodes the panton-valentine leukocidin toxin l. faraj, l.a.s. snyder, n.j. loman, d.p. turner, m.j. pallen, d. ala'aldeen, r. james°(nottingham, birmingham, uk) objective: to determine the genome sequence of a virulent meticillinsensitive staphylococcus aureus (mssa) clinical isolate sanot01. methods: roche 454 sequencing determined the genome sequence of the clinical isolate at 12 times coverage. newbler sequence assembly (roche) generated 10 scaffolds that were annotated using gendb and compared with other s. aureus genome sequences. results: an 11-year-old asian girl presented with fever and a 1-week history of knee pain following a trivial fall. an mr scan revealed a large subperiosteal abscess around the upper tibia secondary to metaphyseal osteomyelitis. a pvl-positive, mssa was isolated from blood cultures and pus. the child deteriorated, required repeated debridement and developed septic shock. further investigation revealed aortic valve endocarditis with an aortic root abscess. whole genome sequencing revealed that sanot01 is the first sequence of an st30 s. aureus isolate to be determined. sanot01 is agr type iii and carries three coding regions that are not found in any other s. aureus genome sequences. amongst the unique genes present in these regions is a dihydrofolate reductase gene (dfrg) which is present in addition to the usual dfrb gene. downstream of the orfx gene, a 6.5 kb remnant of sccmec type ivc was found. this sequence has only previously been found in the mrsa252 genome sequence where it is located between the orfx and sccmec type ii sequences. mrsa252 is unique in sharing 14 genome regions with s. aureus strain rf122, a causative agent of contagious bovine mastitis. all but one of these 14 genome regions are also present in sanot01. conclusions: comparison of the genome sequence of sanot01 and the closely related mrsa252 ha-mrsa (emrsa-16) isolate reveals new insights in the evolution of both ca-mrsa and ha-mrsa isolates and the link to s. aureus rf122. pvl-encoding mssa strains can be significant pathogens but are not currently under mandatory surveillance in uk. as the cost of whole genome sequencing falls further it will become feasible to use this technology to monitor the evolution of both mssa and mrsa in healthcare settings and reveal clinically relevant information that will help to improve patient outcomes. objectives: ca-mrsa often produce panton-valentine leukocidin (pvl), a leukocidin encoded by two co-transcribed genes located on lysogenised phages. five pvl-encoding phages have been described in s. aureus: phipvl, phi108pvl, phislt, phisa2mw and phisa2958. single nucleotide polymorphisms (snps) in the pvl genes tend to vary with lineage and may have structural and functional implications. we examined a selection of pvl-positive ca-mrsa reported in our hospital to determine whether sequence variation and the pvl-encoding phage vary with lineage. methods: twenty-two pvl-positive isolates were chosen to reflect mlst clonal complexes identified in our hospital: cc1, 5, 8, 59, 80, 88 and 154 . isolates were characterised by antimicrobial resistance profile, sccmec and spa type, pulsed-field gel electrophoresis (pfge) profile and multilocus sequence typing (mlst); an oligonuleotide array (clondiag arraytube) was used to detect a range of toxin and antimicrobial resistance genes. primers were designed to amplify and sequence the luksf-pv genes. the pvl-encoding phage was characterised using a recently described pcr-based assay (ma et al. j clin microbiol 2008; 40:3246−58) . results: snps were identified at seven positions in the luksf-pv genes and the snp profile varied with lineage. three of the snps were coding mutations, which may have structural and functional implications. cc1 and cc80 isolates were both found to carry phisa2mw. the pvlencoding phage was not definitively identified in the other lineages, although the cc59 isolates carried a phisa2958-like phage and the cc8, cc80 and cc154 isolates carried elongated head-type phages. one of the cc1 isolates had an unexpected snp pattern compared with other cc1 isolates; this isolate also carried a novel or variant phage. conclusion: pvl gene sequence and the pvl-encoding phage vary with lineage in pvl-positive ca-mrsa isolates. this suggests that certain lineages are susceptible to infection or lysogeny with certain phage types. although ca-mrsa commonly carry pvl genes, some strains do not; it is possible that some pvl-negative types are resistant to infection with pvl-encoding phage, perhaps via restriction modification systems. crucially, our findings suggest the pvl genes have co-evolved with their phage and are not freely transmitted between different phages. further work is required to characterise the pvl-encoding phage in other isolates and to investigate whether the pvl sequence variants result in biological differences. objectives: community-associated mrsa (ca-mrsa) of many different mlst clonal complexes (ccs) can harbour lysogenised bacteriophage dna (prophage) encoding panton-valentine leukocidin (pvl). five pvl phages (phipvl, phislt, phisa2mw, phi108pvl, and phisa2958) have been reported to date. we sought to determine the distribution of chromosomally integrated copies of these lysogenised pvl-phages amongst dominant clones of pvl mrsa in england and wales. methods: seventy isolates of previously characterised pvl-mrsa were analysed by pcrs developed by ma et. al, (jcm, 2008) , to identify and discriminate between the five known pvl phages. to maximise any underlying diversity, representatives of each cc were selected based upon their spa, staphylococcal cassette chromosome mec (sccmec), toxin gene and pulsed-field gel electrophoresis (pfge) profiles. these included isolates of internationally disseminated pvl-mrsa lineages ccs 8, 30 and 80 which resemble the usa300, south west pacific (swp) and european clones, respectively. in addition we analysed pvl-mrsa from ccs 1, 5, 22, 59, 88 and st93. results: all seven cc80 isolates, which included representatives of the european clone, possessed an elongated-head-type phage and were positive by the pcr specific for the phisa2mw phage. one of the cc30 isolates possessed a phi108pvl phage, four swp representatives had elongated head type phages, whilst the remaining four cc30 isolates harboured an icosahedral-head-type phage. one cc30 was positive for both head shapes. the 12 cc8 (including representatives of usa300), eight cc1, six cc88 isolates and the st93 isolate were all positive for elongated-head-type phage. nine cc5 isolates were non-typeable for phage head shape and specific phage pcrs. three of four cc59 isolates, harboured a phisa2958-like phage of an unknown head type and the other cc59 isolate was non-typeable. all 14 cc22 isolates possessed an icosahedral-head-type phage, 13 were positive for the phipvl phage type and one possessed phi108pvl type. we have determined the pvl phages present in a diverse panel of distinct pvl-mrsa clones and found considerable inter-lineage variation in the pvl prophage present. there was also evidence of intra lineage variation in some major ccs such as ccs 22, 30 and 59. together with variation in mlst cc and sccmec, these data suggest pvl-mrsa have evolved on multiple occasions, sometimes within the same lineage. o44 transcriptional profiling of klebsiella pneumoniae genes controlled by the transcription factor, rama objectives: rama is an arac/xyls family transcriptional activator where over expression is associated with a multidrug resistance phenotype. in both multidrug resistant klebsiella and salmonella isolates, the rama gene has been associated with increase in expression of the acrab efflux pump. in salmonella it has been shown that a deletion of the rama locus prevents the emergence of multidrug resistant mutants. therefore in order to understand the role of this key regulator in the emergence and development of antibiotic resistance, transcriptomic analyses of its regulon were undertaken in k. pneumoniae. methods: rna was extracted from a combination of isogenic mutants and clinical isolates using the qiagen or ribopure kits. rna integrity was assessed using nanodrop and agilent nanochip systems. the rna was transcribed into double stranded cdna prior to labelling with cy3. the cdna was hybridised to the nimblegen expression array platform designed from the k. pneumoniae mgh 78578 genome. results: approximately 50 genes were found to be affected by rama expression, of which twenty (involved in metabolism, physiology, transcription, drug efflux, protection responses and the cell envelope) were confirmed by rt-pcr. the rama protein appears to affect drug efflux operons not previously shown to be associated with multidrug resistance and or affected by similar proteins such as mara. comparative transcriptome analyses of different k. pneumoniae clinical isolates overexpressing rama showed that variations exist in the levels of expression of the drug efflux genes. of note genes shown to be directly regulated by rama have a marbox-like sequence within the promoter sequences. conclusion: in this study, the transcriptome of the regulatory protein, rama, was determined in the pathogen k. pneumoniae. drug efflux proteins not previously associated with rama overexpression were found to be directly affected. the rama regulon overlaps with the mara and soxs regulons in e. coli and salmonella but is directly associated with regulating the expression of a subset of genes via a marbox sequence. interestingly, variations in the levels of the expression of the regulon genes were found in the different rama overexpressing strains. m. eshoo°, c. crowder, h. li, h. matthews, s. meng, s. sefers, r. sampath, c. stratton, d. ecker, y.w. tang (carlsbad, nashville, us) objectives: the potential for fatal outcome from tick-borne human infections such as ehrlichiosis emphasizes the need for rapid diagnosis. we developed and validated an ibis t5000 assay (ibis biosciences, inc., carlsbad, ca) that can detect and identify a wide range of tick-borne pathogens from clinical samples. methods: a multi-locus assay was used that employs 16 broadrange pcr primer pairs targeting all known bacterial tick-borne pathogen families. electrospray ionisation mass spectrometry of the pcr amplicons was used to determine their base composition. these base composition signatures were subsequently used to identify the organisms found in the samples. the assay was developed using field collected ticks and a wide range of clinical sample types and has been shown to be sensitive to the stochastic limits of pcr. results: whole blood (198) , cerebrospinal fluid (20) and plasma (1) samples, which were originally submitted for ehrlichia species detection by a colorimetric microtiter plate pcr (pcr-eia), were collected consecutively from january 5 to august 1, 2008 at vanderbilt university hospital. among the total 219 specimens, pcr-eia detected 40 ehrlichia species with a positive rate of 18.3%. the ibis system detected ehrlichia in 38 of the 40 pcr-eia-positive samples and 1 in 179 of the pcr-eia-negative specimens, giving sensitivity and specificity of 95.0% and 99.4%, respectively. the ibis system further characterised the 38 ehrlichia-dual positive specimens to the species level (e. cheffeensis, 35; e. ewingii, 3) with a 100% agreement to that identified by pcr-eia using additional species-specific probes. in addition we demonstrated the detection of borrelia burgdorferi from the blood and skin of a patient with lyme disease. conclusions: we demonstrate broad-range detection of tick-borne pathogens in a single assay using skin, whole blood, plasma, skin and csf. in addition to ehrlichia, the ibis system detected 4 rickettsia rickettsii positive specimens, which were confirmed by serology and clinical findings. the ibis t5000 system, which can be completed within five hours from specimen processing to result reporting, provides rapid and accurate detection and identification of a broad range of pathogens causing tick-borne human infections. r. sampath°, l. blyn, r. ranken, c. massire, t. hall, m. eshoo, r. lovari, h. matthews, d. toleno, r. housley, s. hofstadler, d. ecker (carlsbad, us) objective: to investigate the use of a novel platform-based approach for rapid characterisation of hai organisms. pathogens that cause healthcare-associated infections (hais) pose an ongoing and increasing challenge to hospitals, both in the clinical treatment and in the prevention of the cross-transmission of these problematic pathogens. here we describe the utility of a pcr electrospray ionization mass spectrometry (pcr/esi-ms) detection platform as an innovative, rapid approach for detection and complete characterisation of important hai pathogens. methods: we have developed pcr/esi-ms based methods to rapidly identify and characterise mrsa, vre, c. difficile (nap-1 strain), p. aeruginosa and a. baumannii. each target organism can be analyzed using an independent 8-well assay that can be run on the same platform and can provide species and strain id, virulence factors, antibiotic resistance and genotyping as appropriate. validation studies were performed using 100-300 retrospective, well-characterised clinical isolates for each organism. this was followed by a prospective study for one of the 5 organisms, mrsa, that included screening of 557 clinical specimens (nares swab) from patients who were admitted to a medical unit with a high prevalence of mrsa clinical infections. results: for each of the five hai organisms, pcr/esi-ms species identifications were compared to gold standard testing results from the clinical microbiology laboratory and showed 100% concordance. for s. aureus, p. aeruginosa and a. baumannii, molecular genotyping by pcr/esi-ms was compared to pulse field gel electrophoresis (pfge) clusters and showed >95% concordance. characterisation of virulence and/or drug resistance was performed for mrsa, vre and c. difficile and showed 90−95% correct detection compared to existing testing methods. analysis of clinical specimens for mrsa showed that of the 557 swabs, 95 (15%) contained mrsa, either singly or as a dual infection with cons, 33 (5%) were mssa and 358 (58%) contained meca+ coagulase negative staphylococcus (mr-cons). comparison to gold standard analysis showed 100% sensitivity for mrsa detection with 96.8% specificity, 84% ppv and 100%npv. the pcr/esi-ms technology is a high throughput assay system useful for infection control and for epidemiological studies. it is capable of simultaneous identification of hai organisms while detecting presence of key phenotypic markers and genotypic strain characterisation. m. reijans°, j. ossel, j. keijdener, g. simons (maastricht, nl) objective: molecular diagnostics play an increasingly important role in the detection of infectious agents in cerebrospinal fluids. however, the growing list of targets and the relatively small sample volumes are challenges that demand an improved molecular diagnostic approach. the meningofinder is a multifinder assay allowing the simultaneous detection of 7 viruses and 1 internal control in 1 reaction. until now, the analysis of multifinder assays was based on size-fractionation, identifying each multifinder probe due to its specific length. here we present an alternative approach allowing realtime detection of eight meningofinder probes in a single tube. the realtime detection enables a faster analysis, less handling and lowers the risk of contamination. method: the meningofinder assay is a multifinder assay which detects herpes simplex virus 1 and 2 (hsv1−2), human parechovirus (hpev), cytomegalovirus (cmv), epstein-barr virus (ebv), enterovirus (ev) and varicella-zoster virus (vzv) plus an internal control in a single reaction. each meningofinder probe can be distinguished based upon the specific length of each probe by size-fractionation using gel or capillary electrophoresis. we developed an alternative detection method using fluorescently labelled probes which allow specific identification of 8 multifinder probes in a realtime pcr machine. results: a large number of qcmd samples (n = 44), several enterovirus types (n = 27) and characterised clinical samples (n = 66) were analyzed using the meningofinder. all meningofinder reactions were analyzed by capillary electrophoresis and by fluorescently labelled probes in a realtime pcr machine. the results of the meningofinder showed a very good correlation with the expected results (>95%). furthermore, the results of both meningofinder analyses showed a high degree of correlation. the realtime detection of the meningofinder probes decreases the analysis time and post pcr handling dramatically. we developed a new assay for the realtime detection of 8 meningofinder probes. the realtime analysis showed a very good correlation with the conventional capillary electrophoresis analysis. in addition, the realtime detection reduced contamination risk and patient results became available more quickly. the combination of multifinder technology combined with realtime detection shows great potential in fast and easy multiparameter screening of clinical samples for infectious pathogens. in-house naats were applied to nucleic acid extracts obtained by own in-house methodology in each centre. results: sensitivities for the detection of the respiratory viruses were 40% for commercial mx naat, 86% for in-house mw naat, and 90% for mono in-house naat. the viral load was low each time false-negative results were obtained. false positive results were obtained by all methods used, resulting in specificities ranging from 88%-97%. for the atypical bacteria, the 2 multiplex naats failed to detect low l. pneumophila positive samples and low m. pneumoniae positive sample resulting in sensitivities of 25% and 75% compared to 100% in the inhouse mono naats. the commercial mx naat also failed to detect strong positive samples. no false positive results were obtained for the atypical bacteria. revisiting phage therapy against problematic pathogens s61 how the past feeds the future: from d'herelle to modern phagotherapy the increasing antibiotic resistance problem boosts the interest in alternative treatments for infections. a prominent example for this is the so-called phagotherapy. it makes use of bacterial viruses − bacteriophages − as drugs against bacterial agents. these bacteriophages are isolated from nature, characterised and then tested against the bacterial strains that are targeted. in theory, this approach has several advantages. for instance, bacteriophages infect, as a rule, their bacterial prey very specifically. therefore, they do not harm the commensal bacteria of the patient. additionally, if a bacterial strain becomes resistant against a certain bacteriophage strain, evolution will provide for new and active bacteriophage strains. in practice, phagotherapy has been used for a long time. already one of the two discoverers of bacteriophages, félix d'herelle, was an ardent advocate of this method. in fact, he was the first to use bacteriophages against infections − 1919 against bacterial diarrhoea (shigella spp.). after that, phagotherapy has been used to quite some extent in europe, the us and other parts of the world until penicillin entered the market in the 1940 s. in some parts of the former soviet union and the eastern bloc, the method has been utilised until today. now, several companies and university researchers are developing bacteriophages for therapeutical purposes again. historical documents related to phagotherapy and oral history reveal a fascinating past. bacteriophages have been employed against a wide variety of bacterial diseases in a time in which there were virtually no other anti-infectives. for example, in india, millions of cholera patients were treated with bacteriophages in the 1930 s. anti-cholera phages were also poured into drinking wells as prophylactics. bacterial viruses have also been utilised by the german and soviet armies in the second world war. the history of phagotherapy makes for more than an exciting story, however. analysis of the old literature helps identify important factors for success and failure. this is especially relevant for a field which holds promise but which has had limited funds at its disposal in the past few years − and which, therefore, has been making rather slow progress. additionally, examination of the strategy used for phagotherapy in the soviet union and poland also contributes to a better application of this method today. the discovery of bacteriophages, particularly their ability to replicate and lyse pathogenic bacteria may have been among the most important milestones in the history of biomedical sciences. in the pre-antibiotic era of the early 20th century, phage therapy was becoming a powerful weapon against infectious diseases of bacterial aetiology. unfortunately, phage treatment and research was largely forgotten in the western world as antibiotics became widely available. nowadays, the rapid propagation of multi-drug resistant bacterial strains is leading to renewed interest in phage therapy. in contrast to its decline in the west, phage therapy remained a standard part of the healthcare systems in eastern europe and the ussr during the second half of the 20th century. phage preparations were used for diagnostic, therapeutic and prophylactic purposes to combat various bacterial infections. the eliava institute of bacteriophages, microbiology and virology (tbilisi, georgia) is perhaps the most famous institution in the world focused on the study of bacteriophages, particularly the isolation and selection of phages active against various bacterial pathogens. phages have been isolated against bacterial strains received from all over the former ussr and socialist east european countries; consequently, a huge collection of phages and pathogenic bacterial strains has been constructed at the institute. thousands of people were treated with individual phages and phage mixtures during the soviet era. the preparations developed in tbilisi have been studied through extensive preclinical and clinical trials. however, little of this information has ever been published and even when details are available, the trial reports do not meet internationally approved regulations and standards. bacteriophages have a number of advantages in comparison to antibiotics. phage therapy as an alternative approach for treatment of infections has become an evident and promising remedy. today, many people from various parts of the world express their willingness to take phage treatment against different infections, including those that are caused by antibiotic-resistant bacterial pathogens. the eliava institute has elaborated new, phage-based products and technological schemes for their production. strong collaboration with the medical community in the design of clinical trials according to international standards is absolutely critical to supporting the broader implementation of phage therapy. an australian male aged 57 years died from an intracerebral haemorrhage ten days after he returned from a trip to rural yugoslavia. his kidneys and liver were donated to three female recipients aged 44 years (kidney), 63 years (kidney), and 64 years (liver). four to five weeks after the organ donation, all three recipients died. all had febrile illnesses with altered mental status. subsequent testing of post-mortem tissues from the recipients identified a novel arenavirus, which was related to lymphocyctic choriomeningitis virus (lcmv). this viral detection process involved the use of high-throughput sequencing techniques to identify novel microbial rna sequences. confirmatory testing was performed using the techniques of reverse transcriptasepolymerase chain reaction, immunohistochemical analysis for arenavirus antigens, and immunofluorescent testing for igg and igm antibodies. the clinical features in these four patients as well as other similar problems with transplant-related illness from classic lcmv will be discussed, as well as details of the laboratory identification of this new virus, and implications for organ transplantation protocols in future. successful management of invasive fungal infections depends on timely and correct treatment. over the last decades a number of new tests have become available which have improved the diagnostic options. in contrast to the scenario for bacterial infections, acquired resistance in fungi is rare and thus species identification is a valuable tool guiding choice of treatment. therefore, microscopy & culture is still a corner stone in diagnosis, but culture and identification are time consuming (app. 1−5 and 1−3 days, respectively). the sensitivity and speed of microscopy have been improved by the use of fluorescent brighteners such as calcofluor white or blankophor. but only with the recent development of pna probes specific for a number of the candida spp. has species identification become possible directly from a positive blood culture before subculture on agar media. chromogenic agars allow a presumptive identification of several candida spp. and facilitate the recognition of yeast isolates in samples containing several yeasts or yeast and bacteria in combination. the use of such plates has been shown to lead to a better identification of mixed cultures in a recent nordic eqa scheme including more than 50 laboratories. rapid species identification of the most important candida spp. is possible in the routine laboratory using easy commercially available kits. thus, a species identification of c. albicans, c. dubliniensis and c. krusei can be obtained within minutes using latex agglutination kits (bichro-dubli, krusei-color; fumouze diagnostics) and c. glabrata can be rapidly identified due to its high amounts of preformed intracellular trehalase enzyme (glabrata rtt; fumouze diagnostics). finally, pna probes and fluorescence microscopy can also be used for a same day identification of a range of the clinically relevant candida spp. (advandx). susceptibility testing is possible using etest and the results are comparable with those obtained by reference methodologies in head to head comparisons. however, recent data from eqa distributions suggest that detection of isolates with acquired resistance causes many laboratories difficulties. this illustrates that a critical number of isolates should be tested per technician per week and quality control strains should be included on a regular basis. in conclusion, a number of new diagnostic tests have become available over the last decade and the diagnostic laboratories are encouraged to take advantage of these new options. 19th eccmid, oral presentations since the introduction of newer antifungals with different in vitro spectra, the aetiology of invasive fungal infections (ifi) has become a major diagnostic issue as a prerequisite for a guided antifungal therapy. while molecular methods, such as pcr and sequencing for the diagnosis of ifi have been evaluated from specimens such as blood and bronchoalveolar lavage fluid for some years, they have been less studied for biopsies. characteristics inherent to these molecular methods, e.g. sensitivity, specificity and short turnaround time makes them promising as adjuncts to conventional diagnostic tests, e.g. culture and histopathology from organ biopsies. studies using tissue from animal models of mould infections suggest that pcr might be more sensitive than culture and allows for a better species identification than histopathology. however, most of these studies used assays detecting only a small range of agents or even single organisms. while this may increase the sensitivity of the assays and reduces the likelihood of contaminations it limits the usefulness in the clinical setting, given the broad range of potential fungal pathogens. studies using fresh clinical samples suggest that the detection and identification of a wide range of fungi is possible using broad range assays in combination with sequencing or by combining more specific pcr assays. further studies are needed to optimise dna extraction, define the best molecular targets and the best method for amplicon detection. the prevention of contaminations due to ubiquitous fungi and unspecific amplifications are a major problem, especially when using broad range assays. in contrast, fish probes may potentially be more specific than pcr due to the visualisation of fungal elements in tissue. in contrast to pcr, they appear to work well with formalin fixed specimens. species identification might be more challenging than by pcr and sequencing. direct comparisons between fish and pcr are needed to characterise the pros and cons of each method in determining the aetiology of ifi. molecular tissue diagnosis has the potential to evolve into a useful method to describe the aetiology of ifi even in culture negative samples. results might be obtained fast enough to guide the antifungal therapy in patients with ifi progressive to empiric antifungal therapy. in these patients, the risk associated with invasive tissue sampling might be outweighed by potential benefits of a guided antifungal therapy. the two groups of carbapenemases (serine carbapenemases and metallobeta-lactamases (mbls)) can be encoded by genes that can be carried on plasmids. the serine carbapenemases are distinctly either class a or oxa (class d); the latter being mainly associated with acinetobacter spp. the dominant mbl subgroups, vim and imp have genes that are reportedly carried on plasmids and chromosomes. recent evidence has shown that the majority of blavim-2, even those initially reported, are indeed plasmid mediated and probably accounts for their rapid dissemination. blavim-1 genes have been recently shown to be carried on incn and incw plasmids. the "brazilian" mbl gene, blaspm-1, is exclusively chromosomally encoded. the mbls sim-1 and aim-1 are both chromosomally encoded whereas gim-1 is encoded from a plasmid of approx. 48 kb. the recently described blakmh-1 gene is also carried on a plasmid (200 kb). hitherto, only two mbl-positive plasmid sequences are available thus far -those carrying blaimp-8 and blavim-7. the former carries other resistance genes and are approx. 302 kb (inchi2), whereas the latter is a small plasmid (24 kb) and shows similarities with incp plasmids. oxa carbapenemase genes have been shown to be both plasmid and chromosomally mediated. thus far, the blaoxa-23 and blaoxa-24/40 clusters can be both plasmid and chromosomal and have mainly been found in acinetobacter spp. the blaoxa-48 and blaoxa-58 clusters have been found in k. pneumoniae and acinetobacter spp., respectively, and both are plasmid mediated. blaoxa-48 and blaoxa-58 have been shown to be carried on 70 kb and 28-100 kb plasmids, respectively. a blaoxa-58 plasmid has been recently sequenced and shown to carry two different replicases. the class a carbapenemase genes, blakpc, blaimi-2 and blages are all carried on plasmids. blakpc is found mainly in k. pneumoniae and carried on plasmids that vary in size 12−95 kb and mostly possessing the origin of replication incn. however, kpc-2 has recently described in a pseudomonas as being chromosomally mediated. blaimi-2 is exclusive to the usa and carried on a 66 kb plasmid although blaimi-1 is chromosomal. the blages genes have been found in p. aeruginosa and enterobacteriaceae of which ges-2, 4, 5 and 6 have been shown to be plasmid mediated although little else in known. this lecture will provide a synopsis, discuss the evolution of resistance due to plasmids and briefly predict what we may face in the 21c with respect to carbapenemase resistance. nosocomial infections caused by multidrug-resistant pathogens, especially gram-negative bacilli, have become a serious clinical concern in every healthcare setting worldwide. as well as carpapenemhydrolysing metallo-b-lactamases, ctx-m-type b-lactamases, and qunolone-resistance genetic determinants such as qnr, aac(6 )-ib-cr, and qepa, plasmid-mediated novel molecular mechanisms such as rmta, rmtb, rmtc, rmtd, arma, and npma responsible for pan-resistance to aminoglycosides have recently been identified in pseudomonas aeruginosa, acinetobacter spp., serratia marcescens, esherichia coli, klebsiella pneumoniae, proteus mirabilis etc. since 2003, and these enzymes have indeed methylation activity of 1405g or 1408a at the a-site of the bacterial 16s rrna as found in aminoglycoside-producing actinomycetes. these plasmid-mediated 16s rrna methylases are speculated to be originated from some nonpathogenic environmental microbes that produce aminoglycosides or some similar compounds, so it is quite natural that several new enzymes would be further identified hereafter in both clinical and livestock farming environments. rmtb and arma have widely spread in asia, europe, america and australia via various pathogenic gram-negative bacilli, we should pay special attention to the further spread of such hazardous microbes. in my talk, i would like to give an outline of newly identified molecular mechanisms that confer pan-resistance to aminoglycosides in pathogenic microbes isolated from both human and veterinary environments. [ acquired resistance to quinolones mainly results from chromosomal mutations responsible for modification(s) of dna gyrase and topoisomerase iv, and for a decrease of drug accumulation into bacteria due to decreased permeability and/or overexpression of efflux systems. plasmid-mediated quinolone resistance (pmqr) was first reported in 1998 from the usa, and two other mechanisms have been identified to date. the first pmqr determinants, qnr proteins, belong to the family of pentapeptide repeat proteins. five determinants have been identified: qnra, qnrb, qnrc, qnrd, and qnrs with 6, 20, 1, 1, and 3 different variants, respectively. they may act by binding directly to both dna gyrase and topoisomerase iv leading to protect them from quinolone inhibition. they confer resistance to nalidixic acid and reduced susceptibility to fluoroquinolones (fqs), but may facilitate recovery of mutants with higher level of resistance. the overall prevalence of qnra, qnrb, and qnrs determinants generally ranges from 1 to 5%, and they have been identified worldwide mostly in esbl-producing enterobacterial isolates. the origin of the qnra and qnrs genes were identified as shewanella algae and vibrio splendidus, respectively. the second type of pmqr determinant, aac(6 )-ib-cr, is a variant of the aminoglycoside acetyltransferase aac(6 )-ib which confers resistance to kanamycin, tobramycin and amikacin. this variant possesses two substitutions (trp102arg and asp179tyr) that are sufficient to acetylation of ciprofloxacin and norfloxacin with a 2-to-4-fold mic increase. the overall prevalence of aac(6 )-ib-cr may range from 0.4 to up to 34%, and it has been reported mainly in escherichia coli and klebsiella pneumoniae. the third type of pmqr determinant, qepa, has been identified in two e. coli clinical isolates from japan and belgium. the qepa gene encodes a 14-transmembrane-segment putative efflux pump belonging to the major facilitator superfamily. this protein confers decreased susceptibility to hydrophilic fqs (e.g. norfloxacin, ciprofloxacin and enrofloxacin) with an 8-to-32-fold mic increase. the two epidemiological surveys for qepa may indicate its low prevalence (<1%). the natural reservoir of qepa remains unknown but might be an actinomycetal species. discovering of three main mechanisms of pmqr within the last ten years is peculiar. it may reflect the emergence of novel mechanisms of resistance but also a deeper investigation of resistance mechanisms in clinical isolates. emerging infections: can we cope with them? a. kühn°, c. schulze, h. ranisch, p. kutzer, h. nattermann, r. grunow (berlin, frankfurt-oder, de) objective: little is known about the prevalence of francisella tularensis in humans and animals in germany. interestingly, the pathogen emerged recently when several marmosets (callithrix jacchus) died from tularaemia and a group of hunters became infected in the areas of western germany. to find out more about the distribution of the pathogen also in eastern germany we investigated the seroprevalence of tularaemia under foxes (vulpes vulpes) and raccoon dogs (nyctereutes procyonoides) in the area of brandenburg (around berlin). methods: sera of animals (n = 351 and n = 32, respectively) from the years 2007 and 2008 were tested for f. tularensis − lps antibodies in an indirect elisa and suspicious samples were confirmed by western blot for lps ladder recognition using protein g − pod conjugate. furthermore we investigated the serum samples by a competitive elisa using a peroxidase-conjugated anti − lps monoclonal antibody. results: from the serum collection, we tested 31 (8.8%) foxes and 3 raccoon dogs (9.4%) positive for specific f. tularensis antibodies. the geographical distribution showed hot spots in the area of the investigated region. our results indicate for a higher seroprevalence in wildlife for tularaemia in eastern regions of germany than assumed. since the reported human cases for the last decade seem to be underestimated, the real prevalence of the pathogen is unknown. the high number of tularaemia antibody positive foxes and raccoon dogs indicates that this zoonose is present in wildlife in eastern germany. however, the impact of transmission of zoonotic pathogens from wildlife to domestic animals and humans is not yet well studied. in conclusion, the obtained data will contribute for creating of up-to-date strategy for more efficient control of the two rickettsial zoonoses. objective: helicobacter pylori is established as the primary cause of gastritis and peptic ulceration in humans. in a minority of patients with upper gastrointestinal symptoms long tightly coiled spiral bacteria, clearly distinct from h. pylori, and provisionally named as "h. heilmannii", can be observed in gastric biopsies. our objective was to isolate and identify the spiral organism, resembling "h. heilmannii" from the gastric mucosa of a finnish patient presenting with severe dyspeptic symptoms. methods: we used two different selective media for the isolation of the bacteria from gastric biopsy samples before and after treatment of the patient with a 7-day course with lansoprazole, tetracycline and metronidazole. the isolates were characterised by testing for urease and catalase activity, light and electron microscopy, and sequencing the partial 16s rrna and ureab genes. single enzyme aflp was used to analyse the genetic diversity among the isolates. results: growth of long spiral organisms was obtained from 7 out of 8 antrum and all 8 corpus biopsies before and all three antrum biopsies after treatment of the patient. the partial 16s rrna gene sequence showed high sequence similarities with other gastric helicobacter species. the partial ureab gene showed high sequence similarity with h. bizzozeronii and was clearly distinct from other gastric helicobacter species. aflp indicated that the isolates belonged to the same clone however some minor genetic diversity was observed among the isolates. results: b. pseudomallei was primarily found in close proximity to streams and in grass-rich areas but was also correlated with environmentally disturbed soil such as caused by the presence of animals, farming or irrigation. prediction maps are currently being verified by sampling predicted b. pseudomallei "hot-" and "cold-spots". see in figure a prediction map for rural darwin with red areas indicating high probability for presence of b. pseudomallei. this study contributes to the elucidation of the environmental distribution of b. pseudomallei in endemic tropical australia and to the clarification of environmental factors influencing its occurrence. it also raises concerns that b. pseudomallei are spreading due to changes in land management. o82 concurrent multi-serotypic dengue infections in various body fluids w. kulwichit°, s. krajiw, d. chansinghakul, g. suwanpimolkul, o. prommalikit, p. suandork, j. pupaibool, k. arunyingmongkol, c. pancharoen, u. thisyakorn (bangkok, th) objectives: dengue virus infection is one of the rapidly-spreading emerging diseases worldwide. the virus is divided into 4 distinct serotypes with limited cross-protective immunity; therefore, one can be reinfected with different serotypes. while each episode is usually caused by a single serotype, an individual can occasionally be infected by concurrent multiple ones. our group has previously detected dengue virus from urine and oral specimens of some patients. in this study, we sought to determine the characteristics of multi-serotype infections when analysing beyond the patients' blood compartments. methods: during 2003 during -2007 and adult patients suspected of dengue infections were enrolled. plasma, peripheral blood mononuclear cells (pbmc), urine pellets, buccal brushes, and saliva were collected during and after the febrile episode. only specimens from patients with both positive dengue serology and pan-dengue-specific rt-pcr were included. serotype-specific rt-pcr was then performed on the aforementioned various specimens of each patient. results: 95 patients met the above criteria. serotyping was successful in 85 patients. den-4 was the most common serotype, accounting for half of the cases. 20 of these 85 (23.5%) demonstrated multiserotypic infections when combining data from all specimen types in each individual. serotyping using single, conventional serum/plasma specimens, however, would detect only half of the cases. the phenomenon of concurrent multi-serotypic infections was present in all examined specimen types, including urine pellets, buccal brushes, and saliva. the most frequent combinations were den-1 + den-4 and den-2 + den-4 (5 cases each). two patients were simultaneously infected by serotypes 1, 2, and 4 and one by serotypes 1, 3, and 4. there was no demonstrable significant difference in clinical severity between single-and multi-serotypic infections. conclusion: in a dengue-hyperendemic country with simultaneous circulation of all four serotypes, the phenomenon of concurrent multiserotypic infections are more common than previously demonstrated by traditional serotyping on single serum/plasma specimens. this may be explained by the sensitivity limitation of the detection method or by biological behaviour of the virus. our findings have an implication for potentially more accurate epidemiologic studies in the future, and for further exploratory investigations regarding dengue virus in various secretions and excretions. o83 emerging concepts about the evolutionary history of hantaviruses h.j. kang, s.n. bennett, l. sumibcay, s. arai, a.g. hope, j.a. cook, j.w. song, r. yanagihara°(honolulu, albuquerque, us; tokyo, jp; seoul, kr) objective: recent discovery of genetically distinct hantaviruses in shrews (family soricidae), captured in widely separated geographic regions, challenges the conventional view that rodents are the principal and progenitor reservoir hosts of hantaviruses, and raises the possibility that other soricomorphs, notably moles (family talpidae), harbour hantaviruses. methods: using oligonucleotide primers based on conserved genomic regions of rodent-and soricid-borne hantaviruses, rna extracts from tissues of the japanese shrew mole (urotrichus talpoides), american shrew mole (neurotrichus gibbsii) and european common mole (talpa europaea) were analyzed for hantavirus sequences by rt-pcr. newfound s-, m-and l-segment sequences were aligned using clustal w and were analyzed phylogenetically by the maximum-likelihood and markov chain monte carlo tree-sampling methods, with the gtr+i+g model of evolution. results: novel hantavirus genomes, designated asama virus (asav), oxbow virus (oxbv) and nova virus (nvav), were detected in tissues of urotrichus talpoides, neurotrichus gibbsii and talpa europaea, respectively. sequence and phylogenetic analyses indicated that asav and oxbv were related to hantaviruses harboured by soricine shrews in eurasia and north america, respectively. by contrast, phylogenetic analyses of full-length s-and l-segment sequences showed that nvav formed a unique clade, clearly distinct and evolutionarily distant from all other hantaviruses. despite the high degree of sequence divergence at the nucleotide and amino acid levels, the secondary structures of the nucleocapsid proteins, as well as the l-segment motifs, of the moleassociated hantaviruses were well conserved. conclusions: while cross-species transmission has influenced the course of hantavirus evolution, such host-switching events alone do not satisfactorily explain the co-existence and distribution of genetically distinct hantaviruses among species in two taxonomic orders of small mammals spanning four continents. when viewed within the context of molecular phylogeny and zoogeography, the close association between distinct hantavirus clades and specific subfamilies of rodents, shrews and moles is likely the result of alternating and variable periodic codivergence at certain taxonomic levels through evolutionary time. thus, the primeval hantavirus might have arisen from an insect-borne virus, with ancestral soricomorphs, rather than rodents, serving as the original mammalian hosts. from south-eastern france m. kaba, b. davoust, j.l. marié, m. barthet, m. henry, c. tamalet, j.m. rolain, d. raoult, p. colson°(marseille, toulon, fr) objectives: autochthonous hepatitis e is currently considered as an emerging disease in industrialised countries and several studies suggest that hepatitis e is a zoonosis, especially in pigs, boars and deer. we aimed to study whether hepatitis e virus (hev) is commonly present in domestic pigs in southern france, and to determine the relationship between hev sequences detected from pigs and those described in human hepatitis e cases. methods: serum and stools samples were collected from 207 three or six-month-old pigs from different regions of southern france. 107 sixmonth-old pigs were from a slaughterhouse, and 100 three-month-old pigs were from a pig farm. swine igg anti-hev antibodies testing was performed using a commercial elisa kit for clinical diagnosis with minor modifications. swine hev rna detection was conducted by realtime pcr and amplification/sequencing assays using in house protocols targeting the 5 orf2 region of the hev genome. results: 40% of pigs were seropositive, and 65% of three-monthold pigs were hev rna-positive, whereas none of the six-monthold pigs were hev rna-positive. hev rna was significantly more frequently detected from stools than from serum (65% versus 22%; p < 0.001). phylogenetic analysis showed that swine hev sequences belong to genotype 3f or 3e and formed two clusters within which sequences showed high nucleotide homology (>97%). these clusters were correlated with the geographical origin of pigs as well as with their repartition into pens and buildings in the pig farm where samples were collected. swine hev sequences from the present study were genetically close to hev sequences found from humans or swine in europe, although no strong phylogenetic link could be observed neither with these latter sequences nor with those from human hepatitis e cases diagnosed in the laboratory. conclusion: our data indicate that three-month-old farm pigs from southern france might represent a potential source of contamination to humans, and they underscore the great potential of hev to cause epizootic infections in populations of farm pigs. o85 clostridium difficile: changing epidemiology trends, 2000 -2007 objectives: clostridium difficile infection (cdi) has become a growing concern world-wide with an increased reported incidence and an increase in the associated financial burden. our aim therefore was to review trends in cdi occurring from 2000-2007 inclusive. methods: all patients admitted to lothian university hospitals division (luhd) tested for c. difficile toxins a+b by eia were included. retrospective analysis of prospectively collected data was performed. the number of occupied bed days was provided by nhs-lothian statistics department. the most recent published costs associated with cdi were used to estimate potential costs to lothian nhs trust. results: 50,590 faecal samples were tested for c. difficile toxins from 2000-2007 inclusive; of these 7301 samples were positive. overall cdi was identified in 15.2 cases/10000 patient days and 5.8 cases/1000 inpatient hospital admissions. the incidence of identified cdi rose from 3.6cases/10000 patient days in 2000 to 14.8cases/10000 patient days in 2007. incidence also increased with age from 3.3cases/10000 patient days in the 0−20 years age group to 18.1cases/10000 patient days in the 61−80 years age group. renal medicine and intensive care had the highest incidences of identified cdi with greater than 57cases/10000 patient days each followed by infectious diseases and gastrointestinal medicine whose rates were 47.5 and 42.6 cases/10000 patient days respectively. medicine of the elderly in comparison had an incidence of 19.5cases/10000 patient days. of note 10% of all patients were transferred through a minimum of two specialties during the period in which they remained positive for c. difficile toxins. estimated costs over the study period for toxin testing alone were in the region of £126,500 and the minimal potential hospitalisation costs of patients with cdi was in the region of £20,000,000. conclusion: the incidence of patients identified with cdi has risen markedly and not surprisingly the incidence has also been noted to increase with age. medicine of the elderly however had a much lower incidence than several other specialties and therefore risk assessment of cdi development and containment should now also be targeted within other specialties. with 10% of identified cdi patients transferred through different specialties and the significant financial burden cdi imposes on healthcare institutions judicious application of infection control measures remains an important factor to prevent cdi spread. isolates of this strain were pvl negative, but positive for enterotoxin a (sea) and, in most cases, also for seb, sek and seq. a fifth strain was the "taiwan clone", st59/952-mrsa-v (wa mrsa-9 and -52) which also comprised two closely related sequence types. this strain carried a sccmec element of type v(t) or vii as well as pvl and, usually, seb, sek and seq. it was the most common cc59 strain in wa. the sixth strain differed from the "taiwan clone" in the presence of a sccmec type v element and in the absence of pvl. the differentiation of this clonal complex into various different strains indicates a rapid evolution and spread of sccmec elements, and the diagnostic microarray technology allows one to distinguish beyond mlst level and hence to accurately trace outbreaks and spread of these strains. a sample taker 12 has daily contact with poultry and is excluded from analysis. b sample taker 5 reported no contact with livestock elsewhere than in this study at that moment (spa-types of sample taker 5 and farm are not corresponding). c sample taker 6 tested mrsa-negative in following tests. d sample taker 9 was not tested again. complete data sets (samples taken before, directly after and 24 hours after a visit) were collected on 141 visits by 29 sample takers visiting 50 farms. on 28 farms mrsa was collected from pigs or stabledust (56%). these farms were visited 78 times by 23 different sample takers. one sample taker (#12) was positive for mrsa before visiting a farm, he was removed from the following analysis. fifteen of the 78 (19%) visits to mrsa-positive farms resulted in acquisition of mrsa and 11/23 (48%) sample takers acquired mrsa at least once after visiting a positive farm. of these 11 positive sample takers 2 acquired mrsa twice and 1 sample taker acquired mrsa three times after separate visits. of the 15 acquisitions of mrsa, 13 were negative after 24 hours. the spa-types of mrsa isolates found on the farms and sample takers were grossly comparable. on the 32 negative farms, none of the 60 visits resulted in mrsa acquisition. for further information see the table. discussion: mrsa-cc398 was acquired by 48% of the sample takers after occupational exposure in this study. however, in 11 of the 13 cases the strain was not recovered the next day, therefore acquisition was of short duration, posing a limited treat to human health. some persons seemed to be more vulnerable to acquire mrsa during their work. the sample size of this study was too small to draw final conclusions concerning this inter-personal variation. this requires a more extensive study. [ objectives: community-associated mrsa is an increasing problem and an association with food animal contact has been made in some regions. this has led to concerns about the potential role of food in mrsa transmission. the objective of this study was to evaluate the prevalence of mrsa colonisation of retail pork in canada. methods: pork chops, ground pork and pork shoulders were purchased at retail outlets in four canadian provinces in conjunction with the canadian integrated program for antimicrobial resistance surveillance. both direct inoculation of meat into enrichment broth and rinsing of meat in broth were performed for pork chops and shoulders, followed by inoculation onto chromogenic agar. ground pork was tested only using the direct method. mrsa isolates were typed by pfge and spa typing. real time pcr was used to detect panton-valentine leukocidin genes. results: mrsa was isolated from 31/402 (7.7%, 95% ci 5.5−10.7%) of samples. there was a significant difference between provinces (p < 0.001) but no difference between different products, with mrsa isolated from 23/296 (7.7%) pork chops, 7/94 (7.4%) ground pork and 1/12 (8.3%) pork shoulders (p = 0.99). 21/403 (5.2%) samples were positive using direct culture while mrsa was isolated from 15/355 (4.2%) of samples testing using the rinse method. nine samples were positive on direct culture but negative using the rinse method, while 10 others were positive only with the rinse method and only 5 were positive with both methods. seven samples (ground pork) that were positive on direct culture were not tested using the rinse method. 3 main clones were present. the most common (40% of isolates) was a group of 3 related spa types (t064, t008 and new related type) were classified as canadian epidemic mrsa-5 by pfge, an st8 human epidemic clone that has been associated with horses. pfge-non-typable spa t034 were not surprisingly common, accounting for 30% of isolates. the 3rd main group was 3 related spa types (t002, t045 and new type) that were cmrsa-2 (usa100), an st5 clone that is common in humans in canada, that also accounted for 30% of isolates. the clinical relevance of mrsa contamination of pork is currently unclear. it is possible that contact with contaminated food could be a mode of mrsa transmission in the community, although further study of the prevalence of contamination, amount of mrsa in contaminated samples, sources of contamination and implications on human health are required. o95 prevalence of the novel trimethoprim resistance gene dfrk among german staphylococcal isolates of the bft-germvet monitoring study k. kadlec°, s. schwarz (neustadt-mariensee, de) objectives: very recently a novel trimethoprim resistance gene, dfrk, was identified on a tet(l)-harbouring plasmid in a porcine mrsa isolate from the bft-germvet monitoring study. this study included in total 248 independent coagulase-positive and coagulase-variable staphylococci collected between 2004 and 2006 all over germany: 46 isolates from infections of the urinary-genital tract of pigs, 44 isolates from skin infections of pigs, 57 isolates from respiratory tract infections of dogs/cats, and 101 isolates from infections of skin/ear/mouth of dogs/cats. in this study, we investigated the prevalence and the plasmid location of the dfrk gene among these isolates. methods: pcr primers were designed and a pcr with subsequent restriction analysis of the pcr product was established to detect dfrk. isolates with positive results were tested for a plasmid location of dfrk by transfer experiments and dfrk-carrying plasmids were further analysed. the trimethoprim resistance gene dfrk was detected in another 10 isolates. all isolates were from pigs: 9 from skin infections and the remaining 1 from a urinary-genital tract infection. six staphylococcus hyicus subsp. hyicus isolates, 3 s. aureus isolates (2 mrsa and 1 mssa) and 1 s. pseudintermedius. all these isolates harboured plasmids. in 7 isolates (4 s. hyicus, 2 mrsa and the single s. pseudintermedius), the plasmid location of dfrk was confirmed by protoplast transformation with subsequent susceptibility testing and pcr analysis of the transformants. in all 7 cases, the plasmids harbouring dfrk also carried a tet(l) tetracycline resistance gene. the results of a combined pcr assay with primers from tet(l) and dfrk confirmed that the dfrk gene was always located immediately downstream of the tet(l) gene. further analysis of these dfrk-and tet(l)-harbouring plasmids showed that they varied in size between 6 and 40 kb and that similar sized plasmids differed in their ecorv and hindiii restriction patterns. the novel trimethoprim resistance gene dfrk occurred in 11 (12.2%) of the 90 porcine staphylococcal isolates from the bft-germvet study. in 8 (72.7%) of the 11 isolates, it was located on structurally diverse plasmids, however, always in close proximity to a tet(l) gene. the linkage of the dfrk and tet(l) genes allows the maintenance and coselection of such plasmids under selective pressure by either tetracyclines or trimethoprim, both of which are widely used in veterinary medicine. (table) . the isolates were resistant to ciprofloxacin, clindamycin, erythromycin, gentamicin but susceptible to vancomycin. only one se was methicillin-susceptible and two isolates were quinupristin/dalfopristin non-susceptible. all strains were clonally related and clustered into three subtypes (a, a1 and a2). cfr gene was detected in a linezolid non-susceptible strain (mic, 64 mg/l), which was recovered from a 57 y/o male who underwent liver transplantation. plasmid analysis identified six plasmid bands ranging from c.a. 1.5-to 154-kb in the cfrcarrying strain. hybridisation signals were observed from the 154-kb plasmid band as well as from a chromosomal band after i-ceui digestion. mutations at the 23s rrna, l4 or l22 were not detected. the cfr increased the linezolid mic value between 8-and 16-fold. this report highlights the ability of se to acquire linezolid resistances. the potential mobility of cfr combined with the clonal tendency for dissemination among staphylococcus spp., represent a serious threat to several potent gram-positive-active agents, including oxazolidinones. active surveillance combined with effective infection control and molecular studies seem prudent to minimise the spread of these resistance mechanisms. the objective is to get a glimpse of the potential impact of infectious diseases on music, as regards to the composer's or performing musician's own disease, living conditions or other relevant elements which might have affected the end result, the music we enjoy today. as music is an art of senses, full of drama, despair, realities of life − or just the opposite, blissful ignorance of those realities, full of romance, beauty, and delicacy − various forms of music was researched paying special attention to infections which potentially have played a significant role in the birth of that particular piece or performance. the entire research process was subjective, biased, and emotional, but done wholeheartedly. it aimed at to taking into account, not only the personal life of a composer or performing musician, but also the historical context in which the music was born. musical examples, served to the audience along with the essential background data, will show the extent to which infections have impacted music. regarding the aetiology of those infections, bacterial, viral and parasitic agents are well represented. in addition, many epochs in history have played their role. sometimes, the connections are surprising, even dramatic. if listened to with a tender ear, music quite often turns out to be affected also by infectious diseases. as physicians we should realise the strength with which some people are driven by this demonic, divine − but altogether beautiful force: music. the prevalence of antibiotic resistance has been increasing in asian countries in recent years. this problem has most likely arisen due to a combination of inadequate infection control practices particularly in hospital settings and the widespread misuse of antibiotics in hospital and community settings. factors that lead to antibiotic misuse include inappropriate antibiotic prescription due to a lack of clinical, microbiological and/or imaging data in many clinical settings in the asian region. a lack of separation of prescribing and dispensing by medical practitioners as practised in many countries in asia as well as the easy availability of over the counter medications also contribute to antibiotic misuse. optimal control of antibiotic use can only be achieved through a multipronged approach that includes better education of the public and medical practitioners on rational use of antibiotic, a review of the health system structure, as well as better control of over the counter sales of antibiotics. upgrading of microbiology and other laboratories and radiological facilities that will enhance the accuracy of clinical diagnosis is also urgently needed in most developing countries to keep pace with the complexities of managing patients in this new era to minimise the widespread practise of inappropriate antibiotic use. examination of the csf for microorganisms, wbc and differential counts, and concentrations of glucose and protein is the primary investigation to diagnose meningitis. however, this csf examination may not always be conclusive, and it can be difficult to distinguish bacterial from viral meningitis. therefore, improvement in diagnostic sensitivity and specificity of bacterial meningitis and development of rapid test for a bacterial aetiology are still needed. this presentation gives a review of the strength and weakness of several analyses and methods to reveal the microbiological agent (i.e. csf microscopy and culture, antigen or antibody detection, molecular methods to detect dna or rna) and the use of several mediators of the host immune response for diagnostic and prognostic purposes. bacterial meningitis is a medical emergency that requires a multidisciplinary approach. a diagnosis of bacterial meningitis is often considered, but the disease can be difficult to recognize. recommendations for antimicrobial therapy are changing as a result of the emergence of antimicrobial resistance. in this lecture, current concepts of the initial approach to the treatment of adults with bacterial meningitis will be summarised. the management of the critically ill patient with bacterial meningitis poses important dilemmas. controversial areas (i.e., prehospital admission antibiotics) will be reviewed and relevant literature will be discussed in the framework of current treatment guidelines, highlighting new developments in adjunctive dexamethasone therapy. acute bacterial meningitis (abm), especifically when caused by infection with streptococcus pneumoniae, still has an unacceptably poor prognosis with a mortality of 10−30%. bacterial infection of the meninges causes one of the most powerful inflammatory reactions known in medicine. yet 50 years ago, this inflammatory reaction was suggested to contribute substantially to brain damage. this concept underlies the use of anti-inflammatory agents as adjunctive therapy in abm. of all adjunctive treatments in abm, only corticosteroids have been properly evaluated in clinical trials. these trials recommend corticosteroids in patients with haemophilus influenzae type b and pneumococcal meningitis (pm). however, adjunctive corticosteroid therapy has several weaknesses such as a narrow treatment window and borderline effects on neurologic sequelae. thus, there is still the need for additional or alternate adjuvants in the therapy of abm. experimental studies using animal models (predominantly of pm) have provided insight into the pathogenic mechanisms underlying brain injury in abm. it is now clear that the autodestructive inflammatory reaction is initiated by the interaction of bacterial components with host pattern recognition receptors (prr) like toll-like receptors (tlr). prr signaling results in the activation of transcription factors like nf-kb which up-regulate the production of proinflammatory cytokines. cytokines like il-1b are also potent triggers of nf-kb activation and therefore can exaggerate the inflammatory reaction (via positive feedback loops). as a consequence, great numbers of neutrophils are recruited to the meninges. activated neutrophils release many potentially cytotoxic agents including oxidants and matrix metalloproteinases that can cause collateral damage to brain tissue. additionally to the inflammatory response, direct bacterial cytotoxicty has been identified as a contributor to tissue damage in abm. thus, experimental studies point at four different targets of adjunctive therapy, namely interference with (i) the induction of inflammation (e.g., tlr blockade), (ii) the exaggeration of inflammation (e.g., il-1 antagonism), and (iii+iv) the generation of cytotoxic factors (either of host or bacterial origin, e.g., scavenging of oxidants). this presentation will give an overview of the pathophysiology of abm (with special emphasis on pm) and highlight promising targets for adjunctive therapy in abm, as deduced from experimental studies. a clinician's approach to managing difficult infections s120 acute post-surgical prosthetic joint infection optimal management of prosthetic joint infections (pji) remains undefined. important issues such us when the implant can be retained (conservative strategy), optimal duration of antimicrobial therapy (at) or the role of rifampin are yet matter of controversy. in spite of a number of reports, literature appears confusing. among the limitations of the literature we must emphasize: 1) different criteria to classify pji; 2) different criteria to select for conservative strategy (cs); 3) no description of the initial population from which patients were selected for cs; 4) very different at (from 4 weeks to chronic suppressive therapy); 5) low numbers of patients or short follow-up; 6) absence of clinical trials. it is not so surprising that the rates of cs success have varied from 0 to almost 100%. the most useful classification to approach pji was proposed by tsukayama (1996) . in his series 25 out of 35 patients with early pji managed by a cs (debridement, exchange of polyethylen and implant retention) were cured after 4 weeks of at. the spanish group for the study of pji was constituted in 2003 within the spanish network for the study of infectious pathology (reipi), a public funded initiative. data from 139 consecutive cases of early pji attended in 10 hospitals were recorded in an online database. 117 cases managed with cs could be analysed (mean followup of 2 years). sixty-seven patients (57.3%) were cured after a mean of 81 days of at. in 35 (29.9%) the infection was not controlled (or relapsed) after a mean of 84 days of at, and the implant had to be removed. in other 15 patients (12.8%) the implant was not removed, but suppressive at was given because of suspected ongoing infection. results were significantly worse in one hospital. no other factors resulted statistically significant, but there was a trend of worse results for mrsa produced infections (p = 0.06). time from the symptoms appearance to debridement was shorter in successfully treated cases (median, 7 days) than in failures (median, 10 days); p = 0.08. good functional results were obtained in patients with successfully cs. in summary, a substantial proportion of early pji can be managed with cs strategy and a definite (non suppressive) at. it is difficult to identify patients at higher risk for failure, although mrsa aetiology and longer time until debridement seem to predict failures. different outcomes in some centres suggest that surgical technique could be an important factor for failure. more than 3 million cardiac pacing systems are implanted worldwide and the estimated rate of infections after implantation of permanent endocardial leads is 1% to 2%, but varies between 0.1 to 20%. pacemaker infections correspond to different clinical situations including localised infection in the device pocket, pacemaker leads to systemic infection associated with bacteraemia and lead-associated endocarditis. this latter represents 10 to 25% of all cases of pacemaker infections. the severity of pacemaker related infective endocarditis is sustained by a mortality range between 10 to 20%. risk factors related to infections of implanted pacemakers are correlated with fever before 24 h before implantation, temporary pacing before implantation and early re-interventions (haematoma, lead dislodgment). in contrast, an inverse correlation is observed between development of infection and antibiotic prophylaxis and implantation of a new system. data to guide therapy in patients with pacemaker infection are limited and the most appropriate management remains to be determined. according to different series, staphylococci accounted for 60 to >90% of the responsible organisms. coagulase-negative staphylococci (cns) are reported as predominant pathogens following by staphylocococcus aureus. the biofilm production, responsible for bacterial survival, and the emergence of methicillin-resistant in s. aureus and cns have complicated the management of pacemaker infections. this implies that empiric treatment of suspected pacemaker infection should coverage for staphylococci including methicillin-resistant strains. streptococci, corynebacterium spp, propionibacterium acnes, gram-negative bacilli and candida spp can cause occasional infections. the optimal therapy combines complete device extraction (percutaneous ablation or surgical removal during extracorporeal circulation) and prolonged course of antibiotics, in particular in case of multiresistant bacteria. leaving the device intact is associated with increased mortality and risk of relapsing or persistent infections. in absence of prospective studies, the duration of antibiotic treatment remains to be determined but 1 month has been shown not to be associated with an increased incidence of relapse. shortest course of treatment (2 weeks) has been proposed in case of vegetations strictly localised to leads without affecting cardiac valves. antibiotic therapy working alone should be reserved for highly selected patients. infection remains the most critical complication of ventriculoperitoneal shunt placement with an incidence of 2.2−39%. factors as the age of patient, aetiology of hydrocephalus, the type of shunt implanted, and the surgeon's experience are determined to be associated with increased risk of infection. children are more likely than adults to acquire shunt infection. the possible reasons are longer hospital stay, higher skin bacterial concentrations, immature immune systems, or more adherent strains of bacteria. staphylococci, as skin commensals, are the main causative organisms. nevertheless, in recent years a change in the epidemiology of microorganisms was observed with an increase of gram-negative bacteria. appropriate systemic antibiotics according to the antimicrobial susceptibility testing and surgical removal of the shunt with temporary external cerebrospinal fluid drainage and shunt replacement following the eradication of the infection are the cornerstone of the treatment of cerebrospinal fluid shunt infections. good compliance with infection control practices, inserion of the catheter under aseptic techniques and short-term perioperative antimicrobial prophylaxis in order to prevent the emergence of drug-resistant subpopulations are important steps in the prevention of shunt infections. o125 influenza in adults admitted to canadian hospitals: data from two seasons a. mcgeer, d. gravel, g. taylor°, c. weir, c. frenette, j. vayalumkal, a. wong, d. moore, s. michaud, b. amihod (toronto, ottawa, edmonton, montreal, saskatoon, sherbrooke, ca) objective: seasonal influenza (flu) remains a cause of substantial morbidity and mortality. antiviral treatment should be considered for all hospitalised patients with influenza. to better understand the epidemiology and burden of illness within the hospital sector in canada and the current use of antiviral therapy, we carried out a multihospital survey of virologically confirmed flu in hospitalised adults. methods: cnisp is a network of largely teaching hospitals across canada that collaborates to collect data on infections in hospitalised patients. during two consecutive years (2006/2007 and 2007/2008) hospitals within cnisp identified inpatients >16 years who had virologically confirmed flu. case patient charts were reviewed to capture demographic and clinical data and to determine whether flu was community (ca) or hospital acquired (ha). cases were reviewed at 30 days to determine outcomes. deaths at 30 days were reviewed to determine whether flu was a main or contributing cause. results: fifteen (06/07) and 11 (07/08) hospitals were recruited from the cnisp network. 532 virologically confirmed cases of flu were found, 182 in 06/07 (95% flu a) and 358 in 07/08 (56% flu a). mean patient age was 67 years, 52% were male. there was documentation of patient vaccination that season in 29%. incidence of ca flu was 11/10,000 admissions in 06/07 (range by hospital 2 − 23) and 27 in 07/08 (1 − 47). admitting diagnoses in ca cases were: pneumonia or influenza 48%, exacerbation of copd 20%, sepsis or fever not otherwise specified 9%, cardiac diagnoses 7%, other diagnoses 16%. 24% of cases were ha, range by hospital 3.9 − 5.4/100,000 patient days. 68% of patients were managed with droplet and contact isolation practices, an n-95 mask was used in 19%. 29% of ca cases but 75% of ha cases received antiviral therapy p < 0.01, almost entirely oseltamivir. 9% of cases were admitted to an icu; 30-day mortality was 8% with 2.6% attributed to influenza. conclusion: there is considerable season-season and hospital-hospital variation in flu in patients in canadian hospitals. hospitalised patients ca flu present with a wide spectrum of clinical diagnoses; nearly a quarter of all cases were ha. few ca cases but most ha cases were treated with antiviral drugs. attributable 30 day mortality was 2.6%. v. papastamopoulos, e. kakalou°, t. panagiotopoulos, j. baraboutis, m. samarkos, a. skoutelis (athens, gr) objectives: our study sought to describe influenza vaccination coverage among adults in greece for the season 2007/08. methods: we conducted a random-sampling, telephone based household survey among adult individuals in greece. for this purpose a sample of 1104 adults representative of the basic demographic, social and geographical characteristics of the overall greek population according to the latest national survey, was used. two target groups were determined for analysis: persons >65 years of age and persons with chronic conditions such as respiratory and heart conditions (other than hypertension), diabetes mellitus and other conditions. results: the influenza vaccination rate for the season 2007/08 among the adult population in greece was: 16% for the overall adult population (19.5% for men, 12.7% for women), 48.1% for people >65 years of age, 31% for persons with chronic illness (32.5% for persons with respiratory illness, 50.2 for persons with heart conditions, 35% for persons with diabetes mellitus). a high rate of 81% of the overall population reaching 88% among persons with chronic conditions report having had any type of contact with the national health system or a private physician within the last three years. among them only 20.1% had been recommended to get vaccinated. among the ones recommended any vaccination, 80.5% of persons with respiratory illness, 100% of persons with diabetes mellitus and 89.1% of persons with heart conditions had been recommended to get the influenza vaccine. conclusions: available data show unacceptably low levels of influenza vaccination coverage among vulnerable groups such as the population over 65 years of age and people living with chronic illness. influenza vaccination is the only preventive measure reducing influenza morbidity and mortality and its use has proven cost-effective among high risk groups. it is also the main vaccine recommended by physicians. however the overall rate of physicians recommendation of vaccination is very low. dynamic efforts are thus needed to design and implement strategies and policies that have demonstrated their rigorous effectiveness in enhancing influenza vaccination coverage rates. conclusions: nasopharyngeal sampling with flocked swabs is well tolerated and suitable to be used in an outpatient setting. implementation of real-time mono and multiplex naats results in a significant improvement of the rate in diagnosing lrti. hrv account for the majority of viral lrti in primary care followed by influenza and coronaviruses but also rsv and hmpv are prevalent in an adult population. in this study, 19 polyomaviruses were detected of which 10 were involved in a double infection. methods: observational analysis of a prospective cohort of 1041 nonseverely immunosuppressed adults with pp requiring hospitalisation (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) . of them, 556 were diagnosed by urinary antigen and/or 650 were diagnosed by culture. overall, 86% of pneumococcal strains were available for serotyping (quellung) and 58% for pfge (smal) and or mlst. the diagnosis of septic shock was based on a systolic blood pressure <90 mmhg and peripheral hypoperfusion with clinical or bacteriologic evidence of uncontrolled infection. results: a total of 114 (11%) patients with pp had septic shock at presentation. patients with shock were younger (61 vs 66 yrs; p = 0.003), were more frequently current smokers (45% vs 28%; p = 0.002), had received more commonly corticosteroid therapy (13% vs 6%; p = 0.015), and were more frequently classified into high-risk psi classes (81% vs 60%; p < 0.001) than those who did not have this complication. they were also less likely to have received prior influenza vaccine (31% vs 48%; p = 0.007) and had more frequently bacteraemia (41% vs 30%; p = 0.014). no significant differences were found in rates of penicillin-(2% vs 2%) and erythromycin-resistance (16% vs 12%). serotype 3 was more commonly associated with shock (40% vs 24%; p = 0.007), whereas serotype 1 was rarely associated with this complication (2% vs 9%; p = 0.041). no significant differences were found regarding genotypes: st2603 (26% vs 16%), netherlands-ser8-st53 (10% vs 3%), netherlands-ser3-st180 (10% vs 8%), spain-ser9v-st156 (10% vs 12%). patients with shock required more frequently mechanical ventilation (38% vs 4%; p < 0.001), and had longer los (19 vs 10 days; p < 0.001). early (10% vs 1%; p < 0.001) and overall case-fatality rates (25% vs 5%; p < 0.001) were higher in patients with shock. conclusions: pp presenting with septic shock is still associated with a poor outcome. it occurs mainly in current smokers, patients receiving corticosteroids, and in those infections caused by serotype 3. prior influenza vaccination and pp caused by serotype 1 are associated with a lower risk of shock. o131 high long-term mortality rate after initial recovery from severe community-acquired pneumonia background: despite the presence of antibiotics and vaccination strategies against pneumocci, community-acquired pneumonia (cap) is still a major cause for mortality in developed countries. however, it is unclear how an episode of cap influences long-term survival after initial recovery. therefore, we determined mortality up to 5 years after discharge in patients hospitalised because of an episode of severe cap in a non-intensive care setting. methods: in 5 hospitals in the netherlands, patients (pts) with severe cap (psi class iv and v without need for treatment in icu) were prospectively followed for 28 days and mortality up to 5 years after discharge was determined using the dutch municipal public records database. we used cox regression analysis to examine predictors for mortality. results: compared to strategy 2, strategy 1 resulted in slightly higher costs (chf 8,748 vs. 8,981) but fewer infections (.008 vs. 0.006) during patients' mean length-of-stay, producing an incremental costeffectiveness ratio (icer) of chf 83,303 per mrsa infection avoided. strategy 3 was dominated by strategies 1 and 2 (both more costly and less effective). sensitivity analyses suggest that prevalence of colonisation on admission is a stronger predictor of cost-effectiveness than the costs of infection or rapid screening, the probability of cross-transmission, or the incremental costs of isolation and contact precautions. increasing the relatively low on-admission prevalence at our centre by 20% lowers the icer to chf 60,973 per infection avoided. in contrast, increasing the cost of each infection, the cost of rapid screening, or the risk of cross-transmission by 20% only marginally affects the icer. conclusion: this analysis suggests that compared to risk factor identification and pre-emptive isolation, universal rapid screening upon surgical admission is not strongly cost-effective at our centre. however, local epidemiology plays an important role. in particular, settings with higher prevalence of colonisation on admission may find universal rapid screening more cost-effective. of note, no screening is undesirable, as costs and infections would be higher. results: admission and weekly screening coupled with patient isolation was found to dramatically reduce the number of mrsa acquisitions. the largest reductions were obtained with pcr technology, followed by chromogenic agar. the differences, however, were surprisingly small, and all screening technologies achieved reductions in mrsa acquisition of close to 80% compared with the no-intervention scenario. nonetheless, chromogenic and pcr-based systems were able to decrease the number of unisolated mrsa-bed-days by approximately 15 and 35% respectively. conclusions: the small differences in the ability of the screening technologies to reduce mrsa acquisition reflect both a relatively low estimated isolation efficacy and the observed highly skewed distribution of icu-stays, and may provide some important insights into the reasons for recent disappointing trial results. in particular, the skewed length of stay distribution means that most mrsa-bed days are accounted for by relatively long-stay patients for whom rapid detection will make the least difference. key sources of uncertainty were found to be isolation effectiveness and attributable mortality due to mrsa infections, both of which are difficult to accurately estimate with currently available data. the model results allow us to quantify the expected value of reducing these key uncertainties, and help to provide a rational basis for setting future research priorities. objectives: we have shown that there is substantial colonisation of mrsa among nursing home residents and staff with our recently conducted point prevalence study in 45 nursing homes which revealed an overall prevalence rate of 24% in residents and 7.6% in staff.1 the aim of this study was, therefore, to test the effectiveness of an intervention in nursing homes which sought to improve standards of infection control as a means of reducing mrsa prevalence. methods: a cluster randomised controlled trial (crct) involving 32 nursing homes, with each home representing the unit of analysis, was performed. the study ran for 12 months with data collected at baseline, 3, 6 and 12 months. nasal swabs were taken at baseline from consenting residents and staff in all homes prior to randomisation with an audit of infection control procedures also undertaken. following collection of these baseline data, nursing homes were allocated to the intervention or control arm (1:1). intervention home staff were trained in infection control, specifically hand hygiene, catheter care, barrier approaches such as use of gloves, aprons and masks, and decontamination of equipment and the environment with usual practice continuing in control homes. after each data collection timepoint, feedback was given to the intervention homes in terms of their performance and further education and training provided as required. the primary outcome was the prevalence of mrsa in intervention homes compared to control sites. results: preliminary analysis of the data has revealed no significant change in the prevalence of mrsa in the intervention and control homes, taking account of the clustering, over the one-year intervention period [risk ratio 0.83; 95% confidence intervals (ci) 0.53−1.29]. however, there was an improvement in infection control audit scores in the intervention homes, with a mean score in control homes at 12 months of 64.4% compared with 81.7% in the intervention sites; these scores were significantly different (paired t-test, p < 0.0001). the results suggest that infection control education and training as implemented in this study was not sufficient to affect mrsa prevalence. therefore, a more detailed education and training package either alone or in combination with mrsa decolonisation of staff and residents, may be required to reduce mrsa prevalence within this unique environment. [ objectives: in a response to the rapid global increase in the nosocomial prevalence of multi-resistant micro-organisms, infection control measures, such as patient isolation, are increasingly used. it is unknown how these measures influence the quality of life (qol) of patients during short-term isolation, and this was determined in a prospective matched cohort study. methods: all adult patients needing isolation in a single-patient room between 11/06 and 03/07 in the umc utrecht were eligible and included 24−48 hours after start of isolation (after giving informed consent and being able to fulfil study requirements). for each index patient we identified two control patients, admitted to the same wards at the same time, yet not subjected to any isolation measure. anxiety and depression and qol were assessed using the hospital anxiety and depression scale (hads) and visual analogue scale (eq-5d-vas) in all patients. opinions on and experiences with isolation were measured in isolated patients by means of a self-developed 'isolation evaluation questionnaire'. results: 42 isolated patients and 84 controls were included, with comparable baseline characteristics (age, sex, nationality, level of education, length of hospital stay and severity of underlying disease and co-morbidity (using the cumulative illness rating scale)). reasons for isolation were clostridium difficile-associated disease (n = 17, 40%), high risk for mrsa carriage (n = 12, 29%), or resistant gram-negative bacteria (n = 7, 17%). mean scores of questionnaires are presented in table 1. isin univariate analysis only duration of isolation of 48 hours (compared to 24 hours) was associated with a reduced quality of life (vas 57.7 compared to 68.7, p 0.02). on a visual analogue score of opposite terms isolation measures were rated with means of 87.5, 83.3 and 70.8 for safety, usefulness and quietness, respectively. conclusion: short-term isolation (up to 48 hours) is not associated with anxiousness or depression, but with positive feelings about safety, usefulness and quietness. index patients (n = 42), mean (sd) 4.7 (3.5) 5.3 (3.5) 9.9 (6.0) 62.3 (15.5) control patients (n = 84), mean (sd) 5.4 (3.7) 5.2 (3.6) 10.6 (6. objectives: there is a lack of data about the impact of healthcare associated infection (hai) on the experience of individual patients. this information is essential to empower health organisations to understand, prioritise, develop and implement solutions that will minimise risks to patients. this study explored comparable narratives from patients who had experienced a staphylococcus aureus blood stream infection with patients who had not. we conducted qualitative semi-structured interviews with eighteen adults who had previously been an in-patient in an acute teaching hospital in scotland. nine patients had had a laboratory diagnosed staphylococcus aureus blood stream infection and nine had no blood stream infection. all patients were interviewed for 20−40 minutes. the interviewer asked patients about their thoughts around hai, what concerns they had or still do, what measures they took to safeguard themselves from hai and how their experience impacted on their confidence of the nhs. probing questions were then asked depending on the responses given to the initial questions. all interviews were recorded, transcribed and analysed thematically. results: analysis of transcribed interviews is ongoing. preliminary analysis showed that all patients had positive and negative comments about infection prevention and control practice in the hospital. specific concerns included poor communication, poor cleanliness, awareness of patient boarding, lack of facilities, staff shortages and multi-tasking. some patients who had experienced bacteraemia said they had not been informed about the infection. those who had been informed were not given clear information about treatment or subsequent results. most patients were not specifically told what they or their family should do to safeguard them from infection and little or no written information about hai was provided. most patients are worried about hai on future admissions. the concerns of patients were not fundamentally different if they did or did not experience blood stream infection. the patient's reported experiences show that they have a broad awareness of systems issues that may increase risk of infection. consequently we need to involve patients in the design and evaluation of systems change and information that will improve patient experience. improving the safety and reliability of the system will have direct benefits for all patients in the hospital, not just the ones at risk of hai. analysis of surgical specialties separately revealed a significant reduction of mortality in cardiothoracic surgery who had been treated with mup-chx (2.3% (5/218) vs. 6.5% (11/170), p = 0.040, figure) . in other surgical specialties no significant difference was found. conclusion: peri-operative application of mup-chx in nasal carriers of s. aureus undergoing cardiothoracic surgery results in a threefold reduction of mortality after one year. o142 a lot done, more to do − a survey of teaching about healthcare-associated infections in uk and irish medical schools h. humphreys°, d. o'brien, j. richards, k. walton, g. phillips (dublin, ie; norwich, newcastle-upon-tyne, dundee, uk) objectives: patient safety and the prevention of healthcare-associated infections (hcai) are increasingly important health issues. medical doctors have traditionally been poor in complying with preventative measures to minimise hcai such as hand hygiene compliance. we surveyed medical schools in the uk and ireland to assess what is being taught and assessed in this area. methods: a questionnaire was drafted, piloted and then subsequently forwarded to the heads of medical schools as well as to known contact professionals with an interest in hcai in 38 medical schools. the questionnaire surveyed topics covered in the curricula, the modalities used to assess knowledge and practice, the usefulness of various teaching methods and materials, e.g. lectures, and what education resources were available. results: replies were received from 31 (82%) medical schools; two supplied data on their undergraduate and postgraduate courses. only 18 (60%) covered hcai as a quality and safety issue but over 90% covered prevalence, recognised risk factors, transmission, and preventative measures. 24 (80%) medical schools assessed competence in undertaking aseptic techniques and the disposal of sharps and mcqs were the most common (87%) means of assessment. case scenarios, resource materials and clinical skills stations were used in educating students in 26 (87%), 22 (73%) and 22 (73%) medicals schools respectively. 25 (83%) medical schools would be willing to share educational resources on hcai with other medical schools. conclusions: medical schools in the uk and ireland include hcai in their curricula but its importance as a safety and quality issue needs to be further emphasized. there is potential for agreeing a core curriculum on hcai and for sharing teaching resources such as videos and e-learning material. objectives: noroviruses are most common cause of outbreaks of gastroenteritis in uk national health service hospitals, leading to ward closure costing as much as £115 million per annum. using a detailed data set on norovirus outbreaks from three hospital systems in the south west of england, we estimated (1) the relative importance of introduction of norovirus from the community and within the hospital and (2) the cost effectiveness of ward closure at different time points during an outbreak. methods: using regression models we examined the association between number of new outbreaks in a hospital and community levels of activity and number of outbreaks currently occurring in other wards within the hospital. we examined the effect of different ward types (admission, general and long stay units) and whether the ward was open or closed to new admissions on a given day. we then undertook as analysis of cost (-effectiveness) of unit closure by developing a dynamic transmission model taking into account that ward closure may reduce norovirus transmission within and between wards. the stochastic simulation model was based on the actual characteristics of an acute hospital and the norovirus transmission parameters quantified in the statistical analysis. we measured the costs and benefits of closing affected wards at 1, 3 and 5 days after the onset of symptoms in the first case. results: community level of norovirus infection had a significant effect on the occurrence of new outbreaks as did outbreaks in admission and general medical units. the cost of closing wards to new admissions varied between £0.5 million to £0.9 million depending on the assumed effectiveness of closure in curtailing transmission. cost of bed day loss − compared with staff illness -accounted for around 90% of the total cost of closure. although the total number of cases tends to fall with rapid ward closure (by around 50% compared with no closure), the actual cost of control is similar regardless of when the closure is performed. we have developed a modelling framework to assess the effectiveness and cost-effectiveness of strategies to control norovirus outbreaks in hospital settings. ward closure is effective at preventing cases but since closure itself is an expensive intervention, it may not always be cost-effective. . other prevalent ribotypes were 001 (25%) and 106 (36%). 76% of the 027 isolates originated from 5 hospitals located in 2 healthboard areas. the remaining 18 isolates of ribotype 027 originated from 11 hospitals across scotland. in vitro 96% of 027 isolates were resistant to clindamycin with a mic range of 8−24 mg/l, mic50 of 12 mg/l and mic90 of 16 mg/l. furthermore 100% of the 027isolates were highly resistant to erythromycin (mic50 256 mg/l, mic90 256 mg/l), and to levofloxacin and moxifloxacin (mic50 32 mg/l, mic90 32 mg/l for both), while 65% of these isolates were resistant to cefotaxime (mic50=64 mg/l, mic90=96 mg/l). all 027isolates were susceptible to metronidazole, vancomycin, meropenem and piperacillin-tazobactam. high frequencies of clindamycin, erythromycin, levofloxacin, moxifloxacin and cefotaxime resistance were also found among isolates of ribotype 001 (90−99%) and 106 (94-100%). conclusion: until 2008 c. difficile ribotype 027 was only reported infrequently in scotland. in 2008, reports of ribotype 027 became more frequent and clusters were detected in 5 hospitals. the majority (96%) of ribotype 027 isolates were resistant to clindamycin. three other european countries have previously reported clindamycin resistance in pcr ribotype 027, albeit with a higher mic90 of >256 mg/l. objectives: to analyze trends in mortality due to clostridium difficile enterocolitis and to describe the most affected groups in order to better understand current clostridium difficile changing epidemiology. methods: we reviewed mortality data from the flanders and brussels regions in belgium (about 7 million inhabitants). we selected those records in which icd-10 code a04.7 (enterocolitis due to clostridium difficile) appeared as underlying cause of death within the death certificate. age-and sex-specific mortality rates were calculated for the period 1998-2006. direct standardisation was performed using the european standard population and 95% confidence intervals were calculated. stata 10 ® and excel ® were used as statistical software. objectives: toxigenic clostridium difficile is an enteric pathogen typical in the hospital environment but also community-acquired cases have been reported. however, relatively few attempts have been made to clarify the role of soil or water as a source of c. difficile infection. in november-december 2007, the drinking water distribution system in the town of nokia, finland was massively contaminated with treated sewage effluent resulting in a large gastroenteritis outbreak. the aim of the present study was to evaluate if contaminated water in this outbreak was also a potential source of c. difficile infection. a sample from the contaminated tap water and a treated sewage effluent sample were collected as soon as possible after the massive faecal contamination of the drinking water distribution system had occurred. c. difficile was isolated from heat-treated water samples by filtrating of 100 ml, 10 ml and 1 ml volumes of water and placing the membranes on selective ccey agar plates, which were anaerobically incubated for 3 d. stool samples from the patients fallen ill during the epidemic were examined for enteric pathogens, including c. difficile. all potential c. difficile colonies were subcultured on ccfa agar plates and toxin-positive isolates were identified by pcr. pcr ribotyping was performed according to the protocol of the anaerobe reference unit in cardiff, uk, using the cardiff-ecdc culture collection as a set of reference strains. after gel electrophoresis, the band patterns were analyzed using the bionumerics software. results: altogether 22 c. difficile isolates were found in water samples. twelve isolates were toxin-positive; 5 isolates were from contaminated tap water and 7 isolates from treated sewage effluent, the latter being the contamination source. among the tap water and sewage effluent isolates, 4 and 5 distinct pcr ribotype profiles were identified, respectively. the 9 human faecal c. difficile isolates detected were divided into 4 distinct pcr ribotype profiles. none of the profiles were identical with that of the hypervirulent pcr ribotype 027. two isolates, one from tap water and another from a patient, had an indistinguishable pcr ribotype profile. conclusion: our observation implies that c. difficile contamination of a tap water distribution system had occurred. waterborne transmission of toxigenic c. difficile and subsequent c. difficile infection seems possible. objectives: an accurate and rapid method is needed for typing of toxigenic clostridium difficile. a commercial automated repetitive pcr system (rep-pcr; diversilab ® , biomérieux inc., st louis, usa) utilises amplification and subsequent automated electrophoretic separation of the repetitive extragenic palindromic sequences of c. difficile. our aim was to evaluate the performance of this rep-pcr method for genotyping of c. difficile isolates and to compare it to pcr ribotyping. in addition, the correlation between the rep-pcr and the virulence gene profiles of c. difficile strains was studied. methods: a total of 195 toxin-positive c. difficile isolates were studied. we included consecutive isolates from two laboratories in finland, containing also strains of the hypervirulent c. difficile ribotype 027. in addition, selected c. difficile strains with >18 bp deletions in their tcdc genes were analyzed. the dna was extracted and the rep-pcr performed according to the manufacturer's instructions. the amplification products of rep-pcr were detected and analyzed using the diversilab system. further analysis was performed with the web-based software accompanying the system. the usefulness of the library construction option of the diverslab system for isolate comparison was tested. the virulence genes (tcda, tcdb, cdta, cdtb and tcdc) were analyzed by conventional pcr and the whole gene sequencing of tcdc was performed from isolates with deletions >18 bp. pcr ribotyping was performed using the protocol of the anaerobe reference unit in cardiff, uk. the correlation between the rep-pcr profile and the ribotype was excellent. all major ribotype groups were clustered in their own rep-pcr groups. interestingly, subgroups could be found with rep-pcr within two most prevalent ribotypes 001 and 027. the automated rep-pcr proved to be reproducible; the results from separate dna isolations and pcr-runs/microfluid electrophoresis as well as the results performed by different individuals of laboratory personnel were comparable. the rep-pcr profiles and pcr ribotypes correlated also with the virulence gene profiles. conclusion: this automated rep-pcr represents an effective and reproducible method for the genetic characterisation of c. difficile strains in clinical laboratories with molecular biology facilities. the constructed c. difficile library allows comparing the relatedness of c. difficile strains and their fingerprints over time. objectives: clostridium difficile infection (cdi) is a serious diarrhoeal illness associated with high morbidity and mortality. currently available treatments (oral vancomycin or metronidazole) usually produce good resolution of diarrhoea but are associated with a 20% to 30% incidence of recurrence. opt-80, the first in a new class of macrocyclic antibiotics, is bactericidal via unique inhibition of rna polymerase. this phase 3, non-inferiority clinical trial was conducted in more than 100 sites in north america and compared the efficacy and safety of opt-80 and vancomycin in treating cdi. methods: eligible patients were adults with acute cdi symptoms and a positive stool toxin test. patients received oral opt-80 (200 mg twice daily) or oral vancomycin (125 mg 4 times daily) for 10 days. primary end point was clinical cure (resolution of symptoms and no further need for cdi therapy 2 days after stopping study drug). secondary end point was cdi recurrence (diarrhoea and positive stool toxin test within 4 weeks after treatment). global cure was defined as a clinical cure with no recurrence. results: 629 patients were enrolled and 87% were evaluable. in the per protocol (pp) population (n = 548), mean age was 61.3±17.1 years and 44.0% of patients were male. equivalent rates of clinical cure were observed with opt-80 (92%) and vancomycin (90%) in the pp analysis; similar outcomes were observed in a modified intent-to-treat (mitt) analysis. significantly fewer patients treated with opt-80 (13%) than vancomycin (24%) experienced recurrence in the pp analysis (p = 0.004) and in the mitt analysis (15% vs 25%; p = 0.005). significantly more opt-80-treated patients achieved global cure (78%) than vancomycintreated patients in the pp analysis (67%; p = 0.006) and in the mitt analysis (75% vs 64%; p = 0.006). opt-80 was well tolerated with an adverse event profile similar to that of vancomycin. in this study -the largest comparative trial of a new antimicrobial agent versus vancomycin for the treatment of cdi -clinical cure rates after treatment with opt-80 or vancomycin were equivalent. however, opt-80 was associated with a significantly lower recurrence rate and a higher global cure rate than vancomycin. opt-80 is an oral, non-absorbed agent that has a convenient (twice daily) dosing schedule and low risk of adverse events. opt-80 represents a potential new treatment option for cdi that is associated with a lower recurrence rate than currently available treatments. results: sequence analysis (sa) revealed that locus a is absent in type 078 and that some mismatches are present in the primer annealing sites for loci b, c and g. lowering the annealing temperature and increasing the magnesium chloride concentration for loci b, c and g resolved the low yield of pcr products. applying the mlva on 54 type 078 strains revealed that 42 (80%) strains, encompassing isolates from human (n = 42) and porcine (n = 11) origin, are genetically related with a summed tandem repeat differences (strd) 10). three clonal complexes (cc, defined by strd 2) were recognized; one cc contained both human (n = 4) and porcine (n = 3) strains. the optimised mlva identified 3 genetically related clusters and 6 cc among the 67 isolates from e and ni. ccs contain isolates from more than one hospital and indeed for several clusters isolates from both e and ni. 2 isolates obtained from ni 8 years earlier were part of one large cc. the optimised mlva can distinguish and/or group type 078 strains from distinct settings. type 078 strains from human and animal origin are genetically related. the clustering of some isolates from distinct settings is consistent with community sources for type 078. the last 2 observations suggest zoonotic transmission. objectives: this paper updates our assessment of the contribution that community-associated clostridium difficile infection (cdi), as reported to the english mandatory surveillance scheme since 2007, makes to both the acute and community sectors of the national health service (nhs) in england. methods: nhs acute trusts (hospital groups) in england are required to report all c. difficile toxin positive diarrhoeal specimens processed by their laboratories whether the patients were in hospital or the community at the time of onset of the illness or when the specimen was taken via a web enabled reporting system. positive specimens from the same patient within 28 days are not reported. reported cases in patients under 2 years of age were omitted from this analysis. enhanced surveillance data (including information on date of admission, patient location prior to testing, sex, age and patient category) on cdi have been collected through a web-enabled reporting system since april 2007. risk factor information is completed on a voluntary basis. results: more than 75,000 cases of cdi in patients aged >2 years were reported, 23% of these cases were taken in non-acute settings of which 74% were taken by a general practitioner. a further 17% of specimens were taken on presentation or <2 days of admission into an acute trust. approximately 32% of all cases had at least one risk factor field completed, >19,000 cases reported risk factor information on episode category; 23% of these cases were community associated and 77% were hospital acquired. the information reported suggests that only 3% of the community associated cases were from patients with continued infection or relapsed episodes of cdi, this is compared to 8% of the hospital acquired cases who had continued infection or relapsed episodes of cdi. conclusions: 23% of the c. difficile specimens reported by acute trusts were diagnosed in a community setting. published studies suggest that 12−15% of these might be expected to have been acquired during a hospital stay within the previous month (i.e. were community onset hospital acquired cases). future work is required to investigate whether there are differences in the epidemiology, risk factors e.g. antibiotic exposure and outcome of patients with community onset disease. o152 clostridium difficile-associated disease: a newly notifiable disease in ireland m. skally, f. roche, d. o'flanagan, p. mckeown, f. fitzpatrick°( dublin, ie) new cases of clostridium difficile-associated disease (cdad) became notifiable in ireland on 4th may 2008. the main objective of this new notification process was to provide a national overview of the epidemiology and burden of cdad. this paper review the first six months of preliminary data notified. methods: the interim case definitions for new and recurrent cdad cases proposed by the european society for clinical microbiology and infectious diseases (escmid) study group for c. difficile were employed. this report reviews the weekly events of cdad extracted from the computerised infectious disease reporting (cidr) system in january 2009. census of population 2006 figures were used as denominator data in the calculation of incidence rates. results presented represent 34 weeks of data submitted. results: there were 1581 new cdad cases notified on cidr between the 4th may 2008 and 27th december 2008, representing a crude incidence rate (cir) of 37.3 cases/100000 population (estimated annual cir is 57.0 cases/100,000). all cases were laboratory confirmed. there was a higher occurrence of cases in females. the male:female ratio for the period was 1:1.6. in 0.4% of cases the sex was unknown. 71.4% of cases were in the greater than 65 years age category. the preliminary data submitted on cidr indicate that 63.0% of cases were hospital inpatients and 8.9% of cases were either gp patients or outpatients. the origin of 28.1% of samples is unknown. there was large variation between the 8 public health regions (table 1) . the incidence of cdad in ireland is prominent in older age groups and in healthcare settings. what is more remarkable is the regional variation of cases reported. this varies from 9.1 per 100,000 in the north east to 52.4 per 100,000 in the west. the seasonal trend is indistinguishable at present due to late and batch notifications from institutions. o153 clostridium difficile-associated diarrhoea in immunosuppressed patients with cancer objective: to assess the epidemiology, clinical features and outcome of clostridium difficile (cd) associated diarrhoea in immunosuppressed patients with cancer. methods: review of all episodes of cd associated diarrhoea documented in adults with cancer and haematopoietic stem cell recipients (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) . microbiologic diagnosis included cd isolation from stool samples, direct detection of cd toxin, and testing for cytotoxin production by the isolated strain. we documented a significant increase of cd associated diarrhoea, from 0.34/1000 admissions in 2000 to 4.05/1000 admissions in 2008 (p < 0.01). there were 56 episodes in 54 patients. thirty-one patients were male (55%) with a mean age of 52 years (± 16). forty three (77%) patients had an haematological underlying disease and 13 had solid tumour; 41 (73%) had received previous chemotherapy, 14 (25%) were stem cell transplant recipients (3 presenting with gvhd) and 17 (30%) were neutropenic (<500). in the previous month 52 patients (93%) had received one or more antibiotics (cephalosporins 63.5%, glycopeptides 40%, carbapenems 38.5%, betalactam + betalactam inhibitors 29%, quinolones 19%). fever >38ºc (71%) and abdominal pain (44%) were the most frequent manifestations, and the diarrhoea was hemorrhagic in 8% of the cases. most patients (77%) were treated with metronidazole (median 11 days), and the antibiotic therapy was discontinued in 56%. in 5 patients who had recovered from neutropenia, the diarrhoea resolved just by discontinuing the antibiotic therapy. no patient developed toxic megacolon or needed surgery. three patients (5.5%) had relapses. overall mortality (<30 days) was 22% (12 patients). the incidence of cd associated diarrhoea in cancer patients has increased significantly in recent years. it is related with important morbidity and mortality. better strategies to improve its prevention and treatment are needed. s154 linking research to the clinic: how laboratory findings relate to management of invasive candida infections the role of the research laboratory in the management of invasive candida infections goes beyond routinely available tests for identification of candida species and susceptibility testing of antifungal agents. cutting-edge molecular epidemiology technologies have been used to type isolates of candida species based on their dna sequences. multilocus sequence typing schemes have been designed for c. albicans, c. dubliniensis, c. glabrata, c. krusei and c. tropicalis. multi-locus sequence typing can be used to investigate possible hospital outbreaks of infection (finding widely different strain types within a unit indicates no outbreak, although the converse is not true). for c. albicans, typing multiple isolates from the same patient has shown that people tend to harbour as commensals a mixture of closely related but different strain types, which may provide for selection of the most appropriate type for invasion of a particular tissue or in response to antifungal treatment. strains in c. albicans clade 1, the largest group of related strain types, have a higher proportion of isolates resistant to flucytosine than other clades, and they all share a common resistance mechanism. research on mechanisms of resistance of candida species to many types of antifungal has progressed to the point that some investigators are looking to design dna chips that could be used both for identification and for susceptibility testing of a candida isolate. much research effort goes into detailed study of host-fungus crosstalk in experimental candida infections. animal models of infection have been greatly refined and the latest research shows how early release of chemokines that attract neutrophils into infected tissues contributes to the immunopathology of candida infection. this rapid, innate immune response also emphasizes the need for antifungal intervention at the earliest possible stage to provide the best chance for successful treatment of a disseminated candida infection − a finding now supported by clinical data as well as experimental models. translation of the latest research advances into practical diagnostic tests and new therapeutic approaches for candida infections always takes a long time − typically years − and not all research results find clinical applications. however, the level of effort invested in basic candida research ensures support for steady progress in diagnosis and management. the echinocandins are semi-synthetic lipopeptides that are increasingly used for the prevention and treatment of invasive fungal infections. understanding the pharmacokinetic and pharmacodynamic (pk/pd) characteristics of these compounds is critical for their optimal clinical use. the echinocandins have potent in vitro activity against candida spp., although c. parapsilosis is less susceptible than other candida species. the molecular mechanisms of resistance in candida species, which relate to amino acid substitutions in 'hot spots' within the fks1 gene, are becoming well characterised. susceptibility breakpoints for all three clinically available compounds have been determined recently by the clinical laboratory standards institute, with a 'susceptible-only' breakpoint of >2 mg/l suggested. the pk/pd of the echinocandins have been determined in experimental models of disseminated candidiasis, and of both disseminated and pulmonary invasive aspergillosis. these studies suggest that the echinocandins: (1) display concentration-dependent antifungal killing (or effect); (2) are extensively distributed into peripheral tissues, where they exhibit prolonged mean residence times at the site of infection; (3) are fungicidal against candida spp. and induce dose-dependent morphological changes in aspergillus spp.; and (4) result in a diminished propensity for angioinvasion by aspergillus spp. recent evidence also suggests that the echinocandins have important immunomodulatory properties, which may contribute significantly to their observed antifungal effect. pk/pd modelling and laboratory animal-to-human bridging techniques have been used to identify safe and effective dosages for the echinocandins for relatively uncommon clinical syndromes such as neonatal haematogenous candida meningoencephalitis. these techniques are an efficient method of identifying effective regimens for humans that can be expedited for study in clinical trials. pk/pd modelling techniques can and should be used to address outstanding clinical queries in relation to these compounds, including optimal dosages, decision-support analysis for the setting of in vitro antifungal susceptibility breakpoints and the clinical relevance of inherent or acquired reduced antifungal susceptibility. s156 invasive candidiasis: which antifungal treatment for which patient? management of patients with invasive candidiasis represents a complex issue owing to the heterogeneity of patients in whom these infections occur. established risk factors for invasive candidiasis, which include total parenteral nutrition, multiple organ failure and candida colonisation, are common to many types of patients that are treated within the critical care setting. furthermore, the severity of the underlying condition in these patients necessitates swift antifungal treatment to ensure optimal outcomes. an additional factor for consideration when treating candida infections is the changing epidemiology of candida species; potentially fluconazole-resistant species such as c. glabrata and c. krusei are becoming more common, particularly in patients with prior fluconazole exposure. a range of antifungal agents is available with in vitro activity against candida species. however, not all of these agents are suitable options for the clinical management of invasive candidiasis because of the overall complexity of both infection and underlying condition. for example, the position of the polyenes, particularly amphotericin b deoxycholate, is becoming less tenable as the risk of renal complications is increasingly regarded as unacceptable in patients that are likely to have or be at risk of multiple organ failure. furthermore, because of the increasing prevalence of fluconazole-resistant species, recent guidelines no longer recommend the use of azoles as first-line treatment for invasive candidiasis except in special cases, focusing instead on the echinocandin agents. there is now a wealth of clinical data available for the echinocandins. micafungin, for example, has been assessed in invasive candidiasis in clinical trials that included a wide variety of underlying conditions and patterns of infection, including neutropenic patients and those with deep infections such as peritonitis. furthermore, micafungin is the most extensively evaluated of the echinocandins in paediatric patients, having been tested both in children up to the age of 16 years and in premature infants and neonates. optimal management of patients with invasive candidiasis depends on a strategy that takes into account the complex nature of the disease. judicious selection of antifungal treatment should be accompanied by consideration of non-drug-related factors that improve survival, such as careful assessment of intravenous catheters and their potential involvement in candida infections. patients with invasive candidiasis often have underlying conditions that are severe illnesses in themselves. these range from neutropenia during cancer chemotherapy to the multi-organ failure of intensive care unit patients. against this background of severe underlying illness, it can be difficult to appreciate the success or otherwise of treatment strategies for candida infections. in the last decade, major advances have been made in antifungal therapy with the introduction of 1. echinocandins; 2. extended-spectrum azoles; and 3. lipid formulations of amphotericin b. robust clinical studies for their successful use in candidaemia have been published. however, it is important to translate these studies into practical strategies for the care of individual patients. in this presentation, individual cases will be used to provide insights into the successes and failures of these antifungal classes for the management of invasive candidiasis. specific interest will be focused on the use of fluconazole versus the echinocandins. these micafungin-based cases will be supported by insights from the evidence-based literature combined with practical experiences at the bedside. the factors to be considered are: 1. spectrum of activity; 2. drug toxicity; 3. drug interactions; 4. drug resistance; 5. pharmacology; 6. diagnosis; 7. site of infection; 8. use of biomarkers/cultures in treatment strategies; and 9. costs. it is important to realise that large clinical trials exclude many patients with invasive candidiasis. therefore, with the use of individual cases, it is possible to provide further insights into the clinical use of these outstanding antifungal agents. patient management: the era of rapid diagnostic results (symposium organised by cepheid) s161 will community mrsa and clostridium difficile change infection control in hospitals? infections caused by methicillin-resistant staphylococcus aureus (mrsa), vancomycin-resistant enterococci, and clostridium difficile are inter-related in healthcare institutions. the emergence of epidemic mrsa and c. difficile strains has placed a greater burden on infection control systems in healthcare facilities, which often must increase surveillance and change disinfection strategies to halt the transmission of these pathogens in hospitals. ironically, the usa300 mrsa strain arose in the community but now is being transmitted frequently in healthcare settings, while the epidemic nap1/bi/027 c. difficile strain was originally a healthcare-associated pathogen, which now is causing considerable morbidity in community settings. to successfully slow the spread of these pathogens, infection control must work closely with both the laboratory and pharmacy services to ensure that these organisms are detected rapidly and that the selective pressure to maintain the organisms in the institution are reduced. clearly, bundles of interventions, rather than single approaches, are necessary to contain the spread of these organisms in hospitals. the continued influx of patients with communityacquired mrsa and c. difficile infections into healthcare institutions is a challenge for infection control practitioners that will clearly increase in the future. the food borne pathogen l. monocytogenes discovered by murray in 1926 is responsible for a severe infection with various clinical features (gastroenteritis, meningitis, meningoencephalitis and materno foetal infections) and a high mortality rate (30%). the disease is due to the ability of listeria to cross three host barriers during infection: the intestinal barrier, the placental barrier and the blood brain barrier. it is also due to listeria capacity to survive in macrophages and to enter into non phagocytic cells, such epithelial cells. recovery from infection and protection against reinfection are due to a t-cell response, explaining why listeria has since many years has become a model in immunology. nearly three decades of molecular biology and cell biology approaches coupled to genetic and post-genomic studies have promoted listeria among the best models in infection biology. in depth studies of the mechanism of entry into cells has help unraveling how listeria crosses the intestinal and placental barrier. unsuspected concepts in cell biology were discovered. post-genomic studies have recently allowed to unveil the listeria transcriptional landscape during switch from saprophytism to virulence. the talk will give an overview highlighting recent results in the frame work of well established data. the last several decades of research in medical mycology have offered great insights into fungal cell biology, epidemiology, phylogenetics and the cells and molecules involved in the pathogenesis of fungal disease. a legitimate question is to ask to what extent our extensive advances in comprehension of the biology of fungal pathogens have contributed to improvements in diagnosis and treatment. to what extent do patients benefit from translation of basic research into tools for clinical management? and the equally valid question: to what extent does biological science benefit from study of fungi that are opportunistic pathogens? the speaker will examine some of these questions from the perspective of long experience in the field and the curmudgeonly attitude that develops with age. objectives: the incidence of invasive meningococcal disease (imd) has been reported in the czech republic since 1943. in response to the emergence of a new hypervirulent clonal complex, cc11, nationwide enhanced surveillance of invasive meningococcal disease was implemented by the national reference laboratory for meningococcal infections (nrl) in 1993. the case definition is consistent with the ecdc guidelines. culture and pcr are used for confirmation of cases. notification is compulsory and is performed by local epidemiologists. strains of neisseria meningitidis isolated from imd cases are referred by the field laboratories to the nrl to be characterised by serogrouping, pora and feta sequencing (http://neisseria.org/nm/typing/) and multilocus sequence typing (mlst) (http://pubmlst.org/neisseria/). in the nrl, the epidemiological database is matched against that of strains to avoid duplicate reporting in the final enhanced surveillance database. results: despite the stable trend in imd incidence (0.8/100 000) since 2005, the case fatality rate was high (11.8%) in 2007. the disease was caused mainly by serogroup b meningococci (67.4%) in 2007, followed by serogroups c (20.9%) and y (9.3%). the most frequent clonal complexes were cc18, cc41/44 and cc32 (typical for serogroup b) and cc11 (typical for serogroup c). the highest age-specific morbidity rates were observed in the lowest age groups, i.e. 0−11 months and 1−4 years (11.4/100 000 and 4.5/100 000, respectively), and were associated with high prevalence of serogroup b. the case fatality rate was the highest in infants under 1 year of age (38.5%). the incidence of imd caused by serogroup c is currently low and there is no indication for mass vaccination with menc conjugate vaccine. menb vaccine is needed for infants, but the sero/subtype coverage by the currently developed porin-based vaccines is low for czech meningococcal isolates (maximum 56.8% for nine-valent meningococcal pora vaccine). methods:the vaccination programme incorporates dedicated vaccine clinic with a multi-disciplinary team including a nurse, data manager, a pharmacist specifically appointed to the unit. additional interventions to improve vaccine uptake and outcome have included use of sms texting to announce availability of influenza annually and improve adherence to completion of hepatitis b vaccination, educational programmes changes in guidelines e.g. varicella vaccination and creation of a vaccine passport. we reviewed vaccination clinic activity in the cohort of 1,700 hiv positive patients since introduction of a dedicated vaccine service. results:there has been a large increase in the uptake of vaccinations since introduction of this service. the varicella vaccination uptake increased from 8 (2007) to 43 (2008) due to targeted vaccine programme.(see graphic, legend reads left to right) conclusion: strategies implemented increased the uptake of recommended vaccinations in our hiv population. these included appointment of a dedicated health professional team, use of it supports, education of staff and patients and development of a vaccine passport. we developed the vaccine passport to help with patient education and awareness and it will serve as a record of vaccine administration for physicians off site. in the latter year, post guideline change, we have targeted our varicella non immune population. the next intervention planned is to assess all late entrants to our healthcare system to determine need for catch up vaccines, including mmr. results: column purified recombinant protein sspb1 was found to be a good antigen for both groups of animals used for immunisation. antibodies against the recombinant sspb1 tested by opsonophagocytosis were found to enhance phagocytosis of 4 gbs strains belonging to different serotypes at the average 5.5 times relatively to control. affect against gas strains was less pronounced (2.5 times) but still statistically significant. antibodies were also capable to interfere with adherence of gbs strains carrying sspb1 relatively to the strain without the protein. adherence of the strain with sspb1 towards different cell lines was dramatically higher which proves the function of the protein as adhesin. in passive protection test carried out with mice challenged with virulent gbs or gas strains introduced intranasaly were eliminated from the lungs of the animals 20 times faster in case of the usage of anti sspb1 serum relatively the control. in the experiments with active protection sspb1 immunised animals were found be significantly better protected against gbs and gas infection. (table 1) . similar results were obtained in the analysis of factors associated with 90-day mortality. conclusion: these data suggest that outcomes of both community-onset and nosocomial bloodstream infections due to s. aureus may be improved by an expert consultation service. the factors most critical for better outcomes and modifiable in time by id specialist consultation remain to be determined and may be explored as process of care quality indicators. objective: worldwide, the present tuberculosis epidemic is characterised by an alarming emergence in drug resistance. given the limited therapeutic options in mdr (and especially xdr) tuberculosis, there is a need to define the resistance levels and mechanisms present in clinical isolates categorised as drug resistant on the basis of critical concentration testing, so as to facilitate rapid therapeutic decisions. methods: we determined quantitative resistance levels of drug resistant isolates of mycobacterium tuberculosis sampled in switzerland over the past 3 years. resistance-conferring genetic alterations were identified by probe assays and pcr-mediated gene sequencing. results: rifampicin resistant isolates unanimously showed a high-level resistant phenotype (>50 mg/l) associated with mutations in rpob. in contrast, a significant fraction of clinical tb isolates categorised as isoniazid resistant on the basis of critical concentration testing showed a low-level resistant phenotype (mostly mutations in inha); heterogeneous phenotypic resistance levels were associated with mutations in katg. one third of streptomycin resistant clinical isolates had a low-level resistance phenotype (<10 mg/l). ethambutol resistance occurred mostly in mdr strains and was linked to alterations in embb, but resistance never exceeded 25 mg/l. our data indicate that some first line agents may be considered as therapeutic treatment option despite in vitro resistance at the critical concentration. diagnostic mycobacteriology would benefit from standardised measures of quantitative drug susceptibility testing in particular for those drugs were significant variations in phenotypic resistance levels are found in clinical isolates, e.g. isoniazid, ethambutol and streptomycin. introduction recent advances in the diagnostics of varicella zoster virus (vzv) infections have changed the perception of this virus as a cns pathogen. a real-time pcr method amplifying a 70 nt segment of the vzv gb region gave 0.5 log improved sensitivity over conventional pcr and was employed for routine diagnosis of vzv dna in samples of cerebrospinal fluid (csf). in addition, a new elisa method for detection of antibodies in the csf to glycoprotein e was developed, using a mammalian cell expression system for optimal glycosylation of the antigen. these methods were utilised for studies of vzv-induced cns infections. in a retrospective study, almost all patients had a reactivated vzv infection, but only 60% showed skin lesions. the following diagnoses were made: acute aseptic meningitis (aam), n = 34; encephalitis, n= 22; meningoencephalitis, n = 6; cranial nerve affections, n = 20; encephalopathy, n = 5; and cerebrovascular disease, n = 6. in 66 patients in whom vzv dna levels were determined, significantly higher viral loads were found in those with aam and encephalitis compared to patients with cranial nerve affection (including ramsay hunt syndrome). of the 50% (n = 50) who had a follow-up, 50% (n = 25) had neurological complications after 3 months. sixty-two percent had a ct/mri scan of the brain performed and 46% of these had pathological findings. vzv encephalitis showed a more broad disease spectrum as compared with herpes simplex encephalitis (hse), as will be presented. detection of intrathecal synthesis of vzv ge antibodies was positive in the vzv encephalitis patients, as well as in some of the hse patients, arguing for a previous suggested role for vzv as a co-pathogen at least in some cases of the latter disease. vzv vasculitis was a more common finding (6% of all cases) than expected from the literature of case reports. mr findings showed that middle and posterior cerebral arteries were targeted. surprisingly, despite substantial vzv dna loads in the csf of these patients, investigated serum samples were pcr negative. thus, vzv might be suggested to be neuronally transported to the arterial walls rather than haematogenously spread. conclusions: vzv is a serious and underestimated cause of cns infection. a substantial number of the patients presented with serious neurological symptoms and sequela, and pathological findings on ct/mri of the brain were abundant, especially in patients with encephalitis and vasculitis. pk/pd controversies for the clinician s190 pk/pd and azoles the triazoles have revolutionised the treatment of invasive and allergic fungal diseases. fluconazole, itraconazole, voriconazole and posaconazole are available for clinical use. isavuconazole and ravuconazole are in development. the triazoles have broad spectrum antifungal activity. the pharmacokinetics and pharmacodynamics (pk-pd) of the triazoles have been extensively investigated in murine models of disseminated candidiasis. the pd parameter that optimally links drug exposure with the observed antifungal effect is the ratio of the area under the concentration-time curve (auc) to mic (auc:mic). there is increasing information on the magnitude of the auc:mic that is required for optimal antifungal effect. pk-pd principles have been used to define in vitro susceptibility breakpoints. the triazoles are fungistatic against candida spp. their mode of action against aspergillus spp. is less well defined, although they clearly exhibit dose-dependant decrement in fungal burden in laboratory animal models of invasive pulmonary aspergillosis. the triazoles accumulate in tissues and this is important for an understanding of their antifungal effect. in humans, the triazoles are characterised by complicated pharmacokinetic properties. both itraconazole and voriconazole exhibit nonlinear pharmacokinetics. the triazoles all exhibit clinically relevant exposureresponse relationships. recent work from our laboratory suggests that itraconazole exhibits clinically relevant concentration-toxicity relationships. higher concentrations of voriconazole are associated with a progressively higher probability of hepatotoxicity, photopsia and central nervous system toxicity. because of the significant pharmacokinetic variability and clinically relevant drug exposure-response relationships, therapeutic drug monitoring (tdm) is frequently used. a strong argument can be made for the routine monitoring of itraconazole and voriconazole. there may also be grounds to consider monitoring posaconazole levels. tdm should be considered for all patients receiving triazoles who have refractory disease. furthermore, tdm should be considered when compliance, drug interactions and variable pharmacokinetics result in uncertainty about resultant drug exposures. an understanding of the pk-pd relationships of the triazoles has been instrumental in optimising their clinical efficacy. innate immunity s192 the inflammasomes: danger sensing complexes triggering innate immunity the nod-like receptors (nlr) are a family of intracellular sensors of microbial motifs and 'danger signals' that have emerged as being crucial components of the innate immune responses and inflammation. several nlrs (nalps and ipaf) form a caspase-1-activating multiprotein complex, termed inflammasome, that processes proinflammatory cytokines including il-1beta. amongst the various inflammasomes, the nalp3 inflammasome is particularly qualified to sense a plethora of diverse molecules, ranging from bacterial muramyldipeptide to monosodium urate crystals. the important role of the nalp3 inflammasome is emphasized by the identification of mutations in the nalp3 gene that are associated with a susceptibility to inflammatory disorders. these and other issues related to the inflammasome will be presented. it is now 20 years since charles janeway hypothesized the existence of clonally derived pattern recognition receptors and pointed to the importance of these in initial responses to bacterial and viral infections. janeway's hypothesis has been validated by the discovery of three groups of prrs. first, are the toll-like receptors which detect microbial lipids and non-self nucleic acids at the cell surface an in intracellular compartments. in addition cytoplasmic sensors of bacteria (nods) and of viral nucleic acids (rigs) have also been characterised. as well as being critical for responses to infections, these prrs also underlie a large burden of autoimmune and inflammatory disease in the human population and are thus important targets for therapy. in my talk i will describe the molecular mechanisms by which these conserved pathogen associated moecules are recognized by the tlrs with particular reference to lipo polysaccharide and single stranded viral rnas. i will also present new results which show how receptor activation is coupled to downstream signal transduction and in particular the role played by oligomeric signaling platforms assembled form adaptors and other signaling molecules involved in the pathway. i will discuss the potential for structural analysis to be used in the rational design of new drugs. this session proposes a critical review of the most salient recently published papers in the field with a special focus on control of multi drug-resistant organisms, prevention of infections in the intensive care unit, surgery etc. and highlights the need for validity/scope assessment. it emphasizes also the importance to prioritise information published in the abundant literature available so as to be able to summarise and understand the potential changes in clinical practice, and identify unresolved issues and areas of possible future clinical research. tourism is europe's face to the world. it is also a major source of revenue, employment and productivity. each year over 450 million arrivals are recorded into the continent, and of those, approximately 4 million are from latin america. returning travelers are even more numerous and more often associated with disease transmission into europe. within countries of the european continent, imported cases of environmental and zoonotic illnesses such as cholera, dengue, malaria, viral haemorrhagic fevers and west nile virus infections are a rare but established fact. diseases imported from latin america with the potential for autochthonous transmission (chikungunya, malaria, yellow fever) and or high infectivity (viral haemorrhagic fevers) will be described in detail and the possibility of european outbreaks from latin american countries will be discussed. cutaneous leishmaniasis (cl) is a worldwide disease, endemic in 88 countries, that has shown an increasing incidence over the last two decades. so far, pentavalent antimony compounds have been considered the treatment of choice, with rates of curing close to 85%. however, the high efficacy of these drugs is counteracted by their adverse events. recently, in vitro and in vivo studies have shown that no plays a key role in the eradication of the leishmania parasite objective: to determine whether a no donor patch (developed by electrospinning technique) is as effective as meglumine antimoniate in the treatment of cl while causing less adverse events methods: a double-blind, randomised, placebo-controlled clinical trial was conducted with 178 patients diagnosed with cl in santander, colombia, south-america. the patients were randomly assigned to two groups. during 20 days group 1 received simultaneously meglumine antimoniate and placebo of nitric oxide patches while group 2 received active nitric oxide patches and placebo of meglumine antimoniate. biochemical determinations (aspartate aminotransferase, alanine aminotransferase, creatinine and pancreatic amilase) were measured at he beginning and at the end of the treatment. a follow up was realised 21, 45 and 90 days after the beginning of the treatment results: the study included 69 (38.77%) women and 109 (61.23%) men. the average age in group 1 was 30.80±14.23 years; while in group 2 it was 27.88±13.79 years. clinical and demographic data were similar in the two groups. after the follow up period, the complete clinical healing of group 1 was 94.81% versus 37.14% for group 2 (p= 0.0001). treatment with no patches generated both, a lower frequency of non-serious adverse events (fever, anorexia, myalgia, arthralgia, headache), and a reduced variation in biochemistry determinations (asat 26 the treatment with no patches resulted in a lower percentage of complete clinical response compared with meglumine antimoniate. despite its inferior effectiveness, the safety, the lower frequency of adverse events, the facility of administration (topical) and the low cost of the patches justifies its evaluation in further poblational studies, especially in populations as the colombian ones, where the serious adverse events due to glucantime have increased dramatically. objectives: trichinellosis is a zoonotic disease which has never been reported in taiwan and is rarely linked to consumption of reptiles. we investigated the first documented outbreak of trichinellosis in taiwan consisting of 8 patients who became acutely ill after eating at the same restaurant in may 2008. we conducted a retrospective cohort study by interviewing the patients and persons who ate together with them. a case was defined as illness in an attendee who had fever (>38.0ºc) or myalgia 4 weeks after the festivals and was seropositive to trichinella antigen using an enzymelinked immunoassay and immunohistochemical staining. environmental study of the soft-shelled turtle farm was performed. results: of the 23 attendees, 8 persons met the case definition (attack rate = 35%). the most common presenting symptoms were myalgia (88%), fever (88%), and periorbital swelling (38%). all 8 patients sought medical care; five were hospitalised. of the 7 patients who underwent blood test, all had moderate eosinophilia. all 8 patients' serum samples were strongly reactive to trichinella excretory-secretory antigen. the only food item significantly associated with illness was the raw softshelled turtle meat (relative risk undefined; p = 0.005). traced back to the farm, histological examination of soft-shelled turtles was negative for trichinella species. the most likely cause of this outbreak was consumption of raw soft-shelled turtle served in the festivals. this investigation indicates taiwan is not free of trichinellosis. prevention and control programs of trichinellosis should be established. the public should be aware of the risk of acquiring trichinellosis from consumption of raw soft-shelled turtle. objective: to develop and evaluate a modified, rapid giemsa staining procedure for detection of malaria parasites in blood smears. disadvantage of the rapid commercially available staining methods is that they require highly experienced technicians for interpretation of results because the interpretation can be difficult. for this reason, many laboratories use the giemsa stain. shorter giemsa staining times have been reported previously, however, to our knowledge, the effect of 5 and 10 minute staining in different giemsa dilutions have not been evaluated. the stock solution of giemsa stain (merck, darmstadt, germany) was used in different dilutions (1:10 and 1:5) and incubated for different lengths of time (10 min and 5 min). the staining effect was compared to our standard giemsa stain (1:40, 45 min). sensitivity was determined by examining smears of p. falciparum from fresh and edta blood. the level of parasitaemia was followed in two patients admitted to our hospital with p. falciparum parasitaemia's of 21.5% and 28.8% (see table; patient a and b) by examination of blood smears taken at different time points after initiation of therapy. these samples were used to evaluate the different giemsa dilutions and staining times. smears were read by three independent observers (a clinical microbiologist, a laboratory technician specialised in parasitology, and a resident in clinical microbiology). in the table results of the three staining methods on blood from two patients from ghana with high parasitaemia's on admission and during follow-up are shown. all smears were equally easy to read and yielded parasite counts within internationally accepted ranges of variation (see united kingdom national external quality assessment service). conclusion: staining blood smears for detection of plasmodium falciparum parasites with a 1:5 dilution of giemsa stain for five minutes provides easy to read slides and results comparable to those obtained with the standard giemsa staining. advantage of the rapid method is the shorter turnaround time, disadvantage is the larger amount of stain used. objectives: diarrhoeal diseases are common in developed and developing countries and are major causes of morbidity and mortality worldwide. the need to differentially diagnose protozoan parasites versus other gastrointestinal (gi) aetiologies is well recognized. the most common gi protozoan parasites infecting humans worldwide are considered to be entamoeba histolytica, giardia lamblia, blastocystis hominis, dientamoeba fragilis and cryptosporidium spp. laboratory detection of these parasites is relying on microscopic analysis of stool samples and water concentrates, as well as enzyme immunoassay (eia) tests. utilising the microscopic examination usually results in underdetection of gi parasites, while usage of eia is often not cost-effective. methods: savyon diagnostics is currently engaged with developing an approach aiming to address the unmet needs and the current limitations in this field. this approach includes 3 major aspects: (1) the ability to detect a panel of all the above 5 organisms in one test kit, (2) the possibility to perform the diagnosis in two steps − first, simultaneous detection of these organisms without distinguishing between the different species for screening of large number of specimens, and second, distinctive detection of the specific aetiology in the positively-found specimens, and (3) the ability to apply eia diagnosis in formalin-preserved specimens for all the mentioned parasites. results: polyclonal antibodies were produced in-house based on native antigen extracts, recombinant antigens and synthetic peptides. the resulted inventory of antibodies enabled finding the optimal combination that provided the desired performance parameters for separate detection of each of the parasites in fresh, frozen or formalin preserved faeces specimens. the analytical limit of detection and the performance in characterised clinical specimens were comparable to microscopy or to reference eia, when available. the results show unique detection of e. histolytica in formalin-preserved specimens, which is comparable to detection in fresh specimens. furthermore, we demonstrate simultaneous detection of the parasites without compromising performance characteristics in fresh or preserved specimens. the presented work is a paradigm of an innovative approach, expected to advance the diagnosis of protozoan parasites in gi patients, thus, enabling appropriate and cost-effective diagnosis and treatment. objectives: systemic administration of certain facultative anaerob bacteria to mice bearing solid tumours leads to accumulation in tumours compared to normal target organs, like spleen and liver, and to retardation of tumour growth. salmonella enterica serovar typhimurium (s. typhimurium) as well as escherichia coli 1917 nissle (ecn) are such bacteria. preliminary experiments showed that such bacteria that exhibit the ability to form biofilms in vitro might also do so in tumours. in the present study this was systematically investigated. methods: biofilm formation of bacteria were detected on low-salt biofilm plates. additionally, salmonella-or e. coli-infected ct26tumours of balb/c mice that were left untreated or were treated with anti-gr1 to deplete neutrophilic granulocytes were removed two days post infection, fixed and prepared for electron microscope analysis. the expression of different genes which are probably involved in the biofilm formation were tested via real-time pcr. results: when examined after colonising tumours s. typhimurium sl7207 and sl1344 as well as ecn are almost exclusively found extracellular although they are able to invade the ct26 cells in vitro. interestingly, like in vitro all three bacteria form biofilms to various extend when residing in the tumours. this was followed in more detail for s. typhimurium sl7207. biofilms were not formed by sl7207 when neutrophils had been removed by antibodies. in addition, when arda a central switch for biofilm formation in the salmonellla had been deleted no biofilms could be found. importantly, now bacteria could be found intracellularly most likely in neutrophilic granulocytes. conclusion: the formation of biofilms by facultative anaerobic bacteria when residing in solid tumours is a novel and surprising finding. when neutrophils were removed, no biofilms are formed, while uptake into neutrophils is allowed when the ability of the bacteria to form biofilms was blocked. hence, it appears that the bacteria use biofilm formation as a defence system against the immune system of the host. objectives: rama is an arac/xyls family transcriptional activator found in klebsiella pneumoniae, salmonella spp. and enterobacter spp., the overexpression of which is associated with an mdr phenotype. recently a tetr-like gene that lies upstream of rama, known as ramr, has been identified as a repressor of rama. k. pneumoniae kp342 is a diazotrophic endophyte strain which has been reported to exhibit notable resistance to antibiotics. despite its mdr phenotype kp342 has been shown to exhibit attenuated pathogenicity in mouse models in comparison to clinical k. pneumoniae strains. the aims of this study were to: determine the levels of rama expression and establish its role in kp342's mdr phenotype; determine the effect of ramr complementation on rama expression and antibiotic susceptibility. methods: genome and sequence analysis performed in k. pneumoniae strain kp342 demonstrated a 96 bp deletion within the ramr gene. cloning and complementation with full size wild type ramr was performed in kp342 (hereby known as kp342/ramr). rt-pcr was used to assess levels of gene expression which were subsequently quantified using bio-rad quantity one software. mic testing was performed against chloramphenicol (cm), norfloxacin (nor) and tetracycline (tet) according to bsac guidelines. biofilm formation was measured using a modified protocol of o'toole and kolter. results: kp342 containing the mutated ramr gene (96 bp deletion) was shown to overexpress rama and the putative outer membrane protein roma. complementation of the ramr gene resulted in the repression of both rama and roma transcription by 3−4 fold. interestingly, the ramr complemented strain demonstrated increased biofilm formation (up to 9-fold increase) over a 72 hour period in both lb and m9 medium after static growth at 37ºc. mics of the tested antibiotics were reduced up to 16-fold in kp342/ramr compared to the ramr mutated kp342. conclusions: this result demonstrates that ramr acts as a repressor of both rama and putative outer membrane protein roma thereby increasing its susceptibility to antibiotics. however the restoration of a functional ramr in kp342 also increases biofilm formation significantly, suggesting that ramr plays a role in the regulation of biofilm formation genes and possibly bacterial virulence. rifampicin showed the highest activity on biofilm matrix and bacteria in sa and pa biofilms. results also indicated that biofilm viable mass was more susceptible to treatment than the biofilm matrix, which is mainly responsible for biofilm persistence. further research should specifically focus on compounds destroying matrix and which can be used as an adjunct to antibiotic therapy. [ objectives: staphylococcus epidermidis is a common cause of foreignbody infections (fbi) because of its ability to form biofilms. biofilms are very resistant to antibiotics. active and passive immunisation against biofilm-associated bacterial antigens may be an alternative. we studied the effect of immunisation against the lpxtg protein sesc in s. epidermidis biofilms in vitro and in vivo. we previously reported that sesc is present in all s. epidermidis strains tested. sesc is mainly expressed during the early and late fbi and at a higher level in sessile cells than in planktonic cells. methods: we used rabbit polyclonal anti-sesc-iggs (4 mg/ml) to study biofilm inhibition in vitro and in vivo in our rat model (50 mg igg per rat) on 1-day old biofilms. we also vaccinated rats twice with sesc according to standard protocols. serum samples taken at day 0 and 2 weeks after the 1st and 2nd immunisation were tested by elisa and showed an increase in anti-sesc antibody levels. s. epidermidis strains 10b and 1457 are biofilm forming strains and have been described before. for in vitro experiments, s. epidermidis 10b or 1457 were mixed with anti-sesc-iggs and incubated for 2 hours at 4ºc. subsequently 10 6 cells were added to each well. after 24 h at 37ºc biofilms were washed and stained with crystal violet and od595 was measured. for in vivo experiments, catheter fragments were pre-incubated with s. epidermidis 10b and implanted subcutaneously in each rat. after explantation, the average number of cfu was determined after 24 hrs. results: our data show that rabbit anti-sesc-iggs inhibit in vitro biofilm formation by s. epidermidis strains 10b and 1457 by 74% and 65%, respectively (n = 9). in the in vivo rat model, rabbit anti-sesc-iggs reduced the bacteria in a 1-day old biofilm 60-fold (n = 18). active immunisation with recombinant sesc led to a 10-fold reduction of cfu compared to control rats in 1 day-old biofilms (n = 10). after 3 days, the reduction in biofilm-associated bacteria in the immunised rats was 15-fold (n = 10) (fig 1.) . conclusion: sesc represents a promising target for prevention of s. epidermidis biofilm formation. the higher effect of passive immunisation compared with active immunisation is probably due to the subcutaneous injection of anti-sesc-iggs at the place of catheter insertion. objectives: staphylococcus epidermidis has emerged as a pathogen associated with infections of implanted medical devices impeding their long-term use. characteristics of s. epidermidis that allow persistence of infection are the ability of bacteria to adhere to surfaces in multilayered cell clusters, followed by the production of a mucoid substance more commonly known as slime, encoded by the ica operon. the adherent bacteria and slime are collectively known as biofilm. the coupled effects of specific chemical terminal surface groups and flow conditions on slime production and biofilm formation by s. epidermidis were investigated in correlation to the expression of two genes of the ica operon. methods: reference control strains (atcc35984, slime-positive and atcc12228, slime-negative), and two clinical strains isolated from different hospitalised patients, (one ica-positive/slime-positive and one ica-positive/slime-negative) were tested. bacteria grown in bhi medium were suspended in physiological saline at a concentration of~3×10 9 cells/ml. hydroxyl (oh)-terminated (hydrophilic) and methyl (ch3)terminated (hydrophobic) glass surfaces were used as substrates in a parallel plate flow chamber. bacterial adhesion was examined under two flow rates: 2 ml/min and 20 ml/min for two and four hours. total rna from both planktonic (p) and adherent (a) bacteria, after detachment with trypsin, was isolated by the trizol method. reverse transcription followed by relative real-time pcr (rrt-pcr) towards a 207 bp part of 23s rrna gene, allowed the detection of expression levels of icaa and icad. adherent bacteria were investigated with scanning electron and confocal laser microscopes. results: higher expression levels of both icaa and icad genes onto glass and especially methyl-terminated glass surfaces were calculated by rrt-pcr, under higher flow rate in two hours by the reference and the clinical slime-positive strains. these results correlate well with adherent bacterial cell counts and images taken by both microscopes. the icapositive slime-negative clinical strain showed lower expression levels of ica genes, less adherent ability and pia production on glass surfaces, as observed by microscopes. higher flow rate enhances the expression level of both ica genes, with a peak in two hours. hydrophobic biomaterial surfaces seem to play a crucial role to initial adherence, increasing ica gene expression and pia synthesis. consenting men and women with dfi (predefined by clinical signs and symptoms) caused by mrsa were potentially eligible including those associated with bacteraemia. patients with initial osteomyelitis were excluded. patients could receive l 600 mg bid either iv or po. primary end point were cure or improvement rates (c+i) and microbiologic eradication (me) at 60 days after the beginning of l. secondary end points were c+i on days 5 and 30 after the beginning of treatment and hospital discharge day, need of amputation, duration of therapy and mortality rates. all the adverse events were collected. results: 70 patients were enrolled. relation men:women was 2.1.the age of patients was 63.2±13 years and the average period from the diagnosis of diabetes was 16.5±9.7 years. associated bacteraemia was present in 27.1% of patients included. primary end points: c+i 60 days after the beginning of l was achieved in 91.4% of patients and me was obtained in 84.3% of patients. secondary end points: c+i on day 5, hospital discharge day and day 30 after the beginning of treatment and were; 70%; 84.3% and 88.6% respectively. only 8 patients needed a minor amputation. the primary and secondary end points in the subgroup of bacteraemic episodes were not statistically different of those previously described. the mean duration of therapy was 29.5±18.4 days. global mortality was 4.3%. only one episode of polineuropathy was reported. neither thrombocytopenia nor lactic acidosis was found. conclusions: l achieved excellent c+i even at first evaluation visit in documented dfi caused by mrsa. l also showed high me rates. although patients received prolonged periods of treatment, l was a safe drug. objectives: azithromycin microspheres formulation (azm) was developed to enable a higher dosage of 2 g to be administered as a single oral dose without decreasing the safety profile. this study compared azm with moxifloxacin (mox) aimed at confirming the efficacy and safety of azm in acute exacerbations of chronic bronchitis (aecb). methods: this prospective, multicentre, randomised, double-blind, double dummy study compared azm 2 g single dose with mox 400 mg once daily for 5 days, enrolled aecb patients 50 years old and above, with anthonisen type 1 exacerbations, and with at least 2 exacerbations of aecb in the past 12 months. subjects were to have a history of smoking of at least 20 pack-years and documented forced expiratory volume in 1 second (fev1) less than 80% of predicted. they were followed up for up to 9 months. results: a total of 396 patients were treated (198 in each of the treatment groups) the distribution of the age, and mean fev1 were similar for the 2 treatment groups. pathogens were isolated from 62.9% of the patients (61.1% of patients on azm and 62.9% of patients on mox). the clinical success (signs and symptoms related to the acute infection had returned to the subject's normal baseline level, or clinical improvement was such that no additional antibiotics were deemed necessary) rate for the per protocol population at test of cure (toc) at day 12−19 was 93.0% for azm and 94.2% for mox group (95% ci −5.8, 3.9). bacterial eradication rate (bacteriologic pre protocol population) at toc was 96.0% for azm group and 96.7% for mox group (95% ci −4.5, 3.3). although the study population had history of at least 2 exacerbation in the past 12 months, less than half of the subjects experienced a recurrence during the follow-up, and there was no statistically significant treatment difference in time taken to first occurrence of aecb. both treatments were well tolerated. the incidence of treatment related adverse events was low, being reported by 17% of subjects receiving azm and 12% of subjects receiving mox. most aes were mild or moderate in severity. the most common aes were gastrointestinal disorders, being reported by 14% of subjects receiving azm and 8% of subjects receiving mox. conclusions: a single oral dose of azm was as effective as a 5-day course of mox in the treatment of aecb and was well tolerated. objectives: optimal duration of gentamicin containing regimen for therapy of human brucellosis is not clearly determined. methods: this randomised clinical study was conducted to compare the efficacy of gentamicin 5 mg/day for 5 days plus doxycycline 100 mg twice daily for eight weeks (gd group) versus streptomycin 1gr im for 2 weeks plus the same dose of doxycycline for 45 days (sd group). all cases were followed for one year after cessation of therapy. efficacy of both regimens (failure of therapy or relapse) were compared. results: seventy-nine patients with the mean age of 35±14.5 years and 75 cases with the mean age of 36.7±13.9 years were treated with regimen of gd or sd, respectively. the clinical manifestations in these two treated groups were similar. failure of therapy was seen in one patient in gd group and in 2 cases in sd group ( objectives: to study the efficacy of telavancin (tlv), an investigational bactericidal lipoglycopeptide, for the treatment of complicated skin and soft tissue infections (cssti) caused by presumed or confirmed grampositive organisms. methods: atlas 1 and atlas 2 were methodologically identical, double-blind, randomised, multinational, phase 3 studies. adult men and women presenting with cssti including major abscess were randomised 1:1 to tlv 10 mg/kg intravenous (iv) q24 h or vancomycin (van) 1 g iv q12 h for 7 to 14 days. test-of-cure (toc) visit was conducted 7 to 14 days after end of study treatment. the all-treated population (at) included patients with confirmed diagnosis of cssti who received 1 dose of study medication. this analysis examined the baseline characteristics and cure rates at toc for patients with major abscess in the combined atlas at population. results: in the pooled at population of atlas, 772 patients presented with major abscess. more than 60% of these patients required hospitalisation. the baseline lesion surface area exceeded 5 cm 2 in 98% of the cases, while 65% of the patients presented with lesions exceeding 50 cm 2 (table 1) . elevated white blood cell counts were found in more than 40% of the cases (table 1) . nearly all patients required surgical drainage, with approximately 2/3 performed prior to the first dose of study medication. very few patients required a surgical procedure more than 4 days after the start of study medication. clinical cure rates at toc are presented in table 1 . overall, adverse events in the at population were similar between the treatment groups with regard to type and severity. conclusion: telavancin administered once daily was non-inferior to vancomycin for the treatment of major abscess. objectives: b. fragilis and related species, members of the normal bowel flora, are the most widely isolated anaerobic bacteria from different infections. to follow the development and spread of the resistance among these strains is difficult, as antibiotic susceptibility testing of clinically relevant anaerobes in different routine laboratories in europe is less and less frequently carried out due to the fact, that clinicians treat many presumed anaerobic infections empirically. to follow the changes in the antibiotic resistance of bacteroides strains three europe-wide studies were organised during the past twenty years. the evaluation of the results of these studies may show changes in the resistance to different antianaerobic drugs. only clinical isolates and no normal flora members of bacteroides strains belonging to different species were collected from different countries throughout europe during these studies. agar dilution method was used for the antibiotic susceptibility determination. actual breakpoints accepted by nccls (clsi) and eucast were used. molecular genetic investigations were carried out to detect resistance mechanisms. since the first study the chromosomally mediated beta-lactamase production and tetracyclin resistance is the most prevalent among bacteroides strains in europe. clindamycin resistance in bacteroides is mediated by a macrolide-lincomycin-streptogramin (mls) mechanism and its frequency differs in different countries in europe. resistance to beta-lactam-beta-lactamase inhibitor combinations was studied using amoxicillin-clavulanic acid and/or piperacillintazobactam. increase in resistance was observed to both combinations throughout the years. the same is true for cefoxitine and in the third study several hetero-resistant isolates were found. the occurrence and spread of resistance to imipenem and metronidazole among bacteroides strains merit special clinical importance. the presence of the cfia gene is much more prevalent than the expression of the imipenem resistance; however the spread of the cfia gene among species other than b. fragilis is still very rare. the molecular genetic methods looking for the resistance genes among strains with elevated mics against these antibiotics prove that resistance breakpoints should be reconsidered. the resistance to moxifloxacin shows great differences in different countries. the lowest resistance rate was observed in the case of tigecyclin. many factors may affect the response to treatment such as site of infection, surgical procedures, severity of the illness, patient status, presence of other pathogens (mixed infection), pk/pd parameters of the antibacterial drugs. thus, correlation between treatment failure and antibiotic resistance among anaerobes remains difficult to assess. the main discrepancies came from intra-abdominal infections and a worrisome disjunction between surgeon and microbiologist opinions emerged in the 1990's. but, patients in whom primary therapy failed had more resistant strains compared with patients in whom therapy succeeded. in contrast many failures may be due to the lack of isolation of anaerobes from clinical samples! during anaerobic bacteraemia, salonen et al. demonstrated that mortality increased dramatically from 17% for initially effective treatment to 55% when an ineffective treatment was started. facing new mechanisms of resistance and global increase resistance to many antibiotics among anaerobes may lead nowadays to a different answer. clindamycin vs. penicillin studies for the treatment of lung infections pointed out the failure due to b-lactamase production among gram-negative anaerobes. we found many reports of failure after clindamycin treatment in osteomyelitis, septic arthritis, brain abscess in presence of clindamycin-resistant anaerobes (bacteroides fragilis group and prevotella), probably because when resistance occurs, clindamycin mic's are high. similarly, the lack of coverage of an undetected resistant anaerobe allows the selection of an anaerobic strain resistant to the treatment chosen against the associated aerobes such as imipenemresistant eghertella lenta or metronidazole-resistant strains of prevotella or bacteroides fragilis. the later failures may give opportunity to set up a new metronidazole breakpoint for resistance (mic > 4 mg/l). the main problem is related to the difficulty to detect some heterogeneous resistant strains, that needs prolonged incubation period on agar medium. this kind of situation is probably the most suitable to correlate the bacterial antibiotic resistance with the failure of the antibiotic treatment. methicillin-resistant s. aureus isolates causing community-acquired infections (ca-mrsa) in children is a major problem in several areas around the world. ca-mrsa are associated with both skin and soft tissue infections and invasive infections. recurrent soft tissue infections and infections within the family caused by ca-mrsa isolates are common. ca-mrsa s. aureus isolates containing gene coding for pvl have been associated with serious staphylococcal pneumonia as well as osteomyelitis complicated by subperiosteal abscesses or venous thromboses. in addition to vancomycin, ca-mrsa generally are susceptible to clindamycin and trimethoprimsulfamethoxazole. treatment of superficial skin and soft tissue infections involves surgical drainage of abscesses followed by an oral agent such as tmp-smx or clindamycin. minocycline or doxycycline is a consideration for children >8 years old. empiric vancomycin is typically administered for more serious and invasive infections such as osteomyelitis, septic arthritis, serious head and neck infections or suspected staphylococcal pneumonia. clindamycin is efficacious in treating invasive ca-mrsa infections caused by susceptible organisms. linezolid or daptomycin is another option in selected circumstances. mri is the optimal imaging modality for assessing children with ca-mrsa osteomyelitis. aggressive surgical drainage of subperiosteal abscesses or sites of pyomyositis is recommended. venous thombosis is increasingly recognized as a complication of ca-mrsa osteomyelitis. anti-coagulation until the thrombus has resolved is recommended. the optimal approach to prevention of recurrent ca-mrsa infections is unclear but a strategy that includes emphasizing personal hygiene, plus/minus antimicrobial soaps, mupirocin to the nose or "bleach baths" is frequently suggested. s226 understanding the pathogenesis of group a streptococcal disease: the bedside-to-bench approach invasive group a streptococcal (gas) infection presents itself in a range of guises, most notoriously necrotising fasciitis and the streptococcal toxic shock syndrome. as a human pathogen, gas pathogenesis research should ideally be shaped by clinical questions arising from either epidemiological or case-based investigation of human disease. in the mid 1990 s, large epidemiological studies pointed to a central role for specific t cell-stimulating superantigens in the aetiology of streptococcal toxic shock. this sparked a series of clinical and laboratory investigations that demonstrated production of superantigens during infection which were indeed capable of triggering massive t cell activation in patients but were unlikely, alone, to account for all the features observed in toxic shock. genomic, clinical and laboratory-based investigations have identified novel and highly potent superantigens that appear to directly contribute to sepsis pathogenesis and, together, may constitute targets for adjunctive treatments in invasive disease. epidemiological, clinical, and laboratory studies have highlighted a role for blunt trauma in the aetiology of at least a quarter of cases of gas necrotising fasciitis. one of the most striking findings on examination of tissues from patients suffering with necrotising fasciitis is the failure of neutrophils to migrate to the focus of infection. investigation of patients with invasive gas infection led to the discovery that gas produces an enzyme that can cleave and inactivate human chemokines and study of patients with bacteraemia has highlighted a likely role for the causal enzyme spycep in disease pathogenesis; this bacterial surface enzyme has also shown promise as a potential vaccine antigen. notwithstanding a potential role for individual virulence factors in disease causation, clinical studies have demonstrated that gas bacteria may persist at the site of infection despite high concentrations of bactericidal antibiotics, and this has been borne out by experimental studies; the reasons behind such persistence are unclear but may include internalisation of gas by immune cells, formation of biofilm, and antibiotic penetration of necrotic tissues. the persistence of viable bacteria in such cases is not widely recognized and deserves focused consideration in the research laboratory. genome-wide analysis of microbial pathogens and molecular pathogenesis processes has become an area of considerable activity in the last 10 years. these studies have been made possible by several advances, including completion of the human genome sequence, publication of genome sequences for many human pathogens, development of microarray technology and high-throughput proteomics, and maturation of bioinformatics. despite these advances, relatively little effort has been expended in the bacterial pathogenesis arena to develop and use integrated research platforms in a systems biology approach to enhance our understanding of disease processes. we have exploited an integrated genome-wide research platform to gain new knowledge about how the human bacterial pathogen group a streptococcus causes disease. results of these studies have provided many new avenues for basic pathogenesis research and translational research focused on development of an efficacious human vaccine and novel therapeutics. new data stemming from use of a systems biology approach to provide new data about group a streptococcus pathogenesis will be presented. streptococcal toxic shock syndrome and necrotising fasciitis caused by group a streptococcus are rapidly progressive invasive diseases that are associated with significant morbidity and mortality, ranging from 30−80% despite prompt antibiotic therapy and surgical debridement. s. pyogenes is known to primarily cause disease by activating and modulating host immune responses. the exotoxins with superantigenic activities have been demonstrated to be crucial triggers of excessive inflammatory responses and consequently systemic toxicity, organ dysfunction, tissue necrosis and shock. another important virulence determinant is the m-protein, which is classically known for its antiphagocytic properties, and lately, was shown to trigger pro-inflammatory responses as well as induction of vascular leakage and shock. this likely represents important mechanisms contributing to the rapid development of shock and systemic toxicity in patients with severe invasive group a streptococcal infections. the understanding of these infections as hyperinflammatory diseases highlighted the potential of immunotherapy to improve outcome. one such strategy includes the administration of intravenous polyspecific immunoglobulin (ivig) as adjunctive therapy. the mechanistic actions of ivig in this setting are believed to include opsonisation of the bacteria, neutralisation of the superantigens and suppression of the pro-inflammatory responses. there is growing evidence to support the use of ivig in patients with streptococcal toxic shock syndrome. these studies include one observational cohort study based on canadian patients identified through active surveillance of invasive group a streptococcal infections, and one european multicentre placebo-controlled trial. however, the question remains whether ivig is efficacious also for the severe streptococcal deep tissue infections. an observational study of seven patients with severe streptococcal deep tissue infections suggested that the use of high-dose ivig in patients with severe gas soft tissue infections may allow an initial non-operative or minimally invasive approach, which can limit the need to perform immediate wide debridements and amputations in unstable patients. the fact that seven patients with severe group a streptococcal infections survived with this approach definitely warrants further studies to be conducted on the use of ivig in these severe infections. hepatitis o229 prevalence and outcome of pregnancy in chronic hepatitis c virus infection i. julkunen°, a. sariola, m. sillanpää, k. melen, p. koskela, p. finne, a.l. järvenpää, s. riikonen, h.m. surcel (helsinki, oulu, fi) objectives: in the western countries the incidence of hepatitis c virus (hcv) infection has steadily been increasing especially among young adults. it is thus likely that an increasing prevalence of hcv infection is also found in pregnant women. methods: to assess the frequency of hcv infection in the metropolitan area of helsinki selected anti-hcv antibody testing was carried out for pregnant women during the years 1991-1999. in addition, hcv prevalence was analysed in serum specimens collected from pregnant maters during the years of 1985-2005. results: altogether 145 mothers were identified among 44680 mothers. the frequency of anti-hcv positivity rose from 0.13% in 1991 to 0.43−0.53 in 1997-1999. in early 90's only 20% of mothers knew about their seropositivity, whereas by the end of the follow-up period almost 70% of mothers knew about their hcv infection already before the pregnancy. intravenous drug abuse was the major risk factor (71% of cases) for contracting the disease. in 90% of the mothers chronic hcv infection was well under control and in this population the mean serum alanine aminotransferase (alt) values decreased towards the end of the pregnancy. however, 10% of anti-hcv ab positive mothers developed intrahepatic cholestasis (odds ratio 16.4) as characterised by itching and elevated serum bile acid levels. the correspondig value in the control pregnancies was only 0.7%. anti-hcv ab positive mothers were younger, delivered earlier and gave birth to babies with smaller birth weight as compared to control deliveries. to have a more comprehensive view of the problem of hcv infection during pregnancy randomly selected serum specimens from the finnish maternity cohort were tested. 2000-5000 serum specimens were tested in selected cohorts (1985, 1990, 1995, 2000 and 2005) . in 1985 the nationwide prevalence was 0.19% and it steadily role to 0.50% in 2005. in the metropolitan area of helsinki the prevalence was higher being 0.68% and 0.70 in 1997 and 2002, respectively. conclusion: our study indicates that there is an increasing problem of hcv infection in pregnant women in finland. although most women cope well with their disease during pregnancy there is a subpopulation of mothers who develop cholestasis and their liver status should thus be followed-up carefully. testing of all mothers for serum anti-hcv antibodies is recommended. objectives: the viral genome of hepatitis c virus constitutes a 9.6kb single-stranded positive-sense rna which encodes altogether 11 viral proteins. in order to study the humoral immune responses against different hcv proteins in patients suffering from chronic hcv infection, we produced three structural (c, e1 and e2) and six nonstructural proteins (ns2, ns3, ns4a, ns4b, ns5a and ns5b) in sf9 insect cells by using the baculovirus expression system. the recombinant hcv proteins were purified and used in western blot analysis to determine antibody responses against individual hcv protein in 68 hcv rna and antibody positive human sera that were obtained from patients suffering from genotype 1, 2, 3 or 4 infection. results: these sera were also analysed with inno-lia score test for hcv antibodies against core, ns3, ns4ab and ns5a, and the results were similar to our western blot method. based on our western blot analyses we found that the major viral antigens were the core, ns4b, ns3 and ns5a proteins and they were recognized in 97%, 86%, 68% and 53% of patient sera, respectively. there were no major genotype specific differences in antibody responses to individual hcv proteins. a common feature within the studied sera was that all except two sera recognized the core protein in high titers, whereas none of the sera recognized ns2 protein and only three sera (from genotype 3) recognised ns5b. the data shows significant variation in the specificity in humoral immunity in chronic hcv patients. anti-hcv antibody pattern also remains very stable within one individual. alt and ast levels were tested in all subjects. the presence of hbv-dna was determined quantitatively in plasma samples of hd patients with anti-hbc alone (hbsag negative, anti-hbs negative and anti-hbc positive) by real-time pcr using the artus hbv rg pcr kit on the rotor-gene 3000 real-time thermal cycler. results: of 289 patients enrolled in this study, 18 subjects (6.2%, 95% ci, 3.5%-8.9%) had anti-hbc alone. hbv-dna was detectable in 9 of 18 hd patients (50%, 95% ci, 27%-73%) with anti-hbc alone. plasma hbv-dna load was less than 50 iu/ml in all of these patients. our study showed that detection of anti-hbc alone could reflect unrecognized occult hbv infection in hd patients. the majority of these infections are associated with low viral loads. were included in the study. all the subjects had never been exposed to antiretroviral therapy. genotypic resistance testing was performed at the time of diagnosis with a sequence-based assay (trugene hiv-1 genotyping test) targeted at the protease region (codons 1 to 99) and rt region (codon 40 to 247) of the hiv-l genome. results: 21 of 218 patients (9.63%) harboured a virus with at least one mutation associated with phenotypic resistance; 1/218 with mutations associated with resistance to nucleoside reverse-transcriptase inhibitors (nrtis), 17/218 to non-nucleoside reverse-transcriptase inhibitors (nnrtis) and 3/218 to protease inhibitors (pi). resistance to nrtis was associated with the key mutation m184v, while resistance to nnrtis was associated with y181c and k103n mutations. among mutations to pi, major resistance mutations l90m and d30n were found in three patients, whereas there was a high prevalence of accessory pi resistance mutations at positions 10, 20, 36 and 63. conclusion: our data estimate the prevalence of primary resistance and mutations patterns among naive hiv patients, underlining the importance of genotypic resistance testing in hiv patients before starting treatment, especially when nnrtis would be included in the initial antiretroviral therapy. objectives: few data are available on the genetic mechanisms of protease inhibitor (pi) resistance in non-b hiv-1, and pi resistanceassociated mutations (rams) are commonly observed in pi-naive patients with subtype a/e infection. this study aimed to compare pi-rams between pi-naive and -experienced patients. methods: genotypic resistance testing was conducted among a cohort of hiv-1 infected patients who had virologic failure. patients were categorised into 2 groups: pi-naive and pi-experienced. we focused on pi-rams previously described by ias-usa 2008. results: we studied 137 patients (mean age, 41.8 years; 64% male). median cd4 cell count and hiv-1 rna at virologic failure were 169 cells/cu.mm. and 14100 copies/ml, respectively. 85% of patients were infected with subtype a/e; the others had subtype b (12%), ab (2%), and c (1%). there were 75 patients in pi-naive group and 62 patients in pi-experienced group. the clinical characteristics between 2 groups were similar (p > 0.05) except for the duration of antiretroviral therapy which was shorter in pi-naive group (31.5 vs. 46.8 months, p = 0.028). percentage of patients who had primary pi-rams was 1% in pinaive and 19% in pi-experienced groups (p = 0.001). the most common primary pi-rams in the latter group were v82a (10%) and i54v (7%). percentage of patients with secondary pi-rams in the corresponding groups was 99% and 98%, respectively (p = 1.000). median number of secondary pi-rams was also similar between 2 groups (p = 0.244). the most common secondary pi-rams in both groups were m36i (91%), h69k (34%), l89m (30%), i13v (26%), l63p (25%), l10i we also defined a "silent score" (ss) and a "resistance score" (rs) as the number of synonymous mutations and of resistance mutations (in the second sequence in comparison with the first one) divided by number of days between the two tests, respectively. (12); pts with drms in non-b-st (%) were 7 (23.3), 6 (14), 5 (7) and 3 (4.2). a significant increase of non-b-st (p = 0.021) and a significant decrease in drms (p < 0.001) were observed. crf02_ag was the prevalent non-b st (44%). 35.3% of non-b st pts were italians. among b-st, drms predicted a reduced susceptibility to one drug class in 23, 17, 15 and 14 cases in the different periods; to two drug classes in 4, 6, 5 and 8; to three classes in 3, 2, 0 and 0. in non-b-st, a reduced susceptibility to one drug class was found in 6, 6, 4 and 0 cases; to two drug classes in 1, 0, 0 and 2; to three drug classes in 0, 0, 1 and 1, respectively. among pts with one or two classes of resistance, a decrease of percentage of protease inhibitors related drms, and a persistence of non nucleoside rt inhibitors involving drms, mainly 103n and 190a, were observed. methods: from hiv+ persons with a history of, or an acute episode of opc, oral fungal burden was evaluated bi-weekly and buccal mucosa tissue was collected bimonthly for a period of one year. tissue was evaluated for the presence of cd8+ t cells and e-cadherin by immunohistochemistry or flow cytometry. objectives: to define the secular trends in the epidemiology of candidaemia in queensland, australia (population, 4.1 million) over a 10-year period. methods: all episodes of candidaemia within queensland public hospitals from 1999-2008 were identified from laboratory information systems. data on species identification, antifungal susceptibility, demographics, and hospital ward of diagnosis, and denominator data (hospital admissions, accrued patient-days (pt-days) and fluconazole usage) were collected. results: over the 10-year period, 1137 unique episodes (100% case ascertainment) were identified from 42 healthcare facilities (8 tertiary, 2 paediatric, 11 secondary and 21 smaller hospitals). the median patient age was 56.4 years. the overall incidence-density was 0.45/10000 ptdays, highest in paediatric (1.28/10000 pt-days) and tertiary hospitals (0.62/10000 pt-days). over the 10 years, the incidence-density increased 3.2-fold in tertiary hospitals and 6.6-fold in secondary hospitals (both p < 0.0001 for trend), but not in paediatric or smaller hospitals. the incidence-density in icus (5.2/10000 pt-days) was 10-fold higher than in non-icu wards, but did not significantly increase over the study period. the relative proportion of episodes occurring in adult general medical/surgical (ie non-oncology/non-icu) wards significantly increased (p < 0.001), accounting for 62% of episodes at the end of the 10-year period, whereas that occurring in paediatric and adult oncology wards decreased (p < 0.001 and p = 0.07 respectively). overall, c. albicans accounted for 44%, c. parapsilosis 27% and c. glabrata 13%. although the incidence-density of all species increased over the study period, the relative proportion caused by c. albicans decreased (p = 0.007) and c. parapsilosis increased (p = 0.01). despite significantly increased fluconazole usage (from 19.7 to 30.6 ddd/1000 pt-days, p < 0.0001), the relative proportion caused by c. glabrata/c. krusei did not change (p = 0.5). the overall incidence of candidaemia has increased almost 400% in queensland public hospitals over the last 10 years. the relative proportion of episodes occurring among general medical/surgical patients and caused by c. parapsilosis has increased. candidaemia is an increasing problem the epidemiology of which continues to evolve. it is increasingly affecting patients outside traditional risk groups. conclusions: this surveillance study and pharmaco-economic modelling has proved immensely beneficial in setting up inhouse processing, improved tat, reduced costs of outsourcing and subsequent use of expensive antifungals. reduction in mortality has been noted but is not statistically significant. c. albicans was the commonest isolate; fluconazole resistance is minimal and associated mortality is lower than reported from europe. many pts received systemic prophylaxis (72%); itraconazole and fluconazole were used in 68 and 33 pts respectively. no differences emerged between empirical vs pre-emptive therapy and none of the drugs resulted to significantly influence outcome. in 66% of pts initial empirical/pre-emptive drug remained unchanged after ia diagnosis, while in 16% clinicians shifted to a combined treatment. conclusion: this study allows as to analyzed multiple factors as potentially influencing outcome. we confirmed that aml phase and neutropenia influence ia outcome. present data confirm the perception that during last years the application of a correct and timely diagnostic work-up and the availability of more efficacious and less toxic drugs (i.e. voriconazole, liposomal amphotericin b, caspofungin) have modified the course of ia. however none of the new drugs emerged as the most efficacious in our series. even combined treatment did not confer any advantage in survival analysis. (<3% each). the first line therapy was monotherapy with voriconazole (49%), caspofungin (14%), lipid formulations of amb (9%) or used antifungal drugs combination (20%). the mortality rate at day 90 was 41% when first line therapy included voriconazole compared to 60% when it did not (p < 0.001). conclusion: comprehensive collections of cases based on systematic reporting and description of cases using a dedicated network of hospitals in selected regions and stringent definition criteria applied by trained clinicians and microbiologists are useful to describe ia, to assess its burden and secular trends, and to identify potential changes in diagnostic and therapeutic procedures. this network will expand to other regions in the near future, and data will help assessing the impact of new management strategies such as prophylaxis with posaconazole, the impact of modification of new diagnostic criteria as recently proposed (clin infect dis, 2008), and identifying new populations at risk for ia. nosocomial aspergillosis represents a serious threat for severely immunocompromised patients and outbreaks have been attributed to airborne sources. the role of hospital-independent fungal spread sources e.g. the private homes or business suites are not known. we investigated the relationship between fungal exposure prior hospitalisation and the ensuing onset of invasive mould infections (imi) in patients at risk. patients admitted to the department of haematology and oncology or to the department of transplant surgery of the innsbruck medical university received a structured questionnaire regarding their fungal exposure prior hospitalisation. questions inquired heavy fungal exposures up to five days prior hospitalisation. 234 patients were enrolled in this study and 19% were smokers, 22% suffered from an airborne allergy, 62% lived in old buildings, 73% were ruralists, 82% and 92% were exposed to any outdoor or indoor fungus sources. poor housing conditions and other fungus exposures were associated with the onset of community-acquired imi only in patients with acute myelogenous leukaemia (p < 0.01). aml patients being more at risk for imi when smoking cigarettes (p < 0.05), living on the country site (p < 0.05), having two or more fungus exposures (p < 0.05) and suffering from allergy to dust, pollen and/or moulds (p < 0.05). a similar trend was for lung transplant recipients receiving extensive immunosuppressive agents to treat allograft rejection. overall, 88% of imi were community-acquired cases. hospital-independent fungal sources highlight risk-factors for imi in severe immunocompromised patients and the rate of communityacquired imi does increase. an analysis of an individual patient's risk factors for fungal infection and the type of fungus to which they are most susceptible, indicates the preventative strategies that are likely to be successful. to the icu-mhs with aspergillus spp detected in significant amounts in clinical samples. the underlying conditions of the patients were heart transplantation (n = 5), major heart surgery (n = 4), and other (n = 2). eight (72.7%) patients developed proven/probable ia (4 with lung infection, 2 with mediastinitis, 1 with disseminated ia, and 1 with prostate involvement). the mortality of patients with ia was 87.5%. the icu-mhs is divided into 3 areas, one of which is equipped with hepa filters. only 1 case of ia occurred in the protected area. we measured the fungal conidia levels in the air of each of the 3 areas (508 samples analyzed) monthly. a total of 172 strains of a. fumigatus (110 clinical strains from 10 patients and 62 environmental strains) were genotyped using microsatellites (de valk et al, jcm 2005) . the mean airborne conidia levels (6 months) before and after the outbreak were, respectively, 5.6 (0−15) cfu/m3 and 1.8 (0−10) cfu/m3. no cases of ia occurred during these periods. however, all cases of ia were linked to 4 peaks of abnormally high airborne conidia levels (65, 70, 200 and 500 cfu/m3). a. fumigatus was involved in 7 cases of ia; 1 patient was infected by non-fumigatus aspergillus (not further genotyped). in 4 patients (1 mediastinitis, 2 pulmonary ia and 1 colonisation), we demonstrated similar genotypes in the air and in clinical samples. patient 1 was located in the protected area and had a unique genotype. patient 2 had two different clusters of genotypes: one cluster was similar to that of patient 3 and the other was also found in patient 4 and in the air. the genotype present in patients 2 and 4 was also detected in the air during a 6-month period. conclusions: epidemiologic and molecular typing suggests that there is a causal relationship between aspergillus causing ia and those present in the air. our finding also supports the need for hepa filtration in icu-mhs. j. guinea is contracted by fis (cm05/00171). sensitivity, specificity, positive predictive value (ppv) and negative predictive value (npv) were calculated in reference to proven and probable cases of ia. reasons for performing bronchoscopy on patients were also recorded. the protocol received approval by the local ethic committee. results: from the 117 samples studied, 5 (4.3%) were classified as proven, 6 (5.1%) as probable, and 35 (29.9%) as possible cases of aspergillosis. twelve samples (10.3%) represented colonisation, and 59 bal samples were obtained during routine surveillance. pulmonary aspergillosis was the main clinical presentation of ia (63.6%). using roc analysis, the best cut-off for galactomannan testing in bal was defined as 1.5 (sensitivity 90.9%, specificity 90.6%, ppv 48% and npv 99.1%). median bal gm index for the group of patients with proven/probable aspergillosis and for 'negative cases' were 3.3 and 0.5, respectively (p < 0.001). overall mortality was 20% (n = 12). the odds for death for patients diagnosed with ia were 11.8, in comparison to patients who did not have this infection (95% ci 2.9−48.4). conclusion: gm testing in the bal added to the diagnosis of ia in lung transplant recipients. in order to avoid false-positive results, a higher test cut-off should be applied to bal samples, in comparison to sera. increasing the cut-off to 1.5 resulted in a very high npv, with an associated sensitivity of >90%. objectives: 1) determine the performance characteristics of the galactomannan (gm) assay in broncho-alveolar lavage (bal) in haematology-oncology patients; 2) evaluate the prognostic value of the gm assay in this particular population. methods: the platelia gm eia assay (bio-rad) was performed on all bal specimens obtained from haematology-oncology patients at our institution between march 2005 and april 2008, in addition to routine laboratory stains and cultures. all results were reported to physicians. we conducted chart reviews to classify cases as proven, probable, possible or without invasive pulmonary aspergillosis (ipa) according to the revised definitions of invasive fungal disease from the eortc/msg consensus group. for performance characteristics, proven and probable cases were considered as ipa; possible cases were considered as without ipa. the result of bal gm was not considered as a criterium to classify cases in order to avoid incorporation bias. in patients with >1 positive (gm index >0.5) specimen, only the first one was considered for the analysis. mortality was calculated at 60 days following the first bal procurement. data were analyzed with stata 8.0. results: there were 173 bal samples from 145 patients, including 101 haematopoietic stem cell transplant (hsct) recipients. we found 5 proven, 7 probable and 35 possible cases of ipa (total of 12 ipa cases; 6.9%). gm on bal was positive in 47 (27.2%) specimens. the sensitivity and specificity of the gm assay in bal were 100% and 78.3% respectively. positive predictive and negative predictive values were 25.5% and 100%, respectively. false-positive results were found in 21 patients without ipa and in 14 with possible ipa. an index value 0.5 was significantly associated with a 60-day mortality risk (12/39 patients with a positive gm died within 60 days after bal compared to 13/106 with a negative gm (or = 3.2, 95%ci 1.3−7.8; p = 0.01). this association was even stronger when restricted to hsc recipients (or =4.6, 95%ci 1.5−13.6; p = 0.006). the clinical utility of gm assay in bal mainly lies in its negative predictive value, identifying patients at low risk of ipa. this test also carries a prognostic value in predicting patients at higher risk of mortality. (see table below) . not significant differences have been found among pneumocystis colonisation and copd status evaluated by fev-1%. as well as no significant differences respect to age, sex or lymphocytes and leucocytes blood count were found. background: infliximab, a monoclonal antibody targeting tumour necrosis factor alpha (tnf-a), is indicated for the treatment of rheumatoid arthritis (ra) and other autoimmune diseases. however, its use has been associated with opportunistic infections, including pneumocystis jirovecii pneumonia (pcp). moreover, p. jirovecii has been observed colonising to humans with several disorders. objectives: to obtain information about p. jirovecii colonisation among patients with rheumatologic disease treated with infliximab. this information could be useful for assessing new strategies in the prevention of pcp in patients at risk. methods: 62 consecutive patients treated with infliximab for rheumatic disorders were included in the study. oropharyngeal washes (ow) samples were collected for p. jirovecii detection. clinical and demographic data were collected (sex, age, rheumatologic diagnosis, duration of infliximab use, concomitant use of other drugs for rheumatologic treatment, use of any other anti-tnf-a agent, use of anti-pc drugs in the last six months, smoking, and diagnosis of chronic pulmonary respiratory disease). p. jirovecii colonisation was identify in ow samples by pcr at mtlsu-rrna gene, with primers paz102-x and paz102-y. we adapted a method previously described to a real-time pcr setting, using a lightcycler 1.5 (roche, germany). individuals in whom the presence of p. jirovecii was detected at two independent assay in the absence of respiratory symptoms or radiological findings suggestive of pcp were considered to be colonised. results: clinical and demographic data for 62 patients treated with infliximab are presented in table 1 objectives: most research with human bocavirus, a recently found respiratory pathogen, has been done by molecular biology (polymerase chain reaction, pcr). the results have been ambiguous because the virus has often been found in co-infection with other viruses, and also in clinically healthy subjects. it has been proposed that, for bocavirus, antigen detection could better indicate the aetiology than qualitative nucleic acid detection. we have developed a rapid antigen detection test for the virus. the one-step test for bocavirus vp2 antigen is based on a separation-free two-photon excitation fluorometry (arcdia tpx assay technique). the assay protocol is simple; the swab sample is dissolved in sample buffer, and the solution is dispensed (20 ml) onto a 384-well microtitre plate (containing the reagents in dry form) for incubation and automated quantitative measurement. the immunoassay applies microspheres as solid-phase carriers of purified bocavirus-specific polyclonal antibodies. the virus antigens concentrate onto the solid-phase which is probed in real-time with fluorescently labelled antibody reagents. strong positive samples are reportable in 15 minutes, while low positive and negative samples are reported in 2 hours. the performance of the method was studied with recombinant human bocavirus-like particles (vp2), and purified respiratory pathogens (group a streptococci, streptococcus pneumoniae, and influenza a and b, respiratory syncytial, metapneumo, adeno, and parainfluenza 1−3 viruses). results: analytical detection sensitivity of the method (lowest limit of detection, 0-control + 3sds) was 3 ng/ml, dynamic concentration range was three orders of magnitude, and intra-assay imprecision was 5−10%. cross-reactions with the other respiratory pathogens were not found. the new method enables rapid detection of bocavirus antigens. the new test is very easy to perform in comparison to standard elisas. the analytical sensitivity of the method is expected to allow analysis of clinical samples. the sensitivity of the antigen detection test could be significantly increased by the use of monoclonal antibodies (10-100 fold). our future objectives include increasing the detection sensitivity, and analysis of clinical samples in order to study the correlation of antigen detection and the clinical aetiology. life-year for patients who survived. all analyses were performed using treeage software (2008). results: the overall mortality rates for empiric vancomycin (v) and semi-synthetic-penicillin (ssp) was 30% and 35%, respectively, as apposed to 24% for those receiving the rapid mrsa pcr testing. these mortality rates were similar in both the eu and us subsets. furthermore, the number needed to test in order to save one life was 20 and 11 for empiric v and ssp, respectively. using sensitivity analysis the prevalence of mrsa was varied from 5% to 80% and yielded an absolute mortality difference favouring the pcr testing group of 10% and 2%, respectively as compared to empiric v and 1% and 18% compared to empiric ssp. in eu the c/e for empiric v and ssp treated patients was €873 and €949, respectively as compared to €807 for rapid pcr testing. in the us the c/e for empiric v was $1,049 as compared to $971 for rapid pcr testing. using sensitivity analysis the prevalence of mrsa was varied from 5% to 80% and yielded favourable c/e in both the eu and us for rapid pcr testing regardless of the empiric treatment regimen. conclusion: rapid mrsa pcr testing using the xpert mrsa/sa blood culture pcr assay appears to improve mortality rates and is cost effective in the eu and us across a wide range of mrsa prevalence rates. background: rapid detection of gastro-intestinal carriage of glycopeptide-resistant enterococci (gre) from screening cultures is crucial for an efficient control of their spread. we assessed 4 media − 2 chromogenic, chromid, (biomérieux), and chromagar (chromagar microbiology), and 2 selective, vre selective (oxoid) and eccv (bd) − for their ability to detect gre using well-characterised isolates and stool samples from hospitalised patients at high risk of gre colonisation. methods: twenty-five isolates consisting of 13 gre. faecalis/faecium carrying various van genes and 12 non-vre at concentrations of 10 6 -10 1 cfu/ml and 10 6 cfu/ml, respectively, and 37 stool samples were randomised and spiral plated on all media and scored by 5 blinded investigators for characteristic colonies after 24 hrs incubation. standard confirmatory tests were done on 1 putative gre colony or on 1 characteristically coloured colony each for e. faecalis/faecium from the selective and chromogenic media, respectively. detection of van genes, and ddl or soda based speciation was done on pcr-sequencing. mean sensitivity (sen) and specificity (spec), and confidence intervals (cis) were estimated for each medium by a logistic regression model using a penalised likelihood approach based on the reader response for the stool samples and isolates, and additionally on confirmation test results for the stool samples, both at the aggregated (gre detected) and penalised level (correct species-colony colour correlation). results: chromagar showed the highest sen based on reader response at the aggregated and penalised level for both stool samples and isolates (table) . using confirmation test results at the aggregated level, sen for eccv was highest while the two chromogenic media showed a decrease in sen by at least 11% in comparison to the values obtained based on reader response. sens for the 2 chromogenic media were even lower (<70%) based on confirmation test results at the penalised level. eccv and chromid showed the highest specs with both reader response (stool samples) and confirmation test results at the aggregated level, and chromid also at the penalised level, with narrow cis indicating a high precision of this parameter estimate. for isolates, specs were highest for chromagar at both levels. conclusions: chromagar showed the best overall performance considering both sen and spec estimates. eccv performed well as a selective medium for gre detection from stool samples. objectives: metallo-beta-lactamases (mbls) expressed from pseudomonas are able to confer resistance to all beta-lactams with the exception of aztreonam. however, enterobacteriaceae possessing mbls exhibit moderate cephalosporin and low carbapenem mics and thus are often underestimated. herein, we describe data from new etest prototypes specifically designed to detect this problematic resistance mechanism. methods: 82 mbl-positive (vim or imp derivatives) enterobacteriaceae clinical isolates from 8 countries and 27 randomly selected enterobacteriaceae negative controls (including the atcc type strains) were tested against the 4 different etest mbl prototypes. beta-lactam substrates used were imipenem (ip), meropenem (mp), ceftazidime (tz) and cefotaxime (ct) with or without the inhibitors dipicolinic acid (dpa) and edta. the etest standard procedure for gram negative aerobes was used and a reduction of beta-lactam mic by equal to or greater than 3 dilutions by edta or dpa was interpreted as positive for mbl. presence of esbls was tested using the etest ct/ctl, tz/tzl and cefepime (pm)/pml strips. ampc production was detected using the etest cefoxitin (fx)/fxi and cefotetan (cn)/cni strips. of the 784 select specimens that were negative for gbs, 345 grew turquoise-blue colonies, but the majority that required further work to rule out gbs grew after 48 hours. two strains of gbs that were missed grew as white colonies on select, and even at 48 h, did not exhibit the characteristic turquoise-blue colour. conclusion: ssb enrichment followed by select subculture was extremely sensitive (99.2%) and superior to cna/ssb for detection of gbs from genital specimens. however, non-gbs organisms can produce turquoise-blue colonies on select and further work must be performed to rule out the presence of gbs. objectives: screening for chlamydia trachomatis (ct) specific antibodies is valuable in investigating recurrent cause of miscarriage, pelvic inflammatory disease and tubal damage following repeated episodes of pelvic inflammatory disease. immunofluorescence (if) is considered the gold standard for detection of ct antibodies. the present study aims to compare the performance of 4 other commercial tests for the detection of serum igg antibodies specific for ct: two ct igg pelisa both using major outer membrane protein (momp; ["momp-medac", ct-igg-pelisa; medac, wedel, germany and "momp-ruwag", ct pelisa; ruwag, bettlach, switzerland), one ct hsp-60 igg pelisa ("hsp60-medac", chsp60-igg-pelisa; medac, wedel, germany), and a new automated epifluorescence immunoassay ("inodiag", "must chlamydiae; inodiag, signes, france). methods: a total of 405 patients with (n = 251) and without (n = 154) miscarriages were tested by all 5 serological tests described above. sensitivity and specificity were calculated using if as gold standard. a second standard, defining true positive or negative samples as sera respectively positive and negative in all 4 others tests, was also used (see table) . objectives: participation in diagnostic microbiology internal and external quality control (qc) processes is good laboratory practice, an essential component of a quality management system and compulsory in some european countries. currently, there is no qc scheme for diagnostic oral microbiology. the aim of this study was to collate information on current qc needs, and processes undertaken in diagnostic oral microbiology laboratories. method: an on-line questionnaire was devised to ascertain interest in participating in an oral microbiology qc scheme and sent to oral microbiology diagnostic laboratories. the laboratories were identified from participants attending the european oral microbiology workshop in helsinki, 2008. following this, a pilot round of qc samples was distributed to all interested laboratories. results: we identified 12 individuals that worked in diagnostic oral microbiology laboratories and received 7 (58%) positive responses. of these 7 laboratories (representing 6 european countries) 71% did not participate in either internal or external qc. each laboratory processed on average a total of 4135 samples annually. 86% of participants were in favour of a european-wide oral microbiology qc scheme. the preferred frequency for receiving external qc specimen was once in 3−4 months. the most preferred specimen types were periodontal pocket and oral pus specimens (both 29%), followed by oral mucosal swabs and caries activity tests. all participating laboratories were willing to share and harmonise their specimen processing and interpretation standard operating procedures. the pilot round specimen was a periodontal pocket sample. six laboratories reported their findings in the specified time. the predominant pathogens (aggregatibacter actinomycetemcomitans, porphyromonas gingivalis) were identified by 5 of 6 laboratories. in addition to conventional culture, one laboratory used pcr. 5 laboratories performed antibacterial sensitivity testing primarily by disc diffusion. conclusions: this is the first attempt to a standardised europeanwide approach to diagnostic oral microbiology. the findings from this feasibility study have indicated that a qc scheme for oral microbiology is of interest and have raised a number a pointers for subsequent rounds of specimens. further work to improve the quality, to standardise the methodology and the interpretation of diagnostic oral microbiology at the european level is on-going. objectives: since severe sepsis with acute organ dysfunction can be fatal within hours, it is customary to start empirical broad-spectrum antimicrobial therapy in all patients hospitalised for a suspicion of systemic inflammatory response syndrome. however, increased use of broad-spectrum antimicrobials over the years has contributed to the emergence of drug resistant strains of bacteria. especially, drug resistance among gram-positive bacteria, the leading cause of sepsis, is now a serious problem. the objective of this preliminary study was to develop a method for distinguishing between gram− and gram+ bacterial infection. methods: in this prospective study, leukocyte and neutrophil counts, crp, esr, and quantitative flow cytometric analysis of neutrophil complement receptors 1 (cr1/cd35) and 3 (cr3/cd11b), were obtained from 289 hospitalised febrile patients, of which 89 had bacterial and 38 viral infection. the patient data were compared to 60 healthy controls. results: it was noticed that in gram− infection (n = 21) the average amount of cd11b on neutrophils was significantly higher than in gram+ infection (n = 22). on the contrary, serum crp level was significantly higher in gram+ than in gram− infection. other measured parameters did not differ significantly between gram+ and gram− infections. we derived a crp/cd11b ratio dividing the serum crp value by amount of cd11b on neutrophils. in thirteen (76%) out of 17 patients with gram+ sepsis had crp/cd11b ratio cutoff value of 3.1 (figure 1 ). of these 13 patients, 9 (70%) were diagnosed with streptococcus pneumoniae, 2 with staphylococcus aureus, 1 with enterococcus faecalis, and 1 with both streptococcus intermedius and streptococcus oralis. corresponding percentages in patients with local gram+ infection, gram− infection, clinical pneumonia, other clinical infection, and viral infection were 20%, 14%, 30%, 15%, and 0%, respectively. conclusion: the detection of gram+ sepsis is possible after combination of neutrophil cd11b data and serum crp level. crp/cd11b ratio viral infections of the central nervous system s61 displayed 76% sensitivity and 80% specificity for detection of gram+ sepsis. the proposed crp/cd11b ratio test could, for its part, assist physicians to decide appropriate antibiotic treatment in patients with severe bacterial infection. a bacterial biofilm is a structured consortium of bacteria cells surrounded by a self-produced polymer matrix. biofilms may be monospecies or polyspecies biofilms. biofilm growing bacteria give rise to chronic infections, which persist in spite of therapy and in spite of the host's immune-and inflammatory responses. biofilm infections are characterised by persisting pathology and immune response (in contrast to colonisation). bacterial biofilms use both biofilm specific (b) and conventional (planktonic) resistance mechanisms (p) when they are exposed to antibiotics. the following resistance mechanisms have been described in bacterial biofilms: 1. stationary phase physiology (b), low oxygen tension (b) and slow growth (b) especially inside biofilms whereas the surface of biofilms is more similar to planktonic growth. 2. penetration barriers (b), binding to the polymer matrix (b). 3. mutations, hypermutators (b, p). 4. chromosomal betalactamase is upregulated (b, p). 5. antibiotic tolerance/adaptive resistance (b). 6. efflux pumps (b, p). 7. alginate production (b). 8. high cell density and quorum sensing (b, p). 9. pbp 3 − sos response ? (b). the knowledge of these resistance mechanisms can, however, be used to design new therapeutica approaches especially as regards quorum sensing inhibitors. we consider two factors that contribute to treatment failure in the absence of inherited resistance, the density of the population being treated and the physiological state of the bacteria. we also explore how these factors might contribute to the evolution of inherited resistance during the course of treatment. we conclude with a computer-and chemostat-assisted consideration of the potential clinical implication of these density and physiology effects and make suggestions for treatment protocols to deal with them. using in vitro cultures of staphylococcus aureus atcc25923 or the clinical isolate ps80 and antibiotics of six different classes we determined the functional relationship between the inoculum density and the efficacy of the antibiotics. as measured by the rates and extent of kill and/or the minimum inhibitory concentration (mic), the efficacy of all of these antibiotics declined with increases in the density of bacteria, albeit to different extents. for daptomycin and vancomycin, much of this density effect can be attributed to bacteria-associated declines in the effective concentration of the antibiotic in the medium. for gentamicin, vancomycin, ciprofloxacin and oxacillin, our bioassays failed to reveal significant reductions in their effective concentration in the medium. the effects of the physiological state of s. aureus on the efficacy of these antibiotics were examined for bacteria from cultures in "stationary phase" for different times and from chemostats run at different generation times. these experiments are currently under way but by the time of the symposium we will have the full (and true) story. it is, however, clear that the efficacy of all of these antibiotics declines with the time in stationary phase (its "age"). and, even slowly dividing cultures from chemostats are more susceptible to antibiotic-mediated killing that early stationary phase batch cultures. the efficacy in killing non-growing bacteria varies among the bactericidal antibiotics examined. to ascertain the potential clinical implications of these density and physiological effects, we use both computer and in vitro simulations of antibiotic treatment. the results of these simulations provide compelling support for the proposition that antibiotic treatment regimes, including those designed to prevent the ascent of resistance, should take into account the anticipated density and physiological state of the target population of susceptible bacteria. there have been an increasing number of neurotrophic viral infections playing an important role in the world over the last decade. the list includes west nile virus, nipah and hendra virus (both paramyxoviruses), as well as chikungunya virus which suddenly emerged. furthermore, the relation between jc virus in progressive multifocal leukoencephalopathy (pml) in patients with multiple sclerosis treated with a new immunosuppressive drug, has triggered our attention. the development and implementation of molecular based amplification method has assisted us to detect these viruses more efficiently. these technologies have been used now routinely in a large number of laboratories to enable the detection of more commonly known neurotrophic viruses, like hsv, vzv and the neurotrophic picornaviruses like enterovirus and parechovirus. the pitfalls of these molecular methods have been generally solved by implementing regular quality control testing schemes, like organised by qcmd (quality control of molecular diagnostics) and the introduction of internal controls during the whole diagnostic process. finally, with the ability to quantify the amount of nucleic acid present in csf, more information on the pathogenesis of these viral infections, as well as significant tool to monitor the antiviral effect of treatment options for these viruses, has become available. to as a rare disease in europe restricted to some endemic foci. however, current data suggest that the incidence of ae has significantly increased, and the disease is spreading to the north, west, and east. ae has become an emerging disease in the baltic countries. thus, human infections with e. multilocularis have arrived in the "centre" of europe. ae is a lifethreatening disease, and is characterised by a tumour-like lesion in the liver. the larva can infiltrate the surrounding tissues and metastasize to distant organs. in an attempt to classify the large variety of anatomical findings in ae, the pnm-classification system was developed and serves as a benchmark for standardised evaluation of diagnostic and therapeutic measures. modern imaging techniques, such as ultrasound, ct or mri and pet/ct contributed not only to a much better description of the lesions, but also to a judgment upon the activity of the metacestode. the differential diagnosis of ae varies from haemangioma-like lesion of the liver or cancer. the diagnostic skills are limited, and are the reason for frequent misdiagnosis in geographic areas where ae is rather unknown. continuous treatment with benzimidazoles is the backbone of a lifelong management of ae. however, radical resection is the procedure of choice and should always be strived for. ae is still a rare disease in europe, but where it occurs, it is often diagnosed too late. patients are misdiagnosed for months and years, before receiving the correct treatment. at that late stage the disease has progressed, and radical cure of the liver lesion(s) is not anymore possible. recent reports provided hints for an accelerated larval growth of echinococcus spp. in the immunodeficient host. a careful monitoring of patients receiving immune-modifying drugs is warranted. the modern clinical management and long-term parasitostatic treatment with benzimidazoles are highly effective. thus, a higher alertness for the "tumours from the centre" would increase the prognosis of this hepatic disease resembling liver cancer. the percutaneous treatment of liver hydatid cysts were considered to be contraindicated due to two main potential risks: anaphylactic shock and abdominal dissemination of the disease. since the first case percutaneously treated was published, several series of successful percutaneous treatment of the liver and the other abdominal organs, peritoneum, thorax, soft tissue and orbital cavity hydatid cysts have appeared in the literature. percutaneous treatment of hydatid liver disease is an effective and safe procedure with its unique advantages (e.g., shorter hospital stay, low complication rate). today, the percutaneous approach has an important role in treatment of hydatid cysts not only in the liver but also in the other organs and tissue. therefore it must be first treatment option whenever it is indicated. in europe, dirofilaria immitis and dirofilaria repens are responsible of autochthonous filariases in dogs. adults of d. immitis kills the dogs with an heart location and d. repens is often found in subcutaneous nodules in dogs and cats. the microfilariae are present in the blood of these animals. dirofilariasis is due to the transmission of microfilariae by some mosquito bites (aedes, culex, anopheles, mansonia, psorophora and taeniorhynchus). usually non pathogenic to humans, these parasites are particularly present around the mediterranean basin. d. immitis is very rare in humans in europe, sometimes found in a pulmonary nodule and the heart location is not described. d. repens is more frequent and emerging in humans. usually, only one larva develops, producing an immature adult worm inside a subcutaneous nodule. ultrasound examination may suggest the parasitic origin of the lesion before an extraction and a parasitological diagnosis of the worm. more often, a fortuitous diagnosis is made on histological examination. very rarely, an adult worm may mature and produce systemic diffusion of microfilariae. dirofilariasis due to d. repens can present problems in diagnosis and treatment. an ocular and subconjunctival location of the worm and a subcutaneous nodule enclosing an immature adult are the commonest clinical forms. exceptional pulmonary locations are described. the subcutaneous locations described are: skull, cheek, breast, inguinal area, buttocks, arms and legs. cases of testicular location with painful symptoms have been observed. blood hypereosinophilia was exceptionally observed in human. it is treated surgically, by excision, without chemotherapy. while the majority of esbls, isolated in clinically-relevant gram negative bacteria (gnb) (mostly enterobacteriaceae, p. aeruginosa, a. baumannii) are tem-, shv-or ctx-m-types, a few others have been reported (sfo, bes, bel, tla, ges, bel, per, veb-types, and some oxa-esbls). laboratory detection of esbl-producers is important to avoid clinical failure due to inappropriate antimicrobial therapy and to prevent nosocomial outbreaks. selective culture media (macconkey and drigalski agar supplemented with cefotaxime and/or ceftazidime) have been proposed for detection of gnb resistant to expanded-spectrum cephalosporins (esc). media using chromogenic based substrates and selective antibiotics have been developed recently for the detection and presumptive identification of esbl-producing enterobacteriaceae directly from clinical specimens. detection of esbls based only on susceptibility testing is not easy due to the variety of b-lactamases and their variable expression of blactam resistance. commercially available esbl detection methods yield at most 90% accurate esbl identification, since some esbl-producers may appear susceptible to some escs. therefore, any organism showing reduced susceptibility to esc should be investigated using esbl confirmatory tests. these tests should be able to discriminate between esbl-producers and those with other mechanisms conferring esc resistance. these phenotypic tests (double-disk synergy test, esbl etest, and the combination disk method) are based on clavulanate inhibition and esc susceptibility testing. they often need slight changes by either reducing the distance between the disks of esc and clavulanate, the use of cefepime (not hydrolysed by ampcs), the use of cloxacillincontaining plates (that inhibits ampc), or by double inhibition by edta and clavulanate (masking metallo-enzymes). enzymatic tests have also been proposed for identification of esbl-producers. several pcr-based techniques (end-point or real time) have been developed on clinical samples or on colonies. several esbl genes have been detected using pcr coupled to either pyrosequencing, inverse hybridisation, to dhplc, or to fluorescent probes. these techniques even though more specific require technical knowledge, special equipment, are costly and detect only known genes, regardless of their expression. detection of esbl-producer remains a challenge for the microbiology laboratory and one shall be aware that esbl screening media are now available. resistance to antimicrobial agents has become common in many bacterial species, particularly those that cause human infections. the rapid detection of resistant organisms directly in clinical samples by real-time pcr coupled with molecular beacons, or of potentially resistant bacteria and yeast in blood culture bottles by peptide nucleic acid-fluorescence in situ hybridisation (pna-fish) is already having a positive impact on antimicrobial therapy. the direct detection of mycobacterium tuberculosis in sputum in approximately 2 hours with concomitant detection of mutations in rpob indicating rifampin resistance (as a surrogate for multidrug resistance) in the near future will likely improve the outcomes for tuberculosis patients in many developing and developed countries. several molecular technologies, including microarrays, bacterial tag encoded flx amplicon pyrosequencing (btefap), and ultra deep sequencing, have not yet transitioned to clinical laboratories but will likely provide even greater information about antimicrobial resistance not in just a single species, but in a whole community of microorganisms. complex wounds, like diabetic foot ulcers, containing multiple resistance genotypes are amenable to analysis by btefap. the implementation of these technologies in the clinical laboratory will be expensive but the potential to dramatically improve therapeutic outcomes especially for life-threatening diseases is unprecedented. objective: to determine the appropriateness of antimicrobial therapy (amt) in 11 dutch hospitals. method: data were obtained from a prevalence survey performed within the dutch surveillance network for nosocomial infections (prezies). amt administrated on the day of the survey was registered. antiviral and antifungal drugs, tuberculostatics, cements containing amt and prophylaxis administrated in the operation-theatre were excluded. the appropriateness of amt was assessed according to a standardised algorithm based on the local antimicrobial prescription guidelines. per patient a classification in appropriate use, inappropriate use and insufficient information was made. figure: relative risk of ia use of amt against largest hospital (hospital c). results: a total of 3,546 patients were included of which 1,075 (30%, range per centre (rpc): 23−37%) received amt. in the latter group, amt was considered appropriate in 70% (rpc: 57−84%), inappropriate in 17% (rpc: 3−32%) and was not judged because of insufficient information in 13% (rpc: 1−30%). there was considerable variation in inappropriate use among the participating centres (figure). in univariate analysis older age, the use of quinolones, being on the urology ward and presence of a suprapubical catheter were associated significantly with inappropriate use. admission on the icu and presence of an intravascular catheter were associated significantly with appropriate use. in a multivariate analyses the presence of suprapubical catheter, being on the urology ward and the use of quinolones were determinants for inappropriate use. this study showed large differences in overall use and appropriateness of use of amt between hospitals. based on these results it is possible to define targets for intervention to improve the prudent use of amt. the high fraction of patients with insufficient information in several centres may have influenced the analyses and should be addressed in future studies. m. struelens°, s. metz-gercek, r. mechtler, f. buyle, a. lechner, h. mittermayer, f. allerberger, w. kern objectives: the eu-project antibiotic strategy international (abs) qi team developed process qis for auditing the performance of key treatment and prophylactic practices. an international network of pilot hospitals tested these tools for feasibility, reliability and sensitivity to improvement. methods: qis included: 1. surgical prophylaxis (indication, drug choice, timing and duration of administration); 2. management of community-acquired pneumonia (cap) (blood culture and legionella antigen tests and drug choice for empirical treatment); 3. management of s. aureus bacteraemia (echocardiography, iv catheter removal and duration of therapy); and 4. iv-po switch for bio-available antibiotics. a minimum of 40 consecutive cases per centre and qi were retrospectively reviewed from clinical, laboratory and administrative records and assessed for data availability, inter-observer reliability, data collection workload and performance score. results: a total of 1240 patients were evaluated in 11 acute care hospitals from 5 countries, with a range of 80 to 500 cases and 2 to 9 centres per indicator. seven centres had already implemented antibiotic quality improvement and audit programmes. availability of data was >85% of cases and ranged between 87% (catheter removal in s. aureus bacteraemia) and 100% (diagnostic tests for cap). 13/14 indicators were found to be reliable with kappa 0.60 (good to excellent agreement). the workload per case ranged from a median time of 16 (cap) to 35 min (iv-po switch). the intention to treat qi scores showed high levels of adherence to the surgical prophylaxis qi bundle, with median values of 81 to 97% for hip prosthesis and 65 to 92% for colo-rectal surgery. for cap management, diagnostic testing appeared sub-optimal (<56% compliance with idsa guidelines). for s. aureus bacteraemia management, indicator results ranged from 60 to 65%. for use of bio available antibiotics, a median of 45% iv administrations were avoidable. there were marked differences of scores between centres for all qis. conclusions: the abs qis are reliable and broadly applicable tools for auditing antibiotic treatment and prophylactic practices. inter-hospital variation in adherence to recommended practice indicates substantial potential for improvement with different local priorities. these qis can be recommended for assessing the effect of quality of care interventions at either local or multi-centre level. d.j. noimark°, e. charani, s. smith, b. cooper, i. balakrishnan, s.p. stone (london, uk) introduction: reduction of clostridium difficile infection (cdi), which often follows use of third generation cephalosporins, is a national priority. over a three year period, antibiotic policies were reviewed and changed in an elderly medicine department according to local sensitivities of common pathogens and levels of cdi. a laminated pocket-sized card describing antibiotic policies was given to all doctors in the department on induction with instructions not to depart from these without microbiologists' approval. this prospective controlled interrupted time series examines whether this intervention increased compliance with antibiotic policy and decreased cdi incidence. methods: the department's "narrow-spectrum, no cephalosporin" antibiotic policy was changed on 1st august 2006 to replace trimethoprim with cephradine (1st generation cephalopsporin) as empiric treatment for urinary tract infection, reflecting local escheriscia coli sensitivities. in october 2007, all cephalosporins and quinolones were removed from the policy as cdi levels had increased. notional 7 day antibiotic usage was calculated from prospective pharmacy generated data with aspirin, calcium, bisphosphonate & laxative prescription use as a non-antibiotic control, and analysed by segmented regression with a robust variance estimator. cdi rates were prospectively collected separately & analysed by a poisson regression model. results: an immediate response to change in antibiotic guidelines was observed (figure) . from august 06-sep 07 there was a highly significant increase in cephalosporins (85-100% of which was cephradine alone) (p < 0.001), a significant fall in trimethoprim (p < 0.004) and a significant increasing trend in cdi ( no tools existed to assess the readiness of public hospitals to receive this technology, and therefore guide resource allocation to facilitate implementation. aim: to assess the readiness of victorian public hospitals to introduce electronic antimicrobial stewardship. method: literature on readiness for change, organisational culture and information technology acceptance were reviewed. group interviews with project teams at site initiation meetings, one on one interviews with project officers at subsequent meetings, and observation where appropriate were all used to determine potential barriers and enablers. this information was recorded using a 'readiness assessment tool' and analysed to identify a number of key domains. to triangulate the data, questionnaires were distributed to project officers asking them to assess their sites' readiness to implement the system. results: a novel 'readiness assessment tool' was developed. it covered the domains of technical readiness, skills readiness, process readiness, administrative support readiness, resource readiness and hospital organisational characteristics. assessments at several hospitals highlighted a variety of issues at different sites and allowed early efforts to address these. a formative readiness assessment can be used to identify systematic problems that might facilitate or hinder uptake of electronic antimicrobial stewardship and to inform the adopters of potential resources required. [1] buising, k, thursky, k, robertson, m, black, j, street, a, richards, m & brown, g (2008) . electronic antibiotic stewardship-reduced consumption of broad-spectrum antibiotics using a computerised antimicrobial approval system in a hospital setting. j antimicrob chemother. w.v. kern°, m. steib-bauert, a. pritzkow, g. peyerl-hoffmann, h. von baum, u. frank, m. dettenkofer, c. schneider, k. de with, h. bertz (freiburg, ulm, de) objectives: fluoroquinolone prophylaxis (fqpx) may reduce morbidity and mortality in cancer patients (pts) with neutropenia, but the development of fluoroquinolone resistance (fqr) in escherichia coli and other target organisms limits its usefulness. we evaluated changes in the incidence density of gram-negative bloodstream infection (gnb) and in the in vitro fqr rates after the introduction of fqpx (with levofloxacin) as a standard of care for pts with high risk neutropenia in a university hospital. methods: we collected individual data for 357 pts admitted during baseline and during the first months following the intervention to assess clinical outcomes. individual pt data were compared with aggregate data (3-month periods). aggregate data analysis (unit-wide antibiotic consumption, gnb and numbers of in vitro fqr bloodstream isolates) was continued for a total of eight 3-month periods for both the haematology-oncology service and for general internal medicine. the new policy was introduced in the second half of the year 2005 when unit-wide baseline fqr of e. coli and of coagulase-negative staphylococcal (cons) bloodstream isolates had been 15% and 80% in the haematology-oncology unit, and 8% and 60% in general internal medicine, respectively. the individual pt data analysis revealed that pts not given fqpx had a much higher incidence of gnb than those given fqpx ( -2007) . the monthly use of iv and oral quin was calculated based on data from the pharmacy department. statistical analyses were performed using segmented linear regression analysis. bayesian model averaging was used to account for model uncertainty. results: before the interventions the use of quin (both iv and total) was stable. the best fitting models indicated that the first intervention was associated with a stepwise reduction in iv use of 71 prescribed daily doses (pdd) (95% ci: 47, 95 (p < 0.001)). there was also an indication of smaller reduction in iv use associated with intervention 4, but only the intervention 1 effect was robust to model uncertainty. the overall use of quin was also significantly reduced (figure) with a large stepwise reduction of 107 pdd (95% ci: 58, 156) associated with intervention 2. this study showed that the hospital-wide use of quin can be significantly improved (and decreased) by an active policy consisting of multiple interventions. marwick°, j. broomhall, c. mccowan, s. gonzalez-mcquire, k. akhras, s. merchant, p. davey (dundee, high wycombe, uk; raritan, us) aim and objectives: to describe the antibiotic treatment and outcomes stratified by severity in a representative sample of adult patients aged 18 or older who were treated in hospital for skin and soft tissue infections. inadequate. we also judged that 43% of patients received unnecessarily broad spectrum therapy. conclusions: ssti is common and is associated with significant mortality. however, choice of empirical therapy is not evidence based, with significant under treatment of high risk patients. ab were mostly (16/17) prescribed by gps and delivered by public (n = 14) or hospital pharmacies (n = 3). surveillance of ab use in nhs was organised in only 4 ms. in 3 countries a nh specific pharmaceutical formulary was available. prescription profiles by prescriber were available in 5 countries. other quality improvement initiatives in nhs such as regular training of prescribers, promoting microbiological sampling, collection of antimicrobial resistance profiles or pharmacist advice on ab prescription were scarce. guidelines for ab treatment of most frequent infections were available in many countries but were focussing on ambulatory care and did not consider the specific nh situation. only in 1 country the presence of an infection control practitioner was compulsory and partnership with hospital infection control teams was legally imposed in 3 ms. conclusion: important structural, functional and regulatory nh differences exist between eu countries. specific tools to improve infection prevention and ab therapy in nhs should take into account these differences. a european nh network was created in the framework of the esac nh subproject, which will organise point prevalence surveys on ab use in 2009. c. escherichia coli in south-western finland j. jalava°, o. meurman, h. marttila, a. hakanen, m. lindgren, k. rantakokko-jalava (turku, fi) objectives: extended-spectrum betalactamases (esbls), especially enzymes of the ctx-m group, are spreading rapidly in europe. enterobacteriaceae with reduced susceptibility to third generation cephalosporins and a positive esbl confirmatory test are also increasing in southwest finland. the purpose of this work was to study the resistance genetics of these esbl-positive enterobacteriaceae. methods: the study comprises a total of 271 clinical enterobacteriaceae strains isolated from both inpatient and outpatient specimens. all enterobacteriaceae strains that were esbl confirmatory test positive between january 2004 and december 2008 were included in this study (263 escherichia coli, 8 klebsiella pneumoniae, one isolate per patient). of these strains, 225 (83%) were urine isolates. resistance determinations were done using disk diffusion method (clsi) or vitek 2 and esbl confirmations by the double disk method using cefotaxime and ceftatzidime with and without clavulanate. thus far, 219 strains (those collected by end of june 2008) have been analysed for the presence of the most important esbl genes (tem, shv and ctx-m) using pcr and pyrosequencing as described before (haanpera et al. aac, 52:2632; 2008) . results: in 2004 only 10 esbl-positive strains were found. all of them harboured a ctx-m type esbl gene. since then, the number esblproducing enterobacteriaceae strains has increased significantly being tenfold in 2008 compared to year 2004 (figure) . a high majority, 197 (90%) of the 219 strains analysed thus far had a ctx-m-type esbl gene. most of those (79%) belonged to the ctx-m-1 group according to the pyrosequencing results. ctx-m-9 group was the next common, with 20% of the ctx-m genes belonging to this group. only two strains with ctx-m group 2 enzyme were found. conclusions: enterobacteriaceae strains which produce esbl are increasing rapidly in southwest finland. this is especially true with e. coli strains isolated from urine. towards the end of the study period, the esbl enzymes were almost exclusively ctx-m, ctx-m-1 group being the most common. further research is needed to characterise genetic elements that carry these esbl genes. esbl strains and the proportion of ctx-m genes in 2004-2008. (2000) (2001) (2002) (2003) (2004) (2005) (2006) in france (n = 6), spain (n = 4), portugal (n = 6), uk (n = 11), kuwait (n = 2), canada (n = 13) and china (n = 10), including hong kong (n = 3) were studied. clonality was established by pfge and phylogenetic groups of ec and kp were determined as reported. susceptibility testing (clsi), blactx-m-14 transferability and location (i-ceu-i/s1 nuclease) were investigated. plasmid analysis included determination of inc group (pcr-replicon typing, hybridisation, sequencing) and comparison of rflp patterns. association of blactx-m-14 with isecp1, isecp1-is10 or iscr1 was established by pcr and sequencing. we identified 42 pfge types among 52 isolates: 38/47 ec, 3/4 kp and 1/1 cf. distribution among phylogroups were as follows: i) ec: a (n = 7), b1 (n = 3), b2 (n = 5) and d (n = 23), and ii) kp: kpi (n = 2) and kpii (n = 1). resistance to tetracycline (76%), nalidixic (74%), streptomycin (67%), sulfonamides (67%), ciprofloxacin (60%) and trimetroprim (43%) was common. were spreading horizontally in our hospitals and, here, we characterised the plasmids responsible in the major k. pneumoniae strains identified during the survey. methods: plasmids from representative k. pneumoniae strains with ctx-m-15 enzyme were extracted by alkaline lysis and compared by apai, psti and ecori restriction analysis. they were transferred into e. coli dh5a by electroporation. transformants were selected on cefotaxime-containing agar and were screened by pcr for beta-lactamase genes, the aminoglycoside resistance genes aac(6 )-ib and aac3-iib, and the plasmid-mediated quinolone resistance genes qnra/b/s. results: twelve isolates were characterised, representing 5 major strains (a-d, and f) found in the most-affected hospitals. restriction analysis divided their plasmids into several groups. representatives of strain a (n = 4) had essentially the same plasmid (group 1), as did the two representatives of strain d (group 2a). one strain f isolate had a plasmid (group 2b) very similar to plasmid 2a from strain d, indicating possible horizontal transfer. plasmids of group 3 were retrieved from representatives of strains b and c, again indicating probable transfer. plasmids from three other strains differed substantially from each other and from plasmids 1, 2a, 2b and 3. nevertheless, on all plasmids, blactx-m genes were linked to an upstream isecp1 element, known to be involved in their mobilisation. all encoded multi-resistance: all but one group 1 and one ungrouped plasmid carried aac(6 )-ib; blaoxa-1 and aac(3)-iia were detected on all except group 1 plasmids; blatem was found on group 1, 2b, one group 3 and two ungrouped plasmids. blashv and qnra/b/s genes were not detected. the considerable diversity of plasmids encoding ctx-m-15 enzyme in major slovenian k. pneumoniae strains suggested only limited transfer, even when multiple strains were present in the same hospital. evidence of plasmid transfer was between strains b and c, and possibly between strains d and f, although these plasmids were not strictly identical. analysis of resistance genes encoded by the plasmids revealed diversity, with groupings coinciding largely with those based on restriction profiles. a. ingold, g. borthagaray, a.k. merkier, d. centrón, h. bello, c.m. márquez°(montevideo, uy; buenos aires, ar; concepción, cl) objectives: to examine the genetic context of class 1 integron harbouring blactx-m-2 in fifteen nosocomial k. pneumoniae isolates from south america in order to enhance the understanding of the antibiotic resistance spread among the region. methods: dna was extracted with the use of axypreptm bacterial genomic dna miniprep kit. the analysis of the cassette array was carried out with the use of primers hs458/hs459 targeting adjacent conserved regions. the examination of the surroundings were performed using two pcr primer pairs, hs817/hs818 and hs825/hs826, to amplify the initial(iri) and the terminal(irt), inverted repeat boundary, respectively. the primer pair hs825/hs911 was used whenever a negative result was obtained with hs825/hs826. all pcr products were purified and sequenced and the data was analyzed with ncbi blast tool. the sequence obtained with primers hs817/hs818 revealed the presence of three different transposons backbones at the iri end. the tn5036-like module and the tn21-like module were present in 4 isolates, the tn1696-like module was present in 7 isolates. no amplicons were obtained with the use of primers hs825/hs826 that amplify a tn21-like insertion. two uruguayan isolates with a tn5036 boundary at the iri end were tested with hs825/hs911 that target a tn5036-like backbone and one generated a product consistent with a tn5036-like mer region. uruguayan isolates carried a single aada1 cassette (4/5) and the other one contained a dfra17-aada5 array, while the four argentinian isolates carried the combination aaca4-aada1-orfd. chilean isolates arrays are in process. conclusions: among the extended-spectrum beta-lactamases, the cefotaximases constitute a rapidly growing cluster of enzymes that have disseminated geographically. there is a high frequency of isolation of ctx-m-2 producing k. pneumoniae associated with a class 1 integron in the region. despite being common the presence of iscr1 linked to blactx-m-2 in k. pneumoniae isolates, this study provides new and relevant information in the sequence context at the iri. here we report about the cassette array diversity and the diversity of elements in which the class 1 integron are embedded. different integron/transposons carrying the blactx-m-2 gene seem to be circulating and different regional patterns could be emerging, this study highlights the ability of different genetic elements to act cooperatively to spread and rearrange antibiotic resistance. l. vinué, a. garcía-fernández, d. fortini, p. poeta, m.a. moreno, c. torres, a. carattoli°(logroño, es; rome, it; vila real, pt; madrid, es) objectives: ctx-m enzymes are frequently detected in europe. in particular, ctx-m-1 and ctx-m-32-producing strains have been recovered from both humans and farm animals in spain, italy, greece, and portugal, suggesting the existence of community reservoirs for these enzymes. the aim of this study was to compare escherichia coli strains and plasmids harbouring blactx-m-1 and blactx-m-32 genes isolated from human and animals. methods: four e. coli ctx-m-1 and eight ctx-m-32 epidemiologically unrelated producers from sick or healthy animals (pig, dog, cow and chickens) and from humans (urine, blood and faecal samples) were analysed by xbai-pfge, plasmid transferability, pcr-based replicon typing, plasmid restriction analysis and southern blot hybridisation. all isolates were from spain but the dog isolate was from portugal. the genetic context of the blactx-m genes was previously investigated for all the strains. results: three ctx-m-32 strains (one from healthy chicken and two from hospitalised patients) showed the same pfge pattern. a chromosomal localisation of the blactx-m-32 gene was suspected in these strains. the five remaining ctx-m-32 producers showed the blactx-m-32 gene on plasmids belonging to the incn (4 strains) or untypable groups (1 strain). two incn plasmids showed identical pvuiirestriction patterns: one was identified in a strain from a healthy chicken and one was from a hospitalised human patient; these two strains were isolated in 2002 and 2004, respectively and showed different pfge patterns. ctx-m-1 producers (three from animal strains and one a healthy human) did not show clonality by pfge and the blactx-m-1 gene was always located on plasmids, three belonging to the incn and one to the inci1 groups. two of the incn plasmids carrying the blactx-m-1 gene showed highly related restriction patterns: one was from a healthy dog and one from a healthy human. conclusion: this study demonstrated the presence of clonal e. coli ctx-m-32 producers in animal and human sources and also detected epidemic incn plasmids disseminating among unrelated isolates from humans and animals, clearly suggesting a potential animal reservoir for the blactx-m-1/32 genes. o309 characterisation of bladim-1, a novel integron-located metallo-beta-lactamase gene from a pseudomonas stutzeri clinical isolate in the netherlands l. poirel°, j. rodriguez-martinez, n. al naiemi, y. debets-ossenkopp, p. nordmann (k.-bicetre, fr; amsterdam, nl) objectives: characterisation of the mechanism involved in the uncommon resistance to carbapenems observed from a pseudomonas stutzeri isolate recovered from a patient hospitalised in the netherlands with a chronic tibia osteomyelitis. that strain was resistant to ticarcillin, piperacillin-tazobactam, imipenem and meropenem, of intermediate susceptibility to ceftazidime and cefepime, and susceptible to aztreonam. methods: screening for metallo-beta-lactamase (mbl) production was performed using the e-test method with a strip combining imipenem and edta. shotgun cloning was performed with xbai-digested dna of p. stutzeri and pbk-cmv cloning vector. selection was performed on amoxicillin and kanamycin-containing plates. results: e. coli top10 (pdim-1) recombinant strains were obtained, displaying resistance to penicillins and ceftazidime, reduced susceptibility to cefepime, imipenem and meropenem, and full susceptibility to aztreonam. sequence analysis identified a novel ambler class b betalactamase dim-1 for "dutch imipenemase" (pi 6.1) weakly related to all other mbls. dim-1 shared 52% amino acid identity with the most closely related mbl gim-1, and 45 and 30% identity with the imp and vim subgroups, respectively. dim-1 hydrolyzes very efficiently imipenem and meropenem, expanded-spectrum cephalosporins, but spares aztreonam. the bladim-1 gene was as a form of a gene cassette located at the first position in a class 1 integron, but the 59be of that gene cassette was truncated giving rise to a fusion with an aadb gene cassette encoding an aminoglycoside adenylyltransferase. the third and last gene cassette corresponded to the qach cassette encoding resistance to disinfectants. conclusion: a novel mbl gene was identified in p. stutzeri further underlining (i) the diversity of acquired mbl genes, especially among non-fermenters, (ii) that pseudomonas sp. may be a reservoir of these genes and (iii) the possibility of spread of important resistance determinants in northern part of europe. isolates in greece p. giakkoupi, o. pappa, m. polemis, a. bakosi, a. vatopoulos°( athens, gr) objectives: metallo-beta-lactamases of the vim family are the main mechanism of carbapenem resistance in p. aeruginosa in greece. in this preliminary report we attempted to survey the subtypes of vim betalactamase currently prevailing in p. aeruginosa clinical isolates in greek hospitals, the genetic relatedness of the respective isolates, as well as the genetic environment of the blavim gene. methods: fifteen mbl producing and epidemiologically unrelated p. aeruginosa clinical isolates were collected in september 2006 from fifteen different hospitals around greece. mbl production was initially identified by an edta synergy test. identification of blavim gene, as well as mapping of the blavim cassette carrying integrons were performed by pcr and sequencing of the products. the o serotypes of the isolates were determined by a slide agglutination test using p. aeruginosa antisera (biorad). molecular typing was performed by pulse-field gel electrophoresis of spei-restricted genomic dna. results: blavim-2 gene was detected in nine isolates, blavim-4 in five and blavim-1 in only one isolate. the blavim-2 cassette of all nine isolates was located on the 1600 bp variable region of a class i integron, preceded by aaca29 gene cassette. blavim-4 cassette of all five isolates was the first cassette of the 3200 bp variable region of a class i integron, followed by the aaca4 and blapse-1 gene cassettes. blavim-1 was the unique cassette of a class i integron. vim-2 producers belonged to o8, o11 and o12 serotypes, whereas four isolates were non-typeable. vim-4 producers belonged to the same three serotypes, whereas only one was non-typeable. the vim-1 producer belonged to o12 serotype. the nine vim-2 producing p. aeruginosa isolates revealed a great degree of variability in pfge molecular typing, belonging to seven types. contrary, the five vim-4 producing p. aeruginosa isolates displayed higher genetic similarity and fell into one major type with 85% homology, which also included the vim-1 producing isolate. there was no correlation between the results of serotyping and molecular typing. conclusions: mbl production in p. aeruginosa in greece seems to be mainly due to specific class i integrons harbouring either blavim-2 or blavim-4 genes. genetic variability was higher among bacteria carrying vim-2 beta-lactamase, a fact indicating wider intraclonar spread of the respective integron. j.m. rodriguez-martinez, l. poirel°, p. nordmann (k.-bicetre, fr) objectives: extended-spectrum beta-lactamases of ampc-type (esacs) contributing to reduced susceptibility to imipenem have been recently reported from enterobacteriaceae. the aim of the study was to evaluate the putative role of natural ampc-type beta-lactamases of p. aeruginosa in a similar resistance profile. methods: thirty-two non-repetitive p. aeruginosa clinical isolates recovered in our hospital in 2007 were included. they were selected on the basis of criteria of intermediate susceptibility or resistance to ceftazidime and intermediate susceptibility or resistance to imipenem. mics were determined by agar dilution and e-test techniques. the level of expression of the ampc beta-lactamases was evaluated by measuring specific activities. pcr, sequencing, and cloning allowed to characterise the different bla(ampc) genes. identified esacs were purified and their km and kcat values for beta-lactams determined by spectrophotometry. results: using cloxacillin-containing (an ampc beta-lactamase inhibitor) plates, the susceptibility to ceftazidime was restored for 25 out of 32 isolates, suggesting overproduction of the ampc. in addition, in presence of cloxacillin, reduced mic values were also observed with ceftazidime, cefepime and imipenem for 21 out of those 25 isolates. cloning and sequencing identified 10 distinct ampc b-lactamase variants among the 32 isolates. recombinant plasmids expressing the ampcs were transformed into reference p. aeruginosa strain and reduced susceptibility to cefepime and imipenem was observed only with recombinant p. aeruginosa strains expressing ampc beta-lactamases that had an arginine residue at position 105. the catalytic efficiencies (kcat/km) of the ampc variants possessing this arginine residue were increased against oxyiminocephalosporins and imipenem. in addition, in-vitro assays demonstrated that those ampc variants constituted a favourable background for selection of additional degree of carbapenem resistance. conclusions: some ampcs of p. aeruginosa possessing extended activity torward carbapenems may contribute to carbapenem resistance. background: most oxa-type esbls are oxa-10, oxa-2 or oxa-1 derivatives. they display a very low homology, the percentage of which is between 20% and 30%. oxa-type esbls are divided into five groups according to the different homology by frederic bert, etc. group 1 includes oxa-5, oxa-7, oxa-10 and its derivants;group 2 includes oxa-2, oxa-3, oxa-15 and oxa-20;group 3 includes oxa-1, oxa-4, oxa-30 and oxa-31; group 4 is named after oxa-9; group 5 only includes a single enzyme called lcr-1. oxa-type esbls has been reported widespread in the world since the first report in 1987, such as turkey, france, england and so on. but there is few report about it in china. objective: to investigate the prevalence and genotype distribution of oxa-type extended-spectrum beta-lactamases (esbls) in clinical pseudomonas aeruginosa strains isolated from xiangya hospital of central south university in changsha city, hunan province, china. methods: ninety-seven non-repetitive clinical isolates of p. aeruginosa were collected between october 2006 and january 2007 from the hospital. they were screened for oxa-type esbls production by polymerase chain reaction pcr with five pairs of primes specific for blaoxa genes, respectively. then amplification of oxa-type esbls production was performed by pcr with specific primers. the purified and amplified products were sequenced to confirm the genotype of the oxa-type esbls. results: the sequences of the three oxa-type esbls pcr products were then compared in genbank database and there were no the completely same ribonucleotide and amino acid sequence with them. they were two novel oxa-type esbls, named as blaoxa-128 and blaoxa-129, which have been registered in genbank database under accession numbers eu573214 and eu573215, respectively. conclusions: there have occurred infections caused by p. aeruginosa producing oxa-type esbls in xiangya hospital of central south university. two novel oxa-type esbls in p. aeruginosa strains have been discovered in our study, which are named blaoxa-128 and blaoxa-129, respectively. pneumonia is one of the most common nosocomial infections and is associated with high mortality. in the last 15 years, gram-positive bacterial pathogens have risen in prevalence as a cause of hospitalacquired pneumonia (hap), including that occurring during mechanical ventilation (ventilator-associated pneumonia; vap). in particular, staphylococcus aureus is a major cause of hap, including vap. the rise of multidrug-resistant infections is a source of concern, with methicillinresistant s. aureus (mrsa) accounting for >40% of s. aureus isolates in some european hospitals. this symposium will take the format of a question-and-answer roundtable session in which experts will answer questions and initiate discussion surrounding emerging concerns and appropriate therapeutic strategies in nosocomial pneumonia, including that caused by multidrug-resistant gram-positive pathogens. recently, shifts in the susceptibility of s. aureus to established therapeutic agents for nosocomial pneumonia have added to the challenge of selecting appropriate empiric therapy. in patients with suspected multidrug-resistant infections or those who are mechanically ventilated, prompt initiation of therapy, often before the pathogen has been confirmed, is critical. vancomycin is the gold-standard treatment for multidrug-resistant infections and resistance has been remarkably slow to emerge. however, clinical reports in europe of 'mic creep' and the emergence of vancomycin-intermediate s. aureus (visa), hvisa and linezolid-resistant mrsa have presented new clinical dilemmas. elevated vancomycin mics are linked to treatment failure and increased mortality. hence, while vancomycin remains a useful therapeutic tool, treatment decisions present an increasing challenge, especially in groups of patients in whom rapid eradication of infection with appropriate agents is critical. telavancin is a novel lipoglycopeptide under investigation for treatment of nosocomial pneumonia. a number of key features suggest telavancin as a potentially attractive option for nosocomial pneumonia. telavancin has a unique dual mechanism of action that disrupts both bacterial cell wall biosynthesis and cell membrane integrity. the agent is rapidly bactericidal against a broad range of clinically relevant grampositive bacteria, including mrsa. two pivotal phase iii studies have demonstrated telavancin efficacy equivalent to vancomycin in hap, including vap, including in seriously ill patient subgroups and in that caused by mrsa. hantaviruses are enveloped rna viruses, each carried primarily by rodents or insectivores of specific host species. they have coevolved with the hosts in which they cause almost asymptomatic and persistent infections. in humans some hantaviruses cause disease: haemorrhagic fever with renal syndrome (hfrs) in eurasia. in europe puumala (puuv) from bank voles and saaremaa (saav) from field mice cause mild hfrs and dobrava (dobv) from yellow-necked mice severe hfrs. in asia hfrs is caused mainly by hantaan and seoul viruses. in americas some viruses cause hantavirus cardiopulmonary syndrome: sin nombre, andes and other viruses carried by sigmodontine rodents, not found in eurasia. in addition, in europe the common vole carries tula and rats seoul virus. however, they have not been definitely associated with disease in europe, although both can infect humans. we discuss the epidemiology, molecular genetics, detection of infection in carrier hosts and humans (including rt-pcr and 5-min serological tests), functions of hantaviral proteins, risk factors for humans to catch hantavirus infection (including smoking) and disease (including risk and protective hla haplotypes), role and mapping of epitopes of cytotoxic t-cells, mechanisms of hantavirus-induced apoptosis, newly discovered clinical features (including hypophyseal haemorrhages in puuv infection), and long-term consequences and pathogenesis of hfrs (endothelial permeability, thrombocytopenia, tnf-alpha and il-6). puuv occurs widely in europe except in the far north and mediterranean regions, saav in northern, eastern and central europe and dobv mainly in the balkans. the epidemiological patterns differ: in western and central europe hfrs epidemics follow mast years with increased oak and beech seed production promoting rodent breeding. in the north, hantavirus infections and hfrs epidemics occur in 3−4 year cycles, driven by prey-predator interactions. the infections and hfrs are on the increase in europe, partly because of better diagnostics and partly perhaps due to environmental changes. in several european countries hantavirus infections are notifiable and in some countries (e.g. belgium, finland, france, germany, scandinavian countries, slovenia) their epidemiology is relatively well studied. in large areas of europe, however, hantavirus infections and hfrs have not been studied systematically and they are still heavily under-diagnosed. mrsa screening − will we ever agree? s330 mrsa: universal screening! the successful control of any outbreak or epidemic relies on detection of those harbouring the pathogen (infected and colonised persons) combined with eliminating spread to new individuals. the approach to containment and reduction of the global mrsa pandemic is now being discussed. a challenge for this infection is that most persons harbouring mrsa do not exhibit signs of disease and thus in order to detect all potential spreaders of this organism some surveillance must be done. the required level of detection (surveillance through screening) is not known and likely varies with the prevalence of colonisation and disease. for a given mrsa prevalence, the factor that seems most crucial in reducing spread is the percentage of potential isolation days captured. the operational processes that highly influence this are 1) the sensitivity of screening detection (including sites tested and laboratory methods used), 2) the speed at which results of newly detected positive patients are reported from the laboratory (assuming pre-emptive isolation is not employed), and 3) the selection of patient populations who are to undergo screening. laboratory testing has a major impact on detecting mrsa colonised patients with real-time pcr having a sensitivity of 98% and a possible 2 hour reporting time compared to direct chromogenic agar cultures with a sensitivity of 80% and >24 hour reporting and enriched chromogenic agar testing with a sensitivity of 90% and >48 hour reporting (am j clin pathol, 2009); both reduced sensitivity and prolonged reporting time negatively impacting the success of mrsa timely isolation. we have shown that capturing 33% of mrsa isolation days in a modest mrsa prevalence setting (9 infections/10,000 patient days) with a high sensitivity test having a >24 hour result reporting time did not reduce hospital-wide mrsa disease (ann int med 148:209, 2008) . others have demonstrated that surveillance in an icu with similar mrsa prevalence, again with a high sensitivity test having 1 day result reporting, did not reduce icu disease until preemptive isolation was initiated (crit care 10: r25, 2006) . finally, we demonstrated that universal admission surveillance and decolonisation capturing 85% of possible mrsa isolation days had a dramatic impact by reducing 70% of all in-hospital infections from mrsa. future research in this area should focus on better defining those patients that benefit from mrsa screening and the role of decolonisation in these programs. clostridium difficile infection (cdi) is a toxin-mediated intestinal disease and extraintestinal manifestations are exceptional. clinical outcomes can range from asymptomatic colonisation to mild diarrhoea and more severe disease characterised by inflammatory lesions and pseudomembranes in the colon, toxic megacolon or bowel perforation, sepsis, shock, and death. the main clinical symptoms, secretory diarrhoea and inflammation of colonic mucosa, can be in great part explained by the actions of two large protein toxins, toxin a (tcda) and toxin b (tcdb). both toxins are cytotoxic, destroy the intestinal epithelium and decrease colonic barrier function by disruption of the actin cytoskeleton and tight junctions resulting in a decreased transepithelial resistance allowing fluid accumulation. in addition, c. difficile toxins also cause release of various inflammatory mediators which affect enteric nerves, sensory neurons and promote inflammatory cells, adding to the fluid secretion, inflammation and transmigration of neutrophils. some experimental evidence points also to possible extraintestinal action of c. difficile toxin b. in zebrafish embryos tcdb caused damage and edema in cardiac tissue and in hamsters the same toxin caused lung damage. only recently efficient systems have been developed to genetically manipulate c. difficile. comparison of knock-out mutants producing only one of both toxins have shown that tcdb-positive-only mutants retain the ability to kill hamsters, whereas tcda-positive-only mutants were not virulent for hamsters. these results are in concordance with epidemiological findings that naturally occurring a-b+ strains still cause the entire spectrum of cdi, but are not in concordance with effects observed after intragastric challenge of hamsters with purified toxins tcda and tcdb. the role of the third toxin produced by c. difficile, binary toxin cdt in the development of human disease is not well understood. cdt was shown to have enterotoxic effect in rabbit ileal loop assay, but natural strains producing cdt but neither tcda nor tcdb colonised animals but were not lethal in hamsters. comparative genomic analysis will most likely reveal additional factors involved in pathogenesis and in increased virulence (including cell surface layer proteins, sporulation characteristics and antibiotic resistance). additionally, the role of the host immune response in cdi has just started to be better understood. since 2002, there has been an escalation in rates of clostridium difficile infection (cdi) with epidemic c. difficile (pcr ribotype 027/north american pulsed-field type 1 [nap1]) responsible for outbreaks of severe infection in north america and europe. while fluoroqinolone resistance and over-use are thought to be driving the epidemic, the ageing population and improved case ascertainment are contributing to the dramatic increase in cases. other factors may also be important, such as the increase in prescription of proton pump inhibitors. in the netherlands, since 2005, there has been an increase in prevalence of human cdi with ribotype 078 strains usually found in animals. these infections were in a younger population and more frequently community acquired. there was alarm when it was reported that 20% of retail beef samples in canada contained c. difficile. the figure is higher in the usa where more than 40% of packaged meats (beef, pork and turkey) from 3 arizona stores contained c. difficile. most animal isolates of c. difficile produce binary toxin, and both pigs and cattle harbour pcr ribotype 078 a strain that, like ribotype 027, also produces more toxins a and b, and binary toxin. in the eastern part of the netherlands where >90% of pig farms are located, >20% of human isolates are now ribotype 078, and human and pig strains of c. difficile are highly genetically related. it has been suggested that the overlap between the location of pig farms in the netherlands and the occurrence of human ribotype 078 infections involves a common source. that source is likely to be the environment. the upsurge in cdi has prompted diagnostic companies to try to either improve current tests or develop new ones. laboratory diagnostic methods can be divided into 3 groups; traditional faecal cytotoxin detection (with or without culture), enzyme immunoassays (eias) and molecular methods. faecal cytotoxin detection is specific but lacks sensitivity, culture is sensitive but lacks specificity. new eias should find a niche in medium sized laboratories. current in-house pcr methods have the potential for great sensitivity and specificity but have been available only in larger laboratories. new commerciallyavailable platforms will make this methodology more accessible to smaller laboratories. whatever method is chosen, it is necessary for the laboratory to have as fast a turn-around-time as possible, particularly in an outbreak situation. d. lévy-bruhl°(saint-maurice, fr) in 2005, the advisory board on immunisation (abi) has been asked to make recommendations to the ministry of health regarding the inclusion or not in the french immunisation schedule of the soon to be licensed first hpv vaccine. the main elements considered in the establishment of the benefit-risk balance of routine hpv vaccination were: on the benefit side: -the very significant potentially preventable burden of diseases; -the very high efficacy of the vaccine against persistent hpv 16/18 infections in naive subjects; -the expected additional impact on other hpv16/18 related lesions and cancers; -the fact that vaccination, by preventing the pre-cancerous lesions, has the advantage over screening to reduce the cost and anxiety related to their detection and management; -the available data in favour of a satisfactory safety profile; -the benefit of vaccination for the women not covered by the opportunistic screening program. on the "risk" side: -the high cost of vaccination; -the unknown duration of protection; -the need for continuation of screening, even for vaccinated women; -the fact that the majority of residual cervical cancers could be prevented by the organisation of the screening program; -the risk of a decrease in compliance to screening for vaccinated women; -the low benefit if vaccinated and screened women were the same. a cost effectiveness analysis, carried out on a multi cohort markov model, showed that, over a 70 years period, the impact of vaccinating 80% of 14 years old girls or of organising the screening were comparable (reduction of cancer deaths close to 20%). however, the cost-effectiveness ratio of the vaccination was higher than that of the screening organisation, resp. 45,200 and 22,700 € per life year saved (at a 3% discount rate). on the basis of the economical analysis, the screening organisation was therefore the first priority. however, if both interventions were implemented, the overall reduction in cervical cancer deaths was estimated at 32%. the cost-effectiveness of the addition of vaccination on the top of the organisation of the screening appeared acceptable (55,000 € per life year saved). based on those results, the abi issued in march 2007 a recommendation to include the hpv vaccination in the immunisation schedule for 14 years old girls, together with a catch up for 15 to 23 years old women not having started their sexual life more than one year ago. the vaccine cost has been reimbursed since july 2007. clinical microbiology − is outsourcing the way to go? s338 the (r)evolution of clinical microbiology in europe − is it good or bad? laboratory medicine in general and clinical microbiology in particular is presently subject to rapid (r)evolution. are we aware? are we in command? do we know where we are going? should we oppose or cooperate? do we have a choice? do we recognise a driving force other than money? is it good, bad or just plain necessary? and are we gaining or losing? it is not one evolutionary process -it is several parallel processes with varying emphasis in different areas. there are at least four distinctive major trends over the last 15 years; the gradual formation of bigger and bigger units (concentration), the amalgamation of many different laboratory services into one (laboratory medicine), accreditation and an explosion of professional proficiencies and backgrounds of staff in microbiological laboratories. personally i have withstood the first two, with pleasure succumbed to the latter. a recent 5th trend, outsourcing microbiology services to large private consortiums, is splitting clinical microbiology into a purely analytical high-throughput money-saving activity, often leaving the consultative, clinical part of microbiology and health care infection control adrift. what is driving the evolution? not only cost-saving but also our inability to recruit medically trained microbiologists, the need to broaden the knowledge base of microbiology laboratories, automation, the development of new techniques and apparatus common to many laboratory disciplines, computerised medicine, political trendiness, power struggles, and much more. there is much to be gained by both concentration and amalgamation but much to be lost as well and many consider the heart and soul of clinical microbiology at risk. over a period of years, rational high-throughput production has won over consultation and personalised microbiology. that may be fine for the production of negative hiv-antibody/antigen analysis as for the screening of blood-donors but certainly not for the bacteriological cultures taken in conjunction with a hip replacement. or when it comes to understand and advise on the intricacies of antimicrobial resistance development. in other cases "outsourcing" and/or "amalgamation" mean that blood cultures are sent to x-town, cmv-antibodies to y-town and everything else to z-ville. when that happens clinical microbiology is lost. there are several instances where concentration, amalgamation and/or outsourcing of clinical microbiological services, alone or with other services, have meant that the tie between clinical microbiology and infection control has been severed and that many, both small and large hospitals have lost the personalised service so necessary to control outbreaks of multi-resistant bacteria and other health care related infections. a good service requires a strong knowledgeable and enthusiastic champion. a service which encompasses too many branches of laboratory medicine cannot be expected to champion each and every one with equal strength and fervour. and when outsourced to "big companies", there is no "clinical", only "microbiology". in 2008 "medical microbiology" broke out from "laboratory medicine" in uems. we are now striving towards a strong "medical microbiology" service in europe. it will have many facets, much strength, some weakness, great opportunities, but many threats. escmid certainly intends to help shape microbiology in europe. the optimal organisation of microbiology laboratories in european metropolis is an evolutionary task, driven by the evolution in laboratory tasks, laboratory technologies, communication technologies, regulations and financial issues. in the past five-ten years, medical and societal query for a more rapid and refined detection and identification of pathogens and antimicrobial resistance determinants coincided with the expansion of internet-based and remote tools for communication, an unprecedented revolution in laboratory technologies and new financial constraints. the concentration of laboratory workforces into one unique laboratory is one way to address these apparently contradictory issues. the tertiary medical school hospital system in marseille, a 2-million metropolitan area in france, comprises four hospitals for a total of 3,500 beds. the system had once four microbiology laboratories which have been progressively embedded into a unique, 600,000 acts per year, laboratory which deals with bacteriology, virology and environmental microbiology and hygiene. the medical staff comprises of 17, the ingenior staff of 11, technical staff of 88 and support staff of 13 persons for a total of 129 persons. this organisation allowed reducing labour time for routine microbiology, to develop prospective and sophisticated time-consuming diagnostic methods and to develop advanced diagnostic methods such as molecular methods (real-time pcr-based tests, sequencing, and mass spectrometry identification) and new generation serology. new, sophisticated technologies such as automated serology and mass spectrometry were corner-stones on which to base the constant diminution of routine labour time and the development of time-consuming tasks such as fastidious organisms' isolation. these evolutions paralleled the exponential increase in the ratio of ingeniors in the laboratory. this paradigm allowed for the constitution of large collections of biological specimens for retrospective analyses, the specialisation of every medical senior in one particular field of internationally recognized expertise and the increase in knowledge output in terms of peer-reviewed papers, patents and grants. implantation of point-of-care in the emergency department, in permanent internetbased connection with the central laboratory, was the last, but not least, evolution of this system. when tuberculosis epidemiology is seen in a global perspective, and the millennium development goals are considered, it is clear that two regions of the world, africa and europe, are severely behind in the control of the disease. in africa, especially sub-saharan africa, the tb problem is closely related to the endemic hiv/aids situation. in europe, especially the eastern part and in parts of the former soviet union, the main obstacle to an effective tb control is related to drug resistant forms of m. tuberculosis. the prevalence of the most severe forms of resistance, mdr-and xdr-tb, is so high that it makes control efforts both extremely complicated and very expensive. unfortunately, increasing levels of drug resistant tb are today also seen in many african countries, and hiv infection is spreading in eastern europe. during the last ten-year period new tools, based on molecular fingerprinting of m. tuberculosis strains, have been increasingly adapted to study tb transmission. with such molecular methods to characterise clinical isolates of m. tuberculosis it is now possible to study the spread of individual strains of the bacteria in detail. the laboratory tools used, rflp, miru/vntr, spoligotyping and others, will be presented and their use exemplified. how molecular epidemiology contributed to the detection and characterisation of a major outbreak of drug resistant tb in the stockholm area will be discussed. molecular characterisation of clinical isolates from different parts of the world has led to an increased recognition of the differences between different families of m. tuberculosis strains. to further describe and understand the role of these differences in the clinical field as well as for tb epidemiology is an ongoing and interesting field of research. an increased understanding of how tb is transmitted will hopefully help in the efforts to control this global health threat both on the local level and in a global perspective. living in the era of increasing tuberculosis drug resistance, the importance of making an early and accurate diagnosis with drug sensitivities has never been greater. the epidemiology of tuberculosis defines the extent of latent disease and the proportion which becomes active. accurate diagnosis is vital if patients are to be treated in a timely manner and to reduce the amount of time infectious individuals go untreated in the community disseminating disease. in many areas of the world, dots programmes are at the forefront of tuberculosis control. however, as a diagnostic this currently relies on sputum smear microscopy which is known to miss 50% of cases of tuberculosis and provides no data on drug sensitivity. the second major issue around tb is the lack of worldwide diagnostic facilities. there is a need for a simple, low cost, easily implemented diagnostic test. this talk will briefly consider the issues around the diagnosis of latent and active disease which are quite distinct. the focus will be on the diagnosis of active infection. in particular, the use of mods (microscopic observation drug-susceptibility) assay in diagnosis of tuberculosis will be discussed. the potential for using this in resource poor countries will be reviewed as well as the way sophisticated technology maybe harnessed to improve reporting and allow translation to all parts of the world. the important issue of how to distinguish patients with latent and active disease will also be considered. key issues and principles in diagnosis both now and in the future will be reviewed. in terms of treatment, there are 2 main issues. the first is that even short-course therapy is prolonged being a minimum of 6 months leading to issue of compliance. this may result in drug resistance. the massive rise of multi-drug resistant tuberculosis to approximately 500,000 cases world-wide with around 50 countries reporting extensively drug-resistant disease means that the need for new approaches to therapy are urgent. the second part of this talk will review different approaches to using current anti-mycobacterial drugs, the emergence of a small number of new drugs such as the diarylquinolones and entirely novel approaches to control and treat tuberculosis. there has been great success and also many threats in the field of infectious diseases during the previous year. the antimicrobial resistance, especially increasing carbapenem resistance among aerobic gram-negative rods and xdr mycobacterial tuberculosis strains are already big threats in some countries and they will probably spread to many other areas all over the world in the future and we will need new drugs for these indications but unfortunately very few new promising drugs seem to be in the pipeline at the moment for these purposes. the virulent clostridium difficile 027 strain spreads rapidly to many new countries and e.g. in finland it killed many times more people compared with mrsa and esbl strains in 2008. however, it is possible to stop its spreading but it needs new thinking in antibiotic use policy and infection control policy in hospitals. clostridium difficile 027 infection has a high relapse rate after metronidazole or vancomycin therapy, but an experimental "stool exchange treatment" is a promising therapy although controlled studies are needed to prove this assumption. an interesting research area during the last years has been the role of infections in the etiopathogenesis of chronic diseases like cancer, atherosclerosis, cardiovascular diseases and many autoimmune diseases. we can fight against many cancers like liver cancer and cervix cancer with virus vaccines and gastric cancer with antimicrobial drugs. also the high incidence of malignant tumours seems to decrease during haart treatment in hiv patients. the role of infections in the etiopathogenesis of cardiovascular diseases and atherosclerosis is complex. it is obvious that infections play a role in the etiopathogenesis of atherosclerosis, stroke and myocardial infarction but the undirected routine antimicrobial treatment is not recommended for these patients but there seems to be subgroups in patients with various cardiovascular diseases which may benefit from antimicrobial treatment. recent studies seem to suggest that there are hla types which protect or make people susceptible for coronary heart disease. the hla type hla-b*35 seems to be a risk factor for coronary heart disease but it is also a risk factor for chronic chlamydia pneumoniae infection. the feared pandemia due to h5n1 influenza a did not appear during the recent year and the world is now much more prepared to meet the next pandemia which, however, hopefully does not come during the next year. ø. samuelsen°, c. giske, u. naseer, s. tofteland, d.h. skutlaberg, a. onken, r. hjetland, a. sundsfjord (tromsø, no; stockholm, se; kristiansand, bergen, oslo, førde, no) objectives: the worldwide dissemination of kpc-producing multidrugresistant enterobacteriaceae is worrisome. the first kpc-producing klebsiella pneumoniae in norway was isolated late 2007 from a patient after hospitalisation in greece. throughout the following year seven additional kpc-producing k. pneumoniae isolates have been detected in clinical samples from six new patients. the aim of this study was to perform molecular characterisation of the strains and examine their epidemiological relatedness. materials and methods: antimicrobial susceptibility was examined by etest. molecular characterisation was performed by mlst, pfge and sequencing of the blakpc genetic structure. plasmid analysis was carried out by pfge of s1 nuclease-digested total dna and southern blot hybridisation using a blakpc probe. relevant epidemiological data were collected retrospectively. results: eight kpc-producing clinical isolates of k. pneumoniae have been identified from seven patients in two different regions of norway from the following specimens: blood culture (n = 3), urine (n = 2), expectorate (n = 1), perineal swab (n = 1) and wound secretion (n = 1). two blood culture isolates with clonally related but different pfgeprofiles were observed in one patient. the detection of kpc-producing k. pneumoniae isolates in norwegian patients was associated with import in four cases after hospitalisation in greece. two patients had been hospitalised at the same hospital in greece. isolation of a kpc-producing isolate in a fifth patient was epidemiologically linked to one of these imported cases and was a case of nosocomial transmission in norway. for the latter two cases no risk factors were identified with respect to recent hospitalisation or travel abroad. molecular analysis of six isolates has shown genetically related pfge-patterns and a common sequence type (st258). st258 has been associated with dissemination of ctx-m-15 in hungary. the blakpc gene was localised in tn4401 on a~97 kb plasmid. the two most recent isolates are currently undergoing similar analysis. conclusion: the first seven cases of kpc-producing k. pneumoniae in norway are associated with hospitalisation abroad, nosocomial transmission in norway, or urinary tract infections in outpatients without obvious risk factors. the clonal relationship between isolates underlines the existence a biological fit genetic lineage of kpcproducing k. pneumoniae with an epidemic potential. objectives: two recent publications have reported the isolation of kpc producing k. pneumoniae from infections in two patients, one in france and one in sweden, who originally had been hospitalised in greece. since this resistant mechanism had not been identified before in this country, the purpose of this report was to confirm the presence of blakpc producing k. pneumoniae in greece, to assess the extent of its spread and to study the genetic relatedness of the respective bacterial strains and the transferability of the blakpc harbouring plasmids. methods: for a three month period (february to april 2008) 40 hospitals participating in the greek system for surveillance of antibiotic resistance (www.mednet.gr/whonet) were asked to seek for possible kpc producers among k pneumoniae isolates displaying reduced susceptibility to imipenem (equal or higher than 1 mg/l), a positive hodge test for the presence of carbapenemase and a negative edta synergy test for the presence of metalloenzymes. the presence of blakpc gene in these strains was confirmed by pcr and sequencing. mics to carbapenems were determined by etest. conjugation experiments were carried out both in broth and on agar. the possible absence of ompk36 porin was detected by pcr. molecular typing was performed by pulse-field gel electrophoresis of xbai-restricted genomic dna. results: ninety two k. pneumoniae clinical isolates (one per patient) from 13 hospitals all over greece were found to harbour blakpc-2 gene. although colonies present in the inhibition zone made the exact determination of imipenem mic difficult, the absence of ompk36 porin was always associated with mic of imipenem higher than 32 mg/l. all isolates exhibited resistance to all other drug classes except colistin, tetracycline and tigecycline. pfge analysis revealed that 85 isolates from 12 hospitals displayed more than 95% similarity and were classified into one pulsotype, whereas the remaining seven isolates belonged into four different pulsotypes. blakpc-2 gene could not be transferred by conjugation from strains belonging to the main pulsotype. however, it was transferred from strains belonging to three out of the four remaining pulsotypes. conclusion: production of kpc-2 betalactamase seems to be a new emerging resistance mechanism in klebsiella pneumoniae in greece. blakpc-2 gene's possible clonal spread imposes the urgent need of implication of infection control practices in the affected hospitals. i. galani, m. souli, e. papadomichelakis, f. panayea, n. mitchell, a. antoniadou, g. poulakou, f. kontopidou, h. giamarellou°(athens, gr) background: until now, carbapenem resistance among klebsiella pneumoniae (kp) clinical isolates in greek hospitals has been attributed to the dissemination of vim-1 metallo-beta-lactamase. we describe the first outbreak of kpc-producing kp in greece; the first to occur outside the usa or israel. setting: 21-bed icu of attikon university hospital, athens. methods: kp isolates with an imipenem mic > 1 mg/l and a negative edta-imipenem disk synergy test were submitted to boronic acid disk test, to pcr for a kpc gene with specific primers and sequencing. records from patients colonised or infected with a kpc-producing kp were retrospectively reviewed for clinical and epidemiological data. environmental cultures for kpc-producers were performed. clinical isolates were submitted to molecular typing using pfge. results: from february to november 2008, 552 kp were isolated from 95 patients, 132 (23.9%) of which were boronic acid positive and produced kpc-2. most of them (126/132, 95.5%) were isolated since august. a total of 24 patients were identified as colonised or infected by a kpc producer which in 22 of them belonged to the same genetic clone. the source was faeces (73), bronchial secretions (26), blood (7), cvc tip (5), urine (15), pus (4) and throat (2). among patients whose medical records were available, median age was 74, apache ii score; 21, length of preceding hospital stay; 28 days, total length of stay; 50 days, immunosuppresion was identified in one and crude mortality was 71%. the kpc-producing kp was more frequently icu acquired whereas in a minority of patients it was already present on icu admission. seventy percent of the patients had previously received a carbapenem for a median of 15 days. environmental colonisation was not identified. ten (7.6%) of the kpcproducers from 8 (33.3%) patients were identified as the cause of an infection: bacteraemia (7), ventilator-associated pneumonia (2) and surgical site infection (1) and exhibited mic90 (mg/l) for imipenem, >8; meropenem, >8; gentamicin, 4; ciprofloxacin, >2; fosfomycin, >128; colistin, 0.5 and tigecycline, 4. most patients were successfully treated with a colistin-containing combination mostly with a beta-lactam. there was no attributed mortality. isolates from the same bacterial species were typed by pfge or automated ribotyping. kpc-encoding gene was fully sequenced. plasmid preparations and i-ceu digestion of total dna were resolved in agarose gels, blotted and hybridised with a blakpc probe. the blakpc-carrying element (tn4401) was amplified with various primer pairs, digested with eag i and sequenced. results: 30 strains each carried kpc-2 and kpc-3. one e. cloacae carried kpc-4. 13 k. oxytoca were kpc-2-producers and 2 s. marcescens harboured blakpc-3, all from usa. great genetic diversity was observed among the isolates (41 different types). one clone of 10 e. cloacae was detected in new york state (2006) (2007) . small clusters of 2 and 3 strains were detected among e. coli, e. cloacae, k. oxytoca. plasmids were present in all but 3 isolates. persistence of clones throughout the years was not observed. in 35 isolates the kpc-encoding gene was located in high molecular weight plasmids (>54 kb). blakpc was located in the chromosome of 11 strains (e. cloacae, e. coli and k. oxytoca) and the location of this gene could not be determined in 15 strains. small plasmids were present in several strains, but did not harbour blakpc. tn4401 carried blakpc in 46 isolates, and the transposon element was conserved. this structure was not detected in 12 strains. conclusions: kpc-encoding genes were most often located in tn4401 among several enterobacteriaceae species collected in usa and israel. this blakpc-carrying element was located in plasmids and on the chromosome. this study highlights the importance of tn4401 in the dissemination of blakpc genes in several genetically diverse bacterial species. blakpc was not associated with tn4401 in only 12 of 61 strains. these strains are under further investigation. objective: to evaluate the carbapenem resistance mechanism in a raoultella planticola bacteraemia isolate recovered from a patient hospitalised in ohio, usa. methods: species identification was performed by vitek 2 and confirmed by 16s rrna sequencing. susceptibility testing used clsi broth microdilution method. blakpc was amplified and sequenced. the blakpc genetic element (tn4401) was amplified and sequenced. plasmid extractions and conjugation experiments were carried out and the isolate was screened for esbl-encoding genes, qnr and qepa. a 83 year old female patient was admitted to a hospital located in akron with a diagnosis of cap in may/2008. sputum, paracentesis and blood cultures were negative. urine culture grew e. coli and patient received courses of moxifloxacin, ceftriaxone, azithromycin and meropenem. the patient was discharged and returned after three weeks with respiratory problems. tracheal aspirate grew a multidrug resistant a. baumannii and the blood culture grew the enteric-like gramnegative bacillus. the isolate was identified as r. planticola by the vitek 2, which was confirmed by 16s sequencing. r. planticola strain demonstrated resistance against most b-lactams, including carbapenems. screening for kpc-encoding genes was positive and this strain carried blakpc-2. fluoroquinolone and aminoglycoside mic values were elevated. kpc-2-encoding gene was located in tn4401, but conjugation experiments failed. esbl and qnr/qepa genes were not detected. conclusions: kpc serine-carbapenemases have been detected in several gram-negative species commonly isolated from clinical specimens. kpc genes are embedded in transposon-like structure usually harboured in conjugative plasmids carrying multiple antimicrobial resistance mechanisms. this is the first report of kpc-producing r. planticola that is an environmental organism related to klebsiella spp. the similarity between these organisms could facilitate the transfer of genetic material. kpc-producing isolates appear to be prevalent among different enterobacteriaceae species in usa hospitals and was detected in an isolates of apparent environmental origin. objectives: it is long known that not all individuals with a specific disease present with the same clinical manifestations, nor do they have identical prognoses or responses to treatments. it has become clear that variations in the human genome are likely to have an impact on these aspects. tank-binding kinase 1 (tbk1) is a central molecule in the induction of a.o. the type i interferon response to pathogens. our goals for this study were 1) to investigate the frequency of single nucleotide polymorphisms (snps) in the promoter and coding region of tbk1 in a dutch caucasian population and 2) to search for potential associations between these snps and bloodstream infections. methods: whole blood samples or samples of positive blood cultures were collected and after genomic dna was isolated, pcr and sequencing were performed for snp identification. functional studies included promoter activity measurements using a luciferase assay as well as electrophoretic mobility shift assays (emsa) to study binding of the transcription factor usf1 to the wt and mutant promoter. snp incidences were studied in a case control study. results: in samples from dutch caucasian healthy volunteers, 4 snps were found with allele frequencies higher than 5% whereas 6 other known snps had frequencies lower than 5% in our cohort. two snps (rs89208169 and rs89208163) located in the promoter region were studied in a larger cohort of 350 anonymised patients from the maastricht university medical center with either gram-positive or gram-negative blood cultures. we found that the prevalence of rs89208169 was significantly increased in patients with positive blood cultures in comparison with those with negative blood cultures or healthy volunteers. further investigation of this snp showed that it is located just outside a usf1-binding site. measuring the promoter activity using luciferase assays, the mutant promoter exhibited a decreased activity of <35%. this observation was confirmed by emsa which showed that recombinant usf1 protein had a reduced binding affinity to the mutant promoter. conclusions: snp rs89208169 in the promoter region of tbk1 has a significant association with gram-positive infections. our results demonstrate that this is likely due to a decreased expression of tbk1 due to reduced binding of the transcription factor usf1 to the mutant promoter. our results support recent findings that tbk1 plays also an important role in the host response to gram-positive infections. objective: lymphocyte apoptosis has been recognized as an important factor contributing to both the onset of sepsis post infection and to the progression into septic shock. animal data suggest that prevention of lymphocyte apoptosis by caspase inhibition stabilises the immune system, improves bacterial clearance and decreases mortality in experimental sepsis. the present study evaluated the potential of vx-166, a novel broad caspase inhibitor, as a therapy for sepsis. methods and results: initial characterisation of vx-166 in a number of enzymatic and cellular assays clearly demonstrated that the compound is a broad caspase inhibitor with potent anti-apoptotic activity in vitro. in vivo, vx-166 was tested in a murine model of endotoxic shock and a clinically relevant model of peritonitis. in the endotoxic shock model, male cd-1 mice (n = 28 per group) were administered lps (20 mg/kg iv) and survival was monitored for 96 h. vx-166 administered by repeat iv bolus (0, 4, 8 and 12 h post-lps) significantly improved survival in a dose-dependent fashion (p < 0.0001). in the rat peritonitis model, adult male sprague-dawley rats (n = 12 per group) underwent caecal ligation and puncture (clp) and survival was monitored over 10d. continuous administration of vx-166 by mini-osmotic pump (0.9 mg/kg/h) immediately following surgery significantly improved survival (p < 0.01) from 38% in the control group to 88% in the compound-treated group. mode of action studies in the rat clp model confirmed that vx-166 reduced thymic atrophy and lymphocyte apoptosis (p < 0.01), supporting the anti-apoptotic activity of the compound in vivo. in addition, vx-166 reduced plasma endotoxin levels (p < 0.05), strongly suggesting an improved clearance of bacteria from the bloodstream. most importantly, we demonstrated that vx-166 fully retained its efficacy when dosed 3 hours after insult (p < 0.01) by improving survival to 92% versus 42% in control animals, further highlighting the potential of anti-apoptotic therapy in sepsis. overall these data demonstrate that vx-166 inhibits lymphocyte apoptosis, improves the clearance of bacterial endotoxin and improves survival in experimental sepsis. importantly vx-166 improves survival in the clp model when dosed post insult, and therefore represents significant progress in the development of therapeutically viable broad caspase inhibitors for the treatment of this disease. v. vankerckhoven°, s. van voorden, n. hens, h. goossens, g. molenberghs, e. wiertz (wilrijk, be; leiden, nl; hasselt, be) objectives: toll-like receptors function as key regulators of both innate and adaptive immunity. lactobacilli modulate the immune system in different ways. the aim of this study was to examine toll-like receptor (tlr2, tlr2/6 and tlr4) signalling induced by clinical and probiotic lactobacillus strains. methods: a total of 45 lactobacillus strains (19 l. paracasei and 26 l. rhamnosus) of different origin (22 probiotic, 2 faecal, and 21 clinical) were tested for tlr2, tlr2 in combination with tlr6, and tlr4. tlr signalling was measured as relative il-8 promotor activation in transfected human embryonic kidney (hek) 293 cells. il-8 concentrations were measured using an enzyme-linked immunosorbent assay. heat-killed listeria monocytogenes (hklm) was used as positive control in all assays, whereas pam3, pam2, and lps were used as positive controls for, respectively, tlr2, tlr2/6, and tlr4. all assays were performed at least in duplicate. linear mixed model analyses and stepwise model selection were used to identify the statistically significant effects. random effects were used to account for heterogeneity across and homogeneity within isolates. p < 0.05 was considered statistically significant. results: hek-tlr2 and hek-tlr2/6, but not hek-tlr4, cells released il-8 upon stimulation with uv-inactivated lactobacilli, which was enhanced by co-transfection with cd-14. interestingly, the production of il-8 was shown to be variable for the different lactobacillus isolates. although similar results were seen for all isolates for tlr2 and tlr2/6, il-8 production was significantly higher for tlr2 (8.4 log pg/ml) compared to tlr2/6 (6.05 log pg/ml) (p < 0.0001). no significant differences in il-8 production were seen between clinical and probiotic isolates. however, l. rhamnosus isolates induced a significantly higher il-8 production compared to l. paracasei isolates in both cell lines, 7.88 and 6.84 log pg/ml, respectively (p = 0.0004). intra-isolate correlation was found significant (p < 0.0022). conclusions: our study shows that lactobacilli activate both tlr2 and tlr2 in combination with tlr6. our results also indicate that heterodimerisation of tlr2 with tlr6 does not lead to an improved recognition of lactobacilli. furthermore, taking intra-isolate correlation into consideration proved to be important. finally, our results suggest that differences in immunomodulation by lactobacilli may be related to differential signalling through tlrs, including tlr2 and tlr2/6. m.c. gagliardi, v. sargentini, r. teloni, m.e. remoli, g. federico, m. videtta, g. de libero, e. coccia, r. nisini°(rome, it; basel, ch) objective: to gain insights into the mechanisms used by mycobacterium tuberculosis and bacillus calmette guérin to cause human monocytes differentiation into cd1 negative dendritic cells (my-modc), unable to present lipid antigens to specific t cells. methods: human monocytes infected or not with mycobacteria were induced to differentiate into dc with gm-csf and il-4 in the presence or absence of p38 or erk specific inhibitors. kinases activation was detected by western blot using antibodies specific for phosphorylated and non phosphorylated isoforms. differentiation of monocytes into dc and the cd1a, cd1b and cd1c expression was evaluated by flow cytometry and by real time pcr at different time points from infection. functional expression of cd1 molecules was assessed by recognition of lipid antigens by cd1 restricted t cell clones. results: we show that mycobacteria trigger phosphorylation of erk and p38 mitogen-activated protein kinase in human monocytes as well as of activating transcription factor (atf)-2. mycobacteria-infected monocytes treated with a specific p38 inhibitor, but not with a specific erk inhibitor become insensitive to mycobacterial subversion and differentiate into cd1 positive my-modc, which are fully capable of presenting lipid antigens. data indicate that phosphorylation of p38 is directly involved in cd1 inhibition. conclusions: we propose p38 signaling as a pathway exploited by mycobacteria to affect cd1 expression, thus representing a novel target of possible pharmacological intervention in the treatment of mycobacterial infections. s. ebert°, s. ribes, r. nau, u. michel (gottingen, de) objective: activin a (act a) is a multifunctional cytokine with roles in the immune system and the inflammatory response. act a levels are elevated in the cerebrospinal fluid of patients with meningitis. microglial cells, the major constituents of innate immunity within the brain, express toll-like receptors (tlrs) recognising exogenous and endogenous ligands. upon stimulation with tlr agonists, primary mouse microglial cells become activated and release nitric oxide (no), cytokines, and also act a, suggesting that they are a source of elevated conclusions: pre-treatment with act a enhances no release from microglial cells activated by agonists of the principal tlrs involved in the recognition of bacteria. these findings provide further evidence for a role of act a in the innate immune response and suggest that act a acts as an pro-inflammatory modulator during infection and inflammatory processes in the cns. insertion sequences (is) are genetic tools that can mediate expression of previously silent genes or be responsible for the overexpression of certain genes (in each case by providing promoter sequences). in addition to be involved in gene transcription levels, is elements also play a very important role for gene acquisition/mobilisation. an is is usually made of of two inverted-repeat sequences (irs) bracketing a gene encoding the transposase which activity enables this entity to replicate and target another sequence. the is-related mechanisms at the origin of antibiotic resistance gene acquisition are diverse, including composite-transposition, rolling-circle transposition, one-ended transposition. is elements may be also involved in gene acquisition by mediating co-integration processes, or recombination events as hypothetized for is26 in relation with blashv extendedspectrum b-lactamase (esbl) genes originating from the chromosome of klebsiella pneumoniae. the blactx-m esbl genes known to be extremely widespread worldwide are encoded on plasmids, and have been found in association with isecp1 (acting by one-ended transposition) or iscr1 (acting by rolling-circle transposition). in that case, iss have played a role in the mobilisation from the chromosome of kluyvera spp. being the blactx-m progenitors and then in their expression. also, genes encoding acquired ampc b-lactamases, being of the blaacc, bladha, and blacmy-types, are mostly found in association with iscr1 or isecp1. sometimes antibiotic resistance genes are mobilised by composite transposons which are made of two copies of a given is bracketing the mobilised fragment. in acinetobacter baumannii, the worldwide disseminated blaoxa-23 carbapenemase gene is part of a composite transposon structure made of two copies of isaba1, forming transposon tn2006 which had mobilised a chromosomal fragment from acinetobacter radioresistens that actually corresponds to the progenitor of blaoxa-23. another possibility can be the forming of composite transposon structure bracketed by two different is (sharing similar irs) as observed with the blaper-1 esbl gene in pseudomonas aeruginosa. this diversity of iss elements at the origin of mobilisation/acquisition of antibiotic resistance genes is therefore responsible for the very efficient dissemination of many of them. s362 resistance islands − their role in the accumulation and spread of antimicrobial resistance genes historically, multi-antibiotic resistance in many bacterial species was largely attributed to the acquisition of resistance (r)-plasmids encoding one or more resistance determinants. however, over the last decade the r-plasmid paradigm has begun to be challenged. 'resistance islands' comprising large, chromosomally-integrated spans of alien dna harbouring multiple antibiotic resistance genes have been identified in the major hospital pathogens methicillin-resistant staphylococcus aureus (mrsa) and multi-resistant acinetobacter baumannii, and the foodand water-borne diarrhoeal pathogens shigella, salmonella and vibrio cholerae. in addition, comparative genomics analysis of the archetypal haemophilus influenzae conjugative resistance element that had spread worldwide revealed that it belonged to a large syntenic family of integrative islands, members of which could be found in at least 15 other b-and g-proteobacteria. with the exception of the a. baumannii island, these elements can be described as classic self-excising, -circularising and -integrative elements. all three functions are mediated by short island-flanking direct repeats and cognate integrase proteins encoded by the islands. in 2006 fournier et al. described an 86 kb a. baumannii island (abar1) which harboured 45 resistance genes packaged within a highly mosaic, integron-rich element that had almost certainly evolved via recombination, transposition and integron-mediated cassette capture from an 'empty' ancestral prototype. abar1 probably represents a new class of resistance island as it exhibits several features reminiscent of complex nested transposons, suggesting a distinct functional natute. however, despite the widespread distribution of resistance and genomic islands only a minority are known to code for part or all of the conjugative machinery necessary for their dissemination; others have been mobilised by helper plasmids or bacteriophages. regardless, data on the mechanisms of mobilisation of the vast majority of similar nonresistance islands remain sparse. importantly, resistance islands may not consists merely of packages of resistance genes. on the contrary, these diverse and frequently hybrid entities could potentially confer upon their hosts other advantageous traits relating to host-pathogen interaction, virulence, survival in the environment and/or transmissibility, truly justifying the label 'selfish islands' and further explaining their evolutionary success. due to the availability of new techniques, genome sequencing of bacteria has become fast and inexpensive. furthermore, recent methods using paired-end reads located several kb apart in the genome eases the assembling process, even though no reference sequence is available. in a reasonably close future, it should be possible to obtain the fully assembled sequence of a bacterial isolate overnight. the new sequencing techniques generate enormous amounts of genomic data and, thereby, a need for new tools. these should able to quickly analyze genomes and point to zones of interest, prompting further analysis on a reduced number of regions or genes, such as genomic islands. pathogenicity islands, a subset of genomic islands, carry genes such as toxins or resistance genes and have the particularity to be mobile, i.e. they may transfer to other species or strains. thereby, they confer their new hosts a more resistant or infectious phenotype, making this phenomenon particularly important to study. nucleotide composition of genomes is fairly homogeneous inside bacterial genomes. in general, horizontally transferred regions can be spotted due to their particular nucleotide content, because they tend to retain the composition of their original host and don't share the one of their new hosts. to do an analogy with languages, genomes speak dialects, and as one would easily spot a paragraph in finnish in an english text while not knowing finnish, one can spot genomic and pathogenicity islands transfers in a given genome. several techniques relying on various compositional aspects and on different algorithmic methods have been recently developed to detect pathogenicity islands in bacterial genomes. even very simple measures of the genome composition, such as the variation in t vs. a bias (ta skew) can lead to the identification of all known prophages in streptococcus pyogenes. it can even trigger the discovery of a putative ancient genomic island carrying a large number of genes related to pathogenicity in all strains of that species. in conclusion, with the rise of fast and inexpensive genome sequencing, new quick and simple methods are being developed. they take the advantage of the homogeneous nucleotide composition of bacterial genomes to uncover mobile genetic elements carrying genes involved in pathogenicity. in the past 10 years, significant progress has been achieved in the management of chronic hepatitis b with the successive development of six potent antiviral medications (lamivudine, adefovir dipivoxil, pegylated interferon alpha, entecavir, telbivudine and tenofovir). however, the clinical results of antiviral therapy have been limited by the emergence of antiviral drug resistance especially with the first generation of nucleoside analogs (lamivudine, adefovir and telbivudine). furthermore, the unique mechanism of viral genome replication and persistence within infected cells is responsible for viral persistence even after prolonged therapy with the newer antivirals (entecavir and tenofovir). this is the major reason why life-long treatment is envisaged in the majority of patients, which may expose them to long-term risk of developing resistance. the use of in vitro phenotypic assays has been crucial for the characterisation of newly identified resistant mutants and determine their cross-resistance profile. results allowed to understand the different mechanism of viral resistance to lamivudine and adefovir, the mechanism of primary failure to adefovir therapy, the unique mechanism of entecavir resistance, and to characterise the emergence of multi-drug-resistant strains in patients receiving sequential antiviral therapy. the crossresistance profile for the main resistant mutants was determined which allowed to provide recommendation to clinicians for treatment adaptation based on molecular virology data. the understanding of the development of hbv drug resistance has allowed to significantly improve the management of antiviral resistance and to design better treatment strategies to prevent resistance. the current standard of care relies on treatment initiation with antivirals combining a strong antiviral potency and a high barrier to resistance. a precise virologic monitoring is required to measure antiviral efficacy, and to diagnose partial response or viral breathrough at an early stage. this allows to adapt antiviral treatment preferrably using an add-on strategy with a drug having a complementary cross-resistance profile. this strategy has been shown to be efficient in controling viral replication and preventing liver disease progression in the majority of patients. treatment of chronic hepatitis b virus (hbv) infection is aimed at suppressing viral replication to the lowest possible level. in many prospective clinical trials it has been shown that a sustained hbv dna response was correlated with serologic, histologic, or biochemical responses. despite the recent progress in hepatitis b antiviral treatment, it is shown that antiviral drug resistance is inevitable against many of the nucleoside analogs. the emergence of antiviral-resistant strains of hbv leads to viral and subsequently biochemical breakthrough and may lead to disease progression and increased death. most of the data on the clinical impact of antiviral resistant hbv came from the data derived from studies of lamivudine therapy. there is limited data on other hbv antiviral drugs like adefovir. it is shown in several studies that treatment of hbeag-negative chronic hepatitis b with lamivudine effectively suppresses hbv replication and results in biochemical remission and histologic improvement in more than two thirds of patients. however, relapse has occurred in the majority of hbeag-negative patients after the cessation of therapy. there are several studies to support the occurrence of severe hepatic flares, and liver failure after the emergence of lamivudine resistance. several studies, where liver biopsies were taken, demonstrated that histological improvement was reduced in those patients experiencing lamivudine resistance. the clinical outcome for patients with antiviral resistance is related to their age, the severity of the underlying liver disease and the severity of the hepatic flares. on the other hand in a different study it was found that long-term lamuvidine treatment was associated with a reduced chance of developing cirrhosis and hcc in patients without advanced disease but, although resistant mutants reduced the benefits from lamivudine therapy, the outcome of these patients was still better than untreated patients. results of several clinical trials have shown that the addition or substitution of newer antiviral agents can restore suppression of viral replication, normalisation of liver function and reverse histological progression in patients with antiviral resistance. consequently, well-tolerated, potent therapies that offer a strong genetic barrier against the development of resistance are desirable, since antiviral resistance and poor adherence are key risk factors for treatment failure and subsequent reversal of clinical improvement. resistance of enteric fever-causing and non-typhoid salmonella serovars to agents traditionally used to treat these infections in the past shows extensive geographical variation. decreased susceptibility to ciprofloxacin is rapidly increasing all over the world with target alteration and increased efflux being the most important mechanisms behind. infections with such strains often result in extended hospitalisation or even in therapeutic failures. furthermore, it is likely that moderately increased mic values facilitate the development of strains with higher level of resistance, i.e. a pattern described at various locations. screening methods based on quinolone sensitivity testing may fail to indentify decreased fluoroquinolone susceptibility both in typhoid, as well as in non-typhoid salmonella. plasmid mediated quinolone resistance genes are detected increasingly all around the world although neither the frequency nor the variety of genes identified has approached that seen in some other members of enterobacteriaceae. treatment with gatifloxacin or azithromycin are alternative options for invasive and systemic infections caused by strains with decreased susceptibility to ciprofloxacin. at some parts of the world resistance to extended spectrum cephalosporins reached such incidence that may have therapeutic implications particularly when initial, empiric treatment of invasive infections is concerned. resistance is due to plasmid coded ampc type beta lactamases (particularly to cmy-2), and most often to esbls of which usually some of ctx-m types are the frequently encountered ones. carbapenem resistance is still rare, albeit does occur, among salmonella isolates. the recent description of a non-typhoid salmonella strain with the blaimp-4 gene co-located on a class-1 integron with several other resistance determinants on a conjugative plasmid is of particular concern. campylobacters exhibit natural resistance to a variety of antimicrobials. the drugs of choice used to be fluoroqunolones or macrolides. however, the current incidence of ciprofloxacin resistance made the former drugs already obsolete or seriously limited their use at several parts of the world. with the exception of few locations the incidence of macrolide resistance is still relatively low and is seen more frequently in c. coli than in c. jejuni. however, strains exhibiting resistance against both groups of drugs have been emerging, particularly in south-east asia. neisseria meningitidis, the meningococcus, is a major cause of meningitis and septicaemia worldwide while neisseria gonorrhoeae, the gonococcus, is responsible for one of the most widespread sexually trasmitted disease. the behaviour of these two species towards antibiotics is very different: resistance in n. gonorrhoeae is now widespread occuring as both chromosomally and plasmid mediated to a variety of drugs, whereas, besides resistance to sulphonamides, n. meningitidis remains largely susceptible to antibiotics used both for therapy and prophylaxis. however, as in the gonococcus, the resistance to antibiotics of n. meningitidis is also evolving, as documented by the ever higher frequency of strains with intermediate resistance to penicillin in many countries. transformation has apparently provided both species with a mechanism by which they can increase resistance to penicillin by replacing part of their pena gene, which encodes pbp2, with part of the pena gene of related species that fortuitously produces forms of pbp2 less susceptible to the antibiotic. n. meningitidis is still at this step, whereas n. gonorrhoeae has acquired also mutation in the pona gene that encodes pbp1, mutation in porin ib, increased expression of efflux pump and the tem-1 b-lactamase plasmid. the emergence and the spread of gonococci fully resistant to penicillin since the second half of the 1980 s years led to the recommended use of fluoroquinolones as primary therapy. however, this class of antibiotics became rapidly unefficacious, mainly in asia, due to the emergence of mutations in gyra and parc which are able to block the activity of the quinolones on gyrase and topoisomerase iv. since 2006, cdc no longer recommends their use for treatment of gonococcal diseases. fortunately, the occurrence of quinolone resistant meningococci, due to mutations in gyra, is still rare but even if cases are still few they are of great concern for the epidemic potential of this pathogen and the required prophylaxis of contacts. also for the other antibiotic, frequently used to this aim, rifampicin, some meningococci have showed to be resistant, again for the presence of mutations, in this case in the rpob gene coding for the b-subunit of the meningococcal rna polymerase. the molecular epidemiological identification of clonal clusters for both neisseria species with distinct resistance profiles is required to monitor ongoing trends that may pose problems both in therapy and prophylaxis. l. brookes-howell°, c. butler, k. hood, l. cooper, h. goossens (cardiff, uk; antwerp, be) introduction: grace is a european network of excellence established to focus on antibiotic use for community-acquired lower respiratory tract infection (lrti) and antimicrobial resistance across europe. grace-02, the second study to begin within grace, is a large qualitative study that explores the attitudes of clinicians and patients to antibiotic use for lrti and antibiotic resistance. aims: this presentation will focus on clinicians' accounts of the factors that contribute to variation in management of lrti and patient views on when antibiotics are necessary. methods: semi-structured interviews with 81 clinicians and 121 patients were conducted in primary care networks in nine european countries. interviews were audio-recorded, transcribed and, where necessary, translated into english for analysis. themes were identified, organised and compared using a framework approach. results: analysis of clinician interviews shows that, beside clinical findings, factors which influence the management decision for patients can be divided into two main areas. firstly, within each european network there is a group of country specific factors imposed by the system in which consultations take place. these factors include: near patient test usage, self-medication, patients' finances and lack of consistent, local prescribing guidelines. secondly, there is a group of factors, similar across all networks, that relate to personal characteristics of certain groups of clinicians. these include clinicians' professional ethos, self-belief in decision making and attitude towards the doctorpatient relationship. analysis of patient interviews shows that beliefs about antibiotic use tend to draw on clinical factors, namely the severity of specific symptoms (fever and/or coughing). many patients also implied a period of waiting or alternative action required before antibiotics are used − to identify whether the immune system would fight the infection or whether nonantibiotic management was effective before turning to antibiotics. discussion and conclusion: with a greater understanding of the factors that contribute to the decision to prescribe, we discuss ideas to enhance appropriate prescribing. this analysis highlights the need for interventions to be sensitive to factors relating to the systems in which different european networks operate, to target the individual characteristics of specific groups of clinicians and to build on the clinical beliefs already held by patients. o377 pre-treatment with low-dose endotoxin prolongs survival from experimental lethal endotoxic shock k. kopanakis, i. tzepi, e.j. giamarellos-bourboulis°, a. macheras (athens, gr) objective: clinical trials of immunointervention with anti-endotoxin antibodies in patients with severe sepsis have failed to disclose survival benefit. these failures led us to the assumption that the opposite approach with a low endotoxin stimulus may result to low level immunoaralysis and subsequent survival benefit. this approach was tested in an experimental setting. methods: a total of 36 male c57b6 mice were studied divided into two groups: group a stimulated with the ip injection of sodium saline followed after one day by the ip injection of 30 mg/kg of lipopolysaccharide (lps) of escherichia coli o155:h5; and group b stimulated with the ip injection of 3 mg/kg of lps of the same isolate followed after one day by the ip injection of 30 mg/kg lps. lps was diluted in sodium saline and the volume of each injection was 0.2 ml. survival was recorded at six hour time intervals. results: survival of group b was considerable prolonged compared with group a (log-rank: 5.435, p: 0.020) as shown in figure 1 . thirteen mice of group a died (72.2%) compared with seven mice of group b (38.9%, p: 0.044 between group). conclusions: administration of low doses of lps prolongs survival after lethal endotoxic shock. this approach opens a promising novel pathway for immunointervention in sepsis. fragilis isolates with an mxf mic of 2 mg/ml (n = 5), 4 mg/ml (n = 20) and 8 mg/ml (n = 8), which were virulent in the mgp model, were used to determine the efficacy of mxf. for the mgp model, pouches were created by injecting 5 ml of air and 0.5 ml of 0.1% croton oil in olive oil under the skin of the back. on day 3, the air was withdrawn and replaced by 1 ml soft agar. on day 5, a bacterial suspension was injected into the pouch. infected mice (n = 6 mice/group) were treated with mxf 100 mg/kg iv, b.i.d. for 2 days. this dose simulates the auc of the human 400 mg once-daily mxf iv dosage. efficacy was assessed by the reduction in colony forming units (cfus) in pouch exudates 48 hours post-infection compared with the untreated infection control. results: in the mgp model, mxf, 100 mg/kg b.i.d., displayed good efficacy in term of cfu reduction against all used strains in this study. there were no non-responders in terms of cfu reductions. conclusion: the loss of atle had no impact on the mics of cloxacillin and vancomycin. conversely, the mutant atle(−) strain was less susceptible to bactericidal activity of both antibiotics, supporting the implication of atle in the tolerance of s. epidermidis to cell wall active antibiotics. the loss of atle did not alter the virulence of s. epidermidis in the mouse peritonitis model, whereas it decreased virulence in previously published experiments using an intravenous catheter infection model. therefore, the mouse peritonitis model was suited to compare antibiotics efficacy against atle(+) and atle(−) strains. our results showed that the loss of atle did not alter significantly the activity of cloxacillin and vancomycin in the mouse peritonitis model. this study shows that the loss of atle results in decreased susceptibility to bactericidal activity of cell wall active antibiotics, with no apparent impact on the activity of these antibiotics in the mouse peritonitis model. in infant rat pneumococcal meningitis, ceftriaxone plus daptomycin versus ceftriaxone attenuates brain damage and hearing loss while ceftriaxone plus rifampicin versus ceftriaxone does not d. grandgirard, m. burri, k. oberson, a. bühlmann, f. simon, s.l. leib°(berne, ch) objectives: lytic antibiotics for therapy of bacterial meningitis (bm) increase the release of pro-inflammatory bacterial compounds which, in turns, induce inflammation. exacerbation of the inflammatory response in cerebrospinal fluid (csf) contributes to the development of neurological sequelae in survivors of bm. daptomycin, a nonlytic antibiotic acting on gram-positive bacteria has been shown to decrease inflammation and brain injury vs. ceftriaxone in experimental pneumococcal meningitis. with a view on the clinical application for empiric therapy of paediatric bacterial meningitis we investigated, whether therapies combining daptomycin or rifampicin with ceftriaxone are beneficial when compared to ceftriaxone monotherapy in infant rat pneumococcal meningitis. methods: eleven day old wistar rats were infected by intracisternal injection of s. pneumoniae and animals were treated with daptomycin (10 mg/kg, s.c., daily) plus ceftriaxone (100 mg/kg, s.c., bid), rifampicin (20 mg/kg, i.p., bid) plus ceftriaxone or ceftriaxone alone. csf was sampled at 6 h and 22 h after the initiation of therapy and assessed for concentrations of chemo-and cytokines (mcp-1, mip-1a, il-1b, il-6, il-10; il-18 and tnf-a). a subset of animals was sacrificed 40 h post infection (h pi) and brain damage quantified by histomorphometry. the remaining animals were treated for 3 d and were tested for hearing loss, by assessing the auditory brainstem response (abr) at 3 weeks after infection. results: compared to ceftriaxone alone, daptomycin plus ceftriaxone significantly (p < 0.04) lowered csf concentrations of mcp-1, mip-1alpha and il-6 at 6 h and mip-1a and il-1b at 22 h after initiation of therapy, led to significantly (p < 0.01) less apoptosis assessed at 40 h pi, and significantly (p < 0.01) improved hearing capacity. while rifampicin plus ceftriaxone also led to lower csf inflammation (p < 0.02 for il-6 at 6 h), apoptosis and hearing loss were not significantly different from the ceftriaxone group. conclusion: compared to ceftriaxone monotherapy, daptomycin plus ceftriaxone lowers the level of pro-inflammatory mediators in the csf and reduces hippocampal apoptosis and hearing loss in infant rat pneumococcal meningitis. d. croisier-bertin°, l. piroth, p.e. charles, d. biek, y. ge, p. chavanet (dijon, fr; alameda, us) objectives: ceftaroline (cpt) is a novel, parenteral, broad-spectrum cephalosporin exhibiting bactericidal activity against gram-positive organisms, including methicillin-resistant s. aureus (mrsa) and multidrug-resistant s. pneumoniae, as well as common gram-negative pathogens. the efficacy of simulated human dosing with cpt or ceftriaxone (cro) was evaluated in a rabbit model of penicillin-resistant pneumococcal pneumonia. methods: 3 s. pneumoniae strains were used to induce pneumonia in rabbits: pssp, pisp, and prsp. mics (mg/l) were 0.06/0.015, 1/0.125, and 4/0.25 for cro and cpt, respectively. the animals were randomised to no treatment (controls), intravenous (iv) cpt human equivalent (he) dosage (600 mg/12 h), iv cro he dosage (1 g/24 h), or intramuscular (im) cpt (5 or 20 mg/kg) for prsp-infected rabbits. serum levels were measured by microbiological assay and pk data were obtained. evaluation of efficacy was based on bacterial counts in lungs and spleen (per gram tissue). results: 5−7 animals/group were tested. for iv cpt/iv cro, mean auc0−24 was 155/938 mg.h/l, cmax was 20/158 mg/l and cmin was 1.3/6 mg/l, respectively. bacterial counts in target tissues are listed in the iv cpt and iv cro were highly efficacious against pssp and pisp. iv and im cpt were superior to iv cro against prsp with a quasi sterilisation of lungs and spleen. combined results from the iv and im studies indicated that %t > mic for cpt of 30% and 45% were associated with 50% and 100% bacterial count reductions, respectively. in this rabbit model of penicillin-resistant pneumococcal pneumonia, cpt administered iv (with he dosing) or by im administration was more effective against prsp than iv cro. r. endermann°, d. hoepker, k. merfort, m. glenschek-sieberth (wuppertal, de) objective: moxifloxacin (mxf) is approved in the usa and other countries for the treatment of complicated intra-abdominal infections (ciais). we compared the efficacy of mxf with piperacillin/tazobactam (pip/taz), a commonly used treatment for ciais, in three different models: ( . c. clp model: survival over 10 days was significantly higher in the mxf group than in the pip/taz group (p < 0.0001). conclusions: using humanised dosages, mxf had greater antimicrobial activity and provided higher survival rates that pip/taz in three different models for ciai. m. nairz, i. theurl, a. schroll, m. theurl, s. mair, t. sonnweber, g. fritsche, r. bellmann-weiler, g. weiss°(innsbruck, at) mutations in hfe predispose to hereditary haemochromatosis type i, a frequent genetic disorder characterised by progressive parenchymal iron deposition and eventual organ failure. since hfe mutations are associated with reduced iron levels within mononuclear phagocytes, we hypothesized that hfe deficiency may be beneficial in infections with intramacrophage pathogens. using hfe+/+, hfe+/− and hfe−/− mice in a model of typhoid fever, we found that animals lacking one or both hfe alleles are protected from systemic infection with salmonella typhimurium, displaying prolonged survival and improved bacterial control. this increased resistance can be referred to an enhanced production of the siderophore-binding peptide lipocalin 2 and the reduced availability of iron for salmonella engulfed by hfe deficient macrophages. this effect is mediated via stimulation of lipocalin 2-dependent iron export from infected cells since hfe−/− macrophages concurrently knocked out for lipocalin 2 are unable to efficiently control the infection or to withhold iron from intracellular salmonella. correspondingly, infection of hfe+/+ and hfe−/− mice with siderophore deficient salmonella abolishes the protection conferred by the hfe defect. thus, by inducing the formation of the iron-capturing peptide lipocalin 2, the hfe mutation harbours a genetically determined immunological advantage towards infections with intracellular pathogens such as salmonella. i. koutelidakis, a. kotsaki, p.d. carrer, k. louis, a. savva, e.j. giamarellos-bourboulis°(thessaloniki, athens, gr) objective: the majority of clinical trials of immunointervention in severe sepsis have failed to disclose survival benefit. a likely explanation may be administration of therapy when immunoparalysis of the septic host supervenes. in an attempt to reverse immunoparalysis, injection of mononuclear cells was attempted in experimental sepsis by multidrugresistant pseudomonas aeruginosa (mdrpa). methods: peripheral blood mononuclear cells (pbmcs) diluted in rpmi were isolated from five healthy human volunteers after gradient centrifugation over ficoll. 1×10 7 /kg of one mdrpa live or heat-killed isolate from one patient with severe sepsis was injected intraperitoneally for bacterial challenge. a total of 72 male c57b6 mice were studied divided into four groups: group a (n = 26) pre-treated with rpmi and challenged after one hour with live isolate; group b (n = 26) pretreated with 5×10 7 pbmcs/kg and challenged after one hour with live isolate; group c (n = 10) pre-treated with rpmi and challenged after one hour with heat-killed isolate; group d (n = 10) pre-treated with 5×10 7 pbmcs/kg and challenged after one hour with heat-killed isolate. survival was recorded for 20 mice of groups a and b and for all mice of groups c and d. six mice of groups a and b were sacrificed six hours after challenge. blood was collected from the lower vena cava and tnfalpha and il-6 were estimated in serum by an enzyme immunoassay. bacterial growth of liver and lung at the same time was assessed. results: median survival of group a was 24 hours and of group b 88 hours (log-rank: 4.524, p: 0.033). nineteen animals of group a died (95%) compared with eight animals of group b (40%, p: 0.038). four animals of group c died (40%) compared with nil animals of group d (0%, log-rank: 4.274, p: 0.03). median serum tnf-a of groups a and b at sacrifice was 31 and 184 pg/ml respectively (p: 0.048). respective values for il-6 were 2084 and 2231 pg/ml (pns); for liver bacterial cells 3.63 and 4.99 log10 cfu/g (pns); and for lung bacterial cells 2.56 and 4.22 log10 cfu/g (pns). conclusions: allogeneic transplantation with pbmcs prolonged survival in experimental sepsis by mdrpa. its mechanism of action was related with a) blockade of cell wall structures as shown by survival experiments with heat killed isolate; and b) reversal of immunoparalysis as evidenced by increase of serum tnf-a. this approach creates a promising novel perspective for immunointervention in sepsis. a. marangoni°, c. nanni, m. donati, r. aldini, d. di pierro, s. trespidi, s. accardo, s. fanti, r. cevenini (bologna, it) objectives: chlamydia trachomatis is one of the world's major causes of sexually transmitted diseases of the cervix and urethra and it is a major agent of pelvic inflammatory disease. genital tract infection of female mice with chlamydia muridarum closely mimics acute genital tract infection in women. aim of this study was to assess the predictivity of 68ga-chloride small animal positron emission tomography ( o387 inadequate statistical power of published comparative cohort studies on ventilator-associated pneumonia to detect mortality differences between the compared groups m. falagas°, v. kouranos, a. michalopoulos, s. rodopoulou, a. athanasoulia, d. karageorgopoulos (athens, gr) objective: comparative cohort studies are often conducted to identify novel therapeutic strategies or prognostic factors for ventilator-associated pneumonia (vap). we aimed to evaluate the statistical power of such studies to provide statistically and clinically significant conclusions. methods: we searched in pubmed and scopus for comparative cohort studies evaluating the mortality of patients with vap. we calculated for each of the included studies the statistical power to detect the observed difference in mortality between the compared groups (observed power), as well as 3 expected, clinically relevant, effect sizes (expected power). we identified 39 (20 prospective) comparative cohort studies on vap as eligible for inclusion in this analysis. the median observed power of these studies was 17.9% [interquartile range (iqr), 9.8−52.4%]. the median expected power was 10.0% (iqr, 7.2−13.6%) for a risk ratio for mortality of 0.85 between the compared groups; 14.7% (iqr, 10.6−21.8%) for a risk ratio of 0.80; and 7.9% (iqr, 6.3−10.2%) for a reduction in mortality from 30% to 25%. all expected power measures were significantly lower than the observed power. the statistical power of most cohort studies to detect the observed difference in mortality between compared groups of patients with vap is low. the power is even lower when expected, clinically relevant, differences in mortality are considered. for a wiser utilisation of resources allocated to research, we favour the conduction of cohort studies with larger sample size so that potential differences between the compared groups are more likely to be shown. objective: to clarify issues regarding the frequency, prevention, outcome, and treatment of patients with ventilator-associated tracheobronchitis (vat), which is a lower respiratory tract infection involving the tracheobronchial tree, while sparing the lung parenchyma. methods: we performed a systematic review and meta-analysis of relevant available data, gathered though searches of pubmed, scopus, and reference lists, without time restrictions. a conservative random effects model was used to calculate pooled odds ratios (or) and 95% confidence intervals (ci). results: out of the 564 initially retrieved articles, 30 papers were included. frequency of vat was 10.2%. selective digestive decontamination was proved an effective preventive strategy against vat. presence, as opposed to the absence, of vat was not associated with higher mortality (or: 1.18, 95% ci 0.90−1.53). administration of systemic antimicrobials (with or without inhaled ones), as opposed to placebo or no treatment, in patients with vat was not associated with lower mortality (or: 0.56, 95% ci 0.27−1.14). most of the studies providing relevant data noted that administration of antimicrobial agents, as opposed to placebo or no treatment, in patients with vat was associated with more ventilator-free days and lower frequency of subsequent pneumonia, but without shorter length of intensive care unit stay or shorter duration of mechanical ventilation. conclusions: approximately one tenth of mechanically ventilated patients suffer from vat; an infection potentially prevented by the implementation of selective digestive decontamination. antimicrobial treatment of patients with vat may protect against the development of subsequent ventilator-associated pneumonia. degranulation. subsequently, allergen specific ige to chlorhexidine was demonstrated and skin prick/intradermal testing was positive to chlorhexidine, confirming the diagnosis of chlorhexidine-precipitated anaphylaxis in each patient. a detailed review of the case-notes revealed that each patient had manifest evidence of minor cutaneous reactions to pre-operative chlorhexidine use that had not been ascribed to chlorhexidine at the time. discussion: fda issued a public health notice [1998] following 1st description of anaphylaxis to chlorhexidine coated central venous catheter. a recent case cluster has also been reported from another cardiac centre in the uk [3-cases over a 9-month period]. references to be presented. it is interesting that these reports of chlorhexidine anaphylaxis have all occurred in patients undergoing cardiac surgery. these patients receive multiple exposures to chlorhexidine during their pre-operative investigations and preparation. this has increased recently as a result of the drive to reduce the incidence of hospital-acquired infections. we wish to postulate that these patients have been sensitised by repeated topical exposure to chlorhexidine and have exhibited anaphylaxis when this allergen was presented to the patient in the form of the chlorhexidine coated central venous catheter. type i strains of helicobacter pylori possess the cag pathogenicity island to deliver virulence factors. cag is a specialised type iv secretion machinery that is activated during infection and comprises 31 genes originated from a distant event of horizontal transfer. after translocation the effector protein caga is phosphorylated on tyrosine residues restricted to a previously identified repeated sequence called d1. this sequence is located in the c-terminal half of the protein and contains the five amino acid motif epiya, which is amplified by duplications in a large fraction of clinical isolates. tyrosine-phosphorylation of caga is essential for the activation process that leads to dramatic changes in the morphology of cells growing in culture. in addition, we observed that two members of the src kinases family, c-src and lyn, account for most of the caga-specific kinase activity in ags cell lysates. translocated caga interacts with the zo-1 and jam host-cell proteins causing disruption of the apical junctional complex. transfection of the caga gene into polarised epithelial cells induces disruption of cell-to-cell contacts and altered morphology. strikingly caga-expressing cells become migratory and invasive penetrating into collagen gel. the study of different portions of the molecule revealed the presence of two distinct functional domains and both are necessary to induce abnormal cell differentiation through interactions with host cell morphogens. cell polarity and invasion have been suggested to contribute to both early and late stages of cancer formation. these results suggest a mechanism by which caga may acts at the early stage of tumorigenic progression causing loss of cell polarity, increased cell motility and invasiveness of epithelial cells. after a period of 50 years of silence, a disease with an unpronouncable name, "chikungunya" (chik), has recently become a medical reality and reached the public throughout the world. conclusion: low mhla-dr expression after septic shock independently predicts ni. this promising biomarker may be of major interest in identifying patients at increased ni risk who could benefit from targeted and tailored therapy aimed at restoring immune functions. pneumonia, the leading infectious cause of death in the us, kills more people annually than aids, tuberculosis, meningitis and endocarditis combined. from a wide range of observational studies of communityacquired pneumonia (cap), only half of the cases had an aetiologic agent identified. streptococcus pneumoniae was consistently the predominant bacterial aetiology. this lecture will primarily focus on the innate immune response to pneumococcal pneumonia. toll-like receptors (tlrs) are key molecules that recognize pathogen associated molecular patterns (pamps) and induce an inflammatory response. pneumolysin, an intracellular toxin found in all s. pneumoniae clinical isolates, is an important virulence factor of the pneumococcus that is recognized by tlr4. although tlr2 is considered the most important receptor for gram-positive bacteria, tlr2 does not play a decisive role in host defence against s. pneumoniae pneumonia; likely, pneumolysin-induced tlr4 signalling can compensate for tlr2 deficiency during respiratory tract infection with s. pneumoniae. besides tlr2 and tlr4, tlr9 contributes to an effective host defence against s. pneumoniae in the airways. the importance of tlr signaling for host defence against pneumococcal pneumonia is illustrated by the fact that mice lacking the common tlr adaptor protein myd88 are highly susceptible to this infection. activation of tlrs results in the production of proinflammatory cytokines. there is ample evidence that underlines the importance of tumour necrosis factor (tnf) and interleukin (il)-1 in host defence in bacterial pneumonia: in a murine s. pneumoniae pneumonia model, treatment with a neutralising anti-tnf mab strongly impaired antibacterial defence. in addition, il-1a receptor type i deficient mice infected with s. pneumoniae displayed an increased bacterial outgrowth. of considerable interest, treating il-1 receptor deficient mice with a neutralising anti-tnf antibody made them extremely susceptible to pneumococcal pneumonia. infection of the lower airways by s. pneumoniae is associated with complex interaction between the pathogen (e.g. cell wall components, pneumolysin) and the host (e.g. tlrs, cytokines). these interactions play a crucial role in the outcome of this clinically important infection. severe bacterial pneumonia remains uncommon unless specific conditions exist that tip the balance between the host and pathogen in favour of the microorganism. such conditions include: persons at the extremes of age; exposure to especially virulent organisms; patients with concomitant illness impairing pulmonary clearance mechanisms; and immunocompromised hosts. pathogens overcome an array of innate and acquired host defences to successfully invade the host. the known virulence traits of three common respiratory pathogens (streptococcus pneumoniae, staphylococcus aureus, and pseudomonas aeruginosa) will be briefly reviewed. the capsular polysaccharide of pneumococci is the major anti-phagocytic virulence trait but many other factors contribute to disease pathogenesis including the critically important exotoxin known as pneumolysin, bacteriocins, adherence factors, choline binding proteins, lipoteichoic acid, iron, manganese and magnesium transporters, pili, competence and biofilm capacity, and virulence genes that promote invasion and impair clearance once the organism has entered the blood stream. s. aureus is notorious for the numerous a/b type toxins, cytotoxins, and superantigens it generates during the course of invasion. staphylococci deploy a complex series of quorum sensing signals that coordinate adhesin and invasion genes within biofilms or between planktonic organisms and likely contribute to the success of this pathogen. p. aeruginosa produces an array of extracellular exotoxins and cytotoxins delivered by type iii secretion systems. these include elastase, phospholipases c, a series of apoptotic and anti-phagocytic exotoxins, along with an alginate capsule and an unusual and variable lps structure that participate in microbial invasion. the pathogen expresses at least three interacting, quorum sensing systems to coordinate virulence and biofilm formation. a detailed understanding of these virulence factors is now providing therapeutic options to control these respiratory pathogens. surface expressed and extracellular toxins of pneumococci have been selected as new vaccine targets. inhibitory peptides and small molecule inhibitors of quorum sensing and biofilm formation are under investigation for staphylococcal and p. aeruginosa infections. these innovative and non-antibiotic treatment strategies are gaining greater importance as progressive antibiotic resistance threatens the management of these severe bacterial infections in the future. brucellosis, possibly the commonest zoonotic infection worldwide, has troubled humans since antiquity. recent years have seen the expansion of the animal reservoir of the disease to a wide spectrum of wildlife species, extending to marine mammals, and the recognition of novel brucella species. furthermore, animal and human disease has re-emerged in numerous countries which were brucellosis-free, and currently the most important endemic foci include near east and central asia. complex socioeconomic and political factors may be incriminated for these alterations in endemicity. the complex mechanisms by which brucella evades immune response and survives intracellularly are progressively clarified. novel diagnostic techniques as real time pcr may shed light in the life cycle of brucella inside the human host; preliminary studies have indicated that the pathogen may persist in latent form for years after apparent clinical cure, in asymptomatic individuals. treatment principles have not evolved significantly. the expert guidelines issued recently under the name of "ioannina recommendations" support the need for a six-week combined treatment that includes traditional antibacterials and is modified accordingly in serious complications as spondylitis and central nervous system involvement. the road to the development of a vaccine for humans seems long though. anthrax is ancient diseases and relatively a forgotten disease in western world until 2001 when spores were mailed in usa causing five deaths. currently, human anthrax is seen most commonly in agricultural regions of the world where anthrax in animals is prevalent, in which countries of middle east, in africa, central asia and south america. it is also an endemic disease in turkey. human cases may occur in an agricultural or an industrial environment. the infection is an occupational hazard of workers who process hides, hair, bone and bone products, and wool and of veterinarians and agricultural workers who handle infected animals. the main route of transmission is contact with or ingestion of contaminated meal with or inhalation of bacillus anthracis spores. leptospirosis is a very old disease that has been known for more than a hundred years and possibly even longer since the time of hippocrates. it remains a major cause of illness in many tropical and subtropical countries and thus in travellers. it has also been identified as a zoonosis in europe and north america. it is a disease that can surprise us because the clinical presentations are not always typical. in recent years, pulmonary and other atypical presentations have been more widely recognised. there is no effective vaccine but chemoprophylaxis is effective in selected populations. prompt recognition and early institution of appropriate treatment as with most other infectious diseases appear to be critical in ensuring a good outcome for our patients. there are interesting new developments in diagnostics and molecular epidemiology but clearly there are many challenges remaining in this field. objectives: the spread of carbapenemase genes within gram negative bacteria is of great cause for concern. in 2008, the first report of a blaoxa-58 gene outwith acinetobacter baumannii was reported in acinetobacter genospecies 3. we had also identified a genospecies 3 isolate encoding a blaoxa-58-like gene, and the aim of this study was to examine the genetic environment of the gene to investigate the mobilisation between species. methods: restriction analysis of rrna was used to confirm identity to the species level. susceptibility to imipenem and meropenem was determined through the plate doubling dilution method. screening by pcr for blaoxa-51-like, blaoxa-23-like, blaoxa-40-like and blaoxa-58-like genes was carried out. analysis of the genetic environment surrounding the blaoxa-58-like gene was conducted by sequencing inverse pcr products and gene-walking fragments. the structure of the surrounding sequence was confirmed using internal primers, which were also used to screen other blaoxa-58-like positive isolates in our collection. results: restriction analysis confirmed the isolate belonged to acinetobacter genospecies 3. the isolate showed reduced susceptibility to imipenem and meropenem with mics of 2 mg/l for both antibiotics. the isolate was negative for a blaoxa-51-like, blaoxa-23-like or blaoxa-40-like gene, but positive for a blaoxa-58-like gene. analysis of the genetic environment of the blaoxa-58-like gene revealed the gene was within a novel genetic structure. upstream of the blaoxa-58-like gene was the left-hand end of an isaba3 element, interrupted by an isaba125 element. the elements contained putative promoter sequences. downstream was an arac1 and a lyse gene, followed by a sequence similar to the re27 element described previously. following this was a complex region containing the right-hand end of an isaba3 tnpa gene, interrupted by an incomplete tnpa gene with 99% similarity to isaba3, itself interrupted by an isaba125 sequence. this region was followed by a second blaoxa-58-like gene. all other blaoxa-58-like positive isolates in our collection were negative for isaba125 upstream of blaoxa-58. this study is the first to report multiple copies of a blaoxa-58-like gene in an acinetobacter genospecies 3 isolate, and has identified a novel structure containing two blaoxa-58-like genes and two isaba125 sequences. the isaba125 elements may be responsible for the duplication of the blaoxa-58-like gene. objective: acinetobacter baumannii is an important nosocomial pathogen with wide intrinsic resistance. however, due to the dissemination of the acquired resistance mechanisms; such as extended-spectrum beta-lactamase (esbl) and metallo betalactamase (mbl) production, multidrug resistant strains have been isolated more often. per-1 was first detected in turkey and was found to be widespread among acinetobacter spp. and p. aeruginosa. since then, per-1 has been discovered in other countries, and most recently found in northern italy and in korea. in this study, the presence of per-1 type esbl was investigated in caftazidime resistant a. baumannii strains isolated from bloodstream infections by pcr and also the clonal relatedness of the isolates were investigated by random amplified polymorphic dna (rapd) and pulsed field gel electrophoresis (pfge) in all per-1 producing a. baumannii strains. methods: a. baumannii strains isolated from bloodstream infections was included in this study. the isolates were identified as a. baumannii by conventional methods and phoenix 100 bd automated system system (becton dickinson diagnostic systems, sparks). ceftazidime resistance was determined by e-test. per-1 genes were screened by these clusters encode: (i) resistance genes and transporters plausibly involved in drug efflux (30 transporters of the mfs, dmt, abc, rnd, mop and acr3 families were unique of drug resistant strains and absent in the susceptible sdf strain); (ii) pili and fimbriae systems related to biofilm formation and motility; (iii) haemolysin-and haemagglutininrelated proteins differently distributed among the four genomes, (iv) iron uptake and other metabolic genes. conclusion: genome comparison identified unique features of a. baumannii epidemic clones and provided novel insights into the genetic basis of multidrug resistance and pathogenesis in this species. this study may contribute to understand the concept of infection, invasiveness and colonisation in the emergent pathogen a. baumannii. hard to swallow − emerging and re-emerging issues in food-borne infection (symposium arranged with efwisg) s460 mrsa in food products: cause for concern or case for complacency? in 2003 first, a switch from intravenous-to oral medication (01-2006); second, education programs for interns/residents and physicians and the release of a new antimicrobial formulary (05-2006); third, a restriction note was printed on all laboratory rapports (10-2006) and fourth, active monitoring and giving feedback on prescriptions (01-2007). susceptibility patterns for e. coli including ciprofloxacin, cefuroxim, ceftazidim, co-trimoxazole and tobramycin from hospitalised patients were analyzed starting in 2004. statistical analyses were performed using segmented poisson regression models to look at effect of interventions on resistance (both sudden stepwise changes and changes in trends). bayesian model averaging was used to account for model uncertainty. results: before the start of the interventions the resistance rate was increasing by an average of 2.6% per year. the interventions resulted in a significant reduction of quin use from on average 550 prescribed daily doses to 350 pdd per month. in the best fitting poisson model for the resistance data, a significant stepwise decrease was found to be associated with interventions 2 and 4. however, there was substantial uncertainty in the model choice, and after accounting for this there was no conclusive evidence in support of any particular intervention, although there was evidence that at least one of the interventions was associated with the observed reduction in resistance. there were no stepwise decreases or decreasing trends in resistance rates to other antimicrobials during the study period. conclusion: many mds prescribe antibiotics often and believe their practice may have an effect on antibiotic resistance. results indicate that mds value information, interventions and surveillance in order to support responsible use of antibiotics. there is an ongoing effort in germany to address these findings at the national level e.g. by establishing a surveillance system for antibiotic resistance and antibiotic usage. table) . . ir for pn, er and tt were always higher in children (ch) than in adults (ad). significant differences were found for pn (1995), er (1997 er ( , 2004 er ( , 2006 er ( , 2007 er ( , 2008 , tt (2004 tt ( , 2006 . generally, cp-ir was higher in ad than in ch. ir was lower in the north (n) than in the south (s). significant differences: pn (2005 pn ( , 2006 , er (2003 er ( , 2004 er ( , 2005 , tt (2005) . both n and s knew a deceasing ir tendency: pn= n (12.1−8.1), s (18.8−13.2); cp= n (11.6−5.9), s (18.9−5.9); tt= n (27.4−21.5), s (35.9−23.5). er increased in the n (20.9−29.7). total outpatient antibiotic use (did) decreased from 26.2 (1999) to 22.7 (2004) and increased to 24.2 (2006) . did for pn and fq increased, mls stabilised and tt decreased. conclusions: since 2001-2003 an ir decrease was noted for pn, cp and tt. er-ir increased further over the years. the decrease paralleled the start of public campaigns on antibiotic use. ir rates remain higher in ch than in ad. the n/s difference became less marked. objectives: parachlamydia acanthamoebae is a new recognized member of the order chlamydiales. growing evidences suggest that this bacteria may have a pathogenic role in humans causing respiratory diseases. it has also been recently identified as an agent of bovine abortion and may be a cause of miscarriage in women. in contrast, little is known about the pathogenic role of rhabdochlamydia crassificans, another related chlamydiales. molecular diagnostic tools are useful to detect these obligate intracellular bacteria because of their inability to grow on conventional culture media. the aim of this work was (i) to develop a real-time pcr for the diagnosis of rhabdochlamydia infection and (ii) to study respiratory secretions of newborns for the presence of parachlamydia and rhabdochlamydia dna. methods: a new quantitative real-time taqman pcr (q-pcr) to be used on abi prism 7900 was developed. the q-pcr was then blindly applied to 41 consecutive respiratory samples (endotracheal or nasopharyngeal secretions) taken from 29 critically-ill newborns admitted in the neonatology ward of our university hospital. these samples were also tested using a previously developed parachlamydiaspecific pcr. results: most newborns (28/29) were premature (median gestational age: 28.6 weeks; range: 24.6−41.2). initial respiratory distress syndrome was present in 86% of them. positive pcr results were obtained in 12/29 (41%) patients (8 parachlamydia, 3 rhabdochlamydia, 1 both species) at a median of 17.5 days (range: 2-230) after birth. when compared to the control group (17 patients with negative pcr), these 12 newborns had a significantly worse primary adaptation and a higher incidence of resuscitation maneuvers at birth (table) . duration of noninvasive mechanical ventilation and stay in neonatology ward were also significantly longer. a fatal issue was observed in 3 infected cases, as compared to no death in controls (p = 0.06). gestational age at birth as well as the incidence of pulmonary or systemic infections did not differ between cases and controls. conclusion: a high prevalence of parachlamydia and rhabdochlamydia dna was observed in respiratory secretions of premature critically-ill newborns. the presence of dna of these microorganisms was associated with a worse primary adaptation, a more severe respiratory distress syndrome and a trend towards a higher mortality. their pathogenic role should be further investigated. the genus kingella consists of 3 species, k. kingae, k. oralis and k. denitrificans. all are gram negative, sometimes difficult to stain, rod shaped bacteria that are normal respiratory and genitourinary flora. they are slow-growing and fastidious. although improved recovery was shown when using fan or peds-f blood culture bottles, the majority of these infections remain undetected, especially in pre-treated patients. we report the use of real time polymerase chain reaction (rt-pcr) assays for detection of k. kingae and s. aureus in paediatric osteoarticular infections. methods: 116 synovial fluid samples from 97 patients, 1 month and 17 years of age, were collected over 19 months (03/2006 to 10/2007). the samples were from 54 knees, 39 hips, 9 ankles, 6 elbows, 4 shoulders, 2 wrists and 2 femur abscesses. after automated dna/rna extraction, specimens were subjected to 4 hour pathogen-specific rt-pcr. samples were inoculated onto sheep blood and chocolate agar as well as a peds-f bottle. final species identification and antimicrobial susceptibilities were determined by phoenix (tm). results: 45 patients (56 specimens) had positive culture and/or rt-pcr, resulting in an overall positivity rate of 46%. s. aureus was the predominant pathogen accounting for 31 specimens of 23 patients (12 mrsa, 11 mssa) and. 37% of positive specimens (18 patients) were due to k. kingae (n = 21). among children 0−2 years (n = 35), k. kingae was the predominant pathogen accounting for 16 positive patients (46%), followed by mssa in 4 patients (11%). the positivity rate for this age group was 57%. only 2 children >2 years (5 and 9 years) were positive for k. kingae. mrsa was the predominant pathogen in 6−12 year olds, and mssa was evenly distributed among children 3−17 years old. culture detected only 5 of 21 specimens positive for k. kingae and 25 of 31 s. aureus. 4 other pathogens were detected by culture only. the use of these molecular assays enhances detection of organisms, especially for k. kingae (19% vs. 5% for culture). additionally, faster identification (tat 4 hrs) allows for rapid targeted therapy. this improvement in tat could lead to shorter hospital stays in about 54% of cases. results: genotyping revealed a high degree of diversity, indicative of a panmictic bacterial population. further, there was no association between genotype and colonisation frequency, or year of isolation. pcr screening for virulence genes revealed an incidence of 98% for uspa1, 81% for hag, 82% for uspa2 and 18% for uspa2h. no significant difference was observed in the prevalence of virulence-associated genes between isolates originating from children who were colonised only once or children colonised on all 3 occasions (p = 1). pcr-rflp analysis of uspa1, hag and uspa2 showed many gene variants, with no association between pcr-rflp patterns and colonisation frequency, or year of isolation. conclusion: even in relatively localised geographical settings, the genotypic diversity of m. catarrhalis isolates colonising children is large, with no yearly pattern of genotype predominance. children serially colonised with m. catarrhalis isolates appear to clear a particular genotype only to become subsequently colonised with a different genotype. the incidence of virulence genes in this relatively localised study group is remarkably similar to that reported in global m. catarrhalis isolates, possibly indicating that similar selection pressure exists for m. catarrhalis at both the local and global level. virulence gene variation appears to be high, even in this relatively restricted geographical group. these results could have consequences for vaccines designed against virulence genes. a. naessens°, i. foulon, a. casteels, w. foulon (brussels, be) objectives: to evaluate the epidemiology of cytomegalovirus in pregnancy and to evaluate the risk for delivering a child with congenital cmv (ccmv). methods: between 1996-2006, 11825 unselected mother-infant pairs were included. in the mother a serological screening was performed consisting in the detection of cmv igg and igm antibodies at the first prenatal visit and at birth. in the neonate cmv urine culture was performed to diagnose congenital infection. when a pregnant woman was found to have a second trimester spontaneous abortion or a death in utero, an investigation for possible congenital cmv infection was carried out. results: serological screening at the first prenatal visit showed no immunity in 4701 women, evidence of past infection (igg positive igm negative) in 6877 women (58.2%) and in 250 women (2.0%) both igg and igm antibodies were detected. after investigation of stored and follow up samples from these 250 patients, 14 could be classified as having a primary cmv infection during pregnancy, 99 patients had previous immunity before the current pregnancy and from 137 patients the type of the maternal cmv infection could not be determined. follow-up serology of the 4701 women without immunity revealed a seroconversion in 58 of them (1.2%). a total of 61 (0.52%) congenital infections (ccmv) were diagnosed. the incidence of the ccmv among the different groups of women are summarised in the table. conclusion: ccmv infection occurs in 0.52% of our population of pregnant women. ccmv was considered to be due to a primary maternal cmv infection in 54% of the infants; 33% due to a recurrent maternal cmv infection and in 13% the type of maternal infection could not be determined. the risk for a seronegative pregnant woman of acquiring cmv during pregnancy is 1.2%. the transmission risk after a maternal primary infection is 45%. women with prior immunity have a very low risk (0.20%) for ccmv, this risk increases to 3% when igm are find in women with know prior immunity. the risk for women with undetermined infectious status in early pregnancy to give birth to a congenitally infected neonate is 5.8%. this report provides the first data on rotavirus epidemiology and disease burden in norway. further studies are needed to assess the economic impact of rotavirus disease and the cost-effectiveness of vaccination to inform decisions on introduction of rotavirus vaccines into the national program of childhood immunisation. pseudomonas aeruginosa may colonise the lungs of cystic fibrosis patients over years but may also cause acute infections in mechanically ventilated patients and immuno-compromised hosts within a matter of days. despite aggressive antibiotic treatments the organism is rarely eradicated. instead p. aeruginosa adapts to its host environment by developing resistance mechanisms and changing its lifestyle and virulence properties. focusing on mechanically ventilated patients, we will detail the dynamics of resistance emergence and persistence of p. aeruginosa lung populations during antibiotic therapy. we further discuss how p. aeruginosa populations evolve naturally in the absence of any antimicrobial treatment within the lungs of intubated patients by changing their virulence properties. the relevance of these findings both with respect to concepts of social evolution and the development of novel anti-infective strategies will be highlighted. the genome of p. aeruginosa encodes many potential efflux systems. however, only a few of them appear to play a significant role in antibiotic resistance. in this respect, the mex (for multiple efflux) systems are of particular interest because of their ability to extrude a wide range of antimicrobials. these polyspecific machineries result from the assembly of (i) a drug/proton antiporter, (ii) a periplasmic adaptor protein, and (iii) an outer membrane gated channel. it is now well established that the constitutive expression of the tripartite pump mexab-oprm provides p. aeruginosa with a relatively high intrinsic resistance to quinolones, blactams (except imipenem), tetracyclines, macrolides, chloramphenicol, trimethoprim, and novobiocin. this protective mechanism is potentiated by the poor permeability of the outer membrane and activity of another pump, mexxy/oprm, whose expression is induced by substrates targeting the ribosome (e.g., tetracyclines, macrolides, aminoglycosides). accumulating reports indicate that multidrug resistant mutants upregulating one or both of these systems are quite common in the clinical setting. such mutants, which are readily selected by sub-optimal treatments with fluoroquinolones, b-lactams or aminoglycosides, tend to accumulate various resistance mechanisms without loosing the wildtype pathogenicity of p. aeruginosa. whether the low resistance levels (mic x 2-to 8-fold) conferred by efflux may promote second-step mutants with altered drug targets (gyra, gyrb, parc) or derepressed ampc b-lactamase has not been confirmed in vitro. in the specific context of cystic fibrosis (cf), a recent study from our laboratory showed that the mexxy/oprm pump can be responsible for much higher resistance levels to aminoglycosides (64-to 128-fold). this increased efficacy of the system partially results from adaptive mutations in the mexy gene. in contrast, subpopulations deficient in mexab-oprm tend to emerge during long-term colonisation of cf airways. while easily selected in vitro on selective media, mutants overexpressing other mex systems (mexcd-oprj, mexef-oprn, mexghi-opmd, mexjk/oprm, mexvw/oprm) have been rarely described in cf and non-cf patients. some data support the notion that up-regulation of mexcd-oprj or mexef-oprn might be detrimental to the virulence of p. aeruginosa. in conclusion, therapeutic strategies based on efflux inhibitors should target the mexab-oprm and the mexxy/oprm systems in priority. european aspects of malaria s478 rapid diagnostic tests for malaria: twenty years to convince . . . prompt diagnosis and treatment of malaria are critical factors in reducing morbidity and mortality. microscopy has long been the gold standard for malaria diagnosis, but the newer rapid diagnostic tests (rdts) now offer considerable advantages, especially so in endemic countries. after close to twenty years of development and operational research, the diagnostic performance of rdts is now established in all settings. meta-analyses have clearly demonstrated equivalence of rdts over expert microscopy to detect parasites, and clear superiority over routine microscopy. actually, one of the major reasons that have delayed successful implementation of rdt in endemic areas was the use of poor quality microscopy that has impeded reliable measurement of sensitivity and specificity and undermined confidence of health workers in rdts. other factors were poor product performance, inadequate methods to determine the quality of products and a lack of emphasis and capacity to deal with these issues. for the potential of rdts to be realised, it is crucial that high-quality products that perform reliably and accurately under field conditions are made available and that quality insurance is performed on all steps of the procedure. in achieving this goal, the shift from symptom-based diagnosis to parasite-based management of malaria can bring significant improvement for the management of fever in endemic areas. for travelers returning in temperate climates with fever, rdts have also the potential to improve diagnostic procedures, especially so in hospitals where reliable microscopy is not available out of hours. in patients with no danger sign or significant thrombopenia, a negative rdt is sufficient to exclude malaria and allows waiting 12−24 hours for performing or reading the microscopy slide. rdts should be repeated every 12−24 hours for three consecutive days if fever persists and in the absence of alternative diagnosis. rdts represent a revolution in the fight against malaria and will tremendously help to manage appropriately patients with fever, especially so when malaria is declining and hence other causes of fever increasing. the ambitious deployment that is foreseen in the coming years in africa through large grants from the global fund should contribute to achieving the millennium goals. fever is the key symptom of malaria among returning travellers (97%). headache, chills, myalgia, sweating and lack of a focus are frequently recorded, but non-specific. nausea and vomiting are often seen in children. the differential diagnosis of other infections, mainly of viral origin, is further difficult because (dry) cough and (mild) diarrhoea are often present. laboratory findings (thrombocytopenia, low or normal leucocyte count) can be helpful in the assessment of mild to moderate malaria. clinical signs and symptoms, e.g. fever, may be mitigated in semiimmune patients (visiting friends and relatives, foreign visitors) seen in non-endemic countries who represent the majority of cases diagnosed in industrialised countries. caution is warranted in assessing such patients as many of them may no longer be exposed to malaria in their countries of origin, thus no longer partially protected and also at risk of suffering from severe complications. up to 10% of all imported malaria cases may be severe, presenting with jaundice, impaired consciousness to coma, acute renal failure, and, in the course of events, acute respiratory failure. delay in diagnosis and start of treatment is partly responsible for fatality rates of 1% and more in some countries. if you don't look for them, you won't find them: anaerobes revisited s481 anaerobic microbiota of the mouth − friend or foe? anaerobes form a major part of the commensal microbiota in the digestive tract where they constitute an integral component of the function on mucosal surfaces. in the mouth, teeth create a unique, non-shedding environment for bacteria to attach and to form biofilms. there is an age-related succession order of species in bacterial colonisation of the mouth, and once established, individual anaerobic species tend to remain as members of the oral microbiota. the agerelated pattern of the colonisation of anaerobic bacteria is partly connected with the development (or loss) of the dentition. interactions between different bacteria residing in the same microenvironment influence the composition of the microbiota − or the development of pathologic conditions. although commensal bacteria are regarded beneficial to the host, some anaerobic members of the oral microbiota contain characteristics potentially detrimental for the health status of an individual. molecular means of characterisation have resulted in increased knowledge about the "normal" microbiota of the mouth and in detection of new species and genera as well as phylotypes, which can be associated with infectious situations in the mouth. oral infections are multifactorial and polymicrobial in nature, and their aetiologic organisms originate mainly from the oral resident microbiota. the involvement of anaerobes is most obvious in infections of root canals, periodontal tissues, and tissues surrounding erupting wisdom teeth where typical anaerobic findings are gram-negative rods. in addition, gram-positive anaerobic cocci and non-spore-forming gram-positive anaerobic rods are common in odontogenic infections. on some occasions, anaerobes of localised dentoalveolar infections can spread to adjacent tissues and even to the bloodstream, resulting in severe complications in extraoral sites. interestingly, a relatively limited number of anaerobic species are involved in clinically severe infections, however, microbial findings seem to vary depending on geography. concomitant with the increase in the number of immunosuppressed patients, the number of opportunistic infections caused by commensal anaerobes may increase. identification to the species level will help to establish associations between individual anaerobic species and specific disease states. studies on the bacteriology of diabetic foot infections (dfi) have yielded varied and often contradictory results. the role of anaerobes is particularly unclear, often because the type and severity of the infection is poorly defined, recent antibiotic therapy is unknown, and specimen collection and culture techniques are inadequate. when optimal collection, transport, and culture techniques are used, multiple organisms including aerobes and anaerobes are usually recovered from severe dfi. interactions within these polymicrobial soups lead to production of virulence factors, such as haemolysins, proteases, collagenases, and short chain fatty acids, which promote inflammation, impede healing and contribute to the chronicity of the infection. to better define the bacteriology of diabetic foot infections, we analyzed our data from a large prospective u.s. multicentre trial of patients with moderate to severe infection that required initial parenteral antibiotic therapy and used optimal post-debridement sample collection, transport and culture procedures. of the 427 culture-positive specimens (of 454 total), only 16.2% were pure cultures while 30.4% yielded 5 or more organisms. a total of 462 anaerobes (range 0−9, average 2.3, per specimen) were recovered from 49% of patients, with gram-positive cocci (gpc) accounting for 45.5% of all anaerobic strains. s485 is culture still the gold standard, really? tremendous technological advances are made in culture-independent methods of detection and identification of human bacterial pathogens, such as pcr or hybridisation of their genomic dna. yet, time honoured pastorian bacterial culture in liquid and solid nutritive media still remains the gold standard for the laboratory diagnosis of a majority of bacterial infections. this unusual robustness of a 19th century technology stems from its unmatched operational characteristics: 1. broad range of detected agents, depending on adequate combination of media/incubation conditions; 2. unlimited source of clonal population for individual isolate, allowing versatile characterisation of antibiotic susceptibility and/or pathogenic factor production and/or epidemiological subtyping; 3. possibility of storage/bio-banking of cells for complementary clinical testing, research and diseases surveillance collections; 4. proof of pathogenic role of agent at the time of viable cell isolation from the site of infection, in contrast to false-positive results with molecular tests (tissue translocation or persistence of bacterial dna, soluble antigen,. . . ). major drawbacks of bacteriological culture include long turn-around time, cost and labour/skill intensity. these are partly alleviated by new technologies, including automated processing, physical/chemical growth detection and rapid molecular fingerprinting (maldi-tof, raman spectrometry, 16s rdna snp detection). it is likely that the next decade will see a complete redefinition of the place of direct detection methods and culture-based confirmation methods in clinical bacteriology, enabling a rejuvenation rather than elimination of culture as a daily diagnostic tool. the advent of real-time pcr revealed instrumental to the successful implementation of molecular methods in routine clinical microbiology laboratories. automated nucleic extraction platforms can now be coupled to robotic handling for large-scale detection and quantification purposes, mostly in virology. i will review here the attempts of implementing home-brew and commercial nucleic-acid based detection methods directly from blood samples and highlight hopes and pitfalls. i will then expand on two promising nucleic acid amplification methods: lamp (loop mediated isothermal amplification) and a protein-free method called dnazyme. these isothermal amplification methods share several strengths: robustness across highly diversified physico-chemical conditions, versatility in assay development and minimal requirements (if any) for sample preparation. they will definitely compete against current real-time pcr assays and might become a novel standard, due to lower costs and improved performances. the ribosomal rna (rrna) approach to microbial evolution and ecology has become an integral part of microbiology. rapidly growing databases exist that encompass besides the 16s rrna sequences of almost all validly described bacteria and archaea also numerous 16s rrna sequences of so far uncultivated microbes, directly retrieved from the environment by pcr or metagenomics. based on the patchy evolutionary conservation of rrna genes oligonucleotide probes can be designed in a directed way with specificities ranging from species up to large evolutionary entities like phyla or even domains. when such probes are labeled with fluorescent dyes or the enzyme horseradish peroxidase they can be used to identify single microbial cells by fluorescence in situ hybridisation (fish) directly in complex environmental samples. an update on recent applications and methodological improvements will be given which includes the identification of small bacterial cells by catalyzed reporter deposition (card)-fish. with optimised methods and proper controls fish yields exact cell numbers and spatial distributions for defined bacterial populations also in highly complex mixed microbial communities. r. amann & b.m. fuchs (2008) nature reviews microbiology 6:339-348. quick and reliable species identification of microorganisms is of great importance in medical microbiology. several bacterial and fungal species can be identified only using laborious and time-consuming methods. furthermore, in many cases misidentification occurs due to e.g. limited biochemical reactivity, different morphotypes or limited information in reference panels. in this talk, matrix-assisted laser desorption/ionisation time-of-flight (maldi-tof) mass spectrometry will be presented as a method for species identification. this technology applies protein pattern matching based on mass spectrometry. during the identification process, a mass pattern is generated for each organism. the subsequent comparison of this pattern with a database comprising reference patterns derived from well-characterised reference strains leads to species identification. as examples, the identification of various nonfermenting bacterial strains isolated from clinical specimens in comparison to partial 16s rdna sequencing will be shown. moreover, speed, accuracy in comparison to other methods, and inter-and intra-laboratory reproducibility of maldi-tof ms-based species identification will be discussed. o489 trends in invasive streptococcus pneumoniae serogroup 1 sequence types in belgium t. goegebuer, k. van pelt, j. verhaegen, j. van eldere°(leuven, be) objectives: s. pneumoniae serogroup 1 (sg1) isolates frequently cause invasive pneumococcal disease, particularly in children. from 2003 onwards a marked increase in sg1 isolates was observed; overall prevalence increased from 8. 2% (1998-2002) to 13.6% (2003) (2004) (2005) (2006) . we determined the sequence types (st) in sg1 isolates in order to better understand trends in sg1 resistance and spread. methods: as national reference centre, we receive all invasive isolates from more than 100 of 182 laboratories in belgium. 124 randomly chosen sg1 isolates from all ages from 1998 to 2006 were analysed via multi-locus sequence typing (mlst) as described by enright & spratt (microbiol. 1998; 144: 3049−60) . we also included data on strain characteristics and patient characteristics. results: 10 different sequence types (st) were identified: st350 (n = 66), st306 (n = 24), st304 (n = 13), st227 (n = 10), st228 (n = 5), st2915 (n = 2), st305 (n = 2), st612 (n = 1), and st217 (n = 1 mutations usually increase the mic slightly, but enhance the probability of further mutations. efflux pumps like pmra reduce antibiotic concentrations in the bacterial cell, enabling longer survival. we hypothesised that efflux positive bacteria are more likely to develop resistance than efflux negative bacteria. the following questions were addressed: 1. do the efflux pump inhibitors reserpine and verapamil reduce the mutation frequency? 2. do fluoroquinolone-susceptible efflux positive pneumococci exhibit higher parc or gyra qrdr mutation frequencies than efflux negative isolates? 3. does efflux phenotype impose a fitness cost? methods: matched efflux positive and negative pneumococcal isolates with identical or similar genotype according to multi-locus sequence typing collected by the german community acquired pneumonia network capnetz were analysed (n = 17). strains tigr4 and r6 were included as efflux negative controls. ciprofloxacin (cip) mics and efflux phenotype were measured by agar dilution method, for efflux detection reserpine (10 mg/l) was added and a fourfold decrease in mic was considered as efflux positive. mutation frequencies were determined by plating bacterial suspensions onto agar with and without cip. after incubation colonies were counted and the ratio of cfu/ml yielded the mutation frequency. equally, the mutation frequency was determined adding different concentrations of verapamil (10, 25, 50, 100, 500 mg/l) or reserpine (0.01, 0.1, 1, 5, 10 mg/l). biological fitness was calculated as the maximum slope of growth curves recorded in a microtitre plate reader. results: 1) even at low concentrations, reserpine clearly reduced the mutation frequency of efflux positive and, to a lesser extent, efflux negative pneumococci when exposed to cip (figure 1); verapamil exhibited this effect merely at high concentrations. 2) efflux positive isolates produced more frequently mutants (8/9) than efflux negative isolates (2/10) (p = 0.005, fisher's exact test). 3) efflux phenotype had no measurable impact on the biological fitness. conclusion: a positive efflux phenotype increases the qrdr mutation frequencies in the presence of fluoroquinolones and this effect can be inhibited by very low concentrations of reserpine. as a matter of concern, efflux is not associated with decreased biological fitness. background: use of fluoroquinolone (fq) has been associated with increasing fq resistance in s. pneumoniae. because respiratory fqs (levofloxacin (levo) and moxifloxacin (moxi)) are first line therapy for serious respiratory infections, increasing fq resistance (fqr) in sp is a concern. levo targets parc, and moxi targets gyra, which may permit differentiation of degree of selective pressure. we examined fq use, and changes in the prevalence of fqr and qrdr mutations in canadian isolates of sp. methods: cbsn is a canadian collaborative network of microbiology laboratories that has performed surveillance for antibiotic resistance in sp since 1988. antimicrobial resistance is performed in a central lab to clsi standards. we sequenced qrdr regions of all fqr isolates and a stratified sample of fq susceptible isolates. population fq use was obtained from ims canada. results: from 1995 to 2007, fq use increased from 53 to 97 rx/ 1000pop/yr; levo use from 0 to 10 rx/1000pop/yr, and moxi use from 0 to 17 rx/1000pop/yr. 31081 isolates were available for testing. levo r rates increased from 0 in 1993 to 1.8% in 2002 then remained stable until 2008 (1.6% in 2008). moxi r rates increased to 0.6% in 2004, then stabilised (0.7% in 2008). the prevalence of parc only mutations has not increased significantly in the last decade (see table) . the prevalence of isolates with both parc and gyra mutations increased until 2002, but has decreased in 2008. the first gyra only mutant was detected in 2000; the prevalence of gyra only mutants since then has increased, but remains very low (7/2044, 0.34% in 2007) . conclusion: despite increasing use of respiratory fqs, fqr in pneumococci is very low and not increasing in canada. the prevalence of isolates with parc mutations is decreasing. isolates with mutations in gyra alone remain extremely rare, suggesting that moxi exerts minimal selective pressure for resistance. in streptococci, two well characterised macrolide resistance have been described: target modification and active drug efflux. target site modification is mediated by the erm genes -erm(b), erm(a), erm(c)which confers the mlsb phenotype. target modification by mutations in 23s rrna as well as mutation in l4 and l22 ribosomal proteins have also been reported. expression of mef(a) genes activate an efflux mechanism responsible for m-type resistance we characterised a clinical isolate of s. agalactiae mb56gbs022 exhibiting the mlsb phenotype and tetracycline resistance. in this study, we determined the resistance genes, their association, and their localisation and mobility by conjugation. methods: the macrolide and tetracycline resistance genes were confirmed by pcr. the association between macrolide and tetracycline genes was investigated by long-pcr and sequencing. conjugation experiments were performed by filter matings. the genetic localisation of resistance genes was determined by endonuclease i ceui -followed by pfge and southern blot. the hybridisation study was performed using three specific probes for the 16s and 23s rrna genes, for erm(b) and tet(o) genes. results: s. agalactiae mb56gbs022 carried erm(b) and tet(o) genes on the same amplicon of 7 kb in size. the nucleotide sequence analysis of the entire product was identical to the peoc01 of 11 kb from pediococcus acidilactici that contains four orfs, of which orf2 and orf3 encode a putative resolvase and topoisomerase type i, respectively. the endonuclease i ceui method, that easily distinguishes between plasmid and chromosomal localisations as i-ceui only cuts chromosomal dna, revealed the localisation of resistance genes on the plasmid. all attempts to transfer erm(b)-tet(o) structure by conjugation from s. agalactiae mb56gbs022 to og1ss e. faecalis as recipient failed. conclusion: our results show the first case of the association between erm(b) and tet(o) genes on the unique mosaic structure in s. agalactiae, probably on the plasmid, as demonstrated by the i ceui-assay. further studies are on going to characterise the entire genetic element carrying resistance genes. o499 improving influenza pre-analytic collection systems: alternative collection systems to inactivate, preserve, or extract influenza for rapid testing s. castriciano°, k. luinstra, m. ackerman, a. petrich, m. smieja (brescia, it; hamilton, ca) objectives: in this study, 3 alternative influenza sample collection systems were evaluated for potential use in a pandemic situation. the objectives were to develop: 1) a non-temperature dependent swab collection and transport system, that inactivates influenza virus infectivity but preserves cell morphology and nucleic acid (na) for the detection of suspected influenza infections and/or 2) a system compatible with direct na testing without the need for purification prior to detection by a rapid real-time rt-pcr. methods: flocked nasopharyngeal swabs (nps) collected in utm (u) were compared to nps collected in a cymol (c), m-swab (m) or dry (d) flocked swab collection system (copan, italia). cymol is an alcoholbased medium that preserves cells for dfa testing. the m-swab contains 600 ul of medium and 150 ul of glass beads, and requires no na purification step. shell vial culture was used to assess influenza virus inactivation after 30 minutes exposure to the collection media. a mockinfected influenza a virus sample was absorbed to duplicate swabs then placed into the 4 collection systems. the infected collection media were held at rt for 30 minutes and then inoculated in duplicate into shell vial culture and stained after 48 hours. influenza a stability and na recovery after mock infection of each collection system was assessed after 1, 7, 14 and 21 days (d) at 4ºc, −20ºc, room temperature (rt) and 37ºc. aliquots of infected collection media were extracted by easymag and 5 ul of purified na tested by a quantitative influenza a rt-pcr on the roche lightcycler. m-swab collected samples were also tested directly or after boiling, without na purification. results: shell vial culture found that influenza a virus was inactivated after 30 minutes exposure to the c medium but not when exposed to the u and m media. influenza a was detected by dfa from the u and c cell smears. quantitation of influenza a rna was constant after 1, 7 and 14 d in u, c, m and d collection systems at −20, 4ºc and rt. the quantity of rna recovered declined significantly after 14 d at 37ºc in all 4 collection systems. m with boiling yielded data comparable to the easymag extraction. the copan cymol medium inactivates influenza infectivity, preserves cells and stabilises rna up to 14 days at −20, 4ºc and rt. cymol medium is a potential alternative for safe sample collection during a pandemic influenza situation. the m-swab presents a rapid testing alternative. luminex respiratory viral panel in respiratory specimens from children r. selvarangan°, s. selvaraju, d. baker, k. estes, l. hays, d. abel, s. hiraki (kansas city, us) objective: luminex respiratory viral panel (rvp) is a multiplex pcr capable of detecting and differentiating twelve different respiratory viruses and their subtypes; influenza a (flu a) (subtypes h1 and h3), influenza b (flu b), respiratory syncytial virus (rsv) (subtypes a and b), adenovirus (adv), parainfluenza 1 (piv 1), parainfluenza 2 (piv 2), parainfluenza 3 (piv 3), human metapneumovirus (hmpv) and rhinovirus (rhv). the aim of this study was to evaluate the analytical performance characteristics of rvp assay and to evaluate its ability to detect respiratory viruses from nasopharyngeal aspirates obtained from children. method: analytical sensitivity, specificity, accuracy and precision of the luminex rvp assay were determined using control viral stocks and respiratory specimens previously tested by rmix shell vial culture. result: luminex rvp assay reliably detected atcc viral stocks of flu a, flu b, rsvb, rhv and piv3 in the range of 10e-2 to 10e-4 tcid50/ml. no cross reactivity was noted with cmv, hsv, hhv6, ebv, vzv, piv4, cornoavirus 229e and oc43. among 146 respiratory specimens previously characterised by culture 138 specimens were accurately detected with overall accuracy of 95%. the median coefficient of variation in mean fluorescent index values of signals from replicate analyses of influenza a, b and rsv was 9% (7% to 25%). the 146 clinical specimens tested by rvp assay included 109 culture positive and 37 culture negative specimens. respiratory viruses isolated from the culture positive specimens include the following; 19 adv, 11 flu a, 10 flu b, 19 rsv, 9 piv1, 6 piv2, 5 piv3, 19 hmpv and 14 rhv. rvp assay detected all of the respiratory viruses except one each of rsv, piv1 and piv2 virus with overall sensitivity ranging from 88% to 100% for the different respiratory viral groups. among the 37 culture negative specimens 20 respiratory viruses were detected by rvp of which 15 were subsequently confirmed by repeat analyses. conclusion: luminex rvp assay is a highly sensitive and specific test useful in the detection of commonly encountered respiratory viruses in respiratory specimens. the addition of rvp assay to the viral testing algorithm of respiratory infections in children provides rapid results, improves diagnostic yield and may result in decreased antibiotic usage, reduced diagnostic testing and reduced hospital stay. m. savvala, i. daniil, i. berberidou, a. koutsibiri, a. stambolidi, m. papachristodoulou, n. spanakis, d. petropoulou°, a. tsakris (athens, gr) objective: in developed countries, viruses, particularly noroviruses, are recognized as the leading cause of acute gastroenteritis. we determined the aetiology, prevalence and seasonal distribution of viral gastrointestinal infections in hospitalised patients with acute diarrhoea. methods: during one-year period (november 2007-november 2008), a total of 201 faecal specimens were collected from 165 children, 21 premature neonates and 15 adults who were hospitalised with symptoms and signs of acute gastroenteritis. stool samples were tested for the presence of rotavirus, adenovirus, astrovirus and norovirus. rotavirus, adenovirus and astrovirus antigen detection was performed by chromatographic immunoassays (rotavirus and adenovirus, vikia ® -biomerieux, france; h&r astrovirus-vegal farmaceutica, spain). noroviruses were detected by an enzyme immunoassay (ridascreen ® rbiopharm, germany) and confirmed by reverse transcription-pcr. data were analyzed for seasonality of infection and possible transmission mode. the overall incidence of viral identification in acute diarrhoeal stool was 24% (48 of 201 patients). fifty one viral antigens were detected one patient with positive antigen detection is suffering from a disease of unclear aetiology. so, an association of replication of cihhv-6 with the disease might be considered. in contrast, the other patient did not show any symptoms at the time of antigen detection. this patient shows a special mode of acquisition of cihhv-6 (by bmt) possibly resulting in differences in the immunological priming and response. in addition, in the latter patient cihhv-6 is restricted to blood cells. two other patients did not show antigen expression. so, it is unclear how the transcription and translation of viral genes is influenced? furthermore, is there a pathophysiological impact of viral replication in individuals with cihhv-6? objectives: several case studies have reported on meningo-encephalitis caused by a primary epstein-barr virus (ebv) infection. we aimed to investigate the viral loads, and the inflammatory characteristics of this thus far poorly defined disease entity. we evaluated all cases from 2003-2008, in which an ebv polymerase chain reaction test (pcr) was requested on a cerebro spinal fluid (csf) sample. primary infection was defined as a clinical presentation with sore throat/pharyngitis/malaise in combination with lymphocytosis, and detectable heterophile antibodies or positive ebv igm antibodies. patients with proven neuroborreliosis served as control group. leukocyte response and ebv viral loads in csf, and serum were compared between primary ebv and neuroborreliosis cases. results: we identified six cases with a primary ebv infection (median age: 22, male: 4) with neurological symptoms ranging from meningeal signs to encephalitis. these were compared to 14 patients with neuroborreliosis (median age: 27, male: 6). in four out of six patients with a primary ebv infection with neurological symptoms ebv dna was detected in csf and in serum, whereas all neuroborreliosis cases were ebv pcr negative in both compartments. viral loads were lower in csf as compared to serum. in blood, leukocytes, lymphocyte, and monocyte counts were significantly increased as compared to the neuroborreliosis cases (see table 1 ). specific for vp7 and vp4 genes, using pools of g and p type specific primers. all strains (niv/brv/68, niv/brv/79, and niv/brv/86) were not typeable for the vp4 and vp7 genes. after purification by "qiaquick gel extraction kit" (qiagen, germany), the vp4, vp6, vp7, and nsp4 first amplicons of the borv-a strains were subjected to sequence analysis with automated sequencer abi 3130 xl dna analyzer (applied biosystems, usa). phylogenetic analysis was performed using mega version 4.0. objectives: dengue is a flavivirus and is among the most widely-spread viral diseases. our previous report demonstrates existence of live dengue virus in blood and urine even in the convalescent postfebrile period. in some cases, excretion in the patient's urine can be detected as late as 28 days after the onset of illness. this goes along with the model of west nile virus, another type of flavivirus, which can be excreted in the urine for months after acute infection in both animal studies and human case report. here we report a pilot study to address a magnitude of such findings. methods: between april 2007 and october 2008, paediatric and adult febrile patients suspected of dengue infection were enrolled. diagnosis of dengue was based on standard specific serology on paired sera. patients with negative serology served as controls. blood and urine specimens were collected at several time points. whole blood was separated into plasma and peripheral blood mononuclear cells (pbmc). these have been aliquoted and used for earlier studies and some stored in freezers. available plasma, pbmc, and urine were processed and inoculated into aedes aegypti. surviving mosquitoes at 14 days after inoculation were employed for viral detection by dengue-specific rt-pcr. indirect fluorescence antibody (ifa) staining of mosquito heads was performed on all positive rt-pcr specimens, except for the one from pbmc (awaiting ifa result). results: 5 and 45 cases of primary and secondary infections, respectively, and 4 negative controls were included. these translated into 55 and 59 early and late dengue specimens, and 6 and 4 early and late negative-control counterparts, respectively. dengue virus were isolated in some blood and urine specimens as late as 46 days after the onset of illness. no virus was isolated from control specimens. all but 5 positive rt-pcr specimens also demonstrated positive ifa. 4 out of 5 negatives were from early-phase specimens. conclusion: our study demonstrates prolonged survival of dengue virus after clinical recovery. this finding has pathologic and epidemiologic significance, adding a potential role of urine in the transmission of the disease. spread of the virus to humans might occur through infectious urine with help from arthropod vectors. this research could provide new insights into our understanding of the pathogenesis of denv infection. isolation of dengue virus from blood and urine specimens during early (days 1−7 after onset of illness) and late (days 8−46) phases of infection (specimens with dengue isolated/total specimens for mosquito inoculation) early phase late phase plasma 16/25 (64%) 0/13 (0%) pbmc not performed 1/2 (50%) urine 8/29 (28%) 12/44 (27%) all specimens 24/54 (44%) 13/59 (22%) dna copies) 226 (<50-1461) † ; n = 2 <dl all <dl ebv pcr in serum (dna copies) 1507 (<50-14127) † ; n = 2 <dl all <dl data presented as median (interquartile range). *p < 0.05; † p < 0.01; comparison by mann-whitney u-test. csf: cerebrospinal fluid. ebv: epstein-barr virus y. achermann°, c. spormann, c. kolling, c. remschmidt, j. wüst, b. simmen, m. vogt (baar, zurich, ch) objectives: elbow arthroplasty is increasingly used for treatment of rheumatic or posttraumatic arthritis. data on epidemiology, characteristics and treatment outcome of elbow prosthetic joint infection (pji) is limited. furthermore, no validated therapeutic algorithm exist as for hip or knee pji. we analyzed all pji, which occurred in a cohort of implanted elbow prostheses during a 13-year-period. methods: between 01/1994 and 12/2007, all cases with implanted elbow prosthesis at our institution were retrospectively included. elbow pji was defined as visible purulence, acute inflammation on histopathology, sinus tract or microbial growth in periprosthetic tissue. patients were regularly follow-up at outpatient orthopedic visits and were in addition recently contacted by phone. a kaplan-meier survival analysis was performed. results: during the study period, 358 elbow prostheses were implanted. overall, 25 of 358 cases (7%) developed elbow pji (median age 61 y, range 41−82 y, 40% males). among them, 14 (56%) had a rheumatic disorder and 11 (44%) a posttraumatic arthritis. 12 infections were early ( 3 months), 3 were delayed (3−24 months) and 10 were late ( 24 months). more infections were acquired intraoperatively (n = 15, 60%) than haematogenously (n = 10, 40%). the following pathogens were cultured: staphylococcus aureus (n = 11), coagulase-negative staphylococci (n = 7), streptococcus agalactiae (n = 2), corynebacterium sp. (n = 1), enterococcus sp. (n = 1), enterobacter cloacae (n = 1), mixed infections (n = 1) and culture-negative (n = 1). treatment approaches included débridement with implant retention (n = 19), one-stage exchange (n = 2), two-stage exchange (n = 1), resection arthroplasty (1) and antibiotics only (n = 2). at follow-up, 16 (64%) patients were free of infection (median follow-up time 2.6 y, range 0.7−11.3 y) and 9 (36%) had a relapse (median time to infection 0.4 y, range 0.1−4.0 y). one patient died due to infectious endocarditis with secondary haematogenous elbow pji. the relapse-free survival (95% confidence interval) was 75% (58%-93%) after 1 year, 70% (52%-89%) after 2 years, 62% (39%-85%) after 3 years and 52% (27%-78%) after 4 years. the infection incidence after elbow arthroplasty was higher (7%) than reported after hip (<1%) or knee arthroplasty (<2%). most infections (48%) manifested early ( 3 months). underlying rheumatic disorder were common in elbow pji (58%). the relapse-free survival after elbow pji was 75%, 70%, 62% and 52% after 1, 2, 3 and 4 years. e.a.n. oostdijk°, a.m.g.a. de smet, h.e.m. blok, e.s. thieme groen, j.a.j.w. kluytmans, m.j.m. bonten (utrecht, breda, nl) introduction: selective digestive tract decontamination (sdd) and selective oropharyngeal decontamination (sod) aim to eradicate gram-negative bacteria (gnb) from the intestinal en respiratory tract in intensive-care-unit (icu) patients. we aimed to quantify effects of sdd and sod on bacterial ecology in 13 icus that participated in a clustered group-randomised cross over study in the netherlands, in which sdd, sod or standard care (sc) was used during consecutive periods of 6 months (nejm 2009; 360:20) . the order of periods was randomised per icu. methods: point prevalence surveys of rectal and respiratory samples were performed once monthly in all patients in icu (receiving or not receiving sod/sdd). selective media were used to detect gnb and mic testing was done for ceftazidime (cft), ciprofloxacin (cip) and tobramycin (tob). effects of sdd on rectal carriage were determined by comparing data from 6 sdd months in each icu to data from all months preceding and following (in which sod or sc was given). combined effects of sdd/sod on respiratory tract carriage were determined by comparing data from 12 months sdd/sod (in any order) to data from the 6 sc months before and afterwards. results: 2583 rectal and 2023 respiratory tract samples were analysed. during sdd average proportions of patients colonised with gnb resistant to either cft, tob, cip were 5%, 7% and 7% and these proportions were 15%, 13% and 13% during the post-intervention period (p < 0.05 in each case). this effect is most explicit for cft with resistance levels increasing from 2.6% in the last month of sdd to 11.4% in the 1st month after sdd (p < 0.05). during sdd and sod resistance levels in respiratory tract samples were <6% for all three antibiotics, but prevalence increased gradually (for cft and tob resistance; p < 0.05 for trend). after discontinuation of sdd and sod average proportions increased to levels >10% for all three antibiotics (p < 0.05 in each case). cft resistant isolates in rectal samples mainly included enterobacteriaceae not being escherichia coli and klebsiella spp, whereas tob and cip resistant isolates mainly included e. coli. conclusion: sod and sdd have marked effects on the bacterial ecology in an icu with a rapid and persistent increase in resistance after intervention. antibiotic resistance remains a major concern associated with these infection control measures. o391 throwing caution to the winds? three cases of anaphylaxis to chlorhexidine coated central venous catheters from a regional cardiac centre in northwestern england this blaoxa-58-producing clone showed resistance to several b-lactams (including imipemem), susceptibility to ceftazidime, netilmicin and minocycline, and variable susceptibility to meropenem, cefepime, and aztreonam. mics for colistin and tigecycline ranged from >16 mg/l and from 0.25−4 mg/l, respectively. all oxa-58-producing isolates presented the isaba3 downstream of the blaoxa-58 gene. hybridisation assays revealed a plasmidic location for the blaoxa-58 gene with ca 90kb. plasmid sequencing showed an isaba3-like truncated at the 3 end upstream of the blaoxa-58 gene, a fact that may explain the observed negative carbapenemase-production bioassay. conclusion: blaoxa-58-carrying a. baumannii is, apparently, more ancient than initially imagined. although undetected from 2004 onwards, the fact that it possessed a non-expressible gene, due to alterations in the promoter region, suggests that this information might have been incorporated from a still unidentified source. twenty-seven (45%) were male. isolates were recovered from respiratory secretions (33 isolates, 55.0%), blood (11, 18.3%), urine (7, 11.7%), catheter (5, 8.3%) and other secretions (4, 6.7%). only 24 (40.0%) of 60 patients received appropriate antimicrobial therapy either with polymyxin b (79.2%), ampicillin-sulbactam (12.5%) or tigecycline (8.3%). overall 30-day mortality of patients with crab was 50%. mortality rates were 3.2 per 1000-patient/day. these rates were significantly higher among patients who have not received appropriate therapy (1.2 per 1000-patient/day) compared with those who have received it (0.3 per 1000-patient/day; p = 0.001; figure 1 ). in the cox regression model only receiving appropriate treatment (hazard ratio [hr] 3.29; 95% confidence interval [ci] 1.35−8.02); p = 0.009) was independently associated with 30-mortality. positive blood culture for crab remained in the final model (hr 1.85; 95% ci 0.86−4.00; p = 0.12). all 25 isolates submitted to pcr were positive for blaoxa-23. all these isolates were susceptible to polymyxin b and tigecycline. conclusion: high 30-day mortality occurred in this icu outbreak. many patients did not receive appropriate therapy, which significantly increased mortality. other clinical risk factors for mortality in this outbreak are currently under investigation. acinetobacter baumannii in norwegian strain collections reveal major discrepancies to phenotypic identification and the presence of carbapenemase-producing clonal lineages baumannii isolates the per-1 gene was identified in 18 (23%). the similarity of the bands were calculated according to "dice smilarity coefficients" and all per-1 positive isolates were found as clonally related. conclusion: in our study the prevalence of per-1 was lower than the previous studies. but the presence of high ceftazidime resistance rates among these isolates may indicate the presence of other beta-lactamases. dna analysis by pfge and rapd revealed an outbreak caused by a unique clone. detection of clonal related isolates among different services may be because of the treatment of these patients at the same services before and this may explain the spread of per-1 positive strains.o442 resistance genomic islands related to abar1 are common in acinetobacter baumannii strains belonging to european clone i l. krizova°, m. maixnerova, l. dijkshoorn, a. nemec (prague, cz; leiden, nl) objective: acinetobacter baumannii strains belonging to european (eu) clone i are commonly resistant to multiple antimicrobial agents. a number of resistance genes were recently detected on an 86-kb genomic resistance island (abar1) inserted in the atpase gene of eu clone i strain aye. the aim of this study was to assess the presence of abar1related structures in epidemiologically unrelated strains of eu clone i. methods: the study set included 25 multi-drug resistant (mdr) strains of eu clone i collected in 19 european countries in 1978-2004 and 10 genotypically unique, fully susceptible strains. using pcr, all strains were investigated for the presence of the atpase gene and for nine genes found to be associated with abar1. furthermore, the strains were tested for the disruption of the atpase gene using pcr primers directed against the 3 and 5 ends of this gene. strains with the disrupted gene were investigated for the presence and structure of the atpase gene-abar1 connecting regions using pcr mapping and rflp. pcr primers were derived from the known sequence of strain aye. results: all strains were positive for the atpase gene. the 10 susceptible strains had an intact atpase gene whereas all mdr strains failed to produce the expected amplicon in the atpase disruption test. all eu clone i strains yielded positive results for the atpase gene-abar1 connecting regions, the structure of which corresponded to those of aye. these findings suggest the presence of atpase integrated elements in clone i strains, the integration of which had invariably taken place at the same locus site. none of the abar1-associated resistance genes were found in any of the susceptible strains. in contrast, the mdr strains harboured the following abar1-associated genes (% positive strains): aacc1 (21), aada1 (21), aadb (4), apha1 (21) stra (3), mera (20), teta (18), cat (23), the gene encoding heavy metal detoxification protein (25). individual mdr strains carried from one to nine abar1-associated genes in 11 different combinations. there was a good correlation between the content of resistance genes and resistance phenotypes. conclusion: genetic structures related to abar1 are common in strains belonging to eu clone i. the heterogeneity of resistance patterns in this clone is likely to result from the variations in the content of abar1related structures. supported by grant 310/08/1747 of the grant agency of the czech republic. objectives: to study the differences in mutation frequency and evaluate the possible correlations between drug resistance development and mutation rate in acinetobacter baumannii (ab). the mutation frequency (mf) of rifampicin (rif) resistance was used as a surrogate measure of differences in mutation rate and for detection of the presence of mutator phenotype. 10-and 100-fold higher when larvae were infected with atcc17978 and sdf, respectively. thus, the sdf genome was used as reference genome to identify functions acquired by pathogenic strains with a possible role in antibiotic resistance and pathogenicity. sixty-two clusters, corresponding to almost 870 cdss, were identified in the acicu and aye genomes (and partially in atcc17978) that were absent in sdf. this study found that targeted interventions that reduce the use of quin were associated with a decrease of the quin resistance rate in e. coli. e. velasco°, w. espelage, i. noll, a. barger, t. eckmanns (berlin, de) objectives: growing populations of older and immunocompromised patients, changes in epidemiology and unchecked use of antibiotics can led to a rise in consumption as well as resistance to certain treatments. medical doctors (mds) often have an important role alongside contributing factors. we conducted a national survey of mds in germany on their behaviours and expectations for intervention. we aimed to assess md behaviours with and influences on antibiotic prescribing and the potential for related interventions that address antibiotic resistance.methods: a representative sample comprised 10,610 mds with differing practice specialties, from both stationary and ambulatory settings (respectively: 36% and 0% internists, 0% and 54% general practitioners, 32% and 11% surgery, 3% and 4% ear/nose/throat, 10% and 10% paediatrics, 5% and 3% urology, 9% and 13% gynaecology, 2% and 4% dermatology, 3% and <1% other) in 15 federal states. we developed study questions to capture baseline information on mds and their practice with antibiotics. questions also focused on selected influences that may affect behaviour in practice. other questions solicited opinions about interventions that may improve practice. mailed questionnaires were distributed to participants via state medical associations. results: among survey respondents (n = 3,613; response rate = 34%), 66% reported that they prescribe antibiotics daily, and 90% indicated they do so at least weekly. of all surveyed mds, 60% reported that they think their own prescribing practice has an influence on antibiotic resistance in their region. of all mds, 83% found it "important" to continually improve use of antibiotics through industry independent experts providing consultation, audits and feedback. of all mds, 96% found it "important" to have provision of regional coverage of antibiotic resistance with appropriate feedback for practicing mds, and 82% found it "important" to have provision of antibiotic regulations of prescriptions with appropriate feedback for practicing mds. (results in table 1 .) -a not all results shown and remaining percentages are as follows: a closed three category scale was used for options "yes", "no", "do not know". a closed four category scale was used with options "very important", "important", "less important" and "not important". a closed five category scale was used for options "daily", "weekly", "monthly", "seldom" and "never". a closed five category scale was used for options "strongly agree", "agree", "neutral", "disagree" and "strongly disagree". objectives: to investigate the mlsb and tetracycline resistance and the emm gene distribution among the invasive streptococcus pyogenes (gas) strains. methods: between january 2006 and december 2008, a total of 991 strains responsible for invasive infections for adult patients were sent to the french national reference center for streptococci to be studied. antibiotic susceptibility testing was done by disk diffusion method according to the ca-sfm guidelines. mics were determined by e-test method. streptococcal emm sequence was done according to the cdc protocol. detection of macrolide and tetracycline resistance genes: erm(b), erm(tr), mef(a), tet(m), tet(o), tet(k), and tet(l) was performed by pcr. results: among the 991 streptococcus pyogenes invasive strains; more than ten different emm-types were identified. the most frequent emm sequence types were emm1, emm28 and emm89. a total of 80 strains (8%) were resistant to erythromycin. erythromycin resistance prevalence had decreased during the three years period (12. 2%-2006, 7.6%-2007, 5.5%-2008) . 69 had an mlsb constitutive (65 strains) or inducible (4 strains) phenotype due to erm(b) or erm(tr) resistance gene. 11 with the m phenotype and mef(a) gene were susceptible to clindamycin. among the 132 (13.3%) tetracycline resistant isolates tet(m), tet(o) and tet(l) genes were detected in 86, 27 and 19 strains, respectively. tetracycline resistance prevalence had also decreased during the three years period (16. 8%-2006, 14%-2007, 8.7%-2008) . conclusion: most of the invasive french gas isolates remained erythromycin and tetracycline susceptiple during three years. nontheless, the resistance rates have had the tendency to decrease slightly. taking into account the resistance trends helps to guide the therapy for penicillin-allergic patients. objectives: during a survey on antimicrobial susceptibility in betahaemolytic group c and g streptococci (gcgs) from portugal, a macrolide resistance rate higher than previously reported in other european countries was found (22%) among s. dysgalactiae subsp. equisimilis isolates. to gain further insights into the resistance mechanisms involved and the clonal structure of the resistant population, we undertook the phenotypic and molecular characterisation of macrolide resistant s. dysgalactiae subsp. equisimilis isolates and compared it with the susceptible population. methods: antimicrobial susceptibility testing and macrolide resistance phenotype were determined by disk diffusion. all the macrolideresistant isolates were further characterised by mic testing and genotype determination by pcr. a combination of emm typing and pulsed-field gel electrophoresis (pfge) was used to type the population and the simpson's index of diversity (sid) with 95% confidence intervals was calculated as previously described.results: a total of 69 isolates were resistant to erythromycin (mic range, 4 to >256 ug/ml). the vast majority of isolates presented a mlsb phenotype (n = 64) and carried the erm(a) gene (n = 55), while the mefencoded m-phenotype was expressed by only 5 isolates. among resistant isolates, 13 distinct emm types were found distributed by 10 pfge clusters that overlapped with the main clusters detected in the susceptible population. the emm types stg480, stg6, stg485 and stg2078 accounted for approximately two thirds of the resistant isolates. pfge did not always separate neither macrolide-resistant from susceptible isolates nor erm(b) and mef(a) from the prevailing erm(a) isolates. the sids of emm and pfge calculated for resistant isolates were not statistical different from the overall population. the two most prominent mls resistant lineages were one with stg480/erm(a) isolates (n = 8) and stg485/mef(a) (n = 3), and another including stg2078/erm(a) (n = 8).conclusion: although most of the resistant isolates presented a mlsb phenotype and carried an erm(a) gene, molecular typing revealed extensive diversity in both emm types and pfge clones. macrolide resistance had a polyclonal origin, with resistance emerging among most susceptible clones. monitoring of macrolide resistance patterns in s. dysgalactiae subsp. equisimilis is essential as this pathogen is increasingly recognised as an important human pathogen. a.s. simões°, r. sá-leão, s. nunes, n. frazão, a. tavares, h. de lencastre (oeiras, pt) while performing pneumococcal nasopharyngeal colonisation surveillance studies among children attending day care centres (dcc) in portugal, we observed that the rate of strains with penicillin mic 2 ug/ml more than tripled from 1.8% in 2006 to 6% in 2007 (p = 0.002). the aim of this study was to characterise the 20 isolates recovered in 2007 which had a mic to penicillin 2 ug/ml. methods: pneumococci were isolated and identified on the basis of selective growth on gentamycin blood agar plates, optochin susceptibility, colony morphology, and alfa-haemolysis. susceptibility to antimicrobials agents was performed according to the clsi recommendations and definitions. strains were serotyped by the quellung reaction and/or multiplex pcr using specific primers for each serotype. pulsed-field gel electrophoresis (pfge), after restriction of the total dna with smai, was performed to compare genetic backgrounds. results: sixteen of the 20 isolates belonged to serotype 14, three were serotype 19a and one was of serotype 15a. strains of serotype 14 were also resistant to sulfamethoxazole-trimethoprim and belonged to a single pfge cluster identified as clone spain 9v st156. the penicillin resistant serotype 14 strains were isolated in two dcc, from nine children vaccinated with the 7-valent pneumococcal conjugate vaccine (pcv7), four non-vaccinated children and three children with unknown vaccination status. five of these carriers had received antibiotics recently. in these two dcc the overall proportion of children vaccinated with pcv7 was 64%; 27% of the children had received antibiotics within the previous month and 16% had received three or more courses of antibiotics in the last six months. since the introduction of the pcv7 in portugal, in june 2001, the proportion of penicillin resistant pneumococci recovered from colonisation has been stable (c.a. 2%). the sudden increase in the levels of penicillin resistance observed in the 2007 surveillance study was found to be largely due to the dissemination of clone spain 9v st156 serotype 14 variant in two dcc with high consumption of antibiotics. the observations suggest a combination of high antibiotic selective pressure and transmission rates resulting in an outbreak-like situation with a penicillin resistant vaccine type clone being disseminated among children in day care despite use of pcv7. background: beside target mutation, active efflux is another common resistance mechanism to fluoroquinolones (fq) in s. pneumoniae. two main efflux systems have been described so far, namely pmra (member of the mfs superfamily) and the two abc transporters pata/patb. we have studied the inducibility of pmra, pata and patb genes expression when bacteria are exposed to subinhibitory concentrations of fq. we used a wild-type sensitive strain (atcc49619), two clinical strains resistant to fq (sp13 and sp295), and two efflux mutants (sp334 and sp335; selected in vitro after exposure to ciprofloxacin [jac 2007, 60:965-972] ). mic were determined according to clsi. induction was obtained by growing bacteria in todd-hewitt broth added by half the mic of each fq (cip, nor, lvx, mxf, gmf) for 4 h at 37ºc in 5% co2 atmosphere. expression levels of pmra, pata and patb genes were determined by real-time pcr. reversibility of induction was tested by re-cultivating bacteria for 4 h in drug-free medium. results: antimicrobial susceptibilities for cip and mxf and gene expression at basal level and after exposure to these fq are shown in the in women with single infection, the most common hpv types were hpv-6 and hpv-16, followed by hpv-51, hpv-31, hpv-53 and hpv-66, whereas in women with multiple infections hpv-6 was the most commonly detected type, followed by hpv-66, hpv-31, hpv-16 and hpv-51. a different distribution of hpv types and a higher rate of multiple infections were observed in young vs. older women, suggesting the existence of a natural selection of hpvs which preserve a better fitness. high-risk hpvs were detected in all high-grade cervical intraepithelial lesions, with hpv-16, hpv-18, hpv-31, and hpv-51 as the most frequent types. however, hr-hpv types were detected also in a high rate of women with a negative pap test as well as in women with a negative cervical biopsy, suggesting the need to improve the accuracy of available cervical cancer screening tests. the results of this study, which provide information on the epidemiology of hpv infection and type distribution in women from south italy, should be taken into consideration in the implementation of local vaccination programs. objectives: chromosomal integration of the hhv-6 genome (cihhv-6) into the human genome occurs in 1−2% of healthy individuals and leads to persistently high levels of hhv-6 pcr copy numbers in blood and tissue. consequently, this may be interpreted as persistent active hhv-6 infection. although hhv-6 mrna has been detected in a few individuals with cihhv-6, there is no evidence of replication of viral particles up to now. viral cultures have shown negative results. so, cihhv-6 is thought not to be linked to any disease. methods: we performed hhv-6 antigen detection in pbmcs of 4 individuals with fish proven cihhv-6 by means of antibodies directed against hhv-6 variant a and b (indirect immunoperoxidase staining). results: in 2 unrelated female adolescents (both with cihhv-6 variant a) we detected hhv-6 antigen. one patient is suffering from recurrent parotitis since 5 years and from hypoimmunoglobulinaemia. the other patient (15a) was treated with allogeneic bone marrow transplantation (bmt) for acute myeloid leukaemia (aml) and acquired cihhv-6 from the healthy donor. so, cihhv-6 is only found in blood cells. in the latter patient only symptoms attributable to the post bmt course have been observed (prolonged mixed haematological chimerism, protracted mucositis, transient hypertension and transient neuropathy). at the time of antigen detection 5 years after bmt the patient was clinically well. in 2 individuals (a girl after fatal myocarditis and her healthy father − both with variant b) no hhv-6 antigen has been detected. discussion: up to now cihhv-6 is considered not to cause any disease. for the first time we show the expression of hhv-6 antigen, which indicates the replication of viral particles. this might have a pathophysiological impact. sixty-seven % of cases with ebv meningo-encephalitis have detectable viral dna amounts in csf and serum, whereas neuroborreliosis patients do not. cases with primary ebv meningoencephalitis have increased systemic leukocytosis, with higher lymphocyte, and monocyte levels compared to neuroborreliosis patients.o506 incidence of post-herpetic neuralgia in treated and untreated patients with herpes zoster followed for 1 year in an italian prospective cohort: preliminary results g. parruti°, f. sozio, c. rebuzzi, m. tontodonati, e. polilli, a. agostinone, a. manna, f. di masi, a. consorte, g. congedo, l. cosentino, d. d'antonio, l. pippa, l. manzoli, c. granchelli (pescara, chieti, it) objectives: a large prospective cohort of patients with herpes zoster (hz) was enrolled between may 2006 and june 2008 in pescara, italy, with a planned 1-year follow-up after clinically and/or molecularly assessed diagnosis. aim of the study was to evaluate predictors of prolonged acute course and/or incidence of post-herpetic nevralgia (phn). methods: data from all enrolled patients were collected by a network of 51 general practitioners. suspected cases and patients with intense acute pain were referred to our institution for immediate evaluation. clinical and demographic information was mandatory at baseline, as photographs of enrolled patients. for uncertain cases, varicella-zoster virus (vzv) antibodies and vzv dna pcr on plasma and/or vesicular eluates (whenever available) were performed. follow-up data were collected at outpatient control visits or by phone calls at 1, 3, 6 and 12 months after onset of hz. phn was diagnosed when pain persisted or relapsed at least one month after complete clearing of dermatomeric lesions. adverse events other than pain were classified according to who grading scale and reported if 2. all statistical calculations were performed by stata 8.0 software package. results: 523 patients were enrolled, 306 (58.5%) females, with a mean age of 57.7 years, 1-year follow-up data being now available for 489. hz was localised at thorax in 45.4% and head in 20.7%; pain in the acute phase was reported as intense or very intense by 127 (25.97%) patients; 54 (11.04%) patients were referred for molecular diagnosis as clinically uncertain, 37 (68.5%) being confirmed as vzv-related cases. forty eight (9.82%) patients were not prescribed any antiviral drug at diagnosis by referring physicians, in spite of extensive support in the study plan. during follow-up, 163 (33.3%) patients reported any type of adverse event (at a mean of 91.2±74.8 days), including 93 (19.02%) patients reporting phn. phn was significantly more frequent in untreated vs treated patients (37.5% vs 17.0%, p = 0.001), as were total adverse events (54.2% vs 31.1%, p = 0.001). untreated patients did not significantly differ from those treated by age (56.3% vs 57.7%, p = 0.66) and sex (females vs males 11.9% vs 6.9%, p = 0.056), whereas they complained for more intense pain (15.0% vs 8.0%, p = 0.024) at presentation. conclusion: our study confirms the importance of early diagnosis and prompt antiviral treatment at the onset of hz in order to minimise the risk of phn. methods: faecal specimens (n = 78) from apparently healthy and diarrheic calves (aged <1 year) were collected per-rectally and investigated for detection of group a rotavirus by antigen capture elisa (generic assay, germany). elisa positive specimens (n = 3) were investigated further for molecular characterisation. genotyping of borv-a strains was carried out on dsrna extracted from 10% pbs faecal suspensions by a nested and/or heminested rt-pcr key: cord-022526-j9kg00qf authors: jones, samuel l.; blikslager, anthony t. title: disorders of the gastrointestinal system date: 2009-05-18 journal: equine internal medicine doi: 10.1016/b0-72-169777-1/50015-9 sha: doc_id: 22526 cord_uid: j9kg00qf nan however, the abdominal wall is too rigid to allow effective palpation of intraabdominal structures. abdominal auscultation is particularly useful for assessing the motility of the large intestine. progressive motility of the small intestine, conversely, is difficult to distinguish by auscultation from nonprogressive motility. the distinct character of the borborygmi produced during propulsive contractions of the cecum and ascending colon allow evaluation of the frequency and strength of retropulsion and propulsion. propulsive contractions of the cecum and ventral colon occur every 3 to 4 minutes and give rise to prolonged rushing sounds heard over long segments of intestine. retropulsive sounds presumably are similar to propulsive sounds, but they occur less frequently. the distinction of propulsion from retropulsion is not important clinically because both types of contractions signify normal motility. inter-and intrahaustral mixing contractions produce nonspecific sounds of fluid and ingesta movement that are difficult to distinguish from other borborygmi, such as small intestinal contractions or spasmodic contractions. 1 auscultation over the right flank and proceeding along the caudal edge of the costal margin toward the xiphoid allows evaluation of the cecal borborygmi. auscultation over a similar area on the left side allows evaluation of the pelvic flexure and ascending colon. typical progressive borborygmi heard every 3 to 4 minutes on both sides of the abdomen indicate normal motility of the cecum and ascending colon. less frequent progressive sounds may indicate a pathologic condition of the large intestine or may result from anorexia, nervousness (sympathetic tone), or pharmacologic inhibition of examination of patients with disease of the gastrointestinal tract must include evaluation of the metabolic and cardiovascular status of the patient, because acute conditions of the proximal or distal intestinal tract have the potential to lead to endotoxemia and sepsis. examination of the cardiovascular system (heart, peripheral pulse, and mucous membranes), lungs, and abdomen is essential to detect clinical signs of systemic inflammation from endotoxemia, coagulation disorders, dehydration, ileus, shock, and other abnormalities resulting from injury to the small or large intestine. chapter 13.7 covers clinical signs of systemic inflammation from endotoxemia and sepsis. one performs the physical examination of the abdomen primarily by auscultation, transabdominal ballottement, and transrectal palpation. abdominal distention often indicates distention of the large intestine; however, small intestinal distention also can cause visible abdominal distention if a large proportion of the small intestine is involved. one can perform abdominal palpation in neonatal foals; after several weeks of age, motility (i.e., α 2 -adrenergic agonists such as xylazine). [2] [3] [4] absolute absence of any auscultable borborygmi suggests abnormal motility and indicates ileus resulting from a serious pathologic condition but is not specific to any segment of the intestine. 3, 5 if borborygmi are audible but progressive sounds are not detectable, determining whether a significant abnormality exists is difficult. 5 borborygmi heard more frequently than normal may result from increased motility following feeding; from excessive stimulation from irritation, distention, or inflammation; or after administration of parasympathomimetic drugs such as neostigmine. large intestinal motility increases in the early stages of intestinal distention regardless of the site. 6 mild inflammation or irritation of the large intestinal mucosa also can stimulate motility. 3 parasympathomimetic drugs stimulate contractions and auscultable borborygmi in the large intestine; however, an increase in parasympathetic tone may result in segmental contractions, which actually inhibit progressive motility. 2 one can detect sand or gravel in the large intestinal ingesta by auscultation behind the xiphoid process. one can hear sand or gravel particles grinding together during progressive contractions of the ascending colon. the presence of sand in the ingesta becomes clinically detectable by auscultation or fecal sedimentation before the amount of sand is enough to produce clinical signs of pain or irritation (diarrhea). 7 if progressive contractions are audible without hearing sand sounds, clinically important quantities of sand likely are not present. if the frequency of progressive contractions is low or absent, detecting sand by auscultation is difficult. percussion of the abdomen during auscultation can reveal gas in the large intestine. the characteristic ping produced by simultaneous digital percussion and auscultation over a gas-filled viscus often is associated with abnormal accumulation of gas under pressure. this technique is particularly useful in foals, ponies, and miniature horses because of the limitations of palpation per rectum. one can use transabdominal ballottement to detect large, firm masses or an abnormal volume of peritoneal fluid. the usefulness of this technique is usually limited to animals too small to palpate per rectum. one can detect soft tissue masses or fetuses by bumping the structures with a hand or fist. if excessive peritoneal fluid is present, one can generate a fluid wave by ballottement; however, this technique is not as useful in horses older than 4 weeks because the abdominal wall is rigid. transrectal palpation is the most specific physical examination technique for investigation of intestinal disease and is particularly valuable when evaluating obstructive diseases. 8, 9 the primary objectives of transrectal palpation are to assess the size, consistency, and position of the segments of the large intestine; to determine the presence of any small intestinal distention; and to detect intraabdominal masses. evaluation of the wall thickness and texture and the mesenteric structures (blood and lymphatic vessels and lymph nodes) also may aid in diagnosis of large intestinal disease. the interpretation of transrectal palpation findings in light of clinical signs and laboratory results is an important diagnostic aid for developing appropriate treatment strategies for intestinal diseases manifested by abdominal pain. enlargement of one or more segments of large intestine detected by transrectal palpation provides evidence of obstruction at or distal to the enlarged segment. by systematically evaluating each segment, one may determine the site of obstruction. obstruction of the pelvic flexure, for instance, results in enlargement of the pelvic flexure and ventral colon, but the dorsal and descending colons are of normal size. enlargement of a segment of the large intestine usually is accompanied by abnormal consistency of the contents. one may distinguish accumulation of gas, fluid, or ingesta and may detect foreign bodies in palpable segments. accumulation of gas and fluid infers complete and acute obstruction, whereas accumulation of ingesta infers chronic and incomplete obstruction. accumulation of fluid usually indicates ileus. one must evaluate the consistency of the contents in light of the size of the segment; ingesta in the ventral colon of a dehydrated patient may be firm, but the size of the ventral colon will be normal. conversely, if the ingesta is firm because of a distal obstruction, the ventral colon will be enlarged. displacement of a segment of the large intestine may create an obstruction detectable by enlargement of the segment and accumulation of gas and fluid, even if the site of obstruction is not palpable. torsion of the ascending colon at the sternal and diaphragmatic flexures results in acute accumulation of gas and fluid proximal to the torsion, causing distention of the left dorsal and ventral colons. depending on the degree of torsion, the position of the ventral and dorsal colons may not be significantly abnormal. displacement of a segment of large intestine often results in incomplete obstruction, and the diagnosis relies solely on detection of the displaced segment in an abnormal position. the position of the displaced segment may not be palpable, and the diagnosis then relies on the inability to find the segment in a normal position. one must take care to ensure that the segment that appears to be displaced is not in a normal position but has become too small to palpate from a decrease in the volume of ingesta. the cecum, right dorsal and ventral colons, pelvic flexure, and descending colon are palpable in most horses. one should palpate the nephrosplenic space to detect the presence of intestine, usually pelvic flexure, entrapped within the ligament. small intestine is not normally palpable in the horse. distention is an indicator of ileus with gas or fluid retention, usually following a strangulating or nonstrangulating obstruction. strangulating obstructions result from conditions such as volvulus or torsion, lipoma, or entrapments. such conditions often are accompanied by severe pain, dehydration, peritoneal fluid changes, and a varying degree of gastric fluid accumulation. the small intestine in these cases is turgid and firm on palpation. one should assess the mesentery and wall thickness as for large intestinal disorders. careful palpation of the inguinal rings in stallions with small intestinal distention is crucial for determining inguinal herniation. evaluation of the wall thickness and mesenteric vessels can reveal venous congestion (mural edema and enlarged blood and lymphatic vessels) or inflammation (mural edema with normal vessels). disruption of arterial blood flow does not cause venous congestion, but the arterial pulse is not detectable. mesenteric tears may not be palpable, but the entrapped ischemic intestinal segment may be thickened with edema. one may detect acute or chronic inflammation with cellular infiltration of the intestinal wall as thickening of the wall without edema and also may note enlargement of mesenteric lymph nodes. one should interpret abnormalities in the wall or vessels in light of the size, consistency, and position of the segment of intestine and the clinical signs. several conditions involving small intestinal strangulating lesions do not necessarily cause abnormal rectal examination findings until the disease has been present for an extended time. these conditions include diaphragmatic herniae and epiploic foramen entrapments. peritoneal fluid analysis may be normal in these cases as well because the fluid is trapped in the thorax or in the cranial abdomen. surgery is usually necessary for diagnosis. nonstrangulating causes of small intestinal distention can be divided further into intraluminal and extraluminal obstructions. ileal impactions are probably the most common cause of intraluminal obstructions, and on rare occasions one can palpate the impaction in the upper right quadrant, near the ileocecal opening. intraluminal masses caused by lymphoma, eosinophilic enteritis, foreign bodies or ascarid impactions often lead to small intestinal distention and are usually indistinguishable from one another based on palpation alone. small intestine in these cases can be moderately to severely distended, depending on the degree of obstruction. extraluminal obstructions include abdominal masses, abscesses or tumors, and large colon displacement. one always should palpate the rest of the abdomen carefully to help rule out these causes. some cases of small intestinal distention result from a physiologic rather than a mechanical obstruction. ileus may result postoperatively or following inflammatory diseases of the bowel (proximal enteritis) or peritoneal cavity (peritonitis). the bowel is usually mildly to moderately distended and almost always is accompanied by significant amounts of accumulated gastric fluid. the small colon is easily distinguishable by the presence of normal fecal balls and an antimesenteric band. in cases of impaction of the small colon, a long, hard, tubelike structure is present in the caudal abdomen, and the band is palpable along the length. fluid stool is often present in the rectum in these cases, as is tenesmus. one can detect and carefully evaluate rectal tears by palpation. one can detect mural masses in palpable segments of intestine or mesentery; however, if a mass causes obstruction, one can detect the result of the obstruction in proximal segments of intestine even if the mass is unreachable. palpation of the mesenteric vessels may reveal thickening and thrombosis, which can lead to ischemia or infarction. one can perform visual inspection of the mucosa of the rectum and descending colon with a speculum or flexible endoscope and also can evaluate rectal tears or perforations, mural masses, strictures, or mucosal inflammation. one also can perform guided biopsy of the mucosa or masses. the obvious limitations are the amount of fecal material interfering with the examination and the distance of the lesion of interest from the anus. these techniques offer little advantage over palpation in many cases unless the patient is too small to palpate. examination of the oral cavity in cases of dysphagia or weight loss is a necessary part of the physical examination. one should adequately sedate the horse and should use a full-mouth speculum to allow palpation and visualization of all parts of the oral cavity. one should examine the area for abnormal dentition, foreign bodies, fractures, abscesses, and ulceration. the presence of fluid accumulation in the stomach indicates a decrease or absence in propulsive motions of the small intestine or obstruction of gastric outflow. decreased small intestinal motility may result from a functional or mechanical blockage. masses, feed impactions, or strictures in the pylorus or in the proximal duodenum may obstruct gastric outflow. one routinely assesses fluid accumulation in the stomach by siphoning off the gastric contents with a nasogastric tube and examining the fluid for amount, color, and any particular odor. normal fluid is green and may contain foamy saliva. the volume obtained by gastric lavage is usually less than 4 l. large volumes of fluid (>8 to 10 l) accumulate in the stomach of horses with proximal enteritis, and the fluid is foul smelling and often has an orange to yellow discoloration. if one suspects proximal enteritis, one can submit the fluid for culture and gram staining. salmonella sp. and clostridium sp. have been cultured in some cases. patients with postoperative ileus also frequently accumulate large amounts of gastric fluid. horses with section 13.1 examination for disorders of the gastrointestinal tract strangulating obstructions or luminal obstructions often accumulate moderate amounts of gastric fluid, but the amount is generally less than in horses with proximal enteritis or postoperative ileus. hemorrhage in the gastric fluid usually indicates devitalized small intestine, stomach wall, or severe gastric ulceration. fluid with large amounts of food material often indicates a gastric impaction, and one should lavage the stomach until obtaining no more ingesta. horses and foals with chronic gastric ulceration in the glandular mucosa of the stomach or in the duodenum may develop strictures and have fluid accumulate in the stomach. endoscopy or contrast radiography aids in diagnosing gastric outflow obstruction. evaluation of the hemogram is essential when one assesses conditions of the gastrointestinal tract. however, hematologic alterations associated with diseases of the gastrointestinal tract are often nonspecific, reflecting systemic response to inflammation, endotoxemia, or sepsis. neutrophilic leukocytosis and normochromic, normocytic anemia with or without hyperfibrinogenemia commonly are associated with chronic inflammatory conditions of the intestine. anemia from chronic blood loss occurs infrequently in adult horses because of the large iron stores and high concentrations of iron in their diet; usually anemia follows chronic inflammation, as do alterations in the leukon and plasma fibrinogen concentrations. plasma protein concentrations vary depending on gastrointestinal losses of albumin and globulin and elevation of globulin concentration from antigenic stimulation. protein-losing enteropathies may manifest predominantly as a hypoalbuminemia or may have a concurrent hypoglobulinemia. immunoglobulin quantification can be useful in selected cases; immunosuppression with low immunoglobulin m concentration has been shown to occur in some cases of lymphosarcoma. 10 parasitic infections, especially strongylosis, may be characterized by elevated serum immunoglobulin g(t) concentration. 11 significant alterations of the hemogram do not accompany acute disease of the intestine unless severe inflammation, dehydration, endotoxemia, or sepsis is present. during the early stages of endotoxemia, elevations in circulating concentrations of inflammatory mediators, epinephrine, and cortisol produce characteristic changes in the hemogram. leukopenia, with neutropenia and a left shift, toxic changes in the neutrophil cytoplasm, and lymphopenia occur commonly. 12 hemoconcentration and hyperfibrinogenemia are also common. thrombocytopenia and other coagulopathies are also features of endotoxemia. indeed, thrombocytopenia may be the earliest indicator of sepsis. 13 endotoxemia and circulating mediators of inflammation activate the coagulation cascade, causing a hypercoagulable state that can lead to consumption of coagulation factors and coagulation defects manifested as elevated prothrombin time, partial thromboplastin time, fibrin degradation products, and bleeding time, and reduced activity of antithrombin iii. [14] [15] [16] neutrophilic leukocytosis occurs during the later stages of endotoxemia. 14 the most common serum biochemical abnormalities with diseases of the large or small intestine are electrolyte imbalances. serum calcium concentrations are often low with strangulating obstructions and acute inflammatory diseases. 17 inflammation of the mucosa can disrupt electrolyte fluxes severely. diarrhea or gastric reflux greatly exacerbates the loss of sodium, potassium, calcium, magnesium and bicarbonate. ischemia of the intestine causing hypoxia and cellular damage may be reflected by an elevated serum phosphate concentration resulting from phosphate leakage from damaged cells. 18 ischemia and cellular hypoxia in any segment of the intestine also causes a shift in energy metabolism to anaerobic glycolysis, resulting in increased production of lactate and elevated serum lactate concentration. reduced perfusion of peripheral tissues from hypotensive shock and intestinal ischemia can cause elevations in serum lactate. however, obstruction of the intestine during ischemia may result in absorption of lactate from the lumen. 19, 20 anion gap is an indirect measurement of organic acid production during states of tissue hypoxia and is a reasonable estimate of serum lactate concentration. 20 metabolic acidosis may accompany lactic acidemia, but an inconsistent association exists between the two, especially when mixed acid-base imbalances are present. 20, 21 elevations of hepatic enzymes, specifically γ-glutamyltransferase, may occur with large colon displacements, duodenal strictures, or anterior enteritis. relative polycythemia from hemoconcentration or splenic contraction and changes in red blood cell deformability from hypoxia or hypocalcemia may increase blood viscosity. blood viscosity increases in patients with acute obstructive disease. hyperviscosity reduces perfusion of capillary beds, thereby exacerbating ischemia and tissue hypoxia. 22 hyperviscosity is one manifestation (along with lactic acidemia, coagulopathies, and clinical signs of shock) of the pathophysiologic events that take place during acute inflammatory or vascular injury to the large intestine. laboratory tests designed to reflect the systemic effects of endotoxemia, ischemia, sepsis, and shock are important to design therapeutic strategies, and monitor response to therapy. abdominocentesis and analysis of peritoneal fluid (pf) is a diagnostic technique performed on many patients with disease of the gastrointestinal tract. one can quantitate cytologic examination of pf; white blood cell and red blood cell counts; protein, fibrinogen, lactate, phosphate, and glucose concentrations; lactate dehydrogenase, creatine kinase, and alkaline phosphatase activity; and ph. the results of pf analysis may help establish a specific diagnosis but more importantly may reflect inflammatory, vascular, or ischemic injury to the intestine requiring surgical intervention. pf reflects a sequence of events that takes place during acute vascular injury to the intestine. the pf protein concentration first increases, followed by an increase in the red blood cell count and fibrinogen concentration. a transudative process resulting from vascular congestion and increased endothelial permeability allows small macromolecules (albumin) to escape into the pf, followed by larger macromolecules (globulin and fibrinogen), and finally diapedesis of cells (red blood cells, then white blood cells). 23, 24 if ischemic inflammation of the intestine and visceral peritonitis occur, an exudative process ensues. severe inflammation of the intestine and visceral peritoneum causes large quantities of protein and white blood cells, primarily neutrophils, to escape into the pf. 24 as damage to the bowel progresses, the protein concentration and red blood cell and white blood cell counts continue to rise. as the degree of irreversible damage to the intestine increases, the pf characteristics become more exudative. 23, 24 eventually, bacteria begin to translocate across the intestinal wall and appear in the pf as the mucosal barrier breaks down. neutrophils predominate, and their cytoplasm becomes granulated, and döhle bodies often are visible. if perforation occurs, bacteria and particles of ingesta appear in the pf, and the neutrophils become degenerate, that is, pyknotic, with karyorrhexis, karyolysis, and smudge cells. 23 elevated pf protein concentration is a sensitive indicator of early inflammation, whereas elevated red blood cell counts in the presence of normal white blood cell counts suggest vascular damage without significant tissue ischemia. 24 elevation of the white blood cell count usually indicates severe tissue inflammation or intestinal injury. 25 the gross color of the pf can be helpful in detecting injury and necrosis of the intestine. a serosanguinous appearance indicates vascular injury, whereas orange or brown-red indicates necrosis with the release of pigments such as hemosiderin. serial samples of pf are most useful in determining the nature and extent of damage to the intestine, but in many cases of ischemia, irreversible tissue damage has occurred by the time pf abnormalities appear. tissue hypoxia and ischemia cause a rapid elevation of pf lactate dehydrogenase, creatine kinase, and alkaline phosphatase activity and lactate concentration. 19, 20, 26 phosphate concentration increases when cellular disruption occurs. 18 pf enzyme activities, phosphate, and lactate concentration increase faster and higher than serum activities. [18] [19] [20] 26 pf ph and glucose concentration tend to decrease during intestinal ischemia, but not as low as in septic peritonitis. 27 although biochemical alterations may provide early indicators of intestinal ischemia and necrosis, they are nonspecific and offer no advantage over conventional methods of pf analysis in many cases. pf alkaline phosphatase has been shown to arise predominantly from degenerating white blood cells, and elevations of other enzyme activities may occur with many inflammatory diseases. 26 thus the specificity of many tests run on pf is questionable. however, in selected cases in which conventional pf analysis and physical examination do not provide sufficient information to develop a treatment plan, biochemical analysis of the pf may be useful. cytologically examined cells of the pf may reflect chronic inflammatory conditions of the large intestine, especially eosinophilic or lymphocytic processes. 28 infectious and inflammatory conditions often cause increases in the neutrophil count and may be indistinguishable unless bacteria are visible. one also may detect neoplastic diseases by pf examination. chronic infection and inflammation may be associated with elevated pf protein and fibrinogen concentrations. culture of pf usually is required to distinguish bacterial infections from noninfectious inflammation unless bacteria are visible on cytologic examination. however, culture of pf is often unrewarding because factors that are found in inflammatory pf inhibit bacterial growth, and leukocytes phagocytose many bacteria in the pf. 29 decreases in pf glucose concentrations (<30 mg/dl) and ph (<7.3) are early indicators of a septic process. the glucose concentration and ph in the pf should approximately equal the blood glucose concentration and ph. a pf fibrinogen concentration greater than 200 mg/dl also indicates bacterial infection. 30 gross examination of the feces can provide information about digestion and transit time in the large intestine. large fiber particles in the feces represent poor mastication or poor digestion in the large intestine. small, mucuscovered, hard fecal balls indicate prolonged transit through the descending colon, whereas increased fluidity implies decreased transit time. feces containing sand or gravel are not necessarily abnormal. however, a significant amount of sand implies that large quantities are present in the colon. frank blood indicates substantial bleeding into the distal colon (right dorsal colon and/or small colon) from mucosal damage. laboratory analysis of the feces is performed frequently in cases of diarrhea. fecal cytologic examination and tests for occult blood detect mucosal inflammation, section 13.1 examination for disorders of the gastrointestinal tract erosion, or ulceration. severe inflammatory diseases in human beings, invasive bacterial infections in particular, have been shown to increase the shedding of leukocytes in the feces. a higher percentage of horses with salmonellosis and diarrhea have fecal leukocyte counts greater than 10 cells per high power field than horses with negative fecal cultures for salmonella. these results suggest that high fecal leukocyte counts indicate salmonellosis in horses with diarrhea. however, the specificity of this test is probably low. low fecal leukocyte counts do not rule out salmonellosis. 31 fecal occult blood tests detect blood in the feces, presumably from erosion or ulceration of the mucosa, but do not distinguish the source of the blood. large volumes of blood (1 to 2 l) given by nasogastric tube were required to produce a positive test for occult blood in the feces, but the amount of blood originating from the large intestine required to produce a positive test is unknown. a positive test implies significant hemorrhage into the gastrointestinal tract. newer, more sensitive tests detect not only occult blood but also degraded blood and may be useful to determine the site and quantity of blood loss. 32 a positive test implies significant hemorrhage into the gastrointestinal tract. bacteriologic examination of the fecal flora has been used to quantitate specific bacterial species in the feces of horses with diarrhea. quantitation of clostridial species may be beneficial in diagnosing clostridial infection of the large intestine. 33 tests to detect clostridial toxins in intestinal contents or feces are important to determine whether clostridia cultured from the feces are causing disease. the most common bacterial pathogens isolated from the feces of horses are salmonella and clostridium. the number of salmonella organisms isolated from the feces of horses with clinical salmonellosis is usually higher than from horses with asymptomatic infections. however, the volume of feces in many cases of acute diarrhea is high, and the concentration of salmonella organisms may be lower than would be expected, accounting for many false-negative fecal cultures. the sensitivity of fecal cultures for detecting salmonella infection may be as low as 20%. culture of five consecutive daily fecal samples is recommended to increase the sensitivity of the test. because salmonellae are intracellular organisms, culture of rectal scrapings or a rectal biopsy sample, along with fecal material, may increase the sensitivity of culture for detecting salmonella infection to 50%. 34 one can perform a polymerase chain reaction assay on fecal samples to detect dna from salmonella sp. the polymerase chain reaction test is more sensitive than culture and is frequently positive in clinically normal horses that continuously shed small amounts of bacteria. polymerase chain reaction or immunologic tests also may detect clostridium perfringens and c. difficile exotoxins in the feces. qualitative fecal examination is a technique to detect nematode and cestode ova, protozoan oocysts, parasitic larvae, and protozoan trophozoites. a direct smear of fecal material is a rapid method to screen feces for ova and oocysts, to detect parasite larvae and trophozoites, and to observe motility of ciliates and parasite larvae. fecal flotation is a more sensitive technique for isolating and detecting ova and oocysts because the eggs are concentrated from the sample. zinc sulfate and sucrose solutions are often used to concentrate less dense ova and oocysts. zinc sulfate produces less distortion of trophozoites and larvae than sucrose solutions. fecal sedimentation is particularly appropriate for ciliates, giardia, and trichomonads. quantitative techniques such as the cornell-mcmaster method allow one to estimate the number of eggs per gram of feces and are most appropriate in monitoring parasite control programs. 35 survey radiography of the normal esophagus is usually unrewarding but may be useful in horses with esophageal obstructions to determine the extent and location of the obstruction. one may detect foreign bodies or soft tissue masses, and in cases of esophageal rupture, one may see free air and ingesta in the tissues surrounding the esophagus and may observe pneumomediastinum. 36 thoracic radiographs may be necessary to detect intrathoracic esophageal obstructions, megaesophagus, or cranial mediastinal masses causing extraluminal obstruction. one may use barium swallows or double-contrast esophagrams after resolution of the obstruction to determine whether a stricture or diverticulum or other underlying disorder is present. 37 barium sulfate is the usual contrast medium and can be administered orally via a dose syringe or by nasogastric tube (50 to 100 ml of a 40% barium sulfate suspension or barium paste). oral administration is preferred for evaluation of swallowing and lesions in the proximal esophagus. administration of contrast using a nasogastric tube (preferably cuffed) allows for delivery of larger volumes of barium (up to 500 ml) but should be performed without sedation if possible. one can follow administration of contrast material with air insufflation to create a double-contrast effect. if one suspects a rupture of the esophagus or if the likelihood of aspiration of the contrast material is high, one should use iodinated organic compounds in an aqueous solution as contrast material. 36 contrast radiography may be the most definitive method for the diagnosis of primary megaesophagus or other functional disorders such as autonomic dysautonomia (grass sickness) affecting the esophagus. 37 one should take care when interpreting esophageal radiographs if the horse is sedated. acepromazine or detomidine administration causes esophageal dilation in normal horses, especially after passage of a nasogastric tube. 38 radiography of the adult equine abdomen is an effective technique in detecting radiodense material in the large intestine, such as enteroliths, sand, and metallic objects. 39, 40 one survey demonstrated that radiography has 76.9% sensitivity and 94.4% specificity for diagnosing enterolithiasis. 39 radiography also can be a useful tool for detecting sand accumulation in the colon that causes diarrhea or impactions ( figure 13 .1-1) and for monitoring resolution in medically treated horses. 41 the large size and density of the adult abdomen precludes evaluation of soft tissue structures because the detail and contrast of the radiographs are usually poor. one is more likely to obtain diagnostically useful abdominal radiographs from small ponies and miniature horses than from full-size adult horses. accumulation of gas is visible on radiographs of adult horses, but distinguishing normal intestinal gas from obstruction is often difficult. horses should be fasted for 24 to 48 hours to reduce the amount of ingesta in the large intestine before radiography. abdominal radiography is more useful in foals than in adult horses. radiographs are more detailed and contrast can be good. radiographic evidence of gas distention in the large intestine may indicate large intestinal obstruction, and radiographic signs of displacement are often diagnostic. one may diagnose impactions, intussusceptions, foreign bodies, and other disorders with the aid of radiography. functional ileus may be difficult to distinguish from mechanical obstruction. 42, 43 administration of contrast (barium sulfate 30% at 5 ml/kg) via nasogastric tube increases the diagnostic capabilities of radiography. 44 gastric ulceration also is recognizable with contrast radiography in the foal, although this is not as accurate a method as endoscopy. 45 contrast administered retrograde via a 24-f foley catheter inserted into the rectum at a dose of up to 20 ml/kg has excellent potential for diagnosing disorders of the small colon, transverse colon, and large colon in foals. 46 ultrasonographic evaluation of the abdomen can add valuable information in cases of acute or chronic gastrointestinal disease. examination of the adult horse requires a 2.5-to 5.0-mhz transducer at minimum. one may use sector, linear, or curved linear transducers. clipping of the hair over the area to be examined, along with the application of isopropyl alcohol and ultrasound coupling gel, enhances evaluation. to evaluate the abdomen adequately, one must know the anatomic location and normal appearance of the individual organs. in the left cranial abdomen, one can assess the greater curvature of the stomach between the eleventh and thirteenth intercostal space, and one can use the spleen and the large splenic vein as landmarks. cases of gastric dilation from gas or impaction appear as an enlargement of the viewing area to cover greater than five rib spaces. 47 one also can evaluate the stomach for intramural or extramural masses such as abscesses or for squamous cell carcinoma. 48 the lesser curvature is not routinely visible. assessment of the small intestine should include evaluation for changes in thickness, motility, location, and visibility. one may find small intestinal loops easily in the left lower quadrant of the abdomen, but these normally are visible in other locations. one can visualize the duodenum consistently on the right side of the abdomen deep to the liver in the tenth to twelfth intercostal space or deep to the right kidney at the fifteenth to sixteenth intercostal space. mural thickening (>4 mm) may occur in cases of infiltrative or proliferative diseases, postoperative cases, enteritis, and paralytic or mechanical ileus. thickening of the small intestinal wall in foals, with or without the presence of gas shadows within the wall, should raise suspicions of clostridial enteritis. one can assess motility by monitoring a specific area for contractions over time. ultrasonography is an accurate method of distinguishing strangulating versus nonstrangulating disorders of the small intestine. strangulated small intestine has thicker small intestinal walls and larger intestinal diameter than in nonstrangulating disorders. strangulating lesions have decreased motility in the incarcerated segments with normal motility elsewhere. 49 cases of paralytic ileus or nonstrangulating obstruction have a diffusely decreased peristalsis, but not to the degree observed with strangulating lesions. 47, 49 one may diagnose some specific lesions of the small intestinal tract using ultrasonography. one may see ascarids in foals in cases of ascarid impaction 47 and epiploic foramen entrapments as edematous loops of small intestine found in the right cranial abdomen. 50 one may note small intestinal intussusceptions as targetlike lesions when viewed in cross sections. 51 the presence of bowel loops, stomach, or liver in the thoracic cavity indicates the presence of herniation through the diaphragm and should be confirmed using radiography or surgical exploration. evaluation of the large intestine may be difficult because of the large amounts of gas within the lumen. however, certain disorders are readily identifiable via ultrasonography. one can assess the nephrosplenic ligament area for bowel entrapment in the left paralumbar fossa. in cases of entrapment, the spleen will be pulled away from the body wall and fluid or gas shadows will be observable dorsal to the spleen, 52 obscuring the kidney, which is normally adjacent and abaxial to the spleen. small colon, small intestine, or pneumoperitoneum also may produce a gas shadow and obscure the kidney from view. 47 sand impactions may appear as hyperechoic bands on the ventral abdominal wall. 47 one may see ileocecal and cecocolic intussusceptions in the upper right paralumbar fossa. 53 in cases of colitis, large, fluid-filled colons may be visible with or without intramural edema. one can find the right dorsal colon consistently abaxial to the liver, within the right thirteenth to fifteenth intercostal space and may be thickened (>5 mm) in cases of right dorsal colitis. evaluation of the abdomen always should include assessment of the peritoneal space for any evidence of an increased amount of pf or increased cellularity of the fluid as indicated by an increase in echogenicity. ultrasonography also can be useful in determining the ideal location for abdominocentesis. one also should evaluate the liver, kidneys, and spleen. one may detect choleliths, nephroliths, masses, abscesses, or enlargement of any of these organs. abscesses or tumors not associated with visceral organs may be difficult to visualize and interpret via ultrasonography. although more commonly used to diagnose lameness and musculoskeletal problems, nuclear scintigraphy has several uses for evaluation of the gastrointestinal tract. scintigraphy is now available at most universities and many private referral hospitals. one must use proper isolation protocols and waste disposal techniques strictly. the procedure requires special gamma cameras and the injection of radioactive materials into the bloodstream. one can use one of two methods: injection of technetium-99m methylene diphosphonate ( 99m tc-mdp) directly into the blood or injection of 99m tc-labeled leukocytes. labeling of leukocytes involves aseptically collecting heparinized blood samples, isolating the buffy coat, and mixing those leukocytes with a radioactive dye ( 99m tc hexamethylpropyleneamine oxime, or 99m tc-hmpao) in vitro. 54 one then reinjects the labeled leukocytes and obtains images. the principle of nuclear scintigraphy then lies in increased uptake of the dye or the white blood cells into areas of inflammation. one of the most common uses of nuclear scintigraphy in evaluating the gastrointestinal tract is diagnosis of dental disease. scintigraphy using 99m tc-mdp proved to be more sensitive in cases of dental disease than was radiography. scintigraphy was slightly less specific, however, and therefore should be used with radiography or computed tomography for ultimate accuracy. 55 scintigraphy using radiolabeled white blood cells can support a diagnosis of right dorsal colitis in the horse. 40 images taken of the abdomen 20 hours after injection showed an increased linear uptake of leukocytes in the region of the right dorsal colon in horses with right dorsal colitis compared with normal horses. this technique also may prove useful for diagnosing intraabdominal abscesses in the horse. other uses of nuclear scintigraphy include evaluation of metastasis of abdominal tumors to bony areas, assessment of biliary kinetics, and determination of gastric emptying times. [56] [57] [58] endoscopy endoscopic examination of the gastrointestinal tract begins with evaluation of the pharyngeal area by examination for any signs of collapse or dysfunction. one should evaluate the ability of the horse to swallow. the floor of the pharynx should be clean and free of feed material and foreign bodies. one can examine the oral cavity with the horse under heavy sedation or anesthesia and with the help of a full-mouth speculum. one can examine the teeth for any irregularities, obvious cavities, sharp points, or hooks and the hard and soft palpate for completeness and any evidence of ulceration, masses, or foreign bodies. one should use a 3-m flexible fiberoptic endoscope to examine the esophagus, which is accomplished best by passing the endoscope into the stomach and viewing the esophagus as one withdraws the endoscope while dilating the lumen with air. the esophageal mucosa normally should be a glistening, light pink color. ulceration can occur with cases of choke, reflux esophagitis or in horses that have had an indwelling nasogastric tube. erosions may be punctate, linear, or circumferential. one should evaluate carefully for any ulcers to ensure that no areas of perforation through the entire thickness of the esophageal wall exist. distinguishing normal peristaltic contractions from areas of stricture requires observation of the area and its motility over time. one also may note diverticula as outpouchings of the mucosa, sometimes associated with a stricture distally. megaesophagus, although rare, appears as a generalized dilation of the esophagus. one may detect food or foreign body impactions of the esophagus via endoscopy. one always should reevaluate the esophagus after removing any obstruction to detect the presence of complications (ulceration, rupture) or initiating causes (strictures, diverticula, and masses). a 3-m flexible endoscope also allows examination of the stomach. the horse should be fasted for at least 12 hours before endoscopy. one can examine the cardia and fundus easily, as well as the margo plicatus. the squamous mucosa should resemble the esophageal mucosa. the glandular mucosa should be glistening red and may have a reticulated pattern. one should carefully examine for evidence of ulceration or masses. one can obtain transendoscopic biopsy material easily from esophageal, pharyngeal, or gastric masses, and because the biopsy size will be small, one should take several samples for histopathologic examination. pharmacologic agents (bethanechol) to empty the stomach and provide complete visualization of the entire fundic region, the pylorus, and the duodenum may be useful. for a complete description of gastroscopy and evaluation of gastric and gastroduodenal ulceration, please refer to chapter 13.10. d-glucose or d-xylose absorption tests are useful in determining malabsorption of carbohydrates from the small intestine in horses. the protocol for absorption tests using either carbohydrate is similar. the horse should be fasted for 18 to 24 hours before testing. increased periods of fasting actually have been shown to decrease absorption of d-xylose and interfere with results. 59 one administers a dosage of 0.5 to 1 g/kg of d-glucose or d-xylose via a nasogastric tube. administration of sedatives may increase the blood glucose levels falsely and interfere with gastrointestinal transit times. one then collects blood samples to measure glucose or xylose concentrations at 0, 30, 60, 90, 120, 150, 180, 210 , and 240 minutes after administration. one may take additional samples up to 6 hours after dosing if the results are questionable. one should measure glucose in blood samples collected with sodium fluoride as an anticoagulant and measure xylose in samples collected in heparinized plasma. a normal d-glucose absorption test, also known as an oral glucose tolerance test, should have a peak between 90 and 120 minutes, and this peak should be greater than 85% above the resting glucose value. 60 complete malabsorption is defined as a peak less than 15% above the resting levels, and partial malabsorption is defined as a peak between 15% and 85% above the resting level. one must keep in mind that gastric emptying, gastrointestinal transit time, length of fasting, cellular uptake and metabolism, and endocrine function influence glucose absorption curves. malabsorption demonstrated by the oral glucose tolerance test is sensitive but not specific. diseases that may cause a lowered or delayed peak include infiltrative lymphosarcoma, inflammatory bowel disease (lymphocytic-plasmacytic or eosinophilic), cyathostomiasis, chronic colitis (salmonella sp.), multisystemic eosinophilic epitheliotropic disease, food allergies, and small intestinal bacterial overgrowth. 61 d-xylose absorption tests have some advantages over the oral glucose tolerance test because xylose is not metabolized in the small intestinal mucosa and insulin does not influence its absorption. gastric and intestinal motility, intraluminal bacterial overgrowth, and renal function still influence xylose absorption, because the kidneys clear xylose. 61 the other main drawback to d-xylose is that it is generally available only in research settings. however, xylose measurements are available at most major universities. a normal d-xylose absorption curve should peak between 20 and 25 mg/dl at 60 to 120 minutes after dosing. 62 decreased xylose absorption can occur in horses with inflammatory bowel disease, lymphosarcoma, multisystemic eosinophilic epitheliotropic disease, cyathostomiasis, extensive small intestinal resections, and any cause of villous atrophy. 61 maldigestion is a common occurrence in foals with diarrhea. bacteria (especially clostridium sp.) and viruses (especially rotavirus or coronavirus) may invade and destroy the villous epithelial cells that manufacture lactase and other disaccharidases, resulting in an inability to digest lactose. in this case, continued ingestion of the mare's milk may cause an osmotic diarrhea, which may exacerbate the underlying enterocolitis. one can perform lactose tolerance testing to assess the degree of maldigestion. one administers d-lactose at 1 g/kg as a 20% solution via nasogastric tube and measures glucose concentrations in the blood at 0, 30, 60, 90, 120, 150, 180, 210 , and 240 minutes. a normal curve shows doubling of glucose levels compared with baseline by 60 minutes after administration. 63 accurate measurement of gastric emptying can be difficult to assess. several methods are currently available. multiple diagnostic imaging techniques have been used to study gastric emptying times. one can use contrast radiography to assess gastric emptying in foals. in the normal foal, barium remains in the stomach for varying amounts of time, but a significant amount should be gone within 2 hours. 44 gastric emptying of solid, nondigestible, radiopaque markers also has been used in adult horses and ponies, but the results were variable and unpredictable even in the normal horse. 64 nuclear scintigraphy is used commonly in human beings to measure gastric emptying and can be used in horses where available. this technique requires oral administration of 99m tc pentenate (10 mci), and serial images taken of the cranial abdomen. the tracer is usually not visible 60 minutes after administration in normal horses. 58 alternatively, if nuclear scintigraphy is not available, one can use acetaminophen absorption testing as an indirect determination of gastric emptying. 58, 65 one performs this test by administering 20 mg/kg of acetaminophen orally and measuring subsequent blood values and calculating the time to reach maximum serum concentrations and the absorption constant. in human beings, the proximal small intestine absorbs almost all of the acetaminophen. 66 the median time to reach peak plasma levels using acetaminophen absorption in horses was 47.7 minutes. 58 one often requires histopathologic examination of tissues from the intestine to diagnose chronic inflammatory, infiltrative, or neoplastic conditions, and such examination can be useful in evaluating the extent of injury after obstruction or ischemia. rectal mucosal biopsies are easy to collect with few complications. however, to collect a full-thickness biopsy of the intestine requires a surgical approach (flank or ventral midline approach). laparoscopy offers a safer technique to observe the large intestine and other abdominal structures. 67 one can obtain biopsies of masses, lymph nodes, mesentery, or intestinal serosa via laparoscopy and mucosal biopsies of the upper gastrointestinal tract via endoscopy. other diagnostics, specifically laparoscopy and computed tomography, are available but require specialized equipment and personnel with specific training. flexible or rigid endoscopes used for laparoscopic evaluation of the abdomen allow for visualization of visceral organs and potentially for collection of biopsy material from masses or organs. full-thickness biopsies of the intestines are not routinely possible through the laparoscope and usually require flank or ventral midline laparotomy. the laparoscopic procedure can be done in the standing or recumbent horse. advantages of this technique over a flank or ventral midline celiotomy include smaller incisions, less healing time, and less procedure time. disadvantages include the large amount of equipment needed, skill involved, and the limitation as a diagnostic modality, rather than a treatment. 68 clinical applications of diagnostic laparoscopy include rectal tears, percutaneous abscess drainage, assessment of adhesions, displacements, and integrity of the serosa of various bowel segments, and biopsy of abdominal masses. 67 computed tomography scans are available at several universities across the country. they have been used frequently to evaluate dental disease and may be useful in evaluating tumors and masses of the head, larynx, pharynx, and proximal esophagus. 69 computed tomography also has promise for evaluating abdominal disorders in foals. most equipment can accommodate up to 400 lb. restrictions to computed tomography as a diagnostic aid include expense, availability, expertise, and weight and size limitation. 12 permeability increases, cells are recruited rapidly into the tissue, plasma protein cascades are activated, and a myriad of soluble products are released that coordinate the response, trigger innate and adaptive immunity, and mobilize reparative elements. although the cellular and vascular response and the secreted mediators of inflammation are important for killing pathogens and limiting invasion of injured tissues by commensal organisms, they can be damaging to host cells and proteins if not tightly regulated. thus if the inciting stimulus is not eliminated quickly, the inflammatory response itself causes significant tissue injury. the mechanism regulating inflammation has been the focus of much research to identify therapeutic targets to modulate the damage to host tissues during many gastrointestinal diseases. recent work has provided some of the molecular and cellular details of this complex physiology and has led to novel therapeutic strategies for treating inflammation. the gastrointestinal epithelium interfaces with a luminal environment inhabited by potentially hostile microbial organisms. the epithelium presents a physical barrier to invasion by the flora of the gastrointestinal tract, consisting of the apical cellular membrane, intercellular tight junctions the permeability of which is highly regulated, and a secreted layer of mucus. breaching of the mucosal barrier by invading pathogens generates potent soluble and neural signals that initiate an inflammatory response. 1 conceptually, the epithelium can be thought of as a sensory organ detecting pathogen invasion to trigger an appropriate host defense and reparative response. noninfectious mucosal injury or invasion of epithelial cells by pathogenic organisms such as salmonella activates synthesis of proinflammatory chemokines (chemoattractants) by epithelial cells and triggers a robust influx of neutrophils into the tissue within hours of the damage. 1 of the chemoattractants produced by epithelium, interleukin-8 (il-8) has a particularly important role in initiating inflammation by recruiting neutrophils from blood [2] [3] [4] and regulating neutrophil migration through tissue matrix adjacent to epithelium. 5, 6 bacteriaderived formylated chemotactic peptides also act as potent chemoattractants that are fully capable of stimulating a robust inflammatory response in the intestine if the epithelial barrier permits the diffusion of the peptides across the mucosa. epithelial cells activated during infection produce cytokines such as tumor necrosis factor α (tnf-α), arachidonic acid metabolites, and other proinflammatory mediators that activate recruited leukocytes. 7 bacterial products, particularly lipopolysaccharide and other cell wall components, are potent activators of leukocytes recruited into the tissue. once the inflammatory response has been initiated, tnf-α, il-1β, and other proinflammatory products of neutrophils, monocytes, mast cells, and epithelial cells amplify the inflammatory response. the enteric nervous system has a key role in sensing and regulating inflammatory responses in the intestine. for example, clostridium difficile toxin a activates a neural pathway that triggers mast cell degranulation and neutrophil influx into the tissue. 8, 9 blockade of this neural pathway is sufficient to abolish the profound inflammatory response induced by toxin a and many of the effects of toxin a on enterocyte secretion. other pathogens and immune-mediated hypersensitivity reactions similarly stimulate inflammation by mechanisms that involve the enteric nervous system. thus the epithelium interacts in a highly complex manner with the intestinal milieu, the enteric nervous system, and inflammatory cells to regulate the tissue response to injury and infection. resident macrophages located in the lamina propria, submucosa, and intestinal lymphoid organs are among the first cells beyond the epithelium to respond to infection or injury. macrophages are activated by bacterial products via pattern recognition receptors and begin to produce proinflammatory molecules important for recruiting and activating neutrophils and monocytes. pattern recognition receptors recognize microbial products ranging from lipopolysaccharide to peptidoglycan and even cpg-containing bacterial dna and signal the invasion by pathogens. of the pattern recognition receptors, the lipopolysaccharide receptor complex is perhaps the best defined. lipopolysaccharide activates macrophages via the cd14-toll-like receptor complex to initiate transcription of the inflammatory cytokines tnf-α and il-1β, which synergize with lipopolysaccharide to amplify the macrophage response. 10 lipopolysaccharide, particularly in concert with inflammatory cytokines, stimulates macrophages to produce copious amounts of nitric oxide, which is microbicidal and vasoactive. nitric oxide and other nitrogen radicals react with reactive oxygen intermediates (rois) to produce some of the most toxic molecules of the host defense system: the peroxynitrites. 11 il-8 is produced as well to recruit neutrophils. as the response progresses, other inflammatory mediators, particularly the arachidonic acid-derived lipids, are produced. these lipids have potent vasoactive effects and are important stimuli of endothelial cells, neutrophils, and platelets. four important changes occur in the intestinal vasculature during inflammation: 1. alteration of blood flow 2. increased vascular permeability 3. increased adhesiveness of endothelial cells, leukocytes, and platelets 4. exposure of the basement membrane and activation of the complement, contact, and coagulation cascades a wide range of mediators alters blood flow during intestinal tract inflammation, from gasses such as nitric oxide (a major vasodilator of the intestinal vasculature) to lipids (prostaglandins, leukotrienes, thromboxanes, and platelet-activating factor), cytokines, bradykinin, histamine, and others. the major sources for these mediators include activated leukocytes, endothelial cells, epithelial cells, and fibroblasts. the primary determinant of blood flow early in inflammation is vascular caliber, which initially decreases in arterioles, but then quickly changes to vasodilation coincident with opening of new capillary beds, increasing net blood flow. the increase in blood flow is short lived, for the viscosity of the blood increases because of fluid loss and tissue edema through leaky capillaries. leukocyte margination, platelet adhesion to endothelial cells and exposed matrix, and areas of coagulation protein accumulation further decrease local circulation. inflammatory mediator actions on the endothelial cells initially increase vascular permeability. histamine, leukotrienes, platelet-activating factor, prostaglandins, bradykinin, and other mediators stimulate endothelial cell contraction, and interendothelial gaps form. 12, 13 this stage of increased vascular permeability is readily reversible. concurrently, mediators such as the cytokines tnf-α and il-1β induce a structural reorganization of the interendothelial junctions, resulting in frank discontinuities in the endothelial monolayer. 14 cytokines also stimulate endothelial cells to express adhesion molecules that support adhesion of leukocytes and platelets, 15 leading to the next and perhaps most devastating event. leukocytes (primarily neutrophils) and platelets adhere to exposed basement membranes and activated endothelial cells. adherent neutrophils and platelets then are exposed to the mediators of inflammation present in the surrounding milieu, which activates the cells to release oxidants and proteases (particularly elastase) that injure the endothelium and have the potential to cause irreparable harm to the microvasculature. [16] [17] [18] marginated neutrophils begin to transmigrate between endothelial cells (as described in later sections), and if their numbers section 13.2 pathophysiology of gastrointestinal inflammation are large enough, they disrupt the integrity of the interendothelial junctions, worsening the vascular leakage. 17 conceptually, these stages of enhanced vascular permeability can be thought of as a mechanism to allow plasma proteins to enter the tissues and to potentiate the critical influx of leukocytes into tissues. however, if not regulated precisely, alterations in hydrostatic and oncotic forces and irreversible damage to the vascular bed may have devastating consequences. moreover, inappropriate activation of plasma protein cascades and leukocytes by activated endothelium and exposed matrix proteins can contribute to systemic inflammation (systemic inflammatory response syndrome; see chapter 13.7 for more information) characterized by hypotension, generalized vascular leak syndrome, and multiorgan dysfunction, which may be fatal. phosphodiesterase inhibitors reduce endothelial permeability in ischemia-reperfusion injury and other models of inflammation-induced vascular leakage 19, 20 by increasing endothelial tight junction integrity and thus may be a viable therapeutic strategy to prevent or reduce the permeability alterations associated with inflammation. endothelial cells respond to products of activated epithelial cells and macrophages in the intestinal tissue to recruit cells and humoral mediators of inflammation into the tissue. activated endothelial cells display a range of molecules critical for neutrophil and platelet adhesion. intercellular permeability increases to expose basement membrane proteins that trigger humoral defense systems (complement, coagulation, and contact system cascades) and to provide access for these macromolecules to the tissue. endothelial cells are an important source of inflammatory mediators that amplify the response and vasoactive substances (particularly nitric oxide) that alter blood flow. infection or injury to the gastrointestinal mucosa causes an influx of leukocytes from the blood that lay the foundation of the inflammatory response. neutrophils, being the first to arrive during inflammation, have a dominant role in the acute response. within minutes, neutrophils are recruited into the tissue where they are activated to release products that not only are proinflammatory and lethal to pathogens but also may damage host cells and tissues. not surprisingly, much attention has been paid to the role of neutrophils in the pathophysiology of many inflammatory conditions. 21 neutrophil depletion is protective in many models of gastrointestinal inflammatory disease. of interest to clinicians, blockade of neutrophil migration into inflamed tissues prevents many of the pathophysiologic events associated with infectious enteritis, ischemia-reperfusion injury, and other gastrointestinal diseases. 16, [22] [23] [24] [25] [26] neutrophil transendothelial migration is a multistep process that is temporally and spatially regulated and has a degree of cell type specificity ( figure 13.2-1) . the predominant sites of neutrophil transendothelial migration are in the postcapillary venules and, in some tissues, the capillaries. endothelial cells in these vessels respond to cytokines and other soluble signals by expressing molecules that promote neutrophil adhesion and transmigration, including selectins and counterreceptors for integrins. as neutrophils flow through these vessels, they are first tethered to activated endothelium. tethering is mediated by selectin molecules expressed on neutrophils (l-selectin) and on activated endothelial cells (p-and e-selectins) that bind to p-selectin glycoprotein ligand-1 (psgl-1), e-selectin ligand-1 (esl-1), and other mucin counterreceptors. 27, 28 tethering functions to increase the exposure of the neutrophil to activating chemokines presented on the surface of the endothelial cells. stimulation of neutrophils by il-8 and other chemokines activates the second step of transendothelial migration. chemokine binding to their receptors on the neutrophil generates signals that activate the binding of integrin adhesion receptors to their ligands, called intracellular adhesion molecules or vascular cell adhesion molecules expressed on endothelial cells in inflamed mucosa. integrin ligation to cellular adhesion molecules arrests the tethered neutrophils, resulting in firm adhesion to the endothelium. of the integrins expressed on neutrophils, the β 2 integrins have a particularly important role in transendothelial migration. calves and human beings with a disorder known as leukocyte adhesion deficiency illustrate the requirement for β 2 integrinmediated adhesion in neutrophil function. leukocyte adhesion deficiency results from an autosomal recessive trait causing the lack of the β 2 integrin expression. the neutrophils from these individuals cannot migrate into most tissues and do not function normally, resulting in poor tissue healing and profound susceptibility to infection, especially at epithelial barriers. 29, 30 other integrins also have a role in transendothelial migration. β 1 integrins mediate transendothelial migration in some cells and seem to be particularly important for mediating emigration of monocytes into many tissues. 31 following this firm adhesion step, neutrophils migrate through the endothelium along a chemotactic gradient of il-8 and other chemoattractants such as leukotriene b 4 . 3, 17, 32 neutrophils migrate across the endothelial monolayer at intercellular junctions via a mechanism involving a series of integrin-ligand interactions mediated by β 2 and β 1 integrins and other adhesion molecules 28 that is generally capable of maintaining the integrity of the endothelial barrier. 33 however, massive flux of neutrophils through the endothelium alters endothelial tight junctions and injures the basement membrane, resulting in increased endothelial permeability to molecules as large as plasma proteins and even endothelial cell detachment from the basement membrane. 17, 18 nonintegrin molecules such as platelet/endothelial cell adhesion molecules (pecams) also are involved in transendothelial migration of neutrophils. 28 homotypic binding of pecams on adjacent endothelial cells form part of the intercellular junction. neutrophils express an integrin of the β 3 family that can bind pecam, and via sequential binding of β 3 integrins to pecam, the neutrophil can , and other proinflammatory mediators. endothelial cells stimulated by inflammatory mediators produce chemoattractants (such as il-8) and display adhesion molecules that promote neutrophil emigration. the three steps of neutrophil (polymorphonuclear [pmn]) emigrationcapture/rolling (mediated by selectins), adhesion (mediated by β 2 integrins), and transendothelial migration (mediated by integrins and platelet/endothelial cellular adhesion molecule [pecam])-occur on activated endothelium. chemoattractant molecules, such as il-8 trigger neutrophil emigration. in inflamed tissues, cytokines (il-1β and tnf-α) and a variety of other proinflammatory mediators stimulate the neutrophil oxidase complex to produce reactive oxygen intermediates (rois; o 2 and h 2 o 2 and their derivatives). activated neutrophils degranulate to release proteases and other hydrolases, cationic peptides (defensins), myeloperoxidase, and other products into the tissue. activated neutrophils synthesize a variety of inflammatory mediators, including prostaglandins (pge 2 ) that modulate the inflammatory response. the products of activated neutrophils (rois, proteases, and mediators) stimulate epithelial secretion and alter tight junction permeability, promoting diarrhea. neutrophils eventually migrate across the infected epithelium by a mechanism that involves integrins, disrupting tight junction integrity and increasing permeability to bacterial products, thus exacerbating the inflammatory response. "unzip" the intercellular junction and migrate through, closing it behind itself. a key feature of neutrophils and other leukocytes is the requirement for integrin-mediated adhesion to extracellular matrix proteins (ecms) or other cells to achieve an optimal effector phenotype. 34 critical components of the ecms in inflamed tissues include fibronectin, fibrinogen, and vitronectin, deposited in tissues as a result of plasma leakage and by synthesis of new proteins by stromal cells and resident macrophages in response to inflammatory mediator activation. the changing composition of the matrix proteins deposited in tissues during inflammation serves as a clue as to the nature of the tissue environment for recruited inflammatory cells as they become activated. individual gene expression studies have demonstrated that adhesion to matrix proteins induces the expression of cytokines and chemokines and their receptors, arachidonic acid-derived lipid mediator synthases, metalloproteinases, growth factors, transcription factors, and other genes that influence the differentiation and activation of inflammatory cells. 35 roi production, phagocytosis, degranulation, and other effector functions stimulated by inflammatory mediators and bacterial products are optimal only when neutrophils adhere to the ecms. 34 adhesion to distinct ecm proteins selectively activates signaling pathways and gene expression of neutrophils, monocytes, and other leukocytes with differing abilities to promote certain functions such that the composition of ecms in many ways controls the development of the ultimate effector phenotype. thus integrin-mediated adhesion provides a mechanism by which neutrophils and other leukocytes can sense the complex tissue environment and respond appropriately. of the activators of neutrophils at sites of inflammation, complement (c3-opsonized particles), cytokines (tnf-α and il-1β), platelet-activating factor, immune complexes, and bacterial products are among the most potent stimuli. other mediators produced during inflammation may modify neutrophil activity, particularly formylated bacterial peptides, chemokines, complement fragments (c5a), leukotriene b 4 , and prostaglandins. activated neutrophils are highly phagocytic; produce large amounts of rois; degranulate to release myeloperoxidase, cationic antimicrobial peptides (defensins), serine proteases (mainly elastase), and metalloproteinases; and secrete inflammatory mediators (tnf-α, il-1β, prostaglandins, leukotrienes, and others) (see figure 13 .2-1). mast cells strategically reside in mucosal tissues, including the submucosa and lamina propria of the gastrointestinal tract, and constitute a crucial first line of defense at epithelial barriers. however, they are also important effector cells of the pathophysiology of inflammatory gastrointestinal diseases. 36 experimental depletion of mast cells, genetic deficiency in the development of mast cells, or pharmacologic stabilization of mast cells to prevent degranulation have a protective effect in a variety of models of gastrointestinal inflammatory disease, including dextran-or trinitrobenzenesulfonic acid-induced colitis, 37, 38 ischemia-reperfusion injury, 39, 40 and immediate hypersensitivity responses. 41 mast cells are activated by a wide variety of microbial products and host-derived mediators. 42 among the activators of mast cells the so-called anaphylatoxins (complement fragments c3a, c5a, and c4a), are potent stimuli causing release of mediators of inflammation. in addition, mast cells are the primary effector cells of immunoglobulin e-mediated anaphylaxis (type i hypersensitivity reactions) by virtue of their high affinity receptors for immunoglobulin e. cross-linking of receptor-bound immunoglobulin e on mast cell surface by antigens (i.e., food antigens) causes rapid degranulation, resulting in the explosive release of granule contents. 43 neural pathways in the intestine also regulate mast cells. mast cells respond to enteric pathogen invasion via neural reflexes that stimulate the release of inflammatory mediators. activated mast cells release preformed histamine, 5-hydroxytryptamine, proteases, heparin, and cytokines from granules. activation also stimulates de novo synthesis of a range of inflammatory mediators, including prostaglandins, platelet-activating factor, and leukotrienes. transcription of a number of peptide mediators, such as the cytokines tnf-α and il-1β among many others, also increases on stimulation of mast cells. mast cell products have profound effects on the vasculature, increasing endothelial permeability and causing vasodilation. 44 moreover, mast cell-derived mediators greatly enhance epithelial secretion by a mechanism that activates neural pathways of epithelial secretion and directly stimulates epithelial cells. 43 mast cell products significantly alter intestinal motility, generally increasing transit and expulsion of intestinal contents. mast cell-derived leukotrienes and tnf-α also have a crucial role in host defense against bacterial pathogens, acting to recruit and activate neutrophils. 45, 46 mast cells have a newly identified role in host defense and inflammatory responses to bacterial pathogens, which in part is caused by the release of proinflammatory mediators during bacterial infection, which is critical for recruiting and activating other innate host defense cells such as neutrophils. however, mast cells are also phagocytic, have microbicidal properties, and can act as antigen-presenting cells to the adaptive immune system. 47 although accumulating evidence was establishing the role of mast cells in innate immunity, a seminal study that unconditionally identified the importance of mast cells in host defense demonstrated that mast cell-deficient w/ w v mice have impaired responses to gram-negative bacterial peritonitis, resulting in a significant increase in mortality. the role for mast cells in host protective responses appears to be as a sensor of bacterial invasion. unlike immunoglobulin e-mediated responses, bacterial products seem to elicit a highly regulated and selective response from mast cells. the complement cascade is a fundamental part of the inflammatory response. activation of the complement cascade by immune complexes (classical pathway) or by bacteria or bacterial products, polysaccharides, viruses, fungi, or host cells (alternative pathway) results in the deposition of complement proteins on the activating surface and the release of soluble proteolytic fragments of several complement components. in particular, activation of either pathway results in the deposition of various fragments of the complement protein c3, which are potent activators of neutrophils and monocytes. 48 opsonization of particles with c3 fragments constitutes a major mechanism of target recognition and phagocyte activation. 49 during the activation of the complement cascade culminating in deposition of c3, soluble fragments of c3 (c3a), c5 (c5a), and c4 (c4a) are liberated. these fragments, termed anaphylatoxins, have potent effects on tissues and cells during inflammation. perhaps most notably, anaphylatoxins are chemotactic for neutrophils (particularly c5a), activate neutrophil and mast cell degranulation, and stimulate roi release from neutrophils. 48 the termination of the complement cascade results in the formation of a membrane attack complex in membranes at the site of complement activation, and if this occurs on host cells such as endothelium, it may cause irreversible cell injury. although the primary source of complement is plasma, epithelial cells of the gastrointestinal tract also produce c3, suggesting that local production and activation of the complement cascade during inflammation occurs in intestinal tissues. clearly, if the regulatory mechanisms of the complement cascade fail, then the inflammatory response may be inappropriate and tissue injury can occur. the role of complement in gastrointestinal inflammation has been most studied extensively in models of ischemia-reperfusion injury. activation of the complement cascades has a major role in altered endothelial and epithelial permeability in these models. several lines of evidence support the importance of complement in intestinal injury. mice deficient in c3 or c4 are protected against ischemia-reperfusion injury. 50 moreover, administration of monoclonal antibodies against c5 reduced local and remote injury and inflammation during intestinal reperfusion injury in a rat model. 51 administration of a soluble form of complement receptor 1, a regulatory protein that halts the complement cascade by dissociating c3 and c5 on host cell membranes, reduced mucosal permeability, neutrophil influx, and leukotriene b 4 production during ischemia-reperfusion injury in rats and mice. 50, 52 although neutrophils and mast cells mediate many of the pathophysiologic effects of the complement cascade, the membrane attack complex may have a primary role in altered vascular permeability during ischemia-reperfusion injury. 53 four components initiate the contact system of coagulation: hageman factor (hf), prekallikrein, factor xi, and high-molecular-weight kininogen. hf is a large plasma glycoprotein that binds avidly to negatively charged surfaces. 54 bacterial cell walls, vascular basement membranes, heparin, glycosaminoglycans, and other negatively charged surfaces in the intestine capture hf and the other three important initiators of the contact system in a large multimolecular complex. of the surfaces that bind hf, the extracellular matrix is a potent activator of the contact system. once bound, hf is converted to hf-α, which cleaves prekallikrein to kallikrein and factor xi to factor xia. the ultimate result is further cleavage of hf by kallikrein and triggering of the contact system cascade, activation of intrinsic coagulation by factor xia, activation of the alternative pathway by hf, and proteolytic cleavage of high-molecular-weight kininogen by kallikrein, releasing biologically active kinins. the products of the contact system, particularly bradykinin, have several important biologic properties that drive many of the vascular and leukocytic responses during inflammation. 54 bradykinin induces endothelial cell contracture and intracellular tight junction alterations that increase vascular permeability to fluid and macromolecules. bradykinin also affects vascular smooth muscle contracture, resulting in vasoconstriction or vasodilation depending on the location. bradykinin also increases intestinal motility, enhances chloride secretion by the intestinal mucosa, and intensifies gastrointestinal pain. in neutrophils, kinins stimulate the release of many inflammatory mediators, including cytokines, prostaglandins, leukotrienes, and rois. 55 kallikrein cleaves c5 to release c5a, a potent chemotactic factor for neutrophils, and thus has a role in recruiting and activating inflammatory leukocytes. the plasma kallikrein-bradykinin system is activated in a variety of acute and chronic inflammatory diseases of the gastrointestinal tract. 56, 57 recent evidence has demonstrated that blockade of the pathophysiologic effects of bradykinin has clinical applications. oral or intravenous administration of the bradykinin receptor antagonist icatibant reduces the clinical signs, onset of diarrhea, and many of the histopathologic changes in experimental models of colitis in mice. 58 inhibition of kallikrein by oral administration of p8720 attenuated the intestinal inflammation, clinical score, and systemic manifestations in a model of chronic granulomatous enterocolitis. 57 thus the contact system is a viable therapeutic target for inflammatory diseases of the intestine. changes in blood flow to the mucosa and other regions of the intestine that reduce perfusion of the tissues can potentiate the initial damage caused by infection or injury. for example, reperfusion of ischemic tissues is associated with platelet and neutrophil clumping in the small vessels of the mucosa, which can impede blood flow. 59 platelets are activated and adhere to exposed basement membrane and activated endothelial cells and provide a surface for leukocyte adhesion. the accumulation of platelets and leukocytes can reduce vessel diameter and blood flow significantly while potentiating local coagulation and thrombus formation. soluble mediators released by activated leukocytes and endothelial cells also affect blood flow. histamine and the vasoactive lipids derived from arachidonic acid (leukotrienes, prostaglandins, thromboxane, prostacycline, and platelet-activating factor) have a prominent role in regulating local perfusion during inflammation and also may have systemic effects on blood flow. procoagulant mediators released by inflammatory cells in response to the inflammatory process (i.e., tissue factor produced by macrophages or endothelial cells), exposed basement membrane proteins, and bacterial components can trigger the contact system and the coagulation and complement cascades, the products of which affect blood flow. nitric oxide, whether produced by endothelial cells or leukocytes (macrophages), is a potent regulator of blood flow and has a significant role in the control of perfusion during inflammation. 60 many of the mediators that affect perfusion also affect endothelial permeability, altering osmotic and hydrostatic balance and tissue edema. in extreme cases, local and systemic coagulopathies initiated by vascular injury and absorption of microbial products and inflammatory mediators induce a hypercoagulable state, leading to microthrombus formation, which can reduce blood flow, or macrothrombus formation, which causes tissue infarction. the cellular mediators of inflammation have the potential to inflict severe injury to intestinal tissues. neutrophils have an important role in the pathophysiology of many intestinal diseases, including ischemia-reperfusion injury, 16, 22 infectious enterocolitis, [23] [24] [25] nonsteroidal antiinflammatory drug-induced mucosal ulceration, 26 and others. depletion of neutrophils, blockade of their emigration into tissues, or inhibition of neutrophil activation reduce the severity of these and other inflammatory diseases. 61 thus many antiinflammatory therapies are emerging that specifically target neutrophil adhesion, migration, and activation. migration of neutrophils through endothelium during emigration into inflamed tissues is remarkable in that the permeability of the endothelial monolayer is preserved under most circumstances. however, a limit exists above which neutrophil migration alters the permeability characteristics of the endothelium. the effect is in part physical in that mere movement of large numbers of neutrophils through the endothelium is sufficient to disrupt the tight junctions mechanically and is caused in part by toxic products of neutrophils that damage endothelial cells and basement membranes. 59, 62 serine proteases (particularly elastase) and metalloproteinases released by degranulating neutrophils destroy tissue matrix proteins and cell-surface proteins that make up endothelial intercellular junctions. these degradative enzymes are particularly damaging to basement membranes and the cellular barriers of the endothelium, thus contributing to vascular permeability (and local tissue edema) and thrombosis. the permeability may be affected to the extent that not only water but macromolecules (albumin, matrix proteins, complement, etc.) leak into the interstitium. blockade of neutrophil adhesion to endothelium with anti-β 2 integrin antibodies has a sparing effect on the microvasculature in experimental intestinal ischemiareperfusion injury, reducing the alterations in vascular permeability and histopathologic evidence of microvascular damage. 59 similar to the endothelium of inflamed tissues, massive neutrophil transmigration occurs across the epithelium in response to infection or injury. neutrophil transepithelial migration increases epithelial permeability by disrupting tight junctions. 62 like the endothelium, neutrophils disrupt the epithelial barrier mechanically as they migrate through (see figure 13 .2-1). proteases, particularly elastase, degrade basement membrane components and tight junction proteins. products of activated neutrophils (tnf-α and interferon-γ) increase tight junction permeability by direct effects on the enterocytes. prostaglandins released by activated neutrophils stimulate epithelial secretion, thus contributing to diarrhea. subepithelial accumulation of neutrophils can lead to deadhesion of the epithelial cells from the basement membrane and mild to severe ulceration. the physiologic results of the effects of neutrophils and their products on the epithelial barrier include protein-losing enteropathy and absorption of bacterial cell wall constituents, which potentiates the local and systemic inflammatory responses. neutrophils in inflamed tissues stimulated by potent host-derived activators (such as il-1β and tnf-α) and bacterial products (lipopolysaccharide) release copious amounts of rois (see figure 13 .2-1). although these oxygen and oxyhalide radicals are important for killing pathogens, they are also potentially toxic to epithelial and endothelial cells and matrix proteins. reactive nitrogen intermediates produced primarily by macrophages during inflammation combine with rois to form peroxynitrites, which are particularly toxic. 11 in addition to injury to mucosal tissues, rois also have an as yet ill-defined role in recruiting and activating neutrophils, thereby potentiating the inflammatory response. 63 in support of the role of rois in inflammatory diseases of the gastrointestinal tract, administration of inhibitors of roi production or pharmacologic roi scavengers can be protective in many models of reperfusion injury or enterocolitis. many therapies are aimed at inhibiting neutrophil activation and effector functions in tissues have been evaluated for use in intestinal diseases. phosphodiesterase inhibitors, by causing cyclic adenosine monophosphate accumulation in neutrophils, are antiinflammatory by virtue of their ability to suppress neutrophil activation and roi production. new phosphodiesterase inhibitors selective for the predominant neutrophil isoform of phosphodiesterase hold promise for use in many inflammatory diseases. subepithelial mast cells also have an important role in altering epithelial permeability in inflamed intestine. during the intestinal hypersensitivity response, subepithelial mast cell release of mast cell protease ii by degranulation increases epithelial permeability via an effect on tight junctions. 41, 64, 65 this alteration in tight junction permeability results in enhanced transepithelial flux of macromolecules, including proteins and bacterial products. cytokines released by mast cells and phagocytes also regulate tight junction permeability. interleukin-4, a product of mast cells and macrophages, increases epithelial permeability. 66 moreover, tnf-α and interferon-γ, products of many inflammatory cells, synergistically increase tight junction permeability. 67 acute equine colitis causes rapid, severe debilitation and death in horses (more than 90% of untreated horses die or require euthanasia). 1 since 1919, several reports have described a number of different acute diarrheal conditions in the horse that appear to share a common characteristic clinical presentation. 2-10 diarrhea associated with acute equine colitis occurs sporadically, is highly fatal, and is characterized by intraluminal sequestration of fluid, moderate to severe colic (abdominal pain), and profuse watery diarrhea with resultant endotoxemia, leukopenia, and hypovolemia. 7, 10, 11 the condition can affect adult horses of all ages but usually occurs in horses between 2 and 10 years of age. disease onset is sudden with a rapid progression and often is preceded by a stressful event. a definitive diagnosis is made in only about 20% to 30% of cases. 7, 11 most ante-and postmortem diagnostic tests remain speculative. treatment of the condition in horses is costly because of the massive fluid therapy required. currently, no curative treatment is available for acute colitis in horses, human beings, or other mammals. treatment regimens provide rehydration, electrolyte and plasma protein replacement, mitigation of the effects of circulating endotoxin, and antimicrobial therapy when indicated. attempts during the past 40 years to develop appropriate treatments (i.e., vaccines or pharmacologic agents) have been hampered by the unavailability of acceptable equine models and have been unsuccessful because of the complex pathophysiology of the intestinal epithelium. although the mechanisms responsible for the fluid losses are not known, inflammatory cells may play an integral role because this condition is characterized by large numbers of granulocytes infiltrating the large intestinal mucosa. [12] [13] [14] [15] [16] equine cecal and colonic tissues collected during the acute stages of experimentally induced acute equine colitis (equine ehrlichial colitis, lincomycin with and without clostridium spp. inoculation, nonsteroidal antiinflammatory drug administration) reveal the presence of numerous neutrophils and eosinophils in the lamina propria and submucosa. 12, 15, 17, 18 granulocytederived reactive oxygen intermediates are crucial to antimicrobial defenses in the gut and stimulate chloride and water secretion by interactions with enterocytes. 19, 20 normal equine intestinal tissue is unique compared with that in most other mammalian species for a preponderance of eosinophils located in the intestinal mucosa and submucosa. 6, 21 production of reactive oxygen intermediates by stimulated phagocytic granulocytes following mucosal barrier disruption may be responsible for the massive fluid secretory response that occurs during the early stages of acute equine colitis. colitis refers to inflammation and mucosal injury of the colon and cecum (typhlocolitis) that may occur in response to a number of causes. 22, 23 the cause of the colonic injury may be well-defined such as in naturally occurring infectious or experimentally induced colitis. however, many cases of human and animal diarrhea have a speculative or unknown diagnosis or no diagnosis. 11, 24, 25 irrespective of the underlying or initiating cause of colonic injury, the colon apparently has a limited repertoire of responses to damage because most forms of colitis demonstrate similarities in histopathologic appearance and clinical presentation. various degrees of mucosal erosion and ulceration, submucosal/mucosal edema, goblet cell depletion, and presence of an inflammatory cellular infiltrate within the mucosa and submucosa are common to many types of human and animal colitis. 21, [23] [24] [25] characteristic clinical manifestations include intraluminal fluid sequestration, abdominal discomfort, hypovolemia, and most often profuse, watery diarrhea. large bowel diarrhea results from abnormal fluid and ion transport by cecal and colonic mucosa. loss of fluid by the large intestine can result from malabsorptive or hypersecretory processes and is often a combination of the two. 26 colonic secretory processes are a function of the crypt epithelium, whereas absorptive processes are limited to surface epithelial cells. 27 under normal baseline conditions, an underlying secretion by crypt epithelium is masked by a greater rate of surface epithelial cell absorption. abnormal forces influencing the rates of secretion and absorption can result in massive, uncontrolled secretion and malabsorption by large intestinal mucosal epithelial cells, leading to rapid dehydration and death. 26, 27 two intracellular processes control colonic secretion: the cyclic nucleotide (cyclic adenosine monophosphate [camp] and cyclic guanosine monophosphate [cgmp]) and the calcium system. 28, 29 agents may activate adenyl cyclase (vasoactive intestinal peptide, prostaglandin e 2 [pge 2 ]) or guanyl cyclase (bacterial enterotoxins) and induce increases in camp or cgmp, respectively. this reaction causes phosphorylation of specific protein kinases that induce the actual apical and basolateral membrane transport events. increases in intracellular free calcium may arise from cyclic nucleotide-dependent release of stored calcium within the cell or from increased calcium entry across the cell membrane. 26, 27 calcium may act through calmodulin, which then can activate membranephosphorylating protein kinases. at least four central systems control intestinal secretion: (1) the hormonal system, (2) the enteric nervous system, (3) bacterial enterotoxins, and (4) the immune system. 29, 30 hormonal control of colonic electrolyte transport is exerted primarily through the renin-angiotensinaldosterone axis. 31, 32 the enteric nervous system controls transport through three separate components: (1) extrinsic nerves of the parasympathetic and sympathetic pathways; (2) intrinsic ganglia and nerves, secreting a variety of neurotransmitters including peptides; and (3) neuroendocrine cells (intraepithelial lymphocytes) that reside in the epithelium and release messengers onto the epithelial cells in a paracrine manner. 26, [29] [30] [31] [32] many bacterial enterotoxins can induce intestinal secretion by camp or cgmp signal transduction. 33 bacterial enterotoxins can stimulate enteric neurons, providing evidence for interaction between two controlling systems. 34 preformed inflammatory mediators such as histamine, serotonin, or adenosine and newly synthesized mediators such as prostaglandins, leukotrienes, platelet-activating factor, various cytokines, the inducible form of nitric oxide, and reactive oxygen metabolites can initiate intestinal secretion by directly stimulating the enterocyte and by acting on enteric nerves indirectly to induce neurotransmitter-mediator intestinal secretion. 30 for instance, when added to the t84 colonic cell line, the known mast cell mediators histamine, adenosine, and pgd 2 induce chloride secretion. [35] [36] [37] prostaglandins of the e and f series can cause an increase in chloride secretion in intact tissue and isolated colonic cells. [38] [39] [40] leukotrienes, platelet-activating factor, and a number of cytokines have been shown to have no effect on t84 cell secretion but have a significant effect on electrolyte transport in intact tissue, suggesting that intermediate cell types may be involved in these secretory responses. [41] [42] [43] the epithelial cell chloride secretory response occurs via prostaglandin-and adenosine-mediated increases in cellular camp, whereas histamine acts by h 1 receptor induction of phosphatidylinositol turnover, production of inositol triphosphate, and mobilization of intracellular calcium stores. 30, 33 lipoxygenase products (leukotrienes) are capable of activating a colonic secretory response and do not appear to involve the cyclic nucleotides or calcium ions. 41 phagocyte-derived reactive oxygen mediators (roms) can induce colonic electrolyte secretion in vitro, suggesting that oxidants may contribute directly to the diarrhea associated with colitis. [44] [45] [46] [47] [48] reactive oxygen species initiate the secretory response by increasing cellular camp or stimulating mesenchymal release of pge 2 or prostacyclin, which in turn stimulates the epithelial cell or enteric neuron, respectively. [44] [45] [46] [47] [48] [49] sodium nitroprusside, an exogenous source of nitric oxide, stimulated an increase in chloride secretion in rat colon that was mediated by cyclooxygenase products and enteric neurons. 50 table 13 .3-1 summarizes inflammatory mediator-induced epithelial cell chloride secretion. acute colitis rarely develops by a simple cause or effect phenomenon but is influenced by many extrinsic and intrinsic host and microorganism factors. inflammatory mediators released from mast cells and monocytic or granulocytic phagocytes cause intestinal chloride and water secretion and inhibit neutral sodium and chloride absorption. 29, 30, 67 inflammatory cells, particularly the phagocytic granulocytes, play an important role in mucosal pathophysiology in cases of colitis. 20, 68 large numbers of these cells are observed on histopathologic examination of tissues from human and animal cases of colitis. products of cell activation stimulate direct and indirect secretory responses in intestinal cells and tissues. [28] [29] [30] [45] [46] [47] [48] [49] products of phagocyte secretion may amplify the inflammatory signal or have effects on other target cells in intestine such as enterocytes and smooth muscle cells (table 13 .3-2). the nadph-oxidase system of phagocytes (neutrophils, eosinophils, monocytes/macrophages) is a potent inducer of superoxide radicals used as a host defense mechanism to kill invading microorganisms. 20, 69 during inappropriate stimulation such as inflammation, trauma, or ischemia followed by reperfusion, increased levels of toxic oxygen species are produced, causing damage to host tissues. engagement of any of several receptor and nonreceptor types including phagocytosis mediators, chemotactic agents, various cytokines, and microbial products can stimulate phagocytes. 20 resident phagocytes or those recruited to colonic mucosa early in the disease process are considered to augment mechanisms causing fluid and electrolyte secretory processes, a so-called amplification process. 70, 71 activation of the respiratory burst results in the production and release of large amounts of superoxide anion (o 2 − ) and h 2 o 2 . 69, 72 in addition to these roms, activated phagocytes secrete peroxidase enzyme (myeloperoxidase from neutrophils and eosinophil peroxidase from eosinophils) into the extracellular space. the peroxidases catalyze the oxidation of clby h 2 o 2 to yield hocl, the active ingredient in household bleach products. the peroxidase-h 2 o 2 -halide system is the most cytotoxic system of the phagocytes; hocl is 100 to 1000 times more toxic than o 2 or h 2 o 2 . 69 hocl is a nonspecific oxidizing and chlorinating agent that reacts rapidly with a variety of biologic compounds including dna, sulfhydryls, nucleotides, amino acids, and other nitrogen-containing compounds. hocl reacts rapidly with primary amines (rnh 2 ) to produce the cytotoxic n-chloramines (rnhcl). the mechanisms by which hocl and rnhcl damage cells and tissue remain speculative, but possibilities include direct sulfhydryl oxidation, hemoprotein inactivation, protein and amino acid degradation, and inactivation of metabolic cofactors of dna. 73 peroxidase-derived oxidants have been shown to degrade hyaluronic acid and collagen. 74 in addition, luminal perfusion of specific roms increased mucosal permeability and serosal application caused increases in clsecretion in vitro. 75 tissue myeloperoxidase activity, an index of tissue granulocyte infiltration, is used clinically and experimentally to assess degree of intestinal inflammation. 76, 77 myeloperoxidase activity is elevated in acute flare-ups of human inflammatory bowel disease and various animal models of acute colitis. [76] [77] [78] [79] [80] the acute inflammatory response in these conditions is characterized predominantly by neutrophils, the predominant source of myeloperoxidase activity. however, this assay measures total hemoprotein peroxidase, which includes monocyte and eosinophil peroxidase in addition to neutrophils. 77 moreover, levels of peroxidase activity in equine circulating eosinophils are greater than in circulating neutrophils, 81 and this may apply to resident tissue eosinophils as well. arachidonic acid metabolites are thought to play a role in intestinal inflammation in diarrheal disease. 30, 45, 82 elevated levels of these intermediate metabolites have been demonstrated in natural disease and experimental models of colitis and appear to parallel increases in roms in inflamed intestine. 82 addition of h 2 o 2 or hocl to rat colonic tissue in ussing chambers has been shown to induce pge 2 release and active clsecretion. 47, 48 prostaglandins can stimulate increases in clsecretion in intact intestinal tissue 45, 46, 48 and in isolated colonic t84 cells. 47, 49 interactions between roms and mesenchymal release of pge 2 /pgi 2 may be relevant to the mechanisms producing the diarrheic condition. fibroblasts co-cultured or juxtaposed to colonic t84 cells greatly increased the clsecretory response to h 2 o 2 in vitro through the release of pge 2 . 49 in addition, equine colonic mucosa has an increased sensitivity to endogenously released prostaglandin by exhibiting a significant secretory response under in vitro conditions. 83 endotoxin, the lipopolysaccharide component of the outer cell wall of gram-negative bacteria, is present in large quantities in the large intestine of healthy horses. 81, 83 endotoxins are released into the immediate surroundings when gram-negative bacteria undergo rapid proliferation or die. 84, 85 the intact bowel forms an effective barrier to the transport of significant amounts of these highly antigenic toxins, but the diseased gut absorbs these macromolecules in large amounts, causing the subsequent adverse systemic effects that are often life threatening. 86 disruption of the intestinal barrier (i.e., ischemia, trauma, inflammatory conditions) overwhelms the capacity of the liver to clear endotoxins, and systemic endotoxemia ensues. endotoxins have been shown to be potent activators of the inflammatory process, stimulating the production and release of numerous cytokines by activated macrophages and other immunocytes. 87 in vitro studies suggest that endotoxin activates phagocytic granulocytes to secrete roms, increase release of lysozymes, and enhance the migratory response to chemotactic stimuli. 88 prostacyclin and thromboxane a 2 mediate hemodynamic dysfunction, and lipoxygenase products may induce tissue ischemia. 89 the cytokine interleukin-1 causes a febrile response and initiates the acute phase response. 90 tumor necrosis factor contributes to many of the abnormal physiologic responses, particularly hemostatic functions that potentiate coagulopathy. 91 additional mediators include interleukin-6, platelet-activating factor, procoagulant mediators, and various other speculated substances. 84 endotoxins trigger mucosal immune cells and subsequent release of inflammatory mediators in cases of colitis. the first report of experimentally induced endotoxemia described clinical signs and hematologic findings that closely paralleled those reported for severe colitis in horses. 92 studies in which endotoxin was administered intravenously in human beings and laboratory animals caused significant dose-related gastrointestinal changes, ranging from mild diarrhea to bloody, watery diarrhea. 93, 94 in vitro studies on the effects of endotoxin on intestinal water and electrolyte transport in adult male rats showed a significant decrease in net colonic sodium absorption and increased colonic permeability. 55 in animal models of protein energy deficiency, endotoxin-induced mortality increased compared with that of well-nourished control animals. endotoxin depresses lymphocyte responses to specific mitogens. 95 thus the adverse effects of malnutrition and endotoxin are mutually aggravating. the importance of a normal immune system to the defense of the mucosal surface of the gastrointestinal tract is evident in the immunosuppressed state. primary immunodeficiencies affecting the gastrointestinal tract are well documented. [96] [97] [98] common agammaglobulinemia is the most frequently reported gastrointestinal disease and causes b cell deficiency-associated giardiasis. 99 interestingly, selective immunoglobulin a (iga) deficiency rarely results in intestinal disease because of a speculated increase in mucosal igm response. however, combined iga and igm deficiencies with a higher incidence of intestinal disease occur. a selective deficiency of secretory iga has been associated with intestinal candidiasis. certain mucosal pathogens may enhance their pathogenicity by producing iga proteases. 99 defects in cell-mediated immunity are associated most commonly with intractable diarrhea, and organisms frequently involved include salmonella spp., escherichia coli, and shigella spp. 100 acquired immunodeficiency or immunosuppression in adults can result from infectious diseases (particularly viral), nutritional deficiencies, aging phenomenon, and drugs (corticosteroids, azathioprine, cyclophosphamide). nutrition is a critical determinant of immunocompetence and risk of illness. 101, 102 impaired systemic and mucosal immunity contribute to an increased frequency and severity of intestinal infections observed in cases of undernourishment. abnormalities occur in cell-mediated immunity, complement system, phagocytic function, mucosal secretory antibody response, and antibody affinity. morbidity caused by diarrheal disease is increased particularly among individuals with stunted growth rate because of malnourishment. 102 the critical role of several vitamins and minerals in immunocompetence has been substantiated in animals deprived of one dietary element and findings in human patients with single-nutrient deficiency. tables 13.3-3 and 13 .3-4 summarize nutritional-related immune system abnormalities. in summary, nutritional deficiency can cause increased colonization of the intestine with microorganisms, alter the symbiotic characteristics of resident intestinal bacterial populations, and impair defenses of the gastrointestinal tract, allowing increased risk of systemic spread of infection and absorption of macromolecules (in particular, endotoxin). indigenous microflora greatly impede colonization of the gastrointestinal mucosa by pathogenic organisms. the ability of a potential pathogen to initiate an infection depends on its ability to breach the mucosal epithelial barrier. one mechanism by which the normal flora inhibit establishment of pathogens is by preventing adherence of the pathogen to mucosal cells by occupying the site or by stearic hindrance. [102] [103] [104] [105] resident microbes also produce byproducts such as antibacterial factors that allow symbiosis rather than competition between them. another hindrance mechanism is production of volatile fatty acids by normal microbial digestive processes to create an environment that is toxic to many bacterial populations, particularly the enterobacteriaceae. 106 disturbances in motility patterns occur during inflammatory diseases of the colon, but the role of motility alterations in the pathogenesis of diarrhea remains unclear. invasive bacteria cause characteristic motor patterns in the colon consisting of rapid bursts of motor activity that appear to decrease transit time through the large intestine. the result is reduced clearance of bacteria from the large intestine, which may contribute to the virulence of the organism. 107 absorption of endotoxin and the release of inflammatory mediators such as prostaglandins disrupts the motility patterns of the large intestine, resulting in less coordinated contractions, and may contribute to the alterations in motility seen with invasive bacteria. although the effect of endotoxin and prostaglandins on transit time is not profound, the disruption of coordinated activity may play a role in causing diarrhea. 108 thorough mixing and prolonged retention time of ingesta are important not only in microbial digestion of nutrients but also in absorption of microbial byproducts and fluid. 32, 109 the ingesta is viscous and therefore must be mixed to bring luminal ingesta in contact with the mucosa for absorption. 109 in addition, poor mixing increases the thickness of the unstirred layer, decreasing contact of ingesta with the mucosa and decreasing absorption. 32, 109 progressive motility must be present, however, if a diarrheal state is to occur. 32, 109 ileus may be accompanied by increased fluid in the lumen of the large intestine, pyridoxine, folic acid, impairs cell-mediated immunity and vitamin c, vitamin e reduces antibody response. vitamin b 6 decreases lymphocyte stimulation response to specific mitogens. zinc deficiency affects humoral and cell-mediated immunity. iron inhibits bacterial multiplication. copper depresses antibody response. needed by neutrophils and lymphocytes for optimal function, which may be related to myeloperoxidase and ribonucleotidyl reductase deficiencies. but without progressive motility the fluid is not passed. frequently, acute colitis causes a period of ileus characterized by scant stool. diarrhea is apparent only when motility returns and the ingesta is passed. increased progressive motility has been suggested to cause diarrhea by decreasing transit time and is thought to play a role in irritant catharsis and in the mechanism of action of some laxatives. 110 irritation and distention increase motility and may well decrease transit time, but increased secretion also is thought to contribute to diarrhea caused by these substances. 111 one should direct the clinical investigation of malabsorption at ascertaining and trying to localize the source of the abnormality. in medical practice, impairment of one or more phases of the digestion and absorption of dietary constituents may precipitate clinical signs that are associated primarily with carbohydrate, protein, or fat malabsorption. this level of differentiation is not possible in the horse because of the herbivorous diet and the contribution of large intestinal functions. in human and small animal medicine, disturbances in digestive processes especially from exocrine pancreatic insufficiency or reduced intestinal bile salt concentration are principal determinants of many clinical malabsorption syndromes. the rarity of pancreatic problems in horses and the herbivorous diet makes maldigestion less of a concern and difficult to pursue diagnostically. nevertheless, maldigestion undoubtedly contributes to chronic weight loss conditions in horses, which may be significant with severe infiltrative disease of the small intestine with partial to total villous atrophy and flattened mucosa. impairment of digestive processes may exacerbate diarrhea in the suckling foal through reduced intestinal bile salt concentrations from hepatic or ileal dysfunction. malabsorption is not synonymous with diarrhea, although diarrhea may be a feature. adult horses rarely exhibit diarrhea with small intestinal problems unless large intestinal involvement is concomitant. chronic diarrhea is predominantly a large intestinal disorder that reflects an overload of water and electrolytes and thus may be considered a state of impaired absorption. primary small intestinal disease is more likely to occur in neonates and young foals. for example, acquired small intestinal brush border lactase deficiency may result in increased lactose fermentation in the large intestine and induction of osmotic diarrhea. 1 box 13.4-1 lists conditions that have been or potentially could be associated with malabsorption syndromes and maldigestion in the horse. malabsorption in horses has no pathognomonic clinical syndrome. case recognition derives from the robust investigation of horses with chronic wasting. prevalence is unknown. no strict case definition exists, even for chronic wasting. interest generated by unusual clinical test results and their related pathologic findings has stimulated publication of reports of cases considered as malabsorption in horses. pathologic description of the predominant cellular infiltrate and the pattern of intestinal distribution have resulted in the classification of many conditions as representing examples of chronic inflammatory bowel disease (cibd) (see box 13.4-1), drawing analogies from human medicine. in the affected animal, coexistent enteric protein loss reflecting changes in mucosal integrity from extensive infiltration and inflammation in the intestinal tract is likely to be more debilitating than the malabsorption. the principal concern of the owner is the weight loss and poor condition of the horse. many clinical examination findings, except for body condition, may appear within normal limits. investigation of the weight loss, together with the clinical pathologic findings, helps to eliminate other more commonly encountered causes of wasting. box 13.4-2 lists clinical signs that may be associated with malabsorption syndromes. no characteristic clinical pathologic profile of malabsorption exists. findings relate to the stage of the underlying disease process and intercurrent problems. the syndrome tends to cause anemia (normocytic, normochromic) and neutrophilia. hemolytic or macrocytic anemia and thrombocytopenia have been observed in alimentary lymphosarcoma. lymphocytosis (leukemia) rarely is encountered. eosinophilia is uncommon even with suspected immune-mediated conditions and widespread tissue eosinophilia. many animals are hypoalbuminemic and hypoproteinemic; horses with alimentary lymphosarcoma may exhibit hyperproteinemia and hypergammaglobulinemia. serum or plasma may be lipemic. the clinician may find elevated hepatic and biliary tract enzymes (γ-glutamyltransferase and alkaline phosphatase) in multisystemic conditions; for example, eosinophilic granulomatosis (multisystemic eosinophilic epitheliotropic disease; eg [meed]). abdominocentesis has been of diagnostic value in several alimentary lymphosarcoma cases, but rarely in the granulomatous conditions. ultrasonographic examination of the abdomen can yield infomation on intestinal distention, wall thickness, and unexplained masses detected on rectal palpation. rectal biopsy is easy to perform and may provide an indication of cellular infiltration that could be present at more proximal locations. however, pathologists examine few equine rectal samples, and the interpretation is frequently equivocal. adoption of standardized grading or classification would improve the diagnostic value. a proposed classification system was based on a retrospective study of 130 rectal biopsies from 116 horses ages 1 to 18 years with clinical signs of intestinal disease. necropsy results were studied from 40 horses. biopsy specimens (21 horses) and necropsy rectal tissue (9 horses) from 30 horses ages 4 to 22 years served as controls. simple proctitis, the presence of neutrophils in the crypt or surface epithelium, was an abnormal finding compared with mild scattered neutrophil infiltration in controls. simple proctitis was found in association with malignant lymphoma and other inflammatory disorders. inflammatory bowel disease was diagnosed from rectal biopsy specimens in 6 of 12 eg (meed) cases and 4 of 9 granulomatous enteritis cases confirmed at necropsy. 2 rectal biopsy aided diagnosis for 3 of 7 horses in a series of lymphocytic-plasmacytic enterocolitis cases. 3 eosinophils were demonstrated on impression smears of rectal mucosal biopsies from 1 of 2 horses with eosinophilic enterocolitis. 4 skin biopsies or ultrasound-guided biopsies of liver, lymph node, or lung may reveal evidence of multisystemic disease. one can obtain intestinal and lymph node biopsies via a standing laparotomy. exploratory laparotomy facilitates rigorous inspection of the gastrointestinal tract and associated organs to obtain multiple biopsies from intestinal sites and lymph nodes. the procedure may provide a diagnosis, enabling one to make decisions on potential treatment and management options. cost and potential postoperative complications may limit surgical procedures for diagnosis. laparoscopy may provide an alternative means to facilitate biopsy of certain tissues. however, one should consider surgical exploration as an option early in the process rather than as a last resort. the noninvasive breath hydrogen test used to assess carbohydrate malabsorption in human beings has not proved reliable in equine studies. 5 intestinal function tests can provide a practical and inexpensive means to assess the absorptive capability of the small intestine. for clinical practice purposes this is limited to carbohydrate absorption. abnormality of carbohydrate absorption has become an important precept on which to base a diagnosis of malabsorption in the horse. however, results of the oral glucose tolerance test (ogtt) or d-xylose absorption test require cautious interpretation. pathologic changes in the mucosa and submucosa must be extensive and widely distributed to greatly affect the peak plasma concentration and shape of the curve. the tests are easy to perform in practice and require a baseline blood sample predosing and further samples for up to 6 hours after administration of the solution. many commercial laboratories conduct glucose and xylose assays. the immediate dietary history, gastric emptying rate, intestinal transit, age, and hormonal effects of the horse influence glucose peak and curve shape. higher glucose peaks are recorded from healthy animals eating grass or hay than from those eating concentrates. recent appetite or the level of cachexia may affect test results. maximum plasma glucose level (>85% baseline) is reached by 120 minutes in healthy animals given 1 g glucose per kilogram body mass as a 20% solution. 6, 7 break points below which the probability increases of carbohydrate malabsorption associated with intestinal morphology changes have been proposed. 7 a referral population of 42 mature horses with chronic weight loss was divided into three groups based on ogtt results to determine if any concurrence with the morphologic diagnoses existed. group 1 (n = 5) had a normal ogtt (peak glucose concentration at 120 minutes >85% baseline) and contained animals that had normal small intestinal morphology, and a few with large intestinal lesions. group 2 (n = 25) had partial malabsorption and included 18 horses with small intestinal infiltrative disease that allowed some glucose uptake. diagnoses included lymphosarcoma, villous atrophy, granulomatous enteritis and eg (meed). seven horses had normal small intestinal histologic findings. peak glucose concentrations were less than 85% and greater than 15% of baseline at 120 minutes. seventeen horses in the group had large intestinal pathologic conditions. group 3 horses (n = 12) had total malabsorption; the peak concentration at 120 minutes was less than 15% above baseline. these horses had severe infiltration throughout most of the small intestine that was attributed predominantly to lymphosarcoma or granulomatous enteritis. however, the test is far from definitive; one cannot assume a flat curve indicates malabsorption and a poor prognosis. two horses with chronic weight loss initially diagnosed with malabsorption based on flat ogtt curves subsequently showed more normal ogtt responses. 8 full-thickness intestinal biopsies were unremarkable. one horse had an elevated serum immunoglobulin e to oat allergen. oats and oat straw were removed from access. dexamethasone was given on a tapered protocol, and a repeat ogtt was normal at 18 months. the other horse received oral probiotics to counter suspected small intestinal bacterial overgrowth, was clinically normal in 2 months, and had an improved ogtt with a 60 minute peak. therefore malabsorption, as defined by an absorption test and weight loss, may occur in the horse without significant morphologic changes in the intestine, and the condition may be transient. demonstration of carbohydrate malabsorption in 16 of 24 horses with chronic diarrhea showed poor diagnostic sensitivity for small intestinal involvement. impaired glucose absorption was recorded in horses with predominantly large intestinal problems, cyathostomiasis, chronic colitis, alimentary lymphosarcoma, and meed. 9 although prior dietary history influences peak plasma xylose concentration, xylose is not confounded by hormonal effects or mucosal metabolism. gastric emptying rate, intestinal motility, intraluminal bacterial overgrowth, and renal clearance do affect curve shape. healthy mares not fed for up to 96 hours had flatter curves and a slower decrease in plasma xylose than when deprived for 12 to 36 hours. 10 hence recent appetite or the level of cachexia may influence test results. abnormal d-xylose absorption represented by a flat curve or delayed absorption is considered indicative of significant jejunal disease and has been observed with most examples of cibd, parasitism, and idiopathic villous atrophy. 11, 12 ponies may have lower peak d-xylose concentrations at 60 and 90 minutes than horses, although the range of peak values at the test dosage (0.5 g d-xylose per kilogram body mass in a 10% solution) is wide. potentially diagnostic discriminatory cut off points for peak plasma xylose concentrations have not been determined. abnormal absorption curves have been detected in the absence of small intestinal histologic changes, 13 and interpretation is clouded further by findings from small intestinal resection studies in healthy ponies. nine ponies with 70% distal small intestinal resection and four shamoperated controls were placed on interval feeding for 5 weeks and then turned out to pasture until 6 months after surgery. grazing was supplemented by twice daily (meal feeding) concentrate rations. all ponies gained weight and were clinically normal, and none developed diarrhea. however, the mean peak xylose concentration at 60 minutes declined progressively (at monthly intervals) over the study period in the resection group to 15% of that of controls. lack of clinical malabsorption was attributed to adaptation of the residual 30% of healthy small intestine and of large intestinal function. 14 bacterial overgrowth in the small bowel remnant from refluxed cecal contents (resected ponies had ileocecal valve bypass) may have contributed to the abnormal xylose assimilation. by contrast, xylose absorption decreased over 6 months, associated with substantial weight loss, lethargy, and diarrhea, in an earlier study of extensive (≥60%) small intestinal resection in ponies. 15 an important difference was the feeding pattern; those ponies received pelleted feed twice daily for the entire 6 month follow-up period. consequently, horses with suspected malabsorption may adapt to an interval feeding regimen. the critical factor could be the availability of sufficient unaffected or minimally affected small intestine and large intestinal functional capacity. the outcome for animals with small intestinal disease and some unknown degree of large intestinal pathologic dysfunction may be less successful than shown in the experimental study. abnormal xylose absorption reverted to normal following 35 days of corticosteroid therapy in an adult thoroughbred gelding with a 6-week history of weight loss and diarrhea for 3 weeks; peak xylose concentration at 60 minutes was within normal limits and the horse had gained weight. 4 d-xylose absorption was abnormal in an adult standardbred gelding with a 2-month history of poor performance, weight loss, intermittent fever, mesenteric lymphadenopathy, elevated fibrinogen, and decreased albumin and globulin levels. multiple fullthickness small intestinal biopsies revealed evidence of granulomatous enteritis. the horse received antibiotics postoperatively and then corticosteroids parenterally for 4 to 5 months. after 3 weeks, peak plasma xylose had increased, although absorption was delayed. five months after cessation of corticosteroid therapy, the horse had regained weight and was bright and alert, and d-xylose absorption was normal. 16 diagnostic predictions were made retrospectively by examining d-xylose absorption in horses with granulomatous enteritis compared with those with eg. 17 peak xylose concentrations were much lower in horses with granulomatous enteritis than those with eg, whereas in eg the absorption curve shifted to the right with the peak occurring at 240 minutes. the small intestine is affected predominantly in granulomatous enteritis with extensive villous atrophy and more diffuse lesions in the large intestine, whereas in eg (meed) the large intestine is more involved. hence, the extent and distribution of pathologic changes in the small and large intestines may influence xylose absorption test results. the chronic wasting horse with suspected malabsorption and probable enteric protein loss has at best a guarded to poor prognosis. prognosis may be improved through early and aggressive investigation to achieve a diagnosis, and perhaps assess the stage in the natural progression of the disorder. the owner may elect euthanasia of the animal or may be willing to determine whether the condition can be improved. in the short term, intravenous infusion of plasma or colloids, with or without fluids and electrolytes, may be necessary to stabilize the condition. prognosis is much worse for the horse that is inappetent. prolonged intensive total parenteral nutrition and/or oral alimentation may not be a realistic course of action. the overall therapeutic and management plan can prove to be expensive. the owner must be cognizant from the start that the outcome may not be altered, even after protracted therapy. one cannot make predictions for outcome of therapy without meaningful data because only a few case reports of successful responses with long-term follow up exist. some level of digestive and absorptive capability remains in the diseased small intestine. interval feeding of small quantities of food may be beneficial if the horse continues to eat, and particularly for animals with ravenous appetites that seem able to maintain their reduced state of body condition without further losses. diet should include feeds with a high fiber content to favor large intestinal fermentation, including grass hay and access to pasture complemented by commercial high-fiber rations based on beet pulp and soybean hulls. energy intake can be increased through feeding high-energy dense fats that provide 2.25 times more calories than carbohydrates. most affected horses should tolerate high fat (5% to 10%) processed feeds containing vegetable oils or rice bran (up to 20% of the concentrate mix, equivalent to 8% vegetable oil) to achieve the higher-fat composition. changeover to a higher-fat concentrate should be gradual. even in healthy animals that can eat up to 20% added fat, appetite may decrease as the percentage increases, and fecal consistency may change. clearly, the objective for the horse with suspected malabsorption is to sustain, and preferably increase, dietary intake, value, and efficiency. the owner of an affected horse must be prepared to experiment with feeds, must be patient, and must keep records. no standard procedure exists. exposure to a feed component may contribute to the problem as an allergen eliciting a hypersensitivity reaction. identifying the potential allergen through immunologic testing or by stepwise removal and outcome assessment over a longer period may be difficult. the clinician should give immunosuppressive drugs early in the process. immunosuppressive agents have produced the most promising responses to ameliorate the effects of conditions associated with malabsorption, particularly cibd. short-duration, and in some cases more prolonged and sustained, improvements in body condition, weight gain, demeanor, energy and activity levels have occurred following corticosteroid administration. one should start treatment as early as possible. one should follow initial parenteral (intramuscular or intravenous) loading doses of dexamethasone (sodium phosphate) with a series of depot injections, or orally administered prednisolone or prednisone, on a tapered dose protocol over a period of months. interval low-dose therapy may be necessary if clinical signs return after treatment ends. one uses the lowest dose to control the clinical signs for alternate-day therapy. clinical benefits far outweigh concerns over potential adverse effects. chemotherapeutic agents such as vincristine, cytosine, cyclophosphamide, and hydroxyurea have been tried in a few cases of cibd or lymphosarcoma with no apparent success, probably related to the advanced stage of the disease when treatment was initiated and the dose selected. resection of a segment of intestine that is edematous, hemorrhagic, or constricted is an option in localized forms of cibd, 18, 19 particularly if gross changes are not discernible in adjacent or distant parts of the intestinal tract, that is, malabsorption is not a feature. long-term outcome has been favorable. removal of a substantial proportion of the diseased small intestine may be indicated in a horse with malabsorption, considering that resection of 70% distal small intestine was performed in healthy animals without inducing adverse effects. however, because pathologic changes may exist in normalappearing small or large intestine that is not resected or biopsied, the prognosis remains guarded. two young horses with granulomatous enteritis had the thickened terminal small intestine resected with positive outcomes; one survived 4 months, the other has a follow up extending more than 10 years. 20 anthony t. blikslager to gain an appreciation of the mechanisms whereby the mucosa is injured and subsequently repaired, one must understand how the integrity of the mucosa is regulated physiologically. regulation of mucosal integrity is referred to as mucosal barrier function, which is vital because it prevents bacteria and associated toxins from gaining access to subepithelial tissues and the circulation. however, the mucosa has two conflicting functions: it must serve as a protective barrier and continue to absorb solutes necessary to maintain well-being of the host. this conflict is most notable at the intercellular (paracellular) space, which allows passage of select solutes and water, 1-4 but which does not admit large molecules, including bacterial toxins. 5 the paracellular space is regulated almost exclusively by the tight junction, 6 which is the interepithelial junction at the apical-most aspect of the paracellular space. although these tight junctions originally were viewed as inert cellular adhesion sites, what has become clear in recent years is that tight junction permeability depends on tissue-specific molecular structure and is regulated by a complex array of intracellular proteins and the cytoskeleton. tight junctions consist of a group of transmembrane proteins that interdigitate from adjacent cells. although occludin originally was thought to be the predominant tight junction transmembrane protein, a group of proteins termed claudins appear to be more critical. 7 these transmembrane proteins interact with the cytoskeleton via a series of intracellular proteins, including zonula occludens 1, 2, and 3; cingulin; and others. 8 in addition, local regulatory proteins such as the small guanosine triphosphatase-rho are also critical to tight junction function. in general the relative contractile state of the actin cytoskeleton determines the degree to which tight junctions are open or closed, but the complexities of regulation of this process are understood poorly. 9, 10 the most sensitive measure of mucosal barrier function is transepithelial electric resistance, which is measured by mounting mucosa in an ex vivo system called an ussing chamber, because this measurement is largely a reflection of the permeability of mucosa to ions. 11, 12 ions may follow one of two routes when traversing epithelium: transcellular and paracellular. 5 because cell membranes have a resistance to passive flow of ions 1.5 to 3 log units greater than that of the epithelium as a whole, measurements of transepithelial resistance largely reflect the resistance of the paracellular space, and in particular the tight junctions that regulate paracellular flow of ions. 12 because tight junctions differ in structure from different portions of the mucosa, 13 measurements of transepithelial resistance reflect the net resistance of epithelium of variable permeability within a given tissue. for example, tight junctions in the intestinal glandular structures called crypts are leakier than those in the surface epithelium because of fewer and less organized tight junction strands. 11, 14 conversely, surface epithelium has a greater number of well-organized tight junction strands that result in epithelium with a high resistance. 11 this correlates well with the absorptive function of epithelium located on the mucosal surface and the secretory function of crypt epithelium. structure of tight junctions also varies with the segment of intestine. for example, tight junctions have more strands in the ileum than in the jejunum, which is reflected by a higher transepithelial resistance in the ileum. 15 the stomach has four regions based on the type of mucosal lining (in an orad to aborad order): nonglandular stratified squamous epithelium, cardiac epithelium, proper gastric mucosa, and pyloric mucosa. 16 stratified squamous epithelium has distinct differences in terms of barrier function compared with the remainder of the gastrointestinal tract. this epithelium has baseline transepithelial resistance measurements of approximately 2000 to 3000 ω/cm 2 , which is an order of magnitude higher than the adjacent cardiac mucosa. 17, 18 thus the stratified squamous mucosa is exceptionally impermeable. this in effect is the only mechanism this mucosa has to defend itself against injury. the stratified squamous epithelium consists of four layers: the outer stratum corneum, stratum transitionale, stratum spinosum, and the basal stratum germinativum. however, not all layers contribute equally to barrier function, the barrier being composed mostly of interepithelial tight junctions in the stratum corneum and mucosubstances secreted by the stratum spinosum. 17, 19 the relative impermeability of stratified squamous mucosa can be demonstrated by the effects of hcl on this type of epithelium in vitro, which has little effect until it reaches a ph of 2.5 or lower. 18 thus although most of the literature on equine ulceration pertains to the effects of hcl and inhibitors of hcl secretion, [20] [21] [22] [23] other factors may be critical to the development of gastric ulcer disease. the site of hcl secretion (proper gastric mucosa) also is protected from so-called back-diffusion of h + by a high transepithelial electric resistance (compared with cardiac mucosa), but a number of other critical mechanisms also exist to prevent acid injury. the gastric mucosa secretes mucus and bicarbonate, which together form a hco 3 --containing gel that titrates acid before it reaches the lumen. 24, 25 the mucus layer is formed principally by glycoproteins (mucins) secreted by goblet cells but also includes other gastric secretions and sloughed epithelial cells. mucins consist of core peptides with a series of densely packed o-linked polysaccharide side chains that, once secreted, become hydrated and form a viscoelastic gel. however, the mucus layer does not form an absolute barrier to back-diffusion of acid. thus for acid that does back-diffuse into the gastric mucosa, epithelial na + /h + exchangers are capable of expelling h + once the cell reaches a critical ph. 25 recent studies have renewed interest in the protective mechanisms of mucus because of the discovery of a group of compounds secreted by goblet cells called trefoil peptides. the name of these peptides is derived from a highly conserved cloverleaf structural motif, which confers substantial resistance to degradation by proteases including pepsin. three members of this group are known, ps2, sp, and intestinal trefoil factor, the latter of which is secreted solely by goblet cells in the small and large intestine. ps2 and sp are secreted by goblet cells within the stomach and are believed to intercalate with mucus glycoproteins, possibly contributing to the barrier properties of mucus. 26 these peptides also play a critical role in repair of injured mucosa. an additional mucosal function that serves to reduce the level of injury is adaptive cytoprotection, wherein application of topical irritants to gastric mucosa results in subsequent protection of mucosa in response to repeated exposure to damaging agents. for example, pretreatment with 10% ethanol protected against mucosal damage in response to subsequent application of absolute ethanol, and this effect was abolished by treatment with the cyclooxygenase inhibitor indomethacin. 27 the cytoprotective effect of prostaglandins has been demonstrated directly in studies in which preadministration of prostaglandins protected gastric mucosa from damage by agents such as concentrated hcl and hypertonic saline. 28 prostaglandins appear to be cytoprotective in the stomach at doses less than those used to inhibit gastric acid secretion, ruling out a simple antacid mechanism. 29 although not fully characterized, cytoprotection has been attributed in part to prostaglandin-stimulated mucus production. 30 an associated beneficial effect of prostaglandins is the increased production of bicarbonate, which is trapped within mucus on the surface of the mucosa. 31, 32 interestingly, prostaglandin e 2 (pge 2 ) appears to lose its cytoprotective activity in the presence of the mucolytic agent n-acetylcysteine. attention also has been directed at enhanced mucosal blood flow as a potential mechanism for prostaglandin-mediated cytoprotection. for example, pretreatment with pgi 2 protected against ethanol-induced mucosal damage as a result of increased mucosal blood flow. 33 although pge 2 , which is also cytoprotective, does not increase blood flow, 34 it may prevent vascular stasis associated with irritant-induced vascular damage resulting from inhibition of neutrophil adherence to damaged endothelium. 35 sensory nerves also have been implicated in cytoprotective mechanisms. these nerves are distributed throughout gastrointestinal mucosa. as an example of their importance in mucosal cytoprotection, pretreatment of newborn rats with capsaicin (to which sensory nerves are sensitive) renders the mature rats more susceptible to gastric injury. 36 alternatively, use of a low dose of capsaicin, which stimulates rather than destroys sensory nerves, protects gastric mucosa against injurious agents. 37,38 sensory nerves contain neuropeptides such as calcitonin-gene-related peptide (cgrp) and substance p, which may play a protective role via vascular mechanisms. for instance, cgrp stimulates increased gastric blood flow, which is theorized to reduce injury in much the same way as prostaglandins do. in fact, recent studies suggest that the roles of prostaglandins and cgrp in gastric cytoprotection are intertwined intimately. in particular, pgi 2 is believed to sensitize sensory nerves following treatment with a mild irritant, with resultant increases in cgrp release and mucosal flow. similar studies have shown that antagonists of cgrp inhibit the cytoprotective action of pge 2 . 39 another neural mediator, nitric oxide, also has been implicated in adaptive cytoprotection. interestingly, nitric oxide has a number of actions that are similar to those of prostaglandins, including maintenance of mucosal blood flow. 40 regulation of barrier function in the intestine is not as well characterized as that of the stomach, although mechanisms of barrier function, including secretion of mucus and regulation of mucosal blood flow, are presumed to be similar. the proximal duodenum also has to protect itself from acid damage as it receives gastric contents, and this involves secretion of mucus and bicarbonate in much the same way as the stomach. one other mechanism that helps the stomach and the intestine to maintain mucosal barrier function is the speed with which the mucosa repairs. thus for a defect to develop in the mucosal barrier, injurious factors have to outpace mucosal recovery. such recovery initially involves epithelial migration across denuded regions of basement membrane (restitution), 26 a process so rapid that epithelial defects may be resurfaced within minutes. for example, in bile salt-injured colon, denuded surface mucosa was covered completely by restitution. 41 in the small intestine, villi greatly amplify the surface area of the mucosal luminal surface, which in turn takes far longer to resurface with restituting epithelium once it has become denuded. 42 however, intestinal villi are able to reduce the denuded surface area considerably by extensively contracting. 43 these mechanisms are described in detail under mechanisms of gastrointestinal mucosal repair. although the stratified squamous epithelium is relatively impermeable to hcl, a number of factors can enhance the damaging effects of hcl in this epithelium. in particular, bile salts and short-chain fatty acids are capable of breaking down the squamous epithelial barrier at an acid ph, thereby exposing deep layers to hcl, with subsequent development of ulceration. 18, 44 high concentrations of short-chain fatty acids normally exist within the equine stomach because of microbial fermentation. 17 these weak acids penetrate squamous mucosa and appear to damage na + transport activity principally located in the stratum germinativum. bile salts also may be present in the proximal stomach because of reflux from the duodenum. although such reflux has a high ph, bile salts appear to adhere to stratified squamous epithelium, becoming lipid soluble and triggering damage once the ph falls below 4. 45 diet and management (e.g., periods of fasting) also play crucial roles in the development of conditions conducive to gastric ulceration. typically, a ph gradation in horses exists from proximal to distal compartments of the stomach, with the lowest ph values in the distal stomach. 46 however, fasting disrupts this stratification such that low ph values may be recorded in the proximal stomach. 47 fasting conditions also increase the concentration of duodenal contents within the proximal stomach, particularly bile. 45 proper gastric mucosa is exposed to injurious agents, including pepsin, bile, and acid. parietal cells in the horse secrete acid constantly as an adaptation to near-continuous intake of roughage, 16 but the enterochromaffin-like cells within the proper gastric mucosa and g and d cells within the pyloric mucosa tightly regulate acid secretion. histamine released by enterochromaffin-like cells amplifies acid secretion and interacts with h 2 receptors on parietal cells and g cells, which release the prosecretory hormone gastrin. a combination of histamine and gastrin can have a synergistic effect on parietal cell gastric secretion, because these mediators have distinct receptors and second messengers. however, d cells are sensitive to an acidic environment and release somatostatin, which inhibits acid secretion. 48 nonetheless, gastric mucosa may be exposed to acid for prolonged periods of time, particularly in horses that are extensively meal fed and that do not have the benefit of roughage, which tends to buffer stomach contents. 45, 48 aside from peptic ulceration induced by combinations of acid and pepsin, research in human medicine has revealed the tremendous importance of helicobacter pylori in inducing ulceration. infection with this organism has the effect of raising gastric ph because of disruption of gastric glands and also induces an inflammatory reaction that causes damage. 49 however, little evidence to date indicates that this organism is involved in gastric ulcers in horses. in the absence of a known role for infectious agents in gastric ulceration in animals, ulceration likely develops from injurious factors similar to those found in the proximal stomach, including gastric acid and bile. however, some factors that are important to induction of squamous epithelial ulceration may not be important in development of proper gastric mucosal ulceration. for example, feed deprivation and intensive training reproducibly induce squamous epithelial ulceration in horses but have little effect on proper gastric mucosa in horses. 50 gastric acid likely plays a key role, whereas other factors such as nonsteroidal antiinflammatory drugs (nsaids) serve to reduce gastric defense mechanisms. in particular, inhibition of prostaglandin production reduces mucus and bicarbonate secretion while also reducing gastric mucosal blood flow. 51 some of the nsaids also have a topical irritant effect, although this appears to be of minor significance because the route of administration (oral or parenteral) seems to have little influence on development of ulceration. 52 the source of prostaglandins responsible for gastric protection originally was assumed to be cyclooxygenase 1 (cox-1), because this isoform is expressed constitutively in gastric mucosa, whereas cox-2 is not expressed in the stomach unless induced by inflammatory mediators. however, mice in which the cox-1 gene has been knocked out fail to develop spontaneous gastric lesions, 53 possibly because of compensatory increases in prostaglandin production by cox-2. 54 this concept agrees with recent data indicating that inhibition of both cox isoforms is required to induce gastric ulceration. 55 from a clinical perspective this data indicate that drugs selective for cox-1 or cox-2 may be less ulcerogenic in the horse. because cox-2 elaborates prostaglandins induced by inflammatory stimuli, selective inhibitors of cox-2 may be particularly useful because of their ability to serve as antiinflammatory agents that are less ulcerogenic. 56 the most notable cause of intestinal mucosal injury in horses, particularly those suffering from colic, is ischemia. initially, that a reduction in gastrointestinal blood supply leads to mucosal injury seems intuitive. however, the anatomy of the gastrointestinal tract and the differing structure of the intestinal mucosa at various anatomic locations have a significant influence on the extent of mucosal injury. furthermore, ischemic injury may be induced by several different mechanisms, including occlusion of arterial supply by a thrombus, strangulation of intestinal vasculature, and generalized reduction in blood flow associated with various shock states. in addition, a number of seemingly distinct mechanisms of intestinal injury, such as intestinal distention, also trigger mucosal injury via an ischemic mechanism. finally, reperfusion injury also may influence the extent of mucosal injury following an ischemic episode and has been proposed as a potential site of therapeutic intervention. 57, 58 thus understanding the mechanisms of ischemia-reperfusion injury is critical to developing an understanding of the severity of various clinical conditions and beginning to formulate a therapeutic approach to diseases characterized by this devastating form of injury. the intestinal circulation is capable of closely regulating blood flow during periods of low systemic perfusion pressure. 59, 60 in particular, local regulation of resistance vessels within the microvasculature is particularly prominent, whereby metabolic end products of adenosine triphosphate (atp) result in continued dilation of resistance vessels despite reductions in systemic arterial pressure. dilation results in continued perfusion of gastrointestinal tissues during the early stages of shock, while other organs such as skeletal muscle undergo massive shunting of blood resulting from increased constriction of resistance vessels. the reasons for these differences in regulation are not entirely clear but may relate to the high level of energy required to fuel the intestinal mucosa and the serious systemic effects of breaches in the mucosal barrier. however, as blood flow falls below a critical level, regulatory systems are no longer effective and oxygen uptake by the gastrointestinal tissue decreases, culminating in tissue damage. 59 the tip of the villus is the most susceptible region affected by hypoxia in the equine small intestine, largely because of the countercurrent exchange mechanism of blood flow in the small intestinal villus. 59 this countercurrent exchange mechanism is attributable to the vascular architecture, which consists of a central arteriole that courses up the core of the villus, arborizes at the tip, and is drained by venules coursing down the periphery of the villus. 61 as oxygenated blood flows into the central arteriole, oxygen tends to diffuse across to the adjacent venules, which flow in the opposite direction. this series of events takes place along the length of the villus, resulting in a tip of the villus that is hypoxic even under normal conditions. furthermore, reduced blood flow as occurs in shock exacerbates the countercurrent exchange of oxygen, and the tip becomes absolutely hypoxic. 59 this mechanism might explain why the small intestinal mucosa is more susceptible to ischemic injury, compared with the colon, which has no villi. for example, the duration required to produce severe morphologic damage to the equine colon is approximately 25% longer than in the small intestine. 62 intestinal mucosal epithelium is susceptible to hypoxia because of the high level of energy required to fuel the na + /k + -atpase that directly or indirectly regulates ion and nutrient flux. the first biochemical event to occur during hypoxia is a loss of oxidative phosphorylation. the resulting diminished atp concentration causes failure of the energy-dependent na + /k + -atpase resulting in accumulation of sodium, and subsequently intracellular water. the ph of the cytosol drops as lactic acid and inorganic phosphates accumulate from anaerobic glycolysis. the falling ph damages cell membranes, including lysosomal membranes, resulting in the release and activation of lysosomal enzymes into the cytosol, further damaging cellular membranes. damage to the cell membrane allows the accumulation of high concentrations of calcium in the cytosol, which activates calciumdependent degradative enzymes. 63 these events result in cytoplasmic blebbing of the basal membrane with subsequent detachment of cells from the underlying basement membrane. recent studies on epithelial injury during ischemia suggest that most epithelial cells undergo programmed cell death (apoptosis) during ischemia and reperfusion rather than necrosis, allowing retention of reusable components of irreversibly injured cells. 64 in one study, 80% of detached epithelium during small intestinal ischemia and reperfusion underwent apoptosis. 65 although the most obvious result of apoptosis is loss of surface epithelium, a number of cells on the lower portion of the villus (in the small intestine) and cells within the crypts also may undergo apoptosis that only may become evident up to 24 hours following reperfusion of ischemic tissue. 66 morphologic changes observed in ischemic-injured small intestinal mucosa follow a similar sequence regardless of whether ischemia alone or ischemia and reperfusion induce injury (table 13 .5-1). 67 initially, epithelium separates from the underlying basement membrane, forming a fluid-filled space termed grüenhagen's space ( figure 13 .5-1). the mechanism of fluid accumulation in this space is not understood entirely but may result from continued epithelial absorption of nacl and water before it has detached fully from neighboring epithelial cells. this fluid accumulation likely exacerbates epithelial separation from the basement membrane. subsequently, epithelium progressively sloughs from the tip of the villus toward the crypts, which are the last component of the intestinal mucosa to become injured. [68] [69] [70] injury of crypts likely relates to the vascular architecture, because crypts receive a blood supply separate from the vasculature involved in the villous countercurrent exchange mechanism. the early morphologic changes observed in the equine large colon during ischemia are different from those described in the equine small intestine because of the lack of intestinal villi. however, as might be expected, the more superficially located surface cells are sloughed before those in crypts. 62, 71 the orderly progression of tissue injury has been used by one group of investigators to predict accurately the survival of horses with large colon volvulus. the researchers took biopsies from the pelvic flexure, which has been shown previously to reflect mucosal changes along the length of the colon accurately, 72 and examined them histologically for the width of the crypts and intercrypt interstitial space. they expressed the latter measurements as a ratio of interstitium to crypt width (i:c) and defined nonviable colon as that which has greater than 60% loss of crypt and an i:c ratio greater than 3. using this methodology, researchers correctly predicted survival in 94% of horses. 73 because of the dramatic decline in strongylus vulgarisinduced colic, which was associated frequently with infarction of intestinal arterial blood supply, 74 most ischemic lesions are associated with strangulating obstruction. therefore considering mechanisms of ischemic injury in horses with naturally occurring strangulating lesions is important. the majority of experimental work has assessed complete ischemia (complete occlusion of the arterial blood supply) 62 or low-flow ischemia (during which arterial blood flow is reduced). 75, 76 however, during intestinal strangulation, a disparity between the degree of occlusion of the veins and arteries occurs whereby veins are occluded before arteries because of differences in compliance of vascular walls. thus strangulating lesions are typically hemorrhagic (hemorrhagic strangulating obstruction) as the arteries continue to supply blood to tissues that have little or no venous drainage. the result is ischemic injury, as previously outlined, but also a tremendous congestion of the tissues. such hemorrhagic congestion has two opposing effects: it disrupts tissue architecture, including the mucosa and its epithelium, and continues to provide oxygenated blood to the tissues during much of the ischemic episode. in contrast, when strangulation results in sudden cessation of arterial blood flow (ischemic strangulating obstruction), tissues appear pale, and the mucosa rapidly degenerates because of a complete lack of oxygenated blood. 70 because intestine that may look nonviable (dark red) may in fact have less mucosal injury than that of ischemic strangulated intestine. 77 an additional consideration in clinical strangulating obstruction is the degree of ischemia that intestinal distention may induce. for example, experimental distention (18 cm of h 2 o for 2 hours) and decompression (2 hours) of jejunum resulted in a significant increase in microvascular permeability and a significant decrease in tissue oxygenation similar to that which would be expected with low-flow ischemia. 78, 79 in particular, microscopic evaluation of vasculature revealed capillary endothelial cell damage and local edema formation. 80 this data suggest that distended intestine proximal to an obstruction may undergo mucosal injury despite its normal appearance. indeed, in one study, intraluminal pressures greater than 15 cm h 2 o in naturally occurring cases of colic correlated with a poor prognosis for survival. 81 although that reperfusion of ischemic tissues results in exacerbation of mucosal injury recently has been taken for granted, one should remember that mechanisms underlying intestinal reperfusion injury have been defined largely in laboratory animals under specific conditions. [82] [83] [84] [85] [86] however, studies on reperfusion injury in horses have had some conflicting results. 68, 76, 87 the conflict may be attributable to the way in which the studies have been performed. in particular, the type of ischemia used in most laboratory animal studies has been low-flow ischemia (in which the blood flow typically is reduced to 20% of baseline flow), whereas studies in horses have used a number of different ischemic models, including various types of strangulating obstruction. although strangulating obstruction is of great clinical relevance, this type of ischemic insult is less likely to develop reperfusion injury. 68, 88, 89 conversely, low-flow ischemia appears to prime tissues for subsequent injury once the tissue is reperfused, and considerable evidence supports the presence of reperfusion injury in horses following low-flow ischemia. 75, 76, 80, 90 nonetheless, lowflow ischemia may not be a common clinical entity. in addition to the type of ischemia, other factors are involved in priming tissues for reperfusion injury, including species and anatomic-specific variation in oxidant enzyme and neutrophil levels ( table 13 .5-2). for example, the foal appears to have low levels of small intestinal xanthine oxidase, an enzyme that has been shown to play a critical role in triggering reperfusion injury in laboratory animals, 84, 85, 91 whereas adult levels are much greater, particularly in the proximal small intestine. 92 in addition, horses appear to have low numbers of resident neutrophils in the intestinal mucosa, 93 and this population of neutrophils (rather than those recruited from the circulation) appears to be most critical for induction of reperfusion injury. 86 however, studies demonstrating reperfusion injury in the equine colon following low-flow ischemia have shown significant accumulation of neutrophils within the mucosa. 75 therefore a complete understanding of mechanisms of neutrophilic infiltration and the mechanisms whereby they damage tissue requires further study. reperfusion injury is initiated during ischemia when the enzyme xanthine dehydrogenase is converted to xanthine oxidase and when its substrate, hypoxanthine, accumulates simultaneously because of atp use ( figure 13 .5-2). 57, 94 however, little xanthine oxidase activity occurs during ischemia, because oxygen is required as an electron acceptor. during reperfusion, xanthine oxidase rapidly degrades hypoxanthine in the presence of oxygen, producing the superoxide radical as a by-product. 57 the superoxide radical contributes to oxidative tissue damage and, most importantly, activates neutrophil chemoattractants. 84, 85 thus inhibition of xanthine oxidase in feline studies of intestinal ischemiareperfusion injury prevents infiltration of neutrophils and subsequent mucosal injury. 83, 84 however, inhibition of xanthine oxidase has had no effect on ischemiareperfusion injury in equine small intestine 87 and colon, 95 suggesting that reperfusion injury is simply a continuation of injury initiated during ischemia, as suggested in some equine studies, 63 or that the classic reperfusion injury pathway is activated by alternate sources of reactive oxygen metabolites. the latter has been suggested by studies in feline models of ischemia-reperfusion injury in which the source of a significant proportion of reactive oxygen metabolites is unknown and is independent of xanthine oxidase and neutrophils. 83 a veterinary review of the pathogenesis of intestinal reperfusion injury in the horse suggested the concept of a therapeutic window wherein treatment of reperfusion injury would be beneficial. 57 the basis of this concept is that certain conditions exist under which ischemic injury is minimal and that tissues are damaged severely during reperfusion. 88 thus under conditions of low-flow ischemia, little injury is demonstrated during 3 hours of ischemia, but remarkable injury occurs during 1 hour of reperfusion. [83] [84] [85] however, a therapeutic window may not exist under conditions of strangulating obstruction in which severe injury occurs during ischemia and minimal injury occurs during reperfusion. 96 this in turn greatly reduces clinicians' ability to ameliorate ischemiareperfusion injury with treatments such as antioxidants at the time of reperfusion. mechanisms of gastric repair depend greatly on the extent of injury. for instance, superficial erosions can be covered rapidly by migration of epithelium adjacent to the wound; a process termed epithelial restitution. however, ulceration (full-thickness disruption of mucosa and penetration of the muscularis mucosa) requires repair of submucosal vasculature and extracellular matrix. the formation of granulation tissue initiates repair and supplies connective tissue elements and microvasculature necessary for mucosal reconstruction. connective tissue elements include proliferating fibroblasts that accompany newly produced capillaries that form from proliferating endothelium. recent studies indicate that nitric oxide is critical to both processes, 40, 97 which likely explains the reparative properties of nitric oxide in the stomach. 98 once an adequate granulation bed has formed, newly proliferated epithelium at the edge of the wound begins to migrate across the wound. in addition, gastric glands at the base of the ulcer begin to bud and migrate across the granulation bed in a tubular fashion. 99 repairing epithelium expresses epidermal growth factor, which appears to facilitate these processes. 100 in addition, a mucoid cap facilitates these events and retains reparative factors and serum adjacent to the wound bed. 51 once the ulcer crater has been filled with granulation tissue and the wound has been reepithelialized, the subepithelial tissue remodels by altering the type and amount of collagen. despite the remodeling process, ulcers tend to recur at sites of previous ulceration, and the concern is that this remodeling can result in excessive deposition of collagen and fibrosis. 26 reparative mechanisms are similar in the intestine, except that in the small intestine, mucosal villi contribute to mucosal repair. once intestinal epithelium is disrupted, two events occur almost immediately to reduce the size of the denuded portion of the villus: contraction of the villus and epithelial restitution ( figure 13 .5-3). for example, in porcine ileum subjected to 2 hours of ischemia, villi were 60% of their former height and 50% of the denuded villous surface area was covered in flattened epithelium within 6 hours. 42 enteric nerves appear to regulate villous contraction, because inhibition of enteric nerve conduction prevents villous shortening following injury. the contractile component of the villus is a network of myofibroblasts distributed throughout the lamina propria of the villus and along the central lacteal. inhibition of villous contraction results in retarded epithelial repair because of the larger denuded surface that remains to be covered by migrating epithelium compared with similarly injured villi that have contracted. 43 pge 2 also has been implicated in regulating villous contraction, because application of pge 2 resulted in villous contraction when perfused through normal rat ileum. 101 as villi contract, assuming the basement membrane is intact, epithelium from the margins of the wound migrates centripetally to resurface toward the tip of the villus. 43 the process of restitution is similar in denuded colonic mucosa, except that it may proceed more rapidly because of the lack of villi. 41 epithelial restitution is solely a migratory event that does not depend on provision of new enterocytes by proliferation. cellular migration is initiated by extension of cellular lamellipodia that receive signals from the basement membrane via integrins. intracellular signaling converges on the actin cytoskeleton, which is responsible for movement of lamellipodia. specific components of the basement membrane appear to be critical to the migratory process. for example, application of antibodies to collagen types iii and iv, which are important components of intestinal mucosal basement membrane, impeded epithelial restitution. 102, 103 other elements of the basement membrane, including proteoglycans, hyaluronic acid and noncollagenous proteins such as fibronectin and laminin also may provide important signals. 104 these subepithelial matrix components that facilitate restitution may form the basis for clinical treatments designed to speed up the repair process, analogous to administration of matrix components to horses with articular cartilage damage. although epithelial restitution results in gross closure of previously denuded regions of gastrointestinal mucosa, closure of interepithelial spaces ultimately is required to restore normal epithelial barrier resistance. because the tight junction is principally responsible for regulating the permeability of the interepithelial space, repair and closure of this structure likely is critical to restore intestinal barrier function. recent research indicates that prostaglandins play a vital role in recovery of tight junction resistance, 105 indicating that administration of nonselective cox inhibitors to horses with colic, particularly those recovering from strangulating obstruction, may be deleterious. therefore judicious use of nsaids is appropriate until more selective drugs that allow continued production of reparative prostaglandins are available for use in horse. 56 after restoration of the epithelial barrier, the epithelium must reestablish normal mucosal architecture to allow normal gut absorptive and digestive function. in porcine ileum subjected to 2 hours of ischemia, the epithelial barrier was restored within 18 hours, but villi were contracted and covered in epithelium with a squamous appearance. restoration of normal villous architecture required another 4 days. 42 newly proliferated crypt epithelium replaces the flattened villous epithelium that characterizes restitution. under normal circumstances the dividing stem cells, of which the base of each mucosal crypt has approximately four, form new enterocytes. newly divided enterocytes migrate from the crypt onto the villus. 106 during migration, enterocytes differentiate and acquire specific absorptive and digestive functions. fully differentiated enterocytes reside on the upper third of the villus for 2 to 3 days and then are sloughed into the intestinal lumen. 107 this process accelerates during mucosal repair and requires increased proliferative rates. a variety of locally available gut-derived factors, including luminal nutrients, polyamines, and growth factors, may stimulate increased proliferation within 12 to 18 hours. 42 the return of the normal leaflike shape of the villus occurs following the appearance of normal columnar epithelium. although prostaglandins have been implicated in mucosal cytoprotective function, few studies have assessed their importance in mucosal repair. one study implicated prostaglandins in growth factor-stimulated restitution, 108 but a more prominent role of prostaglandins in mucosal repair is their ability to close interepithelial tight junctions. 105, 109, 110 for instance, ischemic-injured small intestine rapidly recovers barrier function (as measured in vitro as transepithelial resistance) in the presence of pgi 2 and pge 2 , despite the fact that these prostanoids had little effect on villous contraction and epithelial restitution. however, electron microscopic examination of tissues reveals dilation of tight junctions in tissues treated with nsaids, 110 whereas those additionally treated with prostaglandins have closely apposed tight junctions (figures 13.5-3 and 13.5-4). prostaglandins stimulate closure of tight junctions via the second messengers cyclic adenosine monophosphate and ca 2+ , 105 which interestingly were among the first mediators found to modulate tight junction permeability. 111, 112 such tight junction closure is of importance to patients with intestinal injury that are treated with nsaids, because reduced prostaglandin levels may result in increased intestinal permeability. for example, in a study on ischemic-injured porcine ileum, treatment with the nsaid indomethacin resulted in a significant increase in intestinal permeability to inulin and lipopolysaccharide compared with tissues that were treated additionally with pgi 2 and pge 2 . 105 section 13.5 pathophysiology of mucosal injury and repair a b figure 13 .5-4 ultrastructural appearance of repairing ischemic-injured mucosa. a, restituting epithelium 2 hours following a 1-hour ischemic episode in the presence of the nonselective cyclooxygenase inhibitor indomethacin. dilation of the interepithelial space and the apical tight junction (arrows) correlates with a leaky intestinal barrier, b, similar restituting epithelium had been treated additionally with prostaglandins e 2 and i 2 . the close apposition of the tight junction (arrows) and the interepithelial space correlate with normalization of intestinal barrier function. 1-cm bar = 6 µm. the process of restitution absolutely depends on a group of compounds called polyamines. 113, 114 the rate-limiting enzyme in the formation of the polyamines spermine, spermidine, and putrescine is ornithine decarboxylase. in rats with stress-induced duodenal ulcers, systemic administration of the ornithine decarboxylase inhibitor α-difluoromethylornithine significantly reduced polyamine levels and greatly reduced epithelial restitution. furthermore, intragastric treatment of these same rats with putrescine, spermidine, and spermine prevented the delayed mucosal repair induced by α-difluoromethylornithine. 113 interestingly, gastric tissue levels of ornithine decarboxylase increased in rats with stress-induced gastric ulcers, suggesting that tissue injury enhances polyamine production, which may contribute to the normal rapid rate of epithelial restitution. 115 the mechanisms whereby polyamines stimulate epithelial restitution are not clear. mccormack, wang, viar, et al. hypothesized that polyamines increase transglutaminase activity, an enzyme that catalyzes the cross-linking of cytoskeletal and basement membrane proteins. 116 further investigation of the role of polyamines in iec-6 cell migration showed that depletion of polyamines resulted in disruption of the cytoskeleton and reduced the physical extension of lamellipodia. 117 more recent studies have clarified this pathway. in particular, polyamines have been shown to regulate cytoskeletal cellular migration via activation of the small guanosine triphosphatase-rho-a by elevating intracellular ca 2+ levels. these elevations in ca 2+ result from polyamine regulation of expression of voltagegated k + channels and altered membrane electric potential. 118 polyamines also play a role in the normal physiologic regulation of crypt cell proliferation and differentiation. 119,120 polyamines are produced by fully differentiated enterocytes at the tip of the villus and may reach the crypt within sloughed luminal epithelium or via local villous circulation. 121 following intestinal injury, polyamines appear to stimulate enhanced proliferation by increasing the expression of protooncogenes, which control the cell cycle. 122 the mechanism whereby polyamines influence gene expression likely relates to the cationic nature of these compounds, which may influence the tertiary structure of negatively charged dna and rna. 113 locally produced growth factors-including epidermal growth factor (egf), transforming growth factor α (tgf-α), tgf-β, and hepatocyte growth factor-have the ability to modulate mucosal recovery. the most important of these growth factors in early mucosal repair events is tgf-β, which is a potent stimulus of epithelial restitution and modulator of the extracellular matrix. 26 neutralization of tgf-β retards epithelial migration in vitro, and tgf-β apparently may serve as a point of convergence for mediators of restitution, because neutralizing tgf-β also inhibits the effects of other peptides. however, tgf-β paradoxically inhibits epithelial proliferation, thereby reducing the supply of new enterocytes for mucosal repair. conversely, egf, produced by the salivary glands and duodenal brunner's glands, and the related tgf-α, produced by small intestinal enterocytes, are potent stimulants of enterocyte proliferation. these growth factors share approximately 30% of their amino acid structure, bind to the same receptor on the basolateral surface of enterocytes, and are not related to tgf-β. 123 the physiologic role of egf is difficult to discern because it is present in the intestinal lumen, with no apparent access to its basally located receptor. however, egf has been proposed to act as a "surveillance agent" that gains access to its receptor during epithelial injury (when the egf receptor likely would be exposed) to stimulate proliferation. 124 tgf-α presumably has a similar role, but it is present in greater concentrations in the small intestine because it is produced by differentiated villous enterocytes. the mature peptide is cleaved from the extracellular component of the transmembrane tgf-α precursor and released into the lumen. 123 another group of proreparative peptides produced within the gastrointestinal tract are the trefoil peptides. under physiologic conditions, trefoil peptides are secreted by mucus-producing cells at distinct anatomic sites. for example, gastric epithelium produces the trefoil peptide ps2, whereas the small and large intestine mucosa produce intestinal trefoil peptide. 125 however, any of the trefoil peptides may be upregulated within repairing epithelium regardless of anatomic site. 26, 126 in addition, trefoil peptides have the ability to induce their own expression, amplifying the level of these reparative factors at sites of mucosal repair. 127 trefoil peptides are the most potent stimulants of epithelial migration in vitro, and their effects are independent of growth factors, including tgf-β. 128 however, recent evidence suggests that egf receptor activation is required for induction of ps2 and another of the trefoil peptides, termed spasmolytic peptide, in gastric epithelium in vitro. the importance of trefoil peptides to the mucosal repair response in vivo is illustrated by gene knockout studies, in which mice deficient in intestinal trefoil factor have greatly reduced ability to repair intestinal injury. 129 in fact, detergent-induced mucosal injury was lethal because of a lack of restitution compared with wild-type mice that fully recovered from similar mucosal injury. the fact that administration of intestinal trefoil factor restored restitution has important therapeutic implications. the mechanism whereby trefoil peptides stimulate epithelial migration is yet to be characterized fully but appears to involve translocation of the adherens junction protein e-cadherin, thereby allowing cells to become untethered from neighboring cells. 26 the principal metabolic fuel of enterocytes is glutamine and of colonocytes, butyrate. however, recent studies suggest that glutamine and butyrate have more specific proliferative actions aside from their role as nutrients. for example, in the piglet ipec-j2 enterocyte cell line, glutamine enhanced gene transcription by increasing mitogen-activated protein kinase activity. 130, 131 similarly, butyrate stimulated mucosal growth following colonic infusion in the rat. 132 because of such growth-promoting actions, glutamine was shown to prevent intestinal mucosal atrophy and dysfunction that accompanies starvation 133, 134 and long-term total parental nutrition. 135, 136 additionally, glutamine improves function of transplanted small intestine 137, 138 and protects intestinal mucosa from injury if administered before chemotherapy 139 and radiation therapy. 140, 141 intestinal nutrients also may synergize with other proliferative agents. for example, administration of glutamine and tgf-α to porcine ileum that had been subjected to 2 hours of ischemia resulted in a synergistic increase in mitogen-activated protein kinase activity, enterocyte proliferation, and villous surface area. 42 although concern has arisen that such early return to normal surface area may result in dysfunctional mucosal digestive and absorptive function because of resurfacing denuded mucosa with immature epithelium, nutrients and growth factors also appear to promote early differentiation. in the case of glutamine and tgf-α restoration of postischemic small intestine, rapid recovery of digestive enzymes also was documented. 142 effective gastrointestinal motility involves a complex interaction between the enteric nervous system, muscular wall, and luminal contents. additional factors that influence the net transit of digesta include gravity, the volume and viscosity of the contents, and pressure gradients created by simultaneous contraction and relaxation of adjacent segments of bowel. casual use of the term intestinal motility in veterinary medicine often underestimates the complexity of the processes involved in the transit of intestinal contents. this is particularly true when the term is used to describe the frequency and or intensity of intestinal sounds, or borborygmi. the existence of borborygmi does not always equate with progressive movement of intestinal contents. disruption to normal motility occurs commonly in horses for a variety of reasons. examples of diseases in which altered motility may be present include gastroduodenal ulceration, intraluminal obstruction or impaction, excessive wall distention, strangulating obstructions, peritonitis, and inflammatory bowel diseases such as duodenitis proximal jejunits or colitis. ineffective intestinal motility is also a feature of several neonatal diseases, including prematurity, systemic sepsis, and perinatal asphyxia. certain parasitic infections, electrolyte derangements, and endotoxemia can modify digesta transit in horses of all ages. general anesthesia and specific sedatives, such as xylazine, romifidine, or detomidine, also disturb motility. the inhibition of propulsive bowel activity usually is referred to as ileus. ileus is ascribed most frequently to the condition that occurs after laparotomy and is termed simple or uncomplicated postoperative ileus (poi). the term complicated or paralytic ileus describes intestinal motility disturbed for longer periods after surgery. poi in horses is associated most commonly with surgery of the small intestine, particularly after resection and anastomosis, 1,2 is a common complication of small intestinal surgery, and can have a negative effect on short-term postoperative survival. 3, 4 motility dysfunction likely is present in all horses after laparotomy, but many are affected subclinically and require minimal or no specific intervention. in symptomatic animals, clinical signs are apparent shortly after recovery and include colic, tachycardia, dehydration, decreased borborygmi and fecal output, and sequestration of fluid within the stomach. rectal examination and ultrasound reveal small intestinal distention with rare or absent wall movement. the severity and duration of intestinal stasis varies, lasting from minutes to days. a specific motility disorder involving the cecum or ileocecocolic region occurs sporadically in horses. [5] [6] [7] the condition most commonly occurs after general anesthesia and extraabdominal surgery, particularly orthopedic and upper airway procedures, and therefore often is categorized as a form of poi. anecdotally, horses at greatest risk are young male performance animals. other cases occur spontaneously, often in animals with painful primary conditions such as uveitis or septic tenosynovitis. the syndrome is frustrating in that clinical signs are often subtle unless cecal perforation has occurred. in horses with a cecal emptying defect after anesthesia, overt signs are usually apparent 3 to 5 days after the procedure. the earliest detectable signs include depression and a reduction in feed intake and fecal output. ineffective emptying results in overfilling of the cecum with moist contents, which is manifest by signs of mild to moderate colic. if the condition is recognized late or untreated, the cecum may rupture and result in fatal peritonitis. the inherent rhythmicity of electric activity in the intestine is controlled by the interstitial cells of cajal, specialized cells that are electrically coupled to myocytes via gap junctions. 8 these cells are responsible for generating and propagating slow-wave activity and may be critically involved in a range of motility disorders. the enteric nervous system primarily controls and coordinates intestinal contraction. a combination of central and autonomic innervation influences events, but contraction does not require external neural input. the parasympathetic supply to the gastrointestinal tract is via the vagus and pelvic nerves, and the sympathetic supply is through postganglionic fibers of the cranial and caudal mesenteric plexuses. a complex network of interneurons within each plexus integrates and amplifies neural input; the intensity and frequency of resultant smooth muscle contractions are proportional to the amount of sympathetic and parasympathetic input. additional binding sites for a number of other endogenous chemicals, including dopamine, motilin, and serotonin exist within the enteric nervous system and on smooth muscle cells. 9 acetylcholine is the dominant excitatory neurotransmitter in the gastrointestinal tract and exerts its action through muscurinic type 2 receptors on smooth muscle cells. sympathetic fibers innervating the gastrointestinal tract are adrenergic, postganglionic fibers with cell bodies located in the prevertebral ganglia. activation of α 2adrenergic receptors on cholinergic neurons within enteric ganglia inhibits the release of acetylcholine and therefore reduces intestinal contraction. β 1 -, β 2 -, and β-atypical receptors are directly inhibitory to the intestinal smooth muscle. 10 inhibitory nonadrenergic, noncholinergic neurotransmitters include adenosine triphosphate, vasoactive intestinal peptide, and nitric oxide. 11, 12 these neurotransmitters are critical for mediating descending inhibition during peristalsis and receptive relaxation. substance p is a nonadrenergic, noncholinergic neurotransmitter that may be involved in contraction of the large colon. 13, 14 the rate and force of intestinal contractions along the small intestine and large colon of the horse are important determinants of intestinal motility; of even greater importance to the net propulsion of digesta are the cyclical patterns of contractile activity. these patterns are known as the small intestinal and colonic migrating motility (or myoelectric) complexes (mmcs). 15, 16 the colonic complex usually originates in the right ventral colon and variably traverses the ascending and descending colons. many of these complexes are related temporally to a specialized motility event of the ileum, the migrating action potential complex. local inflammation within the intestinal muscularis and inhibitory neural events are important initiators of intestinal ileus. 17, 18 intestinal inflammation not only is important in primary intestinal diseases in horses, such as duodenitis-proximal jejunitis and colitis but also is induced after simple intestinal handling during laparotomy. experimental data from other species suggests that handling of the small or large intestine at the time of surgery activates resident macrophages with resultant increased expression of p-selectin and intercellular adhesion molecule 1 on endothelial cells within the vasculature of the muscularis. the upregulation of associated ligands on leukocytes leads to sequential "sticking and rolling," followed by neutrophil migration into the interstitium. the subsequent release of neutrophil products interferes with cell signaling and results in reduced intensity of smooth muscle contraction. furthermore, the inflamed intestine fails to contract normally in response to putative prokinetic agents. another key factor in the development of intestinal stasis after inflammation is the local overproduction of nitric oxide caused by the upregulation of inducible nitric oxide synthase (inos) by resident macrophages. nitric oxide is a key inhibitory neurotransmitter of the nonadrenergic, noncholinergic system. 12 nitric oxide synthase inhibition has been a pharmacologic target in the treatment of experimental ileus. the inhibitory effects of α 2 -agonists such as xylazine and detomidine on cecal and large colon motility are well described. [19] [20] [21] [22] [23] [24] intravenously administered xylazine inhibits cecal and large colon motility for 20 to 30 minutes without seriously disrupting small intestinal myoelectric activity, and detomidine can reduce large intestinal myoelectric activity for up to 3 hours. the α 2 -antagonist yohimbine has a weak but positive effect on cecal emptying in normal ponies, suggesting that normal motility is under constant α 2 -adrenergic tone. 24 atropine is a postganglionic blocking agent that binds to muscarinic receptors. when administered at 0.04 mg/kg, atropine inhibits individual small intestinal, cecal, and colonic contractions for about 120 minutes but supresses small intestinal and colonic migrating complexes for up to 8 hours. 25 neural reflexes also may mediate inhibition of motility associated with peritoneal inflammation. 26, 27 the afferent segment is composed partly of capsaicin-sensitive visceral afferent c fibers that terminate in the dorsal horn of the spinal cord, where they can activate inhibitory sympathetic fibers or synapse directly on the sympathetic ganglia. consequently, the efferent limb of the reflex expresses increased sympathetic outflow, primarily mediated through stimulation of α 2 -adrenoreceptors, and inhibition of acetylcholine release, which provides the rationale for α 2 -blockade in treating ileus. intraluminal infusion of capsaicin before abdominal surgery ameliorated the severity of poi in experimental rats. this finding highlights the importance of visceral afferent fibers in the development of poi. 28 ileus also can occur in association with intestinal obstruction or displacement. mild to moderate distention of the bowel, such as that occurring in the early stages of an intraluminal obstruction, evokes an increase in local contractile activity. 29, 30 excessive distention results in inhibition of motility within the distended segment of bowel. intestinal stasis is not always detrimental and under certain conditions may be protective. endotoxemia is a clinical feature of many diseases of the equine gastrointestinal tract, and endotoxins independently can exert a negative effect on intestinal motility and transit. 31 a variety of mediators likely are involved, but activation of α 2 -adrenoreceptors and production of prostanoids appear to be important, for pretreatment with yohimbine or nonsteroidal antiinflammatory drugs (nsaids; phenylbutazone or flunixin), respectively, ameliorates the inhibitory effects of experimental endotoxin infusion. 32, 33 endotoxin infusion induced an inflammatory response in the intestine of rats that mimicked the response induced by handling during laparotomy. 34 the similarity of the responses were highlighted in a recent study that demonstrated that prior exposure of the muscularis to endotoxin protected the intestine from the effects of manipulation. 35 the pathophysiology of cecal emptying defect is not known. this syndrome may best mimic poi in human beings and generally is considered a large intestinal disorder. an important difference in horses is that laparotomy is a rare predisposing factor, and most cases occur in horses undergoing routine extraabdominal surgical procedures. general anesthesia itself is a potent inhibitor of gastrointestinal motility in horses, but these effects are short-lived and reversible within hours of anesthetic withdrawal. 15 the return of normal motility in horses after experimental ileus was most delayed in the cecum, suggesting that this may be a common site of ileus in horses. 36 a link between routine postoperative medications, such as phenylbutazone and aminoglycoside antibiotics, has been suspected but not established. an inhibitory effect of nsaids on large colon contractility has been demonstrated using in vitro techniques. 37 primary sympathetic overstimulation could be involved, for many of the affected animals are young, male horses or animals with painful diseases. the duration of surgery influences the development of small intestinal poi, but not cecal emptying dysfunction. 7,38 technique may have a weak influence on small intestinal poi after jejunojejunostomy. the duration of intestinal ileus was shorter in animals that received a sideto-side stapled anastomosis than those that had a hand sewn end-to-end procedure. 3 the duration of ileus after stapled end-to-end anastomosis was not different from that after either procedure. reported risk factors for the development of poi in horses include age (>10 years), small intestinal resection and anastomosis, breed (arabians had a greatest risk than other breeds), and duration of surgery. 38 interestingly, performing a pelvic flexure enterotomy and emptying the colon had a protective effect against poi. the diagnosis of ileus is based on history and physical examination findings. important tests include determination of pulse rate and rhythm, auscultation and percussion of the abdomen, rectal palpation, and passage of a nasogastric tube. a complete blood count with fibrinogen estimation and cytologic analysis of peritoneal fluid may improve the accuracy of diagnosis. affected animals may be colicky because of accumulation of fluid in the upper gastrointestinal tract (classical poi) or cecal contents (cecal emptying defect). decompression of the stomach is important diagnostically and therapeutically in horses with poi after small intestinal surgery. failure to relieve pain with gastric decompression could point toward mechanical obstruction, severe inflammation of the intestine, or peritonitis. most animals with ileus are depressed and have reduced fecal output and intestinal borborygmi. one should interpret intestinal sounds with caution, however, because the presence of borborygmi does not always equate to progressive intestinal motility and merely may reflect local, nonpropagated contractions. rectal palpation findings in cases of persistent poi or duodenitis-proximal jejunitis are usually nonspecific but may reveal dilated, fluid-filled loops of small intestine. the clinician occasionally can palpate roughened peritoneal surfaces if peritonitis is present. one can palpate cecal distention with digesta in horses with advanced cecal dysfunction. distinguishing functional ileus from mechanical obstruction is important and can be difficult, but horses with mechanical obstruction typically have sustained high volumes of gastric reflux that vary little over time. the management of intestinal ileus depends on the segment of gastrointestinal tract involved. therapy for ileus of the proximal gastrointestinal tract involves a combination of gastric decompression, fluid and electrolyte therapy, and antiinflammatory drug therapy. electrolyte therapy is critical, particularly for maintaining adequate extracellular concentrations of potassium, calcium, and magnesium. calculation of the volume of fluid to be administered should include maintenance requirements (40 to 60 ml/kg/day) plus an estimate of losses, especially those lost through gastric decompression. one should consider parenteral provision of calories when feed has been withheld for more than 96 hours, particularly after the horse has had surgery. a combination of amino acids and dextrose with or without lipids effectively provides these calories. hand walking also may provide some benefit to these animals but is not likely to have a direct effect on intestinal motility. one should avoid drugs that may impair normal intestinal motility, including the anticholinergics such as atropine and opiate receptor agonists such as morphine and meperidine. butorphanol appears to have little or no adverse effect on small or large intestinal motility. 39, 40 one should use α 2 -agonists sparingly because of their inhibitory effects on large intestinal motility. fluid therapy is the key component in managing cecal emptying defect, usually in combination with lubricants or laxatives, such as mineral oil or magnesium sulfate, and with careful use of antiinflammatory drugs. horses with primary cecal impaction or impaction caused by an emptying defect frequently require surgery to prevent fatal rupture. the surgical management of these cases is controversial and may include typhlotomy alone, typhlotomy with a bypass procedure such as ileocolic or jejunocolic anastomosis, or a bypass without typhlotomy. 41 most horses that undergo simple typhlotomy have an uneventful recovery, 42 although a small number experience impaction again and require a second laparotomy. experimental and anecdotal evidence provides a strong rationale for using antiinflammatory drugs to prevent and treat gastrointestinal ileus, particularly in animals that may have endotoxemia. 43 flunixin meglumine is used widely in equine practice as an analgesic and antiinflammatory agent, and it ameliorates many of the adverse systemic effects of endotoxin, particularly those on the cardiovascular system. a potential negative effect of nsaids on large intestinal contractility has been suggested. broad-spectrum antimicrobials are indicated when one suspects sepsis or for the compromised immune system, as in cases of moderate to severe endotoxemia. theoretical concerns have been raised regarding the use of aminoglycoside antibiotics in animals with ileus. high concentrations of aminoglycoside antimicrobials inhibited intestinal contractions in exposed sections of intestine in vitro, but this inhibitory effect is unlikely to occur at clinically relevant doses. 44 motility-enhancing drugs have been advocated to treat gastrointestinal ileus. unfortunately, information directly pertinent to horses is limited and must be extrapolated cautiously from that of other species because of the differences in intestinal anatomy and physiology. prokinetic drugs potentially can shorten the length of hospitalization, thereby reducing the cost of treatment and the number of potential complications such as weight loss, thrombophlebitis, and laminitis. experimental evidence indicates that prokinetic drugs can minimize the development of postoperative abdominal adhesions. 45 most prokinetic drugs require a healthy gut wall to enhance intestinal contraction. therefore one should not assume that many of these drugs would be effective in the presence of an inflammatory injury such as that which can occur after intestinal manipulation at surgery or that associated with duodenitis-proximal jejunitis. bethanechol is a parasympathomimetic agent that acts at the level of the myenteric plexus and directly on intestinal smooth cells through muscarinic receptors. bethanechol is a synthetic ester of acetylcholine and is not degraded by anticholinesterase. bethanechol has cholinergic side effects, including abdominal discomfort, sweating, and salivation, although these are minimal when the drug is administered at 0.025 mg/kg body mass subcutaneously or orally. bethanechol has efficacy in diseases that involve abnormal gastric emptying and delayed small intestinal transit and has been shown to increase gastric contractility and hasten the emptying of liquid and solid phase markers from the stomach of normal horses. [46] [47] bethanechol also increases the strength and duration of wall contractions in the cecum and right ventral colon and consequently speeds up cecal emptying. neostigmine increases receptor levels of acetylcholine by inhibiting cholinesterase. the drug (0.022 to 0.025 mg/kg intravenously) promotes cecal and colonic contractile activity and hastens the emptying of radiolabeled markers from the cecum. 24 neostigmine has been used to manage small intestinal ileus, but it significantly delayed the emptying of 6-mm beads from the stomach of normal adult horses. 48 metoclopramide acts principally as a 5-hydroxytryptamine 4-receptor (5ht-4) agonist and 5ht-3-receptor antagonist. in contrast to newer generation benzamides, metoclopramide is also an antagonist at dopamine 1 (da 1 ) and 2 (da 2 ) receptors. antagonism of prejunctional da 2 receptors facilitates acetylcholine release and smooth muscle contraction. metoclopramide crosses the blood-brain barrier, where its antagonist properties on central da 2 receptors can result in extrapyramidal signs, including seizure. these signs were responsible for poor acceptance of the drug in equine practice. most investigators have failed to demonstrate significant effects of metoclopramide in experimental animals, but constant intravenous infusion (0.04 mg/kg/hr) in a population of postoperative horses significantly decreased the volume and duration of gastric reflux over control and intermittent drug infusion groups. 49 infusion was well tolerated and appeared to be superior to intermittent infusion or no treatment at all. cisapride is a second-generation benzamide that acts as a 5ht-4 agonist and 5ht-3 receptor antagonist but is without antidopaminergic action. stimulation of 5ht-4 receptors within the enteric nervous system enhances release of acetylcholine from the myenteric plexus. several reports suggest the efficacy of cisapride in managing intestinal disease in horses, including the resolution of persistent large colon impaction, treatment of equine grass sickness, and as a preventative for poi in horses after small intestinal surgery (0.1 mg/kg body mass intramuscularly during the postoperative period). [50] [51] [52] [53] the horse erratically absorbs tablets administered rectally, but a method for preparing a parenteral form of the drug from tablets has been described. 54 cisapride has the potential to cause adverse cardiac side effects mediated through blockage of the rapid component of the delayed rectifier potassium current that include lengthening of the qt interval and development of torsades de pointes, a potentially fatal arrhythmia. these adverse effects have resulted in withdrawal of the drug in the united states. domperidone acts as a competitive antagonist at peripheral da 2 receptors. the drug is a therapeutic agent (1.1 mg/kg/day) for mares grazing endophyte-infected tall fescue, principally because of drug-enhanced prolactin release. the potential prokinetic effects of domperidone have not been studied extensively in horses, but a modest efficacy of domperidone (0.2 mg/kg intravenously) has been demonstrated in experimental ileus in two ponies. erythromycin is a direct motilin receptor agonist on smooth muscle cells and also may act within the enteric nervous system to facilitate the release of acetylcholine and motilin. erythromycin enhances gastric emptying in normal horses but has a more pronounced effect on the hindgut. 47, 55 erythromycin lactobionate (1.0 mg/kg intravenously) hastens cecal emptying in normal animals and induces colonic mmc-like activity across the colon. administration often is associated with defecation and abdominal discomfort. the drug may help prevent cecal impaction in horses after anesthesia, although its effectiveness on cecal motility in the immediate postoperative period may be reduced. 36 high doses, constant infusion, or prolonged use of erythromycin induces receptor downregulation and inhibition of activity. erythromycin can induce diarrhea in adults, therefore one should avoid dosing over many days. naloxone (0.05 mg/kg intravenously) induces contractile activity in the cecum and left colon. 56 defecation commonly follows administration of naloxone within 15 to 20 minutes. α 2 -adrenoreceptor antagonists such as yohimbine or tolazoline counteract increased sympathetic outflow in response to nociceptive stimulation. yohimbine infusion (75 µg/kg) also may attenuate the negative effects of endotoxin on motility. 32 intravenous infusion of lidocaine may suppress primary afferent neurons, thereby limiting reflex efferent inhibition of motility. an infusion dose of 15 to 20 mg/min over 5 to 6 hours has been recommended for horses. lidocaine infusion is associated with reversible side effects that include muscle fasciculations, ataxia, and seizure. consequently, the rate of infusion requires close monitoring. katharina l. lohmann, michelle henry barton endotoxemia is defined as the presence of endotoxin in the bloodstream. most often, however, the term is used to refer to the associated clinical manifestations caused by an overshooting inflammatory reaction. in its pathophysiologic consequences the innate immune response to endotoxin (lipopolysaccharide) is similar to the response to other stimuli; for example, overwhelming bacterial infection, viral infection, or severe trauma. the term systemic inflammatory response syndrome therefore was introduced to describe a general systemic inflammatory process independent of cause. sepsis is defined as the "systemic inflammatory response to infection," and septic shock as "sepsis-induced hypotension, persisting despite adequate fluid resuscitation, along with the presence of hypoperfusion abnormalities or organ dysfunction." 1 according to these definitions the diagnosis of sepsis requires documentation of infection by culture in addition to two or more of the following findings: hypo-or hyperthermia, tachycardia, tachypnea or hypocapnia, and leukocytosis, leukopenia, or an increased proportion of immature leukocyte forms. organ failure is a common sequela of endotoxic or septic shock, and the term multiple organ dysfunction syndrome describes insufficiency of two or more organ systems, as evident by clinical or clinicopathologic changes. in horses one should include the laminae of the feet in the list of organs susceptible to failure. german scientist richard pfeiffer (1858-1945), in working with vibrio cholerae, first described endotoxin as a toxin "closely attached to, and probably integral of, the bacterial body." 2 he observed this toxin to be distinct from the actively secreted, heat-labile, and proteinaceous bacterial exotoxins. endotoxin later was found to be a heat-stable lipopolysaccharide structure, and the terms endotoxin and lipopolysaccharide now are used interchangeably. lipopolysaccharide is a major structural cell wall component of all gram-negative bacteria, including noninfectious species (figure 13 .7-1). with 3 to 4 × 10 6 molecules per cell, lipopolysaccharide makes up about 75% of the outer layer of the outer cell membrane and is a key functional molecule for the bacterial outer membrane, serving as a permeability barrier against external noxious agents. the lipopolysaccharide molecule consists of four domains, which are essential for the virulence of gram-negative bacteria. 3 three of the domains (inner core, outer core and o-specific chain) represent the hydrophilic polysaccharide portion of the molecule, whereas the lipid a portion represents the hydrophobic lipid portion ( figure 13 .7-2). combined, these domains confer the overall amphiphilic properties of the molecule that lead to the formation of micellar aggregates in aqueous solutions. o-specific chains (also called o-antigen polysaccharides or o-chains) are characteristic of any given type of lipopolysaccharide and show enormous structural variability between bacterial serotypes. 4 o-chains are synthesized by addition of preformed oligosaccharide blocks to a growing polymer chain and therefore have a repetitive structure. o-specific chains determine part of the immunospecificity of bacterial cells 5 and, on interaction with the host immune system, serve as antigens for the production of species-specific antibodies. 6 o-specific chains are further responsible for the smooth appearance of gram-negative bacterial colonies on culture plates, 3 and lipopolysaccharide molecules containing an o-chain are termed smooth lipopolysaccharide. the inner (lipid a-proximal) and outer (o-chainproximal) core oligosaccharide portion is more conserved between different strains of gram-negative bacteria than the o-specific chain. 4 the core of all lipopolysaccharide molecules contains the unusual sugar kdo (3-deoxy-dmanno-oct-2-ulopyranosonic acid), which links the core region to the lipid a molecule. synthesis of a minimal core is essential for the survival of bacteria, 7 and the smallest naturally occurring lipopolysaccharide structure consists of lipid a and kdo. 8 in contrast to the s-form colonies, colonies of gram-negative bacteria with lipopolysaccharide molecules that lack the o-specific chain but contain a core region show a rough appearance on culture plates. rough lipopolysaccharide molecules are denoted further as ra, rb, etc. to indicate the length of the core region. in re-lipopolysaccharide (also called deep rough lipopolysaccharide), the core region is reduced to a kdo residue. remutants often are used to raise antibodies against the core region in an attempt to provide cross-protection against a variety of bacterial species. the lipid a portion serves to anchor the lipopolysaccharide molecule in the bacterial outer membrane and has been identified as the toxic principle of lipopolysaccharide, 9 and its structure is highly conserved among gramnegative bacteria. the common structure shared by lipid a molecules is a 1,4'-bisphosphorylated β1,6-linked d-glucosamine disaccharide backbone (lipid a backbone), which is acylated by up to six fatty acids. 4 figure 13 .7-3 shows the acylation pattern for escherichia coli lipopolysaccharide. variation in the lipid a structure between gramnegative bacteria affects the number, length, and position of fatty acids and the backbone structure and the substitution of phosphate by other polar groups. 6 according to its nature as a structural cell wall component, the presence of endotoxin implies the presence of gram-negative bacteria as a source. depending on the nature of the underlying disease, these bacteria may circulate in the bloodstream in their intact form (i.e., bacteremia), may be confined to a localized infectious process, or may be part of the endogenous bacterial flora colonizing the gastrointestinal tract. in any of these scenarios, endotoxin molecules are released as a by-product of bacterial growth and in large numbers on bacterial cell death. 10 common infectious conditions associated with endotoxemia in horses include neonatal gram-negative sepsis, bacterial pneumonia and pleuropneumonia, endometritis, peritonitis, and infectious colitis with bacteria such as salmonella spp., that are not part of the normal intestinal flora. in one study, for example, endotoxin was detectable in plasma of 50% of foals evaluated for presumed sepsis. 11 the term translocation describes entry of endogenous bacteria and bacterial products from the gastrointestinal tract into tissues and the systemic circulation. 12 the natural intestinal flora of horses consists mainly of gramnegative, anaerobic bacteria, and thus large amounts of endotoxin normally exist in the lumen of the equine intestinal tract. 13 even in health, small amounts of endotoxin cross the intact mucosal barrier and reach the portal circulation and the liver. these molecules are cleared, however, by the mononuclear phagocytic system in the liver and only lead to a localized and restricted activation of the host immune system. for endotoxin translocation to become detrimental, excessive amounts have to cross the intestinal barrier and overwhelm the mononuclear phagocytic system or the capacity of the liver to detoxify lipopolysaccharide must be compromised. the latter may be a concern in conditions such as hepatitis, cholangiohepatitis, or portosystemic shunting of blood. permeability of the intestinal mucosal barrier frequently increases in cases of acute gastrointestinal disease. colic patients are prime candidates to development endotoxemia, and plasma endotoxin was detectable in 10% to 40% of colic patients on admission. 14,15 a higher percentage of horses tested positive for endotoxin when only patients presented for surgical intervention were evaluated. 15 aside from gastrointestinal rupture, increased permeability to intact bacteria or free endotoxin molecules is thought to be associated most commonly with ischemic insults such as strangulating obstruction and bowel infarction, severe inflammation as in proximal enteritis and colitis, bacterial overgrowth, and intraluminal acidosis, which occurs with grain overload. 16, 17 one study, however, found no difference in plasma endotoxin detection between disease groups, therefore emphasizing the fact that any disease of the abdominal cavity can induce endotoxemia in horses. in the same study, endotoxin was approximately 3 times more likely to be detected in peritoneal fluid as opposed to plasma samples. similarly, higher cytokine concentrations have been measured in peritoneal fluid than in plasma. the likely explanation for these findings is a local inflammatory response in the peritoneal cavity elicited by translocated bacteria and/or lipopolysaccharide molecules before their absorption into the systemic circulation. 14 although certainly the most important factor in horses, conditions other than gastrointestinal disease may result in translocation of endotoxin and bacteria. in experimental studies using laboratory animals, entry of gutassociated bacteria into the lymphatic system was demonstrated after hypovolemic shock, burn injuries, trauma, malnutrition, and starvation. [18] [19] [20] furthermore, endotoxin itself caused bacterial translocation into mesenteric lymph nodes after intraperitoneal administration to mice. 21 these findings have received much attention in the literature concerning human patients because they serve to explain cases of endotoxic shock in the absence of demonstrable bacterial infection. one should keep in mind the possibility of translocation when evaluating cases of presumed systemic inflammatory response syndrome in horses, in which one cannot demonstrate bacterial infection or gastrointestinal disease. endotoxin translocation also may be associated with strenuous exercise, which results in reduced splanchnic blood flow, hypoxemia, and a higher body temperature. in fit racehorses a significantly increased mean plasma lipopolysaccharide concentration was found after racing, whereas antilipopolysaccharide immunoglobulin g levels were decreased. fit horses showed significantly higher antilipopolysaccharide immunoglobulin g concentrations at rest than sedentary controls, suggesting leakage of small amounts of endotoxin from the intestinal lumen during training and racing. 22 the clinical significance of these findings requires further investigation. the initiating event in the pathophysiology of endotoxemia is the activation of lipopolysaccharideresponsive cells by endotoxin, resulting in altered cellular functions and increased expression of inflammatory mediators. immune cells such as macrophages, which are the first to encounter endotoxin, respond to minute amounts of lipopolysaccharide, which usually allows them to eliminate gram-negative bacteria and free lipopolysaccharide molecules efficiently. an important factor in the exquisite sensitivity to lipopolysaccharide is the presence of lipopolysaccharide-binding protein (lbp). 4 lbp is an approximately 60-kd plasma glycoprotein 23 synthesized by hepatocytes 24 and belongs to the group of acute phase proteins. under the control of inflammatory agents and cytokines, lbp concentration in plasma increases approximately 100-fold within 24 hours of an inflammatory stimulus. 25 the main function of lbp is to transfer lipopolysaccharide to endotoxin-responsive cells, which include mononuclear phagocytes, neutrophils, lymphocytes, and endothelial cells. the importance of a highly sensitive response to lipopolysaccharide for protection against gram-negative bacterial infection is demonstrated in experiments using lbp "knock-out" mice (mice that lack the lbp gene and are therefore unable to synthesize lbp). although these animals are resistant to the effects of isolated lipopolysaccharide, they are unable to control bacterial infection and rapidly succumb. 26 despite its crucial importance for an effective host defense, lbp is not essential for lipopolysaccharide-receptor interaction per se, because high concentrations of lipopolysaccharide can activate cells in the absence of lbp. 27 aside from its role as a catalyst of cellular activation by lipopolysaccharide, lbp has opsonizing activity 28 and participates in the phagocytosis of lipopolysaccharide by macrophages and neutrophils. 29, 30 although phagocytosis of lipopolysaccharide is receptor dependent, it appears to be uncoupled from intracellular signaling events and occurs in the absence of cell activation. 31 lbp further catalyzes transfer of lipopolysaccharide to lipoproteins such as high-density lipoprotein, which neutralizes lipopolysaccharide activity. 32 this detoxifying effect may become important when large amounts of lipopolysaccharide are present. a protective effect of lbp against lipopolysaccharide challenge and infection has been demonstrated in a murine model. 33 the most important lipopolysaccharide receptors known to date are cluster differentiation antigen 14 (cd14) 27 and toll-like receptor 4 (tlr4). 34 both are classified as pattern recognition receptors, 35 which means that they recognize lipopolysaccharide as a pattern common to all gram-negative bacteria. cd14 is a 53-kd protein that in its membrane-bound form (mcd14) is inserted into the cell membrane via a glycosylphosphatidyl-inositol anchor. 36 cd14 is expressed primarily on monocytes and tissue macrophages and to a lesser extent on neutrophils. 37 cd14 also is found in a free, or soluble, form (scd14) 38 that can bind to cell types lacking cd14, such as endothelial cells, and make them lipopolysaccharide-responsive. in addition to this proinflammatory effect, high concentrations of scd14 can sequester and neutralize lipopolysaccharide. 39 the amount of circulating scd14 greatly increases during inflammation, which makes it a useful marker of acute and chronic inflammation. 37 although cd14 is known to be crucial for cellular activation, it cannot transmit signals to the inside of the cell because it lacks a transmembrane domain. the missing link between cd14 and the cytosolic environment is a toll-like receptor in association with a molecule named md-2. 40 the name toll-like receptor stems from the homology of the mammalian receptor with a receptor type in drosophila (toll) that is important for dorsoventral orientation and immune responses in the fly. a number of toll-like receptors have been identified in mammalian species so far, but tlr4 appears to be the receptor subtype most important for lipopolysaccharide signaling. 34 the importance of cd14 and tlr4 in the cellular response to lipopolysaccharide has been demonstrated in a number of experiments. mice deficient in cd14 are incapable of mounting a normal inflammatory response to lipopolysaccharide, 39 whereas mutation or deletion of the gene encoding for tlr4 causes lipopolysaccharide hyporesponsiveness. [41] [42] [43] after binding of lipopolysaccharide to cellular receptors, a multitude of signaling events takes place within the cell and results in the alterations of cellular metabolism known as cell activation. signaling pathways are characterized by sequential phosphorylation and thereby activation of enzymatic activities. a typical end result of intracellular signaling is the activation of transcription factors; for example, proteins that bind to dna and promote gene transcription. translational mechanisms are activated in a similar manner. among the bestcharacterized pathways in endotoxin-induced cell signaling are the mitogen-activated protein kinase (mapk) pathways and the activation of transcription factor nuclear factor κb (nfκb) (figure 13.7-4) . 44, 45 in the nfκb pathway the intracellular domain of tlr4 associates with the adapter protein myeloid differentiation factor 88 and recruits interleukin-1 receptor-associated kinase to the complex. activation of interleukin-1 receptor-associated kinase, tumor necrosis factor receptor-associated factor, nfκb-inducing kinase, and iκb-kinase follow, and lastly, iκb is phosphorylated. iκb is an inhibitor protein complex that sequesters and inactivates nfκb in the cytoplasm. on phosphorylation, iκb is ubiquinated and degraded, and nfκb is translocated to the nucleus where it unfolds its activity. 46 nfκb is a dimeric protein complex with several isoforms of which the p65/p50 heterodimer is the most important inducible complex in mammals. 47 proteins of importance for the pathogenesis of septic shock, the genes of which contain promoter elements for nfκb, include cytokines, inducible nitric oxide synthase, and cyclooxygenase 2 (cox-2). 44 three groups of mapks known to be crucially important for lipopolysaccharide-induced signal transduction are extracellular signal-regulated kinase, c-jun-terminal kinase, and p38. final effects of signaling through mapk pathways include the activation of several transcription factors, translation initiation factors, and cytosolic enzymes such as phospholipase a 2 , as well as an increase in the expression of adhesion molecules on the cell surface. 44 despite the characterization of seemingly separate pathways, one should recognize that interaction and synergy between pathways is likely to occur. for example, simultaneous activation of p38, c-jun-terminal kinase, and extracellular signal-regulated kinase results in much higher levels of tumor necrosis factor (tnf) reporter expression than activation of a single pathway. 44, 48 aside from the mechanisms described here, pathways involving atypical protein kinase c 49,50 and receptor-independent integration of lipopolysaccharide into the cell membrane and ceramide-like second messenger activity of lipopolysaccharide 37 have been proposed. additional pathways are likely to be uncovered in the ongoing investigation of intracellular signaling mechanisms and their in vivo significance. although endotoxin can exert some direct effects, cytokines are a primary mediator of lipopolysaccharide effects. cytokines are glycoprotein molecules that regulate inflammatory and immune responses by acting as a signal between cells. 51 cytokines of major interest in the pathogenesis of endotoxemia include tnf, the interleukins, chemokines, and growth factors such as granulocyte-monocyte colony-stimulating factor. tnf is thought of as the most "proximal" cytokine released in response to lipopolysaccharide. studies corroborate this by showing that administration of recombinant tnf mimics the effects of lipopolysaccharide, 52 and that antibodies directed against tnf protect against the lethal effects of endotoxin. 53 increased plasma activity of tnf is associated with increased mortality in equine patients with acute gastrointestinal disease and in septic neonates. 14 despite being a structurally diverse group of proteins, cytokines share several characteristics that allow them to execute their complex functions in the inflammatory response. 51 any individual cytokine generally is produced by several different cell types, can act on different cell types, and has multiple effects on any given cell. furthermore, cytokine effects are redundant, meaning that different cytokines can share the same effect. in endotoxemia, this is particularly true for the effects of interleukin-1 (il-1) and tnf. 54 many of the biologic activities of cytokines in vivo result from synergistic or antagonistic actions involving two or more cytokines. 55 within itself the cytokine response is highly regulated: cytokines induce or suppress synthesis of other cytokines including their own (feedback regulation), regulate expression of cytokine receptors, and regulate cytokine activities. additional regulatory mechanisms include the release of specific cytokine inhibitors such as soluble il-1 and tnf-α receptors, cytokine receptor antagonists such as il-1 receptor antagonist, and antiinflammatory cytokines including il-10, il-4, il-13, and transforming growth factor β. glucocorticoids also are produced increasingly in response to endotoxin and inhibit the production of cytokines. 56 during a controlled inflammatory response, therefore, cytokine secretion is a selflimited event, whereas excessive stimulation of cytokine release can lead to the perpetuation of the inflammatory response even after the initial stimulus has been removed. conversely, the compensatory antiinflammatory reaction can become severe enough to cause anergy of the immune system and increased susceptibility to infection, which has been termed the compensatory antiinflammatory response syndrome. overall, excessive and unbalanced stimulation of the immune system therefore may result in predominantly proinflammatory (systemic inflammatory response syndrome), antiinflammatory (compensatory antiinflammatory response syndrome), or combined (mixed antagonist response syndrome) responses. 57 interestingly, tolerance to endotoxin develops after repeated exposure to lipopolysaccharide. 58 tolerance can be demonstrated in vitro and in vivo and encompasses decreased production of cytokines and a diminished clinical response. 58, 59 mechanisms that likely are responsible for the development of endotoxin tolerance include receptor downregulation and inhibition of intracellular signaling pathways. 60, 61 cytokines such as tnf are important mediators in the development of endotoxin tolerance. 62 the development of endotoxin tolerance in horses has been reported. 63, 64 aside from cytokines, a number of other molecules function as inflammatory mediators in the pathogenesis of endotoxemia, the synthesis and release of which are stimulated by endotoxin and by cytokines. these mediators include the arachidonic acid metabolites or prostanoids, platelet-activating factor (paf), oxygenderived free radicals, nitric oxide (no), histamine, kinins, and complement components. table 13 .7-1 summarizes the origins, targets, and effects of the most important inflammatory mediators involved in the pathogenesis of endotoxemia. figure 13 .7-5 shows the pathways of arachidonic acid metabolism by cox and lipoxygenase. cox products are the prostaglandins (pgs), prostacyclin (pgi 2 ) and thromboxanes, and the lipoxygenase produces the leukotrienes. the innate immune response to lipopolysaccharide is an efficient defense mechanism that provides maintenance of homeostasis and therefore health in the face of an almost continuous exposure to microorganisms and their products. 65 detrimental consequences of this immune response only occur if excessive and uncontrolled mediator output results in endothelial damage, neutrophil-mediated tissue damage, and uncontrolled activation of the coagulation and fibrinolytic cascades and the complement system. ultimately, the combination of these events culminates in cardiovascular instability, impaired hemostasis, organ failure, shock, and death. the following discussion addresses the various pathophysiologic events in the development of endotoxemia and shock and the role of inflammatory mediators. normal endothelium plays an important role in regulating blood pressure and regional tissue perfusion and provides an anticoagulant surface. endothelial dysfunction and damage result in a decreased responsiveness to vasoactive agents (vasoplegia), increased vascular permeability, and a tendency for clot formation in the microvasculature. if the basement membrane and underlying matrix are compromised, further microvascular hemorrhage can occur. endothelial cell damage is primarily neutrophilmediated. more specifically, damage is caused by oxygen-derived free radicals, which are produced within endothelial cells via reactions involving neutrophil-derived elastase and hydrogen peroxide molecules, endothelial cell enzymes such as xanthine oxidase, and endothelial cytosolic iron. the hypochloric anion radical (ho˙) is thought to be responsible most directly for endothelial cell cytotoxicity. no˙produced by constitutively expressed nitric oxide synthase in endothelial cells may afford protection from oxygen radical-induced endothelial cell damage. no is able to scavenge superoxide radicals and react with them to form peroxynitrite. variations in the ability to produce no may explain why vascular beds in different organs vary in their susceptibility to neutrophilmediated damage. 66 excessive production of no by an inducible form of nitric oxide synthase (i nos), however, contributes to tissue damage, and increased peroxynitrite concentrations may be responsible in part for paf-induced increases in vascular permeability. 67 in addition to oxygen-derived free radicals, activated neutrophils release matrix metalloproteinases, which contribute to tissue damage. 56 vascular endothelial cells are further susceptible to direct effects of various cytokines, most prominently tnf-α and il-1. these cytokines are thought to cause damage via the induction of cox activity and production of prostanoids and through generation of free radicals. neutrophil activation by lipopolysaccharide and cytokines results in stimulation of phagocytosis and the respiratory burst, release of lysosomal enzymes and inflammatory mediators, and expression of adhesion molecules. perhaps the single most specific clinicopathologic indicator of endotoxemia is pronounced neutropenia, 68 which temporally correlates with peak plasma concentrations of tnf. 69 neutropenia is caused primarily by margination of neutrophils in the vasculature, whereas significant loss through active migration into peripheral tissues likely is limited to the presence of a localized source of infection. margination is made possible by adhesion molecules on endothelial cells and leukocytes that interact and allow sticking of leukocytes to the endothelial lining of blood vessels. endotoxin or cytokines such as tnf and il-1 can initiate expression of adhesion molecules. 70 subsequent transmigration of cells into tissue spaces is aided by the production of leukocyte collagenase, which allows enzymatic destruction of the vascular basement membrane. margination and transmigration of neutrophils occurs in three phases. 70, 71 in the first phase of tethering and rolling, endothelial cells are stimulated to express p-selectin and e-selectin, which bind to p-selectin glycoprotein ligand-1 and sialylated lewis-x-like structures on leukocytes, respectively. whereas p-selectin is stored preformed in weibel-palade bodies of endothelial cells, e-selectin is expressed only following stimulation by cytokines. additionally, constitutively expressed l-selectin on neutrophils can bind to endothelial glycoproteins and glycolipids. during the second phase, firm adhesion is mediated by binding of neutrophil integrins (lfa-1 and mac-1, also known as cd11a/cd18 and cd11b/cd18) to intercellular adhesion molecule 1 (an immunoglobulin structure) on endothelial cells. although integrins are expressed constitutively on the leukocyte surface, activation signals are necessary to induce a high-affinity state and interaction with the endothelial surface. transmigration finally requires the expression of yet another adhesion molecule, namely platelet/endothelial cell adhesion molecule 1, which is located at the intercellular junction of endothelial cells. 71 chemotactic factors including activated complement factor c5a and the cxc chemokines control transmigration. 66 the latter group includes il-8, which is expressed by endothelial cells in response to activation. rebound neutrophilia, which is observed frequently following episodes of endotoxemia, is caused by neutrophil release from the bone marrow reserve pool and by stimulation of myeloid cell proliferation via granulocyte-macrophage colony-stimulating factor and is mediated primarily by tnf and il-1. 54 in health, coagulation and fibrinolysis underlie stringent control mechanisms that allow appropriate clot formation and their resolution. coagulopathies frequently are observed in horses with colic 16, 72, 73 and foals with sepsis 11 and are likely attributable to endotoxemia. disseminated intravascular coagulation (dic) results from a widespread activation of the coagulation and fibrinolytic systems and failure of their control mechanisms. ultimately, this leads to disseminated fibrin deposition in the microvasculature, consumption of platelets and clotting factors, and accumulation of fibrin degradation products (fdps). depending on the underlying disease process and the impairment of the systems, dic can manifest as a diffuse thrombotic syndrome leading to ischemic organ failure, a fibrinolytic syndrome with uncontrolled hemorrhage, or a combination of both. 74 a procoagulant state in which one can detect clinicopathologic abnormalities precedes dic. activation of the coagulation cascade culminates in the cleavage of fibrinogen to fibrin by the serine protease thrombin. thrombin deposition on endothelial cell surfaces leads to platelet adherence and their activation by surface-bound paf. 56 the intrinsic and extrinsic arms of the coagulation cascade are activated in endotoxemia. the intrinsic pathway is initiated by activation of coagulation factor xii (hageman factor), prekallikrein, and highmolecular-weight kininogen, which compose the contact system. 75 although direct activation of coagulation factor xii by endotoxin has been demonstrated, 76 the extrinsic pathway likely is more important for the development of coagulopathy in endotoxemia and sepsis. 75 activation of the extrinsic pathway depends on the interaction of coagulation factor vii with tissue factor, which is the only coagulation factor not constitutively present in blood. tissue factor is present in subendothelial tissues and is exposed on vascular injury but also is expressed on endothelial cells and mononuclear phagocytes in response to lipopolysaccharide. 77, 78 increased expression of monocyte tissue factor (also described as increased procoagulant activity) was found to be associated significantly with coagulopathy and poor prognosis in horses with colic. 79 furthermore, lipopolysaccharide-induced tissue factor expression by equine peritoneal macrophages may be associated with the development of intraabdominal adhesions. 63 regulatory mechanisms of the coagulation cascade include tissue factor pathway inhibitor, antithrombin iii (at iii), and the protein c system. 75 protein c acts as an anticoagulant by inactivating clotting factors v and viii and promotes fibrinolysis by inactivating plasminogen activator inhibitor (pai). 80 protein c activation by thrombin-thrombomodulin complexes is important for the anticoagulative properties of normal endothelium, 75 and downregulation of endothelial thrombomodulin expression by tnf and il-1 and decreased expression of at iii and tissue factor pathway inhibitor by damaged endothelial cells contribute to the procoagulant state in endotoxemia and sepsis. [81] [82] [83] in addition, activation of vascular endothelial cells leads to a loss of prostacyclin and no production and an increased release of thromboxane a 2 (txa 2 ). as a result, platelets are stimulated to aggregate and release txa 2 and paf, thereby further promoting clot formation. 17 the crucial step in the fibrinolytic cascade is the conversion of plasminogen to plasmin, a fibrin-degrading enzyme. 75 tissue-type (tpa) and urokinase-type (upa) plasminogen activator are the major initiators of fibrinolysis, whereas pai and α 2 -antiplasmin are the main regulatory components. 84, 85 tnf and il-1 have been shown to induce the release of upa and tpa and the synthesis of pai. 75 activation of fibrinolysis leads to consumption of α 2 -antiplasmin and accumulation of fdps, which if present in high concentrations can interfere with platelet aggregation, fibrin polymerization, and thrombin formation and can promote bleeding. additionally, fdps mediate an increase in vascular permeability. lipopolysaccharide infusion in rabbits 86 and human beings 87 resulted in an early increase in plasma tpa activity, followed by a later profound rise in pai activity and fall in tpa activity. increased plasma pai concentrations also were found in horses with colic compared with controls. 88, 89 thus although fibrinolysis may compensate initially for accelerated coagulation, its subsequent inhibition contributes to clot formation. activation of the complement system in endotoxemia occurs via the alternative pathway through interaction with lipopolysaccharide. increased concentrations of plasmin and kallikrein (caused by activation of the fibrinolytic and contact system) further promote this pathway by directly activating complement factors c3a and c5a. aside from being key molecules in the complement cascade, c3a and c5a are anaphylatoxins and cause an increase in vascular permeability via mast cell degranulation. c5a further activates the lipoxygenase pathway in neutrophils and monocytes, acts as a chemotaxin for leukocytes and monocytes, and promotes neutrophil adhesion to endothelial cells. in response to acute inflammation, synthesis and secretion of a number of proteins called the acute phase proteins increases in hepatocytes, whereas synthesis of albumin decreases. the primary function of this acute phase response may be to suppress and contain inflammatory responses. 56 il-6 and il-1 are the most important cytokines that induce the acute phase response, 90 which typically begins within a few hours of the insult and subsides within 24 to 48 hours, 91 unless the initiating cause persists. in horses, fibrinogen (the most commonly evaluated), haptoglobin, transferrin, ferritin, ceruloplasmin, coagulation factor viii:c, serum amyloid a protein, c-reactive protein, α 1 -acid glycoprotein, and phospholipase a 2 are considered part of the acute phase response. 92 one must consider the effect of acute inflammation on the serum concentration of several coagulation factors when evaluating coagulation profiles. serum fibrinogen concentration is determined primarily by the acute phase response, although fibrinogen is consumed increasingly on activation of the clotting cascade. shock is characterized by a loss of homeostasis attributable to breakdown of hemodynamic control mechanisms, decreases in cardiac output and the effective circulating volume, and inadequate perfusion of vital organs. shock caused by endotoxemia is classified as distributive shock 93 and is largely initiated by vascular dysfunction in the periphery. peripheral vascular beds are of major importance for the regulation of local tissue perfusion and affect systemic blood pressure by regulating total peripheral resistance. normally, vascular smooth muscle tone is regulated by endothelin-1 (vasoconstriction), no, and prostacyclin (vasodilation) released from vascular endothelial cells. 94 as mentioned before, detrimental effects of no are attributable to induction of i nos in macrophages and other cell types, rather than endothelialderived no. peripheral vasomotor effects of endotoxin manifest as vasodilation and vasoplegia and are mediated by pgi 2 , no, and mediators such as bradykinin. widespread vasodilation leads to vascular blood pooling, decentralization of blood flow, decreased venous return, and in effect decreased effective circulating volume and cardiac output. 93 compensatory responses in the form of an initial hyperdynamic phase include tachycardia, increased cardiac output and central venous pressure, pulmonary hypertension, peripheral vasoconstriction, and increased peripheral vascular resistance. 93, 95, 96 the early vasoconstrictive phase corresponds to an increased serum concentration of txa 2 , 17 but additional vasoconstrictors such as arginine vasopressin, angiotensin ii, serotonin, endothelin, and norepinephrine likely are implicated in the pathogenesis of shock and organ failure. 56 with progression of disease, the animal enters a stage of decompensated shock and progressive systemic hypotension, which correspond to increased plasma concentrations of prostacyclin, pge 2 and bradykinin. 17, 56 inadequate blood flow and oxygen delivery to tissues caused by hypotension is confounded by direct myocardial suppression via no, 93 increased vascular permeability, 17 intravascular microthrombosis, and impaired tissue oxygen extraction 93 and results in progressive metabolic acidosis and inhibition of normal cellular metabolism. quantification of endotoxin in plasma samples is possible. the limulus amebocyte lysate assay is an activity assay based on the endotoxin-sensitive hemolymph coagulation cascade in the horseshoe crab limulus polyphemus. in limulus this reaction is thought to be a defense mechanism against gram-negative infection. 97 although frequently used as a research tool, the assay is not convenient enough to become a routine clinical test. the clinician therefore must appreciate the primary disease processes associated with a high risk of endotoxemia and rely on clinical signs and clinicopathologic data to achieve a diagnosis. in some cases, endotoxemia may be the first indication of disease or may be the most overt of otherwise subtle clinical manifestations. with colitis or proximal enteritis, for example, one may detect signs of endotoxemia before the development of colic, diarrhea, or gastric reflux, which more specifically indicate the nature of the primary illness. diseases such as peritonitis or pleuritis, however, may show nonspecific clinical findings including fever, anorexia, and depression. findings such as neutropenia, which indicate endotoxemia, should urge the clinician to search for a septic process. in vivo experiments in horses clearly show that many of the clinical signs associated with acute gastrointestinal disease and sepsis are attributable to the activities of lipopolysaccharide and cytokines such as tnf. on administration of sublethal doses of lipopolysaccharide the clinical response can be divided into the early hyperdynamic and the later hypodynamic or shock phases. clinical signs during the first phase, which begins within 15 to 45 minutes after lipopolysaccharide administration, include anorexia, yawning, sweating, depression, evidence of abdominal discomfort, muscle fasciculation, and recumbency. heart and respiratory rates increase, and decreased borborygmi suggest ileus. hyperemia of the mucous membranes and an accelerated capillary refill time indicate the hyperdynamic state. 68 if one administers large amounts of lipopolysaccharide or if exposure is ongoing, depression worsens progressively, anorexia persists, and feces develop diarrheic character. signs of colic typically abate after the initial stage. fever develops as a result of direct action of tnf on the thermoregulatory center and il-1-induced local production of pge 2 in or near the hypothalamus. 98, 99 because of compromised peripheral perfusion, mucous membrane color changes to brick red or purple, a dark "toxic" line appears, and capillary refill time is prolonged. 68 inadequate peripheral perfusion and compromised organ function finally characterize the hypodynamic shock phase. body temperature may become subnormal and the skin, especially on extremities, is cool to the touch. the arterial pulse weakens and venous fill is decreased. vascular endothelial damage and increased capillary permeability result in a muddy mucous membrane color and diffuse scleral reddening. hemostatic abnormalities can manifest in the form of thrombosis, such as of the jugular vein, or increased bleeding tendency with mucosal petechiation or ecchymoses and prolonged bleeding from venipuncture sites. 74 bleeding also may occur in spontaneous epistaxis or prolonged hemorrhage after nasogastric intubation. 17 additional clinical signs typically reflect the development of organ failure. renal failure and laminitis appear to be common complications of endotoxemia in horses. renal failure results from ischemic cortical necrosis and acute tubular necrosis caused by coagulopathy-induced afferent arteriolar obstruction. clinical signs may include oliguria, anuria, or hematuria caused by renal infarction. laminitis may lead to lameness, increased digital arterial pulsation, increased warmth of the hoof wall, and sensitivity to hoof tester pressure. other signs of organ failure include icterus, anorexia and depression caused by liver failure, 74 tachypnea and dyspnea caused by pulmonary failure, colic and bleeding caused by ischemia-induced gastrointestinal ulceration and abnormal motility patterns, 17 and persistent tachycardia or cardiac arrhythmia in cases of cardiac failure. in pregnant mares, fetal death and abortion can occur because of increased production of pgf 2α and decreased serum progesterone concentrations. 100, 101 alterations in the hemogram and serum biochemical profile are nonspecific and mainly reflect the underlying disease process and the occurrence of organ failure. leukopenia caused by neutropenia may be the most specific indicator of acute bacterial sepsis or endotoxemia. 68 in prolonged cases, an increased proportion of immature neutrophil forms (bands) and toxic changes are observable. toxic changes resulting from neutrophil activation include vacuolation, cytoplasmic granulation, basophilic cytoplasm, and döhle's bodies. because neutropenia occurs early in the development of endotoxemia, it also may be a useful parameter for monitoring horses at risk. 68 on recovery, neutropenia typically is followed by a pronounced rebound neutrophilia. an elevated hematocrit and total serum protein concentration are evidence of dehydration; however, splenic contraction caused by increased sympathetic stimulation and protein losses also influence these parameters. a normal or only slightly decreased serum protein and albumin concentration in the face of an elevated hematocrit and clinical signs of dehydration should alert the clinician to the possibility of protein loss. hypoproteinemia and hypoalbuminemia can occur because of loss via the gastrointestinal or urinary tract or with pleural or peritoneal cavity effusion. increased vascular permeability and edema formation contribute to hypoproteinemia. serum electrolyte abnormalities primarily depend on the nature and duration of underlying disease processes and need to be evaluated individually. common sources of electrolyte loss are gastrointestinal secretions, urine, and sweat; however, severe effusion into body cavities may contribute. in anorexic patients, lack of dietary intake is a confounding factor that warrants consideration. in human patients, gram-negative sepsis frequently is associated with hypocalcemia, more specifically a decrease in serum ionized calcium concentration. endotoxin is thought to be a causative factor, and proposed mechanisms include acquired parathyroid gland insufficiency, dietary vitamin d deficiency, impaired calcium mobilization, and renal 1α-hydroxylase insufficiency leading to decreased 1,25-hydroxylation of vitamin d. hypocalcemia in septic human patients was found to be associated with hypotension and poor outcome. 102 in horses with surgically managed gastrointestinal disease, decreased serum ionized calcium concentration was a common finding and was most severe in patients with strangulating or nonstrangulating infarctions. in some horses, ionized calcium concentration decreased further throughout surgery. treatment with calcium gluconate resulted in normalization of serum ionized calcium concentrations in all cases. 103 septic neonatal patients are frequently hypoglycemic. aside from decreased oral intake and generally increased metabolism, glucose use by the infecting bacteria, inhibition of gluconeogenesis by endotoxin, and insulinlike activity produced by macrophages are responsible for hypoglycemia. 17 interestingly, experimental endotoxin administration results in transient hyperglycemia in adult horses, 95 whereas profound hypoglycemia occurs in foals. 104 one should evaluate coagulation parameters if coagulopathy is suspected. the most significant changes can be expected with severe inflammatory disease such as colitis, 72,73 devitalized intestine as with strangulating obstruction, 73, 105 and with increased duration of disease. in 30 horses with acute gastrointestinal disease, coagulation profiles were considered normal in only 2 horses. 72 although coagulation times may be shortened during the procoagulant state, commonly observed abnormalities with developing dic include an increased concentration of fdps and soluble fibrin monomer, prolonged prothrombin time indicative of factor vii consumption, prolonged activated partial thromboplastin time indicative of factor viii:c and ix consumption, prolonged thrombin time, decreased at iii activity, thrombocytopenia, and decreased protein c and plasminogen activities. fibrinogen concentration frequently increases and reflects the acute phase response rather than coagulation abnormalities. 79 some clinicians make a diagnosis of dic if three or more coagulation parameters (specifically at iii, fdps, platelet count, prothrombin time, and activated partial thromboplastin time) are abnormal, 105 whereas others require overt clinical signs of hemorrhage and concomitant thrombosis in addition to classic laboratory findings. 73 the prognostic value of coagulation parameters has been evaluated. 16, 73, 89 overall, persistence or worsening of abnormalities in the face of treatment appears to be more indicative of poor outcome than alterations in any specific parameter. in one study, decreased serum at iii concentration was the parameter most commonly associated with fatal outcome in mature horses with colic. 72 one should further evaluate the serum biochemical profile regarding compromise or failure of specific organ systems. increases in serum creatinine and urea nitrogen concentration can have prerenal, renal, or postrenal causes. in cases of endotoxemia and sepsis, prerenal azotemia caused by dehydration and decreased renal blood flow and renal azotemia caused by organ failure are most likely to occur. one can use urine specific gravity and the response to fluid therapy to differentiate renal from prerenal causes of azotemia. although ideally one should perform urinalysis before initiating fluid therapy, one should never delay treatment to obtain a sample and instead should use the first available urine sample. with prerenal azotemia, urine specific gravity is increased, urinalysis is normal in other respects, and azotemia resolves with adequate fluid therapy. azotemia in the face of normal or decreased urine specific gravity, however, indicates compromised renal function. depending on the extent of renal damage, proteinuria and hematuria also may be present. bacteriuria and an elevated urine leukocyte count may occur if urinary tract infection is the underlying cause for the development of endotoxemia. in these cases, urine culture and sensitivity testing are indicated to aid appropriate antimicrobial therapy. increased serum activity of liver enzymes (aspartate aminotransferase, γ-glutamyltransferase, sorbitol dehydrogenase, alkaline phosphatase) are common in endotoxemic patients; however, liver failure caused by endotoxemia is rare. sorbitol dehydrogenase is the most liver-specific of the enzymes and a sensitive indicator of acute hepatocellular necrosis; however, sorbitol is unstable and routine assays may not be available. one should evaluate liver enzymes and function tests (serum indirect and direct bilirubin concentration, serum bile acids and blood ammonia) in cases of prolonged and profound depression to rule out hepatoencephalopathy. one should evaluate arterial blood gases in patients with primary respiratory disease or with clinical evidence of respiratory failure and in profoundly depressed, recumbent patients, especially neonates. hypoxemia observed in response to endotoxin infusion is thought to be caused by an increase in ventilation-perfusion mismatch rather than pulmonary edema as occurs in human patients with acute respiratory distress syndrome. the lung is not a major shock organ in horses; however, pulmonary edema may occur in patients with associated sepsis or complications such as dic. 106 the ideal treatment for endotoxemia is prevention. if one possibly can recognize and closely monitor patients at risk, one can provide treatment proactively and may reverse the effects of endotoxin before the inflammatory response has developed a dynamic of its own. unfortunately, endotoxemia can develop rapidly, and horses are exquisitely sensitive to the effects of endotoxin; therefore, many equine patients are not evaluated until reaching more severe stages of endotoxemia or shock. prognosis and patient outcome then frequently depend on the severity of complications associated with endotoxemia. 17 treatment of endotoxemia involves multiple aspects, and the following strategies have been proposed 107 : • inhibition of endotoxin release into the circulation • scavenging of lipopolysaccharide molecules to prevent direct effects and interaction with inflammatory cells • inhibition of cellular activation by lipopolysaccharide • inhibition of mediator synthesis • interference with the effects of inflammatory mediators • general supportive care in addition, complications such as renal failure, one also must address liver failure, cardiac failure, laminitis, and abortion in pregnant mares. when evaluating reports concerning the efficacy of any one treatment, one should keep in mind differences in underlying disease processes and the complexity of the inflammatory cascade. a "one for all" treatment most likely will not be found, and similarly, any one treatment can only address one or few pathophysiologic aspects of endotoxemia. understanding the rationale for different treatment strategies is important to be able to tailor treatment to the needs of the patient. inhibition of endotoxin release requires identification and removal of its source. therefore whenever endotoxemia is evident, the clinician should strive to reach a diagnosis of the underlying disease and ascertain whether ischemic or inflamed bowel or a gram-negative septic process is present. aside from history, physical examination, and routine laboratory tests, evaluation may include exploratory laparotomy in colic patients, roentgenologic and ultrasonographic evaluation of the pleural and peritoneal cavity and organs, ultrasonographic evaluation of umbilical remnants in neonatal foals, evaluation of passive transfer and calculation of a sepsis score in foals, and repeated culturing of blood or other specimens. if one suspects an infectious process, one should pursue identification of the responsible microorganisms and their antimicrobial sensitivity spectrum; however, one should not delay treatment to obtain culture results. specimen containers with removal devices for antimicrobials are available and are useful in cases for which one has initiated treatment before specimen collection. once one reaches a diagnosis, one must take appropriate measures to correct the primary disease process. examples are removal of devitalized sections of bowel or infected umbilical remnants, drainage of infected pleural or peritoneal fluid, and gastric lavage followed by administration of mineral oil and/or activated charcoal in cases of grain overload to prevent further absorption of endotoxin. one must address any septic process with appropriate antimicrobial therapy. initially, broad-spectrum coverage of the most likely organisms is recommended; one then should specify therapy according to results of culture and sensitivity testing. sepsis in foals is caused predominantly by gram-negative organisms, of which e. coli, actinobacillus spp., klebsiella spp., salmonella spp. and pasteurella spp. frequently are identified. 108 the reader is referred to other texts for review of general principles of antimicrobial therapy. regarding endotoxemia specifically, antimicrobial therapy has been suggested to increase the amount of circulating endotoxin by inducing endotoxin release on cell death of gram-negative bacteria. a recent in vitro study compared endotoxin release and inflammatory mediator activity between antimicrobials commonly used to treat e. coli septicemia in foals and specifically evaluated amikacin, ampicillin, amikacin plus ampicillin, ceftiofur, and imipenem. although these antimicrobials showed no difference in the ability to kill bacteria, amikacin and the amikacin/ampicillin combination resulted in the lowest and ceftiofur in the greatest release of endotoxin. endotoxin release appeared to be dose-dependent in that lesser amounts were released at higher antimicrobial concentrations. 109 based on these results and clinical experience, combining antimicrobial therapy with endotoxin-binding agents such as polymyxin b may be beneficial, especially when using β-lactam antimicrobials. antimicrobials frequently are given perioperatively to colic patients to lower the risk of peritonitis, incisional infection, and generalized sepsis and endotoxemia. because antimicrobial therapy has been implicated in the development of colitis, the duration of treatment should be minimal. unless evidence of sepsis, such as fever or changes in the leukogram, is present, perioperative administration of antimicrobials should not exceed a 24 to 48 hours. conversely, antimicrobial therapy frequently is used in cases of infectious colitis to treat the inciting cause and to prevent sepsis from translocation of bacteria. endotoxin typically has a short plasma half-life and is removed rapidly by mononuclear phagocytes or neutralized by binding to serum proteins and lipoproteins. many conditions responsible for the development of endotoxemia in horses, however, are associated with an ongoing release of endotoxin. examples include severe gastrointestinal inflammation as in proximal enteritis or colitis, grain overload, or uncontrolled sepsis. therapy directed against endotoxin itself may be able to interrupt the continuous activation of the inflammatory cascade in these cases. further benefits of antiendotoxin treatment may be derived if large amounts of endotoxin have been released before the inciting cause can be addressed. an important consideration regarding the efficacy of immunotherapy is the region of the lipopolysaccharide molecule against which antibodies are raised. the o-chain of lipopolysaccharide acts as a potent antigen on infection with gram-negative bacteria 6 ; however, antibodies directed against the o-chain are serotype specific and cannot afford significant cross-protection against heterologous bacterial strains. the core and lipid a region, both of which show a much higher degree of homology between lipopolysaccharide derived from different bacterial strains, offer a more promising target for immunotherapy. active immunization against endotoxin has been reported for horses. vaccination with a bacterin/ toxoid vaccine prepared from rough mutants of salmonella typhimurium or s. enteritidis protected horses against homologous and heterologous endotoxin challenge 110, 111 and carbohydrate overload. 111 despite these encouraging results and the current availability of a vaccine for use in horses (endovac-equi, immvac inc., columbus, missouri), active immunization against endotoxin does not appear to be a common practice. in comparison, passive immunization with antilipopolysaccharide antibodies is used widely. rough bacterial mutants, most commonly j5 of e. coli o111:b4 and s. minnesota re595, are used to immunize donor horses and subsequently prepare serum or plasma products. proposed mechanisms of action after binding of the antibodies to lipopolysaccharide include steric blockade of lipid a interaction with cellular receptors and enhanced bacterial clearance by opsonization. [112] [113] [114] studies concerning the efficacy of antibody administration in equine patients vary in their results. beneficial effects have been described in experimental models of endotoxemia, acute gastrointestinal disease, and neonates with sepsis, 111, [115] [116] [117] whereas in other studies, antibodies failed to protect foals and horses against endotoxin effects. 118-120 furthermore, administration of a s. typhimurium antiserum to foals was associated with an increased respiratory rate and higher serum activities of il-6 and tnf. 118 various equine serum and plasma products are currently commercially available. an antiserum raised against the lipopolysaccharide-core of s. typhimurium (endoserum) is available for administration to endotoxemic horses at a recommended dose of 1.5 ml/kg body mass. diluting the serum ten-to twentyfold in crystalloid intravenous solutions, administering it slowly over 1 to 2 hours, and monitoring the patient for adverse reactions is advisable. although the product is marketed for use in foals with failure of passive transfer, adverse effects have been reported, 118 and one should use caution when administering it to neonates. plasma from donors inoculated with j5 (e. coli) and s. typhimurium (re mutant) is available under a restricted license (polymune-j, vet dynamics, inc., san louis obispo, california). the manufacturer recommends administration of at least 1 to 2 l in cases of endotoxemia. in addition, hyperimmune plasma, which has a guaranteed minimum immunoglobulin g content but does not contain specific antiendotoxin antibodies (hi-gamm equi, lake immunogenics, inc., ontario, new york; polymune and polymune-plus, vet dynamics, inc.), is marketed for treatment of failure of passive transfer, and many clinicians use it to treat endotoxemia and sepsis. in addition to antibodies and protein, plasma contains active constituents such as complement components, fibronectin, clotting factors, and at iii 116 and therefore may be particularly useful in patients with endotoxemia-induced coagulopathy. volumes of 2 to 10 ml/kg body mass of hyperimmune plasma have been recommended for use in endotoxemic patients. 56, 121 polymyxin b polymyxin b is a cationic polypeptide antibiotic that binds to the anionic lipid a portion of lipopolysaccharide and neutralizes its endotoxin capacity. 122 at dosages required for antimicrobial activity, polymyxin b carries the risk of respiratory paralysis and ototoxic, nephrotoxic, and neurotoxic side effects; however, a much lower dose is required for endotoxin-binding activity. the effects of polymyxin b in horses have been evaluated in different experimental models. 118, 122, 123 in an in vivo study in foals, treatment with polymyxin b at a dosage of 6000 u/kg body mass before infusion with s. typhimurium lipopolysaccharide resulted in significantly less severe elevations of body temperature, respiratory rate, and serum activities of tnf and il-6 compared with untreated controls. 118 similarly, polymyxin b treatment of adult horses given endotoxin significantly ameliorated clinical signs and decreased plasma tnf activity. 124 in the latter study, benefits of treatment were also evident at lower dosages of polymyxin b (1000 and 5000 u/kg body mass) and administration of polymyxin b 1 hour after the start of endotoxin infusion. conversely, polymyxin b failed to ameliorate clinical signs of endotoxemia or prevent the development of coagulopathy, acidosis, lameness, and shock in experimental carbohydrate overload. 125 side effects suggestive of neurotoxicity appeared after repeated administration of 5 mg/kg body mass (36,000 u/kg) and in milder form, 2.5 mg/kg body mass (18,000 u/kg) polymyxin b. nephrotoxicity was not observed. currently, use of polymyxin b in equine patients is recommended at dosages of 1000 to 5000 u/kg body mass every 8 to 12 hours. 126 one should initiate treatment as early in the disease process as possible, because the beneficial effects of lipopolysaccharide scavenging are limited to the first 24 to 48 hours after the onset of endotoxemia, before tolerance develops. side effects in the form of neuromuscular blockade and apnea, which necessitate slow infusion of the drug in human patients, have not been observed in horses. one therefore can administer the entire dose as a slow bolus. if one uses polymyxin b in horses with hypovolemia, dehydration, or azotemia, one should attempt to improve peripheral tissue perfusion, minimize the polymyxin b dose, and closely monitor patients for nephrotoxicity. close monitoring is also important if one administers medications such as aminoglycoside antibiotics, which share a similar spectrum of potential side effects, concurrently. azotemic neonates have been reported to be more susceptible to the nephrotoxic effects of polymyxin b than adult horses. 124 in an attempt to decrease the risk for adverse effects while preserving lipopolysaccharide-neutralizing ability, a conjugate of polymyxin b with dextran has been developed. 127 in conjugated form, polymyxin b is prevented from extravasation into tissues, where it exerts toxic effects by interaction with cell membranes. in addition, conjugation increases the residence time of polymyxin b in the circulation and therefore should prolong the antiendotoxic effect. the polymyxin b-dextran combination was evaluated at a total dose of 5 mg/kg body mass of polymyxin b in 6.6 g/kg body mass dextran given 15 minutes before administration of endotoxin in horses. 128 treatment was found to block the development of tachycardia, tachypnea, fever, and neutropenia completely and to prevent increases in serum concentrations of tnf, il-6, txb 2 (a txa 2 metabolite), and the prostacyclin metabolite 6-keto-pgf 1α . although mild adverse effects in the form of tachypnea, sweating, and increased systolic blood pressure were observed, these were transient and could be prevented by pretreatment with ketoprofen. the polymyxin b-dextran combination is not commercially available at this time. natural endotoxin-binding proteins such as lbp, lipoproteins, and scd14 have been evaluated experimentally. results of these studies are controversial, and detrimental effects occurred in some cases. 129 a protein receiving much attention regarding potential therapeutic efficacy is the bactericidal permeability-increasing protein (bpi). this protein is structurally similar to lbp but is expressed exclusively in myeloid precursors of polymorphonuclear leukocytes. 130 bpi is stored in primary granules of mature neutrophils and during inflammation is expressed on their cell membranes and secreted into the extracellular environment. 131 bpi has an even higher affinity for lipopolysaccharide than lbp 132 and shows antibacterial activity specific for gram-negative bacteria. 65 binding of bpi to the gram-negative bacterial membrane results in growth arrest and is an important factor in the antibacterial activity of intact neutrophils. furthermore, bpi binding disrupts normal membrane organization and makes bacteria more susceptible to hydrophobic substances, including antimicrobials. 133 experimentally, recombinant bpi has been shown to protect against the toxic and lethal effects of isolated lipopolysaccharide and intact gram-negative bacteria, and clinical trials in human patients show promising results concerning its therapeutic use. 134 the biology and potential use of bpi in horses has not been evaluated. treatments aimed at inhibiting lipopolysaccharide interaction with cells or turning off intracellular signaling pathways are under investigation. nontoxic lipopolysaccharide or lipid a structures can act as endotoxin antagonists, if they competitively inhibit binding to lbp or cellular receptors or inhibit cellular activation by other mechanisms. of the potential antagonists that have been evaluated experimentally, lipopolysaccharide and lipid a from the phototrophic bacterium rhodobacter sphaeroides, and a synthetic compound (e5531) the structure of which is based on r. sphaeroides lipopolysaccharide, have been most promising. [135] [136] [137] [138] [139] unfortunately, species differences exist regarding cellular response to these structures, and r. sphaeroides lipopolysaccharide acts as a potent inducer of cytokine expression in equine cells. 140 based on results of receptor transfection studies in other species, 141,142 tlr4 is likely responsible for this phenotypic variation. additional compounds including lipopolysaccharide derived from nitrogen-fixing plant bacteria of the species rhizobium are being evaluated to reveal further insight into structural requirements for endotoxin antagonists in horses. nonsteroidal antiinflammatory drugs (nsaids) are probably the most commonly used drugs to treat endotoxemia. the rationale for their use is inhibition of prostaglandin endoperoxide h synthase, that is, cox, and thereby inhibition of prostanoid production (see figure 13 .7-5). additional beneficial effects may include scavenging of oxygen-derived free radicals and iron chelation; however, side effects may occur at dosages required to achieve these effects. 143 prostanoids have been identified as important mediators in the inflammatory response in a number of studies, and inhibition of their synthesis is associated with beneficial effects. two cox isoforms are recognized: constitutively expressed cox-1 and inducible cox-2. upregulation of cox-2 expression results from various proinflammatory stimuli, including lipopolysaccharide, tnf-α, and il-1. 144 constitutively expressed cox products are likely important for maintenance of homeostasis, whereas increased production of prostanoids by cox-2 is thought to be responsible for detrimental effects during inflammation and shock. research has focused on the development of selective cox-2 inhibitors; however, none of these products are currently available for use in horses. in horses the most commonly used nsaid to treat endotoxemia is flunixin meglumine. beneficial effects of flunixin meglumine have been described in experimental models of endotoxemia [145] [146] [147] and in clinical cases. in equine colic patients, treatment with flunixin meglumine before exploratory surgery resulted in reduced plasma concentrations of txb 2 and pge 2 and had a favorable effect on cardiovascular parameters. 148 flunixin meglumine was shown further to maintain cardiac output and systemic arterial blood pressure, improve blood flow to vital organs, reduce pulmonary endothelial damage, and improve survival on endotoxin challenge. [149] [150] [151] [152] nsaid use in horses carries the risk of side effects, most importantly the development of gastrointestinal ulceration and renal papillary necrosis (renal crest necrosis). in a study comparing the side effects of flunixin meglumine (1.1 mg/kg body mass), phenylbutazone (4.4 mg/kg body mass), and ketoprofen (2.2 mg/kg body mass) given 3 times daily for 12 days, lesions of the gastric glandular mucosa occurred most commonly. phenylbutazone resulted in the most severe side effects, which included small intestinal edema, erosions, and ulcers in the large colon and decreased serum albumin concentration. renal crest necrosis occurred more frequently in horses treated with phenylbutazone but also occurred with flunixin meglumine treatment. 153 despite the higher risk of side effects, use of phenylbutazone has been suggested for certain cases. in colic patients, phenylbutazone may provide analgesia and ameliorate endotoxin-induced ileus without masking cardiovascular effects of endotoxin, which are used to determine the necessity of surgical exploration. 154 for similar reasons and to minimize side effects a reduced dose of flunixin meglumine (0.25 mg/kg body mass) has been suggested and is used widely in horses. 155 at this dosage, flunixin meglumine was shown to inhibit eicosanoid synthesis efficiently in an in vivo model of endotoxemia. 156 reduction of clinical signs, however, was dose dependent, and therefore one should choose the appropriate dose based on the circumstances of each case. ketoprofen has been suggested to have superior effects because of a proposed dual inhibitory effect on cox and lipoxygenase and may carry a decreased risk of side effects compared with flunixin meglumine and phenylbutazone. a comparison of cytokine and eicosanoid production by lipopolysaccharide-stimulated isolated monocytes in vitro, however, showed no significant difference between horses pretreated with flunixin meglumine (1.1 mg/kg body mass) or ketoprofen (2.2 mg/kg body mass), respectively. 157 eltenac has been evaluated in an experimental endotoxemia model in horses. 158 given 15 minutes before lipopolysaccharide infusion, eltenac at a dose of 0.5 mg/kg protected against changes in clinical, hemodynamic, and hematologic parameters and blunted the lipopolysaccharide-induced rise in plasma cytokine concentrations in comparison with controls. some parameters, however, including heart rate, leukocyte count, lactate concentration, and plasma tnf activity, were not improved. ibuprofen may have beneficial effects superior to the other nsaids, because it may be possible to achieve tissue concentrations safely that allow iron chelation to occur. according to a study in healthy foals, dosages of ibuprofen up to 25 mg/kg every 8 hours can be given safely for up to 6 days. 143 the use of corticosteroids for antiinflammatory therapy in sepsis and endotoxemia has been controversial in human and equine patients, and beneficial effects superior to the ones achieved by nsaids have not been demonstrated consistently overall. corticosteroids inhibit the activity of phospholipase a 2 and the release of arachidonic acid from cell membrane phospholipids, as well as the production of tnf, il-1, and il-6 in response to a lipopolysaccharide stimulus. experimentally, beneficial effects of dexamethasone in equine endotoxemia have been demonstrated. 159, 160 to inhibit tnf production by equine peritoneal macrophages, however, the required concentration of dexamethasone was high and corresponded to an in vivo dosage (approximately 3 mg/kg body mass) greatly exceeding current recommendations. 159 although single doses of corticosteroids are unlikely to carry a disproportionate risk of side effects, one should consider the suggested association of laminitis with corticosteroid use in horses. in cases of sepsis, further immunosuppressive effects could be detrimental. in human patients with certain types of septic shock, dysfunction of the hypothalamic-pituitary-adrenal axis has been recognized and successfully treated with hydrocortisone replacement therapy. 161 use of corticosteroids for this indication has not been evaluated in horses. pentoxifylline, a methylxanthine derivative and phosphodiesterase inhibitor, has been suggested for use in endotoxemia because of its effects on neutrophil function and its ability to inhibit the production of various cytokines, interferons, and thromboplastin. decreased production of tnf, il-6, txb 2 , and thromboplastin in response to endotoxin was shown in an equine ex vivo model. 162 in horses given endotoxin followed by treatment with pentoxifylline (7.5 mg/kg body mass followed by continuous infusion of 3 mg/kg/hr for 3 hours), however, only minimal beneficial effects were observed. 163 treatment significantly improved body temperature, respiratory rate, and whole blood recalcification time, but no effect was observed regarding heart rate, blood pressure, leukocyte count, plasma fibrinogen concentration, and serum cytokine concentrations. the conclusion was that benefits of treatment with pentoxifylline might be restricted to administration of high bolus doses or continuous infusion early in the pathophysiologic process. in an in vivo endotoxemia model in horses, combination of pentoxifylline (8 mg/kg body mass) and flunixin meglumine (1.1 mg/kg body mass) was found to have greater benefit than each treatment on its own. 164 the currently recommended dosage for oral administration of pentoxifylline is 8 mg/kg every 8 hours. because of its rheologic properties, that is, the ability to increase erythrocyte deformability and microvascular blood flow, pentoxifylline may be particularly useful in endotoxemic patients showing evidence of laminitis. an intravenous preparation of pentoxifylline is not commercially available. dimethyl sulfoxide (dmso) is used frequently in an attempt to scavenge oxygen-derived radicals. the treatment may be most appropriate in cases of ischemia-induced intestinal damage and associated reperfusion injury. however, dmso failed to show beneficial effects in an experimental model of intestinal ischemia when administered on reperfusion of the ischemic intestine. 165 dmso at the commonly used dose of 1 g/kg body mass was shown to increase mucosal loss after ischemia and reperfusion of the large colon, 166 and hence a reduced dose of 0.1 g/kg body mass has been proposed for cases of intestinal ischemia. for intravenous administration, dmso needs to be diluted in polyionic solutions to a concentration not exceeding 10%. oral administration of a 10% to 20% solution via nasogastric intubation is also possible. aside from dmso the xanthine oxidase inhibitor allopurinol has been suggested as a treatment to prevent oxygen radical-induced tissue damage. during periods of ischemia, tissue xanthine dehydrogenase is converted to xanthine oxidase, which on reperfusion catalyzes the generation of superoxide radicals. 167, 168 evaluation in horses showed beneficial effects of 5 mg allopurinol per kilogram body mass administered 12 hours before endotoxin challenge. 169 in another study, mucosal damage attributable to oxygen-derived free radicals was not attenuated by allopurinol in an experimental ischemia-reperfusion model. 166 lidocaine given intravenously has been suggested as an antiinflammatory, analgesic, and prokinetic agent, and some clinicians use it to treat colic and laminitis in horses. in an experimental endotoxemia model in rabbits, lidocaine was found to inhibit hemodynamic and cytokine responses to endotoxin profoundly if given immediately following lipopolysaccharide infusion. 170 use of lidocaine therefore may have additional merit in endotoxemic patients. a common regimen for lidocaine use in horses is administration of an initial bolus (1.3 mg/kg body mass) section 13.7 endotoxemia followed by continuous infusion at a rate of 0.05 mg/ kg/min. one should monitor patients for toxic neurologic effects associated with a lidocaine overdose. high concentrations of ω-3 fatty acids can alter the phospholipid composition of cellular membranes toward a decreased ratio of ω-6 to ω-3 and thereby can affect membrane functions such as phagocytosis, receptor binding, and activities of membrane-bound enzymes. 68 most importantly for the treatment of endotoxemia, ω-3 fatty acid incorporation into cell membranes decreases the availability of arachidonic acid (an ω-6 fatty acid) for eicosanoid synthesis 171 and provides alternative substrates. metabolism of ω-3 fatty acids via the cox and lipoxygenase pathway leads to the production of 3-series prostaglandins and 5-series leukotrienes, which have less biologic activity than their 2-series and 4-series counterparts derived from arachidonic acid. aside from these mechanisms, ω-3 fatty acids prevent lipopolysaccharideinduced upregulation of cd14 in monocytic cells and therefore may be able to block transmembrane signaling of lipopolysaccharide. 172 cells from horses given linseed oil (high in ω-3 fatty acids) for 8 weeks before blood collection showed significantly decreased expression of procoagulant activity, txb 2 , and tnf in response to lipopolysaccharide stimulation. 173, 174 in an in vivo experimental model of endotoxemia in horses, treatment resulted in prolonged activated partial thromboplastin time and whole blood recalcification time, suggesting an anticoagulant effect; however, a significant beneficial effect on clinical response and serum eicosanoid concentrations was not observed. 175 because dietary addition of ω-3 fatty acids requires several weeks of treatment, intravenous infusion was evaluated and shown to alter the composition of cell membrane phospholipids rapidly. 176 further evaluation of this treatment for use in horses is necessary before dosage recommendations can be made. monoclonal and polyclonal antibodies against equine tnf have been evaluated. [177] [178] [179] administration of a monoclonal antibody preparation before lipopolysaccharide infusion resulted in significantly reduced plasma tnf-activity, improved clinical abnormality scores, lower heart rate, and higher leukocyte count compared with controls. 178 furthermore, plasma concentrations of lactate and 6-keto-pgf 1α were reduced significantly, whereas txa 2 production was not affected. 177 in another study, 179 administration of a rabbit polyclonal antibody against recombinant human tnf was unable to improve clinical and hematologic parameters when given shortly (15 minutes) after lipopolysaccharide infusion, although inhibition of tnf activity was present in vitro. 179, 180 findings in horses are in agreement with studies in other species and suggest that beneficial effects of tnf inhibition may be limited to administration before lipopolysaccharide exposure. widespread clinical use therefore is unlikely to become feasible. clinical trials in human patients have not shown significant benefits of tnf antibody treatment. 181, 182 the effects of selective paf receptor antagonists have been evaluated. paf is implicated in the development of systemic hypotension, 183 lipopolysaccharide-induced platelet aggregation, 184 ileus, 185 and increased vascular permeability 186 and may mediate recruitment of leukocytes to inflamed tissues. 187, 188 a study in horses using the paf receptor antagonist sri 63-441 before lipopolysaccharide infusion showed significant decreases in heart rate and shorter elevation of lactate concentrations in response to the treatment. although not statistically significant, additional beneficial effects included delayed onset of fever, a shortened period of neutropenia, and reduced maximal platelet aggregation. 189 whenever possible, the clinician should correct volume and electrolyte deficits, or at least improve them, before anesthetizing a patient for a surgical procedure. for initial resuscitation, polyionic solutions such as lactated ringer's solution given at rates of 10 to 20 ml/kg/hr are appropriate. patients with severe hypovolemia and shock may require higher fluid volumes. a viable alternative to large-volume resuscitation with isotonic fluids is the use of small volumes of hypertonic solutions, which transiently raise plasma osmolality, thereby causing a fluid shift from the interstitial space into the vasculature and rapidly restoring circulating volume. hypertonic saline solution (7.5% sodium chloride) is the most commonly used hypertonic solution and has been shown to have beneficial effects in endotoxemic horses. 190 a dose of 4 ml/kg is recommended, which one should give as a bolus infusion over 10 to 15 minutes, followed by administration of an isotonic solution to restore total body fluid volume. one should use hypertonic saline with caution in patients with sodium and/or chloride derangements and should monitor serum electrolyte concentrations in the case of repeated administration. improvement of the cardiovascular status in response to fluid therapy is indicated by normalization of heart rate, mucous membrane color, and capillary refill time. failure of urination to occur despite appropriate fluid resuscitation should result in critical evaluation of renal function. once one has stabilized the patient, one should choose a maintenance fluid rate to maintain adequate hydration and plasma volume. for adult horses, the maintenance fluid rate is approximately 2 ml/kg/hr, whereas neonatal foals that are not nursing may require larger volumes (4 ml/kg/hr). one should monitor fluid administration carefully in endotoxemic patients, because lowered plasma oncotic pressure caused by hypoproteinemia along with an increased vascular permeability increase the risk of tissue edema formation. furthermore, a rapid increase in total body fluid volume may be detrimental in patients with compromised cardiac and peripheral vasomotor function and may increase the severity of vascular pooling in peripheral organs. in these patients, hypertonic saline or colloids may be more appropriate means of stabilization than large volumes of crystalloid solutions. plasma is an ideal colloid and should be administered to maintain a serum total protein concentration above 4.2 g/dl. 121 to raise plasma protein concentration and colloid osmotic pressure significantly, however, horses often require large volumes of plasma (7 to 10 l or more in a 450-kg horse), and one should consider alternative colloids. furthermore, high-molecular-weight polymers are thought to provide superior oncotic effects in cases of sepsis and endotoxemia, when vascular permeability is increased. hetastarch, or hydroxyethyl starch, (hespan) is commercially available as a 6% solution in 0.9% sodium chloride. hetastarch molecules have very high molecular weight, and degradation must occur before renal excretion. 191 these properties result in a longer plasma half-life and prolonged oncotic effects compared with other colloids; persistence of the oncotic effect for 24 hours was found in hypoproteinemic horses. 192 a dosage of 5 to 15 ml/kg given by slow intravenous infusion along with an equal or greater volume of crystalloid fluids is recommended. 191, 193 in human patients, prolonged activated partial thromboplastin time, decreased factor viii activity, and decreased serum fibrinogen concentration have been described in association with hetastarch use. 194 in the limited number of equine studies, bleeding times were not affected 195, 196 ; however, one should monitor patients treated with hetastarch for coagulopathy. one should base correction of serum electrolyte concentrations on the results of laboratory evaluation. ideally, one should evaluate serum electrolyte concentrations of patients receiving fluid therapy daily. one should take ongoing losses and lack of dietary intake into account, especially when serum concentrations, as in the case of potassium, poorly reflect total body electrolyte stores. potassium supplementation is recommended in patients experiencing prolonged (greater than 48 hours) periods of anorexia. one can add calcium in the form of calcium gluconate, which is available as a 23% solution. based on a study in healthy horses, rates of administration for calcium gluconate in the range of 0.1 to 0.4 mg/kg/min are recommended, 197 and as a guideline, one should administer 0.5 to 1 ml/kg body mass per day of a 23% solution. one can add potassium in the form of potassium chloride or potassium gluconate to intravenous solutions at a dose of 20 to 40 meq/l given at a maintenance rate. administration of potassium should not exceed a rate of 0.5 to 1 meq/kg/hr. metabolic acidosis in endotoxic shock is attributable to lactic acidemia and inadequate tissue perfusion. 198 acid-base balance often improves considerably after fluid resuscitation (preferably with alkalinizing solutions such as lactated ringer's solution) alone; however, additional sodium bicarbonate may be required in cases in which serum bicarbonate concentration remains below 15 meq/l. for adult horses, the bicarbonate deficit (in meq hco 3 ) is calculated as 0.3 × body mass (kg) × base deficit, whereas for foals one should use a factor of 0.5. as a general rule, one should administer half the required amount as a bolus followed by the remaining half over 12 to 24 hours. because endotoxemia is a dynamic process and losses are ongoing, one should reevaluate acid-base status at least once daily. foals with sepsis are frequently hypoglycemic, and 5% dextrose solutions are useful as initial resuscitation fluids. one should reduce the glucose concentration of intravenous solutions according to the blood glucose concentration to avoid prolonged hyperglycemia. administration of hyperimmune plasma (20 to 40 ml/kg body mass) is highly recommended in foals with evidence of partial or complete failure of passive transfer. one should consider positive inotropic and vasomotor agents in patients with persistently inadequate tissue perfusion. lower dosages of dopamine (0.5 to 2 µg/kg/min) result in vasodilation of the renal, mesenteric, coronary, and intracerebral vasculature via dopaminergic effects, whereas higher dosages (up to 10 µg/kg/min) also exert stimulation of β 1 -adrenergic receptors, resulting in increased myocardial contractility and heart rate. 199 dobutamine is a direct β 1 -adrenergic agonist and does not appear to have significant vasodilator properties. dosages for dobutamine of 1 to 5 µg/kg/min as continuous intravenous infusion have been recommended for use in horses. in addition, norepinephrine was evaluated in hypotensive critically ill foals that were refractory to the effects of dopamine and dobutamine. 200 at dosages up to 1.5 µg/kg/min administered concurrently with dobutamine, six out of seven foals showed an increase in mean arterial pressure, and all foals had increased urine output. because of the risk of cardiac side effects, close monitoring of heart rate and rhythm should accompany infusion of inotropes. indirect blood pressure measurements using a tail cuff may be used to monitor the effects of treatment. more frequently than overt thrombosis or bleeding attributable to dic, hemostatic abnormalities occur in the form of alterations in the coagulation profile. a procoagulant state with shortened bleeding times or prolonged bleeding times caused by consumption of clotting factors may be evident. one should address abnormalities in the coagulation profile as early as possible but especially if they persist more than 24 hours after initiation of therapy. because of the complex interactions of coagulation and fibrinolysis during endotoxemia, one should combine anticoagulant therapy with the administration of fresh frozen plasma to replace clotting and fibrinolytic factors. heparin acts as an anticoagulant by activation of at iii and subsequent inhibition of thrombin, release of tissue factor pathway inhibitor from endothelial cells, and inhibition of platelet aggregation. 201 because endogenous at iii levels frequently are decreased in patients with coagulopathy, addition of heparin to fresh frozen plasma may be the most effective route of administration. an initial dose of 100 iu/kg body mass followed by 40 to 80 iu/kg body mass 3 times daily has been recommended. 121 anemia caused by erythrocyte agglutination occurs in some patients during therapy with unfractionated heparin 202,203 but typically resolves within 96 hours if therapy is discontinued. 121 because of the risk of microthrombosis associated with erythrocyte agglutination, use of low-molecular-weight heparin (50 iu/kg body mass subcutaneously every 24 hours) has been recommended 204 but may be cost-prohibitive. one may give aspirin orally (10 to 20 mg/kg body mass, every 48 hours), which irreversibly inhibits platelet cox activity, to inhibit platelet aggregation and microthrombosis. platelet hyperaggregability has been implicated in the pathogenesis of carbohydrate-induced laminitis, 205 and heparin and aspirin have been recommended to prevent development of laminitis. in an in vitro study, however, aspirin did not inhibit endotoxin-induced platelet aggregation. 206 luteolysis caused by increased concentrations of pgf 2α leads to pregnancy loss in endotoxemic mares before day 55 of pregnancy. 207 daily administration of altrenogest (regu-mate, hoechst-roussel agri-vet, somerville, new jersey) at a dose of 44 mg orally consistently prevented fetal loss in mares if administered until day 70 of pregnancy. 100 treatment with flunixin meglumine, by blockade of pgf 2α release, 101 also may contribute to the maintenance of pregnancy in endotoxemic mares. the pathogenesis of fetal loss and abortion caused by endotoxemia, surgery, or systemic disease later in gestation is not understood completely. proposed mechanisms include direct effects on the fetus, placental function, or placental progesterone production. 208 the pathophysiology of laminitis caused by endotoxemia is understood incompletely; however, decreased digital blood flow 209, 210 and intravascular microthrombosis have been implicated. decreased no production by vascular endothelial cells in response to endotoxin has been suggested as a mechanism for vasoconstriction and decreased blood flow 211 ; however, use of no donors remains controversial. maintenance of adequate peripheral perfusion and anticoagulant and antiinflammatory therapy may be helpful in preventing and treating laminitis caused by endotoxemia. although the innate immune response to endotoxin (lipopolysaccharide) is crucially important for the preservation of homeostasis and health, large amounts of endotoxin can evoke an excessive and uncontrolled inflammatory response and result in a dysfunction of hemostatic and circulatory control mechanisms, loss of vascular integrity, and finally tissue damage. conditions commonly associated with the development of endotoxemia in horses are acute gastrointestinal diseases, especially of ischemic and severe inflammatory nature, and localized or generalized infections. although measuring endotoxin concentrations in equine plasma is possible, this is not feasible in a clinical setting, and one typically reaches a diagnosis of endotoxemia based on clinical signs and clinicopathologic data. successful treatment of endotoxemia requires resolution of the primary disease process in addition to neutralization of circulating endotoxin, interference with the activities of inflammatory mediators, and general supportive care. newer treatments, such as blockade of endotoxin-interaction with cells or interruption of cell signaling pathways, are under investigation. possible sequelae of endotoxemia include dic, multiple organ failure, circulatory failure, and death. frequently, the outcome of conditions associated with endotoxemia in horses depends on the severity of associated complications; for example, renal compromise, laminitis, and abortion. resting state the lateral margins of the vesicle, that is, the buccal mucosa, are in close contact with the cheek teeth. caudally, the external space communicates with the pharynx through the aditus pharyngis. the mucous membrane of the mouth is continuous at the margin of the lips with the skin and during life is chiefly pink but can be more or less pigmented, depending on the skin color and the breed type. the lips are two muscular membranous folds that unite at angles close to the first cheek teeth. each lip presents an outer and an inner surface. the upper lip has a shallow median furrow (philtrum); the lower lip has a rounded prominence or chin (mentum). the internal surface is covered with a thick mucous membrane that contains small, pitted surfaces that are the openings of the ducts of the labial glands. small folds of the mucous membrane called the frenula labii pass from the lips to the gum. the free border of the lip is dense and bears short, stiff hairs. the arteries of the mouth are derived from the maxillary, mandibular, labial, and sphenopalatine arteries of the major palatine artery. the veins drain chiefly to the lingual facial vein. sensory nerves originate from the trigeminal nerve (cranial nerve v) and the motor nerves from the facial nerve (vii). the cheeks spread back from the lips and form both sides of the mouth and are attached to the alveolar borders of the bones of the jaws. the cheeks are composed of skin and muscular and glandular layers and then the internal mucous membrane. the skin is thin and pliable. in contrast, the oral mucous membrane is dense and in many areas of the oral cavity is attached firmly to the periosteum so that construction of oral mucosal flaps can be achieved only by horizontal division of the periosteal attachment. such a feature is important in reconstructive techniques applied to the oral cavity. the blood supply to the cheeks comes from the facial and buccal arteries and the sensory nerves from the trigeminal and motor nerves from the facial nerve. the hard palate (palatum durum) is bounded rostrally and laterally by the alveolar arches and is continuous with the soft palate caudally. the hard palate has a central raphe that divides the surface into two equal portions. the word mouth is used commonly to signify the first part of the alimentary canal or the entrance to it. 1 the mouth is bounded laterally by the cheeks, dorsally by the palate, and ventrally by the body of the mandible and by the mylohyoideus muscles. the caudal margin is the soft palate. the mouth of the horse is long and cylindric, and when the lips are closed, the contained structures almost fill the cavity. a small space remains between the root of the tongue and the epiglottis and is termed the oropharynx. the cavity of the mouth is subdivided into sections by the teeth. the space external to the teeth and enclosed by the lips is termed the vesicle of the mouth, and in the enter the nose from the glands of the vomeronasal duct. to what extent these secretions aid in pheromone reception is not known. 2 that portion of the palatine mucosa immediately behind the incisor teeth frequently is swollen (lampas) during eruption of the permanent teeth. this swelling is physiologic and not pathologic. the tongue is situated on the floor of the mouth between the bodies of the mandible and is supported by the sling formed by the mylohyoideus muscles. the root of the tongue is attached to the hyoid bone, soft palate, and pharynx. the upper surface and the rostral portion of the tongue are free; the body of the tongue has three surfaces. the apex of the tongue is spatulate and has a rounded border. the mucous membrane adheres intimately to the adjacent structure and on the dorsum is dense and thick. the lingual and sublingual arteries supply the tongue from the linguofacial trunk and matching veins. the linguofacial trunk drains into the linguofacial vein. the lingual muscles are innervated by the hypoglossal nerve (xii) and the sensory supply is from the lingual and glossopharyngeal (ix) nerves. the formula for the deciduous teeth of the horse is 2 times i3-3 c0-0 p3-3 for a total of 24. the permanent dental formula is 2 times i3-3 c1-1 p3-3 or p4-3 m3-3 for a total of 40 or 42. in the mare the canine teeth are usually small or do not erupt, hence reducing the number to 36 or 38. the first premolar tooth (wolf tooth) is often absent and has been reported as occurring in only 20% of the upper dentition of thoroughbred horses. 3 the teeth of the horse are complex in shape and are compounded of different materials (dentin, cementum, and enamel). they function as grinding blades to masticate and macerate cellulose food in the important first stage of the digestive process. the cheek teeth in the horse are a well-documented feature of the evolution of equus caballus. the first incisor is present at birth or the first week of life. the second incisor erupts at 4 to 6 weeks of age; the third incisor, at 6 to 9 months of age; the first and second premolars, at birth to 2 weeks of age; and the third premolar, 3 months of age. the eruption times for the permanent teeth are as follows: first incisor, 2 1 / 2 years of age; second incisor, 3 1 / 2 years of age; third incisor, 4 1 / 2 years of age; the canine tooth, 4 to 5 years of age; the first premolar (wolf tooth), 5 to 6 months of age; the second premolar, 2 1 / 2 years of age; the third premolar, 3 years of age; the fourth premolar, 4 years of age; the first molar, 10 to 12 months of age; the second molar, 2 years of age; and the third molar, 3 1 / 2 to 4 years of age. this eruption sequence clearly indicates that the eruption of the second and third permanent premolar teeth give the potential for dental impaction. the modern horse has six incisor teeth in each jaw that are placed close together so that the labile edges form a semicircle. the occlusal surface has a deep enamel invagination (infundibulum) that is filled only partially with cementum. as the incisor teeth wear, a characteristic pattern forms in which the infundibulum is surrounded by rings of enamel, dentin, enamel, and crown cementum in a concentric pattern. each incisor tooth tapers from a broad crown to a narrow root so that as the midportion of the incisor is exposed to wear, the cross-sectional diameters are about equal; that is, at 14 years of age, the central incisor tooth of the horse has an occlusal surface that is an equilateral triangle. observations on the state of eruption, the angles of incidence of the incisor teeth, and the pattern of the occlusal surfaces are used as guides for aging of horses. the canine teeth are simple teeth without complex crowns and are curved. the crown is compressed and is smooth on its labial aspect but carries two ridges on its lingual aspect. no occlusal contact occurs between the upper and lower canine teeth. when erupted, the six cheek teeth of the horse function as a single unit in the mastication of food. each arcade consists of three premolar and three molar teeth. the maxillary arcade is slightly curved, and the teeth have a square occlusal surface. the occlusal surfaces of the mandibular teeth are more oblong, and each arcade is straighter. the horse is anisognathic, that is, the distance between the mandibular teeth is narrower (one-third) than the distance between the upper cheek teeth. this anatomic arrangement affects the inclination of the dental arcade as the jaws slide across each other in the food preparation process. the unworn upper cheek tooth presents a surface with two undulating and narrow ridges, one of which is lateral and the other medial. on the rostral and lingual side of the medial style is an extra hillock. the central portion of these surfaces is indented by two depressions that are comparable with, but much deeper than, the infundibula of the incisor teeth. when the teeth have been subjected to wear, the enamel that closed the ridges is worn through and the underlying dentin appears on the surface. thus after a time the chewing surface displays a complicated pattern that may be likened to the outline of an ornate letter b, the upright stroke of the b being on the lingual aspect. dentin supports the enamel internally, cementum supports the enamel lakes, and the peripheral cementum fills in the spaces between the teeth so that all six teeth may function as a single unit, that is, the dental arcade. transverse ridges cross each tooth so that the whole maxillary arcade consists of a serrated edge. the serrations are formed so that a valley is present at the area of contact with adjacent teeth. these serrations match fitting serrations on the mandibular arcade. the true roots of the cheek teeth are short compared with the total length of the tooth. cheek teeth have three roots: two small lateral roots and one large medial root. by custom, that portion of the crown embedded within the dental alveolus is referred to as the reserve crown, and the term root is confined to that area of the tooth that is comparatively short and enamel free. wear on the tooth gradually exposes the reserve crown, and the roots lengthen. in an adult 1000-lb horse the maxillary cheek teeth are between 8.0 and 8.5 cm in length. dental wear accounts for erosion and loss of tooth substance at a rate of 2 mm/yr. the pulp chambers of the teeth are also complex. the incisors and canines have a single pulp chamber. the mandibular cheek teeth have two roots and two separate pulp chambers. the maxillary cheek teeth, although they have three roots, have in fact five pulp chambers. as occlusal wear proceeds, deposition of secondary dentin within the pulp chambers protects the chambers (e.g., the dental star, medial to the infundibulum on the incisor teeth). in the mandibular cheek teeth the transverse folding of the enamel anlage (during morphogenesis of the tooth) does not take place, and the occlusal surface is a simple surface of central dentin surrounded by enamel. each tooth then is conformed to a single arcade by the presence of peripheral crown cementum. the oral cavity and oropharynx are subject to a variety of diseases. however, many conditions affecting the first portion of the alimentary system produce the same clinical signs, regardless of their cause. the clinical signs may include inappetance or reluctance to eat, pain on eating or swallowing, oral swelling, oral discharge, and fetid breath. affected animals may show some interest in food but hesitate to eat it. salivation may be excessive and may be contaminated with purulent exudate or blood. the occurrence of bruxism (i.e., grinding of teeth) can indicate discomfort in other areas of the alimentary tract; for example, bruxism and frothing oral saliva are characteristic features of gastric ulceration in the horse. the clinician needs to be aware that considerable weight loss can occur rapidly with inability to feed and swallow. diseases that result in denervation of the pharynx and inappropriate swallowing can have the complication of inhalation pneumonia. after a complete physical examination and ascertaining the history, the clinician should approach examination of the mouth systematically in all cases. one can examine a considerable portion of the mouth and teeth from the outside by palpation of the structures through the folds of the cheek. most horses allow an oral examination without sedation or the use of an oral speculum. in many cases, however, one best achieves the detailed oral examination by sedation and the use of an oral speculum and a light source. one should irrigate the mouth to wash out retained food material so as to be able to inspect and palpate the lips, cheeks, teeth, and gums. the classic signs of dental disease in the horse include difficulty and slowness in feeding, together with a progressive unthriftiness and loss of body condition. in some instances, the horse may quid, that is, it may drop poorly masticated food boluses from the mouth, and halitosis may be obvious. additional problems reported by owners include bitting and riding problems and headshaking or head shyness. facial or mandibular swelling may occur. nasal discharge can result from dental disease associated with maxillary sinus empyema. mandibular fistulae frequently are caused by lower cheek tooth apical infections. some correlation exists between the age of the animal and clinical signs (table 13 .8-1). ancillary aids for a complete examination of the oral cavity of the horse may include radiology, endoscopic examination, fluoroscopy, biopsy, and culture. one should take care always during endoscopic evaluation of the oral cavity using a flexible endoscope. the author recommends sedation and the use of an oral speculum to prevent inadvertent mastication of the endoscope. if one uses general anesthesia as part of the diagnostic workup, then endoscopic evaluation of the oral cavity is much easier. in selected cases, advanced imaging technologies such as computed tomography, magnetic resonance imaging, or nuclear scintigraphy may be beneficial. the lips of the horse are mobile and prehensile. in many ways they function like the tip of the elephant's trunk in that they test, manipulate, and sample the environment for potential nutritive value. consequently, loss of motor function (e.g., facial palsy) affects the efficiency of the prehensile system. the lips grasp food in grazing or browsing, and the incisor teeth section the food. with mastication and lubrication with saliva, the bolus of food forms and is manipulated from side to side across the mouth, assisted by the tight cheeks of the horse and the palatine ridges. swallowing begins as the food bolus contacts the base of the tongue and the pharyngeal walls. during swallowing, the soft palate elevates to close the nasopharynx, the base of the tongue elevates, and the hyoid bone and the larynx move rostrally following contraction of the hyoid muscles. during this process, the rima glottidis closes and the epiglottis tilts dorsally and caudally to protect the airway so that food is swept through lateral food channels around the sides of the larynx into the laryngoesophagus. fluoroscopic studies in nursing foals in the dorsoventral view showed that contact occurs between the lateral food channels in the midline so that in outline the food bolus achieves a bow tie shape. 4 dysphagia is defined as a difficulty or inability to swallow. anatomic classifications for dysphagia include prepharyngeal, pharyngeal, and esophageal (postpharyngeal) dysphagias. the site of the cause for dysphagia influences the clinical signs. prepharyngeal dysphagia is characterized by dropping food (quidding) or water from the mouth, reluctance to chew, hypersalivation, or abnormalities in prehension. pharyngeal and esophageal dysphagias are characterized by coughing; nasal discharge containing saliva, water, or food material; gagging; anxiousness; and neck extension during attempts to swallow. the following section describes esophageal dysphagia in more detail. causes of dysphagia can be divided into four types: painful, muscular, neurologic, or obstructive (table 13 .8-2). pain and obstruction cause dysphagia by interfering with the mechanics of prehension, bolus formation and transfer to the pharynx, and deglutition. muscular and neurologic causes of dysphagia impede prehension and swallowing by affecting the motor function of the lingual or buccal musculature, muscles of mastication (temporal and masseters), and pharyngeal and cranial esophageal muscles. sensory loss to the lips, buccal mucous membranes, pharynx, or tongue also may cause dysphagia. neurologic causes of dysphagia may affect the forebrain, brainstem, or peripheral nerves that control prehension (cranial nerves vm, vs, vii, and xii), transfer of the food bolus to the pharynx (cranial nerves vs and xii) and swallowing (cranial nerves ix and x). diagnosis of the cause of dysphagia is based on physical examination including a careful oral examination, neurologic examination, clinical signs, and endoscopy of the pharynx, esophagus, and guttural pouches. radiology may be useful to assess the bony structures of the head and throat. ultrasonography is valuable for examining the retropharyngeal space and esophagus to detect and evaluate masses. one may detect pharyngeal or esophageal causes of dysphagia with routine endoscopic examination or with contrast radiography. although one also can use endoscopy to assess deglutition, one must remember that sedation adversely affects the deglutition mechanism. one may assess deglutition using fluoroscopy 4 or manometry, 5 but these techniques require specialized equipment. specific diagnostic procedures for nonalimentary causes of dysphagia are covered elsewhere in this text (see chapter 3). specific treatments aimed at resolving the underlying disorder causing dysphagia are discussed in detail elsewhere. one should avoid feeding roughage with long fiber length (hay or grass) to most horses with dysphagia. dietary modifications that promote swallowing such as feeding slurries made from complete pelleted feeds may be sufficient to manage some cases of partial dysphagia. one must take care to prevent or avoid aspiration pneumonia in horses with pharyngeal or esophageal dysphagia. one can manage foals by feeding mare's milk or a suitable substitute through a nasogastric tube. one also may administer pellet slurries or formulated liquid diets via nasogastric tubes to older horses. prolonged nutritional management of dysphagic horses may require extraoral feeding using a tube placed through an esophagostomy. 6 formulated pelleted diets are often easy to administer through a tube as slurry and are balanced to meet the nutritional requirements for healthy horses. one must feed sufficient quantities to deliver adequate calories (16 to 17 mcal/day for a 500-kg horse). adjustments may be necessary for horses that are cachectic or have extra metabolic demand (such as pregnancy). adding corn oil to the ration (1 cup every 12 or 24 hours) is a common method of increasing fed calories. liquid diets also have been used for enteral feeding 7 but may not be tolerated as well as pelleted diets. regardless of the method of nutritional management, one must monitor and replace salivary losses of electrolytes. saliva contains high concentrations of na, k, and cl. a group of ponies with experimental esophagostomies 8 and a horse with esophageal squamous cell carcinoma 9 were fed a complete pelleted diet through esophagostomy tubes but developed metabolic acidosis, hyponatremia, and hypochloremia apparently because of salivary losses. surprisingly, salivary losses of potassium did not result in hypokalemia in these cases, presumably because of replacement in the diet. however, if the diet is deficient in potassium, hypokalemia may result. one often can accomplish electrolyte replacement by adding nacl and kcl to the diet. one can maintain horses for months with frequent feedings through an esophagostomy tube. 9 parenteral nutrition (total or partial) may be useful in the short term but is not often feasible for long-term management. tooth eruption is a complex phenomenon involving the interplay of dental morphogenesis and those vascular forces responsible for creating the eruption pathway. these changes are responsible for osteitis and bone remodeling within the maxilla and mandible. young horses frequently show symmetric bony swelling resulting from these eruption cysts. in some cases, additional clinical signs of nasal obstruction with respiratory stridor or nasal discharges may be apparent. pathologic problems associated with maleruption include a variety of dental diseases. oral trauma can displace or damage erupting teeth or the permanent tooth buds. as a result, teeth may be displaced and erupt in abnormal positions or may have abnormal shapes. supernumerary teeth, incisors and molars, can develop, as well as palatal displacement of impacted teeth (maxillary p3-3, or third cheek tooth). in almost all of these conditions some form of surgical treatment is necessary. significant evidence from the location of apical osteitis in diseased teeth (table 13 .8-3) confirms that dental impaction is a major cause of dental disease in the horse. in a series of 142 extracted teeth, 63 were p3-3 or p4-4 (cheek tooth 2 or 3, respectively). 10 early observations had indicated that the first molar (m1, or cheek tooth 4) was the most commonly diseased tooth, and an "open infundibulum" in this tooth has been suggested as the cause. 11 studies on cementogenesis of the maxillary cheek teeth have shown, however, that in fact most maxillary cheek teeth have a greater or lesser degree of hypoplasia of cementum within the enamel lakes and that this "lesion" rarely expands into the pulp. the central infundibular hole is the site of its vascular supply to the unerupted cement lake. on those occasions in which cases one can use apicoectomy and retrograde endodontic techniques to save the diseased tooth. one must take care, however, in selection of patients. in most cases of apical osteitis in the horse that result from dental impaction, immature root structures make achieving an apical seal of the exposed pulp difficult. gingival hyperemia and inflammation occur during the eruption of the permanent teeth and are common causes of a sore mouth in young horses (particularly 3-year-olds as the first dental caps loosen). such periodontal changes usually resolve as the permanent dental arcade is established. during normal mastication, the shearing forces generated by the occlusal contact of the cheek teeth essentially clean the teeth of plaque and effectively inhibit deposition of dental calculus. wherever occlusal contact is ineffective, periodontal changes and calculus buildup occur; for example, the deposition of calculus on the canine teeth of mature geldings and stallions is common. routine dental prophylaxis forms an important component of maintaining normal occlusal contact, and for this reason one should remove arcade irregularities that result in enamel point formation on the buccal edges of the maxillary cheek teeth and the lingual edges of the mandibular cheek teeth. one should remove these edges annually in horses that are at grass and twice yearly in young horses, aged horses, and stabled horses. horses at grass have been shown to have a greater range of occlusal contact and therefore better periodontal hygiene than stabled horses. in stabled horses the range of occlusal contact is narrower and the formation of enamel points occurs more frequently with subsequent buccal ulceration and the initiation of a cycle of altered occlusal contact and hence irregular arcade formation. this process leads to severe forms of periodontal disease and wave mouth formation. periodontal disease occurs with abnormal occlusal contact and initiation of the cycle of irregular wear and abnormal contact. such changes progress to loss of alveolar bone, gross periodontal sepsis, and loss of tooth support. in this sense periodontal disease truly is the scourge of the equine mouth and results in tooth loss. 13 palatine clefts may result from an inherited defect and are caused by failure of the transverse palatal folds to fuse in the oral cavity. harelip accompanies few palatine clefts in the horse. the degree of palatine clefting depends on the stage at which interruption in the fusion of the 852 part ii disorders of specific body systems caries of cementum occurs, that is, secondary inflammatory disease and acid necrosis of the cementum, apical osteitis may develop. pulpitis is key to the pathogenesis of dental decay in the horse. the initiation of inflammatory pulp changes may be a sequela to dental impaction or dental caries or may result from fracture of a tooth. if the onset of the inflammatory process is slow, then formation of secondary dentin within the pulp chambers may protect the pulp and the tooth. secondary dentin formation occurs from stimulation of odontoblasts within the pulp chamber. such changes are the normal process of protection during dental wear and attrition as crown substances wear away and the reserve crown comes into wear. in acute disease, however, this defense mechanism is ineffective, and the changes that occur and that are sequelae to pulpitis reflect the location of each affected tooth. for example, pulpitis and apical osteitis of the third mandibular cheek tooth most commonly results in the development of a mandibular dental fistula. pulpitis of the third maxillary cheek tooth, however, results in an inflammatory disease within the rostral maxillary sinus and in development of chronic maxillary sinus empyema (figure 13.8-1) . oblique radiographs greatly assist the diagnosis of dental decay by demonstrating sinus tract formation, sequestration of bone, mandibular osteitis, hyperplasia of cementum, and new bone formation (so-called alveolar periosteitis). 12 the management of dental decay in the horse usually involves surgical extraction of the diseased tooth. in some palatopalatal folds occurs. toxic or teratogenic effects are documented in other species, but little data are available in the horse. in recent years, treatment for repair of uncomplicated palatine defects has been recommended but prognosis is generally poor because of the considerable nursing care required and the high incidence of surgical failures. one should emphasize early surgery and the use of mandibular symphysiotomy in affording surgical exposure. the combination of mandibular symphysiotomy and transhyoid pharyngotomy to approach the caudal margins of the soft palate affords surgical access, and one can construct mucosal flaps to repair the defects. however, the incidence of surgical breakdown is high, and healing by first intention is the exception rather than the rule. a recent surgical report documented the successful closure of a median cleft of the lower lip and mandible in a donkey. 14 foals born with a severely deviated premaxilla and palate have a wry nose. one can achieve surgical correction of the deviated premaxilla by submucosal division of the premaxilla across the nose at the line of the first cheek tooth. circumstantial evidence indicates that such a defect has a genetic cause, and the defect occurs most frequently in the arabian breed. other developmental abnormalities are subepiglottic cysts resulting from cystic distortion of remnants of the thyroglossal duct, which may cause dyspnea and choking in foals. surgical removal of these cysts results in normal function. the most significant developmental defect of dental origin is a maxilla that is longer than the mandible, that is, the horse is parrot-mouthed. an overbite of 2 cm in the incisor arcade may be present in a horse with a mismatch of less than 1 cm between the first upper and lower cheek teeth. parrot mouth and monkey or sow mouth are thought to be inherited conditions. some correction of minor incisor malocclusion occurs up to 5 years of age. recognition and detection of parrot mouth are important in the examination of potential breeding stock. surgical attempts to inhibit overgrowth of the premaxilla by wiring or by the application of dental bite plate procedures have been documented in recent years. 15 as has been indicated, the horse is by nature a curious animal and uses its lips as a means of exploring a variety of objects. wounds of the lips, incisive bone, and the mandibular incisor area occur commonly in the horse and usually result from the horse getting the lips, jaw, or teeth caught in feeding buckets, in fence posts, or in halters or having a segment of tongue encircled with hair in tail chewing. as the horse panics and pulls away from its oral entrapment, considerable trauma can occur to the lips, teeth, and gums. most wounds repair satisfactorily, provided one finds them early and observes the basic principles of wound hygiene, excision of necrotic tissue, and wound closure. one must ensure that oral mucosal defects are closed and that effective oral seals are made before external wounds are closed. in some cases, offering specially constructed diets or even feeding the horse by nasogastric tube or esophagostomy during the healing processes may be necessary. foreign body penetration of the tongue, cheek, or palate has been reported in grazing and browsing horses and in particular in horses that have certain hay sources that contain desiccated barley awns or yellow bristle grass. 16 other plant material and grass awns also occasionally may penetrate the tongue, gingiva, or cheek, causing inflammation or abscesses. ulcerative stomatitis also results from the toxicity of phenylbutazone therapy. 17 vesicular stomatitis is a highly contagious viral blistering disease described in more detail elsewhere. treatment of glossitis and stomatitis primarily aims at removing the inciting cause. actinobacillus lignieresii, the causative agent of actinobacillosis, has been isolated and identified from ulcers on the free border of the soft palate and oral and laryngeal granulomata. the bacterium also was reported in a sublingual caruncle in a horse with a greatly swollen tongue. 18 therapy with 150 ml of 20% sodium iodide and 5 g of ampicillin every 8 to 12 hours effected a clinical cure. saliva is important for lubricating and softening food material. the horse has paired parotid, mandibular, and polystomatic sublingual salivary glands. the parotid gland is the largest of the salivary glands in the horse and is situated in the space between the ramus of the mandible and the wing of the atlas. the parotid duct is formed at the ventral part of the gland near the facial crest by the union of three or four smaller ducts. the duct leaves the gland above the linguofacial vein, crosses the tendon of the sternocephalicus muscle, and enters the mouth obliquely in the cheek opposite the third upper cheek tooth. the parotic duct orifice is small, but some dilation of the duct and a circular mucous fold (the parotid papillae) exist at this point. the mandibular gland is smaller than the parotid gland and extends from the atlantal fossa to the basihyoid bone. for the most part, the mandibular gland is covered by the parotid gland and by the lower jaw. the mandibular duct is formed by union of a number of small duct radicles that emerge along the concave edge of the gland and run rostral to the border of the mouth opposite the canine tooth. the orifice is at the end of a sublingual caruncle. the mandibular gland possesses serous, mucous, and mixed alveolar glandular components. the parotid gland is a compound alveolar serous gland. the parotid salivary gland can secrete saliva to yield rates of 50 ml/min, and a total daily parotid secretion can be as much as 12 l in a 500-kg horse. parotid secretion only occurs during mastication, and administration of atropine or anesthesia of the oral mucosa can block secretion. parotid saliva is hypotonic compared with plasma, but at high rates of flow, concentrations of sodium, chloride, and bicarbonate ions increase. parotid saliva of the horse has a high concentration of calcium, and occasionally calculi (sialoliths) form within the duct radicles of the parotid salivary gland. 19 congenital parotid duct atresia, acquired stricture from trauma to the duct, or obstruction by plant material (sticks or foxtails and other seeds) also may occur. the clinical signs of sialolithiasis or other forms of ductule obstruction include a fluid swelling in the form of a mucocele proximal to the stone and occasionally inflammation of the parotid gland. ultrasonography is useful to diagnose salivary mucoceles and to detect foreign bodies or sialoliths. measurement of electrolyte concentrations in aspirates from suspected mucoceles might be helpful to distinguish them from hematomas. salivary potassium and calcium concentrations are higher than plasma. treatment may require surgical removal of the stone or plant material in the case of sialolithiasis or foreign body obstructions. other causes of obstruction may require resection of the affected portion of the duct or chemical ablation of the gland. 20 primary sialoadenitis is unusual but can occur in one or both glands. the condition is painful and may be associated with a fever and anorexia. secondary sialoadenitis is more common and usually is associated with trauma. infectious sialoadenitis from corynebacterium pseudotuberculosis 21 or other bacterial pathogens also may occur. diagnosis is by physical examination and by finding an enlarged edematous parotid gland tissue on ultrasonographic examination. culture and cytologic examination of aspirates may be useful for diagnostic purposes. treatment in usually palliative, consisting of nonsteroidal antiinflammatory drugs. appropriate antibiotic therapy is indicated as directed by culture and sensitivity results. chemical irritation, glossitis, stomatitis, or other causes of prepharyngeal dysphagia cause ptyalism or excessive salivation in horses. specific therapy for the ptyalism usually is not required as long as salivary losses are not excessive, resulting in dehydration and electrolyte imbalances. ingestion of the fungal toxin slaframine also causes hypersalivation in horses. 22 the fungus rhizoctonia leguminicola, which produces slaframine, causes black patch disease in red clover. slaframine is a parasympathomimetic compound that stimulates exocrine secretion in the parotid gland. slaframine toxicosis most commonly occurs in the spring or early summer and rarely requires treatment other than removal from the pasture. mowing removes the source in most cases because regrowth in pastures often has less fungal contamination. 23 15. the esophagus has no digestive or absorptive functions and serves as a conduit to the stomach for food, water, and salivary secretions. the esophageal mucosa is a keratinized stratified squamous epithelium. 1 the submucosa contains elastic fibers that contribute to the longitudinal folds of the esophagus and confer elasticity to the esophageal wall. a transition occurs in the muscle type composing the tunica muscularis from striated skeletal muscle in the proximal two thirds of the esophagus to smooth muscle in the distal third. in the proximal esophagus the skeletal muscle layers spiral across one another at angles. within the smooth muscle layers of the distal esophagus the outer layer becomes more longitudinal, whereas the inner layer thickens and becomes circular. the wall of the terminal esophagus can be 1 to 2 cm thick. deep cervical fascia, pleura, and peritoneum contribute to the thin fibrous tunica adventitia of the esophagus. motor innervation to the striated skeletal muscle of the esophagus includes the pharyngeal and esophageal branches of the vagus nerve, which originate in the nucleus ambiguus of the medulla oblongata. parasympathetic fibers of the vagus nerve supply the smooth muscle of the distal esophagus. sympathetic innervation of the esophagus is minimal. passage of ingesta through the esophagus can be considered part of the swallowing process, which consists of oral, pharyngeal, and esophageal stages. the oral stage is voluntary and involves transport of the food bolus from the mouth into the oropharynx. during the involuntary pharyngeal stage the food bolus is forced through the momentarily relaxed upper esophageal sphincter by simultaneous contractions of the pharyngeal muscles. in the esophageal phase of swallowing the upper esophageal sphincter closes immediately, the lower esophageal sphincter opens, and esophageal peristalsis propels the bolus into the stomach. 2 unlike a food bolus, liquids do not require peristalsis to reach the lower esophageal sphincter and may precede the food bolus during swallowing. the upper esophageal sphincter prevents esophagopharyngeal reflux during swallowing and air distention of the esophagus during inspiration. upper esophageal pressure increases in response to pressure from a food bolus and to increased intraluminal acidity, as would occur with gastroesophageal reflux. the lower esophageal sphincter is a smooth muscle located at the gastroesophageal junction that is morphologically ill defined but forms an effective functional barrier. 2 normally the lower esophageal sphincter is closed in response to gastric distention to restrict gastroesophageal reflux. relaxation of the lower esophageal sphincter permits passage of ingested material from the esophagus to the stomach. distention of the stomach with ingesta mechanically constricts the lower esophageal sphincter. gastric distention also triggers a the esophagus is a musculomembranous tube that originates from the pharynx dorsal to the larynx and terminates at the cardia of the stomach. 1 in adult thoroughbred horses the esophagus is approximately 120 cm long. the cervical portion is approximately 70 cm long; the thoracic portion, approximately 50 cm long; and the short abdominal portion, only approximately 2 cm long. the cervical esophagus generally lies dorsal and to the left of the trachea in the cervical region. in the thorax the esophagus courses through the mediastinum lying dorsal to the trachea and crosses to the right of the aortic arch dorsal to the heart base. impactions. intramural causes of esophageal obstruction include tumors (squamous cell carcinoma), strictures, diverticula, and cysts. [3] [4] [5] [6] [7] [8] [9] [10] mediastinal or cervical masses (tumors or abscesses) may cause extramural obstructions. congenital anomalies are covered in detail later. the clinician must perform a thorough physical examination, including complete oral and neurologic examination, to help rule out causes of dysphagia and nasal discharge other than esophageal obstruction. the clinical signs associated with esophageal obstructions are related primarily to regurgitation of food, water, and saliva caused by esophageal (postpharyngeal) dysphagia. 11 horses with esophageal obstruction are often anxious and stand with their neck extended. one may note gagging or retching, particularly with acute proximal obstructions. bilateral frothy nasal discharge containing saliva, water, and food material; coughing; odynophagia; and ptyalism are characteristic clinical signs, the severity of which varies with the degree and location of the obstruction. distention in the jugular furrow may be evident at the site of obstruction. one may observe other clinical signs related to regurgitation of saliva, water, and food material, such as dehydration, electrolyte or acid-base imbalances, weight loss, and aspiration pneumonia. in extreme cases, pressure necrosis from the impaction or trauma to the esophagus may cause esophageal rupture. if the rupture is in the cervical esophagus, crepitus or cellulitis may be evident along with signs of systemic inflammation. thoracic auscultation is important to determine whether aspiration pneumonia is present. intrathoracic esophageal rupture may result in pleuritis and its associated clinical signs. passage of a nasogastric tube is an effective way to detect and localize an obstruction but provides little information about the nature of the obstruction or the condition of the esophagus. the most direct method for diagnosis of esophageal obstructions is endoscopic examination. most cases of esophageal obstruction occur at sites of natural narrowing of the esophageal lumen, such as the cervical esophagus, the thoracic inlet, base of the heart, or the terminal esophagus, thus one may need an endoscope longer than 1 m for complete evaluation. endoscopic evaluation is useful before relief of an impaction to localize the obstruction and to investigate the nature of the impaction if one suspects a foreign body. foreign bodies may be retrievable via transendoscopic tethering. 12 one can obtain critical diagnostic and prognostic information following resolution of the impaction. assessing the affected esophagus for mucosal ulceration, rupture, masses, strictures, diverticula, and signs of functional abnormalities is important (figure 13.9-1) . ultrasonography of the cervical region is useful not only to confirm a cervical esophageal impaction but also 856 part ii disorders of specific body systems vagal reflex that increases lower esophageal sphincter tone, a safety mechanism against gastroesophageal reflux. the mechanical and vagal mechanisms that promote lower esophageal sphincter tone prevent spontaneous decompression of the stomach, which along with a lack of a vomiting reflex in the horse, increases the risk of gastric rupture during episodes of severe distention. esophageal obstruction has many causes (table 13 .9-1) and most often is manifested clinically by impaction of food material and resulting esophageal dysphagia. esophageal obstruction may be caused by primary impactions (simple choke) of roughage, particularly leafy alfalfa hay, coarse grass hay, bedding, and even grass. prior esophageal trauma or poor mastication caused by dental abnormalities may predispose horses to primary esophageal impaction. 3 wolfing or gulping food may precipitate primary impactions, particularly if the horse is exhausted or mildly dehydrated after a long ride or is weakened from chronic debilitation. impactions also may result from disorders that physically impede the passage of food material and fluid by narrowing the luminal diameter, reduce the compliance of the esophageal wall, or alter the conformation of the esophageal wall such that food material accumulates in a pocket or diverticulum. foreign bodies, intra-or extramural masses, or acquired or congenital anomalies cause these so-called secondary to provide critical information about the location and extent of the impaction and esophageal wall thickness and integrity. ultrasonography may provide information about the cause. 13 radiographic assessment of the esophagus can confirm the presence of esophageal obstruction in cases in which one cannot view the affected area adequately using endoscopy. one can detect impacted food material in the esophagus by a typical granular pattern and often can observe gas accumulation proximal to the obstruction. air or barium contrast radiographic studies are most useful for evaluating the esophagus following relief of the impaction if one suspects a stricture. one often can detect esophageal dilation, diverticula, rupture, functional disorder (megaesophagus), or luminal narrowing caused by extraluminal compression more easily using contrast radiographic studies instead of endoscopy ( figure 13 .9-2). 14-16 one should take care when interpreting radiographic studies in sedated horses, particularly after passage of a nasogastric tube or other esophageal manipulations that may contribute to esophageal dilation. 17 the primary goal of treatment for esophageal impaction is to relieve the obstruction. parenteral administration of acepromazine (0.05 mg/kg intravenously), xylazine (0.25 to 0.5 mg/kg intravenously) or detomidine (0.01 to 0.02 mg/kg intravenously), oxytocin (0.11 to 0.22 iu/kg intramuscularly), and/or esophageal instillation of lidocaine (30 to 60 ml of 1% lidocaine) may reduce esophageal spasms caused by pain or may decrease esophageal tone. [17] [18] [19] [20] some clinicians advocate parasympatholytic drugs such as atropine (0.02 mg/kg intravenously) to reduce salivary secretions and lessen the risk of aspiration. however, undesirable effects of atropine including excessive drying of the impaction and inhibition of distal gastrointestinal motility may preclude its use. resolution of an impaction may require physical dispersal of the material. 18 one can use a nasogastric tube to displace the impacted material along with external massage if the obstruction is in the cervical region. often, carefully lavaging the esophagus with water via an uncuffed or a cuffed nasogastric tube while the head is lowered is necessary to aid in breaking up the impaction. some clinicians advocate a dual tube method whereby a tube is placed through each nasal passage into the esophagus for ingress and egress of the lavage fluid. because of the risk of aspiration of water and food material, esophageal lavage sometimes is done under general anesthesia with a cuffed nasotracheal tube. in refractory cases, intravenous administration of isotonic fluid containing 0.9% nacl and kcl (10 to 20 meq/l) for 24 hours at a rate of 50 to 100 ml/kg/ day along with esophageal relaxants such as oxytocin may promote hydration and softening of the impaction and help prevent or alleviate any electrolyte or acid-base imbalances resulting from salivary losses of chloride, sodium, and potassium. 21 one should note that the effects of oxytocin on esophageal tone occur in the proximal two thirds of the esophagus and may not be effective for mucosa has recovered as assessed by endoscopy, one can feed the horse soft food (moistened pellets and bran mashes). one can return the patient gradually to a highquality roughage diet over 7 to 21 days, depending on the degree of esophageal damage induced by the impaction and the nature of any underlying disease. the prognosis for survival is good (78%), but some horses may require permanent dietary modification if persistent chronic obstruction is a problem. 3 aspiration pneumonia and perforation are potential complications of severe or prolonged esophageal obstructions. if aspiration is suspected, administration of broad-spectrum antibiotics that are effective against gram-positive and gram-negative organisms, including metronidazole (20 mg/kg orally every 8 hours) for anaerobes is advisable. a subsequent section describes treatment of esophageal perforation or rupture. esophagitis refers to a clinical syndrome of esophageal inflammation that may or may not be ulcerative. the major protective mechanisms of the esophageal mucosa include salivary and food material buffers, normal peristaltic motility, and the barrier formed by the gastroesophageal sphincter. reflux esophagitis is caused by repeated episodes of gastric fluid regurgitation into the distal esophagus and subsequent chemical injury to the mucosa ( figure 13 distal obstructions. 19, 20 rarely, esophageal obstruction ultimately may require esophagotomy to relieve the impaction. one must enforce strict restriction of food and water, including access to bedding material, until the obstruction is resolved and the esophagus has regained function. systemic effects of dysphagia associated with esophageal impaction include dehydration, hyponatremia, hypochloremia, and metabolic alkalosis from prolonged loss of salivary free water and electrolytes. 21 if the duration of a complete esophageal obstruction is 48 hours or longer, one should correct dehydration and electrolyte and acid-base imbalances. one can restore fluid and electrolyte balance with oral electrolyte solutions if the patient is less than 6% to 7% dehydrated and the esophageal obstruction is resolved. horses that are greater than 6% to 7% dehydrated or those that have a refractory obstruction or moderate to severe electrolyte imbalances may require intravenous fluid therapy with solutions containing 0.9% nacl and kcl (10 to 20 meq/l). one should perform esophageal endoscopy after relief of the impaction to determine whether any complications of the impaction have developed or if a primary cause of the obstruction is present. endoscopic examination is critical to determine the postobstruction treatment plan and for follow-up evaluation of esophageal healing. one should reevaluate the horse every 2 to 4 weeks following resolution of the impaction if one notes esophageal dilation or mucosal injury. additional evaluation via radiography may be warranted to assess motility and transit times. dilation proximal to the site of obstruction, mucosal injury from trauma, stricture formation, formation of a diverticulum, megaesophagus, and esophagitis are sequelae to esophageal obstruction that predispose patients to reobstruction. the rate of reobstruction may be as high as 37%. depending on the duration of the obstruction and the degree of trauma or dilation, the risk of reobstruction is high for 24 to 48 hours or longer, thus one should withhold food for at least 24 to 48 hours after resolution of the obstruction. sucralfate (20 mg/kg orally every 6 hours) may hasten healing if esophageal ulceration is evident, but the efficacy of sucralfate for this purpose is not established. some clinicians suggest that administration of a nonsteroidal antiinflammatory drug (nsaid) such as flunixin meglumine (1 mg/kg orally or intravenously every 12 hours) or phenylbutazone (1 to 2 mg/kg orally or intravenously every 12 to 24 hours) for 2 to 4 weeks after resolution of the impaction may reduce the development of strictures. judicious use of nsaids is recommended to prevent nsaid-induced worsening of esophageal mucosal injury. one should avoid orally administered nsaids if esophagitis is present. after 48 to 72 hours or when the esophageal duodenal strictures caused by chronic ulceration commonly have reflux esophagitis. diagnosis requires endoscopic examination of the esophagus. one may note diffuse, patchy, linear, or coalescing erosion or ulcerations (see figures 13.9-3 and 13.9-4). one also may observe significant edema or hyperemia. determining whether an underlying disease, such as infection, neoplasia, esophageal strictures, or diverticula, is present is important. in addition, one must examine the stomach to determine whether the esophagitis is associated with gastritis, gastric obstruction, or gastric ulcer disease. contrast radiography may be helpful to detect esophageal ulceration and is useful to assess esophageal motility and transit time. 14 the principles of therapy for reflux esophagitis include control of gastric acidity, mucosal protection, and correction of any underlying disorder contributing to gastroesophageal reflux. reduction of gastric acid production with h 2 histamine receptor blockers such as ranitidine or proton pump antagonists such as omeprazole is critical for resolution of the esophagitis. some clinicians advocate using sucralfate to promote healing of ulcerated esophageal mucosa. however, the ability of sucralfate to bind ulcerated esophageal mucosa is not proven, nor is the efficacy of sucralfate for hastening esophageal ulcer healing. horses with reflux esophagitis following delayed gastric outflow caused by gastroduodenal ulcer disease, gastric paresis, or proximal enteritis may benefit from prokinetic drugs that act on the proximal gastrointestinal tract. metoclopramide (0.02 to 0.1 mg/kg subcutaneously every 4 to 12 hours) reduces gastroesophageal reflux by increasing lower esophageal sphincter tone, gastric emptying, and gastroduodenal coordination. one should exercise caution when giving metoclopramide to horses because they are prone to extrapyramidal neurologic side effects of the drug. cholinergic drugs such as bethanechol (0.025 to 0.035 mg/kg subcutaneously every 4 to 24 hours or 0.035 to 0.045 mg/kg orally every 6 to 8 hours) may improve gastric emptying and are effective for treating reflux esophagitis. for esophagitis from trauma or pressure injury after esophageal impaction, judicious use of nsaids may be warranted to reduce esophageal inflammation and pain. dietary modification may be necessary for patients with esophagitis, depending on the degree of ulceration or if motility is impaired. one should feed horses with mild esophagitis frequent small meals of moistened pellets and fresh grass. severe esophagitis may necessitate withholding food and complete esophageal rest for several days. although the prognosis for esophagitis is good in the absence of underlying disease, the risk of esophagus is delayed, such as in functional disorders of the esophagus. like ulceration of the squamous portion of the stomach in horses, gastric acid and bile salt chemical injury is a major mechanism of esophageal squamous epithelial ulceration. 22, 23 reflux esophagitis may occur along with gastric ulcer disease, motility disorders, increased gastric volume from gastric outflow obstructions, gastric paresis, intestinal ileus, or impaired lower esophageal sphincter function. 7, 22 other causes of esophagitis in horses include trauma (foreign bodies, food impactions, nasogastric tubes), infection (mural abscesses), or chemical injury (pharmaceuticals, cantharidin) ( figure 13 .9-4). [24] [25] [26] [27] the clinical signs of esophagitis are nonspecific and similar to esophageal obstruction and gastric ulcer diseases. gagging or discomfort when swallowing may be evident, and hypersalivation and bruxism are signs of esophageal pain. esophageal (postpharyngeal) dysphagia may be evident. one may note partial or complete anorexia such that horses with chronic esophagitis may have significant weight loss. esophageal hypomotility dysfunction caused by the inflammatory process may result in esophageal impaction. clinical signs of underlying diseases that predispose to esophagitis may predominate or mask the signs of esophagitis. horses with gastrointestinal motility disorders such as proximal enteritis or gastric outflow obstruction are at a high risk of developing reflux esophagitis because of the presence of gastric acid and bile salts in the fluid reflux. foals with gastric, pyloric, or stricture formation is high if severe circumferential or coalescing ulcerations are present. esophagitis from severe trauma or infection may be prone to stricture formation. motility dysfunction of the equine esophagus is caused most commonly by hypomotility resulting in esophageal dilation (ectasia) or megaesophagus. although megaesophagus in horses most commonly is acquired, reports indicate idiopathic megaesophagus in young horses may be congenital. [28] [29] [30] [31] acquired megaesophagus in horses may be a consequence of chronic or recurrent esophageal obstruction. 3, 7 esophageal impactions of a short duration cause a proximal dilation of the esophagus that is generally reversible. 14 however, if the duration of the obstruction is long enough, the motility of the esophagus proximal to the site of obstruction may be impaired permanently. other causes of acquired megaesophagus include extraesophageal obstruction by tumors or abscesses, pleuropneumonia, and vascular ring anomalies. 3, 8 acquired megaesophagus also may result from neurologic, neuromuscular, and muscular disorders. neurologic diseases that cause vagal neuropathy-such as equine protozoal myeloencephalitis, equine herpesvirus myeloencephalitis, and idiopathic vagal neuropathy-have been associated with megaesophagus in horses. pleuropneumonia may be associated with a vagal neuropathy resulting in megaesophagus. megaesophagus is an early sign of equine dysautonomia 32 and may be observable in patients with botulism. myasthenia gravis is a well-known cause of megaesophagus in nonequine species but has not been reported in horses. also in other species, electrolyte disorders, cachexia, primary myopathies, myositis, and addison's disease may affect esophageal motility but have not been associated with megaesophagus in horses. one can induce iatrogenic megaesophagus by the α 2adrenergic agonist detomidine, but this is transient and reversible. 17, 33 nonetheless, the use of this drug may complicate clinical evaluation of esophageal motility. esophageal inflammation, particularly reflux esophagitis, may affect motility and cause megaesophagus. however, because esophageal hypomotility affects the tone and function of the lower esophageal sphincter, reflux esophagitis also may be a complication of a primary functional disorder. thus assessing esophageal motility in horses with esophagitis that is not responding appropriately to treatment is important. along with a complete physical examination one should include a careful neurologic examination to help rule out primary neurologic causes of megaesophagus. because esophageal hypomotility is a functional obstruction, the clinical signs of esophageal hypomotility or megaesophagus are similar to esophageal obstruction. unlike mechanical obstruction the onset of clinical signs is insidious rather than acute. the clinical signs include those associated with esophageal dysphagia. 7, 8, [28] [29] [30] [31] the cervical esophagus may be dilated enough to be evident externally. weight loss is a common sign. signs attributable to an underlying disease may be evident. diagnosis of esophageal hypomotility requires transit studies. one can measure the transit time of a bolus from the cervical esophagus to the stomach by fluoroscopy or contrast radiography. 14,32 other signs of esophageal hypomotility and megaesophagus include pooling of contrast material and an absence of peristaltic constrictions. 7,14,28,32 endoscopy may reveal a dilated esophagus and an absence of peristaltic waves. 7,28 one may observe evidence of underlying disease causing obstruction or esophageal dilation. 3, 7 one should evaluate the esophagus for evidence of esophagitis that is causing esophageal motility dysfunction or is a result of impaired esophageal clearance of gastric fluid. esophageal manometry may be useful to document abnormal postdeglutition contraction pressures, contraction time, and propagation times but is not often available for routine clinical application. 28, 34 one should perform other diagnostic tests such as a complete blood count and chemistry to help determine a possible underlying cause. cerebral spinal fluid analysis may be indicated to rule out neurologic disorders. specialized testing such as electromyography to detect neuromuscular disorders may also be indicated. treatment of esophageal hypomotility or megaesophagus should aim at treating the underlying cause. dietary modification should aim at improving esophageal transit of food. one should feed the horse slurries of pellets, and feeding from an elevated position to promote transit may be beneficial. metoclopramide or bethanechol may benefit patients with reflux esophagitis associated with megaesophagus by increasing lower esophageal tone, gastric emptying, and reducing gastroesophageal reflux. the prognosis depends on the underlying cause and the degree of dilation. although many cases of megaesophagus associated with reflux esophagitis respond well to treatment, many other forms of megaesophagus including congenital megaesophagus have a poor prognosis. strictures most commonly are caused by pressure necrosis from esophageal impactions that induce circumferential erosion or ulceration of the esophageal mucosa, although esophageal injury caused by oral administration of corrosive medicinal agents and trauma to the neck may also result in stricture formation. 35 congenital strictures also have been reported. 36 strictures caused by mucosal and submucosal trauma are termed esophageal webs or rings. strictures may also originate in the muscular layers and adventitia of the esophagus (mural strictures) or in all of the layers of the esophagus (annular stenosis). 36, 37 horses with these lesions have a presentation similar to those with simple obstructions, because strictures result in partial obstruction and impaction of food material in the lumen. one can detect esophageal webs or rings with endoscopy (see figure 13 .9-1), whereas identification of mural strictures or annular stenosis may require a double-contrast esophogram (see figure 13 .9-2). in a retrospective study of horses with esophageal stricture following simple obstruction, maximal reduction in esophageal lumen diameter occurred within 30 days of the esophageal obstruction. although surgery has been used to relieve such strictures, initial medical management is warranted because strictures may resolve with conservative therapy, and the esophagus continues to remodel for up to 60 days following ulceration. in one report, seven horses with esophageal obstruction-induced stricture were treated conservatively by feeding a slurry diet and administering antiinflammatory and antimicrobial medications, and five of seven were clinically normal within 60 days. 35 one of the five successfully treated horses had a 10-cm area of circumferential ulceration, suggesting that the potential exists for extensive mucosal injury to resolve without permanent stricture formation. if resolution of strictures within 60 days is insufficient, one should investigate other methods to increase esophageal diameter. bougienage has been used successfully in small animal patients and human beings. the technique involves passage of a tubular dilatable instrument down the esophagus and stretching of the stricture. one may perform the technique by passing a nasogastric tube with an inflatable cuff. however, one has to perform the procedure frequently to have any success, and horses do not tolerate it well. 36 alternatively, a number of surgical techniques have been used to resolve strictures, including resection and anastomosis, 38,39 temporary esophagostomy with fenestration of the stricture, 37 esophagomyotomy for strictures of the muscularis and adventitia, 40, 41 or patch grafting with local musculature. 42 however, such surgeries are fraught with complications, largely because of the propensity of the traumatized esophagus to restricture. 3, 35 the esophagus lacks a serosal layer and does not rapidly form a fibrin seal as does the remainder of the intestinal tract, so anastomoses tend to leak. 38 in addition, tension on the esophagus during swallowing and movement of the neck impairs healing of anastomoses. 37, 39 in spite of these difficulties, the long-term prognosis for horses with chronic esophageal strictures treated surgically is better than for those treated nonsurgically. 3 two types of diverticula are traction (true) diverticula and pulsion (false) diverticula. traction diverticula result from wounding and subsequent contraction of periesophageal tissues, with resultant tenting of the wall of the esophagus. pulsion diverticula arise from protrusion of esophageal mucosa through defects in the muscular wall of the esophagus and usually result from trauma or acute changes in intraluminal pressure. 36 traction diverticula appear as a dilation with a broad neck on contrast esophagography, whereas pulsion diverticula typically have a flask shape with a small neck on an esophagram (see figure 13 .9-2). 10, 43 although traction diverticula are usually asymptomatic and of little clinical significance, pulsion diverticula may fill with feed material, ultimately leading to esophageal obstruction. [43] [44] [45] a movable mass in the midcervical region may be noticeable before onset of complete obstruction. 36 pulsion diverticula may be corrected surgically by inverting or resecting prolapsed mucosa and closing the defect in the wall of the esophagus. 10, 43, 45 inversion of excessive mucosa may reduce the diameter of the esophageal lumen and predispose horses to esophageal obstruction and therefore should be reserved for small diverticula. 10 congenital disorders of the esophagus are rare. reported congenital abnormalities include congenital stenosis, 46 persistent right aortic arch, 8 esophageal duplication cysts, [47] [48] [49] intramural inclusion cysts, 9, 50 and idiopathic megaesophagus. 28, 30, 31 in the one report of congenital stenosis, double-contrast radiography revealed concentric narrowing of the thoracic esophagus in the absence of any vascular abnormalities at the base of the heart. successful treatment included having the foal stand with the forelimbs elevated off the ground following each feeding. 46 persistent right aortic arch is a congenital anomaly in which the right fourth aortic arch becomes the definitive aorta instead of the left aortic arch, which results in constriction of the esophagus by the ligamentum arteriosum as it extends between the anomalous right aorta and the left pulmonary artery. clinical signs may include those associated with esophageal (postpharyngeal) dysphagia, drooling, and distention of the cervical esophagus resulting from partial obstruction of the thoracic esophagus. 8, 51 endoscopic examination typically reveals dilation of the esophagus cranial to the obstruction section 13.9 esophageal diseases with evidence of diffuse esophagitis. successful surgical treatment of persistent right aortic arch has been reported in one foal. 51 esophageal duplication cysts and intramural inclusion cysts cause typical signs of esophageal obstruction, including salivation, esophageal dysphagia, and swelling of the cervical esophagus as the cysts enlarge. 47, 49, 50 such signs can make them difficult to differentiate from other forms of esophageal obstruction (choke). endoscopic examination may reveal compression of the esophageal lumen and communication with the esophageal lumen if it exists. ultrasonographic examination may be the most useful method of antemortem diagnosis if the cyst is in the cervical esophagus. examination of an aspirate of the mass may aid in the diagnosis by revealing the presence of keratinized squamous cells. 47, 50 surgical treatments have included complete surgical resection and surgical marsupialization. 47, 49, 50 the latter appears to be more successful and results in fewer complications. 49, 50 complications of surgical resection have included laryngeal hemiplegia following surgical trauma to the recurrent laryngeal nerve in the region of the esophagus and esophageal fistula formation. 50 perforation typically occurs in the cervical region in response to external trauma, necrosis of the esophageal wall caused by a food impaction, or rupture of an esophageal lesion such as an impacted diverticulum. the esophagus is particularly vulnerable to external trauma in the distal third of the neck because only a thin layer of muscle covers it at this point. 52 iatrogenic perforation may occur in response to excessive force with a stomach tube against an obstruction or a compromised region of the esophagus. 24 esophageal perforations may be open or closed and tend to cause extensive cellulitis and necrosis of tissues surrounding the wound because of drainage of saliva and feed material within fascial planes. systemic inflammation associated with endotoxemia from septic cellulitis may occur. closed perforations of the esophagus are particularly troublesome because food material, water, saliva, and air may migrate to the mediastinum and pleural space via fascial planes. 24, 52 because of the leakage of air into the tissues surrounding the rupture, extensive subcutaneous and fascial emphysema frequently develops and is usually evident clinically and on cervical radiographs. pneumomediastinum and pneumothorax are potentially fatal complications of esophageal ruptures. treatment should include converting closed perforations to open perforations if possible, 53 extensive debridement and lavage of affected tissues, broadspectrum antibiotics, tetanus prophylaxis, and esophageal rest. the clinician may achieve the latter by placing a feeding tube into the esophagus via the wound. alternatively, one may place a nasogastric tube using a small tube (12-f diameter) . 24 for open perforations, once the wound has granulated and contracted to a small size, one may attempt peroral feeding. 52 extensive loss of saliva via esophageal wounds may lead to hyponatremia and hypochloremia. in addition, transient metabolic acidosis occurs because of salivary bicarbonate loss, followed by progressive metabolic alkalosis. 21 although reports of esophageal wounds healing well by second intention exist, healing takes a prolonged time. 54 in addition, some perforations never completely heal and form permanent esophagocutaneous fistulae that may require surgical correction. the development of esophageal strictures is not common because wounds are usually linear and not circumferential. however, traction diverticula may develop. other complications of esophageal wounds include horner's syndrome and left laryngeal hemiplegia. 52 in a retrospective study on esophageal disorders, only 2 of 11 horses with esophageal perforations survived long-term 3 ; in a report of esophageal trauma following nasogastric intubation, 4 of 5 horses were euthanized. 24 the prognosis is therefore poor in horses with esophageal perforations, largely because of the extent of cellulitis, tissue necrosis, shock, and local wound complications. 14 specialized endoscopic equipment allowing visual inspection of the entire adult equine stomach has become increasingly available to veterinarians in academia and private practice. thus gastric disease in horses recently section 13 .10 diseases of the stomach has gained increasing awareness among veterinarians, owners, and trainers. peptic ulcer disease is defined as erosions or ulcers of any portion of the gastrointestinal tract normally exposed to acid. 1 mucosal damage can include inflammation, erosion (disruption of the superficial mucosa), or ulceration (penetration of the submucosa). in severe cases, fullthickness ulceration can occur, resulting in perforation. the proximal (orad) portion of the equine stomach is lined by stratified squamous mucosa similar to the esophageal lining. the distal (aborad) portion of the stomach is lined with glandular mucosa, and the distinct junction between the two regions is deemed the margo plicatus. ulceration can occur in either or both gastric regions, although different clinical syndromes and pathophysiologic mechanisms apply. as a result, the broad term equine gastric ulcer syndrome (egus) has been used to encompass the wide array of associated clinical syndromes. egus develops in horses of all ages and continues to be of major clinical and economical importance. 2 the prevalence of gastric ulceration has been reported for a variety of breeds and types of horses; however, most current data involve thoroughbreds in race training. the prevalence of squamous ulceration in horses in race training varies from 70% to 94% 3-8 and can be as high as 100% when limited to animals actively racing. 4 in a survey of 50 active show horses, 58% had gastric ulceration, with only 1 horse having ulceration of the glandular fundus. 9 in one large retrospective study (3715 adult horses from 1924 to 1996) evaluating incidence of gastric ulceration identified at necropsy, an overall prevalence of 10.3% was found. the highest prevalence was found in thoroughbreds (including arabians) and standardbred trotters, and cold-blooded horses were affected significantly less. lesions were located most commonly in the squamous mucosa along the margo plicatus, followed by the glandular body, proximal squamous mucosa, and antrum. 10 many studies investigating prevalence of gastric ulceration do not differentiate between squamous and glandular lesions or evaluate only squamous disease. in a recent study in which the gastric antrum and pylorus were evaluated in 162 horses in a hospital setting, 58% had antral or pyloric erosions or ulcerations, 58% had squamous mucosal lesions, and 8% had lesions involving the glandular body. 11 a correlation between the presence or severity of squamous disease and antral/pyloric disease was not identified. the reported prevalence of gastric ulceration in foals varies from 25% to 57%. [12] [13] [14] an imbalance between inciting and protective factors in the mucosal environment can result in ulcer formation. 15, 16 the major intrinsic factors promoting ulcer formation include hydrochloric acid, bile acids, and pepsin, with hydrochloric acid being the predominant factor. various intrinsic factors protect against ulcer formation such as the mucus-bicarbonate layer, maintenance of adequate mucosal blood flow, mucosal prostaglandin e 2 and epidermal growth factor production, and gastroduodenal motility. in human beings, extrinsic ulcerogenic factors include nonsteroidal antiinflammatory drugs, helicobacter pylori, stress, changes in diet, or gastrointestinal disorders, especially those resulting in delayed gastric emptying. 1 in human neonates, physiologic stress associated with a major primary illness seems to be associated strongly with gastric ulcers. 17 many of the other factors mentioned previously are believed to be important in horses, but clear evidence of an infectious agent has not yet been identified in horses or foals with egus. 18, 19 recently, the possibility of helicobacter infection in horses has reemerged with the identification of polymerase chain reaction products from urel, a protongated urea channel unique to gastric-dwelling helicobacter species, in the squamous epithelium of three horses, two of which had squamous erosions. 20 the specific factors involved in injury and the protective mechanisms vary between regions of the proximal gastrointestinal tract. the pathophysiology of squamous mucosal ulceration in the horse appears similar to that in gastroesophageal reflux disease in human beings and ulceration of the nonglandular mucosa in pigs. excess acid exposure is the predominant mechanism responsible for squamous mucosal ulceration, although many details remain unclear. 21 hydrochloric acid is secreted by parietal cells in the gastric glands via a hydrogen-potassium adenosine triphosphatase (h + ,k + -atpase) pump on the luminal side. horses secrete acid continuously, and measured ph of equine gastric contents varies from less than 2 to greater than 6 depending on the dietary state of the horse (fed or fasted). 22,23 a protocol of repeated 24-hour periods of fasting and feeding has been shown to induce squamous erosion and ulceration. 24 because this protocol results in periods of prolonged gastric acidity (ph <2.0) and because concurrent administration of the histamine 2 (h 2 ) receptor antagonist ranitidine reduces lesion severity, the protocol supports the role of acid exposure in the pathogenesis of squamous ulcer disease. several peptides can stimulate or inhibit parietal cell secretion of acid. the predominant stimuli for hydrochloric acid secretion are gastrin, histamine, and acetylcholine via the vagus nerve. 1 g cells release gastrin within the antral mucosa, whereas mast cells and enterochromaffin-like cells release histamine in the gastric gland. histamine binds to type 2 receptors on the parietal cell membrane, causing an increase in cyclic adenosine monophosphate and resulting in phosphorylation of enzymes that activate the proton pump. gastrin and acetylcholine can act via calcium-mediated intracellular pathways and also stimulate histamine release directly. 25 isolated equine parietal cells respond maximally to histamine stimulation and only minimally to carbachol and pentagastrin. 26 gastrin release is controlled primarily by gastrin-releasing peptide, which is stimulated by gastric distention and increased luminal ph, but the interaction between gastrin and histamine has not been elucidated fully in the horse. somatostatin, released by fundic and antral d cells, is the primary inhibitor of gastric acid secretion by parietal cells. the inhibitory effect of somatostatin is primarily paracrine, but plasma levels of somatostatin negatively correlate with gastric luminal acidity. 27 epidermal growth factor, a peptide produced in saliva, also inhibits gastric acid secretion. 28 foals can produce significant amounts of gastric acid by the second day of life, with consistent periods of acidity (ph <2.0) in clinically normal animals. 29, 30 in one study, foals tended to have a high gastric ph at day 1 of age, 30 but in a study of critically ill foals, some foals demonstrated periods of gastric acidity on the first day of life. 31 suckling was associated with an immediate rise in gastric ph, whereas periods of rest in which foals did not suck for more than 20 minutes were associated with prolonged periods of acidity. 29 whereas premature human infants are capable of gastric acid production at 28 weeks of gestation, 32 only 1 of 7 premature foals demonstrated an acidic ph recording in a study of gastric ph profiles in critically ill foals. 31 however, multiple factors likely were involved in critically ill foals of this study, and the true ontogeny of gastric acid production in foals is currently unknown. equine squamous mucosa is thin at birth but becomes hyperplastic and parakeratotic within days. 33 the parallel between decreasing ph and proliferation of squamous epithelium correlates with that observed in other species. 34 the combination of a thin gastric epithelium with a high acid output may leave neonatal foals susceptible to ulcer formation at a young age. in addition, one must remember the difference in normal appearance of the squamous mucosa when interpreting gastric endoscopy in a neonatal population. in esophageal squamous mucosa, intercellular tight junctions and bicarbonate secretion are the major factors involved in protection against acid injury in other species, although squamous bicarbonate secretion had not been documented in the horse. [35] [36] [37] the principal barrier is a glycoconjugate substance secreted by cells in the stratum spinosum, with a contribution from the tight junctions in the stratum corneum. 37 this barrier function is considered weak at best, and thus a functioning lower esophageal sphincter, normal salivary flow, and salivary mucins contribute to the prevention of acid injury in human gastroesophageal reflux disease. in horses a mechanical barrier like the lower esophageal sphincter is not available to protect the gastric squamous mucosa from acid exposure. the normal gastric fill line rests just below the cardia, so only the squamous mucosa along the lesser curvature adjacent to the margo plicatus should receive exposure to acidic gastric contents regularly. not surprisingly, this correlates with the most common location of squamous mucosal ulceration. bile salts and pepsin have been implicated as contributing factors to ulcer disease in many species. in rabbit esophageal mucosa, bile salt absorption occurs and is correlated directly with mucosal barrier disruption. the unconjugated bile salts cholate and deoxycholate have a pk a (negative logarithm of the ionization constant of an acid) of 5 and 5.3, respectively, and therefore cannot remain in solution and cause mucosal damage in the presence of acid. alternatively, the conjugated bile salt taurocholate (pk a 1.9) can cause mucosal injury in the ionized salt form at ph 7 or the un-ionized acid form at ph 1 to 2. 38 in the pig, bile salts or acid alone cause squamous mucosal damage, whereas a combination of the two result in extensive damage in vitro. 39 in the horse a similar synergistically damaging effect was found with the addition of bile salts and acid (ph 2.5) to stratified squamous mucosa in vitro in one study. 40 in addition, the investigators were able to document levels of bile salts and acid sufficient to cause mucosal damage in gastric contents within 14 hours of feed deprivation. this is not surprising, given that duodenogastric reflux occurs normally in the horse. 41 in a separate in vitro study of equine squamous mucosa, prolonged exposure to acid alone (ph 1.5) had a damaging effect, and synergism with exposure to a combination of acid and pepsin or taurocholate was not found. 42 the lack of synergism likely is caused by the lower ph used in this study and stresses the importance of acid exposure in squamous ulcer disease. pepsinogens are secreted primarily by chief cells, although secretion by neck cells, cardiac glands, and antral pyloric glands also occurs. 43 in an acidic environment (ph <3.0), pepsinogen is converted to the active pepsin. although the proteolytic activity of pepsin normally is directed toward dietary protein, it also can act on the gastric mucosa. 44 thus acid remains the major contributing factor to squamous mucosal damage, although other factors such as pepsin and bile salts may play an important role as well in the initiation or perpetuation of disease. several mechanisms help protect the glandular mucosa from acid injury. the mucus-bicarbonate layer serves to titrate h + ion from the gastric lumen to co 2 and h 2 o. cellular restitution and prostaglandins of the e series, which enhance mucosal blood flow and secretion of mucus and bicarbonate in the glandular mucosa have not been documented in squamous epithelium. 21, 36 of these mechanisms, mucosal blood flow is likely the most important contributor to overall gastric mucosal health. nitric oxide is a key regulator of mucosal blood flow and prostaglandin synthesis and thus may play a role in mucosal protection. 45 dietary factors also have been implicated in ulcer disease. horses in race training have a high incidence of gastric ulceration and frequently are fed high-concentrate, low-roughage diets. in one study, higher volatile fatty acid (acetic, propionic, and isovaleric acid) concentrations, higher gastric juice ph, and lower number and severity of nonglandular ulceration were documented after feeding an alfalfa hay-grain diet compared with a bromegrass hay diet. 46 however, many factors differed between the diets, such as digestible energy, bulk, crude protein, and mineral content (especially calcium). thus dietary factors represent an important area of further investigation in the pathophysiology of egus, particularly squamous ulceration. the pathophysiologic correlation between exercise and squamous ulcer disease has not yet been defined despite the high prevalence of ulceration in performance horses. preliminary work suggests that gastric compression occurs during treadmill exercise, presumably because of an increase in intraabdominal pressure. 47 such contracture could result in increased acid exposure to the squamous mucosa by raising the fill line of gastric contents. further studies in this laboratory have provided support for this theory by demonstrating a high ph in the proximal stomach, immediately distal to the lower esophageal sphincter, during resting conditions that decreases during treadmill exercise (m. lorenzo-figueras and a.m. merritt, personal communication, 2002) . risk factors associated with gastric ulceration include gender and age, and the reported prevalence of gastric ulcers has increased over time. in one study, ulcers were found more commonly in stallions, and the prevalence of gastric ulceration decreased with age, independent of gender, although this trend was only significant in the population of standardbred trotters. 10 interestingly, the frequency of gastric ulceration increased from less than 6% before 1945 to approximately 18% after 1975. in a study of thoroughbred horses in race training, an increase in squamous ulcer severity was noted in horses 3 years old or older and in those horses that had raced. 4 in the same study, severity of glandular lesions did not change between examinations, and age (>3 years) was the only factor associated with glandular lesion severity. several studies have failed to document a correlation between nonsteroidal antiinflammatory drug (nsaid) administration and naturally occurring ulcer disease. 3, 4, 6, 7, 10 however, nsaid administration is a well-known cause of gastric ulceration under experimental conditions. [48] [49] [50] [51] [52] nsaid-related ulceration typically is described as predominantly glandular, although nonglandular ulceration also can occur by a mechanism that has not yet been characterized fully. nsaids cause a decrease in prostaglandin e 2 synthesis because of inhibition of the cyclooxygenase pathway. therefore a resultant decrease in glandular mucosal protection, most notably via decreased mucosal blood flow and mucus production, is the most likely mechanism of action. in one study, however, phenylbutazone administration resulted in ulceration of the glandular mucosa at the pyloric antrum but did not alter mucosal prostaglandin e 2 concentration significantly. 52 clinical signs typically associated with gastric ulceration in foals include poor appetite, diarrhea, and colic. many foals probably never exhibit clinical signs, and some do not exhibit clinical signs until ulceration is severe or fatal perforation has occurred. glandular ulceration typically is considered the most clinically significant type of disease in this population. the physiologic stress of a concurrent illness has been associated with gastric ulceration in foals. retrospectively, 14 (23%) of 61 foals up to 85 days of age with a clinical disorder were found to have lesions in the gastric glandular mucosa, 13 and prospectively 8 (40%) of 20 foals up to 30 days of age with a clinical disorder had glandular ulceration. 53 by contrast, only 4% to 9% of clinically normal foals examined in endoscopic surveys had lesions observed in the gastric glandular mucosa. 14, 54 critically ill neonatal foals can have a greatly different ph profile compared with that in clinically normal foals, potentially because of alterations in gastric motility and acid secretion. 31 gastric ulceration was not identified in any animals at necropsy in that study; however, ulceration has been documented in a similar population. 12 thus factors other than acid exposure, most notably mucosal blood flow, may play an important role in the stressrelated ulceration in neonates. subjectively, gastric ulceration and rupture in the hospitalized neonatal population occurs less commonly now than in previous reports. advances in overall neonatal care, especially supportive care, likely have contributed to this decline. in suckling foals less than 50 days old, lesions typically originate in the squamous mucosa adjacent to the margo plicatus along the greater curvature. such lesions can occur in foals as young as 2 days of age and have been observed in 50% of foals less than 50 days old. histologic examination of these lesions has revealed disruption of the epithelial layers of the mucosa and a neutrophilic infiltration. another phenomenon that occurs in young foals is the shedding, or desquamation, of squamous epithelium, which appears as flakes or sheets of epithelium. desquamation occurs without ulceration in up to 80% of foals less than 35 days of age, and this process typically is not associated with clinical signs. 13, 14, 54 in older foals, lesions become more prevalent in the squamous mucosa, particularly along the lesser curvature. 53 lesions also are found in the squamous mucosa of the fundus and adjacent to the margo plicatus. these lesions can be severe and often are associated with clinical signs such as diarrhea, poor appetite, and poor growth and body condition. diarrhea is the most frequent sign in symptomatic foals with squamous mucosal lesions and is associated with more diffuse erosion or ulceration of the squamous mucosa than that which occurs in asymptomatic foals. in some foals, poor growth, rough hair coat, a potbelly appearance, or all of those occur along with moderate to severe squamous mucosal ulceration. in horses with severe or diffuse squamous ulceration, bruxism or colic may occur. gastroduodenal ulcer disease occurs almost exclusively in suckling and early weanling foals. clinical signs of duodenal ulceration are similar to those described for gastric ulceration (bruxism, colic, salivation, diarrhea), but the consequences are often more severe. lesions occur primarily in the proximal duodenum and range from diffuse inflammation to severe ulceration. foals with duodenal ulceration often have delayed gastric emptying and may have gastroesophageal reflux. complications can include gastric or duodenal rupture, duodenal stricture, and ascending cholangitis. severe squamous and esophageal ulceration and aspiration pneumonia can occur following gastroesophageal reflux. 15, [55] [56] [57] [58] the gastroduodenal ulcer disease syndrome can occur in outbreaks and most commonly is identified in intensive breeding operations. the cause of duodenal lesions in foals is not known. one theory is that the problem begins with diffuse duodenal inflammation that can coalesce down to a focal area of ulceration (g.d. lester and a.m. merritt, personal communication, 2002) . a temporal relationship between gastroduodenal ulcer disease and rotaviral diarrhea has been suggested, but an infectious cause remains unproven. although lesion location and severity associated with rotaviral infection varies among species, duodenal ulceration has not been reported. 59 clinical signs attributable to egus in older horses vary and classically include anorexia and chronic or intermittent colic of varying severity. 60 many horses with endoscopic evidence of disease may appear to be clinically normal or have vague signs that include decreased consumption of concentrates, postprandial episodes of colic, poor performance or failure to train up to expectations, poorquality hair coat, and decreased condition or failure to thrive. diarrhea typically is not associated with gastric ulceration in adult horses, although ulceration can occur concurrently with other causes of diarrhea. horses actively racing are more likely to have squamous ulceration than those solely in training. 4 lesions occur predominantly in the squamous mucosa, particularly adjacent to the margo plicatus ( figure 13.10-1) . in more severe cases, lesions can extend dorsally into the squamous fundus. clinically relevant lesions typically affect a greater portion of the squamous mucosa and can be deep enough to cause bleeding. however, bleeding from ulcers in the gastric squamous mucosa typically is not associated with anemia or hypoproteinemia. according to a recent study, the incidence of glandular lesions, particularly within the pyloric region, may be higher than previously reported, 11 which emphasizes the importance of a thorough endoscopic examination and proper documentation of lesion location when reporting or discussing egus, especially the differentiation between squamous and glandular disease. although one may suspect a diagnosis of egus based on clinical signs and response to treatment, the only current method of confirmation is via gastroendoscopy, which one can perform easily in the standing horse or foal with mild sedation. in adult horses a 3-m endoscope allows for visual inspection of the entire stomach, pylorus, and proximal duodenum. shorter scopes permit examination of the gastric body and fundus, but not the pyloric antrum in most cases. one should use an endoscope with a maximum external diameter of 9 mm for neonatal foals. numerous scoring systems for lesion severity have been described, but a recent consensus has been published by the equine gastric ulcer council (table 13 .10-1). 2 duodenal ulceration can be difficult to confirm. duodenoscopy is the most specific means of diagnosis, although the procedure is more difficult than gastroscopy. additionally, an endoscope at least 200 cm in length is needed for foals up to 5 to 7 months old, and a longer endoscope usually is required for older animals. diffuse reddening or inflammation may be the only recognizable lesion in cases of early duodenal disease. excessive enterogastric reflux of bile through the pylorus suggests duodenal dysfunction. however, the pylorus frequently appears open, and some degree of enterogastric reflux is common under normal conditions. ulceration at the pylorus or pyloric antrum also suggests the presence of a duodenal lesion. if one can perform gastroendoscopy, but not duodenoscopy, the severity of lesions, particularly in the glandular mucosa and in the squamous mucosa of the lesser curvature dorsal to the pyloric antrum, usually will be severe when duodenal ulcers are present. multiple pharmacologic treatments have been suggested for treating egus. because acid has been implicated as the most important pathophysiologic component of squamous ulcer disease, most antiulcer therapy centers on suppression or neutralization of gastric acid. severity and location of gastric lesions and severity and duration of clinical signs, as well as medication cost, can play a role in the therapeutic management of egus (table 13 .10-2). if gastroendoscopy is unavailable, some guidelines to therapy can be used, but the efficacy of the treatment is based on clinical signs, which are often vague or nonspecific. signs of colic or diarrhea that result from gastric ulcers often resolve within 48 hours. one can note improvements in appetite, bodily condition, and attitude within 1 to 3 weeks. if one does not observe improvement in clinical signs, treatment has not been effective or gastric ulceration was not the primary problem. the principal therapeutic options for ulcer treatment include h 2 antagonists (cimetidine, ranitidine, famotidine, nizatidine), proton pump blockers (omeprazole, pantoprazole, rabeprazole, esomeprazole), the mucosal adherent sucralfate, and antacids. the h 2 antagonists suppress hydrochloric acid secretion through competitive inhibition of the parietal cell histamine receptor that can be overcome partially with exogenous pentagastrin. 61 use of h 2 antagonists has been successful in raising gastric ph and resolving gastric lesions in foals and adult horses. 29, 55, 62 clinical and experimental evidence has demonstrated greater individual variability with lower dosages of h 2 antagonists. 63 thus dosage recommendations are based on levels necessary to increase gastric ph and promote ulcer healing in a majority of horses. commonly recommended dosages are 20 to 30 mg/kg orally every 8 hours or 6.6 mg/kg intravenously every 6 hours for cimetidine and 6.6 mg/kg orally every 8 hours or 1.5 to 2 mg/kg intravenously every 6 hours for ranitidine. famotidine has been used less extensively in the horse, but a dose of 10 to 15 mg/kg/day has been recommended. because gastric perforation caused by glandular ulcer disease has been reported in hospitalized neonates, many clinicians routinely use prophylactic antiulcer therapy in this population. although clinically normal foals respond predictably to ranitidine, 29 sick neonates have shown variability in ph response to intravenously administered ranitidine, with a much shorter duration of action and in some cases no noticeable response. 31 thus currently used dosing schedules for hospitalized foals may be inadequate. because some critically ill foals have a predominantly alkaline gastric ph profile and because gastric acidity may be protective against bacterial translocation in neonates, the need for prophylactic ulcer therapy is controversial. in critically ill human neonates, intravenous administration of ranitidine raises gastric ph and gastric bacterial colonization but does not increase the risk of sepsis. 64 in a retrospective study of 85 hospitalized foals less than 30 days of age, no difference in the frequency of gastric ulceration at necropsy was found between those foals that received prophylactic treatment for gastric ulcers and those that did not. 65 because the study was retrospective, specific details regarding lesion location and severity were not available; however, none of the foals in the study died because of gastric ulcer disease. h 2 antagonist therapy should continue for 14 to 21 days, but complete ulcer healing may take 30 to 40 days. if an animal is kept in race training during therapy, clinical signs may resolve but the lesions may not. currently, cimetidine and ranitidine are available in injectable, tablet, and liquid forms. famotidine and nizatidine are available in tablets. proton pump inhibitors block secretion of h + at the parietal cell membrane by irreversibly binding to the h + ,k + -atpase proton pump of the cell. these agents have a prolonged antisecretory effect, which allows for once-daily dosing. omeprazole, the first proton pump inhibitor to be developed, is the only currently approved agent for the treatment of egus. several studies have documented the safety of orally administered omeprazole in foals and adult horses. 66, 67 omeprazole has demonstrated efficacy in the healing of nsaid-induced ulcers in horses and in naturally occurring cases of egus. 68, 69 more importantly, omeprazole has been shown to eliminate or reduce the severity of gastric ulcers in thoroughbreds maintained in race training. 70 the available equine preparation of omeprazole (gastrogard, merial, ltd., duluth, georgia) is recommended at a dose of 4 mg/kg orally every 24 hours. initial reports suggested that 3 to 5 days of omeprazole therapy were necessary to achieve maximum acid suppression; however, an increase in gastric ph and a decrease in acid output are evident 5 to 8 hours after omeprazole paste administration. 71 after initial treatment (28 days), treatment with 2 or 4 mg/kg every 24 hours has been shown to decrease or prevent the recurrence of disease in animals maintained in training. 72 the powder form of omeprazole degrades rapidly in an acidic environment, thus one must use an enteric-coated capsule (as used in the human preparation) or a specially formulated paste (such as gastrogard) to allow delivery of the active drug to the small intestine for absorption. many compounding pharmacies prepare omeprazole in liquid or paste formulation for use in horses, but their efficacy has not been evaluated to date. other proton pump inhibitors have been developed recently for use in human beings, including rabeprazole, lansoprazole, esomeprazole, and pantoprazole. in gastroesophageal reflux disease treatment in human beings, esomeprazole has demonstrated a higher rate of healing at 4 and 8 weeks compared with omeprazole, but rabeprazole, lansoprazole, and pantoprazole have similar efficacy. 73 an intravenous formulation of pantoprazole recently became available commercially and may prove beneficial for patients in need of antiulcer therapy that cannot be treated orally. research regarding the pharmacokinetics and efficacy of other proton pump inhibitors in horses is not currently available. sucralfate is effective in treating peptic ulcers and preventing stress-induced ulcers in human beings. the mechanism of action likely involves adherence to ulcerated mucosa, stimulation of mucus secretion, enhanced prostaglandin e synthesis, and increased concentration of growth factor at the site of ulceration, although the prostaglandin effects may not play an important role in ulcer healing. 74 these are factors relevant to glandular mucosa, and the efficacy of sucralfate in treating ulcers in the equine gastric squamous mucosa remains undetermined. sucralfate may be effective in preventing stress-induced ulcers in neonatal foals, because these occur in the glandular mucosa, although no clinical evidence directly supports this concept. in human beings, sucralfate provides protection against stress-induced ulcers with a decreased risk of pathogenic gastric colonization. 75 one should give sucralfate at a dosage of 10 to 20 mg/kg every 6 to 8 hours. the efficacy of sucralfate in an alkaline ph is controversial but appears likely. [76] [77] [78] moreover, at the time of administration of an section 13. 10 diseases of the stomach h 2 antagonist, the gastric ph likely will have returned to an acidic ph since the last dosage and will remain so for 30 to 60 minutes depending on the route of administration; thus one likely can administer the agents simultaneously if so desired. the use of antacids to treat gastric ulcers has not been examined critically in the horse. research in horses has shown that 30 g aluminum hydroxide per 15 g magnesium hydroxide results in an increase in gastric ph above 4 for approximately 2 hours. 79 thus although antacids may be useful for treating ulcers in horses, a dose of approximately 180 to 200 ml at least every 4 hours is necessary for a standard adult horse. the use of synthetic prostaglandin e 1 analogs, such as misoprostol, has been effective in treating gastric and duodenal ulcers in human beings, and the proposed mechanism of action involves inhibition of gastric acid secretion and mucosal cytoprotection. 80 frequently reported adverse effects of intestinal cramping and diarrhea in human beings have precluded the use of misoprostol in horses. one should consider prokinetic drugs in foals with duodenal disease and gastroesophageal reflux and when one suspects delayed gastric emptying without a physical obstruction. the cholinergic drug bethanechol has been shown to increase the rate of gastric emptying in horses. 81 in cases of acute gastric atony, bethanechol 0.025 to 0.030 mg/kg administered subcutaneously every 3 to 4 hours has been effective in promoting gastric motility and emptying, followed by oral maintenance dosages of 0.35 to 0.45 mg/kg 3 to 4 times daily. adverse effects can include diarrhea, inappetance, salivation, and colic, but at the dosages stated, adverse effects have been infrequent and mild. a complete review of ileus and prokinetic therapy is available in chapter 13.6. for foals with severe gastroduodenal ulcer disease that have developed duodenal stricture, surgical therapy is necessary. 57, 82 these animals require a serious financial commitment because intensive perioperative medical therapy is critical for a successful outcome. even with surgical therapy, these foals often warrant a guarded prognosis. pyloric stenosis is a structural resistance to gastric outflow. congenital pyloric stenosis has been reported in foals and one yearling and results from hypertrophy of the pyloric musculature. [83] [84] [85] acquired pyloric stenosis can result from neoplasia or duodenal ulceration. [86] [87] [88] [89] clinical signs depend on the degree of obstruction and include abdominal pain, salivation, and teeth grinding. complete or near complete obstruction can result in gastric reflux and reflux esophagitis. in foals with congenital pyloric hypertrophy, clinical signs may begin with the consumption of solid feed. in foals one can make a presumptive diagnosis via gastric endoscopy and radiography (plain and contrast studies). depending on the cause and severity of disease, gastric endoscopy may provide a presumptive diagnosis in the adult horse. measurement of gastric emptying can aid the diagnosis. several methods of measurement are currently available, including nuclear scintigraphy, acetaminophen absorption, and postconsumption [ 13 c] octanoic acid blood or breath testing. 81, 90, 91 exploratory laparotomy shows a distended stomach and thickened pylorus accompanied by a relatively empty intestinal tract. if complete obstruction is not present, medical therapy with a prokinetic such as bethanechol can increase the rate of gastric emptying. 81 phenylbutazone and cisapride also have been shown to attenuate the delay in gastric emptying caused by endotoxin administration. 90, 92 surgical repair is necessary for definitive treatment of complete or near-complete obstruction and consists of gastroenterostomy or pyloroplasty. 57, 82 gastric dilation can be classified as primary, secondary, or idiopathic. causes of primary gastric dilation include gastric impaction, grain engorgement, excessive water intake after exercise, aerophagia, and parasitism. 86, 93 secondary gastric dilation occurs more commonly and can result from primary intestinal ileus or small or large intestinal obstruction. time to development of gastric reflux is proportional to the distance to the intestinal segment involved, with duodenal obstruction resulting in reflux within 4 hours. 94 clinical signs of gastric dilation include those associated with acute colic and in severe cases, ingesta appearing at the nares. associated laboratory abnormalities include hemoconcentration, hypokalemia, and hypochloremia. 86 the most common reported cause of gastric rupture in horses varies between reports. in a retrospective study of 54 horses, gastric rupture occurred most commonly as a secondary phenomenon (65%), usually because of small intestinal obstruction, with primary gastric dilation and idiopathic rupture occurring almost equally (15% and 17%, respectively). 93 in another retrospective study of 50 horses in combination with a search of the veterinary medical database (vmdb), 60% of the gastric rupture cases were classified as idiopathic. 95 risk factors for gastric rupture include feeding grass hay, not feeding grain, gelding, and a nonautomatic water source. 93, 95 nasogastric intubation does not preclude the possibility of gastric rupture, and the amount of reflux obtained before rupture varies greatly. 93 because these reports were retrospective, one cannot rule out confounding factors with certainty. regardless of the initiating cause, gastric rupture usually occurs along the greater curvature. in horses with rupture caused by gastric dilation, tears in the seromuscular layer are frequently larger than the corresponding tears in the mucosal layer, indicating that the seromuscularis likely weakens and tears before the mucosa. 93, 95 in contrast, horses with gastric rupture following gastric ulceration usually demonstrate full-thickness tears of equal size in all layers. gastric rupture is usually fatal because of widespread contamination of the peritoneal cavity, septic peritonitis, and septic shock. initial clinical signs vary with the primary disease; however, when rupture occurs, a previously painful animal can exhibit signs of relief. subsequent signs are consistent with peritonitis and shock, including tachypnea, tachycardia, sweating, and muscle fasciculations. surgical repair is thus limited but has been reported for partial-thickness tears, 96 and in one case of a combined tear of the mucosa and muscularis with only a focal serosal tear, a full-thickness repair was performed with a favorable outcome. 97 gastric impaction can result in acute or chronic signs of colic in the horse. although a specific cause is not always evident, ingestion of coarse roughage (straw bedding, poor-quality forage), foreign objects (rubber fencing material), and feed that may swell after ingestion or improper mastication (persimmon seeds, mesquite beans, wheat, barley, sugar beet pulp) have been implicated. possible predisposing factors include poor dentition, poor mastication and rapid consumption of feedstuffs, and inadequate water consumption. clinical signs can vary from anorexia and weight loss to those consistent with severe abdominal pain. in severe cases, spontaneous reflux may occur, with gastric contents visible at the nares. in cases of acute severe abdominal pain, one often makes a diagnosis during exploratory celiotomy. in animals not exhibiting signs of colic warranting surgical intervention, an endoscopic finding of a full stomach after a normally adequate fast (18 to 24 hours) often can confirm the diagnosis. abdominal radiographs are reserved for smaller horses and ponies. in addition to pain management, specific treatment consists of gastric lavage via nasogastric intubation or massage and injection of fluid to soften the impaction during laparotomy. [98] [99] [100] nonulcerative gastritis rarely occurs in the horse; however, a single case of emphysematous gastritis caused by clostridium perfringens has been reported. 101 mimic that of a strangulating or nonstrangulating small intestinal obstruction, so distinguishing between the two syndromes is important because appropriate treatment of small intestinal obstruction usually requires surgical intervention. studies suggest that the survival rate for horses with dpj that endured surgical exploratory laparotomy was poor compared with those treated medically, although differences in disease severity may have accounted for the results in these early reports. 1, 2 the clinical syndrome of dpj was well described in the 1980s, and although recognized by its classical presentation, varying degrees of focal intestinal and systemic illness may occur. 1-4 dpj usually occurs alone but can occur along with gastritis, ileitis, typhlitis, and or colitis. typical pathologic findings in horses with dpj include involvement of the duodenum and usually the proximal jejunum. 3 the ileum and large colon usually are determined to be grossly normal. gastric distention is a common finding and is thought to be caused by hypersecretory mechanisms in the proximal small intestine and a functional ileus of affected enteric segments. the small intestine may be 5 to 7 cm in diameter because of fluid distention with malodorous, red to brown-red intralumenal fluid accumulation. duodenal (and jejunal) serosal surfaces may have varying degrees and distribution of bright-red to dark-red petechial and ecchymotic hemorrhages and yellow to white streaks. the enteric mucosal surfaces are usually hyperemic and have varying degrees of petechiation and ulceration. microscopically, the most severe lesions have been located in the duodenum and proximal jejunum but may extend proximally to the gastric mucosa and aborally to the large intestinal mucosa and submucosa. 3 microscopic lesions consist of varying degrees of mucosal and submucosal hyperemia and edema. more severe lesions include villus degeneration with necrosis and more severely, sloughing of villous epithelium. the lamina propria, mucosa, and submucosa may have varying degrees of granulocyte infiltration (predominantly neutrophils), and the muscular layers and serosal surfaces contain small hemorrhages. proximal small intestinal serosal fibrinopurulent exudate is a common finding in the more severe cases; therefore the term hemorrhagic fibrinonecrotic duodenitis-proximal jejunitis has been suggested as a more descriptive name for this syndrome. horses with dpj often have evidence of multiple organ involvement such as hepatic changes including congestion and varying degrees of biliary duct hyperplasia. additional systemic involvement likely is caused by endotoxin absorption, metabolic imbalances such as acidemia, and circulatory changes. the cause of this syndrome remains an enigma (much like the cause of other inflammatory conditions affecting the intestinal tract). several microorganisms have been implicated as playing a role in triggering dpj, including clostridium spp., salmonella spp., and some mycotoxins, but efforts to reproduce the syndrome experimentally have been futile. 5 a recent dietary change with an abrupt increase in dietary concentrate level has been suggested to predispose a horse to developing dpj because of intraluminal microbial imbalances. two intracellular processes control intestinal secretion, the cyclic nucleotide (cyclic adenosine monophosphate and cyclic guanosine monophosphate) and the calcium systems. 6 agents (inflammatory mediators, microorganisms, toxic agents) can activate adenyl cyclase (vasoactive intestinal peptide, prostaglandin e 2 ) or guanyl cyclase (bacterial enterotoxins) and induce increases in cyclic adenosine monophosphate and cyclic guanosine monophosphate, respectively. this reaction causes phosphorylation of specific protein kinases, which induce the actual mucosal membrane transport events. increases in intracellular free calcium may arise from cyclic nucleotidedependent release of stored calcium within the cell or from increased calcium entry across the cell membrane. 7 calcium may act through calmodulin, which then can activate membrane-phosphorylating protein kinases. the net effect is increased movement of sodium and chloride into the mucosal cell from the interstitium, with secretion of sodium and chloride into the intestinal lumen. water follows the directional flux of sodium and chloride through highly permeable intercellular spaces. several bacterial toxins and endogenous mediators can cause active secretion and contribute to a synergistic mucosal secretory response. passive secretion of protein-rich fluid into the lumen occurs following damage to the mucosal epithelium, capillary endothelium, and submucosal inflammation in the proximal small intestine. the clinically relevant events that result from active and passive fluid secretion are proximal small intestinal distention and nasogastric reflux, dehydration, and circulatory shock. the concentration of protein in the peritoneal fluid from horses with dpj is usually higher than in horses with small intestinal obstruction. a disproportionate increase in total protein concentration relative to nucleated cell count occurs probably by leakage of blood or plasma into the peritoneal cavity without a significant stimulus for leukocyte chemotaxis. suggested mechanisms for increased abdominal fluid protein concentration include serositis associated with inflamed intestine and small intestinal distention causing passive congestion and increased capillary hydrostatic pressure of visceral peritoneal vessels. 8 small intestinal ileus is another hallmark sign of dpj and the pathophysiology is complicated, involving primary and secondary dysfunction of the central, autonomic, and enteric nervous systems and their purported roles in governing intestinal motility. 9 primary role-players in dpj-associated ileus include peritoneal inflammation, inflammatory cell migration/activation within the muscularis, small intestinal mechanical distention, and effects of endotoxin absorption. the use of prokinetic agents for treating ileus and gastric/small intestinal distention in horses with dpj is becoming more common, but veterinarians should realize that a potential restriction on their use is the need for normal intestinal integrity. in spite of that, one may use motility modifiers judiciously. the veterinarian has the challenge of differentiating horses with dpj from horses with small intestinal obstructive lesions so as to avoid surgical intervention (table 13 .11-1). horses with dpj typically show signs of acute abdominal pain initially, and then after gastric decompression, volume replacement, and analgesic therapy, the colic signs subside, but signs of lethargy and malaise become more apparent. in contrast, horses with obstructive lesions of the small intestine usually show signs of abdominal pain until the affected viscus is repaired via surgical intervention or the viscus ruptures. another differentiating characteristic is the large volume (>4 to 20 l with each decompressive effort) of nasogastric reflux that is often malodorous and orange-brown or red-brown. dpj-affected horses have moderate to severe small intestinal distention palpated on rectal examination, temperature of 38.6°to 39.1°c (101.5°to 102.5°f), dehydration, brick-red mucous membranes, lethargy and absent borborygmi, prolonged capillary refill time, tachycardia (>60 beats/min), and tachypnea. although the signs of abdominal pain usually resolve after gastric decompression, most horses remain severely lethargic. without periodic removal of the fluid that accumulates in the proximal intestinal tract, signs of abdominal pain usually recur. horses with dpj often require gastric decompression at 2-hour intervals, with 2 to 10 l of fluid recovered each time. nasogastric tubes left in place for long periods of time cause varying degrees of pharyngitis, laryngitis, and esophagitis. typical clinical laboratory findings include an increased packed cell volume and total plasma protein reflective of volume depletion, a metabolic acidosis (with elevated anion gap) in longstanding or severe cases, an increased peritoneal fluid protein concentration (often >3.5 g/dl), and a mild to moderate elevation of the peritoneal white blood cell count, although the count usually is less than 10,000 cells per microliter. 3, 4 the peritoneal fluid is usually yellow and turbid, but in severe cases diapedesis occurs resulting in a serosanguinous color. the white blood cell count in the peripheral blood may be normal, decreased, or increased. in addition, hyponatremia, hypochloremia, hypokalemia, and acid-base alterations (elevated anion gap) are often evident. the loss of enteric bicarbonate through evacuation of enterogastric reflux and poor tissue perfusion from hypovolemia can lead to metabolic acidosis. one makes a definitive diagnosis of dpj in most cases by gross examination of the duodenum and proximal jejunum at surgery or at necropsy. some equine practitioners have observed an apparent geographic relationship in the incidence and severity of the syndrome, with more cases occurring in the southeastern united states. horses with dpj appear to share a common characteristic clinical presentation, and the mechanisms leading to electrolyte imbalances, fluid loss, ileus, and endotoxemia and septicemia are similar. treatment regimens are supportive and aim at plasma volume replacement (usually in the form of crystalloid fluid replacement), analgesia and antiinflammatory therapy, gastric decompression, antiendotoxin therapy, antimicrobial therapy if indicated, nutritional support, and nursing care. one should institute aggressive intravenous polyionic fluid therapy immediately in a horse with dpj. one should calculate the total fluid deficit based on clinical assessment of dehydration (e.g., for 8% or moderate dehydration, 0.08 × 450 kg body mass = 36 l) and should administer replacement fluids rapidly (up to 6 to 10 l per hour per 450-kg adult horse). administering intravenous hypertonic saline (7%) may be useful to treat hypovolemic shock in horses with severe circulatory shock. the use of 1 to 2 l of hypertonic saline (7% nacl) improved systemic blood pressure and cardiac output in horses with hemorrhagic shock and in a model of equine endotoxemia. 10 if one chooses this treatment option, intravenous administration of replacement isotonic fluids must follow immediately to maintain tissue integrity. one should not allow horses with significant volumes of gastric reflux to ingest foodstuffs or liquids orally. once one has administered replacement fluids and the horse is well hydrated, one should administer maintenance fluid amounts, which may be as high as 120 ml/kg/day. unfortunately, the intravenous fluid therapy itself may accelerate the flux of fluid from the vasculature into the intestinal lumen because of a reduction in intravascular oncotic pressure and an increased capillary perfusion pressure, which can result in an increased volume of gastrointestinal reflux. however, the veterinarian should not consider reducing the volume of intravenous fluid therapy because excessive fluid losses continue to occur. one should monitor plasma protein concentration, overall hydration, and the volume of reflux and then determine the rate of intravenous fluid administration. during the initial hours of therapy, even aggressive intravenous fluid administration results in only moderate clinical improvement. the clinical response, as evidenced by improved hydration status, decreased nasogastric reflux, improved attitude, and improvement in values reflecting kidney function (decreased blood urea nitrogen and creatinine), correlates with improvement of intestinal damage. horses with dpj that continue to reflux large volumes of enterogastric fluid frequently for more than 36 to 48 hours most likely will experience protein loss from the inflamed and disrupted intestinal mucosal barrier and from systemic protein catabolism. decreased colloid oncotic pressure leads to decreased effective circulating fluid volume and edema. total plasma protein may decline to below 4 g/dl and the albumin may decrease to below 2.0 g/dl. fresh or thawed frozen plasma is ideal for replacement of functional proteins. one should consider treatment with intravenous plasma therapy or a combination of plasma and synthetic colloid (e.g., synthetic amylopectin) as soon as one sees evidence of a consistent decline in total plasma protein or albumin (<2.0 g/dl) or if the horse is developing dependent edema. fresh plasma (preferred) or fresh frozen plasma is the treatment of choice if coagulation disorders accompany protein loss. an average-size horse (450 kg) requires 6 to 10 l of plasma (albumin 3.0 g/dl) or synthetic colloid to improve plasma oncotic pressure. administration of additional aliquots of 2 to 10 l of a balanced colloidal solution may be necessary if the dpj crisis continues. in addition to albumin (the major colloid component), plasma contains other components that provide overall systemic support (e.g., fibronectins, complement inhibitors, elastase and proteinase inhibitors, antithrombin iii). one may administer a 6% solution of hydroxyethyl starch (hetastarch (6%), abbott laboratories, north chicago, illinois), a synthetic colloid, at 5 to 10 ml/kg. because of the large size of the starch molecules, this solution is an effective plasma volume expander, resulting in sustained dosedependent decreases in packed cell volume and plasma protein concentration with increased oncotic pressure. the cost of an appropriate amount of commercial plasma or synthetic colloid solution for treatment of adult horses with dpj may be prohibitive but can be life-saving. horses with enteritis frequently absorb large amounts of endotoxin from the disrupted intestinal mucosal barrier, therefore putting these horses at a high risk for laminitis. one should monitor digital pulses every 4 to 6 hours until systemic signs of enteritis have abated (fever, leukopenia, etc.). treatment to combat endotoxemia is critical, and several therapeutic approaches are available. choice of treatment options is based on severity of disease, renal function, hydration status, and economics. the reader is referred to chapter 13.7 for a thorough discussion of endotoxemia pathophysiology, treatment, and prevention. nonsteroidal antiinflammatory drugs are the most frequently used group of drugs for treatment of abdominal pain in horses (flunixin meglumine 1.1 mg/kg intravenously every 12 hours or phenylbutazone 2.2 mg/kg orally or intravenously every 12 hours). the clinician must weigh the benefit of the analgesic effect of nonsteroidal antiinflammatory drugs with the possibility of further damage to the intestine by potentially blocking the protective effects of intestinal mucosal prostaglandins. one should consider other classes of drugs for treating colic associated with dpj. butorphanol (torbugesic; an opioid analgesic) at 0.06 to 0.1 mg/kg with detomidine (dormosedan; an α-agonist) at 0.01 to 0.02 mg/kg given intramuscularly every 6 to 8 hours is a useful combination that has minimal effects on gastrointestinal motility. because clostridium spp. are suspected as a causative agent of dpj, penicillin often is administered to affected horses. however, one should consider broad-spectrum antimicrobial coverage for horses with dpj. one can add an aminoglycoside (gentamicin, amikacin) or thirdgeneration cephalosporin (ceftiofur [naxcel], upjohn co., kalamazoo, michigan) to the penicillin therapy, keeping in mind the potential adverse effects of these drugs on renal function. effective antisecretory medications targeting the equine small intestine have not been identified. one should consider the nutritional needs of horses with dpj. most horses have a total body protein loss from cachexia and a protein-losing enteropathy. total parenteral nutrition may be indicated in horses that remain anorectic for more than 3 to 4 days. parenterally administered solutions containing glucose, balanced amino acid solutions, lipid emulsions, balanced electrolyte and trace minerals, and vitamins have been administered to adult horses with small intestinal ileus or enterocolitis. based on a small number of horses, this therapy has proved promising in terms of minimizing protein losses and decreasing the duration of illness. providing for part of the nutritional requirements of the horse (8000 to 12,000 kcal/day) is possible with glucose-amino acid solutions, which are of moderate cost. one may suppose reasonably that providing nutritional support to an anorectic, severely ill horse will facilitate the healing process and even shorten the duration of illness. thus the overall cost of providing parenteral nutritional supplementation to horses with dpj may well be offset by quicker recovery and diminished requirements for other, expensive treatments. normal (healthy) intestine is necessary for optimum performance of prokinetic agents in horses. many motilitymodifying agents likely are ineffective in cases of dpj. however, some benefit may come of the judicious use of prokinetic agents in inflammatory conditions of the equine intestine, particularly if the agent provides additional effects such as analgesia. for example, lidocaine infusion has several actions that may be beneficial in the treatment of ileus, including suppression of primary afferent firing, antiinflammatory properties, an observed analgesic effect, and direct stimulation of smooth muscle. 9 an infusion dose of 15 to 20 mg/min over 5 to 6 hours has been recommended. the reader is referred to chapters 13.6 and 13.15 for a complete description of motility modifying agents. medical therapy is sufficient in most cases of dpj, but in those cases in which the horse continues to produce copious enterogastric reflux, one may consider surgery as an option. refractory cases have been observed to improve with surgical intervention; however, some horses with refractory dpj have been observed to recover with supportive medical care alone even after 20 days of refluxing large amounts of fluid every 2 to 4 hours (personal observation). the decision of when to intervene surgically often is difficult. one may elect surgery to determine the extent of gross pathologic condition and intestinal distention and to perform intestinal bypass so as to direct enterogastric reflux toward the cecum and colon, where the fluid can be reabsorbed. allen and clark 5 have described two approaches for surgical therapy in such cases. a standing right flank laparotomy with resection of the last rib has been used to approach the duodenum and cecal base. using this approach, one makes a small stoma between the duodenum and cecum using a handsewn 1.0-to 1.5-cm side-to-side anastomosis. the stoma may act as a shunt to decompress the proximal small intestine and deliver the small intestinal fluid to the cecum for reabsorption. following recovery, the stoma likely will close. when a veterinarian is confronted with a horse exhibiting abdominal discomfort, with small intestinal distention palpable per rectum, and greater than 2 l of gastric reflux, the veterinarian should recommend referral of the horse to a facility capable of performing abdominal surgery. the chance that such a horse has an intestinal obstruction is too great to decide to treat it as if it may have dpj. surgery on such horses is not unusual, even though dpj is possible, to rule out an obstruction. at present, the survival of horses with dpj that undergo surgery is much greater than previously described, and certainly greater than that of horses with small intestinal obstruction that do not have surgery. horses with dpj that receive appropriate therapy have a reasonably good chance of making a full recovery. horses that continue to have frequent episodes of voluminous nasogastric reflux and systemic signs of endotoxemia and septicemia have a poorer prognosis for recovery. frequent complications of dpj include laminitis, thrombophlebitis, and weight loss. the clinical signs of chronic wasting and poor body condition, although nonspecific for a diagnosis of malabsorption antemortem, can be attributed to proliferative or inflammatory intestinal disorders, often collectively referred to as chronic inflammatory bowel diseases. 1 clinical signs include alimentary lymphosarcoma, granulomatous enteritis, multisystemic eosinophilic epitheliotropic disease (meed), and lymphocyticplasmacytic enterocolitis-conditions affecting young and adult horses. proliferative enterocolitis, 2 a transmissible disease of foals 3 to 7 months of age characterized by significant small intestinal pathologic changes, will be included in this group. however, several other primarily small intestinal conditions described from a morphologic perspective, such as chronic postinfarctive inflammation and mycobacterial infections, 3 will not be discussed. in addition, a single case of aa amyloid-associated gastroenteropathy in an 18-year-old morgan stallion that had evidence of severe malabsorption based on poor d-xylose absorption is included. 4 for comparative purposes, table 13 .12-1 lists the clinical and clinicopathologic features of the diseases, and tables 13.12-2 and 13.12-3 present the gross morphologic and histopathologic findings, respectively. the extent of small intestinal disease is the key to determine whether one can demonstrate malabsorption based on abnormal carbohydrate absorption. as described in chapter 13.4, this is not an all-or-nothing situation. in the same animal the staging of the pathologic changes differs in different regions of the small and large intestines, thus influencing severity of clinical signs and absorption findings. furthermore, the extent of pathologic changes in different animals with ultimately the same morphologic diagnosis affects absorption studies and progress of the disease. early diagnosis remains a challenge, and even multiple intestinal biopsies taken at exploratory laparotomy may prove unhelpful. by contrast, intestinal infiltration with the predominant cell types can be found in grossly normal appearing intestinal tissue. alimentary lymphosarcoma of the horse may represent a primary neoplasia of the gut associated lymphoid tissue with significant cellular infiltration of the small intestine and associated lymph nodes with minimal large intestinal or systemic involvement. case series and pathology reports indicate that young horses 2 to 4 years of age primarily are affected, although the age range can be broad. [5] [6] [7] no breed or sex predilection exists. prevalence is unknown. despite the progressive nature of lymphomata, onset of clinical signs can be rapid and the animal may become acutely ill. as with all adult cases of chronic inflammatory bowel disease, antemortem diagnosis is by a process of exclusion and usually is confirmed post mortem. frequently, the horse has anemia, thrombocytopenia, neutrophilia or neutropenia, hypoalbuminemia, normal serum protein or hyperproteinemia, and hypergammaglobulinemia. lymphocytosis is rare. one may palpate intraabdominal masses, mainly enlarged mesenteric lymph nodes, rectally. abdominocentesis has been of diagnostic value. carbohydrate absorption tests usually reveal partial to total malabsorption indicative of the severely reduced surface area resulting from significant villous atrophy and the extensive mucosal or transmural infiltration. rectal biopsy has aided diagnosis. early confirmation of a suspected diagnosis necessitates exploratory laparotomy to obtain multiple intestinal and lymph node biopsies. in the future, markers of cancer cells may become available and may be cost-effective to aid diagnosis. prognosis is poor. natural progress of the disease is unknown. most horses are presented in an advanced state of disease. immunosuppressive drugs or chemotherapy may afford temporary improvement. however, outcome is unaffected. the chronic wasting condition granulomatous enteritis was first described in 1974 8 ; 9 of 10 horses were young standardbreds. most affected horses are 2 to 3 years of age. case reports from many countries revealed a predominance of standardbred over thoroughbred horses by three to one. 9,10 some of the standardbreds were related, implicating a genetic predisposition. prevalence is low. the condition is sporadic and has an insidious onset, and the course can be protracted. significant diagnostic features include anemia, slight increases or decreases in white blood cell counts, hypoalbuminemia, normal serum protein or hypoproteinemia, occasional increases in serum alkaline phosphatase activity, normal serum γ-glutamyltransferase activity, and enlarged mesenteric lymph nodes on rectal palpation. reduced carbohydrate absorption to the level of partial to total malabsorption is reported frequently, consistent with the severe morphologic changes throughout the small intestine. one can attribute the low proportion of horses exhibiting diarrhea 9,10 to the preferential distribution of inflammatory infiltration in the small intestine, 11 with lesser involvement of the large intestine. rectal biopsy can be a useful aid to diagnosis. 12 treatment of horses with granulomatous enteritis with a variety of drugs, particularly corticosteroids, has not affected the outcome except in the short term. 13 one successful response has been reported. prolonged corticosteroid administration produced clinical remission in a 6-year-old standardbred gelding based on improvement in clinical signs and in d-xylose absorption. 14 five months after cessation of approximately 5 months therapy, d-xylose absorption was normal and the horse was bright, alert, and resumed a level of athletic performance. parenteral administration of dexamethasone sodium phosphate was tapered to achieve a minimal effective dose to reduce intestinal inflammation and abolish clinical signs. adverse effects were not reported. the outcome of this single case is encouraging. surgery may be indicated if the disease is localized. two young horses underwent resection of the thickened terminal small intestine to confirm a diagnosis and provide a means of treatment; one horse died 4 months after surgery, and the other has remained clinically normal for at least 10 years. 10 the cause of granulomatous enteritis is unknown. several infectious agents have been implicated, including mycobacterium avium. 15 the condition may represent a granulomatous hypersensitivity reaction. immunemediated responses to dietary, parasitic, or bacterial antigens may be important initiating factors. 1 recently, six cases purported to represent granulomatous enteritis were linked to environmental contamination with aluminum. 16 although the case definition was flawed and problems existed with the data and interpretation, 17 the report nevertheless raised the possibility that a toxicologic basis may exist for some equine inflammatory bowel disorders. lumen from parasitic, bacterial, or dietary sources. infectious agents have not been identified. 18, 19 widespread use of the avermectins has tended to reduce parasite loads and composition to favor small strongyles (cyathostomes). eosinophilia is a feature of parasitism in the equine intestinal tract, although nematodes rarely have been identified in any lesions of meed. 3, 18 however, failure to detect larval structures in these lesions may be attributable to chronicity of the disease and destruction of the parasites in tissue. 10 biopsies of the rectal mucosa 12 or of the skin, liver, intestinal tract, and lymph nodes may assist in diagnosis. treatment has been attempted with a variety of drugs, including antibiotics, corticosteroids, and anthelmintics with larvicidal activity. immediate improvement has not been borne out in the long term. prognosis is poor. the clinical objective is to reach a tentative diagnosis early in the course of the disease for intervention to be more than transient. unlike the other conditions (see table 13 .12-1), meed has definitive liver and pancreatic involvement, and thus maldigestion may make a significant contribution to the wasting disease. for example, the lowered albumin and protein could result in part from impaired pancreatic enzyme digestion, and the effects of inflammatory lesions in the liver and ileum may decrease bile salt concentrations. the morphologic findings in lymphocytic-plasmacytic enterocolitis reflect the predominant infiltrative cellular elements of this rarely encountered condition. a retrospective study of 14 horses 23 provided the information presented in the tables. no specific clinical or clinicopathologic features differentiate this condition antemortem from other inflammatory diseases of adult horses. carbohydrate absorption was abnormal or delayed in 9 of 12 horses, consistent with the predominance of small intestinal pathologic changes. rectal biopsies were abnormal in 3 of 7 horses, two of which were reported as having lymphocytic-plasmacytic proctitis. prognosis is poor. treatment has been unsuccessful, probably because of the advanced nature of the condition at the beginning of treatment. proliferative enteropathy has not been associated with abnormal carbohydrate absorption based on three horses subjected to carbohydrate absorption tests. however, the florid mucosal lesions in the jejunum and ileum undoubtedly contribute to impaired digestive function and potential malabsorption of vitamins, minerals, and amino acids in the distal small intestine. the condition meed encompasses disorders characterized by a predominant eosinophilic infiltrate in the gastrointestinal tract, associated lymph nodes, liver, pancreas, skin, and other structures and accompanied by some degree of malabsorption and enteric protein loss. the disorders include chronic eosinophilic gastroenteritis, 18 eosinophilic granulomatosis, 9 chronic eosinophilic dermatitis, 19 and probably basophilic enterocolitis. 20 the condition differs from idiopathic eosinophilic enterocolitis, 10 in which segmental lesions in the small or large intestine induce signs of colic requiring surgical intervention 21,22 without evidence of malabsorption or multisystem involvement. although prevalence is low, meed appears to be more common than granulomatous enteritis based on the accumulated published reports and personal experience in australia and the united states. most affected horses are 2 to 4 years of age, and standardbreds and thoroughbred are reported to predominate. the condition is sporadic and has an insidious onset, and the course is protracted with a duration of 1 to 10 months. diarrhea is common in contrast to granulomatous enteritis. severe skin lesions with exudative dermatitis and ulcerative coronitis are prominent and frequently are the principal reason for veterinary attention being sought. despite extensive tissue eosinophilia, systemic eosinophilia is rare. hematologic values are usually unremarkable. notable features include hypoalbuminemia and normal serum protein or hypoproteinemia, and because of liver involvement, serum γ-glutamyltransferase and alkaline phosphatase activities may be increased. most reports of carbohydrate absorption test findings (glucose or d-xylose) indicate retarded absorption and a reduced or normal peak concentration delayed to at least 180 minutes. one can interpret this pattern as the existence of sufficient small intestinal absorptive capacity to enable moderate absorption with possibly delayed gastric emptying or ileocecal ejection. morphologic changes are less pronounced in the small intestine than in the large intestine, 9 and small intestinal lesions predominate segmentally in the proximal duodenum and distal ileum. furthermore, significant hyperkeratosis of the fundic region may contribute to gastric muscle contractile disruption. diarrhea can be a consequence of the severe segmental or multifocal granulomatous lesions in the large intestine with mucosal and transmural thickening and extensive ulceration. abundant fibrosis is a feature of all affected tissues (see table 13 .12-3). the cause of meed is unknown and could represent a chronic ongoing immediate hypersensitivity reaction against undefined antigens ingested or excreted into the affects foals 3 to 7 months of age, particularly those that have been weaned recently. the disease is caused by lawsonia intracellulare, an obligate intracellular bacterium found in the cytoplasm of proliferative crypt epithelial cells of the intestine. the condition in a foal was described first as intestinal adenomatosis, 24 because of similarity to the swine disorder of the same name. later, molecular studies showed that intestines from an affected foal contained l. intracellulare sequences as determined by polymerase chain reaction analysis and confirmed by southern blot hybridization. 25 recently, studies of a cluster of affected foals on three breeding farms in canada provided much information on the clinical syndrome, laboratory investigations, and response to treatment. 2 two of the three farms bred arabians, hence a demographic predominance of arabian foals exists. clinical signs included depression, rapid and significant weight loss, edema, diarrhea, and colic. poor body condition, a rough hair coat, and potbelly appearance were common findings. other problems often were concurrent, including respiratory tract infection, dermatitis, intestinal parasitism, and gastric ulceration. significant laboratory findings were anemia, transient leucocytosis, hypoalbuminemia, hypoproteinemia, and elevated serum creatine kinase concentrations. diagnosis was confirmed by identifying characteristic intracellular bacteria within the apical cytoplasm of proliferating crypt epithelial cells using silver stains and by results of polymerase chain reaction analysis and immunohistochemical testing. antemortem diagnosis relied on clinical signs, hypoproteinemia, and exclusion of common enteric infections. one can confirm diagnosis in live animals by fecal polymerase chain reaction analysis (positive in 6 of 18 foals tested) and serologic testing; 7 foals with proliferative enteropathy were evaluated serologically and had antibodies against lawsonia intracellulare. 2 treatment is effective. most foals received erythromycin estolate (15 to 25 mg/kg per os every 6 to 8 hours), alone or with rifampin (7 to 10 mg/kg per os every 12 hours) for 2 to 4 weeks. foals frequently needed supportive therapy at the outset for stabilization. response to therapy has been excellent. 2 rapid improvement in clinical signs even within 24 hours preceded the rise in plasma protein concentration. the source of the infection was undetermined. no apparent link existed between the three farms and a swine operation or solid and liquid waste disposal on pasture. however, one cannot exclude airborne spread of dried fecal material over distances. comparisons of epidemiologic findings from the swine disease indicated that overcrowding, feed changes, antibiotic usage, and mixing and transportation were potential risk factors at two of the farms. recent weaning appeared to be a key element in the pathogenesis. 24 samuel l. jones acute diarrhea caused by colitis in adult or young horses is a potentially life-threatening disorder of a variety of causes (table 13 .13-1) characterized by hypersecretion of fluid, motility disturbances, altered microbial flora in the colon, and an impaired mucosal barrier caused by direct injury or inflammation. many of the clinical and clinicopathologic features are similar regardless of the cause. severe dehydration with profound electrolyte abnormalities is common, as is systemic inflammation from absorption of endotoxin or other bacterial products through the compromised mucosa. gastrointestinal protein loss may result in reduced colloid oncotic pressure from hypoproteinemia, leading to tissue edema. colitis is a highly catabolic disorder, and weight loss may be rapid and severe. some cases of colitis may be complicated by extensive mucosal ulceration, serosal inflammation, or mural ischemia/infarction extending from the inflammation or resulting from coagulopathies. thus diagnostic measures aimed at determining the cause necessarily must be accompanied by clinical and laboratory assessment of hydration, electrolyte and acid-base balance, plasma protein concentration and colloid oncotic pressure, organ function, and evaluation of the degree of systemic inflammation and of the integrity of the intestinal wall. although therapeutic strategies are similar for many causes of colitis, consisting primarily of control of local and systemic inflammation, maintenance of fluid and electrolyte balance, promotion of tissue perfusion, replacement of plasma protein, preservation of colloid oncotic pressure, promotion of mucosal repair, restoration of the microbial ecology of the colon, and nutritional management, some causes of acute colitis have specific therapies aimed at eliminating the cause. a variety of infectious organisms has been identified as causes of acute colitis in adult horses. the clinical syndromes associated with these infections are indistinguishable in most horses. however, appropriate diagnostic tests including fecal bacterial culture, fecal bacterial toxin analysis, pcr, and/or serology may identify specific infectious organisms. salmonella is a genus of gram-negative facultatively anaerobic bacteria that are common gastrointestinal pathogens in horses. many serotypes of salmonella have been reported to infect horses, but those classified in group b appear to be associated more commonly with disease than those in other groups. group b includes s. typhimurium and s. agona, two of the species most frequently isolated from horses. 1-3 s. typhimurium is the most pathogenic serotype in horses and is associated with a higher case fatality rate than other species of salmonella. 1 the number of horses that are infected inapparently with and actively shed salmonella in their feces has been reported to be as high as 10% to 20%, but actual prevalence of salmonella-shedding in the general horse population is likely to be much lower, less than 1% to 2%. 4 horses shedding salmonellae are a potential source of infection to susceptible horses, 1,5 as are environmental reservoirs. [6] [7] [8] for these reasons, salmonellosis is one of the most common nosocomial diseases in horses. nosocomial salmonellosis significantly affects morbidity and mortality in hospitalized horses. 9 the emergence of multidrug resistance in equine salmonella isolates has been a cause of concern because of the importance of salmonellosis as a nosocomial disease and because salmonella represents a significant zoonotic pathogen. 7, [10] [11] [12] the virulence of the bacteria varies tremendously with serotype and even among strains of the same serotype in part because of the important role of host susceptibility in the pathogenicity of particular organisms. the infective dose is generally millions of organisms inoculated orally, but various environmental and host factors can reduce the infective dose to a few thousand or even hundreds of organisms. [13] [14] [15] environmental factors or stresses that increase susceptibility to salmonella infection are not well defined, but high ambient temperature, for example, is known to increase the prevalence of salmonellosis in horses greatly. indeed, the peak incidence of salmonellosis in horses occurs in late summer and fall. 6, 14, 15 other environmental and host factors that increase the risk of salmonella infection include transportation, antibiotic administration, gastrointestinal surgery, general anesthesia, preexisting gastrointestinal disease, change in diet, and immunosuppression. 1, 8, 15 host factors that restrict gastrointestinal colonization and invasion by pathogens include gastric ph, commensal gastrointestinal flora, gastrointestinal motility, the mucosal barrier and mucosal immunity. 1, 16 gastric acidity is an important defense mechanism preventing live organisms from reaching the intestine. altering the gastric ph with histamine 2 receptor antagonists, for example, may increase susceptibility to infection. gastrointestinal flora inhibits the proliferation and colonization of salmonella by secreting bacteriocins, short-chain fatty acids, and other substances that are toxic to salmonella. in addition, elements of the normal flora compete for nutrients and space, especially on the mucosa. 16 being predominantly anaerobic, the normal flora maintain a low oxidationreduction potential in the environment of the large intestine, which inhibits the growth of many bacterial pathogens. 17 the importance of normal host gastrointestinal ecology is illustrated by the fact that disturbances of the colonic flora with antibiotics, changes in feed, ileus, or other underlying gastrointestinal disease greatly increase the susceptibility of the host to infection by salmonella, often resulting in serious disease. the immune status of the host may be one of the most important factors determining not only the susceptibility to salmonella infections but also the degree of invasion and subsequent outcome of the infection. local immunity, such as mucosal antibody secretion and enterocyte-derived cationic peptides, prevents colonization of the mucosa. 16, 18, 19 opsonizing antibodies and activation of the complement cascade are important in fighting systemic invasion by salmonella by increasing the efficiency of phagocytosis and by direct bactericidal activity. humoral immunity, however, is often ineffective in preventing disease and dissemination once invasion occurs and salmonella has established in its intracellular niche. following invasion, salmonella is capable of surviving and multiplying within macrophages, rendering humoral (noncellular) immune systems ineffective. 20, 21 specific cellular immunity may be the most effective defense mechanism in the host arsenal against dissemination and systemic infection by salmonella. 21, 22 oral inoculation with small numbers of virulent organisms may induce protective immunity in horses and calves, but the duration of the immunity is not known. 23, 24 oral and parenteral vaccines using killed or attenuated organisms and bacterial products have been promising but are effective only against homologous organisms and are usually not cross-protective among different serogroups. [23] [24] [25] in adult horses, salmonella primarily infects the cecum and proximal colon, causing enterocolitis, and the ability to disseminate beyond the intestine and cause enteric fever is limited. in foals, however, salmonellosis often is associated with septicemia. the ability of salmonella to cause enterocolitis depends on the ability of the bacteria to invade the gastrointestinal mucosa. 16, 20 invasion of the gastrointestinal mucosa occurs preferentially through specialized enterocytes called m cells that overlay intestinal lymphoid tissues such as peyer's patches in nonequine species. a variety of enteric pathogens exploit m cells during infection of intestinal tissue. 26 invasion of the epithelium occurs by self-induced uptake via the apical membrane of the m cell, often killing the cell in the process. 20 salmonellae then invade neighboring cells via the basolateral membrane, eventually spreading the destruction of the epithelium beyond the principle area of attack. virulent salmonellae have a well-developed invasion mechanism involving generation of an apparatus called a type iii secretory system that enables virulence gene products to be injected directly into enterocytes. 27 virulence proteins injected by salmonellae into enterocytes engage the cellular machinery and induce the cell to engulf the bacteria by macropinocytosis. salmonella virulence gene products also induce enterocyte chloride and fluid secretion and upregulate enterocyte transcription of inflammatory cytokines (tumor necrosis factor α and interleukin-1β) and chemokines that trigger a mucosal inflammatory response. 20, 27, 28 after salmonellae invade the mucosa, they are phagocytosed quickly by macrophages and dendritic cells in the lamina propria and lymphoid tissues. the ability of salmonellae to disseminate systemically and cause enteric fever is associated with the ability to survive and proliferate in macrophages. indeed, phagocytes have an important role in dissemination of the pathogen to blood, lymph nodes, liver, and spleen. most salmonellae in the blood and tissues of infected animals that are competent to cause enteric fever are within phagocytic cells. 29 in adult horses with salmonellosis, dissemination appears to be limited to the intestine and mesenteric lymph nodes, and salmonella rarely is cultured from blood. however, in foals and in some adults, salmonella causes an enteric feverlike disease with dissemination to mesenteric lymph nodes, liver, spleen, and blood. salmonella organisms require specific virulence gene clusters encoded on the chromosome or on plasmids for intracellular survival in macrophages. 20 some of these genes are sensors that signal the bacteria that it has entered an intracellular environment and turn on genes required for intracellular survival. others, like invasion genes, are transported from the bacteria and injected into macrophage cytosol by a type iii secretory system to prevent phagosome/lysosome fusion and subvert other essential macrophage killing mechanisms. salmonellae also possess multiple genes that confer resistance to reactive oxygen and nitrogen metabolites, perhaps the most lethal antimicrobial mechanisms of macrophages. 30 diarrhea associated with salmonellosis has multiple causes. a salmonella cytotoxin inhibits protein synthesis in mucosal cells, causing morphologic damage and altered permeability. 31 virulent salmonellae also produce an enterotoxin similar to the heat-labile toxin (lt) produced by escherichia coli. 32, 33 the enterotoxin contributes to but is not required in the pathogenesis of diarrhea. 34, 35 salmonella enterotoxin increases secretion of chloride and water by colonic mucosal cells in many species, including horses, by increasing intracellular cyclic adenosine monophosphate concentrations. the ability of virulent salmonellae to cause diarrhea appears to be associated most closely with the ability to invade enterocytes and to trigger an inflammatory reaction in the intestinal tissue. 20, 36 gene products injected into enterocyte cytosol by the type iii secretory system of invading salmonellae stimulate chloride and fluid secretion. 27 salmonella invasion of enterocytes is also a potent activator of inflammatory chemokine and cytokine production, resulting in the recruitment of leukocytes, particularly neutrophils, and activation of resident macrophages and mast cells. products of these activated leukocytes, including prostaglandins, leukotrienes, reactive oxygen metabolites, and histamine, are potent stimulators of chloride secretion in the colon of many species. 16, [37] [38] [39] the enteric nervous system integrates the diverse processes of pathogen recognition, triggering of the inflammatory response, and induction of enterocyte fluid secretion. 39 many of the inflammatory mediators studied stimulate colonic secretion by prostaglandin-dependent mechanisms, resulting in increased intracellular cyclic adenosine monophosphate or calcium concentrations or both in mucosal cells. 37 in addition, these mediators and the enteric nervous system may stimulate secretion by prostaglandin-independent mechanisms, inhibit sodium and water absorption, cause motility disturbances, and potentiate tissue injury, all of which enhance the pathogenicity and dissemination of salmonella and contribute to the pathogenesis of diarrhea. 37, 39 neutrophils recruited to the mucosa by signals generated by the infected enterocytes physically contribute to mucosal injury by producing a variety of products that are lethal to pathogens but are also toxic to host cells. 40, 41 moreover, neutrophils attracted to infected epithelial cells accumulate beneath the monolayer, lifting it off the basement membrane in sheets. neutrophils also migrate across the epithelial monolayer in potentially massive numbers. transepithelial migration of neutrophils increases the permeability to macromolecules, bacterial products, and even bacteria. 41 potentially massive losses of electrolytes, water, and protein can occur depending on bacterial and host factors. perhaps most devastatingly, mucosal injury and altered permeability allow systemic absorption of bacterial products and dissemination of bacteria, resulting in systemic inflammatory responses such as occur with endotoxemia and septicemia. four syndromes of salmonella infection have been described clinically and reproduced experimentally in horses: (1) inapparent infections with latent or active carrier states; (2) depression, fever, anorexia, and neutropenia without diarrhea or colic; (3) fulminant or peracute enterocolitis with diarrhea; and (4) septicemia (enteric fever) with or without diarrhea. inapparent infections can be activated to clinical disease in compromised horses, such as horses with colic or horses being treated with antibiotics, causing mild to severe enterocolitis. in addition, latent infections (nonshedding) can become active infections (shedding) under certain conditions, such as transportation stress and antibiotic treatment. horses with depression, anorexia, fever, and neutropenia without diarrhea generally have a good prognosis and recover in several days without specific treatment. 42 the septicemic form is restricted mostly to neonatal foals and is uncommon in adult horses. this discussion focuses on acute enterocolitis. acute enterocolitis is characterized by severe fibrinonecrotic typhlocolitis, with interstitial edema and variable degrees of intramural vascular thrombosis that may progress to infarction. 1 severe ulceration of the large intestinal mucosa may occur with serosal ecchymoses and congestion. the earliest signs of enterocolitis are usually fever and anorexia. 1, 15 signs of colic may be apparent early in the course of the disease, especially if ileus is present. clinical signs of endotoxemia are common and range from fever, elevated heart and respiratory rates, poor peripheral perfusion, and ileus to fulminant and rapidly progressive signs of endotoxemic shock. oral mucous membranes are often pale with perigingival hyperemia (a toxic rim) but may be brick red or cyanotic, with prolonged capillary refill time. one may note weakness, muscle fasciculations, cold extremities, and other signs suggestive of hypotensive shock; synchronous diaphragmatic flutter; abdominal pain; and significant metabolic and electrolyte abnormalities in severe cases of enterocolitis. one also may note signs of mild dehydration before diarrhea is apparent. once diarrhea is evident, dehydration may become severe rapidly. occasionally, horses die peracutely, without developing diarrhea. diarrhea may not be apparent for several days but usually occurs by 24 to 48 hours after the fever begins. 1, 15 the duration of the diarrhea may be days to weeks. the character of the first diarrheal feces is usually watery with particles of roughage but may become fluid rapidly without solid material. finding frank blood and fibrin in the feces is unusual. the volume of feces is often large, with frequent defecation. one may note straining or signs of colic when the patient is defecating, and rectal prolapse may occur occasionally. persistent straining and rectal prolapse may be a sign of colonic infarction. abdominal borborygmi are often absent early in the course of the disease because of ileus but become evident later, usually when diarrhea begins. fluid and gas sounds are commonly audible, but normal progressive motility is less frequently audible than normally. transrectal palpation may reveal edematous rectal mucosa and colon and fluid-filled colon and cecum. one may obtain gastric reflux, especially early in the course when ileus is evident. hematologic abnormalities early in the course of the disease include moderate to severe neutropenia, lymphopenia, and leukopenia, a mild to moderate left shift, and toxic changes in the neutrophils. 1, 15 thrombocytopenia, moderate to severe hemoconcentration, and hyperfibrinogenemia are also common. neutropenia is an early but nonspecific indicator of salmonellosis, often occurring concurrently with the onset of fever. 1 later in the course of disease, one may see neutrophilic leukocytosis, indicating recovery. a degenerative left shift, with metamyelocytes and myelocytes in the peripheral blood, is a poor prognostic sign. serum biochemical analysis may reveal azotemia, elevations in serum sorbitol dehydrogenase and γglutamine aminotransferase activity, and elevated serum lactic acid concentration. azotemia is often prerenal, but acute hemodynamic renal failure may occur in severely dehydrated, endotoxemic, or septicemic patients. indeed, elevation of creatinine concentration is a poor prognostic indicator in horses with acute colitis. 43 hemodynamic renal disease may be complicated by toxic injury caused by administration of nephrotoxic drugs. hyponatremia may also contribute to prerenal azotemia. elevations in hepatocellular enzymes are usually mild and reflect damage to the hepatocytes from absorbed toxins such as endotoxin and from poor perfusion caused by hypotensive shock or dehydration. lactic acidemia may be present, reflecting poor tissue perfusion. plasma protein rapidly drops as protein is lost in the gastrointestinal tract, causing moderate to severe hypoalbuminemia and hypoglobulinemia. peripheral or organ edema (vascular leak syndrome) may occur if hypoproteinemia is severe, coupled with increases in endothelial permeability induced by systemic inflammation. hypokalemia, hyponatremia, hypochloridemia, and hypocalcemia are common electrolyte abnormalities in patients with enterocolitis. metabolic acidosis also may be present. coagulopathies, such as decreased antithrombin iii activity and disseminated intravascular coagulation, may occur. urinalysis may reveal isosthenuria, proteinuria, hematuria, cylindruria, and glucosuria if hemodynamic or toxic renal injury is present. the number of leukocytes in the feces usually is elevated, and occult blood may be detectable. peritoneal fluid is usually normal except when severe mural inflammation or colonic infarction occurs. routine detection of salmonellae in feces involves five daily cultures of large samples (10 to 30 g) of feces using enrichment techniques. 1, 44, 45 however, the sensitivity of fecal culture can be as low as 30% to 50%, even if one cultures several fecal samples collected daily. concurrent culture of rectal biopsy specimens and feces increases the sensitivity of culture techniques to 60% to 75%. 45 currently, the polymerase chain reaction (pcr) is the most sensitive and rapid test for detecting salmonella in feces. a single pcr test applied early in the course of disease is a more sensitive test for the presence of salmonella than repeated fecal cultures. 46, 47 detection of salmonellae in feces does not prove a diagnosis of salmonellosis, but the positive predictive value of a positive pcr or culture results is high in horses with compatible clinical signs. culture of peripheral blood may allow isolation of the organism if bacteremia or septicemia is present, but blood cultures are not a sensitive test for salmonellosis in adult horses. although foals are more likely than adults to become septicemic, culture of blood is recommended in all cases with signs suggestive of septicemia. increased numbers of fecal leukocytes suggest an invasive process in the colon but are not specific for salmonellosis. early in the course of the disease, dehydration, electrolyte and acid-base imbalances, endotoxemia, and sepsis may be life threatening. aggressive treatment during the acute stages to replace fluids lost in the diarrhea and to control sepsis and endotoxemia is often effective in controlling the primary disease. weight loss and hypoproteinemia are often severe. complications such as multiorgan dysfunction, vascular leak syndrome with peripheral and organ edema, laminitis, acute renal failure, venous thrombosis and septic phlebitis, irreversible protein-losing enteropathy or chronic malabsorption, pulmonary aspergillosis, and gastrointestinal infarction can occur. in many instances, horses recover from acute salmonellosis with aggressive treatment, only to succumb to complications of the disease, partially explaining the high fatality rate of equine salmonellosis compared with human salmonellosis. chronic, mild to moderate diarrhea occasionally occurs in horses after a bout of severe salmonellosis, usually with protein-losing enteropathy. if the chronic diarrhea persists beyond 4 to 5 weeks after the onset of signs, the prognosis for recovery is poor. 15 potomac horse fever (equine monocytic ehrlichiosis) is caused by the obligate intracellular rickettsial organism neorickettsia risticii. [48] [49] [50] [51] the disease is most common from late summer to early fall, with a peak incidence in july and august. potomac horse fever was described first in the northeast but since has been diagnosed in most areas of the continental united states, with a particularly high prevalence in the northeast and midwest. the geographic distribution is characterized by a significantly higher percentage of cases found along waterways and rivers. 48, 49 the disease occurs sporadically, temporally and geographically, and can affect any age group of horses. the case fatality rate is 5% to 30%. 48 transmission of n. risticii has been reproduced experimentally by oral, intramuscular, intradermal, subcutaneous, and intravenous routes. 48, 52 however, the natural route of infection has remained a mystery until recently. the epidemiologic data, the fact that many other rickettsial diseases are transmitted by insect vectors, and the finding that the disease can be transmitted via whole blood have implicated insect vectors in the natural transmission of the organism. attempts to transmit the disease experimentally with ticks (dermacentor variablis) or biting flies (stomoxys calcitrans) have been unsuccessful. 53, 54 recently, n. risticii has been found to infect virgulate cercariae larval stages of trematodes that use operculate freshwater snails (juga spp.) as part of their life cycle in northern california. 55 infected virgulate cercariae have been identified in aquatic snails collected in other parts of the country as well. virgulate cercariae are part of the life cycle of trematodes that are common parasites of many species and use freshwater snails and aquatic insects as intermediate hosts. although the trematode species infected with n. risticii remains to be identified definitively, at least two species are considered potential vectors. 52 during the trematode life cycle, aquatic snails release large numbers of infected cercariae into water, where they seek their next intermediate host. infected metacercaria have been identified in a variety of aquatic insects. 56 preliminary studies suggest that n. risticii in fact may be transmitted via ingestion of mature caddis flies containing infected metacercariae. 57 possibly horses are infected by drinking water containing infected cercaria released from snails or by ingesting infected metacercariae in other aquatic insects. 52 the number of pcr-positive snails in endemic regions corresponds to the seasonal incidence of potomac horse fever and may be as high as 26%. 58 the pathogenesis of n. risticii is not understood completely. the organism infects and survives in monocytes and monocyte-derived leukocytes and can be found in blood monocytes during natural infections, but the sequence of events resulting in enterocolitis remains speculative. the organism appears first to infect blood monocytes in experimentally infected horses, which may be the vehicle of organ infection. 50, 59 however, in naturally infected horses, whether leukocytes of monocytic lineage or epithelial cells are infected first is unclear. the target organ is the gastrointestinal mucosa, with the most severe lesions found in the large intestine. 59, 60 infection of human colonic cells in vitro does not cause major cytopathologic effects for several days. disruption of the microvilli in the region of the plasma membrane where sodium chloride channels are located has been observed in human colonic cell cultures. 61 infection in horses is associated with variable degrees of morphologic damage. 59, 60 mild morphologic damage and mononuclear cell infiltration of the lamina propria occur early during the infection, but fibrinous, necrotizing typhlocolitis with severe mucosal ulceration and inflammation of the lamina propria may occur later in the disease. vasculitis and intravascular coagulation are consistent features in the large intestine, with perivascular edema. 60 one can observe n. risticii in mucosal cells and macrophages and mast cells of the lamina propria. 59,60 n. risticii can survive and multiply in macrophages by inhibiting the production of reactive oxygen intermediates and by avoiding lysosomal digestion by blocking phagosome-lysosome fusion. [62] [63] [64] evidence of impaired sodium chloride absorption in the colon has been suggested to contribute to diarrhea in infected horses and may be related to destruction of the enterocyte membrane structure in the region of sodium chloride channels. 61, 65 direct injury to the mucosa by n. risticii and colonic inflammation are likely to be prominent features leading to diarrhea, especially later in the disease. 60 fluid, protein, and electrolyte loss likely is caused by mucosal injury and effects on enterocyte fluid secretion caused by the inflammatory response. like other inflammatory conditions of the colon, systemic inflammation caused by absorption of bacteria and bacterial products is a potential complication of n. risticii infections if mucosal injury is severe, which contributes to the clinical signs seen during the disease. n. risticii infection is clinically similar to other forms of enterocolitis and is characterized by anorexia, depression, and fever. 48, 60, 66 experimental infections produce a biphasic fever occurring 6 to 7 days apart. decreased gastrointestinal motility, manifested as reduced borborygmi, occurs during the early stages before the onset of diarrhea. diarrhea occurs in 75% of cases and occurs 2 days after the second fever episode during experimental infections. 66, 67 the diarrhea can be moderate to severe and dehydrating. ileus can develop at any stage of the disease and can cause signs of moderate to severe colic. systemic signs of endotoxemia, shock, and peripheral edema may occur and are similar to those described for salmonellosis. experimental and natural infection with n. risticii can cause abortion of infected fetuses in pregnant mares. 68, 69 laminitis is a complication in 20% to 30% of naturally occurring cases and is often severe. other complications include protein-losing enteropathy, thrombosis, and renal failure, as described for salmonellosis. hematologic abnormalities reflect endotoxemia, dehydration, and sepsis and are essentially identical to those described for salmonellosis. neutropenia with a left shift is a consistent feature and occurs concurrently with or soon after the onset of diarrhea. thrombocytopenia is common and often severe. 67 neutrophilic leukocytosis occurs later in the course of the disease. hyperfibrinogenemia is usually more pronounced than that with salmonellosis. serum electrolyte, acid-base, and biochemical abnormalities are also similar to those described for salmonellosis. coagulopathies are common during n. risticii infection and reflect activation of coagulation pathways. disseminated intravascular coagulation is common and may be related to the high frequency of laminitis associated with n. risticii infection. 70 one cannot base diagnosis of n. risticii infection solely on clinical signs because the disease is clinically similar to other forms of enterocolitis. however, in endemic areas, acute colitis is likely to be caused by n. risiticii, and thus the clinical signs of acute inflammatory colitis in fact may have a high predictive value. serologic evidence of infection, such as rising antibody titers to n. risticii detected by indirect immunofluorescence or enzymelinked immunosorbent assay in paired serum samples may be helpful in establishing a diagnosis. 49, 71 one should take care when interpreting the indirect immunofluorescence serologic test for n. risticii because the test appears to have a high false-positive rate. 72 culture of the organism from blood is possible but is difficult and is generally useful only in the research laboratory. recently developed polymerase chain pcr tests for n. risticii dna are rapid, highly sensitive (as sensitive as culture), and specific for n. risticii infection and can be applied to blood or feces. [73] [74] [75] prevention prevention of the disease by reducing exposure to the causative organism is difficult because the mode of transmission is not known. a killed vaccine has been developed that is effective in preventing clinical illness other than fever in 80% of experimentally challenged horses using the vaccine strain. however, field studies suggest the vaccine has limited benefit for prevention or decreasing the severity of natural infection. vaccine failures have been attributed to strain differences in antigenicity or to poor antibody responses to the vaccine. 76, 77 clostridiosis is an important cause of acute enterocolitis in foals and adult horses. clostridium perfringens and c. difficile are associated most commonly with intestinal clostridiosis in horses, but other clostridial species, including c. septicum, c. cadaveris, and c. sordellii also have been isolated from horses with enterocolitis. [78] [79] [80] [81] [82] [83] in horses of all ages, clostridial enterocolitis appears to be a common antibiotic-associated and nosocomial cause of enterocolitis. 82, 84, 85 however, clostridiosis in neonatal foals is a distinct clinical entity and is discussed in more detail elsewhere. this chapter focuses on adult intestinal clostridiosis. clostridia are obligate anaerobic to aerotolerant spore-forming gram-positive rods that are ubiquitous in the environment in the spore form. 83 clostridia are elements of the normal flora of horses of all ages and are among the first bacteria acquired after birth. however, clostridia inhabiting the gastrointestinal tract normally are found in low numbers and do not produce enterotoxins. clostridiosis is associated with an increase in the number of a particular species of clostridia in the gastrointestinal tract and, perhaps most importantly, exotoxin production. although the conditions resulting in exotoxin production are not understood fully, several factors increase clostridial numbers in the gastrointestinal tract. dietary factors are known to affect the numbers of clostridium species shed in the horse feces. 78 experimental induction of colic increases fecal shedding of clostridium species in the absence of diarrhea. 86 antibiotics, particularly administered orally or recycled via the enterohepatic system, are well documented to increase the recovery of clostridia colony-forming units (cfus) in equine feces and may result in clinical clostridiosis. 79, 81, [87] [88] [89] [90] indeed, clostridiosis associated with c. perfringens or c. difficile is likely to be the most important cause of antibiotic-induced enterocolitis in the horse. clostridium perfringens c. perfringens is made up of many genetically distinct strains of variable virulence that produce one or more of a large group of exotoxins. the pattern of exotoxin production is used to classify c. perfringens into five types, a, b, c, d, and e. c. perfringens type a is the most common clostridium isolate from healthy horses of all ages and adults and foals with diarrhea worldwide. c. perfringens types a, b, c, and d have been associated with hemorrhagic enteritis in foals less than 10 days of age, with type c being the most common cause in north america. the primary toxin produced by c. perfringens type a is α-toxin (phospholipase c), which interferes with glucose uptake and energy production and activates arachidonic acid metabolism and signaling pathways in enterocytes. 83 oral administration of α-toxin does not cause tissue necrosis but causes increased secretion by small intestinal mucosal cells in human beings. 91, 92 the β-toxin of types b and c is a cytotoxin that causes enterocyte necrosis, ulceration, and ultimately severe intestinal inflammation and hemorrhage. 93 a novel toxin designated β2 may also have a role in c. perfringens enterocolitis. 94 the biologic activity of the β2-toxin is similar to β-toxin, but β2-toxin is not related to β-toxin in sequence. the β2-toxin was prevalent in two groups of horses with acute enterocolitis but not in healthy horses. 95 the β2-toxin appears to be associated predominantly with c. perfringens that would have been classified otherwise as type a but that in fact may represent a previously undescribed type. virulent strains of c. perfringens type a and to a lesser extent type c also may produce enterotoxin. enterotoxin is a cytotoxin that inserts into cell membranes to form pores, which alter permeability to water and macromolecules and ultimately lead to cellular necrosis. 96 massive desquamation of the intestinal mucosa resulting from enterotoxin cytotoxicity triggers an inflammatory response, intestinal edema, mural hemorrhage, and systemic inflammation. 97 enterotoxin also alters tight junction integrity, resulting in increased paracellular permeability by a noncytotoxic mechanism. 98 clostridium difficile c. difficile produces several toxins, but only two, toxin a and toxin b have been studied in detail. toxin b is a potent cytotoxin in vitro, but its role in enterocolitis is less clear than the role of toxin a. toxin b does not induce fluid secretion, inflammation, or characteristic alterations in intestinal morphology. c. difficile induces an inflammatory response with hypersecretory diarrhea that is induced in large part by the enterotoxin toxin a. 99 toxin a induces neutrophil influx into intestinal tissue, mast cell degranulation, and secretion of prostaglandins, histamine, cytokines, and 5-hydroxytryptamine by these activated leukocytes. 100, 101 the products of neutrophils and mast cells have a prominent role in the vasodilatory and secretory responses in the intestine during c. difficile infection. the enteric nervous system is central to the induction of intestinal inflammation and mucosal secretion by toxin a. a model for toxin a-induced secretory diarrhea has emerged in which toxin a stimulates substance p-containing afferent sensory nerve fibers, which in turn stimulate mast cell degranulation, recruitment and activation of polymorphonuclear leukocytes, and vasodilation. [102] [103] [104] toxin a-induced stimulation of enterocyte secretion can occur via secretomotor neuronal stimulation by substance p-containing sensory neurons or products of mast cells and polymorphonuclear leukocytes. neural blockade or depletion of substance p abolishes mast cell degranulation, polymorphonuclear leukocyte influx, and enterocyte secretion. how toxin a triggers the sensory component of the enteric nervous system is not known yet, but toxin a-induced necrosis of enterocytes likely exposes afferent neurons to the noxious milieu of the intestinal contents. equine intestinal clostridiosis is clinically similar to other forms of acute enterocolitis in horses. 78, 83 although the clinical course is usually acute, peracute colitis with rapid death may occur. occasionally, a milder, more prolonged clinical course occurs. one may note fever, anorexia, and depression before the onset of gastrointestinal signs, but more commonly no prodromal signs are apparent. signs of endotoxemia and shock may accompany acute signs of colic and severe, dehydrating diarrhea. diarrhea may not be profuse but is usually dark and foul smelling. like the clinical signs, hematologic and serum biochemical abnormalities are similar to those associated with other forms of enterocolitis and reflect fluid, protein, and electrolyte loss and systemic inflammation from endotoxemia. neutropenia, leukopenia, and hemoconcentration are common. hypoproteinemia may be profound. one often may note hyponatremia, hypokalemia, hypochloremia, hypocalcemia, and a mixed prerenal/renal azotemia, as well as metabolic acidosis and coagulopathies. serum concentrations of hepatocellular enzymes such as sorbitol dehydrogenase may be elevated, and liver function may be reduced. preliminary diagnosis of equine intestinal clostridiosis caused by c. perfringens is based on the isolation of greater than 100 cfus of c. perfringens type a per gram of feces from patients with diarrhea and signs suggestive of toxemia. similar criteria are used to screen human patients for c. perfringens type a infection. normal horses shed fewer than 100 cfus/g of feces, and usually horses with intestinal clostridiosis shed greater than 1 × 10 6 cfus/g. 78, 105 however, identification of increased numbers of clostridium organisms in the feces does not prove infection. detection of c. perfringens toxins in feces or intestinal contents in horses with increased numbers of fecal cfus and clinical signs of enterocolitis is more conclusive evidence of an enterotoxigenic infection than culture alone. immunoassays are available that are primarily designed to detect c. perfringens enterotoxin. 83 however, the reliability (specificity) of some immunoassays for diagnosis of c. perfringens infection has come into question. recently, pcr multiplex and gene probe assays have been developed to detect the major lethal toxins in isolates or fecal samples to determine the pattern or toxin production and are currently the preferred methods of detection. [106] [107] [108] as for c. perfringens, diagnosis of c. difficile infection consists of culture of the organism from feces and identification of toxins in the feces. bacterial culture of c. difficile may be difficult and may be an insensitive test in horses. [109] [110] detection may require enrichment techniques and culture of multiple fecal samples. 110, 111 detection of toxins a and b in feces is regarded as the preferred test for diagnosis of c. difficile infection in human beings. 83 commercial enzyme-linked immunosorbent assays are available for toxins a and b that are specific and appear to be more sensitive than a single culture for identifying c. difficile infection in adult horses. 109, 110 one also may induce toxin production by c. difficile isolates. sensitive pcr methods also have been developed for application to fecal samples and isolates to detect the genes for toxins a and b. 83 proliferative enteropathy is a chronic hyperplastic disorder of the small intestine and has been described in a variety of mammalian and avian species. 112, 113 the only causative agent identified to date that induces proliferative enteropathy is the obligate intracellular pathogen lawsonia intracellulare. 113, 114 the pig is the most frequently naturally affected species. however, the reports of equine proliferative enteropathy associated with l. intracellulare have increased in recent years. [115] [116] [117] [118] the relatedness of the strains of l. intracellulare causing proliferative enteropathy in pigs and horses or even among other affected species is not known. no host restriction is apparent because hamsters and other rodents can be infected with porcine strains of l. intracellulare. before the year 2000, reports of proliferative enteropathy in the literature describing isolated cases were sporadic. [116] [117] [118] however, since 2000, outbreaks on breeding farms have been documented on farms in canada, suggesting that a new strain has emerged. 115 the mode of infection is fecal-oral, and infected animals can shed large numbers of organisms in feces. 113 affected animals shedding the organism in the feces serve as a source of infection for herdmates. possibly nonequine species serve as reservoirs contributing to outbreaks on horse farms. factors that increase the risk of proliferative enteropathy in pigs include overcrowding, ration changes, transport, and weaning. 113, 114 like pigs, horses are affected as weanlings. factors associated with weaning and other stresses may affect immunity and increase susceptibility to infection. the incubation period is 2 to 3 weeks in nonequine species and is presumed to be similar in horses. experimental l. intracellulare infection produces characteristic pathologic lesions in pigs and hamsters that are identical to lesions in horses with proliferative enteropathy. 113, 114 a profound hyperplasia of the mucosa predominantly caused by proliferation of crypt epithelium and crypt hyperplasia is induced locally in infected islands of tissue and eventually extends to the entire distal jejunum and ileum. l. intracellulare preferentially infects proliferating cells, thus the tropism for the crypt epithelium. infected cells proliferate far more rapidly than uninfected cells, suggesting that l. intracellulare directly induced the proliferative response. however, the molecular basis for the enhanced proliferation is not known. l. intracellulare penetrates epithelial cells in a membrane-bound vesicle but eventually escapes the vacuole and is found free in the cytoplasm concentrated at the apical pole of the cell. the gross pathologic lesions found in equine proliferative enteropathy are characteristic. [115] [116] [117] [118] lesions may be segmental and typically are found in the ileum and terminal jejunum in horses. however, lesions also may affect the duodenum. severe mucosal hypertrophy often occurs but may wane during the chronic stages of the disease. the mucosa may become corrugated with focal erosions or ulcers. one often can identify submucosal edema easily on cut sections of affected segments. moderate to severe crypt hyperplasia with atrophy of the intestinal villi is a consistent feature. the hyperplastic crypts are branched and may herniate into the submucosa. necrosis, edema of the submucosal and lamina propria, hemorrhage, mononuclear inflammation and muscular hypertrophy have been reported in affected intestinal segments but are not consistent. special stains such as silver stain are required to detect intracellular organisms. the organisms are curved or comma-shaped rods found clustered in the apical cytoplasm of hyperplastic crypt epithelium. the proliferative response of the intestinal mucosa alters absorption of nutrients and fluid secretion by disrupting the architecture of the villi and by altering the maturation of epithelial cells into absorptive cells, accounting for the secretory diarrhea and often severe weight loss. 112, 114 the combined effects of the inflammatory 892 part ii disorders of specific body systems response and malabsorption may account for the protein-losing enteropathy. proliferative enteritis most commonly affects weanling foals ages 4 to 6 months. the clinical signs of proliferative enteropathy include ill thrift, weight loss, peripheral edema, diarrhea, and colic. [115] [116] [117] [118] the diarrhea is usually in the form of soft feces but may be profuse and watery. some foals with mild diarrhea have black, tarry feces. secondary complications such as gastric ulceration, bronchopneumonia, or parasitism may occur concurrently with the proliferative enteropathy. clinicopathologic features include mild to moderate anemia, moderate to severe hypoalbuminemia (often <2 g/dl), hypoglobulinemia, neutrophilic leukocytosis, and hyperfibrinogenemia. creatine kinase activities may be elevated in affected foals. prerenal azotemia and electrolyte imbalances such as hyponatremia may be associated with diarrhea. peritoneal fluid analysis is usually unremarkable. ultrasonographic examination of the small intestine often reveals significant thickening of the intestinal wall ( figure 13 .13-1). intestinal edema may be evident as a hypoechoic appearance to one or more layers of the intestinal wall. methods for antemortem diagnosis include serologic analysis of l. intracellulare antibodies and pcr analysis of feces. 115 serologic analysis using an indirect immunofluorescent antibody test may be the most useful single test available. the pcr test is specific but the sensitivity may be low. by the time clinical signs appear, 90% of pigs are serologically positive for anti-lawsonia intracellulare immunoglobulin g (igg). in contrast, only 37% of pigs had positive fecal pcr tests. 119 of the seven foals tested in an outbreak of equine proliferative enteropathy, 115 four foals with confirmed disease and three with suspected proliferative enteropathy had serologic titers against l. intracellulare of 1:30 or greater. in contrast, serum samples collected from 72 foals before the outbreak were negative for l. intracellulare antibodies. fecal pcr for l. intracellulare was positive in 6 of 18 foals tested, and half of the serologically positive foals had negative fecal pcr tests. many clinicians combine serologic analysis with fecal pcr testing to increase the sensitivity and specificity of these diagnostic methods. isolation and culture of the organism requires cell culture techniques that are not widely available. thus no practical method exists for culturing the organism from feces or tissues that is available for clinical use. definitive diagnosis requires histopathologic examination of affected tissues. 112 diagnosis is based on typical histopathologic findings of mucosal hypertrophy and submucosal edema and identification of small, curved, rod-shaped intracellular bacteria at the apical pole of epithelial cells in affected segments of intestine. special stains such as warthin-starry silver stain are required to detect the bacteria in histopathologic specimens. pcr analysis of affected intestinal tissue is a specific test for the presence of l. intracellulare and, unlike fecal pcr analysis, appears to be sensitive. 120 strongyle infections in horses are caused by two groups of nematodes: large and small strongyles (see the section cyathostomiasis). large strongyles that are pathogenic in horses include strongylus vulgaris, s. edentatus, and s. equinus. of these species, s. vulgaris is by far the most important cause of disease in the large intestine and in fact is the most pathogenic parasitic infection in horses. s. vulgaris infection in horses is manifested clinically by two forms: acute and chronic disease. 121 the age and resistance of the host, the infective dose, and the size and function of the affected arteries influence the type and degree of disease that occurs. sudden ingestion of large numbers of infective larvae by a naïve host causes acute strongylosis, whereas ingestion of fewer infective larvae over a long period of time by an older, more resistant host causes chronic strongylosis. acute strongylosis is more likely to cause colic than diarrhea and may be rapidly fatal. chronic strongylosis tends to cause debilitation and signs of colic but may also cause diarrhea. diarrhea associated with acute strongylosis occurs within several days of infection and is likely to be caused by migration of the larvae through the intestinal wall. fourth-stage larvae migrate through the mucosa and submucosa into the arterioles of the intestine, causing mural edema, hemorrhage, and infiltration with inflammatory cells into the intestinal wall. 121,122 increased secretion and decreased absorption of fluid and electrolytes, stimulated by inflammatory mediators such as prostaglandins and histamine, may play a role in the diarrhea induced by s. vulgaris. interstitial edema and damage to the interstitial matrix and mucosa may result from inflammation and migration of the parasites, causing increased secretion of fluid and albumin loss. abnormal gastrointestinal motility also may play a role in the development of diarrhea. migration of larvae through the intestinal wall early in the course of infection affects myoelectric activity and motility in the large intestine and may affect retention of ingesta and absorption of fluid. 123,124 the cause of death in acute strongylosis has not been addressed but may be related to massive migration through the vasculature, causing thrombosis with ischemia and infarction of the intestine. chronic strongylosis causes typical verminous arteritis and is associated more commonly with natural infections in horses than with acute strongylosis. 121 lesions of the large intestinal vasculature caused by migration of larvae through the intima are characterized by thrombus formation, narrowing of the arterial lumen, fibrosis, and thickening of the arterial wall. 121,122 embolization may occur, causing acute segmental infarction of the large intestine, but more commonly reduced blood flow without embolization causes ischemia and occasionally infarction. 122,125 postmortem examination of horses with colonic infarction failed to reveal embolization as the cause in most cases. 125 reduced blood flow in the tissues of the intestine usually results from narrowing of the arterial lumen by the thrombus and formation of microthrombi at sites independent of the parasites. release of vasoconstrictive inflammatory mediators such as leukotrienes from platelets, neutrophils, and eosinophils and elaboration of parasitic antigens or toxins may cause vasoconstriction and ischemia. 126 horses with experimental strongylosis were found to have a 50% reduction of blood flow in the colonic vasculature. 127 clearly, reduced blood flow is an important effect of chronic strongylosis, but the relationship between blood flow and diarrhea is unclear. disrupted motility resulting from ischemia may lead to diarrhea by reducing the retention of ingesta and absorption of fluid. acute infarction and mucosal ulceration have been found to cause severe chronic diarrhea in naturally infected horses. 128 release of inflammatory mediators such as prostaglandins, histamine, and kinins from inflammatory cells associated with thrombi and inflamed intestine also may affect secretion, absorption, and motility, leading to diarrhea. the clinical signs of acute strongylosis caused by s. vulgaris infection are characterized by depression, moderate to severe colic, and fever. 129 diarrhea is less often a feature of acute strongylosis than is colic. 121 most cases of acute strongylosis occur in young, naïve horses that are introduced to an infested environment or are inoculated experimentally with infective larvae. this form of strongylosis often is not recognized naturally. chronic strongylosis, however, occurs most commonly as a natural syndrome. weight loss or poor weight gain; chronic, intermittent colic; fever; poor appetite; and diarrhea are frequent signs. 121,122 diarrhea may be profuse and watery, or the feces may be soft but of normal volume. transrectal palpation may reveal thickening and fremitus in the cranial mesenteric artery. young horses are most commonly affected, but older horses also may be affected. horses with acute infarction or large intestinal ulceration following chronic strongylosis may have signs of severe abdominal pain, sepsis, and endotoxemia, and profuse, watery diarrhea is common. hematologic abnormalities associated with strongylosis include neutrophilic leukocytosis and eosinophilia. [129] [130] [131] neutrophilia appears to be an early event during the course of the disease, and eosinophilia tends to appear later. 129, 131 hyperfibrinogenemia also may occur, especially later in the course of the disease. serum αand β-globulin and igg(t) concentrations are characteristically elevated. [130] [131] [132] horses with chronic ulcerative colitis following strongylosis may exhibit severe hypoalbuminemia. 128 peritoneal fluid analysis may reveal an elevated protein concentration and eosinophilia. 130, 131 tentative diagnosis is based on clinical signs, hematologic abnormalities, and peritoneal fluid analysis. elevated serum αand β-globulin concentrations and igg(t) concentration support the diagnosis. 132 fecal analysis may reveal strongyle eggs, but fecal egg counts are often unreliable because nonpatent larvae cause the disease. appropriate preventive measures are important in controlling this disease, including management procedures such as preventing overcrowding, reducing exposure of susceptible individuals, and instituting proper deworming schedules. ivermectin is the preferred anthelmintic used to control strongylosis in horses. monitoring fecal egg counts as a means of evaluating the efficacy of parasite control measures is recommended. infection with small strongyles (cyathostomiasis) is well recognized as a cause of diarrhea and large intestinal disease in horses of all ages. [133] [134] [135] [136] [137] [138] clinical disease is caused by intramural larval stages. the cyathostome life cycle requires migration by fourth-stage larvae through the mucosa of the large intestine and may include a period of hypobiosis during which the larvae remain encysted within the mucosal layer of the large intestine. after a period of hypobiosis the larvae emerge in response to a largely unknown stimulus. most cases occur when larval emergence takes place, classically in the late winter and spring in the northern temperate zones when larvae are expected to emerge and in the late fall or winter months in the southeastern united states and subtropical regions. 133 sudden emergence of encysted larvae causes the mucosal injury, ulceration, and inflammatory reaction responsible in large part for the clinical disease. 133, 139 however, migration of the larvae as they penetrate the mucosa affects motility patterns and can cause inflammation that may contribute to diarrhea. 139 chronic, eosinophilic, granulomatous colitis and diarrhea with histopathologic evidence of hypobiotic cyathostome larvae in the large intestine have been reported in two horses during a period in which emergence of larvae would not be expected to occur (early winter). 133 natural emergence of cyathostome larvae causes fibrinous inflammation of the large intestine, focal necrosis, mural hemorrhage, and ulceration of the large intestinal mucosa, which even may result in bleeding into the lumen. mild to moderate eosinophilic and mononuclear inflammation of the lamina propria occurs, and moderate to severe interstitial edema frequently occurs. 122, 139 colonic inflammation and interstitial edema may contribute to the diarrhea, along with the loss of the mucosal barrier, by causing increased active and passive secretion of fluid, electrolytes, and protein. protein loss is often significant, resulting in profound hypoalbuminemia and interstitial edema of skin and other organs. chronic, granulomatous colitis has been reported to occur in response to encysted larvae and may cause diarrhea by increased secretion following granulomatous inflammation or disruption of the interstitium by granulomatous infiltration. administration of an anthelmintic to horses with a heavy load of encysted larvae also may cause rapid larval death and acute and often severe inflammation similar to natural emergence. cyathostomiasis may be the most commonly identified cause of chronic diarrhea in the horse. [140] [141] [142] however, an acute syndrome also has been associated with cyathostomiasis. 138 clinical signs of cyathostomiasis are characterized by moderate to severe weight loss or poor weight gain, ill thrift, ventral edema, intermittent fever, and intermittent, mild colic. acute onset of diarrhea is typically profuse and progresses to chronic diarrhea that is often mild, is the consistency of bovine feces, and may be intermittent. [133] [134] [135] [136] [137] [138] 142 appetite is usually normal, but affected horses occasionally have a ravenous appetite. transrectal palpation usually does not reveal any abnormalities. cyathostomiasis may affect any age of horse, and clinical signs are more common during periods of emergence of larvae, corresponding to late winter and spring in northern temperate zones. the deworming history may appear to be adequate. neutrophilic leukocytosis is typically evident, but the white blood cell count may be normal. [133] [134] [135] [136] [137] [138] profound hypoalbuminemia is a characteristic feature of cyathostomiasis, manifested clinically by ventral edema. plasma αand β-globulin concentrations may be elevated, which can result in a normal total plasma protein concentration in spite of hypoalbuminemia. [134] [135] [136] the serum igg(t) concentration, however, has been reported to be normal, which may help distinguish cyathostomiasis from s. vulgaris infection. 133, 135, 136 in addition, peritoneal fluid analysis does not usually reveal any abnormalities, in contrast to horses with s. vulgaris infection. fecal analysis may be unrewarding because the infection is often not patent when clinical signs are apparent. measurement of plasma fructosamine may provide a measure of protein catabolism or protein loss in the absence of hypoalbuminemia. plasma fructosamine concentrations are significantly lower in horses with experimental cyathostomiasis than in normal controls, 142, 143 suggesting that this test may be a useful diagnostic tool. however, the test has not yet been validated in naturally occurring cases, and neither the specificity nor the sensitivity is known. rectal scrapings or rectal mucosal biopsies may reveal evidence of cyathostome larvae. 133, 136 definitive diagnosis usually requires microscopic examination of biopsy specimens of the cecum and ascending colon, collected by laparotomy. examination of biopsy specimens collected from the small intestine is recommended to rule out other causes of weight loss and diarrhea. one should include appropriate diagnostic tests, such as culture of feces for pathogenic bacteria, in the workup to rule out other causes. preventive measures are appropriate for other horses on premises known to have a problem with cyathostomiasis, particularly frequent deworming (every 6 weeks) during times of high infectivity (spring and summer in the north and fall, winter, and early spring in the south) to eliminate parasites before they become patent. 133 because of high levels of resistance to benzimidazoles, avermectins (ivermectin or moxidectin) are the drugs of choice. [144] [145] [146] resistance to ivermectin has been demonstrated, but the prevalence of ivermectin resistance appears to remain low. 144 although daily pyrantel pamoate administration also has been reported to reduce worm burdens and pasture infectivity in young and mature horses effectively, 147 cyathostome resistance has been reported and is a concern for the use of this drug as a routine preventive anthelmintic. 145, 148 diarrhea in adult horses may also occur secondary to administration of antimicrobial or antiinflammatory medications or after ingestion of toxic compounds. affected horses exhibit clinical signs that may be indistinguishable from signs exhibited by horses with diarrhea of infectious etiology. antibiotic-associated diarrhea has been reported in many species, including horses. 149 certain antibiotics-such as trimethoprim-sulfonamide combinations, erythromycin, penicillins, tetracyclines, clindamycin, and lincomycinare associated with naturally occurring and experimental enterocolitis syndromes in horses. 79, [149] [150] [151] [152] in some cases, such as with trimethoprim-sulfonamide combinations, the geographic incidence of antibiotic-associated diarrhea appears to differ considerably. clostridium perfringens, c. difficile, and salmonella spp. are apparently the most common causes of antibioticassociated diarrhea in horses. outbreaks of c. difficile have been reported in hospitalized horses being treated with antibiotics. 81, 85 in sweden, accidental erythromycin ingestion has been associated with c. difficile enterocolitis in mares in which their foals were being treated for rhodococcus equi. 89, 151, 153 interestingly, this phenomenon has not been reported in other areas of the world. foals being treated with erythromycin are at a higher risk for diarrhea than foals being treated with other antibiotics. tetracycline administration has been shown to be associated with an increase in the numbers of gram-negative enteric bacteria and c. perfringens in the feces of horses and reactivation of salmonellosis and prolongation of fecal shedding of salmonella. 78, 154 the most common mechanism by which antibiotics cause diarrhea is by disrupting the gastrointestinal flora. the normal large intestinal flora, comprised of mainly obligate anaerobes and streptococci, protects the host from pathogenic bacteria by colonization resistance. 17 ecologic factors play an important role in colonization resistance. for example, surface bacteria in the large intestine interact with receptors on the mucosal cells, facilitating adherence to the mucosa. 17, 155 in doing so, the normal organisms compete more successfully for this important niche. competition for space and nutrients is an important means of preventing colonization and proliferation of pathogenic bacteria. in addition, anaerobic bacteria produce short-chain fatty acids (scfas) and other metabolites that are toxic to facultative anaerobic bacteria, especially in the conditions of the large intestine. 16, 17, 155 organisms of the normal flora also produce bacteriocins that inhibit growth of potential pathogens. 16 antibiotics that deplete the population of obligate anaerobes and streptococci efficiently decrease colonization resistance. 16 production of fatty acids diminishes, thus reducing competition for space and nutrients. as a result, gram-negative enteric bacteria such as salmonella are able to proliferate. in addition, pathogenic anaerobes normally found in low numbers can proliferate. antibiotic-resistant strains of bacteria, especially gram-negative enteric bacteria and possibly clostridia, may be selected by antibiotic administration, allowing proliferation of pathogenic bacteria resistant to many antibiotics. 156 obligate anaerobic commensal organisms, perhaps the most critical group of microbes for maintaining colonization resistance, are usually susceptible to macrolides, tetracyclines, β-lactams, and lincosamides, perhaps explaining the high incidence of diarrhea associated with the administration of these antibiotics. 83 in addition to reduction of colonization resistance, depletion of the normal anaerobic microbial population in the intestine decreases carbohydrate fermentation and production of scfas, which contributes to the pathogenesis of antibiotic-associated diarrhea by decreasing absorption of sodium and water by the colonic mucosa. 157 ampicillin decreases colonic fermentation of carbohydrates in human beings. 158 human patients with antibioticassociated diarrhea have greatly impaired colonic fermentation and low production of scfas. erythromycin, ampicillin, or metronidazole treatment is associated with decreased production of scfas in patients with and without diarrhea. 88 absorption of sodium and water is stimulated by absorption of scfas in the equine colon, suggesting that reduction of colonic scfa content by antibiotic-induced depletion of anaerobic flora has similar effects in horses as in human beings. 157 broad-spectrum antibiotics exert a more profound effect on the gastrointestinal flora than narrow-spectrum antibiotics. antibiotics administered orally, especially those that are poorly absorbed, are more likely to cause diarrhea than are parenterally administered antibiotics. for instance, clindamycin is less likely to cause diarrhea in human beings when administered intravenously than when administered orally. antibiotics with extensive enterohepatic circulation, such as tetracyclines and erythromycin, are excreted in high concentrations in the bile and are associated more commonly with diarrhea than antibiotics that do not undergo enterohepatic circulation. 159 antibiotics may cause diarrhea by means other than by disrupting the normal flora. direct toxic effects may play a role in producing irritation, increasing secretion, and disrupting motility patterns. tetracyclines are irritating to the gastrointestinal mucosa and may cause inflammation and increase secretion. 159 erythromycin has been shown to interact with smooth muscle cells, stimulating gastrointestinal motility. 159, 160 normal peristalsis plays an important role in suppressing the population size of potentially pathogenic bacteria. normally, bacteria that are prevented from adhering to the mucosa by colonization resistance are swept aborally by peristalsis and are excreted in the feces. disruption of normal motility patterns may prevent clearance of pathogenic bacteria, contributing to the colonization of mucosal surfaces. diarrhea induced by antibiotics usually occurs within 7 days of antibiotic administration or can occur several days after cessation of antibiotic treatment. the clinical syndrome of antibiotic-associated diarrhea can vary from mild diarrhea to fulminant enterocolitis with severe diarrhea. mild cases of diarrhea are common, especially in foals receiving erythromycin, trimethoprim-sulfonamide combinations, or rifampin. 151, 161 mild cases of diarrhea are usually not clinically significant. however, acute, severe enterocolitis can occur in all ages of horses receiving antibiotics and can be life threatening. clinical signs are identical to other causes of acute enterocolitis. severe, dehydrating diarrhea, endotoxemia, sepsis, and shock may occur. hemoconcentration, neutropenia, hypoproteinemia, and electrolyte and acid-base imbalances are common. severe hyponatremia may occur in foals with antibiotic-associated diarrhea, especially if trimethoprimsulfonamide and rifampin combinations are the cause. 161 more detailed descriptions of the clinical and laboratory findings were given previously. diagnosis is presumptive, because definitive diagnosis of antibiotic-associated diarrhea is impossible. fecal culture and pcr testing may reveal salmonella or clostridium infection. toxicity resulting from nonsteroidal antiinflammatory drug (nsaid) administration has been well documented in several species, including horses. [162] [163] [164] [165] [166] [167] [168] in horses and human beings, nsaid toxicity is manifested by renal and gastrointestinal disease. elderly human patients are more susceptible to nsaid toxicity, but the effects of age on nsaid toxicity in horses are less well defined. foals are considered to be more susceptible than adult horses to gastrointestinal disease following nsaid administration, and ponies may be more susceptible than horses. all nsaids are capable of inducing gastrointestinal and renal damage at toxic concentrations, and the toxicity is not significantly different among products. aspirin is potentially more toxic than other nsaids because it irreversibly inactivates cyclooxygenase by acetylation, whereas other nsaids reversibly inhibit cyclooxygenase. 162 however, phenylbutazone is the drug most commonly reported to cause toxicity in horses, perhaps because of its widespread use by veterinarians and horse owners. phenylbutazone toxicity in horses is characterized by mucosal ulceration throughout the gastrointestinal tract, oral ulceration, renal papillary necrosis, vasculopathy, thrombosis, and protein-losing enteropathy with hypoalbuminemia. [164] [165] [166] this discussion focuses on the toxic effects of nsaids on the large intestine but necessarily includes elements of upper gastrointestinal and renal disease. horses with large intestinal disease resulting from nsaid toxicity generally are receiving inappropriately large doses. the dosage regimen recommended for phenylbutazone (4.4 mg/kg twice in 1 day and then 2.2 mg/kg twice daily) is considered to be safe. experimental studies in horses, however, have shown toxicity to occur when greater than the recommended dosage (6.6 mg/kg/day) is administered for several days. 164, 165 in most reported cases of phenylbutazone toxicosis horses were receiving higher than recommended dosages. 166, 168, 169 regardless, administration of phenylbutazone at the recommended dosage has been reported to cause a significant decrease in plasma protein concentration and gastrointestinal disease. 165, 170 moreover, signs of nsaid toxicity have been reported in normovolemic horses treated with appropriate doses of phenylbutazone. 170, 171 dehydration, sepsis, and endotoxemia exacerbate the renal and gastrointestinal toxicity of nsaids. 162 clearly, the margin of safety is narrow for phenylbutazone and probably for other nsaids used in horses as well. gastrointestinal disease induced by nsaids is manifested by mucosal ulceration, inflammation, bleeding, and protein-losing enteropathy. 164, 165, 168, 170 in addition to direct effects on the mucosal barrier, nsaid administration has been shown to cause an acute relapse of preexisting colonic inflammatory disease and worsen colonic inflammation in human beings. 164, 165, 170 whether this occurs in horses is not clear. the mechanism by which nsaids induce mucosal damage is probably multifactorial. direct irritation may play a role in oral and gastric irritation and ulceration; however, parenteral administration of nsaids produces oral and gastric ulceration as well. inhibition of prostaglandin synthesis by inhibition of cyclooxygenase 1 (the constitutive cox) and cyclooxygenase 2 (the inducible cox) appears to be the most important mechanism of mucosal injury. prostaglandins, particularly pge 2 and pgi 2 , are critical for mucosal health. 172,173 pge 2 has been shown to increase mucosal blood flow; increase secretion of mucus, water, and bicarbonate; increase mucosal cell turnover rate and migration; stimulate adenyl cyclase activity; and exert other protective effects in the gastric mucosa of several species. 162, 172, 173 perhaps most importantly, pge 2 and pgi 2 have a role in maintaining epithelial tight junction integrity, which is indispensable for mucosal barrier function and repair after mucosal injury. 172 in spite of the overwhelming amount of information about the role of prostaglandins in maintaining the mucosal barrier in other species and clear clinical and experimental evidence that nsaids injure the equine colonic mucosa, the role of prostaglandins in mucosal protection in the equine colon is not yet well defined. inhibition of cox-1 and cox-2 in equine colonic mucosa with flunixin meglumine resulted in reduced electric resistance of the mucosa and increased permeability to macromolecules in vitro (a.t. blikslager and s.l. jones, 2002) , suggesting that flunixin treatment disrupts the epithelial tight junctions in the equine colon. mucosal changes were correlated with a profound inhibition of pge 2 and pgi 2 concentrations in the treated tissues. in other studies, administration of a pge 2 analog prevented the gastrointestinal manifestations of phenylbutazone toxicosis in ponies. 165 recent development of nsaids specific for cox-2 have greatly reduced the frequency and severity of gastrointestinal side effects in human beings taking nsaids for chronic musculoskeletal conditions. 174 thus cox-2-specific nsaids hold promise for use in horses to treat arthritis and reduce the incidence of toxicity. for example, the cox-2-specific inhibitor etodolac was less harmful to equine colonic mucosa than flunixin meglumine in vitro (a.t. blikslager and s.l. jones, 2002) . moreover, etodolac was significantly more permissive than flunixin for recovery of the mucosa in equine ischemic-injured intestinal tissues, and in fact, recovery was no different than control tissues. 175 however, their use is at present limited because the specificity of the so-called cox-2selective inhibitors and their efficacy as analgesics have not been demonstrated in the horse. nsaid-induced mucosal injury is associated with a significant inflammatory response to microbial products exposed to the lamina propria. 176 this inflammation exacerbates mucosal dysfunction and injury associated with nsaid toxicity. for example, depletion of neutrophils or blockade of neutrophil influx into gastrointestinal tissues or inhibition of neutrophil activation and release of toxic products prevents many of the pathophysiologic effects of nsaid toxicity in the gastrointestinal tract. [177] [178] [179] [180] the inflammatory response alone may result in moderate to severe gastrointestinal ulceration, mural vascular thrombosis and edema, fluid secretion, protein-losing enteropathy, and mucosal hemorrhage. nsaid colitis manifests as two clinical syndromes: right dorsal colitis (rdc) and generalized nsaid toxicity. rdc is an ulcerative disorder isolated to the right dorsal segment of the large intestine. 167, 168, 171 the most prominent clinical signs of rdc are anorexia, lethargy, and colic. anorexia, depression, diarrhea, fever, and signs of section 13.13 inflammatory diseases of the gastrointestinal tract causing diarrhea endotoxemia also may be features. if the rdc is chronic, weight loss, intermittent colic, lethargy, anorexia, and ventral edema are common clinical signs, along with soft and unformed feces. severe ulceration of the right dorsal colonic mucosa results in proteinlosing enteropathy and significant hypoproteinemia attributable mainly to hypoalbuminemia. hypoproteinemia may be severe enough to cause peripheral (usually ventral) edema.in some cases, one may note dehydration, electrolyte abnormalities, neutropenia or anemia, azotemia, and biochemical abnormalities if the ulceration and diarrhea are severe or if systemic inflammation is present. clinical signs of generalized nsaid toxicity may vary from mild diarrhea with no systemic signs to severe dehydrating diarrhea with anorexia, fever, depression, peripheral edema, oral ulceration, and colic. 165, 166, 169 clinical signs of systemic inflammation caused by endotoxemia may occur, manifested as poor peripheral perfusion, tachycardia, tachypnea, weakness, trembling, and cyanotic or hyperemic oral mucous membranes. hematuria or oliguria may be present if renal involvement is present. complications associated with other forms of severe enterocolitis, such as laminitis, thrombophlebitis, and severe weight loss, may occur. hematologic abnormalities of generalized nsaid toxicity are nonspecific and include neutropenia with a left shift or leukocytosis and hemoconcentration. serum biochemical analysis is characterized by profound hypoproteinemia, hyponatremia, and metabolic acidosis. 169, 170 hypocalcemia, hypokalemia, hypochloremia, and elevated hepatocellular enzyme activities also may occur. hypoproteinemia may occur without signs of diarrhea. azotemia may be prerenal from dehydration but frequently is caused by renal failure resulting from a combination of hemodynamic and toxic renal injury. urinalysis frequently reveals hematuria, proteinuria, cylindruria, and isosthenuria. fecal occult blood is frequently detectable. diagnosis of either form of nsaid colitis is often presumptive, with a history of overdose of nsaids being strong evidence of nsaid toxicity. but as discussed earlier, toxicity may occur with dosage regimens that are not considered inappropriate, particularly if the horse experiences a concurrent period of dehydration. one can use ultrasonographic examination of the right dorsal colon to confirm a diagnosis of rdc, but the sensitivity of this method is questionable. ultrasonography (3.5-to 5-mhz transducer at the right twelfth to fifteenth intercostal spaces below the margin of the lung axial to the liver) may reveal a thickened right dorsal colon (>0.5 cm) and evidence of colonic edema in horses with rdc. 181 however, the sensitivity of this method of diagnosis is questionable. one can use nuclear scintigraphy of horses after infusion with technetium 99-labeled white blood cells to document inflammation of the right dorsal colon. 182 diagnosis of rdc may require one to perform laparotomy or laparoscopic examination of the right dorsal colon. one must rule out other causes of enterocolitis, such as salmonellosis, potomac horse fever, clostridiosis, and antibiotic-associated diarrhea. cantharidin is the toxic principle found in beetles of the genus epicauta, commonly known as blister beetles. [183] [184] [185] ingestion of the beetles in contaminated alfalfa hay causes release of the toxin from the tissues of the beetle and absorption through the gastrointestinal tract. transcutaneous absorption may occur but appears to be rare in horses. 184 blister beetles feed on the flowers of alfalfa and may be incorporated into processed alfalfa hay if the hay is cut and processed simultaneously, as by crimping. [183] [184] [185] the beetles often swarm, and one may find large numbers of beetles in small portions of hay. the lethal dose of cantharidin is less than 1 mg/kg, but the concentration of cantharidin varies from species to species of blister beetles and between sexes. 183, 184 as many as 100 to as few as 6 to 8 beetles may be lethal. usually, only one or a few horses fed contaminated hay ingest beetles because the beetles are concentrated in a small portion of the hay. however, outbreaks involving many horses on a farm have occurred. most cases occur in texas and oklahoma, but horses in other states may be affected as well, especially if hay is imported from states where blister beetles are common. peak incidence is in late summer and fall. 186 the fatality rate may be 50% or greater, 183, 187 but if the patient survives several days, recovery is probable. cantharidin is absorbed from the gastrointestinal tract and excreted via the kidney. cantharidin is a potent irritant, causing acantholysis and vesicle formation when applied topically. 183, 185, 187 the chemical is thought to disrupt oxidative metabolism in the mitochondria, causing mitochondrial swelling, plasma membrane damage, and changes in membrane permeability. 183 the mucosa of the gastrointestinal tract is affected most commonly in horses because they ingest the toxin. cell swelling and necrosis occur, resulting in mucosal ulceration. oral, esophageal, gastric, and small and large intestinal ulceration have been observed in natural and experimental canthariasis. 183, 185, 187 severe fibrinous to pseudomembranous inflammation and submucosal edema of the intestine also have been reported. diarrhea probably results from the severe ulceration and inflammation of the large intestine, causing increased secretion of water, electrolytes, and protein and decreased absorption of fluid. large volumes of fluid and protein are lost in the gastrointestinal tract, causing hemoconcentration and profound hypoalbuminemia in some cases. 183, 184, 187 cystitis and myocarditis occur in natural and experimentally produced cases of cantharidin toxicity. 183, 185, 187 cystitis occurs because renal excretion of cantharidin results in high concentrations in urine. occasionally, hemorrhagic cystitis may occur, with hematuria or frank hemorrhage into the bladder. 183 the cause of the myocarditis and myocardial necrosis is unknown but also may be a direct effect of the toxin on the myocardium. elevated plasma creatine kinase activity often occurs and has been postulated to arise from the damaged myocardium. 183, 184 horses have a characteristically stiff gait, but histopathologic evidence of skeletal muscle injury that explains the elevated plasma creatine kinase activity has not been observed. 184 the kidneys are often pale, swollen, and moist, with occasional infarcts. 185 hypocalcemia and hypomagnesemia are biochemical features of cantharidin toxicity in horses that have not been explained. 183, 184, 187 hypocalcemia may occur from hypoalbuminemia, but the ionized calcium concentration often is decreased along with the total calcium concentration, indicating that hypoalbuminemia is not responsible for the hypocalcemia. 184 in addition, clinical signs of hypocalcemia, such as synchronous diaphragmatic flutter, are often associated with hypocalcemia from cantharidin toxicity. hypocalcemia associated with hypoalbuminemia alone does not produce clinical signs. cantharidin toxicity can cause a range of clinical signs from mild depression and abdominal discomfort to fulminant signs of toxemia and rapid death, depending on the ingested dose of toxin. most commonly, clinical signs include depression, sweating, irritability, abdominal pain, elevated heart and respiratory rates, fever, polyuria, polydypsia, and profuse diarrhea. 183, 184, 187 blood is rarely visible in the feces. affected horses frequently posture to urinate; indeed, stranguria and pollakiuria are characteristic of cantharidin toxicity. 183 signs of hypocalcemia include synchronous diaphragmatic flutter and tremors. a stiff and stilted gait may be evident. one may note neurologic signs such as head pressing, swaying, and disorientation. 187 signs of systemic inflammation from endotoxemia may be apparent in severe cases. some horses develop severe depression and toxemia and may die within hours after ingestion of cantharidin without developing diarrhea. 183, 187 hematologic abnormalities include hemoconcentration and neutrophilic leukocytosis. occasionally, neutropenia and leukopenia may accompany endotoxemia. serum biochemical analysis usually reveals elevated creatine kinase activity, hypocalcemia, and hypoalbuminemia. 183, 184 biochemical abnormalities include hypocalcemia (ionized and total calcium concentrations), hypomagnesemia, and azotemia. 183, 184, 187 urine specific gravity is characteristically in the hyposthenuric range. 183, 184 microscopic hematuria and mild proteinuria may be evident. fecal occult blood is often present, but hematochezia is unusual. one can make a tentative diagnosis based on clinical signs and the finding of blister beetles in the hay. determining the species of the insects may be necessary to estimate the amount of cantharidin ingested. all species of epicauta contain cantharidin, but some have small amounts. definitive diagnosis requires the measurement of the cantharidin concentration in gastric or intestinal contents and urine. 183, 186 measurement of cantharidin concentration in the beetles is often done but is not necessary. arsenic toxicosis is an unusual cause of diarrhea in horses, resulting from ingestion of arsenic-containing herbicides, insecticides, and other pest control products contaminating water or roughage used as a food source. 188 the toxicity of arsenic depends on the valence of the element. 188, 189 arsenate may be reduced to arsenite in mammalian systems, and arsenite is thought to be more toxic than arsenate and less rapidly excreted in urine. arsenate and arsenite uncouple oxidative phosphorylation, leading to breakdown of energy metabolism in the cells of many tissues. 189 widespread cellular injury and death occur rapidly during acute arsenic toxicosis. multiorgan failure usually results. in fact, cardiomyopathy and pulmonary disease are common causes of death in human beings. 190 damage to the large intestine is probably caused in part by direct cellular toxicity and corrosion by the compound. however, vasculitis is a hallmark of the disease in human beings and horses and is thought to be the most important mechanism of large intestinal disease in human beings. 181, 191 acute hemorrhagic colitis is a feature of arsenic toxicosis, with severe mural edema and mucosal ulceration. 188 profuse, hemorrhagic diarrhea and abdominal pain result. chronic arsenic toxicity can occur but appears to be rare in horses. acute depression, weakness, abdominal pain, hemorrhagic diarrhea, and shock are characteristic of acute arsenic toxicosis in horses. death may occur before diarrhea is evident. initial clinical signs may be difficult to distinguish from other peracute forms of colitis and are related to endotoxic shock, metabolic disturbances, and dehydration. later, cardiac arrhythmias, pulmonary edema, acute renal failure, and neurologic deficits (ataxia and stupor) may develop. 188 one may observe anuria or polyuria. hemolytic anemia caused by preferential binding of arsenic compounds to red blood cells is a feature of arsenic poisoning in human beings. hematologic abnormalities may be apparent after the peracute stages from injury to bone marrow cells and ongoing hemolysis. leukopenia and thrombocytopenia have been described in human patients. 190 serum biochemical analysis may reveal azotemia, hepatocellular enzyme activities higher than generally attributed to endotoxemia, and elevated creatine kinase activity. 188 urine specific gravity may be in the isosthenuric range, with hematuria, cylindruria, and proteinuria evident by urinalysis. diagnosis may be possible by measuring blood and urine arsenic concentration, but these tests may not be diagnostic. postmortem diagnosis is by measuring the arsenic concentration in liver and kidney samples. 188 history of exposure and clinical signs remain the primary means of diagnosis. other disorders associated with diarrhea in adult horses include anaphylaxis, carbohydrate overload, and sand enteropathy. careful evaluation of history, environment, and management will assist the clinician in arriving at an accurate diagnosis. severe intestinal anaphylaxis is a syndrome in horses characterized by peracute, rapidly fatal colitis. 192 the severe syndrome is clinically and pathologically similar to other known causes of peracute colitis, such as salmonellosis, clostridiosis, and antibiotic-associated diarrhea. some cases are less severe and manifest as mild to moderate diarrhea or colic. an ige-mediated type i hypersensitivity or an ige-independent anaphylactoid reaction can produce the syndrome of intestinal anaphylaxis. 193, 194 local gastrointestinal exposure to a food, environmental contaminant, drug, or other allergen usually induces intestinal anaphylaxis, 193, 195 but anaphylaxis also may occur with systemic exposure to an allergen. [196] [197] [198] [199] massive mast cell degranulation, secretion of inflammatory mediators, and activation of enteric neural reflexes in the intestine causes profound alterations in blood flow, increased vascular permeability and interstitial edema, recruitment of neutrophils, altered motility, mucosal injury, absorption of microbial products, and mucosal hypersecretion. [200] [201] [202] [203] [204] systemic signs may be caused by the anaphylactic reaction or may be associated with systemic inflammation triggered by microbial products (endotoxin) absorbed through the injured and hyperpermeable mucosa. intestinal anaphylaxis in horses may be a peracute, fulminant enterocolitis with endotoxemia that may be fatal. 192, 205 this form is characterized by severe intramural edema and hemorrhagic inflammation of the large intestine, often producing submucosal thickening on the order of many centimeters. vascular thrombosis may be widespread with mucosal and serosal petechia and ecchymoses. less severe forms of intestinal anaphylaxis may manifest as patchy areas of intestinal edema and congestion. 196 diarrhea results from intestinal inflammation initiated by the type i hypersensitivity response. many of the mediators of type i hypersensitivity, such as histamine and 5-hydroxytryptamine, have well-documented stimulatory effects on mucosal secretory activity, vascular and epithelial permeability, and motility [200] [201] [202] in the intestine. systemic inflammation from endotoxemia may be overwhelming once the mucosal barrier breaks down. infarction of intestinal segments and other organs may occur from intravascular coagulation. ileus, abdominal distention, and moderate to severe abdominal pain may result from motility disturbances and infarction of the large intestine. the clinical signs are similar to those described for other forms of peracute colitis. however, the severity may vary, manifesting as colic or moderate diarrhea. characteristically, severe shock, signs of systemic inflammation from endotoxemia, and severe metabolic disturbances are observable. 192, 205 heart and respiratory rates may be elevated greatly, with other signs of cardiovascular collapse such as weak and thready peripheral pulses and peripheral vasoconstriction. however, peripheral vasodilation may occur later in the course of disease. dark red, muddy, or cyanotic mucous membranes with a prolonged capillary refill time signify sepsis. borborygmi are usually absent, and abdominal tympany may be heard on percussion, following ileus. moderate to severe colic may accompany ileus. severe diarrhea may occur, but death may occur before diarrhea is evident. multiorgan failure from disseminated intravascular coagulation is not unusual. rapid onset of weakness, staggering, and trembling commonly precedes death. the syndrome may cause death in 4 to 24 hours. hematologic abnormalities include severe neutropenia and leukopenia, thrombocytopenia, and hemoconcentration. 192 serum biochemical alterations include hyponatremia, hypokalemia, hypocalcemia, and severe metabolic acidosis. blood urea nitrogen and creatinine may be elevated from prerenal or renal azotemia. if acute renal failure accompanies the colitis, hyperkalemia may result. hepatocellular enzyme activity may be elevated in the serum from endotoxemia. severe coagulopathies are common, resulting in prolonged coagulation times, elevated fibrinogen, decreased antithrombin iii activity, and elevated plasma concentration of fibrin degradation products. analysis of peritoneal fluid may be valuable because infarction of the large intestine is not unusual. protein concentration and the white blood cell count may be elevated. red blood cell counts are less likely to be elevated, because infarction and not strangulation of the intestine occurs. diagnosis is based on clinical signs, postmortem findings, and exclusion of other causes. cultures and toxicologic analysis of fecal samples and gastrointestinal tissues fail to demonstrate a clear cause. other diagnostic tests are also inconclusive. if an antigen is suspected as the trigger of the anaphylaxis, a prausnitz-küstner passive cutaneous anaphylaxis sensitization test can confirm the presence of antigen-specific ige in the patient serum. 196 overeating of soluble carbohydrates, especially so-called hot grains such as corn, overwhelms the digestive capability of the small intestine, resulting in a high percentage of the soluble carbohydrates entering the large intestine. the amount of soluble carbohydrates that produce diarrhea varies according to the previous dietary history of the individual. horses fed diets higher in soluble carbohydrates are more resistant to the deleterious effects of carbohydrate overload. gradual accommodation to a diet high in carbohydrates can be accomplished over several weeks. however, horses fed an unusually large amount of grains or other form of soluble carbohydrates often develop diarrhea and may, depending on the amount ingested, develop severe colitis, systemic inflammation from endotoxemia, metabolic acidosis, and laminitis. [206] [207] [208] [209] the pathogenesis of colitis from carbohydrate overload is caused primarily by the toxic effects on the microbial flora in the large intestine. 207 a sudden delivery of soluble carbohydrates to the large intestine causes rapid fermentation by gram-positive lactic acid-producing bacteria and a sudden increase in organic acid production. the cecal ph rapidly decreases, and the lactic acid concentration rapidly increases. rapid organic acid production overwhelms the buffering capacity of the large intestine not only by directly depleting the buffers found in the contents but also by reducing the efficiency of buffer secretion. bicarbonate secretion is linked to absorption of volatile fatty acids, which are produced in low amounts by fermentation of soluble carbohydrates. the contents of the large intestine become profoundly acidic, resulting in unfavorable conditions for the microbial flora. lactic acid-producing bacteria flourish, while the gram-negative bacteria, especially the enterobacteriaceae, are killed in large numbers by the acids. large quantities of endotoxin are released from the dying bacteria. 208 the osmotic load from the lactic acid produced in the large intestine is an important factor in the development of diarrhea because organic acids such as lactic acid are absorbed poorly. mild cases of carbohydrate overload may result purely from osmotic diarrhea. in more severe cases, the acidic contents of the large intestine are toxic to the mucosa, causing necrosis of the mucosal tissues, similar to that occurring in ruminal acidosis. mucosal ulceration allows absorption of large quantities of endotoxin and lactic acid produced by the massive die-off of acid-intolerant microbes and fermentation of soluble carbohydrates, normally poorly absorbed by intact mucosa. 209 systemic inflammation from endotoxemia may be overwhelming, and profound metabolic acidosis may occur. secretory diarrhea caused by the direct effects of acid luminal contents on the mucosa, as well as the effects of inflammatory mediators on enterocyte secretion, worsens the acidosis and dehydration. systemic inflammation from endotoxemia, along with intestinal inflammation, adversely affects intestinal motility, and ileus develops. ileus and gas production from fermentation of the carbohydrates may cause severe distention of the large intestine and signs of abdominal pain. laminitis is a frequent complication of endotoxemia and lactic acidosis. in fact, carbohydrate overload is used to induce laminitis as an experimental model because of the consistency of the laminitis produced. [207] [208] [209] clinical signs of colitis from carbohydrate overload can vary according to the amount of carbohydrates ingested and accommodation of the flora to a high-carbohydrate diet. mild cases may result in a transient osmotic diarrhea with no systemic effects. more severe cases are characterized by signs similar to those described for other forms of colitis, including abdominal pain, moderate to severe diarrhea, and dehydration. signs of endotoxemia and sepsis are frequently present in severe cases. elevated heart and respiratory rates are common, with peripheral vasoconstriction early in the disease, followed by peripheral vasodilation as the disease progresses. depression may be profound from metabolic acidosis and endotoxemia. abdominal auscultation and percussion may reveal ileus and intestinal tympany. nasogastric intubation may yield significant gastric acidic reflux. one may note particles of grain in the gastric reflux and the feces, if grain overload is the source of the carbohydrate overload. laminitis may complicate mild and severe cases of carbohydrate overload, especially if the animal has had previous bouts of laminitis. hematologic abnormalities include neutropenia and leukopenia. severe dehydration may result in profound hemoconcentration. protein loss later in the course of disease may result in hypoproteinemia. serum biochemical abnormalities include azotemia, elevated hepatocellular enzyme activity, hyponatremia, and hypokalemia. severe hypocalcemia and metabolic acidosis are characteristic of the disease. serum lactate concentrations are elevated in the absence of evidence of intestinal strangulation or infarction. peritoneal fluid analysis often reveals no abnormalities. sand enteropathy is described in more detail under the heading of obstructive diseases, because acute obstruction is often associated with abnormally large amounts of sand in the large intestine. 210 however, chronic sand-induced diarrhea is a distinct syndrome that can occur at any age from abnormal accumulation of sand in the large intestine. 211, 212 chronic diarrhea and signs of colic may occur without obstruction. the pathogenesis of sand accumulation in individual horses, other than simple ingestion of large quantities, is unclear. presumably the sand causes irritation and may disrupt motility, leading to diarrhea. the diarrhea is usually not severe and dehydrating and may be intermittent. weight loss is characteristic and can be severe in some cases. complications may occur such as peritonitis and acute obstruction. 211 diagnosis usually is based on finding abnormal amounts of sand in the feces. because sand-induced chronic diarrhea is associated primarily with sand accumulation in the ventral colon, auscultation of the ventral abdomen immediately behind the xiphoid process may reveal characteristic sand sounds. 213 this technique is only sensitive if peristalsis is present. ultrasonography also may be useful to identify sand in the ventral colon but is not useful to quantitate the amount of sand. occasionally, radiography may be required to detect sand in the colon. 211 the principles of therapy of acute diarrhea from colitis are similar regardless of the cause and include replacement of fluid and electrolyte losses, control of colonic inflammation and reduction of fluid secretion, promotion of mucosal repair, control of endotoxemia and sepsis, and reestablishment of normal flora. this section focuses on a review the principles of therapy with references to specific therapies for particular causes as they arise. replacement of fluid and electrolyte losses is of primary concern in treating horses with salmonellosis. depending on the severity of the disease, fluid losses may be minimal or massive. one can administer fluid and electrolytes orally or intravenously. some horses with mild to moderate diarrhea may maintain hydration and electrolyte balance by consuming water and electrolytes voluntarily. freshwater and water containing electrolytes should be available in all cases. in many instances, periodic nasogastric intubation and administration of water and electrolytes via the tube may be sufficient to maintain hydration. 214 in more severe cases, one can maintain indwelling nasogastric tubes and can administer up to 4 to 8 l of fluid by the tube every 20 to 30 minutes, if ileus is not evident. however, intravenous administration of fluids is preferred in most cases, requiring significant quantities of fluid to replace and maintain hydration and electrolyte balance. 215 for patients with severe diarrhea to require large volumes (50 to 100 l/day) of intravenous fluids to maintain hydration is not unusual. frequent monitoring of packed cell volume, serum electrolyte concentration, venous blood gases or total serum carbon dioxide, blood urea nitrogen and creatinine, urine protein and cytologic findings, and body weight is important to monitor hydration, electrolyte and acid-base balance, and renal function. isotonic sodium chloride or lactated ringer's solution frequently is used to restore and maintain fluid and electrolyte balance. one can add potassium chloride to the fluids and administer it at a rate up to 0.5 to 1.0 meq/ kg/hr. generally, a rate of less than 0.5 meq/kg/hr is used. hypertonic nacl solutions (1 to 2 l of 3% to 5% nacl) have been used in horses that are severely hyponatremic (<120 meq/dl). one should not administer hypertonic solutions to severely dehydrated horses, but such solutions have been used clinically without complication and with considerable beneficial effect in patients with endotoxemia. the beneficial effects of hypertonic nacl are short-lived (30 to 60 minutes). one should administer isotonic solutions concurrently or immediately following administration of hypertonic nacl solutions. isotonic (1.3%) or hypertonic (5.0%) sodium bicarbonate solutions are used to correct metabolic acidosis. prolonged administration of sodium-containing fluids may promote diuresis and renal water loss or accumulation of peripheral edema and should be used conservatively when one notes a free water loss. administration of isotonic dextrose (5%) or 2.5% dextrose/0.45% nacl solutions may be beneficial when free water loss (sodium excess) is evident. many horses with acute colitis are concurrently hypoproteinemic because of gastrointestinal losses and are absorbing bacterial products that induce a systemic inflammatory response. thus plasma oncotic pressures are abnormally low in the face of increased vascular permeability. interstitial edema formation is a clinical problem in these patients and contributes to organ dysfunction. crystalloid fluids, although critical for replacing water and electrolyte losses from diarrhea, actually may contribute to a drop in plasma oncotic pressure because of hemodilution. 216, 217 administration of colloid solutions are important for volume expansion and to maintain plasma oncotic pressures, which improve tissue perfusion and oxygenation and organ function in hypovolemic, hypotensive, and hypoproteinemic patients with or without systemic inflammatory response syndrome. 218 colloids are more effective than crystalloid fluids at expanding plasma volume and thus require smaller volumes. moreover, the effect of colloid volume expansion is longer lasting than crystalloid fluid volume expansion, because colloids are retained in the vasculature better. 217, 218 natural colloids, such as plasma and purified albumin are used commonly. in addition to its beneficial colloidal properties, plasma harvested from donor horses immunized with rough mutants of escherichia coli (j5) or salmonella typhimurium may have other benefits for treatment of endotoxemia from gastrointestinal disease. 219, 220 the horse may require large volumes (6 to 8 l/day) to increase and maintain plasma protein concentration significantly. synthetic colloids such as dextrans, starches, or polymerized hemoglobin are also available for use in the horse. hetastarch (5 to 10 ml/kg of a 6% solution) increases colloidal oncotic pressures for up to 24 hours in hypoproteinemic horses and has beneficial effects on cardiac output and other cardiorespiratory parameters, vascular permeability, interstitial fluid content, and tissue perfusion in models of hypoproteinemia and systemic inflammatory response syndrome. when one administers synthetic or even natural colloids, monitoring plasma oncotic pressure may be more relevant than monitoring plasma protein concentrations as a means of assessing the need for plasma or other colloid administration. 216 hetastarch may prolong bleeding times by altering von willebrand's factor function; thus one should use this synthetic colloid cautiously in horses with suspected coagulopathies, active hemorrhage, or other bleeding problems. 217 control of colonic inflammation and secretion is a difficult and poorly studied aspect of equine acute colitis. the role of inflammation and mediators such as prostaglandins as causes of fluid loss is well known for salmonella and clostridium infections. cox inhibitors (nsaids) have antisecretory effects in the equine colon and in models of salmonellosis that appear to extend to clinical management of salmonellosis. 16, 36, [221] [222] [223] indeed, nsaids commonly are administered to horses with salmonellosis. however, prostaglandins such as pge 2 and pgi 2 are also cytoprotective to gastrointestinal mucosa and critical for mucosal repair. 172 the doses of nsaids used pharmacologically to inhibit colonic inflammation and secretion in fact may be detrimental to the mucosa if not used judiciously. nsaids have been shown to exacerbate colonic inflammation in human beings with inflammatory colitis, impede mucosal healing in several models of mucosal injury, and have well-documented detrimental effects on colonic mucosa in horses. 164, 172, 224 in addition to toxicity to the colonic mucosa, gastric ulceration is not unusual in horses with enterocolitis and may be related to treatment with nsaids. in addition to nsaids, other drugs occasionally are used as antiinflammatory or antisecretory therapy. metronidazole has beneficial effects in experimental models of gastrointestinal inflammation, including nsaid toxicity 176 and may be useful for treating horses with colitis, but evidence supporting its use is lacking. bismuth subsalicylate solutions administered orally often are used to decrease inflammation and secretion in the colon. in adult horses the volume of solution necessary to be beneficial is large (3 to 4 l every 4 to 6 hours). often the solution is administered twice daily instead of 4 to 6 times daily. if one does not achieve a beneficial effect within 3 to 4 days of treatment, one should discontinue administration of bismuth subsalicylate solution. one can administer the treatment more frequently in foals, and clinical improvement occurs more often in foals than in adult horses. in light of the role of reactive oxygen metabolites in colonic inflammation, free radical scavengers have been advocated to reduce the effects of these molecules. sulfasalazine metabolites have been shown to reduce reactive oxygen metabolite-induced colonic inflammation in other species, 176 and sulfasalazine has been used to treat chronic inflammatory disease in horses but has not been used to treat acute colitis. the only free radical scavenger used commonly in horses with colitis is dimethyl sulfoxide, which at a dosage of 0.1 to 1.0 g/kg intravenously every 12 to 24 hours in a 10% solution has been used in clinical cases of colitis, but evidence of efficacy has not been established. systemic inflammatory response syndrome associated with endotoxemia frequently occurs in patients with salmonellosis. the principles of therapy for endotoxemia are covered in detail elsewhere in this chapter. oral administration of activated charcoal and mineral oil is used commonly to reduce absorption of endotoxin in horses with colitis. low doses of nsaids (such as flunixin meglumine at 0.1 to 0.25 mg/kg intravenously every 6 to 8 hours) inhibit eicosanoid synthesis induced by endotoxin. in addition, administration of nsaids prevents laminitis from endotoxemia, a devastating complication of salmonellosis. one must remember that prostaglandins are important for mucosal healing and may worsen mucosal injury in colitis. although the benefits of low doses of nsaids administered to horses with systemic inflammatory response syndrome are believed to outweigh the risks of worsening gastrointestinal damage, judicious use is recommended. sucralfate (20 mg/kg orally every 6 hours) has been advocated to aid in healing the colonic mucosa, but the efficacy in the large intestine is questionable. 94 misoprostol (2 µg/kg orally 3 to 4 times daily) and other synthetic pge analogs have been shown in several species including horses to enhance mucosal healing in the intestine and promote recovery in experimental models of colitis. 225 misoprostol may be particularly useful for treating nsaid toxicity, the generalized form or rdc. however, the efficacy of misoprostil for hastening mucosal healing is clinically unproven in equine colitis. the primary drawbacks of prostaglandin analogs such as misoprostol are the side effects of the drug, including abdominal cramping, diarrhea, sweating, and abortion in pregnant mares. one can add psyllium mucilloid to the diet (5 tablespoons once or twice daily) to increase the production of scfas in the colon. amylase-resistant fermentable fiber such as psyllium is hydrolyzed by colonic bacteria to scfas such as butyrate, which represent a major energy source for colonocytes. butyrate and other scfas hasten epithelial maturation and stimulate salt (and thus fluid) absorption in the colon, improve the clinical course of ulcerative colitis, and hasten colon healing. 226 psyllium is itself a source of butyrate in the colon and also promotes the movement of amylase sensitive carbohydrates into the distal colon, which then are fermented to scfas. thus psyllium is thought to be clinically useful for promoting mucosal healing in colitis. many horses with salmonellosis or other forms of colitis have mild to severe signs of abdominal pain from gas and fluid distention of the colon, colonic ischemia, or infarction. one can accomplish analgesia with nsaids such as flunixin, but the potential for worsening mucosal injury or nephrotoxicity may prevent the use of analgesic doses, especially in horses with suspected nsaid toxicity. newer nsaids that specifically target cox-2 (the inducible cox) but have little activity against cox-1 (the constitutive cox) may be useful analgesics that spare the gastrointestinal mucosa. for example, etodolac (10 to 15 mg/kg intravenously or orally once daily) has analgesic properties in horses and may spare the intestinal mucosa from the detrimental effects associated with nonselective cox inhibitors (a.t. blikslager, personal communication, 2002) . however, the specificity for cox-2 in horses is unproven. thus avoiding the use of any nsaids in horses with rdc or other forms of nsaid toxicity is advisable. xylazine or detomidine may provide temporary relief of pain. butorphanol is a useful analgesic that one can administer intramuscularly (0.1 mg/kg every 6 hours) or as a continuous infusion. an infusion of 13.2 µg/kg/hr in isotonic crystalloid fluid such as lactated ringer's solution has been suggested. 227 continuous lidocaine infusions (1.3 mg/kg intravenous loading dose administered slowly over 5 minutes and followed by 3 mg/kg/hr infusion in isotonic crystalloid fluids) can provide profound visceral analgesia and may have added prokinetic benefits if ileus is present. broad-spectrum antibiotic treatment often is recommended in neutropenic horses or horses with signs of septicemia. neutropenia is associated with an increased risk of septicemia and septic complications such as septic phlebitis and infection of surgical site. 1 septicemia is a potentially life-threatening complication of enterocolitis and may be caused directly by salmonella, clostridium, other invasive enteric bacteria, or indirectly by toxic injury to the colonic mucosa that breaks down the barrier to luminal microbes. neutropenia possibly may weaken host defenses enough to render horses susceptible to organisms that breach the mucosal barrier. although most attempts to culture bacteria from the blood of adult horses with colitis fail to isolate organisms, no detailed studies have been undertaken to determine the prevalence of bacteremia or septicemia in these patients. disseminated aspergillosis has been reported in horses as a complication of acute colitis, demonstrating the potential for systemic infections with rarely pathogenic organisms stemming from colonic mucosal injury in the face of potential immunosuppression from neutropenia. 228, 229 broad-spectrum antibiotics lessen septic complications in human patients. however, evidence supporting this principle in horses with colitis is lacking. treatment with antibiotics is controversial in horses with salmonellosis and is not thought to alter the course of the enterocolitis. antibiotics directly targeted at the salmonella are reserved for patients with the enteric fever (septicemia) form of salmonellosis, documented with positive blood cultures. lipid-soluble antibiotics are suited ideally for salmonella infections, because the bacteria persist intracellularly. trimethoprim-sulfadiazine or other potentiated sulfa drugs, enrofloxacin, and chloramphenicol are preferred antibiotics for the enteric fever form of salmonellosis for this reason. as with other causes of enterocolitis, the use of antibiotics for equine monocytic ehrlichiosis is controversial. fear of inducing salmonellosis or other forms of antibiotic-induced diarrhea and the difficulty of diagnosing the disease early have caused most authors to recommend judicious use of antibiotics. 49 however, in patients with a high suspicion of neorickettsia risticii infection, treatment with antibiotics often is indicated before definitive diagnosis. lipid-soluble drugs are desirable because the organism can live within cells. oxytetracycline (6.6 mg/kg intravenously every 24 hours), doxycycline (10 mg/kg orally every 12 hours), trimethoprim-sulfadiazine (5 mg/kg trimethoprim orally or intravenously every 8 to 12 hours and 25 mg/kg sulfadiazine every 8 to 12 hours), or erythromycinrifampin (30 mg/kg and 5 mg/kg, respectively, orally every 12 hours) have been used effectively to treat clinical cases. 49, [230] [231] [232] the tetracyclines appear to be the most effective antibiotics for treatment of potomac horse fever. treatment is most successful if initiated before the onset of diarrhea. 49, 231 clostridiosis if one has administered antibiotics since the onset of enterocolitis, one should discontinue administration as soon as possible. specific treatment with metronidazole (15 to 25 mg/kg orally every 8 hours) is effective for treating clostridiosis in human beings and appears to be effective in horses. 83, 233 metronidazole resistance in clinical isolates of clostridium difficile has been reported in one outbreak but appears to be rare in most human and equine cases. 234 metronidazole-resistant isolates were sensitive to vancomycin, which may be effective for treating clinical cases if one suspects metronidazole resistance. however, metronidazole remains the treatment of choice. some authors describe the off-label use of c. perfringens type c antitoxin in cases of neonatal clostridiosis, described in more detail elsewhere. 235 antitoxin preparations generally are not advocated for use in adult horses with clostridiosis. lawsonia intracellulare is susceptible to a variety of antibiotics in vitro, including chlortetracycline, erythromycin, penicillin, difloxacin, and ampicillin. 236 lipid-soluble antibiotics with a large volume of distribution usually are chosen to treat proliferative enteropathy because l. intracellulare is an intracellular organism. erythromycin estolate (15 to 25 mg/kg orally every 6 to 8 hours) alone or with rifampin (5 mg/kg orally every 12 hours) is the most commonly reported efficacious treatment for proliferative enteropathy. chloramphenicol (50 mg/kg orally every 6 hours) has also been reported to be effective if erythromycin worsens the diarrhea. 115 anecdotal reports suggest that oxytetracycline and doxycycline also may be effective. supportive care including maintenance of hydration and electrolyte balance and plasma or colloid administration to increase colloid oncotic pressure in hypoalbuminemic patients is also indicated. one should treat affected foals until clinical signs, hypoproteinemia, and ultrasonographic evidence of intestinal thickening resolve. the prognosis depends on the duration of the disease and the degree of fibrosis and destruction of the intestinal architecture. hypercoagulability is a common complication of enterocolitis, associated with systemic inflammation from endotoxemia. administration of heparin (20 to 80 iu/kg subcutaneously or intravenously every 6 to 12 hours) may prevent thrombosis in these patients, provided antithrombin iii concentrations are adequate in the plasma. concentrated sources of antithrombin iii are not available for use in horses, but whole plasma may provide an important source. treatment with heparin is thought to decrease thrombosis, especially of the jugular vein, a serious complication of salmonellosis. low-dose aspirin treatment (15 mg/kg orally every 24 to 48 hours) along with heparin treatment may provide added benefit by irreversibly inhibiting platelet function. 237 heparin and aspirin may have protective effects on the digital lamina. 237, 238 heparin also may enhance the phagocytic activity of the reticuloendothelial system by enhancing the efficiency of opsonins such as fibronectin and immunoglobulin, thereby stimulating phagocytosis of products of coagulation and possibly other particles, including bacteria. 239, 240 maintenance of the bacterial flora and antagonism of pathogenic bacteria such as salmonella in the gastrointestinal tract are important defense mechanisms preventing colonization by pathogenic bacteria. the use of probiotic preparations containing beneficial bacteria has been shown to prevent colonization of pathogenic bacteria, including salmonella, in poultry. 241 little work has been done to investigate the efficacy of these products in preventing salmonellosis in horses, but ongoing studies may provide important information. probiotic and other preparations designed to restore normal flora to the gastrointestinal tract, such as fecal suspensions, sour milk, and yogurt, have been used clinically to shorten the course of salmonellosis, with variable results. therefore prevention of infection by using probiotic agents and other means is important. exposure of susceptible horses to salmonella should be avoided, but the task is difficult, especially because asymptomatic infections are common and the bacteria are ubiquitous in the environment. prophylactic use of probiotic preparations, judicious use of antibiotics in susceptible horses, control of environmental conditions such as temperature, and restricted exposure to pathogenic bacteria are important for control of salmonellosis. because altered large intestinal flora appears to play an important role in the pathogenesis of equine intestinal clostridiosis or any antibiotic-associated diarrhea, probiotic preparations have been advocated to treat affected horses. sour milk, a product containing lactose-producing streptococcus species, appears to improve the clinical course greatly in horses suspected of having clostridium perfringens type a infection. sour milk may benefit the patient by altering the flora and antagonizing enterotoxigenic c. perfringens type a but also is reported to be bactericidal against c. perfringens type a. 78 preparations of saccharomyces boulardi are effective for reducing diarrhea and the frequency of c. difficile recurrence in human beings. 83 however, whether relapse is a problem in horses with c. difficile colitis is not clear. lactobacillus preparations have a protective effect in human beings and decrease the severity and duration of antibioticassociated diarrhea. 242, 243 however, evidence of their clinical usefulness in horses is lacking. good nursing care and adequate nutrition are vital to the treatment of horses with salmonellosis. salmonellosis is a severely catabolic disease, increasing caloric requirements greatly. normal intake of roughage to provide energy may be inadequate; however, one should avoid feeding of grains to prevent carbohydrate overload. dietary management usually consists of restricting or eliminating long-stem roughage (hay) from the diet and feeding exclusively a complete pelleted diet (at least 30% dietary fiber). the rationale behind this recommendation is to reduce the mechanical load on the colon. frequent meals (4 to 6 times a day) are recommended. one can add corn oil (1 cup every 12 to 24 hours) to the pellets to increase the caloric intake without adding roughage or grain. one should note that if a horse with colitis refuses to eat pelleted feed, then one should feed good-quality grass hay. in anorectic or severely catabolic patients, enteral and parenteral nutrition (total and partial) has been used successfully to provide calories and nutritional support. strongylus vulgaris infection requires treatment of the migrating parasite larvae and the lesions produced by the parasite. fenbendazole (10 mg/kg orally every 24 hours for 3 days or 10 mg/kg orally every 24 hours for 5 days) and ivermectin (200 mg/kg orally) are effective in killing fourth-stage larvae. 121 other anthelmintics also may be 906 part ii disorders of specific body systems effective when given at higher doses than those required to kill adult worms. the efficacy of these anthelmintics against larvae within thrombi is not known. thrombolytic and antithrombotic therapy has been advocated in horses with suspected strongylosis. 121, 128 heparin (20 to 80 iu intravenously or subcutaneously every 6 to 12 hours) is often administered as an anticoagulant. aspirin (10 to 30 mg/kg orally every 12 to 48 hours) is usually combined with heparin to inhibit platelet adhesion. aspirin also may inhibit release of platelet products such as thromboxane that affect the motility of the large intestine. low-molecular-weight dextrans have been advocated as antithrombotics that act by inhibiting platelet function and coagulation. 128, 218 the clinical efficacy of dextran administration appears to be good, but no controlled studies have been performed. anthelmintic administration is usually the only treatment necessary for mild to moderate cases of cyathostomiasis treated early in the course of the disease (within 1 to 3 weeks of onset). fenbendazole is effective against many larval stages, but resistance is increasing. although the reported efficacy of ivermectin varies against certain stages, 244 one study reported an overall efficacy of 75%. 245 currently, fenbendazole (7.5 to 10 mg/kg orally every 24 hours for 5 days) followed on day 6 by ivermectin (200 mg/kg orally) is the most commonly advocated treatment regimen. 133, 246 moxidectin (400 µg/kg orally once daily) also may be effective against adults and l 3 and l 4 larval stages 247 and may be useful for treating cyathostomiasis. antiinflammatory therapy also may be beneficial, especially in severe or refractory cases. nsaid administration may have limited value, but dexamethasone appears to be efficacious in refractory cases when used with larvicidal anthelmintics. 133, 136 pretreatment with dexamethasone or prednisolone is indicated before anthelmintic administration if heavy larval loads are suspected to prevent an acute exacerbation of the disease by rapid death of encysted larvae. bismuth subsalicylate often is administered orally as an antisecretory agent in young animals. supportive care may be necessary in severe cases, particularly if hypoproteinemia is severe. horses occasionally require administration of intravenous crystalloid fluids and plasma or other colloids. proper nutritional support is also important. supportive care is the most important principle of therapy for cantharidin toxicity. intravenous fluid administration; maintenance of electrolyte balance, especially calcium; and prevention of further renal and urinary tract damage is important. 183, 187 diuresis by intravenous fluid administration is often sufficient to prevent renal failure. furosemide often is administered after rehydration of the patient to further promote diuresis and to decrease the concentration of the toxin in the urine, which may ameliorate some of the effects on the urinary tract mucosa. diuresis also has been suggested to increase clearance of the toxin, but no evidence for this has been found. judicious use of nsaids may be necessary to control abdominal pain but should be reserved until the patient is rehydrated and renal failure has been ruled out. cantharidin is lipid-soluble; therefore oral administration of mineral oil may prevent further absorption of the toxin. 183 activated charcoal often is administered with the mineral oil. to reduce arsenic absorption, one should initiate administration of cathartics such as mineral oil and magnesium sulfate slurries and activated charcoal by nasogastric tube immediately. chelation therapy with sodium thiosulfate 20 to 30 g in 300 ml of water orally and dimercaprol (bal) 3 mg/kg intramuscularly every 4 hours is indicated. 188 dimercaprol is a specific antidote for trivalent arsenicals, but its efficacy in horses is questionable. intravenous fluid administration may help treat shock, replace fluid lost in feces, and promote diuresis but should be monitored carefully because pulmonary edema is a frequent complication. the horse may require more specific treatment of renal, cardiac, pulmonary, or neurologic disease. treatment of intestinal anaphylaxis is in principle similar to treatment of other forms of colitis but is often unsuccessful because of the rapidly progressive nature of the syndrome. inclusion of heparin in intravenous fluids (20 to 80 iu/kg intravenously every 8 to 12 hours) may help prevent vascular thrombosis. administration of hypertonic saline solutions or colloids may prove to be useful during initial periods of shock. early treatment with prednisolone succinate (10 to 20 mg/kg intravenously) or dexamethasone (0.1 to 0.2 mg/kg intravenously) may be essential for successful treatment. 192 mild cases of carbohydrate overload may not require treatment other than exclusion of grains from the diet for several days to weeks and gradual reintroduction of grain into the diet later if the horse needs the extra energy. patients showing signs of colic or diarrhea without other systemic signs may benefit from administration of mineral oil, charcoal, and fluids via nasogastric tube. one also may lavage residual carbohydrates from the stomach with the nasogastric tube. nsaids such as phenylbutazone (2.2 to 4.4 mg/kg/day intravenously) or flunixin meglumine (1 mg/kg intravenously every 12 hours) often are administered to prevent laminitis. phenoxybenzamine and heparin given before the onset of laminitis may prevent or decrease the severity of laminitis. 238, 248 more severe cases with dehydrating diarrhea, systemic signs of endotoxemia, or metabolic acidosis require intravenous fluid support to maintain water, electrolyte, and acid-base balance in addition to the previously mentioned treatments. large amounts of bicarbonatecontaining solutions may be required. one should take care when administering hypertonic bicarbonate solutions, because many patients already may be hyperosmotic from lactic acidemia. isotonic sodium bicarbonate 1.3% may be useful in the hyperosmotic patient. careful attention to calcium balance is also important, because severe hypocalcemia may occur. one should institute aggressive therapy for systemic inflammation from endotoxemia. one should administer broad-spectrum antibiotics intravenously to combat bacteremia and septicemia, which frequently complicate colitis induced by carbohydrate overload. in extreme cases, especially if the patient has ingested a large quantity of grain, surgical removal of the grain from the large intestine may be indicated, especially if one can accomplish surgery before the onset of severe clinical signs. however, administration of oral cathartics, such as magnesium sulfate slurries or mineral oil, or a combination of these, is often sufficient to clear the carbohydrates from the large intestine before fermentation, mucosal damage, and absorption of endotoxin and lactic acid occur. oral administration of activated charcoal may prevent absorption of endotoxin by binding the molecules in the lumen of the bowel. in any case, one should discontinue feeding of the source of the soluble carbohydrates, such as grains. one should feed the horse low-carbohydrate and low-protein roughage such as grass or oat hays until the microbial flora recovers. oral administration of probiotic preparations containing lactobacillus is contraindicated; however, other sources of normal equine large intestinal microbial flora, such as fecal extracts from normal feces, may be useful to reintroduce appropriate microorganisms. complications from laminitis and sepsis are common and often cause death. treatment of sand enteropathy requires removal of the sand from the gastrointestinal tract using psyllium products and magnesium sulfate slurries administered orally. analgesics may be required initially to relieve pain and stimulate appetite. a diet high in roughage often stimulates further passage of sand. treatment may require several weeks to remove as much sand as possible. prevention of the disease is important, and recurrence is not unusual. lumen results in clinical signs similar to those of simple obstruction, occlusion of the blood supply results in a more rapid deterioration of the intestinal mucosa and subsequent onset of endotoxemic shock. although a great deal of interest in the relevance and treatment of intestinal reperfusion injury has arisen recently, 1-3 the lesion that develops during strangulation is often severe, leaving little viable bowel for further injury during reperfusion. 2 although extensive lengths of strangulated small intestine may be resected, strangulation of the large colon presents a much greater treatment dilemma because strangulated intestine usually extends beyond the limits of surgical resection. 4 therefore horses with large intestinal strangulation often recover with extensive intestinal injury left in place. thus subtle degrees of reperfusion injury may be important in horses with large colon disease, warranting further work in this area in an attempt to reduce mortality. 3 strangulating obstruction may be divided into hemorrhagic and ischemic forms. 5, 6 hemorrhagic strangulating obstruction, which is most common, involves initial occlusion of veins before occlusion of arteries because of the greater stiffness of arterial walls. this lesion is characterized by a darkened appearance to affected bowel and increased thickness as blood is pumped into the lesion. ischemic strangulating obstruction occurs if the intestine is twisted tightly enough to occlude arteries and veins simultaneously. in the case of the colon, such strangulation has been suggested to be determined by how much ingesta is in the colon, because intestinal contents may prevent the intestine from twisting tightly. 7 tissue involved in ischemic strangulating obstruction appears pale and of normal or reduced thickness because of a complete lack of blood flow ( figure 13 .14-1). bowel peripheral to strangulating lesions also may become injured because of distention, which reduces mural blood flow once it reaches critical levels. furthermore, as this intestine is decompressed, it also may undergo reperfusion injury. [8] [9] [10] small intestinal strangulation horses with small intestinal strangulating obstruction typically have moderate to severe signs of abdominal pain that are only intermittently responsive to analgesic medications. during the latter stages of the disease process, horses may become profoundly depressed rather than painful as affected intestine necroses. horses have progressive signs of endotoxemia, including congested mucous membranes, delayed capillary refill time, and an elevated heart rate (>60 beats/min in most cases). in addition, one typically obtains reflux following passage of a stomach tube, and one usually can detect loops of distended small intestine on rectal palpation of the abdomen. 11 however, these latter findings vary depending on the duration and location of the obstruction. for example, horses with ileal obstructions tend to reflux later in the course of the disease process than horses with a jejunal obstruction. furthermore, a horse that has an entrapment of small intestine in the epiploic foramen may not have palpable loops of small intestine because of the cranial location of these structures. 12 abdominocentesis can provide critical information on the integrity of the intestine and is indicated in horses in which one suspects strangulation of the small intestine. 13 a horse that has signs compatible with a small intestinal obstruction and additionally has serosanguinous abdominal fluid with an elevated protein level (>2.5 mg/dl) is likely to require surgery, although one must differentiate these a b figure 13 .14-1 ischemic strangulating obstruction of the small colon by a mesenteric lipoma. a, the lipoma (arrow) has encircled a segment of small colon tightly. b, following resection of the lipoma, a pale area of strangulated small colon clearly is demarcated (arrows), the appearance of which is consistent with ischemic strangulating obstruction. cases from proximal enteritis. in general, horses with small intestinal strangulation show continued signs of abdominal pain, whereas horses with proximal enteritis tend to be depressed after initial episodes of mild abdominal pain. in addition, horses with small intestinal strangulation continue to deteriorate clinically despite appropriate medical therapy and will likely begin to show an increased white blood cell count (>10,000 cells/µl) in the abdominal fluid as the duration of strangulation increases. however, cases occur in which the differentiation between small intestinal strangulation and proximal enteritis is not clear, at which point one may elect surgery rather than risking delay of abdominal exploration of a horse with a potential strangulating lesion. 14 the prognosis for survival in horses with small intestinal strangulating lesions is generally lower than for most forms of colic. 15 however, recent studies indicate that in excess of 80% of horses with small intestinal strangulating lesions are discharged from the hospital. 16 nonetheless, veterinarians should warn owners that the long-term survival rates are reduced substantially to below 70%, 17 in part because of long-term complications such as adhesions. 18, 19 in addition, the prognosis is particularly low for some forms of strangulation, including entrapment of small intestine within a mesenteric rent. 20 the epiploic foramen is a potential opening (because the walls of the foramen are usually in contact) to the omental bursa located within the right cranial quadrant of the abdomen. the foramen thus is bounded dorsally by the caudate process of the liver and caudal vena cava and ventrally by the pancreas, hepatoduodenal ligament, and portal vein. intestine may enter the foramen from the visceral surface of the liver toward the right body wall or the opposite direction. studies differ as to which is the most common form. 12, 21 in the case of entrapments that enter the foramen in a left-to-right direction, the omental bursa ruptures as the intestine migrates through the epiploic foramen, which may contribute to intraabdominal hemorrhage often seen with this condition. clinical signs include acute onset of severe colic with examination findings compatible with small intestinal obstruction. the condition tends to be more prevalent in older horses, 12 possibly because of enlargement of the epiploic foramen as the right lobe of the liver undergoes ageassociated atrophy. 22 however, the disease also has been recognized in foals as young as 4 months of age. 23 one makes a definitive diagnosis at surgery, although ultrasonographic findings of distended loops of edematous small intestine adjacent to the right middle body wall suggest epiploic foramen entrapment. 12 in general, thickened, amotile intestine on ultrasonographic examination is highly predictive for small intestinal strangulating obstruction. 24 small intestine entrapped in the epiploic foramen may be limited to a portion of the intestinal wall (parietal hernia), 25 and the large colon may become entrapped within the epiploic foramen. 26 in treating epiploic foramen entrapment, one must not enlarge the epiploic foramen by blunt force or with a sharp instrument, because rupture of the vena cava or portal vein and fatal hemorrhage may occur. prognosis has improved substantially over the last decade, with current short-term survival rates (discharge from the hospital) ranging from 74% 27 to 79%. 12 preoperative abdominocentesis has been found consistently to be the most predictive test of postoperative survival. 12,27 lipomata form between the leaves of the mesentery as horses age and develop mesenteric stalks as the weight of the lipoma tugs on the mesentery. the stalk of the lipoma subsequently may wrap around a loop of small intestine or small colon causing strangulation. one should suspect strangulating lipomata in aged (>15 years old) geldings with acute colic referable to the small intestinal tract. 28, 29 ponies also appear to be at risk of developing disease, 29 suggesting alterations in fat metabolism may predispose certain horses to development of mesenteric lipomata. one usually makes the diagnosis at surgery, although on rare occasions one can palpate a lipoma per rectum. 30 treatment involves surgical resection of the lipoma and strangulated bowel, although strangulated intestine is not always nonviable. 28 studies indicate that approximately 50% 29 to 80% 28 of horses are discharged from the hospital following surgical treatment. a volvulus is a twist along the axis of the mesentery, whereas torsion is a twist along the longitudinal axis of the intestine. small intestinal volvulus theoretically is initiated by a change in local peristalsis or the occurrence of a lesion around which the intestine and its mesentery may twist (such as an ascarid impaction). 11 volvulus is reportedly one of the most commonly diagnosed causes of small intestinal obstruction in foals. 31, 32 the theory is that young foals may be at risk of small intestinal volvulus because of changing feed habits and adaptation to a bulkier adult diet. onset of acute, severe colic, a distended abdomen, and radiographic evidence of multiple loops of distended small intestine in a young foal suggest small intestinal volvulus. however, one cannot differentiate volvulus from other causes of small intestinal obstruction preoperatively. in adult horses, volvulus frequently occurs in association with another disease process, during which small intestinal obstruction results in distention and subsequent rotation of the small intestine around the root of the mesentery. although any segment of the small intestine may be involved, the distal jejunum and ileum are affected most frequently because of their longer mesenteries. 11 one makes the diagnosis at surgery by palpating a twist at the origin of the cranial mesenteric artery. treatment includes resection of devitalized bowel, which may not be an option because of the extent of small intestinal involvement (similar to large colon volvulus). prognosis is based on the extent of small intestine involved and its appearance following surgical correction of the lesion. in general, horses with greater than 50% of the small intestine devitalized are considered to have a grave prognosis. 33 a number of structures, when torn, may incarcerate a segment of intestine (typically the small intestine), including intestinal mesentery, 20 the gastrosplenic ligament, 34 the broad ligament, 35 and the cecocolic ligament. 36 horses with such incarcerations have signs typical of a horse with strangulating small intestine, including moderate to severe signs of abdominal pain, endotoxemia, absent gastrointestinal sounds, distended small intestine on per rectal palpation, nasogastric reflux, and serosanguinous abdominal fluid. however, the prognosis for many of these horses appears to be lower than for horses with other types of small intestinal strangulations. for example, in horses with small intestine entrapped in a mesenteric rent, only 7 of 15 horses were discharged from the hospital, and only 2 of 5 horses for which follow-up information was available survived long term (>5 months). 20 poor outcome may result from the difficulty in unentrapping incarcerated intestine, the degree of hemorrhage, and the length of intestine affected. inguinal herniae are more common in standardbred and tennessee walking horses that tend to have congenitally large inguinal canals. 11 inguinal herniae also may occur in neonatal foals but differ from herniae in mature horses in that they are typically nonstrangulating. the nature of the hernia (direct versus indirect) is based on the integrity of the parietal vaginal tunic. in horses in which the bowel remains within the parietal vaginal tunic, the hernia is referred to as indirect, because strictly speaking the bowel remains within the peritoneal cavity. direct herniae are those in which strangulated bowel ruptures through the parietal vaginal tunic and occupies a subcutaneous location. these direct herniae most commonly occur in foals and should be suspected when a congenital inguinal hernia is associated with colic, swelling that extends from the inguinal region or the prepuce, and intestine that may be palpated subcutaneously. 37, 38 although most congenital indirect inguinal herniae resolve with repeated manual reduction or application of a diaper, surgical intervention is recommended for congenial direct herniae. 37 historical findings in horses with strangulating inguinal herniae include acute onset of colic in a stallion that recently had been used for breeding. a cardinal sign of inguinal herniation is a cool, enlarged testicle on one side of the scrotum (figure 13 .14-2). 39, 40 however, inguinal herniae also have been reported in geldings. 41 one also can detect inguinal herniae on rectal palpation, and one can use manipulation of herniated bowel per rectum to reduce a hernia, but this is generally not recommended because of the risk of rectal tears. in many cases, the short segment of herniated intestine greatly improves in appearance after reduction and in some cases can be left unresected. the affected testicle will be congested because of vascular compromise within the spermatic cord, and although the testicle may remain viable, resection generally is recommended. 42 the prognosis in adult horses is good, with up to 75% of horses surviving to 6 months. 40 horses that have been treated for inguinal herniae may be used for breeding. in these horses, the remaining testicle will have increased sperm production, although an increased number of sperm abnormalities will be noticeable following surgery because of edema and increased temperature of the scrotum. although umbilical herniae are common in foals, strangulation of herniated bowel is rare. in one study, 6 of 147 (4%) horses with umbilical herniae had incarcerated intestine. 43 clinical signs include a warm, swollen, firm, and painful hernia sac associated with signs of colic. the affected segment of bowel is usually small intestine, but herniation of cecum or large colon also has been reported. in rare cases, one may find a hernia that involves only part of the intestinal wall, called a richter's hernia. in foals that have a richter's hernia, an enterocutaneous fistula may develop. in one study, 13 of 13 foals with strangulating umbilical herniae survived to discharge, although at least 3 died of long-term complications. 44 an intussusception involves a segment of bowel (intussusceptum) that invaginates into an adjacent aboral segment of bowel (intussuscipiens). the reason for such invagination is not always clear but may involve a lesion at the leading edge of the intussusception, including small masses, foreign bodies, or parasites. in particular, tapeworms (anoplocephala perfoliata) have been implicated. 45 ileocecal intussusceptions are the most common intestinal intussusceptions in the horse and typically affect young animals. in one study evaluating 26 cases of ileocecal intussusception, the median age of the horses was 1 year old. acute ileocecal intussusceptions are those in which the horses has a duration of colic of less than 24 hours and involve variable lengths of intestine that ranged in one study from 6 to 457 cm long. in acute cases the involved segment of ileum typically has a compromised blood supply. chronic ileocecal intussusceptions typically involve short segments of ileum (up to 10 cm long), and the ileal blood supply is frequently intact. 46 abdominocentesis results vary because strangulated bowel is contained within the adjacent bowel. obstruction of the small intestine often is evident, including nasogastric reflux and multiple distended loops of small intestine on rectal palpation. horses with chronic ileocecal intussusceptions have mild, intermittent colic, often without evidence of small intestinal obstruction. in one study, a mass was palpated in the region of the cecal base in approximately 50% of cases. 45 transabdominal ultrasound may be helpful in discerning the nature of the mass. the intussusception has a characteristic target appearance on cross section. 47 other segments of the small intestine also may be intussuscepted, including the jejunum (figure 13.14-3) . in one study of 11 jejunojejunal intussusceptions, the length of bowel involved ranged from 0.4 to 9.1 m. 48 attempts to reduce intussusceptions at surgery are usually futile because of intramural swelling of affected bowel. one should resect jejunojejunal intussusceptions. for acute ileocecal intussusceptions, one should transect the small intestine as far distally as possible and perform a jejunocecal anastomosis. in horses with particularly long intussusceptions (up to 10 m has been reported), one may attempt an intracecal resection. 49 for horses with chronic ileocecal intussusceptions, one should perform a jejunocecal bypass without small intestinal transection. the prognosis is good for horses with chronic ileocecal intussusceptions and guarded to poor for horses with acute ileocecal intussusceptions, depending on the length of bowel involved. 46 herniation of intestine through a rent in the diaphragm is rare in the horse and may involve any segment of bowel, although small intestine is herniated most frequently. diaphragmatic rents may be congenital or acquired, but acquired herniae are more common. congenital rents may result from incomplete fusion of any of the four embryonic components of the diaphragm: pleuroperitoneal membranes, transverse septum, and esophageal mesentery. in addition, abdominal compression of the foal at parturition may result in a congenital hernia. 50 acquired herniae are presumed to result from trauma to the chest or a sudden increase in intraabdominal pressure, such as might occur during parturition, distention of the abdomen, a sudden fall, or strenuous exercise. 51 herniae have been found in a number of different locations, although large congenital herniae are typically present at the ventral most aspect of the diaphragm, and most acquired herniae are located at the junction of the muscular and tendinous portions of the diaphragm. 50 a peritoneopericardial hernia has been documented in at least one horse. 52 figure 13 .14-3 jejunojejunal intussusception in a horse presented for colic. the intussusceptum has become ischemic because of invagination of intestine and its mesenteric blood supply into the intussuscipiens. clinical signs usually are associated with intestinal obstruction rather than respiratory embarrassment. 51 however, careful auscultation may reveal an area of decreased lung sounds associated with obstructed intestine and increased fluid within the chest cavity. 53 such signs may prompt thoracic radiography or ultrasound, both of which one can use to make a diagnosis. auscultation also may reveal thoracic intestinal sounds, but differentiating these from sounds referred from the abdomen typically is not possible. in one report, two of three horses diagnosed with small intestinal strangulation by diaphragmatic hernia had respiratory acidemia attributable to decreased ventilation. 54 treatment of horses with diaphragmatic hernia is fraught with complications because of the need to reduce and resect strangulated bowel and the need to repair the defect in the diaphragm. 55, 56 because dorsal defects in the diaphragm are among the common forms of diaphragmatic defect, closing the diaphragmatic hernia via the approach used for abdominal exploration may not be possible. however, because herniation is likely to recur, 55 scheduling a second surgery using an appropriate approach to resolve the diaphragmatic defect is appropriate. horses with large colon volvulus have rapid onset of severe, unrelenting abdominal pain, most often in postpartum broodmares. 4 once the large colon strangulates (≥270-degree volvulus), gas distention is significant, leading to gross distention of the abdomen, compromised respiration as the distended bowel presses up against the diaphragm, and visceral pooling of blood as the caudal vena cava is compressed. horses with this condition are frequently refractory even to the most potent of analgesics. these horses may prefer to lie in dorsal recumbency, presumably to take weight off the strangulated colon. an abbreviated physical examination is warranted in these cases, because the time elapsed from the onset of strangulation to surgical correction is critical. under experimental conditions, the colon is irreversibly damaged within 3 to 4 hours of a 360-degree volvulus of the entire colon. 57 despite severe pain and hypovolemia, horses may have a paradoxically low heart rate, possibly related to increased vagal tone. in addition, results of abdominocentesis often do not indicate the degree of colonic compromise 4,58 and in many cases are not worth attempting because of extreme colonic distention. 59 palpation per rectum reveals severe gas distention of the large colon, often restricting access to the abdomen beyond the pelvic brim. one may make the diagnosis tentatively based on signalment, severity of pain, and degree of distention. at surgery, the volvulus typically is located at the mesenteric attachment of the colon to the dorsal body wall and the most common direction of the twist is dorsomedial using the right ventral colon as a reference point. however, the colon may twist in the opposite direction, twist greater than 360 degrees (up to 720 degrees has been reported) or twist at the level of the diaphragmatic and sternal flexures. 4 in all cases, one should decompress the colon as much as possible, and in many cases a colonic evacuation via a pelvic flexure enterotomy greatly aids correction of the volvulus. one must determine after correction of the volvulus whether the colon has been injured irreversibly and should base the determination on mucosal color and bleeding (if an enterotomy has been performed), palpation of a pulse in the colonic arteries, serosal color, and appearance of muscular motility. if one judges the colon to be damaged irreversibly, one can consider the feasibility of a large colon resection. although 95% of the colon can be resected (that part of the colon distal to the level of the cecocolic fold), damage from the volvulus usually exceeds that which can be resected. in these cases, surgeons may elect to resect as much damaged bowel as possible or may advise euthanasia. 7 the prognosis is guarded to poor because of the rapid onset of this disease. in one study the survival rate was 35%. 58 in a more recent report the survival rate was 36% for horses with 360-degree volvulus of the large colon compared with 71% for horses with 270-degree volvulus. 4 however, one study in central kentucky documented a high success rate, possibly because of early recognition of the disease and the proximity of the hospital to the surgical caseload. 60 postoperative complications include hypovolemic and endotoxic shock, extensive loss of circulating protein, disseminated intravascular coagulation, and laminitis. in addition, large colon volvulus has a propensity to recur. although one study documented a recurrence rate of less than 5%, 58 some authors believe recurrence may be as high as 50%. 7 therefore one should consider methods to prevent recurrence in patients at risk of recurrence, particularly broodmares that tend to suffer from the disease recurrently during the foaling season. 61, 62 the most common intussusceptions of the large intestine are cecocecal and cecocolic intussusceptions. 63, 64 both are likely attributable to the same disease process, with variable inversion of the cecum. these conditions doughnut-shaped prolapse of rectal mucosa and submucosa. type ii prolapses involve full-thickness rectal tissue, whereas type iii prolapses additionally have invagination of small colon into the rectum. type iv prolapses involve intussusception of proximal rectum or small colon through the anus in the absence of prolapse of tissue at the mucocutaneous junction at the anus. 73 one can differentiate type iv from other forms of prolapse by their appearance and a palpable trench between prolapsed tissue and the anus. type i prolapses occur most frequently in horses with diarrhea, in which the rectal mucosa becomes irritated and protrudes intermittently during episodes of tenesmus. if tenesmus persists, rectal mucosa can remain prolapsed. rectal mucosa rapidly becomes congested and edematous under these conditions, which one should treat with osmotic agents such as glycerin or magnesium sulfate and by massaging and reducing the prolapse. 74 a purse-string suture may be required to keep the mucosa inside the rectum. topical application of lidocaine solution or jelly, epidural anesthesia, and sedation may help reduce tenesmus that incites and exacerbates rectal prolapse. one can apply similar treatments to type ii rectal prolapses. however, these more severe prolapses may not be reducible without surgical resection of mucosa and submucosa from the prolapsed bowel. 70, 74 type iii and iv rectal prolapses are more serious injuries because of involvement of small colon. 75 in horses with type iii prolapses, one should perform an abdominocentesis to determine if injured small colon has resulted in peritonitis. one should reduce the small colon component manually if possible, although prolapsed rectal tissue typically requires mucosal/ submucosal resection. one should perform surgical exploration of the abdomen to determine the status of the small colon, although one can use serial abdominocenteses in lieu of surgery to detect progressive necrosis of bowel. type iv prolapses occur most commonly in horses with dystocia. 73 these prolapses are almost always fatal because of stretching and tearing of mesenteric vasculature, with subsequent infarction of affected bowel. therefore euthanasia usually is warranted tend to occur in young horses (63% were less than 3 years old in one study) and may be associated with intestinal tapeworms. horses show highly variable clinical signs, including acute severe colic, intermittent pain over a number of days, or chronic weight loss. 64 these variable presentations likely relate to the degree to which the cecum has intussuscepted. initially, the cecal tip inverts, creating a cecocecal intussusception, which does not obstruct flow of ingesta. as the intussusception progresses, the cecum inverts into the right ventral colon (cecocolic intussusception), obstructs flow of ingesta, and often causes severe colic. the cause of abdominal pain is often difficult to differentiate in these cases, although detecting a mass on the right side of the abdomen by per rectal palpation or ultrasound examination sometimes is possible. 63, 64 treatment involves manual surgical reduction by retracting the intussusceptum directly 63 or via an enterotomy in the right ventral colon. 65 however, a number of cases occur in which one cannot reduce the cecum readily because of severe thickening or in which surgical procedures result in fatal contamination. for example, one report stated that 8 of 11 horses were euthanized in the perioperative period because of complications, 63 and another report stated that 12 of 30 horses were euthanized before or during surgery. the latter included all of the horses with chronic disease because of irreversible changes to the cecum. 64 however, one recent report on cecocolic intussusceptions indicated that seven of eight horses that underwent right ventral colon enterotomy and cecal resection survived long-term, 65 suggesting that continued improvements in surgical techniques may improve the prognosis. colocolic intussusceptions are rare but have been reported to affect the pelvic flexure and the left colons. [66] [67] [68] [69] although the condition is reported to be more common in young horses, 67-69 the condition may affect older horses. 66 clinical findings may include a palpable mass on the left side of the abdomen. 67 ultrasonography also may be useful. treatment requires manual reduction of the intussusception at surgery, 67, 69 or resection of affected bowel. 66 because the left colons may be exteriorized extensively and manipulated at surgery, 66-69 the prognosis is fair. rectal prolapse may occur following any disease that causes tenesmus, including diarrhea, rectal neoplasia, and parasitism, 70 or prolapse can occur following elevations in intraabdominal pressure during parturition or episodes of coughing. 71, 72 rectal prolapses are classified into four categories (table 13. 14-1) based on the extent of tissue prolapsed and the severity. type i rectal prolapse is most common and is characterized by a intussusception of rectum and poor small colon through the anus based on physical examination findings. however, confirmation of severe small colonic injury requires abdominal exploration via a midline approach or laparoscopy. 76 a horse with compromised small colon conceivably could undergo a colostomy of the proximal small colon, but the compromised small colon typically necroses beyond that which can be resected via a midline abdominal approach. 74 nonstrangulating infarction occurs following cranial mesenteric arteritis caused by migration of strongylus vulgaris and has become a rare disorder since the advent of broad-spectrum anthelmintics. although thromboemboli have been implicated in the pathogenesis of this disease, careful dissection of naturally occurring lesions has not revealed the presence of thrombi at the site of intestinal infarctions in most cases. 77 these findings suggest that vasospasm plays an important role in this disease. 78 clinical signs vary greatly depending on the extent to which arterial flow is reduced and the segment of intestine affected. any segment of intestine supplied by the cranial mesenteric artery or one of its major branches may be affected, but the distal small intestine and large colon are more commonly involved. no clinical variables exist that one can use to differentiate this disease from strangulating obstruction reliably. in some cases, massive infarction results in acute, severe colic. 77 occasionally, one may detect an abnormal mass and fremitus on palpation of the root of the cranial mesenteric artery per rectum. one should consider this disease a differential diagnosis in horses with a history of inadequate anthelmintic treatment and the presence of intermittent colic that is difficult to localize. although one should perform fecal parasite egg counts, they are not indicative of the degree of parasitic infestation. in addition to routine treatment of colic, dehydration, and endotoxemia, medical treatment may include aspirin (20 mg/kg every 24 hours) to decrease thrombosis. 78 definitive diagnosis requires surgical exploration. however, these cases are difficult to treat because of the patchy distribution of the lesions and the possibility of lesions extending beyond the limits of surgical resection. in addition, further infarction may occur following surgery. the prognosis is fair for horses with intermittent mild episodes of colic that may be amenable to medical therapy but is poor in horses that require surgical intervention. 77, 78 surgical exploration of a horse with on-going intestinal injury exacerbates shock induced largely by endotoxin traversing damaged mucosa, and this in turn correlates with mortality. 3 the initial clinical step in the workup of horses with colic is taking a thorough history. however, one may have to delay taking a complete history until after the physical examination and initial treatment, because management of abdominal pain may take precedence. if possible, one should obtain the vital components of the history before examination and treatment: the duration and severity of colic symptoms, analgesics already administered, and a history of any adverse drug reactions. the two most critical factors from a history that would support a decision to explore a horse with colic surgically are the duration of signs and the extent of pain. one deduces the latter from asking the owner about the presence and frequency of pawing, looking at the flanks, rolling, repeatedly going down and getting back up, posturing as if to lie down or urinate, among other clinical evidence of pain. 4 table 13 .15-1 lists other important components of the history one should obtain to try to ascertain why colic has occurred. just as the history necessarily may need to be brief to allow rapid treatment of colic, so the clinician must be able to alter the extent of the physical examination to treat the horse in a timely fashion. the most critical examination finding is the heart rate of the horse, because it provides an excellent assessment of the cardiovascular status of the horse. 4 the heart rate is likely the single most reliable predictor of the need for surgery and survival. 4, 5 because analgesics can alter the heart rate dramatically, if possible, one should obtain the heart rate before administering analgesics. other components of the examination are designed specifically to gather information about the cardiopulmonary status of the horse (quality of the pulse, mucous membrane color, capillary refill time, respiratory rate, and full auscultation of the chest), and the nature of the intestinal obstruction (auscultation of gastrointestinal sounds, per rectal palpation of the abdomen, and presence of nasogastric reflux). although classic presentations exist for horses with obstructions of the small or large intestine (table 13. clinical management of colic is distinctly different from management of many other clinical syndromes because the initial focus is often not on defining the definitive diagnosis but rather on deciding whether a horse requires surgical exploration. therefore the clinician must collect historical, physical examination, and clinicopathologic information and make a decision whether these findings warrant medical management or whether to perform surgical exploration of the abdomen because of a suspected obstructive or ischemic lesion. for example, one may examine a horse with signs of severe abdominal pain, poor cardiovascular status, and abdominal distention that may be compatible with an extensive list of differential diagnoses but that more importantly indicate the need for abdominal exploration to minimize the extent of intestinal injury. the speed with which one can make this clinical decision has a tremendous effect on the well-being of the patient, 1,2 because delaying gastric fluid accumulation because of direct compression of the small intestine by distended colon or via tension on the duodenocolic ligament. the most useful diagnostic test for determining the type of intestinal obstruction is rectal palpation of the abdomen. 4 however, one can reach only approximately one third of the abdomen via the rectum, and this percentage may be substantially less in large horses or heavily pregnant horses. nonetheless, attempting to determine the type of obstruction present (small intestine versus large intestine, and simple obstruction versus strangulating obstruction) is worthwhile; this information directly affects prognosis. in one study, interns and residents at a veterinary teaching hospital were able to predict the type of lesion with a specificity exceeding 90%. 6 findings from palpation are helpful in educating the client about the potential findings in surgery and the likelihood of survival for the horse. before considering how to manage signs of colic, one should remember that such signs are poorly localized. therefore although colic is most frequently associated with intestinal disease, one should consider dysfunction of other organ systems, including urinary obstruction, 7,8 biliary obstruction, 9 uterine torsion or tears, 10,11 ovarian artery hemorrhage, 10 and neurologic disease as differential diagnoses. 12 however, the duration and severity of colic the most immediately useful clinicopathologic information in horses with colic are the packed cell volume and total protein, because one can use them to substantiate clinical estimates of dehydration and they correlate strongly with prognosis. 20, 21 a serum biochemical profile is useful for assessing electrolyte imbalances, tissue perfusion (anion gap or lactate), and kidney and liver function. one can use serum biochemical or blood gas analysis to assess acid-base status. horses with colic most frequently show evidence of metabolic acidosis associated with poor tissue perfusion caused by hypovolemia or endotoxemia, but one may note other abnormalities such as metabolic alkalosis in association with extensive loss or sequestration of stomach chloride. metabolic acidosis has been investigated further in horses with colic by measuring blood lactate, although this test is not offered routinely in many laboratories. lactate levels also have been inferred from measurement of the anion gap, although one study noted that lactate in horses with colic did not account for the entire anion gap. 22 lactate levels and anion gap closely correlate with prognosis for survival. 20, 23, 24 other key components of assessment of the horse with colic are abdominocentesis and complete blood count. the total white blood cell count and differential can provide crucial evidence of systemic inflammation associated with endotoxemia stemming from colic attributable to colitis (leukopenia, neutropenia, and a left shift) rather than an obstruction (highly variable complete blood count findings). peritoneal fluid may be helpful in determining the integrity of the intestine. specifically, as the intestine becomes progressively devitalized, the peritoneal fluid becomes serosanguinous as red blood cells leak into the abdomen, followed by an elevation in the total protein (>2.5 g/dl) and progressive increases in total nucleated cell count (>10,000 cells/µl). however, these findings do not always correlate well with the condition of the intestine, particularly in horses with large colon volvulus. for example, in a study of 57 horses with large colon volvulus, the average total protein (2.5 g/dl) and total nucleated cell count (1000 cells/µl) were normal despite the fact that only 36% with a 360-degree volvulus survived. 4, 25 these measures may appear normal because the development of severe mucosal injury following large colon volvulus is rapid and may not allow enough time for protein and leukocytes to equilibrate with the abdominal fluid. 26 investigators have taken all the variables routinely assessed during evaluation of horses for colic and have attempted to develop models to predict accurately the need for surgery and the prognosis for life. [27] [28] [29] [30] none of these predictor models has taken the place of clinical decision making, although these studies have added 924 part ii disorders of specific body systems signs are excellent predictors of whether a horse requires surgical exploration of the abdomen. in fact, refractory pain supersedes all other predictors of the need for surgery in the colic patient. once signs of colic have been recognized and categorized as to their severity, rapidly and effectively relieving the pain is critical for the well-being of the horse and to reduce the owner's anxiety. in addition, pain is best managed before it becomes severe. 13 several classes of analgesics are readily available to treat horses with colic (table 13. 15-3), including α 2 -agonists (xylazine, detomidine), opiates (butorphanol), and nonsteroidal antiinflammatory drugs (nsaids, such as flunixin meglumine). although much of this information is familiar to most practitioners, several principles deserve emphasis. the short-duration drugs xylazine and butorphanol, which provide analgesia for 30 to 45 minutes, allow the veterinarian to determine if pain is recurrent within the time period of the typical examination. in contrast, flunixin meglumine is not as potent as an analgesic but has a much longer duration of action. to avoid deleterious effects on gastrointestinal mucosa and the kidneys, one should not administer flunixin meglumine more frequently than recommended. 14, 15 the recent discovery of two isoforms of cyclooxygenase (cox), the enzyme inhibited by nsaids, has resulted in discovery of drugs that can more selectively inhibit proinflammatory cox-2 while permitting continued constitutive production of prostanoids. such specificity may be advantageous in horses with colic, particularly when one considers recent evidence of reduced intestinal recovery from an ischemic event with flunixin compared with a drug that is more selective for cox-2. 16 one should reserve the α 2agonist detomidine for horses with severe, unrelenting pain because of its tremendous potency. 17 in addition, one should remember that α 2 -agonists reduce the heart rate associated with a transient increase in blood pressure, 18, 19 thereby reducing the predictive value of the heart rate and pulse pressure. tremendously to understanding of the importance of some prognostic factors, particularly those reflecting cardiovascular function. simple obstruction involves intestinal obstruction of the lumen without obstruction of vascular flow. however, because a tremendous volume of fluid enters the small intestinal lumen daily, 31,32 the obstructed intestine tends to become distended, which in turn may reduce mural blood flow. 33 ultimately, such distention may result in necrosis of tissues, particularly in the immediate vicinity of the obstruction. 34 few are the causes of simple obstruction in the small intestine, and the incidence of these obstructions is low (approximately 3% of all referred horses in one large hospital-based study). 5 however, in some geographic regions, this type of obstruction is prevalent. for example, in the southeastern united states, ileal impactions are common. 35 ileal impactions most commonly occur in adult horses in the southeastern united states. although feeding of coastal bermuda hay has been implicated in the regional distribution of the disease, separating geographic location from regional hay sources as risk factors has been difficult. nonetheless, feeding coastal bermuda hay likely places horses at risk of ileal impaction, particularly if the coarse fiber content of the hay is high. furthermore, sudden changes in feed from an alternate type of hay to coastal bermuda hay likely places a horse at risk of ileal impaction. 38 studies in england have revealed tapeworm infection as another important risk factor for ileal impaction. based on risk analysis, the data suggested that in excess of 80% of the ileal impaction cases studied were associated with serologic or fecal evidence of tapeworm infection. 39 because of the poor sensitivity of fecal analysis for tapeworms, proudman and trees have developed a serologic test (enzyme-linked immunosorbent assay) with a sensitivity of approximately 70% and a specificity of 95%. 40 clinical signs of horses with ileal impaction are typical for a horse with small intestinal obstruction, including onset of moderate to severe colic and loops of distended small intestine palpable per rectum as the condition progresses. because the ileum is the distal most aspect of the small intestinal tract, nasogastric reflux may take a considerable time to develop and is found in approximately 50% of horses requiring surgical correction of impacted ileum. 35, 41 one usually makes the diagnosis at surgery, although on occasion one may palpate an impacted ileum per rectum. multiple loops of distended small intestine frequently make the impaction difficult to palpate. ileal impactions may resolve with medical treatment 36 but frequently require surgical intervention ( figure 13.15-2) . at surgery, one can infuse fluids directly figure 13 .15-1 appearance of roundworms that have been retrieved within the nasogastric reflux from a foal with an ascarid impaction. the large size of these ascarids (bar = 1 cm) contributes to the risk of impaction following sudden kills of these parasites by broad-spectrum anthelmintics. into the mass, allowing the surgeon to breakdown the impaction. the surgeon may include dioctyl sodium sulfosuccinate in the infused fluid to aid in disruption of the mass. extensive small intestinal distention and intraoperative manipulation of the ileum may lead to postoperative ileus, 42 but recent studies indicate that this complication is less frequent as the duration of disease before admission decreases. 35 recent studies indicate that the prognosis for survival is good. 35, 36 ileal hypertrophy is a disorder in which the muscular layers (circular and longitudinal) of the ileum hypertrophy for unknown reasons (idiopathic) or following an incomplete or functional obstruction. for idiopathic cases, proposed mechanisms include parasympathetic neural dysfunction resulting in chronically increased muscle tone and subsequent hypertrophy of the muscular layers of the ileal wall. such neural dysfunction possibly could result from parasite migration. alternative hypotheses include chronic increases in the muscular tone of the ileocecal valve, leading to muscular hypertrophy of the ileum as it contracts against a partially occluded ileocecal valve. the jejunum also may be hypertrophied, alone or with the ileum. clinical signs include chronic intermittent colic as the ileum hypertrophies and gradually narrows the lumen diameter. in one study, partial anorexia and chronic weight loss (1 to 6 months) were documented in 45% of the horses, most likely because of intermittent colic and reduced appetite. because hypertrophy does not affect the ileal mucosa, no reason exists to believe that these horses experience malabsorption of nutrients. one usually makes the diagnosis at surgery, although one may palpate the hypertophied ileum per rectum in some cases. for treatment, one performs an ileocecal or jejunocecal anastomosis to bypass the hypertrophied ileum. without surgical bypass, intermittent colic persists and the thickened ileum ultimately may rupture. 43 the prognosis is fair with surgical treatment. 44 secondary ileal hypertrophy is most commonly notable in horses that previously have had colic surgery and that may have a partial or functional obstruction at an anastomotic site. for example, in one case report, a horse developed ileal hypertrophy after surgical correction of an ileocecal intussusception. 45 ileal hypertrophy also was noted in a horse with cecal impaction in which an ileocolic anastomosis was oriented incorrectly. 46 horses are typically re-presented for recurrence of colic in these cases. surgical therapy is directed at addressing the cause of small intestinal obstruction and resecting hypertrophied intestine. meckel's diverticulum is an embryonic remnant of the vitelloumbilical duct, which fails to atrophy completely and becomes a blind pouch projecting from the antimesenteric border of the ileum. 47, 48 however, similar diverticula also have been noted in the jejunum. 49 these diverticula may become impacted, resulting in partial luminal obstruction, or may wrap around an adjacent segment of intestine, causing strangulation. 47 occasionally, an associated mesodiverticular band may course from the diverticulum to the umbilical remnant and serve as a point around which small intestine may become strangulated. mesodiverticular bands also may originate from the embryonic ventral mesentery and attach to the antimesenteric surface of the bowel, thereby forming a potential space within which intestine may become entrapped. clinical signs range from chronic colic for an impacted meckel's diverticulum to acute severe colic for intestine strangulated by a mesodiverticular band. one makes the diagnosis at surgery, and treatment requires resection of the diverticulum and any associated bands. the prognosis is good for horses with simple impaction of a meckel's diverticulum and is guarded for horses with an associated small intestinal strangulation. 50 adhesions of one segment of bowel to another or of a segment of intestine to other organs and the body wall most typically occur following abdominal surgery and may be clinically silent, cause chronic colic attributable to partial obstruction, or result in acute obstruction. these differing clinical syndromes are attributable to the type of adhesions that develop. for example, a fibrous adhesion that does not by itself obstruct the intestinal lumen might serve as the pivot point for a volvulus, whereas an adhesion between adjacent segments of the intestinal tract may create a hairpin turn that causes chronic partial obstruction. 51 the number of adhesions that develop also may vary greatly from horse to horse. some horses may develop a single adhesion adjacent to an anastomotic site or a discrete segment of injured intestine, whereas other horses may develop diffuse adhesions involving multiple segments of intestine, likely because of widespread inflammation of the peritoneum at the time of the original surgery. the mechanism whereby adhesions develop is complex but likely involves initial injury to the serosa initiated by intestinal ischemia, reperfusion injury, and luminal distention. 52 importantly, such injury involves infiltration of neutrophils into the serosa accompanied by loss of mesothelial cells. in one study assessing the margins of resected small intestine, extensive neutrophil infiltration was documented in the serosa, particularly in the proximal resection margin that had been distended before correction of a variety of strangulating lesions. 53 regions of serosal injury and inflammation subsequently undergo reparative events similar to any wound, including local production of fibrin, de novo synthesis of collagen by infiltrating fibroblasts, and ultimately maturation and remodeling of fibrous tissue. unfortunately, during this process, fibrin may result in injured intestinal surfaces adhering to adjacent injured bowel or an adjacent organ. once a fibrinous adhesion has developed, new collagen synthesis may result in a permanent fibrous adhesion. alternatively, proteases released by local phagocytes may lyse fibrinous exudate, thereby reversing the adhesive process. thus one can view formation of adhesions as an imbalance of fibrin deposition and fibrinolysis. 54 prevention of adhesions depends on inhibition of the mechanisms involved in adhesion formation, including reduction of serosal injury with early intervention and good surgical technique, reduction of inflammation by administration of antiinflammatory medications, physical separation of inflamed serosal surfaces (e.g., carboxymethylcellulose and hyaluronan), [55] [56] [57] and pharmacologic modulation of fibrinous adhesion formation (e.g., heparin). 58 in addition, early return of motility in the small intestine after surgery may reduce contact time between inflamed surfaces of intestine, thereby reducing the chances of adhesion formation. 54 horses at greatest risk of developing adhesions after colic surgery appear to be those that have small intestinal disease. 51, 59 in one study of horses undergoing surgical correction of small intestinal obstruction, 22% developed a surgical lesion associated with adhesions. foals appear to have an increased incidence of adhesions compared with mature horses regardless of the nature of the abdominal surgery. 51 one study indicated that 17% of foals developed lesions attributable to adhesions regardless of the type of initial surgery. 60 studies conflict as to whether the degree of surgical intervention influences adhesion formation, 51 but in one study, horses that require enterotomy or resection and anastomosis were at greatest risk of developing adhesions. 59 as an indication of the importance of postoperative adhesion formation, adhesions were among the most common reasons for repeat laparotomy in postoperative colic patients. 59, 61 clinical signs of horses with adhesions vary greatly depending on whether the adhesion is causing partial obstruction or complete luminal obstruction or involves intestinal vasculature. adhesions would be an important differential diagnosis for intermittent colic in the postoperative period, particularly if such colic was not relieved by nasogastric decompression of the stomach. continued intermittent colic should prompt abdominocentesis to determine if septic peritonitis is present, which may contribute to adhesion formation. placement of a large bore drain and peritoneal lavage ( figure 13 surgery should prompt immediate nasogastric intubation to decompress the stomach. treatment should include attempts at obtaining reflux from the horse at frequent intervals rather than relying on passive flow of reflux. in addition, administration of intravenous fluids should account for the maintenance requirement (50 ml/kg/day, about 1 l/hr in the average horse) and fluid losses via reflux. in practice, this requires frequent monitoring of packed cell volume and total protein to ensure that the horse remains well hydrated. although concerns have arisen that overhydrating horses may contribute to increased nasogastric reflux, 42 keeping horses well-hydrated to avoid hypovolemic shock is critical. additionally, one should monitor electrolytes frequently, particularly considering their potential role in smooth muscle contraction and nerve excitability. because of the important role of inflammation in postoperative ileus, including elaboration of cox-2-produced prostanoids, 70 administration of nsaids is indicated. nsaid administration is particularly necessary if postoperative ileus is associated with endotoxemia, because lipopolysaccharide-induced prostanoid production disrupts propulsive motility in horses. 71, 72 interestingly, phenylbutazone is more effective than flunixin meglumine at reducing the deleterious actions of lipopolysaccharide on intestinal motility. 73 however, one should use caution when administering nsaids to patients with postoperative ileus in light of research suggesting that complete inhibition of prostanoid production can alter motility patterns in normal equine intestine. 68 the advent of selective cox-2 inhibitors may provide optimal antiinflammatory treatment in the future. 74 other treatments aimed at specifically modulating intestinal motility include lidocaine (bolus of 1.3 mg/kg followed by 0.05 mg/kg/min for 24 hours), erythromycin (0.5 to 1.0 mg/kg slow intravenous infusion in 1 l saline every 6 hours), and metoclopramide (0.04 mg/kg/hr). 66, 75, 76 the mechanism of lidocaine is presumed to be inhibition of sensory nerve activity within the wall of the intestine, thereby reducing reflex sympathetic inhibitory activity. in addition, intravenously administered lidocaine appears to be an effective analgesic. thus an important feature of intravenous lidocaine therapy may be to control postoperative pain-induced reduction of gastrointestinal motility and mucosal secretory activity. 77 metoclopramide may stimulate intestinal motility by several mechanisms, including dopamine receptor blockade, cholinergic stimulation, and adrenergic blockade. 66 although metoclopramide has been shown to be beneficial for reversing postoperative ileus in clinical patients and research animals, it has central nervous system excitatory side effects in the horse that make its use difficult. nonetheless, administration of metoclopramide to horses with postoperative ileus resulted in elect repeat laparotomy or laparoscopy. in one study of adhesions, 70% of repeat laparotomies were performed within 60 days, suggesting that surgical colic attributable to adhesions typically occurs within 2 months of an initial surgical procedure. unfortunately, the prognosis for horses with colic attributable to adhesions is low, with only 16% of horses in one study surviving from adhesion-induced colic. 51 the definition of ileus is intestinal obstruction, including physical and functional obstructions. however, in veterinary medicine, the term typically is used to designate a lack of progressive aboral propulsion of ingesta resulting in functional obstruction. 62 one typically bases the diagnosis of postoperative ileus on the presence of excessive gastric fluid accumulation (reflected as excessive nasogastric reflux). postoperative ileus may occur following any abdominal exploratory procedure. however, horses undergoing surgery for strangulating small intestinal lesions or small intestinal obstructive lesions such as an ileal impaction are at greatest risk. 42 recently, the syndrome of postoperative ileus in horses has been broadened to include those horses that may have delayed transit of ingesta through the large intestine following surgery. this large intestinal ileus may follow any type of surgery, particularly horses that have had orthopedic surgery, and is characterized by reduced fecal output (fewer than three piles of manure per day) rather than excessive nasogastric reflux. 62 however, horses with excessive nasogastric reflux are unlikely to have normal fecal output, so the distinction between these two manifestations of ileus is not absolute. mechanisms involved in precipitating postoperative ileus characterized by small intestinal dysfunction likely involve local inflammation, reduced coordination of progressive motility, and increased sympathetic tone. a recent series of studies in the rat has shown that surgical manipulation of intestine results in delayed transit time associated with infiltration of neutrophils into intestinal longitudinal muscle [63] [64] [65] and upregulation of inducible nitric oxide synthase and cox-2. the mechanisms in the horse may be similar in that extensive manipulation of the intestine resulted in abnormal intestinal motility in ponies, 66 and prostanoids and nitric oxide alter or reduce intestinal motility in horses. [67] [68] [69] clinical signs of postoperative ileus following colic surgery include evidence of abdominal pain, increased heart rate, reduced gastrointestinal sounds, and reflux of gastric fluid via a nasogastric tube. of these signs, heart rate is critical because it appears to be a more sensitive indicator of pain in the postoperative period than overt evidence of colic. therefore a sudden increase in the heart rate of a postoperative patient following colic a significantly reduced duration of reflux and shorter postoperative hospital stays compared with horses not receiving this drug. 76 in the same study, constant infusion of metoclopramide was superior to intermittent infusion. recent in vitro studies indicate that metoclopramide effectively increases smooth muscle contractile activity throughout the small intestine. similarly, the motilin agonist erythromycin had stimulatory effects on equine small intestine, although the results were not uniform throughout the small intestine. erythromycin stimulates contractile activity in the longitudinal muscle of the pyloric antrum but inhibits contractile activity in circular smooth muscle in this segment of the gastrointestinal tract. 75 the latter may be attributable to activation of motilin receptors on inhibitory nerves and may result in enhanced gastric emptying. in vivo studies on erythromycin confirmed the stimulatory action of this drug on the distal small intestine and indicated this drug also stimulates contractile activity in the cecum and pelvic flexure. however, the stimulation depends on the temporal association with surgery. erythromycin stimulated contractile activity in the postoperative period in the ileum and pelvic flexure but not the cecum, 78 suggesting this drug may be useful for treating select cases of postoperative ileus. for horses with presumed ileus of the large colon, signs included reduced fecal output (fewer than three piles of manure per day), reduced gastrointestinal sounds, variable presence of colic, and on occasion a palpable impaction of the cecum or large colon. risk factors for this syndrome include orthopedic surgery, length of the operative period, and most importantly inadequate treatment with phenylbutazone, presumably resulting from insufficient control of postoperative pain. although treatment of large colon impaction in the postoperative period typically is uncomplicated, onset of cecal impaction is fatal in many cases because of the difficulty in recognizing horses that have cecal dysfunction. therefore one should pay close attention to fecal production and optimal analgesic treatment in any horse following an orthopedic procedure. 62 other painful procedures, including ophthalmologic procedures, also likely place horses at risk of developing ileus of the large intestine. simple obstructions of the large intestine such as impaction tend to have a more gradual onset than those of the small intestine, although horses may become acutely and severely painful with some forms of colon displacement. in fact, some of these cases mimic and may progress toward large colon volvulus. medical therapy is frequently successful in correcting large colon impactions. however, cecal impactions present much more of a dilemma because of the greater propensity of this organ to rupture, the relative difficulty of surgically manipulating the cecum, and the onset of cecal dysfunction that may prevent the cecum from emptying following surgical resolution of impaction. cecal impaction may be divided into two syndromes: primary cecal impactions that result from excessive accumulation of ingesta in the cecum and secondary cecal impactions that develop while a horse is being treated for a separate problem. 79, 80 although primary impactions typically consist of impacted, relatively dry fecal material and secondary cecal impactions tend to have fluid contents, considerable overlap exists between the two syndromes, and one must approach each case carefully. in horses with primary cecal impactions, onset of abdominal pain occurs over a number of days, reminiscent of the development of a large colon impaction. one should differentiate cecal impactions from large colon impactions on the basis of rectal palpation findings. cecal impactions have a propensity to rupture before the development of severe abdominal pain or systemic deterioration and therefore must be monitored closely. 79 secondary cecal impactions typically develop following unrelated surgical procedures that result in postoperative pain (particularly orthopedic surgeries). secondary cecal impactions may be even more difficult to detect because one may attribute postoperative depression and decreased fecal output to the operative procedure rather than to colic. by the time horses with secondary cecal impactions show noticeable signs of colic, the cecum may be close to rupture. in many cases, no signs of impending rupture are evident. 80 therefore all horses that undergo surgeries in which considerable postoperative pain may develop should have feed intake and manure production closely monitored. a recent study indicated that horses that produce fewer than three piles of manure daily in the postoperative period are at risk of developing a large intestinal impaction. furthermore, horses that underwent prolonged (>1 hour) orthopedic surgery that received inadequate treatment with phenylbutazone were at considerable risk of reduced postoperative fecal output. 62 these results are in contrast to statements indicating that nsaids may place horses at risk of impaction, statements that appear to be based largely on clinical impressions rather than on risk analysis. 80 the diagnosis of primary cecal impaction is based on palpation of a firm, impacted cecum per rectum. in some cases, cecal impactions may be difficult to differentiate from large colon impactions. however, careful palpation reveals the inability to move the hand completely dorsal to the impacted viscus because of the attachment of the cecum to the dorsal body wall. treatment for horses with primary cecal impactions may include initial medical therapy, including aggressive administration of intravenous fluids and judicious use of analgesics. 80 however, if the cecum is distended grossly or if medical therapy hasno effect within a reasonable period of time, surgical evacuation of the cecum via a typhlotomy is indicated. 79 in addition, performing an ileocolostomy to bypass the cecum is advisable, because postoperative cecal motility dysfunction with recurrence of the impaction is common. 46, 81 in horses that develop secondary cecal impactions, diagnosis is based on palpation of a greatly distended cecum filled with semifluid intestinal contents. the nature of the contents likely is related to the more rapid progression of this disease compared with primary cecal impaction. one should not delay surgery because of the risk of cecal rupture. 82 however, if the cecum appears healthy following typhlotomy and evacuation, bypass of the cecum is not as critical as it is for primary impactions as long as one can control the inciting cause of the impaction (such as orthopedic pain). the prognosis is guarded for surgical treatment of all cecal impactions because of the potential for the cecum to rupture during prolonged medical treatment or during surgical manipulation, the possibility of abdominal contamination during surgery, and the extensive surgical procedures required. in a recent report, seven of nine horses for which cecal impaction was treated by typhlotomy and ileocolostomy or jejunocolostomy lived long term. 46 however, a separate report indicated that all horses with cecal impaction following another disease process had cecal rupture without any signs of impending rupture. 80 ingesta impactions of the large colon occur at sites of anatomic reductions in luminal diameter, particularly the pelvic flexure and the right dorsal colon. 83 although a number of risk factors have been reported, most have not been proved. however, a sudden restriction in exercise associated with musculoskeletal injury appears frequently to be associated with onset of impaction. 84 another consideration is equine feeding regimens, which usually entail twice daily feeding of concentrate. such regimens are associated with large fluxes of fluid into and out of the colon, associated with readily fermentable carbohydrate in the colon and subsequent increases in serum aldosterone, respectively. one may prevent these fluid fluxes, which may cause dehydration of ingesta during aldosterone-stimulated net fluid flux out of the colon, with frequent small feedings. 32 amitraz, an acaricide associated with clinical cases of colon impaction, can induce impaction of the ascending colon. 85, 86 this effect may provide some clues as to the pathogenesis of large colon impaction. in particular, amitraz appears to alter pelvic flexure pacemaker activity, resulting in uncoordinated motility patterns between the left ventral and left dorsal colon and excessive retention of ingesta. absorption of water from the ingesta increases with retention time, dehydrates the contents of the colon, and results in impaction. conceivably, parasite migration in the region of a pacemaker may have a similar action. 87 other factors implicated in large colon impaction include limited exercise, poor dentition, coarse roughage, or dehydration. clinical signs of large colon impaction include slow onset of mild to moderate colic. fecal production decreases, and the feces are often hard, dry, and mucuscovered because of delayed transit time. the heart rate may be elevated mildly during episodes of pain but is often normal. signs of abdominal pain are typically well controlled with administration of analgesics but become increasingly more severe and refractory if the impaction does not resolve. the diagnosis is based on palpation of a firm mass in the large colon per rectum. however, one may underestimate the extent of the impaction by rectal palpation alone because much of the colon is out of reach. adjacent colon may be distended if the impaction has resulted in complete obstruction. one should attempt initial medical treatment. administration of analgesics (e.g., flunixin meglumine at 0.5 to 1.1 mg/kg intravenously every 8 to 12 hours; butorphanol at 0.04 to 0.1 mg/kg intramuscularly every 4 to 6 hours; or xylazine at 0.3 to 0.5 mg/kg intravenously as needed) controls intermittent abdominal pain. administration of oral laxatives such as mineral oil (2 to 4 l by nasogastric tube every 12 to 24 hours) and the anionic surfactant dioctyl sodium sulfosuccinate (6 to 12 g/500 kg diluted in 2 to 4 l of water by nasogastric tube every 12 to 24 hours) are used commonly to soften the impaction. saline cathartics such as magnesium sulfate (0.1 mg/kg in 2 to 4 l by nasogastric tube) also may be useful. one should not permit access to feed. for impactions that persist, one should institute aggressive oral and intravenous fluid therapy (2 to 4 times the maintenance fluid requirement). if the impaction remains unresolved, the horse becomes uncontrollably painful, or extensive gas distention of the colon occurs, surgery is indicated. in addition, one can monitor abdominal fluid serially to determine the onset of intestinal compromise. 83 at surgery, one evacuates the contents of the colon via a pelvic flexure enterotomy. the prognosis is good for those horses in which impactions resolve medically (95% long-term survival in one study) and fair in horses that require surgical intervention (58% long-term survival in the same study). 84 enteroliths are mineralized masses typically composed of magnesium ammonium phosphate (struvite). 88 however, magnesium vivianite also has been identified in enteroliths, along with variable quantities of sodium, sulfur, potassium, and calcium. the formation of magnesiumbased minerals is puzzling because of the relative abundance of calcium in colonic fluids, which would favor the formation of calcium phosphates (apatite) rather than struvite. 89 however, elevated dietary intake of magnesium and protein may play a role. many horses that develop enteroliths are located in california and are fed a diet consisting mainly of alfalfa hay. analysis of this hay has revealed a concentration of magnesium approximately 6 times the daily requirements of the horse. 90 furthermore, the high protein concentration in alfalfa hay may contribute to calculi formation by increasing the ammonia nitrogen load in the large intestine. enteroliths most commonly form around a nucleus of silicon dioxide (a flintlike stone), but nidi have included ingested nails, rope, and hair. 88 enteroliths usually are found in the right dorsal and transverse colons. 90 although enterolithiasis has a wide geographic distribution, horses in california have the highest incidence. in one california study, horses with enterolithiasis represented 28% of the surgical colic population, and arabians, morgans, american saddlebreds, and donkeys were at greatest risk of this disease. 91 in a study of enterolithiasis in texas, risk factors also included feeding of alfalfa hay and arabian breed. however, in that study, miniature horses were also at risk. 92 horses with enteroliths are rarely under 4 years old, 90 although an enterolith in an 11-month-old miniature horse has been reported recently. 93 enterolithiasis is characterized by episodic, mild to moderate, intermittent abdominal pain. 90 progressive anorexia and depression may develop. the amount of pain depends on the degree of obstruction and amount of distention. partial luminal obstruction allows the passage of scant, pasty feces. heart rate varies and depends on the degree of pain. in some cases, an enterolith is forced into the small colon, where it causes acute small colon obstruction. one may diagnose enteroliths by abdominal radiography or at surgery. on rare occasions, one may palpate an enterolith per rectum, particularly if it is present in the distal small colon. in general, these cases require surgery, although enteroliths being retrieved per rectum have been reported. in fact in one study, 14% of horses presented for treatment of enterolithiasis had a history of passing an enterolith in the feces. however, enteroliths typically are located in the right dorsal colon, transverse colon, or small colon. at surgery, one gently pushes the enterolith toward a pelvic flexure enterotomy, but removal frequently requires a separate right dorsal colon enterotomy to prevent rupture of the colon. following removal of an enterolith, one must conduct further exploration to determine if other enteroliths are present. solitary enteroliths are usually round, whereas multiple enteroliths have flat sides. the prognosis is good (92% 1-year survival in one study of 900 cases), unless the colon ruptures during removal of an enterolith. in one recent study, rupture occurred in 15% of cases. 91 sand impactions are common in horses with access to sandy soils, particularly horses eating feed placed on the ground. some horses, especially foals, deliberately eat sand. fine sand tends to accumulate in the ventral colon, whereas coarse sand may accumulate in the dorsal colon. 94, 95 however, individual differences in colonic function may contribute to accumulation of sand, because some horses can clear consumed sand, whereas others cannot. distention from the impaction itself, or gas proximal to the impaction, causes abdominal pain. in addition, sand may trigger diarrhea, presumably because of irritation of the colonic mucosa. 96 in horses with sand impactions, clinical signs are similar to those of horses with large colon impactions. 94 one may find sand in the feces, and auscultation of the ventral abdomen may reveal sounds of sand moving within the large colon. 97 however, unlike sand-induced diarrhea, one may not hear sand impactions easily because of the lack of colonic motility. to determine the presence of fecal sand, one places several fecal balls in a rectal palpation sleeve or other container, which subsequently is filled with water. if sand is present, it accumulates at the bottom of the container. in addition, one may detect mineral opacity within the colon on abdominal radiographs, particularly in foals, ponies, and small horses. abdominal paracentesis typically yields normal fluid and poses some risk because large quantities of sand in the ventral colon make inadvertent perforation of the colon more likely. 95 peritoneal fluid is often normal but may have an elevated protein concentration. initially, medical therapy is warranted. administration of psyllium hydrophilic mucilloid (0.25 to 0.5 kg/500 kg in 4 to 8 l of water by stomach tube) may facilitate passage of sand. one should administer the solution rapidly because it will form a viscous gel. an alternative method of administration is to mix psyllium with 2 l of mineral oil, which will not form a gel and can be pumped through a nasogastric tube easily. one then pumps 2 to 4 l of water through the tube. the psyllium separates from the oil phase and mixes with the water, forming a gel within the gastrointestinal tract. psyllium is thought to act by stimulating motility or by agglutinating the sand. however, a recent experimental study failed to show a benefit of this treatment for clearing sand from the colons of otherwise normal horses. 98 if a severe impaction is present, one should not give the psyllium until softening the impaction by administrating intravenous or oral fluids and other laxatives. perforation is a potential complication in horses with sand impactions because the sand stretches and irritates the intestinal wall and causes inflammation. therefore if colic becomes intractable, one should perform surgical evacuation of the large colon. the prognosis is generally good. 94, 95 displacement of the ascending colon is a common cause of large intestinal obstruction. the ascending colon is freely movable except for the right dorsal and ventral colons. contact with adjacent viscera and the abdominal wall tends to inhibit movement of the ascending colon from a normal position; however, accumulation of gas and fluid or ingesta may cause the colon to migrate. 99 feeding practices, including feeding of large concentrate meals, likely plays a role in initiating displacement of the large colon. large concentrate meals increase the rate of passage of ingesta, allowing a greater percentage of soluble carbohydrates to reach the large intestine, 31 which in turn increases the rate of fermentation and the amount of gas and volatile fatty acids produced. the production of large amounts of volatile fatty acids stimulates the secretion of large volumes of fluid into the colon. 100 the association between feeding concentrate and development of displacements of the large colon is illustrated by studies indicating that ascending colon displacement is more prevalent in horses fed a highconcentrate, low-roughage diet. 101 abnormal motility patterns of the ascending colon also have been suggested to contribute to the development of colonic displacement. feeding stimulates colonic motility via the gastrocolic reflex, but large meals may alter normal motility patterns and concurrently allow rapid accumulation of gas and fluid from fermentation. 31, 102 migration of parasite larvae (strongyles) through the intestinal wall also has been shown to alter colonic motility patterns. other experimental studies also have shown that strongylus vulgaris infection results in reduced blood flow to segments of the large intestine without necessarily causing infarction. electric activity of the colon and cecocolic junction increases after infection with s. vulgaris and cyathostome larvae, probably reflecting a direct effect of migration through the intestine and an early response to reduced blood flow. 103 displacements of the ascending colon generally are divided into three types: left dorsal displacement, right dorsal displacement, and retroflexion. left dorsal displacement is characterized by entrapment of the ascending colon in the renosplenic space. the colon often is twisted 180 degrees such that the left ventral colon is situated in a dorsal position relative to the left dorsal colon. the entrapped portion may be only the pelvic flexure or may involve a large portion of the ascending colon, with the pelvic flexure situated near the diaphragm. the colon may become entrapped by migrating dorsally between the left abdominal wall and the spleen or may migrate in a caudodorsal direction over the nephrosplenic ligament. occasionally, one can palpate the ascending colon between the spleen and abdominal wall, lending support to the first mechanism of displacement. gastric distention is thought to predispose horses to left dorsal displacement of the ascending colon by displacing the spleen medially, allowing the colon room to migrate along the abdominal wall. right dorsal displacement begins by movement of the colon cranially, medial (medial flexion) or lateral (lateral flexion) to the cecum. according to one author, the proportion of right dorsal displacements with medial versus lateral flexion is approximately 1:15. 104 in either case the pelvic flexure ends up adjacent to the diaphragm. retroflexion of the ascending colon occurs by movement of the pelvic flexure cranially without movement of the sternal or diaphragmatic flexures. displacement of the ascending colon partially obstructs the lumen, resulting in accumulation of gas or ingesta and causing distention. secretion of fluid in response may exacerbate the distention. 105 tension and stretch of the visceral wall is an important source of the pain associated with colonic displacement. tension on mesenteric attachments and the root of the mesentery by the enlarged colon also may cause pain. 99 ischemia rarely is associated with nonstrangulating displacement of the colon. however, vascular congestion and edema often occur in the displaced segments of colon, resulting from increased hydrostatic pressure from reduced venous outflow. morphologic damage to the tissues is usually minor. clinically, displacement of the ascending colon is characterized by intermittent signs of mild to moderate abdominal pain of acute onset. however, one also may note an insidious onset of colic. 104 one may note dehydration if the duration of the displacement is prolonged. the heart rate may be elevated during periods of abdominal pain but is often normal. abdominal distention may be present if the colon is enlarged by gas, fluid, or ingesta. fecal production is reduced because progressive motility of the large intestine is absent. one often diagnoses left dorsal displacements by palpation per rectum. one can feel the left ventral colon in a dorsal position; it often is filled with gas. one can trace the ascending colon to the nephrosplenic space, and the spleen may be displaced medially. alternatively, one can reach a tentative diagnosis using abdominal ultrasonography. the spleen is visible on the left side of the abdomen, but the gasdistended bowel obscures the left kidney. evaluation of this technique indicates that false positives occur in few instances, although false negatives occasionally may occur. 106 a definitive diagnosis therefore may require surgery. right dorsal displacements are characterized by the presence of the distended ventral colon running across the pelvic inlet and may be felt between the cecum and the body wall if a lateral flexion is present. the pelvic flexure is usually not palpable. retroflexion of the ascending colon may produce a palpable kink in the colon. if the displaced colons are not distended by gas in the instance of right dorsal displacement and retroflexion, the ascending colon may not be palpable and is conspicuous by its absence from a normal position. peritoneal fluid may increase in amount, but the color, protein concentration, and white blood cell count are usually normal. however, as the displaced segment becomes edematous, fluid leaking through the serosa into the peritoneal fluid increases the protein concentration. surgical correction of colon displacement is the most effective means of resolving this disorder. however, nonsurgical intervention has been successful in select cases of nephrosplenic entrapment of the large colon. [106] [107] [108] before attempting such manipulations, the clinician must be certain of a diagnosis. one anesthetizes the horse and places it in right lateral recumbency, rotates the horse up to dorsal recumbency, rocking it back and forth for 5 to 10 minutes, and then rolls the horse down into left lateral recumbency. 109 one should palpate the nephrosplenic space per rectum to determine whether the entrapment has been relieved before recovering the horse from anesthesia. one may administer phenylephrine (3-6 µg/kg/min over 15 minutes) to decrease the size of the spleen. 110 more recently, phenylephrine has been used successfully with 30 to 45 minutes of exercise to reduce nephrosplenic entrapments in four of six horses. 26 the authors suggested that the technique be used on horses with mild to moderate colonic distention, particularly when financial constraints are severe. a number of cases occur in which nonsurgical interventions do not correct the problem and others in which nonsurgical manipulations correct the entrapment but result in large colon volvulus or displacement. 111 one should take horses in such condition to surgery promptly. the prognosis for horses with large colon displacement is good. in one study on horses with nephrosplenic entrapment of the large colon, survival exceeded 90%. 108 the horse, particularly young horses, may ingest foreign material that can cause obstruction, such as bedding, rope, plastic, fence material, and feedbags. these foreign bodies may result in impaction with ingesta and distention of the intestine, typically in the transverse or descending colon. young horses usually are affected. in one study the obstructing mass could be palpated per rectum in three of six horses. 112 fecaliths are common in ponies, miniature horses, and foals. 113 older horses with poor dentition also may be predisposed to fecaliths because of the inability to masticate fibrous feed material fully. fecaliths commonly cause obstruction in the descending colon and may cause tenesmus. 112 other clinical signs are similar to those of enterolithiasis. abdominal radiography may be useful in smaller patients to identify the obstruction, especially if gas distention around the foreign body or fecalith provides contrast. the horse usually requires surgical treatment. mural masses such as abscesses, tumors (adenocarcinoma, lymphosarcoma), granulomata, and hematomas ( figure 13 .15-4) can cause luminal obstruction and impaction, typically in older horses. impaction may result from obstruction of the lumen or impaired motility in the segment of intestine with the mass. abscesses may originate from the lumen of the intestine or may extend from the mesentery or mesenteric lymph nodes. intramural hematomas form most commonly in the descending colon and cause acute abdominal pain. 114 once the acute pain from the hematoma subsides, impaction proximal to the hematoma develops because of impaired motility through the affected portion of the colon. trauma, ulceration of the mucosa, and parasitic damage are speculated causes of intramural hematomas. 114, 115 stricture of the large intestine occurs when fibrous tissue forms in a circular pattern around or within the intestine, reducing the luminal diameter and the ability of the wall to stretch. strictures may be congenital or may follow peritonitis, previous abdominal surgery, or inflammatory bowel disease. in a report of 11 horses with inflammatory bowel disease, 6 horses had strictures, four of which were in the small intestine and two of which were in the large colon. 116 clinical signs vary according to the degree of luminal obstruction. partial obstruction and impaction tend to produce mild to moderate abdominal pain of insidious onset. mural hematomas tend to produce signs of acute abdominal pain. 114, 115 per rectal palpation of the abdomen may reveal the presence of a mass or simply the impacted segment but not the mass itself. one may note fever, weight loss, and anorexia if an abscess or tumor is the cause. an elevated white blood cell count; hyperfibrinogenemia; hyperglobulinemia; or normocytic, normochromic anemia may occur with abscesses or tumors. peritoneal fluid may reflect the cause of the mass. tumor cells may occur infrequently. one may note evidence of inflammation with bacteria if the cause of colic is an abscess or granuloma, in which case one should culture the fluid. hematomas may cause hemorrhage into the peritoneal fluid. treatment usually requires surgical resection of the mass. one may treat abscesses with appropriate antibiotics if the impaction can be resolved medically with oral or intravenous analgesics and laxatives. streptococcus spp, actinomyces pyogenes, corynebacterium pseudotuberculosis, rhodococcus equi, anaerobic bacteria, and gram-negative enteric organisms commonly are involved in abscesses. atresia of a segment of the colon is a rare congenital abnormality in horses. the heritability and causes of the condition are unknown. one potential mechanism for development of the lesion is intestinal ischemia during fetal life, which results in necrosis of a segment of intestine. clinical signs include a failure to pass meconium and colic within the first 12 to 24 hours of life. secondary abdominal distention results from complete intestinal obstruction, and abdominal radiographs may reveal gas-distended colon. one makes the diagnosis at surgery. any portion of the colon may be absent, but the distal segment of the large colon or the proximal small colon usually is affected most severely. if sufficient tissue is present, one may attempt anastomosis to the proximal blind end of the colon. 117 the prognosis depends on which segment of the colon is absent but is usually poor because of an absence of distal colon. neoplasia in the alimentary tract of the horse is uncommon. 1 primary and metastatic neoplasia can affect multiple locations within the oral cavity and gastrointestinal tract (boxes 13.16-1 and 13.16-2). neoplasia is not limited to older horses. the average age of horses with squamous cell carcinoma is 8.6 to 14.6 years. 2, 3 the alimentary form of lymphoma occurs most commonly in horses less than 5 years of age. 4 identification of benign versus malignant tumors is imperative to justify treatment and predict survival. clinical signs associated with alimentary neoplasia are related to the tumor location. clinical signs of oral neoplasia can include enlargement or ulceration of the mandible or maxilla. 48 neoplasia of the tongue results in weight loss, quidding, prepharyngeal dysphagia, halitosis, and nasal discharge containing feed material if the oropharynx is involved. [6] [7] [8] tumors of the esophagus cause signs typical of esophageal dysphagia, ptyalism, choke, intermittent colic, fever, weight loss, and halitosis. 10, 49, 50 gastric neoplasia can be associated with abnormal chewing and swallowing behavior, anorexia, weight loss, chronic intermittent colic, abdominal distention, and intermittent fever. 16 abdominal neoplasia has been implicated in 4% of horses with intermittent or chronic colic. 51, 52 altered stool character, weight loss, ventral edema, and recurrent fever have been associated with intestinal neoplasia. 4 acute signs of abdominal discomfort can occur in intestinal obstructions from malignant and benign neoplastic disease. paraneoplastic syndromes may occur in the horse. the most common syndromes are cancer cachexia, ectopic hormone production, anemia, leukocytosis, thrombocytopenia, hypergammaglobulinemia, fever, and neurologic abnormalities. 53 horses with cancer cachexia have profound weight loss despite adequate consumption of calories. diagnosis of alimentary neoplasia can be challenging. data collected from a complete blood count, biochemistry panel, and urinalysis may support the diagnosis of neoplasia but rarely confirms it. normocytic normochromic anemia indicates chronic disease and is the most likely cause of anemia associated with neoplasia. blood loss anemia (via gastrointestinal tract) and immune-mediated hemolytic anemia (lymphoma) 54 are less frequent causes of anemia associated with abdominal neoplasia. peripheral eosinophilia has been reported in association with multisystemic eosinophilic, epitheliotropic disease with lymphoma. 14 leukocytosis and hyperfibrinogenemia are common findings. serum chemistry can confirm hypoalbuminemia caused by inflammation of the bowel wall. hyperglobulinemia can be characterized with serum electrophoresis, which is nonspecific and can reveal chronic inflammation. a few cases of lymphoma have been identified with monoclonal hypergammaglobulinemia. 55 ectopic hormone production may result in hypercalcemia (calcium >14 mg/dl), which is associated with alimentary neoplasia such as lymphoma, multiple myeloma, carcinomata, and ameloblastoma. 2, 56 hypoglycemia (blood glucose <70 mg/dl) can occur with neoplasia of the pancreas or liver. 2 rectal examination may detect an abdominal mass, thickening of the intestinal wall, lymph node enlargement, or a gritty texture in horses with carcinomatosis. 2 rectal biopsy can reveal lymphoma in some cases. 42 fecal occult blood test is nonspecific for neoplastic disease but can reveal blood loss through the gastrointestinal tract. occasionally, abdominocentesis can identify neoplasia if the tumor exfoliates cells into the abdomen. one can diagnose squamous cell carcinoma, adenocarcinoma, and mesothelioma from peritoneal fluid. 10, 45, 46, 57 characterization of peritoneal fluid as an inflammatory exudate or modified transudate without any neoplastic cells present is common. cytologic analysis of peritoneal fluid samples collected by abdominocentesis accurately predicted the presence of neoplasia in 11 of 25 cases in one study. 58 cytologic examination of two or more peritoneal fluid samples increases the sensitivity of this test for detecting abdominal neoplasia. measurement of peritoneal fluid glucose concentration and ph is valuable to differentiate inflammation in the peritoneum caused by neoplasia from bacterial peritonitis. abdominal neoplasia typically is associated with peritoneal glucose concentrations similar to blood and ph higher than 7.3. d-xylose absorption tests can reveal malabsorptive diseases that include lymphoma. 42, 59 immunoglobulin m deficiency is associated with lymphoma in some young adult horses, but the prevalence of immunoglobulin m deficiency in horses with lymphoma and the value of measuring serum immunoglobulin m concentrations for the diagnosis of lymphoma have not been evaluated. 60 dna cell cycle analysis of suspect neoplastic cells has been used to detect lymphoma in equine patients confirmed with the disease. this method of evaluating fluid or tissues aspirates may increase the accuracy for diagnosing neoplasia in the future. 61 a complete evaluation of the oral cavity may include using a full-mouth speculum, radiographs, and endoscopy of the pharynx. evaluation of the esophagus and stomach with a 3-m endoscope can reveal intralumenal masses. 11 pleuroscopy has been used to obtain biopsy samples of extralumenal masses surrounding the esophagus. 49 contrast radiography can assist in the diagnosis of neoplasia within the wall or outside of the esophagus. 49, 62 ultrasonography of the stomach, small intestine, cecum, and large colon is useful in detecting intestinal wall thickness, abdominal masses, and excessive peritoneal fluid. 63 identification of neoplasia in the liver, kidney or spleen may support metastasis to other parts of the gastrointestinal tract or lymph nodes. laparoscopy and exploratory laparotomy often are required to obtain a final diagnosis. 64 lymphoma is the most common neoplasia in the horse and has been divided into four categories. this section covers only the intestinal/alimentary form. in the past, lymphoma has been called lymphosarcoma, but the preferred term by oncologists is lymphoma because no benign form of this disease exists. 2 lymphoma originates from lymphoid tissue and predominantly affects the small intestine and intestinal lymph nodes. chronic weight loss from malabsorption, intermittent colic, and fever are the most common clinical findings. 27, 65 chronic diarrhea has been reported in some cases. 66 paraneoplastic pruritus and alopecia have been identified in one case of diffuse lymphoma. 67 one generally does not note peripheral lymphadenopathy, but one may palpate enlargement of the intestinal lymph nodes on rectal examination. 4 large colon resection for treatment of lymphoma in horses has increased short-term survival in two horses. 35 chemotherapy in two mares that were pregnant extended their lives long enough to foal normally. 68 long-term prognosis for intestinal lymphoma is poor. squamous cell carcinoma (scc) is a malignant tumor of the gastrointestinal epithelium. scc is the second most common neoplasia in the horse and is the most common oral neoplasia. however, the incidence of scc is rare. 10, 16, 50 in the oral cavity scc may affect the lips, tongue, hard palate, pharynx, and mucosa. 69, 70 treatment for scc in the oral cavity may involve surgical resection, iridium-192 brachytherapy, 5-fluorouracil, or intralesional cisplatin. 5, [71] [72] [73] the prognosis for survival is good if complete removal of the tumor is possible. metastasis beyond the regional lymph nodes is rare for oral scc. squamous cell carcinoma is the most common tumor of the stomach and esophagus 11, 16 and can invade these areas and metastasize to the lymph nodes and lungs. abnormal masses were palpated on rectal examination in four of five cases of gastric scc. 16 treatment by surgical resection is not possible in most cases and the horses die or are euthanized. 2 adenocarcinoma is a malignant tumor that can occur in the small intestine, cecum, and large colon. 18 the tumor arises from the glandular crypts of the gastrointestinal tract and has been reported in middle-aged and older horses. metastasis to the lymph nodes, liver, and lungs can occur. intestinal adenocarcinoma has been reported to metastasize to the bone and was diagnosed using nuclear scintigraphy following injection of technetium-99m hydroxymethylene diphosphate. 29, 32 no reports of successful surgical resection have been published. leiomyosarcoma is a malignant tumor of the smooth muscle lining the gastrointestinal tract and has been reported in the stomach, small intestine, and rectum. 13, 22, 23, 40, 58 in one case report, gastroscopy could not identify the mural mass in the stomach that was found during exploratory surgery. another report describes a favorable outcome for surgical resection of a leiomyosarcoma that was protruding from the anal sphincter in a 4-year-old quarter horse. 40 prognosis for survival is favorable if surgical resection is possible. leiomyoma is a benign tumor of the smooth muscle of the gastrointestinal tract that can occur in the stomach, small intestine, and small colon. 37, 38 clinical signs are consistent with intestinal obstruction. surgical resection and anastomosis of the affected portion of the intestine have been performed without complications. lipoma is a benign tumor that occurs in older horses (10 to 26 years) and arises from mesenteric adipocytes. the tumor grows on a stalk that wraps around the intestine, causing a strangulating lesion manifested clinically by acute obstructive colic. intestinal injury caused by pedunculated lipomata may occur in the small intestine, small colon, and rectum. long-term survival with surgical resection and anastomosis of the affected segment has been reported to be 40% to 50%. 26, 74 oral neoplasia oral cavity neoplasia may involve the dental tissue (odontogenic tumors), bone (osteogenic tumors), or soft tissues (see box 13.16-1). ameloblastoma occurs in horses greater than 10 years old and mainly affects the mandible. ameloblastic odontoma affects younger horses and usually involves the maxilla. both are benign but locally invasive. radiographs may distinguish the difference between an ameloblastoma (radiolucent lesion) and ameloblastic odontoma (radiolucent lesion with partially mineralized density). the best treatment option is surgical resection and radiation therapy regardless of the type. 48 juvenile mandibular ossifying fibroma occurs in the rostral mandible of young horses between the ages of 2 months and 2 years. the fibroma may cause significant distortion of the bone. with early diagnosis and surgical excision of the mass, the horse has a good prognosis. 75 melanomas, sarcoids, and oral papilloma occur on the mouth and lips. melanomas rarely metastasize, but they commonly are found in the parotid salivary glands and lymph nodes. sarcoids are the most common skin tumor that can involve the mouth. ulcerations of the buccal mucosa are difficult to treat. intralesional cisplatin, cryosurgery, radiation, and laser excision have been tried with limited success. 5 equine papilloma virus is responsible for the common skin wart found on the lips and muzzle of young horses. these lesions are usually selflimiting but may be removed successfully by cryosurgery or excision. a number of detailed and informative reviews are available describing the anatomy, physiology, and pathophysiology of the equine peritoneum. [1] [2] [3] [4] [5] the peritoneum consists of a single layer of mesothelial cells lining the peritoneal cavity and serosal surfaces of the intraabdominal viscera. the mesothelial lining of the diaphragm, abdominal walls, and pelvic cavity is termed parietal peritoneum. the visceral peritoneum includes the serosal surfaces of the intraabdominal organs. the parietal and visceral portions of the peritoneum are contiguous with each other through the omentum, mesenteries, and ligaments. caudally, the peritoneum reflects over the surfaces of the pelvic organs (portions of the urogenital tract and rectum), excluding them from the peritoneal space, and thus much of the pelvic cavity and contents are described as retroperitoneal. the peritoneal space communicates with the lumen of the uterus (and thus the external environment) via the fallopian tubes in females. in males the peritoneum forms a true blind sac. the vascular supply and nervous innervation of the visceral peritoneum are supplied by the splanchnic vessels and visceral autonomic nerves, respectively. branches of the intercostal, lumbar, and iliac arteries supply the parietal peritoneum, and the phrenic and intercostal nerves provide nervous innervation. the clinical relevance is that inflammation of the parietal peritoneum is perceived as somatic pain, resulting in a splinted abdominal wall, pain on external palpation, and reluctance to move. visceral pain is mediated by small type c sensory fibers, which are believed to be stimulated by bowel distention, smooth muscle spasms, tension on the mesentery, and ischemia. the peritoneal lining functions as a semipermeable barrier to the diffusion of water and low-molecular weight solutes between the blood and the abdominal cavity. 1 the peritoneum secretes a serous fluid that lubricates the abdominal cavity, inhibits adhesion formation, and has minor antibacterial properties. 1,2 macrophages, mast cells, mesothelial cells, and lymphocytes provide immune function within the peritoneum. 2,3 peritoneal macrophages impart antibacterial activity via complement receptors, phagocytic activity, interaction with t lymphocytes, neutrophil chemotaxis, and fibroblast activation. the peritoneal surface maintains a high level of fibrinolytic activity through the production of plasminogen activators by mesothelial cells. this function, together with the lubricant properties of the peritoneal fluid, helps to maintain gliding surfaces within the peritoneum and prevent adhesion formation. in quadrupeds, peritoneal fluid produced by the mesothelium tends to move ventrally and cranially, aided largely by diaphragmatic movement. peritoneal fluid, waste products, and foreign material (including bacteria) exit the peritoneal cavity to enter the lymphatic system through diffusely distributed subendothelial pores or via the large diaphragmatic stomata, depending on particle size. large molecules and particles greater than approximately 40,000 mw (such as bacteria) exit through the diaphragmatic stomata and ultimately enter the thoracic duct. peritonitis is inflammation of the mesothelial lining of the peritoneal cavity and is characterized by desquamation and transformation of mesothelial cells; chemotaxis of neutrophils; release of several soluble mediators of inflammation; exudation of serum, fibrin, and protein into the peritoneal cavity; and depression of fibrinolytic activity. peritonitis occurs in association with a variety of disorders that result in mechanical, chemical, or infectious insult to the peritoneal lining. [1] [2] [3] [4] any process resulting in disruption or irritation of the peritoneal lining, inflammation or infection of abdominal organs, or compromise of the intestinal wall can result in peritonitis (box 13.17-1). common mechanical injuries include blunt or perforating trauma to the abdominal wall, breeding and foaling accidents, and abdominal surgery. a variety of traumatic insults of iatrogenic origin can cause peritonitis, such as the pathogenesis of peritonitis as a series of stages, as reviewed and described by trent, is useful. 2 the contamination stage, lasting 3 to 6 hours, involves introduction of bacteria into the peritoneum and initiation of the acute inflammatory response previously described. if the organisms are not eliminated and infection is established, the process evolves to the stage of acute diffuse peritonitis. although the overall movement of contaminants is toward the diaphragmatic stomata and into the thoracic duct, the nature of the peritoneal circulation is such that regardless of the location of the initial contamination, bacteria spread throughout the peritoneum within several hours. the stage of acute diffuse peritonitis lasts up to 5 days. the inflammatory response persists and escalates with continued exudation of proteinaceous fluid and influx of inflammatory cells. offending organisms are delivered to the lymphatic system and may be eliminated by the immune system. organisms, however, may gain access to the systemic circulation in sufficient numbers to result in clinically relevant septicemia. in human beings and laboratory animals having undergone polymicrobial contamination of the peritoneum, the organisms causing septicemia at this stage are usually coliforms, e. coli in particular. this stage of the disease process has the highest mortality because of the effects of severe peritoneal inflammation, endotoxemia, and septicemia. if the animal survives this stage but fails to eliminate the infection in the peritoneal cavity, the disease enters a transitional phase referred to as the acute adhesive (or localizing) stage. this stage occupies a time frame of perhaps 4 to 10 days after the initial insult. neutrophils are still active, macrophages are increasing in numbers, and fibrin aggregates are being organized or lysed. in human beings and laboratory animals, selective reduction and synergism continue such that anaerobes and gram-negative aerobes predominate. if infection persists beyond this point, organization of fibrin proceeds and organisms become isolated from host defenses. at this point, the disease process enters the stage of chronic abscessation. this stage can begin as early as 8 days after inoculation and persists indefinitely. clinical signs of peritonitis depend on the primary disease process, the duration of the problem, and the extent of peritoneal inflammation. localized peritonitis may have few or no systemic manifestations, whereas severe localized or generalized peritonitis often is accompanied by severe toxemia or septicemia or both. septic peritonitis usually causes more severe clinical signs because of the inflammatory mediators released in response to bacterial toxins and because of the presence of endotoxin when gram-negative organisms are involved. most clinical signs are nonspecific and include fever, depression, inappetance, decreased borborygmi, and dehydration. additional signs, reported in 30 horses (ages 2 months to 16 years) with peritonitis, were colic, ileus, weight loss, and diarrhea. 14 horses with peracute peritonitis, as occurs with rupture of the bowel or rectal tear, have severe toxemia, weakness, depression or severe colic, tachycardia, tachypnea, and circulatory failure. fever may not be present depending on the degree of shock. typical clinical findings include sweating, pawing, muscle fasciculations, weak peripheral pulses, red to purple mucous membranes, prolonged capillary refill time, and decreased skin elasticity. parietal pain, characterized by reluctance to move, splinting of the abdominal wall, and sensitivity to external abdominal pressure occur in some acute cases. urination or defecation may be painful for the horse, and urine and fecal retention may be evident on rectal examination. palpation of the abdomen externally may elicit flinching, aversion movements, or groaning. with extensive abdominal fecal contamination, rectal examination may reveal a gritty feeling of the serosal and parietal surface of the peritoneum because of fibrin deposition and a dry texture of the peritoneum. in horses with more chronic peritonitis, rectal examination findings can include pain on palpation of fibrinous or fibrous adhesions, intestinal impaction or distention following ileus and dehydration, an abdominal mass (abscess or neoplasia), or an impression of bowel floating in fluid. in many cases, one can detect no abnormalities on rectal examination. horses with localized, subacute, or chronic peritonitis may have signs of chronic or intermittent colic, depression, anorexia, weight loss, intermittent fever, ventral edema, exercise intolerance, decreased or absent intestinal sounds, and mild dehydration. heart rate and respiratory rate may be normal. fecal output may be normal; however, horses with chronic diarrhea and weight loss have been reported. 14 foals with peritonitis usually exhibit signs of colic (acute or chronic) and are febrile, depressed, and inappetant. in some foals with primary peritonitis, pleural effusion occurs. in young foals, peritonitis can cause rapid metabolic deterioration, and determination and correction of the primary problem requires immediate attention. in older foals, peritonitis may occur insidiously, as occurs following s. equi or r. equi infections. clinicopathologic abnormalities vary depending on the time of onset and severity of peritonitis. horses with acute, septic peritonitis can have leukopenia, hemoconcentration, metabolic acidemia, azotemia, and electrolyte imbalances reflective of systemic inflammation from endotoxemia and hypovolemia. horses with peritonitis of a few days' duration may have leukocytosis and hyperfibrinogenemia. plasma protein levels vary depending on the hydration status, degree of exudation into the peritoneum, and type of underlying problem. in chronic peritonitis, hyperproteinemia with hyperglobulinemia may be present. neonates with uroperitoneum caused by urinary bladder rupture or urachal disease tend to develop azotemia, hyponatremia, hypochloremia, hyperkalemia, and acidosis. foals with peritonitis following septicemia, severe enterocolitis, severe meconium impaction, intussusception, small intestinal volvulus, gastric or duodenal rupture, or ascarid impactions usually have clinicopathologic findings reflective of systemic inflammation, such as inflammatory leukogram or leukopenia, hemoconcentration, and acidosis. chronic abscessation, as occurs in foals with r. equi and streptococcal infections, results in clinicopathologic findings reflecting chronic inflammation (anemia, hyperfibrinogenemia, hyperglobulinemia). abnormalities in the composition of peritoneal fluid occur with peritoneal inflammation, and peritoneal fluid analysis is principal to the diagnosis of peritonitis. one collects peritoneal fluid through puncture of the abdomen on the ventral midline. one should clip and prepare an area aseptically. usually, the lowest point of the abdomen, 5 to 10 cm caudal to the xiphoid cartilage, is prepared for puncture; although in some cases one may perform paracentesis more caudally, particularly when one suspects a specific area of sequestered fluid or abscessation. in addition, one may choose a site to the right of midline in an attempt to avoid the spleen. one can perform peritoneal puncture using a 1 1 / 2 -inch, 18-gauge needle or, following local anesthesia and a stab incision with a no. 15 scalpel blade, using a sterile cannula. one collects fluid by gravity flow and should collect fluid in a tube containing anticoagulant, preferably edta for cytologic examination, and in a sterile tube without anticoagulant for visual inspection and, if desired, for culture. one should fill the edta tube to half its volume, because the edta will alter the refractive index of the fluid, resulting in a falsely elevated value for total solids when one collects only a small volume and tests it with a refractometer. one should evaluate peritoneal fluid routinely as to color, turbidity, total protein, white blood cell (wbc) count and differential, and the presence of bacteria as determined by gram stain. normal peritoneal fluid is clear and straw-colored and does not coagulate spontaneously. peritoneal fluid becomes turbid when increased numbers of white blood cells and concentration of protein are present. pink or red fluid indicates free hemoglobin or hemorrhage. blood introduced into the peritoneal fluid iatrogenically in some cases may be differentiated from blood from internal hemorrhage based on the presence of platelets and hematocrit. fluid with iatrogenic blood contamination contains platelets, whereas fluid with blood following internal hemorrhage or diapedesis often does not have platelets. blood contamination resulting from splenic puncture often results in the packed cell volume of the sample being greater than that of the blood. large volumes of dark brown or green fluid with a fetid odor obtained from several sites strongly suggest bowel rupture, but one should perform cytologic examination for confirmation. the distribution of polymorphonuclear and mononuclear cells varies widely, and one should interpret the results of cell counts and differentials as supporting a number of disorders rather than a specific diagnosis. normal equine peritoneal fluid contains fewer than 5000 nucleated cells per microliter. 2, 15 wbc counts in acute peritonitis (>100,000/µl) are reported to be higher than those in chronic peritonitis (20,000 to 60,000/µl) [14] [15] [16] ; however, this is not always the case, and the wbc count depends most on the cause of the peritonitis. the wbc level does not always correlate with severity of peritonitis or the prognosis. the peritoneal fluid wbc count can be greater than 100,000/µl following enterocentesis, with no clinical signs or problem. 17 conversely, peritoneal wbc counts of fewer than 100,000/µl may be found in foals or horses with intraabdominal abscesses. 18 the peritoneal wbc count can increase to greater than 150,000/µl following celiotomy 19 and can be higher if an enterotomy is done. postoperatively, the wbc count normally continues to decline and returns to near normal by 5 to 7 days. failure of the wbc count to decrease suggests peritonitis resulting from a postoperative complication. finally, peritoneal fluid wbc counts greater than 500,000/µl indicate severe focal or generalized peritoneal sepsis. the distribution of polymorphonuclear and mononuclear cells varies in normal peritoneal fluid, 2,15 but polymorphonuclear cells usually predominate. with acute peritonitis, polymorphonuclear cells typically increase to a greater degree than mononuclear cells, but this depends on the cause. in horses that have bowel disease accompanied by endotoxemia, the number of peritoneal mononuclear cells increases, as does transformation of mesothelial cells to macrophages. in chronic cases, one easily may mistake transforming mesothelial cells for neoplastic cells, which can make diagnosis difficult, particularly when the presenting problem is compatible with a neoplastic process. in such cases, consultation with a clinical pathologist regarding cytologic findings is prudent. factor, and interleukin-6 have been measured in the peritoneal fluid of horses with abdominal disorders, but the diagnostic and prognostic implications of the presence or absence of these enzymes and analytes is limited. [20] [21] [22] one should submit peritoneal fluid samples in appropriate media (port-a-cul vial, bbl microbiology system) for aerobic and anaerobic cultures in an attempt to identify the pathogenic organism(s). obligate anaerobic bacteria such as bacteroides are difficult to culture, because one must collect, transport, and culture the sample under strict anaerobic conditions. frequently, bacterial cultures are negative when bacteria are present in peritoneal fluid. to enhance recovery of bacteria, one can inoculate peritoneal fluid into blood culture medium (septi-chek columbia, hoffmann-laroche inc., nutley, new jersey), and if the horse has received antimicrobial treatment, one first should pass fluid through an antimicrobial removal device (a.r.d., becton dickinson & co., cockeysville, maryland). early and aggressive therapy is required if treatment of peritonitis is to be successful. the goals of treatment are to resolve the primary problem, minimize the inflammatory response, and prevent long-term complications. in the acute phase, one gives primary consideration to the arrest of endotoxic, septic, or hypovolemic shock; correction of metabolic and electrolyte abnormalities and dehydration; and management of pain. in the absence of blood gas and electrolyte determinations, adequate volumes of a balanced electrolyte solution are required to correct dehydration and support the cardiovascular system. if the plasma protein concentration of the horse is less than 4.0 g/dl, one should consider administration of plasma or synthetic colloids. one should administer flunixin meglumine (banamine) for its local and systemic antiinflammatory effects. dosages vary depending on the severity of peritonitis, degree of toxemia, severity of pain, and hydration status of the horse and range from 0.25 mg/kg intramuscularly or intravenously every 6 to 10 hours to 1.0 mg/kg intramuscularly or intravenously every 12 hours. the higher dosage provides greater visceral analgesia, whereas the lower dosage is effective in modifying the effects of experimental endotoxemia. 23 in addition to analgesic and general antiinflammatory effect, flunixin meglumine may be effective in retarding adhesion formation when administered early in the acute, diffuse stage of septic peritonitis. 2 heparin therapy has been recommended to prevent adhesion formation and to render bacteria more susceptible to cellular and noncellular clearing mechanisms. in experimental models using laboratory animals, normal peritoneal fluid protein concentration is less than 1.5 g/dl. 15 protein levels between 1.5 g/dl and 2.5 g/dl can be difficult to interpret, but one should consider levels greater than 2.5 g/dl to be elevated abnormally. fibrinogen concentration increases with inflammation, and levels greater than 10 mg/dl in the peritoneal fluid suggest that an acute inflammatory process is present. 20 fibrinogen content will also increase from blood contamination. the presence of free and phagocytosed bacteria in peritoneal fluid indicates generalized suppuration, abscessation, or compromised bowel. if one observes numerous microorganisms of mixed types free in the peritoneal fluid or if one observes plant material, massive bacterial contamination of the abdomen following bowel rupture likely has occurred. the presence of toxic or degenerate neutrophils and bacteria within polymorphonuclear cells helps to distinguish peritoneal fluid from intestinal contents in such cases. enterocentesis yields discolored fluid containing mixed microorganisms and plant material and that is largely devoid of white blood cells. bacterial contamination of a sample can occur during collection of the sample, and iatrogenic contamination of a sample can result in free and intracellular bacteria in peritoneal fluid, particularly if processing is delayed. in such cases the bacterial numbers are few and the neutrophils appear healthy. in some cases of gastrointestinal perforation the luminal material, inflammatory cells, and protein may be sequestered by the omentum and further contained by fibrinous adhesions. abdominal fluid obtained via standard ventral paracentesis may have low cellularity and protein content but large numbers of mixed bacteria indicating bowel rupture. 5 examples include gastric rupture along the greater curvature of the stomach between the omental layers (omental bursa) and perforated gastric or duodenal ulcers in foals. correlating all cytologic findings with clinical and clinicopathologic findings is important for interpreting the results of peritoneal fluid cytologic examination. biochemical analysis of peritoneal fluid may be useful in detecting sepsis when cytologic examination and culture are negative or otherwise unavailable. in a prospective study by van hoogmoed, rodger, spier, et al., peritoneal fluid ph and glucose concentrations from horses with septic peritonitis were significantly lower than horses with nonseptic peritonitis and healthy horses. 21 peritoneal fluid ph less than 7.3, glucose less than 30 mg/dl, and fibrinogen concentration greater than 200 mg/dl were considered highly predictive of septic peritonitis. serum to peritoneal glucose concentration differences of greater than 50 mg/dl was considered the most diagnostically useful test for septic peritonitis in the study. increased activities of alkaline phosphatase, lactic dehydrogenase, creatine kinase, aspartate aminotransferase, tumor necrosis heparin therapy was associated with decreased adhesions in septic peritonitis. 24 heparin has not yet been demonstrated clearly to have similar efficacy in horses, although it may. suggested dosages range from 20 to 40 iu subcutaneously every 12 hours for 48 hours 4 to 40 to 80 iu/kg subcutaneously every 8 hours. 5 one should note that heparin induces red blood cell aggregation in horses, 25 which may adversely affect capillary blood flow. one should initiate antimicrobial therapy after making a diagnosis of peritonitis and before the results of peritoneal culture are available, because isolating an organism may take several days and often culture fails to isolate the organism(s). intravenous administration of antimicrobials is preferred over oral or intramuscular routes in acute, diffuse, septic peritonitis because more reliable levels of drug are achieved in the tissues and peritoneal fluid than otherwise would be obtained in horses with hypovolemia or decreased intestinal motility. 26 the combination of a β-lactam antibiotic with an aminoglycoside is appropriate in most circumstances and certainly in the acute diffuse stage of septic peritonitis. these drugs act synergistically to provide a broad spectrum of activity against a variety of gram-positive and gramnegative aerobic and anaerobic bacteria. 27 potassium penicillin (22,000 to 44,000 iu/kg intravenously every 6 hours) combined with gentamicin (6.6 mg/kg every 24 hours) is an appropriate regimen. in most cases, peritonitis will have resulted from bowel contamination, and thus one should presume a mixed infection with gram-negative aerobic bacteria and gram-positive and gram-negative anaerobic bacteria. 2 one also should presume the same in many cases of traumatic peritonitis, as occurs with foreign body puncture, breeding trauma, or foaling trauma. therefore a strong possibility exists of infection involving penicillin resistant bacteroides fragilis, so that adding metronidazole (15 mg/kg orally every 6 to 8 hours) to the regimen is prudent. combination therapy with β-lactam and aminoglycoside antibiotics (and metronidazole when indicated) is a standard and generally effective protocol. one can modify this antimicrobial regimen when culture and antimicrobial sensitivity results become available. aminoglycosides and nonsteroidal antiinflammatory drugs have the potential to induce acute renal tubular damage, particularly when dehydration and decreased renal perfusion are present. therefore adequately rehydrating the patient and ensuring that renal function is intact before initiating treatment with these drugs are important. furthermore, maintaining hydration and monitoring renal function during the course of treatment are important. monitoring serum creatinine concentration; performing serial uninalysis observing for pigment, red blood cells; and casts; determining the ratio of γ-glutamyltransferase to creatinine in the urine; and therapeutic drug monitoring 26 of aminoglycoside levels are useful in this regard. sodium ampicillin and ceftiofur sodium are β-lactam antibiotics that may be useful in combination therapy. these drugs have an extended gram-negative spectrum compared with penicillin. however, as a third-generation cephalosporin, ceftiofur is less effective against anaerobes than penicillin. one also may consider ceftiofur, trimethoprim-potentiated sulfonamides, amikacin, and enrofloxacin for treatment of gram-negative infection based on culture and sensitivity results. enrofloxacin is a quinolone drug with excellent activity against gramnegative pathogens, including pseudomonas, 27 and also can be effective against resistant staphylococci (personal observation). such staphylococci may be involved in infections caused by traumatic puncture of the abdominal wall. enrofloxacin has a variety of potential toxic effects, including cartilage damage in young growing animals. 29 however, a recent study concluded the drug was safe when administered to adult horses intravenously at 5 mg/kg every 24 hours for 3 weeks. 30 one probably should avoid using the drug in young, growing animals until the issue of cartilage damage is resolved. administration of enrofloxacin to horses constitutes off-label usage. one should treat horses with acute, diffuse, septic peritonitis with antibiotics until the white blood cell count, plasma fibrinogen, and abdominal fluid analysis are normal. in horses that respond to therapy, this process takes a variable amount of time depending on the offending organisms and stage of disease at the time treatment is initiated. horses with abdominal abscessation resulting from polymicrobial infection may require many months of antibiotic treatment. abdominal abscesses caused by streptococci and corynebacterium pseudotuberculosis also may require long-term treatment (weeks to months). long-term antibiotic treatment generally necessitates the use of oral antibiotics, and the options are limited. trimethoprim-potentiated sulfonamides are administered orally and are effective against a variety of gram-positive and gram-negative organisms, although some streptococci are resistant. metronidazole is an orally administered drug effective against anaerobic bacteria, as previously discussed. other orally administered antimicrobials one may consider for long-term use include doxycycline (broad spectrum), erythromycin (gram-positive spectrum), and enrofloxacin (mostly gram-negative spectrum). importantly, rifampin, when used with other drugs, can be effective in penetrating and resolving abscesses. combination therapy with erythromycin and rifampin is the standard treatment for rhodococcus equi infection in foals. peritonitis caused by actinobacillus equuli usually is manifested as a diffuse, supporative peritoneal exudate. 6 the same is true for some cases involving streptococci (personal observation). these infections generally respond well to combination therapy with penicillin and gentamicin. if streptococci are involved as the sole pathogen, then penicillin alone should be effective. streptococci potentially can be involved in mixed, synergistic peritoneal infections in horses. 2 drainage or lavage of the peritoneal cavity may be of benefit in removing toxic bacterial by-products and products of inflammatory cells. 31 high numbers of inflammatory cells and release of their mediators can persist even after the primary stimulus of the inflammatory response has resolved. infusing large volumes of isotonic, warmed fluid into the peritoneal cavity also dilutes the inflammatory mediators, possibly reducing their deleterious effects. when successful, peritoneal lavage decreases the peritoneal fluid wbc count and total protein, potentially reflecting a decrease in diffuse inflammation. the benefits of peritoneal lavage are controversial, and a positive effect may be more likely during the acute, diffuse stage of disease. 2, 4 some studies suggest peritoneal lavage, along with heparin therapy, may reduce the incidence of adhesions. 2 one should perform peritoneal drainage and lavage using a drain of no less than 24f diameter. foley-type catheters can be used, but "mushroom" drains provide a larger area for fluid to enter the drain. two approaches to peritoneal lavage are (1) retrograde irrigation through a ventrally placed ingress-egress drain and (2) placement of ingress catheter(s) in the paralumbar fossa(e) for infusion of fluids, with a drain placed ventrally for removal of infused fluid. one must recognize that thorough peritoneal lavage can be achieved only via ventral midline laparotomy. complications associated with the use of abdominal drains or repeated peritoneal penetration to drain fluid include retrograde infection, local irritation, pneumoperitoneum, and subcutaneous seepage around the drain and resultant cellulitis. if the patient is hypovolemic or hypoproteinemic, one should consider volume replacement and administration of plasma before removing large quantities of fluid from the abdomen. in horses with suspected parasite involvement, such as verminous arteritis, one should give larvicidal doses of an anthelmintic once the condition of the horse is stabilized. ivermectin, fenbendazole, and thiabendazole have been recommended as larvacidal therapies. visualization of auscultation sounds of the large intestine small intestinal betagalactosidase activity in the horse rectal biopsy diagnosis in horses with clinical signs of intestinal disorders: a retrospective study of 116 cases equine lymphocyticplasmacytic enterocolitis: a retrospective study of 14 cases eosinophilic enterocolitis and dermatitis in two horses breath hydrogen measurements in ponies: a preliminary study the oral glucose tolerance test in the horse small intestinal malabsorption in the horse: an assessment of the specificity of the oral glucose tolerance test transient glucose malabsorption in two horses: fact or artifact? chronic diarrhoea in adult horses: a review of 51 referred cases effect of food deprivation on d-xylose absorption test results in mares malabsorption syndromes in the horse the diagnostic value of the d-xylose absorption test in horses with unexplained chronic weight loss small intestinal malabsorption in horses effects of extensive small intestinal resection in the pony effects of extensive resection of the small intestine in the pony clinical remission of granulomatous enteritis in a standardbred gelding following long term dexamethasone administration clinical and pathophysiological features of granulomatous enteritis and eosinophilic granulomatosis in the horse inflammatory bowel disease in horses: 11 cases segmental eosinophilic colitis: a review of 22 cases chronic idiopathic inflammatory bowel diseases of the horse section 13.4 malabsorption syndromes and maldigestion: pathophysiology, assessment, management, and outcome references of critical care medicine consensus conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis sisson and grossman's the anatomy of domestic animals observational study of "urine testing" in the horse and donkey stallion oral examination and diagnosis: management of oral disease fluoroscopic investigations of swallowing in the horse esophageal dysfunction in a weanling thoroughbred cervical esophagostomy to permit extraoral feeding of the horse use of a liquid diet as the sole source of nutrition in six dysphagic horses and as a dietary supplement in seven hypophagic horses acid-base and electrolyte alterations associated with salivary loss in the pony dysphagia caused by squamous cell carcinoma in 2 horses diseases of the teeth comparative dental pathology (with particular reference to caries and paradental disease in the horse and the dog) some aspects of equine dental radiology some aspects of equine dental decay the median cleft of the lower lip and mandible and its surgical correction in a donkey sisson and grossman's the anatomy of domestic animals esophageal disorders of the horse esophageal disorders in 61 horses: results of nonsurgical and surgical management recurrent esophageal obstruction due to squamous cell carcinoma in a horse squamous cell carcinoma of the lower cervical oesophagus in a pony squamous cell carcinoma: an unusual cause of choke in a horse megaesophagus and aspiration pneumonia secondary to gastric ulceration in a foal persistent right aortic arch in a yearling horse intramural esophageal cyst in a horse surgical correction of esophageal diverticulum in a horse on the true definition of dysphagia retrieval of an esophageal foreign body in a horse dysphagia caused by squamous cell carcinoma in two horses peptic ulcer pathophysiology recommendations for the diagnosis and treatment of equine gastric ulcer syndrome (egus) gastric ulcers in horses: a comparison of endoscopic findings in horses with and without clinical signs pipers fs et al: factors associated with gastric lesions in thoroughbred racehorses cross-sectional study of gastric ulcers of the squamous mucosa in thoroughbred racehorses gastric ulceration in mature thoroughbred horses epidemiological study of gastric ulceration in the thoroughbred racehorse: 202 horses 1992-1993 endoscopic evaluation of the relationship between training, racing, and gastric ulcers prevalence of gastric ulcers in show horses postmortem findings of gastric ulcers in swedish horses older than age one year: a retrospective study of 3715 horses (1924-1996) endoscopic findings of the gastric antrum and pylorus in horses: 162 cases gastric and duodenal ulcers in foals: a retrospective study endoscopic appearance of gastric lesions in foals: 94 cases prevalence of gastric lesions in foals without signs of gastric disease: an endoscopic survey gastroduodenal ulceration in foals regional gastric ph measurement in horses and foals peptic ulcer disease in the pediatric population is helicobacter (campylobacter) pylori associated with gastritis/ulcer disease in asymptomatic foals? aetiopathogenesis and treatment of peptic ulcer in the horse: a comparative review evidence of helicobacter infection in the horse. proceedings of the society for microbiologists comparative pathophysiology of nonglandular ulcer disease: a review of experimental studies section 13.10 diseases of the stomach references 1. blackwell rb, white na: duodenitis-proximal jejunitis in the horse hemorrhagic fibrinonecrotic duodenitis-proximal jejunitis in horses: 20 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gastrointestinal side effects of oral antimicrobial agents prokinetic effects of erythromycin on the ileum, cecum, and pelvic flexure of horses during the postoperative period hypovolemic hyponatremia and signs of neurologic disease associated with diarrhea in a foal toxicology of nonsteroidal antiinflammatory drugs colitis induced by nonsteroidal anti-inflammatory drugs: report of four cases and review of the literature the effects of phenylbutazone on the intestinal mucosa of the horse: a morphological, ultrastructural and biochemical study experimentally induced phenylbutazone toxicosis in ponies: description of the syndrome and its prevention with synthetic prostaglandin e2 phenylbutazone toxicosis in the horse: a clinical study ulceration and stricture of the right dorsal colon after phenylbutazone administration in four horses phenylbutazone toxicity in a horse biochemical and haematological effects of phenylbutazone in horses medical management of right dorsal colitis in 5 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metronidazole-resistant strains equine neonatal clostridiosis: treatment and prevention antimicrobial susceptibility of ileal symbiont intracellularis isolated from pigs with proliferative enteropathy antithrombotic actions of aspirin in the horse evaluation of heparin for prophylaxis of equine laminitis: 71 cases (1980-1986) phagocytosis of gelatin-latex particles by a murine macrophage line is dependent on fibronectin and heparin cold insoluble globulin and heparin interactions in phagocytosis by macrophage monolayers: mechanism of heparin enhancement probiotics in man and animals double-blind report on the efficacy of lactic acid-producing enterococcus sf68 in the prevention of antibiotic-associated diarrhoea and in the treatment of acute diarrhoea effect of lactobacillus gg yoghurt in prevention of antibiotic associated diarrhoea comparative efficacy of moxidectin and ivermectin against hypobiotic and encysted cyathostomes and other equine parasites efficacy of oral ivermectin paste against mucosal stages of cyathostomes elimination of mucosal cyathostome larvae by five daily treatments with fenbendazole moxidectin: spectrum of activity and uses in an equine anthelmintic program references 1. laws eg, freeman de: significance of reperfusion injury after venous strangulation obstruction of equine jejunum how important is intestinal reperfusion injury in horses? clinical relevance of intestinal reperfusion injury in horses strangulating volvulus of the ascending colon in horses mucosal alterations in experimentally induced small intestinal strangulation obstruction in ponies histologic findings in the gastrointestinal tract of horses with colic large colon resection evaluation of the microcirculation of the equine small intestine after intraluminal distention and subsequent decompression mesodiverticular bands as a cause of small intestinal strangulation and volvulus in the horse induction of peritoneal adhesions with small intestinal ischaemia and distention in the foal diseases of the small intestine small intestinal herniation through the epiploic foramen: 53 cases (1987-1993) determining the diagnosis and prognosis of the acute abdomen duodenitis-proximal jejunitis risk factors and clinical signs associated with cases of equine colic short-term survival and prevalence of postoperative ileus after small intestinal surgery in horses short-and longterm survival and prevalence of postoperative ileus after small intestinal surgery in the horse survival after small intestine resection and anastomosis in horses abdominal adhesions after small intestinal surgery in the horse mesenteric rents as a source of small intestinal strangulation in horses: 15 cases (1990-1997) small intestine incarceration through the epiploic foramen of the horse right hepatic lobe atrophy in horses: 17 cases incarceration of the jejunum in the epiploic foramen of a four month old foal use of diagnostic ultrasonography in horses with signs of acute abdominal pain parietal hernia of the small intestine into the epiploic foramen of a horse transection of the pelvic flexure to reduce incarceration of the large colon through the epiploic foramen in a horse incarceration of the small intestine in the epiploic foramen: report of 19 cases pedunculated lipomas as a cause of intestinal obstruction in horses: 17 cases (1983-1990) an analysis of 75 cases of intestinal obstruction caused by pedunculated lipomas strangulation of the rectum of a horse by the pedicle of a mesenteric lipoma abdominal surgery in foals intestinal surgery in the foal effects of extensive resection of the small intestine in the pony incarceration of small intestine through rents in the gastrosplenic ligament in the horse jejunal displacement through the mesometrium in a pregnant mare strangulating obstruction caused by intestinal herniation through the proximal aspect of the cecocolic fold in 9 horses congenital inguinal hernias associated with a rent in the common vaginal tunic in five foals ruptured inguinal hernia in new-born colt foals: a review of 14 cases acquired inguinal hernia in the horse: a review of 27 cases surgical treatment of acquired inguinal hernia in the horse: a review of 51 cases different types of inguinal herniation in two stallions and a gelding surgery of the small intestine complications of umbilical hernias in horses: 13 cases strangulated umbilical hernias in horses: 13 cases (1974-1985) surgical management of intussusception in the horse ileocecal intussusception in horses: 26 cases ultrasonographic diagnosis of small-intestinal intussusception in three foals jejunal intussusception in adult horses: 11 cases ileocecal intussusception corrected by resection within the cecum in two horses diaphragmatic hernias in horses and cattle diaphragmatic hernias in the horse: a review of the literature and an analysis of six additional cases peritoneopericardial hernia in a horse diaphragmatic herniation as a cause of lethargy and exercise intolerance in a mare diaphragmatic hernia repair in three young horses surgical repair of a diaphragmatic hernia in a racehorse diaphragmatic hernias in the horse: a review of the literature and an analysis of six additional cases morphologic alterations observed during experimental ischemia of the equine large colon equine large intestinal volvulus: a review of 124 cases diseases and surgery of the large colon large colon volvulus: surgical treatment of 204 horses colopexy in broodmares: 44 cases cecocolic intussusception in horses: 11 cases (1979-1989) cecocolic and cecocecal intussusception in horses: 30 cases (1976-1996) cecal amputation via a right ventral colon enterotomy for correction of nonreducible cecocolic intussusception in 8 horses resection of intussuscepted large colon in a horse intussusception of the large colon in a horse intussusception of the left dorsal colon in a horse intussusception of the colon in a filly rectal prolapse in the horse rectal prolapse and 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of 115 cases of colic in the pregnant mare surgical management of uterine torsion in the mare: a review of 26 cases rabies in horses: 21 cases mechanisms of pain and their therapeutic implications gastrointestinal pharmacology nonsteroidal anti-inflammatory drugs the role of cyclooxygenase inhibitors in repair of ischaemic-injured jejunal mucosa in the horse alpha 2 adrenoceptor agonists in the horse: a review cardiovascular effects of medetomidine, detomidine and xylazine in horses cardiovascular effects of xylazine and detomidine in horses prognosis in equine colic: a study of individual variables used in case assessment a: study of variables commonly used in examination of equine colic cases to assess prognostic value clinical evaluation of blood lactate levels in equine colic use of clinical pathology in evaluation of horses with colic the anion gap as a prognostic indicator in horses with abdominal pain strangulating volvulus of the ascending colon in horses diseases and surgery of the large colon multivariable prediction model for the need for surgery in horses with colic prognosis in equine colic patients using multivariable analysis prognosis in equine colic: a comparative study of variables used to assess individual cases prognostic index for acute abdominal crisis (colic) in horses feeding and digestive problems in horses: physiologic responses to a concentrated meal effect of meal feeding on plasma volume and urinary electrolyte clearance in ponies evaluation of the microcirculation of the equine small intestine after intraluminal distention and subsequent decompression morphologic effects of experimental distention of equine small intestine surgical reduction of ileal impactions in the horse: 28 cases medical treatment of horses with ileal impactions: 10 cases ascarids: recent advances the purported role of coastal bermuda hay in the etiology of ileal impactions: results of a questionnaire (abstract) tapeworm infection is a significant risk factor for spasmodic colic and ileal impaction colic in the horse use of excretory/secretory antigens for the serodiagnosis of anoplocephala perfoliata cestodosis ileal impaction in the horse: 75 cases evaluation of factors associated with postoperative ileus in horses: 31 cases idiopathic muscular hypertrophy of the equine small intestine: 11 cases (1980-1991) obstruction of the ileum in the horse: a report of 27 clinical cases ileal muscular hypertrophy and rupture in a pony three years after surgery for ileocaecal intussusception jejunocolostomy or ileocolostomy for treatment of cecal impaction in horses: nine cases (1985-1995) small intestinal strangulation caused by meckel's diverticulum in a horse volvulus associated with meckel's diverticulum in the horse congenital jejunal diverticulum in a foal mesodiverticular bands as a cause of small intestinal strangulation and volvulus in the horse abdominal adhesions after small intestinal surgery in the horse induction of peritoneal adhesions with small intestinal ischaemia and distention in the foal the characteristics of intestinal injury peripheral to strangulating obstruction lesions in the equine small intestine current concepts in management of abdominal adhesions one percent sodium carboxymethylcellulose prevents experimentally induced abdominal adhesions in horses effect of carboxymethylcellulose and a hyaluronate-carboxymethylcellulose membrane on healing of intestinal anastomoses in horses intraperitoneal use of sodium carboxymethylcellulose in horses undergoing exploratory celiotomy prevention of intraabdominal adhesions in ponies by low-dose heparin therapy retrospective analysis of the results of 151 exploratory laparotomies in horses with gastrointestinal disease surgical treatment for colic in the foal retrospective evaluation of repeat celiotomy in 53 horses with acute gastrointestinal disease risk factors for reduced postoperative fecal output in horses: 37 cases (1997-1998) role of inducible nitric oxide synthase in postoperative intestinal smooth muscle dysfunction in rodents surgically induced leukocytic infiltrates within the rat intestinal muscularis mediate postoperative ileus surgical manipulation of the gut elicits an intestinal muscularis inflammatory response resulting in postsurgical ileus pathophysiology of equine postoperative ileus: effect of adrenergic blockade, parasympathetic stimulation and metoclopramide in an experimental model the effect of prostaglandin e1 on motility of the equine gut in vitro investigation of the effect of prostaglandins and nonsteroidal antiinflammatory drugs on contractile activity of the equine smooth muscle of the dorsal colon, ventral colon, and pelvic flexure evaluation of nitric oxide as an inhibitory neurotransmitter in the equine ventral colon prostanoid production via cox-2 as a causative mechanism of rodent postoperative ileus the action of low dose endotoxin on equine bowel motility sir frederick hobday memorial lecture: all wind and water-some progress in the study of equine gut motility antagonism of endotoxin-induced disruption of equine bowel motility by flunixin and phenylbutazone cyclooxygenase inhibitors in equine practice in vitro effects of erythromycin, lidocaine, and metoclopramide on smooth muscle from the pyloric antrum, proximal portion of the duodenum, and middle portion of the jejunum of horses efficacy of metoclopramide for treatment of ileus in horses following small intestinal surgery: 70 cases (1989-1992) role of the enteric nervous system in the fluid and electrolyte secretion of rotavirus diarrhea prokinetic effects of erythromycin on the ileum, cecum, and pelvic flexure of horses during the postoperative period cecal impaction in the horse caecal disease in equids ileocolostomy: a technique for surgical management of equine cecal impaction diseases and surgery of the cecum treatment of impaction colics large colon impaction in horses: 147 cases (1985-1991) effects of amitraz, several opiate derivatives and anticholinergic agents on intestinal transit in ponies experimental studies of druginduced impaction colic in the horse retropulsion-propulsion in equine large colon clinical and structural features of equine enteroliths petrographic and geochemic evaluation of equine enteroliths enteroliths in horses evaluation of enterolithiasis in equids: 900 cases risk factors for enterolithiasis among horses in texas obstructive enterolith in an 11-month-old miniature horse surgical treatment of sand colic in equids: 48 cases (1978-1985) surgical treatment of sand colic: results in 40 horses diarrhea associated with sand in the gastrointestinal tract of horses abdominal auscultation in the detection of experimentally induced gastrointestinal sand accumulation failure of psyllium mucilloid to hasten evaluation of sand from the equine large intestine nonstrangulated colonic displacement in horses functions of the equine large intestine and their interrelationship in disease comparisons of age, breed, history and management in 229 horses with colic motor functions of the intestine the effect of strongylus vulgaris larvae on equine intestinal myoelectrical activity displacement of the large colon reversal of colonic net absorption to net secretion with increased intraluminal pressure use of ultrasound in horses for diagnosis of left dorsal displacement of the large colon and monitoring its nonsurgical correction renosplenic entrapment of the large colon in horses: 33 cases renosplenic entrapment of the large colon in horses: 57 cases further experiences with non-surgical correction of nephrosplenic entrapment of the left colon in the horse effect of phenylephrine on hemodynamics and splenic dimensions in horses displacement of the large colon associated with nonsurgical correction of large-colon entrapment in the renosplenic space in a mare foreign body obstruction of the small colon in six horses fecalith impaction in four miniature foals obstruction of the small colon by intramural haematoma in three horses submucosal haematoma as a cause of obstruction of the small colon in the horse: a review of four cases inflammatory bowel disease in horses: 11 cases intestinal atresia in horses clinical survey of tumours and tumourlike lesions in horses in south east queensland abdominal neoplasia (excluding urogenital tract) clinical manifestation of squamous cell carcinoma in horses lymphoma (lymphosarcoma) in horses oral and dental tumors in equine denistry t cell-rich b cell lymphosarcoma in the tongue of a horse multiple myeloma in a horse rhabdomyosarcoma of the tongue in a horse paraneoplastic bullous stomatitis in a horse gastric squamous cell carcinoma in three horses use of esophagoscopy in the diagnosis of esophageal squamous cell carcinoma in a horse gastric hyperplastic polyp in a horse gastric leiomyosarcoma in a horse multisystemic, eosinophilic, epitheliotropic disease with intestinal lymphosarcoma in a horse an immunohistochemical study of equine b-cell lymphoma squamous cell carcinoma of the equine stomach: a report of five cases six cases of squamous cell carcinoma of the stomach of the horse small intestinal adenocarcinoma in a horse ganglioneuroma as a cause of small intestinal obstruction in the horse: a case report intestinal carcinoid in a mare: an etiologic consideration for chronic colic in horses leiomyoma of the small intestine in a horse jejunal intussusception associated with leiomyoma in an aged horse duodenal leiomyoma associated with colic in a two-year-old horse leiomyosarcoma of the duodenum in two horses pedunculated lipomas as a cause of intestinal obstruction in horses: 17 cases (1983-1990) clinical aspects of lymphosarcoma in the horse: a clinical report of 16 cases multiple peripheral nerve sheath tumors in the small intestine of a horse equine adenocarcinomas of the large intestine with osseous metaplasia intestinal myxosarcoma in a thoroughbred mare gastrointestinal stromal tumors of the equine cecum colonic adenocarcinoma with osseous metaplasia in a horse intestinal adenocarcinoma causing recurrent colic in the horse equine colonic lipomatosis large colon resection for treatment of lymphosarcoma in two horses colic in a mare caused by a colonic neurofibroma small colon intussusception associated with an intralumenal leiomyoma in a pony leiomyoma of the small colon in a horse an analysis of 75 cases of intestinal obstruction caused by pedunculated lipomas rectal leiomyosarcoma in a horse strangulation of the rectum of a horse by the pedicle of a mesenteric lipoma rectal biopsy diagnosis in horses with clinical signs of intestinal disorders: a retrospective study of 116 cases standing rectal and tail surgery disseminated peritoneal leiomyomatosis in a horse ascites as a result of peritoneal mesotheliomas in a horse a case of peritoneal mesothelioma in a thoroughbred mare omental fibrosarcoma in a horse neoplasia of the mouth and surrounding structure pleuroscopic diagnosis of gastroesophageal squamous cell carcinoma in a horse recurrent esophageal obstruction due to squamous cell carcinoma in a horse chronic colic in the mature horse: a retrospective review of 106 cases recurrent colic in the mature horse: a retrospective review of 58 cases paraneoplastic syndromes lymphosarcoma and associated immune-mediated hemolytic anemia and thrombocytopenia in horses differentiation of chronic lymphocytic leukemia in the horse: a report of two cases hypercalcemia associated with malignancy in a horse adenocarcinoma of intestinal origin in a horse: diagnosis by abdominocentesis and laparoscopy differentiation between intra-abdominal neoplasms and abscesses in horses, using clinical and laboratory data: 40 cases (1973-1988) malabsorption in the horse associated with alimentary lymphosarcoma immunodeficiency associated with lymphosarcoma in a horse flow cytometric methods to diagnose selected equine immune-mediated disorders pleural effusion associated with squamous cell carcinoma of the stomach of a horse use of diagnostic ultrasonography in horses with signs of acute abdominal pain the indications for equine laparotomy: an analysis of 140 cases equine lymphosarcoma diarrhoea in the horse as a result of alimentary lymphosarcoma paraneoplastic pruritus and alopecia in a horse with diffuse lymphoma lymphoma in the horse. proceedings of the twelfth annual meeting of the american college of veterinary internal medicine squamous cell carcinoma of the pharyngeal wall in a horse squamous cell carcinoma of the oral, pharyngeal and nasal mucosa in the horse treatment of superficial ulcerative squamous cell carcinoma in three horses with topical 5-fluorouracil intratumoral chemotherapy with cisplatin in oily emulsion in horses excision of oral squamous cell carcinoma in a horse extensive resection and anastomosis of the descending (small) colon in a mare following strangulation by a mesenteric lipoma section 13.17 peritonitis references 1. hosgood g: peritonitis. 1. a review of the pathophysiology and diagnosis the peritoneum and peritoneal cavity large animal internal medicine diseases of the peritoneum and mesentery equine internal medicine peritonitis associated with actinobacillus equuli in horses: 51 cases veterinary gastroenterology peritonitis and other intra-abdominal infection antibiotic susceptibility of bacterial pathogens from horses peritonitis in horses: 67 cases biologic reactions to endotoxin effect of dietary alpha-linoleic acid on equine monocyte procoagulant activity and eicosanoid synthesis review of 30 cases of peritonitis in the horse reference values for equine peritoneal fluid diagnostic cytology in the equine species: overview of effusions (peritoneal, pleural, and synovial joint) and transtracheal wash effects of enterocentesis on peritoneal fluid constituents in the horse internal abdominal abscesses in the horse: a study of 25 cases equine peritoneal fluid analysis following celiotomy analysis of equine peritoneal fluid evaluation of peritoneal fluid ph, glucose concentration, and lactate dehydrogenase activity for detection of septic peritonitis in horses tumor necrosis factor and interleukin-6 activity and endotoxin concentration in peritoneal fluid and blood of horses with acute abdominal disease low dose flunixin meglumine: effects on eicosanoid production and clinical signs induced by experimental endotoxemia in horses heparin in the treatment of experimental peritonitis erythrocyte agglutination associated with heparin treatment in three horses therapeutic strategies involving antimicrobial treatment of large animals with peritonitis effect of long-term administration of injectable enrofloxacin solution on physical and musculoskeletal variables in adult horses peritoneal lavage in the horse pharmacologic principles therapeutic drug monitoring: a tool for rational drug therapy. proceedings of the seventh american college of veterinary internal medicine forum toxicity of quinolones although a number of potential causes of peritonitis exist, sepsis is a common and serious complication, and the identification and control of bacterial sepsis is critical for a successful outcome. bowel leakage (as well as external trauma) results in contamination of the peritoneum with large numbers of many types of bacteria. the intestinal tract contains a mixed population of bacteria, and the quantity of bacteria and prevalence of anaerobic species increase in the distal segments. [1] [2] [3] [4] [5] [6] [7] there are approximately 1 × 10 9 anaerobic and 1 × 10 5 aerobic bacteria per milliliter of cecal and colonic fluid, thus the potential for bacterial contamination of the peritoneum is great. high mortality is associated with contamination from the lower bowel because of the large numbers of bacteria present. 8 hirsch and jang 9 reported isolation of an infective agent from equine peritoneal fluid in approximately 25% of attempts. obligate anaerobic bacteria were cultured most frequently, followed by members of the enterobacteriaceae family (escherichia coli). penicillin-resistant bacteroides fragilis was isolated from 10% to 20% of cases. in another study in which bacteria were identified in equine abdominal fluid by cytologic examination or culture, e. coli was the organism most commonly isolated. 10 in human beings and laboratory animals the well-established fact is that despite the variety of organisms initially introduced subsequent to these events, established infections are characterized by only a few types of bacteria, which are often gram-negative aerobes and anaerobic bacteria. 2 this selectivity occurs through the processes of selective reduction of bacterial populations and bacterial synergism. a well-known example of synergism in human beings and laboratory animals is peritonitis involving e. coli and b. fragilus. the presence of each organism is beneficial to the survival of the other, and each is important in the overall pathogenesis of the disease. e. coli is associated with septicemia and early mortality, whereas b. fragilis infection tends to result in chronic abscessation with delayed morbidity and mortality. some evidence suggests that in horses, in addition to coliforms and anaerobes, streptococci and perhaps c. psuedotuberculosis may survive selective reduction and participate in synergistic infection following polymicrobial contamination.biologic events resulting from contamination of the abdomen or injury to the mesothelial cells have been described [1] [2] [3] [4] and include release of catecholamines, histamine, and serotonin from peritoneal mast cells; vasodilation and hyperemia; increase in peritoneal vascular permeability; secretion of protein-rich fluid into the peritoneum; transformation of mesothelial cells into macrophages; and influx of polymorphonuclear cells, humoral opsonins, natural antibodies, and serum complement into the peritoneal cavity. additionally, depression of the peritoneal fibrinolytic activity, fibrin deposits on the peritoneal surface, and sympathetic-mediated ileus of the gastrointestinal tract can occur.these processes benefit the animal by confining contamination and infection, and indeed, with clean, minimally invasive procedures such as enterocentesis or trocharization, this is effective. however, with greater severity of peritoneal contamination or irritation, these processes are magnified and become deleterious, resulting in problems such as hypovolemia, hypoproteinemia, ileus with resultant bowel distention, ischemia of the bowel wall with subsequent absorption of bacteria and toxins, and ultimately adhesion and abscess formation. additionally, systemic responses to bacterial toxins, particularly lipopolysaccharide, 11, 12 can compromise the metabolic condition of the patient further. equine peritoneal macrophages release several mediators when exposed to bacterial lipopolysaccharide, 13 undoubtedly an important component of septic peritonitis.pathologic description of peritonitis includes origin (primary or secondary), onset (peracute, acute, chronic), distribution (localized versus diffuse), and presence of bacteria (septic versus nonseptic). 3, 4 clinically, viewing key: cord-001221-due9tloa authors: nan title: ecr 2014, part a date: 2014-02-27 journal: insights imaging doi: 10.1007/s13244-014-0316-6 sha: doc_id: 1221 cord_uid: due9tloa nan percutaneous needle biopsy has been a mainstay of oncologic diagnosis for almost three decades, since the advent of ultrasound and ct. the basic principles of fine-needle aspiration and core needle biopsy can be applied to almost any site in the body, with subtle differences in technique depending on the organ being investigated and the imaging modality utilised. while excisional biopsy is still appropriate in certain cases, percutaneous needle biopsy has become the standard of care in the diagnosis of most tumors throughout the body and is also used to diagnose noncancerous conditions, such as infection. percutaneous biopsy is also beneficial in the staging of patients with cancer, particularly when another treatment method may be more appropriate than surgical resection. the advantages of percutaneous biopsy over surgical excisional biopsy include time and cost savings and reduction in morbidity. the aim of this course is to discuss the practical aspects of biopsy, needle selection, and guidance techniques and to show how to approach difficult lesions and avoid complications. imaging after treatment of breast cancer is for confirmation of lesion removal, identification of postprocedural fluid collections, detection of residual or recurrent cancer and screening for metachronous cancers. posttherapy changes -which include fluid collections, edema, skin thickening, architectural distortion, scarring and calcifications -are mainly due to surgery, axillary dissection and radiotherapy. the greatest treatment-related changes occur 6-12 months after therapy, and mammographic stability is achieved after two to three years. for mammography, pre-and all posttherapeutic images have to be compared. ultrasound is the method of choice for evaluation of fluid collections. mri is for problem solving (i.e. differentiation between scar and relapse) and should not be performed prior to 12 months after therapy to avoid false-positive diagnoses. dystrophic calcifications may develop in areas of fat necrosis mimicking malignancy. fat necrosis predominantly occurs at the treated site; however, it can develop anywhere in the ipsilateral breast. its appearance may be indistinguishable from cancer at all imaging modalities. to differentiate between fat necrosis and other common post-treatment changes from relapse, it is important to know the timeline when these changes occur and schedule follow up imaging accordingly. mammography serves as the basis for postoperative surveillance. ultrasound is helpful in the early postoperative phase, whereas mri is the method of choice, especially for differentiation of scar and relapse in the later postoperative phases. breast radiologists need to be familiar with post-treatment imaging findings in patients with breast cancer, but often patients are also imaged after a diagnosis of benign entities which are treated surgically (fibroadenomas, radial scars, papillary lesions) or after a percutaneous diagnosis of a high-risk lesion which has undergone a surgical biopsy to avoid underestimation (atypical ductal hyperplasia, lobular neoplasia or flat epithelial atypia). these procedures will leave an imprint on the breast which can be a cause of concern due to the surgical scar. furthermore, imaging findings after plastic surgery for mastopexy, reduction mastoplasties, implants or auxiliary techniques (lipofilling, hyaluronic acid) are becoming frequent in our daily practice and have their peculiarities that can overshadow breast cancers. interventional percutaneous procedures can also be a cause of tissue distortion. there are advanced systems for biopsy (bles) and for percutaneous removal of benign lesions (fibroadenomas, papillomas), which use large-gauge needles and have to be accounted for due to their trace in the breast tissue. endoscopy is currently considered the reference standard for the evaluation of colonic disease activity in patients with inflammatory bowel disease (ibd). however, it only allows evaluation of the mucosal surface and is not always complete. it cannot, therefore, help to estimate the depth of involvement of transmural inflammation and extraluminal complications, both characteristics of ibd. an evolving role for cross-sectional imaging in the evaluation of patients with ibd is increasingly recognised, especially in the setting of crohn's disease (cd) since the cross-sectional imaging has been demonstrated to have a high diagnostic accuracy not only for assessing the presence and extension of luminal disease, but also for evaluating the cd-related acute or chronic complications. available evidence suggests that ultrasound, computed tomography and magnetic resonance have similarly high diagnostic accuracy in the detection of disease activity, location, severity and complications: in particular, the penetrating and stricturing lesions which are characteristic of cd. thus, the choice of the technique for assessing cd may be influenced by local availability or expertise. in the case of ulcerative colitis, cross-sectional imaging, although less evaluated, may also be helpful in certain circumstances. there is evidence indicating that cross-sectional imaging is an alternative problem-solving tool to endoscopy whenever tissue sampling is not required and can provide valuable guidance for performing medical and surgical treatment with maximised efficacy and safety. overall, findings from crosssectional imaging accurately reflect disease activity and provide reliable information for decision-making and patient care optimisation. learning objectives: 1. to learn about optimised examination protocols for ulcerative colitis and colonic crohn's disease in the acute, subacute and chronic disease setting. 2. to become familiar with the criteria for the assessment of disease activity through ct, mri and ultrasound. 3 . to learn about an integrated approach to the use of cross-sectional imaging in colonic inflammatory bowel disease. liver transplantation is the accepted treatment of patients with irreversible liver cell failure and some metabolic disorders and in a selected group of patients with hepatocellular carcinomas. over the last decade, major transplant centres have reported improving survival rates, though during this period they have developed more complex surgical techniques, including split-liver, auxiliary and live-related transplantation, and have treated more marginal higher risk patients. this successful outcome has been dependent on appropriate recipient selection, robust surgical technique, improvements in immunosuppression and intensive care management and the prompt recognition and treatment of complications. diagnostic and interventional radiology have been core specialties in achieving the goals of improved graft and patient survival. improvement in surgical techniques has decreased the more common vascular and biliary complications, but the newer techniques present differing diagnostic and interventional challenges, particularly in paediatric recipients. developments in mr and mdct allow many of these vascular, biliary and infective complications to be diagnosed non-invasively. vascular techniques of angioplasty and stent placement may reverse the sequel of graft ischaemia or portal hypertension. mrc allows the diagnosis of biliary strictures that may be treated by dilatation or stent placement. imaging is also important in the diagnosis of recurrent disease and the acquired diseases of prolonged immunosuppression including atypical infections and the post-transplant lymphoproliferative disorders (ptld). this interactive session will present these appearances by case example and provide guidance of the appropriate diagnostic and treatment paradigm. learning objectives: 1. to understand the common imaging findings after liver transplantation. 2. to recognise significant complications following liver transplantation. a-010 16:45 b. imaging of treated liver tumours i. bargellini; pisa/it (irenebargellini@hotmail.com) imaging findings after systemic and loco-regional treatments vary greatly depending on baseline features of the treated tumour and treatment modality. conventional uni-dimensional and bi-dimensional criteria (such as recist 1.1 and who criteria) have been extensively validated in metastatic lesions treated with conventional chemotherapy. however, their prognostic value is limited in patients treated with new molecular targeted therapies and after locoregional treatments. in the setting of hepatocellular carcinoma (hcc), specific response criteria (such as easl and mrecist) have been proposed that take into account variation in the size of the viable tumour. these criteria have been extensively validated, although their interpretation could be troublesome after some specific treatments, such as molecular targeted agents and y90radioembolisation. on the other hand, there is no consensus regarding tumour response criteria for metastatic lesions after loco-regional treatments. the role of morphological criteria and several imaging biomarkers (such as those provided by diffusion and perfusion imaging, fdg activity, dual source ct) is under investigation, being able to provide additional information on tumour activity and biology. while new drugs with different mechanisms of action and new treatments are becoming available, the work of radiologists is changing and there is increasing evidence that tailored radiological response criteria are required for these new targeted and tailored treatments. learning objectives: 1. to understand the common imaging findings after chemotherapy for liver tumours. 2. to recognise common imaging findings after radiofrequency ablation of liver tumours. 3. to be aware of the common imaging findings following transarterial treatment of liver tumours. vessel size is practical, since it is related to the pathological changes as well as to the clinical and radiological presentation. the two main large vessel vasculitides are giant cell arteritis and takayasu arteritis. behcet disease may combine large and small vessel vasculitis. imaging plays an important role in primary vasculitis. chest radiographs are not especially useful in large vessel vasculitis. contrast ct and mri further detect and especially help in the characterisation of large vessel vasculitis. vessel wall changes are well detected with both techniques. contrast enhancement, distribution of vessel involvement and morphological vascular changes should be considered. today, pet/ct is the recommended imaging technique in the assessment of vessel wall inflammatory changes and in the evaluation of treatment response. although the clinical scenario differs usually between takayasu and giant cell arteritis, the radiologist should combine the imaging findings with clinical and laboratory data to suspect a specific vasculitis. therefore, this presentation will concentrate on the basic signs and associated findings in large vessel vasculitis, pathologic correlation, imaging protocols and the differential diagnosis. the term vasculitis refers to a variety of clinico-pathological entities. the most widely used chapel-hill classification divides the vasculitis syndromes into three groups based on the size of vessels primarily involved. small vessel vasculitis such as anca-associated granulomatous vasculitis (wegener's disease), churg-strauss granulomatosis and microscopic polyangitis are most often associated with pulmonary abnormalities. the spectrum of hrct findings is quite variable and differs by entity. the hrct findings will be discussed together with clinical and laboratory findings to be integrated into a multidisciplinary diagnostic approach. the typical findings in wegener's granulomatosis include solitary or multiple, often cavitary nodules or masses, or focal or diffuse consolidations, churg strauss is dominated by interlobular thickening or transient multifocal and nonsegmental consolidations frequently in subpleural distribution. all types of pulmonary vasculitis may present with focal or diffuse pulmonary haemorrhage that produces pulmonary ground glass or consolidations in various distributions. a number of collagen vascular diseases (e.g., lupus erythematosus) or other granulomatous diseases (e.g. sarcoidosis) may affect the small pulmonary vessels causing haemorrhage or pulmonary hypertension. per disease entity, the course will review typical and more rare hrct features and key features that allow for diagnosis and classification, discuss side-to-side overlapping of morphologic features important for differential diagnosis and illustrate the findings of other diseases that represent the most challenging differential diagnosis, e.g. oedema, infection or malignant diseases. learning objectives: 1. to learn when hrct is of value in investigating pulmonary vasculitis. 2. to appreciate the different appearances of pulmonary vasculitis on hrct. a-014 17:07 d. inflammation and remodeling a.a. bankier; boston, ma/us (abankier@bidmc.harvard.edu) the presentation will lay out the pathological and pathophysiological basis for the complex processes of inflammation and remodelling. the implications of these processes for imaging will be discussed and illustrated by selected pathologies. finally, the presentation will indicate how the imaging reflections of these processes could be used in the future as imaging biomarkers for the diagnosis, follow-up, and outcome evaluation of disease. at (marcus.hacker@meduniwien.ac.at) appropriate diagnosis and therapy of coronary artery disease (cad) frequently require information about both the morphological and functional status of the coronary artery tree. thus, combined imaging consisting of invasive coronary angiography (ica) plus spect myocardial perfusion imaging (mpi) is practiced in clinical routine diagnostic of patients with stable angina since many years and can therefore be accepted as the reference standard in the diagnosis of hemodynamically relevant coronary artery stenoses. both morphological and functional information are mandatory for the decision of performing an interventional therapy or initiating/maintaining medical treatment in numerous symptomatic patients. the hemodynamically relevance of coronary artery lesions is a major condition to decide whether an interventional therapy should be performed or not. a non-invasive concept providing both information could provide accurate allocation of perfusion defects to their determining coronary lesion and specific morphological and functional classification of patients with coronary artery disease. in symptomatic patients, a normal stress mpi confers a very low short-term risk for cardiac death and/or acute myocardial infarction. however, a normal mpi does not exclude the presence of underlying coronary atherosclerosis, which may be extensive although not yet flow-limiting. in this regard, ct will unmask a sizeable subgroup of patients with coronary atherosclerosis who should receive more intensive antiatherosclerotic intervention than would have been indicated by mpi results alone. knowledge regarding the presence and extent of subclinical coronary atherosclerosis in patients who do not have ischemia by mpi can be of importance in patient management. learning objectives: 1. to appreciate the scope of information a spect/ct cardiac study can deliver. 2. to become familiar with protocols of spect/ct studies. 3. to learn a structured approach to performing and reporting a spect/ct study. a-017 17:00 c. mr/pet: do we really need it? h.h. quick; erlangen/ de (harald.quick@imp.uni-erlangen.de) following pet/ct and spect/ct, mr/pet hybrid imaging is the most recent addition to the palette of hybrid imaging modalities. mr/pet synergistically combines the excellent soft tissue contrast and detailed image resolution of mr with metabolic information provided by pet. integrated mr/pet systems furthermore offer the ability to acquire hybrid imaging data simultaneously. this can be applied to mr-based motion correction of pet data. these features open up several cardiac applications, e.g. evaluation of cardiac function and viability, diagnosis of cardiac inflammatory diseases and tumorous diseases. to fully assess the diagnostic potential of mr/pet, however, several technical challenges have to be considered: attenuation correction (ac) of the patient tissues in mr/pet has to be based on mr-images and is currently hampered by a limited number of tissue classes and undercorrection of bone tissue. cardiac radiofrequency coils and ecg gating equipment are currently not considered in ac. consequently, quantification of pet data therefore might be biased. the clinical workflow is rather complex and needs to be tailored to cardiac examinations. few research groups currently explore this new hybrid imaging modality in selected cardiac applications. cardiac mr/pet: do we really need it? considering the sparse clinical experience that is available today, it is quite early to answer this question yet. however, once the remaining technical hurdles are overcome and the diagnostic potential can be fully exploited clinically, the answer is most likely positive. the majority of malignant bone tumours can be detected on plain radiography. the age of the patient, location of the tumour in a bone and history of a preexisting bone abnormality should be included in determining the likely diagnosis. careful analysis of the pattern of bone destruction, periosteal reaction and matrix mineralisation allow for characterisation of most cases of osteosarcoma, ewing's sarcoma, chondrosarcoma and adamantinoma. mri is the best imaging technique for staging by displaying 1. the extent of bone marrow involvement, including epiphyseal infiltration and skip lesions, 2. the presence and extent of extraosseous soft tissue mass, 3. involvement of the neurovascular bundle, muscle compartments and adjacent joint. this allows to find the best biopsy approach and establish the feasibility of limb salvage as opposed to amputation. longitudinal non-contrast t1 sequences are the most accurate for determining intraosseous extent. axial fat-suppressed pd or t2 sequences optimally demonstrate soft tissue extension, and dynamic contrastenhanced mri is useful for differentiation of extraosseous tumour from edema and for assessment of tumour response to chemotherapy. chest ct is the most sensitive modality for detection of pulmonary metastases, and technetium skeletal scintigraphy is still frequently used for detection of osseous metastases. the most valuable, readily available and easy-to-use techniques to assess response to radiation therapy and chemotherapy are dynamic contrast-enhanced mr imaging, diffusion mri and colour-doppler ultrasound. to evaluate local control of disease and for detection of local recurrence, mri is usually the best imaging technique. plain radiography may detect complications of prosthesis. learning objectives: 1. to consolidate knowledge on malignant primary bone tumors on plain radiography, ct and mri. 2. to understand the principles of tumour staging and monitoring chemotherapy. 3. to become familiar with imaging findings following chemotherapy and surgery. oncologic approach to malignant primary bone tumours c. dhooge; ghent/be (catharina.dhooge@ugent.be) the most common bone sarcomas are osteosarcoma (os) and ewing sarcoma. os occurs primarily in long bones, ewing sarcoma occurs also in the pelvis, spine or chest wall. localised disease confers a 65% cure rate, and initially metastatic disease 25%. a multidisciplinary approach which includes neo-adjuvant systemic chemotherapy and local control measures for primary and metastatic sites followed by adjuvant chemotherapy has become the standard of care. complete surgical excision is mandatory in os; in ewing, radiation can also be used. standard chemotherapy for os is based on a combination of cisplatin, doxorubicin and high-dose methotrexate. ifosfamide and etoposide will be further considered (euramos). systemic therapy for ewing includes vincristine, doxoribicin, cyclofosfamide, ifosfamide and etoposide. high-dose chemotherapy with autologous stem cell reinfusion is evaluated in intermediate prognosis and metastatic disease (euro-ewing). among the different prognostic factors, response to neo-adjuvant chemotherapy by measuring chemotherapy-induced necrosis is a powerful indicator of outcome in bone sarcomas. patients who achieve a good histological response to pre-operative chemotherapy, defined as < 10% viable tumour at the time of tumour resection, have a better survival than those who show poor response (>= 10% viable tumour). five-year survival for good responders is 7o-75% compared to 45-50% for poor responders. however, the outcome for malignant bone tumours has improved little in the last 25 years. large international studies exploring new drugs such as biologic agents (interferon) or mechanisms conferring drug resistance (topoisomerase inhibitors) in randomised controlled trials will hopefully lead to therapeutic innovation. learning objectives: 1. to become familiar with the principles of chemotherapy in malignant primary bone tumours. 2. to understand what the oncologist expects from the radiologist. 3 . to recognise the value and limits of chemotherapy in malignant primary bone tumours. thursday a-024 16:45 surgical approach of malignant primary bone tumours g.m.l. sys; ghent/be (gwen.sys@ugent.be) in primary malignant bone tumours, three surgical procedures are necessary: biopsy, resection and reconstruction. whether a biopsy is performed in an open or a percutaneous way is a matter of preference, but in each case it should provide sufficient and representative material for pathological investigation without compromising the following treatment. the area of interest and the trajectory should be determined preoperatively in a multidisciplinary meeting. as the biopsy tract has to be removed during the resection surgery, it should be close to the planned approach for the subsequent resection. if a biopsy is performed improperly, the diagnosis may be wrong or the following resection may be impaired because of extensive contamination of compartments, resulting in a severe functional deficit. surgery planning is based on clear imaging and a multidisciplinary discussion of tumour extension, aiming for a wide resection of the tumour with clear margins. correct perioperative measurements are based on predefined fixed bony landmarks that should preferably be visible on the same image as the tumour. an amputation is performed if a surgical limb-salvage procedure is expected to result in a non-functional limb. nowadays, several reconstruction techniques for bones (bone grafts or prostheses), tendons (artificial or human ligaments) and skin (skin flaps or grafts) are available. invasion of the soft tissues such as the neurovascular structures, muscles and skin, will determine which reconstruction technique (s) are necessary to restore the patient's function. each reconstruction technique bears inherent complications requiring a regular follow-up. we outline the current opportunities and threats in diagnostic radiology: traditional diagnostic radiology has been rapidly replaced by clinical radiology and the role of the radiologist is changing from image interpreter to clinical manager of imaging data. to care for the patient`s medical problem and not only his images is important. this contains great opportunities for radiology to develop and for the radiologist to become a central player in patient management. however, this requires not only clinical knowledge and involvement, but also visibility and sometimes even 24/7 availability. the need for " only" image reporting is declining as clinical subspecialisation easily brings image interpretation into the domain of non-radiologists. to understand the importance of identity, visibility is very important. visibility can be achieved by being part of mdt s and also in many other ways. clinical radiology is an idea which, after all these years, has not been very well embedded in current radiology and radiology training. to understand the importance of certified training, maybe the most important action we have to undertake now is to capitalise on our radiological expertise. image interpretation in a clinical context can only be done or franchised (to non-radiologist) under conditions of certification and accreditation by radiology. we should never let the primate of education and certification slip to non-radiologists. radiology certification should be a quality standard, recognised by international and national medical bodies, such as medical chambers and specialist societies. the latter should have high priority. session objectives: 1. to learn about the current opportunities and threats in diagnostic radiology. 2. to understand the importance of identity. 3. to acknowledge the importance of certified training. where are the turf battles in diagnostic imaging? g.m. bongartz; basle/ch (georg.bongartz@usb.ch) turf battles in radiology are a foreseeable development for most imaging techniques which evolve push-button methods and readily interpretable imaging results. we as radiologists must learn to accept competition. turfs should rather be seen as challenge than as threat. predominantly, nonirradiating techniques like ultrasound and mri have become progressively easier to apply (us) or to understand (mri), where the final image in some standardised areas (eg joints) can readily be interpreted by medical specialists in this field. but also x-ray diagnostics in dental medicine or orthopedic imaging is largely applied outside the radiologic department. ct today seems still relatively excluded because of its complexity. but with increasing resolution, optimal 3d reconstruction and fast accessibility, it is only a question of time when the added value of the radiologist will be under question. radiology has changed. we must become experts with respect to patho-anatomy and radiological differential diagnosis. this requires profound education, both initial training and ongoing education. radiology must be advertised internally and externally. in radiological publications, outcome studies are still underrepresented. demonstration of our dedicated skills, fostering our special expertise and offering this as support to our medical colleagues will preserve radiology for the future. cooperation with partners seems the only way out of a turf battle -we need to search for alliances and integrate our partners to create a win-win situation. a-027 16:23 beating threats in europe with radiological training a.k. dixon; cambridge/uk (akd15@radiol.cam.ac.uk) by introducing radiology to medical students, it is hoped that they will begin to appreciate how difficult it is! likewise, when teaching residents, they must come to understand the basic anatomy and principles better than their clinical colleagues; this is very much the tenet of subspecialty training. they should also appreciate that patient care is optimal when there is close collaboration between clinicians and radiologists. passing of an examination (national or edir) offers some proof that a radiologist has attained a certain standard, but the principle of testing oneself formally or informally at regular intervals again provides a measure of continuing competence. such certification can be of value in the case of litigation. radiology is one of the fastest growing specialties and the techniques that we learn during training are quickly outdated; hence, the need for life-long learning and effective continuing professional development. learning objectives: 1. to understand how to teach radiology to undergraduate medical students. 2. to become familiar with the principles of self-assessment. 3 . to appreciate the necessity for life-long learning. history of ultrasound in radiology: lessons learned l.e. derchi; genoa/ it (derchi@unige.it) the relationship between radiology and us has never been an easy love story, and still isn't. in the early 1970s this new imaging field was not readily covered by radiologists and many other colleagues established us sections within their departments. then, important fields of us (cardiology, obstetrics, gynecology) became almost exclusive domain of non-radiologists. in the 1980s, the increasing success of us initiated turf battles with other clinicians. nowadays, clinical specialists perform > 50% of us examinations wordwide. in europe, most in-hospital us examinations is still performed in radiology, but this is not the case in all countries. a strong practice in us is quite important since this is often the first approach to patients. if initial us referrals are kept, radiologists will continue to guide decisions in subsequent imaging workup. furthermore, us keeps close to patients; in europe the examination is usually done directly by radiologists or, if by sonographers, the radiologist usually checks the case with limited directed us imaging. this clearly shows our role as physicians. to maintain a key role in us radiologists need to: 1) have the best specialists in us; attention must be given to us in residency programs. 2) invest in us technology (as examples: ceus, elastography, 3d/4d). 3) invest in us research. 4) have high visibility in the us community, keeping close contact with all clinical colleagues. 5) present higher visibility of us within radiology, with leaders supporting us within the radiological community and each radiologist promoting us in his/her environment. learning objectives: 1. to understand why ultrasound has moved out of the hands of radiology in some subspecialties. 2. to learn what this means for daily radiology practice and the quality of work. 3 . to know about the threats and how we should deal with them. thursday a-029 16:59 interdisciplinary cooperation without losing identity m.f. reiser; munich/de recently, major shifts in the paradigms of patient care took place: interdisciplinary counseling and including the patient in the decision making process for diagnostic and therapeutic measures. the new concept is that the patient no longer comes to the specialist, but the specialists come jointly to the patient. this is reinforced by the competition among health care providers, political decision makers and the public. in many hospitals this general trend has resulted in the establishment of various centers and boards such as the breast cancer centers, vascular centers and tumor boards for several cancer entities to name only few. at the university hospital of munich 46 centers and boards have been implemented up to now. in almost all of them the participation of radiologists is required. this results in a major challenge in terms of personal resources. together with the regular clinical-radiological rounds the time necessary for these activities equals 2 full-time radiologist posts. the participation of radiologists has many beneficial aspects: acknowledgement of radiology as an important clinical discipline and of the radiologist as a clinical consultant; participation in and influence on the creations of sops and (internal) guidelines; opportunity to advocate appropriate radiological methods for diagnosis and interventions; increase of knowledge in clinical medicine and new concepts of therapy; close personal links with our clinical partners. in order to prevent radiologists from losing their identity as radiologists it is mandatory that they remain firmly integrated in the radiology department and to strengthen the position of radiology as the central institution for providing cost-effective imaging and interventional services. moreover it must be taken care to offer attractive career options within the field of radiology. at (michael.fuchsjaeger@medunigraz.at) ultrasound (us) is the adjunct method of choice to mammography in breast imaging. over the past two decades, us technology has undergone profound advancements and refinements. us has, therefore, become an assessment tool with a defined field of indications as well as a unique set of diagnostic descriptors for breast lesion differentiation. the acrin 6666 study has demonstrated the special benefit of us in patients at risk with dense breast tissue. the bi-rads lexicon for ultrasound, in its second edition, expanded the role of breast us. further enhancement of image quality as well as the recent advent of automated breast us has even fueled scientific discussions on the potential role of us for breast cancer screening. automated breast us, which is based on computed generation of a 3d imaging data set obtained from many parallel 2d images, offers a different approach with a variety of benefits. images are obtained by the sonographer in standardised fashion, whole breast data sets can be reviewed at any time after the examination, reducing operator dependence, and image fusion with, i.e. mri is easily possible. the basic physical background, the significance as well as important aspects of practical use of handheld and automated breast us will be explained and illustrated by the respective imaging examples. emphasis will be laid on strengths and potential weaknesses of both us technologies with regard to breast imaging. the terms "complicated cyst" and "complex-cystic lesion" are based on breast ultrasound (us) terminology. the simple cyst is a fluid-filled, clearly defined, anechoic lesion without any suspicion of a solid intracystic mass. if a simple cyst is complicated by echogenic fluid, it is called complicated cyst. this echogenic fluid can be caused, e. g., by cell debris. thin echogenic septa are common in complicated cysts. vascularisation can never be found in these echogenic components. a complicated cyst has no solid component and no thickened wall or thickened septa. the expected probability of malignancy is 2%. the us criteria of a complex-cystic lesion following berg et al. categorise it into 4 types: type 1, thick outer wall and thick internal septa (alone or in combination of both); type 2, one or more intracystic masses; type 3, mass of mixed cystic and solid components (at least 50% cystic); type 4, predominantly solid with eccentric cystic foci (at least 50% solid). complex means there is a suspicion of a tumour inside a cyst or a solid tumour with cystic components. a complicated cyst will usually be followed by us after 6 months. a complexcystic lesion needs a correlation with mammography. us-guided large core needle biopsy in combination with a us and mammography visible marker placement is useful in type 3 and in type 4 complex-cystic lesions. in type 1 and type 2 complex-cystic lesions, a preoperative hook wire placement and excision surgery is the typical procedure. learning objectives: 1. to learn about the us appearance of complicated cysts and complex-cystic lesions. 2. to consolidate knowledge on differential diagnosis for these respective lesions. 3. to understand the diagnostic algorithm for a work-up of these lesions. renal colic is the most frequent non-obstetric cause for abdominal pain and subsequent hospitalisation during pregnancy. intervention is necessary in patients who do not respond to conservative treatment. ultrasound (us) is widely used as the first-line diagnostic test in pregnant women with nephrolithiasis, despite that it is highly nonspecific and may be unable to differentiate between ureteral obstruction secondary to calculi and physiologic hydronephrosis. magnetic resonance imaging (mri) should be considered as a second-line test, when us fails to establish a diagnosis and there are continued symptoms despite conservative management. moreover, mri is able to differentiate physiologic from pathologic dilatation. in fact in the cases of obstruction secondary to calculi, there is renal enlargement and perinephric oedema, not seen with physiological dilatation. in the latter, there is smooth tapering of the middle third of the ureter because of the mass effect between the uterus and adjacent retroperitoneal musculature. when the stone is lodged in the lower ureter, a standing column of dilated ureter is seen below this physiological constriction. mri is also helpful in demonstrating complications such as pyelonephritis. in the unresolved cases, computed tomography remains a reliable technique for depicting obstructing urinary tract calculi in pregnant women, but it involves ionising radiation. nephrolithiasis during pregnancy requires a collaboration between urologists, obstetricians, and radiologists. learning objectives: 1. to list the us, mr and ct imaging findings of urolithiasis and urinary tract infections. 2. to discuss the role and the appropriate uses of us, mr and ct for imaging these suspected conditions in pregnancy. 3 . to discuss how imaging can influence the management of nephrolithiasis during pregnancy. oncology t.f. hany; zurich/ch (thomas.hany@gmail.com) in malignant tumours, pet/ct imaging using 18-fluoro-deoxyglucose (fdg) is widely used nowadays. fdg-uptake is an unspecific process and results in physiological as well as pathological malignant and non-malignant tissue uptake. to properly understand and interpret pet/ct imaging, knowledge of the mechanism and pathways of fdg in different tissue types like brain and the gastrointestinal tract is key. intrinsic as well as extrinsic factors influence uptake pattern not related to oncological disease like uptake in brown fat in patients exposed to cold ambient temperature and psychological stress or increased muscular uptake in nonfasting patient. typical treatment-related changes occur during and after treatment and must be recognised correctly so as not to overstage patient disease. a systematic analysis and knowledge of all these factors facilitate and improve the reading of oncological clinical cases. learning objectives: 1. to understand pattern of physiological fdg-uptake. 2. to learn about the pattern of non-pathological uptake in several tissue types. 3 . to understand the influence of chemotherapy and other agents on fdguptake in the body. radiologists mostly prefer to use the comparative technique while evaluating radiological images, especially when the anatomy is identical for both sides. comparative analysis mostly works if the anatomic details are not complex or the right resembles the left. however, the complex anatomy and relatively high incidence of individual variations in head and neck may hinder this way of interpretation. variable pneumatisation of paranasal sinuses and temporal bone may cause difficulty. vascular system, especially venous structures may be sources for pseudolesions. for example, asymmetrically enlarged jugular vein or venous plexuses at any location may be misinterpreted as mass of any origin. veins may also become problematic on mr imaging due to entry slice phenomenon, in-plane flow, and flow turbulence effects and can have variable enhancement. normal anatomical structures such as facial nerve may enhance and can be mistaken to be pathologic on mri. technical issues can be considered as a group that may cause pseudolesions. images of the improperly positioned patient may become problematic while evaluating tiny structures. pet and pet-ct carry their own risks for pitfalls. normal structures may confound interpretation and result in false-positive findings. the situation may become much more complicated when there is asymmetry. similarly, atrophy and unilateral absence of a structure may be misread as a mass on the contralateral side. because of the complex anatomy and relatively high incidence of individual variations, head and neck imaging demands much more attention and careful analysis. the appropriate imaging technique and detailed knowledge of anatomy are essential to recognise pseudolesions. as a general rule, detailed knowledge of the patient's clinical history is essential before any imaging study is performed, to evaluate the appropriateness of the indication, tailor the acquisition protocol and correctly interpret the study. in head and neck imaging, this rule particularly fits in the emergency setting. in certain circumstances, the swelling and enhancement of soft tissues produced by infectious lesions may mimic a neoplasm. even more so, in patients already treated with surgery or chemoradiation. in these patients, the challenge is double: to identify any abnormality in the new anatomy produced by treatment and to discriminate between inflammation, complication and relapse. these can be very difficult without knowledge, for example, of the reconstructive procedure after surgery. previous images are extremely useful, not only because they help detect abnormalities, but also because through indirect information on the growth rate of the lesion they are crucial for correct interpretation of findings. tablets in radiology represent a novelty. since the introduction of the tablets on the market, the radiological field has been probably the first medical discipline to discover the many advantages of these devices. in fact, many applications for image management have been made available on the app stores (apple and android), and allow radiologists and non-radiologists to handle dicom images on the tablet, as part of the patient's record. however, the emerging applications are driving the process from the simple dicom image viewing to the full integration of the tablet with the pacs, allowing the handling of a patient's full record and presumably the possibility to report. in view of this rapid technological development, again radiology falls in the middle of a storm and is asked to find a solution to problem: are tablets suitable to read and report dicom images? and if so, which kinds of images (ct, mri, x-ray, etc) .? how can we manage the portability of patients' data (security issues, data loss, etc).? what will be the impact on teleradiology? these issues will be addressed by the panel of experts who will speak in the refresher course. session objectives: 1. to appreciate the current state of tablet technology and its practical use in radiology. 2. to understand the pros and cons of the use of tablets. 3 . to learn about specific critical areas of utilisation (dicom images reading and teleradiology). a. tablet-computers: a technical overview j. fernandez-bayo; sabadell/es (jfernandezb@cspt.es) since their introduction in 2001, tablet pcs have evolved extensively. they have become very popular, filling the gap between laptop computers and smart mobile phones. we will review technical aspects like the processors, storage space and memory, size and weight, connectivity and networking, software, autonomy, and battery life in different devices. special focus will be on the displays and different possible uses in radiology. for diagnostic purposes, different technical aspects must be taken into consideration, like the display size, resolution, pixel size (pixel pitch or pixels per inch), luminance, and contrast. displays in radiology normally have sizes between 20" and 24" and resolutions up to 5 mpx, with luminance that ranges from 250 cd/m 2 to 600 cd/m 2 . by contrast, tablets have screen sizes between 9" and 10" and resolutions up to 3 mpx, with luminance that ranges from 370 cd/m 2 to 480 cd/m 2 . due to their screen size, tablets score better in pixel pitch, with around 250 ppi versus 150 ppi in medical displays. the two systems have similar contrast ratios. other technical aspects of display that we should take into consideration are the number of distinguishable grays that can be represented, which in tablets correlates with the number of colours that can be displayed (color gamut) and colour accuracy (delta-e). additionally, we should take into consideration that displays should be calibrated for medical diagnostic purposes and tools to calibrate tablets have recently become available. learning objectives: 1. to learn about the pc evolution: from desktops, to laptops and tablets. 2. to appreciate the versatility features of a tablet. 3 . to understand the hardware features with a specific focus on display. 4. to understand the hardware features with a specific focus on networking. a-046 16:28 b. reading dicom images on the tablet o. ratib; geneva/ch touch screen tablets are becoming widely available, providing convenient mobile solutions for physicians and health-care providers. this is particularly attractive in medicine to "nomad" physicians, who need to be able to access relevant patient data and images anywhere-anytime in their daily practice where they are rarely at a single location. while they may not always be adequate for routine diagnostic tasks, they provide a convenient mobile solution for on-call and remote consultations. there are different types of software architecture that can be implemented for such tasks. two different major designs are: (1) online web-based applications where the device serves as a "thin-client" to display images rendered and manipulated on a remote computer and (2) local applications that reside on the mobile device and can run independently after images have been downloaded on the device. the first solution requires the user to be constantly connected to the network, while the second solution can continue to function after being disconnected from the network. most pacs vendors are starting to provide web access to their imaging solutions that can be accessed from mobile devices. web access can however be slow and dependent on reliable access to wireless network. we chose to develop a stand-alone companion application to our open source imaging platform osirix. with the increasing capacity and computing power of mobile devices, users will soon be able to perform most of the processing and image manipulation functions that are today only feasible on desktop or laptop computers. learning objectives: 1. to learn which dicom readers are available for tablets. 2. to appreciate the different approaches to dicom reading (local vs remote) and the pacs/tablets integration. 3. to understand the pros and cons of dicom image reading with the tablet in regards to image quality and displays. the optimisation of clinical breast cancer care comprises the prevention of over-diagnosis, reduction of over-treatment, and avoiding unsuccessful treatments. these goals are targeted in the vph-prism project by seven european and two us partner institutions. from the prospectively collected data, we will derive optimised imaging protocols that comprehensively take a woman's history and risk factors into account. the tight integration of radiological and histopathological images enables joint assessment of quantitative tissue parameters from microscopic and macroscopic imaging. more informed therapy decisions can be taken by such enhanced multidisciplinary data, backed by a powerful case database. the reduction of overtreatment, and highly individualised diagnosis and therapy decisions are closely related. we ultimately aim at deriving predictive parameters from the multi-modal and multi-disciplinary database to select the treatment option with the best chance of enduring recurrence-free survival. prospectively collected data, personal risk factors, and corresponding imaging data fed into the database from three large cohort studies are expected to provide insights into the individual preconditions and factors affecting disease progression. to optimise therapy, the decision between therapy options is key. this will be addressed by a decision support system using the project database. for surgical excision planning, vph-prism will aim at providing better estimates of tumour size, and with visual planning aids supporting radiologists and surgeons. for chemotherapy, quantitative lesion parameters, tracked over time during therapy, may help to detect success or failure of the treatment early on, such that a chemotherapy regime can for a non-responder be switched to a different regime in due time. quantitative imaging biomarkers in dementia; the fp7 vph-dare@it project w.j. niessen; rotterdam/nl (w.niessen@erasmusmc.nl) the number of individuals suffering from dementia today is roughly 36 million. due to ageing societies, this number is predicted to increase to 115 million by 2050. worldwide annual costs are estimated to be â�¬450 billion. in 2012, the who declared dementia a global health priority, highlighting the urgent need for improvements in this area. vph-dare@it's aim is to enable more objective, earlier, predictive and individualised diagnoses and prognoses of dementias to cope with the challenge of an ageing european society. the expected impact of vph-dare@it will influence the scientific, clinical and industrial communities across europe and internationally to improve health care of dementia patients. in this presentation we will introduce the vph-dare@it project. we will then focus on the development, validation and implementation of quantitative imaging biomarkers for the early detection and differential diagnosis, which will take place as part of the project. author disclosure: w.j. niessen: advisory board; part-time detached to quantib bv as scientific director. shareholder; co-founder and shareholder of quantib bv. horizon 2020: improving diagnosis and medical interventions and support to medical imaging j.-l. sanne; brussels/be (jean-luc.sanne@ec.europa.eu) research and innovation contribute to increasing europe's competitiveness. at the same time, research and innovation help make people's lives better by improving things like healthcare. in january 2014 the european union launches horizon 2020, the biggest eu research and innovation programme ever, with a budget of â�¬ 79 billion (current prices) over seven years (2014) (2015) (2016) (2017) (2018) (2019) (2020) . eu support for research and innovation helps drive international projects across the european union and beyond, and promotes the progress of knowledge and technology. one of the three key pillars of horizon 2020 will be tackling societal challenges (priority 3) such "health, demographic change and well-being". one feature is the development of new and more effective diagnostics. relevant tools and technology innovations will be supported in view to improve disease outcomes through earlier, more accurate diagnosis and by allowing for more patient-adapted treatment. support will be provided through the work programme 2014 -2015 of societal challenge 1 "health, demographic change and wellbeing". additional opportunities are offered in the work programme 2014 -2015 of priority 2 (industrial leadership) "leit -information and communication technologies". practically, all imaging modalities have been used in space research since a long time ago. first of all, radiology is targeted in research activities, because by definition all cosmonauts and astronauts are healthy persons. the biggest volume of examinations had been performed on crew members for studies of organs and functions of the human body before and after long-term flights. health effects of zero gravity were of special interest. for example, multiple studies with involvement of both russian and international specialists were done on bone mineralisation (bone densitometry), muscle volume (mri) and metabolism (mr-spectroscopy) both in astronauts and healthy control subjects. first, ultrasound (us) examinations were conducted in space onboard russian orbital stations in 1982. complex us studies were done by the author himself during his flight as a crew member of "salut-7" orbital station in 1984. the author had found some complex changes in blood and fluid dynamics under weightlessness. teleradiology was used for data transfer to medical specialists on the earth. today, we are continuing to use radiology for research on astronauts. for example, applications of sophisticated brain mri and fmri methods are of special interest for studies of subtle brain changes in space travellers. among our targets are flights to the moon, mars and large asteroids. to be better prepared for that task, we need better diagnostic tools. new versions of mobile us systems, miniature x-ray and ct machines suitable for use inside spaceships are under development. there are several mri pitfalls that should be recognised when imaging the female pelvis. mri appearances of uterus and ovaries are dependent on the phase of menstrual cycle/use of exogenous hormone therapy. normal postsurgical and post-radiation appearances of the pelvis can sometimes mimic tumour recurrence. it is important to become familiar with these appearances to avoid potential pitfalls. one very common pitfall is differentiation of transient myometrial contraction from adenomyosis. interrogation of all imaging planes over the duration of the entire mri examination can be useful to distinguish between the two, although myometrial contractions can last up to 45 min. the choice of the correct imaging plane is crucial for the precise classification of uterine anomalies (coronal oblique) and accurate evaluation of parametrial invasion (axial oblique) in patients with cervical cancer. both dynamic contrast-enhanced mri and diffusion-weighted mri improve the accuracy of mri in the evaluation of malignant pelvic conditions. however, certain pitfalls related to each technique should be recognised to avoid misinterpretation. it is crucial to be familiar with the anatomy of the uterovesical (uv) ligament, as it is often the site of pelvic lymphoma (such as bladder or cervix lymphoma). however, some benign conditions such as endometriosis can involve the uv fold and invade both bladder and uterine wall. certain mri features can be helpful in making the correct diagnosis. learning objectives: 1. to become familiar with normal variations in mri appearances of female pelvis resulting from physiological conditions (e.g. different phases of menstrual cycle) and treatments (including exogenous hormone therapy, surgery and radiation) potentially mimicking disease. 2. to consolidate knowledge on the role of the correct mr imaging plane in avoiding potential mis-classification of uterine anomalies and parametrial invasion in patients with cervical cancer. 3 . to learn about certain pitfalls related to dynamic contrast-enhanced mri and diffusion-weighted mri. a-057 09:15 b. pitfalls in ultrasound k. kinkel; chãªne-bougeries/ch (karen.kinkel-trugli@wanadoo.fr) pitfalls of sonographic findings in the pelvis can be related to technical issues, interpretation errors or to the patient's specific condition or pathology. common problems consist of insufficient bladder filling, misinterpretation of posterior enhancement or shadowing according to the anatomical structure and pathology of a size that goes beyond the field of view of the probe. organspecific problems will be illustrated in interactive questions, particularly for the uterus and the ovaries. identification of diseases can be difficult in many areas of abdominal imaging and therefore misses are easily made, also by the more experienced radiologist. it is difficult in the mesentery and peritoneum, covering a large area but being a very thin structure where abnormalities are easily missed. therefore, knowledge of the peritoneal anatomy and pathophysiology of peritoneal diseases is not widespread and differential diagnosis can be difficult. hence, special attention should be paid to prevent misses. another difficult area is diagnosing occult gastrointestinal bleeding. here, the choice of the proper imaging method is crucial as well as understanding the pros and cons of the method. the technique used should be optimised, as otherwise sometimes subtle signs of bleeding are missed. the presence of bowel dilatation itself is often correctly diagnosed, but the extent of the obstruction, the cause of the obstruction and especially complications (ischaemia) might be misdiagnosed. ct is the preferred technique for evaluation of bowel dilatation. care should be taken to scrutinise the examination for principal findings in patients with bowel obstruction. a. mesentery and peritoneum d. akata; ankara/tr (dakata@hacettepe.edu.tr) imaging findings of neoplastic or inflammatory diseases within the peritoneal cavity and the mesentery sometimes overlap and cause difficulties in interpretation. even disease processes in the peritoneum, mesentery or omentum may not be recognised on radiological examination, causing major difficulties in the management. peritoneal anatomy and physiopathology of peritoneal diseases must be well understood for better evaluation. ct is the best modality to assess the whole cavity. mr is equally sensitive with better contrast resolution; however, both modalities have advantages and limitations. ultrasound has a complementary role in evaluating the peritoneal fluid content. the presence of lacelike mobile thin septa is highly significant for tuberculosis. for better diagnosing the pathology, systematic approach is needed such as assessing the presence or absence of fluid in the peritoneal cavity, its character and location, accompanying soft tissue densities and their location. some inflammatory or infectious causes, such as acute pancreatitis and tuberculosis, involve typically parietal peritoneum and certain peritoneal reflections. peritoneal carcinomatosis involves typically both visceral and parietal peritoneum as well as subdiaphragmatic space. contrast enhancement patterns of the peritoneal membranes and the mesentery also have a complementary role in differentiating a variety of diseases. learning objectives: 1. to learn about the imaging characteristics of peritoneal and mesenteric masses and their differentials. 2. to appreciate the potential and limitations of imaging techniques in the detection of such lesions. 3. to understand the common pitfalls in diagnosis. a-060 08:58 a. filippone; chieti/ it (a.filippone@rad.unich.it) patients with persistent, recurrent, or intermittent bleeding from the gastrointestinal tract for which no definite cause has been identified by initial oesophagogastroduodenoscopy, colonoscopy, or conventional radiologic evaluation are considered to have an occult gastrointestinal bleeding (ogib). the management of ogib is clinically challenging, since the causes of such a bleeding frequently arise in the small bowel (sb), until now considered as the ''dark continent''. conventional barium contrast studies allow only a limited evaluation of sb, whereas angiographic diagnosis is strictly related to active bleeding. the introduction of capsule endoscopy (ce) as well as of crosssectional imaging dedicated to the sb visualisation, such as multidetector-row computed tomography enteroclysis (cte) and magnetic resonance enteroclysis (mre), represents significant technological advances that have overcome the limitations of older diagnostic tests. although ce is recommended as a first-line investigation in ogib patients, cte or mre are alternative diagnostic tools when ce is contraindicated due to suspected/known obstruction or stricture. moreover, in patients in whom a tumour is suspected, cte or mre may be the preferred initial test. therefore, radiologists have to be familiar with cte and mre techniques, in terms of bowel distension, scanning parameter selection, contrast administration as well as with specific imaging findings. similarly, they have to be aware of the potential pitfalls such as suboptimal bowel distension, artefacts due to peristalsis or breathing, intraluminal food debris and previous surgery. learning objectives: 1. to understand the causes of gi bleeding and underlying pathophysiology. 2. to appreciate the strengths and limitations of the imaging techniques used in diagnosis. 3 . to learn about common pitfalls in diagnosis. dilatation. presently, ct takes a major place in this setting with a reduced role for plain films. sonography is an alternative method when ct is not recommended. the questions of mondor in 1947 were pointed before the advent of cross-sectional imaging; these are still valid and have to be answered: 1) is this a true occlusion (how to differentiate it from adynamic ileus)? 2) does the obstruction concern the small bowel or the colon (impacting on the decision to operate or not)? 3) what is the cause of the obstruction? 4) are there signs of bowel ischaemia? the key points to avoid missing imaging diagnoses in bowel dilatation are to make the distinction between true mechanical obstruction and adynamic ileus (an early sign of mesenteric infarct) and to detect signs of strangulation leading to ischaemia (such imaging findings are present despite normal blood tests). in this setting, ct is the preferred technique; if it is not available, plain films and sonography can help in an optimal medical decision. the national lung screening trial (nlst) found a 20% reduction in lung cancer mortality with three annual screens using helical ct relative to chest xray. the us preventive services task force has issued draft recommendations to provide annual ct screening to high risk individuals defined by age and smoking criteria. questions remain regarding the implementation of ct screening: the determination of risk to identify those who should be screened, the frequency and duration of screening, definitions of screen positivity based on detected nodule characteristics, diagnostic algorithms for the follow-up of positive screens, overall societal costs of screening, and methods to adequately diffuse this technology across all socioeconomic groups at risk. answers to these questions are being addressed by several groups through ongoing research and secondary analyses of trial data. several models exist to identify individuals at highest risk of lung cancer (and lung cancer mortality), which may be enhanced if validated molecular markers are included. ongoing analyses of nodule features and likelihood of lung cancer will better inform screening interpretation guidelines and diagnostic algorithms. estimates from the nlst suggest that screening as performed in the nlst will be cost effective: the base case estimates $67,000 per quality adjusted life year gained (qaly). subset analyses suggest that screening is much more cost-effective in women than men, in higher versus lower risk groups, and in current versus prior smokers. while several variables influence cost-effectiveness, major drivers of cost are the cost of ct screening exams as well as the number of follow-up ct scans per positive screen (1.26 in nlst). while the national lung screening trial (nlst) had shown a significantly reduced lung cancer-specific mortality and all-cause mortality, the current results from the various european trials do not show such positive results. the dutch-belgian nelson trial, the german lusi trial and the british ukls have not yet published their results. so far, more cancers were detected in the screening arm of published danish and italian trials, but the positive effect on cancer mortality could not yet be shown. the italian mild trial even showed higher mortality in the yearly screening arm, and no difference between 2yearly screening and the control arm. this presentation discusses the implications of these findings and the consequences on implementation on screening in clinical practice. while limited in number of participants, european trials used advanced approaches that are most likely to be used if screening will ever be implemented. this presentation will discuss issues such as growth assessment and volumetry as critical factors for nodule assessment, handling of sub-solid lesions, computer aided detection and evaluation, and use of nonradiologists for reading and standardised follow-up. the goal is to provide an insight into how the european trials have affected our idea on practical implementation of lung cancer screening. the discussion will address the following issues: 1. are there sufficient data to support the implementation of individual lung cancer screening in clinical practice? 2. if yes, how to move from efficacy to effectiveness: what are the most optimised risk profiles for screening? what is the minimum level of infrastructure support and organisation required? how should subjects be informed about screening? what are the optimal follow-up duration and screening interval? what are the technical and positive screen management requirements? 3. what about the alternatives of waiting for additional data from ongoing trials or the validation of new biomarkers of lung cancer, permitting better selection of screened population before implementing individual lung cancer screening? attendees' opinions will be collected interactively. the speakers will be asked to comment and debate. treatment of prostate cancer depends strongly on the stage of the disease at the time of detection. however, treatment is controversial, even in prostate cancers found through early detection. this presentation will be based on a careful recent literature review. early detection of prostate cancer by use of psa testing leads to a significant reduction of at least 30% of disease-related mortality in screened men. this is however at the price of 40-50% of overdiagnosis, usually resulting in overtreatment. diagnostic developments which reduce overdiagnosis and the proper identification of cases which may not require treatment are central issues of current research and will be addressed by referring to available evidence. active observation of potentially nonaggressive cancers is an option in the management of this disease until, preferably, the diagnosis of such cases can be avoided all together. radical prostatectomy and radiotherapy are the options for treating those cancers which are judged to be aggressive. treatment recommendations for prostate cancer continue to evolve and are affected by technological advances in surgery, new discoveries in tumour biology, and the development of predictive and prognostic biomarkers. with the increased complexity of treatment decision-making, the role of mri is also evolving. the more individualised and targeted the treatment approach, the greater is the role of imaging in treatment selection, planning and follow-up. mri is especially crucial for planning technologically sophisticated treatment approaches such as robotic surgery, igrt, or focal therapy and in assessing patients' eligibility for active surveillance. though needs for uniform interpretation and standardised reporting remain unresolved, the value of mri in pretreatment staging of prostate cancer, particularly for evaluating extracapsular extension and seminal vesicle invasion, has been documented. not only the tumour stage, but also its size, volume and grade (aggressiveness) are important factors that influence treatment selection. therefore, the introduction of functional mr is essential. when added to t2weighted mri, diffusion-weighted mri, dynamic-contrast-enhanced mri, and mr spectroscopy, in addition to improving tumour detection, can provide an indication of tumour aggressiveness. mri performance on all sequences is dependent on lesion size/volume and grade, and this should be considered when applying mri results to treatment selection and planning. while it has been shown that multiparametric mri is generally more accurate and informative than anatomic mri alone, evidence-based guidelines specifying which combinations of sequences are essential for specific indications in patients with prostate cancer are yet to be developed and validated in welldesigned studies with robust outcome measures. in major trauma, it is essential to immediately recognise life-threatening conditions and to initiate early treatment. the majority of these patients succumb at the site of the injury to severe injuries of the central nervous system, heart and great vessels. however, there is another peak of early deaths within the first four hours after the injury. in the majority, these patients are at risk due to haemorrhage which is basically controllable by early minimally invasive treatment. consequently, this means that the vast majority of internal injuries can be survived as long as bleeding control is achieved within the first four hours after an injury. minimally invasive interventional techniques are already in use at a very early stage of the clinical decisionmaking process. particularly, we have witnessed a major paradigm shift in the treatment of blunt aortic injuries. endovascular repair has replaced open repair in many trauma centres. in appropriately selected patients, this adoption of endovascular stent grafts has resulted in a reduction in perioperative mortality, stroke and paraplegia, as compared to open repair. this entire session will provide knowledge about indications, requirements, standard procedures, and outcome of vascular emergencies, pardon me, urgencies. a. aortic emergencies m. cejna; feldkirch/ at (manfred.cejna@lkhf.at) aortic emergencies can be classified into several categories. "acute aortic syndrome": acute aortic syndrome is an entity of changes of the aortic wall. these include aortic dissection, intramural thrombus, and penetrating atherosclerotic aortic ulcer. besides coronary malperfusion and aortic valve insufficiency (type a dissection), emergency presentation is often due to visceral/limb ischaemia. sequelae of aortic syndromes are pseudoaneurysm formation and potentially aortic rupture. endovascular treatment has been established as the treatment option in at least type b dissections and penetrating aortic ulcers. aortic aneurysm rupture: with increasing diameter, aneurysms in the thoracic, thoraco-abdominal and abdominal aorta are prone to rupture. signs of impending aortic rupture are pain and imaging signs are sometimes subtle just like blurred contours of the aorta and (blister like) vascular wall deformation. endovascular treatment is an alternative to vascular surgery. aortic trauma: in severe thoracic trauma (mostly deceleration trauma), pseudoaneurysm formation and aortic rupture occur at the level of the aortic isthmus. endovascular treatment is considered the treatment of choice. inflammation, mycotic aneurysms and aorto-enteric fistulae: with acute and chronic inflammation, aneurysm and pseudoaneurysm formation and fistulae to enteric structures can occur. endovascular treatment is more often considered as bridging to vascular surgery instead of being a definitive cure. iatrogenic aortic injuries: besides accidental aortic injury during operations or interventional procedures, transaortic valve replacement and placement of aortic balloon pumps can result in iatrogenic trauma. endovascular treatment may be a minimally invasive approach. the focus will be on systematic presentation of aortic emergencies and the role of endovascular treatment. there are a number of vascular visceral emergencies that may be traumatic or nontraumatic in origin. the degree of urgency or potential for urgency varies with each condition and the subsequent management and intervention techniques will vary accordingly. an understanding of the natural history, pathophysiology, diagnostic tests and interventional techniques for these conditions will aid the diagnostic and interventional radiologist in identifying the pathology and knowing when to refer or initiate definitive treatment. i talk about embryonal development and anatomical differentiation of cardiovascular system, with special attention to the peripheral vascular system. the goal of this part of presentation would be to understand the anatomical structure and architecture of arteries and capillaries. we will discuss the casual classification of different kinds of peripheral arterial emegencies; e.g. congenital, posttrauma, arteriosclerotic and iatrogenic. the audience will learn about different therapy approaches, interventional and non-interventional, with accent on pad (classification, pathophysiology, risk factors, statistical facts and therapy). at the end, we will review different studies about combination therapy (conventional and interventional) with different possibilities and outcomes. modern cancer research and increasing therapy are mechanism based with the development of disease-modifying therapies that target the hallmarks of cancer. modern imaging tools enable the visualisation and quantitative assessment of the expression of molecular targets, of their interaction with potential ligands, as well as of the functional consequences of interactions at a molecular, cellular, metabolic, physiological, and morphological levels in a temporo-spatially resolved manner. the ability to gather such information from the intact organism renders imaging highly attractive for biomedical research and drug development. the determination of cell proliferation with radiolabelled thymidine is a wellestablished method in various life science branches where [3h]thymidine has been used for more than 40 years and still represents the gold standard for the assessment of tumour cell proliferation. since non-invasive determination of this parameter is required in clinical studies, considerable efforts have been made in radiopharmaceutical research. the synthesis of a large series of proliferation markers resulted therefrom mostly focussing on pyrimidine nucleosides. the labels used were gamma as well as positron emitting radionuclides. here, [18 f]flt (3'-deoxy-3'-fluorothymidine) is examined and discussed with respect to its preclinical and clinical application. since apoptosis is an important mechanism of cell death in tumours responding to treatment, the non-invasive assessment of apoptosis with tracers for the detection of phosphytidyl-serine presentation and/or caspase activation could be used as surrogate marker for therapeutic efficacy. several approaches have been followed during the last years; their potential and limitations will be presented. angiogenesis is one of the hallmarks of cancer that is considerably easy to characterise with many different imaging modalities and methods. it is not only crucial for invasive and metastatic tumour growth, but is also a prerequisite for the accumulation of anticancer drugs and highly impacts the success of radiotherapy. this talk summarises our experiences in microstructural, functional, and molecular imaging of tumour angiogenesis. the microarchitecture of vessels can longitudinally be studied using high-resolution ( )ct. dce mri and hf-us are introduced as favourable tools to characterise perfusion, vessel permeability and vessel maturation during antiangiogenic treatments. using targeted probes, it is shown that "fluorescence molecular tomography (fmt)", mri and us are capable of estimating the expression of angiogenic marker molecules on tumour vessels and of matrix-associated enzymes in the interstitial space during vascular remodelling. additionally, examples are also given for epr-based nano-sized theranostics and it is shown how us can aid in better accumulating them at the target site by inducing vascular permeation. many of these novel imaging concepts and tools can relatively easily be translated into clinics. thus, one can expect them to play a major role in the clinical management of tumour treatments soon. mammography technique from the point of view of radiographic compression and positioning is no different from film screening and radiologists ignore this at our peril. we will discuss the danger areas at the edges and the back of the breast and help you to find lesions only seen on one view. with digital capture the technologist can view images immediately, but the temptation is for them to repeat exposures to obtain radiographic perfection on otherwise clinically acceptable images. however, the task of assessing quality cannot be left to them, as viewing conditions on the 'lower resolution' acquisition monitor in a bright x-ray room is not enough. there is now evidence from 2 population screening programmes that poor image quality can reduce cancer detection from between 15% in france to 24% in ontario. 'quality' can be lost at 3 keys points in the imaging chain: the x-ray beam and dose, the detector and finally display. in flanders, poor detector performance was compensated for by increasing the x-ray dose by 60% and by meticulous quality control. postprocessing is less well understood, but reader studies now show different algorithms will affect performance particularly for the detection and classification of micro-calcification. finally, it does not matter how good all the equipment is if we try and read the images with the lights on full. mammography is the most important breast imaging technique allowing the visualisation of masses and micro-calcifications. however, in conventional mammography the three-dimensional breast tissue is reduced to a twodimensional image. therefore, small lesions may be undetectable due to superimposed glandular tissue. digital breast tomosynthesis (dbt) has emerged as a new imaging modality to overcome this limitation. several lowdose mammographic projections are performed over a limited angle of up to 50 degree using a standard mammography system. the average glandular dose of a tomosynthesis scan is somewhat higher compared to one-view mammography, but lower compared to a standard mammography in two projections. based on the low-dose projections, a stack of cross-sectional images covering the entire breast is reconstructed with an interslice distance of about 1 mm. several studies have shown that tomosynthesis improves both tumour detection and the characterisation of focal masses. due to the crosssectional nature of dbt, the techniques allow on the one hand the reliable differentiation of true focal masses from summation artefacts. on the other hand, tomosynthesis improves the detailed analysis of the lesions' border to differentiate benign lesions and carcinomas. additionally, contrast-enhanced spectral tomosynthesis may allow analysing signal-intensity time curves. in conclusion, dbt adds important information to standard two-projection mammography and can replace spot compression and rolled views as problem solver for difficult cases. however, the impact of tomosynthesis on breast cancer screening has to be investigated in larger clinical trials. reading screening mammograms is not the same as reading diagnostic mammograms. the vast majority of women attending a screening programme are usually asymptomatic and do not have abnormalities associated with a malignancy. the task of a mammogram reader is to scan a mammogram and perceive any possible abnormalities that could be associated with a malignancy. in other words, we are talking about perception and not diagnosis of a finding. examples will be shown about this crucial step. in modern population-based screening programmes, we use computerised reading and recording systems. since the work flow is rather quick, we have to ensure basic steps such as identity control and see that both ris and pacs are synchronised so that decisions of screening readings are recorded in both the systems of one and the same patient. in computerised screening programmes, we use standard reports informing a woman that no signs of malignancy have been detected on her screening mammograms. in case of findings that need further assessment, there are several ways to deal with this situation. the most common way is via a phone call, but this can also be done with a letter. a screening report should be short and concise and should only inform whether we see signs of a possible abnormality that can be associated with a malignancy. extensive reports describing the contents of a breast or findings of no clinical relevance should not be part of a screening report. emergency radiology services are very much on the rise in the last decade. medical emergencies and trauma are of enormous importance and a leading cause of death in all age groups. the use of radiological imaging in emergency departments showed an exponential increase since the 1990s. the annual growth rate in ct is 5-15% per year depending on the institution. even for advanced level 3â° medical centres running an own emergency radiology unit, it is a challenge to integrate advanced radiology services in an interdisciplinary team treating patients with acute traumatic and non-traumatic emergencies. general principles: radiology and radiological imaging procedures should be integrated in an interdisciplinary team. imaging should be guided by interdisciplinary clinical algorithms or guidelines (e.g. nexus or canadian cspine rule). many clinical diagnoses relay today on a early and thorough initial radiological diagnostic workup -mostly based on mdct. emergency radiology (er) is still a relatively young subspecialty in european radiology -it deserves specific training. the lecture will cover: the development of emergency radiology and its future perspectives; the use of conventional radiography, ultrasound and mdct; logistics and management of the patient; clinical guidelines and mdct in the primary patient survey (e.g. using atls for trauma) and advanced scanning protocols for mdct. infants and children with abdominal emergencies present special diagnostic challenges because of similarities in clinical findings between various paediatric conditions. imaging is frequently a critical part of the diagnostic process, but the choice of the best imaging modality can be controversial. patient age and safety issues such as radiation exposure must be taken into consideration when planning imaging. because certain pathologies are more likely to occur in specific age groups, patient age is a primary determinant of the imaging approach. this presentation will illustrate the differences in pathology between several paediatric age groups and discuss effective imaging algorithms for congenital and developmental, inflammatory, and obstructive conditions. the optimal use of radiographs, ultrasound, ct, and mri will be discussed. pitfalls that should be avoided in ultrasound and ct will be emphasised. in diagnostic imaging, we tend to focus on radiation protection, justification and optimisation, as the primary opportunity for radiographers and radiologists to ensure the safety of patients, both adults and children; however, this ignores some other important issues. this session aims to raise awareness amongst medical imaging professionals of some key considerations in relation to a number of child protection issues. when imaging a child in case of suspected non-accidental injury, every detail of that examination from conversations with the child and their parents or guardians, technical aspects of the examination, observations during the examination and the language used following the examination need to be carefully considered. another area of medical imaging requiring attention is how we communicate any radiation risks associated with examinations or procedures with children and their parents. there is evidence that while consent processes for invasive procedures are usually in place, these often lack focus on the risks associated with a high exposure to ionising radiation. these two medico-legal areas, suspected non-accidental injury and risk communication, are commonly encountered by radiographers and radiologists and as such it is important to make sure that we operate at the highest possible professional standards and in keeping with both regulations and best practice including the production of witness statements/contemporaneous notes. on rare occasions, we may find ourselves involved in legal proceedings as a witness or expert witness and it is thus important that we are all aware of the key considerations in this regard. session objectives: 1. to appreciate the need for radiographers to focus on more than just the imaging procedure in paediatric examinations. 2. to understand the extremely vulnerable nature of paediatric patients and the need for all health professionals to pay particular attention to this. a. professional responsibilities: an international perspective m. davis; dublin/ie (michaela.davis@ucd.ie) radiographers play a vital role in imaging children with suspected nonaccidental injuries. this session will also explore the wider role that radiographers have in child protection. current legislation and its implications will be explored from a variety of countries including those outside europe. in addition, case studies will be presented focussing upon child protection issues that have arisen in the x-ray department during imaging procedures. several of the barriers to radiographers becoming involved in child protection will be explored. radiographers and their contribution to child protection will be discussed and practical examples given. learning objectives: 1. to become familiar with current legislation and guidelines which have particular relevance to radiographers from an international perspective. 2. to appreciate best practice in child protection and the need for all radiographers to be aware of this. 3. to learn about child protection case reports involving imaging, radiologists and radiographers. a-085 08:58 b. risk communication in paediatric examinations j.l. portelli; msida/ mt (jonathan.portelli@um.edu.mt) medical imaging plays a vital role in the diagnosis and treatment of numerous medical conditions for millions of patients worldwide. however since most medical imaging examinations utilise ionising radiation, the associated risks of radiation exposure also need to be acknowledged, especially since high doses of radiation are known to cause adverse biological effects. medical imaging professionals should have a good understanding of the benefits and risks associated with the imaging examinations they perform, so as to ensure a high benefit-risk ratio for all patients undergoing diagnostic imaging procedures, and to be able to appropriately communicate such information to patients, their families and other healthcare professionals. this may be particularly more important when imaging paediatric patients, who are relatively more susceptible to the effects of radiation and receive a higher effective dose per unit of radiation when compared with adults undergoing the same medical imaging examination. indeed, following worldwide media attention about radiation incidents and their adverse effects, some parents/legal guardians may be concerned and reluctant to pursue important medical imaging examinations requested for their child, as they may have a misconception of the risks involved. in this regard, this lecture will seek to enhance awareness about the radiation doses associated with common paediatric imaging examinations; highlight the importance of medical imaging professionals having an appropriate understanding of benefits and risks associated with these examinations; and encourage such professionals to improve patient care by making use of this knowledge to have better discussions with referring clinicians, patients and their families. learning objectives: 1. to appreciate the frequency and radiation dose associated with certain paediatric imaging examinations. 2. to become familiar with the current status quo in the communication of radiation dose-related risks. 3. to understand best practice and potential considerations in providing accurate information to referring clinicians, patients and their families. c. what to do if you find yourself being called to give evidence m.d. viner; london/uk radiology is a powerful tool in the investigation of cases of suspected nonaccidental injury and suspicious death in children. the evidence obtained can be pivotal in bringing successful prosecutions against suspects and protecting the child and others from further harm. it is essential that evidence is obtained, recorded and presented in accordance with applicable rules of evidence in order to be admissible in court. it is thus important that those undertaking such examinations are appropriately trained, conversant with standards of evidence and maintain continuity of evidence throughout the investigation. this presentation will review rules of evidence for cases of suspected child abuse and their application to imaging examinations. it will examine the role of the radiographer and the importance of training and familiarity with legislation and guidelines that underpin forensic practice, highlighting the pitfalls that lawyers may exploit if procedures have not been followed. drawing on examples, it will discuss best practice from the radiographer's perspective, detailing the importance of continuity of evidence and maintenance of contemporaneous notes and witness statements. it will address key considerations for radiographers and others who provide evidence or act as an expert witness. imaging professionals play a pivotal role in the investigation of suspected child abuse. it is essential that this evidence is obtained, recorded and presented with regard to the applicable standards of evidence. for those called to give evidence, the importance of appropriate imaging protocols and procedures, detailed documentation and thorough preparation cannot be understated. learning objectives: 1. to understand the importance of contemporaneous notes and witness statements if involved in any forensic or suspected non-accidental injury examination. 2. to become familiar with the importance of continuity of evidence in forensic examinations. 3. to appreciate the key considerations if you are asked to provide evidence or act as an expert witness in court. brain tumours are the second most common neoplasms in children after leukaemia. as "paediatric brain is not just a small brain", paediatric brain tumours are not the same as tumours in adults. mri is a method of choice in their diagnosis in accordance with the principle alara in the paediatric population. by the age of approximately 3 years, supratentorial tumours dominate; later (4-10 years of age), the majority of children show infratentorial neoplasms which are pilocytic astrocytomas, most often found in the hemispheres, and medulloblastomas or ependymomas -in the fourth ventricle. after the age of 10, both groups are diagnosed with equal frequency. cerebral hemispheric tumours include astrocytoma which is the most frequent, teratoma in neonates, and in older children atypical teratoid/rhabdoid tumour, ependymoma, pnet, ganglioglioma and dnet. in the midline, we deal with chiasmatic or hypothalamic glioma, craniopharyngioma and germ cell tumours of the pineal region. extraparenchymal tumours are uncommon in the paediatric population. apart from the location, imaging pattern in various sequences, and contrast enhancement of the tumour, advanced mri techniques are helpful in establishing the diagnosis. dwi helps to differentiate between tumours of high and low cellularity showing low adc values in case of medulloblastoma and high in astrocytoma. mrs, pwi and dti also add important information to the diagnosis. mri of the spinal canal is obligatory in case of these primary brain neoplasms that have a high propensity to metastasise to other parts of the central nervous system such as medulloblastomas, ependymomas, high-grade gliomas, cerebral neuroblastomas, and pineal region neoplasms. learning objectives: 1. to learn about the difference between paediatric and adult brain tumours. 2. to understand the imaging strategy for the paediatric population. 3. to become familiar with the most common paediatric brain tumours. pancreatic endocrine tumours (p-nets) include both pancreatic neuroendocrine tumours associated with a functional syndrome (functional p-nets) and those associated with no distinct clinical syndrome (non-functional p-nets). non-functional p-nets may show immunohistochemical positivity for hormones which may be produced, but not secreted, which are clinically inert and whose serum concentrations are insufficient to induce symptoms. among functional p-net, the most common are gastrinomas and insulinomas, whereas those secreting vasoactive intestinal peptide, glucagon, somatostatin and other hormones are considered together as a group called rare functional p-nets. non-functional p-nets are classified, according to the who 2010 classification, in well-differentiated neuroendocrine tumours and poorly differentiated neuroendocrine carcinomas (necs) of small or large cell type. well-differentiated neuroendocrine tumours are then divided according to a grading scheme based on mitotic count or ki67 index in nets-g1 (with a mitotic count < 2 per 10 high-power fields (hpf) and/or 2% ki67 index), and nets-g2 (with a mitotic count 2-20 per 10 hpf and/or 3-20% ki67 index). all poorly differentiated neuroendocrine carcinomas are graded g3 (with a mitotic count > 20 per 10 hpf and/or > 20% ki67 index). most pancreatic nonfunctional p-nets are well-differentiated tumours, whereas poorly differentiated neuroendocrine carcinomas are uncommon. pancreatic endocrine tumours (p-net) are divided into functional p-nets and non-functional p-nets. diagnostic imaging of these tumours includes detection, characterisation and staging. there are significant differences when dealing with functional p-nets and non-functional p-nets. in fact, in the first case the main aim of diagnostic imaging modalities is the detection of the tumour, while for non-functional p-nets the main aim is the characterisation and the differential diagnosis with other tumours of the pancreas, mainly with pancreatic adenocarcinoma. staging is also important for both tumours, but mainly for non-functional p-nets. a large number of imaging modalities are available, both "morphological" and "functional". we can arbitrarily divide the imaging modalities for the diagnosis of p-nets into three levels: the first level includes us (with contrast-enhanced us), mdct, mri and nuclear medicine techniques; the second, endoscopic us, angiography and venous sampling; the third, intra-operative us. functional p-nets are represented mainly by insulinomas and gastrinomas which are small in size in most cases. their detection is still difficult, but significant improvements have been made with us, mdct and mri, so that these tumours are detected in most cases if appropriate imaging techniques are performed. however, still, no single modality is 100% effective. non-functional p-nets can be differentiated from pancreatic adenocarcinoma, since they are hypervascular and usually large in size. since they are potentially malignant, they require accurate staging by imaging modalities, both morphological (mdct, mri) and functional (pet/ct) to plan surgery and chemotherapy. there is worldwide consensus about surgical treatment of resectable p-nets in the following clinical situations: proven malignancy, whenever it is possible to remove the primary tumour and at least 90% of liver metastases (debulking); p-nets associated with a clinical syndrome caused by hormonal hypersecretion (insulinomas and gastrinomas mainly); non-functional p-nets with a size larger than 2 cm. vice versa, there are different expert opinions about the surgical treatment of functional and non-functional p-nets in men1 syndromes and in sporadic non-functional p-nets less than 2 cm in size. in men1 all insulinomas should be resected, while for gastrinomas the extent of resection is patient tailored, deserving standard whipple for selected cases. in the most common sporadic small incidentalomas, where long-term prognosis is favourable, surgical treatment has to be weighted with co-morbidities and morbidities of the patient and the procedure planned. these tumours have a risk of node metastases at the time of diagnosis in less than 10 % of patients. whenever possible, mini-invasive approach with pancreas-sparing operations should be recommended. in elderly patients, a first period of follow-up should be preferable and surgery should be offered only if the size of the tumour demonstrates increasing trends. the "acute aortic syndrome" includes three closely related emergency entities of the thoracic aorta: aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. as these conditions present with similar symptoms, cross-sectional aortic imaging is essential for diagnosis, triage and treatment planning. initial imaging features of these pathologies including typical early complications as well as their differential diagnosis will be reviewed. as nowadays several of these patients will undergo early endovascular thoracic aortic repair, an update on its indication, the different technical options and their clinical results will follow. finally, the focus will be on repair-related late complications and progression of aortic disease. imaging follow-up protocols, features of chronic complications and their interventional repair will be discussed. a. pre-therapeutic radiological evaluation j. ferda; plzen/cz (ferda@fnplzen.cz) the acute thoracic aorta syndrome covers patients suffering from acute chest pain and those injured during high-energy trauma. despite the similar symptoms, the aortic pathologies are heterogeneous, including acute aortic injury, intramural haematoma, aortic dissection, and ruptured thoracic aortic aneurysm and mycotic aneurysms. the diagnostic approaches could include the whole pallete of the imaging modalities: chest x-ray, transesopheageal echocardiography (tee), multidetector ct angiography (mdcta), mri and pet/ct. because of some disadvantages of tee, like problems with intubation in injured patients or problems of mri with seriously ill patient monitoring, mdcta has become the most used modality due to its ability of discrimination between aortic and non-aortic pathologies, and also due to its high sensitivity, specificity, availability and especially superior geometrical resolution and potential of 3d imaging. the proper pre-therapeutic mdcta protocol is using sub-millimeter isotropic resolution covering the entire aorta with pelvic arteries. when the pathology of thoracic aorta is found during the triple rule-out triage protocol, additional mdcta of the rest of the aorta and pelvic arteries has to be completed. ecg triggering could be an important advantage in the reduction of pulsation-derived artefact. the volume of applied contrast material used should be as small as possible to plan applications during endovascular treatment. 3d reconstruction of the thoracic aorta with its side branches and advanced vessel analysis have a crucial role in the measurement of the aortic diameter, diameter profile and lengths in the selection of proper stent graft type and size. they can be accommodated even in patients with small vessels and tortuous anatomy. calcified arteries can be no longer considered absolute exclusion criteria. some devices are designed to reduce the incidence of endoleaks, improving sealing capabilities by the use of a polymer to better adjust to the variable morphology of the proximal neck or to fill the aneurysmatic sac completely. more importantly, the introduction of fenestrated devices has resolved the problem of facing difficult anatomies when the aneurismatic pathology involves renal or visceral arteries. obviously, the use of these new devices requires a learning curve. beyond an increase of cost, they permit treating those patients who in the past were considered unfit candidates for evar. the evar new frontier requires performing the procedure in an outpatient fashion. a multicentre study was conducted on 100 patients who were discharged 4/6 hours after uncomplicated stent-graft implantation. cases (4%) with access vessel complications required additional procedures and patients were hospitalised overnight. the 30-day readmission rate was 4% for access vessel stenosis or false aneurysm. from the time of the first evar procedure, significant improvements have been achieved but there is still room for further progress. the standard imaging modality after endovascular treatment for thoracic aortic pathology (tevr) is ct angiography (cta). cta enables the radiologist to assess for the patency of the endografts, the presence of any complications after tevr, and the development of any new pathology related not only to the aorta, but elsewhere above and below the diaphragm. the role of mr is reduced compared with cta, particularly in the presence of stainless steel endografts. however, good images can be obtained by mri and mra if nitinol endografts have been inserted. mr is a useful modality for follow-up in young patients who require lifelong follow-up and, therefore, limited exposure to ionising radiation. ultrasound has no practical role in the follow-up after tevr, and although plain thoracic radiographs are routinely performed by some centres post-tevr, in practice almost equivalent information can be obtained by ct. the main complications after tevr are endoleaks, type a dissection, paraplegia and stroke. the classification of endoleaks is similar to the classification for evar. type 1 and type 3 endoleaks require treatment by additional endograft coverage with or without supraaortic or visceral artery bypass. other treatment options include the use of branched, fenestrated endografts or the use of chimneys and snorkels. type 2 endoleaks are less common than post-evar. similar to the evar population, intervention is mandated for an enlarging aortic diameter and involves embolisation in most cases. interventional oncology is a discipline that uses imaging-guided procedures in the treatment of cancer patients. when the malignant disease in not curable, interventional techniques such as biliary and oesophageal stenting can provide useful palliation and improve the patient's quality of life. in patients with potentially curable tumours, thermal ablation, cryotherapy and radioembolisation provide useful alternatives to radiotherapy and surgery in carefully selected patients. interventional radiologists who treat patients with cancer should practise as clinicians, participating in multidisciplinary meetings where treatment choices can be discussed with specialists from other oncological disciplines. they should involve themselves in all stages of clinical practice, including pre-treatment consultations, ward rounds and patient follow-up. radiation oncology and interventional oncology have much in common, including the potential for curing cancer using minimally invasive techniques. interventional oncologists can usefully adopt many of the principles and methods of practice in radiation oncology, including quality assurance and the collection of robust outcome measures. an alliance between these disciplines would be beneficial to clinical practice and research in both disciplines. session objectives: 1. to understand the contribution of interventional radiology to oncology. 2. to appreciate the areas of overlap between radiation oncology and interventional oncology. 3. to understand the need for a clinical pattern of practice in interventional radiology in oncology. the current scope and future challenges j.i. bilbao; pamplona/es (jibilbao@unav.es) together with chemotherapy, surgery and radiotherapy, interventional radiology (ir) is the fourth pillar in oncology. transcutaneous and endovascular procedures, guided by imaging, constitute a fundamental knowledge essential for the multidisciplinary management of oncologic patients. the range is wide and covers most of the needs in patientâ´s care. in short: obtaining samples for making an accurate diagnosis and also to know more about its specific biology (biomarkers); ir covers any possibility needed for vascular access; percutaneous needle ablation is the best alternative in selected patients; endovascular embolisation with "vehiculisation" of therapies is an outstanding method for selective treatment, and sometimes precise ablation, of different tumors; ir is a unique way to offer palliation in a wide range of tumoral complications, such as embolisation for bleeding, stenting for vein obstructions or drainage of fluid collections. there is an obvious need of continuous technical refinement. image-guided therapy is a continuous process that implies many disciplines and that includes every step, from staging through guidance of the procedure to the evaluation of the outcomes, both immediately, during and in the follow-up. future developments in ir may be focused towards the personalisation of therapies to each patient and to a better understanding of the biological mechanisms of tumour response or progression and their image expression. finally, radiologists must be actively involved in the whole process of clinical trials, from the creation of new lines to the performance of therapy until the evaluation and diffusion of the data. radiation treatment has a fundamental role in the multidisciplinary management of people with cancer. the evidence base for radiation therapy is robust and approximately 50% of people diagnosed with cancer will benefit from radiation treatment. most of this benefit comes from an increase in cure. the technical quality of delivery of radiation treatment is of great importance in avoiding a geographic miss and also in reducing the amount of normal tissue being irradiated unnecessarily. as well as the excellent technical delivery of any treatment offered, of paramount importance is the intelligent integration of care with attention to evidence base choices for both local and systemic treatment. multidisciplinary teams are in the best position to integrate surgery, radiation treatment, interventional oncology and systemic therapy in a planned and deliberate fashion. best practice: how to organise an interventional oncology unit a. gangi, j. garnon, g. tsoumakidou; strasbourg/fr (gangi@unistra.fr) interventional oncology is a fast growing field. interventional oncology is a clinical and technical speciality. solid clinical knowledge associated with the technical skills is mandatory for a successful practice. the technical skills should be associated to the clinical part. the knowledge of all treatment modalities and the participation of a multidisciplinary team is vital for the best practice. every single patient should be seen by the interventional oncologist and followed-up. the interventional oncologist is part of a multidisciplinary team, taking care of the patient. the team includes oncologists, radiotherapists, pain specialists, psychologists, surgeons, and anesthesiologists. the interventional oncology unit should include specialised nurses, technician, anesthesiologist, anesthesiologist nurses, and the interventional radiologist. the team should be able to take care of the patient's follow-up and eventual complications. to summarise, high-quality interventional oncology services are essential for safe and effective patient care. the technical skills of the interventional oncologist should be associated with an excellent clinical knowledge of the disease. a multidisciplinary team work is mandatory for a successful interventional team. harmonisation of training and appropriate credentialing is required for clinical services of the best quality. interventional radiologists continuously improving their skills and knowledge, patient access to safe and effective minimally invasive treatment options is increasing. whereas cardiac ct and mri are routine examinations for specialised radiologists, it has been necessary to wait for the introduction of fast scanning techniques to modify the behavior of nonspecialised radiologists regarding the interpretation of cardiac cavities. the objective of this session is twofold. first, cardiac radiologists will underline the role of these imaging modalities in the assessment of congenital heart disease but also in ischaemic and nonischaemic cardiomyopathies. in the second part of this session, chest radiologists will focus on the diagnostic information accessible at the level of the right ventricle, known to be the target of numerous respiratory disorders. two practical situations will illustrate this approach: pulmonary thromboembolic and chronic respiratory diseases. accurate assessment of the right ventricle (rv) is crucial for the management of congenital heart disease. echocardiography can provide some information, but as the rv sits directly behind the sternum and as many patients have undergone multiple operations, visualisation can be difficult. furthermore, for long-term follow-up and treatment planning, accurate measurement of ventricular size and mass, and valvular flow (tricuspid and pulmonary), and assessment of anatomy in 3d and 4d are vital. this presentation will outline the role of cross-sectional mri and ct for assessing the rv, and describing the indications, imaging protocols, technical pitfalls and relevant information for treatment planning. right heart failure in ischaemic and non-ischaemic cardiomyopathies m. grothoff; leipzig/de (matthias. grothoff@herzzentrum-leipzig.de) the role of the right ventricle (rv) has been underestimated for many years. today, we know that the rv is of importance for keeping up a sufficient circulation and that right heart failure in both ischemic and non-ischemic cardiomyopathies can result in hemodynamic compromise. rv ischemia has a higher in-hospital morbidity and mortality but post-infarction chronic right heart failure is a rare finding. as the rv has a different physiology from the left ventricle (lv), also the pathophysiology of ischemia is different here. using our standard cmr tools t2 weighted imaging for detection of edema and late gadolinium enhancement imaging for detection of necrosis/scar we can find that the rate of myocardial salvage is much higher in the rv than in the lv and that rv failure in the acute phase is basically caused by reversible ischemic effects. in non-ischemic cardiomyopathies like hcm and dcm changes in the rv myocardium mostly resemble changes of the lv. in arrhythmogenic right ventricular cardiomyopathy/dysplasia (arvc/d) however, there are specific findings in the rv and the role of imaging in diagnosing arvc has been strengthened by the revised task force criteria published in 2010. cine imaging should be performed carefully for detection of rv akinesia, dyskinesia or small aneurysms as well as the planimetry of the rv. findings like the detection of fibrosis in lge imaging and the detection of fat in t1 imaging can provide additional information, but are not diagnostic for arvc. learning objectives: 1. to learn about the different ct and mri techniques for evaluating right heart morphology and function. 2. to understand the prognostic impact of right heart involvement in ischaemic heart disease. 3 . to learn about the basic morphological and functional features of different non-ischaemic cardiomyopathies. right heart and chronic respiratory diseases: can ct be used as a onestop-shop? m. remy-jardin; lille/fr (martine.remy@chru-lille.fr) over the last decade, ct technology has evolved towards fast scanning capabilities and high temporal resolution, enabling improved evaluation of the heart and surrounding structures in the course of routine thoracic ct imaging. this has progressively modified the radiologist's implication in the interpretation of chest ct examinations. firstly, it is more and more common to integrate the physiological interactions between heart and lung when analysing the ct features depicted on a given examination. secondly, it is now possible to integrate cardiac functional information into a diagnostic ct examination of the chest, providing prognostic information in the management of patients with a wide variety of chronic respiratory disorders. the purpose of this presentation is to provide non-specialised radiologists with some practical guidelines in the choice of the scanning protocols and range of functional information that can be deducted from chest ct examinations. right ventricular dysfunction and levels of pressure within the pulmonary circulation are the key points of such approaches. learning objectives: 1. to appreciate the clinical impact of a cardiothoracic evaluation from the same ct examination. 2. to learn about the scanning protocols enabling such a combined analysis. 3. to understand its compatibility with other non-invasive modalities. rv and prognosis in pulmonary thromboembolic disease n.j. screaton; cambridge/uk (nicholas.screaton@papworth.nhs.uk) right ventricular failure is the most common cause of early death following acute pulmonary embolism and in patients with chronic thromboembolic pulmonary hypertension. echocardiography is sensitive in diagnosing and quantifying rv dysfunction. ct is the reference standard for the diagnosis of acute pe diagnosis and has the potential to provide comprehensive evaluation of the pulmonary arteries, heart and lung parenchyma. ct signs of right ventricular dysfunction which have shown predictive value for adverse outcome include: flattening of the inter-ventricular septum or bowing towards the left ventricle, reflux of contrast medium into the ivc, relative rv/lv diameter ratios on transverse and 4-chamber reconstructions, and ventricular volumetry as assessed both on routine non-gated ctpa and ecg-gated ct. in patients with cteph, mri permits imaging of the pulmonary vasculature and functional evaluation of the right ventricle and pulmonary circulation, enabling both morphological assessment and prognostic evaluation. learning objectives: 1. to learn about clinical and imaging factors associated with prognosis of thromboembolic disease. 2. to understand the benefits and weaknesses of different imaging modalities in predicting prognosis in thromboembolism. 3. to discuss the merits of comprehensive imaging evaluation in the routine diagnostic workup of suspected thromboembolic disease. multimodality imaging including ultrasound has within recent years been introduced in several anatomical regions. pet, ct and mri datasets can after an initial co-registration be fused and shown either side by side or using overlay on screen while doing real-time ultrasound; thus, the pet, ct or mri dataset is reformatted in a projection to fit the real-time ultrasound images. several methods of aligning the images are available and have been shown to have a high accuracy. image fusion involving ultrasound has been tested in phantoms, animals and in patient studies, mainly in abdominal imaging. by combining several imaging modalities, it is possible to benefit from the strengths of each modality. it is useful for characterisation of and intervention on liver lesions, abscesses containing air and lesions in areas with poor overview by ultrasound. also, the method is useful for characterisation and biopsy of pet-positive lesions, especially in patients with a history of cancer. the background of the method and clinical examples, mainly from abdominal applications, will be covered. also, perspectives and future research topics will be highlighted. contrast-enhanced ultrasound (ceus) has proved to improve the detection and characterisation of pathologies compared to conventional ultrasound, ct and mri in a number of indications. ultrasound contrast agents (uca), which are purely intravascular, do not show any interstitial diffusion or glomerular filtration like iodinated complexes or gadolinium chelates. dynamic contrastenhanced ultrasound (dce-us) allows to display the enhancement of a lesion with a high frame rate after bolus or infusion administration of uca, and to compare enhancement profiles between normal and abnormal tissue. quantification of dce-us is useful to quantify tumour enhancement and to limit intra-and interobserver variability. mathematical models with several perfusion parameters can be used. dce-us has shown to be of interest after antiangiogenic therapies as it allows an earlier evaluation of tumour response than usually done with ct and mri, which remain mainly based on the recist criteria. the common perception of 3d ultrasound (us) is of surface-rendered images, especially of the foetus. the same approach, enhanced by new transducer technology and software, can be used to take ultrasonography to another level in general body imaging, providing different image presentations and working practices similar to those of ct and mr. the technology involved in a us volume acquisition was represented initially by mechanical 3d transducers, and more recently by purely electronic, matrix probes. this latest technology allows bi-plane real-time acquisitions, fast switch to volume acquisition up to 100 degrees, and 4d acquisitions with acceptable frame rates. protocols have been described for major abdominal and retroperitoneal organs, with fast optimisation of acquisition settings. the technology supports contrastenhanced ultrasound (ceus). after volume acquisition, interpretation for volume us datasets requires a post-treatment phase, including multi-planar reconstruction, multislice imaging, and volumetric analysis. virtual cystoscopy and volume ceus quantification are new options. the implementation of this new, efficient us modality in a radiology department supposes deep changes in the daily practice with delayed post-treatment reporting times. it should represent a more effective way for comparison between different examinations and a better communication tool with clinicians. the proven and potential benefits, in terms of clinical accuracy, training, workflow and overall efficiency, will be discussed. the purpose of this lecture is to emphasise some pitfalls in liver imaging. morphologic changes in the liver are usually attributed to chronic liver disease where liver cirrhosis represents the most important cause. however, noncirrhotic diseases may also induce atrophy-hypertrophic changes of the liver. the most common mechanisms are related to venous obstruction (either portal or hepatic venous) and biliary obstruction. multidetector ct and mr imaging are essential to highlight these abnormalities. when dealing with liver tumours, the most important question that has to be solved is tumour characterisation. yet, it is often difficult to assess whether a large tumour is intra-or extrahepatic. imaging findings that might be helpful will be shown. last, some liver lesions can mimic liver tumors. vascular disorders and focal fatty changes or focal fatty sparing are the most common causes. some other conditions can be also mimickers and such cases will be shown. the technique and the anatomy of the bile duct and pancreatic duct will be described. the anatomical variants of the biliary duct and the pancreatic duct system will be analysed and their possible role in generating diagnostic imaging pitfalls described. strategies to avoid pitfalls in diagnostic imaging of the bile duct and the pancreatic duct system will be illustrated, considering the possible source of pitfalls. diagnostic imaging findings of different diseases involving the biliary ducts and pancreatic duct system will be illustrated, as well as the diagnostic imaging criteria useful for the differential diagnosis. over the last two years, the number of ct and mri units has increased by 30%, and modern pet centers and leading centers for radiotherapy have been built. we can identify an approximately 20% increase in the number of radiological research projects--mainly ultrasound, ct, and mri investigations. during the last ten years the total number of vascular interventions and mr studies has increased by ten times, four times for ct, and the annual growth of us and x-ray investigations is about 10%. unfortunately, these technical innovations are not always accompanied with pacs and ris installations; this is a reason why all advantages of digital equipment are not achieved. we see rapid development of private medicine; new private hospitals and ambulances have grown by more than 10% and investment companies are looking for new projects in this field. however, the professional education of radiologists is not enough to work with new diagnostic equipment. this is a reason why in 2014 we will start a pilot project to create a new system of continuing medical education in clinical medicine, including diagnostic radiology. we hope, this pilot project will increase the efficiency of clinical practise. differential diagnosis (dd) including tumour and non-tumour brain pathologies is an integral part of neuroradiological diagnostics and in some cases is a challenge to experienced neuroradiologists. more than 5000 patients with different cns pathologies have been investigated in the department of neuroradiology, burdenko neurosurgical institute since 2002. in the vast majority of the cases, there were tumours. we used deconvolution method for bv, bf, mtt and ps maps reconstruction on commercially available software (perfusion 1.2.0, 4.0 protocols, adw, ge). ct perfusion has demonstrated high level of information in determining the degree of malignancy in glial brain tumours. a strong correlation between bv and ps and tumour degree has been demonstrated. the use of ct-pwi makes it possible to successfully carry out dd between radiation necrosis and tumour progression. some histological types of brain lesions are characterised by unique haemodynamic properties which enable using this method as non-invasive "biopsy". ct-pwi has been especially useful in dd of the skull base region, bone and extracranial pathologies. the absence of artefacts created by the skull base bones makes this method especially valuable as compared to the mri t2*-and asl-perfusions. ct-pwi makes it possible to successfully differentiate tumours and a number of non-tumour cns lesions including demyelinating diseases, infectious and non-infectious granulomas, etc. ct-pwi is a powerful method for differential diagnosis of brain pathology. t-pwi can provide unique functional information regarding tumour pathophysiology and haemodynamics, which are not available with routine ct and mri. learning objectives: 1. to become familiar with the technique of brain perfusion ct. 2. to understand the added diagnostic value of perfusion ct. 3 . to learn about input of ct perfusion for assessment of treatment. interlude: development and use of web-based teleradiology in russia o.s. pianykh; newton highlands, ma/us (opiany@gmail.com) the largest territory in the world, russia, presents a perfect teleradiology use case of extremely unevenly distributed health care, concentrated in moscow and spread thin outside over an enormous area and sparse population. this unevenness deeply affects the quality and availability of radiological services, and cries out for efficient and practical teleradiology solutions. however, the same unevenness in medical expertise, financing and it infrastructure frequently acts against the advancement of teleradiology projects, blocking their natural progress. as a result, technical, financial, educational and clinical matters, interleaved into the nascent russian teleradiology ventures, require serious and predictable solutions, based on analysis and adaptation of already developed, internationally proven strategies. currently, russian teleradiology simply takes advantage of whatever is available to make its progress better, but needs to develop itself up to the tasks it faces. tuberculosis in russia: a challenge for a national radiological service i.e. tyurin; moscow/ ru (igortyurin@gmail.com) approximately, 1.7 billion people worldwide are infected with mycobacterium tuberculosis, of which 20 million are active cases. the reasons for resurgence of tb infection include the hiv epidemic, a rise in reactivation disease in the elderly, a growing migrant population and spread of drug-resistant strains. the incidence of atypical tb infection is also on the rise, of which mycobacterium avium intracellulare is the most important human pathogen. the pathologic form of the pulmonary infection depends on the sensitivity of the infected host and is classified as primary or postprimary. primary tb pattern represents infection resulting from recent contact with the pathogen. postprimary tb pattern results from reactivation of a dormant focus within the lungs. thoracic tuberculosis produces a broad spectrum of radiographic abnormalities. the radiological patterns had been described as parenchymal, airway, vascular, mediastinal, pleural, and chest wall lesions. common causes of a missed diagnosis of thoracic tuberculosis are failure to recognise hilar and mediastinal lymphadenopathy as a manifestation of primary disease in adults, overlooking of minimal productive lesions or reporting them as inactive, and failure to recognise that an upper lobe or superior segment of lower lobe mass might be tuberculosis. in aids patients, the imaging features depend on the degree of immune suppression. a pattern of postprimary tb is also usually seen among patients with decreased immunity due to alcoholism, renal failure, diabetes mellitus, ageing, malignancy, and renal and cardiac transplantation. learning objectives: 1. to understand the scope of the problem with tuberculosis screening in the russian federation. 2. to learn about the changing imaging patterns of thoracic tuberculosis. 3. to appreciate the current role of imaging in the differential diagnosis and follow-up of this pathology. interlude: mystery of denisov's cave and paleoradiology m. mednikova; moscow/ ru (medma_pa@mail.ru) this study focuses on the anatomical identification of fossil bones from altai highland in southern siberia, their radiological description, and parallels among other hominin fossils. methods describe the small and isolated tubular bones. we used microct versaxrm-500 by xradia inc. and digital microfocus x-ray. denisova cave is the best studied paleolithic cave in north asia. archaeological data suggest that about 300 thousand years before the present, a group of humans migrated to southern siberia from the west. their descendants had lived in the altai mountains in relative isolation for 250 thousand years. the taxonomic status of the early inhabitants of southern siberia was clarified thanks to palaeogenetic studies. it was concluded that the altai hominin was genetically twice further from modern humans than were neanderthals. phylogenetic analysis suggests that this clade diverged from that ancestral to humans and neanderthals very early -about 1 billion years ago. descendants of this clade apparently survived in the altai refugium until the period 50 -40 thousand years ago. due to structural patterns of preserved pedal and manual phalanxes, humans from denisova cave could be expected to be the bearer of "archaic" traits. the extraordinarily thick walls of tubular bones in adults reflect a high level of occupational stress. radiological volumetric microscopy of the denisovan girl phalanx gave evidence for the histological estimation of the developmental age. radiological methods seem to be the perspective approach in the study of rare and fragmentary fossil human remains, differentiating between archaic and modern humans. advances in imaging of pancreatic masses g.g. karmazanovsky; moscow/ru (karmazanovsky@ixv.ru) modern diagnostic radiology allows not only to detect pancreatic tumours, but also to carry out their differential diagnosis with high accuracy. this is especially important because many benign tumours of the pancreas do not require immediate surgery. at the same time, many benign tumours may become malignant. the differential diagnosis of the pancreatic cystic lesions using endoscopic ultrasound and magnetic resonance pancreaticocholangiography has now become particularly accurate. contrast enhancement allows detecting signs of tumor invasion into the main blood vessels and adjacent organs. modern developments of radiology help to use extended operations for malignant tumours and sparing surgery with minimal removal of intact functioning pancreatic tissue in benign tumours. learning objectives: 1. to become familiar with major types of pancreatic masses and their radiological manifestations. 2. to understand approaches to the selection of diagnostic pathways in pancreatic tumours. 3. to become acquainted with new developments in diagnostic imaging of pancreatic tumours. interlude: an artistic view of ct a.l. yudin; moscow/ ru (prof_yudin@mail.ru) radiology is a specialty based largely on figurative perception of diagnostic imaging. the radiological picture of many symptoms reminds one of objects and environmental phenomena (for example, vanishing lung, draped aorta, geographic liver, porcelain gallbladder, dirty fat and others). training of creative mentation promotes lasting assimilation of educational material at the associative level. metaphorical thinking skills can also be improved by searching for amusing fragments in radiological images similar to the objects in everyday life; animals, cartoon characters, and others. the essential help in the study of the physical foundations of radiology and functional capabilities of workstations provide the execution and study of x-ray films, ct or mri of fruits and vegetables, flowers, various artifacts and other objects in the environment. eventually, it is just beautiful. ultrasound of the breast is an established imaging technique with several advantages. it has been used to differentiate solid from cystic breast lesions for a long time. it has also been increasingly used to visualise small lesions in mammographically dense breasts and is the initial imaging method of the breast in young women. the features of the lesions that need to be analysed are: shape, relation to anteroposterior to laterolateral diameter, margins, internal structure and absorption of sound (distal acoustic phenomena). color doppler enables the thorough assessment of flow within the breast lesions. elastography is established as a useful method to differentiate breast lesions on the basis of their stiffness, which can be quantified. the accurate staging of axillary disease is an important aspect in the management of patients with breast cancer. it is recognised, however, that underlying malignancy can be found in lymph nodes that appear morphologically normal. a variety of morphological features that may be seen in pathological nodes have been described (cortical thickness of > 3.5 mm and absence of a fatty hilum). the automated breast ultrasound technique has been known for a long time, but with recent improvements now may play an important role. the automated breast volume scanner (avbs) employs frequencies of 5-14 mhz. avbs has various major advantages, such as being independent of the experience of the operator as well as supplying consistent and reproducible results. additionally, for the first time it has become possible to obtain coronal images of the complete breast, which greatly assists in the planning of surgical interventions. to study the technical basics in breast ultrasound (us), a breast scanning phantom helps to understand different us settings of greyscale imaging. typically, breast us work has a linear array transducer with a minimum field of view of 3.8 cm and a high frequency of minimum 7 mhz. a broadband transducer (e.g. 6-16 mhz) with different bands is preferred. in the central axillary area, a lower frequency band offers a deeper penetration depth. high frequencies improve the tissue contrast and optimise the axial and lateral resolution. the transmitter focus is adapted to the region of interest. highly sensitive color doppler detects slow flow rates (1 cm/s and less). for frequencies and power settings used in diagnostic greyscale and color doppler studies, no safety limitations have to be considered. breast us is mainly used as a second-line imaging tool to mammography (mg). a correlation between both imaging modalities is crucial. skin markers and additional mgs may help to solve the correlation problem. in bi-rads 4 or 5 us lesions with unclear correlation in mg, a marker placement after us-guided large-core needle biopsy helps to clear the problem. the pathomorphological growth pattern of a lesion is the basis to understand different imaging aspects with different modalities. second-look us after mri is an important correlation of lesions, which were first visible with mri. understanding the complementary imaging criteria will help to reduce the number of false-positive results. a practical imaging approach to brain and neurovascular trauma will be reviewed, with an emphasis on understanding the correlation between pathophysiology and imaging signs. guidelines on when to order acute neurovascular studies will be presented. special technical considerations to help optimise ct and mr imaging protocols for suspected brain injury, cns haemorrhage, and arterial dissection will be discussed. neurological emergencies are often associated with high morbidity and mortality, and thus require prompt diagnostic and therapeutic action. nontraumatic emergencies may however have a subacute onset, and radiological signs may be subtle, which can lead to delay in diagnosis and treatment. since clinical features are often nonspecific, the radiologist may be the first to point the clinician in the direction of the correct diagnosis. it is therefore of great importance that the radiologist is aware of and familiar with the various imaging findings, on both computed tomography (ct) and magnetic resonance imaging (mri), of non-traumatic neurological emergencies. these include vascular, infectious and inflammatory diseases. commonly encountered emergencies are ischaemic and haemorrhage stroke, venous thrombosis, arterial dissection, abscess, acute disseminated encephalomyelitis (adem), and encephalitis. radiological findings in rarer diseases may mimic those in the more commonly occurring diseases, but need to be correctly interpreted as therapeutic strategies and prognosis may be entirely different. such entities include for instance posterior reversible encephalopathy syndrome (pres), reversible cerebral vasoconstriction syndrome, susac's syndrome, and status epilepticus. furthermore, initial findings of (impending) complications of brain disease, such as hydrocephalus and herniation of brain structures, may be subtle, while early recognition allows for prompt and adequate intervention. finally, diagnostic and therapeutic interventions performed in an emergency setting may interfere with the diagnosis and interpretation of clinical and imaging findings. associated limitations and pitfalls therefore need to be recognised to avoid false-negative or false-positive diagnosis, respectively. learning objectives: 1. to learn about the modalities (ct/mri) and protocols for non-traumatic neurological emergencies. 2. to learn how to diagnose the main non-traumatic neurological vascular and non-vascular emergencies. 3. to become aware of the pitfalls and limitations of clinical presentation and imaging findings in non-traumatic neurological emergencies. the current century has brought with it new challenges in radiation protection, many of which follow the development of mdct which greatly enhanced diagnostic capabilities and substantially reduced scanning time to just a single breath-hold for chest ct, making ct scanning both patient-friendly and the physician's preferred tool. ct has also been added to nuclear imaging systems to create hybrid scanners (pet/ct; spect/ct image gently 5 years later: lessons learned in radiation protection for children. the alliance for radiation safety in pediatric imaging was founded in 2007 to promote radiation protection for children worldwide through awareness, education and advocacy. comprising over 75 medical professional societies and agencies, the alliance seeks to change practice locally for improved paediatric patient safety in medical imaging. since its inception, the alliance has had 6 campaigns in ct, diagnostic and interventional radiology, nuclear medicine, digital radiography and an outreach campaign to parents and 3 educational summits. yet, there is still work to be done. there is a need for parents and patients to receive information about their imaging test prior to the performance of imaging procedures, particularly those involving ionising radiation. the paediatric medical imaging community should work tirelessly with the manufacturers of imaging equipment to tailor equipment for children to optimise the study and ensure that the users of the equipment are knowledgeable in its safe use in children. the routine display of size-specific dose estimate on ct scanners will better estimate patient dose for quality improvement within facilities and in dose registries. finally, there is a need for diagnostic reference levels in paediatric radiology. this presentation will update the audience in progress to date regarding these challenges. the image wisely programme continues to move forward, guided largely by its steering committee, composed of two representatives each from acr and rsna and one representative each from aapm and asrt. the image wisely website (www.imagewisely.org) has educational content for imaging professionals (radiologists, medical physicists, and technologists) and referring physicians. a patient tab features links to radiologyinfo.org and the image gently website. a tab for "my equipment" links visitors to radiation dose-related 'microsites' developed by ge, hitachi, philips, siemens and toshiba. as of august 29, 2013, 18,646 individuals, facilities and associations have taken the image wisely pledge. to attract traffic to its website, image wisely has recently instituted 'news' and 'top reads' sections on the splash page highlighting recent articles and announcement, highlighting breaking news coverage and journal publications on relevant topics. in 2012, content on nuclear medicine procedures was finalised, completing two of the three targeted foci of the initial action plan_ct and nuclear medicine. in october 2013, a launch meeting will initiate the process of developing content for the third target area, fluoroscopy. in 2012 and 2013, image wisely has concentrated on efforts to engage referring physician communities, with particular interest in paediatricians and emergency medicine physicians. progress has been slow, but has recently gained traction with emergency medicine in the form of radiologist participation in a 2015 symposium, diagnostic imaging in the emergency department: a research agenda to optimise utilisation, organised by the society of academic emergency medicine. learning objectives: 1. to learn about the image wisely campaign for radiation protection of adults. 2. to understand the lessons learnt while communicating messages. lessons from a national approach to patient safety in radiation protection p. cavanagh; taunton/uk (petecavanagh@gmail.com) in considering a european campaign on radiation awareness, it is useful to gain information from similar campaigns in health care. there have been a number of national patient safety campaigns based on the institute for healthcare improvement (ihi) 100,000 lives campaign initiated in the usa in 2006. following the success of this, a similar campaign was launched in england. part of this process included an analysis of the success of the programme and the key interventions and drivers that were considered essential at both the national and local level. these included strong leadership, 1. bone (pseudo)-tumours: the majority of bone tumours can be detected on plain radiography. the age of the patient, location of the tumour in a bone and history of pre-existing bone abnormality should be included in determining the likely diagnosis. careful analysis of pattern of bone destruction, periosteal reaction and matrix mineralisation allow for characterisation of most bone tumours and differentiation from pseudotumours. ct may be useful for osteoid osteoma and mri is the best imaging technique for further diagnosis and staging by displaying tumour composition and extent of bone marrow involvement, including skip lesions, presence and extent of extraosseous soft tissue mass, and involvement of neurovascular bundle, muscle compartments and adjacent joint. this allows to find the best biopsy and surgical approach. to evaluate local control of disease and for detection of local recurrence, mri is usually the best imaging technique. 2. soft tissue (pseudo)-tumours: the majority of soft tissue tumours can be detected on ultrasound. except for cysts and subcutaneous lipoma, mr will be the next imaging technique for diagnosis, local staging, and eventually to find the best biopsy and surgical approach. the age of the patient, location of the tumour and careful analysis of the signal characteristics on mri allow for characterisation of many soft tissue tumours and differentiation from pseudotumours. plain radiography and ct may be useful for detection of calcifications and myositis ossificans. to evaluate local control of disease and for detection of local recurrence, ultrasound and mri are the best imaging techniques. in this honorary lecture, i will review a number of personal impressions that may contribute to the successful performance of research projects in cardiovascular radiology. also, issues and obstacles in performing successful research in the field of radiology will be considered. key factors for success include guidance by inspiring mentor, genuine interest and motivation, some creativity and serendipity. radiology has developed tremendously with many innovative modalities over the last 25 years, providing ample opportunity to participate in clinical research. potential issues that should be addressed are subspecialisation, turf battles, competition from other clinicians/ imaging specialists and adequate training in radiology research. the field of imaging research includes traditionally more clinically oriented research by focussing on developing and testing of new modalities and applications, now becoming more basic by including molecular imaging, population imaging, outcome studies and alike. silicone-filled implants (single or double lumen) require a dedicated sequence where silicone exhibits a high signal intensity, whereas signals from fatty and fibro-glandular tissues are cancelled. diagnosis of intracapsular rupture relies on the detection of a linguine sign (direct sign) or multiple "key-hole" and/or " teardrop" images (indirect signs). extracapsular rupture is defined as the presence of silicone outside the capsule (breast, soft tissues, lymph nodes). breast reconstruction after mastectomy may involve autologous tissue flaps (skin, fatty tissue, muscle and fascia). the transferred muscle is inserted in front of the major pectoralis muscle and enhances after contrast medium injection. the most common benign findings seen in such reconstructed breasts and also after a breast-conserving treatment are oedema, seroma, haematoma, fat necrosis and fibrosis. diffuse thickening of the skin and trabeculae is usually observed the first year after completion of radiation therapy. small focal areas (less than 5 mm) of non-mass-like enhancement and thin linear or rim enhancement at the lumpectomy site can all be expected findings. these benign findings decrease progressively, but residual enhancement may be observed in 15% of women at 5 or more years. in patients who were switched from tamoxifen to aromatase inhibitors, a stronger or re-appearance of a background enhancement may be observed. before classifying such findings as benign or probably benign, clinical examination and standard imaging data must be taken into account. highly suspicious lesions in such patients are similar to bi-rads 5 lesions in the nontreated breast. prevention strategies for women at high lifetime risk of breast cancer are usually adapted to the individual woman's risk of breast cancer. women at high risk (brca mutation carriers or women with a 30% likelihood of brca-heterzygosity) are offered primary prevention, which includes chemoprevention by tamoxifen or surgery (risk-reducing mastectomy and/or salpingooopherectomy, where the latter also helps reduce the risk of subsequent breast cancer by 30%). if women opt for secondary prevention (active surveillance/screening), this has to start at 30 at the latest. mri is considered a compulsory component of all programs worldwide. due to the very limited added cancer yield of mammography in this subset of women, and because of the still unsettled issue of possibly increased radiosensitivity of brca-mutation carriers, mammographic screening is not recommended until the age of 40. there is broad agreement that (at least) an annual screening is important; especially for brca1 mutation carriers, screening every 6 months may be more appropriate. we recommend interleaved screening, with annual mri and annual ultrasound (â± mammography) phase-shifted by 6 months. there are important differences between brca1-and brca2-associated cancers in terms of age distribution and incidence rates, histologic features, but also specific imaging features which must be known by radiologists. mri screening protocols must be adjusted to the specific needs of this (usually very young) screening population. this presentation will review the current evidence with respect to screening of women at high familial risk of breast cancer and will provide information on all aspects mentioned above. chest trauma is directly responsible for 25% of all trauma deaths and is a major contributor in another 50% of all trauma mortality. blunt trauma, accounting for 90% of chest injuries, is the third most common site of injury in polytrauma patients. plain radiographs still have a role in recognition of some acute thoracic pathology that requires immediate further management, either diagnostically and/or therapeutically, such as tension pneumothorax, major transdiaphragmatic herniation, large hemothorax or obvious mediastinal hematoma. mdct of the chest is now typically included in a whole body scan with iv contrast to facilitate rapid diagnosis on polytrauma cases using less radiation than selected segmental scans. mdct is the well-proven diagnostic gold standard for chest injury evaluation. the major advantages of mdct over other modalities include identification of active bleeding, direct signs of trachea or esophageal injury, direct evidence of major arterial vascular injury, such as pseudoanurysms, pneumo and hemopericardium, location and extent of lung contusion and laceration, and assessment for thoracic spine, shoulder girdle and rib fractures. diaphragm injuries are well depicted by mdct, especially on the left by identifying both the torn diaphragm edges, herniation and constriction of abdominal contents at the level of the torn diaphragm (collar sign), and direct contact of herniated structures with the posterior chest wall (dependent viscera). tracheal injuries are suggested by diffuse and progressive pneumomediastinum, dilated tracheostomy cuff, ectopic endotracheal tube, and direct connection of mediastinal air with the trachea lumen. ct-angiography eliminates the majority of indications for diagnostic catheter angiography. pulmonary symptoms such as chest pain, shortness of breath or wheezing are common non-traumatic symptoms prompting er visits. because clinical symptoms are very non-specific, imaging plays a major role in differentiating life-threatening from less severe diseases and forming a diagnosis. the chest radiograph remains the first imaging despite its limited sensitivity for certain diseases and being prone to inter-observer variability. comprehensive cardiothoracic ct examinations using most modern ct equipment are well evaluated in their diagnostic accuracy to determine the presence of vascular life-threatening events such as aortic dissection, acute coronary disease or pulmonary embolism. protocols and literature evidence will be discussed. the main focus of the course, however, will lie on the analysis of pulmonary ct findings and its contribution to the differential diagnosis of pulmonary emergencies (e.g. pneumonia, oedema, pneumothorax, exacerbation of fibrotic or obstructive lung diseases) and how to further integrate imaging findings, laboratory findings, patient history and clinical information to tackle the differential diagnosis. imaging findings will be discussed by clinical case studies, key findings and also overlapping morphological features of other differential diagnosis will be discussed side by side, illustrating the options and also limitations of imaging findings. mentor was first introduced in greek mythology, and in its modern usage first recorded by a french writer, franã§ois fã©nelon, in 1699. since then, this concept has been widely used in the development of mentoring, mentorship and more recently of mentees, with an overarching principle based on accompanying, sowing, catalysing, showing and harvesting. this concept remains today as a fundamental one in all teaching activities and implies generally a close contact between the mentor and the mentee. however, the development of internet with concomitant e-learning capabilities, which are hugely increasing, raises the very challenging necessity to re-think this concept and to adapt it to this new era. the esr is very concerned by this endeavour in the context of the striking development of esor, on one hand, and with the launching of its e-library, on the other. n. gourtsoyiannis; athens/gr (gournick@gmail.com) the presentation "esor in action" gives an overview on all esor activities in 2013 and 2014. a detailed report on the esor courses and teaching programmes in 2013 is presented, containing statistics about the number of course participants and of scholarship and fellowship grants. additionally, all educational activities in 2014, including dates, venues, topics and local organisers, are announced. evidence-based radiology: the basics evidence-based medicine (ebm) was derived from clinical epidemiology during the last century. it "is the conscientious, explicit, and judicious use of current best evidence in making decision about the care of individual patients" (dave l. sackett, 1996) . this means integrating (1) individual clinical expertise with (2) the best available external evidence from systematic research and (3) patient's values and preferences. when considering evidence-based radiology (ebr), the needed expertise is not only clinical, but also technical, while (4) radioprotection issues assume a relevant value according to the "as low as reasonably achievable" (alara) principle. ebm (and ebr) can be practised according to the "top-down" model, when using guidelines issued by governmental, professional, or academic bodies, or the "bottom-up" model, when local physicians (1) formulate an answerable question, (2) search for the best evidence; (3) appraise critically; (4) apply findings to practice; and (5) evaluate the performance. a hierarchy of radiological studies has been established according to the investigated matter: 1. technical performance; 2. diagnostic performance; 3. diagnostic impact; 4. therapeutic impact; 5. patient outcome; 6. societal impact. different degrees of recommendations are based on different levels of evidence, with experts' opinion as the lowest level and meta-analyses of high-quality homogeneous studies and multicenter studies being the best level of evidence. to practise ebr, radiologists should be familiar at least with basic statistics and epidemiology as well as of methods for study design, thus recognising the principal types of bias which can limit the value of published studies. learning objectives: 1. to understand the historical development and general principles of evidence-based medicine (ebm) with its top-down and bottom-up approaches. 2. to learn how to apply ebm principles to radiology (evidence-based radiology, ebr) and to illustrate the main reasons for the relative delay in developing ebr, including the challenges of fast technological innovation in medical imaging. 3 . to learn about the relationship between levels of evidence and the strength of recommendations for diagnostic imaging and interventional radiology. 4. to learn how radiologists could play a stronger role in building the evidence in favour of diagnostic imaging and interventional radiology, taking the patient's interest as the primary aim of clinical practice and science. education in research: action plan j. hodler; zurich/ch a survey regarding education in research has been commissioned by the esr and published in insights imaging (2012) 3: 535-542. the results indicate that education in research, associated with career models, needs promotion. the research committee of the esr is working on possible future steps to promote research through education. several problems will have to be addressed, most notably inhomogeneity within europe, motivation issues, illdefined career paths as well as funding issues. several stakeholders will play an important role, including scientific societies, although this is the core business of academic radiology chairmen. most young professionals starting a career in academic institutions are eager to expand their professional and personal aptitudes. an effective way to support young professionals in this regard is by mentoring. mentorship is a relationship where the mentor supports a junior faculty member (mentee) in personal and professional development. the mentee benefits from early determination and initiation of career-relevant steps, greater productivity in research and publishing activity and developing techniques in networking and collaboration. moreover, the mentee gains perspectives on how his/her discipline operates academically, socially and politically, improves self-efficacy and deals more confidently with challenging intellectual work. the mentor, a knowledgeable, experienced and regarded person, benefits from fresh ideas, energy and curiosity of mentees, as well as through acceptance as a mentor an enhanced status in the department. it is a trusted relationship of dialogue, learning and challenges, based on mutual interests. however, the mentor is not automatically the best friend or the sole exclusive advisor of the mentee. more and more academic medical institutions offer facilitated mentoring programmes, which help the mentoring pairs to create an effective mentoring relationship to accomplish the desired skills. evaluation of faculty mentoring programmes in academic medical institutions demonstrates the importance of mentoring in research and academic development as well as in patient care. especially in radiology where over many years there have been challenges in recruiting and retaining talented young professionals, mentoring is considered as an essential way for preparing the next generation of scientific and intellectual leaders. pitfall: "a hidden or unexpected danger or difficulty". imaging methods can provide an extraordinary amount of useful data to specialists treating head and neck (cancer) patients. it is crucial that these data are used to full advantage of individual patients. the most important factor in this process is mutual cooperation between the physicians in charge of patient care and the diagnostic imaging specialist. pitfalls in the head and neck may present in various ways: normal variants may look like disease, incidental findings are frequently encountered and suboptimal technique may obscure important findings. moreover, many pitfalls are directly related to technical errors. the presentation aims to familiarise general radiologists, who have an interest in head and neck imaging, with common pitfalls encountered on ct and mr studies focussing on the neck. in an interactive setting, examples from daily practice will be discussed. imaging of the skull base and maxillofacial skeleton requires a meticulous imaging technique and a good knowledge of normal anatomy and possible anatomical variants. asymmetry in the pneumatisation of the paranasal sinuses, skull base or temporal bone is a common reason for misinterpretation. for example, hypoplasia of the maxillary sinus may be misinterpreted on conventional radiography as maxillary sinusitis or orbital blowout fracture, depending on the context; asymmetric pneumatisation of the petrous apex or mastoid bone may mimic, respectively, a cholesterol granuloma and fluid effusion in the non-pneumatised side on mri. vascular variants may also cause interpretation problems. for example, turbulent flow in a large jugular bulb may mimic a jugular foramen tumour on mri. variants in the vascular plexus surrounding the trigeminal or facial nerve may occur, and cause asymmetric findings on mri, possibly mimicking neuritis or perineural tumour spread. incomplete maturation or arrested development of skull base structures may also cause confusion. examples are the cochlear cleft, not to be confused with otosclerosis, or arrested pneumatisation of the sphenoid sinus, possibly mimicking a tumoural lesion in the central skull base. to avoid problems, one should keep in mind the existence of such variants, while correlating the imaging findings with the clinical problem; in some cases, an additional imaging study may be needed to exclude a pathological process more confidently. this short 5-min introduction by the session chairman will give an overview of the current state of cardiac computed tomography (ct) for diagnosis and prognosis. in addition, the introduction will provide the basis for the subsequent dedicated lectures covering low radiation dose, diagnostic accuracy, and incidental findings in cardiac ct. what are the protocols with the lowest radiation dose in clinical practice? j.-f. paul; le plessis robinson/fr (pauljf@ccml.fr) the radiation dose delivered for coronary ct angiography using retrospective gating is high, because only a small part of the total radiation delivered is used for the reconstruction of the image in the retrospective mode. on average, 20% of the radiation burden is used to reconstruct one phase of the cardiac cycle. ecg-triggered tube current modulation allows reducing the nominal dose by up to 96% in the systolic phase. another approach for reducing radiation exposure is to use prospective, sequential acquisition, with this approach being associated with 75% dose reduction compared to the spiral retrospective acquisition. exposure time may be also shortened by an increase of pitch, in particular on the dual-source ct. however, applicability to each dose-sparing technique depends on the heart rate and its regularity. dose-sparing strategies should be modified in case of high or irregular heart rate and radiation dose reduction may be less effective. for coronary ct angiography, individually weight-adapted protocols have been successfully applied, by adjusting mas to patient's weight. more recently, settings of 100 kv and even 80 kv have been successfully used for cardiac studies, especially in slim patients or children. reduction of exposure time and individual adaptation have an additive effect on dose reduction: it has thus been possible to scan down under 1 msv in selected, slim patients, using this combined approach. in many cases, using the latest technology, radiation dose may be lower than the mean radiation dose associated with conventional angiography. learning objectives: 1. to understand various protocols to lower radiation dose in cardiac ct with regard to the clinical situation and the risk of image quality impairment. 2. to learn how to tailor the radiation dose level to each patient in terms of morphology. 3. to become familiar with modulating exposure windows in regards to a patient's ecg. how accurate and prognostically valid is coronary ct angiography? f. cademartiri, e. maffei; monastier di treviso/it (filippocademartiri@gmail.com) the role of cardiac computed tomography in cardiovascular diseases is becoming increasingly important. cct is a robust and reliable investigation for the detection and exclusion of significant coronary artery disease. in addition, cct provides reliable noninvasive information concerning coronary plaque burden (severity, distribution, type), morphology and function of left and right ventricle, valves, aorta, and so forth. in the past 5 years, the prognostic role of cct has been established. the prognostic information that can be extrapolated from cct is very diverse and most of it is still under investigation. there are converging evidences that cct can stratify cardiovascular risk better than conventional clinical methods, especially in symptomatic patients. for asymptomatic individuals, the role is still controversial since coronary calcium score alone has a very important role already. several aspects of cct information seem to have importance for prognostic stratification: plaque presence, obstruction, plaque type and distribution. more recent studies have started showing the relationship between cct and pharmacological treatment. this is a very new and appealing topic, since the evidence is towards the fact that the most effective pharmacological treatment (e.g. statin) should be restricted to patients with at least some nonobstructive cad as detected by cct. this might become a revolutionary concept in cardiovascular medicine with several implications. learning objectives: 1. to learn about and integrate the prognostic information from coronary ct angiography into conventional methods. 2. to learn about coronary ct angiography and conventional methods. 3. to appreciate the prognostic impact of coronary ct angiography and conventional methods. incidental findings in cardiac ct: how to report and proceed s. leschka; st. gallen/ch (sebastian.leschka@kssg.ch) rapid advances in computed tomographic (ct) technology have facilitated the widespread use of ct for cardiac imaging worldwide, and can be considered nowadays an essential part of the clinical workup of patients with suspected coronary artery disease. albeit that the performed ct study is focussed on the cardiac structures and the coronary arteries, adjacent noncardiac structures are in the field of view whenever a patient undergoes cardiac ct to quantify coronary calcium or to perform a noninvasive coronary angiogram. in addition, the location of the heart near other anatomic regions, including the lungs, mediastinum, upper abdomen, and bones, necessitate that these structures are included when acquiring coronary ct angiographic images. several publications have demonstrated a high frequency of incidental findings on coronary ct angiography. the availability of this information is part of an ongoing clinical debate. while some radiologists believe that every image should be interpreted completely, others believe that examining noncardiac structures reveal too many incidental findings of uncertain clinical significance, which may harm because additional testing increases risk, cost, and patient anxiety. the aim of this lecture is to separate solid facts from opinions and beliefs. the diagnosis of pulmonary embolism (pe) is usually established by a combination of clinical assessment, d-dimer testing, and imaging with either pulmonary ventilation-perfusion (v/q) scintigraphy or pulmonary multidetector ct angiography (ctpa). v/q scintigraphy is a functional imaging method using isotopes for the visualisation of ventilation and perfusion distribution in the lungs. in recent years, the imaging techniques for diagnosing pe have improved. many nuclear medicine centres have adopted the single photon emission computed tomography (spect) technique as opposed to the planar technique when diagnosing pe. the introduction of 3-dimensional v/q spect technology instead of 2-dimensional planar v/q scintigraphy has resulted in fewer indeterminate results and a higher diagnostic value. the latest improvement is the addition and combination of a low-dose ct without contrast to the v/p spect (spect/ct) technique. the spect/ct in combination has been compared to ctpa, planar scintigraphy and spect alone, and one study has shown that spect/ct in combination had the highest diagnostic accuracy for pe diagnosis. spect in combination with low-dose ct without contrast enhancement is superior, especially for small subsegmental emboli; however, consensus is lacking regarding the clinical impact and treatment. spect and spect/ct may provide alternative diagnosis if pe is refuted and are feasible in almost all patients, because there are no definitive contraindications. in the present lecture, spect and spect in combination with low-dose ct are discussed in the context of diagnosing pe. over the last few years, emergency radiology (er) has been a subspeciality with growing interest. because of rapid developments in technology, ct has become the most useful tool in evaluating trauma and other emergency patients. in this lecture, the basics of planning and organising an er department are presented and discussed. besides optimising technical equipment and protocols for imaging, different logistic concepts have to be considered in planning and organising er departments. first of all, logistic concepts have to be considered for obtaining an optimal workflow: the radiology department has to be in close proximity to the emergency department and the admitting area, in particular. the whole workflow must be optimised for speed and accuracy. this also mandates having dedicated and standardised examination and viewing protocols for ct. in contrast to the usa where dedicated emergency radiology departments are well established, nonspecialised radiologists still frequently do the reading of emergency radiology cases in european countries. the radiologic staff involved has to be trained for interpretation of trauma and other emergent cases. this does not only account for residents, but also for consultants and attending radiologists. since a large number of cases will arrive during after hours and on weekends, staffing has to be adjusted to this fact, which includes attending radiologists to be available during these hours on call or, preferably, on-site. this lecture will give an overview of logistic concepts and organisation of an emergency department and will also discuss critical issues in polytrauma imaging. at least during the radiological training in hospitals, every radiologist will personally be confronted with the treatment of polytraumatised patients. it is a fact that standardised whole body mdct (wb-ct) as an independent predictor is able to save around 20% of patient lives. thus, wb-ct is the major diagnostic tool and should be performed as fast as possible. some institutions bypass the emergency room and directly start patient stabilisation in the ct cabinet. however, radiographs and focused ultrasound remain important in general settings as long as they are performed in a way which does not delay ct diagnostics. after scanning, specially trained radiologists support the whole interdisciplinary team with correct, appropriate and prioritised diagnoses. besides optimisation of parameters like logistics, patient positioning preferably 'feet first', reading and communication, 'choosing the right protocol' is a crucial factor for ideal radiological patient care. four types of protocols should be differentiated: there is a wide agreement that for patients with polytrauma, integrating whole body computed tomography (ct) scan into early trauma care significantly increases the probability of survival. therefore, ct is today considered the most important imaging technique in the diagnostic workup of polytrauma patients. the downside of whole body ct represents the relatively high radiation exposure. to overcome this handicap, the following measures can be taken: 1. positioning of the arms during whole body ct above the head results in reduction of radiation dose; 2. adaption of scan parameters, especially reduction of tube voltage to 100 kv reduces radiation dose; 3. installation of recent technical improvements like iterative reconstruction algorithm reduces noise in the image, allowing a downward adjustment in radiation dose to obtain standard diagnostic quality images; 4. installation of dose control software enables optimisation and improved dose management over time. another disadvantage of high-resolution whole body ct is the amount of acquired data. to optimise the workflow in the evaluation of a couple of thousand submillimetre images it is necessary to connect the mdct scanner with a dedicated workstation for volume image reading, which offers the possibility of quick multiplanar online evaluation. in this introduction i will define the connectome (a comprehensive map of neural connections in the brain) and related concepts such as scaling, structural and functional connectivity as well as the integration-segregation paradigm. the development of mri-based techniques such as white matter tractography and segmentation of white and gray matter has played a crucial role in the emergence of connectomics by providing tools to map in vivo the entire human structural connectivity at a macroscopic scale. i will explain these methods and how from mr imaging a human connectome can be mapped and represented as a network (set of nodes and edges). finally, i will also review the validation work related to those techniques and mention the foreseen technical advancements in the field. session objectives: 1. to learn what the human connectome is and how it is affected by brain disease. 2. to understand how the human connectome can be imaged and characterised with mri. 3. to become familiar with the network formalism and its interpretation. 4. to understand the relationship between brain function and underlying structural connectivity. 5. to understand the conceptual ideas behind connectomics. 6. to learn about the general workflow, from diffusion imaging to mapping a structural brain network. 7. to become familiar with the robustness of the technique by reviewing validation studies and getting a glimpse of the technical challenges. the economics of brain networks e. bullmore; cambridge/ uk (etb23@cam.ac.uk) we review the methods and recent results of network analysis of human neuroimaging data. human functional mri and structural mri data can be analysed using mathematical tools drawn from graph theory to quantify the complex (non-random) topological properties of brain networks. these results can be substantiated by meta-analysis of prior neuroimaging results and analysis of non-human nervous systems. brain networks consistently express complex topological features, such as small-worldness, hubs, modules and rich clubs. some of these features entail disproportionate biological cost, but may be "worth it" by supporting integrative information processing and adaptive behaviours. highly connected hub nodes are high cost/high value network components that likely also represent special points of vulnerability for diverse brain disorders. these economical principles of brain network organisation are expressed at the microscopic scale, e.g., in the nervous system of the nematode worm c. elegans, and may therefore provide a new axis for translation between macro and micro systems neuroscience. neuroimaging can be used to elucidate the economical principles of human brain network organisation in health and disease. connectomics in brain pathology m.p. van den heuvel; utrecht/nl (m.p.vandenheuvel@umcutrecht.nl) healthy brain function depends on efficient functional communication within a complex network of structural neural connections, a network known as the connectome. conversely, damage to the brain's network, disrupting local neuronal processes and/or global communication between remote functional systems may lead to brain dysfunction. in the last few years, emerging evidence from a wide variety of studies suggests that connectome abnormalities may indeed play an important role in the aetiology of several brain disorders. in my talk, i will discuss the results of recent studies suggesting an important role for affected connectome organisation in a number of neurological and psychiatric disorders. in particular, i will highlight the findings of affected functional and structural brain network in neurodegenerative disorders such as alzheimer's and als, as well as discuss how the application of network science and connectomics may aid our understanding of the biological basis of psychiatric disorders such as autism and schizophrenia. learning objectives: 1. to understand the role of connectome architecture in (cognitive) brain function and dysfunction using diffusion mri/functional mri. 2. to become familiar with connectomics as a tool for examining disease pathology in a wide range of neurological and psychiatric brain disorders. linking structure and function: the role of modeling in understanding the pathophysiology the interplay of the brain's intrinsic activity and the external world has seen a revival in the last decade, especially in neuroimaging. a long-held assumption in many of these studies has been that ongoing brain activity is sufficiently random that it averages out in statistical analysis. hence, imaging studies are termed 'activation' paradigms, where experimental manipulation results in the activation of cerebral circuits that are necessary for performing the task. nevertheless, a large amount of recent literature reports a body of observations that there are consistently distributed patterns of activity during rest. this fact has led to the suggestion that it might be possible to characterise network dynamics without needing an explicit task to drive brain activity. indeed, numerous neuroimaging experiments have evidenced the solid existence of spontaneous long-range correlations, i.e. functional connectivity (fc), by fmri, meg, and eeg techniques. the functional connectivity is defined as the statistical dependence between remote neurophysiological dynamics. the emergence of resting functional connectivity is intrinsically linked with the underlying anatomical connections between those areas, i.e. the structural connectivity. whole brain modeling can indeed establish a direct link between structure and function. furthermore, the modeling can shed light on the origin of pathological functional disfunction by making the link with the underlying anatomy explicit. we will show how, structural dti tractography, functional imaging and modelling studies can be combined for reaching this goal. traumas to the paediatric pelvis and hip include traumatic dislocations of the hip, fractures of the femoral neck, fractures of the pelvic ring, acetabular fractures and apophyseal avulsion fractures. traumatic dislocations of the hip, fractures of the femoral neck, fractures of the pelvic ring and acetabular fractures are rare in children (less than 5% of paediatric fractures), as compared to adults. these fractures are commonly the result of high-energy trauma. imaging is based on plain radiographs, but ct and mri are very useful to precisely assess bone (ct) and cartilage and soft tissue (mri) lesions. imaging enables accurate diagnosis, appropriate treatment and detection of potential complications (femoral head osteonecrosis, premature physeal closure â�¦). in contrast with the previous injuries, apophyseal avulsion fractures of the hip and pelvis are common in children and adolescents, usually associated with athletic activities. in most cases, these fractures are of good prognosis and can be treated conservatively when minimally displaced. plain radiographs confirm avulsion injuries to ossified apophyses, but mri and ultrasound are the modalities of choice to demonstrate injuries to nonossified apophyses and to assess apophyseal displacement. the elbow is a very common site for fractures in a child. the challenge for the radiologist is to differentiate normal variants of growth from possible injury and this is usually achieved by having good-quality radiographs and an understanding of normal growth. it is important to recognise those fractures which require surgical intra-operative treatment. in a small number of cases when assessing for vascular integrity, intra-articular extent and injury to cartilaginous structures, ultrasound and mr imaging have a valuable role. this lecture will give an overview of the radiographic appearance of fractures, highlight the features which require orthopaedic intervention and illustrate the use of additional imaging modalities. learning objectives: 1. to become familiar with the types of injuries seen in the paediatric elbow. 2. to understand the strengths and weaknesses of different imaging modalities. a-162 17:00 the diagnosis of c-spine injury is more complex in children than in adults. early diagnosis is crucial since delayed diagnosis results in high morbidity and mortality. leading mechanisms of pediatric c-spine trauma are motor vehicle accidents, sports and pedestrian injuries. due to their anatomy, children are prone to different types and locations of injuries. children < 10 yeas of age are more likely to injure the spinal cord itself and are prone to dislocations and high (c1-c4) bony injuries. children > 10 years of age more often sustain c-spine fractures. in children under the age of 2 years, radiographs are rarely helpful. ap and lateral radiographs are helpful in children aged between 2 and 8 years. in children aged > 8 years, additional lateral and odontoid views are obtained. anatomical variants such as pseudosubluxation of c2-c3, widening of the atlantodental interval and ossification centres may appear to be of concern on imaging, but are normal. abnormal radiographic findings require additional imaging to differentiate them further with ct on the area of concern. mri is mandatory if signs of atlantorotary subluxation and spinal cord injury without radiologic abnormality (sciwora) are present. mri identifies injuries to the spinal cord that are not apparent with other modalities, and should be used when a child presents with a neurologic deficit but normal radiographs on ct scan. nowadays, ultrasound (us) has become the first choice for performing most breast biopsies. the main advantages of this technique are non-ionising radiation, full control of the needle position in real time and widespread use of us equipments at all centres. us allows access to difficult places (such as the axilla or near the nipple), multiple lesions can be safely biopsied in one single session, the breast is not compressed, there is excellent comfort for patients and radiologists, local anaesthesia and haematoma do not hide the lesion and it is a cost-effective technique. however, the main limitation is that the lesion must be visible on us. us-guided fine-needle cytology was widely used in the past, but today its use has decreased. us-guided core-needle biopsy has proven to be a reliable technique to perform a biopsy for breast lesions, showing a sensitivity value of about 98%. furthermore, it can be safely used for performing biopsies of axillary lymph nodes. vacuum-assisted devices can be used not only for diagnostic purposes, but also for therapeutic ones, because small palpable benign lesions (such as fibroadenomas), papillomas and radial scars can be completely removed. stereotactic breast biopsy is the performance of tissue sampling under mammographic guidance. as with any imaging technique, some lesions are only seen with mammography. when these lesions are suspicious (e.g. birads 3 or higher), there are no imaging techniques that can downgrade this suspiciousness directly, although for birads 3 lesions follow-up might be a viable alternative. in mammography, most lesions that are only visible on the mammogram consist of clusters of microcalcifications. these harbour a likelihood of around 25% being malignant and should thus be classified as birads 4. this implies that tissue sampling is mandatory. different from ultrasound-guided biopsy, it is not possible to perform a real-time biopsy under mammographic guidance. rather, stereotactic biopsy uses triangulation to assess the depth of a lesion within the breast, while the lesion location in the xand y-plane is assessed on a scout view. the needle is positioned using the coordinates thus obtained. since there is no real-time feedback of the accuracy of needle positioning, it is necessary to obtain substantially more tissue than under ultrasound guidance. therefore, vacuum-assisted systems are essential. in case of calcified lesions, the biopsy result is controlled by x-ray. calcifications should be present in the sample. biopsy complications that occur under stereotactic guidance are usually limited. most common is the formation of large haematomas. scarring may also occur. breast magnetic resonance (mr) imaging is the most sensitive modality available to evaluate the breast for cancer. it can detect lesions that are occult at mammography and ultrasound. it has a limited sensitivity and the positive predictive value ranges between 15 and 40%. histopathological assessment of mr-detected lesions is therefore mandatory. some of these lesions will be visible at second-look ultrasound and can be biopsied sonographically. a significant number however will only be discernable on mr, and mr-guided biopsy is therefore the sampling technique of choice. mr biopsy has become an essential component of any breast imaging practice. several mr-biopsy techniques are available including the grid-localising, pillar and post and the freehand techniques. the technique for preparing and performing a mr-guided vacuum-assisted biopsy using the grid-localising technique is reviewed. potential complications, limitations of mr breast biopsy and actions to prevent failure are discussed. imaging-histologic correlation is essential to ensure accurate sampling. clip placement and follow-up imaging should be performed to ensure sampling, including ultrasound correlates. finally, new developments in mr-guided therapeutic interventions are discussed. abdominal injuries require a timely and reliable diagnosis to prevent potentially lethal outcomes. the armoury of clinical tools (physical examination, lab tests) does not fulfil these criteria, since they are either not fast or not reliable. imaging diagnostic modalities help the clinician to acquire the necessary amount of information to initiate focused and effective treatment. however, the selection of the appropriate imaging algorithm, modality and technique, as well as the precise detection and interpretation of essential imaging findings are frequently challenging, especially because the circumstances, under which these examinations are performed (open wounds, bandages, non-removable life-supporting equipment, lack of patient cooperation, etc)., are frequently less than optimal. knowledge of critical imaging signs, symptoms and the role they play in the evaluation of the patient's condition, as well as fast decision-making and ability to closely cooperate with the clinicians are skills of key importance for radiologist members of the trauma team. this presentation will describe the technique and important findings for ct stone studies as well as the accuracy of this study. an explanation of when iv contrast should be given to augment a ct stone study and findings of gu and non-gu diseases that can mimic symptoms of stone disease will be provided. examples and descriptions of acute mesenteric vascular abnormalities, bowel obstruction and infectious conditions will be included. ways to differentiate and categorise emphysematous infections for proper treatment will be described. lower tract emergencies will also be illustrated and described. a systematic approach to evaluating abdominal cts will be described to avoid mistakes. using cases and an audience response system, this segment of the course will go over the optimal imaging approach for patients presenting with acute abdominal pain and abdominal injuries. ct findings will be emphasised. key imaging findings of traumatic and nontraumatic causes of acute abdominal pain including gastrointestinal tract and urinary tract pathology will be explained. a systematic approach for the imaging evaluation of patients with abdominal emergencies will be illustrated and explained including proper scan protocols and analysis of imaging findings. imaging diagnosis of blunt and penetrating abdominal injuries, urinary tract obstruction, infection, bowel obstruction, and ischemia will be emphasised. transcatheter renal denervation represents a novel therapy for treating patients with treatment-resistant hypertension, leading to higher risk of major cardiovascular events. an overview of sympathetic nervous system anatomy, physiology and physiopathology will be followed by a description of the technical aspects of renal denervation. first, results in patients with therapyresistant hypertension look very promising. however, these data need to be confirmed. importantly, long-term efficacy and safety need to be assessed. as a consequence, the treatment cannot be considered, at the moment, standard therapy. future studies need to address other disease conditions characterised by sympathetic hyperactivity, including heart failure, chronic kidney failure and others. it is a general opinion that in the near future the treatment will also be applied to lesser severe hypertensive patients. future studies should also include formal cost-effectiveness analyses. renal denervation can be achieved by a number of different techniques that include radiofrequency ablation, intraluminal and high-intensity focussed ultrasound ablation, chemical ablation and radiation ablation. radiofrequency and ultrasound ablation are currently the most commonly used techniques. most of the evidence to date is derived from studies and trials based on devices that use radiofrequency ablation technology. there are a number of currently ce-marked devices available and each device differs in the catheter design, generator design and energy delivery. these device types include single-point ablation, multi-point ablation, balloon-mounted systems and irrigated technology. the indications for renal artery denervation have been formulated by various international and european societies based on the various clinical trials and studies. these indications include patients with true resistant hypertension, age 18-85 years, egfr > 45 ml/min/1.73 m 2 (mdrd formula), single renal arteries with diameter > 3-4 mm with a landing zone of 20-21 mm depending on the device, no significant renal artery stenosis > 30%, no renal artery aneurysm, no previous renal artery angioplasty or stenting and the absence of significant valvular heart disease where lowering blood pressure will be dangerous. renal denervation of the sympatic nerves around the renal arteries is a new catheter technique to treat patients with resistant hypertension. resistant hypertension is seen in about 10%-20% of all patients with hypertension. the mechanism of sympatic nerve driven resistant hypertension will be explained. the available techniques for rdn will be discussed, focusing on the pros and cons of each technique. currently, rf ablation, hifu and cryo-ablation are the techniques under investigation. the technique and physics of renal denervation with radiofrequency ablation will be explained in more detail, focusing on available devices in the market. patient selection and nonresponders will be discussed. the current evidence from the available trials will be reviewed. the future of rdn and the role of radiology and the radiologist will be illuminated. the adrenal glands are composite endocrine organs consisting of the steroid hormone-producing cortex and the catecholamine-synthesising medulla. the increased use of imaging modalities has demonstrated the presence of varying sized mass lesions in up to 5% of individuals subjected to ct studies for reasons unrelated to adrenal dysfunction. most of these incidentally discovered lesions are non-functioning benign lesions of cortical origin. however, incidentalomas may also represent functioning lesions and malignant masses. clinical diagnostic and biochemical evaluation is used to further subdivide functional and non-functional adrenal lesions. f-dopa has been found to be of high sensitivity and specificity in pet imaging of pheochromocytoma. ct and mr imaging are first choice in characterisation of adrenal lesions. techniques of dual energy ct and histogram analysis may offer additional information. pet-ct has been shown to contribute to the diagnostic power, especially in oncologic patients. knowledge of the physiologic appearance of adrenal glands in 18-fdg pet is necessary to correctly identify pathologic processes. fdg-pet also has the ability to detect metastatic lesions in non-enlarged adrenal glands. in addition, fdg-pet has the advantage of simultaneously detecting metastases at other sites. the role of mr-dwi and mr-spectroscopy in characterising adrenal masses has to be defined by further studies. differentiating benign from malignant adrenal masses using non-invasive imaging methods can reduce the need for percutaneous adrenal biopsy in patients with underlying malignant disease and the follow-up imaging of incidentally detected adrenal adenomas. renal cell carcinoma (rcc) is the most common malignant tumour of the kidney. as response rates to radiation and nonantiangiogenic chemotherapy are low, surgical excision, i.e. radical nephrectomy has been the treatment of choice. however novel treatment options have emerged, so that imaging of rcc is of increasing interest. nephron sparing partial nephrectomy has become an accepted operative option and antiangiogenic agents such as inhibitors of tyrosine kinase (tk) and mammalian target of rapamycin (mtor) have been approved for treatment of advanced rcc. thus, it has become important to perform correct local staging and identify patients suitable for partial nephrectomy using standardised scoring systems such as renal or padua. furthermore, optimal imaging strategies for monitoring of advanced and metastatic rcc are discussed, as current antiangiogenic therapy evaluation in clinical routine is based only on morphological imaging information, but changes in tumour size may lag behind functional changes. finally, common side effects, i.e. pneumonitis, of vascular disruptive agents are addressed. characterisation of renal masses can be performed using three categories with respect to the lesion size and gross architecture: the indeterminate very small masses, the cystic, and solid renal masses. lesions with diameters below 10 mm are usually difficult to classify due to partial volume effect that prevents accurate ct attenuation measurement. in the general population, these lesions are likely to be microcysts and do not require further workup. better characterisation remains needed in selected patient populations such as patients with hereditary renal tumour disease and previous history of renal carcinoma. in this case, mri combining t2w, diffusion-weighted imaging and dynamic contrast enhanced sequences or contrast-enhanced us may help differentiate very small cysts from solid neoplasms. cystic renal mass characterisation still relies on bosniak's classification with 5 categories: benign (i) and minimally complicated (ii) cysts, indeterminate cystic lesions (iif and iii) and malignant cystic masses (iv). some cystic masses remain unclassified at ct because of atypical attenuation characteristics or enhancement properties. us, contrast-enhanced us, and mri are now playing a key role by providing additional diagnostic information that help distinguish between atypical fluid filled masses and atypical solid neoplasms, especially poorly enhancing solid papillary rcc. the characterisation of small solid renal tumours starts at ct with the identification of macroscopic fat, a typical feature of angiomyolipoma. in the case of non-fatty indeterminate renal neoploasms, percutaneous-guided biopsy can be performed when accurate characterisation is needed before surgery or when renal metastases or lymphoma are suspected. drug development being a complex and costly process, there is an increasing need for imaging biomarkers to take go/no go decisions in the early clinical phases. the recist criteria based on tumour size measurements at ct are currently used for this purpose. however, additional functional and molecular biomarkers have been developed to assess the early biological effect of drugs on tumours. development of imaging biomarkers is a structured process in which new biomarkers are discovered, validated and qualified against biological processes and clinical end points. the validation not only concerns the determination of the sensitivity and specificity, but also the measurement of reproducibility. reproducibility assessments, standardisation of the acquisition and data analysis methods and quality control are crucial when imaging biomarkers are used in multi-centre trials. functional and molecular parameters obtained at perfusion imaging, diffusion-weighted mr imaging and pet are being developed and validated. the perspectives (earlier assessment of response to treatment) and limitations (limited validation and standardisation) of these imaging biomarkers in cancer drug development will be presented. more recently, pharmacodynamic imaging biomarkers such as fdg-suv and k trans have been introduced. drug developers are reluctant to use more exploratory unvalidated imaging biomarkers (i.e. cannot distinguish a true negative from a false negative). the extensive literature on biomarker validation mostly refers to biochemical biomarkers extracted as analytes from biospecimens and is unhelpful to radiologists. unlike biospecimen biomarkers, the quality and validity of imaging measurements as biomarkers depend crucially on the use of a diagnostic imaging device, in the presence of the patient, in a manner for which the device (a) was not designed, (b) has not received regulatory approval and (c) may be unfamiliar to the user in the trial site. technical validation and biological validation are orthogonal activities. ''technical validity'' is confidence that the imaging biomarker can be measured reliably anywhere in the world. ''biological validity'' is confidence that the biomarker correctly reports some underlying biology that is important to the patient's future clinical outcome. since the physician always has access to the patient's clinical status and history, the biomarker is only useful if it provides a better forecast than clinical data alone. (if the forecast is near perfect, the biomarker might be a surrogate end point). technical and biological validations are massive undertakings best achieved by consortia, and in particular publicprivate partnerships, of which the innovative medicines initiative in europe and the biomarkers the standard imaging assessment of tumour response relies on size measurements, which, with predominantly cytostatic targeted agents, may not reflect the drug effect. functional imaging biomarkers have the potential to quantify the biological characteristics of tumours and measure on-target and off-target effects that indicate early likelihood of response to a specific therapy, which can then be used to guide the optimal biological dose and drug schedule. serial, non-invasive assessments of whole tumour are possible. this is particularly important in the context of inter and intra-patient tumour heterogeneity, as different parts of the tumour and primary vs metastatic lesions may be biologically different and these characteristics may change with treatment. however, functional imaging end points suffer from variability, which can be very significant in a multicentre setting. strict quality assurance and quality control measures need to be implemented at the start of a trial and the variability across centres documented. data acquisition protocols need to take account of equipment variations. data analysis methodology needs standardisation of software, central review and preferably double reading of scans. automation may not always prove the most robust and reliable option. this presentation will focus on the factors that are crucial in determining the compatibility of data in multicentre trials with functional imaging end points. learning objectives: 1. to learn about the potential role of quantitative imaging in processes related to tumour growth such as cell metabolism, cell death, and vascular function in the assessment of tumour response. 2. to become familiar with the issues of accuracy, reproducibility and standardisation for using functional imaging biomarkers in drug development. quantitative nuclear medicine in drug development w. weber; new york, ny/us nuclear medicine techniques can detect and quantify very low concentrations of radiolabelled pharmaceuticals in the human body. this allows investigators to use nuclear imaging for various purposes during drug development. nuclear imaging can visualise drug targets that are only present in nanomolar concentrations and can thus identify patients most likely for therapies directed against these targets. a recent example is folate receptor spect imaging for the selection of patients for treatment with a folate-targeted drug conjugate. in addition, nuclear imaging and specifically pet can measure the concentration of pharmaceuticals within tumour and normal organs over time. nuclear imaging can also be used to monitor target inhibition, for example the blocking of oestrogen receptors by anti-oestrogens. finally, nuclear imaging can assess tumour response to therapy by measuring changes in tumour metabolism or proliferation, e.g. with fdg-and flt pet/ct. this allows an earlier and more sensitive detection of tumour response than morphologic techniques. since pet is a whole body imaging technology, pet imaging can also be used to study the heterogeneity of target expression, tissue pharmacokinetics, target inhibition and response. pet imaging is now widely available in many countries and has become internationally standardised. it is therefore a robust clinical technique that will increasingly be used during drug development. there are about 80.000 patients per year in europe who lose their leg. about 70% are due to diabetic ischaemic and ulcerative leg problems. in diabetic patients the prevalence of foot ulcerations is about 20% and the risk for developing foot ulcerations is increased four times. diabetic foot problems may be due to neuropathy and malperfusion or a combination of both. the neuropathic ulcer and the neuroischaemic ulcer are usually at the plantar pedis, have a punched-out appearance and are painless. bone deformities (charcot foot) may be associated. the arterial ulcer is usually at the toe, forefoot and ankle, with pale, cold skin and it may be painful. patients need a multimodality approach involving a diabetologist, vascular specialist (angiologist, vascular surgeon, interventional radiologist) and podiatrist. pain control, antibiotic and antithrombotic treatment and the treatment of cardiovascular risk factors and other co-morbid disease have to be done first. in case of ischaemic pain and ulceration imaging such as mra and cta is the next step. patients should be referred to a team of vascular specialist early in the course of their disease to plan for revascularisation options. revascularisation is the optimal treatment for patients with an ischaemic and neuroischaemic diabetic foot. a. pathophysiology of the diabetic foot v. bã©rczi; budapest/hu (berczi@hotmail.com) the incidence of diabetes mellitus, associated with both predisposing genetic and environmental factors, is increasing globally. several major clinical trials have proved that complications may occur many years following proper glycaemic control. besides peripheral arterial disease, sensory and motor neuropathy along with an altered response to infection is of crucial importance. recent studies have showed that microvascular occlusive arterial disease is not a major factor affecting the diabetic foot; infrapopliteal macrovascular disease and microvascular dysfunction (e.g. arteriovenous shunting, precapillary sphincter malfunction, capillary leakage, venous pooling) are major components of impaired perfusion of diabetic foot. there are no randomised controlled trials analysing the major outcome following endovacular or open bypass surgery. the major outcomes, however, were similar in the case series: 1-year limb salvage showed a median of 85% (interquartile range 80-90%) and 78% (interquartile range 70.5-85.5%) following open surgery and endovascular treatment, respectively. limb salvage rate, however, was considerably higher with either type of revascularisation compared to medical therapy. negative pressure wound therapy, hyperbaric oxygen therapy, effective off-loading or nonweight-bearing therapies (total contact casts rather than removable devices) have also shown promising results in recent publications. endovascular arterial revascularisation is today a solid option in the management of cli with low complication rates and limb salvage rates comparable with surgery. the restoration of adequate blood flow to the foot is crucial to facilitate wound healing, provide pain relief, and avoid whatever amputations. the angiosome concept was first introduced in 1987 by taylor and further developed by attinger for planning treatment of ischaemic lesions of the foot. they divided the foot into six distinct angiosomes, arising from tibial and peroneal arteries. planning the procedure on the basis of this concept will yield the best local results of wound healing, compared with the indirect intervention. a proper pre-procedure assessment through colour doppler us and dsa of lower limbs is mandatory for guiding the procedure through the vessels of the foot. several studies have evaluated the efficacy of pta in the btk and the reliability of the angiosome model, approaching 100 % with a limb salvage rate of up to 87% at 12 months. on the basis of these data, we can conclude that pta in diabetic patients with btk disease is a safe and effective technique. the first endovascular treatment option is related to the angiosome model, but when not feasible the indirect technique is also a valid and similarly effective procedure. to face technical failures, up to 20% in crural chronic total occlusion a decade ago, different approaches and dedicated devices and technologies have been developed in the last few years. furthermore, percutaneous revascularisations are gaining more interest, particularly in patients with critical limb ischaemia not only as first-line treatment, but also as the only possible treatment for complex lesions and high-risk patients. special techniques for crural endovascular revascularisations are by design techniques rarely used in routine practice, but could offer wide possibilities for the interventional radiologist to solve challenging situations and manage complex lesions. these techniques include options for arterial access (trans-popliteal, trans-tibial, trans-pedal), approaches for crossing chronic total occlusion (assisted endoluminal, lambda technique, re-entry technologies) and uncommon routes for angioplasty/recanalisation (trans-metatarsal loop technique, trans-collateral techniques). combined antegrade and retrograde approaches have also been developed as well as related methods for successful re-entry. deciding when the patient/lesion is a potential candidate for special techniques is also a crucial issue. the interventional radiologist should be able to convert at any time if necessary the strategy of treatment to another one. he should also be able to select the most appropriate technique for the patient in planning revascularisation. continuous medical education and training is however mandatory and for some techniques the learning curve is relatively long. pathology of the eye and orbit is rare in the radiologist's practice. however, differential diagnosis is not too difficult if the compartment model is applied. in the orbit, different anatomical structures like the optic nerve as part of the cns, muscles for moving the globe, vascular structures and glandular tissue are present in a very small space. each anatomical structure is found in a special compartment; each compartment may give rise to a different group of pathologies, and only to these pathologies: glioma in the optic nerve, rhabdomyosarcoma in the eye muscles, varix in the venous vessels (intraconal compartment) and pleomorphic adenoma in the lachrymal gland. understanding the compartments in the orbit is therefore the key to differentiating different pathological entities. this presentation explains the orbital anatomy, how the compartments are differentiated, and what changes in anatomy treatment may induce. orbital congenital lesions are uncommon. they can be diagnosed prenatally, at birth or later during childhood. several orbital components can be involved. we will focus on congenital globe lesions (such as staphyloma, coloboma, persistent hyperplastic primary vitreous, coats disease), the developmental cysts such as epidermoids and dermoids, and vascular malformations such as lymphangioma and vascular tumours, e.g. capillary haemangioma. orbital inflammatory and infectious lesions are on the other hand common. orbital pseudotumour can involve any area of orbit, being one of the great mimickers in the orbit. if located in the orbital apex and/or cavernous sinus, it will be called tolosa-hunt syndrome. other inflammatory processes in the orbit are sarcoidosis and wegener and sjogren syndrome. among infections the most common is the orbital cellulitis, mostly secondary to a sinusitis and frequent in the urgency setting. the role of the radiologist is to assess whether it is preseptal or already postseptal or complicated by a subperiosteal phlegmon or abscess. also of importance is to know and evaluate the possible intracranial complications. finally, we will focus on inflammatory and infectious lesions of some specific regions such as the globe and lachrymal gland and give some clues for their differentiation. as more than 100 pathologies can be seen in the orbit, a systematic approach is very important to come to the right diagnosis. the main and most helpful criteria of differential diagnosis of any orbital pathology is the definition of the affected orbital compartment, as some tumours may only or preferentially involve specific orbital structures. the criteria of the most frequent masses of the globe, malignant melanoma and retinoblastoma are presented as well as those of cavernoma and lymphoma, the main representatives of intraconal tumours. there are numerous extraconal neoplasms, only few arising from the nasal sinuses, and only a little number of tumours of the optic nerve. the presentation will include the most frequent as well as rare, but important tumours. the routine practice of oncologic imaging requires standardisation, which means that we need to harmonise technical protocols and agree on the meaning of selected words for the radiological report. the words "response, "progression" and "stable disease" are precisely defined according to internationally accepted thresholds and criteria. although the rules are quite simple and rather easy to apply, they are very efficient in the classification of the response to treatment, and therefore for the medical decisions. however, the role of the radiologist is not limited to measurements and calculation. the detection of new lesions may be challenging and requires experience. the differential between cancer progression and complications of the treatment might be very difficult and requires an adequate communication with the referring clinician. overall, most of the decisions taken by the clinician will be related to imaging results, stressing the importance of adequate protocols and reports. in solid as well as non-solid tumours, pet/ct imaging using 18-fluorodeoxyglucose (fdg) has demonstrated the ability to a) correctly stage disease, b) demonstrate therapy response and c) predict therapy outcome. fdg uptake can be measured objectively; however several factors in the standardisation processes of tracer application, image acquisition and post-processing are needed for reproducibility. the term standard uptake value (suv) measurement is used for compensating the influence of injected dose, decay time and body mass and represents fdg uptake in any selected pixel of the image. for therapy assessment, drop in fdg uptake represents tumour cell kill, notably a negative pet scan does not exclude viable tumour cells but overall has a better outcome. pet response criteria in solid tumours (percist 1.0) have been introduced to refine previously established pet response criteria by eortc. major changes concern the use of lean body mass-based suv (sul), sulpeak measurement in a fixed roi, use of only a single target lesion and normalization to liver uptake. metric measurements in ct component of the pet/ct as an intrinsic asset like in recist 1. 1 have not yet been introduced, but might be crucial in the future. the proposed percist 1.0 criteria are not yet standard, since several limitations hamper its general use but may improve metabolic tumour response assessment. malignant gliomas (who grade iii and iv) are the most common primary tumours of the brain. according to consensus guidelines, the standard of care of these tumours includes maximal safe surgical resection followed by combined treatment with chemoradiotherapy. radiological assessment is critical in the follow-up and should be performed at four different times: 1. within 72 hours after surgery, an early post-operative mri must be done to evaluate residual tumour and to be used as baseline for follow-up. 2. two to six weeks after completing radiotherapy, a new mri examination is recommended to evaluate the response to treatment. four possibilities are envisaged according to the rano criteria: complete response, partial response, stable disease or progressive disease. the evaluation of this first mri examination after rt is challenging and the pseudoprogression phenomenon can appear. advanced mr techniques may be of help in this respect. 3. additional follow-up should then be performed by mri every 2 to 4 months to rule out clinically silent progression. 4. in any case, an mri examination must be completed when there is a clinical suspicion of progressive disease. several options for treatment can be offered when progressive disease is detected, including antiangiogenic drugs. evaluation of response to these drugs is challenging too, and the pseudoresponse phenomenon can then appear. due its complexity, it is recommended that the management of malignant gliomas be performed in the context of multidisciplinary teams and that the radiologists are strongly involved in these teams. we are facing complex times with no parallel in human history. the worldwide economic crisis, in combination with a non-regulated process of globalisation, is pressuring countries to change their social and political model. these changes are affecting academic institutions and the health-care sector. higher education was always more internationally open than most sectors because of its immersion in knowledge, which was never worried about country juridical boundaries. it is well recognised that it was the knowledge created by universities research that contributed to the development of societies. we, as european citizens, must be able to transmit the message that having more knowledge and being capable of understanding better the world we live in will make us stronger, more successful and more competitive. european academic institutions must be prepared for this shift of paradigm and understand that they are no longer educating only for their country but for the globalised world. it is also important to bear in mind that developed health-care systems are suffering several pressures and a call for a new inter-professional collaboration concept is needed, based on each one's roles and responsibilities, towards a better and more efficient health-care delivery for the patients. in this session, the invited speakers will give us an overview about the challenges that academic institutions will face in the near future and the way they must adapt to become more attractive and at the same time guarantee that radiographers and radiologists are educated and trained according to the highest professional standards. session objectives: 1. to appreciate the challenges that academic institutions must face in order to educate graduates with the ability to work internationally and to actively contribute to the healthcare sector of the future. 2. to explore innovative approaches in education and assessment. 3. to highlight the importance of inter-professional collaboration in order to ensure that graduates are ready to meet the demands of the modern healthcare sector. challenges in undergraduate education l.j.o.c. lanca; lisbon/pt (luis.lanca@estesl.ipl.pt) radiographers operate a wide range of sophisticated equipment and perform a range of techniques in several radiological procedures. they are responsible for the radiation delivered to the patient while assuring safety and image quality at an acceptable level for an accurate diagnosis. education and training in radiography, in line with the constant technological developments, is a requirement to be fulfilled by higher education institutions (hei). this is of major importance in undergraduate education where radiographers learn to play an effective role as healthcare providers in planning, preparing and performing accurate and safe radiological procedures within the diagnostic or therapeutic field. the european qualifications framework (eqf) for radiography, in terms of the development of knowledge, skills and competences, provides a european standard for the development of radiography learning outcomes at eqf level 6. this constitutes an opportunity to develop, tune, advance and promote standards of radiographic practice, education and research throughout europe. the eqf provides guidance to increase the educational and professional recognition of radiography in europe. at a european level, the cooperation between hei in undergraduate radiography education would be an opportunity to provide discussions of mutual concern, explore new perspectives and views of different cultures, and also share learning and teaching methods. international cooperation is an opportunity to improve and provide the harmonisation of education regarding a professional group that plays an effective role in healthcare in their field of competence and expertise. there is a vast amount of evidence available from the published literature that higher education institutions continue to explore innovation in both teaching and assessment practices. this is especially true of health professional programmes as evidenced by the abundance of literature relating to medicine, nursing, radiography and other allied health professions. such higher education, health professional programmes would appear to be more innovative than many other disciplines often as a direct attempt to mirror the dynamic clinical environment in which most graduates will work. there are, however, challenges associated with any such educational innovations and novel approaches to delivery and assessment. these specific challenges must be carefully considered in parallel with the larger challenges facing higher education institutions, both nationally and internationally, along with the professions which they contribute to. through a case study approach, supported by published peer-reviewed literature, institutional reports and research, this presentation will consider international best practice in education along with the value of collaborative, inter-professional approaches to teaching and assessment. haemodialysis accesses have become the most commonly performed type of vascular surgical procedure. however, only 50% of all haemodialysis accesses remain patent at 3 years. autogenous fistulas have a higher rate of primary failure compared to prosthetic grafts (50% vs. 15%), but the long-term patency of fistulas is superior to that of grafts. autogenous fistulas fail after a median of 3 to 7 years, whereas prosthetic arteriovenous grafts fail after a median lifetime of only 12 to 18 months. the pathogenic stenoses causing access failure occur in various locations, but the most common site in prosthetic arteriovenous grafts is at the anastomosis between the graft and outflow vein, as identified in 47% (23,246) to 60% of cases, or in the outflow vein itself in autogenous arteriovenous fistulas. clinical assessment alone will detect a large number of failing fistulas. by assessment of the thrill, pulse character, palpation of the fistula itself, excessive bleeding and difficulty needling a fistula may all indicate a failing fistula. if the venous pressures during haemodialysis exceed 120 mm hg, fistula flow falls to< 500 ml/min, graft flow decreases to< 650 ml/min, or access blood flow falls by more than 25%. a fistulogram is recommended if monitoring or surveillance suggests that thrombosis is either imminent or has already occurred. duplex can be used to assess the fistula, but cannot visualise the central veins. mr and ct venography has also been used in many patients successfully. treatment of symptomatic stenosis of vascular access is essential as it can lead to thrombosis and loss of vascular access. but treatment can lead to restenosis. the treatment of stenosis remains a challenge which requires a good knowledge of different materials (guidewire, catheters, balloons and stents). though the pathophysiological mechanism of stenosis is different for native fistulas, grafts or restenosis, the treatment technique remains the same. the basic principle is the use of high inflation pressure balloon angioplasty. whatever the material used, the key is to have no residual stenosis greater than 30%. so far, no study has demonstrated the superiority of the "new" tools (cutting balloon, drug-eluting balloon, cryotherapy) regarding restenosis. except perhaps for anastomotic grafts stenosis, stents should be reserved to treat complications or failure of balloon angioplasty. the stents indications are residual elastic stenosis, wall obstructive damage, acute rupture during angioplasty, aneurysm or restenosis. complications of stenosis treatment are rare, but can lead to the loss of vascular access. the main complications are thrombosis and acute rupture. as with any treatment, there have been contraindications: infection, distal ischaemia, high flow, newly created or surgically revised access (< 6 weeks). when dealing with a vascular stenosis access, never compromise on the future, but think about the surgical alternative. so, the management of stenosis vascular access must also be multidisciplinary. percutaneous treatment of a thrombosed dialysis access can be extremely challenging. the major concern does not stem from the fact that the procedure can be complexly long, but arises rather from the management of its complications, which can be serious particularly when the access is branched onto the brachial artery. access infection is an absolute contraindication. temporary contraindications include fluid overload and severe hyperkalaemia. percutaneous thrombectomy of grafts is very well standardised and predictable: size of 6 mm, well palpable wall which is easy to needle, small average clot burden, and an underlining stenosis almost always found at the venous anastomosis. thrombectomy of avfs is subject to variations in approach and technical difficulties depending on their anatomical particularities. all techniques employed follow 2 rules: first, the removal of thrombi and, second, dilation of the stenosis responsible for the thrombosis. heparin and antibiotics must be injected. the basic principle is to place in the arterialized vein or graft 2 introducer sheaths in opposite directions to work on both the venous outflow and arterial inflow. thrombus lysis or removal can be achieved by mechanical, pharmacological and pharmaco-mechanical methods. all techniques may work in grafts given that the modest amount of thrombus (3.2 ml on average) can be simply pushed into the lungs. prosthetic grafts are thus easier to declot than native fistulas, but they are much more prone to early rethrombosis. thrombi located at the arteriovenous anastomosis form a firm and rubbery plug, frequently and notoriously resistant to thrombolysis. drug-induced lung disease is an increasingly common cause of morbidity and mortality. the diagnosis is based on clinical history and consistent radiologic findings. lung biopsy is performed in a small percentage of cases. highresolution ct may demonstrate different parenchymal patterns including diffuse alveolar damage, acute or chronic alveolar haemorrhage, nonspecific interstitial pneumonia (nsip), hypersensitivity pneumonitis, organising pneumonia, and eosinophilic pneumonia. the imaging and histologic manifestations are often nonspecific. a systematic approach to the radiological evaluation of drug-related lung diseases is essential and includes not only chest imaging pattern recognition, but also integration of available clinical information. in this interactive session, we will present and discuss several cases illustrating thoracic changes after instrumental procedures in the thorax such as surgery, radiofrequency ablation, interventional endoscopy, and intensive care. radiologists have an important role in assessing the results of these procedures as well as in depicting the complications. however, knowledge of the normal appearance after those procedures has to be presented. the initial imaging workup of polytrauma patients remains challenging. besides hardware requirements, workflow issues continue to evolve, with the current focus on the introduction of whole body ct into the early resuscitation phase of severely injured patients as a standard and basic diagnostic imaging method. this session is aimed at a thorough discussion on the requirements for advanced imaging in the early clinical situation in emergency radiology. focus is directed on the issues of radiation dose as well as on ct and contrast media protocols. a. chest and abdomen m. scaglione; castel volturno/it (mscaglione@tiscali.it) thoraco-abdominal injuries are a significant cause of death in the polytraumatised patients. early recognition and communication of lifethreatening thoraco-abdominal injuries is the major task of the radiologists involved in the emergency room. although most of these patients reach the hospital prior to dying, lethality continues to remain high. heart, thoracic great vessels, trachea, bronchus, pleura, lung, diaphragm, abdominal/retroperitoneal, vascular and solid organ injuries are potential cause of death. any appropriate surgical/interventional management approach must be carried out "around the clock", before thoraco-abdominal injuries reach the level of clinical evidence. on the other hand, non-operative management has actually become the standard of care for the most serious thoraco-abdominal injuries. these goals become feasible if a correct contrast-enhanced mdct diagnosis, in a dedicated facility in which the trauma team works effectively 24 h a day, 7 days a week, is performed. thus, in this lecture, the most serious thoraco-abdominal injuries will be illustrated, with special emphasis on vascular/injuries as well as the value of post-processing techniques, protocols, pitfalls, tips and tricks. furthermore, the importance of a rational and integrated imaging approach will be pointed out and, finally, the role of the radiologist in the emergency room will be emphasised. spinal and musculoskeletal trauma account for significant morbidity in severely traumatised patients. traumatic injuries to the spine encompass a variety of frequently occurring disorders and primarily result in stable injury. although rare, unstable disorders comprise injuries to the bone, the discs, and the ligaments. in the majority of cases, spinal cord injuries result in devastating medical and social consequences. severe musculoskeletal disorders usually are the result of high-impact accidents, such as motor vehicle accidents and falls from a height. for instance, the injured pelvic ring causes one of the most life-threatening conditions that the trauma team must handle. pelvic injuries are often associated with severe arterial, venous, and/or osseous bleeding. radiography is no longer recommended as the primary screening modality in spinal and pelvic trauma for adults. despite the radiation dose burden of ct, patients with a high risk of spine injury receive mdct imaging, as it is the method of choice. mr imaging is indicated primarily when patients present with myelopathy, and to search for spinal cord pathology. interventional radiology plays a major role in the therapy of complex traumatic pelvic disorders. extremity injuries in patients after polytrauma can be complex and are initially often difficult to be fully diagnosed. emergency radiology diagnosis is today mostly based on a standardised whole body ct (wbct), which can be extended with cta and adapted to cover extremity injuries. extremity injuries comprise: fractures of (1) long bones, (2) articular joints, (3) complex fractures of hands and feet, (4) vascular, (5) soft tissue, (6) nerve and plexus injuries and (7) amputations. imaging protocol: *mdct is indicated in all major and complex bony fractures and is carried out early or integrated with wbct. cta using mips and mprs enables a thorough workup. * the role of us and cr is limited. * the role of mr and mra (in stable patients only) is to evaluate unstable articular injuries, injuries of tendons or major ligaments and nerve and plexus injuries). * the role of dsa is mostly for intervention. clinical findings and findings from wbct determine how to proceed, "first things are done first" in a priority-oriented clinical algorithm. treatment of extremity injuries must therefore be priority oriented and carefully planned in the context of possible concurrent injuries and a possible risk of multi-organ failure (mof). systemic drugs can be used for the treatment of cns and non-cns diseases. both classes can affect the brain inadvertently. common general drugs that affect the brain in a bystander manner are steroids (~1% brain volume reduction), recreational drugs (alcohol, cocaine, heroin, xtc), metronidazole and anti-epileptic drugs (corpus callosum demyelination) and immunosuppressants like cyclosporine/tacrolimus (pres/rpls) and methotrexate. mechanisms of action include neurovascular compromise, fluid/metabolite shifts and toxic effects to myelin of other tissue components. among cns-targeted drugs, especially immunomodulating agents may cause specific side effects. cytokine-release syndromes may occur with broad-acting agents such as general t cell antibodies. specific side effects may occur in multiple sclerosis, where treatment with natalizmumab may cause reactivation of jc virus leading to progressive multifocal leukencephalopathy (pml). upon withdrawal of therapy, this may then evolve into an immune reconstitution inflammatory syndrome (iris). in alzheimer disease, novel antibodies or vaccinations against amyloid may cause amyloid related imaging abnormalities (aria), which may present with microhaemorrhage on t2* images, or with edema and effusion on flair. the objective of this session will be to review the diagnostic value of conventional sequences as well as the use of contrast in the monitoring of brain tumours, with special attention to gliomas. also, we will address the advantages and limitations of advanced techniques: perfusion, diffusion, and spectroscopy. immediately after surgery, the main objective of neuroimaging is the detection of the remaining tumour. it may also be necessary to rule out complications such as haemorrhage, ischaemia or infection. the fundamental technique is mri with contrast in the first 48 hours and also diffusion sequences. in late follow-up, the goal is to differentiate the changes secondary to treatment of those related to tumour progression or recurrence. in these cases, conventional sequences present important constraints and are useful studies of diffusion, perfusion and spectroscopy. during follow-up after chemoradiotherapy, the objective is to assess tumour response. the response according to the new rano criteria will be revised. the combination of chemotherapy and radiotherapy, as well as the use of anti-angiogenic drugs causes changes that complicate the assessment of the response to treatment, with cases of pseudoprogression and pseudoresponse. in these cases, perfusion techniques, diffusion and spectroscopy can provide relevant information, although it is necessary to standardise the quantification to make its wide use possible. the speakers in this course will update the audience on contrast media safety such as steps to be taken before contrast administration and present the newest safety guidelines. the first speaker will cover new concepts of non-renal reactions to contrast media explaining which hypersensitivity reactions are allergic and non-allergic. the audience may learn assessing symptoms according to the ring and messmer classification and understand the importance of tryptase sampling and skin testing in the follow-up. the second speaker will address nsf. the presentation will review the pathophysiology, risk factors, recent recommendations and prevention of nsf. patients with gfr less than 30 ml/min/1.73 m 2 have increased risk of developing nsf. lowstability gadolinium contrast media show the strongest association with nsf. following existing guidelines on the use of gadolinium contrast agents minimises the risk of nsf. potential long-term harm from gadolinium accumulation in the body and legal issues are discussed. the last speakers will cover contrast medium-induced nephropathy with more recently published guidelines related to that issue. the presentation will include the definition of cin and the choice of contrast medium and prophylactic measures. recent changes in esur guidelines will be explained. the risk of cin is considered significantly lower following iv. cm administration and patients referred for enhanced ct are genuinely at risk if they have an egfr < 45 ml/min/1.73 m 2 . volume expansion with isotonic saline or sodium bicarbonate may be used for preventing cin in at-risk patients. acute immediate hypersensitivity reactions occur within the hour following the administration of contrast media. they can be seen with iodinated and gadolinium-based contrast agents. over the last ten years, new concepts have emerged in the way of understanding, managing and exploring hypersensitivity reactions. the clinical appearance is best classified by the ring and messmer scoring, from grade 1 (cutaneous and subcutaneous signs) to grade 4 (cardiovascular arrest). the mechanisms involve either true ige-mediated hypersensitivity or non-allergic hypersensitivity. the differential diagnosis in favour of allergy is made on a triad: clinical signs (the more severe, the more are the chances to be allergic), elevated tryptase levels in the plasma (indicating mastocyte triggering) and positive skin tests performed one month after the reaction. these new concepts induce important consequences in managing hypersensitivity reactions: be prepared to treat the patient adequately, be prepared to draw blood after the reaction to dose tryptase levels, send the patient to a dedicated allergologist, and forget about the preventive role of premedication against severe reactions. the authorities have introduced several restrictions on the use of high-risk agents, which will be followed by every physician in the eu. the agents are contraindicated in 1) patients with severely reduced renal function including dialysis, 2) acute renal insufficiency, 3) neonates and 4) pregnant women. they may only be used with caution in patients with moderately reduced renal function and children less than 1 year old. there must be at least 7 days between 2 injections in those patients. renal function must always be determined by laboratory methods before use of high-risk agents. women should stop lactation for 24 hours. these agents should never be given at doses higher than 0.1 mmol/kg per examination in any patient. for the intermediate and low-risk agents, the restrictions are significantly less; they should only be used with caution in patients with severely reduced renal function including dialysis. if a physician does not follow these rules, he or she will have legal problems as they have been introduced into the spc by the authorities. the contrast media safety committee (cmsc) of the esur has updated its guidelines on contrast medium-induced nephropathy (cin). the acr recently updated its guidelines as well. new guidelines were produced by nephrological societies. the topics reviewed include the definition of cin, the choice of contrast medium, and the prophylactic measures used to reduce the incidence of cin. the cmsc considered it appropriate to keep the definition of cin that was agreed in 1999. however, nephrologists have recently agreed on a new definition. in the previous guideline, a number of risk factors were listed (raised s-creatinine levels, particularly secondary to diabetic nephropathy, dehydration, congestive heart failure, age over 70 years, concurrent administration of nephrotoxic drugs). the significance of these risk factors has been confirmed and new risk factors were added. the cmsc agreed that the risk of cin was significantly lower following intravenous cm administration and concluded that patients referred for enhanced ct were genuinely at risk if they had an egfr < 45 ml/min/1.73m 2 . the previous cmsc guideline suggested the use of low or iso-osmolar cm in patients with risk factors for cin and the cmsc considered that this previous guideline should not be changed. the cmsc considered that there was enough evidence to recommend that either volume expansion with isotonic saline or sodium bicarbonate may be used for preventing cin in at-risk patients, while the efficacy of nac and other drugs in reducing the incidence of cin remained unproven. guidelines produced by other societies provide very similar suggestions, thus further validating these recommendations. jia is the most common rheumatic entity in childhood and includes a subset of childhood arthritis, all of which are characterised by chronic synovitis with a potential risk of progressive joint destruction. radiological investigations in jia should ideally be able to determine the presence and degree of active inflammation, precursors of bony destructions and established erosions. however, there are many pitfalls in the interpretation of joint pathology in children. ultrasonography is often the initial tool in the assessment of arthritis and can depict joint fluid and synovitis. erosions and cartilage destruction of small joints may also be seen. the major problems are standardising the imaging technique and the lack of normal standards of anatomy in us in children. radiographs can show bone erosions and may depict cartilage loss indirectly through joint space narrowing, but are insensitive to inflammation and early joint destruction. mri is the only imaging modality that can assess all relevant anatomical structures in joint inflammation and is sensitive to early inflammation and destruction. however, large variations in the amount of joint fluid, bone marrow oedema-like lesions and changes resembling erosions are seen in children and also in healthy individuals. the differentiation between true pathology and normal findings on mri in children remains a challenge, particularly in early disease. in this lecture, the role of radiographs, ultrasound and mri and the typical radiological findings in joint pathology in jia will be presented. current knowledge on validity and reliability of the different imaging techniques in jia will be discussed. brain mri plays an important role in those criteria, as it can demonstrate the classical dissemination in time and space and helps earlier diagnosis, which is of major importance since the present recommendation in children is to start immunomodulating treatments as soon as diagnosis is established. among paediatric ms, 14% begin before the age of 6 years and 30% before the age of 10 years, frequently with an adem presentation in young children as initial manifestation of ms. however, only 20% of the adem indicate ms onset and the most predictive factors should be known, i.e. periventricular, deep white matter, corpus callosum high t2 signal lesions and black holes on t1 sequences. mri evaluation is also instrumental in differential diagnoses such as nonrelapsing adem, vasculitis, immunogenetic diseases and occasionally leukodystrophies. finally, brain mri is useful to evaluate the risk of more severe ms. the obesity epidemic represents one of the most significant european and public health challenges in the 2 1 st century with prevalence of the disease having tripled in many countries during the past 30 years. this is resulting in an ever increasing cost to healthcare systems including hospital and in particular radiology services which face unique challenges when imaging this group of patients. obesity significantly increases the patient's risk of various comorbid diseases including the incidence of cancer, diabetes, and cardiovascular and liver pathology with a multidisciplinary team approach mandatory for optimal patient care. this multidisciplinary symposium will review the implications of the epidemic with cutting edge, in-depth lectures presented by european experts addressing the epidemiology, role of imaging in the bariatric surgical patient as well as the importance of abnormal fat deposition in the liver. session objectives: 1. to learn about the impact of the obesity epidemic on european healthcare. 2. to appreciate the value of imaging techniques in the management of the post-operative bariatric patient. 3. to understand the role of radiology in fatty liver disease and the importance of imaging during subsequent patient surveillance. obesity: causes and consequences to the patient r. batterham; london/uk (r.batterham@ucl.ac.uk) obesity is one of the greatest 2 1 st century public health challenges. its prevalence has tripled in many european union (eu) countries since the 1980s. currently, 52% of eu adult population is overweight and 17% obese, and the numbers of those affected continue to rise. overweight and obesity are risk factors for numerous health problems, including hypertension, diabetes, cardiovascular diseases, respiratory problems, musculoskeletal diseases and some forms of cancer. mortality also increases sharply once the overweight threshold is crossed. because obesity is associated with higher risks of chronic illnesses, it is linked to significant additional health care costs and is already responsible for 2-8% of health costs. changes in our environment are the main driver for this increase in overweight/obese. however, a person's genetic make-up can either increase or decrease their chances of becoming overweight. the gastrointestinal tract is the body's largest endocrine organ producing hormones that regulate bodyweight. dietary modifications, such as caloric restriction, are the first-line obesity treatments. however, dieting produces only moderate weight-loss with poor weight-loss maintenance. compensatory gut hormone changes induced by dieting are thought to contribute to the failure of dieting. in contrast, bariatric surgery is an efficacious treatment modality for obesity, producing durable weight-loss, amelioration of obesity-associated co-morbidities and reduced mortality. consequently, the number of bariatric procedures undertaken within europe has doubled in the last 5 years with 112,000 procedures undertaken in 2011. there is increasing evidence that surgically-induced alterations in circulating gut hormones mediate the weight-loss and metabolic beneficial effects of bariatric surgery. learning objectives: 1. to understand the epidemiology of obesity and its impact on european healthcare provision. 2. to appreciate the aetiology of obesity and the scientific rational for surgical treatment. 3 . to learn about the effects of obesity on health. imaging of modern surgical procedures and their complications m. rengo; latina/ it (marco.rengo@gmail.com) we will illustrate the common bariatric procedures, in particular their normal appearance on different diagnostic technique as well as their early and late complications. we will illustrate the correlation between conventional barium studies and advanced imaging with mdct and mr. we will explain how to optimise mdct and mr acquisition protocol according to the clinical indication. we will explain what to evaluate before redo surgery, in particular quantitative and functional analysis. we will illustrate the role of interventional radiology in the management of early postoperative complications, in particular in the management of patients subjected to gastric banding. non-alcoholic fatty liver disease comprises a variety of pathological disorders ranging from simple steatosis to steatohepatitis. this condition is common in the western population and is typically associated with obesity and the metabolic syndrome. its incidence increases dramatically. diagnosis of fatty liver and distinction between simple steatosis and steatohepatitis are keys because the latter can lead to extensive fibrosis and cirrhosis with an increased risk of hepatocellular carcinoma (hcc). imaging plays a crucial role in diagnosing fatty liver. the two most important imaging modalities are ultrasound and mr imaging. ultrasound can exclude major steatosis but lacks accuracy to precisely quantify fat, while mr is the most accurate for quantification. the technique of reference is mr spectroscopy, but sophisticated sequences based on chemical shift principle have been shown as accurate as mr spectroscopy. unfortunately, imaging has still limitations to assess the presence of fibrosis and inflammation which are associated with steatohepatitis and functional tools could be of interest. today, imaging is combined with clinical and biological biomarkers to evaluate the risk of steatohepatitis. due to the increased risk of hcc and cirrhosis-related complications in patients with steatohepatitis, patients at risk should be enrolled in the surveillance programme. learning objectives: 1. to understand the pathophysiology of fatty liver disease and its link to cirrhosis. 2. to become familiar with the role of imaging in the detection and quantification of fat in the liver. 3 . to learn about the importance of imaging in the surveillance of patients with fatty liver disease. the concept of breast cancer units originates from the need for making available to all women in europe high-quality breast services where breast disease could be looked after by specialists working as teams. such teams have to provide all the services related to breast cancer, including genetics and prevention, treatment of the primary tumour, care of advanced disease, palliation and follow-up of previously treated women. the breast unit is made up of a group of dedicated breast cancer specialists including a radiologist, radiographer, surgeon, reconstructive surgeon, pathologist, medical oncologist, radiation oncologist and breast care nurse. the specialists involved in breast cancer units have access to all the facilities required for high-quality care and spend most of their working time dealing with breast cancer. in our hospital, we routinely work as a team and to make it possible we organise weekly meetings involving specialists from different disciplines to evaluate and plan patient care at any step of the diagnostic and therapeutic process. each year, we take care of about 1.500 newly diagnosed patients with primary breast cancer and of 10.000 patients in follow-up. about 500 are patients who undergo rt. after a short introduction from our fellows from pathology, surgery, oncology and radiation therapy, who will discuss their role in the breast unit, we will try to give a practical demonstration of the everyday work of breast units with particular emphasis on the role of the radiologist. the european society of urogenital radiology (esur) published, in 2012, the new clinical guidelines for evaluation of the multi-parametric mri of the prostate. this structured reporting/scoring system (pi-rads) is based on literary evidence and consensus of experts' opinions. the pi-rads scoring system is similar to that already employed by breast imaging (bi-rads) and reflects the probability of a prostatic lesion to be significant. each lesion can be scored in all sequences used in the multi-parametric prostate mri protocols (t2-and diffusion weighted imaging, dynamic contrast enhanced imaging and mr spectroscopy) based on defined mri criteria, which are specific for each sequence. based on the scoring in the particular sequences a final pi-rads score for each lesion can be assessed. for each lesion a five-grade scoring systems was created where, for example, the score 1 means that clinically significant disease is highly unlikely to be present and score 5 clinically significant disease is highly likely to be present. this lecture elucidates the principles of this scoring system and its impact on the target definition for the invasive diagnostics and therapy. prostate cancer screening with psa and extended systematic biopsy protocols have led to the over-detection and over-treatment of small and well differentiated cancers, considered clinically insignificant. these cancers cover up to 70% of the overall prevalence and may not be of any threat. multiparametric (mp)-mri has shown recently its value in the detection, localisation and characterisation of prostatic tumour foci larger than 0.2 cm, and may be of value to address the issue of over-detection and over-treatment. an mri-targeted biopsy strategy alone, without any additional systematic biopsies, has been suggested to decrease the detection rate of insignificant tumours while increasing that of potentially aggressive tumours. in patients with no evidence of lesion on mp-mri, the biopsy may probably be deferred. in patients with localised prostate cancer, mp-mri may also become a cornerstone in the selection, guidance and surveillance of patients managed with focal therapy. the rational for this new modality of treatment is to decrease over-treatment by destroying exclusively the index lesion detected on mp-mri. the precision of such treatments may be increased with mritransrectal ultrasound image fusion, allowing for real time navigation during the procedure. the accuracy of multiparametric mri has greatly improved the ability of localising tumour foci of prostate cancer. this property can be used to perform a trus-mr image registration, a new technological advance, which allows for an overlay of an mri onto a trus image to target a prostate biopsy towards a suspicious area. three types of registrations have been developed: cognitivebased, sensor-based and organ-based registration. cognitive registration consists of aiming at a suspicious area during biopsy with the knowledge of the lesion location identified on multiparametric mri. sensor-based registration consists of tracking in real time the trus probe with a magnetic device, achieving a global positioning system which overlays in real time prostate image on both modalities. its main limitation is that it does not take into account prostate and patient motion during biopsy two systems (artemis and uronav) have been developed to partially circumvent this drawback. organbased registration (koelis) does not aim at tracking the trus probe, but the prostate itself to compute in a 3d acquisition the trus prostate shape, allowing for a registration with the corresponding 3d mri shape. this system is not limited by prostate/patient motion and allows for a deformation of the organ during registration. the pros and cons of each technique and the rationale for a targeted-biopsy only policy are discussed. radiotherapy of the prostate typically takes the form of either external beam radiotherapy or alternatively, brachytherapy using radioactive seed implants. in both cases, the use of ultrasound has been proven to be highly useful and this presentation will give an current state of the art overview of ultrasound in external beam and radioactive seed radiotherapy. in the case of external beam radiotherapy, accurate localisation of the prostate is essential to ensure adequate target coverage with minimal damage to normal tissue. dedicated ultrasound scanners are able to provide sub millimeter localisation of the prostate superior to the imaging traditionally obtained using ct scanners. this positional information can be obtained daily. in addition, ultrasound allows the imaging of patients with metal hip implants which are normally difficult to image using ct. apart from the benefits of the technique, some pitfalls will also be highlighted. in the case of prostate brachytherapy, the use of ultrasound in the 3-d volume imaging of the prostate both prior and during treatment will be discussed. in both cases, some time will be spend discussing the quality assurance requirements for ultrasound imaging systems. image-guided radiation therapy (igrt) with onboard kilovoltage cone-beam ct (cbct) allows image guidance during radiotherapy treatments for patient setup and dose replanning. all these items will be discussed in connection with other topics: organ dose and image quality. it is compulsory to convert cbctimage's pixels from arbitrary grey scale to hounsfield unit (hu). this conversion was obtained using a catphan 600 phantom. the same phantom is used for image quality evaluation; standard ctdi head and body phantoms and a farmer chamber were used to measure the cbdi to estimate organ and effective doses by monte carlo software of different protocols of acquisition. ctdosimetry software (ver.1.0.4-impact) and pcxmc2.0 rotation software were used. to verify the dose replanning techniques by cbct, horizontal and vertical dose profiles were compared with the same obtained from ct. patient replanning was verified using cbct vs ct in terms of conformity index. image quality parameters of cbct (in comparison with ct images) are fine for spatial resolution, but are less useful for low contrast. cbdi of 5.7 mgy/100 mas was measured; 4 msv effective dose, 26 mgy prostate dose and 32 mgy bladder dose were evaluated and discussed during the presentation. replanning on cylindrical phantom shows a mean percentage difference for each profile 2% and a variation on d mean in all inserts < 3%. the mean percentage difference between parameters characterising ct and cbct-based plan values is less than 5%. the replanning showed a substantial agreement with doses evaluated on the reference ct-image; patient dose must be evaluated for all radiation sources. cranial nerves i-vi have an anteroposterior course and are best examined in the coronal plane. cranial nerves vii-xii run in an anterolateral direction and are therefore best examined in the axial plane. these two planes also allow left-right comparison which makes lesion detection easier. lesions involving the cranial nerve nuclei can be detected on axial proton-density/t2/multi-echo-ge images and diffusion-weighted images can exclude acute infarction. the cisternal segment of the cranial nerves is best detected on heavily t2-weighted images (drive/fiesta/3d-tse/ciss). at 3-tesla, 3d-sequences (e.g. b-ffe) can be used and it is often possible to cover the cisternal segments of all 12 cranial nerves. in the cavernous sinus, the cranial nerves can only be evaluated on coronal gadolinium-enhanced high-resolution t1-weighted images and similar axial images are needed to evaluate the nerves in the jugular foramen and hypoglossal canal. axial and coronal gd-enhanced highresolution t1-weighted with or without fat suppression are used to image the extracranial course of the cranial nerves. today, the tse-dixon sequences provide non-fatsat and fatsat images simultaneously, making cranial nerve imaging faster and easier. time-of-flight images can be used to study neurovascular conflicts, although these can also be detected on submillimetric gd-enhanced t1 images. of course, it is important to know the major anatomy of the cranial nerves and the most frequently occurring lesions. the abovementioned imaging techniques, the most important anatomy and the most frequently occurring lesions will be demonstrated and discussed in this lecture. mri study of the lower neck space includes the study of anatomy and pathologies of the thoracic outlet, or cervicothoracobrachial junction, extending from the cervical spine and the mediastinum to the lower border of the pectoralis minor muscle, the brachial plexus and the supraaortic vessels (carotid, subclavian arteries and veins). for this, use of a dedicated head and neck coil is fundamental to avoid frequent artefacts arising from air and the passage between different surfaces. only in case of thoracic outlet evaluation, a dynamic angio-mri study should be performed and this means the use of a surface coil. mri protocol of the lower neck should include t1-and t2weighted sequences. both fat-saturated proton density and t2 with stir sequences can be used to overcome the inhomogeneity of the magnetic field, especially with large fov. sand bags can be placed on either side of the neck and suprascapular region of the patient to improve image quality. also, flow saturation bands can be utilised to limit blood flow artefacts. also, volumetric sequences are in common use to obtain a quick examination. breath or cardiac gating can be helpful. abnormal findings of brachial plexus consist of nerve signal abnormalities with mild or marked hyperintensity on t2-weighted, being aware of magic angle effects and swelling. in case of thoracic outlet syndrome, mri protocol should define the compression of brachial plexus components arteries and or veins, both in indifferent and dynamic mri acquisition. learning objectives: 1. to learn how to overcome difficulties in performing a lower neck study. 2. to understand how to avoid the most common pitfalls. 3. to become familiar with differential diagnosis. c. ct and mri of temporal bone: user's guide f. veillon; strasbourg/fr ct and mr imaging of the temporal bone must be performed with a precise technique. in ct it is important to locate the box of the study above and not in the orbit to avoid the lenses. irradiation is divided by 10 compared with a study through the orbit. the axial sections must be parallel to the lateral semicircular canal the coronal, sagittal sections are completed by oblique coronal views through the long process of the incus and the head of the malleus to get the ossicular v. double oblique sections through the 2 componants of the v permit a view of the stapes and also the malleus and incus in 3 d (mip : 3 mm). mri must be performed parallel to the roof of the orbit permiting very good axial sections in the plane of the lateral semicircular canal (t1 and t2). the internal auditory meatus and the inner ear must be analysed with 1 mm axial sections (se) after intravenous gadolinium injection completed by a high resolution t2 (gradient echo or se) 0.3-0.4 mm, depending on the machine (3t, 1,5 t). the middle ear in chronic otitis media must be studied with t1, diffusion and high resolution t2. there is no need of contrast medium injection apart from the complication: fistula of the lateral semicircular canal, thrombosis of the sigmoid sinus. the different pathologies are then discussed: external auditory meatus and middle ear pathologies: ct first. mri is useful for postoperative cholesteatomas. inner ear malformations, otosclerosis, trauma: ct. labyrinthitis, inner ear hemorragia, schwannomas, internal auditory canal content: mri. revascularisation time windows for patients with acute ischemic stroke are generally restricted up to 4.5 hours in the anterior and up to 8 hours is the posterior perfusion area. later treatment attempts require more accurate prediction of risk and benefit, as safety and efficacy at these time strata are less well. thus, rapid and effective imaging is important for decision-making concerning intrarterial catheter based recanalisation and/or thrombolytic therapy. advanced imaging techniques identify irreversible infarction as well as tissue at risk. diffusion-weighted mri detects ischemia within minutes of onset, whereas perfusion-weighted mri and ct perfusion studies disclose the ischemic penumbra. combined, they provide information on mismatched tissue, i.e. potentially salvageable brain. in addition, non-catheter angiographic techniques like ct or mr angiography are a useful adjunct to localise arterial occlusion. as an attempt to a reliable emergency examination, the following protocol has been proven to be robust: for the anterior perfusion area, a non contrast ct may exclude cerebral bleeding and is followed by ct angiography (including supraaortic and intracranial vasculature). if technical available, ct perfusion should be performed in addition. in ischaemic strokes of the vertrebrobasilar region, cta is essential to exclude basilary stenoses or thrombotic occlusion. if the stroke onset remains unclear or might extend the above mentioned time window, mr stroke imaging (i.e. diffusion, flair and perfusion sequences) is suggested as mr offers a higher sensitivity. anyway, the best method for each emergency stroke imaging center is depending on clinical availability 24h/365 days, technical equipment and -finally -individual experience of the emergency team. some recent publications have questioned interventional treatment of stroke as an alternative to iv thrombolysis only. these papers -albeit published in highranking sources -usually do not describe the modern concepts of interventional stroke treatment. interventional radiologists, therefore, are convinced by their practical experience that the modern concept of combining iv thrombolysis with mechanical thrombectomy by stent retrievers offers a benefit to a subgroup of patients with severe stroke. this includes anatomical level of occlusion -basilar artery or single vertebral artery, proximal carotid occlusion with distal tandem occlusion, carotid t obstruction and m1 occlusion. m2 occlusions are debatable. besides location, the clinical status of the patient before stroke and time of onset, absence of early ct signs of stroke or bleeding and clinical contraindications to iv thrombolysis such as recent surgery influence the decision-making. more difficult than the description of technical success is prediction of clinical success. there are a couple of scores such as thrive available that may be used for outcome forecasting. the amount of collateral flow is frequently used as a decision tool, but is not always easy to quantify. mismatch scores and penumbra have been questioned recently. in conclusion, anatomical factors are pretty easy to identify to indicate treatment, but the clinical and functional setting still lacks quick and reliable parameters that allow a clear decision-making, particulary in borderline cases. the refresher course addresses the current state-of the-art use of different mechanical revascularisation strategies, devices and potential complications. in addition, multimodal imaging applications with a focus on patient selection for endovascular recanalisation therapies, as well as new techniques to guide endovascular therapy within the angio suite are presented. finally, some organisational aspects important for providing an interdisciplinary interventional stroke service are discussed. the ultimate goal of an acute endovascular stroke intervention is neurological recovery or improvement. recanalisation of an arterial occlusion is key in achieving this goal. clinical data suggest that endovascular stroke treatment results in higher recanalisation rates and may provide superior clinical outcomes when compared with intravenous thrombolytic therapy only. however, these higher recanalisation rates are far away in being paralleled by equally higher rates of favourable outcomes in recanalised patients. thus, patient selection remains crucial. besides the careful neurological assessment, brain imaging is here of major importance. the case presentations illustrate that imaging may help in patient selection for subsequent thrombolytic/endovascular therapies by differentiation of patients who may profit from intravenous or interventional therapy in an even extended time window from those who do not. there are a number of key areas supported by evidence-based medicine necessary for a high-level interventional stroke service. as a precondition, a neurointerventional stroke service has to be organised within a multidisciplinary acute stroke team. inside the hospital, it is all about streamlined pathways. any possible delays should be minimised at every step. sacroiliac joint pain may arise from a number of conditions including inflammatory arthritis, degeneration, fractures and tumours. studies suggest a prevalence of 10% to 60% pain arising from the joint in patients with positive clinical signs. temporary effect is provided by a mixture of local anaesthetics with steroids with a response varying between 50% and 80% in reported series. dual blocks using agents of differing duration are considered more precise, but are less often used in practice. imaging including mr and scintigraphy are of limited predictive value. injections may be into the synovial joint, around the joint or adjacent to the nerve innervation of the joint. there is evidence that para-articular sources of pain are common and injection outside the joint may be more effective. sl-joint injections are performed through a dorsal approach guided by ultrasound, fluoroscopy or low-dose ct. shortacting agents may have lasting benefit, but radiofrequency ablation has been employed in an attempt to obtain long-term response. the evidence for lasting therapeutic response to intra-articular or periarticular injection of steroids and conventional radiofrequency neurotomy is weak. there is fair evidence of longterm response to cooled radiofrequency neurotomy. facet joints account for 25-40% of all low back pain. they are affected by osteoarthritis, joint space narrowing, intra-articular vacuum phenomenon/fluid, osteophytes, synovial cyst and ligament hypertrophy. conservative therapy is initially proposed. percutaneous facet joint steroid infiltrations are minimally invasive procedures involving injection of corticosteroid with or without local anaesthetic inside the joint. they also can provide diagnostic verification of a certain facet joint acting as the pain source. the injectate usually contains a long-acting corticosteroid mixed with a local anaesthetic. sodium hyaluronate solutions or ozone were tested; however more and extensive studies are necessary. other options are either percutaneous ablation or surgical arthrodesis. fluoroscopy, computed tomography or magnetic resonance can be used for guidance. fluoroscopy has the advantage of real-time imaging. cone-beam ct can also be used. computed tomography provides better anatomy information, but has increased radiation dose for the patient. magnetic resonance has higher cost and longer duration. a recent study concluded that it is twice the cost of ct-guided infiltrations. mri can be used in combination with focal ultrasound for ablation, a technique which is still under investigation. success depends upon patient selection (59-94% immediate and 27-54% long-term relief). the level of evidence is moderate for lumbar spine concerning short-and long-term improvement. however, the most recent guidelines released (american society of pain physicians) state that it is the oldest and most commonly used technique. the success rates with its safety profile and least invasiveness seem to make it an attractive therapy. although promising for early assessment of response to treatment, these newer functional biomarkers need extensive validation and standardisation for their wide clinical use. validation includes the assessment of reproducibility and accuracy, whereas standardisation concerns image acquisition and postprocessing. the added value of the more complex functional biomarkers relative to the viability parameters should also be shown. viability and functional imaging biomarkers are evolving and emerging parameters for the early assessment of response to treatment. mri biomarkers must be able to show how tumours respond to specific treatment. they need to allow assessment of the effectiveness of new treatment more rapidly than classical clinical end points. these biomarkers must be easy to obtain to facilitate a large spread of the technique. they have to be reproducible. the longest diameter of the tumour remains the easiest biomarker that can be obtained from any kind of morphologic acquisition with no need of post-processing. additional information about the tissular organisation and cellularity can be now easily obtained using modern scanners through diffusion-weighted sequences. the ease with which those sequences are obtained for a while masked the necessity to perform a more complex postprocessing than the one initially done to get reliable biomarkers. there are numerous mri biomarkers of microcirculation, reflecting o2 consumption, blood volume, blood flow, vessel permeability and extravascular volume. to get them, we need more sophisticated acquisitions and image processing that take into account the t1 of the tissue, arterial input function, respiratory motion, etc. most of these new mri biomarkers are now used in research and in phase i studies, but have not been validated in more advanced clinical trials or in clinical practice. to use them widely and reliably, we need to perfectly understand the consequences of the choices we make during the acquisition and post-processing of these biomarkers. new targeted treatments in cancer can be effective without significantly reducing tumour size. there are already a large number of targeted treatments that are licensed to treat a range of cancers. for some of these cancers, there is currently no reliable method to tell whether the drug is effective and new response, predictive and prognostic biomarkers are required. functional imaging techniques such as diffusion-weighted mri, dynamic contrastenhanced mri and fdg-pet imaging are being developed or applied as response biomarkers. however, for these to be useful in a wider multi-centre setting, the measurements need to be precise, repeatable and reproducible. we discuss these properties in the context of emerging imaging response biomarkers. learning objectives: 1. to understand imaging biomarker precision (repeatability and reproducibility) and accuracy and how it is evaluated. 2. to learn how to interpret biomarker precision and accuracy in the context of the biomarker's intended use. coronary artery disease (cad) and its related cardiac disorders are still the number one cause of death in the usa and the western world. up to date, single photon computed tomography (spect) using traditional radiotracers like thallium-201 or tc-99m sestamibi is the most utilised imaging technique for the assessment of myocardial perfusion. however, over the past decade, there has been a growing interest in cardiac imaging with positron emission tomography (pet) and, indeed, a paradigm shift has been witnessed in the use of myocardial perfusion imaging (mpi) with pet taking advantage of the superior imaging properties of pet over spect. therefore, pet mpi is now being increasingly used for routine clinical evaluation of patients with known or suspected cad. furthermore, it is being used not only at large academic institutions, but also at community hospitals and even in private practice. several factors contribute to this shift in the use of pet mpi, including the growing availability of combined pet and computed tomography (ct) systems, mainly driven by oncological applications, radiotracer, like rubidium-82 or 18 fflurpiridaz, which can be used in clinical routine, changes in reimbursement, and the increasing clinical evidence supporting the value of pet/ct mpi. the lecture "pet for evaluation of perfusion, absolute myocardial blood flow and coronary flow reserve" will cover several aspects of the growing field of pet mpi. besides the visualisation of coronary morphology, computed tomography (ct) has shown feasibility to also assess myocardial perfusion. currently, there are two different approaches to ct-based myocardial perfusion imaging: singleshot and dynamic, sequential acquisitions over a predefined scan time. the presentation will cover basic concepts of both approaches and highlight protocol details and findings in these stress acquisitions. also, emerging scientific results with respect to diagnostic accuracy, the detection of hemodynamically relevant coronary stenosis and prognostic implications will be discussed. over the past few years, cardiovascular magnetic resonance imaging (cmr) has been increasingly established as an important method in the diagnosis of cardiovascular disease. many studies have shown the equality or even superiority of cmr compared to other imaging modalities (e.g. nuclear medicine and echocardiography). cmr offers important advantages like the absence of ionising radiation, high spatial resolution, and the combination of perfusion imaging with tissue characterisation. the main clinical applications in the assessment of coronary artery disease (cad) include ventricular function, myocardial viability and perfusion. in clinical routine, myocardial perfusion is determined by contrast-enhanced first-pass perfusion techniques during pharmacological stress using coronary vasodilators (e.g. adenosine) or ã�adrenergic agents (e.g. dobutamine). non-invasive characterisation of myocardial microcirculation is thought to reflect myocardial tissue supply much better than mere luminographic detection and quantification of epicardial coronary stenosis, and has been shown to be useful for planning of revascularisation procedures and cardiac risk stratification. in several studies on the prognostic value of cmr in cad assessment, normal stress perfusion cmr was highly predictive for a good prognosis, thus able to identify patients in whom invasive angiography can be deferred safely. the purpose of this lecture is to demonstrate how it is possible to sensitise the mr signal to water molecules diffusion in tissue and how to use calculated indices to reflect structural integrity. the concept of diffusion-weighted imaging will be introduced with particular emphasis on the pulsed gradient spin echo (pgse) sequence. methods to calculate the apparent diffusion coefficient (adc) will be described and the concept of the diffusion tensor (dt) will be explained. image processing of diffusion data includes steps like eddy current distortion correction, model fitting and potentially registration of maps to a reference space. indices that are reproducible and rotationally invariant will be described, such as fractional anisotropy (fa), mean diffusivity (md), axial diffusivity (ad) and radial diffusivity (rd). examples of when to use the adc maps or the dt indices will be given in relation to pathologies such as stroke, multiple sclerosis and neurodegenerative diseases. strategies for result presentation such as region of interest approach, histogram analysis and tractbased methods will be shown. limitations and advantages of diffusion imaging methods such as dt do not preclude the use of this technique in research and clinical radiology for investigating structural changes in disease. diffusion imaging methods have a lot of potential to be used in clinical practice. however, although diffusion-weighted imaging has been increasingly applied, clinical use of diffusion tensor imaging is limited to date. this is in part due to the lack of standardisation and the need for more complex analysis tools to evaluate the data. during this lecture, an overview will be provided of some analysis methods for diffusion-weighted and tensor imaging. i will discuss the different parameters that can be obtained as well as some advantages and limitations of the different analysis methods. it is highly recommended to include diffusion-weighted imaging (dwi) in the routine protocols for mri of the brain. dwi as well as automatically calculated apparent diffusion coefficient (adc) map is used for evaluation. the adc values of gray and white matter are identical in the adult brain. restricted diffusion (high signal on dwi and low signal on adc) is seen not only in acute stroke, but can also be present in some brain tumours, the necrotic centre of abscesses, some acute mr plaques, some contusions, encephalitis, creutzfeldt-jakob disease, metabolic diseases, etc. this finding is thus not specific, but is very helpful combined with clinical information and the signal pattern on other sequences. acute stroke has restricted diffusion during the first 7-10 days and the diffusion gradually increases to become very high in a chronic infarct. the diffusion changes in ischemic brain and spinal cord tissue are usually irreversible, but may be reversible. brain tumours with high cellularity, such as lymphoma, glioblastoma multiforme, medulloblastoma and metastases from small cell lung carcinoma, usually have restricted diffusion. the surrounding vasogenic oedema has increased diffusion. in the central necrosis of a pyogenic abscess the diffusion is restricted, while it is increased in the necrotic centre of a malignant brain tumour. reversible diffusion restriction in the cortex, the hippocampi and thalami can be seen in patients with status epilepticus. diffusion tensor imaging has so far had limited clinical use, but may be useful, e.g. for the preoperative evaluation of brain tumours. learning objectives: 1. to understand the differential diagnostic possibilities of high signal intensity lesions on diffusion weighted images (dwi) of the brain and spinal cord. 2. to become familiar with the appearance of acute, subacute and chronic stroke on dwi. 3. to learn about the appearance of cerebral tumours, infection/inflammation, neurodegenerative diseases and traumatic lesions on dwi. 4. to understand the present use of diffusion tensor imaging (dti) and diffusion tensor tractography (dtt) in clinical neuroradiology. the signal intensity in diffusion-weighted imaging (dwi) reflects the cell density in the tissue. dwi, including apparent diffusion coefficient (adc) maps, can therefore be used to differentiate highly cellular from acellular regions of tumours, distinguish cystic from solid lesions, and monitor change in tumour cellularity over time, reflecting response to therapy. in general, tumours have high signal intensities in dwi, but low corresponding adc values compared to normal/benign/reactive tissues. dwi has a wide range of clinical applications, which includes cancer imaging, imaging of infections and inflammations, evaluation of trauma and visualisation of peripheral nerves. of these, the most promising application appears to be in oncological imaging. there is, e.g. now evidence to recommend inclusion of dwi in mri protocols for lesion detection and characterisation in the liver. the advent of whole body (wb) mri including wb-dwi (from root of the neck to groin) has introduced tumour imaging with a systemic approach compared to established multi-modal diagnostic algorithms. it has been found valuable for staging, therapy evaluation and surveillance of tumours, especially in children. however, dwi is generally recommended to be incorporated into oncologic mri protocols of both wb-mri and of selected organs, because it provides additional valuable information to the conventional mr sequences. dwi of the body is frequently prone to imaging artefacts, which can obscure or mimic lesions. to minimise misinterpretations, analysis of the raw b-value images directly in conjunction with adc maps and conventional coregistered sequences is recommended. spinal surgery is most frequently performed to decompress (disc herniation, stenosis, malignant infiltration), fuse and stabilise (particularly following trauma or infiltrative destructive processes) and correct deformity. often, there may be a combination of these procedures at one operation. surgical instrumentation or bone graft is sometimes employed. patients may present themselves with symptoms early or late following the procedure. this interactive session seeks to address the variety of surgical procedures undertaken and subsequently imaged post-operatively because of symptoms. the session aims to help one to understand and become familiar with the expected post-operative imaging appearances related to the surgical procedure, learn about abnormal pathological features as a cause of symptoms in the acute and more chronic situation and explore the diagnosis and differential diagnosis. this may include post-operative fibrosis versus recurrent disc herniation versus post-operative infection. failure of fusion due to failure of instrumentation or inadequate take of bone graft can give rise to pseudoarthrosis. recurrent stenotic symptoms may relate to an inadequate decompression, recurrent disc herniation, postoperative haematoma, extension of a malignant process or ischaemic damage. joint replacement surgery for the treatment of arthritis most often offers the patient excellent results. however, there are potential complications that a radiologist should know about. it is essential to understand the importance of pre-and postoperative imaging for evaluating patients. most commonly, standard radiographs are used to assess the patients after joint replacement. however, ct, nuclear medicine methods as well as mr imaging play an increasing role in such patients. the radiologist should be aware of the most common type of prosthesis and the most common complications after joint replacement. these complications include postoperative prosthesis loosening, prosthesis fractures, periprosthetic fractures, postoperative infection, rotation failure of the prosthesis, and soft tissue abnormalities such as surrounding tendon tears. this interactive session seeks to address the variety of joint replacements which are undertaken and subsequently imaged postoperatively as a result of symptoms. the session aims to help one to understand and become familiar with the expected postoperative imaging appearances related to joint replacement, learn about abnormal pathological features as a cause of symptoms and explore the diagnosis and differential diagnosis. learning objectives: 1. to learn about changes related to surgery. 2. to understand changes related to non-surgical treatments. serbia is a beautiful country where east and west merged and often collided for centuries, and where nowadays eastern cultural heritage meets and mixes with the western heritage in a lovely and unprecedented way, with a lot of charm and with a variety of extraordinarily natural beauty and plenty of both traditional and gastronomical wonders to explore. it extends from the edges of the pannonian flatland in the north, over the danube and sava rivers to the gradually growing wonderful mountains in the south. already in 1897, the first x-ray unit was installed, and only twenty years later x-ray units are present in most state-owned and private hospitals in serbia. nowadays, slightly more than half of the thousand radiologists in serbia perform a broad variety of diagnostic imaging and interventional techniques in different radiological units, including numerous ct, mri, and few pet/ct units distributed in five university centers, a number of public clinical centers and hospitals, and also in the private sector. several centers are fully equipped with pacs and ris systems, and are capable of performing teleradiology services. there are still significant challenges in serbian radiology in the field of education and research, planning and implementation of national radiology networks, improvement of standard clinical practice and financing the new equipment. yet since radiologists' enthusiasm overwhelms most of the difficulties, radiology in serbia provides nowadays a broad variety of modern and competent diagnostic and interventional procedures, improving the management and treatment of our patients. radiology in serbia, since its beginning, has been inextricably linked to european radiology. there are written documents testifying to the fact that the first x-ray appliances in serbia had emerged and had been used for medical purposes only two years after wilhelm conrad rã¶ntgen discovered x-rays in 1895. the real beginnings of diagnostic radiology in serbia can be linked to the establishment of the general state hospital in 1908, where the first x-ray cabinet was installed. later discoveries in the field of radiological techniques, materials and contrast agents were also immediately accepted by the serbian radiology community. the first cerebral angiography was performed in 1935, which may be considered as the beginning of neuroradiology in serbia. the second half of the twentieth century is characterised by the introduction and wide application of ultrasound, ct and mr diagnostics and outbreak of vascular and nonvascular interventional radiology procedures in the areas of neuroradiology, uroradiology, and cardiovascular and gastrointestinal radiology. for years, serbian interventional radiology has successfully kept pace with achievements of the most relevant centres worldwide. nowadays, serbian radiologists monitor and enforce the most complex modern procedures in different areas of radiology. the rapid development of science and information technology has enabled the daily monitoring of all modern developments, methods and approaches and their increasingly faster introduction into practice. non-ischaemic cardiomyopathies (nicm) refer to myocardial diseases caused by mechanical and/or electrical disorder in the absence of significant coronary artery disease, valvular heart disease, hypertension, or congenital heart disease. nicm often present with genetic mutations, but no clinically apparent disease. in some cases, the presence of fibrotic tissue could cause adverse events and, therefore, the use of late enhancement (le) post-gadolinium technique is necessary in evaluating these patients. le suggestive of fibrotic tissue could be found in up to 35% of patients with nicm. in the majority of cases (up to 65%), midwall/subepicardial enhancement could be found; patchy enhancement, often at septal junctions, has been registered in 35% of patients, while the least common pattern of le was subendocardial (5%). in ischaemic cardiomyopathy (icm), subendocardial or transmural is a typical pattern of hyperenhancement and is related to coronary artery distribution. furthermore, le has the potential to provide important information for risk stratification in clinical practice. in nicm, the extent of fibrosis has been shown to be independently associated with increased rates of future adverse events including all-cause mortality, while in icm myocardium with le in more than 50% of wall thickness is unlikely to recover contractile function following coronary revascularisation. as many nicm disorders are associated with the presence of scar tissue, le in nicm is nonspecific and should be correlated with clinical presentation and history, which is critical in the evaluation of these patients. interlude: hop-on, hop-off sightseeing tour of serbia s. stojanovic; novi sad/ rs (tupsons@gmail.com) in the interlude between scientific lectures, you are most welcome to hop on a sightseeing tour around serbia during which we shall stop at a few stations where the natural and cultural heritage of our country will be shown. nota bene: some of the sights will be visible to everyone and some only to radiologists. ten thousand years of human effort and five billion years of european soil refinement will blink in front of your eyes through the window we have made with red churches' walls, azure skies and a silver sparkle of our spirit. all the time, a bit of grayscale shadow will supplement the picture as we in radiology are so used to. fragments of past and present will make a mosaic, the glance of which will hopefully light up your day. when you hop off our tour, we believe, some pictures will become part of your emotional memory and maybe will make you wish to see them in vivo. the role of prenatal mri in foetal central nervous system abnormalities: a case-based pictorial review k. koprivsek; sremska kamenica/rs (katarina.koprivsek@gmail.com) mri provides a unique opportunity for studying in vivo central nervous system development. its higher contrast resolution compared with prenatal sonography allows better visualisation of sonographically occult normal cns structures as well as structural abnormalities. in clinical praxis, prenatal mri has become a mandatory tool in evaluating: a) foetuses that have abnormalities suspected on the basis of foetal sonography; b) foetuses with increased risk for brain abnormalities even in the setting of a normal prenatal sonogram (family history of cns anomalies or a genetic/metabolic disorder); c) foetuses potentially at risk due to maternal illness; d) foetuses with congenital malformation, which are candidates for prenatal or neonatal surgical treatment; e) foetuses that could not be evaluated by sonography due to oligohydroamnion, maternal obesity, difficult position of the foetal head, or us reverberation on foetal calvaria in advanced gestational age. we will present a selection of foetal cns abnormalities detected in our institution during the last 8 years, including ventriculomegaly, abnormalities of the posterior fossa, agenesis of the corpus callosum, cerebral cortex developmental abnormalities, spine developmental abnormalities and a variety of encephaloclastic lesions. in all previously listed cases, prenatal mri could provide either crucial or additional information, which can lead to the accurate diagnosis of different cns developmental abnormalities (cortical, commissural and posterior fossa malformation), specific disorder or syndrome, further enabling adequate pregnancy management and parents' counselling. this lecture will cover the standard mammographic views required, the reporting systems for mammograms together with birads and other european systems, breast density, feature analysis, information the clinician requires in a cancer case and how to approach a b3 lesion. acr practice guidelines (2008) recommend obtaining previous mammograms as you can dismiss an abnormality that is unchanged for 5 years or that has been previously worked up and are able to detect subtle new lesions more easily, although this has not been confirmed in the screening situation. in a structured report the following information is recommended: indication, breast density, description of lesion, size, location, comparison to previous findings, overall assessment, management recommendations and a score to indicate the level of suspicion. examples of different common conditions seen on mammography will be shown including soft tissue masses, microcalcification, architectural distortion and asymmetry. breast ultrasound is one of the main imaging modalities in breast radiology, it allows us to characterise lesions and also guide interventional procedures. the bi-rads categorisation of ultrasonographic findings facilitates the diagnostic approach and also helps the radiologist to use a common language, understood not only by the rest of the radiological community, but also by other breast cancer professionals. ultrasound can be a diagnostic procedure on its own, but is mainly a modality that characterises the findings of other modalities (mammography and mri) and, as such, correlation between all these techniques is the mainstay of everyday clinical practice. this act of correlating and integrating the information of all modalities is what makes a breast radiologist a key actor in the diagnosis, staging and follow-up of breast cancer and other benign or high-risk entities. the final product of this integration will be the radiological report, the means by which we convey all the information we have gathered through all the procedures to our clinical colleagues. this report shall also follow some composition rules to be clear and concise. as with any other modalities, breast magnetic resonance imaging (mri) examinations should be reported in a structured way following the guidelines of the respective national, continental or international societies. adequate nonclinical information (i.e. patient name, date and type of examination, etc). is indispensable. any breast imaging report has to follow a stringent structure including indication, clinical history, clinical findings, brief description of technology used, assessment of parenchymal density, detailed description of significant findings, comparison with previous imaging studies and final assessment according to bi-rads. indications and contraindications of breast mri will be discussed. significant findings at breast mri include foci (small contrast-enhancing spot, nos, < 5 mm), mass lesions, "non-mass-like enhancement" (no mass lesion, partly diffuse regional contrast enhancement of various size) and associated findings. furthermore, as breast mri is a functional study, the different appearance patterns of kinetic contrast enhancement will be presented. the current status and the appropriate use of the bi-rads mri lexicon will be discussed. any breast mri report should not only follow the guidelines, but also follow a red thread, be consistent, express confidence and be comprehensible to clinicians. the overall final bi-rads assessment is based on the most worrisome finding, taking into account both breasts and all imaging methods (mammography, ultrasound, mri) evaluated. furthermore, adequate communication of the result, as well as do's and don'ts of the report wording will be discussed. the prostate is a small glandular organ, whose main function is to secrete seminal fluid. in young men it comprises of mainly the peripheral zone (70%) and a smaller central gland. however, the central gland enlarges with age to form the larger part. the main diseases of the prostate are inflammation, hyperplasia, and cancer (the most important). approximately 70% of cancers arise in the peripheral zone. the main applications of mri are for cancer detection, staging, and recurrence. mri is increasingly used for radiotherapy planning owing to its good soft-tissue contrast when compared with ct scanning. endo-rectal rf receiver coils, usually inflated with air or perfluorocarbon but sometimes of a rigid design, improve signal detection of the prostate. phased-array surface coils may also be used or (preferably) in combination. t1-weighted imaging helps to distinguish haemorrhage caused by biopsy. on t2-weighted images the peripheral zone appears brighter, owing to a larger proportion of prostatic ducts, while tumours generally appear darker. more sophisticated mr methods are increasingly used to help diagnosis. in diffusion-weighted images (dwi) tumours appear relatively bright, but dark in the corresponding calculated map of apparent diffusion coefficient (adc), owing to the more cellularly-dense nature of tumours, and hence, reduced diffusion. in dynamic contrast-enhanced mri (dce-mri) tumours appear bright owing to increased vasculature. magnetic resonance spectroscopic imaging (mrsi) of normal prostate is dominated by high levels of citrate from the prostatic ducts; in cancer this is reduced while choline is increased. prostatectomy samples allow one to verify image contrast against histology. recent studies on prostate cancer have provided a number of relevant targets for imaging and treatment purposes. today, imaging plays an important role in different aspects of the disease, but its role should grow in answering clinical questions at various phases of the disease. relevant targets for imaging include metabolites (including glucose, acetate, choline, and amino acids), antigens (including prostate-specific membrane antigen), receptors (grp receptor, cxcr4, androgen receptor), proliferation, angiogenesis, and hypoxia. in this presentation, a range of radiotracers for potential use in the imaging of prostate cancer will be discussed, as well as options to tailor nuclear imaging tracers to the various phases of the heterogeneous disease. the fusion of morphologic (ct and mri) and functional (pet, spect) imaging modalities (pet, spect) has become widely available and part of the standard diagnostic workup in cancer patients. for many years, neurosurgeons have already relied on multimodal imaging data during brain tumour surgery to identify hyper-or hypometabolic tissue. the availability of pet and spect data during percutaneous ablation procedures may also be helpful to facilitate treatment planning, probe placement, probe re-positioning, and early detection of residual disease following percutaneous image-guided ablation of cancer. however, up to now conventional us-and ct-guided thermal ablation procedures rely on morphologic information only. intraoperative implementation of multimodal data requires the application of frame-based or frameless stereotactic techniques, both relying on the establishment of an accurate relationship between the patient's preoperative image space and the intraoperative physical space. in image-guided neurosurgery, ct/mrt/spect/pet data are registered to the patient using rigid body transformation. due to respiratory motion and different patient positioning during image acquisition and the actual intervention, soft tissue deformations in the liver occur. thus, the images and the surgical presentation do not match between preoperative imaging and intervention, leading to an extensive degradation of spatial guidance. this presentation illustrates solutions for these fundamental problems that occur during 3d-navigated liver interventions, including patient immobilisation and repositioning, respiratory triggering and intraoperative imaging. r. bale: equipment support recipient; isys has supported the section of microinvasive therapy with testing equipment. patent holder; rb is a (co-) inventor of the atlas aiming device and the bodyfix immobilisation device and a (co-)shareholder in its financial returns. the goal of ultrasound-triggered, image-guided drug delivery is to increase the therapeutic index and decrease adverse effects of drugs. the bio-effects of focused ultrasound can lead to local tissue heating, cavitation, and radiation force, which can be used for 1) local drug release from nanocarriers circulating in the blood, 2) increased extravasation and cellular uptake of drugs and/or carriers, and 3) enhanced diffusivity of drugs. thermo-sensitive liposomes have been suggested for local drug release in combination with local hyperthermia more than 25 years ago. microbubbles may be designed to enhance cavitation effects. real-time imaging methods, such as magnetic resonance, as well as optical and ultrasound imaging have led to novel insights and methods for ultrasound-triggered drug delivery. image guidance of ultrasound can be used for: 1) target identification and characterisation; 2) spatio-temporal guidance of actions to release or activate the drugs and/or permeabilise membranes; 3) evaluation of biodistribution, pkpd; 4) physiological read-outs to evaluate the therapeutic efficacy. liposomes may carry both hydrophilic and hydrophobic drugs in their aqueous interior and lipid bilayer membrane, respectively. the circulation half-life may be increased by incorporating polyethylene glycol (peg)-lipids in the bilayer. recent publications have shown that ultrasound-triggered delivery is feasible. realtime imaging methods, such as magnetic resonance, optical and ultrasound imaging may lead to novel insights and methods for ultrasound-triggered drug delivery. up to now, the success of surgical tumour resection has always been limited by the surgeonâ´s vision. the human eye is not an accurate detector of small cancer cell clusters and it cannot accurately differentiate cancerous from healthy tissues due to lack of "visible" contrast. by combining a fluorescent probe targeting the folate receptor and a multi-spectral real-time fluorescence camera to observe the operating field, we found that, using fluorescence molecular imaging, 3-fold more lesions can be identified compared to conventional surgery. these first in-human results point to molecular-based clinical decision-making in surgical and endoscopic procedures as a paradigm shift over decision-making based on human vision. the talk describes current progress with instruments, methods and applications in the field of intraoperative imaging. pre-clinical and clinical results are presented and the advantages and limitations of the method as well as future directions will be discussed. the emerging field of multispectral optoacoustic tomography (msot) is also outlined. mysteries of the human brain unveiled: imaging of white matter microstructure and neuroplasticity p.m. parizel; antwerp/be (paul.parizel@uantwerpen.be) the human brain remains one of nature's great mysteries, and is considered science's final frontier. this greyish lump of tissue with a weight of 1.5 kg contains some 100 billion neurons, each of which are connected to thousands of other nerve cells in an intricate network of white matter fibers. in the previous century, the brain was perceived as a fixed three-dimensional landscape, with brain functions confined to certain locations (e.g. motor and sensory cortex, visual cortex, auditory cortex). this concept of neurolocalisationism was in line with the philosophy that there should be "a place for everything, and everything should be in its place". advanced quantitative mri techniques for acquisition and data analyis (fmri, dwi, dti, vbm), help to unravel white matter connectivity of the human brain, and are able to show that the brain can modify its structure and function in response to changing circumstances (such as learning, memory, hormones). this process, which is known as neuroplasticity, occurs at different levels and different time scales. for example, in response to injury, changes may occur at cellular level as well as on a larger scale with cortical remapping. some processes may take months or years (e.g. physical therapy and training) whereas some forms of neuroplasticity happen within hours or days (e.g. changes in brain volume and connectivity during the female menstrual cycle, which have been linked to behavioral changes). in summary, quantitative mri techniques help to unveil the mysteries of the human brain and have opened exciting new fields of active research such as white matter connectivity and neuroplasticity. there are a host of inflammatory and infective insults that can manifest focally or diffusely within the musculoskeletal system. the appearances of the underlying pathological processes in both the soft tissues and skeleton cover a very wide imaging spectrum. the appearances vary, depending on the timing and degree of inflammatory insult and the host response in the involved tissues. the approach of this lecture will cover the imaging manifestations using all modalities covering radiography, ultrasound, ct, scintigraphy and magnetic resonance imaging. the basic knowledge that is required will be displayed in 4 major musculoskeletal categories covering disorders involving the soft tissues, joints, bones and entheses. the imaging manifestations will also be linked with the evolution of the pathological processes covering acute, sub-acute and chronic stages of the inflammatory/infective disorders. by the end of the session the audience should have a clear understanding in making best use of the imaging modalities in the correct diagnosis of a wide variety of inflammatory and infective conditions that can affect the musculoskeletal system. arterial pta and stenting is firmly established as primary treatment in the management of athero-occlusive disease, particularly of peripheral limb arterial disease (pad). patients are selected on the basis of symptoms such as short distance claudication or critical limb ischaemia for lower limb disease or appropriate ischaemic symptoms in other territories in the renal and mesenteric territories and head and neck vessels. commonly used grading systems such as the fontaine or rutherford scores can be useful in patient selection. where treatment is required, noninvasive imaging is utilised to look for the site, severity and extent of arterial disease. most centers use duplex imaging as the primary imaging modality; mra or cta are often used with a higher sensitivity and specificity; and invasive angiography is reserved for problem solving or immediately prior to intervention. the tascii classification has been devised to select patients for either endovascular or surgical intervention. however, most centres will adopt an endovascular approach first. all patients should be on good medical therapy, i.e. aspirin and statins, with good blood pressure and diabetic control where appropriate. when carrying out interventions, an access sheath is used, peri-procedural heparin administered and lesions crossed using selective catheters and commonly hydrophilic guidewires. subintimal crossing of occlusions can be much simpler than trying to cross lesions luminally. balloon angioplasty and or stenting may be applied differently depending on the site and extent of the lesions. the evidence for drug-eluting technologies has also been growing with improved patency rates compared to standard balloon angioplasty. during the efrs meets russia session, radiographers have the opportunity to get information about the role and education of radiographers in the different european countries. the radiographer is a health-care team member who interacts with other professionals in the primary and secondary health-care environment to provide an optimum diagnostic or therapeutic outcome. radiographer education therefore requires that the curriculum covers a wide range of scientific, medical, pathological, sociological, ethical and technical subjects together with the development of appropriate clinical skills. the curriculum should also include the development of research and audit skills to ensure the constant improvement of service quality for the benefit of service users. the session will include a panel discussion about the role of the radiographer in image acquisition and processing. the tasks of the assistant to the radiologist are: filling of the protocol of research, survey of the patient, instructing the patient according to safety measures, positioning the patient, placement of coils of strengthening, beginning of magnetic and resonant research -the research is approved by the doctor, introduction of contrast substance (in the presence of the certificate of the procedural sister) and supervision over the patient during mr research. furthermore, the other tasks are briefing on patient safety, excluding introduction of the patient to metal objects on mr tomography, explaining the procedure of the study, informing about the duration of the study, wearing noise-cancelling headphones, warning about possible vibration and loud sounds, and providing a globular button to call the nurse. today coronary ct-angiography has become a well-established and proven diagnostic modality. quality of coronary and cardiac cta datasets has tremendous significance for correct diagnosis. a radiographer has a pivotal role in performance of coronary cta. coronary cta is one of the most challenging examinations for radiographers because even a small mistake at any stage of examination may ruin the whole study. before the scanning procedure, the radiographer performs a check for possible contraindications to contrast media injection (history of adverse reactions to contrast media and impairment of renal function are the most important ones). the radiographer checks the patient's heart rhythm and takes part in administration of betablockers for control of the heart rate. a detailed knowledge of different scanning modalities of ct-machine is a must. radiation exposure to the patient from coronary cta examinations has been one of the major public concerns. this is why the radiographer should be aware of different approaches to the performance of low-dose cta (prospective gating, tube current modulation, high-pitch scanning) according to patient body composition. the radiographer should have knowledge of when and how to use radiation dose control in an appropriate way. another big issue is injection protocols. selection of optimal bolus timing and iodine load results in highquality cta images. the radiographer has to know the basics of ct image reconstruction and interpretation in order to perform different types of reconstructions from the raw data according to the radiologist's requests and be able to recognise image artifacts. clinical examples of the radiographer's role for performance of coronary cta will be given. every country is famous for its architecture, history, literature, music, museums, etc. however, there are some distinctive features for russia. "russia is a riddle wrapped in a mystery inside an enigma." these words by the famous british statesman winston churchill aptly throws light on the pulsating art and culture of russia. the different aspects of russian art and culture find its best expression in the rich heritage. just feeling the nature and boundless expanses of the country can understand the mysterious russian soul, works of art and real masterpieces. cardiac mdct in children with congenital heart diseases v. bereznitskiy, k. serkova; moscow/ ru (vsber@mail.ru) in ct studies of children with congenital heart diseases, it is mandatory to keep the x-ray dose, amount of contrast agent and study time as low and as short as possible and simultaneously get the best diagnostic image quality. how can we reduce the x-ray dose? by minimising the volume coverage, reducing the voltage, minimising the effect of "overranging", use of x-ray protective equipment, use of tube current modulation technique, use of iterative reconstruction technique. how can we reduce the amount of contrast agent by volume? by covering of only necessary anatomic volume, minimising scanning time, use of adequate speed injection in ml/sec, which depends on catheter position and size, blood flow and anatomic structures. how can we reduce the amount of iodine concentration in the contrast agent? by lowering the voltage we may reduce the iodine concentration and get higher absorption ct values (hu). how can we reduce the time of cardiac ct studies? by preparing the study protocol ahead, preparing all necessary equipment in the ct room, warming up of the contrast agent before the study. what is the radiographer's role in cardiac ct studies? to take care along with the responsible radiologist the above-mentioned needs, to take care of adequate room and instrument temperature, to take care that only absolutely necessary people with adequate x-ray protection are in the study room, for performing the necessary image post-processing, archiving and distribution of studies. the purpose is to evaluate the quality of imaging in forced position of patients with anesthetic support. the role of laboratory technician in ct post processing. we analysed images of unconscious patients on artificial lung ventilation on 24-and 64-slice computer homographs ge and siemens and monitored them through the infusion. during investigation the patients were in forced positions, as a result they got artifacts from upper extremities on the abdominal cavity. we analysed 157 patients -hands under the butt, 135 patients -hands on the chest (abdomen), 57 patients -arms along the body. according to the images the smallest number of artifacts was identified when the patient was on the table with hands under the butt. different variations of the patient's hands position and the problem of choice of this position will be offered for researching. the reconstruction the laboratory assistant can execute and also the results of tests will be presented. by order of the doctor the laboratory technician builds 3d and 4d reconstructions of fractured ribs, pelvis, facial skeleton, sagittal and coronary reconstructions of spine in case of its fracture. gastrointestinal stromal tumours (gist) are a rare disease that metastasises in up to 85% of patients with subsequent median progression-free survival (pfs) of around 30 months. tumours are characterised by activating mutations in the kit or the pdgfra gene and treatment is mainly based on tyrosine kinase inhibitors designed to block mutated receptors. however, drug resistance is often based on mutations changing the conformity of the receptor, leaving little effective therapeutic options. to date, second line chemotherapy offers a median pfs of 6-9 months and external beam radiotherapy is limited by organs at risk close to the tumour. alternative approaches like endoradiotherapy or minimally-invasive ablation techniques are effective for local control but are inconsistently used and are not tailored to the individual patient's type of disease. to address these issues, the mitigate project proposes a closed-loop personalised treatment concept combining endoscopic-assisted tissue sampling, inline biotechnology and targeted molecular pet imaging probe development combined with minimally-invasive treatment monitored by new mr imaging techniques. a consistent value chain across european research institutes and smes will be established for mass spectrometry of tumours, linkage of radiochemical molecular imaging probes, design of new animal models and targeted therapeutic radiopharmaceuticals. this closed-loop platform will minimise fragmentation of treatment approaches by a coherent molecular-based multimodality concept, thus providing new treatment options. the mitigate platform can be expanded to further patient cohorts with oligometastatic diseases such as other sarcomas or renal cell carcinoma. gastrointestinal stromal tumours (gist) are characterised by highly specific genetic mutations. several specific targets are overexpressed in a majority of the tumours. on the other hand, secondary resistancies limit the usability of highly specific chemotherapeutics such as imatinib. instead of applying cascades of alternative tki inhibitors in order to find an efficient one, quantitative molecular imaging and targeted endoradiotherapy could be considered. for the detection of gist by imaging, 18 ffluorodeoxyglucose (fdg)-pet is widely accepted to visualise the tumour burden. however, as fdg gives no molecular information of potential targets for treatment, new radiopharmaceuticals have to be developed to visualise and quantify other target-structures expressed by gist that would be able to be addressed. this molecular information can be used both for designing a conventional treatment or an advanced strategy: i.e. targeted endoradiopharmaceuticals. compared to conventional chemotherapy this method has the great advantage that not only tumour cells expressing the targeting vector are affected but also tumour cells within the range of the radiation of the decaying radiopharmaceutical. this method is used with great success in the case of neuroendocrine tumours using labeled octreotate derivatives (a small cyclic peptide binding to the somatostatin-receptor) and non-hodgkin's lymphoma applying y-90 labeled zevalin (a monoclonal antibody binding to the cd20 antigen). the success of these methods relies on the crossfire-effect, meaning that a certain margin of tissue surrounding the cell targeted by the specifically accumulating endoradiopharmaceuticals is destroyed as well, depending on the penetration range of the emitted radiation. thus, the development of new radiopharmaceuticals for the specific diagnosis and treatment of gist would strongly improve the outcome of the tumour patient. stereotactic radiofrequency ablation of liver tumours: does improved targeting increase tumour response? r. bale, g. widmann, p. schullian, m. haidu, w.r. jaschke; innsbruck/at (werner.jaschke@i-med.ac.at) the purpose is to describe stereotactic radiofrequency ablation (srfa) and to review its inital results in the treatment of patients with primary and secondary liver tumours. one retrospective review includes 90 consecutive patients with 106 srfa sessions for the treatment of 72 hepatocellular carcinomas (hcc) and 105 metastases (1). in two other studies the outcome after srfa of intrahepatic cholangiocellular carcinomas (icc) (2) and colorectal liver metastases (crlm) (3) was evaluated. the overall technique effectiveness was 95.5% with a local recurrence at 1 year of 2.9%. technique effectiveness was not significantly different for lesions< 3 cm (95.9%) and 3-5 cm (100%). after treatment of 17 inoperable consecutive patients with 52 iccs a median overall survival of 60 months was achieved. a median os of 58 months and os rates of 92%, 66% and 48% at 1, 3 and 5 years in patients with resectable crlm were achieved. tumour size did not affect os and dfs. rfa probes can be precisely planned, positioned and distributed by means of stereotaxy. especially in large liver tumours the local recurrence rate can be greatly reduced by precise stereotactic placement of multiple radiofrequency probes. these improved local control rates result in better long-term survival rates. author disclosure: r. bale: shareholder; coshareholder atlas aiming device. other; coinventor atlas aiming device. functional and molecular imaging in tumour therapy response assessment s. aime; turin/ it (silvio.aime@unito.it) in the mitigate project further development of currently used mri and ct techniques will be tackled in order to obtain functional and metabolic information which are mandatory to detect early response to the targeted radiopharmaceutical approach. new gd-based agents are under scrutiny in order to improve dce-mri procedures and attain more precise information on the tumour microvascularity level as well on the vessel permeability and the assessment of extracellular ph and mmp activity. the x-nuclei mri ( 23 na sodium) is a non-invasive imaging technique, which enables the measurement of the tissue sodium concentration (tsc) in humans. the direct link of the tsc with the tissue integrity and viability provides a promising approach for monitoring tumour tissue, and could also help to assess cytoxicity and cell death by means of breakdown of the sodium-potassium-pump. however, 23 na mri is challenging because of the low in vivo abundance, the fast transversal relaxation rate and the low gyromagnetic ratio of the 23 na ions in human tissue. new mr measuring sequences for x-nuclei mri will be developed to establish a standardised tsc measurement method within the eu for better comparability. furthermore, the x-nuclei mr data will be reconstructed, scaled and fused with further imaging modalities. lung cancer is the leading cause of death related to cancer. most patients are inoperable as they present with advanced stage disease or even a localised tumour associated with poor general condition, limited cardiopulmonary function or a too high surgical risk. according to the stage of the disease, chemotherapy, radiotherapy and percutaneous ablation therapies are the current therapeutic options for inoperable patients. it is important that radiologists are familiar with the various response and complication imaging patterns related to each of those treatments. the timeline modifications after radiation therapy and percutaneous ablation and the diagnostic management of drug-induced lung disease will be reviewed. this presentation will summarise the current evidence and how to detect early recurrences after those treatments. learning objectives: 1. to learn about changes after radiotherapy. 2. to learn about sequela after percutaneous ablation of lung tumours. 3. to understand changes after chemotherapy of lung cancer. cardiovascular medicine owes much of its spectacular development to the parallel evolution of imaging techniques in the last thirty years. the complex contemporary techniques in interventional cardiology, electrophysiology, and cardiac surgery require advanced imaging modalities. in current times, a wide spectrum of imaging techniques -such as fluoroscopy, mri, non-contact mapping, echo techniques -is performed in organised cardiovascular labs while computed tomography and nuclear techniques are provided by the collaborative departments of radiology and nuclear medicine. it is indeed the collaborative spirit among specialists that bring about the results patients desire. cardiac magnetic resonance (cmr) is a very versatile imaging technique for the assessment of patients with left ventricular dysfunction and has become a central method for characterising the etiology of the dysfunction. indeed, wall thinning less than 6 mm and aneurysmal motion are morphological signs of transmural necrosis. furthermore, a low dosage of dobutamine (10-20 microg/min) is used to detect functional reserve in the case of viable tissue. a further option offered by cmr is late contrast enhancement (le) imaging, which allows identifying the presence of fibrotic tissue as well as necrotic infarcted myocardium. the sensitivity and specificity of late hyperintensity is, respectively, 0.86 and 0.94. similar results can be obtained with 99mtctetrofosmina g_spect. there is a relation between transmural extension of hyperenhancement and the recovery of contractile function after coronary revascularisation. the chance of recovery decreases progressively with the transmural extension of late hyperintensity, since the average value of the latter is 10â±7% in the segments that recover and 47â±14% in the segments that do not recover contractile function. cmr was also shown to be able to predict response to cardiac resynchronisation therapy differentiating between nonischemic and ischaemic cardiomyopathy le-cmr may allow to precisely delineate the presence and the location of fibrosis, avoiding the placement left ventricular leads in necrotic areas and in particular when the scar is located in the posterolateral area. at the beginning of the presentation, a short overview will be given on the relevance and prevalence of valvular heart diseases with special focus on europe and the data collected in the euroheart survey. also, the aetiologies of the various valve diseases will be briefly mentioned. in the second part, special attention will be given to aortic stenosis (as) and mitral regurgitation (mr), as these two entities are responsible for up to 60% of all valvular heart diseases. echocardiography is well accepted as the backbone examination of any valvular heart disease evaluation. echocardiographic criteria for severe as and mr are reviewed as well as their importance for the indication of valve repair or valve replacement. in the third part, we will focus on newer "cross-sectional" imaging technologies such as cardiac mr and ct. in particular, the strengths of cardiac mr in the assessment of regurgitant lesions will be demonstrated. in addition, the value of cardiac mr for the pre-interventional evaluation of congenital heart diseases will be discussed. similarly, the crucial role of cardiac ct in the workup for transaortic valve implantation (tavi) will be illustrated. finally, the yield of these novel techniques in the context of combined valvular and ischaemic heart disease will shortly be reviewed. learning objectives: 1. to better understand the role of cardiac mri in valvular heart disease. 2. to appreciate the added value of mri vs other imaging modailities. cardiac resynchronisation therapy (crt) and transcatheter valve heart (thv) interventions have been important therapeutic breakthroughs for heart failure patients and patients with valvular heart disease and contraindications for surgery. patient selection is crucial to optimise procedural outcomes and therapeutic efficacy. multimodality imaging plays a central role in patient selection and procedural strategy planning. assessment of left ventricular dyssynchrony, cardiac venous anatomy and extent and location of myocardial scar are key to identify heart failure patients who will respond to crt. stepwise use of non-invasive imaging modalities, including echocardiography, nuclear imaging, magnetic resonance imaging and multidetector row computed tomography (mdct), has been common practice to select patients for crt. recent technological advances have allowed integration or fusion of imaging modalities to create 3-dimensional models that provide relevant information. multimodality imaging is also crucial to optimise the results of thv interventions. detailed anatomical and geometrical evaluation of the mitral valve with current 3-dimensional imaging techniques has permitted better selection of patient candidates for transcatheter edge-to-edge mitral valve repair and accurate procedural guidance. for transcatheter aortic valve implantation, accurate measurement of the aortic annulus with 3-dimensional echocardiography or mdct allows us accurate selection of the prosthesis size to minimise the risk of complications, and evaluation of the procedural access (transarterial or transapical) with mdct permits accurate procedural strategy planning. the learning objectives of this session include: providing an overview of current imaging modalities to select patients for crt and thv interventions and how to use them in clinical practice. the inner layer of the anal canal consists of squamous and columnar epithelium with the transitional zone at the dentate line. the muscular component of the anal sphincter consists of an inner layer of circular smooth muscle (internal sphincter), extending downwards from the rectum, and an outer striated muscular layer extending downwards from the levator ani muscle, comprising the puborectalis muscle and the external sphincter. between these layers is the fat-containing intersphincteric space, including the continuation of smooth-muscle fibers of the longitudinal muscle of the rectum. outside the anal sphincter is the fat-containing ischioanal space. magnetic resonance imaging (mri) and endoscopic ultrasonography have become the mainstay for preoperative imaging of perianal fistulas. for complex tracts, mri seems preferable. mri can be performed using an endoluminal coil or a phased-array surface coil. a state-of-the-art imaging protocol should include t2 tse sequences in three orthogonal planes, with the axial and coronal sequences angulated at the anal canal. addition of a fat-saturated t2 tse sequence is recommended for optimal conspicuity of inflammatory changes and post-contrast t1-weighted imaging can also be helpful. intersphincteric infection is the principal feature of perianal fistulas; this is generally not found in other conditions. veins can be mistaken for fistulas, but in contrast to fistulas, veins usually are thin-walled, tortuous, symmetric structures. a pilonidal sinus may resemble a fistula, but absence of extension to the intersphincteric space helps one to discriminate between them. haemorrhoids and anal tags may resemble small submucosal fluid collections, but are easily diagnosed at clinical examination. this lecture will describe the pathogenesis of fistula-in-ano, with a focus on cryptoglandular disease, so that the radiologist can understand how the various classifications of fistulas arise. the park's classification for fistula-inano will be described with reference to cryptoglandular disease and other aetiologies. the surgical questions that need to be answered by imaging will be presented, followed by a description of what the radiologists need to include in their report for it to be clinically useful. the role of anal ultrasound and mri for preoperative fistula imaging will be described, with explanation as to why the latter is fundamental to modern management of the disease. perianal fistulising disease develops in approximately half of the adult and paediatric patients with crohn's disease (cd), with a relevant impact on their quality of life. in patients with cd, particularly those with severe fistulising ileal or colo-rectal disease, complex ramified anal fistulas associated with abscesses (parks' classification type 3-4 or s.james hospital classification type 4-5) are more frequently observed than in other patients. perianal disease thus represents a severe complication of cd, which may change disease management, by requiring specific pharmacological and/or surgical treatments. a non-responsive disease eventually may lead to total proctectomy with ileostomy. mri represents the gold standard diagnostic modality, because it provides a comprehensive staging of both enteric and perianal disease, with high accuracy and without invasiveness. moreover, mri is the ideal tool for monitoring disease response to therapy, being able to detect the inflammatory activity of perianal fistulas with high accuracy. so far, several clinical indexes have been proposed to measure fistula's activity, including the perianal disease activity index (pdai). similarly, several mri classifications of fistula's activity, based either on t2-weighted or t1-weighted contrast-enhanced imaging, have been proposed, although a widely accepted imaging severity score is not available yet. several cases of complex perianal fistulising cd of increasing severity will be shown, with anatomical and clinical correlations, staging and activity description, particularly in patient follow-up and treatment monitoring. finally, differential diagnoses with other benign conditions which may affect the anal canal, including inflammatory infective diseases, hydradenitis and pilonidal disease will be discussed. ground glass opacity (ggo) is characterised on hrct by the presence of a hazy increase in lung opacity that does not cause obscuration of underlying bronchial and vascular margins. although a very common finding, it also constitutes a very nonspecific term since it can be seen in a variety of different intraalveolar and interstitial processes with different histology including inflammatory, infectious and neoplastic diseases that have a common physiologic mechanism: partial displacement of air. ground glass opacity may even be seen in normal processes such as poor ventilation in dependant lung areas and in expiration. moreover, ggo can represent either an ongoing, active and potentially treatable disease or an irreversible process. to interpret correctly this highly nonspecific but very significant finding, it is crucial to attempt to further classify the different large main entities in which this radiological finding appears. are there specific radiological and hrct findings that can help us differentiate ggo in autoimmune inflammatory conditions from infectious and neoplastic processes? are there associated findings other than ggo, such as nodules, reticulation or focal disease, and distribution of findings that can narrow the differential diagnosis? systematic evaluation of ggo and associated findings as well as integration with clinical information (acute, subacute or chronic symptoms) is essential in defining ggo subtypes to improve the radiological diagnosis. radiologists who regularly review high resolution ct (hrct) should be aware of the range of patterns and, more importantly, their potential pathological meaning. a pattern of ground-glass opacification is one of the more common hrct findings but, to the unwary, its interpretation can be problematic. an important underlying principle is that a ground-glass pattern may be caused by any process -physiological or pathological -which partially displaces air. physiological (i.e. non-disease-related) ground-glass opacification is perhaps most commonly seen in subjects who, for whatever reason (e.g. breathlessness, obesity), are unable to maintain or achieve a satisfactory inspiratory effort during scanning. a generally increased lung density (in contrast to adults) is also a feature in infants and young children simply because there are fewer alveoli in the developing lung. finally, it is worth noting that intravenous contrast administration (presumably because of a relative but temporary increase in capillary blood volume causing partial displacement of air) can unpredictably increase lung density. disease processes which lead to partial filling of the air spaces, thickening of the interstitium, partial collapsing of alveoli, and/or increased capillary blood volume will also manifest as a pattern of ground-glass opacification. in clinical practice, the recognised causes of ground-glass opacities on hrct include pulmonary oedema (cardiogenic or otherwise), infections (e.g. pneumocystis jiroveci pneumonia) and some of the idiopathic interstitial pneumonias (e.g. non-specific interstitial pneumonia and respiratory bronchiolitis associated interstitial lung disease). the presentation will review and revise the causes of physiological and disease-related ground-glass opacification on hrct. ground-glass opacity (ggo) is defined as increased attenuation of the lung parenchyma without obscuration of the pulmonary vascular markings on ct images. ggo may be the result of a variety of interstitial and alveolar infectious and noninfectious inflammatory diseases. as an imaging finding alone, ggo does not usually allow a specific diagnosis. ggo in inflammatory disorders is often present in the company of other interstitial or alveolar findings. however, the number of diseases that cause diffuse isolated ggo or ggo as the predominant finding is relatively small and can be prioritised with clinical information. the most common cause of diffuse isolated ggo in immunocompromised hosts are a variety of diffuse, opportunistic pneumonias, e.g. pneumocystis jiroveci pneumonia (pcp), cytomegalovirus pneumonia (cmv) or herpes simplex pneumonia (hsv), which constitute the first differential. chronic onset disorders in immunocompetent patients include cellular nonspecific interstitial pneumonia (nsip), subacute hypersensitivity pneumonitis (hp), organising pneumonia, air-space sarcoid, and drug-induced lung disease. in these disorders, ancillary findings such as an associated reticular pattern with traction bronchiectasis/bronchiolectasis (nsip), mediastinal lymphadenopathy (sarcoidosis), superimposed nodularity or cysts or may help to refine the diagnosis. in patients with collagen vascular disorders, e.g. scleroderma, ggo secondary to pulmonary involvement needs to be differentiated from drug-induced lung disease. this refresher course will put ggo in the context of outpatients versus inpatients, the acuity of clinical symptoms, e.g. fever, cough and dyspnoea, signs of massive systemic inflammation, and the clinical situation such as inhalational history, pneumotoxic drug administration, immunocompromise, or bone marrow suppression. in this course, we will review the dysplastic and neoplastic conditions that are associated with persistent ggo in the lung parenchyma. we will separate these conditions into those that are responsible for localised diseases such as single nodular ggo and those responsible for more extended diseases. nodular ggo can be separated into pure or mixed or part-solid nodules. pathology-radiology correlations show that nodular ggo are related to atypical adenomatous hyperplasia (aah), adenocarcinoma (adc) in situ (ais), minimally invasive adc (mia), and invasive adc according to the new iaslc/ats/ers lung adenocarcinoma classification. differential diagnosis includes exceptional metastases of angiosarcoma and melanoma as well as infection, inflammation and localised fibrosis. diffuse ggo related to neoplastic conditions is rare and may be due to lepidic adc (former advanced adc with bac component), diffuse large b-cell non-hodgkin's lymphoma, intravascular lymphomatosis (ivl) or mucosa-associated lymphoid tissue (malt) lymphoma. these neoplastic diseases should be differentiated from infectious and inflammatory causes of diffuse ggo. we will review the value of different morphological ct criteria to differentiate benign from malignant localised ggo, such as the size, the morphology (round, oval, flat), presence of mixed vs. pure ggo, and the multiplicity of nodular shadows. discussion will also include the changes that may occur within the nodule as well as the mean doubling time. the role of pet ct and transthoracic biopsy will be discussed. finally, we will present the current recommendations regarding the management of nodular ggo. it is the purpose of this lecture to briefly discuss ankle distortion-related lesions with emphasis on failed radiographic diagnosis, discuss their significance and management implications and define the diagnostic pathways in the acute and subacute stage. significant lesions are those with no return to sports activities after 12 months; these have our major interest. in the acute setting of ankle distortion, the ottawa clinical decision rules are accepted to decide whether or not radiographic evaluation is needed; about 35% of radiographic examinations can be avoided. additional evaluation is restricted to patients with residual pain during reevaluation one week after trauma. assessment of fractures with the lauge hansen classification has a major advantage, as it defines the stability at the talocrural and distal tibiofibular joint. only in restricted cases, additional examinations may be needed to rule out instability. although radiographs easily detect displaced fractures, occult fractures may occur; also, grade ii-iii ligament lesions and peroneal tendon dislocation may go undetected. additional imaging evaluation should focus on the detection of significant lesions. significant lesions are talar fractures and complete calcaneofibular ligament tears. the latter is explained by the instability at the level of the subtalar joint with associated sinus tarsus syndrome. in case of residual local tenderness posterior and inferior to the lateral malleolus, the fibulocalcanear ligament and retinaculum peroneorum lesions are best evaluated with (dynamic) ultrasound. mri or ct is used to detect occult fractures in case of residual talocrural joint effusion with anterior talar tenderness during endorotation and plantar flexion. the ankle and foot can be affected by inflammation from a number of diseases. the main focus of this lecture will be inflammation secondary to infection and systemic inflammatory disorders. due to its function in locomotion and weightbearing, the foot is specifically susceptible to infections secondary to penetrative trauma including foreign bodies or to abnormal repetitive pressure. in addition, both seropositive and seronegative arthropathies can affect the foot. other unusual causes of inflammation include chronic recurrent multifocal osteomyelitis, osteoarthritis, mechanical disorders and sensory loss. this lecture will deal with the various patterns of inflammation in the context of pathogenesis and discuss the imaging features that aid in diagnosis. the importance of the clinical context in diagnosis will also be discussed. characterising tumours before deciding on the most appropriate treatment is a general rule in oncology. cystic tumours are now adequately graded based on bosniak's classification. however, this pre-therapeutic characterisation is not currently systematic in case of solid renal tumours, as it remains difficult in clinical practice due to the high prevalence of renal cell carcinomas (rcc) and the lack of reliable imaging criteria for recognition of benign versus malignant tumours. as a result, approximately 10% to 20% of surgically excised renal masses are actually benign. to avoid these unnecessary ablations, pretherapeutic image-guided biopsy has been proposed, but its use is still debated as it is invasive and time consuming. new validated imaging criteria, able to accurately differentiate the most common tumour types but also indolent vs more aggressive malignant lesions, would be useful to reduce the number of unnecessary biopsies or to consider the most appropriate treatment for a tumour or active surveillance. among these, mr imaging plays a major role based on chemical shift gradient echo (gre) sequences, signal intensity on t2-weighted images, dynamic contrast-enhanced sequences, diffusionweighted sequences and late contrast-enhanced images. multiparametric mr imaging is now performed in clinical practice in most primary care centres. therefore, using different combinations of two or several parameters, it is now possible to distinguish certain renal tumours. a larger validation of all these combinations is still necessary to define those having a clinical significance for routine practice. targeted therapies such as vegf mab bevacizumab, vegf tyrosine kinase inhibitors (sunitinib, pazopanib, axitinib and sorafenib) and mtor inhibitors (temsirolimus and everolimus) have been approved and included in european guidelines. pre-therapeutic imaging prerequisites are mainly based on the natural history of mrcc. this justifies imaging through a thoracoabdominal ct scan. outside clinical symptoms, there is no need for bone imaging or brain ct scan; the latter nevertheless could be done because of influencing the therapeutic strategy. pet scan should not be done due to low sensitivity. the evolution of metastatic sites by comparison from previous imaging is useful to evaluate the natural history. outside clinical trials or research imput the strategy is to use the drug in an optimal way to increase pfs. so far, monitoring has to inform about change in recist criteria for cr, pr, sd or pd, and if pd is a real pd such as recist pd or a slowing pd. in conclusion, standard ct scan and recist are adapted to real life. nevertheless, more information on the mode of action of targeted drugs should be interesting for knowledge and research purpose, without any impact on the management of patients. additional imaging could be done with additional criteria than recist on ct scan, by vascular functional imaging and pet scan. breast mri is recognised as a useful tool for a number of clinical indications, but remains relatively challenging. recognising the importance of an evidencebased approach to the development of protocols will influence the further integration of this technique into everyday clinical practice in the management of breast cancer patients. there remain concerns regarding the potential of over-diagnosis from breast mri. the aim of this integrated rc is to inform the clinical practice with regard to the establishment of breast mri in specific clinical and imaging scenarios, namely, using mri for surveillance in high-risk patients, monitoring response to neo-adjuvant chemotherapy and developing protocols for the indeterminate imaging scenario of non-mass-like enhancement. the establishment of protocols to maximise the specificity and sensitivity of the technique of breast mri in such indeterminate clinical and imaging scenarios will be discussed. non-mass like enhancement is a frequent finding in breast mri. it relates to the fact that enhancement occurs in the normal-appearing fibroglandular tissue that surpasses that of the other parts of the parenchyma. there is no associated space-occupying lesion. in pre-contrast non-fat-suppressed or fatsuppressed t1-and t2-weighted images, there is usually no correlate observable. the differential diagnosis of non-mass-like enhancement is between benign nonspecific fibrocystic disease/adenosis, hormonal stimulation, and subclinical mastitis on one hand, vs dcis or (less likely) diffusely infiltrating (usually lobular) cancer on the other. key components of differential diagnosis is configuration of the enhancement (does it follow the orientation of the milk duct or not?) and symmetry (symmetric or asymmetric). less important criteria are internal enhancement (internal architecture) and enhancement kinetics. it is important to realise that enhancement kinetics can only be used to corroborate the suspicion of dcis -but they cannot be used to alleviate the indication to biopsy a finding which, based on configuration and asymmetry, is suspicious. management depends on the different constellation of clinical, mammographic, and mri findings. it usually includes short-term follow-up (6 months) and, if stable/persistent, mr guided vacuum biopsy. assessment of the change in tumour burden is an important feature of the clinical evaluation of cancer therapeutics. tumour shrinkage and time to the development of disease progression are important end points in cancer clinical trials. however, these end points are useful only if based on widely accepted and readily applied standard criteria. criteria, known as recist, were published and are updated on a regular base. the revised recist includes a new imaging appendix and underlines the importance of moving from anatomic unidimensional assessment to either volumetric anatomical assessment or functional assessment with pet or mri. the goal of the lecture is to discuss the value of the different mr imaging techniques (e.g. mr spectroscopy, diffusion-weighted imaging, angiogenesis mapping, pet-mri), which evaluate response to treatment in breast cancer. participants will learn about particular imaging challenges of assessing response to neo-adjuvant chemotherapy. in addition, they will learn to understand clinical aspects of neo-adjuvant chemotherapy based on recist. currently, the esr has been using social media in many successful ways to improve the contacts among members and to boost our fast development as one of the most advanced scientific communities in the world. our session "the role of social media in radiology" presents the view of 4 experts, acknowledged leaders of international it projects. it seems to be important to discuss the major implications of social media for radiology, the leading clinical discipline in information technology. davide caramella will clarify the relationship of social media to professional societies and especially to the esr, including their basic features. the "social media generation" has developed from schoolkids to students and, recently, to teachers as well. alexander sachs represents the young professional expert of elearning in radiology and will reflect the current user behaviour. osman ratib will share his view on how social networks enhance the communication between radiologists, nonradiologists and patients. critical aspects of the pros and cons of large communication scenarios are followed by some ideas of future developments. jã¼rgen brandstã¤tter will indicate the patientâ´s view. most patients see social network communications with their radiologist as useful for, e.g. appointment management or other non-sensitive communication. besides communicating personal health data, a wide area of potential useful other possibilities are at hand, like anonymised health data for reviewing purposes, second opinion or education of patients. the fast development of social media may induce hopes and fears; the four speakers of this session will present them in a panel discussion. the widespread use of social networks in all professional activities has attracted a great interest in the recent years. in medical applications, the main concerns include the possible consequences in terms of patients' confidentiality protection, perceived role of the physician, patient-physician relationship, and caregivers' distraction during professional activities. there are no doubts, however, that social networks are beneficial in enhancing the information flow between scientific societies and their professional members, without any interference at the point of care. social networks have proved to be extremely effective in updating members about relevant news concerning their areas of interests and in allowing them to be informed about the educational activities promoted by their scientific societies. this presentation focuses on the social network activities promoted by the esr via facebook, youtube, twitter and other blogs. impact of social media on the training of radiologists a. sachs; vienna/ at (alexander.sachs@meduniwien.ac.at) in modern times, social media have gained more and more important value in exchanging first experiences in radiology from resident to resident. social networks such as facebook, twitter, google plus and others are used to start discussion groups about cases and share the growing knowledge with different educational concepts in each hospital. growing e-learning modalities as moocs, applications for smartphones or tabs and web-based case series or learning platforms support the training of radiologist in social media. modern elearning platforms use social media as their first choice of sharing knowledge around the whole world about certain illnesses, cases or different decisions of therapy. though sharing information seems to be easier and shows several advantages than in former times, social media can also highlight new problems. this lecture focuses on user behaviour to improve learning, the pedagogic evidence for large group learning with networks and the importance of using networks to manage time. social media networks in communication between radiologists, nonradiologists and patients o. ratib; geneva/ch while social networks have gained unprecedented popularity in our daily environment, they have only limited utilisation in medical applications. the paradigm of communication within a given community for exchange and sharing of imaging data would certainly have its place in a medical environment where there is an increasing need for multidisciplinary collaborative work. the required security and confidentiality in management of sensitive patient data have often precluded the usage of existing public social networks. professional proprietary systems have emerged in a more restricted way with much less flexibility leading to limited use. the exchange of medical images adds a level of complexity due both to the size of the data and the need for appropriate browsing and visualisation tools. traditional pacs and teleradiology system offer such features, but in a very limited way, far from the desired convenience of social networking between groups of users. a prototype of such a system aimed essentially at the community of users that need to exchange anonymised medical images and data for academic and research purposes will be presented and discussed. the project nicknamed dicom sandbox is being tested and evaluated by some users in europe under the coordination of the esr subcommittee of ehealth and informatics. developed with open source software components, it allows using existing cloud-based storage services with additional layers of secure dicom file management and visualisation. it allows the community of users to share dicom data with all social networking and notification features beyond simple peer-to-peer exchange. interactions between patients and radiologists through social media j. brandstã¤tter; wiener neudorf/ at (j.brandstaetter@codewerk.at) social networks have become integral parts of most citizen's use of the internet. especially, the younger generation uses social networks extensively; however the way those tools are used should be chosen carefully. it is one thing to use a social network for private interests, but a different one to use it as transport media for sensible data like personal health-care data. the sensitiveness of citizens regarding privacy has been increased recently by different events of misuse or fraud, especially accelerated by the recent privacy affairs caused by governmental agencies. though most patients see social network communications with their radiologist useful for, e.g. appointment management or other non-sensitive communication, personal medical reports or images shall not be shared across this media. besides communicating personal health data, a wide area of potential useful other possibilities are at hand (e.g. anonymised health data for reviewing purposes, second opinion, education of patients, â�¦). future developments shall make use of social media where useful, but always with deep respect to the patient's privacy rights. apart from the historical, but ever present clinical expectation from the neuroradiologist is the answer to the most important question if the patient has a brain tumour or not. nowadays, due to the outstanding technological advances in imaging techniques during the last decades, the stakes are growing much higher and it is the neuroradiologist on whom lies the initial responsibility of answering a large number of questions that are of utmost importance for further brain tumour patient care and treatment. having the opportunity to provide the usual and generally basic information regarding tumour morphology and exact location and to narrow the differential diagnostic possibilities, neuroradiologic expertise now opens a wide spectrum of techniques, especially those derived from mri, such as mr spectroscopy, mr perfusion, dwi, dti, swi, etc. these provide us the unique possibility of not only obtaining and comparing images, but also of exploring multiparametric brain maps, allowing us to gain insight into the internal architecture of the tumour and the functional and molecular features of the tumorous tissue. this consequently defines the actual stand of neuroradiology, indicating the uprising clinical urge not only to provide the answers regarding the tumour type, grade and possibilities of the most appropriate and patient-individualised therapy modality, whether surgical or nonsurgical, but also to accurately assess the post-treatment tumour behaviour and status, by differentiating the true tumour progression from pseudoprogression, represented by inflammatory responses to the radio-and/or chemotherapeutical treatment, and to monitor other neurooncological response assessment criteria. a. differential diagnosis and pseudo-tumoural lesions h.r. jã¤ger; london/uk (r.jager@ucl.ac.uk) conventional contrast-enhanced mr imaging gives an indication about the likely tumour type and histological grade, but advanced mr imaging methods, including perfusion-weighted (pwi) and diffusion-weighted (dwi) imaging, mr spectroscopy (mrs) and pet imaging provide additional information which helps to refine the diagnosis of intrinsic brain tumours. contrast enhancement can be a feature of low-grade (pilocytic astrocytoma and ganglioneuromas) as well as high-grade gliomas (who grade iii anaplastic gliomas and who grade iv glioblastomas). infiltrative low-grade (who grade ii) astrocytomas do not usually enhance, whereas who grade ii oligodendrogliomas can enhance. higher-grade glial tumours (who grade iii and iv) tend to have an elevated relative cerebral blood volume (rcbv) on pwi, a decreased adc on dwi and increased choline turnover on mrs and pet imaging. a raised rcbv can, however, also be seen in low-grade oligodendrogliomas, particularly in those with a 1p/19q chromosomal translocation, which is associated with a better response to chemotherapy. pwi and dwi are useful in the differentiation of glial neoplasms from cerebral lymphoma, which has an increasing incidence in the immuno-competent population. dwi and pwi are also very useful in the differentiation of enhancing pseudo-tumoural lesion such as cerebral abscesses, tumefactive demyelination, pseudoprogression and radiation necrosis. perfusion imaging plays an important role in the characterisation and management of brain tumours. low-grade brain tumours may transform into high-grade gliomas at some point, which is a transformation that is highly variable and difficult to predict in an individual patient. conventional contrastenhanced computed tomography (ct) and magnetic resonance (mr) imaging are found to be insufficient to depict this transformation and angiogenesis and therefore to detect malignancy. however, perfusion imaging provides additional information over conventional imaging in terms of tumour physiology and haemodynamics, providing important biomarkers for malignancy and prognosis. perfusion ct and mr perfusion techniques such as arteriel spin labelling and dynamic susceptibility-weighted perfusion imaging are more practical and widely used compared to nuclear medicine methods. these perfusion techniques should be considered and used in routine clinical workup of brain tumours to asses grading and prognosis. maximal safe resection, radiation therapy and temozolomide chemotherapy are the current standard of care for newly diagnosed high-grade gliomas. still, hgg have a poor survival rate. a contributing factor to the poor survival is the inability of currently available imaging techniques to accurately delineate the tumour, with the result that targeted focal treatment my not be effective. conventional imaging is not able to give an early assessment of the effectiveness of radiation and/or chemotherapy. in addition, conventional imaging has difficulties in differentiating pseudo-progression, which is a common phenomenon in conventional chemo-radiation therapy, from true progression. early identification of patients who suffer from tumour recurrence can be of great advantage: it provides the opportunity to adjust individuals more rapidly, sparing patients unnecessary morbidity and delay in the initiation of other, maybe more effective, treatment. in recent years, different functional imaging approaches such as perfusion mri, diffusion-weighted imaging and spectroscopy, have been complementarily used for imaging evaluation of treatment response. in this lecture, different advanced mr and ct imaging methods used to support differentiation between pseudo-progression and true tumour progression to assess treatment response will be discussed. in addition, a novel recently published promising technique, the parametric response mapping (prm), a novel voxel-wise analytical method of monitoring physiological and environmental changes in a tumour volume during treatment will be presented and compared to the traditional methods used. finally, the aim of the lecture is to consolidate the present knowledge and novel ideas in brain tumour imaging for assessment of pseudo-progression versus true tumour progression. learning objectives: 1. to understand the challenges and limitations of routine mri in monitoring brain tumour treatment. 2. to become familiar with the role of advanced imaging biomarkers for early assessment of treatment response. 3. to learn how to integrate routine and advance mri into clinical practice after tumour therapy. the purpose of this lecture is to describe the role of functional radiological imaging modality-ct and mr perfusion in the evaluation of head and neck tumors. conventional contrast-enhanced ct and/or mr imaging are the current standard techniques for the diagnosis and treatment evaluation of the head and neck tumors. however, this method is limited in its ability to depict the angiogenesis which is a hall-mark of tumor growth. perfusion imaging provides a rapid evaluation of tissue perfusion and can be easily implemented in every head and neck ct or mr protocol. the determination of tissue perfusion is based on examining the relationships between the arterial, tissue and potentially the venous enhancement after the introduction of a bolus of contrast material. the quantification of the perfusion values helps to outline the malignant tissue as well as to differentiate recurrent disease from nonspecific post-therapeutic changes and can be used as a therapeutic monitoring tool during and after tumor therapy. in recent years diffusion-weighted mri (dwi) gained increasing importance and also acceptance in head and neck radiology. although this functional technique is challenging due to air tissue interfaces, its ability to improve the diagnostic accuracy is widely accepted. dwi can be applied to detect lesions not only in adults, but also in children. it is helpful in lesion characterisation and has a great potential to differentiate recurrence from posttherapeutic changes. initial promising results to improve lymph node staging however are difficult to reproduce. image interpretation is performed qualitatively based on visual assessment of the high b-value images (b= 800-1000sec/mm 2 ) and the corresponding apparent diffusion coefficient (adc) map. quantitative image analysis is based on the measurement of the underlying adc value. solid tumors including recurrences are bright on the high b-value images and dark on the corresponding adc map, whereas posttherapeutic changes are bight on both the high b-value images as well as the adc map. cystic and necrotic lesions are typically dark on the high b-value image and bright on the adc map. furthermore, malignant lesions tend to have a lower adc compared to benign and cystic lesions provided that no necrosis is present. therefore, image interpretation always has to be performed together with morphological images to avoid misinterpretation of functional images. pet/ct has established itself as a robust, rapid and reliable technique in head and neck oncology. it is mainly used to stage nodal disease, to detect distant metastases and synchronous tumours, to identify unknown primary tumours in patients with metastatic neck nodes, to assess treatment response and prognosis after chemoradiotherapy and for radiotherapy planning. mri with diffusion-weighted imaging (dwi) is routinely used for the assessment of submucosal tumour spread, to stage nodal disease, to monitor treatment response and to detect recurrent disease. the information provided by pet/ct and mri is often complementary and the recent implementation of hybrid mr/pet systems in clinical settings holds promise because it can combine morphologic, functional and molecular information. this lecture focuses on clinical applications of pet/ct and mr/pet in the head and neck. current evidence about the combined use of pet/ct and mri with dwi is discussed. the principles of mr/pet data fusion are summarised as well as current knowledge regarding the diagnostic performance of mr/pet in the head and neck. typical radiologic findings of tumour manifestations are reviewed with particular emphasis on the early detection of lesions, their appearance on different imaging modalities and the added value of hybrid imaging techniques. the variable appearance of functional phenomena mimicking disease as well as the potential pitfalls of image interpretation and how to avoid them are equally addressed. major emphasis will be put on how to report the findings in a comprehensive way. multi-energy and functional imaging ct has reached a robustness allowing the use of this new technology in clinical routine for a variety of different clinical questions. this presentation will discuss the basic principles and the strengths and limitations of the techniques. implementations of multi-energy methods for material characterisation and of ct methods for functional imaging will be discussed. contrary to normal single-energy ct systems, multi-energy ct scanners allow simultaneous scanning at two peak x-ray energies. when the attenuation is measured at two energies, their values are not exactly proportional to each other, which open new diagnostic possibilities. measurements at two spectra can be achieved using multiple kvp and/or filtration or with detectors with energy discrimination. these methods have different pros and cons such as sensitivity to subject motion and dose efficiency. to be able to acquire functional data such as perfusion, images are acquired dynamically following the injection of a contrast agent and physiological models are used to convert the measured contrast agent concentration to perfusion estimates. methods that acquire multiple images have the potential to increase the radiation dose to the patient, so ct protocols need to be optimised. in computed tomography, 3d images are reconstructed from a number of x-ray radiographs that were acquired at different angles. tomographic reconstruction relates to the generation of a 3d image based on these acquired radiographs. most tomographic reconstruction methods are based on a technique called filtered back projection (fbp) in which a sharpened version of the radiographs are back projected to generate the 3d image. while it has been the standard reconstruction method, mostly due to its speed and good quality if many radiographs are available, iterative reconstruction methods are emerging. the reason for that is that fbp suffers from important disadvantages. in this talk, the basic concepts of iterative reconstruction are explained and its virtues are detailed. the flexibility of iterative reconstruction methods is demonstrated for the field of x-ray computed tomography. finally an outlook is given with respect to future research on tomographic reconstruction. interventional radiology (ir) has been increasingly applied in the management of obstetric and gynaecological haemorrhage. national reviews of maternal deaths from post-partum haemorrhage have recognised that maternal deaths may be prevented by ir and that all obstetric units should have protocols and arrangements in place to ensure appropriate and timely referral to ir. the important role that irs play in the management of fibroids has also highlighted how these techniques can be applied to other gynaecological conditions which may result in haemorrhage. this session will start by describing which gynaecological disorders may result in haemorrhage and the technical aspects of treatment followed by the published evidence for embolisation. the session will then focus on obstetric haemorrhage, with an emphasis on prophylaxis and how women deemed at high risk for haemorrhage might be managed safely. the techniques used for prophylaxis of haemorrhage will be described in detail and the published data presented. the final presentation will concentrate on the technical aspects of embolisation when haemorrhage has occurred to ensure the best results by knowing the relevant anatomy and appropriate technique of embolisation. the published evidence of the results of embolisation in pph will be presented. these presentations will be followed by a panel discussion on how irs can reduce the radiation dose whilst simultaneously ensuring successful outcomes for their therapies, an important issue in a young and fertile group of women. gynaecologic massive bleeding related to benign and malignant causes is under the scope of all radiologists because of being diagnostic and also because of its implication in interventional radiology procedures. the causes are uterine fibroids (uf) and post-partum hemorrhage (pph). however, oncologic disease, arterio-venous abnormalities, or iatrogenic injuries are less commonly known to be eligible for embolisation procedures. usually, surgical homeostasis attempts or radical hysterectomy is preferred to embolisation procedures. despite the good clinical outcome for hysterectomy and the hazardous success rate of conservative treatment, both are unsatisfactory to patients. pelvic artery embolisation (pae) could dramatically change the patients' clinical issue. the purposes of this lecture are to: revise the pelvic arterial anatomy (possible arterial anastomosis or variation); outline the aetiology of non-obstetric massive menometrorrhagia; expose the typical clinical presenting features; describe the imaging appearances of the etiologies; and discuss patient section, procedure technique, pitfalls and complications. obstetric haemorrhage occurring mainly in the postpartum period is a significant cause of maternal morbidity and death. blood loss of over 500 and 1000 ml after vaginal delivery or caesarean section, respectively, complicates 4% of deliveries. major blood loss of more than 1000 ml occurs following less than 1% of all deliveries. the causes include uterine atony, retained placenta products, placental abnormalities, uterine rupture, lower genital tract laceration, cervical ectopic pregnancy and coagulopathies. generally, treatment is based on administration of uterotonic drugs, vaginal packing, surgical ligation of uterine arteries and even hysterectomy is sometimes needed. transcatheter embolisation of uterine, pudendal, vaginal arteries and ovaries is considered to be superior and should be the first-line treatment for intractable obstetric haemorrhage where interventional radiology is available. angiography reveals extravasation of contrast agent in more than 50% of these patients. the most frequent extravasation is from vaginal artery, and then from pudendal and uterine arteries. depending on the extravasation location and haemodynamic stability of a patient, 5 f catheters or coaxial microcatheter technique is utilised for catheterisation. gelatin foam, microparticles acrylic glue and microcoils are the most frequent embolic agents. the embolisation procedure usually does not require general anaesthesia and can be repeated if bleeding continues. primary success rate in bleeding control is reported from 80 to 90 %. the most commonly reported long-term side effects after embolisation were transient buttock numbness and urinary frequency. the transcatheter pelvic artery embolisation for obstetric intractable bleeding is a fertility-preserving alternative to hysterectomy. medical imaging has nowadays integrated the diagnostic armamentarium of anosmic patients regarding not only qualitative assessment of the olfactory tract, but also quantitative evaluation of olfactory bulb volumes which are known to closely correlate to the olfactory function. many clinical studies on various pathological conditions have evidenced the value of such measurements in the workup of olfactory dysfunction for both aetiologic and prognostic purposes. imaging workup also plays a role in the medico-legal evaluation of post-traumatic anosmia together with electrophysiological and clinical olfactory tests. technical improvements in fibre tracking (ft) using diffusion-tensor imaging (dti) and appropriate designs of olfactory stimulation at bold-based functional mri (fmri) are expected to allow insights into the neurophysiological processes and circuitry of olfaction in the very near future. imaging workup of the anosmic patients will be the cornerstone of this lecture. the relevance of the different imaging techniques will be detailed. beyond the workup of anosmia, a comprehensive overview of the most common lesions of the olfactory tract seen in clinical practice will be given. additional review of lesions observed at the anterior cranial fossa in the near vicinity of the olfactory tract will be done, which comprehensively includes all commonly observed developmental, traumatic, inflammatory and neoplastic conditions not arising from the olfactory tract. their potential impact on the olfactory function or on other sensory/neurological functions will be underlined. clues to clinical/radiological differential diagnoses of the most common conditions and radiological features of the anterior cranial fossa will be highlighted. the central skull base, the floor of the middle cranial fossa, has a complex anatomy and is pierced by a variety of foramina and canals providing crossroads for spread of disease between the extra-cranial head and neck and the intracranial compartment. disease spread into the intracranial compartment indicates a dismal prognosis, as often it becomes inoperable due to involvement of vital structures including cranial nerves, carotid artery and/or brain parenchyma. imaging plays a pivotal role in the assessment of these structures which are not amenable to clinical inspection and can dramatically change the patient's management. in this complex anatomical area, ct and mr have a complementary role in providing a comprehensive roadmap for treatment planning. of major importance is the pterygopalatine fossa, the cavernous sinuses and orbital apex. the former, lying between the pterygoid plates and the maxillary sinus, is a major crossroad between the intra-and extracranial compartments and should be carefully inspected. pathologies affecting the central skull base are varied and may originate from the skull base proper, from the middle cranial fossa or from the extracranial head and neck. by looking at the centre of the lesion, its tissue characteristics and pattern of growth, it is often possible to provide a useful differential diagnosis and, most importantly, to map the lesion's extent. here, we present a radiologist-friendly approach to central skull base pathology highlighting the most important features in the differential diagnosis and treatment planning. 1. the jugular foramen: the jugular foramen is an opening in the skull base. the radiologic evaluation requires high-quality imaging with ct and mr. angiography is reserved for preoperative embolisation. it is important to recognise the "pseudo lesions". the most common tumour of the jugular foramen is the paraganglioma. the second is the schwannoma of the lower cranial nerve, and the jugular foramen meningioma is the third most common. the differential diagnosis shall be discussed. 2. the cerebellopontine angle (cpa) and the internal auditory canal (iac): the iac is a bony conduit for several nerves and a vessel, the neurovascular bundle. the cpa is a cistern of the peripheral cerebral spinal fluid, and several anatomical structures pass through this. it is also the place of some frequent disease processes. most of the lesions in the cpa are benign tumours with order of frequency: vestibular schwannoma and meningioma. the third most common lesion is a benign cystic lesion: the epidermoid cyst. in the iac, you can encounter the same benign tumoural lesion as in the cpa, but also inflammatory lesions, viral lesions and malignant lesions. why is it important in your imaging protocol of the iac and cpa region to use gadolinium? the differential diagnosis of different lesions shall be discussed. learning objectives: 1. to learn about the imaging techniques and anatomy in the posterior cranial fossa. 2. to become familiar with the imaging findings of common posterior cranial fossa pathologies. 3. to learn how to differentiate between the lesions in the posterior cranial fossa. health care is characterised by several specific features making it different from traditional markets. two of the key features are: the impossibility of patients to make choices, due to asymmetry of knowledge between them and their health-care providers; the fact that patients create an agency relationship with health-care providers, delegating to them the decision about the care delivered. due to these characteristics and to the fact that patients are fragile when they need care, there is a natural tendency for patients to rely on healthcare professionals. it is in this complex socio-technical environment that radiographers must be aware of their roles and responsibilities and ensure professional autonomy and accountability; demonstrate an ethical and knowledgeable understanding of the profession; apply professional practice in securing, maintaining or improving health and well-being; develop knowledge, skills and competences that underpin their education and training, contributing to the wellbeing of the patient; understand that professional advancement arises out of evidence-based practice and is acquired through focused research. this demands for a focus on patient care and safety, based on high professional standards. ebp is the best way to achieve this desideratum, as it combines the best research evidence with clinical knowledge and expertise, addressing the patient in a holistic way. since the radiographer is the ultimate interface between patient and technology, it is crucial to create a real teamwork concept, using guidelines for the roles and responsibilities of each team member as the pathway to minimise practice error, maximising patient and staff safety. the use of ionising radiation in medical exposures is well documented across countries. recent studies indicate that a substantial fraction (20 to 50%) of these procedures is unnecessary when taking into consideration patient clinical indication. defensive medicine, economic interest, poor patient clinical information, patient pressure and the lack of knowledge about other alternative procedures, taking into account the benefits and risks, are the principal causes of unnecessary radiological examinations. patients must be referred to a medical imaging department for an examination that should be justified according to clinically appropriate image criteria and informed of the potential benefits and risks. following justification, the optimisation of practice is essential to ensure the minimal exposure of radiation dose to the patient whilst diagnostic efficacy is maintained. the principal aim of optimisation is getting a narrower dose distribution, with lower mean and 75 th percentile values of the diagnostic reference level. optimisation processes need to consider several factors including the type of examinations, body region, clinical information, available equipment technology and image processing tools. to implement this process, a multidisciplinary teamwork is essential where radiographers, being the pivot between patient and technology, have an essential role. to understand and apply optimisation procedures, radiographers should be aware of the international guidelines, standards and directives. all medical imaging procedures must be audited to analyse if the workflow processes (referral, justification, optimisation and radiation protection principles) are according to the recommendations to create a radiation protection safety culture. although we are approaching the year 2014, a lot of clinical radiography is not based on best evidence. lot of clinical decision-making is based on, for example, traditional practices that we cannot argue as being the best possible ones. in this presentation, barriers to using research and other sources of evidence and facilitators of evidence-based (eb) radiography are described. the role radiographers have in developing eb guidelines and procedures may vary according to educational level and work description. developing eb guidelines is not the work of every radiographer, but obeying them is. the speaker gives some suggestions on what to do in a situation if there are no eb guidelines and procedures in ones' country or institution and no group that develops them. with the framework of "the new work order" and increasing implementation of new work processes, professionals are faced with new modes of collaboration requiring communicative skills as well as multiprofessional competencies between all the stakeholders across the hospital. some evidence about the consequences of ineffective communication in the field of radiography is presented. in addition to benefits associated with the procedure of clinical audit, uniform good quality protocols for examinations and uniform national/international criteria help to perform comparisons between radiology units. clinical audit also works as an educational tool and as a feedback tool for the staff on their performance. it also points out the need for corrective actions. initiatives from professional organisations are probably the most powerful engines for the construction of europe, and in many cases open the road for legal and political advances. many medical specialties felt that there was a need for the harmonisation and standardisation of medical training over europe. the esr has shared this opinion and has elaborated a unanimously appreciated training curriculum, which is constantly updated. establishing the ebr (european board of radiology), with the mission to organise a european diploma was the logical next step. today, 10 examinations have already been organised and more that 350 candidates from european countries and abroad have applied. the trainee who passes the examination proves his professional skills and has reached the objectives assigned in the curriculum. in this session, we will explain how esr organises the diploma. we will review, capitalising on our current experience, the main lessons learnt from the past editions, the keys for success and reasons for failure, as seen by the examiners. we will also learn about the "diploma adventure", from the point of view of a successful candidate. national radiology training programmes in europe differ to a large extent, regarding length of training, content, and the presence or absence of a national board examination for certification. thus, for cross-border radiologic activities, the level of training and expertise applying to radiologists is difficult to assess under these circumstances. there is an increasing number of medical subspecialties, which organise european diplomas. more than 20 subspecialties (e.g. anaesthesiology, ophthalmology, urology, etc). organise european examinations, which are well received among the respective communities. growing numbers of residents in training successfully stand this test of knowledge and practical skills. recognition of european diplomas by national authorities is an issue, which will increase the level of acceptance. the present status of the recognition process in european countries will be summarised. case material for the diploma will test knowledge in general radiology at a standard to be expected at the end of training as outlined in the esr curriculum. all ten esr-recognised subspecialty areas of the curriculum will be tested. the written exam comprises two computer-based sections, a multiple response section, and a short case section. there will be 75 multiple response questions. these questions comprise both multiple options format, a single stem with 5 answer options, and short imaging studies where candidates are asked to either annotate the image from a drop-down menu, or select the radiological features displayed or differential diagnosis from the options given. a special scoring system has been developed to prevent guessing. the short case section comprises 4 or 5 case-based questions. you may practice using the self-assessment tests on the esr website which follow the same format as the written examination. for the oral cases, you must have a systematic method and perform under pressure, which takes practice. you may rehearse with experienced radiologists who feedback on your performance. you can break a radiology report into 3 areas, observations, interpretation and conclusion. conclusions should take into account the clinical information. candidates often forget this under pressure, so ask for it to be repeated. your differential diagnosis should be logical and comprehensive. the 3 commonest causes of an abnormality is a good topic to revise. suggest if further imaging tests are indicated and give an indication of urgency. each case is marked separately. as a well-known statement in the academic world of education, "assessment drives learning". with the help of carefully prepared and performed examinations, it is possible to emphasise and instill the training curriculum. due to different reasons, training of radiology in european countries is highly varied. like in our experience in turkey, a central examination system, accompanied by a neatly prepared training charter and curriculum, is a good starting point to solve the problem. we believe that a common european assessment system like edir will contribute a great deal to the harmonisation of radiological training and establishment of quality standard in every country. the need for harmonising the training is not unique to radiology. this is why in more than 30 medical disciplines, european diploma examinations are now being organised. furthermore, in some disciplines like urology, annual and online "in-service assessment" of residents and practising urologists allows the participants to evaluate their current knowledge base against the current european standards, and also provides the trainers and directors knowledge about the teaching and learning process in education centres. although there are huge diversities among different european centres, the urgent need of harmonising radiology training and setting a standard of quality are felt by all radiologists in europe. establishing and institutionalising a common assessment system in european radiology appears to be the shortest way to reach this goal. this is why we should support "european diploma in radiology" by any means and work hard to promote its recognition throughout the continent. the majority of emergency ct studies reported by junior radiologists or general radiologists out-of-hours comprise brain scans. brain ct studies are often performed to detect acute life-threatening abnormalities, such as stroke, intraparenchymal or subarachnoid haemorrhage, cerebral edema, etc. misrecognition of these often subtle, but life-threatening abnormalities can lead to inappropriate patient management and worsen patient outcome. errors in interpretation can generally be categorised as either perceptual or cognitive in nature. perceptual errors are those in which the radiologist does not see the abnormality, resulting in a false-negative interpretation (e.g. basilar artery thrombosis, deep cerebral venous thrombosis, pres,â�¦). cognitive errors, on the other hand, are those in which an abnormality is identified but the meaning or significance of the abnormality is not recognised. cognitive errors can result in false-positive interpretation if, for example, a normal anatomic variant is mistaken for a pathologic condition. while the more common normal variants and artefacts often do not present a problem to experienced clinicians and neuroradiologists, less experienced individuals should beware of these diagnostic hazards. to reduce false-negative and false-positive reporting, a checklist of the review areas (blind spots) to be verified on any brain ct scan will be offered and the most frequent normal variants will be discussed. pitfalls in brain imaging comprise perceptual or cognitive errors of interpretation of imaging findings. errors of perception refer to a missing of a pathology that is present on an image, while cognitive errors consist of a wrong interpretation of a seen structure or pathology. interpretation may be false negative or false positive. in addition, a wrong conclusion may be drawn resulting from missing, incomplete or false clinical information, or as a consequence of a lack of knowledge of differential diagnoses. perception errors are frequently the consequence of incomplete examination protocols where lesions are missed (for instance, acute ischaemic changes without the use of diffusion-weighted imaging) or signals, for instance, flow-related phenomena are misinterpreted. asymmetric positioning of the patient`s head may also lead to misinterpretation of side differences, especially in the temporal lobe. another source of perception errors might be reduced attention (especially at night shifts) and have been proved to occur in regions that are "potential blind spots", as the sulci, cavernous sinus, meckel cave, dural sinuses, brainstem, and skull base foramina. perceptual errors may be avoided by following a checklist when reading images. all sequences should be used for comparison of signal intensities to distinguish artefacts from pathology. another very important fact to avoid misinterpretation lies in a profound knowledge of morphologic and metabolic age-related changes of the brain and of anatomical normal variants (such as, for instance, accentuated virchow robin spaces in certain locations). cystic liver lesions can be classified based on their nature as benign and malignant. in the benign category are, among others, developmental and infectious/inflammatory cysts, while neoplastic cyst can be subdivided into primary and secondary. developmental cysts originate from abnormal ductal plate malformation and consist of hepatic (bile duct) cyst, bile duct hamartomas, caroli's disease and polycystic liver disease. infectious/inflammatory cysts include, among others, abscesses (pyogenic and amoebic) and hydatid cysts. primitive neoplastic cystic lesions are cystoadenoma and cystoadenocarcinoma. secondary lesions can originate mostly from mucinous tumours such as colon and ovary. the role of crosssectional imaging in the detection and characterisation of these entities will be discussed, with an emphasis on the differential diagnosis with ct and mr imaging. benign hepatocellular neoplasms are being recognised with increased frequency using cross-sectional imaging. one of the main goals is to be able to make a clear-cut differential diagnosis between focal nodular hyperplasia (fnh) and hepatocellular adenoma (hca) since patient management is substantially different. despite the sound knowledge acquired in the last few years about the morphological features of fnh using various cross-sectional imaging techniques, new players in the field have arisen such as diffusionweighted mr imaging (dwi) and use of hepatobiliary contrast agents. these new biomarkers offer a different view over fnh and allow a more accurate characterisation even in more atypical cases. concerning hca, current knowledge implies that the sub-types of this neoplasm should be known since, again, patient management differs and these patients are no longer seen as compulsory surgical candidates. these sub-types will be further discussed and the role of imaging for risk stratification (haemorrhage and malignant transformation) will be addressed. further, illustrative cases of combined fnh/hca cases will be demonstrated along with the main imaging clues for a successful differential diagnosis. imaging in the early postoperative period is complex. it is essential for radiologists to know the new anatomic arrangement after surgery and to understand the range of normal postoperative appearances. this latter aspect can be particularly difficult, because the radiological findings are affected by the type of operation performed (open vs. laparoscopic) and the complexity of the surgery (such as the presence of adhesions or haemorrhage) as well as the underlying comorbidity of the patient. patients may be considered in 4 broad categories: haemodynamically unstable patients who may be bleeding; patients with distension or unopened bowels who may have obstruction or ileus; patients with sepsis in whom to search for an intraabdominal collection or leak; and patients who do not follow an expected recovery for which the cause is unclear. ct is the primary imaging technique, with ultrasound reserved predominantly for liver and renal transplants or assessment of perihepatic collections, and fluoroscopy for routine postoperative assessment of upper and lower gi anastomoses. ct protocols should be optimised to detect particular complications with positive luminal contrast for assessment of anastomotic leaks (8%), triple phase imaging for bleeding (without positive oral contrast) and delayed phase imaging to detect ureteric injury. since each operation has a specific range of expected complications, these should be considered when deciding on the protocol and in light of the patient's clinical status. excellent communication with the surgical team is required to make an accurate diagnosis and in particular where haemostatic compound or mesh for hernia repair was used. learning objectives: 1. to understand the best imaging options for investigating suspected postoperative complications. 2. to appreciate the normal appearances of the abdomen and pelvis after surgery, in particular with regard to free fluid, haematoma and free gas, and when to suspect complications. radiologists should be aware of the newer surgical techniques and expected post-operative alterations, to yield a correct interpretation of a post-surgery imaging examination, thus being able to differentiate a normal post-operative finding from a potential complication. in this setting, it is crucial to perform a technically adequate imaging examination, so that post-operative anatomical and functional findings may be evaluated. therefore, the aim of this lecture is to give an overview of the contribution of various imaging modalities in the diagnosis of late post-operative complications following gi tract surgery. it will include a mention of the technical issues that need to be considered to achieve better diagnostic accuracy, as well as a description and illustration of the main imaging findings of late post-operative complications. those include diseaserelated (recurrence for malignancy or inflammatory disease) and procedurerelated (anastomotic strictures, internal herniation, adhesions and intussusception, among others) complications. focus will be placed on crosssectional imaging techniques, which at present constitute the workhorse for detecting and characterising late post-operative complications after gi tract surgery. in this way, imaging has an obvious and pivotal role in planning therapy, since some late complications are usually treated in a conservative way while others require a surgical approach. lung biopsy of a suspected lung cancer remains a well-established technique for histopathologic examination in patients with suspected lung cancer. complications can nevertheless occur and therefore indication should be given after carefully balancing the benefits and drawbacks for a particular patient. the method should be clearly considered complementary to alternate methods of tissue sampling, fiberoptic endoscopic, mediastinoscopy or us-guided endoscopy, surgical biopsies and resection during a multidisciplinary discussion. several steps are needed in the preparation of the biopsy procedure, including informed consent, management of anticoagulation and anti-platelet medications, imaging assessment of the lesion and its environmental lung, and planing of the needle trajectory procedure. the choice of the guiding method and the most appropriate biopsy needle is still largely dependent on local skills and habits. ct-guided percutaneous biopsies using coaxial automated core biopsy needles offer many advantages. needle manipulation can help to reach difficult targets. participation of the patient is needed in terms of respiratory manoeuvres and breathhold. complications may occur such as pneumothoraces haemorrhage and air embolism. knowledge of the respective risk factors and the potential method of prevention or treatment by operators are essential. the therapeutic response of lung cancer can be objectively evaluated on the basis of changes in the tumoural size or depiction of metastases, such proposed in the recist criteria (response evaluation criteria in solid tumours). recent advances in cancer biology have triggered development of novel targeted therapies designed to disrupt specific biologic pathways. among them, antiangiogenic drugs represent a promising strategy for non-small cell lung carcinomas (nsclc). these agents are more cytostatic rather than cytotoxic, explaining the limitations of tumour response assessment based on morphological criteria. dynamic contrast-enhanced imaging techniques have the potential to quantify tumoural angiogenesis. in particular, dynamic contrastenhanced multidetector-row ct (dce-ct) represents a promising tool to provide non-invasive and repeatable assessment of the angiogenic process within non-small cell lung cancers (nsclc), offering the possibility to generate morphological and functional information from the same examination. dce-ct allows the calculation of regional tumour blood flow, blood volume, flowextraction product, and permeability-surface area product, over the entire tumoural volume, using mathematical models and dedicated softwares. dce-ct can depict early changes in lung cancer vascularity, before tumour shrinkage, that could help predict response to antiangiogenic drugs. becoming familiar with this technique enables the radiologist to integrate it into clinical practice and to assist the thoracic oncologist in the pre-therapeutic and follow-up evaluation of nsclc patients treated by antiangiogenic drugs. this new approach should improve patient's selection for targeted therapies. a-343 09:30 it is now accepted that pet-ct is of value in the staging of lung cancer and reduces the number of unnecessary thoracotomies. its role has been further clarified by recent publications on its value in assessing mediastinal nodal involvement, tumour aggressiveness using either standardised uptake value or total glycolytic volume, and response to neoadjuvant chemotherapy. more recently, mri has been investigated as a tool to detect distant disease using diffusion-weighted imaging, and there are a number of trials that have compared both pet-ct and dwi mri retrospectively and prospectively. this presentation will summarise the current available data and the likely benefits of either imaging modality neurological deficits in children are an urgent condition that depends significantly on imaging for a prompt and accurate diagnosis because of the significant overlap present in clinical history, presentation and neurological examination. different imaging modalities, such as ultrasound, computed tomography (ct) or magnetic resonance imaging (mri), are utilised dependent on the age of the patient and neurological symptoms. the purpose of the present lecture is to discuss the causes and imaging appearance of acute neurological conditions in childhood, broadly classified into stroke, infection, inflammatory demyelination, metabolic disorder, cerebral neoplasm or neurotoxicity. imaging also plays an outstanding role in the management of paediatric oncology patients presenting with acute neurological symptoms related to disorders of blood cell counts, immunosuppression, neurotoxicity of therapy, or progression of the primary malignancy. a review of the main indications to perform a neuroimaging procedure in these children will be undertaken as well as a differential diagnosis based on representative cases selected from the daily routine in a paediatric tertiary hospital. practical algorithms with the preferential use of either ct or mri will be developed for each section. ct continues to be the first imaging modality in these patients in many centres, despite the accompanying radiation, because of the easy availability and no requirement of sedation. however, mr imaging is nowadays better for imaging these children owing to no radiation, the more completely provided information and the useful advanced techniques that can be used, such as diffusion imaging (di), spectroscopy, arterial spin labelling (asl), and susceptibility weighted imaging (swi). learning objectives: 1. to learn about the currently limited role of ct in the non-traumatic acute setting. 2. to become familiar with radioprotection strategies and protocols adapted to children. 3. to consolidate knowledge on the role of mri as the modality of choice for acute non-traumatic neurologically ill children, with an emphasis on newer techniques. 4. to become familiar with imaging findings and the main differential diagnosis of acute neurological conditions in children. b. imaging of acute chest pain and distress in children c.e. de lange; oslo/no (clange@ous-hf.no) acute chest pain in children is a common complaint in the emergency department, but patients rarely present with significant distress or lifethreatening symptoms requiring immediate care or resuscitation. the most frequently reported cause is benign musculoskeletal pain followed by respiratory and gastrointestinal causes, while cardiac causes are less frequent. a thorough clinical history and careful physical examination will determine, in most cases, the patients in need of further investigation to establish a diagnosis. in this regard, radiology plays an important role, especially in the emergency setting in patients with more serious associated symptoms like acute breathing difficulties, swallowing problems, fever or sepsis. when choosing the appropriate technique for investigation, the consequences of radiation exposure in children must be considered. plain radiography and fluoroscopy still remain the most important and frequently used tools to gain information on various acute chest/pulmonary problems. ultrasonography is the first choice for diagnosis/treatment of pleural effusions. multidetector computed tomography and magnetic resonance imaging are mainly used for investigating pulmonary/mediastinal masses and congenital abnormalities of the great vessels and the lungs. this lecture will discuss the choice of imaging technique and the urgency of radiological management depending on the symptoms and age of the patient. the imaging characteristics of the different causes of acute chest pain and/or distress in children will be reviewed, represented by the more common conditions involving the chest wall, respiratory tract, oesophagus and the heart, as well as less frequent causes such as tumours, manifestations of congenital malformations and nonaccidental trauma. outcome data from trauma series have demonstrated improved patient survival by the prompt diagnosis of a range of injuries and the recognition of life-threatening sequels, principally that of active arterial haemorrhage. widely used trauma scoring systems are applicable in the paediatric population, although the mechanisms and combination of injuries may differ from those encountered in adults. a ct diagnosis of active haemorrhage demands early operative or non-operative intervention with embolisation or use of alternative endovascular techniques including deployment of vascular stents. this principle is applicable to blunt or penetrating liver, splenic, renal or pelvic trauma. it is also applicable in some cases to severe mediastinal and limb vascular injury. important caveats are firstly the use of ct in an overall trauma service and avoidance of any inappropriate irradiation. secondly, in paediatric interventional practice, due regard needs to be given to the delivery of implantable devices that may have adverse sequels in later life. nevertheless, the demand for immediacy in intervention may outweigh any such consideration. this presentation will summarise the importance of imaging and intervention in both the early and delayed complications of trauma with an emphasis on abdominal and thoracic trauma. brachial plexus originates from the ventral branches of the cervical nerve roots from c5 to t1. it is composed of roots, trunks, divisions, cords, and branches, topographically divided into supraclavicular (roots and trunks), retroclavicular (divisions), and infraclavicular sections (cords and branches). mri has the advantages of multiplanar imaging, high tissue contrast, and relative paucity of artefacts. the t1-weighted sequences display topographic anatomy including muscles, blood vessels, and nerves stressed by tissue fat planes. the nerves appear as elongated fibres that are isointense to the scalene muscle, posteriorly and superiorly to the curvilinear flow void of the subclavian artery. the fat-suppressed pd and t2-weighted and stir sequences detect signal alterations of the bp. general abnormal findings include: loss of fat planes around part or all bp components, nerve signal abnormalities with mild or marked hyperintensity on t2-weighted images that can be associated with swelling, focal or extensive enhancement of the nerves after gad injection on t1 fat sat images. differences in signal intensity should be judged by visual inspection, which is susceptible to a subjective point of view; the comparison of both sides of bp has a relevant role in judging the presence of signal alterations, especially when they are smooth and/or focal. the pathology of brachial plexus can be divided into nontraumatic and traumatic brachial plexopathies. among nontraumatic brachial plexopathies, we find radiation fibrosis, metastatic breast cancer and primary or metastatic lung cancer. other pathologies are tumours and inflammatory disease or thoracic outlet disease. the peripheral nerves of the upper limb are affected by a number of entrapment and compression neuropathies. these syndromes involve the brachial plexus as well the musculocutaneous, axillary, subscapular, ulnar, radial and median nerves. clinical examination and electrophysiological studies are traditionally the mainstay of diagnostic workup. however, ultrasonography and magnetic resonance imaging (mri) may provide key information about the exact anatomic location of the lesion or may help to narrow the differential diagnosis. in certain patients with the diagnosis of a peripheral neuropathy, imaging using either ultrasonography or mri may help establish the cause of the condition and provide information crucial for conservative management or surgical planning. in addition, imaging is particularly valuable in complex cases with discrepant nerve function test results. a variety of peripheral neuropathies can be encountered in the lower limb. most are entrapment syndromes affecting many nerves, such as the sciatic, gluteal, femoral, lateral femoral cutaneous, obturator and pudendal around the hip, the peroneal and its branches and the saphenous at the knee, the superficial peroneal at the lateral leg, the tibial with its plantar and calcaneal branches at the ankle, the deep peroneal and the interdigital nerves in the foot. although clinical examination and nerve conduction studies are the mainstay of the diagnostic workup of peripheral neuropathies, ultrasound (us) and magnetic resonance (mr) imaging may provide key information about the exact anatomic location of a lesion and the nature of the constricting finding or may help narrow the differential diagnosis. in patients with peripheral neuropathies of the lower extremity, us and mr imaging may provide critical information for planning an adequate treatment strategy. although us and mr imaging have followed parallel paths for nerve imaging with little comparison of the two modalities, us seems to have some advantages over mr imaging, including higher spatial resolution, time effectiveness, the ability to explore long nerve segments in a single study and to examine tissues in both static and dynamic states. advances in diagnosis of acute stroke have been achieved by brain imaging. ct or mri distinguish ischaemia from haemorrhage and may identify acute clot (dense artery sign) or vessel wall pathology by "black blood mri". dwi provides evidence of early infarction. ct and mra enable identification of large vessel pathology as potential source of embolic or haemodynamic ischaemia. supplementary techniques are ct or mr perfusion. on mri perfusion, a mismatch between the area of restricted diffusion and perfusion (pwi) is a signature of the penumbra. the tissue of pwi restriction outside of the dwi abnormality represents "tissue at risk". similarly on ct perfusion, the region of reduced cerebral blood volume presumably represents irreversible infarction and the area of reduced cbf and extended mtt visible beyond the cerebral blood volume abnormality represents potentially reversible ischaemia. morphologic imaging and advanced standardised perfusion/penumbral stroke protocols aim at identifying lesions that are amenable to acute stroke therapy and exclude pathologies that mimic stroke but do not represent vascular disease. since iv tpa has become an approved therapy from 1996, the number of acute stroke patients entitled for treatment has remained limited (~ 5) despite extension of the time frame from 3 to 4.5 h. dwi-flair mismatch and an individualised assessment of the ischaemic penumbra may serve in the identification of patients within the appropriate time frame. by selection of patients with advanced brain imaging and initiation of appropriate therapy, a further increase in good outcomes and reduction of the incidence of symptomatic haemorrhage may be achieved. in recent years, the role of imaging in the patient admitted with an acute neurologic deficit has changed significantly, due to the arrival of new treatments for acute stroke, aimed at re-establishing blood flow, reducing infarct size and protecting the brain at risk. the first goal is to differentiate haemorrhagic from ischaemic stroke and to rule out other stroke mimics. this can be achieved by performing nonenhanced ct scan of the brain. the next strategic imaging objectives include: demonstration of major blood vessel occlusion (e.g. by ct angiography) and identification of potentially salvageable brain tissue, the so-called "penumbra" (e.g. by ct perfusion). ct angiography is performed during rapid intravenous bolus injection of a high-concentration iodinated contrast agent. the fov should cover not only the intracranial arterial circulation, but also the arteries of the neck, to exclude dissection. ct perfusion is also achieved by bolus injection of contrast, followed by a series of fast images or volume acquisition. ct densities change over time and reflect the iodine concentration. perfusion images are processed to generate parametric maps, which reflect: regional cerebral blood flow (rcbf), blood volume (rcbv), mean transit time (mtt), and time to peak (ttp).the combination of ct angiography and ct perfusion provides a unique insight into the pathophysiology of the cerebral circulation. these techniques are now essential tools in the management of acute stroke and in selecting those patients who are potential candidates for advanced therapies such as thrombolysis or thrombectomy. learning objectives: 1. to become familiar with a comprehensive imaging protocol in patients with suspected stroke. 2. to understand the advantages and limitations of cta and perfusion in the initial work-up of stroke patients. 3. to recognise the different imaging patterns in stroke and their prognostic value. a-352 08:58 b. stroke mimickers and pitfalls p. vilela; lisbon/pt (ferrovilela@sapo.pt) "stroke mimic" is classically used to describe nonvascular diseases that present with acute focal neurologic deficit corresponding to a consistent vascular distribution, which may resemble or may even be indistinguishable from stoke. it is estimated that up to 15% of stroke-like presentations are due to mimickers. there are several neurological and psychiatric disorders that can have such a clinical presentation, such as seizures and/or postictal status, the most frequent one. the other classical clinical stroke mimickers include: multiple sclerosis, migraine (specially hemiplegic migraine), metabolic disturbances (more commonly hypoglycaemia/hyperglycaemia), intracranial tumours or infections and the conversion reactions. brain imaging plays a key role in the diagnosis and management of acute stroke by differentiating ischaemic from haemorrhagic lesions, identifying the vessel occluded and estimating the viable brain tissue that is at risk for stroke. imaging is also important to exclude some of the aforementioned stroke mimics. the more comprehensive stroke imaging protocols, with ct perfusion/angiography and/or with mri, have reduced significantly the misdiagnosis of stroke. mri-dwi is the most sensitive and specific imaging modality for depicting ischaemic stroke. however, it is also essential to be aware that there are some pathological processes that can mimic stroke in imaging studies. these include some disorders that may present themselves with lesions associated with restricted diffusion, like transitory postictal brain abnormalities, migraine and encephalitis. the author reviews the most common clinical and imaging stroke mimics and highlights the importance of brain imaging in depicting these mimickers and avoiding the potential adverse effects of stroke therapy in these patients. learning objectives: 1. to learn the differential diagnosis of stroke. 2. to understand the role of ct and mri in the work-up of stroke and related disorders. 3. to recognise imaging patterns that may mimic stroke clinically and radiologically. imaging plays a central role in the management of stroke, which is an important health issue according to the number of patients involved and the severity of the disease. it helps to select patients who will benefit from a revascularisation therapy (iv thrombolysis or endovascular treatment) at the acute phase of stroke. if the value of perfusion/diffusion mri mismatch in the evaluation of penumbra is still a matter of debate, other imaging factors are associated with the clinical outcome including length of clot, flair positivity, and collateral circulation. if iv thrombolysis using rtpa is still the reference treatment, endovascular treatment is emerging since several years as a feasible and efficacious alternative singularly since the appearance of stent retrievers. recent neutral randomised trials comparing iv thrombolysis and endovascular treatment have shown the critical role of appropriate imaging in the selection of patients who can benefit from acute revascularisation as well as the importance of using the most efficacious endovascular devices. prevention of stroke is partially based on the treatment of cervical and intracranial stenosis. several randomised trials comparing carotid angioplasty and carotid endarterectomy were initially negative, but a recent meta-analysis showed that below the age of 70 years both techniques were equivalent. the place and value of endovascular treatment of intracranial arterial stenosis is still controversial after the publication of the sammpris results. the management of thyroid nodules has been continuously evolving. i hope that during this session you will understand the important differences in the upto-date national and international guidelines on thyroid nodule management and understand the role of the radiologist in the multidisciplinary thyroid meetings. the features that are suggestive of benign, indeterminate and malignant nodules will be demonstrated. advances in both radiological and cytological techniques such as us elastography and braf mutation analysis that may help triage patients with thyroid nodules will be covered. the differing biopsy techniques (fine needle aspiration, non-aspiration (fna and fnnac) and trucut biopsy) and their roles will be highlighted. there will be time for an open question and answer discussion with all the speakers before the end of the session. the management of thyroid nodules and the guidelines of the various interested parties, surgeons, endocrinologists, nuclear medicine physicians, radiologists and ultrasound specialists, vary across the world, indeed between different countries within the eu, and are constantly evolving. i will discuss how the thyroid multidisciplinary meeting (mdt) works at our institution and the role of the radiologist in it. the current differing international guidelines on the management of thyroid nodules will be mentioned, highlighting their salient points and differences. the role of the differing imaging modalities used in the management of thyroid nodules will be discussed based on differing clinical scenarios. finally, the management of the common clinical scenario of the incidental thyroid nodule will also be discussed. learning objectives: 1. to understand the role of the radiologist as part of a multidisciplinary team. 2. to learn about current guidelines on the management of the thyroid nodule. 3. to understand the role of various imaging modalities in the patient with thyroid nodule. thyroid disease is ubiquitous and usually benign; therefore accurate imaging of the thyroid is a major challenge for radiology. significant advances in conventional ultrasonography allow superb visualisation and anatomic characterisation of thyroid pathology and the impact of broader bandwidths, higher frequencies, spatial compound imaging and novel signal processing techniques will be discussed in this session. the key b mode features of thyroid nodules are discussed with reference to relevant clinicoradiological guidelines, specific pitfalls and limitations. a significant number of nodules remain indeterminate after conventional assessment, and imaging advances that enable more accurate, non-invasive thyroid characterisation are highly attractive, potentially reducing unnecessary biopsy and surgery for a large number of patients. ultrasound elastography offers a potentially useful adjunct to conventional sonography in thyroid disease with a growing evidence base indicating that thyroid malignancies are typically stiffer than benign lesions and that a 'soft' cutoff value with a high negative predictive value is feasible. however, elastography studies have included a variety of different techniques, patient/nodule selection and assessment methods; therefore the current role of elastography will be discussed. fine needle biopsy of the thyroid nodule f. campoy-balbontã­n, m.c. jurado-gomez; sevilla/es (fcampoy2000@gmail.com) thyroid nodules are very common. the clinical importance of thyroid nodules rests with the need to exclude thyroid cancer, which occurs in 5-15%. ultrasound (us) has been widely attempted to differentiate benign from malignant nodules and to guide fine needle biopsy (fnb). however, considerable overlap between benign and malignant characteristics has been found. nowadays, there are a number of different guidelines for the management of thyroid nodules. at our hospital, we have adopted the guideline proposed by the society of radiologist in ultrasound (2005). the different elements necessary to perform the fnb procedure are demonstrated; the transducer probe, the needles, the slides, the syringe. the way of managing these elements is shown by figures and videos, with different skills and performances to optimise the procedure and get the best sample. uscontrol fnb can be in parallel or perpendicular, both methods are demonstrated. thyroid fnb is usually non-aspirated, but sometimes it has to be undertaken with aspiration; when and how to change from one method to another is explained. with good technique, the insufficient cytological rate can be significantly reduced, with which the need for core biopsy diminishes. although the complication rate for core biopsy is low, fnb is safer and if performed correctly has a high diagnostic yield. core biopsy should be limited to those nodules with a second insufficient fnb cytological result, with us findings suspicious for malignancy. multimodality breast imaging is emerging as radiologists have access to new technologies coinciding with the refinement of operative techniques. one of the challenges for radiologist remains the correct preoperative staging, especially the metastatic involvement of axillary lymph nodes. multimodality imaging has new accurate solutions. the imaging follow-up of patients with sophisticated oncoplastic techniques is another challenge where multimodality breast imaging is the solution. coincident with this increasing contribution to the diagnostic process is the emerging role of the breast imager as a therapeutic clinician, making use of innovative image-guided procedures. in this integrated rc, experts will present a clinical update on these newer techniques and there will be an opportunity to discuss how the evolution of such techniques is changing the nature of the modern multidisciplinary team meeting. a. conventional, functional and interventional lymph node assessment r.m. pijnappel; utrecht/nl (r.m.pijnappel@umcutrecht.nl) metastatic involvement of axillary lymph nodes has been known to be one of the most important prognostic factors for women with breast cancer. the traditional approach to staging the axilla is either lymph node sampling procedures or sentinel node biopsy. the main diagnostic features of potentially malignant involvement of the axilla are abnormal lymph node morphology (shape and cortical thickness). there has been a concerted effort in recent years to find imaging techniques that might facilitate accurate axillary staging. so far, no imaging technique alone (ct, mri, scintigraphy and ultrasound) has been capable of differentiating between positive and negative lymph nodes of the axilla in breast cancer. recent techniques like gadofosveset-enhanced magnetic resonance imaging and high spatial resolution 7-t mri imaging appear promising; however ultrasound-guided sampling of suspicious lymph nodes by core or fna remains the standard of care in assessing the axilla prior to treatment planning. ultrasound-guided axillary lymph node sampling is an effective method of assessing the axilla. a recent meta-analysis shows that ultrasound can be expected to achieve sensitivity approaching 50% for detecting abnormal nodes in those that eventually prove to be nodal metastatic disease. the false-negative rate where biopsy is performed is around 25%. it is impossible to detect the sentinel node by ultrasound alone. therefore a new promising technique was introduced, injecting an ultrasound-contrast agent around the nipple. using this method, it is possible to detect the sentinel node in 90% and therefore lower the false-negative rate of us-guided biopsy with another 15%. oncoplastic breast procedures were introduced to fill the gap between comprehensive oncologic surgical treatment of breast cancer and the achievement of cosmetic results that fulfill patient expectations in both, body imaging and psychological well-being. due to its complexity and relevance for the patient, the decision of performing these procedures must be made as part of the multidisciplinary approach of breast cancer treatment. as a consequence, the role of breast radiologists has expanded beyond the anatomic region of the breast and the usual imaging techniques. basic knowledge of the different oncoplastic techniques is mandatory to understand the spectrum of findings from a multi-modality approach. implants and/or autologous reconstruction techniques (pedicle, free or perforator flaps, as well as lipofilling techniques) are widely applied. the role of the radiologist in the multidisciplinary team is twofold: assessment during the planning stage, and imaging evaluation at follow-up. the assessment during the planning stage includes the determination of the local extent of the disease that makes the choice of the appropriate surgical technique possible, and the imaging study of the donor site in those cases where autologous reconstruction is elected. imaging evaluation at follow-up comprises the recognition of changes and potential pitfalls after reconstruction, the identification of short/mid/long-term reconstruction complications, and the detection of recurrent/second carcinomas. controversial aspects will be reviewed, such as the probability of recurrence after oncoplastic surgery, the need to establish multimodality follow-up protocols and the interrelations between the autologous tissues and the mastectomy bed or remaining breast. the use of image guidance for surgical planning has only recently been accepted. the use of intraoperative ultrasound in women undergoing lumpectomy is associated with a higher rate of negative margins. the combination of image guidance and radiological intervention techniques also harbours the possibility of tumour treatment without surgery. most techniques make use of the placement of needles within the tumour. treatment is performed by heating, freezing or extracting the tumour tissue. currently, radiofrequency ablation under ultrasound guidance is being furthest evaluated. however, in rfa even after optical complete tumour ablation, residual vital tumour tissue is still found in many cases. this is mainly dependent on tumour size with poorer results (50-60% success rates) in tumour over 2 cm, and better results (~90% success rate) in smaller tumours. adequate tumour size estimation is thus of vital importance. currently, since remaining vital cells cannot be excluded, the technique is limited to use in patients who cannot undergo surgery due to poor health state. larger series in which rfa is combined with radiotherapy have not been reported. it is therefore not clear whether it is important to actually excise residual vital tumour. similar restrictions currently hold for cryotherapy, laser ablation and hifu. large vacuum-assisted needles and the breast lesion excision system can be used to remove the tumour through a minimal incision in the skin. however, margin evaluation is difficult. nevertheless, these techniques are already optional for the removal of high-risk lesions and can potentially be combined with (focused) radiotherapy. the mã¼llerian ducts are paired embryologic structures that undergo fusion and resorption between the 6 th -11 th weeks of gestation to give rise to the uterus, fallopian tubes, cervix, and upper two-thirds of the vagina. non-development, defective vertical or lateral fusion, or resorption failure of the mã¼llerian ducts can result in formation of mã¼llerian duct anomalies (mdas), whose reported prevalence ranges between 0.4% and 8%-10%. the classification revised by the american society for reproductive medicine in 1988 is the most widely accepted. obstructive mda can occur in infants as palpable pelvic mass, at menarche with cyclic pelvic pain, or pelvic mass, and primary amenorrhea. complications include hematocolpos, hematometra, hematosalpinx, endometriosis, pelvic adhesions, and obstruction of urinary tract. mdas are commonly associated with renal and other anomalies; thus, identification of both kidneys is important. accurate diagnosis of an mda is essential because of the high associated risk of infertility, endometriosis and miscarriage, and since the management approach varies depending on the type of malformation. hysterosalpingography (hsg) is routinely used in evaluation of infertility. because a key component of mdas characterisation is the external uterine fundal contour, hsg is limited for this purpose. ultrasonography (us) is initially performed to evaluate uterine anatomy and to assess for associated renal abnormalities. mri is reserved for complex or indeterminate cases to characterise the uterine anomaly and evaluate the possibility of a vaginal abnormality, or after a seemingly normal us when clinical opinion ensures its use, or to make decisions on management strategies and preoperative planning. this refresher course will focus on the radiologist's approach to using pet-ct within the context of the gynaecologic oncology multidisciplinary meeting. the current indications for using fdg-pet/ct will be discussed for cervix, endometrial and ovarian cancer as well as the potential use of fdg-pet/ct in rare gynaecologic cancers. the value of adding fdg-pet/ct to the patient management pathway will be presented alongside the potential pitfalls in interpretation as well as controversies. future developments, including potential new tracers, will be mentioned. cystic lesions account for the vast majority of ovarian masses and are detected incidentally in 5-18%. their spectrum ranges from non-neoplastic cysts to benign tumours, e.g. cystadenomas and dermoids to the rare ovarian cancer. diagnostic criteria in us, ct and mri are based on the clinical background (age, menopausal status, medical history, and tumour markers) and the morphology of the ovarian mass. typical of a benign cystic lesion is its pure cystic structure or thin septations, fatty or haemorrhagic contents, and mild enhancement of solid components in a complex solid and cystic ovarian mass. thus, patients can be categorised into 3 different risk groups. sonography has been established as the first-line imaging modality to assess the ovaries. recently, management guidelines have been adopted for cystic ovarian lesions. in these guidelines, also cystic adnexal incidentalomas are included. mri is most useful as a complementary technique in sonographically indeterminate masses. an algorithmic approach will render a specific diagnosis in the vast majority of cases. in complex cystic lesions, integration of dwi and dynamic contrast-mri allows differentiation of rare benign complex tumours, e.g. cystadenofibroma from ovarian cancer. pitfalls of cystic ovarian tumours include cystic fibroids, peritoneal cysts, and extraperitoneal cystic tumours. compared to us, both ct and mri are superior in assessing large cystic pelvic masses. criteria to differentiate between intra-and extraperioneal origin include displacement patterns and identification of the vascular pedicle. careful analysis of imaging and clinical findings usually allows differentiation of inflammatory tumours from ovarian cancer. learning objectives: 1. to learn about specific imaging algorithms of ovarian cystic tumours. 2. to understand certain imaging features that can differentiate ovarian from non-ovarian cystic tumours in the pelvis. 3. to become familiar with the pitfalls in imaging of ovarian cystic tumours and the lessons to be learned from them. the diagnostic methods available in patients with conductive hearing loss are: personal and family history, otoscopy, audiology, imaging, surgical inspection and counseling. the most important reasons for imaging are: atypical history, suspicion of congenital hearing loss, suspected otoscopic image, asymmetric bone conduction thresholds, profound mixed hearing loss and suspected tympanometry. ct can be used to detect otosclerosis, tympanosclerosis, posttraumatic ossicular lesions, superior semicircular canal dehiscence and cholesteatoma. mri can be used to exclude schwannoma, congenital cholesteatoma and residual and recurrent cholesteatoma after prior surgery. this lecture will illustrate the value of ct and mri in the evaluation of cholesteatoma patients as well as prior to first stage surgery and prior to second look surgery. different subtypes of surgery will be highlighted and illustrated. the growing importance of mr imaging and diffusion weighted (dw) imaging in particular will be illustrated in the evaluation of cholesteatoma patients. the role of echo-planar and non-echo-planar dw imaging will be discussed as well as the eventual use of delayed gadolinium-enhanced t1weighted imaging. mr is the modality of choice in patients with congenital or acquired sensorineural hearing loss (snhl) and the complete auditory pathway from the cochlea to the auditory cortex must be studied in these patients. the labyrinth, internal auditory canal (iac) and cerebellopontine angle (cpa) are best studied using submillimetric heavily t2w images, showing the intralabyrinthine fluid and nerves. but submillimetric gd-enhanced t1w images or 3d-flair images remain more sensitive. the auditory pathway in the brainstem is best studied with a multi-echo sequence (m-ffe/medic/merge) or t2w tse sequence and the auditory cortex is best studied on t2w tse images. the clinical information provided by the otologist will direct the radiologist to a certain part of the auditory pathway or will let him use certain imaging techniques. for instance, congenital malformations in the labyrinth and iac must be excluded in case of congenital snhl, and in case of mixed hearing one will start with ct to exclude otosclerosis. the most frequent pathology in the labyrinth (labyrinthitis, intralabyrinthine schwannoma, congenital malformation, post-traumatic lesions), the iac and cpa (cochleovestibular schwannomas, meningiomas, epidermoid tumours and facial nerve neuritis) and central auditory pathway (ms, infarction, tumor and trauma) will be illustrated using clinical examples and the important "otologist-radiologist" team work will be stressed. for tumours that nearly always arise from the investing mucosa, like in the larynx and hypopharynx, it is endoscopy that directly maps the superficial extent and grades the functional impairment (arytenoid and vocal cord movement, pyriform sinus distensibility). in addition to white light, the recent use of narrow band imaging endoscopic technology, enhancing fine capillaries in the mucosal surface, enables the detection of neoangiogenesis caused by early squamous cell carcinoma. conversely, submucosal spread is the domain of cross-sectional imaging techniques. therefore, it is the integration of the two classes of data, along with the information about patient conditions, which permits the choice of the most proper treatment strategy. in early and advanced glottic cancer, treatment planning is modulated by information about deep neoplastic invasion into the paraglottic space, the cartilage or the suprasubglottis subsites. this information can be derived by discriminating the tumour tissue from intra-laryngeal muscles, fat spaces and the cortical rim of ossified cartilages. though mr shows a greater contrast resolution than ct, it is hampered by a significantly longer acquisition time. this means more artefacts caused by breathing and movement. nevertheless, mr has the potential to unravel the signals from submucosal tissues, separating tumour from oedema, muscles, fat and ossified cartilages. advanced laryngeal and hypopharyngeal cancers need to preliminary assess local (nodes) and distant (metastases) spread. ct-pet is the more accurate tool. the multidisciplinary approach to the processing of the whole frame of data is essential to offer the patient the best care. traditionally, x-ray ct scanners were equipped with a single or a few detector rows only, image reconstruction was assuming parallel slices, which was a good approximation for these fan-beam systems. about a decade ago the number of slices increased to 16 or more and the parallel slice approximation was no longer valid. the cone-beam nature of these multi-slice ct (msct) scanners had to be taken into account by specific cone-beam reconstruction algorithms. while these msct systems -today they are simultaneously acquiring up to 320 slices -are cone-beam ct systems in a general sense, the notion of cone-beam ct (cbct) is also associated with a specific kind of conebeam ct, namely those equipped with flat detectors, i.e. the non-diagnostic or non-clinical ct systems. msct, in contrast, is a cone-beam ct system for diagnostic use, i.e. a clinical ct system. this distinction between msct and cbct is useful, as there are decisive differences in application, performance, and in image reconstruction. these differences will be reviewed in the presentation, with a particular focus on why image quality in msct is so much better than in cbct. cone-beam (cb) imaging with flat detectors is performed on a variety of different imaging systems. the most important area is cb imaging using interventional c-arm systems. the minimally invasive procedures carried out on these systems benefit from the availability of high-resolution 3d images for intervention planning, guidance and outcome control. interventional cb imaging was first applied in neuroradiology using rotational angiography acquisitions. today, it is used for a variety of procedures in interventional radiology, cardiology and oncology based on angiographic and soft tissue protocols. one of the inherent advantages of this approach is the direct registration of the volume images into the interventional procedure. other application areas of cb imaging using different scanning systems are onboard imaging in radiation therapy or the integration of flat detector tomography and spect. this part of the course teaches the generation of 3d volume information from flat detector systems and its utilisation in different clinical applications. image acquisition protocols, scan modes, and system design parameters are explained. application-specific calibration and processing steps are introduced to show how cb imaging is tailored for specific clinical applications. examples are presented for angiographic and soft tissue volumetric imaging. medical applications utilising the tomographic images for diagnosis, intervention planning, guidance, or outcome control are discussed. in the last decade, three-dimensional dentomaxillofacial imaging through conebeam ct (cbct) technology has become widely available. dental cbct (digital volumetric tomography; dvt) equipment is compact and often affordable to dentists. the driver for dental cbct was implant dentistry, but its use has spread to other areas, including paediatric applications. radiation doses are variable. some systems offer a fixed, large, field of view and others fixed exposure factors, obstructing attempts at optimisation. typically, doses are at least an order of magnitude greater than for "conventional" imaging. image quality is also variable, which means that certain equipment may be unsuitable for some clinical applications. there is often scope for lower exposure factors to be used than those recommended by manufacturers. a key aspect of using cbct relates to justification. imaging in three dimensions may be perceived by dentists as inevitably superior, a view which is often implicitly encouraged by those selling equipment. the research on diagnostic efficacy is, however, limited. in 2012, the european commission published "radiation protection 172: evidence-based guidelines on cone beam ct for dental and maxillofacial radiology". this provides a comprehensive set of recommendations, including referral criteria, a quality assurance programme and optimisation strategies. priorities for future research relate to exposures to the necessary image quality requirements for specific clinical applications, along with research on the impact on clinical outcomes of cbct-based treatments. it is clear that much work remains before the place of cbct in dentistry can be established. the role of nonvascular interventional radiology of thorax for both diagnosis and treatment has significantly increased in the last 20 years. although these procedures are technically easy with highly successful results, thoracic nonvascular interventional procedures are not unfortunately routinely performed in all of the interventional units. the most commonly performed procedures generally under ct guidance are transthoracic biopsies of the lung, mediastinal lesions and pleura. the others include percutaneous drainage of thoracic collections such as pleural effusions, empyema and mediastinal collections. image-guided tumour ablation performed by either radiofrequency ablation (rfa) or microwave (mw) as a nonvascular thoracic intervention has become a serious treatment alternative in patients with lung tumours (either non-small cell lung cancer or lung metastasis) since the year 2000. interventional radiologists are expected to understand the clinical indications of these procedures at the first step. in addition, the techniques of the procedures and possible risk of complications in their management methods should be learnt by interventional radiologists as well. this refresher course will help us to discuss the main indications, techniques and complication management of these procedures. a. lung biopsy t. sabharwal; london/uk (tarun. sabharwal@gstt.sthames.nhs.uk) lung biopsy is most commonly now performed under ct guidance. it has a high technical success rate. common complications include pneumothorax, bleeding, sepsis, pain and failure. air embolism is a rare complication. pet scan is a useful tool to guide for appropriate target. ultrasound is useful for biopsying pleural-based lesions. drainage of thoracic fluid collections is a relative emergency. we will review the different thoracic fluid collections that can be drained by radiologists: pleural (parapneumonic, empyema, and malignant effusions), mediastinal, chest wall, pulmonary (lung abscesses and infected tumours) and pericardial effusions. we will answer the following questions about the main thoracic fluid collections: how to diagnose, when and how to drain, which guidance (ultrasound or ct-fluoroscopy), and procedures to perform before and after the drainage. the choice of imaging to detect thoracic fluid collections and guide drainage depends on the availability of the modalities, the imaging characteristics, location of the collection, and the comfort and expertise of the operator with the specific modalities. we will also review the main complications of percutaneous drainage of thoracic fluid collections (pneumothorax, pain, drain dislodgement and drain blockage) and compare these complications with those related to large-bore chest catheters inserted by thoracic surgeons. the incidence of lung cancers continues to increase and primary lung cancer remains the leading cause of cancer-related deaths in both women and men. therapy of lung tumours includes resection, radiation therapy, chemotherapy, thermal ablation or a combination of these treatment modalities. image-guided percutaneous thermal ablation therapies are minimally invasive techniques established in the local treatment of hepatic, renal, or osseous tumours. among these techniques, radiofrequency ablation (rfa) has now attained consideration for therapy of small pulmonal tumours. other ablation techniques that have been used for treatment of lung tumours include cryoablation, laser (litt) and more recently microwave ablation (mwa) and irreversible electroporation (ire). ablative techniques may produce a complete and irreversible tumour tissue destruction through application of either hot or cold thermal energy, or through permeabilisation of the cell membrane while using ire. ct is currently the imaging modality that is most widely used for planning, monitoring the ablation's course and for assessment of treatment response. only patients with stage i and stage ii lung cancer and those with small metastases are potential candidates for ablation. the medical history and physical examination of the patient as well as recent imaging with ct should be evaluated to determine the indication for thermal ablation. percutaneous lung rfa is considered as a safe procedure with an overall morbidity rate from 15.2% to 55.6% and mortality rate from 0% to 5.6%; it requires less costs and offers faster recovery, and reduced morbidity and mortality. sorafenib, a tyrosine kinase inhibitor, has shown clinical efficacy in patients with hepatocellular carcinoma (hcc) and is the standard of care for patients with advanced-stage hcc. nowadays, many targeted therapies are evaluated in hcc either as sole treatment or in combination with other treatments such as tumour ablation, chemo-embolisation, and surgical resection. therefore, there is a need to assess the efficacy of targeted therapy in hcc. recist is the reference method to evaluate treatment efficacy in solid tumours, but does not seem appropriate in evaluating targeted therapy as objective responses are seen in very few cases in patients treated with sorafenib or sunitinib. new criteria have been proposed to evaluate the treatment efficacy of nonsurgical treatments in patients with hcc. the most common ones are the choi criteria, the easl criteria, and the modified recist criteria. all these criteria mainly focus on internal tumour changes such as appearance of necrosis or disappearance ot tumour hypervascularity. many examples will be shown during the lecture. another approach is based on functional imaging and especially perfusion-related imaging. contrast-enhanced ultrasound, ct perfusion and dynamic contrast-enhanced mr imaging have the capability to assess perfusion changes in patients under treatment. the advantages and disadvantages of these modalities will be discussed. lastly, other functional tools that are not routinely used will be presented. the evaluation of treatment efficacy is a key issue with prognostic and patient survival implications. it is crucial to have objective and reproducible criteria for specific groups of patients. the goal of ablative therapies of hcc is to induce tumoural tissue destruction. complete response (cr) after initial chemical and thermal percutaneous ablation, defined as the absence of contrast enhancement of the treated tumour at ceus, dynamic ct or dynamic mr, has been reported to correlate to long-term survival. nevertheless, the clinical effectiveness of imaging techniques to assess initial treatment success differs according to tumour size. the success rate of rf has been demonstrated to be superior to pei in hccs > 2 cm, and depends on the ability to ablate all viable tumour tissue including an adequate tumour-free margin all around the lesion of 0.5 to 1 cm. thus, the effectiveness of rf directly depends on the tumour location and size. rf is considered an effective treatment in lesions 3 cm and its effectiveness is progressively reduced along with tumour size and it is not effective in lesions > 5 cm. ceus beyond 1 month may confirm or detect residual tumour, deserving a final ablation procedure. ct and mr are more effective in the follow-up to confirm cr and detect local recurrence, or additional hcc lesions in the liver parenchyma. the presence of transient hyperaemic inflammatory changes in the periphery of the treated area is a common finding that should be considered to avoid overestimation of the recurrence rate. one of the major characteristics of medical imaging in the twenty-first century is the dramatic influx of novel technology. this impact of new technology and techniques is experienced in all imaging modalities. the continuous development and implementation of highly sophisticated medical products and devices is key to the evolution of medical imaging leading to the improvement of patient care in terms of quality and positive outcomes. this session will analyse state-of-the-art displays (monitors, smartphones, tablets) and their applications in modern imaging. the session will provide a brief overview of displays in the current imaging chain. it will then evaluate the various specifications and parameters associated with displays. the session will evaluate current qa standards of modern displays as well as the challenges surrounding such novel technologies. image quality can be described in terms of resolution and contrast. an image displayed on a monitor consists of differences in brightness. the display monitor is at the end of the image chain in radiology, which starts at the x-ray tube. there are several factors in this chain that have influence on the contrast displayed on the monitor. diagnostic image quality can be described as observed contrast, which is not only dependent on the displayed image, but is also influenced by ambient conditions. for the primary class displays, typical characteristics of display monitors; such as resolution, homogeneity, luminance, contrast, monochrome or color, must be appropriate for the radiologist to execute a reliable diagnosis. calibration of display monitors is also important. which parameters are significant and what is the effect of variation of these parameters. there are standards like dicom gsdf and technical standard from acr-aapm-siim. both within and outside the clinical environment, the use of smartphones and tablet computers is increasing. reported applications range from teaching and education to navigation in surgical procedures. interest in the use of smartphones and tablets for viewing radiological images has been growing. however, these portable displays can differ significantly from conventional radiological displays. in order to determine where and how smartphones and tablets can be used appropriately, it is important to understand these displays and the challenges associated with them. this presentation will outline the current and potential uses of smartphones and tablet computers in radiology and compare their performance with other radiological displays and standards. the possible limitations/benefits of smartphones and tablets as display devices for radiological images will be discussed. recent research in the field will be reviewed, with emphasis on studies of diagnostic efficacy. in modern clinical environment, diagnostic monitors have replaced glowboxes and films and have become an important part of the imaging chain. the required specifications and the quality of monitors largely depend on their purpose, beginning from quite simple monitors used for the preview of radiographic images placed on modality or in control room to monitors used by high-end diagnostic workstations. decision about the kind of monitor for certain workplace is also very important from the economic standpoint as there are large differences in their prices. besides monitor specifications, also ambient conditions and ergonometry in the reading rooms are also very important issues which need to be considered to ensure optimal environment for clinical image reading. some of good and bad examples will be given in the presentation. as with other radiological equipment, also diagnostic monitors need to be controlled to ensure their optimum performance. quality control begins with monitor acceptance testing and setting up measurement parameters which are to be followed. practically all monitor vendors include some qc software within their workstations which can, together with some independent measurements, form an efficient quality control programme. in the last steps, how to deliver all information regarding image quality and possible presets on the diagnostic monitor and how not to confuse the user are important. sitting an examination is always a source of anxiety. the edir exam is no exception. this workshop is dedicated to those who want to take the edir exam, or become examiners, and would like to learn more about its format and discover some tips and tricks. the edir organisers and examiners have decided to build an interactive, friendly and enjoyable session in order to teach the essentials. some will play the role of the examiners, some the role of the candidate. in order to simulate the candidate's experience, this session will have no safety net. some senior members will expose themselves to real difficult questions in general radiology. fortunately, we hope that the attendees will be able to help the "candidates" to succeed. hopefully, you will enjoy this session and get some very useful information for your edir exam. abdominal malignancies are an important health problem in mexico. like in many other middle-income countries, there has been an epidemiological transition with an overall increase in oncologic diseases. colorectal, gastric and liver carcinomas are some of the frequent abdominal malignancies. colorectal cancer is a disease that is curable if detected early and even preventable if precursor polypoid lesions are removed. imaging plays a critical role in staging at diagnosis. additionally, virtual colonoscopy is an accepted modality in cancer screening. high-resolution magnetic resonance imaging (mri) has become a pivotal modality in the pretreatment assessment of rectal carcinoma. computed tomography (ct) is an excellent modality in the preoperative staging of gastric cancer and follow-up after treatment. positron emission tomography (pet) combined with ct (pet/ct) is particularly helpful for gastric and colonic carcinoma staging. hepatocellular carcinoma (hcc) is also common. cirrhosis related to alcohol and hepatitis c infection are by far the commonest aetiologies. ultrasound (us) in conjunction with alpha-protein is the most widely used modality for screening purposes. ct and mr are confirmatory modalities. the advent of hepatospecific gadolinium contrast agents has been very helpful in the characterisation of focal lesions in cirrhotic patients. the use of multidetector ct (mdct) in pancreatic carcinoma for the detection of vascular and adjacent organ invasion is crucial in treatment planning. over the last few decades, there has been an important improvement in imaging techniques resulting in better quality images. imaging is critical not only for the diagnosis, but also for treatment planning and follow-up. learning objectives: 1. to learn about the imaging of common oncologic gastrointestinal diseases. 2. to understand the importance of imaging in liver and colon cancer. 3. to learn how imaging supports oncologic institutions. activity, ultrasound is readily available and gives detailed local information but is limited by the restricted field of view, communication of results to clinicians and comparison of examinations on time. computed tomography (ct) is fast, readily available and gives a detailed, reproducible overview, but radiation exposure and contrast resolution are limitations. magnetic resonance imaging combines a good, reproducible overview with high contrast resolution, dynamic information and no radiation exposure and is therefore preferable in many situations, but the longer examination times than for ct, availability and costs are limiting factors. for the diagnosis of stenoses, fistulas and abscesses, either technique can be used, although the unrestricted view of ct and mri favour these techniques in many situations. in acute situations, us and ct are more accessible than mri. in that setting us can be considered, but when the examination is inconclusive or the patient has clear inflammatory signs, ct is preferable. endoscopy is currently considered the reference standard for the evaluation of colonic pathologies, including colitis. it allows direct visualisation of the mucosa and in obtaining tissue sample. however, it has major limitations including the invasiveness of the technique, incomplete endoscopy and risk of perforation. endoscopy cannot, therefore, help to estimate the depth of involvement of transmural inflammation and extraluminal complications. by contrast, an evolving role for cross-sectional imaging in the evaluation of patients with colitis has been increasingly recognised, especially in the setting of crohn's disease (cd), since cross-sectional imaging has been demonstrated to have a high diagnostic accuracy not only for assessing the presence and extension of luminal disease, but also for evaluating cd-related acute or chronic complications. establishing the ultimate cause of colitis may sometimes be challenging and histology cannot be conclusive. however, cross-sectional imaging may provide additional information that is useful in the workup of colitis. the use of cross-sectional imaging has been increasing in the evaluation of inflammatory bowel disease. following their presentations on imaging protocols and features of small bowel disease and colitis, each speaker will present a case to illustrate the learning points covered in their lectures. the session will be moderated by the chairman and the audience will have full opportunity to ask questions of all the panel. multimodality imaging is essential in a wide variety of oncology situations. anatomic imaging, whether using us, ct or mri, is mandatory for tumour localisation. moreover, the evaluation of treatment response mostly relies on size assessment, whether uni-or bi-dimensional. with the advent of new targeted bio-therapies, functional imaging has progressively been integrated in the imaging strategies whether for better tumour characterisation or for optimal evaluation of treatment response. hence, assessment of molecular targets by pet is supplemented by the recent developments of diffusion mri, reflecting tissue architecture and cellularity, tissue perfusion, reflecting angiogenesis, and magnetisation properties of tissues. hcc is a primary liver tumour where the use of multimodal anatomic, functional and metabolic imaging appears of particular interest. according to easl and aasld recommendations, noninvasive diagnosis of hcc can be performed using dynamic contrast enhanced cross sectional imaging. liver mri provides optimal sensitivity and specificity for the detection of as small as 1 cm large hcc. recent reports have suggested that the prognosis of hcc lesions could be anticipated based on the combined analysis of metabolic 18 f -fdg pet ct, as well as with diffusion weighted imaging. the objective of this lecture will be to highlight the potential of combining both metabolic and multimodal cross sectional imaging in order to improve the management of patients with hcc. the (extra)ordinary night shift at the er k. petrovic; novi sad/rs (smakap@sbb.rs) besides the accuracy, working at the er requires maximal shortening of the diagnostics time, which has a significant influence on the patient's outcome. thus, it is the radiologist's duty to be familiar with the pathophysiological mechanism of the disorders, specific protocols, possibilities and limits of certain examinations, and also to be aware of all possible pearls and pitfalls, to make the correct diagnosis. pathology encountered at the er has an extremely wide range and requires expertise in all imaging modalities from head to toe. the more the radiologist is aware of all possible situations, the more is the diagnosis accurate, and information given to the clinician is more valuable. the aim of this presentation is to point out the possibility of encountering different pathological conditions in different body regions. moreover, it is important to be reminded that in radiology there are different modalities, each of which has its own indications and limits. this lecture reviews the selected series of cases from the er department of clinical center of vojvodina, pointing out the most common possible differential diagnosis and possible diagnostic mistakes, which often occur due to the lack of experience. learning objectives: 1. to point out the in-depth knowledge and experience in all imaging modalities and all body regions required for a radiologist to perform a routine work at the er. 2. to present a series of cases that are most and less often encountered at the er, discuss the possible differential diagnosis and mistakes which could potentially be made. diagnosis and management of pancreatic cystic lesions r.j. mã©ndez; madrid/ es (ramiro.mendez@salud.madrid.org) pancreatic cystic lesions are frequently diagnosed in patients with clinically suspected pancreatic disease, but they are also increasingly detected on imaging studies performed due to other abdominal processes. the prevalence of pancreatic cysts increases with patient's age. most symptomatic cysts will be surgically resected, whereas asymptomatic lesions should be managed depending on the likelihood of causing harm to the patient. cystic lesions can be inflammatory or neoplastic. the incidence of pseudocysts is low without a history of pancreatitis. some pancreatic cystic neoplasms are malignant, but even benign lesions can become symptomatic depending on its size and location in the pancreas. the radiologist detects most of the pancreatic cystic lesions and should also play an important role in the clinical decision-making process. cyst size, morphology, calcifications, contrast enhancement, location in the pancreas, relation with pancreatic ducts, patient's age and gender are important data to classify the lesion. a specific radiological diagnosis is not possible in every patient, but in many cases this information is enough to decide on a conservative approach with imaging follow-up. if a more aggressive lesion is a concern, then endoscopic ultrasound and fluid analysis can help to better characterise some pancreatic cystic lesions. cyst puncture is only recommended if fluid analysis results will modify the patient's management. patient's age, status and preferences should also be taken into account. when follow-up is recommended, the preferred imaging technique and interval should be indicated. the chair will set the scene for the need for effective radiation protection in clinical radiology and highlight the role of clinical audit as a tool in achieving this. clinical audit is defined as a professionally led method of improving patient care through the systematic examination of systems, processes and outcomes against chosen and agreed standards. it can readily be carried out by individuals, groups or whole departments. if properly conducted, clinical audit can be an effective way of examining what we do to provide reassurance on performance, and to improve patient care. the clinical radiology audit committee (crac) of the royal college of radiologists (rcr) co-ordinates national radiology audit activity. it promotes and facilitates audit through nominated audit leads in each hospital, who act as a link between the rcr and their department. at least one national audit is carried out annually, with data collected via electronic submission and the anonymised results presented at an annual audit forum. individual departmental results are analysed using statistical process control (spc) methodology. this enables identification of departments underperforming against the national mean, and recommending corrective action, by redesigning the process being audited, or by identifying and eliminating specific root causes locally. the committee has developed a web-based tool for facilitating local audit, "auditlive", a fully searchable collection of templates which can be downloaded and adapted. fellows are also able to submit their own templates for publication hence sharing best practice. trainees are encouraged to participate in audit through audit poster competitions at national radiology scientific meetings. our experience leads us to believe that audit succeeds when relevant, locally owned and properly structured, and multi-professional, and the rcr model encourages this. models of external audit in the netherlands s. geers-van gemeren; utrecht/nl in the netherlands clinical audit is legally obligatory for healthcare professions in order to be able to practise since 2010. clinical audit is a tool designed to improve the quality of patient care, experience and outcome through formal review of systems, pathways and outcome of care against defined standards, and the implementation of change based on the results. the quality of the provision of care by professionals is assessed by peers. in the fields of radiology, nuclear medicine and radiotherapy, different models of clinical audit are used. for radiotherapy a multidisciplinary audit has been used since 2003. for nuclear medicine a multidisciplinary audit has been implemented since 2013. for radiology the clinical audit for radiologists and for radiographers are separate. implementation of the multidisciplinary audits needs requirements and adjustments of the audit system. this process is complex and needs approval of the members of all involved societies. to support the clinical audit a web based tool adas (general digital audit system) is used. the development of professional standards is a prerequisite to start clinical audit. the use of adas in multidisciplinary audits is a requirement to be able to audit different professions and focus on the content and the quality of their contribution to patient care. clinical audit is a good tool to improve the quality of patient care. important are the professional standards, the culture of learning and willing to improve by the professionals. "every defect is a treasure." learning objectives: 1. to learn about the different dutch models of external clinical audit. 2. to comprehend the importance of professional standards, the culture of learning and willingness to improve. 3. to become familiar with the use of a digital audit system to support multidisciplinary clinical audit. external regulatory audit in finland r. seuri; helsinki/fi (raija.seuri@hus.fi) directive 97/43/euratom states that the clinical audit of medical imaging should be carried out in accordance with national procedures. the finnish solution has been regulatory external audits every five years by radiological professionals with special training for audits. all radiological units have so far been audited at least twice, and the third time is performed on site in the unit. although the purpose is to audit the process of radiological practises compared to "good practise", special focuses are recommended by the finnish advisory committee for clinical audit, set by the national institute for health and welfare. at the beginning focus was on the organisation and documentation of the structure and processes of imaging practise like justification, optimisation and quality control, but also encouragement and guidance to self-assessment. later special focus has been on paediatric imaging and ct, and the third cycle will target deeper to ct practises. the auditing group includes at least a radiologist and a radiographer to audit a small unit, and a medical physicist if the unit has high-dose modalities like ct. during the audit the auditors work for an independent organisation. multi-professionality gives both insight and the possibility to contact all professionals in imaging practise. the focus of clinical audit is on quality improvement; it is a way to both give and get feed-back and education. it is not control or inspection, but encouragement and guidance to self evaluation and implementation of good practises. we often think of the scientific researcher as detached, objective, and dispassionate, nobly labouring without any expectation of reward. nothing could be further from the truth. scientists are as subject to ambition, competitiveness, envy and even guile as any person. lifting the veil on scientific discovery reveals to us the human dramas that underlie not only the coveting of recognition, but also great conflicts over priority and credit. nowhere are the stakes higher than for that pinnacle of scientific honour: the nobel prize. mri has had a notably tempestuous genesis -a cogent episode that has much to teach us. it involved an explosive clash of personalities; deceit and rampant self-interest; challenges to the basic concept of scientific behavior; legal suits and validation by the united states supreme court; and declamations of denunciation in the international press. it persisted as a 30year battle -a prize fight, a blood feud -between two protagonists: one whose seminal contribution established the biologic basis of mri, and the other whose flash of insight served as a cornerstone of diagnostic imaging. 1. metabolic disorders of the skeleton involve the mineralised components of the skeleton. they affect all bone components histologically, but involvement patterns may vary depending on the age of the patient (growing versus adult skeleton) as well as the type of bone (cortical versus trabecular bone). they can be depicted on radiographs and ct images, but remain occult on mr images because the bone marrow is spared in the vast majority of these disorders. mr imaging can help in the assessment of local complication such as fractures. 2. metabolic disorders of the bone marrow can affect either red (anemiaâ�¦) or yellow marrow as well as the balance between these 2 marrow types in the body. medical imaging plays a limited role in the assessment of these disorders, but marrow changes associated with these metabolic conditions must be recognised to avoid confusion with neoplastic conditions. in primary and secondary malignant tumours of solid organs, in most of the cases surgical resection is considered the curative treatment. however, this is possible only in about 20% of the cases with tumour-dependent recurrence rates of 60% and even more. the main components for adjuvant, neo-adjuvant and finally palliative therapy are the permanently growing number of chemoand antibody therapies. nevertheless, in many cases these therapies provide no definitive or long-lasting success, necessitating multimodality treatment concepts. in the meantime, local ablative techniques represent the main components of these concepts. three main minimally invasive tumour-ablative techniques can be differentiated: chemo-ablation (percutaneous alcohol injection, transarterial chemo-embolisation, chemotherapy, chemo-perfusion), thermo-ablation (radiofrequency-, microwave-, laser-ablation, high-intensified focused ultrasound, cryo-ablation) and radio-ablation (radio-embolisation, interstitial brachytherapy, percutaneous stereotactic radiation). these ablation techniques differ significantly among each other with respect to their mode of action and indications; nevertheless, their benefit is high tolerance and at the same time high therapeutic efficacy, which can easily be combined with other treatment modalities. the different minimally invasive techniques will be discussed together with specific short-and long-term results and complications. missed lung lesions are one of the most frequent causes of malpractice issues. chest radiography plays an important role in the detection and management of patients with lung cancer, chronic airways disease, pneumonia and interstitial lung disease. among all diagnostic tests, chest radiography is essential for confirming or excluding the diagnosis of most chest diseases. however, numerous lesions of a wide variety of disease processes affecting the thorax may be missed on a chest radiograph. the chest radiograph will also help narrow a differential diagnosis, help to direct additional diagnostic measures, and serve during follow-up. the diagnostic usefulness of the radiograph will be maximised by the integration of the radiological findings with the clinical features of the individual patient. ct has a tremendous spatial resolution that helps detect lesions in the chest and has proven to be more sensitive and specific than chest radiographs. however, missing lesions or misinterpreting lesions in ct of the chest is not uncommon. in this session, we will provide interactive cases of chest examinations (radiographs and ct) in which lesions have been missed and or misinterpreted, with a special focus on how correlation with mdct of missed lung lesions can help improve interpretation of plain chest radiographs. this session will explore the value of imaging for facilitating precision medicine, in which molecular data (including genomics, proteomics and metabolomics) is used to classify patients into subpopulations and tailor treatments to the specific molecular characteristics of their diseases. imaging already plays a limited role in precision medicine, primarily through the use of molecular imaging techniques (e.g. pet/ct, mri/pet and hyperpolarised mri) and theranostics (the combination of an imaging agent with a therapeutic entity). in the near future, the role of imaging in precision medicine will increase at a gradually accelerating pace through the development of new molecular imaging probes and theranostic agents and through progress in radiogenomics (the correlation of radiologic findings with genomic features). this session will discuss recent findings and methodologies in radiogenomics as well as the use of nanotechnology for designing novel molecular imaging probes and theranostics. in addition, as theranostics is often considered the essence of precision medicine, the session will provide an in-depth look at current and emerging theranostic strategies and their special benefits for treatment selection, assessment of dose distribution of targeted therapies, and treatment follow-up. radiogenomics and personalised (precision) medicine g.p. krestin; rotterdam/nl (g.p.krestin@erasmusmc.nl) "precision medicine" as well as related notions, such as personalised medicine, or stratification medicine, all revolve around the idea that the consideration of individual characteristics -molecular and otherwise -can improve medical research and practice. precision medicine is a multi-faceted approach to medicine that integrates molecular and clinical research with patient data and outcomes. individual assessment of the location and extent of an alteration is and always has been the basis of medical imaging, whether the 'alteration' is a disease, a malformation, or an injury. as such, medical imaging intrinsically enables "precision medicine". the addition of genomic data in the last twenty years allows new correlations to be made between cellular genomics and tissue-scale imaging. structural and functional imaging and the automated analysis of large amounts of image data have only recently reached a stage where they can be used on a large scale and in a population setting. identifying common genetic variants that contribute to explain variance in imaging phenotypes by a systematic analysis of the genome is based on genome-wide association studies (gwas). the power of gwa analyses has been recently demonstrated with the identification of susceptibility genes involved in a range of imaging phenotypes like coronary artery calcifications, intracranial volume, or size of the hippocampus. these developments highlight new etiological pathways and are expected to improve the understanding of the molecular basis of some diseases. correlation between genotype and imaging phenotypes may be relevant for further characterising the development of disease states. use of nanotechnology, imaging and therapy t. lammers; aachen/ de (tlammers@ukaachen.de) advances in nanotechnology and chemical engineering have led to the development of a significant number of novel materials for diagnosis and therapy. many different diagnostic and therapeutic nano-and micro-materials have been designed and evaluated over the years, including, e.g. gadoliniumcontaining dendrimers, uspio nanoparticles and microbubbles for functional and molecular imaging, and drug-loaded liposomes, polymers and micelles for temporally and spatially controlled drug delivery to tumors and to sites of inflammation. in the literature, such advanced nano-and micromaterials are generally claimed to be highly useful and broadly applicable. a critical reflection on their specific capabilities, however, as well as on their pharmacokinetic properties, biodegradability and toxicity is often lacking. in the present lecture, i will briefly introduce the rationale for using diagnostic and therapeutic nanomaterials. i will highlight several clinically relevant examples in which nano-and micromaterials hold potential for improving disease diagnosis and detail how combining diagnostic and therapeutic properties within a single 'nanomedicine' formulation can be used to individualise and improve (chemo-) therapeutic treatments. learning objectives: 1. to learn about the design and construction of nanoparticles for use in imaging and therapy. 2. to appreciate both the advantages and limitations of using nanoparticles as agents for both imaging and therapy. 3. to learn how nanotechnology enables multimodality imaging and therapeutic agents. theranostics w. weber; new york, ny/us precision medicine requires diagnostic tests that predict the effectiveness of specific therapeutic interventions for individual patients. this close interaction between therapeutics and diagnostics is expressed in the term "theranostics". a frequently used example for a theranostic is the staining of tumours for her2 expression prior to therapy with her2 antibodies, such as trastuzumab or pertuzumab. theranostic has also been practised since many years in nuclear medicine by using radioiodine scans to select patients for treatment with iodine-131. a more recent example is the selection of patient for peptide receptor-targeted radiotherapy (prrt) by somatostatin receptor imaging. imaging is highly attractive for theranostics, because it allows investigators to study the spatial and temporal heterogeneity of target expression, whereas in vitro assays generally analyse a small part of the tumour at one point in time. several molecular imaging probes, such 89 zr-trastuzumab or folate receptor targeting ligands, are in clinical development as in vivo companion diagnostics. imaging companion diagnostics can also be used to assess tissue pharmacokinetics and thereby help to determine the optimal dose and dose schedule of therapeutic agents. they can also identify unexpected interactions between two therapeutic agents. for example, studies with 11 c-docetaxel have shown that bevacizumab can markedly decrease the intratumoral delivery of docetaxel. finally, imaging-based companion diagnostics can assess target inhibition, as demonstrated by the inhibition of uptake of the androgen receptor ligand 18 f-fdht in metastatic prostate cancer treated with anti-androgens. imaging-based companion diagnostics are therefore expected to play an important role in establishing precision medicine. erus technique as well as the state-of-the-art mr imaging protocols tailored according to the presenting rectal tumor site, allowing trained radiologists to obtain all necessary information for appropriate treatment decision-making, will be described. normal cross-sectional appearances as well as morphological and signal changes encountered in pelvic structures/tissues that may be involved in primary rectal cancer will be illustrated. the influence of imaging findings on initial therapeutic approach and potential limitations of different imaging techniques will be discussed. the staging and categorisation of malignant lymph nodes in patients with rectal cancer is a topical issue and has resulted in some degree of confusion. much enthusiasm has been expended in determining whether mesorectal nodes are, or are not, involved in the primary disease process, as there is a perception that nodal disease is an important determinant of local recurrence. this incorrectly perceived association of nodal status and a high risk of pelvic recurrence have propagated the concept that this should be the primary indication for neoadjuvant therapy regardless of whether tme surgery is to be performed. furthermore, misinterpretation of involved local nodes results in over-treatment of patients, if firstly involved nodes alone are considered as a poor prognostic factor, and secondly the optimal treatment of involved nodes is pelvic radiotherapy plus a non-systemically acting but radiosensitising dose of chemotherapy within chemoradiotherapy (crt) schedules. in this lecture, the evidence for risk factors associated with nodal disease and validated risk factors for local recurrence will be reviewed. the evidence for both the optimal techniques and objective criteria for assessing lymph nodes with magnetic resonance imaging (mri) will be presented. the standard treatment for advanced rectal cancer is preoperative chemoradiotherapy (crt) followed by standard resection of the rectum and mesorectum. neoadjuvant crt allows downsizing and downstaging of the tumour, leading to improved resectability and local control. while the role of mri in rectal cancer treatment is recognised and mri is recommended as part of the standard staging workup, its role for restaging after preoperative treatment is more controversial. this lecture will provide an understanding of whether and how mri can assess treatment response in rectal cancer and how it may impact treatment decision. the attendees will learn about the difficulties in image interpretation and learn about potential new imaging techniques to improve its performance. primary tb typically presents with consolidation in the middle and lower lobes, and necrotic lymphadenopathy. fibrosis, tuberculomas and calcified nodes may result as sequelae. cavitation and tree-in-bud appearance involving the apical and posterior segments of the upper lobes and the superior segments of the lower lobes are the hallmarks of reactivation tb is typically seen in immunocompetent patients. in immunocompromised patients, primary tb findings are more commonly observed, as miliary or disseminated disease or atypical manifestations in case of severe immunosuppression. pleural effusion and tracheobronchial involvement may be observed. the "classical" appearance of non-tb mycobacteria (n tm ), less common and more indolent than tb, typically affects males more than 50 years old with pre-existing pulmonary disease or underlying immunologic disorder. despite a great overlap in the radiologic appearances of both infections, the presence of cavities on sites other than the upper lobes should suggest an n tm infection. the "nonclassical" form related to mac infection that predominantly affects elderly women with no pre-existing pulmonary disease mainly consists in mild bronchiectasis and centrilobular nodules predominantly located in the lingula and middle lobe. a high rate of lymphadenopathy and disseminated disease are seen in immunocompromised patients. the radiologist has to ensure the diagnosis of active tb and mention scarring before starting specific treatments; to suggest n tm infections, immune reconstitution inflammatory syndrome with paradoxical worsening in haart treated hiv-infected patients as multi-drug resistant tb; to appreciate the extent of disease and follow-up; to diagnose the complications; to propose mri or pet scans in some situations. learning objectives: 1. to appreciate the imaging features of primary and post-primary infections in tb. 2. to learn about the similarities and differences between tb and non-tb mycobacterial infections. 3. to understand the radiologist's role in diagnosis. the appropriate investigational technique, frequently targeted differential diagnosis, and the special needs of immunocompromised patients need to be understood by the referring physician as well as by the radiologist. thus, an intensive interdisciplinary co-operation on a patient basis, as well as on a department basis is essential. early detection of a focus is the major goal in febrile neutropaenic patients. as pneumonia is the most common focus, chest imaging is a special radiological task. the sensitivity of chest x-ray, especially in the supine position, is known to be low. therefore, the very sensitive thinsection multislice-ct became the gold standard in neutropenic hosts and might be cost-effective in comparison to antibiotic treatment. the infiltrate needs to be localised, so that this information can be used as guidance for invasive procedures for further microbiological workup. furthermore, the radiological characterisation of infiltrates gives a first and rapid hint to differentiate between different sorts of infectious (e.g. typical bacterial, atypical bacterial, fungal) and non-infectious aetiologies. follow-up investigations need careful interpretation according to disease, recovery, and concomitant treatment. due to a high incidence of fungal infiltrates, interpretation of the follow-up of an infiltrate must use further parameters besides the lesion size. besides the lungs, also other organs systems such as brain, liver and paranasal sinuses need attention and are to be imaged with the appropriate technique. despite advances in diagnosis and treatment, new pulmonary infections have been diagnosed. streptococcus pneumoniae remains the main aetiological agent in outpatients with community-acquired pneumonia (cap). elderly patients or those with toxic habits and various comorbidities favour the development of severe cap. in addition, the development of nucleic acid amplification techniques has emphasised the role of concomitant bacterial and viral pneumonia in the outcome of cap in elderly patients. healthcareassociated pneumonia has been recently defined as a different infectious condition by the american thoracic society/infectious diseases society of america (ats/idsa). the main concern of this new disease is the risk of having an infection due to multidrug-resistant pathogens. with the advent of haart and increased long-term survival of hiv-positive patients, the range of pulmonary manifestations has also evolved. in patients with haematological malignancies or after hsc transplant, aspergillus is a common infection. actually, aspergillus spp. isolation from lrt samples in copd may indicate an increased diagnosis possibility of ipa. new emerging viruses such as human metapneumovirus (hmpv), sars-associated coronavirus, and avian influenza caused by the h5n1 virus have been diagnosed. in 2009, an outbreak of a novel swine-origin influenza a (h1n1) virus was reported. the clinical diagnosis of new pulmonary infections as well as the presence of concomitant bacterial and viral infections has been significantly enhanced by improved laboratory methods. a systematic approach to the radiological evaluation of lung infections is essential and includes not only chest imaging pattern recognition, but also integration of available demographic, clinical and laboratory information. the paediatric central nervous system is a complex structure undergoing rapid development. as such, there is a rapid, continuous modification of what is "normal" in relation to age and the stage of development. knowledge of the normal patterns of brain development in the clinically relevant ages from 0 to 18 years is necessary to interpret neuroimaging findings correctly. knowledge of embryology and normal variants is also greatly helpful. mr imaging equipment and parameters need to be adjusted and optimised for paediatric studies. pitfalls often occur from the misunderstanding of normal conditions that are perceived as abnormal based on a comparison with the appearance of the normal brain in adults. this includes, for instance, the evaluation of the brain in the first 2-3 years of life during the course of the process of myelination. a summary of the most frequent conditions that may lead to misinterpretation of findings will be provided. a wide spectrum of anomalies of thoracic and abdominal organs may be encountered on radiologic evaluation. these anatomic variants and developmental anomalies can all pose a diagnostic challenge to the radiologist. familiarity with these anomalies, the imaging techniques available for their study, and their variable imaging manifestations is necessary for differentiating them from pathology. a basic understanding of the embryologic development and normal anatomy of thoracic and abdominal organs and vessels is also essential for identifying these anomalies. this review explores the wide variability in appearance of the normal thoracic and abdominal organs during imaging, stressing a thorough understanding of normal anatomy to recognise normal variants. the skeleton of a child is a developing system with a variety of changing normal appearances. imaging studies, especially plain films, are requested for many clinical reasons, and the radiologist is in the position to determine if an image is a normal finding or we are dealing with a lesion. the way the physis and epiphysis grow, ossify, and fuse constitutes a great source of physiologically bizarre appearances, which the radiologist must be familiar with. this talk will concentrate on the plain film diagnosis of some of the most common musculoskeletal variants. other imaging modalities will also be shown when appropriate for the case. irregularities, asymmetries, partial fusions, hypo-or hyper-dense bone areas, accessory bones, prominent normal structures, external artifacts, and potential fracture lines are the most often encountered pseudolesions. a defective radiological technique may also be potentially misleading. patient age, location of the supposed "abnormality" and lack of significant local symptoms are key factors. usually plain films, correlated with regional clinical findings, are the only imaging method that is required. however, in certain doubtful situations, ultrasound, ct, mri, bone scan, or even biopsy may be needed to reach the right diagnosis. unnecessary overuse of these imaging modalities, and the subsequent family anxiety that ensues from this overuse, should be avoided with careful analysis of the x-ray and clinical findings. the purpose of this lecture is to cover the clinical presentation, underlying pathological processes and essential mri features of relatively common conditions affecting the hip. as the hip is afflicted by different conditions according to age, this is how the various pathological entities will be presented. a simple imaging algorithm is presented showing the role of mri. the role of mr arthrography in the assessment of the dysplastic hip and femoroacetabular impingement is covered. a structured approach to mri reporting is outlined. (claudia.schueller-weidekamm@meduniwien.ac.at) mri of the hand requires high spatial resolution, perfect immobility, and homogeneous fat suppression. the hand can either be placed in the superman position, which often is uncomfortable for the patients, or both hands can be placed above the abdomen next to each other while the patient is in the supine position. standard sequences are axial pd, followed by coronal t1 tse, and t2 tse fs in the coronal and sagittal planes. additional 3d gradient echo sequences with fat saturation are recommended to assess ligaments and cartilage, as well as the triangular fibrocartilage complex (tfcc). in certain cases, mr arthrography with thin-slice t1 fs is helpful for further evaluation of the wrist ligaments. in inflammatory diseases, such as rheumatoid arthritis, static or dynamic t1 fs sequences are useful to assess tenosynovitis and synovitis. the most common injuries and inflammation of the hand and wrist are discussed with special emphasis on key findings for an accurate diagnosis. the awareness of advantages and drawbacks of other imaging modalities, such as conventional radiographs and ct, should be strengthened. the clinical impact of the radiological report is discussed to strengthen the importance of proper terminology for the description of pathological findings. the structure of the report should be clear and concise, and should allow an interaction and broad communication with clinicians. gastro-enteropancreatic neuroendocrine tumours (gep-net) are a heterogeneous group of cancers that differ in their biology and clinical presentation. diagnosis of these tumours has been improved by advances in pathology and classification and by the combined use of structural imaging and functional imaging modalities. multimodal imaging is increasingly recognised both in detecting and staging disease and also in characterising biological patterns of lesions that may be relevant to the selection and delivery of therapy. in this course, the complex nature of gep-net and the intrinsic uses and limitations of each diagnostic imaging modality will be underlined. insights to hybrid structural and molecular imaging techniques will be provided and discussed. a. tumour biology, pathogenesis and classification b. wiedenmann; berlin/ de (bertram.wiedenmann@charite.de) neuroendocrine tumour cells are characterised by the coexpression of neuronal and epithelial proteins and cellular organelles such as synaptic vesicles containing synaptophysin of neurons and intermediate filaments/cytokeratins of the epithelial cells. based on the presence of secretory vesicles and the continous, uncontrolled vesicular release of biogenic amines, neuropeptides and hormones, patients suffer in half of the cases of so called functional symptoms and syndromes. examples are the carcinoid syndrome (excessive release of serotonine) or the zollinger-ellison syndrome (excessive release of gastrin). activation or inhibition of certain g-protein coupled receptors (e.g. somatostatin receptors) or channel proteins (r-type calcium channels) can lead to the control of the hypersecretion or so called functionality of the affected patients. medical interference with signal transduction pathways involving tyrosine kinase receptors as such mtor and channel proteins can lead to an inhibition of cellular and tumour growth. these observations have led to the establishment of new therapies, especially for pancreatic nets using especially mtor and tyrosine kinase inhibitors. whereas the tumorigenesis is unknown in the case of sporadic nets, hereditary nets appear to develop via a menin mutation through the intermediate stage of hyplasia before they develop the full metastatic potential. based on the above given tumour biological and histopathological findings, a rather robust classification for nets has been developed by the european neuroendocrine tumor society (enets) using a tnm-classification together with a gradingsystem. furthermore, the formerly used terms such as apudoma, neurocrestoma, carcinoid, etc. have been largely replaced by the meanwhile generally accepted term neuroendocrine tumour. this presentation will focus on the pivotal role of nuclear medicine in the diagnosis and treatment of neuroendocrine tumours (nets). the metabolic and molecular imaging capabilities of both positron emission tomography (pet) and single photon emission tomography (spect) have made a great impact on the clinical management of patients with these tumours. a poster child of molecular imaging in oncology is scintigraphy of the somatostatin receptor (ssr). 111 in-dtpa-octreotide has a substantial value in detection, diagnosis and staging of net and more particularly in gastroenteropancreatic nets. newer ssr-binding radiopharmaceuticals have been developed for pet, mainly with gallium-68 as radiolabel, with higher affinity and more advantageous pharmacokinetics. when used with high-resolution and rapidthroughput multimodal whole body imaging of modern pet/ct cameras, these tracers provide the current state-of-the art ssr imaging. we will also discuss the clinical value of metabolic tracers, such as [ ]5-hydroxytryptophan) for amino acid metabolism imaging. the clinical merits and indications of these tracers will be explained. the continuously evolving quest to develop tracer for other receptor systems expressed on nets will be illustrated, e.g. bombesin, vip, cck and glucagon-like peptide receptor ligands. finally, the role of imaging as selection for metabolic and peptide receptor radionuclide therapy will be discussed. gastroenteropancreatic neuroendocrine tumours (gep-nets) are a heterogeneous group of neoplasms that arise from cells of the diffuse neuroendocrine system and may present with a wide spectrum of clinical presentations. their prognosis is mainly related to their biology, proliferation and differentiation. the main goals of imaging are the diagnosis and the staging of these tumours. the diagnostic challenge is very different in functional tumours where clinical presentation and laboratory parameters are of utmost importance and in nonfunctional tumours where imaging may show characteristic features such as hypervascularisation and calcifications. staging is also essential as locoregional involvement and distant metastases (such as liver metastases) may change the therapeutic approach and are major prognostic factors. multimodal workup included morphological imaging modalities with ct and mr imaging, and endoscopic ultrasound was the most useful and functional imaging. the latter includes somatostatin receptor scintigraphy, fdg pet and more recent functional tools such as pet using 68ga and 18 f-dopa. imaging may also play a role in assessing prognosis in combination with tumour differentiation and tumour proliferation, obtained from pathologic examination. last, imaging is useful in evaluating tumour response after treatment. although surgery remains the only potentially curative therapy for patients with primary gep-nets, other available treatments include chemotherapy, interferon, somatostatin analogues, and targeted therapies. imaging criteria rely not only on changes in tumour size, but also on internal tumour changes. the purpose of this session is to bring the audience up to date with a novel mri method capable of measuring brain perfusion. this method is called arterial spin labelling (asl) and provides a complete non-invasive means to quantitatively assess cerebral blood flow (cbf). as with any mri technique, asl relies on proper setting of many technical parameters to provide an adequate image quality, with minimal influence from potential artefacts. a recent position paper, co-signed by members of the perfusion study group from the international society for magnetic resonance in medicine and the european cost-funded action on 'asl in dementia', has established a series of simple guidelines to help promote this technology in clinical practice. these guidelines will be provided within this session. the created cbf maps will then be analysed, and a simple description of the main features and clinical characteristics of these physiological images will be given to the audience. in particular, a proper difference in the meaning of cbf in several diseases will be highlighted, as it can be either causative, such as e.g. in stroke and cerebrovascular diseases, where a reduced cbf leads to a breakdown in tissue homeostasis, or consequential, as in e.g. dementia, in which a reduction of cbf is the mere reflection of impaired metabolism, combined or not with an underlying brain atrophy. following this session, the radiologist or clinician should be able to better appreciate asl-based sbf maps in several neurological conditions. perfusion is an important parameter to assess the status and liability of organs and tissue. typically, exogenous contrast agents are administered to measure this quantity. arterial spin labelling (asl) is capable of estimating perfusion without the use of exogenous contrast media by labelling inflowing blood magnetically. this labelling process can happen either in a short time over an extended region or over a longer time period, but in a localised area. these techniques are called pulsed asl (pasl) or continuous asl (casl), respectively. for quantification, a critical parameter is the time the labelled blood takes to flow from the region of labelling to the imaging region. this time is typically called bolus arrival time (bat) or arterial transit time (att). it is important to either reduce the influence of this transit time on measured signal intensity or directly estimate it. applying proper bio-physical models, the perfusion-weighted data can then be converted in absolute measures of perfusion. more sophisticated methods allow measuring of the main feeding artery of each imaging voxel (vascular territory mapping) or assessing other parameters beyond perfusion, allowing more detailed assessment of tissue status and function." the use of asl in cerebrovascular disease j. hendrikse; utrecht/nl (j.hendrikse@umcutrecht.nl) obvious applications of arterial spin labelling in clinical mr protocols are cerebral blood flow measurements in patients with acute or chronic cerebrovascular disease. in patients with acute stroke, the cerebral blood flow measurements may indicate the infarct core, with severely decreased perfusion and the infarct penumbra, with decreased perfusion but still viable brain tissue. in chronic cerebrovascular disease, arterial spin labelling cbf measurements show the regionally impaired haemodynamics distal to a carotid obstruction. with adequate collateral blood flow, these areas may be relatively small and with a failure of compensatory mechanism the cerebral blood flow may fall below a critical level. in acute stroke patients, asl mri may show compensatory hyperperfusion in stroke regions after the recanalisation of an occluded artery. other applications of arterial spin labelling are clinical mr protocols in children. in addition to cbf-weighted images, asl mri has also the ability to measure timing parameters: typically, the time it takes for the magnetically labelled arterial blood to flow from the arteries in the neck to the brain tissue, which may be delayed in patients with cerebrovascular disease. furthermore, asl mri has the ability to visualise the (collateral) perfusion territories of the brain feeding arteries in many clinical applications. in patients with cerebrovascular disease, a pitfall may be the absence of label in brain regions due to delayed (collateral) flow, which also may result in high asl signals in (collateral) arteries. learning objectives: 1. to appreciate the different roles of asl in cerebrovascular diseases. 2. to become familiar with the different types of calculated images obtained from multi-time points and selective pulses asl. 3. to become familiar with the limitations and pitfalls of asl. the use of asl in non-vascular brain disease m. smits; rotterdam/nl (marion.smits@erasmusmc.nl) arterial spin labelling (asl) is a non-invasive mri technique with which cerebral blood flow (cbf) can be measured quantitatively. although the first publications of asl mri date over 10 years back, it is only now that asl is commercially available on mri systems from all major vendors and is making its way into clinical practice. the main areas of interest for current and future nonvascular clinical application of asl mri of the brain are dementia and neuro-oncology. asl is proposed as a diagnostic alternative to fluorodeoxy-dglucose (fdg)-pet in the workup of dementia patients. asl has several advantages over fdg-pet. crucially, it can easily be added to the routinely performed structural mri examination. feasibility studies show that asl provides reliable cbf maps in dementia. in patients with established alzheimer's disease and frontotemporal dementia, hypoperfusion patterns are seen that are similar to hypometabolism patterns with fdg-pet. current and future studies in this field will need to demonstrate the validity of asl in the diagnostic workup of the individual patient, early in the disease process. studies on asl in brain tumour imaging indicate a high correlation between areas of increased cbf as measured with asl, and increased cerebral blood volume as measured with dynamic susceptibility contrast-enhanced perfusion imaging. the major advantages of asl for brain tumour imaging are the fact that cbf measurements are not influenced by breakdown of the blood brain barrier, as well as its quantitative nature, facilitating multicentre and longitudinal studies. the analysis of a sinonasal tumour requires mri for differentiation between tumour and secretions or polyps, to assess the local extension and spread into adjacent compartments (skull base, intracranial, orbit, deep facial compartments) and to depict perineural spread. t2, t1 and high-resolution postcontrast series preferably in three, but at least in two different planes, are needed. ct provides additional information of bony structures and serves as a road map for surgical navigation. a fascinating benign sinonasal tumour is inverted papilloma, which has a high recurrence rate if not removed in toto and may harbour carcinoma in < 5% of patients. ct may show the attachment of the tumour as an area of increased sclerosis, which directs the surgeon to plan the operation. in patients with recurrent inverted papilloma, providing information to the radiologist about its presumed localisation is important, the more so in patients suffering from polyposis. malignant tumours are uncommon and of a large histologic variety. about 80% arise in the maxillary sinus; 70% are squamous cell carcinomas. they are often large at diagnosis, because clinical symptoms of nasal obstruction or headache are non-specific. diagnosis is by biopsy. in view of the rapid development of advanced endoscopic techniques, preoperative imaging is extremely important to assess accurately tumour extension. the skull base and dura as well as the lamina papyracea should be scrutinised for tumour locations to foresee an additional cranioendoscopic approach to a standard endonasal endoscopic approach. finally, imaging may play a role in differentiating non-nasal disease, e.g. primary bone tumours, from mucosal disease. to discuss risk/benefit considerations in medical imaging from the perspective of patients and highlight some of the pre-requisites to ensure trust and confidence. this presentation will draw on the work of the european patients' forum on patient safety, quality of care, health literacy, and patient empowerment, to explore what are the key factors to consider in radiation risk analysis, from a patient's perspective, recognising that 'one size does not fit all'. it will examine what constitutes quality information in this environment, effective dialogue between the patient and the radiologist, and the interdisciplinary team, informed consent and transparency of data. it will also highlight some of the particular challenges regarding vulnerable patients, and those requiring on-going treatment due to chronic disease (s). the justification for medical procedures is based on the assumption that the benefit outweighs the risk. this presentation looks at the radiation risk factors from recent high-profile papers (pearce et al., 2012) and publications from international bodies such as beir and icrp. at lower radiation doses (< 100 msv), quantifying, understanding and communicating radiation risk to staff, patients and referring clinicians presents a range of challenges. advances in health information systems will facilitate more precise dose risk relationships. there are a number of approaches to stochastic radiation risk assessment such as organ-/age-based assessment and effective dose equivalent assessment. at-risk groups, such as children and pregnant women, need special focus. eu directives demand special attention for high-dose interventional procedures and ct scans. these techniques, particularly if repeated, require further risk assessment regarding potential deterministic effects such as erythema, hair loss, and radiation-induced cataractogenesis. this paper looks at strategies in consenting, monitoring, and follow-up of such high-dose effects. the practical implications of the new occupational icrp eye dose limits for interventional practice are also examined. with the advent of higher field scanners in clinical practice and the construction of 'mri compatible' implanted devices, the list of the do's and don'ts while performing an mri examination changes constantly. in this presentation basic safety guidelines and rules will be explained regarding static magnetic field effects, time varying magnetic field effects, radiofrequency field effects and acoustic noise effects both with regard to the patient as well as the personnel using the equipment. due to the advances in medical technology the list of possible 'safe' and 'unsafe' items changes almost daily. therefore it is very important to have all the information about the patient's condition and implants prior to the mri procedure in order to asses possible contraindications in advance. while until a couple of years ago cardiac pacemakers and neurostimulators were contraindicated in the mri environment, the advent of 'mri compatible' pacemakers and other implanted devices introduces challenges in patient safety. in fact these devices are only safe in certain configurations and also in a lot of cases specific mri scan sequences and rf antennas are only allowed. following the european emf directive, where the mri part is derogated, the protection of staff working with em fields also became a topic of debate. what are the possible risks for staff working with mri magnets and how can one implement practical rules for the safe use of the mri equipment. the field of image-guided ablation has expended recently with new ablation techniques like micro-wave, irreversible electroporation, cryoablation. nevertheless, after each treatment, whatever the technique used, we will leave in place in the treated organ, a scar instead of the tumour. follow-up of these treated areas are done by radiologists using ct of mr or contrast enhanced ultrasound. standardisation of terms has been done in 2003 by an international committee presided by dr. goldberg. this allows reporting criteria identical from one center and from one country to another. furthermore, it allows a more homogeneous literature and evaluation of success. nevertheless, techniques are not all the same and the cellular and tissue damage in the tumour and around it in the healthy parenchyma are not identical and does not have the same evolution over time. thermal ablation is frequently used to treat liver, lung and bone tumoural lesions because of its safety, efficacy and tolerability. one issue is the lack of reliable imaging modality to assess treatment efficacy and to detect early relapse. several papers have demonstrated that 18 fdg pet/ct is a useful tool to follow-up ablated liver tumour, detecting residual disease easily and earlier than conventional imaging. few reports evaluating the usefulness of 18 fdg-pet/ct in the follow-up of ablated lung lesions are available, but prospective studies show promising results, with a high negative predictive value of this technique. very few data are available on bone lesions and further studies are needed to assess the role of 18 fdg-pet/ct in the follow-up of these lesions. in general, the in vivo typical aspect of completely ablated lesion on 18 fdg-pet/ct is a ring shape, diffuse, peripheral, homogeneous 18 fdg uptake at the treated lesion; on the other hand, the presence of heterogeneous and focal uptake is more frequently related to disease relapse. suvmax (standardised uptake value) is not a reliable indicator. it is higher in case of disease relapse than in completely ablated lesions, but also in case of important inflammatory reaction. finally, the best time point to evaluate ablation efficacy still remains to be defined, but 18 fdg-pet/ct should be performed at least 3 months after treatment to avoid dubious or inconclusive findings due to inflammatory reaction. the aim of thermal ablation treatment is to generate an area of thermocoagulation whose diameter is larger or at least equivalent to that of the tumour. this necrotic scar usually shrinks with time, but most often very slowly. therefore, the criteria of response based on size measurement cannot be applied. the pattern of thermal ablation is similar whatever the thermo-ablation technique used. on ct imaging, thermal ablation areas are well circumscribed and oval shaped. the criterion commonly used to assess the efficacy is the absence of enhancement in the thermal ablation necrosis, which corresponds to tissue devoid of viable tumour. on mr imaging, the thermo-ablation areas are typically hyperintense on unenhanced t1 due to the presence of proteinaceous material, and hypointense on t2, explained by the dehydrating effect of thermal damage. the residual tumour is typically round in shape and located at the periphery of the necrotic area or in contact with large vessels. mr imaging allows earlier detection of residual liver tumour than ct imaging. neurodegenerative diseases, cancer and heart disease perhaps summarise the major challenges to medicine in this century, a challenge in accurate diagnosis and also in treatment. recent technological advances in medical imaging technology mean that these challenges can be dealt with more efficiently. anatomy can be studied faster, safer and with higher spatial resolution and precision. in addition to anatomy, the study of function has become feasible; more sophisticated hardware and software are being used to get the required data to map out the functionality and understand how this relates to anatomy to offer a more comprehensive view of normal development and explain pathological conditions. at the same time, researchers and clinicians are urged to create a platform for reciprocal communication to facilitate translation of the research findings to a graspable clinical benefit for the patients. this translational platform will allow flagging the major clinical questions, inform current and future research experiments and at the same time help utilise recent research findings in the clinical setting. this session will review state-of-the-art mri techniques and document different approaches to translational imaging. it will also allow understanding the obstacles and remedies in implementing translational medicine. many neurological diseases are associated with progressively reduced cognitive function. recent evidence suggests that proficient cognitive function depends on an appropriate interaction between large-scale cognitive control networks in the brain. it is hypothesised that damage to white matter microstructure, as found in many neurological diseases, disrupts the integrated operation of these networks and results in impaired cognitive function. diffusion tensor imaging (dti) has been used to investigate alteration to white matter micro-structure and resting state fmri (rsfmri) has proven to be a useful technique to assess brain function in multiple cortical systems. however, the combined use of these techniques in the clinical setting has not yet taken hold. in this presentation, i will demonstrate the flexibility of these mri techniques in assessing brain structure and function and address their feasibility of use in a clinical setting. imaging in oncology is a growing field within radiology. different tomographic techniques are used either isolated or as multimodality-multivariable imaging, as there is an increasing need to combine morphological and functional information. different cutting-edge modalities, such as pet-ct, dw-mr, ce-mr and mr-spectroscopy, are standard in most clinical scenarios. new images have advantages providing excellent soft-tissue contrast and multidimensional functional, structural and morphological information. the development of new diagnostic imaging research areas, mainly in the field of oncology, cardiology and neuropsychiatry, will impact the way medicine is performed today. both clinical and experimental multimodality studies, in humans and animals, will have to demonstrate an efficient use of the imaging information provided by the modalities to affect the future of medical imaging. we will comment on the impact of continued technological developments in medical imaging on patients with cancer (diagnosis, staging and follow-up) and the challenges of imaging technologies from research into clinical reality. the recent advances and developments in measurements and biomarkers which have led to a greater understanding of cancer will be commented, together with the morphologic, metabolic and functional oncological imaging research and clinical practice. finally, the role of the radiographer in advanced oncological imaging techniques will be evaluated. when imaging the head and neck region with ct or mri, teeth are always present. we frequently encounter radiolucent or radiopaque lesions of the jaw on scans performed for other indications. familiarity with typical dental conditions is necessary to subject the patients to the right therapy. to correctly evaluate and describe those lesions, this special focus session on dental imaging gives the radiologist a tool to report dental lesions. the anatomy of panoramic and ct images will be reviewed in the first talk. technical details as well as pitfalls will be presented. in the second talk, the focus is on pre-and post-surgical imaging with ct where typical lesions of the jaw will be presented. an insight into imaging the teeth with mri will be given by the third speaker. the discussion on the impact of radiologists on dental images will complement this special focus session's theme. panoramic radiography produces a single image of the maxilla, mandible, teeth, temporomandibular joints and maxillary sinuses. during the exposure, the x-ray source and the detector rotate synchronously around the patient producing a curved surface tomography. this horseshoe-shaped zone of sharp image is called the focal trough/image layer. advantages of this technique are a good overview of lower facial hard tissues, the convenience of an extraoral examination, a low patient radiation dose, and low costs. disadvantages are limited width of the sharply imaged layer, variable magnification, and oblique projection, especially in the upper premolar region. patient positioning is most important for obtaining a detailed panoramic radiograph. in addition to patient position errors, patient movement during exposure and metal objects can cause artefacts. also, ghost images caused by structures located between the x-ray source and the rotation centre can hamper diagnostics. cbct is a radiographic imaging method that allows accurate 3d imaging of hard tissues. during a cbct scan, the scanner rotates around the patient's head (180â°-360â°) obtaining multiple sequential planar projection images by a 2d detector. the scanning software collects the data which is processed to create a volumetric data set with isotopic voxels with varying fov. disadvantages of cbct imaging are poor soft tissue contrast and artefacts. in addition to normal panoramic and cbct anatomy, after this presentation the audience will be familiar with the panoramic and cbct techniques as well as common errors and pitfalls of these techniques. pre-surgical and post-surgical imaging with mdct and cone-beam ct a. gahleitner; vienna/at (andre.gahleitner@meduniwien.ac.at) multislice-ct and more recently cone-beam-ct have become an established method for anatomic imaging of the jaws prior to dental implant placement. commonly referred to as "dental-ct", these high-resolution imaging techniques have gained importance in diagnosing dental-associated diseases of the mandible and maxilla. especially in patients with inflammations, cysts, oro-antral fistulas, odontogenous sinusitis, impacted teeth and dental fractures, new indications have emerged. unfortunately, most radiologists have had little experience in this area and many of the dental-ct findings remain undescribed. hence, we will determine the ct appearance of frequent dentalrelated diseases of the jaws and demonstrate typical pre-and postoperative findings. this presentation reflects our experiences from 18 years of performing dental-ct with 36.000 investigations, closely working together with dentists and oral surgeons. learning objectives: 1. to learn about the typical findings from pathological conditions of the jaw, which confront dentists and oral surgeons. 2. to understand these findings in cross-sectional imaging like multislice and cone-beam ct. 3. to learn about the usual treatments for these conditions in order to know how they are used in dental radiology. dental mri s. rohde; dortmund/ de (stefan.rohde@klinikumdo.de) this lecture will discuss the potential of dental mri in the field of inflammatory and neoplastic disease of the periodontal space. experimental and preliminary clinical data from high-field dental mri will be presented with a special focus on the visibility of critical anatomical structures on high-resolution sequences. the results will be compared to high-resolution cone-beam ct. based on representative cases, we will review the main causes of thoracic non-traumatic vascular emergencies (acute aortic syndrome, pulmonary thromboembolism and haemoptysis); mdct angiography has become the firstline imaging test for the diagnosis of these entities. as acute aortic disease is the most common fatal condition in patients with chest pain and prompt recognition and treatment are of paramount importance, we will review the spectrum of acute aortic pathology focusing on the distinctive findings of each entity (classic dissection, intramural haematoma and penetrating aortic ulcer) and upgrading the clues for their diagnosis. acute pulmonary embolism (pe) remains a common clinical challenge. mdct pulmonary angiography has become the first-line imaging study in the diagnosis of pe because of its speed, accuracy, low interobserver variability and ability to provide alternative diagnoses. we will review the role of mdct in the evaluation of acute thrombotic pe: findings of acute pe (including how to evaluate the severity of an episode of pe at ct pulmonary angiography) and some potential pitfalls. massive haemoptysis is a life-threatening condition that is associated with a high mortality rate. haemoptysis usually involves bleeding from the bronchial arteries or, less frequently, from nonbronchial systemic arteries. haemoptysis of pulmonary arterial origin is rare, estimated at less than 10% of haemoptysis cases. mdct angiography permits noninvasive, rapid, and accurate assessment of the cause and consequences of haemorrhage into the airways and helps guide subsequent management. acute respiratory failure can have multiple underlying causes including infection, fluid overload, immunological diseases or exacerbation of preexisting lung disease. since the clinical symptoms are nonspecific, imaging plays an important role. the first imaging method is mostly the chest radiograph, easy to access and to obtain, but non-diagnostic in many cases. (hr)ct offers more possibilities to define the differential diagnosis. the option of this interactive workshop will be to get familiar with the spectrum of diseases that can cause acute respiratory failure and learn about key findings in radiography as well as ct to reduce the differential diagnosis. the interaction between preexisting lung disease, clinical information (e.g. chemotherapy, rheumatoid arthritis, copd) and imaging findings will be discussed using clinical case studies. options and also limitations of imaging findings will be illustrated. the following scenarios will be taken into account: acute cardiac failure and various appearances of oedema; acute immunological-toxic disorders including druginduced lung disease and inhalational injuries; exacerbations of preexisting lung disease including fibrotic and obstructive lung disorders; severe infections causing respiratory failure and their complications. contrast-enhanced ultrasoud (ceus) and elastography are evolving us techniques that have already found their ways into clinical practice (ceus) or will do so in the next few years (elastography). ceus is performed with 2 nd generation us contrast media, but these contrast media are not available worldwide. in many european countries, sonovueâ® (bracco, it) is the only available contrast, consisting of micro-bubbles less than the size of red blood cells. in contrast to ct and mr contrast media, these bubbles are strictly intravascular. for us imaging, low mechanical index us techniques are used to see the resonance of sound by these bubbles. ceus is excellent for the differential diagnosis of focal liver lesions based on vascularisation and specific contrast uptake (imaging the wash-in and wash-out of us contrast over time with excellent temporal resolution) and increases us sensitivity to liver metastases in colorectal cancer patients. however, ceus is only useful when there are excellent us conditions. in pancreatic us, ceus allows to differentiate adenocarcinoma from neuroendocrine tumours based on vascularisation (us contrast uptake). whereas elastography (strain elastography or shear wave elastography) is established for the diagnosis of liver fibrosis, there are no general recommendations for using these various techniques to measure the "hardness of a focal lesion" in focal liver and pancreas lesions. diffusion-weighted mr imaging (dw-mri) provides information on tissue cellularity, extracellular space tortuosity and integrity of cell membranes by measuring the motion of water molecules in tissues modified by flows (blood vessels, glandular ducts,.). and interaction with cellular components. integrated in conventional-mr acquisition protocol, dw-mri increases sensitivity for lesion detection. the apparent diffusion coefficient (adc) can be calculated using a mono-exponential relationship between signal attenuation and b-value. this fitting is influenced by microcapillary perfusion. a more sophisticated approach (intravoxel incoherent motion, ivim) would enable estimation of parameters that separately reflect tissue diffusivity and microcapillary perfusion. using ivim-analysis, the derived quantitative parameters describe tissue diffusivity, perfusion and perfusion fraction. by providing qualitative and quantitative information, dw-mri is applied in oncology to characterise malignancy, including lesion aggressiveness, and to monitor treatment response. perfusion imaging is a useful tool to achieve information concerning tissue vasculature, microvascular permeability and interstitial space characteristics. dynamic contrast-enhanced techniques (dce-ct, dce-mr) are based on the analysis of the contrast agent (tracer) biodistribution in tissues. quantitative parameters are obtained using pharmacokinetic models, as transfer constant ktrans, extracellular-extravascular space fraction ve, vascular tissue fraction vp and the rate constant kep. quantitative dw-mr and dce-mr parameters are increasingly used as imaging biomarkers to predict tumour response and/or to monitor the effects of therapy, especially when anticancer agents with novel models of action are used (anti-angiogenic, tyrosine kinase inhibitors and several others). therefore, these new imaging biomarkers may have a pivotal role in correctly evaluating tumour response and stratify and managing cancer patients. elderly and the young can all present special problems that require a greater depth of understanding to obtain a diagnostic study. this session will help you in your quest for reliable high-quality investigations for all. a. coronary cta in patients with severe arrhythmias and high heart rate c. loewe; vienna/ at (christian.loewe@meduniwien.ac.at) besides all advances in scanner technology, heart rate remains a critical issue for coronary cta, and motion artefacts due to cardiac function represents still the most frequent reason for limited diagnostic image quality in cardiac cta. thus, the target heart rate is defined depending on the scanner system used and ranged between below 60 bpm and below 70 bpm. however, in a number of patients heart rate control is not possible or not successful (i.e. children, emergencies, heart transplant recipients), whereas a relevant proportion of ctas are performed in patients with heart rates higher than the target frequency. during this presentation, the possibilities for heart rate control by beta blocker injection and beyond will be discussed and possible workflows will be presented. furthermore, examination strategies for patients with high heart rates will be presented including reverse dose modulation, high-pitch scanning, systolic scanning and more. finally, tools for reconstruction and assessment of patients scanned at higher heart rate will be introduced. different to high heart rates and even more critical with regard to image quality is arrhythmia. due to the complexity of cardiac synchronisation, a ct suite is not the place for cardiac resynchronisation, whereas the indication to cta has to be reevaluated depending on referring diagnosis and severity of arrhythmia. since there are patients undergoing cta because of arrhythmia including patients prior to ablation treatment, strategies for examination and image reconstruction in case of arrhythmic patients have to be established and will be presented. cardiac computed tomography (ct) has become a widely available diagnostic tool used in a range of heart conditions. the commonest application of this technique is in the evaluation for coronary artery patency (coronary ct angiography) in patients with chest pain. when coronary arteries are heavily calcified, or post-coronary angioplasty with stent implantation, diagnostic problems can occur. in these circumstances, the evaluation of the coronary arteries on ct is hampered by the occurrence of high-density artefacts caused by calcifications and stent struts. these artefacts may preclude the appropriate assessment of the coronary lumen. the presence of motion artefacts in the dataset or image noise in very large patients may exacerbate the problem. in this scenario, accurate patient selection and preparation remain key to ensure that the diagnostic yield of the cardiac ct study is good. optimisation of scan parameters (kv), contrast injection protocol and use of appropriate postprocessing techniques (e.g. dedicated convolution filters) play an important role in daily clinical practice. recent technical developments include dualenergy scan techniques and gemstone spectral detector systems that acquire simultaneously high and low kilovoltage datasets. this is done to achieve tissue differentiation. in principle, by using monochromatic image reconstruction, the effect of high-density artefacts may be decreased. using a similar principle, high-density structures can be subtracted from the image. the introduction of iterative reconstruction algorithms may play a role in that these algorithms are theoretically more accurate in the modeling of physical noise and tissue geometries. lack of movement artefacts is one of the major prerequisites for good image quality in cardiac mr. it is crucial to have the minimum possible image acquisition time. it is important to make both te and tr as short as possible. data acquisition should be synchronised with patient's ecg or pulse. special attention should be paid to good quality of ecg recordings (good contact of electrodes with the skin, electrodes positioning, using of dielectric pad). in patients with arrhythmia, prospective ecg synchronisation should be used instead or a retrospective one, or special protocols may be applied for arrhythmia correction. breathing artefacts are usually not a problem for cardiac mri, because most sequences are acquired during a single breath-hold. using ssfp and parallel imaging allows obtaining a complete set of cine mr images through the whole heart in 1-8 short breath-hold periods. the technique of realtime cardiac mr is a good way to perform successful examinations even in difficult patients, especially the ones with heart failure. other systemic mrartefacts (aliasing, chemical shift, magnetic susceptibility, off-resonance) should be recognised and diminished or eliminated by the operator. these artefacts are more prominent in case of 3 t systems. late-enhancement studies with gd are very dependent on the correct selection of the ti time. phase-contrast mri requires venc calibration in cases of valve stenoses. to meet the challenges and the benefits of cardiac mri, one must balance the constraints of signal-and contrast-to-noise ratios, spatial and temporal resolution, scan time and image quality. scoliosis, a common spinal deformity in teenagers, especially girls, progresses during their growth until the end of puberty. therapeutic choices, which are either medical -with corset -or surgical, depend on this progression. follow-up is mainly clinical. however, radiographs are often indicated to give precise information: ap and lateral views of the spine in standing position remain the basis of this follow-up. obtaining a good image quality at all levels of the spine has been a technical challenge for a long time, and the question of radiation dose is also a main concern, as these radiographs require a high radiation dose. fortunately, radiographic techniques have greatly improved over the past few years: from the conventional 90 or 120 cm film to digital screens and now flat screens, we now obtain better quality images with less radiation. today, eos system using xenon chamber is the best to give good ap and lateral views. it allows 3d reconstructions with minimal radiation dose. on these radiographs, measures can be performed, essentially cobb's angle. it helps in evaluating progression of the curves and making surgical decisions. other imaging techniques are requested only in particular situations as in the presence of neurological symptoms or general disease such as neurofibromatosis, or in young children with malformative scoliosis and sometimes preoperatively. ct is best to study the vertebrae; it objectivates vertebral malformations (agenesis, hypoplasia, blocks). mr will be requested to study the cord, nervous roots, craniospinal junction and the soft tissues. collaboration between the radiologist and spinal surgeon is essential. the key elements in the diagnostic process, as for most bone lesions, are: the age of the patient, the type of bone and bone segment involved, the location within the bone, the presence of signs of aggressiveness (type of osteolysis, limits, presence and type of periosteal reaction). conventional x-rays should never be absent from the initial workup of a focal bone lesion in a child, as they provide essential features for differential diagnosis and, in most cases, eliminate the need for other more costly techniques. the need and priority for other imaging techniques, such as ct, mri and bone scintigraphy, are decided on a case-by-case basis and sometimes a combination of these techniques, which complement each other, is needed. it is the radiologist's responsibility to recommend histological analysis of a lesion via biopsy whenever the imaging aspect is not characteristic or indicates signs of possible malignancy. learning objectives: 1. to recognise the most common benign bone tumours and pseudo-tumours. 2. to understand the differences between benign bone tumours, pseudotumours and malignancies in children. 3. to understand imaging modalities that could help in the differential diagnosis of benign bone tumours and pseudo-tumours in children. a-472 17:00 a.c. offiah; sheffield/uk (amaka.offiah@nhs.net) the 2010 nosology and classification of genetic skeletal disorders subdivides 456 conditions into 40 groups defined by molecular, biochemical and/or radiographic criteria. 316 conditions are associated with mutations in at least one of 226 different genes. some of these conditions are rare or even extremely rare (occurring in fewer than 1 in 100,000 of the population). clearly, the general paediatric radiologist cannot be expected to correctly recognise and diagnose all of these conditions. the approach is to perform a set of radiographic images dependent on the patient's age/size and to develop a standard system for reviewing these images. the standard set of images for a patient over 2 to 3 years of age consists of ap and lateral skull, ap chest, ap pelvis, lateral thoracolumbar spine, ap one upper limb, ap one lower limb and dp left hand. variations on this routine dysplasia skeletal survey will be discussed and a standard system for interpreting the images will be presented using radiographs of the commoner skeletal dysplasias as examples. in the last few years, interest in body composition (bc) analysis, which is the quantification and characterisation of relative amounts of muscle, fat, bone, and other vital parts composing the human body, has grown rapidly for clinical, research and epidemiological purposes. studying body composition has gained great importance for the comprehension and decoding of a multitude of patho-physiological processes (e.g. obesity, diabetes and endocrine diseases and also gastrointestinal, renal, nervous, infectious diseases, etc). and physiological and para-physiological conditions as in athletes or growth and ageing processes. although the main imaging techniques, which include dualenergy x-ray absorptiometry (dexa), computed tomography (ct), and magnetic resonance imaging (mri), offer a differentiated and attractive analysis of bc, they still need to find a definite position in clinical practice. through 'programming' low birth weight is associated with increased rates of coronary heart disease, stroke, hypertension & non-insulin dependent diabetes. prediction of morbidity and mortality from body composition, particularly fat, stimulates the importance and application of accurate and precise methods for quantitative assessment of body composition; the gold standard for which is cadaver analysis, but other methods have to be implemented in vivo. body composition alters in many chronic diseases, starvation cases, metabolic syndromes, and senescence stages, and is a key component of health. several techniques are available which vary in simplicity and complexity of use. each make assumptions and may not measure body composition directly, but make predictions from other measurements made. skinfold thickness measurements assess regional fat and are quick and simple to perform at all ages. reproducibility is good, but less so in obesity. there is some limitation of reference data to express results as standard deviation scores (sds). body mass index (bmi; weight/height 2 ) is widely used as an index of relative weight expressed as sds for gender, age and ethnicity. waist circumference (wc) is a measure of central fat, and can also be expressed as a ratio to hip circumference. bioelectric impedance analysis (bia) measures body impedance to a small electric current, which estimates total body water (tbw) from which can be derived fat free mass (ffm). tbw can also be measured by neutron activation. air displacement plethysmography (bod pod) is a new method for body composition assessment. learning objectives: 1. to understand normal body composition in children and adults. 2. to learn how body composition can be altered by disease. 3. to appreciate the clinical relevance of assessing body composition. 4. to understand the non-imaging methods available for measuring body composition, with their advantages and limitations. computed tomography: what does it measure and how? j. damilakis; iraklion/ gr (damilaki@med.uoc.gr) ct allows measurement of total body fat and enables differentiation of subcutaneous from visceral adipose tissue. body fat can be estimated using the conventional technique of manual planimetry. using planimetry, the user delineates manually the boundaries of subcutaneous and visceral fat in each ct image. however, this method is labour intensive, time-consuming, and, therefore, not easily applicable in routine clinical practice. another ct method used for the estimation of abdominal fat is the semiautomatic measurement of adipose tissue area. abdominal fat is assessed in a ct slice by using a fixed range of hounsfield units to define the area of adipose tissue. a limitation of this method is that the attenuation range of fat may vary among individuals. the stereological volume estimation method is based on the cavalieri's principle. according to this principle, the volume of an object can be measured by cutting it into equally spaced slices and measuring the area of the object on each slice. to measure body fat using stereology, a square grid of test points is randomly superimposed on each ct section. all points lying inside the fat tissue region are selected by the user and the software automatically calculates the total number of points hitting the fat. stereology provides the possibility for efficient fat volume assessment. however, research studies are needed to optimise the stereological estimation of fat and compare stereological measurements with those from other adipose tissue measurement ct techniques. learning objectives: 1. to appreciate the role of ct imaging in body composition analysis. 2. to learn how to measure visceral and subcutaneous adipose tissue using ct. 3. to understand the advantages and limitations of ct techniques (planimetry, thresholding, stereology) in evaluating adipose tissue. mri: current and future applications d.c. karampinos; munich/ de (dimitrios.karampinos@tum.de) mri has been emerging as an ionising radiation-free imaging modality to measure fat distribution in the human body and fat content in different organs. the present talk will first introduce mri methods to measure fat distribution, including the well-established t1-weighted imaging and the emerging dixon imaging approaches. the challenges related to the data acquisition and image post-processing of the two imaging approaches in the study of fat distribution will be reviewed. examples will be shown from the current use of mri in investigating adipose tissue distribution alterations or differences in patients with metabolic disorders, including obesity and diabetes. quantitative mri methods enabling the measurement of fat content with high spatial resolution will be then presented, with a focus on water-fat separation methods. the technical challenges associated with the establishment of mri-based fat content, as an accurate and reproducible imaging biomarker will be discussed. the selection of pulse sequence parameters and image reconstruction algorithm in a state-of-the-art water-fat separation experiment will be explained. applications will be shown from the growing literature of mri-based fat quantification in abdominal organs (e.g. liver) and in skeletal muscles, aiming to show the great premise of quantitative water-fat mri in quantifying fat content with high spatial resolution in different body parts. at the end of the talk, the potential of quantitative water-fat mri will be discussed in the emerging application of measuring bone marrow fat content and its association with bone health and metabolic disorders. the key role of dual-energy x-ray absorptiometry (dxa) in the management of metabolic bone diseases is well known. the role of dxa in the study of body composition and in the clinical evaluation of disorders which directly or indirectly involve the whole metabolism as they may induce changes in body mass and fat percentage is less known or less understood. dxa has a range of clinical applications in this field, from assessing associations between adipose or lean mass and the risk of disease to understanding and measuring the effects of pathophysiological processes or therapeutic interventions, in both adult and paediatric human populations as well as in pre-clinical settings. dxa analyses body composition at the molecular level that is basically translated into a clinical model made up of fat mass, non-bone lean mass, and bone mineral content. dxa allows total and regional assessment of the three abovementioned compartments, usually by a whole body scan. since body composition is a hot topic today, manufacturers have steered the development of dxa technology and methodology towards this. new dxa machines have been designed to accommodate heavier and larger patients and to scan wider areas. new strategies, such as half-body assessment, permit accurate body scan and analysis of individuals exceeding scan field limits. although dxa is a projective imaging technique, new solutions have recently allowed the differential estimate of subcutaneous and intra-abdominal visceral fat. the transition to narrow fan-beam densitometers has led to faster scan times and better resolution; however, inter-or intra-device variation exists depending on several factors. in cancer patients, disease-free survival is a good indicator for tumour response, but for many common cancers, treatment of disseminated disease is often noncurative. the increased duration of survival is related to changes in tumour size after treatment. however, the anatomical determination of tumour response has some limitations, especially when non-cytotoxic targeted therapies are used. with these new treatments options, the lack of progression may be associated with a good improvement in outcome, even in the absence of major shrinkage of tumours. new imaging biomarkers are therefore needed to assess therapeutic response. molecular imaging is now playing a prominent role in the monitoring of cytostatic targeted therapies. pet-ct, dynamic contrast enhancement studies or diffusion-weighted imaging are the most promising ones. the aim of this session is to present the state of the art in tumour response assessment with regard to new therapeutic regimens. in early oncologic times, treatments of different malignancies were reported in different ways. c. gordon zubrod and others first articulated the model of multicentre clinical trials and argued for standards to be agreed for included and excluded subjects, the method of assigning treatment and in measuring response. nowadays, we have better knowledge of tumour biology; however, we continue using the classical response criteria (who and recist) and overall survival as a primary goal for effective treatment in most of the malignancies. in the last few years, different criteria for responses have been reported to evaluate the disease and a lot of discussions between authors have been reported. now, we can use the recist criteria v1.1, implement the percist criteria and also forget the immunotherapy criteria. furthermore in the last few years, different treatments such as vaccines, antiangiogenics and targeted therapies have increased our arsenal in the treatment of different malignancies such as kidney cancer, prostate cancer, breast cancer and so on. another problem for our patients is that those diseases have a long evolution after the first-line treatment. we have to be able to define in each disease the treatment line and type of treatment to determine which evaluation criteria are necessary and which is the objective of treatment, pfs or os. we have to be aware that if we are not able to define such topics, we may be losing active treatments. recist 1.1 are the criteria most often used in studies to evaluate response to treatment in solid tumors. on each follow-up examination, response is defined by a combination of unidimensional measurement of 'target lesions', qualitative evaluation of 'non-target' lesions, and presence/absence of 'new lesions'. ct and mri are the preferred modalities for recist evaluation, and evaluations must be performed using the same modality, in the same plane. we will review anatomic locations which should be avoided, and how to deal with intercurrent events resulting in the impossibility of measurement. cases when recist seems inadequate will be discussed, including evaluation of bone metastases, and focal therapy. finally, though these criteria were developed for drug trials, they may provide a frame for reading examinations and writing reports in routine practice. reproducible, objective and quantitative criteria help to define or in the obese patient. ct is especially helpful in those with suspected retroperitoneal pathology, in the investigation of immunocompromised patients and those with complex post-operative problems. ct guidance may be required to facilitate percutaneous abscess drainage, particularly for deep pelvic collections. in addition, ct plays a vital role as a 'problem-solver' when ultrasound has failed to fully answer the clinical question posed. this short presentation will utilise clinical studies to illustrate the benefits of ct in the investigation of the acute abdomen, both as the initial imaging modality and as a second line tool following ultrasound. learning objectives: 1. to understand the advantages of ct as a primary imaging modality for children with acute abdomen. 2. to learn about clinical scenarios in which ct is relevant. 3. to appreciate the use of ct as an adjunct to ultrasound. abdominal trauma: us is better v. miele; rome/it (vmiele@sirm.org) ultrasonography (us) is a reliable technique whose advantages are rapidity, portability and accuracy in depicting intraperitoneal fluid without interrupting resuscitation and without radiation exposure. in the haemodynamically unstable paediatric patients, it represents the first line together with the x-ray evaluation. us for trauma has become more standardised and is worldwide known with the acronym of fast (focused abdominal sonography for trauma) or e-fast (extended-fast) used in depicting also pleural and pericardial effusions and pneumothorax. nevertheless, many parenchymal injuries are not correctly visualised at baseline us and some traumatic solid organ lesions can occur without hemoperitoneum. in case of haemodynamically stable patients, who have suffered a low-energy trauma, the greater time available allows the use of specific us contrast agents, enabling a better identification of traumatic organ injuries. contrast-enhanced ultrasonography (ceus) has a greater sensibility and specificity in the identification of parenchymal traumatic lesions, both in the first evaluation and follow-up, and could avoid unnecessary radiation and iodinated contrast medium exposure. in case of haemodynamically stable paediatric patients, who have suffered a high-energy trauma, us is not recommended as first-line investigation, because ce-mdct should be performed first. only in the follow-up, ceus can be considered an alternative to ct. in conclusion, e-fast and ceus should be considered as a useful tool in the assessment and monitoring of paediatric trauma. this examination can be performed at the patient's bedside, representing a useful alternative to ct in the paediatric traumatised patients and in the follow-up of a known abdominal injury. learning objectives: 1. to understand the differences in the diagnostic paths of paediatric patients. 2. to learn about the diagnostic efficacy and limitations of ultrasonography. 3. to become familiar with the use of the contrast-enhanced ultrasonography (ceus). abdominal trauma: ct is better m. raissaki; iraklion/gr (mraissaki@yahoo.gr) ct has been considered a sensitive, specific, and accurate test in the identification and grading of injuries, especially in the severely injured child. it should be overemphasised that traumatised children differ from adults: haemodynamically stable children may actually be actively bleeding and rapidly deteriorate. conversely, children have smaller calibre vessels, stronger vasoconstriction, and stronger solid organ capsules; bleeding may stop spontaneously, organ rupture is more difficult and delayed rupture is rare. this is why few children will undergo laparotomy or trans-arterial embolisation. the goal of imaging is to clear the abdomen in multi-traumatised children, identify those that may rapidly deteriorate because of clinically silent active bleeding, increase the surgeon's confidence level and define short-and long-term medical management. due to children's increased radiosensitivity, all ct scans should be indicated based on appropriate early clinical evaluation, assessment of risk factors for abdominal injuries and evaluation of the closely monitored child. alara includes the availability of outside scans upon admission, avoiding non-contrast scans and multiple phases and applying age-and weight-dependent exposure parameters. ct should not be performed as follow-up unless there is clinical deterioration. ct has the advantage of rapidly identifying and delineating with high resolution solid organ, vascular, mesenteric, bowel injuries and pending oligaemic collapse (hypoperfusion complex or shock bowel). important fractures and thoracic injuries may be simultaneously revealed with ct. the objective documentation of intraabdominal injuries is extremely important in suspected child abuse. evaluation of mr imaging in a patient with an intramedullary lesion should focus on key features: a) the location of the lesion on the cross-sectional area of the cord, best evaluated on axial images, b) the length of the lesion evaluated on sagittal images, c) the presence of cavitation and cysts, d) signal intensity on t2-wi, e) the presence of enhancement and enhancement type, and f) associated leptomeningeal enhancement. the knowledge of the presence or absence of the brain lesions is important information for narrowing the differential diagnosis. the clinical picture and the onset of symptoms will help the differentiation between the neoplastic and inflammatory and vascular lesions. in this lecture, the imaging characteristics and typical patterns of intramedullary lesions will be presented. a diagnostic algorithm, which includes imaging, clinics and csf analysis, will be discussed. a common clinico-radiological situation is the differentiation between spinal infection, degenerative changes and osteopaenia, and spinal tumour. in most cases, conventional ct and/or mri will allow a certain differentiation, and additional biopsies are mainly used to obtain tissue for bacteriological or histopathological classification. advanced mr techniques such as dwi may sometimes help in increasing diagnostic certainty, but are seldomly used in day-to-day practice. spinal infections typically present around the intervertebral disc, but may also present as isoloated spondylitis without disc involvement, and sometimes the infection quickly spreads to the epidural space. degenerative changes my sometimes mimic infection due to strong gadolinium enhancement. the main differential diagnosis of spinal tumorous processes is osteopaenic changes (oedema), and ct may be helpful in such cases, for example to demonstrate degenerative gas in the vertebral body. rare causes of spinal abnormalities such as atypical pathogens and rare tumours may cause diagnostic problems; often the fastest road to a diagnosis is biopsy in those cases. the correct clinical diagnostic approach to spine disease is mandatory in the selection of patients to be treated. the anatomy and the relationship between different structures must be known in detail to understand the source of the pain and so to treat it percutaneously. mr, ct, dynamic x-ray and nm bone scan in selected cases can be used to understand the reason for the pain. mr with t2 stir sequence or t2 fat supp technique is mandatory to show bone marrow oedema and to decide on which metamer to perform the treatment. ct is often necessary after mr in primary and secondary spine tumours. disk disease can be seen either on ct or mr. two major treatments must be considered: discogenic pain and vertebrogenic pain, and for this reason disk treatment and vertebral treatment. disk treatment includes many mini-invasive systems to use; however, no treatment has been shown to be superior to the others, with good clinical results in 75-80% of the cases, even at long-term follow-up. vp and assisted techniques are available for the treatment of not within a few minutes following ablation, ct of the ablation zone will demonstrate an extensive area of ground glass opacity (ggo). a ggo of at least 4.5 mm peripheral to the tumour is predictive of complete ablation. as early as 24 hours post-treatment, the entire ablated region usually appeared as a well-demarcated homogeneous dense opacity on ct that corresponded to necrotic tissue and its surrounding rim of granulation tissue. this zone of ablation is the "baseline post-ablation imaging" for follow-up. then, a relatively slow involution of the ablation zone will occur with various patterns, including nodular, fibrosis, disappearance, cavitation and atelectasis. morphologic features of local tumor progression are an increase in the overall size or a change in the shape of the ablation zone (even without enhancement). it is generally considered that an ablation volume that does not increase in size on subsequent imaging after the baseline post-ablation imaging is a complete ablation. the relatively slow decrease in size of the ablation zone renders ct morphologic evaluation responsible for late discovery of local tumour progression. pet/ct is able to discover incomplete ablation earlier than ct at a stage the disease remains small. patients who have very early evaluation with pet/ct are at risk of either false-positive result due to early inflammation process, or false-negative result due to early inflammation masking active tumor foci. 3 or 6 months after ablation can be a reasonable time for pet/ct. learning objectives: 1. to consolidate knowledge on the imaging aspects of successful ablation. 2. to become familiar with the main pitfalls of post-ablation imaging. 3 . to learn about the imaging aspects of most common complications. a-503 17:00 c. follow-up imaging of thermal ablative therapies for kidney tumours d.j. breen; southampton/uk (david.breen@uhs.nhs.uk) image-guided ablation of kidney tumours has been increasingly set to become the standard of care treatment for smaller (< 5 cm) renal tumours, yet ablation remains a non-extirpative technique and is therefore paramount, in this curative setting, that imaging follow-up should reliably confirm complete tumour eradication. early on in radiofrequency ablation (rfa), control remained problematic and inadequate treatment was evidenced by residual marginal crescents of viable, enhancing disease. in the current era of more definitive ablation with multipolar techniques, cryo-and microwave ablation (mwa), this pattern of treatment failure should rarely, if ever, be encountered. typically following adequate ablation imaging should confirm a completely nonenhancing tumour and a related cortical ablation zone. whilst nonenhancement is an accepted surrogate of tumour non-viability, most practitioners look for additional collateral features such as the 'halo' sign, appearing as a soft tissue ring in the adjacent peri-renal fat, usually a sound marker of complete tumour eradication. follow-up data have shown that cryoablation (cra) can yield robust outcomes, but often incurs notable haemorrhagic change and a 'rind-like' feature around the ablation zone. cra also appears to induce faster involution of the treated tumour, whereas rfa and mwa can induce a persistent granulomatous mass which only very slowly involutes over a number of years. late local recurrence is increasingly rare at around 2-3%, but can occur as nodules of enhancing disease as late as 3-6 years after the initial treatment. subtraction mr can be useful, but to date pet and perfusion techniques still lack resolution and specificity. multiple percutaneous image-guided therapies are currently available for thermal ablation of bone tumours. thermal sources for these treatment modalities include high-intensity ultrasound, laser, microwave, radiofrequency, and cryotherapy. the predictability of thermal ablation is adequate to limit collateral damage and complications, however, is limited by biologic and anatomic variability of tissue. clinical evaluation is essential in symptomatic tumours. close imaging follow-up with ct, mri, bone scan, and pet plays a vital role in the management of the post-thermal ablation patient and detection of complications. recurrences or regrowth can be considered for repeated thermal ablation if the lesion is discovered early, before the tumour geometry, location, or distribution become unfavourable. the imaging features could vary with the different ablation method. the radiologist reporting the follow-up imaging should be familiar with different ablation methods. mri with dynamic contrast enhanced imaging and subtraction allows to detect recurrences in hypervascular tumour. contrast enhancement on t1-weighted mri imaging seems to be predictive of clinically unsuccessful ablation. on ct scan, bone reconstruction can be visualised but is a slow process, particularly in adults. pet scan is an excellent morphologic and metabolic image to follow-up the tumours. however, the inflammation produce after ablation can be misleading, particularly during the first three months. imaging follow-up plays an essential role in the management of the post-thermal ablation patient and detection of complications. interventional radiology (ir) is an evolution of radiology that treats many diseases, originally treated by traditional surgery. the clinical importance of ir has been demonstrated over the years by performing procedures that offer the benefit of therapeutic treatments, competitive from the point of view of a shorter hospitalisation time. indeed, thanks to ir, patients are treated in a less invasive manner, hospitalisation is limited and thus promotes the containment of social costs. to maintain standards clinical oversight needs to focus upon correct organisational, functional and technological appropriateness of practice. to achieve correct ir performance, it is necessary to guarantee that all the instrumental guides (fluoroscopy, ultrasound, computed tomography equipment) function optimally, the procedural equipment including guides/catheters/stents, etc. are chosen according to their technical features and their characteristics are appropriate for use, incorporating cost considerations. as the complexity and variety of interventional procedures grow, there is an increasing need to ensure the appropriate training of specialised ir staff. consideration of dedicated education and continued professional development options for radiographers working in ir is of priority. the italian association of interventional radiographers (aitri) is very important in sharing guidelines in a multidisciplinary environment to standardise and harmonise the knowledge and skills of the team in hybrid theatre and interventional suites. interventional radiology technology is rapidly expanding and, to maintain safe and efficient practice, careful consideration of current and potential future organisational needs and the training of staff within an ir suite require detailed consideration. the lecture will discuss where new and current knowledge about radiation risk and effects are coming from. a brief overview of the different sources of knowledge, including hiroshima and nagasaki life span study, will be given. the most important stakeholders involved in research and formulating guidelines for radiation protection, with special emphasis on the new main publication from the international committee on radiological protection (icrp), and the impact on radiographic practice will be discussed. new tissue weighting factors for breast glandule gives a significant higher risk for females today, especially in the pubertal age. on the other hand, they have the risk for hereditary effects significantly decreased. estimation of risk, both in general and in the individual, will be discussed. regarding staff protection, there is a new recommendation for annual dose limit for the eye lens. the previous annual dose limit was 150 msv, and this is now recommended to be decreased to 20 msv averaged over five years with no single year exceeding 50 msv. the new recommendation can be a limiting factor in interventional radiology and cardiology, if sufficient protection is not used. learning objectives: 1. to understand the importance of radiation protection in interventional radiology for patients and staff. 2. to appreciate the latest recommendations for staff radiation protection in interventional radiology. 3. to appreciate the important role of the interventional radiographer in radiation protection. a-506 17:00 the improvement of patient care and aims for the highest possible levels of service are to the forefront of the modern "interventional suite". role development experiences will be explored, considering need, effect and management of development. service demands, the need to extend those provided, the limited number of radiologists, financial constraints and the requirement for continuous professional development at state level provide much stimulus for professional radiographic role development. increased job satisfaction, reduced waiting lists and improved patient experience all provide largely positive results it appears. resistance from radiologists, multidisciplinary team members and radiographers themselves however, can provide unnecessary barriers to change. once abridged the blurring of professional lines and insecurity within multidisciplinary team members may also occur. various experiences would suggest that only by allowing ownership of change by all the clinical stakeholders involved, thus empowering them, leads to successful development. on examination clear guidelines and distinct protocols must be established, taking account of current workload, to create the ideal scenario for good multidisciplinary team ethos, where members have overlapping yet clearly defined roles. professional accountability, responsibility and an understanding of those role's are all key, but without correct training, including support and resources, no regime for role development can be achieved successfully. clinical audit not only ensures the delivery of high quality and effective care in line with best practice, whilst ensuring cost effectiveness, but also provides the confidence for all involved, especially the interventional patient. learning objectives: 1. to understand the factors influencing change in professional roles within interventional radiology. 2. to learn about the potential impact of enhanced professional roles and a multidisciplinary team approach on service delivery and patient outcomes. 3. to understand the need for clear protocols and guidelines along with appropriate training and audit of practice when implementing such changes. there have been many attempts to develop gene reporters for mri, however these give relatively modest image contrast that can be difficult to detect. i will describe in this talk a reporter that gives intense and positive contrast in mr images (up to ~8x increase in signal), which can also be used with radionuclide imaging, thus combining the sensitivity of radionuclide imaging with the spatial resolution of mri. the contrast obtained is directly related to the degree of gene expression and is readily reversible, thus allowing longitudinal studies of changes in expression. the transplantation of pancreatic islet into the liver is an excellent example of successful cell therapy. transplanted islet visualisation in vivo using a noninvasive imaging method, for example mri, is necessary to prove technical success. monitoring of transplanted islets in vivo and long-term tracking their fate using mri requires their labelling by a suitable contrast agent in vitro prior to transplantation. under encite project we successfully performed animal experiments, which proved therapy potential of labelled pancreatic islets. labelled islets implanted into the rat liver were viable and induced long-term normoglycemia in diabetic rats. mri proved their viability and even distribution in the host tissue. these results allowed performing a clinical study on a group of 12 patients, which were transplanted by iron labelled pancreatic islets from cadaver donors. the successful pilot experiment enabled introducing of transplantation of native islets into routine clinical practice. search for better alternative sites, improved immunosuppression and alternative insulinproducing cells require multimodal and multifunctional molecular probes. currently we test polymer meshes as artificial transplant sites, effect of mesenchymal stem cells as a supportive net for beta cells, and novel cellular probes combing 1h, 19 f labels and fluorescent ones. optical imaging in the clinic j. dijkstra; leiden/nl (j.dijkstra@lumc.nl) recently a lot of developments have been done in the field of optical imaging. new sensitive devices made it possible to use both visible and near infrared light as diagnostic tool and guidance tool. the advantage of near infrared is that the penetration depth in tissue is much better than for visible light, allowing to see deeper. by using techniques like augmented reality, the data from infrared, both anatomical and functional, can be presented to the operator in real-time. optical imaging is used e.g. as an evaluation tools for mammography where the optical spectral properties of the tumor cells is used to monitor the effectiveness of chemo treatment. the spectral properties of the breast are measured using a laser at different wavelengths and a camera to create tomographically a 3d volume. dedicated near infrared probes which bind to certain tissue types make it possible to look for e.g. remaining tumor tissue in resection margins during surgery. this techniques also allow to visualise structures which should be avoided during procedures like nerves. by adding multispectral imaging, the endogenous contrast can be used. different tissues have their own absorption spectrum which can be shown as additional information, for instance the ration hb/hbo2. optical imaging also allows for acquiring images at near microscopic resolution real time in-vivo by using optical coherence tomography. this modality is being tested to provide information about the presence of certain cell types very fast where otherwise histology is needed. mesenchymal stem cells constructs for image-guided cell therapy in myocardial ischemia and digestive fistulas o. clã©ment, e. blondiaux, g. rahmi, l. pidial, a. silva, f. gazeau, c. wilhelm, g. autret; paris/fr (olivier.clement@inserm.fr) regenerative medicine has recently emerged as a potential therapeutic tool. a number of preclinical and clinical trials have been conducted in many diseases ranging from diabetes to myocardial infarction and neuro-regenerative diseases that assess the feasibility and benefits of injecting stem cells. however, outcomes relating to graft survival remain generally unsatisfactory, whether the process of injection is direct, intravenous or catheter-guided. to overcome such issues, tissue engineering has potential to improve cell engraftment and therapeutic response including functional parameters. this work aimed to evaluate mesenchymal stem cell constructs for image-guided cell therapy in myocardial ischemia and digestive fistulas. we tried to options: 1. fibrin patches based on fibrinogen monomers polymerised with thrombin and seeded with cells. 2. constructs based on 3d multilayers of confluent cells sheets. tissue constructs were labelled with iron oxide particles and evaluated in a model a myocardial infarction for the fibrin patches or digestive fistula for the 3d constructs. mri at 4.7 was performed at various time points after treatments using a high resolution coil. fibrin patches could induce a therapeutic effect by increasing the left ventricular ejection fraction compared to sham. 3d constructs induced an increased number of fistula healing and enhanced micro-vasculature density compared to controls. mri of labelled stem cell constructs allowed a good evaluation of the models and showed increased therapeutic efficacy. the proposed paracrine mechanisms will be discussed. is cell imaging relevant for the clinic? lessons to be learned from preclinical research u. himmelreich; leuven/be (uwe.himmelreich@med.kuleuven.be) non-invasive imaging of therapeutic cells has become a popular field of research over the last decade. this interest was mainly based on the hope that the location, migration but also function of immune, stem and other cells can be visualised over time in individuals. the development of novel contrast agents and mechanisms for mri but also other imaging methods has resulted in exciting basic research findings. in particular, the application of relatively biotolerant iron oxide based nanoparticles has fostered the hope for direct translation into clinical research and general practice. however, pre-clinical research has also highlighted several limitations of nanoparticle based cell imaging by using mri including the generation of unspecific contrast, difficulties to quantitatively image engrafted cells, unambiguous contrast, adverse effects on cell biology, limitations for longitudinal follow-up or the lack of functional information. such shortcomings are traditionally overcome in preclinical research by combining mri with other imaging modalities like bioluminescence imaging or positron emission tomography. our research focuses on the optimisation of cell labeling strategies for robust, sensitive and potentially quantitative visualisation of stem and progenitor cells in therapy models in vivo to assess cell behavior after engraftment. the sensitivity, stability, toxicity and adverse effects on the cell biology by the labeling procedure were studied for iron oxide based particles. the potential of gdchelates and 19 f labeled compounds for cell labeling has been assessed in vitro and in vivo. based on our preclinical research finding the potential of future applications in patients will be explored. cardiac ct is becoming the imaging modality of choice for an increasing number of clinical indications, not only to rule out coronary artery disease but also to evaluate cardiac morphology and function, and to determine patient outcome after coronary artery revascularisation. however, as with any other imaging tools, appropriate interpretation of cardiac ct examinations is required to assess the clinical value of this newly established diagnostic imaging modality. this process requires performance of thorough cardiac ct acquisition protocols, detailed knowledge of standard cardiac anatomic and physiologic terminology, as well as appropriate postprocessing, reading and reporting. in particular, radiologists need to recognise and be aware of the imaging findings that may confound and lead to interpretation errors. this lecture will summarise the practical aspects of postprocessing, reading and reporting of non-invasive cardiac ct examinations. the value and limitations of every available ct postprocessing technique including two-dimensional multiplanar reformations, curved multiplanar reformats, maximum intensity projection (mip) and volume rendered images will be explained. moreover, hints for improving reading results by recognising technical causes for various artefacts in cardiac ct will be elucidated and reading approaches to diminish false positives, false negatives and inaccuracies when assessing coronary artery stenosis will be suggested. cardiac magnetic resonance (cmr) is a complex imaging technique due to the intrinsic anatomical and technical peculiarities of the exam. these include the non-orthogonal cardiac orientation within the chest cavity requiring dedicated acquisition planes and the complex respiratory and cardiac motion to which the heart is subject and requiring a combination of ecg-gated and breath-hold sequences. potential additional anatomical pitfalls also include normal structures and variants like the moderator band, papillary muscles, and the presence of prominent crista terminalis or myocardial trabeculations, whose recognition is mandatory and may mimic in some cases a pathological condition. technical issues of cmr concern the continuous intracavitary inflow of protons and the associated "slow-flow" artifacts (limiting visualisation of endomyocardial border in some cases) pitfalls related to ecg gating, like inadequate synchronisation or the t-wave swell phenomenon; and finally a series of specific artifacts intrinsically related to the use of different pulse sequences that may interfere with image quality. an additional, more complex issue to consider is also the widespread diffusion of high-field magnets which have further enhanced those aspects. knowledge of the spectrum of those cmr peculiarities is mandatory to approaching and providing a correct diagnosis according to the main clinical request. the present lecture will review the most important anatomical and technical pitfalls of cmr examination and offer, when possible, practical solutions to overcome those limitations. shoulder imaging and intervention are becoming increasingly important in clinical practice. this session considers the indications, techniques, imaging findings and relative merits of diagnostic ultrasound and mri of the shoulder. the indications, techniques and results of us-guided interventional procedures are also considered. a panel discussion will deal with controversies in shoulder imaging such as the accuracy of us and mri in assessing rotator cuff tears, tendinosis, impingement and muscle atrophy, and the efficacy of us-guided interventions. audience participation in the discussion will be welcome. the shoulder is an anatomic area that is very commonly evaluated with musculoskeletal ultrasound. ultrasonography is widely recognised as a reliable means of assessing rotator cuff disease with accuracies reaching 100% for fullthickness tears and 90-95 % for partial-thickness tears. diagnostic accuracy depends mostly on the skills and experience of the examiner. a comprehensive ultrasound (us) examination requires, first of all, sound knowledge of the anatomy. a specific scanning protocol must be adopted in every us examination in patients with shoulder disease, because focal symptoms do not correlate with the location of the disease. the greatest importance of ultrasonography in rotator cuff assessment lies in its dynamic character. several dynamic manoeuvres can reveal pathologies such as subacromial impingement. last, but not least there are several scanning pitfalls such as anisotropy. anatomy key structures as well as the us technique and scanning protocol will be presented in this lecture. dynamic manoeuvres will be described and demonstrated with videos. scanning pitfalls will be emphasised. advantages and disadvantages of the us examination compared to other imaging modalities will be discussed. guidelines concerning the mr examination technique of the rotator cuff will be presented in this session. on intermediate-weighted mr images, tendinopathy and partial and complete tears of the rotator can be differentiated with high diagnostic accuracy. indications for mr arthrography, especially for the detection of small articular sided partial tears in athletes, will be presented as well. established classification systems for the description of rotator cuff tears will be discussed. besides characterisation of rotator cuff lesions, especially in view of therapeutic decision-making, recognition of the underlying pathomechanism is necessary. therefore, the role of imaging is to detect different structural findings that are suggestive of a possibly underlying impingement syndrome. in primary impingement syndromes imaging abnormalities of the rotator cuff, the overlying bursa and the coracohumeral arch represent the centre of imaging findings. primary extrinsic impingement is caused by structural abnormalities of the coracoacromial arch, whereas secondary extrinsic impingement is related to glenohumeral instability. types of internal impingement (posterosuperior and anterosuperior impingement) are secondary to rotator cuff and/or capsular dysfunction. posterosuperior impingement can be diagnosed on mr arthrograms by identification of the socalled "kissing lesion" pattern, with corresponding lesions of the undersurface of the rotator cuff, posterosuperior labrum, greater tuberosity and superior glenoid. imaging abnormalities of this condition will be discussed. the shoulder is one of the joints in the human body that is most subject to a number of pathologic conditions, both in young and in elderly subjects, such as subacromial-subdeltoid bursitis, calcific tendinopathy, and degenerative conditions. being inexpensive, readily available, and radiation-free, ultrasound is the imaging modality of choice to guide interventional procedures around the shoulder. thanks to its high resolution and multiplanar capabilities, ultrasound can be used to guide needles precisely in the tendons of the rotator cuff or within the joint space, both gleno-humeral and acromio-clavicular. this approach can be used to perform a number of different procedures. when dealing with bursitis, a needle can be guided within the subacromial bursa to aspirate fluid and to inject anti-inflammatory drugs. in case of calcific tendinopathy, one or two needles can be used to dissolve calcium deposit and drain it, providing patients prompt relief. in selected patients with overuse tendinopathy, ultrasound can be used to guide intratendinous injection of platelet-rich plasma that has been reported to be helpful in stimulating tendon healing. although minimally invasive, these procedures should be performed in an ultrasound ward with a high degree of sterility, as risk of infection can be concrete. multi-detector computed tomography (ct) offers new opportunities in the imaging of the gastrointestinal tract. its ability to cover a large volume in a very short scan time, and in a single breath-hold with thin collimation and isotropic voxels, allows the imaging of the entire oesophagus, stomach, and the whole chest and abdomen with high-quality multiplanar reformation and threedimensional reconstruction. preparation of the patients by fasting from solid food approximately 6 hours prior the examination is important. proper distention of the oesophagus and stomach by oral administration of effervescent granules and water, and optimally timed administration of intravenous contrast material are required to detect and characterise the disease. preoperative staging of oesophageal and gastric carcinoma appears to be the main indication for mdct and may replace endoluminal ultrasound (eus) in the staging of advanced cancers. the use of various reconstruction techniques, including virtual gastroscopy (vg) using a volume-rendering (vr) technique, is promising for the detection of early gastric cancer. the application of the texture analysis technique to distinguish between the different types of gastric and esophageal tumors is still evolving. finally, the introduction of fdg pet, in combination with mdct, has resulted in further optimisation of the diagnostic workup of oesophageal cancer, as well as specific types of cases of gastric cancer. by providing morphologic and functional information in the same setting, this technique has come to be the modality of choice, when available. the diagnosis of oesophageal and gastric cancer is usually based on endoscopic findings accompanied by biopsy. however, staging is a matter for diagnostic imaging and is the major determinant of disease management. this should be discussed within a multidisciplinary forum (multidisciplinary team [mdt] meeting) in which the radiologist plays a crucial part. accurate stagingusually based on the tnm staging criteria -is essential and the radiologist's report should reflect this pivotal role. the tnm staging of oesophageal cancer and gastric cancer will be discussed in detail. the phases in staging is essentially a filtering process which seeks to initially exclude distant metastasis and/or advanced local disease, initially by optimally protocolled ct scanning, if ct shows advanced disease, treatment is palliative, but even under these circumstances imaging will help determine the method of palliation. conversely, if ct demonstrates localised disease, 18 f fdg-pet scanning for oesophageal cancer and for selected cases of gastric cancer is indicated. if this, too, shows no nodal or distant metastasis, accurate t staging with eus will help determine whether the patient proceeds directly to surgery or undergoes neo-adjuvant chemo/radiotherapy prior to surgery, or in the case of oesophageal cancer may be suitable for emr. the role of staging laparoscopy in gastric cancer will also be discussed. in summary, the radiologist and nuclear medicine physician are crucial in determining treatment. their reports are lynch pins in the mdt discussion of patient management. it is therefore essential that the imaging report should optimally inform this discussion. learning objectives: 1. to learn about the latest tmn staging in oesophageal and gastric cancer. 2. to appreciate the imaging criteria for local, nodal and metastatic disease, and understand the accuracy of imaging staging. 3. to become familiar with the structure of a perfect imaging report. a-520 09:10 c. assessment after treatment a.m. riddell; london/uk (angela. riddell@rmh.nhs.uk) it is now established that for the majority of patients with oesophageal and advanced gastric cancer, there is survival benefit from the use of neoadjuvant therapy. therefore, there is a requirement for imaging to accurately restage the tumour and to assess the response to neoadjuvant therapy, to provide prognostic information and to direct future management. restaging following therapy is challenging, as differentiating treatment-related fibrosis/oedema from viable tumour is problematic with both ct and endoscopic ultrasound. the t and n staging accuracy for both modalities falls following neoadjuvant therapy. inconsistencies in measurements due to alterations in the degree of gastric/oesophageal distension can also limit the accuracy of recist criteria to determine the response. functional imaging techniques such as pet-ct offer an improved method for assessing response. alterations in the standardised uptake value (suv) occur much earlier than changes in size; therefore a metabolic response can be detected sooner, allowing for more rapid alterations in treatment strategies. acute complications following oesophagogastrectomy generally occur within the thorax and are either related to a leak at the anastomosis/mediastinitis or respiratory complications such as pneumonia or a pleural effusion. intra-abdominal collections may develop following oesophagogastrectomy and gastrectomy. late complications following both procedures are often due to tumour recurrence: locoregional such as lymph node recurrence or at the anastomosis; metastatic spread such as haematogenous spread or via the peritoneum or pleura. currently, there is no consensus on the most appropriate timing or frequency of postoperative imaging. a. an overview of pulmonary artery hypertension n.j. screaton; cambridge/uk (nicholas.screaton@papworth.nhs.uk) pulmonary hypertension is defined by increased mean pulmonary arterial pressure > 25 mmhg at rest or > 30 mmhg during exercise. ph causes significant mortality and morbidity, but commonly presents with non-specific clinical signs and symptoms resulting in significant delay in accurate diagnosis and specific treatment. untreated ph is progressive with increased pulmonary vascular resistance leading to right ventricular failure and ultimately death. the current dana point classification of pulmonary hypertension is clinically based. it groups diseases with similar pathophysiological mechanisms and therapeutic approaches. groupings include conditions characterised by diffuse small vessel narrowing (group 1 and group 1'), ph secondary to left sided cardiac disease (group 2), chronic hypoxic pleuro-parenchymal disease (group 3), chronic thrombo-embolic pulmonary hypertension cteph (group 4), and a miscellaneous group of diseases with either unclear or multi-factorial aetiologies (group 5). in the dana point classification, small vessel diseases are subdivided into group 1 which primarily affect the pulmonary arterioles and group 1' affecting the capillary/venous pulmonary circulation (pulmonary capillary haemangiomatosis and pulmonary veno-occlusive disease). the differentiation of group 1 from group 1' diseases is important since in group 1' arteriolar dilatation treatments can cause life-threatening pulmonary oedema. group 4 is synonymous with cteph with other causes of large vessel obstruction (vasculitis and pulmonary artery tumour) being considered as group 5 disorders. recent advances include an increased understanding of molecular mechanisms underpinning pah, facilitating targeted therapy development, a rapidly expanding role of surgical pulmonary endarterectomy in proximal cteph, and recognition of imaging as a potential therapeutic end point. ct allows depicting pulmonary hypertension (ph) and helps identifying its cause, therefore playing a crucial role in the diagnostic workup. ct features of pulmonary arterial hypertension include dilatation of the pulmonary artery trunk, with a diameter greater than or equal to 29 mm, a ratio to the aortic diameter greater than 1:1 and a segmental artery-to-bronchus ratio greater than 1:1 in at least three pulmonary lobes. on ecg-gated ct, right pulmonary artery distensibility shows the best diagnostic value with 86% sensitivity and 96% specificity for a cutoff value of 16.5%. among the various causes of secondary ph, ct is especially useful for detecting signs of chronic thromboembolic pulmonary hypertension, including wall-adherent thrombi, bands, webs or chronic arterial occlusion, mosaic lung attenuation and systemic collateral supply. ct shows signs of pulmonary edema, such as thickening of the interlobular septa, centrilobular ground glass opacities, mediastinal lymph node enlargement and pleural effusion in ph caused by pulmonary veno-occlusive disease, left heart diseases or mediastinal fibrosis. signs of lung parenchyma diseases may be indentified on ct; ph is a late complication in patients with pulmonary fibrosis, sarcoidosis or chronic obstructive lung disease, but may affect systemic sclerosis patients with limited lung parenchyma involvement. congenital cardiac abnormalities with untreated right-to-left shunting resulting in eisenmenger syndrome, such as ventricular or atrial septal defect and patent ductus arteriosus are easily recognised on ct. conversely, signs of peripheral pulmonary arteriovenous shunting in portopulmonary hypertension and ph caused by hepatopulmonary syndrome are more difficult to assess. learning objectives: 1. to learn about the ct diagnosis of pulmonary artery hypertension. 2. to become familiar with the causes of pulmonary artery hypertension on ct. a-524 09:30 c. mri in pulmonary artery hypertension j. biederer; heidelberg/ de (juergen.biederer@med.uni-heidelberg.de) for the assessment of pulmonary arterial hypertension (pah), the dedicated 30 min mri protocol would comprise a free breathing and noncontrastenhanced examination, short t2-w sequences, dynamic contrast-enhanced perfusion imaging, a high-resolution angiogram, a 3d breath-hold acquisition, dynamic steady-state free precession or gradient echo sequences of the heart and a study of myocardial late enhancement. the morphologic sequences show typical features of pah: right atrial/ventricular dilatation, enlargement of the pulmonary trunk/main pulmonary arteries and peripherally attenuated pulmonary vessels. incidental infiltrates, nodules or masses of the lung, mediastinum and chest wall would be covered. the first pass contrastenhanced perfusion imaging demonstrates an increased mean transit time/decreased pulmonary blood flow, but a relatively homogeneous lung perfusion (important to differentiate from cteph, where multiple segmental perfusion defects would be expected). the cardiac part shows right ventricular mass, wall thickness and functional changes correlating with elevation of pulmonary arterial pressure: distortion of the interventricular septum, area change of the pulmonary trunk, right ventricular volume/stroke volume as well as pathologic right/left ventricular end-diastolic volume indexes. late enhancement of the right ventricular wall would correlate with myocardial fibrosis. furthermore, optional experimental velocity-encoded sequences (ideally for multidirectional flow visualisation, "4d flow") show a decreased pulmonary artery blood flow velocity, increased retrograde flow and inhomogeneous velocity profiles. in conclusion for the near future, given the availability of scanner time and appropriate experience of the team, thoracic mri is probably the most comprehensive and effective single examination for the diagnosis and follow-up of pah. in the era of organ-based radiology, the group of diseases known as multisystemic malignancies represents an obvious challenge to both radiologists and oncologists. the necessity to match the growing possibilities of different imaging modalities with widespread multisystemic pathology and clinical sufficiency resulted in upgrading well-known diagnostic algorithms. the precise knowledge of clinical staging systems and classification, and the pathologic and physiologic mechanisms of the disease pathways are important for planning imaging modalities and specific protocols. perfect imaging of multisystemic malignancies now includes not only traditional anatomic-based modalities, but also much more often different types of whole body scanning such as ct, mri, pet and their combination in spect/ct, pet/ct and now even pet/mri. new imaging modalities and growing possibilities of traditional imaging techniques obviously influence the current clinical guidelines for this disclosure: c. heussel: consultant boehringer ingelheim, grifols, novartis. a common language between radiologists and clinicians, so that the latter can make an informed treatment decision based on sound conclusions to become familiar with the conditions necessary to implement them to understand the limits of their application to learn useful lessons from these criteria for routine clinical practice chairman's introduction a. palko this requires a thorough knowledge of the relevant brain anatomy, choice of appropriate structural and molecular imaging modalities and interpretation of mri and pet/spect in the most prevalent disorders in a structured fashion the presentation has the objective of giving the audience a synthesised panorama of our country situated in north america, with more than 110 million inhabitants and a large prehispanic history based on the aztec, toltec and maya cultures, and also of interesting facts related to the three centuries of colonial existence under the spain influence and dominium until the 1810 war of independence. after 1880, mexico has never had an international war; the last was against the northern border country, the united states. also, we will give important data on how in 1910 the mexicans rebelled against a 30-year dictator, general porfirio diaz. the mexican revolution was a long and cruel war, but later opened the doors to democracy and a complex developmental era began that is still in process. some demographic and contributions to health, science and culture issues will be mentioned and also the works of mexican scientists, writers and philosophers who have been presented awards including the nobel prize. in relation to well-known mexican artists such as diego rivera and frida khalo, some facts of their works will be presented. interventional radiology in oncologic patients g. elizondo-riojas; monterrey/ mx (elizondoguillermo@hotmail.com) interventional radiology (ir) is becoming an increasingly prominent subspecialty in the care of oncologic patients. its role extends from initial diagnosis to minimally invasive treatment of the malignancy and its complications. image-guided biopsies are increasingly performed using minimally invasive techniques. also, an integral part of care of these patients is vascular access as a means of medication, chemotherapy or parenteral nutrition, and interventional radiologists can place required the devices with well-established safety and efficacy. ir also plays a substantial role in the therapy of oncologic patients, through local tumor treatments such as transarterial chemo-embolisation and locoregional control with radiofrequency/cryo ablation, as well as management of complications of malignancy such as pain, obstruction (biliary, ureteral, etc) ., venous thrombosis and drainage of thoracic and abdominal collections. in mexico, ir is a growing subspecialty, and more medical students nowadays want to be radiologists and eventually become interventional radiologists. this is a paradigm shift. more and more radiologist wants to be involved with patient management and to be more than just "observers" in the process of patient care. we have to be prepared to offer this opportunity to our residents; otherwise other specialties will "have to fill the empty space" that we have left. interventional oncology has all the advantages to fulfil this opportunity. it is our chance to contribute to the advancement of medical care. learning objectives: 1. to appreciate the role of interventional radiology in the management of oncologic patients. 2. to learn how interventional radiology changes the quality of life for patients with cancer. 3. to understand the impact of interventional radiology procedures in the outcome of some neoplastic diseases. interlude: origins and development of radiology in mexico m.e. stoopen-rometti; mexico/mx (mstoopen@clinicalomas.com.mx) mexican radiology started in 1896, just a few months after the discovery of xrays. during the last few decades, as well as in other countries, there has been a great development both in public and private sectors, which will be described in this interlude. learning objectives: 1. to learn about the history of radiology in mexico. 2. to learn about the development of radiology in mexico. 3 . to learn about the present and future of radiology in mexico. modern issues in oncologic ultrasound j. mexico/mx (jtanus59@hotmail.com) advances in ultrasound (us) technology allow confident characterisation of masses. these include harmonic imaging, compound imaging, power doppler, faster frame rates, higher resolution transducers, three-dimensional (3d) us, us contrast agents and, more recently, elastography and fusion imaging. highfrequency transducers provide superb spatial and soft-tissue resolution, permitting substantially improved differentiation of subtle lesion, margin resolution, and lesion conspicuity in the background of normal tissue. elastography features such as size ratios, shape, homogeneity, and maximum lesion stiffness complement conventional us in the analysis of lesions. ultrasound contrast agents have overcome some of the limitations of doppler ultrasound techniques with demonstration of irregular branching central or penetrating vascularity within a solid mass raising suspicion of malignant neovascularity (neoangiogenesis). ultrasound contrast agents can provide important information in the assessment of lesions to be treated by locoregional therapies, which include ablation (feeding vessels), trans-arterial chemo/radio-embolisation, detecting viable tumour persistence following this treatment; facilitation of needle positioning in cases of poor lesion delineation, and assessment of local tumour progression. it facilitates needle positioning in cases of incomplete or poor lesion delineation on unenhanced ultrasound. us contrast agents are an important key during the evaluation of the immediate treatment effect of ablation and guidance for immediate re-treatment of residual tumour. learning objectives: 1. to understand the role of ultrasound in the management of oncology patients. 2. to learn how ultrasound is used in large oncology centers. 3 . to learn about the modern concepts of ultrasound in oncology patients. the aim of this lecture is to give an overview of the techniques for imaging inflammatory bowel disease (ibd) of the small bowel and the colon with either ultrasound (us), multidetector row computed tomography (mdct) or with magnetic resonance imaging (mri) and compare the different modalities for its strength and weakness. optimal imaging of the bowel begins with the preparation phase. the small bowel has to be distended for a concise examination. this is mainly done orally, which is named enterography. a solution of 2.5% mannitol seems to be the one preparation technique mostly used for small bowel distension. another technique is the enteroclysis, application of contrast after intubation of the small bowel. the comparative advatages and disatvantages of the two preparation methods will be discussed. this intraluminal contrast gives a neutral contrast in ct and a biphasic signal in mr. the colon can be prepared in a fashion similar to colonoscopy meaning total cleansing. another possibility is the so called fecal tagging whereas the stool will be contrasted with an additive to standardised food. therefore no cleansing is needed for preparation. imaging parameters will be discussed for mr and ct. the aim of imaging for the bowel should be to establish the following: 1) presence, severity, and extent of disease; 2) activity of the disease and 3) extra-intestinal complications. us, mr and mdct have proven to be a good tool to evaluate the extent, the activity of the disease and the presence of extraluminal complications. pros and cons will be discussed when to use which technique. learning objectives: 1. to understand state-of-the-art mri, ct and us protocols for imaging ibd. 2. to appreciate the comparative advantages and disadvantages of enterography and enteroclysis protocols. 3 . to learn about protocol modifications when evaluating the colon.a-393 10:50 b. small bowel disease j. stoker; amsterdam/nl (j.stoker@amc.uva.nl) classification of small bowel crohn's disease is helpful for assessing disease activity and treatment monitoring. similar to clinically based classification, also imaging-based classification systems have been developed, of which some have been externally validated. important imaging features for determining disease activity include bowel wall thickness and vascularity/enhancement; at mri, also wall oedema plays a role. stenoses, fistulas and abscesses are important sequels. for assessment and monitoring of small bowel disease the breast imaging reporting and data system (bi-radsâ®) for mammography of the american college of radiology (acrâ®) consists of several components, a standardised lexicon of terms to be used during reporting, a 4-step coding system for the mammographic density as a surrogate parameter for the mammographic sensitivity, and a group of assessment categories ranging from 0 to 6 for structured communication regarding the recommended further management. the goal of bi-radsâ® is to improve the quality of breast imaging reporting and communication. in addition, by providing structured reports it facilitates regular quality assurance measures. the bi-radsâ® atlas for mammography is currently in its fourth edition and was released in 2003. the upcoming 5 th edition is expected soon and will be incorporated into the course as it becomes available. the breast imaging reporting and data system (bi-rads) was first developed by the american college of radiology for standardising the reporting of mammography. since its first publication in 1993, new editions have also addressed breast ultrasound (us) and mr imaging examination. the new (fifth) edition will be published soon. on the form, this new version was designed to include a web-based format. substance includes updates in lexicon descriptors, e.g. masses, calcifications, associated features (now comprising surrounding tissue with stiffness assessment), and special cases. us descriptors will be reviewed in the lecture. of note, guidance on how to link bi-rads descriptors with management recommendations has been added in the report section. a new approach to outcome assessment (audit section) is being proposed for screening us. the appropriate use of descriptors is expected to increase the accuracy of imaging interpretation. for relevant patient management, us analysis is to be integrated with other available imaging, as well as with clinical data. learning objectives: 1. to learn about the bi-rads lexicon. 2. to understand the usefulness of bi-rads system. a-434 15:00 c. mri k. pinker-domenig, p.a.t. baltzer; vienna/at (katja.pinker@meduniwien.ac.at) dynamic contrast-enhanced magnetic resonance imaging (dce-mri) of the breast is a well-established non-invasive imaging technique. it has clinical application in the screening of high-risk patients, diagnosis and staging of breast cancer, monitoring neoadjuvant chemotherapy and post-treatment follow-up. to standardise the reporting of dce-mri of the breast and minimise false-positive results without compromising sensitivity, the american college of radiology (acr) introduced the breast imaging-reporting and data system (bi-radsâ®) mri lexicon in 2003. bi-rads relies on the combined analysis of morphological appearance and lesion enhancement kinetics. it is widely used for reporting dce-mri of the breast and is applicable at any given field strength. it aims to provide an up-date report on the bi-radsâ® lexicon and instill confidence in using bi-radsâ® descriptors. the bi-radsâ® system may be placed in a broader clinical context to highlight its value for standardised reporting of dce-mri of the breast. mr-guided focused ultrasound is a new therapeutic modality which can allow selective destruction and or heating of tissues in deep body areas under close image guidance control. these talks will introduce the field and allow you to understand the areas of current work and areas of future development in this rapidly expanding field. session objectives: 1. to become familiar with mr-guided focused ultrasound. 2. to understand the advantages of focused ultrasound. 3. to learn in which areas focused ultrasound is evolving successfully. description of technique c. moonen; utrecht/nl (c.moonen@umcutrecht.nl)high-intensity focused ultrasound (hifu) is the only clinically viable technology that can be used to achieve a local temperature increase deep inside the human body in a non-invasive way. mri guidance of the procedure allows in situ target definition and identification of nearby healthy tissue to be spared. in addition, mri can be used to provide continuous temperature mapping during hifu for spatial and temporal control of the heating procedure and prediction of the final lesion based on the received thermal dose. the primary purpose of the development of mr-guided hifu was to achieve safe non-invasive tissue ablation. the technique has been tested extensively and is now accepted in the clinic for ablation of uterine fibroids. mr-guided hifu for ablation shows conceptual similarities with radiation therapy. however, thermal damage generally shows threshold-like behaviour with necrosis above the critical thermal dose and full recovery below. mr-guided hifu is being clinically evaluated in the cancer field. this presentation will cover the basic technologies for treatment of stationary tissues, and some advances towards treatment of mobile abdominal organs. for state-of-the-art mr liver and pancreatic imaging, a field strength of at least 1.5t is required. all non-blood pool gadolinium chelate-based contrast agents are suitable for dynamic liver and pancreatic mri. all gadolinium chelates should be routinely administered at a rate of 1-2 ml/s followed by a 20 ml saline flush at 1-2 ml/s using a power injector. to obtain hepatobiliary phase imaging in addition to dynamic phase imaging, the use of liver-specific contrast agents is required. gd-eob provides the highest hepatocyte enhancement, but an overlap between delayed phase and hepatocyte phase has to be considered during dynamic evaluation. the hepatocyte phase can be considered adequate when contrast is detected in the intrahepatic bile ducts. hepatobiliary phase imaging benefits from a gradient echo high flip angle, depending on magnet field strength. in the absence of liver function impairment and biliary obstruction, contrast-enhanced mr cholangiography can be obtained with gd-eob at 20-40 minutes, and with gd-bopta at 60-120 minutes. when the differential diagnosis is primarily between solid benign lesion vs. metastasis, the use of a liver-specific ca is recommended, due to the ability to diagnose fnh confidently. the combined interpretation of dynamic and hepatobiliary phase improves diagnostic accuracy of mr imaging for the detection of hcc.hemangiomas and intrahepatic ccc result in relative hypointensity in the late vascular phase after gd-eob administration. when combined with t2weighted mrcp, contrast-enhanced mrc allows morphologic and functional assessment of the biliary system. gastrointestinal stromal tumours (gist) are rare malignant tumours arising within the wall of the gut from the interstitial cells of cajal, which act as pacemaker cells controlling peristalsis. the crude annual incidence of clinically detected gists is approximately 10 cases per million in europe. the median age at diagnosis is approximately 63 years, and 80% of patients are older than 50 years. however, a small number of cases do occur in younger people and children, and these are usually syndromic gists. gists can occur at any site of the gut from the oesophagus to rectum, although they can also arise in the extra-gastrointestinal abdominal and pelvic locations, so-called e-gists. the commonest location is the stomach (55%), followed by the small intestine (35%) and rectum (5%). diagnosis is by biopsy, with spindle cell or epithelioid morphology, and immunohistochemical staining for cd117 (the protein product of the kit gene) and/or dog-1 receptors. approximately, 80% of gists have mutations in the kit gene, 10% have mutations of the pdgfra gene, and the remaining 10% have no mutation (wild-type) or rare gene mutations. early stage disease is managed by surgery, followed by 3 years of adjuvant imatinib (a tyrosine kinase inhibitor with activity against kit and pdgfra receptors) for cases at high risk of relapse. advanced metastatic disease is treated with imatinib, with a median duration of response of approximately 2 years. at disease progression, second-line treatment is with sunitinib, with a median duration of response of approximately 6 months. imaging plays a major role in the detection, characterisation and staging of gastrointestinal tumours (gists). imaging of gists depends on the mode of presentation and the local availability. endoscopic ultrasound and computed tomography (ct) are the most widely used imaging methods. gists have a spectrum of radiological appearances depending on tumour size and site of origin, but often show certain key radiological features. multiphase multidetector row ct is necessary to detect and stage gists and multiplanar imaging is important so as to define the likely organ of origin of the mass, which may be a challenging task. the clinical diagnosis of a gist is based mainly on imaging, as biopsy runs the risk of tumour rupture or seeding of the biopsy tract. in patients with an unresectable primary tumour or metastatic disease at presentation, biopsy confirmation is important before starting medical treatment. ct or/and mri are used to assess primary tumour extension, local invasion and the presence of metastases, with main sites of metastasis being the liver and the omentum. gastrointestinal stromal tumours (gists) are treated with targeted therapy regimes. these treatment strategies are based on the suppression of tumour vasculature using the tyrosine kinase inhibition pathway. drugs like imatinib and sunitinib exhibit specific changes in tumours and metastases that can be detected on cross-sectional imaging. these changes differ significantly from standard treatment effects of cytotoxic chemotherapy. while the latter leads to destruction of tumour cells and thereby to a reduction of tumour size, the former will cause a decrease in vascularity and thereby in attenuation and enhancement of lesions while the size may remain unchanged. radiologists have to be aware of these specific patterns of response to treatment. this presentation will include a review of the choi criteria which have been developed for the assessment of gist lesions under treatment. also, current imaging strategies focusing on time-resolved ct imaging (ct perfusion imaging) will be presented. the aim of this lecture is to provide a practical approach to response imaging in gist patients integrating both existing and novel strategies. radiological response evaluation using anatomical imaging was developed in the 1980s in early phase ii clinical trials. potential new anti-cancer agents were assessed by measuring tumour size before and during therapy and a predetermined reduction in size constituted response. radiological response represents an objective surrogate for patient benefit and was the primary end point in early phase ii studies. if a pre-defined percentage of patients achieved the required response, then the agent proceeded to large phase ii and iii studies where clinical time to progression or progression-free survival comprised the primary end point. between 1980 and 2000, there were extraordinary advances in cross-sectional imaging techniques which became widely available. different imaging techniques were introduced piecemeal with different co-operative groups adding different requirements, so meaningful comparisons from one trial to another could not be made. in 2000, the recist criteria were introduced requiring specific imaging stipulations and a minimum baseline tumour size to unify the different criteria and enable meaningful comparisons from one study to another. further advances continue to be made regarding anatomical and functional imaging. not all anti-cancer agents are cytocidal and many studies now use time to progression or progression-free survival defined by radiological imaging as the primary end point. certain tumour types respond in a unique manner requiring the employment of specific response criteria in these tumour types to adequately demonstrate response. some of these tumour types and their specific response criteria will be discussed. learning objectives: 1. to learn about the role of radiological response evaluation in clinical trials. 2. to understand how radiological response evaluation has evolved and continues to evolve. 3. to understand which response criteria are utilised in specific tumour types. emerging biomarkers for response assessment: pros and cons m.c. roethke; heidelberg/ de (m.roethke@dkfz.de) non-invasive response assessment of new specific anti-cancer therapies is an emerging field of oncologic imaging. in the past few years, large efforts were undertaken to develop new functional biomarkers to enable an earlier diagnosis, improved risk stratification and treatment monitoring of oncological diseases. imaging biomarkers reflect changes in tumour biology, which can be differentiated into certain categories (e.g. cell density, tumour heterogeneity, iron concentration, elastic properties, or cellular receptors). in a first step, alternative qualitative and quantitative imaging biomarkers for the different modalities (mri, ct, pet) are elucidated. for magnetic resonance imaging, new techniques with potential for treatment response monitoring such as diffusion-weighted imaging, susceptibility weighted imaging, and elastography will be assessed. then, quantification of iodine uptake of contrast-enhanced ct as an imaging biomarker will be addressed. novel pet imaging strategies for therapy monitoring will be mentioned with focus on receptor targeting tracers (e.g. psma, dotatoc). furthermore, the role of pet-ct/mri is mentioned to facilitate functional techniques in oncological imaging with imaging biomarkers. the potential clinical use of prior introduced biomarkers is demonstrated for several cancer entities (e.g. hcc, prostate cancer, malign melanoma, multiple myeloma, glioblastoma). advantages and disadvantages of the illustrated imaging biomarkers are discussed during this part of the lecture. the goal is to image the right patient, at the right time, using the right test and with the right interpretation so that patients will be advised on the right therapy. ultimately, the aim is to maximise patient outcomes at an affordable cost. this session will cover the state of the art in ebr, cer, and hta and demonstrate how the results are used in imaging decisions. the application of evidence-based medicine to medical imaging was relatively delayed in comparison to other specialties. radiologists should be aware of the necessity to justify radiological examinations and imaging-based interventional procedures on the basis of the best available evidence. diagnostic tests can be evaluated with studies exploring their value in terms of: 1. technical performance; 2. diagnostic performance; 3. diagnostic impact; 4. therapeutic impact; 5. patient outcome; 6. societal impact. notably, this is a one-way logic chain. while improvement at the upper levels implies improvement at some of the lower levels, the vice versa is not always true (e.g., a better diagnostic performance does not always imply a therapeutic impact or a better patient outcome). moreover, different degrees of recommendations are based on different levels of evidence, with experts' opinion as the lowest level of evidence and meta-analyses of high-quality homogeneous studies and multicentre studies being the best level of evidence. the quality of studies needs to be evaluated in terms of internal and external validity, the former regarding study implementation (protocol violations, reference standard, measurements, and readers' independence), the latter regarding study planning (study design, subjects selection, methods, and statistical analysis). biases influencing the internal validity limit the intrinsic value of study results, while those influencing external validity limit the generalisability of study results to clinical practice. finally, high-quality research must be planned to build the evidence in favour of radiological procedures, especially for new technologies which tend to enter the market without any preliminary demonstration of efficacy. state-of-the-art methods in ebr, cer, and hta relevant to imaging u. siebert; hall i. tirol/at more and more, clinical guideline developers and reimbursement decision makers need to base their work and decisions on solid evidence. this presentation will introduce the key concepts and principles of evidence-based medicine (ebm), comparative effectiveness research (cer), and health technology assessment (hta) and their application to the field of radiology. in particular, it will be discussed which role observational studies, clinical trials, and decision-analytic modeling play in ebr, cer, and hta and when each of these study types is needed to assess imaging technologies. specific topics include the assessment of bias, optimising cutoffs and multiple test strategies, making causal inferences, explicitly weighing benefits, risks and costs, and considering ethical, legal and social implications (elsi). the excitement generated by the discovery of x-rays led to the early adoption of this technology in many hospitals around europe. over the last three decades, the explosion of new medical imaging technologies together with the recognition by clinicians of the value of these for their patients has meant that imaging budgets have increased exponentially. evidence based radiology (ebr) is a relatively new approach designed to inform clinicians of the most appropriate technique to use in a given clinical scenario. the comparative effectiveness research (cer) is used by healthcare systems to develop a strategic approach to rationalise the availability of imaging investigations. the health technology assessment (hta) funding approach is a mechanism to assess new and emerging imaging technologies in a systematic timely manner. the uk has a nationally funded healthcare system which is designed to deliver equitable care for the population free at the point of delivery. the challenge for the uk has been to ensure the highest quality service by delivering the most appropriate technology and care for patients in a timely manner. the national institute for clinical excellence (nice) is an independent body which gives guidance on new drugs and medical devices. this body requires robust scientific evidence on which to base their decisions. to create the evidence base, the imaging studies need to be of a certain standard to be included (consort, stard, etc). an example from oncologic imaging will be used to show how ebr influences daily practice. acute abdomen and abdominal trauma are both emergencies with potential fatal sequela when under/ misdiagnosed. imaging plays a crucial role in the diagnosis and management. us is the imaging technique of choice in most cases, as it is rapid, portable, lacks radiation and there is no need for sedation in young infants. us accuracy can be enhanced by iv contrast agents administration. however, limitations may occur in obese children, in deep structures, or because of gas filled bowel loops. on the other hand, ct provides excellent visualisation without limitations by obesity, gas, or deep lesions. however, there is always the radiation exposure risk of the radiosensitive paediatric patient, while sedation is required in non co-operative young children. the aim of this session is to understand "which" is the modality of choice and "why", for the most common paediatric abdominal emergencies. the acute abdomen: ct is the answer a. paterson; belfast/uk (anniezunz@gmail.com)abdominal pain is a common symptom in children, and whilst the majority will have a self-limiting condition, in some the pain may indicate an acute medical or surgical condition that requires prompt investigation and treatment. in the paediatric setting, the primary imaging modality for those with an acute abdomen is ultrasound. however, there are certain patient groups -often older children or adolescents -in whom ct plays an important role. it is well acknowledged that ct is non-operator dependent: an important factor for children presenting to emergency departments outside children's hospitals. the speed of a ct exam is valuable in the acute setting, as is the capability to obtain images without having to touch the tender abdomen of a distressed child. ct offers a global perspective of the abdomen, and image quality is not hindered by the presence of excessive bowel gas, an abnormal body habitus only porotic fragility fractures, but also of primary and secondary spine tumours such as traumatic fractures. a wide variety of lesions in and around the orbita can impair eye movement. ct and mr imaging is frequently used to confirm or exclude lesions in and around the orbit in patients with impaired eye movement. first of all, it is very important to know the exact clinical history of the patients. ct is excellent for confirming a mass; however mri is more sensitive and arrives often at a single most likely diagnosis. characteristic imaging features may help distinguish among lesions that have overlapping clinical presentations. this review focuses on some of the common orbital masses. in this lecture common benign and malignant lesions will be discussed. vascular lesions include capillary (infantile) haemangioma, cavernous haemangioma, and lymphangioma. benign tumours include optic nerve sheath meningioma, schwannoma, and neurofibroma. malignancies that are reviewed include: lymphoma, metastasis, rhabdomyosarcoma, and optic glioma. in addition, benign and malignant lesions affecting the eye movement from outside of the orbit (e.g. from the paranasal sinuses, nasopharynx and skull base) will be discussed. trigeminal neuralgia is a unique form of facial pain, defined by the international association for the study of pain as a sudden, unilateral, brief, stabbing, recurrent pain in the distribution of one or more trigeminal nerve branches, triggered by a specific event. additional diagnostic criteria of the international headache society include paroxysmal, stereotypic pain attacks and absence of associated neurological deficits. it is due to trigeminal nerve compression at the root entry zone, a transitional zone between central and peripheral myelination, where the myelin sheath is thinner and more prone to compression and electrical stimulation. the most common cause is vascular compression, by aberrant loops of the sca, aica, pica or vertebro-basilar dolichoectasia, leading to a neurovascular conflict. small size of the prepontine and cpa cisterns has been identified as a predisposing factor. occasionally, expansile lesions of the skull base or cns compress the root entry zone and lead to atypical trigeminal neuralgia. mr imaging is the modality of choice to evaluate these patients and requires specific tailored protocols to depict its causes, including 3d heavily t2w images reconstructed in the three planes and an angiographic sequence for the depiction of neurovascular conflicts. as neurovascular contacts are quite common in the general population, strict imaging criteria for the diagnosis of nvc have emerged. the offending vessel needs to cross the nerve perpendicularly and deviate or indent its course at the rez. a pictorial review of the most common causes of trigeminal neuralgia and trigeminal neuropathy will be presented. learning objectives: 1. to understand the causes of trigeminal neuralgia and its clinical symptoms. 2. to learn about the relevant anatomy and appropriate imaging methods. 3. to become familiar with the relevant radiological images, differential diagnosis and limitations of the method. c. facing problems of the face: facial pain, tics and palsy b. verbist; leiden/nl (b.m.verbist@lumc.nl) facial impairments may be due to neuropathies of the trigeminal and facial nerve. this lecture will focus on the seventh cranial nerve. this nerve is a complex, mixed nerve with motor fibres, parasympathetic fibres, sensory fibres to the external auditory canal and special sensory (taste) fibres to the tongue. the most common presentation of facial nerve dysfunction is facial palsy. the paresis or paralysis of facial muscles may be caused by several conditions such as developmental abnormalities, infectious or inflammatory disease or tumoural lesions. other presentations of facial nerve dysfunction are facial tics or hemifacial spasm and pain. the indications for imaging, choice of imaging modality and possible imaging findings in case of facial palsy, facial tics and facial nerve-related pain will be discussed. in this presentation, the procedures used to create the standard will be reviewed and some of the most recent changes discussed. as a collaboration of professional societies and companies, integrating the healthcare enterprise (ihe, www.ihe.net) seeks to establish methods wherein health computer systems can communicate to achieve specific functional objectives. these involve development of methodologies to implement standards such as dicom, hl7, etc. in this presentation, the procedures used to create the ihe profiles will be reviewed. patient dose tracking is rapidly growing in the usa as a large number of commercial products are available in response to user demand. these products leverage the work that has gone into the development of the dicom dose structured report and the proliferation of digital imaging systems. medical physicists are crucial team members as they are most capable of performing patient dose measurements and calculations. noteworthy is that the 'toolbox' of the medical physicist is expanding. informatics with patient dose tracking tools invariably includes familiarity at some detail with dicom structure and tags, dose structured reports (sr), sr readers, ris content and orders, modality work list broker content, modality (imaging) specific content as well as pacs, archive rules for storage/retrieval and emr. patient-specific information and the highly detailed specifics of the individual dose prescription are necessary for advanced estimates of information. a dose tracking system (a qa tool outside of the normal imaging device that uses content provided by dose sr and other information systems) usually strives to elevate the quality of the dose estimate, using informatics tools such as patient and organ models, dosimetry engines, and predictive statistics. general use cases for dose tracking will be presented including advanced dose estimations for individual patient exams and qa review for both ct and fluoroscopy. examples of tracking of prescriptions by patient, protocol/procedure and operator for determination of patient dose history, 'outliers', continuous improvement (using dmaic tools) or for meeting regulatory or accrediting bodies will be included. with the introduction of digital radiology, it is possible to have automatic systems to collect and archive patient dose data individually, in addition to demographic, geometric, and other procedural parameters, as part of the dicom header or through other dicom services. these automatic systems mean significant benefits for patient dosimetry and quality control. different approaches were used, depending on the availability and level of implementation of the dicom standard, including extracting the technical information from the headers, using the radiation dose structured reports (which contain accumulated dose over several irradiation events), analysing the mpps messages sent by the modalities to the radiology information system, and implementing optical character recognition techniques on saved screen images. before issuing a formal patient dose report, the medical physicists should verify and correct all patient dose data. all these approaches allow managing more information and provide better capacity to audit the full imaging procedure and to help with the optimisation. the current level of technology allows doing so at a reasonable cost and with a great benefit for the clinical practice. automatic detection of abnormal patient doses or mistakes in the technical parameters used and their prompt correction is possible. diagnostic reference levels will be effortlessly reviewed with such systems. some examples of pitfalls and possible optimisation actions will be presented. pathology. finally, the perfect assessment of clinical course of the disease and possible outcomes, the understanding of tumor response criteria and therapyinduced changes are significant for image interpretation in patients with multisystemic malignancies. multiple myeloma is a haematologic disorder characterised by the infiltration and proliferation of monoclonal plasma cells mainly in the bone marrow. the main symptoms are hypercalcaemia, renal impairment, cytopaenia/anaemia and bone disease -summarised as crab-criteria. symptomatic multiple myeloma is consistently preceded by asymptomatic premalignant stages called monoclonal gammopathy of undetermined significance and smoldering multiple myeloma. these stages also present with detectable monoclonal protein and/or monoclonal plasma cells in bone marrow, but do not show any end organ impairment. staging of multiple myeloma is based on the measurement of the monoclonal protein in serum and urine as well as the assessment of impairment of haematopoiesis, renal function and mineralised bone. in the last decade, the development of novel therapeutic agents has led to an increase in response rates and survival time of patients with multiple myeloma, which further stresses the value of response assessment by imaging. cross-sectional imaging like mri, ct and pet-ct is currently replacing conventional radiological surveys in the initial workup and follow-up of patients with monoclonal plasma cell diseases. recent studies demonstrate the added value of mri in improving initial staging by unravelling a diffuse infiltration of bone marrow by plasma cells, a focal pattern or a combination of both. also, pet-ct can detect response to therapy earlier than conventional response criteria. furthermore, recent studies revealed that a complete remission of myeloma confirmed by mri or pet-ct goes along with a better prognosis compared to a complete response based only on serological parameters. learning objectives:1. to learn about the role of clinical staging systems and imaging in work-up and classification of plasma cell disorders with a focus on multiple myeloma and to learn about parameters of disease activity. 2. to understand the pathophysiologic mechanisms of multiple myeloma and to learn about the effects of abnormal plasma cells on bone remodeling cells.3. to become familiar with response criteria and therapy-induced changes and to compare the significance of imaging and serological markers for response evaluation in multiple myeloma. 4. to learn about recent studies on imaging based response assessment and prognostic significance.a-527 08:58over the last 40 years, there have been numerous efforts to classify lymphoid malignancies, culminating in the who classification introduced in 2008. so it is clear that malignant lymphomas require a sophisticated diagnostic approach based on clinical features, morphology, immunophenotyping and genetic analysis. it is essential that such an approach underpins the clinical management of these diseases, many of which are amenable to cure. the same situation is present in radiology staging procedures -it has a multidisciplinary approach. a wide range of staging procedures can include all radiology methods from cxr and chest and abdominopelvic computed tomograph to whole body mri, scintigraphy and pet-ct scans. lesions of the regional lymph node system. distant spread of mm is thought to transpire intra-and extravascularly (along the external vessel lattices) supported by specific mechanisms of extravasation and protection of mm cells against the local immune system. to date, many imaging methods, such as ultrasound, computed tomography (ct), magnetic resonance imaging, and positron emission tomography/ct, are used in the diagnosis of mm and its metastases, whereas lymphoscintigraphy has become an important tool for workup of the lymph node drainage patterns. radiological challenges include improved staging and re-staging of multi-systemic mm. accordingly, current imaging guidelines and the role and applications of the different imaging modalities in advanced mm (stage iii / iv) are reviewed with regard to their usefulness in patient management. however, standardised imaging protocols and integration of functional information to morphological imaging are needed in the future to allow for improved detection and guidance of treatment in patients with mm. the original atlanta classification of acute pancreatitis established in 1992 is outdated. in 2012, an international working group has modified the atlanta classification for acute pancreatitis to update the terminology and provide new morphologic classifications.the revised classification of acute pancreatitis identified two phases of the disease: early (first week) and late (after the first week). acute pancreatitis is subdivided into two types: interstitial oedematous pancreatitis and necrotising pancreatitis. if the diagnosis of acute pancreatitis is established by abdominal pain and by increases in the serum pancreatic enzyme activities, a contrast-enhanced ct is not usually required for diagnosis in the early phase. this revised classification introduces new terminology for pancreatic fluid collections. depending on the presence or absence of necrosis, acute collections in the first 4 weeks are called acute necrotic collections or acute peripancreatic fluid collections. once an enhancing capsule develops, persistent acute peripancreatic fluid collections are referred to as pseudocysts and acute necrotic collections, as walled-off necroses. all can be sterile or infected. this classification of acute pancreatitis allows a consistent, worldwide classification and should avoid confusion in the terminology of pancreatic fluid collections. the role of diagnostic imaging in chronic and inflammatory pancreatitis and ipmns is to detect structural changes of the ducts and of pancreatic parenchyma, assess the functional integrity of the gland, detect associated complications, and assist in management. these goals are generally fully achieved using mdct and mr imaging. in this lecture, the advantages and limitations of each technique will be discussed and illustrated. key features allowing differential diagnosis of both entities will be underlined. autoimmune pancreatitis (aip) was first described in 1961 and represents a rare form of immune mediated chronic pancreatitis which is characterised by a marked infiltration of lymphocytes and plasma cells into pancreatic tissue. whilst the majority of cases present with diffuse gland involvement, approximately 30% of patients demonstrate either segmental or focal involvement of the pancreas. clinical presentation is very variable with patients describing a range of symptoms; severe pain however is uncommon. imaging plays a central role in the diagnosis and management of aip and knowledge of the radiological appearances, which can vary significantly due to the various degrees of fibrosis and inflammatory infiltrate, is critical. cardinal features include focal or diffuse pancreatic enlargement with the loss of normal lobular architecture. in addition, pancreatic duct involvement as demonstrated by single or multiple focal strictures with limited more proximal dilatation is common. whilst these appearances may suggest a diagnosis of aip correlation with clinical history, serology and histopathology is mandatory to accurately diagnose atypical cases. in contrast, paraduodenal pancreatitis is a specific and rare form of segmental chronic inflammation characterised by fibrous tissue formation in the "groove" area between the duodenum, head of pancreas and lower common bile duct. the pathology was first described in 1973 and has since been subdivided into pure, segmental and non-segmental forms. whilst the radiological diagnosis of both aip and paraduodenal pancreatitis remains challenging, the presentation will emphasise relevant imaging strategies as well as provide tips and tricks for accurate diagnosis. bone scintigraphy is often used in combination with ct and clinical information for staging and therapy response evaluation of bone metastases. magnetic resonance (mr) imaging is a technique that is known to be valuable both for detection of bone metastases and for evaluation of their response to treatment. integrated positron emission tomography with computed tomography (pet/ct) combines the functional data from pet with anatomic information of ct in a single examination. 18 f-fluoride is a non-specific pet tracer that has recently shown very high sensitivity for bone metastases. for accurate response evaluation, it is important to recognise not only changes in bone metastases, but also the effects of treatment on unaffected, normal parts of the bone marrow. these latter therapy-related benign changes could otherwise be misinterpreted as disseminated disease or vice versa. despite the fact that the methods mentioned above, alone or in combination, have improved the assessment of bone metastases, they often remain non-specific. a specific diagnosis can in many cases only be achieved with a bone biopsy. this refresher course will give you an overview of the present imaging methods for detection and characterisation of bone lesions. indications for, and how to perform, ablation and cementoplasty of bone metastases will be presented. optimal algorithms for treatment follow-up of bone metastases and advantages and disadvantages with different imaging methods will be reviewed. also, future development of diagnostic and therapeutic methods will be included in the presentations, e.g. potential role of emerging pet imaging probes for assessing bone malignancies. author disclosure: h. ahlstrã¶m: research/grant support; astrazeneca. a. diagnostic approach: the role of hybrid imaging k. herrmann; wã¼rzburg/ this presentation will include a short review of the epidemiology of primary and metastatic bone disease, its classification and staging definitions. then we discuss the role of radionuclide imaging in initial and subsequent treatment strategy considerations. another aim is to provide guidelines for the appropriate use and applications of diagnostic radionuclide approaches for the assessment of bone diseases. the focus of this presentation will be on the role of radionuclide imaging in metastatic prostate, breast and lung cancer in the context of other available diagnostic imaging approaches. the ability of hybrid imaging technologies to achieve improved diagnostic accuracy will be emphasised and when appropriate the potential role of emerging pet imaging probes for assessing bone malignancies discussed. if feasible, the availability and effectiveness of radionuclide-based therapeutic approaches for malignant bone diseases will be reviewed. skeletal metastases are associated with significant morbidity and have high impact on health costs. effective palliative treatments are available, but less than 50% of patients respond in terms of tumour markers, pain or quality of life and all treatments are associated with some toxicity. it is generally accepted that the current imaging techniques are inadequate for measuring treatment response in a clinically relevant time frame such that skeletal metastases are usually considered as non-measurable disease in clinical routine and trials. there is therefore a need for non-invasive, objective methods to evaluate treatment response of skeletal metastases at earlier time points to guide clinical care. in addition to imaging structural changes in bone (e.g. x-ray, ct), it is now possible to image a number of biological characteristics of bone metastases including tumour metabolism, tumour cellularity, and osteoblast and osteoclast activity. methods currently available, or being actively investigated, include 99m tc-mdp spect/ct, 18 f-fluoride pet/ct, 18 f-fdg pet/ct, 11 c/ 18 f-choline pet/ct, rgd-spect/pet and dw-mri. some of the tracer methodologies will potentially be applicable for and complementary to pet/mri. the timing of follow-up imaging after commencing treatment is still under investigation. it is likely that tumour-specific methodologies may reflect response/non-response earlier than bone-specific methods due to a prolonged flare in reactive bone in responding metastatic sites. learning objectives: 1. to understand the techniques and quantitative parameters used for treatment response evaluation. 2. to learn the optimal timing for follow-up imaging after treatment. 3. to become familiar with common pitfalls in the interpretation of posttreatment mri and pet. panel discussion: how to differentiate between bone metastases and chronic inflammatory or treatment-induced changes 09:44 structured reporting is an opportunity and a challenge at the same time. expert speakers of this session will present and discuss their views on the subject, contributing to the clear vision of the members of audience on this complicated subject, convincing us to take this technique as an opportunity to improve and standardise the quality of our reporting activities. even though structured reporting (sr) has been appreciated as one of the effective methods of electronic reporting, there are not that many real applications to facilitate utilisation of this technique in practice. why it is so?the radiologists want a flexible tool to create clear, concise reports in a reasonably short time. like all template-based reporting systems, the application must be tailored to preferences of multiple users in a radiology department. the report templates should also be flexible in terms of length to avoid inappropriately detailed reports. the final appearance of the report is critical for acceptance by clinicians. accordingly, the technical challenges of development of sr systems may be grouped as: "user interface", "database structure", and "output file/document" problems. flexibility to comply with different user preferences will lead to both user interface design and database structure challenges. one of the major technical challenges is the transformation of structured data to a final text to be acceptable and applicable for the referring physician. also, exporting of reports to dicom format using dicom-sr concepts is still a challenge. multi-media formats are becoming more and more popular specially in sr reports. effective communication of radiology results is critical to high-quality health care. to that end, the radiological society of north america (rsna) has developed a library with more than 200 best-practice radiology reporting templates. the templates are freely available online (www.radreport.org) and have been accessed more than 750,000 times. the new ihe "management of radiology reporting templates" (mrrt) profile builds upon the web's hypertext markup language version 5 (html5) to provide an international standard for describing and exchanging reporting templates. this presentation will describe the rsna report template library, introduce the international mrrt standard for report templates, and describe opportunities for esr members and affiliated societies to participate. the broad goals of this initiative are to improve the quality of radiology reports, increase the productivity of radiologists, promote the use of practice guidelines, and advance data-driven health care.learning objectives:1. to explore a library of 'best practices' radiology reporting templates. 2. to become familiar with international standards for radiology reporting templates.3. to understand how structured reporting will promote the use of practice guidelines and will advance data-driven health-care. structured reporting in europe: the esr initiative o. ratib; geneva/chthe rsna has initiated a new initiative called radreport with the aim of helping promote standard reporting and improve reporting practices by creating a library of clear and consistent report templates (http://reportingwiki.rsna.org/). this project also supported in part by the national institute of biomedical imaging and bioengineering (nibib) has already gained the participation of numerous countries around the world, contributing with reports in different languages. these report templates are "structured" in the sense that they incorporate reusable knowledge, or meaning, to the clinical reporting process. structured interpretation and reporting for detecting significant prostate cancer is crucial, as it allows comparing inter-observer interpretation variability, reduces this variability by stimulating discussion of the individual scores, enhances communication with the clinicians in a uniform way, facilitates quality assurance plus research, and in this way improves patient outcome. in this presentation, the pi-rads scoring system will be shown and discussed, and fast effective structured reporting using computer software will be presented. in a rapidly ageing society, dementia prevalences are sharply increasing. furthermore, knowledge about disease mechanisms is constantly evolving. a more nosologic approach in the workup of dementia is required to improve prognostication, patient management as well as select appropriate treatment. a. anatomy of the limbic system t.a. yousry; london/uk (t.yousry@ucl.ac.uk)the term "limbic" has been used in many different connotations. to understand the anatomy, we have to define the term first. the clearest definition stems from broca: "le grand lobe limbic". defined as such, the limbic lobe is composed of 2 main structures: the limbic and the intralimbic gyri. 1. the limbic gyrus is composed of the subcallosoal gyrus anteriorly, followed in an arc by the cingulate gyrus, isthmus and parahippocampal gyrus. the latter is composed of 2 parts: i) a posterior narrow segment, the superior surface of which is called subiculum, and ii) a more voluminous anterior segment, also known as the piriform lobe. the latter consists of the anterior part of the uncus and the entorhinal area. 2. the intralimbic gyrus arches within the limbic gyrus. it is divided into 3 parts: i) anterior (prehippocampal rudiment); ii) superior (indusium griseum); and iii) inferior (hippocampus). the latter consists of 2 lamina rolled inside each other: the cornu ammonis and the dentate gyrus, with the cornu ammonis consisting of 4 neuronal fields (ca1-4). to understand the function, we have to understand the connections that define this function. the interplay with the insula is of particular importance. in summary, we will review the mri characteristics of the components of the limbic lobe, their connections, and their function, using 1.5 t, 3 t and 9.4 t high field imaging. at the end of this lecture, you will know definition (s) of the limbic lobe, its major subdivisions, connections and functions. structural neuroimaging is increasingly used in the diagnosis of neurodegenerative diseases. in a memory clinic setting, computed tomography (ct) and magnetic resonance imaging (mri) have become the most important paraclinical diagnostic tools. recent guidelines on the diagnosis and management of disorders associated with dementia state that neuroimaging should be performed at least once during the diagnostic workup. in the past, neuroimaging had been performed to exclude potentially treatable causes of dementia. however, this exclusionary approach of neuroimaging in the diagnosis of dementia has been replaced by an inclusionary approach driven by conclusive evidence that ct and mri can substantially support the clinical diagnosis by the demonstration of a distinct atrophy pattern and the assessment of vascular (co)morbidity. for these purposes, the use of visual rating scales allows a fast and reproducible assessment of global/regional cortical atrophy and vascular white matter pathology. more recently, new imaging markers such as cerebral microbleeds and superficial siderosis haven been identified and linked to alzheimer pathology. in addition, next to structural mri, advanced and quantitative mri methods have been introduced in the clinical setting. mri perfusion techniques such as arterial spin labelling (asl) demonstrated a diagnostic value in memory clinic patients, particularly in those showing no or inconclusive pathology on structural mri. de (horst.urbach@uniklinik-freiburg.de) cognitive decline is a clinical symptom in many neurodegenerative disorders. mri is typically performed in the initial diagnostic workup of these patients. as a structural imaging modality, mri is often unrevealing while several molecular imaging modalities show disease-associated alterations: 18 f-fdg-pet shows reduced glucose metabolism in neocortical association cortices, mainly in the posterior cingulate, precuneus and temporoparietal regions. since glucose metabolism is normally higher in the posterior cingulate and precuneus, reduced glucose metabolism must be specifically sought for or highlighted by voxel-based analysis. dynamic imaging of swallowing from the mouth to the duodenum is the only clinical test providing a fast and accurate diagnostic overview of the upper gi function. swallowing disorders are divided into those with dysphagia that means problems during eating or drinking, with suspicion of aspiration as an important subgroup and those with sensations like the globus syndrome or noncardiac retrosternal pain. oropharyngeal dysphagia in patients with neuromuscular diseases or postoperative conditions can be evaluated precisely and within the same session as oesophageal motility disorders, stenoses or postoperative problems are detected and in a complementary fashion to endoscopy, ph monitoring and manometry. the exclusive ability of dynamic imaging of swallowing is to diagnose combined disorders of the pharynx and the oesophagus, to detect and localise subtle and multiple benign stenoses of the upper gi tract and to combine visualisation of pathophysiology and bolus transport as well. radiologic evaluation concentrates on 7 functional units, which represent the visible "moving areas" of deglutition, where evident pathologic conditions can be found: 1) oral cavity and tongue, 2) soft palate, 3) epiglottis, 4) hyoid and larynx, 5) pharyngeal constrictors, 6) pharyngoesophageal segment, 7) oesophagus and stomach. this lecture intends to explain the common causes of dysphagia, the approach to a tailored examination and the use of an advanced imaging technique. further, the basics of taking the swallowing history and the structure of reporting swallowing disorders along the seven functional units will be provided. hoarseness is defined as a rough or noisy quality of voice. the possible causes of hoarseness are manifold, ranging from benign diseases such as the common cold to malignant tumours. therefore, hoarseness as a symptom should always be taken seriously. evaluation of a patient with hoarseness by a head and neck specialist will always starts with a history and a physical examination including laryngoscopy. after these examinations, a diagnosis can be established in most patients without additional imaging. the aetiologies of hoarseness are: 1) inflammation/infection, 2) trauma, 3) neoplasms, 4) others (including medical conditions, e.g. hypothyroidism) and 5) vocal cord paralysis. this presentation will focus on imaging of vocal cord paralysis. vocal cord paralysis should not be considered a diagnosis, but as a symptom of (possible) underlying disease. when vocal cord palsy is discovered, this is frequently a reason to perform cross-sectional imaging. the radiological workup needs to include the full course of the vagus nerve. moreover, reporting radiologists need to be able to recognise the radiological signs of vocal cord palsy in the absence of hoarseness, since many patients with cord palsy are asymptomatic (up to 30%). the anatomy of the vagus nerve and its laryngeal branches that innervate the intrinsic muscles of the larynx will be discussed. then the (expected) course of the vagus nerve and recurrent laryngeal nerve will be shown. finally, radiological signs of vocal cord palsy will be discussed using examples from daily practice. in contemporary medicine, endovascular techniques often replace conventional methods of treatment, including surgery, in the management of an increasing range of diseases. this requires development of specific methods assessing the effectiveness of treatment and able to detect complications that may be much different from those occurring in conventional therapy. this is first of all seen in the endovascular treatment of patients suffering from vascular lesions and neoplastic diseases. commonly, there is a high initial technical success of endovascular treatment, but the durability is not always satisfactory and needs to be further examined. endovascular treatment is bound to the risk of specific complications, often without clinical symptoms. therefore, there is a need to use imaging follow-up of these patients.interventional radiologists are aware of the importance of those issues and should play an important role in developing and deciding about the follow-up scheme and choice of the best imaging methods for these patients. besides indepth knowledge of the treatment, radiologists are also familiar with the possible complications and can offer an optimal, minimally invasive and cost effective diagnosis and treatment. the potential imaging methods for follow-up after angioplasty (pta) and/or stenting include doppler ultrasound, cta and mra. although excellent images can be obtained by cta and mra, the drawbacks of these studies for routine follow-up are obvious. (access to ct and mr equipment, cost, contrast medium, ionising radiation, etc). in the uk, the most common imaging method is duplex ultrasound. there is no established role for the use of ultrasound contrast agents. ultrasound is freely available in the majority of centres, is inexpensive and complication free. follow-up by ultrasound may be undertaken by radiologists, although more usually by technologists in vascular laboratories. in practice, few patients are followed up by any imaging study at all unless they develop symptoms. the main category of patients who undergo some form of imaging follow-up after pta/stenting are patients with surgical bypass grafts, who are usually routinely followed up whether they have undergone angioplasty/stenting or not. in view of the fact that this is a lecture on follow-up after intervention, procedural complications are excluded from the discussion. the complications of angioplasty and stenting are similar. the main early complications are restenosis or reocclusion. other early complications are related to the arterial puncture site and include haematoma, dissection, occlusion and pseudoaneurysms. the main late complications are restenosis and reocclusion. treatment of restenosis and reocclusion usually involves additional angioplasty or stents using conventional or drug-eluting balloons or stents. cutting balloons, atherectomy and cryotherapy have a controversial role based on limited evidence. imaging follow-up of oncologic patients after embolisation procedures j.i. bilbao; pamplona/es (jibilbao@unav.es)the term "embolisation" groups different procedures in which imaging guidance is fundamental for both performing the procedure and for the early detection of complications. it has been demonstrated by several studies that "tumoural response" is tightly associated with survival, thus it is of major interest to measure accurately how the tumour is modified by the treatment. the "world health organisation" -who -first published the objective criteria for the evaluation of response. these criteria were slightly modified in 2000 and named as "response evaluation criteria for solid tumors"-recist. accordingly, "complete response" (cr) corresponds to the disappearance of the tumour, "partial response" (pr) is defined when there is a decrease in the tumour size equal to or higher than 30% and "progressive disease" (pd) is applied when there is an increase equal to or higher than 20%. "stabilisation of the disease" (sd) corresponds to measurements in between > 30% (pr) and < 20% (pd). tumours (until five nodules in the same viscera), no matter if necrotic or viable, were evaluated with one measure (its largest diameter). a new version ("1.1 recist) has introduced modifications, among which is the number of nodules (2 instead of 5) that needs to be evaluated. in some circumstances, when morphologic criteria (recist and who) fail to predict the outcome, then new functional criteria have been recently established. "mrecist" (which only measures the tumour that uptakes contrast) is an accurate classification for hcc. new methods "beyond recist" have been established for some specific treatments such as targeted therapies. in this session, the audience will have a comprehensive overview of the elastography, its principles and current state-of-the-art clinical applications. the session will deliver an overview of currently available methods of both ultrasound elastography (use) and magnetic resonance elastography (mre), their physical principles, technical and equipment requirements as well as the influence of various factors for obtained results. following this session, the audience will have insight into clinical applications of elastography in liver, prostate and brain diagnostics. the strengths and weaknesses of elastographic modalities will be compared and discussed under consideration of more established imaging modalities. the session will present potential developments of use and mre and possible future clinical applications. panel discussion will aim at defining the place of elastography in current and future diagnostic algorithms. the well-known sensitivity of the palpating hand for detecting lesions is related to the incredibly wide range of values of the shear modulus in the body, spanning over eight orders of magnitude. elastography was invented to exploit this high variability of constants by introducing the shear modulus into the image contrast of medical ultrasound or magnetic resonance imaging. today, both ultrasound elastography (use) and magnetic resonance elastography (mre) are in clinical use, predominantly for staging liver fibrosis or discriminating tumours in the breast, liver, and prostate. the talk reviews the physical principles, technical requirements and current methods of both use and mre. furthermore, the strengths and weaknesses of elastographic modalities are compared and discussed under consideration of more established imaging modalities. an outlook of elastography is given, highlighting the real-time feasibility of use and the sensitivity of mre to tissue pressure. suspicion of prostate cancer (pca) exists in the case of elevated psa serum values and/or suspicious findings on digital rectal examination (dre). systematic biopsy (sb) will be done to confirm or rule out pca. unfortunately, an elevation of psa serum values often is caused by benign changes, e.g. prostatitis or adenomyomatosis and not every cancer is palpable on dre. furthermore, sb may miss clinically significant disease in up to 35%. therefore, a more targeted approach would be desirable and imaging of pca is currently under strong effort. one possibility for visualisation of pca is the representation of tissue elasticity. usually, cancers have higher cell and vessel density than the normal surrounding tissue and therefore are associated with increased stiffness. in contrast to dre, where only the posterior parts of the prostate can be reached, rte does not have this problem, since all anatomical regions can be evaluated. furthermore, this noninvasive technique is time-and cost-effective and targeted biopsy or focal therapy of the prostate can be done under real-time conditions. another important issue is that rte can be performed by both urologists and radiologists. nevertheless, rte is of limited value in the detection of small cancer lesions and there may be problems in visualising pca with predominantly gleason pattern 3. the lack of data about inter-and intraobserver variability and of multicentre studies (now in process) are probably the reasons why rte has not been included in the guidelines of urological societies so far. cerebral tissue structure is altered in many neurodegenerative diseases, but also during physiological processes like maturation or ageing. structural changes directly affect the mechanical tissue properties. magnetic resonance elastography (mre) is an imaging technique capable of assessing biomechanical brain parenchymal properties non-invasively. viscoelasticity can be quantified by analysing the propagation of mechanically elicited shear waves in the investigated tissue. thus, mre could be a helpful tool to detect physiological or pathological processes influencing the cerebral tissue integrity. learning objectives: 1. to appreciate the advantages and limitations of a virtual palpation of the brain. 2. to become familiar with mechanical wave induction and detection in cerebral measurements. 3 . to learn about current and potential clinical applications. 4 . to learn about the relationship between microscopic and macroscopic, as well as focal and globally diffuse biomechanical brain parenchymal alterations. are based on the generation of shear waves inside the liver tissue with specific mr liver drivers and ultrasound probes. subsequently, phase images revealing the displacement of the waves will be investigated for healthy and pathological (alcoholic fibrosis) livers. moreover, the development of phantoms mimicking the stiffness of biological soft tissues (liver, muscle, â�¦) will be also presented. the viscoelastic (elasticity and viscosity) properties of healthy and fibrotic livers were measured, and the relevance of these parameters, used as a liver diagnostic marker, was analysed. in parallel, an increase of the wavelength as a function of the stiffness was obtained for the developed set of phantoms. the characterisation of the elastic properties is an excellent marker to differentiate minor and major fibrosis. a summary of the advantages and disadvantages of us and mr elastography techniques will be presented. a-558 09:00 the breast lesion excision system (bles) has evolved as a breast radiological technology over the last decade and is now in widespread use in europe and across the world. it was designed as a large biopsy device, but more recently due to its unique capability to obtain a single large breast tissue specimen in only a few seconds by utilising a radiofrequency cutting and cauterising wave, it has increasingly been explored in the therapeutic setting. it is easy to use under ultrasound or mammographic guidance with procedures taking a similar length of time to that of a vacuum biopsy, and with patient preparation and anaesthetic essentially identical. the technical aspects of performing these procedures will be detailed as well as its use specifically to perform excisional biopsies. this is limited by patient and lesional factors, all of which will be discussed in more detail. following a bles, the post-procedure appearances need to be considered so that follow-up imaging can be interpreted accurately. the risks and complications of this procedure are outlined as well as a discussion made of the latest papers in this field that may suggest future applications and developments. learning objectives: 1. to understand the mechanism of the bles technique. 2. to become familiar with the post-bles aspects of various types of imaging. during the past few years, it has been shown that there is not a single disease entity called "breast cancer". there are different subtypes that entail diverse recurrence risks. this is the first issue to take into account, and patients will be stratified accordingly before any follow-up is planned. imaging findings in a patient treated for breast cancer will depend on the type of treatment: breast conserving therapy (bct), mastectomy (and all the reconstructive techniques), radiotherapy and minimally invasive techniques. to differentiate between fat necrosis and other common post-treatment changes from relapse, it is important to know the timeline when all these changes take place and also schedule the follow-up imaging procedures accordingly. other important issues to take into account are the limitations and indications of the different modalities (mammography, ultrasound and mri). although ultrasound and mammography have traditionally been used in the follow-up of these patients, mri is being used more and more often due to its superior multiplanar capabilities and the functional information not supplied by the other techniques. blood clot formation in the veins is referred to as venous thrombosis (vt). vt is most common in the deep veins of the legs and pelvis. if the thrombus dislocates to the pulmonary arteries this is referred to as pulmonary embolism (pe). the combination of deep vein thrombosis (dvt) and pe is referred to as venous thromboembolism (vte). the diagnosis of dvt and vte is essential, as vte is potentially fatal. furthermore, undiagnosed, non-fatal dvt may result in negative long-term pathologies (e.g. post-thrombotic syndrome). major risk factors for the development of vte are thrombophilia, history of dvt, age > 60, surgery, obesity, long travel, cancer, immobility and pregnancy. in addition, underlying congenital abnormalities or compression syndromes (may-thurner syndrome) are also important to diagnose. diagnosis of vte is not always easy. primary diagnosis includes clinical (wells score) and lab testing (d-dimer). first line imaging testing is done by leg ultrasound (us). if pe is suspected ct is indicated immediately. ct of the pulmonary arteries (ctpa) may be combined with indirect ct venography (ctv). the question of when to combine ctpa and ctv still remains. a favourable approach is to add ctv in a negative ctpa. recently mr venography (mrv) is emerging as comprehensive imaging tool especially in patients with chronic dvt to assess the extent and underlying causes. in this respect imaging without radiation dose with high spatial delineation of vascular abnormalities facilitates intervention for thrombolysis or interventional therapy including recanalisation and stenting. alternatively, intravenous unfractionated heparin is used in situations when a quick reversal is necessary. b) non-medication: early mobilisation has been widely adopted to activate the muscle pump. if early mobilisation is not possible, compression stockings and/or pneumatic compression boots are applied to better empty the veins. 3. treatment: a) anticoagulation: the main goal of anticoagulation is to prevent progression and recurrence of dvt. typically, anticoagulation is started with lmh, followed by vitamin k antagonists (coumadin). the first dvt is generally treated for 3-6 months; recurrent dvt for 12 months. b) compression therapy: compression stockings ameliorate pain and leg swelling of acute dvt. in addition, the development of a post-thrombotic syndrome (pts) should be reduced. c) thrombolysis: the main goal of thrombus removal is prevention of pts. in addition, thrombolysis is used for severe ilio-femoral dvt, especially with phlegmasia coerulea dolens. there are different ways of thrombolysis: systemic thrombolysis was abandoned because of high bleeding complications. catheter-based thrombolysis has shown to reduce the bleeding risk, but it is quite time and resource consuming. the latest development is pharmaco-mechanical catheter thrombus removal which combines thrombolytic drugs with a mechanical maceration. recent studies (cavent,torpedo) have shown a reduction of pts compared to anticoagulation. the use of inferior vena cava filters (ivcfs) is a controversial method for the prevention of pulmonary emboli. there are large variations in their usage; often with ten to one hundredfold differences in placement between different countries. ideally, ivcf usage is based on sensible protocols derived from clinical experience and trials. in practice, this is less frequently the case. indications, contraindications and questionable indications (mainly during venous thrombolysis) will be discussed. familiarity with ultrasound guidance will be stressed. the key technical steps in the insertion and removal of ivcfs will be discussed. the question that this refresher course is aimed to answer is whether novel it tools may actually help in improving quality and workflow efficiency in daily radiological practice. in fact, since the early installations of pacs, it tools have often been considered as mere productivity tools rather than enabling technologies for fostering quality in medical care. the three distinguished lecturers in this course will address the following topics: improving quality and efficiency of computerised order entry through decision support, improving quality and efficiency of reporting through structure and templates, and improving quality and efficiency of dose management through exchange between modalities and registries. they will cover all aspects of the radiological workflow: from the selection of the most appropriate diagnostic procedure, to the efficient reporting of diagnostic and non-diagnostic data (such as radiation dose information and contrast media information). they will demonstrate how newly adapted it tools may provide assistance throughout the radiological workflow, with potentially enormous gains in terms of patients' safety and total quality management. session objectives: 1. to appreciate the need for it tools to ensure quality control. 2. to understand how to collect data concerning radiation dose. a. improving the quality and efficiency of computerised order entry through decision support p. mildenberger; mainz/ de (peter.mildenberger@unimedizin-mainz.de) electronic communication of requests for radiological procedures is a logical and relevant extension to integrated information systems in health care. this communication of orders and the entry (oe) into ris improve the workflows. but, quality improvements require additional efforts to link order-entry-solutions with health knowledge for ordering the appropriate imaging procedure. these clinical decision support (cds) tools should be based on generally accepted and implemented criteria, e.g. evidence-based medicine. it is known that the acceptance of such systems, if successful and efficient implementations are given, is very good. it concepts for cds are well known and standards for classifications are available, but semantic interoperability is still a developing area. actually, clinical information systems provide different levels of integration of oe and cds. further developments could be an implementation of interoperability profiles and the representation of cds knowledge in webbased services of non-commercial organisations. b. improving quality and efficiency of reporting through structure and templates e. neri; pisa/it (emanueleneri1@gmail.com)the report represents the final stage of the diagnostic imaging process, for which the radiologist is responsible. this process is driven by an accurate selection of the diagnostic tests, based on the clinical question. therefore, the report should be an expression of this path, depending on the question asked by the clinician. the structure of a radiology report for the same clinical problem and the same method of investigation varies from country to country and between different radiologists. this diversity can be a problem in the global world where a patient can have imaging tests from different places with different reporting languages, or when patient data is transmitted and shared between different centres. there is, therefore, the need to standardise the report as much as possible; finalising its structure and contents to a specific clinical problem, and possibly using a standard terminology. an attempt to solve this problem is in progress with the joint initiative on structured report esr-rsna (http://www.rsna.org/reporting_initiative.aspx), aimed at improving reporting practises by creating a library of clear and consistent report templates. the main expected benefits of structured reporting templates are report uniformity and improvement of communication between referring physicians. literature evidences that structured reporting can also quicken report turnaround, and reduce costs and lexical errors; thereby improving the quality and safety of radiological practise. the european directive on medical exposures requires the assessment and evaluation of patient doses, especially in procedures involving high doses to the patient. in the current draft of the new directive on basic safety standards, some requirements on patient dosimetry in diagnostic and interventional radiology have been reinforced: x-ray systems should provide dosimetric information with the capability of being transferred to the examination report (for all ct and interventional systems). diagnostic reference levels (drls) shall be reviewed regularly. these requirements will push the industry and the users to develop better strategies to evaluate patient doses, transfer these values to patient reports (contributing to the patient exposure tracking system) and also use available software to process these dosimetric data and perform some automatic analysis. this analysis should: a) include periodic calibration factors for patient dose quantities, b) include automatic detection of high dose values (especially relevant for interventional procedures), c) include statistical analysis to update drls and compare with the existing ones and d) suggest corrective actions to fulfil the quality assurance programmes and the clinical audit requirements. dicom radiation dose structured reports represent a significant advantage, but more efforts will be necessary for the automatic process of the relevant data contained in the report to verify that the radiological risk is acceptable and to suggest, if appropriate, corrective actions to improve clinical practice. without these last steps, patient dosimetry efforts and european regulations for radiation safety could only have a moderate impact. gastrointestinal tumors include a variety of lesions, with the most frequent being adenocarcinoma of the small and large intestine, small bowel lymphoma, neuroendocrine tumours (nets) and gastrointestinal stromal tumours (gists). according to histology, location and initial imaging staging, those lesions may require completely different therapies: surgery alone, adjuvant chemotherapy (cht), neoadjuvant cht followed by surgery or a combination of neoadjuvant chemoradiotherapy (crt) followed by surgery. after treatment, imaging follow-up is mandatory. the most common post-operative findings after small bowel or colonic resections will be presented, together with clues for early detection of recurrence. in those cases which underwent adjuvant cht, imaging findings and diagnostic criteria related to the use of either cytotoxic or cytostatic drugs will be shown, to facilitate the interpretation of radiologists in assessing response to therapy. finally, tissue changes following neoadjuvant crt will be discussed, particularly in rectal cancer. the possibilities of different imaging modalities in assessing either complete or partial response to therapy will be presented, with a critical analysis of different imaging findings. unlike infectious enteritis, in patients with crohn's disease (cd) the changes in clinical activity have poor correlation with changes in inflammatory lesions after medical treatment. mucosal healing (mh) and improvement in patient's symptomatology are usually considered the main objectives of medical treatment. however, improvement in clinical symptoms is not always associated with mucosal healing and the persistence of severe inflammatory lesions augurs a more aggressive disease course in terms of flare-ups, hospitalisation requirements and the need for surgery. endoscopy is the gold standard for the assessment of luminal lesions in cd, but given the good correlation shown between endoscopy and cross-sectional imaging in assessing the activity and severity, imaging is increasingly introduced as a tool to monitor medical treatment. there is some evidence indicating that crosssectional imaging can be considered a responsive and reliable tool as it detects meaningful changes in patients' status over time after therapeutic interventions. besides this, cross-sectional imaging is capable of monitoring the colon and the small bowel and penetrating lesions that cannot always be assessed by endoscopy. becoming familiar with the radiological changes during and after treatment will be key in the decision-making process. degeneration is routinely defined as a morbid change of cells, tissues and even organs. in the msk system degeneration occurs in bones, joints (synarthrosis and diarthrosis), muscles and tendons. primary degeneration implies ageing as well as overuse, based on mircrotrauma. the latter may be related to constitutional, professional or sports-related factors. a distinction between ageing and overuse is not possible with the use of histology and imaging. only the intensity of the changes, which may be inadequate in relation to the age of the patient, may give a hint. on the contrary, the term "secondary degeneration" should be used for clearly defined events or diseases, which finally will result in the degeneration of tissues. the causes are inflammation (ra, infection), metabolic disease (e.g. cppd) or trauma. other ways to classify degeneration of the msk system are related to the anatomy. accordingly, degeneration of the particular parts of the peripheral or axial skeleton, muscles and tendons has to be discussed. one has to have in mind that bones, cartilage, muscles and tendons form a complex unit. the single elements of these complex units jointly undergo degenerative deterioration, e.g. bone, cartilage, fibrocartilage and capsule are jointly involved in case of oa of the knee joint. the same holds true for the synchondroses of the spine. at the rotator cuff not only the tendons, but also the underlying bone and the muscle tissue are changed. (o.m.vandelden@amc.uva.nl) there are many different types of embolisation, but all share many basic principles. the specific approach, technique, materials and equipment used may differ depending upon many variables such as the type of vascular territory involved (venous, arterial, small vessels, large vessels), clinical setting (elective or emergent procedure), and type of underlying disease to be treated (e.g. tumor embolisation, acute haemorrhage, vascular malformation, arteriovenous fistula, etc). pre-procedural imaging and planning are essential for most embolisation procedures and intra-procedural navigation can be done with fluoroscopy, dsa, and new 3d-techniques. with proper imaging workup prior to embolisation procedure time, radiation dose and contrast load can be significantly reduced. embolisation materials can be roughly divided into liquid agents (alcohol, glue, polymers), particulate agents (pva, calibrate microspheres, drug-eluting beads) and coils (detachable, non-detachable) and plugs (amplatzerâ®-plugs). plugs and coils are deployed at the exact site of destination and usually easy and safe to use. particles and liquid agents reach their site of destination by flow guidance and can be more difficult and unpredictable in their use. complications include puncture-site complications (thrombosis, dissection, haematoma), systemic complications (contrastinduced nephropathy, allergic reactions) and specific embolisation-related complications (non-target organ embolisation, end-organ ischaemia, postembolisation syndrome). when used with expertise and proper experience, most types of embolisation have good results with acceptable complication rates. although there has been advancement in imaging techniques, several pitfalls in the assessment of diseases of the pancreas, small bowel and rectum remain. the differentiation and the correct characterisation of tumours and inflammatory disease in some cases may be difficult. also, atypical presentation of common tumours or uncommon tumours persists and is a challenge. problematic situations are constantly represented as intestinal bleeding and unexpected findings. in this session, we point out the procedure of the best imaging modality and protocols of challenging cases. a. pancreas c. triantopoulou; athens/gr (ctriantopoulou@gmail.com)pancreatic imaging and interpretation of focal lesions remains a challenging issue. despite the advances in imaging techniques and the dedicated protocols that are now in use, a possibility for pitfalls remains. these pitfalls are related either to the inability of the early recognition of a lesion, or to the wrong characterisation of a "mass". both pitfalls are of great importance, taking into account the lethal pancreatic cancer and the possible complications that may follow an unnecessary pancreatic surgery. there are many variants of the pancreatic parenchyma, the ducts or even vessels, and deep knowledge of the pancreatic anatomy and embryology is needed, to be able to recognise these variations in imaging. a pancreatic variant may not only be misinterpreted as a severe pancreatic disease (e.g. ectopic spleen vs neuroendocrine tumour), but may also be the underlying cause of pancreatic inflammatory lesions (e.g. ectopic pancreas on the duodenal wall causing groove pancreatitis). other pitfalls are related to the atypical presentation of a common lesion (e.g. isoattenuating pancreatic adenocarcinoma), the presence of uncommon tumours, diffuse or multifocal diseases, the co-existence of two different entities and the heterogeneous or overlapping appearance of cystic lesions. in any challenging case, a focused methodology should be applied and the diagnostic procedure based on predefined imaging parameters, taking also into consideration the clinical and laboratory findings. excluding pancreatic cancer should be the first goal and every attempt should be made to differentiate between surgical and non-surgical cases. endoscopy is the gold standard in small bowel diseases, but it is a challenging technique: the pillcam is a commonly used tool and multidetector ct is a diffuse investigation technique. ct enteroclysis/enterography is a worldwide tool in intestinal exploration. throughout the investigation of the small bowel, morphologic anomalies or embryonal development defects may be present (meckel's diverticulum, duplications of intestinal tracts). artefacts may be determined and there may be misunderstanding. mdct is the first tool in emergency diagnosis; imaging pitfalls are possible. unsuspected diseases may be revealed: we will see a case of gist in a patient affected by intestinal bleeding of an obscure origin. ct enteroclysis may find unknown or unsuspected diseases: correct technical parameters have to be respected, as artefacts may be derived from an improper acquisition technique, such as a limited distension or poor intravenous enhancement. in follow-up, mr is preferred to investigate the intestine, mainly in the young population. unexpected findings may be due to rare pathology: we met a case of endometriosis, with ambiguous presentations; patients affected by autoimmune pathologies (pyoderma gangrenosum or lupus erythematosus), with unknown inflammatory intestinal chronic diseases. in oncology, pet-ct imaging is the main diagnostic tool, but there are abdominal pitfalls that limit its effectiveness (intestinal hot spots, artefacts from peristalsis): the small bowel may frequently obstruct an easy diagnosis. in case of emergency, if the radiological diagnosis is not clear, the surgeon determines the management of the patient. in case of a defective study technique, a correct examination may be repeated. endoscopy or pillcam may help to detect mucosal lesions invisible at ct. mri plays a key role in the assessment of disease of the rectum and in particular for the staging (and restaging) of rectal cancer. in this session, the relevant mr anatomy of the rectum will be discussed. furthermore, the strengths and weaknesses of mri in the assessment of rectal cancer during primary staging and restaging after chemoradiotherapy will be highlighted using various rectal cancer cases. finally, we will discuss some rare tumours of the rectum (including gist and carcinoid). optimisation of ct and mr techniques has provided new challenges for imaging in the assessment of airway and lung diseases. phenotypic abnormalities which can be recognised on visual and quantitative evaluation of ct images in copd patients may improve the diagnostic accuracy, help optimise treatment and provide a framework for clinical trials. although expiratory ct helps assess air trapping due to small airway obstruction and excessive dynamic collapse of large airways, potential tricks in technique and interpretation of ct images must be known. owing to multiple and successive improvements over years, functional and morphologic evaluation of the lung using mri has become reality for clinical practice. already regarded as a favoured cross-sectional imaging in paediatric chest radiology, mri of the lung is gaining new indications also in lung diseases occurring in adults. the potential for high-resolution computed tomography (hrct) to uncover several morphological subtypes that come under the umbrella term chronic obstructive pulmonary disease (copd) is now more familiar to both radiologists and specialist respiratory physicians. a complete approach to the classification of copd would ideally assimilate several parameters through a combined visual-quantitative hrct analysis. the insight that some subjects given the label of copd have "pure" airways diseases or emphysema can be readily provided by a simple visual evaluation. the subtypes -centrilobular, panlobular, and paraseptal emphysema -can be reliably distinguished on hrct images. the visual assessment of bronchial abnormalities and accompanying smoking-related interstitial lung disease may also complete the phenotypic classification of copd. furthermore, it is now possible to objectively quantify the global extent of emphysema, gas-trapping, and bronchial metrics by two types of softwares which are now increasingly available on latest ct workstations. learning objectives:1. to learn about the classification of copd. 2. to appreciate the role of hrct in the classification of copd. a-578 16:28 this presentation will examine the role of expiratory ct in the diagnosis of small and large airways diseases. small airways disease or air trapping may be a feature of asthma, copd and hypersensitivity pneumonitis, and is typically characterised by a mosaic attenuation pattern on ct. tracheobronchomalacia and excessive dynamic airway collapse (edac) are large airways conditions that may be recognised by tracheal narrowing on inspiratory and/or expiratory ct. the typical clinical and ct manifestations of these diseases will be reviewed. additionally, a number of important caveats with regard to ct in small and large airways disease will be discussed: 1) the comparative strengths and limitations of ct, bronchoscopy and lung function testing in making the diagnosis; 2) the overlap in appearances that exists between diseased and healthy individuals; 3) the variability in definitions of conditions such as tracheobronchomalacia. the optimal ct technique for imaging of airways disease, including the role of dynamic expiratory ct, will also be reviewed. for routine clinical applications, a standardised mri protocol has been widely implemented. it addresses the major challenges of mri of the lung, i.e. low proton density, susceptibility artefacts as well as respiratory and cardiac motion. beyond visualisation of lung morphology, which is done in an inspiratory breath-hold, functional imaging has become an integral part of the routine protocols: perfusion, blood flow, ventilation, respiratory motion, diffusion. for perfusion imaging, inspiratory or expiratory scans can be used, blood flow measurement should be performed during shallow breathing, and ventilation and diffusion are mainly assessed in inspiration. respiratory motion is best assessed by dynamic image acquisitions. continuous breathing can also be combined with triggering or navigators to improve image quality or derive functional maps. mri is recommended as the first-line cross-sectional imaging modality in paediatric chest radiology, including cystic fibrosis, complicated pneumonia, any pulmonary or cardiovascular anomaly, as well as the assessment of mediastinal masses in children and adults. mri is also challenging pet/ct in the staging of lung cancer (tnm) as well as ct and echocardiography in the assessment of pulmonary arterial hypertension. mrieven without contrast -is an alternative in the diagnosis of acute pulmonary embolism if iodinated contrast medium is contraindicated or in pregnant women. mri should also be used in complicated pneumonia, e.g. in immunocompromised patients as well as for the functional assessment of chronic obstructive pulmonary disease (copd) or severe asthma. the role of mri in interstitial lung disease stills needs to be determined. unlike the simple forms of cranisynostosis whose modalities and timing of surgical correction are well established, the management of faciocraniosynostoses requires a multispecialistic and repeated evaluation of the single patients. their evolution, in fact, depends on the specific genetic anomalies but also on the phenotype, which can vary in time, of their clinical expression which may lead to different degrees in severity of the associated functional disturbances (csf dynamics impairment, visual deficits, respiratory anomalies, etc). consequently these conditions may require several surgical steps the timing of which are dictated by the exact clinical diagnosis and the evaluation of the functional status at different ages. current management of faciocraniostenoses is thus based not only on the radiological studies but also on the functional assessment of the brain function (e.g. mri imaging studies, metabolic and cerebral blood circulation investigations, respiratory pathways volume evaluation, sleep recording). today's surgical multidisciplinary management may benefit a large variety of techniques which extend from free bone cranioplasty with intraoperative active fixed expansion to more dynamic and less invasive methods which exploit the physiological brain expansion in infants or the gradual cranial vault expansion mechanically stimulated by springs or distractors. in the present report, we will review the decision making process and the rationale on which, at the necker-enfants malades, we base the use of the currently available techniques for skull expansion and correction of cranial malformations according to the accurate dynamic radiological and functional evaluation at different stages of the disease. learning objectives: 1. to learn about the imaging patterns of faciocraniosynostoses. 2. to learn how and when to image. 3. to become familiar with associated brain anomalies. b. all about the paediatric pituitary gland m.i. argyropoulou; ioannina/ gr (margyrop@cc.uoi.gr) mr is the imaging modality of choice for the assessment of the pituitary gland (pg) and the hypothalamus. the normal adenohypophysis is bright during the first two months of life and appears isosignal to the brain parenchyma afterwards. the neurohypophysis is bright, provided that the child is well hydrated. the pg height decreases during the first year of life and then increases until puberty. adenohypophyseal deficiency has been associated with a small pituitary size, an ectopic neurohypophysis, a hypoplastic or absent pituitary stalk, hypothalamic gliomas, craniopharyngiomas and iron overload states. precocious puberty may be idiopathic, but it has also has been associated with hypothalamic hamartomas, craniopharyngiomas and hydrocephalus. diabetes insipidus may be secondary to histiocytosis x, germinomas and trauma causing pituitary stalk interruption. the hypothalamopituitary axis is evaluated by using sagittal and coronal t1-weighted images without and with contrast administration. dynamic contrast enhancement may be useful in the evaluation of disorders responsible of diabetes insipidus. magnetisation transfer imaging may be useful in the evaluation of pituitary deficiencies or precocious puberty. familiarity with orbital and ocular anatomy is crucial to the understanding of disease processes of the orbit. lesions of the orbit may be divided into those which are intraocular and those which are extraocular. the underlying aetiology and geneses of many different lesions that can occur in the orbits vary depending on the location of the lesions and sometimes on additional nonorbital conditions. ct and mri play crucial roles in the evaluation of orbital pathology where often mri still is a complement to ct examination in the evaluation of orbital lesions familiarity with the radiologic appearance of common orbital lesions is important, as many of these lesions will not be seen on physical examination. after a very brief anatomic overview, most of this lecture will focus on the more common benign and malignant lesions as well as differential diagnosis involving the orbit and lachrymal gland in both the paediatric and adult population. the lecture will also present suggested imaging protocol and standard of care with respect to imaging. learning objectives: 1. to understand the embryology and imaging findings of the most common malformations.2. to learn about space-occupying lesions and the differential diagnosis of tumours and inflammatory conditions. 3. to be aware of the role of conventional and advanced mr sequences in the diagnostic approach to lesions in the orbit. room e1 the hand and wrist injury to the wrist and hand is an important clinical problem. first, such injury is relatively common. second, the spectrum of abnormalities is complicated. the purpose of this presentation will be to learn more about the imaging appearances of soft tissue and osteoarticular injury of the wrist and hand using multiple imaging techniques. emphasis will be placed upon pathomechanics and characterisation of greater and lesser arc injury patterns of the wrist. the various posttraumatic instability patterns of the wrist will be also discussed. rheumatoid arthritis (ra), psoriatic arthritis (psa) and other inflammatory disease can be diagnosed and sometimes differentiated in the early stages of the disease on the basis of mri and/or pdus features of the hand and wrist. rheumatoid arthritis (ra) activity is closely correlated with inflammation. the synovial membrane is the principal site of inflammation in which the inflammatory process enhances capillary perfusion and permeability. doppler ultrasonography (dus), using the amount of colour pixels in the region of interest, and dynamic magnetic resonance imaging (de-mri) are both able to detect this inflammation in the wrist and hand. although these techniques are both capable of monitoring synovium inflammation modifications after ra treatment, pdus has become an essential tool for ra joint monitoring in routine practice in view of its sensitivity in the detection of synovitis, feasibility in outpatient clinics, and low cost. (ellopis@hospital-ribera.com) radiological study of the wrist and hand is challenging due to its complex anatomy with many small structures and the number of normal bone and soft tissue variants that might mimic injuries. moreover, many findings can be asymptomatic. their knowledge is important to avoid misdiagnosis. during this lecture we will also review the role of the different imaging modalities, such as plain films for wrist alignment and bone structures as well as the important role of us and mr in differentiating tumour from tumour-like conditions. we will become familiar with some specific radiological findings that allow us to make accurate diagnoses of soft tissue and bone lesions. learning objectives: 1. to learn more about the spectrum of intra and para-articular soft tissue tumours, and soft tissue tumour-like lesions. 2. to become familiar with us and mri findings of specific soft tissue lesions. room e2oncologic imaging chairman's introduction c. pfannenberg; tã¼bingen/ de (christina.pfannenberg@med.uni-tuebingen.de) with recent advances in cross-sectional imaging, the frequency of detecting "incidental findings" has markedly increased. incidental findings (=incidentaloma) are defined as unexpected, asymptomatic abnormalities detected by imaging performed for an unrelated reason. these incidentalomas have created a management dilemma for both radiologists and clinicians, particularly in the cancer patient in whom any mass warrants further evaluation. discovery of incidental findings often leads to a cascade of additional tests that is costly, provokes anxiety and exposes patients to the risk of unnecessary radiation and intervention. the workup of incidentalomas varies widely by physicians, and strategies for optimising patient management are only beginning to emerge. in this course, guidelines concerning a rational approach to some of the more common incidental abnormalities in cancer patients are presented. basic principles and tools for interpretation of incidental findings, common pitfalls and protocol issues regarding the differentiation of benign and malignant lesions as well as treatment-induced abnormalities will be addressed with a focus on the liver, lung and skeletal system. at the end of the session, the speakers will discuss the role of functional imaging techniques for characterisation of incidental lesions. session objectives: 1. to become familiar with basic principles and common pitfalls in interpretation of incidental findings in the lung, abdomen and skeletal system. 2. to learn how functional imaging (dwi, pet/ct, bs) can help in lesion characterisation.3. to provide attendees with clear and practical messages for the management of the most common incidental findings in cancer patients. a. abdomen: common pitfalls and protocol issues a. ba-ssalamah; vienna/ at (ahmed.ba-ssalamah@meduniwien.ac.at) an incidentaloma is quite a frequent diagnosis in medicine, in general, and in radiology, in particular. by definition, an incidentaloma is an abnormality or a tumour found by coincidence without clinical symptoms or suspicion. these incidental findings have long posed challenges to physicians, and particularly to radiologists as well as health-care providers due to the resulting high costs. the scope and scale of these challenges have increased with the introduction of new technologies, in particular cross-sectional imaging, such as mdct and mri using sub-millimetre thin slices. incidentalomas still cause a management dilemma for clinicians, radiologists and even for the patients themselves. this dilemma is particularly pertinent to oncology patients. therefore, a precise knowledge of the broad spectrum of incidental findings is crucial. based on this knowledge, we can choose the appropriate radiologic examination that will provide a confident diagnosis. this way, needless uncertainty, for both the patient and the physician in charge, is avoided. furthermore, invasive procedures, such as biopsies, with the potential for complications, as well as cost-intensive follow-up examinations, can be reduced. furthermore, mri is usually used to detect the side effects of chemotherapy of the liver. simple steatosis is usually reversible, unless the liver receives a 'second hit' of damage from other causes leading to other manifestations, including chemotherapy-associated steatosis, sinusoidal obstructive syndrome, nodular regenerative hyperplasia, veno-occlusive disease, peliosis, pseudo-cirrhosis, and sclerosing cholangitis largely due to microvascular injury. finally, the effects of chemotherapy on peritoneal and mesenteric structures after performing intraperitoneal chemotherapy will be discussed. this presentation will discuss the complex topic of incidental findings in thoracic imaging of oncological patients. incidental findings will be presented with respect to their respective organs and anatomical regions. the presentation will emphasise the clinical relevancy of the findings as well as the specific of risk estimation in oncological patients. finally, the presentation will discuss the usefulness (or lack thereof) of current management guidelines for incidental findings, as designed for the general population. illustrative clinical scenarios will be discussed. radiographs and ct often detect incidental observations in bones, corresponding either to normal variants or benign conditions, which require additional imaging to rule out malignant conditions. mri most often provides nonambiguous explanation for these observations. beside this, mri, targeting either the whole body or only the axial skeleton, often including diffusionweighted (dwi) sequences, is increasingly used for bone tumour detection in many "osteophilic" cancers and haematologic malignancies, without need for contrast material injection and without irradiation, with unparallelled sensitivity to bone lesions. an important advantage and also a challenge for musculoskeletal radiologists are the all organ screening capabilities of dwi, demanding careful study of the huge information provided and knowledge extending far beyond bones in terms of organs and metastatic spread of different cancers. a second major advantage is its ability to detect lesion changes under therapy. however, benign lesions and non-neoplastic conditions, as well as artefacts may also lead to confusing observations on mri, and particularly on dwi. anatomical mr sequences as well as other imaging modalities are of utmost help to recognise these pitfalls. whole body mri including dwi sequences has to position itself among other diagnostic tools, bone scan, spect, and especially pet with its variety of tracers, in the currently evolving strategy of bone screening techniques, which will most likely vary according to the primary cancer. learning objectives: 1. to present most frequent x-ray and ct pseudo lesions and benign conditions and show how mri often enables straightforward interpretation of these abormalities. 2. to highlight the strengths of mri with diffusion weighted imaging (dwi) for malignant lesion detection and characterisation within bones, but also beyond bones. 3. to highlight the typical appearance of malignant lesions on projectional and cross-sectional imaging. 4. to learn to differentiate these lesions from normal marrow variations, stress lesions, bony pseudo-lesions and other benign conditions, and to become familiar with treatment induced changes within lesions and their environment. 5. to situate mri amongst other functional imaging techniques (pet, spect, ). colorectal cancer is the 3 rd most commonly diagnosed cancer in the world with 60% of cases diagnosed in the developed world. with an estimated 1.3 million new cases clinically diagnosed and over 600,000 people killed worldwide by this disease on an annual basis, colorectal cancer is a true public health concern. survival of colorectal cancer is directly related to the extent of disease and specifically presence of liver metastases. imaging plays a key role in the initial staging of colorectal cancer and is the gold standard in evaluating extra colonic disease, primarily liver metastases. imaging is also widely used for therapy monitoring and staging. ct, mri, pet/ct and pet/mri are the key imaging modalities. in addition, tumour response therapy assessed with morphological and functional biomarkers is increasingly used by advanced gastrointestinal oncologic programs. furthermore, image-guided therapy is widely used for patients with unresectable lesions. liver colorectal metastases were the first liver metastases to be treated with image-guided ablation techniques. a gamut of ablative techniques exists ranging from transarterial embolisation, radiofrequency ablation, highly intensified focused ultrasound, brachitherapy etc. in short, diagnosing, characterising and finally assessing tumour response after neoadjuvant and image-guided therapy are all functions where imaging plays a pivotal role. this course is divided into three logical segments dealing with current treatment options, morphological and finally functional biomarkers and it is followed by a panel discussion which includes audience participation. a. current treatment options t.k. helmberger; munich/de (thomas.helmberger@klinikum-muenchen.de) hepatic metastases in colorectal cancer may occur in 20% to 80% of the cases. considering the general oncological (isolated hepatic tumour load; prognostic benefit), and technical (size, number, location of hepatic metastases; expected hepatic functional reserve) framework, surgical resection is still considered to be the method of choice -even if this statement never had been verified by rtcs. nevertheless, in clinical reality only 20-30% of patients with liver metastases may qualify for resection. in consequence, the majority of patients need other or at least modified therapeutical pathways including adjuvant or neoadjuvant chemotherapy and more and more image-guided local ablative therapies. the latter encompass chemo-(transarterial chemoperfusion/-embolisation), thermo-(radiofrequency-, laser-, microwave ablation, high intensified focused ultrasound), and radio-ablative (radio embolisation, interstitial brachytherapy, etc). techniques. particularly, thermalablative techniques gained wide acceptance over the last years, since ample evidence could be presented showing that this method can be applied as primary and also complementary therapies in resectable and non-resectable metastatic disease. furthermore, recent data confirm that in multimodality therapy concepts, progression free survival and overall survival in patients with primarily unresectable and with unfavourable prognosis is comparable to surgery with 5-year survival rates more than 50%. minimally invasive, imageguided therapies will not replace surgical resection; however, these therapy modalities are eligible in a large number of cases and should be implemented consequently in multimodality treatment regimens according to the interdisciplinary consensus of oncologists, interventional radiologists, and surgeons. colorectal liver metastases are typically identified as low attenuation lesions on portal venous phase ct. planning of optimal therapy depends on accurate localisation and characterisation of all focal liver lesions and this is best achieved with mri, which should include diffusion-weighted imaging and use of hepatocyte-specific contrast medium. the typical mri signature of colorectal metastases includes low signal on t1w, moderately increased signal on t2w, irregular peripheral arterial phase enhancement with low signal on portal venous phase, restricted diffusion and absent hepatocytes. morphological tumour response can be assessed with either modality. size-based systems for assessing tumour response are widely applied, with recist 1.1 the most widely used at present. recist 1.1 includes several modifications that make it more user friendly than recist 1.1. more advanced morphological criteria have been described for new targeted and molecular therapies, including overall attenuation, the tumour-liver interface and the appearance of the peripheral rim of enhancement. as hepatic surgeons become more aggressive in their approach to resection in patients with liver metastases, it is important to understand that disappearance or calcification of liver metastases after treatment does not necessarily equate to a complete pathological response. the timing of imaging is therefore critical in assisting the surgeon to remove all previously affected hepatic segments after chemotherapy. learning objectives: 1. to learn about the algorithm for detecting and characterising liver metastases. 2. to understand conventional imaging criteria for assessing tumour response. 3 . to learn about the rationale for monitoring patients after radical and palliative treatments. conventional size measurement criteria remain the most widely used method to determine the response of colorectal liver metastases to treatment. however, tumour size reduction is assessed relatively late (e.g. 12 weeks after treatment) and new targeted treatment may be effective without reducing tumour size. new functional imaging techniques can be applied to quantify different aspects of tumour biology and to develop response, and predictive and prognostic biomarkers. we discuss the use of diffusion-weighted mr imaging, dynamic contrast-enhanced mr imaging and fdg-pet imaging in the evaluation of treatment response in patients with colorectal liver metastases. digital breast tomosynthesis (dbt) is a promising technique for breast imaging based on a full-field digital mammography (ffdm) platform. the x-ray tube moves through a proscribed arc, and several low-dose projection images are acquired. images are reconstructed into a stack of 1 mm slices. the radiation dose is about the same or slightly higher than for ffdm. the most important advantage of dbt is the elimination of superimposed tissue, which improves detection of lesions otherwise hidden by dense breast parenchyma and reduces the interpretation problems caused by overlapping tissue. dbt is suggested to improve sensitivity as well as specificity in women with dense breast. dbt is superior to ffdm in tumour size assessment and for mass visibility and cancer conspicuity. dbt is comparable to ffdm for evaluation of microcalcifications. dbt is superior for the detection of spiculated masses and architectural distortion. the potential to improve sensitivity and specificity is of interest for screening. an open question is whether dbt should be applied in one or two views. two-view dbt would mean a doubling of radiation dose, but a solution is the implementation of synthetic 2d images reconstructed from the 3d dataset of dbt. the synthesised images are created by summing and filtering the stack of reconstructed dbt slices. using synthetic 2d allows "combo mode" to be implemented in screening with the same radiation dose as for conventional 2d. results using dbt in breast cancer screening are very promising. different study design of published studies may explain the variations of results. magnetic resonance imaging of the breast provides a multitude of techniques for detection of breast cancer and differentiation of benign from malignant lesions. in the last few years, significant improvements of scanner hardware and equipment in terms of coils as well as sequence software have been achieved. to date, multiparametric quantitative measurement of perfusion, diffusion and tissue chemistry is possible at field strengths up to 7 tesla. although higher field strengths and improved sequence protocols provide higher signal and allow faster imaging, specific technical issues have to be considered to avoid artefacts and pitfalls. this talk aims to demonstrate the possibilities and limitations of multiparametric and (ultra-)/high-field mri. furthermore, these new techniques are put into the broader clinical context to determine the potential value for breast lesion detection and differentiation. positron emission mammography is a recently developed imaging device using positron emission technology. after injection of a positron-emitting radiotracer, the radiation is detected by a dedicated high-resolution camera, providing high spatial resolution. commercially available systems include cameras where the breast is compressed and which display a 2d image similar in its layout to a mammogram and hanging breast devices where a 3d image similar in its layout to mri is produced. these devices have been compared to pet/ct and have shown higher spatial resolution, accuracy and sensitivity in detecting malignant breast lesions. the most widely studied tracer in pet/ct and in pem is fluorodeoxyglucose (fdg). fdg is a glucose analogue and has had a major impact on oncology imaging with pet/ct. breast carcinomas demonstrate increased glucose consumption and the intensity of the uptake has been correlated with prognosis, hormonal receptor and her2 status, ki67 and nodal involvement. current potential indications for pem are detection and characterisation of breast lesions, local staging in patients with known breast cancer and baseline assessment prior to neoadjuvant chemotherapy. future developments of pem will involve new tracers and fusion with other breast imaging modalities. fluorothymidine is a proliferation tracer that seems promising in early assessment of response to chemotherapy. fluoroestradiol has the potential to image oestrogen receptor status in vivo. the possibility of pem-guided biopsy is a very exciting development and has the potential to select lesions with the highest intensity of uptake. fusion with mri, us and mammography will increase the diagnostic accuracy. the presentation will focus on two frequent findings on mri with increasing incidence during ageing, notably "unspecific" hyperintense lesions on t2/flair and cerebral mircobleeds (cmbs) on t2* or swi images. clinicoradiologic studies suggest that these t2/flair lesions are associated with increased risk of cognitive decline, stroke and death. the clinical relevance of these lesions probably depends on periventricular versus deep white matter location. radiologic-histopathologic studies correspondingly indicate that the degree of histopathologically confirmed demyelination also depends on the location of these t2/flair lesions. cerebral mircobleeds (cmbs) are punctate hypointense lesions on t2* or swi images. while multiple cmbs are associated with diseases such as cerebral amyloid angiopathy (caa), clinicoradiologic studies demonstrate increased incidence of sporadic cmbs in mild cognitive impairment (mci) and alzheimer dementia, indicating a degrading effect of cmbs on cognition. on the other hand, radiologic-histopathologic studies show that not all black spots on t2* or swi correspond to cmbs. cmb mimics include micro-calcifications. the presentation will demonstrate typical manifestations of these "unspecific" t2/flair lesions and cmbs during ageing and provide tips for the interpretation of these lesions during daily clinical routine. with the increasing use of mri, it has become more common to discover incidental brain findings. these findings may be non-specific or have some morphological characteristics and geographical distribution highly suggestive of a demyelinating disease. the term "radiologically isolated syndrome" (ris) was introduced by okuda in 2009 to describe those asymptomatic patients with radiographic abnormalities highly suggestive of multiple sclerosis (ms). sometimes, these lesions may even meet the mri criteria for dissemination in space, which are currently used to predict future development or conversion to ms in patients presenting a clinically isolated syndrome (cis). however, we must not forget that these radiological criteria should be applied only when the patient had experienced any clinical manifestations suggestive of a demyelinating disease. therefore, what happens in those patients in whom we found highly suggestive lesions but have never had symptoms? due to lack of knowledge about the natural history or evolution of this new syndrome, clinical and therapeutic management of these patients is not well established, nor is the risk of conversion to ms. recent data, however, indicate that the presence of gadolinium-enhancing cervical cord and cortical lesions significantly increases the risk of conversion to cis or ms. all these data have improved the characterisation of ris subjects and in our understanding of risk factors for initial symptom development. incidental findings on brain imaging are defined as previously undetected abnormalities of potential clinical relevance that are unexpectedly discovered and unrelated to the purpose of the imaging. incidental findings are increasingly detected in clinical practice, with screening, and in the research setting. data on the prevalence of these abnormalities are scarce, the clinical course of the findings is often unknown, and the management of such lesions is not clear. the prevalence of incidental findings can be expected to vary depending on the purpose of the imaging exams. with improvements in imaging technology (higher field scanners, new pulse sequences), the number of detected incidental findings will increase dramatically. another important point is the advent of imaging biomarkers. advanced techniques for postprocessing and analysis, such as automated segmentation of brain structures or voxel based morphometry, will lead to the discovery of imaging biomarkers. once the predictive value of these markers has been established, most mri studies of the brain, both in the clinical and research setting, will reveal information that might be relevant for the well-being of patients or participants. although still incidental, these findings can unfortunately no longer be considered unexpected. we will soon face large medical, ethical, and practical problems as a result of technical improvements. in this lecture, the most important incidental findings and their prevalence will be reported. the management of incidental findings in the clinical and research setting will be discussed. finally, recommendations for follow-up will be provided. the primary assessment of laryngeal cancer is provided by endoscopy, which is accurate in delineating both the superficial extent and functional impairment. imaging techniques are recommended to grade submucosal invasion, local and distant spread. in the last few decades, open and endolaryngeal surgical procedures as well highly sophisticated rt techniques have been developed to treat the tumour while preserving critical laryngeal functions. for example, early glottic tumours (tis-t2) can be treated by endoscopic laser excision or rt. the integration of information acquired by endoscopy and imaging is essential for proper treatment planning. the radiologist has to know that the site of origin (supraglottis vs glottis or subglottis) and local extent (superficial and submucosal) are the key tumour-related factors in planning the type of treatment. submucosal invasion has a variable impact depending on the location of the primary tumour. the 5 key issues in glottic cancers include the invasion of: the posterior paraglottic space, crico-arytenoid joint, and anterior commissure and contralateral true vocal cord, and vertical spread towards supra and/or subglottis, thyroid or cricoid cartilage. the 5 key issues in supraglottic cancers encompass the invasion of: base of the tongue, preepiglottic space, piriform sinus, vertical spread into glottis and subsequent cartilage invasion (observed exclusively in transglottic cancers). functionsparing surgical techniques -as supracricoid laryngectomies -can be applied in advanced cancers when sparing of the posterior commissure, the ipsilateral crico-arytenoid joint, the mucosa investing the upper cricoid and the outer perichondrium of the thyroid cartilage is demonstrated by endoscopic and imaging mapping. the detection of recurrent laryngeal carcinoma is often challenging. to better appraise the expected findings after initial surgery of laryngeal cancer, the classical partial laryngectomy and laser laryngeal surgery are briefly presented.(chemo)radiotherapy has become an important treatment modality for laryngeal carcinoma. the recurrence rate in t2-t4 laryngeal carcinoma is reported to be between 25% and 50%. the difficulty in differentiation between radiation reaction (such as oedema, fibrosis and soft tissue and cartilage necrosis) and recurrent disease is discussed. a histologic study on wholeorgan sections of 29 recurrent glottic carcinomas is also presented: recurrent disease presents with different tumour spread than does a primary carcinoma, resulting in difficulties in estimating the extent of tumour recurrence. currently, selected recurrences of early glottic carcinoma are, whenever possible, treated by larynx-preserving salvage surgery. in those cases, a precise evaluation of the recurrent tumour extent is mandatory for planning larynx-preserving salvage surgery. this is especially true in critical regions such as the preepiglottic space, infiltration into cartilage, contralateral tumour spread and subglottic tumour extension. the accuracy of crt-classification is relatively low: many patients with signs and symptoms suggesting tumour recurrence present with post-radiotherapy changes; small tumor foci, often localised in the subglottic region, are undetectable by imaging studies. tissue changes in the neck treated by surgery and/or radiotherapy (rt) make the detection of residual or recurrent tumour more difficult. clinical evaluation of the neck is also hampered by these changes. rt-induced fibrosis and postsurgical scar tissue make palpation of the neck very difficult. endoscopy is hampered by endolaryngeal oedema which can persist for many months post-rt. therefore, any (non-invasive) method helping in the detection of recurrence is welcome. patients at risk for local failure after rt can be successfully identified by a post-rt ct (or mr) study between 1 to 6 months after rt. the optimal time point to perform such a 'baseline study' seems to be about 3 to 4 months post-rt. patients with indeterminate findings are candidates for 'imaging surveillance'; i.e. follow-up imaging every 3 to 4 months up to a period of 2 years after rt. however, ongoing studies suggest that metabolic imaging (fdg-pet) may detect local recurrences with a higher accuracy than 'conventional' anatomically based imaging techniques, such as ct and mr. ct and/or mr-findings in the treated neck are frequently inconclusive. at present, new techniques are available to detect recurrent cancer. pet-ct is widely applied in the post-treatment setting. also, advanced mr-techniques such as diffusion weighted imaging (dwi) and dynamic contrast-enhanced mr (dce-mr) can be applied. focusing on the larynx, the advantages of these techniques as well as the limitations will be shown using imaging examples from daily practice. during the last 10 years, several hundred new radiotracers for pet imaging of cancer have been developed and tested preclinically. these tracers are based on proteins (e.g. antibodies and antibody fragments), peptides (e.g. g proteincoupled receptor ligands) or small molecules (e.g. radiolabelled protein kinase inhibitors or metabolic substrates). using these radiotracers, the expression and function of a variety of proteins can be studied in patients, including for example glutamine/glutamate metabolism, neutral amino acid transport, psma, grpr, sstr, cxcr4, folate and alpha-v beta-3 integrin expression. some of these radiopharmaceuticals are potential companion diagnostics and may allow selection of patients for treatment with radiopharmaceuticals or targeted drug conjugates. preclinical and initial clinical data are promising for several new radiotracers, but the key challenge is the clinical validation and dissemination of these compounds. validation and dissemination have been hampered so far by regulatory hurdles as well as by the lack of standardised trial designs for the validation of imaging agents and the lack of accepted and appropriate end points to prove clinical utility. addressing these issues will be critical for the future clinical use of pet and other molecular imaging technologies. imaging targets in cancer range from simple size measurements to more specific biomarkers on functional, cellular, metabolic and molecular levels. as our understanding of basic tumour biology has advanced, techniques have been developed to exploit this information to produce increasingly specific molecular imaging tools. the biodistribution of these molecular imaging probes should be more specific in diagnosing and assessing cancer than the morphological information acquired using anatomical imaging alone. this lecture will discuss current and emerging functional and molecular imaging techniques using mri and their applications in oncology. functional measures of tumour blood flow and vascular permeability can be made using dynamic contrast-enhanced mri. diffusion-weighted imaging is a surrogate for the cellular content of the tumour and emerging methods can be used to probe features of the extracellular space such as tumour ph and stromal content. on the molecular level, cell surface expression of specific proteins and enzyme activity within the cell can be imaged; labelled probes have been developed which bind to these proteins and a new mr technique is being developed for assessing tumour glucose in a similar way to pet. hyperpolarisation methods are emerging to overcome the major limitation of mr: low sensitivity. one such approach is dynamic nuclear polarisation, which can probe carbon metabolism non-invasively in patients with cancer. functional and molecular imaging techniques with mri will increasingly be used in radiology in conjunction with anatomical imaging methods to improve diagnosis and prognosis, target biopsies, as well as predict and detect response to treatment. with mr-spectroscopy, diffusion-weighted imaging, pet-and spect-ct, as well as pet-mri, molecular imaging has already become part of clinical routine diagnosis. also, some contrast agents such as spio for mps-labelling and scavenger-receptor binding gadolinium chelates are clinically applied for liver and lymph node imaging. however, there are still a number of highly promising novel tools that are expected to emerge clinically in the near future. in this context, the first part of the talk will give an overview on how optical imaging basically works and which future clinical applications can be expected. in this context, raman spectroscopy, fluorescence optical reflectance imaging, fluorescence mediated tomography, photoacoustic imaging and cerenkov luminescence imaging will be addressed. the second part of the talk introduces molecular ultrasound imaging as a safe and preclinically wellevaluated method. besides the diagnostic use of molecular ultrasound contrast agents, which have been already evaluated in clinical trials, the potential of this method also for theranostic purposes will be highlighted. the assessment of the amount of arterial calcification with computed tomography is a standard method in the risk stratification of coronary heart disease. coronary calcium detection by ct has been shown to identify atherosclerotic plaque and to quantitatively assess coronary calcium. many studies have demonstrated the association between the degree of coronary calcium, the burden of atherosclerosis, and the risk for cardiovascular events associated with coronary calcium. the cac scoring can provide individual risk assessment and reclassify the low and particularly intermediate framingham risk cohort into lower-and higher-risk strata. the absence of cac is associated with a very low risk of future cardiovascular events, with modest incremental value of other diagnostic tests in this very low-risk group. the role of cac in the workup of symptomatic patients is under discussion and there is evidence that the absence of cac has a high negative predictive value for ruling out acute coronary syndrome. although cac measurement is highly standardised, some technical aspects have to be considered and all possibilities of dose reductions utilised. this presentation will show the technical and epidemiological fundamentals of cac scoring and discuss the clinical applications of the method. coronary cta has gained an important role in the evaluation of patients with chest pain, suspected of coronary artery disease (cad). in comparison to invasive coronary angiography, coronary cta with 64-multidetector ct has an excellent sensitivity for coronary stenosis. specificity for stenosis is less excellent, but has improved with newer ct generations. the strongest impact of coronary cta has been on the exclusion of stenosis in symptomatic patients at low-intermediate pre-test probability. in contrast to invasive angiography, coronary cta yields more information than just the severity of stenosis. coronary cta also allows determination of plaque types (calcified, non-calcified, partly calcified) and quantification of the atherosclerotic plaque burden. also, new developments point to the possibility to assess the haemodynamic significance of stenosis based on ct density measurements in the coronary arteries, or evaluation of myocardial perfusion. thus, coronary cta yields quantitative imaging biomarkers that could be used for risk stratification in the future. recent studies have shown that whether or not a patient has stenosis and plaque, as well as the type and burden of plaque, affects the risk of myocardial infarction and mortality. therefore, the impact of coronary cta imaging biomarkers reaches beyond the mere assessment of stenosis for symptomatic treatment and could potentially alter medical management of patients for improvement of long-term prognosis. a-608 17:00 c. added value of carotid and peripheral artery imaging for risk assessment l. natale; rome/ it (lnatale@rm.unicatt.it) technical protocols optimisation of mra and cta of carotid and peripheral arteries is crucial for image quality and to complete the analysis of both lumen and vessel wall. furthermore, mra protocol needs to be integrated with dedicated pulse sequences in order to obtain vessel wall imaging that is already included in cta datasets. new ct and mr scanners allow this optimisation in terms of radiation exposure, contrast media dose reduction and spatial resolution. all these parameters will be discussed for both techniques. according to international guidelines, non-invasive imaging indications will be discussed, with particular attention to high risk population (e.g.: diabetic patients). some possible imaging biomarkers of plaque composition will be discussed. learning objectives: 1. to become familiar with optimal technical considerations for performing cta and mra of the carotid and peripheral arteries. 2. to understand clinical indications for carotid and peripheral cta and mra. 3. to discuss the role of cta and mra parameters including plaque imaging as biomarkers of cardiovascular disease. key: cord-274481-k1dp1ilv authors: falavigna, maicon; colpani, verônica; stein, cinara; azevedo, luciano cesar pontes; bagattini, angela maria; de brito, gabriela vilela; chatkin, josé miguel; cimerman, sergio; corradi, mirian de freitas dal ben; da cunha, clovis arns; de medeiros, flávia cordeiro; de oliveira junior, haliton alves; fritscher, leandro genehr; gazzana, marcelo basso; gräf, débora dalmas; marra, lays pires; matuoka, jessica yumi; nunes, michelle silva; pachito, daniela vianna; pagano, cássia garcia moraes; parreira, patrícia do carmo silva; riera, rachel; silva júnior, amilton; tavares, bruno de melo; zavascki, alexandre prehn; rosa, regis goulart; dal-pizzol, felipe title: guidelines for the pharmacological treatment of covid-19. the task-force/consensus guideline of the brazilian association of intensive care medicine, the brazilian society of infectious diseases and the brazilian society of pulmonology and tisiology date: 2020 journal: rev bras ter intensiva doi: 10.5935/0103-507x.20200039 sha: doc_id: 274481 cord_uid: k1dp1ilv introduction: different therapies are currently used, considered, or proposed for the treatment of covid-19; for many of those therapies, no appropriate assessment of effectiveness and safety was performed. this document aims to provide scientifically available evidence-based information in a transparent interpretation, to subsidize decisions related to the pharmacological therapy of covid-19 in brazil. methods: a group of 27 experts and methodologists integrated a task-force formed by professionals from the brazilian association of intensive care medicine (associação de medicina intensiva brasileira amib), the brazilian society of infectious diseases (sociedad brasileira de infectologia sbi) and the brazilian society of pulmonology and tisiology (sociedade brasileira de pneumologia e tisiologia sbpt). rapid systematic reviews, updated on april 28, 2020, were conducted. the assessment of the quality of evidence and the development of recommendations followed the grade system. the recommendations were written on may 5, 8, and 13, 2020. results: eleven recommendations were issued based on low or very-low level evidence. we do not recommend the routine use of hydroxychloroquine, chloroquine, azithromycin, lopinavir/ritonavir, corticosteroids, or tocilizumab for the treatment of covid-19. prophylactic heparin should be used in hospitalized patients, however, no anticoagulation should be provided for patients without a specific clinical indication. antibiotics and oseltamivir should only be considered for patients with suspected bacterial or influenza coinfection, respectively. conclusion: so far no pharmacological intervention was proven effective and safe to warrant its use in the routine treatment of covid-19 patients; therefore such patients should ideally be treated in the context of clinical trials. the recommendations herein provided will be revised continuously aiming to capture newly generated evidence. early in december 2019, the first cases of novel pneumonia from unknown etiology were described in the city of wuhan, china. subsequent studies have the recommendation panel was composed of 13 voting members, guideline methodologists (five members), and researchers responsible for the literature systematic review (nine members). the participants were indicated by the specialty societies or by the group methodologists, aiming to provide representativity and balance of technical competencies. potential conflicts of interest data were collected with the standard who formulary. members with a direct financial conflict of interest related to a given intervention had no right to vote for the related questions. a list of participants, their role in the guideline, and statement of conflicts of interest are provided in appendix 1. the questions were first proposed by the group of methodologists, and revised by the panel experts. the inclusion criteria were: a drug available for prescription in brazil, and a clinical practice variability, or a clinically relevant doubt related to its use, being this last the prioritizing factor for clinical questions. eight questions were prepared according to the acronym pico (population, intervention, comparator, and outcome), considering six drug classes (aminoquinolines, antivirals, antibiotics, corticosteroids, anticoagulants, and immunobiologicals). each research question could generate one or more recommendations. remdesivir was not included in this document as, by the assessment time, it was not approved for prescription in brazil. were considered, but not prioritized, questions related to the use of nonsteroidal anti-inflammatory drugs and angiotensin receptor blockers (arbs) or angiotensinconverting enzyme inhibitors. during the conduction of the recommendations panel, the question on the use of heparin was requested to be included, once it was not part of the initial scope. the searches were conducted on medline (via pub-med®), the cochrane central, and embase databases, and also in the grey-literature bases, between april 22 and 30, 2020. additionally searches on prepublication articles sources, such as opengrey (http://www.opengrey.eu), medrxiv (https://www.medrxiv.org), and biorxiv (www. biorxiv.org) were conducted; these articles were considered during the analyses, even though not peer-reviewed. the search strategies are shown in appendix 2. additional evidence, emerging during the process and identified by members of the group, were considered during the discussions, although not included in the initial search results. literature search, data extraction, and synthesis were performed by one single investigator and checked by a second revisor in case of doubts or inconsistencies. (11, 12) the synthesis was conducted in a qualitative model. first, titles and abstracts of the identified manuscripts were identified by the search strategy, and potentially eligible studies preselected. second, the full text of the selected papers was assessed, to confirm eligibility. considering the limited number of studies published so far, the following study designs were taken into consideration according to the evidence hierarchy: randomized clinical trials, quasi-randomized clinical trials, non-randomized clinical trials, cohort studies, casecontrol studies, series and case studies. the assessment of methodological quality and/or risk of bias of the included articles was conducted with tools appropriate for each study design: amstar-2 for systematic reviews with and without metanalysis; (13) cochrane's risk of bias table for randomized clinical trials; (14) robins-i for non-randomized or quasi-randomized clinical trials; (15) robins-i or newcastle-ottawa for longitudinal comparative observational studies (case-control and cohort); (15, 16) the joanna briggs institute case-series tool for phase i or phase ii trials without a direct comparator and case-series (17) and the joanna briggs institute toll for cross-sectional studies. (18) the grade (9, 19) system was used for the assessment of the quality of the evidence and the development of recommendations. previously to the recommendations meetings, the certainty of the evidence was rated either as high, moderate, low, or very low (table 1) . according to this methodology, recommendations may be either strong or weak (conditionals), favorable or against the intervention. the implication of the strength of the recommendation is shown in table 2. the data from the systematic review for each pico question were compiled into evidence profiles and presented to the experts' panel. (20) (21) (22) (23) (24) for the development of recommendations were considered: benefits, risks, quality of the evidence, costs, and variability of implementation. the recommendations were agreed upon by teleconferences held on may 5, may 8, and may 13, 2020. whenever appropriate, the panel could provide recommendations according to subpopulations. a consensus was aimed for all the recommendations; if no consensus could be achieved, a voting procedure was conducted, and a simple majority required for approval of that specific recommendation. the target population for the recommendations is constituted of patients either diagnosed or clinically suspected of sars-cov-2 infection. clinical suspicion is when, based on epidemiological data, clinical history, signs, and symptoms, in addition to complementary tests, covid-19 is the most likely diagnostic hypothesis. information on diagnosis can be found elsewhere. (25) (26) (27) the disease severity was grouped into five categories, in line with the national institutes of health (nih) guidelines for the treatment of covid-19 (table 3 ). (28) for the categorization of acute respiratory distress syndrome (ards) the berlin's criteria were adopted as presented in table 4 . eleven recommendations were issued. these recommendations are summarized in table 5. detailed information on the evidence is shown in appendix 3, as grade evidence profiles, with complete references. high strong confidence that the true effect lies close to that of the effect estimate. it is unlikely that additional trials will change the confidence in the estimated effect. moderate moderate confidence in the effect estimate. future trials may modify the confidence in the effect estimate, and also can change the estimate. limited confidence in the effect estimate. future trials are likely to importantly impact our confidence in the effect estimate. very low uncertain confidence in the effect estimate. any effect estimate is uncertain. source: grading of recommendations assessment, development, and evaluation (grade) working group. handbook for grading the quality of evidence and the strength of recommendations using the grade approach. updated october 2013. available from: https://gdt.gradepro.org/app/handbook/handbook.html. (19) the recommendation should be adopted as a healthcare policy in most of the situations. substantial debate required and the involvement of stakeholders. most of the individuals would want the intervention to be indicated, and only a small number would reject the recommendation. a large portion of the individuals would want the intervention to be indicated; however, some individuals would reject the recommendation. most of the patients should receive the recommended intervention. the clinician should acknowledge that different choices are appropriate for each patient and choose consistently with his/her values and preferences. may 18] . available from: https:// www.covid19treatmentguidelines.nih.gov/. (28) recommendation 1 -we suggest against the routine use of hydroxychloroquine or chloroquine for treatment of covid-19 patients (weak recommendation; level of evidence: low). summary of the evidence: the systematic review identified three comparative clinical trials with available data on the effects of hydroxychloroquine (hcq) in covid-19 patients: two open randomized clinical trials (29, 30) in a patient population with mild to moderate disease, and one cohort study. (31) no trials comparing chloroquine (cq) to non-cq therapy were found. the combined data from both clinical trials failed to show clinical-radiological improvement (relative risk -rr = 0.61; 95% confidence interval [95%ci] 0.26 -1.43), or improved viral negativation rates within seven days (rr = 2.00; 95%ci 0.02 -20.00), (29, 31) however, one of the studies prepublication version has shown on the raw data analysis an increased improvement rate with hcq (80.6% versus 54.8%; p = 0.0476). (30) mortality and mechanical ventilation requirements, considered to be clinically relevant outcomes, were assessed in an observational study with 364 patients, (32) showing an increased mortality rate with hcq (hcq: 27.8%; hcq + azithromycin: 22.1%; standard therapy: 11.4%), with a significant association remaining after the propensity score-adjusted analysis comparing hcq to the standard therapy (hazard ratio -hr = 2.61; 95%ci 1.10 -6.17). (32) after the review date, an additional cohort study was identified involving 1,376 moderate to severe covid-19 hospitalized patients. in this study, no association was found with death or invasive mechanical ventilation requirement (hr = 1.04; ci95% 0.82 -1.32). (33) this trial was considered in the evidence analysis and because it was a well-designed observational study, with adjustment for confounders and appropriate sample size, the degree of confidence for the lack of benefit was increased from very low, to low. the association between hcq and arrhythmias is well-known. an observational study has shown that seven out of 37 (19%) patients receiving hcq monotherapy developed a qt interval ≥ 500ms. (34) additionally, in a randomized clinical trial that compared patients using high-dose (1,200mg cq for 10 days; total dose 12g) versus a lower dose (900mg on the first day, followed by 450mg daily for four days; total dose 2.7g), a 13.5% (95%ci 6.9 -23.0%) overall mortality rate was found in association with the high-dose (in this trial both groups had a cointervention with ceftriaxone and azithromycin), suggesting a potential dose-response gradient. (35) comments: the recommendations panel interpreted that the available evidence suggests no clinically significant benefit of hcq or cq therapy. there was an agreement that the risk of cardiovascular adverse events is moderate, particularly regarding arrhythmias. so far, the existing comparative trials have only assessed hospitalized patients, therefore providing no basis for considerations on using or not these drugs in outpatients. the prescription of these products may be considered on a shared clinicianpatient decision, only for severe or critically ill patients, hospitalized, under constant qtc interval monitoring, and avoiding concomitant qtc prolonging therapies. its use should preferably be under clinical trial protocols. recommendation 2 -we suggest against the routine use the hydroxychloroquine or chloroquine plus azithromycin combination for treatment of covid-19 patients (weak recommendation; level of evidence very low). summary of the evidence: no clinical trials were identified to assess azithromycin monotherapy. azithromycin added to an hcq regimen was assessed in one single trial, showing improved viral negativation in the group treated with the combination therapy (hq + azithromycin 100%; n = 6/6 versus hq 57%; n = 8/14; six-day negativation). (36) no randomized clinical trials were identified for the comparison of hcq + azithromycin versus standard therapy. viral negativation was assessed by four studies, three from the same research group, showing viral negativation above 90% after five to 10 days therapy; (36) (37) (38) in contrast, in one study treating ten patients with hcq + azithromycin, negativation was found in only two patients (20%). (39) a total of six studies assessed mortality, with 35 deaths among 1,342 patients. (35, (37) (38) (39) (40) (41) regarding adverse cardiovascular events, eight studies were identified. five of them found a prolonged qt interval in some patients treated with hcq/cq plus azithromycin. (35, 39, 40, 42, 43) a retrospective analysis of 130 thousand rheumatoid arthritis patients showed an increased risk of cardiovascular death with hcq + azithromycin as compared with hca + amoxicillin (hr = 2.19; 95%ci 1.22 -3.94; 30-day outcome). (44) the same analysis has also shown an increased risk of angina (hr = 1.15; 95%ci 1.05 -1.26) and heart failure (hr = 1.22; 95%ci 1.02 -1.45). in a non-comparative trial with 1,061 patients with hcq + azithromycin, no patient has shown to have heart toxicity. (38) comments: the recommendations panel interpreted that the available evidence does not suggest a clinically significant benefit from the treatment with hcq or cq in combination with azithromycin. there was an understanding that there is an associated moderate increase of cardiovascular adverse events, especially arrhythmias, potentialized by the association of hcq/ cq with azithromycin, and additional care related to these adverse events is required. so far, the existing comparative trials have only assessed hospitalized patients, providing no basis for discussions on using or not this combination in outpatients. its use may be considered in a shared clinician-patient decision, only in severe or critically ill patients, hospitalized, with frequent qtc interval monitoring and avoiding qtc prolonging concomitant therapy. its use should be preferentially under clinical trial protocols. recommendation 3 -we recommend against the use of oseltamivir for the treatment of covid-19 in patients with no suspected influenza coinfection (strong recommendation; level of evidence very low). recommendation 4 -we suggest the use of empirical oseltamivir treatment in patients with severe acute respiratory syndrome (sars) or flu-like syndrome with risk factors for complications when a diagnosis of influenza cannot be ruled out (weak recommendation; level of evidence very low). summary of the evidence: no randomized clinical trial assessing the effectivity of oseltamivir in covid-19 patients was identified. a cohort study with 504 covid-19 hospitalized patients assessed the use of oseltamivir, lopinavir/ritonavir, and umifenovir. (45) the mortality rate in the oseltamivir group (n = 66) was 12.2% versus 16.2% in the non-oseltamivir group (odds ratio -or = 0.71; 95%ci 0.28 -1.59). also, no difference was found regarding lung injury improvement as assessed by a chest ct scan (41.2% versus 43.3%). the study has important methodological issues, such as lacking randomization, sample representativity, and control for confounders. comments: the recommendations panel interpreted that there is no evidence to support the use of oseltamivir for sars-cov-2 therapy; besides, there is no theoretical rationale to support this use. however, oseltamivir may be considered in cases of suspected influenza infection in patients with ards or flu-like syndrome with risk-factors for influenza complications (chronic diseases, immunosuppression, age ≥ 65 years, and pregnant women). (46) the usual dose for adults with appropriate renal function is 75mg twice daily for five days. (25, 47) suspected influenza should take into consideration the patient's symptoms, radiological findings, as well as local epidemiology. a suspect may remain even in individuals with a history of immunization, once the vaccine's effectiveness is rarely above 80%. (48, 49) if testing for influenza is possible, oseltamivir may be stopped upon negative results, given the available test has appropriate sensitiveness for seasonal a, b, and h1n1 influenza. the decision on oseltamivir use was made based on indications for its use out of the context of the covid-19 pandemic, with no appropriate information on the behavior of influenza in the scenery of a sars-cov-2 epidemics. (46) if well-developed local protocols are in place, we suggest them to be adhered to. recommendation 5 -we suggest against the routine use lopinavir/ritonavir for treatment of covid-19 (weak recommendation; level of evidence low). summary of the evidence -two randomized clinical trials assessed the use of lopinavir/ritonavir in covid-19 patients. (50,51) one of them assessed 90 patients in the lopinavir/ritonavir group and 100 patients with standard therapy. patients in the intervention group had lower but not statistically significant mortality rates (19.2% versus 25%; 28-day mortality rate), and no clinically significant improvement within 14 days (45.5% with the intervention versus 30% in the control group; p < 0.05); the time to clinical improvement was reduced in one day (median: 15 days versus 16 days; hr = 1.39; 95%ci 1.00 -1.91; modified intention-to-treat analysis, excluding three early mortality patients). (50) another randomized clinical trial included 21 patients in the lopinavir/ritonavir group and seven in the control group, with no statistically significant difference between the groups for outcomes such as fever, coughing relief rate, clinical condition deterioration rate, and ct scan improvement. (51) in both trials, there was no viral negativation difference between the groups. the adverse effects observed included anorexia, nausea, abdominal discomfort or diarrhea, acute gastritis, and reduced appetite; the lopinavir/ritonavir discontinuation rate was 13.8%. (5l) comments: the recommendations panel interpreted that the available evidence suggests no clinically significant benefit from the lopinavir/ritonavir therapy. this therapy could be considered promising, and the lack of observed benefits may result from the small number of assessed patients. despite the high discontinuation rate due to adverse events and potential drug interactions, lopinavir/ ritonavir is a relatively safe therapy for short term courses. this drug may be considered upon a clinician-patient shared decision, in hospitalized severe and critically ill patients, in centers with professionals experienced with this therapy. it should be preferably used under clinical trial protocols. recommendation 6 -we suggest against the routine use corticosteroids for covid-19 patients' treatment (weak recommendation; level of evidence very low). summary of the evidence: no clinical trials specifically assessing the use in covid-19 patients were found. four observational studies reported that the use of corticosteroids during hospitalization is associated with increased mortality; these studies combined hospitalized patients' populations, however, with heterogeneous clinical features. (52-55) one trial, however, suggests that the use of methylprednisolone reduced the risk of death in patients with ards (hr = 0.38; 95%ci 0.20 -0.72). (56) the outcomes for respiratory symptoms are variable in hospitalized patients. (57, 58) the studies' limitations include the lack of randomization and control groups, variable doses used, small samples, and retrospective analysis of the data. despite the systematic review conducted did not involve other coronaviruses infections, indirect information on sars and mid-east respiratory syndrome (mers) show an absence of impact on mortality (rr = 1.07; 95%ci 0.81 -1.42) and a prolonged time to viral negativation (3.78 days; 95%ci 1.16 -6.41 days). (59) comments: the recommendations panel interpreted that there is no evidence supporting the routine use of corticosteroids for covid-19 patients. corticosteroids should be avoided during the first seven to 10 days after the symptoms start, when the viral response is more relevant, as there is evidence that corticosteroids may delay viral negativation. some evidence points out to a potential benefit for moderate to severe ards patients out of the viral infection context. (60) its use may be considered for selected cases with moderate to severe ards, without suspected uncontrolled bacterial infection, 10 to 14 days after the covid-19 symptoms start. the doses used in the studies ranged between 10mg and 20mg dexamethasone or 40mg to 120mg methylprednisolone daily, for five to 10 days. their use should preferentially be under clinical research protocols. patients with other indications for corticosteroids use (e.g.: asthma and exacerbated chronic obstructive pulmonary disease -copd) should use these drugs according to the clinical indication, assessing other potential risks and benefits during covid-19 infection. recommendation 7 -we suggest against the routine use tocilizumab for covid-19 treatment (weak recommendation; level of evidence very low). summary of the evidence: no comparative trials evaluating tocilizumab effectiveness in covid-19 patients were found; only two case series were identified. one of the series included 21 patients, all with chest ct changes, 20 on ventilatory support (45% with high-flow oxygen, 35% with a nasal cannula, 5% with an oxygen mask, 5% with non-invasive mechanic ventilation and 10% with invasive mechanical ventilation). within five days, 75% of them had their ventilatory support requirements reduced; no deaths occurred during the follow-up period. (61) in another case series 15 patients were included, two moderately ill, six with severe disease, and seven in a very severe condition. of the 15 patients, three died, two had increased severity, nine had clinical stabilization and one showed clinical improvement. serum interleukin-6 (il-6) was reduced in 10 patients after tocilizumab; increased il-6 was found in the five patients with treatment failure, all of them with an initially very severe condition. (62) comments: the recommendation panel interpreted that no benefit and safety evidence was shown that would suggest the routine use of tocilizumab. besides, this drug is costly, and especially during an epidemic, the use of resources should be rationalized, and the use of interventions with no benefit evidence avoided. this drug may be considered in a shared clinician-patient decision for severe and critically ill hospitalized patients, with a confirmed diagnosis of sars-cov-2 infection, and significantly increased markers or inflammation (e.g.: il-6, d-dimer, c reactive protein, lactate dehydrogenase -ldh, and ferritin). the use of tocilizumab should be restricted to centers with professionals who are experienced in its use. tocilizumab use should preferentially be under clinical trial protocols. recommendation 8 -we recommend the routine use of venous thromboembolism prophylaxis in covid-19 hospitalized patients (strong recommendation; level of evidence very low). recommendation 9 -we suggest against the routine use therapeutic heparin doses for covid-19 treatment (weak recommendation; level of evidence very low). summary of the evidence: two retrospective cohorts were identified. (63,64) one of them assessed 449 severe or critically ill hospitalized covid-19 patients; 99 of them were given heparin for at least seven days (94 enoxaparin 40mg -60mg daily and five unfractionated heparin 10,000 -15,000iu/daily), and 350 control patients (without any anticoagulant or heparin, or less than seven days of use). in this study, the 28-day mortality rate was similar (heparin 30.3% versus controls 29.7%). in the subgroup with an international society on thrombosis and hemostasis -sepsis-induced coagulopathy score (isth sic) ≥ 4 (from one of the following features: platelets < 100,000, international normalized ratio -inr > 1.4 or a sequential organ failure assessment -sofa -score ≥ 2), the mortality in the heparin group was lower (40% versus 64.2%; p = 0.029; n = 97). increased effectiveness was also seen in patients with increased d-dimer, with a significantly reduced mortality in a group with d-dimer values above or equal to six-times the upper limit of the normal (32.8% versus 52.4%; p = 0.017). (64) in a study that assessed 42 patients, all of them with an immunosuppressor or corticosteroids, and severe to moderate covid-19, 21 patients were given low molecular weight heparin (13 enoxaparin 40mg daily, two enoxaparin 20mg daily, four nadroparin 4,100iu daily and two low molecular weight sodium heparin 5,000iu daily, median: 11 days) and 21 controls, d-dimer and il-6 levels were significantly reduced, and lymphocytes counts were increased, with no hospital length of stay differences. (65) comments: the recommendations panel interpreted that there is no indication for therapeutic dose heparins (e.g.: enoxaparin 1mg/kg subcutaneously -sc -every 12 hours) for the treatment of covid-19. the rationale for other anticoagulants is analogous. anticoagulation is associated with an increased risk of bleeding events and should be restricted to patients with a clear indication (e.g.: atrial fibrillation, pulmonary thromboembolism, deep venous thrombosis, among others), according to appropriate protocols. covid-19 patients apparently have an increased risk of thromboembolic events, and the assisting team should be aware of developing signs and symptoms. covid-19 hospitalized patients should be given thromboembolism prophylaxis according to risk-stratification strategies, adhering to local hospital protocols. however, the use of prophylactic doses can be extended to all covid-19 patients, as some sars-cov-2 patients appear to have a hypercoagulability state, with increased thromboembolic events rate as seen in observational clinical trials and post mortem examinations. (66,67) as an example, enoxaparin 40mg to 60mg sc oncedaily doses, or unfractionated heparin 5,000iu sc twice or three times a day, could be used. although there is limited evidence for pharmacological prophylaxis in covid-19 patients, this is a low-cost and well-tolerated intervention that may potentially prevent major clinical events. heparin should not be used for cases with contraindications (e.g.: increased risk of bleeding, active bleeding, and severe thrombocytopenia); (68) low molecular weight heparin should be used carefully in renal dysfunction patients. recommendation 10 -we suggest against the use prophylactic antibiotics in patients with a suspected or confirmed covid-19 diagnosis (weak recommendation; level of evidence very low). summary of the evidence: no randomized clinical trials were found to assess the empirical antibiotics therapy effectiveness in covid-19 patients without evidence of bacterial infections. therefore, so far there is no clinical data enough to show benefits or risks of antibiotics in covid-19 patients with no signs of bacterial infection. we did not access the evidence for bacterial infections therapy. comments: the panel interpreted that considering the lack of evidence, there is no base for prophylactic antibiotic therapy in covid-19 patients. in addition to the lack of benefit evidence, this could result in adverse events, increased antimicrobial resistance, and costs. there is no appropriate data on bacterial coinfection in covid-19 patients, however, one should bear in mind that overlapping infections may occur. it is understood that those patients should be given antibiotics, similarly to covid-19 patients, taking into consideration the local epidemiology and adhering to local protocols and guidelines from infection control services. table 6 shows a didactic summary of the recommendations according to the evaluated interventions, presenting their judgment regarding perceived benefits, risks, costs, availability, and evidence. appendix 4 presents the most important drug interactions of potential covid-19 therapies. during epidemics, when consolidated effective therapies are not available, there is a trend to use therapies based on preclinical studies results, or based on observational studies with important limitations. (69) experiences from other epidemics have shown that such interventions benefits may be far below the expected, as with oseltamivir during the influenza a (h1n1) epidemics in 2009. (60,70) during the ebola virus epidemics in 2014, several interventions were tested, including cq, hcq, favipiravir, immunobiological agents, and convalescent plasma; none was proven effective. (71) by the time when this guideline is publicized, we face a scenario where no specific covid-19 proposed intervention is proven effective. regarding safety, drugs such as hcq (especially when combined with azithromycin) at the doses proposed for covid-19 have been shown relevantly associated with cardiovascular events. (34, 35, 40, 45) in the absence of effective therapies, treatment under clinical trial protocols should be encouraged. in this context, healthcare professionals should seek information on therapeutic clinical trials, especially randomized clinical trials, already approved by regulatory agencies and ethical committees possibly ongoing in their institutions. several other interventions are proposed, such as remdesivir, beta interferon, ivermectin, nitazoxandine, convalescent plasma, umifenovir, among others. (72) (73) (74) (75) (76) (77) this guideline chose to prioritize those interventions raising more clinical practice concerns in brazil by the time of its development. of note, the current speed of covid-19 knowledge generation renders these recommendations prone to become outdated in a short frame of time. as most of the interventions are based on evidence from small observational or interventional trials, we understand that as new well-designed clinical trials, with appropriate sample sizes, are published, there is a huge potential that herein presented recommendations shall be changed. therefore, it is of paramount importance that readers of this guideline keep this in mind as one of the most important limitations of this document. also, it is necessary to understand that a clinical guideline aims to guide the clinical practice not necessarily applicable to every patient. the scarcity of evidence with appropriate methodology renders impossible to provide more categorical recommendations; we stress that a significant portion of the studies we evaluated was preliminary published in ahead of print bases, with no editorial board and peer review evaluations. therefore, in this document we present suggested actions, to be contextualized according to features such as the patient's clinical profile, existing comorbidities, and risk of developing adverse effects, in addition to the assisting team's experience with the proposed interventions, patient's preferences, service structure, as well as costs and available resources. regarding costs, in the context of public health, it is important to emphasize that, in a scenario of an epidemic, resource allocation should be prioritized to interventions more likely to be beneficial, such as personal protective equipment and interventions related to the patient's ventilatory support. therefore, under the light of the current covid-19 knowledge, some investments in pharmacological therapies are debatable. however, the treatment of patients under clinical trial protocols, with appropriate study design and the potential to provide an answer to the society, should be encouraged. with this document we hope to guide clinical practice in a national context, therefore reducing the therapeutic variability. in addition to the evidence available in the scientific literature, the recommendations took into consideration some brazilian specific features, such as the availability of some drugs (either because of lack of regulatory clearance or due to difficult access), population and healthcare professionals acceptance, and costs associated with their use. also, most of this document's recommendations are in line with who therapeutic recommendations. (27) this document consists of a joint positioning by three medical societies, taking into consideration the need for the development of encompassing recommendations and contextualization of different medical specialties regarding of the frailty of the available evidence, that may be an applicable tool both for physicians working in the public health system and the supplementary system. the developing group is committed to strive for periodically bring updates to this document, in a context of living guidelines, (78) where recommendations are updated as new evidence becomes available. additional interventions will be included as they become relevant doubts for covid-19 therapy. ) or "bulbul coronavirus hku11" or "thrush coronavirus hku12" or "novel coronavirus" or "covid-19" or "sarscov 2" or "betacoronavirus*" #2 "anti-bacterial agents" [mesh] or "anti-bacterial agents" or "agents, anti-bacterial" or "anti-bacterial agents" or "antibacterial agents" or "agents, antibacterial" or "anti-bacterial compounds" or "anti-bacterial compounds" or "compounds, anti-bacterial" or "bacteriocidal agents" or "agents, bacteriocidal" or "bacteriocides" or "anti-mycobacterial agents" or "agents, anti-mycobacterial" or "anti mycobacterial agents" or "antimycobacterial agents" or "agents, antimycobacterial" or "antibiotics" or "antibiotic" or "antimicrobials" or "antibacterials" or "azithromycin" [mesh] or "azythromycin" or "sumamed" or "toraseptol" or "vinzam" or "cp-62993" or "cp 62993" or "cp62993" or "zithromax" or "azitrocin" or "azadose" or "ultreon" or "zitromax" or "azithromycin dihydrate" or "dihydrate, azithromycin" or "azithromycin monohydrate" or "monohydrate, azithromycin" or "goxal" or "zentavion" #5 "enoxaparin"[mesh] or enoxaparin or enoxaparine or "pk-10,169" or "pk 10,169" or "pk10,169" or "pk-10169" or "pk 10169" or "pk10169" or "emt-967" or "emt 967" or "emt967" or lovenox or clexane or "emt-966" or "emt 966" or "emt966" #6 "nadroparin"[mesh] or nadroparine or "nadroparin calcium" or "calcium, nadroparin" or fraxiparin or fraxiparine #7 "dalteparin"[mesh]" or tedelparin or "dalteparin sodium" or "sodium, dalteparin" or fragmin or fragmine #8 #2 or #3 or #4 or #5 or #6 or #7 #9 #1 and #8 or "bulbul coronavirus hku11" or "thrush coronavirus hku12" or "novel coronavirus" or "covid 19" or "sarscov 2" or "betacoronavirus*" #2 "anti-bacterial agents" [mesh] or "anti-bacterial agents" or "agents, anti-bacterial" or "anti-bacterial agents" or "antibacterial agents" or "agents, antibacterial" or "anti-bacterial compounds" or "anti-bacterial compounds" or "compounds, anti-bacterial" or "bacteriocidal agents" or "agents, bacteriocidal" or "bacteriocides" or "anti-mycobacterial agents" or "agents, anti-mycobacterial" or "anti mycobacterial agents" or "antimycobacterial agents" or "agents, antimycobacterial" or "antibiotics" or "antibiotic" or "antimicrobials" or "antibacterials" or "azithromycin" [mesh] or "azythromycin" or "sumamed" or "toraseptol" or "vinzam" or "cp-62993" or "cp 62993" or "cp62993" or "zithromax" or "azitrocin" or "azadose" or "ultreon" or "zitromax" or "azithromycin dihydrate" or "dihydrate, azithromycin" or "azithromycin monohydrate" or "monohydrate, azithromycin" or "goxal" or "zentavion" or "vancomycin" [mesh] or "vancomycin" or "ceftriaxone" [mesh] or "ceftriaxone" or "cefepime" [mesh] or "cefepime" or "levofloxacin" [mesh] or "levofloxacin" or "fluoroquinolones" [mesh] or "fluoroquinolones" or "amoxicillin" [mesh] or "amoxicillin" or "ciprofloxacin" [mesh] or "ciprofloxacin" or "cephalexin" [mesh] or "cephalexin" or " bibliografia: borba et al., 2020 (7) ; million et al., 2020 (8) ; lane et al., 2020 (9) ; gautret et al., 2020 (10) ; molina et al., 2020 (11) ; chorin et al., 2020 (12) ; columbia university kidney transplant program, 2020 (13) ; gabriels et al., 2020 (14) ; ramireddy et al., 2020 (15) ; chang et al., 2020 (16) ; gautret et al., 2020 (4) avaliação da certeza , gautret et al., 2020 (10) , molina et al., 2020 (11) , chorin et al., 2020 (12) , columbia university kidney transplant program, 2020 (13) , borba et al., 2020 (7) ) mostrou (11) ); § borba, et al, 2020 (7) avaliaram pergunta 4 -lopinavir associado a ritonavir comparado a cuidados padrão em paciente com infecção por covid-19 bibliografia: cao et al., 2020 (18) ; li et al., 2020 (19) ; deng et al., 2020 (20) ; ye et al., 2020 (21) ; zhu et al., 2020 (22) ; shi et al., 2020 (23) ; liu et al., 2020 (17) ; sun et al., 2020 (24) avaliação da certeza (25) ; wu et al., 2020 (26) ; guan et al., 2020 (27) ; shang et al., 2020 (28) ; cao et al.,2020 (29) ; li et al., 2020 (30) ; xu et al. (31) , 2020; zha et al., 2020 (32) ; lu et al., 2020 (33) ; wang et al., 2020 (34) bibliografia: luo et al., 2020 (35) ; xu et al., 2020 (36) avaliação da certeza bibliografia: shi et al., 2020 (37) ; tang et al., 2020 (38) avaliação da certeza epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study china novel coronavirus investigating and research team. a novel coronavirus from patients with pneumonia in china baseline characteristics and outcomes of 1591 patients infected with sars-cov-2 admitted to icus of the lombardy region presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with covid-19 in the new york city area covid 19. painel de casos de doença pelo coronavírus 2019 (covid-19) no brasil pelo ministério da saúde treating covid-19-off-label drug use, compassionate use, and randomized clinical trials during pandemics chicken soup in the time of covid covid-19 -a 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diagnóstico e tratamento da covid-19 clinical care for severe acute respiratory infection: toolkit. covid-19 adaptation. geneva: world health organization national institutes of health. treatment guidelines panel. coronavirus diseases 2019 (covid-19). covid-19 treatment guidelines zhejiang da xue xue bao yi xue ban hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: openlabel, randomized, controlled trial efficacy of hydroxychloroquine in patients with covid-19: results of a randomized clinical trial outcomes of hydroxychloroquine usage in united states veterans hospitalized with covid-19 observational study of hydroxychloroquine in hospitalized patients with covid-19 risk of qt interval prolongation associated with use of hydroxychloroquine with or without concomitant azithromycin among hospitalized patients testing positive for coronavirus disease 2019 (covid-19) effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection: a randomized clinical trial hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 covid-19 patients with at least a six-day follow up: a pilot observational study early treatment of covid-19 patients with hydroxychloroquine and azithromycin: a retrospective analysis of 1061 cases in marseille, france a pilot study of hydroxychloroquine in treatment of patients with moderate covid-19. zhejiang da xue xue bao yi xue ban efficacy of hydroxychloroquine in patients with covid-19: results of a randomized clinical trial hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: open-label, randomized, controlled trial hydroxychloroquine and azithromycin as a treatment of covid-19: results of an open-label non-randomized clinical trial risk of qt interval prolongation associated with use of hydroxychloroquine with or without concomitant azithromycin among hospitalized patients testing positive for coronavirus disease 2019 (covid-19) observational study of hydroxychloroquine in hospitalized patients with covid-19 effect of high vs low doses of chloroquine diphosphate as adjunctive therapy for patients hospitalized with severe acute respiratory syndrome coronavirus 2 (sars-cov-2) infection: a randomized clinical trial early treatment of covid-19 patients with hydroxychloroquine and azithromycin: a retrospective analysis of 1061 cases in marseille, france safety of hydroxychloroquine, alone and in combination with azithromycin, in light of rapid wide-spread use for covid-19: a multinational, network cohort and self-controlled case series study clinical and microbiological effect of a combination of hydroxychloroquine and azithromycin in 80 covid-19 patients with at least a six-day follow up: a pilot observational study no evidence of rapid antiviral clearance or clinical benefit with the combination of hydroxychloroquine and azithromycin in patients with severe covid-19 infection the qt interval in patients with sars-cov-2 infection treated with hydroxychloroquine/ azithromycin early description of coronavirus 2019 disease in kidney transplant recipients in new york inpatient use of mobile continuous telemetry for covid-19 patients treated with hydroxychloroquine and azithromycin. heartrhythm case rep experience with hydroxychloroquine and azithromycin in the covid-19 pandemic: implications for qt interval monitoring inpatient use of ambulatory telemetry monitors for covid-19 patients treated with hydroxychloroquine and/or azithromycin the effect of arbidol hydrochloride on reducing mortality of covid-19 patients: a retrospective study of real world date from three hospitals in wuhan a trial of lopinavir-ritonavir in adults hospitalized with severe covid-19 an exploratory randomized, controlled study on the efficacy and safety of lopinavir/ritonavir or arbidol treating adult patients hospitalized with mild/moderate covid-19 (elacoi) arbidol combined with lpv/r versus lpv/r alone against corona virus disease 2019: a retrospective cohort study clinical efficacy of lopinavir/ritonavir in the treatment of coronavirus disease 2019 arbidol monotherapy is superior to lopinavir/ritonavir in treating covid-19 evaluation of antiviral therapies for coronavirus disease 2019 (covid-19) pneumonia in shanghai incidence of adverse drug reactions in covid-19 patients in china: an active monitoring study by hospital pharmacovigilance system potential benefits of precise corticosteroids therapy for severe 2019-ncov pneumonia risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in wuhan, china clinical characteristics of coronavirus disease 2019 in china the treatment and outcomes of patients with covid-19 in hubei, china: a multi-centered, retrospective, observational study clinical features and short-term outcomes of 102 patients with corona virus disease 2019 in wuhan, china risk factors for severity and mortality in adult covid-19 inpatients in wuhan factors associated with prolonged viral rna shedding in patients with covid-19 corticosteroid treatment of patients with coronavirus disease 2019 (covid-19) adjuvant corticosteroid therapy for critically ill patients with covid-19 no clear benefit to the use of corticosteroid as treatment in adult patients with coronavirus disease 2019 : a retrospective cohort study tocilizumab treatment in covid-19: a single center experience effective treatment of severe covid-19 patients with tocilizumab the potential of low molecular weight heparin to mitigate cytokine storm in severe covid-19 patients: a retrospective clinical study anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy key: cord-000843-e1bn79ui authors: nan title: ecr 2011 book of abstracts a postgraduate educational programme date: 2011-03-01 journal: insights imaging doi: 10.1007/s13244-011-0078-3 sha: doc_id: 843 cord_uid: e1bn79ui nan for pet-ct, the ct exam is generally performed as standard whole-body exam from the base of the skull to the upper thighs. standard parameters are non-ionic iodinated intravenous contrast material at 0.5 g/kg bodyweight with a venous delay of 70 seconds after injection and 3-5 mm thick continuous axial reconstructions with medium soft convolution kernels. ct images frequently contain important diagnostic information beyond mere 'anatomic landmarking', so generally a diagnostic, contrast enhanced normal-dose ct should be performed except if a recent diagnostic ct scan is available for fusion. then, a low-dose ct is sufficient for attenuation correction. a difference from routine ct protocols is the expiratory position to match the respiratory position of pet acquisition. also, negative oral contrast material should be applied and the whole body should be included in the field of view to allow effective attenuation correction of pet images. diagnostic reading has to include lung, soft tissue and bone windows. optimally, the assessment should be performed by one reader evaluating ct and pet images simultaneously on multiplanar reformats. learning objectives: 1. to get acquainted with standard ct examination parameters for oncological imaging including the requirements for an effective attenuation correction. 2. to see the diagnostic value of ct beyond 'anatomical landmarking'. 3 . to learn effective ways to interpret pet-ct examinations. nuclear medicine perspective t. beyer; zurich/ch combined pet/ct images were first proposed as early 1984. since 1998 pet/ ct became available for broader clinical testing. since its commercial introduction in 2001 more than 5'000 pet/ct systems were installed worldwide. pet/ct is a logical and technical consequence of early, manual or semi-automatic efforts to align functional and anatomical images for easier and improved diagnosis. pet, or positron emission tomography, is an emission tomographic imaging method based on the application of radioactively labelled biomolecules in order to measure and quantitate signalling or metabolic pathways. ct, computed tomography, on the other hand, uses an external ionising radiation transmission source to generate projection data of the transmitted radiation, thus helping to generate high spatial resolution images of the anatomy of the subject. both sets of information can be combined easily in a pet/ct, whereby both the pet and ct components can be operated in close spatial proximity within a single gantry without cross-talk effects. through the combination of ct and pet overall examination times of oncology pet studies are reduced by 30%. in addition, pet instrumentation has been advanced to include time-of-flight measurements for improved signal-to-noise ratio, extended axial field-of-view-coverage for higher sensitivity and novel image reconstruction for improved contrast. today, high-quality one-stop shop staging with pet/ct is possible in 10 min, or less. learning objectives: 1. to illustrate the origin of combined pet/ct imaging. 2. to motivate the strength of pet: high spatial sensitivity, quantification and functional information. 3. to appreciate the difference between "contrast" and "tracer" imaging. 4. to highlight novel developments in pet imaging: time of flight (tof), extended axial field-of-view. computed tomography is the main contribution to diagnostic medial radiation exposure to the public. in the year 2001, ct accounted for only 6% of all radiationassociated examinations; however, at the same time it accounted for 47% of the total radiation exposure. since the beginning of this century numerous international surveys had been performed with the aim to define diagnostic reference levels in european countries. radiation exposure by ct has increased particularly by cardiac ct examination, what has caused awareness to utilise all strategies for radiation protection in ct. modern ct scanners are equipped with automated anatomical or organ sparing exposure control. it is the ct investigators responsibility to check the clinical indication, limit the scan range and decide for the appropriate scan protocol with the least radiation exposure. newer technical developments in ct scanner hard and software will enable to further reduce the dose from ct. all these strategies are essentially necessary since the number of ct investigations and the scope of clinical indications are expanding with advancing medical progress. learning objectives: 1. to understand the meaning of diagnostic reference values. 2. to become aware of dose intense ct protocols. 3 . to learn about strategies for radiation protection in ct. nuclear medicine perspective s.p. mueller; essen/de different radiopharmaceuticals labelled with positron emitting radioisotopes are used to study a multitude of molecular processes using a positron-emissiontomography (pet) scanner which nowadays is typically integrated with a ct scanner (pet/ct). this lecture will enable the attendee to comprehend that the radiation exposure from pet depends on the biodistribution and kinetics of the radiopharmaceutical, the physical half-life of the positron emitting radioisotope used for labelling, and the injected activity, leading to an understanding that there is no generic "radiation exposure from pet or pet/ct". learning objectives: 1. to learn that the comparison of doses for different radiopharmaceuticals is based on the concept of the effective dose which expresses the total stochastic risk from the non-uniform radiation exposure to individual radiosensitive organs in terms of a uniform whole body radiation dose. 2. to understand that the effective dose from certain radiopharmaceuticals may be reduced by simple means, e.g. if it is renally eliminated by frequently voiding the bladder, and that the effective doses for the most prevalent radiopharmaceuticals lie within the typical range of other diagnostic nuclear medicine tests and compare favourably to the radiation exposure from the ct portion of a whole-body pet/ct scan. pet and pet/ct are non-invasive, 3-dimensional imaging modalities which have become standard of care in patients with malignant lymphomas. these modalities have been extensively studied for staging, restaging, monitoring response to therapy, surveillance after definite treatment, and assessment of transformation. more recently, pet tracers have been suggested as surrogate markers for cancer drug development. learning objectives: 1. to understand in which clinical scenarios pet and pet/ct imaging are superior to standard imaging modalities or other diagnostic tests. 2. to learn the diagnostic accuracy and predictive potential of pet and pet/ct for staging/restaging hodgkin's disease and non-hodgkin's lymphoma. of the examination. therefore, for oncologic applications, pet-ct has already gained widespread acceptance for the initial staging of cancer, the management of recurrent cancer, and for monitoring the response to therapy. the development of a large variety of radiotracers is an evolving procedure. the most frequent used radiotracer in clinical practice, 18 f fdg, is based on the identification of the fundamental aspects of tumour glucose metabolism. new radiotracers, with promising potential for pet-ct, are also currently available to visualise specific cellular and molecular tumour pathway and more being developed. learning objectives: 1. to appreciate the advantage of a combined pet-ct technique. 2. to consolidate our knowledge of optimal examination protocols and to be aware of the pitfalls that may be encountered using this technique. 3. to understand the indications for pet-ct in the diagnosis, staging, and therapy monitoring of a large variety of gi tumours. 4. to become familiar with the different radiotracers to obtain a tailored and personalized diagnosis for the large variety of gi tumours. a-013 13 integrated positron emission tomography (pet)/ct provides combined metabolic and anatomic information of malignancies. the addition of ct to pet for urogenital purposes is very useful. ct should be performed with oral and intravenous contrast agent administration as a full diagnostic technique. if performed under these conditions, this technique can help to avoid pet pitfalls including focal retained activity in ureters and urinary bladder, and increased uptake in physiologic and benign pelvic processes such as endometrial uptake in the menstrual phase, leiomyomatosis, endometriosis or infection. we will describe the use of pet/ct in the characterisation, staging and surveillance of urogenital malignancies including kidney, prostate, bladder, uterine cervix, endometrium and ovaries. pet/ct is internationally accepted as the most useful surveillance imaging tool in patients with ovarian cancer, and its use as a problem-solving modality has also rapidly grown in the rest of urogenital malignancies. learning objectives: 1. to learn the appropriate protocols and settings of a diagnostic ct in pet/ct for urogenital purposes. computed tomography remains the workhorse of clinical cross sectional imaging due to its good availability, enormous speed, high spatial resolution and sufficient tissue contrast to evaluate most diseases based on morphology. compared to pet and spect, room for improvement remains in sensitivity and specificity for certain diseases and, compared to ultrasound and mri, in dynamic imaging. however, already today there are new ct techniques which can provide diagnostically equivalent information as spect or pet but with higher spatial resolution, in shorter acquisition time and without radioactive tracers. one of these techniques is ct perfusion imaging with repeated low-dose acquisitions of the same organ. with this method, a detailed evaluation of brain perfusion is feasible e.g, for stroke assessment, or of tumour perfusion, e.g. to assess early therapy response. another option is dual energy ct which does not require additional dose but can provide additional important diagnostic information similar to pet or spect. examples are the evaluation of lung ventilation und perfusion with xenon gas and iodine contrast. for oncological imaging, the evaluation of tumour perfusion based on spectral identification of iodine is an attractive option to increase specificity without additional dose or radioactivity. similarly, it is feasible to assess myocardial perfusion along with coronary ct angiography. for some diseases, even the molecular substrate can be identified with this technique, e.g. uric acid in gout patients. these new techniques provide significant advantages in oncological imaging and may further add to disease characterisation if combined in pet-ct. learning objectives: 1. to understand the strengths of current ct technology in oncological imaging based on morphology. 2. to learn about the diagnostic value of ct beyond anatomical referencing. energy ct as options to improve disease characterisation. tracers beyond fdg in daily routine m. beheshti; linz/at the ability of positron emission tomography (pet) to study different biological processes opens up new windows for both researches and daily clinical use. addition of computed tomography (ct) to pet improves detection efficiency and results in better localization of the lesions. the aim of this review is to consolidate knowledge of oncological applications of pet tracers other than [(18)f]fluoro-2-deoxy-d -glucose] (fdg) in the daily clinical practice. fdg, as a non -specific tracer, has limited value in the assessment of different cancers such as prostate cancer, neuroendocrine tumours (net), brain tumours, hepatocellular carcinoma (hcc), and some types of breast cancers. hence, due to high sensitivity of pet in performing non-invasive functional studies, further investigations and developments are warranted for defining specific pet radiotracers and theirs clinical applications regarding different tumour entities. oncological non-fdg pet tracers can be generally categorized into 3 groups: those labeled with f-18, c-11 and other non-fdg tracers. fluorine-18 and c-11 are labeled with different amino acids, substrates involved in fatty acid synthesis, protein synthesis, amino acid transport substrate and tracers linked to nucleic acid synthesis. these tracers are also labeled with specific ligands for receptor imaging. the other non-fdg a-024 16 with the increasing use of abdominal cross-sectional imaging, incidental adrenal masses are being detected more often. the important clinical question is whether these lesions are benign adenomas or malignant primary or secondary masses. benign adrenal masses such as lipid-rich adenomas, phaeochromocytomas, myelolipomas, adrenal cysts and adrenal haemorrhage have pathognomonic cross-sectional imaging appearances. however, there remains a significant overlap between imaging features of some lipid-poor adenomas and malignant lesions. the nature of incidentally detected adrenal masses can be determined with a high degree of accuracy using computed tomography and magnetic resonance imaging alone. positron emission tomography is also increasingly used in clinical practice in characterising incidentally detected lesions in patients with cancer. the performance of the established and new techniques in ct, mri and to a lesser extent pet, that can be used to distinguish benign adenomas and malignant lesions of the adrenal gland will be reviewed. with the increasing use of imaging, incidentally detected renal masses are very common. while masses detected by ct or mr usually can be properly classified, renal masses detected by ultrasound frequently require further workup. the following considerations determine the diagnostic workup: simple cysts are very common but may present atypically. renal cell carcinomas may be cystic but usually display at least a small solid component. renal cell carcinomas have a bad prognosis when metastasized but metastases hardly every develop before the tumour has reached 3 cm in diameter. differentiation between solid tumours by imaging alone is exceedingly difficult, save for the identification of angiomyolipomas in adults. this course will discuss suitable diagnostic algorithms based on the initial presentation of the mass. typical imaging findings of various benign and malignant renal masses will be presented. the role of the bosniak classification will be illustrated. newer developments such as a waitand-see approach or primary biopsy for small solid renal masses will be discussed. learning objectives: 1. to learn how to detect and characterise a renal mass. 2. to understand how to apply adequate protocols according to the clinical situation. the wrist and hand are characterised by variability of bones, fibrocartilage, ligaments, muscles and neurovascular structures. coalitions (most commonly lunotriquetral, prevalence of 0.1%), ulnar impaction positive variance of the ulna, carpe bossu and an accessory medial lunate facet associated with osteoarthritis are typical variants of bone. the triangular fibrocartilage complex (tfcc) and the interosseous ligaments often present with small defects. radial tfcc defects are present in 64% of symptomatic but also in 46% asymptomatic wrists. in addition, their prevalence increases with age, apparently without increasing symptoms. accessory muscles are common and may clinically mimick a neoplasm. disease may also be mimicked by imaging artifacts. magic angle effects cause increased tendon signal and may thus lead to the incorrect diagnosis of tendinopathy. the lunate appears to be more dorsally tilted on sagittal mr images than on standard radiographs (radiolunate angle ~20° larger on mr images). this value increases to ~37° if the wrist is positioned in ulnar deviated as is commonly the case when the wrist is examined in the "superman position", with the arm above the head. magic angle artefacts are commonly encountered in the wrist. the extensor and flexor pollicis longus are especially prone to such artefacts, due to their oblique course approaching the critical 55° with regard to the b 0 field. in conclusion, variability is rather the rule than the exception in the hand and wrist. only part of the findings have clinical meaning. technical aspects add another dimension of variability. learning objectives: 1. to become familiar with the normal anatomy. 2. to be able to identify normal variants. 3 . to appreciate the range of pitfalls that may simulate pathology. the imaging of the trauma stratifies the severity and the treatment strategy. the leading modalities in low-energy trauma are x-ray and ultrasound. the different approach has to be used in high-energy trauma -the silent life-threatening injury must be actively searched. although the first examination on the site of the accident could estimate whether the severe trauma is present, the imaging must confirm or exclude it. besides fast transport to the trauma centre has the extraordinary impact on survival the diagnostic algorithm. the installation of ct, ultrasound and x-ray directly within the emergency department is extremely important for the trauma management. if the focused assessment sonography for trauma (fast) is replaced by whole body ct, the life-threatening injury is detected at fastest. protocol includes imaging of non-enhanced ct head and cervical spine followed by the contrast-enhanced ct of the entire thorax, abdomen and pelvis, in cases of lower extremities trauma covering whole body. ct could be performed also under resuscitation, because whole imaging takes about three to five minutes. following findings listed recently according to their impact on survival must be confirmed or excluded: intracranial injury, cervical spine trauma, aortic injury, overpressure pneumothorax, severe bleeding in the abdominal cavity, organs injury, peripheral vascular trauma, bone trauma; the trauma team including anaesthesiologist, surgeon and radiologist discusses the findings and plans of the treatment. over the last two decades, spiral-ct has become a highly reliable imaging modality to diagnose haemorrhage in trauma, while the role of catheter angiography has changed from a diagnostic to a therapeutic modality. traumatic injuries of the heart and aorta lead to sudden death occurring at the accident site, whereas uncontrollable haemorrhage from larger arteries and parenchymal organs is the most frequent cause of mortality during the first 4 h following severe trauma. in patients with ruptured aorta or major arteries, stenting and temporary balloon occlusion may contribute to saving lives, while transcatheter embolisation may prevent exsanguination in haemorrhage from visceral organs, arteriovenous fistulas, and secondary onset haemorrhage. however, a haemodynamically stable patient is a prerequisite for all angiographic interventions. definite haemostasis using the above-mentioned techniques can be obtained in 80-100% (major and periphery arteries) and 82-100% (visceral organs), respectively. possible complications following angiographic haemostatic interventions depend very much on the treated vessel bed but are, in general, as low as 5%. learning objectives: 1. to understand potential treatment options and when to treat and when not to treat. a s15 c b d e f g h to current best practice, restriction of opinions to one's own expertise, expression of opinions that take into consideration all of the material facts, and the readiness to change that opinion if additional information becomes available. any unusual, contradictory or inconsistent features of the case should be highlighted. the expert should highlight whether a proposition is a hypothesis (in particular a controversial hypothesis) or an opinion deduced in accordance with peer-reviewed technique, research and experience accepted as a consensus in the scientific community. he/she should indicate whether the opinion is provisional (or qualified), stating the qualification and the reason for it, and identify what further information is required to give an opinion without qualification. when there is a range of opinion on any question to be answered by the expert, (a) the range of opinion should be summarised, (b) highlight whether that range of opinion includes an 'unknown cause' (because of limited facts of the case or limited research/peer-reviewed publications), and (c) give reasons for the opinion expressed. reprints of scientific publications will assist the court, but will also enable the attorneys to undertake a more robust cross examination! learning objectives: 1. to learn about imaging findings in relation to whether or not abuse has occurred. 2. to understand in which cases the diagnosis of child abuse should be raised in the radiology report. 3. to become familiar with the terms that should be used when highly specific imaging indicators are identified in an otherwise normal infant. the radiologist at the eye of the storm 17:14 imaging plays a central role in the diagnosis of child abuse. is there any risk of the radiologist having a detrimental impact on either the welfare of the patient or the judicial process by either under-diagnosing or over-diagnosing child abuse? ovarian cancer continues to be a challenge to radiologists and clinicians, as it is one of the most lethal female tumours. this is mainly due to its diagnosis in an advanced stage in the majority of patients. however, new developments can be observed: new insights in tumour biology, advances in imaging and new concepts of ovarian cancer treatment and surveillance. furthermore, a multidisciplinary expert team approach has also substantially changed the management of patients with suspected ovarian cancer. the findings of radiology are becoming pivotal in a more individualised patient care. the role of radiology includes (a) characterisation of sonographically indeterminate adnexal masses, (b) staging as guidance for surgery and treatment planning (including identification of sites of non optimal resectabilty) in suspected ovarian cancer, (c) assessment of recurrent disease, and (d) in selected cases image-guided biopsy. in this session we provide an update on the aetiology and current concepts of treatment of ovarian cancer and on the contribution of radiology in characterisation and staging in patients with the working diagnosis of ovarian cancer. the panel discussion will focus on the role of radiology in multidisciplinary conferences in suspected ovarian cancer. session objectives: 1. to learn about new concepts in etiology and treatment of ovarian cancer. 2. to become familiar with optimised imaging protocols to diagnose ovarian cancer. 3 . to learn about the value of ct and pet/ct as a basis for treatment planning in ovarian cancer. 4. to appreciate the role of the radiologist in multidisciplinary consensus conferences. session objectives: 1 . to learn about current imaging practices in the evaluation of suspected child abuse. 2. to learn about imaging changes which permit a firm diagnosis of child abuse. 3. to become familiar how to construct a comprehensive report providing evidence of child abuse. how to image and detect patterns of skeletal injury indicating child abuse p.k. kleinman; boston, ma/us (paul. kleinman@childrens.harvard.edu) in infants, skeletal injury may form the basis for the diagnosis of abuse. the first step is the acquisition of a skeletal survey utilising meticulous technique adhering to a rigorous imaging protocol. a proper interpretation is ensured when the radiologist is familiar with the various patterns of skeletal injury, their specificity for abuse and those entities which may simulate inflicted injury. appreciation of the lesion morphology, the fundamental pathologic alterations and mechanism of injury are essential in assessing the significance of the findings and placing them in the clinical context. dating fractures poses a significant challenge, but in most cases, injuries can be placed in a certain time frame, especially if a follow-up skeletal survey is obtained. although radiography forms the basis of skeletal imaging, ultrasound, ct, scintigraphy and mri may clarify findings and optimise diagnosis and management. the radiology report must be constructed with care and the language should be crafted with the expectation that the radiologist may be called to testify in court, a daunting challenge in an often highly adversarial environment. learning objectives: 1. to learn about the appropriate imaging protocols and quality for skeletal survey in suspected child abuse. 2. to learn about patterns of skeletal injury typical of child abuse. 3 . to become familiar with findings that point to alternative diagnoses. imaging strategies to fully determine intracranial injury resulting from child abuse c. adamsbaum, c. rey-salmon; paris/fr (c.adamsbaum@svp.ap-hop-paris.fr) radiologists play a key role in the early diagnosis of abusive head trauma (aht). symptoms are various and may range from coma to asymptomatic children. changing elements of the history provided previous injuries, bruising in non-ambulatory children and delay in seeking care raise a high index of suspicion. the most common finding in aht is of multifocal subdural haematomas over the cerebral hemispheres, the convexity, the posterior interhemispheric fissure and the posterior fossa. the haematomas are often associated with hypoxic-ischaemic injury and retinal haemorrhages. ct is the first diagnostic examination to be used for patients with acute injury. it can reveal intracranial haemorrhage, fracture and soft tissue swelling with a high degree of sensitivity. ct should be repeated after a time interval if the findings are doubtful or if there is a discrepancy with the neurological picture. mri (including t1, t2, t2*, diffusion sequences and cervical spine examination) is required to fully determine intracranial injury as it can exquisitely demonstrate hypoxic-ischaemic injuries by showing areas of cytotoxic oedema. it is impossible to date precisely a haematoma whose pattern is influenced by numerous factors. however, the main point is to determine the presence of 'age-different' lesions. this not only provides a strong argument for the diagnosis but also suggest repetitive violence and thereby, a high risk for further injury unless protective action is undertaken. brain imaging must be performed in all siblings younger than 2 years, living in the same conditions as the index case. learning objectives: 1. to learn about imaging protocols designed to: a) detect acute treatable conditions b) depict fully and determine the timing of all injuries. 2. to become familiar with imaging findings that are highly suggestive of child abuse. 3 . to learn about head trauma that may simulate child abuse. what is the information required by any court and how the radiological reports should be phrased s. chapman; birmingham/uk (stevechapman@doctors.org.uk) this presentation will describe the role of a paediatric radiologist as an expert witness (as opposed to a witness to fact). the expert has an overriding duty to the court that takes precedence over any obligation from whom the expert has received instructions or by whom the expert is paid. particular duties include advice that conforms a-040 16:05 ovarian cancer: update and role of radiology j.a. spencer; leeds/uk (johnaspencer50@hotmail.com) ovarian cancer is known as the 'silent killer'. it is usually diagnosed late and most women have disease disseminated to the peritoneum (and/or pleura) at presentation. standard treatment comprises cytoreductive surgery followed by platinumbased chemotherapy. an alternative is neoadjuvant chemotherapy followed by interval debulking surgery (ids) then completion chemotherapy. data from the eortc 55971 trial show this to be as effective as the standard of care. there are strong genetic predispositions to ovarian, fallopian tube and primary peritoneal cancers. there is linkage with breast cancer in women with brca gene mutations and with colon cancer with the hnpcc gene. ongoing trials are screening women in the general population and at high risk of the disease. these use the serum tumour marker ca125 followed by us as screening tools. mr imaging is an effective tool to assess sonographically indeterminate adnexal masses and offers an earlier diagnosis of cancer than interval reassessment with us. ct is the most commonly used modality for assessment of disease extent prior to surgery. image-guided biopsy is necessary prior to starting neoadjuvant chemotherapy. the eortc 55955 and mrc (uk) ov05 trials of women with treated ovarian cancer have shown no outcome advantage for women treated early at 'ca125 relapse' of disease versus later with clinical or ct evidence of relapse. this questions the role of ca125 in follow-up and argues against investigation of the 'ca125 +ve, ct -ve' woman with more expensive and scarce imaging resources such as ct-pet and dcemr. learning objectives: 1. to become familiar with clinical features of ovarian cancer. 2. to learn about the etiology of ovarian cancer, including genetic predisposition and the current research into screening. 3. to become familiar with new concepts of treatment ovarian cancer and surveillance of the treated patient and their impact for the use and choice of imaging modalities. imaging of adnexal masses: is it feasible to diagnose ovarian cancer? i. thomassin-naggara; paris/fr (isabelle.thomassin@tnn.aphp.fr) adnexal masses can be depicted by many imaging modalities (us, ct, mr and pet-fdg). however, the characterisation of adnexal tumours is mainly based on two techniques: us and mri. for complex adnexal masses, mr imaging add to conventional criteria of malignancy common to all imaging modalities (bilaterality, tumour diameter larger than 4 cm, predominantly solid mass, cystic tumour with vegetations, and secondary malignant features, such as ascites, peritoneal involvement, and enlarged lymph nodes) specific features based on the characterisation of the solid tissue (including vegetation, thickened irregular septa, and solid portion) of the adnexal tumour. signal intensity of solid tissue on t2 sequence (fibrous tissue), perfusion (neoangiogenesis), and diffusion (cellularity) are combined to make a decision tree analysis. low t2 signal, absence of high b1000 signal, and time intensity curve type 1 are predictive of benignity whereas high t2 signal and time intensity curve type 3 are predictive of malignancy. combining common classical features and specific mr features for predicting malignancy, mr imaging has a high degree of accuracy (96%) for characterising complex adnexal tumours. this high diagnostic confidence rate may help young women wishing to preserve childbearing potential to opt for conservative surgery and avoid the systematic removal of benign complex adnexal masses in menopausal women. learning objectives: 1. to understand the role of ultrasonography in assessing and managing complex adnexal lesions. 2. to learn how to optimise the mri protocol and how to improve the characterisation of indeterminate complex adnexal masses. 3. to understand the added value of functional sequences (dce mri and dwi) in diagnosing adnexal masses. the european and american guidelines include breast ultrasound in a restricted diagnostic scenario for breast cancer diagnosis. the fourth edition of the european guidelines (2006) reviewed in 2008 refers to us in only twice. acr in its 2007 acr practice guideline reduces breast ultrasound examination to seven situations. evaluation of the axilla and ultrasound as a screening tool on high risk women is considered an area of research. the progression of us makes guidelines become obsolete very fast. its application still remains pending on the results of clinical trials. image smoothing on sono-ct or multiple frequency transducers will produce images, eventually with more diagnostic information. second tissue harmonics will produce sharper and more clear images. cad systems, doppler and contrast doppler will help in diagnosis. 3d with the new software and automatic probes constitute a very promising work in progress. they will make a dramatic change in our workload. the radiologist will be released of performing the exam, to review the images in the workstation. sonoelastography has evolved from the manual to the actual automatic shearwave. this system measures the transversal transmission of sound in biologic tissues. it is a new and promising technology, probably more objective and non-operator dependant, that is able to differentiate benign from malignant conditions. all of these systems will be reviewed and evaluated for its actual situation. the problem now is how to introduce new terms, new descriptors, and new technologies in the bi-rads system, once clinical evidence is demonstrated. diffusion-weighted mri (dwi) is a promising technique in oncology. it can be used for in vivo quantification of the combined effects of capillary perfusion and diffusion. using echoplanar imaging (epi), dwi is possible with fast imaging times minimising the effect of gross physiologic motion from respiration and cardiac movement. in this lecture, we will discuss the acquisition, post-processing and quantification methods and results of dwi in abdominal and pelvis tumours. we will also review the mechanisms associated with diffusion changes in tumours. mri-pathologic correlation will be shown. finally, limitations and future directions of the technique will be reviewed. diagnostic potentials -as well as limitations -associated with morphological cross-sectional imaging on the one hand and functional imaging on the other are increasingly well understood. it has become obvious that in many cases both kinds of imaging complement one another. hence, hybrid pet/ct imaging must be considered one of the most promising new developments in medical imaging. however, some questions have to be raised and challenges have to be met to avoid overrating pet/ct in oncology. pet/ct with [18 f]-2-fluoro-2-deoxy-d-glucose (fdg) as a radioactive tracer has been reported to be more accurate than either imaging modality alone and sometimes even more accurate than ct and pet read side by side. however, the clinically important question should rather be the following: does this higher accuracy have an impact on patient management? furthermore, some tumours do not have an increased glucose metabolism making them fdg-pet negative. the most recently launched line of pet/ct scanners combines high-definition pet with high-end multislice ct. these imaging systems not only provide a higher diagnostic accuracy based on detection of smaller lesions with ct and pet, but also offer integration of complex ct protocols into the pet/ct scan. these protocols include ct perfusion, three-dimensional ct image reconstruction or virtual fly-through. the aim of this talk is to give an overview concerning pet/ct in oncology. the mechanism of radionuclide uptake, different tracers, the indications of pet/ct in oncology and its accuracy will be addressed. learning objectives: 1. to understand why uptake of the tracer provides information on the viability of solid tumours. 2. to learn whether pet/ct is able to give reliable quantitative information. 3 . to know whether pet/ct is a valuable tool for tumour response to treatment. to gain additional functional information. functional imaging techniques such as diffusion tensor imaging and tractography as well as fmri are increasingly used and relied on in clinical practice. with diffusion tensor imaging and tractography the location, course and integrity of the major white matter tracts can be depicted, while with fmri the brain's cortical function is visualised. despite major technical advances, these techniques are still time consuming, labour intensive and have several limitations. they therefore need to be used and interpreted with care. the purpose of this lecture is to review the functional anatomy of the brain in a clinically relevant context and to illustrate when additional functional imaging techniques may be indicated. the most important eloquent brain areas are addressed and include the motor, visual and language systems. routine clinical cardiac mri requires speed and efficiency as a result of physical motion. consequently, the challenges and benefits of rapid mri are nowhere more apparent than in the field of cardiovascular mr imaging. to meet these challenges, one must balance the competing constraints of signal-to-noise ratio (snr), contrastto-noise ratio (cnr), spatial resolution, temporal resolution, scan time, and image quality. one of the main determinants of snr is the static magnetic field strength. hence, cardiovascular mri at 3.0 t or more holds the promise to overcome some of the snr limitations and to extend the capabilities of cardiac mri. all studies in cardiac mri at higher field strength have proven the feasibility of cardiac mri for the comprehensive assessment of cardiac morphology and function. the studies demonstrated a significant snr increase, but also outlined image-quality problems associated with b 1 -field inhomogeneities and specific absorption rate (sar) constraints. with regard to acquisition speed, parallel imaging mri capabilities form an important enabling factor, especially if enough snr is available. therefore, the combination of higher field strength and parallel imaging strategies may help to overcome several of the present limitations in cardiac mri like cardiac perfusion and coronary artery imaging. the present indications, advantages and limitations of cardiac mri at 3.0 t will be discussed. the risks associated with the exposure of ionising radiation has raised increasing concerns in the radiological community. the recent years have shown an overall increase in the use of ct for the imaging of the heart and the coronary arteries. the downside of this increased use of cardiac ct is the increase in the collective radiation dose with cardiac ct which have been reported to be associated with an effective radiation dose of 20 msv or more. increased awareness of the radiation dose with cardiac ct led to the development of several effective radiation dose reduction strategies including prospective ecg gating technique, anatomy and ecg-based tube current modulation, high pitch acquisition, and adaptation of the ct scanning parameters to the body habitus. however, the dose reduction strategies should be selected carefully on an individual patient basis in order to avoid serious image quality impairment by noise and artefacts. the lecture outlines the different radiation dose saving techniques currently used in clinical practice, the anatomy of the brain is often perceived as being complicated. especially the cortex is seen as an irregular arrangement of variable structures, which are difficult to differentiate and to identify. we will review the overall subdivision of the brain into lobes and describe their boundaries and their major gyri and sulci. we will then describe the location of specific functions. 1. primary sensorimotor cortex: motor is located in the precentral gyrus, sensory in the postcentral gyrus around the central sulcus (cs), hence the importance of always correctly identifying the cs. we will present 4 interlocked methods to identify the cs in the axial plane (a) knob, (b) lateral axial, (c) medial axial, (d) gyral/cortical thickness and 3 to identify it in the sagittal plane (a) lateral sagittal, (b) hook, (c) medial sagittal. 2. primary auditory cortex (a1): centred at the postero-medial part of heschl's gyrus (hg), we will present simple landmarks in each of the 3 planes: (a) axial: adhaesio interthalamica, (b) sagittal: omega/heart shape of hg, (c) coronal: omega shape of hg. 3 . primary visual cortex (v1): centred on the calcarine sulcus, we will discuss the characteristic shape that allows the identification of this structure in all 3 planes. at the end of this lecture, you will know the subdivision of the cortex; the methods and landmarks necessary to identify the primary sensorimotor, speech, auditory, and visual areas. magnetic resonance imaging (mri) has undergone a rapid development in the last decade with numerous new techniques. nevertheless, pattern recognition of brain lesions based on signal intensities on conventional mr sequences (t1-and t2-weighted, flair) is the first step in diagnostic "work up". good examples for pattern recognition are lesions with t1-shortening ("bright" on t1wi) such as: fat containing lesions (lipoma), melanoma, lesions with colloid content, calcifications, and haemorrhagic metastatic lesions. t2-shortening ("dark" on t2wi) in enhancing lesions is suggestive of lymphoma and certain infections (tuberculosis, fungal abscesses). flow void (absence of signal) reflects high velocity flowing blood or csf, and will help in diagnosing vessel abnormalities and related pathologies. the purpose of this lecture is to refresh knowledge on patterns and normal variants useful for clinical practice. a simplified "pipeline" consisting of easy consecutive steps will be introduced. learning objectives: 1. to learn important normal variants of different structures and lesions in the brain. 2. to learn about recognition patterns that might be helpful in suggesting the most likely etiology of common brain lesions. 3. to consolidate the key imaging findings in different types of lesions and normal variants. a-051 17:00 c. clinical symptoms correlated to brain anatomy m. smits; rotterdam/nl (marion.smits@erasmusmc.nl) diagnostic neuro-imaging heavily depends on a thorough understanding of brain anatomy in relation to the brain's function. clinical neurological symptoms and deficits not only give us an indication of the brain area(s) involved but may also direct us towards the use of specific imaging techniques, such as diffusion tensor imaging and tractography, as well as functional magnetic resonance imaging (fmri). specific imaging findings, on the other hand, may direct clinical management in a neurologically intact patient, such as the decision to resect a brain tumour in or near an eloquent brain area. again, specific imaging techniques may be used evaluation of response to treatment allows an early assessment of tumour response typically after 2-4 cycles of chemotherapy. this evaluation is most commonly performed with pet/ct during therapy for high grade non-hodgkin's lymphoma. this review presentation looks at the potential roles that ct, regional mri and whole body mri do and could play in response evaluation from a radiology perspective. the presenter is a radiologist who is clinical director of a medium volume pet/ ct centre. the talk focuses on discrepancies between ct and pet findings in tumour response and on tumours or situations where ct is the primary modality to determine tumour response. potential roles for whole body mri in response evaluation and assessment of solid tumours by mri are examined. at a general level, the role of the radiologist as part of the multidisciplinary oncology meeting (mdm), including when and where to use image-guided biopsy in response evaluation and the use of recist versus precist criteria is discussed. the aim of the presentation is to outline the role of ct in tumour response evaluation in the era of pet/ct and to explore potential roles particularly for whole body mri in tumour assessment. the presenter hopes to encourage radiologists to get fully involved in mdm discussions regarding ct, mri and pet/ct evaluation. learning objectives: 1. to learn the standard method (tumour measurements) for the evaluation of tumour response to treatment. 2. to understand the limits of international standard. 3. to become familiar with methods that provide functional or structural information, like perfusion ctmr or dw-mri. evaluation of tumour response to therapy: the role of nuclear medicine a. chiti; milan/it (arturo.chiti@humanitas.it) the high costs and possible side effects of chemotherapy and radiation therapy treatments favour the use of effective ways to monitor the treatment efficacy in oncology. molecular imaging demonstrated to be effective in evaluating the response after and during the course of therapy, in order to assess chemo-sensitivity and chemo-resistance of a particular neoplasm. the use of pet-ct in this setting can vary from very sophisticated and complex quantitative evaluation to simple qualitative analyses. in malignant lymphoma, international criteria for monitoring response to therapy have recently been revised, and fdg now plays a central role in defining tumour response. in a variety of solid tumours, studies have indicated that fdg pet-ct may provide early and accurate assessment of tumour response, suggesting that it could play a significant role in personalising the treatment of malignant tumours. performed during and after therapy for hl and aggressive nhl, fdg pet results have a high prognostic value and correlate with survival. fdg pet has been incorporated into revised response criteria for aggressive lymphomas, and several ongoing trials are under way to investigate the value of treatment adaptation based on early fdg pet results for hl and aggressive nhl. many technical aspects must be taken in consideration to avoid critical errors in evaluating response. from patient preparation to image acquisition a series of possible pitfalls must be avoided. in the clinical practice, the most widely used parameter is the suv, which can improve the accuracy of qualitative image assessment in many clinical settings. learning objectives: 1. to understand why pet-ct can be used to assess tumour viability. 2. to become familiar with the principles of signal quantification and to discuss its advantages and limits. 3 . to learn about the incoming tracers that might enhance the role of pet-ct in the evaluation of tumour response. alzheimer's disease: the role of radiology j. alvarez-linera; madrid/es (jalinera@ruberinternacional.es) neurobiological changes in alzheimer's disease (ad) occur in an stereotypical pattern that begins in the medial temporal lobe (mtl) years before the clinical manifestation (brain reserve). brain atrophy is a marker of neurodegeneration that reflects the neurobiological disorder and is correlated with the neuropsychological changes at all stages of the disease. other imaging markers may reflect changes in microstructural (diffusion), functional (perfusion) or metabolic (mrs) domains that would provide additional information but are awaiting wider validation. in the early stages of ad, the most effective mri markers are those that reveal atrophy in mtl, particularly the measures of the hippocampus. the mtl atrophy mea-the required conditions in whom they may be successfully used, and how these techniques could be implemented in the daily clinical practice. proper linking of the data acquisition to the patients ecg is among the crucial prerequisites for successful cardiac imaging. while cardiac ct data acquisition itself does not impose any effect on the patients' ecg, inherent physical effects in the mr environment does show impact on the ecg trace and may hamper proper r-peak delineation. in addition, patient-related factors such as arrhythmia might affect image quality (iq). dose saving strategies in cardiac ct limit the possibilities of retrospective iq optimisation and as such more emphasis is recommended prior to data acquisition which is mainly related to patient selection/heart rate control. in cardiac mr a high amplitude ecg without influence of magnetic or scanning effects is of outmost importance. arrhythmia also remains a challenge that might be overcome by arrhythmia-rejection algorithms or real-time imaging. suboptimal contrast enhancement ought to be avoided by proper planning and timing as the majority of post-processing algorithms is based on signal behaviour. in the unfortunate situation of suboptimal contrast enhancement often only the use of standard post-processing tools is possible while semi-automated tools for cardiac post-processing may fail or necessitate substantial user interaction. the use of straight forward visualisation techniques is recommended for diagnosis while complex visualisation tools may add on confidentiality but are mainly suited for case presentations. coronary evaluation is typically performed using centerline tools allowing for the easy assessment of cad. while these tools potentially allow for estimation of the degree of diameter and area stenosis, accuracy though may still be limited. this is the second session between esr and eanm at each society's annual congress. few would argue but that patient's interests are best served by crossfertilisation and open communication between specialties. this is particularly true for radiology and nuclear medicine. this session elaborates on clinical scenarios where cross-fertilisation between both specialties is particularly important. the session will elaborate the radiologist and nuclear medicine perspectives on two common clinical scenarios, i.e. tumour response to therapy and evaluation of alzheimers disease. session objectives: 1. to appreciate how nuclear medicine and radiology provide complementary information. 2. to learn how each method can enhance the mutual performance of the radiologist and nuclear medicine physician. 3 . to learn about recent advances in the field of tumour evaluation and early detection of alzheimer's disease. shown on mdct-images in the axial, coronal, and sagittal plane. variants of the normal anatomy, which are important to describe and to know are also shown. some of these variants are also delineated on mr images. in the second part of the lecture, the different expressions of congenital malformations of the external and middle ear will be explained. the different findings of the severity of the malformations will be shown and their importance for further clinical-therapeutical procedures will be explained. imaging investigation of cholesteatoma is required before surgery. if no surgery has been performed previously, ct will provide information about the location of the lesion (epi, pro, meso, retro, hypotympanum), the partial or total destruction of the ossicles, and possible extension to the inner ear. if there is no doubt about any of these factors ct is sufficient. in doubtful cases an mri examination is performed to confirm or refute the presence of cholesteatoma using t1 sequences without iv contrast medium, and diffusion weighted imaging with or without high resolution t2, depending on the age of the patient. in postoperative recurrent cholesteatoma, mri is becoming the modality of first choice for detecting cholesteatomas, appearing : low in signal on t1 sequences, high in signal on diffusion weighted imaging. however, care is required since performing diffusion weighted imaging without t1 may lead to false positives. a granuloma with a slightly or markedly increased t1 signal is often associated with a high signal on diffusion. measurement of adc is useful for detecting cholesteatomas, infected cholesteatomas or abscess. finally whilst mri is the first examination in the follow-up of postoperative patients, the use of contrast medium is not necessary in most of the cases. a-062 17:00 c. implants and postoperative findings in the middle ear b. verbist; leiden and nijmegen/nl many conditions which affect the function of the middle ear may require surgical intervention. postoperative imaging will be requested either to evaluate complete removal of diseases (eg in cholesteatoma) or because of new, persisting or recurrent complaints of the patient (e.g. vertigo after stapes replacement). in this presentation, different surgical procedures will be reviewed including the indications for a certain surgical approach as well as the different types of prosthesis. the normal postoperative imaging appearance of the most common surgical techniques will be shown. it will be discussed whether ct or mri should be performed to answer the clinical questions. an overview of possible failures and complications will be given. the management of patients with vascular malformations is often suboptimal. the reasons for this are many but include confusion regarding classification, uncertainty about the most appropriate imaging of the various forms of malformation and a sures are helping to propose new diagnostic criteria for ad, allowing a diagnosis of probable ad in predementia stages, when memory loss criteria are attached to imaging criteria (mri or pet) or measures of amyloid/tau in csf. the use of atrophy markers (global or mtl) increases the effectiveness in clinical trials (both by reducing the size of the sample and increasing the statistical power) and is therefore contributing significantly to the development of new treatments. the association of multiple markers of structural and functional imaging (mri and pet) and the use of advanced computational analysis techniques will allow better management of ad but it needs a broader validation and know the most efficient combination of biomarkers at each stage of the disease, including the preclinical period. scientists, researchers and clinicians all benefit from molecular imaging in dementia providing exciting new insights into their basic biology and pathophysiology. targeting specific aspects of neurotransmission, metabolism, inflammation or plaque formation -just to mention some of the current molecular approaches -increasingly gains impact on establishing the correct diagnosis, following the course of dementia or developing cns drugs. this talk will highlight the molecular targets and major pet and spect tracers for application in dementia, and will update on the results of the clinical imaging studies published in recent years. typical imaging patterns of alzheimer's disease (ad) will be discussed, including also the diagnostic discrimination from other types of neurodegenerative dementias such as frontotemporal dementias, lewy body dementia, and others. assessment of mci patients and the probability of transition in manifest dementia (predominantly ad) will be addressed together with its prognostic relevance. furthermore, recent advances in analysing tools which further improved the high diagnostic accuracy already reached by visual assessments will be presented. even though in competition with other modalities, ‚standard fdg' pet has shown to be a robust and both, sensitive and specific marker in the diagnostic work-up of dementia. fdg information will be markedly extended in clinical practice by specific amyloid imaging in the near future when these tracers are approved and thus generally available. learning objectives: 1. to become familiar with the nuclear medicine method that enables detection and evaluation of alzheimer's disease. 2. to learn about the potential development of functional studies using nuclear medicine. 3. to understand how nuclear medicine and radiology can provide complementary information. symptoms may require explanation and reassurance only. lesions with a mainly cutaneous element may be treated with laser. deeper lesions are usually treated with several episodes of sclerotherapy. agents such as alcohol, polidocanol and std will be discussed and the relative advantages and issues explained. informed consent is vital, and the approach to this will be outlined. high flow lesions are frequently associated with severe cosmetic changes, invasion of surrounding tissues, haemorrhage, and high output cardiac failure. lesions may be life threatening. in the extremities peripheral ischaemia and ulceration due to steal of blood by the arteriovenous malformation is common. informed consent will again be discussed, as potential for major complications is high. key to endovascular management of these lesions is an understanding of the nidus, arterial inflow and venous outflow. the role of liquid and solid embolic agents and specifics of transarterial, venous and direct approaches will be discussed. avms pose a major problem regarding classification and treatment. a case report discussed by the panellists demonstrates how these patients should be approached. the importance of establishing an interdisciplinary outpatient clinic is also presented. the most important organisational steps for providing an efficient clinical service are given. in addition, the most common pitfalls and complications of treatment are illustrated. computer-aided detection/diagnosis (cad) is recognised as a workstation or a system developed in order to assist the radiologists (clinicians) in performing their daily diagnostic tasks. clinically implemented cads are available at workstations and (if dicom compliant) may serve as a plug-in to pacs. the three-layer cad system includes: (1) image analysis procedures whose development requires a medical and technical knowledge, (2) a database module that is managed by experienced radiologists and it professionals, and (3) graphical user interface (gui) that enables a user-friendly access to the data, the processing tools, and the results. a modern cad development involves a multidisciplinary team whose members are experts in medical and technical fields. a close collaboration of all experts is required at all stages of system life-cycle. at each stage the physicians knowledge and experience are indispensable. it includes medical analysis of the diagnostic problem, data collection, image analysis evaluation, and clinical verification. design, testing, and evaluation have to be successful in order to ensure cad implementation in a daily clinical routine. in this session three experts will share their experiences in the area of the overall cad architecture, its evaluation, validation and acceptance by clinicians, advantages and restrictions of solutions and clinical implementation in lung, breast and colon cancer. reading paradigm (primary, concurrent, second) in oncology as well as results of cad clinical implementation will be presented. perspectives in clinical cad implementation in diagnosis and treatment will be discussed. patients presenting with vascular malformations mostly are nomadic and hopeless individuals looking for help. finally having reached a "multidisciplinary specialistgroup" after a sometimes long and misleading trip throughout the ocean of "singleplayers" of different specialities these patients do not ask for any more diagnostics -they strongly claim for therapy. vascular malformations are congenital lesions, although merely seen at birth they become evident throughout the individuals growth. these developmental errors can affect all components of the vascular tree in any area of the body. the therapeutic goal must be defined rather as "control" than "cure" of this disease. to make this point understandable for both patients and collegues a fundamental understanding of the pathogenesis and natural course must be created. in special cases of complex vascular malformations the precise diagnosis and the information about all potential side-effects as well as risk-factors of progression enables these patients to manage their daily life. therefore, indications for treatment vary depending on the specific type of slow flow or high flow lesion, location, pain, functional and cosmetic impairments and general side-effects of each particular lesion, since no single specialist has enough knowledge to diagnose or treat vascular anomalies beyond the border of his distinct speciality multidisciplinary working-groups emerged at these interdisciplinary interfaces. their common language in classifying and their overall understanding of pathogenesis, prognosis offer these mostly hopeless patients a custom-fit treatment addressing their symptoms. imaging of vascular malformations should be directed by clinical assessment of the type of malformation to be expected, clinical symptoms and need for treatment. in order to make the proper decision of the required imaging modality or treatment, it is essential that the (interventional) radiologist is a member of a dedicated vascular malformation team. imaging needs to be tailored to the individual patient although general rules can be applied. duplex ultrasound together with a clinical assessment is often sufficient to make a proper diagnosis. this is especially true for the paediatric population. if more information about the extent of the lesion is needed, mr is often used in case of low flow lesions (venous/lymphatic), and mra or cta in case of high flow lesions. angiography is mandatory if an avm is diagnosed and treatment is planned. high frame rate imaging and selective injections are the only options for a proper evaluation of the nidus architecture of the avm. there are exceptions that warrant deviating from the above general rules. in this lecture, both the general rules and the exceptions will be discussed. at the onset of the 21 st century humankind is focusing its attention on a very small molecule, as controlling co 2 in the atmosphere is becoming a major goal, economically, socially and politically. yet, there is another small molecule which is going to play a more prominent role in the near future. h 2 o, especially in its liquid form, the 'blue gold', is just indispensable to our lives. water makes 60 to 70% of the human body weight and is crucial to the working of the biological machinery. still, how such a tiny molecule with its 105° 'magic' angle could have been at the origin of life remains largely a mystery. different organisms have adopted different strategies in the way they get the most out of water, depending on their environment, and water contributes to the biodiversity. faulty mechanisms in the use of water by tissues may lead to severe diseases or death. clearly, water deserves to be seen as the prime 'biological molecule', and radiologists have long recognised its importance from the days of 'dry' (bone and air) radiology to the advent of ct which allowed contrast from 'wet' tissues to be explored. with mri one went one step further, as magnetisation of water is the sole source of contrast. life has led to intelligence, and recent mri studies have suggested that water may also actively contribute to the mechanisms underlying brain function. could the 'molecule of life' also be the 'molecule of the mind'? clearly, water must be radiologists' best friend. learning objectives: 1. to comprehend how the structure of the water molecule makes it important to life. 2. to understand the importance of water in biological and cellular processes. 3. to become familiar with the different ways water is responsible for image contrast in radiology. a. the role of cad in modern-day imaging a. todd-pokropek; london/uk (a.todd@ucl.ac.uk) the use of cad in medicine is an important and growing area of research. firstly good data must be acquired including not just images but associated information. the first step in that of preprocessing, notably (but not only) noise reduction. the data are then passed onto the segmentation step. often this step is semi-automatic requiring some manual intervention. conventional edge detection methods are not often of value, but active shape and appearance models, the use of markov random fields etc are commonly used. the next step is that of feature extraction both of shape and texture. these data are then submitted to one of several classifiers such as artificial neural networks (including mtanns) support vector machines (svm) and data reduction using principle and independent component analysis, and multiple voting techniques such as adaboost are also of value. the output may simply be returned to the observer (clinician) or as further input for a decision support system. examples considered will be in breast imaging (mammography), lung nodule detection, virtual colonoscopy and lumber spine. the use of the cad system as a simultaneous assistant or as a second reader is important. the use of cad in therapy is of increasing important. the assessment of such cad system (evaluation and validation) is still controversial. the difficulty of bringing systems both instrumentation and software for use in clinical practice in often underestimated and there have been some notable failures. some example of 'failures' will be given. ct colonography has evolved rapidly and disseminated widely over the last decade. the ability to provide an accurate whole colon examination with near perfect completion rates, use of reduced laxative bowel preparations and extra-colonic organ review has attracted very considerable interest amongst the wider radiological and gastroenterological community. inclusion of ct colonography in several core radiological training programmes confirms its evolution from super-specialist technique (performed in only a few centres) to mainstream. however, evidence supports highly variable performance, which is perhaps unsurprising given the complexity of both technique and interpretation methods -both which require specific training. notably, attendance at a training workshop generally represents the beginning of a radiologist's experience of ct colonography. indeed, most delegates rapidly progress from unconscious to conscious incompetence, acknowledging the need for a planned implementation strategy prior to offering ct colonography in their routine clinical practice. thankfully a decade of intensive research and large volume clinical experience has equipped the radiological community with knowledge and experience to inform successful ct colonography implementation strategies. by combining this experience with training and accreditation practices developed for colonoscopy, the prospect of a robust quality assurance framework is realistic and necessary to reassure both service commissioners and the general public alike. step one: the publication of international ct colonography standards, co-authored by eminent radiologists from across europe and beyond has been achieved. this talk will review the likely next steps. computer-assisted detection (cad) for ct colonography is now widely available in europe from a number of different vendors. this presentation will detail factors that potential users will need to know in order to properly evaluate cad systems, use them in clinical practice, and evaluate their likely impact. the different ways in which the performance of cad systems can be assessed will be discussed and the difference between weak methodologies (e.g. internal validation) and more valid assessments (e.g. external validation) will be explained. now that the diagnostic performance of ct colonography has been well-established, this state-of-the-art symposium will deal with issues related to the implementation ct colonography in day to day clinical practice. the lecturers will deal with the diagnostic performance of ct colonography, the technical requirements necessary to obtain high quality diagnostic data, the factors that underpin a high-quality service (including reader training), how implementation differs across different countries, and the possible impact of new developments, including computer-assisted detection (cad). two decades ago spiral ct technology initiated a new era in diagnostic imaging with virtual colonoscopy or ct colonography (ctc) as a major innovation. introduced by david vining in 1994, ctc was rapidly endorsed as a potential tool for colorectal cancer screening. after an initial pioneering period defining the basic ctc principles, the advent of multi-slice ct significantly improved spatial and temporal resolution, allowing for isotropic image reconstruction with detailed 3d rendering of the colonic wall and very short acquisition times, reducing motion artefacts. furthermore, application and refinement of (ultra-) low dose technique almost completely tackled the issue of radiation dose. these improvements have resulted in the perfect optical colonoscopy imitator with reliable fly through of the colon in a timely manner. consecutively, the primary 3d reading paradigm with 2d problem-solving is getting more and more adepts, although in experienced hands primary 2d-read with 3d-problem solving is a solid contender. to improve depiction of the colonic wall new 3d visualisation methods were developed. these technical improvements with the application of state-of-the-art ctc technique have resulted in a very good performance of polyp detection. in three multi-centre studies, totalising 3775 patients, sensitivity ranged between 78-91% and 90-92% and specificity between 84-93% and 84-98% for lesions > 6 mm and > 10 mm, respectively. finally, it may be expected that further refinements of cad, laxative-free ctc with electronic cleansing and dual energy ct will bring ctc to the next level and will enhance it as the reliable and cost-effective tool for colorectal cancer screening. learning objectives: 1. to review the evolution of ct colonography since its introduction, with a focus on data acquisition and methods of data visualisation and interpretation. 2. to review the currently achievable test characteristics of ctc (sensitivity, specificity, accuracy) via reference to current trial data. 3. to become familiar with imminent developments that may further enhance ctc test characteristics. astinitis and extension of infection from adjacent spaces (neck, pharynx, pleura or retroperitoneum). typical cases including the role of radiologic findings with respect to sensitivity and specificity, and important differential diagnosis will be discussed. the distinction between a parapneumonic pleural effusion and an empyema based on radiologic findings is often impossible. features suggesting a "complicated" course requiring interventional or even surgical treatment at some point will be discussed. features of empyema and lung abscess at ct will be illustrated as well as ct indices of severity of empyema and its effect on the underlying lung that allow some prediction of functional outcome after surgical decortication. an empyema necessitatis describes a chronic empyema that attempts to decompress through the chest wall. infectious agents include tuberculosis, actinomyces, staphylococcus and various types of fungi. it has to be differentiated from other mostly neoplastic diseases that cross fascial planes such as lymphoma or pancoast tumour. most lymphomas arise in lymph nodes or other lymphatic tissues. extranodal lymphomas arise in tissues normally devoid of lymphoid tissue. involvement of so-called extranodal organs is a common finding after staging investigation, however, and a substantial part of nhl even arises in these sites. the latter form is often referred to as primary extranodal nhl. splenic lymphoma is common in both hodgkin disease and non-hodgkin lymphomas but it may be difficult to detect by imaging techniques because lymphoma nodules in the spleen are often smaller than 1 cm. splenic enlargement alone is not a good indicator of lymphomatous involvement. primary hepatic lymphoma is rare compared with disseminated diseases at both nodal and extranodal sites. several forms of hepatic involvement can be seen including mass lesions/nodules, diffuse infiltrative form and extrahepatic involvement of the hepatic ligament. lymphomatous involvement of liver hilum nodes often infiltrates along the hepatic artery and portal vein toward the head of the pancreas and produces an infiltrative bulky mass that involves the liver, pancreas and duodenum. primary pancreatic lymphoma is very rare and can be difficult to differentiate from pancreatic adenocarcinoma. definitive pathological diagnosis of lymphomas is often obtained using image-guided biopsy. this noninvasive procedure is important as the prognosis and management of lymphomas differ greatly from that of adenocarcinoma or metastatic diseases. staging (ann arbor classification or modifications) and response to therapy is primarily by ct. community acquired pneumonia (cap) is a major health care problem because of their high morbidity and mortality rates. patients exposed to non-hospital risks who develop pneumonia have been traditionally categorised as having communityacquired pneumonia (cap). healthcare-associated pneumonia (hcap) is a new designation for pneumonias affecting individuals residing in non-hospital health care facilities, patients undergoing outpatient procedures or therapies, and patients who have been recently discharged from the hospital setting. when the diagnosis of cap or hcap is suspected, imaging studies are mandatory for the evaluation of affected patients. a nosocomial pneumonia is defined as one not acquired in a hospital or a long-term care facility. it occurs most commonly among icu patients, predominately in individuals requiring mechanical ventilation. pulmonary infection is a major cause of morbidity and mortality in patients with impaired immune function. increasing numbers of patients are becoming immunosuppressed, because of solid organ and hematopoietic stem cell transplantation, the use of immunosuppressive agents for treating a host of inflammatory diseases, or congenital and acquired diseases such as acquired immune deficiency syndrome (aids). mildy impaired host immunity as it occurs in chronic debilitating illness, diabetes mellitus, malnutrition, alcoholism, advanced age, prolonged corticosteroid administration and chronic obstructive lung disease have also been regarded as predisposing factors of pulmonary infections. the rapid diagnosis and treatment of pulmonary infections are essential. combination of pattern recognition with knowledge of the clinical setting is the best approach to pulmonary infectious processes. acute mediastinitis is a potentially life threatening but fortunately rare condition that requires prompt diagnosis and treatment. spontaneous or iatrogenic oesophageal rupture is the by far most common cause. other causes include post-surgical medi-ask the patient for those information. at the time of mr imaging plain films and/ or results of an ultrasound exam of the shoulder, if possible, should be available. however, only such prerequisites allow to run a tailored examination protocol and to support the orthopaedic colleague with the needed answers for further adequate therapy. the patient has to be placed in the magnet in a pleasant situation to avoid artefacts due to patients movement, which usually cause motion artefacts. it is very important to explain to patients to keep quiet during the whole examination, because artefacts may need repetitions of sequences, and lead so to prolongation of total examination time. furthermore, they make diagnosis more difficult and eventually more or less inaccurate. lastly, sequence repetitions decrease patient throughput and therefore cost effectiveness. imaging in three orientations (axial, paracoronalparallel to the supraspinatus tendon, and parasagittal -parallel to the glenoid cavity) using t1w (pdw) and/or t2w sequences have to be performed. in case of specific questions regarding lesions of the labrum intraarticular administration of contrast agent (mr arthrography) should be considered, which is sometimes (different from country to country) possible after discussion with referring orthopaedic surgeon only. mr imaging (mri) and mr arthrography are the primary diagnostic imaging modalities applied to patients with degenerative, traumatic and sports-related shoulder lesions. in this categorical course the characteristic mr imaging and mr arthrographic features of articular pathologies of the shoulder, in particular, instability-associated injuries, rotator cuff tears and biceps tendon lesions are discussed. beside lesion detection the radiological analysis comprises the understanding of the underlying pathomechanism and recognition of possible interrelations between different type of lesions (for example, secondary impingement and associated lesions of the posterosuperior labrum). the use of classification systems for specific lesions is introduced in order to improve the radiological report. a reasonable structure for written reports is discussed comprising a brief and clear description of pathological findings with subsequent interpretation and categorisation of findings with a view of therapeutic decision making. tissue changes in the treated neck by surgery and/or radiotherapy (rt) make the detection of residual or recurrent tumour more difficult. clinical evaluation of the neck is also hampered by these changes. therefore, any (non-invasive) method helping in the detection of recurrence is welcome. in order to evaluate the treated neck, radiologists should be familiar with expected post-rt findings. histological changes post-rt will be discussed in combination with imaging examples. this knowledge will enable radiologists to recognise non-expected findings post-rt. non-expected post-rt findings can be caused either by tumour recurrence, or by complications of treatment (e.g. chondro-radionecrosis). imaging examples will be shown. especially after surgery, including various types of neck dissection, lymphatic drainage patterns of the head and neck are altered. it is important that radiologists are aware of these changes. imaging examples will be shown. ct and/or mr-findings in the treated neck may be inconclusive. in these cases, there may be an additional role for metabolic (pet) imaging. at present, the position of metabolic imaging in the imaging protocol for the treated neck is unclear. information from the recent literature will be discussed. also, examples from daily practice will be shown, with emphasis on the importance of base-line imaging after treatment and the timing of such base-line scans. this knowledge will help in understanding the current indications and limitations of post-treatment metabolic (pet) imaging of the head and neck. an increasing number of functional and metabolic imaging options reflecting relevant aspects of tumour biology have rapidly been incorporated into clinical trials and, progressively, into clinical practice. while tumour staging according to the tnm system still rules most decisions regarding treatment choice in head and neck cancer, biological information from the tumour and its microenvironment has proven to have important predictive and prognostic value heading for a tailored and individualised patient's management. ct, mr and pet are the mainstay imaging modalities to access tumour extent, both of the primary tumour, lymphatic and distant metastases and for early depiction of recurrence during patient's follow-up. hypoxia and angiogenesis, the major driving forces for tumour aggressiveness, long linked to chemo and irradiation treatment failure, can now be imaged both by pet (18 f-miso or 60cu atsm) or mri (bold and pwi, respectively). this information is being used to define biological tumour volumes, to tailor conformational and intensity modulated radiation treatments and to select patients for specific treatments such as radiosensitizers, hypoxia selective cytotoxic and antiangiogenic drugs. overexpression/amplification of egfr (epidermal growth factor receptor) are common genetic abnormalities in scc linked to increased cell proliferation and worse prognosis. imaging techniques reflecting cell proliferation/ density (18 f-flt -desoxyfluorothymidine-and diffusion-weighted mri) can be used to select patients for treatment with egfr inhibitors. this special focus session will review the use of these imaging modalities both prior, during and after treatment of head and neck cancer focusing on their specific advantages and accuracies in these different settings. contrast-enhanced ct and mri are routinely used in order to determine the precise localisation, size and anatomic extent of the primary lesion. on the other hand, positron emission tomography (pet) is the most sensitive and specific technique for in vivo imaging of metabolic pathways and receptor-ligand interactions in the tissues. a common question is which of these techniques should be used in a particular patient. the most widely used technique is ct, as it has a number of important advantages over mri, like wide availability, relative low cost and short examination time. however, ct also has a number of disadvantages compared to mri: relative low soft tissue contrast resolution, severe image quality degradation by dental fillings or other metallic foreign objects, and radiation exposure. pet in combination with ct and/or mri has a good sensitivity and specificity for the detection of primary tumour and for nodal staging as well as for detection in a single examination distant metastases, occult tumours, second synchronous tumours, and for radiotherapy planning. by combining pet with ct and mri studies, either sequentially or synchronous performed, the diagnostic accuracy is significantly higher. in those situations, it has been proven that magnetic resonance (mr) imaging is a valuable adjunct to delineate the pathology. in non-pregnant woman the radiological evaluation is less difficult. still, a multimodality approach may be needed in certain cases. in this lecture, radiological features of non-gynaecologic emergencies such as acute appendicitis, diverticulitis, renal calculi and pyelonephritis will be discussed. the purpose is to discuss the role of imaging and the potential of different methods applicable in childhood uti -with a focus on us. the imaging task in uti has changed, and new questions arouse for radiology. in addition, growing economical demands pressurise radiology to restrict imaging to those conditions where an evident benefit has been demonstrated. this efficacy-oriented approach is difficult in children due to the lack of evidence-based data. thus, controversies exist on if, when and how to investigate childhood uti, trying to minimise procedures and reduce burden on children and health budgets without missing important conditions that may pose a threat to the kidney. furthermore, modern imaging with new methods, applications and potential (e.g. contrast-enhanced voiding urosonography = ce-vus) may influence the imaging algorithm. the in utero and post-natal follow-up of foetuses with urinary tract dilatation has provided lots of information about the proper management of urinary tract malformations. nowadays, affected neonates are evaluated following standardised charts panel discussion: the three musketeers were actually four 09:44 ct, mr and pet: how to choose between modalities in head and neck cancer patients. an increasing number of imaging modalities reflecting functional and metabolic aspects of tumours have rapidly been incorporated into clinical practice. these modalities provide additional information on tumour vascularisation/ angiogenesis (ct and mr perfusion); on tumour metabolism, hypoxia and proliferation (pet using different radioactively labelled substances) and on tumour architecture and cellular density (dwi). hybrid imaging, pet-ct and, in the near future pet-mr, can provide morphologic, metabolic and functional information in a one-stop-shop examination. the choice of the best modality (ies) to answer specific questions in the diagnosis, follow-up and in the prediction of response to treatment and prognosis will be addressed. acute abdominal and pelvic pain in pregnant women may be the manifestation of various gynaecological and non-gynaecological conditions. the correct diagnosis of the causes of acute pain during pregnancy is critical to minimise maternal-foetal morbidity and mortality. although ultrasound (us) is the primary imaging investigation in the diagnostic evaluation of the pregnant patient, the role of magnetic resonance (mr) imaging in the evaluation of foetal and maternal diseases in pregnant patients continues to expand. mr imaging offers different potential advantages in comparison to us for evaluating acute abdominal and pelvic pain; these include multiplanar imaging capabilities, a higher soft tissue contrast and the ability to detect and distinguish blood from other fluid collections. when us is equivocal or nondiagnostic, mr imaging is a valuable complement to determine the exact aetiology of acute abdominal pain. the intrinsic safety and the accuracy of mri in diagnosing abdominal and pelvic disease make it an excellent choice for triage of pregnant patients with acute abdominal and pelvic pain. mr imaging provides important information that influences patient management, and it is important for the radiologist to recognise the mr imaging appearance of the common causes of acute abdominal and pelvic pain during pregnancy. this lecture will discuss the use of mr imaging for maternal diseases that cause acute abdominal and pelvic pain during pregnancy. moreover, this lecture will discuss the different mr imaging techniques to use, and will show how to detect and to differentiate the gynaecologic and non-gynaecologic causes of pain during pregnancy. in this lecture, the role of imaging in the evaluation of gynaecologic emergencies will be presented. a combined approach using both clinical findings and imaging features is necessary. accurate evaluation is important as failure to make a diagnosis may lead to serious consequences. presenting symptoms, such as pelvic pain or vaginal bleeding or discharge, may overlap with pregnancy-related emergencies and with non-gynaecologic abdominal emergencies. the range of conditions to be considered include ovarian cyst emergencies (cyst rupture, haemorrhage or torsion), infective conditions (bartholins' or vulval abscess, pelvic inflammatory disease or tubo-ovarian abcess) and acute bleeding (from inflammation, neoplasm, or trauma). pain may be related to the menstrual cycle, as in endometriosis or ruptured corpus luteum, or may be unrelated, such as in fibroid or ovarian torsion or pelvic inflammatory disease. the imaging features of these acute abnormalities will be reviewed and discussed in the context of the differential diagnoses. the major functional imaging tools for tumour management are obtained with dynamic contrast-enhanced imaging, diffusion-weighted mr imaging, and mr elastography. these acquisitions allow understanding of tumour angiogenesis and perfusion, and tumour architecture. dynamic contrast material-enhanced imaging allows assessment of perfusion parameters. diffusion-weighted mr imaging provides information that reflects tissue cellularity and the integrity of cellular membranes. mr elastography evaluates the mechanical properties of tissue such as stiffness and viscosity. to date, tumour detection is mainly based on morphologic features. however, changes in perfusion parameters have been shown as early parameters of liver metastases detection in patient with colorectal carcinoma or breast carcinoma. tumour characterisation is usually based on morphologic features. yet, perfusion parameters have been shown to correlate with microvascular density and tumour differentiation helping tumour characterisation. furthermore, apparent coefficient diffusion (diffusion-weighted mr imaging) and stiffness and viscosity (mr elastography) are significantly different in benign and malignant tumours. despite these differences, these last parameters usually do not allow definitive subtyping. functional imaging starts playing a major role in non-surgical treatment follow-up especially with targeted cancer therapy. changes in perfusion parameters, apparent coefficient diffusion, and stiffness and viscosity are observed in responders. interestingly, these changes appear promptly after treatment initiation. these functional variables are not included in recist 1.1 but might be part of response criteria in the next future. many examples of functional imaging for tumour management will be provided. learning objectives: 1. to understand the potential of functional imaging in tumour detection. 2. to understand the potential of functional imaging in tumour characterisation. 3 . to learn about the future use of functional imaging in treatment planning and follow-up. (among others, thanks to the esur-espr working group). at birth, a confirmatory ultrasound is performed in order to evaluate the type and degree of the malformation. urinary tract dilatation are separated into mild, moderate and marked. mild and moderate dilatation will be followed by us. voiding cystogram and functional studies will be performed only if the dilatation is significant or persists. the prognosis is usually good. patients with marked dilatation would be managed more "aggressively". their work-up would be initiated as soon as diagnosed in order to diagnose cases that need therapeutic manoeuvre. for them voiding cystogram, anatomical and functional studies cannot be skipped and are important for the prognosis. long-term follow-up are needed to prevent further damage. learning objectives: 1. to learn which infants with antenatal diagnosis of urinary tract dilatation require imaging and when. 2. to become familiar with the most important differential diagnosis. 3 . to learn about the imaging strategies in these infants. c. renal and pararenal masses: basic rules p. tomà; rome/it (paolo.toma@opbg.net) the differential diagnosis of renal and pararenal masses firstly depends on the age of the child. wilms tumour (nephroblastoma) is the most common abdominal tumour in 1-8 years old (80% of cases in children less than 5 years old -peak age 3.6 years). renal non-wilms tumours represent a significant proportion of renal tumours in children, especially in children aged less than 6 months or greater than 12 years. neuroblastoma most commonly arises from the adrenal gland but can arise anywhere along sympathetic chain; it is the most common tumour in children under 2 years of age (90% of cases in children less than 5 years -mean age < 2 years). adrenal adenomas and carcinomas also occur in childhood. us is the initial imaging modality to investigate an abdominal mass in children. ct or mri is used to confirm the us findings and not uncommonly add new, valuable information. concerning wilms tumour there is a very diverse approach to treatment according to geographical location. this variation in therapeutic attitude has consequences for the choice of imaging modality at diagnosis. neuroblastoma staging includes also 123i-mibg, and laboratory investigations (bilateral bone marrow aspirates with histochemical tests and urine catecholamine level measurements). we focus on the points under discussion: revision to the staging of neuroblastoma, the problems inherent in distinguishing nephrogenic rests from wilms tumour and the approach regarding small lung nodules in children with wilms tumour. the principle of bi-rads 3 imaging finding should be that of "quasi-benign" type, i.e. with a very low associated risk of malignancy (< 2%), opening the possibility of a short-term imaging follow-up as an alternative to imaging-guided needle biopsy. however, a number of issues should be regarded as relevant to radiologists and patients. 2) radiologists' differences in classification. 2. when needle biopsy is optioned, vacuum-assisted biopsy under stereotactical guidance for mammographic only findings (typically, microcalcifications) and core-biopsy for sonographic findings should be used; fine needle aspiration cytology should be avoided due to the high probability of benign lesions which need larger tissue samples. 3. when short-term follow-up (typically, 6 months) is optioned, the same technique on which the bi-rads 3 lesions was initially detected should be used. 4. in the screening setting, short-term follow-up option is commonly not considered and the reader is forced to give a dichotomic reading (recall/not recall). 5. the choice between the two options should be clearly discussed with the patient, including the psychological cost of waiting six months to get a conclusive report, and a really informed consent should be obtained. 6. till now, there is insufficient evidence for using tomosynthesis or mri for evaluating mammographic or sonographic bi-rads 3 findings. the premise behind the bi-rads 3 classification is to identify a group of low risk lesions that can be safely placed on follow-up rather than biopsy. in practice this can be very difficult and is anachronistic to the principles of the european population screening programmes where the radiology objective is to diagnose or discharge. the panel will discuss these dilemmas. starting in the late 1980s an american college of radiologists task force developed the concept of guidelines to standardise mammography reporting: breast imaging reporting and data system (bi-rads). there is evidence that over time there have been improvements in consistency of use, sensitivity, specificity and positive predictive value. however, bi-rads 3 'probably benign; short interval follow-up recommended; less than 2% risk of malignancy' has always been the most difficult and controversial, with the highest levels of discordance between classification and recommendation, wide variation in both intra-and inter-observer agreement and a 2007 literature review demonstrating ppv for malignancy of between 0 and 8%. management of breast disease has moved on a great deal since the 1990s. in the main driven by increasing specialisation associated with population screening programmes. nowadays a specialist breast radiologist works with a wide variety of needle options at his hip to such an extent that the breast multi-disciplinary team increasingly feels that failure to obtain a non-operative diagnosis of discrete lesions is unacceptable. in this setting, and mindful of the medico legal consequences of 'delayed diagnosis', is there still room to allow a patient to leave the one stop clinic without a definitive diagnosis? as the leaders of the diagnostic team we also have to take account of the emotional and psycho-social consequences for our patients as well as the financial costs to patient and the healthcare economy. breast imaging reporting and data system (bi-rads) was developed for standardising reporting and include mammography, ultrasound, and mri. bi-rads category 3 "probably benign finding -short-interval follow-up suggested" should have less than 2% risk of malignancy. category 4 has been subgrouped into 4 a, 4b, and 4c, and this influence the classification of bi-rads 3. mammographic bi-rads 3: three nonpalpable findings in this category include clusters of punctate microcalcifications, well-circumscribed and noncalcified solitary masses, and benign-appearing asymmetric density. digital mammography will increase detection of amorphous microcalcifications and the number of bi-rads 3 (or 4 a) lesions. intramammary lymph nodes and calcified fibroadenomas are bi-rads 2 lesions. ultrasonographic bi-rads 3: a most important bi-rads 3 lesion is a solid oval mass ("tumour") with gently lobulations, circumscribed margins, and parallel orientation. using strict criteria, the negative predictive value is approaching 99%. two other lesions are nonpalpable "complicated cyst" and clustered microcysts. the "complex" cyst, i.e., a mass with cystic and solid components, should be classified as bi-rads 4. mri bi-rads 3: there is lack of evidence which mri findings should be categorised bi-rads 3. nonmass-like enhancement (nmle) and enhancement kinetics are unique to mri. lesions less than 5 mm ("foci") need no assessment. a challenge is mri-detected tumours < 10 mm as morphologic analysis is of limited value. benign kinetic curves may justify short-term follow-up. in high-risk women, mri-guided vacuum-assisted biopsy should be considered. in conclusion, bi-rads 3 is justified in diagnostic settings but should be avoided or kept at a minimum in screening. what will be the standard machine and field of the future? l. darrasse; orsay/fr (luc.darrasse@u-psud.fr) improving the sensitivity has still been an essential issue in mri, because the signal from nuclear spins relies on extremely weak magnetic interactions dominated by thermal fluctuation. to push the signal-to-noise ratio upward, the basic routes have been (i) to increase the field strength, (ii) to improve the signal detection with radiofrequency coils and (iii) to enhance the signal dynamically with contrast agents or alternative preparation techniques. the first route is the most obvious one, driven by the trends in analytical mr spectroscopy and small-animal mri. going up to or even above 7 t represents a considerable challenge, both technically and in view to renew the mr equipment market. however, this way is limited by safety issues, radiofrequency penetration concerns and susceptibility artefacts. alternatively, improving the radiofrequency system relies on a complex electrodynamics background, where tissue conductivity and different sources of noise have to be considered. during the last half-period of mri development, radiofrequency coil arrays have appeared as a powerful mean to improve the signalto-noise and to accelerate the spatial encoding process, even able to overcome some pitfalls with high-field mri. finally, the topics of an optimal field strength has always been highly controversial because the contrast mechanisms, on which the diagnostic information is mainly founded, are essentially field-dependent. basically, the contrast mechanisms tend to be dominated, respectively, by macromolecular cross-relaxation at low field, and by susceptibility-weighted diffusion at high field. an emerging question is then to address different pathologies or organs with either general-purpose or dedicated mri systems. learning objectives: 1. to learn about the possibilities of gaining a jump in signal. 2. to understand the respective strategies of field increase and coil improvements. 3. to consider the probable system in 2020. will new technologies allow a jump in sensitivity? j. hennig; freiburg/de (juergen.hennig@uniklinik-freiburg.de) imaging technologies have made breathtaking progress for several decades and in all aspects of medical imaging -mr, ct, us and pet. amongst the current developments in mri there are several areas which hold promise to redefine the boundaries of sensitivity. ultrahighfield mri with field strengths of 7 t and more starts to reveal insights into tissue microstructure so far inaccessible to mr (or any other technique). this is still under intense technological development with some key issues to resolve notably safety issues related to the high radiofrequency power. the unique contrast and resolution does hold promise for highly relevant applications such as neurodegenerative disease, small vessel disease, ms and others -although definite clinical studies for a ‚killer application' are still lacking. 13c-hyperpolarisation of metabolites such as pyruvate, succinate, bicarbonate, etc. lead to an increase in detection sensitivity by factors of 10-100,000. finally, the development of targeted probes is progressing extremely rapidly and for all imaging modalities. most of this work is aimed at preclinical research, but the tremendous impact of the new insight in translational research promises to be of high impact for clinical application. will these technologies allow a jump in sensitivity? yes and no. image quality, contrast and sensitivity will grow significantly. the biggest impact will, however, lie in the combination of the new possibilities with other data -imaging as well as non-imaging. a true change in paradigm will only be achieved if the current parcellated knowledge about various aspects of the disease is unified into a comprehensive picture. learning objectives: 1. to review the recent developments in rf-coils and gradients. 2. to learn about the new measurements technologies. 3. to envision how these new tools will allow a huge gain in sensitivity. will new mr contrast probes compete with pet? s. aime; turin/it (silvio.aime@unito.it) purpose: molecular imaging is a new science that will have a tremendous impact in the development of innovative diagnostic tools. in the first stage of its enrolment, it has relied massively on pet/spect and optical imaging technologies because of the superior sensitivity of their probes. in the long-term, mri/mrs approaches may recover a central role, provided that further sensitivity improvements will be attained. high sensitivity mri probes have been designed and tested for molecular imaging applications. in the case of paramagnetic based systems they rely on improved design of the coordination cage as well as on the encapsulation/incorporation in proper nanocarriers. for multiple detection studies, cest as well hyperpolarized c-13 containing molecules have been considered. results: as molecular imaging is the evolution of biologists' in vitro work that has revolutionized the way living cells and intact tissues were investigated, mri multiplex-visualization of biological processes appears to be a key task for the forthcoming years for an efficient translation of such outstanding achievements. the search for frequency-encoding mri contrast agents represented by cestand hyperpolarized c-13 containing molecules have opened the interesting perspective of detecting more than one agent in the same anatomical region. this task is largely precluded to nuclear probes. moreover merging mri and nanotechnology allows the attainment of high sensitivity systems also with the classical relaxation agents. conclusion: recent achievements in amplification procedures allow to tackle the intrinsic insensitivity of mri probes to make them more competitive in the arena of molecular imaging applications. the use of imaging to monitor response to treatment has become central in the care of patients with cancer. it is crucial therefore that radiologists involved in the management of patients with cancer understand the place of imaging within the clinical context of the management of patients with cancer; that they are aware of the criteria of the accepted current criteria for assessing response and are familiar not only with new developments in imaging that act as a surrogate end-point for evaluating the success of treatment but are also aware of how imaging is used to predict the likely response early in the patient's pathway. this session will concentrate on all these aspects on the use of cancer imaging in monitoring response to treatment in patients with cancer. we are in the era of targeted cancer therapy, whether by small molecules derived from knowledge of the molecular pathogenesis of tumours, or from biological therapies emerging from our understanding of immunology and cell biology. these approaches convey new challenges for the monitoring of response. small molecule therapeutics often stabilise tumours for significant periods without producing clear reduction of masses, and for these the assessment of surrogate endpoints takes on increasing importance. the measurement of pharmacodynamics is central to early phase trials in which confirmation of on-target effects is required to determine the biologically effective dose, and in many cases this is best done by functional imaging. biological therapeutics such as monoclonal antibodies and cellular immunotherapy also need novel approaches for the determination of their actions in vivo, particularly as they are frequently tested in the setting of low level disease. randomised trials are underway to assess the contribution of functional imaging, in particular ct-pet as a means to guide therapy. the emerging data suggest that there are broad variations in accuracy, both according to the disease in question and the context in which studies are performed, even before factors such as imaging quality control and standardised reporting are included. for the future, standardisation of techniques and common quality control will play a vital part in advancing our understanding in this rapidly evolving field. tas. there is regression of portions of these arches, but several remnants normally persist. any failure in this process can result in congenital anomalies of the aorta or pulmonary vessels. these anomalies can be categorised into aortopulmonary anomalies, systemic arterial anomalies, and pulmonary artery anomalies. the aortopulmonary anomalies comprise truncus arteriosus, hemitruncus arteriosus, aorticopulmonary window, patent ductus arteriosus, and transposition of the great arteries. the systemic arterial anomalies include the anomalies of the aortic arch, of which the most common is a left aortic arch with aberrant right subclavian artery. double aortic arch is the most common cause of a vascular ring and is characterised by left and right aortic arches arising from the ascending aorta and encircling the trachea and oesophagus. a right aortic arch can have three "subtypes": aberrant left subclavian artery, mirror image branching, or isolated subclavian artery. the first type is the most common one and is the second most common cause of vascular ring. aortic coarctation, pseudocoarctation and interruption of the aortic arch are other systemic arterial anomalies. the most important pulmonary artery anomalies are idiopathic dilatation of the pulmonary trunk, absence or proximal interruption of a pulmonary artery, pulmonary arterial stenosis, and pulmonary sling. cardiovascular magnetic resonance (cmr) imaging has become integrated into the assessment pathways for congenital heart disease in both paediatric and adult patients. cmr provides a powerful tool, giving anatomical and haemodynamic information that echocardiography and catheterisation alone do not provide. extracardiac anatomy, including the great arteries, systemic and pulmonary veins, can be delineated with high spatial resolution. vascular and valvular flow can be assessed, shunts can be quantified, and myocardial function can be measured accurately and with high reproducibility, regardless of ventricular morphology. finally, cmr surpasses both catheterisation and echocardiography in providing high resolution, isotropic, three-dimensional (3d) datasets. this allows for reconstruction of data in any anatomical imaging plane, giving complete visualisation of complex congenital cardiac anomalies, without the use of ionising radiation. in the congenital heart disease, cmr can be justified for any patient in whom clinical or echocardiographic data are insufficient for monitoring, decision-making or surgical planning. due to the complexity of both the anatomy and physiology of congenital heart disease, it is essential to have a systematic approach for cmr when assessing these patients. with the development of novel ct scanners, especially the dual source ct, novel strategies of examining congenital heart disease became possible. especially newborns and infants younger 3 years of age are difficult to examine, since compliance cannot be expected. also young children are especially susceptible to ionizing radiation and should be exposed as little as possible. in a first step the course will illustrate the underlying technical principle how to examine children in < 1 sec with sub msv exposure. also the course will teach how to avoid sedation in children of any age. in a second step the course will show how to apply contrast media in children of all ages and what strategy to use. in a third step the course will show how to appropriately choose scanning parameters for the ct scan since the size and weight varies considerable in children as there are small to date newborns with < 2 kg body weight up to adolescents with a body weight > 60 kg. since little comprehensive data is available how to examine with an optimal compromise between sufficient image quality and unnecessary radiation overexposure the data of the erlangen study will be presented and discussed. in a forth part typical indications for the exam are shown and how to interpret the exam. also limits for the exams are shown. in a final step a comparison with mri is shown which method is used for which pathology. in this session contrast-induced nephropathy and nephrogenic systemic fibrosis will be discussed. measures to reduce the incidence these adverse effects will also be presented. the pathophysiology of cin is complex and not well understood. basically, a misbalance between vasodilatation and vasoconstriction takes place inside the kidney after intra-arterial or intravenous cm administration. furthermore, increased oxygen demand of tubular cells due to increased reabsorbtion of sodium and water is a second mechanism, leading to transient medullar ischaemia. identifying the patient at risk is the first step in prevention. knowledge of the patient's medical record and a recent basic kidney function are mandatory. high-risk patients should receive prevention. two major topics in cin prevention are the questions whether iso-osmolar cm cause significantly less cin than low-osmolar cm and whether hydration schedules with nahco 3 give significantly less cin than hydration schedules with nacl 0.9%. currently up to 50% of all mri examinations worldwide are performed using contrast agents, either an extracellular agent or an organ-specific agent. the extracellular mri contrast agents are chelates that contain the paramagnetic ion gadolinium which strongly affects the relaxation properties of water protons, leading to changes in tissue contrast. gd-dtpa was the first extracellular agent to be introduced in clinical practice. since the introduction of gd-dtpa in 1988, various gadolinium chelates with different chemical properties became available for clinical use. for many years, it was believed that gadolinium-based contrast agents (gbca) a s33 c b d e f g principles in the use of conventional/anatomic imaging for response assessment l. schwartz; new york, ny/us (lschwartz@columbia.edu) the standard way to assess a patient's response to chemotherapy is to use computed tomography (ct) to measure tumour size using uni-dimensional (recist) or bi-dimensional (who) criteria. this methodology has changed little in the past 30 years despite the emergence of new therapies and advances in imaging technology. measuring the changes in the size of tumours in one or two dimensions does not always capture the effects of novel therapies on primary tumours and metastases. radiographic changes in the size of tumours treated, for instance, with epidermal growth factor receptor tyrosine kinase inhibitors such as gefitinib or erlotinib or inhibitors of angiogenesis such as bevacizumab do not necessarily occur at the same magnitude or speed as observed in those individuals treated with standard cytotoxic therapies. with these newer agents, tumours respond by undergoing cystic change, central necrosis, and density changes that may not be captured by conventional measurements of the largest lesion diameter. learning objectives: 1. to understand and appreciate the use of conventional/anatomic imaging for response assessment in clinical practice as well as in clinical trials. 2. to understand general and disease-specific challenges associated with response assessment at imaging. 3. to recognise potential improvement in imaging and image post-processing for response assessment. pet in monitoring response w. weber; freiburg/de pet imaging and specifically pet/ct with the glucose analogue fluorodeoxyglucose (fdg) has been evaluated in a significant number of studies to monitor tumour response in patients undergoing chemotherapy, radiotherapy or targeted therapies. the clinical value of for differentiation of residual or recurrent viable tumour and therapy-induced fibrosis or scar tissue has been established for malignant lymphomas and various solid tumours. furthermore, there are now several reports suggesting that quantitative assessment of therapy-induced changes in tumour fdg-uptake may allow prediction of tumour response to chemotherapy and targeted drugs very early in the course of therapy. in non-responding patients treatment may be adjusted according to the individual phenotype of the tumour tissue. current studies investigate whether fdg-pet can be used to "personalise" treatment and to reduce the side effects and costs of ineffective therapy. in addition to fdg, several other imaging probes are in clinical studies to monitor tumour response to therapy. these include among others [ 18 f]fluorothymidine (flt) for imaging of cellular proliferation, [ 18 f]fluoromisonidazole for assessment of tumour hypoxia and radio-labelled rgd-peptides for angiogenesis imaging. preclinical and early clinical trials with these imaging probes are encouraging, but need to be confirmed in larger clinical trials. learning objectives: 1. to understand how image acquisition and reconstruction influence visual and quantitative analysis of pet studies. 2. to describe current criteria for assessing tumour response in lymphoma and solid tumours and recognise the limitations of these criteria. 3. to understand how differences between scanner models can influence response assessment by pet. panel discussion: why does the radiologist need to understand the importance of monitoring response and how it is done? 09:45 monitoring the response to treatment has become a critical part of the management of patients with cancer. the markedly improved diagnostic performance of crosssectional imaging in delineating the extent of malignancy has meant that imaging has become increasingly important as a surrogate end-point. these two factors have resulted in an increasing need for a standardisation of the criteria of response both in therapeutic trials and in clinical practice. it is vital that all radiologists imaging patients with cancer are familiar with the limitations, pitfalls and strengths of these changing criteria and also are aware of the possibility of using imaging to evaluate the changing molecular make-up of the cancer. stent-grafts is steadily increasing. therefore, knowledge of this treatment option is fundamental to provide basis for procedure planning and a meaningful radiological reporting. imaging plays a crucial role in the assessment of patients with aortic aneurysms. eligibility for endovascular treatment depends very much on detailed anatomical knowledge of the aorta, its branches and vascular access through the iliac arteries. we will review the role of imaging modalities: us, ct, mr for detection and evaluation of anatomy of thoracic and abdominal aneurysms. the strength and weakness of each modality will be reviewed and inclusion criteria for endovascular aortic aneurysm repair will be presented. the precise sizing of the stentgraft obtained from the images is certainly one of the most critical points of the endovascular procedure and a condition of its success. although it is a minimally invasive treatment it is associated with complications. there is a strong need for general radiologists to know about the most prevalent normal and abnormal findings of the post-treatment aorta. the session will end with discussion addressing the central role of imaging in pre-and post-treatment evaluation of the patients with aortic aneurysms. indications for and experience with placement of endovascular stent grafts in the thoracic aorta are still evolving. recent advances in imaging technologies have drastically boosted the role of pre-procedural imaging. the accepted diagnostic gold standard, digital subtraction angiography, is now being challenged by the state-ofthe-art computed tomography angiography (cta), magnetic resonance angiography (mra) and trans-oesophageal echocardiography (tee). among these, technological advancements of multidetector computed tomography (mdct) have propelled it to being the default modality used, optimising the balance between spatial and temporal resolutions and invasiveness. mdct angiography allows the comprehensive evaluation of thoracic lesions in terms of morphological features and extent, presence of thrombus, relationship with adjacent structures and branches as well as signs of impending or acute rupture, and is routinely used in these settings. in this presentation, we review the current state-of-the-art radiological imaging for thoracic endovascular aneurysm repair (tevar), especially focusing on the role of mdct angiography. after analysing the technical aspects for optimised imaging protocols for thoracic aortic diseases, we will discuss pre-procedural determinants of candidacy, and how to formulate interventional plans based on cross-sectional imaging. the purpose is to present the essential principles of endovascular repair of abdominal aortic aneurysms (evar). abdominal aortic aneurysms (aaa) larger than 5.5 cm should be treated. inclusion criteria for evar include satisfactory aneurysm neck morphology and suitable access vessels. preprocedural imaging involves cta from the diaphragm to the femoral arteries. several devices may be used to cover a wide range of anatomy. evar procedures are generally performed as combined procedures by teams of vasculr surgeons and interventional radiologists. patients are followed up indefinitely by cta (or ultrasound) and plain radiography. the periprocedural mortality is three times lower compared with surgery. late mortality rates are similar between surgery and evar. quality of life issues favour evar in the short and medium term. early published series reported high complication and reintervention rates for evar, although these have reduced with increased experience and improved device technology. gene-reporter imaging has been used to monitor cell-based therapies in neurology. one of the most promising applications of molecular imaging principles is the targeting of amyloid deposition in the patients with alzheimer's disease. it is hoped that early diagnosis of the neurodegeneration may lead to better therapies. the advent of hybrid-imaging will be associated with the need for multimodal contrast agents exploiting the imaging characteristics of the involved instrumentation for more differentiated visualisation of structure, physiology, and biology. learning objectives: 1. to understand the working mechanism and radiation of current clinical tracers. 2. to become familiar with the potential clinical indications and applications. 3 . to learn about potential new tracers. panel discussion: what specific precautions are mandatory in order to guarantee contrast media safety to patients and healthcare professionals? 09:44 current contrast agents are safer than previous products. however there are still safety aspects to consider, including patient's kidney function, thyroid metabolism, allergy, radiation exposure, or specific medical history, and there is no such thing as total or complete safety. while these simple precautions may appear obsolete in the era of sophisticated technical approaches, these issues are still quite complex and crucial in maintaining a high safety level. the discussion will give guidelines and tips for achieving a high level of safety when using contrast agents. room q the abc of evar magnetic resonance imaging (mri) is the best tool to explore white matter disorders (wmd), including the most common demyelinating disease: multiple sclerosis (ms). the formation of demyelinating lesions is related to an "inflammatory attack". new techniques as diffusion tensor imaging (dti), perfusion weighted imaging and uspio enhancing can explore earlier and more specifically lesions formation. acute demyelinating lesions may resolve (remyelination) or persist as "chronic black holes". chronic demyelinating lesions lead to axonal injury and wallerian degeneration. a diffuse neurodegenerative process leading to cerebral atrophy is actually a major landmark in ms. conventional mri sequences allows visualisation of white matter lesions (seen as hyper t2/flair lesions, low signal t1 lesions and possible gadolinium contrast enhancement), presently the basis of ms diagnosis. ms follow-up is usually clinic but imaging could provide prognosis and therapeutic parameters ("surrogate markers") even if disease progression and axonal loss are independent from "lesion load". mr spectroscopy, dti or magnetization transfer imaging (mti) provide measurement of diffuse tissue damage in clinical research, and may correlate to disease progression, as well as brain volume measurement. after exclusion of alternative diagnosis (mri "red flags" as other wmd), mri lesions dissemination in space and time criteria are the main points in ms diagnosis. the widely used revised mcdonald criteria may be replaced by more simple and efficient magnims criteria. such criteria could allow starting "modifying disease treatments" as soon as the first "clinical isolated syndrome". since blood oxygenation level-dependent (bold) signal changes have been observed using mri and modulated using neuronal stimuli, functional mri (fmri) has quickly become the most popular non-invasive functional neuroimaging technique in clinical practice and cognitive neuroscience. indeed, high-field mr scanners and bold-sensitive sequences are now widely accessible in both clinical and research settings. bold signal that relies on deoxyhaemoglin concentration is detectable without injection of external contrast media. the colourful activation maps combined with three-dimensional brain anatomy may have also made this imaging method as much attractive as controversial. numerous applications of fmri have been suggested in medicine. after a 15-year long history in clinical practice and thousands of scientific papers even in prestigious journals, the role of fmri remains mostly dedicated to map eloquent cortex before a neurosurgical procedure. in fact, bold fmri is challenging because the relationship between the neuronal response to a stimulus and the activation blobs relies on neurovascular coupling, haemodynamic response, mr signal detection, and complex time-series analyses. besides an obvious and partially elucidated complexity, and several concerns on the interpretation of experimental paradigms in cognitive neuroscience, fmri is based on a robust physiological and physical framework. bold signal is reproducible across subjects and mr scanners. fmri requires a rigorous methodology to acquire and analyse data, an advanced knowledge in sulcogyral and functional neuroanatomy to estimate spatial displacement and reorganisation in patient with focal lesion, and a solid experience in bold imaging to distinguish artefacts and potential confounds from appropriate results. learning objectives: 1. to know the key points of quality in fmri. 2. to know the main pitfalls in fmri interpretation. 3 . to learn more about advances in fmri of brain perfusion. a-120 09:21 the role of imaging in follow-up k.a. hausegger; klagenfurt/at (klaus.hausegger@lkh-klu.at) the goal of surveillance after evar is to prevent late rupture eurysm. high pressure els (type i and type iii el) are risk factors for late rupture therefore have to be treated. type-ii, iv and type v (endotension) els are low pressure els with a low rupture risk. thus, it is essential not only to detect els but also to classify els correctly. until recently stent graft surveillance has been performed with contrast enhanced multislice ct (msct), typically 1, 3, 6 and 12 months after evar and thereafter in yearly intervals. however, although msct proved to be a very effective in fu cumulative radiation exposure, repetitive contrast medium load and increasing work load have to be seen critically. therefore, alternative surveillance protocols especially including ultrasound have been evaluated. several studies have shown that a risk-adjusted follow-up regime might be most efficient. patients with low risk of aneurysm-related mortality after evar have a normal 1-and 6-month msct scan and sack shrinkage at 12 months. in these patients regular contrast enhanced us in yearly intervals have been proven to be safe for further fu. a one yearly non-enhanced low-dose ct or a plain film may be recommended to detect distortion or migration of the stent-graft. patients with a persistent type ii el after one year need to be followed more closely and imaging modality is chosen depending on the character of the el. in most cases el classification can be made correctly by msct or us; however, sometimes dsa may be needed. panel discussion: the key role of imaging in endovascular aortic aneurysm repair 09:44 many patients with aortic aneurysms are currently treated endovascularly. therefore the number of patients imaged pre and post-procedurally is increasing. radiologists evaluating aortic aneurysms with different modalities should know the key imaging features to look for in pre-treatment as well as follow-up examinations. j.-p. pruvo; lille/fr (jppruvo@chru-lille.fr) neuroimaging is one of the fields of radiology with the most exciting recent advances. moreover, these advances show dramatically important clinical applications. some are useful for the specialised neuroradiologist, but most are critical for the general radiologist as well. in this session, we will try to address some of the most relevant issues: white matter disorders are common diseases. expertise of the radiologist is important in detecting the disease, and in the evaluation of the activity after treatment. with this respect, standardisation of criteria is desirable for appropriate medical decisions. functional imaging is a fascinating insight into the human brain. it opens new horizons and has found many applications in the evaluation of psychiatric diseases, and in the planning before treatment of brain lesions, among other potential applications. although it is obvious that we ignore much more than we know, this field is already one of the most exciting topics in neuroradiology. although these methods are still in the field of specialists, everybody should be aware of the possibilities of functional imaging of the brain and its recent developments. stroke is by excellence a clinically relevant problem. because it is an emergency situation, time really matters, and we have more than one imaging tool to explore these patients, it is mandatory to provide strong recommendations and guidelines for the radiologist, in accordance with the clinical situation and with the treatment options. at the end of this session, the attendees will be aware of important advances in the domain of neuroradiology, and will take home very important landmarks for their own clinical practice. jaundice is rare in children but imaging has a major role to establish the cause which differs according to age. in the neonatal period the leading cause is biliary atresia (ba) which consists of the obliteration of the extrahaepatic bile duct (bd) without dilatation of intrahaepatic bd and requires urgent surgical treatment to reduce the need for liver transplantation. ba must be considered when there are persistent white acholic stools and firm hepatomegaly. us shows the absence of dilated bd and in a few cases a cyst at the porta hepatis or findings of the splenic malformation syndrome, but often it is not conclusive. mrcp has not yet proved to be reliable for the diagnosis of ba. other neonatal cholestases include medical intrahepatic causes which can be identified by biological tests or histological findings and rare causes of extrahepatic obstruction with dilated bd such as lithiasis, choledochal cyst or spontaneous perforation of bd. in childhood, us easily identifies all causes of extrahepatic obstruction by showing dilated bd; the main causes include choledochal cyst (the most frequent congenital malformation, defined by an abnormally long common bilio-pancreatic channel), cholelithiasis, tumoural compression, sclerosing cholangitis, portal vein obstruction, postsurgical or posttraumatic stenosis… in all these cases, in our experience, mrcp has become the modality of choice and has replaced invasive procedures which are nowadays reserved for treatment. mdct may be useful in rare instances, for example, to differentiate calculi and aerobilia after surgery. imaging protocols and illustrative cases will be presented. neonatal bowel obstruction generally presents within hours of birth. the diagnosis of bowel obstruction is clinical but imaging is vital to determine the cause. the plain radiograph will distinguish upper from lower intestinal obstruction. the radiograph alone is diagnostic in duodenal atresia and jejunal atresia and the baby may be taken directly to surgery. if the radiograph shows multiple dilated loops of bowel, more than 4 loops, then the obstruction is distal ileal or colonic. the radiograph may give some clues as to the possible cause, such as a large fluid level in the dilated loop proximal to an atresia. contrast enema, usually with low osmolar water soluble contrast, is used in most cases, however, to determine the cause of lower intestinal obstruction because the management of this is different for different causes of obstruction. meconium ileus and ileal atresia are the commonest ileal causes of obstruction and hirschprung's disease and meconium plug syndrome are the commonest colonic causes of obstruction. colonic atresia is rare and imperforate anus is a clinical diagnosis. radiologically guided reduction is used to treat meconium ileus. intestinal obstruction in the older neonate may be due to volvulous, pyloric stenosis, duodenal stenosis or omphalomesenteric band. in the baby born prematurely, obstruction may be caused by stricture secondary to necrotising enterocolitis. radiographs and contrast studies are also used to evaluate these conditions. learning objectives: 1. to learn about the most common causes of neonatal obstruction. 2. to understand the role of plain radiography in establishing the diagnosis. 3. to know when upper and lower gi contrast studies are indicated and the contrast medium used. stroke around the clock: will the challenger (ct perfusion) beat the champion (diffusion mri)? in patients admitted for a suspected stroke, time management is the most important criterion for therapeutic decisions. less than four hours and a half, all patients admitted in emergency for an acute neurological deficit without impairment of consciousness (nih < 25) and presented with a brain ischaemia of less than one third of the territory of the middle cerebral artery should receive iv thrombolysis. brain imaging must exclude bleeding and quantify the extent of ischaemic damages. between 4.5 and 6 hours after onset of symptoms, intravenous thrombolysis and/ or intraarterial mechanical or chemical thrombolysis may be indicated in selected cases. the assessment of ischaemic penumbra and vessel permeability is particularly important for the therapeutic decision. this may be evaluated either by mri or ct. mri is the technique of choice that should be used whenever possible because of the absence of irradiation and iodine-related side effects, the optimal anatomical coverage, the detection of lacunar infarct and its sensitivity for evaluating ischaemic brain damages of the posterior fossa. imaging protocol should include flair (fluid attenuated inversion recovery), t2*, diffusion/perfusion and mr angiographic sequences. in case of unstable patient or if mri is not available, a non-contrast ct scan must be performed and completed by perfusion ct and ct angiography. the main advantages of this technique are the short time of data acquisition and the absolute quantification of perfusion due to the linear relation between attenuation and concentration. pneumonia is a common cause of attendance to hospital. chest infections in children are usually viral and self limiting, but sometimes chest infections can be prolonged or repeated. there are many underlying causes for this, for example, congenital anatomical causes, underlying patient susceptibility, inhaled foreign bodies and unusual organisms. one of the more common causes seen in hospital is when pneumonia has become complicated by empyema. very rarely other conditions such as kawasaki's disease or tumours can masquerade as pneumonia. this session will review these conditions together with the benefits and limitations of plain radiography. it will also consider times when other imaging modalities such as ct and ultrasound can help to guide diagnosis and treatment. in children, congenital heart disease (chd) is more frequent than acquired heart disease. diagnosis and subsequent management of patients with chd relies heavily on different and often multiple complementary imaging modalities. serial assessment of the morphology and function of the heart and thoracic vessels is needed at various stages of care. although chest radiography is frequently used for monitoring the cardiorespiratory status and complications that may arise during clinical care or intervention, it rarely provides a complete diagnosis. echocardiography, as first line imaging modality, often provides all information required for diagnosis and follow-up, especially in small children with good acoustic windows. contrastenhanced computed tomography (ct) and magnetic resonance (mr) imaging are valuable for detailed three-dimensional evaluation of the extracardiac vasculature and cardiac anatomy. in addition to being radiation free, mr has the advantage to provide both morphologic and functional information with the use of different techniques including ecg gated gradient-echo cine imaging, gadolinium-enhanced angiography and velocity-encoded phase-contrast imaging. a comprehensive mr evaluation including quantitative measurements of ventricular volumes and function as well as blood flow in vessels and across valves can give important information on long-term sequelae of the underlying cardiac defect, the significance of residual lesions, and potential complications of surgery. it is also valuable for planning and timing of future interventions. today, ct and mr have become the next line of investigation when echocardiography does not provide sufficient information, while catheter angiography is reserved for the assessment of coronary arteries, measurements of pulmonary vascular resistance and interventional procedures. over the past years, diagnostic imaging has witnessed a veritable explosion in the modalities available for studying patients. when applied to the study of the thorax, they contribute to earlier detection of abnormalities and greater diagnostic accuracy. yet, the conventional radiographic examination of the chest continues to be the most commonly performed imaging study and, when properly interpreted, continues to demonstrate a wealth of information. for a correct interpretation of the chest radiograph, several premises should be met by the radiologist: a proper knowledge of the anatomy and semiology of the thorax, stressing the need for a lateral projection, understand the importance of reviewing previous studies and try to avoid unnecessary cross-sectional studies. this lecture will address the radiological approach to imaging children of all age groups presenting with cough. this is a common symptom with very diverse causes, from acute viral infection to complex vascular and intrinsic congenital tracheal anomalies and can be the presenting symptom of acute (rapidly fatal if not managed adequately) and chronic effects of foreign body aspiration. the various causes of cough vary with age and whether cough is acute, sub-acute or chronic. this has effects on radiological investigations deployed, and thence on subsequent clinical management. we will present a pragmatic approach to radiological investigations in this diverse set of patients, using simple algorithms and illustrate the more important (and often rarer) causes of cough with discussion around deployment of examinations that are fit for purpose using alara principles. guidance on imaging algorithms and ct technique will be given to children with this important presenting symptom of myriad diverse pathological processes. the attendee will learn the value and optimal use of imaging with tips on optimising ct technique as fit for purpose. learning objectives: 1. to learn about the differential diagnoses in the very young child and in older children. 2. to learn which imaging modalities best help to determine the final diagnosis in the various age groups. 3. to understand radiation protection requirements in chest ct examinations. clinical examples of dual energy ct l.s. guimarães; viseu/pt (luis.s.guimaraes@gmail.com) dual energy (de) computed tomography (ct) allows the discrimination of different materials, which has several clinical applications. the ability to differentiate calcium from uric acid renal stones allows the identification of patients that will benefit from drugs that alkalinise urine. a musculoskeletal application of the same technique is in tophaceous gout, where the crystals can be differentiated from bone. postprocessing of ct angiography images can be facilitated using de techniques to identify and remove the calcium signal. such an approach removes both bones and calcified plaques. "virtual non-contrast" images can be obtained by identifying and removing the iodine-containing voxels of contrast-enhanced ct images, simulating non-contrast images and potentially eliminating the need for some non-contrast acquisitions, but it should be realised that small misclassifications could result in missing tiny caliceal tip stones, for example. dect also allows the utilisation of low energies without the prejudice of unacceptable noise. since iodine signal is significantly higher at low energies, disease conspicuity can be improved. this is particularly beneficial in the liver (for hepatocellular carcinoma identification), in the pancreas (for visualisation of hypo-and hypervascular lesions), and in enterography (to increase the identification of hyperenhancement). the approach for displaying the enhanced iodine signal may be one of blending information from the two energies (into a single grey-scale image), or via an iodine-only view. further validation of dual energy techniques and their limitations is needed to understand the patient populations in which such techniques can be utilised and where conclusions based on dual energy data can be trusted. ct perfusion imaging is a quantitative technique that employs rapid sequences of ct images after bolus administration of intravenous contrast material to measure a range of physiological processes related to the microvasculature of tissues. ct perfusion parameters can provide surrogates for tissue hypoxia as well as the physiological processes such as vasodilatation that represent vascular responses to hypoxia. although the basic techniques for dce-ct have been available for decades, more recently a range of technological advances have contributed to the greater applicability of perfusion ct in the clinical environment including wider ct detectors, shorter gantry rotation times, 'table-toggling', radiation dose reduction and software corrections for image mis-registration due to respiratory or other patient motion. consensus guidelines are now available for the acquisition and processing of ct perfusion studies for the brain and body. to date, the main applications of ct perfusion imaging in stroke have been the confirmation of stroke diagnosis and extent, identification of penumbra and selection of patients for thrombolysis. the main applications in oncology have been in lesion characterisation, risk-stratification and assessment of treatment response. computed tomography (ct) systems have provided three-dimensional (x, y, z) data since their clinical introduction in the 1970s. this session will address the extension of ct imaging into the fourth and fifth dimensions. the rapid acquisition capabilities of modern ct scanners open the door to the fourth dimension -time -where a time-course ct scan can provide clinical information about blood flow, perfusion and other physiological measures regarding organ function. the door to the fifth dimension -energy -is opened by dual energy image acquisition techniques, which are made possible by dual source ct scanners or rapidly switching x-ray source ct scanners. dual energy ct images can be manipulated to provide quantitative information with regard to the elemental composition of tissues, which, in turn, can be used to differentiate between bone and iodine contrast, with many other applications possible as well. modern ct scanners now provide multidimensional data sets characterised as i (x, y, z, t, e), and the additional information provided by these five-dimensional data sets provide genuinely useful clinical information which add to the diagnostic potential of computed tomography. x-ray computed tomography (ct) usually measures the attenuation of the patient or object cross-section in question at a fixed chosen voltage value; the result is presented as the linear attenuation coefficient µ expressed in hounsfield units (hu). dual energy ct (dect) acquires data at two different mean energies and evaluates the differences in attenuation. dual energy ct imaging has been a topic since the 1970s. the acquisition modes have changed over the years from two separate scans at different voltages to single scans with rapid kv-switching, and dual source ct operating with different voltages and pre-filtrations. these concepts will be explained in detail including future options of energy-discriminating detectors. the basic physics principles remain the same for all acquisition schemes. the two independent measurements allow separating two tissue characteristics contributing to attenuation. for example, low and high effective atomic number material densities can be determined in the so-called basis material decomposition. arbitrary combinations such as monoenergetic or electron density and effective atomic number images can then be provided. these will be illustrated and explained by examples such as differentiation between plaque and contrast agent or virtual unenhanced abdominal organ imaging. dect meanwhile offers quite a number of accepted clinical applications which will be covered in a separate talk. ous lesions (adenomas) and curable early-stage cancer, screening for crc has high potential for reducing incidence and mortality of the disease. nevertheless, the benefit of population-based crc screening needs to be weighed against potential risks, psychological distress and required resources since only a minority of the population develops the disease and may thus benefit from screening. several industrialised countries offer faecal occult blood testing as a primary screening tool, with positive test results being followed up by colonoscopy. some countries, such as the united states and germany, also offer colonoscopy as a primary screening tool. while the results of randomised controlled trials regarding screening colonoscopy are still outstanding, there is evidence from observational studies that support its effectiveness in population-based crc screening. recent evidence suggests that colonoscopy, when performed in the community setting, is more effective in protecting from neoplasms in the left colon and rectum than in the right colon. decision-analytic models support the (cost)-effectiveness of screening colonoscopy but results vary, among others, according to compliance, (country-specific) cost estimates and screening schedules. learning objectives: 1. to learn about the incidence and prevalence of colorectal cancer and its precursors in the target population of screening. 2. to understand the rationale for colorectal cancer screening. 3. to become familiar with estimated (cost) effectiveness of colorectal cancer screening when using optical colonoscopy as a primary screening tool. facts from the statistician (true for once?): how accurate is ct colonography the issue of diagnostic accuracy of ctc for crc and polyps has been debated for a long time, because of the conflicting results published in the literature. those results led researchers to design three important studies: two large, multicenter trials testing the performance of ctc in comparison with cc in asymptomatic individuals (acrin and impact) and one randomised, double-arm trial (siggar) conducted on symptomatic patients with the aim to detect crc. both the acrin and impact reported per-patient sensitivity of 90% for polyps > 10 mm and 78-84% for polyps larger than 6 mm; per-patient specificity was extremely high, over 85%, independent of lesion size. the major drawback of the acrin was represented by the poor positive predictive value (ppv) (23% for polyps ≥10 mm); a definitely better ppv was documented in the impact trial (62% for lesions larger than 6 mm) as well as in studies obtained in high-experienced centers. however, the negative predictive value in both the acrin and the impact was rather high, approaching 100%; this is extremely important in order to reassure negative patients about the significance of the examination. excellent results were also obtained in the munich colorectal cancer prevention trial, a single-center study where around 300 asymptomatic subjects underwent low-dose ctc in comparison with other screening tests (cc, sigmoidoscopy and fobt). despite the good results there are still some open issues: the significance of diminutive (< 6 mm) polyps, the management of intermediate (6-9 mm) lesions and the detection rate for non-polypoid, flat lesions. colonoscopy is a very useful and important method to examine the colon. in recent years virtual colonoscopy has become a popular alternative to optical colonoscopy. disorder of the colon includes colorectal cancer, which is one of the most common cancers worldwide and presents a threat to life since the mortality is almost 50%. colorectal cancer screening has been shown to be an efficient method to find early forms of colorectal cancer and also to reduce mortality in this disease. in this session we will discuss the various methods used to examine the colon, how useful they are and the economy behind using them. facts from the epidemiologist: incidence, prevalence, rationale for screening, standard results of optical colonoscopy. colorectal cancer (crc) is the third most common cancer in the world, with about 1 million new cases and more than 500.000 deaths per year. incidence of crc strongly increases by age and is higher in men than in women. the lifetime risk differs between countries and is about 7% in the united states. because most cases of crc develop from removable precancer-stabilisation complex system a dual echo t2/dp sequence could be performed in a sagittal-oblique plane drawing an imaginary line which on an axial image used as reference plane, is done perpendicular to popliteous tendon. gradient echo (ge) sequences are useful in cartilage and traumatic pathology. t2-weighted sequences understimate cartilage thickness since cortex and cartilage have the same signal. pd sequences may have the similar signal for cartilage and adjacent joint fluid, obscuring defects; fat suppression solves this. if available, acquisitions performed in orthostatism could give further information in the assessment of meniscal and patello-femural pathology. learning objectives: 1. to understand the influences of patient positioning, scan parameters and magnet/coil technology on image quality. 2. to learn how to optimise scan protocols to maximise patient throughput without compromising diagnostic quality. 3. to recognise how and when to modify scan protocols to answer specific clinical questions. this talk will review appearances of normal anatomic variants identified at mri of the knee including discoid meniscus, transverse meniscal ligaments meniscal flounce, ossicles, and pseudotears. subsequently the talk will focus on diagnostic pitfalls reflecting both imaging technique and variations in anatomy such as the effect of motion, imaging plane and anatomic variations in patella shape. mri of the knee is one of the most frequent performed investigations, thus indicating that common abnormalities need to be familiar to the general radiologist. a simple and straightforward method of enabling assessment of clinically relevant anatomical entities is based upon a (pre)structured radiology report. use of speech recognition facilitates implementation of pre-structured reporting in a kiss manner. since one now is enabled to structure the report, using digital tools, terminology used should be discussed between the reporting radiology department and the clinical partners. it is mandatory that the important message, the clinical relevance of the information that radiologists put in their report, is understood by the referring clinician in the same manner as it was meant to be. we should consider the background of our referring physician, and tailor our report, both in chosen terminology as well as detailed information. when working in a centre in which both specialised orthopaedic surgeons as well as general practitioners (gps) or sports physicians are referring for mri, each of the three needs a tailored report, especially considering advise for secondary referral: gps and sports physicians will need different approach, compared to medical specialists. also, the knowledge of terminology used should be considered. the presentation focuses on common encountered pathologies, considering common abnormalities. emphasis is given to common abnormalities, and pitfalls that should be dealt with. some sports specific entities are discussed. implication of clinical correlation is stressed. the presentation will include casebased clinical illustrations. learning objectives: 1. to review the imaging appearances of common abnormalities. 2. to understand the use of terminology to describe pathological findings. 3. to learn how to structure a radiological report to ensure clarity and brevity. of view and the "third eye" colonoscope are under investigation. at the moment, however, the combination of both, exact diagnostic and sufficient therapeutic action at the same time, is the reason why optical beats virtual in this particular indication. since its evolution ct colonography has been advocated as a safe well tolerated alternative to colonoscopy, particularly in the context of colorectal cancer screening. notably perforation rates are lower than those of colonoscopy and cardiovascular effects are less. however, patient preference studies have produced mixed results and it is not clear if standard ctc will increase compliance with screening. furthermore, issues over apparent inferior sensitivity for polyp detection compared to colonoscopy, need for prolonged radiologist education and radiation dose exposure have been cited as barriers to widespread implementation in a screening context. technical developments in recent years are beginning to address these issues. use of reduced laxative regimes supplemented with faecal tagging have shown good results with superior patient acceptability. software developments have also speeded up dataset analysis -notably panoramic or "virtual pathology" 3d views reducing or eliminating hidden areas within the colon. furthermore, computer-aided detection software is increasingly fit for purpose and good data show a positive effect on radiologist performance both in the research setting and day to day clinical practice. this presentation will review the data on patient preference and safety and highlight developments in those areas in which ctc holds advantages over conventional endoscopic techniques. discussion will focus not only on colon cancer screening but also the on data supporting ctc in older symptomatic patients who are at higher risk of adverse events during colonoscopy. learning objectives: 1. to review the patient safety of ct colonography and conventional colonoscopy. 2. to review advanced computer techniques for maximising visualisation of the colon during ct colongraphy including 3d visualisation methods and computer aided detection. 3. to review the data on ct performance with particular emphasis on patientfriendly reduced laxative regimens. 4. to consider patient preference data. osteoporosis, osteomalacia, hyperparathyroidism and paget's disease have conventionally been considered the disease entities that comprise metabolic bone disease. the lecture will follow this convention and discuss the imaging characteristics that suggest osteoporosis in the elderly or anorexia nervosa in younger patients by the distribution of fractures and marrow changes as well as the role of bone mineral density evaluations in osteoporosis. oncogenic osteomalacia will be discussed in the context of appropriate imaging for detecting the tumour and emphasise the basic biochemical abnormality that most radiologists should be familiar with that leads to the diagnosis. radiologists most frequently encounter hyperparathyroidism in renal osteodystrophy with over a million patients worldwide kept alive by dialysis. dialysis-induced imaging changes such as amyloid and the spectrum of findings from long-term dialysis will be shown and demonstrated. paget's disease is on the decline. its distinctive mri signal characteristics in uncomplicated cases, in contrary to most bone lesions encountered in clinical practice, will be explained. learning objectives: 1. to get an overview of the entities that are considered in the realm of metabolic bone disease. 2. to understand common, less common and rare findings. 3 . to learn about some imaging findings that occur as a consequence of treatment. osteoporosis is of great socioeconomic impact, as approximately 30% of all postmenopausal women have osteoporosis in developed countries. ageing of populations worldwide will be responsible for a major increase of the incidence of osteoporosis in postmenopausal women. in 1994, the who working group defined osteoporosis according to measurements of bone mineral density (bmd) using dual energy x-ray absorptiometry (dxa) as a bone density t score at or below 2.5 standard deviations (t score) below normal peak values for young adults. the relative risk of a fracture is between 1.3 and 1.6 for each unit decline in spine or total hip t score. due to limitations of the t-score concept a 10-year risk calculating tool has been developed by the who to determine intervention thresholds. fragility fractures are, however, not only related to bone mineral density (bmd). trabecular bone microarchitecture is a significant determinant of the bone's mechanical properties and is thus of major clinical relevance in predicting fracture risk. trabecular bone structure analysis can be based on images from multidetector computed tomography, high-resolution peripheral computed tomography, highresolution mri and projection radiography. advantages and disadvantages of the different methods depend on radiation, costs, availability and a reasonable time for in vivo scanning. the purpose of this refresher course is to demonstrate bone ablation. the main aim of thermal tumour ablation is to destroy the tumour using ionic movement to kill the malignant cells without damaging adjacent vital structures. multiple sources of energy have been used to induce cell death. rf energy is an electromagnetic one. radio waves emanate from the non-insulated distal portion of the electrode. heat is produced by resistive forces (i.e., ionic agitation) surrounding the electrode as the radio waves attempt to find their ground. other type of ablations (using different wave lengths) include microwave, electoporosis, laser and radiofrequency ablation is still seeking its place among bone interventional techniques. this presentation is an overview, in an area of non-vascular interventions in the spine and the appendicular skeleton. it will explain the patient selection, indication and possible approaches to a bone lesion. available material will be discussed, as well as possible combinations of them in order to yield maximum results, while reducing possible drawbacks. over the last two decades, open nephron sparing surgery has become the preferred surgical alternative to nephrectomy for treatment of patients with a single, small (< 5 cm) localised renal mass and a normal contralateral kidney. because 25-49% of newly diagnosed small renal masses are identified incidentally on crosssectional imaging, often in elderly patients, less invasive surgical nephron sparing alternatives have been advocated, including laproscopic partial nephrectomy and laproscopic cryoablation, for select tumours in an effort to reduce surgical mortality and morbidity while preserving renal function. percutaneous image-guided ablation offers potential advantages over surgical methods including the minimally invasive nature of the procedure, less mortality and morbidity than surgery, shorter hospital stay, and quicker recovery. local tumour control rates of up to 95% have been reported for small tumours. central tumours and tumours greater than 3 cm in diameter are more difficult to successfully treat with local tumour progression occurring 25% of central tumours. tumours larger than 3 cm in diameter typically require overlapping ablations and incomplete treatment can result from residual tumour at the ablation interfaces. while in some reports, local tumour progression occurred in up to 20% of tumours larger than 3 cm, in contrast, others have shown that all exophytic tumours, despite their size, can successfully be treated using multiple overlapping ablations and complete treatment may require more than one ablation session. the most clinically relevant and potentially avoidable complication is ureteral injury with resultant obstruction of the intrarenal collecting system. percutaneous image-guided radiofrequency ablation (rfa) represents as a safe and effective minimally invasive procedure in selected patients with unresectable or medically inoperable lung malignancies. when adequately performed, in selected patients, the procedure is associated with over 95% immediate technical success rate and relatively low incidence of major (8-15%) and minor complications (20-40%). pneumothorax represents the most frequent complication (up to 60%) but presentation, the worse the outcome in adulthood. avn is a significant complication. ct/mr assists orthopaedic planning. imaging strategy: plain radiographs. small children localise pain poorly. whole limb radiographs may be needed. us detects hip effusions but cannot differentiate pus from effusion. nuclear medicine may need sedation for scanning phase. a full bladder may obscure the pelvis. mr is sensitive for soft tissue pathology and marrow disease included in the area imaged. radiographs are needed before mr, which is insensitive for bone detail. other causes: spinal problems -discitis, avulsions of muscle origins, trauma -toddler's fracture, diffuse bone disease, localised bone disease; blind areas: spine, pelvis/sacroiliac joints. learning objectives: 1. to learn about the imaging approach to the child with suspected developmental hip dysplasia. 2. to become familiar with the differential diagnosis in the older child with a limp. 3. to learn which imaging modalities best help to arrive at a diagnosis. skeletal injuries are the most common findings noted on imaging studies in cases of child abuse. in infants, certain lesions, such as the classic metaphyseal lesion and posteromedial rib fractures are sufficiently characteristic to point strongly to the diagnosis of inflicted trauma. other fractures are less specific for abuse, but when correlated with other imaging findings and clinical information, their presence may add strong support for the diagnosis. many of the most specific injuries produce subtle radiographic alterations, and meticulous technique, adhering to a strict imaging protocol, is vital in providing optimal detection of the fractures. in recent years, increasing attention has been given to those conditions that may simulate inflicted injury. a variety of normal variants, naturally occurring diseases and accidental injuries may be confused with the findings of child abuse. other conditions, real or hypothetical, may be suggested by consultants in medico-legal proceedings. to be credible, a witness must be prepared to counter reckless and irresponsible testimony given by uninformed or biased medical "experts". to ensure that investigators and finders of fact are provided with testimony that is clear, concise and accurate, the radiologist must be fully informed and prepared to address the radiologic alterations and their significance to a reasonable medical certainty. learning objectives: 1. to learn in detail the investigation of a child with suspected non-accidental injury. 2. to learn about the typical skeletal injuries seen on plain radiography and the differential diagnosis. 3. to understand when further imaging is required and which imaging modality is best. acute osteomyelitis and septic arthritis are diagnostic and therapeutic emergency in children. diagnosis remains challenging because of their variable expression (acute, subacute, chronic stages, causative agents and hosts). imaging strategy relies on a multimodality approach including radiographs and ultrasonography as first line examinations with a complementary role for bone scintigraphy and mri. mri is especially useful for misleading challenging presentations (such as axial skeleton, pelvis and calcaneus osteomyelitis) and for detection of reversible osteocartilaginous ischaemia requiring urgent surgical drainage. juvenile idiopathic arthritis (jia) is an heterogeneous group of chronic inflammatory disorders that are classified on their mode of onset (systematic, pauci and polyarticular diseases). it is a diagnosis of exclusion and imaging plays a major role in the differential diagnosis. radiographic scoring systems of jia are different from adult scoring systems with less emphasis on joint space narrowing. doppler-ultrasonography and mri play an increasing role in a the assessment of disease activity and response to treatment. learning objectives: 1. to learn about the imaging approach to a child with suspected osteomyelitis and septic arthritis and to outline the classical features. 2. to learn how best to investigate a child with suspected arthropathy and the specific findings. 3. to understand the differential diagnoses of bone and joint infections. semiquantitative scoring method. vertebral morphometry is based on radiographs or scans from dxa-machines calculating ratios of vertebral heights with normal values to identify vertebral fractures. great need for early, accurate and reliable imaging indicators of tumour response to anti-angiogenic drugs which is ultimately defined by overall survival rate, but is mostly based on changes in number and size of measurable tumour "targets", i.e. blood vessels. thanks to its characteristics of high temporal and spatial resolution in limited fields and lack of ionising radiation and side effects (i.e. easy repeatability), contrast-enhanced us (ceus) is currently the simplest and also most reliable imaging modality for detection, analysis and quantification of intratumoural macro-and microvascularity (up to 40 μm in diameter). even minimal changes can be easily detected and quantified with ceus during anti-angiogenic treatments: early disappearance (or severe reduction) of tumoural vascularisation is highly predictive of complete (or significant) response even before tumour volume decreases. initial clinical studies were conducted on hypervascular hepatic metastases (e.g. metastases from gists), but recently also hypovascular hepatic metastases and primary cancers of different organs are being assessed. for the quantitative analysis of tumour vascularity changes several parameters (peak intensity, time-to-peak intensity, area under the curve, etc). are currently being investigated and specific perfusion software connected to working stations are being developed and clinically tested. the clinical application of mr-mammography (mrm) in the last 26 years has shown that this imaging tool has had significant diagnostic advantages in the field of breast diagnosis, e.g. the proof of small breast cancers, the differentiation between scar and recurrent tumours, the detection of multifocality/multicentricity, the search for primary tumours, the delineation of implants, etc. the clinical use of mr-mammography is steadily increasing. however, many still describe a "high sensitivity but a low specificity", which is wrong. achieving a high quality is not an easy task; a lot of teachers have to be learned and considered. this refresher course is focussing on high quality concerning technical and diagnostic aspects, especially focussing the question of improving specificity. dynamic contrast enhanced computed tomography (dce-ct) is a noninvasive method showing haemodynamic changes in living tissue in various oncologic and non-oncologic applications. recently, it has gained an increased popularity for studying malignant tumour blood supply and formation of new vessels, also known as angiogenesis, that plays a critical role in the growth of cancer. technical remarks: repeated rapid ct scans are acquired at the same location to allow determination of time-attenuation curves (tac). several quantitative parameters are assessed: tumour blood flow (tbf) (ml/min/100 g), tumour blood volume (tbv) (ml/100 g), permeability surface product (psp) (ml/min/100 g) and mean transit time (mtt) (s) are calculated using dedicated perfusion software. indication: perfusion ct may be used by the distinction of benign from malignant lesions when conventional methods are unreliable, may improve staging by demonstrating occult hepatic metastases, may guide biopsy to the tumour region most likely to be of highest grade. several tumours with higher perfusion are more sensitive to the chemoradiation than that with lower perfusion. findings at dce-ct images after chemoradiotherapy are a significant predictor of early tumour response and overall survival. its applications have been stimulated by the development of anti-angiogenesis therapy for monitoring the effects of therapy and additionally may be used as a noninvasive tool in detection of hepatic toxicity of chemotherapy. in the future, new prognostic information could impact clinical management. studying the response of cancers by measuring changes in their blood flow may provide useful information on oncologic patients for managing cancers in the future. advanced imaging is now widely utilised in the research and clinical settings. in the clinical setting, qualitative, semi-quantitative and quantitative approaches such as review of colour-coded maps to roi analysis and analysis of signal intensity curves are being applied in practice. we will also compare the relative advantages for t1 dce mri with t2* dsc mri in the estimation of perfusion and permeability metrics in the clinic as well as some more automated histogram analysis methods. the role of advanced imaging in the characterisation of tumour biology and different pathologies will be reviewed. differentiating between recurrent tumour and therapeutic necrosis is often a challenge. we will review the role of advanced imaging and also the effects of anti-angiogenic therapies on tumour microvasculature/microenvironment resulting in changes in diffusion, perfusion and mrs. pseudophenomenon has made conventional imaging with gadolinium contrast agent almost obsolete necessitating mechanistic techniques to differentiate entities such as pseudoprogression which is seen more commonly as a result of therapy with temozolomide and radiation for high grade gliomas as well as pseudo-response and pseudo-pseudoprogression. lastly to combine and apply these different imaging techniques in a multi-parametric algorithmic fashion in the clinical setting can be shown to increase our diagnostic specificity and confidence. learning objectives: 1. to become familiar with different advanced mr techniques used in brain tumour imaging. 2. to learn the role of permeability, perfusion, diffusion imaging and mr spectroscopy in characterising brain tumour biology and differential diagnostics. 3. to become familiar with a complete imaging protocol, which can be implemented in a multi-parametric algorithm fashion in brain tumour diagnosis. monitoring and prediction of treatment response p.c. maly sundgren; lund/se (pia.sundgren@med.lu.se) high-grade gliomas have a poor survival rate despite improvements in surgery, radiation and chemotherapy. a contributing factor to the poor survival is the inability of currently available imaging techniques to accurately delineate the tumour which results that targeted focal treatment my not be effective. conventional imaging is not able to give an early assessment of the effectiveness of radiation and/or chemotherapy. early identification of patients with a poor treatment response or who suffer from tumour recurrence can be of great advantage: it provides the opportunity to adjust individual more rapidly, and sparing patients unnecessary morbidity, and breast mri has shown diagnostic sensitivities of 94-99% for invasive breast cancer; however, specificities have been reported significantly lower with values between 37% and 86%. the specificity of breast mri is in a routine clinical setting based on the evaluation of morphologic features and relative "slow" dynamic characteristics of enhancing lesions. the only moderate specificity that is achieved using these characteristics can result in a significant number of false positive findings during, for instance, screening or pre-operative imaging. these findings will often require short-term follow-up, target ultrasound with biopsy or even mri-guided biopsy. fast dynamic imaging, spectroscopy and diffusion weighted imaging (dwi) have been described to have potential for improving the specificity of breast mri. the use of fast dynamic imaging sequences result in a more accurate evaluation of the initial enhancement of the lesion. in combination with pharmacokinetic modelling this can result in a more quantitative evaluation of enhancement. in proton-mr spectroscopy (mrs) the presence of a choline signal, a cell-membrane precursor, in breast lesions can be used to differentiate benign from malignant lesions. the specificity of mrs varies between 67 and 100% in literature (average 87%). dwi has also shown potential in differentiating between benign an malignant lesions, but, like with other techniques, varying specificity values are reported ranging between 46% and 93%. in this presentation the value of these techniques for improving the performance of breast mri will be discussed. although bedside chest radiograph is one of the less elaborate imaging examinations in our diagnostic armamentarium, it remains the most frequent radiologic procedure performed in intensive care patients. despite its limitations chest imaging is an important tool in the management of the critically ill patient. though the advent of digital radiography has vastly contributed to improved image quality of the bedside radiographs, optimal positioning and technique remain a real challenge for the performing technologist. in addition, the interpretation of chest radiography in the critically ill patient poses a challenge for the radiologist, because findings are frequently unspecific and lung opacifications have similar appearances in a variety of different cardiopulmonary pathologies. clinical information and an interdisciplinary approach are therefore crucial for optimal interpretation of these chest radiographs. the american college of radiology has established expert recommendations for the use of bedside chest radiography. current recommendations suggest that routine daily chest radiographs should be reserved for patients with acute cardiopulmonary problems and in patients receiving mechanical ventilation. acquisition of a portable chest radiograph is recommended after insertion of endotracheal tubes, central venous catheters, pulmonary artery catheters, chest tubes, and nasogastric tubes. therefore, knowledge of correct positioning of catheters, tubes, and monitoring devices and of various malpositions and associated complications is essential for the interpreting radiologist. chest ultrasonography (chus) is a useful imaging tool in patients at intensive care units, because of its simplicity and reproducibility. however, there are some limitations such as low specificity of some crucial sonographic signs and limited searching area (soft tissues, pleural cavity and lung consolidations). the icu patient can be examined in supine or sometimes in lateral or partly lateral position using intercostal spaces as an acoustic window. supine analysis of the anterior chest wall rules out pneumothorax, while lateral approach detects clinically relevant pleural effusion and parenchymal consolidations. chus is a method of choice in detection as well as in characterisation and volume estimation of free and/or loculated pleural fluid. with chus we can explore and characterise lung consolidations from the moment they reach the visceral pleura. they can be in contact with pleural line or can be observed through an effusion. however, in case of subcutaneous emphysema and/or diffuse oedema of soft tissues the lung parenchyma can not be reliably assessed. also, in the question of pulmonary embolisms in critically ill patient, chus could be contributive. sometimes small pleural effusion can be visible with some peripheral lung tissue consolidations indicating minute pulmonary infarction. typical pulmonary infarction is triangular tissue consolidation with air bronchogram and absence of doppler blood flow signals within consolidated lungs but cect for confirmation is mandatory. chus exploration of the diaphragm can reliably evaluate respiratory movements since pleural effusion even substantial does not affect the amplitude of diaphragmatic excursion. learning objectives: 1. to understand the advantages and limitations of bedside thoracic ultrasonography. 2. to learn about the us findings of pleural and parenchymal diseases suitable for bedside ultrasonography. 3. to review current guidelines for estimation of pleural effusion volume. delay in initiation of other maybe more effective treatment. in recent years, different functional imaging approaches such as dynamic contrast-enhanced (dce) and dynamic susceptibility-weighted contrast (dsc) mri, diffusion-weighted imaging and spectroscopy have been complementary used for diagnosis and treatment response. in this lecture different advance mr and ct imaging methods as well as the traditional way of monitoring to assess treatment response will be discussed. in addition, a novel recently published promising technique will be described -the parametric response mapping (prm), a novel voxel-wise analytical method of monitoring physiological and environmental changes in a tumour volume during treatment will be presented and compared to the traditional methods used. finally, the aim of the lecture is to consolidate the present knowledge and novel ideas in brain tumour imaging for future monitoring of treatment response and the possibility and limitations for future individualisation of cancer therapy. learning objectives: 1. to gain an understanding of the present traditional model for the treatment cycle for brain tumours and how they are monitored. 2. to learn about different imaging biomarkers for early assessment of brain tumour treatment response that might result in individualisation of cancer therapy. 3. to consolidate present knowledge and ideas in brain tumour imaging for future brain tumour therapy and monitoring of response. radiation necrosis and pseudo-progression vs recurrent tumour pseudophenomenon has made conventional imaging with gadolinium contrast agent almost obsolete necessitating mechanistic techniques to differentiate entities such as pseudoprogression which is seen more commonly as a result of advanced multimodal therapeutic concepts. advanced, non-enhanced and contrast enhanced mr imaging techniques include mr-spectroscopy, perfusion mr imaging, dynamic contrast enhanced mri and diffusion tensor mr. in the presentation we will analyse the application of those techniques in brain tumour assessment with focus on the post-therapeutic brain to differentiate therapy induced from tumourinduced changes. the results of the available studies in literature, all with relatively limited patient numbers, indicate that the combination of functional mri proved to be useful in the post-therapeutic workup of gliomas, lymphomas and metastatic disesease. the typical patterns of tumour recurrence and the different therapyinduced effects will be presented. in perfusion (dsc-mri) and dynamic contrast enhanced magnetic resonance imaging (dce-mri) the signal intensity measurements of the tumour reflect a composite of tumour perfusion, vessel permeability, and the extravascular-extracellular space. in contrast to conventional enhanced mri, which simply presents a snapshot of enhancement at one time point, both techniques permits a fuller depiction of the wash-in and wash-out contrast kinetics within tumours, and this provides insight into the nature of the bulk tissue properties on its microvascular level. with the strong demand in drug development the identification of biomarkers that can assess tumour microvascular properties noninvasive dynamic mri is the method of choice to assess tumour response and to identify atypical tumour response findings. indications and spectrum of pathological findings functional abnormalities of the pelvic floor represent a significant health-care problem, as they affect approximately 15% of older multiparous women. moreover, nearly 300.000 surgeries in united states are annually performed to correct those disorders. the success of medical and surgical therapies relies on the correct classification of dysfunction and identification of the pelvic compartments involved. clinical classifications of pelvic floor abnormalities are primarily topographic, rather than functional. however, as the pelvic floor muscles tend to act as a unique functional entity, their dysfunction usually leads to dysfunction of more than one organ system (genitourinary or gastrointestinal), resulting in a wide spectrum of symptoms variably associated, including dysuria, urinary incontinence, uterine prolapse, anal or pelvic pain, obstructed defaecation, rectal prolapse or faecal incontinence. because of the variability of symptoms and complexity of physio-pathological mechanisms, diagnosis of pelvic floor disorders is usually achieved by combining different diagnostic tools. dynamic mri of the pelvic floor has emerged as an alternative and effective modality for assessing and understanding of these disorders. it currently offers a complete morphological and functional evaluation of all three compartments at the same time. constipation and pelvic organ prolapse are the most common indications for a dynamic mri. the physio-pathological features of the main pelvic floor disorders and their mri findings will be shown in detail. mr images and movies, with particular regard to posterior pelvic floor abnormalities, such as rectocele, rectal invagination and prolapse, enterocele, descending perineal syndrome and spastic pelvic floor syndrome, will be illustrated and discussed. the ability to perform and interpret dynamic pelvic floor imaging is essential for the modern gastrointestinal (and indeed urogynaecological) radiologist. the other speakers in this session will be reviewing indications, pathologic findings, clinical relevance, and mr technique. although i will detail the mr and fluoroscopic techniques used at my institution, i will focus on the specific technical and diagnostic advantages and disadvantages of both dynamic pelvic mr and conventional fluoroscopic evacuation proctography (defecography). many practitioners wising to initiate this type of imaging will wish to know what modality to chose and existing practitioners using fluoroscopy will possibly be interested in migrating their practice to mr. i will illustrate what imaging findings are best imaged by each technique, continually referencing this to whether the finding is ultimately important to the referring clinician or not. using examples from our own research programme and clinical practice, i will illustrate why we have migrated our practice exclusively to dynamic mr. although dynamic pelvic mr imaging is increasingly used for imaging pelvic floor disorders, the crucial question is whether the technique can completely replace conventional techniques. although mr imaging provides excellent soft-tissue contrast which is a particular advantage when imaging the pelvis, it has to be acknowledged, that the examination is performed in supine position and not in physiological sitting position. this presentation will review the ultrasound appearances of pleural disease in ward and itu-based patients, and will discuss the indications for pleural procedures and the complications associated with them. the use of colour doppler to aid the diagnosis of effusions will be discussed, as will the identification of septations and the need for intrapleural fibrinolytic therapy. the advantages of guided versus blind drain insertion will be presented, and the benefits of large versus small bore drains will also be discussed. pelvic floor function and structure is complex. imaging has a key role in guiding the clinician in managing patients with incontinence, constipation, difficult rectal evacuation and pelvic organ prolapse. dynamic imaging is of particular interest for assessment of the pelvic floor since this kind of imaging gives a near physiological data set of what is happening and gives us a better understanding of the multifactorial causes of pelvic floor dysfunction. whereas conventional evacuation proctography was over years standard of reference for dynamic imaging of the pelvic floor, dynamic mr imaging of the pelvic floor is gaining increasing acceptance among radiologists and clinicians. however, dynamic mr imaging of the pelvic floor is (due to the architecture of most the clinically mr magnets) usually performed in supine position which does exclude the axial load on the pelvic floor. the lack of a physiological patient positioning during dynamic pelvic floor mr imaging is still brought into discussion if dynamic mr imaging of the pelvic floor can replace conventional techniques or not. the pelvic floor is a complex anatomic and functional unit. in clinical routine a simple anatomic concept of the female pelvic floor has gained acceptance. especially for treatment planning, the female pelvic floor may be separated into three functional compartments: the anterior compartment (bladder and urethra), the middle compartment (vagina, cervix, uterus, and adnexa), and the posterior compartment (anus and rectum). intact structure of the pelvic floor is a basic prerequisite for a normal mechanism of defecation and continence. over the last years, mr imaging has gained increasing acceptance as imaging modality for evaluation of the pelvic floor, which enables a global and integrated approach to the pelvic floor. using static t2weighted sequences the morphology of the pelvic floor can be visualised in great detail. a rapid half-fourier t2-weighted, balanced steady state free precession (bssfp), or gradient-recalled echo (gre) sequence are used to obtain sagittal images while the patient is at rest, during pelvic squeeze, during pelvic strain and to document the evacuation process. on these images the radiologist identifies the pubococcygeal line (pcl) (which represents the level of the pelvic floor). in normal findings, the base of the anterior and the middle compartment are above the pcl at rest, and the pelvic floor elevates during contraction. during straining, although most clinical diagnostic imaging studies employ anatomic techniques such as computed tomography (ct) and magnetic resonance (mr) imaging, much of radiology research currently focuses on adapting these conventional methods to physiologic imaging as well as on introducing new techniques and agents for studying processes at the cellular and molecular levels in vivo, i.e. molecular imaging. molecular imaging promises to provide new methods for the detection of minimal changes in diseased tissue and support for personalised therapy. although molecular imaging has been practiced for over 20 years in the context of nuclear medicine, other imaging modalities have only recently been applied to the noninvasive assessment of physiology and molecular events. nevertheless, there has been sufficient experience with specifically targeted contrast agents and high-resolution techniques for mr imaging and other modalities that we must begin moving these new technologies from the laboratory to the clinic. several projects relevant to oncology will be discussed with emphasis on how they were/will be moved from the bench to the clinic. aortic dissection is increasingly managed by endovascular means. it is important for all radiologists to understand the benefits and disadvantages of varying imaging modalities in the differential diagnosis and the fundamental anatomical requirements for assessing suitability for endovascular repair. the causes, detection, classification and complications of aortic dissection will be discussed followed by a panel discussion of imaging strategies which give the best information for diagnostic work-up, endograft planning and monitoring of patients during and after treatment. with the introduction of targeted therapeutics and personalised therapy regimen there is increasing need to improve diagnosis of diseases in a way that insight into pathophysiological and molecular regulation is provided. in this context, molecular imaging can be of tremendous help in basic research, drug development and the clinics. many interesting approaches of molecular imaging have been tried in small animal models. new methods and tools have been identified, which are easy enough to handle, aceptable in its costs and, most importantly, reliable enough to be translated to clinical practice. unfortunatenly, as soon as they have entered the clinics they are often not classified as molecular imaging anymore. among those are mr-spectroscopy, spio/uspio enhanced liver and res imaging but also contrast agents like gd-eob-dtpa and most applications for pet/spect. other interesting applications such as targeted ultrasound imaging are already established tools in preclinical research and very close to first clinical use. near infrared optical imaging is another example of a rapidly developing technology and first clinical devices and dyes (e.g. to detect arthritic lesions) are availibe now. it can be expected that with the availability of targeted and activatable probes the acceptance and the use of optical imaging methods will further rise. most proably, this will initially happen in context with intraoperative diagnosis and endoscopy. in summary, it is the aim of this talk to give a realistic overview on the available molecular imaging tools and on their potential for preclinical research and patient use. cardiovascular diseases remain the number one cause of morbidity and mortality, both in the developed and developing countries, and in men and women alike. it is expected that these numbers will continue to increase in the coming decades due to escalating proportions of obesity and the aging population. atherosclerosis is the major cause for cardiovascular disease. since in about 50% of cases a stroke or acute myocardial infarction is the first symptom of atherosclerosis, it is of paramount importance to identify patient at high risk. a first step in the identification is the use of clinical risk profiling, such as the framingham risk score, which has an area under the curve (auc) of about 0.8 using roc analysis. however, clinical risk profiling alone is not sufficient to identify individual patients at imminent risk to develop a cardiovascular event in the near future. a next step in a more precise identification of the patient at risk is the development of serum biomarkers for atherosclerotic disease. however, so far serum biomarkers have failed to contribute substantially to improve the auc in the prediction of cardiovascular events using roc analysis. a major step forward in risk stratification is provided by the rapid development of cardiac computed tomography, which offers a rapid visual access to the coronary tree, at low radiation dose and in a patient friendly manner. however, for the identification of the vulnerable plaque we need to go beyond anatomical imaging, and use molecular imaging tools. in the lecture i will discuss the different targets for molecular imaging within the vulnerable plaque, such as inflammation, apoptosis and angionenesis. imaging of these substrates of plaque vulnerability may offer opportunities for a precise identification of the patient at risk, at the individual level. the aim of the lecture is to familiarise the audience with the specific paediatric conditions in trauma radiology. it will be described the major pathophysiologic differences in childhood and the consecutive altered injury pattern. the standard radiological imaging protocol for various involved body regions and different trauma settings/varying queries will be described, with suggestion for standardised diagnostic algorithams in some typical settings. special regard will be given to radiation protection and the potential of imaging modalities such as ultrasound, multi-detector ct as well as mri in paediatric trauma patients. the roll of the lecture is to provide some basic guidelines for young radiologists and general radiologists who less often have to deal with paediatric patients. learning objectives: 1. to become familiar with the major pathophysiologic differences in childhood trauma 2. to standardised diagnostic algorithm in some typical settings in field of pediatric trauma. basic principles in the interpretation of signal intensities on t1-and t2weighted images g. wilms; leuven/be (guido.wilms@uz.kuleuven.ac.be) the signal intensities of normal structures and pathological findings on conventional t1-and t2-weighted mr images depend on many factors. the amount of water, proton density, chemical structure and/or binding, presence or absence of flow (of blood or csf), calcification, fat, blood degradation products, melanin, mucine and even air are all factors that influence the signal characteristics. t1-and t2-lenghtening is the rule in most tumoural, vascular and infectious lesions and therefore is rather unspecific. t1-and t2-shortening can be due to the presence of fat (lipoma), melanin (melanoma and metastasis of melanoma), mucine (metastasis of sigmoid carcinoma), colloid material (colloid cyst, rathke cleft cyst) and even calcification (falx!). t1-shortening with t2-lengthening can be due to cholesterine (cholesterol granuloma, craniopharyngioma), high protein content (tumoural cysts), and methaemoglobin (late haemorrhage, thrombus). t1-lengthening and t2-shortening is almost exclusively due to deoxyhaemoglobin. acute haemorrhage and meningioma can be iso-intense on t1-weighted images, while some meningiomas and micrometastases can be iso-intense on t2-weighted images. absence of signal can be due to high-velocity flowing blood (aneurysm, avm, hypervascular tumours), high velocity flowing csf (normal pressure hydrocephalus, cortical bone or extensive calcification, air and a large amount of iron (coils, clips). it is concluded that the simple use of a combination of t1-and t2-signal intensities on conventional mr images can be used to arrive at the diagnosis and differential diagnosis of brain lesions. complications occurring after acute aortic dissections should be separated into those related to the disease per se and those related to post-treatment conditions. life-threatening complications related to the disease should be familiar as immediate consequences for treatment may ensue. most of these are either located in the aortic root or related to mal-perfusion syndromes. the aortic root with very thin walled structures of the sinus of valsalva is located within the pericardial sac. the structure is prone to rupture and may produce life-threatening pericardial tamponade or present clinically as sudden onset of severe aortic regurgitation. all imaging modalities suitable for diagnostic workup in such conditions have to be rapidly accessible and performable. this precludes lengthy mr imaging procedures and renders ultrasound and ct as the mostly used modalities. the condition that has to be recognised as the most important inductor of malperfusion syndromes in the descending aorta is the progression of dissection into aortic branches and the true lumen collapse. both conditions are easily discernible with ct imaging. complications related to treatment should be sub-classified into those after pure surgical treatment and those related to endograft repair. the acute surgical complication with most deleterious effects is related to spinal cord ischaemia. the condition also applies to endograft repair. it is therefore beneficial for the radiologist involved either in pre-surgical imaging or interventional treatment to acquire thorough knowledge of the spinal cord blood supply. endograft complications of interest encompass endoleak formations, stent migrations and endoluminal stent collapse. learning objectives: 1. to learn the most common complications. 2. to learn the most appropriate imaging strategy for diagnosis. 3. to understand the clinical significance of the most common complications. which imaging modality is best for endovascular management? 17:14 the various imaging modalities for establishing the diagnosis of acute non-traumatic dissections will be discussed. the panellists will present recommendations for diagnostic work-up with special respect to differential diagnosis such as acute myocardial infarction and acute pulmonary embolism. also, the problem of sizing the endograft and planning the procedure will be addressed. the panellists will discuss strategies for detection of complications and for monitoring patients following treatment. the quality of radiographs is determined by many parameters from both technical and clinical origin. during the presentation, we will make an overview of the particular features of x-ray tubes and plain films that affect the quality of the radiological image. the training session will start from very simple x-ray tubes and film, and gradually introduce more sophisticated, state-of-the-art technology. we will briefly explain concepts such as focal spot, heel effect, beam quality, filters, grid, film sensitivity, automatic exposure control, etc. from a practical point of view. the european commission and selected research groups have developed criteria to judge the quality of the images and we will show how they can be used to improve the daily practice. a more technical evaluation of quality is possible with images of test objects, some of which are very straightforward and interesting if problems have to be retrieved. x-ray quality should be at a high level every day. therefore quality control procedures have a role. one example evaluates the stability of the imaging chain by means of acquisitions of homogeneous blocks of pmma. we will illustrate typical findings with repercussions on the radiological practice, and show that the fight against artefacts is a never ending process. both with film and digital detectors, radiologists should be aware that quality management and quality control procedures are needed. quality has to be organized, and quality control procedures have to be automated and included in the routine practice. there are diverse underlying causes for "diagnostic mistakes". missed lesions due to inadequate technique, "satisfaction of search" or lack of perception have to be differentiated from interpretative mistakes of lesions that have well been seen but erroneously interpreted due to the lack of experience, misconception or overlap of findings that complicates the differential diagnosis. each of these underlying reasons require a different approach to avoid them or reduce their risk of occurrence. the first type of mistake arises more often when interpreting chest radiographs and refers to the detection of mostly small focal parenchymal densities but also to the interpretation of mediastinal and hilar contours. by analysing typical cases, visual "tricks", helpful display techniques and strategies for systematic review and analysis will be outlined that are thought to be helpful in reducing the risk of "missing" a lesion. the second type of mistake mostly represents a problem of interpreting parenchymal abnormalities seen on ct. since the lung has limited means to "react" against an injury, many radiologic findings are aspecific. interpretation of pathology of parenchymal changes is based on pattern analysis, the knowledge of disease distribution and additional findings of pleura and mediastinum. in many cases, an interdisciplinary approach of radiologists and clinicians is essential for correct interpretation. cases will be analysed to illustrate difficult differential diagnosis occuring in daily routine (e.g., infectious pneumonia versus organising pneumonia) and key features helping in going into the right interpretative direction will be outlined. emphasis will lie on focal lung disease rather on the interpretation of diffuse interstitial lung diseases. learning objectives: 1. to learn about visual tricks and strategies to overcome typical perception errors in chest radiography. 2. to become familiar with overlaps of morphologic findings of focal parenchymal lesions frequently occuring in daily routine when interpreting thoracic ct. 3. to recognise those additional findings that represent the "helpful clue" for correctly narrowing the differential diagnosis. panel discussion: what have we learned from our mistakes? 09:44 interpreting the results of imaging studies is more and more challenging and time consuming due to the large volume of data to evaluate, compare and post-process. moreover, errors in the interpretation of imaging studies can have significant effects on patient care, particularly in acute medicine and oncology. so the question is how to be aware of the potential pitfalls that may be encountered in the realisation and the interpretation of imaging studies and how to avoid them or to learn from them. acute pancreatitis remains a potentially life threatening condition with an overall mortality rate of 5%. its outcome is strongly related to a precise and timely diagnosis, a correct estimate of severity and subsequent appropriate treatment. radiologic imaging, particularly ct, plays a key role in staging the severity and therefore helps guiding therapeutic decisions. management of interstitial or edematous pancreatitis is supportive while severe or necrotising pancreatitis requires intense monitoring and specific therapies. the latter has a higher mortality and guarded prognosis, since it may lead to organ failure, infection, pseudocyst formation and extrapancreatic parenchymal and vascular complications. a number of severity indices have been established to determine the prognosis of acute pancreatitis, based both on clinical and imaging criteria. a ct-based severity index has become the main prognostic method to predict outcomes. this course reviews relevant imaging findings of various stages of acute pancreatitis and its complications by ct, including special conditions such as groove pancreatitis and autoimmune pancreatitis. currently established and modified severity indices are reviewed to learn how to estimate prognosis and guide therapy. interpreting the results of imaging studies is more and more challenging and time consuming due to the large volume of data to evaluate, compare and post-process. radiology errors are inevitable, affect all radiologists and may be defined as a mistake that has management implications for the patient. errors can be broadly classified into technical errors, active errors (errors in perception, judgment or knowledge) and errors of communication. the majority of errors are false-negative interpretations and occur during interpretation of ct examinations. good communication between the referring physician and the radiologist is essential. unfortunately, only a small minority of radiologists keep a personal record of their errors. patient safety should benefit from the repeat organisation of "error meetings" through the act of collective learning. radiologists and radiology departments must continue to improve the process of recording and addressing errors. a-185 08:58 radiologists do make mistakes, diagnostic errors can be the cause of severe consequences to patients or, luckily, in many cases, they can be corrected. learning from mistakes is quite important since understanding why a mistake has been made help to avoid it in the future. during this lecture a series of mistakes made in the field of gu will be presented and causes which have lead to each of them will be analysed. dyspnoea is a common symptom in patients presenting to the emergency room. in almost two-thirds of all cases, dyspnoea is caused by either a pulmonary or a cardiovascular disorder. imaging in patients with dyspnoea depends mainly on the clinical presentation and the medical history of the patient. chest radiographs are a cost-effective and rapid test for the evaluation of patients with dyspnoea, with a fair sensitivity and specificity. for this reason, chest radiographs are usually performed early in the diagnostic evaluation of patients with acute and chronic dyspnoea. chest radiographs enable the diagnosis of frequent causes of dyspnoea of pulmonary origin, such as pneumonia, pneumothorax, pleural effusions, interstitial lung diseases, and emphysema. the diagnosis of cardiovascular disorders, such as pulmonary venous hypertension, cardiomyopathy, as well as valvular diseases, is also facilitated by chest radiographs. if chest radiographs, clinical studies, and laboratory tests, however, are non-diagnostic or equivocal, ct is indicated. ct offers high sensitivity and specificity for the evaluation of pulmonary embolism and for diseases of the pulmonary parenchyma and the airways. high-resolution ct represents the method of choice for the evaluation of suspected diffuse lung disease. additional expiratory scans are useful for the evaluation of mosaic perfusion and air-trapping. chronic pancreatitis (cp) is an inflammatory disease of the pancreas, with irreversible morphologic changes and fibrotic replacement of the gland, which progressively result in loss of exocrine and endocrine function. cp is morphologically characterised by irregular sclerosis associated with destruction and permanent loss of the exocrine parenchyma which may be either focal, segmental or diffuse. the primary symptoms of cp are abdominal pain and maldigestion, which may be physically and socially debilitating, although it is acknowledged that chronic pancreatitis can occasionally be painless. a classification based on the causes of cp is useful in order to better define the therapeutic interventions. however, morphological changes of the pancreatic ducts are the main rule of thumb for the classification in order to better compare the results of the treatment. imaging techniques have a role both on the diagnosis -especially in the early phases of the disease -and on the classification of cp, either for the grading of the disease, to explain the aetiology -even for rare forms -and to differentiate the focal mass from ductal adenocarcinoma. ct, mri and ercp have a specific role in the assessment of cp, due to the different capacity of the techniques to explore the pancreatic gland. however, thanks to heavily t2w sequences, mri has a competitive role with ercp, which actually has more an interventional role in case of obstructive cp. finally, mri thanks to secretin test and dwi sequences is able to give a non-invasive assessment of pancreatic exocrine function. complications of pancreatitis may include fluid collections and pseudocysts, vascular complications such as arterial pseudoaneurysm or thrombosis of the portal venous system, and stenosis of common bile duct and pancreatic duct. inflammatory fluid collections in the context of acute pancreatitis often resolve spontaneously. drainage may become necessary in the presence of clinical complications such as abdominal pain, compression of adjacent organs by large pseudocysts, or if superinfection of a pseudocyst occurs. depending on clinical, morphologic, or technical factors, drainage may be accomplished with image-guided external catheter placement, by endoscopic internal (transgastric) drainage or by internal surgical drainage. arterial pseudoaneurysm carries the risk of acute intra-or extraperitoneal bleeding, and transarterial embolisation is usually indicated when pseudoaneurym is detected. strictures of the common bile duct secondary to chronic pancreatitis may require percutaneous or endoscopic retrograde intervention. learning objectives: 1. to review interventional techniques that are used to manage fluid collections in the setting of pancreatitis. 2. to compare the results with those obtained by surgical and/or endoscopic approach. 3. to learn about algorithms used for clinical decision making, and for treatment evaluation and follow-up. 4. to understand major shortcomings and complications and how to avoid them. discussion 09:45 ants include the presence of accessory muscles, a low-lying peroneus brevis muscle belly, pseudosubluxation of the peroneus brevis tendon, and a bifurcated or mildly crescentic peroneus brevis tendon. accessory muscles in the ankle area include in the lateral aspect the peroneal tertius and peroneal quartus, in the medial aspect the flexor digitorum accessorius longus, and posteriorly the peroneocalcaneus internus, tibiocalcaneus internus and accessory soleus. as variations are commonly seen in asymptomatic ankles, matching with clinical symptoms is important. pitfalls include pseudoloose bodies in the ankle joint, pseudolipomas, and artefacts such as the "magic angle" effect, chemical shift, susceptibility, motion, "ghost" and partial volume averaging. knowledge of normal anatomy, pitfalls and variants, aids radiologists in making the precise diagnosis of various disorders. the aetiology of dyspnoea is varied. it may be due to pulmonary or pleural disease, cardiac pathology or extrathoracic causes. imaging is an useful adjunct in the diagnosis of majority of cases of dyspnoea. in this lecture we will present selected cases which will demonstrate the usefulness of different imaging modalities, emphasising when cross-sectional imaging is indicated. learning objectives: 1. to review typical cases illustrating the role of imaging modalities in the differential diagnosis of dyspnea cases. 2. to motivate the audience by the use of voting pads to be involved in the diagnostic process. 3. to highlight the conclusion that may be drawn on the basis of the discussed cases. the term bone marrow oedema was introduced to describe ill-defined bone marrow hypointensity on t1wi and hyperintensity on t2wi and water sensitive sequences. bone marrow edema can be found in many similar unrelated disorders, such as bone contusions, osteonecrosis, inflammatory or degenerative disease, being a non-specific mri abnormality representing a diagnostic challenge for radiologist. recently has been demonstrated that bone marrow oedema might be a prognosis marker for oa (osteoarthritis) and inflammatory disease, and could be used as a powerful predictive tool for treatment options. therefore our role as radiologist is to try to increase specificity to help patient management and decrease progression. subchondral bone marrow lesions (bmls) are a hallmark of osteoarthritis (oa) on mri. radiologically, bmls in oa are understood as non-cystic subchondral areas of ill-defined hyperintensity on t2w images and of hypointensity on t1w images, but only water-sensitive fat-suppressed sequences depict the lesions to their maximum extent. bmls are observed regularly in conjunction with adjacent cartilage alterations. higher grades of cartilage loss are associated with higher prevalence and greater volume of concomitant bmls. as the disease progresses, an increase in bml volume is seen in the same region subchondrally in many patients, which is positively correlated with an increase in cartilage loss and radiographic joint space narrowing. cysts are strongly associated with bmls in the same subregion and develop within non-cystic bmls. the published data on the natural history of bmls are ambiguous but recent reports showed that the majority of subchondral bmls may regress or resolve completely. note that progression and regression of bmls may be observed within the same knee simultaneously. histologic correlation studies showed that the lesions consisted of a mixture of different tissue patterns with only little oedema. specific changes in bone mineralisation and remodelling in areas of bmls have been shown, and they appear sclerotic compared to unaffected regions from the same individual. differential diagnoses of oa-related bmls include traumatic bone contusions and fractures with or without disruption of the articular surface. osteonecrosis, inflammation, idiopathic bmls, red marrow and post-surgical alterations should also be considered. learning objectives: 1. to learn about the basic physiopathology of oa and its relation with bme. 2. to analyse the distribution and natural history of bme in oa. 3. to understand the differential diagnosis and relevance of bme in staging oa and as a marker of prognosis. b. bme and early inflammatory disease a.j. grainger; leeds/uk (andrew.grainger@leedsth.nhs.uk) marrow oedema is identified as a feature of many forms of inflammatory and mechanical arthritis, but has been most studied in the inflammatory arthritides and particular in rheumatoid arthritis. it was first reported as a feature of ra as far back as 1986. work has been undertaken both using human specimens and specimens from animal models which suggest that marrow oedema seen on mri in ra corresponds to areas of inflammation been associated with invading pannus, lymphocytic aggregates and hypervascularity. there is also evidence that the marrow lesions seen on mri in ankylosing spondylitis correspond to histopathological inflammatory change. marrow oedema has been shown to be an important predictor the recent technological advances of ctu and mru have had an exceptional impact on the assessment of chronic/intermittent obstruction. imaging studies should help answer the clinical questions raised concerning the presence, level, and cause of obstruction. in this session, the recommended techniques of ctu and mru will be described and their relative merits and limitations reviewed. 3d ct images should be used as an adjunct to the transverse images, instead of a replacement, because volume-rendered images best depict the lumen and not the wall of the urinary tract. thin-section reformatted ct images likely are as sensitive as transverse images in the detection of urinary tract abnormalities. mru is being increasingly used because it provides excellent anatomic and functional imaging in a single setting. it has proved particularly valuable in pregnant women and children. the relative advantages of static-fluid mru and excretory mru will be discussed. the main aetiologies of chronic/intermittent obstruction will be illustrated, including intraluminal diseases (stones, clots, etc.), wall abnormalities (transitional cell carcinomas, tuberculosis, etc.) and extraluminal diseases (pelvic and retroperitoneal tumours, retroperitoneal fibrosis, gi tract diseases, etc.) upj syndrome is the most common site of urinary tract obstruction in children. vessels crossing a ureteropelvic junction obstruction contribute to the degree of hydronephrosis in up to 46% of these patients. demonstration of these vessels and their location anterior or posterior to the obstruction facilitates surgical planning. at the end of the lecture, attendees will become familiar with moderate or severe urinary obstruction and their various features and causes. 1. technological advances in both computed tomography (ct) and magnetic resonance (mr) imaging have improved the diagnostic imaging of the urinary tract, surpassing ultrasound and the intravenous urogram. multidetector computed tomography urography (ctu) is defined as ct examination of the kidneys, ureters and bladder with at least one imaging series acquired during the excretory phase of contrast enhancement. mr urography (mru) can be performed using heavily t2-weighted sequences without contrast material or t1 spoiled gradient -recalled echo sequences during the excretory phase after administration of gadoliniumbased contrast material. in adults, ctu or mru is now the preferred examination. technical aspects of image acquisition and processing will be explored and technical tips relating to protocol design given. 2. the typical and atypical appearances of upper urinary tract urothelial tumours and bladder cancers will be demonstrated. a method of fluoroscopic biopsy of upper tract tumours is described for validation of the imaging diagnosis. 3. early and accurate diagnosis of urinary tract tumours helps optimise prognosis but conventional investigative pathways are complicated and lengthy, utilising multiple imaging tests and many diagnostic algorithms exist without rigorous evaluation. ctu offers a single imaging test of high diagnostic accuracy with the potential to replace multiple alternative imaging tests in the diagnostic pathway, improve patient experience, improve diagnostic performance and accelerate diagnosis. mru is a promising technique that may be used for the initial evaluation of patients at high risk for developing upper-tract urothelial carcinoma when ctu or intravenous urography is contraindicated. rhage and periventricular echodensities. the posterior fontanelle approach improves the detection of grade ii haemorrhage in 30% more cases than the anterior fontanelle, and the mastoid fontanelle approach is essential for diagnosing cerebellar haemorrhage. ventricular dilatation is the main complication of intraventricular haemorrhage and resolves spontaneously in approximately 65% of cases. the main challenge with periventricular echodensities is to differentiate them from classical periventricular leukomalacia. when cysts appear during follow-up, the diagnosis is straightforward. mri is considered to be more sensitive than us for evaluating white-matter damage. congenital brain malformations including ventricular dilatation of diverse aetiologies, corpus callosus agenesis and posterior fossa malformations are usually diagnosed prenatally. mri complements us for this purpose. acquired abnormalities arise mainly from infections and hypoxic-ischaemic injury. although mr is considered the gold standard, us still plays an important role in the study of hypoxic-ischaemic lesions when used to its full capacity. depending on the duration and severity of the hypoxic insult, patterns different from those seen in premature infants may be observed. brain malformations are conditions where the brain has not formed properly during pregnancy. these problems in brain structure are almost often (with some exceptions) associated with neurological and developmental problems. often, brain malformations are part of syndromic complexes that require a multidisciplinary approach. malformations may be caused by inherited genetic defects, spontaneous mutations within the genes of the embryo, or effects on the embryo due to the mother's infection, trauma, or drug use. classification schemes are currently shifting from a morphological to a genetic approach. the most frequent congenital brain abnormalities may be categorised into anomalies of the corpus callosum and telencephalic commissures, holoprosencephalies and related entities, malformations of the cerebral cortex, and malformations of the cerebellum. these congenital brain defects are diagnosed either from direct physical examination or from imaging studies including ct and mri. prenatal mri offers a viable method to improve detection and characterisation of these entities in utero. learning objectives: 1. to learn about the common supra-and infratentorial congenital abnormalities. 2. to learn when mri is required and the appropriate imaging protocol. 3. to learn if and when ct is still useful in the investigation of congenital anomalies. in addition to predicting bone destruction for erosion, marrow oedema is independently predictive of joint space loss and therefore cartilage destruction. it also correlates well with other measures of disease activity. we have applied dynamic contrast enhancement techniques to show that treatment with anti-tnf therapy brings about a reduction in contrast uptake in areas of marrow oedema in patients with ra. in the seronegative arthritides marrow oedema in the spine in ankylosing spondylitis has been shown to be predictive of future changes and of response to treatment. diffusion weighted imaging of marrow lesions in ankylosing spondylitis can also be used to show a treatment response, seen as a change in the apparent diffusion coefficient. bone marrow oedema, also referred as bone contusion or bone bruise, is frequently identified at magnetic resonance imaging after an injury to the musculoskeletal system. it may result from a direct blow to the bone, compressive forces from adjacent bones impacting one another, or from traction forces that occur during an avulsion injury. its location reflects the mechanism of injury, which allows for a focused search for predictable patterns of associated internal derangements. it is seen in any joint but are particularly common in the knee reflecting mechanisms such as pivot shift, hyperextension, contrecoup or dashboard injuries, as well as lateral patellar dislocation. in a context of trauma, bone marrow oedema, identified at mr imaging as areas of poorly marginated signal intensity alteration (best seen on fat-suppressed sequences) in the cancellous bone and marrow, represents areas of oedema and haemorrhage secondary to trabecular injury. it can be seen as soon as one hour after trauma and usually resolves in the following six to eight months, except in case of subsequent chondral lesion. learning objectives: 1. to learn about bhe physiopathology in trauma scenario, direct and indirect mechanism. 2. to recognise bme as a footprint that allows other soft tissue injuries to be ruled out. 3. to analyse whether bme can be a value tool for follow-up. can we still use the term bme or should we be more specific? 09:44 the term bone marrow oedema was introduced to describe ill-defined bone marrow hyperintensity on t2 weighted images. since then many studies have demonstrated that it can be found in many similar unrelated disorders, such as bone contusions, osteonecrosis, inflammatory or degenerative disease, and that it is a non-specific mri abnormality. it has been demonstrated that bone marrow oedema might be a prognosis marker for oa (osteoarthritis) and inflammatory disease, and could be used as a powerful predictive tool for treatment options. therefore our role is to increase specificity to help patient management and decrease progression. room e2 sonography is an essential tool for studying the neonatal brain. brain scans are usually performed via the anterior fontanelle; however, a more complete assessment of the brain can be achieved using the posterior and mastoid fontanelles, high-resolution linear array transducers and colour or power doppler. the most common lesions in premature infants are intraventricular/periventricular haemorat initiation, tumours in a pre-vascular phase are supplied by oxygen and nutrients that diffuse from pre-existing normal vessels. when the tumour reaches a critical size of approximately 1-4 mm diameter, the resultant ischaemia leads to secretion of angiogenic factors. these factors, such as vascular endothelial growth factor (vegf), recruit and maintain tumour vessels. "new" vessels (neovasculature) exhibit increased blood volume and permeability compared with normal vessels. various new specific therapies in oncology target tumour vasculature or tumour neoangiogenesis. it is not uncommon that these targeted therapies have pronounced cytostatic and not predominantly cytotoxic effects. this limits the usefulness of size-based morphological tumour response assessments. of newer magnetic resonance imaging (mri) modalities, perfusion mri has emerged as a valid marker of tumour-induced blood vessels and their function. mri perfusion measures the vascularity within a tumour, as well as its component heterogeneous parts. of parameters which can be measured to date, blood volume and permeability are commonly applied in patient studies. blood volume measures the aggregate size of the vascular space, while the permeability function informs about the integrity of vessels and their ‚leakiness' to contrast agents. we will describe the use of mr perfusion to monitor such new therapies and discuss its specific advantages and limitations in comparison to ct perfusion protocols. pet-based strategies for targeted treatment-monitoring in oncology will be briefly mentioned, with prospect on the significance of combined vascular and metabolic imaging for further optimising non-invasive response assessment in specific anticancer therapies. after a brief review of physical and technical principles of diffusion-weighted mr imaging and pet-ct, the lecture describes the ability of these techniques in evaluating functional parameters in tumour tissue. diffusion-weighted sequences have been used in an attempt to further increase the diagnostic capability of baseline and dynamic mr study by providing functional information. diffusion-weighted mr imaging is based on the random microscopic movement of molecules that can be quantified by means of apparent diffusion coefficient (adc). in the early post-treatment period after loco-regional therapies, tumours may not change in size. recent studies demonstrated that water diffusion can be used to differentiate viable and cellular regions from necrotic area in the tumour, regardless morphologic or dimensional changes. moreover, new classes of antitumour therapy have been developed that have an antiproliferative effect, inducing a delay in tumour shrinkage. diffusion mr imaging can be promising in this clinical setting as a biomarker to predict early response to systemic chemotherapy. on the other hand, pet/ct, combining the functional and the structural imaging approach, was shown to be superior regarding conventional imaging modalities in the identification of intrahepatic and extrahepatic metastases. less experience and less publications are available for pet-ct in monitoring tumour response after interventional therapies, but the ability of pet-ct to measure early metabolic changes could make this technique useful in the development of novel anticancer drugs. until now, in oncology, only the recist criteria based on anatomical measurement of the tumour size are used for drug trials or in clinical practice because this is a standardised way to assess the tumour response that allows the calculation of the progression-free survival (pfs) or the time to progression (ttp) that are usually accepted as surrogate end point for overall survival. however, tumour follow-up evaluation using only morphology is usually delayed and with the emergence of new numerous and very expensive targeted therapies there is now a need to move beyond morphology to find new ways to assess tumour responses or progression not only for clinical trials but also in clinical practice to maintain or to change quickly a treatment. this is the aim of the functional imaging using ultrasound, ct, mri or pet. the ultimate goal of these technique is to find biomarkers able to predict the likely course of disease, irrespective of treatment (prognostic biomarkers) or able to forecast the likely response to treatment (predictive biomarkers); before (baseline values of a parameter) or during the treatment (dynamic variation of the parameter during the follow-up). during this session the presenters will discuss the technical issues and the results obtained today using ultrasound with share-waves or microbubbles, functional ct, dynamic contrast enhanced mri, diffusion weighted mri and pet-ct. the candidate biomarkers will be presented as well as the limits and the problems that are still to be overcome. a. us and ceus m. claudon; vandoeuvre-les-nancy/fr (m.claudon@chu-nancy.fr) for tumour evaluation, the main advantages of ultrasound (us) associate a high frame rate and a large range of data and parameters potentially extracted from the signal backscattered from tissues. beyond morphology, elastography is a first modality, based on in vivo estimation of the mechanical properties of tissues. data on displacement or strain of tissues and lesions can be obtained by manual external compression, but shear wave generation techniques allow for a quantitative and more precise estimation of their visco-elastic properties. in oncology, clinical evaluation included first breast. contrast-enhanced us (ceus) is obtained after intravenous administration of microbubbles which are pure blood pool contrast agents. ceus is capable for detection, characterisation and follow-up of tumour lesions, based on enhancement profiles during bolus, destruction-replenishment, or contrast burst depletion imaging. quantification of perfusion in normal tissues and lesions may be obtained by extracting various blood flow and blood volumerelated parameters from time-intensity curves. protocols have entered validation processes to improve reproducibility. as a predictive technique, ceus is a promising tool for monitoring changes of haemodynamic parameters and evaluating the early response during chemotherapy or antiangiogenic treatment. it is helpful in the guidance and follow-up of lesions treated by radiofrequency or cryoablation. recent advances of us and ceus include 3d/4d real-time imaging with matrix technology, and the evaluation of targeted agents, to be released on site after bubble destruction by the us beam. interventional radiology (ir) is the part of clinical radiology based on the percutaneous or endoluminal treatment of widespread conditions. the procedures performed by the interventional radiologists require a deep level of knowledge of clinical imaging and specific training in patient management and care. technical skills are also needed because complex devices and materials are used in some procedures. therefore, specific training programmes are required to address the training needs for the interventional radiologist. a multidisciplinary approach is required (based on team work) with defined levels in patient care. ir procedures have become the treatment of choice for many conditions as an alternative for some surgical procedures. even for some conditions without a defined treatment are now being treated by ir. thus, it is a discipline with a great deal of interaction with other clinical specialities that requires a clear definition. ir specialists have to receive recognition in the patient care process and their activity has to be known by the medical community. the recognition of ir as a subspecialty of clinical radiology by the uems will contribute to the development of specific training programmes in the european community and will promote training centres with certified specialists. interventional radiology (ir) procedures are complex and require specific training to ensure good results. in the uk, a curriculum for subspecialty training was established in 1998 specifying the required knowledge, training and core procedures expected of trainees. this curriculum has undergone several reforms since that time. however, training is not uniform throughout europe and this stimulated the development of a europe wide ir training document to ensure similar training in all countries as a way of ensuring good medical practice. radiology training is based on 3 years of common radiology training and 2 years of subspecialty training with an option for further specialist training in the 6 th year. regular appraisals and assessments of trainees' performance should guide progress at local training institutions with the aim that competence is assessed formally at the end of training by a european board examination. this qualification will be recognised thoughout europe and ensures that the required proficiency in ir procedures has been attained. competence in the core skills for ir occurs during the first 3 years of training. in the next 2 years, trainees undertake modular training depending on their areas of interest and ultimate goals. the majority of this training is practical, supervised training in interventional suites and theatres, with clinical exposure. simulators play a role alongside the more traditional training methods and allow early training in a more forgiving environment away from the patient. development and validation of such simulation models is progressing. discrimination of individual x-ray quanta, i.e. the detectors can 'see' the colour of the x-rays. different materials attenuate the energy spectrum in their own characteristic way. by comparing the measured spectra with the spectrum emitted from the x-ray tube the penetrated material can be characterised. colour x-ray imaging can be used in breast imaging to detect, for example the uptake of an iodinated contrast agent to show the vasculature of a tumour while reducing the impact of the structures from the surrounding tissue. it can also be used to estimate the breast density and as a material decomposition technique to separate the digital mammogram into compositional images, showing different material types separately. colour x-ray imaging can, for example be realised with pulse height discrimination in a photon counting detector, multiple exposures with different x-ray tube settings or filtering the x-ray beam before or after the object. the most simple form of colour x-ray is dual energy where two images are acquired at different x-ray energies. lung cancer staging is based on imaging techniques in combination with tissue diagnosis and surgical exploration. the tnm staging system describes the local tumour extent (t1-t4), presence or absence of lymph node metastases (n0-n3) and distant metastases (m0/m1). different combinations of t-, n-and m-factors translate into tumour stages (stages ia-iv). therapeutic decisions and assessment of prognosis are based on these tumour stages. recently, the tnm system has been modified: tumour size is now used more precisely for t staging: tumours <= 2 cm: t1a, > 2-3 cm: t1b, > 3-5 cm: t2a, > 5-7 cm: t2b, > 7 cm: t3. satellite tumour nodules in the same lobe are now classified as t3 (previously t4) and in a different lobe of the ipsilateral lung as t4 (previously m1). satellite nodules in the contralateral lung (previously m1) and pleural or pericardial metastases (previously t4) are now classified as m1a, whereas distant metastases outside the chest are classified as m1b (previously m1). also, the tnm staging system should now be applied not only to non-small cell lung cancer (nsclc) but also to small cell lung cancer (sclc). during this refresher course the different t-, n-and m-stages will be presented including the recent changes and examples will be presented and discussed with the audience. therapeutic strategies in different tumour stages will be described and key decisions highlighted. the accuracy of different imaging procedures and findings will be presented and the role of biopsy in specific clinical scenarios will be discussed. x-ray computed tomography (ct) has been proposed and evaluated recently as a potential alternative method for breast imaging. efforts so far showed success with respect to contrast-enhanced dynamic imaging, but suffered from limited spatial resolution. respective efforts and clinical results will be reviewed. the new concept presented here builds upon micro-ct scanning approaches and aims at providing both high spatial resolution at around 100 µm for micro-calcification imaging and advanced dynamic scan capabilities with continuous acquisition and scan times of about 10 seconds for differential diagnosis of lesions. to achieve this, spiral scan modes, slipring technology, high-resolution detectors and high-power micro-focus x-ray tubes are demanded. the concept has been evaluated and confirmed by simulations and basic experiments; feasibility studies are expected by the end of 2011. colour x-ray imaging can best be described as the x-ray analogy to optical colour imaging. in optical imaging the wavelength -the energy -of the light gives the different colours that we see. emerging x-ray detector technologies enable energy maintenance of confidentiality of patient information. in contrast, more hierarchical cultures often defer to elders for decision-making whereas communal cultures may involve community leaders in a shared decision-making process. gender and religious issues can also affect the provision of high-quality procedures with same gender care being a requirement within some cultural groups and gowning procedures that maintain cultural values frequently being an expectation. in addition, in many countries in the developing world, radiation still has mystique and fear associated with it, affecting participation in screening programs and recruitment to medical radiation technology educational programs. this presentation will present findings from a variety of countries and cultures that will help to contextualise these issues through a cross-cultural imaging lens. first line image interpretation is now commonly used in the united kingdom. for many years radiographers have used a system commonly known as "red dot" in order to identify to the referring clinician that an abnormality has been recognised on a radiographic image. this has more recently evolved into radiographer comment where the radiographers' experience in recognising abnormalities can help referring clinicians. junior doctors are often inexperienced at image interpretation, thus this system can assist in ensuring that a higher percentage of fractures and injuries are observed and the appropriate treatment obtained. this presentation will demonstrate the fundamentals of basic image interpretation of the cervical, thoracic and lumbar spine in a trauma situation. it will include basic anatomy, mechanism of injury, common fractures and soft tissue signs. using these principles this will encourage radiographers to use the comment system, both developing the radiographer's role and helping to improve patient care. two fasciae cross the suprahyoid neck: the superficial cervical fascia (scf) and the deep cervical fascia (dcf). the latter can be divided into three parts and these layers define different fascial spaces or compartments. the descriptions of these compartiments in the literature vary almost as much as those of the fasciae themselves. in addition, the names of the formed compartiments vary within the literature. despite these controversies, the knowledge of these compartiments is inestimable for correct differential diagnosis of pathologies that arise in the suprahyoid neck. with the utilisation of cross-sectional imaging, it has been noticed that growth of some tumours appears restricted by fasciae and knowledge of the anatomy of these fasciae allows not only prediction of growth patterns. by allocation of a tumour to a certain compartiment the number of differential diagnosis drop dramatically due to the fact that in different compartiments different types of tissue occur. in addition, the exact localisation of infectious disease of the suprahyoid neck may predict further intracranial or mediastinal spread. even though the number management of cancer patients, imaging pitfalls must be recognised to avoid both false-positive and false-negative interpretation. the principles and good practices of pet/ct will be explained. normal distribution of fdg, pitfalls and normal variants will be presented. specific examples will be discussed to demonstrate how the combined information of images of human anatomy upon which biological information within body structures is added improves delineation of disease, can guide surgical and radiation planning and biopsy. advances in technology result in new training requirements for radiologists who should promote close collaboration with nuclear medicine specialists. the metabolic syndrome refers to the clustering of cardiovascular risk factors including diabetes, obesity, dyslipidaemia and hypertension. the association between metabolic syndrome and cardiovascular diseases raises important questions about the underlying pathological processes. insulin resistance and visceral obesity have been recognised as the most important pathogenic factors. metabolic syndrome generally precedes and is often associated with type 2 diabetes. cardiovascular risk reduction in individuals with metabolic syndrome should include (1) control of obesity, diet and physical activity and (2) control of the individual components of metabolic syndrome, especially atherogenic dyslipidaemia, hypertension, hyperglycaemia and prothrombotic state. appropriate management of metabolic syndrome should be able to prevent the progression from impaired glucose tolerance to frank diabetes and thus to prevent the increasing prevalence of type 2 diabetes and vascular diseases. each 1% increase in hba1c is associated with a 28% increase in risk of incident pad. diabetes is also highly associated with progression of pad and especially with the development of critical limb ischemia. rigorous control of blood glucose prevents the microvascular complications of diabetes, although similar benefits on the macrocirculation have not been ascertained. patients with diabetes and pad should have an aggressive control of blood glucose levels with a hba1c goal of < 7.0% or as close to 6% as possible. in the new tasc paper this recommendation is graded as c, meaning that it is based on evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities, while there are no applicable studies of good quality. peripheral arterial disease (pad) is a common cardiovascular complication in patients with diabetes. in contrast to non-diabetic pad, it is more prevalent and, because of the distal territory of vessel involvement and its association with peripheral neuropathy, it is more commonly asymptomatic. diabetic pad thus may present later with more severe disease and have a greater risk of amputation. the pervasive influence of diabetes on the atherothrombotic milieu of the peripheral vasculature is unique. the abnormal metabolic state accompanying diabetes results in changes in the arterial structure and function. the proatherogenic changes include increases in vascular inflammation and derangements in the vascular cellular components, alterations in blood cells and haemostatic factors. these changes are associated with an increased risk for accelerated atherogenesis as well as poor outcomes. in contrast to the focal and proximal atherosclerotic lesions of non-diabetic pad, in diabetic patients the lesions are more likely to be more heavily calcified, diffuse, and distal, sparing the proximal vessels and mainly affecting the more distal arteries in the calf and, in a later stage, the foot. by identifying a patient with subclinical disease and instituting preventative measures, it may be possible to avoid acute, limb-threatening ischaemia. the primary imaging modality to be used should be duplex ultrasound, due to its non-invasive nature, lower risks and costs. ct-angiography and mr-angiography are now replacing dsa as standard imaging methods, providing a non-invasive assessment of the localisation and extension of a vascular lesion and allowing an accurate planning of endovascular and/or surgical treatment. of spaces in the literature varies from seven to fourteen, the use of seven spaces or compartiments seems to be helpful for a sufficient diagnostic approach using cross-sectional imaging. anatomic landmarks and the radiologic appearance in a non-pathologic suprahyoid neck and a pathologic involvement of the suprahyoid compartiments will be reviewed extensively in a coherent manner. the anatomy of the suprahyoid neck is complex and the spectrum of diseases is wide. to improve studies of the neck, radiologists should become increasingly more familiar with the anatomy and expected pathology in the various spaces. this familiarity provides crucial information required for the selection of treatment options and therapeutic planning. in addition, radiologists should be aware of situations when diagnostic inaccuracies may lead to serious consequences and complications. for example, surgical approach to a deep lobe parotid tumour as though it is a parapharyngeal lesion will in all likelihood result in facial nerve injury. mri artefacts such as complex flow-induced increase in signals may be mistaken as a lesion prompting an unnecessary operation. an awareness of such pitfalls helps to improve the quality of imaging studies. this presentation highlights some pertinent anatomical knowledge that may help to improve the diagnostic accuracy of neck studies and at the same time explain the existence of pitfalls that may ruin imaging studies. three layers of the deep cervical fascia define the suprahyoid neck compartments, which include: prevertebral, retropharyngeal, carotid, masticator, parapharyngeal and pharyngeal mucosal space. knowledge of the structures inherent to these spaces will provide the radiologist with an accurate basis for differential diagnosis. also, expanding lesions will distort or displace adjacent structures and fascia in predictable fashion, which is crucial in defining the site of origin. both mri and ct are frequently used in the imaging of suprahyoid neck lesions. the introduction of functional imaging has also given some benefits. primary and secondary, benign and malignant processes occupying major suprahyoid neck spaces will be discussed, with regard to crucial findings necessary for appropriate treatment selection and treatment planning. since correct diagnosis requires close collaboration with ent surgeons, clinical findings will also be discussed, together with practical information needed for surgery. in vivo proton mr spectroscopy is a non-invasive mr technique that is routinely used to assess a number of paediatric neurologic conditions. it is based on the fact that protons belonging to different metabolites resonate at slightly different frequencies (chemical shift). using water suppression and volume localisation techniques we can obtain a spectrum (single voxel) or spectra (si) containing metabolite peaks corresponding to predetermined anatomical site(s). in paediatrics the majority of spectroscopy is performed in the brain and the metabolites detected usually are: n-acetyl aspartate, n-acetyl aspartyl glutamate, creatine and phosphocreatine, choline containing compounds (free choline, acetylcholine, phosphocholine, cytidine diphosphate choline and glycerophosphocholine), myoinositol, myoinositol monophosphate and glycine, aminoacids (glutamine, glutamate and gaba), lactate, lipids and macromolecules. these metabolites participate in fundamental metabolic pathways and their levels are being disturbed by various pathologies. thus, mr spectroscopy has a vast field of application including paediatric tumours, infarction, hypoxia, ischaemia, infection, inflammation, metabolic disorders neurological disorders and trauma. in many cases, it can redirect or narrow differential diagnoses; in selected instances, it may provide the key finding that points to a final diagnosis. however, mr spectroscopy alone is usually not specific, but can be very helpful especially in combination with other clinical, diagnostic and other mr methods. finally, particular caution is needed in data evaluation because spectral appearance and concentrations of the most prominent metabolites are affected by (a) experimental and preprocessing factors and (b) brain development. stroke in children is most often of ischaemic origin and thrombophlebitis is the second cause of stroke in children. stroke is considered as rare compared to the adult population. however, numerous aetiologies impose to look for a cause through series biological investigations. the goal of brain imaging is to confirm the diagnosis of stroke, to evaluate the extension of ischaemia and mostly to participate in the search of a cause for the stroke. prognostic is mostly related to the aetiology. a lot of cases are performed under general anaesthesia leading to limited indications of mra in the acute phase compared to adult. the role of cta at the acute phase is mostly to confirm thrombophlebitis and is the primary method to assess intracranial vessels at the acute phase of haemorrhage of arterial or venous origin. it is also the primary method to assess arterial vessels at the neck level (especially when dissection is suspected). cta permits to confirm or rule out arterial lesion that was suspected on mr: indeed, cases with pitfalls are numerous with mr angiography. the role of mra, also always performed in the acute phase or follow-up of vascular diseases, is not as clear as cta role because of artefacts especially in young children. the role of angiography (dsa) is finally limited to prove vasculitis when the other methods are not contributive and in cases of arterial or arterio-venous malformation to plan the treatment (endovascular procedure versus surgery or radiosurgery). diffusion tensor imaging (dti) studies demonstrate progressive apparent diffusion coefficient (adc) decrease within grey and white matter areas starting from foetal life as sign of brain maturation; meanwhile, fractional anisotropy (fa) increases in some white matter structures. changes in fa and adc, together with radial and axial diffusivity values, during cell proliferation-migration and during myelination, well correlate with modifications known from developmental histologic studies. acute adc decrease (i.e. ischaemia) can be detected already in foetal stroke and its measure is pivotal in monitoring neonatal hypoxic-ischaemic encephalopathy. adc calculation allows also to assess acute osmotic and metabolic anomalies in neonate (i.e. hypernatremia, hypoglycaemia, etc.). early fa decrease, with radial and axial diffusivity changes, is observed in white matter areas as sign or early wallerian degeneration after acute brain damage. chronic regional white matter fa reduction is detectable in sequelae of periventricular leukomalacia or adjacent to malformative cortex. also, in children with neurodevelopmental delay (autism, adhd, dyslexia, etc.). fa reduction and radial or axial diffusivity changes have been demonstrated, but in these conditions not on a single case basis rather in cohort quantitative studies. finally, building fiber tracking and colour coded (rgb) maps from dti data may help in better characterising suspected structural anomalies on a single case basis (i.e. corpus callosum, hippocampal fornix, optic radiation, cerebellar peduncles malformations, etc.). however, the potentials of fiber tracking applications still need to be fully exploited, especially in view of future higher spatial resolution image acquisitions. learning objectives: 1. to understand the relationship of adc-fa values with the structural characteristics of the normal developing brain. 2. to understand adc-fa value changes in paediatric cns diseases. 3 . to learn about the potential impact of fibre tracking in clinical paediatric neuroradiological practice. congenital pulmonary malformations may involve the lung parenchyma, bronchi, arterial supply, and venous drainage. the pulmonary developmental abnormalities that most commonly result in clinically significant complications in neonates and children are hypogenetic lung syndrome, bronchopulmonary sequestration (bps), congenital lobar emphysema (cle), bronchial atresia, congenital cystic adenomatoid malformation (ccam), and bronchopulmonary foregut cysts. it should be noted that there is often considerable overlap between these conditions and that multiple lesions may be identified in the same patient either separately or as hybrid lesions. the aim of this presentation is to illustrate the characteristic imaging manifestations of the most important congenital lung diseases and their main differential diagnosis. emphasis will be given to pre-natal diagnosis using ultrasound or magnetic resonance imaging (mri) and post-natal diagnosis using mri or low dose ct in multidetector scanners. ultrasonography (us) is the primary screening modality in prenatal imaging. its diagnostic accuracy is usually very high so that the indications for foetal mri should be very rare. in some countries, because us is considered of secondary importance and is not exploited as much as it could be, there is a progressive shift from us to mri as a prenatal imaging modality. consequently, there are many discrepancies regarding the relative contributions of foetal us and mri in the prenatal literature. the main indications for foetal mri will be discussed, with emphasis on the central nervous system, which remains the main field of application. in daily practice, the technique of foetal mri has not changed during the last decade and most diagnoses can be assessed using t1, t2 and t2* sequences. the basic technique and patient preparation will be described. new techniques, based on a functional or a metabolic approach, have been developing during the past few years but their impact on daily practice is still very limited. many studies have underlined the high diagnostic contribution of foetal mri compared with us. however, the diagnostic accuracy of mri has not been studied in large series. comparison between pre-and postnatal data or between foetal mri and pathological findings make it possible to define the main limits of foetal mri. regarding the brain, migration or cortical development disorders are often overlooked or underdiagnosed. a tight collaboration between colleagues practicing prenatal us and mri should increase diagnostic accuracy, both modalities being complementary. founded on september 15, 1948, the brazilian college of radiology comprises 23 regional societies and ten thousand associates. the college is a branch of the brazilian medical association (amb) acting as its scientific department of radiology, imaging diagnosis and radiotherapy. it collects, under the same umbrella medical professionals and legal entities in the field of diagnosis and treatment using imaging methods and/or ionising radiation. session objectives: 1. to get an introduction to the practice of radiology in brazil. 2. to understand the importance of radiology as a method for diagnosing diseases in brazil. granulomatous interstitial lung disease: hrct path correlation c.i.s. silva; salvador/br (c.isabela.silva@gmail.com) granulomatous interstitial lung diseases are a group of lung diseases in which granulomas are an important component of the histologic findings. the most common conditions are hypersensitivity pneumonitis and sarcoidosis. hypersensitivity pneumonitis is very common in brazil because of the warm and humid climate in most regions and a large number of birds. the prevalence of sarcoidosis in brazil seems to be lower than that in north america and europe. other ubiquitous causes of granulomatous interstitial lung disease include intravenous talcosis, drug reactions, and some forms of vasculitis (e.g. churg-strauss syndrome). the aim of this presentation is to illustrate the characteristic high-resolution ct and histologic manifestations of the most common granulomatous interstitial lung diseases and to summarise the main differential diagnosis based on the pattern and distribution of abnormalities seen on high-resolution ct. learning objectives: 1. to become familiar with the characteristic high-resolution ct and histologic findings of the most common granulomatous interstitial lung diseases (hypersensitivity pneumonitis and sarcoidosis). 2. to learn about the most helpful features in distinguishing the granulomatous interstitial diseases from other parenchymal lung diseases. a-233 11:00 the most common granulomatous lung diseases are fungal infections and tuberculosis. these infections are particularly prevalent in brazil, the most common fungal infection being paracoccidioidomycosis (south american blastomycosis). histoplasmosis and coccidioidomycosis may occur but they are uncommon. paracoccidioidomycosis is the most frequent endemic systemic mycosis in latin america, being seen particularly in brazil, argentina, colombia, and venezuela. the lungs are the main target organ of p. brasiliensis organisms, and infection of the lungs is the leading cause of morbidity and mortality in these patients. fungal infections need to be considered not only in patients living in endemic regions but also in patients who have travelled to these areas. although the prevalence of pulmonary tuberculosis has decreased in brazil in recent years it remains one of the most important causes of pulmonary morbidity and mortality. the aim of this presentation is to discuss the radiologic manifestations of the granulomatous pulmonary infections with emphasis in paracoccidioidomycosis and tuberculosis and to summarise the main differential diagnosis. magnetic resonance imaging (mri) is a highly sensitive technique that provides complementary information to conventional breast imaging (i.e. mammography and ultrasonography) for the detection of multinodular disease and for the assessment of primary tumour extent. the use of mr breast imaging has increased considerably in the past decade. although its use is well established for some indications, e.g. detection of unknown primary and assessment of uncertain disease extent, breast mri is still under investigation for other applications such as preoperative assessment in patients eligible for breast conserving therapy on the basis of conventional imaging and clinical examination. despite its superior ability to visualise disease spread, recent studies have shown increased rates of mastectomy without reduction in positive surgical margins or local recurrence rates. nonetheless, a shift in paradigm is occurring, focusing on the use of breast mri to reduce involvement of healthy tissue in breast-conserving therapy. this paradigm involves new methodology to optimise the transfer of information to the surgeons and radiation oncologists. new technological developments, such as diffusion-weighted imaging (dwi) and magnetic resonance spectroscopy (mrs) provide new insights to establish a link with underlying biology of the tumour. contrast-enhanced mri, dwi and mrs are examined for their ability to extract prognostically relevant information to individualise therapy to individual patients and tumours. this overview aims to summarise the current status of breast mr imaging and new developments geared towards providing therapists with patient-tailored information for treatment decision, treatment guidance and therapy response. this talk will review the current literature and clinical use of foetal mri in cases with ventriculomegaly. the initial part will discuss antenatal ultrasound in the detection, categorisation and diagnosis at the 20-week anomaly scan. the role of foetal mri will be discussed including which cases may benefit most from foetal mri when the resource is limited. the timing of the foetal mr with relation to gestational age and the value of further foetal mr scans at a later gestational age will also be discussed. this is still a controversial and debated area especially when the resource is limited or there are financial constraints. the current literature will be discussed on the issues around foetal mri in cases with ventriculomegaly both isolated ventriculomegaly and ventriculomegaly associated with other abnormalities. finally, this section will conclude by looking at the common associated abnormalities seen in cases referred with ventriculomegaly. the final section will discuss the role of foetal mr in imaging the posterior fossa, an area often difficult with ultrasound especially in the later stages of pregnancy. again the current literature will be discussed and the use of foetal mr in clinical practice. the concluding time will be used to summarise the referral pathway used by local centre in the uk. this will differ with other uk centres and centres worldwide. hopefully, time will allow an open discussion on this at the end of the session. learning objectives: 1. to learn about the differential diagnoses of ventriculomegaly identified on foetal ultrasonography. 2. to learn when mr should be performed and its value when compared to ultrasonography. 3. to understand the value of mri in assessing posterior fossa abnormalities. prenatal diagnosis involves obtaining genetic, anatomic, biochemical and physiological information about the foetus and analysing whether there are any alterations that might have repercussions during the foetal period or after birth. magnetic resonance imaging (mri) has been useful in the diagnosis of foetal anomalies for many years. thoracic abnormalities play an important role in infant morbidity and mortality. survival after birth depends largely on adequate lung development during gestation, and various pulmonary problems can affect foetuses. heart defects are present in 8 of 1000 live births, and up to 25% of these are associated with other malformations. other thoracic anomalies (tracheoesophageal malformations, chest wall defects, and tumours, amongst others) can also cause morbimortality. congenital abdominal anomalies can affect many organs. it is essential to determine the location and morphological characteristics of the lesion to ensure an accurate diagnosis. mri's excellent contrast resolution between tissues is very useful in the diagnosis of these conditions. prenatal diagnosis also makes it possible to detect anomalies that can be difficult to recognise clinically in newborns but require early treatment to minimise possible complications.this presentation stresses the importance of diagnosing chest and abdominal problems before birth and analyses the usefulness of mri in this context. learning objectives: 1. to learn about the mr protocol when investigating the foetal chest. 2. to recognise the situations in which mri is helpful in assessing chest abnormalities. 3. to understand the value of mri when compared to ultrasonography in assessing congenital renal and gastrointestinal abnormalities. a s65 c b d e f g h structured reporting: improving the quality of radiology reports c.e. kahn; milwaukee, wi/us (kahn@mcw.edu) the radiology report communicates the results of an imaging procedure and provides the enduring legal record of the procedure. structured reporting uses standardised language and predefined formats to create reports. structured reports can integrate information collected during the imaging procedure, such as clinical data, technical parameters, measurements, annotations, and key images. in this presentation, well defined structured reporting describes its advantages and disadvantages, and identifies the motivations for its adoption. this session will discuss how structured reporting can make it easier to retrieve reported information, evaluate the appropriateness of exams, and aggregate data across health care enterprises. structured reporting can support radiology quality improvement, research, and education, and has the potential to improve the quality of communication between radiologists and their referring colleagues. beyond air-space disease is secondary to occupation of the acini and alveoli by oedema, exudates or malignant cells. it presents in the chest radiograph as ill-defined densities which tend to coalesce. the presence of an air bronchogram is pathognomonic. when the disease is widespread it shows the typical "butterfly" appearance. airthe pixel data set of modern imaging is transformed into a life altering insight for the individual patient through the radiologic report. a good report is patient and service centred, and forms the basis of the reciprocal relationship between radiologist and referring clinician. it is a creative process with serious scientific purpose and becomes part of the permanent record in a person's life. its primary role is communication of diagnostic and procedure-related imaging information but it has many vital adjunct roles in quality service delivery. in current practice of multidisciplinary care the report content must be of value to all the stakeholders beyond radiology. structured reports must have uniformity where possible to permit data-mining and audit whilst preserving the individual radiologist practice and style and the individual nature of each patient's health. report design has a particular role in modern alerting and safety-net systems when unexpected or critical imaging findings are discovered. the properly written report can be vital in medico-legal defence to reflect good practice. ultimately guidelines and standards on reporting must be meaningful to the users and appropriate to local resources, systems and needs. learning objectives: 1. to comprehend the role of the modern radiological report. 2. to understand the role of the report in communication and patient safety. 3. to become familiar with structured report formulations. structured reporting: european perspective r. silverio; grosseto/it (rsilverio@sirm.org) in the last decade, we observe an increasing interest in structured report (sr). this is a part of the dicom standard, where the technical and clinical information are organised in a standard format so that it can be retrieved and reused for clinical, statistical and research scopes. structured reports have three important features: a "structured" format, with fixed paragraphs, heading and subheading in which to describe technical data and clinical findings, impressions and conclusions; a consistent, "itemised" organisation, leading to a better way of reporting, even with automated speech recognition systems; and the possibility, or rather the need, of a common, shared language. when defined terms from a standard lexicon are associated with imaging reports, the information in the report becomes more accessible and reusable. moreover, sr allows the interoperability between the dicom world and the complex sphere of the e-health (electronic patient record, patient care, etc). it is possible to convert a radiological report created as sr in a cda2 (clinical document architecture) document. this clinical document will be used in every computerised healthcare application, as well in the several regional e-health projects (epsos, elga, calliope, renewing health, etc). promoted by european community. integrating the healthcare enterprise (ihe) initiative is as a key partner in fostering the adoption of structured report. in short, question of whether sr will be adopted by radiologists is now a question of "when", not "if." learning objectives: 1. to become familiar with structured report. 2. to keep up to date on the developments of e-health projects in europe. acute mesenteric insufficiency (ami) is due to arterial or venous occlusion. arterial ami is an emergency. the typical patient is elderly, may have atrial fibrillation and has recent onset intense visceral pain disproportionate to clinical signs. ct is the mainstay of diagnosis and may be supplemented by ct angiography (cta). waste no time if arterial ami is suspected. average mortality rates of 71% (59-93%) have been reported and symptom duration before therapy is an independent predictor of mortality. age > 70 years, metabolic acidosis and renal failure are other danger signs. interrupt routine ct lists; ensure that these patients are scanned as soon as possible -neutral oral contrast and high-dose iv contrast are essential. ct appearances should be correlated with serum lactate as acute arterial occlusion without reperfusion may produce falsely 'normal' bowel wall thickness. early diagnosis and aggressive surgical intervention combining bowel resection with revascularisation offer the best prognosis. venous ami may present with a more chronic, intermittent course of pain, fever, abdominal tenderness and ascites. therapy is bowel resection and anticoagulation. ischaemic colitis occurs in elderly patients with atherosclerosis spontaneously or after aortic aneurysm repair. this invited lecture explores the groundbreaking use of ct for studying antiquities and artworks from a wide range of cultures, irrespective of their age or material. dr. marc ghysels, a former interventional radiologist, comes from a family of artists and collectors. about ten years ago he set up a private radiology practice in brussels where he analyses antiquities and artworks. over the years he has built an international reputation among collectors and art dealers as well as museum curators and experts working in auction rooms. art specialists call on his radiological skills and knowledge to authenticate antiquities, and more specifically to show: what methods were used to make the works, what damage they have suffered over the years, how much restoration has been done, and to expose the many tricks used by forgers to deceive not only the discerning eye of the collector but also the methods of scientific analysis more commonly used than ct scans. his presentation will highlight the prominent role of ct as a nondestructive test to explore selected artworks made in wood, terracotta, stone, and ivory. acute abdominal organ ischaemia may be caused by hypovolaemic shock, spasm (ergotism), embolisation and aortic dissection. embolisation is the most common cause. it occurs typically in elderly patients with atrial fibrillation, after myocardial infarction or due to a thoracic aortic aneurysm (taa). the primary diagnosis is made by ct with contrast enhancement which can also demonstrate cardiac thrombi or a taa. interventional treatment can be performed with a thrombectomy device or fibrinolysis with recombinant tissue plasminogen activator (rt-pa; 10 mg loading dose, 5 mg/hr infusion dose). acute aortic dissection may cause dynamic compression of the true lumen with occlusion of the ostium of the visceral arteries (floating visceral sign). the primary diagnosis is made by ct. occlusion of the primary entry tear with a thoracic aortic stentgraft may decompress the false lumen followed by reexpansion of the true aortic lumen followed by reperfusion of the visceral arteries. chronic abdominal ischaemia in younger patients may be due to fibromuscular dysplasia, takayasu arteritis or neurofibromatosis. in the elderly it is usually caused by arteriosclerosis. the patient may have post-prandial abdominal pain (angina abdominalis), diarrhoea and/or weight loss. due to the collateral circulation, symptoms usually occur only if more than one of the major arteries (celiac trunk, superior and inferior mesenteric artery) is narrowed. the diagnosis can be made by color doppler ultrasound (cdus), ct and mr with contrast enhancement. endovascular treatment is done by pta and stent placement. to learn what to include in the report of cns infections for the treatment planning. 4. to learn how to report follow-ups and treatment monitoring of cns infections. finding of a palpable mass in the abdomen always raises the possibility of an important clinical problem. a potentially life-threatening process, especially malignancy is the major concern. the list of differential diagnosis of "abdominal mass" is a very long one. in the process of differential diagnosis the most common approach is to evaluate the patient according to the gender, age, patient history and co-existing clinical and laboratory findings. the accompanying symptoms and signs and the location of the abdominal mass are the key indicators in the clinician's way of thinking in the process of differential diagnosis. for instance, a palpable mass with acute abdomen or intestinal obstruction will be assessed differently than a mass found incidentally. imaging is commonly required to confirm or ascertain the diagnosis. cross-sectional imaging is required to accurately evaluate a palpable abdominal mass in most situations. ultrasound and computed tomography have each been used successfully in evaluating patients with palpable abdominal mass. although each modality is appropriate in most situations, the advantages and disadvantages of each modality in certain situations will be addressed and the appropriateness criteria will be reviewed in this lecture. knowledge of a detailed clinical history is as important to the radiologist as to the clinician. its impact on the diagnostic accuracy in the interpretation of the images will also be addressed. a palpable abdominal mass has a long list of benign and malignant differential diagnoses. these diagnoses may be as different as a hydatid cyst of the liver, a volvolus, an aneurysm, or a giant renal cell carcinoma. the diagnostic approach is based on two major steps: first, the affected organ must be indentified. second, the differential diagnosis must be established based on imaging characteristics. the choice of ultrasound, ct or mri should be based on location and size of the mass. despite the fact that ultrasound is frequently used as a first step, the overview and anatomic orientation in large masses may be hampered, making ultrasound a better technique for image-guided biopsy than for primary diagnosis. in the vast majority of cases, multidetector ct is the first technique of choice. a thin-section protocol should be used to allow for high-quality multiplanar imaging. a pre-contrast scan is usually not required but can be helpful in suspected hemorrhage. for most upper and middle abdominal masses, biphasic imaging in the arterial and portal phase is recommended in order to establish the relation of the mass to the vasculature and to assess vascularity. in the small pelvis, mr is the superior imaging technique. otherwise, mri is mainly used for problem-solving. this course will discuss how to use the various imaging tool efficiently to narrow the differential diagnosis, decide about the need for biopsy and establish a suitable therapy. the most common viral infection of the brain is herpes encephalitis (hsv1). it is a necrotising encephalitis with a a mortality of more than 50%. on imaging studies lesions will be seen in the "limbic system", i.e. the temporal lobes, hippocampi, insular cortex and cingulate gyrus. they appear as hypodensity on ct, t2-and flair hyperintensity on mri, possibly with haemorrhagic transformation. diffusion is restricted in the early phase. enhancement occurs at a later stage. human immunodeficiency virus (hiv) infection is a multifocal giant-cell encephalitis eventually leading to a progressive leuco-encephalopathy. on mr atypical focal or diffuse symmetrical signal abnormalities are seen neither with mass-effect nor with enhancement and typically sparing the u-fibers. spectroscopy can show an increase of myo-inositol. progressive multifocal leuco-encephalopathy (pml) is due to reactivation of the jc polyomavirus in immunocompromised patients, 10% of which are hiv positive. on mri "scalloped" multifocal asymmetrical lesions are seen with minimal mass-effect and without enhancement. new treatments of hiv, especially highly active antiretroviral therapy (haart) can lead to a paradoxical worsening of patients due to the immune reconstitution inflammatory syndrome (iris). on mri mass lesions are seen with diffuse patchy enhancement. cerebral toxoplamosis appears as multiple enhancing lesions with marked perilesional oedema. calcification is possible. prion diseases are caused by a proteinaceous infectious particle leading to creutzfeld-jacob disease in humans. diffusion weighted mr-images show high signal intensities in the cortex and the basal ganglia. abnormalities on t2-weighted images and flair occur at a later stage where atrophy is mostly prominent. to learn how to assist clinicians for the diagnosis and differential diagnosis of bacterial and parasitic cns infections. susceptibility effects, increased radiofrequency (rf) field inhomogeneity and more pronounced magnetic shielding effects. in the mean time, many investigators have proposed strategies to optimise imaging protocols and to decrease sar levels and to reduce artefacts including optimised coil and hardware design, in combination with parallel imaging and modulation of refocusing flip angles. many clinical applications in neurology and angiography for high field mri that were recently being investigated showed benefits over 1.5 t. however, as of to date, virtually no prospective comparative studies have been performed and published that could help to estimate whether or not there would be any clinical benefit of 3.0 t msk over 1.5 t. although many authors described the improved snr of msk imaging at 3.0 t allowing for higher spatial resolution this has not been prospectively investigated with comparison to 1.5 t. further studies have to show whether the improvement in speed and resolution will also translate into increased patient throughput and earlier depiction of disease in msk applications at 3.0 t. ultrasound is the best imaging modality for evaluation of acute scrotal conditions. mri is used only rarely, when us findings are equivocal and in cases of suspected infarction. ct is used exceptionally, for example, to detect air in the scrotal wall. high-frequency transducers with modern software like compound imaging and native harmonic, and very good colour sensitivity for low flow in small vessels provide excellent insight into testicular morphology and vascularisation. it is very important to distinguish testicular torsion from the acute inflammation, as it has important therapeutic and even medicolegal consequences. in testicular torsion rapid diagnosis is vital, and salvage rate is directly related to timely operation. torsion is more common in younger patients and orchiepididymitis is more common in adults. infection usually starts at the epididymis and then spreads to testis the patient presenting with an abdominal mass represents a common clinical problem. clearly, the differential diagnosis is large and obviously will depend on the age and sex of the patient as well as location of the mass. of course history and clinical examination are mandatory, but formal diagnosis will usually rest on radiological interpretation. contrast examinations have now been replaced by cross-sectional imaging and endoscopy and it behoves the clinical radiologist to be aware of the advantages and limitations of these methods in order to reach a diagnosis. particular difficulty may be encountered when the mass is so large that it is difficult to determine the organ of origin. the purpose of this interactive case discussion is to explore the relative merits of ultrasound, ct, mr and endoscopy in establishing a diagnosis in two different cases. the cases concerned are: 1. a 21-year-old man who presents with a right iliac fossa mass, but is otherwise asymptomatic. 2. a 54-year-old woman who presents with anaemia and a large upper abdominal mass. active audience participation will be encouraged by means of key pads in order to respond to issues raised during the debate. the most straightforward expectation from 3 t mri scanners is a gain in snr that could be translated in improving spatial resolution and/or reducing imaging time at an at least constant cnr. together with field strength, susceptibility effects, chemical shift and t1 increase and t2 and t2* decrease. also, relaxation properties of contrast agents are modulated. rf power deposition is higher at 3 t and is often a limiting factor in sequence parameter optimisation. hence, the need to optimise mri sequence protocol parameters at 3 t. for cartilage, muscle, synovial fluid and fat, t1 increases by between 14% and 22%, t2 decreases by between 10% and 37% and r1 of gd chelates decrease by 5% to 10% when b0 increases from 1.5 t to 3 t. in most applications reduced t2 and increased t1 work synergistically towards a reduced snr. since the change in relaxation times is not linear for the different tissues, cnr varies with field strength, too. a relatively straight forward approach is to lengthen tr in order to compensate for longer t1 and to shorten te to compensate for shorter t2 (*). in non-fat-sat images bandwidth needs to be increased to control chemical shift effects. because of the better fat and water peak separation, 3 t often helps improve frequency-based fat saturation but may also be greatly impaired by field inhomogeneities in the presence of metallic materials. field strength (b0) and appropriate dedicated multi-element coils are the hardware prerequisites to bring high resolution (hr) isotropic imaging into clinical routine. depending on the age of the child, hip symptoms may predict a variety of diseases. in the infant, developmental dysplasia and infection should be considered. after the age of 4, irritable hip most commonly due to transient synovitis is the commonest disease but infection is the more worrying condition. perthes disease affects some and this condition overlaps into those over 8 who may have a slipped upper femoral epiphysis. fractures and rare cases of osteonecrosis and chondrolysis are a concern in the adolescent. in the young and indeed in most cases, ultrasound provides a useful first line test. aspiration of effusion may be both diagnostic and therapeutic. in the older child and, especially when sufe is a risk, conventional radiographs with an external rotated "frog leg" view is very important. despite the logistics problems in children, there is an important role for mri especially in cases where the initial imaging does not explain the symptoms. i will review the imaging pathways and provide examples of common diseases. i will also discuss how to manage the difficult case and show recent audit data on detection rates and clinical management. fai refers to a conflict between the proximal femur and the acetabulum. both an abnormal shape of the proximal femur (fai of the "cam-type": aspheric femoral head with a laterally increasing radius and/or a waist deficiency of the femoral neck) and the acetabulum (fai of the "pincer-type": acetabular retroversion or a deep acetabulum) or a combination of the two may be present. for a long period the fai may be asymptomatic and the only clinical finding will be an impaired internal rotation of the hip joint. later as the disease progresses, cartilage damage (outside-in abrasion of the acetabular cartilage/cartilage delamination) and labral tears occur. labral tears are most common in the anterosuperior aspect of the acetabulum. a typical labral tear is an incomplete detachment with a tear located at the base of the labrum. anatomic variants such as a sulcus may be present and should be distinguished from tears. a sulcus is common at the junction of the labrum with the transverse ligament and is generally located beyond the equator of the hip joint. insufficiency fractures about the hip commonly occur in the region of the femoral neck. another site vulnerable to overuse is the symphysis pubis. often, a bone marrow oedema pattern around the symphysis pubis is observed. a characteristic finding is the "secondary cleft sign", which reflects a partial tear of the adductor tendon aponeurosis at the symphysis pubis. understanding age-related changes is essential for interpretation of imaging studies. age is a risk factor strongly correlated with osteoarthritis (oa) which is the most common hip joint disease seen in adults. the diagnosis of oa is based on a combination of radiographic findings and characteristic subjective symptoms. the lack of a radiographic consensus definition has resulted in a variation of the that is painful and hypervascularised on colour doppler imaging. in cases of torsion b-mode findings are non-specific, while on colour doppler flow is absent in complete torsion, but may be present and diminished in incomplete torsion, or increased in intermittent torsion. in cases of trauma ultrasound is important to diagnose haematoma, haematocele to evaluate integrity of testis and assess whether the testicular fracture is present or if the surgery is needed in cases of testicular rupture. imaging is helpful in cases of rare causes of the acute scrotum, such as fournier gangrene, testicular appendage torsion, vasculitis, and also in evaluation non-scrotal causes of symptoms, like in cases of renal colic, abdominal inflammatory and traumatic conditions, etc. a scrotal mass is an important clinical problem and a source of anxiety to the patient. radiologists play an important role in the management of these cases, since imaging is required to provide information about precise anatomical location of the lesion, its size and extension and, possibly, to elucidate the nature of the disease. the us and mri findings of the many different scrotal tumours will be presented in this lecture. special attention will be given to two topics. the first are the possibilities offered by imaging to differentiate among the different pathologies, especially to differentiate between benign and malignant lesions. the second will be the problem of the small, non-palpable, indeterminate testicular mass. such lesions have been shown to be relatively frequent. prevalence of malignancy varies widely in the literature, and orchidectomy seems not justified in all cases. the use of contrast-enhanced mri and of advanced us techniques (contrast-enhanced us and elastography) may help to narrow the differential. furthermore, the use of intraoperative us to guide removal of non-palpable testicular nodules can help to perform conservative surgery in lesions with no malignant potential. learning objectives: 1. to understand the typical imaging appearance of benign and malignant scrotal tumours. 2. to review differential diagnosis of intra and extratesticular scrotal tumours and the impact of imaging. c. imaging of the penis m. bertolotto; trieste/it (bertolot@univ.trieste.it) ultrasonography (us) is the first-line imaging modality in patients with penile disease. using high-end equipment after pharmacologically induced erection penile anatomy is well defined and virtually all clinically significant penile vessels can be evaluated in normal and in impotent men. the superior soft-tissue contrast resolution afforded by mr imaging provides an opportunity to advance imaging evaluation of the penis in selected cases. in the clinical practice, erectile dysfunction is the most frequent penile abnormality which is investigated with doppler us. the clinical role of this evaluation, however, reduced after the introduction of oral medications for impotence. differentiation among different forms of erectile dysfunction is mainly based on evaluation of doppler waveform changes in the cavernosal arteries. peyronie's disease is the most frequent cause of penile induration. imaging is often required to evaluate the extension of the plaques, involvement of the penile septum, and relationship between the plaques and penile vasculature. in patients with penile traumas, imaging allows accurate evaluation of albugineal tears, extra-albugineal and cavernosal haematomas, vascular lesions producing high flow priapism and other pathological changes. compared with us, mr imaging has some advantages in identification of small albugineal tears, and is more accurate in identification of urethral or spongiosal involvement. other situations in which penile imaging can be required are circumscribed or diffuse cavernosal fibrosis, tumours, priapism, severe inflammation, and evaluation of postsurgical complications. most of these conditions are first investigated with us; mr imaging is optimal for tumour staging. endocrine tumours of the pancreas are derived form the apud cell system. they often show early clinical sign related to the hormones produced by these tumours. the usually very specific symptoms raise the suspicion of an endocrine tumour of the gastro-entero-pancreactic tract and initiate imaging studies for tumour detection. in this setting usually the pancreas is among the most frequent tumour sites. since endocrine active tumours of the pancreas usually show a strong vascularisation, they can be differentiated from other solid tumours of the pancreas -including adenocarcinoma of the pancreas. metastases in the pancreas are very rare -however, they represent a potential differential diagnosis either for non-functioning neuroendocrine tumours or for adenocarcinoma of the pancreas. since the evaluation of the whole pancreas is crucial, transabdominal ultrasound plays an only limited role for the detection of endocrine pancreatic tumours. usually mri and ct -alone or in combination with specific nuclear medicine tracers in pet -are needed for accurate diagnosis and staging of these tumours. published incidences and prevalence of oa. the progression of oa traditionally has been measured using radiographic joint space width (jsw). weight-bearing radiographs centered on the hip are the most reproducible and reliable ones. the sequence of degeneration includes the following radiographic findings: joint space narrowing, osteophyte formation, subchondral sclerosis, and cyst formation. current definitions of radiological oa based on reduced jsw and osteophytes display predictive validity for clinical hip oa. radiographs are also useful for assessing developmental dysplasia and other congenital disorders which may lead to early oa. there are cases though, that radiographs show minor changes and the clinical suspicion of early disease can be confirmed with more sophisticated imaging methods, such as ct and mri. ct is helpful for additional measurements such as femoral and acetabular abnormal version which might lead to oa. femoroacetabular impingement has been shown to cause labral and chondral lesions and leads to oa. prompt recognition of abnormal head-neck junction on radiographs enables proper conservative or surgical treatment planning. mr arthrography is the method of choice for assessing the labra whereas ct arthrography might be used as an alternative for articular cartilage assessment. cystic tumours of the pancreas include a variety of masses which can be classified into cystic tumours of the exocrine pancreas, cystic tumours of the endocrine pancreas, cystic tumour-like lesions of the exocrine pancreas. in order to simplify the approach only the relatively common cystic tumours -the intrapapillary mucinous tumours (ipmt), the serous cystoadenoma (sc) and the mucinous cystoadenoma (mc) -will be considered. ipmt are characterised by ductal dilatation. imaging characteristics of ipmt are best displayed at mr-cholangiopancreatography. on the basis of the extent, these tumours can be divided into ipmt of the main duct (or central), ipmt of the secondary ducts (or peripheral) and mixed ipmt. central and mixed ipmt have a malignant behaviour and therefore need to be treated surgically, while peripheral ipmt have a benign behaviour and, in general, need only follow-up. sc are characterised by a microcystic architecture in most cases. imaging features are typical in cases of microcystic appearance and consist of small amounts of fluids interspersed within multiple septae of a "sponge like" mass. the differential diagnosis with a mucinous cystoadenoma is difficult in cases with a oligo-macrocystic appearance. mc appears as a uni-oligolocular cystic mass, with a simil-ovaric stroma in the tail of the pancreas. imaging features include a cystic mass with a definite wall and inner septae. when calcifications and enhancing nodules are present, a mucinous cystoadenocarcinoma has to be suspected. therefore, a careful evaluation of imaging features of pancreatic cystic tumours is needed to differentiate benign form malignant masses. learning objectives: 1. to understand the classification and management of cystic pancreatic tumours using rad/path correlation. 2. to learn how to provide a differential diagnosis and how, when and why imaging techniques should be used. 3. to review pathological and imaging findings of intra-ductal cystic tumours. 4. to learn how to deal with the incidental pancreatic cyst. a s71 c b d e f g the evolving role of the radiologist p. brader; vienna/at (peter@brader.md) in the past two decades, enormous strides have been made in medical imaging and many new technologies and agents are now available for breast cancer research, clinical trials and patient care. advances in experimental and clinical breast imaging are likely to improve our knowledge of how breast cancer arises at the cellular level, which will help not only to identify and locate tumours but also to assess the activity of biological processes within these tumours. this recent and concomitant progress, in imaging in general, and in breast imaging in particular, has been facilitated by the convergence of molecular cell biology, pathology, chemistry, physics and engineering in a multimodality and multidisciplinary way. the challenge for radiology is to begin thinking at the molecular level. it is, therefore, important that the next generation of radiologists become more involved in multidisciplinary research and clinical work, and that younger radiologists receive special training in diagnostic imaging and nuclear medicine, as well as a solid understanding of physics, radiochemistry, pathology and biology. applying this approach to breast cancer patients should allow earlier detection, stratification of patients for treatment, and objective evaluation of new therapies. the outcome will be considerably better management and care of those with breast cancer. breast cancer is the leading cause of cancer death among women worldwide. imaging plays a key role in the early detection of breast cancer. mammography is an accepted screening modality with some limitations such as over-treatment. to overcome these limitations research is going on to characterise breast cancer more accurately. currently researchers are working on different strategies spanning the spectrum from tomography-based systems to mri and even molecular imaging. this panel discussion will focus on these different strategies. the auditorium will learn if in 2025 imaging still plays a major role in breast cancer detection or whether a simple blood test will eventually solve the problem. breast cancer is the leading cause of cancer death among women world wide. imaging plays a key role in the early detection of breast cancer. mammography is an accepted screening modality with some limitations such as over treatment. to overcome this limitations, research is going on to characterise breast cancer more accurately. currently researchers are working on different strategies spanning the spectrum from tomography-based systems to mri and even more molecular imaging. this panel discussion will focus on these different strategies. the auditorium will learn if in 2025 imaging still plays a major role in breast cancer detection or a simple blood test will eventually solve the problem. is mammography still an accepted modality for breast cancer imaging in 2025? m.j. yaffe; toronto, on/ca (martin.yaffe@sunnybrook.ca) x-ray mammography is currently the only imaging modality that when used in routine screening has been demonstrated to contribute to reduced mortality in women in the age range 40-74. but, the accuracy of mammography is limited with respect to both sensitivity and specificity. digital mammography has provided increased sensitivity in women with dense breasts and three-dimensional methods such as digital breast tomosynthesis or dedicated breast ct promise to yield further improvement. however, these techniques are dependent on detecting rather gross physical changes as masses, microcalcifications or architectural distortions develop and, therefore, their ultimate potential is limited. it is likely that before 2025, detection tools that are more specifically targeted to molecular characteristics or early functional changes associated with cancer will be clinically available. these may be either in the form of an imaging test, based on a specific biomarker for the cancer or possibly an innocuous test designed to sense a circulating biomarker in the blood or urine. in the latter case, a positive test would be followed by an imaging study to provide localisation for therapy. such tests could not only detect the presence of disease but would also provide prognostic information to guide the type and aggressiveness of therapy so that overtreatment could be avoided. promising imaging techniques based on targeted imaging with ultrasound, x-ray contrast agents, mr and radio-labelled agents are already under investigation. by exploiting new molecular or functional signals one of these is almost certain to replace mammography before 2025. can we assess cell density of tumours with imaging techniques? d.-m. koh; sutton/uk imaging is increasingly used to define endpoints of clinical trials in oncology. tumour cellular density may be inferred by diffusion-weighted mr imaging (dw-mri) and measurement of the t2 relaxation time. dw-mri is unique as the mechanism of contrast is based on differences in the mobility of water between tissues, which can be quantified by the apparent diffusion co-efficient (adc). tumours are frequently more cellular compared with their tissue of origin which impedes water diffusion, resulting in increased conspicuity on dw-mri and lower adc values. studies have shown negative correlations between histopathologically determined cell density and adc in several tumour types, including prostate cancer, soft tissue sarcomas and cerebral tumours. dw-mri is sensitive for tumour detection, especially for disseminated peritoneal disease, liver and bone metastases. whole body dw-mri with background suppression (dwibs) is an emerging technique that has shown substantial promising for staging of lung cancer, prostate cancer, lymphoma and multiple myeloma. effective treatment results in reduction in cell density due to cell lysis, apoptosis and necrosis, leading to a rise in adc value. adc increase has been observed within 30 days of anti-tumour treatment (including chemotherapy and radiotherapy); and as early as one to two weeks after treatment. quantitative adc measurements may also be prognostic as tumours with higher pre-treatment adc have been shown to respond poorer to chemotherapy and radiotherapy. nevertheless, a number of challenges still have to be overcome to qualify adc as a response and prognostic biomarkers in a multi-centre setting across different imaging platforms. angiogenesis is an essential process whereby tumours derive vascular supply from adjacent tissue, to sustain tumour growth and metastatic spread. newer targeted antiangiogenic therapies differ significantly from current cytotoxic therapies for cancer. the methods of dose selection are either invasive, such as biopsy and histology, or time consuming, such as tumour shrinkage and time to disease progression, both of which take months to assess and fraught with other limitations. moreover, cancer is a very variable disease, which means that some patients will respond to a particular therapy while others will not. there is, therefore, a great need to establish surrogate markers for drug response that are both rapid and reliable, not only for clinical trials of new drugs but also to aid in the selection of optimal treatment for individual patients. multiparametric imaging techniques provide a non-invasive insight into tumour cell density, vascularisation, and biochemistry. imaging data have the potential to provide information on disease profiling pertaining to diagnosis, prognosis, selection of therapy, monitoring of response to therapy, and pharmacokinetic information of drugs. undoubtedly, these methods hold great promise, but how can we standardise these techniques, in terms of acquisition parameters and image analysis (post-processing), and validate imaging parameters as biomarkers in multicenter international cancer trials. beginning with a review of the frequently used response evaluation criteria in solid tumours (recist), the development and optimisation of new imaging parameters as biomarkers of treatment response and optimised monitoring of tumour therapy in multicenter eortc clinical trials will be presented. dw-mri is sensitive for tumour detection; adc is affected by the different cellular density of a tumour. still, a number of challenges need to be overcome to qualify adc as a response and prognostic biomarker in a multicenter setting. the large variety in primary tumours and imaging methods, as well as the large variety and continual evolution of imaging equipment, point towards the need for a concerted design of imaging protocols in order to assure that these protocols are applicable to multicenter trials. furthermore, reliable evaluation of imaging data requires imagers experienced in the area of the definite cancer targeted in this trial and in the use of imaging tools for lesion quantification. from this session, a roadmap for future collaboration between eortc and esr combining different imaging modalities will emerge. session objectives: 1. to prove that advanced multiparametric imaging techniques play a crucial role in the diagnosis, staging, treatment monitoring and follow-up of oncological patients. 2. to explore avenues for future collaboration between eortc and ecr. 3. to suggest input of radiologists in the design and implementation of multicenter trials. the eortc imaging group: vision and strategy on cancer imaging s. stroobants; antwerp/be (sigrid.stroobants@ua.ac.be) response to cancer treatment is evaluated by subsequent assessments of target lesions and is defined as a significant decrease in measurable tumour dimensions (who, recist). the new targeted therapeutics which cause cytostasis rather than cytotoxicity have challenged volume-based response criteria and tumour regression is increasingly recognised as an unreliable end point. new imaging modalities looking at tumour biology, like positron emission tomography (pet) or diffusion weighted (dw) and dynamic contrast enhanced (dce) magnetic resonance imaging (mri) or increasingly used to identify subpopulation of patients most likely to respond. recently, new response criteria were introduced that incorporate fdg-pet (recist 1.1 for solid tumours and new cheson criteria for lymphomas). since imaging is becoming increasingly important in novel trial design, the eortc decided to invest in an imaging platform. eortc has established a medical imaging exchange infrastructure allowing to store imaging data linked to the clinical databases. a functional imaging expert group is set up to review protocols, organise central review and develop specific initiatives for imaging biomarker validation. eortc is part of the quicconcept consortium that within the eu innovative medicine initiative (imi) will try to validate the use of novel pet probes and dw-mri as biomarkers for apoptosis and proliferation. functional imaging techniques can only evolve successfully into biomarkers that are clinically valuable and important for drug development, when there is agreement on the standards for measurement and analysis and working groups are set up in collaboration with the different professional organisations (esr, eibir, eanm) to set up imaging guidelines. conditions such as ttts in twin pregnancies and foetal demise. the living foetus can also suffer from abnormal blood supply to the cns, and thus showing small or even large hemispheric infarcts. other diffusion technique, dti is also used to demonstrate the white matter formation of the foetal brain. mrs is also used in the evaluation of the foetal brain. the values of the naa, choline and the existence of lactate are different than the values in the paediatric and adult brain. learning objectives: 1. to explore the new imaging techniques for the study of the foetal brain. 2. to understand the use of diffusion-weighted imaging in the foetal brain. 3. to become familiar with the accurate use of t1-weighted sequences in the foetal brain. 4. to understand the possibilities of tractography in the fetal brain. the paediatric central nervous system is a complex structure undergoing rapid development. as such, there is a rapid, continuous modification of what is "normal" in relation with age and the stage of development. knowledge of the normal patterns of brain development in the clinically relevant ages from 0 to 18 years is necessary to interpret neuroimaging findings correctly. knowledge of embryology and normal variants is also greatly helpful. mr imaging equipment and parameters need to be adjusted and optimisation for paediatric studies. pitfalls often occur from the misunderstanding of normal conditions that are perceived as abnormal based on a comparison with the appearance of the normal brain in adults. this includes, for instance, the evaluation of the brain in the first 2-3 years of life during the course of the process of myelination. a summary of the most frequent conditions that may lead to misinterpretation of findings will be provided here. learning objectives: 1. to understand a different approach to neuroimaging in the developing paediatric brain and spine. 2. to appreciate that, despite the wide and potentially complex spectrum of diseases seen in neuropaediatrics, most interpretations can be made through the thoughtful application of basic neuroradiological analytical techniques. 3. to be aware of certain areas where common pitfalls, myths and misunderstandings occur. the ability to develop more aggressive treatments of acute neurological disorders in children is nowadays improving; however, infants and children are often uncooperative, clinical signs are not always easily localised, and diagnosis and therapy may be both delayed. effective imaging of the central nervous system assumes an increasingly important role in the evaluation of these critically ill children. this lecture will review the main indications to perform a neuroimaging procedure in children with a neurological emergency. with didactic purposes, acute conditions will be classified in traumatic and non-traumatic (ischaemic and haemorrhagic stroke, infection and acute metabolic disorders). differential diagnosis will be discussed based on representative cases selected from the daily routine in a paediatric tertiary hospital. the varied neurological complications that can occur in the child admitted at the intensive care unit will also be presented in a didactic manner, including pres (posterior reversible encephalopathy syndrome), acute liver failure, osmotic demyelination syndrome, hypoglycaemic encephalopathy or induced neurotoxicity. eventually, some peculiarities in oncologic and immunosupressed children, particularly opportunistic infections, will be highlighted. practical algorithms with the preferential use of either ct or mri will be developed for each section. ct continues being the primary modality for trauma, although it should be better used in cases of non-available mri in the other acute conditions to save radiation in children. mr imaging is nowadays better for imaging these children owing to the new techniques that can be used, such as diffusion imaging (di), spectroscopy, arterial spin labelling (asl) or susceptibility-weighted imaging (swi). learning objectives: 1. to learn the characteristic neuroimaging findings that may be useful in establishing differential diagnoses. 2. to understand the various neurological complications that can occur in the intensive care unit and to become familiar with their most typical imaging patterns. 3. to consolidate knowledge of the best neuroimaging protocols for the acutely ill child and establish the main indications for the use of mr imaging, particularly diffusion and spectroscopy. challenges for morphologic imaging in oncology trials: reproducibility and reading f.e. lecouvet; brussels/be (frederic.lecouvet@uclouvain.be) beside clinical endpoints and biological or molecular parameters, beside emerging perfusion or diffusion imaging techniques, morphologic imaging remains the cornerstone of the evaluation of treatment response in the majority of primary or metastatic tumours. the large variety in cancers and imaging methods, as well as the large variety and permanent evolution in imaging equipments, raises the need for a concerted design of imaging protocols to guarantee transposability of these protocols to multiple centers. the reliable evaluation of imaging studies obtained in trials requires readers experienced in the area of the definite cancer targeted in this trial, and in the use of imaging tools for lesion quantification. the imaging group of the eortc targets this optimisation of imaging protocols. first, the different "organ groups" of the eortc will benefit from the availability of expert radiologists in the different fields of oncology, involved in the choice and tuning of adequate and generalisable imaging tools from the beginning of trials design. the design of ct or mri studies should target acquisition parameters transposable in a large number of centers; there is no need for "cutting edge" protocols for a reliable assessment of response in a majority of cancer patients. second, the central review of imaging studies will be possible based on the involvement of expert radiologists, and on a robust imaging platform that guarantees availability, quality control, and "side by side" evaluation of baseline and follow-up examinations. principles and limits of response evaluation by morphologic imaging in oncology will be illustrated. a practical approach to hrct of the chest for diagnosis of diffuse lung diseases includes: recognition of the abnormalities, definition of their distribution within the secondary lobule or the lung, identification of associated findings. when combined with the patient clinical history, these 3 steps allow to shorten the list of differential diagnoses and may sometimes lead to a specific diagnosis. a reticular pattern consists of multiple lines as the result of interlobular septal thickening, intralobular lines or cystic walls of honeycombing. when present as a predominant abnormality, thickening of interlobular septa has a limited differential diagnosis which includes pulmonary oedema/haemorrhage, lymphangitic spread of cancer, sarcoidosis and alveolar proteinosis. honeycombing represents destroyed and fibrotic lung tissue containing numerous cystic airspaces with fibrous walls and is considered a ct feature of established pulmonary fibrosis. when honeycombing is present, uip is likely the histologic pattern and ipf is the most likely diagnosis, in the absence of a known disease. a nodular pattern consists of multiple rounded opacities 2-10 mm in size. the distribution of nodules is the most important factor in making an accurate diagnosis. a centrilobular predominance of nodules that typically spare pleural surfaces is a frequent sign of bronchiolitis and airway disease. a perilymphatic distribution is most frequently seen in patients with sarcoidosis, silicosis and lymphangitic spread of cancer. a random distribution with nodules diffusely and uniformly distributed can be the result of infection, haematogenous metastases and other rare diseases such as langerhans cell histiocytosis. the diffuse interstitial lung diseases (dilds) are a heterogeneous group of disorders which principally affect the lung parenchyma. basic hrct patterns are common to many disease processes and are usually non-specific. however, their distribution and their temporal evolution are often characteristic enough for diagnostic purposes. increased lung opacity: air-space consolidation, by definition, occurs when alveolar air is replaced by fluid, cells, or other material. on hrct, consolidation results in an increase in lung opacity associated with obscuration of underlying vessels. conversely, ground-glass opacity is defined as: "... hazy increased attenuation of lung with preservation of bronchial and vascular margins". the significance of ground-glass opacity depends on the clinical scenario. cysts and decreased lung opacity: a cyst appears as a round parenchymal lucency or low-attenuating area with a well-defined interface with normal lung. lung diseases characterised by cysts include langerhan´s cell histiocytosis, lymphangioleiomyomatosis, lip, postinfectious pneumatoceles, and amyloidosis. recently, lung cysts have been reported in association with extrinsic allergic alveolitis. honeycombing is a process characterised by the presence of cystic spaces.the determination of the presence or absence of honeycombing on hrct in patients with idiopathic interstitial pneumonia is of great importance. honeycombing may have an atypical distribution particularly in asbestosis, sarcoidosis, non-specific interstitial pneumonia (nsip), drug-related fibrosis and hypersensitivity pneumonitis. hrct is now an integral component of the clinical investigation of patients with suspected and established interstitial lung disease. a knowledge of the close relationship between histopathological changes and ct appearances. learning objectives: 1. to understand the different patterns on hrct scans of the chest. 2. to learn about a systematic approach to differential diagnosis of diffuse lung diseases. 3. to review key imaging findings. how do we report ct of the chest? 17:14 the radiology report is often the primary method of communicating imaging findings to the referring physician. practical guidelines on how to report ct scans of the chest for diffuse infiltrative lung diseases will be provided by the panel. emphasis will be placed on both report content and style in order to provide the clinician a tool for good patient care. with the advent of volumetric data acquisition and with increasing knowledge of patho-radiological correlations, hrct has further matured over the last decade and provides the radiologist with an excellent tool for accurately demonstrating gross lung anatomy and precisely analysing abnormal findings. the radiologic diagnosis of many pulmonary abnormalities is based on an assessment of their pattern and distribution. while the pathologist has the advantage of being able to evaluate specimens microscopically, the radiologist is confined to the assessment of more gross disease. however, the radiologist is able to examine the entire lung providing him with information about the distribution of disease and about additional diagnostic clues in mediastinum and pleura. both together, characterisation of the gross findings and knowledge of their distribution represent the key features for arriving at a confident diagnosis. session objectives: 1. to become familiar with the standardized and internationally accepted terminology for describing and analysing hrct findings. 2. to learn how a structured analysis of the predominant pattern and its distribution represent the key for making a specific diagnosis in the best case scenario or to understand how it helps to narrow the differential diagnosis. 3. to promote the understanding how the variability of manifestations of some diseases can cause an overlap of findings being responsible for difficulties the radiologist encounters when categorizing diffuse diseases of the lung parenchyma. a. most radiological reports consist of a ‚descriptive part' in which the radiologist describes the findings and a short ‚conclusion part' containing the interpretation of what is seen. both parts are filled with ‚jargon'. some terms are typical radiological ‚language' while others refer to terminology also used by clinicians and pathologists. some terms are purely descriptive but others may contain already some interpretation of what is seen and hence narrow the differential diagnosis. the meaning of a term may also change over time. it is very important that both radiologists and the readers of their reports speak the same language and know and understand the meaning and full content of each term. this is especially important when radiological findings in patients with diffuse lung diseases are described and interpreted. diagnosis of diffuse lung disease is indeed largely based on the recognition and description of the appearance pattern of the disease because this often allows developing an appropriate list of differential diagnosis. members of the fleischner society have introduced a glossary of terms for thoracic imaging. this presentation will emphasise on the importance of such a glossary for both describing and interpreting chest images. special attention will be given to the terms used to describe the different patterns in diffuse lung diseases: (1) reticular and short linear opacities, (2) nodular opacities, (3) increased lung opacity and (4) cysts and decreased lung opacity. a s75 c b d e f g h the purpose is to describe ethical dilemmas related to the use of radiation in finnish radiographer's work in diagnostic imaging. the data were collected during the spring and summer of 2008, and it consisted of thematic interviews of diagnostic radiographers (n=8) whose working experience varied from 4 to 31 years. the data were analysed by the method of data-oriented qualitative inductive content analysis. ethical dilemmas related to the use of radiation were found to concern justification and optimisation principles, which were found to be inadequately implemented by radiographers. the background factors of these dilemmas were found to be both dependent on and independent of the employee, resulting in worsened well-being at work and in seeking for change. the current processing methods of dilemmas were found to be insufficient, and suggestions for better processing methods were made. the results suggest that there may be shortcomings in radiographers' knowledge of radiation usage. attitudinal problems within the work community seem to maintain ethical shortcomings. instead of ethically inadequate routines and passing the baton to other professionals, radiographers should be encouraged in committing themselves into responsibility and safety culture. respondents repeatedly described powerlessness and inability to intervene in ethical problems. the common cold is one of the most frequent illnesses in europe and the united states. although most cold are mild and resolve within a short time period, colds cost billions of dollars per year, mostly due to lost time at work and school. the common cold is a group of symptoms caused by one of a large number of viruses. rhinoviruses cause the greatest number of colds; there are more than 100 different varieties of rhinovirus. the average adult experiences two to three colds per year, while children average 8-12 colds per year. in most cases, colds do not cause serious illness. most colds last for 3-7 days, although many people continue to have symptoms (coughing, sneezing and congestion) for up to 2 weeks. some viruses that cause the common cold can also depress the immune system or cause swelling in the lining of the nose or airways; this can lead to bacterial infection. one of the more common complications is sinusitis, which is usually caused by viruses and rarely (about 2% of the time) by bacteria. however, it can be difficult to distinguish bacterial sinusitis from sinusitis caused by a cold because the signs and symptoms can be similar. however, due to the fact that a runny nose can also result from inflammation, trauma, foreign body and other abnormal processes, including tumours, an excellent diagnostic workup is necessary. the purpose is to examine the relationship between man and technology within radiography without considering man and technology as separate entities. the study is designed as an observational study which took place in a danish radiological department. it involved 20 examinations followed up by three semi-structured interviews. through emergent narratives radiographers construct a practice in which the relationship between man and technology is marked by a struggle of domination of one over the other. the struggle expresses itself through two competing plots: a diagnostic plot with a prevailing, but not merely chronological structure mostly composed of events tied to pathology. the life story, in opposition, plots the examination as a significant experience in the patient's life, transforming it into events stretching towards a future yet unknown. most often the radiographers contributed to the domination of man over technology through active engagement of their narrative alertness. errors and failure to keep the time schedule can, however, lead the radiographers to a change of perspective that makes them displace man from the scene of radiography by playing on the premises of technology. in several stories technology can be labelled ‚setting' while the patient plays the main role. the radiographers act with the patient as point of origin, but they reason with technological arguments. hence, the human aspects of radiography constitutes an underground practice, which is not explicitly articulated valuable. this creates a field of tension between man and technology, with risk of technological dominance. the private life of everyone of us as well as the everyday practice of our profession is deeply embedded in ethical/deontological aspects which play a critical role into: our profession, the relationship with our patients, with our colleagues, with the health care team we work with, and with ourselves. the radiographer's everyday practice has to take this aspects into account. ethics finds its origins in the fusion of three different sources, as if it were a compromise between: the species we belong to, the society we live in, and ourselves. yet, we are not obliged to abide to these three elements. it is through our actions that we decide how to behave in certain situations. and this is the reason why every single action towards the others gathers importance, the simple rites when individuals meet play a pivotal role in the creation of a relationship with the others. shaking hands, greeting and using polite forms of speech, all these actions are ethically important, they allow us to catch the benevolence of our interlocutor and to discourage any possible hostility. what would happen if our professional identity were perceived and acknowledged through the way we can interact and relate to others? in this case, the work no longer ennobles the man, but it is the man, through his actions, who ennobles his profession. behaving ethically towards one's own profession, towards the others and towards ourselves, is it, or could this be the common ground of european professional ethics? whenever a diagnostic x-ray examination of a pregnant patient is considered to be necessary, conceptus dose estimation is an important step in assessing the risks to the unborn child. accurate estimation of conceptus dose is also needed after inadvertent irradiation of a pregnant patient from a diagnostic x-ray procedure. several methods have been developed to estimate conceptus dose from radiologic examinations. when the uterus is remote from the directly exposed tissues, the conceptus is exposed to scattered radiation and its dose is negligible (< 1 mgy). examinations involving the abdomen-pelvis may deliver higher dose to the child. variations in maternal body size and uterus position should be taken into account to obtain accurate conceptus dose estimation. multidetector ct (mdct) scanners have replaced conventional ct technology. conceptus doses from abdominal mdct range from about 13 to about 31 mgy during the first post-conception weeks for a scan acquired at 120 kvp, 200 mas with a pitch of 1.0, depending on maternal body size and uterine position. multi-phase abdominal ct examinations may deliver relatively high doses to the unborn child. doses to the conceptus below 100 mgy should not be considered a reason for termination of pregnancy. the risk to the embryo/foetus for stochastic effects is assessed on the basis of dose using appropriate risk factors. although these risks from a single diagnostic procedure are low for the majority of diagnostic x-ray examinations, it is important to ensure that doses are kept as low as reasonably achievable. learning objectives: 1. to learn how to manage and counsel pregnant patients in case of (a) intentional and (b) accidental exposure. 2. to learn how to estimate conceptus radiation dose from diagnostic x-ray examinations. 3. to learn how to assess the radiogenic risks to the embryo/foetus from diagnostic x-ray examinations. epithelial cells. the mucociliary transport drains each sinus in a specific pattern through its ostium to the nasal cavity and ensures a constant flow of mucus containing bacteria and particulate matter. functional endoscopic sinus surgery (fess) aims to enlarge the preformed ostia to allow physiologic drainage. preoperatively, anatomic variants have to be ruled out or shown by ct to avoid injury. special emphasis lies on the ostiomeatal unit, a complex anatomic region at crossroads of mucociliary drainage from frontal, anterior ethmoid and maxillary sinuses (uncinate process, haller, agger and frontoethmoidal cells, inverse turbinate). description of the level of the cribriforme plate in relation to the roof of the ethmoid is another key element in a report to avoid skull base injury (keros i-iii). preoperative identification of variations in the location of the optic nerve and the cavernous portion of the internal carotid artery is also mandatory. furthermore, the close proximity of the sinuses to neighbouring structures and their thin bony walls predispose to certain pathways of spread. runny and stuffy noses may be due to a long list of pathologic conditions, which require distinct imaging strategies and treatment options. acute rhinosinusitis, for example, is normally managed by gps without any imaging study. occasionally, signs and symptoms suggest orbital or intracranial complications: in such cases msct allows a prompt diagnosis and is preferred to mri for wider availability and faster acquisition. persistence of signs/symptoms for longer than 12 weeks classifies rhinosinusitis as chronic (crs); the condition may or may not be associated with the presence of nasal polyps. in patients affected by crs cross-sectional imaging aims at precisely depicting bone structures and air conduits. in detail, imaging shows the anatomic arrangement of sinus drainage pathways and their patency, maps anatomic variants that may facilitate crs or increase surgical risk, depicts bone changes induced by crs or by the mechanical pressure exerted by polyps. these tasks are better accomplished by ct, even more so after the advent of multislice technology allowed multiplanar reconstructions along oblique planes. after surgery, imaging is required when signs/symptoms recur -to asses presence and extension of crs or nasal polyps -or when late complications are suspected -such as mucosal synechiae impairing mucus drainage or mucocele. mri plays a limited role in sinusitis because it fails to demonstrate thin bone structures; nonetheless, its use is advocated in aggressive inflammatory diseases (such as invasive mycoses and wegener's granulomatosis) to demonstrate the involvement of deep spaces of the face and of the skull base. sinonasal tumours are rare and comprise only 1% of all malignancies. the clinical and radiological challenge is to differentiate malignancy from benign or inflammatory changes. most malignant tumours present at advanced stages. malignant tumours are most common in the 5 th -7 th decades and have a male preponderance. squamous cell carcinomas are the most prevalent (80%) followed by adenocarcinomas. squamous cell carcinomas are most common in the maxillary sinus, next the nasal cavity and ethmoid sinuses, while adenocarcinomas are most often seen in the ethmoid sinuses, and commonly caused by occupational exposures, e.g. nickel and hardwood workers. inverting papilloma is one of the most common benign tumours and have been associated with human papillomavirus. ct should be the first modality in paranasal sinus imaging, while complementary mri before and after gadolinium i.v. is mandatory to differentiate tumour from inflammatory disease. a general rule is that tumours more often have unilateral extension and that malignant tumours usually erode the bone. however, malignancy may mimic benign tumours with thickening or remodelling of the adjacent bone. while ct is superior to demonstrate changes in the bone, mri can differentiate tumour from inflammatory changes and demonstrate tumour invasion and perineural spread. malignant tumours are: squamous cell carcinoma, adenocarcinoma, adenoid a s77 c b d e f g h b. x-ray imaging and pregnancy: justification and optimisation of exposure p. vock; berne/ch (peter.vock@insel.ch) as outside pregnancy, justification and optimisation are the main steps to be done when an imaging examination using ionising radiation is considered during pregnancy. however, the risk concerns the embryo/foetus in addition to the mother which means that justification has to be more critical whenever the uterine dose is not neglectable. the practical approach to an examination in any woman of child-bearing age starts by ruling out pregnancy, whether by taking history or by a laboratory test. when pregnancy cannot be ruled out, further steps will depend on the type of examination needed and the urgency of diagnostic clarification. ultrasound is the alternative to be preferred when it can answer the clinical question. but even among x-ray examinations, the uterine dose is varying widely which asks for a careful selection, optimisation and, maybe, for postponing the test. once pregnancy is confirmed, the major question is whether the specific type of diagnostic examination will include the uterus in the primary radiation field. examinations not involving the uterus by direct radiation -despite a potentially significant exposure by scattered radiation -can usually be performed without a relevant risk to the embryo/ foetus. the situation is more critical when the uterus is within the examination field and when therapeutic interventions are considered. the presentation will discuss the practical approach to these different situations, the influence of the stage of pregnancy, optimisation methods and the choice between alternative methods in some frequent clinical situations. this paper explores the risks to the foetus when magnetic resonance imaging (mri) is used. mri uses three main components to produce images from inside the body: a static magnetic field; a pulsed radio-frequency (rf) fields and time-varying gradient electromagnetic fields. the exact frequencies of these fields depend on the mri system purchased, for example; a 0.5t scanner uses 21 mhz rf, a 1.5 t system uses 63 mhz and a 3 t system uses 127 mhz rf. there is also a wide range of options for gradient strengths and slew rates to be considered as well. the overall exposure for the foetus depends ultimately on the imaging sequence used and the area being scanned. this paper will discuss particular hazards that need to be addressed for pregnant women including biological effects of the static and time-varying magnetic fields, heating effects of the rf pulses and acoustic noise generated by the spatial encoding gradients. the circumstances for foetal exposure in mri will also be discussed including the following situations: the patient may not be aware that she is pregnant, likely to be in the first trimester; the mother is referred for direct foetal imaging after ultrasound (normally second or third trimester); the expectant mother may need diagnosis; research on pregnant volunteers. the exposure for pregnant staff working in mri is also an essential consideration. finally, how to minimise the exposure for the foetus during mr imaging will be discussed. a b c d e f g h in terms of cerebral perfusion (rcbf, rcbv, mtt and ttp) and cell metabolism (cytotoxic versus vasogenic oedema, diffusion restriction). the fundamental goals of stroke imaging in the acute phase are: 1. to rule out intracranial haemorrhage, and other non-stroke causes of the patient's symptoms; 2. to show occlusion of a major blood vessel, e.g. by ct or mr angiography; 3. to demonstrate ischaemic brain tissue (cytotoxic oedema), e.g. by diffusion-weighted mri; 4. to reveal tissue blood flow and to identify areas of salvageable brain tissue ("penumbra"), e.g. by perfusion ct or mri; 5. to select candidates for thrombolytic therapy within the critical 3 to 6 hour time window. the purpose of this presentation is to review how new developments in neuroimaging improve our understanding of the pathophysiology of acute stroke and to demonstrate that multiparametric techniques now play a crucial role in the rapid diagnosis, clinical management, therapy and outcome prediction of patients with an acute stroke. organisation is crucial to the practice of dethrombosis. the first step is to grasp the fact that ischaemic stroke is an emergency. stroke victims require an organisation similar to that provided for heart attack patients. patients must be taken to hospital in an ambulance manned by a specifically trained crew. ideally equipped with a mini ct scanner recently made available. this device provides an immediate morphological scan and ct angiogram to be sent by satellite to the reference hospital so that the problem will be clear and the medical team ready on the patient's arrival. clinical and neurological assessment of the patient must be undertaken immediately along the lines of uk practice implementing a simple, clear and rapid procedure. if the clinical, ct and ct angiography findings indicate intra-arterial treatment, responsibility shifts to the neuroradiology team, organised to work a 24 hour shift, at the hospital or at least on call. dedicated imaging systems must be available: a multi-layer ct device (ct angiography and perfusion studies). dedicated angiography suite is essential. a flat panel system would be ideal. there is growing evidence supporting the availability of an mr system. this device would certainly enhance the possibilities of a stroke unit but it is not essential in the initial stages. a stroke unit should be based on a dedicated facility, with emergency access separate from the general emergency room, dedicated equipment, dedicated ambulances and appropriate links including a dedicated ward and a rehabilitation unit essential to the success of the project. learning objectives: 1. to learn about the benefits and risks in stroke intervention. 2. to consolidate knowledge of different methods of intervention in stroke therapy. 3. to learn about the different imaging methods used to decide on and perform stroke intervention. where do we stand in stroke therapy today? 09:44 stroke is a common health problem with high socio-economic costs. in recent years much effort has been focused on finding ways to ensure early intervention as well as new methods not only for early detection but for early treatment. the discussion will focus on where we stand today and whether we think stroke imaging and treatment will advance further. during the last decade imaging of stroke has developed from a minor field dealing with a barely treatable disease to one of the most dynamic parts of neuroradiology. the routinely treatment with intra-venous thrombolysis within the 4.5 hour time window and the continuously expanding treatment of severe strokes with intra-arterial thrombectomy have lead to increasing requests from clinicians and interventional neuroradiologists to provide imaging information for treatment guidance. all radiologists involved in the management of stroke are facing mainly three demands: first, to have good knowledge of the causes and the pathophysiology of ischaemic stroke and a proper understanding of the current models for infarct development, as a prerequisite for rational decision making and efficient communication with the clinicians. second, to be able to choose and to use appropriate imaging modalities for the acute work up of patients with stroke and to be aware of the benefits and drawbacks of ct and mri. finally, is good knowledge about the therapy options mandatory in order to be able to support the clinicians in the time critical treatment decision. this session will try to cover these three demands in order to give an overview on the current status and the opportunity to discus future perspectives. a. aetiology and pathophysiology of stroke r. von kummer; dresden/de (ruediger.vonkummer@uniklinikum-dresden.de) "stroke" is the commonly used diagnosis for disturbances of brain blood supply due to ischaemia, haemorrhage, or venous obstruction. it is evident that "disturbances of blood supply" in stroke patients do not represent a useful concept in order to develop effective treatment. it is the radiologist's task to describe the acute brain pathology, its conditions (pathophysiology), and its aetiology to give directions for specific treatment and prophylaxis. the approach is vascular and brain tissue imaging. brain ischaemia is the cause of stroke in about 85% of patients, intracranial haemorrhage in 15% of patients. arterial obstruction causing brain ischaemia is thrombotic or embolic. it can as well be caused by arterial wall dissection or inflammation. arterial wall diseases and heart diseases including a patent foramen ovale are sources for brain embolism. the obstruction of a brain supplying artery causes brain tissue ischaemia of various degrees depending on the capacity of collaterals supplying the same arterial territory. the chances for collateral compensation depend on the site of obstruction and the development of collateral vessels. neurons cannot tolerate low cerebral blood flow (cbf) below 10 ml/100 g x min for more than 20 minutes and develop first cellular then irreversible ionic oedema. they survive, but do not function with low cbf between 10 and 20 ml/100 g x min. enhancement of cbf in such regions, e.g. by arterial recanalisation can mean functional recovery. the imaging diagnosis of damaged brain is therefore the first aim in acute ischaemic stroke patients. focal liver lesions are part of our everyday practice because radiologists performing various types of examinations may encounter them without being aware of any clinical condition rising the suspicion of these changes. in a situation like this several important decisions are to be made by the radiologists, like: is the lesion clinically significant, is the lesion benign or malignant, are additional imaging examinations necessary, does it require medical, surgical or interventional radiological action, should it be, and if yes, how frequently followed up, etc. for providing a well-established answer to these questions the reporting radiologist has to be familiar with medical history and results of former examinations (physical, laboratory, imaging, etc.); consider the age, gender, physical condition, eating and drinking habits, potential drug abuse of the patient; bearing in mind the prevalence and statistical probabilities of different pathologic conditions. with all this information at hand the thorough analysis of images obtained by different modalities will allow a rather reliable differential diagnosis and a well-established planning of therapy of the incidentally detected lesions. learning objectives: to learn more about the clinical conditions that may result in the appearance of focal liver lesions. 2. to be informed about the clinician's way of thinking in the process of differential diagnosis. the spectrum of differential diagnoses is broad in the liver. therefore, incidentally discovered liver lesions represent a challenging clinical situation. fortunately, there are specific imaging features for the most common benign and malignant liver lesions (such as, e.g. hemangioma, fnh, cysts, vascular pseudolesions, hcc and metastases) so that a minimal-invasive diagnosis with a biopsy is not needed in a lot of cases. in ultrasound, the echogenity and recently also the contrast agent behaviour are used for liver lesions characterisation. in ct, attenuation and also contrast agent behaviour are used for characterisation. mr imaging offers several options including t1-and t2-weighted images, use of chemical shift imaging, gre sequences with long echos and diffusion weighted images, so that tissue components such as fat, water, glycogen, iron, etc. can be evaluated already in the pre-contrast examination. beside the evaluation of dynamic signal characteristics in the early dynamic phase after contrast agent application, mr can utilize also tissue-specific contrast agents dedicated to the res or to the hepatocytes. other modalities such as angiography, pet or other nuclear medicine methods usually only play a minor role nowadays in the evaluation of incidental liver lesions in nononcological patients. in oncological patients the clinical consequences and also the range of diagnoses and pre-test probabilities are different from the non-oncological group; therefore, the demands to imaging are even higher. in case of atypical presentation of otherwise benign liver lesions such as sclerosed hemangioma close follow-up or even biopsy can be necessary in such a setting. thyroid nodules are common. in 4-8% of adults nodules can be palpated and at ultrasonographic examination nodules are seen in 10-41%. most nodules are benign, the eventual diagnosis in patients with a palpable nodule is carcinoma in only 5% of cases. the incidence of thyroid carcinoma is low. papillary carcinoma is the most common type and is found in 75-80% of thyroid cancer. lymph node metastases in thyroid carcinoma are primary to the paratracheal and prelaryngeal nodes (level vi), and the upper (level iii) and lower (level iv) jugular nodes. malignancy should be suspected when there is rapid growth, a firm or fixated mass, when enlarged lymph nodes are present or in case of vocal cord paralysis. in patients with multiple thyroid nodules the cancer risk per patient is not altered. ultrasound is the primary imaging technique in patients with a palpable thyroid nodule. it is best performed with the patient supine, the neck slightly extended and using a high frequency linear-array transducer. several ultrasonographic features are more often associated with benign or malignant nodules. however, while some ultrasonographic features may strongly suggest malignancy it may be very difficult to rule out malignancy by means of these features alone. ultrasound-guided fine needle biopsy can be performed in an attempt to differentiate between benign and malignant nodules. unfortunately, even with ultrasound guidance, an important number of cytological examinations will be non-diagnostic. in addition, in follicular lesions it is usually impossible to differentiate cytologically between benign and malignant follicular nodules. learning objectives: 1. to learn about the optimal settings for us examination of the thyroid. the neck is host to a large variety of benign and malignant diseases ranging from simple cysts to acute inflammation with complications to highly malignant sarcomas and imaging plays an important role to assess the nature and the extention of disease. patient history and clinical findings will decide which imaging technique is best suited to resolve the diagnostic dilemma. ultrasound is recommended to differentiate between a cystic or solid lesion, to guide fna, being quick and accurate. pathologic flow within or around a lesion can be assessed adding doppler technique. in acute illnesses with anticipated complications, such as a deep neck abscess, contrast-enhanced ct is required to evaluate local extention and demonstrate spread from the neck deep to the mediastinum. mri is indicated to assess non-inflammatory, subacute or chronic diseases, such as vascular malformations, branchial cleft cysts, benign and malignant soft tissue tumours, brachial plexus pathology and neurologic diseases. vascular malformations are easily depicted with mri using t2 sequences in different image planes. persistent fistulas of the branchial system can also be depicted by mri running from the anterior border of the sternocleidomastoid muscle to the lateral pharyngeal wall. assessing the origin of a soft tissue tumour has major implications for surgery. staging a malignant soft tissue tumour must comprise the skull base and upper mediastinum including local extention, pathologic neck nodes and perineural spread. follow-up during chemotherapy and postoperative monitoring of malignant disease are important indications for (mr) imaging, the more so in young patients, diminishing ionising radiation. learning objectives: 1. to identify different compartments in the neck. 2. to be able to choose the optimal imaging technique relating to request. 3. to become familiar with the most common pathology in adults and children. 4. to be able to address a short list of differential diagnoses. patients (92%) and by ultrasound in 95 patients (93%). the activity of the disease was assessed correctly in 91% patients by ultrasound, compared to 74% patients by enteroclysis. there was no statistically significant difference. bowel us is a useful investigation for the diagnosis and follow-up of patients with crohn´s disease. learning objectives: 1. to learn about us techniques used in the assessment of patients with inflammatory bowel disease. 2. to learn tips for interpretation of us in the diagnosis and follow-up of patients with inflammatory bowel disease. 3. to understand the pros and cons of using us, including ceus, in the diagnosis and follow-up of patients with inflammatory bowel disease, including assessment of disease activity. 4. to appreciate the accuracy, reproducibility and usefulness of us compared with other imaging techniques in assessing patients with inflammatory bowel disease. a-304 08:58 the use of computed tomography (ct) in the diagnostic imaging of patients affected by inflammatory bowel disease (ibd) has a long standing history. ct techniques such as ct-enteroclysis and ct-enterography have been reported as efficient tools for a radiological assessment of disease. the state-of-the art methods will be reported and their potentialities in diagnostic accuracy discussed in different clinical type of ibd. the acute setting of unknown ibd could be demanded as well to ct examination performed in emergency without endoluminal contrast medium administration. the ct appearance of the intestinal wall of the segments involved by an active disease could be not correctly interpreted if the knowledge of basic and classic typical findings of ibd is not combined to consider different pathologic entities that could affect the intestine, offering similar but not even equal signs. the entire abdominal background needs to be evaluated according to the clinical symptoms, signs, laboratory parameters and history of the patient. ct examination could be an efficient tool to determine the degree of disease activity in patient with known ibd as well as to assess the presence of an acute inflammatory disease of the intestine in patients with unknown ibd affection. the actual role of ct in the early diagnosis of ibd, in disease staging and detection of complications as well as monitoring therapy in follow-up will also be considered and discussed. learning objectives: 1. to learn about state-of-the-art ct techniques for the assessment of patients with inflammatory bowel disease. 2. to learn tips for interpretation in terms of diagnosis and differential diagnosis of inflammatory bowel disease. 3. to discuss the value of ct in determining disease activity and monitoring therapy. the aim of this lecture is to give an overview of the techniques and typical findings for imaging crohn's disease (cd) with either multidetector row computed tomography (mdct) or with magnetic resonance imaging (mri) and compare the two different modalities. optimal imaging of cd begins with the preparation phase. the small bowel has to be distended for a concise examination. this can be done either invasively, i.e. enteroclysis or orally, which is named enterography. there is much debate on which of these two preparation methods is better. for the administered intraluminal contrast, best is water with some additives, which are neutral in ct and biphasic in mr. imaging in mdct is done 40 sec and 70 sec after iv administration of iodinated contrast with a thin collimation. all image data are reconstructed in axial, coronal and sagittal planes. the aim of imaging in cd should be to establish the following: (1) presence, severity, and extent of the disease; (2) its activity; and 3) extra-intestinal complications. both modalities have proven to be a good tool to evaluate the extent, the activity of the disease and the presence of extraluminal complications. both are also able to identify the type of the disease, being either the active/inflammatory, the fistulising/perforating, the fibrostenosing or the reparative/regenerative type. the challenge for mri is mostly the in-plane resolution of the image data whereas radiation dose is for ct. incidental lesions are frequently discovered during routine radiographic evaluations. correlation with clinical history and additional confirmatory imaging is essential to the development of an accurate, focused differential diagnosis and for appropriate management. the objective of this presentation is to describe the imaging findings associated with incidentally found liver lesions and to review those clinical and radiologic features, which should be considered in development of an ordered and accurate differential diagnosis. learning objectives: 1. to introduce typical cases illustrating the role of imaging modalities in the differential diagnosis of unexpected liver lesion cases. 2. to motivate the audience by the use of voting pads to be involved in the diagnostic process. 3. to highlight the conclusion that may be drawn on the basis of the discussed cases. the diagnosis of ibd is based on complex evaluation of clinical signs, endoscopic appearance, radiological imaging, laboratory tests and histology. besides crohn's disease (cd) and ulcerative colitis (uc) the modern classification advises to use the term ibdu (ibd unclassified) colitis to those 10% of cases, where the distinction between cd and uc is impossible based on the results of multiple exams. these cases are usually clinically more severe, with humbler therapeutic results. the new classification of cd types includes besides the phenotype (b1: inflammatory non stenosing non penetrating, b2: stenosing, b3: penetrating) the age (a1: ≤16 y, a2: 17-40 y, a3: > 40 y) the location (l1: ileum, l2: colon, l3: ileocolic, l4: upper gi tract) and p perianal involvement. in uc the most important clinical factors are extent, type and severity. the classification includes length and clinical types as acute, relapse-remission and chronic continuum. the radiological imaging in cd is needed for lesions not reachable by the endoscope, for categorising, for follow-up and detecting complications. different modalities fit best for these different tasks. the goal of imaging in uc is rather to help differential diagnosis and detection of complications. while in uc there are good correlation between laboratory and endoscopic signs of activity and severity so there is not much need for radiological activity indices, in cd the clinical activity does not correlate with the histological changes. although cdai is widely used for clinical studies, it includes several subjective factors, thus radiological activity indices may be of help. crohn's disease is more likely a systemic disease governed by a shift in the immune response, thus affecting the whole malt system. bowel ultrasound is a quick, simple and effective investigation. the method is simple and requires no bowel preparation. we use both -convex (c 5-1 -overview, anatomical orientation) as well as linear transducer (l 12-5 -preferred, incl. ceus, l 17-5 -children and very slim patients, l 9-3 -tdps, deep structures). we examine patients in supine position, first small bowel, than mesentery and large bowel. finally, we examine the terminal ileum and cecum or the areas of anastomoses. we assess folds, hastrum, wall thickness, vascularity, echogenity of the surrounding fat, the presence of nodes and peristalsis. in some cases we use intravenous contrast (ceus). at least four studies have prospectively compared the diagnostic accuracy of us with radiological studies, endoscopy or surgery in those with suspected crohn's disease. in these studies, the sensitivity of us ranged between 84% and 90% and its specificity reached 98% and 100%. in our prospective study we investigated patients by ultrasound and enteroclysis. we established the diagnosis by enteroclysis in 94 the central venous vasculature and particularly the upper venous system may be obstructed by either benign or malignant lesions. malignant central venous obstructions are mainly due to bronchial carcinoma, mediastinal metastasis, mesothelioma or lymphoma. the most common cause for benign central venous obstruction is haemodialysis related; other benign reasons are rather uncommon but increasing due to the omnipresent use of permanent central venous access catheters as well as implantable cardiac rhythm management devices. the incidence of haemodialysis-related central venous obstruction resulting in angioplasty is described to be more than 10 times higher compared to, for example, pace-makerinduced stenosis. in any case, early detection and treatment of complications are essential to provide adequate care. contrast venography for many years has been the standard of reference; yet this procedure has its shortcomings. sonography is not consistently reliable for detection of central pathologies, owing to difficult access to these vessels. today contrast enhanced ct is employed to define the site of the obstruction and the presence of possible thrombosis and reveal surrounding soft tissue alterations. mri is of comparative or even higher sensitivity and specificity in evaluating the patency of the central veins. the efficacy and safety of stent placement in central venous occlusion of benign and malignant origin lead to rapid relief. stenting provides fast symptomatic help. repetitive percutaneous intervention can prolong the cumulative patency. thrombolysis may be required to improve the final result, should, however, not be employed as a sole means for revascularisation. us and mr are excellent imaging techniques for studying tendons and muscles. during this integrated session we will review the advantages and disadvantages of us and mr for the diagnosis and follow-up of sports injuries. tricks of both techniques will be addressed, together with some useful guidelines for specific sports injuries. ultrasound is being used at the pitch side and in sports medicine practice as an adjunct to clinical practice. with this in mind there are a number of questions that will be answered in these talks. 1. when us and mri are the primary imaging and when they are complimentary. 2. what advances have there been in us and mri imaging to help advance our use of these techniques in tendon and muscle injury. 3. should we be aspirating haematomas and using autologous blood injections or prp to treat tendon or muscle disease. 4. can we predict the athletes return to sport? a-310 08:35 muscle imaging is inherently complex and presents unique morphologic challenges and continuing integration of dynamic, physiologic and functional capabilities. in sports medicine, ultrasound (us) has proved to be an excellent tool to evaluate muscle strain and contusion injuries in athletes providing good correlation with clinical findings. in the acute phase, us has nearly equal sensitivity to mr imaging to diagnose muscle strains, except in the first few hours after the injury, when fresh haemorrhage and oedema have similar echogenicity to normal muscle and strains may go unnoticed. later in the process, us has been shown to be a useful tool in assessing the sequential stages of muscle repair, showing progressive resolution of blood fluid products, decrease in oedema and formation of scar tissue, thus aiding rehabilitation planning. dynamic us during muscle contraction can be valu-3. to compare the diagnostic accuracy of ct versus mri in crohn's disease. 4. to learn about a strategy for the use of ct and mri in the radiological workup of patients with inflammatory bowel disease. five good reasons for the radiologist to be at the forefront 09:44 the chairman and speakers will debate the optimum imaging paradigms according to (1) the clinical indication, (2) assessment of those with suspected but as-yetundiagnosed disease, (3) staging of the small bowel in those with newly diagnosed crohn disease, (4) evaluation of response to therapy and (5) assessment of those with long standing disease. the optimum approach to assessing and monitoring disease activity will be discussed. deep vein thrombosis (dvt) is a common condition which can lead to possible lifethreatening pulmonary embolism (pe). the primary imaging modality nowadays is duplex ultrasound. in cases where the pelvic veins and/or the vena cava is involved, a venous-phase ct is helpful to determine the exact extend of the clot burden. standard therapy for dvt is anticoagulation. however, if there is a contraindication or a complication (bleeding) to anticoagulation a vena cava filter is a good option to prevent pe. a filter should also be considered if a catheter directed thrombolysis is performed. with the new optional filters the filtration can be terminated either by removing the filter or by converting the filter into a stent. one problem which was observed with these optional filters is that (too) many of them are left in place. despite a low complication rate of filters, a filter may cause an increased risk of further dvt, or a caval occlusion and in rare cases even a migration or penetration is possible. therefore, patients with optional filters should be followed and filters should be retrieved when clinically no longer needed. varicose veins are an early manifestation of venous insufficiency of the lower limbs which can also lead to skin changes including extensive ulceration. it is a very common problem affecting up to 30% of adults in europe. patients presenting with venous insufficiency must first be assessed by a history and clinical examination to determine the presence and extent of the disease. a duplex ultrasound examination is essential to determine the cause from which an appropriate treatment plan can be decided. depending on the patients wishes and their funding options it is perfectly reasonable to treat all stages of the disease even if just cosmetic. treatment aims to eliminate the reflux in all contributing veins starting proximally and moving distally. surgery used to be the commonest treatment offered to patients but this has been largely superceded by endovenous methods which have significant advantages including: no general anaesthesia, outpatient based, no cuts, no scars, low recurrence, rapid convalesence. there are several endovenous methods using laser, rf, foam sclerotherapy and most recently steam heating and a combined mechanical/sclerosant system (clarivein (r)). laser and rf give almost identical results and 95% permanent truncal vein closure is to be expected. foam sclerotherapy is cheaper and quicker but long-term results are poorer and patients often have to return for repeat procedures. having ablated the main truncal veins using laser or rf at least 50% of patients require additional treatments for residual varicosities, e.g. microavulsions or foam sclerotherapy. adenocarcinoma is the most common pancreatic malignancy, affecting the head in 60-70%. mdct is very effective in detection and staging of adenocarcinoma, with a sensitivity of up to 90% for detection and accuracy of 80-90% for staging, but it has limitations (detection of small cancers, characterisation). mri is a problem-solving tool in equivocal ct to depict small cancers. mri with mrcp helps to differentiate between adenocarcinoma and focal pancreatitis. the "duct penetrating sign" at mrcp is indicative of an inflammatory mass. examination protocols for mdct include oral administration of 1-1.5 l of water ("hydro-ct"), iv contrast administration of 2 ml/kg b.w. (app. 140-150 ml), a flow rate of 4-5 ml/s, and a biphasic scan in parenchyma and venous phases. mri protocol should include non-fatsat and fat-sat t1w gre, t2w tse, dwi, mrcp, and contrast-enhanced sequences. gadoliniumenhanced t1w 3d-gre are helpful for assessment of vessel infiltration and cystic tumours, whereas mangafodipir-enhanced sequences improve delineation of small tumours. in patients with locally advanced tumours, neoadjuvant chemoradiation may be used for tumour downsizing to make it amenable to radical surgery. however, pancreatic cancer often does not shrink after tumour response, which renders mdct or mri unreliable for tumour assessment in this setting. pet/ct may play a role in this indication. in conclusion, ce hydro-mdct is an excellent and robust tool for pancreatic cancer detection and staging. mdct in combination with mri or eus provides high accuracy for characterisation of tumours. further improvement is needed to assess tumour response after neoadjuvant chemoradiation. ct is the established imaging technique for evaluation of pancreatic adenocarcinoma. mri, however, can play a major role in this disease. technical advances of mri including parallel imaging techniques, multichannel receive coils of the abdomen, dynamic gadolinium-enhanced t1-weighted fat sat 3d gre sequences, 3d mrcp sequences, mangafodipir-enhanced mri and diffusion weighted imaging (dwi) have greatly improved the results of mri in the assessment of pancreatic tumours. standard imaging sequences include t1-weighted gre with fat saturation, in-phase and opposed phased t1-weighted, axial single-shot turbo spin-echo (tse) and coronal/oblique 2d and/or 3d mr cholangio-pancreatography (mrcp) pulse sequences, post-gadolinium-enhanced 3d t1-weighted fat sat sequence and dwi with multiple b values. mr imaging may be useful as subsequent examination for: (1) detection of small non-contour-deforming tumours with isoattenuated appearance at ct, (2) evaluation of local extension and vascular encasement, (3) detection of the presence of lymph node and peritoneal metastases, and (4) detection and characterisation of associated liver lesions and liver metastases. diffusion-weighted imaging may be helpful as a complementary imaging method in the differentiation between mass-forming focal pancreatitis and pancreatic adenocarcinoma. due to its superior soft-tissue contrast compared with ct, mri ap-able to monitor the healing process. local complications, such as vein thrombosis, irritation of adjacent neurovascular bundles, chronic haematoma and myositic ossificans can be demonstrated with this technique as well. however, us tends to underestimate the extent of injury and the abnormalities seen disappear more quickly when compared with mr imaging. at least in elite athletes, mr imaging seems, therefore, to play a more significant role in management of muscle injury, particularly when decisions regarding the time at which the patient can return to play are needed. by contrast, us is more accessible, and cheaper than mr imaging. in most clinical settings, us should be regarded as the first-line imaging choice for assessing skeletal muscle injury. learning objectives: 1. to understand the mechanism of injury of muscles in athletes. sports activity can affect tendons due to chronic overuse or acute injury. both can result in complete tendon rupture. us is helpful in precise assessment of rupture severity and extend, but enables alsofor assessment of tendon degeneration, where rupture of individual collagen fibres stimulates a chronic cycle of reparative response caused due to repetitive microtrauma. in chronic tendinopathy histopathological changes, such as hypoxic, mucoid, calcifying, or lipoid degenerations are present. us enables for differentiation of partial tears, tendinosis, tenosynovitis or paratendinosis, because of active and passive dynamic examination possibilities, and high-resolution capability when using high frequency probes. us developments as power doppler us, sonoelastography and contrast enhanced us allow further for new insights into tendinopathy. with the use of us, tendon changes can be diagnosed before they become symptomatic and a reduction of tendon load and initiation of treatment before the condition becomes chronic seem to gain important place in therapeutic regimes. furthermore, us-guided therapies are advisable over blinded-guided injections to minimise side effects and to allow an accurate targeted therapeutic approach. although diagnosis of acute muscle injuries in athletes is usually clinical, magnetic resonance imaging (mri) is a very helpful adjunct tool in this setting, showing the location, extent and severity of the injury and thereby streamlining the management of the patient. portability of ultrasonography (us) on the playfield in the acute setting is not matched by mri, which nevertheless has distinct patterns of grade 1-3 muscle strains; however, it is usually with nonacute and deeper injuries of the muscles that mri is especially helpful. presence of bone contusion, stress reaction, or stress fracture is readily displayed by mri and this is practically beyond the limits of us. evolving haematomas, fibrosis, scarring, and myositis ossificans are sequelae of direct or indirect muscle injury which are usually outlined in a single field of view by mri. delayed onset muscle soreness and chronic exertional compartment syndrome, as well as acute and chronic stages of muscle denervation changes, are readily diagnosed with mri. by providing an understanding of distinct muscular denervation changes, mri may actually noninvasively point to the entrapped or involved nerve and guide medical or surgical intervention. foci of mucoid degeneration within the muscle, myotendinous junction, or tendon itself are readily shown by mri, which thereby displays potential sites of failure during sport activities. diffusion tensor imaging may have a role in displaying the subtle architectural disruptions of directly or indirectly injured muscles. learning objectives: 1. to understand the specific role of mri in the evaluation of muscle and tendon injuries in athletes. 2. to recognise imaging patterns of tendon abnormalities in athletes: acute and over-use injuries. 3. to review different mechanisms of muscle injuries: direct and indirect. 4. to understand how mri might be used in the management of athletes. when a defect occurs in the bowel wall, air will appear within the peritoneal cavity, most frequently due to perforated peptic ulcer and perforated sigmoid diverticulitis. in most perforating gastrointestinal conditions however, the -imminent-perforation is walled-off by neighbouring bowel loops, mesentery and especially by the omentum, nick-named "policeman of the belly". if this walling-off process occurs timely and effectively, no or only minimal free air will appear. the most important causes of walled-off gastrointestinal perforation are appendicitis, peptic ulcer disease, sigmoid diverticulitis, bowel malignancy, crohn disease and -often underdiagnosed-accidently ingested sharp foreign bodies, as toothpicks, fish bones, chicken bones, etc. the extent to which the perforation is walled-off, determines the eventual course of the disease. the us hallmark of -imminent-perforation is inflamed fat around the involved bowel structure. inflamed fat on us corresponds to what is often called "dirty fat" on ct scan: hypodense fat is interspersed with hyperdense streaks. this represents oedema or cellular infiltration of the fatty mesentery and omentum, which have migrated towards the site of the imminent perforation in an attempt to seal it off. on us inflamed fat is recognised as hyperechoic, non-compressible fatty tissue often interspersed with hypoechoic streaks. if fluid collections occur within the inflamed fat, this implies abscess formation. inflamed fat is an important and valuable sign in perforating gastrointestinal conditions. if found in the absence of bowel pathology, the diagnosis is usually epiploic appendagitis or omental infarction. mdct is an extremely powerful tool when the search for a gi perforation is required. the high spatial and contrast resolutions make mdct the most accurate imaging method to identify even small amount of free intraperitoneal air. there is general consensus about the acquisition of a contrast-enhanced scan acquired during the portal venous phase of enhancement (delay of around 60-70 sec). controversies are still present in the literature about the utility of a pre-contrast scan as well as the need for a preliminary administration of an oral soluble iodinated cm or for an enema or gaseous distention of the distal gi tract. image reviewing needs the use of a workstation because multiplanar reformations have been demonstrated to improve the detection of small amount of free air. an appropriate window setting is mandatory and it makes mdct 100% accurate for identification of free air and almost 90% accurate in the identification of the precise site of perforation. the aim of the examination is not only to assess the presence of free air but also to detect the site of perforation: this is an extremely useful clinical information especially if surgeons decide to perform a laparoscopic repair. several ct signs have been described, able to guide the diagnosis and to differentiate between a perforation originating in the upper gi tract (stomach and duodenum), in the small bowel or in the colon. evidence-based radiology' (ebr) is based on best current evidence, traditionally acquired radiological expertise, the alara principle and the values of referring doctors and patients. any appropriately trained radiologist can formulate an answerable question, search the literature, appraise the retrieved evidence, apply their findings to local practice and evaluate the results. this presentation will describe and illustrate the 'ebr' process. patients with chronic pancreatitis (cp) may present with features resembling pancreatic carcinoma, for which cp is a risk factor with an incidence of 5.9% after 20 yrs. ebr methods were applied to the problem of differentiating mass-forming cp from pancreatic adenocarcinoma. a focused question and literature search found no secondary literature or imaging guidelines. primary literature searching found 53 relevant papers, 9 comprised current best evidence. for ct, time-attenuation curve characteristics had a sensitivity of 94% and a specificity of 83% for carcinoma. for mr, dynamic time intensity curve characteristics were only reported in a descriptive study but the duct penetrating sign (mrcp) had a sensitivity of 85% and a specificity of 96%. for pet/ct, 18 f-fdg had a sensitivity for carcinoma between 86% and 96% with specificity of 87%-100%. for eus/fna, the sensitivity for carcinoma in pre-existing cp was consistently low (54-74%), but the specificity was 100%. simple bayesian analysis was used to establish the best order in which to apply these studies in practice. an algorithmic approach will be presented. the presentation will also consider other 'grey areas' in the field of pancreatic adenocarcinoma imaging using ebr methods. learning objectives: 1. to learn about evidence-based methods of literature searching and appraisal. 2. to understand how these methods can be used to produce diagnostic algorithms using the differentiation of pancreatic adenocarcinoma from mass-forming chronic pancreatitis as an example. 3. to learn about diagnostic algorithms based on different clinical scenarios (local and distant staging, advance versus early disease) involving multiple imaging techniques. 08:30 -10:00 room f1 the hole in the guts in recent years, continuing trends in radiology have diminished the importance of plain films of the abdomen significantly. ultrasonography and mdct are applied with enormous success to the investigation of many abdominal conditions in the emergency setting. in the eyes of the radiologist, plain films, therefore, seem irrelevant in the presence of such powerful imaging procedures. surprisingly, referring physicians, mostly surgeons, gastroenterologists and urologists, still request plain films although the potential of mdct is obvious to them as well. in their perception, the plain film is either a definitive examination before initiation of treatment (e.g. stone at the ureteropelvic junction in us proven hydronephrosis) or a preliminary study prior to mdct or surgery (exclusion of pneumoperitoneum or ileus). in the present climate of cost and radiation consciousness this trend may continue. moreover, many surgeons, gastroenterologists, urologists, etc. have greater skills in reading plain films than in understanding mdct. therefore, the radiologist should poration. all these techniques remain investigational at this time for the treatment of breast cancer. the limitations of and challenges associated with each ablation technique and the issues raised by early pilot studies, which have so far prevented these techniques from replacing standard surgical techniques, will be discussed. in the elderly the co-existence of several diseases, the prevalence of involutional and degenerative aspects, together with physical and cognitive problems represent 'the norm'. it is therefore important to know how to distinguish the healthy elderly from those in need of treatment to avoid overdiagnosis and overtreatment. so the question is how to be aware of the potential and limits of diagnostic imaging and its applications in geriatric patients. brain development occurs rapidly during the last trimester of pregnancy and continues at a rapid pace in the first two years of life. more subtle maturation, for example in the white mater, occurs well into the third decade of life, as evidenced by diffusion tensor imaging (dti). evidence of brain degeneration is occurring soon afterwards and includes mild brain volume los, reductions in white mater integrity on dti, widening of virchow-robin spaces and accumulation of incidental white matter lesions (wml). severe wml and incidental cerebral microbleeds (mbs) are associated with know cardiovascular risk factors and while the concurrent impact may be subtle in terms of cognition, they carry a poor prognosis in the long run. the same is true for silent cerebral infarcts, which increase the risk of dementia. neurodegenerative (general brain volume loss, ventricular dilatation and hippocampal atrophy) changes also occur well before the onset of clinical signs of dementia. in genetically predisposed subjects (e.g. apoe4 carriers) abnormal (compensatory) brain activity on functional mri and increased (compensatory) cerebral metabolism on fdg-pet have been observed that predict subsequent cognitive decline. more recently, pet studies employing amyloid tracers have shown abnormal binding in a significant proportion of cognitively elderly, suggesting that these subjects are at risk to develop alzheimer's disease -the pace of which is currently undetermined. the objective of percutaneous needle biopsy of the breast is to obtain an accurate preoperative diagnosis with a low upgrade rate post-surgery. indications arise in both symptomatic and screen-detected lesions. a range of biopsy needle designs are available and their selection depends on being aware of the range of needle design types, their advantages and limitations. cutting needles, guns, vacuum systems and mr compatible devices will be discussed. guidance technique for ultrasound, x-ray stereotaxis and mr-guided procedures is extremely important, beginning with patient positioning and anaesthesia prior to commencing the procedure. accurate needle placement under direct vision using high frequency ultrasound probes, x-ray stereotaxis with digital systems and mr guided -with the option of using a cad system for distance calculation -will be presented. typical imaging signs and potential pitfalls of each technique, both anatomical and technical, will be highlighted. methods to increase accuracy including the use of meticulous technique, adequate sampling and correlation of specimen pathology with imaging findings at multidisciplinary meetings are essential. there is always the possibility of a false negative biopsy results in any type of percutaneous image-guided needle biopsy (fnac, core biopsy, vacuum-assisted biopsy). the risk depends upon the quality of the harvested cytologic or histologic material. the quality is closely related to the amount of material collected and the accurate targeting of a lesion. some lesions are at a higher risk of underestimation (sizes < 5 mm, architectural distortions, microcalcifications, stellate lesions) than others (i.e. focal lesions). the false-negative rates for microcalfications using vacuum-assisted biopsy were reported to be 1.2%, for mass lesions 0.8%. using ultrasound-guided 14 g-core needle biopsy the false-negative rates were reported to be in the range of 2.5%. radiologic-histologic correlation plays a key role in the definite and correct judgement of the diagnostic result. in case of imaging-histologic discordance re-biopsy, possibly using larger needle diameters, or even open biopsy should be considered. the european guidelines for quality assurance of breast cancer screening and diagnosis define outcome parameter for breast biopsies. guidelines from the european society of breast imaging published in 2007 define the standards and skills necessary to perform these procedures. documentation standards should be used (b1-b5) to allow continuous yearly evaluation of the individual institution results and quality improvement. the aim of any needle biopsy is to get as much, i.e. representative material as possible. nevertheless, a certain amount of underestimation, caused by lesion type (adh, dcis, lin, papilloma, for example) will remain and has to be reflected. the presentation will discuss the role of large vessel arteritis within the spectrum of thoracic vascular diseases. it will detail the pathological entities and their morphological, functional, and clinical characteristics. it will present typical ct and mri findings and discuss key elements to the differential diagnosis. it will finally discuss the clinical relevance of this diseases, with a special emphasis on overall evolving importance of thoracic vascular disorders. severe haemoptysis can occur in about 5% of patients. it is associated with high mortality due to asphyxiation, if not treated, and needs urgent and comprehensive evaluation of the lung parenchyma, airways, and thoracic vasculature. multidetector row ct angiography is a very useful noninvasive imaging modality for initial assessment of haemoptysis in stable patients. it can accurately identify the source and the most common predisposing causes of haemoptysis (bronchiectasis, chronic bronchitis, lung malignancy, tuberculosis and fungal infection) and the effects of haemorrhage on the lungs and airways. moreover, the combined use of thin-section axial and complex reformatted images allows clear depiction of the origins and trajectories of abnormally dilated systemic arteries that may be responsible for the bleeding in over 90% of cases requiring intervention with arterial embolisation or surgery. nonbronchial arteries may also represent an important cause of haemoptysis. the road maps of dilated bronchial and nonbronchial arteries provided by ct angiography represent a useful guide for endovascular treatment. ct angiography is a quick and noninvasive tool that is helpful in the diagnosis and management of haemoptysis. disorders that affect the elderly population. some misleading radiological presentations typically occurring in this population will be also presented. in the elderly the coexistence of several diseases, the prevalence of involutional and degenerative aspects, together with physical and cognitive problems represent 'the norm'. it is therefore important to know how to distinguish the healthy elderly from those in need of treatment to avoid overdiagnosis and overtreatment. so the question is how to be aware of the potential and limits of diagnostic imaging and its applications in geriatric patients. fast development in the area of imagining modalities demands a lot of work in dose and image quality optimisation and management. deterministic harms have been reported both in interventional and diagnostic radiology. there are also some special groups (e.g. children) which need a lot of attention and especially tight indications for x-ray examinations. radiation dose and image quality optimisation can be applied with small steps in everyday clinical work as a part of self assessment, if the safety culture is agreed by all professionals. the vendors put the settings high in order to reach the best image quality. after installation the settings must be re-evaluated before starting clinical use of the equipment. also, the sensitivity of aec (automatic exposure control) must be turned according the detector. using the air gap (30 cm) instead of grid, e.g. in hip axio-lateral project or scoliosis, dose decrease can be even two thirds. the role of radiographer is expanding to new areas. quality assurance and dose and image optimisation could be parts of the expanded role. the new technical solutions in imaging offer a lot of possibilities for dose reduction, if we want, but there is also danger of dose creeping if the doses are not followed up frequently. the management and legislation offer the basics but the work must be done among those who are working in radiological departments. commitment to the safety culture on all levels in medical radiation offers better care and procedures with lower doses to the patients. radiological procedures are performed because of medical benefits to patients, but they also cause some harm because of the dose. if medical benefit overweighs detriment the procedure is justified. the purpose of the optimisation is then to adjust the procedure in a way to maximise the ratio of benefit over harm. question is who is responsible to do it and how it can be done. who should participate: we believe there is a major role of radiographer as she/he is present at each and every radiological procedure performed. but it is absolutely mandatory for them to understand benefits of the procedure and understand harm (dose). radiographer's position is the connection between radiologist, medical physicist and vendor's engineers. radiologists usually do not have in depth knowledge of technology and dose and physicists and engineers on the other hand do not understand in depth the medical aspects of procedure. radiographers must also understand operational possibilities of every x-ray machine. to get to know them they should be there at the acceptance of the x-ray machine and talk to service engineers and applicators. they should also talk to physicist when he/she is doing tests. and finally simulation of procedure(s) using different phantoms is the best way to understand how machine parameters are affecting image quality and dose. in presentation, some examples for different modalities will be given. learning objectives: to gain knowledge about how to start with optimisation of radiological procedures. 2. to understand the basics of quality control (qa) for radiographic modalities and how to use experience acquired from qa in daily work. 3. to become familiar with guidelines and applications for good radiological practice and how to implement them in the optimisation process. 4. to consolidate knowledge of technology of radiographic modalities and the use of materials in daily practice according to guidelines, and to be familiar with the radiographers responsibility in the field of radiation protection. the availability of magnetic resonance (mr) scanners operating at 7 t and above has already proved beneficial for mr imaging and spectroscopy of the human brain and promises similar benefits in the human body. these advantages result from the increases with the magnetic field of the intrinsic signal-to-noise ratio, blood oxygenation level dependent (bold) contrast, which forms the basis of the vast majority of functional mr imaging (mri) experiments, and chemical shift dispersion. these gains can be exploited in improving the spatial and/or temporal resolution of anatomical and functional mri experiments and in increasing the spectral resolution in volume selective spectroscopy or chemical shift imaging. operation at the increased magnetic field also offers easier access to t 2 * -contrast and improved implementation of susceptibility-weighted imaging (swi) in which the phase of gradient echo images provides information about local variation of magnetic susceptibility. in the brain, such variation appears to be dominated by differences in iron concentration and myelin content, so that high-field swi may provide useful information about the progression of neurodegenerative disease. the elevated t 1 relaxation times at 7 t also offer benefits for arterial spin labelling and time of flight angiography. current and potential future applications of high-field mri in clinical and pre-clinical studies in a number of areas and will be discussed in this presentation, along with the barriers to wider usage of 7 t systems for clinical studies. the purpose is to present and discuss the role of imaging in non-traumatic acute abdomen, with particular focus on ultrasound (us). the neonatal gi tract emergencies, associated with specific disorders and imaging strategies, are excluded. acute abdomen in children refers to a wide variety of conditions ranging from benign disorders, such as gastroenteritis, to threatening disease, such as midgut volvulus or intussusception. the recognition of a surgical emergency requires usually, after a competent clinical evaluation, an imaging investigation in order to avoid negative or unnecessary surgery. abdominal plain film is known as poorly sensitive in most situations, except bowel occlusion. ultrasound requires experience and a thorough examination but has demonstrated a high sensitivity and specificity for diagnosing bowel obstruction, midgut volvulus, intussusception, acute appendicitis, over the recent years the clinical mri field strengths have gradually been increased to 3 tesla; however, whole body mri systems with higher fields of up to 9.4 tesla have become available in experimental settings. compared to clinical field strengths, mri at very high magnetic fields has several advantages but also some unique challenges. with increasing field strength the signal-to-noise ratio increases, which can be used to either increase the spatial resolution in the images, or to acquire the images more rapidly. unfortunately, the energy deposited in the human body via the rf excitation scales quadratically with the field strength. thus, the specific absorption rate (sar) is a critical factor in all rapid imaging protocols, and requires the design of rf pulses with low sar, (e.g. verse pulses). inhomogeneities of the rf field which are induced by standing wave phenomena have to be compensated, and make the design of efficient spin echo pulse sequences very difficult. at higher field also the field inhomogeneities become larger and stronger imaging gradients are required to overcome the susceptibility-induced image distortion. stronger gradient systems are difficult to manufacture, and the usable gradient slew rate is limited by peripheral nerve stimulation thresholds. furthermore, stronger and faster gradients become very loud at high fields, and special measures for sound protection are required. despite these limitations, high-field mri offers image with very high resolution, it provides unique contrasts, a better spectral separation of the resonance lines and high signal for non-proton applications. clinical mri usually aims to depict anatomic regions of interest with uniform coverage and contrast behaviour. to this end it is essential to use suitably homogeneous radiofrequency (rf) magnetic fields for spin excitation, refocusing, and saturation. traditionally, such uniform transmit fields are generated by volume resonators based on quasi-stationary electrodynamics, which, however, gradually cease to apply as clinical mri explores high field strengths of 3 t and beyond. the concomitant increase in operating frequency entails shorter rf wavelength and increasing tissue interactions, which render the tailoring of rf fields substantially more complex and patient-dependent. one promising response to this challenge is to depart from volume resonators and perform rf transmission by multiple, individually fed transmitter elements. with such transmit arrays the effective rf field can be tailored on a per-patient and per-scan basis by adjusting the relative magnitude and phase of driving the elements (rf shimming). in advanced imple-08:30 -10:00 room z neural stem cells are in the process of finding their translation into the clinic. however, it is well-known that the cells by themselves do not regrow lost tissue. to this end, neural stem cells need further support and guidance. tissue engineering is using biomaterials to provide a structural support for cells, but can also incorporate the release of factors that guide the fate of transplanted cells. ideally, an in vivo imaging approach would encompass all these processes. we here demonstratethe use of a 19 f mri contrast agent to detect clinical-grade human neural stem cells non-invasively over 7 days within a tissue cavity formed by stroke. to provide structural support for these transplanted cells within the tissue cavity, cells were mixed with an engineered de-cellularisedextracellular matrix (ecm). using diffusion mri, we were able to detect the presence of the ecm within the stroke cavity. this approach hence provides a novel approach as to how we can study transplanted cells and tissue regeneration in vivo by mri. our lab has been among the first to exploit dendritic cell (dc) therapy to treat melanoma patients. over the past years, immunological responses are increasingly reported and clinical responses have consistently been observed. moreover, dc therapy often has much milder side effects than standard chemotherapy. a key hurdle in the development of the dc therapy is accurate delivery of the cells to lymph nodes (lns), or their successful migration from the site of injection to lns. in particular, tools for measuring cell migration in vivo are necessary. ideally, we would be able to quantify the number of dcs at the relevant site, with high resolution anatomical context to allow differentiation of lns and the possibility of longitudinal data acquisition. furthermore, functional data on the ensuing immune response is also required. towards these ends, we have been working on developing imaging techniques to study dcs in vivo, for example with scintigraphy on 111 in-labeled dcs, and magnetic resonance imaging (mri) on iron-labelled dcs. scintigraphy is quantitative, but it is restricted to the relatively short half-life of the radioisotope and is unable to resolve individual lns. mri allows high resolution anatomic localisation, but the use of contrast agents such as iron oxide is not quantitative. our recent work has focused on imaging the functionality of these dcs using positron emission tomography (pet) to study ln activation. finally, we have also developed in vitro assays that closely mimic in vivo dc migration in 3d scaffolds imaged using quantitative 19 f mri, as a substitute for in vivo optimization. we plan on applying 19 f mri to the tracking of dcs in vivo, as the technique allows both quantification and high-resolution anatomic detail. hypertrophic pyloric stenosis, etc. it enables some differential diagnosis such as infectious ileocolitis, ischaemic colitis, henoch schonlein purpura, complicated meckel diverticulum or duplication, etc. or even pyelonephritis. it can provide some findings suggesting mesenteric adenolymphitis, viral gastroenteritis, etc. the us findings will be described as well as the potentialities and limitations of us in each of these conditions. the accurate knowledge of the clinical findings together with the results of us will guide the need for another imaging modality: enhanced ct in case of suspected appendicitis with inconclusive us, upper gi series in an infant with bilious vomiting and impossibility to display the mesenteric vessels, etc. at last, some aspects of pancreatic and biliary tract emergencies will be shown. the purpose is to discuss the role of emergency imaging in acute paediatric gu conditions, with particular focus on the potential of ultrasound (us). besides gu tract trauma conditions such as urosepsis, renal failure, renal colics, ovarian or testicular torsion with all the respective relevant differential diagnoses have to be considered and urgently addressed adequately. particularly with respect to radiation protection (alara-principle) and due to the superb us potential in childhood, us is often used as the primary imaging tool. in many conditions us will reveal all treatment relevant information and no additional imaging is necessary in the acute setting. however, in other conditions such as severe (multiple) trauma ct remains the best primary imaging tool, however, only by using age-adapted ct protocols. the work-up and follow-up may also require imaging, usually achievable by us and partially by mri, scintigraphy and/or cystography. all these lead to imaging algorithms that differ from adults. the most important conditions, their imaging appearance, the potential pitfalls and some important methodical details will be presented, also discussing the recommended dedicated paediatric imaging algorithms. in most paediatric acute gu conditions us is adequate as the first and often sufficient imaging modality. rarely other imaging is necessary particularly in the acute setting -except for ct in severe (multiple) trauma. all imaging should be indicated with respect to therapeutic consequences and the alara principle, and proper paediatric protocols as well as methododical skills (e.g., dedicated paediatric us) should be provided 24 hours throughout the year. learning objectives: 1. to learn about the diagnostic imaging approach in acute urinary tract disease. computed tomography (ct) is the imaging method of choice in the evaluation of abdominal injury after blunt trauma in haemodynamically stable children. an unstable patient needs to be stabilised prior to ct or to proceed directly to surgery. evaluation with ct allows for accurate detection and quantification of injury to solid and hollow viscera, and can also identifies an active haemorrhage. ct can help prioritise optimal management by diagnosing the major or most life-threatening site of haemorrhage or injury. ct can also demonstrate associated bony injury to ribs, spine, and pelvis. a normal ct examination may prevent other unnecessary explorations. the decision for operative intervention in the small percentage of children who require surgical haemostasis is primary made based on clinical criteria and not on ct findings. interventional techniques deeply changed approach to treatment of diseases. in each country, interventional radiology practice establishment varies according to local factors, but following a standard strategy seems better to set up this facility. according to above-mentioned points, i decided to establish this specialty in our hospital since 1996 as the pioneer center in interventional radiology iran. at first the procedures included percutaneous laser disc decompensation (pldd), and vertebroplasty followed by vascular procedures such as uae in later years. now, we are performing all interventional procedures in our country including aortic stent and all neurointervention procedures. the following items will be discussed: 1. prepare step by step strategies for establishing intervention. 2. solving issues regarding interventions procedures. 3. modified techniques for lowering costs to cover interventions in poor people. 4. setting of fellowship courses. 5. co-operation with dedicated and pioneer international centers such as using neocrylate for treatment of brain aneurysms in conjunction with ucsd for the first time on human. when presenting our experience we want to review how we should start interventional radiology in developing countries. fibroids are the most common benign tumours of the uterus during female reproductive age. uterine artery embolisation (uae) is a procedure in which using embolic particles (pva, gelfoam, etc.) we block blood supply to uterine fibroids. it has been reported as a relatively safe, effective, and durable nonsurgical alternative method diminishing fibroid-related symptoms. uae is typically performed in both uterine arteries by an experienced interventional radiologist. after uae, reduction in menorrhagia has been reported as 80-93% and the mean decrease in fibroid size varies from 50% to 78% in the literature. complications including amenorrhoea are frequency ranging from 1% to 7% in the literature. uae may be followed by menopause in 1% of the cases. nevertheless, it is usually encountered in women in their late 40s. it seems that the future of uae depends on optimal selection of patients based on the prediction of volume-shrinkage, the outcome of fertility, and the long-term efficacy. although pregnancy is possible after embolisation, neither fertility preservation nor its improvement can be definitely guaranteed. women who desire to become pregnant should definitely be cautioned about potential complications during pregnancy. in this presentation we are going to review the position of uae in iran and to present our experience about the efficacy, and safety of uae. besides, we will discuss some methods of dose reduction during uae and the effects of uae on fertility and pregnancy outcome. purpose: labelling pancreatic islets (pi) with superparamagnetic markers enables their detection as hypointense spots on magnetic resonance (mr) images. we tracked pi transplanted into the liver and quantified their signal loss in liver tissue using mr imaging over a six-month period. methods and materials: pi were labelled with ferucarbotran 5 μl/ml for 6-44 hours and transplanted into the portal vein in 8 c-peptide negative recipients (12 infusions). the liver was examined prior to transplantation and subsequently 1 day and 1, 2, 4 and 24 weeks after transplantation using a 3 t mr scanner. results: in all recipients significant c-peptide levels and near-normal hba1c values were achieved with 50-80% insulin dose reduction. no side-effects related to the labelling procedure were documented. a significant decrease in the number of islet spots was detected at 1 week post-transplantation (on average 60%) with a subsequent only slight decrease for up to 24 weeks. in two subjects with a labelling period of less than 6 and 10 hours respectively only a few islet spots were detected corresponding to poor islet visualization in phantoms labelled for the same period of time. conclusion: pi visualization was successful in all recipients but was less efficient if the labelling period was less than 16 hours. a significant decrease in islet spots occurred at 1 week post-transplantation suggesting early islet destruction or impaired engraftment. then, the decrease in islet spot numbers slowed and islets were still detected at 24 weeks post-transplantation. data shows that mr detection of ferucarbotran-labelled islets correlates with sustained c-peptide production. areolar complex), the presence of other imaging findings (extension to the skin, inflammatory cancers) and the status of regional lymph nodes. this information influences the type of treatment given to the patient and it is very important to gather as much information as possible in order to obtain a one-step surgical excision with free margins at pathology. on the basis of this information and on discussions held in multidisciplinary meetings, markers will be placed wherever needed in order to locate the exact distribution of the tumour(s). the different parts of a structured report (clinical data relevant to the report, technical description of the diagnostic or the interventional modality, pitfalls during the exam, description of breast composition, description of lesions, categories and overall assessment) should always be included in order to guarantee that all the important information is there. breast imaging, like other subspecialties in radiology, is a multimodality area of knowledge where it is vital to integrate the information obtained through diagnostic and interventional procedures in order to supply the clinician with a body of data that is useful and straightforward. liver metastases are of the most difficult therapeutic challenges in oncologic managements. surgery is frequently impossible due to disease extent and systemic chemotherapy usually fails. in other body parts, the combination of radiotherapy and systemic chemotherapy is used for several types of malignancies. we successfully adopted a novel image-guided form of this combination for such masses referred to as radiochemoembolisation, which substantially intensifies the treatment locally. patients underwent transarterial radiochemoembolisation with chemotherapy protocol of mitomycin, doxorubicin, and cisplatin and embolisation with radioisotope particles of 32 p. the effectiveness of method was determined by comparing contrast-enhanced ct images, pre-and post-intervention. treatment response was evaluated using recist criteria. we also used some arbitrary criteria such as tumoural mean density and enhancement pattern. for stable and partial-response cases, the procedure was repeated. we did not repeat the treatment for progressive diseases. complete-response cases were only followed. after completing treatment sessions, regardless of the tumour source, considerable amount of patients showed substantial response. in terms of recist criteria, a significant portion of patients gained at least a "partial response". but the decrease in tumour density and the appearance of non-enhancing tissues were more promising. radiochemoembolisation is an effective method for the treatment of patients with unresectable hepatic metastases. although this study lacks a control group, it shows the effectiveness of the treatment. literature review showed the response to treatment with regard to recist criteria had been better in our study comparing with studies only used chemoembolisation or radioembolisation. , which showed the superiority of digital mammography for younger and perimenopausal women, as well as those with dense breasts; the national ct colonography trial (nctct), demonstrating the equivalence of ctc with colonoscopy; and the national lung screening trial (nlst) which has preliminarily reported a 20% decrease in lung cancer-specific mortality associated with annual ct screening. acrin's current focuses include the assessment of emerging imaging biomarkers for the prediction of and monitoring of response to treatment and the extension of its activities to disease processes beyond cancer. according to the second approach, termed as ‚dark lumen mrc', dense barium or tapped water is used to distend the colon in conjunction with post-gadolinium 3d gradient echo with fat-saturation sequences. the colonic wall and the corresponding polyps exhibit high signal intensity as a result of gadolinium uptake while the colonic lumen presents with low signal intensity. mr imaging of the pancreas and bile ducts relies upon a combination of t2-w and t1-w strategies in order to safely acquire anatomic, cross-sectional and functional information. tissue-imaging strategies include free breathing t2-w imaging (obtained with echo-train spin-echo sequences with or without fat saturation) and breath-hold 3d-gradient echo t1-w imaging (obtained with fat saturation) without gadolinium and in the capillary phase and in the interstitial phase post-gadolinium. this combination is valuable in the assessment of the full spectrum of pancreatic diseases and malignant bile duct obstruction. hardware improvements (gradients) and the advent of more sophisticated phased-array coils and parallel imaging capabilities in modern mr scanners allowed to increase the spatial and temporal resolution of "conventional" t2-w and t1-w sequences. furthermore, it provided the possibility of adding high-b-value diffusion weighted imaging (dwi) to our routine protocol in order to increase the sensitivity of mri in detecting malignant and inflammatory diseases. to obtain conventional mrcp imaging thick-slab heavily t2-w tse sequences or 3d heavily t2-w tse sequences may be used. advantages and limitations of both sequences will be underlined. functional bile duct imaging is obtained imaging modality or technique for this problem. increasing technological capabilities and knowledge of how to optimise ct/mr contrast utilisation provides better ways to characterise tumours than ever before such that key clinical specialties outside of radiology now recommend nonbiopsy imaging diagnosis of hcc to triage patient treatment. radiologists must work extra diligently to learn the clinical issues, triage points and implications that are associated with specific clinical presentations and imaging findings. the perfect test that does not require cognitive interpretation of the constellation of imaging findings with integration of the patient clinical presentation to optimise patient care is not in our near future. this lecture emphasises historical advances in liver imaging and how data in the literature impacted patient care decisions in ways that may be different than expected from radiologists. an emphasis on pathologic-imaging correlation will be used to put apparent disparate published results in proper perspective to allow radiologists to meaningfully interact with clinical colleagues in determining optimal patient treatment. liver mri is undertaken to assess the liver parenchyma, vasculature, and biliary system. it is necessary to use a variety of unenhanced and contrast-enhanced mr pulse sequences to achieve lesion detection and characterisation. a set of t1-, t2-w and dwi sequences is now standard for lesion delineation and assessment of liver fat and iron content. in-phase and opposed-phase t1-w gre images show focal or diffuse fatty infiltration and focal sparing. a fat-suppressed t2-w tse sequence is robust and provides high tumour contrast, with 3.0 t units now allowing acquisition of isotropic 3d-tse sequences. the quite popular t2-w half-fourier single-shot tse (e.g., haste) pulse sequences show anatomic detail (including bile ducts), but lack lesion contrast. in case of suspected iron overload (i.e., haemosiderosis and haemochromatosis) an additional t2*-w gre is recommended. acquisition of dwi patient transport into the radiology department, contact to other potentially infectious persons, and things such as breath-holding are reasonable burdens and dangers to immunocompromised patients. when searching the focus of fever, imaging should help to identify an affected organ system in order to eventually guide invasive procedures to identify underlying micro-organism or non-infectious disease. equally relevant is the exclusion of its involvement with a reasonable specificity. depending on local epidemiology, organ system, and the clinical signs and symptoms, suspected differential diagnosis can be derived from image patterns. some of these diagnoses might be exclusion diagnosis, others might require invasive procedures including time consuming and costly analysis to be verified. invasive procedures, however, require adequate hemostasis, which is usually not available for a substantial duration due to pancytopenia in patients who underwent chemotherapy. if imaging fails to derive the underlying disease confident and conclusively in a fast way, clinicians might need to treat on an empirical basis. empirical treatment plays a major role in immunocompromised or severely ill patients at risk, because mortality rises within hours of untreated disease. on the other hand, empiric treatment causes relevant toxicity and substantial costs, while imaging might become cost-effective. using contrast agents that are taken up by hepatocytes and excreted through the biliary system in combination with volumetric t1-w sequences. we use this technique in postoperative complications and to elucidate complex biliary anatomy. functional imaging of the pancreas is obtained by combining mrcp along with hormonal stimulation with secretin. in addition, secretin improves anatomic delineation and allows mri quantification of fluid production by the exocrine pancreas. despite the advance of cross-sectional techniques, the chest radiograph remains a basic tool for the initial approach to heart diseases. in this lecture we will present our current approach to evaluate cardiac pathology in conventional radiography illustrating it with selected cases. the basic approach consists of seven steps, evaluating the size and shape of the cardiac silhouette, cardiac calcifications, pulmonary circulation and lung changes, great vessels and implanted devices, all of them correlated with the clinical findings. looking at the heart on a chest film may be considered at a first glance as wasting time since, today, many other techniques are available today to offer an impressive luxury details of the morphological and functional evaluation of heart. nevertheless, the chest film remains often the first modality performed in many situations in which symptoms can be both from pulmonary or cardiac origin and then, careful analysis of heart may avoid rough mistakes in patient management. acquired and congenital pericardial or cardiac abnormalities may be responsible for a deformity of the cardiac silhouette and lead to explore the patient by a chest ct. ct with fast scanning capabilities can acquire images of the thorax with reduced cardiac motion artefacts, improving the evaluation of the heart in the course of a thoracic ct. unexpected findings of cardiac structures on both unenhanced and enhanced acquisition can dramatically influence the patient's clinical management. in many situations, a chest ct is performed without cardiac gating and it may be necessary to complement the initial examination by a gated acquisition to provide a more dedicated analysis. the normal appearance of cardiac structures and the most common cardiac abnormalities should be known by all the radiologists. various conditions such as idiopathic and acquired cardiomyopathy, ischaemic heart disease, valvular dysfunction can be identified even on non-gated scans. pulmonary diseases may also involve pericardium and cardiac structures and this should be clearly identified. learning objectives: 1. to learn how to detect and characterise cardiac abnormalities in the chest radiograph. 2. to learn how to detect and characterise cardiac abnormalities on chest ct. 3. to learn the limitations of the interpretation of cardiac abnormalities on ungated chest ct. 4. to learn when further evaluation is required. nal in discs and vertebrae to the adult shape and signal pattern will be reviewed. the normal pattern of unfused bony segments and apophyses in the child and fusion to the mature adult form will be reviewed. normal variants such as persistent segmentation/non-union leading to limbus vertebrae and dysraphism will be reviewed. intervertebral discs, vertebral body endplates, posterior elements and bone marrow show a wide degree of variation and the borderland of normal variant versus pathological abnormality is often difficult to navigate. common borderland findings such as schmorl's nodes versus scheuermann's disease will be discussed. transitional vertebrae as such are normal but incomplete transitional changes are associated with clinical symptoms. even without associated pathological changes the terminology of transitional vertebrae is a common pitfall. simple coping strategies will be reviewed. various imaging artefacts can have an influence on image interpretation though lumbar spine mr imaging is more resistant to these than imaging of the cervical and thoracic spine. this talk will review an approach to imaging complications of total hip replacements. the talk will briefly review surgical techniques and types of prostheses. the talk will subsequently review early and late complications of prostheses and focus on the integrated use of all modalities including radiographs, aspiration arthrography, scintigraphy and mri in achieving a diagnosis. there are many surgical techniques to repair meniscal tear, focal cartilage defect, cruciate ligament tear, malalignment, fracture, osteoarthrosis, etc. conventional radiography, ct-scan, ct-arthrography and mri play an important role in evaluation of the knee after surgery or arthroscopy. indications for postoperative imaging are infection, persistent pain and dysfunction. every radiologist should be familiar with "normal" imaging findings after arthroscopy, osteosynthesis, ligament reconstruction, osteotomy, knee prosthesis and meniscal or (osteo)chondral repair, but also recognise the main complications after knee surgery or arthroscopy. orthopaedic hardware is usually evaluated on plain radiography or ct, and only a relative contraindication for mri. microscopic metal artefacts and fibrotic scarring are frequently seen along the course of the instrumentation tract. after partial meniscectomy, an obtuse angle at the apex of the meniscus and increased signal intensity of the remnant part of the meniscus are normal findings, whereas fibrillation and recurrent tear may explain the complaints of the patient. various intra-and extra-articular reconstructive procedures exist for anterior and posterior cruciate ligament reconstruction. besides the neoligament, an osseous tunnel, screws and metal artefacts are also visible. postoperative findings of the extensor apparatus include a thickened patellar tendon, focal myxoid degeneration, fibrosis and focal defects, e.g. after harvesting tendon tissue for acl reconstruction or after release of the lateral patellar retinaculum for 'unstable' patella. accelerated osteoarthritis may be a late postoperative finding. mri very well depicts incorporation and alignment of osteochondral auto-or allografts, and the position, morphology and integrity of the meniscus after repair or transplantation. to evaluate postsurgical patients it is important to know the primary clinical diagnosis, the surgical treatment, the interval since surgery, and patients' current clinical symptoms. radiography is the most common imaging modality to evaluate the postoperative ankle, particularly in traumatic cases; after reduction and fixation of a fracture or dislocation it is generally carried out as routine. ultrasonography is highly sensitive and specific in postoperative tendon assessment, thanks to the superb resolution, and the opportunity for dynamic evaluation of tendon integrity. chest drains (28-30 fr) with underwater seals achieved decompression of pleural fluid collections. recent literature suggests small bore drains may be adequate, with image guidance playing an important role. pleural space anatomy, including fissural locations will be revised. aetiology of transudates, exudates and empyemas, along with typical clinical presenting features are outlined. various examples of plain film, ultrasound, multi-detector computed tomography and mri appearances of pleural collections and their aetiologies are presented. selection of patients, image guidance methods, catheter size, insertion technique, pitfalls and procedure complications are discussed. importance of physician-radiologist liaison with respect to catheter management and catheter dwell times is emphasised. pleural space fluid collections are common clinical entities that radiologists can accurately diagnose as well as successfully treat. overview of aetiology, radiological appearances and method of image-guided drainage of infected pleural fluid collections is provided. pelvic abscess drainage may employ more difficult access routes due to anatomic restrictions. the procedure may carry a higher risk of complications compared to simple abdominal drainage. to optimise patient preparation, correction of coagulation deficits, optimisation of antibiotic treatment, and sedation or anesthesia may be needed. the usual access routes for deep pelvic abscesses are the anterolateral and the posterior transgluteal approach. in selected cases, a transvaginal or transrectal approach may be the safer and more efficient option. depending on the viscosity of the drained fluid, the presence of necrotic solid tissue and gas, different sizes of drainage material may be needed. do not hesitate to employ large drainage catheters if indicated. an overview of the available material will be given. intestinal laceration is a major complication which can be managed percutaneously in selected circumstances. often, the weakest part of percutaneous drainage is the postinterventional management. it is advocated that the management is actively guided by the interventionalist who ensures that the drainage is properly handled, rinsed, and cleaned, that follow-up imaging is performed at the right intervals, and who is also responsible for indicating drain removal. chest ct and mri are commonly performed to evaluate patients with acute chest pain. a number of imaging techniques are available that may cover the entire chest, including the cardiovascular system. the radiologist will encounter more and more cardiovascular disease that was not visible with ungated ct and mri techniques. the differential diagnosis of acute chest pain may include over 30 possible diagnoses, a substantial number related to cardiovascular disease. it is important to recognise chronic and acute coronary disease, myocardial infarction and its complications, left ventricular function, pericardial disease, atrial disease and large vessel disease. case material will be presented and discussed using both ct and mri techniques to illustrate the spectrum of usual and more unusual cardiovascular pathology that should be considered in the differential diagnosis of unexplained chest pain. pulmonary hypertension (pht) remains a disease difficult to diagnose because the clinical findings are nonspecific, often leading to a delayed diagnosis. once recognised, it is necessary to determine the underlying cause and to estimate the severity of pulmonary hypertension. among the noninvasive methods of assessment of pht, ct angiography (cta) now plays an important role in the diagnosis and post-therapeutic management of pht. numerous recent technological advances of multidetector-row ct technology (mdct) have reinforced the clinical impact of this technology by introducing new tools for the morphological evaluation of small-sized pulmonary arteries and pulmonary capillaries, the latter being accessible with dual energy ct and often referred to as pulmonary "perfusion". the role of ct now also includes the possibility to investigate the presence of pht on the basis of functional parameters, such as the distensibility of the pulmonary arterial wall, and to integrate cardiac functional information, with great interest towards right ventricular function. the major clinical impact of these new scanning modes is that morphology and function can be obtained from the same data set, with no restriction on the diagnostic performance of high-resolution ct angiographic images. the purpose of this lecture is to review these new trends in imaging of pht and estimating right ventricular function through practical clinical situations, including the most common causes of pht. ct scans of the chest are usually performed and reported as if the lungs were the only organs in the thoracic cage. however, the heart and pulmonary arteries can show significant abnormalities either as associated findings of the parenchymal disease or as incidental findings. so the recommendation is: do not forget the heart and pulmonary vessels when reporting a ct scan of the chest. mri has rapidly become important in post-operative assessment of the ankle, because it provides high soft-tissue contrast, multiplanar capability and osseous structures visualisation. it shows signal changes of ligaments and tendons, hypointense subchondral sclerosis, subchondral bone marrow oedema, joint effusion, capsular thickening, fibrosis, and synovitis. mri has also an important role in the evaluation of post-surgery ankle pain due to impingement syndrome and in the hindfoot chronic instability related to postoperated sinus tarsi syndrome; it demonstrates the anatomy of sinus tarsi, chronic synovitis and nonspecific inflammatory changes, synovial cysts, fibrosis and subtalar joint effusion. it is important also in the follow-up of tumours and tumour-like conditions of bone and soft tissues after surgery. computed tomography is the most valuable method to define the osseous anatomy of the postoperative ankle, so it is important in the follow-up of the operated osteochondral lesions of the talus. ct allows the evaluation of irregularities or degenerative changes, and progressive degenerative arthritis; however, ct usually fails to evaluate soft tissue's ankle lesion. the development of subsecond mdct scanners with high temporal and spatial resolution has significantly reduced scanning times and now it is possible to have very good quality images of the heart during routine chest ct examinations. therefore, the importance of looking at the heart and pulmonary vessels on a ct scan performed for non-cardiac reasons will be emphasised. anatomic cardiac details that every radiologist should know will be discussed in the first talk; the presentation is aimed mainly at the non-cardiac radiologist. it will review normal cardiac anatomic details, as routinely encountered on modern multi-detector ct studies. it is now possible to delineate much of the intracardiac anatomy on a contrast enhanced study and significant pathology may also be evident on non-enhanced ct examinations. important incidental findings and their clinical relevance will be discussed in the second talk. unexpectedly, cardiac abnormalities may be diagnosed when lung disease is clinically suspected and vice versa; the focus of this presentation will be the comprehensive evaluation of lung and heart/large vessels diseases.the strong correlation existing between pressure in the pulmonary artery system and dilatation of the pulmonary trunk and central branches will be discussed in the last talk. ct is considered more useful than echocardiography because it can depict the cardiac structures in all patients including those with extensive parenchymal abnormalities. at the end of the presentations we should try to answer the question about the routine reporting of cardiovascular findings on ct scan of the chest. a. anatomic cardiac details that every radiologist should know s.p.g. padley; london/uk (s.padley@ic.ac.uk) this presentation is aimed at the non-cardiac radiologist. it will review normal cardiac anatomic detail, as routinely encountered on modern multi-detector ct studies. it is now possible to delineate much of the intracardiac anatomy on a contrast enhanced study, and significant pathology may also be evident on non-enhanced ct examinations. this study will primarily review normal cardiac anatomy, including cardiac chambers, valves and coronary vessels. the typical radiological appearances of innocent incidental intra-pericardial abnormalities will then be reviewed. important incidental pathology will be discussed in the next talk. liver fat, inflammation, and fibrosis are important pathological features in patients with diffuse liver disease. the clinical gold standard for assessing these features is liver biopsy. due to its invasiveness and sampling variability, however, liver biopsy is suboptimal for screening, monitoring, and clinical research. there is, therefore, a need to develop biomarkers to assess liver fat, inflammation, and fibrosis non-invasively. in recent years, many quantitative imaging techniques have been developed, refined, tested, and made available. the question becomes: are these techniques ready for routine clinical use or are they most appropriate for research? in this special focus question, we will begin with a brief overview of diffuse liver disease and discuss basic concepts of biomarker validation and qualification. dr. reeder then will discuss conventional and state-of-the-art imaging-based biomarkers of liver fat. dr. cobbold will discuss the current status of non-invasive biomarkers for liver inflammation. dr. van beers will discuss ultrasound-and mr-based biomarkers of liver fibrosis, with emphasis on techniques such as transient elastography and mr elastography that measure visco-elastic properties of liver tissue. we will conclude with a panel discussion asking the question: are the repeatability, reproducibility, and robustness of the non-invasive biomarkers presented in this session adequate for routine clinical implementation? session objectives: 1. to review the clinical importance of diffuse liver disease. 2. to understand that key features of diffuse liver disease include fat accumulation, inflammation, and fibrosis. 3. to understand the need for non-invasive biomarkers to assess fat, inflammation, and fibrosis. 4. to review basic concepts in biomarker validation and qualification. quantification of liver fat s.b. reeder; madison, wi/us (sreeder@wisc.edu) intracellular deposition of fat within hepatocytes (steatosis) is a common condition of the liver. fat is the histological hallmark of non-alcoholic fatty liver disease (nafld) but also may occur with alcohol abuse, viral hepatitis, hiv and genetic lipodystrophies, and chemotherapy. nafld alone afflicts an estimated 20-80 million in the us and is a rapidly growing condition in other western societies, paralleling the expanding epidemics of obesity and diabetes type ii. this talk will review the clinical, pathogenic and histological features of liver fat, including an overview of fatty liver disease and diseases where fat is an important disease feature. next, it will review the current use and limitations of non-targeted biopsy in diffuse liver disease, and why quantitative non-invasive biomarkers of liver fat and iron would be beneficial. currently available conventional magnetic resonance imaging techniques that attempt to detect and quantify liver fat will then be discussed, as well as known confounding factors that corrupt the ability of conventional methods to quantify fat. this lecture will then describe emerging quantitative imaging methods for accurate and precise quantification of liver fat, and the advantages offered by these methods address in comparison with conventional methods. finally, remaining challenges and unsolved problems for quantifying liver fat will be discussed. conventional mri techniques, such as t2w and gadolinium-enhanced t1w sequences, which are highly sensitive for detecting demyelinating plaques, are recognised as the most important paraclinical tool for diagnosing multiple sclerosis (ms). however, the changes seen on mri in patients with ms are not diseasespecific, as focal white matter t2 hyperintense lesions (thl) are also commonly observed not only in the elderly but also in middle age and young patients, and in a large list of different disorders such as hypoxic-ischaemic vasculopathies (atherosclerotic and hypertensive small vessel disease, cadasil, fabry's disease and susac's syndrome), cns vasculitis, sarcoidosis, adult forms of leucoencephalopathies, trauma and radio chemotherapy, and acquired metabolic conditions (hepatic encephalopathy, alcoholism), among others. while it is recognised that a combination of findings from clinical history, physical examination and laboratory tests is commonly required to correctly establish a firm and clear aetiological diagnosis of thls, a detailed analysis of different mri features should also be considered essential, e.g. lesions shape, size, and distribution; contrast-uptake; and associated structural lesions (microbleeds, infarcts, spinal cord, brainstem and cerebellar involvement, …). in addition to these conventional mri-based features, non-conventional mr techniques (diffusion, mrs and perfusion) may also provide in some cases useful diagnostic information. knowledge of these features will assist the diagnostic work-up of patients presenting with thls, and should be considered a first step to take full advantage of the potential of mri, and in doing so should result in a reduced chance of misdiagnoses and facilitate the correct diagnosis of sometimes treatable disorders. learning objectives: 1. to be aware of the limited specificity of brain multifocal t2 abnormalities. 2. to learn about recognition patterns that might be helpful in suggesting the most likely etiology of brain multifocal t2 lesions. 3 . to learn about the role of spinal cord imaging and advanced neuroimaging techniques for the differential diagnosis of brain t2 hyperintense lesions. 4. to be able to establish a neuroimaging diagnostic strategy in patients with multiple brain t2 lesions of unknown origin. breast imaging reporting and data system (bi-rads) was developed by american college of radiology in order to set standards for mammography reporting, common terminology and data collection. bi-rads is being used widely for over a decade and many studies have assessed the validity of the system. an important component of bi-rads is the lexicon which gives descriptors of specific imaging features that facilitate image interpretation and unify the reports. two main titles for these descriptors are about masses and calcifications. an asymmetry is called a mass when it is seen in two projections. a mass is defined with its shape, margin and density. definition of a mass with these three modifiers would help the radiologist to determine the type of the mass and probability of its malignancy. calcifications are divided into three categories by their shapes and another descriptor is defined for their distribution. the first category is for typically benign calcifications. the other two are for probably malign calcifications where biopsy should be suggested. the distribution modifiers for calcifications can also play an important role in assessing the probability of malignancy. bi-rads defines 7 assessment categories from 0 to 6 for the final report that facilitate data management for yearly audits. category 3 is the transition zone between malignant and benign lesions where the suspicion for malignancy should be less than 2% and requires short-term follow-up. bi-rads morphology and distribution descriptors are effective in assessing the risk of malignancy with a reasonable positive predictive value. the breast imaging reporting and data system (bi-rads ® ) for ultrasound (us) was developed by the american college of radiology (acr) and published in 2003. although this lexicon was created to achieve a consensus among radiologists when describing breast abnormalities, clinical practice shows substantial intraobserver agreement but only moderate interobserver agreement. most problems are reported for descriptors related to shape (when trying to classify abnormalities containing lobulations and/or elliptical with not-parallel orientation), echo pattern and margin. especially mass margin is a critical feature for determining whether a lesion should be biopsied or not. other problems are related to the final assessment, including difficulties in applying the subcategories and the relatively high percentage of false negative cases for lesions interpreted as category 3. many computer-aided diagnosis software have shown the potential to improve performance amongst less experienced readers and decrease interobserver variability; still they do not solve all the problems. the bi-rads ® lexicon is actually under advanced revision by an international panel and ellen b. mendelson chairs the us subcommittee. revision is reviewing both descriptors and categories; it will include also new parameters linked to the evolution of us technology as colour flow mapping and elastography. troubles. characterisation of aml is possible, based on identification of its fatty content mainly using ct. when microscopic, this component may be missed and biopsy is required with immunostaining. mr imaging may be helpful using chemicalshift sequences but thresholds, to rule-out clear cell carcinoma, have to be better defined. presence of necrosis or calcifications rules-out diagnosis of aml. amls must be treated if haemorrhagic, painful or if diameter exceeds 4cm. embolisation is the main nonsurgical method, using microparticles, alcohol and/or coils but postembolisation syndrome must be prevented. volume regression may require all agents whereas aneurysm occlusion requires coiling. the effect on volume and on haemorrhagic risk is substantial making surgery as an alternative method for nephron sparing purposes. secondary surgery is required in less than 10% of embolisation. rf ablation is also possible but its efficacy is still under evaluation. the number of small renal tumours is increasing due to the large amount of imaging examinations of the kidneys performed with various modalities and the true increasing incidence of renal cancer. conservative therapy of small renal tumours is now widely recognised as the reference technique for the treatment of these small lesions. the increasing rate of chronic renal failure in the elderly and the efficacy of conservative therapy to treat cancer as demonstrated by the urologists performing partial nephrectomy and tumourectomy emphasise the role of percutanaeous minimally invasive ablative procedures, particularly in patients with surgical contraindications. radiofrequency ablation and cryotherapy are the two most developed techniques, but new technical approaches are under development such as microwave ablation, electroporation, etc. the evaluation of the success of the procedure relies on imaging techniques showing the lack of enhancement within the lesion and the size and shape of the necrotic covering the entire tumour area. the techniques, indications, results, and complications of both radiofrequency ablation and cryotherapy will be discussed. a variety of diseases including neoplasms, but also infectious, inflammatory, vascular and traumatic processes, may present as focal intracranial mass lesions. modern neuroimaging, primarily with mri, enables differentiation of these entities allowing for accurate diagnosis in almost all cases. the requirements are appropriate image acquisition and detailed analysis of imaging findings, while pertinent clinical information may be very helpful in certain cases. the distinction is frequently broad, between different disease processes, such as with tumefactive demyelination versus neoplasm, which is often sufficient for clinical decision making and patient management; at times this may be more specific, approaching histological diagnosis, such as with pilocytic astrocytoma versus medulloblastoma. this presentation will go briefly over the imaging techniques and various disease processes, while heavily concentrating on the differentiating features of intraaxial primarily non-haemorrhagic mass lesions. the emphasis will be on the key distinguishing imaging features, such as presence or absence of mass effect or vasogenic oedema, signal intensity characteristics, presence and pattern of contrast enhancement, as well as diffusion and perfusion features. decision making process will be discussed. a number of cases with intracranial masses will then be reviewed and analysed, using a step by step approach, accentuating the most reliable distinguishing findings. the role of mr imaging in adult gliomas consists of many steps. (1) is there a lesion in the brain? (2) is the lesion a tumour? (3) is the tumour a glioma? (4) is it a high-or low-grade glioma? (5) if there is a suspicion and a biopsy is planned, which part of the tumour should be targeted at biopsy. (6) how the surgery should be performed to avoid injury to functional areas of the brain (e.g. motor cortex). (7) if there is need for adjunctive radiotherapy, how the extent of the tumour should be defined? (8) after radiotherapy, if a new enhancing lesion occurs, is it a recurrent neoplasm or radiation necrosis? conventional anatomical mr imaging is not always powerful enough to answer these questions. however, with advanced mr imaging techniques such as diffusion mr (including tractography), perfusion mr, mr spectroscopy and functional mri (fmri) we can answer the above questions reliably in most cases. the purpose is to gain numerical information of accuracy in the treatment of localised prostate cancer and calculate the necessary size of the safety margin around the clinical target volume (ctv-ptv). in addition, the purpose was to evaluate the accuracy in treatment set up with patients with high bmi to find out whether patients with high bmi need a larger safety margin. portal imaging was used to measure off-line random set-up error from bony structure. the sample size was 40, i.e. all the patients who received radiation treatment for localised prostate cancer in landspítali -university hospital (lsh) 2006. a total of 3032 portal images were acquired. in 2010, the task was repeated for 38 patients having gold fiducial markers in the prostate. the calculated 3-d imrt safety margins in lsh 2006 was to be 15.8 mm. correlation is with high bmi and set-up errors in medio lateralis (m-l) direction (r=0.21). this indicates that a patient with an increased pelvic circumference has a tendency to have more set-up errors. reformed procedural workflow resulted in more acceptable calculated margins in 2010. when corrected on line 3 times per week the margin is to be 7.2 mm and 3.0 mm if corrected 5 times per week. in conclusion, for delivery of 76-78 gy to the prostate with imrt and spare surrounding healthy tissue effort is needed to secure the accuracy in the overall procedure of treatment planning and delivery. learning objectives: 1. to gain knowledge on how to improve the target accuracy in treating prostate cancer with radiation therapy using electronic portal imaging. 2. to understand the importance of gaining numerical information of accuracy in the treatment of clinically localised prostate cancer and how to use the information to calculate the necessary size of the safety margin around the clinical target volume. 3. to become familiar with the preparation needed before starting treatment with imrt and be aware that there is a need to look at all the treatment elements including the technical side, quality, education, staff and patients. 4. to consolidate knowledge of radiation therapy for prostate cancer and the meaning of giving high dose to the target while minimising radiation dose to healthy tissue. b. image-guided radiation therapy: when imaging meets therapy a. sarchosoglou; athens/gr (anastasia71@hotmail.com) the aim of this presentation is: to understand the necessity of imaging in the delivery of external radiotherapy; to be familiar with the technology of image-guided radiation therapy and to to gain knowledge about the implementation of 3d igrt. the aim of radiotherapy is to deliver high dose to target volume while minimising the dose to surrounding healthy tissues. however, during treatment delivery many uncertainties may arise that can result in higher toxicity and poor local control. thus, it is crucial to monitor and adjust if necessary, the actual treatment. image-guided radiation therapy is the process where images are taken immediately prior or during a course of radiation treatment, to assess and improve the accuracy of therapy. manufactures have developed a number of systems to perform igrt providing the options of ionising radiation images/non-ionising imaging technology and gantry mounted/room mounted equipment. 3d igrt can be performed by acquiring computed tomography images on the treatment unit. these images are matched with reference images from planning ct and potential discrepancies are recognised, calculated and corrected by couch shifts giving optimal results. such advanced technologies require quality assurance systems to be in place and high trained personnel. when properly implemented, igrt meets the aim of radiation therapy. imaging provides confidence to radiation therapy to be aggressive, to fight cancer. imaging promises radiation therapy a great future with improvements in clinical outcomes and patient survival! multicentre trials have shown that ct colonography is ready for widespread clinical use. however, these studies have also highlighted the inconsistent performances of ct colonography, with divergent results being recorded in different centres and between readers. inter-observer and inter-centre variability may be related to reader experience but it is also affected by how ct colonography is performed. while faecal tagging has been accepted universally as the proper way to prepare patients for ct colonography, there is no consensus on which tagging agent is better, on the timing of contrast agent administration and on whether laxatives should be administered and in what dosage. in a similar way it is not yet clear which is the best way to obtain colon distension, whether by administering spasmolytic agents routinely or by changing patient's decubitus. standardising bowel preparation and technique is one of the most important goals that need to be achieved for ct colonography to be universally accepted and this presentation will attempt to deal with the issue using an evidence-based approach. the evaluation of ct colonography (ctc) studies is based on detection, interpretation and reporting of colonic findings. it is performed on a computer workstation equipped with dedicated ctc software by a primary 2d or a primary 3d approach. in either case, the alternative viewing technique must be available for rapid correlation and characterisation of suspicious findings. primary 2d evaluation is based on "lumen tracking" by interactively scrolling through the axial slices and multiplanar reformatted images, focusing only on the air-distended colonic lumen from one end to the other one. primary 2d evaluation provides information about the attenuation of findings during the search process and is time-efficient. primary 3d evaluation is based on 3d virtual endoscopy in an antegrade and retrograde fashion and increases both, the conspicuity, especially of small and medium-sized polyps, and the duration of visualisation. the use of advanced 3d displays like virtual dissection or unfolding techniques may reduce the interpretation time for primary 3d evaluation. computer-aided detection (cad) algorithms used as a 2 nd reader were shown to reduce the number of perceptual errors by pointing out possible abnormalities that might otherwise be missed. colonic findings are characterised by their morphology, their attenuation characteristics, and by their mobility. knowledge of ctc imaging features of common colonic lesions and artefacts is necessary for characterisation of findings and differentiation between definite colonic lesions and pseudo-lesions. standardisation of ctc reporting facilitates classification and communication of findings and the comparison with previous studies, thereby better assisting physicians in making appropriate management decisions. the revolutionary development in multidetector ct (mdct) technology during the past decade has contributed to a substantial increase in its diagnostic applications and accuracy in children. a major drawback of mdct is the use of ionising radiation with the risks of radiation-induced side effects, of which the induction of secondary cancer is the most important. therefore, justification and optimisation of paediatric mdct is of great importance in order to reduce these risks as much as possible (‚as low as reasonably achievable' principle). optimisation of paediatric mdct starts with a solid understanding of all technical aspects of ct, including the most relevant scan parameters, dose reduction techniques and technique of iv contrast material administration. furthermore, due to the smaller size and lack of visceral fat in young children the interaction and absorption of radiation will be different which will influence the choice of the various technique and scan parameters. although all these issues are pivotal for a successful ct examination, it may become worthless if the importance of pre-scan issues such as justification and patient preparation are ignored. after a short overview concerning the current knowledge on radiationrelated risks in children, this lecture will focus on several aspects relevant for mdct optimisation in children. issues such as justification, patient preparation, technique and scan parameters will be addressed. finally, some guidelines for radiation dose level-based ct protocols will be given. the purpose is to present an overview of the safety hazards and safety protocols related to infants undergoing mri examinations. mri infrastructure-dependent safety hazards originating from: (a) static and fringe magnetic fields, (b) gradient subsystems, (c) radiofrequency subsystems and (d) acoustic noise sound pressure will be reviewed and discussed. safety hazards related to upcoming technological issues and future trends concerning mri will be presented. the current status of the organisations responsible to the problems of mr safety will be reviewed. which authority is responsible and where the responsibility is addressed to (directives, legislation policies, etc). an optimised protocol related to a variety of clinical mr sequences in reference to temperature measurements, emf measurements, sar and acoustic noise figures using basic commercially available infrastructure will be presented. 2d/3d tse sequences with different etl's, 2d/3d gre, 2d/3d ssfp and se/gre epi sequences with multi-(b) diffusion gradients and 3d tof mr angiography sequences will be examined. in vitro measurements of snr, spatial resolution and scan times will be performed for each clinical mr sequence. a comprehensive mri equipment operational policy (optima: (etl, tr, te, b-value, epi factor etc).) for a safety protocol for infants undergoing mri is proposed. recommendations for safe infant mri examinations will be summarised and presented. conclusion: mri equipment can operate safely for infant imaging but require policies and procedures beyond those required for standard diagnostic mri examinations. learning objectives: 1. to get an overview of the three basic safety hazards related to infants undergoing mri examinations. 2. to become familiar with safety hazards related to upcoming technological issues and future trends. 3. to learn about a safety protocol that could be applied in mri examinations for infants. a s105 c b d e f g h perfusion imaging. new possibilities arise in mri almost every day. imaging algorithms are to provide the correct diagnosis in the shortest time with the lowest expenses and harm to the patient. mri is the first method of choice in neurological diseases with two exceptions: acute stroke and acute trauma, ct providing the necessary information, more available and with easier patient care. adequate imaging protocols optimally visualise the anatomical region of interest and pathological processes, optimise the comparison between serial examinations and provide the information in reasonable examination time. appropriate and well understood clinical information is indispensable (neuroradiology means good clinical knowledge combined with expertise in imaging methods and their evaluation). complicated protocols are superfluous without competent clinical background but adequate information must be provided to experienced clinicians. basic protocols help to gather important information but do not exclude additional necessary methods. examples to be demonstrated are mri protocol for the pituitary, epilepsy, multiple sclerosis and spine. the up-to-date concepts of image evaluation and interpretation will be demonstrated for brain ct, brain mri and spinal mri, including the importance of follow-up. the body and conclusion part of the structured neuroradiological report will be discussed. consultation with other neuroradiologists and with clinicians is the final tool to reach the goal: to help in recovering the patients' health. ten authentic and original typical clinical cases illustrating the importance of imaging modalities in the differential diagnosis of focal neurological symptoms from headache to epilepsy will be presented while respecting the privacy of the patient. the spectrum of pathologies includes vascular, inflammation, metabolic, degenerative diseases, congenital malformations and neoplasms of the central nervous system. each case story will be described shortly in a standard form followed by demonstration of typical ct and/or mri images. in some cases, conventional mri will be supplemented by multi-voxel mr spectroscopy, dti, mr tractography images, and morphological pictures. follow-up images will be presented where appropriate. several diagnostic options will be offered for attendants. the audience will be asked to participate in the diagnostic process by the use of voting pads. after highlighting of final diagnosis the basic differential diagnostic considerations will be briefly summarised and emphasised from the clinical and imaging point of view for each presented case. learning objectives: 1. to introduce typical cases illustrating the role of imaging modalities in the differential diagnosis of focal neurological symptoms. 2. to motivate the audience by the use of voting pads to be involved in the diagnostic process. 3. to highlight the conclusion that may be drawn on the basis of the discussed cases. diagnostic quality mri of soft tissue masses can be performed using a variety of magnetic equipments and a variety of field strengths. regardless of system design, efforts should be made to maximise signal-to-noise ratios (snr) using the most appropriate coil to include the lesion and associated oedema. fov should be tailored to the size of the patient and the size of the mass. it is important to obtain images in at least two planes through the lesion. slice thickness vary depending on the size of the lesion and interslice should be not more than one-half of the slice width. imaging matrix should be balanced to in-plane spatial resolution. parallel while ctc has achieved excellent results in average risk individuals with regard to detection of clinically relevant polyps, it has not yet been implemented on a large scale in colorectal cancer (crc) screening programmes. this is mainly due to the fact that it uses ionising radiation. there is uncertainty about adequate screening strategies and the risk of radiation-induced malignancy. this presentation will summarise recent results of ctc in a screening setting, will look at the dose associated with ctc, and summarise calculations of radiation-associated risk of malignancy. the key question is whether low doses from ctc will cause relevant negative effects in the screening population. the lecture will also feature a comparison between ct and mr colonography, an imaging test that might be able to provide high sensitivity crc screening without ionising radiation. from headache to epilepsy… or from "normal", physiological "headache" to life threatening pathological conditions. when do we need "neuroimaging" and what is the optimal diagnostic work-up? the radiologist must and should remain first of all a medical doctor: he/she should keep close contact with the clinical world and always keep an active dialogue with the referring clinician. indeed, medical imaging has become more and more sophisticated but also more expensive. imaging is not a "screening procedure" in brain pathology but should be performed in order to confirm a clinical, suspected diagnosis keeping still in mind that differential diagnosis must be considered as well. imaging plays also a unique role in lesion evaluation and treatment monitoring. the radiologist must answer precise questions about the patient's suspected pathological condition and if necessary, discuss the imaging findings with the clinician in order to narrow the differential diagnosis. each mri or ct must be performed with a clear knowledge of the clinical question and the suspected pathology. therefore, the radiologist will make the proper choices of imaging techniques especially with mri where imaging sequences have become numerous. headaches and seizures are symptoms only and may be present in multiple and very diverse pathological conditions as infectious, neoplastic, haemorrhagic, vascular diseases: by knowing the clinical history a good "clinically conscious" radiologist will undoubtedly be of greater "added value"! learning objectives: 1. to learn more about the clinical conditions causing focal neurological symptoms. 2. to be informed about the clinician's way of thinking in the process of differential diagnosis. neuroradiology has a continuously changing and developing array of modalities. conventional radiography has lost its importance. angiographic practice has shifted from diagnostics to therapy. ms-md ct scanners provide high-quality ct angiography and a s107 c b d e f g h t2w-mri to localise pz-zone pca. in the t-zone, stromal nodules commonly have a low adc value simulating pca. significant differences in tumour adc values existed between patients with low-risk, and those with higher risk localised p-zone pca. with s-mri, the best accuracy for diagnosing pca is obtained by combining a positive t2w-mri and a choline+creatine/citrate ratio > 0.75. in the t-zone, s-mri has the same limitations than dce and dw-mri. multiparametric functional mri accuracy of mri to detect pca can be improved by combining different functional sequences. at the moment, it seems that the most widespread used protocol is a combination of dw and dce-mri for detection of p-zone tumours. performance of functional mri to detect t-zone pca is less well established. multiparametric mri can now be used to perform stereotaxic trus-guided biopsies after trus-mri image fusion. the role of imaging in patients with increased psa level after radical prostatectomy or radiation therapy is to aid in differentiating locally recurrent disease which can be managed with local therapy from distant metastatic disease requiring systemic therapy. although the majority of local recurrences in post-surgical patients can be detected by mri in the perianastomotic region which can also be evaluated with trus and trus-guided biopsy, some recurrences can occur at pelvic sites that are beyond the range of trus; mri has a role of labelling these sites for trusguided biopsy. the combination of an external phased-array coil and endorectal coil is recommended for detecting local recurrent cancer. current protocols involve t2-weighted mri combined with functional techniques such as dynamic contrastenhanced mri (dce-mri), magnetic resonance spectroscopy and diffusionweighted mri. in the post-prostatectomy bed, recurrences present as lobulated masses having low to intermediate signal intensity on t2-weighted images and showing early, nodular enhancement with early washout of gadolinium on dce-mri. the predominant finding after radiotherapy is a diffusely low signal intensity with an indistinct zonal anatomy where the contrast between a hypointense recurrence and benign irradiated tissue decreases. on dce-mri, peripheral zone enhancement is lower after radiotherapy and any focal enhancement should be regarded as suspicious. the overall diagnostic efficacy of dce-mri for detecting recurrent prostate cancer is better than t2-weighted mri alone. on mri, bone metastases have low and high signal intensity on t1-and t2-weighted images, respectively, and enhance after intravenous gadolinium administration. learning objectives: 1. to understand the role of mri in the follow-up of the patients with prostate cancer after radical prostatectomy or radiotherapy. in this presentation new techniques with potential clinical value will be described with a focus on prostate cancer multi-modality mr imaging. techniques such as t2w, dwi, dce and mrsi will be addressed, and their role in screening, determination of tumour aggression and localisation, mr-guided biopsy, mr-guided minimal invasive focal therapy (laser, cryo, hifu), and mr-guided radiotherapy will be discussed. examples will be shown. the major area of debate is how to approach patients with increased psa levels. the discussion has two parts: one is the patient who has not had a prior cancer diagnosis and the other one is the patient who has already been treated for prostate cancer. what is the role of mr (as well as mrs, dw mr and dynamic mr) in precluding the need for multiple biopsies? when should we stop in cases with high or increasing levels of psa despite consecutive negative biopsy outcomes? a s109 c b d e f g h and that radiation therapy and systemic treatments play a major role for curing minimal residual disease. for evaluating and predicting response to neo-adjuvant treatments, the major question is the debate between morphology (size and volume) and function (perfusion, spectroscopy and diffusion). for follow-up after treatment, considering the number of women concerned, cost benefit analyses are mandatory to offer the most efficient imaging strategies based not only on defined subgroups (risk factors of local relapse) but also over time. one of the first take home messages of this course is the multidisciplinary approach of this disease or in another way: we do not treat images but patients! a. evaluation of residual disease after excisional biopsy c. boetes; maastricht/nl (c.boetes@mumc.nl) mammography can have an additional value in evaluating if microcalcifications are left behind in the case of dcis and irradical operation. ultrasonography has proven to have no additional value in evaluating the postoperative breast, because of haematoma and scar tissue. mr imaging of the breast can of all imaging techniques predict residual disease in the most accurate way. however, false positive results can exist because of enhancing scar tissue. also, false-negative results exist, especially owing to residual low and intermediate grade dcis. it is recommended to perform postoperative breast mri in premenopausal women in the right time of the menstrual cycle, that means between the 5 th and 12 th day after the start of the menstrual cycle. unclear is how soon after the operation one should perform breast mri. if a large mass of residual disease is suspected, mri is an excellent tool to confirm this fact. but, if a mastectomy is considered, pathological confirmation before the re-operation is recommended. another imaging technique is tc-99m-mibi scintimammography. this seems a promising technique with a high sensitivity and specificity. neoadjuvant chemotherapy is regularly used for downstaging of locally advanced breast cancer. while it is equivalent to adjuvant therapy regarding overall survival and occurrence of distant metastasis, more patients are eligible for surgical treatment by less aggressive breast conservative therapy. neoplastic growth depends on blood supply with nutrients and oxygen. hypoxia-induced angiogenesis is an early step in tumour progression. mri is the imaging modality providing highest sensitivity for detection of breast cancer, highlighting tumour vascularisation by injection of t1-shortening contrast agents. characteristic differences between benign and malignant lesions are cause. ultrasound (us) and computed tomography (ct) are readily available and widely used imaging techniques for this work up. us comprises an examination of the abdomen with the graded compression technique. a transducer should be used optimised for the visualisation of the bowel. the ct protocol includes the use of intravenous contrast medium, while oral contrast medium will not be routine in many institutions. findings are bowel wall thickening (or enlarged appendiceal diameter), fat infiltration, free air and fluid collections. the present evidence on the role of imaging in appendicitis and diverticulitis is substantial and has been summarised in systematic reviews. although us is accurate in diagnosing appendicitis and diverticulitis, ct is more accurate than us. further advantages of ct are better identification of alternative diagnoses and better comparison between consecutive examinations. thereby, ct is more helpful in communicating the diagnosis to the referring physician. cost effectiveness of ct in acute appendicitis has been demonstrated as well as the positive impact on management. for colitis, the evidence is more limited and imaging has more limitations here. drawback of ct is ionising radiation exposure. an imaging strategy with initial us and ct only in inconclusive of negative us cases results in the highest sensitivity, reduces ionising radiation exposure and is cost effective. accurate and rapid diagnostic imaging is essential for the appropriate management of acute biliary tract disorders. ultrasonography (us) continues to be the first and often the only test needed to confirm suspected diagnoses affecting the ducts and gallbladder. however, there has been an increase in the overall use of computed tomography (ct) in the emergency room setting, mostly because for its widespread availability and the relative speed, ease and uniformity with which evaluations can be performed. thus, ct may be the first imaging examination performed on patients presenting with signs and symptoms that are less specific for biliary diseases. magnetic resonance (mr) imaging has similarly robust potential as ct, although its integration into the acute care setting requires greater technical and logistical effort. improved mr imaging sequences, advances in coil technology, streamlined imaging protocols, and increased technical and professional familiarity with the modality make it an increasingly attractive option when there is concern about patient radiation exposure or allergy to iodinated contrast material, as in pregnant patients with acute abdominal symptoms. mr can also be used as a problem-solving modality. in this presentation, the common and uncommon imaging appearances on us, ct and mr of acute diseases of the biliary tract and gallbladder will be reviewed. potential pitfalls to be avoided with the three modalities are also illustrated. learning objectives: 1. to learn the etiology and clinical presentation of acute inflammatory liver diseases. 2. to understand imaging strategies using us, ct and mri. 3. to know typical findings and the spectrum of differential diagnoses. pancreatitis is an abdominal condition potentially life threatening. imaging plays a key role not only in the diagnosis but also in the staging and patient management of acute and chronic pancreatitis. pancreatic inflammation and necrosis can be easily identified by imaging methods and has prognostic implications. the clinical prognostic criteria in acute pancreatitis are currently coupled with imaging criteria. ct plays a central role in the evaluation of patients with known or suspected pancreatitis. a ct-based severity index is the main prognostic method to predict outcomes. in addition, mri and mrcp play increasingly important roles in pancreatitis evaluation. integrity of the pancreatic duct can be easily evaluated by this last method, particularly if enhanced with the use of secretin. imaging appropriateness criteria determine the value of distinct imaging modalities with regard to the stage of disease. we review the modern imaging criteria for the diagnoses, staging and patient management in acute and chronic pancreatitis. we also discuss current severity indices and imaging appropriateness criteria. advancements in ct and mri technology have lead to an increasing use of these modalities in the non-invasive assessment of coronary arteries, myocardial perfusion, and cardiac function. while their role in detecting coronary artery disease and functional disorders has been widely accepted, it is still unclear whether they could be adopted in triaging patients for the best therapeutic approach. large studies have already suggested that indication for surgery and percutaneous interventions cannot be solely based on the demonstration of morphologic alterations and that such "cosmetic" interventions are not always leading to the expected outcomes. therefore, non-invasive imaging techniques have to offer more then just the detection of grades of coronary artery stenosis, of areas of infarcted myocardium, or of valvular alterations. adjustment of imaging protocols for additional evaluation of coronary flow reserve, of myocardial perfusion and contractility and of valve size, position and damage with subsequent quantification of degree of stenosis and/ or regurgitation are necessary in order to allow to choose the most appropriate therapeutic approach and thus become the "gold standard" for prognosis and pretherapeutic diagnosis of cardiac diseases. a. can ct predict the outcome of percutaneous intervention? c. loewe; vienna/at (christian.loewe@meduniwien.ac.at) the outcome of coronary revascularisation is not only defined by primary technical success but also by improvement of symptoms and quality of life. thus, despite the individual comorbidities, the outcome and thus the potential benefit of coronary revascularisation depends on many different factors, including morphology, distribution and severity of coronary lesions, myocardial viability, and ventricular function. consequently, the detection of coronary stenosis is not sufficient for planning an optimised treatment. it should be evaluated if the myocardial territory supported by the diseased artery is still vital. in addition, lesions at risk for plaque rupture (culprit lesions) should be identified and treated to avoid major coronary events. cardiac ct allows for the exact assessment of coronary morphology including length, calcification and severity of lesions. based on this morphological information, success of a percutaneous revascularisation procedure can be anticipated with high prognostic accuracy. in addition, the possibility of identification of culprit lesion by means of coronary ct has been described recently. by this, dedicated treatment of only the relevant stenosis should become possible avoiding multiple, potentially unneeded, stents. finally, even the assessment of myocardial viability by means of ct becomes possible. using all the possibilities of cardiac ct optimised treatment plan can be established, and outcome can be estimated. radiological interpretation always incurs some degree of error due to the nature of disease presentation coupled with the difficulty in diagnosis, especially where early signs of disease need to be identified such as in medical screening. early research studies of radiologists' performance concentrated upon the chest radiograph but more recent work has studied breast screening extensively, as well as mri and ct. as radiology is now almost fully digital then research has also examined observer behaviour with a range of digital images, viewing conditions, and image display presentations. it is possible that radiological interpretation will never be accomplished without some errors occurring; however, it is important that steps are taken to minimise any causes of errors as far as possible. the reported error rates found in numerous investigations across different radiological domains will be reviewed and the reasons for these will be elucidated. appropriate reporting conditions will be highlighted for different image viewing scenarios. a theoretical framework for understanding error causation, especially where abnormalities are missed will be detailed. furthermore, the underlying visual, perceptual and cognitive processes which lead to errors will be detailed and approaches to minimise error occurrence will then be proposed. the relationship between human perceptual and cognitive skills and computer imaging processing will be discussed and the usefulness of cad systems outlined as how they can best aid the radiologist from the human performance viewpoint. learning objectives: 1. to review the basic principles of perception, detection and detectability. 2. to learn about specifics of perception in medical imaging. 3. to learn how image processing can help us with the perception process. ing using graf's method led to higher treatment and follow-up rates than that based on nhi alone, i.e. 3-5% vs. 0.4-1.5% and 10-20% vs. 6-7%, respectively. however, improved examination techniques and a better understanding of the findings have led to a more tailored approach, and an extensive meta-analysis performed in 2000, including 534 papers, could not find any differences in treatment rates due to different ultrasound techniques. in this lecture i will present a crude status for us techniques used and also give recommendations for a worth while screening strategy based on present knowledge, and on work performed within the espr's ddh task force group. with technological advances in recent years, paediatric whole body imaging is now a clinically feasible and increasingly accessible technique. the two principle modalities available are pet, with or without co-registered ct images, and whole body mri (wb-mri), both of which can be utilised to evaluate widespread disease states efficiently. the main application of these techniques has hitherto been oncological; however, as these techniques become more accepted, their use is becoming more varied. pet provides functional assessment, utilising a radiotracer, most commonly fdg-18, to assess metabolic activity within tissues, with areas of greater metabolic activity depicted as increased tracer uptake. the use of combined ct-pet enables accurate specific uptake values (suv) to be determined, via attenuation correction, and anatomical co-registration which reduces perceptual errors. wb-mri primarily provides an anatomical assessment, using tissue contrast to identify pathology. this typically uses water sensitive sequences to provide high sensitivity. "physiologic" mri sequences, such as diffusion weighted imaging (dwi) can also be employed to obtain functional mri data, either qualitatively or quantitatively. there are advantages and disadvantages to both techniques, including ionising radiation exposure, acquisition times, movement and other artefacts, and reproducibility, which all need to be considered when choosing a particular technique for whole body assessment in any given paediatric patient, with the disease process being investigated also influencing the technique used. the relative merits, clinical applications and evidence base for the use of pet/ct and wb-mri in paediatrics will be discussed. near future developments, such as pet-mri will be touched upon. the practice of medical image diagnosis is currently undergoing a fast transformation. vast amounts of data can be generated in standard examinations and focus is shifting from improving the collection of relevant data for diagnosis to development of effective methods to analyse, visualise, navigate and interact with medical information. it is now becoming generally accepted in the medical community that one of the most important keys to manage the increasing information work load is the use of 3d and 4d applications. this talk will take its starting point in state-ofthe-art medical visualisation and then discuss the need for a research agenda that focuses on the development of the next generation of medical visualisation tools, emphasising the fact that these tools must be based on medical user requirement and work flow studies as well as on new technical developments. childhood osteomyelitis is a relatively rare finding in childhood with an estimated annual incidence of 1 per 5000 and is predominantly seen in young children (< 5 years). it can be caused by via haematogenous spread, contiguously from local areas of infection or from penetrating trauma or surgery. usually it is caused by bacterial infections, but occasionally fungi, viruses or parasites are causative agents. clinical findings can range from mild to severe and depends on many factors such as age, site of infection, acute versus chronic osteomyelitis, and causative agent. the crp and sedimentation rate are usually elevated; however, this is not always the case. given the variability in clinical presentation radiology plays a crucial role in the detection of osteomyelitis. although conventional radiography (cr) has a limited sensitivity and specificity for the diagnosis of osteomyelitis, its wide availability makes it the first diagnostic technique of choice in children. for further analysis both mri and radionuclide bone scintigraphy (rbs) have shown to have a high sensitivity for the detection of osteomyelitis. the advantages and disadvantages of both the techniques will be addressed. ct mostly plays a role in the diagnosis of chronic osteomyelitis or in the pre-surgical work-up. the use of radiology also allows for a differential diagnosis of osteomyelitis, based on clinical cases, an overview of this differential diagnosis will be given. the aim of this lecture is to present an evidence-based diagnostic strategy for childhood osteomyelitis. developmental dysplasia of the hip (ddh) is the most common musculoskeletal disorder in childhood, with a reported prevalence of 1-4% according to method of ascertainment and definitions used. ultrasound has enabled a detailed view of both neonatal hip stability (nhi) and morphology, and two different schools have developed; one arguing that nhi alone is the major pathology warranting splinting, the other including acetabular dysplasia as an important feature. both static (graf, morin) and dynamic (harcke) ultrasound techniques, as well as a combination of the two (modified graf (rosendahl)), have been described and are currently used. in europe, graf's ultrasound technique or a modification of this is commonly used within the german speaking countries and areas, in parts of scandinavia, the uk, italy, france, hungary and the netherlands. others use a modified morin's method while harcke's method is used only occasionally. initially, universal ultrasound screen-(helium or xenon), oxygen-enhancement or other technologies. all of these might also provide quantitative read-outs for disease and/or therapy monitoring. learning objectives: 1. to learn how ct and other imaging methods can be used to examine the structure-function relationship in sad. 2. to review the state-of-the-art imaging methods that can provide information about disease extent, disease activity and global and regional lung function in patients with sad. 3. to become familiar with the current use and the future developments of these techniques. panel discussion: signs of small airways disease can be seen on ct but when and why do they really matter? 09:44 signs of small airways disease are a frequent finding on ct especially when expiratory scans are performed in addition to inspiratory scans. when should we report these changes? are they always important, do they perhaps predict the development of more severe disease, or are there cases where they have little influence on diagnosis and therapy? when should an expiratory scan be performed? careful preoperative staging and preoperative using high-resolution mri together with preoperative multidisciplinary team discussion has been shown to reduce margin involvement by tumour from 30% to < 5% by identification of patients that require more radical preoperative therapy and surgery. the detailed demonstration of preoperative prognostic factors also recognises patients on imaging that are not at risk of local recurrence and therefore the avoidance of unnecessary preoperative therapy in a proportion of patients. the use of eus can help in the assessment of early stage flat lesions suitable for local excision and is a powerful complementary tool. pet-ct is crucial for the preoperative work up of patients undergoing radical procedures such as metastatectomy. follow-up for colorectal cancer patients at high risk for developing recurrent disease is now well established, and the emergence of specialised multidisciplinary teams, combined with a range of treatment options for recurrent disease has improved curative resection rates following metastatectomy and pelvic recurrence surgery. radiologists with a solid understanding of not only the pathological manifestations of primary and recurrent rectal cancer but also the treatment options available play a key role in enabling the appropriate selection of patients -increasing overall cure rates and reducing treatment-related morbidity. this refresher course aims to provide radiologists with an understanding of local staging of rectal cancer, the assessment of recurrent disease, and assessing response to treatment. the course will highlight how imaging underpins the key preoperative decisions for surgical and oncological treatment planning in rectal cancer. a. staging with us and ct a. maier; vienna/at (andrea.maier@meduniwien.ac.at) for rectal cancer surgery a variety of alternative operations are currently possible. furthermore, there is an increasing trend towards treating patients with radiotherapy before surgery. the choice of operation and the decision whether to employ radiotherapy is based on preoperative staging. in patients with primary rectal cancer accurate assessment of tumour extent and the presence or absence of lymph node invasion are factors for determining prognosis and risk of tumour recurrence. endorectal ultrasound (eus) is effective for t-staging. it has been recommended as the investigation of choice in the selection of potentially curative local excision. lymph node staging by this method is less precise than tumour staging. initial reports of the use of ct for tumour staging were encouraging. studies which compare ct with eus staging consistently show the latter to be more accurate for both tumour stage and lymph node stage. thus, the usefulness by the speakers at the end of the session. at the other end of the clinical and imaging spectrum to obliterative bronchiolitis is exudative small airways disease, typified by (japanese) diffuse panbronchiolitis. the exudative bronchiolitides are characterised by direct signs on hrct, notably a tree-in-bud pattern. while this is a readily appreciated and specific sign, other diseases that mimic this hrct finding will be discussed. bronchiectasis of variable severity is a usual accompaniment to both obliterative and exudative bronchiolitis and the relationship between large and small airways disease will be explored. the instances in which hrct findings of obliterative and exudative bronchiolitis co-exist are relatively few, and the differential diagnosis for this situation will be considered. in practice, hrct will often show signs of bronchiolitis (whether obliterative or exudative) limited to a segment or even subsegment, and the interpretation of the clinical significance of such a chance finding is sometimes a difficult judgement. learning objectives: 1. to become familiar with the direct and indirect signs of small airway involvement on ct. 2. to know how to correlate these signs with the pathological changes. 3. to understand the differential diagnosis with other diseases that can show similar ct findings. from pattern to diagnosis c. beigelman; paris/fr various schemes of classification of sad have been proposed according to clinical, pathologic or imaging criteria that are confusing. an optimal approach, mainly based on ct analysis of direct and indirect features, usually allows the recognition of the two main types of sad, namely inflammatory/exudative and fibrotic/constrictive/ obliterative bronchiolitis. a miscellaneous group that corresponds to bronchiolar involvement in diverse diffuse lung diseases may also be individualised. direct signs of sad that refer to direct visualisation of diseased bronchioles strongly suggest inflammatory bronchiolitis. they mainly consist in centrilobular nodules with tree in bud appearance. conversely, indirect signs mainly represented by mosaic attenuation, air trapping, bronchial wall thickening and dilation characterise fibrotic bronchiolitis. volumetric acquisition, performed a dose reaching that obtained with classical hrct protocols, may be of interest in several ways. particularly, maximum intensity projection tool may facilitate the recognition of the tree in bud pattern. the minimum intensity projection mode may optimise the recognition of the mosaic attenuation pattern requiring an appropriate contrast resolution, as well as the analysis of proximal airways. expiratory ct, optimally performed on a dynamic mode, may be useful in some conditions at a dose equivalent to around 2 chest x-rays. a combination of post-processing tools from a volumetric acquisition performed with carefully chosen parameters might therefore appear useful in the evaluation of sad. furthermore, additional co-existing findings such as ground glass opacity or other features of interstitial pneumonias may be detected. their analysis may help to recognise the cause of sad in addition to clinical data. structural changes associated with sad are difficult to depict directly on ct. indirect signs of sad, such as mosaic attenuation on an inspiratory scan and/or air trapping on an expiratory scan, are common findings. they nicely illustrate the structure-function relationship between obstruction or expiratory collapse of the small airways and the subsequent effects on ventilation (local hyperinflation) and perfusion (hypoxic vasoconstriction). these "functional" signs are thought to be more sensitive than the direct visualisation of the underlying structural changes. careful interpretation and software tools help to generate data about disease extent as well as global and regional lung function. beyond paired inspiratory-expiratory ct scanning, dynamic expiratory cine as well as perfusion and ventilation imaging on the basis of both, ct and mri, can be applied to increase sensitivity, specificity and accuracy of the diagnosis of sad. some of them are ready for routine clinical use, such as dynamic expiratory cine ct, cine mri during continuous breathing as well as gadolinium-enhanced perfusion mri. future developments in the fields of ct and mri will provide novel technical approaches for functional imaging of sad. these will include novel applications of dual energy/spectral ct using iodine-enhancement for perfusion and xenon-enhancement for ventilation enhancement as well as ventilation mri using hyperpolarised gases to understand the advantages and limitations of bi-rads in clinical practice to appreciate the potential of an automated analysis of the descriptors to trace continuous modifications required by technological advancements. 4. to review bi-rads categorisation with case illustrations a. how i do it p. richards; stoke-on-trent/uk (paula.richards@uhns.nhs.uk) 1 . always report in the same logical manner for each examination, which imprints normal pathology 'jumps out at one'. 2. evaluate all images before looking at the clinical information to prevent bias and satisfaction of search. 3. review every scout image. scoliosis transitional vertebrae and pseudoarthrosis become more obvious on coronals. single kidneys, hydronephrosis and renal tumours may explain 'back pain', especially if there are mets. 4. review any x-rays or old ivus, remembering that abdominal x-rays show the spine. 5. indications; summarise the reason for the scan. think of the differential diagnosis to exclude. 6. technique; allows one to check the levels scanned. be sure there has been no area missed between 2 studies. 7. report vertebral alignment and disc height. 8. mri just like an x-ray, i.e. there is normal alignment from d10 to s3. 9. start at the far sagittals and look at the nerve roots in the 'key hole', the pars and facets. 10. determine the worst abnormality on the axials and report the most significant findings first. check the facets at each level. 11. have a checklist of normals at the end; 'the bone marrow, cord and csf return normal signal. the conus ends normally with no pars or metastasis'. 12.opinion: explain what you think is causing the patient's symptoms. assume this is the only part read, so if there is only one kidney reiterate here. the lecture will illustrate additional information on scout images and benefits of coronal images. learning objectives:1. to understand the influences of patient positioning, scan parameters and magnet/coil technology on image quality. 2. to learn how to optimise scan protocols to maximise patient throughput without compromising diagnostic quality. 3. to recognise how and when to modify scan protocols to answer specific clinical questions.a-371 14 the lumbar spine undergoes morphological changes with age. normal appearances and relevant normal variants will be discussed. in particular, the morphological change from an almost round intervertebral disc in newborns with high water sig-postgraduate.educational.programme s102 a b c d e f g h radiotherapy is an area with a rapidly improving development of new techniques and improved possibilities for accuracy. this lecture aims to illustrate and discuss points of contact and the need for collaboration between radiotherapy and radiography. european educational programmes and working fields for radiotherapy nurses and radiotherapy technicians are compared. radiotherapy nurses and radiotherapy technicians are responsible for the administration of radiotherapy to cancer patients and for the clinical care related to the treatment. apart from prevention and treatment of side effects and psychosocial support during the treatment, it encompasses preparations, delivery and verification of the radiation dose. educational programmes differ in terms of academical level and target groups, whether it is nurses or technicians in radiology or radiotherapy exclusively. areas in the radiotherapy process where competences from radiography are needed are discussed, considering both technical development and research progresses. learning objectives:1. to gain knowledge about the differences and similarities between the areas of education and profession in radiography and radiotherapy from a historical perspective. the demand from the public for greater accountability and standards has increased the importance of audit and accreditation in modern healthcare delivery. specifically radiology departments participate in audit and accreditation by a number of entities. these include: 1. national bodies concerned with improving radiation safety particularly originating from eu 97/43 directives. 2. hospital wide accreditation surveys from state and private accrediting organisations. 3. auditing of standards from within professional bodies. 4. following from investigation of specific incidents such as misdiagnosis or radiation concerns. 5. modality-specific standards.although the specific requirements of the accrediting or auditing body may differ, the processes and practical aspects in demonstrating compliance with standards and quality improvement are generally similar. mechanisms such as outcomes, quality cycles, and performance indicators are critical in the success of any accreditation or audit program. in addition to fulfilling basic regulatory requirements, the medical physicist is playing an increasing role in developing performance indices particularly in radiation safety, clinical image quality and equipment management. the increasing role of the medical physicist in audit underpins the requirement for inclusion of audit and accreditation as part of their education. recent experience of setting up and participating in eu 97/43 directive-based clinical audit in ireland highlighted the critical need for clarity of roles and ownerships of processes to be communicated to those who are carrying out audit and those who are being audited in hospitals and dental practices. performing imaging studies in a child requires basic knowledge. the first point is to reassure and to avoid stressful/painful procedure. training of radiographer and radiologist is fundamental. explanations, presence of a parent (if not pregnant…), are preferable. specific devices may be useful for immobilisation and to avoid repeated exposures. antalgic drugs (traumatic circumstances) or sedative nitrous oxide inhalation (mcug) may be useful. x-rays exposition in relation with conventional radiology is lower than the one encountered with ct. but dose depends on type of examination and also on imaging equipment. new devices, such digital fluoroscopy with x-rays pulsed emission, flat-panel detector, slot-scanning x-ray imager need less ionising radiation than conventional screen-films devices or even photostimulable phosphor imaging plates. the scale between the higher and the lower dose for the same examination can be from ten to one. common principles of protection that apply to all x-ray imaging procedures, known as alara concept (as low as reasonably achievable), have to be used daily. act in accordance of the medical justification of the examination, without any non-ionising alternative method, remains the first step. the second one is the optimisation of each procedure, the limitation of expositions, with control of the x-ray beam adjusted to optimise the critical balance between image quality and exposure to the child. measure of the dose is mandatory to demonstrate appropriate levels on child exposure and to be sure in the future that very low radiation doses received during conventional imaging procedures will not produce adverse effects. the council directive 97/43/euratom introduced the concept of clinical audit to medical radiological (diagnostic radiology, nuclear medicine and radiotherapy) procedures. clinical audit is a systematic review of the procedures in order to improve the quality and the outcome of patient care. according to the directive, clinical audits shall be implemented in accordance with national procedures. the review of its implementation in europe has revealed a high variation of approaches and many practical problems. therefore, the european commission has published further guidelines on clinical audits in its report radiation protection no. 159 (2009). the purpose is to improve the implementation of clinical audits and to enable the member states to adopt the model of clinical audit with respect to their national legislation and administrative provisions. the guideline points out the importance of both internal and external assessments for clinical audit. it deals with all types and levels of clinical audit and gives practical guidance for application. it defines the list of topics which should be covered, while the actual criteria of good practice are discussed on generic levels only. the borderline between clinical audit and other quality assessments (accreditations, certifications, peer reviews) and regulatory inspections is also discussed. the guideline is addressed to all professional groups, hospital management, auditing organisations and regulatory bodies. it is important to recognise that the guideline is not a legal requirement. this refresher course lecture will give a summary of the ec guidelines and discuss briefly the implementation of clinical audits in europe.learning objectives: 1. to understand the purpose and essential contents of the european commission guideline on clinical audit. b. national perspective: clinical audit inspections s. ebdon-jackson; didcot/uk (steve.ebdon-jackson@hpa.org.uk) european council directive 97/43/euratom requires under article 6 (4) that "clinical audits are carried out in accordance with national procedures". implementation of this requirement across europe has been varied. this paper will reflect on the experience in the uk and will consider examples of the various initiatives undertaken in the uk by professional bodies and organisations. this will be contrasted with the role of the regulator and the aims of the inspection process with regard to compliance with the specific regulation addressing clinical audit and the remaining regulations addressing justification, optimisation, etc. examples will be provided of the type of audits undertaken within uk hospitals. a uk perspective of ec and iaea initiatives in clinical audit will be provided. percutaneous radiofrequency ablation (rfa) is a safe and effective treatment for well selected patient with hepatic tumours such as hepatocellular carcinoma (hcc) and liver colorectal metastases (lcm). an appropriate selection is crucial. it is based on clinical and technical arguments. clinically, surgical resection of the haepatic tumours remains the gold standard. indeed, survival data following rfa are not as good as surgical resection. the only exception seems to be the rfa of the very early hcc (≤3.0 cm) in cirrhosis that is not candidate for liver transplantation. most often, the rfa offers an alternative for patients with medical comorbidities, poor liver function or prior hepatectomy. technically, there are three decisive points for complete ablation. the first point is the good visualisation of the tumour either under ultrasound or un-enhanced computed-tomography (ct) examination. metallic coil placement, lipiodol tattoo and virtual ct sonography with magnetic navigation are technical tricks that allow the rf ablation of "invisible" tumour. the second point is the tumour size: in most series, a diameter less than 25-35 mm is commonly admitted as a prognostic factor. this is probably because the maximal ablation diameter is slightly larger than 40 mm with the electrode needles available now. micro-waves ablation might improve the local control by increasing the ablation diameter. the last point is the "heat-sink effect" that requires a temporary occlusion of a large vessel close to the tumour. the quality of follow-up imaging is a key factor for evaluation of tumour destruction. partial hepatectomy for liver metastases or primary liver tumours can only be performed when the future remnant liver volume (frlv) is considered large enough to avoid the risk of post-operative liver failure. in normal livers a frlv of 25-30% is considered safe whereas in compromised livers a frlv of at least 40% is required. in patients whom the flrv is considered to small, pve may be performed pre-operatively to increase the frlv. pve involves percutaneous selective embolisation of the portal venous (pv) system, usually of the right liver lobe, which leads to atrophy of the embolised lobe. this, in turn, leads to hypertrophy of the frlv. because of the dual vascular supply to the liver (arterial and portal venous), necrosis of the embolised lobe does not occur. this compensatory hypertrophy of the left lobe facilitates resection in patients in whom the frlv would otherwise have been to small to allow resection. pve is most often performed percutaneously under conscious sedation and local anaesthesia through an ipsilateral approach, using a combination of particles, such as polyvinyl-alcohol (pva) and embolisation coils. potential complications of pve include thrombosis of the contralateral pv, liver abscess formation or cholangitis and are rare. most of the hypertrophy occurs in the first 3-4 weeks after pve and increase in volume of the frlv averages 12% after this time period. ct-volumetry should be performed both before pve and after 3-4 weeks to measure increase in frlv. accurate identification and reporting on soft tissue extremity masses is essential for correct diagnosis and optimal treatment planning. this lecture focuses on the mri signs to stage and grade-characterise soft tissue mass lesions. these two objectives are the major structural components of the mri report and fit the request of the referring clinician. this implies an accurate description of these signs with appropriate terminology in the report. local staging is essential for the preoperative work up. important staging parameters are size, compartmental location, skip lesions and relationship to neurovascular structures and joints, as well as distance to the nearest joint space. grading and characterisation is complex and multifactorial and classifies the lesions as "certainly benign" (no biopsy needed) and "possibly " or "certainly malignant" (biopsy needed). grading parameters are homogeneity, (changing) signal intensities in multiple acquisition techniques and static and dynamic gadolinium enhancement pattern. these are used to define the composition of the lesion, i.e. fat, met-hb, hemosiderin, myxoid tissue, collagen, viable, cystic or necrotic components. other important grading and parameters are lesion margin, shape, perilesional invasion or destruction, multiplicity, specific location and associated findings but also age and gender of the patient. image guidance and imaging fusion techniques represent an integral element in oncologic interventions and liver surgery. in addition, several liver planning techniques such as the virtual liver surgery planer enhance simulation of a proposed liver resection. using roboter-assistance or navigational guidance combined with thermal ablation techniques such as radiofrequency ablation, significantly enhances accuracy of ablation probe placement and efficacy of ablation necrosis. furthermore, the local recurrence rate can be considerably reduced, and the amount of complete tumour ablation is significantly more likely. integrating magnetic resonance imaging, and focused ultrasound to deliver and activate nano-capsules carrying anti-cancer drugs to effectively target tumours will be another task. this will involve drugs being injected into the body in the form of tiny capsules, which are harmless until they are activated by a concentrated focused ultrasound `blast'.the mri scanner will then be used to track the passage of the drugs, visualise the target and monitor the delivery of the drug treatment. the risks associated with radiation exposure in ct is of concern to radiologists, medical physicists, government regulators, and the media. thoracic ct is a technically robust, non-invasive imaging technique for the evaluation of several traumatic and non-traumatic thoracic emergencies. technical advances in the past years have resulted in improvements in image acquisition speed, spatial resolution, and the temporal resolution. consequently, thoracic ct can now be performed rapidly in emergency conditions without substantial delay in treatment. state-of-the-art ct systems are now capable of imaging the entire thorax within a few seconds. however, radiation exposure associated with thoracic ct have been increased with the advantages of modern ct systems particularly in the evaluation of chest pain syndrome. thoracic aortic ct angiography with cardiac gating may now be considered the preferred technique for the evaluation of chest pain syndrome in selected patients but is associated with a substantial higher radiation dose than routine non-gated thoracic ct. several effective strategies have been developed to limit the radiation exposure in cardiac gated thoracic ct including prospective ecg gating techniques, anatomy and ecg-based tube current modulation, high pitch acquisition, and adaptation of the ct scanning parameters to the body habitus. in addition, several techniques are available to reduce the radiation exposure in nongated thoracic ct depending on the patient's body habitus and the clinical indication. because of advancing technical developments and increasing diagnostic utility of mdct in emergency care, its use has expanded significantly and has changed patient care, especially in chest emergencies. however, mdct has important drawbacks in cost and radiation exposure. the first presentation will discuss mdct in acute chest pain (acp). scan techniques in different scanners will be addressed. the reasons why cta/ctca can be a viable application for acp and the current evidence for cta in acp will be discussed followed by an update on indications. the next presentation will address mdct in chest trauma. its significance, the utility of this imaging method and its advantage compared to other modalities will be discussed. the examination protocol and the role of post-processing methods will be addressed. the interpretation of mdct, findings, benefits, limitations and pitfalls will be shown. the utility of chest x-ray and ultrasound as primary examinations and the indication for mdct, routine or selective, will be discussed. our last speaker will familiarise us with procedures to measure radiation dose in thoracic mdct, followed by an update of radiation exposure associated with the protocols for the different clinical indications. finally, available techniques for radiation dose reduction in ecg-gated and non-gated mdct and their effectiveness in radiation dose reduction will be demonstrated. however, the best way to reduce radiation is to perform mdct only when there is an appropriate indication and this will be the focus of the concluding panel discussion of this session. chest trauma is, particularly in younger population, a significant cause of morbidity and mortality. it is directly responsible for 20-25% of trauma-related deaths and in other 50% of deaths it is an important contributing factor. imaging methods play the key role in management of this group of patients. introduction of mdct in the last decade of the 20 th century markedly changed the diagnostic approach to the thoracic trauma. fast data acquisition and increased resolution in the z-axis enabled reliable assessment of all chest anatomical components (often together with other parts of the body) in one examination. compared to x-ray mdct defines more accurately the extent and severity of traumatic changes and may detect serious in 85% of nontraumatic cases, subarachnoid haemorrhage (sah) is the result of aneurysmal rupture. other causes of sah include perimesencephalic sah (10%) and other disorders (5%) such as arteriovenous malformation (avm), vertebrobasilar artery dissection, dural av-fistula, cortical vein thrombosis, amyloid angiopathy, … sah represents an emergency situation and diagnosis should be established asap.plane computed tomography (ct) is the initial diagnostic test of choice (wide availability, easy accessibility, high sensitivity and specificity). if ct is negative, lumbar puncture and/or mri of the brain (including flair images) and spine should be performed. 3d tof mr angiography (mra) sequences have high sensitivity and specificity in detecting cerebral aneurysms; but because of their lower spatial resolution are insufficient to analyse in detail aneurysm morphology. this in contrast with cta. both cta and mra may be proposed as a first-choice, noninvasive examination, but the negative predictive value is poor, and therefore digital subtraction angiography (dsa) is mandatory for all sah cases with negative cta or mra. catheter angiography remains the golden standard in the detection and evaluation of cerebral aneurysms (size, relationship between neck and adjacent vessels, etc). increased attenuation (ct) and hyperintense signal (flair) within the basal cisterns and sulci are a characteristic finding of sah; however, it is aspecific. pattern and location of the blood may help to locate the ruptured aneurysm; sometimes helpful when multiple aneurysms are found. pseudo-sah may be a potential imaging pitfall because it may be observed in other acute neurological conditions (cerebral edema, bacterial meningitis, etc). recurrent disease following treatment for primary breast cancer can occur in the same breast following conservation surgery, ipsilateral breast tumour recurrence (ibtr) or in the contralateral breast, metachronous contralateral breast cancer (mcbc). estimations for the rate of recurrence are between 04 and 0.8% each year. the rate of recurrence is higher than breast cancer incidence in the general population. risk factors for recurrence are young age (< 50), high grade disease, incomplete tumour excision and no radiotherapy. due to the large numbers of women who develop and survive breast cancer the cost and resource required to follow-up these women is considerable. there are variable guidelines in europe for the surveillance of women but most regimes include clinical follow-up and mammography. variations concern the frequency of mammography, the length of follow-up required, and whether clinical examination is required. the clinical effectiveness and cost-effectiveness of different surveillance mammography regimens after the treatment of primary breast cancer will be reviewed together with the results of systematic reviews. modelling of two data registries was undertaken to ascertain the survival benefit. alternative methods of surveillance will be considered such as mri with the diagnostic accuracy of the various imaging techniques considered. a summary of the economic evaluation will be presented to demonstrate the assumptions that require to be made in this complex area where there is a paucity of evidence.learning objectives: 1. to understand the risk of recurrent disease and second primary following the treatment of breast cancer. 2. to review literature on surveillance mammography and other imaging methods for detection. 3. to appreciate the range of recommendations for surveillance mammography and clinical follow-up with cost benefit analysis. the new challenge in breast cancer: evaluation of response 17:14evaluation of the treated breast is one of the major challenges in breast imaging.there is especially much debate on the evaluation of response to therapy. the best imaging modality, the best imaging criteria, timing, accuracy and limitations of imaging are currently being investigated. whether it is time to reach conclusions regarding these aspects is the issue of this panel discussion. intracranial aneurysms are abnormal dilatations of the arteries, and will be found in 1% to 14% in general population. in 90% cerebral aneurysms are saccular and develop from the arteries of the circle of willis or its major branches. aneurysms typically become symptomatic between the age of 40 and 60 years, with subarachnoid haemorrhage (sah) or intracerebral haematomas. less common are giant aneurysms usually found in middle-aged women presenting with signs more indicative of a mass lesion. ct angiography (cta) has been proven to be an excellent tool to visualise intracranial arteries. the average sensitivity of cta for the detection of intracranial aneurysms reaches 90%. post-processing allows assessment of the aneurysm with maximum intensity projections (mip) and surface-rendered 3d projections in multiple plains. mr angiography (mra) is a practical and noninvasive tool for screening of high-risk individuals for aneurysms. dsa is diagnostic method of choice for assessment of intracranial aneurysms and was considered to be a 'gold standard' for evaluation of cerebral vessels. a clear shift from invasive to noninvasive imaging of cerebral vessels has been noticed in the last decade. this lecture will discuss advantages and disadvantages of cta, mra and dsa in detection, assessment, and post-treatment evaluation of intracranial aneurysms. intracranial aneurysms have a multifactorial origin. a heterogeneous and complex group of pathogenic mechanisms including luminal, mural and extramural factors interact for the development and growth of aneurysms. there are several types of intracranial aneurysms, being the saccular the most common type. the aneurismal treatment is dependent on its type and needs a multidisciplinary approach including endovascular and microsurgical teams. endovascular treatment is recognised as the first-line treatment for most of the ruptured saccular intracranial aneurysms. there has been an enormous improvement in the endovascular technology and techniques offering a wide spectrum of treatment possibilities that broadened the variety of aneurysms that can be treated. the treatment options include the use of coils with/without the help of balloon-remodelling and/or stenting. other options include the use of covered stents, of "flow-diverter" stents, of liquid embolics, or the parent vessel occlusion. the multislice computer tomography angiography (mscta) is a reliable method for pretreatment evaluation of intracranial aneurysms. for the posttreatment evaluation, magnetic resonance angiography (mra) can be used for the follow-up of embolised aneurysms; and mscta may be used for the follow-up of surgically treated aneurysms. there are several challenges remaining in aneurysm management. in the diagnostic field, improvement of the non-invasive techniques for the diagnosis, for the morphological and haemodynamic characterisation and for the posttreatment follow-up of aneurysms is expected. in the endovascular field, technological breakthroughs to improve the occlusion rate, to increase the treatment durability, and to promote the vessel wall healing are desired. learning objectives:1. to learn about present treatment of brain aneurysms. 2. to understand the strategies for multimodal ct and mr aneurysm imaging pre and post-treatment. 3. to present the challenges for neuroimaging in the field in the near future. where do we stand in brain aneurysm treatment today? 17:14there is a significant difference in the management of patients with ruptured versus un-ruptured brain aneurysms. this panel discussion will focus on the management of patients with brain aneurysms and will with simple case presentations show the management in ruptured and un-ruptured aneurysms and discuss the involvement of the neurosurgeon in more complex cases.cone beam ct (cbct) is a method for obtaining ct-like images using a c-arm system. our aim was to investigate the accuracy of these images compared with multi-detector ct (mdct) as a gold standard in radiological imaging of abdominal aortic aneurysms (aaa). 40 patients with aaa referred for elective evar were included in a pre-therapy protocol (20 patients) and in a post-therapy protocol (20 patients). all were exposed to standard mdct and one additional cbct. image data were evaluated by two radiologists and statistically compared using a linear mixed model. first, 6 predefined arterial measurements were performed, then 9 predefined anatomical areas were assessed and scored for visibility on a scale from 1 to 4. all measurements were chosen to be relevant for evaluating of aaa before and after evar. for the arterial measurements no significant differences were found between mdct and cbct. visibility for the anatomical areas was significantly better for mdct; however, most of the cbct readings were above lowest acceptable level. visualisation of the iliac arteries was suboptimal. we think that our results support the start of clinical trials that scientifically can test the outcome without the use of mdct immediately before and after evar. the problem with poor visualisation of the distal iliac arteries might be solved with newer technology. in conclusion, the result indicates that cbct in the operation room gives sufficient image-based information to support evar in a pre-and post-therapy setting. undertaking theatre radiography can appear a daunting task for the radiographers lacking in confidence in their ability but others (like all expert practitioners) make it look easy and uncomplicated. theatre radiography requires all the knowledge, skills and abilities of a competent radiographer together with assertiveness, reflection and the ability to modify your technique at a moment's notice. there are a multitude of 'traits' which distinguish the expert from the novice. these include production of optimum images, effective use of the equipment, radiation protection, infection control, effective communication and teamworking. there is also a clear depth of knowledge together with a multitude of skills and abilities. the key to a stress-free experience is preparation. it is essential that there is a mechanism for theatre staff and the radiology department to communicate effectively and give the radiographer prior notice of all cases requiring their attendance. it is also desirable to be in the theatre when the patient arrives for their examination to enable you to check the patient's identity, pregnancy status and ensure the patient is positioned correctly to facilitate screening. there are few excuses to give the surgeon if you cannot screen the area of interest because of poor positioning of the patient and equipment. this paper will discuss the knowledge, skills and abilities required to undertake theatre radiography in a safe and proficient manner without feeling threatened by the experience. learning objectives: 1. to understand the key skills required to undertake radiographic procedures in the operating theatre. 2. to gain an insight into the interpersonal skill required for effective radiographic practice in the operating theatre. prediction of coronary revascularisation outcome represents a major clinical question because a large number of medical and surgical options have become available for ischaemic cardiomyopathy with need to identify more rigorous criteria for patient's selection. the combination in a single examination of function, stress-perfusion and tissue characterisation with t2-weighted 'oedema-sensitive' and late-gadolinium enhancement (lge) techniques supported the role of cardiac mr (cmr) as an important technique for the evaluation of patients candidates to revascularisation. besides more "traditional" indicators such as ejection fraction, end-diastolic wall thickness or endsystolic volumes, extent and distribution of myocardial scar depicted with lge has been identified as one of the most important predictors of post-revascularisation outcome with direct influence on functional recovery and on major adverse cardiovascular events (mace) due to the potential induction of arrhythmias from the scar.lge technique has been shown to be superior to nuclear medicine for the assessment of myocardial viability due to the higher spatial resolution (up to 60-fold greater than spect) and an intrinsic high contrast resolution. a further technique that could be adopted before revascularisation is stress imaging. myocardial ischaemia detected by either cmr adenosine first-pass perfusion or dobutamine-induced wall motion abnormalities has been shown to predict subsequent cardiac death whereas normal stress perfusion showed a high negative predictive value for mace. in conclusions, although as a relatively new diagnostic modality prognostic evidence is predominantly derived from singlecenter studies, cmr is increasingly becoming an important tool for risk stratification of patients before revascularisation, offering indications about outcome and mortality. cardiac valve diseases are an important public health problem, strongly linked to the general increasing age of the western population. the most frequent valve disease is aortic stenosis, for which percutaneous aortic valve replacement (pavr) is currently evolving to a feasible alternative therapy for the classical surgical approach in high-risk patients. nevertheless, careful evaluation of all aspects of this new approach is still required to avoid uncontrolled diffusion. imaging plays a key role in selecting patients who may be eligible for pavr, focusing on the evaluation of leaflet anatomy, severity of valve dysfunction, haemodynamic consequences and potential problems in the access route. while echocardiography is commonly used for both the anatomical and functional evaluation, multidetector ct (mdct) has important intrinsic advantages providing state-of-the-art 3d imaging with a high spatial resolution over a large anatomic coverage. during this course, we will discuss the advantages and disadvantages of mdct compared to other imaging modalities. the relevant anatomy of the aortic valve and annulus will be reviewed, with emphasis on correct alignment of the imaging planes, and its implications for correct reporting of the necessary measurements targeted at the clinicians need. furthermore, mdct scan protocol design will be reviewed, focusing not only on optimal implementation of common scan parameters but also on the need of ecg-triggering and its consequences. finally, we will present the current status of evidence on using mdct in pavr procedures, and discuss future challenges and perspectives. learning objectives: 1. to understand how to optimise the imaging protocol for aortic valve imaging. 2. to learn how to report the findings and what to include in the report. 3. to understand the impact of this approach on patient management. the need for quantitative image analysis in radiology is universal: computer-aided detection, segmentation for 3d volume visualisation, image enhancement, pattern recognition, etc. all need effective, robust and preferably generic (not 'ad hoc') algorithms for the computer. how to design such algorithms? a good inspiration source is the functionality of the visual system, the best investigated brain structure today. in this talk we will explain how we think the brain calculates features in images, why the retina measures at a wide range of resolutions and how we can exploit this. the visual system is strongly adaptive and self-learning. new optical recording techniques have given new insight in how the cells in the visual cortex are functioning. we will go through these functionalities step-by-step. what we discover is quite amazing. we recognise huge amounts of filter banks in the first stages of vision: many filters analyse each pixel of the incoming image at a range of scales, orientations, derivative order, for each colour, and also as a function of time. extensive feedback loops take care of optimal settings locally. we programmed these filters into the computer, and were able to build many interesting applications for computer-aided diagnosis: detection of catheters at seriously reduced levels of x-ray radiation dose, automatic polyp detection, quantitative analysis of ischaemic heart ventricle deformation, breast cancer cad, pulmonary emboli cad and analysis of in vivo microscopy images now so abundant in modern life-sciences research. postgraduate.educational.programmethe gi tract are leading causes but any tumour involving the abdominal cavity or haematological malignancy may be implicated. during treatment with chemotherapy or radiotherapy acute abdominal symptoms are common as a consequence of direct toxicity. imaging must be used as an adjunct to clinical assessment. patterns of abdominal involvement are often modified in the later phases of disease. gi tract obstruction may be due to progression or the mechanical consequences of prior surgery and is more commonly at multiple levels. perforation or fistulation may occur with either progressive disease or tumour lysis in response to therapy. cancer does not protect against the common inflammatory conditions but poor host response and the use of steroids may mask signs leading to extensive abnormality at diagnosis. bone marrow suppression increases susceptibility to infection including neutropenic enterocolitis and haemorrhage. bone marrow transplantation and consequent graft versus host disease is a potent cause of acute abdominal symptoms. ct is the major imaging technique although mr has an increasing role particularly in the assessment of the female pelvis. major determinants when considering the differential diagnosis include; the nature and initial stage of the primary, any prior anatomical modification (surgery), the nature and relationship to current treatment and the bone marrow status. this workshop will begin by describing the current limitations of mri in evaluating prostate cancer patients and will show how to overcome these with advanced imaging techniques including diffusion weighted mri (dw-mri), mr spectroscopic imaging (1h-mrsi) and dynamic contrast enhanced mri (dce-mri). the emphasis will be on the use of processing tools that are readily available for clinical practice. we will describe how to analyse images and provide a scheme for reporting findings back to surgeons/oncologists. we will show that using more than one mri tool improves imaging performance and that the relative importance of each technique remains unresolved. we will demonstrate new indications for advanced mri in prostate cancer patients. abdominal hernias are common in daily practice and can be divided into: external or abdominal wall hernias, internal hernias and diaphragmatic hernias. external hernias typically involve protrusion of abdominal contents through a defect in the abdominal wall. internal hernias involve protrusion of viscera through congenital or acquired defects in the mesentery or the peritoneum. diaphragmatic hernias involve protrusion of abdominal contents into the chest. among these conditions, the diagnosis of internal hernia is the most challenging. bariatric surgery and liver transplantation with biliary-enteric anastomosis, with the roux-en-y loop placed in a retrocolic position, are recognised predisposing factors for internal hernia development. symptoms of hernia are nonspecific and vague, and clinical and radiologic diagnosis can sometimes be challenging. immediate diagnosis is mandatory because misdiagnosis can be complicated by bowel obstruction, volvulus, strangulation, incarceration, or trauma. mdct with its multiplanar capabilities is widely believed to facilitate this diagnosis, because it is able to delineate hernia type, location, size, and shape and is particularly useful to diagnose unsuspected hernias. it also allows distinguishing hernias from masses of the abdominal wall, such as tumours, haematomas and abscesses. as a result, knowledge of the ct findings of abdominal hernias may allow early and more accurate diagnosis, with a resultant decrease in the mortality rate. the title of this talk limits the discussion of torsion to the mesentery and omentum. it has to be mentioned, however, that an abnormal twist (torsion) can involve any peritoneal reflection of those suspending and fixating hollow viscera, (e.g. stomach, small bowel, cecum, sigmoid and gallbladder), solid organs, (e.g. spleen, ovaries), or even extraperitonel (extraabdominal) organs such as the testicles, leading to the pathologic entity of volvulus or torsion of the corresponding viscous with its associated (different) imaging findings, prognosis and treatment. moreover, twisting of the mesentery and volvulus can occur secondary to a variety of conditions including congenital anomalies of intestinal rotation with variable prognosis. finally, torsion of the omentum can be either primary or secondary, also associated with different pathology, imaging findings and treatment. consequently, a broad spectrum of abnormalities ensues related to the pathophysiology of torsion which requires a detailed classification, an accurate description and the use of correct terminology making it impossible to be covered within the time limits of a presentation. therefore, focusing the discussion on to abnormal twist of small bowel mesentery and omentum will simplify the approach to avoid overlaps and confusion. this case-based lecture will present typical clinical cases of pelvic pain as well as some unusual but important causes. cases of acute and of chronic pelvic pain, and benign as well as malignant disease will be included. the audience will have the opportunity to participate in case discussion by the use of interactive voting pads. the selection of imaging modality for each clinical presentation and the importance of knowing the clinical findings at the time of the radiological interpretation will be discussed. for each case, the key radiological features will be illustrated. the essential elements of the radiology report and the key information required by the clinician will be discussed. in each case, the differential diagnosis and the need for follow-up imaging will be considered. the key teaching points for each diagnosis will be reviewed. this lecture provides a practical approach to the fundamentals of normal cross-sectional anatomy of the hip. basic knowledge necessary to identify the different portions and contents of the joint anatomy is provided. a special emphasis is on cartilaginous structures, the acetabular fossa, and capsular fibers and ligaments. functional anatomy of muscles and tendons about the hip is reviewed. the location of bursae and their association with adjacent structures is discussed. in the second part of the lecture attendees will learn how to avoid commonly seen pitfalls about the hip. a special focus on anatomic variants of the acetabular labrum simulating disease is given. osseous variants including acetabular ossicles and the superior acetabular notch will be explained and explored. debates about the role of herniation pits referred to as a normal variant are reviewed. the lecture offers an overview of muscular and tendinous variations around the hip joint. pelvic pain is an important part of clinical practice for any clinician who provides health care for women. pelvic pain may be acute, recurrent or chronic. acute pelvic pain (app) rarely lasts more than one month without crisis, resolution, or cure. pain of more than 1 or 3 or 6 months of duration is considered as chronic pelvic pain (cpp) and in many settings may be considered and treated as an illness itself. women who present with app frequently exhibit nonspecific signs and symptoms. diagnostic considerations encompass multiple organ systems, including obstetric, gynaecologic, urologic, gastrointestinal, and vascular aetiologies. as the first priority, urgent life-threatening conditions (e.g. ectopic pregnancy, appendicitis and ruptured ovarian cyst) and fertility-threatening conditions (e.g. pelvic inflammatory disease and ovarian torsion) must be considered. adolescents and pregnant and postpartum women require unique considerations. ccp is a common and significant disorder of women, with a prevalence of 3.8-12%. many disorders of the reproductive tract, gastrointestinal system, urological organs, musculoskeletal system, and psychoneurological system may be associated with ccp, the most common being endometriosis, adhesions, irritable bowel syndrome and interstitial cystitis. ultrasonography should be the initial imaging test because of its sensitivities across most aetiologies and its lack of radiation exposure. computed tomography (ct) serves an important role in patients with nonlocalizing symptoms, an indeterminate us evaluation, or in patients who require a wider search beyond the field of view available with us. magnetic resonance imaging is an extremely useful second-line modality for problem solving after us or ct. fat-suppression sequences help to establish fat-containing lesions and increase the conspicuity of inflammatory lesions. different sequences will be discussed. mr is rated below us and ct for evaluation of acute pelvic conditions, but is excellent alternative when administration of iodinated contrast media or radiation exposure is undesirable, especially in young or pregnant patients. long imaging times, limited access and cost are major drawbacks of mri. imaging findings of various gynaecologic and nongynaecologic conditions causing female pelvic pain will be presented. an overview of the interventional radiology management of painful osseus metastases will be presented. consideration will be given to patient, lesion and treatment modality selection (including radiofrequency ablation, cryoablation, microwave ablation, laser ablation, ethanol ablation, mr focused ultrasound ablation, cement osteoplasty, transarterial embolisation and combinations therein, e.g. combined radiofrequency ablation and cement osteoplasty). the evidence supporting these techniques and patient outcomes will be reviewed. molecular imaging -defined as the non-invasive assessment of biological mechanisms at molecular and cellular level -will play a major role in future disease diagnosis and treatment planning. in this context, the aim of this session is to introduce in simple terms several major research areas in molecular imaging and to discuss their future potential for clinical radiology. the differential diagnosis of hip pain is broad and includes intra-articular pathology, extra-articular pathology including referred pain from the spine, and mimickers including groin pain and pain from the joints of the pelvic ring. the diagnosis of all causes of hip pain/pathology has improved with greater use of magnetic resonance imaging (mri) to complement traditional investigations. in this session pathology involving the hip and groin will be reviewed in a systematic way which will outline an approach to the hip that will allow the reader to maximise their diagnostic ability. the review will include evaluation of bone marrow disorders such as avascular necrosis and transient osteoporosis and intra-articular pathology including labral tears and femoroacetabular impingement (arthritis and traumatic fractures will not be reviewed). extra-articular diagnoses such as bursitis, groin pain (osteitis pubis and adductor/ gracilis dysfunction) and common muscle and tendon injuries will then be reviewed. today, many procedures of bone and joint are performed under imaging control. minimally invasive procedures require less resources, time, recovery, and cost, and often offer reduced morbidity and mortality, compared to other modalities. many percutaneous techniques are available. some aim to treat pain and consolidate bone (cementoplasty). others ablate or reduce the tumour (chemical and thermal ablation techniques). the interventional radiologist with an efficient imaging-guided technique (flat panel fluoroscopy, ct, and mri) can increase the precision of the above-described procedures allowing an improvement of the results and reduction of the complications. furthermore, the presented interventions are carried out either on an outpatient basis or with 24 hours hospitalisation which contributes to the reduction of overall costs and presents a major advantage for patients of working age. some of these minimally invasive procedures can be considered as alternatives to surgery without excluding further surgical options if necessary. back pain is one of the most common complaints, it is estimated that almost 50% of working adults will experience it in any given year. diseases of peripheral skeleton may produce painful symptomatology as well. some of the algogenic structures of the spine and peripheral skeleton are lumbar intervertebral discs, facet joints and atlanto-axial/occipital joints, sacroiliac joints, nerve root dura, periosteum, ligaments, fascia. among several aetiologies which can involve these structures, spine degenerative pathology plays the leading role. nowadays, several different interventional techniques are available, each one with its specific target of action. with the right indication each of them has been proved to be effective as painkilling modality. herein, we present an up to date comprehensive overview on the interventional techniques available with their own indications. small airways and small airways diseases (sad) have attracted a lot of interest that has resulted in a large number of publications since the early 1970s. despite the several histopathological and clinical subtypes that have been described diagnosis is not always obvious. the introduction of thin section ct and the fact that this ct technique is able to depict signs of sad has not only renewed interest but has also improved insights in these disorders. in this session the direct and indirect ct signs of sad will be presented and the ct techniques that can improve their detection will be explained. correlations between pathological findings and the presence of these ct signs will be made and diseases that can mimic these ct findings will be discussed. schemes of classification of sad based on clinical and pathological findings will be discussed briefly, but most attention will be given to the radiological classification, which is based on the recognition of the direct and indirect signs of sad. algorithms that help to identify the cause of sad will be presented. finally, the use of ct and also of mr as a tool to examine the structure-function relationship in sad will be discussed. it will be shown how careful interpretation and software tools can help to generate data about disease extent and global and regional lung function. the ability to recognise direct and indirect signs of small airways disease on hrct has led to renewed interest in these elusive disorders. the "purest" of these diseases is constrictive obliterative bronchiolitis which is manifested on hrct by the indirect sign of a mosaic attenuation pattern; the differential diagnosis for mosaicism and an algorithm that helps to identify the correct cause of small airways disease will be presented. the necessity for routine expiratory hrct to make the diagnosis of obliterative bronchiolitis is controversial and will be discussed jointly whole body fluorescent imaging and bioluminescent imaging are now widely applied in small animals to study all kinds of biological and molecular processes like i.e. gene expression, tumour progression and metastasis, apoptosis, inflammation, angiogenesis, proteolysis and to follow trafficking, differentiation and fate of cells (i.e. stem-, immune-and tumour cells). this has been done mainly by using gene reporters expressing fluorescent proteins or luciferases. recently new mutated red shifted fluorescent proteins (with better light penetration and less absorption and autofluorescence) and codon optimized and mutated luciferases have been developed making optical imaging more sensitive and offering the possibility to use dual gene reporters. apart from new "smart gene reporters" there has also been a great development in injectable near infrared fluorescent (nirf) probes, especially for tumour detection. these nirf probes can either be targeted or enzyme-cleavable. these new developments has opened up the possibility to apply nirf imaging in the clinic especially to image tumour tissue and to identify sentinel lymph nodes during operation. the assessment of the tumour-free margin during cancer surgery is critical to completely remove the tumour and improve the prognosis of the patient. by injecting a tumour specific nirf probe, tumour tissue and local metastases can be visualised in real-time during operation using a dedicated nirf camera system. we now already use nirf imaging in the clinic to detect the sentinel lymph node (sln) in several types of cancers. in the current presentation preclinical and clinical applications of nirf imaging in image-guided surgery will be discussed. targeted ultrasound contrast agents have opened up the door for molecular imaging with sonography. these contrast agents, which consist of encapsulated gas microbubbles, are coated with antibodies or specific ligands. injected into the circulation, microbubbles are retained in diseased tissue where they can be detected and quantified by different approaches such as "semiquantitative 2-d" or "quantitative 3-d" imaging techniques. due to their size, microbubbles behave similar to red blood cells and remain within the intravascular space. therefore, the disease process must be characterised by specific molecular changes on the surface of the endothelial cells to be assessable by ultrasound. several angiogenic markers such as vegfr2, α v β 3 -integrins, icam-1 and vcam are known to be overexpressed by the endothelium in neoplastic, inflammatory and vascular diseases. thus, molecular ultrasound imaging seems perfectly suited to detect these markers and monitor changes which might occur during treatment response or disease progression. today, targeted ultrasound contrast agents are becoming a routinely used preclinical tool and the first application of specific microbubbles in a clinical scenario is expected for the near future. this talk will introduce into the principles of molecular imaging with ultrasound. based on recent studies, basics of tumour biology, potential endovascular targets, synthesis of molecular probes and different imaging approaches for a preclinical and clinical application of molecular ultrasound will be discussed. in this rc, a general insight of imaging in epilepsy, including indications, protocols, and the most common neuroradiological conditions to be identified, will be covered. particular interest will be given to tumours as a cause of epilepsy, and to their more relevant neuroradiological aspects. finally, the contributions of different imaging techniques in the specific context of epilepsy surgery will be reviewed. brain tumours are a common cause of epilepsy more often in adults, less in children.tumours detected in patients with chronic epilepsy are predominantly located in the brain cortex area, affecting the temporal lobe most often. any benign or malignant brain tumour can be responsible for seizures, but some are more frequently associated with epileptic symptoms. low-grade astrocytomas, oligodendrogliomas, gangliomas, dysembryoplastic neuroepithelial tumours (dnets) and glioblastomas multiforme are the tumours significantly often presenting with seizures in adult population. brain tumour-related epileptogenesis in not fully understood yet, but one can list a number of factors playing an important role in this process, including: disruption of physiological neuronal structure, tumour affection on the release of neurotransmitters and abnormal electrical activity of the brain. different imaging techniques are widely used for evaluation for neoplasms in epileptic patients. ct is reserved for acute conditions, one must remember to exclude other possible aetiologies of seizures like haemorrhage, trauma or inherited malformations. mri remains the gold standard in imaging investigation of patients with epilepsy. conventional pre-and post-contrast se sequences are mandatory to perform in every subject. newer and more sophisticated techniques such as diffusion-weighted imaging (dwi), functional studies (fmri), spectroscopy (mrs) and pet are helpful in qualification for surgery and preoperative functional mapping. mri has become established as the modality of choice for preoperative local staging of rectal cancer. the most important general advantages of mri compared to other crosssectional imaging modalities are the soft tissue contrast resolution between the propria muscle layer of the rectum and the perirectal fat, the ability to visualise the different pelvic compartments including the visceral pelvic (mesorectal) fascia and the surrounding tissues in the pelvis. high resolution t2-weighted sequences sagittal, transaxial and perpendicular to the tumour is the basic standard for morphological evaluation of the tumour, the distance of the tumour to the anal verge and for evaluation of extramural extension and the distance to the circumferential resection margin. presence of other adverse features such as extramural venous invasion and local lymph node metastases is also noted. the mr-images are ideally demonstrated by the radiologist in a local multidisciplinary conference to make sure that the information is used to select the best possible treatment for the patient. when neo-adjuvant treatment is administered, mri is usually performed both before and after treatment to assess treatment response. when planning surgery, both the pre-as well as the post-treatment images should be available for surgical planning. finally in this lecture, the potential benefits of 3 t compared to 1.5 t for pre-operative imaging of rectal cancer as well as the present role of additional techniques, such as diffusion-weighted imaging (dwi) and specific contrast agents that have been evaluated for assessment of rectal cancer will be addressed. locally recurrent rectal cancer is the main concern after rectal cancer surgery and has long been regarded as a rarely curable disease. patients were treated palliatively, and subsequent median survival was 14 months and the 5-year survival rate was 5%. however, during the past 20-30 years, more patients were considered candidates for curative treatment due to better treatment options. patients with distant recurrences from colorectal cancer, especially those in the liver or lung, have improved chances for cure with better imaging, better surgery and alternative minimal invasive treatment. in the follow-up after colorectal cancer surgery it is thus important to detect recurrences at an early stage. besides cea, imaging is often used as a surveillance tool. it is still unclear which is the most cost-efficient (imaging) tool for monitoring distant and local recurrences. this lecture aims at providing the evidence for surveillance by imaging and reviewing the guidelines for the detection of recurrences after colorectal cancer surgery. it will also discuss the role of mri for establishing resectability of locally recurrent rectal cancer and the imaging patterns and features of recurrent disease. its strength comprises a high sensitivity in detecting coronary stenosis > 50% and an excellent negative predictive value. the stringent limitation of cta lies in its confinement to anatomic grading of coronary stenosis and a lack of information regarding whether a stenosis causes reversible myocardial ischaemia indicating the need for coronary revascularisation. recently published data in animals and humans indicate that myocardial computed tomography perfusion (ctp) imaging is feasible, promising and accurate. the advantage of cta is the comprehensive evaluation of coronary arteries and myocardial perfusion defects from the same datasets, which permits both visualisation of coronary anatomy and physiology.further, ct provides information about regional and global myocardial function. the aim of this course is to understand basic principles of ct perfusion and functional imaging, to learn "how-to" perform ctp and comprehensive cta/ctp scans, to review current scientific evidence and to discuss potential clinical applications. nuclear medicine tests (spect and pet), mri and more recently mdct have been involved in myocardial perfusion imaging. in clinical practice, perfusion analysis is routinely performed with qualitative or semiquantitative assessment, both based on relative evaluation of uptake or enhancement of myocardium, considering a remote region as normal. however, the assumption of part of myocardium as normal can be wrong and cause false negatives. absolute quantification has been introduced mostly with pet perfusion imaging (water, ammonia and rubidium), but its incremental value for the clinical decision making has not been widely investigated. more recently, mr perfusion imaging has been used for quantitative analysis with different technical approach. there are some clinical scenarios where quantification can change the clinical interpretation: 1. multivessel coronary artery disease (cad), 2. balanced multivessel cad, 3. exclusion of cad in symptomatic patients, 4. microvascular disease, 5. revascularised patients. however, there are still some limitations in the use of absolute quantification: first, the setting of cutoff value for normal or abnormal perfusion; second, some clinical situations, such as heart failure patients, where perfusion is reduced and heterogeneous. finally, studies concerning the prognostic value and the cost-effectiveness are needed. epilepsy is a common disorder with a prevalence of up to 1% in the general population. epilepsies are broadly classified into generalized and focal. though most generalised seizures are controlled pharmaceutically, 30% of focal seizures are medically intractable. in this subset of patients, the overall sensitivity of mri in identifying responsible substrates is approximately 80%. the purpose of neuroimaging in epilepsy patients is to identify underlying structural abnormalities that require specific treatment (usually surgical) and to aid in formulating a syndromic or aetiologic diagnosis. in this presentation imaging findings of the most common non-neoplastic lesions responsible for focal epilepsy, namely: a. hippocampal sclerosis, b. malformations of cortical development, c. vascular abnormalities and e. gliosis, will be discussed along with their differential diagnosis and pertinent imaging pitfalls. since routine mr imaging is suboptimal in identifying epileptogenic substrates, imaging should be tailored accordingly. hippocampal sclerosis, the most common cause of mesial temporal lobe epilepsy, is best demonstrated when the temporal lobes are imaged with thin sections in coronal plane perpendicular to the longitudinal axis of the hippocampus. inversion recovery sequences best demonstrate morphology and volume loss in the hippocampus, mammilary body and fornix. t2 and flair images best demonstrate the increased signal due to gliosis. for malformations of cortical development flair is useful in assessing hyperintense signal. t1 gradient volume sequences can demonstrate subtle developmental malformations. finally, because many epileptogenic lesions are subtle and easily overlooked, a systematic diagnostic approach to mri interpretation in the clinical setting of epilepsy is helpful and will be discussed. epilepsy surgery is an effective and safe therapy for selected patients with intractable localisation-related epilepsy. when morphological mri fails to reveal focal, structural pathology (e.g. tumour, dysplasia, etc). as the putative aetiology for the seizures, other modalities may be taken into account. in the absence of structural pathology it is essential to identify the epileptogenic zone as exactly as possible in order to (a) increase the chance of a good outcome (reduction or termination of seizures) and (b) limit post-surgical sequelae. this lecture will cover some modalities that may add valuable information in this process. the need to individualise the pre-surgical evaluation and the concept of a multimodality epilepsy protocol will be discussed. the main focus will be on spect (single-photon-emission computed tomography), functional mri, pet (positron-emission tomography) and the added value of co-registration on morphological mri (e.g. siscom). briefly, ictal spect may help to identify focal areas of hyperperfusion (ictal zones). functional mri is used for several reasons. one is to determine language laterality (dominant hemisphere); another is to localise eloquent cortical structures to aid the planning of the surgical approach. pet may detect hypometabolic areas corresponding to areas involved in epilepsy. mrs (magnetic resonance spectroscopy), meg (magnetoencephalography) and intradural eeg-registration and stimulation will be mentioned. the term epilepsy covers a wide spectrum of symptoms and underlying etiologies. an essential part of the work-up of patients with epilepsy includes the radiological examination. in recent years more sophisticated methods radiological methods have emerged and the discussion will focus on how these new advanced techniques may help finding underlying causes and be of help in the pre-surgical work-up. excellence in teleradiology: key issues in workflow management j. schillebeeckx; bonheiden/be (jan.schillebeeckx@imelda.be)the healthcare market is undergoing significant change. the market is evolving from a provider centric to a patient centric model, requiring relevant data to converge at patient level in a timely and structured fashion. the push towards setting up collaborative networks for radiology is strong in most european countries. the most important challenge for teleradiology is to ensure that it develops in a manner that benefits patient care and ensures overall patient safety, and does not in any way reduce the quality of radiology services provided to the citizen. therefore, these collaborative networks require more than just it infrastructure with it support. but as important is case management, workflow management and the administrative and management support that provides all the stakeholders with operational, analytical and statistical qa reports. through a centrally operated hub, the radiology workflow is optimised to ensure throughput of cases, involving radiologists in the network, with the difference that only the services are provided by the hub to the network, not the medical acts, which remain in the hands of the radiologists. learning objectives:1. to learn about the technical needs of a teleradiology infrastructure adapted to a distributed environment. 2. to understand that teleradiology involves much more than just technology.optimising the workflow and time management are also important. 3. to appreciate how creating collaborative networks can improve the efficiency of radiology procedures and bring improved work/life balance to radiologists. to make teleradiology an integrated part of clinical radiology, it must change from being a provider of radiology reports into a close collaboration with the client radiology department. there are many different aspects on workflow in a clinical setting and the teleradiology service should adapt to these specific needs in order to make a seamless collaboration. however, there are advantages with the global aspects of teleradiology that could improve diagnostic accuracy and efficiency in the clinical setting that should be woven into the collaboration. teleradiology services have developed substantially over the last few years from limited use between hospitals and tertiary care centres for second opinions and patient transfer to the international provision of reporting services. there is no doubt that teleradiology provides a valuable service in some circumstances, but it also has a number of inherent limitations regarding the proper provision of imaging services to the patient and therefore may increase risks for the patient. we will highlight the problems that have arisen and reiterate key parts of the guidelines which were developed for the benefit of patient care. this lecture will demonstrate a multimodality approach to the imaging of salivary colic. the relevant us and mri salivary anatomy will be highlighted and the ultrasound, computed tomography and magnetic resonance appearances of salivary grafts. respectively. graft sclerosis develops in 38% of nonoccluded venous bypass vessels after 5 years and in 75% after 10 years. this sclerosis causes more than 50% luminal narrowing in approximately half of the affected vessels. non-invasive imaging of coronary bypass grafts by md-ct require information about the operative procedure. with the increasing implementation of 64slice ct scanners and beyond, it is possible to scan the heart and the full anatomic extent of grafts with sub-millimeter slice-thickness within a single breath-hold. when analysing the grafts, three graft segments should be assessed: the origin or proximal anastomosis, the body of the graft and the cardiac anastomosis, either single or sequential. recent studies have shown that graft patency and the presence of significant graft stenosis can be assessed with an accuracy of 100% using most recent md-ct technology (256/320 slice ct or dual source ct). the assessment of native coronaries with respect to the progression of cad may still be problematic in cases with severe calcifications of the native coronary arteries. in these cases, mr perfusion imaging in combination with cine and late gadolinium enhancement (lge) imaging may be helpful in detecting newly developed, stress-induced myocardial ischaemia. teleradiology services have developed substantially over the last few years from limited use between hospitals and tertiary care centres for second opinions and patient transfer to the international provision of reporting services there is no doubt that teleradiology provides a valuable service in some circumstances, but it also has a number of inherent limitations regarding the proper provision of imaging services to the patient and therefore may increase risks for the patient. we will highlight the problems that have arisen and to reiterate key parts of the guidelines which were developed for the benefit of patient care. it is now well understood that teleradiology cannot be considered just as 'telereporting', i.e. the simple interpretations of images remotely acquired and sent as a message in the bottle. teleradiology procedures, being medical acts, must ensure the full involvement of the interpreting radiologist in all phases of the well established practice of diagnostic imaging: appropriateness check, personalised acquisition protocols, access to clinical history and prior imaging examinations, communication with referring physician and patient. any obstacle that teleradiology causes to these activities may put our patients at risk (and therefore may expose us at liability suits). the presentation will describe the organisational as well as technological remedies for reducing such risk. for several decades, monte carlo simulation has been recognised as a powerful technique to simulate the transport of radiation in media, as well as to provide solutions for calculations too complex for classical approaches. several general purpose codes and databases providing particle interaction cross-sections have been developed, and with the increase in computing power, simulation has become more and more popular within the field of medical imaging. using monte carlo simulation methods, the different steps involved in the formation of a medical image can be analysed in detail, and the whole system optimised. a topic that has deserved particular attention in the past is the simulation of x-ray tubes and x-ray spectra, which is the first step in the simulation of a medical imaging system. when simulating an x-ray tube, various complex phenomena need to be taken into account, such as the electron multiple scattering, bremsstrahlung interactions, characteristic x-rays emitted from the k-shell and auger electrons emitted during a photon interaction. together with the simulation of the target material and the filtration of the x-ray beam through permanent (e.g. a be window) and added filtration (e.g. al, mo, rh, ag, etc)., this technique can lead to a good estimation of the emitted x-ray spectrum, a task which is hard to achieve with experimental methods. this review will provide an overview of the basic knowledge necessary to start the simulation of an x-ray tube as well as of how to accelerate the calculations. emphasis will be given to mammographic x-ray tubes. breast cancer screening and diagnostic imaging, as all clinical imaging, are increasingly multimodality. a number of new imaging modalities have been developed, including digital breast tomosynthesis and dedicated breast ct. they have shown promise in early studies; however, their technological complexity present obstacle for optimisation. the ultimate technology tests are clinical trials, which are, however, challenging, particularly for breast cancer screening, as large studies are needed due to the small number of detected lesions. clinical trials are costly, long, and they involve repeated exposure of women to radiation. as an alternative, we have been developing virtual clinical trials, based upon our virtual breast phantoms and simulation of phantom images. this talk will describe the development of anthropomorphic computer breast phantoms, and illustrate their use in the analysis of phantom digital mammography and digital breast tomosynthesis images. different currently used phantom designs will be compared in terms of their flexibility and realism. specific phantom requirements related to different imaging modalities will be emphasised. the role of phantoms in tissue-specific analysis of the radiation dose during mammography will be discussed. in addition to the anthropomorphic phantoms for breast imaging, the use of virtual patients in various clinical imaging disciplines will also be illustrated. learning objectives:1. to learn about requirements for anthropomorphic phantoms (virtual patients). 2. to understand the value of anthropomorphic phantoms for breast imaging. 3. to compare advantages and disadvantages of several types of anthropomorphic phantoms. 4. to learn how to estimate typical patient doses from simulations with virtual phantoms.colic will be shown and techniques for optimising the imaging of salivary colic given. the use of us, ct, mri, and both mri and conventional sialography in the imaging of salivary colic will be discussed. the role of interventional sialography and minimally invasive techniques in benign salivary gland obstruction will be demonstrated. trigeminal neuralgia is defined as recurrent episodes of lancinating pain most common in the second (v 2 ) or third division (v 3 ) of the trigeminal nerve. the pathogenesis is a neurovascular conflict by an artery or vein associated with focal demyelination of sensory fibers at the glia-schwann cell junction. apposition of demyelinated fibers induces abnormal generation and transmission of impulses. mr imaging is based on high-resolution 3d sequences: ciss/fiesta/3d t2space with coronal and sagittal oblique mpr and a 3d tof intracranial sequence with axial and coronal thin mip reconstruction to delineate the course of vessels along the trigeminal nerve form the pons, and glia schwann cell junction to the gasserian ganglion. the brainstem and brain are assessed by t2, flair and 3d isotropic gd-enhanced t1 sequences; the viscerocranium is examined by a noncontrast and coronal t1 gd fat suppressed sequence. analysis of images is focussed on recognition of displacement and distortion of the proximal trigeminal nerve by the sca, rarely by the aica, ba or petrosal, pontomesencephalic or peduncular vein. correlation of the circumferential site of distortion at the root entry zone with the somatopic representation of fibres increases the, in general, low specificity of the neurovascular contact. ruling our compressive tumours, neoplastic infiltration, inflammation or demyelination and delineating a neurovascular conflict stratifies patients for potential microvascular decompression in case of failure of medication. the purpose of this lecture is to provide an overview of the key imaging features of painful swallowing with or without associated mucosal pathology. in the presence of a mucosal lesion, painful swallowing is most often caused by infectious, neoplastic or traumatic lesions of the pharynx itself, whereas in the absence of mucosal alterations, painful swallowing is the result of functional disorders (dysfunction of the cricopharyngeus muscle), infectious, inflammatory or neoplastic diseases affecting adjacent neck spaces (retropharyngeal and paraphyrngeal space), neurologic impairment (glossopharyngeal neuralgia), carotidodynia and eagle's syndrome. the indications for ct, mri, us and videofluoroscopy will be reviewed and their respective role in the detection and precise description of the underlying cause. major emphasis will be put on how to report the findings in a comprehensive way. learning objectives:1. to recognise the most common causes of painful swallowing in patients with a normal pharynx at clinical examination. 2. to review the role of different imaging techniques in the diagnosis and treatment of painful swallowing. 3. to review the key imaging techniques in the diagnosis and treatment of painful swallowing. 4. to review the key imaging features of the most common causes of painful swallowing as seen with the respective imaging techniques.the typical hrct features of interstitial lung disease are ground-glass opacity, consolidation, pulmonary nodules, tree-in but sign, bronchiolar wall thickening, mucoid impaction, air trapping, septal thickening, mosaic perfusion and honey combing. most frequent diseases in children to be dealt with are bronchiectasis, cystic fibrosis, asthma, constrictive bronchiolitis, bronchiolitis obliterans and extrinsic allergic alveolitis and they will be demonstrated with use of a systematic approach. during the lecture we will present and validate methods to simulate radiographic images with the monte carlo software mcnp/mcnpx in a time efficient way. we will start the lecture by introducing three image detector models that can be used in mcnp/mcnpx. the first detector model that will be presented is the standard semideterministic radiography tally, which has been used in previous image simulation studies. furthermore, we will present two alternative stochastic detector models: a perfect energy integrating detector and a detector based on the energy absorbed in the detector material. the image detector models will be validated by comparing calculated scatter-to-primary ratios (sprs) with published and experimentally acquired spr values. subsequently, we will introduce a method to modify the images, generated with the mcnp/mcnpx image detector models, for the physical characteristics of a computed radiography (cr) imaging systems. the method presented in this lecture takes into account the signal intensity variations due to the heel effect along the anode-cathode axis, the spatial resolution characteristics of the imaging system and the various sources of image noise. to demonstrate the accuracy of our model we will compare the threshold-contrast detectability in simulated and experimentally acquired images of a contrast-detail phantom. thoracic trauma in children is most commonly seen in a polytrauma context, and is associated with significant morbidity and mortality. blunt trauma accounts for the majority of cases, often resultant from motor vehicle accident and pedestrian crash. common thoracic injuries include pulmonary contusion, rib fractures, pneumothorax and haemothorax. diaphragmatic and mediastinal injuries, such as aortic rupture and tracheobrocheal tear, are rare but potentially life threatening. different patterns of injury are seen in children due to anatomical and physiological differences, and these should be recognised. chest radiography is the first and most important imaging modality. mdct allows accurate diagnosis for most traumatic injuries, and is usually performed for severe chest and/or polytrauma. adapted paediatric protocols are essential. foreign body inhalation is a common paediatric domestic accident, with potential serious or even fatal consequences. clinical history is the key for the diagnosis. with a definite history, bronchoscopy is the modality of choice for both diagnosis and treatment. however, in many cases the aspiration event is not witnessed and the diagnosis is often delayed or overlooked. the majority of aspirated foreign bodies are non-opaque and imaging findings largely result from complete or incomplete airway obstruction. chest radiography is the first imaging modality. expiratory films (or lateral decubitus or fluoroscopy) are very useful to demonstrate air-trapping. chest mdct offer excellent details of the tracheobronchial tree and pulmonary parenchyma, and is usually reserved for more complex cases and/or long-standing foreign bodies. high-resolution ct of the chest is the imaging technique of choice for the evaluation of most infiltrative diseases of the chest. in children dose-adapted protocols should be used and recommendations for suitable protocols will be given in the course. the mediastinum is a region of the thorax that separates both lungs and communicates with the neck and the abdomen. these two anatomic features are very important to understand the behaviour of some diseases and their radiological manifestations. most asymptomatic mediastinal masses are benign, while clinical symptoms might raise the possibility of a malignant lesion. imaging plays a very important role, especially ct and mri. in the presence of a mediastinal mass we must ask ourselves two questions: 1. where is the mass located? the classic divisions of the mediastinum in compartments remains very useful, because it narrows the differential diagnosis. 2. is the lesion cystic or solid? pure mediastinal cysts are benign and their characterisation depends on their location. thymic cyst (anterior mediastinum), bronchogenic and duplication cysts (middle mediastinum) and menyngoceles (posterior mediastinum). solid lesions may be benign or malignant while some lesions may have a cystic component. solid lesions of the anterior mediastinum are usually thymomas, germ cell tumours or lymphomas. in the middle mediastinum most masses are of lymphatic origin but we should also include aortic or oesophageal pathology. intrathoracic thyroid usually follows the trachea and thus is situated in the upper-middle mediastinum although posterior and anterior extensions may occur. in the posterior mediastinum most masses are of neural origin. there are some locations that will typically indicate specific diagnosis or a narrow differential. such is the case of the cardiophrenic angle masses, juxtadiaphragmatic lesions and thoracic inlet pathology. colorectal cancer is common. approximately 280,000 new cases occur each year in the 500 million population of the 27 states which comprise the eu. after lung, it is the second commonest cause of cancer death resulting in approximately 140,000 deaths per annum. these relatively high mortality figures are a reflection of the fact that the disease is often advanced at the time of presentation. efforts to reduce mortality, therefore centre on early detection as well as accurate staging. the latter is particularly important in rectal cancer-the commonest site for colonic cancer. detection depends on presentation, which is often protean or non-existent; hence, the introduction of screening programs. typical diagnostic tools include the barium oenema, optical colonoscopy and ct colonography. the limitations of the barium enema have been exposed by optical colonoscopy and it can no longer be advocated in this role. ct colonography, however, rivals optical colonoscopy in the detection of polyps and tumours, although of course has no therapeutic potential. major advances in the treatment of rectal cancer include total mesorectal excision (tme) of the rectum as well as neo-adjuvant therapies such as chemo-radiation. their use depends on highly accurate staging of the primary disease, which can only be achieved by mr examination, although of course ct or pet/ct is required for the assessment of more distant metastatic disease. finally, once treated, it is essential that these patients are followed-up; usually by a regime of colonoscopy and ct. these issues will be discussed in an interactive lecture. decreased opacity of the lung may be a bilateral or unilateral process. if unilateral, it may involve an entire lung, a lobe or a segment. faulty radiological technique must always be excluded. the most common cause of unilateral decreased opacity is a previous mastectomy. bilateral decreased opacity occurs in copd and asthma. it is also caused by decreased blood flow in the lung/s. expiratory films separate the true lung causes from all the others, by demonstrating air trapping. pulmonary nodules are spherical radiographic opacities (solid and subsolid) that measure up to 30 mm in diameter. extremely common in clinical practice, pulmonary nodules, especially small ones under 1 cm in diameter, are a challenge to manage. it is important to identify malignant nodules because they are potentially curable. the first step in assessing a pulmonary nodule on a chest radiograph is to determine that it is indeed a lung nodule rather than a pleural or chest wall abnormality. it is essential to review images from previous examinations, because a solid nodule that remains stable for at least 2 years is probably benign. topics discussed in this talk include the importance of nodule size, growth rate, margin morphology, density (solid, ground-glass and part solid), calcifications or fatty components within the nodules, the significance of cavitations or bubble-like densities, enhancement patterns at dynamic contrast-enhanced ct, and findings on positron emission tomography (pet). the talk also covers the current guidelines for the management of incidentally detected nodules (solid and subsolid). this presentation has the purpose to familiarise radiologists with the spectrum of mesenteric and omental cystic masses, demonstrating the additional correlation with the underlying pathology. cystic masses of the mesentery or omentum are not common lesions; however, radiologists should be aware of these entities as well as with other cystic lesion of the abdomen. important tool for the diagnosis is to determine the organ from which the mass originates. common types of mesenteric and cystic masses include lymphangioma, enteric duplication cyst, enteric cyst, mesothelial cyst and non-pancreatic pseudocyst. other entities such as cystic mesothelioma, cystic spindle cell tumour and cystic teratoma could be located in the mesentery also. due to the overlap in the imaging features, not always the final diagnosis could be reached by imaging only and therefore histologic examination is necessary to establish the diagnosis. however, it is important for the radiologist to define the cystic nature of the mass and demonstrate the potential mesenteric or omental origin, targeting to the correct differential diagnosis of the cystic lesion. cancer cells from intraabdominal neoplasms, carried by peritoneal fluid throughout the abdominal cavity, result in widespread metastases in the form of implants, the socalled peritoneal carcinomatosis. the location of implants development is governed mostly by peritoneal fluid circulation and by specific anatomic pathways formed by peritoneal reflections. the most common sites where the peritoneal fluid may temporarily arrested facilitating implantation of cancer cells include cul-de-sac, distal small bowel mesentery, right paracolic gutter, posterior sub-hepatic space, greater omentum and sub-phrenic spaces. the role of imaging is to disclose the presence and extent of the disease -i.e. fundamental in candidates for cytoreductive surgery -to monitor response to treatment and to reveal recurrences. mdct with thin collimation and i.v. contrast material supplemented by multiplanar reconstructions is the primary imaging modality for the investigation of peritoneal carcinomatosis. ascitis, contrast enhanced smooth, nodular, or plaque-like peritoneal thickening, peritoneal nodules, plaques or masses, rounded, ill-defined soft-tissue or cystic mesenteric masses, mesenteric fixation with increased attenuation values and thickening, irregular soft-tissue permeation of omental fat or confluent solid omental masses are the most frequent ct findings of peritoneal carcinomatosis. ct has a sensitivity and specificity between 85 and 95%, depending on the size/location of implants and examination protocol used. mr imaging employing a post-gadolinium-enhanced 3d flash sequence with fat saturation may alternatively be used and it is advantageous in cases of diffused layered type of peritoneal/mesenteric involvement. diffusion mri may be of value in post-treatment imaging evaluation. primary solid tumours of the peritoneum and mesentery occur much less frequently than metastatic disease in the same location. however, these rare primary neoplasms (peritoneal mesothelioma, primary peritoneal serous carcinoma, desmoplastic small round cell tumour, mesenchymal tumours, mesenteric fibromatosis or mesenteric desmoid tumour, mesenteric sarcoma, etc.) are often first detected at ct and should be considered in the absence of a known primary organ-based malignancy. ct appearance combined with patient's relevant clinical and demographic data can help narrow the differential diagnosis for a primary peritoneal or mesenteric tumour in many cases; diffuse sheetlike thickening of the peritoneum and stellate appearance of the mesentery at ct or mri are suggestive of primary malignant mesothelioma in older men with high level of asbestos exposure. absence of an ovarian mass is mandatory in suggesting the diagnosis of primary peritoneal serous carcinoma in a post-menopausal woman. desmoplastic small round cell tumour occurs in young men and often presents with a large primary peritoneal mass with calcification. a solid mesenteric mass at ct or mri, regardless of its pre-and post-contrast appearance, occurring in a patient with familial postgraduate.educational.programme embolisation of hcc with drug eluting beads k. malagari; athens/gr (kmalag@otenet.gr)drug eluting beads have proved predictable pharmacokinetics and achievement of higher doses of the chemotherapeutic, prolonged contact time with cancer cells.in addition, research data today have shown response, and tolerance benefit of drug eluting beads compared to conventional chemoembolisation for the more advanced subgroup of bclc -class b patients. for diameters larger than 100 μm dc bead loaded with doxorubicin have proven to be more effective with respect to local response, recurrence rates and time to progression (ttp) compared to bland embolisation with similar diameters. in this session results of studies on dc bead loaded with doxorubicin for the treatment of hcc will be discussed, and guidelines for optimal clinical use will be presented. selective internal radiotherapy j.i. bilbao; pamplona/es (jibilbao@unav.es)selective internal radiotherapy, also called radioembolisation (re), consists in the delivery of beta-radiation to liver tumours using microspheres loaded with yttrium-90 (y90) that are injected into the hepatic artery or its branches. y90 is a pure beta-emitting radioisotope, with a limited tissue penetration (average: 2.5 mm and maximal: 11 mm) and a half life of 64 hours. y90 can be either incorporated or labelled into glass or resin microspheres (25 µm). once the particles are infused into the hepatic artery, they travel to the distal tumoural arterioles, from where the beta-emissions from the isotope irradiate the tumour. with traditional external beam radiation, doses are limited to 30-40 gray (gy) due to the risk of radiation-induced liver disease that may occur with higher doses. with re, tumours can receive a higher dose of radiation due to their preferentially arterial vascularisation and a higher tolerance of the non-tumoural liver parenchyma to this form of radiation. re has shown an encouraging antitumoural activity with a good safety profile in patients with hepatocellular carcinoma, even in the presence of portal vein thrombosis or invasion. local tumour growth control is achieved in the majority of patients although response rates using volumetric criteria are achieved in only 20-40% of patients. in liver-predominant unresectable metastases, there is promising evidence that re combined with systemic chemotherapy significantly extends the time to progression of liver metastases and increases objective response rates as well as enabling patients to receive systemic chemotherapy for a longer period of time. learning objectives:1. to learn about the technique, legal and safety requirements in the cathlab. 2. to understand the diagnostic and interventional procedures before radioembolisation. combined therapies before and after ablation r. lencioni; pisa/it (lencioni@med.unipi.it) image-guided rfa is currently established as the standard of care for patients with early-stage hcc when transplantation or resection is precluded. however, histologic data from liver specimens of patients who underwent rfa as bridge treatment for transplantation showed that the rate of complete tumour eradication is highly dependent on the size and the presence of large abutting vessels. combined percutaneous-transcatheter approaches that aim at increasing the ablation volume by minimising heat loss due to perfusion-mediated tissue cooling have been developed, using either a balloon catheter occlusion of the tumour arterial supply at the time of the rfa or by performing a prior tace. experimental studies in animal tumour models have shown that lowering the temperature threshold at which cell death occurs by combining sublethal heating with cell exposure to trans-arterial chemoembolisation takes advantage of the largely portal vascularisation of liver tissue, while metastatic tissue is supplied almost exclusively by hepatic arteries. the benefit of intra-arterial application of chemotherapeutic drugs is proportional to the first pass extraction of the drug by the target tissue and inversely proportional to the body clearance of the drug. these figures vary greatly with different chemical properties of the drug. intratumoural drug concentration after transarterial application (compared to intravenous application) is approximately 20x for thp-adriamycine, 5x -10x for 5 fu, 6x -8x for mitomycine, 4x for cisplatin or oxaliplatin, and 2x for doxorubicin. several trials support superiority of intraarterial 5 fu over i.v. application in response rate, and partly with a moderate survival benefit. however, with the advent of novel chemotherapeutics (mainly oxalyplatin, irinotecan), response rates of i.v. chemotherapy approached the results after i.a. 5 fu. more recently, i.a. oxaliplatin has shown a 45% response rate in a multicenter trial on non-responders to i.v. oxalyplatin. also, combinations of i.a. oxalyplatin and i.v. 5 fu and cetuximab have achieved promising response rates as first line therapy. even though intraarterial chemoembolisation alone can achieve promising response rates, the actual survival benefits are limited to date. also, the beneficial effect of additional embolization (over conventional arterial injection) remains largely unproven for a large number of different embolisation agents in hepatic metastases. in an attempt to further increase tumour uptake, chemotherapeutic agents (anthracyclines and irinotecan) have been electrostatically coupled to microspheres. irinotecan-eluting microspheres have been untilized in the treatment of crc metastases in smaller case series. due to the high parenchymal drug uptake, appropriate medications to mitigate postembolization side effects need to be emphasised. while the initial response rates were over 60% (according to easl), tumour progression was observed within 6 months in the majority of responders, suggesting potential stimulation of angiogenesis at the tumour boarders. potentially, adjuvant antiangiogenic treatment can provide an overadditive effect in these patients.primary bone tumours require both local staging and the identification of distant metastases to guide management. mr imaging is the modality of choice to determine local disease extent and allows excellent depiction of intra-and extraosseous disease. chest ct enables pulmonary metastases to be identified and bone scintigraphy allows evaluation of the presence of bone metastases. the roles of whole body mri and pet/ct in the staging of bone tumours will also be discussed. whilst imaging may allow a narrow differential diagnosis to be reached, histological confirmation of the nature of the lesion is required pre-operatively to plan appropriate treatment. image-guided biopsy may be performed using fluoroscopy, ct, mri and occasionally ultrasound guidance. the relative values of each of these techniques will be covered. percutaneous therapies are increasingly being utilised in the treatment of a number of primary bone tumours. radiofrequency ablation is the method of choice for osteoid osteoma and is now used in the treatment of chondroblastoma. alternatives include microwave therapy, cryotherapy and sclerotherapy. these percutaneous techniques may also be used for local disease control where disease recurrence is encountered. magnetic resonance imaging (mri) has evolved to become the most important diagnostic method for local staging of primary bone tumours and for detecting postoperative tumour relapse. it allows accurate preoperative staging of local tumour extent and helps to obtain adequate safety margins. mri is a noninvasive technique that can be used to obtain information regarding tumour vascularisation, metabolism, and pathophysiology, and allows early assessment of therapeutic effects of cancer drugs. one approach is dynamic contrast-enhanced (dce) mri, which measures tumour vascular characteristics after administration of a contrast medium. mri enhanced with small-molecular-weight contrast agents is extensively used in the clinic to differentiate benign from malignant lesions, as well as to monitor tumour microvascular characteristics during treatment. diffusion-weighted mri (dwi) is a more recent technique and it allows noninvasive characterisation of biologic tissues based on the random microscopic motion of water proton measurement. several studies have shown that dwi allows early detection of tumour response to chemotherapy. the use of water diffusion is a surrogate marker used to distinguish highly cellular regions of tumour from acellular and necrotic regions. whole body diffusion-weighted sequence (wb dwi) is a new promising technique feasible to evaluate multifocal disease. dwi has revealed great potential in the evaluation of patients with cancer or benign disease, as it supplies both quantitative and qualitative information of the whole body. this presentation will focus on the potential role of dwi in combination of dce mri in bone tumours as well as on the possibilities of wb dwi. in this integrated refresher course, the impact of basic and advanced imaging on the entire process, from diagnosis to treatment of bone tumours, will be addressed. diagnosis is based on understanding the imaging features from a histopathologic chemotherapeutic agents is an attractive alternate strategy to increase tumour necrosis. the efficacy of a combination therapy, including rfa plus the intraarterial administration of drug-eluting beads has been recently demonstrated, while the use of intravenously administered, thermally sensitive drug carriers is currently being explored. despite the advances in local treatment, the long-term outcome of treated patients remains unsatisfactory because new tumours emerge in about 80% of the cases within 5 years. clinical trials evaluating the usefulness of adjuvant molecular targeted therapies with anti-angiogenic and anti-proliferative activity in preventing early recurrence after successful ablation are ongoing. in this integrated refresher course, the impact of basic and advanced imaging on the entire process from diagnosis to treatment of bone tumours will be addressed. diagnosis is based on understanding the imaging features from a histopathologic perspective. staging, biopsy and image-guided treatment require an integration of imaging findings with basic knowledge of surgical-oncological principles, as well as skills. can technically driven development of advanced mr techniques change how we diagnose, monitor therapy and determine prognosis. techniques and procedures that improve patient outcome in a cost-effective way will be identified based on 3 presentations and a panel discussion. a. diagnosis: from radiographs to mri k. wörtler; munich/de (woertler@roe.med.tum.de)the diagnosis of a bone tumour is based on clinical findings, the age of the patient, the location of the lesion, its radiologic appearance, and, if imaging does not allow for a specific diagnosis, its histopathologic features. radiography remains the initial imaging modality for evaluation of the localisation of the lesion with respect to the longitudinal and axial planes of the involved bone, for the depiction of matrix mineralisations, and for estimation of biologic activity by analysing the patterns of bone destruction and periosteal response. ct can add "radiographic" information particularly in regions of complex skeletal anatomy such as the spine, pelvis and shoulder girdle. mr imaging has classically been used to determine the local extent of a bone tumour (local staging). in addition to radiography and/or ct, it can at times also be valuable in establishing the differential diagnosis, especially in cystic bone lesions and cartilaginous tumours. whole-body applications have recently gained importance in demonstrating the presence and extent of bone (marrow) involvement in benign and malignant systemic/polyostotic tumourous diseases. this course reviews the basic principles of diagnosing bone tumours in a multimodality approach (with an emphasis on conventional radiography). the different steps of morphologic analysis as well as the advantages and disadvantages of the individual imaging techniques are illustrated on the basis of pathologically confirmed cases. s130 a b c d e f g h review: (1) the biological rationale for using perfusion imaging in brain tumours, (2) methods available for the imaging of microvascular structure and function in brain tumours. we will discuss the relevant advantages and disadvantages of t1 versus t2 weighted acquisition strategies. early diagnosis and treatment of acute stroke is crucial for a favourable prognosis. while non-contrast mri is much more sensitive to ischaemia in comparison with non-contrast ct, perfusion studies make both techniques comparable. ultrafast ct scanners cover most of the brain with perfusion imaging; the scanning is faster and quality imaging results depend less on patient co-operation than in mri. however, mri enables diffusion imaging adding more specific information to the diagnostic process. because of the short time window to eventual vascular intervention, in many institutions ct is the technique of choice. besides depiction of hyperacute stroke by means of diffusion weighted imaging, mri has the advantage of performing a contrast agent-free perfusion study using a promising new technique called arterial spin labelling (asl). thus, an mri perfusion study can be performed even in patients with impaired renal functions where iodine and gadolinium-based contrast agents may be dangerous. perfusion imaging is an emerging non-invasive tool that enables evaluation of brain function via assessment of various hemodynamic measurements such as cerebral blood volume, cerebral blood flow, and mean transit time. these techniques have become important clinical tools in the diagnosis and treatment of patients with cns disorders via evaluation of brain tissue during cerebrovascular diseases, noninvasive histopathologic assessment of tumours, evaluation of neurodegenerative conditions and assessment of the effects of drugs. perfusion imaging is helpful to analyse and assist in judging the biological behaviour (especially haemodynamic features) of central nervous system diseases. qualitative and quantitative information can be obtained to evaluate pathoanatomical structures and pathophysiological changes of the lesions. cerebral blood flow (cbf), cerebral blood volume (cbv), mean transient time (mtt), permeability surface (ps), regional blood volume, microvascular permeability measurements and more information can be obtained for the diagnosis and differential diagnosis of the diseases. advantages and disadvantages of the ct perfusion imaging (ctp) and magnetic resonance perfusion imaging (mrp) in the different diseases will be evaluated in detail. hints and tips for the better applications and postprocessing will also be discussed. techniques for ct and mr, post-processing, radiation r.a. meuli; lausanne/ch (reto.meuli@chuv.ch)brain perfusion can be assessed by ct and mr. for ct, two major techniques are used. first, xenon ct is an equilibrium technique based on a freely diffusible tracer. first pass of iodinated contrast injected intravenously is a second method, more widely available. both methods are proven to be robust and quantitative, thanks to the linear relationship between contrast concentration and x-ray attenuation. for the ct methods, concern regarding x-ray doses delivered to the patients need to be addressed. mr is also able to assess brain perfusion using the first pass of gadolinium based contrast agent injected intravenously. this method has to be considered as a semi-quantitative because of the non linear relationship between contrast concentration and mr signal changes. arterial spin labeling is another mr method assessing brain perfusion without injection of contrast. in such case, the blood flow in the carotids is magnetically labelled by an external radiofrequency pulse and observed during its first pass through the brain. each of this various ct and mr techniques have advantages and limits that will be illustrated and summarised. learning objectives: 1. to understand and compare the different techniques for brain perfusion imaging. 2. to learn about the methods of acquisition and post-processing of brain perfusion by first pass of contrast agent for ct and mr. 3. to learn about non contrast mr methods (arterial spin labelling). brain tumours a. jackson; manchester/uk (alan.jackson@manchester.ac.uk) this presentation will discuss the current 'state of the art' in the use of perfusion imaging techniques in neuro-oncology. the term "perfusion imaging" is commonly used but is in fact a misnomer since perfusion and blood flow are not the only imaging biomarkers of microvascular structure and function in common use. indeed, in oncological applications measurements of proportional blood volume, endothelial capillary permeability or vessel size can be of equal or greater importance. we will reproduction is by spore formation which is prolific and therefore human respiratory tract exposure is almost constant. the spectrum of aspergillus infection includes aspergilloma (mycetoma), chronic pulmonary aspergillosis, chronic necrotising pulmonary aspergillosis (subacute invasive, chronic airway invasive), invasive pulmonary aspergillosis (angioinvasive, non-angioinvasive including acute tracheobronchitis, exudative bronchiolitis and bronchopneumonia), and allergic disease (allergic bronchopulmonary aspergillosis (abpa) and bronchocentric granulomatosis). immunocompromised individuals are particularly susceptible to invasive aspergillosis. the risk factors for invasive aspergillosis include: profound neutropenia, haematopoietic stem cell transplant recipients, solid organ transplantation, potent immunosupressive therapy, prolonged corticosteroid use and aids. invasive aspergillosis can be further subdivided into angioinvasive and non-angioinvasive forms. the imaging features of angioinvasive aspergillosis are characterised on ct by nodules with a 'halo' of surrounding ground glass opacity due to alveolar haemorrhage. in the context of neutrophil recovery, nodules may demonstrate cavitation. airway invasive aspergillosis may manifest as areas of consolidation (bronchopneumonia), nodular 'tree-in-bud' densities on ct (exudative bronchiolitis), or an acute tracheobronchitis with large airway thickening. falling rates are stabilising in europe. tuberculosis is developing new faces due to changes in host cellular immunity, such as hiv infection, immunosuppressive therapy, malignancy and due to multi-drug resistance. chest radiography plays a major role in screening, diagnosis, and response to treatment of patients with tb; however, radiographs may be normal or show only mild or nonspecific findings in active disease. ct and high-resolution ct (hrct) are more sensitive than chest radiography in the detection and characterisation of parenchymal disease, small foci of cavitation, mediastinal lymphadenopathy, and pleural complications. based on these findings, hrct is useful in determining disease activity and plays also an important role in the management of tb. radiological manifestations of primary tuberculosis are lymph node enlargement, airspace consolidation and pleural effusion. the most common findings of post-primary tuberculosis are centrilobular nodules, branching linear and nodular opacities, patchy or lobular areas of consolidation, and cavitation. miliary tuberculosis results from acute haematogenous dissemination of tb bacilli in lungs and other organs and ct-findings consist of innumerable small nodules randomly distributed throughout both lungs. airway tuberculosis is characterised by circumferential wall thickening and luminal narrowing, with involvement of a long segment of the bronchi.sensitive diagnostic tool. radiological semiotics are always useful and often very specific in addressing the diagnosis: some fundamental concepts include the peculiar pattern of vasogenic oedema, which, in opposition to what happens in the brain, tends to involve the central grey more than the peripheral white matter. distribution pattern of the lesion can also often address to aetiological diagnosis. in fact, lesions selectively involving posterior or lateral columns, asymmetrically, and sparing the central grey matter, are more typical expression of demyelinatinginflammatory diseases (multiple sclerosis, adem, devic's disease, les, behcet's disease), while selective and symmetrical involvement of both posterior columns, extended for more than 2 myelomers, and possibly associated with involvement of lateral columns, is typical expression of combined sclerosis (b12 vitamin deficit). ischaemic lesions are also usually symmetrical, but they involve both grey and white matter, extending to the anterior two-third of the cord, or, sometimes, remain limited to the central grey matter. on the other hand, selective involvement of the anterior horns is typical of poliomyelitis. early stage head and neck cancer can be cured by surgery or radiotherapy. the choice depends on the functional and cosmetic result to be expected, tumour histology, patient's condition and preference, and institutional policy. in advanced lesions, nowadays concomitant chemoradiotherapy is offered, with surgery reserved for salvage. a relatively high locoregional control rate can be obtained, at the expense of acute and late toxic side effects, and a higher incidence of treatment complications. on post-therapeutic imaging studies, treatment-induced tissue changes are often visible; these changes should not be misinterpreted as evidence of persistent or recurrent tumour, or treatment complication. after radiotherapy, the visible changes depend on the radiation dose and rate, the irradiated tissue volume, and the time elapsed since the end of treatment. basically, thickening of the laryngeal and pharyngeal walls, increased attenuation of fat planes, postirradiation sialadenitis, lymphatic tissue atrophy, and retropharyngeal oedema will be seen. these irradiation-induced tissue changes usually appear symmetrical. the acute effects of radiotherapy occur during or immediately after treatment, and usually settle spontaneously. complications of radiotherapy are usually seen months to years after the end of treatment. there is no clear consensus regarding optimal time points for surveillance, but clinical assessments are more frequent in year 1 and are performed over at least 2-3 years, during which time most locoregional failures and second primary tumours are detected. ideally for imaging surveillance at least one post-treatment baseline head and neck scan (mri/ct) should be performed at 3-6 months, and often closer surveillance is desirable. candidates for salvage surgery after (chemo) radiotherapy undergo a post-treatment scan at 6-8 weeks, followed by regular scans (4-6 months in year 1; 6-12 months thereafter, the exact time period being tailored to the patient the most recent advances of radiotherapy techniques are characterised by the increased precision with which the radiation energy is released to the target, the reduced collateral damage to adjacent non-neoplastic tissues, and the synergic viral agents are part of the spectrum of organisms which cause community acquired pneumonias. furthermore, they are thought to function as a trigger for bacterial infections in the hospital or health care setting. in addition, viruses play a significant role as causative agents for infections in the immunocompromized host. within the last years, outbreaks of viral infections have challenged regional, national and even global health care systems, have effected thousands of individuals and have resulted in significant morbidity and mortality. most of the involved viral agents represented emerging organisms with an unpredictable impact on individual and society health. the radiologic community has learned several lessons from the documented outbreaks, and radiologists around the world have contributed to the early diagnosis of the disease, the monitoring of its course, and the documentation of complications as well as of response to therapy. thus, imaging plays an important role in the diagnosis and management of these patients. in this course, epidemiologic aspects, patho-physiology and clinical features of emerging viral infections will be presented. in addition, their radiologic features and the role of radiology in diagnosis and management will be discussed. attendees will learn how to understand, recognize, report and follow patients with emerging viral infections. major changes in the treatment of head and neck neoplasms encompass the advances of endoscopic-based surgical techniques, mainly for nasosinusal and laryngeal tumours, and the application of sophisticated radiation therapy techniques, combined with chemotherapy. as most tumours arise from the mucosa of the upper aero-digestive tract, clinical surveillance is necessary to detect superficial recurrences, while morphological and 'functional' imaging techniques are indispensable to detect subclinical extra-mucosal and nodal recurrences. how can imaging techniques discriminate recurrence, inflammation, necrosis or scar? key points include the knowledge of the normal appearance of tissues (morphology and signals) on ct, mri, and pet-ct after surgery and chemo-radiotherapy. specifically, when non-surgical treatment has been used, that means to become familiar with the expected changes both of tumour and adjacent tissues. morphology-based imaging techniques are often inadequate to discriminate small recurrences from vascularised scar tissue (enhancing). ct or mri do require to be integrated by information provided by functional-based imaging techniques, fdg-pet-ct being the most established. recently, a great interest among radiologists is focused on the application of dce-ct or dce-mri and dwi-mri in the follow-up of head and neck neoplasms. in fact, several studies have credited these techniques for providing functional information about tissues (perfusion, water exchange) that help to discriminate scar from recurrences. obviously, the horizon pursued is to combine morphology and functional data in a single examination. though clearly promising, these new techniques share significant limitations, like the reproducibility of ct and mr-based functional results, their introduction and feasibility in the day practice. today, ct angiography (cta) is considered as a safe, non-invasive and wellestablished procedure for vascular imaging. modern multi-slice ct technology allows for coverage of larger vascular territories -even the whole body -in just several seconds. further technical improvements such as wide detectors of up to 16 cm width or moving table techniques are making new applications possible, such as perfusion imaging, or time-resolved ct angiography. especially with the moving table technique (the so-called "shuttle-mode"), vascular territories of up to 50 cm can be covered in a dynamic fashion, which can be helpful in the diagnosis of aortic dissections or peripheral vascular occlusive disease. on the other side, radiation exposure has to be maintained within a reasonable range applying these repeated acquisition modes. another interesting field opening new options in cta is dual energy ct (dect). a number of technical setups may allow for spectral ct imaging, such as systems with two tubes (dual source ct), ct systems with switching kv modes or with special detectors. in vascular applications, dect is especially helpful for automated bone removal, plaque removal, and potentially for "perfusion" imaging (iodine mapping). in this course, the basics of modern ct angiography will be highlighted, with a special focus on new applications such as time-resolved cta and dual energy cta. angio-3d with digital flat-panel detector has recently been adapted for use with c-arm systems and provides a higher detector quantum efficiency (dqe) than conventional detectors based on ii camera. this configuration represents the next generation of imaging technology available in the interventional radiology suite and is predicted to be the platform for many of the three-dimensional (3d) roadmapping and navigational tools that will emerge in parallel with its integration. it provides projection radiography, fluoroscopy, digital subtraction angiography, and volumetric computed tomography (ct) capabilities with the ability for immediate multiplanar post-treatment assessment in a single patient setup, within the interventional suite. such capabilities allow the interventionalist to perform intraprocedural volumetric imaging without the need for patient transportation. the clinical benefits of 2d angiography with these new systems have been assessed in the fields of cardiology and interventional radiology. these key features alone may translate to a reduction in the use of iodinated contrast media, a decrease in the radiation dose to the patient and operator, and an increase in the safety and performance of interventional procedures. proper use of this new technology requires an understanding of both its capabilities and limitations. this article provides an overview of the potential of this new technology. learning objectives: 1. to learn the basic principles of flat panel ct. 2. to review imaging protocols, results and radiation exposure aspects. 3. to become familiar with the most common applications.effect of chemo-radiotherapy. as the treatment planning becomes progressively 'tailored', strong predictive factors for the individual tumour arising in a specific patient have to be identified. these factors would ideally provide a quantitative assessment of the risks of both relapsing (in the primary, nodal or distant sites) and developing treatment-related (early or late) complications. predictors are related to tumour's characteristics (biology, metabolism, site, volume and spread) and to patient's overall clinical conditions. imaging-based predictive factors have been founded upon morphological findings (2d, volume) until the development of new techniques, which analyse 'functional' parameters like fdg-pet-ct, the most established, and perfusion-ct or dwi-mri. evidence of level a has been provided on the impact of negative predictive value of fdg-pet-ct in ruling out residual disease, whilst there is no clear data regarding the role of pre-treatment intensity of glucose metabolism (suv) in predicting the outcome after radiotherapy. this limitation can be addressed to the enrolment of tumours arising in various sites in the head and neck. a major disadvantage common not only in pet studies but also in most dce and dwi-mri studies. perfusion-ct and dwi-mr are promising techniques, as they provide information about neo-angiogenesis and water-flow in submicroscopic tissue compartments. however, these techniques still require randomised trials and confirmation studies about the reproducibility of their interesting results. in the follow-up after minimal invasive surgical techniques or chemo-radiation, a major limitation of standard morphological imaging is the differentiation of the highly vascularised scar tissue (enhancing, with mass effect) from persistent or recurrent neoplasm. is it time for integrating standard imaging with the functional information provided by dwi and/or ct or mr perfusion techniques? which evidence level are we at presently? is it now feasible in daily practice? three-tesla mri scanners offer an increased signal and contrast for mr-angiography (mra) compared to 1.5-tesla machines. mra can be performed within a shorter time enabling the acquisition of temporally resolved three-dimensional datasets with high spatial resolution. due to high signal and contrast the dose of gadolinium may be reduced. furthermore, novel imaging protocols for mra at 3.0-tesla with intravasal contrast agents and prolonged enhancement during high-spatial-resolution steady-state enable new possibilities for angiography of the upper and lower extremities including veins and vessels below the knee, spinal arteries, vascular malformations, and double-gated angiography of coronary arteries and bypass vessels to compensate for the complex cardiac motion pattern. a 3.0-tesla mri system equipped with a matrix coil system allows for whole body mra with continuous table movement, which is an applicable technique for imaging peripheral vessels without the need for planning different steps and field of view positioning, thereby considerably reducing the examination time. phase contrast magnetic resonance angiography may develop into an important, noninvasive method for obtaining quantitative information on blood flow. in addition, non-enhanced three-dimensional mr angiography using turbo spin echo (tse) imaging with non-selective refocusing pulses may be a promising imaging technique for vascular imaging in patients with renal insufficiency. the advent of minimally invasive surgery has made even more important the place of preoperative imaging assessment of patients selected for this type of surgery. in fact, the loss of tactile feed-back and the bi-dimensional intraoperative vision have limited the capability of surgeons to assess extent and anatomic relationship of a given disease, particularly cancer. preoperative planning can be further enhanced by the use of 3d models of the target anatomy, derived from ct scan dataset. in addition, dedicated technology can be implemented to introduce mixed reality environments in the operative room. using 3d helmets with built-in microcameras, the surgeons' view of the operative field can be fused with the preoperative 3d anatomy of the patient. localiser should be used, either infrared based or electromagnetic. the last step would be intraoperative navigation. this offers special problems to be addressed, due to organ shifting and soft tissue in the setting of abdominal surgery. the appropriate use of information and communication technology (ict) and associated systems is considered by many experts as a significant contribution to improve workflow and quality of care in clinical settings. a conceptual design and prototypical implementation of such an infrastructure, i.e. a therapy imaging and model management system (timms) will be introduced as a solution to a patientspecific medicine. a timms is an information technology concept and framework for the collection, organisation, and utilisation of medical information from sources such as the electronic medical record, pacs, etc. timms was originally designed as a surgical assist system, but has many general medical uses as well, including all forms of model-guided medicine and may therefore be generalised to a medical information and model management system. the architectural framework and a number of individual ict components of a timms have been realised. these include standardised interfaces for communication of patient-specific and workflow models, thereby creating a unified environment for the input and output of data, including the representation and display of information and images, as well as the electromechanical control of interventional and navigational devices. in conclusion, the patient-specific model (psm) is the central construct for a patient within a personalised medicine environment in order to provide a clinician with a real-time representation of critical information about the patient. the required information concerning the patient for model-guided therapy is extracted by timms agents and assembled within the framework of an active psm and workflow management system. the introduction of picture archiving and communication systems (pacs), through a much more effective image sharing, has dramatically changed the role of radiology both within the hospital and on a geographic perspective. historically, the latter has become apparent first with the early implementation of teleradiology applications. physicians and the general public have understood that digital images can be read, processed, and stored independently on the site of production. therefore, teleconsultation and telereporting activities have been carried out among medical users, and generic users have learnt to include radiological images in their own on-line personal health records. only later the full potentialities of multidisciplinary image sharing within the hospital have been discovered, and now it is increasingly common to see advanced integration between radiologists and surgeons for planning and guiding surgical interventions. during this session, the lecturers -exceptionally expert in their respective fields -will give insights into image sharing: from the geographical applications (teleradiology) to the hospital-based applications, with specific reference to the support to surgeons (intraoperative guidance and model-guided surgery). medical imaging is part of a changing medical environment, a changing patient environment and consequently a new medical world. in the recent decennium one of the most important changes in radiology is the conversion from analogue to digital. in no time medical images have become interchangeable through the digital highway and could be post-processed in a different location. teleradiology has become a reality since then. we have seen the maturation of commercial international teleradiology companies offering a wide portfolio of services. another aspect is the availability of image data for all medical specialties beyond radiology and beyond the regular medical disciplines. an increasing number of surgical or oncological specialties and even pharmaceutical companies increasingly use image data to prepare a strategy for operative procedures, to choose the right therapy, to decide which prosthesis to the best to use, for follow-up or for post-processing purposes. they are supported by many new techniques and software. an increasing number of medical computer applications such as complex navigation and visualisation tools based upon digital images is already in clinical use or under development. another trend is the increasing interest in e-health and telemedicine in europe, also among european policy makers. now we see mobile health that brings care directly into the patient environment. the purpose of this presentation is to give a comprehensive overview of and insight into these new developments and to create awareness among radiologists of the increasing importance of integration of medical imaging in a multidisciplinary environment. key: cord-022754-ehq9qnoo authors: nan title: liver date: 2012-07-25 journal: canine and feline gastroenterology doi: 10.1016/b978-1-4160-3661-6.00061-4 sha: doc_id: 22754 cord_uid: ehq9qnoo nan the basic elements of the biliary tract are the hepatic canaliculi, bile ductules, intralobular ducts, interlobular ducts, hepatic ducts, cystic duct, gallbladder, common bile duct, and the pancreaticobiliary sphincter (of oddi). 2 there are many variations on this central theme, the most important of which are (a) the pancreaticobiliary sphincter is a common physiologic and anatomical channel at the duodenal papilla in the cat 3 and (b) there are many anatomic variations in the feline gallbladder, from single gallbladder to bilateral gallbladders, body duplication, fundic duplication, complete duplication, septate, and y-shaped gallbladder. 4 hepatocytes account for 60% to 80% of the liver cell mass (see table 61 -1) and contribute to a wide range of metabolic activity, including carbohydrate, protein, lipid, nucleic acid, porphyrin, metal, vitamin, glutathione, hormone, and xenobiotic metabolism; coagulation factor synthesis; biliary secretion; and immune surveillance. 1, 5 hepatocytes have an eosinophilic cytoplasm reflecting numerous mitochondria, and basophilic stippling caused by large amounts of rough endoplasmic reticulum and free ribosomes. hepatocyte nuclei are round with dispersed chromatin and prominent nucleoli. anisokaryosis is common and often reflects various degrees of polyploidy, a normal feature of more than 50% of hepatocytes. the average life span of the hepatocyte is 5 to 6 months reflecting their ability to regenerate. hepatocytes are organized into plates separated by vascular channels (sinusoids), an arrangement supported by a reticulin (collagen type iii) network. the sinusoids have a discontinuous, fenestrated endothelial cell lining. the endothelial cells have no basement membrane and are separated from the hepatocytes by the space of disse, which drains lymph into the portal lymphatics. hepatocytes are supported by a number of other cell types, which account for 40% of the liver cell mass. representing 3% to 10% of liver cell mass, cholangiocytes are also known as biliary epithelial cells. 6 they secrete water, bicarbonate, and cations into the bile in the physiologic state, but they may also participate in the immune response as antigen-presenting cells in disease states. the biliary tract is a convergent system of canals that begins in the canaliculi, followed by the bile ducts, and ending with the common bile duct. bile secretion depends on the function of membrane transport systems in hepatocytes and cholangiocytes and on the structural and functional integrity of the biliary tract. the hepatocytes, constituting the most abundant liver cell population, generate the so-called primary bile in their canaliculi. biliary canaliculi are blind tubular structures, with a very high surface-to-volume ratio that by means of osmotic gradients favors the formation of bile flow. cholangiocytes, which constitute 3% to 10% of the liver cells, modify the canalicular bile by secretory and reabsorptive processes as bile passes through the bile ducts, and they are responsible for approximately 30% of bile volume. in contrast to hepatocytes, where secretion is constant and poorly controlled, cholangiocyte secretion is broadly regulated. 5, 6 the immunoglobulin family, without which the liver cannot clear complement system-coated pathogens. in disease states, kupffer cells contribute to the pathology of ethanol and other toxic principles through production of inflammatory mediators, activation of toll-like receptors, and elaboration of tumor necrosis factor (tnf-α). 7 kupffer cell activation is responsible for early ethanol-induced liver injury, common in chronic alcoholics. ethanol activates the toll-like receptor 4 and cd14, receptors on the kupffer cell that internalize the endotoxin lipopolysaccharide. internalization activates the transcription of tnf-α and production of superoxide (a prooxidant). tnf-α then enters the stellate cell in the liver, leading to collagen synthesis and fibrosis. fibrosis eventually causes cirrhosis or loss of function of the liver (see the role of the stellate cell, which is discussed in "stellate cells" section that follows). hepatic stellate cells (hscs) (also referred to as vitamin a-storing cells, lipocytes, interstitial cells, fat-storing cells, and ito cells) exist in the space between parenchymal cells and liver sinusoidal endothelial cells of the hepatic lobule and store 50% to 80% of vitamin a in the whole body as retinyl palmitate in lipid droplets in the cytoplasm. [7] [8] [9] [10] in physiologic conditions, these cells play pivotal roles in the regulation of vitamin a homeostasis. in pathologic conditions, such as hepatic fibrosis or liver cirrhosis, hscs lose vitamin a and synthesize a large amount of ecm components, including collagen, proteoglycan, glycosaminoglycan, and adhesive glycoproteins. the morphology of these cells also changes from that of the star-shaped stellate cell to that of the fibroblast or myofibroblast. hscs are now considered to be targets of therapy of hepatic fibrosis or liver cirrhosis. 11 activation of hscs, a key event in liver fibrosis, is caused by diminished adipogenic transcription. 12 wnt signaling inhibits antiadipogenic activation of hscs and liver fibrogenesis; wnt antagonism inhibits hsc activation and liver fibrosis. 9 also known as natural killer (nk) cells or large granular lymphocytes, pit cells represent 1% of liver cell mass, and serve as part of the immune surveillance mechanism in the hepatic sinusoids. pit also known as browicz-kupffer cells or stellate macrophages, these cells represent 2% to 5% of the liver cell mass, and are specialized macrophages localized to the sinusoids as part of the mononuclear phagocyte system. kupffer cells begin their development in the bone marrow with the genesis of promonocytes and monoblasts into monocytes, and then on to peripheral blood monocytes, completing differentiation into kupffer cells within the liver. in health, kupffer cells are involved in the metabolism of erythrocyte hemoglobin. during perfusion of the liver, senescent red blood cells are phagocytized by the kupffer cells, and the hemoglobin molecule is further metabolized into its component parts. globin chains and amino acids are reutilized; the iron-containing portion of heme is removed, transported, and stored; and heme is further oxidized into bilirubin, conjugated with glucuronic acid within hepatocytes, and secreted into the bile. kupffer cells also express a complement receptor of progenitor cells have multilineage potential and similar characteristics to stem cells. the late progenitor cells have differentiated further and produce progeny in only a single lineage. although they divide rapidly, they are capable of only a short-term tissue reconstitution and they do not self-renew. 15 early studies in hepatocyte turnover and liver regeneration showed that the parenchymal cell, the hepatocyte, was the primary and only cell involved in tissue renewal. however, new studies of liver regeneration, hepatocarcinogenesis, liver transplantation, and various cell lines show that a variety of cell types participate in maintaining hepatocyte number and mass. recent studies indicate the presence of both intrahepatic and extrahepatic stem/progenitor cell populations that serve to maintain the normal organ and to regenerate damaged parenchyma in response to a variety of insults. the intrahepatic compartment most likely derives primarily from the biliary tract, particularly the most proximal branches, that is, the canals of hering and smallest ductules. the extrahepatic compartment is at least in part derived from diverse populations of cells from the bone marrow. embryonic stem cells are considered as a part of the extrahepatic compartment. 16 the precise role(s) of each of these individual cells remains to be determined, but it is clear that in the aggregate they confer the vast regenerative capacity of the liver . the liver is involved in many aspects of intermediary metabolism. 1 the liver is at the center of carbohydrate metabolism through its role in maintaining normoglycemia. glucose is the primary energy source for most mammalian cells, and its metabolism is tightly regulated to guarantee that a sufficient supply is available to glucosedependent organs, particularly the brain. glucose can be made available from two sources: absorption of dietary glucose from the intestine, and release of glucose from organs such as the liver and kidney. early in fasting, the majority of endogenous glucose is generated by glycogenolysis where glycogen in the liver is converted to glucose-6-phosphate under the regulation of debranching enzyme, hepatic glycogen phosphorylase, and phosphorylase kinase. with more prolonged fasting, endogenous glucose is generated by gluconeogenesis from certain substrates such as amino acids, lactate, and glycerol. both processes generate glucose-6-phosphate, which must then be dephosphorylated in order to transport glucose out of the cell. • early fasting: glycogen → glycogenolysis → glucose → normoglycemia • prolonged fasting: amino acids → gluconeogenesis → glucose → normoglycemia the enzyme responsible for the dephosphorylation of glucose-6phosphate is glucose-6-phosphatase-α. alterations in quantity, location, or activity of glucose-6-phosphatase, such as those seen in type 1 glycogen storage diseases, effectively result in a lack of all endogenous glucose production and severe hypoglycemia develops during periods of fasting. 17 the liver is an important site of protein metabolism. amino acids and proteins absorbed from the intestine or produced in the body are delivered to the liver. the liver deaminates amino acids and cells belong to the group of sinusoidal cells, together with kupffer, endothelial, and fat-storing (stellate) cells. pit cells use the fasl fas ligand (fasl) and perforin/granzyme pathway to kill target cells. fasl on effector cells binds the fas that is present on the target cell membrane, which results in oligomerization of fas and activation of caspase 8. perforin and granzymes, of which granzyme b is the most potent, reside in granules of the cytotoxic lymphocytes and are released by exocytosis. intracellular delivery of granzyme b results in the initiation of the caspase cascade by proteolytic activation of caspase 3, either directly or through a mitochondrial-dependent pathway. caspases play a central role in the execution of apoptosis. lymphocyte recruitment from the circulation into tissue is dependent on the ability of the lymphocyte to recognize and bind molecules on the endothelial cell surface that promote transendothelial migration. a multistep model of leukocyte adhesion to vascular endothelium has been described and is broadly applicable, although the details of the signals involved differ between tissues. 13, 14 in a generally accepted model, tethering or rolling receptors expressed on endothelial cells capture free-flowing leukocytes. these receptors may be either selectins or members of the immunoglobulin superfamily. once captured, the leukocyte can receive activating messages presented by endothelial cells in the form of chemokines that activate specific g-protein-coupled receptors on the leukocyte surface. occupancy of these receptors triggers a cascade of intracellular signals that results in the presentation of high-affinity integrin receptors on the leukocyte surface that bind to immunoglobulin family of counterreceptors on the endothelium to promote leukocyte arrest on the vessel wall. in the presence of the appropriate migratory signals the leukocyte will migrate across the endothelium into tissue, where it follows a hierarchy of chemotactic signals toward the focus of inflammation. representing 2% to 5% of the liver cell mass, smooth muscle cells are located primarily in the hepatic artery and portal vein and their tributaries, and serve primarily to regulate the hepatic microcirculation. hepatic fibrosis is a common outcome of hepatic injury in the dog. activated fibroblasts that develop myofibroblastic characteristics play an essential role in hepatic fibrogenesis, and are comprised of three subpopulations: (a) portal or septal myofibroblasts, (b) interface myofibroblasts, and (c) the perisinusoidally located hscs. it is difficult to arrive at a universally applicable definition of a stem cell because some of the defined properties of a stem cell can be exhibited by the stem cells in some tissues or organisms but not in others. in spite of that, a generally acceptable consensus defines a stem cell as an undifferentiated cell that has capacity to self-renew, for production of progeny in at least two lineages, for long-term tissue repopulation after transplantation, and for serial transplantability. in addition, stem cells exist in a mitotically quiescent form and clonally regenerate all of the different cell types that constitute the tissue in which they exist. they can undergo asymmetrical cell division, with production of one differentiated (progenitor) daughter and another daughter that is still a stem cell. the offspring of stem cells are referred to as progenitor cells, also named as transit amplifying cells and therefore cannot be serially transplanted, and are classified as early and late. the early progenitor or stem/ either removed from the circulation by the liver or undergo further transformation by lipoprotein lipase and/or hepatic lipase to form intermediate-density lipoproteins and ldls. ldls, which are relatively depleted of triglyceride and enriched in cholesteryl esters and phospholipid, circulate in the blood and bind to specific ldl receptors that are widely distributed throughout tissues in order to deliver cholesterol. hdls produced by the liver play an important role as donors and acceptors of apo c, apo e, and various lipids from other lipoproteins in the circulation. reverse transport. hdls play an important role in the reverse transport of cholesterol from the periphey to the liver. lecithin cholesterol acyl transferase esterifies hdl cholesterol and cholesteryl esters move to the core of the hdl molecule to allow more free cholesterol to be absorbed into the particle. continued absorption of free cholesterol and subsequent esterification by lecithin cholesterol acyl transferase leads to the formation of the larger, cholesteryl ester-rich hdl2s. hdl2 molecules continuously acquire cholesteryl esters, resulting in the formation of the hdl1 molecules. on hdl1, cholesteryl esters are transferred from tissues to the liver for disposal or reuse, and not to ldl or vldl molecules (as in humans), which transfer cholesterol to peripheral tissues. this function of hdl1s may account for the lower incidence of atherosclerotic disorders in dogs compared with humans. 23, 24 nucleic acids pyrimidine biosynthesis is one of the classic roles of the liver in nucleic acid metabolism. more recently, micrornas have been impugned in the normal development and regeneration of the liver, as well as in hepatic pathology. micrornas are small noncoding rnas that regulate both messenger rna and protein expression of target genes, which results in alterations in messenger rna stability or translation inhibition. micrornas influence at least one-third of all human transcripts and are known regulators of various important cellular growth and differentiation factors. micrornas recently emerged as key regulatory molecules in chronic liver disease. 25 porphyrins porphyrins are intermediates of the heme biosynthetic pathway. porphyrins are found in hemoglobin, myoglobin, cytochromes, catalase, and peroxidase enzyme. the liver and biliary tract serve as an excretory route for the porphyrins. the liver stores iron, which can be toxic in excessive amounts (hemochromatosis). the amount of iron in the body is largely determined by regulation of its absorption in the upper small intestine. iron is stored intracellularly as ferritin in a number of tissues, with the liver having a large storage capacity. when the capacity of the liver is exceeded, iron accumulates as hemosiderin. the liver incorporates copper into specific copper proteins such as cytochrome c oxidase, mitochondrial monoamine oxidase, and ceruloplasmin. mobilization of copper from hepatocytes takes place by at least two mechanisms: ceruloplasmin and bile secretion. cholestatic liver disease is associated with secondary copper retention, which may then induce hepatocyte injury. 26, 27 vitamins the liver is importantly involved in vitamin metabolism. the liver produces bile for absorption of fat-soluble vitamins (a, d, e, k), and the liver is an important site for vitamin storage. converts them to carbohydrates and lipids. [18] [19] [20] [21] deamination produces α-keto acids, which can be metabolized for energy or used for synthesis of monosaccharides and fatty acids. 20 the liver synthesizes amino acids from intermediates of carbohydrate and lipid metabolism by amination and transamination. 21 examples of amino acid transaminations include: • alanine + α-ketoglutarate ↔ pyruvate + glutamate • aspartate + α-ketoglutarate ↔ oxaloacetate + glutamate the liver synthesizes many proteins, including albumin and fibrinogen, most α globulins, and some of the β globulins. prothrombin and clotting factors v, vii, viii, ix, and x are produced in the liver, as well as ceruloplasmin, ferritin, and many serum enzymes. lipid metabolism and transport is organized into three basic transport systems: (a) exogenous transport, which is associated with the metabolism of exogenous (dietary) lipids, (b) endogenous transport, which is associated with the metabolism of endogenously produced lipids, and (c) reverse transport, which is associated with the transport of lipids from the periphery (e.g., skeletal muscle, adipose, connective tissue) to the liver. exogenous transport. triglyceride is the major dietary lipid, along with cholesterol, phospholipids, and fat-soluble vitamins. 22 the digestion of dietary lipids begins in the proximal gi tract with the action of lingual and gastric lipases, and is completed in the small intestine with the actions of pancreatic lipase, cholesterol ester hydrolase, and phospholipase a 2 . lipid digestion and absorption is more complicated than carbohydrate and protein digestion and absorption because of lipid solubility characteristics, and involves emulsification of lipids by bile salts, hydrolysis by pancreatic lipase and colipase, solubilization of fatty acids and monoglycerides into mixed micelles, absorption, reesterification, chylomicron formation, and transport into the intestinal lymphatics or portal capillaries. chylomicrons containing short-and long-chain triglycerides, and the newly incorporated b-100 apoprotein, are preferentially absorbed into the intestinal lymphatics where they are transported into the cisterna chyli, thoracic duct, and systemic circulation where they acquire apolipoproteins c and e from circulating high-density lipoproteins (hdls). apolipoprotein (apo) c-ii activates lipoprotein lipase in the capillary beds of adipose and skeletal muscle, where they are stored as is or hydrolyzed into free fatty acids, β-monoglyceride, and glycerol. the cholesterol-rich remaining particles (now referred to as chylomicron remnants), return apo c-ii molecule to hdl and are recognized by specific hepatic apo e and apo b-100 receptors that rapidly remove them from the circulation by endocytosis. the cholesterol found in chylomicron remnants can be used in very-low-density lipoprotein (vldl), lipoprotein synthesis, bile acid formation, or cholesteryl storage. endogenous transport. while chylomicrons are the apoprotein responsible for transport of dietary lipids, vldls, intermediatedensity lipoproteins, low-density lipoproteins (ldls), and hdls are instead involved in the metabolism of endogenously produced lipids. triglycerides and cholesterol produced by the liver combine with phospholipids, apo b-100, and apo b-48 to form vldls. when secreted from the liver, vldls acquire the apo c and apo e from hdl. vldl apo c-ii activates lipoprotein lipase located in the capillary beds, where once again triglyceride hydrolysis takes place with the production of free fatty acids and glycerol. the vldl molecules remaining after hydrolysis of vldl triglycerides are intestinal bacteria to produce the secondary bile acids, deoxycholic acid, and lithocholic acid. 2, 5, 28 prior to secretion, bile acids are conjugated with taurine and/or glycine to form tauro-and glycoconjugated bile salts (see figure 61 -3, c). conjugation lowers the pk a to well below the physiologic range of biliary and intestinal ph, and conjugated bile acids become ionized anions (referred to as bile salts) rather than undissociated bile acids. in the ionized form, they are less likely to be absorbed by the small intestine and so maintain a higher intraluminal concentration appropriate for emulsification, digestion, and absorption of lipids. dogs and cats conjugate primarily with taurine. dogs can convert to glycine conjugation if taurine is deficient, but cats cannot. cats are obligate taurine conjugators, and have an essential dietary taurine requirement. 2, 5, 28 bile salts are amphipathic molecules with polar and nonpolar domains imparting two important functions. bile salts have an initial detergent effect on fat particles in food permitting the breakup of fat globules into smaller sizes. this is the initial emulsification phase of bile salts that facilitates intraluminal lipid hydrolytic digestion. bile salts further assist in the absorption of fatty acids, monoglycerides, cholesterol, and other lipids through the formation mixed micelles. these micelles serve to transfer digested lipids across the unstirred layer of the mucosa. following emulsification and micellarization of fat, most of the secreted bile salts are transported along the gi tract to the ileum where they are absorbed into ileal enterocytes and portal blood flow via na + -bile salt cotransporters. 2, 28 the liver plays an important role in maintaining hemostasis. the liver produces procoagulant, anticoagulant, and fibrinolytic proteins, and also removes normal and abnormal clotting factors from the circulation. 29 hepatocytes synthesize most of the clotting factors including clotting factor i (fibrinogen), ii (prothrombin), v, vii, ix, x, xi, and xiii. the site of biosynthesis of factor viii remains controversial, but it is probable that the liver plays an important role in this factor, too. the liver is also responsible for the activation of the vitamin k-dependent factors ii, vii, ix, and x and protein c. in addition to the production and activation of coagulation factors, the liver is also essential for the clearance of activated coagulation water bilirubin -vitamin a is stored in both stellate cells and hepatocytes. approximately 95% of total body vitamin a is stored in the liver, representing a 1-to 2-year supply. the liver continues to release vitamin a to maintain normal blood concentrations despite reductions in its content. liver and plasma vitamin a concentrations are reduced by malnutrition, liver disease, and intestinal malabsorption, but signs of deficiency do not appear until abnormalities become severe. fat-soluble vitamins a, d, e, and k require normal bile secretion for absorption. vitamin k is particularly essential for synthesis of the prothrombin-complex clotting factors. water-soluble vitamins, with the exception of vitamin b 12 (cobalamin), are readily absorbed from the small intestine. these vitamins are used primarily as coenzymes in metabolic processes. vitamin phosphorylation, occurring primarily in hepatocytes, is required to produce some coenzymes. thiamine is phosphorylated to thiamine pyrophosphate, for example, primarily in the liver and kidney. nicotinic acid is a precursor in pyridine nucleotide synthesis, and an initial step in its conversion is nicotinamide synthesis in the liver. pyridoxine is phosphorylated to its active form in the liver, as is the transformation of pantothenic acid to coenzyme a. folic acid is converted to its active form in the liver. large amounts of all water-soluble vitamins except vitamin c are stored in the liver. glutathione is synthesized in most if not all mammalian cells. the liver is particularly active and has relatively high levels of glutathione. glutathione performs a variety of physiologic and metabolic functions, including thiol transfer reactions that protect cell membranes and proteins; thiol-disulfide reactions involved in protein synthesis, protein degradation, and catalysis; reduction of capacity; detoxification of hydrogen peroxide, organic peroxides, free radicals, and foreign compounds; and metabolism of various endogenous compounds. seen in dogs with chronic hepatitis plus cirrhosis, which may be a result of reduced synthesis rather than increased consumption of coagulation factors. numerous foreign compounds, including drugs, are so hydrophobic that they would remain in the body indefinitely were it not for hepatic biotransformation. cytochrome p450 (p450 or cyp) comprises a superfamily of enzymes that catalyze oxidation of a variety of xenobiotic chemicals such as drugs, toxic chemicals, and carcinogens, as well as endobiotic chemicals including steroids, fatty acids, prostaglandins, and vitamins. the cytochrome p450 enzymes in families one to three mediate 70% to 80% of all phase i-dependent metabolism of clinically used drugs and participate in the metabolism of a huge number of xenobiotic chemicals. there are 57 known active p450 genes and 58 pseudogenes in the human genome. with 54 active genes, dogs are phylogenetically closest to the human. although there are many similarities between dogs and humans, there also are many important differences. [30] [31] [32] [33] dogs present an products and the production of clotting factor inhibitors, such as antithrombin and α 1 -antitrypsin, as well as fibrinolytic proteins like plasminogen. in liver disease, factor and inhibitor synthesis and clearance of activated factors in both the coagulation factors and fibrinolytic system may be impaired. the extent of coagulation abnormalities depends upon the degree of disturbed liver function. 29 patients with hepatic failure may present with the entire spectrum of factor deficiencies and may even develop disseminated intravascular coagulation. in a study of 42 dogs with histologically confirmed liver disease, one or more coagulation abnormalities were found in 57% of dogs with liver disease. 29 activated partial thromboplastin time was significantly prolonged in dogs with chronic hepatitis with or without cirrhosis. mean platelet numbers, antithrombin, and factor ix activity were significantly lower in dogs with chronic hepatitis with cirrhosis, compared to dogs with other hepatopathies. d-dimers were not significantly increased in any group. only three dogs, all with different histologic diagnoses, satisfied the criteria for disseminated intravascular coagulation. hemostatic abnormalities were primarily where nh3 = ammonia; adenosine triphosphate = adenosine triphosphate; adp = adenosine diphosphate; p i = inorganic phosphate; and amp = adenosine monophosphate. mineralocorticoids (aldosterone), glucocorticoids (cortisol, corticosterone), and sex steroids (androgens, estrogens, progesterone) are metabolized by the liver. changes in the concentrations of total and free cortisol and of the binding capacity of corticosteroid-binding globulin have been reported in canine liver disease. as a consequence of hypercortisolemia, dogs with liver disease and hepatoencephalopathy have clinical and biochemical characteristics of pdh, including polyuria, high basal cortisol levels, and α-melanotropin. 37, 38 chronic hypercortisolism is associated with impaired osmoregulation of the release of vasopressin and inadequate urinary concentration. 39 the multiple physiologic functions of the liver require an immune response that is locally regulated. pathogenic microorganisms must be efficiently eliminated, while the large number of antigens derived interesting challenge in the assessment of p450-mediated drug-drug interactions because most of the enzymes have not been completely characterized, diet and aging induce significant changes in gene expression, and dogs are often treated off-label with a number of human drugs with little idea of risk for drug-drug interaction. drug metabolism takes two general forms: phase i metabolism (modification reactions) and phase ii metabolism (conjugation reactions). phase i metabolism typically subjects a drug to oxidation or hydrolysis. it involves the cytochrome p450 (cyp) enzymes, which facilitate reactions that include n-, o-, and s-dealkylation; aromatic, aliphatic, or n-hydroxylation; n-oxidation; sulfoxidation; deamination; and dehalogenation. phase ii metabolism conjugates the drug to hydrophilic substances, such as glucuronic acid, sulfate, glycine, or glutathione. phase i metabolism usually precedes phase ii metabolism, but this is not always the case. 34 the liver is an important site of drug toxicity and oxidative stress because of its proximity and relationship to the gi tract. seventyfive percent to 80% of hepatic blood flow comes directly from the gi tract and spleen via the main portal vein. portal blood flow transports nutrients, bacteria and bacterial antigens, drugs, and xenobiotic agents absorbed from the gut to the liver in a more concentrated form. drug-metabolizing enzymes detoxify many xenobiotics but might activate the toxicity of others. hepatic parenchymal and nonparenchymal cells may all contribute to the pathogenesis of hepatic toxicity. the toxicity of drugs can be considered in five contexts: on-target toxicity, hypersensitivity and immunologic reactions, off-target pharmacology, bioactivation to reactive intermediates, and idiosyncratic drug reactions. 35, 36 ammonia ammonia is an important by-product of amino acid metabolism. organisms that cannot easily and quickly remove ammonia usually have to convert it to some other substance, like urea or uric acid, which are much less toxic. insufficiency of the urea cycle occurs in from the gi tract must be tolerated. the liver favors the induction of tolerance rather than the induction of immunity. although hepatocytes constitute the major cell population of the liver, direct interaction of hepatocytes with leukocytes in the blood is unlikely. sinusoidal endothelial cells, which line the hepatic sinusoids and separate hepatocytes from leukocytes in the sinusoidal lumen, and kupffer cells, the resident macrophage population of the liver, can directly interact with passenger leukocytes. in the liver, clearance of antigen from the blood occurs mainly by sinusoidal endothelial cells through very efficient receptor-mediated endocytosis. liver sinusoidal endothelial cells constitutively express all molecules necessary for antigen presentation (cd54, cd80, cd86, major histocompatibility complex [mhc] classes i and ii, and cd40) and can function as antigen-presenting cells for cd4 + and cd8 + t cells. 40, 41 thus, these cells probably contribute to hepatic immune surveillance by activation of effector t cells. antigen-specific t-cell activation is influenced by the local microenvironment. this microenvironment is characterized by the physiologic presence of bacterial constituents such as endotoxin and by the local release of immunosuppressive mediators such as interleukin-10, prostaglandin e 2 , and transforming growth factor-β. 42 regeneration liver regeneration after partial hepatectomy is a very complex and well-orchestrated phenomenon. it appears to be carried out by the participation of all mature liver cell types. 43, 44 the process is associated with signaling cascades involving growth factors, cytokines, matrix remodeling, and several feedbacks of stimulation and inhibition of growth related signals. 45, 46 the liver manages to restore any lost mass and adjust its size to that of the organism, while at the same time providing full support for body homeostasis during the entire regenerative process. in situations when hepatocytes or biliary cells are blocked from regeneration, these cell types can function as facultative stem cells for each other. gene expression in the regenerating liver is a multistep process with at least two critical steps: the transition of quiescent hepatocytes into the cell cycle ("priming"), and the progression beyond the restriction point in the g 1 phase of the cell cycle. hepatocytes must first be primed before they can fully respond to growth factors. as many as 70 different genes participate in the early response to hepatectomy, but tumor necrosis factor (tnf), interleukin (il)-6, and interleukin-22 appear to be the major cytokines involved in the priming of hepatocytes. 47 the proliferative effect of tnf on hepatocytes is further influenced by reactive oxygen species, nitric oxide, and glutathione content, and multiple transcription factors (e.g., nuclear factor kappa b, stat3, ap-1, and c/ebpβ) play major roles in the initiation of early liver regeneration. 47 progression through the cell cycle beyond the initiation phase requires growth factors, primarily hepatocyte growth factor and transforming growth factor-α (tgf-α). the subsequent expression of cell-cycle genes establishes the stage at which replication becomes growth factorindependent and autonomous. at this point, the hepatocyte is irreversibly committed to replicate and the cell cycle replication machinery takes over. the proliferation of hepatocytes advances from periportal to pericentral ares of the lobules, as a wave of mitoses. hepatocytes surrounding the central veins are the last ones to undergo cell replication. proliferation of biliary epithelial cells occurs a little later than hepatocytes. proliferation of endothelial cells starts at 2 to 3 days and ends around 4 to 5 days after partial hepatectomy. the kinetics of proliferation of stellate cells is incompletely understood. the regenerative capacity of the residual hepatocytes may restore liver mass and function after as much as 65% to 70% hepatectomy and it takes place over 7 to 14 days in most animal species. 48 a small wave of apoptosis in hepatocytes occurs at the end of regeneration. the liver is the second largest organ in the body and performs an estimated 1500 essential biochemical functions. 1 these diverse functions include drug metabolism; removal of exogenous and endogenous toxins (e.g., ammonia, food antigens); synthesis of vital substances such as albumin and blood clotting factors; protein, fat, and carbohydrate metabolism; vitamin storage and activation; glycogen, triglyceride, and mineral (e.g., copper, iron) storage; activation, conversion, secretion, deactivation, and excretion of various hormones; bile salt synthesis; conjugation and excretion of bilirubin in bile; among others. symptoms (defined here as abnormalities noted by the owner), clinical signs (defined here as abnormalities found during the physical examination), and diagnostic results reflect impairments in these functions. hepatitis represented approximately 1% of the clinical population of the companion animal teaching hospital of utrecht university. box 61-1 summarizes the most common liver diseases with their possible etiologies in dogs and cats. a properly taken history is pivotal to defining the most clinically relevant problems that need to be resolved. a structured interview process and understanding the basics of communication are important success factors to retrieve this crucial information. fortunately, the knowledge about communication in the medical profession and the focus on the veterinary curriculum, has increased considerably during the last few years. 2, 3 some basic principles should be kept in mind to understand the symptoms in dogs and cats with diseases affecting the hepatic parenchyma, portal vasculature, and the biliary system. first, for most of its functions, the liver has a tremendous (approximately 80%) reserve capacity and a remarkable potential to regenerate. 4 symptoms occur only when progressive disease exhausts hepatic reserves. diseases often remain subclinical for lengthy periods of time; symptoms may be relatively mild and nonspecific because the liver reserve prevents overt abnormalities. symptoms such as lethargy, vomiting, or mild polyuria and polydipsia (pu/pd) may alert the clinician that a liver disorder could be developing. serious symptoms may indicate loss of hepatic reserves. the onset of symptoms may be acute, but they may be the end result of a disease that has been present for many weeks or months. because no specific physical abnormalities occur with most liver diseases, it is important to remember that liver disease may be present when symptoms of illness are unexplained or nonspecific. sensitive and specific laboratory tests may easily detect such liver diseases. 5 second, most liver diseases cause similar signs and symptoms (table 61 -2). one of these is acholic feces, which occurs nearly exclusively in dogs with common bile duct obstruction. 6 owners b documented in humans, may occur in dogs and cats. a more likely to present with chronic rather than acute liver disease. the clinical signs listed in table 61 -2 are candidates for having a primary hepatopathy. in all such cases, further diagnostic studies should be performed to confirm or exclude liver disease ( figure 61 -5). breed, sex, age, and drugs may predispose dogs and cats to hepatopathies. the presence of numerous risk factors should be a stimulus for an extended diagnostic workup; other diseases should be investigated in the absence of such suspicions. caused by hypersensitivity to sulfonamides, destructive cholangiolitis is the most common drug-induced liver disease. 14 a recent history of therapy with sulfonamides or other potentially hepatotoxic drugs, combined with icterus makes this condition likely and should prompt immediate discontinuation of the medication. breed associations may occur when a disease is (in part) determined by genetic factors. breeders may, by chance, increase the incidence of hepatic diseases by familial selection. because dog breeds may represent more or less closed populations in a country, breed predispositions may vary among countries. therefore this section only mentions generally applicable predispositions; locally, other breed associations may be more pertinent. chronic hepatitis and cirrhosis, both of which are, as a rule, different stages of one disease, occur more frequently in certain breeds. 15 hepatitis may develop at any age, but typically not before 2 years of age. only lobular dissecting hepatitis tends to occur at a young age (i.e., often before 1 year of age). 16 breeds associated with hepatitis are doberman pinschers, bedlington terriers, west highland white terriers, american and english cocker spaniels, labrador retrievers, and many other breeds. recent copper excretion studies have shown that hepatitis is caused by copper retention and not vice versa in doberman pinschers. 17 the cause of copper retention remains unclear; many of the tested candidate genes (including murr 1, the affected gene in bedlington terriers) were excluded as monogenetic causes for copper-associated subclinical hepatitis in may note the light-gray appearance of stool, which in combination with icterus is virtually diagnostic for extrahepatic cholestasis. different combinations of clinical signs and symptoms may occur with any liver disease. statistically, one disease may be associated with a typical pattern of signs and symptoms in dogs and cats. however, overlapping patterns are so great that it is useless to try to identify the exact disease based on clinical signs and symptoms alone (table . clinical signs and symptoms associated with liver diseases of cats are similar to those in dogs, except for pu/pd, which is not clinically overt in most cats. certain liver diseases cause neurobehavioral signs associated with hepatic encephalopathy, 7 and these signs may wax and wane in their frequency and severity. any medication given may appear to be effective because of the natural fluctuation of signs. therefore signs of hepatic origin may be easily missed. seizures alone are never caused by hepatic encephalopathy; if they do occur, they occur in combination with other signs seen with this syndrome. 5 furthermore, very few, if any, medications to treat liver diseases have been tested in double-blind, placebocontrolled studies, making decisions about the best therapeutic regimens difficult. 8 it is usually not possible to differentiate between hepatic diseases and diseases of other organs based on symptoms and clinical signs. signs associated with hepatic diseases are nonspecific; similar signs may occur in diseases of many other organ systems, most notably the gi, neurologic, renal, and hematologic systems (see table 61 -2). 9 of the gi tract-related symptoms, nausea expressed as vomiting in acute cases or reduced, irregular appetite with occasional vomiting and weight loss over time, is very common in liver and biliary diseases of dogs and cats. for biliary diseases these are always the most prominent symptoms. diarrhea, however, is not a major symptom of liver disease, and in cases in which diarrhea is the leading symptom the liver is only rarely the causative organ (except for rare cases with complete common bile duct obstruction). a rare sign (not included in table 61 -2) is an ulcerative form of dermatosis, so-called superficial necrolytic dermatitis, hepatodermal, or hepatocutaneous syndrome. this syndrome occurs rarely in dogs with liver cirrhosis and nodular hyperplasia and whose pathogenesis is poorly understood. 10 this symptom and the more common symptoms of lethargy, inappetence, vomiting, diarrhea, weight loss, pu/pd, and neurobehavioral symptoms are frequently associated with diseases of other organs. therefore the history often discloses symptoms that may suggest hepatic disease, but may also be caused by other disorders. two main reasons account for the nonspecificity of liver-related symptoms. first, the liver is the central organ for many metabolic and detoxifying pathways; consequently, failing liver function may cause dysfunction of other organs. one example is hepatic encephalopathy; metabolic dysfunctions of the liver cause neurotransmitter dysfunctions of the brain, resulting in neurobehavioral signs. 11 second, toxic factors resulting from diseases of other organ systems (especially from the gi tract) often secondarily affect the liver. examples include hepatic lipidosis in diabetes mellitus, steroidinduced hepatopathy in cushing syndrome, reactive hepatitis in gi diseases, and centrolobular liver necrosis in acute, severe anemia. 5 therefore signs and symptoms of liver disease may be hidden within signs of other organ dysfunction, and vice versa. because clinical and physical examination findings may be compatible with hepatic disease, and because laboratory tests to detect hepatic disease are also abnormal with primary and secondary hepatopathies, it is often necessary to make a histologic diagnosis of the liver disorder to resolve this dilemma. 12, 13 lack of specific physical examination findings may prevent recognition of a primary liver disease. most dogs with illnesses causing pathetic innervation; therefore dilation (e.g., extrahepatic cholestasis), cholecystitis, or cholelithiasis should be suspected in vomiting dogs and cats. 5 vomiting is also common in upper gi disease. in many gi diseases, translocation of bacteria and endotoxins may cause secondary, nonspecific, reactive hepatitis. 30 this occurs frequently in dogs, but rarely in cats. reactive hepatitis is characterized by intrahepatic canalicular cholestasis, liver cell necrosis, and an exudative inflammatory reaction. clinical signs, symptoms, and diagnostic results associated with primary liver disease and reactive hepatitis are similar; therefore, a further diagnostic workup is important to reveal the primary cause. small bowel-type diarrhea occurs frequently with hepatic diseases (see table 61 -2). two primary mechanisms may account for clinical signs. first, cholestatic diseases (intrahepatic or extrahepatic caused by common bile duct obstruction) disrupt the normal enterohepatic cycle of bile acids; therefore less bile reaches the duodenum. 30, 31 decreased resorption of dietary fat may cause hyperosmotic intestinal contents and diarrhea. however, studies in rats show that cholestasis must be severe before steatorrhea as a result of disruption of the enterohepatic bile acid cycle occurs. another mechanism for diarrhea in liver disease is increased resistance to portal blood flow, resulting in portal hypertension and congestion of splanchnic organs. intestinal vasculature congestion reduces intestinal water resorption and increases intestinal volume content. this is the predominant mechanism underlying diarrhea in diseases such as chronic hepatitis, lobular dissecting hepatitis, portal vein thrombosis, and portal vein hypoplasia. 5 alternatively, when the primary cause of diarrhea is intestinal disease, the liver may be affected secondarily. in those cases, the hepatic macrophage system should remove the increased absorption of (endo)toxins or bacteria by the affected intestinal wall. increased exposure, however, can lead to secondary, nonspecific, reactive hepatitis. endotoxins also effectively inhibit bile formation and flow, leading to cholestasis. it is therefore common to find increased plasma liver enzyme activities and bile acid levels in cases of reactive hepatitis; clinical icterus may even be apparent. the cause of diarrhea can be determined only by further diagnostic methods, including histologic evaluation of liver biopsy specimens. reactive hepatitis resolves rapidly when the primary disease is treated successfully. in the authors' experience it is very rare to find diarrhea as single or the leading symptom in cases of liver disease. if present, it is usually one of the less prominent symptoms in the spectrum of other more prominent symptoms such as apathy, pu/pd, or vomiting. one may therefore elect to follow liver laboratory values after treatment of the intestinal disease and perform a liver biopsy if liver parameters fail to improve within a few weeks. hepatic encephalopathy is a complex of neurobehavioral signs resulting from portosystemic shunting of blood in combination with a reduction of functional liver mass. 11 it may occur in animals with cpss or in those with apscapsc because of portal hypertension. diseases associated with the latter form are chronic hepatitis, cirrhosis, portal vein hypoplasia, lobular dissecting hepatitis, and portal vein thrombosis. 32 cats, because of their dependence on some essential amino acids (e.g., arginine), may develop hepatic encephalopathy without portosystemic shunting, especially when they have a severe form of hepatic lipidosis. 33 doberman pinschers. 17 the hepatitis in doberman pinschers is sex linked, confined to females, and aggressive. 18 it is responsive to medication with penicillamine, 19 but may terminate in micronodular cirrhosis. this form of cirrhosis, predominantly seen in copper toxicosis, differs from other forms of chronic hepatitis, in which patients typically develop macronodular cirrhosis with large hyperplastic nodules. hepatitis is overrepresented in female doberman pinschers by a factor of 10; a study in finland showed that approximately 10% of doberman pinschers may be affected. 20 inherited copper toxicosis is also a well described entity in bedlington terriers worldwide. 21 both sexes may be affected. clinical signs usually develop after 4 years of age as a result of the gradual accumulation of copper. it is caused by a defect in the murr 1 gene, leading to a severely decreased excretion of copper by hepatocytes. other affected breeds are west highland white terriers (particularly in the united states), skye terriers, dalmatians, anatolian shepherd dogs, and labrador retrievers. [22] [23] [24] [25] [26] siamese cats may also be predisposed to copper-associated hepatopathies. 9 although essential for life, copper is usually ingested to excess and must be eliminated by the liver to prevent toxicity. the central role of the liver in copper homeostasis makes it vulnerable if elimination processes fail. 27 furthermore, increased copper levels add to the oxidative stress, which is an important component in chronic inflammatory and cholestatic diseases in dogs. 25 spaniels seem to have the form of chronic hepatitis unrelated to copper toxicosis and develop macronodular cirrhosis when left untreated. no sex predisposition exists, but there seems to be a worldwide overrepresentation of hepatitis in this breed. congenital portosystemic shunts (cpss) are seen in both sexes in various breeds. intrahepatic shunts predominate in large breeds, whereas extrahepatic shunts predominate in small and toy breeds. although cpss are most likely inherited in some fashion in all affected breeds, this has only been proven in irish wolfhounds 28 and cairn terriers. 29 worldwide predispositions occur in irish wolfhounds, australian cattle dogs, labrador retrievers, dachshunds, yorkshire terriers, cairn terriers, maltese terriers, and miniature schnauzers. 7, 9 in the united states, an increased prevalence of shunts has also been reported to occur in german shepherd dogs, doberman pinschers, and golden retrievers. cpss occur most often in mixed-breed cats; however, persian and himalayan cats are frequently overrepresented. clinical signs are usually seen in young dogs and cats (<1 year old) with congenital shunts. 5, 9 pathogenesis of common symptoms of primary liver diseases vomiting is one of the most common symptoms noted in dogs and cats with liver disease. vomiting may be caused by direct stimulation of the vomiting center via the chemoreceptor trigger zone in the fourth ventricle by (endo)toxins that are not cleared by the liver. 30 this typically occurs when toxins from the gi system bypass the liver and access other body systems. vomiting is common in all conditions that share portosystemic shunting and liver dysfunction (e.g., congenital shunts and acquired shunts because of hepatitis, fibrosis, cirrhosis, and portal vein hypoplasia or thrombosis). hepatic diseases that cause an abnormal liver shape may reposition the upper gi tract and induce nausea and vomiting by vagal stimulation. causes include hepatic tumors, especially liver cell (or hepatocellular) carcinomas, and unilateral collapse and contralateral hypertrophy, which may occur with thrombosis of a main branch of the portal vein. the gallbladder and larger bile ducts have a rich sym-form ammonium urate. affected dogs usually have clinical signs related to shunting and liver dysfunction, such as hepatic encephalopathy, pu/pd, or vomiting. in the other category, the enzyme uricase, which forms allantoin, is inactive because of an inborn error affecting only this function. ammonium urate urolithiasis occurs commonly in dalmatians but may occur in other breeds. 43 affected dogs only have signs related to urolithiasis (e.g., pollakiuria, stranguria, dysuria). an owner may note acholic feces, which can provide a direct clue to the underlying diagnosis. steatorrheic feces that do not contain normal bile pigment are seen only when bile flow into the intestinal tract is completely disrupted, usually as a consequence of extrahepatic obstruction of the common bile duct. 6 destructive cholangiolitis is the only intrahepatic process severe enough to seriously disrupt bile flow. the latter disease is caused by a hypersensitivity reaction to sulfonamide-containing drugs. the smaller bile ductules become necrotic and liver lobuli may be disconnected from the biliary tract. affected dogs have a history of recent medication with sulfonamides. acholic feces contain excess fat because resorption is impaired. the lack of normal black-brown fecal pigments occurs because their precursor, bilirubin, does not reach the duodenum. therefore, the feces from affected animals are gray-white and soft. animals with this condition often are icteric. the presence of icterus reduces the likelihood of exocrine pancreatic insufficiency as a diagnosis. abdominal distention may occur in dogs and cats with liver disease for several reasons. first, ascites is a frequent finding associated with liver disease in dogs as a result of portal hypertension, but is less common in cats. abdominal distention may also result from organ enlargement, which in the case of liver disease may include the liver and, in the spleen in the presence of portal hypertension. in contrast to dogs, cats often have hepatomegaly with liver disease. nonspecific symptoms, such as apathy, reduced appetite or anorexia, and weight loss, may occur in dogs and cats with liver disease. retarded growth is common in young animals. these problems reflect the central role of the liver in many metabolic and detoxifying functions. in addition, nausea, inappetence, vomiting, and diarrhea can result in a catabolic state, which, in turn, may aggravate hepatic encephalopathy. signs of early hepatic encephalopathy include depression and other nonspecific problems. anemia, another common finding in liver disease (see below), can cause general malaise. dogs with liver cell carcinoma often are hypoglycemic, 44 which may be the primary problem underlying apathy and weakness. production of insulin-like growth factors by the tumor may be responsible. as with historical findings, physical examination findings rarely provide enough information to pinpoint the liver as definitive cause of the presenting problems. possible findings include icterus, hepatomegaly, splenomegaly, ascites, and pale mucous membranes. petechiae of the skin or mucous membranes occur infrequently. of these possible findings, only icterus and hepatomegaly are more or less specific for liver diseases; other abnormalities on the physical examination occur more frequently with diseases of other organ systems. hepatic encephalopathy is caused by derangement of neurotransmitter systems caused by defective metabolic processes in the liver. 34 inadequate metabolism of ammonia and aromatic amino acids by the liver may reduce the excitatory glutamatergic and monoaminergic neurotransmitter system tones, respectively. 35 in addition, there is an increased tone of the inhibitory γ-aminobutyric acid (gaba) system. 36 these neurotransmitter derangements make anesthesia risky in some animals with liver disease. the liver inactivates many anesthetics and the unforeseen delay of recovery from anesthesia may suggest an underlying liver disease as a cause for nonspecific clinical signs. this occurs especially in dog and cats with portosystemic shunting, either congenital or acquired. in addition to reduced hepatic clearance, anesthetics exert their action via various neurotransmitter systems in the brain, which may already be functioning abnormally as a consequence of hepatic encephalopathy. 34 this is especially true of drugs that act via the gaba-benzodiazepine pathway. that pathway is already overstimulated and may provoke an exaggerated and prolonged anesthetic effect. pu/pd is one of the most frequent signs (50% of cases) in dogs with liver disease, but is less common in cats. pu/pd is most common in diseases associated with congenital or acquired portosystemic shunting and, therefore, with hepatic encephalopathy. in affected dogs, abnormal neurotransmitter disturbances lead to increased secretion of adrenocorticotropic hormone (acth) from the anterior and intermediate pituitary lobes. 37 chronically elevated acth stimulates increased levels of free cortisol. increased levels of free cortisol, in turn, affect the posterior lobe of the pituitary creating an increased threshold for the release of arginine vasopressin. 38, 39 thus, a higher plasma osmolality is required to stimulate antidiuresis through arginine vasopressin, and before reaching that threshold, affected dogs become thirsty and start drinking. 38 pu/pd is not only present in cases with hepatic encephalopathy, but also frequently in all other liver diseases. this may be caused by certain bile acids, which are often increased in plasma of animals with liver diseases. bile acids may inhibit the activity of 11β-hydroxyl steroid dehydrogenase. 40 this enzyme protects the aldosterone receptor from occupation by cortisol, by converting cortisol into cortisone, which cannot bind to the receptor. present in plasma in tenfold excess compared with aldosterone, cortisol can occupy and stimulate the aldosterone receptor thereby inducing pseudohyperaldosteronism and pu. 41 reduced hepatic formation of urea is another possible but undocumented mechanism that may play a role in the pathogenesis of pu/ pd. in urea deficiency states, the kidney does not have sufficient urea available to build up an osmotic gradient in the medulla. apart from this mechanism, pd also occurs in liver diseases not associated with hepatic encephalopathy (e.g., extrahepatic cholestasis and liver tumors). the mechanism is unclear; however, nausea with an impulse to drink and compensation of water loss by vomiting and diarrhea may play a role. 5 dysuria may occur as a result of insufficient liver function when nonmetabolized uric acid is excreted by the kidneys and precipitates to form uroliths. such calculi are seen in dogs but rarely in cats. 42 there are two main categories of liver dysfunction that cause ammonium urate urolithiasis. most frequently it is caused by congenital portosystemic shunting, whereby the liver is underdeveloped and fails to metabolize uric acid into allantoin. in urine, uric acid flocculates easily in the presence of high ammonia concentrations to a result of congestive heart disease can, in most cases, be recognized easily by physical examination of the circulatory system. measurement of central venous pressure is diagnostic. the exception is liver congestion caused by a thrombus in the caudal vena cava proximal to the liver, which is assessed by other methods. when the liver is overtly enlarged because of congestion, ascites is usually present. ascitic fluid has the typical slightly hemorrhagic appearance of congestive fluid. dogs with enlarged livers and no signs of congestive disease often have liver cancer, which may be primary, metastatic, or a form of malignant lymphoma. with most tumors, the liver is diffusely enlarged, but primary hepatocellular carcinomas or adenomas may cause enlargement of the affected lobe only. bile duct carcinomas disseminate easily over the biliary system and usually cause pronounced icterus and hepatomegaly. most cats with hepatic disease develop pronounced enlargement of the liver. in cats, liver enlargement occurs with cholangitis, hepatic lipidosis, amyloidosis, hepatic tumors (primarily malignant lymphoma), and congestive disease. when the liver is involved in feline infectious peritonitis, it may not be enlarged. cats with cpss have small livers. splenomegaly and ascites in association with liver disease are nonspecific findings. they occur especially with hepatic diseases causing portal hypertension. both findings are frequent in dogs but rare in cats. there is a positive undulation test with distinct ascites; slight ascites can be found with ultrasonography rather than physical examination. the liver may be enlarged with central causes of venous congestion. canine liver diseases associated with portal hypertension include chronic hepatitis and cirrhosis, portal vein hypoplasia, and lobular dissecting hepatitis. portal hypertension is sometimes seen with cirrhosis because of advanced cholangiohepatitis in cats. in these diseases, hepatic encephalopathy is also common. portal vein thrombosis is a prehepatic cause of portal hypertension that usually causes ascites. although as a rule the liver is small in these cases, unilateral obstruction of a main branch of the portal vein may cause hypertrophy of the rest of the liver, which may be palpable. diseases of the hepatic parenchyma, hepatic vasculature, and biliary tract are relatively common in dogs and cats. because the symptoms and signs accompanying liver disease are quite nonspecific, and the liver may be secondarily involved in diseases of other organs, liver disease can easily go undetected. therefore, after taking a thorough history and performing a physical examination, it is critical to perform additional biochemical tests with the highest possible diagnostic accuracy whenever liver disease is included in the differential diagnosis. if liver disease cannot be ruled out based on these examinations, additional testing is necessary to define the type of liver disease, most notably ultrasonography of the cranial abdominal quadrant and examination of a liver biopsy specimen. the algorithm in figure 61 -5 summarizes this approach. diagnosis usually depends on histopathologic examination of liver tissue, especially for parenchymal liver diseases, many biliary tract diseases, and tumors of the liver or biliary tract. although biopsy methods are beyond the scope of this chapter, excellent sources exist. 13 one note of caution: blood coagulation testing is vital before collecting a liver biopsy specimen for histopathology. most animals, for example, have one or more abnormal coagulation tests. [47] [48] [49] [50] [51] [52] factors involved may include vitamin k deficiency, reduced ascites and hepato-and splenomegaly may have been noted by the owner as abdominal enlargement. 5 biochemistry analyses are an integral part of the diagnostic process for liver diseases. most of these analyses are not a decisive factor in the diagnosis of liver disease, but serve to rule out liver disease from the differential diagnosis. 8 icterus is the most frequently encountered specific abnormality noted on the physical examination in dogs and cats with liver disease. however, only approximately 20% of dogs with hepatobiliary diseases and 30% to 40% of cats are icteric. icterus results from bilirubin accumulation in the blood and extravascular space as a result of increased production, reduced clearance, impaired conjugation by the liver, and/or impaired bile flow. in most cases, a combination of these factors is involved. cholestasis is predominant; therefore conjugated bilirubin is the fraction present in greatest quantity. hemolysis alone does not result in icterus with normal liver function. when hemolysis is severe, however, it may result in such a degree of portal hypoxia that the centrolobular zones of the liver lobules become necrotic. in those cases, icterus results from the combination of increased production and reduced liver function and cholestasis. 45 if hemolysis is the primary cause of icterus, it must be severe, and the mucous membranes will be extremely pale. primary liver diseases that may cause icterus are commonly accompanied by hemolysis. whereas the erythrocyte lifetime is reduced to 6 to 10 days in dogs with severe primary hemolytic disease; it is 20 to 60 days (normally 100 days) in hepatobiliary disease. increased production of bilirubin and liver dysfunction with cholestasis result in a combined conjugated and unconjugated hyperbilirubinemia in dogs and cats with primary hepatic or hemolytic disease. 46 icterus caused by hemolytic disease is characterized by pale mucous membranes, whereas the mucous membranes in animals with primary liver disease are normal or only slightly pale. the combined evaluation of icterus and the color of the mucous membranes immediately reveal the nature of the underlying process. as previously discussed, most hepatobiliary diseases are accompanied by increased degradation of red blood cells. the mechanisms behind hemolysis in liver disease are not completely clear. hypersplenism and reduced portal blood flow due to portal hypertension may drastically prolong the transit time of erythrocytes through the spleen, with a greater chance that they will be trapped when they are slightly abnormal. increased fragility of red cell membranes may be a result of the high bile acid levels in most liver diseases, whereas a reduced clearance of enteral endotoxins and bacteria by the liver may also induce immune-mediated hemolysis. apart from hemolysis, nonregenerative anemia also may occur as part of the syndrome of anemia of chronic disease as an expression of catabolism and slight deficiencies of iron and b vitamins. although common in liver diseases, 12 anemia, in contrast to icterus, is nonspecific. like icterus, hepatic enlargement is a distinct sign of an abnormal liver. in dogs, most liver diseases do not cause hepatomegaly. exceptions include tumors of the liver, liver congestion, and secondary liver involvement in metabolic diseases. examples of the latter conditions are glycogen accumulation in the liver in cushing disease, fatty liver with diabetes mellitus, and rare cases of amyloidosis of the liver. the more chronic liver diseases of dogs tend to reduce liver size, and acute diseases cause little change in size. liver enlargement as hormones and drugs, leading to an increase in their serum activities in patients without primary hepatic disease. additionally, serum hepatic enzyme activities can be increased as a consequence of secondary hepatopathies. the magnitude of hepatic enzyme activity increases may aid in the assessment of the severity or the extent of hepatic injury but should not be considered to be prognostic. the liver has a large capacity for regeneration, so even in cases of severe hepatic injury, with dramatically raised hepatic enzyme activities, a full recovery is possible. this is especially true when the injury is acute. conversely, in cases of chronic end-stage liver disease, such as cirrhosis, serum hepatic enzyme activities may not be markedly increased, or may even be within the reference interval as a result of the replacement of hepatocytes with fibrous tissue. consequently, serial evaluation of serum hepatic enzyme activities is more useful for assessing prognosis than measurement at a single point in time. consistent decreases of a previously increased activity are considered a favorable sign in acute liver injury, whereas a decreasing hepatic enzyme activity in a patient with chronic liver disease that is clinically deteriorating suggests loss of hepatocytes because of fibrosis. it is important to note that serum hepatic enzyme activities do not provide an assessment of liver function. alt is an enzyme found primarily in the cytosol of hepatocytes. alt is released into the serum when hepatocyte membrane permeability is increased, or if there is hepatocellular necrosis. alt is considered to be the most liver-specific enzyme. alt is also produced by cardiac muscle, skeletal muscle, and the kidneys. 1 apart from the hepatic form, only the muscle isoenzyme is clinically significant. although uncommon, severe muscle injury can result in an increased serum alt activity. hepatic microsomal induction in response to some drugs can also produce small increases in alt activity. some controversy exists regarding the serum half-life for alt in dogs. the mean serum half-life of alt was reported as being 149 minutes in one study 1 and 59 hours in another. 2 the serum half-life of alt is generally believed to be shorter in the cat than in the dog. a mean serum half-life of 207 minutes was reported in an experiment involving three healthy cats. 3 the shorter half-life in cats means that increases in serum alt activity are considered more clinically important in this species. as alt is metabolized in the liver its serum half-life may be longer in patients with liver disease. 4 increased cell membrane permeability in the absence of hepatocyte destruction can cause a rapid increase in serum alt activity. because of this, alt activity is a considered to be a highly sensitive marker of hepatocyte injury. this also means that an increased alt activity does not imply severe or irreversible hepatocellular injury. the highest increases in alt activity are seen during acute hepatic inflammation or necrosis, but because of the capacity for the liver to regenerate these do not indicate irreversible damage. consequently, a single measurement of alt activity does not provide an accurate prognosis. however, the degree of the alt activity increase is believed to have some correlation with the number of hepatocytes that have been injured. cholestasis can also result in an increased serum alt activity because of hepatocellular damage caused by the accumulation of bile acids. certain drugs can lead to increases in serum alt activity. these are usually minor, for example, phenobarbital used at therapeutic doses frequently leads to small increases in serum alt activity, in the absence of hepatic insufficiency. these increases are thought to occur as a result of subclinical hepatic injury rather than induction of hepatic microsomal enzymes. 5 toxic doses production of clotting factors, some degree of disseminated intravascular coagulation (dic), and severe protein deficiency. 13, 52 it should be noted that taking a fine-needle aspiration biopsy should be considered safe, even if abnormalities in coagulation are present. however, its diagnostic value is limited as the liver architecture is lost. diagnosis of circulatory hepatic diseases depends on information obtained from laboratory results, ultrasonography (most reliable diagnostic test to date), and histopathology. 13 a recent paper found that fasting ammonia concentration was superior to fasting bile acids for diagnosing portosystemic shunting in dogs. 53 ammonia is easily measured in practice with dry chemical methods, some of which provide reliable results. 54 another recent publication showed ultrasonography to be a reliable diagnostic method to noninvasively characterize the underlying hepatic disease in dogs with hyperammonemia. 55 diagnostic evaluation of the hepatobiliary system has several aims: (a) to determine if hepatobiliary disease is present, (b) to assess liver function, (c) to determine if liver disease is primary or secondary, (d) to definitively diagnose hepatobiliary disease, and (e) to monitor response to treatment. despite the apparent clarity of these aims, hepatobiliary disease can present a diagnostic challenge for a number of reasons. first, as clinical signs can be nonspecific, hepatobiliary disease should be a consideration when evaluating any patient with signs of systemic disease. dogs and cats with hepatobiliary disease may not have any clinical signs. furthermore, because of the liver's central role in metabolism and detoxification of endogenous toxins and xenobiotic agents, a number of extrahepatic diseases can secondarily affect the liver. it is important to distinguish these secondary hepatopathies from diseases that originate in the liver (primary hepatopathies). additionally, serum markers of hepatocellular damage, cholestasis, and hepatic function can be abnormal in the absence of hepatobiliary disease. finally, the liver's large reserve capacity means that detectable loss of liver function often occurs late in the course of disease. thus, when assessing a patient with suspected hepatobiliary disease, it is important to consider the clinical presentation, results of laboratory testing, diagnostic imaging findings, and the results of cytologic and/or histopathologic evaluation together. hepatic enzymes can be divided into markers of hepatocellular damage and markers of cholestasis. serum alanine aminotransferase (alt) and aspartate transaminase (ast) activities are the two most commonly measured markers of hepatocellular leakage, while serum alkaline phosphatase (alp) and γ-glutamyltransferase (ggt) activities are the two most commonly measured markers of cholestasis. although increased serum hepatic enzyme activities are considered to be sensitive, they are not specific for primary liver disease because they are produced by extrahepatic tissues. the relative importance of these extrahepatic isoenzymes varies, but their extrahepatic release can lead to increased serum activities. also, the production of some hepatic enzymes can be induced by certain alp (b-alp), and kidney alp (k-alp) are transcribed from the tissue nonspecific alp gene. the other gene encodes intestinal alp (i-alp) and probably glucocorticoid-induced alp (g-alp). 13 in dogs the serum half-lives of placental alp, k-alp, and i-alp are less than 6 minutes. 14 in cats the serum half-life of i-alp is less than 2 minutes. the half-lives of placental alp and k-alp are also assumed to be short in the cat as they have similar structures to i-alp. because of this, only l-alp, b-alp, and, in the dog but not the cat, g-alp, are believed to contribute significantly to serum alp activity. the serum half-life of l-alp is approximately 70 hours in the dog 14, 15 and 6 hours in the cat. 16 l-alp is bound to the membranes of the hepatocytes by glycosylphosphatidylinositol linkages. cleavage of these links by glycosylphosphatidylinositol-phospholipase allows the enzyme to be released into the bloodstream. 17 as bile acids have detergent-like properties; accumulation of bile acids during cholestasis facilitates this process. cholestasis can also result in the induction of synthesis of l-alp (and g-alp in the dog). consequently, serum alp activity is often severely increased in patients with cholestatic disorders. in the dog, alp is considered to be a sensitive marker for cholestasis with a sensitivity of 85%. 18 the short half-life of l-alp in cats means that increases in alp during cholestasis are not as high as in the dog. consequently, alp is a less-sensitive marker of cholestasis in the cat than in the dog, with a reported sensitivity of only 48%. 19 however, the shorter half-life in cats and the absence of g-alp means that any increase in alp activity should be considered clinically important in this species. an increased serum alp activity does not differentiate between intrahepatic or extrahepatic cholestasis. a wide variety of liver diseases can cause intrahepatic cholestasis. this is generally caused by hepatocyte swelling, causing obstruction of the small bile canaliculi. the increase of alp following a hepatic insult is delayed compared to rises in markers of hepatocellular leakage. the reason for this is that it takes time for the enzyme to be synthesized and released into the systemic circulation. alp often remains increased for some time after the resolution of liver injury. b-alp is released into the bloodstream as a result of the activity of osteoblasts. therefore any condition that results in increased bone formation can lead to increased serum alp activity. in animals that are skeletally immature, mild increases in serum alp activity are commonly observed. animals with increased osteoblast activity, such as those with hyperparathyroidism, neoplasia involving bones, and osteomyelitis, may have mild to moderate increases in alp activity. these causes of increased b-alp activity are unlikely to be confused with primary liver disease because the increases are smaller than would be expected with cholestasis, and because bone diseases are often clinically apparent. finally, an increased serum activity of b-alp was reported in a family of asymptomatic huskies. 20 in dogs, but not in cats, g-alp and tissue-nonspecific alp may be induced by corticosteroids. g-alp is believed to be an isoform of i-alp with a prolonged serum half-life that is produced by the liver. 13 posttranslational glycosylation of the g-alp is believed to be responsible the prolonged half-life. induction of g-alp may cause an increase in total serum alp activity after administration of exogenous corticosteroids. synthesis of this isoenzyme can also be induced by the administration of anticonvulsant drugs, such as phenobarbital. similarly, hypercortisolemia frequently causes an increased serum alp activity because of induction of g-alp. however, in dogs with excess serum concentrations of endogenous or exogenous corticosteroids, hepatocyte swelling caused by glycogen accumulation (vacuolar hepatopathy) may lead to intrahepatic cholestasis, another potential contributor to increased serum alp of phenobarbital can cause dramatic increases of serum alt activity and hepatic insufficiency. prednisone and other glucocorticoids can cause an induction of alt (and steroid hepatopathy) and consequently small increases in serum alt activity. serum alt activity can also be increased with any secondary hepatopathy. however, a persistently increased serum alt activity, even with an apparently normal liver function, is an indication for further diagnostic testing. serial evaluation of serum alt activity can be helpful to prognosticate but must be done while considering the patient's clinical signs and other laboratory values. in general, a declining serum alt activity after acute liver injury is considered a good sign. ast is another aminotransferase enzyme that is used as a marker of hepatocellular leakage. ast is found in skeletal muscle, the brain, liver, kidney, cardiac muscle, and to a lesser extent within other tissues. 6 the extrahepatic isoenzymes of ast are relatively more important than they are for alt. muscle disease can cause an increase in serum ast activity. because of this, ast is considered less liver specific than alt. however, by looking at serum ast activity in conjunction with the activities of other hepatic enzymes and muscle enzymes, it is usually possible to differentiate increases caused by muscle damage from increases caused by hepatic damage. again, there is controversy regarding the serum half-life of ast. in dogs one study 1 reported the half-life to be a mean of 263 minutes; another study reported a mean of 22 hours. 2 one study reported the mean half-life to be 78 minutes for cats. 7 unlike alt, a considerable proportion of ast (approximately 30%) is found within hepatocyte mitochondria rather than the cytosol. 8 the cytosolic fraction of ast is released into the serum from hepatocytes when cell membrane permeability is increased, or in case of hepatocellular necrosis. in contrast, the mitochondrial fraction is only released during hepatocellular necrosis. release of ast from hepatocytes into the serum parallels the release of alt. therefore, like serum alt activity, serum ast activity is considered a sensitive marker for hepatocyte injury. it has been suggested that increased ast activity may be more sensitive than increased alt activity for the detection of hepatocellular injury in cats. 9 corticosteroids and phenobarbital may cause mild increases in serum ast activity. because of the considerable overlap in the information provided by the measurement of serum alt and ast activities, measurement of serum ast activity may be redundant. alp is an enzyme bound to the membranes of the hepatocytes that comprise the bile canaliculi and the sinusoidal membranes. it is considered a sensitive marker for cholestasis, especially in the dog, but is not liver specific. cholestasis, canalicular cell necrosis, and increased hepatic synthesis may lead to the release of this enzyme into the circulation. synthesis of this enzyme can be induced by certain drugs, most notably corticosteroids. the possibility that an increase in serum alp activity could be caused by extrahepatic disease, or could be induced by glucocorticoids in the dog, can make the interpretation of this finding challenging. in the dog a wide variety of tissues exhibit alp activity, including intestinal mucosa, kidney (cortex), bone marrow, pancreas, testicle, brain, lung, kidney (medulla), lymph node, liver, skin, spleen, skeletal muscle, and cardiac muscle. 6 there is disagreement in the literature regarding the relative contributions of alp activity from each of these tissues in cats. [10] [11] [12] there are two genes encoding alp in the dog. different forms of alp arising from the same gene are called isoforms. differences among these isoforms arise because of differing posttranslational processing. liver alp (l-alp), bone globulins are produced in the liver, but not exclusively so. the liver produces α-globulins and β-globulins, whereas lymphoid cells produce immunoglobulins (γ-globulins). hepatic insufficiency rarely leads to a decrease in serum globulin concentration. conversely, inflammatory liver disease may be associated with hyperglobulinemia because the nonimmunoglobulin fraction produced by the liver includes several acute-phase proteins (c-reactive protein, haptoglobin, and serum amyloid a). the hepatic synthesis of these proteins is increased during systemic inflammation [26] [27] [28] [29] possibly leading to a rise in the total serum globulin concentration. additionally, immunoglobulin production may be increased in infectious, neoplastic, or autoimmune diseases. coagulation factors (except factor viii), anticoagulation factors (antithrombin and protein c), and the fibrinolytic protein plasminogen, are all synthesized by the liver. the liver is also the site of activation of the vitamin k-dependent clotting factors: ii, vii, ix, x, and protein c. furthermore, as bile acids are needed to emulsify fat and aid in the absorption of vitamin k from the intestine, vitamin k malabsorption may develop secondary to cholestasis. consequently, hepatobiliary disease can affect hemostasis in more than one way. in canine and feline liver disease, coagulation parameter abnormalities have been reported in specific clotting factor activities, prothrombin time, aptt, [30] [31] [32] proteins induced in the absence of vitamin k, 33, 34 fibrin degradation products, fibrinogen, and protein-c activity. 35 these abnormalities of hemostasis are not specific for liver disease but may support its presence. patients with liver disease may develop dic, which can be difficult to distinguish from coagulopathy because of reduced hepatic synthesis of clotting factors alone. although spontaneous bleeding seldom occurs in patients with liver disease, the assessment of the coagulation status of these patients is important, especially when an invasive procedure such as a liver biopsy is being considered. a recent study investigated the diagnostic value of serum protein c as a marker for hepatobiliary disease and portosystemic shunting in dogs. serum protein-c measurement was reported to aid in the differentiation of portal vein hypoplasia without portal hypertension (formerly called microvascular dysplasia) from portosystemic shunt (pss). dogs with portal vein hypoplasia without portal hypertension had a significantly higher serum protein-c concentration than those with portosystemic shunting. 35 urea is produced from ammonia in the liver, released into the systemic circulation, and subsequently excreted by the kidneys. serum urea nitrogen concentration may be close to or below the lower limit of the reference interval in patients with hepatic insufficiency, pss, 36 or urea cycle enzyme deficiencies. however, serum urea nitrogen concentration may also be decreased because of medullary solute washout caused by diuresis, malnutrition, or a protein-restricted diet, and is a normal finding in neonates. in a patient with liver disease, a high fasting serum urea nitrogen concentration relative to the serum creatinine concentration suggests gi hemorrhage. ammonia (nh 3 ) is produced in small intestinal enterocytes from the catabolism of glutamine and in the colon as a consequence of bacterial deamination. ammonia is a highly diffusible gas and passes readily through the bowel wall into the bloodstream. in the blood, at a ph of 7.4, most of the ammonia exists in the form of ammonium ions (nh 4 + ). the ammonium is transported in the blood from the intestines through the hepatic portal circulation to the liver. the extraction of ammonia from the portal circulation is highly efficient. endogenous ammonia is produced from the breakdown of activity. before diagnosing primary liver disease in a dog with an increased serum alp activity, induction of g-alp by endogenous or exogenous steroids should be ruled out. recently a group of scottish terriers were found to have increased serum alp activity with no identifiable underlying cause. 21 it is technically possible to selectively measure the activity of g-alp using techniques such as levamisole inhibition. measurement of g-alp activity was initially investigated as a way to differentiate increases in alp caused by corticosteroids from those caused by cholestasis. unfortunately, measuring g-alp is not clinically useful as g-alp activity may be increased in a variety of conditions, including hepatic disease, diabetes mellitus, hypothyroidism, and pancreatitis. ggt is a glycoprotein enzyme that is bound to the membranes of those hepatocytes that form the bile canaliculi and bile ducts and also periportal hepatocytes. in comparison to alp its distribution includes more distal areas of the biliary tract, but measurement of serum ggt activity is not useful to distinguish between intrahepatic and extrahepatic cholestasis. ggt is also produced by a number of extrahepatic tissues. most of the ggt activity in serum is thought to be a result of the hepatic isoenzyme. colostrum also contains ggt, which is responsible for the mild increases in serum ggt activity that are seen in suckling animals. 22 changes in serum ggt activity generally parallel those in serum alp activity, in that activity is often increased in patients with cholestasis. because ggt is also induced by glucocorticoids, its activity may be increased in patients with hyperadrenocorticism or those exposed to exogenous steroids. in dogs, an increased serum ggt activity is considered to be more specific, but less sensitive than alp activity for the presence of liver disease. 18 in cats, measurement of serum ggt activity is more sensitive but less specific for the detection of liver disease than alp. cats with hepatic lipidosis may be an exception to this as they often have a normal serum ggt activity but an increased serum alp activity. 19 the liver plays a central role in protein metabolism. it is responsible for the synthesis of plasma proteins, deamination of amino acids, conversion of ammonia to urea, amino acid synthesis, and interconversion of amino acids. 23 consequently, in patients with hepatic disease these functions may be compromised. albumin is an important plasma protein that is produced exclusively by the liver. the rate of albumin synthesis must equal the rate of albumin loss to maintain serum albumin concentrations. mild decreases in serum albumin concentration can occur from a variety of conditions. however, the differential diagnoses for severe hypoalbuminemia (<2 g/dl) are limited to hepatic insufficiency, severe exudative skin disease, protein-losing enteropathy, and proteinlosing nephropathy. it is possible to determine the cause of severe hypoalbuminemia from a combination of clinical findings, measurement of the serum globulin concentration, urinalysis (including protein creatinine ratio), tests of gi protein loss, and tests of liver function. as albumin contributes significantly to colloid oncotic pressure, 24 severe hypoalbuminemia can lead to ascites, pleural effusion, and/or subcutaneous edema. the liver has a large reserve capacity for the synthesis of albumin and albumin has a serum halflife of approximately 7 days in dogs. 25 consequently, hypoalbuminemia is a relatively insensitive marker for hepatic insufficiency and is only likely to be seen in patients with advanced chronic liver disease or portosystemic shunts (psss). for hepatobiliary disease in dogs or cats. in patients with severe hepatic insufficiency or pss 49 serum cholesterol, concentration may be decreased as a consequence of impaired hepatic synthesis. hypocholesterolemia might also occur as a result of inadequate dietary intake, maldigestion, malabsorption, or hypoadrenocorticism. the serum cholesterol concentration of patients with hepatobiliary disease may be within the reference interval. patients with cholestatic disease can become hypercholesterolemic. 50 fasting hypercholesterolemia also may be observed in patients with various endocrinopathies, obesity, protein-losing nephropathy, pancreatitis, or primary hyperlipidemias. serum triglyceride concentration may be increased or normal in patients with liver disease. however, an increased fasting serum triglyceride concentration is not a sensitive or specific marker for hepatobiliary disease in dogs or cats. a mild increase in serum triglyceride concentration may develop in patients with cholestasis. there is some evidence that hypertriglyceridemia is associated with gallbladder mucocele formation. 51 hypertriglyceridemia is associated with increased serum hepatic enzyme activities in miniature schnauzers. 52 increased fasting serum triglyceride concentrations are also observed in patients with endocrinopathies, obesity, pancreatitis, and primary hyperlipidemias. the liver plays a central role in carbohydrate metabolism and is responsible glycogen storage, conversion of galactose and fructose into glucose, gluconeogenesis, and the synthesis of many compounds from carbohydrates. 23 blood glucose measurement is not a sensitive or specific marker for liver disease. the liver has a large reserve capacity for glucose production. consequently, hepatic insufficiency must be severe for hypoglycemia to occur. hypoglycemia occurs in a proportion of patients with congenital pss. 53 hepatic neoplasia can also lead to hypoglycemia. this is thought to be caused by release of insulin-like substances. 54 a variety of extrahepatic conditions can also lead to hypoglycemia. bilirubin is a yellow pigment produced from the breakdown of heme-containing compounds. measurement of serum bilirubin concentration can be used to assess liver function. hyperbilirubinemia can be the result of hepatobiliary or extrahepatic disease. icterus is the yellowish pigmentation caused by the retention of bilirubin in the soft tissues. laboratory assessment is the most sensitive way to detect increased serum bilirubin concentrations. hyperbilirubinemia is classified as prehepatic, hepatic, or posthepatic in origin. bilirubin may be artifactually increased by in vitro hemolysis or by the administration of synthetic hemoglobin polymers. when assessing a hyperbilirubinemic patient it is critical to localize the underlying cause. bilirubin is the major product of the degradation of hemecontaining compounds by cells of the mononuclear phagocyte system. bilirubin is released from the mononuclear phagocyte system and is transported in the plasma. the bilirubin is reversibly bound to albumin as it is water insoluble. the unconjugated bilirubin is absorbed through the hepatocyte cell membranes and is bound to glucuronic acid (conjugation). conjugated bilirubin is water soluble and is actively excreted from the hepatocytes into the bile canaliculi, eventually being excreted into the intestines. once in the intestine some of the bilirubin is converted into urobilinogen by bacteria. some of the urobilinogen is reabsorbed from the intestines, but most of this is immediately reexcreted by the liver. when nitrogenous substances in the body, especially glutamine. in the liver the ammonium is converted to urea by the enzymes of the urea cycle, or is used during the conversion of glutamate to glutamine. 37 urea enters the circulation and is excreted by the kidneys. ammonium that is not removed by the liver enters the systemic circulation. the liver has a large reserve capacity for the conversion of ammonia into urea. because of this, plasma ammonia measurement is a relatively insensitive marker for hepatic insufficiency. however, measurement of blood ammonia concentration is a sensitive test for congenital psss and apsc shunts (also known as acquired psss). this is because when portosystemic shunting occurs, the ammonia absorbed from the intestines bypasses the liver and reaches the systemic circulation directly. the sensitivity of plasma ammonia measurement for the detection of pss is reported to be between 81% and 100% in dogs [38] [39] [40] [41] and 83% in cats. 41 the measurement of postprandial venous ammonia is more sensitive than the measurement of fasting ammonia (sensitivities of 91% and 81%, respectively) for the detection of congenital pss. 42 however, the sensitivity for detecting dogs with hepatocellular disease is only 36%. generally, hyperammonemia is considered specific for hepatic insufficiency or pss. however, although they are uncommon, urea-cycle enzyme deficiencies may also cause an increased blood ammonia concentration. these enzyme deficiencies can be hereditary as a result of the absence of a particular enzyme 43 or secondary to cobalamin or arginine deficiency. 44, 45 arginine deficiency is especially relevant in cats with hepatic lipidosis. ammonia is one of the substances that cause hepatic encephalopathy (he). therefore blood ammonia measurement is a useful marker for he. however, other substances can also cause he and the plasma ammonia concentration of a patient with he may be within the reference interval. ammonium ions are labile in plasma, so sample handling is critical when measuring plasma ammonia concentration. samples should be collected, placed immediately on ice, and the plasma separated from the red blood cells as soon as possible. the plasma must be kept cooled and should be analyzed within 30 minutes of collection. these handling requirements have meant that ammonia measurement has been mainly confined to practices with immediate access to a commercial laboratory. measurement of plasma ammonia is available on an in-house dry chemistry analyzer (vettest, idexx laboratories, westbrook, me) although this method was only considered to reliably agree with a reference method for serum ammonia concentrations greater than 150 µm. 46 a recent study found that a point of care blood ammonia analyzer (pocketchem ba, menarini diagnostics, florence, italy) may be suitable for the measurement of blood ammonia concentrations in dogs and cats. 47 ammonia tolerance tests (atts) have been investigated in an attempt to increase the sensitivity of ammonia measurement for detecting hepatic insufficiency and pss. however, the oral administration of ammonium salts can cause vomiting and potentially worsen he signs. ammonium chloride or sulfate can also be given rectally, which is less likely to produce adverse. this method is sensitive for the detection of pss in dogs. 48 the liver plays a central role in lipid metabolism and is responsible for oxidation of fatty acids, synthesis of cholesterol, synthesis of lipoproteins, and synthesis of fatty acids from proteins and carbohydrates. 23 serum cholesterol concentrations may be increased, normal, or decreased in patients with liver disease. increased or decreased fasting serum cholesterol concentrations are not sensitive or specific (fasting or postprandial) suggest hepatic dysfunction, pss, or cholestasis, but they are not specific for any particular liver disease. bile acids are exclusively synthesized in the liver from cholesterol. nearly all of the bile acids that are produced by the hepatocytes are conjugated to an amino acid. in both dogs and cats conjugation is primarily to taurine, but dogs may also convert to a conjugation with glycine. 61 in contrast, even taurine depleted cats conjugate their bile acids almost exclusively to taurine. 62 the conjugated bile acids produced by the liver are called primary bile acids. these are secreted in the bile, and then stored in the gallbladder. cholecystokinin is released from endocrine cells in the small intestine. this hormone stimulates gallbladder contraction and the flow of bile into the duodenum. when the gallbladder contracts the bile acids are released into the intestines. spontaneous gallbladder contraction also occurs during the interdigestive phase. 63 bile acids act as ionic detergents, aiding the emulsification of dietary lipids and their subsequent intestinal absorption in micelles. 64 bile acids are recycled in a process known as enterohepatic circulation ( figure 61-6 ). primary bile acids are lipid insoluble and thus are only absorbed from the intestines when they bind to specific high affinity ileal mucosal receptors. 64 this ileal reabsorption is very efficient. the reabsorbed bile acids enter the portal circulation and upon reaching the liver they are efficiently extracted from the plasma and subsequently reexcreted. the total bile acids pool can be recirculated several times in a day. consequently, the rate of hepatic bile acid synthesis and the fasting serum bile acids concentration in dogs and cats with normal hepatic function is low. because of the increased release of stored bile acids during the postprandial period, small increases in total sba concentration occur in animals with normal hepatic function. primary conjugated bile acids can undergo bacterial deconjugation in the intestinal lumen. the resulting unconjugated bile acids are called secondary bile acids. these are readily absorbed from the colon by passive diffusion. first-pass extraction and reexcretion of secondary bile acids is less efficient than that for primary bile acids. consequently, secondary (unconjugated) bile acids are often present in postprandial serum samples. 65 hepatobiliary disease can cause increased sba concentrations by interfering with hepatocellular function, by causing decreased bile flow (cholestasis), or by altering the hepatoportal blood flow. the main clinical use of sba measurement is to assess hepatic function in patients suspected to have hepatic disease, with serum exposed to air the urobilinogen remaining in the intestines is altered and oxidized into the brown pigment sterocobilin. 23 prehepatic hyperbilirubinemia is caused by increased production of bilirubin as a result of hemolysis. the liver has a large reserve capacity for bilirubin excretion so, for hemolysis to cause hyperbilirubinemia, hepatic bilirubin clearance must be decreased. 55 this occurs if the hemolytic anemia results in hepatocyte dysfunction because of hypoxia. if hepatic hypoxia occurs serum hepatic enzymes activities are often increased. prehepatic hyperbilirubinemia is mainly distinguished from other causes of hyperbilirubinemia by the presence of severe anemia. other supportive evidence includes the presence of a regenerative erythroid response, characteristic changes in red blood cell morphology, and possibly the detection of red blood cell bound antibodies. 56 hepatic hyperbilirubinemia is caused by a decreased rate of hepatocyte bilirubin uptake, conjugation, or excretion (as a result of intrahepatic cholestasis). usually, hepatocyte dysfunction and intrahepatic cholestasis occur concurrently. hepatic enzyme activities (both hepatocellular leakage markers and cholestatic markers) are often increased, although they can also be increased with both prehepatic and posthepatic hyperbilirubinemia. because of the hepatic reserve capacity, hepatic disease must be severe in order to cause hyperbilirubinemia. a range of primary and secondary hepatopathies can cause hepatic hyperbilirubinemia. hepatic hyperbilirubinemia can usually be distinguished from prehepatic hyperbilirubinemia by assessment of the patient's hematocrit, and from posthepatic hyperbilirubinemia by abdominal ultrasound. other markers of hepatic insufficiency, when present, provide additional support for the presence of hepatic hyperbilirubinemia. posthepatic hyperbilirubinemia is a result of extrahepatic bile duct obstruction. this is often caused by pancreatic inflammation or, much less commonly, neoplasia. the main diagnostic tool for documenting extrahepatic bile duct obstruction is abdominal ultrasound. typically, extrahepatic bile duct obstruction leads to dramatic increases in serum cholestatic enzyme activities (compared to hepatocellular leakage enzyme activities) and hypercholesterolemia. when the bile duct is completely obstructed, acholic (pale-colored) feces may be noted. rupture of the biliary tract frequently leads to hyperbilirubinemia as bilirubin accumulates in the abdomen. it is possible to measure the concentration of serum conjugated bilirubin. however, this test is not considered to be clinically useful for distinguishing between prehepatic, hepatic, or posthepatic hyperbilirubinemia, and is thus rarely performed. bilirubin can covalently (nonreversibly) bind to albumin. this biliprotein cannot be cleared by the liver and thus persists in the plasma. biliprotein has a serum half-life comparable to albumin. this is of clinical importance because it means hyperbilirubinemia (and icterus) may persist for several weeks after the resolution of its cause. 57 bile acids (or bile salts when they are deionized) are formed from cholesterol in the liver and are the major constituent of bile. serum bile acids (sbas) measurement is a useful test of liver function in dogs and cats. sbas are either measured as a fasting sample (after withholding food for 12 hours) or by collecting paired fasting and 2-hour postprandial samples. 58 both of these tests are simple to perform and safe. enzymatic measurement of the concentration of total bile acids in serum has become widely available and has replaced other techniques such as radioimmunoassays. 59, 60 once collected, the samples of serum can be stored at room temperature, making it possible to send them to an outside laboratory for evaluation. lipemia and hemolysis of the blood samples should be avoided as both can interfere with the assay. increased sba concentrations recent study did not support the use of a 13 c-labeled galactose breath test for assessment of liver function in dogs. 80 the metabolism of endogenous substances has been investigated to find possible markers of hepatic cellular metabolism. dogs with hepatic disease (hepatitis and neoplasia) had significantly higher serum l-phenylalanine concentrations than did healthy dogs and those with nonhepatic diseases. 81 further investigations are needed to determine the utility of these tests for assessing liver function in veterinary patients. urine specific gravity can be decreased in patients with hepatic insufficiency or pss. this can be caused by an inability to fully concentrate urine, resulting in pu, or from primary pd. bilirubin is commonly measured semiquantitatively in canine and feline urine using urine dipsticks. bilirubinuria (<2+ on a dipstick) can be a normal finding in dogs (especially males). 82 bilirubinuria in dogs without hemolytic or hepatobiliary disease can occur as a consequence of the loss of unconjugated bilirubin that is bound to albumin in proteinuric patients and renal filtration of small amounts of conjugated bilirubin that has leaked from the liver. additionally, the renal tubular cells of male dogs have the enzymes needed to produce and conjugate bilirubin. as cats have a higher renal threshold for bilirubin than dogs, bilirubinuria should always be considered abnormal in cats. bilirubinuria in cats and excessive bilirubinuria in dogs implies hemolytic or hepatobiliary disease. because dogs have a relatively low renal threshold for bilirubin, bilirubinuria is often detected before bilirubinemia or jaundice. ammonium biurate crystals are detected in the urine sediment by light microscopy. uric acid is a product of purine catabolism and is converted to allantoic acid by hepatic urate oxidase. in cases with severe hepatic insufficiency or pss, the serum uric acid concentration may be higher than the renal threshold. this combined with hyperammonemia may lead to ammonium biurate precipitation in the urine. urate urolithiasis seems to be more common in patients with pss than those with other types of hepatic dysfunction. between 40% and 70% of dogs with pss were found to have urate crystalluria. 83 however, it should be noted that urate crystalluria is not specific for hepatobiliary disease. the erythrocyte series may be affected by hepatobiliary disease, resulting in erythrocyte dysmorphias and anemia. these abnormalities are suggestive of, but are not specific for, hepatobiliary disease. patients with hepatobiliary disease can be anemic as a result of blood loss, in which case signs of a regenerative response are normally present within 3 days of hemorrhage. acute, severe hemorrhage may occur in patients with hepatobiliary disease following invasive procedures such as liver biopsy or as a consequence of hemorrhage from a hepatic neoplasm or hepatic rupture. less-severe anemia may occur as a result of gi bleeding. 84 chronic gi blood loss may eventually lead to iron-deficiency anemia. this is characterized by microcytic hypochromic erythrocytes and a variable regenerative response. additionally, hepatobiliary disease may lead to anemia of chronic disease, which is typically nonregenerative with normocytic normochromic erythrocytes. red blood cell morphologic changes are sometimes observed in dogs with hepatobiliary disease. poikilocytosis, characterized by the presence of acanthocytes and target cells, may be seen in patients with chronic hepatic disease. this is thought to be a result of altered phospholipid metabolism. patients with pss can have microcytic red blood cells. this is more common in dogs than in bilirubin concentrations that are within the reference interval. measurement of postprandial sba concentration does not seem to have an advantage over fasting sba concentrations or vice versa. sensitivity can be increased by collecting paired preprandial and twohour postprandial samples. 66 numerous studies show that sba measurement is a useful test for diagnosing hepatobiliary disease, including pss in dogs and cats. 41, [66] [67] [68] [69] [70] a recent study found the sensitivity of fasting sba measurement for diagnosing pss (using a cutoff value of 20 µmol/l) to be 93% for dogs and 100% for cats. the reported specificities were 67% for dogs and 71% for cats. 41 however, the sensitivity of sba measurement for detecting hepatic insufficiency is lower than that for detecting pss. measurements of sba concentrations have several limitations. first, this test does not allow differentiation between various types of hepatobiliary disease. also, measurement of serum bile acids in a patient with proven cholestasis is of no clinical benefit. additionally, there is limited utility in measuring sbas concentrations in patients with hyperbilirubinemia, although potentially sba measurement could be useful in distinguishing prehepatic from hepatic or posthepatic causes of hyperbilirubinemia. with prehepatic causes of hyperbilirubinemia, the bile acid concentrations should be within the reference interval. however, in most cases prehepatic hyperbilirubinemia is easily distinguished by the presence of severe anemia. it should also be noted that the magnitude of increases of sba concentration are not correlated with prognosis or disease severity. it is important to note that fasting sba concentrations may be higher than the upper limit of the reference interval or higher than the postprandial value because of spontaneous contraction of the gallbladder in the fasting state, or because of delayed gastric emptying. this could result in an increased fasting sba concentration in the absence of hepatobiliary disease. increased fasting and postprandial serum bile acids concentrations can be the result of increased bacterial deconjugation of primary bile acids into secondary bile acids. 71 false-negative results may occur if enterohepatic circulation of bile acids does not occur from a lack of gallbladder contraction. this could be a problem if a patient is anorectic, does not eat enough food, consumes a diet with insufficient protein or fat, vomits the test meal, or has delayed gastric emptying. ceruletide is an injectable cholecystokinin analogue that has been used to stimulate gallbladder contraction when using sba measurement to diagnose hepatobiliary disease. 72, 73 this test circumvents many of the factors that influence postprandial sba concentrations. urine bile acids measurement has been described in dogs and cats. the diagnostic performance was similar to that of sba measurement in both species. this test does not offer any advantages over sba measurement. [74] [75] [76] [77] excretion of exogenous tracers, such as the anionic cholephilic dyes, bromsulphalein, and indocyanine green have been used historically to assess hepatic function in veterinary patients. however, these tests are considered unreliable and have been replaced by the measurement of sba concentrations. the metabolism of exogenous substances can be used to assess liver function. a variety of substances have been investigated as markers for hepatic metabolism in human medicine. assessment of the metabolism of aminopyrine has been investigated in dogs and to a lesser extent in cats. the 13 c-labeled aminopyrine demethylation blood test involves intravenous administration of 13 c-labeled aminopyrine to the subject. the aminopyrine is metabolized by the liver, resulting in the production of 13 co 2 . this is measured in the blood by fractional mass spectroscopy. 78, 79 further investigation of the utility of this test for assessment of liver function is needed. a in dogs with liver disease than in dogs with extrahepatic disease, and were higher in dogs with cirrhotic liver disease than in dogs with noncirrhotic liver disease. blood ha concentration may prove be a useful marker for hepatic fibrosis in dogs but further studies are necessary to evaluate its clinical utility. histopathologic analysis of liver biopsies or identification of a shunting blood vessel is often required to definitively diagnose hepatic disease. however, the pattern of laboratory test abnormalities, particularly when interpreted in conjunction with the patient's clinical presentation, and the results of diagnostic imaging, can increase or decrease a clinician's index of suspicion for specific liver diseases (table 61-3) . it is important to note that there is considerable overlap between the patterns for different diseases. to avoid misinterpretation and misdiagnosis when evaluating a patient for liver disease, it is essential to consider the limitations of the laboratory tests discussed above. diagnostic imaging is an important part of the investigation of hepatobiliary disease in dogs and cats. diagnostic imaging may help to determine whether or not hepatobiliary disease is present, identify the cause of a secondary hepatopathy, aid in the diagnosis of specific hepatobiliary diseases, and provide prognostic information. however, with the exception of diagnosis of a pss, imaging seldom yields a definitive diagnosis. radiography and abdominal ultrasound are the most frequently used imaging modalities for assessment of the hepatobiliary system in dogs and cats, but alternative imaging techniques are now being used more frequently. abdominal radiographs allow assessment of hepatic size, shape, opacity, and location in most patients. 91 radiography may also allow identification of extrahepatic abnormalities that affect the liver. however, radiographs provide limited information about the hepatic parenchyma. it is important to note that patients with hepatobiliary disease often have normal abdominal radiographs. radiography allows subjective assessment of liver size. cranial displacement of the gastric axis may be observed on lateral abdominal radiographs when microhepatia is present. however, subtle microhepatia is unlikely to be appreciated radiographically. psss and hepatic cirrhosis are the most common conditions causing microhepatia. mild bilateral renomegaly may also be cats. 83 microcytosis also occasionally occurs in patients with hepatocellular disease. altered iron metabolism is thought to lead to a delay in red blood cell precursors gaining a sufficient amount of hemoglobin to be released into the circulation. this delay leads to the precursors undergoing an extra cell division in the bone marrow, resulting in microcytosis. 85 microangiopathy can occur as a result of hepatic neoplasia or dic, and may lead to the formation of schistocytes. the leukocyte series may be affected by hepatobiliary disease in a variety of ways. the resultant abnormalities are inconsistent and are not specific for hepatobiliary disease. leukocytosis, leukopenia, and sometimes an inflammatory leukogram may be present when infectious and, less commonly, inflammatory or neoplastic processes affect the hepatobiliary system. a leukocytosis was found to be present in 44% of dogs with chronic hepatitis. 86 the thrombocyte series is occasionally affected by hepatobiliary disease, but changes are both inconsistent and nonspecific. mild to moderate thrombocytopenia may occur in patients with severe liver disease. 86 this may be the result of a decreased production of thrombopoietin by the liver. disseminated intravascular coagulopathy associated with liver disease also may lead to thrombocytopenia. additionally, infectious diseases affecting the liver, such as leptospirosis may result in thrombocytopenia. 87 genetic testing for copper hepatotoxicosis has been developed in bedlington terriers. affected bedlington terriers have an autosomal recessive defect of their commd1 gene. dogs with a homozygous affected genotype develop copper hepatopathy as a result of impaired biliary excretion of copper. initially, a microsatellite marker that is in linkage disequilibrium with the mutation was discovered and used to identify affected dogs and select dogs homozygous unaffected dogs for breeding. 88 subsequently, a mutation of the commd1 gene (a deletion of exon 2) was identified as the cause of the condition in the majority of bedlington terriers. 89 a genetic test for this disease has become commercially available (vetgen, ann arbor, mi). this test is run alongside the linked marker as a small proportion of bedlington terriers do not have the deletion but are nevertheless affected by the disease. these dogs are likely to have a rare second mutation of their commd1 gene which the linkage markers may track. hyaluronic acid is a major constituent of the ecm and hyaluronic acid (ha) concentration in blood has been used as a marker for hepatic fibrosis in humans. a recent study investigated the use of ha concentration as a marker for hepatic disease in dogs. 90 this study found that blood ha concentrations were significantly higher the size of the liver can be subjectively assessed by abdominal ultrasonography. the findings of a small liver and cranial displacement of the stomach suggest microhepatia. hepatomegaly is another subjective finding and can be generalized or focal. the finding of rounded liver lobe margins suggests hepatomegaly. hepatic parenchymal changes can be classified as being diffuse, multifocal, or focal. a wide variety of disease processes can cause diffuse changes to the hepatic parenchyma. these changes can be isoechoic, hypoechoic, hyperechoic, or of mixed echogenicity. in some cases the architecture of the liver will not be altered, but in other cases changes will occur. examples of diseases in which the echogenicity of the hepatic parenchyma is diffusely changed but no changes in architecture occur include cholangitis, neoplasia, hepatic lipidosis, other vacuolar hepatopathies, toxic hepatopathy, and early micronodular hyperplasia with various degrees of fibrosis. 100 hyperechogenicity of the liver compared to the falciform fat, poor visualization of the intrahepatic blood vessels, and increased attenuation of the ultrasound beam have been used as criteria for the sonographic diagnosis of feline hepatic lipidosis. 101 diseases where the hepatic architecture is altered are easier to detect sonographically. these include neoplasia, micronodular hyperplasia, and chronic hepatitis with fibrosis. cystic structures, abscesses, hematomas, and granulomas are examples of focal parenchymal liver disease. these lesions are usually easily detected sonographically. sonography seldom allows a definitive diagnosis of hepatic parenchymal disease to be made. in one study the overall accuracy of ultrasound for discrimination among different categories of diffuse liver disease was 36.5% for dogs and 54.6% for cats. hepatic lipidosis in cats could be diagnosed slightly more accurately than other diffuse hepatic diseases. 102 cytologic or histologic evaluation of a hepatic tissue sample is usually needed to make a definitive diagnosis. hepatic neoplasia, whether primary or metastatic, can be diffuse, multifocal, or focal in its distribution. round cell tumors are the most likely tumor type to diffusely infiltrate the liver. these tumors can cause hypoechoic, hyperechoic, or mixed-echoic changes, or appreciated radiographically for patients with pss. urate uroliths can be radiolucent so they might not be visible on plain abdominal radiographs. hepatomegaly can be generalized or focal. generalized hepatomegaly can be caused by a number of conditions including neoplasia, vacuolar hepatopathies, congestion, or amyloidosis. focal hepatomegaly can be caused by neoplasia, abscesses, granulomas, or a liver lobe torsion. radiographic signs associated with hepatomegaly are rounded hepatic borders, caudal displacement of the gastric axis, and extension of the hepatic silhouette beyond the costal arch. radiography does not allow appreciation of mild hepatomegaly. additionally, it can be normal for the hepatic silhouette to extend beyond the costal arch in brachycephalic breeds, chondrodystrophic breeds, neonatal animals, or geriatric animals. 91 the liver is normally appreciated as an area of homogenous softtissue opacity on radiographs. radiolucent areas within the liver indicate accumulation of gas within the hepatic parenchyma, biliary tract, or portal vasculature. gas in the parenchyma of the liver can be associated with an hepatic abscess. 92 gas in or around the gallbladder has been reported in dogs with emphysematous cholecystitis. 93 although uncommon in dogs and cats, if choleliths or choledocholiths contain enough calcium, they may be appreciated as mineral opacities within the hepatic silhouette. 94 mineralization of the gallbladder wall can be associated with a biliary adenocarcinoma in the dog. 95 parenchymal mineralization can be associated with granulomas, abscesses, 96 hematomas, neoplasia, or hepatic necrosis. 91 angiography allows the visualization of the hepatoportal vasculature, including abnormal vessels. this often provides a definitive diagnosis of pss and is indicated in patients that are suspected of having a pss, where the shunt cannot be adequately evaluated by abdominal ultrasound. anatomical characterization of congenital pss is important when planning attenuation, and angiographic procedures often allow this. there are several techniques for mesenteric portography. operative mesenteric portography is commonly performed immediately prior to surgical attenuation of a congenital pss and involves catheterization of a mesenteric vein and injection of a contrast agent. operative contrast portography allows evaluation of the portal vasculature before and after shunt attenuation. this technique has the disadvantage of being relatively invasive. cranial mesenteric portography can be accomplished less invasively by using ultrasound guidance to percutaneously catheterize the splenic vein. 97 however, this can be technically demanding and may not be possible in smaller patients. transvenous retrograde portography has been described and involves the catheterization of the jugular vein. 98 this technique allows selective catheterization of the shunting vessel and measurement of portal pressures (figure 61-7) . transvenous retrograde portography has been applied during percutaneous transjugular coil embolization of intrahepatic shunts. 99 percutaneous splenoportography involves percutaneous injection of contrast media into the spleen. this technique is simple to perform, but there is a risk of complications such as splenic infarction or hemorrhage. abdominal ultrasonography is the most commonly used imaging modality for evaluating small animal patients with suspected hepatobiliary disease. ultrasonography allows assessment of the hepatic parenchyma and biliary tract. evidence of extrahepatic disease causing a secondary hepatopathy may also be detected. additionally, ultrasound guidance is often used when collecting samples for cytologic and histologic evaluation of the liver. gallbladder mucoceles can also lead to biliary obstruction, which might also be appreciated sonographically. the sensitivity of ultrasound for the detection of a gallbladder wall rupture in dogs with gallbladder mucoceles is reported to be 85.7%. 109 abdominal ultrasound can be used to assess the liver for vascular disease. congenital pss is classified as being intrahepatic or extrahepatic. although angiographic techniques are considered to be the gold standard for the detection and characterization of pss, abdominal ultrasound is being used increasingly for this purpose. sonographic assessment of the portal vasculature is time-consuming and highly operator dependent. because of this there should be a high index of suspicion for pss before performing these studies. secondary findings consistent with pss include mild bilateral renomegaly, urolithiasis (because of urate crystalluria), and microhepatia. ascites and hepatic parenchymal changes are not consistent with congenital pss. extrahepatic shunts typically occur in small-breed dogs and arise from the splenic vein or the right gastric vein while intrahepatic shunts typically occur in larger breeds of dogs and arise from the right or left portal branch. an intrahepatic pss is usually easier to detect sonographically than an extrahepatic pss in dogs. cats typically have single extrahepatic shunts with a wider degree of anatomical variation than in the dog. ultrasonography has been reported to have a sensitivity of 92% and a specificity of 98% for detecting pss in dogs. 110 portal hypertension can develop as a result of chronic hepatitis with fibrosis, hepatic arterioportal fistulas, portal vein thrombosis, primary portal vein hypoplasia, extraluminal compression of the portal vein, or after ligation of a congenital pss. the finding of hepatofugal or reduced velocity hepatopetal blood flow using doppler ultrasound is consistent with portal hypertension. 111 however, not all patients with portal hypertension will have these changes. ascites frequently, but not always, develops secondary to portal hypertension and this can be readily detected on abdominal ultrasound examination. acquired portosystemic collaterals (also known as acquired pss) may develop when sustained prehepatic or hepatic portal hypertension is present. 112 sonography may allow detection of portal hypertension and apscapsc although apsc vessels are more difficult to identify than congenital pss. posthepatic portal hypertension does not result in the development of may not affect the echogenicity of the liver at all. neoplasia can also lead to the appearance of nodules within the hepatic parenchyma. malignant liver nodules have a variable appearance and size and can be difficult to distinguish from nonmalignant conditions such as cysts, hematomas, benign hyperplastic nodules, granulomas, or abscesses. the finding of one or more target lesions in the liver or spleen had a positive predictive value of 74% for detecting malignancy, and thus should not be considered a specific finding. 103 cytologic or histologic evaluation of a tissue sample is needed to differentiate between malignant and benign liver nodules. tumors, such as hepatoma or hepatocellular carcinoma, can also focally infiltrate the liver. contrast-enhanced harmonic ultrasound allows assessment of tissue perfusion patterns. gas-filled microbubbles are administered intravenously to the patient. the microbubbles are relatively echogenic. when they reach the tissue of interest, they produce a more potent harmonic signal than the surrounding tissue. this technique allows enhanced differentiation between tissues with varying perfusion patterns. in one study the sensitivity of contrast enhanced ultrasound for differentiation between benign and malignant liver nodules in dogs was reported to be 100% and the specificity was reported to be 94.1%. 104 sonography is also a valuable tool for the evaluation of the biliary system. biliary disease can be classified as being obstructive or nonobstructive. the term cholangitis refers to a group of nonobstructive biliary diseases, which are more common in cats than in dogs. typical ultrasound findings in cats include a hypoechoic hepatic parenchyma and prominent portal vasculature. 105 additional findings can include evidence of pancreatic inflammation, thickening of the gallbladder wall, and dilation of the intrahepatic and extrahepatic biliary system. it is important to note these changes are not always present. cytologic or histologic confirmation and bacterial culture are needed to confirm this diagnosis. generalized gallbladder wall thickening can occur as a result of cholecystitis, cholangitis, or hepatitis. however, the gallbladder wall can also appear to be thickened when peritoneal effusion or hypoproteinemia are present. gall bladder wall masses can be identified sonographically as a focal thickening of the gallbladder wall. sonography has also been used to assess gallbladder motility in dogs. 106 it should be noted that gravity dependent gallbladder sludge can be found in dogs without hepatobiliary disease, so this finding should be considered incidental. 107 abdominal ultrasound is the most commonly used imaging modality for the detection of biliary obstruction in dogs and cats. findings consistent with biliary obstruction include common bile duct distention, intra-and extrahepatic bile duct distention, and/or gallbladder dilation. a retrospective study showed that common bile duct dilation greater than 4 mm was 97% sensitive for the detection of biliary obstruction in cats. 108 sonography can also aid in identifying the cause of biliary obstruction. biliary obstruction can be classified as being luminal or extraluminal. extraluminal causes include nonneoplastic pancreatic disease, abdominal adhesions, and, rarely, pancreatic neoplasia. luminal causes include gallbladder mucocele, biliary neoplasia, inflammation, and cholecystolithiasis. biliary tract obstruction can progress to biliary rupture and bile peritonitis. sonographic signs of biliary rupture include loss of gallbladder wall continuity, free peritoneal fluid, and signs of localized peritonitis. gallbladder mucoceles occur in the dog, but have not been described in cats. mucoceles have a variable sonographic appearance; typical findings include a stellate or finely striated bile pattern with a hypoechoic rim, which is not gravity dependent, and gb lt specificity of 100%. 119 the disadvantages of ct and mri include their limited availability, cost, and the need for anesthesia. although cytologic evaluation of the liver provides a definitive diagnosis, often histologic examination is also required. there are a variety of techniques to collect cytologic samples of the hepatobiliary system. abdominal effusion, when present, can be collected percutaneously. fine-needle aspirates (fna) of the liver can be collected percutaneously under ultrasound guidance. cholecystocentesis can also be performed percutaneously with ultrasound apsc vessels, but can lead to a distention of hepatic veins and ascites. nuclear scintigraphy involves administering a radioactive tracer substance (radiopharmaceutical) to the patient, which localizes to a specific organ or tissue. the radioactive decay of this substance is detected by a gamma camera and used to form images. scintigraphy has been used to detect pss and to assess gallbladder emptying in small animals. however, specialized equipment and a license for the use of radioisotopes are required. consequently, availability of this imaging modality is currently limited to academic institutions and specialty referral hospitals. technetium-99m pertechnetate is the most commonly used radiopharmaceutical for assessing the portal circulation of small animal patients. two techniques have been described: per-rectal portal scintigraphy and transsplenic portal scintigraphy. by analyzing the radiation emitted from regions of interest drawn over the patient's liver and heart, pss can be detected and a shunt fraction can be calculated. this allows for the minimally invasive diagnosis of pss, differentiation of pss from portal vein hypoplasia without portal hypotension (previously known as microvascular dysplasia), and comparison of the degree of shunting before and after shunt attenuation. transsplenic portal scintigraphy is preferred over perrectal portal scintigraphy as it is simpler to perform, uses lower doses of the radiopharmaceutical, and is more sensitive (figure 61-9 ). transsplenic portal scintigraphy is 100% sensitive and specific for the diagnosis of congenital pss, and significantly more likely than per-rectal portal scintigraphy to detect shunt number and termination in dogs. 113 nuclear scintigraphy has been used to quantify liver function and to assess biliary tract patency in dogs. in a retrospective study hepatobiliary scintigraphy was found to be 83% sensitive and 94% specific for the detection of extrahepatic biliary obstruction in dogs and cats. 114 computed tomography (ct) (figure 61 -10) and magnetic resonance imaging (mri) have been used to detect hepatic parenchymal neoplasia in humans. compared to abdominal ultrasound these techniques have an improved accuracy for the diagnosis of hepatic neoplasia in humans. however, there is limited data in the veterinary literature evaluating their diagnostic performance. in one study the diagnostic accuracy of ct for detecting hepatic masses was not found to be significantly different from that of abdominal ultrasound in dogs. 115 in another study mri was found to have a sensitivity of 100% and a specificity of 86% for the differentiation between benign and malignant liver lesions in dogs. 116 ct angiography is being used increasingly in dogs for the diagnosis of congenital pss and other hepatic vascular diseases. it offers the advantage of being less invasive than operative angiography, allows for improved assessment of the portal vasculature, and allows the creation of a three-dimensional reconstruction. the vasculature detail afforded by ct angiography is particularly useful when planning attenuation of a congenital pss. the diagnostic utility of ct angiography for detecting and characterizing pss in dogs was shown to compare favorably to that of other techniques, including surgical exploration. 117 transsplenic ct portography has been described in dogs without pss. this technique offers more intense enhancement of the splenic and portal veins than ct angiography. 118 mri angiography diagnoses pss in dogs with a sensitivity of 80% and a the findings above may aid in making a diagnosis of liver disease but are not a substitute for histopathologic analysis, as cytologic specimens do not allow assessment of the hepatic architecture. furthermore, only a tiny proportion of the liver is sampled when cytologic samples are examined. these limitations are reflected by the results of a retrospective study that found the overall agreement between the histopathologic and cytologic diagnosis of liver disease to be 30.3% for dogs and 51.2% for cats. 123 cytologic evaluation of bile can also be useful for the diagnosis of biliary disorders, particularly in cats. world small animal veterinary association (wsava) standards for the clinical and histological diagnosis of canine and feline liver disease suggest that the cytologic evaluation of bile forms part of the minimum diagnostic requirement for cats with extrahepatic cholestasis and for dogs guidance. these techniques are minimally invasive and the risk of complications is relatively low but caution should be exercised in patients with bleeding disorders. liver disease can cause abdominal effusion by several mechanisms. in cases with hepatic insufficiency, severe hypoalbuminemia (<1.5 g/dl) can occur. this can lead to the formation of a pure transudate as the result of a reduced plasma colloid oncotic pressure. increased capillary hydrostatic pressure because of portal hypertension may lead to formation of a pure or modified transudate. hepatic neoplasia can also lead to a formation of a modified transudate. biliary tract rupture can lead to bile peritonitis and abdominal effusion. an exudate with a bilirubin concentration greater than twice that of the plasma is suggestive of bile peritonitis. 120 cytologic evaluation of hepatic fna can aid in making a diagnosis of liver disease. suppurative, mixed inflammatory, lymphocytic and, more rarely, eosinophilic patterns of inflammation can be appreciated cytologically. each pattern of inflammation suggests a group of possible diagnoses. the finding of dark green or black bile casts suggests cholestasis. infectious diseases such as histoplasmosis can be definitively diagnosed based on the cytologic finding of the infectious agent ( figure 61-11 ). hepatocellular vacuolation can be classified as being caused by lipid or not. lipid vacuolation of hepatocytes is characterized by colorless cytoplasmic vacuoles. severe lipid vacuolation is suggestive of hepatic lipidosis in cats ( figure 61 -12). however, feline hepatic lipidosis often occurs secondary to another disease process. a group of cats with cytologic findings suggestive of hepatic lipidosis were reported to have underlying infiltrative liver disease. 121 nonlipid vacuolation is characterized by generalized hepatocyte swelling and lacy vacuolation ( figure 61-13 ). vacuolar hepatopathy occurs secondary to a wide variety of extrahepatic disease processes in dogs. 122 metastatic tumors and round cell tumors, such as lymphoma ( figure 61-14) , affecting the liver can often be diagnosed cytologically. additionally, cytologic evaluation can aid in distinguishing liver nodules because of extramedullary hematopoiesis from those caused by neoplasia. however, it is not possible to distinguish hepatic nodular hyperplasia from hepatic adenoma or well-differentiated carcinoma cytologically. some cases of hepatocellular carcinoma can be diagnosed cytologically if criteria for malignancy are present. and cats suspected to have cholangitis. 124 the finding of neutrophils and bacteria on bile cytology supports a diagnosis of feline neutrophilic cholangitis. cytology is essential for the diagnosis of this disease, as cats with neutrophilic cholangitis may not have typical hepatic histopathologic changes and it can be difficult to distinguish these cats from those with lymphocytic cholangitis. bile should also be submitted for aerobic and anaerobic bacteriologic culture. histopathologic evaluation is required to make a definitive diagnosis of most liver diseases. histopathologic evaluation of the liver allows a morphologic and sometimes an etiologic diagnosis to be made (see chapter 29) . in addition to routine staining with hematoxylin and eosin, a variety of other staining techniques can be employed to demonstrate hepatic pathology. to optimize the value of histopathologic evaluation of the liver, particular attention should be paid to specimen collection, specimen handling, and communication between the clinician and the pathologist. although liver biopsy is considered to be relatively safe, the patient should be assessed for bleeding disorders before this procedure. this assessment should include a platelet count, coagulation times, and a buccal mucosal bleeding time. liver biopsies can be collected in a number of ways. each method has advantages and disadvantages, and there is controversy in the veterinary literature as to which technique is optimal. laparotomy allows collection of relatively large wedge biopsies, with direct visualization. this technique does not require specialized equipment or training, and excessive bleeding can be readily identified. however, laparotomy requires general anesthesia and is the most invasive biopsy technique. percutaneous needle biopsy techniques have been described. these techniques may be possible under heavy sedation and are the leastinvasive method for collecting liver biopsies. ultrasound guidance is often used, allowing biopsy of focal lesions. it is also possible to biopsy tissue that is deeper within the hepatic parenchyma than is possible with other techniques. however, the specimens that are collected are relatively small and may be inadequate for accurate assessment in some patients. a prospective study showed that there was agreement between the histomorphologic diagnoses made upon examination of needle biopsies and those made on wedge biopsies collected during laparotomy or necropsy for only 48% of dogs and cats. 125 excessive hemorrhage after biopsy may not be identified immediately. laparoscopy allows collection of biopsies using forceps with laparoscopic guidance. this technique requires general anesthesia, but is less invasive than laparotomy. the biopsies collected are larger than needle biopsies and excessive bleeding can be visualized. however, laparoscopy requires specialized equipment and training. the use of biopsy forceps may result in crushing artifact and the tissue collected may be too superficial to identify lesions that lie deeper within the hepatic parenchyma. 126 regardless of the technique used, a tiny proportion of the organ is sampled and, because liver disease can affect the hepatic parenchyma in a heterogeneous manner, sampling error is possible. to reduce the effect of sampling error, several biopsies from different areas of the liver should be collected and focal lesions should be specifically biopsied. the clinician should provide the pathologist with all the pertinent information from the patient's history, physical examination findings, the results of laboratory testing, and the findings from diagnostic imaging. in turn the histomorphologic diagnosis that the pathologist makes should be interpreted by the clinician along with the other clinical data. when the histopathologic diagnosis does not fit the clinical picture, the pathologist should be consulted and when necessary a second opinion should be requested. variation in the assessment of hepatic pathology between pathologists was highlighted by a study that found agreement between examiners for only 44% of needle biopsies and 65% of wedge biopsies examined. 125 hopefully, the adoption of wsava standards for the clinical and histological diagnosis of canine and feline liver diseases since the aforementioned study will reduce this interobserver variation. quantification of hepatic metal concentrations requires submission of tissue for flame atomic absorption spectroscopy. although zinc has a role as an antioxidant, hepatic copper and iron retention can lead to oxidative liver injury. copper is the most frequently course of the evaluation. in patients that are asymptomatic and have abnormal biochemical testing, repeat evaluation is sometimes warranted. a general guideline is to obtain a liver biopsy in asymptomatic patients if there are moderate to severe elevations in serum hepatic enzyme activities that persist for at least 3 months, or if there are mild to moderate elevations in serum hepatic enzyme activities that persist for at least 6 months. if clinical signs of hepatic disease develop, then biopsy should not be unreasonably delayed. if there are concurrent elevations in serum bile acids, biopsy should also not be delayed. other indications for hepatic biopsy are ultrasound imaging abnormalities. if there are focal hepatic masses or diffuse echotextural changes, a biopsy may be warranted, depending on results of laboratory testing. in one study, abdominal ultrasound findings alone were not reliable for obtaining a diagnosis of infiltrative hepatic disease with diffuse changes in echogenicity (either hypoechoic or hyperechoic, uniform or mottled). 1 in another study, sonographic detection of a hepatic mass greater than or equal to 3 cm, ascites, abnormal hepatic lymph node(s), and abnormal spleen were predictive of liver neoplasia based on cytology. 2 conversely, sonographic detection of hepatic nodules less than 3 cm was predictive of vacuolar hepatopathy on cytology. thus several sonographic findings, alone or combined, may be predictive of liver ultrasound-guided fine-needle aspiration cytology results. in light of the fact that ultrasound-guided fine-needle aspiration cytology of the liver has limitations , the results of ultrasound and cytology should be adjuncts to other findings. another indication for hepatic biopsy is the need to assess response to therapy. in cases of chronic hepatitis in dogs, it is often difficult to determine if there is ongoing inflammation and resolution/ progression of fibrosis during long-term therapy. this is particularly true when the patient is receiving glucocorticoid therapy as these medications cause variable increases in serum alp and transaminase activities independent of the underlying disease. repeat or serial hepatic biopsy analysis is often helpful to guide therapeutic decisions in these cases. among the most serious complications of liver biopsies are hemorrhage, infections, and injury to the adjacent viscera. consequently the clinician must take into account the clinical question, the appropriate invasive biopsy method, and methods of managing postbiopsy complications. postbiopsy hemorrhage is often the first concern, although it is unclear as to what the best predictor of hemorrhage is in patients about to undergo hepatic sampling. in one study of 200 human patients in which bleeding was evaluated laparoscopically, there was no correlation between any in vitro coagulation test and "liver bleeding time." 3 other studies in man have used laparoscopy and ultrasonography to assess hepatic bleeding time following needle biopsy, and most have shown similar poor correlation between coagulopathies and hepatic bleeding times. similar studies have not been reported in veterinary medicine. there also have been studies in human and veterinary medicine evaluating risk factors for bleeding complications (as opposed to "hepatic bleeding times"). 4,5 bigge et al. correlated coagulation profile findings and bleeding complications after ultrasound-guided biopsies in 310 dogs and 124 cats. 5 there was no apparent correlation between coagulation parameters and major complications following liver biopsy. studies show that clotting times assessing proteins induced by vitamin k antagonism are more sensitive in detecting coagulopathies in patients with hepatic disease. 6, 7 the measured of these metals and quantification is essential for the diagnosis of hepatic copper retention. these measurements are usually performed on freeze-dried pieces of liver. specimens for metal measurement should not be stored in saline and should be kept in metal-free containers. recently, it was shown that measurements of the concentration of copper and iron, but not zinc, can be ascertained from deparaffinized-archived liver tissue. 127 hepatobiliary diseases can be challenging to diagnose. although diagnostic tests that employ biochemical, molecular biologic, serologic, functional, as well as imaging techniques are capable of establishing the etiology of some chronic or acute liver diseases, in most instances the gold standard for definitive diagnosis and the assessment of stage and severity of liver diseases is the histologic evaluation of a liver sample. recent advances in imaging technology, the use of multiple imaging modalities, and newer biopsy methods have resulted in improvement in the ability to safely procure hepatic tissue for evaluation. there are several means of obtaining hepatic samples including fine-needle aspiration, ultrasound-guided biopsy, laparoscopy, and laparotomy. all techniques have both advantages and disadvantages, which should be carefully considered before choosing the appropriate sampling method. many biochemical tests are available to evaluate the anabolic and/ or catabolic function of the liver and the hepatic circulation. these include measurement of concentrations of bile acids, ammonia, bilirubin, and the ability to excrete organic dyes. other tests of hepatic function include measurement of serum albumin, glucose, urea nitrogen, and clotting factor analysis. hepatic function can be markedly abnormal despite maintenance of the hepatocellular membrane and therefore normal serum activities of hepatic enzymes. examples include psss, terminal cirrhosis, and metastatic hepatic neoplasia. likewise, the liver can continue normal anabolic or catabolic function despite severe hepatocyte leakage of intracellular enzymes because of its marked reserve capacity. this can occur, for example, in certain cases of hepatocellular necrosis, blunt abdominal trauma, or primary hepatic neoplasia. thus, the limitations of serum hepatic enzyme activities must be taken into consideration. hepatocellular leakage enzyme activities include alt and ast. enzyme activities that increase with biliary tract obstruction include serum alp and ggt. no laboratory test identifies a specific problem, helps determine specific therapeutic management, or predicts an outcome. this is because different diseases produce similar alterations in hepatic function or in laboratory tests. once biochemical tests identify the presence of hepatic disease, the diagnosis must be pursued further. in some instances, diagnostic imaging can reveal specific abnormalities (e.g., psss and extrahepatic bile duct obstruction). when results of imaging do not give a specific etiology, the next step is often to pursue a morphologic diagnosis obtained by analysis of a biopsy specimen. often it is a judgment call as to when to pursue hepatic biopsy. in cases with severe clinical signs and/or severe biochemical abnormalities, biopsy is usually warranted early in the fine-needle aspiration has several advantages. little to no sedation is usually required. because the size of the needle is so small, there is little risk of hemorrhage. therefore multiple sites can easily be sampled. the procedure is rapid and can usually be performed on an outpatient basis. there is also less cost to the client. the primary disadvantage of fine-needle aspiration is its questionable accuracy. the sample size often limits the number of available cells to obtain an accurate diagnosis, and hemodilution makes it difficult to assess whether inflammatory cells were present in the liver or peripheral blood. there are several important elements used to interpret pathologic information including lobular architecture, presence and location of inflammation within a lobule, presence and severity of fibrosis, metal accumulation, vascular abnormalities, and lobule heterogeneity. these criteria cannot be accurately determined using a cytologic sample obtained using fna. several studies have compared fine-needle aspiration cytology with biopsy with histopathology. [9] [10] [11] [12] in one study with a total of 34 cases, there was good correlation in 35% of cases, partial correlation in 35% of cases, and no correlation in 30% of cases. 9 poor correlation was found with a variety of histologic changes, including vacuolar change, lipidosis, cholestasis, inflammation, and neoplasia. in a similar study with 97 cases, complete agreement between fineneedle aspiration and histopathology was seen in only 30% of cases in dogs: 25% agreement with inflammation, 14% agreement with neoplasia (mainly carcinoma), and 64% agreement with vacuolar hepatopathy. 10 in cats, there was overall agreement in 51% of cases: 27% agreement with inflammation, 33% agreement with neoplasia (lymphoma), and 64% agreement with vacuolar hepatopathy. although vacuolar hepatopathy was the most sensitive diagnosis, it was also the most common misdiagnosis using cytology. in another study, the best correlation between hepatic cytology and biopsy was seen with lipidosis, lymphoma, and carcinoma, whereas the worst performance was seen with inflammatory and fibrotic disorders. 11 another study found high sensitivity and specificity with fine-needle aspiration in detecting inflammatory hepatic disease in dogs. 12 however, further information was not provided such as the severity of the inflammation or other histopathologic features. additionally, for noninflammatory hepatic disease, cytology was inaccurate in 76% of cases. proteins-induced-by-vitamin-k-antagonism test is more than twice as sensitive in dogs and more than three times as sensitive in cats in detecting coagulopathies compared with prothrombin time (pt) and aptt. 6, 7 however, in a pilot study performed by me, hepatic bleeding times assessed via laparoscopy did not correlate with proteins induced by vitamin k antagonism times. thus it appears that indices of coagulation in the peripheral blood are generally unreliable guides of the risk of bleeding after liver biopsy, and hence, are of limited value in determining contraindications to this procedure. this lack of correlation may be explained by the high concentration of clotting factors in the hepatic parenchyma and by mechanical compression of the needle tract by the elastic tissue within the liver. in most cases of significant hemorrhage, technical errors such as damaging a large vessel are the cause rather than persistent oozing from a needle biopsy site. controlled studies in veterinary patients will be necessary to make final conclusions regarding postbiopsy hemorrhage in the patient with a coagulopathy. in one study of normal dogs, biopsies taken from the left lateral hepatic lobe using a biopsy punch, biopsy needle, ligature method, laparoscopic biopsy forceps, and ultrasonically activated scalpel resulted in minimal hemorrhage (<2 ml). 8 however, this investigation did not assess the risk of hemorrhage in dogs or cats with hepatic disease. these risks will be discussed later under each sampling method. with the exception of fine-needle aspirations, each patient should have a prebiopsy packed cell volume and 3 and 6 hours postbiopsy packed cell volume for close monitoring of potential hemorrhage. fine-needle aspiration involves obtaining a small amount of hepatic tissue for cytologic analysis, and is typically performed in conjunction with, and guided by, ultrasound. ultrasound imaging helps determine if there is a diffuse abnormality (e.g., increased or decreased echogenicity, diffuse mottling) or if there are focal abnormalities (e.g., discrete nodules, cysts, masses, or focal areas of heterogenous mottling). an appropriate site to be sampled is chosen. often multiple sites are chosen to represent different lobes, and in the case of focal lesions, to sample more than one area of abnormal tissue and sample seemingly normal tissue. the sites are also chosen based on accessibility. for example, a solitary nodule in the dorsocranial aspect of the liver in a large deep-chested dog would be impossible to reach with a 1.5-inch needle. a lesion adjacent to the gallbladder or caudal vena cava would involve considerable risk. the clinician would need to decide whether the relative risk of sampling such lesions is the appropriate decision, or whether other methods of sampling would be more appropriate such as laparoscopy or laparotomy. figure 61 -15 depicts a typical setup for fine-needle aspiration. usually a 22-gauge, 1.5-inch needle is used. for most patients, the procedure is performed without sedation or local anesthetic. if it is determined that the animal is moving too much during the initial ultrasound examination, a sedative may be necessary (or an anesthetic in extreme cases). the needle is inserted without a syringe using ultrasound guidance. the needle is rapidly agitated in and out (sometimes referred to as mimicking the action of a sewing machine) and simultaneously twisted multiple times for a few seconds to obtain a sample. this method relies on capillary action rather than suction to get tissue into the needle, resulting in less hemodilution. after removing the needle from the liver, a syringe is attached and cells are expelled onto a glass slide for cytologic examination. often three to five separate attempts are made to increase the sample size and diversity. examination is performed prior to biopsy. this allows planning of the procedure based on echo pattern, lesion size, proximity to other organs, proximity to blood vessels, determination of cystic or solid tissue, and optimal approach of the needle path. care must be taken prior to taking samples to ensure that vessels and other organs are not within the path of the needle. for diffuse lesions, the transducer is typically placed caudal and to the left of the xiphoid, and aimed at the left medial or lateral lobes. in patients with a small liver, it may be difficult to adequately visualize the needle without gastric gas interference. placing these animals in a 45-degree right lateral oblique position can reduce this interference. if the animal is under general anesthesia, an assistant can compress a rebreathing bag to hold the animal in deep inspiration, which serves to move the diaphragm and liver caudally to improve visualization. the area is surgically prepared. the ultrasound transducer is covered with sterile wrap and sterile lubricant is used to enhance skin contact. a small stab incision is made in the skin at the desired needle insertion site. while one hand maneuvers the transducer, the other hand advances the needle into the liver under direct ultrasound visualization. the image should be optimized to maximize the chance of recognizing the needle within the liver. to allow distinction of the needle from other echogenic structures, the needle can be gently moved in and out with minimal movements (attempting to move the liver within the abdominal cavity rather than the needle within the liver). occasionally the needle cannot be seen, and indirect evidence of organ penetration must be used such as movement of the liver or visualization of movement at the liver border. the needle is then directed so the trajectory will avoid other structures when it is fired. the needle is then fired, and immediately removed. for most cases, four to five samples are obtained, and are submitted for aerobic/anaerobic culture, histopathologic evaluation, and metal (copper, zinc, and iron) quantification. in one study, liver tissues with high metal concentrations had significantly lower copper and iron in needle-core versus wedge biopsy specimens. 13 consequently the value of needle-core biopsy specimens for measurement of metal concentrations is questionable. careful examination for post-biopsy hemorrhage is then performed. external digital pressure may be used to help control hemorrhage in smaller patients. usually an abdominal compression wrap is ineffective for controlling hemorrhage. ultrasound-guided biopsy has many of the advantages of fine-needle aspiration, including the need for minimal sedation in some patients, the ability to sample multiple sites, and low to moderate cost to the client. additionally, tissue is obtained for histopathology. one disadvantage of ultrasound-guided biopsy is the risk of bleeding (especially when multiple sites are sampled and largergauge needles are used). in one study, 96 percutaneous transabdominal hepatic needle biopsy samples were obtained with no adverse consequences noted 14 ; however, this study was performed in normal dogs, and still carries high risk. additional disadvantages of ultrasound-guided biopsy include the needing sedation or anesthesia in some patients, difficulty of imaging small livers, difficulty of obtaining liver tissue in patients with fibrosis, and, most importantly, the obtaining of samples that have a questionable representation of the underlying hepatic pathology. the diagnostic accuracy of needle biopsy has been questioned by many clinicians, observing that results of needle biopsy analysis often do not adequately reflect the clinical and laboratory features of the patient. this questionable accuracy is in most part a result of potential for sampling error. this method still results in a relatively small sample size, possible although fine-needle aspiration is easy to perform, involves little risk, and little to no sedation, the information is of little value if it is inaccurate as often as it is accurate. there is institutional bias regarding its accuracy, which may relate to the experience and expertise of the cytologists. given its clear limitations, fine-needle aspiration is best used as an adjunctive diagnostic modality in conjunction with other techniques or clinical findings, and does not replace histopathology. the clinician must be aware of its inherent inaccuracy before undertaking fine-needle aspiration and relying on the cytologic findings. ultrasound-guided hepatic biopsy uses a cutting-type needle as a sampling tool. automated needles are preferred and should be either completely automated or semiautomated. these are spring-loaded needles similar in style to the manual tru-cut needle. completely automated needles thrust the inner obturator (containing the biopsy tray or specimen notch) followed by the outer cutting sheath into the liver in a fraction of a second. these needles can be operated with one hand while the other hand operates an ultrasound transducer to allow precise placement of the biopsy instrument. there is minimal displacement of the liver, a shorter intraparenchymal phase, and a more reliable yield of tissue. this allows a smaller diameter needle to be used and a lighter degree of sedation in some cases. using the rapid cutting action, the hepatic tissue tends to be less fragmented. semiautomated needles require manual placement of the internal obturator into the liver, followed by an automatic thrusting of the outer cutting sheath by a spring-loaded mechanism. these needles have the additional advantage of control over the final needle position, as the tip of the needle can be precisely localized before the outer cutting sheath is deployed. i generally use a 16-gauge needle for ultrasound-guided hepatic biopsy. figure 61 -16 depicts a typical setup for ultrasound-guided biopsy. in most dogs, the liver can be biopsied using local anesthesia and minimal sedation. most cats require general anesthesia to safely obtain tissue. it must be emphasized that the degree of sedation must be tailored to each individual patient. a careful ultrasound peritoneal space through a stab incision using a number 11 scalpel blade. after ensuring no obstruction and negative pressure using the infusion and aspiration of saline, the abdomen is insufflated with carbon dioxide gas and maintained at a pressure of approximately 12 mm hg. a scope port (cannula) is then placed 4 cm right lateral to the veress needle. the veress needle is then removed and replaced with an instrument port. hepatic sampling is achieved using a "spoon" or oval cup biopsy forceps. multiple samples are obtained under direct visualization, and samples are submitted for aerobic/anaerobic culture, histopathologic evaluation, and metal (copper, zinc, and iron) quantification. following procurement of all the biopsy specimens, the sites are inspected for hemorrhage. the abdomen is then decompressed, and lidocaine and bupivacaine are infused into the peritoneal cavity through either port. both the instrument and scope ports are removed, and the port site incisions are closed using either a cruciate or simple interrupted pattern in the body wall, subcutaneous tissue, and skin. this technique enables gross evaluation of the entire liver, extrahepatic biliary system, and surrounding structures while obtaining multiple large specimens of liver. the ability to obtain multiple samples decreases the risk for sampling artifact in cases of regional diversity within the liver. additionally, by directly visualizing the hepatic parenchyma, the clinician can correlate the histopathologic findings and clinical data with the gross appearance of the liver to render the most accurate diagnosis. this method also enables the visualization of smaller masses and irregularities that may not be evident with ultrasonographic imaging. these masses can also be individually sampled. laparoscopy also gives the clinician an excellent view of the liver regardless of the hepatic size or conformation of the patient, making it an easy method to sample the liver in patients that are difficult to image with ultrasound. there is generally minimal bleeding during this procedure, even in patients with in vitro coagulopathies. using a "spoon" or oval-cup biopsy forceps typically results in a marked decrease in the amount of hemorrhage when compared with needle biopsies. any hemorrhage can be directly visualized for adequate clot formation. if hemorrhage persists, direct pressure using a blunt probe for 5 minutes can be used. if the site continues to bleed, electrocautery can be applied to the biopsy site or a topical hemostatic agent (gelfoam) can be placed directly on the biopsy site using laparoscopic forceps. disadvantages of laparoscopy include the need for expensive equipment, the need for extensive training, the need for general anesthesia in most cases, and higher cost to the client. laparoscopy gives the clinician the advantages of a laparotomy (large sample size, ability to best direct sampling, and ability to take multiple samples, thus resulting in the highest diagnostic accuracy), though with a relatively minimally invasive procedure. the complication rate (especially hemorrhage) is far less than with ultrasoundguided biopsy in my practice. for these reasons, it is my method of choice for obtaining hepatic biopsy specimens in most cases. wedge biopsy via laparotomy is another potential method for obtaining hepatic biopsies. if a random liver biopsy is needed and a section of liver is protruding, a guillotine suture can be used. a preformed encircling ligature of 4-0 monofilament absorbable suture material is placed around the protruding section of liver. fragmentation of fibrous tissue, and may not enable sampling of abnormalities located in other lobes (the left medial or lateral lobes are generally sampled because of their ease of imaging). in one study, percutaneous hepatic sampling using core biopsies resulted in 92% diagnostic quality samples, however these were not compared with large wedge biopsy to assess the accuracy of this method. 15 in another study, the diagnostic accuracy of the tru-cut-type needle biopsy was compared with the gold standard of surgical wedge biopsy of the liver in 124 patients. 16 the overall discordance between the two methods was 53% in dogs and 50% in cats, with a greater than 60% discrepancy occurring with chronic hepatitis or cirrhosis, cholangitis/ cholangiohepatitis, portosystemic vascular anomalies, microvascular dysplasia, fibrosis, and miscellaneous disorders. these disorders are the most commonly seen among dogs and cats with hepatobiliary disease. the greatest accuracy was with neoplasia (80% concordance). figure 61 -17 is an example of a mass amenable to an ultrasound-guided needle biopsy. use of a 14-gauge versus 18-gauge needle may reduce this discordance as it raises the number of portal triads sampled from an approximate mean of four to seven, though larger needles carry the risk of increased hemorrhage. in summary, ultrasound-guided hepatic biopsy is relatively easy to perform, but involves more risk to the patient (primarily bleeding). like fine-needle aspiration, ultrasound-guided biopsy has questionable accuracy. the accuracy may be increased by using a larger-gauge needle, but this carries a greater risk of postbiopsy hemorrhage. if the patient is suspected of having inflammatory disease, vascular abnormalities, or significant fibrosis, or is at risk for hemorrhage, laparoscopy or laparotomy should be considered. chapter 28 provides a detailed description of laparoscopic liver biopsy. briefly, laparoscopy is performed under general anesthesia with the patient in dorsal recumbency tilted 45 degrees to the left. a veress needle is placed at the level of the umbilicus into the acute hepatitis and necrosis are common morphologic hepatic lesions in dogs and cats presenting with acute liver disease caused by infectious, toxic, metabolic, and ischemic disorders (box 61-1). however, acute liver disease can also be associated with other pathologic processes such as severe hepatic lipidosis (cats), granulomatous hepatitis (fungal infections), intrahepatic cholestasis (bacterial cholangitis, leptospirosis), and malignant infiltration (lymphoma, malignant histiocytosis). canine adenovirus i, canine and feline herpesvirus in the neonate, clostridium piliforme, and toxoplasma gondii are specific examples of infectious agents that cause acute hepatic necrosis (with variable inflammation), often as part of a multisystemic disorder. 2 although leptospirosis is a well-recognized infectious cause of acute liver disease in dogs, hepatic necrosis is an uncommon histologic feature and hepatic lesions are typically characterized by cholestasis, liver cell dissociation, and nonspecific reactive hepatitis. 3 despite the large number of potential causes of acute hepatitis and necrosis, a specific etiology is often not determined. 4, 5 in a recent case series of 101 dogs with primary hepatitis (acute and chronic hepatitis) that were presented to a referral clinic, 21 dogs were diagnosed with morphologic features of acute hepatitis. 4 a cause could not be determined in the majority of these cases, although increased hepatic copper was detected in five dogs with acute hepatitis, suggesting that copper accumulation could be a significant contributing factor. 4 despite numerous potential causes of hepatocyte death, two general mechanisms are recognized: apoptosis and necrosis. 2 these two mechanisms have traditionally been considered to be distinct events. however, it now appears that apoptosis and necrosis are alternate outcomes of the same initiating causes and signaling pathways. 1 apoptosis is adenosine triphosphate-dependent (caspasedependent) programmed cell death that causes shrinkage of the cell (apoptotic bodies or acidophil bodies) with orderly resorption of cellular contents, minimal leakage of cellular components, and minimal secondary inflammation. 1,2 necrosis occurs when depletion of adenosine triphosphate results in cellular swelling, loss of integrity of the cell membrane and cell lysis, with release of cell contents and secondary inflammation. 1, 2 diffuse hepatic necrosis is the most consistent histological lesion detected in dogs and cats with acute liver failure. 5 acute liver failure (alf) is a rare clinical syndrome (usually fatal) that occurs when a sudden severe insult to the liver compromises at least 70% of functional hepatic mass. liver cell death exceeds hepatic regenerative capacity, resulting in clinical signs of liver failure. 5 the clinical and laboratory features of alf are not specific for the inciting cause but reflect disruption of one or more major hepatic functions. once hepatocellular injury has occurred (and assuming the patient survives), the morphologic hepatic response to injury may include parenchymal regeneration, fibrosis, and ductular proliferation. 2 nearly complete hepatic regeneration is possible if hepatocyte injury is limited and the reticulin network remains intact. 2 with severe parenchymal destruction or extensive loss of hepatocytes, periportal ductular proliferation, hepatic fibrosis, postnecrotic scarring, and regenerative hepatic nodules are more likely. 2 dogs with acute hepatitis may also progress to chronic hepatitis. 4 the clinical presentation of dogs and cats with acute hepatitis and necrosis varies with the underlying cause and the extent and severity of the hepatic lesions. the spectrum of hepatic involvement may the ligature is then tightened until it has crushed the hepatic parenchyma. after completing several throws in the knot, the sample is excised 1 to 2 mm distal to the ligature using metzenbaum scissors or a scalpel blade. if a specific area of liver is needed, a sample can be obtained using the transfixation method or a biopsy punch. the transfixation method entails placing a ligature through the liver lobe approximately 8 to 10 mm from its edge. the ligature is tightened to crush through the hepatic parenchyma along one border of the desired biopsy specimen. an additional throw is made at a right angle to the first ligature, and this throw is tightened to crush the parenchyma of the second border of the specimen. the sample is removed 1 to 2 mm distal to the crushed area using a scalpel blade or metzenbaum scissors. if the desired area does not lie near the edge of a liver lobe, a 6-mm biopsy punch can be used. the biopsy punch should be inserted into the hepatic parenchyma ensuring not to penetrate the opposite surface. if the biopsy site is close to the hilus, extra caution must be used so that no more than half of the thickness of the liver is penetrated. the biopsy sample is removed from the liver using scissors. hemorrhage can be controlled by filling the defect with a topical hemostatic agent (gel foam) and applying digital pressure for 3 to 5 minutes, or by suturing the hepatic capsule with fine, absorbable monofilament suture in a cruciate pattern. akin to laparoscopy, this method has similar advantages and disadvantages as listed previously. although it is more invasive, it allows easier biopsy of other abdominal organs (such as intestine and mesenteric lymph node) and the ability to perform therapeutic maneuvers (such as hepatic mass removal or biliary diversion). etiology hepatocyte death (necrosis and apoptosis) in dogs and cats occurs secondary to a broad variety of insults, including infectious agents, drugs and toxins, hypoxia, immunologic events, and metabolic disorders. hepatic necrosis and acute inflammation often occur together and the relationship between these two processes is complex. acute inflammation may be the primary event, or necrosis of hepatocytes can be followed by a substantial inflammatory response, the "hallmark" of necrotic cell death. 1 the term acute hepatitis traditionally has been used when infectious agents cause hepatocellular necrosis, even though in the early stages, hepatic inflammation can be minimal or absent. 2 controversy exists among veterinary pathologists regarding the preferred terminology (acute hepatitis versus acute hepatic necrosis), when necrosis predominates and is caused by noninfectious insults such as toxins or ischemia. 2 for the purposes of this discussion, lesions of acute hepatitis and acute hepatic necrosis are discussed together, recognizing that the primary contributions of each lesion may be variable, depending on the cause, host response, and passage of time. acute hepatitis, a form of primary hepatitis, should be differentiated from "nonspecific reactive hepatitis," a response of the liver to a variety of extrahepatic disorders that is characterized by focal inflammation without necrosis. 2 nonspecific reactive hepatitis is discussed in a later section of this chapter. synthesis. 7 increased activity of the cholestatic liver enzymes, alkaline phosphatase, and ggt, also commonly occur with acute hepatitis and necrosis, but the magnitude of the increase is much less than for the alt and ast. abnormalities in biochemical tests such as hyperbilirubinemia, increased sbas, hypoglycemia, and hyperammonemia indicate compromised hepatic function. hyperbilirubinemia and bilirubinuria support more significant hepatic injury once prehepatic (hemolytic) causes have been discounted. primary biliary tract disorders including posthepatic mechanisms of hyperbilirubinemia should also be considered in the differential diagnosis. other considerations for hypoglycemia in conjunction with acute liver disease include xylitol toxicity (excess insulin release) and sepsis. hypoalbuminemia usually suggests chronic rather than acute liver disease, because of the long serum half-life of albumin. if azotemia is detected, dehydration, gi blood loss, and concurrent renal damage (e.g., leptospirosis, nonsteroidal antiinflammatory drugs [nsaids]) should be considered. interpretation of azotemia is facilitated by concurrent urinalysis. renal injury is supported by findings of cellular or granular casts, glucosuria, isosthenuria, and proteinuria. the complete blood cell count may reveal an inflammatory response suggesting underlying infectious or inflammatory disorders, and it is also useful for ruling out hemolytic anemia as cause of jaundice. documentation of a coagulopathy is required for the clinical diagnosis of alf. laboratory findings indicative of a coagulopathy include prolonged pt and activated partial thromboplastin time (aptt), decreased fibrinogen, increased fibrin degradation products, and thrombocytopenia. abdominal radiographs are often unremarkable in dogs and cats with acute hepatitis and necrosis. the liver may appear normal or increased in size. on abdominal ultrasound, the liver may appear normal or hypoechoic. thoracic and abdominal imaging may be helpful to evaluate for other causes of acute hepatic disease, and biliary tract disorders. because dogs and cats with acute hepatitis and necrosis present with nonspecific signs of acute liver disease, the clinician should maintain a broad perspective regarding the many potential diseases and processes that can acutely affect the liver. prior to obtaining a liver biopsy, ancillary testing (cytology or biopsy of more accessible lesions, infectious disease titers or molecular tests, diagnostic imaging) should be performed to evaluate for systemic disorders with secondary hepatic effects or multisystemic infections, thus providing a diagnosis of other causes of acute liver disease in a less-invasive manner. when acute hepatitis or hepatic necrosis is suspected (or confirmed by liver biopsy), a thorough history is essential to identify exposure to potential hepatotoxins and infectious agents. the owner should be questioned regarding recent medications, including prescription and over-the-counter drugs, and alternative medicines such as herbal and dietary supplements. the potential for exposure to chemicals or hepatotoxins (amanita mushrooms, blue-green algae, sago palms, aflatoxins, or xylitol) should be assessed (for more details, see "drug and toxin-induced liver injury" section). other pertinent historical questions include current vaccination history (canine adenovirus, leptospirosis), travel history (fungal infections or tick-borne diseases), and exposure to other animals (infectious causes). liver biopsy is required to document the presence of acute hepatitis and necrosis; evaluate for specific causes; and differentiate acute from chronic disease. in patients with mild (or absent) clinical signs and liver enzyme elevations that correspond to recent medication administration, a liver biopsy may be postponed, the medication discontinued, and clinical signs and liver enzymes monitored for include (a) subclinical (biochemical abnormalities only), (b) clinical signs of acute liver disease, or (c) the clinical syndrome of alf. when liver injury is mild (focal necrosis and inflammation), clinical signs may be absent, mild, or related to an underlying cause in another organ system. in this setting, hepatic involvement may not be recognized until biochemical evaluation reveals increased liver enzyme activity or mild hyperbilirubinemia. it has been suggested that many dogs with acute hepatitis are not recognized clinically, because signs are mild and self-limiting, and dogs recover spontaneously regardless of treatment. 6 clinical signs of acute hepatitis include acute onset of lethargy, anorexia, vomiting, diarrhea, pu, and pd, in a previously healthy animal. these are nonspecific findings of acute liver disease, which overlap those of other systemic disorders. the finding of icterus on the physical examination is a more specific indicator of hepatobiliary disease, especially in the absence of anemia. dogs and cats with acute diffuse hepatic necrosis often present with alf. 5 in addition to the signs of acute liver disease described above, animals in alf show signs of he (depression, behavioral changes, dementia, ataxia, pacing, circling, blindness, hypersalivation, seizures, and coma) and clinical evidence of a bleeding tendency (melena, hematemesis, or cutaneous and mucosal hemorrhages), which suggest severe hepatic dysfunction. 5 signs of alf are rapidly progressive (over hours to days) and this clinical syndrome is often fatal, with reported mortality varying from 25% to 100%. 5 with acute hepatic disease, the history typically reveals acute onset of signs in a previously healthy animal. however, liver failure that is recently recognized may not necessarily be recent in onset. with occult chronic liver disease, clinical signs may be vague and go unrecognized by the owner until a final phase of hepatic decompensation. the owner should be questioned about any subtle signs of chronic illness that would suggest the underlying liver disease may be chronic rather than acute, and that the current illness may be an exacerbation or decompensation of chronic liver disease. dogs and cats with alf are generally in good nutritional status compared with those with chronic hepatic disease. findings of cachexia, emaciation, ascites, or edema suggest a more protracted illness and are characteristic of chronic rather than acute liver disease. it is important to make a distinction between acute and chronic liver disease as the intensive supportive care indicated in alf might not be warranted in chronic end-stage liver disease. the long-term prognosis is better for acute hepatitis than chronic hepatitis. 4 an initial database consisting of complete blood cell count, serum chemistry, and urinalysis should be obtained in dogs and cats with acute liver disease. liver enzyme elevations are a common finding in dogs and cats with acute hepatitis and necrosis. with mild hepatic injury or focal hepatic necrosis, increased alt activity may be the only finding on an otherwise unremarkable biochemical profile. alt and ast activities are moderately to markedly increased, because of enzyme leakage from damaged hepatocytes. 7 although alt activity increases with many hepatic diseases, the largest magnitude of increase is seen with acute hepatic necrosis and roughly correlates with the number of involved cells. 7 alt activity may be increased as much as 100 times the upper range of normal, with increases in ast activity that parallel but are generally lower (30 times the upper limit of normal) than the alt. it should be noted that some recognized hepatotoxins (aflatoxin and microcystin in blue-green algae) are not associated with severe or protracted increases in alt activity because of toxin-suppressed transaminase improvement over a 2-to 3-week period. for patients with alf and coagulopathy, the clinician must carefully weigh the benefits of histologic characterization versus the risk of excessive bleeding from the procedure. acute hepatitis is characterized histologically by a mononuclear or mixed inflammatory pattern, accompanied by hepatocellular apoptosis or necrosis. 2 necrosis should be further characterized by the pathologist as to the morphologic pattern of injury (focal, multifocal, confluent, bridging, massive, or piecemeal) because the pattern of necrosis may provide insight into the pathogenesis of the lesion. 2 for example, because centrilobular hepatocytes have an abundance of cytochrome p450 enzymes, these hepatocytes are preferentially affected in drug-induced hepatotoxicity, when cytochrome p450 metabolism of the parent drug results in toxic metabolites. 8 quantitative copper analysis and histochemical staining for copper are recommended, as copper accumulation may be an underappreciated cause of acute hepatitis in dogs. 4 infectious causes of acute hepatitis may be diagnosed on liver biopsy, or by additional tests performed on liver tissue (culture, immunohistochemistry, polymerase chain reaction [pcr], virus isolation; table 61 -4). unfortunately, in most cases, routine liver biopsy is unlikely to reveal a specific cause of acute hepatitis. 2, 4 findings of inflammation and necrosis/apoptosis accompanied by nodular regeneration and fibrosis suggests chronic rather than acute hepatitis. the long-term prognosis is better for acute hepatitis than for chronic hepatitis. 4 if a probable cause of acute hepatitis and hepatic necrosis can be determined, then specific treatment is directed at the primary etiology (e.g., discontinuing potentially hepatotoxic medications, treating for leptospirosis with doxycycline, or chelating hepatic copper with penicillamine). in most cases specific therapy is unavailable and treatment is directed at more general supportive and symptomatic treatment of liver disease. glucocorticoid therapy is not typically indicated in the treatment of acute hepatitis. 4 empirical treatment with antioxidants such as s-adenosylmethionine (same; 20 mg/ kg po q24h), milk thistle (siliphos; 3 to 6 mg/kg po q24h), or vitamin e (10 to 15 iu/kg q24h) may be warranted, as oxidative stress is believed to play a role in drug (carprofen, potentiated sulfonamides, diazepam, methimazole, lomustine, others), and toxin (aflatoxin, organic solvents, and heavy metal toxicity) induced hepatic injury. 9 same and milk thistle have additional cytoprotective properties that could be beneficial in necroinflammatory hepatopathies and hepatotoxicity. antioxidants and cytoprotective agents are discussed in more detail in chapters 40 and 46, respectively. liver biochemistries should be monitored to assess patient response to therapy. repeat liver biopsy performed 6 to 8 weeks after the initial diagnosis has been recommended, to confirm that acute hepatitis has improved or resolved, or to document a progression toward chronic hepatitis. 4, 6 it has been suggested that most dogs with mild idiopathic acute hepatitis (not in alf) recover after several days, regardless of treatment. 6 for patients with alf, aggressive supportive treatment is required. goals of therapy are to treat the underlying cause when possible, allow adequate time for hepatic regeneration and repair, and prevent or control complications of liver failure, such as hypoglycemia, coagulopathy and anemia, he, gi ulcers, and septicemia. intravenous n-acetylcysteine (nac), a glutathione source/ antioxidant, is the antidote of choice for treatment of acetaminophen toxicity. nac also appears to have additional potential benefits (improved systemic hemodynamics and tissue oxygen delivery), and should be considered for use in any dog or cat with alf. 9 the optimal dose regimen when nac is used for this purpose has not been determined. treatment of complications of liver failure are discussed in "complications of liver disease" section. the prognosis for recovery in dogs with acute hepatitis is good, as most dogs recover uneventfully. 4 however, there is a potential for dogs with acute hepatitis to develop chronic disease. 4 if animals present with signs of advanced liver failure (e.g., he, coagulopathy, hypoglycemia), the prognosis is guarded. if the animal survives, hepatic lesions such as periportal ductular proliferation, hepatic fibrosis, postnecrotic scarring, and regenerative hepatic nodules are likely. 2 if a hepatic drug reaction is suspected, reexposure of the patient to the suspect drug should be avoided. etiology hepatic abscesses from bacterial infection of the liver occur uncommonly in dogs and cats. [10] [11] [12] [13] abscesses may form as solitary or multiple macroscopic masses or microabscesses. in newborn animals, gram-positive and gram-negative bacteria cause hepatic abscesses, presumably related to postpartum umbilical infections. 14 in adult animals, gram-negative enteric bacteria (especially escherichia coli) and anaerobes (especially clostridia spp.) are most commonly identified; multiagent infections are frequent. 10, 12 other organisms such as yersinia spp., actinomyces spp., nocardia asteroides can also cause hepatic abscesses as part of a systemic infection. 14 the pathogenesis of hepatic abscesses in dogs and cats is unclear. hepatic abscesses are usually associated with extrahepatic infections or regional hepatic parenchymal damage. small numbers of bacteria, including clostridium spp., can be cultured from liver tissue of healthy dogs. hypoxia of hepatic tissue caused by hepatic neoplasia, liver lobe torsion, or trauma may predispose to abscess formation, because small numbers of existing anaerobes (e.g., clostridium spp.) can proliferate under these conditions. other potential sources of bacteria include hematogenous spread (via the umbilical vein, hepatic artery, or translocation of intestinal bacteria into the portal blood), ascension via bile ducts, penetrating abdominal and caudal thoracic wounds, and direct extension from local suppurative diseases. concurrent diseases or potential predisposing factors in dogs include systemic infections (pneumonia, pyelonephritis, prostatitis, pyometra, endocarditis), gallbladder rupture, pancreatitis, diabetes mellitus, liver lobe torsion, coexisting hepatic disease such as hepatic neoplasia (infected necrosis), longterm phenobarbital administration, long-term corticosteroid administration, and previous surgical biopsy. 10, 11 concurrent diseases in cats include cholecystitis, pyothorax, and hepatic neoplasia. 12 solitary abscesses are more common in dogs, whereas cats are more likely to be septic and have multiple hepatic abscesses. 11, 12 no association with feline leukemia virus or feline immunodeficiency virus infection has been made. 12 solitary liver abscesses are more likely to involve the right liver lobe in cats and the left liver lobe in dogs. 11, 12 clinical examination when adult dogs and cats are diagnosed with hepatic abscesses, they are usually older than 8 years of age. [10] [11] [12] clinical signs are nonspecific and can be attributed to sepsis, inflammation, and hepatic dysfunction. the most common signs are anorexia, lethargy, vomiting, and diarrhea. 10, 11 clinical signs of hepatic involvement may be overshadowed by signs of the associated disease process (e.g., neoplasia, pyelonephritis, pancreatitis). dogs with hepatic abscess may have a history of failure to respond to antibiotics or improvement that relapsed when antibiotics are discontinued. 10 physical examination findings are often vague and include depression, dehydration, fever, abdominal pain, hepatomegaly, abdominal mass, and abdominal effusion. [10] [11] [12] hypothermia is a more common finding than fever in cats with hepatic abscesses. 12 because the clinical findings are vague and nonspecific, hepatic abscesses often go undetected until an abdominal ultrasound is performed or they rupture and are discovered during laparotomy. rupture of a hepatic abscess leads rapidly to peritonitis, septic shock, and death. clinicopathologic abnormalities are consistent with an inflammatory hepatic disease. potential findings on the complete blood count include neutrophilia with a left shift (or neutropenia and degenerative left shift if rupture occurs), mild anemia, and thrombocytopenia. 10, 12 increased alt and alp activity are common findings although the alt may be in the normal range. 10 liver enzyme elevations are a less-consistent finding in cats with hepatic abscesses and 79% in cats. 12 the survival rate appears to be better when solitary abscesses are detected. 12, 13 granulomatous hepatitis is characterized histologically by focal or multifocal aggregates of activated macrophages with an epithelioid appearance, usually accompanied by lymphocytes and plasma cells. 14 this inflammatory response is distinct from that encountered in canine chronic hepatitis. systemic infectious diseases are an important cause of granulomatous hepatitis and this lesion has been described with fungal infections (histoplasmosis, coccidioidomycosis, many others), bacterial infections (mycobacteria, bartonella, nocardia, actinomyces, rhodococcus), protozoal diseases (cytauxzoonosis, leishmaniasis); parasitic diseases (visceral larval migrans, schistosomiasis, alveolar echinococcus, hepatozoon americana), and disseminated protothecosis (see table 61 -4). 15, 16 in cats, feline infectious peritonitis (coronavirus) is an important cause of multisystemic granulomatous or pyogranulomatous inflammation. other causes of granulomatous inflammation include a local response to foreign material (crystalline material, sutures, plant material) or a drug reaction. in humans, granulomatous liver lesions have been associated with administration of diltiazem, sulfonamides, quinidine, allopurinol, interferon-α, and phenytoin. 17, 18 however, drug therapy as a cause of granulomatous hepatitis in dogs and cats has not been specifically reported. granulomatous lesions in the liver has been described in a small number of dogs with lymphangiectasia, lymphosarcoma, and histiocytosis. 19 many cases of granulomatous hepatitis are idiopathic. 16 hepatic lipogranulomas ("fatty cysts"), which are often found in dogs with congenital portosystemic shunt, are aggregates of pigment-laden foamy macrophages and should not be confused with granulomatous hepatitis. clinical findings with granulomatous hepatitis are highly variable, depending on the underlying cause. when granulomatous hepatitis is identified on liver biopsy, special stains for fungal and mycobacterial organisms should be performed. other diagnostics to either identify an organism (cytology, culture, fecal exam, pcr) or detect antibodies against the organism (serology) vary widely with the underlying agent (see table 61 -4). if a cause cannot be found after a thorough diagnostic evaluation, consideration should be given to presumptive treatment for undiscovered infectious agents such as atypical mycobacteria, bartonella spp., or systemic fungal infection. corticosteroids or other immunosuppressant agents should only be used when diagnostic testing and empirical treatment have been unsuccessful, as steroid-induced immunosuppression may exacerbate an underlying infection. 19 eosinophilic hepatitis occurs rarely in dogs and cats. 2 potential causes include visceral larval migrans (toxocara), schistosomiasis, liver fluke infections, sarcocystis canis, and possibly, fungal infections (see table 61 -4). 2 with parasitic causes, eosinophils are often located at or near the site of the parasitic lesion in the liver. dogs and cats with systemic allergic, parasitic (heartworms), or hypereosinophilic syndromes, may also have scattered eosinophils in the liver, a variant of nonspecific reactive hepatitis. 2 hepatic druginduced liver injury should also be considered. phenytoin and minocycline are associated with eosinophilic infiltrates in humans with drug-induced liver injury. 18, 20 potentiated sulfonamides have been suggested to cause drug-induced eosinophilic hepatitis in dogs, 2 although a more typical pattern is acute hepatocellular necrosis or a cholestatic hepatopathy. 21 when eosinophilic infiltrates are identified, efforts should be directed at diagnosing parasitic causes (fecal, (increased alt and alp activity occurred in less than 50% of cats). 12 other potential biochemical findings include hyperglobulinemia, mild hyperbilirubinemia, and hypoglycemia (sepsis). laboratory abnormalities may also reflect the associated disease processes (e.g., hyperglycemia with diabetes mellitus, increased pancreatic lipase immunoreactivity with acute pancreatitis). if an abscess ruptures, cytology of the abdominal infusion reveals septic suppurative inflammation. abdominal radiographs may be normal or reveal hepatomegaly, hepatic mass lesion, or decreased abdominal detail or effusion associated with secondary peritonitis. with proliferation of gas-producing organisms, radiolucent areas may be seen in the liver. ultrasonographic examination permits earlier detection of hepatic abscesses. 11 ultrasonographically, a liver abscess appears as a hypoechoic or anechoic structure with irregular, hyperechoic margins. 11, 13 the ultrasonographic pattern is similar to that seen with hepatic hematomas, cysts, neoplasia, and biliary cystadenoma. gas may be seen within the abscess. 11 if abscess rupture has occurred, concurrent abdominal effusion may be detected. additional ultrasonographic findings may reflect associated disorders such as pancreatitis, cholecystitis, or pyelonephritis. ultrasound-guided fine-needle aspiration of a suspected liver abscess can be safely performed to obtain samples for cytology and culture to confirm the diagnosis. 11 if ultrasonography is not available, the diagnosis of hepatic abscesses is usually established during exploratory laparotomy (or at necropsy). an attempt should be made to isolate and identify the organism(s) associated with abscessation so that appropriate antibiotic therapy can be instituted based on sensitivity testing. aerobic and anaerobic cultures can be performed on abscess contents (by fine-needle aspiration), abdominal exudate, blood or hepatic tissues. treatment of hepatic abscesses consists of surgical resection or drainage of focal lesions, administration of appropriate antibiotics, correction of associated fluid, electrolyte, and acid-base imbalances, and identification and treatment of any underlying disease process. treatment of large unifocal hepatic abscesses has typically involved surgical resection of affected tissue, which may necessitate partial or full lobectomy. 10, 12 if perforation and peritonitis are present, surgical abdominal drainage and lavage are indicated. ultrasound-guided percutaneous drainage of a solitary abscess may resolve the abscess or allow stabilization until surgical resection can be performed. 11 the successful management of focal hepatic abscesses (up to 8 cm in diameter) by ultrasound-guided percutaneous drainage and alcoholization has been described in five dogs and one cat. 13 broad-spectrum combination antibiotic therapy (directed toward both aerobic and anaerobic bacteria) should be initiated as soon as cultures have been obtained. results of a gram stain on the exudate may provide preliminary information as to type of organism and guide the empirical choice of potentially effective antibiotics. recommendations for broad-spectrum antimicrobial coverage of hepatobiliary infections include either a fluoroquinolone combined with amoxicillin/clavulanate or a fluoroquinolone combined with penicillin and metronidazole, until culture results are available. the dose of metronidazole should be adjusted in animals with hepatic dysfunction (7.5 mg/kg po q8-12h). antibiotic therapy should be continued for at least 6 to 8 weeks. response to treatment can be monitored with serial ultrasound examinations and repeated blood work. historically, hepatic abscesses have carried a grave prognosis, with an overall reported mortality rate of approximately 50% in dogs 10 case series (see chapter 62) . breeds of dogs at increased risk for chronic hepatitis include the bedlington terrier, 22, 23 west highland white terrier, 24, 25 doberman pinscher, [26] [27] [28] american and english cocker spaniel, [29] [30] [31] [32] [33] skye terrier, 34 dalmatian, 35 labrador retriever, [36] [37] [38] and english springer spaniel. 39 unfortunately, with the exception of hereditary copper-associated liver disease in bedlington terriers, information is lacking for most of the breed-related disorders. female dogs appear to be at increased risk in some studies, 4,40 while others report that male and female dogs are equally affected. 41, 42 within particular breeds, sex differences have been noted (female doberman pinschers, labrador retrievers, and english springer spaniels; male cocker spaniels). 26, 29, 36, 38, 39 dogs diagnosed with chronic hepatitis are generally 4 to 7 years of age, but adult dogs of any age (or breed) can be affected. 4, 29, 41 etiology and pathogenesis ideally, canine chronic hepatitis should be classified on an etiologic basis. however, with the exception of copper-associated liver disease in bedlington terriers, the cause, pathogenesis, natural history, optimal treatment, and prognosis of these disorders are unknown (table 61 -5) . idiopathic chronic hepatitis is the most common clinical diagnosis. 4, 32, 40, 41 infectious causes. viral infections are a common cause of chronic hepatitis in humans, but are not currently recognized as an important etiology in dogs. in humans, viruses have the potential heartworm test; see table 61 -4), systemic eosinophilia, and hypersensitivity reactions. if no specific cause can be determined, empirical treatment with fenbendazole should be considered, followed by corticosteroid therapy as described for idiopathic chronic hepatitis. the term nonspecific reactive hepatitis is used to describe the slight to moderate widespread inflammatory infiltrates of the liver that occur secondary to a spectrum of extrahepatic disease processes. 2 lesions of nonspecific reactive hepatitis are associated with febrile and inflammatory disorders, especially those involving the gi tract and pancreas, or they may represent residual evidence of a previous intrahepatic inflammatory disorder. 2 inflammation occurs in portal or parenchymal areas and necrosis is absent. neutrophils predominate with acute extrahepatic disorders, whereas mononuclear inflammation occurs with chronic extrahepatic disorders or residual hepatic inflammation. the liver may be secondarily affected by systemic disorders because of changes in liver blood flow, portal blood delivery of bacteria, drugs, hormones, cytokines, or other substances from the gi tract, or activation of intrahepatic kupffer cells (monocyte-macrophage system) involved in the hepatic immune response. it may be challenging to differentiate nonspecific reactive hepatitis from resolving acute hepatitis or mild chronic hepatitis, without supportive clinical information. clinical signs in dogs and cats with nonspecific reactive hepatitis are usually referable to the extrahepatic disorder. liver enzyme elevations (alt-two times the upper limit of normal; alpthree-to fourfold increases) are common, thus mimicking primary hepatic disease. however, tests that reflect liver function, including serum bile acids, are usually normal. it is important to consider extrahepatic disorders that can secondary affect the liver, prior to focusing on primary hepatic disease. treatment is directed at the underlying extrahepatic disorder. chronic hepatitis, a heterogeneous group of inflammatorynecrotizing diseases of the liver, occurs commonly in dogs, but is rare in cats. cholangitis, which is inflammatory liver disease that targets the biliary tract, rather than hepatocytes, is more common in cats but also occurs in dogs.the term chronic hepatitis, rather than chronic active hepatitis or chronic persistent hepatitis, is recommended. 2, 15 if the etiology is known, it should be included as an adjective, such as "drug-induced chronic hepatitis," or "copper-associated chronic hepatitis"; otherwise, it is considered "idiopathic chronic hepatitis." chronic hepatitis in dogs is defined based on histopathologic features of hepatocellular necrosis or apoptosis associated with inflammation and evidence of regeneration and fibrosis. 2 lymphoplasmacytic inflammation is characteristic, but a neutrophilic component may be present. 2 the histopathologic features of chronic hepatitis are similar, regardless of the underlying cause. chronic hepatitis has the potential to progress to cirrhosis. 15, 16 recommendations have been made to include a clinical component to the definition of chronic hepatitis, such as documenting an increase in alt activity along with histologic evidence of hepatic inflammation for a minimum of 4 months. however, many dogs with chronic liver disease are not clinically apparent until the advanced stages, so duration can be difficult to evaluate. the early stages may not be recognized unless biochemistries are monitored for hepatic injury. a familial predisposition to develop chronic hepatitis has been suggested by demographic studies, pathologic surveys, and clinical hepatitis (acute and chronic) accounted for one-third of all dogs with primary hepatitis. 4 hepatic copper accumulation and hepatopathy have been described in cats but appears to be rare. 58, 59 the severity of hepatic injury correlates with the amount of hepatic copper, but subcellular localization of molecules and the molecular association also plays a role. 54 serum copper levels do not accurately reflect hepatic copper content and quantitative analysis of copper in the liver is required. 56 hepatic copper concentration in normal dogs is between 150 and 400 µg/g dry weight (parts per million). 28, 57 inflammatory hepatic injury does not consistently occur until copper concentrations exceed 2000 µg/g dry weight. 60, 61 however, there may be breed variations; for example, in doberman pinschers hepatic inflammation is present with copper concentrations of less than 2000 µg/g. 27, 57 transient acquired fanconi syndrome has been described in dogs with excess hepatic copper accumulation. 62, 63 copper granules were demonstrated on renal biopsy in some but not all dogs. potential mechanisms for hepatic copper accumulation include primary metabolic defects in hepatic copper metabolism, cholestasis causing impaired biliary excretion of copper, and excess copper absorption. 54, 56 a primary defect in hepatic copper metabolism occurs in bedlington terriers with a genetic mutation in the gene encoding the copper transport protein, commd1 (formerly murr1), resulting in a defect in biliary copper excretion. 64, 65 in to cause hepatitis either because of a persistent hepatic infection or as a transient infection that triggers an immune response because of a cross-reaction between the virus and liver antigens. 43 in an attempt to identify infectious causes of canine hepatitis, pcr screening of liver tissue was performed in 98 dogs with various stages of hepatitis to look for canine adenovirus type 1, hepadnaviridae, hepatitis a virus, hepatitis c virus, hepatitis e virus, helicobacter spp., leptospira spp., and borrelia spp. 44 based on negative results, the authors concluded that canine hepatitis is not typically caused by these infectious agents. 44 however, dogs that are experimentally infected with canine adenovirus type i, but are partially immune, can develop chronic hepatitis that progresses to cirrhosis. 45 the virus could not be detected beyond the first week postinfection, although the disease progressed over a period of months. 45 canine adenovirus antigen has been demonstrated by immunohistochemical techniques in formalin-fixed liver sections from five of 53 dogs with various hepatic inflammatory lesions, suggesting that canine adenovirus 1 (cav-1) may play a role in spontaneous chronic hepatitis. 46 in contrast, pcr and immunohistochemistry failed to detect canine adenovirus in liver tissue of 45 dogs with chronic liver disease. 47 whether cav-1 is a significant cause of chronic hepatitis under natural conditions is unknown. another proposed viral cause of chronic hepatitis and cirrhosis is the "canine acidophil cell hepatitis virus," reported from great britain in the 1980s. 48, 49 this transmissible agent, most likely a virus, is distinct from cav-1. it was transmitted experimentally by subcutaneous injection of serum or liver extracts from affected dogs, resulting in experimentally induced acute and chronic hepatitis. no further studies have been published to clarify the nature of this infectious agent or the associated hepatitis. canine leptospirosis is typically associated with acute cholestatic hepatic disease and acute renal failure. however, persistent infection can cause chronic hepatitis in the absence of azotemia. 50, 51 leptospira serovar grippotyphosa was incriminated as a cause of chronic hepatitis in a kennel of american foxhounds, based on serologic evidence and demonstration of spirochetes in the liver. 50 leptospira serogroup australis (serovars australis, bratislava, and muenchen) infection was suspected to cause chronic hepatitis in 16 young beagle dogs in a breeding colony routinely vaccinated against leptospirosis serogroups canicola and icterohaemorrhagica. 51 canine leishmaniasis has been associated with histologic evidence of chronic hepatitis, 52 but clinical features suggestive of hepatic involvement (hepatomegaly, ascites, or icterus) were absent. histologic findings revealed granulomatous hepatitis in most dogs, but some dogs had marked portal infiltration with lymphocytes and plasma cells, and mild portal fibrosis. leishmania amastigotes were routinely identified in macrophages in liver or other affected tissues. bartonella clarridgeiae dna was amplified from a liver biopsy of a doberman pinscher with copper-associated chronic hepatitis, although the significance of this finding is unclear. 53 copper accumulation. copper is an essential trace element in diets and is required for a number of physiologically important enzymes. cells have highly specialized and complex systems for maintaining intracellular copper concentrations. at toxic concentrations, free intracellular copper initiates oxidative damage causing hepatocellular necrosis and inflammation. 54, 55 normal copper metabolism has been reviewed in detail elsewhere. 54, 56 copper accumulation in the liver can be associated with significant hepatic injury resulting in acute hepatitis, chronic hepatitis, and cirrhosis ( figure 61-18) . 4, 54, 57 it is one of the few well-documented causes of canine chronic hepatitis. in one study, copper-associated a b liver of 37 dogs but was not identified in any control samples from healthy livers. none of the dogs had decreased serum levels of α 1antitrypsin. positive α 1 -antitrypsin staining was a more consistent finding in english and american cocker spaniels with chronic liver disease, than in other breeds. the authors concluded that accumulation of α 1 -antitrypsin might play a role, but it could not be determined if it was the cause or a result of chronic liver disease. 31 drugs and toxins. drug or toxin exposure is a potential cause of canine chronic hepatic disease. drugs that have been incriminated include anticonvulsants (phenobarbital, primidone, phenytoin), oxibendazole-diethylcarbamazine, lomustine, and possibly carprofen. [70] [71] [72] [73] chronic hepatitis and cirrhosis from long-term phenobarbital therapy is most widely recognized. 70, 71 exposure to aflatoxin from contaminated commercial dog food is usually associated with alf, but low-level long-term exposure in dogs can result in chronic hepatic injury (biliary hyperplasia, fibrosis, nodular regeneration). a breeding colony of german shepherd dogs developed chronic hepatitis and cirrhosis that was suspected (but never confirmed) to be a result of exposure to a porphyrinogenic substance, based on the finding of aggregates of crystalline pigments with orange birefringence with polarized light. 74 early recognition of drug-or toxin-induced chronic hepatic injury requires biochemical monitoring of liver enzymes, as dogs are clinically asymptomatic in the early stages. autoimmune/immune mechanisms. autoimmune hepatitis has not been documented in dogs. however, some dogs with chronic hepatitis appear to respond to corticosteroid therapy and thus may correspond to autoimmune hepatitis in humans. 41 autoimmune hepatitis in humans is a progressive chronic hepatitis of unknown cause that is believed to occur when an environmental agent (viruses, medications) triggers a cascade of t-cell-mediated events directed at liver antigens, in a genetically predisposed individual. 43 women are more commonly affected than men. hyperglobulinemia is a common finding. an infectious cause is difficult to document, as exposure may have occurred many years prior to the overt autoimmune disease. 43 certain drugs may induce or unmask an autoimmune hepatitis, or simply cause hepatocellular injury that mimics autoimmune hepatitis. 43 an autoimmune component to doberman pinscher hepatitis has been speculated, because of the breed's predisposition, high female predominance, and the finding that expression of mhc class ii antigens on hepatocytes of affected dogs correlates with degree of inflammation and decreases after treatment with prednisolone. 75 dogs with chronic hepatitis may have concurrent disorders associated with immune aberrations (immune hemolytic anemia, hypothyroidism, atopy, glomerulonephritis), but whether this is coincidental or indicative of the presence of multiple immune disorders as seen with autoimmune hepatitis in humans is unknown. 37, 76, 77 autoimmune hepatitis in humans is diagnosed when other causes of acute or chronic hepatitis have been excluded and serum autoantibodies (antinuclear, antismooth muscle, antibody to liver/ kidney microsomes type 1, antibody to liver cytosol type 1) are detected. 43 a number of studies have evaluated the role of liverassociated antibodies and cell-mediated response in dogs with chronic hepatitis, but none answers the question of whether the immune response is the primary cause of the hepatitis or a secondary phenomenon. twenty-four dogs with chronic hepatitis were evaluated for circulating autoantibodies (against cell nuclei, smooth muscle, liver membrane, and mitochondria) by indirect immunofluorescence. 77 antibodies to cell nuclei and liver membranes were the early stages, copper is sequestered in hepatic lysosomes and hepatic damage is minimal. however, with progressive accumulation of copper, hepatic injury becomes significant. the average copper concentration in bedlington terriers with chronic hepatitis is approximately 6000 µg/g dry weight and values up to 12,000 µg/g dry weight have been reported. 23, 57 inherited copper-associated liver disease is also described in the west highland white terrier, skye terrier, doberman pinscher, dalmatian, and labrador retriever, but with the possible exception of dalmatians, the hepatic copper levels are much lower than in bedlington terriers. [25] [26] [27] 34, 35, 38 the pathogenesis of copper accumulation and the relationship to chronic liver disease in these breeds is poorly understood. it seems likely that these breeds have a hereditary disorder of copper handling, but it is unlikely to be the same as described for the bedlington terrier. hepatic copper accumulation in the liver may also be a consequence rather than the cause of chronic hepatitis. because copper is normally excreted in the bile, chronic cholestasis and impaired bile flow can result in secondary copper accumulation. 57, 66 secondary copper accumulation is predominantly periportal and is usually less than 2000 µg/g dry weight. 57, 66 the effect of cholestasis on hepatic copper content was evaluated in three groups of dogs: bedlington terriers with copper toxicity, dogs with extrahepatic biliary obstruction (the prototype example of a cholestatic disorder) and chronic hepatitis in breeds not known to be at risk for copper-associated liver disease. 66 hepatic copper content was evaluated by a semiquantitative method based on copper staining of liver tissue with rubeanic acid, using a scale of 0 (no copper) to 5. 67 copper staining revealed absent to mild increases (scores of 0 to 2+) in dogs with biliary obstruction and chronic hepatitis when compared with bedlington terriers (scores of 5+). it was concluded that copper scores of 3+ or higher were suggestive of a primary copper storage disease. 66 unfortunately, quantitative copper analysis was not evaluated. markers of oxidative injury and altered defense mechanisms were similar in the three groups, consistent with the concept that copper, inflammation, and cholestasis can all contribute to oxidative injury. 66 high dietary copper intake appears to be an unlikely explanation for hepatic copper accumulation and liver disease in dogs. 56 however, the copper content of commercial dog foods ranges from 12 to 16 mg/kg dry matter, which is relatively high compared with recommended minimum daily copper requirements in dogs. 56 there is speculation that the recent increase in pathologically elevated hepatic copper concentrations (specifically evaluated in labrador retrievers), may coincide with a pet food industry recommendation to replace cupric/cuprous oxide in feed formulations because of its low bioavailability. 68 many dogs with copper-associated chronic hepatitis also have increased hepatic iron concentrations. 69 hepatic iron accumulation usually correlates with degree of inflammation. 40, 69 whether iron, as an oxidant, interacts with copper to contribute to lesions seen in copper-associated hepatitis remains to be determined. α 1 -antitrypsin deficiency. inherited α 1 -antitrypsin deficiency is a well-recognized cause of chronic hepatitis and cirrhosis in humans, and may play a role in the pathogenesis of chronic hepatitis in some dogs. 31 α 1 -antitrypsin is a circulating protease inhibitor that is synthesized and secreted by the liver. α 1 -antitrypsin deficiency in affected humans results in defective formation and impaired hepatic secretion of α 1 -antitrypsin, resulting in hepatic accumulation of α 1 -antitrypsin and hepatic injury. serum levels of α 1 -antitrypsin are typically low. in a study of 57 dogs with chronic liver disease, α 1antitrypsin was detected by immunohistochemical staining in the early stages of chronic hepatitis, ultrasonography of the liver may be normal or reveal nonspecific changes in echogenicity. when chronic hepatitis has advanced to cirrhosis, potential ultrasonographic findings include microhepatia, irregular hepatic margins, focal lesions representing regenerative nodules, increased parenchymal echogenicity associated with increased fibrous tissue, and ascites. splenomegaly and acquired psss may also be detected. a liver biopsy is essential for the diagnosis of chronic hepatitis. wedge biopsies are preferred over needle biopsies because they provide more tissue and are more likely to represent pathologic process(es) in the liver. when cirrhosis is present, laparotomy or laparoscopy often provide a better appreciation for the gross nodularity of the liver than can be ascertained from blind percutaneous needle biopsy (figure 61-19 ). chronic hepatitis is characterized histologically by moderate to severe inflammation (usually combinations of lymphocytes and plasma cells) associated with piecemeal necrosis. piecemeal necrosis, also referred to as interface hepatitis, is necrosis involving the layer of hepatocytes adjacent to the portal tract or "limiting plate." 2 the term bridging necrosis is used when necrosis and inflammation dissect across the hepatic lobule from portal areas to central veins or to adjacent hepatic lobules and suggests a severe form of chronic hepatitis. 2 histopathologic evaluation of the liver should not only consider etiology, but the pathologist should also comment on the activity (amount of inflammation, extent of apoptosis and necrosis) and the stage of disease (extent and pattern of fibrosis; architectural distortion suggestive of cirrhosis). 2 biopsies from dogs with chronic hepatitis should routinely be evaluated for copper accumulation. on hematoxylin and eosin staining, excess copper appears as golden brown refractile granules. 28 histochemical stains, such as rhodanine or rubeanic acid, can be used to semiquantitatively evaluate for copper in the liver (see figure 61 -19) . these stains consistently detect copper when amounts exceed 400 µg/g dry weight. 60 values obtained by quantitative copper analysis have a strong correlation with the number and size of granules seen with histochemical stains within the range of 400 to 1000 µg/g of liver tissue. 60 zonal distribution of copper detected, but were also found in dogs with other types of hepatic disease, suggesting a nonspecific secondary response. patterns of circulating autoantibodies found in dogs differed significantly from those found in humans with chronic liver disease. 77 in another study, serum anti-liver-membrane-protein antibody-positive dogs (1 : 40 to >1 : 1600) had higher alt activity, total bilirubin concentration, and more severe hepatic lesions than did anti-liver-membraneprotein antibody-negative dogs, but it was not determined whether autoantibodies were primary or secondary. 78 cd3+ lymphocytes are the most common hepatic lymphoid cells in dogs with chronic hepatitis and are associated with hepatic necrosis, 79-81 but also account for 54% of hepatic lymphocytes in normal dogs. 82 historical and physical examination findings in dogs with chronic hepatitis are indicative of chronic hepatic disease, and are similar regardless of the underlying cause. signs are often initially vague and nonspecific, such as anorexia, lethargy, vomiting, diarrhea, weight loss, pu, and pd. 4, 32 with increased severity of hepatic dysfunction, signs of overt liver failure develop, such as ascites, jaundice, and he. the presence of ascites and he suggest that chronic hepatitis has progressed to cirrhosis, and ascites is a negative prognostic indicator. 4, 42 melena associated with gastroduodenal ulceration or coagulopathy is also more likely with advanced liver disease. 32 because of the large functional reserve capacity of the liver, the onset of signs may appear very recent, initially suggesting an acute rather than chronic hepatic disorder. clinicopathologic features that support chronicity include poor body condition, ascites, microhepatia, hypoalbuminemia, and histologic evidence of fibrosis. in the early (subclinical) stages, dogs are asymptomatic and only identified by biochemical screening for liver enzyme elevations. increased serum alt activity, reflecting ongoing hepatic injury, is reported in 75% to 95% of dogs with chronic hepatitis. 4,7 serum alt activity may exceed 10 times the upper normal limit. 7 periods of normal alt activity may reflect cyclic disease activity and the varying severity of necrosis. 7 serum alp activity is also commonly increased, but the magnitude of the increase is generally lower than seen with alt activity. when chronic hepatitis advances to cirrhosis, liver enzyme activity may be normal, indicating decreased viable parenchymal mass. 7 abnormalities in biochemical tests such as hyperbilirubinemia, hypoalbuminemia, decreased blood urea nitrogen (bun), hypoglycemia, and increased sba indicate hepatic dysfunction and a more advanced stage of disease. 32 hyperglobulinemia can be seen in dogs with cirrhosis, but it remains to be determined whether this corresponds with increased autoantibodies as occurs in humans with autoimmune hepatitis, or whether it reflects nonspecific systemic antibody production in response to antigens from the portal blood which bypass the liver through acquired psss. 83 mild nonregenerative anemia may be a reflection of chronic disease. regenerative anemia can occur from blood loss secondary to a coagulopathy or bleeding gi ulcers. copper-associated hemolytic anemia has only been documented in bedlington terriers. abnormal hemostatic parameters (prolonged aptt and pt) are indicative of severe hepatic dysfunction or dic. a prolonged pt and thrombocytopenia may be negative prognostic indicators. 16, 37 analysis of ascitic fluid reveals a transudate or modified transudate. 32, 42 abdominal radiographs are unremarkable except when advanced stages of disease are accompanied by microhepatia or ascites. in the kg every 48 hours is most often recommended for treatment of canine chronic hepatitis. complications of corticosteroid therapy include gi bleeding (which may precipitate he), secondary infections, iatrogenic cushing disease, and worsening of ascites. dexamethasone (0.2 mg/kg po q24h) may be preferred in dogs with ascites or edema, because it lacks mineralocorticoid activity, which could exacerbate these signs. prednisone is often used in combination with azathioprine, especially if side effects of prednisone become objectionable. azathioprine is an antimetabolite with antiinflammatory and immunemodulating effects, and is commonly used in combination with prednisone in humans with autoimmune hepatitis. 43 the dose of azathioprine in dogs is 1 to 2 mg/kg/day po every 24 hours for 1 to 2 weeks, then tapered to every 48 hours for maintenance therapy. prednisone (0.5 to 1.0 mg/kg/day) is given on the alternate days. because azathioprine may cause bone marrow suppression and acute hepatotoxicity, the complete blood count and biochemical profile should be monitored. antiinflammatory agents and immunosuppressive drugs are discussed in more detail in chapters 38 and 49, respectively. because glucocorticoids increase liver enzyme activity (especially serum alp activity), response to therapy is best evaluated by a followup liver biopsy performed 3 to 6 months after starting therapy. if glucocorticoid therapy is eventually discontinued, clinical and biochemical parameters should be periodically monitored to detect a relapse. dogs with hepatic copper concentrations greater than 1500 µg/g, should be treated with the copper chelator penicillamine at a dose of 10 to 15 mg/kg po every 12 hours. 57 treatment usually requires months to years to produce significant decreases in hepatic copper. a mean decrease in copper of approximately 1500 µg/g was achieved in bedlington terriers treated for 6 months. 86 dogs with secondary copper accumulation appear to respond more rapidly, possibly because hepatic copper content is lower in these breeds. 86 doberman pinschers with subclinical hepatitis treated with penicillamine for 4 months had a mean decrease in copper from 1036 µg/g to 407 µg/g. 87 penicillamine has additional effects beyond copper chelation, which may be beneficial in dogs with chronic hepatitis, including inhibition of collagen deposition, stimulation of collagenase activity, immunosuppression, and immunomodulation. 54 common side effects of penicillamine therapy include anorexia, nausea, and vomiting, which can be minimized by giving the medication with a small amount of food. the copper chelator, trientine (10 to 15 mg/kg po q12h), is also effective for reducing hepatic copper concentrations. 86 it has fewer side effects than penicillamine and is effective in dogs with hemolytic anemia caused by copper release from necrotic hepatocytes. iatrogenic copper deficiency (microcytosis and hepatic dysfunction) has been described in a dog treated with long-term copper chelation therapy (trientine) and a copper-restricted diet. 88 decisions on duration of chelator therapy are based on followup liver biopsies with periodic monitoring of quantitative hepatic copper content. oral zinc salts can be used for maintenance therapy after copper chelation, or as initial therapy in dogs with hepatic copper concentrations between 400 µg/g dry weight and 1500 µg/g dry weight. zinc supplementation is typically used in conjunction with dietary copper restriction. zinc decreases intestinal copper absorption by inducing the intestinal copper-binding protein, metallothionein, within intestinal epithelial cells, which preferentially binds dietary copper and prevents its absorption. zinc acetate is given at a dose of 100 mg po bid for 2 to 3 months, then at a maintenance dose of 50 mg po bid. 89 a minimum of 3 months of zinc therapy is required before copper uptake from the intestinal tract is blocked. 89 accumulation should be noted, as copper accumulation starting in the centrilobular area is more likely with a primary metabolic defect in copper metabolism. 54 copper granules can also be detected on cytology of hepatic aspirates or impression smears stained with rhodanine or rubeanic acid. quantitative analysis for copper, by atomic absorption analysis on fresh hepatic tissue, is the definitive method to document increased hepatic copper content. needle core biopsy specimens may not be reliable for metal analysis, as copper and iron values are consistently lower in needle core versus wedge biopsy samples. 84 formalin-fixed tissues should be avoided, because formalin may contain copper or leach copper from the tissue. 57 hepatic copper can be reliably determined retrospectively on deparaffinizedarchived liver biopsy specimens. 84 once chronic hepatitis has been confirmed, a careful consideration of known causes of chronic hepatitis is essential (see table 61 -5) . findings that would support a primary metabolic defect in copper metabolism include a previously recognized breed predisposition, copper accumulation that precedes cholestasis or inflammation, centrilobular (zone 3) distribution of copper, histochemical score for copper of 3+ or greater, or quantitative copper measurements that exceed 2000 µg/g dry weight. 54, 57, 66 special stains of the liver should be requested to evaluate for infectious agents such as leptospirosis; serum antibody titers for leptospirosis may be indicated. a history of chronic drug therapy should be sought, especially long-term anticonvulsant therapy or other drugs listed in table 61 -5. recommendations for treatment of chronic hepatitis are empirical at best, because of the lack of controlled therapeutic studies on a well-defined population of dogs with this disorder. if a probable cause or category of injury can be determined, then specific treatment is directed at the primary etiology, for example, discontinuation of phenobarbital, treatment of leptospirosis, or chelation of hepatic copper with penicillamine. in most cases, specific therapy will be unavailable. treatment of chronic hepatitis in dogs has traditionally centered on the use of corticosteroids, presuming that, as in humans with the autoimmune form of hepatitis, immunologic mechanisms (inflammatory cells and mediators, local cytokines), contribute to hepatic inflammation and progression to cirrhosis. corticosteroids have antiinflammatory, immune-modulating, and antifibrotic effects, which may be beneficial in chronic hepatitis. a large retrospective study suggested that corticosteroid therapy at initial immunosuppressive doses (2.2 mg/kg/day; eventually tapered to 0.6 mg/kg/day) improved survival in dogs with chronic hepatitis. 41 however, many concurrent drugs were given and, undoubtedly, a heterogeneous group of disorders were included under the diagnosis of "chronic hepatitis." corticosteroid therapy appears warranted in dogs with histologic features of active inflammation and persistent increases in serum liver enzyme activity, for which known causes of chronic hepatitis (including infectious causes) have been excluded. 41, 85 glucocorticoid therapy is not indicated for treatment of chronic hepatitis caused by drug therapy, infectious agents, or primary hepatic copper accumulation. the optimal dose and duration of corticosteroid therapy for treatment of canine chronic hepatitis is unknown, including whether immunosuppressive doses are required, or whether lower, anti-inflammatory levels would suffice. 76 even in humans with autoimmune hepatitis, immunosuppressive doses of corticosteroids may not be required. 43 prednisone (or prednisolone) at an initial dose of 1 to 2 mg/kg/day po and then gradually tapered to 0.5 to 1.0 mg/ is correlated with the amount of hepatic copper. hepatic injury is believed to occur when progressive copper accumulation exceeds the storage capacity of the lysosomes; copper is released to the cytoplasm, damaging mitochondria, initiating lipid membrane peroxidation, and eventually causing cell death. affected dogs can be asymptomatic (in the early stages) or show signs of acute hepatic necrosis, chronic hepatitis, or cirrhosis. 54 in young dogs, copper accumulates in centrilobular (zone 3) hepatocytes and is sequestered in hepatic lysosomes. during this first stage, copper concentrations are between 400 and 1500 µg/g, dogs are asymptomatic, biochemical testing is within normal limits, and liver biopsy findings are unremarkable. in the second stage, when hepatic copper concentrations are between 1500 and 2000 µg/g, copper granules are also found in midzonal (zone 2) and periportal (zone 1) hepatocytes. although dogs are still asymptomatic, focal hepatic inflammation (centrilobular mixed cell foci, with necrotic hepatocytes, lymphoplasmacytic inflammation, and copper-laden macrophages) is seen on biopsy, and increased serum alt activity reflects hepatocellular injury. in the most advanced stage, when hepatic copper concentration exceeds 2000 µg/g, morphologic changes reveal chronic hepatitis that may progress to cirrhosis, and clinical and biochemical evidence of liver disease become apparent. clinical signs include anorexia, lethargy vomiting, and weight loss. with progression to cirrhosis, findings of jaundice, ascites, and he may develop. biochemical findings vary with the stage of disease. increased serum alt activity is the most sensitive laboratory indicator, although findings will be normal in young dogs in stage i, because of the lack of hepatic inflammation. other serum biochemical abnormalities typical of chronic hepatic dysfunction eventually develop. in some cases, acute hepatic necrosis and alf occur. hepatocellular necrosis may be associated with release of copper from necrotic hepatocytes, resulting in hemolytic anemia. during episodes of hemolysis, plasma copper levels are increased; other findings include low packed cell volume, hemoglobinemia, and hemoglobinuria. liver biopsy and quantitative analysis of hepatic copper concentrations is required for definitive diagnosis and staging of the disease. serum copper or ceruloplasmin concentrations are not helpful to make a diagnosis. 57 liver biopsies should be performed in all bedlington terriers considered for breeding, in order to identify and remove affected dogs from breeding programs. screening of asymptomatic dogs with a liver biopsy at 6 months and 15 months of age can determine if an affected dog is homozygous or heterozygous (a carrier). 15 affected dogs (both homozygous and heterozygous) typically have increased hepatic copper by 6 months of age. however, copper concentrations in dogs who are carriers (heterozygous) return to normal by 1 year of age, whereas copper concentrations in homozygous dogs continues to increase. 57 selective breeding programs in the netherlands has decreased the prevalence of bedlington terrier copper-associated liver disease from 46% (1976) (1977) (1978) (1979) (1980) (1981) (1982) (1983) (1984) (1985) (1986) to 11% (1990-1997) . 92 dna testing of bedlington terriers is available from vetgen (www.vetgen.com). this assay evaluates a linkage-based dna marker (co4107, allele 2) that is located in the chromosome close to the gene for copper toxicity. 93 the test can identify normal, affected, and carrier dogs with 90% accuracy. however, the marker can only be relied on for diagnosis of the genetic status of an individual dog when supported by a pedigree study. 93, 94 significant discrepancies were reported in 22 bedlington terriers, when comparing results of liver biopsy and the dna marker. 94 this may be attributed to different subpopulations of bedlington terriers with variations in the disease-causing mutation of the commd1 gene or a second mutant copper gene could play a role. 94 liver biopsy for quantitative zinc administration should be separated from meals by at least 1 hour and should theoretically not be prescribed at the same time as a copper chelator. 54 serum zinc concentrations should be monitored to achieve a level of 200 to 400 µg/dl. zinc concentrations greater than 500 µg/dl may be toxic (hemolytic anemia). low-copper diets are most beneficial for managing early (subclinical) copper accumulation in dogs affected with primary metabolic defects in hepatic copper metabolism. feeding a low-copper diet decreases hepatic copper content in labrador retrievers with subclinical copper-associated liver disease. 90 additional treatment with zinc does not appear to increase the copper-lowering effect of dietary management. 90 foods containing large amounts of copper (liver, other organ meats, shellfish, eggs, bean/legumes, chocolate, nuts, cereals, and copper-containing vitamin supplements) should be avoided. because oxidative stress is a significant mechanism for hepatic damage associated with copper accumulation and necroinflammatory hepatic disorders, 66,91 antioxidant therapy with vitamin e (10 to 15 iu/kg/day), or same (20 mg/kg/day) has been advocated. 9 other cytoprotective agents such as silymarin (milk thistle) and ursodeoxycholic acid may also be beneficial. 9 chapters 40 and 46 discuss cytoprotective agents used in the treatment of hepatobiliary disease in detail. when end-stage cirrhosis is diagnosed, treatment is mainly supportive, as cirrhosis itself is essentially irreversible. measures should also be instituted to control the complications of chronic liver failure, such as ascites, he, gastroduodenal ulcers, and coagulopathy, which are discussed in more detail in "complications of liver disease" section. the response to treatment of chronic hepatitis is variable, which is not unexpected as it is likely a heterogeneous group of diseases. some dogs can eventually be taken off medication and remain in remission, but more often, therapy must be continued indefinitely. other dogs fail to respond, especially those that have advanced disease with cirrhosis. 4, 32 in one study, the estimated median survival time in 42 dogs with idiopathic chronic hepatitis was 18 months (range: 0 to 49 months) and in 23 dogs with copper-associated chronic hepatitis it was 17 months (range: 7 to 27 months). 4 mean survival time in 20 dogs with cirrhosis was 1 week. 32 bedlington terriers develop chronic hepatitis and cirrhosis from copper toxicity, as a consequence of an inherited metabolic defect resulting in impaired biliary copper excretion. 23, 57, 76 the disorder is transmitted by autosomal recessive inheritance. the gene responsible for this metabolic disorder is commd1, which is different than that described for copper toxicity (wilson disease) in humans, in which the gene involved is atp7b. 64 there is no gender predilection. at one time, it was speculated that as many as 60% of the breed might be affected. 57 hepatic copper concentration in normal bedlington terriers ranges from 91 to 358 µg/g with a mean of 206 ± 56 µg/g dry weight. 23 bedlington terrier copper-associated liver disease is associated with progressive, hepatic copper accumulation (copper levels of up to 12,000 µg/g) unless treatment is instituted. the lowest hepatic concentrations of copper are found in the youngest dogs and concentrations increase with age, peaking at around 6 years. copper content usually declines thereafter in affected dogs, but not to normal. this decline may be a result of replacement of copper-containing hepatocytes by fibrous tissue or regenerative nodules that do not contain copper. the severity of hepatic disease recent efforts have focused on identification of affected doberman pinschers prior to advanced hepatic disease. in finland, a survey of 626 randomly selected, clinically healthy doberman pinschers, revealed that 8.8% of dogs had increased alt activity, and 3.4% had hepatitis (parenchymal and portal mononuclear inflammation and positive stains for copper). 99, 100 the mean age of dogs with subclinical hepatitis was 3.8 years, compared with clinically affected dogs (5.5 years). the asymptomatic period lasted an average of 19 months. the prevalence of subclinical doberman hepatitis was investigated in 106 randomly selected 3 year old doberman pinschers in the netherlands. 27 subclinical hepatitis was identified in 22 dogs (19 females and three males); hepatic copper concentration was higher in dogs with hepatitis (419 ± 414 µg/g dry weight) than those without liver disease (197 ±113 µg/g). 27 serial liver biopsies over at least a 2-year period, revealed that hepatitis persisted only in dogs with copper levels greater than 400 µg/g dry weight, and copper levels continued to increase in these dogs (939 ± 299 µg/g), supporting a relationship between copper, inflammation and hepatitis. 27 it has also been proposed that hepatic copper is incidental to chronic hepatitis in this breed, based on the findings that five of 35 doberman pinschers with chronic hepatitis had normal copper levels, and histologic changes were similar regardless of copper status. 81, 26, 75 an immune-mediated mechanism has been suggested, based on the finding that expression of mhc class ii antigens on hepatocytes of dogs with doberman hepatitis was correlated with degree of inflammation. 75 aberrant mhc class ii molecule expression on nonlymphoid cells could be a result of toxins, drugs, viral infection, or autoimmunity, and hepatocytes with mhc class ii expression might become a target as an antigen-presenting cell for cd4+ t cells. 75 dogs treated with low-dose prednisolone (0.1 to 0.5 mg/kg/day) for 4 to 5 months had significantly decreased expression of mhc class ii antigens. 75 chronic hepatitis should be suspected in any doberman pinscher (especially females) with clinical or biochemical evidence of hepatic disease. definitive diagnosis requires liver biopsy. other causes of chronic hepatitis should also be considered, since doberman pinschers appear to be at risk for drug-induced hepatitis. 71 early detection of chronic hepatitis provides the best opportunity for treatment. it has been recommended that all doberman pinschers older than 1 year of age be screened for alt activity. 99 persistent increases in alt activity suggest further evaluation including liver biopsy is warranted. the magnitude of increased alt activity is not different between subclinical and clinically affected dogs. hyperbilirubinemia is suggestive of more advanced disease. 28, 99 effective treatment for doberman pinschers with chronic hepatitis has not been established. however, a preliminary study showed that if diagnosed in the subclinical stage, treatment with penicillamine (200 mg total dose po bid for 4 months) lowered hepatic copper content and improved hepatic histopathology. 87 traditionally, antiinflammatory or immunosuppressive drugs such as prednisone with or without azathioprine have been instituted. the efficacy of this treatment remains to be determined but generally, the response is poor if dogs are presented in advanced stages of liver failure. the use of ursodeoxycholic acid (15 mg/kg po bid) deserves special consideration in this chronic cholestatic disorder, but has not yet been objectively evaluated. treatment of copperassociated hepatitis in doberman pinschers with advanced disease is usually unsuccessful. most dogs die within weeks to months. the prognosis appears more favorable if the disease is detected in the early stages, but the optimal therapeutic regimen remains to be determined. copper and morphologic examination remain the best option for diagnosis in the individual dog. 94 a database for certification of bedlington terriers is maintained on the web site (www.caninehealthinfo.org) of the canine health information center, which is sponsored by the akc/canine health foundation and the orthopedic foundation for animals. affected bedlington terriers who are asymptomatic (copper >400 µg/g dry weight but less than 1500 µg/g dry weight) should have dietary copper restriction and zinc supplementation. bedlington terriers with copper accumulation (copper >1500 µg/g dry weight) and chronic hepatitis should be treated with a copper chelator such as penicillamine or trientine. 57 early diagnosis and treatment with either zinc or copper chelators will allow most dogs to lead a normal life. 57 treatment of hemolytic anemia may require a blood transfusion. trientine dihydrochloride (but not penicillamine) may be effective in chelating circulating copper during a hemolytic episode. chapter 43 discusses copper-chelating agents in more detail. doberman pinschers are at increased risk for the development of severe chronic hepatitis and cirrhosis. 26, 28, 81, 95 doberman hepatitis accounted for 4% of all deaths in a dutch population of 340 dobermans. 96 middle-aged (4 to 7 years) female dogs are at increased risk, but males also may be affected. although a hereditary mechanism is suspected, the pathogenesis of this disorder is unclear. 28 copper accumulation appears to be associated with hepatic damage, but the pathogenesis is different from the bedlington terrier disorder. 27 immune mechanisms may also play a role. 75, 81 many doberman pinschers are diagnosed in the advanced stages of hepatic failure. 26 evidence of excessive bleeding (gingival bleeding, epistaxis, and melena) are common. signs of he often predominate in the terminal stages. common physical examination findings include ascites, jaundice, and weight loss. splenomegaly (associated with portal hypertension) is common. laboratory findings included increased alt and alp activity, hyperbilirubinemia, hypoalbuminemia, hyperammonemia, coagulopathy, and thrombocytopenia. 26 typical histologic lesions include portal inflammation (lymphocytes, plasma cells, and macrophages), piecemeal necrosis, bridging necrosis, bile duct proliferation, and portal fibrosis. hepatic copper concentrations are increased in most affected dogs and are typically between 1000 and 2000 µg/g dry weight, although values as high as 4700 µg/g have been reported. 28, 81 the significance of the increased hepatic copper concentration in this breed remains controversial. copper accumulation was originally attributed to secondary mechanisms, as doberman pinschers with advanced disease (chronic hepatitis and cirrhosis) have biochemical and histologic evidence of cholestasis. however, evaluation of affected dogs in the early (subclinical) stage, reveals that copper accumulation precedes cholestasis, 27, 95 and decreased biliary excretion of radiolabeled copper has been documented. 97 the hepatic distribution of copper and location of inflammation varies with the stage of disease. in the early stages, the copper (and focal inflammation) is centrilobular. 27, 81, 95 as the disorder progresses, copper accumulation and inflammation are more pronounced in periportal regions and areas of bridging necrosis. 95 although copper appears to be related to the hepatic inflammatory reaction, copper levels are typically less than 2000 µg/g dry weight, the minimum amount of copper that is believed to cause hepatocellular injury in bedlington terriers and west highland white terriers. 60,61 a primary copper retention disorder has been proposed, 28 but the genes associated with bedlington copper toxicity (commd1) and wilson disease in humans (atp7b) have been excluded. 98 same, milk thistle), and symptomatic therapies that are not designed to lower hepatic copper. 37 feeding a low-copper diet to 20 labrador retrievers with hepatic copper accumulation (seven of 20 dogs had varying degrees of hepatitis) was effective in decreasing hepatic copper concentrations, but severity of inflammation remained unchanged. 90 additional treatment with zinc did not appear to increase the copper-lowering effect of dietary management. 90 long-term survival appears variable. 36, 37 dogs who died within 2 months of diagnosis were more likely to have a prolonged pt and thrombocytopenia. 37 dalmatians are reported to have acute hepatic necrosis, chronic hepatitis, and cirrhosis associated with increased hepatic copper concentrations. 35, 102 cholestasis is not a prominent biochemical or histologic feature until later in the disease, suggesting that hepatic copper accumulation is more likely to be caused by a familial metabolic disorder rather than secondary to altered hepatic biliary copper excretion. most dogs presented initially with acute gi signs (anorexia, vomiting, and diarrhea). biochemical findings revealed markedly increased alt activity with lesser increases in alp activity. hyperbilirubinemia and hypoalbuminemia were seen with advanced disease. glucosuria (in the absence of hyperglycemia) and proteinuria were identified in some dogs. ultrasound findings were usually unremarkable. liver biopsy revealed piecemeal necrosis, bridging fibrosis, and inflammation (predominantly lymphocytes or neutrophils). the mean hepatic copper level was 3197 µg/g dry weight (normal <400 µg/g dry weight) with a range of 754 to 8390 µg/g dry weight. in five of nine dogs, copper exceeded 2000 µg/g. rapid progression of the disease was characteristic. copper chelation therapy may be beneficial if diagnosed before advanced liver disease occurs. chronic hepatitis and cirrhosis associated with hepatic copper accumulation (800 to 2200 µg/g dry weight) in genetically related skye terriers has been described. 34 in the early stages, copper accumulation is absent, and biopsy findings indicate hepatocellular degeneration with cholestasis and mild inflammation. chronic lesions are associated with intracanalicular cholestasis, chronic hepatitis, and cirrhosis. skye terrier hepatitis is speculated to be a disorder of disturbed bile secretion with subsequent accumulation of copper. american and english cocker spaniels have an increased incidence of chronic hepatitis and cirrhosis. 29, 30 the cause is unknown. hepatic copper accumulation does not appear to be a consistent feature. it is unclear whether accumulation of α 1 -antitrypsin in hepatocytes, a well-recognized cause of cirrhosis in humans, is important in the pathogenesis. 31 male cocker spaniels (average age: 5 years) are at increased risk. 29, 30 despite the chronicity and severity of the underlying hepatic lesions, most affected dogs have a short duration of clinical illness, usually less than 2 weeks. ascites is the most consistent presenting complaint. profound hypoalbuminemia (mean: 1.7 g/dl) is a consistent laboratory finding. total serum bilirubin concentration is normal or only mildly increased, supporting that cholestasis is not a key feature of the disorder. ascitic fluid analysis is consistent with a transudate or modified transudate. on liver biopsy, hepatic lesions are consistent with chronic hepatitis and cirrhosis. treatment of cocker spaniels with chronic hepatitis consists of general supportive therapy for the complications of liver failure. corticosteroid therapy prior to progression to cirrhosis may west highland white terrier west highland white terriers are at increased risk to develop chronic hepatitis and cirrhosis. 25, 76, 101 males and females are equally affected. the mode of inheritance for the familial copper-associated disorder has not been established. 24 decreased biliary excretion of radiolabeled copper occurs in affected dogs. 89 centrilobular (zone 3) copper accumulation occurs during the first year of life, but rarely exceeds 2000 µg/g dry weight. 24 in contrast to the bedlington terrier, west highland white terriers do not continuously accumulate copper over their lifetime; in fact, copper content may actually decrease with time. 56 in one report of 395 clinically normal west highland white terriers, most dogs had hepatic copper levels between 100 and 1500 µg/g dry weight with normal liver biopsies. 25 in west highland white terriers with chronic hepatitis, histologic lesions include multifocal hepatitis, subacute bridging necrosis, massive necrosis, and cirrhosis. 25 the relationship of hepatic copper to chronic hepatitis in the west highland white terriers is unclear. there appears to be at least two types of chronic hepatitis. 25 some dogs have copper-associated hepatitis with elevated copper content (>2000 µg/g) and multifocal centrilobular hepatitis. copper concentrations do not usually exceed 3500 µg/g dry weight. lesions of chronic hepatitis can also be seen in the absence of substantial copper accumulation, and have been described as "idiopathic chronic hepatitis." 25 quantitative copper analysis is necessary to determine if copper accumulation is a significant (>2000 µg/g dry weight) contributing factor. if chronic hepatitis and cirrhosis are associated with increased hepatic copper content (>2000 µg/g dry weight), treatment for hepatic copper accumulation should be instituted. mature west highland white terriers with chronic hepatitis and less than 2000 µg/g dry weight of copper may not require chelation therapy, as hepatic copper accumulation is not continuous throughout life. other therapeutic options for treatment of idiopathic chronic hepatitis, such as glucocorticoids, should be considered in these dogs. labrador retrievers are at increased risk for chronic hepatitis. 29, 37 age at presentation ranges from 2.5 to 14 years, with an average age of 7 to 9 years. [36] [37] [38] a female predisposition was noted in two studies, 36, 38 whereas in another study, males and females were equally affected. 37 most affected dogs have increased hepatic copper, which has been described as centrilobular (zone 3) or diffuse. [36] [37] [38] copper concentrations exceeded 2000 µg/g dry weight in 10 of 12 dogs (mean copper: 3369 µg/g; range: 2375 to 4972; reference interval: 120 to 400 µg/g). 38 most dogs also had elevated iron levels with a mean of 4117 µg/g (reference interval: 350 to 1750). 38 a genetic basis is suspected, based on the finding of increased copper concentrations in asymptomatic related dogs, but the genetic defect remains to be determined. 36 a retrospective survey of hepatic copper content in labrador retrievers during two time periods (1980-1997 and 1998-2008) , revealed significantly higher copper concentrations in the more recent period both in dogs with chronic hepatitis and in control dogs; no difference in age or gender was noted. 68 it was speculated that increased hepatic copper might reflect increased dietary copper bioavailability, because of pet food industry recommendations to replace cupric/cuprous oxide in feed formulations. 68 treatment with penicillamine (15 mg/kg po q12h) appears to be effective in decreasing hepatic copper content and inflammation. 36, 90 however, some dogs appear to respond to immunosuppressive (prednisone, azathioprine), supportive (ursodeoxycholic acid, clinical features of cirrhosis in dogs include ascites (portal hypertension, hypoalbuminemia), he (intrahepatic and extrahepatic portosystemic shunting of blood), and evidence of decreased hepatic function (hypoalbuminemia, increased sba, coagulopathy, hyperbilirubinemia). findings on hepatic ultrasonography (small nodular liver, splenomegaly, and acquired psss) are suggestive for cirrhosis, but liver biopsy is required for confirmation. because cirrhosis is essentially irreversible, treatment is mainly supportive, emphasizing measures that control complications of severe generalized liver failure, such as ascites, encephalopathy, gastric ulcers, coagulopathy, and infection (see "complications of liver disease" section). if clinical signs of liver failure are already present, the prognosis is poor. prevention of fibrosis, an important long-term goal, is best achieved by early specific treatment directed at the probable cause of injury (e.g., discontinuing a suspect drug, penicillamine for copper-associated liver disease, antiinflammatory drugs for idiopathic chronic hepatitis, surgical relief of extrahepatic biliary obstruction). many therapeutic agents used for treatment of liver disease, such as penicillamine, prednisone, azathioprine, milk thistle, ursodeoxycholic acid, and zinc, have potential antifibrotic properties, 9 and are discussed in more detail in other chapters. colchicine, a microtubule assembly inhibitor which increases collagenase activity, has been recommended for treatment of hepatic fibrosis, but its effectiveness in dogs has not been critically evaluated. the recommended dose in dogs is 0.025 to 0.03 mg/kg/day po. reported side effects include nausea, vomiting, and diarrhea. bone marrow toxicity and myoneuropathy have been reported in humans. lobular dissecting hepatitis is a specific histologic form of cirrhosis seen in neonatal or young adult dogs. 2, 4, [110] [111] [112] it is suggested to be a nonspecific response to a variety of hepatic insults. 111 the age at presentation is younger than for dogs with either acute or chronic hepatitis. 4 in 21 affected dogs, the median age was 11 months, with 12 dogs (54%) being 7 months or younger. 4, 110 females appear to be at increased risk. 4, 111 lobular dissecting hepatitis may occur in an isolated dog or in groups of dogs from the same litter or kennel. 111 standard poodles may be at increased risk. 110, 112 clinical features are those of advanced hepatic failure and portal hypertension. 111 the most consistent clinical finding is ascites. liver enzymes are typically increased and hypoalbuminemia and increased sba concentrations are common. 4, 111 liver biopsy is required for diagnosis and to differentiate it from other types of chronic hepatitis and cirrhosis. the lesion is characterized histologically by lobular hepatitis: inflammatory cells (lymphocytes, plasma cells, macrophages, and neutrophils) are scattered throughout the hepatic lobule rather than concentrated in periportal regions. bands of collagen and reticulin fibers dissect around single or small groups of hepatocytes and disrupt hepatic lobular architecture. 111 copper stains are negative or moderately positive, consistent with secondary copper accumulation. specific treatment has not been reported, but general measures for management of chronic liver failure are appropriate. 4 in a small group of dogs with lobular dissecting hepatitis, the mean survival time was approximately 3 months, which was significantly shorter than for dogs with acute or chronic hepatitis. 4 infection of the liver is an important cause of hepatic disease in dogs and cats. 113 the liver may be the primary target of infection (e.g., infectious canine hepatitis, bacterial cholangitis, hepatic abscess) or be beneficial. the prognosis is poor and most dogs die within a month of diagnosis. a recent report described seven american cocker spaniels with histologic features resembling lobular dissecting hepatitis. 33 males and females were equally affected. in contrast to previous reports of hepatitis in cocker spaniels, most dogs in this study improved with corticosteroid therapy. 33 english springer spaniel a preliminary report has described chronic hepatitis in 34 english springer spaniels from norway and the united kingdom. 39 female dogs were overrepresented. copper does not appear to play a role. the prognosis appears to be poor, with most dogs dying 4 to 7 months after diagnosis. 39 hepatic cirrhosis (end-stage liver disease), is characterized by fibrosis, regenerative nodules that alter liver architecture and intrahepatic (microscopic) psss (see figure 61 -19) . 2 hepatic fibrosis is not synonymous with cirrhosis. cirrhosis is common in dogs but less so in cats. 2 cirrhosis can result from postnecrotic scarring after acute massive necrosis or from chronic hepatic injury caused by a variety of insults such as infection (e.g., leptospirosis, cav-1), hepatotoxins (e.g., copper, phenobarbital, aflatoxin), inflammation (chronic hepatitis), or hypoxia. the common denominator is hepatocyte death, which leads to repair by fibrosis and nodular regeneration. when cirrhosis is fully developed, the histologic features of the original inciting injury often are obscured by the cirrhotic changes. substantial hepatic fibrosis (without "cirrhosis") can be seen with long-standing extrahepatic biliary obstruction, noninflammatory fibrosis, congenital hepatic fibrosis (a disorder of biliary system development), and congenital portal vein hypoplasia. 2,103-105 a unique form of macronodular cirrhosis, characterized by noninflammatory regenerative hyperplastic nodules and diffuse vacuolar hepatopathy, is seen in dogs with hepatocutaneous syndrome (superficial necrolytic dermatitis). hepatic fibrosis was once considered irreversible, but is now recognized to be a dynamic process, which exists in a balance between synthesis and degradation. a better understanding of the underlying mechanisms may provide potential therapeutic targets. 106 the major fibrogenic cell in the liver is the activated hsc (ito cell, vitamin a-storing cell), which is normally present in the perisinusoidal space. 106, 107 under the influence of fibrogenic stimuli (inflammation and the immune response, oxidative stress, apoptosis, hypoxia, steatosis), the hsc is activated to a myofibroblast, which produces collagen and other extracellular matrix (ecm) constituents. 106 the cytokine, tgf-β, appears to play a central role in fibrogenesis in humans and dogs. 106, 108 perisinusoidal fibrosis decreases the permeability of normal sinusoids, impairing metabolic exchange between hepatocytes and sinusoidal blood further compromising hepatic function. 106 excess fibrous tissue also limits the ability of vessels and sinusoids to distend, resulting in increased resistance to hepatic blood flow and portal hypertension. when fibrotic septae become vascularized, these microscopic communications (between portal vein or arterial artery and hepatic vein) lead to portosystemic shunting of blood. reversal of hepatic fibrosis and improvement in liver function can occur, especially if the underlying cause of injury is treated or removed. 106 examples in human medicine include antiviral drugs for hepatitis b and hepatitis c and prednisone for autoimmune hepatitis. although fibrosis is potentially reversible, cirrhosis for all practical purposes is not, because of the accompanying architectural changes and psss. 109 these ocular complications occur in approximately 20% of naturally infected dogs, and are caused by corneal endothelial damage and antigen-antibody complexes. ich should be suspected in any young, unvaccinated dog with evidence of alf. ich must be differentiated from diseases with similar clinical signs, such as canine distemper, parvoviral enteritis, and hepatotoxicity. abnormalities on the leukogram are common and vary with the clinical stage of infection. during viremia, neutropenia and lymphopenia are often present. neutropenia is also a common a feature of canine parvovirus, a much more prevalent disease of puppies. rebound lymphocytosis and neutrophilia occur in the recovery stages of ich (7 days after infection). biochemical findings are characteristic of acute hepatic necrosis and include increased serum alt and alp activity, and abnormal liver function tests. hyperbilirubinemia is a less-consistent finding. hypoglycemia may complicate the terminal stages of the disease. coagulation parameters are consistent with dic. other potential findings include proteinuria secondary to glomerular damage, abdominal fluid consistent with an exudate, and an increase in protein and mononuclear cells in the cerebrospinal fluid. the clinical diagnosis of ich is usually suspected on the basis of age, vaccination history, clinical signs, and laboratory findings, and is confirmed by liver biopsy or necropsy findings. additional diagnostic tests that are used less frequently include serologic testing, virus isolation, and direct immunofluorescence. therapy for alf caused by ich is primarily supportive care and control of complications that frequently occur such as dic, he, and hypoglycemia. the prognosis in dogs with ich depends on the severity of hepatic necrosis and the incidence of serious complications such as dic. hepatic regeneration and recovery is possible unless widespread coagulation necrosis destroys entire lobules. ich can be effectively prevented by vaccination. canine herpesvirus causes an acute, afebrile, rapidly fatal disease in neonatal puppies (1 to 3 weeks of age). 116 hepatic necrosis is one manifestation of the widespread multiorgan necrosis and hemorrhage that occurs in this systemic viral infection. clinical signs include acute onset of depression, diarrhea, failure to suckle, crying, and abdominal pain in previously healthy puppies. other findings include petechial hemorrhages and vesicles of the mucous membranes. jaundice is rare. seizures and loss of consciousness may be present in the terminal stages, and most pups die within 24 hours of onset of clinical signs. typical gross pathologic findings include focal areas of necrosis and hemorrhage in the liver, kidneys, lungs, and serosal surfaces of the intestines. microscopically, these areas are characterized by foci of necrosis with occasional intranuclear inclusions. neonates are infected by oronasal exposure to the virus in utero or by secretions from an infected bitch or littermates. neonates are particularly susceptible, possibly because of their low body temperature and immature mechanisms for temperature regulation. the diagnosis of canine herpesvirus is primarily based on the history, physical examination, and pathologic findings. laboratory findings are inconsistent but include neutrophilia or neutropenia, and increased serum alt activity. treatment of affected puppies is generally unsuccessful because of the acute fulminant nature of the disease. maintenance of body it may be one of several organ systems involved in a multisystemic disease process such as feline infectious peritonitis (coronavirus), toxoplasmosis, or histoplasmosis (see table 61 -4). infectious agents can be associated with widespread invasion of organs with a large mononuclear phagocytic component, including the liver, spleen, lymph nodes, and bone marrow, although clinically significant liver disease is uncommon. liver biopsy can be diagnostically useful for identification of these organisms in infected animals. etiology infectious canine hepatitis (ich) caused by cav-1 has long been recognized as a cause of acute hepatic necrosis in dogs. 114 this virus is genetically and antigenically distinct from cav-2, a cause of infectious canine respiratory disease. the incidence of clinical disease caused by cav-1 is now very low because of effective vaccination procedures. neutralizing antibodies to cav-1 are also found in mature, unvaccinated dogs, suggesting that natural exposure to the virus is widespread. cav-1 has a special tropism for vascular endothelial cells and hepatocytes. 114 dogs with sufficient immunity (neutralizing antibodies >1 : 500) do not develop clinical signs of disease. susceptible dogs (titer <1 : 4) develop widespread centrilobular to panlobular hepatic necrosis, which is often fatal. distinctive intranuclear inclusions are present in hepatocytes and the endothelium of other tissues. experimentally, dogs with an intermediate titer (between 1 : 16 and 1 : 500) develop chronic hepatitis that can progress to cirrhosis. 115 whether cav-1 is a significant cause of chronic hepatitis under natural conditions is unknown. cav-1 antigen was demonstrated in formalinfixed liver sections from five of 53 dogs with various naturally occurring hepatic inflammatory lesions, suggesting that cav-1 may play a role in spontaneous chronic hepatitis. 46 other attempts to identify cav-1 in dogs with chronic hepatitis have been negative. 44, 47 clinical examination ich is seen most commonly in unvaccinated dogs younger than 1 year of age. clinical signs vary with the stage of disease. dogs that are peracutely ill do not have clinical evidence of hepatic disease but simply become depressed and moribund, and die within a few hours. dogs with a more extended clinical course (5 to 7 days) have signs associated with acute hepatic necrosis that include vomiting, diarrhea, and abdominal pain. a hemorrhagic diathesis may occur during the viremic phase and is manifested by epistaxis, petechial or ecchymotic hemorrhages of the skin, or excessive bleeding from venipunctures. failure of the liver to clear activated clotting factors and impaired hepatic synthesis of clotting factors probably also contributes to development of dic. signs of central nervous system (cns) dysfunction include depression, disorientation, seizures, and coma and have been attributed to he or nonsuppurative encephalitis. common physical examination findings include fever, enlarged tonsils, pharyngitis, laryngitis, cervical lymphadenopathy, and subcutaneous edema of the head, neck, and trunk. hepatomegaly, abdominal pain, and abdominal effusion can occur. jaundice is rare but can develop in dogs that survive the acute fulminant stage of ich. an uncomplicated clinical course lasts approximately 5 to 7 days before recovery begins. unilateral or, less frequently, bilateral corneal edema and anterior uveitis ("hepatitis blue eye") are complications that may become evident during the recovery period. diagnosis of fip should be supported by cytologic or histologic evidence of pyogranulomatous inflammation. the currently recommended "gold standard" for fip diagnosis is immunohistochemistry performed on effusions or lesions containing infected macrophages. 117 the prognosis for recovery is poor. etiology canine leptospirosis is caused by leptospira interrogans sensu lato, with at least 10 serovars appearing to have clinical significance in dogs. 118 serovars canicola and icterohemorrhagica have been included in vaccines for more than 30 years and the incidence of clinical disease from these serovars has decreased accordingly. an epidemiologic shift in serovars causing clinical disease has since occurred, with increasing reports of disease associated with serovars grippotyphosa, pomona, and bratislava. 118 it has been suggested that serovars icterohemorrhagica and pomona are more likely to be associated with hepatic damage. 118 however, other reports have been unable to correlate serogroups with specific clinical features. 119, 120 chronic hepatitis has been associated with serovar grippotyphosa 50 and serogroup australis. 51 reports of clinical leptospirosis in cats are rare, although antibodies to several serovars have been demonstrated. 118 pathophysiology acute renal failure is the most common clinical disease syndrome in dogs with leptospirosis. 121 the liver can also be a target organ and alf may occur concurrently in 10% to 20% of dogs with acute renal failure or independent from renal involvement. 121 with acute hepatic involvement, the liver is enlarged, friable, and yellowbrown. tissues are often markedly jaundiced. microscopic changes in the liver include intrahepatic cholestasis, liver cell dissociation, and nonspecific reactive hepatitis. 3, 122 hepatic necrosis is an uncommon histologic feature. the liver may not show striking changes, presumably because hepatic dysfunction can be caused by a toxin that produces mainly subcellular damage. organisms can be identified in tissues with a warthin-starry stain. common clinical signs include anorexia, depression, and vomiting. hepatocellular involvement is suggested by jaundice. other findings may include arthralgia or myalgia, pu, pd, fever, and dehydration. widespread petechial and ecchymotic hemorrhages of the mucous membranes, sclera, and skin are caused by thrombocytopenia and dic. the terminal stages include signs of cardiovascular collapse, shock, coma, and death. a diagnosis of leptospirosis should be considered in dogs with acute cholestatic liver disease, especially when accompanied by acute renal failure. hematologic findings vary with the stage and severity of disease. leukocytosis and left shift are frequent, but in the early stages of leptospiremia, leukopenia is more likely. thrombocytopenia can also be seen. coagulation parameters are normal unless complicated by dic. routine serum chemistry and urinalysis findings reflect involvement of the liver or kidney. serum liver enzyme activity is usually increased with hepatic involvement, and the magnitude of the increase in serum alp activity is usually greater than that of serum alt activity owing to intrahepatic cholestasis. other findings include hyperbilirubinemia, bilirubinuria, and abnormal liver function tests. an increase in bun or creatinine may result from renal failure or prerenal uremia. the urinalysis is often compatible with acute nephritis with findings of proteinuria and increased temperature (36.7°c to 37.8°c [98°f to 100°f]) may be helpful. intraperitoneal infusion of 1 to 2 ml of hyperimmune serum obtained from bitches with previously infected litters may reduce mortality rates. vaccination for herpesvirus infection is not routinely performed because of the low incidence of disease. canine acidophil cell hepatitis, which encompasses a spectrum of hepatic lesions ranging from acute and chronic hepatitis to cirrhosis and liver failure, has been reported in great britain. 48, 114 it is caused by a transmissible agent, suspected to be a virus that is distinct from cav-1, although a specific virus has never been identified. the disease is experimentally transmissible by serum or liver extracts from affected dogs. in the experimentally induced disease, acute hepatitis can progress to chronic hepatitis in the absence of clinical signs. episodic increases in serum alt activity and fever spikes correspond with histologic evidence of acute hepatitis. the liver is enlarged and friable in the acute stages, and becomes progressively smaller and nodular with chronicity. the most notable histologic feature, regardless of the stage of disease, is the acidophil cell. acidophil cells are dying hepatocytes with an angular shape, reduced volume, hyperchromatic nucleus, and strongly acidophilic cytoplasm caused by small acidophilic coalescing granules. end-stage hepatic disease is accompanied by typical findings of cirrhosis. most dogs with spontaneous disease are presented with signs of chronic hepatic failure. the duration of clinical signs can exceed 1 year. based on experimental studies, it is speculated that the early mild stages may go unrecognized until advanced hepatic disease and failure is present. biochemical findings are consistent with hepatic inflammation and necrosis, evidenced as increased serum alt activity. with advanced disease, severe hepatic dysfunction is noted. the diagnosis requires liver biopsy. recommendations for specific therapy of acidophil cell hepatitis await further information on the causative agent. supportive measures should be instituted as needed. feline infectious peritonitis (fip) is a highly fatal coronaviral infection of both domestic and wild cats. the liver is one of many organs (kidneys, spleen, pancreas, mesenteric lymph nodes, cns, uveal tract, omentum, serosal surfaces) that can be affected by widespread immune complex vasculitis and granulomatous or pyogranulomatous inflammation (see table 61 -5). 117 clinical findings in cats with hepatic involvement are nonspecific and include lethargy, depression, anorexia, dehydration, weight loss, and fever. jaundice is a common finding. extrahepatic findings include nodular renomegaly, abdominal mass (lymph node), and ascites or dyspnea (pleural effusion). ophthalmoscopic examination may detect chorioretinitis or anterior uveitis, which must be differentiated from similar ocular changes seen with the other systemic disorders that involve the liver such as lymphosarcoma, toxoplasmosis, and the systemic mycoses. serum hepatic enzyme (alp and alt) activities are usually normal or only mildly increased. mild to moderate increase in serum bilirubin concentration is common. other findings indicating hepatic dysfunction include bilirubinuria and increased sba concentrations. hyperglobulinemia, neutrophilia, and mild to moderate nonregenerative anemia are other laboratory features of fip. abdominal and pleural effusions, when present, are usually pyogranulomatous exudates with greater than 3 g/dl protein. serologic detection of a high coronaviral antibody titer may support a diagnosis of fip, but is not definitive because of its lack of specificity. the serum bile acid concentration can be markedly increased (>200 µmol/l). 124 extrahepatic bacterial infection-induced hepatic damage should be considered when evidence of cholestatic hepatopathy is found concurrently with extensive bacterial infection in other organ systems (e.g., pyometra, peritonitis) or with extrahepatic disorders likely to be associated with endotoxemia (e.g., parvoviral enteritis). associated clinical findings that would be compatible with endotoxemic crisis include shock, fever or hypothermia, hypoglycemia, neutrophilia or neutropenia with left shift, toxic changes of the neutrophils, and hyperbilirubinemia that is disproportionately increased in comparison to serum alp activity. 124 it is important to recognize that jaundice can occur secondary to extrahepatic infection from a diagnostic standpoint, so that the clinician is not misled into considering that the cause is a primary hepatic or biliary disease. in jaundiced patients with evidence of an inflammatory process, key differential diagnoses include acute pancreatitis, extrahepatic bacterial infections, and primary hepatobiliary disorders such as leptospirosis (dogs only), cholangiohepatitis, cholecystitis, ruptured gallbladder mucocele, and hepatic abscesses. specific therapy for hepatic disease is not usually required, and hepatic damage is reversible with control of sepsis. morbidity is related to the underlying disease process and not overt hepatic failure. etiology hepatotoxicity can be caused by a variety of drugs (prescription or over-the-counter), herbal and dietary supplements, or biologic toxins or chemicals (see box 61-1). 17, 126, 127 the liver is uniquely susceptible to xenobiotic substances because it is directly exposed to them following absorption from the gi tract. the liver is also vulnerable to toxic injury because it plays a central role in the metabolism of many substances. hepatic metabolism renders lipophilic substances more hydrophilic, which promotes excretion via the urine or bile. 17 the process is controlled by phase i and phase ii reactions. phase i reactions are catalyzed by the cytochrome p450 enzyme systems, which activate or detoxify (oxidize, reduce, or hydrolyze) a drug or toxin. phase i reactions may lead to generation of unstable chemically reactive intermediates, which can be toxic. phase ii reactions conjugate drugs or metabolites and produce products that are nontoxic. during biotransformation, the liver can either reduce or enhance the toxicity of the parent compound. for example, after carbon tetrachloride ingestion, the liver converts the nontoxic parent compound into toxic metabolites, which subsequently cause severe hepatocellular damage. genetic polymorphisms of phases i and ii enzymes have the potential to influence drug metabolism in the individual animal. there has been an increased awareness and recognition that drug-induced liver injury can be a significant cause of liver disease in dogs and cats (see box 61-1). this information has been gained from isolated case reports, retrospective clinical studies, and experimental studies. unfortunately, for many of these drug reactions, characterization of the clinical and pathologic features are lacking because only small numbers of affected animals have been described, and liver biopsies are not typically obtained when drug withdrawal results in clinical and biochemical improvement. it is possible that drug-induced liver injury is underrecognized in dogs and cats, as in humans, drug-induced hepatic injury accounts for more than 50% of the cases of alf in the united states, and is the most frequent reason cited for withdrawal of an approved drug from the market. 17 leukocytes, erythrocytes, and granular casts. increased serum creatine kinase activity may indicate leptospiral-induced muscle damage. leptospirosis is most easily diagnosed in the clinical setting by demonstration of a fourfold rise in serum antibody titer (microscopic agglutination test) in paired samples taken at initial presentation and 2 to 4 weeks later. the rise in titer indicates recent or active infection and differentiates a titer from previous exposure or previous vaccination. the optimum treatment regimen for leptospirosis is unknown. traditionally, intravenous ampicillin, 25 mg/kg every 6 hours (with dose reduction in dogs with renal failure), or penicillin g (25,000 to 40,000 units/kg iv q12h), has been used for initial treatment of leptospirosis. 121 doxycycline (5 mg/kg po q12h for 2 to 4 weeks), was recommended as followup therapy to eliminate organisms from renal tubules. however, doxycycline, 5 mg/kg orally or intravenously every 12 hours for 2 weeks, appears to be effective in clearing all phases of leptospiral infection and may be the most effective treatment strategy. 121 management of fluid, electrolyte, and acidbase imbalances is important supportive therapy. the prognosis generally depends on the degree of renal dysfunction and is poor when oliguria develops. c. piliforme (formerly known as bacillus piliformis), a spore-forming gram-negative bacteria, is a rare cause of multifocal hepatic necrosis and necrotizing ileitis in dogs and cats. 123 the infection is mainly opportunistic in stressed or immunocompromised animals with a predisposing disorder (e.g., canine distemper, feline panleukopenia, feline leukemia) or familial hyperlipoproteinemia in kittens. 123 clinical signs include an acute onset of anorexia, lethargy, depression, and abdominal discomfort. jaundice may be observed, especially in cats. these signs rapidly progress to a moribund state; death occurs within 24 to 48 hours. marked increases in alt activity may be detected. histopathology reveals multifocal periportal hepatic necrosis and necrotic ileitis or colitis. bacilli are best seen with special staining techniques (warthin-starry or giemsa), or methylene blue-stained impression smears of fresh tissue. organisms appear as large, slender, intracellular filamentous organisms within hepatocytes surrounding areas of necrosis and in intestinal epithelial cells. routine culture techniques are ineffective for isolation of this organism. the disease is rapidly fatal, and successful therapy has not been reported. 123 extrahepatic bacterial infection associated with sepsis and endotoxemia is an important cause of acute functional cholestatic hepatopathy. however, morbidity is generally related to the underlying infection and not overt hepatic failure. 113, 124 studies in humans and experimentally in dogs, suggest that endotoxemia and the subsequent release of cytokines induces functional changes that interrupt the transport and excretion of conjugated bilirubin. 113, 125 microscopically, hepatic lesions are often mild and nonspecific. intrahepatic cholestasis, characterized by bile canalicular plugs and bile pigment accumulation in hepatocytes, is the most consistent finding. 124 a mild periportal lymphocytic infiltrate can be seen, with scattered foci of macrophages or neutrophils, and occasional individual necrotic hepatocytes. total serum bilirubin concentrations as high as 30 mg/dl can be seen and are disproportionately high compared to the mild to moderate increases in serum alp activity. increased serum alt activity is a less consistent finding. hepatic injury caused by drugs, herbal and dietary supplements, biologic toxins, or chemicals can occur via a number of mechanisms, which influence the histologic pattern of disease. 17, 20 although hepatic necrosis is the most common histologic response, drug-and toxin-induced liver injury can also potentially mimic the full spectrum of acquired hepatic disorders, including acute and chronic hepatitis, granulomatous hepatitis, cholestatic hepatopathy, vacuolar hepatopathy (lipid or glycogen accumulation), hepatic fibrosis and cirrhosis, and venoocclusive disease. hepatic necrosis occurs when covalent binding of a drug or toxin to intracellular proteins disrupts cellular functions, or formation of drug-enzyme adducts stimulates an immunologic response (antibody-or t-cell-mediated cytotoxicity). hepatic inflammation (typically lymphoplasmacytic, but may be granulomatous or eosinophilic), suggests an underlying immunoallergic mechanism. intrahepatic cholestasis occurs when drugs or toxins interfere with hepatic transport proteins at the canalicular membrane, which interrupts bile flow. hepatic lipid accumulation results when direct damage to mitochondria disrupts fatty acid oxidation and energy production, and is the predominant hepatic lesion seen with stanozolol hepatotoxicity in cats, 132 and tetracycline in dogs and cats. 126 hepatic vacuolation caused by glycogen accumulation occurs in dogs treated with corticosteroids, and typically does not cause significant clinical evidence of hepatic dysfunction. damage to the sinusoidal epithelium can result in peliosis hepatic or venoocclusive disease. mechanisms of drug-induced liver injury (and also injury from herbal and dietary supplements) can be characterized as either intrinsic (predictable) or idiosyncratic (unpredictable) reactions. 126 intrinsic hepatotoxic reactions are dose-related and occur shortly after a consistent threshold of toxicity is reached. because intrinsic hepatotoxins predictably damage the liver in an exposed population, they can be experimentally reproduced and studied. hepatic injury is caused by a direct toxic effect of the parent compound (or a reliably generated toxic metabolite) on vital cell targets. acetaminophen is an intrinsic hepatotoxin in dogs and cats and is discussed in more detail later in this section. with intrinsic hepatotoxins, lowering the dose, rather than stopping the drug can be tried. in many cases, most such drugs or chemicals, (e.g., carbon tetrachloride, phosphorus, and chloroform), are no longer used for therapeutic purposes once their intrinsic hepatotoxicity is recognized, but accidental exposures could still occur. in contrast, idiosyncratic hepatotoxic reactions occur at therapeutic doses in only a small number of individuals in the exposed population. these reactions are unpredictable and infrequent; most individuals treated with the drug do not have a reaction, even at high doses. however, toxicity may be more pronounced at higher doses in susceptible individuals. 72, 133 examples of drugs causing idiosyncratic drug-induced liver injury in dogs and cats that have a dose-related effect are phenobarbital, itraconazole, amiodarone, and lomustine (ccnu). 134 idiosyncratic reactions are characterized by a variable latency period (5 to 90 days, but may be longer for some drugs, such as phenobarbital, ccnu, amiodarone) from initial drug ingestion to recognition of hepatic injury. because of the infrequent occurrence (approximately 1 in 100,000), the potential for hepatotoxicity may not be recognized in preclinical screening of a new drug, and cannot usually be reproduced in an experimental setting. individual differences in susceptibility to idiosyncratic drug-induced liver injury may reflect genetic differences in either (a) alternate metabolic pathways by which a drug is converted to different (potentially hepatotoxic) metabolites, (b) the ability of the individual to detoxify the toxic intermediates, (c) an underlying the center for veterinary medicine of the food and drug administration, washington, dc, maintains a registry (http://www.fda.gov/ animalveterinary/default.htm) for reporting adverse drug reactions in animals. this service has been useful to accumulate data and to alert veterinarians to suspected drug effects, including hepatotoxicity. however, because reporting of adverse drug reactions is voluntary and the information obtained may be incomplete, only subjective trends can be identified. furthermore, because mild hepatic injury may not be associated with clinical signs, these cases will not be detected unless biochemical testing is performed while the animal is receiving the drug. evaluating the incidence of druginduced liver injury in dogs and cats is further clouded by the fact that there are no pathognomonic clinical, laboratory, or biopsy findings to distinguish drug-induced liver injury from other causes of liver disease. specific drugs that have been reported to cause druginduced liver injury are listed in box 61-1. herbal and dietary supplements (herbs or other botanicals, nutraceuticals, vitamins, minerals) have the potential to cause hepatotoxicity, similar to drug-induced injury. [127] [128] [129] in humans, herbal and dietary supplements are reported to account for 10% of patients with "drug-induced" liver injury. 127 the incidence of hepatotoxicity may be underrecognized, as only a third of humans taking herbal and dietary supplements reported their use of these products to their health care provider. 127 causality is difficult to prove, because herbal and dietary supplements are often dispensed without medical supervision, fda oversight of product quality is minimal, multiple active ingredients contribute to product variability, and product contamination with hepatotoxic substances (toxic herbs or heavy metals) may occur. [127] [128] [129] drug interactions between herbal and dietary supplements and prescription medications may also occur, because medicinal plants can have effects on hepatic p450 enzyme systems. 129 the rate of dietary supplement use in dogs and cats appears to be lower than that reported for humans. 130 however, because these products are often marketed as "all natural," pet owners may assume they are safe and underreport their use to the veterinarian. reports of herbal and dietary supplement hepatic injury in animals are rare. pennyroyal oil, a volatile oil derived from plants of the labiatae family (pennyroyal, squaw mint, or mosquito plant) was associated with fatal acute hepatic necrosis in a dog after topical application for use as a flea repellent. clinical signs occurred within 1 hour after application and included vomiting, diarrhea, hemorrhage, seizures, and death. other reports include the finding of increased liver enzyme activity in dogs consuming st. john's wort, and increased alt activity and hypoglycemia after accidental ingestion of high doses of α-lipoic acid in two dogs. 129, 131 the paucity of reported hepatic reactions does not necessarily mean herbal and dietary supplements are safe, and the clinician should maintain a high level of suspicion regarding their potential toxicity. box 61-1 lists the herbal and dietary supplements that have been incriminated as causing hepatic injury in humans with potential relevance to dogs and cats. for more detailed information on hepatic injury and herbal and dietary supplements, additional sources should be consulted. [127] [128] [129] hepatic injury may also occur after exposure to a wide variety of industrial chemicals, organic solvents, pesticides, heavy metals, and biologic toxins. most information on chemical hepatotoxins is derived from experimental studies in dogs or extrapolated from information in other species. very few clinical case reports are available in the veterinary literature. isolated reports and case series of clinical liver disease in dogs associated with exposure to biologic toxins, such as aflatoxin, amanita mushrooms, blue-green algae, and cycads (sago palms) have been published. selected hepatotoxins are listed in box 61-1. increased liver enzyme activity is a common finding with hepatotoxicity. increased alt activity (more than three times the upper limit of normal, but can be as high as 100 times the upper limit), suggests hepatocellular injury (often necrosis), and is of more concern than an isolated increase in alp activity (reflecting cholestasis), although mixed patterns commonly occur. progressive increases in alt activity or those accompanied by evidence of hepatic dysfunction (hyperbilirubinemia, increased serum bile acids, coagulopathy, hypoglycemia, hyperammonemia, hypoalbuminemia) are more likely to represent serious hepatic injury. when drug-induced liver injury is suspected, the diagnostic approach is determined by the clinical presentation. if clinical signs are absent or mild, a minimum database consisting of complete history and physical examination, complete blood cell count, serum chemistry, and urinalysis should be performed. if the only abnormality detected is increased liver enzyme activity, and these increases correspond to the recent administration of a drug (especially those listed in box 61-1), the drug should be discontinued and serum biochemistries should be repeated in 10 to 14 days. in many instances, clinical and biochemical abnormalities resolve after the suspected hepatotoxic drug is discontinued and a liver biopsy is not performed. further evaluation of the liver, including sba concentrations, abdominal radiographs, ultrasonography, and liver biopsy, may be warranted if biochemical abnormalities persist, or if initial clinical and biochemical findings suggest hepatic dysfunction. with suspected drug-or toxin-induced liver disease, a liver biopsy can be helpful to (a) characterize the histologic changes (are they consistent with previously described lesions caused by this particular drug or toxin?), (b) determine the severity (focal or diffuse necrosis?) or reversibility (is cirrhosis present?) of the lesions for prognostic purposes, and (c) rule out known causes of liver disease. histologic changes secondary to drug-and toxin-induced hepatic injury are nonspecific and similar to those seen with other nondrug-related causes of acute and chronic liver disease. 126 the most common pathophysiologic response is necrosis without inflammation. 126 hepatic necrosis may be centrilobular (zone 3) or panlobular (figure 61-20) . centrilobular hepatocytes have an abundance of p450 enzymes, and are preferentially affected in drug-induced hepatotoxicity when p450 metabolism of the parent drug results in toxic metabolites. 8 drugs or toxins can also cause a variety of other hepatic lesions, such as cholestasis, lipidosis, or mild inflammation. a chronic response to injury is reflected by findings of biliary immunologic or allergic reaction, or (d) an individual's tolerance or ability to "adapt" to hepatocellular injury (mechanisms unknown) with resolution of injury despite continued medication administration. 20, 135 oral medications with substantial hepatic metabolism are more likely to be associated with adverse hepatic events in humans, presumably because of hepatic generation of reactive toxic metabolites. 136 because of the unpredictability of an idiosyncratic reaction and the low incidence of occurrence, a cause-and-effect relationship is difficult to establish. if an idiosyncratic reaction occurs, the drug must be discontinued or it could result in death of the patient. an idiosyncratic mechanism is suspected for most of the drugs that cause hepatic injury in dogs and cats. susceptibility to hepatotoxicity in humans is influenced by a number of factors such as age, sex, nutritional status, and concurrent drugs. 20 the most important factor may be the effect of genetic polymorphisms on hepatic drug metabolism. 20 in humans, preexisting liver disease does not appear to enhance susceptibility to druginduced liver injury, but impacts the patient's ability to recover. 20 this may be because drug-metabolizing enzyme systems are remarkably preserved in hepatic disease. similar information on risk factors for hepatotoxicity in dogs and cats has not been determined. however, because many toxic metabolites are normally detoxified by glutathione, some metabolites may become more toxic when hepatic glutathione stores are depleted (e.g., animals with preexisting chronic necroinflammatory and cholestatic liver disease). 126 a breed predisposition has been suggested for doberman pinschers (sulfonamides, amiodarone, diethylcarbamazine/oxibendazole) and labrador retrievers (carprofen), which may be a reflection of a genetic predisposition. 21, 71, 73, 134, 137 clinical examination the spectrum of drug-and toxin-induced liver injury and, thus, the associated clinical presentation, can vary from subclinical hepatic injury with only increased serum liver enzyme activity, to severe liver damage manifested as alf, or chronic end-stage liver disease. acute rather than chronic liver injury is more likely for most of the drugs and toxins listed in box 61-1. clinical features often include acute onset of lethargy, anorexia, vomiting, diarrhea, pu, pd, or jaundice in a previously healthy animal, which corresponds to hepatotoxin exposure. alf (signs of acute liver disease plus he and coagulopathy) is most likely with drugs or toxins that cause diffuse hepatic necrosis. drug-and toxin-induced injury is an important diagnostic consideration in dogs and cats presenting for acute hepatitis and hepatic necrosis. drugs or toxins also have the potential to cause chronic hepatic disease, if the initial hepatic injury is mild and goes unrecognized, and exposure to the drug or toxin is continued. for example, phenobarbital, ccnu, or chronic aflatoxicosis can cause chronic liver injury in dogs. 70, 72, 138 diagnosis there are no pathognomonic clinical, laboratory, or biopsy findings that distinguish drug-or toxin-induced liver injury from other causes of liver disease. the diagnosis of drug-induced liver injury often relies on the clinician maintaining a high level of suspicion, and obtaining an accurate and thorough medication history (including prescription and over-the-counter drugs, and herbal and dietary supplements), in every animal with unexplained increases in liver enzyme activity or clinical liver disease. a definitive diagnosis of hepatic injury caused by biologic toxins or chemicals is rarely possible in a clinical setting, unless the owner specifically observes ingestion of a substance that is a known hepatotoxin. prevented. treatment of drug-induced hepatic disease consists of discontinuing the suspect drug. after a drug is discontinued, clinical (and biochemical) improvement usually occurs within a few weeks, even with chronic drug administration. however, exceptions can occur. for example, in dogs with amiodarone toxicity, liver enzyme elevations can transiently progress despite discontinuation of the drug, and biochemical abnormalities may not resolve for 6 to 8 weeks. 137 with the exception of nac for acetaminophen, and silymarin for amanita mushroom toxicity, no specific antidotes are available, and treatment of drug-and toxin-induced liver injury is primarily supportive and symptomatic. however, nonspecific hepatoprotective therapy with antioxidants (vitamin e), glutathione replacement (nac, same), or milk thistle (silymarin) may be helpful and are discussed in more detail in chapter 46. use of nac (or same) may be beneficial, as glutathione depletion may predispose to hepatotoxicity (e.g., methimazole) or impair metabolism of toxic metabolites to a nontoxic form. nac has been suggested to be beneficial for treatment of alf associated with toxicities such as diazepam, methimazole, carprofen, and trimethoprim-sulfa. 9 in addition to treating amanita mushroom hepatotoxicity, silymarin may be beneficial in the treatment of carbon tetrachloride and acetaminophen toxicity. 9,140,141 corticosteroids are not typically indicated for treatment of drug-and toxin-induced hepatotoxicity. it is important to consider a drug-induced cause of liver injury because rapid recognition and prompt discontinuation of an hepatotoxic drug can lead to improvement or complete resolution of hepatic disease, depending on the specific drug and the stage of the lesion. when drug-or toxin-induced hepatic injury causes severe or widespread hepatic necrosis, rapid deterioration and death in 3 to 4 days often occur. with less-severe hepatic injury, complete recovery is possible. acetaminophen acetaminophen is well known as an intrinsic hepatotoxin in dogs and cats. 142, 143 although acetaminophen is occasionally used as an analgesic in dogs (therapeutic doses up to 15 mg/kg tid), most toxicity occurs because of accidental ingestion of improperly stored medication (dogs) or owner administration without veterinary supervision (dogs and cats). 142 toxic metabolites of acetaminophen cause oxidative injury to erythrocytes and hepatocytes, resulting in methemoglobinemia, anemia, and hepatic necrosis. in therapeutic doses, acetaminophen is detoxified by a combination of hepatic glucuronidation and sulfation and renal excretion. 144 after acetaminophen overdosage, these pathways become saturated and a greater proportion of acetaminophen is metabolized through the p450 system, leading to production of the toxic metabolite, n-acetylp-benzoquinoneimine (napqi). glutathione detoxifies napqi and thus protects hepatic cellular constituents from its direct toxic effect. however, once glutathione levels are depleted by large amounts of napqi, centrilobular necrosis occurs. toxicity occurs in a dose-dependent manner. there are substantial species differences in both the metabolism of acetaminophen and the toxic manifestations. 142 cats are uniquely sensitive to acetaminophen because of a deficiency of glucuronyl transferase and limited sulfation capabilities. clinical signs in cats may develop after administration of as little as 162.5 mg ( 1 2 tablet). signs of methemoglobinemia usually dominate the clinical picture, such as cyanosis, dyspnea, facial edema, depression, hypothermia, hyperplasia, fibrosis, and cirrhosis. although individual drugs and drug classes may follow the same pattern, there is often not a consistent reaction for any given drug. for example, hepatic injury in dogs secondary to potentiated sulfonamides may cause hepatic necrosis, primary cholestasis, or marked inflammation. 21 for many of the potentially hepatotoxic drugs listed in box 61-1, histologic features have not been fully characterized. it should be emphasized that for most drug-induced disorders, the diagnosis is presumptive and cannot be proved. it can be especially difficult to pinpoint the causative agent when the patient is receiving a combination of drugs. a clinical diagnosis of drug-induced hepatic injury is easier to establish when the hepatotoxicity of the drug has been previously described and the associated clinical and pathologic features have been characterized (see discussion of specific drugs). the diagnosis may be less convincing when the suspected drug has not been previously incriminated as causing liver damage. however, a drug reaction should still be considered, since an idiosyncratic reaction could occur with any drug. the clinician should also maintain a level of suspicion regarding the potential for hepatotoxicity in newly marketed drugs that have not yet been used widely in the population, where idiosyncratic reactions are often first detected. the suspected hepatotoxic drug should be discontinued while a complete diagnostic evaluation is pursued for other causes of liver disease, for which a specific treatment might be available. a diagnosis of drug-induced injury is supported by the following: (a) evidence of liver injury that occurred within the first 3 months of drug therapy (especially if predrug liver enzyme activity was within normal limits); (b) clinical and biochemical improvement when the drug is discontinued; (c) exclusion of other causes of liver disease; (d) reccurrence of hepatic damage after a challenge dose of the same drug (or inadvertent reexposure). it should be emphasized that rechallenge with a suspected hepatotoxic drug is not recommended as a diagnostic consideration, because it is potentially dangerous, especially with a drug that causes acute hepatic necrosis. rechallenge should only be considered if the association of the drug with hepatic injury is highly questionable and there is no alternative drug available for a significant medical condition. with hypersensitivity or immunologic reactions, the hepatic reaction is more rapid and severe with repeated exposure. 20 hepatic injury because of a biologic toxin or chemical is suspected when exposure to a potential hepatotoxin has been documented. a clinical diagnosis of "toxic" hepatic injury is often made when an episode of acute hepatic injury occurs, hepatic biopsy indicates diffuse hepatic degeneration and necrosis, and no other cause for liver disease can be identified. in selected cases, tissues, blood, or food (aflatoxin) samples can be submitted to a toxicology lab to confirm a suspected toxin. toxin-induced injury should also be considered in the absence of known exposure to toxins, because potential hepatotoxins can be present in contaminated dog food or garbage (aflatoxins), pond water (blue-green algae), and many other unobserved sources. when ingestion of a potential hepatotoxin (e.g., toxic mushrooms, sago palms) has occurred within the preceding 8 hours, general procedures for gi decontamination are recommended, including induction of emesis or gastric lavage (within first 3 hours), followed by administration of activated charcoal (1 to 3 g/kg). 126, 139 induction of vomiting is contraindicated if the patient is comatose or debilitated in such a way that the gag reflex is diminished, which could predispose to aspiration pneumonia. whenever possible, the source of toxin exposure should be identified and further exposure or given as alternate-day therapy), with careful monitoring of liver parameters every 2 weeks. 146 hepatotoxicity appears to be at least partly dose related, as dogs receiving higher daily doses of itraconazole (10 mg/kg) are more likely to be affected. icterus and evidence of hepatic dysfunction suggests a more serious, potentially fatal hepatopathy, requiring discontinuation of medication and symptomatic and supportive care. it is recommended that liver enzymes be monitored on a monthly basis in all animals receiving ketoconazole or itraconazole. azathioprine, a purine analogue commonly used for treatment of immune-mediated disorders in dogs, is commonly listed as a potential hepatotoxin. 126 however, few clinical details regarding the hepatotoxic reaction are available. in a clinical study of 12 dogs with atopic dermatitis treated with azathioprine (2.2 mg/kg daily for 8 weeks) as a single agent, an increase in alt or alp activity was noted in the first 2 weeks in 10 (83%) of the dogs. 147 three dogs had clinical signs suggestive of liver disease, which resolved uneventfully when azathioprine was discontinued. in an experimental study of dogs given azathioprine at a dose of 2 to 4 mg/kg po daily for 40 days, all dogs had increased liver enzyme activity (alt >> alp) within 2 to 7 days of initiating therapy. 148 values peaked within the first 2 weeks and then declined, but not to normal, despite continued medication administration. hyperbilirubinemia was absent. liver biopsies in most dogs revealed centrilobular degeneration and necrosis, with intrahepatic cholestasis but no inflammation. 148 these findings raise the possibility that azathioprine may be an intrinsic (dose related) hepatotoxin in dogs, with possible adaptive tolerance to liver injury. it should be noted that doses used in this study exceeded current clinical recommendations of 1 to 2 mg/kg daily or every other day for maintenance therapy. hepatotoxicity is considered a class characteristic of nsaids, despite the fact that there are many different chemical classes of nsaids, and no consistent mechanism of liver injury. 149 with the exception of aspirin, which is an intrinsic (dose-related) hepatotoxin, the mechanism with other nsaids is believed to be idiosyncratic (either immune or as a consequence of toxic metabolites). 149, 150 toxicity does not appear to be related to prostaglandin inhibition like the renal or gi side effects. 149 preexisting hepatic disease has not been shown to be a risk factor for nsaid-induced liver injury. 150 all nsaids have the potential to cause idiosyncratic hepatotoxicity in dogs, but hepatic reactions appear to be rare. 150 carprofen has specifically been reported as a cause of drug-induced liver injury in dogs. 73 labrador retrievers were overrepresented in the series, but it is not clear whether this is a true breed predisposition. 150 clinical signs (anorexia, lethargy, vomiting, pu/pd) occurred within the first 4 weeks of therapy and icterus was a common finding on physical examination. biochemical evaluation revealed marked increases in liver enzymes (alt activity usually exceeded alp activity) and hyperbilirubinemia. hepatic biopsy findings revealed multifocal to diffuse hepatic necrosis, mild to moderate lymphocytic-plasmacytic inflammation, secondary cholestasis, and variable biliary hyperplasia and bridging fibrosis. 73 concurrent renal toxicity (glucosuria without hyperglycemia, proteinuria, granular casts) also was noted in some dogs. most dogs recovered with discontinuation of carprofen and appropriate supportive care, although some dogs died of alf. general hepatoprotective therapy with same or silybin has been recommended, although the benefits are unproven. nac has been suggested for ancillary treatment when carprofen causes alf. 128 and vomiting. although increases in serum alt activity may be detected, centrilobular hepatic necrosis appears to be uncommon. clinical signs in dogs are more likely when doses exceed 200 mg/kg and can be indicative of methemoglobinemia and/or centrilobular necrosis. 142 laboratory features include methemoglobinemia, anemia, increased serum alt activity, and hyperbilirubinemia. intravenous nac is the treatment of choice for acetaminophen toxicity in dogs and cats. 142 nac increases the synthesis and availability of glutathione, which when conjugated to napqi, decreases toxicity. for maximum effectiveness, nac should be given within 12 hours of acetaminophen exposure; however, there may still be a benefit if given 36 to 80 hours after exposure. nac (10% solution) is diluted 1 : 2 or more with saline and given intravenously through a nonpyrogenic 0.25 µm filter at an initial dose of 140 mg/kg over a 20-to 30-minute period. a maintenance dose of 70 mg/kg is given iv or orally every 6 hours for seven treatments. same also serves as a glutathione source and has been shown to have protective effects against acetaminophen-induced oxidative stress on the erythrocytes in cats and dogs. 143, 145 in an experimental study in cats, silymarin (30 mg/kg po) was as effective as nac for treatment of acetaminophen toxicity when given up to 4 hours after exposure. 140 vitamin c (30 mg/kg iv q6h) may be helpful in the treatment of acetaminophen toxicity because of its antioxidant effects. cimetidine (5 mg/kg iv q8h) is also recommended as adjunctive therapy in the early stages (first 16 hours) because it inhibits hepatic p450 enzymes and decreases napqi formation. the antiarrhythmic drug amiodarone is associated with a reversible hepatotoxicity in dogs. 134, 137 doberman pinschers may be at increased risk. 134 toxicity, which appears to be at least partially dose related (doses of 400 mg/day), was identified in 45% of doberman pinschers treated with amiodarone in one clinical series. 134 clinical signs (anorexia, lethargy, vomiting, diarrhea) and biochemical abnormalities (increased alt and alp activity ± hyperbilirubinemia) developed 6 days to 8 months after initiation of therapy. liver biopsy in one dog revealed multifocal hepatocellular necrosis with mild lipidosis and lymphoplasmacytic inflammation. 137 clinical improvement usually occurs within a few days of stopping the drug, but liver enzyme elevations may not return to normal for 3 months. 134 transient progression of enzyme abnormalities despite discontinuing the drug has also been noted, which may reflect the long half-life of amiodarone causing a delay in systemic elimination. 137 biochemical changes precede clinical signs, so monitoring of liver enzymes at least monthly is recommended. the azole antifungal drugs ketoconazole and itraconazole (and rarely fluconazole) are associated with increased liver enzyme activity and icterus in dogs and cats. 146 hepatotoxicity is more likely with ketoconazole than with itraconazole. cats are more sensitive to the hepatotoxic effects than are dogs, but considerable individual variation occurs. histologic findings are poorly characterized but include bile duct proliferation and infiltration of mononuclear cells. transient mild subclinical elevations of liver enzymes (alt and alp activity) are common, and do not necessarily require a change in therapy. a clinically significant hepatic reaction is suggested by alt activity that exceeds two to three times the upper limit of normal, especially when accompanied by clinical signs of anorexia and vomiting. drug therapy should be stopped for 1 to 2 weeks until appetite and liver enzymes return to normal. a rapid recovery usually occurs, and treatment can be restarted at a lower dose (50% of previous dose decreased appetite, weight loss, pu/pd, vomiting, ascites, and pleural effusion. ascites was due to a combination of hypoalbuminemia and portal hypertension. common biochemical abnormalities included increased liver enzyme activity (alt, ast, alp, ggt) and hypoalbuminemia. other less-consistent findings included hyperbilirubinemia, hypercholesterolemia, and increased serum bile acid concentrations. glucosuria (without hyperglycemia) and renal failure were noted in some dogs, possibly attributable to ccnu renal toxicity. 72 liver biopsy findings were nonspecific (hemosiderinladen kupffer cells, hepatocellular vacuolization, mild to moderate periportal inflammation, and fibrosis) but suggested chronicity. the majority of affected dogs died from progressive chronic liver disease. in a recent study, routine monitoring of alt activity prior to each subsequent dose of ccnu suggested that subclinical elevations of alt activity (greater than five times the upper limit of normal) are common. 155 thirty-two of 109 dogs (29%) had increased alt activity, which developed most commonly after one to three doses of ccnu. 155 increases in alt activity were not associated with cumulative dose. the lower incidence of clinical hepatotoxicity in this study (3 of 109 or 2.8%) versus the kristal study (11 of 179 or 6.1%), was attributed to prompt cessation of ccnu treatment in dogs with significant increases in alt activity. 155 however, it was noted that chronic administration of ccnu could be associated with chronic irreversible hepatopathy, in the absence of a significant alt elevation. the mechanism of hepatotoxicity is suspected to be a result of generation of toxic intermediate metabolites (e.g., isocyanates, diazonium hydroxide), and depletion of glutathione may play a role. 126 preliminary results of a clinical study using denamarin (same and sylibin; nutramax labs, lancaster, sc) for prevention of ccnu hepatotoxicity, suggested that dogs receiving denamarin had less-severe liver enzyme elevations. 156 methimazole, an antithyroid drug, is associated with hepatic injury in cats with hyperthyroidism. clinical findings include anorexia, vomiting, lethargy, jaundice, markedly increased serum liver enzyme activity, and hyperbilirubinemia that usually occurs within the first month of therapy. 126 histologic lesions have not been fully characterized, although biopsy findings in one cat revealed hepatic degeneration and necrosis. clinical signs resolve within a week of discontinuing therapy but biochemical resolution may take up to 45 days. reduced hepatic glutathione concentrations, which have been documented in other species with hyperthyroidism, may predispose to hepatic injury. 126 treatment with same may be beneficial. phenobarbital is associated with chronic hepatic disease and cirrhosis in dogs. 70 most dogs have been treated with phenobarbital for more than a year before the liver disease is apparent. the mechanism of hepatic injury is not known but higher doses, higher blood levels (>40 µg/ml), and long duration appear to be important risk factors. 70 clinical signs in dogs reflect chronic liver disease and include sedation, ataxia, anorexia, weight loss, weakness, ascites, jaundice, coagulopathy, and encephalopathy. phenobarbital-induced hepatic injury should be suspected in any dog with a history of chronic phenobarbital therapy and clinical and biochemical evidence of hepatic dysfunction. routine biochemical screening (every 4 to 6 months) of dogs on long-term phenobarbital therapy is recommended for early detection of hepatic injury. however, mild liver enzyme elevations (especially alp) are commonly seen in dogs treated with phenobarbital, who do not have clinical or histologic evidence of significant liver early recognition of hepatotoxicity (including periodic monitoring of liver enzymes during the first 3 months) and discontinuation of drug therapy provides the best opportunity for full recovery. whether dogs with previous carprofen hepatotoxicity can be safely switched to another nsaid without experiencing a hepatic reaction is unknown. oral diazepam has been incriminated as a cause of acute idiosyncratic fatal hepatic necrosis in cats. 151, 152 intravenous diazepam, and oral oxazepam, clonazepam, and zolazepam also have been implicated. 126, 152 onset of signs occurs within 5 to 13 days of initiating therapy. clinical signs and biochemical evaluation are consistent with acute hepatic necrosis and liver failure. most cats die within 15 days of initial administration of the drug. if treatment of a cat with oral diazepam is unavoidable, liver enzymes should be checked before and within 5 days after starting therapy. if liver enzymes are increased, the drug should be discontinued and symptomatic therapy should be started. ancillary treatment of alf with nac may be beneficial. 9 glucocorticoid therapy in dogs is commonly associated with increased serum alp activity and development of a reversible vacuolar ("steroid") hepatopathy as a result of hepatic glycogen accumulation. these hepatic effects can be seen with virtually any glucocorticoid preparation (including topical ophthalmic and otic preparations) and are influenced by drug preparation (e.g., repositol versus short-acting), dose, duration of therapy, and individual dog susceptibility. in contrast, cats are quite resistant to the hepatic effects of glucocorticoids and only rarely develop these hepatic changes. 153 increased serum alp activity can occur within 3 days after initiating glucocorticoid therapy in dogs and is often striking (up to 64 times normal). glucocorticoids are associated with the induction of a specific corticosteroid-induced isoenzyme of alp, which may account for 60% to 100% of the total alp activity. 154 in contrast, serum alt activity is often normal or only mildly increased. in most dogs, glucocorticoids do not cause significant hepatic dysfunction or clinically relevant hepatic disease and biochemical tests reflecting hepatic function (serum bilirubin, albumin, glucose, blood ammonia concentration, and coagulation tests) are typically normal. serum bile acid concentrations are normal or only mildly increased (<60 mmol/l). hepatic glycogen accumulation causes hepatomegaly (which can be detected on abdominal radiographs), and diffuse or multifocal increases in hepatic echogenicity (detected on ultrasonography). the hepatic effects of glucocorticoids are reversible after drug withdrawal. the length of time required for complete resolution is unpredictable, varying from weeks to months. lomustine ccnu [1-(2-chloroethyl)-3-cyclohexyl-1-nitrosourea] is an oral nitrosourea alkylating agent that is used for chemotherapy of lymphoma, mast cell tumor, histiocytic sarcoma, and brain tumors in dogs. idiosyncratic dose-related hepatotoxicity was described in 11 of 179 (6.1%) dogs given an oral dose of ccnu (50 to 110 mg/m 2 ), with a dosing interval of 3 to 6 weeks. 72 the median time to detection of hepatic disease (from the last dose of ccnu) was 11 weeks and ranged from 2 to 49 weeks. delay in onset was noted, with an inverse relationship between the size of dose, and length of time before abnormal serum alt was detected. 72 a cumulative dose effect was suspected. clinical findings of hepatotoxicity included glutathione precursors (nac, same) and vitamin c in treatment. 21 dogs with hepatopathy are less likely to recover (46%) than are dogs with nonhepatic manifestations of sulfonamide hypersensitivity (89%). 159 tetracycline can predispose to hepatic lipid accumulation because it inhibits protein synthesis and interferes with hepatic secretion of triglyceride-rich lipoproteins. 126 however, it does not appear that these hepatic effects are clinically significant in most dogs and cats, although clinically significant idiosyncratic hepatic injury has been reported. increased liver enzyme activity was a common finding in dogs treated with doxycycline (increased alt activity in 39.4%; increased alp activity in 36.4%), but the clinical significance remains to be determined. 160 aflatoxicosis aflatoxins are metabolites, produced primarily from strains of the saprophytic fungus, aspergillus, which cause toxic hepatitis in dogs and many other species. 138, 161 exposure in dogs may occur through the inadvertent use of aflatoxin-contaminated corn or peanut meal during the commercial production of dog food, or after ingestion of homemade pet foods, moldy garbage, or improperly stored dog food. 161 dogs are relatively susceptible to aflatoxins and the liver is the target organ. clinical cases of aflatoxicosis in cats have not been reported. aflatoxin b1 is most commonly implicated in hepatotoxicity and toxic effects are seen when levels exceed 60 µg/kg of food. 161 aflatoxin b1 is readily absorbed from the gi tract and undergoes hepatic metabolism by cytochrome p450 enzymes, to a toxic intermediate (aflatoxin b1 8,9-epoxide) , which binds to essential molecules within the cell, leading to hepatocyte necrosis and decreased protein synthesis. detoxification of aflatoxin b1 8,9epoxide occurs by conjugation to glutathione. depending on the amount consumed, dogs may present with acute, subacute, or chronic liver disease. high-dose exposure is associated with acute hepatic failure, jaundice, dic, and death. repeated exposure to low doses can lead to chronic liver disease and cirrhosis. in 2005, an outbreak of aflatoxicosis occurred in at least 100 dogs, as a result of eating a commercially available dog food manufactured with aflatoxin-contaminated corn. 138 severity of clinical signs varied significantly among dogs. some dogs died suddenly without preexisting signs of illness. other dogs were presented with signs of anorexia, lethargy, vomiting, jaundice, diarrhea (including melena and hematochezia), abdominal effusion, he, and evidence of a bleeding disorder. common biochemical features included increased liver enzyme activity (especially alt), hyperbilirubinemia, electrolyte disturbances, hypoalbuminemia, hypocholesterolemia, and prolonged clotting times. reduced plasma antithrombin iii and protein c activities and hypocholesterolemia were suggested to be the most sensitive biomarkers of aflatoxin ingestion in dogs with minimal clinical signs, possibly reflecting an early effect of aflatoxin on biosynthesis of certain proteins and cholesterol. 138 in dogs with acute or subacute aflatoxicosis, the liver is enlarged and pale yellow with histologic features of diffuse hepatic vacuolation (lipid accumulation), scattered individual hepatocyte necrosis, biliary hyperplasia, and modest inflammation. collapse of zone 3 hepatocytes around the central vein, associated with perivenular inflammation, may explain clinical features of portal hypertension. with chronic low-level exposure, findings include a small liver with regenerative nodules, acquired pss, and histologic evidence of marked biliary hyperplasia and periportal fibrosis. disease. 157 potential indicators of clinically significant liver injury include increases in alt and alp activity that exceed five times the upper limit of normal; alt activity that exceeds alp activity; any elevation in ast activity; or enzyme elevations accompanied by evidence of hepatic dysfunction (hyperbilirubinemia, hypoalbuminemia, hypocholesterolemia, increased sba). hepatic cirrhosis associated with chronic phenobarbital therapy is characterized grossly by a small, nodular liver and histologically by bridging portal fibrosis, nodular regeneration, biliary hyperplasia, and mild inflammation (see figure 61-19) . 70 these lesions are by no means pathognomonic for phenobarbital-induced hepatic damage; however, in the absence of other known causes of hepatic damage, circumstantial evidence would support drug therapy as a likely cause. chronic phenobarbital therapy also is associated with superficial necrolytic dermatitis (hepatocutaneous syndrome) in dogs. 158 liver biopsy changes were typical of those seen with hepatocutaneous syndrome (marked vacuolar change and parenchymal collapse), which are distinct from the characteristic chronic hepatitis and cirrhosis as described above. 158 phenobarbital should be decreased or discontinued if possible in dogs with biochemical and histologic evidence of hepatic disease. in dogs with phenobarbital-associated toxicosis, clinical, biochemical, and histologic improvement can occur if the drug is discontinued or used at a reduced dosage prior to severe, end-stage liver disease. improvement in clinical signs can be noted within days to weeks of decreasing serum phenobarbital levels. primidone also is associated with chronic liver disease in dogs, likely as a consequence of metabolism of primidone to phenobarbital. phenytoin can cause acute or chronic hepatitis in dogs, as well as jaundice and death. the risk of hepatotoxicity is increased with combination therapy of phenobarbital, primidone, and phenytoin. 126 sulfonamides potentiated sulfonamides (trimethoprim-sulfadiazine, trimethoprimsulfamethoxazole, and ormetoprim-sulfadimethoxine) are associated with the acute idiosyncratic drug-induced liver injury in dogs. 21 trimethoprim-sulfadiazine was implicated in over 20% of hepatic drug reactions in dogs that were reported to the center for veterinary medicine between 1988 and 1990. 71 doberman pinschers are suggested to be at risk for development of polyarthropathy from sulfonamide hypersensitivity, but not necessarily the idiosyncratic hepatic reaction. 159 onset of clinical signs occurs within 5 to 36 days (mean: 12 days) from starting the drug. 159 previous exposure to sulfonamides is not required. doses of potentiated sulfonamides are generally higher in dogs who develop the idiosyncratic hepatic reaction, as compared with other systemic manifestations of sulfonamide hypersensitivity (thrombocytopenia, fever, polyarthropathy, other). 159 biochemical findings include increased liver enzyme activity (alt > alp) and hyperbilirubinemia. liver biopsy usually reveals marked hepatic necrosis; however, cholestasis and marked lymphocytic-plasmacytic inflammation also have been described. 21 the pathogenesis of the idiosyncratic hepatic reaction is unclear. dogs in general may be at increased risk for sulfonamide reactions because they lack genes that express the n-acetylation enzymes, which is a major metabolic pathway of detoxification of sulfonamides in humans. 21 however, this does not explain individual risks among dogs. hepatotoxicity may be a result of p450 oxidation of sulfonamides to reactive metabolites, such as hydroxylamine and a nitroso metabolite, which may be associated with hapten formation, t-cell proliferation, or direct cytotoxicity. 21 impaired detoxification of reactive metabolites via a deficiency in glutathione, cysteine, and ascorbate, may play a role, and theoretically supports the use of hepatocyte uptake of amanitins and has been shown to be protective against experimental a. phalloides liver damage in beagles, when given at a dose of 50 mg/kg iv twice, at 5 and 25 hours after exposure. 141 however, an intravenous form of silymarin is not currently available for clinical use in the united states. experimental studies suggest that penicillin g may also reduce hepatic uptake of amanitins, even several hours after ingestions. 162 iv nac may be beneficial as described for treatment of acetaminophen toxicity. overall mortality rate with amanita mushroom toxicity is high. ingestion of toxin-producing blue-green algae (microcystis aeruginosa) is a rare cause of hepatotoxicity and alf in dogs. 164 algae proliferate in shallow, stagnant water, especially in hot, dry weather. dead or dying algae form a thick blue-green scum on the water's surface, and release the toxic principle, microcystins. toxicity is caused by ingestion of algae-contaminated water. signs occur rapidly (within 1 hour of ingestion) and include vomiting, diarrhea, and lethargy, followed by progressive tachypnea and dyspnea, icterus, and coma. biochemical features reflect hepatocellular injury with increased alt and ast activity (that typically exceed increases in alp activity), and hyperbilirubinemia. however, profound or protracted increases in alt activity may not be detected, because microcystins can interfere with transaminase biosynthesis. 7 hepatic lesions consist of massive hepatic necrosis of the centrilobular to midzonal hepatocytes. treatment is symptomatic and supportive. oxidative injury may play a role, 164 which suggests that glutathione supplementation (nac or same) may be of benefit. the prognosis is guarded. cycads (sago palms) are native to tropical and subtropical regions, and are used as houseplants and in residential landscaping. concentrations of cycasin, the primary toxin in cycads, are highest in the seeds and roots, but present in all parts of the plant. 165 ingestion of as few as one to two seeds can be fatal in dogs. following ingestion, cycasin is metabolized by gi bacteria to its active compound, methylazoxymethanol, which causes gi and hepatic toxicity in dogs. 165 most dogs that ingest cycads develop gi signs, including vomiting, diarrhea, and abdominal pain. neurologic signs (weakness, ataxia, depression, proprioceptive deficits, seizures, coma) are also common, but it is not clear if they are a result of a neurotoxin or he. 165 onset of clinical signs ranges from 15 minutes to 3 days and may last from 24 hours to 9 days. 165 hepatic injury is suggested by findings of progressive depression, icterus, he, and excessive bleeding accompanied by increased liver enzyme activity, hyperbilirubinemia, hypoglycemia, and hypoabuminemia. 166, 167 centrilobular hepatic necrosis is found on liver biopsy. 166 no specific treatment is available. mortality has been reported to vary between 32% and 58%. 165, 167 xylitol xylitol, a 5-carbon sugar alcohol used as a sugar substitute, is associated with hypoglycemia and hepatic necrosis in dogs. 168, 169 xylitol is safe in humans and is commonly used in sugar-free gum and other oral care products, and is available as a granulated powder for baking. xylitol was first introduced into the united states in 2002, and since that time, reports of toxicity to the aspca animal poison control center have increased from two dogs in 2002 to 2512 dogs in 2008. 168 ingestion of more than 0.1 g/kg in dogs is associated with a rapid, severe, increase in blood insulin, which results in signs of hypoglycemia within 30 to 60 minutes of ingestion. when amounts exceed 0.5 g/kg, alf may occur within 9 to aflatoxicosis associated with consumption of a commercially manufactured pet food product should be suspected when there is a geographic or temporal cluster of cases in a household, kennel, or region. the history may reveal recent changes in diet or feeding from a new bag. it should be noted that some dogs may consume contaminated food for weeks to months before signs develop. definitive diagnosis of aflatoxicosis is based on chemical detection of increased levels of aflatoxin (>60 µg/kg) in the food. when aflatoxicosis is suspected, the owner should be advised to retain 1 kg of food in an airtight zippered plastic bag (or four cans of food), for laboratory testing. it is also recommended to save packaging information, including product and date code, to help identify contaminated lots of food. if a sample of food is no longer available, serum or liver samples can be submitted for testing for aflatoxin m1 (aflatoxin metabolite), although usefulness may be limited because of the rapid metabolism and excretion of aflatoxin. detection of aflatoxin m1 in urine is only useful if the dog is still consuming the contaminated diet, as levels fall below detectable levels within 48 hours. there is no specific antidote for aflatoxicosis and treatment consists of symptomatic and supportive management of liver failure. nonspecific hepatoprotective therapy with antioxidants (vitamin e), glutathione replacement (nac, same), milk thistle (silymarin), and l-carnitine have been recommended. 138 the prognosis is guarded if clinical signs of aflatoxicosis are present, with a reported mortality rate of 64% in a series of 72 dogs that consumed aflatoxincontaminated dog food. 138 dogs that survive acute liver injury have the potential to develop chronic liver disease. consequently, monitoring of liver function is recommended in recovering dogs and treatment with thiol donors such as same for 2 months has been empirically recommended. 138 amanita mushrooms amanita phalloides (and other varieties such as amanita verna and amanita bisporigera), are poisonous mushrooms found throughout north america that can cause acute hepatic necrosis in dogs and cats. 162, 163 toxicity is attributed to extremely toxic cyclopeptide toxins called amanitins. ingestion of two a. phalloides mushrooms can be lethal to an adult dog. 163 clinical signs occur within 6 to 24 hours after ingestion and are characterized initially by gi signs such as vomiting, bloody diarrhea, and abdominal pain. the late phase (36 to 84 hours after exposure) is characterized by alf (hemorrhage, marked hypoglycemia, he, and terminal coma) caused by severe massive hepatic necrosis (see figure 61 -20) . toxin-induced renal tubular necrosis may also result in renal failure. 162 biochemical features reflect severe hepatic injury and include increased liver enzyme activity (alt exceeds alp), refractory hypoglycemia, and hyperbilirubinemia. diagnosis is usually made based on positive identification of the suspect mushroom, evidence of its ingestion, and consistent clinical features. mushroom pieces in gastric contents can confirm exposure, but are difficult to identify. accurate mushroom identification requires consultation with an experienced mycologist. the suspect mushrooms should be wrapped in paper towels and stored in a paper (not plastic) bag. 162 definitive confirmation can be established by detecting amanitins in liver or kidney tissue (or serum and urine samples collected during the gi phase) by liquid chromatography-mass spectrometry, through the california animal health and food safety laboratory. 163 gi decontamination procedures are recommended as soon as possible after exposure, as described in the "treatment" section of "drug and toxin-induced liver injury". symptomatic and supportive treatment for alf is indicated, including close monitoring and treatment of marked hypoglycemia. silymarin is believed to reduce lower urinary tract disease ammonium biurate uroliths are formed most of the time in the bladder (and rarely in the renal pelvis) and can cause dysuria, urethral obstruction in males, and seldom uroabdomen as a result of chronic inflammation and subsequent devitalization of the bladder wall. 3 ammonium biurate crystalluria is not pathognomonic for portosystemic shunting, and it may occasionally occur in normal dogs and cats, or be found in certain breeds, such as dalmatians, because of an inborn error of metabolism. prolonged recovery from anesthesia or sedation may occur in seemingly normal dogs and cats that have cpss. the liver plays a crucial role in the detoxification process of toxins and drugs, including anesthetics. patients with cpss or apsc have insufficient functional hepatic mass for detoxification. in addition, dogs with portosystemic shunting have increased endogenous benzodiazepine and gabaergic activities. 4 therefore administration of diazepam or barbiturate to these animals may have prolonged and exaggerated effects (see "pathogenesis" section). recurrent fever together with resultant depression and anorexia can be the only clinical manifestation of cpss in some dogs. 5 portosystemic shunting should be excluded in dogs experiencing recurrent fever. this rare manifestation has only been reported in a few dog. 6 its pathogenesis is not understood. elderly dogs with extrahepatic cpss may present with characteristic signs of hypercortisolism (e.g., pu/pd, polyphagia, thin skin, symmetric alopecia, muscle wasting, pot belly) as primary complaints. these are unusual clinical manifestations of cpss. although small body size is observed in cats with cpss, it infrequently occurs in dogs. many dogs with extrahepatic cpss show no or only nonspecific clinical signs throughout their lives and the shunt is detected as a coincidental finding at the time of necropsy. it is not understood why certain dogs become clinically ill and others do not with the same type of portal vein anomaly. cpss never cause icterus, ascites, or spontaneous hemorrhages. portal vein disorders are much less common in cats than in dogs. most cats are younger than 6 months of age when the first signs appear. 7 cats with cpss are often of smaller stature and have unkempt hair coat. episodic salivation and/or central neurologic signs, for example, compulsive pacing or seizures, as manifestations of he are the most typical presenting complains. 8, 9 portal hypertension clinical signs can develop at any age and arise from the presence of increased hydrostatic portal venous pressure, portosystemic 72 hours. 169 alf is not necessarily preceded by early signs of hypoglycemia. the mechanism of hepatotoxicity is unknown, but has been speculated to be caused by cellular depletion of adenosine triphosphate resulting in hepatocellular necrosis, or production of reactive oxygen species causing oxidative injury. 169 in addition to signs of hypoglycemia, dogs with alf may have vomiting, icterus, and evidence of excess bleeding. biochemical findings include markedly increased alt and ast activity, mild to moderate increased alp activity, hyperbilirubinemia, hypoglycemia, hyperphosphatemia, prolonged pt and aptt, and thrombocytopenia. if ingestion occurred within the last few hours, induction of emesis is recommended (unless showing signs of hypoglycemia). activated charcoal may be of limited value in adsorbing xylitol, but is still recommended if large amounts have been ingested. 168 treatment recommendations include hospitalization for observation and monitoring, dextrose supplementation for control of hypoglycemia, and symptomatic and supportive care for complications of liver failure. hepatoprotective therapy with nac, same, and silymarin may be beneficial. the prognosis is good for recovery in dogs with uncomplicated hypoglycemia and guarded to poor for dogs in liver failure. however, survival after liver failure does not necessarily correlate with amount of xylitol ingested. 169 vascular hepatic diseases include congenital and acquired disorders of the portal vein. congenital anomalies result from (a) hypoplasia or aplasia of the portal vein, (b) macroscopic communications between the portal vein and a systemic vein, or (c) between the portal vein and an artery. acquired diseases result from conditions that increase the hydrostatic pressure in the portal vein (i.e., portal hypertension). macroscopic venous connections between the portal and systemic venous systems result in portosystemic shunting (i.e., blood flows from the portal to the systemic veins) via a congenital portosystemic shunt (cpss) or acquired portosystemic collaterals (apsc). neurologic signs hepatoencephalopathy (he) is a reversible central neurologic manifestation of hepatic insufficiency. 1 cpss causes chronic he. the following grades of chronic he are recognized 2 : grade 1-depression, behavior changes; grade 2-ataxia, compulsive pacing, circling, hypersalivation, head pressing, blindness; grade 3-stupor and seizures; and grade 4-coma. chronic he is characterized by periods of severe (grades 2 to 3) signs (lasting usually several hours to a few days alternating with longer periods (days to weeks) of no or mild (grade 1) symptoms. 2 periods of cortical blindness are accompanied by apparent mydriasis. signs of he may be triggered by ingestion of protein-rich meals. pd means excessive fluid intake (in dogs >100 ml/kg body weight/24 h and in cats >50 ml/kg body weight/24 h). pu may be more difficult to diagnose than pd, as pet owners cannot readily measure urine volume. repeated low specific gravity of morning urine (<1.025 in dogs and <1.030 in cats) is compatible with pu. macroscopic connections exist between major vessel systems or their tributaries. single or multiple portosystemic venous connections allow the portal venous blood to flow directly to the systemic venous system without first flowing through the hepatic sinusoids. this toxin-rich blood will be delivered to all cells of the body through the following route: gut > portal vein > shunt > systemic vein > right heart > lungs > left heart > arteries. a connection through a single, or rarely double, large-bore vein without the presence of portal hypertension is considered to be a cpss. single or multiple connections in the presence of portal hypertension are apsc. whenever a macroscopic venous connection is present between the portal vein (or one of its tributaries) and a systemic vein, the blood will flow from the portal vein to the systemic vein, because the pressure in the portal vein is higher (8 to 10 mm hg) than that in the systemic veins (0-5 mm hg). 8 normal portal venous pressure is approximately 8 to 10 mm hg (10 to 13 cm h 2 o). increased pressure in the portal venous system results in portal hypertension. anatomically, portal hypertension can be classified 17 as (a) prehepatic (i.e., portal vein), (b) intrahepatic or (c) posthepatic (i.e., hepatic veins, thoracic caudal vena cava, or heart). posthepatic (postsinusoidal) portal hypertension. all cardiac diseases that result in right-sided congestive heart failure cause posthepatic portal hypertension. these diseases include the (a) congenital or acquired severe insufficiency of the tricuspid valve (e.g., dysplasia, myxomatous degeneration, annulus dilation caused by dilated or arrhythmogenic cardiomyopathy, pulmonary hypertension of various etiologies), (b) pericardial diseases (pericardial tamponade caused by idiopathic or neoplastic effusion or constrictive pericarditis), (c) various congenital anomalies such as cor triatriatum dexter, atrial septum defect, tricuspid or pulmonic stenosis, (d) intracardiac tumors affecting the right heart, and (e) caval syndrome (caused by dirofilaria immitis heart worms). kinking or compression of the thoracic caudal vena cava (by diaphragmatic hernia or a mass) occurs rarely. compression, stenosis or thrombosis of the hepatic veins (the so-called budd-chiari syndrome) does not occur in dogs and cats. 13,13a in posthepatic portal hypertension the portal and caval pressures increase equally. therefore no apsc develop, and the blood ammonia concentration remains within reference range. the high postsinusoidal hydrostatic pressure causes a large amount of protein-rich hepatic lymph to be filtered through the hepatic capsule into the abdominal cavity causing accumulation of a modified transudate. modified transudate has high protein content because the fenestrated endothelial cells of the hepatic sinusoids keep only 10% to 20% of the plasma proteins in the capillary lumen. marked generalized hepatomegaly and dilated jugular and hepatic veins as well as caudal vena cava are hallmarks of postsinusoidal portal hypertension. intrahepatic portal hypertension. chronic acquired parenchymal liver diseases lead to hepatocyte necrosis and subsequent collagen deposition. the resultant disorganization of the hepatic architecture and contraction of the connective tissue results in obstruction of the intraparenchymal vessels. the underlying disease processes include viral, bacterial, protozoal, immune-mediated, or copperassociated chronic hepatitis; toxic, drug-induced, or idiosyncratic liver damage; lobular dissecting hepatitis; and chronic bile duct shunting via apsc, and the underlying disease that led to portal hypertension. clinical signs of portosystemic shunting are similar, regardless whether it is congenital or acquired in origin (see "clinical manifestations" section). accumulation of a large amount of pure transudate or modified transudate (clear, straw-colored, or slightly turbid blood-tinged fluid) in the abdominal cavity is commonly detected with physical examination and abdominocentesis. the absence of free abdominal fluid does not exclude portal hypertension. depending on the etiology and the anatomic location of the underlying disease that led to the development of portal hypertension various signs may be seen such as jaundice, periodic vomiting, and anorexia. jaundice and hemorrhagic diathesis are absent in congenital vascular disorders. congenital arterioportal fistula causes transudative ascites in puppies between 2 and 6 months of age. 10 primary hypoplasia of the portal vein (phpv), also described as "noncirrhotic portal hypertension," 11 may result in ascites, vague gi signs, and he, or may be entirely subclinical. 12, 13 when the phpv is not severe enough to cause portal hypertension, clinical signs may not be obvious. this mild form of phpv is also known as hepatic microvascular dysplasia 14 and may be detected serendipitously if plasma bile acid concentrations are measured for unrelated reasons. portal hypertension is rare and is not typically associated with ascites in cats. 15 portosystemic shunting because of cpss or apsc tend to cause similar signs, for example, periodic salivation and seizures, as manifestations of chronic he. the most common acquired disease causing intrahepatic portal hypertension is biliary cirrhosis caused by chronic bile duct obstruction. jaundice and acholic feces are typical findings in extrahepatic cholestasis. the liver receives its blood supply from the portal vein (approximately 75%) and the hepatic artery (approximately 25%). with diversion of portal venous blood flow, a compensatory increase of the hepatic arterial flow occurs. arterial vasodilation is mediated by adenosine from energy-depleted hepatocytes. the portal vein transports blood from the spleen and the gi tract to the liver. 16 the smallest portal venous and hepatic arterial branches terminate in the capillary system of the liver, the so-called hepatic sinusoids. a large amount of plasma is filtered through the fenestrated walls of the sinusoids to the space of disse. from here the filtered plasma is taken by lymphatic vessels to the systemic venous system. the remaining sinusoidal blood is then collected by the hepatic veins, which enter the caudal vena cava. normally no the hepatofugal portal flow prevents the splanchnic venous blood from entering the liver and causes the development of alternative pathways and often times accumulation of pure transudate in the abdomen. interestingly, phpv always accompanies congenital arterioportal fistulas both in dogs and cats. 5, 10, 25 when a cpss and arterioportal fistulas are concomitantly present, apsc and ascites do not develop. 25 arterioportal fistula can be extrahepatic in cats. acquired portosystemic collaterals. in healthy mammals, multiple nonfunctional venous connections may exist between the portal and systemic veins. these virtual communications become functional when their lumen becomes sufficiently widened. gradual dilation takes place when sustained increase of the portal pressure takes place without the simultaneous increase of caval pressure. the resultant apsc are multiple, usually thin, tortuous veins with species-specific anatomical locations; however, large-bore veins may also develop. these latter cases should not be misinterpreted as simultaneous cpss and apsc. in the presence of an existing cpss, no apsc would develop even if hepatic cirrhosis develops as there is an already existing portosystemic connection that is able to drain 100% of the portal blood without allowing the development of portal hypertension. 26 splenorenal collaterals are consistently present in almost every dog with apsc. 10, 27 these apsc drain the portal venous blood via the splenic vein through acquired connections to the left gonadal vein. the left gonadal vein enters the left renal vein, which later empties into the caudal vena cava. these splenorenal apsc are thought to prevent the spleen from undergoing congestion, 17 which is why splenomegaly is not a feature of canine pre-and intrahepatic portal hypertensive disorders. 10 shunting of the portal blood is not only detrimental for the brain, but for the liver as well. normal hepatic development and function requires sufficient amount of portal venous perfusion of the hepatic sinusoids. increased arterial perfusion is unable to compensate for portal hypoperfusion. regardless of whether the insufficient portal venous perfusion is caused by cpss or by prehepatic portal hypertension, the result is the same: reduced hepatic mass and function. in both cases, histopathologic evaluation of the liver shows stereotypical reaction: small or invisible portal branches, increased number of arterioles and sometimes bile ductules in the portal tracts, hepatocellular atrophy, and periportal sinusoidal dilation. 13 this secondary portal vein hypoplasia is reversible and is histologically indistinguishable from phpv. because primary and secondary portal vein hypoplasia show identical microscopic features, histopathologic evaluation of liver biopsy specimens is unable to diagnose simultaneous phpv and cpss. glycine and gaba are the most important inhibitory neurotransmitters, whereas glutamate and dopamine are the most abundant excitatory neurotransmitters in the brain. in he, a net increase in inhibitory transmission occurs. 28 this results from upregulation of gaba receptors and downregulation of dopamine receptors. 29 activation of gaba receptors causes opening of chloride channels, which leads to hyperpolarization of the postsynaptic membrane. in the presence of gaba, benzodiazepines increase the frequency, whereas barbiturates increase the duration of the chloride channel opening. 30 the cause of increased gabaergic tone in he is thought to be gut derived, 4 but gaba may also be formed in the neurons from glutamate. 28 endogenous benzodiazepines are proven to be obstruction. the resultant increase in portal pressure may cause development of apsc as well as ascites. modified transudate may accumulate in the abdominal cavity when the disease process predominantly obstructs the postsinusoidal hepatic venules. however, when the disease process affects predominantly the intrahepatic portal vein branches (presinusoidal portal hypertension) pure transudate will accumulate in the abdomen. primary hypoplasia of the portal vein is caused by insufficient development of the intrahepatic portal venous branches, the left portal vein branch, or the whole portal venous system. 12, 18 when the hypoplasia is severe enough to cause intra-or prehepatic portal hypertension, apsc develop. this condition is also known as "noncirrhotic portal hypertension." if hypoplasia is not severe enough to cause portal hypertension, clinical signs will not develop. because no portosystemic shunting is present, the results of rectal ammonia tolerance test (att), portal scintigraphy, and portography are all normal (see "differential diagnosis" section). if either macroscopic or microscopic portosystemic communications is present, hyperammonemia or abnormal att should also be present, but this has never been documented. the only abnormality that could be detected in these dogs is elevation of serum bile acids levels. 14 the most plausible explanation for this is that the hepatic clearance of bile acids by the hypoperfused liver is probably less effective than that of ammonia. the disease can only be diagnosed by histopathologic examination of liver biopsy specimens. this condition also has been described as "hepatic microvascular dysplasia." although the terms noncirrhotic portal hypertension and hepatic microvascular dysplasia have been used to describe this syndrome, both have been replaced by the term phpv. 13 the occurrence of phpv in the cat is very rare and poorly documented. the most common congenital cause of portal hypertension in cats is congenital hepatic fibrosis as a part of polycystic kidney and liver disease complex. 19 this disease may cause clinical signs with or without the presence of macroscopic hepatic or renal cysts. 20 prehepatic portal hypertension. narrowing of the portal vein lumen may be caused by (a) extravascular compression by a tumor, enlarged lymph node, cyst, abscess, or hematoma, (b) idiopathic circumscribed stenosis, 21 or (c) intravascular obstruction by a thrombus or parasites, all of which can lead to portal hypertension. 22 portal vein thrombosis is always secondary either to neoplasia, or to a systemic disorder that causes hypercoagulability such as nephrotic syndrome, immune-mediated hemolytic anemia, hypercortisolism, acute pancreatitis, peritonitis, or sepsis. 23 parasites in the portal vein also may occur, for example, heterobilharzia americana in north america 24 and schistosoma japonicum in east asia. 13 depending on the degree of portal vein occlusion, increased portal pressure with apsc and ascites may develop. as the hydrostatic pressure in the sinusoids does not increase (in contrast to posthepatic portal hypertension), the resultant ascitic fluid will have a low protein content. the narrowed lumen of the portal vein causes reduced portal flow to the liver, resulting in reduction in the size of the liver. portal vein thrombosis itself rarely causes clinical signs and is usually a coincidental finding. when the liver receives little portal venous blood, an insufficient amount of substrate (i.e., ammonia) is available for hepatic urea production. this theoretically results not only in a low plasma urea concentration, but also in a lower renal medullary urea concentration, which impairs renal concentrating ability and causes pu. increased basal plasma concentrations of acth and cortisol as well as increased urinary cortisol-to-creatinine ratios are invariably present in dogs with portosystemic shunting. [43] [44] [45] [46] cortisol interferes with the action of arginine-vasopressin at the renal tubule, causing a nephrogenic-type diabetes insipidus. 47 hypersecretion of acth (and α-melanocyte stimulating hormone [α-msh]) has been shown to arise predominantly from the intermediate lobe of the pituitary. 43, 48 the hormone secretion of this lobe is regulated by tonic dopaminergic inhibition. acth-hypersecretion can be explained by the production of "false" neurotransmitters (e.g., octopamine), whose effect is about one-fiftieth that of dopamine on the dopamine receptors. 35 central diabetes insipidus also contributes to pu in dogs with he. impaired release of arginine-vasopressin from the posterior lobe of the pituitary is caused by a reduced magnitude of response and a highly increased threshold to increased plasma osmolality. 45 release of arginine-vasopressin is inhibited by the gaba inhibitory neurotransmitter system, whose activity is increased in he. 29, 45 pseudohyperaldosteronism cortisol and aldosterone have similar affinities to bind aldosterone receptors. however, cortisol is normally inactivated by 11β-hydroxysteroid dehydrogenase in tissues where aldosterone action is required. 49 high serum bile acids concentrations inhibit this enzyme, and cortisol can bind to aldosterone receptors resulting in increased mineralocorticoid effect. 45 plasma cortisol concentrations are 10-fold those of aldosterone, causing constant and inappropriate pseudohyperaldosteronism. the resultant sodium retention causes secondary water retention and subsequent pu by pressure diuresis. hypokalemia caused by hyperaldosteronism also contributes to pu 50, 51 according to the following mechanism. the presence of aquaporin-2 channels in the renal collecting ducts' cell membranes is necessary for water reabsorption. intracellular signaling pathways through cyclic adenosine monophosphate regulate the insertion of these channels. hypokalemia decreases the sensitivity of cyclic adenosine monophosphate to arginine-vasopressin, which results in decreased insertion of aquaporin-2 channels into the cell membrane. 50 this leads to nephrogenic diabetes insipidus and pu. congenital portal venous anomalies in dogs are typically associated with enlarged kidney volume. increased renal gluconeogenesis as a compensation of insufficient hepatic gluconeogenesis may cause the kidneys to enlarge. 52 in addition, increased systemic circulating growth factor concentrations released from the pancreas may play a role in this increased volume. 53 normally, these growth factors act only in the liver, as they do not reach the systemic circulation in high concentrations. behavior changes and abnormalities in the thirst center due to he may contribute to pd; however this is difficult to prove in individual patients. produced in the intestines of dogs with cpss. 4 their source is not quite clear: they could arise from the diet, intestinal flora, or by endogenous modification of inactive gut precursors. 4 in all forms of portosystemic shunting the concentration of aromatic amino acids are increased in the systemic circulation whereas the concentration of branched-chain amino acids is decreased. high aromatic amino acid concentration results from impaired hepatic clearance and increased production caused by muscular breakdown exacerbated by hyperglucagonemia. 28, 31 the decreased concentration of branched-chain amino acids results from their increased utilization for gluconeogenesis. 28, 32 this amino acid imbalance may result in the development of "false" neurotransmitters (e.g., octopamine) in the brain, which contribute to the development of he. 33, 34 these "false" neurotransmitters have a fraction of dopamine's excitatory effect on dopamine receptors. drugs with dopaminergic effect, such as bromocriptine, may improve signs of he. [35] [36] [37] intestinal toxins such as ammonia and bacteria are normally inactivated by hepatocytes and hepatic macrophages (kupffer cells), respectively, so that toxin-and bacterium-free blood can enter the systemic circulation. in patients with portosystemic shunting the majority of the portal venous blood bypasses the liver, allowing the toxin-and bacterium-rich blood to enter the systemic circulation. ammonia is a neurotoxin and can contribute to the clinical signs of he. 38 other toxins that are believed to play a role in he are endogenous benzodiazepines, gaba, tryptophan, glutamine, serotonin, mercaptans, indoles, and skatoles. 4, 34, 39 hyperammonemia also leads to impaired glial function through increased intracellular glutamine concentration. 38 glutamine is made in the glial cells through incorporation of ammonia into glutamate by glutamine synthetase. 28 chronically increased glutamine concentrations cause swelling of the glial cells resulting in so-called alzheimer ii type degeneration of astroglias. 40, 41 glial dysfunction contributes to the development of he. 40, 42 during hyperammonemia, the reserve capacity of the astrocytic glutamine synthetase is exceeded, and ammonia can enter the neurons. 42 in the neurons ammonia inhibits glutaminase, an enzyme that converts glutamine to glutamate. because glutamate is an excitatory neurotransmitter, its reduced level contributes to the development of he. 28 portosystemic shunting or an atrophic liver alone is insufficient to allow he to develop; he can only develop when they are both simultaneously present. 28 the reserve capacity of the liver ensures that even in advanced chronic parenchymal liver diseases, he does not develop in the absence of portosystemic shunting. alkalosis and hypokalemia can worsen the signs of he. in alkalosis the nh 3 + h + = nh 4 + reaction shifts to the left, causing the more lipophilic ammonia to enter the cells of the cns. during hypokalemia, potassium ions (k + ) move from the cells to the extracellular space in exchange for h + , which later results in extracellular alkalosis and intracellular acidosis. intracellular acidosis causes nh 4 + trapping within the cells. this might explain why the blood concentration of ammonia is not closely related to the severity of the clinical signs of he in individual cases. several mechanisms contribute to the development of pu/pd in portosystemic shunting. high concentrations of sodium and urea in the renal medullary interstitium are essential for the production of concentrated urine. these create a high osmotic gradient between the renal tubular lumen and interstitium, which is necessary for water reabsorption. to result from reduced enzyme activity of the urea cycle. as no clinical signs are present, no treatment is required. the condition resolves spontaneously with age because these pups develop enhanced incorporation of ammonia into glutamine. peritoneal absorption of ammonia-containing urine can cause hyperammonemia, however in such a patient the clinical signs of acute uremia predominate. the presence of urease-producing bacteria (e.g., staphylococci) are necessary to split urinary urea to ammonia. 67 fulminant hepatic failure ingestion of blue algae or certain mushrooms (e.g., a. phalloides) results in peracute insufficiency of hepatic function. these animals develop hepatic coma and die shortly thereafter. hyperammonemia, dic, and icterus are present in most affected patients. arginine is an essential amino acid in the cat. in anorectic cats hyperammonemia may develop along with hepatic lipidosis because of the insufficient amount of hepatic arginine needed for urea synthesis in the urea cycle. 68 thus, in contrast to adult dogs, hyperammonemia in cats can occur without portosystemic shunting. methylmalonic acidemia associated with cobalamin deficiency in dogs, 69a a cat 69 and a suspected "transient hyperammonemic syndrome" in a german shepherd dog 70 have been reported as extraordinarily rare causes of hyperammonemia. if blood sampling and sample processing are performed inappropriately hyperammonia may be erroneously diagnosed. high bile acids concentration may result not only from portosystemic shunting, but also from any primary or secondary hepatic diseases associated with intra-or extrahepatic cholestasis. 71 therefore, the presence of high serum bile acids concentrations is very sensitive, but not a specific indicator of portal venous disorders. 63 the simultaneous presence of hyperammonemia and a large amount of pure or modified transudate in the abdominal cavity indicates the presence of severe pre-or intrahepatic portal hypertension with apsc. biochemical and cytologic analysis of the peritoneal effusion, ultrasonography and central venous pressure measurement may be useful in identifying the source of ascites. 17 suspected intrahepatic causes should be further evaluated by histopathologic examination of liver tissue. in any animal that is presented with central neurologic signs, portosystemic shunting (along with other metabolic encephalopathies, e.g., hypoglycemia or electrolyte imbalance) should be investigated with appropriate blood tests. no single finding is pathognomonic for diagnosing vascular liver disorders. therefore, a combination of history, physical hyperammonemia results in a higher filtered load and urinary concentration of ammonia. high urinary concentration of uric acid results from decreased hepatic conversion of uric acid to allantoin because of reduced hepatic mass and function. the portal vein carries bacteria and endotoxins from the intestines, which are normally phagocytized by the kupffer cells. shunting of portal blood permits these bacteria and/or endotoxins to enter the systemic circulation causing bacteremia and/or endotoxemia, and subsequent fever. 5 systemic antibiotics may result in temporary resolution of clinical signs, however give no definitive cure. if a cpss occurs within hepatic parenchyma it is called intrahepatic. 54, 55 intrahepatic cpss arise either from the left or right portal branches. a left divisional intrahepatic cpss results from the failure of postnatal closure of the embryological ductus venosus. 56, 57 the intrahepatic cpss arising from the right portal branch and all extrahepatic cpss are thought to be developmental anomalies with poorly understood etiology. in dogs the anatomy of the shunting vessel is fairly consistent: intrahepatic cpss may be left, right, or central divisional, whereas extrahepatic shunts drain the portal venous blood via the splenic or the right gastric vein to the caudal vena cava or the azygos vein. 15 the course of the shunting vein in the cat is much more variable. 15, 58 the inherited nature of the disease has been established in several breeds including the irish wolfhound and the yorkshire and cairn terriers. [59] [60] [61] phpv is a congenital anomaly of unknown etiology. although arterioportal fistulas may develop as a result of neoplasm or trauma (e.g., shot wound or liver biopsy), only the congenital form has been reported in dogs and cats. congenital hepatic fibrosis caused by polycystic kidney disease (pkd) is a genetic disease. 19, 62 differential diagnosis high fasting venous blood ammonia concentrations together with high fasting serum bile acid concentrations are very specific and sensitive tests for diagnosing portosystemic shunting. 63 urea cycle enzyme deficiency reduced activity of one or more enzymes of the urea cycle may result in elevated blood ammonia concentration. 10, 64 serum bile acids levels should remain within reference range in patients with urea cycle enzyme deficiencies. normal hepatic scintigraphy and liver histopathology results should confirm the absence of portosystemic shunting. certain metabolites (e.g., citrulline) and enzyme activities (e.g., argininosuccinic acid synthetase) can be measured in urine and liver biopsy specimens, respectively, to establish a definitive diagnosis. the condition is rare in dogs. one suspected feline case has been reported. 65 irish wolfhound puppies healthy irish wolfhounds commonly have moderate hyperammonemia (<120 µmol/l) at the age of 6 to 7 weeks. 66 this is thought chloride (nh 4 cl) solution is administered at a dose of 2 ml/kg fifteen cm into the descending colon using a soft feeding tube. 75 venous blood ammonia is measured before and 20 and 40 minutes thereafter. in the presence of portosystemic shunting the ammonia concentration will increase at least twofold by the 20-and/or 40-minute sampling times. normal att result excludes portosystemic shunting (figure 61-21) . the degree of increment is a semiquantitative measure of the degree of portosystemic shunting. it should be noted that rectal administration of nh 4 cl solution may cause transient irritation of the colonic mucosa during the first 10 minutes. rectal att is a safe procedure, with signs of he rarely occurring. att should not be performed in patients with very high (>150 µmol/l) blood ammonia levels. postprandial measurement of ammonia is thought to decrease the possibility of iatrogenic hyperammonemic he; however the increase of blood ammonia concentration after feeding takes longer and its peak time point is poorly predictable. 76 markedly increased preprandial (i.e., 12-hour fasting) bile acids concentrations are often found with portosystemic shunting as a result of interrupted enterohepatic circulation of the bile acids. 77, 78 high 12-hour fasting plasma bile acid concentration is a sensitive, but nonspecific indicator of portosystemic shunting. specificity can be increased by simultaneous measurement of venous ammonia. as plasma bile acids concentrations are invariably high in icteric animals, the presence of apsc can only be justified or excluded by measuring blood ammonia concentration or performing an att. in case of a normal 12-hour fasting bile acids concentration (<15 µmol/l), measuring an increased postprandial plasma bile acids concentration (>25 µmol/l) 2 hours after a meal increases the sensitivity, but not the specificity of the bile acids test in diagnosing portosystemic shunting. 79 meal-induced gallbladder contraction causes an endogenous bile acid load, which will be absorbed in the ileum and will substantially increase the plasma bile acids concentration when portosystemic shunting is present. an abnormal postprandial increase of bile acids occurs also in cholestatic liver diseases. in patients with portosystemic shunting hypoalbuminemia, hypoproteinemia, hypocholesterolemia, and low plasma urea concentration may be found as a result of their reduced hepatic synthesis. hypoglycemia may be seen as a result of reduced hepatic glyconeogenesis and glycogen storage. low creatinine concentration reflects the increased glomerular filtration rate. 53 none of these biochemical changes is specific for portosystemic shunting; furthermore, many of these findings may be present in healthy pups. the cause of mild increase of plasma alt and alkaline phosphatase activities is not fully understood. microcytosis with or without mild nonregenerative anemia and leukocytosis may accompany portosystemic shunting. relative iron deficiency is thought to cause the microcytosis [80] [81] [82] and bacteremia may induce the leukocytosis. although aptt is often moderately prolonged in dogs with cpss, no spontaneous bleeding tendency or hemorrhage occurs. 83, 84 hemoabdomen is a possible postoperative complication after surgical attenuation of a cpss. acquired parenchymal hepatic diseases examination, laboratory tests, diagnostic imaging results and histopathology of liver biopsy specimens are often required to establish a specific diagnosis. intrahepatic cpss tend to cause clinical signs between 2 months and 1 year of age in large-breed dogs. bernese mountain dogs, irish wolfhounds, hovawarts, and retrievers are predisposed. australian cattle dogs and male dogs more likely have right-sided than leftsided intrahepatic cpss, 72 whereas irish wolfhounds tend to have left-sided intrahepatic cpss. intrahepatic cpss in small-breed dogs are very rare. extrahepatic cpss usually occur in small breeds and can cause clinical signs at any age. 73 the most commonly affected breeds are maltese dogs, miniature schnauzers, dachshund, yorkshire terrier, jack russell terrier, and cairn terrier. no clear sex predisposition is known. the waxing-waning nature of central neurologic signs is suggestive of chronic he. symptoms may improve spontaneously. physical examination often fails to detect abnormalities. occasionally an enlarged left kidney is palpated. the presence of ascites detectable with physical examination should exclude cpss. some authors suggest that copper-colored iris is a typical finding in cats with cpss; however, no reports exist about its positive or negative predictive value. dogs with intra-or prehepatic portal hypertension may have ascites. jaundice is absent in congenital portal hypertensive disorders, but may be present in acquired parenchymal liver diseases. blood ammonia concentration fasting (12-hour) venous hyperammonemia is a very specific and sensitive indicator of portosystemic shunting. as a single test, increased blood ammonia level is usually sufficient to diagnose portosystemic shunting. because ammonia is formed from amino groups of proteins and urea also in the collection tube, the blood sample (in an ethylenediaminetetraacetic acid tube) should be placed directly on ice after sampling and the measurement should be performed within 30 minutes. because contamination of the sample with airborne ammonia may cause false-positive results, samples should be taken using a closed system (needle on a syringe or directly into a vacutainer). hemolysis may artificially increase ammonia concentration because erythrocytes contain two to three times more ammonia than the plasma. measurement of ammonia should be performed in a clean location, where the air is not contaminated with ammonia from congested urine or cigarette smoke. a number of analyzers offer the possibility of ammonia measurement; however some of them are unreliable. 46 measuring arterial ammonia concentration provides no additional value. if venous ammonia concentration is within the reference range or only slightly elevated, rectal att is the cheapest and quickest test to exclude or justify the presence of portosystemic shunting in patients with a suggestive history. most of these "suspicious" animals also have high fasting plasma bile acids levels. 74 a 5% ammonium anomalies, a high-resolution grayscale ultrasound is often sufficient to establish a definitive diagnosis. 10 although certain secondary changes (such as small liver, large kidneys with hyperechoic medulla, and sediment or stones in the urinary bladder) suggest the presence of cpss, diagnosing a cpss requires the visualization of the anomalous vein from its origin to its termination. the urinary bladder should always be evaluated for the presence of urinary calculi. ultrasonography can be used not only during the initial diagnostic workup, but also during the surgical treatment and postoperative followup of cpss. 86 intraoperative grayscale ultrasonography facilitates localizing the course of an intrahepatic cpss, 26 whereas intraoperative color and spectral doppler examination helps to determine the optimal degree of shunt attenuation. 87 scintigraphy free 99m tc-pertechnetate administered into the colon is absorbed into the portal vein and appears in the liver first in animals without portosystemic shunting, or in the heart in patients with portosystemic shunting. 88 isotopically labeled albumin macroaggregates may be directly administered into a splenic vein with ultrasound guidance. 89 the macroaggregates are trapped in the first capillary bed, which is normally the liver. the fraction of portal may lead to spontaneous hemorrhages because of the presence of dic. plain radiographs give very limited additional information (such as small liver, possibly enlarged kidneys, and sometimes visible uroliths) to the history and laboratory results, so they don't have to be part of the routine diagnostic workup of vascular liver diseases. pure ammonium biurate uroliths are radiolucent. abdominal ultrasonography is the first choice of diagnostic imaging modality, once the presence of portosystemic shunting has been established by fasting hyperammonemia or abnormal rectal att (see figure 61 -21). the major advantage is that ultrasonography requires no sedation or anesthesia. its drawback is in the operator dependence. by using a systematic examination protocol one can accurately differentiate cpss from apsc, and intrahepatic from extrahepatic cpss, as well as readily diagnose arterioportal fistulas and prehepatic portal hypertensive disorders. 15, 85, 86 although colorflow doppler highly facilitates evaluation of portal vascular injection of iodinated contrast agent into the portal vein or into one of its tributaries under fluoroscopy used to be the only form of diagnostic imaging available to diagnose anomalous vessels. angiography allows identification of extra-and intrahepatic cpss as well as apsc. 90 the major drawback of selective portography is its invasiveness and the need for general anesthesia. whereas mesenteric portography requires catheterization of a mesenteric vein during laparotomy, 91 splenic portography can be performed by ultrasoundguided percutaneous injection of contrast material into a parenchymal splenic vein. visualizing portal vein segments with hepatofugal flow or shunt segments with hepatopetal flow (figure 61-22) is problematic, as no contrast reaches these parts of the vessels. blood that bypasses the liver will be trapped in the pulmonary capillaries. splenic venous injection of isotopes makes exact calculation of the shunting fraction possible (i.e., activity in lungs/activity in liver + lungs); however, the procedure requires anesthesia. scintigraphy is the gold standard diagnostic imaging method to justify or exclude the presence of portosystemic shunting. however, differentiating congenital from acquired portosystemic shunting or intrahepatic from extrahepatic cpss is not possible. information provided by a scintigram is a "yes" or "no" answer to the question: does the patient have portosystemic shunting? this answer can be reached much more easily and without using radiopharmaceuticals by documenting a single high blood ammonia concentration or by rectal att. images (a, b) . arrows indicate the direction of blood flow. a and b, intraoperative color-flow doppler ultrasound images of the portal vein at the point where the congenital splenocaval shunt originates. note that the diameter of the shunt (sh) is larger than that of the portal vein (pvcaudsh). the portal vein cranial to the origin of the shunt (pvcrsh) becomes narrower than the portal vein caudal to the shunt origin (pvcaudsh) because of hypoperfusion. a and c, because blood always flows toward the lowest resistance, 100% of the portal venous blood flows through the shunt (sh) to the caudal vena cava (cvc). note that the blood from the gastroduodenal vein (gdv) finds lower resistance to flow caudally toward the shunt, than toward the liver. this creates a hepatofugal flow (i.e., flow away from the liver) in the portal vein segment between the entering point of the gdv and the origin of the shunt (pvcrsh). note that the portal vein becomes even narrower cranial to the point where the gdv enters it (pvcrgdv). the diameter of the various portal vein segments varies because of the varying amount of blood that flows through a certain segment. b and d, note that partial occlusion of the shunt increases the resistance in the shunt to such an extent that the blood from the splenic vein (splv) finds lower resistance to flow through the shunting vessel toward the portal vein. this reversed flow in the shunting vessel (*) prevents the portal venous blood from shunting. thus, even though the shunt is only partially closed, it is nonfunctional. also note that the blood in the whole length of the portal vein is forced to flow toward the liver (i.e., hepatopetal flow direction), establishing normal perfusion of the sinusoids. a portion of the splenic venous blood will continue to flow through the attenuated shunt to the cvc, but the splenic blood contains no more toxins than any systemic vein, so no hyperammonemia develops. rights were not granted to include this figure in electronic media. please refer to the printed publication. rights were not granted to include this figure in electronic media. please refer to the printed publication. rights were not granted to include this figure in electronic media. please refer to the printed publication. pine receptor increases the effect of gaba on its gaba areceptor. 4 the cornerstone of therapy in cases of cpss (until definitive surgical therapy) and in all cases of apsc is a high-quality, low-protein diet. 32, 33, 98, 99 commercially available renal prescription diets are ideal and preferable to most hepatic diets, as the protein content is higher in the latter. 28 to decrease colonic transit time and reduce the production of ammonia, oral administration of lactulose is recommended. the dosage of lactulose should be titrated in individual patients to yield soft feces, but not diarrhea. an initial dosage 0.5 ml/kg q12h is recommended. if diarrhea results the dosage should be reduced. lactulose also stimulates the growth of colonic bacteria that can incorporate ammonia into bacterial protein. additional use of antibiotics (e.g., neomycin, metronidazole) has been recommended by some to diminish ammonia-producing colonic flora. antibiotic administration is usually not necessary to control clinical signs of he; moreover, neomycin is thought to antagonize the action of lactulose and may cause the release of endotoxins. 100 furthermore, chronic antibiotic use may contribute to the development of antibiotic resistance. surgical closure of apsc is generally impossible because of their multiple nature, but also contraindicated, as apsc are usually a compensatory mechanism to resolve high portal venous pressures. surgical narrowing (i.e., banding) of the caudal vena cava to reduce shunting by increasing the caval pressure is currently not recommended. in cases of cpsss, attenuation or complete closure of the shunting vein is the choice of treatment. the goals of shunt occlusion are (a) reducing portal flow via the cpss and (b) simultaneously increasing portal venous perfusion of the liver. 86 the shunt should be attenuated as close as possible to the point where it enters the systemic circulation. attenuating intrahepatic cpss is more risky because of the possibility of major bleeding because of excessive dissection of hepatic parenchyma. there are several techniques described, of which none are perfect. the major problem with shunt reduction is that blood from the portal vein will be redirected to newly perfuse the liver and its vasculature. poorly developed portal branches have insufficient capacity to accept even normal amounts of portal venous blood, and in the case of complete shunt occlusion, splanchnic congestion will develop. the goal of surgery is to sufficiently reduce the amount of shunting blood without causing portal hypertension to develop. 86 although complete shunt occlusion would theoretically be ideal, partial shunt attenuation is often sufficient because (a) partial attenuation often results in functional closure 18 (see figure 61 -22), and moreover (b) complete anatomic occlusion may follow in many cases. 101 partial occlusion of extrahepatic cpsss often results in a better outcome because the chance for development of postligation portal hypertension is much smaller compared to complete occlusion. 86 the liver, which may be less than 30% of its normal size, grows very quickly following successful surgery. regeneration may take 2 to 3 weeks to complete in uncomplicated cases. the regenerating liver receives progressively more portal blood flow usually resulting in spontaneous complete closure of the cpss. helical ct, especially the multiscale versions, makes excellent images of the abdominal vasculature (including cpss) relatively quickly after intravenous injection of iodinated contrast agents. 92 three-dimensional reconstruction provides impressive anatomic details of shunting vessels. 93 the drawback is the limited availability of the new-generation scanners and the need for patient anesthesia. although magnetic resonance angiography can provide highquality images of the abdominal vessels, 94 it has not become popular because of its limited availability and high costs. patents require general anesthesia and the examination lasts longer than ct angiography. characteristic mri changes have been described in the brains of dogs and cats with cpss, 95 but these findings are more of research than of clinical interest. histopathologic examination of liver biopsy specimens is essential in identifying the underlying disease process in intrahepatic portal hypertensive disorders. in the routine diagnostic workup of canine cpss liver histopathology gives no additional information. currently, the presence of coexistent phpv cannot be diagnosed preoperatively in dogs with cpss. 18 this is because the histologic findings of liver biopsies are identical in the following conditions: cpss, phpv, cpss with phpv, congenital arterioportal fistula, any prehepatic portal hypertensive disorder (e.g., portal vein thrombosis). 13 however, taking liver biopsies for histopathologic examination is recommended in cats before deciding about surgical closure of a cpss. this is because congenital hepatic fibrosis as part of pkd can be present simultaneously, especially in persian and persian crossbreeds. 20 surgical shunt attenuation is not recommended when congenital hepatic fibrosis and a cpss are simultaneously present in a cat. patients with grades 2 to 4 he may present on an emergency basis. the source of ammonia and other protein breakdown products, which cause the clinical signs of he, is the colon. the purposes of the treatment are (a) to reduce the production and amount of ammonia in the colon by removing its content with warm water enema, and (b) to inhibit the absorption of ammonia by administering lactulose syrup into the emptied colon. lactulose may be given as a retention enema with a soft feeding tube 0.5 to 1.0 ml/kg deep rectally). lactulose is a nonabsorbable disaccharide, which is metabolized by the colonic bacteria into short-chain fatty acids. these fatty acids acidify the intraluminal content causing to form ammonium ion (nh 4 + ) from ammonia (nh 3 ). because of its polarity, nh 4 + will not pass the enterocystic membrane, and is instead trapped in the colonic lumen. 96 it is also essential (c) to correct the acid-base and electrolytic disorders of the patient with iv fluid therapy as alkalosis and hypokalemia can worsen the signs of he. seizures caused by he can be controlled with intravenous propofol. administration of benzodiazepines (e.g., diazepam) and barbiturates should be avoided as they can worsen the clinical signs. 97 binding of a benzodiazepine molecule to its neuronal benzodiazeacute portal hypertension. variable degrees of portal hypertension necessarily develop subsequent to any cpss attenuation. if portal hypertension is severe, circulatory collapse may develop because of sequestration of blood in the splanchnic veins. 116 slight abdominal enlargement as a result of ascites requires no intervention. this usually resolves spontaneously within 1 week of surgery. severe ascites with signs of shock (e.g., depression, tachycardia, hypotension, prolonged capillary refill time, hemorrhagic diarrhea) necessitates emergency surgery and removal of the ligature or constrictor ring from around the shunt. these signs usually develop within 24 hours postoperatively. unfortunately, the prognosis following emergency surgery is poor. portal vein thrombosis. this rare postoperative complication causes sudden onset of shock usually within several days of shunt attenuation. 87, 117 exaggerated shunt occlusion, severe portal hypertension, and stasis of portal venous blood are believed to be the cause of the thrombosis. no survivals have been reported. chronic portal hypertension. when the growth of the liver and development of portal branches is insufficient following partial shunt closure, chronic portal hypertension may induce formation of apsc. this may occur as late as 4 to 8 weeks postoperatively. in such cases, evaluation usually reveals partially patent shunt and increased portosystemic shunting as a result of newly formed apsc. the development of apsc has been documented with all surgical methods. apsc can develop as a result of underdeveloped portal branches or exaggerated shunt attenuation. 18 in most dogs, these apsc remain clinically silent because the hepatic mass has substantially increased following shunt attentuation. 18 all patients should be re-evaluated at 1 month after shunt attenuation by measuring fasting blood ammonia concentration and performing an abdominal ultrasonography. if fasting blood ammonia concentration is within the reference range, rectal att should be performed. if fasting hyperammonemia is present or the att is abnormal, ultrasonography should identify whether shunting occurs via the narrowed cpss, apsc, or both. in the latter cases, lifelong conservative therapy with dietary modifications and lactulose is recommended. a normal att result implies complete shunt occlusion and the pet will generally have a very favorable prognosis. a second surgery to reach further shunt attenuation should only be attempted in patients with persistent clinical signs that have high fasting blood ammonia concentration or abnormal rectal att result 3 months after the first surgery. 18, 86 spontaneous gradual shunt closure would not occur beyond 3 months after surgical ligation. this rare and usually fatal complication of shunt attenuation causes generalized seizures 1 to 3 days postoperatively, almost exclusively in cats and small-breed dogs (often in maltese dogs). 31, 100, 118, 119 its occurrence is unpredictable. the pathogenesis is unknown, but the sudden decrease of endogenous benzodiazepine ligands is thought to play a role (i.e., "benzodiazepine withdrawal syndrome"). 4 because cerebral edema is suspected to be the initial disorder, intravenous mannitol (0.5 to 1.0 g/kg iv, during 20 minutes) may be administered when a patient shows subtle central neurologic signs during the first three postoperative days. once seizures have developed, the prognosis is usually very poor. most patients are euthanized because of uncontrollable seizures or persistent neurologic defects. propofol gradual shunt attenuation is believed to reduce the risk of portal hypertension by allowing the portal venous branches to adapt gradually to the increased flow. 102,103 apsc do develop with gradual shunt attenuation techniques (e.g., cellophane banding and ameroid constrictor ring). cystic calculi should be removed during the same surgical procedure, because resolution of ammonium biurate uroliths with dietary management can only be achieved in 30% of cases. the shunting vessel is identified by midline laparotomy and narrowed or completely occluded by a nonabsorbable ligature. 104 portal hypertension is determined by direct measurement or estimated based on subjective criteria including severe intestinal cyanosis, increased intestinal peristalsis, reduction in arterial blood pressure, and compensatory tachycardia as a result of stasis in the splanchnic circulation. 105 intraoperative doppler ultrasonography will greatly facilitate determination of the optimal degree of shunt attenuation in extrahepatic cpss, helping to prevent severe portal hypertension. 86, 87 cellophane banding instead of a ligature, a 3-mm-thin, three-layer-thick cellophane band is placed around the shunting vessel with or without narrowing of the shunt diameter. 106 gradual shunt occlusion takes place as a result of inflammation induced by the cellophane. 107, 108 ameroid constrictor ring a metal ring filled with a thick layer of casein is placed around the shunting vessel. swelling of the casein occurs as it absorbs fluid. because of the outer metal ring, the casein can only expand centripetally causing gradual occlusion of the shunt over 1 to 3 months. 102, 109, 110 the major drawback of this simple technique is that the rate and magnitude of occlusion is uncontrollable and kinking caused by the weight of the device may cause acute fatal portal hypertension. moreover, because of its relatively large size it can only be easily applied on extrahepatic cpss. 111, 112 laparoscopy laparoscopic shunt narrowing (by clips) is a less-invasive alternative for shunt ligation (see chapter 28) . 113 with this minimally invasive intravascular technique metal spirals with thrombogenic fibers are placed in the shunting vessel. the coils are delivered via a catheter, which is inserted through the jugular vein into the shunt under fluoroscopic guidance in anesthetized animals. 114, 115 the coils cause thrombus formation in the shunt resulting in its partial or complete occlusion. to prevent coil dislodgment from the shunt, an intravascular stent is often placed in the caudal vena cava to cover the point where the shunt enters the caudal vena cava. coiling is an especially attractive method for treating intrahepatic shunts because liver dissection is thereby avoided. in my opinion, the safest and most effective way for attenuation of extrahepatic cpss is doppler ultrasound-guided partial attenuation via surgical ligature. 86, 87 for intrahepatic cpss, coil embolization appears to be an excellent method. ameroid constrictor and cellophane banding would be ideal in extrahepatic cpss, when the portal vein cranial to the shunt origin is severely hypoplastic and the patient is at risk for severe portal hypertension. spironolactone alone does not resolve ascites, furosemide may be added to the therapy. abdominocentesis for removal of abdominal effusion is not recommended because of loss of protein and exacerbation of starling forces permitting further fluid accumulation. dietary and medical management relieves clinical signs only temporarily in most symptomatic young dogs. 99 without surgical shunt attenuation, gradual deterioration of liver function occurs; consequently, conservative therapy alone offers a guarded prognosis in young dogs. in older animals (>6 years) with newly reported signs of cpss, lifelong conservative treatment may be recommended because of the significantly higher complication rates of surgical therapy in these patients. 105 the prognosis depends on (a) whether the cpss is intra-or extrahepatic, (b) the coexistence of phpv, (c) the extent of shunt attenuation, (d) experience of the surgeon, and (e) the age of the dog at the time of diagnosis. intrahepatic cpss generally has poorer prognosis. complete resolution of clinical signs can be expected in approximately 60% to 80% of dogs with extrahepatic cpss in the hands of an experienced surgeon. this same parameter is approximately 50% to 70% for intrahepatic cpss. [102] [103] [104] [105] with extrahepatic cpss, an excellent prognosis can be expected when blood flow is hepatopetal (i.e., toward the liver) in the portal vein segment, which is cranial to the shunt origin. this can be established preoperatively with doppler ultrasound. 86 in cats, regardless of the shunt type and the surgical method, the success rate is approximately 30% to 50% because of the development of postoperative central neurologic signs. 105, 122, 123 the prognosis of portal hypertensive disorders depends on the underlying disease. in the majority of acquired diseases the underlying disorder is chronic and so severe that even stopping the disease process will not cause regression of apsc. primary liver neoplasms are infrequent in the dog and cat, with an estimated prevalence in necropsy studies of 0.6% to 2.6% in the dog and 1.5% to 2.3% in the cat. liver metastases are more frequent than primary hepatic tumors in the dog, and tend to originate from the spleen, pancreas, and gi tract. primary hepatobiliary tumors are more common than metastatic disease in the cat. [1] [2] [3] [4] [5] the etiology of liver cancer in dogs and cats is incompletely understood. potential causes such as aflatoxins, nitrosamines, food additives, parasites, and radioactive compounds have been reported. [6] [7] [8] liver cancer in the dog has many clinical, pathologic, and histologic homologies with liver cancer in humans. [9] [10] [11] [12] in human medicine, chronic diseases of the liver, such as hepatitis b or c infection, as well as cirrhosis, are often associated with (1 to 5 mg/kg, iv) followed by constant rate infusion [cri]) may be used to control seizures. 120 prophylactic treatment with phenobarbital does not reduce the risk of development of postligation neurologic complications, 118 but may be used in long-term seizure management. preventive use of potassium bromide has not been shown to reduce the possibility of postoperative seizures. in every patient with central neurologic signs in the early postoperative period, hypoglycemia and he should be excluded by measuring venous glucose and ammonia concentrations, respectively. blindness and other types of central neurologic signs may develop in cats shortly after surgery. the pathogenesis of these changes is unknown. hemorrhage from liver biopsy sites or shunt dissection in cases of intrahepatic cpss can lead to hypovolemic shock and death in the early postoperative period. dogs with hepatic insufficiency are prone to develop hemorrhagic complications because of decreased concentrations or abnormal synthesis of coagulation factors. 84 postoperative portal hypertension may also contribute to bleeding tendency from hepatic parenchymal dissection. hemoabdomen should be carefully differentiated from severe portal hypertension and septic peritonitis as they all can cause shock and variable degrees of abdominal distention. coagulation parameters (e.g., pt, aptt) should be routinely monitored after surgery and if they are abnormal or if there is evidence of clinical bleeding, fresh-frozen plasma transfusion should be administered (10 to 20 ml/kg, iv). toy-breed dogs are prone to develop hypoglycemia during or shortly after surgery. 100 blood glucose concentrations should be regularly monitored and hypoglycemia should be treated with glucosecontaining infusions. specific treatment should address the underlying parenchymal liver disease based on the histologic results of liver biopsy. he can often be controlled with dietary modification and lactulose. currently, no specific treatment exists for portal venous hypoplasias. renal or hepatic prescription diets and lactulose may alleviate clinical signs of he in case of apsc. diuretic agents may be useful in dogs with ascites. liver lobe resections have been reported in animals with congenital arterioportal fistulas. however, simultaneous presence of phpv in the whole liver prevents postoperative resolution of portal hypertension and the portosystemic shunting via apsc. 10, 25 therefore, the pet owner should be educated that partial hepatectomy may not result in complete recovery of portosystemic shunting, and that lifelong dietary support and/or lactulose will likely be required. severe abdominal effusions should be treated with diuretic agents. 121 the first choice is spironolactone (1 to 2 mg/kg q12h), an aldosterone receptor antagonist as (a) chronic hepatic insufficiency is associated with hyperaldosteronism, (b) concurrent hypercortisolemia is associated with cortisol binding to the mineralocorticoid receptor, and (c) potassium-sparing diuretics prevent development of hypokalemia and alkalosis, both of which would worsen signs of he. if show no clinical signs, and liver cancer is suspected only with increases in serum liver enzyme activities. 3, 5, 7, 23 the most common physical examination findings are cranial abdominal mass (35%), abdominal bloating (30%), and jaundice (18%). jaundice is a less common finding in cases of metastatic cancer. other manifestations include neurologic signs as a result of he; paraneoplastic syndromes such as hypoglycemia and myasthenia gravis; and skin alterations consistent with hepatocutaneous syndrome. 7, 24 no clear breed predisposition is observed with canine liver cancer, although poodles, fox terriers, miniature schnauzers, labrador retrievers, and male dogs are overrepresented in some reports of hepatocellular carcinoma. 1, 12, 19, 25, 26 labrador retrievers and female dogs are overrepresented in reports of bile duct carcinoma. 1, [26] [27] [28] whether male and female cats are equally at risk for bile duct carcinomas is unsettled, 28, 29 but male cats appear to be at greater risk for bile duct adenomas. 30, 31 neuroendocrine tumors are generally observed in younger animals. 1, 32 diagnosis definitive diagnosis of liver cancer can be made only by liver biopsy. asymmetrical enlargements of the liver detected on physical examination, abdominal ultrasonography, or survey radiography should not be assumed to be neoplastic in origin. similarly, laboratory data do not distinguish hepatic neoplasia from other liver pathologies. 33 the clinical approach to an animal with suspected liver cancer should include basic information such as a complete blood cell count, serum biochemistry, coagulation tests, urinalysis, thoracic and abdominal radiographs, abdominal ultrasound ( figures 61-23 and 61-24) , and fine-needle or core biopsy of the liver. a tnm tumor classification system has been used for staging of liver cancer where t represents tumor (t0, no evidence of tumor; hepatocellular tumors; however, there is no established association between hepatic tumors and viral infections in the dog or cat. moreover, canine hepatic cirrhosis does not appear to predispose to hepatocellular carcinoma (hcc). 1 a possible association between hookworm or whipworm infection and liver cancer has been reported, and cats with chronic cholangitis may have an increased predisposition to biliary carcinoma. 7, 13 several liver mitogens and tumor suppressor genes such as epidermal growth factor, tgf-α, vascular endothelial growth factor (vegf), p53, and tgf-β and its receptors (tgf-β-r) have been associated with liver cancers in humans and these may play a similar role in the dog. [14] [15] [16] [17] in human medicine a small percentage of hccs or cholangiocarcinomas originate from hepatic progenitor stem cells. dogs diagnosed with hcc or cholangiocarcinoma do demonstrate activation of hepatic progenitor stem cells in response to liver injury, but hepatic progenitor stem cell expression in liver tumors is relatively low. 18 the hypothesis of cancer development as a multistep process applies to liver tumors in the dog and the cat, as well. 7, 19 precancerous lesions, such as dysplastic nodules, can be identified before the development of overt malignancy in humans. dysplastic nodules are characterized by cell atypia, cellular crowding, trabecular thickness, microacini, and histochemical markers. 20 dysplastic nodules have not been reported in the dog or cat and further studies are needed to understand the chronology of hepatic malignancy in domestic animals. preliminary reports of histochemical markers have been reported in dogs with hyperplastic hepatic lesions and hepatocellular and biliary neoplasms. 11 liver tumors cause damage to the liver by several mechanisms: inflammatory effects, obstruction of the biliary system, obstruction of the vascular compartment or adjacent organs, and spontaneous rupture with hemoabdomen. 21 hepatic tumors are usually resistant to chemotherapy. 7, 19 in one recent study, p-glycoprotein was more highly expressed in hcc than in cirrhosis, which is consistent with the known resistance of hcc to chemotherapy. p-glycoprotein, which is encoded by the multidrug resistance gene (mdr-1), is normally expressed in tissues with excretory function, including the jejunum, kidney, liver, and adrenal gland. 22 primary liver neoplasms are usually classified according to their cellular origin and macroscopic appearance. with respect to cellular origin, these tumors may be hepatobiliary, hematopoietic, sarcomas, or metastases of other tumors (box 61-2). in relation to macroscopic appearance, they can be classified as lobular, multiple nodular, or diffuse (). the combination of histopathologic and morphologic classification has consequences for prognosis and treatment strategy in these animals (tables 61-6 and 61-7) , and the clinician must always address these factors to arrive at correct management decisions. in dogs, malignant tumors are more common than benign lesions. in cats, biliary neoplasms are the most common presentation, particularly intrahepatic benign forms. 6, 7 most animals with liver neoplasia present with nonspecific clinical signs such as anorexia and weight loss. less-frequent clinical signs include vomiting and diarrhea, pd and pu, pale mucosal membranes, and acute weakness because of anemia and hypovolemia coincident with tumor rupture. 7, 19 up to 25% of affected animals diffuse or infiltrating, multiple coalescent nodules in all the lobes, or diffuse disappearance of the liver parenchyma; lobular, nodule or large mass in a single liver lobe; nodular, several nodules throughout the liver parenchyma, or several affected liver lobes. t1, tumor involving one lobe; t2, tumor involving more than one lobe; and t3, tumor invading neighboring structures); n represents regional lymph nodes (rlns) (n0, no evidence of rln involvement; n1, rln involved; n2, distant ln involved); and m represents distant metastasis (m0, no evidence of metastasis; m1, distant metastasis detected). although recommended, this system has not been universally adopted. 34 table 61 -8 illustrates the most typical hematologic and biochemical findings in dogs and cats affected with liver neoplasia. leukocytosis is a result of inflammation and necrosis of large tumors; anemia tends to be moderate and nonregenerative and is thought to be caused by chronic illness, inflammation, or iron deficiency 19 ; thrombocytosis is attributable to a paraneoplastic syndrome characterized by thrombopoietin production, iron deficiency, or anemia. 7 serum liver enzyme elevation is a frequent, but not universal, finding in animals with liver neoplasia. it should be noted, however, that the degree of serum enzyme elevation does not correlate with the degree of liver involvement or severity of disease. in one survey, animals with primary liver tumors tended to have greater elevations in serum alt and alp activities than animals with metastatic disease, while the latter tended to have greater elevations in serum bilirubin and ast. 35 it also has been suggested that an ast-to-alt ratio of less than 1 is more compatible with carcinoma, while a ratio of greater than 1 is more indicative of a sarcoma or carcinoid. 1 other reported biochemical changes include hypoglycemia, hypo-or hyperalbuminemia, and increased serum bile acids. hypoglycemia as a paraneoplastic syndrome associated with hepatocellular carcinoma is attributed to the secretion of insulin-like growth factor ii. 36 unlike dogs, cats usually present with a high incidence of serum creatinine and bun elevations. 28, 29 coagulation factor abnormalities are more commonly associated with hemangiosarcoma, although dic may be evident in end-stage liver cancer or in decompensated patients. coagulation studies should always be performed before undertaking invasive diagnostic procedures. 23 serum α-fetoprotein has been evaluated in the dog, and increases are reported in 75% of animals with hepatocellular carcinoma, and in 55% of those with biliary carcinomas. the use of this biomarker is limited by the fact that it is increased in cases of hepatic lymphoma and other liver pathologies, and only very dramatic elevations in α-fetoprotein may be taken to indicate hepatocellular carcinoma. [37] [38] [39] abdominal radiographs often reveal a mass effect in the cranial abdomen, although this finding will depend upon the size of the neoplasm and the number and size of metastatic tumors. other reported findings include dorsal displacement of the stomach, hepatomegaly, loss of abdominal detail (because of the presence of free abdominal fluid), and, occasionally, biliary tract calcification. thoracic radiography should be considered as part of the staging procedure for animals with metastatic disease. 25, 40 changes in the ultrasound density of the liver may take a variety of forms (box 61-3). most changes are not pathognomonic for a given disease process, and the final diagnosis is established only on the basis of clinical findings, laboratory testing, and results of cytology or histopathology (see . ultrasound is also very useful for evaluating other abdominal structures, and for the staging of cancer. [40] [41] [42] • diffuse or multifocal liver neoplasms tend to present with hepatomegaly, but this depends on the degree of infiltration. liver carcinomas can be diffuse or affect multiple lobes, with variable ultrasound characteristics depending on the presence of necrosis, inflammation, hemorrhage, or cavitation. in these malignant tumors it is common to observe a mixed echogenicity pattern. lymphoma can affect the liver without detectable ultrasound changes, or cause diffuse hypoechogenicity, hyperechogenicity, or mixed echogenicity with or without hypoechoic nodules. consequently, if lymphoma is suspected, even if the liver ultrasound findings appear normal, fine-needle aspiration cytology is recommended. histiocytic neoplasms are more often associated with multiple nodules and hypoechoic masses, although diffuse liver hypoechogenicity has also been described. mast cell infiltration of the liver tends to produce diffuse hyperechogenicity. • nodular patterns • benign nodular hyperplasia is common, particularly in dogs, and accounts for many of the focal liver lesions identified at ultrasound exploration. it has been estimated that 25% to 36% of all nodular masses detected in the liver are nodular hyperplasia. • benign liver adenomas or hepatomas can manifest as a focal mass of variable size and of normally hyperechoic characteristics. • the liver is a frequent location of metastatic spread, fundamentally through the portal system that drains most of the abdominal structures. • primary liver neoplasms such as hepatocellular carcinoma can present as focal or multifocal masses, although less often so than in the case of metastases. focal hypoechoic lesions with a hyperechoic center or core (referred to as target or bull's-eye lesions) are usually associated with metastases, although some benign processes, such as nodular hyperplasia, can generate similar patterns. • biliary obstruction: ultrasound has become an important tool for evaluating biliary obstruction in icteric dogs and cats. primary tumors of the liver, biliary tract, duodenum, or pancreas are capable of causing biliary obstruction. liver cytology has obvious limitations in that it cannot distinguish between liver adenomas and regenerative nodules, and even some hepatocellular carcinoma aspirates may be composed entirely of normal-appearing hepatocytes. in many cases it may prove necessary to resort to ultrasound-guided biopsy, laparoscopy, or exploratory laparotomy. however, cytology may prove useful in determining the presence of lymphoma, mastocytoma, and histiocytic sarcoma, as well as contribute to the initial classification of tumor type. concordance rates between cytology and histopathology findings may be good for some disease processes, but the reported concordance rate varies from 14% to 86%. 44, 45 the treatment to be provided and the prognosis of animals with primary liver cancer depend on the cell of origin, degree of malignancy, and clinical presentation. the clinician should quickly determine if surgery, chemotherapy, radiation therapy, or palliative care is the treatment of choice in individual patients. palliative treatment is the option for animals that are not surgical candidates, for example, tumors with poor response to systemic chemotherapy, and for whom pain management and general liver failure treatment are the best recommendations. the success of newer options such as chemoembolization, metronomic therapy, antiangiogenic drugs, and tyrosine kinase inhibitors in the treatment of these patients has not been clearly established. [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] the macroscopic presentation is clinically very important (see figure 61 -26), as 100% of the diffuse forms have metastasis at the time of diagnosis, versus 37% of the isolated (massive or nodular) clinical presentations. 27 it should be noted, however, that some dogs with massive hcc present without metastasis, and deaths in these cases may be unrelated to hcc. 1, 26, 54 histopathologic subtype and anaplastic characteristics in general influence the prognosis and predictability of metastasis. 1, 26, 55 metastatic spread usually affects the regional lymph nodes, lungs, and peritoneum. 26, 56 high-field mri scanning has an accuracy of 94% in differentiating malignant from benign lesions with a sensitivity and specificity of 100% and 90%, respectively. mri classified malignant hepatic lesions as hcc in all confirmed cases and correctly predicted the histologic grade of five hcc lesions. these results suggested that mri is a useful modality for abdominal imaging in veterinary patients, and that mri accurately differentiates benign from malignant focal hepatic lesions. 43 liver cytology is useful in the initial evaluation of hepatomegaly and usually permits differentiation between primary tumors, metastatic disease, and focal infection (see . however, cytology does not distinguish between benign focal inflammatory disease and progressive chronic liver disease, and it cannot establish the extent and distribution of disease. likewise, a definitive diagnosis of regenerative nodular hyperplasia cannot be established, and the technique is unable to differentiate a benign inflammatory reaction from cell changes associated with other pathologies. contraindications to ultrasound-guided cytology include the following: • coagulation abnormalities-if one or more coagulation test parameters are altered, it is advisable to administer vitamin k 1 via the subcutaneous route 12 hours before cytology. • cavitary masses-the ultrasound detection of a large cavitary lesion in an elderly dog usually contraindicates cytology, a b tumors are more common in cats. 1, 13, 27, 61 three morphologic forms or presentations have been described: lobular, multifocal, and diffuse. in general, only the lobular form should be considered for surgical removal as long as there is no evidence of metastasis. the prognosis for multifocal and diffuse bile duct carcinomas is very poor, surgery is usually not feasible, and most animals die within 6 months of surgery. 29 no effective chemotherapeutic options have been described for these malignancies in dogs or cats. also known as biliary cystadenomas, biliary adenomas, cholangiocellular adenomas, and cholangiomas, these tumors are common findings in aging cats. males appear to be more frequently affected than females (figure 61-28 ). in cats, 50% of these lesions are isolated or lobular and 50% are multifocal. 59 biliary duct adenomas usually do not cause clinical signs unless they grow and compress other structures. 62 despite the benign nature of these tumors, surgical removal is usually recommended because malignant transformation is always possible and because expansion into the porta hepatis may cause life-threatening consequences. 63 liver lobectomy is recommended for cats with single bile duct adenoma or multifocal tumors confined to one or two lobes. in cats, surgical resection of biliary adenomas may provide cure or tumor-free survival of several years. 28, 29, 31, 59, 62, 63 carcinoid tumors neuroendocrine (carcinoid) tumors are infrequent in the dog and cat. in dogs, carcinoids have an aggressive biologic behavior and are usually not amenable to surgical resection as they tend to present as diffuse lesions (see figure 61 -25). 1, 27 carcinoid tumors in dogs have also been described in the gallbladder, and these have been managed successfully with cholecystectomy. 64, 65 carcinoid tumors in cats can be intrahepatic or extrahepatic involving the bile duct and occasionally the gallbladder. 65 the extrahepatic form of carcinoid tumors may cause biliary tract obstruction, icterus, and increases in serum hepatic enzyme activities. biliary tract diversion procedures should be considered for obstructive lesions involving the extrahepatic biliary tract. unlike the circumstance in dogs and humans, female cats are more often affected by these tumors than males (female-to-male ratio of 5 : 1). 66 the prognosis of carcinoid liver tumors in dogs and cats is generally poor, and metastatic disease is present in 90% of the cases at prognostic factors in dogs with massive hcc include need for surgery, liver lobe involvement, serum alt and ast activities, and ratios of alp to ast and alt to ast. 26 liver lobectomy is recommended for cats and dogs with hepatic tumors that have a massive morphologic appearance without metastases. however surgical complications are reported in more than 28% of cases, with a mortality rate of almost 12%. 26 the predilection of massive hcc for left-sided liver lobes has been reported. 27, 54 advanced imaging and intraoperative ultrasonography may provide useful information on the relationship of right-sided and central liver tumors to the caudal vena cava prior to liver lobectomy. 40, 41, 43 even though right-sided liver tumors have a poorer prognosis because of intraoperative death, there is no difference in the survival time after successful surgery. 26 the considerable regenerative capacity of the liver can permit successful resection of up to 80% of hepatic mass if the remaining tissue is functionally normal and critical supportive care is provided. 56 the median survival time for dogs with massive hcc following liver lobectomy is greater than 4 years. without surgery the average life expectancy is 270 days and the prognosis is generally considered poor. 26 tumor recurrence in dogs with massive hcc is rare and reported to be 0% to 13% after lobectomy. 26, 54 the prognosis for dogs with nodular and diffuse hcc is poor. surgical resection is usually not possible because of involvement of multiple liver lobes. no effective systemic chemotherapy or radiation therapy protocols have been described for hcc treatment. hcc is considered chemoresistant in humans although mitoxantrone has been reported to be helpful in some cases. 7, 56, 57 the most likely reason for the poor response to systemic chemotherapy is the expression of p-glycoprotein in hepatocytes. 22 treatment options for nodular and diffuse hcc in humans include liver transplantation and minimally invasive procedures for regional control, such as ablation, chemoembolization, immunotherapy, hormonal therapy, and low-dose metronomic chemotherapy. 56, 58 a recent report recommends therapy with sorafenib, a multikinase inhibitor and antiangiogenic agent. 47, 48 chemoembolization is a procedure commonly used in the treatment of diffuse hepatocellular carcinoma in humans with median survival times of 1 to 2 years compared with 3 to 6 months with systemic chemotherapy. 52, 51 in veterinary medicine, chemoembolization has been reported with moderate success in the palliation of four dogs with hcc. 52, 53 in cats, hepatocellular carcinoma is less frequent, and less data are available. 28, 59 hepatocellular adenomas these tumors are also known as hepatomas and are more common in cats than in dogs. in the dog it is sometimes very difficult to distinguish adenoma from reactive nodular hyperplasia, and biopsy is needed to clarify the diagnosis. the prognosis for adenomas is usually good, but it is advisable to remove focal mass lesions because they can grow and spontaneously rupture with severe bleeding. 19 bile duct carcinoma (adenocarcinoma and cholangiocarcinoma) bile duct carcinoma is the most common liver malignancy in the cat, and the second most common liver malignancy in the dog (see figure 61 -27) . tumor behavior is very aggressive in both species, and metastases are present at the time of diagnosis in 60% to 88% of cases. bile duct carcinomas usually metastasize to the regional lymph nodes, lungs and peritoneum, kidneys, heart, adrenal glands, eye, and bone. 1, 60 bile duct carcinoma can be intrahepatic or extrahepatic, but rarely occurs within the gallbladder. intrahepatic bile duct tumors are more common in dogs, and extrahepatic bile duct must always be considered as a possibility when a hepatic tumor is diagnosed. benign mesenchymal neoplasms, such as fibroma and hemangioma, have been described but are quite rare. 6, 1, 29, 59 lymphoma in dogs the liver can be involved in variable forms of lymphoma, including multicentric, alimentary, and hepatosplenic forms. a study in cats documented that abdominal lymphoma is currently the most common anatomic location and the liver occasionally is the only organ involved. 69, 70 many protocols are recommended for treatment of lymphoma in dogs and cats; most include vincristine, cyclophosphamide, and prednisone, with variable combinations of l-asparaginase, methotrexate, and doxorubicin. careful evaluation of liver function is necessary before starting chemotherapy because many drugs undergo hepatic metabolism and altered hepatic clearance may lead to unpredictable and potentially increased toxicity. 5 surgical resection with liver lobectomy is recommended for cats with primary hepatic myelolipoma and the prognosis is excellent with prolonged survival time and no reports of local recurrence. 7 in dogs with advanced disease, mast cell tumors can metastasize to the liver. primary visceral mast cell tumors are more common in cats than dogs. the spleen is usually the primary site with metastasis to the liver and bone marrow, and the survival time with splenectomy alone can be a year or more. 71 the overall prognosis for disseminated mast cell tumor in the dog is grave. the median survival time reported in one study was 43 days despite therapy with various chemotherapy agents. 72 canine mastocytoma involving the liver can be controlled with cyclophosphamide, vinblastine, and prednisone. 73 recently, tyrosine kinase inhibitors have shown some promise and ccnu has been shown to be active against feline mast cell tumors. 49, 74 hepatic nodular hyperplasia is a common benign lesion observed in the liver of older dogs that can occasionally be observed in some cats. it is characterized by a discrete accumulation of hyperplastic hepatocytes arising as either macroscopic or microscopic hepatic nodules. it reportedly occurs in 70% of dogs older than 6 years and 100% of dogs over 14 years. [75] [76] [77] the wsava standards for clinical and histologic diagnosis of canine and feline liver diseases include hepatic nodular hyperplasia in its classification system of hepatocellular neoplasia so that it may be differentiated from true neoplasia. 78 the etiology of hepatic nodular hyperplasia is unknown. it has been suggested to be a preneoplastic lesion, 76 but this has not yet been reported in the dog. 77 because of hepatocyte microscopic changes, it is suggested that nutritional and metabolic disorders play a role in the pathogenesis of this lesion. 77 hepatic nodular hyperplasia is characterized microscopically by well-differentiated hyperplastic hepatocytes with increased mitotic activity. [75] [76] [77] hyperplastic nodules may be accompanied by concurrent focal intrahepatic cholestasis, mechanical compression on a higado b the time of diagnosis. 7 a better prognosis is observed with extrahepatic carcinoids with a life expectancy of more than a year. 64, 65 liver sarcomas primary liver sarcomas are rare in the dog and cat. hemangiosarcoma is the most frequent primary hepatic sarcoma in cats and leiomyosarcoma the most common in dogs. 7, 19 there also have been reports of hepatic fibrosarcoma, rhabdomyosarcoma, osteosarcoma, liposarcoma, and histiocytic sarcomas in both animal species. 1, 28, 29, 55 these are usually very aggressive tumors, metastasizing in 86% to 100% of cases to the spleen and lungs, or spreading diffusely within the liver. 5 chemotherapy has not been studied in the treatment of primary hepatic sarcomas, although, similar to other solid sarcomas, response rates are likely to be poor. histiocytic sarcomas respond partially to ccnu, with a mean duration of remission of 85 days and a survival of 172 days. 67 continuous low-dose oral chemotherapy may be an effective alternative to conventional high-dose chemotherapy for adjuvant therapy of dogs with hemangiosarcoma. 50 mass resection may offer some palliation in the circumstance of tumor hemorrhage despite irrefutable evidence of metastasis. a cat with a primary extraskeletal hepatic osteosarcoma was treated with surgery and carboplatin and was alive 42 months after diagnosis with no clinical evidence of disease. 68 on the other hand, metastases feline hepatic lipidosis (hl) is a metabolic syndrome found in obese, middle-aged cats that undergo a period of acute anorexia and catabolism. morbidly obese cats are at increased risk and more than 85% of cats with hl suffer from an underlying disorder that contributes to the initial anorectic event. [1] [2] [3] [4] [5] although the underlying pathogenesis of hepatic lipid accumulation in cats has not yet been completely elucidated, several unique biochemical and nutritional features place this obligate carnivore at risk for fat mobilization and fatty infiltration of the liver during periods of anorexia or starvation (box 61-4). 2, [6] [7] [8] [9] [10] [11] there is a general consensus that reduced caloric intake and protein-calorie malnutrition are important predisposing factors. the result is a rapid mobilization of peripheral fat culminating in fatty accumulation in the liver. 1 intracellular processing of fats is an important function of the hepatocyte. during fasting or starvation, fatty acid metabolism becomes deranged in an obligate carnivore as a result of obesity, catabolism, chronic overnutrition, impaired fatty acid oxidation or vldl secretion, and enhanced hepatic fatty acid synthesis ( figure 61 -29). 1,6-11 hl is a disorder of middle-aged to older cats; domestic short-haired cats are more commonly affected. cats with hl often present with a history of acute stress and/or near-complete anorexia of several days duration. [1] [2] [3] icterus is a variable feature of hl. when serum bilirubin concentrations exceed 1.5 mg/dl, clinical icterus can be observed on the pinnae, mucous membranes, sclera, and hard palate in the cat. in general, most cats with hl are obese at the time of presentation, with many cats being 20% to 30% over ideal body weight prior to an episode of hl. other physical features of hl include hepatomegaly, dehydration, vomiting, and weakness. if he develops as a consequence of hl, neurologic abnormalities such as ptyalism, stupor, coma, ataxia, and seizures may be observed. [1] [2] [3] a minimum database, including complete blood cell count, serum chemistry, and urinalysis, almost always reveals severe liver enzyme elevation and other abnormalities such as nonregenerative anemia, stress leukogram, poikilocytosis, and bilirubin crystalluria. 1 the pattern of liver enzyme elevation is typically cholestatic in nature and characterized by marked increases in serum alp activity, followed by smaller increases in serum alt and serum ast activities. serum ggt activity is often normal in affected cats. increased serum bile acids and bilirubin are often observed in cats with hl, and electrolyte abnormalities, such as hypophosphatemia and surrounding hepatic parenchyma, as well as alterations in the microvascular circulation. vacuolar changes are seen frequently, suggesting a reactive or metabolic condition such us hyperadrenocorticism, lipidosis, or hypothyroidism. 77 nodular hyperplasia affects older dogs with a mean age of 11 years without gender or breed predisposition. hepatic nodular hyperplasia does not appear to cause clinical signs or illness. 77 laboratory findings may include mild to marked increases in serum alkaline phosphatase activity and, less commonly, increases in serum alt activity. liver function tests are usually normal with hepatic nodular hyperplasia. 77 hepatic nodular hyperplasia is usually discovered as an incidental finding during a diagnostic workup for other medical problems. nodular hyperplasia is clinically important because it may easily be confused with primary or metastatic hepatic neoplasia during abdominal ultrasound or at surgery. even microscopically, it may be impossible to differentiate hepatic nodular hyperplasia from hepatocellular adenomas, and a large sample (wedge rather than needle biopsy) may be required to confirm hyperplasia from welldifferentiated hccs. [75] [76] [77] routine abdominal radiographs are generally unremarkable and ultrasonographic features are inconsistent because of the varied hepatocellular morphologic characteristics and size of the nodules. 79 multiple nodules varying in size, distributed randomly among the liver lobes, being superficial or deep within the parenchyma are found in most cases. 77 hyperplasic nodules of hepatocytes need to be differentiated from regenerative nodules. hyperplasic nodules develop in livers of normal mass, whereas regenerative nodules arise as a result of compensatory hyperplasia of surviving hepatocytes in a background of hepatic injury, atrophy, and fibrosis. no treatment is usually required. rupture of large nodules may require emergency mass removal and blood transfusion (rare). hepatic nodular hyperplasia has no significance in the morbidity of affected patients. 77 metabolic disorders of the liver are commonly encountered in companion animal practice. this section focuses on the metabolic liver disease induced by concurrent endocrinopathies (hyperthyroidism, hypothyroidism, diabetes mellitus, and hyperadrenocorticism), lipid disturbances (lipoproteinemias, feline hepatic lipidosis, and hyperlipidemias), and metabolic infiltration (amyloidosis). hepatic lipidosis and hyperthyroid hepatopathy are the primary metabolic hepatopathies in cats. in dogs, steroid (or glycogen vacuolar) hepatopathy is the most frequent metabolic liver disorder; diabetic hepatopathy and hyperlipidemic hepatopathies (lipoproteinemias, hypothyroidism) occur less commonly. • essentiality of dietary arginine 6 • low levels of hepatic ornithine 7 • high dietary protein requirements 7 • lack of hepatic enzyme adaptation to low protein 8 • insufficiency of hepatic glutamate reductase 7 • insufficiency of intestinal ornithine transcarbamylase 7 • diversion to orotic acid metabolism 9 • differences in lipoprotein metabolism (hdls) 10, 11 to 90 kcal/kg body weight in most cats. 1, 18 unless he is present, dietary protein should not be restricted (ideal is 35% to 45% protein on a dry matter basis) and even then protein restriction is controversial as protein is needed to support hepatic regeneration. feeding multiple small frequent meals may help to maintain euglycemia and lessen the metabolic impact on the liver. the protein content of the diet should be considered when he is present (see chapter 32). dairy and vegetable-based proteins are higher sources of branchedchain amino acids than meat-derived proteins and may lessen the signs of he. diets high in fiber generally should be avoided because they decrease the nutrient density of the diet. cats with hl occasionally may experience a refeeding syndrome, a condition that results in metabolic and electrolyte disturbances. 12 with the reintroduction of food, insulin secretion promotes intracellular uptake of phosphorus, potassium, and magnesium. hypophosphatemia can result in muscle weakness and hemolytic anemia. gradual reintroduction of food and correction of electrolytes diminishes the risk of refeeding syndrome. glucose intolerance and hyperglycemia are common in cats with hl and can be addressed by decreasing the carbohydrate content of the diet. canned low-carbohydrate, high-protein formulations without added fiber are ideal for the treatment of feline hl as they provide amino acids, limited carbohydrates, and water, and are easily administered through a feeding tube. small amounts of food should be administered via the feeding tube after residual gastric fluid contents have been removed. trickle feeding can be performed by placing liquefied food into an empty fluid bag and allowing gravity to force flow into the feeding tube. alternatively, a large-bore hypokalemia, may be frequently observed. in particular, the presence of hypophosphatemia should alert the clinician to the possibility of refeeding syndrome. 12 presumptive diagnosis of feline hl can be made on the basis of clinical history, physical examination, clinicopathologic features, ultrasound examination, and liver aspirates. 1, [13] [14] [15] ultrasound examination of the liver often reveals hepatic parenchyma that is hyperechoic to that of falciform fat, but a thorough ultrasound evaluation of the gallbladder, pancreas, intestines, kidneys, bladder, and other abdominal structures is essential to rule out other primary disorders, such as acute pancreatic necrosis, which may be the basis of the anorectic event precipitating an episode of hl. definitive diagnosis is best achieved through liver biopsy 16 ; however, anesthesia and biopsy may not be possible in acutely ill patients because of the presence of coagulopathies from vitamin k deficiency. 17 a liver aspirate that reveals more than 80% fatty infiltration of the hepatocytes may be used for presumptive diagnosis of hl. if there is no response to treatment after 3 to 5 days, liver biopsy may be necessary to rule out other underlying hepatobiliary conditions such as cholangitis. a catabolic state develops quickly in the anorexic cat and prompt measures should be taken to place an enteral feeding tube (table 61-9) . nasoesophageal, esophageal, and gastrostomy tubes can be used for this purpose. the caloric needs should be approximately 60 increases in serum ast and alt activities have been reported in approximately 80% of hyperthyroid cats. 22, 23 liver enzyme elevation has been attributed to increased liver metabolic activity compared to blood flow. long-term untreated hyperthyroidism in human beings can ultimately lead to cirrhosis. [24] [25] [26] middle-aged to older cats are typically affected, and there is no breed or sex predilection. because hyperthyroidism is characterized by hypermetabolism, polyphagia, weight loss, pd, and pu are prominent features of the disease. 22, 23 hyperactivity, tachycardia, pupillary dilation, and behavioral changes are also characteristic of the disease and are associated with activation of the sympathetic nervous system. long-standing hyperthyroidism leads to hypertrophic cardiomyopathy, high-output heart failure, and cachexia. long nails, dermatologic conditions, panting, elevated body temperature, and poor grooming or overgrooming are additional clinical signs of feline hyperthyroidism. clinicopathologic features of hyperthyroidism include erythrocytosis and stress leukogram (neutrophilia, lymphocytosis) caused by increased circulating catecholamine concentrations. increased catabolism of muscle tissue in hyperthyroid cats may result in increased bun, but not serum creatinine. most cats will have decreased urine specific gravity, particularly if they are exhibiting pu as a clinical sign. increased metabolic rate results in liver hypermetabolism, therefore serum activities of liver enzymes (alt, ast) are increased in more than 80% of hyperthyroid cats. 22, 23 diagnosis diagnosis of feline hyperthyroidism is achieved by measurement of serum total thyroxine (tt 4 ) concentration. serum thyroxine concentrations are elevated in more than 90% of hyperthyroid cats, making this a very sensitive test of thyroxine-induced hypermetabolism. 22, 23 false-positive test results are rare to nonexistent, suggesting that hyperthyroxinemia is a specific test for feline hyperthyroidism. in a clinically hyperthyroid cat, thyroid hormones still fluctuate on a daily (and hourly) basis with hormone concentration intermittently decreasing into the normal range. 27 to avoid this type of diagnostic error the clinician should repeat blood sampling 1 to 2 weeks after the first test. nonthyroidal disease can have a significant effect on circulating thyroid hormone concentrations. [28] [29] [30] in the case of persisting nonthyroidal illness (e.g., renal disease), the syringe attached to a syringe pump may be useful in delivering the food through the feeding tube. crystalloid fluids supplemented with fortified b vitamins, including thiamine, riboflavin, niacinamide, d-panthenol, pyridoxine, and cyanocobalamin, should be used. 1 nutritional supplements to enhance antioxidant function, such as vitamin e and glutathione precursors (e.g., same) may also be beneficial. amino acid supplements that support hepatic regeneration and metabolism include carnitine and taurine. 1, [18] [19] [20] carnitine functions in the transport of fatty acids into hepatic mitochondria for energy production. taurine is an essential nutrient for cats and is involved in cns, cardiac, and biliary functions. signs of taurine deficiency may be similar to those associated with he. antiemetic therapy is necessary to control vomiting and facilitate feeding of an appropriate type and quantity of diet (see chapters 23 and 35) . injectable antiemetics, such as maropitant (cerenia, pfizer animal health, kalamazoo, mi), a selective nk-1 receptor antagonist, at a dosage of 1 mg/kg sc or iv on a daily basis, is preferred. 21 oral maropitant at the same dosage or oral ondansetron, a 5-ht 3 receptor antagonist at a dosage of 0.1 to 1.0 mg/kg q12-24 h may be used in cats with larger-bore feeding tubes. persistent vomiting should be investigated to identify feeding tube occlusion or other undiagnosed disease. the prognosis depends upon duration of illness, and the time frame of resolution of hepatic enzyme elevation, hyperbilirubinemia, and other biochemical changes. cats that survive an episode of hl have a greater than 50% reduction in liver enzyme and bilirubin concentrations within 10 days of therapy, whereas cats that die usually do so within 7 days of hospitalization. 1 long-term prognosis for recovery is good with the majority of cats having resolution of hl as long as the underlying disease process (e.g., pancreatitis) is identified and treated. hyperthyroidism in cats is caused by adenomatous hyperplasia of the thyroid gland resulting in increased circulating concentrations of thyroxine and triiodothyronine. 22, 23 hyperthyroxinemia increases hepatic metabolism without proportionate increases in hepatic blood flow with the overall consequence of reduced oxygen delivery to hepatocytes. 24 characteristic lesions of superficial necrolytic dermatitis (hard, cracked foot pads and elbows). painful feet caused by footpad lesions are common. clinicopathologic features include mild nonregenerative anemia, microcytosis (with advanced liver dysfunction), increased serum liver enzyme (alp and alt) activities, hypoproteinemia, hypoalbuminemia, and fasting hyperglycemia. serum bile acids are usually increased. serum glucagon is inconsistently elevated, but plasma amino acid concentrations are often less than 50% of normal. 34, 37 diagnosis abdominal ultrasonography may reveal small, normal or increased liver size; however, there usually is a characteristic "swiss cheese" appearance of the hepatic parenchyma as a result of hepatic degeneration, nodularity, and collapse. 36, 38 pancreatic imaging and biopsy are indicated if a glucagonoma is suspected. symptomatic palliative therapies may be beneficial and include high-protein diets with egg white (approximately 2 to 4 egg whites/ day for a 25-kg dog), zinc (2 mg/kg q24h po) niacinamide (250 to 500 mg/dog q24h po), ursodeoxycholic acid (10 to 15 mg/kg/day po), vitamin e (10 iu/kg daily po), same (20 mg/kg/day po 2 hours before feeding), and fatty acid supplementation. some patients will respond to 10% parenteral amino acid solutions (aminosyn, abbott laboratories, chicago) given at a dose of 500 ml over 8 to 12 hours intravenously through a large-bore central venous catheter. if no response is observed following the initial amino acid infusion, therapy should be repeated every 7 to 10 days for a total of four treatments. prognosis is poor for most cases; however, remissions of longer than 2 years have been reported with intensive amino acid and hepatic support therapy. 37 steroid hepatopathy develops following exogenous corticosteroid therapy, or from endogenous hyperadrenocorticism of pituitary or adrenal origin. the dog liver is uniquely susceptible to both glucocorticoid-and sex steroid-induced liver enzyme elevation, glycogen accumulation, and vacuolar degeneration. 39, 40 pathophysiology in healthy dogs, glucocorticoid administration results in significant liver enzyme (alp and alt) elevation in 2 to 3 days. increased alp and ggt activities develop in parallel as the enzymes undergo induction and release from sinusoidal and canalicular membranes. within 7 days of glucocorticoid administration, the glucocorticoidinduced alp isoenzyme increases significantly. glycogen accumulates within the hepatocyte resulting in a vacuolar degeneration typical of the syndrome. 1, 39, 40 steroid hepatopathy occurs primarily in the dog. there is only one reported case of steroid hepatopathy in the cat. 41 a history of corticosteroid administration or signs consistent with endogenous steroid overproduction (cushing syndrome) are usually evident, for example, pd, pu, panting, potbellied appearance, bilaterally symmetric alopecia on the trunk, and polyphagia. in dogs affected with measurement of unbound thyroxine (t 4 ) or free t 4 may be preferable to repeated tt 4 measurements. free t 4 concentrations are a very sensitive test for the diagnosis of hyperthyroidism with 98% of hyperthyroid cats exhibiting elevated serum free t 4 concentrations. the specificity of free t 4 is not as good as its sensitivity; as many as 12% of euthyroid cats with concurrent illness will have high free t 4 concentrations for reasons that remain unclear. 29 as a result, free t 4 should not be used as a screening test, and free t 4 values should be interpreted in light of the tt 4 concentrations. the combination of a high free t 4 with a low tt 4 is indicative of nonthyroidal illness; however a high free t 4 with a high-normal tt 4 is suggestive of hyperthyroidisim. 31 methimazole (tapazole) is the antithyroid drug most often recommended (2.5 to 5 mg q12h). it is available as a transdermal gel or as an oral tablet. methimazole is often used to prepare the patient for surgical thyroidectomy or radioiodine therapy. antithyroid drugs have several side effects. anorexia and vomiting are common side effects of methimazole, whereas rare side effects include self-induced excoriation of the face, thrombocytopenia, bleeding diathesis, agranulocytosis, development of serum antinuclear antibodies, and cholangitis. bleeding, jaundice, and agranulocytosis necessitate immediate withdrawal of the drug. hepatic injury related to antithyroid therapy such as methimazole is well documented in humans and reported in the cat. 22, 32 mild histologic changes are common, but cases of fulminant hepatic failure with central lobular necrosis have been described. 33 prognosis is excellent with definitive therapy of the hyperthyroidism (surgery or radioactive iodine). hepatic reactions to methimazole will necessitate discontinuation of therapy. the etiology is unknown, but hypoaminoacidemia may play a role in the development of diabetic hepatopathy. 34, 35 fatty acid, niacin, and zinc deficiencies also may be involved in the pathogenesis. increased serum glucagon, originally thought to be the cause of diabetic hepatopathy, is found in only one-third of the reported cases. a much stronger association between the skin lesions of superficial necrolytic dermatitis and glucagonoma, hyperglucagonemia, and poorly regulated diabetes mellitus have been observed in both humans and dogs. 34, 35 pathophysiology hepatopathy is thought to occur secondary to the metabolic abnormalities associated with diabetes mellitus, glucagonoma, or nutritional deficiencies. [34] [35] [36] [37] hepatic features include vacuolar hepatocyte degeneration, hepatic parenchymal collapse, and hepatic nodularity. the disorder is seen most frequently in middle-aged male dogs, and has been reported in one cat. [34] [35] [36] [37] acute presentations may include clinical signs such as vomiting, diarrhea, lethargy, weight loss, pd, pu, icterus, and lameness because of dermatopathy of the footpads. in some cases clinical signs are mild or nonexistent. physical examination may reveal poor body condition, lethargy, and lipoproteinemias etiology genetic abnormalities in lipid metabolism lead to diffuse vacuolar hepatopathy and biliary mucoceles. 1 increased circulating cholesterol and triglyceride cause a vacuolar hepatopathy associated with excess lipid accumulation and/or hepatocyte glycogen synthesis and storage. chronic hypercholesterolemia increases biliary cholesterol content and predisposes to cystic hyperplasia, dysmotility of gallbladder smooth muscle, and biliary mucocele. 1 familial hypercholesterolemia and other hyperlipidemias are found in certain breeds of dogs including the miniature schnauzer, shetland sheepdog, briard, west highland white terrier, scottish terrier, cairn terrier, and beagle. mixed-breed dogs may also be affected. clinical signs are usually associated with necrotizing cholecystitis and may include icterus and cranial abdominal pain. more often, dogs are asymptomatic and biliary mucoceles are identified serendipitously during ultrasound evaluation for some other medical problem (such as pancreatitis). clinical pathology findings usually include hypercholesterolemia or hypertriglyceridemia, and elevated liver enzyme activities, particularly alp. necrotizing cholecystitis may be accompanied by leukocytosis, neutrophilia, and hyperbilirubinemia. diagnosis may be made by characteristic ultrasound findings of nongravitational gallbladder sludge, increased gallbladder wall thickening, "kiwi"-shaped mucosal image, and bi-or trilaminar appearance of the gallbladder wall. the hepatic parenchyma may have a pattern of multifocal hyperechogenicity and hypoechoic nodules. 1 the best treatment for biliary mucoceles is surgical removal of the mucocele and/or cholecystectomy and may become an emergency procedure if the clinical signs of necrotizing cholecystitis are severe. medical therapy following surgical removal is usually necessary and includes a fat-restricted diet and lifelong treatment with ursodeoxycholic acid (15 mg/kg po q24h). prognosis is good for patients undergoing successful removal of the mucocele as long as lifelong medical therapy is continued. in dogs and cats, amyloid deposition is usually secondary to sustained systemic inflammatory response, for example, chronic infection, chronic inflammation, immune disorders, and malignancy. 50 amyloidosis is a familial disorder in the chinese shar-pei dog, and in abyssinian, oriental, and siamese cats. [51] [52] [53] [54] hepatic amyloidosis has also been reported secondary to vitamin a toxicity in cats. 55 pathophysiology deposition of amyloid fibrils within and between hepatic sinusoids results in progressive organ dysfunction. light deposits are found in the space of disse and heavier deposits are often found in the atypical hyperadrenocorticism caused by sex steroid overproduction, dermatologic changes (alopecia, poor hair coat) and reproductive manifestations (perianal adenoma in a castrated male or female dog) are often the only signs suggestive of sex steroid imbalance. atypical hyperadrenocorticism with sex steroid excess may present with no clinical signs except increased serum liver enzyme activities. 1 diagnosis of steroid hepatopathy should be based on a history of exogenous steroid administration or endocrine function testing with or without liver biopsy. classically, liver enzyme elevations consist of moderate to marked increases in alp and ggt, and mild to moderate increases in alt and ast. bile acids may also be increased. 40 the low-dose dexamethasone suppression (ldds) test is considered the screening test of choice for endogenous canine hyperadrenocorticism. 42, 43 the ldds test has a high sensitivity at 92% to 95%. only 5% to 8% of dogs with pdh will exhibit suppressed cortisol concentrations at 8 hours. in addition, 30% of dogs with pdh will exhibit suppression at 3 or 4 hours followed by "escape" of suppression at 8 hours. this pattern is considered diagnostic for pdh, making further testing unnecessary. 43 the major disadvantage of the ldds test is the lack of specificity in dogs with nonadrenal illness. 44 the corticotropin (acth) stimulation test is used to diagnose a variety of adrenopathic conditions, including endogenous or iatrogenic hyperadrenocorticism, as well as spontaneous hypoadrenocorticism. 42, 45, 46 as a screening test for the diagnosis of naturally occurring hyperadrenocorticism, the acth response test has a diagnostic sensitivity of approximately 80% to 85% and a higher specificity than the ldds test. 45, 46 in a study by kaplan and peterson, only 15% of dogs with nonadrenal disease exhibited exaggerated response to acth stimulation. 44 i prefer the acth response test over the ldds test as the acth response test is more accurate for the diagnosis of iatrogenic hyperadrenocorticism (if the history is incomplete) and sex steroid imbalance in addition to pdh or adrenal-dependent hyperadrenocorticism. the urine cortisol-to-creatinine ratio (uccr) is highly sensitive in separating normal dogs from those with hyperadrenocorticism; however, the test is not highly specific for hyperadrenocorticism because dogs with moderate to severe nonadrenal illness also exhibit elevated ratios. [47] [48] [49] an elevated uccr should always be confirmed with an ldds test. in the uccr test, urine is collected for 2 days for a baseline uccr. the animal then is given three doses of dexamethasone (0.1 mg/kg, po q6-8 h) and the final uccr is collected 24 hours after the first dose of dexamethasone. failure of the uccr to suppress into the normal range is diagnostic for hyperadrenocorticism. treatment for exogenous hyperadrenocorticism consists of discontinuation of exogenous steroids by slowly weaning the patient to prevent the development of addisonian crisis. treatment for endogenous hyperadrenocorticism can be achieved with chemotherapy (o,p′-ddd, or trilostane) or surgery (hypophysectomy or adrenalectomy). treatment of sex steroid imbalance can be achieved with mitotane or trilostane. prognosis for steroid hepatopathy is good to excellent if diagnosed early and if corticosteroid injury can be abated by discontinuation of steroid therapy or treatment of the underlying disorder. threefold increases in the frequency of hypothyroidism. 61 the pathogenesis of stone formation in hypothyroidism is believed to involve hypercholesterolemia, gallbladder dysmotility, and bilirubin retention. 61 the most common clinical symptoms of hypothyroidism are lethargy, weight gain, depression, hypothermia, and bradycardia. gi signs such as reflux esophagitis, gastric atony, constipation, diarrhea, and hepatopathy with mucocele formation are rare clinical signs of hypothyroidism in dogs. 62 symmetric truncal or tail-head alopecia are a classic findings in hypothyroid animals. 62 hyperkeratosis, hyperpigmentation, secondary pyodermas, and demodicosis are also observed. clinicopathologic findings such as normocytic normochromic anemia, hypertriglyceridemia, and hypercholesterolemia are seen in the majority of hypothyroid animals because of altered lipid metabolism and binding proteins (increased hdls), decreased fecal excretion of cholesterol, and decreased conversion of lipids to bile acids. 63 total serum t 4 concentration and endogenous thyroid-stimulating hormone (tsh) may be used to confirm the diagnosis of hypothyroidism. this combination of tests has been shown to have the highest specificity, sensitivity, and lowest overall cost. if the tt 4 is in the low normal or below normal range and the tsh is high, the animal is suffering from primary hypothyroidism. 64, 65 if the tt 4 and tsh are both low, free t 4 by dialysis should be determined to distinguish euthyroid sick syndrome (normal free t 4 ) from true secondary hypothyroidism (low canine thyroid stimulating hormone [ctsh] resulting from pituitary tsh deficiency). 66 treatment synthetic thyroid hormone supplementation is the treatment of choice for hypothyroidism. levothyroxine sodium therapy is started at a dosage of 0.02 mg/kg given orally twice daily. 66 thyroid function should be monitored every 6 to 8 weeks for the first 6 to 8 months of treatment and then once or twice yearly thereafter. in stable well-controlled animals, the total treatment may be given once daily with excellent clinical results, as long as adequate peak hormone concentrations are achieved. 67 with thyroid hormone replacement therapy in hypothyroid dogs, the prognosis is excellent. inflammatory disease involving the intrahepatic bile ducts is commonly encountered in veterinary practice. cholangitis is recognized more commonly in cats than in dogs, but both species can be affected. the wsava liver standardization group suggests that cholangitis be considered in the following four groups: neutrophilic cholangitis (nc), lymphocytic cholangitis (lc), chronic cholangitis associated with liver fluke infestation, and destructive cholangitis. 1 sinusoidal lumen. amyloid fibrils are readily detected on routine hematoxylin and eosin or diff-quik staining. amyloidosis is confirmed on examination of congo red-stained aspirates or biopsies under polarized light where the extracellular material shows characteristic green birefringence. 50 concurrent amyloid deposition in the kidneys, liver, spleen, and adrenal glands can occur, but clinical manifestations of liver failure are most common. chronic progressive liver failure with clinical signs of anorexia, weight loss, and lethargy, is the typical clinical course in many cases. some animals may instead present with acute collapse following hepatic rupture and intraabdominal hemorrhage. 50 pallor of mucous membranes, hypothermia, and hepatomegaly are the most frequently recognized physical examination findings. typical laboratory findings include regenerative anemia, leukocytosis, thrombocytopenia, marked elevations in serum alt and ast, and marked prolongations in aptt and pt times. radiography is useful in detecting free peritoneal fluid, hepatomegaly, and irregular hepatic borders. ultrasonography reveals a diffuse, heterogeneous echogenicity with highly echogenic ("sparkling") areas and hypoechoic foci. 50 definitive diagnosis requires tissue biopsy and congo red staining. there are no specific treatments for this disorder. colchicine has been recommended because it may block formation of amyloid in the early stages of the disease, but it is of unproven benefit and has been associated with significant side effects. dimethyl sulfoxide has been recommended because it may promote resorption of amyloid. as there are no specific therapies for this disease, treatment is instead largely symptomatic and supportive. with progressive amyloidosis lesions, the prognosis for long-term survival is poor. a familial hyperlipoproteinemia has been reported in cats that is characterized by fasting hyperchylomicronemia, elevated circulating concentrations of vldls, and hypertriglyceridemia. 56, 57 serum cholesterol is only minimally elevated. the underlying biochemical lesion is a reduction in the activity of lipoprotein lipase, and the disorder is transmitted as an autosomal recessive gene. xanthomas accumulate in the soft tissues, including the liver, but clinical signs are more often related to involvement of the peripheral nerves. dietary fat restriction improves clinical signs in some affected animals. 58 etiology decreased circulating thyroid hormone concentration affect hepatic metabolism and cholesterol turnover in the liver. liver function tests are mildly disturbed in almost 50% of patients with hypothyroidism despite normal histologic findings. 59 pathophysiology decreased hepatic metabolism in hypothyroidism is reflected by reduced oxygen consumption. 33, 59, 60 patients with a common bile duct stone and gallbladder stone have, respectively, sevenfold and infection of bile has been commonly identified in cats with ehbdo, 4, 8 clinical examination. previous literature has highlighted differences in clinical presentation between cats with different forms of cholangitis. however, we have recognized few differences between the various forms 4, 9 and suggest that any statistically significant differences cited previously hold little clinical relevance given the large degree of overlap within data ranges. nc can occur in cats of any age, breed, or sex. clinical signs are nonspecific and include anorexia, lethargy, vomiting, and weight loss. the duration of these clinical signs ranges from a few days to a few months and may be shorter in cats with anc than in those with cnc, 3 but this is not a consistent finding. 4, 9 physical examination findings commonly include dehydration and icterus. fever is present in 19% to 37.5% of cases. 4,10 some reports suggest that fever is more commonly associated with anc than cnc, 10 while others recognize no difference. 4, 9 hepatomegaly is seen in fewer than half of the cases. abdominal pain is noted occasionally. 3, 4, 9 diagnosis. definitive diagnosis is made by examination of liver biopsy specimens, with ancillary diagnostics providing supportive information. hematologic findings are variable and may include poikilocytosis, neutrophilia, and left shift, although these abnormalities are present in fewer than one-third of cases. 3, 4, 9, 10 biochemical analysis commonly reveals increased activity of alt, ast, alp, and ggt ranging in severity from mild to severe. however, increased liver enzyme activity may be absent in some cases. serum total bilirubin is increased in most cases. serum cholesterol may become increased in cases with ehbdo. imaging findings are nonspecific for cholangitis, but may provide useful information regarding concurrent disease. abdominal radiographs are rarely helpful. ultrasonographic appearance of the liver in cats with nc can vary greatly, with the most common abnormality being a diffuse change in echogenicity ranging from hypo-to hyperechoic. 11 dilation of intra-and/ or extrahepatic bile ducts, gallbladder distention, increased gallbladder sediment, and thickening of the gallbladder or bile duct walls may be seen. gallbladder distention and bile duct dilation may indicate ehbdo, but these changes may occur in cats with cholangitis lacking obstruction. ultrasonography will also provide information regarding the presence of concurrent disease, such as pancreatitis and inflammatory bowel disease. wedge liver biopsy during laparotomy is the optimal method for obtaining a definitive diagnosis. other biopsy techniques that may be considered include laparoscopic and ultrasound-guided tru-cut needle approaches. tru-cut needle biopsy diagnoses correlate with wedge biopsies in fewer than 50% of cases. 12 diagnostic accuracy of laparoscopic liver biopsies compared with wedge biopsies have not been evaluated. laparotomy and laparoscopy provide the additional benefit of evaluation and sampling of extrahepatic structures. laparotomy should be performed in any cat suspected of having ehbdo. while the optimal sampling strategy is unknown, biopsies should be obtained from multiple liver lobes, as we have recognized wide ranges of severity between different lobes in the same cat. in patients that are not stable enough for liver biopsy, such as those with hypotension, coagulopathy or he, fine-needle aspiration with cytology offers a less-invasive diagnostic approach as it can usually be performed quickly with light sedation. however, liver cytology correlates with biopsy results in only 39% to 60% of cases. 13, 14 cytology is sensitive for identifying the presence of hl, however this is the most common misdiagnosis when using cytology. 14 cytology is cholangitis is a common hepatobiliary disorder of cats, second only to hl. 2 although varying terminology has created some confusion regarding this syndrome, it is clear that feline cholangitis includes a spectrum of disease processes, including forms displaying neutrophilic inflammation and those lacking neutrophilic inflammation. histologically, nc is characterized by the presence of neutrophils in the lumen and/or epithelium of the bile ducts. 1 the disease is recognized to occur in acute and chronic forms. in acute neutrophilic cholangitis (anc) edema and neutrophilic inflammation are seen in the portal areas, with occasional extension of inflammation to the hepatic parenchyma. in chronic neutrophilic cholangitis (cnc) there is a mixed inflammatory infiltrate consisting of neutrophils, lymphocytes, and plasma cells. varying degrees of bile duct hyperplasia and fibrosis will be present depending on the chronicity of disease. etiology. although the true etiology remains unknown, nc is largely suspected to be caused by ascending bacterial infection from the intestine. 1-3 rates of bacterial isolation using traditional methods have varied greatly, from less than 20% to more than 60% in affected cats. 3, 4 recently, fluorescence in-situ hybridization (fish) with a 16s rdna probe that recognizes bacteria in general has been used to identify and localize bacteria in cats with cholangitis. 5 combining traditional culture and fish, bacteria were isolated in three of three (100%) cats with anc and eight of 13 (61%) with cnc. the localization of the bacteria identified using fish supports translocation of enteric bacteria as the cause of infection. although it appears that bacteria play an important role in the etiology of nc in many cases, it is important to note that they are not identified in all affected cats. some authors theorize that nc, and cnc in particular, may have an immune-mediated etiology with persistent inflammation following an initial bacterial infection or other unknown initiating factor. 3, 6 pathophysiology. nc in cats is commonly associated with inflammatory bowel disease and pancreatitis. 3, 4, 7 the pathophysiology underlying the relationship of these diseases is unknown, but rational theories revolve around the unique anatomy of the feline biliary and pancreatic duct systems. in the cat, the common bile duct and pancreatic duct merge prior to entering the duodenum at the major duodenal papilla. 7 cholangitis may develop secondary to reflux of ascending bacteria from the duodenum during vomiting. pancreatitis may result from bacterial reflux into the pancreatic duct, or from pancreatic duct obstruction secondary to cholangitis. 7 in most reported cases, the inflammatory bowel disease associated with cholangitis is moderate or severe, whereas the pancreatitis tends to be mild chronic interstitial disease. 7 nc is also commonly associated with extrahepatic bile duct obstruction (ehbdo). ehbdo has been identified in 40% of cats with anc and 76% of cats with cnc. 4 cholangitis and/or pancreatitis are the most common cause of ehbdo in the cat. 8 in one study, 64% of cats with ehbdo had cholangitis, representing 93% of cats that did not have a neoplastic cause. 8 it is unknown whether cholangitis is the cause or the result of ehbdo. histologic changes consistent with cnc have been seen in the livers of cats with ehbdo secondary to pancreatic carcinoma, cholelithiasis and surgical occlusion of the common bile duct. 8 in contrast, cholangitis has been implicated as the sole cause of ehbdo resulting from proliferation of mucosa within the common bile duct. 8 bacterial choleretic properties that make it a rational choice for treating cholangitis. because of the possibility of immune-mediated mechanisms in the perpetuation of nc, particularly with cnc, corticosteroids may be appropriate in some cases. initial treatment should always involve antibiotics in cats with nc. failure to improve within 2 weeks of antibiotic therapy, or clinical deterioration prior to that time, warrants initiation of corticosteroid therapy. prednisolone at 1 to 2 mg/ kg twice daily is given initially and gradually tapered to the lowest effective dose. antibiotics should be continued concurrently with corticosteroids for a minimum of 4 weeks. the duration of corticosteroid therapy varies between individual patients. many cases can be gradually tapered off of corticosteroids over 4 to 6 months, while others require lifelong therapy. surgical intervention is required in cats with ehbdo; however, the optimal surgical procedure is unknown. biliary diversion (cholecystocholedochostomy, choledochoduodenostomy, or cholecystojejunostomy) and choledochal stenting are the most common procedures. surgery in cats with ehbdo is associated with significant perioperative morbidity. in many cases, profound hypotension develops intraoperatively after 45 to 60 minutes as a result of decreased vascular responsiveness and decreased myocardial contractility and is often refractory to interventions such as fluid or vasopressor therapy. 8, 18, 19 whichever surgical procedure is chosen, it is clear that anesthesia time should be minimized and long-term medical management will be necessary. biliary diversion is associated with short-term mortality rates of 36% to 57% 8, 18 and is associated with long-term complications. 8, 19 in a small case series describing choledochal stenting in cats with pancreatitis and cholangitis, five of seven experienced long-term survival (≥7 months), but reobstruction occurred in two of seven and chronic vomiting and recurrent cholangitis were reported. 19 prognosis. the prognosis for cats with nc is typically good. 3, 4, 10 survival to discharge was reported in 72% of all cats with cholangitis in one study. 4 median survival time of 29.3 months has been reported in cats with nc, with no difference between anc and cnc. 10 prognostic factors have not been identified. given the high rate of perioperative morbidity and mortality, it seems likely that cats with ehbdo have a worse prognosis than those without ehbdo. thirty percent to 40% of cats with ehbdo secondary to inflammatory disease die within a week of surgery. 8, 18 however, in those that survive to discharge, long-term survival has been reported. 18 the wsava liver standardization group describes lc as a common, slowly progressive, chronic disease of cats characterized histologically by infiltration of small lymphocytes (and occasionally plasma cells or eosinophils) restricted to the portal areas associated with varying degrees of fibrosis and bile duct hyperplasia. 1 they remark that inflammation centered on the bile ducts may be present, but is not a hallmark of the disease. it is also stated that welldifferentiated lymphoma may be difficult to differentiate from lc. based on the existing literature regarding lc in cats, the description from the wsava group includes several clinically and histopathologically different subsets that may or may not revolve around a common pathogenesis. recognition of these different subsets within the umbrella of lc may have therapeutic and prognostic ramifications. several investigators describe a group of cats with lc where inflammation is confined to portal regions and there is a lack of targeting of bile ductules or biliary epithelium. 2, 20, 21 this has been insensitive for identifying cholangitis in cats, diagnosing fewer than 30% of cases. 14 cytologic examination of bile may prove more sensitive for the diagnosis of nc in cats. in five of seven cats with cnc evaluated at this institution, bile cytology revealed neutrophilic inflammation, presence of bacteria, or both. techniques have been described for safely obtaining bile via ultrasound-guided percutaneous cholecystocentesis in lightly sedated cats. 15 samples for aerobic and anaerobic bacterial cultures should be obtained in any cat suspected of having cholangitis. gallbladder bile is preferred to liver tissue as the culture source. in a group of 58 cats suspected of having hepatobiliary disease, bile cultures isolated pathogens in 36% compared with only 14% of liver cultures. 16 in the same study, 22 dogs and cats had both liver and bile cultured and none had a positive liver culture in the absence of a positive bile culture. 16 in a group of cats with cholangitis, bile cultures were more likely to isolate pathogens (75% vs. 33%) and less likely to yield contaminants (4% vs. 29%) than liver cultures. 4 in a small study comparing bile versus liver cultures in 22 cats with various hepatobiliary diseases, bile culture was positive in five (four had cnc) while liver culture was positive in only two. in the two cats with positive liver cultures, the same organism was isolated from bile. 17 it is important to recognize that many cats with nc (and other hepatobiliary diseases that mimic it clinically) are not stable enough to tolerate diagnostic testing. in such patients, the risk of aggressive diagnostics may outweigh the benefits of obtaining a definitive diagnosis. in these cases, the diagnosis may be suspected based on clinical response to supportive care, including broad-spectrum antibiotic therapy. treatment. optimal treatment protocols for cats with nc are unknown and the recommendations herein are based solely on anecdotal clinical experience. antibiotics are the mainstay of treatment. drug selection is ideally based on results of bacterial culture and susceptibility testing. in cases where cultures are not performed, or while results are pending, broad-spectrum coverage should be provided. the most commonly isolated pathogens are aerobic and anaerobic bacteria of enteric origin, 16 including e. coli, enterococcus spp., and clostridium spp., among others. 3, 4, 16 effective empiric antibiotic combinations would include a penicillin, a fluoroquinolone, and metronidazole. the optimal duration of antibiotic therapy is unknown, but we recommend a 4-to 6-week course for initial treatment. supportive care and treatment of specific sequelae of liver disease should be included as indicated. nutritional support is required in many cats and is best accomplished by use of enteral feeding tubes. we recommend placement of esophageal feeding tubes in cats with cholangitis if they are anorexic and stable enough for general anesthesia. in unstable patients, nasoesophageal feeding tubes offer a less-invasive method of providing short-term support. several medications and nutritional supplements (including ursodeoxycholic acid [udca], same, milk thistle, vitamin e, vitamin c, carnitine, taurine, and phosphatidylcholine) have been suggested for treating cats with cholangitis. while most of these compounds have theoretical benefits, a clinical benefit has not been proven. to optimize client compliance and avoid adverse drug reactions, i prefer to minimize the number of medications given to feline patients. because most cats with anc respond well to antibiotic therapy, i rarely include other medications in our treatment protocol. however, in cats with anc that do not quickly respond to antibiotics and in many cats with cnc, i like to use udca. among its theoretical benefits, udca has immunomodulatory and distinction between lc and well-differentiated (small cell) lymphoma can be a challenge even for experienced pathologists. preliminary data using immunohistochemistry and pcr for t-cell receptor clonality has not proven useful in differentiating between the two conditions. surprisingly, cats with both lc and lymphoma had monoclonal t-cell receptors, oligoclonal t-cell receptors, and polyclonal t-cell receptors. 20 using light microscopy, the following features were unique to lc and not present in cats with lymphoma: ductopenia, bile duct targeting by lymphocytes, and the presence of lipogranulomas within portal regions (representing a residual marker of cell death). 20 until more studies are done evaluating molecular techniques, these features may prove useful in differentiating the two conditions. interestingly, bile duct hyperplasia and fibrosis were present in cats with lc and those with lymphoma. this may suggest that an inflammatory state precedes the development of lymphoma, 20 which has been reported anecdotally. treatment. the therapeutic approach to cats with lc should be similar to that described for cats with nc in regards to supportive care and symptomatic treatment of the sequelae of liver disease. because bacteria have been isolated from some cats with lc, i recommend treatment with broad-spectrum antibiotics while awaiting results of bacterial cultures. in contrast to nc, long-term treatment of culture negative cats with antibiotics is not warranted. immunomodulation and immune suppression are the major components of treatment based on a presumed immune-mediated etiology. cats that are culture negative, or that have failed to respond to antibiotics within a few days, should be treated with prednisolone at 1 to 2 mg/kg twice daily. responders should be tapered gradually over 4 to 6 months to the lowest effective dose. other drugs that are useful for immunomodulation include metronidazole and udca. cats that fail to respond completely to corticosteroids and/ or other immunomodulators, or who relapse while being treated, may require additional immunosuppressive drugs. although these drugs have not been well evaluated in cats with lc, chlorambucil and methotrexate are suggested by some authors. 3 cats with small cell lymphoma often respond to combination therapy with prednisolone and chlorambucil, but they may require a multidrug weekly sequential chemotherapy protocol. prognosis. cats with lc have a variable prognosis, 3,6 likely a result of being diagnosed at different stages of a chronic disease process. survival of greater than 5 years has been reported, and many cats that die appear to succumb to disease unrelated to the liver. 22 other cases have been reported that fail to respond to treatment and die more acutely, 6 though this is uncommon in my experience. this is a disease that likely requires lifelong management and monitoring with relapse of illness possible as medication doses taper. trematode parasites of the families dicrocoeliidae and opisthorchiidae may inhabit the gallbladder and bile ducts of cats and rarely dogs. 26 there are multiple species with worldwide distribution. the most commonly identified species include the dicrocoelid platynosomum concinnum and the opisthorchid amphimerus pseudofelineus. [27] [28] [29] p. concinnum is mainly found in tropical and subtropical areas, including the southeastern united states. 26 a. pseudofelineus has a wider area of distribution throughout north and south america. 26 the life cycle is similar for both dicrocoelids and opisthorchids. 26 parasite eggs are ingested by a land snail (subulina octona or eulota [bradybaena] similaris), develop into cercariae and enter a second referred to as lymphocytic portal hepatitis. 2, 21 the connection between this histopathologic finding and clinical disease in cats is unknown, as it may represent a common change associated with aging. it was identified in 82% of cats older than 10 years of age and 96% of cats older than 15 years of age from a necropsy population that did not have primary liver disease. 21 it is also possible that this lesion represents a response to inflammation at a distant site, as it is similar to the lesion of nonspecific reactive hepatitis associated with chronic extrahepatic disease. 1 although clinical signs have been described in cats with lymphocytic portal hepatitis, 10 the common occurrence of concurrent disease in these cats makes it difficult to know if the clinical signs are attributable to the lesions in the liver. in another subset of cats, lc is marked by inflammation targeting bile ductules and infiltrating biliary epithelium, leading to progressive ductopenia. 20, 22, 23 these cases seem more likely to have clinical disease attributable to their liver pathology, although side-by-side comparisons of cases with and without bile duct targeting have not been performed. cats with this form of lc in the united states have a similar clinical picture to cats with nc. 9 in the united kingdom, this lesion has been associated with ascites, icterus, and hyperglobulinemia in young cats and termed progressive lymphocytic cholangitis. 22, 23 etiology. although the etiology of lc is unknown, theories suggest that it is an immune-mediated or infectious phenomenon. genetic factors may also play a role, as persian cats are overrepresented in the united kindgom. 22, 23 immunohistochemistry in affected cats has provided evidence for an immune-mediated pathogenesis, although the inciting antigen is unknown. 20, 23 bacteria have been identified in the liver or bile of fewer than 20% of cats with lc. [3] [4] [5] 17, 20 although helicobacter pylori has been isolated from the liver and bile of cats with cholangitis, the evidence for this organism playing an important role in feline cholangitis is not compelling at this time. 24, 25 pathophysiology. as with nc, concurrent inflammatory bowel disease and pancreatitis appear to be common in cats with lc, 3, 4 although some authors report it to be uncommon. 23 the theory that reflux of duodenal bacteria into the biliary and pancreatic ducts incites inflammation may hold true for cats with lc, although a common immune mechanism must be considered. clinical examination. the clinical picture of cats with lc varies widely and has significant overlap with other forms of hepatobiliary disease in cats, including nc. 4, 9 although some studies describe a predominance of older cats, 3 others describe more younger cats. 22, 23 nonspecific clinical signs, including anorexia, lethargy, vomiting, and weight loss, may be chronic and intermittent. 3, 6, 22 physical examination findings may include icterus, hepatomegaly, or ascites, but none are consistent findings. signs of he (dullness, ptyalism, seizure) may develop in severely affected cats. diagnosis. definitive diagnosis is made by liver biopsy. as discussed for nc, ancillary diagnostics will provide information to support hepatobiliary disease, but are not specific for lc. hematology results may be unremarkable, even though marked lymphocytosis has been described in some cases. 3 activity of serum liver enzymes is increased in many, but not all cases and varies in severity. hyperglobulinemia has been described. 3, 6, 22 abdominal radiographic and ultrasonographic findings are nonspecific, but may aid in the recognition of concurrent disease. amoxicillin-clavulanate, milbemycin oxime, and amitraz prior to the onset of clinical signs. 31, 32 the proposed toxic etiology is based on these case histories and histopathologic similarity to humans with idiosyncratic drug toxicity. other toxic insults and viral infection, such as canine distemper, can also result in destructive cholangitis. 1 affected dogs typically present for signs referable to cholestasis, including anorexia, icterus, vomiting, and acholic feces. 31, 32 activities of serum liver enzymes and total bilirubin are moderately to markedly increased. abdominal ultrasound may be unremarkable, showing only mild dilation of intrahepatic bile ducts. 32 definitive diagnosis is made by liver biopsy. optimal treatment options are unknown, but should undoubtedly involve discontinuation of any medications that preceded illness. corticosteroids for immune suppressive and antiinflammatory effects and udca for immunomodulatory and choleretic effects would be rational treatments options, but their efficacy has not been documented. the prognosis appears to be poor, as six of the eight reported cases were euthanized within 6 weeks and the remaining two had only shortterm followup (<6 months). 31, 32 nc, as described in the cat, has been rarely reported in dogs. [33] [34] [35] [36] [37] bacteria have been isolated from the majority of cases reported, including e. coli, klebsiella spp., proteus mirabilis, streptococcus spp., and clostridium spp. [34] [35] [36] [37] although the bacterial species would support ascending infection from the intestine, the literature is too sparse to make conclusions about the pathophysiology of this disease in dogs. bacterial infection could also spread hematogenously or via translocation from the portal circulation. the clinical presentation and diagnostic findings are similar to those reported for cats with nc. affected dogs present with lethargy, anorexia, vomiting, and icterus usually of acute onset. fever is reported in approximately half of the cases. [33] [34] [35] [36] [37] neutrophilia with or without a left shift is common. activity of serum liver enzymes is typically increased and most dogs have mild to moderate elevation of serum total bilirubin. ultrasonography is nonspecific, with the liver varying from normal to hyperechoic with some heterogeneity. 34, 36 thickening and hyperechogenicity of the gallbladder wall is common. 36 definitive diagnosis is made by liver biopsy with changes similar to those reported in cats with nc. most dogs have some degree of mixed inflammatory infiltrate, similar to cnc. [33] [34] [35] [36] [37] this infiltrate extends into the hepatic parenchyma in the majority of cases. aerobic and anaerobic culture of bile or hepatic tissue should be performed, though bile has been the source of bacterial isolation in most cases. treatment involves antibiotic therapy guided by culture and susceptibility results. duration of treatment should be prolonged, as antibiotic courses of 8 to 12 weeks or greater have been required to completely eliminate bile infections. clinical improvement precedes bacterial eradication. 36 the prognosis appears to be good in most cases, although dogs with concurrent disease may have a worse prognosis. liver cysts arising from the intrahepatic bile ducts are rarely encountered in veterinary practice. although cysts may be acquired secondary to trauma, neoplasia, inflammation, or biliary obstruction, 1,38 the vast majority of cases described in the literature are congenital in origin. congenital cystic liver diseases result in dilation of various segments of the intrahepatic bile ducts, and they are associated with varying degrees of hepatic fibrosis and cysts in other organs (most commonly the kidneys). little is known about inheritance patterns of cystic disease in dogs and cats. the various morphologic patterns of cystic disease likely represent abnormalities of bile duct intermediate host. 26, 27, 29 the dicrocoelids tend to use an arthropod, while opisthorchids utilize fish. typically cats acquire infection by ingesting the second intermediate host. in the case of p. concinnum, the sporocysts leaving the snail intermediate host may be eaten by a paratenic terrestrial isopod host (pill, sow, or dung bugs). 26, 29 cats are infected by ingesting this form in a variety of lizard or amphibian intermediate hosts. cercariae migrate from the cat intestine to the gallbladder and bile ducts, where they develop into adults. eight weeks or more after infection eggs are passed in the feces to complete the life cycle. 27 clinical signs are proportional to parasite burden. cats with light infections are often asymptomatic. 27, 28 clinically ill cats may present with nonspecific signs such as anorexia, lethargy, vomiting, or diarrhea. severely affected cats present with signs of ehbdo such as icterus and acholic feces. [27] [28] [29] [30] preliminary diagnostics are nonspecific for fluke infestation. eosinophilia proportional to the parasite burden may be present. 29 serum liver enzyme activity may be mildly to moderately increased, although it is normal in many cases. [28] [29] [30] abdominal ultrasound often reveals evidence of ehbdo. [28] [29] [30] definitive diagnosis by identification of flukes or fluke eggs in the feces is difficult as small numbers of eggs are shed daily, the eggs have varying morphology at different stages of development, and the eggs are quite small. 27 fecal concentration-sedimentation using the formalin-ether technique is the most reliable method of identifying eggs in stool. 27, 29 eggs may also be identified in cytologic preparations of bile. 28, 30 eggs or adults may be seen in liver biopsy specimens, but they are inconsistently identified. 1, 27, 28, 30 histopathologic changes seen in the liver are characterized by dilation of larger intrahepatic bile ducts associated with papillary projections and marked periductal and portal fibrosis. mild to moderate inflammation may be present within the ducts (neutrophils and macrophages) and in the portal areas (neutrophils, lymphocytes, plasma cells). eosinophils may be present in limited numbers. 1 rarely, chronic cholangitis associated with liver flukes can result in the development of cholangiocarcinoma. 1, 29 optimal treatment protocols have not been established, but praziquantel at 10 to 20 mg/kg daily for 3 days appears to be the most effective. [26] [27] [28] [29] [30] doses as high as 40 mg/kg daily have been used successfully, 28 but this dose has also been fatal in cats. 26 sporadic resumption of egg shedding following praziquantel has been reported, suggesting that it does not completely eliminate infection. 26, 27 for this reason, continued treatment at 12-week intervals has been recommended. 29 symptomatic and supportive therapy should be tailored to the individual patient. cats with ehbdo require surgical decompression. glucocorticoids and udca may have some benefit in controlling inflammation and providing choleresis. although infected cats may remain asymptomatic, patients with ehbdo appear to have a grave prognosis. long-term survival has only been reported in rare cases. 28, 30 cholangitis is rarely reported in dogs. reports of cholangitis in dogs include two distinct entities: destructive cholangitis and nc. destructive cholangitis is characterized histopathologically by a loss of bile ducts (ductopenia) within the smaller portal areas, associated with cholestasis, portal inflammation consisting primarily of macrophages, neutrophils, and occasionally eosinophils, and progressive portal fibrosis. 1, 31, 32 this is a rarely reported lesion of unknown etiology. it has been postulated that the lesion represents an idiosyncratic drug toxicity. however, of the eight cases reported in the literature only three had a prior drug history: two having received potentiated sulfonamides and the other having received adult polycystic disease is most commonly recognized as polycystic kidney disease in persian cats. 44, 45 it has also been reported in cats of other breeds and in dogs. 39, 43 this is similar to autosomal dominant polycystic kidney disease in humans. inheritance in persian cats is autosomal dominant. 45 liver cysts are thought to represent a late defect in the development of peripheral intrahepatic bile ducts. the liver may contain multiple cysts ranging from less than 1 mm to greater than 12 cm in diameter. these cysts typically contain clear, colorless fluid. discrete fibrotic areas containing small, irregularly formed bile ducts, referred to as von meyenburg complexes, may be present. 1 in the kidneys, multiple cysts may form in any segment of the kidney but may involve only a small percentage of the nephron population. this is in contrast to the diffuse cysts seen with congenital dilation of the large and segmental bile ducts and juvenile polycystic disease. 1, 40 hepatic cysts are present in 10% to 40% of cats with polycystic kidney disease, while hepatic fibrosis is recognized in up to 48%. 44, 45 the hepatic cysts are usually incidental findings and the animals are not clinically ill unless they develop renal failure secondary to cysts in the kidneys, which happens in adulthood. biliary atresia is an extremely rare congenital disorder, having been reported in only one dog and one cat. 46, 47 in both cases, the common bile duct was not patent because of atresia. in the dog, the occluded segment of bile duct was histologically comprised of fibrous tissue with minimal inflammation. 47 the etiology is unknown, but this lesion likely represents an embryologic nonfusion of the cranial (hepatic) and caudal (cystic) anlages of the bile ducts during development. 1 other possible explanations include ischemic, toxic, traumatic, or infectious insults occurring pre-or postnatally. 47 affected animals have presented at 4 to 6 months of age with clinical signs of depression, anorexia, vomiting, or lameness associated with rickets because of inadequate vitamin d absorption. 46, 47 affected animals show icterus, hepatomegaly and acholic feces. serum biochemistry abnormalities are consistent with ehbdo. definitive diagnosis is made at exploratory laparotomy. surgical biliary diversion is a viable treatment option depending on the location of atresia, but it was unsuccessful in the one case reported. 47 a guarded prognosis should be given as for any animal undergoing a biliary diversion procedure (see discussion under "neutrophilic cholangitis"). cholestasis is impaired bile flow resulting in the accumulation of bile components in the blood. 1 intrahepatic cholestasis occurs secondary to a variety of primary or secondary hepatobiliary diseases. 1, 48, 49 increased activity of serum liver enzymes, particularly alp and ggt, is common with intrahepatic cholestasis but is not specific for the condition. clinically patients may appear jaundiced, but the predominant clinical sign will be related to the underlying disease process. cholestasis is marked by the presence of bile plugs in canaliculi, phagocytosed bile in kupffer cells, and bile granules within hepatocytes. these changes are easily recognized in cytologic and frozen preparations, but are less apparent in paraffin-embedded specimens, particularly in cats. 1 when cholestasis is identified, ehbdo should be ruled out. this should be easily accomplished by abdominal ultrasonography as animals with intrahepatic cholestasis lack the dilation of intra-and extrahepatic bile ducts that is typical of ehbdo. 48 however, exploratory laparotomy should be considered in highly suspicious cases for confirmation. development at different stages of their formation. the wsava liver standardization group suggests that cystic disorders be classified into one of the following groups: congenital dilation of the large and segmental bile ducts; juvenile polycystic disease/congenital hepatic fibrosis; and adult polycystic disease. 1 congenital dilation of the large intrahepatic bile ducts (i.e., the hepatic ducts and segmental ducts) has been described in dogs. [39] [40] [41] the lesion is similar to that of caroli disease in humans and it is thought to represent an early defect in the formation of the intrahepatic bile ducts. 1, 40 the disease is marked by extreme, diffuse, grossly evident dilation of the extrahepatic portion of the large intrahepatic bile ducts containing pale-yellow viscous fluid. the gallbladder and common bile duct are normal, as these have a separate embryologic origin from the intrahepatic bile ducts. the liver is normal to mildly increased in size, with diffuse cysts of varying sizes throughout. histologically there are areas of marked bridging portal fibrosis containing multiple dilated bile ducts. the lobular architecture of the liver is normal. although concurrent ascending cholangitis commonly occurs in humans, this is rarely reported in dogs. [39] [40] [41] in addition to the hepatic lesions, affected dogs have fusiform, radially arranged renal cysts with moderate to marked fibrosis throughout the renal cortex and medulla. [39] [40] [41] affected dogs are presented early in life, ranging from 13 weeks to 3.5 years. [39] [40] [41] clinical signs include vomiting, weight loss/failure to thrive, decreased appetite, lethargy, ascites, and rarely icterus and neurologic signs. the clinical signs are typically chronic in nature. gi signs, neurologic signs, and ascites are likely a result of portal hypertension caused by pressure of the cysts on the portal vein. hepatomegaly may be noted on physical examination. activity of serum liver enzymes is typically normal to mildly increased, although marked increases in activity of alt and alp have been reported. 40 renal azotemia is present in some patients. ultrasonographically, cystic dilations of the intrahepatic ducts (most with associated calcification) are easily recognized, even though the renal cysts are not always apparent. definitive diagnosis is made on the basis of the gross and histologic findings described above. rational treatment options and prognosis are unknown, as only one dog in the literature has been treated. this dog was doing well on a low-protein diet at 5 months of followup. 40 most of the affected dogs have been fairly stable, and supportive care may be warranted despite the appearance of severe cystic disease. juvenile polycystic disease/congenital hepatic fibrosis has been described in litters of cairn terriers, west highland white terriers, and cats. [42] [43] [44] this form is analogous to autosomal recessive polycystic kidney disease in humans, and the inheritance appears to be autosomal recessive in the few families of veterinary patients that have been described. 42, 43 the liver cysts are thought to represent an intermediate defect in the development of the intrahepatic bile ducts. 1, 40 the liver involvement is primarily microscopic including fibrotic portal areas containing abnormally structured, dilated small bile ducts. the result is a grossly enlarged and firm liver. 40 renal cysts are present and are identical to those described for dogs with dilation of the large and segmental bile ducts. 40 affected animals are usually presented at less than 8 weeks of age for abdominal distention because of renomegaly and hepatomegaly. 42, 43 however, one 12-yearold cat with similar lesions has been reported. 44 most affected animals are ill or have died at the time of presentation. 42, 43 liver enzyme activity has been increased in the few animals in which it was evaluated. 43 abdominal ultrasound may identify cysts and definitive diagnosis is made based on histologic findings as described. treatment has not been attempted, and the prognosis appears to be grave. hepatic progenitor cells. 50 they may be identified at intrahepatic or extrahepatic locations. they appear to have a more aggressive course than cholangiocellular carcinomas, with the majority being present in multiple lobes and greater than 90% having metastasized at the time of diagnosis. 52, 54, 55 the major pathogenetic mechanisms of canine and feline extrahepatic biliary tract disease are obstruction, inflammation, and exudation. the major causes of extrahepatic biliary tract obstruction (ehbo) are pancreatitis, gallbladder mucoceles (in dogs), cholelithiasis, parasitic infections (in cats), and tumors. ehbo is more common in dogs than cats. biliary tract inflammation (e.g., cholecystitis, cholangitis) is primarily caused by bacterial infection, but can be nonseptic or parasitic, especially in cats. gallstones may be associated with biliary tract disease (e.g., infection, obstruction), but the majority of them appear to be clinically silent. stones in the gallbladder are termed choleliths while stones in the biliary tract are termed choledocholiths. biliary tract exudation or leakage can be caused by traumatic (primarily of the bile ducts) or spontaneous rupture (primarily of the gallbladder). the latter is caused by necrotizing cholecystitis, which can be caused by sepsis (e.g., infectious cholecystitis), pressure necrosis (e.g., mucocele), or infarction. biliary tract tumors are rare and of uncertain cause. the common bile duct passes through the lesser omentum and the pancreatic parenchyma before entering the mesenteric wall of the duodenum. in the dog, it empties near the opening of the minor pancreatic duct at the major duodenal papilla, whereas in the cat it joins with the major pancreatic duct before emptying into the duodenum. inflammation and edema with pancreatitis may be sufficient to cause compression and obstruction of the bile duct. this is probably the most common cause of canine ehbo. 1 there is, however, no consistent relationship between clinical severity of the pancreatitis and likelihood of ehbo, possibly because pancreatitis can affect different regions of the pancreas. pancreatitis is a rare cause of ehbo in the cat. chapter 60 discusses the breeds at increased risk for pancreatitis and causes. gallbladder mucoceles occur primarily in dogs. in such cases, the gallbladder is filled with inspissated, semisolid mucus that may extend into the bile ducts causing obstruction. mucoceles can exceed the storage capacity of the gallbladder thereby causing pressure necrosis on the wall of the gallbladder. they can also spontaneously rupture (often at the fundus) 2,3 causing bile peritonitis. the cause of gallbladder mucocele is unknown, but might include dysfunction/hyperplasia of mucus-secreting cells in the gallbladder mucosa. mucoceles may become secondarily infected. 2 gallstones are often clinically silent and observed incidentally only at the time of abdominal imaging. they can be associated with cholecytitis, 4 but they rarely cause ehbo because they must be small enough to enter the cystic bile duct but large enough to lodge there. intrahepatic cholestasis is associated with extrahepatic bacterial infection in dogs. 49 this syndrome is well characterized in humans and may occur in other species such as the cat. it represents an important differential diagnosis for hyperbilirubinemia in animals without primary liver disease, as over 40-fold increases in total bilirubin have been reported. the physiology behind this mechanism is incompletely understood, but it is thought to result from reduction of bile salt-dependent and -independent bile flow caused by bacterial toxins and/or inflammatory mediators. 49 tumors of biliary origin in dogs and cats include cholangiocellular adenoma, cholangiocellular carcinoma, and carcinoid. 50 they are uncommon, representing less than 1% of all canine and feline neoplasms. [51] [52] [53] [54] the tumors of epithelial origin, cholangiocellular adenoma and carcinoma, are the most common, comprising 40% of all hepatic neoplasms in dogs [51] [52] [53] and 56% to 80% of all hepatic neoplasms in cats. [54] [55] [56] tumors showing characteristics of both hepatocellular and cholangiocellular carcinoma have been reported rarely. 50, 52 in dogs, 70% to 100% of biliary epithelial tumors are malignant, 51,52 while in cats 35% to 43% are malignant. [54] [55] [56] cholangiocellular adenomas commonly contain cystic components, especially in cats, and have been referred to as biliary or hepatobiliary cystadenomas in this species. 57,58 cholangiocellular tumors arise predominantly from intrahepatic bile ducts in both species. extrahepatic location is more common in cats than in dogs and is always associated with malignancy. [51] [52] [53] [54] 56 in both species, cholangiocellular carcinomas are more likely to present as multiple or diffuse tumors than are adenomas. 51, 52, 54 carcinomas are highly metastatic (70% to 90% rate) with local lymph nodes, peritoneum, and lung being the most common sites of metastasis. 51, 52, 54 the etiology of biliary neoplasia is unknown. affected dogs and cats are typically middle-aged to older, although animals with malignancy may present at a younger age than those with benign disease. 52, 56 clinical signs are usually vague (such as anorexia and lethargy) and somewhat chronic. malignant tumors are more likely to cause clinical signs, as many benign tumors are incidental findings not associated with illness. 51, [56] [57] [58] hepatomegaly or the presence of a cranial abdominal mass may be identified on physical examination. increased activity of serum liver enzymes is more commonly associated with malignancy, often being absent with benign tumors. 51, 56, 58 even though abdominal radiographs will often identify the presence of hepatomegaly or an hepatic mass, ultrasonography is the preferred imaging method for identification of biliary neoplasms. this modality allows for determination of the cystic nature of the tumors 58 and for the evaluation of metastatic potential. fine-needle aspiration and cytology are of limited utility for diagnosis of biliary epithelial tumors. carcinoma was correctly identified via liver mass aspiration in only 20% of cases in one study. 14 however, cytology is recommended as it likely exhibits high specificity, especially for metastatic lesions. surgical excision and biopsy is the optimal diagnostic and therapeutic technique for tumors confined to one or two liver lobes. surgical excision appears to be curative in cats with benign tumors, 56,57 but malignant tumors carry a poor prognosis in both dogs and cats with many cases not surviving to discharge and survival greater than 6 months not reported in any case. 56, 59 adjunctive chemotherapeutic protocols have not been reported. carcinoids, also referred to as neuroendocrine tumors, are far less prevalent in dogs and cats than the tumors of biliary epithelial origin. 52, 54, 55 these tumors are thought to develop from neuroendocrine cells in the epithelium of bile ducts or gallbladder or from anorexia and vomiting as more prominent symptoms. fever is uncommon, icterus inconsistent, and leukocytosis is often insignificant, even with marked bacterial infections of the biliary tract. gallstones are generally asymptomatic. they can be associated with cholecystitis or ehbo. bilious abdomen can be a clinically mild condition, or it can be associated with life-threatening signs. septic bilious abdomen causes extremely severe peritonitis with systemic inflammatory response syndrome (e.g., anorexia, vomiting, abdominal pain, poor perfusion, fever, and death). these patients may be in the initial hyperdynamic state (e.g., red mucus membranes, bounding pulse, fever, or hypothermia) or, if initially undiagnosed, can be in the late hypodynamic state (e.g., pale mucus membranes, weak pulse, and hypothermia). intraperitoneal bile seems to make septic peritonitis more severe. in contrast, some animals with sterile bilious abdomen (e.g., as a consequence of automobile trauma) are essentially normal except for ascites and icterus. plain radiography is occasionally diagnostic of biliary tract disease. some gallstones are radiopaque (figure 61-30 ). 4 finding air in the gallbladder or in the wall of the gallbladder (i.e., emphysematous cholecystitis; figure 61 -31) is diagnostic of infection with a gas-producing bacterium. "porcelain" gallbladder (i.e., a radiopaque gallbladder because of intramural mineralization of the gallbladder) is associated with carcinoma. 15 ultrasound is generally accepted as the most important and sensitive method for diagnosing extrahepatic biliary tract diseases. 7 many patients that are not suspicious for biliary tract disease are fortuitously diagnosed when ultrasound or radiographs are requested for various reasons. 14 in difficult cases (e.g., partial ehbo versus complete ehbo), nuclear scintigraphy techniques can be used 16 ; however, this seems to be rarely required. diagnosis of ehbo generally relies upon the use of ultrasound. dilation of the bile ducts (normal canine bile ducts are ≤3 mm; normal feline bile ducts are ≤2 to 2.5 mm) is primarily caused by ehbo, and is generally seen by 3 days postobstruction. if one is unsure whether the ducts are dilated, repeating the examination in 3 days should be helpful. enlargement of the gallbladder is not diagnostic of ehbo because anorexia and starvation of any cause may do the same thing. however, failing to find a dilated gallbladder parasites occasionally cause obstruction. platynosomum fastosum (i.e., p. concinnum) is a fluke that inhabits the gallbladder and/or bile ducts of cats that are infected by eating lizards or toads. 5 natural infections are found primarily in florida, hawaii, and the caribbean. it may be asymptomatic or may cause obstruction or fibrosis. they are rare causes of cholecystitis. tumors may cause obstruction, and may be one of the more common causes in cats. 6, 7 cholecystitis is most commonly caused by bacterial infection, ostensibly from bacterial migration up the bile duct. various grampositive, gram-negative, aerobic, and anaerobic bacteria (e.g., clostridium, staphylococcus spp., enterococcus spp., streptococcus spp., klebsiella spp., e. coli, helicobacter spp.) have been reported. [8] [9] [10] [11] infections caused by gas-producing bacteria can produce emphysematous cholecystitis. because of a shared biliary and pancreatic ductal system in the cat, hepatobiliary disease is a well-established risk factor for pancreatitis in the cat. aseptic inflammation of the gallbladder (necrotizing cholecystitis) has been reported, and infarction is one such cause. 11, 12 exudation leakage of bile into the abdomen can be a result of mechanical forces (e.g., automobile trauma) that cause a shearing effect resulting in transaction of the common bile duct or one of the other bile ducts. mechanical rupture has also been reported following gunshot trauma. necrosis of the gallbladder raises the risk for rupture of the gallbladder and occasionally the bile ducts. canine and feline gallstones are typically composed of cholesterol, bilirubin, or may be mixed (as opposed to human gallstones which are usually caused by cholesterol). 4 feline gallstones are typically calcium carbonate or mixed stones. 13 biliary tract diseases can cause severe clinical signs (e.g., anorexia, depression, vomiting, icterus, abdominal pain) or they may be relatively asymptomatic. most symptomatic patients have serum biochemical abnormalities (e.g., increased serum alt, alp, and serum bilirubin). hypercholesterolemia is common in patients with ehbo. hyperbilirubinemia by itself does little besides cause icterus; therefore, patients with extremely high serum bilirubin concentrations can be relatively asymptomatic. renal failure has been attributed to excessively high serum bilirubin concentrations, but it is unclear that bilirubin is the cause or that this is common. shetland sheepdogs 14 appear to have an increased risk for biliary tract disease, and cocker spaniels might also (see chapter 62) . besides icterus, clinical signs in patients with ehbo are primarily a result of the cause of the obstruction, not the obstruction itself. canine pancreatitis in particular may cause severe clinical signs (e.g., anorexia, vomiting, abdominal pain-see "complications of liver disease" section). however, not all patients with pancreatitisinduced ehbo have severe pancreatitis. causes of ehbo that are insidious (e.g., mucoceles, tumors, and stones) are often unsuspected until the patient becomes icteric. biliary tract inflammation such as septic cholecystitis is welldocumented in dogs and cats. shetland sheepdogs appear to be at a greater risk of inflammatory biliary tract disease than most other breeds. 14 clinical signs vary, but most animals are clinically ill with cholecystitis is often diagnosed by ultrasound-guided percutaneous aspiration of gallbladder bile for cytology and culture. this is a relatively sensitive and specific procedure for diagnosing biliary tract infection. 2, 18 the finding of a dilated bile duct coincident with a normal-size gallbladder suggests cholecystitis, prior ehbo, or a rare congenital problem such as caroli disease. 19 it is important to note that patients with bacterial cholecystitis may have no ultrasonographic or gross abnormalities. ultrasound may be suggestive, but is relatively insensitive for cholecystitis. 8, 20 consequently, it is probably best to routinely aspirate bile for cytology and culture in patients with hepatobiliary disease. gallstones are relatively easy to diagnose, some can be found by radiographs, but almost all can be found by ultrasonography ( figure 61 -33). with ehbo, the underlying cause is always the primary concern. ehbo in and of itself is not the primary consideration when deciding upon therapy. pancreatitis, for example, is primarily a medical disease (see chapter 60) . surgery is rarely appropriate in the management of pancreatitis even when it is causing ehbo. if deemed necessary, ehbo caused by pancreatitis can be relieved by percutaneous aspiration 21 or placement of a biliary tract stent. 22 if absolutely necessary, a cholecystoduodenostomy may be performed, but this surgery should be avoided if possible. these procedures are seldom necessary because almost all patients with ehbo caused by pancreatitis will experience resolution of the obstruction with medical therapy. gallstones should be removed only if they are causing obstruction or cholecystitis. it is usually better to perform a cholecystectomy 4,13 as opposed to a cholecystotomy; the former has a lower morbidity and mortality rate in people and presumably in dogs and cats as well. biliary tract tumors can seldom be cured surgically. if a patient has ehbo caused by something that cannot be treated medically (e.g., tumor, pancreatic stricture, traumatically torn bile duct), then a biliary bypass procedure can be performed. cholecystoduodenostomy can relieve the obstruction, although the surgery requires special surgical skills. this surgery can predispose the patient to recurrent, ascending cholecystitis or other complications 10,23 and should only be performed in patients that in a patient with clearly dilated bile ducts suggests biliary tract inflammation or prior ehbo. any dog with ehbo should be suspected of having acute pancreatitis until proven otherwise. chapter 60 details the diagnosis of pancreatitis. if acute pancreatitis is eliminated in a patient with ehbo, then one should look for gallstones and tumors, first by imaging and then by exploratory surgery or laparoscopy if imaging fails to provide a diagnosis. mucoceles are readily diagnosed by ultrasound, although there is some debate about what constitutes a mucocele. "classic" mucoceles are described as producing a "kiwi fruit" appearance without gravitydependent bile movement. "sludge" in the gallbladder is a common finding (and it has gravity-dependent movement), but is not clinically significant. 17 the gallbladder of clinically normal dogs may appear abnormal on ultrasound examination (figure 61-32) , while patients with significant biliary tract disease may appear essentially normal. whether or not patients with ultrasonographic abnormalities of the gallbladder will become symptomatic cannot be reliably predicted. the gallbladder is filled with hyperechoic material (arrows) that was not gravity dependent. the dog was asymptomatic for biliary tract disease and was still in good health without therapy for the gallbladder 10 months after this image was taken. . the stones were found fortuitously during an abdominal ultrasound; there was no evidence that they were causing any clinical signs. gb that has a risk of dehiscence. in general, one should either remove the gallbladder, aspirate gallbladder bile, gently express the gallbladder, or leave it undisturbed. if the leakage is associated with septic peritonitis, then that is a true emergency and requires immediate, aggressive medical and surgical therapy. gallstones may be monitored if the patient is asymptomatic. tumors can rarely be resected; they are generally inoperable when found. rare examples exist of patients with biliary tumors being cured surgically. biliary flukes can be treated with praziquantel (20 to 40 mg/kg sq for 3 days). chapter 60 discusses pancreatitis in greater detail. biliary mucoceles that have not ruptured often have a good prognosis; however, one report found a 32% mortality rate in patients without a rupture versus 68% mortality in patients with bile peritonitis. 14 the report authors recommended a more preemptive approach (i.e., versus waiting until the patent is symptomatic). another group found no difference in mortality between rupture and nonruptured mucoceles (i.e., 21%). 3 gallstones generally are innocuous, and even when they are causing signs have a good prognosis as long as rupture has not occurred. bacterial cholecystitis has a good prognosis as long as the gallbladder is intact and not at risk for rupture. septic bilious peritonitis has a very guarded to poor prognosis, depending upon the severity of the peritonitis. gallstones are usually asymptomatic, but can occasionally cause a problem. they are usually easily removed and resolved. biliary tumors are usually a poor prognostic finding 6, 7 because of late diagnosis. flukes can be treated, but without early recognition, extensive tissue injury may or may not resolve after therapy. the liver serves many important functions including metabolism (carbohydrate, protein, lipid, nucleic acid, xenobiotics, porphyrins, vitamins, minerals, glutathione, endogenous hormones), coagulation factor synthesis, biliary secretion, and immune surveillance (see chapter 1). it is not surprising, therefore, that animals with liver disease experience a broad range of complications reflecting perturbations in one or more of these functions. the hepatic portal venous system accounts for up to 75% of the total hepatic circulation and serves to transport nutrients from the gi tract to hepatic sinusoidal capillaries (and hepatocytes) before coalescing once again into central veins, hepatic veins, and caudal vena cava. in health, the multiple branching of the main portal vein, venules, and capillaries reduces the overall resistance to blood flow (circuits in parallel reduce resistance), and therefore the pressure required to perfuse these capillaries is maintained at a low level of less than 5 to 6 mm hg. 1,2 disease processes that obstruct flow through the intrahepatic branches of the portal vein or sinusoids elevate this pressure and result in significant portal hypertension. hepatocyte swelling impedes portal flow in acute pathophysiologic states, and fibrosis further impedes this flow in absolutely require it. generally speaking, ehbo caused by pancreatitis that is not resolving as quickly as desired is not necessarily a good indication for this procedure; patience and medical therapy generally resolve the problem. in fact, pancreatitis can be a complication of surgery in this region. 24 many animals with hepatic disease are concurrently treated with antioxidants and other hepatoprotectants. although most of these drugs will not hurt patients with biliary tract disease (in fact, they may be beneficial if the disease is extending into the hepatic parenchyma, such as cholangitis/cholangiohepatitis), care must be taken before administering udca. udca is a choleretic agent that stimulates bile flow. this could be disadvantageous in a patient with complete ehbo. mucoceles usually need to be removed surgically. 2, 3, 14 medical management may be attempted (e.g., fat-restricted diet plus udca), but there is a substantially increased mortality rate for patients that experience gallbladder rupture (figure 61-34) ; consequently, surgery is probably the safest course. most patients are not at risk of immediate rupture. as long as ultrasonography does not suggest impending rupture, one should make sure the patient is an optimal anesthetic risk. bacterial cholecystitis, uncomplicated by ehbo or stone, should generally first be treated with antibiotics, usually for 4 to 6 weeks. however, some patients with bacterial cholecystitis cannot be cured with antibiotic therapy, ostensibly because the infection has localized in the gallbladder mucosa. these patients consistently relapse after discontinuation of antibiotics, and therefore a cure may be achieved only with antibiotics plus cholecystectomy. when performing this surgery, great care should be taken to avoid causing a stricture or obstruction of the common bile duct. postcholecystectomy bile duct obstruction may prove fatal. it is also very important to be avoid traumatizing the pancreas to avoid severe pancreatitis. 24 biliary tract leakage is treated based upon the underlying cause. if the gallbladder has ruptured, cholecystectomy is usually most appropriate. if the bile duct has ruptured, it is very difficult to successfully anastomose the two ends. in that instance, one generally must perform a cholecystoduodenostomy and ligate both ends of the torn bile duct. it is important to avoid biopsying the gallbladder as clinical signs associated with he in dogs and cats include depression, behavioral changes, circling/head-pressing, ataxia, apparent blindness, abnormal swallowing or salivation, stupor, seizures, and coma (table 61-10) . salivation is much more common in cats than dogs with he. brain dysfunction in he was historically considered to be a neurotransmitter dysfunction but current evidence suggests lowgrade cerebral edema caused by astrocyte swelling is the predominant pathologic change. 8 there is consensus that ammonia is the key toxin in he but blood ammonia concentrations do not always correlate with severity of clinical signs. this is because a large number of other factors interact with the effects of ammonia to precipitate he. astrocytes play a central role because they express glutamine synthetase and detoxify the ammonia that reaches the cns. intraastrocyte accumulation of osmotically active glutamine in he results in astrocyte swelling and thus low-grade cerebral edema. 8 this is largely reversible if the precipitating factors are treated, but edema can become severe and result in irreversible cns changes in severe and acute he. precipitating factors include inflammatory cytokines, benzodiazepine-type sedatives, and disturbances in amino acid metabolism and dopaminergic neurotransmission. [8] [9] [10] the source of ammonia is primarily absorption from the gut, although other sources also exist as a result of interorgan metabolism. gut-derived ammonia was traditionally assumed to be a by-product of intestinal bacterial metabolism in the colon. this remains an important source in some conditions such as melena. however, recent studies in other species suggest that small intestinal enterocyte metabolism of glutamine as their main energy source is the most important source of postprandial ammonia absorption in the portal vein. 9, 10 this is also likely the case in most dogs on normal diets as it is very unusual for undigested protein to reach the colon, although the source of gut-derived ammonia has never been investigated in dogs. in normal dogs, ammonia is transported to the liver via the main portal vein, and further metabolized chronic pathophysiologic states. sustained portal hypertension is associated with many, but not all, of the complications of liver disease. portal hypertension is an important, potentially life-threatening complication of liver disease in the dog. it is rare or poorly documented in the cat. portal hypertension develops most often in dogs with chronic liver disease and cirrhosis. it is occasionally recognized as a congenital lesion in young animals with arteriovenous fistulas, 3 or as a hypoplastic disorder of the intrahepatic portal vein branches resulting in a condition referred to as noncirrhotic portal hypertension. 4, 5 prehepatic portal hypertension can develop secondary to portal vein thrombosis or congenital hypoplasia of the extrahepatic portal vein, but these are less common. sustained portal hypertension may progress to splanchnic congestion, gi ulceration, ascites, and encephalopathy. portal venous hypertension produces vascular stasis and venous congestion and increases the risk of gi ulceration, particularly in conjunction with other risk factors such as anorexia and steroidal and nonsteroidal antiinflammatory drug usage. portal hypertensionrelated ulceration in the dog is typically duodenal although bleeding esophageal varices, similar to those reported in humans, are occasionally observed. 3 glucocorticoids should be used only with great caution in dogs with portal hypertension. reduced systemic blood pressure is another consequence of portal hypertension and splanchnic venous congestion. changes in systemic blood pressure activate the renin-angiotensin-aldosterone system (as described in chapter 8) and renal sodium retention, and thus increase total circulating fluid volume. the increase in circulating fluid volume (the "overfill" hypothesis) is believed to be the triggering event for the development of ascites in animals with portal hypertension. 6 this is why aldosterone antagonists are the initial treatment of choice in ascites caused by portal hypertension (for more details see chapter 8). ascites is a negative prognostic indicator in dogs with chronic hepatitis, 7 although individual animals with chronic hepatitis and ascites can be managed and maintained for many months. with sustained portal hypertension, multiple acquired psss develop and serve as a conduit for portal blood flow directly into the systemic circulation. shunts serve to dissipate some of the increased portal pressure thus reducing the risk of adverse complications such as venous congestion, gi hemorrhage, and ulceration. they do, however, raise the risk of yet another complication of liver disease-hepatoencephalopathy. he is a syndrome of potentially reversible brain dysfunction resulting from impaired liver function. it results from either severe hepatocyte dysfunction or more commonly the presence of portosystemic collateral circulation, either congenital or acquired, where a variable combination of shunting of portal blood and hepatocyte dysfunction contributes to the clinical signs. it can be acute or chronic in presentation. acute he is most often a result of acute fulminating liver failure (see "consequences of hepatocyte and biliary tract injury" section) and carries a poor prognosis. more chronic he is usually a result of congenital or acquired psss. 2 platelet counts, d-dimers, fibrinogen, or protein c) in 24 (57%) of 42 dogs affected with liver disease. 18 coagulation abnormalities are also common in cats with liver disease and one study found abnormalities in 18 (82%) of 22 cats with liver disease. 19 multiple mechanisms of coagulopathy are possible in liver disease patients. in alf cases such as xylitol toxicity in dogs, 20 hl in cats, 21 and cirrhosis in dogs, 18 loss of normal hepatocyte function results in severe coagulation factor deficiency. vitamin k deficiency has also been implicated in coagulopathy particularly in cats in which cholestasis impedes bile salt secretion, emulsification, and micellarization of fat and fat-soluble vitamins and fat-soluble vitamin absorption. 21 concurrent inflammatory bowel disease and pancreatitis exacerbate this condition in many cats with cholangitis. 21 finally, platelet abnormalities (cytopenia and cytopathy) may contribute to coagulopathy in dogs with liver disease. 18, 22 the liver has the unique ability to regulate its growth and mass. hepatocyte loss caused by viral, bacterial, or chemical injury, or partial hepatectomy triggers hepatocyte replication. 23, 24 liver injury not only stimulates hepatocyte turnover but may also stimulate biliary proliferation and activation and proliferation of hscs. these changes usually occur together in an orchestrated wound-healing response. in the case of hepatocyte loss, normally quiescent hepatocytes replicate to restore the liver functional capacity and mass. these are the main cells that regenerate liver mass. however, in severe injury or where hepatocyte turnover is inhibited by senescence, a progenitor cell reserve may also replicate and regenerate liver mass. 24 although hepatocytes are capable of replication, they have very slow turnover in a normal liver and there are negative consequences of long-term increased stimulation and turnover in chronic liver disease. it has been shown that cycling hepatocytes suffer irreversible erosion of telomeres, which leads to senescence. 25 functional capacity is a relative rather than absolute parameter. the set point for growth regulation is the ratio between liver mass and body mass rather than liver mass per se. the optimization of the ratio indicates that the liver reaches a state in which it performs the amount of metabolic work needed to meet the functional requirements of the body. 24 gene expression in the regenerating liver is a multistep process with at least two critical steps: the transition of quiescent hepatocytes into the cell cycle ("priming"), and the progression beyond the restriction point in the g 1 phase of the cell cycle. hepatocytes must first be primed before they can fully respond to growth factors. as many as 70 different genes participate in the early response to hepatectomy, but tnf and il-6 appear to be the major cytokines involved in the priming of hepatocytes. 20 the proliferative effect of tnf on hepatocytes is further influenced by reactive oxygen species, nitric oxide, and glutathione content, and at least four transcription factors (nuclear factor kappa b, stat3, ap-1, and c/ebpβ) play major roles in the initiation of early liver regeneration. 23, 24 progression through the cell cycle beyond the initiation phase requires growth factors, primarily hepatocyte growth factor and tgf-α. the subsequent expression of cell-cycle genes, particularly cyclin d 1 , establishes the stage at which replication becomes growth factorindependent and autonomous. at this point, the hepatocyte is irreversibly committed to replicate and the cell-cycle replication machinery takes over. the regenerative capacity of the residual hepatocytes may restore liver mass and function after as much as 65% to 70% hepatectomy. 23, 24 progenitor cells are only activated in severe liver injury. they appear to reside in a "niche" that is a particular regulatory environment. 24 a recent immunohistochemical to urea by hepatocytes in the krebs-henseleit cycle. with portosystemic shunting or severe hepatocyte dysfunction, ammonia accumulates in the brain (and other tissues) where it is taken up by astrocytes and results in edema as described previously. dogs with he also show disturbances in cns aromatic amino acid metabolism. 11, 12 the aromatic amino acids (tyrosine, tryptophan, and phenylalanine) accumulate in, the cns in portasystemic shunting. in the brain, β-phenylalanine and tyrosine are metabolized to phenylethanolamine and octopamine, both of which can act as false neurotransmitters. however, dietary supplementation with branched-chain amino acids (e.g., leucine, isoleucine, valine) does not convincingly improve he in either dogs or humans. 9, 12 however, some dietary protein sources appear to be better than others in dogs with he. dogs on soya protein diets show a lower plasma ammonia concentration than those fed meat protein. 13 dogs with he have also traditionally been fed a protein-restricted diet. however, protein restriction is no longer advocated in humans with he 9 and it may be the digestibility and type of protein rather than a reduced amount that are most important in dogs. more studies are needed to investigate this. several other metabolic alterations exacerbate clinical signs associated with he, including acid-base disorders, electrolyte abnormalities, particularly hypokalemia, hypoglycemia, hypoxemia, and arginine deficiency (cats). an important trigger in humans and rodents is inflammation: recent studies confirm that inflammatory cytokines are synergistic with ammonia in precipitating he and that controlling inflammation in other organs is an important part of managing the patient with he. 14, 15 there is anecdotal evidence that this is also true in dogs. the liver has significant structural and functional reserve capacity to support ongoing metabolic needs during mild to moderate forms of liver injury. moreover, the liver has the ability to regenerate liver volume and cell mass during the recovery phase of most forms of liver injury. signs of liver failure develop earlier with acute forms of liver injury than with chronic, progressive liver disease. zones 1, 2, and 3 hepatocytes of the hepatic acinus have differing functions. zone 1 (periportal) hepatocytes, for example, have a high capacity to cycle ammonia through the urea cycle thereby reducing the toxicity of ammonia. zone 3 hepatocytes (nearer the hepatic vein) have a lesser capacity for ammonia and instead convert it to glutamine. 16, 17 in health, zonation permits flexibility in hepatic function such that in metabolic acidosis, for example, the liver can rapidly divert ammonia toward glutamine production, which is necessary for h+ ion excretion in the kidney. in severe acute liver injury, this becomes an important "tradeoff" because acute selective destruction of periportal (zone 1) hepatocytes more readily results in signs of encephalopathy because of the reduced ability of zone 3 hepatocytes to detoxify ammonia. in chronic liver disease, if hepatocytes undergo piecemeal necrosis at different rates in different zones, the remaining hepatocytes can assume some of those functions, so that clinical signs of deficiency are not seen until later in chronic disease processes. coagulopathy is a complication of both acute and chronic liver disease in dogs and cats. a recent study reported one or more coagulation abnormalities (prolongation of coagulation times, changes in the cause of chronic hepatitis is usually unknown. 30 there is increasing evidence that fibrosis and even some forms of cirrhosis in humans and rodent models are reversible if the underlying cause is removed. 28, 31 the challenges are removing the cause and also defining the point at which cirrhosis moves from a reversible to irreversible state. increased fibrous septal thickness, smaller nodule size, and reduced cellularity together with increased collagen cross-bridging have all been associated with an irreversible cirrhotic state in rodents and humans. 28 it is unknown whether liver fibrosis or cirrhosis in dogs is reversible clinically. cases of chronic hepatitis in dogs very rarely have sequential liver biopsies over a long period of time to assess progression of disease and noninvasive markers of fibrosis remain to be validated. serum hyaluronic acid is increased in dogs with cirrhosis 32 as is tgf-β 33 but the usefulness of these markers in following progression in clinical cases has not been assessed. identifying a reliable noninvasive marker of fibrosis for sequential studies in humans and dogs remains a challenge. 34 study suggests that canine and human liver progenitor cells are functionally very similar. 26 further characterization of the molecular events regulating hepatocyte replication and liver regeneration should improve outcome in animals affected with severe liver disease. the normal ecm of the liver provides cells with positional information and a mechanical scaffold for adhesion and migration. the ecm consists of collagens, glycoproteins, proteoglycans, glycosaminoglycans and molecules that are bound specifically by the ecm, such as certain growth factors, cytokines, matrix metalloproteinases, and processing enzymes such as tissue transglutaminase and procollagen propeptidases. a normal liver contains a very small amount of fibrous tissue as a percentage of its total mass. 27, 28 acute or chronic liver injury causes a dynamic wound-healing response with both production and removal of fibrosis. 29 hscs are the major source of the collagens that comprise fibrosis and cirrhosis, as well as of the tissue inhibitors of metalloproteinases (timps) that inhibit collagen degradation. it is the balance between collagen production by hscs and its degradation by matrix metalloproteinases that determines the severity and reversibility of the fibrotic response. following acute or chronic liver damage, hscs are stimulated to multiply and to undergo a complete phenotypic transformation from quiescent vitamin a-storing cells to contractile myofibroblasts which synthesize large amounts of ecm. 25, 29 important stimuli for hsc transformation and multiplication in liver injury include oxidative stress; chemokines including platelet-derived growth factor; vegf and tgf-β; adipokines; and parts of the innate immune system including toll-like receptor ligands. 29 the role of adipokines in stimulating fibrosis is increasingly being recognized in humans, where nonalcoholic fatty liver disease can lead to fibrosis and cirrhosis. they are produced by hscs themselves, as well as fat cells, and increased leptin and reduced adiponectin drive fibrosis. 29 their importance in dogs is unknown and it is also unknown whether vacuolar or fatty liver diseases progress to fibrosis in dogs, but these are important questions to answer in the future given the widespread occurrence of obesity in dogs. the contractile function of activated hscs contributes significantly to the development of portal hypertension, 28 and increases in angiogenic chemokines such as vegf and platelet-derived growth factor not only contribute to fibrogenesis by hscs, but also to the development of portal hypertension, so that the two pathologic processes are inextricably linked. 29 activated hscs have greatly increased production of timps, particularly timp1 and timp2, which prevent the action of matrix metalloproteinases in the ecm. the degree of fibrosis and reversibility then depend on the balance between perpetuation of hsc proliferation and secretion and resolution of hsc by either apoptosis or senescence of hscs or, indeed, their reversion to an inactive state. many factors contribute to hsc apoptosis, senescence, or reversion, including reduction in timps and nuclear factor kappa b and increased fas and p53. 29 however, in spite of all this understanding of the molecular mechanisms of fibrosis, a truly effective treatment for hepatic fibrosis in either humans or dogs has yet to be found. 29 it is important to remember that a normal fibrotic response (scar) is important in walling off pathogens and tissue injury and inhibiting this response without removing the inciting cause (e.g., a viral cause) could lead to spread of the pathology. 28 future treatment strategies for fibrosis should therefore incorporate treatment of the underlying cause of disease. this is clearly a problem in dogs where organizational principles of the liver bile formation and enterohepatic circulation functional and morphological relationships between the feline main pancreatic and bile duct sphincters the extrahepatic biliary tract in common domestic and laboratory animals hormonal regulation of bile secretion physiology of cholangiocytes hepatic stellate cell (vitamin a-storing cell) and its relative -past, 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plasma ammonia and bile acid concentrations in the identification of portosystemic shunting in dogs serum unconjugated bile acids as a test for intestinal bacterial overgrowth in dogs helical computed tomographic angiography of canine portosystemic shunts comparison of transplenic multidetector ct portography to multidetector ct-angiography in normal dogs use of magnetic resonance angiography for diagnosis of portosystemic shunts in dogs surgical treatment of bile peritonitis in 24 dogs and 2 cats: a retrospective study (1987-1994) fine-needle aspirate cytology suggesting hepatic lipidosis in four cats with infiltrative hepatic disease vacuolar hepatopathy in dogs: 336 cases accuracy of ultrasound-guided fine-needle aspiration of the liver and cytologic findings in dogs and cats: 97 cases morphological classification of biliary disorders of the canine and feline liver diagnostic comparison of needle and wedge biopsy specimens of the liver in dogs and cats sampling and handling of liver tissue influence of biopsy specimen size, tissue fixation, and assay variation on copper, iron, and zinc concentrations in canine livers statistical relevance of ultrasonographic criteria in the assessment of diffuse liver disease in dogs and cats can sonographic findings predict the results of liver aspirates in dogs with suspected liver disease? bleeding after liver biopsy does not correlate with indices of peripheral coagulation lack of increased bleeding after liver biopsy in patients with mild hemostatic abnormalities correlation between coagulation profile findings and bleeding complications after ultrasoundguided biopsies: 434 cases (1993-1996) proteins invoked by vitamin k absence and clotting times in clinically ill cats pivka clotting times in dogs with suspected coagulopathies evaluation of hemorrhage, sample size, and collateral damage for five hepatic biopsy methods in dogs diagnostic correlation of liver aspiration cytology with histopathology in dogs and cats with liver 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erythromycin prevalence of gallbladder sludge in dogs as assessed by ultrasonography ultrasonographic features of extrahepatic biliary obstruction in 30 cats gallbladder mucocele in dogs: 30 cases ultrasonographic diagnosis of portosystemic shunting in dogs and cats ultrasonography of portosystemic shunts in dogs and cats ultrasonographic identification and characterization of congenital portosystemic shunts comparison of 99mtco4(-) trans-splenic portal scintigraphy with per-rectal portal scintigraphy for diagnosis of portosystemic shunts in dogs use of hepatobiliary scintigraphy in the diagnosis of extrahepatic biliary obstruction in dogs and cats: 25 cases (1982-1989) comparative evaluation of the liver in dogs with a splenic mass by using ultrasonography and contrast-enhanced computed tomography magnetic resonance imaging of focal splenic and hepatic lesions in the dog inflammatory canine hepatic disease in: ettinger sj,feldman ec chronic hepatitis, cirrhosis, breed-specific 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abscesses in cats: 14 cases percutaneous drainage and alcoholization of hepatic abscesses in five dogs and a cat morphological calssification of parenchymal disorders of the canine and feline liver. 3. hepatic abcesses and granulomas, hepatic metabolic storage disorders and miscellaneous conditions transient acquired fanconi syndrome associated with copper storage hepatopathy in 3 dogs identification of a new copper metabolism gene by positional cloning in a purebred dog population the ubiquitously expressed murr1 protein is absent in canine copper toxicosis copper metabolism and oxidative stress in chronic inflammatory and cholestatic liver diseases in dogs chronic active hepatitis with cirrhosis in the doberman pinscher hepatic copper concentrations in labrador retrievers with and without chronic hepatitis (1980-2008): an emerging syndrome or oversupplementation? canine liver iron, copper, and zinc concentrations and association with histologic lesions hepatotoxicity of phenobarbital in dogs: 18 cases hepatotoxicity associated with pharmacologic agents in dogs and cats hepatotoxicity associated with ccnu (lomustine) chemotherapy in dogs hepatocellular toxicosis associated with administration of carprofen in 21 dogs transient erythropoietic protoporphyria associated with chronic hepatitis and cirrhosis in a cohort of german shepherd dogs upregulation of major histocompatibility complex class ii antigens in hepatocytes in doberman hepatitis chronic hepatitis in dogs: a review of current understanding of the aetiology, progression, and treatment circulating autoantibodies in dogs with chronic liver disease anti-liver membrane protein antibodies in dogs with chronic hepatitis characterization of the inflammatory infiltrate in canine chronic hepatitis phenotypic analysis of hepatic t lymphocytes in a dog with chronic hepatitis histomorphological and immunohistochemical studies of chronic active hepatitis in doberman pinschers phenotypic analysis of hepatic lymphocytes from healthy dogs serum protein electrophoresis as a prognostic marker of chronic liver disease in dogs influence of biopsy specimen size, tissue fixation, and assay variation on copper, iron, and zinc concentrations in canine livers chronic hepatitis: therapeutic considerations chronic hepatitis in the english springer spaniel chronic hepatitis: a retrospective study in 34 dogs effects of corticosteroid treatment on survival time in dogs with chronic hepatitis: 151 cases (1977-1985) ascites is a negative prognostic indicator in chronic hepatitis in dogs autoimmune hepatitis pcr screening for candidate etiological agents of canine hepatitis chronic hepatitis in the dog: the role of immune factors immunohistochemical detection of canine adenovirus in paraffin sections of liver use of polymerase chain reaction and immunohistochemistry for detection of canine adenovirus type 1 in formalin-fixed, paraffin-embedded liver of dogs with chronic hepatitis or cirrhosis a new transmissible agent 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treatment of copper storage disease in a bedlington terrier use of zinc acetate to treat copper toxicosis in dogs dietary management of hepatic copper accumulation in labrador retrievers liver glutathione concentrations in dogs and cats with naturally occurring liver disease population dynamics of inherited copper toxicosis in dutch bedlington terriers (1977-1997) linkage of a microsatellite marker to the canine copper toxicosis locus in bedlington terriers copper toxicosis in the bedlington terrier: a diagnostic dilemma some new aspects of the role of copper in doberman hepatitis morbidity and mortality in 928 doberman pinschers born in the netherlands between 1993 and 1999 hepatic (64)cu excretion in dobermanns with subclinical hepatitis differential expression of copper-associated and oxidative stress related proteins in a new variant of copper toxicosis in doberman pinschers subclinical versus clinical hepatitis in the dobermann: evaluation of changes in blood parameters lesions of 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s-adenosyl-lmethionine (same) for the treatment of acetaminophen toxicity in a dog the role of paraaminophenol in acetaminophen-induced methemoglobinemia in dogs and cats s-adenosylmethionine (same) in a feline acetaminophen model of oxidative injury antimicrobial drug formulary treatment of canine atopic dermatitis with azathioprine: a pilot study factors determining short-and long-term survival after orthotopic liver homotransplantation in the dog hepatotoxicity of non-narcotic analgesics an update on nonsteroidal anti-inflammatory drugs (nsaids) in small animals fulminant hepatic failure associated with oral administration of diazepam in 11 cats acute hepatic necrosis and liver failure associated with benzodiazepine therapy in six cats, 1986-1995 iatrogenic cushing's syndrome and steroid hepatopathy in a cat alkaline phosphatase: beyond the liver prevalence of elevated alanine transaminase activity in dogs treated with ccnu (lomustine) prospective randomized clinical trial assessing the efficacy of denamarin for prevention of lomustine (ccnu)-induced hepatopathy in tumor bearing dogs false neurotransmitter in hepatic coma successful use of bromocriptine in the treatment of chronic hepatic encephalopathy dopaminergic agonists for hepatic encephalopathy direct and indirect enhancement of gabaergic neurotransmission by ammonia: implications for the pathogenesis of hyperammonemic syndromes hepatic encephalopathy: a disorder in glial-neuronal communications l-glutamate and gammaaminobutyric acid uptake in synaptosomes from the cerebral cortex of dogs with congenital chronic hepatic encephalopathy mechanisms of ammonia-induced astrocyte swelling the pituitary-adrenocortical system in canine hepato-encephalopathy increased free cortisol in plasma of dogs with portosystemic encephalopathy (pse) chronic glucocorticoid excess and impaired osmoregulation of vasopressin release in dogs with hepatic encephalopathy fast resolution of hypercortisolism in dogs with portosysemic encephalopathy after surgical shunt closure water transport in the kidney and nephrogenic diabetes insipidus gabaergic inhibition of the pituitary release of adrenocorticotropin and α-melanotropin is impaired in dogs with hepatic encephalopathy mineralocorticoid action: target specificity is enzyme, not receptor, mediated hypokalemia-induced downregulation of aquaporin-2 water channel expression in rat kidney medulla and cortex role of aquaporin-2 water channels in urinary concentration and dilution defects renomegaly in dogs and cats. part i. differential diagnosis glomerular filtration rate and renal volume in dogs with congenital portosystemic vascular anomalies before and after surgical ligation morphology of congenital portocaval shunts in dogs and cats congenital interruption of the portal vein and caudal vena cava in dogs: six case reports and a review of the literature functional closure of the ductus venosus during early postnatal life in the dog the anatomy and embryology of portosystemic shunts in dogs and cats portal hypertension associated with primary hypoplasia of the hepatic portal vein in dogs budd-chiari syndrome) as a cause of ascites in a cat use of endovascular stents in three dogs with budd-chiari syndrome characterization of hepatoportal microvascular dysplasia in a kindred of cairn terriers ultrasonographic identification and characterization of congenital portosystemic shunts and portal hypertensive disorders in dogs and cats gross anatomy of the canine portal vein portal hypertension part i. pathophysiology and clinical consequences ultrasonographic evaluation of partially attenuated congenital extrahepatic portosystemic shunts in 14 dogs polycystic kidney and liver disease in cats acquired portosystemic shunting in 2 cats secondary to congenital hepatic fibrosis portal hypertension in a dog due to circumscribed fibrosis of the wall of the extrahepatic portal vein ultrasonographic diagnosis of unusual portal vascular abnormalities in two cats thrombosis of the portal vein in eleven dogs heterobilharzia americana infection in a dog multiple congenital portal vein anomalies in a dog intraoperative ultrasonography of the portal vein during attenuation of intrahepatic portocaval shunts in dogs portosystemic communications in the dog nutritional aspects of the management of chronic hepatic encephalopathy alterations of gaba-a and dopamine d-2 brain receptors in dogs with portal-systemic encephalopathy clinical presentation and management of moxidectin toxicity in two dogs generalized motor seizures after portosystemic shunt ligation in dogs: five cases nutritional support for dogs and cats with hepatobiliary disease effects of a branched chain amino acid-enriched diet on chronic hepatic encephalopathy in dogs cerebrospinal fluid glutamine, tryptophan, and tryptophan metabolite concentrations in dogs with portosystemic shunts evaluation of twelve-hour preprandial and two-hour postprandial serum bile acids disease in dogs hematologic changes associated with serum and hepatic iron alterations in dogs with congenital portosystemic vascular anomalies characterization of iron status in young dogs with portosystemic shunt iron status and erythrocyte volume in dogs with congenital portosystemic vascular anomalies hemostatic profiles in 39 dogs with congenital portosystemic shunts coagulation profiles in dogs with congenital portosystemic shunts before and after surgical attenuation standard planes for ultrasonographic examination of the portal system in dogs szatmári v: ultrasonography of portosystemic shunting in dogs doppler studies before, during and after surgery ultrasonographic assessment of hemodynamic changes in the portal vein during surgical attenuation of congenital extrahepatic portosystemic shunts in dogs use of transcolonic 99mtechnetium-pertechnetate as a screening test for portosystemic shunts in dogs quantification of portosystemic shunting in dogs by ultrasound-guided injection of 99m tc-macroaggregates into a splenic vein portal vein anomalies in the dog: their angiographic diagnosis use of intraoperative mesenteric portovenography in congenital portosystemic shunt surgery helical computed tomographic angiography of canine portosystemic shunts three-dimensional multiscale helical computed tomography techniques for canine extra-hepatic portosystemic shunt assessment use of magnetic resonance angiography for diagnosis of portosystemic shunts in dogs brain magnetic resonance imaging characteristics in dogs and cats with congenital portosystemic shunts medical management of animals with portosystemic shunts improvement of chronic hepatic encephalopathy in dogs by the benzodiazepine-receptor partial inverse agonist sarmazenil, but not by the antagonist flumazenil apparent dietary protein requirement of dogs with portosystemic shunt medical management of congenital portosystemic shunts in 27 dogs -a retrospective study ultrasonographic diagnosis of congenital portosystemic shunt in 14 cats increasing incidence of hereditary intrahepatic portosystemic shunts in irish wolfhounds in the netherlands (1984 to 1992) determination of inheritance of single congenital portosystemic shunts in yorkshire terriers inherited congenital extrahepatic portosystemic shunts in cairn terriers detection of the single nucleotide polymorphism causing feline autosomal-dominant polycystic kidney disease in persians from the uk using a novel real-time pcr assay diagnostic value of fasting plasma ammonia and plasma bile acid concentrations in the identification of portosystemic shunting in dogs hyperammonemia due to a urea cycle enzyme deficiency a suspected case of ornithine transcarbamylase deficiency in a cat transient metabolic hyperammonaemia in young irish wolfhounds hyperammonemia associated with urethral obstruction in a dog ammonia intoxication in the near-adult cat as a result of a dietary deficiency of arginine cobalamin deficiency associated with methylmalonic acidemia in a cat hyperammonaemic encephalopathy secondary to selective cobalamin deficiency in a juvenile border collie transient hyperammonemia in an adult german shepherd dog evaluation of bile acid concentrations for the diagnosis of portosystemic venous anomalies in the dog and cat epidemiologic factors associated with the anatomic location of intrahepatic portosystemic shunts in dogs association of breed with the diagnosis of congenital portosystemic shunts in dogs: 2400 cases ammonia tolerance test in clinically normal dogs and in dogs with portosystemic shunts rectal ammonia tolerance test in the evaluation of portal circulation in dogs with liver disease postprandial venous ammonia concentration in the diagnosis of hepatobiliary disease in dogs long-term biochemical and physiologic effects of surgically placed portocaval shunts in dogs outcome of ameroid constrictor occlusion of single congenital extrahepatic portosystemic shunts in cats: 12 cases evaluation of 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comparisons with man comparative analysis of hepatocellular carcinoma in men and dogs inactivation of tgfbeta signaling in hepatocytes results in an increased proliferative response after partial hepatectomy mdm2 and p53 polymorphisms are associated with the development of hepatocellular carcinoma in patients with chronic hepatitis b virus infection epidermal growth factor-induced hepatocellular carcinoma: gene expression profiles in precursor lesions, early stage and solitary tumours identification of hepatic stem/progenitor cells in canine hepatocellular and cholangiocellular carcinoma withrow and macewen's small animal clinical oncology status epilepticus after ligation of portosystemic shunts progressive remission of portosystemic shunting in 23 dogs after partial closure of congenital portosystemic shunts gradual occlusion of extrahepatic portosystemic shunts in dogs and cats using the ameroid constrictor methods of gradual vascular occlusion and their applications in treatment of congenital portosystemic shunts in dogs: a review a method for controlling portal pressure after attenuation of intrahepatic portocaval shunts gauged attenuation of congenital portosystemic shunts: results in 160 dogs and 15 cats evaluation of cellophane banding with and without intraoperative attenuation for treatment of congenital extrahepatic portosystemic shunts in dogs cellophane banding for the gradual attenuation of single extrahepatic portosystemic shunts in eleven dogs outcomes of cellophane banding for congenital portosystemic shunts in 106 dogs and 5 cats evaluation of the characteristics of venous occlusion after placement of an ameroid constrictor in dogs evaluation of ameroid ring constrictors for treatment for single extrahepatic portosystemic shunts in dogs: 168 cases evaluation of a portocaval venograft and ameroid ring for the occlusion of intrahepatic portocaval shunts in dogs surgical management of left divisional intrahepatic portosystemic shunts: outcome after partial ligation of, or ameroid ring constrictor placement on, the left hepatic vein in twenty-eight dogs laparoscopic portosystemic shunt attenuation in two dogs transvenous coil embolization of portosystemic shunt in dogs transjugular coil embolisation of an intrahepatic shunt in a cat complications associated with the diagnostic, medical, and surgical management of portosystemic shunts portal vein thrombosis as a complication of portosystemic shunt ligation in two dogs neurologic dysfunction in dogs following attenuation of congenital extrahepatic portosystemic shunts neurologic dysfunction in three dogs and one cat following attenuation of intrahepatic portosystemic shunts use of propofol to manage seizure activity after surgical treatment of portosystemic shunts portal hypertension part ii: clinical assessment and treatment diagnostic comparison of needle and wedge biopsy specimens of the liver in dogs and cats magnetic resonance imaging of focal splenic and hepatic lesions in the 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and chemoembolization for treatment of benign and malignant tumors in three dogs and a goat treatment of unresectable hepatocellular adenoma in dogs with transarterial iodized oil and chemotherapy with and without an embolic agent: a report of two cases results of partial hepatectomy in 18 dogs with hepatocellular carcinoma the pathology of liver tumours in the dog partial hepatectomy in dogs cancer of the liver efficacy of mitoxantrone against various neoplasms in dogs low-dose metronomic chemotherapy with cisplatin: can it suppress angiogenesis in h22 hepatocarcinoma cells? a morphologic and immunocytochemical study of hepatic neoplasms in cats sclerosing adenocarcinoma of the extra-hepatic bile duct in a cat tumors of the liver and gall bladder international consensus group for hepatocellular neoplasia: pathologic diagnosis of early hepatocellular carcinoma: a report of the international consensus group for hepatocellular neoplasia feline hemoperitoneum: 16 cases (1986-1993) 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due to an insulinlike growth factor type-ii secreting hepatocellular carcinoma in a dog detection of serum alpha-fetoprotein in dogs with hepatic tumors alpha-fetoprotein in serum and tumor tissues in dogs with hepatocellular carcinoma serum alpha-fetoprotein values in dogs with various hepatic diseases two-dimensional, grayscale ultrasonography for assessment of hepatic and splenic neoplasia in the dog and cat correlations between ultrasonographic findings and specific hepatic disease in cats: 72 cases (1985-1997) acute pancreatitis in cats with hepatic lipidosis ammonia intoxication in the near adult cat as a result of a dietary deficiency of arginine nutrition of the domestic cat, a domestic carnivore lack of hepatic enzyme adaptation to low and high levels of dietary protein in the adult cat urinary orotic acid-to-creatinine ratios in cats with hepatic lipidosis a study of the lipid transport system in the cat lipid composition of hepatic and adipose tissues from normal cats and from cats with idiopathic lipidosis hypophosphatemia associated with enteral alimentation in cats statistical relevance of ultrasonographic criteria in the assessment of diffuse liver disease in dogs and cats correlations between ultrasonographic findings and specific hepatic diseases in cats: 72 cases (1985-1997) fine-needle aspirate cytology suggesting hepatic lipidosis in four cats with infiltrative hepatic disease ultrastructural hepatocellular features associated with severe hepatic lipidosis in cats proteins invoked by vitamin k absence and clotting times in clinically ill cats nutrition and liver disease dietary l-carnitine supplementation in obese cats alters carnitine metabolism and decreases ketosis during fasting and induced hepatic lipidosis dietary taurine content changes liver lipids in cats safety, pharmacokinetics and use of the novel nk-1 receptor antagonist maropitant (cerenia) for the prevention of emesis and motion sickness in cats textbook of veterinary internal medicine: diseases of the dog and cat feline hyperthyroidism: pretreatment clinical and laboratory evaluation of 131 cases liver changes in patients with hyperthyroidism serum enzyme disturbances in thyrotoxicosis and myxoedema liver tests in hyperthyroidism: effect of antithyroid therapy serum thyroid hormone concentrations fluctuate in cats with hyperthyroidism effect of nonthyroidal illness on serum thyroxine concentrations in cats surgical treatment of hepatobiliary cystadenomas in cats: five cases (1988-1993) biliary cystadenoma of cats a carcinoid tumor in the gallbladder of a dog hepatobiliary neuroendocrine carcinoma in cats: a clinicopathologic, immunohistochemical, and ultrastructural study of 17 cases neuroendocrine carcinoma of the gallbladder in a dog ccnu for the treatment of dogs with histiocytic sarcoma primary extraskeletal hepatic osteosarcoma in a cat feline epitheliotropic intestinal malignant lymphoma: 10 cases feline lymphoma in the post-feline leukemia virus era feline systemic mastocytosis: a review and results of splenectomy in seven cases clinicopathological features and outcome for dogs with mast cell tumors and bone marrow involvement hepatic neoplasia in the dog and cat lomustine for treatment of mast cell tumors in cats: 38 cases (199-2005) nodular hyperplasia in the liver of the dog: an association with changes in the ito cell population nodular hyperplasia of the liver in the beagle dog hepatic nodular hyperplasia wsava standards for clinical and histological diagnosis of canine and feline liver disease correlation of ultrasonographic and pathomorphologic findings in canine hepatic diseases toxic, metabolic, infectious, and neoplastic liver diseases metabolic and hormonal alterations in cats with hepatic lipidosis a retrospective study of 77 cats with severe hepatic lipidosis: 1975-1990 feline hepatic lipidosis hepatic amyloidosis in two chinese shar pei dogs inheritance of renal amyloidosis in chinese shar-pei dogs a canine febrile disorder associated with elevated interleukin-6 familial renal amyloidosis in chinese shar-pei dogs amyloidosis associated with chronic hypervitaminosis a in cats lipid and lipoprotein analysis of cats with lipoprotein lipase deficiency the pathology of an inherited hyperlipoproteinemia of cats dietary diacylglycerol oil has no effect on hypertriglyceridemia in lipoprotein lipase-deficient cats relationship between resting metabolism and hepatic metabolism: effect of hypothyroidism and 24 hours fasting hypothyroidism in dogs: 66 cases epidemiological, clinical, haematological and biochemical characteristics of canine hypothyroidism measurement of serum total thyroxine, triiodothyronine, free thyroxine, and thyrotropin concentrations for diagnosis of hypothyroidism in dogs evaluation of serum free thyroxine and thyrotropin concentrations in the diagnosis of canine hypothyroidism serum total thyroxine, total triiodothyronine, free thyroxine, and thyrotropin concentrations in dogs with nonthyroidal illness treatment and therapeutic monitoring of canine hypothyroidism reexamination of dosage regimens for l-thyroxine (t4) in the dog: bioavailability and persistence of tsh suppression morphological classification of biliary disorders of the canine and feline liver histopathologic evaluation of feline inflammatory liver disease the cholangitis/cholangiohepatitis complex in the cat wsava classification and role of bacteria in feline inflammatory hepatobiliary disease culture-independent detection of bacteria in feline inflammatory liver disease feline cholangiohepatitis complex effect of illness not associated with the thyroid gland on serum total and free thyroxine concentrations in cats influence of systemic nonthyroidal illness on serum concentration of thyroxine in hyperthyroid cats feline hyperthyroidism. diagnostics and therapeutics the relationship between the thyroid gland and the liver consequences of dysthyroidism on the digestive tract and viscera metabolic epidermal necrosis-hepatocutaneous syndrome necrolytic migratory erythema without glucagonoma versus canine superficial necrolytic dermatitis: is hepatic impairment a clue to pathogenesis? clinicopathological, ultrasonographic, and histopathological findings of superficial necrolytic dermatitis with hepatopathy in a cat glucagon-producing neuroendocrine tumour associated with hypoaminoacidemia and skin lesions hepatic ultrasonography and pathological findings in dogs with hepatocutaneous syndrome: new concepts sequential morphologic and clinicopathologic alterations in dogs with experimentally induced glucocorticoid hepatopathy hepatic total 3 alpha-hydroxy bile acids concentration and enzyme activities in prednisone-treated dogs iatrogenic cushing's syndrome and steroid hepatopathy in a cat comparison of acth response and dexamethasone suppression as screening tests in canine hyperadrenocorticism comparison of two low-dose dexamethasone suppression protocols as screening and discrimination tests in dogs with hyperadrenocorticism effects of nonadrenal disease on the results of diagnostic tests for hyperadrenocorticism in dogs. (abstract) plasma cortisol response to exogenous acth in 22 dogs with hyperadrenocorticism caused by adrenocortical neoplasia evaluation of the hypothalamic pituitary-adrenal axis in clinically stressed dogs urinary cortisol in the assessment of pituitary-adrenal function: utility of 24-hour and spot determinations urine cortisol:creatinine ratio as a screening test for hyperadrenocorticism in the dog evaluation of a urine cortisol:creatinine ratio as a screening test for hyperadrenocorticism in dogs spontaneous hepatic rupture in six cats with systemic amyloidosis severe cholestatic liver disease secondary to liver fluke (platynosomum concinnum) infection in three cats destructive cholangiolitis in seven dogs suspected druginduced destructive cholangitis in a young dog primary cholangiohepatitis in a dog cholangiohepatitis in a dog gallbladder aspirate from a dog bacterial cholangitis/ cholangiohepatitis with or without concurrent cholecystitis in four dogs concurrent bacterial cholecystitis and cholangitis in a diabetic spitz dog clinical-pathologic conference congenital cystic disease of the liver in seven dogs congenital dilatation of the bile ducts (caroli's disease) in young dogs congenital dilatation of the large and segmental intrahepatic bile ducts (caroli's disease) in two golden retriever littermates polycystic disease of the kidney and liver in the cairn terrier polycystic kidney and liver disease in two related west highland white terrier litters polycystic kidney and liver disease in cats autosomal dominant polycystic kidney disease in persian and persian-cross cats congenital biliary atresia in a cat: a case report 48. van den ingh ts, rothuizen j, van den brom we: extrahepatic cholestasis in the dog and the differentiation of extrahepatic and intrahepatic cholestasis cholestasis associated with extrahepatic bacterial infection in five dogs morphological classification of neoplastic disorders of the canine and feline liver canine hepatic neoplasms: a clinicopathologic study the pathology of liver tumors in the dog canine biliary carcinoma: epidemiological comparisons with man a morphologic and immunohistochemical study of hepatic neoplasms in cats nonhematopoietic hepatic neoplasms in cats: 21 cases (1983-1988) relationship between inflammatory hepatic disease, inflammatory bowel disease, pancreatitis and nephritis in cats pathogenesis and outcome of extrahepatic biliary obstruction in cats a survey of feline inflammatory hepatobiliary disease using the wsava classification clinical features of inflammatory liver disease in cats: 41 cases (1983-1993) correlations between ultrasonographic findings and specific hepatic diseases in cats: 72 cases (1985-1997) diagnostic comparison of needle and wedge biopsy specimens of the liver in dogs and cats comparison of liver cytology and biopsy diagnoses in dogs and cats: 56 cases accuracy of ultrasound-guided fine needle aspiration of the liver and cytologic findings in dogs and cats: 97 cases percutaneous ultrasound-guided cholecystocentesis in healthy cats bacterial culture results from liver, gallbladder, or bile in 248 dogs and cats evaluated for hepatobiliary disease: 1998-2003 prospective evaluation for bacterial infection in hepatic tissue and bile of cats with diffuse hepatobiliary disease cholecystoenterostomy for treatment of extrahepatic biliary tract obstruction in cats: 22 cases treatment of pancreatitis-associated extrahepatic biliary tract obstruction by choledochal stenting in 7 cats advances in characterization of feline nonsuppurative cholangitis/cholangiohepatitis syndrome characterization of portal lymphocytic infiltrates in feline liver progressive lymphocytic cholangitis in the cat immunohistochemical characterization of the lesions of feline progressive lymphocytic cholangitis/cholangiohepatitis detection of helicobacter pylori in bile of cats association of helicobacter with cholangiohepatitis in cats feline clinical parasitology liver flukes (platynosomum concinnum) in cats cholangiohepatitis and choledochectasia associated with amphimerus pseudofelineus in a cat platynosomum concinnum infection in cats congenital dilatation of the bile ducts (caroli's disease) in young dogs ultrasonographic evaluation of gallbladder wall thickness in cats therapeutic percutaneous ultrasound-guided cholecystocentesis in three dogs with extrahepatic biliary obstruction and pancreatitis choledochal tube stenting for decompression of the extrahepatic portion of the biliary tract in dogs: 13 cases extrahepatic biliary tract surgery in the cat: a case series and review surgical management of gallbladder mucoceles in dogs: 22 cases (1999-2003) chronic bile duct ligation in the dog: hemodynamic characterization of a portal hypertensive model important clinical syndromes associated with liver disease esophageal varices due to a probable arteriovenous communication in a dog portal hypertension associated with primary hypoplasia of the hepatic portal vein in dogs idiopathic noncirrhotic portal hypertension in dogs: 33 cases (1982-1998) fluid retention in cirrhosis: pathophysiology and management ascites is a negative prognostic indicator in chronic hepatitis in dogs pathogenetic mechanisms of hepatic encephalopathy dispelling myths in the treatment of hepatic encephalopathy gut ammonia production and its modulation cerebrospinal fluid glutamine, tryptophan, and tryptophan metabolite concentrations in dogs with portosystemic shunts effects of a branched-chain amino acid-enriched diet on chronic hepatic encephalopathy in dogs soy protein isolate versus meat-based low-protein diet for dogs with congenital portosystemic shunts ammonia and the neutrophil in the pathogenesis of hepatic encephalopathy in cirrhosis changing face of hepatic encephalopathy: role of inflammation and oxidative stress regulation of hepatic ammonia metabolism: the intercellular glutamine cycle nonlymphomatous hepatobiliary masses in cats: 41 cases (1972-1991) biliary cystadenomas of cats ultrasonographic evaluation of biliary cystadenomas in cats partial hepatectomy in two dogs extrahepatic biliary tract obstruction: a retrospective study of 45 cases (1983-1993) ultrasonographic appearance and clinical findings in 14 dogs with gallbladder mucocele gallbladder mucocele in dogs: 30 cases cholelithiasis in dogs: 29 cases (1980-1990) severe cholestatic liver disease secondary to liver fluke (platynosomum concinnum) infection in three cats pathogenesis and outcome of extrahepatic biliary obstruction in cats cholecystoenterostomy for treatment of extrahepatic biliary tract obstruction in cats: 22 cases bacterial culture results from liver, gallbladder or bile in 248 dogs and cats evaluated for hepatobiliary disease bacterial cholangitis/ cholangiohepatitis with or without concurrent cholecystitis in four dogs association of helicobacter with cholangiohepatitis in cats long-term survival and risk factors associated with biliary surgery in dogs: 34 cases surgical treatment of 23 dogs with necrotizing cholecystitis canine gallbladder infarction: 12 cases surgical treatment of cholelithiasis in cats: a study of nine cases gallbladder disease in shetland sheepdogs: 38 cases porcelain gallbladder associated with primary biliary adenocarcinoma in a dog correlation between hepatobiliary scintigraphy and surgery or postmortem examination findings in dogs and cats with extrahepatic biliary obstruction, partial obstruction, or patency or the biliary system: 18 cases prevalence of gallbladder sludge in dogs as assessed by ultrasonography percutaneous ultrasound-guided cholecystocentesis in healthy cats cross-species immunohistochemical investigation of the activation of the liver progenitor cell niche in different types of liver disease is liver fibrosis reversible now there are many (stages) where before there was one: in search of a pathophysiological classification of cirrhosis evolving challenges in hepatic fibrosis chronic hepatitis in dogs: a review of current understanding of the aetiology, progression, and treatment reversibility of liver fibrosis blood hyaluronic acid as a marker for canine cirrhosis transforming growth factor beta-1 signalling in canine hepatic diseases: new models for human fibrotic liver pathologies therapeutic targets in liver fibrosis structural-functional organization of hepatic glutamine and ammonium metabolism coagulation disorders in dogs with hepatic disease coagulation abnormalities in 22 cats with naturally occurring liver disease acute hepatic failure and coagulopathy associated with xylitol ingestion in eight dogs proteins invoked by vitamin k absence and clotting times in clinically ill cats correlation between coagulation profile findings and bleeding complications after ultrasoundguided biopsies: 434 cases (1993-1996) liver regeneration new concepts in liver regeneration defining therapeutic targets for liver fibrosis: exploiting the biology of inflammation and repair key: cord-014687-0am4l5ms authors: nan title: spr 2012 date: 2012-03-29 journal: pediatr radiol doi: 10.1007/s00247-012-2356-8 sha: doc_id: 14687 cord_uid: 0am4l5ms nan dear colleagues, i confess i haven't read many "welcome letters" at the beginning of the spr program book over the years. perhaps the only defensible benefit of this is that there is no preconception about the content of this message…or the length. i will be brief. this meeting is about building bridges…bridges from our past to the future and bridges between all of us who believe fundamentally in maintaining or improving the health of our children. the content, which is detailed on subsequent pages, speaks for itself. this material will be presented during the sessions with an appreciative look back at past accomplishments-the legacy of our subspecialty-with a vision to the future of pediatric imaging. we can only measure how broad and deep our successes have been by connecting with these beginnings. looking beyond the titles (and the speakers), i think you will see that the material is not only about techniques and tactics but about ideas, insights, energy, all conspiring in the creative process … an aggregate for excellence in pediatric imaging. the content is also punctuated by a strong presence of our clinical colleagues. again, this builds bridges. how can we maintain and expand these relationships? moreover, the connections between science and clinical practice are evident in the structured blending of scientific papers and topical presentations by both imaging and clinical experts. this blending is also "fraternal" in that there will sometimes be disagreement and critical commentary, but this is essential in the advancement of medicine. support and criticism make a stronger mortar. in the end, this gathering is about fostering a connected community, including technologists, nurses, physicists and other allied health experts including industry experts. finally, the emblem of pediatric radiology has always been embossed by cooperation, passion, commitment, and humanistic care. i believe the program content, the presenters and you, the participants, all embrace this. i hope that you will feel the spirit and the passion of the meeting and all of us will in many ways be better able to care for children because of this-even if you never read this message! donald p. frush the gold medal of the society for pediatric radiology is our most distinguished honor. the spr medal is awarded to pediatric radiologists who have contributed greatly to the spr and our subspecialty of pediatric radiology as a scientist, teacher, personal mentor and leader. marilyn goske has always wanted to make a differenceand what a difference she has made! her role as an educator, and her lifelong commitment to improving training for residents, fellows, faculty, medical staff and radiologic technologists has resulted in many wonderful initiatives that have benefited all in pediatric radiology. the work she is most proud of-the cleveland clinic web based curriculum, working with the leadership of spr's philanthropic campaign for children, launching the image gently campaign and the pediatric research component within the american college of radiology's dose index registry share a common theme: educating others in providing the best care possible for children. born in berea, ohio, marilyn's father, george, was a chemical engineer. her mother, cornelia aka "corky", loved writing as one of the first women journalists for the associated press and later teaching, passions she passed on to her daughter. while marilyn was blessed with a strong female role model in her mother, it was her brother, james, who was her cheerleader, always pushing her to dream big. he encouraged her to follow in his footsteps first at ohio university, then on to the ohio state college of medicine to pursue an md degree during an era when nursing would have been a more conventional goal. marilyn met her husband rick on a double date in college-unfortunately, they were with different dates! luckily, they were able to get together for an actual date with each other 18 months later. they quickly became engaged and married within a year of that first true date. when rick started his residency in internal medicine, marilyn transferred to the university of connecticut school of medicine in farmington. it was here that she met her first pediatric radiologist-and what a giant-mike ozonoff! when rick moved on to a neurology residency in rochester, new york, marilyn followed and met another pediatric radiology giant: beverly wood, at strong memorial hospital. beverly proved to be a wonderful teacher, mentor, co-researcher and lifelong friend. marilyn describes beverly as inspirational and "fearless" in trying new technologies. it was during her time in rochester that marilyn went to her first spr meeting and, not surprisingly, won the 1984 caffey award for her work on "experimental neonatal intraventricular hemorrhage: clinical, radiographic and pathologic features." by then marilyn had two young children and moved on to the private sector, practicing part-time for several years first in rochester, then in cleveland, ohio. her years in private practice were particularly helpful in learning the importance of patient oriented service-and paved the way for her intuitive public relations strategies when designing the image gently campaign in later years. dr. goske was asked to join the cleveland clinic in 1990, as the first full-time section head of pediatric radiology. it was here that she built a new section and spearheaded the web based education program for pediatric radiology residents with co-founder janet reid. this important free web site with 65 modules is used widely by over 200 radiology residencies nationally and internationally. her passion for education continued, inspiring her to complete a medical education fellowship focused on professionalism within the cleveland clinic lerner college of medicine. her work towards this fellowship has led to many creative educational initiatives including yearly educational summits at the spr. she was named chair of the professionalism committee of the rsna where she along with her committee have sponsored interactive workshops on this topic dear to her heart. dr. goske's energy and effective leadership skills brought her to become involved in the society for pediatric radiology, first as the coordinator for spr's first video-taped course in 1994. mentors diane babcock and carol rumack proposed her for the nominating committee. this was followed by chair of the membership committee, where she organized the first formal survey of the society, then as a board member, then as secretary, and finally as president and chair of the board of directors, completing 12 years on the spr board. working together with stuart royal, she successfully energized the campaign for children raising funds for the research and education foundation of the spr and expanded the work of prior presidents in further organizing the corporate support committee. marilyn's years as president and chairman of the board of the spr were highly successful with many unique strategic goals. she was instrumental in the founding of the junior spr. she led the wonderful 2007 spr national meeting in miami which included the first educational summit to enhance knowledge in adult learning and resident competencies. most people would rest after completing their arduous year as president but as chairman of the board, marilyn was just beginning! she moved to cincinnati children's hospital, joining the radiology department and was named the dr. corning benton endowed chair for radiology education where she got to work with dr. janet strife, another influential mentor and friend. acknowledging spr's long focus on reducing radiation doses in the imaging of children but concerned about the lack of change in practice by a majority of radiologists despite increasing reports of possible side effects, marilyn developed a public relations and awareness campaign. her goal was to inspire all to work towards decreasing radiation exposure to children when possible. with the help of many, she founded the alliance for radiation safety in pediatric imaging and the image gently campaign, initially focusing on ct. her ability to encourage numerous experts and societies to work together and get involved in "child sizing the amount of radiation used" has resulted in a groundswell of research and activity in this area. currently 69 organizations with over 800,000 members have joined the alliance including 24 international societies. the web site, www.imagegently.org, has been immensely successful filled with free information pamphlets in over 12 languages, pqi projects, and modules for parents, physicians, and technologists. the image gently campaign has received several awards including the associations advance america honor roll, rt image magazine group with the "most influence in radiology" and the most effective philanthropy program from aunt minnie. image gently has spawned the creation of the adult-focused image wisely campaign. the alliance has been named by the joint commission, u.s. food and drug administration, and the american medical association in their influential statements on radiation dose as providing much needed guidance and information. marilyn's exceptional talent is inspiring and coordinating experts in multiple fields to work together towards common goals. she continues to work hard on the image gently campaign with more safety and quality messages planned for the coming years. she is also proud of her work with the acr dose index registry and quality improvement registry in ct scans in children in working toward developing diagnostic reference levels with a talented consortium of pediatric radiologists, medical physicists and technologists. she has acted as a national and international expert in her work with the international atomic energy agency, the world health organization and the national council on radiation protection in medicine and the fda. dr. goske's multiple committee appointments are taken seriously, and her work is always meticulous, well thought out, and brought to successful completion. she has been an active member of numerous national and international societies including the john caffey honorary society, acr, rsna, espr, aawr, and scorch. it is important to remember that dr. goske is also a successful researcher with numerous grants obtained through the spr ref including the thorne griscom education award and the rsna scholar grant. she has published over 80 peer-reviewed articles, 19 electronic publications, 7 chapters, and presented 26 scientific exhibits as well as given numerous scientific presentations. an articulate and engaging speaker, she has been invited to give over 130 lectures locally, nationally and internationally. while marilyn has been very focused on her work with the spr, she believes that it is her amazing family and their love that really fuels her life. her husband rick is an internationally known neurologist and researcher in multiple sclerosis. her adult children jamie and brian, both in manhattan, remain close, and spending quality time together as a family remains the joy of her life. whether it is relaxing together in florida cooking or fishing, or taking an exotic vacation to india, being with rick, jamie and brian makes her the happiest. marilyn's genius is partly refusing to take "no" as an answer. along the way, at every turn there were those who believed that what she wanted to do couldn't be done. her approach was to draft the nay-sayers to the team and charge ahead with their willing and enthusiastic help. daniel burnham might have been talking about marilyn and not about his plan for the city of chicago when he said: make no little plans; they have no magic to stir men's blood and probably themselves will not be realized. make big plans; aim high in hope and work, remembering that a noble, logical diagram once recorded will not die, but long after we are gone be a living thing, asserting itself with evergrowing insistence. as an amazing change agent, inspirational leader, and wonderful role model, the spr is proud to honor marilyn goske with the 2012 gold medal. she made big plans! dorothy i. bulas, md pioneer honorees were first acknowledged in 1990 as a means to honor certain physicians who made special contributions to the early development of our specialty. it is time to reevaluate the meaning of the pioneer honoree. the subspecialty of pediatric radiology has been in existence now for more than 50 years. we are beyond "the early development"; we must recognize other pioneering paths and should consider contributions to the subspecialty beyond the bounds of a modality, a technique, an observation or a change in practice. whatever this advancement is, it must be forged with vision, innovative ideas, and the ability to enable and sustain science and application. george s. bisset, iii, m.d. why george bisset? has he been part of the pediatric radiology landscape these last ten years? been part of the dialogue that has been increasingly influential across all of radiology, a conversation steeped in a deep tradition of excellence in diagnosis and treatment, and the safety and welfare of our children? been a leader in science and application? part of the landscape? no. but he has been beyond that and has worked tirelessly within the horizon, surveying…a step before, but guiding us on towards our destiny. a conversant? part of the dialogue? maybe. but he has been defining thought and concept upon which such conversation is born and nurtured. part of the science and application? yes, as much as anyone who promotes, who facilitates and sustains discovery, then here we are. horizons, innovation, and the gift of en-abling…what else is needed to define a true pioneer? how was this done? simply stated, george bisset has devoted at least the last decade to the advancement of our specialty in truly novel ways through his leadership, especially in rsna and the abr. in the rsna, as the scientific program committee chair several years ago he was instrumental in the conception, development and implementation of the integration of scientific papers and refresher course topics. this has been a resounding success, is currently used in other categories during rsna and is a model for other meetings, including the annual meeting for the society for pediatric radiology over the past few years. pediatric radiology was first in this effort. george continued to endorse topics that were marquees for pediatric radiology over the year in his education role on the rsna board of directors. he endorsed and implemented the pediatric campus concept at the 2011 rsna. early returns are that this was an extremely successful model to consolidate experts in pediatric radiology (and those interested in this subspecialty), pertinent science, education and administration. george is now the president of rsna, perhaps the most widely respected scientific and educational organization for our profession across the globe…and i would argue, with more promise for our future success in pediatric radiology than has ever existed. and george bisset, who through two terms as the pediatric trustee for the board of trustees for the abr, again, was on the horizon of a critical, sometimes perilous, and complete transformation of our certification examination process, always mindful of his constituency and colleagues, his duty as a physician, and the public and patients. this required delicate diplomacy, forward thinking, professionalism, and enlistment of a cadre of experts from within our subspecialty to assure excellence in pediatric radiology through abr certification. he was also a leader in the development, validation and implementation of the imagerich computer based examination model (the pediatric caq) now the standard for the new abr examinations. with these successes in mind, who better to embody the concept of bridging horizons that is the theme for this entire meeting? if you were looking for more numbers and accolades, i apologize. here are some: more than 225 contributions to medical and scientific literature, advancing care through pediatric body ct and mr imaging research, a litany of presentations and invited lectures, vice chairs, chairs, chiefs, boards of directors, committee member and committee leader, clinical excellence including as a pediatric cardiologist and interventional radiologist, a superb speaker and author.… all are on his cv but i believe serve really as signposts for his gifts, some of those mentioned above, that a cv simply cannot convey. he could have played it safe with all of these successes on his cv. but pioneers don't play it safe. they are on the horizon, too busy defining thought and enabling (our) advancement-building bridges. i believe it is time to reevaluate the meaning of the pioneer honoree and i have the greatest honor and pleasure of introducing george s. bisset, iii for the pioneer award for 2012. linked with past awardees, he continues an exceptional legacy and i don't believe his explorations and discoveries are finished… donald p. frush, md the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. in 1999, david kushner was recognized by the spr with its first presidential recognition award for his vision and foresight in working with both the american college of radiology (acr) and the society for pediatric radiology (spr) in developing an important new relationship and for his service to the spr. in summarizing his considerable efforts for that award, i noted that he "contributed substantively to the increased visibility of the spr within the acr. his tenure as our treasurer placed our organization on a firm financial foundation." with the current award, the society recognizes his indefatigable continuing efforts on our behalf including: his work with the acr: 1. establishing a pediatric radiology caucus at the annual acr meeting, 2. convincing the acr of the value of managing specialty societies by making the spr its first successful new model for imaging society management, 3. advocating tirelessly for pediatrics and children's health within the acr by serving on the council steering committee and then as acr council vice speaker and speaker, 4. helping establish the first pediatric commission, assuring that pediatric issues will receive support of the college and its resources while serving on the board of chancellors of the acr for the past five years. the spr's "image gently" campaign was a beneficiary of this pediatric commission of the board of chancellors, 5. continuing to shepherd and contribute to the pediatric component of the acr practice guideline process. his work with the spr: since his earlier award, david has served as: foundation from 2000 to 2003, including the launch of the formal fundraising effort, "the campaign for children," 2. spr president 2003 -2004 , organizing and running a very successful meeting in savannah, 3. chair of the board of directors of the spr from 2004 to 2005, including leading a strategic planning process that resulted in a new, more focused division of labor amongst board members and defined board responsibilities. david was born in fargo, north dakota, received a ba from the university of minnesota, and received his medical education at the university of pennsylvania. this was followed by two years of training in pediatrics at children's hospital, boston. he then did a two-year fellowship at the national institute of health in bethesda, performing research in embryology and teratology. he returned to massachusetts general hospital for training in diagnostic radiology. this was followed by a year of residency in pediatric radiology at children's hospital boston, followed by a one-year fellowship. he then became director of the pediatric radiology section at massachusetts general hospital, a position he held from 1979 to 1988. from 1988 to 2005, david was chief of the division of diagnostic imaging and radiology at children's national medical center in washington, dc attracting a strong faculty, training many fellows and promoting research. during that time, he served as a volunteer radiologist and pediatrician to inner city healthcare systems aiding the indigent and homeless, and developing telemedicine capabilities linking free clinics with radiology experts. in 2005, our man inside the beltway moved a bit outside by accepting the medical directorship of radiology at the children's hospital of the king's daughters in norfolk, virginia, and professor of radiology and pediatrics at the eastern virginia medical school. he assures me that life there is good, being a bit more "laid back" with fishing and sailing just outside the door. he also finds time for italian cooking and practicing jazz on his several guitars. fortunately for all of us in the spr, david is close enough to our central office and the acr that he will be able to continue work on our behalf for many years to come. the society bestows presidential recognition awards on members or other individuals whose energy and creativity have made a significant impact on the work of the society and its service to its members. the 2012 spr presidential award is given in recognition of stuart's numerous significant and outstanding contributions to the spr over many years of service. the awardee is selected by the honors committee, a committee comprised of the three most recent past presidents of the society. dr. royal is a proud native of birmingham, alabama. he is a second generation physician who came naturally to his desire to care for children as the son of a pediatrician, arnold royal, who took care of children in the birmingham community until he was 79 years old. dr. royal attended rice university in houston, texas followed by md and ms degrees from the university of alabama at birmingham. he subsequently moved to san francisco, where he completed a pediatric internship followed by a diagnostic radiology residency at the university of california, san francisco. dr. royal credits dr. charles gooding at ucsf for influencing his decision to pursue a career in pediatric radiology. during his internship stuart observed dr. gooding make a plain film diagnosis of tapvr, type 3 on a severely ill and perplexing newborn, and he was immediately hooked into radiology. while at ucsf dr. royal was also appointed as a national institute of health research fellow in the department of radiology. following residency, stuart completed a fellowship in pediatric radiology at the children's hospital medical center in boston. from boston, stuart returned to his roots in birmingham, alabama in 1980, where he was appointed as a pediatric radiologist at the university of alabama and subsequently the children's hospital in birmingham. in recognition of his outstanding leadership skills and accomplishments at the children's hospital, dr. royal was appointed as the radiologist-in-chief in 1987 , and subsequently the harry m. burns endowed chair of pediatric radiology. he also holds appointments as clinical professor of radiology and pediatrics at the university of alabama at birmingham and serves on the children's hospital board of trustees. at alabama dr. royal has earned the high esteem of his colleagues, referring physicians, and staff for his outstanding clinical acumen as a diagnostic radiologist and for his undaunting commitment to excellent care of children. colleagues describe stuart as one who fosters a strong work ethic, high commitment to teaching, and sincere compassion for children. in 2006, stuart was the recipient of the children's advocate award by childcare resources for improving the quality of care and access to radiological services for underserved children in birmingham. stuart has been married to the love of his life, barbara royal, for the past 40 years. stuart and barbara are the proud parents of two very accomplished children, jeremy a budding radiologist in training at the university of alabama, and rachael, who has an mba and works as a vice president for moody's in new york. stuart and barbara are also the proud grandparents of three grandchildren. in conversation, stuart is quick to pull out his iphone and share the latest pictures of family members while recounting their latest activities and milestones. throughout his professional career, dr. royal has worked tirelessly to advance the mission of the society for pediatric radiology. he is past president and chairman of the board of the spr and has served on numerous spr committees. he ran a highly successful spr meeting in new orleans in 2005. those in attendance will recall the jubilant parade stuart led through the streets of new orleans to culminate the meeting. as president and then chair of the spr board, stuart played a critical and instrumental role in bringing the spr management contract under the umbrella of the acr. the synergy achieved by the spr-acr relationship has yielded results well beyond a simple management contract. pediatric radiology and spr now have a voice at the "radiology table." stuart has also been a strong advocate for supporting translational research to advance the care of children via imaging. to help achieve this goal, he has worked aggressively to secure increased funding for the society of pediatric radiology research and education foundation. following the launch of the ref's campaign for children in 2000, stuart made it his personal mission to work with the leadership of the society, both past and present, to discuss major gifts to the foundation. through stuart's personal effort, the foundation received pledges for many significant leadership gifts, including from spr pioneers drs. hooshang taybi and ed singleton and from himself and barbara. the spr is highly fortunate to have benefited from stuart's numerous contributions and dedication to the care of children. the society is very proud to bestow the 2012 president's award on dr. stuart a. royal. the society extends honorary membership to individuals outside of pediatric radiology who have made outstanding contributions to the care of children. this evening, dr. harvey l. neiman, whose leadership of the american college of radiology is resoundingly praised, is the recipient of the 2012 honorary member award. for 2012, as in 2007 when his contributions were similarly recognized, dr. neiman's selection by the society for pediatric radiology honors committee was made in appreciation for the strength of his efforts to further the spr's philosophy, goals, and programs for responsible diagnosis and treatment of the young patient as embodied in the acr and spr's "image gently" campaign. image gently has succeeded not only in raising awareness of the great diagnostic benefits we can offer to pediatric patients but also directs us to acknowledge the downside of overzealous diagnostic efforts where excessive radiation becomes a risk. importantly, the "image gently" campaign, an upbeat, positive program rather than a punitive one, a smile rather than a frown, makes pediatric and all radiologists aware that their best practice reflects balanced, educated, up-to-date utilization of state-of-the art technology with exercise of responsible leadership in protecting the pediatric patient. for adults, awareness of the need for patient protection is communicated in image wisely. dr. neiman's vision and successful achievements are evident on every page of his curriculum vitae. a consummate strategist in assembling teams to make forward-looking goals a reality, harvey now stands at the top of our specialty as the first physician executive director of the american college of radiology. at this time in big-business medicine, as we see the physician, leader of the patient care team, being diminished to one of many "providers," it is so important for our patients' well-being for us to recognize the obligations commanded by our training, clinical experience and commitment. dr. neiman's recognition of the need for physicians' leadership in improving the quality of patient services and his development of programs in all areas of the college's activities have been just short of miraculous-image wisely for adults, quality and safety including the performance guidelines and accreditations, education, government relations, economics, imaging metrix, acrin, and the new radiology leadership institute-to name only a few. all have contributed significantly to the care of our patients and the stature of our specialty. dr. neiman was born in detroit and attended mumford high school. from wayne state university, he received his b.s. in 1964 and his md in 1968. harvey's postgraduate training was at the university of michigan, where he was a resident in radiology (1969 -1972 ), chief resident (1971 , and a 1972-73 fellow in angiography (cardiovascular radiology), receiving abr certification in 1973 and a caq in vascular and interventional radiology in february 1995. dr. neiman often expresses his gratitude to and profound respect for his mentor and beloved chief at the university of michigan, dr. william martel. dr. neiman was chief of cardiovascular radiology at walter reed army hospital and a lecturer in cardiovascular radiology at the afip from 1973 -1975 . in 1975 , he joined the northwestern radiology faculty, rising to professor in 1981, and for ten years he headed up the section of angiography and sectional imaging, advancing its technology and honing the skills of northwestern's radiology residents. harvey also offered a highly sought-after fellowship in interventional radiology, us, and ct. in 1985, dr. neiman left northwestern to assume the chair in medical imaging at the western pennsylvania in pittsburgh. i was the first woman to have completed his fellowship in us, ct, and interventional radiology at northwestern and accompanied him to pittsburgh. his tenure at west penn attests to his talent in making his visions a reality: the department became a highly respected, successful academic private practice notable in many areas including ultrasound, breast and women's imaging, and interventional radiology. harvey instituted an excellent radiology residency program in 1988 as well as fellowship programs in 1986 in the areas of excellence noted above. during the 40 years since harvey received his md, he has been awarded honors from many national, international, and specialty societies, has been an invited lecturer over 181 times on ultrasound, interventional radiologic, radiologic educational, management, turf issues, disruptive and new technology topics to name just a few. dr. neiman, who was a founder of the sru (society of radiologists in ultrasound), has to his credit 122 peer-reviewed articles, 69 scientific presentations and 20 exhibits, a text co-authored with dr. james yao, angiography of vascular disease (1984) , and 26 book chapters. he has received many honors including fellowship in the american college of radiology, american institute of ultrasound in medicine, society of radiologists in ultrasound and the society of cardiovascular and interventional radiology (now sir). as part of his strong commitment to the future leaders of radiology, for diagnostic radiology he has served as a member of the residency review committee of the accreditation council for graduate medical education. he has been a member of the american college of radiology and its committees and commissions for many years including the commissions on education, ultrasound, and economics. he also served as chair of the commissions on ultrasound and economics. from 1994 to 2002 , he was a member on the acr board of chancellors, serving as its chairman 2000-2002. he was president of the radiology advocacy alliance from 1998 to 2000. in 2003, nine years ago, dr. neiman became the acr's executive director. he currently serves in this position, where his excellent business skills, knowledge of health policy and economic issues, and strong administrative background have furthered our specialty. his goal, to ensure that the acr's resources benefit all radiologists and patients across all economic strata, is evident in his actions at the college. harvey has a devoted, wonderful family that often included me and my youngest daughter on many pittsburgh occasions. his beautiful, elegant wife of many years, ellie neiman, is here tonight to celebrate with him the spr's recognition of his many achievements. dr. neiman has two accomplished, lovely daughters, jennifer, extremely successful in her marketing career, and hilary, an attorney. jennie's husband, dr. seth kligerman, one of many young radiologists whom harvey has mentored, is on the radiology staff at the university of maryland. how harvey has had time between, through, and among all of these achievements to have become mentor, colleague, and friend to me and to so many others who have been inspired by his ability to see into the future and to shape it in a positive way is remarkable. now that dr. neiman has taken all of radiology under his wing, not just its component parts, the future of our specialty, one of the best, can be assured but also recognized for its centrality to all of medicine. it is my honor and privilege to introduce to you harvey l. neiman md, facr as this year's society for pediatric radiology honorary member. the singleton-taybi award is given in honor of edward singleton and hooshang taybi, in recognition of their personal commitment to the educational goals of the spr. initiated in 2006, the award is presented annually to a senior member of the spr whose professional lifetime dedication to the education of medical students, residents, fellows, and colleagues has brought honor to him/her and to the discipline of pediatric radiology. it comes as no surprise to those who know him that dr. daneman, "dr. d" as some of us call him, has been named the 2012 recipient of the singleton-taybi award in recognition of his many years of dedication to the education of residents, fellows, and colleagues. born in south africa in 1947, he received his medical degree at the university of the witwatersrand, johannesburg, receiving the harwood-nash award for the most successful student in surgery. initially, dr. d thought he would become a pediatric surgeon; but after passing the part i examination offered by the royal australasian college of surgeons, he changed his mind and began his training in diagnostic radiology. he chose a radiology residency at the royal prince alfred hospital, in sydney, australia. this included a year in pediatric radiology at the royal alexandra hospital for children in sydney where his interest and love of pediatric radiology began. dr. d then had the foresight to pursue pediatric radiology fellowship training at the hospital for sick children in toronto, canada. after completing the fellowship, he was immediately offered a position as staff radiologist at "sick kids." he became director of body imaging in 1984 and radiologist-in-chief in 1988 serving in that capacity for 7 years. his management style was simple but effective. he chose staff that were young, but smart and innovative. he nurtured them and provided them with all the tools they needed to become successful professionals, like him. but contributing to his own department was not enough for him. he also found the time and strength to contribute, teach, train, and help pediatric radiologists in the most remote portions of the globe in every continent, which resulted in recognition from prestigious organizations in places such as south america, israel, europe, taiwan and australia: he is an honorary member of the european society for pediatric radiology and the sociedad latinoamericana de radiologia pediatrica as well as other national societies. dr. d is an "institution" inside the great institution that is sick kids. his teaching is unique and praiseworthy in being enthusiastic, provocative, and fun at the same time. his lectures have been regarded as both instructive and practical by his students and trainees due to his special gift of making the most complicated things look as simple as possible. in sharing his diagnostic knowledge and know-how, he passes his own, innate teaching spirit on to his apprentices. he has earned several awards for this, including the outstanding teacher award granted by the university of toronto fellows at sick kids for the past 5 consecutive years. dr. d receives numerous invitations to present at national and international meetings and symposia and has been invited as a visiting professor to more than a hundred institutions across the globe. he does not only teach us the ins and outs of pediatric radiology, but he makes sure that we learn to love it and understand the importance not only of good practice but also the imperative to pass knowledge on by teaching and publishing. dr. d is someone who inspires us to reach beyond our limits, someone we want to emulate. he shares his knowledge, his wisdom, and his advice freely. he shares with us the most incredible secrets of his own career, so we understand from his personal experience. dr. d never tells you what to do, he suggests to you, in an incredible articulate fashion, what you want to do yourself. dr. d has been and is for many of us, more than an educator, more than a mentor, he is our "coach." well before this concept was introduced into medicine by a. gawande 1 , dr. d intuitively had the vision to "coach" his trainees, trying to get the best out of them, without pressure, but with love and passion, and especially emphasizing the importance of achieving a worklife balance in order to prevent the now so common "stress and burnout" affecting the radiology community 2 . he warned us that many high achievers reach their goals only at the expense of their personal lives, but dr. d has been as successful personally as he is professionally. his wonderful wife of 40 years, louise, his two daughters and his recently newborn granddaughter serve as sources of strength and pride. he is a truthful and generous friend to many, both in and out of radiology. it is not uncommon for many of us, who came through sick kids, to come back and visit and be invited to his house to share a wonderful dinner with other invitees, who may be radiologists from north america or from other parts of the globe visiting sick kids to learn from him. dr. daneman's research has widely influenced the field of pediatric radiology. examples include the work of dr. daneman and his colleagues on intussusception, which has promulgated the use of ultrasound for diagnosis, and the use of air enema for reduction. this approach has been adopted as standard practice at many institutions in north america and across the globe. to share his research with others in the field, dr. daneman has authored or co-authored more than 200 publications, including peer reviewed articles and book chapters on a wide range of topics related to the imaging of children. dr. d is one of those rare people who are irreplaceable. he is a superb teacher, a gifted academician, a capable administrator, and a person called "friend" by so many of us. we are thrilled and proud to present our society's singleton-taybi award to dr alan daneman in recognition of his lifelong accomplishments and personal commitment to the educational goals of the spr. we cannot imagine anyone more deserving of this award than dr. d. thank you "coach"! monica epelman, md and oscar navarro, md john caffey, md 1895 -1978 dr. caffey was regarded throughout the world as the father of pediatric radiology. his classic textbook, pediatric x-ray diagnosis, which was first published in 1945, has become the recognized bible and authority in its field. the seventh edition of this book was completed several months before his death in 1978. it has been among the most successful books of its kind in the medical field. dr. caffey was born in castle gate, utah on march 30, 1895 . it is interesting that he was born in the same year that roentgen discovered the x-ray. dr. caffey was graduated from university of michigan medical school in 1919, following which he served an internship in internal medicine at barnes hospital in st. louis. he spent three years in eastern europe with the american red cross and the american relief administration, and returned to the united states for additional training in medicine and in pediatrics at the universities of michigan and columbia, respectively. while in the private practice of pediatrics in new york city at the old babies hospital of columbia university college of physicians and surgeons, he become interested in radiology and was charged with developing a department of pediatric radiology in 1929. he frequently expressed appreciation and admiration for the late ross golden, chairman of radiology at columbia presbyterian hospital, who allowed him to develop a separate department of diagnostic radiology without undue interference, and who was always available to help and advise him. dr. caffey's keen intelligence and inquiring mind quickly established him as the leader in the fields of pediatric x-ray diagnosis, which recognition became worldwide almost instantaneously with the publication of his book in 1945. dr. caffey received many awards in recognition of his achievements. outstanding among these were the mackenzie davidson medical of the british institute of radiology in 1956, the distinguished service award of the columbia presbyterian medical center in 1962, the outstanding achievement award of the university of michigan in 1965, the howland award of the american pediatric society in 1967, the jacobi award of the american medical association in 1972, and the gold medal award of the american college of radiology in 1975. he had been a member of the american journal of roentgenology. he was a counselor of the society for pediatric radiology and was an honorary member of the european society of pediatric radiology. dr. caffey's contributions to the pediatric radiologic literature were many. he was instrumental in directing attention to the fact that a prominent thymic shadow was a sign of good health and not of disease, an observation that literally spelled the end to the practice of thymic irradiation in infancy. infantile cortical hyperostosis was described by him and is called "caffey's disease." dr. caffey in 1946 first recognized the telltale radiographic changes that characterize the battered child, and his students helped disseminate his teachings about these findings. it was dr. caffey who first recognized and descried the characteristic bony changes in vitamin a poisoning. he recognized and described the findings associated with prenatal bowing of the skeleton. in 1963, three years after his retirement from babies hospital, he joined the staff of the children's hospital of pittsburgh as associate radiologist and as visiting professor of radiology and pediatrics at the university of pittsburgh school of medicine. although dr. caffey came to children's hospital and the university of pittsburgh in an emeritus position, he worked daily and on weekends throughout the years he was there. in pittsburgh, he made four major new contributions to the medical literature. he described the entity, "idiopathic familial hyperphosphatasemia." he recognized and described the earliest radiological changes in perthes' disease. he called attention to the potentially serious effects of shaking children, and used this as a subject of his jacobi award lecture. he described, with the late dr. kenny, a hitherto unrecognized form of dwarfism that is now known as the caffey-kenny dwarf. the john caffey society, which includes as its members pediatric radiologists who have been intimately associated with dr. caffey, or who have been trained by his students, was established in 1961. this society is now among the most prestigious in the field of radiology. his book and the society named in his honor will live on as important memorials to this great man. his greatness was obvious to all who worked with him. he was warm, kind, stimulating, argumentative, and above all, honest in his approach to medicine and to x-ray diagnoses. his dedication to the truth was expressed in his abiding interest in the limitations of x-ray signs in pediatric diagnosis and in his interest in normal variation in the growing skeleton. he was concerned with the written and spoken word and was a skilled semanticist. his book and his articles are masterpieces of language and construction. he stimulated and was stimulated and loved by all who had the privilege of working with him. radiology and pediatrics have lost a great man, but they shall ever have been enriched by his presence. interstitial lung disease, which is more common in infants than older children, is defined as a rare heterogeneous group of parenchymal lung conditions primarily due to underlying developmental or genetic disorders. affected infants typically present with clinical syndromes characterized by dyspnea, tachypnea, crackles, and hypoxemia. mainly due to a lack of evidence based information regarding underlying pathogenesis, natural history, imaging findings, and histopathologic features of interstitial lung disease, the understanding of interstitial lung disease in infants has been limited in the past. however, in recent years, the understanding of interstitial lung disease in infants has been substantially improved primarily due to: 1) advances in imaging technology for better detection; 2) improvement of thoracoscopic techniques for lung biopsy; 3) established pathologic criteria for consistent diagnosis; and 4) development of new classification system based on underlying etiology of the interstitial lung disease. in fact, several forms of interstitial lung disease in infants that exhibit distinct clinical, radiological, and pathological patterns are currently emerging. the overarching goal of this article is to review a new classification system, imaging findings, and pathological correlation of interstitial lung disease in infants. improved understanding of this often challenging disorder can aid in early and accurate diagnosis, which in turn, will result in improved patient care. large airway disease in pediatric patients: impact of advanced post-processing techniques catherine m. owens, bsc mbbs mrcp frcr the introduction of multidetector row computed tomography (mdct) scanners has altered the approach to imaging the pediatric thorax. in an environment where the rapid acquisition of ct data allows general hospitals to image children instead of referring them to specialist pediatric centers, it is vital that general radiologists have access to protocols appropriate for pediatric applications. this lecture will focus on the main principles of volumetric ct imaging that apply generically to all mdct scanners and in particular we describe the reconstruction techniques for imaging the pediatric thorax and the low-dose protocols used in our institution on a 64-slice dual source ct scanner. examples of important clinical applications with the impact and added value of post processing are also given. neoplasms, by definition, comprise an abnormal uncoordinated proliferation of cells that persists even after the inciting stimulus as ceased. the resulting mass may be benign or malignant and arise from any tissue that is normally found in the location where the mass develops. thus, tumors of the chest may arise from bone, lung, pleura, lymphatics, muscle, etc. whether benign or malignant, chest masses may be incidental findings on imaging obtained for other reasons. this presentation will focus on malignant tumors of the chest, address the imaging characteristics and staging of the most common chest malignancies and discuss characteristics that may aid in distinguishing these lesions from their corresponding benign or infectious counterparts. included in this presentation will be the most common chest wall malignancies (ewing family of tumors and rhabdomyosarcoma), mediastinal malignancies (lymphoma, germ cell tumors, and neurogenic malignancies) and pulmonary primary malignancies (pleuropulmonary blastoma and carcinoid). the changing appearance of selected tumors in patients treated with new targeted therapies will be introduced. lung disease is the most common chronic disease of childhood, but young children cannot perform the breathing maneuvers required for the most commonly used method for assessing lung function, spirometry. ct provides exquisite structure information about the lung but concerns regarding the long-term consequences of the relatively high radiation dose limit its use particularly in the pediatric population. magnetic resonance imaging (mri) has the potential to provide regional information about the lung without the use of ionizing radiation. while conventional proton mri has found widespread clinical application in most organs of the body, mri of the lung lags behind because the lung is intrinsically difficult to image with mri. the strength of the mr signal depends on the physical density of protons in the tissue being imaged and the local environment of the protons. the lung has a low physical density and thus a low proton density so little mr signal is generated by the lung. furthermore, the magnetic susceptibility effects from its many air-tissue interfaces cause what little signal is generated to rapidly decay so that the lung typically appears dark on conventional proton mr images. a variety of strategies have been developed to overcome the inherent difficulties of mri of the lung, resulting in recent substantial improvements in image quality. additionally by administering an inhaled gaseous contrast agent, such as the hyperpolarized noble gases helium-3 or xenon-129, direct visualization of lung airspaces in an mr image is possible. a number of unique strategies for evaluating the structure and function of the human lung using hyperpolarized gas mri have been developed. although the level of structure detail possible with lung mri may never equal that of ct, mri may nonetheless has the potential to provide clinically useful information and be a sensitive, effort independent test of pediatric lung disease. for a matter of time, we will focus in this presentation only on the following: intestinal malrotation a normal visceral situs can be inferred sonographically in relation to the right-sidedness of the superior mesenteric vein, to the retromesenteric location of d3 and to the right iliac position of the ileocecal valve. conversely, intestinal malrotation is likely when the 3 aforementioned features are reversed. in addition, cdu can display the whirlpool pattern in case of midgut volvulus or internal hernia, alleviating the need for preoperative opacification. the reliability of us in diagnosing intussusception is well documented since the early 1990s. the value of us in predicting the success or failure of pneumatic reduction and/or bowel necrosis is more debatable, based upon a coexisting bowel occlusion, the presence of interloop fluid, bowel wall changes (intramural air, dilated mural vascular channels), absent blood flow at cdu. the continuous down-grading of us in comparison to ct, and the opposite conclusions of various series regarding imaging of pediatric appendicitis are based upon different prerequisites and definitions. historically and in most usa institutions, sonography reports are either negative (entire normal appendix), positive (abnormal inflamed appendix), or equivocal (non-visualization or partial visualization of appendix). the equivocal group is then logically investigated by a subsequent abdominal ct. in europe, some usa centers, and in our practice, us reporting include 4 groups and take into account ancillary findings: 1. normal appendix (blind-ended, lamellated, compressible, <6 mm in diameter, without peristalsis; 2. appendix not depicted, no secondary signs; 3. appendix not depicted, with one of the following: hyperchoic mesenteric fat, fluid collection, local dilated small bowel loop; 4. appendix inflamed. group 3 represents most cases of perforated appendicitis, groups 1 and 2 the negative sonogram. ct is then indicated only in obese patients and to assess the feasibility of percutaneous interventions. inflammatory bowel disease in the recent literature, mr enterography is often preferred to ct enterography. small bowel series look prehistoric and us is rarely mentioned. sonography however is very valuable both for screening children presenting with abdominal pain, diarrhea, weight loss, or gi bleeding and for following the course of the disease and searching for complication. hypervascularization has been proved to parallel the disease activity. initially mentioned by dr. rita teele, the interest of us for differentiating high-intermediate/low varieties of imperforated anus has been re-emphasized more recently. a perineal rectal cul de sac distance of 15 mm is quoted as the significant cut-off value. us can also display rectourinary fistulae outlined by air. update on mdct and mri of hepatobiliary disease in children: what's new lisa h. lowe, md a variety of disorders may affect the pediatric liver. recent advances in histopathological knowledge and imaging techniques have led to important changes that radiologists must be aware of in order to allow for an accurate limited differential, and in some cases, specific, diagnosis. this presentation will focus on recent developments that have lead to a better understanding of the embryopathogenesis for fibropolycystic liver diseases (including choledochal cysts and caroli disease), histopathological findings that have led to new classification systems for of pediatric vascular anomalies, technological advances and contrast agents in magnetic resonance imaging that are useful to characterize and limit the differential diagnosis of hepatic masses. diagnostic errors in pediatric abdominal imaging: diagnostic pearls and pitfalls george a. taylor, md this presentation reviews the types of diagnostic errors in abdominal imaging occurring over a 13-year period in an academic pediatric radiology practice. radiologists engage in two interrelated processes when interpreting imaging studies: perception and analysis. failures in perception (failure to identify an important finding) are a common source of diagnostic error in pediatric imaging, while failures in the analytic portion of the process (over-or faulty interpretation of a finding) are not as common. under-interpretation of findings can be related to a number of perceptual and visual phenomena including visual isolation where attention is selectively focused on a main area of the image while less or no attention is given to secondary areas, and satisfaction of search which occurs when additional lesions remain undetected after detection of an initial lesion. many analytic errors are the result of commonly used heuristics or shortcuts in reasoning. these include the availability heuristic in which likelihoods are based on memory of a similar case, the framing effect in which a different diagnosis is reached based on how the information is presented, and the anchoring heuristic in which the initial impression is difficult to change, despite conflicting new information. another recognized pitfall is blind obedience, in which a diagnostician stops thinking when confronted by authority. this authority can be human or technical (reliance on a laboratory value). finally, diagnostic errors can result from an attitude of overconfidence. examples of these heuristics and strategies to minimize cognitive errors will be discussed. marta hernanz-schulman, md, faap, facr this session will consider abdominal masses that present in the neonatal period, spanning developmental, inflammatory and neoplastic conditions. time constraints do not allow an exhaustive list or description, but the more important or frequent lesions are discussed. the presentation is subdivided by systems. the renal section discusses various conditions presenting with hydronephrosis, such as ureteropelvic junction obstruction and duplication anomalies, followed by autosomal recessive polycystic kidney disease and multicystic dysplastic kidney, cystic entities commonly presenting in the perinatal period. neoplastic renal entities include lesions with benign behavior, such as ossifying renal tumor of infancy, with the discussion extending to entities with very poor prognosis such as clear cell sarcoma and rhabdoid tumor, while discussing the congenital mesoblastic nephroma, its histologic subtypes and the differences in their presentation, imaging findings and clinical behavior. suprarenal lesions include the adrenal hemorrhage, congenital neuroblastoma and subdiaphragmatic sequestration. hepatic lesions include developmental anomalies that present as mass lesions, such as choledochal cysts, vascular lesions such as congenital and infantile hemangiomas, and neoplastic lesions such as the mesenchymal hamartoma and hepatoblastoma. differences in clinical presentation, imaging characteristics and behavior of the lesions are discussed. the section on pancreatic lesions discusses pancreatic cysts and pancreaticoblastoma. gi tract and mesenteric lesions include duplication cysts, lymphangioma, and meconium pseudocyst, and their relationship to bowel obstruction and persistent perforation. ovarian cysts can present as large masses in neonatal girls, and should be high in the differential diagnosis of large masses encountered in female infants; the imaging characteristics of simple and complicated cysts are described, as well as their course and potential complications. pediatric procedures: from imaging to intervention the spectrum of vascular anomalies in pediatric patients: multimodality imaging evaluation and current treatment patricia e. burrows, md vascular anomalies are categorized into two main groups, vascular tumors and vascular malformations. genetic and molecular regulation of vascular genesis of angiogenesis, and mutations responsible for some of the vascular malformations, have been delineated. in order to implement future targeted treatment of vascular lesions, accurate diagnosis is important. imaging modalities that are effective in distinguishing the various types of vascular anomalies and demonstrating the extent include ultrasonography with doppler interrogation, mri and various forms of mr vascular flow imaging, conventional angiography and venography. techniques used to image lymphatic channel anomalies, conventional lymphangiography, lymphoscintigraphy and infrared fluorescent lymphangiography. in this presentation, common forms of vascular anomalies will be described and rare or recently recognized anomalies will be mentioned. current treatment of the different forms of vascular anomalies will also be discussed, including pharmacotherapy using beta blockers, angiogenesis inhibitors and mtor inhibitors. endovascular techniques used in treating vascular malformations, including embolization and sclerotherapy will be presented. pediatric vascular disease is extremely varied, with a wide range of conditions requiring diagnostic or therapeutic intervention. technological improvements in non-invasive imaging modalities such as mri and ct have reduced the need for diagnostic angiography; however, with advances in interventional techniques, arteriography in the pediatric patient is now often performed for therapeutic reasons. pediatric arteriography presents unique issues and challenges. tremendous variability in patient size and physical maturity limits the ability to standardize technical aspects of performing arteriography. in addition, radiation protection, sedation/anesthetic support, monitoring of fluid balance, and maintaining patient warmth must be considered. a regimented protocol for assessment of the pediatric patient must be followed, with review of the indications for the study requested, and review of patient-specific issues such as coagulation profile, concurrent medical disease, patient weight, and anesthetic concerns. appropriate patient monitoring is imperative to ensure patient safety. vascular access can be quite challenging. ultrasound and micropuncture access techniques have tremendously improved successful access while reducing associated complications. the smallest catheter that can accomplish procedure objectives should be used. for most diagnostic cases, 4 french systems can be used for children>10 kilograms, while 3 french catheters are preferred in those <10 kg. intraprocedural heparinization (75-100 iu/kg) is also more often used, especially in children weighing less than 10-15 kg. rates and volumes of contrast injected for pediatric arteriography are not standardized, as in adult patients. in general, contrast dose should be limited to 6-8 ml/kg, and 4-5 ml/kg in premature infants and neonates. all these new technique are less invasive, improve patients' outcomes and reduce morbidity. they are also cost-effective as patients are discharged home earlier and recover faster from the intervention. the future holds promising new technologies such as high-intensity focused ultrasound (non-invasive method of thermal ablation) and nanoparticles for drug delivery. pediatric interventional radiology will continue to be an essential part of these minimally invasive therapies. musculoskeletal imaging: from planning to performance kirsten ecklund, md the purpose of this talk is to review advanced mr imaging techniques currently being used in the evaluation of pediatric musculoskeletal tumors. the goals of these techniques include improved image resolution and quality, lesion tissue characterization, and increased acquisition speed. diffusionweighted (dw) and perfusion imaging will be emphasized; however, whole body, metallic artifact mitigation, and volumetric sequences will also be discussed. dw mri is based upon the brownian motion of water within extra and intra-cellular spaces which depends upon tissue cellularity. dwi can aid in the differentiation of benign from malignant lesions, which generally have restricted diffusion. there is even greater potential for dwi in the assessment of tumor response to therapy. the apparent diffusion coefficient (adc) maps are critical to accurate interpretation of diffusion sequences. adc maps distinguish between restricted diffusion and t2 effect, both of which appear bright on dwi. both qualitative and quantitative tissue assessments can be made with dwi. challenges for dwi in the pediatric musculoskeleton include susceptibility artifacts from bone, motion vulnerability, and geometric distortion at larger fields of view. our current protocols and parameters for dwi will be presented. contrast-enhanced (dce) mr using one of a variety of vendor specific sequences. qualitative and quantitative assessments of inflow and distribution of contrast have been shown to help differentiate between benign and malignant lesions and to evaluate drug efficacy during therapy. this technique is especially promising in those patients undergoing antivascular and antiangiogenic therapy. tal laor, md congenital abnormalities of the musculoskeletal system can result in alterations of limb size, configuration, and/or segmentation. these disorders often affect both the osteocartilaginous skeleton as well as the surrounding soft tissues and can be localized or diffuse. in this session, we will focus on the imaging features of several congenital abnormalities that result in a small or short limb, in altered configuration of a limb, or in abnormal segmentation. deformities of both upper and lower limbs will be examined. like congenital abnormalities, developmental disorders of the pediatric musculoskeletal system can be limited to a single area or can affect numerous sites within the body. for example, neonatal brachial plexopathy is a localized disorder that produces characteristic musculoskeletal alterations about the shoulder girdle and elbow of affected children. the alterations of morphology and function of the shoulder develop over time with growth of the child and change in response to a variety of therapies. we will review the features of developmental anomalies of the pediatric musculoskeletal system and evaluate the role that imaging plays in the initial evaluation and in the subsequent assessment of these children during treatment. multimodality imaging of skeletal trauma in children: using all of the tools peter j. strouse, md skeletal trauma is a common indication for imaging throughout the pediatric age range. newborns may suffer birth trauma. infants and toddlers may be subject to abusive injury. children of all ages may suffer accidental injury. older children and adolescents are increasing hurt in sporting activity and vehicular accidents. fracture patterns vary with maturation of the child. interference with normal growth is a potential complication. imaging of skeletal trauma begins with radiography. proper anatomic and age specific radiographic technique assures optimal diagnostic yield. radiography suffices in most cases to diagnose fracture or confirm normalcy. "clinical correlation" aids in diagnosis. ultrasound, ct, mri and nuclear medicine may play a role in specific instances where plain radiographs are non-diagnostic or to better delineate certain fractures. arthrography and conventional tomography have occasionally been used in the past and tomosynthesis may prove useful. follow-up radiographs may be useful for diagnosis or confirmation of some fractures. this presentation will focus on the imaging of acute skeletal injury. technique and approach for plain radiography will be emphasized. specific indications and roles for ancillary imaging techniques will be defined and illustrated with representative cases. although classically thought of as a disease of adulthood, stroke is much more common in the pediatric population than was once appreciated. this may be due to many factors, not the least of which is increased awareness due to the presence of subspecialty stroke teams now fairly commonplace in many children's hospitals, and the fairly recent advent of more advanced imaging technique such as diffusion-weighted imaging (dwi) and its routine use in imaging the central nervous system (cns) in the child and adolescent. causes of stroke in children can be protean, and range from idiopathic on one end of the spectrum, to traumatic on the other, with many causes in between, many of which may not be intuitive to the clinician without further research. moyamoya disease and its many causes, such as sickle cell disease (scd), trisomy 21 and neurofibromatosis type i (nf i) can all lead to stroke in children, as can congenital clotting deficiencies such as factor v leiden deficiency and congenital cardiac lesions with their resultant shunting of blood between the left and right cardiac circulations. although usually arterial in nature, strokes may arise from the venous system in clinical scenario of venous thrombosis with resultant venous infarctions. factors contributing to venous thrombosis in children and adolescents can be due to dehydration (especially in the very young), severe iron deficiency anemia, inflammatory bowel disease and exogenous hormone ingestion such as is seen with oral contraceptives (ocp) in young women. advanced imaging techniques for neuroimaging in pediatric patients: where are we now? blaise v. jones, md the past decade has seen a large number of advanced imaging techniques introduced to the clinical armamentarium of the pediatric radiologist. from the development of multidetector ct scanners that can obtain whole head diagnostic studies in less than 2 s to the routine use of 3 t mr imaging, technical advances have dramatically changed our ability to diagnose and manage neurological disorders in children. however, all of these advances are not of equal clinical utility, and it is imperative that the pediatric radiologist be well versed in their judicious and appropriate application. this presentation will discuss the effective use of volume ct scanning, cta, swi, asl, fmr, pmr, and other advanced imaging techniques in the diagnosis of neurological disorders presenting in childhood. at the conclusion of the presentation the attendee will have a better understanding of how to ideally apply these technologies in practice. a spectrum of abnormality in pediatric neck: practical imaging choices and interpretation caroline d. robson, mbchb learning objectives: 1. become familiar with an optimized imaging approach for head and neck infections 2. recognize the complications of head and neck infections 3. recognize the utility and interpretation of imaging for neck masses this talk will cover the imaging approach and interpretation of findings in head and neck infection and neck masses. infection includes acute complicated sinusitis, coalescent mastoiditis, neck infection and local and intracranial complications. optimized imaging protocols and image interpretation for neck masses will also be discussed and illustrated. acute complicated sinusitis is diagnosed when acute sinusitis is accompanied by orbital symptoms (e.g. proptosis) and/or mental status changes, seizures or other neurological findings. coalescent mastoiditis is diagnosed when otomastoiditis is accompanied by tenderness and/or swelling over the mastoid process. ct and mr provide complementary information. ct is obtained with contrast. mr sequences include fatsuppressed t2, t1, diffusion, and fat-suppressed contrastenhanced t1 weighted images with mr venography. intracranial complications include epidural abscess, subdural empyema, meningitis, cerebritis, brain abscess, venous thrombosis and venous infarction. the limitations and usefulness of ct in the diagnosis of neck abscess will be illustrated. the imaging approach to masses depends on patient age, and the size and location of the mass. us, ct, mr, and nuclear medicine studies provide complementary information. as for infection, optimized imaging approaches and key imaging features for various masses will be discussed. embryology and diagnostic approach in spinal dysraphism l. santiago medina, md, mph and esperanza pacheco-jacome, md congenital anomalies of the spine are malformations that can be confusing due to the complexity of their embryology, and to the sometimes unclear classifications and terminology. the purpose of this review is to give a clear and basic understanding of the different stages of the embryological development of the spinal cord, starting with the bilaminar disc in the first week of gestation. during the second week, the formation of a trilaminar disc (gastrulation), the notochord, and the formation of the neural tube or neurulation. also, a review of the development of the distal cord: conus medullaris, filum terminale, ventriculus terminalis, by a different mechanism, canalization and retrogressive differentiation. beside the embryological review, a case correlation will be presented using mr imaging to demonstrate these malformations. open spina bifida entities include meningocele and myelomeningicele. closed or occult spinal dysraphism (osd) is characterized by a spinal anomaly covered with skin and hence with no exposed neural tissue. osd spectrum includes dorsal dermal sinus, thickened filum terminale, diastematomyelia, caudal regression syndrome, intradural lipoma, lipomyelocele, lipomyelomeningocele, anterior spinal meningocele and other forms of myelodysplasia. several studies have shown that mri and ultrasound have better overall diagnostic performances (i.e., sensitivity and specificity) than plain radiographs for detection of occult spinal dysraphism. for h1n1, most patients had mild illness but a small percentage required mechanical ventilation and icu admission. the high risk groups include children <5 years old and those with chronic medical conditions in particular neurodevelopmental impairment. pediatric mortality was 7.5% of all deaths associated with the pandemic reported in the u.s. in both conditions, the most prominent radiographic and ct features were airspace disease including ground glass opacities (ggo) and consolidation, commonly with multi-focal and bilateral involvement. pleural effusion, adenopathy and cavities were absent. in some patients with viral infection, respiratory symptoms may be mild but are complicated by neurological manifestations. a brief review of mri features in h1n1 related encephalopathy including acute necrotizing encephalopathy (ane) will be given. bernard f. laya, do tuberculosis (tb) is a worldwide major public health problem with one-third of the world's population being infected. it is a leading cause of death and disability from infection worldwide. children are amongst the most vulnerable group because of their immature immune status. a child usually gets tb infection after being exposed to a sputum-positive adult. depending on many factors, the infection can lead to latency or tb disease. it can affect virtually any organ in the body and can be devastating if left untreated. tb in children remains a diagnostic challenge. in addition to history of tb exposure, signs and symptoms, laboratory and microbiologic tests, medical imaging remains a valuable tool in its diagnosis. although findings are nonspecific, the radiograph is the most commonly ordered initial imaging tool for screening and diagnosis of pulmonary and musculoskeletal involvement. computed tomography and magnetic resonance imaging offer more detailed assessment especially in cranial and abdominal involvement. medical imaging is also utilized to follow up patients during or after anti-tb treatment. knowledge of the common imaging patterns, pitfalls and dilemma are very important in establishing the diagnosis of tb in children. the pathophysiology of pediatric tb will be discussed as it correlates with imaging findings. the wide spectrum of imaging manifestations in various modalities will be presented. imaging updates along with pitfalls and dilemma in the interpretation will also be discussed. tb can affect almost every organ system but the author will present cases that are more commonly encountered. and concurrent ct/ pet-ct (k00.33) panels. there were more indeterminate nodule predictions by pet-ct (n038 of 75; 51%) and concurrent ct/pet-ct (n 023; 31%) than by ct alone (n012; 16%). the overall accuracy of ct alone was 71%, pet-ct alone 45% and concurrent review 60%. worst case sensitivity and specificity were 85% and 44% for ct alone, 60% and 19% for pet-ct alone, and 67% and 48% for concurrent ct/pet-ct. conclusions: pet-ct assessment of pulmonary nodules in children is feasible but limited by non-diagnostic quality ct images and atelectasis caused by sedation. subjective assessment of nodules by pet-ct does not appear to improve the ability to distinguish benign from malignant histology in children with solid malignancies. semi-quantitative nodule assessment using the standardized uptake value may improve the performance of pet-ct in this setting and will be investigated in the future. purpose or case report: nec is the most common lifethreatening medical/surgical emergency of the gastrointestinal (gi) system in neonates, with an incidence up to 10% in infants weighing <1500 g. with advances in treatment of nec, increased survival rates result in rise in post-nec gi complications such as feeding intolerance. development of post-nec bowel strictures results from healing of involved bowel and can result in bowel obstruction. it has been routine to study the bowel of infants after medical treatment for nec by contrast enema and small bowel follow-through prior to initiating feeding. however, in order to "image gently" we are attempting to decrease the radiation exposure to these patients. we postulate that in patients with no abnormal bowel dilation prior to initiation of feeds, the incidence of colonic stricture would be so low that routine enemas would be unnecessary and could be eliminated from the workup. recorded as present or absent in 6 anatomic abdominal regions defined as: 1 and 2-from the dome of the diaphragm to top of l2 to the right and left of midline, respectively; 3 and 4-from top of l2 to the iliac crest to the right and left of midline, respectively; 5-from the iliac crest to the top of the sacrosciatic notch; 6-below the top of the sacrosciatic notch. we assessed the frequency of findings in each region and how often findings in regions 5 and 6 were associated with findings in regions 1-4. 95% confidence intervals were calculated. results: the fewest pertinent findings were present in region 6 in 10.2% (51/501) (95% ci: 7.7-13.1%) of radiographs. findings included: abnormal bowel 6% (n031), bowel gas paucity 1.4% (n07), pneumatosis 0.4% (n02), inguinal hernia 0.8% (n04) and osseous abnormalities 1.2% (n06). pertinent findings were present in region 5 in 67.7% (339/501) (95% ci: 63.4-71.8%). findings included: abnormal bowel 43.7% (n0 219), bowel gas paucity gas 19.6% (n098), pneumatosis 1.6% (n08), free air 0.2% (n01), and abnormal bowel with pneumatosis 2.6% (n013). among 51 patients with an abnormality in region 6, 49 (96.1%) also had an abnormality within at least one of regions 1 through 4. among the 342 patients with an abnormality in region 5 or 6, 338 (98.3%) also had an abnormality within at least one of regions 1 through 4. catheter/tube tips were located in region 5 in 6.8% (n034) and region 6 in 1.4% (n07) of radiographs, respectively. pneumatosis was present most frequently in regions 3 (5.8%), 4 (4.0%), and 5 (4.2%). free air was present most frequently in regions 1 (1.6%), regions 2 and 3 (0.6% each). conclusions: our preliminary data suggest that pertinent findings on neonatal portable abdominal radiographs are rarely isolated to the pelvis, implying that gonadal shielding of regions 5 and 6 should not compromise diagnostic accuracy. purpose or case report: the purpose of this study was to determine the sensitivity, specificity, and positive and negative predictive value of ultrasound in diagnosing appendicitis when the appendix is visualized, using three diagnostic categories: positive, negative, and equivocal. the 3-category diagnostic accuracies for appendiceal diameter and radiologist impression were compared. methods & materials: a retrospective study was performed evaluating all right lower quadrant ultrasound reports dictated over a 5-month period. included studies were interpreted as positive, negative, or equivocal for appendicitis. report impressions that did not specify one of these categories and studies where the appendix was not seen were excluded. the pathologic diagnosis of appendicitis was considered the gold standard for a positive diagnosis. because virtually all pediatric surgical cases in the region are referred to our hospital, it was assumed that the patient did not have appendicitis if surgery was not performed. logistic modeling using appendiceal diameter as the independent variable established cutoff diameters of ≤6 mm0negative, >8 mm0positive, and 6<x≤ 8 mm0equivocal. sensitivity, specificity, and positive and negative predictive values were calculated for both methods. results: of the 571 patients imaged during the study period, 255 (45%) met the inclusion criteria; 34 (6%) reports did not categorize the impression and in 282 (49%) studies the appendix was not seen. surgery was performed on 122 (48%) subjects, of which 101 (83%) had a pathologic diagnosis of acute appendicitis. using the radiologist impression, there were 68 true positives (tp), 2 false positives (fp), 8 false negatives (fn), and 150 true negatives (tn), for a sensitivity of 97% (95% ci090-100%), specificity of 95% (ci090-98%), ppv of 89% (ci080-95%), and npv of 99% (ci095-100%). there were 27 (11%) cases reported as equivocal; of these, 7 (26%) had a pathologic diagnosis of appendicitis. using appendiceal diameter, there were 46 tp, 6 fp, 2 fn, and 161 tn, for a sensitivity of 88% (ci077-96%), specificity of 99% (ci096-100%), ppv of 96% (ci0 86-99%), and npv of 96% (ci092-99%). there were 41 (16%) cases categorized as equivocal; of these, 25 (61%) had a pathologic diagnosis of appendicitis. conclusions: the use of diagnostic categories enables high ppv and npv with a relatively low number of equivocal cases. using appendiceal diameter alone results in higher ppv than that of the radiologist impression, but also yields a higher number of equivocal cases. purpose or case report: intussusception is an obstructive condition that a segment of the bowel invaginates into adjacent bowel and is an urgency that needs to be reduced as soon as possible to prevent bowel ischemia or necrosis. when it occurs in the infants and young child, it usually develops idiopathically and reduced by the technique such as air enema under the fluoroscopic guidance or saline enema under the ultrasound guidance. the success rate of the non-surgical reduction has reported over 95%. the pneumatic reduction is to introduce air into the patients' rectum via a ballooned foley catheter by hand pump. a mercury manometer connecting with the foley catheter calibrates the pressure of insufflation, and the recommended maximum pressure is 120 mmhg. the hydrostatic reduction is to drip saline from a bag at the height of 3 ft that may be different according to the institute's guidelines. until recently, in both techniques, the precise measurement of the intraluminal pressure was not possible. with the purpose of intraluminal pressure monitoring, we introduced a specific digital pressure gauge that can measure both pneumatic and hydrostatic pressure in various units and can give the collected data to our workstation. with the data, we purpose to make the curve of intraluminal pressure during the procedure and to compare the pattern and difference in both techniques of reduction, which permits suggesting the better technique for reducing the intussusception. from february 2011, we performed the intraluminal pressure monitoring in 8 children; 4 cases of pneumatic reduction and 4 cases hydrostatic reduction. the results indicated that the curves were similar in both techniques. however, the hydrostatic reduction tended to need longer time and higher pressure difference than the pneumatic reduction. we assumed that a higher flow rate and more fluctuating introduction of pressure in the pneumatic reduction made the difference between both methods. purpose or case report: anecdotal evidence suggests that some pediatric brain tumors, particularly pilocytic astrocytomas, demonstrate greater enhancement on delayed post-contrast t1 weighted mr imaging compared to early post-contrast imaging. our goal was to compare immediate post-contrast imaging with delayed post-contrast imaging in pediatric brain tumors. methods & materials: the research protocol was granted exempt status by the institutional review board (comirb# 10-1354). between november 2010 and march 2011, all patients for whom an mri of the brain was ordered to follow-up known brain tumor or to evaluate new brain tumor underwent a modified protocol that included both immediate and 10 min delay post-gadolinium images. the modified protocol sequence order was dwi, t1 mprage, contrast injection, immediate post-contrast t1 mprage, t2, flair, 10 min delayed post-contrast t1 mprage. this sequence allowed both immediate and delayed post-contrast imaging to be performed without scanner downtime. a total of 67 unique patients met inclusion criteria of an enhancing primary brain tumor with the delayed imaging performed within a window of 6-19 min. these studies were evaluated independently by 2 pediatric neuroradiologists (ns and lf) and a radiology resident (jm) to compare the degree of lesion conspicuity and edge discrimination, and to determine an overall preference. in cases of discrepancy between reviewers, final grading was determined by group consensus. results: delayed post-contrast images were preferred in 55/67 tumors (82%), immediate post-contrast images were not preferred in any case, and 12/67 cases were graded as equivalent (18%). notably, delayed imaging was preferred for 19/20 pilocytic astrocytomas (95%). in 9/67 cases (13%), the improvement in conspicuity and edge discrimination on delayed imaging was felt to have a potential impact on clinical management, e.g. by extending resectable or treatable tumor margin. conclusions: delayed post-contrast imaging can be performed easily by reordering existing mri protocols, and no scanner downtime is required for this protocol change. our results indicate that pediatric brain tumors (particularly pilocytic astrocytomas) often enhance more conspicuously on delayed imaging, that no diagnostic confidence is lost on delayed imaging, and that clinical management may be more accurately guided. 3-directions) were retrospectively reviewed, after irb approval. both sporadic (n07) and nf-1 associated optic gliomas (n06) were included. tumors confined to intraconal optic nerve were excluded due to technical limitation of epi dwi within the bony orbit. apparent diffusion coefficient (adc) of the solid portions of the tumor was measured using the region of interest method both at baseline and on follow-up mri. results: for the 13 patients, 7 required treatment (surgery and/or chemotherapy) for symptomatic tumor progression (5 sporadic opg and 2 cases of nf-1). median follow-up interval was 3.1 years (range: 7 months to 10.5 years, sd 2.7 years). there was no difference in adc values between sporadic and nf-1 associated opg. opg that required therapy had significantly higher baseline mean adc (1589 x 10-6 mm2/s, sd 0.22), whereas opg with low mean adc (1255 x 10-6 mm2/s, sd 0.18) remained clinically asymptomatic or stable (stratified mann-whitney test, p00.0002). an increase in mean adc of 100 x 10-6 mm2/s doubled the odds the patient will require treatment (or02.16, 95% ci: 1.51-3.10, p<0.0001). enhancement patterns did not predict tumor behavior or nf-1 status (fisher's exact test, p00.192). conclusions: significantly higher mean adc was seen in opg that required therapy for tumor progression. mri may be a useful prognostic tool in further defining a subset clinically significant sporadic or nf-1 associated opg. purpose or case report: fast brain mri imaging has recently been introduced for assessing brain ventricles in patients with ventriculo-peritoneal shunts (vps). however, there is minimal literature on how this method could be beneficial for other indications. compared to ct, this method reduces lifetime cumulative radiation dose and has multiplanar capabilities. it is much faster than full brain mri, reducing exam costs and potentially reducing the need for sedation. however, fast brain mri has lower resolution than a standard brain mri and cannot detect hemorrhage. the goal of our study is to retrospectively assess additional clinical applications for fast brain mri. methods & materials: patients who had undergone fast brain mri were found in xenobase, a database which references deidentified electronic medical records at our institution. xenobase was then used to identify subgroups by diagnosis. one of the most common diagnoses was arachnoid cyst. after irb approval, patients with fast brain mri and arachnoid cyst were identified so that their fast brain mri could be compared to any full brain mri and to clinical outcomes. fast brain mri findings were excluded if there was not a full brain mri within 1 year. agreement with full brain mri, and documented effect on clinical management were coded for statistical review. results: between 2008 and 2011, there were 14 arachnoid cyst patients with 16 fast brain mri exams. in 12 members of this group, fast brain mri was used alone or in comparison with a full brain mri in the decision to follow or discharge the patient. 2 exams failed to report a pituitary cyst and mass effect which were reported on prior exams. 6 patients had no complications in the year following their fast brain mri. the most common complication was headache (4 cases). conclusions: fast brain mri reduces radiation exposure, time, cost, and the need for sedation in vps patients. these benefits may cautiously be extended to other patient groups also requiring routine imaging, such as those with arachnoid cysts. disclosure: the authors disclose that they will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: susceptibility-weighted imaging (swi) is a new technique that exploits susceptibility differences in different tissues, to provide a different type of tissue contrast. swi is a gradient echo sequence utilizing both phase and magnitude data to achieve exquisite sensitivity to tissue magnetic susceptibility effects. it is extremely sensitive to even minute amounts of paramagnetic substances and therefore for detection of blood products (hemosiderin, ferritin), deoxygenated blood, calcium, iron, and small vein depiction. it is particularly suited for vascular imaging, especially in cerebral ischemia. swi has been shown to be more sensitive in detecting cerebral microbleeds than is conventional t2*-weighted gradient-recalled echo imaging (gre) partly because of its inherent sensitivity, increased spatial resolution and the thinner slices acquired. recent studies have shown that swi detected more microbleeds in more patients, irrespective of their location and that swi may be more sensitive in detecting traumatic lesions than ct or mri. methods & materials: between january 2011 and october 2011 we have performed swi on 75 pediatric patients (from 1 day to 15 yrs old) affected with different pathologies. mri was performed using either a 3-or 1.5-t magnet (achieva ; philips healthcare, best, the netherlands). among these patients 62 also received a classic gre sequence. results: our experience confirms a greater sensibility of swi than gre in detecting microbleedings and larger bleedings. swi is much more helpful in patients younger than 1 year since it can distinguish hemorrhagic and non hemorrhagic punctuate white matter lesions detected as hyperintensities on t1-w images. it is more accurate in distinguishing petechial hemorrhages and ischemic foci in patients with germinal matrix hemorrhages. swi can provide important diagnostic information not only in vascular pathologies but also in tumors showing the altered tumor microvascularity, the degree of intratumoral necrosis and the presence of subtle defects of the bbb within the surrounding parenchymal tissue. the technique also allows the detection of possible bleedings in infectious lesions. conclusions: swi is a valuable technique in the evaluation of a wide variety of intracranial pathologies in the pediatric population and its use is advisable on a routine basis. purpose or case report: a common problem with pediatric mr imaging is motion. diffusion-weighted imaging (dwi) is highly sensitive to the effects of both rigid-body motion and brain pulsation. the resulting motion artifacts can manifest in several ways, and include blurring (motion between volumes), slice 'drop-outs' (motion during the diffusion encoding), and aliasing (motion during the parallel imaging/ghost calibration scan). in order to improve image quality in pediatric dwi and avoid the potential for repeat scans, we have implemented our grappa-accelerated diffusion tensor (dt)-epi sequence on over 1,600 pediatric patients at our institution, and have developed tailored reconstruction software to correct for large motion and reduce the need for general anesthesia (ga). methods & materials: grappa-accelerated epi dti data was collected on 100 patients at 1.5 t and 1,500 patients at 3 t between the ages of 1 month and 18 years old. with these data, we investigate the use of a method to select the best grappa and ghost calibration weights; 3d rigid-body realignment with importance weighting; a new volume rejection criterion for large motion; together with other procedures to lower image noise and reduce phase artifacts. all image reconstruction was performed using compiled threaded matlab code on the vendor's (ge) multiprocessor reconstruction hardware. results: using the maximum motion detected from the 3d realignment procedure on the 1,600 dti exams, 51% of patients did not move (either through co-operation or ga, denoted here by <1 mm of motion); 28% of patients moved between 1-3 mm; 13% between 3-5 mm; 6% between 5-10 mm; and 2% between 10-18 mm. except for 3 patients in total, the motion correction steps employed here were extremely robust in correcting for motion. in addition, the motion correction steps employed here do not blur or negatively affect the data on non-moving patients. conclusions: our proposed integrated reconstruction scheme suggests that correcting for different types of motion at different stages of the dti acquisition is critical to provide scans of diagnostic quality. apart from the very rare instance (0.2%) where the patient moved continuously an extensively throughout the scan, our motion correction procedures employed here are extremely robust. using this scheme, we show that highly diagnostic motion-corrected dti data can routinely be read on our patient database within 10 min. . participating sites followed mutually agreed upon vendor-specific dti protocols used for neonates in clinical practice: ss-epi; b 0700;~2 mm3 voxel; 30-32 directions; te~84 msec; 1 acquisition; parallel imaging; multi-channel (8-32) head coil. tensor data was analyzed at one site using internally developed software in idl. b0 and eddy current distortion were assessed by analyzing grid line distortion on acr slice 5 ; deviations from linearity were measured in the phase encoding direction. acr slice 7 was used to assess snr of the center and periphery of the b00 image, and fractional anisotropy (fa) of the phantom, which should approach 0. deviations from specified sequence parameters were recorded. results: both siemens scanners had some image degradation due to vibration susequently corrected by the vendor. nonlinear gridline distortion was highest on the ge followed by philips but was corrected with the use of 2nd order shimming. eddy current distortion was consistently smaller than acquisition voxel size after image registration. te varied from 74-92 msec; acquisition bandwidth range was 1563-2928 hz/pixel. the 2 mm slice thickness was problematic on clinical ge scanners resulting in non-isotropic voxels. across vendors, snr was consistently higher in the image periphery than center by a factor of 1. 30-0.45 ). the greatest difference was showed in patients with fhc. no association was found between the value of ldl-c and imt. the 62.5% received drug treatment at the time of evaluation. in dbt-1 a no association was found between the imt and the levels of hba1c and lipids. and in the ob group found no association between imt and bmi z score. fhc 31%, 8% of dbt-1 and 6% of ob showed atherosclerotic plaques and intima irregularities. conclusions: the imt ultrasonography was able to demonstrate that patients with chronic diseases, with increased cardiovascular risk in adulthood, showed early alterations of carotid intima media in children. this allows clinical applications of preventive and therapeutic guidance. a benchmark for precision of flow assessment was determined from differences between aortic and pulmonary arterial flows, which should agree. the precision of flow when utilizing a slow flow structure (vein) and a fast flow structure (artery) was then determined, serving as an indicator of the precision of slow flow measurements. this was done in pairs for the upper body (svc flow vs difference between ascending and descending aortic flow), lower body (ivc flow vs descending aortic flow) & total body (svc flow+ivc flow vs ascending aortic flow). paired t-tests were used to identify significant differences in the respective arterial and venous flow rates. with an f-test, the relative precision of the arterial flow (determined from aortic and pulmonary arterial flow) was compared against the precision of agreement between upper, lower, and total body flows, each of which has a slow flow venous component, thus assessing precision of venous flow measurement. results: arterial & venous flow measurements were strongly correlated for the upper body (r00.89), lower body (r00.96) and total body flow (r00.97); net aortic and net pulmonary trunk flow rates were also tightly correlated (r00.97). moreover, there was no significant difference in the precision of arterial & venous flow measurements (t-test, p00.31). lower venc (200 cm/s or lower) improves the accuracy and precision associated with low velocity venous flow, a finding that tended to but it did not reach statistical significance. conclusions: with 4-d pc mri, the accuracy and precision of venous flow quantification are comparable to arterial flow quantification, though venc settings may improve venous flow assessment. disclosure: dr. tariq has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the spatial resolution requirements for imaging tiny target vessels in neonates have so far precluded its use of cemra in this patient population. the purpose of our study, therefore, was to explore the potential of high resolution cemra at 3.0 t in neonates with suspected congenital vascular anomalies methods & materials: 16 neonates (mean age 9.4 days, range 1-28 days; mean weight 2.7 kg, range 1.5 kg-4.2 kg) underwent cemra at 3.0 t. cemra was performed under controlled apnea on a 32-channel 3.0 t system using either a 12-channel head-neck coil (9 pts) or a 15-channel adult knee coil (7 pts). gd contrast delivery was calculated based on a total dose of 0.2 mmol /kg. parallel imaging factors of 4-6 were used, generating 0.7 x 0.5 x 0.6 mm voxels in an acquisition time of 17-22 s. images were scored for quality and the presence of artifacts independently by two observers. the cemra series were evaluated to identify pulmonary arterial and venous anatomy. extra-pulmonary vascular anatomy was divided into 12 sections for image quality assessment on mpr. results: the mra data sets had high mean image quality and low mean artifact grading scores. no significant difference was evident between the two observers for scoring image quality and artifact (p00.9), and there was good interobserver agreement (k00.66, 95% ci: 0.26-0.81). the pulmonary arteries were confidently visualized to at least the 2nd order branches in all 16 patients, at least the 3 rd order branches in 15 (93%). out of 176 evaluated segments, 164 (93%) were graded as the vessel "very well visualized with excellent definition of vessel" pa abnormalities were diagnosed in 10 patients and pv anomalies in 6 patients. correlation was made with open surgical findings in 12 cases, confirming the cemra diagnoses with no discrepancy between the operative and imaging conclusions. the results of our study suggest that high resolution cemra at 3.0 t is extremely promising in neonatal cchd and, in combination with echocardiography, may often provide comprehensive information for treatment planning. with appropriate use of physiological motion compensation, parallel imaging and coil configuration, voxel volumes less than 0.5 mm3 are routinely achievable. purpose or case report: it is not well understood whether transfusion-dependent children (mainly those who have hereditary anemias subject to excessive iron levels from regular blood transfusions) with no or mild cardiac iron overload and without signs of heart failure exhibit early changes in cardiac dysfunction. this study aims to evaluate intramyocardial deformation and subsequent cardiac dysfunction in such patients using the cardiovascular magnetic resonance technique of myocardial tagging as well as assess iron overload by another cardiovascular magnetic resonance technique of t2 star (t2*). we hypothesize that transfusion dependent children undergoing chelation therapy will be at high-risk for cardiomyopathy despite normal or slightly elevated iron levels and no signs of heart failure due to progressive myocardial deformation as assessed by myocardial tagging; that is, we expect abnormal mechanical parameters to exist despite t2* values which correspond to normal or slightly elevated myocardial iron levels. methods & materials: 8 patients (mean age 15 yrs) requiring regular blood transfusions for various reasons (e.g. thalassemia, sickle cell disease, other anemias) were investigated using harmonic phase magnetic resonance tagging and t2* imaging. various myocardial mechanical parameters were quantified and correlated to cardiac iron levels as measured by t2*. results: 2 children with no overt signs of heart failure (as measured by ejection fraction and volume indices) exhibited normal t2* iron levels in combination with global circumferential abnormal myocardial strain and 4 children exhibited regional strain. conclusions: this preliminary data suggests that transfusiondependent children without overt signs of heart failure exhibit early signs of cardiac dysfunction (an effect of strain as assessed by myocardial tagging) in direct relation to normal or slightly elevated myocardial iron levels (as measured by t2*). a larger sample size of children could support the idea of abnormal myocardial mechanics being a diagnostic imaging marker for the development of myocardial iron overload and eventual iron-mediated cardiomyopathy. the choice of coil and field of view varied according to the age and size of the patient. imaging was performed on a 1.5 t magnet (philips mri system). after the cine gradient echo time of flight sequences were acquired, the dynamic keyhole mr angiographic sequence was applied in the coronal orientation. this sequence commenced 2-5 s after initiation of the first bolus administration of 2-10 ml of undiluted gadopentetate dimeglumine (0.5 mmol/ml, magnevist) at a rate of 2-3 ml/sec followed by 10-20 ml of saline at a rate of 2 ml/sec. image acquisition was repeated multiple times without delay for 60 s during shallow breathing. contrast material was administered through a peripheral or central venous line, and sometimes via simultaneous bilateral extremity injections. rarely manual hand injection was performed. the parameters were as follows: centra k-space filling, acquired voxel size 1-1.2 x 1-1.2 x 2-3, reconstructed voxel size 0.4-1 x 0.4-1 x 1-1.5, number of dynamics 8-20, keyhole percentage 25-38%, sense (parallel imaging) factor 2x1-2x2, dynamic times 1-3.6 s, and injection rate 1-3 cc/second. image analysis was based on original contrast-enhanced data sets, mip and volume rendering. the quality of the mrv was graded by a subjective scale from 1-5 (10excellent, no limitations; 50nondiagnostic). comparison with unenhanced mr venographic sequences and doppler ultrasound were available in all cases. results: 4d mrv provided diagnostic information on patency of venous segments in all cases, including the presence of venous occlusion or stenosis, the segments involved, and collateral venous pathways. conclusions: 4d mr venography using the method outlined is a reliable means of estimating central venous thrombosis in children, using short dynamic scan times with high spatial and temporal resolution, creating an effect similar to conventional venography. paper #: pa-033 analysis of optimal phase interval for prospective ekg-triggered cardiac ct in children prakash masand, md, texas children's hospital, savivek bogale, lorna browne, rajesh krishnamurthy purpose or case report: evaluate high temporal resolution cine mri of the heart in children to determine relationship of heart rate to the optimal motion free interval during the cardiac cycle, and to derive a chart depicting optimal reconstruction intervals across a range of heart rates which could be applied for prospective ekg triggered ct imaging of the heart. methods & materials: pediatric patients who had high temporal resolution cine steady state free precession sequence (50 frames acquired across a single cardiac cycle) performed as part of a mri/mra of the heart from 2005-2011 were included. a single reader analyzed the high temporal resolution cine data to determine the location and duration of the motion-free phase interval in systole and diastole for heart rates ranging from 60-140 bpm. the following information was collected: age, heart rate, duration of systole and diastole, ekg phase and phase percentage of motion-free interval, and duration of motion-free interval. heart rates were grouped in ranges of 10 (61-70, 71-80, 81-90 etc.), with at least 25 patients in each group. wilcoxon sum rank test was performed to compare the static durations of systolic and diastolic phases for each heart rate group. two-tailed p-values<0.05 were considered to indicate statistical significance. a chart matching heart rate range to the optimal phase of image acquisition and reconstruction was created. results: optimal reconstruction intervals for motion-free imaging of the heart in systole and diastole, and single best phase for a given heart rate are as follows: (please see table 1 ) mean duration of the motionless phase in systole and diastole for a given heart rate is as follows: (please see table 2 ) conclusions: this is the first time that variability in location of the motion-free interval within the cardiac cycle with respect to heart rate in children has been studied in rigorous fashion. this chart will have immediate application in the so-called 'target scan', which uses prospective ekg triggered acquisition of data in combination with half-scan reconstruction to minimize radiation dose with respect to retrospective ekg gated imaging. results: a total of 10 patients were found to have aberrant pda by ccta. nine patients had a pda emanating from the brachiocephalic artery to the pulmonary arteries and one patient had pda emanating from the carotid or the subclavian artery according to the operative report. all ten patients had echocardiography in addition to ccta. nine of the ten patients underwent surgery. one patient was lost to follow up. comparison between ccta and echocardiography to operative report showed the following: 3 out of the 10 echocardiograms agreed completely with ccta and operative report. 7 out of the 10 echocardiograms did not report aberrant pdas which were seen on ccta and confirmed during surgery. in one patient, the echocardiogram reported a double aortic arch which was found to be an aberrant pda from the left brachiocephalic artery; a finding that changed the surgical management and pre-surgical planning. the results were statistically significant with a p value of <0.05. conclusions: diagnostic accuracy of ductus arteriosus anatomy is important in pre-surgical planning and management of patients with ductal dependent pulmonary circulation. cardiac ct angiography is more accurate as compared to echocardiography in diagnosis of aberrant patent ductus arteriosus. ) in patients younger than 1 year of age. the prospective ecg-gated protocol scanned 50% of the cardiac cycle with 10 msec padding in patients with heart rates greater than 100 bpm. two experienced radiologists evaluated the image quality and course of the coronary arteries. image quality was assessed based on the degree of homogeneity of vascular enhancement, presence of stair-step artifacts, image signal and noise as well as the overall subjective image quality based on a 4 point scale. the course of the left and right coronary arteries was also evaluated based on a 4 point scale, focusing on how well the evaluator was able to visually follow the coronary artery from its origin to its termination. radiation dose was recorded and compared. results: the mean score of the homogeneity of vascular enhancement, stair step artifacts, image noise and signal, overall image quality, and score given to visualization of the course of the coronary arteries showed no significant difference (p>0.35) in the retrospective and prospective ecg gated groups. the mean estimated effective dose was significantly lower for the prospective ecg gated group compared to the retrospective group, (0.83 msv vs 2.39 msv) respectively (p<0.0005). conclusions: prospective ecg-gated cardiac mdct provides comparable assessment of coronary anatomy, image quality with significantly less radiation dose when compared to the retrospective ecg-gated mdct. prospective ecg gated cardiac mdct is a powerful adjunct to the treatment and surgical planning of pediatric patients with congenital heart disease less than 1 yr of age with lower radiation dose. methods & materials: 3 pediatric neuroradiology lectures were recorded and made available to 29 radiology residents at a university program through on-line streaming video viewed through an internet link. topics included brain tumors, phakomatosis, and congenital brain malformations. one lecture per week was recommended prior to case conferences that reviewed the same topic. pre-and post-tests and a feedback survey were administered. nonparametric paired sign test and analysis of covariance were used to evaluate changes in test scores overall and according to feedback responses. spearman's partial rank correlation coefficient was used to evaluate the relationship between the number of viewed videos and test scores. results: twenty-nine residents completed the pre-test and 28 the post-test. the means (sd) scores were 59.3% (12.0%) and 64.8% (14.2%) respectively. there was a significant improvement in test scores (p 00.019). residents that agreed/strongly agreed that the streaming technology lectures were convenient had greater improvement than those who did not (14.0 vs. -3.2%, p00.001). similarly, those who agreed/strongly agreed that being able to replay a lecture was helpful had greater improvement than those who did not (10.9 vs. -6.7%, p 00.001). finally, those who agreed/ strongly agreed that the streaming technology lecture format was a better teaching tool had greater improvement than those who did not (10.8 vs. -4.7%, p00.003). significant positive correlation between number of videos watched postconference and improvement was present (spearman's rho0 0.48, p00.013). conclusions: on-line streaming video with live case conferences enhances radiology resident learning of pediatric neuroradiology. step (mpps) software provided an accurate measurement of scan time. visual charting made gaps in utilization apparent. technologists and nursing notes correlated to gaps identified barriers and opportunities for improvement. nursing and anesthesiology reduced redundancies. standardized protocols lead to more consistent scan times. appointment access for sedated mri was measured by the third available appointment. results: manually entered data points were time consuming, inconsistent and unreliable. the process improvement was most effective when fewer more reliable data points were used to evaluate the effect of change. the program resulted in a reduction of appointment access for sedated mri from 30 days to 2 days with no change in the hours of operation. magnet utilization was increased from 58% to 73%. induction outside the scan room provided the most efficient process tested. we ranked first in utilization in a children's healthcare cooperation of america (chca) survey as measured by exams per scanner. patient preference for a.m. scheduling was shown by survey and corroborated by scheduling data. consistent scan times were achieved by protocol standardization augmented by indication driven decision support. conclusions: a consise definition of mr utilization established a metric that was used in the process cycle of analyze-optimize-measure. anesthesia induction outside the magnet was the most efficient practice but required collaboration between nursing, mr technologists and anesthesiology. protocol standardization were valuable aspects of process improvement essential to optimizing parallel sedation. these adjustments reduced appointment access from 30 days to 2 days, increased utilization from 58% to 73% and produced a number one rank in utilization by chca survey. we exploited the synonym option in epic order entry to translate indications into procedures mapped to specific protocols for mri neuroimaging. the order screen allows the provider to enter an indication. that indication is linked through a synonym option to a specific exam and protocol. the recommendation is based upon institutionally created clinical care guidelines, and can be accepted with a single click to complete the order. the requesting provider retains the option to override the recommendation. an step in process development utilized an order queue established within the epic inbasket. a pediatric radiologist monitored the queue and communicated with referring providers to obtain additional history and educate toward best imaging practice. these interactions facilitated development of a robust index of clinical indications used to create the synonym pool. results: mri neuroimaging indications were expanded into a robust data set linked to specific mri exams aligned with specific protocols. the synonym option within epic created the opportunity for the requesting provider to simply enter an indication which drives the procedure and recommended protocol. provider satisfaction has been high and concurrence with recommendations nearly universal. conclusions: indication driven order entry was achieved through the synonym option in order entry within the epic emr. imaging recommendations are based upon institutional clinical care guidelines developed through consensus. a robust compilation of pediatric mri neuroimaging indications has been created and linked to specific exams and protocols. compliance with the indication driven recommendation has been high. modifications of the current system are currently under development for all cross sectional modalities and organ systems. paper #: pa-039 cost-effectiveness of routine neonatal renal ultrasound in non-syndromic complex congenital heart disease elfrides traipe, tch, extraipe@texaschildrens.org; jill v. hunter, marthe munden purpose or case report: to assess the prevalence of abnormal renal ultrasound in non-syndromic complex congenital heart disease (cchd) and assess the cost-effectiveness of routine renal ultrasound in this population. we restrospectively reviewed the initial neonatal renal ultrasound and any subsequent renal imaging in 97 patients with non-syndromic cchd. etiologies included hypoplastic left heart syndrome (hlhs), transposition of the great vessels (tga), coarctation of the aorta (coa), truncus arteriosos (ta), double outlet right ventricle (dorv) with or without patent ductus arteriosus. patients were recruited consecutively as part of a prospective trial for pre-and post-operative magnetic resonance imaging of the brain. results: the neonatal pre-operative renal ultrasounds were analyzed in 41 female and 56 male patients. only 1 of the 97 patients showed any congenital renal anomaly. this patient was born with hypospadias, that would have routinely stimulated neonatal follow up. conclusions: knowledge of embryology would not lead us to anticipate a high co-incidence of congenital renal and cardiac pathology. based on this statement and our findings, our recommendation to improve cost-effectiveness is not to perform routine neonatal renal ultrasound in non-syndromic cchd, but only if otherwise clinically indicated. purpose or case report: to conduct a meta-analysis of the diagnostic performance of contrast enhanced voiding urosonography (cevus) in comparison to voiding cystourethrography (vcug) or direct radionuclide cystography (drnc). a literature search was conducted for studies published on cevus in the pediatric age group. studies were included if the ultrasound contrast agents (usca) levovist® (bayer-schering pharma, germany) or sonovue® (bracco, italy) were used and enough data was available to extract 2x2 tables. if the cevus was compared to both vcug and drnc in the same patients the results for each were analyzed separately. a bivariate hierarchical model that takes into account the heterogeneity in cevus sensitivity and specificity in different studies was used for the assessment of the summary diagnostic metrics. the summary roc curve was derived and presented graphically from the parameters of the model. additionally, the 95% confidence intervals (ci) and the positive (lr+) and negative (lr-) likelihood ratios were calculated. results: out of 127 publications only 30 comparative studies fulfilled the inclusion criteria. these encompassed 26 cevus studies in comparison with vcug and 4 with drnc with regards to detection of vesicoureteric reflux. in 26 studies the usca levovist® and in 4 sonovue® were used. a total of 2549 children with 5078 pelvi-ureteral-units (puus) were included in the meta-analysis. cevus compared to vcug and drnc had a sensitivity of 90% (ci: 85-93) and a specificity of 92% (ci: 89-94) with lr+and lr-of 11.7 and 0.11, respectively. the performance of cevus was better when compared to drnc than to vcug (sensitivity 94%, specificity 95% versus 90% and 92%, respectively. the meta-analysis of the diagnostic performance of cevus regarding the urethra included 880 patients (682 boys). excellent imaging of urethral anatomy was reported in over 97% of the patients. however, currently there is only one comparative study with 146 patients available. in this study 100% sensitivity and 100% specificity were reported. conclusions: sufficient evidence is available clearly demonstrating the high diagnostic performance of cevus compared to vcug or drnc regarding the detection or exclusion of vur in children. these findings combined with the absence of radiation should be convincing reasons for promoting the widespread use of cevus in children. disclosure: dr. darge has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: prenatal ultrasound (us) has increased identification of infants with asymptomatic renal pelvic dilatation. society for fetal urology (sfu) grading is used in the sonographic evaluation of pediatric hydronephrosis. based on us findings, a nuclear medicine diuretic renogram may assess renal function, which could result in operative intervention. standardized protocols for diuresis renography, the "welltempered renogram," already exist; however, no current study has assessed effect of intravenous hydration (iv) status with us in the evaluation of childhood hydronephrosis. our study assesses the effect of hydration on sfu grading. in this prospective irb approved study, pediatric patients diagnosed with pelvicaliectasis requiring a diuretic renogram were recruited to undergo pre and post hydration renal us. a urinary catheter was placed followed by renal us pre and post iv hydration (10 ml/kg normal saline bolus). imaging was performed by the same sonographer on the same us machine. a well-tempered renogram was then performed. all images were reviewed by two blinded radiologists, one pediatric radiologist who assigned sfu grades to each kidney. results: data were collected from 34 studies, with ages ranging from 6 weeks-16 years, with an average age of 22 months. there were 28 unique patients. of these, 23 underwent a single renogram, 4 underwent two renograms, and 1 underwent 3 renograms. one patient had a solitary kidney due to mcdk. thus, there were 33 usable paired sonograms (67 kidneys) for analysis. sfu grades were compared in the pre-and post-hydration us for each kidney. two-sided statistical tests were done to assess whether sfu grades changed significantly after hydration (sign test). 52 of 67 (78%) kidneys remained the same grade post hydration. when there was a difference, most demonstrated an increase (13 of 15 kidneys and p<0.01). no change in sfu grade pre-and post-hydration differed by more than 1. only 1 kidney went from grade 2 to grade 3. sfu above grade 2 is considered clinically significant. no kidney that was grade 3-4 pre-hydration became grade 0-2 post-hydration. when sfu is dichotomized grade 0-2 vs. 3-4, there was no significant change in grade from pre to post hydration (p01). conclusions: hydration does not appear to have a clinically significant effect on sfu grade. therefore, performance of a "well-tempered" us is unnecessary. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. study type was significantly associated with both total and weighted score (both p < 0.0001). rus was better and mag3 was worse than vcug, rnc, and dmsa, which did not differ from each other. other factors associated with worse total scores included patient age 1-3 years (p<0.001) and non-white race (p00.04). gender, prior testing history, wait time, and parent education were not associated with total scores. in the multivariate model, rus remained the best, mag3 the worst, and dmsa, vcug, and rnc in the middle (p<0.0001). compared directly, dmsa and vcug total score did not differ (p00.59). conclusions: this study documents significant differences among gui studies with respect to the patient and family experience, but there was no overall difference between dmsa and vcug. these findings may be useful to aid decision-making when considering gui for pediatric patients. we retrospectively reviewed the imaging findings of 29 consecutive patients with histologic diagnosis of cd (17 males, 12 females; mean age 14.6 years; age range 5-24 years) who underwent mre between 1/21/ 2011 and 10/10/2011. the mre was performed in a siemens avanto 1.5 tesla scanner. standard departmental volume of polyethylene glycol and fluid were administered for bowel distention. the imaging protocol included dwi with eight b values ranging between 0 sec/mm2 and 800 sec/ mm2 and gadolinium enhanced dynamic 3d vibe (volume interpolated breath hold exam) in the coronal plane. the studies were qualitatively evaluated in a blinded fashion by two board certified radiologists. disease activity was defined as bowel wall thickening and enhancement in the gadolinium enhanced images. dwi abnormality was defined as bowel thickening, increase signal on dwi images and decrease signal on adc maps of the ileum. intra voxel incoherent motion (ivim) dwi parameters were used as quantitative biomarkers for the analysis of slow diffusion (d) and fast diffusion fraction (f). results: gadolinium enhanced vibe images identified abnormal thickening and enhancement of the ileum in 11/29 (38%) patients. dwi identified abnormal signal in 11/29 (38%) patients. the sensitivity and specificity of the qualitative dwi for identifying ileitis, as shown by gadolinium enhanced imaging, were 82% and 89%, respectively. quantitative analysis showed statistically significant difference in ivim maximal values for f (fast diffusion fraction) between abnormal (mean00.67, std00.17) and normal (mean00.8, std00.14) ileum segments (p00.012). there was statistically significant difference in ivim maximal values for d (slow diffusion) between abnormal (mean 02.2 μm2/ms, std 0 0.7 μm2/ms) and normal (mean 02.7 μm2/ms, std 0 0.6 μm2/ms) ileum segments (p00.0084). abnormal loops of bowel had decreased slow and fast diffusion parameters. conclusions: diffusion weighted imaging has excellent sensitivity and specificity for the detection of active ileitis in pediatric cd. furthermore, quantitative ivim model parameters provide effective biomarkers for this condition. ivim dwi has the potential to assess bowel inflammation without intravenous contrast enhancement and further increase our understanding of cd. methods & materials: forty pediatric patients (median age 13.8 years, range 10.0-17.7) with suspected (n035) or confirmed ibd (n05) were included and underwent gastroileocolonoscopy with biopsies followed by mre (median interval 20 days, range 6-55). the mre results were compared with macroscopic and microscopic assessment of the ileum. the clinical importance of the mre results was registered. results: crohn disease (cd) was diagnosed in 25 cases, ulcerative colitis (uc) in 12, and ibd unclassified (ibdu) in three. macroscopic ileitis was detected in 15/25 (60%) of cd cases and in 2/12 (17%) of uc (backwash ileitis). microscopic inflammation was found in another four cd cases and one ibdu patient. in total, discrepancy between macroscopic and microscopic inflammation was found in 9 cd, 2 uc and one ibdu patients. the sensitivity of mri was 64% (against macroscopy and/or microscopy) to 71% (against macroscopy alone), while the specificity was 100% and 92%, respectivley. mre findings was decisive for diagnosis in 4/40 (10%) and led to treatment adjustments in 11/40 (28%) in the following six months. conclusions: mre is a reliable method for imaging of intestinal inflammation in pediatric ibd, and can be supportive or essential for clinical treatment decisions. results: of 15 children with ec, 7 had ct imaging of the abdomen and pelvis. these 7 children ranged in age from 15 months to 16 years (mean 10.2 years +/− 6.3) with a male predominance (n04, 57%). the most common presenting symptoms were abdominal pain (n06), bloody diarrhea (n03), and rectal bleeding (n03). ec was characterized as a dense and predominant eosinophilic inflammatory infiltrate in the lamina propria and/or epithelium without granulomas. ct scans were abnormal in 6 (86%). no colonic luminal contrast was present in 2 patients, and in one of these, the colon appeared normal. abnormal ct findings included cecal wall thickening (n05, 71%), mucosal enhancement without colonic wall thickening, (n01, 14%), mesenteric lymph node enlargement (n02, 29%), terminal ileal thickening (n02, 29%), jejunal and ileal thickening (n01, 14%), and pneumatosis (n01, 14%). of the 5 patients with cecal involvement, 4 primarily involved the cecum with less severe or no ileal or downstream colonic involvement. pneumatosis extended along the length of the colon with rectal predominance. conclusions: the predominant ct finding in our ec series was wall thickening, most severe in the cecum with variable extent downstream with mild or no involvement of the terminal ileum. although there is overlap, these findings are different from the most common patterns encountered with ulcerative colitis or crohn disease and should raise the possibility of ec in children presenting with abdominal pain and bloody diarrhea. purpose or case report: timely identification of childhood arterial ischemic stroke (ais) is critical to development of acute treatment strategies. we present our experience prior to and following development of a pediatric stroke alert system (sas). through multi-disciplinary collaboration in a tertiary care setting, a pediatric sas was established in 2008. we describe the system, imaging protocol evolution, and impact upon the time between admission and mri initiation (time-to-mri) in patients with childhood ais. of 74 patients in our stroke database (comirb #05-0339), 27% met inclusion criteria for stroke alert initiation (acute focal neurological deficit within 12 h). eleven pre-2008 and nine post-2008 patients met criteria. we compared the time-to-mri between these two groups, utilizing a two-tailed t-test. results: the pediatric sas has two phases: i-neurological evaluation and ii-imaging and treatment consideration. phase i stroke alert is initiated when a child presents with an acute focal neurologic deficit. if neurology confirms stroke symptoms and ct head is negative for an alternative etiology, a stroke alert is called prompting an emergent brain mri. if mri confirms an acute stroke, hyperacute therapies are considered. initial mri protocol included dwi, t2, flair, 3d tof cow mra, 2d tof neck mra and fat saturated t1 neck imaging. after internal quality review, t1 mprage brain and contrast enhanced 3d neck mra were added. the sequence order was also altered so diagnostic sequences were scanned first (dwi and cow mra). there was a trend towards decreased time-to-mri in the post-2008 group (mean0152 min, sd +/− 120) as compared to the pre-2008 group (mean 340 min, sd0+/−304; p00.10). conclusions: institution of a pediatric sas improved urgent neurologic evaluation and demonstrated a trend towards shorter time-to-mri. ongoing quality review has enhanced imaging quality and decreased time-to-mri. continued refinement of pediatric sas's will be critical to the success of recently funded phase i clinical trials in the evaluation of hyperacute therapies. results: there were 6 female and 3 male infants. the mean post-gestational age at presentation was 20 days (range 0-90 days), while the corrected age was less than 30 days for all patients. 7 patients presented with seizures and signs of infection; 1 presented with lethargy and later proved to have protein c deficiency. mri was performed 0-12 days from presentation in these 8 patients. another patient with known protein c deficiency underwent mri at 3d for followup of screening us abnormalities. there were a total of 27 deep cerebral white matter lesions: 21 frontal, 4 parietal, 2 temporal lobe. lesions were fluid signal cavities with restricted diffusion. larger lesions had dependent debris. all lesions had associated hemorrhage and most lesions had evidence of adjacent small vessel venous thrombosis. lesions imaged after gad showed peripheral enhancement. three lesions were seen to increase in size on follow-up imaging. three patients, 2 with meningitis confirmed via microbiology and 1 with presumed meningitis by csf counts, underwent surgical aspiration of a total of 6 lesions. all specimens were sent for pathology and culture and were negative for microorganisms. conclusions: recognizing the mr appearance of necrosis and liquefaction after deep white matter cerebral venous infarction in neonates can distinguish this entity from cerebral abscess and potentially avoid an unnecessary neurosurgical aspiration procedure. all four children were initially treated with aspirin but experienced recurrent events on therapy. all four were subsequently anticoagulated. two children have remained on warfarin for 6-7 years without recurrent events, while the other two had recurrent events despite adequate anticoagulation. these two children underwent uncomplicated coil embolization of the affected vertebral artery segment, and they have remained symptom-free for five and 20 months since then. conclusions: dava was diagnosed by ca in 3/4 patients. all four children with dava in our series suffered recurrent strokes despite aspirin therapy. two of the four experienced further strokes on anticoagulation, necessitating endovascular therapy. these findings suggest that dava in children may require ca to diagnose, and that it may be refractory to standard adult therapies. ongoing multicenter efforts in childhood ais should further evaluate the diagnostic approach and recurrence risk of childhood dava. ) and cerebral gray matter abnormalities were present in 6 (1%). posterior fossa lesions were seen on us in 1.6% , but mastoid views were included in only 50% of the centrally read us. conclusions: in the largest extreme preterm cohort to date with near-term mri and serial us, 19% had mod-severe wma on brain mri, similar to previous reports. cerebellar abnormalities were detected more frequently by mri than by us. neurodevelopmental outcomes at 18-22 months and school age will assess the relative and combined values of mri and us as outcome predictors. , an analysis technique based on task-free resting state fmri recording, can be useful in assessing disruption of connectivity in certain disease states, including epilepsy. in healthy control subjects, functional connectivity reveals strong bilateral interhemispheric connectivity in such system as sensory-motor, visual, auditory as well as dorsal attention and default mode networks. in patients with epilepsy associated with unilateral diffuse hemispheric disease such data is limited. differences in the pattern of activation would suggest alteration in connectivity in these entities. this finding would impact the typical interpretation of this data that is becoming routinely collected for epilepsy pre-surgical evaluation. methods & materials: siemens (erlangen, germany) system, 3-tesla (trio) scanner was used for imaging (epibold sequence, te030 ms, flip angle090°). resting state fmri scan were performed in both awake and anesthetized patient. awake patients were instructed to relax and rest while keeping their eyes open. analysis was performed using 1000 functional connectomes project scripts based on afni and fsl software packages. resting state data were analyzed for connectivity with the following seeds: somatomotor, visual, auditory, and default mode (posterior cingulated cortex (pcc)). results: we applied this technique to evaluate 12 patients with hemispheric seizure disorders, including rasmussen's, neonatal infarct and migration disorders. all the subjects demonstrated some deviation from typical interhemispheric connectivity with a spectrum of findings. the figure below shows connectivity patterns in a patient with cortical dysplasia. while some interhemispheric connectivity remained in somatomotor (sm) and auditory (a1) systems, it was disrupted in visual (v1) and default mode (pcc) networks. variable patterns were found across the cases that corresponded to lesion side, supportive of disruption in interhemispheric connectivity as measured by fmri. conclusions: resting state functional connectivity patterns are well documented in healthy subjects. these results suggest that interhemispheric connectivity disruption is a typical feature of unilateral diffuse hemispheric disease though variable in presentation, either being limited to select systems or demonstrating broad disconnect between the two hemispheres. these results should be carefully considered when evaluating data for pre-surgical epilepsy evaluation. purpose or case report: premature birth is associated with white matter injury leading to a wide ventricular system. however,normative standards for ventricular size are lacking for this particular group.aims: we aimed to, in a controlled, population based norwegian cohort of ex-prematures without major handicaps, and for men and women separately,to 1) create standards for radiological indices of ventricular dilatation, 2)investigate associations of these measurements with subjectively assessed ventricular size,3) examine differences in ventricular size between ex-prematures and healthy controls methods & materials: the initial birth cohort included 217 neonates, birth weight below 2000 g (low birth weight)born within hordaland county, norway, between april 1st 1986 and august 8th 1988. 113 of 174 eligible survivors (without major handicaps)underwent mr examination during the period january 2006 to may 2007. 103 of these were expremature (born before gestational age 37 weeks) and were included in this sub-study. based on t2 weighted images, the ventricular size was subjectively judged as being normal, mildly, moderately or severely dilated by an experienced paediatric neuroradiologist, while objective measurements were performed in a blinded fashion, by a second observer (sma) using an imaging software program (nordic ice®). results: the normative standards for the ventricular system in ex-premature young adults showed wide variations, in particular for the occipital horns. the agreement between subjective and objective assessment of ventricular size was good. ex-prematures had smaller heads than those born term (control group). there was no difference in ventricular size between the two groups, even after adjusting for head size. ex-premature males had larger ventricles than females; however, the difference disappeared after adjusting for head size. conclusions: young adults born prematurely with a birth weight below 2000 g do not have larger lateral ventricles than healthy controls born term, even after correcting for a smaller head size. paper #: pa-057 best practice for reproducibility when measuring t2*: implications for liver and cardiac iron assessment mark ferguson, md, radiology, seattle children's hospital, markferg@uw.edu; randolph otto, seth d. friedman purpose or case report: patients with red blood cell transfusion-dependent conditions receive high amounts of iron that can lead to abnormal iron accumulation in tissues resulting in organ damage. while the liver is the dominant excess iron storage organ, iron related cardiotoxicity is a leading cause of morbidity and mortality in patients with transfusion-dependent thalassemia. therefore, accurate determination and tracking of tissue iron levels in both the liver and the myocardium is important for patient prognostication as well as monitoring treatment changes. while multi-echo gradient echo mri (t2*) is widely used and validated method employed for iron assessment, less attention has been given to derived metrics. specifically, the literature almost exclusively reports and uses the mean value for t2* from a pixel-wise (pw) map. infrequently used is the median. the median is a potentially superior metric than the mean because it is insensitive to outliers. outliers will always occur in data because of either noise or imperfect vessel exclusion. to compare mean versus median on reproducibility of t2* measurement, 23 subjects who had paired heart/liver measurements were examined. the entire liver (excluding vessels) and the interventricular septum myocardium were traced on representative images from each series. mean and median t2* values were generated from the pixel maps. r2* (1000/ t2*) and coefficient of variation (cv) were computed on a patient-by-patient basis. these measures were then summarized for the group. results: markedly higher r2* values were observed in both heart and liver using median summary measures (liver: t0−2.79, p0.01, heart: t0−2.8, p0.01). these findings were accompanied by lower cv's (better reproducibility) for the median approach (liver: t01.89, p0.07; heart: t01.91, p0.07). conclusions: the consistent difference in derived t2* values between the methods (median>mean) should be considered when comparing derived r2* values to established normal ranges. cv data support that using the median as the final summary metric will always outperform mean metrics for measuring change in r2*. this finding has immediate implications for the scientific literature and for guiding therapeutic management over time. results: twelve children (age 5mo-13yo; m:f 6:6) with gsds (7 abca mutations, 4 sp-c mutations, 1 undefined mutation) and 16 children (age 2wk-18yo; m:f 10:6) with other dlds (including pulmonary interstitial glycogenosis, neuroendocrine cell hyperplasia of infancy, lymphocytic interstitial pneumonia, lipoid pneumonia, diffuse alveolar damage, granulomatous infection, capillaritis and other pulmonary hemorrhage syndromes) were identified. ct findings with highest sensitivity for gsds were ground glass attenuation (83%), parenchymal cysts (67%), and interstitial thickening (58%). parenchymal cysts, honeycombing, and pectus excavatum were more specific for gsds compared to other dlds (p<0.05). the combination of either parenchymal cysts and honeycombing or ground glass attenuation and pectus excavatum provided the highest specificity (100%) but low sensitivity (25%). the combination of parenchymal cysts and ground glass attenuation provided good specificity (81%) and modest sensitivity (50%). no combination of findings provided both high sensitivity and specificity. conclusions: ground glass attenuation is the most sensitive finding for gsds, while parenchymal cysts, honeycombing, and pectus excavatum are more specific findings for gsds than other chronic dlds of childhood. however, no single finding or combination of findings on chest ct is both highly sensitive and specific for gsds, and chest ct cannot substitute for genetic testing or lung biopsy for the differentiation of gsds from other dlds. pes were observed in 33 scans of patients without a history of congenital heart disease (chd), and 26 pes in 12 scans of patients with a history of chd. z-axis scan lengths for the chest ct exams ranged from 10.1-33.3 cm. a z-axis scan length of 14 cm centered 3.5 cm below the carina captured all pes in all patients, and a length of 12 cm centered 3.5-4 cm below the carina in patients with chd. a z-axis scan length of 8 cm centered 5 cm below the carina was sufficient to capture at least one pe in all patients, and a length of 8 cm centered 4-5 cm below the carina in patients with chd. the radiation effective dose of the chest ctpa exams ranged from 3-10 msv. limiting the z-axis scan length on ctpa exams to 14 cm or 8 cm would have resulted in a 20% or 40% decrease in z-axis coverage, respectively, and estimated radiation effective dose reduction of 21-42% due to less radiation exposure to the intrathoracic structures, thyroid gland and upper abdominal viscera. conclusions: limiting the z-axis scan length coverage for ctpa exams based on a model of the typical anatomic distribution of pes relative to the reference level of the carina permits a substantial reduction of radiation dose in children without reducing the sensitivity for detection of pulmonary emboli. purpose or case report: to determine whether the addition of multiplanar reformation mdct images affects reader performance parameters and provides added diagnostic value compared to the use of axial ct mdct images alone for diagnosing pe in children. this was an institutional review board-approved retrospective study of 60 consecutive pediatric patients who underwent ctpa for clinically suspected pe. two faculty pediatric radiologists and two radiology residents independently reviewed each study initially using only axial mdct images and later using mpr mdct images in any x-, y-, or z-axis for detecting pe. diagnostic accuracy, confidence level, and interpretation time of mpr mdct images were compared to axial mdct images using mcnemar's test and paired t-tests. the kappa coefficient was calculated to assess interobserver agreement. diagnostic accuracy was compared between faculty pediatric radiologists and radiology residents by logistic regression whereas confidence level, interpretation time, and added diagnostic value were evaluated with analysis of variance (anova). results: the final study cohort consisted of 60 ctpa studies from 60 children (28 m/32 f; mean age 14.7 years). nine (15%) of 60 ctpa studies were found to have pe. diagnostic accuracy in correctly detecting pe ranged from 91.7 to 100% (mean096.7%), with no significant differences between the use of axial and mpr mdct images. logistic regression indicated no significant difference in diagnostic accuracy of detecting pe between faculty pediatric radiologists and radiology residents for axial mdct images (p0.48) or mpr mdct images (p0.24). confidence level and interobserver agreement were significantly higher and average interpretation time was longer in evaluating pe with mpr mdct images compared to axial mdct images for all reviewers (p<.001). compared to faculty pediatric radiologists, significantly greater increases in confidence level, interobserver agreement, interpretation time, and added diagnostic value using mpr mdct images compared to axial mdct images to diagnose pe were found for radiology residents (p<0.001). conclusions: use of mpr mdct images in diagnosing pe on ctpa in children significantly increases confidence, interobserver agreement, and interpretation time among faculty pediatric radiologists and radiology residents. because mpr mdct images provide significantly greater improvements in reading parameters for residents than for faculty members, their routine use should be encouraged for trainees. paper #: pa-062 chest ct in children, anesthesia and atelectasis beverley newman, md, radiology, stanford university, bev.newman@stanford.edu; elliot krane, terry e. robinson purpose or case report: in spite of advances in ct equipment and speed, sedation/ anesthesia is required in many young children for optimal quality ct for detailed parenchymal evaluation; resultant atelectasis is a common and important quality issue. our purpose was to evaluate the safety and effectiveness of a standardized lung recruitment technique. methods & materials: with irb approval and parental informed consent, 49 controlled ventilation, low dose, chest ct's (cooperative effort between anesthesia, pulmonology and radiology) were performed in 38 children (7 had 2-4 cts) (21 f, 16 m; ages .02-5.13 yrs, mean 2.5 yrs). indications included cystic fibrosis 8; ciliary dyskinesia 4; chronic or interstitial lung disease 16; evaluate pulmonary metastases 10. ct parameters were 80-100kvp, 25-80mas, iv contrast 11. various prior methods employed by the pediatric anesthesiologists to maintain lung inflation had unpredictable results (a brief survey showed 5/9 nonintubated anesthetized cases had problematic atelectasis). a standardized intubation technique was therefore adopted: 1.use of a tight fitting face mask during induction and iv placement, inspiratory pressures of 20-25 and peep of 5. 2. introduction as early as possible using an appropriately sized cuffed endotracheal tube. 3. alveolar recruitment maneuvers-10-12 3 s breaths to 40 cm h2o/5 (32-35 in 1st 6 cases). 4. three breaths at 25/5, inspiratory breathold followed by 25-30 cm on 4th breath for scout and inspiratory scan, and complete ventilator disconnection for expiratory scan. recruitment breaths repeated before each scan. two experienced readers reviewed and scored the images on a 5 point scale for overall quality and atelectasis. results: all studies were completed safely with no procedural complications. one child had propofol-related postoperative emergence delirium. all ct scans were diagnostically good to excellent with small subsegmental atelectasis in 8 (6/8 were the initial cases with lower recruitment pressures) and segmental atelectasis in 2. 13 cases had prior cts, without this technique, that were suboptimal due to moderate procedural atelectasis, in spite of tracheal intubation in the majority of cases. conclusions: an intubation lung recruitment technique can be performed safely and consistently by different individuals using a standardized protocol. procedural atelectasis that affects quality is reliably absent and repeat sequences are not needed. obtaining a high-quality dynamic airway imaging study is critical for accurate interpretation and subsequent medical decision-making. the ideal mri sleep study is one that allows successful completion while maintaining spontaneous breathing without artificial airway, which can be an anesthesia challenge. dexmedetomidine has been shown to have sedative properties paralleling natural sleep with minimal respiratory depression. we hypothesized that dexmedetomidine compared to propofol would have less effect on upper airway tone and airway collapsibility and provide favorable conditions with less airway interventions required during dynamic mri airway imaging in children with osa. in this prospective study, we examined the requirement for airway intervention for propofol (100-200 mcg/kg/m) and dexmedetomidine(1-3 mcg/kg/h) in children and adolescents with osa. severity of osa was analyzed by overnight polysomnography. for children with history of mild osa there was no intervention unless oxygen saturation decreases below 90%; while for children with history of moderate/severe osa, an artificial airway was placed when oxygen saturation decreased below 85%. results: demographics and osa severity by polysomnography were comparable. requirement for artificial airway by severity of osa as documented by polysomnography will be shown. mri sleep studies required airway intervention in 3/26(12%) children in the dexmedetomidine group versus 7/ 29 (24%) children in the propofol group. mri sleep studies were successfully completed without the use of artificial airways in 23 children (88%) in the dexmedetomidine group versus 22 children (76%) in the propofol group. conclusions: safe and effective anesthetic management is a key factor in obtaining good quality mr images of the airway. although there was no statistical significant difference in the need for airway intervention between drugs, dexmedetomidine provided acceptable sedation for mri sleep studies with less airway intervention in children with osa. dexmedetomidine may be the preferred agent for sedation during mri sleep studies in children, and may offer benefits to children with sleep disordered breathing requiring anesthesia or sedation for other diagnostic imaging studies. an open mouth and administration of cpap resulted in smaller ap diameter of the retroglossal airway compared to images without cpap due to cpap pressure pushing the tongue posteriorly. in patient 1 volume of oral cavity anterior to the tongue increased from 7.41 ml to 11.74 ml. meanwhile, the ap diameter of the retroglossal airway decreased from 4.8 to 1.4 mm (71% decrease). in patient 2 the mouth was initially closed but parted when the pressure of cpap was added with the oral volume increasing from 3.69 ml to 15.80 ml. the ap measure of the retroglossal airway decreased from 8.3 mm to 2.8 mm (66% decrease). in patient 2 the mouth was then closed and cpap reapplied resulting in an ap measurement of 11.0 mm (33% increase). the ap diameter difference between cpap and no cpap were tested with paired t-test, but were not statistically significant (p00.1475). conclusions: positive airway pressure on a patient by full facemask and an open mouth can have an adverse effect on the retroglossal airway. this adverse effect is an important consideration in the use of positive airway pressure to support airways for osa, or during emergency resuscitation when a full facemask is used. paper #: pa-065 the purpose or case report: a nanoparticle blood pool iodinated contrast agent (nctx) has been designed and tested in preclinical animal models. we report data in animal models exemplifying its advantages over conventional contrast in the setting of ct pulmonary angiography methods & materials: nctx blood pool nanoparticles of 125 nm diameter with an encapsulated total iodine concentration of~125mgi/ml were administered by intravenous injection to mice, rabbits, dogs, pigs and sheep. (these studies were actually conducted for other purposes and a review of the data revealed the similarities that motivated this paper.) total injected volumes were~5 ml/kg in large animals, and as high as 10 ml/kg in small animals to provide satisfactory vessel enhancement. iohexol or iopamidol was administered for comparative studies with conventional contrast. in a subset of pigs, iatrogenic pulmonary arterial emboli were introduced prior to contrast administration. toxicity studies were conducted in mice and monkeys. results: the visualization of pulmonary vessels using nctx blood pool nanoparticles was generally at least equivalent to using conventional contrast, and superior in several cases, particularly in small veins and when bolus timing of the conventional contrast was suboptimal. in all cases, satisfactory vessel enhancement was achieved for a duration of several hours following a single infusion of nctx blood pool nanoparticles. there was no evidence of renal toxicity, and only transient elevation of hepatic enzymes at relevant dose levels. conclusions: nctx nanoparticle blood pool agents demonstrate several advantages over conventional glomerularfiltered iodinated contrast agents for ct pulmonary angiography in animal models, including no nephrotoxicity, no dependence on bolus injection technique, superior depiction of small veins, and capability of re-imaging for follow-up studies without needing contrast re-injection. potential applications in human pediatric subjects include the diagnostic and post-therapeutic evaluation of cardiopulmonary anomalies and pulmonary embolism, especially in patients with renal insufficiency or tenuous vascular access. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa-067 cardiovascular image quality using a nanoparticle ct contrast agent: preliminary studies in a pig model rajesh krishnamurthy, radiology, texas children's hospital, rxkrishn@texaschildrens.org; ketan ghaghada, prakash masand, abhay divekar, eric hoffman, ananth annapragada purpose or case report: image quality in a separate study using a long circulating, liposomal-based nanoscale blood pool iodinated contrast agent (nctx) suggests clinical utility in pediatrics, potentially reducing difficulties in contrast-ct of children with congenital heart disease (chd) including the size of intravenous cannula, need for accurate timing, inability to simultaneously opacify multiple targets of interest (requiring repeated contrast administration and/or repeated imaging). methods & materials: six pigs (average weight 30 kg) were imaged after slow intravenous infusion of nctx (105 mg i/ml) at an iodine dose of approximately 900 mg i/ kg (8.5 ml/kg). retrospective ekg gated ct imaging was performed 3 h later using a 128-slice dual-source ct scanner at 80 and 120 kvp. two radiologists analyzed and graded (on a 5-point scale with 1: unreadable, 5: excellent) images aimed at anatomic structures relevant to chd. quality of images obtained at 80 and 120 kvp were compared. uniformity of contrast opacification was measured using a roi-based ctnumber method at various intracardiac and extracardiac sites and mean non-uniformity was calculated. results: there was excellent agreement between the two readers on all counts at 120 kvp. 80 kvp images received lower scores for coronary morphology (4/5), and aortic valve visualization (3.5/5), but were comparable in other aspects. pulmonary artery and pulmonary vein branch visualization extended up to the 5th generation in all cases. visualization of coronary artery branches was possible up to the second generation, with good arteriovenous separation. subtle morphologic features including crista terminalis, thebesian valve, foramen ovale, membranous septum, and chordae of the mitral valve were demonstrated in all cases. automated functional analysis and myocardial mass quantitation was feasible in all cases. there was no significant difference in blood pool attenuation between the atria, ventricles, and extracardiac vasculature on quantitative assessment. no image artifacts were visible on the reconstructed images. conclusions: these findings suggest that nctx promises to be superior to conventional contrast agents for ct imaging of complex congenital heart disease, due to the absence of nephrotoxicity, avoidance of repeated contrast administration, and reduced number of scans performed. avoiding the need for accurately timed scans precludes the need for large bore intravenous access. these attributes make it a promising agent that warrants further studies. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa-068 theoretical cost and x-ray dose reduction in pediatric congenital heart disease imaging by the use of a nanoparticle contrast agent robert bell, the university of texas-houston; rajesh krishnamurthy, gabriela espinosa, christopher petit, ananth annapragada purpose or case report: the purpose of this study is to determine the effective, population averaged reduction in costs and radiation dose that can be achieved in the diagnosis of congenital heart disease by use of a nanoparticle long circulating blood pool contrast agent. methods & materials: a markov model of the decision tree followed at the texas children's hospital in the image based diagnosis of congenital heart disease was constructed in treeage software. the model included ct angiography, mr angiography, cardiac catheterization, and echocardiography diagnostic modalities. patient records, accumulated between 2003 and 2011 were examined to inform the model. the radiation dose and cost for each step were encoded as penalty functions. markov simulations were run for two decision trees: (1) utilizing ct angiography and (2) replacing conventional ct angiography with blood-pool agent based ct angiography. the overall population x-ray dose and accrued cost was calculated for each pass through the model. results: x-ray dose distributions for the example populations showed substantial reductions per ct study, as much as 50%. averaged over the population, since a sizeable fraction of patients are diagnosed without ever being exposed to any x-ray based modality, reductions were more modest, but still substantial. costs per ct study were slightly higher when the blood pool contrast agent was used. when the diagnostic probability using the blood pool agent increased, it led to an automatic overall cost reduction. conversely when the diagnostic probability remained unchanged, costs rose, commensurate with the increased cost of the contrast agent. conclusions: the use of a blood pool contrast agent for ct angiography leads to substantial reduction in radiation dose in the setting of congenital heart disease. cost reductions are more modest, and are driven almost completely by the reduction in the number of mr and invasive angiography procedures resulting from increased diagnostic success using blood pool based ct angiography. the model as constructed does not account for potential workflow changes that might result from the use of a new contrast agent. actual reductions realized may therefore be higher. disclosure: dr. annapragada has indicated that he is a stock holder and consultant for marval biosciences inc. paper #: pa-069 frequencies and patterns of situs discordance in chest and abdomen justin boe, stanford, justinj.boe@gmail.com; beverley newman, shreyas vasanawala, frandics chan purpose or case report: incidence of situs anomalies, including heterotaxy and situs inversus, is estimated at 0.02% of population. as the first step in the segmental analysis of structural heart disease, the determination situs position is of fundamental importance. abdominal situs, as defined by splenic position and morphology, and cardiac situs, as defined by atrial morphology, are usually but not always in agreement. echocardiographers also employ the relative position of the great arteries and vein at the hiatus to determine cardiac situs. we evaluate the frequencies of discordances among abdominal, hiatal and cardiac situses. methods & materials: with retrospective irb approval, imaging records from 2001 to 2011 were reviewed for the diagnosis of cardiac situs inversus and heterotaxy. patients who had cardiac ct or mri were included. images were evaluated on a 3d-processing station by a cardiac radiologist. cardiac situs was determined by the morphology of the atrial appendages. when an atrial appendage was not adequately visualized, cardiac situs was assessed by the relative position of the main pulmonary artery and bronchi. hiatal situs was determined by the relative position of the aorta and the systemic venous return, and abdominal situs by the position and morphology of the spleen. results: thirty-five cases were identified, with 23 cardiac ct and 12 mri. patients' age ranged from 1 day to 35 years old. in the abdomen, the numbers of situs inversus, asplenia, and polysplenia were 11 (32%), 12 (34%), and 12 (34%). for the heart, the numbers of situs solitus, inversus, rightisomerism, and left-isomerism were 2 (6%), 13 (37%), 11 (31%) and 9 (26%). the abdominal and cardiac situses were discordant in 5 (14%) cases. polysplenia had the highest number of discordance with the heart. hiatal situs was discordant with the abdomen in 5 cases (16%) and with the heart in 8 (25%) cases. conclusions: situs disagreement between the abdomen and the heart is not uncommon and they should be documented separately in radiology reports. hiatal situs, as used by echocardiographer, disagrees with the cardiac situs in a quarter of the cases. it should be used with caution in the segmental analysis. paper #: pa-070 diminished asl intracranial perfusion in children with neurofibromatosis type 1 kristen yeom, md, stanford university, kyeom@stanford. edu; cynthia campen, patrick barnes purpose or case report: neurofibromatosis type 1 (nf1), a neuro-cutaneous syndrome affecting 1/3500 children is associated with moyamoya syndrome (mms). however, no comparisons of cerebral perfusion in patients with nf1 and nf1-associated mms to healthy controls exist. we hypothesize cerebral blood flow (cbf), as measured by magnetic resonance imaging (mri) arterial-spin-labeled (asl), is diminished in children with nf1 compared to healthy controls, with the lowest levels seen in patients with nf1-associated mms. methods & materials: twenty children aged 2-18 years with nf1, four with mms, and 26 age-matched controls underwent asl cbf on a 3 t magnet. pseudocontinuousspin-echo-asl technique was used. measurements were taken bilaterally in cerebral cortical-subcortical regions, and the deep gray nuclei. trends in measurements as a function of disease severity were tested with the jonckheere-terpstra test for ordered alternatives. a bonferroni-adjusted p-value less than 0.0013 was considered significant. results: we identified 6/12 areas with significantly diminished asl cbf (ml/100 g/min) in patients with nf1 (midrange), and nf1-associated mms (lowest) compared to healthy controls (highest). these included the: thalami (left: p00.0002, right: p00.0004); superior/middle temporal lobes (left: p 00.0012, right: p 00.0009); temporooccipital lobes (left: p00.0006, right: p00.0003); occipital poles (left: p 00.0008, right: p 00.0001); centrum semiovale (left: p00.0022, right: p00.0005); and left parietal lobe (p00.0012). conclusions: cerebral perfusion diminishes in a graded fashion in children with nf1 and nf1-associated mms, particularly in the posterior circulation and the mca-pca posterior watershed zones. future studies may demonstrate an important role for asl in the presymptomatic diagnosis of cerebral vasculopathy, and the definition of nf1-related vasculopathy patterns. paper #: pa-071 cingulate gyrus mri sign in pediatric nf1 patients: a novel imaging marker nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; nabila hai, rhea udyavar , amir noor, gilbert l. vezina, maria t. acosta purpose or case report: we observed a magnetic resonance imaging (mri) signal abnormality in the anterior cingulate gyrus of pediatric patients with neurofibromatosis type 1 (nf1). the cingulate gyrus could play a role in cognitive deficits of nf1 patients. the first objective here is to document inter-rater reliability scores for visual detection of this sign. the second objective is comparing adc values of the cingulate gyrus in areas of visually abnormal mri signal in nf1 patients to matched normal mris to confirm a pathophysiological basis of the visual mri sign. methods & materials: retrospective analysis, irb approved, 61 nf1 patients and 38 matched controls. in the visual assessment part, two blinded neuroradiologists rated presence or absence of mri signal abnormality in the cingulate gyrus in three different age groups of nf1 patients mixed with normal controls. cohen's kappa inter-rater reliability coefficients were calculated. the same blinded neuroradiologists evaluated the cohort one year later, this time by agreement at the workstation. in the adc measurements part, two researchers, one blinded, manually placed roi's in the anterior and posterior cingulate regions of 26 nf1 patients and their matched controls, and student t-test was used to assess for significance of differences in measured values. results: cohen's kappa for the three age groups showed very good agreement (kappa coefficients were either 0.9 or 1.0). rater agreement at the workstation was 100%. all subjects with a positive finding also had nf1 and the sign was not seen in any of the normal controls. the prevalence of the sign was 43%. adc measurements showed significantly higher adc values in the anterior cingulate gyrus of nf1 patients when compared to normal controls and also when compared to the posterior cingulate gyrus in nf1 patients. conclusions: our results show that visual t2/flair mri abnormalities in the anterior cingulate gyrus are present in 43% of patients with nf1 from ages 2 to 19 years. adc measurements confirm a pathophysiological basis for this finding. future correlation with clinical manifestations, such as learning and behavioral manifestations in patients with nf1, are under way to further evaluate the clinical importance of this finding. tract-based spatial statistical analysis of diffusion tensor imaging in pediatric patients with mitochondrial disease seth friedman, phd, seattle children's, seth.friedman@ seattlechildrens.org; andrew v. poliakov, sandra l. poliachik, dennis w. shaw purpose or case report: often diagnosed at birth or in early childhood, mitochondrial disease presents with a variety of clinical symptoms, particularly in organs and tissues that require high energetic demand such as brain, heart, liver, and skeletal muscles. in a group of pediatric patients identified to have complex i or i/iii deficits, but with white matter tissue appearing qualitatively normal for age, we hypothesized that quantitative dti analyses might unmask deficits in microstructural integrity. methods & materials: dti and structural mr brain imaging data were collected in 10 pediatric patients with confirmed mitochondrial disease and 10 clinical control subjects matched for age, gender, scanning parameters, and date of exam. paired tract-based spatial statistics (tbss) were performed to evaluate differences in fractional anisotropy (fa) and mean diffusivity (md). results: in patients with mitochondrial disease, significant widespread reductions in fa values were shown in white matter tracts. md values were significantly increased in patients, having a sparser distribution of affected regions compared to fa. results of tbss statistical analysis will be shown. to be shown in green is the mean fa skeleton which represents the centers of main white matter tracts. all results p<.05. red and yellow represent a significant increase, blue and light blue represent a significant decrease. conclusions: despite qualitatively normal appearing white matter tissues, patients with confirmed mitochondrial disease have widespread microstructural changes measurable with quantitative dti. this supports the evaluation of such metrics in other populations where gross imaging features may be normal. to extend our studies to patients with other plp1 mutations, we analyzed the brains of 52 male pmd patients (ranging in age from 2 to 45) and 9 female carriers for whom the plp1 genotype had been determined and analyzed by mri. for each patient we measured, white matter volume (wmv) and the intercaudate distance (icd). the mri data were correlated with functional disability scores (fds) using a system we developed for clinical evaluation of pmd patients and which was validated by assessments of 22 pmd patients. brain volume and segmentation were measured using nih image 1.62. the average number of coronal slices analyzed from each patients mri was 60 slices. when graywhite contrast was not adequate, then the intercaudate distance (icd) and intercaudate ratio were measured as described in caon et. al., (2003) . results: comparison of the mr measurements and the fds demonstrated that white matter volume inversely correlates with functional disability, suggesting that the initial disability does correlate with the extent of myelination. the intercaudate distance also correlated with the fds, and may usefully substitute when gray-white matter segmentation is not possible. conclusions: pmd is a clinically and genetically heterogeneous disease caused by mutations in the gene encoding the major cns myelin protein, proteolipid protein (plp). myelin is a major target of disease pathogenesis in most cases of pmd, but how the various mutations cause clinical disability is not fully understood. our data demonstrate that the extent of brain white matter atrophy, measured directly by volumetric fractionation, or indirectly by analyzing the intercaudate ratio, is significantly correlated with the patient's functional disability. white matter atrophy is thus the main cause of clinical disability in patients with pmd of all ages and mutation type. paper #: pa-074 maturational effects on language localization in children demonstrated by fmri susan palasis, md, children's healthcare of atlanta at scottish rite, spalasis@yahoo.com; binjian sun, laura l. hayes, richard a. jones purpose or case report: language localization is of paramount importance when contemplating surgery in children with intractable epilepsy or brain tumors. the potential risk of injury to language centers in the developing pediatric brain needs to be weighed against the potential benefits of surgery. in the past, language localization was crudely and invasively determined using the wada test. most institutions are now transitioning to non invasive localization using functional mri (fmri). the purpose of our study was to analyze language localization relative to age in children using age appropriate language paradigms and fmri. methods & materials: forty three healthy, english speaking, right handed children underwent fmri evaluation for language localization. the studies were performed on a 3 t system. three novel age appropriate language block paradigms were utilized, targeted both to expressive and receptive language processing. these paradigms were the auditory category decision task (audcat), the auditory description decision task (addt), and the listening task. the spatial statistical maps generated by the fmri data were fused to the 3d anatomical mri dataset. language areas were localized and statistical analysis was performed with age as the variable in a general linear model. results: our results demonstrate a distinct trend in language localization and lateralization with brain maturation. in the young age groups (less than 12 years) the localization tended to be less focused and bilateral in the frontal and temporal regions of the brain. in the older age groups (greater than 12 years), language became more localized and lateralized to the expected left sided pattern. the findings were more robustly demonstrated with the addt task and were statistically significant (p<0.05). conclusions: our study clearly demonstrates the plasticity of language centers in the maturing pediatric brain. this observation is significant for neurosurgical planning and rehabilitation in the pediatric population. (3) no slc26a4 mutations were found in 16, 12 and 47 subjects, respectively. significantly higher association with slc26a4 mutations was found in bilateral eva+v/c dysplasia (16/18). double mutations of slc26a4 is more often associated with combined eva+ v/c dysplasia, while a single mutation with eva only. cochlear aplasia without eva (0/2) and snhl with normal imaging (3/21) are less likely associated with slc26a4 mutation. conclusions: slc26a4 mutation is highly associated with eva and v/c dysplasia. once eva with or without v/c dysplasia are found at imaging, genetic investigation is recommended for slc26a4 mutation because of possible thyroid involvement. moderate-severe hie who were randomized to cooling (33.5°c for 72 h). there were 73 in the hypothermia group and 63 in the control group. all mris were reviewed by a cental reader masked to the clinical findings, groupings, and outcomes. the mri findings were scored according to pattern and extent of injury, including involvement of the cerebral hemispheres, basal ganglia, thalami, internal capsules, and other structures. brain injury scores were correlated with death or disability at 18 months postnatal age. results: no mri abnormalities were observed in 38 of 73 infants (52%) in the hypothermia group and in 22 of 63 infants (35%) in the control group (p00.08). infants in the hypothermia group had fewer areas of injury (12%) as compared with the control group (22%, p0 0.02). there were 51 of the 136 infants with death or disability at 18 months. the brain injury score correlated with outcome of death or disability (p00.001) and disability among survivors (p00.0001). conclusions: fewer areas of brain injury on mri were observed following whole-body hypothermia. the mri brain injury score is a marker of death or disability at 18 months following hypothermia for term hie. . presence or absence of the "red dot" on fa color maps was correlated to clinical (ataxia, oculomotor abnormalities etc.) and morphological data, and to fa and md measurements. results: the "red dot" was absent in js and hgpps (genetic cross wiring impairment diseases) and present in coma and wvs (no reported gene abnormalities so far) as in normal controls. js and coma presented on mri molar tooth appearance. hgpps presented "split pons" appearance. js and coma patients presented oculomotor apraxia, wvs and hgpps palsy of the horizontal gaze. mirror movements were found in 2 js and in wvs. ipsilateral responses are present in hgpps. wvs presented multiple cranial nerves impairment. in js, fa and md values of scp, pt and pc were significantly lower than in normal controls (p >0.01). in hgpps high fa and low md were found in pc and pt (p >0.01) and normal in scp. conclusions: the "red dot" absence is unrelated to morphological or clinical abnormalities. absence of the "red dot" is associated to abnormal measurements of fa and md in pc and pt( low in js and high in hgpps). these findings indicate a pivotal role for the pc in the physiopathology of these diseases. the "red dot" absence seems to be a marker of genetic cross wiring diseases. in this view, coma and wvs should not be considered as part of these diseases. sonographic predictors of intermittant testicular torsion in the pediatric patient jennifer williams, md, pediatric radiology, texas children's hospital, jlwilli1@texaschildrens.org; marthe munden purpose or case report: intermittent testicular torsion (itt), defined as sudden onset unilateral scrotal pain with spontaneous resolution, is difficult to confirm both clinically and sonographically. the purpose of this study was to determine if sonographic predictors exist for diagnosing itt in the pediatric patient. methods & materials: a search of the pacs data system for patients presenting with suspected intermittent testicular torsion was performed. fifteen patients with a total of 20 episodes presenting over a 2 year period were found. a retrospective review of the medical records for clinical presentation, surgical outcome, and comorbidities was performed. scrotal ultrasound images and reports were reviewed for testicular size and echotexture, testicular flow, epididymal appearance, vascular bundle appearance, and presence of hydrocele. results: an abnormal appearance of the vascular bundle was found in 85% of episodes (17/20). initial absence of testicular flow followed by reperfusion during the scan was seen in 30% of episodes (6/20); 45% had increased flow (9/ 20), 10% had decreased flow (2/20), and 15% had normal flow (3/20) . nine of the 15 patients had surgery; of these 8 were found to have evidence of itt and 1 was found to have acute testicular torsion. of patients with itt, 88% (7/8) had an abnormal vascular bundle. testicular flow was not initially visualized but returned during the exam in 50% of patients (4/8), was increased in 38% of patients (3/7) and was decreased in 13% patients (1/8). conclusions: itt is a difficult diagnosis. the most reliable sonographic indicator is an abnormal spermatic cord, found in 85% of episodes and 88% of surgically proven itt. dedicated views of the spermatic cord must be obtained in order to differentiate an abnormal epididymis from an engorged vascular bundle (the so-called pseudomass). attention to testicular flow is of particular importance. while visualization of a transition from no or decreased testicular flow to normal flow during the sonogram is certainly diagnostic of itt, increased testicular flow should not lead to false reassurance. purpose or case report: testicular torsion is a common acute condition in boys requiring prompt and accurate diagnosis. the objective was to evaluate ultrasound accuracy and findings, and clinical predictors in testicular torsion in boys presenting to the stollery pediatric emergency department (ed) with acute scrotal pain. methods & materials: retrospective review of us, surgical and ed records for boys aged 1 month to 17 years, presenting with acute scrotum from 2008 to 2011, was performed. age, demographics, clinical symptoms, physical findings, us and surgical techniques, findings and diagnoses were recorded. surgical results and follow-up were used as the gold standard as all pediatric urology in our region is performed at our centre. results: 343 patients presented to ed with acute scrotum with the following diagnoses: 35 testicular torsion, 11 possible torsion-detorsion, 3 torsion of appendix testes, 135 epididymo-orchitis, and 159 other. of 266 us performed, 29 boys had torsion confirmed by surgery. there were 8 inconclusive us reports, none of which had torsion at surgery or follow-up. the false positive rate of us was 1.5% (4 patients), and there were no false negatives. six torsion patients had no us. median time from ed to us and surgery for torsion patients was 159 and 303 min. six patients had non-salvageable testes. diagnostic accuracy of us compared to surgery was 96% for torsion and 67% for other. sonographic heterogeneity was seen in 80% of patients with testes that the surgeon felt were non-viable at surgery and 72% of patients with viable testes (p00.35). sudden-onset scrotal pain (92%), abnormal position (86%) and absent cremasteric reflex (91%,) were most prevalent in torsion patients. conclusions: color doppler us is accurate and sensitive for diagnosis of torsion in the setting of acute scrotum. despite heterogeneity on pre-operative us, many testes were felt to be salvageable at surgery. rate of salvage of torsion was high. common symptoms and findings of torsion were sudden onset of pain, abnormal testicular position and absent cremasteric reflex. paper #: pa-080 diagnostic twists of tubal torsion srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; anjum n. bandarkar, dorothy bulas purpose or case report: fallopian tube torsion is a rare cause of acute pelvic pain in a young female and requires prompt diagnosis for immediate surgical intervention. our purpose is to review varied imaging findings of surgically proven cases of tubal torsion. methods & materials: retrospective review of our data base from 2007 to 2011 revealed 7 cases of surgically proven fallopian tube torsion. ages ranged from 9 to 15 years of age. all had pelvic ultrasound performed, 3 cases had additional ct performed for acute pelvic pain. results: us findings included thickened dilated tubular hypoechoic structure (5), cystic mass (4); adnexal (3), midline (1). five cases had normal ovaries bilaterally (2 with paratubal cysts). ct imaging findings include dilated, fluid filled, thickwalled tube with internal hyperdensity (40hu) likely debris/ hemorrhage in 1 case. additional findings included cystic adnexal mass (3 cases), beak sign (1 case) and increased vascularity (1 case). secondary signs included free fluid (5), peritubular fat stranding (1), vascular congestion and thickening of the broad ligament (1) and enlarged draining vein (1). laparoscopic salphingectomy was performed in 3 cases (including 2 cases with isolated tubal torsion). laparoscopic detorsion was performed in a total of 4 cases. in addition, laparoscopic cyst drainage was performed in 2 out of these 4 cases. detorsion with paratubal cystectomy and hemorrhagic ovarian cystectomy was performed in 1 of the 4 cases. conclusions: imaging diagnosis of tubal torsion can be difficult. it can occur in isolation with a dilated thickened tubular structure adjacent to a normal ovary or potentially mimic appendicitis, pyosalpinx, complex adnexal cyst or cystic adnexal neoplasm. presence of normal ovaries, beaked tapered tubular structure with intratubal fluid level and hemorrhage may help in making the diagnosis. it is important to recognize this entity in a patient with acute pelvic pain to facilitate prompt tubal sparing surgery. paper #: pa-081 adjusted renal length in pediatric bone marrow transplant recipients nicholas bodmer, md, university of washington, nbodmer@gmail.com; teresa chapman, sangeeta hingorani, marguerite parisi purpose or case report: bilateral nephromegaly has been observed in the bone marrow transplant (bmt) patients at our institution. this study aims to quantify this observation, thereby providing radiologists with an adjusted baseline agedetermined renal growth curve for bmt patients. methods & materials: a retrospective clinical chart and imaging review was performed on 185 patients who underwent bmt between 2006 and 2010 and who had abdominal imaging including the kidneys. ultrasound, ct, and mri exams were used for renal length measurement. renal lengths were assessed for each age group, first as an average length of all the patients within that age group overall, and subsequently as an average renal length by age group divided into the following time frames after transplantation: 0-30 days, 31-90 days, 91-180 days, and 181+ days. clinic chart information collected included bun, creatinine, weight, and medication use. results: renal length was measured using 278 imaging cases, distributed across each age group as follows: 6-12 months, n 011; 13 months-2.5 years, n 030; 2.6-4.5 years, n033; 4.6-7.5 years, n038; 7.6-11.5 years, n0 51; 11.6 years and higher, n0115. renal lengths were greater, on average, within every age group, compared with previously established normative age-related renal lengths (rosenbaum et al.) . the augmented renal lengths universally were observed in the 0-30 day post-transplantation timeframe. return to normal renal lengths typically occurred by 6 months post transplant. clinic chart review revealed that the majority (87%) of patients received nephrotoxic medication within two weeks of imaging. conclusions: pediatric bmt patients have larger kidneys in the absence of known renal disease than age-matched peers. a revised, age-based renal length chart for post-bmt patients has been generated which should help prevent the misdiagnosis of nephromegaly in this population, eliminating unnecessary diagnostic evaluations. multiple etiologies to explain renal enlargement in these patients are possible, including fluid overload, nephrotoxic medication, or direct effect of the transplant. purpose or case report: mr urography can be a comprehensive exam for anatomical and functional pediatric renal evaluation. quantification of renal function may benefit when dynamic contrast enhanced images can be obtained at high spatiotemporal resolution and with minimal respiratory motion artifacts. though respiratory triggering may decrease motion artifacts, it results in loss of temporal resolution by a factor of about three. a two-echo gradient echo sequence with segmented outer k-space sampling and view-sharing/dixon image reconstruction (disco, differential subsampling with cartesian ordering) was chosen as a starting point due to its high temporal resolution. it was then modified to enable respiratory triggering while maintaining temporal resolution of one temporal frame every one to two respirations, with segments of k-space only acquired in the expiratory phase of respiration. imaging parameters were: 12°flip angle, ± 167 khz bandwidth, tr~3.56, matrix 256x200, fov 28-34 cm, slice thickness 4 mm, and 2x2 spatial acceleration. with irb approval and informed patient consent 9 consecutive patients referred for mri renal function evaluation were recruited (age range; 0.5 to 9.6 years, mean±sd: 3.99±3.6 years; males 78% females 22%), and scanned on a ge 3 t mr using a 32-channel torso array with the respiratory-triggered high spatiotemporal resolution technique to extract regional gfr maps. two readers by consensus assessed image qualitative snr, motion artifacts and volumetric fat-water suppression performance. results: data acquisition was obtained to completion in all subjects without triggering failure. temporal resolution was approximately 12 s for two respiratory cycles. no case had major fat suppression failure, whereas minor fat suppression failure was seen in 11% (95% c.i. 0 to 37%). all cases had diagnostically acceptable snr. no motion artifacts were noted in 7/9 cases, while some artifacts with ghosting in 2/9 cases. regional gfr maps could be successfully extracted for each patient without the need for image registration. attached figure shows image quality. conclusions: view-sharing offsets loss of temporal resolution from respiratory triggering. thus, high spatiotemporal resolution renal dynamic contrast enhanced respiratory triggered images can be obtained with minimal motion artifacts in a pediatric clinical setting to evaluate renal function. disclosure: dr. chowdhury has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: the study cohort was selected from the irb approved children's oncology group aren03b2 study. cases are evaluated for pre-operative wt rupture based on central review of surgical/pathology findings. 70 wt cases with rupture were matched to 70 wt controls by age and tumor weight (within 6 months and 50 g). ct scans were independently reviewed by 2 blinded radiologists, for presence/absence of rupture and the following ct signs: poorly circumscribed mass, perinephric fat stranding, peritumoral fat planes obscured, retroperitoneal fluid, ascites beyond cul-de-sac, peritoneal implants, ipsilateral pleural effusion, intratumor hemorrhage. sensitivity, specificity of ct for assessing pre-operative wt rupture was determined. the relationship between ct signs and rupture was assessed by mcnemar's test, and the most predictive ct signs determined by backward selection multivariate logistic regression. results: sensitivity, specificity for detecting wt rupture were: reviewer 1-53.7%, 88.4%, reviewer 2-70.2%, 88.4%. kappa coefficient for interobserver agreement was substantial: 0.76 (p<0.0001). all ct signs tested, except peritoneal implants and intratumoral hemorrhage, had significant association with tumor rupture (p<0.01). for reviewer 1, ascites and fat stranding around tumor were most predictive (odds ratio 18.359 and 10.554, p<0.01). for reviewer 2, ascites and retroperitoneal fluid were most predictive (or 8.345 and 4.916, p<0.01). conclusions: ct has high specificity but relatively low sensitivity for detecting preoperative wt rupture. the presence of ascites beyond cul-de-sac is the best indicator of preoperative rupture, followed by fat stranding and retroperitoneal fluid. paper #: pa-084 the failed pyeloplasty: evaluation with mr urography damien grattan-smith, children's healthcare of atlanta, damien.grattansmith@mac.com; ricahrd jones, stephen little, wolfgang cerwinka, hal scherz, andrew kirsch purpose or case report: to identify imaging characteristics associated with failed pyeloplasty seen with mr urography. we have performed mr urography in 142 children following pyeloplasty. from this group, 16 children had follow-up surgical intervention with repeat pyeloplasty or balloon dilatation of the upj. imaging features reviewed included degree of hydronephrosis, calyceal transit times, renal transit times, signal intensity versus time curves, as well as functional analysis based on volumetric and patlak differential function and change in the asymmetry index. results: all children who underwent a second surgical procedure had delayed calyceal transit times. the degree of hydronephrosis and renal transit times were either stable or worse when compared to pre-operative evaluation. functional derangement could show stability, slight improvement or deterioration. the asymmetry index estimated the severity of the obstruction. conclusions: mr urography is valuable in the evaluation of children who have undergone pyeloplasty. the calyceal transit time appears to be the most reliable discriminator when comparing successful and failed pyeloplasty. calyceal transit times may be prolonged before the hydronephrosis becomes progressive. disclosure: dr. grattan-smith has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: initial attempts at interpreting functional mr urography (fmru) can be challenging. a time intensive navigation through a multitude of both subjective and objective functional results is necessary to render a useful interpretation. this is a guided review of fmru, noting the important functional findings in high-grade unilateral pelvicalyceal dilatation (pcd), in the absence of ureterectasis, with a contralateral normal kidney allowing for an optimal functional comparison. methods & materials: a retrospective functional evaluation of 16 cases with unilateral pelvicalyceal dilatation (pcd), without prior pyeloplasty, was conducted. the fmru studies were carried out according to a standard protocol and post-processing using the chop-fmru software. this included iv hydration, bladder catheterization and iv furosemide administration. fifteen minutes after diuretic administration, a dynamic coronal 3d fat saturated t1 sequence was performed in a supine position over 15 min. a sagittal 3d t1 and delayed single coronal t1, both fat saturated, followed in a supine and/or prone position. the following functional features were evaluated: visualization of the ureter, the presence of a contrast-urine level and swirling of contrast in the dilated renal pelvis. the functional results included in the analysis were calyceal transit time (ctt), renal transit time (rtt), time-to-peak (ttp), parenchymal volume (pv), differential renal functions (volumetric-vdrf, patlak-pdrf and volumetric patlak-vpdrf) and the difference between vdrf and pdrf. results: 16 patients were comprised of 8 males and 8 females with an age range of 0.1-17.0 years (median 0.8 yrs). of the kidneys with pcd, the ureter was visualized in 10, 3 during the dynamic sequence, 4/9 during supine delay and 3/7 only in prone position. a contrast-urine level was present in 14 of the dilated systems, and swirling in 6. the ureter was visualized during dynamic sequence in all contralateral normal kidneys and at no time was swirling or a contrast-urine level identified. the average functional parameters are seen in table 1 . a statistically significant (p<0.05) difference between the normal and dilated pelvicalyceal systems was achieved in ttp, pdrf and vpdrf for this small sample size. conclusions: awareness of multiple functional features and the range of calculated results may aid in subsequent combined interpretation of the fmru with the morphologic analysis. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. 2007 and 2011. demographics, clinical presentation , diagnostic studies and treatment outcomes were evaluated. post-procedure imaging was evaluated for clot burden reduction (patency) and residual venous stenosis by two-reader consensus. results: ten patients (5 male; 5 female, mean age 16 years, range 15-18) presenting with acute upper extremity swelling and pre-procedure imaging revealing 100% occlusion of the axillary and subclavian veins received successful endovascular therapy. all 10 patients underwent infusion catheter placement for thrombolysis with tissue plasminogen activator or urokinase. 6 patients received additional pharmacomechanical treatment. angioplasty was also performed in all patients. the mean treatment duration was 33 h (range 16-62). post-procedural imaging revealed that 9 of 10 patients achieved 75-100% patency (clot burden reduction) and 1 patient achieved 50-75% patency. the residual venous stenosis was graded: 5 patients had 0-25% stenosis, 2 patients had 25-50% stenosis and 3 patients had 75-100% stenosis. all patients were discharged on full anticoagulation therapy with low molecular weight heparin. 9 patients had surgical rib resection postthrombolysis with an average length of time from thrombolytic therapy to surgery being 32 days (range 14-73). 3 patients had re-thrombosis events during the follow-up period (mean 10 months; range 1-34), with one re-thrombosis event occurring within one week of thrombolytic therapy, prior to surgery and the other two occurring 3-5 weeks post-rib resection. there were no procedure related complications. one patient was lost to follow-up after initial successful catheter directed therapy. conclusions: percutaneous endovascular techniques such as pharmacomechanical thrombolysis and angioplasty appear to be feasible and safe options for paget schroetter syndrome in otherwise healthy adolescent patients. in attempt to prevent rethrombosis and chronic symptoms, we refer all patients for adjunctive surgical decompression. future larger studies are needed to address optimal strategies for these patients. combined 3d fluoroscopy image guided percutaneous intervention with real-time optical sensing at the tip of a needle for tissue characterization rami nachabe, philips, rami.nachabe@philips.com; john m. racadio, drazenko babic, ross schierling, jasmine hales, benno hendriks purpose or case report: to investigate the feasibility and potential of real-time tissue characterization at the tip of a needle with diffuse optical spectroscopy (dos) sensing capabilities during 3d fluoroscopy guidance using cone beam ct and dedicated needle path planning software. methods & materials: a c-arm x-ray system that combines fluoroscopy and 3d imaging from a cone beam ct was used to image a woodchuck with hepatocellular carcinoma (hcc). the imaging system enabled needle path planning, which was used to perform insertion and navigation of a needle toward the liver tumor. the needle was integrated with optical fibers for real-time tissue spectral sensing at its tip. optical spectra measurements were obtained continuously as the needle passed through healthy liver tissue and then into the tumor. from the diffuse optical spectra measurements, the following clinical parameters were extracted for tissue characterization: blood volume fraction, blood oxygenation, lipid volume fraction and tissue light scattering (related to tissue density). the tissue parameters were compared for healthy liver and tumor using the kruskal-wallis test. results: the tissue density of the healthy liver was lower than that of the tumor. higher blood and lipid volume fractions as well as oxygenation levels were observed in the healthy liver as compared to the tumor. all differences were statistically significant (p<0.01). additionally, a much wider heterogeneity in tissue density was observed in the tumor as opposed to the healthy liver. conclusions: differences in tissue properties between tumor and healthy liver enable discrimination between these two types of tissues. adding real-time optical sensing at the tip of a needle to 3d fluoroscopy image guidance is a feasible technique that complements the imaging information with relevant physiological parameters; it facilitates more precise definition of tumor boundaries despite any target motion during needle insertion. disclosure: dr. racadio has disclosed that he is a consultant for philips healthcare and receives travel reimbursement. rami nachabe, drazenko babic and benno hendriks are employees of philips healthcare. methods & materials: two children aged 6 months and 3 months were treated at this institution for liver failure resulting from urea cycle disorders, with a hepatocyte transplant procedure. the recipient liver was irradiated prior to transplant to facilitate engraftment. the procedure involves the injection of prepared hepatocytes from a suitably screened, compatible donor, via a main portal vein branch into the recipient liver. in both procedures access to the umbilical vein was achieved by the surgery service and a 4 french arterial sheath was placed. a 4 french angled catheter was used for diagnostic runs and to access the right and left main portal vein. a 3 french fogarty catheter (edwards lifesciences, irvine, ca) was placed to isolate each portal vein branch in turn and hepatocytes injected using hand injections. pressures in the main, right and left portal veins were measured and hand injections of contrast made at regular intervals. careful attention must be paid for evidence of pruning of portal branches, indicating occlusion of small portal branches, or portal to hepatic vein shunting. if shunting is seen, infusion must be stopped as embolism of hepatocytes into pulmonary arteries may result with serious clinical sequelae results: in both patients, the desired number of hepatocytes were successfully delivered into the recipient liver. in both cases, mild pruning of the portal vein branches was evident at the end of the procedure. portal vein presssures remained steady. there was no venographic or clinical evidence of pulmonary arterial embolization. conclusions: the interventional radiologist plays a central role in the hepatocyte transplant procedure. familiarity with catheterizing portal branches from an umbilical vein approach, measuring venous pressures, using small occlusion catheters and recognizing venographic end points such as portal vein pruning and portal to hepatic vein shunting are necessary to the safe and successful completion of this new technique. purpose or case report: the aim of the study was to evaluate the trends in term of type of tube placed, number of procedures per year, number and age of the patients as well as the number of procedures per patient and the interval of time between two placements, and finally the irradiation burden borne by the patients. methods & materials: after reb approval the radiologic files of the patients who underwent naso-duodenal-jejunal (ndj) or gastro-jejunal (gj) or jejunal (j) tube placement under fluoroscopy over the past five years (2006 to 2010) were extracted from the ris and reviewed. the results were tabulated as a single batch and stratified by year. results: eighty-nine patients representing 234 procedures (155 ndj, 77, gj, 2 j) were included. only 38 patients underwent a single procedure. the average number of procedures per patient was 2.6 with a maximum of 12 during the study period. the average patient's age was 55.3 months (sd074.88, median0 11.43). the average fluoro time per procedure was 7.2 min (sd08.3, median05.0). the average interval between two procedures was 58 days (sd0108,44, median018). the average fluoroscopy time per patient combining those having a single procedure and those having multiple ones, was 19.57 min (range 0.3 to 151.7, sd024.36, median012.45). conclusions: fluoroscopic placement of enteric tubes delivers a significant amount of irradiation. our data led to two interventions with respect to insertion and management of the tubes. on one hand, when the attempt pursued by a radiologist is not successful after 10 min of fluoroscopy other strategies should be considered including another operator or an alternative technique for tube positioning. on the other hand, information will be distributed toward the clinicians and nurses in order to improve the management of these tubes and avoid fortuitous displacement which was responsible of a significant amount of repeated procedures leading to undue irradiation. purpose or case report: to evaluate drug elution pharmacodynamics of doxycycline in an albumin-based solution, as used in percutaneous imaging-directed therapy of aneurysmal bone cyst (abc) and microcystic lymphatic malformation (lm) methods & materials: doxycycline mixed with 25% human serum albumin (hsa), and doxycycline mixed with saline solution (both 20 mg/ml) were evaluated using a fluid diffusion chamber system over 8 h, recording ph and doxycycline concentration. static ph and doxycycline concentrations were recorded every 5 min for the first 180 min, then every 30 min for a total of 8 h, averaged over 3 trials in each of the hsa and saline systems. statistical analysis evaluated standard deviation and rate of change for the 3 trials in each system. drug elution dynamics data were correlated with clinical experience in the doxycycline/albumin treatment of 49 patients (233 treatments) with aneurysmal bone cyst (abc) and 63 patients with 1263 lymphatic malformation microcysts. results: drug elution was linear in both the hsa and saline systems, with statistically significant (p<.001) slower elution drug release from the albumin system as compared with the doxycycline and saline solution, both over 3 and 8 h. purpose or case report: to describe a successful interventional radiologic approach to the management of paget schroetter syndrome presenting as acute arm swelling in adolecent athletes. methods & materials: institutional review board approval was obtained for this retrospective study. five patients aged 14 to 18 years (mean 16.5 years) were treated at this institution over a 2 year period all presenting with acute arm swelling (july 2009 -july 2011). ultrasound confirmed subclavian vein thrombosis in all cases. all were treated with placement of an infusion catheter (ev3, plymouth, mn), infusion of tissue plasminogen activator (tpa) at a rate of 1 mg/hour overnight and aspiration of remaining clot with a "trellis" (bacchus vascular, santa clara, ca, usa) thrombectomy device. results: clot was successfully removed in all five patients. complete clearance of clot was confirmed by contrarst venography in all cases. in four patients balloon angioplasty of a narrrowing at the junction of the subclavian and brachiocephalic veins was carried out. in one, the thrombus recurred within 6 h. the patient was retreated the next day with aspiration of clot using the "trellis" device and an infusion catheter placed with low dose (0.5mgs/hour) tpa commenced until surgical review; this patient was operated on within 48 h of final thrombolysis. all patients were seen by a vascular surgeon with an interest in this condition. all underwent surgical decompression; at end of the study period all patients were asymptomatic. conclusions: interventional radiologic management of acute axillo-subclavian thrombosis due to paget schroetter syndrome is safe and highly successful in the adolescent population. early recurrence of thrombus is not uncommon and prompt surgical consultation with a view to early surgical decompression is recommended. purpose or case report: diagnostic reference levels (drl) or target radiation dose ranges for pediatric ct scans are needed in the u.s. the first u.s. pediatric ct dose index registry (quircc) within the american college of radiology recorded estimates of patient radiation dose using a new method (ssde) based on body width(bw) for the purpose of developing diagnostic reference levels (drl). in addition to developing drl at the 75th percentile, the purpose of this study was to determine the ssdes associated with the lower range of acceptable image quality through subjective image quality evaluation. methods & materials: six children's hospitals participated in a retrospective review of abdominal ct with iv contrast on patients <18 yrs of age. from 939 exams, each site submitted de-identified images for selected cases based on ssde and patient width. a total of 106 cases were selected from the lowest, first quartile and median ssde. six investigators reviewed 3 images from each case under identical viewing conditions and rated them for subjective quality according to a score sheet and reference scale of images with known quantum mottle. cases were considered non-diagnostic if at least 3 of 6 reviewers ranked them as such. results: first, second, and third quartile ssde and ctdi-vol32 values from 6 sites for each bw will be shown. 6/ 106 cases were ranked non-diagnostic by the reviewers. 4/6 non-diagnostic cases were below the 10th percentile based on ssde. 5/6 of "non-diagnostic" cases had ssde less than the 25th percentile. the unacceptable case with ssde above the 25th percentile (16 cm, ssde 8.2 mgy) was due to subcutaneous metal implant with artifact. the quircc 75th percentile using ctdivol 32 for a 5 yr old is 7.1 mgy which is 30% lower than the acr ct accreditation data's published 75th percentile. conclusions: this consortium developed target dose ranges (drls) for ct of the abdomen with iv contrast for routine exam indications based on evaluation of image quality that establish lower and upper ranges (25-75 percentile) of patient dose(using ssde) associated with clinically acceptable images. this study demonstrates that pediatric radiologists in this consortium are comfortable interpreting images at or above the 25 percentile ssde and judged all but one image within this target range as diagnostically acceptable. table 1 ). with the exception of neonate chest, most used age-based techniques; only two centers reported using thickness. no survey used grids for wrist images, while 2/3 of the surveys used grids for chest and abdomen exams in 5-year-olds. at the most common sid there was up to a 60 kvp variation (5year-old chest ap) and up to 8-fold variation in mas (13 year old scoli lat). only two surveys used equipment that displayed the new iec exposure index. conclusions: participants report variability in the techniques and methods used to acquire common radiographic studies, reflecting differences between detector types and users. radiologists, technologists, medical physicists, manufacturers, and the fda have an opportunity to work together to standardize the techniques based on detector type to optimize radiation exposure for pediatric radiographic exams. disclosure: dr. don has indicated that he performs contract research for carestream and that he is on the speaker's bureau for siemens and receives an honoraria. purpose or case report: this study assesses community adoption of ct radiation dose guidelines after a 10-year international initiative to reduce medical radiation exposure in children. size-specific dose estimates (ssde) from community pediatric body ct scans are compared to ssde from matched scans obtained at a children's hospital that adheres to image gently campaign principles. we reviewed 112 pediatric ct scans (14 chest (c), 80 abdomen/pelvis (ap),18 chest/abdomen/ pelvis (cap)) transferred from 32 community imaging centers to our university children's hospital between july 2010 and february 2011. community scans were acquired with variable parameters and reconstructed with traditional filtered back projection (fbp). comparison was made to 432 children's hospital ct scans, performed in accordance with principles of the image gently campaign. because iterative reconstruction (ir) software was added to our scanner during the study, enabling us to reduce ctdivol by 60%, children's hospital scans were divided into two groups: a) 213 scans obtained with standard weightbased pediatric protocols and fbp (october 2009-october 2010; 58 c, 110 ap, 45 cap) and b) 219 scans obtained with reduced-dose weight-based pediatric protocols and blended ir/ fbp (october 2010-april 2011; 85 c, 104 ap, 30 cap). ctdivol and greatest lateral dimension were recorded from each scan and were used to calculate ssde. mean ssde from community scans was compared to mean ssde from children's hospital groups a and b. statistical analysis was performed with student's t-test. results: patient age range was 0-17 years in both community and children's hospital groups. mean ssde for community c, ap, and cap scans was 1.7, 1.3, and 1.6 times higher than mean ssde for matched scans in control group a (p<0.001) and 5.0, 2.8, and 3.7 times higher than mean ssde for matched scans in control group b (p<0.0001). conclusions: ssde was significantly higher for community pediatric body ct scans than for matched scans performed at a children's hospital that adheres to image gently campaign principles. results suggest that more community outreach and education are required in implementation of low-dose ct protocols outside of children's hospitals. concurrent use of ir provides a means of achieving even greater ssde reduction than is possible with fbp alone and should be encouraged. paper #: pa-095 optimization of tube voltage and current in size-based pediatric ct imaging: a phantom study boaz karmazyn, md, radiology, riley hospital for children, bkarmazy@iupui.edu; yun liang, keith kaser, peter johnson, mervyn cohen purpose or case report: determine the change in ct dose index (ctdivol) required to maintain the same quantum mottle noise when using lower tube voltages (80 and 100 kvp) relative to 120 kvp in different sized cylinder water phantoms (cwp) representing a wide range of pediatric body sizes. we performed 256 mdct scans of 10, 20, 25, and 35 cm cwp. thirty scans were performed for each phantom. the tube currents ranged from 50 to 500 mas with increments of 50 mas, and the tube voltage levels were 80, 100, and 120 kvp. the noise (standard deviation in hu) was measured using center region of interest (roi) that was 80% of phantom's area. two other rois (each 2% of the area) were placed at the center and periphery of the phantom images to measure noise gradient. results: in the smallest (10 cm) cwp, approximately the same noise level was maintained with all three tube voltages without a significant change in ctdivol. for the 20, 25, and 35 cm phantoms, the average ctdivol needed to be increased by 2%, 4%, and 19%, respectively, to maintain same noise level when the voltage was decreased from 120 to 100 kvp. the average ctdivol needed to be increased by 15%, 22% and 52% to maintain the same noise level in the 20, 25, and 35 cm cwp when the tube voltage was decreased from 120 to 80 kvp. the difference between central and peripheral noise increased on average by 11.1%, 19.6%, 23.7%, and 28.0% in the cwp of 10, 20, 25, and 35 cm, respectively. in each cwp, the central to peripheral noise difference was more pronounced (up to 3.7% more) with decrease in kvp from 120 to 100 or 80. conclusions: noise measurements in the water phantom model indicate that tube voltage could be decreased from 120 to 80 in cwp of 10 cm without significant change in ctdivol. it is also possible to decrease the voltage from 120 to 100 kvp with a minimal (< average 5%) increase in dose in cwps of 10, 20, and 25 cm. the noise gradient increases with larger cwp and smaller kvp. paper #: pa-096 comparison of radiation dose estimates, image noise, and scan duration in pediatric body imaging using 320-row and 64-row ct jennifer johnston, md, radiology, cincinnati children's hospital medical center, jhtai@yahoo.com; daniel j. podberesky, erin angels, terry t. yoshizumi, greta toncheva, donald p. frush purpose or case report: to compare effective dose (ed) estimates, image noise, and scan duration for pediatric chest, abdomen and pelvis protocols using 320-row and 64-row ct scanners in various acquisition modes. methods & materials: organ doses were measured using 20 mosfet dosimeters. dose, scan duration, and noise measurements were made in a 5-year-old anthropomorphic phantom for conventional helical, 160-detector helical and volume acquisition modes for chest, abdomen and pelvis protocols on a 320-row ct, and for helical mode on a 64row ct (aquilion one and aquilion 64, toshiba medical systems, otawara, japan) using similar scan parameters representing currently used clinical protocols. mean organ doses from three runs for each protocol, in combination with icrp 103 tissue weighting factors, were used to obtain ed for each protocol. noise was measured as the standard deviation of hounsfield units in 3 equivalent locations at 4 levels for each protocol with an roi tool. ed and noise were compared with a paired t-test or sign test. results: compared to helical acquisitions on the 64-row ct, ed of all tested acquisition modes on the 320-row volume ct were significantly lower for chest, abdomen/pelvis (ap) and chest/abdomen/pelvis (cap) protocols (table) . scan durations were lower across the board on the 320-row volume ct. compared to acquisitions on the 64-row ct, noise was in general similar to those on 320-row ct protocols, but some acquisition protocols on the 320-row ct produced greater noise (table) , specifically volume acquisition for chest ct and 160-detector helical and volume modes for ap and cap protocols. conclusions: dose savings can be achieved for chest, ap and cap ct examinations on a 320-row ct scanner compared to helical acquisition on a 64-row ct, with shorter scan durations. image noise was in general comparable between protocols. although noise differences between some modes did reach statistical significance, the impact on overall image quality will need to be studied further. paper #: pa-097 the observed to expected total fetal lung volume as a predictor of short-and long-term morbidity in surviving infants with congenital diaphragmatic hernia emily stenhouse, the royal hospital for sick children, emilysten@doctors.org.uk; neil patel, judith simpson, watt andrew, gregor walker, carl davis purpose or case report: observed-to-expected total fetal lung volume (o:e tflv) is a validated mr measure which we have previously demonstrated to be significantly reduced in non-surviving infants with congenital diaphragmatic hernia (cdh). our aim was to investigate the relationship between o:e tflv and short-and long-term morbidity outcomes in surviving infants with cdh. methods & materials: a retrospective analysis of cases of isolated left-side cdh referred to our institution for fetal mr evaluation between 24-35 weeks. mr imaging studies were performed on a 1.5 t philips system using a phased array body coil. the observed tflv was calculated by multiplying the summed area of the region of interest by the section thickness. the expected tflv was calculated with a formula previously described in the literature using the gestational age of the fetus. the observed tflv was expressed as a percentage of the expected tflv at a given gestation. morbidity outcome data was obtained from the case records of all surviving infants. specific measures of illness severity relating to short-term intensive care management and long-term outpatient management were recorded. differences in o:e tflv between outcome groups were assessed by t-test. results: 18 liveborn infants with isolated left-side cdh and antenatal mr scans were identified. scans were performed at 24-35 weeks gestation. 12 infants survived to discharge; gestation 38.5 (36.0 -39) weeks, birth weight 3.17 (2.03-3.66) kg. median length of admission was 38 (23-103) days, median duration of follow-up was 3.1 (0.7-5.4) years. o:e tflv was significantly lower in non-surviving infants; 23 vs. 37%, p0 0.005. o:e tflv was significantly lower in infants who received high frequency oscillation ventilation (hfov) versus those who were conventionally ventilated (29% vs 41%, p00.05). o:e tflv was also significantly lower in those infants who had a length of admission greater than the median of 38 days (29% vs. 43%, p00.02). o:e tflv trended lower with other measures of increased morbidity; inhaled nitric oxide use, patch repair of diaphragm, rehospitalisation within 1 year, supplemental feeding at discharge, gastro-oesophageal reflux, and developmental delay. conclusions: as well as predicting survival, lung volume measurement by o:e tflv is a promising predictor of outcome and morbidity in surviving infants with cdh. further studies in larger populations are required to provide quantitative predictive risk data. characterization of the inherent acoustic noise of a dedicated nicu mri system jean tkach, phd, cincinnati children's hospital medical center, jean.tkach@cchmc.org; yu li, ron g. pratt, christopher villa, beth m. kline-fath, charles dumoulin purpose or case report: we have developed a small foot print 1.5 t mri scanner specifically for neonatal imaging that can be easily installed in a neonatal intensive care unit (nicu). the scanner has a maximum patient bore diameter of 21.8 cm (without rf coil), and roughly twice the gradient performance of the best conventional adult whole-body 1.5 t mr systems. it is known that sensory stimulation such as acoustic noise can elicit autonomic instability in both term and preterm neonates. the inherent noise properties of the nicu mri system were measured as part of the initial safety evaluation of the system and compared against that of a conventional 1.5 t mri system. to evaluate the inherent acoustic noise characteristics of the nicu mri scanner, sound pressure level (spl) measurements were performed on it and on a conventional adult sized whole body 1.5 t hdx ge mri system (ge healthcare, waukesha, wi). a brüel & kjaer model 2250 sound level meter (brüel & kjaer sound & vibration measurement a/s, denmark) was used to perform the spl measurements for 6 several different mr acquisitions (spin echo, gradient echo, fast rf spoiled gradient echo, fully balanced steady state free precession, gradient echo echo planar, and diffusion weighted) using acquisition parameters consistent with clinical protocols. the mr sequences, acquisition parameters, noise measurement equipment and methodology were identical for the two mr systems. the maximum spl in units of a weighted decibels (dba) was recorded for each of the mr acquisition/mr system combinations evaluated. results: the maximum spl values measured during each of the 6 mr acquisitions were lower for all sequences (average 11.33dba (range05-18dba)) for the nicu mri unit as compared to the conventional mri scanner ( table 1 ). the average measured maximum spl value, reported in dba, across all 6 acquisitions was 86.2±2.6 for the nicu scanner, and 97.5±2.9 for the conventional mri scanner. the highest spl values were measured for the diffusion-weighted sequence: 85 and 103dba, for the nicu and conventional mri scanner respectively. conclusions: because of the smaller dimensions of the gradient coils in the nicu mri system, acoustic noise is less than that of conventional mri scanners despite the superior gradient performance of the smaller coils. the lower inherent acoustic noise level of the nicu system provides improved safety for the neonate, and facilitates siting of the unit in the nicu. disclosure: dr. tkach has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. paper #: pa-099 late neurologic events in extremely premature infants carlos guevara, md, radiology, duke university, cjg7@duke.edu; brett bartz, caroline l. hollingsworth, caroline w. carrico, michael c. cotten, charles m. maxfield purpose or case report: germinal matrix hemorrhage (gmh) is a major complication of prematurity. persistence of germinal matrix and immature neurovascular autonomic regulation in the premature neonate is thought to predispose to gmh. most gmh in premature population occurs during the first 4 days of life, and yet the persistence of the germinal matrix to 32 weeks gestation may allow for post-natal gmh outside of the immediate perinatal period. to our knowledge, this is the first systematic review of late gmh (after the first week of life) in a large population of extremely preterm neonates (less than 28 weeks of gestation). this irb approved retrospective review included patients weighing less than 750 g or born at less than 28 weeks of gestation from 2008 through 2010. the study population included 150 infants who had a head ultrasound (hus) within the first week of life and at least one follow hus after the first week of life. all hus were reviewed by three experienced pediatric radiologists for the presence and grade of ich or late developing hemorrhagelike lesions (hll). infants with and without hll were evaluated for several clinical variables, including neurodevelopmental outcomes (bayley scales). results: average gestational age of study population was 25.1 weeks. the incidence of gmh in the first week of life was 34% grade 1, 38.6% grade 2, 4.9% grade 3/ 4, and 2.2% posterior fossa. new echogenic foci (hll) at the caudothalamic groove were seen in 13.3% after the first week of life. 70% of these lesions were bilateral. a four-fold increase in incidence of hll was seen in infants <750 g compared to those> 750 g. higher grade hemorrhages were not seen in this patient population, although 6% of infants had late posterior fossa hemorrhages. the clinical course of infants with hll trended towards a higher incidence of stressors, but this was not statistically significant. the psychomotor development index scores were lower than those infants without hemorrhage. conclusions: small hll at the caudothalamic groove are common in extremely preterm infants after the first week of life. higher grade (2-4) hemorrhages were not seen. there were no cases of intraventricular extension and no direct complications. if isolated, this finding necessitates no follow-up imaging, but may be associated with poor neurodevelopmental outcome. disclosure: dr. guevara has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: tof/apv is a rare congenital heart lesion in which pulmonary arteries may become aneurysmally dilated and compress adjacent airways. pulmonary arterioplasty is often required to relieve tracheobronchial compression in addition to intracardiac repair. the purpose of this study was to review pre and postnatal imaging findings and their impact on patient management and clinical course. methods & materials: a retrospective database search identified 9 infants with tof/apv between 2005-2011 (4 fetal diagnosed cases and 5 diagnosed postnatally). for fdc, prenatal ultrasound (us) and fetal mri were correlated with postnatal ct for the size of the central pulmonary arteries, airway compression, and presence / distribution of air trapping/atelectasis. for all cases postnatal ct findings (between 3-9 days of age) were correlated with clinical management and outcome. results: prenatal diagnosis of tof/apv was suggested sonographically, based on dilated central pas, between 21-28 weeks gestational age (ga). fetal mri, performed between 32-37 weeks ga confirmed the diagnosis and aneurysmal central pas and demonstrated air trapping &/or atelectasis in 3/4 with normal appearing lungs in 1 fetus. size of the pas (4/4) and presence and distribution of lung abnormality (3/4) correlated closely between fetal mri and postnatal ct, although detailed visualization of the central airway/ vascular relationships were better defined on ct. fetal mri identified an unexpected diaphragmatic hernia (dh) not seen on us. for the pnd cases, ct showed aneurysmal pas and airway compression with air trapping &/or atelectasis in 4/5 infants. seven infants with airway obstruction on ct required pulmonary arterioplasty; 1 infant with no air trapping did not have arterioplasty. 7/8 operative patients survived, one with concomitant dh died at age 22 days due to hemorrhagic shock. one fdc was inoperable due to poor cardiac function and died at age 7 days. conclusions: prenatal mri correlates well with postnatal ct for assessing pulmonary artery size and location and severity of lung abnormality in patients with tof/apv, this allows for appropriate management planning and may negate the need for an immediate postnatal ct. ct accurately depicts the location and extent of airway compression and resultant air trapping or atelectasis, serving to guide the need for and extent of the arterioplasty procedure. paper #: pa-101 craniosynostosis syndromes: prenatal findings by us and mri eva rubio, md, cnmc, rubioeva@yahoo.com; anna blask, alexia egloff, dorothy bulas purpose or case report: craniosynostosis with associated malformations is a feature of several related syndromes resulting from a fgfr or twist genetic mutation. syndromes include apert, crouzon, pfeiffer, and carpenter syndromes. our purpose was to review imaging findings which aid in suggesting the diagnosis prenatally. we retrospectively reviewed prenatal us and mri findings in 6 cases with prenatal (5 with postnatal/molecular) diagnosis of a craniosynostosis syndrome: 3 cases of apert, 1 case of carpenter, and 2 cases of pfeiffer syndrome. results: 5/6 cases were correctly diagnosed prenatally. in the second trimester findings may be subtle, with mild calvarial changes; digit abnormalities, in particular, may elude the imager in unsuspected cases. although the diagnosis could be made with either modality, the full spectrum of abnormalities was best appreciated using a combined imaging approach of mri and us. by us many salient features were depicted: turribrachycephaly/trigonocephaly/cloverleaf (6/6); syndactyly (4/4); polydactyly (1/1). agenesis of the corpus callosum was identified by us in (2/2) cases. conversely, mri, performed in all cases, contributed additional observations not well seen by us: the fetal airway was well delineated in all cases (6/6); a low lying spinal cord was noted (1/1), midface hypoplasia (6/6) and migrational/sulcation abnormality (1/1). additional findings of absent ductus venosus with biliary atresia (1/1), abdominal wall defect (1/1) and renal anomalies (1/1) were seen with both modalities. reimaging in later pregnancy depicted important changes (2/2), including worsening hydrocephalus and resolution of suspected airway occlusion. conclusions: us and mri are complementary modalities in evaluating fetuses with craniosynostosis. airway patency, midface hypoplasia, spinal cord abnormalities and intracranial abnormalities are often better seen with mri. fetal activity, digits, bone detail, and cardiac anomalies are better appreciated by us. findings may be subtle in the second trimester. repeat imaging in later pregnancy may reveal specific information affecting delivery planning. paper #: pa-102 pcpra best paper 2011 hyperpolarized carbon-13 mrsi for pediatric disease john mackenzie, md, department of radiology and biomedical imaging, ucsf, john.mackenzie@ucsf.edu; yi-fen yen, linda nguyen, jeffrey gu, john kurhanewicz purpose or case report: to study the potential of carbon-13 mr spectroscopic imaging (13 c-mrsi)-a radiation free molecular imaging strategy-for the detection and treatment monitoring of pediatric disease. methods & materials: the potential of 13 c-mrsi to detect pediatric disease was tested in rodent models of pediatric arthritis. animals were induced with arthritis and subsequently given intravenous hyperpolarized 13 c-pyruvate, and imaged. the amount of 13 c-lactate produced from pyruvate in normal and arthritic joints was measured both at single points in time and dynamically at either 3 or 14 tesla. the 13 c-mrsi data were compared with clinical measures of arthritis, cell stimulation studies, and joint changes on conventional anatomic mri and histology. results: alterations in lactate production as measured by 13 c-mrsi appear to depict sites of arthritis and correlate with other more established but potentially less reliable or more invasive measures of disease status. imaging robust mouse models of pediatric disease may be feasible at 14 telsa. this method may also be translated from high-field to clinical equipment with reasonable hardware and software modifications that allow detection of hyperpolarized 13 c compounds. 13 c-mrsi depicts increased lactate production at specific regions of inflammation within arthritic joints and is confirmed by histological inspection and anatomic mri. on average, lactate production is increased by 60% in areas affected by inflammation. conclusions: the intravenous injection of hyperpolarized carbon-13 compounds and subsequent imaging with 13 c-mrsi provides a unique molecular imaging strategy to noninvasively monitor pediatric disease. this non-invasive imaging strategy may eventually provide clinical utility for several pediatric diseases involving inflammation, infection and tumor. disclosure: dr. mackenzie has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. methods & materials: using the hemangioma-vascular malformation clinic registry at cincinnati children's hospital, we searched for patients diagnosed with khe whose evaluation included mri. twenty such patients were found, although three of the patients had no pre-therapy mris. the imaging studies were reviewed by the authors with assessment of the following characteristics: location, margin definition, soft tissue involvement, and pre and post contrast signal intensity. results: location: lesion location was as follows: trunk (9), extremity (3), extremity plus trunk (3), and head/neck (2). signal: all lesions were dark on t1 weighted sequences with diffuse enhancement after contrast administration. the majority of the lesions were bright on t2 weighted sequences, but there were 3 cases that had heterogenous to low t2 signal (with all involving the retroperitoneum). of the 17 cases, only one had both high arterial and venous flow by mri. margin definition: four of the lesions had well defined borders (greater than 50% well circumscribed) with minimal to no adjacent infiltration/edema. two of those four cases were exophytic masses. the remaining 13 cases were poorly defined lesions with adjacent infiltrative fluid signal intensity and enhancement. tissue/organ involvement: tissue/organ involvement was counted if abnormal fluid-signal intensity or enhancement was identified at that site. review of these cases showed fifteen patients with muscular involvement. dermal and subcutaneous involvement was observed in all but 4 cases, with the uninvolved lesions being isolated and deep. additional sites of suspected involvement included bone (3), pleura (1), penis (1), and pancreas (2). conclusions: khe is a rare neoplasm of infancy with a spectrum of features by mri. poorly defined lesions are much more frequent than well-circumscribed masses. however, pathologic correlation of such infiltrative margins is usually not available as treatments after biopsy are primarily medical rather than surgical. common additional mri features include predominant involvement of muscle, subcutaneous fat, and skin over viscera and bone with lesions generally showing increased t2 signal and enhancement. is dedicated chest ct needed in addition to pet ct for evaluation of pediatric oncology patients? ibrahim tuna, montefiore medical center, dristuna@yahoo. com; jeffrey levsky, jeremy rosenblum, rosanna ricafort, benjamin taragin purpose or case report: to evaluate the diagnostic accuracy of low dose ct performed during pet-ct as compared to dedicated chest ct in the assessment of pulmonary findings in children with malignancy. the institutional review board approved this hipaa compliant research. pediatric oncology patients, ages between 0-21, with known solid malignant tumors who were referred to pet-ct and standard chest ct within 30 days for staging or assessment of treatment response between 01-2008 and 01-2011 were eligible for this retrospective study. radiology reports were reviewed for potential discrepancies. two radiologists re-evaluated the standard chest ct and low dose chest ct portion of the pet ct of the discordant cases, while comparing with the most recent prior studies. studies were scored for pulmonary nodules, bony metastasis, adenopathy, and pleural effusions. true discrepancies were assessed by a panel of pediatric oncologists to judge whether the differences in reports might lead to a significant change in management. results: 120 (57 female, 63 male) patients were identified. 31 radiologic reports of 16 different patients (8 female, 8 male) had potential discrepancies based on review of the reports. the primary tumors were rhabdomyosarcoma (n0 6), hodgkin's lymphoma (n 03) and others (n 07). reevaluation of the original images showed true discrepancies in 3.3% (4/ total 120). in 2 studies, the discrepancy had no clinical significance. in 2 studies, a pulmonary nodule was identified on standard chest ct which was not described on the pet-ct. both of these patients had rhabdomyosarcoma. one of these patients had findings that pediatric oncologists considered significant enough to alter patient management. conclusions: we found a low false negative rate for clinically significant findings on the low dose portion of pet-ct as compared to standard chest ct. in the future, improvements in acquisition technique and post processing of the ct portion of the pet-ct may further improve its diagnostic utility, obviating the need for a routine separate diagnostic ct, thereby minimizing radiation exposure in these young patients. methods & materials: 98 low-dose cta examinations were performed in pediatric patients over a three year period to evaluate suspected vascular traumatic injury with some patients receiving scans of more than one area of the body. areas scanned in this include the head and/or neck (n054), chest (n017), abdomen and/or pelvis (n013), upper extremity (n08) and lower extremity (n017). in 80 of these patients, suspected vascular injury was due to a history of either blunt (n 041) or penetrating (n 039) trauma. 64 patients were referred directly from the emergency department, while 27 were inpatients and the remaining 7 were referred from an outpatient setting. patients (32 f:66 m) ranged in age from 0 to 23 years old (mean age 11). studies were performed on a 64-channel mdct scanner with 80 or 100 kv, 40 to 200mas, 1.0 to 1.5 mm section thickness, reconstructed with 50% overlap, and 0.8 to 1.5 pitch. contrast medium was power-injected using weight-based protocols to optimize iodine delivery. exams were interpreted on a workstation using advanced imaging techniques. patient radiation dose was calculated in all cases. clinical outcome was assessed through a 6 month follow-up when possible. results: all studies were technically adequate. 76.5% (n078) of studies revealed no vascular injury, while 23.5% (n023) revealed acute vascular pathology. vascular injuries included vascular occlusion (n012), vasospasm (n03), narrowing/dissection (n04), pseudoaneurysm (n02), and transection (n0 1). extravascular traumatic findings were demonstrated in 51.0% (n050), including fractures, lung injury, soft tissue hematomas, and a ruptured baker's cyst. of the patients with acute vascular findings, 43.4% (n010) underwent surgical management (including 6 for vascular injury), while 52.1% (n012) were managed conservatively. one patient with active extravasation was managed with angiographically-guided embolization. in no case was catheter angiography required to confirm cta findings. conclusions: low dose cta is a reliable means to screen pediatric patients emergently for acute vascular injury. vascular and non-vascular pathology can be diagnosed noninvasively for efficient patient management. paper #: pa-106 elasticity measurement by acoustic radiation force impulse (arfi) technique of normal liver, kidney and spleen in healthy children mi-jung lee, radiology, severance children's hospital, mjl1213@yumc.yonsei.ac.kr; myung-joon kim purpose or case report: there are many previous studies about using acoustic radiation foce impulse (arfi) value to measure the elasticity of tissue, mainly the liver in adult patients. however, there was limited study about arfi measurement in the children. the purpose of this study is to evaluate the arfi value in the normal liver, kidney and spleen in healthy children and to evaluate the effect of sex, age, and body mass index (bmi). the study prospectively enrolled healthy pediatric volunteers who are under 18 years old, and underwent abdominal ultrasonography and arfi between july 2011 and august 2011. arfi velocity measuring was performed by 4-9 mhz linear probe for children under 5 years old and 1-4 mhz convex probe for older children. arfi velocity was measured three times at each organ. however this measurement was stopped if the child cannot tolerate. results: two hundred two children (m:f092:110; mean age, 8±4.7 years) were enrolled. and arfi measurement was performed only two time for some organs in three children. the mean arfi value was 1.12±0.20 m/s in liver, 2.20±0.49 m/s in right kidney, 2.33±0.53 m/s in left kidney, and 2.25 ± 0.41 m/s in spleen. arfi velocity was not different between boys and girls. however, arfi velocity was different between right and left kidneys (p00.001). the arfi value of right kidney, left kidney and spleen was correlated with age, height, weight and bmi (p<0.001). however, the arfi value of liver was not correlated with these parameters. conclusions: arfi measurement is feasible in children with only three times acquisition for each abdominal organ. the mean arfi velocity was increased according to the age, height, weight and bmi in kidney and spleen, but it was constant in liver. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: diagnostic image quality can be achieved over a wide range of radiation exposure in digital radiography. "exposure factor creep" or "dose creep'" in which technologists tend to increase dose to avoid the appearance of noise has been well described. using the alara principle, acceptable images can be achieved while minimizing dose. at our institution "dose creep" has been observed in bedside pediatric chest radiography. to address this we coupled a data mining tool with a continuous quality improvement (cqi) initiative which educates individual technologists on appropriate technique. methods & materials: radiation dose in digital radiography is estimated from an exposure index, a proprietary format that varies among manufacturers. our institution uses a fuji computed radiography system which calculates an s, or sensitivity value, that provides an approximation of the radiation dose to the imaging plate, using an inverse scale. overexposed bedside chest radiographs were defined by a s value less than 150. a data-mining program was developed to extract from the dicom header the s value and other relevant information, on a monthly basis. these data were used to provide training and feedback on a one-on-one-basis. results: with ad hoc feedback and group training initiatives prior to implementation of this new system, approximately 16.7% (344/2057) of bedside chest radiographs were overexposed over a four month period. after one-on-one intervention with the technologists, preliminary findings reveal a trend towards fewer overexposed radiographs with approximately 9.2% (40/435) with s<150. conclusions: our tool provides a simple method for systematically identifying overexposed radiographs and the corresponding responsible technologists. we anticipate that this personalized educational program will continue to reduce the proportion of overexposed radiographs and thus the radiation dose to our pediatric patients. purpose or case report: ensuring radiation protection for children undergoing ct scans is challenging due to rapidly changing technology, differences in ct equipment and potential lack of understanding of unique aspects of scanning children. the joint commission has named technologists' training as an "action" item. we developed 8 online training modules to fill potential gaps in ct technologists' education. methods & materials: four modules were created by pediatric radiologists, radiologic technologists and medical physicists; 4 were developed by education/training experts from major ct vendors (ge, philips, toshiba, siemens) through the medical imaging technology alliance. 4 modules were created as microsoft word documents containing de-identified images and edited by education specialists at the american society of radiologic technologists and the alliance for radiation safety in pediatric imaging. they were converted to audio/video format using question/answer narration.4 vendor modules were created in microsoft powerpoint format and edited. all 8 modules were converted into adobe captivate learning program to achieve uniformity of appearance. modules are hosted on the asrt server and linked to the image gently website. a certificate may be printed as documentation of completion. results: all 8 modules are available at www.imagegently.org. two introductory modules discuss basics of ct equipment and medical physics related to radiation dose in children. the third and fourth modules discuss dose-saving strategies for neu-roct and body ct. four vendor-produced modules address unique aspects of equipment design such as automatic exposure control and dose saving strategies for children. conclusions: through collaborative efforts with medical imaging professionals and vendors, we have developed 8 free online modules addressing radiation protection for children. ct technologist training in specific dose saving strategies for children is variable and limited. these modules have the potential to improve ct technologists' understanding of equipment. end confusion which focused attention on improving communication with patients and families. there is little research regarding health literacy (hl) in radiology. the purpose of our study was to determine if an educational intervention (brochure) improves hl for parents whose child will undergo a fluoroscopic study. methods & materials: an education exemption was obtained from the irb. a multidisciplinary team developed brochures for 5 fluoroscopic procedures. participants were randomly selected and asked to complete a survey to assess their knowledge of the procedure and use of radiation both before and after reading a brochure. a final survey to rate and gain feedback about the brochure was completed. results: median age of children whose parents participated (n0120) was 4 years. vcug was most commonly performed (46%). prior to the brochure, 92% of participants knew the name of the test their child was having. after the brochure, 99% knew the name (p < .0001). prior to the brochure, 81% felt informed about the test, whereas 99% felt informed after (p<.0001). test scores showed an improvement in parent knowledge about the procedure with a median increase of 20 points after the brochure (scale of 1-70; p<.0001). even after reading the brochure, 23% of parents wanted more information. prior to the brochure, 68% of parents knew the test involved radiation compared to 100% afterwards (p<.0001). parents improved their understanding of the relative amount of radiation compared to background from 25% before to 79% after the brochure (p<.0001). overall, 99% rated the brochure >2 on a 3-point scale with 92% rating the brochure 3 (p<.0001). written feedback was uniformly excellent. conclusions: improving hl for parents is part of the mission of radiology medical professionals. our study demonstrates that there is room for improvement in communicating with parents about fluoroscopy. straightforward information for parents provided as a brochure improves their understanding of radiologic fluoroscopic procedures. paper #: pa-110 compendium of resources for radiation safety in medical imaging anum minhas, duke university, anum.minhas@duke.edu; donald frush purpose or case report: diagnostic imaging, including ionizing radiation modalities, maintains a foremost role in evaluation of medical disorders. there is increasing awareness and need for information across varied sectors about low level radiation and potential risks. many medical/scientific organizations have resources discussing radiation risk and management. however, there is no one resource compiling the same available information. methods & materials: websites, including those of national and international medical organizations (e.g., acr, "image gently" alliance, iaea) were reviewed for information on radiation dose, risk, justification, optimization, guidelines (which included general information about improvement in quality and dose reduction without specific mention of optimization techniques), appropriateness criteria, and general principles of radiation safety for radiography, fluoroscopy/angiography, and ct. this information was divided by modalities and separated into adult and pediatric populations. information from organizations that were not arbitrarily considered to be national (e.g., subspecialty society, regional organization, individual institution/practice) was not reviewed. the resources were then organized into 8 tables, organized by modality. websites with training modules were noted as well. results: 29 websites were explored. overall, less information is available about medical radiation safety in children compared to adults. across both, most information is available on ct, then fluoroscopy, and finally radiography. across all groups and modalities, there is no information available for patients/parents on optimization, appropriateness, or guidelines, with the exception of adult radiography where there were some guidelines. conclusions: this compendium on medical imaging radiation serves as a collective resource for communities including the public and regulatory organizations. additionally, the compendium can be used to determine redundant or deficient areas, providing opportunities for more comprehensive and efficient efforts in medical radiation protection for patients. inappropriate and cloned histories in children: how big a problem is it? leann linam, md, radiology, uams/ach, llinam@uams. edu; chetan c. shah, s bruce greenberg purpose or case report: acr standards require appropriate clinical history for obtaining imaging examinations. cloning clinical histories is a federal violation. our purpose is to determine the frequency of inappropriate histories (ih) and/or cloning histories (ch) at a tertiary children's hospital. methods & materials: three pediatric moc radiologists reviewed clinical histories for radiographs obtained at a tertiary children's hospital on 3 randomly selected dates (2 weekdays and 1weekend day) for appropriateness and cloning. appropriate histories have associated icd-9 codes. cloning is defined by identical clinical histories occurring on 3 consecutive days and could be clinically appropriate or inappropriate. only the first patient radiograph on a day was included. χ2 testing was performed to determine significant differences. results: 14% (54/388) of exams had ih. ih were significantly more common in inpatients than outpatients (p< 0.0001). nicu examinations accounted for 52% of all ih and were significantly more frequent than other inpatient locations (p0.006). the cvicu examinations accounted for 11% of all ih and was the second most common patient location for ih, but not significantly different from other inpatient locations (p00.09). the increased frequency in ih on the weekend reflects a change in patient mix with fewer outpatient examinations performed than on weekdays and was not significant (p00.07). the most common ih included: evaluate ett or evaluate lungs (15 each). cloning only occurs in inpatients and was combined with ih in 48% of patients with ch. the nicu accounted 63% of ch which was significantly greater than other inpatient locations (p00.026). conclusions: 1 in 7 radiographs had ih which can lead to misdiagnoses or nonpayment by insurance companies. inpatients, especially the nicu were the most common patient locations. cloning was also a common problem and was frequently combined with ih. identifying the extent of ih allows for corrective educational measures to be instituted which should improve compliance with existing medical and legal standards for ordering radiographs. paper #: in vivo validation of size-specific dose estimates (ssde) through breast entrance skin dosimetry (esd) during pediatric chest ct angiography sjirk westra, md, radiology, massachusetts general hospital, swestra@partners.org; xinhua li, mannudeep kalra, bob liu, suhny abbara purpose or case report: ssde is a new ct dose measure that corrects scanner console ct dose index (ctdi) for cross-sectional body diameter, being a better estimate of absorbed dose in individual patients of varying body size. ssde has been developed through phantom studies and computer simulations of ct dose, but has not yet been validated in vivo. the purpose of our study was to determine correlation between ssde and measured breast entrance skin dose (esd) for pediatric chest cta across a variety of scanning techniques, scanner models and patient sizes. methods & materials: our study was irb-approved, with waiver of written informed consent. during 42 consecutive chest cta exams done on 4 different scanners over a period of 7 years, we measured mid-sternal esd as an approximation of breast dose with skin dosimeters, which was also expressed as mammogram equivalents. for each scan, we recorded patient age, weight, effective ma, kvp, console ctdivol-32 cm and dlp-32 cm (from which we calculated age-adjusted effective dose (ed)). we measured effective chest diameter ø to convert ctdi to ssde, and we correlated ssde with measured breast esd, using linear regression. we evaluated image quality with regard to answering the clinical question. (table) , due to systematic introduction of automatic exposure control, low kv and high pitch scanning techniques. all studies were of diagnostic image quality to address the clinical question. conclusions: ssde is a valid measure of ct dose in pediatric patients undergoing chest cta over a wide range of scanner platforms, techniques, and patient sizes, and may be used to model breast and other organ dose, and to document results of dose reduction strategies over time. purpose or case report: the purpose of this project was to create an automated system capable of quantifying slice-byslice ct image quality and radiation dose data based on patient size. the information generated from this system should enable size-specific optimization of ct scan parameters in order to obtain images of diagnostic quality at the lowest possible radiation doses. methods & materials: a mathematical model was developed to predict ct image noise based on kvp, effective mas, and water-equivalent diameter of the patient. a conical water phantom was used to calibrate the model on multiple scanners and accounting for different operational modes and scan parameters, including tube voltage (kvp), tube current (effective mas), bowtie filter, and focal spot size. a software application was created to process image data from the scout topogram and incorporate dicom metadata from the axial images. a database and data viewing application were developed to display individual and aggregate study data. all of these systems were integrated and automated to enable real-time monitoring of image quality and radiation dose as a function of patient size. results: since the completion of the automated system, 565 ct exams have been processed. a search application allows the user to find an individual study or a collection of studies based on parameters such as body part imaged or study protocol. the viewing application displays slice-by-slice patient diameter, radiation dose, and image quality for each study. radiation dose estimates are adjusted for patient size, yielding size-specific dose estimates. the application also graphs individual study data compared to those of comparative studies that are included in the search. conclusions: we have successfully developed an automated system that monitors ct image quality and radiation dose data based on patient size. the system enables simultaneous real-time monitoring of all studies performed on all ct scanners at our institution. specifically, the system enables size-specific radiation dose estimates at every scan level. this system will be used to guide protocol adjustments in order to optimize ct image quality and thus optimize radiation dose. disclosure: dr. larson has disclosed that he has a patent application in process through cchmc for ct radiation dose reduction. purpose or case report: at many institutions, ct scan parameters for children are determined by patient age or weight. aapm task group 204 recommends cross sectional body dimension, such as patient width to determine size specific dose estimates. the purpose of our study was to develop prediction models of body width based on patient age and weight and compare these models with actual measured body widths for children undergoing body ct. methods & materials: 6 children's hospitals participated in a 3-month retrospective review of abdominal ct scans on patients <18 years of age after local irb approval. recorded values included patient width(cm) from an axial image at the level of the splenic vein, patient age (yrs) and patient weight (lbs). a regression model for predicting patient width as a function of age and weight was determined. results: 939 exams, 472 had all 3 measurements. both age and weight were significant predictors of patient width (p<.0001). there was also a significant interaction between weight and age (p<.0001), indicating that the relationship between patient width and weight depended on the age of the patient. the r2 for the regression model for predicting patient width from age and weight individually were 0.65 and 0.83 respectively. the r2 for the model including both age and weight and their interaction was 0.86 leaving 14% of the variation unexplained. the regression equation for this model is: patient width 014.1 + 0.34 x age(yrs)+ 0.12 x weight(lbs)-0.003 x age x weight. despite the r2 of 0.86 for the model using both age and weight, the average error (rmse) for predicting patient width compared to a direct measurement of width was 1.9 cm. the plot of observed minus predicted values (residuals) versus predicted values indicates that the best model (combination of weight and age) results in measurable errors of predicted patient width relative to direct measurement. conclusions: a combination of both patient age and weight results in a more accurate patient width prediction than using age or weight alone. while age and weight can be used to predict body width, this is not sufficiently accurate for generating ct protocols. therefore, direct measurement of body width form either physical measurement on the patient or from the scout view or an axial image is preferred to select appropriate scan parameters for pediatric abdominal ct. paper #: pa-115 automated size-adjusted dose monitoring for pediatric ct dosimetry olav christianson, clinical imaging physics group, olav. christianson@duke.edu; ehsan samei, donald frush purpose or case report: the potential health risks associated with low levels of ionizing radiation have created a movement in the radiology community to minimize radiation dose during ct imaging; this is especially important for pediatric patients due to their increased sensitivity to radiation. it is thus essential to accurately assess the risks to pediatric patients undergoing ct imaging. current efforts to monitor radiation dose, however, are limited because they do not account for differences in risk from ionizing radiation due to variability in patient size, age, and gender. in this context, we developed an automated size-adjusted dose monitoring program capable of performing patient-specific risk estimation to facilitate protocol optimization. methods & materials: dicom routing software was used to send dose reports and scout images to an image repository on a dosimetry server. optical character recognition was used to extract dose-relevant data from dose reports; patient size was determined from corresponding scout images. based on anatomical location, risk estimation conversion coefficients (qfactors) were determined for each series in the dose reports. the q-factors were adjusted according to patient size, age, and gender and then multiplied by the dlp to estimate the risk to each patient. this process was applied to the cohort of pediatric patients undergoing ct examination at our institution. to evaluate the impact of including patient size, age, and gender, risk estimates were obtained excluding and including the dependencies on size, age, and gender. the results were computed in units of cancer incidence per 1000 cases exposed (cpt). results: the average patient-generic risk estimate for a pilot group of patients undergoing body ct was 0.15±0.14 cpt. by including patient size, the risk estimate was increased to 0.26 cpt±0.27 cpt. by including patient age and gender, the average risk estimate was further increased to 1.0 cpt±0.72 cpt. conclusions: we developed a new size-adjusted dose monitoring program for pediatric ct dosimetry. comparisons between patient-generic and our new patient-specific risk estimates show that failure to consider patient size, age, and gender resulted in risk estimates that were too low by a factor of seven. additionally, the increase in standard deviation we observed demonstrates that our method of including patient size, age, and gender is sensitive to the inherent variability in the patient population. disclosure: dr. christianson has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: treatment of prenatally diagnosed lung masses is controversial, with many specialists recommending elective surgical removal in the first year of life because of a reported or perceived increased risk of infection and malignancy, while other centers recommend a conservative approach to management. the natural history of unresected lung masses is not clear. in our center, our standard recommendation is prophylactic resection of asymptomatic lesions, although not all families choose this option. we asked whether respiratory morbidity increased during the time prior to elective resection of prenatally diagnosed lung masses. methods & materials: ninety-eight pregnant women carrying fetuses with chest masses were imaged by ultrasound (us) and magnetic resonance imaging (mri). medical records of the liveborn infants were retrospectively reviewed. results: fetal diagnosis of a lung mass was made at a mean of 27 weeks gestation (range 17-32 wks). intrauterine fetal demise was documented in 4 pregnancies. there was one elective termination of pregnancy. three infants were lost to follow up. thus, outcomes were available for 90 children (59% m, 41% f) with prenatally diagnosed lung masses. significant respiratory morbidity (rm) was defined as the occurrence of pneumonia, asthma, chronic coughing or wheezing, or respiratory symptoms severe enough to require an emergency room visit or hospitalization. of the 76 children who had surgical removal of their lung mass, 34 (45%) had rm prior to surgery. fifteen out of 90 children did not have surgery but have been followed expectantly, and 3 of 14 (21%) developed some form of rm. fifteen of 76 (20%) infants had immediate and significant rm (tachypnea, grunting, increased work of breathing, increased oxygen requirements or need for intubation) in the newborn period leading to urgent surgery (range of age at surgery: 1-10 d; mean 2.5 d). of the 61 initially asymptomatic infants, 17 (28%) developed rm prior to elective removal of the mass (range 6-96 weeks, mean 17 weeks). of the lesions removed, histology revealed: cystic adenomatoid malformation (ccam) 59%, ccam + sequestration 21%, sequestration 8%, congenital lobar emphysema (cle) 7%, ccam+cle 1%, other 3%. conclusions: the risk of respiratory morbidity appears to be increased during the time prior to elective resection of prenatally diagnosed lung masses, which may be important for parents and pediatric specialists to consider when deciding whether to remove an initially asymptomatic lung mass. purpose or case report: it is now accepted that fetal mri with its superior tissue resolution can be very helpful in clarifying anomalies detected during obstetrical ultrasound. this is particularly the case with intracranial abnormalities, although indications are expanding. the current english medical literature, though, appears to be focused on evolving mri techniques and how mri compares to ultrasound with regards to image quality and detection of additional findings which may alter the diagnosis. however, we found no study specifically evaluating the clinical relevance and impact of the information obtained by fetal mri to the specialists who counsel and treat these patients. a "satisfaction and clinical impact" survey was created and sent to all the members of our fetal diagnosis and treatment group, asking specifically how the clinicians rated their satisfaction with this type of imaging, its influence on their counseling and on various clinical decisions, both prenatal and postnatal. results: we received responses from 37 specialists in 10 different clinical disciplines. the greatest number of respondents came from our obstetricians (28%), many of whom perform their own ultrasounds, and from members of our medical geneticists/genetic counselors (27%), although 46% of respondents were from various other clinical disciplines, both medical and surgical. there was a surprisingly high degree of satisfaction overall with the quality of the images and with the type and amount of information provided. most respondents indicated they felt fetal mri was "moderately" or "extremely" useful for their particular clinical decisions, and most respondents agreed that fetal mri impacted "moderately" or "significantly" on counseling and management of these pregnancies. impact appeared greatest on the counseling of the parents and their decision to terminate/pursue the pregnancy, and the least impact was on issues around delivery. conclusions: fetal mri, in addition to providing images of better quality, particularly in certain conditions, has clinical value in that it directly impacts on the counseling of parents and on clinical decisions. 2006-2011. ultrasound reports were reviewed to determine sonographic diagnoses. selected patients from this cohort underwent mri using ge 1.5 tesla magnet without contrast (sequences included ssfse, fiesta, fgre or dual echo in 3 planes). the images were reviewed and multiple characteristics were assessed for specifiying the area of obstruction. the features included: presence of normal fluid-filled bowel, small rectum for gestational age, signal of meconium in the rectum, and meconium filled dilated bowel. results: 46 cases of sonographically suspected bowel obstruction were identified during the study period; 27 of these underwent fetal mri. of these 27 cases, 4 had normal mri and postnatal outcomes, 2 cases did not have postnatal findings available, and 2 had postnatal meconium peritonitis but no obstruction. one case of congenital chloride diarrhea was diagnosed by fetal mri. a variety of bowel abnormalities were observed amongst the remaining 18 cases. proximal obstruction was diagnosed in 8 cases: jejunal atresia (n07) and multiple atresia (n01). distal obstruction was diagnosed in 10 cases: ileal atresia (n03), meconium plugging (n04), closed gastroschisis (n01), enteral duplication cyst (n01), and imperforate anus (n01). characteristic patterns of features were identified amongst these 18 cases that specified the location of obstruction. these patterns of findings allowed accurate localization of the level of obstruction in all cases when compared to postnatal findings. distal obstruction was characterized by normal fluid-filled small bowel and high t1 signal in distended loops. jejunal atresia was characterized by multiple loops of dilated bowel with high t2 signal primarily in the left upper quadrant. small rectum for gestational age was not consistently associated with proximal or distal atresia. conclusions: evaluation of fetal mri with attention to specific features allows localization of bowel obstruction. this may aid in counseling and postnatal management, including the need and type of postnatal imaging study. early diagnosis and treatment of ph may prevent clinical deterioration. pvt may produce a spectrum of imaging appearances, which has not been fully recorded in the literature. the goal of this paper is to review the spectrum of imaging appearances of neonates and survivors of neonatal pvt with special emphasis on the role of us and to correlate these findings with the clinical findings including outcome. methods & materials: a retrospective review of 133 consecutive neonates admitted between 1999-2003 and diagnosed with pvt was conducted. diagnosis was established by us at a mean age of 9 days (range: 1-40). health records, initial and follow-up (f/u) imaging were reviewed. findings were classified as non occlusive, single branch, pvt (grade 1); occlusive pvt (grade 2) and pvt with extensive parenchymal ischemia (grade 3). results: pvt was diagnosed in 133 patients, 70 of whom were followed up to for 2 years or longer. twelve patients were excluded due to liver disease, 22 expired and 29 were lost to f/u. of the 70 in whom f/u was available, at the time of initial diagnosis, grade 1 pvt was present in 27, all were on the left. grade 2 pvt was diagnosed in 28 and grade 3 pvt in 15. on f/u physical exam, findings were unremarkable in 68/70 patients. liver function tests (lft) and thrombophilia assessment were available in 25 children, mild lft abnormalities were noted in 9 and 6 children had evidence of thrombophilia. us exams were available in 37/70 children. among the 37 survivors of neonatal pvt, us was regarded as normal in only 14 children; 16 showed left lobar atrophy (lla), 5 had slowly progressive splenomegaly without other signs of ph, and 2 developed clinically significant ph requiring shunting. conclusions: pvt has a wide spectrum of imaging appearances, it is possibly underdiagnosed and clinically unsuspected. varying degrees of lla are likely a sequela of clinically silent left pvt. us is a sensitive method for the detection of disease and assessment of progression. paper #: pa-120 fetal mri in arthrogryposis hedieh eslamy, md, radiology, lucile packard children's hospital, hkeslamy@gmail.com; erika rubesova, louanne hudgins, britton rink, richard a. barth purpose or case report: to present the fetal mri findings in fetuses with a prenatal diagnosis of arthrogryposis and correlate with postnatal outcome or autopsy results. arthrogryposis refers to contractures involving more than one joint which often represent deformational changes secondary to decreased or absent fetal movement. prognosis varies widely dependent on diagnosis, ranging from isolated contractures in amyoplasia to lethality in some cases. we hypothesized that fetal mri may demonstrate central nervous system (cns) pathology and muscle abnormalities which are important for predicting postnatal outcome. methods & materials: we identified 6 fetuses with a diagnosis of arthrogryposis between january 2010 and october 2011. all had fetal mri which was performed on a ge 1.5 tesla magnet, with ssfse, fiesta and fgre sequences in 3 planes. the fetal mri's were evaluated for cns and muscle abnormalities. the extremities were evaluated for: muscle mass, increase in subcutaneous fat (indicative of muscle atrophy), and extremity joint positioning. these findings were subsequently correlated with the clinical exam of the neonates, pathology in the abortus and karyotype when available. results: results of fetal us, amniocentesis, fetal mri and post-natal or post-termination outcomes will be summarized. five fetuses had ≥2 limb joint contractures. a sixth case had neck hyperextension and lateral flexion associated with akinesia and hydrops. on mri, no structural brain or spine abnormalities were identified. the abnormalities detected in the extremities were: severe decrease in muscle mass associated with increased subcutaneous fat (3 cases); normal muscle mass (2 cases); moderate decreased muscle mass associated with increased subcutaneous fat (1 case). in the 3 cases that delivered, the diagnoses were amyoplasia (2) and distal arthrogryposis (1). in a fourth case that underwent elective termination, autopsy was consistent with amyoplasia. two cases are pending delivery. conclusions: while fetal mri can be useful to rule out cns anomalies, it may also provide important information on decreased muscle mass as an important prognostic sign in a fetus with arthrogryposis. in our series, severely decreased muscle mass was predictive of amyoplasia, and joint contractures limited to hands and feet with preserved proximal muscle mass was predictive of distal arthrogryposis. both diagnoses are associated with relatively good prognosis and usually normal intelligence. purpose or case report: the purpose of this study is to assess the effects of iterative reconstruction technique (irt) on image quality metrics measured in child-sized anthropomorphic phantoms as kvp is changed. methods & materials: ct scans were performed on anthropomorphic phantoms with sizes of 1, 5 & 10 years (atom phantoms, cirs, norfolk virginia) using low dose pediatric chest protocols (1.6, 3 & 6 msv) to determine baseline noise and dose levels. subsequently three voltage levels (120, 100 & 80 kvp) were used while adjusting mas to maintain baseline ctdivol and without mas adjustment which allowed varied ctdivol. images were reconstructed using 100% filtered back projection (fbp) and blends fbp: ir (80:20, 60:40, & 40:60) . parameters including ctdivol, dose length product, scan length, kvp, and mas, were recorded for each scan. image noise, contrast:noise (cnr), and signal:noise (snr) data were recorded from rois in phantoms and dilute iodine contrast filled syringes (5, 3, 1.5%). results: as kv is lowered from 120 to 80, image noise is doubled if mas is not increased to maintain ctdivol, and cnr is increased but snr is decreased due to the increased image noise. as kvp is lowered from 120 to 80, image noise is increased nominally (8-21%) if mas is increased to maintain ctdivol; therefore the increase in cnr and decrease in snr is negligible. ctdivol is reduced >300% in all phantom scans as kv is reduced from 120 to 80. irt reduces image noise by up to 36% [range 10-41%] in all phantom sizes and in clinical images. as ctdivol is maintained in patient scans, image noise, cnr, and snr are reduced in patients (p<0.05), resulting in improved image quality. conclusions: when lowering kvp, compensation with increases in mas is necessary to maintain ctdivol. however, lower target ctdivol can be achieved when adding irt as image noise can be decreased. for these phantoms, cnr and snr improved using all [selected] levels of ir, even when kv was reduced, resulting in lower ctdivol in phantoms. at all kvp settings when irt is applied, image noise is reduced, resulting in improved cnr and snr for all phantoms. disclosure: dr. bardo has indicated she is in the speaker's bureau and receives an honorarium from koninklijke philips. paper #: pa-122 adaptive iterative dose reduction in evaluation of the pediatric abdomen with ultra-helical 320-channel mdct jeffrey hellinger, md, stony brook university, jeffrey. hellinger@yahoo.com; bernice hoppel, richard mather, monica epelman purpose or case report: radiation reduction is paramount for pediatric patients. ultra-helical 320-channel mdct allows for rapid acquisitions at low dose. we evaluated the ability of a new adaptive iterative dose reduction algorithm (aidr) to reduce noise in low-dose ultra-helical pediatric abdominal ct scans. aidr is an iterative algorithm that adaptively reduces noise in the raw and image domains while preserving image structure. the raw data from 14 consecutive low-dose pediatric abdomen exams was gathered. a dose simulation tool which adds noise to raw projection data was employed to simulate tube current at 1/4 of baseline ma. data were reconstructed with both standard filtered back projection and with aidr. regions of interest were drawn in the liver and lumbar musculature to determine the signalto-noise (snr), contrast-to-noise (cnr) and overall diagnostic quality of each data set. statistical significance was determined using a student's t-test. subjective image quality was evaluated by two reader blind review using a five point scale (50excellent, 10unacceptable). results: the snr and cnr were significantly lower for the 75% dose reduction datasets compared to the original filtered back projection reconstructions (snr: 3.59 vs 2.20, p<0.001; cnr: 1.24 vs 0.75, p00.01). when aidr was applied to the 75% dose reduction data, the snr and cnr improved to be superior to the native case (snr: 3.59 vs 5.48, p<0.001; cnr: 1.24 vs 1.95, p00.02). the average image quality score for the low dose datasets with aidr was 4.2 compared to 3.4 with standard filtered back projection at the baseline ma conclusions: aidr significantly improves the image quality of pediatric abdominal ct images. with a simulated 75% reduction in dose, aidr produces images with significantly greater snr and cnr. the subjective image quality scores for aidr showed dramatic improvement over standard filtered back projection. aidr processing algorithms with ultra-helical 320 mdct will allow 75% reduction in radiation exposure while achieving the same diagnostic quality as compared to routine pediatric abdomen mdct radiation protocols with filtered back projection processing algorithms. purpose or case report: to explore incorporating asir into pediatric head ct protocols, to reduce patient radiation dose while maintaining image quality. methods & materials: an alderson rando head phantom was estimated to approximate the size of a 7-year-old child's head, and was scanned at decreasing 10% ma intervals (100 to 50%, 150 to 75 ma) relative to this institution's age-based head ct protocols. each of these studies was then was reconstructed at 10% asir intervals (0% to 100%), and a 100 mm2 roi was obtained in a consistent location behind the frontal bone to estimate noise (sd). using this phantom data, our ventriculoperitoneal (vp) shunt follow-up ct protocol was modified, and patients were scanned at 20% asir with approximately 20% ma reductions relative to our normal age-based mas. these asir studies were then anonymously compared to older non-asir head ct studies from the same patients (with identical kvp/slice thickness) by two blinded attending pediatric neuroradiologists. all studies were evaluated subjectively for diagnostic utility (1-4), sharpness (1-5), noise (1-4), and artifacts (1-4). 50-100 mm2 rois were drawn in consistent locations to estimate noise in air, bone, csf, and white matter (wm). results: the phantom study suggested similar same noise levels at 100% ma/0% asir (3.9) and 80% ma/20% asir (3.7). 12 patients (average09, range01 to 17 years) were then scanned at approximately 20% ma reductions, with an average of 349 days (range027 to 871 days) between the asir study and prior non-asir study. the average ctdivol and dlp values of the 20% asir studies were 22.4 mgy and 338.4 mgy-cm, and for the non-asir studies were 28.8 mgy and 444.5 mgy-cm, representing statistically significant decreases in the ctdivol (22.1%, p00.00007) and dlp (23.9%, p00.0005) values. there were no significant differences between the asir studies and non-asir studies in respect to diagnostic acceptability (p00.33), sharpness (p0 0.45), or noise (p00.84). there was a non-significant trend that the asir studies had a lower artifact score (1.8 vs 2.1, p0 0.06). there was good to perfect (kappa00.5 to 1.0) agreement. the asir studies had statistically significant decreased csf noise (3.0 vs 4.4, p00.0000008), but no noise differences were seen in air (p00.46), bone (p00.26), or wm (p00.22). conclusions: our findings suggest that asir can provide dose reductions in pediatric head ct without affecting image quality. purpose or case report: to validate the t2 map as a noninvasive quantitative biomarker of fatty infiltration of muscles and to determine whether the t2 map can differentiate between boys with dmd and healthy boys. methods & materials: two groups of boys with similar ages (range 5-15 years) were evaluated: 42 boys with dmd (mean age 10.4 years) and 29 healthy boys (mean age 11.7 years). mr images were performed at 3 t. fatty infiltration of the pelvic and thigh muscles on t1-weighted images (wi) was graded from 0 to 4. on t2 maps with and without fat suppression, the muscle with the greatest fatty infiltration on t1-wi was selected, and a region of interest was placed to obtain t2 values. t2 values from t2 maps with fat suppression were subtracted from values of t2 maps without fat suppression and designated as the "t2 fat value." t2 fat values were obtained from the same muscles in all boys. comparison was made between the t2 fat values of the two groups. the upper reference limit of the reference interval (ri) of t2 fat values was obtained from the control group to establish the normal range and applied to both groups to determine the accuracy of the t2 map. results: the gluteus maximus muscle had the greatest fatty infiltration on t1-wi. median t2 fat value was 73.0 msec for dmd (95% ri 193.8, range 29.2-175.6) and 7.5 msec for the control group (95% ri 19.2, range 1.4-21.6). when applied to the two groups, the upper reference limit of the ri for control patients yielded 100% sensitivity, 93% specificity, 95% positive predictive value, and 100% negative predictive value. conclusions: utilization of t2 maps for the quantitative measurement of fatty infiltration of muscles can clearly differentiate between dmd and normal control boys with a high degree of accuracy and precision. this advanced noninvasive technique may potentially replace invasive muscle biopsies currently used for diagnosis. purpose or case report: prior work has shown that the gluteus maximus muscle has the greatest t2 relaxation time on mr imaging using t2 mapping in boys with duchenne muscular dystrophy (dmd). however, an increased t2 value on t2 relaxation time mapping may reflect both fatty infiltration and inflammation of the muscle. fatty infiltration characteristically follows inflammation in this disease process. therefore, the purpose of this study was to determine the contribution of each component (fat and inflammation) within gluteus maximus muscles and to correlate each component to clinical assessments. methods & materials: forty-six boys with dmd (ages: 5-15 years) were recruited. mr imaging of the pelvis using t2 maps with and without fat suppression were performed. the t2 map "fat values" (t2 value calculated from the t2 map without fat suppression [fs] minus t2 map with fs) and the t2 map "inflammation value" (t2 value from the t2 map with fs) were obtained. clinical assessments typically used to evaluate dmd patients (including clinical functional score, 30 ft run, gower score, and 4 step-up time) were also performed. spearman correlation coefficients between fat and inflammation values and the clinical assessments were calculated. results: there was a statistically significant correlation between the fat value of the gluteus maximus muscle and each clinical assessment test (p<0.05). however, the inflammation value of the gluteus maximus muscle did not correlate with any clinical assessment. conclusions: in dmd, the amount of fatty infiltration of the gluteus maximus muscle has excellent correlation with clinical assessment. the amount of inflammation of the gluteus maximus muscle, however, does not correlate with clinical function. therefore, further study is needed to determine whether components (fatty infiltration or muscle inflammation) of the single most involved muscle reflect the components of all the muscles of the pelvis and thighs and whether the cumulative muscle involvement of each component represents clinical disease severity. utility of contrast-enhanced mr imaging in children with osteonecrosis: does gadolinium help? lamya atweh, md, radiology, texas children's hospital, laatweh@texaschildrens.org; robert c. orth, wei zhang, r. paul guillerman, herman kan purpose or case report: at our institution, gadolinium contrast-enhanced mr sequences are often obtained to assess epiphyseal and non-epiphyseal osteonecrosis in children. several studies have shown that dynamic contrast-enhanced sequences may provide prognostic information about long-term complications and healing of osteonecrosis. to our knowledge, no studies have determined the added value of routine post-contrast mr imaging in assessing acute complications related to chronic osteonecrosis. the purpose of this study was to evaluate the utility of intravenous gadolinium contrast in the mri identification of complications in children with an established diagnosis of osteonecrosis. methods & materials: 64 patients were restrospectively identified (age range: 1.75 years to 25.75 year; m:f 0 59:80) with an imaging diagnosis of chronic osteonecrosis who underwent 139 contrast-enhanced mr studies between 1/2000 and 9/2011. the pre-and post-contrast mr images were consensus reviewed by two caq pediatric radiologists. pre-and post-contrast images were reviewed at separate times. the pre-contrast images were available during the review of post contrast images. studies were assessed for: osteonecrosis location (epiphyseal, non-epiphyseal osteonecrosis, or both), joint effusion, marrow edema, and epiphyseal collapse. 95% confidence interval (ci) and cohen's kappa coefficient(κ) was calculated to assess observed agreement. results: the diagnosis of osteonecrosis without complicating features was made in 49.6% (ci: 41.3-58.0%) (69/139) of pre-contrast studies and 53.2% (ci: 45.0%-61.5%) (74/ 139) of post-contrast studies. when chronic osteonecrosis with complicating features was identified,pre-and postcontrast images idenfied joint effusion in 44.9% (57/127) and 51.2% (65/127) (κ00.686, p<0.001); marrow edema in 50.4% (70/139) and 46.8% (65/139) (κ00.727, p<0.001); and epiphyseal collapse in 51.2% (65/127) and 42.5% (54/ 127) (κ00.796, p<0.001), respectively. myositis or muscle strain was incidentally diagnosed in 12.2% (17/139) pre-contrast and 10.1% (14/139) post-contrast (κ 0 0.674, p <0.001) studies. conclusions: the high observed agreement between the pre-and post-contrast mr images shows that the addition of intravenous gadolinium may not be necessary in the majority of children with chronic osteonecrosis. paper #: pa-127 systematic protocol for assessment of the validity of bold mri in a rabbit model of inflammatory arthritis at 1.5 tesla michael chan, bhsc, university of toronto, mw.chan@ utoronto.ca; afsaneh amirabadi, anguo zhong, antonella kis, rahim moineddin, andrea s. doria purpose or case report: blood oxygen level-dependent (bold) mri has the potential to identify regions of early hypoxic and vascular joint changes in inflammatory arthritis. at this point, there is no standard protocol for data analysis of bold mri measurements in musculoskeletal disorders. standardization of the technique is paramount to compare results between studies and assess the validity of this technique in tissues outside the blood-brain barrier. our objective is to optimize bold mri reading parameters in a rabbit model of inflammatory arthritis by determining the diagnostic accuracy of (1) statistical threshold values (r>0.01 vs r>0.2), (2) summary measures of bold mri contrast [ the mean of the % bold signal differences within the region of interest (roi) (diff_on_off) and the percentage of suprathreshold voxels within the roi (pt%)], and (3) voxel activation algorithm (positive, negative, and positive_negative). methods & materials: using bold mri protocols with a carbogen stimulus on a 1.5 t magnet, we imaged injected and contralateral knee joints of 21 juvenile rabbits at baseline, and days 1, 14 and 28 after a unilateral intra-articular injection of carrageenin. nine non-injected rabbits served as controls. receiver operating characteristic (roc) curves were plotted to determine the diagnostic accuracy of the reading parameters. the bold measures from [(injected knee-control knees)/control knees] were counted as positive cases, while the bold measures from [(contralateral knees-control knees)/control knees] were regarded as negative cases. areas under the curve (aucs) were calculated to determine the most accurate parameters. results: using diff_on_off and positive_negative activations as constants, r>0.01 was found to be more accurate than r>0.2 (p00.03 at day 28). comparison of diff_on_off and pt% yielded no statistically significant difference (p> 0.05). finally, positive_negative activations for diff_on_off and negative activations for pt% using r>0.01 were the most diagnostically accurate (auc00.78, p<0.01 at day 28, and auc00.90, p<0.01). conclusions: from the results of this study, the most diagnostically accurate and clinically relevant reading parameters included the use of a more lenient threshold of r>0.01, a diff_on_off measure of bold contrast, and a positive_negative voxel activation algorithm. pt% may used as an ancillary measure of bold contrast. quantitative versus semi-quantitative mr imaging of cartilage in blood-induced arthritic ankles andrea doria, md, phd, diagnostic imaging, the hospital for sick children, andrea.doria@sickkids.ca; ningning zhang, carina man, pamela hilliard, ann marie stain, victor blanchette purpose or case report: to cross-sectionally compare the ability of a scoring system (semi-quantitative method) with a manual segmentation technique (quantitative method) to evaluate the status of the articular cartilage of growing ankles of children with blood-induced arthritis. methods & materials: 12 boys, 11 with hemophilia (a, n09; b, n02) and 1 with von willebrand disease, median age 13 (range, 6-17) underwent a high resolution mri protocol at 1.5 tesla, x-rays, and physical examination using the hemophilia joint health score (hjhs) system. two blinded radiologists scored the mri examinations for cartilage items (horizontal component: surface erosions, scores 0-2 and vertical component: cartilage degradation, scores 0-4) according to the semiquantitative method (international prophylaxis study group mri scale). an experienced operator applied a validated quantitative 3d-mri method (horizontal components: ac, vc, vctab, thctab; vertical component: thccab) to corresponding high resolution mr images of ankles. results: internal correlation of the semi-quantitative method components was substantial (r00.72, p<0.0001, tibia) to high (r00.91, p<0.0001, talus) in any site of investigation, but it was site-specific with the quantitative method, being significant only in the talar trochlea (r00.86, p<0.0001). external correlation of corresponding components of the semiquantitative and quantitative methods was moderate (r00.55, p00.005) to poor (r00.39, p00.05) for horizontal components, and non-existent for vertical components. components of the semi-quantitative method highly correlated with lifetime number of previous ankle bleeds (r00.74-0.84, p<0.0001), pettersson x-ray (r00.87-0.94, p<0.0001), and hjhs scores (r00.91, p<0.0001). this correlation was poor (r00.42, p0 0.04) to moderate (r0−0.56, p00.004) for horizontal components of the quantitative method. conclusions: the biologic concepts of the semi-quantitative and quantitative mri methods are distinct for assessment of ankles. the semi-quantitative method is valid for assessing cartilage changes in cross-sectional studies of blood-induced arthropathy, however the quantitative method is suboptimal or less powerful for this purpose. paper #: pa-129 shoulder mr arthrography in skeletally immature patients nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email. chop.edu; camilo jaimes, victor ho-fung, diego jaramillo purpose or case report: there has been a well documented increase in sports participation in children which has lead to an increase in sports-related injuries. to date, there are no studies describing the value of shoulder mr arthrography compared with the gold standard, arthroscopy. we retrospectively reviewed 80 mr shoulder arthrograms obtained in pediatric patients between 2004 and 2010 who underwent subsequent shoulder arthroscopy. interpretation of the images was performed by three pediatric radiologists who were blinded to the arthroscopy findings. images were evaluated in consensus and independently. assessment included evaluation of the osseous structures, labral-ligamentous complex, joint space and the rotator cuff interval. the mr results were compared with reported surgical findings. sensitivity and specificity were calculated. results: nine patients were excluded due to technical reasons. of the remaining 71 patients, 48 were boys (9.7-18.5 years, mean 15.7 years) and 23 were girls (12.7-19.3 years, mean 15.6 years). at arthroscopy, 53 patients (74%) had injury to the anterior inferior glenoid labrum. mr sensitivity was 92% for depiction of bankart-type injuries with a specificity of 94%. 37 patients (52%) had hill sach lesions and mr had sensitivity of 86% with specificity of 88%. 24 superior labrum anterior posterior (slap) tears (33%) were identified at arthroscopy with mr sensitivity of 67% and specificity of 89%. overall, mr arthrography had a positive predictive value of 96% for identification of a surgical lesion. agreement between the observers was high. interobserver reliability was calculated with an intraclass correlation coefficient (icc)of 0.638 with a cronbach's alpha of 0.841. conclusions: mr shoulder arthrography can accurately depict labral and osseous injury and provides pertinent preoperative information. a novel multi-channel mr coil for improved pediatric elbow coil imaging suraj serai, phd, cchmc, suraj.serai@cchmc.org; randy giaquinto, kathleen emery, charles dumoulin purpose or case report: single flex coils or adult size coils are currently used for imaging the pediatric elbow. this frequently results in uncomfortable patient positioning, motion, poor fat suppression, low snr and there is currently lack of a dedicated pediatric elbow coil in the commercial market. our goal was to explore the usefulness of a new coil array dedicated for pediatric elbow imaging and to compare quantitative & qualitative imaging findings to commercially available coils. methods & materials: an eight channel elbow coil was designed. the coil frame was designed to be rigid and lightweight. seven identical loop coils were built into a polycarbonate frame and an eighth coil built into a paddle that fits into the top frame. the coil elements were constructed with heavy copper to provide a high q-factor and increased snr. the complete coil including electronics & covering, weighs only 1.4 kg. mr imaging under irb approval was performed on a ge 1.5 t scanner using a routine clinical elbow protocol including t1w, pdw, t2w, fat-sat, non-fat-sat, 2d & 3d sequences. subjects were positioned feet-first with the elbow on the side & were subjectively assessed for comfort level. images obtained from the new coil & from the current commercial coils were compared for snr. results: scan positioning was reported to be comfortable. snr was between 20-25% higher as compared to the routine coils. fat saturation was uniform, indicating that the magnetic susceptibility of the coil is well-matched to human anatomy. anatomical detail depiction was subjectively better for anatomic features such as trochlea. detection & diagnostic confidence of elbow disorders were improved with the new coil & greatly decreased motion artifacts were observed. conclusions: the new pediatric elbow coil provided excellent image quality, patient acceptance and clinical performance improvements over existing coils. the open coil design also allows for imaging of the elbow in a partially flexed position or in a cast. the advantages provided by the new coil are expected to include shortened image acquisition times (via parallel imaging) & increased snr. disclosure: dr. serai has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. incremental value of knee radiography in the interpretation of pediatric knee mri yen-ying wu, texas children's hospital, yxwu@ texaschildrens.org; robert c. orth, wei zhang, r. p. guillerman, herman kan purpose or case report: the acr appropriateness criteria recommendation for the imaging work-up of knee pain is radiography followed by mri. in many cases, mri is performed prior to review of radiographs or the referring subspecialist does not feel radiographs add value, particularly when ligamentous injury is suspected. the purpose of this study is to determine if radiography adds incremental value in the interpretation of knee mr studies electively referred by pediatric sports medicine and orthopedic subspecialists. knee mri studies referred from pediatric sports medicine physicians or pediatric orthopedic surgeons between 9/2008 and 9/2011 (n0194, ages 4-18 years, m:f087:107) with accompanying radiographs were identified. patients were separated into 3 groups based on mri findings: normal, ligamentous injury, or osteochondral injury (osteochondral lesions, bone contusions/fracture, and avulsion injury). knee radiographs were consensus reviewed by two caq pediatric radiologists blinded to mri findings and categorized into the same groups. radiograph and mri findings were compared and categorized into 3 groups: neutral if radiograph and mri findings were the same, misleading if findings were discordant, or helpful if radiographs improved mr interpretation. the latter group was analyzed for impact on mr diagnosis. results: for 194 knee radiographs, 166 were normal, 2 showed ligamentous injuries, and 26 showed osteochondral injuries. when radiographs were interpreted as normal (n0 166), by mr 44% were normal, 33% had ligamentous injury, 10% had osteochondral injury, and 13% had both ligamentous and osteochondral injury. when radiographs were interpreted as ligamentous injury (n02), by mr 50% were normal and 50% had ligamentous injury. when radiographs were interpreted as osteochondral injuries, by mr 8% had ligamentous injury, 38% had osteochondral injury, and 54% had both ligamentous and osteochondral injury. subset analysis of true positive radiographs (n025) found 56% to be helpful and 44% to be neutral in mr diagnosis. for radiographs considered helpful, 0% resulted in a change in mr diagnosis. in regards to the influence of radiographs on mr interpretation, 37% (72/194) were misleading, 56% (108/194) were neutral, and 7% (14/194) were helpful. conclusions: a minority of pediatric knee radiographs aided mr diagnosis, and none resulted in a change in diagnosis. pediatric knee mri and interpretation should not be predicated on radiologist review of knee radiographs in this subset of patients. paper #: pa-132 sonographic evaluation of pediatric skeletal lesions: is it worthwhile? henrietta rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; amish patel, neil lester purpose or case report: the purpose of this paper is to demonstrate how ultrasound(us) may serve as a readily available, cost-effective, non-invasive, non-ionizing, practical tool for the evaluation of a variety of skeletal abnormalities in the pediatric age range. we reviewed the clinical and imaging findings in 31 patients seen during the past 2 years in whom us demonstrated abnormalities related to the skeletal system, excluding patients with hip joint effusions or ddh. results: us proved useful in the following situations: evaluation hard superficial immobile mass (osteoma shin) (1), absent medial end clavicle on x-ray in region of neck mass (us showed abc medial end clavicle)(1), to determine if soft tissue mass involves adjacent bone nodular fasciitis surrounding clavicular head (1), for diagnosis and followup fracture (displaced/non-displaced) in infants (4), diagnosis osteomyelitis in patients with cellulitis (4), question of fracture underlying cephalohematoma or subgaleal hematoma (4), rib mass (osteochondroma) (1) or mass costochondral junctions (contour deformities costochondral cartilage) (6), firm posterior knee mass (baker's cyst) (1), firm anterior knee mass (septated cystic mass suprapatella region due to rheumatoid disease) (1), immobile hard scalp mass due to epidermoid cranial vault (1), painful mass occipital bone with soft tissue components extending through the skull externally and internally due to langerhan's histiocytosis (1), indeterminate mass clavicle clinically thought to be post-traumatic sequellae, resolved on follow-up (1), assessment craniosynostosis (3), for differentiation of pathological entity from normal anatomic structure (lump on back of slender baby proved to be normal posterior spinous process) (1). conclusions: us is worthwhile for evaluation of wide range of pediatric skeletal abnormalities and helps to determine if the a lesion is one that is "touch" or "don't touch". to maximize diagnostic accuracy, the imager should have thorough knowledge of the clinical history, physical findings, laboratory and other imaging findings. in equivocal cases or in those patients in whom the field of view (fov) is insufficient for complete visualization of an obvious lesion or if malignancy is suspected, us serves to triage those patients in whom further imaging is necessary. high incidence of vertebral fractures in children with acute lymphoblastic leukemia 12 months after the initiation of therapy mary ann matzinger, md frcp(c), university of ottawa, matzinger@cheo.on.ca; nazih shenouda , brian lentle, josée dubois, helen r. nadel purpose or case report: vertebral fractures due to osteoporosis are a potential complication of childhood acute lymphoblastic leukemia (all). to date, the incidence of vertebral fractures during all treatment has not been reported methods & materials: we prospectively evaluated 155 children with all during the first 12 months of leukemia therapy. lateral thoracolumbar spine radiographs were obtained at diagnosis and 12 months. vertebral bodies were assessed for incident vertebral fractures using the genant semi-quantitative method, and relevant clinical indices such as spine bone mineral density (bmd), back pain and the presence of vertebral fractures at diagnosis were analyzed for association with incident vertebral fractures. results: of the 155 children, 25 (16%, 95% confidence interval [ci] 11% to 23%) had a total of 61 incident vertebral fractures, of which 32 (52%) were moderate or severe. thirteen of the 25 children with incident vertebral fractures (52%) also had fractures at the time of diagnosis. vertebral fractures at diagnosis increased the odds of an incident fracture at 12 months by an odds ratio of 7.3 (95% ci 2.3 to 23.1, p00.001). in addition, for every 1.0 standard deviation reduction in spine bmd z-score at diagnosis, there was 1.8-fold increased odds for incident vertebral fracture at 12 months (95% ci 1.2 to 2.7%, p00.006). conclusions: children with all have a high incidence of vertebral fractures 12 months after diagnosis, and the presence of vertebral fractures and reductions in spine bmd zscores at diagnosis are highly associated clinical features. purpose or case report: to provide objective measures of acetabular morphology utilizing volume-rendered ct and to better characterize normal acetabular development in adolescents. implications for the diagnosis of femoroacetabular impingement (fai) will be discussed. methods & materials: 146 hips in 73 consecutive patients (36 female, 37 male; ages 13-20 years) who underwent abdominal and pelvic ct for non-hip related complaints were retrospectively examined. examinations were performed for a variety of complaints, including abdominal pain, nephrolithiasis, vomiting etc. patients with obvious hip pathology were excluded. pelvic rotation was eliminated, and pelvic inclination was measured and corrected to 60°u tilizing a volume rendered ct model. measurements of femoral head diameter (fhd), anterior femoral head coverage (fhca), and posterior femoral head coverage (fhcp) were obtained. femoral head area (fha) was defined as π(fhd/2)2. percent anterior femoral head coverage (%fhca) was defined as (fhca/fha)*100. percent posterior femoral head coverage (%fhcp) was defined as (fhcp/fha)*100. acetabular version by volume-rendered ct (avvr) was defined as (fhcp/fhca). results: average pelvic inclination angle (sd) was 70.9 (5.6) for females and 64.8 (6.3) for males. average (sd) %fhca was 22.7 (4.9) for males and 18.6 (5.6) for females. average (sd) avvr was 2.39 (0.57) for males and 3.42 (1.19) for females. among males, average avvr decreased with subject age. on the other hand, there was little change in average avvr with age among females. conclusions: average avvr is greater for females than males, and this difference becomes more striking with increasing subject age. this represents an unexpected finding given the reported increased incidence of "pincer" type fai among females. characterization of acetabular morphology among adolescents with clinical fai should consider subject age and gender. in this regard, volumerendered ct is capable of providing an objective measure of acetabular morphology. mistakes in musculoskeletal plain film interpretation james crowe, pediatric radiology, texas children's hospital, jecrowe@texaschildrens.org; george s. bisset purpose or case report: to evaluate the mistakes made by trained pediatric radiologists when interpreting radiographs of the extremities obtained for the evaluation of outpatient acute pain (mostly post-traumatic). we retrospectively evaluated all radiographs and associated interpretations obtained during a 6 month period from april 15, 2011, to october 15, 2011, of the elbows, wrists, knees and ankles in pediatric outpatients who presented with acute pain in the affected area. all radiographs were previously interpreted by a caq-certified pediatric radiologist varying in experience from 1 year to 57 years. 745 abnormals were identified, including 305 elbows, 168 wrists, 175 knees and 97 ankles. all radiographs were determined to be "as dictated", missed significant finding, or overcall. attention was focused on the missed findings and overcalls. results: findings were as follows: elbow radiographs-14 missed findings and 10 overcalls, wrist radiographs-12 missed findings and 5 overcalls, knee radiographs-9 missed findings and 0 overcalls, ankle radiographs-14 missed findings and 10 overcalls. this resulted in a total of 49 missed findings (6.6% of abnormals) and 25 overcalls (3.4% of abnormals). of the 49 misses, 49% were fractures. the highest mistake percentage occured in the ankles where the combined misses and overcalls approached 25%. this was also the location where we found the highest percentage of missed fractures (9.0%) conclusions: when just abnormal cases were considered, fully trained pediatric radiologists have a mistake rate of approximately 9.8%, if misses and overcalls are included. from a quality improvement perspective, we will review all of the types of misses and overcalls to expose common themes. longitudinal assessment of osteoporosis in a blood-induced hemophilia rabbit model using quantitative ultrasound kuan-chieh wang, university of toronto, kc.wang@ utoronto.ca; afsaneh amirabadi, anguo zhong, christopher tomlinson, andrea s. doria purpose or case report: the reduction of physical activities in hemophilic patients may lead to bone demineralization and consequent osteoporosis. quantitative ultrasound (qus) is free of ionizing-radiation, relatively inexpensive, and easy to use that making this technique suitable for follow-up of hemophilic children with clinical suspicion of osteoporosis. to our knowledge, no previous study has investigated the value of qus for longitudinal assessment of growing bones in an animal model which is paramount for clinical translation of the technique once change in measurements could relate to either the baseline pathology or physiologic bone growth variability. the objective of this study is to investigate the intra-and inter-operator reliability of qus over time, and its ability to discriminate bone loss in pathologic vs control knees of a rabbit model of blood induced arthritis. methods & materials: sixteen juvenile white new zealand rabbits distributed into two groups: 8 received 8 intraarticular blood injections over 17 weeks (n 0 8 pathologic and 8 contralateral knees), and 8 noninjected rabbits were used as controls (n 016 knees). midshaft tibia speed-of-sound (sos) was measured at baseline, and weeks 8 and 17 of the experiment. two operators scanned each site twice at each time point. qus measurements were compared to microct (reference standard) on week 17 to validate the study results. results: the sos measured in the control group increased significantly (p<0.001) over the 17 week period. there was not such an increase in the arthritis sos value (p>0.05). in both groups the overall intra-operator coefficient of variation of sos measurements was 6% at baseline and decreased to 2% at week 17 likely due to increased tibia size. the inter-operator reliability was 6% at baseline and 3% at week 17. with regard to the effect of bone growth on qus measurements for the control group (n 016), sos values increased by 419.13 m/s, whereas for the pathologic group (n08), they only increased by 195 m/s. statistically significant differences in ratios of sos between final/baseline results were noted (p 00.016) between the pathologic and control groups. conclusions: the longitudinal use of qus has an acceptable intra-and inter-operator reliability. even accounting for the significant impact that bone growth has on qus measurements over time, qus can differentiate pathologic from control knees in the proposed animal model and holds potential for clinical use in the assessment of osteoporosis in hemophilic children. methods & materials: the study was approved by the institutional review board. 68 pediatric patients with 73 abdominal tumors (34 malignant and 39 benign lesions) underwent diffusion-weighted mr imaging (dwi) on clinical 1.5 t (n039) and 3 t (n029) mri scanners. adc maps were generated from b0500 dwi and adc values were retrospectively and independently measured by two radiologists. adc values of benign and malignant tumors were compared with the welch two sample t-test. a p value of 0.05 was considered to indicate statistical significant differences. in addition, a receiver operating curve analysis (roc) was performed to determine the optimal cut-off adc value for differentiating benign and malignant tumors. results: the mean adc value (mm2/sec) of benign tumors was 1.681 x 10-3 for the first reader and 1.679 x 10-3 for the second reader. the mean adc value (mm2/sec) of malignant abdominal tumors was 1.018 x 10-3 for the first reader and 1.113 x 10-3 for the second reader. the differences between benign and malignant tumors were statistically significant (p<0.001 for both readers). roc analysis revealed an optimal cut-off adc value for differentiating malignant and solid tumors as 1.1 x 10-3 mm2/sec. conclusions: diffusion-weighted imaging with adc maps can be used to differentiate between benign and malignant pediatric abdominal tumors. creation of a database to evaluate imaging findings in long-term survivors of pediatric malignancy alexander towbin, md, radiology, cincinnati children's hospital medical center, alexander.towbin@cchmc.org; seth hall purpose or case report: over the past 20 years, there have been significant improvements in the treatment of pediatric malignancies. improved therapy has led to an increase in the number of long-term survivors. many of these survivors are now experiencing late effects as a result of the original disease process or its treatment. these late effects are frequently identified on imaging. the purpose of this study is to create a database of the imaging findings of long-term survivors of pediatric malignancy in an attempt to begin to classify the findings and identify associations. methods & materials: after irb approval, the institutional cancer registry was searched to identify all patients younger than 20 years of age who were diagnosed with a solid tumor between 1980 and 2005. patients were included in the database if they survived for more than 2 years from the date of their initial diagnosis. the electronic medical record system was then used to obtain demographic and treatment information for each included patient. the dictated reports from all cross-sectional imaging studies evaluating the chest, abdomen, or pelvis performed more than two years from the date of diagnosis were then reviewed. each positive imaging finding was classified by the involved organ. results: after querying the institutional cancer registry, 909 patients were identified who met the inclusion criteria for this database. the most common neoplasms were neuroblastoma, wilms tumor, and astrocytoma. of the included subjects, 420 had imaging of the chest, abdomen, or pelvis. overall, 2851 reports were evaluated and classified. findings were most commonly identified in the lungs, musculoskeletal system, kidneys, liver, and lymph nodes. conclusions: a database examining the late effects in longterm survivors of pediatric malignancies was created. this database has the potential to help identify the radiologic manifestations of the complications of cancer therapy and thus help guide rationally determined long-term risk-benefit ratios in the treatment of pediatric malignancies. imaging followup of lymphoma in pediatric patients: is pelvic ct necessary? javier lopez bueno, md, children's hospital of eastern ontario, jlopezbueno@cheo.on.ca; nishard abdeen purpose or case report: pelvic ct is often included in the imaging followup of patient with lymphoma before, during and after treatment to assess response to treatment and monitoring for relapses. while such followup is expected to improve detection of relapse, there is little objective evidence of its effectiveness in lymphoma. anecdotally, there are few pelvic relapses in pediatric patients with lymphoma regardless of primary site. we hypothesize that pelvic ct could be avoided as part of the followup without adverse impact on survival or in the detection rate of relapses, and with subsequent significant reduction in the radiation dose, particularly to the gonads. methods & materials: research ethics board approval was obtained. patients diagnosed with lymphoma and with at least one year of followup at our tertiary care pediatric hospital were included. sex, age, type of lymphoma, stage, primary site, site of relapse if any as well as the number of ct scans of the head, neck, chest, abdomen and pelvis were recorded. results: a total of 29 patients met study criteria. there were 21 males and 8 females, with an average age of 11.9 years (range 3-17 years). eighteen patients had hodgkin disease (62%) and eleven had non-hodgkin lymphoma (38%). mean length of followup was 3.8 years (range 1-12 years). an average of 4.5 pelvic scans per patient were performed for surveillance (range 0-12). three relapses were detected. of these only one was in the pelvis, in a patient whose initial t cell non-hodgkin lymphoma was extensive and involved the neck, chest, abdomen and pelvis. conclusions: this study suggests a low incidence of pelvic relapse in pediatric patients with lymphoma. the routine use of pelvic ct in surveillance protocols may therefore be of little benefit while imposing a significant radiation burden. our study is limited by small sample size and short length of followup. further large scale studies are required. (esft) is performed by measuring the size of the tumors before and after chemotherapy. the proposed method of measuring tumor size, however, differs amongst recist 1.1 (response evaluation criteria in solid tumors), who (world health organization) and cog (children's oncology group) response criteria. in our project, we assessed whether response classification differs between the three different methods. methods & materials: after irb approval, we retrospectively analyzed mri studies of 55 patients with ewing sarcoma who were treated at stanford and ucsf medical centers. tumor size was assessed before and after therapy. tumor measurements were obtained using recist 1.1 (longest single diameter), who (longest diameter and perpendicular diameter), and cog criteria (three measurements to calculate tumor volume). tumor response was assessed by the differences in sizes of the tumors before and after treatment using four response categories: progressive disease (pd), stable disease (sd), partial response (pr), and complete response (cr). concordance between the three response classification systems was assessed using cohen's kappa (k) coefficient and percentage of disagreement per response category. results: the k statistic for concordance in cog/who, cog/ recist and recist/who were 0.663, 0.210 and 0.166 respectively. disagreement rates for recist/who, cog/ who, and cog/recist were 12.73, 34.55, and 47.27% respectively. using tumor volume, twenty-six patients were reclassified: twenty-four cases of stable disease coded by recist were reclassified as progressive disease by cog and two cases of partial response coded by recist were reclassified as complete response by cog. conclusions: this study demonstrates poor agreement between the recist 1.1 and cog response criteria in esft. given the degree of discordance between response criteria in esft, evaluation of the prognostic impact of each of these classification systems may guide selection of the optimal system for future use in this disease. imaging recognition of chylous ascites following surgery for abdominal neuroblastoma zeyad metwalli, md, baylor college of medicine, metwalli@bcm.edu; r. p. guillerman, heidi v. russell, eugene s. kim purpose or case report: surgical resection is a standard part of multimodality treatment of neuroblastoma, the most common abdominal malignancy of infancy and early childhood. chylous ascites is a rarely reported complication of surgery for abdominal neuroblastoma, and is likely underrecognized, posing the risk of nutritional deterioration and sepsis. to facilitate early diagnosis and institution of appropriate therapy, we present the salient imaging findings of the largest known series of chylous ascites following surgery for abdominal neuroblastoma. methods & materials: all patients with abdominal neuroblastoma complicated by post-operative chylous ascites over a five-year period at a large children's hospital were identified by a database search. a retrospective review of the imaging studies and clinical charts was conducted. results: chylous ascites developed following surgical resection of abdominal neuroblastoma in 5 of 36 patients, with the diagnosis made between postoperative days 20 and 33. four cases were high-risk neuroblastoma and one was intermediaterisk neuroblastoma. all 5 cases involved resection of an adrenal mass and dissection around the abdominal great vessels. all 5 cases manifested with abdominal distention on physical exam, and ascites was suspected clinically in 3 cases. computed tomography (ct) in all 5 cases revealed a large volume of ascites of near-water attenuation (range of −3 to 16.5 hounsfield units). the 3 cases imaged with ultrasound (us) showed hypoechoic or anechoic ascites without septations. the chylous ascites resolved after 1-4 months of treatment with dietary fat restriction, medium chain triglycerides, intravenous octreotide, or peritoneal catheter drainage. conclusions: chylous ascites is an under-recognized complication of surgical resection for abdominal neuroblastoma, occurring in 14% of patients in this series. the diagnosis is supported by the demonstration on ct or us of a large volume of ascites causing abdominal distention 3-5 weeks post-operatively. the ascites is typically near-water in attenuation rather than fatty in attenuation and should not be misattributed to peritonitis, hemorrhage, bowel leak, or early tumor recurrence. cervical spine injuries in patients with suspected physical abuse nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; zarir p. khademian, tanya hinds, katherine deye, allison m. jackson, eglal shalaby-rana purpose or case report: to evaluate the incidence and nature of cervical spine injuries and relationship to posterior fossa abnormalities in children who underwent brain and cervical spine mri as part of the clinical workup for suspected physical abuse. methods & materials: authors retrospectively analyzed records of eighty-five children less than three years of age who were documented by the child protective services at a level one pediatric trauma center over a period of four years (2006) (2007) (2008) (2009) (2010) . only patients who underwent both mri imaging of the cervical spines (c-spine) in addition to brain imaging as part of the clinical workup were included. cspine and posterior fossa of brain mris were independently reviewed by two pediatric neuroradiologists, both blinded to clinical details. c-spine abnormalities (bone marrow edema, cord edema, intrathecal blood, disc pathology, soft tissue/ ligamentous injury, vascular injury) were documented and correlated with abnormalities seen in the posterior fossa (blood, brainstem edema, cerebellar edema). results: at this time, 40/82 patients have been reviewed. twenty patients (50%) had both cervical spine injuries and posterior fossa abnormalities. there were no patients with isolated cervical spine injuries without posterior fossa abnormalities, but there were five patients (12.5%) that had posterior fossa abnormalities in the absence of c-spine injuries. fifteen patients (37.5%) did not have any spinal or posterior fossa imaging abnormality. none of the patients had bone marrow edema, disc pathology, or intrathecal blood. one patient had vascular neck injury and cord edema. conclusions: our results show that the incidence of cervical spine injury in children under investigation for abusive head trauma is as high as 50%. our data show further that cervical spine injury predicted posterior fossa injury in all patients, while presence of posterior fossa injury predicted concomitant c-spine injury in only 75%. the incidence of c-spine trauma we found in these patients is higher than reported elsewhere in the literature and may impact whether or not routine c-spine mri will be included in national imaging guidelines for children under investigation of abusive head trauma. pediatric skull fracture andre loyd, phd, biomedical engineering, duke university, aml6@duke.edu purpose or case report: skull fractures are often seen in the setting of non accidental trauma (abuse) abuse, and are usually attributed to falls from heights above 1 m. part of the difficulty in assessing height is due to uncertainties in actual distance. objective: to determine what types of skull fractures can occur in pediatric and adult post-mortem human specimens during controlled impacts on hard surfaces from various heights. methods & materials: skull fracture patterns in postmortem human specimens from a unique bank of pediatric specimens (30-week gestation to 16-years-old, n013) were subjected to controlled drops from both arbitrarily low heights (15 and 30 cm) and high heights (2 m) onto an aluminum platen. the specimens were dissected from the neck at the occipital condyles and intracranial were sealed inside the head using pmma. the heads were dropped on to five different impact locations. fractures were identified using palpation and high resolution mdct. results: no specimens between 33-weeks-gestation and 24days-old sustained fractures from the 15-30 cm drops. three out of four (75%) specimens ages between 5-and 22-months old fractured due to the 15 or 30 cm drops. the 9-and 16-year-old specimens and all adult specimens survived the 15-30 cm drops. all specimens subjected to the 2 m drop fractured. the specimen between 11-months and 22-months sustained either a linear fractures or diastatic fractures from the 15 cm and 30 cm drops. the results indicate that some aged infants and young children can sustain skull fractures by being dropped or falling from relatively low heights. drops, as low as 15 cm, can cause linear and diastatic fractures in pediatric skulls. the presences of compliant sutures and fontanelles in neonatal heads allow the head to deform during impact. these data add very important information to mechanisms of skull fractures across ages, including ages in which child abuse is a consideration. evaluation of a new classification system for temporal bone fractures in children aimed at increasing prognostic value badriya al-qassabi, md, mcgill university, albahlania1@ yahoo.com; lucia carpineta, rania ywakim, bahar torabi, andrew m. zakhari, lily h p. nguyen purpose or case report: to compare a new classification of temporal bone fractures which specifically evaluates involvement of the otic capsule against the traditional classification system (transverse versus oblique versus longitudinal), to evaluate whether this new classification is able to better identify patients at risk of adverse otologic outcome and neurologic complications in the pediatric population. methods & materials: a retrospective hospital chart review was performed by ent colleagues searching for all patients with temporal bone fractures seen at our center over the past 10 years. this was followed by a blinded review of the ct heads by a resident and a trained pediatric radiologist with neuro expertise. these cts were evaluated for petrous involvement, otic capsule involvement and any associated intracranial lesions. this information was then correlated with clinical outcome measures including post-traumatic hearing deficit, facial nerve palsy, persisting csf leak and global neurologic sequelae. the new classification was compared to the traditional one, and specifically analysed for the ability to better predict the clinical outcomes. results: expectedly, pediatric temporal bone fractures were infrequent and otic involvement even more rare. fractures with involvement of the otic capsule (versus otic sparing) were found more frequently in boys. they were also more likely to be associated with immediate otologic signs and neurologic findings on presentation. these fractures also had the highest association with conductive hearing deficit (>60%) and were twice as likely as otic sparing fractures to be associated with immediate facial nerve palsy and with more important concomitant intracranial injuries such as midline shift. conclusions: while our numbers are small, our results suggest a trend that when temporal bone fractures show involvement of the otic capsule, there is higher risk of adverse otologic outcome and neurologic complications even in the pediatric population. absence of a causal relationship between mr detected subdural hematomas (sdh) in neonates with hypoxic-ischemic encephalopathy (hie) deniz altinok, children's hospital of michigan; jay shah, harut haroyan, gulcin altinok, nitin chouthai purpose or case report: the existing controversy regarding subdural hemorrhages noted in patients with hie is an important discussion in the medical, legal and child-welfare realms. it is our goal to provide additional information to this critical debate through mr findings on patients with clinically diagnosed hie. methods & materials: all patients born with clinically diagnosed hie, and treated at children's hospital of michigan in the past 8 years were examined; those with head mri taken within 19 days of life were selected. in total, 41 patients fit the criteria, this included: 22 males and 19 females, and an age range of 2-19 days at scan (average age of 10 days at scan). all traumatic births, coagulopathies, and other pertinent clinical findings were noted. mr imaging was reviewed and reported by a blinded pediatric neuroradiologist, these reports were then compared to the "original read". results: all 41 patients were confirmed radiologically to have hie. the causes of hie in all cases examined were either intrauterine/delivery asphyxia, aspiration, or congenital disease. of these 41 cases, the findings were: 6 sdh, 11 parenchymal hemorrhages, 4 intraventricular hemorrhages, 4 cephalohematomas, 3 subarachnoids, 1 large subcutaneous hemorrhage and 1 instance of mca stroke. all 6 patients with mr detectable sdh had 1 or more confounding factors (1 meningitis, 3 coagulopathies, 4 chest compressions, 1 cardiac malformation, 1 pph, 1 severe pulmonary hemorrhage requiring transfusion of plasma and prbc). conclusions: it has been hypothesized that sdh is often found incidentally in children diagnosed with hie, this is however a dubious conclusion considering our results. in fact, the presence of sdh and hie concomitantly is low even when including a population with traumatic births such as ours. sports-related concussion in children: an mri and mrs study kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; todd a. maugans, james l. leach, mekibib altaye purpose or case report: the pathophysiology of sportsrelated concussion (src) is poorly understood, especially for children. following src and mild traumatic brain injury in adults, a few mri and proton mrs studies have identified axonal injury with declines in the neurometabolite n-acetyl aspartate (naa). we wanted to examine a src adolescent population with proton mrs, diffusion tensor imaging (dti) and other mri methods within 72 h of concussion and with short term followup to determine if there were differences in imaging metrics with age and sex matched healthy control participants. methods & materials: twelve children, ages 11-15 years, who experienced src were evaluated with impact neurocognitive testing, t1-weighted mri, susceptibility weighted imaging (swi), dti, proton mrs, and phase contrast angiography (pca) at less than 72 h, 14 days and 30 days or greater post-concussion. healthy, age and sex matched controls for each src participant were recruited and evaluated at a single time point. quantitative imaging metrics included fractional anisotropy, metabolite concentrations, and global cerebral blood flow (cbf). group comparisons were examined by paired t-test or wilcoxon signed rank test. correlational data employed spearman rank correlation. results: impact results revealed significant differences in initial total symptom score (tss), and reaction time (rt) for the src group compared with the control group, with tss resolving by a mean of 14 days and rt at 30 days. no evidence of structural injury was observed qualitatively for either group. analyses between groups or over time within the src group found no decreases in naa or elevation of lactic acid upon mrs, and no changes in fractional anisotropy upon dti. within the src group, significant changes in the global cbf were observed. improvement towards control values occurred by 14 days for 27% and by 30 days for 64% of src group participants. conclusions: pediatric src affects global cbf without evidence of structural or metabolic injury. predictive value of high resolution mr imaging of brain and sella in children with clinical optic nerve hypoplasia for hypopituitarism charles glasier, radiology, arkansas childrens hospital, glasiercharlesm@uams.edu; raghu h. ramakrishnaiah, julie shelton, chetan c. shah, paul h. philips purpose or case report: to review the spectrum of cns abnormalities and their incidence in children with optic nerve hypoplasia and to calculate the sensitivity and specificity of magnetic resonance imaging in predicting endocrine abnormalities. methods & materials: this is an irb approved retrospective study of 44 children with clinical optic nerve hypoplasia who underwent mri of the brain and orbits as part of the clinical workup in a tertiary care pediatric hospital. high resolution mri studies were performed on 1.5 tesla scanners. mri studies were reviewed for optic nerve hypoplasia, absent or ectopic posterior pituitary, absent pituitary infundibulum, absent septum pellucidum, migration anomalies and hemispheric injury.radiologists were blinded to patients endocrinologic status.all patients had clinical evaluation by a pediatric neuro-ophtalmologist and endocrinologist. a standardized panel of serologic testing that included serum cortisol, acth, tsh, and free t4 levels were performed on all patients. statistical analysis was performed to determine the sensitivity and specificity of mr findings in predicting endocrinologic deficiency. results: study included 44 children(26 males and 18 females) who had clinical optic nerve hypoplasia. the mean age of the study population was 3 yr (sd:4.7 yr).15 children had unilateral and 29 children had bilateral optic nerve hypoplasia by mri.6 children had absent posterior pituitary bright spot and 9 had ectopic posterior pituitary,7 had absent infundibulum,1 had complete callosal agenesis,3 partial callosal agenesis and 16 had callosal thinning. 9 had absent septum pellucidum. 2 had hypopituitarism. of the 12 patients with hypopituitarism 8 had abnormal abnormal pituitary on mri, 3 had absent septum pellucidum, and 1 child had migration abnormality. none had corpus callosal abnormality. the sensitivity and specificity of mri in predicting hypopituitarism by demonstration of abnormal pituitary is 75% and 81% respectively. the positive predictive value and the negative predictive value is 60% and 90% respectively. among the 32 patients with normal endocrinologic function, none had pituitary abnormalities on mri. conclusions: pituitary abnormalities are the most common intracranial abnormality in patients with optic nerve hypoplasia followed by absent septum pellucidum. detection of pituitary abnormalities by the mri has high specificity and high negative predictive value for endocrine abnormality. paper #: pa-148 ct imaging pearls for shunted pediatric brains srikala narayanan, md, children's national medical center, snarayan@childrensnational.org; nadja kadom purpose or case report: shunted pediatric patients frequently present emergently with symptoms that could indicate shunt malfunction, such as headache and vomiting. here, we present imaging pearls on non-contrast head ct in shunted children. methods & materials: illustration of each of the following: 1. shunt tip and volume averaging-consider location of side holes and use of multiplanar reformatted images. 2. shunt at burr hole-consider radiolucent shunt parts. 3. shunt rupture in the neck-remember to investigate the lower extracranial shunt parts. 4. shunt in cyst/subdural shunt (vs dislocation)-consider primary shunt location in a cyst rather than shunt dislocation. 5. enlarged temporal horns-look for it. in infants occipital horns may dilate first. 6. enlarged 3 rd ventricle-look for bulging of lateral walls. 7. sulcal effacement-use the "three shades of gray" rule. 8. small cisterns-detecting shape distortion can help. 9. periventricular edema-easily overlooked because of similar low density compared to ventricular fluid. 10. slit-ventricle -requires cautious reporting. conclusions: careful evaluation of ct images in shunted pediatric patients can reveal important clues for making an accurate diagnosis, even when prior images are not available. successful treatment of mice with creatine transporter deficiency kim cecil, phd, cincinnati children's hospital medical center, kim.cecil@cchmc.org; diana m. lindquist, matthew r. skelton, gail j. pyne-geithman, joseph f. clark purpose or case report: creatine transporter deficiency (ctd) is an untreatable x-linked mental retardation syndrome with severe cognitive and speech impairment. patients are identified by an absence of creatine in the brain on mr spectroscopy (mrs) and distinguished from two creatine synthesis deficiency syndromes with genetic testing. for ctd, the absence of the transporter (slc6a8) prevents creatine from crossing the blood brain barrier and entering brain cells. a brain specific ctd knockout mouse was developed replicating key features of the human disease and establishing an animal model for treatment of ctd. we report the successful treatment of the ctd knockout mouse and present confirmation by mrs. methods & materials: brain specific knockout and littermate control mice were randomly assigned and treated with on one of three supplements: agentx (confidential), creatine or maltodextrine as placebo. 1h and 31p mrs data were collected on a 7 t mr system (bruker). mice (n016) were studied with mrs after 9 weeks of supplementation. single voxel 1h data were acquired on a 144 ul voxel covering the cerebrum using a double spin echo sequence. 31p data were acquired with an isis sequence from the same voxel. metabolite quantification was performed with jmrui and compared between groups and over time with statistical tests for significance (t-tests, anova). results: creatine and phosphocreatine levels in the brain were all significantly higher after 9 weeks supplementation of agentx in knockout mice, compared to creatine and placebo fed knockout mice (phosphorus mrs [144 ul brain voxel] with phosphocreatine (pcr) (0 ppm) observed only in agentx treated knockout mice. adenosine triphospate (atp) gamma (−2.5 ppm), alpha (−7.5 ppm) and beta (−17 ppm) peaks are noted in all three knockouts. conclusions: successful treatment was achieved in a slc6a8 brain specific knockout mouse for the second largest known cause of x-linked mental retardation in humans, ctd. disclosure: dr. cecil has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. prevalence of abusive injuries in siblings and contacts of abused children kenneth feldman, md, general pediatrics/children's protection program, university of washington/seattle children's, kfeldman@u.washington.edu purpose or case report: siblings and children who share a home with a physically abused child are thought to be at high risk for abuse. however, rates of injury in these children are unknown. disagreements between medical and cps professionals are common and screening is highly variable. our objective was to measure the rates of occult abusive injuries detected in contacts of abused children using a common screening protocol. this was a multi-center, observational cohort study of 20 child abuse teams who shared a common screening protocol. data were collected for all children <10 years undergoing evaluation for physical abuse and their contacts. for contacts of abused children, the protocol recommended physical examination for all children <5 years, skeletal survey and physical exam for children <24 months, and physical exam, skeletal survey and neuroimaging for children <6 months old. results: among 2,825 children evaluated for abuse, 618 met criteria as "physically abused" and these had 477 contacts. for each screening modality, screening was completed as recommended by the protocol in approximately 75% of cases. of 133 contacts who met criteria for skeletal survey, new injuries were identified in 16 (12.0%). none of these fractures had associated findings on physical examination. physical examination identified new injuries in 6.2% of 257 eligible, examined contacts. neuroimaging failed to identify new injuries among 19 imaged, eligible contacts less than 6 months old. twins were at significantly increased risk of fracture relative to other non-twin contacts (56.3% vs 11.9%, or 19.9). conclusions: these results support physical examinations and skeletal survey, regardless of physical examination results, for contacts of abused children <24 months of age. too few children had cranial imaging to change recommendations to image contact children less than 6 months old. even for children where no injuries are identified, these results demonstrate that abuse is common among children who share a home with an abused child. they support including contacts in evaluations and interventions (foster care, safety planning, social support) designed to protect physically abused children. the project was supported by the health resources and services administration/maternal shown that pediatric rib fractures may be a marker for significant intrathoracic injury. this information has been used to suggest that children with rib fractures and no underlying intrathoracic injury may have sustained them due to insufficient bony mineralization and minor trauma rather than inflicted injury. methods & materials: irb approval was obtained for a retrospective review of all children under 3 years of age with imaging diagnosis of rib fracture over a 6-year period at two university hospitals. children with prior thoracotomy, previously recognized metabolic bone disease, and prematurity <36 weeks were excluded. medical records were reviewed and children with documented abuse or accidental trauma were evaluated. children with indeterminate injury mechanisms were excluded. sixty-six patients with rib fractures were included in analysis, 47 due to abusive injury and 19 due to accidental trauma. children were analyzed for associated intrathoracic, abdominal or intracranial injury, additional fractures and retinal hemorrhage. results: abused children were younger (4.7+/−6.1 months) than accidentally injured children (18.9+/−11.1 months, p< 0.001). children with rib fractures due to accidental trauma had a higher incidence of intrathoracic injury compared to those due to abusive injury (53% vs 13%,p<0.001). there was no difference in the incidence of abdominal or intracranial injury between groups. mortality and icu admission rates were similar. abused children had a higher total number of rib fractures (mean 5.5 vs 3.0, p<0.009) and were more likely to sustain additional fractures outside of the thoracic cavity (77% vs 63%, p<0.001). conclusions: abuse is a more common cause of rib fractures in young children than accidents. children with rib fractures due to abusive trauma are less likely to have intrathoracic injury compared to those sustaining rib fractures due to accidental trauma. this suggests differences in mechanism of injury between groups. pediatric elbow fractures: a different angle on an old topic shannon zingula, md, pediatric radiology, cincinnati children's hospital medical center; kathleen emery, christopher g. anton purpose or case report: the 3 most common elbow fractures classically reported in pediatric orthopedic texts are supracondylar (sc) (50-70%), lateral condylar (lc) (20%), and medial epicondylar (me) fractures (10%) with fractures of the proximal radius (including but not limited to fractures of the radial neck) being relatively uncommon (5-10%). our experience at a large children's hospital suggests a different distribution. purpose: 1) to describe the frequency of different elbow fracture types in a large pediatric population, and 2) to determine the fracture types that were occult on initial radiographs but detected on follow-up. methods & materials: review of medical records identified 468 children, median age 6 years and interquartile range for age of 4-8 years (range, 0.8-18 years) diagnosed with elbow fractures at our institution from october 2010 through july 2011. initial and follow-up radiographs were reviewed in blinded fashion independently by two experienced pediatric musculoskeletal radiologists to identify fracture type(s) on initial and follow up radiographs. note was made of fractures identified on follow up only. results: the most common fractures included sc (n0254, 54%), radial neck (rn) (n080, 17%), and lc fractures (n066, 14%). as compared to classically referenced incidences, rn fractures were seen significantly more (p<0.0001) and me fractures (n025, 5%) significantly less (p0.0008) than would be predicted. in 26 patients without fracture seen on initial films, occult fractures were seen on follow up; sc (n012, 46%) and rn fractures (n08, 31%) were most common. the frequency of rn fractures compared to the overall group (31% vs. 17%) approached but did not reach statistical significance (p00.06). 34 patients with one fracture had additional fractures seen on follow-up not seen initially with olecranon fractures most frequent (n018, 53%.) this was significantly more common than the number identified on initial radiographs (n033, 7%) (p<0.0001). conclusions: sc fractures are the most frequent elbow fracture seen initially and in follow up followed by rn and lc fractures in a distribution different than classically described. the relatively high frequency of rn and olecranon fractures detected on follow up speaks to their potentially occult nature. careful attention to these areas is warranted in patients with initially normal radiographs. purpose or case report: previous studies have found that fractures involving the spine, hands and feet are rare on skeletal surveys for suspected child abuse, leading some authors to suggest eliminating views of these regions from the initial skeletal survey protocol. the purpose of this study was to assess this recommendation by performing a historical review of these injuries in a population undergoing screen-film based skeletal surveys for suspected abuse. this cross-sectional, retrospective irb approved study reviewed the reports of the initial skeletal surveys of all children <2 years of age with suspected abuse imaged between april, 1988 and december, 2001 . infants underwent skeletal surveys according to acr standards acquired on a mammographic type screen-film imaging system with at least 13 line pairs per millimeter resolution. studies in toddlers were performed using a par speed screenfilm system. results: 62% (225/365) of all skeletal surveys demonstrated positive findings, and 44% (98/225) had >1 fracture. 5.5% (20/365) of all studies had fractures involving the spine, hands or feet. of all positive skeletal surveys, 8.9% (20/ 225) had fractures involving the spine, hands or feet, and 20.4% (20/98) of all patients with >1 fracture on skeletal survey had fractures involving these regions. conclusions: these data, acquired in the screen-film era, suggest that fractures of the spine, hands and feet may not be rare in infants and toddlers in cases of suspected child abuse. the benefits of eliminating views of these regions from the initial skeletal survey should be carefully weighed against the cost of missing these potentially important injuries in at-risk pediatric populations. purpose or case report: dating fractures is critical in cases of suspected infant abuse, but there are little scientific data to guide radiologists, and dating is generally based on personal experience and conventional wisdom. we previously reported a scientific scheme for dating fractures in infants based on an analysis of subperiosteal new bone and callus formation in birth-related clavicular fractures. we hypothesize that when used as a guide this system can significantly improve the ability of radiologists to accurately date fractures in young infants. methods & materials: 103 radiographs of presumed birthrelated clavicular fractures in infants 0-3 months were reviewed by 2 pediatric radiologists with 2 (reader a) and 15 (reader b) years experience in two reading sessions separated by one year. for the first read, no guidelines were provided. training was carried out prior to the second session, and readers were given the dating scheme as a guide during fracture analysis. readers were asked to provide an estimate of the minimum and maximum fracture age in both sessions. the primary outcome was whether or not the reader's estimated range for fracture age included the actual fracture age. a secondary outcome was the width of the estimate of fracture age. these outcomes were compared across the two reading sessions. results: the rate of correct response significantly increased after training for each reader (reader a: 66% to 89%, p<.0001; reader b: 76% to 86%, p0.041). the width of estimated fracture age after training was significantly smaller for each reader (reader a: mean width 17 days to 13 days, p<.0001; reader b: 25 days to 15 days, p0.001). conclusions: our results suggest that the ability of a radiologist to accurately date fractures can improve significantly when provided with a scientifically based system outlining patterns of fracture healing. this scheme can be applied in radiologic practice and may prove particularly useful in cases of suspected abuse, where fracture dating often has forensic implications. purpose or case report: to demonstrate the acute and subacute features of proximal femoral physeal fractures in the abused child. also to demonstrate how to recognize this injury in patients with unossified femoral heads. the database of patients with suspected non-accidental trauma, accumulated over 12 years, was reviewed. 254 out of a total of 599 patients (43%) were proven to be cases of non-accidental trauma, as determined by the child abuse pediatrician. from these 254 patients, the cases of proximal femur growth plate fractures were identified. results: 7 patients with proximal femur growth plate fractures were identified for a prevalence of 2.8%. one patient had bilateral proximal femoral fractures, for a total of 8 fractures in 7 patients. 5 were boys, 2 were girls with ages ranging from 2.5 mos to 2 yrs 2mos. in 4 patients, the fracture was revealed on imaging performed because of refusal to bear weight; in the other 3 patients, the fracture was found during imaging for the skeletal survey. the fracture was on the left side in 7 cases and on the right side in 1 (the patient with bilateral fractures). in all of the fractures, there was lateral displacement of the femoral shaft. in 3 fractures, the femoral head was not yet ossified simulating the appearance of a dislocation. location of the femoral head in the hip joint was verified by ultrasound or ct (ct abdomen had already been done in 1 patient) thus delineating the presence of a physeal fracture. 6/8 fractures were salter-harris i and the other 2 were salter-harris ii fractures. the fracture was acute in 2 cases and subacute in 6 cases. in these 6 subacute cases, periosteal reaction and/or calcifying subperiosteal hemorrhage was present in 3, and irregularity and scalloping of the metaphysis was present in the other 3. conclusions: proximal femoral growth plate fractures are quite uncommon in non-accidental trauma. the injuries are typically salter-harris i or ii fractures, seen more often in the healing phase. in the presence of an unossified femoral head, the laterally displaced femoral shaft can simulate hip dislocation; this can be clarified with hip sonogram. purpose or case report: in recent years, metal stents have been used to overcome airway obstruction in children for whom no better surgical option is available. these devices are not designed for use in the airway, however, and may cause significant complications. bioabsorbable airway stents may avoid some of the problems associated with metal stents. methods & materials: this is a retrospective review of all endoluminal insertions of bioabsorbable airway stents at a single institution from april 2010 to september 2011. custom-made polydioxanone stents of various sizes (ella dv, ella, czech republic) were used. results: twelve stents were inserted in the airways of seven children. indications were: recurrent obstruction after slide tracheoplasty (2), persistent airway compression after correction of a congenital cardiac lesion (2), collapse of stem cell supported tracheal homograft, tracheomegaly following fetal balloon insertion, and syndromic tracheobronchomalacia (tbm). eleven stents (diameters 6 to 12 mm) were placed in the trachea and one in the left main bronchus. two stents had to be removed and replaced for technical reasons (one was too long and the other too narrow). the child with syndromic tbm died when treatment was withdrawn because she could not be weaned from the ventilator. the remaining children are alive at a median follow-up of nine months (range 1 to 17 months). the granulation tissue response was similar to that seen after placement of metal stents. the stents were observed to absorb gradually over a period of approximately three months, requiring serial stenting in two children. conclusions: bioabsorbable airway stents are more difficult to insert than metal stents. they cause similar early complications, especially granulation tissue formation, but appear to avoid potential long-term complications of metal stents, including vascular erosion and growth limitation. disclosure: dr. mcclaren has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: renal angiomyolipomas (amls) in tuberous sclerosis complex (tsc) grow at a faster rate, exhibit a wider and more problematic range of symptoms, and hemorrhage more frequently than sporadic amls. we examined the efficacy of prophylactic embolization of renal amls in tsc in decreasing tumor size, alleviating symptoms, and preventing hemorrhage while preserving renal function. we retrospectively reviewed the charts and imaging studies of 47 consecutive patients who underwent transarterial, transcatheter embolization of 52 amls. tumor volume was measured from available ct or mri imaging before and after embolization. pre-and postembolization symptoms and creatinine levels were documented. results: 37 patients had available follow-up imaging at a mean of 63 months post-embolization. the mean preembolization tumor volume was 581 ml and postembolization was 284 ml; median decrease in volume was 76%. using the schwartz method, the mean glomerular filtration rate before embolization was calculated to be 95.75 ml/min/1.73 m2. after embolization the mean value was statistically unchanged at 101.97 ml/min/1.73 m2. none of the patients experienced renal hemorrhage or symptom recurrence during the follow-up period. conclusions: selective embolization of renal amls in patients with tsc decreases tumor volume, relieves symptoms and reduces the risk of future hemorrhage while preserving renal function. etoh was injected percutaneously with 25 g needle; transductal ablation performed through a 4 f micropuncture sheath. drug volumes, technical difficulties, percentage reduction in saliva production, family reported clinical significance, and complications were recorded. results: salivary gland ablation (sga) included bilateral smg and slg ablation without parotid gland ablation in 20 cases, and with unilateral parotid gland ablation in 4 cases. one case of bilateral parotid gland ablation following surgical resection of bilateral smgs. mean etoh dose for smg04.2 ml, and 3.1 ml for slg. one case of focal skin necrosis was noted; no other complications. patient families reported response to sga in 24/25 cases (96%) with mean saliva production of 66%. greatest health and family impact was reported with elimination of hospitalizations for recurring aspiration pneumonia (2 cases), elimination of choking in bed (3 cases) , and improved patient sense of self-hygiene in 8 cases. one complication occurred with temporary marginal mandibular nerve paralysis (resolution in 6 months). conclusions: percutaneous and transductal sga is feasible, safe, and effective in this small patient series, offering an alternative to surgical salivary gland resection, or treatment option following failed surgical intervention. paper #: pa-159 mr-guided procedures in children: initial experience joao amaral, md, diagnostic imaging, the hospital for sick children, joao.amaral@sickkids.ca; michael temple, dimitri parra, philip john, bairbre connolly purpose or case report: the primary purpose of this study was to review our initial experience with mr-guided procedures in children. our secondary objective was to share some aspects on how to start an mr-guided program in a tertiary pediatric center. patients with lesions identified only on magnetic resonance (mr) imaging were selected to undergo an mr-guided procedure. patients' demographic data, primary diagnosis, referring team's clinical suspicion, lesion's anatomical location, tissue adequacy for pathology, final diagnosis and clinical follow up were reviewed. aspects of starting a program of mr-guided procedures, safety concerns, imaging and technical challenges, and mr compatible materials were also addressed. results: to date, 7 procedures (5 bone biopsies, 1 soft tissue biopsy and 1 pre-surgical needle localization) were performed in 6 patients during 9 months. there were 4 girls and 2 boys with a mean age of 10.2 years (3y5mo-17 yrs). one patient had a nasopharyngeal carcinoma, 1 cardiofacial syndrome, 1 wilm's tumor and 3 had no previous medical issues. the clinical suspicion for 2 procedures in 2 patients was metastatic disease and for 5 procedures in 4 patients was primary malignancy or infection. lesions were located in the tibia (2-metaphysis and diaphysis), femur (2 -metaphysis and epiphysis), thigh (1-soft tissues), sacrum (1) and retroperitoneum (1). all biopsies provided adequate tissue for diagnosis. needle localization and hook deployment was also accurate. malignancy was excluded in all patients. final diagnosis included 1 chronic recurrent multifocal osteomyelitis (crmo), 3 osteomyelytis, 1 fibrous tissue, 1 osteoid osteoma, and 1 scar tissue. mean follow up was 6.6 months. no patient required a second procedure to confirm the diagnosis. conclusions: mr with its unique soft tissue resolution and lack of ionizing radiation is an excellent method to guide interventions in children. one of the greatest advantages of this method is the precise target localization especially in lesions located in the bone marrow or lesions better identified on mr. special safety measures, specific mr compatible material (needles, surgical instruments), dedicated imaging techniques to reduce or increase material/needle artifact and careful technique are paramount. 2006-2011. 11 m, 15 f; 2 .5-59 months, mean 8.3 months, median 5 months, mode 5 months. sonographic approach expanded as our experience grew over 71 months. 25 studies performed by a single pediatric radiologist. bilateral sonography included: interscalene and supraclavicular neck, nerve roots at neural foramina, cervical spinal canal, diaphragm during spontaneous respiration, rhomboid muscle, serratus anterior muscle, posterior shoulder, all performed and interpreted blind to other imaging. results: interscalene and supraclavicular neck evaluated in all patients. all exhibited echogenic interscalene portion of brachial plexus.size and extent of traction neuroma varied. nerve roots at foramina noted in axial and coronal planes. in 11 cases enlarged root(s)noted. cervical spinal canal studied in 19 patients: cord oscillated normally, no syrinx, cord concentric in canal. intracanalicular traction pseudomeningoceles on concurrent ct myelography or mri were not apparent on us. in 2 cases a "clumped" retracted nerve root on the cervical cord was later found to correspond to a pseudo-meningocele on ct myelogram. otherwise, cervical spinal canal us was unremarkable in 24 cases. diaphragm motion was evaluated in 23 patients during spontaneous respiration; no phrenic nerve palsy. rhomboid muscle was evaluated for atrophy in 16 patients; 4 had atrophy. the rhomboids are innervated by the dorsal scapular nerve which arises solely from c5, prior to c5 joining the brachial plexus. intact rhomboid indicates that the central c5 root is intact. serratus anterior muscle, innervated by the long thoracic nerve (c5,c6,c7), was evaluated for atrophy in 12 patients; 6 had atrophy. dynamic evaluation of the posterior shoulder looking for posterior laxity was evaluated in 10 patients; 4 had laxity. posterior shoulder dislocation or subluxation is a known sequela of brachioplexopathy which sometimes requires muscle transfer when the child is older. conclusions: comprehensive us evaluation of perinatal brachioplexopathy detects: extent of traction neuromafibroma from the interscalene region peripherally toward clavicles (important for neurosurgeon), thick nerve roots, phrenic nerve diaphragm palsy, muscle atrophy from denervation, and posterior shoulder subluxation. us misses: intracanalicular traction pseudomeningoceles. paper #: alt-001 impact of the image gently campaigns in adult-focused hospitals: a survey of practice leaders brett bartz, duke university medical center; donald frush, kimberly applegate, michael callahan, laura coombs, marilyn goske purpose or case report: the alliance for radiation safety in pediatric imaging is an organization that uses social marketing to promote radiation protection for children and effect change across radiology practices. the impact of the alliance's image gently campaigns on practice patterns in radiology practices has yet to be assessed, especially outside of freestanding children's hospitals. the purpose of this investigation was to assess the impact of the image gently campaigns on academic and private practices/institutions that treat children but primarily serve adults. a web-based survey was emailed to leaders in radiology practices (n01186) who do not practice at freestanding children's hospitals utilizing the acr's pred database. the survey consisted of 18 questions designed to measure the recognition and impact of the image gently campaigns, including the impact on practice patterns. results: a total of 186 practice leaders in 41 u.s. states and territories responded for a response rate of 15.7%. the majority (94%) of sites image pediatric patients in their practices. respondents consisted of department chairs (60%), group presidents/ceos (33%), and division chiefs (13%). the majority (52%) of respondents described their practice as a hospital-based private practice without a dedicated pediatric radiology division. the vast majority (95%) of respondents was familiar with the image gently campaigns; 55% of respondents reported that image gently had effected a change on how they imaged children. specifically, respondents (%) reported that the campaign caused a modification to lower dose protocols for head ct (57%), chest ct (66%), and abdominal/pelvic ct (69%). slightly more than half of respondents (55%), however, estimated that the image gently campaign resulted in no modification of pediatric fluoroscopy exposure. conclusions: to our knowledge, this is the first survey evaluating the impact of the image gently campaigns. there is near universal recognition of the campaigns, which have impacted practice patterns beyond the freestanding children's hospital in ct, but not in fluoroscopy. reliability of shear-wave velocity using different frequencies in acoustic radiation force impulse (arfi) elastography mi-jung lee, radiology, severance children's hospital, mjl1213@yumc.yonsei.ac.kr; suyon chang, myung-joon kim purpose or case report: although there are many studies about acoustic radiation force impulse (arfi) measurement, standard protocol has not been established. and a new probe with high frequency has been developed which can be applied for pediatric patients. the purpose of this study was to assess the reliability of shear-wave velocity (swv) at various depths using different frequencies to suggest standard measurement in arfi elastography. methods & materials: arfi elastography of both the elasticity phantom and normal liver was performed at different depths (2-5 cm) with convex (1-4 mhz) and linear (4-9 mhz) probes. ten valid swv measurements at each depth were performed. it was repeated ten times with the phantom and it was done in 8 healthy volunteers (m:f03:5, age 20-34 years; mean 25.5). the mean value and standard deviation of swv were calculated. results: in both the elasticity phantom and the liver, variability of swv was different between the depths in both probes. the depth with lower variability in the phantom was 4 and 5 cm with the convex probe and 2 cm with the linear probe. in the liver, the depth with lower variability was 4 cm with the convex probe and 3 and 4 cm with the linear probe. in comparison of two probes, the linear probe showed lower variability at 2 and 3 cm depth in the phantom and at 3 cm depth in the liver whereas the convex probe showed it at 4 cm depth in both the phantom and the liver. conclusions: in arfi elastography, measurement of depth shows different variability in both low and high frequency probes. to obtain the most reliable measurement of swv, using high frequency probe is recommended for 2-3 cm depth and using low frequency probe is recommended for 4-5 cm depth. disclosure: dr. lee has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging 100-year-old fetuses sabah servaes, children's hospital of philadelphia; teresa victoria, ann johnson, sandra kramer, richard markowitz, diego jaramillo purpose or case report: to demonstrate normal anatomy and pathology of medical museum specimens without disturbing the specimens. methods & materials: nine fetal specimens from a medical museum were imaged with ct and mri (1.5 t and 3.0 t) when possible with the specimens in their preserving fluid and containers. results: the 9 fetal specimens are estimated to be approximately 100 years old. one specimen is from the first trimester, seven are from the second trimester, and one is from the third trimester. normal anatomical structures at various stages of development including the brain (and varied sulcation pattern), lungs (lobar anatomy), and skeletal structures (several developmental features such as the ossification centers, perichondrial structures, and marrow cavitation) can be evaluated using imaging without causing harm to the specimens. pathologic entities including anencephaly and sirenomelia are also evaluated demonstrating features of these entities. conclusions: imaging historical fetal specimens provide an opportunity to evaluate normal developmental changes and pathological entities and also to gain a better understanding of the museum pieces without damaging the museum specimens. pediatric ct interpretations: does a tertiary care radiologist make a difference? wendy d. ellis, monroe carell jr. children's hospital at vanderbilt university; sumit pruthi, david johnson, christopher eakins, chang yu, marta hernanz-schulman purpose or case report: to determine whether a substantive difference exists between the pediatric imaging reports of community radiologists and reinterpretations by tertiary care radiologists at a free-standing children's hospital; and how those interpretations were related to the final diagnosis. methods & materials: this retrospective review examined the computed tomography (ct) reports of all pediatric patients referred to our tertiary care children's hospital over a 17 month period (1/1/2009-5/31/2010). the outside reports and the requested second interpretation reports were compared and their content categorized as "agreement" vs. "disagreement: major or minor". a representative sample of 92 major disagreements in which there was reliable followup information was correlated with the final diagnosis to determine if there was added value provided by the reinterpretation. results: ct scans from 732 patients were submitted for reinterpretation. disagreements were found in 301/732 cases (41.1%); with 50.5% (152/301) classified as major disagreements. among the 427 neurologic cases, major disagreements occurred in 53 patients (12.4%) and minor disagreements in 92 patients (21.5%). among the 305 body scans, major disagreements occurred in 99 cases (32.5%) and minor disagreements in 57 cases (18.7%). in the cohort of cases reviewed for final diagnosis, the second read interpretation was more accurate in 90.2% of cases with a p-value of <0.0001 (neurologic 84.4%, p0<0.0001; body 95.7%, p0<0.0001). conclusions: in our review, discrepancy rates between community and tertiary care radiologists in interpretation of pediatric ct scans were substantial, with discrepancies occurring in more than 40% of cases. further review of the cases for final diagnosis, showed that a significant number of the tertiary care interpretations were more accurate. possibilities that may account for this discrepancy include subspecialty training and elapsed time since performance of the study, which might provide additional clinical data in some cases. diagnostic ct scans performed at outside institutions should not be repeated considering added radiation burden to the child and additional expense. our data indicates there is added value to the reinterpretation which impacts the accuracy of the report (as assessed by the final diagnosis), and should be recognized by payors as integral to optimal patient care. ionizing radiation exposure from radiography in the neonatal intensive care unit-per-patient cumulative effective doses amaya basta, radiology and biomedical imaging, ucsf; jesse courtier, john mackenzie purpose or case report: to better understand the levels of exposure to ionizing radiation for infants in the neonatal intensive care unit (nicu). we retrospectively collected the number and types of radiographs performed per infant in our nicu by searching our radiology information system database over a five-year period. we focused on the most common examinations (98% of all radiographs) and assigned each an estimated equivalent dose based on published literature: chest and abdomen021.3 micro sieverts (μsv), one-view chest013.3 μsv, abdomen013.5 μsv, twoview chest026.6 μsv, two-view abdomen027 μsv. we then calculated a cumulative equivalent dose (ced) for each infant based on the number of each type of examination they received. descriptive statistics were generated to depict the distribution of number of examinations and ced. results: over five years, 2,626 infants cared for in our nicu received at least one radiograph of the chest and/or abdomen. the number of examinations obtained on these infants was 9.6, 4, 1, 137 (mean, median, minimum, maximum). the 1st quartile was 1 and the 3 rd quartile was 11 examinations. the cumulative equivalent dose these infants received was 157.9, 61.2, 13.3, 2, 092.2 μsv (mean, median, minimum, maximum) . the 1st quartile was 21.3 and the 3 rd quartile was 61.2 μsv. two hundred infants (7.6% of the study population) received a ced of over 500 μsv. conclusions: descriptive statistics provide a valuable assessment for the broad range of radiation that infants receive in the nicu. although the distribution is skewed towards a low level of exposure, a subset of patients (7.6%) received a ced of over 500 μsv. identification of factors that cause infants to enter this group will be important for future dose reduction strategies. poster #: cr-001 congenital cardiac fibroma: a case report earic bonner, meharry medical college, ebonner07@email. mmc.edu; seth crapp, david parra purpose or case report: a 5-week-old male presented to his pediatrician with a ii/vi systolic ejection murmur along the left sternal border. he had mild tachypnea without cyanosis. his oral intake was adequate with no evidence of failure to thrive. he was referred to a pediatric cardiologist who performed an ecg and a transthoracic echocardiogram. the ecg showed normal sinus rhythm at 135 beats per minute with no abnormalities. the transthoracic echocardiogram showed a 25 x 25 x 14 mm homogeneous mass originating from the anterior free wall of the right ventricle, and mild dilation of the right ventricle. mild dynamic subpulmonary stenosis and a secundum atrial septal defect were also noted. although the murmur was significantly louder at one month follow-up, a repeat echocardiogram did not reveal any increase in the size of the mass. at 2 months of age, a cardiovascular magnetic resonance imaging (cmri) study under general anesthesia was performed. cmri revealed a 16 x 21 x 22 mm cardiac tumor that was causing narrowing of the right ventricular outflow tract. the tumor was hypointense on t2-weighted imaging and hyperintense on t1weighted imaging, with positive delayed enhancement. these findings, along with the size and location of the mass, are consistent with a diagnosis of a cardiac fibroma. chest mra, that was also performed, showed normal extracardiac vascular anatomy with no evidence of peripheral branch pulmonary stenosis. cardiac fibromas do not usually increase in size; however, the concern is the child's risk of arrhythmias. frequent holter monitoring was recommended for this patient. considerations were also made for an electrophysiology study in the next 1-2 years to determine the risk of ventricular ectopy. at that point, the patient can be assessed for the possibility of resection of the fibroma. purpose or case report: treatment of pulmonary atresia is complex and demands intricate solutions. one solution is the creation of a conduit between the right ventricle and the main pulmonary artery. the lifespan of these conduits is limited by progressive occlusion over time, which can be treated with endovascular stent placement in lieu of surgical re-intervention. however, these stents are at high (40%) risk for fracture, typically at the stent waist. the radiologist should be aware of this complication, as they may be the first to identify it on chest radiograph. the purpose of this electronic poster is to familiarize radiologists with this entity by presenting 3 cases of stent fracture and migration. methods & materials: over a 6 month period, we identified three children with rv-pa stent fractures and associated stent migrations on chest radiography. imaging analysis was focused on the appearances of these fractured stents. patient management and outcomes were reviewed. results: three children, 2 males, 1 female (ages 4, 3, and 3 years) were found to have asymptomatic rv-pa conduit stent fractures with fragment migration. one chest xray was performed in the er for fever and cough; one was pre-op for gi surgery; one was done to confirm abnormal findings seen on a routine cardiac echo. the time between stent placement and fracture detection ranged from 1 to 22 months. two patients had stent fractures and embolizations to the right ventricle that required open surgery to remove stent fragments. the third patient had embolization to both pulmonary arteries, but did not require treatment. all patients did well. conclusions: stent fractures and migrations are a relatively common complication of rv-pa conduit stent placement. pediatric radiologists need to be aware of this complication in order to provide value-added interpretations. purpose or case report: we describe the case of a 23 week stillborn fetus with a 5.5 cm diameter craniopharyngioma detected by ultrasonography. a g1p0 woman in her third decade had ultrasonographic examination showing hydrocephalus, polyhydramnios and an intracerebral mass. the nature of the mass was uncertain and intracerebral hemorrhage was considered. the pregnancy was terminated at 23 weeks gestation. at postmortem examination the decedent was a 650 g male fetus with a head circumference of 24.5 cm and a crown-rump length of 21.8 cm. anterior and posterior fontanelles appeared large. no other external abnormality was found. the placenta was unremarkable and cytogenetics on placental tissue showed a normal male karyotype. examination of fetal viscera was remarkable for mildly underweight adrenal glands (0.75 g, expected 1.5 g) and hepatomegaly (66.4 g, expected 21.7 g). intracranial csf was increased in volume. there was a suprasellar 5.5 cm diameter somewhat gritty, but smooth-surfaced tumor. the brain and tumor together weighed 135 g. the floor of the cranium and sella turcica were grossly normal. histologic examination of the tumor showed an adamantinomatous type craniopharyngioma with characteristic epithelium, stellate reticulum, focal keratinizing squamous epithelium and calcification. pre-and postnatal mri of caudal regression syndrome claire b. beaumont, md, university of arkansas for medical sciences, cbbeaumont@uams.edu; nafisa k. dajani, leann e. linam purpose or case report: caudal regression syndrome is a rare form of caudal dysplasia characterized by a spectrum of findings including agenesis of the lumbosacral vertebra, multiple orthopedic deformities in the lower limbs, as well as anomalies of the gastrointestinal and genitourinary tracts. the mechansim of caudal regression syndrome is not completely understood but is believed to be secondary to a defect in the induction of caudal elements. mri is a valuable tool for identifying the specific anomalies involved with caudal regression syndrome on a case-by-case basis. the following is a case from our institution which includes both pre-and postnatal mri. unsuspecting tuberous sclerosis diagnosed on neonatal cranial ultrasound vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; puneet gupta, richard thomas, vaseem iqbal, jan najdzionek. purpose or case report: tuberous sclerosis (ts) is a rare autosomal dominant genetic disorder causing hamartomatous proliferation in number of organ systems. because the classical triad of epilepsy, mental retardation and adenoma sebaceum is not commonly seen on clinical examination, imaging plays a central role in the diagnosis and treatment of tuberous sclerosis. central nervous system features of ts include subependymal nodules, cortical tubers, subependymal giant cell astrocytoma, white matter bands and cysts. in patients with ts, cerebral involvement in the form of subependymal nodules is seen in 95% to 100% and white matter abnormalities are noted in 40% to 90% of cases. knowledge of expected radiological features is thus important in making the correct diagnosis. recent studies have indicated that earlier appearance of brain lesions indicate a greater risk of mental retardation and a more severe clinical course. we present a case of a 23-day-old neonate who was referred to us with concerns for hydrocephalus. the cranial ultrasound demonstrated multiple echogenic subependymal nodules of varying sizes and mild asymmetry of the ventricles. the differential diagnosis included ts, torch infections, and x-linked subependymal heterotropia. areas of increased echogenicity were noted within the white matter of the left frontal lobe, which favored ts. subsequently, an mri was performed to validate these findings and assess for additional white matter lesions. the mri showed classic manifestations of ts that included periventricular lesions and streaky, linear, wedge-shaped hyperintensities on flair imaging. a noncontrast ct scan was also performed which revealed classic calcified subependymal nodules. cardiac rhabdomyoma and renal angiomyolipoma are the other recognized manifestations of ts and were respectively excluded by subsequent echocardiogram and renal ultrasound. pyloric atresia with epidermolysis bullosa: fetal mri diagnosis with postnatal correlation arnold c. merrow, md, radiology, cincinnati children's hospital medical center, carl.merrow@cchmc.org; jason s. frischer, anne w. lucky purpose or case report: pyloric atresia (pa) is an uncommon disorder, accounting for 1% of congenital gastrointestinal atresias. up to 55% of cases have associated anomalies, the most common of which is epidermolysis bullosa (eb). prenatal findings have been reported sonographically for each of these anomalies, both in isolation and in the rare case of association. a case of isolated pa has been reported by fetal mri. we present the first reported case of pa with eb diagnosed by fetal mri with corroborative postnatal imaging and surgical findings. the mother of this child was initially referred to the fetal care center of cincinnati at 21 weeks gestation for a possible myelomeningocele diagnosed by prenatal ultrasound at an outside facility. these ultrasound images were not available for review at the time of our workup. a fetal mri was the first study to be obtained at our institution. the mri showed no myelomeningocele or brain anomalies. the stomach was moderately enlarged throughout the exam and did not empty. subjective polyhydramnios was also noted. no duodenal dilation was seen, and there was minimal fluid in the distal bowel loops. this constellation of findings raised concern for pyloric atresia, resulting in a careful search for any sign of epidermolysis bullosa due to a known association of these disorders. prominent debris was seen layering dependently in the amniotic fluid and in the dilated fetal stomach, and the external ears were abnormally small and misshapen. the pa-eb association was proposed as the underlying diagnosis based on our mri findings. it was also postulated that skin blistering over the lumbosacral spine at the time of the prior outside ultrasound could have mimicked a myelomeningocele, thus prompting the referral to our center. at delivery, the baby had numerous skin defects, and the ears were malformed. an abdominal radiograph obtained after nasogastric tube placement and air injection showed no gas beyond the stomach. a pyloric ultrasound showed a distended stomach without a patent pyloric channel to the duodenal bulb, consistent with pyloric atresia. a skin biopsy confirmed epidermolysis bullosa, and the patient underwent a resection of the pa with gastroduodenostomy. the baby subsequently expired less than two weeks later, most likely due to sepsis based on wound cultures and autopsy results. our case demonstrates the ability of fetal mri to diagnose this rare condition and highlights the key imaging manifestations of the pa-eb association. disclosure: dr. merrow has indicated that he is an author for amirsys and receives a royalty accordingly. purpose or case report: we demonstrate a case where the changing position of the contrast filled appendix lead to the diagnosis of malrotation, with review of the embriology of intestinal rotation. a newborn preterm female presented with a golf ball sized umbilical mass, that reduced by itself, thought to represent an umbilical hernia vs omphalocele. she was unstable to undergo an upper gi exam under fluoroscopy, therefore a limited contrast study was performed at bedside and was inconclusive for malrotation. subsequent nicu radiographs showed changing position of the appendix filled with residual contrast, visiting all quadrants of the abdomen in a random pattern over a few days period. this confirmed our suspicion for malrotation. it is well know that in malrotation the position of the cecum can be variable, most commonly located in the right upper quadrant or left lower quadrant. to our knowledge it has not been described yet that the changing position of the appendix can lead to the diagnosis of malrotation. through this case we display the embriology of the intestinal rotation and the radiologic signs of malrotation. poster #: cr-008 mr imaging patters of liver transplant complications in the pediatric population edward richer, md, emory university, richerej@gmail. com; adina alazraki, jonathan loewen purpose or case report: pediatric liver transplantation is a relatively common surgery, with more than 500 transplants in the united status annually. the spectrum of post transplant complications has been previously described, primarily utilizing ultrasound. as mri has become a more widely used technique in pediatric imaging, and ultrasound findings may be non-specific, knowledge of mr imaging patterns is an important adjunct in the post-transplant evaluation. we present a spectrum of complications, including vascular, biliary, hepatic parenchymal, and systemic complications. methods & materials: using an electronic record system, we identified pediatric patients with prior liver transplantation who subsequently underwent abdominal mri at our institution and were found to have a post transplant complication. patient management and outcomes were reviewed. results: our review of a subset of the available patients shows vascular complications to be the most commonly encountered abnormality at our institution, including hepatic artery stenosis/thrombosis, and portal vein stenosis/ thrombosis, cavernous transformation of the portal vein. biliary complications were relatively common, including bilary stenoses and bilomas. hepatic parenchymal and systemic complications, such as ptld, were less common. we demonstrate the mr imaging patterns of these complications. conclusions: pediatric liver transplantation is a relatively common surgery, and the mri appeance of post transplant complications warrants illustration as abdominal mri becomes more widely used in pediatric imaging. we present a pictorial review of common patterns of complication. imaging of progressive familial intrahepatic cholestasis (pfic) matthew d. dobbs, md , radiology, vanderbilt university medical center, matthew.dobbs@vanderbilt.edu; sumit pruthi, stephanie e. spottswood purpose or case report: progressive familial intrahepatic cholestasis (pfic) is a relatively rare pediatric liver disease due to a genetic mutation (abcb11 gene on chromosome 2q24-31) in a bile salt export protein causing cholestasis leading to chronic inflammation within the biliary system. the diagnosis is made clinically with detection of a low ggt in the face of an elevated bilirubin and alkaline phosphatase. genetic testing confirms the diagnosis. one of the 3 subtypes, type 2, was shown in 2006 to be highly related to the development of hepatocellular carcinoma. the vast majority in children in this study developed hcc at less than 2 years of age. radiological contribution to the management of these chronic liver disease patients is to perform surveillance imaging to detect hcc. due to the rarity of this condition, almost no reports exist in the radiological literature describing the imaging features or management of this condition. our presentation will review the imaging findings in our small population of pfic type 2 patients on us, ct, and mri. we will also review suggested surveillance imaging techniques and imaging algorithms. renal rhabdoid mimics wilms tumor vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; paul montgomery, jan najdzionek, vaseem iqbal purpose or case report: in the past most pediatric renal tumors have been classified together under the umbrella of wilms tumor. however, over the last decade with advancement in imaging, several distinctive imaging features specific to renal tumors have been recognized which aid in their classification as being distinct pathologically. we present a case of rhabdoid tumor where in the primary tumor arose from the kidney. it had classical imaging features of wilms tumor. we want to highlight that even with the most sophisticated imaging techniques, specific renal tumors cannot always be diagnosed with preoperative imaging and how this alters the management and prognosis for child with a renal mass. in our case, the postoperative findings, pathology and immunohistochemical techniques confirmed a rhabdoid tumor. differentiation of these two tumors is essential since in patients with rhabdoid tumor survival is poor with 4-year overall survival rates of 42% for stages i and ii and 16% for stages iii, iv, and v. on imaging, there are several features that suggest the diagnosis of rhaboid tumor. these include subcapsular fluid collections, linear calcifications outlining tumor lobules, and vascular invasion. also, a pertinent feature of rhabdoid tumor due to its aggressive nature is the presence of lung metastasis (83%) and synchronous malignant brain lesions (15%). these findings were not present on our case, which led us in formulating a diagnosis of wilms. our patient is unusual in the fact that the local renal findings and absence of metastasis, synchronous malignant lesions, and vascular invasion led us to an incorrect diagnosis of wilms tumor. in conclusion, we would like to stress that diagnosis of rhabdoid tumor of the kidney on imaging presents a challenge because of its imaging similarity to wilms tumor. ectopic ureters in young infants: mru findings shin-lin shih, md, department of radiology, mackay memorial hospital; yi-fang chen, chun-chao huang, fei-shih yang purpose or case report: to localize the terminations of ectopic ureters by mri methods & materials: mr urography (mru) was conducted in four female patients with hydroureter and a suspected ectopic orifice. mr imaging was performed with a 3 t mr scanner (achieva; philips). the imaging protocol mainly consisted of a single-shot t2-weighted turbo spin echo sequence with a slice thickness of 4 mm and multiplanar reformations. the ages of the four patients were 1 day, 3 days and 2 months (for two). the latter two patients presented with urinary tract infection. the newborn patients presented with abnormal prenatal examination. the pertinent findings and descriptions of a variety of renal anomalies were described. results: the locations of the ectopic ureters were two in the vagina, one in the uterus and one in the bladder neck. the associated renal anomalies were a right duplex kidney in four, a left duplex kidney in one, a left ectopic dysplastic kidney in one and vesicoureteral reflux in one (confirmed by vcug). conclusions: mru may demonstrate the exact point of termination of an ectopic ureter and also the associated renal anomalies. poster #: cr-012 acquired polycystic kidneys in neuroblastoma survivors richard bellah, , radiology, the children's hospital of philadelphia, bellah@email.chop.edu; bernard kaplan, camilo jaimes, yael p. mosse, jill p. ginsberg, kevin e. meyers purpose or case report: neuroblastoma (nbl) is the most common extracranial solid malignancy of childhood. with current therapy, the prognosis and long term survival of patients affected by this condition has dramatically improved. nevertheless, the treatment for nbl may account for some complications further in life. in patients with neuroblastoma, acute renal failure can occur usually as a result of a thrombotic microangiopathy associated with bone marrow transplantation. in addition, end-stage renal disease has been reported in long-term survivors of nbl. this exhibit describes and illustrates the first case series of five patients with treated nbl in whom the imaging features of polycystic kidney disease (pkd) developed over time, and in some cases, as progressive renal failure ensued. methods & materials: medical and imaging records were reviewed (irb approved) of patients with treated nbl in whom pkd became apparent during the course of followup imaging. results: five patients displayed findings of pkd on us and/or ct. three of the five patients (where images were available) had normal renal imaging at time of nbl diagnosis. the mean age at nbl diagnosis was 2.4 years (range 1.3-3.3 yr). the mean age at time pkd was detected was 14.6 years (range 8-18 yrs). none of the patients had a family history of pkd, or had previously undergone dialysis. all patients received chemotherapy and total body irradiation prior to bone marrow transplantation. four patients survived nbl therapy but eventually developed end-stage renal disease. conclusions: an association between acquired pkd and nbl has not been previously reported. the etiology of this observation is still unclear, but a toxic insult is likely to account for the renal changes. further research is needed to establish the epidemiology, prognosis, and etiology of this association. abnormal migration of the retention anchor suture in a case following gastrostomy tube insertion surendra narayanam, mbbs, dmrd, dnb, division of image guided therapy, department of diagnostic imaging, the hospital for sick children, nrssbabu@gmail.com; joao amaral, luke toh, bairbre connolly, vicente deoliveira, dimitri parra purpose or case report: during percutaneous gastrostomy tube placement, retention anchor suture(s) are deployed into the stomach to tack the anterior gastric wall to the abdominal wall. in our practice the thread of the retention anchor suture is cut at 14 days and the metallic portion passes pre rectum. we report an interesting and very rare migration of the metallic portion of the retention anchor suture in post-primary gastrostomy tube insertion. an 8-month-old girl, with a mitochondrial disease and severe hypotonia underwent percutaneous gastrostomy placement. during the procedure the retention anchor suture thread snapped and the metallic portion of the suture remained within the stomach. day1 post procedure, the child became uncomfortable, so a gastrostomy tube check was performed. the suture was not visible in the abdomen on abdominal x-ray or fluoroscopically. on close review of the images, the suture was found projected over the distal esophagus. initial impression was the anchor suture had refluxed into the esopahgeal lumen. careful attempts were made to remove it along with the nasogastric tube, from above under fluoroscopic control. however on withdrawal of the nastogastric tube, the retention anchor suture moved enbloc with the nasogastric tube. once removed the retention anchor suture was confirmed to be within the nasogastric tube. this case illustrates the importance of examining the chest x-ray carefully before assuming a retention anchor suture has passed. to understand the appropriate post procedural radiographic workup and its technique for timely diagnosis. 3. to learn the potential complications of delayed diagnosis. pediatric retroperitoneal synovial sarcoma ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: pediatric synovial sarcoma most commonly affects the extremities, especially the lower thigh and knee region; other primary sites such as the retroperitoneum have been only infrequently reported. we report an extremely rare case of a retroperitoneal synovial sarcoma masquerading as retroperitoneal hematoma in a 16-year-old white female with non-traumatic back pain and non-contrast enhanced ct findings of right quadratus lumborum and psoas region presumed hematoma. coagulation studies revealed factor xi deficiency also known as hemophilia c. however, on follow-up imaging, the presumed retroperitoneal bleed persisted and a subsequent mr examination revealed a solid enhancing mass. ct, mr, and fdg-pet findings as well as a brief histopathology are discussed. our case is rare in the regards that the tumor occurred in an uncommon retroperitoneal location in a pediatric patient and was mimicking a retroperitoneal hematoma which posed a significant diagnostic challenge. despite a rare entity, synovial sarcoma among other sarcomatous lesions maybe considered in the differential consideration of a spontaneous retroperitoneal hematoma even in hemophiliac patients. longitudinal bracket epiphysis michael jubang, geisinger, mjjubang@geisinger.edu; farzad sedaghat, william j. malone, george wu, william mirenda purpose or case report: longitudinal bracket epiphysis is a rare anomaly with multiple synonyms such as delta bone, triangular bone, and congenital angular deformity. the purpose of this case report poster is to discuss an 11-month-old male born with an adducted right great toe with a broad nail and a notch in the center of the distal phalanx. the review will discuss radiographic findings, the natural progression of the disease, the treatment options, the mri findings used for pre-surgical planning, and associated pathology. whole body mri in pediatric non oncologic diseases: pictorial review ramy el jalbout, md, radiology, chu sainte justine, ramy.jalbout@yahoo.com; vijay moorjani purpose or case report: with the advances in scanning techniques and the scanning sequences, the role of wbmri is expanding. mri has a great role in the pediatric population owing to its inherent advantages namely lack of radiation, high tissue specificity, and high diagnostic yield at the level of the entire body under a single sedation. unlike the application of wbmri in the assessment of metastasis and bone marrow involvement in leukemia, its role in systemic diseases is yet to be further investigated. certain diseases such as crmo are very often multifocal. the extent of osteonecrosis in patients on steroids, dermatomyositis and the lesions related to child abuse are very often wide spread in the skeleton. we intend to present some of the findings of these pediatric systemic and multifocal diseases on wbmri. chronic relapsing multifocal osteomyelitis (crmo): crmo can be acute or chronic and is multifocal. the abnormality manifests as high signal intensity. wbmri can guide for the best site for biopsy and provides monitoring for response to treatment. osteonecrosis: only few small studies evaluated the usefulness of wbmri in the diagnosis of both the symptomatic and asymptomatic sites of osteonecrosis in all patients on steroid therapy. wbmri is more sensitive than conventional radiographs. the abnormalities are typically geographical areas of high stir signal intensity. myopathies: wbmri has also the role of detecting the extent of idiopathic inflammatory myopathies such as dermatomyositis in the entire skeleton. child abuse: wbmri has a low sensitivity for the highly specific fractures that are pathognomonic for child abuse. conclusions: wbmri is a useful examination in the pediatric patient that is radiation free, quick and allows imaging of the entire body. it is an adjunct to dedicated mris to look for multifocality and extent of systemic diseases such as crmo, osteonecrosis in patients on steroids and dermatomyositis. it has a great potential as a screening examination but at the same time can detect both the symptomatic and the asymptomatic lesions in the bone marrow and muscles that are otherwise not seen on conventional radiography. it also allows guidance for biopsy and monitors response to treatment. mobile "cerebroliths" in hemihydranencephaly: a case report usha d. nagaraj, md, the ohio state university medial center, usha.nagaraj@osumc.edu; brent adler purpose or case report: hydranencephaly is a congenital central nervous system disorder manifested by the replacement of the cerebral hemispheres with a thin membranous sac filled with cerebrospinal fluid and necrotic debris. hemihydranencephaly is an extremely rare brain condition in which the vascular anomaly is unilateral, with fewer than 10 cases previously reported in the literature. this is a case of a 4-month-old male who presented to the ophthalmologist for evaluation of possible leukocoria of the right eye. the patient had a history of a difficult vaginal delivery that required forceps delivery with possible associated trauma to the right eye. dilated fundoscopic exam revealed retinal calcifications. this caused a clinical concern for retinoblastoma and ct and mri of the orbits were obtained. ct demonstrated profound dilatation of the left lateral ventricle with only a thin rim of cortex surrounding it. there was some midline shift to the right with mild dilatation of the right lateral ventricle. the thalami and brainstem were spared. there were multiple soft tissue bodies that layered in the dependent portion of the left lateral ventricle, which were isodense to grey matter. mri revealed similar findings consistent with hemihydranencephaly involving the left cerebral hemisphere. there were multiple round soft tissue masses that measured up to 1 cm in size that layered posteriorly in the left lateral ventricle. these masses were isointense to grey matter on t2 and hyperintense on t1. when the patient was placed with his head turned to the left, these masses moved to the dependent portion of the left lateral ventricle. the orbits were normal on both ct and mr. these soft tissue collections are presumed to be mobile collections of infarcted brain tissue. this unusual appearance has not been described in the radiology literature. we review the ct and mr findings and review the relevant literature. purpose or case report: citrullinemia type i is a rare inborn error of urea cycle metabolism resulting in hyperammonemia. in the classic form, the newborn presents with poor feeding, vomiting, progressive lethargy and signs of increasing intracranial pressure 3-7 days after birth, rapidly progressing to apnea, coma and death if left untreated. we present a case of a term infant who presented to the hospital on the 5th day of life with a typical history of poor feeding and profound hypotonia. upon admission he had multiple episodes of apnea and hemodynamic instability prompting intubation and intensive support. laboratory evaluation revealed multiple abnormalities, most notably, hyperammonemia (910umol/l) and elevated citrulline (>800umol/l). mri of the brain performed on the 7th day of life showed findings consistent with term hypoxic ischemic encephalopathy with restricted diffusion in bilateral rolandic cortex and subcortical white matter, bilateral caudate heads and lenticular nuclei, bilateral insular cortex, and bilateral cerebral peduncles. the genu of the corpus callosum, bilateral deep frontal white matter, and the left parietal white matter also demonstrated restricted diffusion suggesting infarction secondary to thrombosis of deep intramedullary veins. an area of restricted diffusion in the right parietal cortex was suspicious for superficial venous infarct. review of the literature reveals that this case of neonatal citrillunemia has unique mri findings. while our patient had diffusion changes with some shared similarities to the previous two cases in the literature, there are also findings consistent with deep intramedullary venous thrombosis and infarction. poster #: cr-020 duplicated internal auditory canal: a rare anomaly of the temporal bone ahmad aouthmany, university of toledo medical center, ahmad.aouthmany@utoledo.edu; asif abdullah purpose or case report: duplicated internal auditory canal (iac) is a rare anomaly of the temporal bone, which is usually associated with sensorineural hearing loss. only a few cases have been previously described in literature. we describe an extremely rare case of duplicated right internal auditory canal in a six month-old patient with a history of down syndrome. a six month-old male with trisomy 21 presented with profound bilateral sensorineural hearing loss. the patient failed the newborn hearing screening tests. past medical history was unremarkable for recurrent ear infections. on focused physical examination, the auricles were normal appearing. external auditory canals were patent bilaterally revealing clear and translucent tympanic membranes. patient did not reveal a facial palsy. subsequently, a high resolution computed tomography (hrct) of the temporal bone was performed. duplicated appearance of the right internal auditory canal with separation of facial and vestibulocochlear segments was noted. the facial nerve canal demonstrated normal caliber while there was significant narrowing of the cochlear canal near the fundus. significant stenosis of the vestibulocochlear segment of the duplicated iac was identified at the porus acousticus. dehiscent right posterior semicircular canal was also seen. an enlarged right vestibule was also noted. a single iac was identified on the contralateral side with significant stenosis at the porus acousticus. high-resolution magnetic resonance imaging of iac was recommended which revealed normal appearance of the bilateral cochlear and vestibular nerves. duplication of the iac is an extremely rare anomaly involving a redundant osseous canal extending from the cerebellopontine angle through the otic capsule bone toward the labyrinth or cochlea. a duplicated iac may or may not be associated with congenital sensorineural hearing loss secondary to aplasia or hypoplasia of the vestibulocochlear nerve. to evaluate for structural abnormalities that may preclude cochlear implantation, it is important to evaluate pediatric patients with sensorineural hearing loss radiologically. although hrct is the best imaging modality for evaluation of osseous iac, the iac contents are best viewed on mri in oblique sagittal planes of the iac using a 3-d volumetric steady state sequence. neuroimaging in hemiplegic migraine: cases and review of the literature nicholas v. stence, md, children's hospital colorado-radiology, nicholas.stence@childrenscolorado.org; sita kedia, john a. maloney, jennifer armstrong-wells, timothy bernard purpose or case report: hemiplegic migraine (hm) is a rare variant of migraine with aura. it is characterized by a motor deficit lasting up to 24 h that is fully reversible. little neuroimaging data for hm exists in the literature. we report our experience with two pediatric cases of hemiplegic migraine. we also review published cases of pediatric hm with abnormal findings on neuroimaging. methods & materials: cases 1 and 2 presented to our institution with severe headache (ha), acute right-side weakness, aphasia, and altered mental status (ams), which did not resolve after 24 h. magnetic resonance imaging (mri) and genetic testing are reviewed for these cases. the literature was reviewed for pediatric cases with neuroimaging changes during hm attacks. results: initial mri, including diffusion-weighted imaging (dwi), was negative in both patients within 24 h of onset. repeat mris at 93 h (case 1) and 75 h (case 2) were both positive for mild hyperintensity on trace diffusion images, and corresponding reduced diffusion on adc maps, involving regions of the cortex and juxtacortical white matter in left middle cerebral artery distributions. these findings completely resolved at 3 months in both cases. mr angiograms (mra) were negative in both cases. case 1 had a family history of migraines and was found to have an unreported mutation in atp1a2 gene at a highly conserved location in vertebrates. case 2 had a family history of hm and was found to have an indeterminant mutation in the cacna1a gene. infectious, metabolic and hypercoagubility work up was negative. case 1 required inpatient rehabilitation and at 1 year follow up was requiring speech therapy. case 2 resolved completely. in the literature, 6 cases of hemiplegic migraine with neuroimaging changes were reported. all cases had prolonged hemiplegic migraines (symptoms>24 h) and showed cerebral edema with or without restricted diffusion. conclusions: all eight hm cases in the literature with abnormal findings on neuroimaging had prolonged attacks. mris for our two cases and two cases reported in the literature were initially normal at admission. mild swelling and restricted diffusion developed in our two cases after 24 h, and resolved on follow up mris. subtle findings on diffusion and t2 imaging may lag behind the clinical picture in hm, therefore serial neuroimaging may be useful in individuals with prolonged symptoms. most cases eventually show resolution clinically and on mri. correlation of neurosonographic anatomy with matching mr scan planes denise castro, hospital for sick children, denisecastro22@ gmail.com; pam rasalingham, omar islam, don soboleski purpose or case report: new high-resolution mr sequences have allowed for exquisive anatomic detail and enables reconstruction of images in any scan plane desired. this ability allows for precise matching of mr image planes with the standard oblique coronal, sagittal and axial images obtained during routine neurosonography. the purpose of this poster is to correlate the morphology demonstrated on neurosonography with the mr image, utilizing this ability in order to enhance our understanding of the neuroanatomy distinguishable on sonographic imaging. we believe this will allow a better appreciation of the subtle differences in echotexture of neuroanatomic structures which are often ignored or overlooked on neurosonography and help improve our detection of subtle sonographic abnormalies. ectopic cerebellum in the posterior cranial fossa: report of a case and review of the literature usha d. nagaraj, md, the ohio state university medical center, usha.nagaraj@osumc.edu; daniel boue, lisa martin purpose or case report: cerebellar heterotopia is a common congenital anomaly frequently encountered in the form of cell rests around the fourth ventricle. however, isolated well-differentiated cerebellar ectopia is extremely rare. of the 8 previously reported cases in the literature, only 4 have presented as a discrete, extraaxial mass and none have been described in the posterior cranial fossa. we present a case of a 5-year-old male who initially presented with persistent daily headaches. physical exam including a detailed neurologic exam was within normal limits. non-contrast computed tomography (ct) of the brain was initially performed, demonstrating no abnormalities. further work-up with magnetic resonance imaging (mri) was performed, which revealed a well-defined, extra-axial mass superior to the cerebellum and inferior to the tentorium, immediately beneath the vein of galen. the mass was isointense to grey matter on t1 and t2 sequences and there was no significant enhancement on post-contrast images. there was mass effect on the vermis and the cerebellar tonsils were displaced 3 mm below the foramen magnum. neurosurgery was consulted and the mass was removed for diagnosis and treatment of the patient's symptoms. the mass was easily identified intra-operatively and gross total resection was accomplished successfully. pathologic analysis of the mass revealed well-formed cerebellar tissue without evidence of neoplasia. to the best of our knowledge this is the only case of ectopic cerebellum presenting as a discrete extra-axial mass in the posterior cranial fossa. our case shows that an extra-axial mass that parallels grey matter on all sequences can be a presentation of ectopic cerebellum. we describe the ct and mri findings, surgical and histopatholgical results and review the relevant literature. pediatric isodense acute subdural hemorrhage jeffrey s. kao, md, msee, university of kansas-wichita, run4boston@gmail.com; debbie desilet-dobbs purpose or case report: the density (attenuation coefficient) of subdural hemorrhage (sdh) in computed tomography (ct) is important in assessing the acuity of sdhs. an acute sdh is traditionally described as hyperdense and then becoming isodense in approximately 3 weeks when entering the subacute phase. in this report, we document the case of a pediatric patient with the new appearance of an acute sdh within 40 h of the prior ct that was isodense. greater than 95% of the collection was isodense, with a small focus of hyperdensity. acute sdhs are known to be isodense to gray matter in patients with anemia (wp smith, am j neurorad 1981). however, the hemoglobin and hematocrit was within normal limits. in addition, acute sdhs that are only a few hours old can have a mixed hyperdense and hypodense appearance because of uncoagulated blood before clotting takes place (j provenzale, ajr 2007) . thus, an acute sdh can have an isodense appearance in a non-anemic patient. radiologists should consider the possibility of an acute sdh with an isodense appearance, especially in case of possible non-accidental trauma where timing of an injury is important. undifferentiated sarcoma of the esophagus in an 11year-old male: case report and radiologic/pathologic correlation michael e. daniel, md, ut southwestern / children's medical center dallas, michael.daniel@utsouthwestern. edu; lisa sutton, sandy cope-yokoyama, neil j. fernandes purpose or case report: mesenchymal neoplasms of the gastrointestinal (gi) tract occur infrequently in the adult and are extremely rare in the pediatric population. the occurrence of these lesions in the esophagus is limited to a collection of case reports in the available literature. most esophageal mesenchymal tumors in the pediatric gi tract are benign leiomyomas. the vast majority of malignant mesenchymal tumors in children are categorized as either sarcomas or gastrointestinal stromal tumors (gist). we report a case of a high grade undifferentiated sarcoma of the distal esophagus in an 11year-old male. while this tumor most closely resembles a gist, the immunohistochemical profile of the lesion is not typical of any distinct mesenchymal neoplasm. a review of the literature demonstrates a single case report of a likely benign undifferentiated mesenchymal neoplasm of the distal esophagus in an adolescent. to our knowledge, this is the first reported case of an undifferentiated esophageal sarcoma in a pediatric patient. we provide radiologic and pathologic features of the above lesion, and review the typical imaging and pathologic characteristics of mesenchymal gi neoplasms. potential airway management issues in sedated children kimberly fagen, md, ms, children's national medical center, kfagen@childrensnational.org; nadja kadom, ira cohen purpose or case report: many pediatric imaging studies require sedation. it has been shown that a variety of health care professionals other than anethesiologists may provide sedation, including advanced practice registered nurses, nurse practitioners, physician assistants, fellow level trainees, emergency medicine physicians, intensivists, pediatricians and, last but not least, radiologists. moderate sedation, also called "conscious sedation", does generally not require an anesthesiologist as there is usually adequate spontaneous ventilation and no airway intervention required. however, in case of a complication during the imaging study intubation may become necessary. for patients with certain congenital or acquired conditions emergent intubation may be very difficult and should be brought to the attention of an anesthesiologist prior to inducing moderate sedation. the four "d's" is a quick way to assess potentially difficult airways that necessitate consultation with anesthesia prior to moderate sedation: dentition (incisor/tooth size, dental alignment, and macroglossia), distortion (swelling from infection, tumor, or trauma), disproportion (hyoid-chin ratio, such as with micrognathia), and dysmobility (jaw or cervical spine movement issues, i.e. trauma or atlanto-occipital instability). presence of some of these features may be an indication to consider general anesthesia for sedation; at the very least, anesthesiologist's awareness of a potentially difficult intubation adds to patient safety during moderate sedation. purpose or case report: lymphangiomatosis describes the presence of multiple lymphangiomas often with multiorgan involvement; typically bones, spleen, mediastinum and lungs. although lymphangiomatosis has been described in patients ranging from birth up to 80 years, it most frequently presents in childhood. the lesions can occur in any tissue in which lymphatics are normally found, with a predilection for neck and chest involvement. the clinical presentation is variable including pleural or pericardial effusion, hemoptysis, protein wasting enteropathy, peripheral edema, hemihypertrophy and disseminated intravascular coagulopathy. the coexistence of lytic bone lesions and chylothorax serves as an important diagnostic clue. we describe typical radiographic, ct and mri findings in the appropritate clinical setting that narrow the differential diagnosis and raise concern for this rare entity as the etiology for the patient's symptoms. we report a 12-year-old girl and 2year-old boy with pulmonary lymphangiomatosis with typical presentation and imaging findings. results: bilateral interstitial infiltrates, pericardial and pleural effusions are evident on chest radiograph. sampling of the pleural fluid demonstrates chylous effusion. ct scans of the thorax reveal diffuse smooth thickening of interlobular septa and bronchovascular bundles with extensive infiltrative involvement of mediastinal fat. osseous and splenic lesions are demonstrated both on ct and mr. differential diagnosis includes interstitial edema, lymphoma and sarcoidosis. conclusions: the natural history of pulmonary lymphangiomatosis is characterized by progressive growth and compression of adjacent structures. therapy should aim to decrease the compressive effects, to control chylous effusions, and to maintain cosmesis. the success of surgical resection is limited by inability to separate lymph collections from normal structures. characteristic clinical and radiographic presentation, chylothorax, and extrathoracic lymphatic dysfunction should prompt a consideration of lymphangiomatosis and prevent delay in diagnosis. aortic arch congenital anomalies: what the radiologist needs to know luana stanescu, radiology, seattle children's hospital, stanescu@u.washington.edu; stephen done purpose or case report: 1. review classic imaging findings in congenital aortic arch anomalies which can improve detection on radiographs and barium esophagogram 2. describe pertinent embryologic basis of the radiologic findings 3. describe correlative imaging findings on ct and/or mri in dedicated cases 4. describe common diagnostic pitfalls methods & materials: after obtaining institutional irb approval we reviewed various patients presentations with this condition and analyzed images to characterize this particular entity and it's manifestations for better definition of diagnostic criteria. results: radiographs and barium esophagogram: algorithmic approach in reviewing chest radiographs in order to improve detection of aortic arch anomalies; classic findings and common pitfalls. cross-sectional imaging (ct and mri): what the surgeons need to know before surgical repair; detection of associated cardiac anomalies. sample cases: double aortic arch, double aortic arch with complete or partial atresia of one of the arches. conclusions: major teaching points of this exhibit are: 1. review of classic features of congenital aortic anomalies on radiographs, esophagogram, ct and mri with pertinent embryologic basis 2. describe the utility of various imaging modalities in congenital aortic anomalies, emphasizing common pitfalls. cardiovascular and mediastinal imaging in children with unexpected clinical presentation shunsuke nosaka, md, radiology, national center for child health and development, nosaka-s@ncchd.go.jp purpose or case report: children with cardiovascular and mediastinal diseases can be congenital or acquired in etiology. they usually present with straightforward clinical course. in certain situation, however, some of the children show unexpected clinical presentation predominantly with those of neighboring organs such as respiratory tract, hepatobiliary system, and gastrointestinal tract. these unexpected presentations can be the cause of delay in proper diagnosis and treatment. the purpose of this exhibit is demonstrate a variety of imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. this exhibit is case based presentation of cardiovascular and mediastinal imaging in children including tips, pitfalls and lessons learned among patients presented with unexpected clinical presentation. diagnostic imaging modalities for cardiovascular disease usually consist of various combinations of plain radiography, ultrasound, ct, mr imaging, fluoroscopy, nuclear medicine, and angiography. the general concept of alara-as low as reasonably achievable-should always be utilized when radiation-producing modalities are indicated in children. the diseases included will be double aortic arch found during workup for the cause of aspiration pneumonia, unilateral pulmonary vein atresia presented with recurrent episodes of pneumonia, severe mitral regurgitation secondary to chordal rupture mimicking fluminant hepatic failure, myocarditis initially present as acute abdomen, cardiomyopathy as unusual initial presentation of neuroblastoma, and thymolipoma mimicking gradual development of cardiomegaly. conclusions: it is important for radiologist to be familiar with imaging findings of cardiovascular and mediastinal diseases in children with unexpected clinical presentation. cardiac embryology made easy: a novel teaching approach using claymation andrew phelps, children's hospital boston, aphelpsmd@ gmail.com; purpose or case report: congenital heart disease can be an intimidating subject for radiology residents, and cardiac embryology is key to its understanding. however, this can be an equally intimidating topic to teach! various diagrams and animations are available in textbooks and online, but much like advanced origami, many of these resources suffer from being visually too complex for the first-time learner. to overcome this teaching obstacle, i created my own cardiac embryology animations using modeling clay and incorporated them into a comprehensive didactic lecture on congenital heart disease. methods & materials: cardiac embryology animations were created using modeling clay, a digital camera, and microsoft powerpoint. surface and cross-sectional views were generated, depicting the key events in cardiac embryology: heart tube formation, cardiac looping, chamber division, truncus arteriosus division, and pulmonary venous connection. example models are shown in figure 1 . results: in this lecture, the animations are presented alongside actual embryonic heart photographs. the lecture then uses the embryology knowledge as a basis to explain the common congenital heart diseases and their mri appearances. examples of septal defects, ventricular hypoplasia, and transposition of the great arteries are presented, among others. conclusions: understanding cardiac embryology is required in order to approach congenital heart disease in a logical fashion. modeling clay animations are a cheap and easy way to simplify this complex topic. arterial tortuosity syndrome: an introduction to the clinical and radiologic manifestations in the pediatric population neal desai, umkc som, neal540@gmail.com; suchit patel, ayushi gupta, marius hubbel, doug rivard purpose or case report: 1. to describe the clinical findings of arterial tortuosity syndrome and give a brief discussion of the disease process. 2. to describe the radiologic manifestations of arterial tortuosity syndrome. 3. to give a brief discussion of loeys-dietz syndrome-a disease with similar arterial findings, but with unique molecular characteristics from arterial tortuosity syndrome. 4. to use this knowledge to help establish the diagnosis and reduce mortality. methods & materials: arterial tortuosity syndrome overview • epidemiology • molecular basis • pathophysiology • review of signs, symptoms and presentation • brief discussion of treatment differential diagnosis of arterial tortuosity syndrome • loeys-dietz syndrome-similarities and differences radiologic findings and discussion • chest radiograph • computed tomographic angiography • magnetic resonance angiography-neck • magnetic resonance angiography-head • conventional angiography making a diagnosis • sample case report • review questions conclusions: arterial tortuosity syndrome is a rare disease whose chief manifestation is severe cardiovascular connective tissue defects. due to the nature of these defects and the significance of rapid intervention, it is important to be aware of and recognize the radiologic manifestations associated with arterial tortuosity syndrome in the presence of appropriate clinical history to help offer a better prognosis to the patient. dynamic pulmonary computed tomography for evaluation of cardiopulmonary disease shilpa v. hegde, md, arkansas childrens hospital, university of arkansas, shilpavhegde@gmail.com; s. bruce greenberg purpose or case report: dynamic pulmonary computed tomography (dpct) is a wide-detector ct technique that allows for continuous chest imaging during respiration. when combined with intravenous contrast, the technique is a unique tool for evaluation of cardiopulmonary abnormalities in children with cardiopulmonary abnormalities. the purpose of this poster is to illustrate the technique of dpct for evaluation of cardiopulmonary disease in children with congenital heart disease and persistent respiratory distress. methods & materials: methods and materials: 8 dpct exams with intravenous contrast were performed on 5 infants with a history of congenital heart disease and palliative surgery. four continuous 350 msec gantry rotations were obtained with respiratory rates set at 40/minute. the imaging was accomplished during the time of a single respiratory cycle. 80 kvp and low ma resulted in effective dose of≈1.5 msv. eight respiratory phases were reconstructed to create 3d and mpr cine loops for evaluation of cardiopulmonary abnormalities. results: cardiopulmonary abnormalities were detected in all patients. patency of sano shunt, blalock tausig shunt or patent ductus arteriosus stent was established. intimal thickening was identified in one sano shunt. hypoplastic branch pulmonary arteries were present in 3 infants and pulmonary vein thrombosis in 1 infant. left bronchomalacia was identified in four of five infants and best or only identified on the expiratory phase of respiration. left lung air trapping was present in two patients. conclusions: dpct with intravenous contrast is the ideal study for evaluation of the post-operative infant with congenital heart disease and persistent respiratory distress. the role of low-dose ct angiography in the evaluation of renovascular hypertension in children jessica kurian, md, chop, kurianj@email.chop.edu; monica epelman, kassa darge, els nijs, jeffrey hellinger purpose or case report: historically, the evaluation of renovascular hypertension has been accomplished via us and conventional angiography. based on the reported adult experience we introduced renal ct angiography (cta) for the evaluation of renovascular hypertension in mid-2006. our institution has a robust, well-established protocol, which results in reproducible, high quality images. we aim to present our imaging strategies for the evaluation of these patients and to discuss and illustrate the role of low-dose cta with 3-d imaging as a noninvasive alternative in the evaluation of pediatric renovascular hypertension. methods & materials: we used our department information system to identify pediatric patients (< 18 years of age) who had documented renovascular hypertension confirmed either by conventional angiography and/or surgery during a 5-year period. we present our protocol and discuss the indications, limitations and benefits of renal cta. ct thin slice data, obtained employing dose reduction strategies, was reviewed and reconstructed in 2d and 3d renderings. pertinent us and mr studies as well as demographic and clinical data were reviewed and recorded. several causes for renovascular hypertension were documented and relevant ct angiographic findings were selected for presentation. results: radiation dose ranged 0.58-4 msv. fibromuscular dysplasia was the most common diagnosis followed by neurofibromatosis type 1. vascular pathology included stenoses, beading, occlusions, and aneurysms. disease was noted in the extraparenchymal renal arteries in approximately 70% of the cases. the choice of the imaging modality for the investigation of renovascular hypertension in pediatric patients remains controversial. in the authors' experience, cta with 3-d imaging is a valuable, non-invasive diagnostic tool for the evaluation of pediatric renovascular hypertension. low dose protocols can reduce the radiation exposure associated with ct. this method can spare patients the complications associated with conventional angiography. fetal mri: brain, head and neck malformations-a pictorial essay sumit singh, md, children's hospital of wisconsin, sumitsingh78@yahoo.com; mohit maheshwari, teresa c. gross kelly, tushar chandra, ibrahim s. tuna, craig johnson purpose or case report: the purpose of the exhibit is to illustrate various brain, head and neck massses/vascular anomalies on fetal mri. we will also briefly discuss the normal fetal brain anatomy as seen on fetal mri. methods & materials: major indications for fetal mri include evaluation of inconclusive sonographic findings in cases of cns malformations. in our institute patients are scanned on 1.5 t mr scanner. a body surface six channel phased array coil is used to maximize signal to noise. all the scans are checked by a neuroradiologist to make sure adequate 3 plane imaging of the brain or other lesion in question were performed. 3 plane scanning of the fetal body is also performed for the laterality determination of the lesion and also screen for other congenital anomalies. results: prenatal usg is frequently inconclusive for evaluation of complex fetal brain and head and neck anomalies. most studies suggest that mri after first trimester is safe. in addition, advent of rapid mri sequences like single shot fast spin echo (ssfse) have helped in reducing scan time and motion artifacts leading to availability of diagnostic quality images. these have led to increasing use of mri as supplemental tool to further investigate inconclusive fetal sonographic findings. mri provides better anatomical delineation of these complex abnormalities. it helps in making appropriate diagnosis with high confidence and aids in appropriate obstetric and prenatal/neonatal surgical planning or intervention. this educational exhibit will illustrate few common fetal anomalies. these will include agenesis of corpus callosum, malformation of cortical development, posterior fossa malformations, ventriculomegaly, in-utero stroke, orbital abnormalities and some fetal neck masses/ vascular malformation. correlation and confirmation with the postnatal mri will also be provided for some cases. conclusions: technical and therapeutic advances have driven the development of fetal mri. it is an important adjunctive tool for prenatal imaging in those instances in which a complex anomaly is suspected by sonography, when fetal surgery is contemplated, or when a definitive diagnosis cannot be determined. it has prognostic implications and may help in optimal and timely obstetric and neonatal management. purpose or case report: this educational report will provide a review of the imaging appearance of intradiaphragmatic and subdiaphragmatic pulmonary sequestrations on fetal mri. the proposed pathophysiology, review of sequestration subtypes, and surgical management options will also be described. case examples will be provided to illustrate the fetal mr imaging findings of these variants of pulmonary sequestration that help support the diagnosis. specifically a "triangle sign" of t2 hyperintense tissue directed toward the diaphragm will be demonstrated. illustrative case examples will be placed in the context of a differential diagnosis for subdiaphragmatic masses seen on prenatal imaging. imaging signs that help make a diagnosis of these pulmonary sequestration variants and separate this entity from other lesions will be emphasized. poster #: edu-009 mri of the fetal head and neck masses alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; joshua shimony, per amundson purpose or case report: fetal magnetic resonance imaging (mri) is a useful problem solving tool for abnormalities detected by prenatal ultrasound (us). masses of the head and neck region can vary from benign incidental lesions to devastating neurological lesions and life threatening tumors. we share our experience in characterizing these lesions by prenatal mri, that can have a bearing on follow up imaging, perinatal management and overall prognosis. we did a retrospective review of all fetal mri studies performed at our tertiary care children's hospital between 11/2002 and 06/2011, to identify fetuses with head and neck masses. we reviewed the maternal demographic and clinical data, prenatal ultrasound, fetal outcomes and post natal imaging (when available). results: out of the 351 fetal mri studies, 20 had dominant head and neck masses. majority were encephaloceles (9 occipital, 1 parietal). the remaining included variety of masses such as nasal glioma, teratoma (3), epidermoid cyst, hemangioma and lymphatic malformation (3) . mri played a useful role in distinguishing encephaloceles from other masses based on underlying bone defect and intracranial extension. it also helped in characterizing other masses based on location and signal characteristics. the presence and degree of airway compromise was determined. intracranial anomalies associated with encephaloceles including callosal dysgenesis, cerebral and cerebellar hypoplasias, migrational disorders and spinal anomalies were also correctly identified. conclusions: we present the prenatal mr imaging findings of a spectrum of head and neck lesions, correlating with prenatal ultrasound, postnatal imaging and clinical or pathological outcomes. purpose or case report: the immaturity of the cns in neonatal infants makes neurologic assessment difficult. neuroimaging plays an essential role in the assessment of brain injury by helping to indentify the injury and expected neurologic outcome. cranial ultrasound (us) is usually the first neuroimaging modality used since the technique is portable, does not involve radiation and can be used sequentially. magnetic resonance imaging (mri), however, is the most sensitive imaging modality for the detection of hypoxic brain injury. the goal of this presentation is to compare the us and mri performed within a 24-hour interval, and evaluate these findings to improve the interpretation of the us which is usually the first methodology used to evaluated these patients. we performed a retrospective review of the neonatal imaging studies with us and mri performed within 24-hour interval on 72 preterm and term newborns with clinical history of hypoxia-ischemia. the imaging findings of the two modalities, mri and us, were correlated with the pattern and severity of the injury and brain maturity. results: diffuse white matter abnormalities were observed in 60% of the patients by us or mri. the ultrasound identified diffuse increased echogenicity which did not show correlation with mri in 30% of patients. focal white matter abnormalities were better identified by mri on non-cavitary leukomalacia which is the most common pvl observed in premature neonates with low birth weight and the most difficult to identified using us. cavitary leukomalacia showed strong agreement in both methodologies. the mri identified 6% more cases of intraventricular hemorrhage, however, the corresponding increase in hemorrhage was of minimal clinical significance. in most cases extra axial hemorrhage was better identified by mri. conclusions: after viewing this exhibit, the viewer will gain a better appreciation and understanding of the neuroimaging characteristics of hypoxia-ischemia in us and mri, and thus improving the interpretation of the us which is usually the first imaging modality used to evaluate this patient population. purpose or case report: the most common thoracic lesions found on prenatal imaging, congenital pulmonary airway malformation (cpam), bronchopulmonary sequestration (bps), and congenital diaphragmatic hernia (cdh), usually have characteristic imaging findings previously described in detail. however, common entities presenting with atypical findings and rarer thoracic entities do occur and can be characterized by fetal magnetic resonance (mr) imaging. the purpose of this educational exhibit is to show examples of atypical presentations of common thoracic lesions and more unusual thoracic entities on fetal mr. when applicable, prenatal mr is compared with prenatal ultrasound, postnatal imaging, operative findings, or pathology. methods & materials: using a radiology information system database, the reports of all fetal mr exams at our institution from january 2005 through january 2011 were reviewed. when unusual thoracic findings were described in the report, all prenatal and postnatal images (when available) were evaluated. in the cases selected, medical charts were reviewed for operative findings and pathologic reports. results: the cases to be described, both pulmonary and extrapulmonary in location, include: hybrid lesion in a horseshoe lung, cpam extending across the midline, bilateral bps, bps located within the mediastinum, bps located within the leaves of the diaphragm, ectopia cordis and cdh as components in pentalogy of cantrell, cdh with herniation of liver into the pericardium, elongated esophageal duplication cyst, chest wall lymphatic malformation, and tight double aortic arch causing congenital high airway obstruction syndrome (chaos). conclusions: after studying this educational exhibit, the reader will be acquainted with a variety of unusual fetal pulmonary and extrapulmonary lesions, with emphasis on fetal mr. prenatal and postnatal imaging findings in megacystis-microcolon-intestinal hypoperistalsis syndrome (mmihs) mary kitazono, chop, mkitazono@gmail.com; richard bellah purpose or case report: to review the classic constellation of findings seen in prenatal and postnatal imaging of megacystis-microcolon-intestinal-hypoperistalsis syndrome (mmihs), as well as to illustrate additional imaging features that are variably seen in this syndrome. the imaging database at our children's hospital was searched for all cases of mmihs diagnosed since 2002. all available prenatal and postnatal imaging studies were reviewed in patients with a diagnosis of mmihs, and representative images are provided with a description of the findings. results: since 2002, 6 patients (5 girls, 1 boy) have been diagnosed with mmihs at our institution, including 4 on prenatal mri and us. the characteristic prenatal imaging findings include marked urinary bladder distension, bilateral pelvicaliectasis, and dilated, tortuous ureters, as well as a diminutive colon containing no or minimal t1w-hyperintense meconium on mri. postnatal imaging studies also characteristically demonstrate a massively distended urinary bladder (with no apparent mechanical cause of obstruction) as well as a small, unused colon with dilated, hypoperistaltic small bowel seen proximal to the microcolon. additional findings which are variably seen include intestinal malrotation, stomach and esophageal hypoperistalsis or aperistalsis, gastroesophageal reflux, and biliary stasis. conclusions: although a rare syndrome, the constellation of imaging findings in mmihs is pathognomonic, and recognition of the classic pattern of findings can allow the radiologist to make a diagnosis of mmihs in both the in-utero and postnatal setting. early diagnosis is essential for allowing prenatal counseling regarding this generally fatal disorder, as well as to optimize early management options. purpose or case report: gastric mass lesion are uncommon. this presentation is an educational review of pediatric gastric mass lesions including gastro-intestinal stromal tumor (gist), inflammatory myofibroblastic tumor (pseudotumor). burkitt's lymphoma, squamous cell carcinoma, gastric teratoma, gastric varices, gastric hamartoma, gastric polyp and hypertrophic pyloric stenosis (hps). clinical presentation is varied with upper gi bleeding, feeding intolerance, pain, weight loss and fatigue manifesting. the imaging work-up might initially have been endoscopy or ultrasound. cross section imaging (ct mr) can be invaluable. the role and impact of fdg pet on the management, staging and follow up of the oncologic pathology will be emphasized. imaging findings in megacystic microcolon intestinal hypoperistalsis syndrome, a rare disease kiery braithwaite, pediatric radiology, emory-egleston, kieryb@yahoo.com; kiery braithwaite, paula dickson, marianne m. ballisty purpose or case report: megacystis microcolon intestinal hypoperistalsis (mmih) syndrome is a rare congenital form of severe functional intestinal obstruction which is more commonly found in females. the presenting clinical and imaging features of this disease can often mimic other causes of proximal bowel obstruction in the neonate. in combination with its common association with intestinal malrotation, the clinical picture of mmih syndrome may be confusing at times. awareness of additional imaging features characteristic of mmih syndrome may help the radiologist suggest this diagnosis. the purpose of this study is to enhance the ability of the pediatric radiologist to suggest this rare diagnosis by recognizing this unusual constellation of imaging features. we retrospectively reviewed the clinical data and imaging studies of four patients with mmih syndrome at our institution. imaging studies included plain radiography, ultrasonography, fluoroscopy, and cross sectional imaging. the initial presentation and clinical outcome was also reviewed. results: the clinical presentations of our patients, who were all female, were somewhat varied but typically included symptoms of intestinal obstruction. the diagnosis of mmih syndrome was made in our patients from the first few weeks of life through early childhood. the four patients demonstrated imaging features characteristic of this disease including a very large dilated bladder, severe bilateral hydroureteronephrosis, gaseous distention of the stomach and proximal small bowel, intestinal hypoperistalsis, and a very small colon. the clinical course of these patients that we observed was also quite variable, with some patients dying in neonatal period while another patient continues to do reasonably well at 14 years old after a multi-organ transplant. conclusions: mmih syndrome is a rare and frequently lethal disease. the ability of the pediatric radiologist to recognize this constellation of imaging findings can help the clinical team arrive at a diagnosis of mmih syndrome. more prompt diagnosis can aid in the development of a long term management plan for the patient and in counseling the family regarding the prognostic implications of this disorder. pathologies of omphalomesenteric duct remnant: radiologic-surgical correlation swapnil bagade, md, pediatric radiology, mallinckrodt institute of radiology, bagades@mir.wustl.edu; geetika khanna, rebecca hulett purpose or case report: 1. to facilitate understanding of embryology of the omphalomesenteric(vitelline) duct and normal anatomy of the umbilicus. 2. review the spectrum of omphalomesenteric duct malformations and diversity of clinical presentations of these remnants. 3. illustrate the imaging findings of omphalomesenteric remnants, from the common such as meckel's diverticulum to the uncommon such as the omphalomesenteric duct cyst, with surgical correlation. methods & materials: cases with complications of persistent omphalomesenteric duct were collected from the joint surgery/radiology conferences at a tertiary level children's hospital. imaging features were correlated with intraoperative findings. conclusions: preoperative diagnosis of complications related to the omphalomesenteric duct remnants can be challenging because clinical and imaging features overlap with other etiologies of acute abdomen. knowledge of the embryologic, clinical, radiologic, and surgical characteristics of omphalomesenteric duct remnants will aid in early and accurate diagnosis. neonatal bowel obstruction-a pictorial essay tanmay patel, university of kentucky; harigovinda challa purpose or case report: bowel obstruction is the most common abdominal emergency in the newborn period and in most cases is secondary to a congenital anomaly requiring early surgical intervention. however not every case of abdominal distension or dilated bowel is secondary to mechanical bowel obstruction or underlying surgical condition. radiologic imaging forms a central role in the work up of newborns with suspected intestinal obstruction. the role of the radiologist is to identify whether or not mechanical obstruction is present; if obstruction is identified on initial radiographs, to determine the level of obstruction, and finally to identify the etiology of obstruction. initial plain radiographic evaluation also helps to determine the subsequent diagnostic or therapeutic approach. methods & materials: a retrospective review of multiple radiographic and fluroscopic examinations in patients with diagnosis of neonatal bowel obstruction was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: neonatal intestinal obstruction generally presents with nonspecific symptoms such as abdominal distention, vomiting, or failure to pass meconium depending on the level of obstruction and time of occurrence of underlying congenital lesion/atresia in the intrauterine life. initial plain radiographs of the abdomen reveal dilated bowel loops when obstruction is present. high intestinal obstruction is suspected when only few dilated loops are identified, while multiple dilated bowel loops are seen in low obstruction. most cases of high obstruction may not need another diagnostic imaging test. all cases of distal intestinal obstruction require water soluble enema to identify the etiology of obstruction. in conditions like functional immaturity of the colon, and meconium ileus water soluble enema is therapeutic and thus surgery can be avoided in most cases. the objective of this presentation is to present an educational exhibit of classical imaging findings of various types of neonatal bowel obstructions, and how to differentiate between them. conclusions: bowel obstruction is the most common abdominal emergency in the new born period. most cases are secondary to a congenital surgical condition and early diagnosis and treatment significantly reduces mortality and morbidity. radiographic evaluation plays a central role in the diagnosis and treatment of these conditions. poster #: edu-017 3d t2-weighted mrcp in the pediatric population-a pictorial review nathan egbert, mbbs mph, university of michigan, nathaneg@med.umich.edu; jonathan r. dillman, peter j. strouse purpose or case report: to demonstrate the utility of 3d t2-weighted magnetic resonance cholangiopancreatography (mrcp) in the pediatric population, and to illustrate the mrcp findings of various conditions affecting in the pediatric pancreaticobiliary system. we identified all mrcp exams performed on pediatric patients (< 18 years of age) from january 1, 2000 through august 1, 2011 by searching institutional electronic medical records. we then identified representative 3d t2-weighted mrcp images of various conditions affecting the pediatric pancreaticobiliary system. results: representative 3d t2-weighted mrcp images (including source, maximum intensity projection, and volume rendered images) from the following conditions will be presented: abnormal biliary narrowing/stricture (including sclerosing cholangitis, anastomotic strictures following kasai procedure & liver transplantation, and "pseudostricture"), biliary atresia, choledochal cyst (including various subtypes, based on todani classification), choledocholithiasis & cholelithiasis, congenital anomalies of the pancreaticobiliary system (including pancreas divisum and anomalous pancreaticobiliary junction), pancreatobiliary system trauma (including main pancreatic duct transection), and other rare conditions affecting the pancreaticobiliary system (including rhabdomyosarcoma of the biliary tree). conclusions: 3d t2-weighted mrcp has become an extremely useful tool in the evaluation of children with suspected disorders of the pancreaticobiliary system. since mrcp has distinct advantages over alternative diagnostic techniques, such as endoscopic retrograde cholangiopancreatography (ercp) or percutaneous cholangiography, including lack of ionizing radiation and noninvasiveness, mrcp is a much preferred initial study for pediatric pancreaticobiliary imaging. this pictorial review is intended to highlight the 3d t2weighted mrcp appearances of various pancreaticobiliary conditions occurring in the pediatric population. purpose or case report: magnetic resonance enterography (mre) is rapidly emerging as an important imaging tool for the diagnosis and follow-up of inflammatory bowel disease (ibd). its lack of ionizing radiation makes this imaging modality especially vital to the pediatric population. using a casebased approach, we will demonstrate the usefulness of diffusion-weighted imaging (dwi) as part of a comprehensive mre protocol for the assessment of ibd in children. the basics of dwi will be discussed with particular attention to abdominopelvic techniques. the role of mre dwi for the evaluation of pediatric crohn disease (cd) and ulcerative colitis (uc) will be reviewed using a case-based approach. key images from pertinent imaging studies will be identified by searching institutional electronic medical records and presented with relevant clinical data. results: a review of pediatric mre examinations suggests dwi can be used to detect the following: 1) small and large bowel segments affected by ibd (both cd and uc) 2) abdominopelvic abscesses (including within the mesentery, body wall, iliopsoas muscle, and liver) 3) abnormal lymph nodes 4) sacroiliitis 5) perianal disease (including abscesses and other penetrating complications). conclusions: dwi has the potential to play a very important role in the diagnosis and follow-up of pediatric ibd. this mre technique is particularly useful for detecting a variety of disease-related complications. as the exact meaning of bowel wall restricted diffusion is poorly understood to date, continued investigation will be necessary to determine the clinical and histologic significance of this finding. cases of cf involving the gi tract were collected from clinical workflow encounters of the authors and from the main hospital medical records database. relevant imaging studies were reviewed for known gi manifestations of cf. these imaging studies were correlated with clinical histories and available intraoperative and pathologic findings. results: cf involvement of the gi tract presents over a wide range of ages, organs involved, and associated symptoms. these manifestations can generally be divided anatomically into those involving the alimentary tract, hepatobiliary system, and pancreas. alimentary tract manifestations consist of meconium ileus in uncomplicated and complicated forms (with the latter including secondary intestinal atresia, volvulus, and perforation with meconium peritonitisdistal intestinal obstruction syndrome, constipation, rectal prolapse, duodenal fold thickening, and appendiceal dilation. hepatobiliary disorders secondary to cf include microgallbladder, cholelithiasis, biliary ductal abnormalities, neonatal hepatitis, and cirrhosis (including complications such as portal vein thrombosis and ascites). pancreatic expressions of cf include fatty infiltration, calcifications, and cysts/ cystosis, frequently in the setting of malnutrition and/or stooling abnormalities. this exhibit will demonstrate the spectrum of clinical and radiologic gi findings in this disease from the fetal and neonatal period through adolescence across a range of imaging modalities. conclusions: gastrointestinal manifestations of cystic fibrosis occur frequently in the pediatric population and may be the earliest clinical expression of the disease. familiarity with the variety of gastrointestinal imaging findings of cystic fibrosis can expedite appropriate diagnosis and therapy, particularly in those children in whom the primary disease is not clinically suspected. beyond acute appendicitis: imaging of additional pathologies of the pediatric appendix kelly dietz, md, cincinnati children's hospital; arnold c. merrow, daniel j. podberesky, alexander j. towbin purpose or case report: primary acute appendicitis (or appendiceal inflammation caused by a superimposed bacterial infection in the setting of appendiceal obstruction) is by far the most common pathology of the appendix, and imaging evaluations to exclude this diagnosis occur daily in the pediatric radiology setting. the clinical and imaging differential diagnosis in a patient with right lower quadrant pain and suspected appendicitis is a broad but well-recognized list that predominantly involves structures adjacent to the appendix including the ovaries, small and large bowel, and ureters. there are, however, less common pathologies primarily involving the appendix which can create an imaging diagnostic dilemma in the setting of right lower quadrant symptoms. our goal is to review the imaging and clinical manifestations of these less commonly encountered appendiceal abnormalities. methods & materials: cases of appendices that were abnormal by imaging but ultimately determined not to be due to primary acute appendicitis were collected from clinical encounters by the authors as well as through a search of the radiology and pathology report databases. clinical course, surgical findings, and pathology reports (if available) were subsequently reviewed through the main hospital medical records system. results: the collected cases demonstrate a wide range of additional pathologies of the appendix outside of primary acute appendicitis. a variety of imaging modalities were employed in the workup of these cases. examples reviewed in this exhibit include crohn's disease, ulcerative colitis, cystic fibrosis, carcinoid tumor, inguinal hernia with incarceration, retained foreign body, pinworm infestation, and ileocolic intussusception. conclusions: despite the frequency of primary acute appendicitis, there is a differential diagnosis when an abnormal appendix is found by imaging. familiarity with these alternative diagnoses may be particularly helpful in guiding management of the patient whose clinical presentation is not typical for primary acute appendicitis. methods & materials: a hospital pacs database search from the past 10 years for patients with bws. selected cases, with multimodality imaging, were cross-referenced with pathology reports from patient records database. results: intricate abdominal pathologies are depicted utilizing multimodality imaging, such as plain films, us, ct, mri and pet/ct, and with pathologic correlation. cases with highlight the following: liver: hepatoblastoma, nonspecific hepatobiliary cysts, multiple hemangiomas mimicking metastatic disease; adrenal: dysplastic organomegaly mimicking neoplasm; pancreas: diffuse and focal hyperplasia in the setting of hyperinsulinism, organomegaly; renal: neprocalcinosis, including medullary sponge kidney, nephroblastomatosis, organomegaly; adnexal: ectopic paraovarian adrenal tissue mimicking metastatic lymph node; urinary bladder: benign fibro-uroepithelial polyp. conclusions: diagnosis of bws can be difficult when the classic clinical and radiological findings are not present. these few cases highlight the unusual abdominal pathologies, so when detected, a radiologist can aid in the appropriate diagnosis and help guide therapy for these young patients. this poster will discuss pharmaceuticals the fda considers investigational for their intended use. disclosure: dr. lecompte has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. radiologic-pathologic review of pancreatic masses encountered at a tertiary pediatric hospital over a 10-year period no kwak, md, radiology, long island jewish medical center, kwak_nb@yahoo.com; karen naar, jeanne choi-rosen, lee collins, sukhjinder singh, anna thomas purpose or case report: review of pathologically proven pancreatic masses in pediatric patients encountered at a tertiary pediatric hospital over a 10-year period. describe the key morphologic features and other pertinent findings using various imaging modalities. correlate pathologic and radiologic findings. methods & materials: illustrate the various imaging characteristics of pathologically proven pancreatic masses including pseudocyst, pancreatoblastoma, solid pseudopapillary tumor, acinar cell carcinoma, ductal adenocarcinoma, lymphoma, pancreatic neuroblastoma, and inflammatory myofibroblastic tumor. correlate pathologic and radiologic findings. identify the key imaging features that allow narrower differential diagnosis. results: pancreatoblastoma and solid pseudopapillary tumor are the more commonly encountered pediatric primary pancreatic tumors. both are bulky and heterogeneously enhancing tumors with solid and cystic elements. pancreatoblastoma occurs more commonly in young children. internal hemorrhage and fibrous capsule favor solid pseudopapillary tumor which more commonly occurs in adolescent girls. ductal adenocarcinoma, acinar cell carcinoma and an inflammatory myofibroblastic tumor, which were pathologically proven in our pediatric patients, are exceedingly rare entities. the imaging findings of these cases and their pathology when available will be presented, as well as a quick literature review of these rare tumors. illustration and correlation of the pathologic and radiologic findings. conclusions: pancreatic masses in children are rare but in general have a better prognosis than in adults. salient imaging findings for the various tumors encountered at a tertiary care center with pathologic and radiologic correlation. evaluation of hepatoblastoma with gadoxetate disodium-typical, atypical, pre and post treatment evaluation arthur b. meyers, radiology, cincinnati children's hospital, arthurbmeyers@yahoo.com; alexander j. towbin, daniel j. podberesky purpose or case report: gadoxetate disodium (gd-eob-dtpa) is a hepatobilliary mri contrast agent that is widely used in adults for characterization of liver tumors and is being increasingly used in pediatric patients. hepatoblastoma is the most common primary hepatic malignancy of childhood. the purpose of this presentation is to describe our experience with the use of this agent in the mri evaluation both before and after initiating therapy in patients with hepatoblastoma. methods & materials: the radiology report system at our institution was queried for all patients with pathology proven hepatoblastomas who underwent a liver mr with administration of gadoxetate disodium between 8/1/10 and 2/28/ 2011. the mr imaging characteristics of the patient's primary hepatoblastoma pre-and post-therapy (when available) and post treatment findings (when available) were reviewed. results: 22 mri studies in 9 different patients were reviewed. the patients ranged in age from 4 months to 12 years. 6 patients had pre and post treatment evaluation with gd-eob-dtpa enhanced mri, 1 patient had only pretreatment evaluation and 2 patients had only post treatment evaluation. 6 of the hepatoblastomas did not take up gd-eob-dtpa during the hepatocyte phase and were therefore low signal intensity during the hepatocyte phase of imaging. this was useful in the pretreatment evaluation of hepatoblastoma, particularly in defining the relationship of the tumor to hepatic and portal veins. post treatment gd-eob-dtpa imaging allowed characterization of the biliary anatomy and demonstrated the communication of a postoperative fluid collection with the biliary tree, consistent with biloma. 1 atypical hepatoblastoma showed uptake of gd-eob-dtpa on hepatocyte phase imaging, similar to what has been described in adults with atypical hepatocellular carcinoma. conclusions: gadoxetate disodium enhanced mri is useful in the imaging evaluation of hepatoblastoma, particularly in defining the relationship of tumor to vascular and biliary anatomy and in characterizing post-treatment complications. disclosure: dr. meyers has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. imaging of the gallbladder and biliary tree in pediatric age group ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; s. pinar karakas, unni udayasankar, neil vachhani, ellen park purpose or case report: interactive educational exhibit to illustrate the embryology, anatomical variants as well as congenital and acquired diseases of the bile ducts and gallbladder in pediatric patients. methods & materials: a)the embryology of the gallbladder and biliary tree will be demonstrated with diagrams. b) imaging techniques for gallbladder and biliary tree including us, ct, mri, ercp and intraoperative cholangiogram will be discussed. c)imaging findings of various lesions with special emphasis on key findings that can lead to accurate diagnosis will be discussed. d)an appropriate list of differential diagnosis will be provided. e)an algorithm for the assessment of suspected biliary pathology will be presented. f)the exhibit will be interactive and the reader will answer questions about the discussed entity, related imaging algorithm and management. results: a)discuss congenital anomalies including duplicated and septated gallbladder, choledochal cyst, caroli disease, situs abnormalities and biliary atresia. b)discuss infectious and inflammatory conditions including cholecystitis, kawasaki's disease, sclerosing cholangitis and hepatitis. c)discuss iatrogenic complications including post transplant biliary stricture and leak. d)discuss benign and malignant neoplasms invoving the gallbladder including polyps, ptld and rhabdomyosarcoma. conclusions: this exhibit will demonstrate a logical approach to imaging of the congenital and acquired diseases of the gallbladder and biliary tree based on the embryology and underlying pathology. postnatal work up of congenital uronephropathies-a pictorial essay harigovinda r. challa, radiology, university of kentucky, hch229@uky.edu purpose or case report: the use of obstetric ultrasound routinely in the prenatal care has lead to the discovery of many fetal anomalies. uronephropathies in the newborn represent one of the largest groups of anomalies amenable to neonatal management. since these uropathies are detected mostly in asymptomatic patients the treatment is mainly preventive. the pediatric radiologist has a key role in the post natal work up and management of these patients with prenatally diagnosed neprhouropathies and familiarity with the congenital urinary tract abnormalities is necessary. methods & materials: a retrospective review of multiple radiographic, sonographic and fluroscopic examinations performed in the newborn babies and infants with prenatal diagnosis of urinary tract abnormalities was performed at kentucky children's hospital. multiple examples of classical imaging findings were compiled and placed into a pictorial review. results: numerous anomalies can be detected in utero, including anomalies of renal number, position, morphology, collecting system dilation and bladder, urethral abnormalities. of these postnatal work of congenital hydronephrosis is the most common routinely encountered clinical entity. renal ultrasound is the initial examination in the evaluation in all cases of prenatal hydronephrosis, which is best performed around postnatal day 5. if collecting system dilatation persists on postnatal ultrasound, further imaging work up with vcug, radionuclide imaging may be required depending on degree of dilatation. conclusions: uroneprhopathies are increasingly detected in the prenatal life with increasing use of obstetric ultrasound. the objective of this presentation is to demonstrate in a pictorial essay of different neprhouropathies and their workup in newborns. isolated fallopian tubal torsion: causes, imaging findings, and how to suggest the diagnosis jesse courtier, md, ucsf dept of radiology, jesse. courtier@ucsf.edu; amaya m. basta, rebecca maine, pierre-alain cohen, shinjiro hirose, john d. mackenzie purpose or case report: the purpose of this educational report is to describe the rare entity of isolated fallopian tubal torsion in the pediatric population and depict the cross sectional imaging findings that help make a diagnosis and guide management. the proposed pathophysiology, predisposing factors, and surgical management will be described. an illustrative case example of 12-year-old female patient will be provided with surgical correlation. the exhibit will review imaging findings on us, ct and mri that help support the diagnosis including, dilated tubular structure in the pelvis, normal ovaries, and corkscrewing and beaking of the proximal fallopian tube. isolated fallopian tubal torsion will be placed in the context of a differential diagnosis for girls presenting with pelvic pain and the imaging signs that help make a diagnosis of isolated tubal torsion and separate this entity from other causes of pediatric pelvic pain will be emphasized. multimodality imaging characteristics of genitourinary rhabdomyosarcoma rhea udyavar, md, george washington university medical center, rudyavar@gwmail.gwu.edu; amir noor, pranav k. vyas purpose or case report: in this pictorial essay, we will demonstrate salient imaging features of mr, us, and ct modalities for the diagnosis of genitourinary rhabdomyosarcoma in male (n04) and female (n04) children ages 2-14 years, evaluated at our institution over the past 6 years. background information, including tumor biology, staging, and treatment will also be discussed. the swollen scrotum: ultrasound technique and differential diagnosis kelli r. schmitz, md, oregon health & science university, schmitzk@ohsu.edu; roya sohaey purpose or case report: to review the ultrasound protocol for the performance of scrotal ultrasound and illustrate the ultrasound appearance of conditions resulting in scrotal swelling in pediatric patients. a retrospective review of the imaging database at a tertiary pediatric referral center was performed to identify pediatric patients who presented with scrotal swelling and underwent diagnostic ultrasound. when available, surgical/pathologic correlation was obtained. results: a variety of pathologic processes result in scrotal swelling. causes illustrated include: testicular torsion, epididymitis/orchitis, hydrocele, varicocele, inguinal hernia, trauma, adrenal rest, and testicular or paratesticular neoplasm. conclusions: the causes of scrotal swelling are myriad, including infectious/inflammatory, developmental, traumatic, and neoplastic etiologies. in children, the clinical presentation of a swollen scrotum is nonspecific, and ultrasound plays a key role in making the correct diagnosis. experiences of starting a functional mr urography program at a university hospital: trials and tribulations steven l. blumer, bsc, montefiore medical center/albert einstein college of medicine, sblumer@montefiore.org; ibrahim tuna, amanda north, benjamin taragin, netta blitman, terry l. levin purpose or case report: starting a functional mru program can be challenging as there are numerous potential hurdles to overcome. this presentation describes the process of starting a functional mr urography (fmru) program at a university hospital and discusses the difficulties encountered starting such a program. selecting a sufficient patient referral base, resolving common and uncommon technological issues, and education of clinicians, patients and technical staff are some of the challenges that will be discussed. conclusions: awareness of the common pitfalls in fmru imaging and close partnering with referring physicians can make establishing a functional mru program easier. despite many potential obstacles, the benefit of exquisite anatomical and functional information provided by fmru in children, without exposure to ionizing radiation, greatly outweighs any challenges. disclosure: dr. blumer has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. pictorial review of ultrasound findings in boys presenting to emergency department/urology with acute scrotum teresa liang, faculty of medicine, university of british columbia, teresaliang86@gmail.com; peter metcalfe, william sevcik, michelle noga purpose or case report: testicular torsion is a common acute condition in adolescent boys. rapid and accurate diagnosis is critical. diagnosis is currently based on history, physical findings, and ultrasound (u/s) with doppler. the objective of this poster is to demonstrate ultrasound findings from a retrospective review of acute scrotum over 3 years, and to demonstrate some pitfalls of the technique with regard to testicular torsion diagnosis. we reviewed the u/s, surgical and ed records at the stollery children's hospital for boys aged 1 month to 17 years, presenting with acute scrotum from july 1, 2008 to 2011. age, demographics, clinical symptoms, and physical findings, u/s and surgical techniques, findings, diagnoses and follow-up were also recorded. results: 343 patients presented to uah stollery ed with acute scrotum: 35 were diagnosed with testicular torsion (2 inguinal torsion), 11 were suspected of a torsion-detorsion, 3 torsion of appendix testes, 135 epididymitis/orchitis, and 159 other diagnoses including hydroceles, varicoceles, epididymal cysts, abscesses, cellulitis and hematomas. for the 266 patients who had ultrasound,100% sensitivity and 88% specificity for testicular torsion. the ultrasound findings including size, vascularity and echogenicity associated with both salvageable and necrotic testicles including use of color and pulse doppler will be reviewed. the sonographic findings and pictorial examples associated with the more common acute scrotum etiologies will be presented. sonographic findings from problematic cases (those with inconclusive ultrasound reports or false positive reports) will also be addressed. conclusions: ultrasound imaging problem case examples and characteristic findings of common acute scrotum presentations at stollery hospital at the university of alberta are reviewed in this poster. primary and secondary amenorrhea in pediatric patients: from the beginning to the end cesar cortes, md, miami children's hospital, n4c03@ hotmail.com; yanerys ramos, ricardo restrepo, alejandro diaz, lorena sequeira, edward lee purpose or case report: to describe the role of imaging in evaluating patients with primary and secondary amenorrhea and to illustrate the normal imaging findings of the reproductive organs in the pediatric population as well as the imaging findings of the different etiologies causing amenorrhea. a search of the literature is done to determine the different etiologies of amenorrhea and the role of imaging in their evaluation. first, we will focus on the normal physiologic hormonal influence and changes of the girl's reproductive organs since birth until adolescence on ultrasound and mri. images of the normal appearance of the female reproductive organs as well as imaging findings of the different common and uncommon etiologies of amenorrhea will be shown. then, specific reference will be made to crucial related concepts such as minipuberty of infancy, latest criteria for polycystic ovarian disease and ovarian failure syndrome among others. finally, the treatment, either medical or surgical will be briefly discussed. results: causes of amenorrhea in children range from disorders affecting the hypothalamus, pituitary gland, adrenal glands, and ovaries, as well as uterine and vaginal structural abnormalities. even though history and clinical exam are essential in evaluating a patient with amenorrhea, the pediatric radiologist plays a pivotal role helping guide the area to be imaged and thus the modality that should be used. mri and ultrasound are the main modalities in the evaluation of amenorrhea. conclusions: ultrasound and mri are the main imaging modalities used in the evaluation of amenorrhea in children and are usually part of the work up. amenorrhea in children can have implications in girl's fertility allowing pediatric radiologists to play an important role in helping not only the patient but also their offspring. imaging of mullerian duct anomalies in children kelly k. horst, md, radiology, university of michigan, khorst@med.umich.edu; maryam ghadimi mahani, deepa pai, jonathan r. dillman, peter j. strouse purpose or case report: the purpose of this educational exhibit is to provide an up-to-date appraisal of mullerian duct anomalies presenting in the pediatric population. the appearances of anatomic variants on ultrasound and mri will be used to illustrate the strengths and potential pitfalls of these imaging modalities. methods & materials: patients who have previously undergone ultrasound and/or mri in the course of their clinical workup within the university of michigan health system (umhs) were identified using electronic medical records. imaging reports were reviewed by a single author in order to identify relevant imaging findings (interesting anatomic variations, associated anomalies, etc.). pertinent images from these imaging examinations were de-identified and saved to a secure hard drive. the medical record was accessed by a single researcher to obtain relevant information regarding the patients' clinical presentations. in cases of corrective surgery, pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of mullerian duct anomalies were reviewed within the pediatric population. clinical manifestations were correlated with imaging appearances. conclusions: mullerian duct anomalies represent a range of developmental variants. although functioning ovaries and age-appropriate external genitalia are characteristic, there may be anomalies ranging from uterine and vaginal agenesis, to duplication of the uterus and vagina, to minor uterine cavity abnormalities. müllerian malformations are frequently associated with abnormalities of the renal and axial skeletal systems, and pediatric patients in particular may present with these associated anomalies. menstrual abnormalities may represent a more typical presentation in the adolescent age group. this is in contrast to the adult population, which may be more likely to present with infertility. the variation in clinical presentations make mullerian duct anomalies difficult to diagnose and, because surgical techniques for correction and treatment depend on the underlying anatomy, understanding these variants in the context of imaging studies is important to their diagnosis and management. patient 2 had radiographs which showed an irregular left humeral metaphysis with an associated fracture. patient 3 had a 3 phase bone scan that showed slightly increased uptake on the angiographic and blood pool phases and increased activity on the delayed phase in the right femur. radiographs showed a moth eaten appearance of the right femur with soft tissue swelling. patient 4 had radiographs that showed periosteal reaction in the right tibia with an associated fracture. patient 5, in addition to radiographs, had an mri that showed osteomyelitis of the left humerus and scapula with an associated subperiosteal abscess. patient 6 had multi focal osteomyelitis that was demonstrated on radiographs by irregular cortices and periosteal reaction involving the upper and lower extremities. conclusions: neonatal osteomyelitis is an uncommon entity that can have severe complications if not diagnosis and treated promptly. it is important to review cases and to review the appearance of neonatal osteomyelitis on multiple modalities. radiographs will usually demonstrate periosteal reaction and possibly soft tissue swelling. additional studies may be obtained to evaluate for complications, such as abscesses or involvement of the joint space. purpose or case report: review the epidemiology of ddh. describe the critical diagnostic imaging findings of ddh. understand the role of imaging accompanying treatment. methods & materials: images including radiographs, ultrasound, ct and mri will be used to demonstrate the current and historical role of imaging in caring for patients with ddh. discussion of the importance of reducing radiation exposure when choosing imaging studies will be included. results: radiographs and ultrasound are used primarily in making the diagnosis of ddh. ultrasound and mri are most often used during the course of treatment to assess its effectiveness. mri is increasingly utilized without sedation for patients in spica cast. conclusions: imaging is critical in the care of patients with ddh. pediatric musculoskeletal ultrasound of the proximal lower extremity (pelvis to thigh) julia rissmiller, md, dept of radiology, children's hospital boston, julia.rissmiller@childrens.harvard.edu; howard christianson, michael j. callahan purpose or case report: to review indications for ultrasound of the proximal lower extremity (pelvis, hip and thigh), and to illustrate the practical use of ultrasound in evaluation of the proximal lower extremity, emphasizing the sonographic appearance of various musculoskeletal disorders. ultrasound is a well-established modality for the evaluation of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. in general, ultrasound has a more limited role for the primary evaluation of other pediatric musculoskeletal disorders including trauma, articular and periarticular diseases and tumors or tumor-like processes. advantages of ultrasound, a relatively non-invasive technique, include excellent spatial resolution, low cost, lack of ionizing radiation, lack of need for sedation, and the ability to image the patient in real-time. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. we present ultrasound examples of pathology involving the proximal lower extremity (pelvis, hip and thigh). cases include developmental hip dysplasia, hip effusion, osseous metastasis to the iliac bone, osteomyelitis of the hip, femoral acetabular impingement, rectus femoris hernia, vascular malformation, ewing's sarcoma and myositis ossificans. results: a range of images from pediatric diagnostic ultrasounds performed of the proximal lower extremity (pelvis to thigh) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: ultrasound is an excellent modality for evaluating the proximal lower extremity in children, beyond the current indications of painful hip, developmental hip dysplasia, soft tissue infection, palpable masses, and foreign bodies in children. a multi-modality pictorial review of lesions of the epiphysis in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco74@gmail.com; jacqueline urbine, evan geller, peter pizzutillo purpose or case report: to review the imaging spectrum of epiphyseal lesions in infants and children. a retrospective review of our imaging database was performed to identify studies with either primary lesions of the epiphysis or processes that affect the epiphysis. results: multiple epiphyseal lesions were elucidated primarily by radiography, with cross-sectional imaging included where clinically necessary. congenital lesions include the epiphyseal dysplasias represented here by chondrodysplasia punctata. epiphyseal infarction may due to multiple etiologies including slipped capitol femoral epiphysis, developmental dysplasia of the hip, sickle cell disease, or idiopathic reasons. neoplasms may occur in the epiphysis, including chondroblastoma and histiocytosis. traumatic lesions include fracture and avulsion. osteomyelitis can occur in the epiphysis as well. pseudolesions that mimic pathology will also be reviewed. other pathologies that can affect the epiphysis include juvenile idiopathic arthritis and hemophilia. conclusions: a wide spectrum of congenital and acquired pathologies may affect the epiphysis in the infant and child. plain radiography, computed tomography, and magnetic resonance imaging all contribute to the diagnosis of these varied lesions. purpose or case report: we aim to present the spectrum of common and uncommon hip disorders in pediatric population. we will formulate a systematic approach and present a flowchart to workup and characterize hip diseases. methods & materials: relevant imaging appearances of normal as well as pathological hip will be presented. normal hip anatomy will be discussed through anatomic drawings and radiological images (plain radiographs, ct, usg, and mri). we will illustrate the various anatomic landmarks, measurements and lines on plain radiographs and ultrasound of hip. results: evaluation of limp and hip pain in the pediatric population has undergone rapid evolution. surgical treatment for these disorders continues to be refined, and our ability to identify patients along the spectrum of disease continues to improve. yet, despite our advances, obtaining an accurate diagnosis can remain challenging, especially in the setting of mild structural abnormalities. many imaging studies can be used to evaluate the bones and soft tissues, but conventional radiography is the primary imaging modality for most clinical conditions. plain radiographs usually are obtained first because they are sensitive and specific for a wide range of bone pathology. more sophisticated imaging modalities including radionuclide scintigraphy (bone scan), ultrasonography (usg), computed tomography (ct) and magnetic resonance imaging (mri) are reserved for specific clinical situations. each of these imaging modalities has specific advantages and disadvantages. it is the aim of this review to guide in selecting and interpreting the appropriate imaging modality for a variety of common disorders. this exhibit will illustrate imaging features of developmental dysplasia of hip, perthes disease, slipped capital femoral epiphyses, hip malformations in syndromes, femoral acetabural impingement, labral disorders, septic arthrits and other disorders. the role of various imaging modalities in evaluation of these disorders will be discussed, along with common imaging pearls and pitfalls. conclusions: a systematic approach is necessary for evaluation of pediatric hip disorders. familiarity with normal appearances, pitfalls and specific imaging of these entities is essential for proper diagnosis and management. osteoid osteomas: a pain in the "night" diagnosis nancy k. laurence, md, the children's hospital of philadelphia, nkang26@gmail.com; monica epelman, richard markowitz, camilo jaimes, diego jaramillo, nancy chauvin purpose or case report: a common benign bone-forming lesion, osteoid osteoma comprises approximately 12% of all benign bone tumors. the tumor is composed of a nidus of vascular osteoid tissue and woven bone lined by osteoblasts, frequently with considerable surrounding inflammation. the radiolucent nidus surrounded by variable degrees of reactive sclerosis usually leads to a straightforward diagnosis; however, sometimes the diagnosis of osteoid osteoma can be challenging, as it may have a non-specific and misleading appearance on different imaging modalities, particularly on mri. the purpose of this exhibit is to review the typical and atypical features of osteoid osteomas on different imaging modalities. we present diagnostic dilemmas of osteoid osteomas from our institution and how imaging characteristics can aid in diagnosis. we performed a retrospective review of our imaging database to identify cases of typical and atypical osteoid osteomas, with special emphasis on cases which posed a diagnostic dilemma on imaging. results: when osteoid osteomas occur in atypical locations the diagnosis can be elusive. when located in the intraarticular space there is often minimal or absent cortical thickening and there may be a joint effusion with synovial hypertrophy. phalangeal lesions may cause extensive bone marrow edema and surrounding soft tissue swelling. both of these types of osteoid osteomas can be mistaken for infection. the recently described "ct vessel" or "vascular groove" sign, a low density vascular groove adjacent to the nidus, is highly specific for osteoid osteoma. in the authors' experience, a rim of sclerosis surrounding the nidus may aid in diagnosis on mri and can be identified as an outer hypointense halo on all sequences. we illustrate the findings in cases of atypical osteoid osteomas which may be difficult to diagnose including intraarticular, phalangeal, and vertebral osteoid osteomas. we also show examples of the newly described sign which has high specificity for osteoid osteoma. conclusions: imaging findings in osteoid osteomas can be misleading and cause misdiagnosis, especially in atypical cases. knowledge of their appearance in atypical locations and specific findings can aid in the correct diagnosis. ultrasound of normal entheses in the growing skeleton nancy chauvin, md, department of radiology, the children's hospital of philadelphia, chauvinn@email.chop. edu; pamela f. weiss, monica epelman, diego jaramillo purpose or case report: ultrasound is an underutilized modality in the evaluation of the pediatric musculoskeletal system. evaluation of tendon insertions about the elbow, knee and foot can be easily performed with ultrasonography. a good knowledge of the age dependent normal ultrasound appearance of the entheses is crucial in order to evaluate for pathology, such as trauma or ethesitis-related arthritis. this exhibit will serve to provide the reader with a practical approach to imaging when assessing tendon insertions. optimal patient positioning and transducer selection will be discussed. in addition, important anatomic landmarks will be described to allow for reproducibility and avoiding pitfalls. methods & materials: transverse and longitudinal ultrasound images of 12 entheseal insertion sites were performed on 20 healthy girls and boys between the ages of 5 and 17 years. ultrasound of the elbow was performed while in full extension and the insertions of the common flexor and common extensor tendons were evaluated. the quadriceps and patellar insertions were imaged with patients in the supine position, with the knees flexed at 30 degrees. the achilles tendon and plantar fascia insertion were evaluated with the patient prone, with the feet hanging off the edge of the table. results: tendons demonstrated the expected fibrillar pattern with parallel echogenic lines. the appearance of the entheses changed as the insertion matured from sonolucent cartilage to echogenic bone. conclusions: using a systematic approach and knowledge of the normal anatomy, sonography of the tendons of the elbow, knee and foot can easily be performed in children. pediatric musculoskeletal ultrasound of the distal lower extremity (knee to ankle) howard christianson, md, radiology, children's hospital boston, howard.christianson@childrens.harvard.edu; julia rissmiller, michael j. callahan purpose or case report: ultrasound is a well-established technique in children for evaluation of the painful hip, developmental dysplasia of the hip, soft tissue infection, palpable masses and foreign bodies. in general, ultrasound has a somewhat more limited role for the primary evaluation of several other pediatric musculoskeletal disorders in the setting of trauma, articular and periarticular diseases and tumors and tumor-like conditions. inherent advantages of ultrasound include excellent spatial resolution, a lack of ionizing radiation, a relatively non-invasive technique and lack of a need for sedation. real-time imaging allows problem solving not available with other modalities which is well suited for musculoskeletal applications, particularly in the setting of trauma. the major disadvantage of ultrasound is operator dependency, which is particularly evident in musculoskeletal applications. the purpose of this study is to illustrate the practical use of ultrasound in the evaluation of the distal lower extremity (knee to ankle) emphasizing the sonographic appearance of various musculoskeletal disorders. examples include: 1) cystic lesions around the joints: baker's cyst, synovial cyst, ganglion cyst and suprapatellar bursitis; 2) infectious processes: pretibial, subperiosteal and intramuscular abscess; 3) tumor and tumor like lesions: nerve sheath tumor, tumoral calcinosis; 4) trauma related injuries: sinding larsen johansson, tibialis anterior muscle herniation, hematoma. methods & materials: cases selected for presentation from a series of diagnostic musculoskeletal ultrasounds performed at our institution. results: a range of images from diagnostic ultrasounds performed of the distal lower extremity (knee to ankle) will be presented emphasizing the sonographic appearance of various musculoskeletal disorders. conclusions: selected musculoskeletal ultrasounds of the distal lower extremity are presented to familiarize the audience with the sonographic appearance of various musculoskeletal disorders and to highlight the tremendous potential of ultrasound in evaluating musculoskeletal disease in children and adolescents. role of conventional and dynamic contrast enhanced magnetic resonance imaging in diagnosis of hemihypertrophy syndromes in children shrey k. thawait, md, phd , radiology, yale university-bridgeport hospital, sthawai2@jhmi.edu; gaurav k. thawait, sally e. mitchell, laura m. fayad, john a. carrino, kate puttgen purpose or case report: hemihypertrophy syndromes in children are complex and there is some overlap among these conditions. hence, establishing a diagnosis can be challenging. identification of the correct vascular anomaly associated with these overgrowth disorders helps to correctly classify the disease into one of the several syndromes, which in turn guides management. in this educational poster, we will review the definition, clinical presentation, conventional magnetic resonance imaging (mri) and contrast enhanced magnetic resonance angiography and venography (mra / mrv) features of hemihypertrophy syndromes in children. methods & materials: 1. learn the diagnostic criteria for overgrowth syndromes in children such as klippel-trenaunay syndrome (kts) and parkes weber syndrome (pws) with special emphasis on associated vascular anomalies. 2. gain knowledge of high resolution mri technique for evaluation of vascular anomalies associated with the hemihypertrophy syndromes. 3. understand the additional value of dynamic contrast enhanced mra / mrv in the differentiation of the hemihypertrophy syndromes in the pediatric age group. results: 1. mri technique for a dedicated "vascular anomaly protocol" consisting of fat saturated t2 weighted, pre contrast axial t1 weighted, and post contrast triplanar t1 weighted fat saturated imaging will be described. 2. special emphasis will be provided on dynamic contrast enhanced mra/mrv. 3. conventional and dynamic mri features of clinically proven cases of hemihypertrophy syndromes will be demonstrated. conclusions: systematic mri interpretation utilizing a dedicated vascular anomaly protocol enables the radiologist to correctly identify the hemihypertrophy syndrome, and provide detailed extent of disease. correlative ultrasound, mri imaging and physical examination of elbows in hemophilic children andrea s. doria, md, the hospital for sick children-diagnostic imaging, andrea.doria@sickkids.ca; frederico xavier, arun mohanta, carina man, ningning zhang, pamela hilliard purpose or case report: 1.to report a systematic ultrasound (us) protocol for assessment of hemophilic elbows. 2. to discuss advantages and disadvantages of us and mri for evaluating hemophilic elbows in comparison with physical examination. 3.to illustrate us and mri findings and associated pitfalls in hemophilic joints. background: the value of physical examination for assessment of early arthropathic changes in hemophilic joints is unknown. us does not require sedation in young children, but involves operator training and standardized technique. mri is the reference standard imaging modality for assessment of pathology in hemophilic joints. standardization of a systematic protocol for data acquisition and interpretation of us findings and understanding of the correlation of findings between physical examination, us and mri in hemophilic elbows is essential for the use us as an outcome measure both in clinical practice and research. so far such information is not available for growing elbow joints. methods & materials: eight hemophilic boys (age range/ median, 7-17/13 years) with a history of prior elbow bleeds underwent us and mr imaging, and physical examination on the same day. corresponding images on us and mri were highlighted to illustrate abnormalities and pitfalls. soft tissues (effusion/hemarthrosis,synovial hypertrophy,hemosiderin deposition) changes were characterized as small, moderate, or large. erosions, cartilage and subchondral abnormalities were graded based on depth or extent of articular changes. results: 1. us is helpful for discriminating synovial hypertrophy, joint effusion/hemarthrosis, and large hemosiderin deposition which otherwise generates susceptibility artifacts on gradient-echo mri obscuring adjacent tissues. 2. us can visualize erosions, cartilage and subchondral abnormalities at the joint periphery. however,differentiation between subchondral cysts and erosions is usually unfeasible by us. 3. prior knowledge of the degree of joint maturation is essential for an accurate evaluation of cartilage loss by us. 4. physical examination has limitations for assessment of early joint changes in contrast to us. conclusions: us can be useful for assessing hemophilic elbows, with advantages over mri in the evaluation of soft tissues. further development of an us-mri atlas on normal cartilage in growing joints is needed for definition of the value of us in the assessment of minimal osteochondral abnormalities. digital atlas of skeletal surveys of common skeletal dysplasias shawn parnell, mbbs, md, dnb, radiology, seattle children's hospital, shawn.parnell@seattlechildrens.org; corey wall, edward weinberger purpose or case report: skeletal dysplasias are conditions of abnormal bone and cartilage growth which result in short stature. developing expertise in the radiographic evaluation of skeletal dysplasias can be difficult, as more than 250 dysplasias exist. exhaustive description of individual dysplasias can be found in hard copy textbooks, without the ability to compare individual dysplasias side by side. by providing radiographic images and descriptive text of thirteen common skeletal dysplasias and two comparative normal skeletal surveys, we aim to facilitate understanding of the terminology and highlight the differences in imaging appearances one may commonly encounter in interpreting skeletal dysplasias. methods & materials: initial skeletal surveys and/or follow up radiographs obtained for evaluation of skeletal dysplasias at our institution from 2005 to 2011 were compiled and reviewed for best quality images. selected images for each case were labeled according to body part and view, to include ap and lateral views of the spine and skull and ap views of the extremities and pelvis. for neonates, ap and lateral babygram images were used. the software program used for viewing the atlas, written in c#, may be freely downloaded. it permits linked scrolling and resizing of the images, and simultaneous comparison of different cases is available. cases may be viewed as unknowns or in a selfteaching mode. results: radiographic images for thirteen common skeletal dysplasias and two comparative normal skeletons (neonate and child) are provided within an interactive digital atlas. cases include achondroplasia, pseudoachondroplasia, cleidocranial dysplasia, thanatophoric dysplasia, diaphyseal dysplasia, multiple epiphyseal dysplasia, osteopetrosis, osteogenesis imperfecta, multiple hereditary exostoses, dysostosis multiplex, fibrous dysplasia, asphyxiating thoracic dysplasia (jeune syndrome), and spondyloepiphyseal dysplasia. conclusions: by displaying radiographic images of several common skeletal dysplasias in an interactive and comparative format with descriptive text, understanding of basic radiographic terminology and appearances will be facilitated. purpose or case report: 1. to classify various pediatric msk soft tissue masses 2. to describe pathogenesis, imaging appearances and differential diagnosis of these lesions methods & materials: radiology and clinical medical records were reviewed and pediatric patients with musculoskeletal soft tissue masses were identified. representative images were collected as examples of each lesion. the lesions were then classified into different groups based on the similar pathology and etiology. brief discussion is done for each of these masses with their multimodality imaging appearances. results: the search yielded pediatric soft tissue masses of multiple different etiologies, including post-traumatic (hematoma, fat necrosis, fibromatosis coli, myositis ossificans), inflammatory or infectious (cellulitis, abscess, granuloma annulare, retained foreign bodies), pseudotumors (synovial cysts, ganglion cysts, vascular malformations) and neoplastic lesions (fatty, vascular, neural, fibrous, muscular). multiple different imaging modalities were used to evaluate these masses, including ultrasound, ct and mri. representative examples of different lesions and their appearances on different imaging modalities will be presented and an organized approach to the diagnosis of these lesions will be discussed. conclusions: musculoskeletal soft tissue masses are relatively common in children. majority of these are benign; however, up to 6% of these lesions can be malignant "sarcomas". multiple different imaging modalities often provide complimentary information in the work-up of these lesions. despite multimodality imaging approach, tissue diagnosis or short interval follow-up is still often required when the mass does not show typical features of a benign etiology. pediatric radiologists should be familiar with various pediatric msk soft tissue masses and their imaging appearances, and should be able to guide appropriate management. results: 199 elbow mri examinations were reviewed on children aged 4 months to 18 years with 28 (14%) of these investigating clinical instability in 25 children. mechanism of injuries included congenital dislocation 10 (36%), traumatic dislocation 13 (46%), fracture or avulsion 2 (7%) and other injuries 3 (11%). the patient's with congenital elbow dislocations most commonly presented with radial head dislocation and associated dysplasia or flattening, effusion and less frequently dysplasia of the olecranon or capitellum. patient's with traumatic dislocations were frequently associated with ligamentous or capsular disruption, bone oedema and epicondylar avulsion with effusion, loose osseous bodies and fractures less often. the epicondylar avulsions and ligamentous or tendon injuries occurred equally often in those few patients with unspecified injury mechanism. conclusions: a number of the bony, ligamentous, articular and developmental anomalies evident on elbow mri have been illustrated highlighting the importance of careful and systematic review of all elbow structures when presented with a child with elbow instability. accurate identification of these abnormalities is vital to facilitate their appropriate management. methods & materials: from our computerized radiology information system, we retrieved all patients that have foot ultrasound for evaluation of vertical or oblique talus deformities in the last 6 years (10/2005-10/2011). the us was performed by a pediatric radiologist using a high resolution linear and tight convex curve probes with foot in neutral, plantar flexion and dorsiflexion. all medical charts, ultrasound scans and foot radiographs were reviewed by a pediatric radiologist. results: we identified nine patients' with foot deformities who were suspected of vertical or oblique talus and were evaluated by ultrasound. seven patients are male; two of them had initial foot radiographs that were not diagnostic. two female patients had unilateral oblique talus deformity. there were 7 patients with vertical talus deformity; three of them had bilateral deformities. conclusions: us can directly visualize the unossified navicular, the talar cartilage and their alignment. dynamic us can. ultrasound evaluation of costal chrondral pathologies in children presented as anterior chest wall mass or pain nucharin supakul, md, radiology, riley hospital for children, tanyasupakul@yahoo.com; boaz karmazyn purpose or case report: to summarize our experience with the use of ultrasonography (us) for evaluation of costal cartilage pathology presented as anterior chest wall mass. methods & materials: from our computerized radiology information system, we retrieved all patients that have chest wall ultrasound for evaluation of a mass in the last 4.5 years (4/2007-8/2011) . the us was performed by a pediatric radiologist using a localized scan with high resolution linear probe. all medical charts, pathology results, ultrasound scans and other imaging studies were reviewed by a pediatric radiologist. results: ten patients were found with costal chrondral pathologies. nine patients presented with anterior chest wall mass and one with chest wall pain. eight patients had angular deformity of a single costal cartilage and one patient had biopsy proven osteochrondroma, presented with anterior chest wall mass. one patient had a non-union fracture after motor vehicle accident, presented with anterior chest wall pain. in patients with rib deformity, the mass was non-tender. nine patients had prior imaging study including chest x-rays (n08), ct scan (n0 2), breast mr (n01). all these studies were negative. conclusions: us optimally demonstrated costal cartilage abnormities. chest radiographs and cross sectional studies were negative. we therefore recommend using high resolution chest wall us in children with negative chest radiograph and anterior hard chest wall mass. challenges in pediatric marrow imaging-boning up on current mr techniques srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; neha kwatra, nabile safdar purpose or case report: a wide range of pathologies demonstrate similar findings when imaged using conventional mr sequences. however, pediatric musculoskeletal imagers are increasingly leveraging newer techniques to add specificity to their diagnoses when abnormal marrow signal is detected. the purpose of this educational exhibit is to review the application of current mr techniques to pediatric marrow imaging across the spectrum of normal, variant, and pathologic processes. methods & materials: cases with potentially overlapping imaging appearances on conventional mr sequences, including hematopoetic marrow, sickle cell disease, osteomyelitis, chronic recurrent multifocal osteomyelitis, and infiltrative neoplasms, will be presented. the basis of various mr techniques including chemical shift imaging, "whole body" marrow imaging, diffusion weighted imaging, and fat-water separation techniques such as dixon or ideal (ge) will be reviewed. the strengths and weaknesses of such techniques in differentiating between infection, neoplasm, and normal variation will be emphasized through the case examples. challenges and pitfalls in the imaging of these pathologies using such techniques will be discussed. results: current mr imaging techniques add specificity to diagnoses of marrow pathology which are otherwise difficult to differentiate using traditional sequences alone. the use of opposed phase imaging can be helpful in differentiate hematopoietic marrow or infection from infiltrative and neoplastic conditions. "whole body" marrow imaging may serve as an alternative to other modalities which involve significant radiation exposure. the use of diffusion weighted imaging is a promising, but developing, technique being applied to marrow pathology. conclusions: pediatric bone marrow mr imaging is a challenging area for a vast majority of the radiologists. understanding normal developmental bone marrow changes and being aware of the pitfalls is crucial to render accurate diagnosis. current techniques such as ideal, chemical shift imaging, and "whole body" mri have a potentially important role in further characterization of marrow abnormalities. radiologists beware: unusual imaging manifestations in child abuse eglal shalaby-rana, mbbs (hons), children's national medical center, erana@childrensnational.org; allison m. jackson, tanya hinds, katherine deye purpose or case report: to present less common imaging manifestations of injuries in child abuse that may not be readily recognized as possibly abusive injury. methods & materials: through bi-monthly review of cases with the child protection team over a period of 12 years, the imaging studies of patients with suspected non-accidental trauma were recorded. of the 654 pts with suspected nonaccidental trauma, outcomes were available in 599 patients. the child protection team concluded 254 (43%) were cases of non-accidental trauma with reasonable medical certainty. this data base was reviewed for less common injuries that were found in these medically confirmed cases of child abuse. results: less common manifestations of abuse identified by radiographs included salter-harris injuries in the proximal humerus, and proximal femur. pelvic fractures were rare and when present were associated with sexual abuse. severe chest wall injury, with associated rib fractures, causing complete or near-complete white-out of the chest was occasionally encountered. soft tissue injures, such as hematomas were found in various locations in the body including the buttocks and anterior abdominal wall, were imaged on ultrasound and ct. paraor prevertebral injuries, with or without associated bone injury were identified; one infant presented with retropharyngeal soft tissue swelling. mri identified cervical spine injuries which included ligamentous injury and intrathecal hematomas. conclusions: while classic metaphyseal lesions and rib fractures are the most common, specific injuries documented by radiologic work up of suspected non-accidental trauma, less common injuries to the soft tissue and skeletal system may occur as a result of child abuse. the ability of the radiologist to recognize these uncommon manifestations of demonstrated in axial, coronal, and sagittal planes. the ligament of interest will be denoted by arrows. at the conclusion of the anatomy section, there will be a self assessment exam. the participants then will be asked to identify the ligament. if answered correctly, a summary slide will be displayed and, if common, images of the relevant pathology will be demonstrated. if an incorrect answer is indicated, a slide will appear denoting the incorrect answer with explanation. conclusions: hopefully, with review of this educational exhibit, the participant will have a better understanding of the relevant ligamentous anatomy of the ankle and hindfoot. purpose or case report: the purpose of this educational exhibit is to demonstrate the pathologic sonographic findings, one might encounter in the pediatric ankle. a systematic methodological approach including patient positioning, transducer orientation and sonographic technique are vital for ideal sonographic assessment of the pediatric ankle. using a data search program from a large academic institution, pediatric ankle ultrasounds performed in the last 10 years were reviewed. pathologies include trauma, inflammation/infection, masses and congenital abnormalities. examples of normal anatomy will be included particularly when demonstrating ligament and tendon pathology. the normal side was often assessed for comparison purposes. results: ankle sonography is a useful modality to evaluate commonly encountered pathologies in the pediatric ankle. radiographically occult fractures may be discovered. ligament and tendon pathology, such as tears of the anterior talofibular ligament, high ankle sprain and peroneus longus tendon tears, can be easily detected. signs of infection that can be radiographically occult such as subtle periosteal reaction or fluid collections can be identified. finally, "lumps and bumps" can be characterized. for example, one of the most commonly encountered masses in the pediatric ankle is a ganglion cyst which can be well characterized sonographically. awareness of imaging pitfalls is also critical to avoid misdiagnosis and to guide appropriate management. conclusions: with basic ultrasound skills and knowledge of normal anatomy, sonography of the pediatric ankle is a useful modality to evaluate soft tissue structures and other pathologies. it is comparable to mri and allows for dynamic evaluation without need for anesthesia. resonance angiography (mra) using time resolved imaging is a relatively new technique that has become increasingly utilized in the diagnosis of vascular anomalies. we will describe the technique used at our institution, time resolved imaging of contrast kinetics (tricks, ge healthcare, milwaukee, wi), and the parameters that can be adjusted to optimize the exam. we will review key imaging features of hemangiomas and vascular malformations in various modalities, with a special emphasis on the tricks appearance. we performed a retrospective review of all the tricks studies performed at our institution for suspected vascular anomalies. in addition to the mr imaging features, we specifically analyzed the t1 weighted with fat saturation post tricks enhancement and the temporal tricks enhancement pattern. we reviewed all additional imaging including plain film, ultrasound, and ct and correlated the radiographic imaging with the available clinical and histopathologic features. results: we present illustrative cases of hemangiomas, kaposiform hemangioendothelioma, venous malformations, arteriovenous malformations, lymphatic malformations, and other pitfall lesions. we propose a diagnostic algorithm that relies heavily on the post contrast t1 weighted with fat saturation post tricks enhancement pattern and the temporal tricks enhancement pattern. conclusions: time resolved contrast-enhanced mra has become an increasingly important adjunct in the diagnosis of vascular anomalies. optimization of the exam technique and familiarity of the tricks imaging appearance is essential and can often assist in accurate lesion characterization. purpose or case report: vertical expandable prosthetic titanium rib (veptr) is increasingly used in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. in contrast to spinal fusion surgery, veptr allows for growth while stabilizing the deformity. we review the indications, pre-operative imaging, normal radiographic appearance, and complications of this device. methods & materials: on review of the literature, the indications for veptr have expanded in the past several years to include thoracic insufficiency, idiopathic and neuromuscular scoliosis, and chest wall defects. we illustrate the normal radiographic appearance of the three common configurations of veptr (cradle-to-cradle assembly, cradle with lumbar extension assembly; cradle-to-ala hook assembly). we discuss the potential complications of veptr, including infection, rib fracture, dislodged hardware, and neurological injury, with an emphasis on imaging diagnosis. results: there is a relatively high rate of reported complications with veptr in the literature. therefore, awareness of the growing number of indications, as well as the expected and unexpected appearance of this device, aids in radiographic diagnosis of complications. conclusions: vertical expandable prosthetic titanium rib (veptr) is gaining acceptance in the treatment of thoracic insufficiency, scoliosis, and chest wall defects in children. recognition of the indications, normal radiographic appearance, and complications of this device will facilitate timely and accurate diagnosis. disclosure: dr. philips has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. spectrum of pediatric spinal neoplasms: an interactive tutorial benjamin t. haverkamp, md, radiology, university of missouri-kansas city, haverkampbt@umkc.edu; salvador f. iloreta, maha jarmakani, lisa lowe, seth gibson purpose or case report: the objective of this educational electronic exhibit is to provide the radiologist with an approach to pediatric spinal neoplasms. emphasis will be placed on narrowing the differential diagnosis using a combination of lesion location, characteristic imaging findings, relevant history, and associations. the exhibit format will include a casebased review of various pediatric spinal neoplasms, radiologicpathologic correlation, and a brief discussion of imaging findings useful in guiding surgical management. an interactive selfassessment exam will be presented at the end of the exhibit. results: a review of the specific etiologies will be presented with classification as intra-and extra-medullary and extradural lesions. radiologic images will be related to gross and microscopic pathology. conclusions: after viewing this exhibit, the learner will be able to: 1. recognize the clinical, imaging, and pathologic characteristics of pediatric spinal neoplasms. 2. understand relevant imaging findings useful in surgical management. 3. test their understanding of the presented material through an interactive exam. poster #: edu-057 craniosynostosis jason tsai, mbchb, children's hospital boston, jason. tsai@childrens.harvard.edu; diana p. rodriguez purpose or case report: to review the normal developmental appearance of the cranial sutures with computed tomography (ct) and to describe ct findings of the various forms of craniosynostoses. in this irb-approved retrospective study we reviewed ct images of subjects diagnosed with craniosynostosis between 2006 and september 2011. we included patients with single-suture synostosis, isolated bilateral coronal synostosis, pansynostosis, and combined craniosynotoses. additionally, we identified individuals with normal appearing sutures from 0 to 5 years of age imaged with head ct to describe the pattern of normal development of the cranial sutures. results: a description of the normal developmental ct appearance of the cranial sutures using computed tomography has been provided. of the group of patients with craniosynostosis the following variables were recorded: age at presentation, the pattern of sutural fusion, skull shape, presence of hydrocephalus, genetic testing, and types of surgical correction. conclusions: we have demonstrated the normal developmental ct appearance of the cranial sutures and the ct patterns of the various forms of craniosynostoses, with clinical, genetic and surgical correlation. posterior fossa tumours: a pictorial review sam byott, md, manchester children's hospital, sambyott@ hotmail.com; neville wright, vivian tang, abdu shabani, stavros stivaros purpose or case report: posterior fossa tumours account for 54-70% of childhood brain tumours. the most common differentials include pilocytic astrocytoma, medulloblastoma and ependymoma. mr imaging is crucial to diagnosis, staging and identification of complications such as hydrocephalus and haemorrhage. soft tissue characteristics alongside tumour location, invasion and clinical history facilitate radiological discrimination prior to surgery. however, there is significant clinical equipoise with regards to the imaging appearances in a significant proportion of cases making definite diagnosis difficult. the aim of this study is to evaluate the radiological findings and correlate with histological data. this will allow identification of the key morphological features that discriminate different tumours. these can then be presented to educate fellow radiologists. methods & materials: radiology pacs and patient notes were used to collate radiological, histological and clinical data. results: there were 27 patients presenting at our institution with posterior fossa tumours. 12 had pilocytic astrocytomas, 8 had medulloblastomas and 7 had ependymomas. one patient had an atypical teratoid rhabdoid tumour (atrt). traditional features alongside more advanced mr characteristics were correlated with histology, and the features allowing for discrimination of tumour types are presented in this pictorial review. conclusions: posterior fossa tumours have a highly variable radiological appearance. we present a range of appearances and describe the important morphological features that allow radiological discrimination of tumour type. poster #: edu-059 3dt1 imaging of the pediatric spine teresa c. gross kelly, children's hospital of wisconsin, tkelly@chw.org; ibrahim s. tuna, mia s. kelly, tushar chandra, sumit singh, mohit maheshwari, hervey d. segall purpose or case report: some abnormalities of the pediatric spine can be challenging. we have discovered that in many such cases, diagnosis of spinal lesions can be faciliated by using the 3dt1 weighted sequence. the purpose of this educational poster is to demonstrate the remarkable usefulness of 3dt1 weighted images for delineating pathology of the pediatric spine. methods & materials: lesions of the spine that will be reivewed in this educational exhibit will be categorized as: (1) vascular (2) due to infection/inflammation (3) neoplastic/ neurogenic (4) congenital (5) traumatic/iatrogenic (6) endocrine/metabolic. the imaging characteristics of lesions found in the pediatric spine will be described and the utility of 3d t1-weighted mr sequences for the evaluation of these lesions will be discussed. finally the role of imaging in the treatment planning of abnormalities of the pediatric spine will be addressed. results: this educational exhibit will provide numerous examples of how 3d t1-weighted imaging can elucidate diagnosis of lesions involving the spine. examples include enhancement of the cauda equina in guillain barre syndrome, lipomatous malformations, spondylolysis in children with low back pain, thecal cysts, filar cysts, metastasis, hydromyelia and ventriculus terminalis. conclusions: 3d t1-weighted images of the spine performed in the sagittal plane with coronal and axial reformations, as well sagittal oblique reformations (scotty dog reformations) for evaluation of spondylolysis, can facilitate the evaluation of lesions involving the pediatric spine. the normal pediatric spine: a pictorial review of mr anatomy and development in the infant, child and adolescent ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; teresa c. gross kelly, tushar chandra, mohit maheshwari, sumit singh, hervey d. segall purpose or case report: radiological evaluation of the pediatric spine can be more challenging in child than in the adult patient due to the wide range of normal anatomic variants and synchondroses, combined with the unique effects of trauma in children. mri is an excellent imaging modality for the evaluation of the pediatric spine. however, in order to provide an accurate interpretation of acute posttraumatic changes in the pediatric spine, particularly in the setting of abusive head trauma, a fundamental knowledge of normal anatomy, variants and pathology of the pediatric spine is required. the aim of this educational exhibit is to illustrate normal mri anatomy of the spine in the infant, child and adolescent. methods & materials: this exhibit will first describe basic spinal embryology and development of the vertebra and spinal cord, followed by mri depiction of the developmental anatomy of the spine from infancy through adolescence. the changing appearance of the spinal canal, spinal cord and vertebral bodies with age will be illustrated using normal cases from the radiology database. sagittal and transverse diameter of vertebral bodies, thickness of the dural thecal sac, dimensions of the spinal canal, normal bone marrow signal changes, vertebral body heights, level of conus medullaris, prevertebral and paraspinous soft tissues and epidural fat thickness will be described and changes according to age will be pointed out. results: in early life, the spinal cord extends to the inferior aspect of the bony spinal column. because the vertebral bodies grow longitudinally faster than the spinal cord does, the conus medullaris may change. ossification of the vertebral bodies and posterior elements is nearly complete by age 10, with a resultant decrease in the spinal canal diameter. the nucleus pulposus becomes smaller after 10 years and spans approximately half the disk space in the sagittal plane. the spinal cord is elliptical in cross section in the cervical spine and demonstrates a difference in signal between the normal gray and white matter of the spinal cord which should not be mistaken for intramedullary pathology. conclusions: a solid understanding of normal spine anatomy and embryological development is essential in evaluation of pediatric spine, mainly in the setting of trauma. familiarity with normal anatomic variants is essential to provide an accurate interpretation of pathology in the pediatric spine. spectrum of intracranial cystic lesions in infants and children ernesto i. blanco, md, st. christopher's hospital for children, eiblanco74@gmail.com; eric faerber purpose or case report: to review the imaging spectrum of intracranial cystic lesions in the pediatric population. methods & materials: a retrospective review of our imaging database was performed to identify studies obtained in which the findings included intracranial cystic lesions. results: multiple cystic lesions were elucidated primarily by computed tomography or magnetic resonance imaging. these lesions can be divided into nonneoplastic and nonneoplastic tumor-associated cysts. the nonneoplastic cysts, which is the largest group, include: cavum septi pellucidi and cavum veli interpositi, choroid plexus cyst, enlarged peri-vascular spaces, pineal cyst, the large spectrum of arachnoid cysts, colloid cyst, epidermoid cyst, rathke cleft cyst, and porencephalic cyst. nonneoplastic tumor-associated cysts include: craniopharyngioma, optic glioma, pilocytic astrocytoma, hemangioblastoma, and ganglioglioma. conclusions: intracranial cystic lesions are relatively common entities in the pediatric population. a wide spectrum of nonneoplastic and nonneoplastic tumor associated pathologies are presented using both computed tomography and magnetic resonance imaging. kelly, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a comprehensive review of imaging features, classification and management of pediatric spinal cord tumors. we also aim to elicit the differences between pediatric spinal cord tumors and their adult counterparts. we will summarize the differences between the individual tumors based on histological cell types and the pertinent implications on management and outcome methods & materials: this exhibit will provide an overview of the common as well as uncommon tumors of the pediatric spinal cord. various classification systems for these tumors-anatomical as well as histological will be discussed. we will illustrate the relevant imaging findings that can help in differentiating these tumors. results: pediatric spinal cord tumors account for 1% to 10% of all pediatric central nervous system tumors. mri is the mainstay for the initial diagnosis as well as the post surgical evaluation and surveillance of these tumors. pediatric and adult spinal cord tumours differ both in terms of anatomical location as well as histology. the disease and treatment related morbidities are also different in children as compared to adults. astrocytomas, ependymomas, glioneural tumors and csf metastasis represent the vast majority of cord neoplasms in the pediatric age group. some of cord tumors may also be associated with inherited syndromes (like neurofibromatosis type 2) or may have genetic predisposition. these would also be discussed. we will also illustrate and discuss common non neoplastic spinal masses that may mimic tumors. conclusions: pediatric spinal cord tumors have varied clinical presentations, imaging appearance and outcome. this review would improve the understanding of these tumors thereby helping in diagnosis, management and follow up of these uncommon neoplasms. multi-modality imaging of pediatric head and neck lesions jason au, md, oklahoma university health sciences center, jasonmau@gmail.com; anthony alleman, mahmoud elkaissi, roy jacob purpose or case report: the purpose of this study is to present a side by side comparison of the multi-modality imaging features of pediatric masses. using cases that have been imaged with multiple modalities, the exhibit will delineate the sonographic, mr, and ct appearance of congenital, infectious, and neoplastic head and neck lesions in the pediatric population. methods & materials: a restrospective search of pacs was performed on studies completed at the oklahoma university medical center on the oklahoma university health science center campus from january 2008 to the present. ultrasound, ct, and mr examinations were selected that depicted relevant pediatric head and neck pathology. all studies were de-identified prior to image export. results: over twenty representative cases of pediatric infections, fibrous tumors, cystic neoplasms, vascular malformation, bony tumors, developmental anomalies, and other neoplasms were selected for inclusion. results: pictorial review of cases including the following representative cases: myelonmeningocele associated with arnold chiari malformation, lipomyelomeningocele, tethered cord with spinal lipoma/fibrofatty filum, tethered cord and dermal sinus tract, and chiari i with syringohydromyelia. several unique cases including the following will be presented as well: thoracic meningocele with arnold chiari malformation, terminal myelocystocele, diastematomyelia, and myelomeningocele without arnold chiari malformation. while mri demonstrates the cranio-cervical junction and the cervicothoracic spinal cord better than ultrasound, ultrasound often allows for improved resolution of the distal spinal cord, lumbosacral spinal canal, and spinal dysraphism structures near the skin surface in the neonate. conclusions: congenital spinal malformations are complex and variable in imaging appearance. it is important to understand the classification in order to determine the appropriate management and prognosis. in the neonatal period imaging should be performed with ultrasound and mri studies, as they may provide different and complementary information. conclusions: hypoxic ischemic injury is a common condition resulting in a wide spectrum of severe neurological defects. while in the past treatment only consisted of supportive care for hii, recent advances have yielded promising treatment options if initiated within a limited time window. thus due to the severity of the disease and the need for rapid intervention, it is important to recognize radiological manifestations of hii along with its clinical signs and symptoms to offer a better prognosis to the patient. craniosynostosis: looking beyond the sutures tushar chandra, md, children's hospital of wisconsin, drtusharchandra@gmail.com; teresa c. gross kelly, mohit maheshwari, sumit singh, ibrahim s. tuna, hervey d. segall purpose or case report: the aim of this educational exhibit is to provide a framework upon which the diagnosis of the various types of craniosynostosis can be facilitated. our goal is to provide an efficient way to evaluate craniosynostosis for the radiologist in clinical practice. we plan to accomplish this goal by providing a succinct review of the sutures, an overview of the various classification schemes for craniosynostosis and potential complications associated with premature sutural closure. the role of imaging in the evaluation of craniosynostosis will be described and the features of craniosynostosis that are most important to the craniofacial surgeon will be elucidated. finally, surgical strategies for the repair of craniosynostosis and postoperative findings will be described. results: some of the forms of craniosynostosis may have a genetic basis, but many are spontaneous in nature. untreated progressive craniosynostosis can lead to inhibition of brain growth, and an increase in intracranial pressure. mdct with mip and 3d surface reformations is the preferred modality for diagnostic evaluation of craniosynostosis. it is also a robust modality for post operative assessment and long-term follow up. mri is a useful adjunct for assessment of associated intracranial anomalies and complications. timely and appropriate imaging is essential to assess for potential complications of craniosynostosis which may include intracranial hypertension, anomalies of external and middle ear, hydrocephalus, chronic tonsillar herniation, cranial base deformity, impaired venous drainage, enlarged emissary foramina and veins and optic atrophy. on the other hand, positional plagiocephaly should not be misinterpreted as craniosynostosis. surgical management is typical for nonsyndromic craniosynostosis, which involves correction of craniosynostosis between three to six months of age. conservative management is the mainstay for syndromic craniosynostosis. postoperative follow up imaging for surveillance for ventricular size and signs of raised intracranial pressure are necessary. conclusions: craniosynostosis is a challenging area of pediatric neuroimaging. knowledge of the sutural anatomy, an understanding of the potential intracranial complications caused by premature sutural closure, as well as the role that imaging plays in presurgical planning, can provide a practical way for the radiologist to evaluate craniosynostosis in a fast-paced clinical setting. poster #: edu-067 the perinatal brain and spinal cord-imaging across a life border: a case-based approach anand dorai raju, md, radiology university of tennessee, araju@uthsc.edu; harris l. cohen, matthew whitehead, asim choudhri purpose or case report: to review normal and abnormal perinatal ultrasound (us) and magnetic resonance (mr) imaging findings and note their significance for the analysis of the fetal and neonatal brain as well as spinal cord and vertebral column using a case based approach. to highlight us and mr capabilities in allowing correct perinatal diagnosis of congenital and acquired central nervous system abnormalities. methods & materials: cases will be shown of normal and abnormal anatomic findings in fetal and neonatal brain and spinal cord imaging. key teaching points necessary for the diagnosis of such brain abnormalities as ventriculomegaly, chiari malformations, holoprosencephaly, and agenesis of the corpus callosum as well as dandy walker malformations and avms will be discussed. intraventricular hemorrhage, periventricular leukomalacia, anoxic injuries and infectious abnormalities will be reviewed. abnormal anatomic findings in fetal and neonatal spine evaluations for congenital and acquired abnormalities and key teaching points necessary for the accurate diagnosis of tethered cord, myelomeninocele, caudal regression syndrome, hydromyelia, diastomatomyelia and sacrococcygeal teratoma will be reviewed. some diagnostic difficulties and controversies will be addressed. conclusions: ultrasound aided by mri can provide ready diagnosis to many central nervous system abnormalities involving fetuses and neonates. ever improving perinatal imaging experience and technique allow for better prenatal as well as postnatal diagnosis. cases showing such imaging and key points helping such imaging diagnoses will be reviewed. overview of imaging of pediatric extraocular orbital tumors srikala narayanan, md, division of radiology, children's national medical center, snarayan@childrensnational.org; nadja kadom, gilbert l. vezina purpose or case report: to show the spectrum of benign and malignant extraocular orbital tumors in children. methods & materials: we reviewed the cross-sectional imaging of orbit (ct and mr) done in the last 5 years. specific imaging signs of extraocular tumors including benign and malignant tumors such as hemangiomas, lymphangiomas, optic nerve glioma, optic nerve sheath meningioma, pseudotumors, rhabdomyosarcoma, orbital myofibroma, eosinophilic granuloma and neuroblastoma metastases will be shown. important imaging features that should be considered when formulating a differential diagnosis will be described. conclusions: the spectrum of diseases affecting pediatric orbit is substantially different from what we see in the adults. it is not easy always to differentiate between different tumors. important imaging characteristics will help us towards better differential diagnosis. in this exhibit, we will illustrate ultrasound anatomy of the neonatal spinal cord. discussion of the normal anatomic variants and pathological conditions of the spinal cord will be provided. representative images of a variety of common and uncommon pathological conditions of the spine will be presented to illustrate teaching points. in abnormal cases, follow up mri images will also be illustrated for comparison. results: ultrasound is a robust screening modality for evaluation of the lumbosacral spine in neonates. it is cheaper, readily available, safer first line imaging modality in neonates suspected to have spinal malformations. under able and well trained operator, diagnostic accuracy of spinal ultrasound approaches mri. however, mri remains the gold standard for imaging evaluation of spine. normal variants that simulate disease processes like ventriculus terminalis, prominent filum terminale and central echo complex will be presented. congenital malformations of the cord such as tethered cord, hydromyelia, lipoma, diastematomyelia, myelomeningocele, lateral meningocele and presacral masses will also be discussed. conclusions: ultrasound is a very useful screening technique for evaluation of pathological conditions of lumbosacral spine in neonates. this review would improve the understanding of utility and limitations of ultrasound in evaluation of neonatal spinal malformations. purpose or case report: although mri is the standard for detecting epilepsy and brain tumor abnormalities, pet-ct is performed to ascertain metabolism related to epileptogenic regions or characterize tumor metabolic activity. asymmetric metabolism often correlates to structural abnormalities like cortical dysplasia. metabolic activity often correlates with tumor aggressiveness or grade. fdg pet is commonly used to assess seizure and tumor metabolism. the lesser utilized amino acid pet tracers (c11 methionine, fdopa) show increasing value with lower grade tumors due to high tumor to normal tissue contrast. literature is accumulating regarding c11 methionine (cmet) in the detection of lesions like cortical dysplasia and its ability to delineate low grade seizure related tumor lesions. despite the established fdg and accumulating cmet literature, little information exists about the imaging seen with both in pediatrics. as these studies are increasingly viewed as part of fusion mri images, there is more scrutiny of focal metabolism correlating with mri findings and less interpretative reliance on abnormality based solely on asymmetry. methods & materials: review of 110 patients who underwent cmet and fdg brain pet-ct was performed. each was imaged on a philips scanner and had prior mri. studies demonstrating a variety of tumors, postoperative findings of residual or recurrent tumor, and pseudoprogression were selected. epilepsy cases with structural cortical abnormalities or seizure-associated tumors were also selected. cmet and fdg studies were analyzed by 3 pediatric neuroradiologists and the imaging findings correlated with prior mri and any pathology or follow-up imaging. pictorial galleries of the cmet and fdg imaging patterns were created. results: pathologically proven low-grade glial tumors showed increased cmet uptake and no hypermetabolism on fdg. high-grade tumors showed increased uptake on cmet and hypermetabolism on fdg. patients with residual or recurrent tumors showed uptake similar to their original tumor. granulation tissue and pseudoprogression changes showed increased uptake on cmet and no hypermetabolism on fdg. epilepsy surgery patients with cortical dysplasia or low grade glial tumors showed increased uptake on cmet and fdg hypometabolism. conclusions: this study illustrates the variety of findings on cmet and fdg pet-ct in pediatric patients clinically evaluated for brain tumor and epilepsy. this atlas provides readers with a guide to the appearance of these findings on an emerging imaging technique. pediatric head and neck neoplasms: a multimodality pictorial review alok jaju, md, mallinckrodt institute of radiology, alokjaju@gmail.com; marilyn j. siegel purpose or case report: neck masses are common in children and most occur in the suprahyoid region. knowledge of the fascial spaces involved in conjunction with imaging features can help in diagnosis. in this pictorial review, we present a multimodality imaging approach based on anatomy of the suprahyoid fascial spaces for evaluation of pediatric neck tumors. methods & materials: radiology information system (ris) at our tertiary care children's hospital was queried to identify patients with suprahyoid neck masses who had imaging performed between july 2004 and present. a variety of conditions having congenital, inflammatory, neoplastic, or vascular origin were identified and the anatomic location in the neck as well as imaging and clinical findings were retrospectively reviewed. results: the imaging evaluation included ultrasound, ct and mri. lesions arose within the following fascial spaces of the suprahyoid neck: superficial, carotid, masticator, submandibular, sublingual, parotid, parapharyngeal, visceral, retropharyngeal and prevertebral. key imaging features important in diagnosis included lesion vascularity, calcification, necrosis and bone invasion. we discuss and illustrate these imaging findings and relate them to specific suprahyoid fascial spaces. specific lesions include vascular and lymphatic malformations, teratoma, nerve sheath tumors, thyroglossal duct and branchial cleft cysts, pleomorphic adenoma, dermoid cyst, ranula, lymphadenopathy, abscess, lymphoma, rhabdomyosarcoma, neuroblastoma and nasopharyngeal carcinoma. conclusions: knowledge of fascial spaces of the suprahyoid compartment and key imaging features on multiple modalities can aid in the diagnosis of pediatric neck masses. pediatric sinusitis: spectrum of imaging findings with clinicopathologic correlation roy jacob, md, university of oklahoma, drjacobr@gmail. com; paul digoy, robert s. glade, anthony alleman purpose or case report: the clinical spectrum of sinusitis in children can range from uncomplicated bacterial sinusitis to invasive fungal sinusitis. most cases respond favorably to medical management. however, complications occasionally occur due to the spread to adjacent structures. imaging plays an important role in characterizing the disease and guiding the clinical and surgical planning and treatment. this electronic presentation outlines the following-1. review radiologic anatomy and unique characteristics of pediatric sinuses. 2. review the clinical features, pathophysiology, and microbiology of sinusitis. 3. review of ct and mri imaging characteristics of sinusitis with representative cases such as complicated sinusitis and invasive fungal sinusitis. 4. review the treatment approaches of sinusitis. methods & materials: a retrospective search of pacs was performed on studies completed at the ou children's hospital in oklahoma city for the last three years. ct and mr examinations were selected that depicted relevant disease processes. corresponding nasal endoscopic pictures were obtained from cases which required surgical management. all studies were de-identified prior to image export. results: over fifteen representative cases of the clinical spectrum of sinusitis and its complications were selected for inclusion. conclusions: this educational exhibit provides a concise review of imaging, clinical features, and treatment of pediatric sinusitis. findings will be richly illustrated with radiological and clinical images. microcephaly or hydrocephalus. knowing the embryology of the cerebellum and 4th ventricle is important to perceive the development of posterior fossa malformations and to further understand the imaging findings. several classifications schemes have been proposed from a pure embryologic to an imaging-based approach using some essential findings such as the size of the posterior fossa, the presence of csf collection or expansion of csf space, and the size and morphology of the cerebellum. mr is the gold-standard for adequately access and characterize the posterior fossa structures. this pictorial essay will review the mr findings of some of the most common posterior fossa malformations including dandy-walker malformation, persistent blakes pouch, mega cisterna magna, arachnoid cyst, paleocerebellar hypoplasia, cerebellar agenesis, cerebellar and pontocerebellar hypoplasia, cerebelar cortical malformations, isolated brainstem hypoplasia/dysplasia and chiari malformations. we will provide a practical approach to the mr findings of posterior fossa malformations in children. conclusions: mr plays a crucial role in identifying and characterizing malformations of the posterior fossa structures. it should give a logical approach to these complex malformations thus guiding the refereeing physician into the clinical approach and in determining further investigations. results: neuroimaging features of abnormal thalami as encountered in the pediatric population were detailed, and wherever applicable, the relevance of additional mr imaging sequences and techniques to determine etiology was described. while there was considerable overlap in imaging appearances, making a precise diagnosis was found to be challenging in difficult cases, and by and large, a stepwise approach was successfully formulated and used to: 1. diagnose the more emergent conditions and to 2. devise a management algorithm for the less acute abnormalities. conclusions: bilateral thalamic lesions are occasionally encountered in pediatric neuroimaging and have a limited differential; a good knowledge base and adequate technique are imperative to tease out the precise diagnosis and institute appropriate management. cortical developmental abnormalities in pediatric seizure patients ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; mohit maheshwari, teresa c. gross kelly, sumit singh, tushar chandra, hervey d. segall purpose or case report: to describe various cortical malformations with illustrative examples. we will also briefly discuss the embryology, genetic basis, classification schemes and characteristic imaging findings . methods & materials: this exhibit will illustrate three main categories of cortical malformations: neuronal proliferation, migration and organization. understanding of this complex topic would be facilitated by brief discussion on the embryological basis and proposed genetic causes of some of these cortical malformations. classification schemes on embryology and imaging will be discussed. characteristic imaging findings of these malformations will be discussed and examples from the authors database will be shown. results: neuroimaging in pediatric seizures is challenging. mri is considered the imaging modality of choice because of superior soft tissue contrast and better ability to characterize the pathologic process. we will also discuss the dedicated seizure protocol which is used in our institute. pet-ct imaging can also provides additional information in cases where mri is negative, inconclusive or does not correlate with eeg/clinical findings. brief discussion on advanced imaging techniques will also be presented. malformations are frequently detected in infancy. however, if the initial mri scan performed in infancy is negative, a repeat scan after 2 years of age may be helpful. conclusions: evaluation of cortical malformation in seizure patients still remains a challenging area of pediatric neuroimaging. reviewing of the embryological basis, classification schemes and characteristic imaging findings would improve the understanding the cortical malformations and interpreting the images. poster #: edu-079 sprs best poster 2011 cystic neonatal lesions associated with the spinal cord: discussion and differential diagnosis for these uncommon lesions jacob pirkle, md, jpirkle@mc.utmck.edu, james boyd, brian dupree purpose or case report: to review intradural cystic neonatal spine lesions and discuss the various causes and appearance of these lesions. this poster presentation provides a brief review of neonatal cystic spine lesions, including their etiologies, and presents the targeted audience (radiology resdients, fellows, and practicing radiologists) a helpful differential diagnosis of these lesions based upon their imaging appearance. methods & materials: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. results: a brief overview of neonatal cystic spine lesions, their etiology, and imaging appearance is presented in poster format utilizing both literature search and printed reference material. images from several cases of cystic neonatal spine lesions are presented. conclusions: neonatal spine ultrasound is often performed to evaluate for abnormalities related to the presence of sacral dimples, cutaneous stigmata, skin tags, hairy tufts, during the evaluation of other congenital anomalies, or when prenatal ultrasound/mri demonstrates an abnormality warranting postnatal follow-up. the identification of cystic spinal cord lesions is relatively rare in the neonate. however, the etiology of these lesions can often be deduced or surmised based upon the location and the imaging appearance of the lesion. the most common cause of a cystic intramedullary spinal lesion is ventriculus terminalis, with a reported incidence of 2.6%. additional lesions include transient dilatation of the central canal, filar cyst, syringohydromyelia, intramedullary arachnoid cyst, and myelomalacia related to in utero/birth trauma. extremely rare etiologies in the neonate include epidermoid/dermoid, cavernous malformation, intranatal cystic infections etiologies, neuroepithelial cysts, and cystic neoplasms. mimics include diastematamyelia, spinal lipomas, and intramedullary hematomas. numerous imaging examples of these lesions are provided in the accompanying poster. brain mri in peroxisomal disorders: a pictorial essay bruno p. soares, md, radiology and biomedical imaging, university of california at san francisco, bruno.soares@ucsf. edu; leonardo vedolin, guido gonzalez purpose or case report: our presentation aims to illustrate the brain mri patterns in peroxisomal disorders. peroxisomes are intracellular organelles involved in important cellular processes including beta-oxidation of very-longchain fatty acids and plasmalogen production. peroxisomal disorders can be categorized into disorders of peroxisomal biogenesis, in which the peroxisomes are abnormally formed and several peroxisomal functions are deficient, and in defects involving a single peroxisomal function, in which the structure of the peroxisome is intact. disorders of peroxisomal biogenesis include zellweger syndrome, neonatal adrenoleukodystrophy, infantile refsum disease and rhizomelic chondrodysplasia punctata. numerous disorders are caused by loss of a single peroxisomal function including x-linked adrenoleukodystrophy and acyl-coa oxidase deficiency. clinical findings in peroxisomal disorders include dysmorphic features, hepatic dysfunction, neurodevelopmental delay, retinopathy and hearing impairment. methods & materials: pictorial essay illustrating brain mri patterns in peroxisomal disorders, including disorders of peroxisomal biogenesis and disorders with loss of a single peroxisomal function. results: brain abnormalities in peroxisomal disorders have a wide spectrum of patterns. neuronal migration disorders with abnormal myelination are typically seen in zellweger disease and neonatal adrenoleukodystrophy. specifically, the association of abnormal myelination with germinolytic cysts is suggestive of zellweger syndrome. classic x-linked adrenoleukodystrophy typically shows posterior central white matter involvement and symmetric demyelination also involving the corticospinal tracts and corpus callosum. a similar pattern of white matter involvement is seen in acyl-coa oxidase deficiency and infantile refsum disease. conclusions: brain mri helps narrow the differential diagnosis and guides subsequent evaluation in infants presenting with clinical features concerning for peroxisomal disorders. therefore, knowledge of the brain mri patterns in peroxisomal disorders is important for the radiologist interpreting neuroimaging studies. clots in tots: role of imaging in diagnosis of acute stroke and its causes in children asif abdullah, c.s. mott children's hospital of the university of michigan, asifa@med.umich.edu; ellen hoeffner, augusto elias purpose or case report: stroke is a major cause of morbidity and mortality in children. long-term neurologic deficits occur in 50% to 85% of infants and children after arterial ischemic stroke. limited awareness regarding pediatric stroke among physicians and in general community is a major concern. imaging plays crucial role in the diagnosis of pediatric stroke. the goal of this presentation is to provide awareness to the reader about the role of imaging in childhood stroke and its myriad causes in children. we will provide a case based approach to imaging diagnosis of acute pediatric stroke based on three categories: (1) arterial ischemic stroke, (2) cerebral venous thrombosis, and (3) hemorrhagic. arterial ischemic stroke (ais) is classified according to the pediatric stroke classification (psc). psc includes eight subtypes of ais: (1) sickle cell disease, (2) cardioembolic disease, (3) moyamoya syndrome, (4) cervical arterial dissection, (5) stenoocclusive cerebral arteriopathy, (6) other determined etiology, (7) multiple probable etiologies, and (8) undetermined etiology. we will describe the role of computed tomography (ct) and magnetic resonance imaging including angiography (mri/mra) in identifying these causes in relation to available clinical data. the etiologies of cerebral venous thrombosis related infarction would be discussed from an imaging perspective with a case-based approach with emphasis on mrv and swi techniques. finally, we will focus on hemorrhagic causes of childhood stroke such as vascular malformation, aneurysm, neurocutaneous disorders, coagulopathy, and a variety of other causes from an imaging standpoint. perfusion imaging in pediatric stroke demonstrates flow within the brain and can detect areas that are at risk of ischemia; however, further studies in the pediatric population need to be validated for the role of this technique in pediatric stroke. results: the most important factors in the diagnosis of childhood stroke are causal investigation, appropriate laboratory tests, and imaging studies. imaging is frequently the first step in the evaluation of an acutely ill child. conclusions: pediatric stroke is a debilitating disease that requires urgent multidisciplinary approach for diagnosis and treatment. in cases of both ischemic and hemorrhagic origin, the radiological approach to be obtained in emergency setting leads to the initial screening and the first therapeutic possibility. methods & materials: this exhibit will illustrate the characteristic imaging findings of vascular anomalies in the head and neck region. vascular anomalies are divided into vascular tumors and vascular malformations which include slow flow malformations (capillary malformations, venous malformations, lymphatic malformations and their combinations) and high flow malformations (arteriovenous fistula and arteriovenous malformations). complex malformations are also seen in several syndromes including klippel-trenaunay syndrome, phace syndrome, etc. cases from author's database will be used for illustration. results: a review of clinical manifestations, characteristic imaging findings and interventional treatment strategies in cases of head and neck vascular anomalies will be presented with pre and post treatment imaging features. ultrasonography and mri are the mainstay in diagnosis of these malformations. ct scan and catheter angiography may occasionally be needed for diagnosis and treatment planning. various imaging findings and main treatment options will be listed. conclusions: head and neck vascular malformations are common in pediatric population. understanding the characteristic imaging findings and clinical presentation is essential in evaluating the vascular malformations. interventional procedures are generally the preferred treatment modality, either alone or in association with surgery in majority of these cases. isolated cortical diffusion restriction in pediatric brain mri ihsan mamoun, md, cleveland clinic, ihsanmamoun@ yahoo.com; sarah stock, s. pinar karakas, unni udayasankar, janet r. reid purpose or case report: diffusion-weighted imaging continues to emerge as a powerful neuroimaging tool. isolated cortical restricted diffusion is a particularly striking pattern with specific differential in the pediatric population. we aim to review this specific imaging pattern supplemented by case examples and key physiologic and imaging concepts. methods & materials: review the concept of diffusion restriction a) pathophysiology b) specific imaging appearances pictorial review of pediatric conditions that lead to cortical restricted diffusion: a) post ictal change b) infection-i. meningoencephaliitis ii. herpes c) hypoxic ischemic injury d) infarct: venous and arterial e) posterior reversible leukoencephalopathy f) mitrochondrial cytopathy g) metabolic: hypoglycemia. discuss certain artifacts. summary table and differential clues conclusions: the pattern of isolated cortical restricted diffusion has specific differential diagnosis in the pediatric population. the radiologist should be aware of this as use of dwi continues to grow. this exhibit with familiarize the reader with common conditions that specifically affect the cortex and produces true restricted diffusion. methods & materials: high resolution ct scan and mri are mainstay of diagnosis and assessment in patients with sensorineural hearing loss. in this exhibit we will present a pictorial review of ct scan and mri images of various causes of sensorineural hearing loss (snhl) that are seen on imaging. reviewing the embryologic basis of these anomalies would enable better understanding of this complex subject. results: the new system classifies these malformations according to descending order of severity into complete labyrinthine aplasia, cochlear aplasia, common cavity, cystic cochleovestibular malformation or incomplete partition-i (ip-i), cochleovestibular hypoplasia, and incomplete partition-ii (ip-ii). there is a lot of confusion in literature pertaining to mondini deformity. the new classification divides incomplete partition into ip-i representing cystic cochleovestibular malformation and ip-ii representing the classic mondini deformity with three components (cystic cochlear apex, dilated vestibule, and large vestibular aqeduct). recently a subclassification of ip-i and ip-ii has been proposed (subdividing into typical and atypical subtypes)[2]. this will be discussed briefly. isolated large vestibular aqueduct without associated cochlear abnormalities will also be discussed. we will discuss the relevant embryology with correlations of malformations to the timing of embryologic insult. conclusions: the new classification system provides precision in description of inner ear malformation. this also helps in providing a uniform scale for comparison of effectiveness of cochlear implant for different malformations. purpose or case report: congenital cranial nerve anomalies often present as sensory and/or motor deficits of unknown etiology in the pediatric age group. the early recognition of a definitive cranial nerve abnormality using high-resolution imaging can focus further clinical investigation and shorten the time to diagnosis. methods & materials: to promote appropriate recognition of cranial nerve anomalies, we present the imaging findings of the most commonly affected cranial nerves and provide correlation with clinical presentation. all studies were performed on a 1.5 t magnet with dedicated high resolution imaging of cranial nerve exit zones. results: ours is a tertiary care pediatric hospital with an extensive neuroimaging database. we intend to review all known cases of cranial nerve anomalies from the prior 5 years and present interesting and representative images including optic nerve hypoplasia as part of septo-optic dysplasia, kallman syndrome, duane retraction syndrome, and mobius syndrome. conclusions: congenital cranial nerve anomalies present with varied symptomatology including anosmia, impaired vision, occulomotor deficits, and hearing loss. additionally, clinical manifestations of cranial nerve anomalies can be difficult to recognize in the pediatric age group. effective imaging and prompt diagnosis is crucial to initiate appropriate clinical management. purpose or case report: mr is the standard for evaluation of tumors or epilepsy. pet-ct imaging is often performed to ascertain metabolic asymmetries related to epileptogenic regions or to better characterize the metabolic activity of tumors. a baseline for normals with pet-ct fdg-18 and c11 methionine does not exist. methods & materials: retrospective review was performed of the 110 pediatric patients who underwent pet-ct with c11 methionine and fdg. representative studies were selected for patients imaged during infancy (<1 yr), early childhood (1-4), childhood (4-7), late childhood (7-12), teenage (13-18). c11 methionine and fdg studies were analyzed for normal patterns of uptake and any trends identified across the stratified age groups. representative pictorial image galleries of the c11 methionine and fdg imaging patterns through development were created. results: the pattern of radiotracer uptake on c11 methionine differed from that of fdg. the c11 uptake remained low level throughout development compared to fdg uptake, which was robust in much of the cortex. the cortical fdg uptake within the frontal lobes progressively increased with age. the c11 uptake within the brainstem and thalamus was equal to cortex throughout development. the fdg uptake within the basal ganglia was equal to cortex while the brainstem and thalamic uptake was generally less than cortex. several anatomic structures showed robust c11 uptake not seen on fdg. these included the lacrimal, submandibular and parotid glands. incidentally, the pituitary gland and hippocampus consistently showed c11 uptake equal to cortex contrary to their appearance on fdg. our institutional protocol regarding the performance of combination c11 methionine and fdg brain pet-ct studies is presented. conclusions: this study illustrated the normal appearance of brain pet-ct imaging performed with c11 methionine and fdg in a representative cohort of the pediatric patients through development. normal variance imaging patterns and developmental trends seen with each radiotracer was demonstrated. the pediatric cerebellum: a pictorial review of normal anatomy using mri and diffusion tensor imaging ibrahim s. tuna, md, radiology, children's hospital of wisconsin, dristuna@yahoo.com; sumit singh, teresa c. gross kelly, mohit maheshwari, tushar chandra, hervey d. segall purpose or case report: the aim of this educational exhibit is to illustrate normal anatomical and functional anatomy of the cerebellum in the pediatric patient. the cerebellum receives sensory input from the brain and spinal cord and integrates this information to coordinate motor control. in addition, the cerebellum also plays a role in some cognitive functions such as attention and language. the first step toward understanding how cerebellar abnormalities can lead to neurological dysfunction, is to provide a solid understanding of the neuroanatomy and functional pathways of the cerebellum. we will describe basic cerebellar embryology, the various cell types and gross anatomy using mr images as well as dti fiber tractography. methods & materials: this exhibit will describe the microstructure, gross anatomy and functional pathways of the cerebellum through illustrations, mr images, diffusion tensor imaging (dti) and pathological correlation. first embryology of the cerebellum will be described, followed by mri depiction of the developmental anatomy of the cerebellum from infancy through adolescence. finally dti tractography images will be used to delineate functional pathways to and from, as well as within, the cerebellum. pathological specimens will be photographed to further illustrate gross anatomy. results: afferent white matter pathways travel mainly via the inferior and middle cerebellar peduncles. the main efferent cerebellar white matter pathway is through the superior cerebellar peduncle. transverse fiber tracts are present in the vermis. there are mainly two main systems of cerebellar white matter fibers which are easily visualized with dti color mapping; however more anterior components of dti tracts are intermixed with afferent white matter projections following the middle cerebellar peduncle. conclusions: knowledge of the precise neuroanatomy and white matter tracts of cerebellum may elucidate our ability to comprehend the clinical manifestations of cerebellar diseases in children. a solid understanding of normal cerebellar anatomy, development and functional fiber tracts in the pediatric patient can provide a baseline that may help predict the clinical outcome of various diseases or interventional procedures. gastroesophageal reflux scintigraphy: a low radiation alternative to gerd evaluation in children vikas menghani, md, pediatric radiology, women's and children's hospital, drvikasmenghani@gmail.com; feraas jabi, jan najdzionek, vaseem iqbal purpose or case report: gastroesophageal reflux disease (gerd) is among the common causes for failure to thrive, recurrent cough and aspiration in children. early diagnosis of gerd is essential in avoiding long-term sequelae such as growth delay, chronic lung disease, esophageal stricture, and esophagitis. gastroesophageal reflux scintigraphy, a noninvasive imaging modality, has been applied for detection of gerd and gastric emptying in children over the past few decades. the radiation burden is considerably small given that a very low dose of radioactivity via a short half-life radioisotope like technetium-99 m tagged to oral sulfur colloid is administered to a patient. this feature makes reflux scintigraphy especially attractive as the patient can be scanned for prolonged and delayed periods without increasing radiation dose permitting not only identification but also assessment of severity of gerd. characterizing gerd severity is essential in determining how aggressive the pediatrician should be with therapy. gastroesophageal reflux scintigraphy also allows a child to be fed their regular meal tagged to radiopharmaceutical without altering food taste. qualitative and quantitative parameters like gastrointestinal transit and gastric emptying time can be measured, respectively. scintigraphy is highly sensitive to low grade reflux making it very desirable for monitoring response to therapy. while scintigraphy like all other imaging modalities,has limitations, it continues to be an excellent technique for gerd identification and characterization as well as in monitoring response to gerd therapy. the pediatric kidney-a review of common and uncommon renal anomalies ruby lukse, staten island university hospital, drjosemorey@gmail.com; josé morey, jeremy neuman, arnold brenner, oren herman, adam bernheim purpose or case report: renal parenchymal imaging in nuclear medicine has long been performed with 99mtcdimercaptosuccinic acid (dmsa) due to its sufficient binding to the renal tubules to permit renal cortical imaging. dmsa is of particular value when high-resolution images of the renal cortex are needed. this poster will be a pictorial review of common and uncommon congenital anomalies evaluated on dmsa imaging, such as horseshoe kidney, pelvic kidney, sshaped kidney and crossed-fused ectopia. the poster will also correlate planar imaging findingss with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: in this poster we will review the differential diagnoses of congenital anomalies that give the appearance of hydronephrosis on renal imaging of the pediatric patient. we will show a pictorial review of both common and uncommon congenital anomalies such as congenital megaureter, ureterocele, uretero-pelvic junction (upj) obstruction, uretero-vesicular junction (uvj) obstruction and posterior urethral valves (puv). we will also review common mimickers of hydronephrosis such as multicystic dysplastic kidney (mcdk) and pseudo-obstruction secondary to bladder overdistention. the poster will also correlate planar imaging finds with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), fluoroscopic imaging and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the pediatric bone scan-a review of neoplastic pathology shrita smith, staten island university hospital, drjosemorey @gmail.com; josé morey, jeremy neuman, arnold brenner, daniel klein, purpose or case report: bone imaging continues to be the second greatest-volume of nuclear imaging procedure performed today, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of 99 m-tc bone imaging of malignant conditions have long been established. in fact, more than 3,450,000 bone scans were performed in the united states in 2005. in this poster we will review the current indications for planar bone imaging for the evaluation of malignant and benign neoplasms in the pediatric population, such as osteoid osteoma, langerhan cell histiocytosis (lch), osteoblastoma, ewing's sarcoma, lymphoma, osteosarcoma and osseous/hepatic metastatic disease from neuroblastoma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). the many faces of duplex kidneys on dmsa scans-a pictorial essay neha kwatra, children's national medical center, nskwatra@childrensnational.org; massoud majd purpose or case report: renal duplication is the most common malformation of the urinary tract and is often seen in children with urinary tract infections (uti). the purpose of this study is to learn to recognize duplex kidneys on dimercaptosuccinic acid (dmsa) scintigraphy, review their entire spectrum of findings and correlate with other imaging modalities. methods & materials: dmsa scintigraphy is routinely performed in the nuclear medicine department with a single-head gamma camera (siemens e.cam, schaumberg, illinois). about 1.5 h after injection of dmsa, posterior and posterior oblique images are obtained using parallel and pin hole collimators. differential renal function is also calculated. dmsa scan reports containing the words "duplex" or "duplicated" from 2006-2011 were populated using a radiology search engine (montage health care solutions inc.). the images were then reviewed in pacs and representative examples were selected for the poster. the scans were evaluated for renal position, size, contour, any evidence of duplication and parenchymal damage. results: patterns of duplication included non complicated duplex kidney recognized by asymmetric renal size and a prominent cortical bar separating the two moieties, complicated duplex systems with hydronephrosis, scarring or pyelonephritis of one or both moieties. a small nonfunctioning upper moiety was sometimes evidenced by just an indentation along the superomedial aspect of the larger lower moiety. cases with bilateral duplex kidneys were also seen. illustrative examples of each will be provided. correlating findings on other imaging modalities will also be included. conclusions: establishing the diagnosis of duplex kidney on a dmsa scan requires a careful systematic review of the images. the findings can be subtle and it is important for the radiologist to recognize them. correlation with other modalities such as ultrasound or voiding cystogram can be complementary. the assessment of parenchymal function of the upper and lower moieties separately on dmsa scintigraphy can be of immense value in patient management and in choosing surgical options. poster #: edu-094 18 f-fdg pet/ct imaging of pediatric brain tumors, neurofibromatosis 1(nf1) and non-lymphomatous head and neck tumors. lisa states, md, radiology, chop, states@email.chop.edu; purpose or case report: this educational poster will review the current literature and summarize the value of 18 f-fdg pet/ct in standard clinical practice in the evaluation of pediatric brain tumors, nf1 plexiform neurofibromas and malignant peripheral nerve sheath tumors, and nonlymphomatous head and neck tumors. normal variants and pitfalls will be reviewed. comparison with other pet tracers will be briefly discussed. case examples will be used to illustrate the value of 18 f-fdg pet/ct in grading, staging, assessment of therapeutic response and detection of residual or recurrent disease in various pathologic entities. results: examples of cases will include: benign brain tumor, residual brain tumor in the post-operative bed, brain metastasis, malignant peripheral nerve sheath tumor in nf1, head and neck rhabdomyosarcoma, mandibular osteosarcoma, and infection. conclusions: an understanding of the value of pet molecular imaging is essential to the success of the next phase of hybrid imaging with pet/mri which has the potential to play an important role in the development of new diagnostic and therapeutic approaches for the treatment of pediatric brain tumors, nf1, and pediatric head and neck tumors. disclosure: dr. states has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the pediatric bone scan-a review of non-malignant pathology josé morey, staten island university hospital, drjosemorey@ gmail.com; jeremy neuman, arnold brenner, vinh phan, cheryl lin purpose or case report: bone imaging continues to be the second most performed nuclear imaging procedure, offering the advantage of total body examination, low cost, and high sensitivity. the diagnostic utility, sensitivity, specificity and predictive value of 99 m-tc bone imaging of benign conditions have long been established. in fact, more than 3,450,000 bone scans were performed in the united states in 2005. in this poster we will review the current indications for planar bone imaging for the evaluation of non-malignant diseases in the pediatric population, such as acute osteomyelitis secondary to salmonella enterobacteriaceae and tubercle bacillus (tb), chronic osteomyelitis, reflex sympathetic dystrophy, spondylolysis, bone infarcts in the setting of sickle cell disease, fractures (occult/stress), ankylosing spondylitis, dermatomyositis and non-accidental trauma. the poster will also correlate planar and single-photon emission computed tomography (spect) imaging findings with appropriate additional imaging including computed tomography (ct), magnetic resonance imaging (mri), positron emission tomography (pet), and plain film radiographs when clinically warranted and in keeping with the as low as reasonably achievable (alara) principle set forth by the american college of radiology (acr). purpose or case report: we review the radiologic features of pathologic conditions linked to diesel exposure. the hydraulic fracturing ("fracking") technique is increasingly used in many areas of the country to extract natural gas from rock formations. diesel fuel, or fluids containing diesel, are one component of fracking fluid and create a potential for ground water contamination and risk to air quality. the toxic effects of diesel exhaust are described in the literature, and include asthma, hydrocarbon pneumonitis, and leukemia. there are no scientific data currently available on the effects of chronic diesel ingestion. methods & materials: multi-modality examples of pathology were obtained from a radiology database at a tertiary care pediatric hospital. the specific cases displayed are not known to have diesel exposure, but are intended to serve as representative examples of the type of pathology that may be encountered in the setting of chronic diesel exposure. results: imaging findings of asthma include hyperexpansion, atelectasis, peribronchial thickening, and air-trapping. hydrocarbon pneumonitis may demonstrate low attenuation consolidation and subsequent pneumoatocoeles with ct. leukemia may present on plain radiographs with lucent metaphyseal bands and with marrow infiltration on mri. conclusions: in conjunction with other symptoms not necessarily evaluated in the radiology department, including rhinitis, laryngitis, acute coronary syndrome, and dementia, the radiologist may suggest the diagnosis of diesel toxicity, particularly in populations that may be at high risk of exposure. pediatric radiology in the philadelphia region: a historical review* richard markowitz, md, children's hospital of philadelphia, markowitz@email.chop.edu purpose or case report: the specialty of pediatric radiology in the philadelphia region has grown and evolved over the past eight decades originating from early "visiting" radiologists to drs. hope and kirkpatrick, the "giants" of the 1950s and '60s, to over fifty practicing pediatric radiologists today. clinical excellence, commitment to teaching, and advancement of knowledge through research remain the goals and ideals, much as they were many years ago. philadelphia has been a fertile home and environment for this evolution, mostly because of outstanding leaders and role models who have trained and influenced generations of pediatric radiologists. developments and leadership at the children's hospital of philadelphia, st. christopher's hospital for children, and a.i. dupont institute are highlighted. the purpose of this poster is to tell the story of the growth and development of pediatric radiology in this area and to explore the intellectual origins, professional "genealogy," and legacies left by those who created and those who have carried on this tradition. *note: this material is based on a previously published article: pediatric radiology (2009) 39:969-981 and "addendum" (pediatric radiology 2010: 1454-1455), but never presented at spr. superficial lumps and bumps henrietta k. rosenberg, md, radiology, the mt. sinai medical school, henrietta.rosenberg@mountsinai.org; diane belvin, neil lester purpose or case report: superficial soft tissue masses in the pediatric age range can be quite challenging to the pediatrician and the imager. the purpose of this presentation is to demonstrate the efficacy of duplex/color doppler ultrasound for the diagnosis and follow up of a large gamut of superficial lumps and bumps. methods & materials: we reviewed our experience during the past 6 years using ultrasound to evaluate superficial soft tissue masses that had been encountered in many parts of the body, from the skull to the soles of the feet, in a large group of patients ranging in age from newborn to 21 years. all sonograms were performed after obtaining pertinent clinical information as well information regarding the clinical characteristics of each of the masses, e.g. location, consistency (firm [solid], compressible [cystic]), fixed or easily movable, smooth or irregular surface, tenderness. the masses were palpated by the imaging team and duplex/color doppler ultrasound was performed. comparison sonographic views of the opposite side were obtained as needed. clinical followup and surgical/pathological correlation was obtained in most of the patients. results: most of the masses were benign and included a wide variety of etiologies. most often, us was sufficient for assessment of soft tissue masses if the entire mass was included in the field of view. if the lesion was too large for the field of view or malignancy was suspected, ct/mri were required preoperatively. nuclear medicine studies are reserved for midline masses likely due to ectopic thyroid and pet was used for more complete evaluation of a lesion that was likely malignant. conclusions: duplex/color doppler ultrasound (us) is the modality of choice for evaluation of superficial lumps and bumps! this modality allows for rapid acquisition of information without the use of ionizing radiation, intravenous contrast material, or sedation/anesthesia. reliable information can be rapidly acquired regarding the size, shape, borders, location, internal consistency, vascularity, vascular encasement/displacement. correlation of the ultrasound and clinical findings helps narrow differential diagnosis. sonography helps to determine what is the next best step: watchful waiting (clinical observation, follow-up us), surgical resection, or us guided interventional procedure. present day imaging of down syndrome rupa radhakrishnan, md, radiology, university of cincinnati college of medicine, radhakrp@ucmail.uc.edu; alexander j. towbin purpose or case report: down syndrome is a common genetic condition characterized by unique physical traits and multisystem anomalies. the purpose of this exhibit is to portray the imaging findings of down syndrome and discuss with illustrative examples, the use of imaging in multidisciplinary management. methods & materials: published literature was reviewed to identify the multisystem imaging findings in down syndrome. the electronic medical record system was then searched to find illustrative case examples from our institution. results: in patients with down syndrome, abnormalities can be found in the musculoskeletal, cardiovascular, respiratory, gastrointestinal, and central nervous systems. abnormalities can range from emergent, life threatening conditions such as malrotation with midgut volvulus to chronic conditions such as scoliosis. examples of abnormalities from each organ system and the modalities used for diagnosis and management are described. cardiovascular system: echocardiogram and cardiac mri and ct are useful in evaluating congenital heart disease associated with down syndrome. respiratory system: micrognathia with macroglossia and hypotonia predisposes patients to sleep apnea which can be evaluated with dynamic mri. chest ct demonstrates subpleural cysts which are characteristic of this syndrome. gastrointestinal system: fluoroscopy and/or radiographs are the mainstay in diagnosing many gastrointestinal disorders including duodenal atresia, malrotation, annular pancreas, imperforate anus, and hirschsprung disease. central nervous system: choroid plexus cysts may be identified on prenatal ultrasound in a fetus with down syndrome. imaging is used in the evaluation of epilepsy, hearing loss and alzheimer disease that is more common in these individuals. musculoskeletal system: multiple skeletal anomalies can be present in patients with down syndrome. radiographs are often used as the method of identifying and, if needed, following the anomalies. prenatal imaging: increased nuchal translucency is the earliest imaging finding. other features of down syndrome can be identified on prenatal ultrasound or mri. prenatal imaging is helpful in determining the prognosis of the fetus and in guiding management. conclusions: modern day multidisciplinary management has improved quality of life and survival in individuals with down syndrome. imaging plays a critical role in guiding management in these individuals. imaging the spectrum of lymphatic malformations in the pediatric patient andrew schapiro, md, radiology, university of wisconsin, aschapiro@uwhealth.org; kara gill, bradley maxfield purpose or case report: lymphatic malformations (lm) occur as a result of abnormal development of the lymphatic system during embryogenesis. as 90% of lm present by 2 years of age, these lesions represent an important pediatric entity. lm can often be suspected clinically in an infant with the classic presentation of an asymptomatic, soft mass in the head, neck, or axilla. however, myriad presentations are possible as lm occur in numerous other anatomic locations, can be multiple, and can be a component of mixed vascular malformations. in addition, the true extent of lm is often not apparent clinically. given these considerations and the implications for proper management, imaging plays an important role in the assessment of lm. the purpose of this exhibit is to review the spectrum of radiographic, ct, sonographic, and mr imaging findings of a variety of lm presentations. methods & materials: cases of lymphatic malformation in pediatric patients identified at a single institution over the past ten years with available imaging were reviewed utilizing pacs. results: images of lm involving the head and neck, chest, abdomen, retroperitoneum, extremities, and skeletal system were identified. in addition, cases of lymphangiomatosis and mixed venolymphatic malformation were identified. various imaging modalities including radiography, ct, sonography, and mr were represented. conclusions: adequate knowledge of the imaging characteristics of lm across multiple modalities enables proper diagnosis, assessment of disease extent, and guidance of appropriate therapy in pediatric patients. results: ct and mr imaging findings in nine cases will be presented. they include 1) congenital absence of the inferior vena cava with thrombosis of the external iliac vein secondary to venous stasis 2) pyelophlebitis complicating ruptured appendicitis 3) left iliac vein thrombosis in a patient with may-thurner syndrome 4) splenic vein thrombosis complicating pancreatitis 5) splenic vein thrombosis following splenectomy 6) renal vein thrombosis in an infant of a diabetic mother 7) adrenal vein thrombosis as the presenting sign of antiphospholipid syndrome 8) budd-chiari syndrome associated with underlying myeloproliferative disease 9) iliac vein thrombosis as a manifestation of behcet's syndrome (hughes-stovin syndrome, a variant of behcet's syndrome, which presents with systemic venous thrombosis and pulmonary artery aneurysms will also be discussed). conclusions: thrombosis of large abdominal and pelvic veins in children and adolescents is uncommon. certain conditions, both congenital and acquired, predispose to the development of venous thrombosis. ct/mr imaging defines the extent of thrombosis, and demonstrates additional findings that may elucidate the nature of the underlying condition leading to clot formation. purpose or case report: because abnormal gait in a young child has a wide range of causes, imaging plays a critical role in establishing the definitive diagnosis. the purpose of this exhibit is to review the clinical clues (age, duration, laboratory markers) and imaging findings of the causes of abnormal gait in a toddler and to assess the strengths and limitations of radiographs, ultrasound, magnetic resonance imaging (mri), and computed tomography (ct). methods & materials: cases, from a single institution experience with various causes for abnormal gait in a toddler, are reviewed and categorized into congenital, traumatic, inflammatory, neoplastic, or neuromuscular etiologies. results: there are various causes of abnormal gait in a toddler. the congenital causes include spinal dysraphism, proximal and distal skeletal deformities and dysplasias. the traumatic causes include non-accidental trauma, toddler's fracture, foreign body, and soft tissue injuries. the inflammatory causes include juvenile idiopathic arthritis, transient synovitis, and infection, including osteomyelitis, septic arthritis, discitis, cellulitis, and abscess. the neoplastic causes include various neurogenic, bone, and soft tissue tumors. the neuromuscular causes include cerebral palsy and spinal bifida. the combination of clinical presentation, supporting laboratory findings, and classic imaging findings help to distinguish the possibilities and often allows confident diagnosis. conclusions: knowledge of imaging findings and clinical factors can demystify the diagnosis of abnormal gait in a toddler. familiarity with the clinical presentation can ensure the performance of the appropriate diagnostic studies, timely diagnosis, and effective treatment. nonaccidental causes should never be overlooked. ultrasonography has become an important tool in the radiologist's armamentarium, augmenting radiography, mri, and ct. approximately 20 different contrast agents for mri and ct are now commercially available for use. although most of them are fda approved in adults, information on usage and safety in children is not readily available. the most important reason is lack of controlled studies in children, especially for the age of 0-2 years. however, the lack of fda approval has not limited the use of these promising agents in children. in fact, there is widespread off-label use of these agents in most major pediatric hospitals in the country. based on a review of relevant literature in children, and based on a survey of radiology faculty at major pediatric hospitals, this poster will address the gap between approved use and reality in the setting of pediatrics. results: using a tabular format, this poster will provide a list of mr and ct contrast agents that are available for clinical use, their relevant clinical properties (ionic or nonionic, viscosity, linear or macrocyclic, degree of relaxivity for mri, iodine concentration for ct, cost, dosage, halftime, incidence of allergic reactions, nephrogenic systemic fibrosis and other adverse reactions), fda approval status (for ages 0-30 days, 30 days-2 years, and 2-17 years), common pediatric applications, and contrast injection protocols for common applications. conclusions: to enlighten imaging personnel about usage and safety of contrast agents in children. disclosure: dr. krishnamurthy has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. a pictorial essay and literature review of the spleen in sickle cell disease david hindson, md, boston medical center, david. hindson@bmc.org; heather imsande, philippa sprinz, ilse castro-aragon purpose or case report: the morbidity and mortality of sickle cell disease (scd) results from acute and chronic infarction events that affect almost every organ. repeated infarction has some of its greatest visual and physiologic impact within the spleen. continuous hemolysis, sequestration and vaso-occlusion within the spleen result in loss of splenic function early in life and frequently autosplenectomy thereafter. by 2 years of age, approximately 90% of children with hemoglobin ss disease will have diminished splenic function, putting them at increased risk for infections. treatments for scd have evolved over the last 20 years, and among others include penicillin prophylaxis and immunizations, hydroxyurea and transfusion therapy (or hypertransfusion program). imaging findings are a reflection of the different treatments and their efficacy. methods & materials: our institution cares for a large group of patients with sickle cell disease, from birth to adulthood. this offers an unprecedented opportunity to document the imaging findings of the spleen with different treatment regimens, and over many years. the splenic size and morphology can be followed, by ultrasound, in a very straightforward way. we have compiled a pictorial essay of the various imaging characteristics of spleens from infants to adults. we also performed a literature review to compare and supplement the findings of our images. results: there is a spectrum of imaging findings in the spleen of patients with scd that changes from birth to childhood. the findings range from the normal appearance of a spleen to a calcified spleen, and include regenerative nodules, fibrosis, altered parenchymal echotexture, increased echogenicity, and changes in size, including enlargement secondary to sequestration. the ultrasound characteristics not only change with advancing age, but also appear to depend on whether or not the patient has received specific treatments, and at what age treatment was initiated. conclusions: the ultrasound appearance of the spleen in patients with scd is variable. treatments such as blood transfusions and hydroxyurea, patient compliance with therapy and type and severity of the disease are some of the factors that affect imaging characteristics. cystic fibrosis: not just for children cindy miller, md, radiology, yale-new haven hospital, cindy.miller@yale.edu purpose or case report: cystic fibrosis has been recognized for hundreds of years with the first descriptions of it including such anecdotes as mothers licking the foreheads of their children and knowing that if it tasted salty, an early death could be predicted. it was not until 1939 that the disease was first named by dr. dorothy andersen, and for the following 50 years, treatment was largely supportive, and imaging was essentially done with plain films alone. in 1989 with the elucidation of the cftr gene, there was an explosion of knowledge which included the range of increased awareness and understanding of the suspected etiology, imaging findings and significance of the ductus bump. the contribution of 3d imaging for evaluation of the pediatric central airways jessica kurian, md, the children's hospital of philadelphia, kurianj@email.chop.edu; monica epelman, david a. mong purpose or case report: evaluation of the central airways in children has historically been accomplished by flexible bronchoscopy, an invasive technique associated with inherent risks and complications. multidetector ct (mdct) with volume rendering offers a noninvasive alternative for airway evaluation. in this educational exhibit, we will review imaging techniques and clinical applications of mdct for the assessment of large airway maladies in children. methods & materials: mdct imaging in children with a variety of tracheobronchial disorders is reviewed. for each entity, the characteristic clinical features are described, and key imaging features are illustrated. emphasis is placed on the contribution of 3d techniques for characterizing complex airway anomalies. dose reduction strategies are also highlighted. results: the entities reviewed in this exhibit include, but are not limited to, congenital anomalies of tracheobronchial branching, airway malformations associated with situs, and congenital or acquired airway compression and/or obstruction. conclusions: mdct with volume visualization is a useful adjunct for evaluation of the pediatric central airways in a variety of pathologies. as a noninvasive technique, it avoids sedation risks and spare patients from complications associated with conventional flexible bronchoscopy. low dose protocols should be used to minimize radiation exposure. bronchopulmonary foregut malformation that result from abnormal budding of the primitive foregut. currently, many such anomalies are initially detected by prenatal ultrasound and are further delineated by fetal magnetic resonance imaging (mri), while others may be incidentally detected on postnatal radiologic examinations or later in life in the setting recurrent pulmonary infection. imaging plays a very important role in the diagnosis and characterization of these lesions and assists surgical planning. the purpose of our educational exhibit is to illustrate the common and uncommon radiologic appearances of cpams using various imaging modalities, including radiography, computed tomography, prenatal and postnatal ultrasound, and prenatal and postnatal mri. methods & materials: all pediatric and adult cpam (including both sequestration and ccam) patients were identified using electronic medical records. pertinent imaging reports (including radiography, prenatal and postnatal ultrasound, ct, and prenatal and postnatal mri) were reviewed by a single author in order to identify relevant imaging findings. relevant images from these imaging examinations were de-identified and saved to a secure hard drive. medical records were accessed by a single researcher to obtain relevant demographic information as well as data regarding the patients' clinical presentations. in cases of corrective surgery, operative and pathology reports were reviewed, if available, for correlation with the imaging findings. results: cases of pediatric and adult cpam were identified and presented in a variety of clinical contexts. their appearances were reviewed through multiple imaging modalities. conclusions: congenital pulmonary airway malformations are varied in their clinical presentation and imaging appearance. the purpose of this pictorial essay is to enhance understanding of their diagnosis and to use a multidisciplinary approach in order to highlight imaging aspects that may alter clinical management. disclosure: dr. horst has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. the imaging evaluation of cystic lung disease in children: an evidence-based approach jordan caplan, md, pediatric radiology, lucile packard children's hospital, stanford university, caplan@stanford. edu; beverley newman purpose or case report: the goal of the poster is to provide a framework for use when confronted with cystic lung disease in a child. methods & materials: the differential diagnosis for the types and causes of cystic lung disease in children will be presented using an evidence-based, age appropriate approach. categories of disease discussed and illustrated with case examples will include: a. congenital cystic bronchopulmonary malformations b. infectious cysts c. autoimmune/inflammatory/vasculitic disease with cavitating lesions d. neoplastic conditions e. collagen/soft tissue abnormalities f. mimics of cystic lung disease results: the pathophysiology, imaging appearance, and demographics of the above entities will be reviewed with attention to relevant recent literature. important educational points include the differentiation of bronchopulmonary malformations from neoplasm, notably pleuropulmonary blastoma (ppb), the relationship between lung cysts and ppb, and the management and surveillance of lung cysts in children. conclusions: an evidence-based approach to the broad spectrum of causes of cystic lung disease in children is a useful starting point in forming a concise and pertinent differential diagnosis. an understanding of the pathophysiology, imaging appearance, and demographics of these entities is essential in guiding patient management. pediatric interstitial lung disease (ild): a pictorial review with radiologic and pathologic correlation hollie west, md, diagnostic radiology, vanderbilt university, hollie.c.west@vanderbilt.edu; melissa a. hilmes, sudha p. singh, jennifer soares, lisa young purpose or case report: while adult interstitial lung disease is a well-described and fairly well understood group of disease processes, pediatric interstitial lung disease (ild) remains a subject of uncertainty and misunderstanding for many clinicians and radiologists. confusion surrounding the phenomenon of pediatric ild stems not only from the rarity of the disease, but also from the extensive list of disease entities that can produce ild, the existence of certain patterns that are restricted to infants and children and the fact that patterns of ild manifest differently in a child's developing lung than in an already developed adult lung. imaging plays an important role in diagnostic work-up of this disease and can guide lung biopsy in specific patient populations. methods & materials: the irb approved retrospective study will show patients at our institution over a 10 year period diagnosed with various types of ild, including pulmonary insterstitial glycogenolysis (pig), diffuse neuroendocrine cell hyperplasia (nehi), surfactant deficiency diseases, and lung diseases associated with other systemic processes such as downs syndrome and inflammatory bowel disease. we will include patients with biopsy proven ild and will provide examples of the major ilds, including clinical, radiologic and pathologic correlation. our pictorial review will describe the radiologic patterns associated with the different forms of ild, emphasizing what the radiologist needs to know and how to be helpful to a multidisciplinary team in the diagnosis and treatment of these diseases. results: the study will report the frequency of ild at our institution, including a breakdown of the various subtypes of ild. we will show examples of the subtypes with correlative chest radiography, computed tomography, and pathology. we plan to highlight specific differentiating factors between the different diseases and demonstrate how a radiologist can be helpful in collborating with clinicians in diagnosing and treating these diseases. conclusions: pediatric ild can be a confusing topic for radiologists. increasing knowledge and awareness of these diseases, their clinincal presentation, work up, and treatment is important for pediatric radiologists who work as part of of a multidiciplinary team. poster #: sci-001 ct radiation dose delivered by community hospitals and imaging centers stephen little, children's healthcare of atlanta, stephen. little@choa.org; damien grattan-smith, bonnie johnson purpose or case report: to evaluate and compare ct radiation dose for pediatric abdominal and cranial ct examinations performed by community hospitals and imaging centers. methods & materials: 148 consecutive ct examinations (49 cranial, 99 abdominal) from 41 community hospitals and imaging centers were reviewed following transfer of care. the examinations were performed between january and july 2011. 433 consecutive ct examinations (241 cranial, 192 abdominal) performed at our own institution were also reviewed. ctdivol and dlp were obtained from the dose report for each examination (32 cm-phantom for abdominal exams, 16 cm-phantom for cranial exams). patient age and weight were obtained from the medical record. results: average ctdivol for abdominal ct performed by local community hospitals and imaging centers was 8.7 mgy, while average ctdivol was 4.3 mgy for abdominal ct performed at choa. there was a wide variation in ct radiation dose delivered. while some sites delivered a ct radiation dose comparable to our own, others delivered a substantially greater dose. in fact, 23% of pediatric abdominal ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm (10 mgy using the 32cm phantom). low kvp technique for imaging small children was infrequent. multi-phase examinations were more often performed, resulting in additional elevation in ct radiation dose when dlp is considered. average ctdivol delivered by local community hospitals and imaging centers for cranial ct was 44 mgy compared to a ctdivol of 30 mgy for cranial ct performed at choa. 8% of pediatric cranial ct exams performed by local community hospitals and imaging centers exceeded the notification value recommended by the aapm (60 mgy for 2-5 years, 80 mgy for >5 years). conclusions: despite ongoing efforts at education, there is wide variation in ct radiation dose delivered for pediatric abdominal and cranial ct examinations performed by local community hospitals and imaging centers. appropriate use of dose check software on newer scanners may help reduce the number of children subjected to excessive ct radiation dose. ultimately, each site performing pediatric ct must take responsibility for minimizing radiation dose while producing diagnostic quality exams. the impact of adaptive statistical iterative reconstruction on ct image quality parameters -a phantom study karen thomas, md, radiology, hospital for sick children, karen.thomas@sickkids.ca; nancy ford, angjelina protik, paul babyn purpose or case report: to quantify the effect of adaptive statistical iterative reconstruction (asir) on ct image quality parameters. methods & materials: phantom (catphan 600) studies were performed on a ge hd750 64-slice scanner to investigate the impact of a) 50% asir compared to routine filtered back projection using variable kvp (80-140) and mas (5-200), and b) incremental asir % (0, 30, 50, 70, 100%), scanning at 75mas and variable kvp (80-120). pitch, acquisition fov and detector width were kept constant. image noise, spatial and contrast resolution, contrast noise ratio (cnr) and wiener spectrum analysis were performed on 0.625 mm ax, 5 mm ax mpr and 2 mm cor mpr series. results: 50% asir resulted in a mean decrease in noise of 30% (0.625 mm ax), 26% (ax mpr) and 28% (cor mpr) and improvement in cnr of 38-49%. incremental advantage was seen with stepwise increase in asir %. however, application of asir was associated with a small reduction in spatial resolution (2-8% at 50% asir). low contrast detectability (lcd) improved except at the smallest target lesion size. image quality effects at very low mas and at high asir % will be presented. conclusions: image noise reduction and improvements in cnr and lcd with asir hold considerable potential for dose reduction in pediatric ct. this study provides quantitative data that may be used to design asir-enhanced protocols with consideration of diagnostic task, balancing image quality benefits and potential pitfalls. pictorial essay on cardiac mr for congenital heart disease on 3 t mr scanner with rf multi-transmit technology (tx) taylor chung, md, diagnostic imaging, children's hospital & research center oakland, taylorchung12@gmail.com purpose or case report: this is a pictorial essay (e-poster) to show artifacts on cine ssfp images pre-tx and post-tx upgrade on congenital heart disease cardiac mr; to illustrate methods prior to tx-upgrade to minimize artifacts. disclosure: dr. chung has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. revisiting the relationship between anthropometric parameters and left ventricular mass abdullahi adamu, md, phd, ahmadu bello university, scorpion68kd@yahoo.com purpose or case report: the purpose of this study was to find the correlation between anthropometric parameters and left ventricular mass in normal adolescents and young adults. methods & materials: 147 healthy individuals in the age range 17 to 23 years (73 males and 74 females) were included in this study. anthropometry was performed with standard anthropometry kit and measurements of height, weight, body surface area (bsa), upper arm circumference and upper hip circumference were taken. echocardiography was performed and the american society of echocardiography (ase)-recommended method was employed for calculation of left ventricular mass (lvm). statistical analysis was performed using statistica 6.0 (stat soft, usa). results: the mean value of lvm for all our subjects was found to be 124.53±2.79 g. there was significant correlation between lvm and height (r00.52, p<0.0001), weight (r00.63, p<0.00001) and bsa (r00.64, p<0.00001). correlation with upper arm circumference was moderate (r0 0.46, p<0.0001), while it was found to be weak with upper hip circumference (r00.23, p<0.01). diagnostic. both field strengths can be used successfully for cardiac and vascular imaging. the decision as to which to use is weighted by local availability and the relative requirement for detailed vascular vs intra-cardiac imaging. disclosure: dr. nguyen has indicated that she will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. poster #: sci-006 color coded 3d cardiac cta of congenital heart disease: a five year experience nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; randy richardson purpose or case report: post-processing of cardiac computed tomography angiograms can be performed on a commercially available workstation to create color coded 3d volume rendered images of the segmented heart and great vessel anatomy in patients with congenital heart disease. these studies optimally demonstrate complex anatomy, streamlining communication between members of the healthcare team and providing a tool for communicating complex anatomy and treatment options with families. these studies have been ordered with more frequency over the past five years. we retrospectively reviewed the types of congenital heart disease demonstrated by cardiac 3d cta over the past five years at a congenital heart center. methods & materials: color coded cardiac cta postprocessing was performed from ecg gated prospective and retrospective cta data on a commercially available workstation for 333/395 patients over the past three years. the anatomy was initially segmented and colored into individual parts of the anatomy of the heart and great vessels as follows rv 0 purple, lv 0 light red, aorta 0 red, pulmonary arteries 0 blue, systemic veins and right atrium 0 aqua, pulmonary veins and left atrium 0 pink, pda or collaterals 0 green, airway 0 yellow, coronary arteries 0 neutral. the anatomy was then reassembled and images obtained every 3°in a 360°rotation for display. results: 3d color coded cta images were used in the treatment and care of congenital heart patients for the following types of congenital heart diseases: 124 cases of complex anatomy (tga, truncus arteriosus, hlhs, tricuspid atresia, tof…), 67 coronary artery anomalies, 68 cases of pulmonary atresia or stenosis, 44 cases of systemic and venous anomalies, 40 cases of coarctation or interruption of the aortic arch, and 56 tracheobronchial tree anomalies. conclusions: color coded cardiac cta post-processing is an effective and viable method for demonstrating anatomy in complex congenital heart patients. it is an excellent tool for demonstrating anatomy which is difficult to see by echocardiography such as: coronary artery anomalies, pulmonic atresia, aortic arch coarctation or interruption, and tracheobronchial anomalies and/or stenosis. neuroimaging in the evaluation of hie in term neonates post hypothermia therapy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu; jatinder bhatia, leann vanlandingham purpose or case report: to illustrate and review the potential utility of brain mri, ct and ultrasound in hypoxic ischemic encephalopathy in newborns treated with hypothermia. neuroimaging studies including brain ultrasound, ct and mri of fifteen term newborns treated in our institution with therapeutic hypothermia, since april 2010 were evaluated retrospectively. more relevant lesions are depicted and the diagnostic and prognostic value of the findings is discussed and compared with a review of the literature. results: recent studies showed that patients treated with cooling had a more favorable prognosis than was suggested by the clinical grade of encephalopathy compared with infants treated with standard care. our institutional protocol includes the performance of mri, and ultrasound. ct is performed when is a clinical impossibility of perform mri. brain ultrasound was performed in all the 15 patients. mri scans were obtained in 11 neonates. ct was obtained in 3 patients. all mri studies included dwi. the utility of dwi and adc maps as an aid in diagnosis of non-ischemic lesions is becoming increasingly established. mri evidence of brain injury was visible on basal ganglia in 8 cases with negative ultrasound. abnormal signal intensity in the posterior limb of the internal capsule coexists with lesions in the basal ganglia and thalami have been associated with abnormal motor outcome. the remaining 3 newborns did not develop significant mri evidence of brain injury. it has been suggested that the ability of mri to predict subsequent neurological impairment is unaltered by therapeutic hypothermia. further research is needed for defining the relation between mri findings and cooling. it is possible that imaging findings might be delayed in cooled infants. conclusions: mri offers the highest sensitivity in detecting anoxic injury of the neonatal brain. mr biomarkers in combination with clinical markers may identify patients with adverse outcome with therapeutic implications. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. purpose or case report: to correlate bowel wall diffusionweighted imaging (dwi) apparent diffusion coefficient (adc) values with multiple mr enterography (mre) and clinical findings in pediatric small bowel crohn disease. methods & materials: 54 pediatric crohn disease patients with mre exams containing diffusion-weighted imaging and demonstrating terminal ileitis were identified. minimum bowel wall adc values were tested for correlation/association with other mri findings and clinical parameters (including laboratory values). results: there is negative correlation between adc value and degree of bowel wall thickening (r0(−)0.27; p00.048). lower adc values were significantly associated with striated pattern of arterial phase postcontrast enhancement (p0 0.007), greater degree of arterial phase postcontrast enhancement (p00.006), and presence of stricture (p00.005). adc values were not associated with diseased bowel length, degree/pattern of delayed postcontrast enhancement, degree of mesenteric inflammation or fibrofatty proliferation, or clinical markers of inflammation. conclusions: restricted diffusion in pediatric small bowel crohn disease is associated with other mri findings of that are suggestive of active disease, including degree of bowel wall thickening and degree and pattern of arterial phase postcontrast enhancement. our data also suggests that dwi may be useful when attempting to characterize small bowel strictures as either predominantly inflammatory or fibrotic, although further investigation is needed. quantification of blood flow into and out of the liver with 4 d phase contrast mri in the pediatric patient binh huynh, md, radiology, stanford, bhuynh@stanford. edu; shreyas vasanawala, albert hsiao purpose or case report: the ability to probe blood flow dynamics in the liver may aid management of children with liver disease, including shunt fractions in portal hypertension and arterial flow fraction in diffuse liver disease. the purpose of this study is to evaluate the ability to measure blood flow into and out of the liver with time resolved volumetric (4d) phase contrast mri in the pediatric patient. methods & materials: nineteen consecutive patients were retrospectively identified who underwent 4d flow imaging through the level of the hepatic vessels on 1.5 t and 3 t magnets. a software enabling 4d flow program was utilized to first assess for the feasibility of measurement of flow in the hepatic artery (ha), portal vein (pv), splenic vein (spv), superior mesenteric vein (smv), supra (sivc) and infrahepatic (iivc) inferior vena cava. if measurable, calculations were performed to evaluate for internal consistency by comparing the sum of smv and spv flow to pv flow. calculations were then performed to compare hepatic inflow (pv+ha) to hepatic outflow (sivc-iivc) and for the percentage of pv and ha contribution to hepatic inflow. results: of the nineteen patients, all of the above mentioned six vessels were visualized and measurable in two patients, both of which were imaged on the 1.5 t magnet. in the remaining patients, flow measurements were limited by respiratory motion artifacts obscuring the smaller vessels, and severe eddy currents, particularly in patients imaged with the 3 t magnet. the evaluation for internal consistency demonstrated an average of 1.2% (0.06% & -1.5%) difference between smv+spv and pv flow. hepatic inflow was found to closely match the measured hepatic outflow with an average difference of 11.1% (19.1% & 3.1%). the portal vein was found to contribute 82.9% and 87.3% to hepatic inflow, while the hepatic artery contributed 17.1% and 12.7%. conclusions: measurement of hepatic flow with phase contrast mri is more challenging than assessment of thoracic flow. when respiratory artifacts are minimal, vessels can be identified and measurements have internal consistency and good agreement between hepatic inflow and outflow at 1.5 t. conversely, flow measurements were limited at 3 t by eddy currents. thus, ongoing efforts are aimed at mitigating respiratory motion artifacts at 1.5 t. poster #: sci-011 mri findings in post-fontan hepatopathy adina alazraki, md, radiology, emory university/children's healthcare of atlanta, adina.alazraki@choa.org; pinar bulut, kiery braithwaite, miriam vos, rene romero, nitika a. gupta purpose or case report: as advances in congenital heart disease continue to improve both mortality and quality of life, associated complications are becoming more prevalent. amongst patients who have had fontan repair for hypoplastic left heart syndrome, tricuspic atresia, or other right heart dysfunction, it is well known that liver disease is a complication. we describe the mri findings in post-fontan patients and propose mri as a useful tool to the hepatologist's evaluation of these patients. methods & materials: irb approval was obtained for a retrospective review of 29 patients who underwent fontan repair and were subsequently referred for hepatology evaluation between 2010-2011. all but one patient was scanned on a siemenstriotrim 3 t magnet; one patient was scanned on a ge twinspeed 1.5 t magnet with an equivalent protocol due to orthodontics. a standardized departmental protocol was utilized. mri findings were correlated with age at surgery and years since surgery. mr images were reviewed independently by 2 pediatric radiologists and compared with the dictated report in the patients record. results: 17 patients underwent mri of the abdomen. 4 patients had mri incompatible hardware and 8 patients were not scanned secondary to insurance denial. patients were divided into 4 groups based on elapsed time since surgery: less than 5 years, 5-10 years, 10-15 years, and greater than 15 years.(table 1) mr images were evaluated for the presence of fibrosis, congestion and any other hepatic abnormalities. fibrosis was determined based on a specific pattern of delayed reticular enhancement in combination with liver morphology. congestion was deemed present if there was increased t2 signal in the liver parenchyma or periportal regions in combination with cloud-like enhancement on dynamic post-contrast images. all patients demonstrated morphologic changes in the liver with varying degrees of hepatic fibrosis and hepatic congestion. fibrotic changes were often non-uniform, and thus could be underdiagnosed by biopsy. interestingly, 4 patients, 24%, had focal arterially enhancing lesions speculated to represent vascular proliferative lesions, however, none warranted biopsy. conclusions: it is established that patients who undergo fontan develop hepatic abnormalities. mri is a reliable, non invasive technique that accurately demonstrates these findings. mri may be a more sensitive method to evaluate the etiology and full extent of hepatic disease. poster #: sci-012 complications within the interventional radiology division of a tertiary care children's hospital: initiatives for ongoing quality and practice improvement brian dillon, children's hospital boston, brian. dillon@childrens.harvard.edu; pamela sanborn, yolanda milliman-richard, darren orbach, stephan voss purpose or case report: between 2004 and 2010, procedure-related complications occurring within the division of interventional radiology at our institution were recorded and classified according to level of severity. the goals of this study were to determine rates of procedurebased complications based on severity, to establish thresholds for complications, and to determine whether measurable trends in complications over time were evident. methods & materials: between 2004 and 2010, 14,042 interventional procedures were performed within the division of interventional radiology at our institution. adverse events were characterized both according to level of severity (using an institutional 5 point severity scale), and with brief descriptions of individual events. adverse events were reviewed monthly at the division's morbidity and mortality conference, with respect to procedure type and operator. based on review of our interventional radiology data and benchmarks rates used for diagnostic errors, threshold complication rates were established by consensus between the department quality improvement committee and the division of interventional radiology. for severe events (level 4 and 5) there is no allowable threshold; all such events were subjected to both internal and institutional review. results: the overall complication rate was less than 1% for all procedures performed. the complication rates for the respective severity levels were: level 1 (0.235), level 2 (0.3), level 3 (0.1), level 4 (0.249), and level 5 (0.028). the severity of a given complication was not associated with procedural complexity. no operator-specific trends were identified. conclusions: since 2003, the society of interventional radiology has offered guidelines and strategies for improving safety and quality in interventional radiology. however, no specific benchmark data or procedural recommendations are available for pediatric interventional procedures. our results demonstrate rates of complications well below published overall complication rates for interventional radiologic procedures. this database of procedure-based complications serves as a foundation for a quality improvement program that allows review of complications with respect to specific procedure types, individual operators, and procedural complexity, in an effort to institute an ongoing and continuous process of quality improvement within interventional radiology. purpose or case report: dysosteosclerosis (dss), an extremely rare dense bone disease, features short stature and fractures and sometimes optic atrophy, cranial nerve palsy, developmental delay, and failure of tooth eruption in infancy or early childhood consistent with osteopetrosis (opt). bone histology during childhood shows unresorbed primary spongiosa from deficient osteoclast action. additionally, there is remarkable progressive flattening of all vertebrae mimic ppi blocking mineralization. during ehdp treatment for gaci, in our patient prolonged high dose ehdp resulted in severe skeletal deformity resembling hypophosphatasia which was reversable with drug stoppage. methods & materials: a 7-year-old boy with gaci referred for profound, acquired, progressive skeletal deformity. he was receiving 200 mg/day of ehdp and was wheelchair bound. we studied him and his response to stopping ehdp. results: skeletal radiographic findings resembled pediatric hypophosphatasia with pancranial synostosis, widened physes with metaphyseal osteosclerosis, "tongues" of radiolucency, along with cupping and fraying, and long-bone bowing. in addition there were large intra and extraarticular calcifications. radiographic features of bp-induced opt included femoral erlenmeyer flask deformity and osteosclerosis (lumbar sine dxa z-score +5.7). biochemical parameters of mineral homeostasis were essentially normal although serum osteocalcin was low and he had markedly elevated serum levels of creatine kinase and trap-5b consistent with osteopetrosis (opt). after stopping ehdp, he improved quickly with remarkable healing of his rachitic appearing skeleton and decreased joint calcifications. conclusions: our patient with gaci had profound skeletal deformities from high-dose ehdp therapy that significatly improved with drug stoppage. magnetic resonance imaging in the evaluation of infants with hypoxic ischemic encephalopathy julio m. araque, md, radiology, medical college of georgia, jaraque@georgiahealth.edu purpose or case report: to illustrate and review a spectrum of brain abnormalities of infants with hie. defining the most useful approaches and mri sequences, to facilitate identification and early diagnosis of lesions with the potential to predict outcome and abnormal neurodevelopment. methods & materials: reviewed available evidence on mri strategies for evaluating infants with hypoxic ischemic encephalopathy. different cases illustrating lesions are presented and discussed for proper diagnosis correlating physiopathology and imaging appearance. more relevant findings are depicted with didactic illustrations. identifying studies where new techniques such as dwi, adc, dti, swi, or mrs adds significant diagnostic value to the overall interpretation. results: mri is routinely performed as a very sensitive method for detection of hie lesions. advanced mr techniques, such as dti, dwi, adc, mrs, swi offer the possibility of detecting injuries at a time when intervention is theoretically possible. the understanding of the physiopathology allows for prediction of the location and extent of lesions, facilitating identification and appropriate classification. the identification of infants with potentially abnormal neurodevelopment, offers the opportunity to provide therapeutic neurodevelopmental interventions in early childhood. mrs is the best mr biomarker to predict neurodevelopmental outcome in asphyxiated full-term neonates. brain metabolite ratios and regional adc values may vary between mr systems and coils. development of normal values for each institution is required, and support of physicists is mandatory. conclusions: mri continues to evolve as a valuable adjunctive tool routinely obtained in nearly all cases of hie. advanced mri techniques increase sensitivity of conventional t1 and t2-w images and outperform computer tomography and ultrasound for confirming the diagnosis of hypoxic-ischemic brain injury or providing prognostic information for the care of patient with hie. disclosure: dr. araque has indicated that he will discuss or describe, in the educational content, a use of a medical device or pharmaceutical that is classified by the food and drug administration (fda) as investigational for intended use. posterior fossa abnormalities in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to demonstrate various conditions involving the posterior fossa in children with emphasis on importance of embryologic development of cerebellum in reaching a correct diagnosis. methods & materials: this pictographic presentation displays the imaging features of cases encountered in our clinical practice on 1.5 tesla magnetic resonance (mr) imaging. results: with the advent of mr imaging, there has been a revolution in identification and characterization of malformations of the brain this is especially true in posterior fossa, where the sensitivity and specificity of mr imaging with its multidimensional imaging capability are far superior to those of computed tomography (ct) in the detection of subtle morphologic abnormalities. however, there is still a great deal of confusion regarding their classification, terminology, and spectrum of expression and this is where neuroembryology is of great help. this exhibit demonstrates : 1) review of embryology and normal anatomy of cerebellum. 2) mr appearance of spectrum of conditions involving posterior fossa in children which includes developmental abnormalities (dandy-walker complex, arnold chiari malformations, cerebellar dysplasia/ hypoplasia, joubert's syndrome, etc.), cysts (arachnoid cyst, giant cisterna magna etc.), tumours (medulloblastoma, ependymoma, hemangioblastoma etc.) and miscellaneous conditions. significantly reduces dose (1/3 of other gadolinium based contrast agents), and doesn't require trigger imaging. conventional mri provides important information regarding the anatomical extent, size, and relation to critical anatomical structures thus when combined with twist, mri provides the best information without use of radiation in children. functional connectivity mri in pediatric brain tumor patients with and without epilepsy andrew v. poliakov, phd, radiology, seattle children's hospital; david bauer, edward novotny, seth d. friedman, dennis shaw, jeff ojemann purpose or case report: functional connectivity mri (fcmri) is a way to evaluate cortical networks across different modalities such as motor, sensory, vision, and the default mode network using functional magnetic resonance imaging. fcmri relies on correlation in fmri image intensity that occurs between functionally connected regions. this effect can be seen in awake as well as anesthetized patients. we evaluated these pathways in pediatric patients with brain tumors. methods & materials: patients were randomly selected from our tumor database. inclusion criteria included age less than 18, history of brain tumor resection, and complete fcmri data. imaging was performed on a 3 t siemens trio system. functional mri data were acquired as part of a clinical imaging protocol over 6.5 -8 min using a gradient echo, echo-planar sequence. preprocessing of fmri data followed by independent component analysis (ica) was performed using fsl software. functional connectivity analysis was performed using software provided by 1000 functional connectomes project, based on afni and fsl software packages. correlation maps were produced by extracting the bold time course from a seed region, computing the correlation coefficient between that time course and the time course from all other brain voxels, correcting for multiple sampling and degrees of freedom and thresholded at a z value of 3.0. results: fourteen patients were included in the study, eight female and six male. tumor types include ganglioglioma (5), pleomorphic xanthoastrocytoma (2), juvenile pilocytic astrocytoma (2), ependymoma (1), anaplastic astrocytoma (1), glioblastoma multiforme (2), and primitive neuroectodermal tumor (1). seven patients had tumor-associated epilepsy, and seven patients did not. the figure shows connectivity patterns in the motor network in patients without (a) and with (b) epilepsy. in the patients without epilepsy, functional connectivity was often displaced but not decreased or absent. in the patients with epilepsy, we observed decreased or absent functional connectivity. similar results were found for default mode network: connectivity was diminished or absent in the patients affected by epilepsy. conclusions: fcmri is a novel technique that may prove useful for evaluation and presurgical planning by giving us insight into how tumors disrupt function. functional connectivity was often displaced but relatively preserved in the patients without epilepsy. it was disrupted or absent in the patients with epilepsy. poster #: sci-022 corpus callosum dti measurements in neurofibromatosis type 1 and normal controls nadja kadom, md, radiology, children's national medical center, nkadom@childrensnational.org; amir noor, rhea udyavar, marine bouyssi-kobar, iordanis evangelou, maria t. acosta purpose or case report: many patients with neurofibromatosis type 1 (nf1) have corpus callosum enlargement; pathogenesis and underlying pathophysiology are unclear. the goal of our study is to investigate the pathophysiological basis of corpus callosum enlargement in nf1 patients through mri diffusion tensor (dti) measurements. methods & materials: retrospective study, irb approved. patients consecutively selected from institutional data base; inclusion criteria: established diagnosis of nf1, brain imaging with dti sequence, abnormally high corpus callosum to skull ratio; excluded were patients with complications of nf1 that could affect size of the corpus callosum. age and gender matched normal controls were randomly selected from the radiology data base. roi were placed manually over the corpus callosum for dti measurements using dti-studio by two independent researchers, one blinded to diagnosis. results: fifteen nf1 patients and matched controls were analyzed. the corpus callosum to skull ratio was found to be significantly different between the experimental and control group (p00.0001). for nf1 patients we found: a trend to lower apparent diffusion coefficient (adc, p00.067), significantly higher radial diffusivity (p00.023), significantly lower axial diffusivity (p00.0002), and significantly lower fractional anisotropy (fa, p00.0012). conclusions: the significantly lower axial diffusivity in nf1 can indicate that there are more crossing fibers in the corpus callosum of nf1 patients than in normal controls. further studies using comparative dti tractography may be helpful in further investigating this stipulation. the significant increase in radial diffusivity can be explained by a variety of factors, including thinner myelin sheaths, increased interstitial fluid, smaller axons, or a combination thereof. the trend of lower adc may indicate low axonal diameter, as adc has been shown to more strongly correlate with axonal diameter without the myelin sheath. in future studies we will correlate abnormal corpus callosum dti markers with cognitive functions in nf1 patients to see if relationships exist that can be used as predictors of cognitive deficits in nf1 patients. screening for vitamin d deficiency in children with suspected non-accidental fracture conor kain, md, tripler army medical center; veronica rooks, laura keller, jordan pinsker, allyson cordoni, sarah frioux purpose or case report: determine if routine screening of vitamin d levels after suspected non-accidental fracture detects vitamin d deficiency and changes clinical outcomes. methods & materials: after irb approval we reviewed all skeletal surveys performed at tripler army medical center (tamc) in the last 10 years and selected the children who were evaluated for suspected non-accidental fracture. we determined if 25-hydroxyvitamin d [25(oh)d] level was requested for these patients and characterized the provider's clinical suspicion of vitamin d deficiency as high or low. per the 2010 institute of medicine report and 2011 endocrine society guidelines we defined vitamin d deficiency as a 25 (oh)d level of less than 20 ng/ml. we calculated the prevalence of children with low 25(oh)d levels whose providers had low clinical suspicion for vitamin d deficiency. results: 396 skeletal surveys were done at tamc from november 2000 to july 2011. 99 were performed after identifying a suspected non-accidental fracture. of these patients 11 children from ages 1 to 7 months had 25(oh)d levels requested. for children whose providers had a low pre-test suspicion for vitamin d deficiency, the prevalence of vitamin d deficiency was 12.5% (95% binomial ci 0.003-0.524, 1 of 8 cases. these results indicate that at least one out of every three hundred children evaluated for nonaccidental fracture could have vitamin d deficiency despite a low clinical suspicion by their provider, although the actual rate is likely much higher given that we found one in eight cases. the child we identified with a low vitamin d level whose provider had no suspicion for rickets was treated with ergocalciferol and continued to be evaluated for abuse. conclusions: routine vitamin d level screening after nonaccidental fracture may detect vitamin d deficiency in children for whom there is low clinical suspicion. as our population resides at a low latitude and receives greater than average sun exposure, the rate of deficiency in children with suspected non-accidental fracture may be much greater in other areas. comet tails and dirty shadows: the secrets behind artifacts in pediatric ultrasound adam edelstein, pediatric radiology, massachusetts general hospital; anuradha shenoy-bhangle, katherine nimkin purpose or case report: to review common ultrasonographic artifacts, explain what causes them, and show how they can be used to aid in diagnosis in a variety of pediatric conditions, including less common entities. methods & materials: ultrasonographic images in patients less than 18 years of age were reviewed. cases were selected that showed classic artifacts which helped with the diagnosis of a variety of entities. results: ultrasound artifacts include comet tail, reverberation, ring down and "dirty" shadowing. these can be used to help characterize a variety of pediatric conditions including gossypiboma, bezoar, subcutaneous foreign body, complications of nec, and staghorn calculus. artifacts can also be used to confirm the presence of stool or bowel gas. conclusions: familiarity with ultrasonographic artifacts is critical for tissue characterization and can help narrow the differential diagnosis in difficult pediatric cases. cardiac cta: non-vascular ring tracheobronchial compression secondary to enlarged patent ductus arteriosus in infants with congenital heart disease. nhi huynh, md, radiology, st. joseph hospital and medical center, e.nhihuynh@gmail.com; todd chapman, randy richardson purpose or case report: tracheobronchial compression or narrowing secondary to a vascular ring has been well documented. the purpose of this study is to describe the frequency of airway compression secondary to an enlarged patent ductus arteriosus detected by ccta without the presence of a vascular ring. methods & materials: a retrospective study of 282 ccta exams in infants was performed over the period between 03/ 28/2007 and 09/28/2011. ccta was performed with a 64-slice mdct, with ekg gating, followed by three-dimensional reformations. results: of the 282 congenital heart disease infant patients, there are 49 patients with tracheobronchial compression or narrowing. of these 49 patients, 20 patients reported to have patent ductus arteriosus as the primary cause of tracheobronchial compression or narrowing. approximately 41% of patients with airway compression in patients with congenital heart disease are secondary to an enlarged and/or tortuous patent ductus arteriosus. none of these cases were due to a vascular ring. of these 20 patients, 10, 6, and 4 patients demonstrated to have mild, moderate, and severe airway compression respectively. conclusions: tracheobronchial compression or narrowing secondary to vascular ring with a patent ductus arteriosus has been well documented. in this study, we demonstrate that a significant percentage of airway compression in patients with congenital heart disease without a vascular ring is due to a tortuous enlarged patent ductus arteriosus. cardiac cta is uniquely equipped to evaluate airway compression due to an enlarged patent ductus arteriosus and can help improve patient care in congenital heart disease patients with respiratory symptomatology. pediatric liver mr elastography: a primer suraj serai, phd, cchmc, suraj.serai@cchmc.org; daniel j. podberesky, alexander j. towbin purpose or case report: a wide variety of pediatric liver disorders may be complicated by the development of liver fibrosis and ultimately cirrhosis. with early interventions, the progression to hepatic fibrosis can be slowed, halted, and in some cases reversed. liver biopsy has long been considered the gold standard for assessing the presence and degree of liver fibrosis. however, liver biopsy has disadvantages, due to its potential sampling error, risk of complications, relatively high cost, intra-and inter-observer variability, and, in general, poor acceptance by pediatric patients and their parents. mr elastography (mre) is a relatively new, non-invasive technique that provides a safe, rapid and cost-effective method for objectively evaluating of a wide variety of hepatic diseases by quantitative stiffness evaluation of the liver-parenchyma. the purpose of this exhibit is to review our clinical experience with this technique and illustrate the application of liver mre in the pediatric population at our medical center. methods & materials: a review of pathogenesis and staging of liver fibrosis in children and current methods available for assessing liver fibrosis will be provided. a review of mre physics and technique, including the specific liver mre protocol used at our institution will be illustrated. we will review widely-used and emerging clinical indications for liver mre, as well as benefits and limitations to the technique, supported by brief literature review. results: in addition to sharing our liver mre technique, we will illustrate clinical case examples from our institution of a variety of liver disorders including non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, storage disorders, cardiac disease, and idiopathic elevated liver enzymes. conclusions: this educational exhibit will review our experience with liver mre, a safe, newly available technique which will play an increasingly important role in the noninvasive evaluation of pediatric liver disease. poster #: sci-027 spectrum of tuberculosis in children amit gupta, mbbs, radiodiagnosis, r.n.t. medical college, udaipur, rajasthan, india, amitsensation@yahoo.co.in purpose or case report: the aim of this exhibit is to present a spectrum of tuberculosis (tb) in the human body which commonly involves pulmonary, nervous, musculoskeletal, gastrointestinal and genitourinary systems. this pictographic presentation displays the imaging features of tb cases encountered in our clinical practice with reference to plain x-rays, ct and mri as appropriate. results: with the advent of the newer modalities, the utility of the plain skaigram has been largely limited a initial screening tool only. whereas ct scores over mri in pulmonary tb (parenchymal disease, lymphadenopathy, pleural effusion, empyema, miliary disease) and abdominal tb (spectrum from mesenteric lymphadenitis to visceral involvement), the magnetic resonance (mr) imaging is much better in diagnosing cns tb (tuberculoma, abscess, meningitis, subdural empyema and myelitis). in musculoskeletal and genitourinary tb, ct and mr imaging may be preferred based on the stage of disease and the character of the lesion. cardiac involvement (pericarditis) is among the less common affections of tb. conclusions: tuberculosis is a multisystem disease that can affect virtually any part of the body from head to toe. tb demonstrates a variety of clinical and radiologic findings and has a known propensity for dissemination from its primary site and therefore can mimic numerous other disease entities. hence it is imperative for radiologists to understand the typical disease distribution, patterns and imaging manifestations of tb. 2010 janet l. strife, md 2011 carol m. rumack md 1987 ole a. eklof, md 1987 clement c. faure, md 1987 andres giedion, md 1987 denis lallemand, md 1987 arnold lassrich md 1992 donald r. kirks, md 1992 beverly p. wood, md 1993 hooshang taybi md 2008 marta hernanz-schulman, md, facr 2009 m. ines boechat, md, facr 2010 neil d. johnson, mbbs 2011 dorothy i. bulas, md *deceased singleton-taybi award investigator award this award is given to the author of the best paper presented by a resident or fellow at the spr meeting md 2002 ricardo faingold, md 2003 andrea doria, md 2004 nina m. menezes, phd anthropometric parameters are a strong determinant of lvm in healthy individuals kiyarash mohajer, pierangelo renella, paul j. finn purpose or case report: despite theoretical advantages of higher field strength ssfp cine imaging, time-resolved magnetic resonance angiography (tr-mra), and high resolution contrast-enhanced mra (ce-mra) were performed. two readers independently evaluated the data for image quality, vessel and cardiac chamber definition, and presence of artifacts. snr and cnr were calculated. results: 95% of ssfp cine images at 3 t were rated as good or excellent quality with 73% having mild and 24% having moderate artifacts (k00.07) 100% of arterial and venous phase ce-mra images were considered good or excellent cardiac chamber definition was considered good or excellent in 95% of arterial and venous phase ce-mra images (k00.08). 100% ce-mra images showed good or excellent definition of the thoraco-abdominal vessels on average, both readers scored cine ssfp images higher at 1.5 t and cemra images higher at 3.0 t. overall diagnostic performance was high at both field strengths. conclusions: mri of pediatric patients with chd and vascular abnormalities at 3.0 t is feasible. relative to 1.5 t, snr and cnr are both improved at higher field strength and higher resolution cemra is achievable t are more prevalent, they rarely render cine imaging non-poster # exclusion criteria were lack of correlating us or follow up information. two pediatric radiologists blinded to us findings reviewed the mr images and analyzed the contents of abdominal wall defect, organ location and attachment; spine anomalies; umbilical cord and limb anomalies. results: our search yielded 16 patients. all fetuses had ventral wall defects, small thorax and eviscerated liver and bowel. in two cases kidneys were in extracorporeal location. in 12/16 there was no membrane covering extruded organs. in five mr showed organs attached to the placenta or uterine wall (mainly bowel and liver) mahmoud al-hawary and, by adolescence, paradoxical metaphyseal osteopenia with thin cortical bone. reports of consanguinity indicate autosomal recessive inheritance our studies, spanning ages 11-44 mo, showed weight 50%, but length diminishing from~30% to −2.3 sd. head circumference was +4 sd. she had frontal bossing, blue sclera, normal teeth, genu valgum, and unremarkable joints. radiographs showed orbital and facial sclerosis, basilar thickening, "bone-in-bone" appearance in the pelvis, sclerotic long bone ends, and fractures of ribs and extremities. progressive metaphyseal widening occurred as vertebrae changed from ovoid to flattened and became beaked anteriorly. consistent with opt, serum pth concentrations reflected dietary calcium levels. serum bone alkaline phosphatase, osteocalcin, and trap5b were sub-normal. iliac crest contained excessive primary spongiosa and no osteoclasts. splice sites and exons were intact for the genes encoding cholride channel 7, t-cell immune regulator 1, opt-associated transmembrane protein 1 the hallmarks include stippled epiphyses, nasal hypoplasia, and hypoplastic distal phalanges and developmental delay. punctate calcifications are seen not only in the epiphyses but also in the paravertebral regions. paravertebral puncta are commonly associated with defective ossifications in the cervical spine. the malformation of the cervical spine causes spinal canal stenosis and instability, which occasionally necessitate surgical intervention none of the cases had brain infarction. conclusions: tortuousity and luminal narrowing of the cervical arteries is a common finding in cdp-bt. this previously unknown malformation is an important factor to discriminate patients at increased risk of cerebral ischemia, particularly in patients undergoing surgical intervention. disclosure: dr. okabe has indicated that she will discuss or describe severe skeletal toxicity from protracted etidronate therapy for generalized arterial calcification of infancy william h. mcalister, md, mallinckrodt institute of radiology campbell sheen purpose or case report: generalized arterial calcification of infancy (gaci) is an autosomal recessive disorder caused by deactivating mutations within the gene for ectonucleotide pyrophosphatase phosphodiesterase-1 (enpp1). enpp1 on osteoblasts, chondrocytes, and vascular smooth muscle cells hydrolyzes nucleotide triphosphates to nucleotide monophosphates and inorganic pyrophosphate (ppi) can time-resolved contrast-enhanced mra (twist) classify soft tissue vascular anomalies in the head and neck in children accurately? aylin tekes, md 28 children from 0-17 years of age were enrolled. twist and conventional mri was performed (triplanar t2-weighted [t2-w] imaging with fat saturation, pre-contrast axial t1-weighted [t1-w] imaging, and post contrast triplanar fat-suppressed t1-w imaging). twist was performed in coronal plane using blood-pool mr contrast agent (ablavar-lantheus) to enhance image quality and spatial resolution of mra. two pediatric neuroradiologists evaluated all patients in two different sessions, 15 days apart: one session conventional mri with contrast was evaluated, in the second session twist was evaluated. clinical evaluation and/or percutaneous venogram/lymphogram data were the gold standard. results: our patients had diagnosis of infantile hemangioma (n04), venous malformation (n012), and lymphatic malformation (n012). twist alone could accurately classify 26/ 28, conventional mri with contrast could accurately classify 22/28. conventional mri with contrast combined with twist could accurately classify all cases. conclusions: twist offers high temporal resolution in the order of seconds, and provides functional data about the dynamics of contrast enhancement comprising the arterial, venous and delayed venous phases kiery cr-2, sci-11 edu-91, edu-92 edu-35, edu-40, pa-045 edu-86, pa-036 a-092, pa-093, pa-108, pa-109, pa-113 edu-7, edu-59, edu-60, edu-62, edu-66, edu-69, edu-78 edu-59, edu-60, edu-62, edu-66, edu-69, edu-78 suraj sci-26, pa-124, pa-125 edu-98 pa-147, edu-86, pa-036 the society for pediatric radiology gratefully acknowledges the support of the following companies in presenting the 55th annual meeting and postgraduate course: cme committee reviewers for this activity have disclosed any relevant financial relationships. no conflicts of interest exist.abuse and offer potential mechanisms of injury may help make the diagnosis of child abuse. the pediatric elbow-mri findings with multimodality correlation michael guandalini, md, royal children's hospital; murray bartlett purpose or case report: to describe and illustrate elbow abnormalities identified by mri performed in a cohort of pediatric patients with multimodality correlation. methods & materials: retrospective review of mri elbow studies performed at the royal children's hospital, melbourne between 2003 and . the studies were reviewed by a pediatric musculoskeletal radiologist and pediatric radiology fellow with patient demographics, clinical indication, findings and selected images recorded. results: 199 elbow mri examinations were reviewed on children aged 4 months to 18 years (123 boys, 76 girls) with equal numbers of left and right sides examined. clinical indications included previous trauma in 147 cases (74%) and nontraumatic conditions in 52 (26%). the most common traumatic indication was suspected or confirmed fractures or avulsions (21%) followed by osteochondral or cartilage injuries (18%), growth arrest (16%), loose bodies (14%) and ligament injuries (10%). hemophilia (38%) was the most frequent nontraumatic indication followed by neoplasm (17%). mild to severe arthropathy, fractures, physeal growth arrest, subluxations, osteochondral lesions and loose bodies were the most frequently demonstrated abnormalities. ligament strains and tears, bone oedema, neuromuscular abnormalities, infections and several neoplasms including lipomas, vascular/lymphatic malformations and bone tumors also featured. conclusions: this pictorial review illustrates the broad range of abnormalities one might expect to encounter on pediatric elbow mri studies, highlighting the major features and corresponding appearances on ct and plain x-ray. spectrum of patellar tendon avulsive injury on mri in children: differentiation between acute and chronic avulsive injuries of the inferior patellar pole and tibial tuberosity zeyad metwalli, md, baylor college of medicine, metwalli@ bcm.edu; herman kan, scott rosenfeld, r. p. guillerman purpose or case report: the extensor mechanism of the knee is an intricate component of the joint and is frequently injured in pediatric athletes. due to the strength of the patella tendon, trauma to the anterior knee is often manifested by avulsive injuries, which may occur on an acute or chronic repetitive basis. purpose: this pictorial review will illustrate differentiating radiographic and mri features of acute and chronic avulsive injuries of the pediatric knee. outline: 1. anatomy and physiology a. discuss the anatomic differences of the pediatric and adult knee extensor mechanism b. pathophysiology and biomechanical basis for chondro-osseous avulsion injuries versus tendon tears in the skeletally immature. purpose or case report: the purpose of this educational exhibit is to demonstrate the magnetic resonance imaging (mri) appearance of the ankle and hindfoot ligaments using an interactive approach. methods & materials: a 3 tesla siemens mri scanner with a multichannel ankle coil was utilized in the acquisition of images of ankle and hindfoot. three dimensional volume acquisition proton density images will be used to demonstrate the ligamentous anatomy of the ankle and hindfoot in axial, axial oblique, coronal, and sagittal planes. results: the exhibit will begin with an interactive review of the ankle and hindfoot ligamentous anatomy with each ligament poster #: edu-073 cns imaging findings in hemophagocytic lymphohistiocytic syndrome rupa radhakrishnan, mbbs, md, dnb, radiology, university of cincinnati college of medicine, radhakrp@ucmail. uc.edu; marcia k. kukreja, alexandra filipovich, alexander j. towbin purpose or case report: hemophagocytic lymphohistiocytosis (hlh) is a rare, life threatening condition caused by an uncontrolled proliferation of activated lymphocytes and histiocytes with high levels of inflammatory cytokines. the organs most commonly involved in this disorder include the liver, spleen, lymph nodes, bone marrow and central nervous system (cns). the purpose of this exhibit is to review the cns imaging findings associated with hlh, its complications, and its management. the published literature was reviewed to identify the potential imaging findings hlh. the electronic medical record system was then searched to find illustrative case examples from our institution. cases demonstrating the primary imaging findings as well cases highlighting complications of the disease or its therapy were selected. results: cns involvement is common in hlh with approximately 75% of patients demonstrating neurological symptoms. ct findings of cns involvement include diffuse parenchymal atrophy, low attenuation lesions in the white matter and calcifications. mr findings include diffuse leptomeningeal and perivascular enhancement, t2 hyperintense lesions with nodular or rim enhancement as well as confluent white matter lesions, and diffuse parenchymal volume loss of the cerebrum and cerebellum. restricted diffusion has been demonstrated in some lesions. ring enhancing parenchymal lesions have been described representing active demyelination. intracranial hemorrhage may occur as a result of thrombocytopenia and coagulation abnormalities. sepsis with opportunistic organisms can involve the cns and produce intracranial findings such as parenchymal abscesses. cns changes, such as posterior reversible encephalopathy syndrome, are also seen with the commonly used immunomodulatory regimen used in the treatment of hlh. conclusions: this exhibit will aid the viewer in identifying the cns imaging findings of hlh as well as the complications of the disease and its therapy. while the cns imaging findings are not specific, they may help the radiologist formulate a diagnosis in association with the other clinical and imaging findings; furthermore, imaging can help the clinical team in managing the disease and its complications. methods & materials: medical records of our pediatric patients with palpable head masses over the last 5 years, were reviewed and images were collected. correlation of us of these lesions with other imaging modalities and/or pathologic diagnosis was done. results: us appearances of various head masses including congenital/developmental (encephalocele, meningocele, dermoid, occipital protuberance), traumatic (cephalhematoma, subgaleal hematoma, calvarial fracture), inflammatory/infectious (sebaceous cyst, histiocytosis, dermatitis), vascular (malformations, pseudoaneurysm) and neoplastic (benign and malignant lesions including metastases) etiologies, will be illustrated with case based approach. mri and/or ct or tissue diagnosis can be problem solving. role of ultrasound guidance for percutaneous procedures (biopsy, sclerotherapy) will also be described. conclusions: ultrasound can play an important role in the delineation, diagnosis and guiding further management of pediatric palpable head masses. us can differentiate various scalp lesions and suggest the underlying calvarial defect or involvement to some extent, helping to narrow the differential diagnosis for such lesions. color doppler us can be useful to detect vascularity within the lesion or vascular lesions. given that us is often requested for the evaluation of palpable head masses, pediatric radiologists should be familiar with their sonographic features. posterior fossa malformations-a pictorial review rui santos, md, bc children's hospital, ruiradiologia@gmail. com; khalid khashoggi, angela t. byrne purpose or case report: posterior fossa malformations are a group of central nervous system anomalies that may be detected during pregnancy or present early infancy with features that include hypotonia, developmental delay, mutations responsible for the disease and proposals as to mechanism of action of the mutation with respect to disease manifestations. this preceded the development of hypotheses regarding the relationship between genotype and phenotype and the attempt to utilize imaging modalities that could better assess disease activity as it related to functional status. the purpose of this exhibit is to briefly review the history pre-1989 and to focus on the numerous ways in which the understanding has improved since that time. conclusions: 1. there are over 1000 different mutations of the cftr gene responsible for cystic fibrosis with varying prevalence throughout the world. 2. the class of mutation often dictates its particular mechanism of action. 3. there is some relationship between genotype and phenotype-particularly with respect to pancreatic involvement. 4. newer imaging modalities including ct and mri with or without hyperpolarized helium are better predictors of disease severity than is plain film. imaging pulmonary tuberculosis in infants: what are the most useful diagnostic radiological findings? handan cakmakci, pediatric radiology, dokuz eylul university hospital, handancakmakci@gmail.com; nevin uzuner, filiz tetik purpose or case report: early diagnosis and treatment are very important for infants with tuberculosis. infantile pulmonary tuberculosis is more symptomatic, and the risk of severe and life-threatening complications such as tuberculous meningitis or miliary tuberculosis is higher. bacteriologic confirmation of the disease in children is difficult and in younger infants (<3 months), the tuberculin skin test is frequently negative. therefore, radiological findings play important role in diagnosing tuberculosis in infants. the purposes of this study are to identify chest x-ray and lung ct findings in pulmonary tuberculosis of infants and consider the most useful diagnostic findings of these age group patients.methods & materials: chest radiographs and chest ct images of 7 infants who were diagnosed in our hospital from 2005 to 2011 were retrospectively reviewed. the study group included 2 boys and 5 girls ranging in age from 2 to 12 months (mean age, 6 months). chest x-ray and computed tomography images were analyzed considering air space consolidation, nodular lesions, cavitating lesions, mediastinal enlargement, hyperinflation, bronchial narrowing, atelectasis pleural effusion on plain radiography and additional mediastinal calcific or caseating lymph nodes on ct images.results: air space consolidation was seen on 5 out of 7 chest x-ray and computed tomography images. nodular lesions were seen 2 out of 7 chest x-ray and computed tomography images. cavitating lesion was seen on 1 out of 7 chest x-ray and computed tomography images. mediastinal enlargement suggesting lymph node was seen 5 out of 7 chest x-ray and computed tomography images. hyperinflation, bronchial narrowing was seen 2 out of 7 chest x-ray and computed tomography images. atelectasis, pleural effusion was seen 1 out of 7 chest x-ray and 2 out of 7 computed tomography images. mediastinal caseating lymph nodes, mediastinal calcific lymph nodes were seen 3 out of 7 computed tomography images. conclusions: frequent and the most useful diagnostic radiological findings of pulmonary tuberculosis in infants are mediastinal or hilar lymphadenopathy with central necrosis and air space consolidations. disseminated nodules including miliary lesions and airway complications are also detected in this age group. ct can show detailed parenchymal lesions and tuberculous lymphnodes especially calcified ones. the ductus bump: radiographic findings of this normal variant and differential diagnoses anusuya mokashi, staten island university hospital, anusuya.mokashi@gmail.com; jeremy neuman, cheryl lin purpose or case report: the ductus bump: review of radiographic findings, differential diagnoses and current controversies. the ductus bump was first described in 1965 by berdon et al as a transient physiologic mass in the chest in newborn infants. some controversy remains as to the exact etiology and clinical significance. although initially thought to represent a dilated ductus arteriosus, recently it has been suggested that it actually represents a ductus arteriosus aneurysm that spontaneously resolves. others contend it represents dilation of the infundibulum of the closing ductus. regardless of etiology, the time of discovery, location, and rapid resolution are characteristic of this entity. in this presentation we will review the radiographic and echocardiogram findings of the ductus bump, as well as discuss the differential diagnosis. the frontal radiographic findings are a round mass to the left of the vertebral spine projecting from the mediastinum near the aortic arch. this mass does not indent the esophagus and it cannot be seen on the lateral view. it is classically said to resolve within the first few days of life. the controversy regarding the etiology has also led to some disagreement involving the clinical significance and appropriate follow up, which will also be discussed. after reviewing this educational poster, the reader will have conclusions: abnormalities of the posterior fossa are often difficult to differentiate solely on the basis of their radiologic appearances alone. however, an accurate diagnosis is essential for proper treatment planning and genetic counselling. therefore it is imperative for radiologists to be well versed with the normal anatomy and development of cerebellum so as to correctly diagnose the various posterior fossa abnormalities.poster #: sci-019imaging of oculoauriculofrontonasal syndrome with low-dose 3-dimensional computed tomography paritosh c. khanna, md, radiology, seattle children's hospital, pkhanna@uw.edu; kelly evans, gisele ishak, joseph gruss, michael cunningham, anne hing purpose or case report: oculoauriculofrontonasal syndrome (oafns) combines elements of abnormal morphology of the frontonasal and maxillary processes of the face. the aim of our exhibit is to demonstrate the low-dose computed tomography (ct) features of this syndrome, in seven patients who have been followed at seattle children's hospital (sch) over 18 years. we underscore the imaging features of this condition, and describe additional features including bony nasal abnormalities not previously described in the literature, to improve imaging recognition of this spectrum. we present 3d ct imaging features of a series of eight patients with oafns. in keeping with the alara (as low as reasonably achievable) concept and the image gently recommendations (www.imagegently. org), ct head and face studies were obtained on six of eight patients at sch, while two had prior exams at outside institutions. using a 64-slice multidetector ct scanner (ge lightspeed vct, waukesha wi), low-dose ct (120 kv, 150 mas or lower depending on age) of the head and face was obtained. planar bone window and 3d surface rendered images were analyzed. results: our series of patients demonstrated bifid nasal bones, uni-or bilateral mandibular hypoplasia, temporomandibular and zygomatic dysplasia and bony external auditory canal abnormalities. one patient had an interfrontal bone with a frontal bony defect that was contiguous with the metopic suture. we describe additional previously unidentified ct anomalies of the nasal bones, anterior nasal spine and nasal septum. these structures are involved in all patients who had ct imaging available, although unique features are present in each case. conclusions: ct is the mainstay of imaging of craniofacial anomalies in the post-natal period, both pre-and postoperatively. in addition to our low-dose ct imaging findings of oafns, novel nasal bone anomalies identified by our group serve to identify a new subset of patients with this syndrome and may help refine the phenotype of the oafns spectrum. key: cord-350571-6tapkjb6 authors: nan title: 45th escp-nsf international symposium on clinical pharmacy: clinical pharmacy tackling inequalities and access to health care. oslo, norway, 5–7 october 2016 date: 2017-01-10 journal: int j clin pharm doi: 10.1007/s11096-016-0404-4 sha: doc_id: 350571 cord_uid: 6tapkjb6 nan pharmacy, sint maartenskliniek, ubbergen, 2 pharmacy, radboud university medical centre, nijmegen, 3 clinical pharmacy and toxicology, maastricht university medical centre, maastricht, netherlands please specify your abstract type: research abstract background and objective: according to literature adherence to statins ranges from 32 to 71%. medication adherence is affected by both practical barriers and patient's beliefs about medication. however, physicians also have their beliefs about medication. several studies have shown that these beliefs also impact the decision of patients to agree with a particular treatment or not. as current published interventions on medication adherence (which focus predominantly on patients) are not or just partly effective, physicians' beliefs might be a promising target for interventions to improve adherence. however, there is currently no information available on physician's beliefs about statins and whether these beliefs affect patient's beliefs and adherence. therefore, the objective of this study is to examine whether physicians' beliefs about statins influence the beliefs and adherence of patients using a statin. setting and method: this cross-sectional study was conducted in gp practices and community pharmacies, between september 3, 2014 and march 20, 2015. physicians' and patients' beliefs about statins were assessed with the beliefs about medicine questionnaire (bmq) specific. patients' adherence on statins was assessed with both the mars-5 and the morisky-8 questionnaires. please specify your abstract type: research abstract background and objective: nhs highland and nhs western isles are the most remote and rural health boards in the united kingdom, with high numbers of dispensing medical practices. a pilot is underway in dispensing practices with clinical pharmacists undertaking targeted medication reviews. a previous quantitative service evaluation demonstrated its value, with pharmaceutical care issues identified in almost all patients, the vast majority of which (86.7%) were managed by the pharmacist without any need for general practitioner (gp) referral. the objective was to undertake a qualitative exploration of the service. setting and method: all patients and staff involved in the service were invited to participate. a semi-structured interview schedule was developed and piloted. telephone interviews were conducted with all consenting staff and a purposive sample of consenting patients recruited to the point of data saturation. interviews were audiorecorded, transcribed verbatim and analysed thematically. nhs ethics and research and development approvals were obtained. were the most confident with doacs (range from 73.4 to 75.7%) please specify your abstract type: research abstract background and objective: patients are at risk of drug-related problems (drps) at transition points during hospitalization. the community pharmacist (cp) is often the first healthcare professional patients visit after discharge. cps lack sufficient information about the patient and so they may be unable to identify problems in medications, which may lead to dispensing the wrong drugs or dosage, and/or giving wrong information. we aim to assess the impact of a complex intervention comprising of medication reconciliation performed at discharge by a hospital pharmacist (hp) with communication between the hp and cp on drps during the 7 days following discharge. setting and method: cluster randomized crossover trial involving medical and surgery care units (each unit corresponding to a cluster) in french hospitals during two consecutive 14-day periods, randomly assigned as 'experimental'(e) or 'control' c (usual care) periods. during the experimental period, the hp performed a medication reconciliation that was communicated to the patient's cp. main outcome measures: the primary outcome was a composite outcome of any kind of drp (prescription/dispensation, gap or patient) during the 7 days following discharge assessed at day seven post-discharge by phone from patient and cp. the secondary outcomes were 1/unplanned hospitalizations assessed by phone contact at day 35 after discharge and 2/the iatrogenic potential exposure scale from 0 to 3 for each patient established by a clinical team. analysis was conducted in intention to treat. results: 22 hospitals corresponding to 48 clusters enrolled 1092 patients (536 e group v/s 548 c group). no difference was observed on age, sex, autonomy, and number of drugs in home medication at admission and discharge. at day 7; 236 (45.6%) patients in e group had at least one drp v/s 280 (52.6%) in c group (or 0.77; ic 95% [0.61; 0.98] p = 0.034). intervention was especially efficient for patient discharged from surgery unit (or 0.64 ic 95% [0.43; 0.94]) and aged less than 75 years (or 0.71 ic 95% [0.53; 0.94] . although intervention decreased patient exposure to drp with high iatrogenic potential (from 8.7 to 5.2% p \ 0.0006), un-planned hospitalizations at day 35 weren't different between groups (5.8 vs. 4.5% p = 0.50). conclusion: medication reconciliation associated to communication between hospital and community pharmacists is efficient to decrease patient exposure to drp but not sufficient to decrease un-planed hospitalization. hp-pc003: clinical pharmacists bridging health care levels by medication reviews in primary care katherine wendelbo *,1 , kristine lundereng 2 1 namsos hospital pharmacy, central norway hospital pharmacy trust, namsos, 2 levanger hospital pharmacy, central norway hospital pharmacy trust, levanger, norway please specify your abstract type: descriptive abstract (for projects) background and objective: nord-trøndelag county is sparsely populated and many inhabitants live far from the hospital. additionally, only half (12 of 23) of the municipalities have a local pharmacy. traditionally, namsos and levanger hospital pharmacies have performed quality audits of the implementation of drug administration procedures in primary care units. since 2013, a service where clinical pharmacists participate in multidisciplinary medication reviews in 19 municipalities throughout the county has been established. the objective of this poster is to describe the practical approach and design of the service. design: a descriptive report of an implemented clinical pharmacy service in primary care where clinical pharmacists, as part of multidisciplinary teams, perform medication reviews. results: medication reviews are performed on patients admitted to nursing homes and patients in home care, receiving help with handling of their drugs. primary care nurses prioritise patients (by selecting frail elderly with multiple co-morbidities and polypharmacy), usually five patients in each meeting. prior to the review, nurses collect medical information using a checklist including; diagnosis, drug-related symptoms, standard laboratory tests and an updated medication list. the clinical pharmacist receives de-identified medical information by postal mail or e-mail before the meeting. based on this information the pharmacist identifies possible drugrelated problems (drps) and provides recommendations on how to solve them. this is performed in a structured approach according to the integrated medicine management (imm) model. subsequently, the pharmacist visits the municipality and discusses the medication reviews in a multidisciplinary team meeting with nurses and physicians. in addition, the pharmacist gives lectures in a medication related topic (e.g. treatment of insomnia and anxiety, oral anticoagulants and cognitive side effects). following the meeting, the pharmacist reports the drps and suggested interventions to the multidisciplinary team, for further follow-up. during 2015, totally 220 medication reviews were performed in 19 municipalities. in the same period, 25 lectures were given by the clinical pharmacists. conclusion: this clinical pharmacy service enables multidisciplinary medication reviews even in municipalities with limited health professionals and resources. as a part of multidisciplinary teams, the clinical pharmacists contribute with medical competence. camille castel 1 , arnaud de la blanchardière 2 , vincent cattoir 3 , guillaume saint-lorant *,1 1 pharmacy, 2 infectious and tropical diseases, 3 microbiology, chu caen, caen, france please specify your abstract type: research abstract background and objective: antimicrobial stewardship have clearly demonstrated their efficiency towards a more adequate use of antibiotics. since 2014, the use of daptomycin, a ''critical last resort antibiotic'' has intensified in our hospital, occasionally outside the scope of its approved indications. this situation has led to the implementation of an antimicrobial stewardship and the drafting of local guidelines. the aim of this study is to analyse the evolution and pertinence of daptomycin prescriptions, after distribution of these guidelines within our institution. setting and method: a monocentric prospective study was conducted between july 2015 and november 2015 in a 1500-bed university hospital. each daptomycin prescription recorded by pharmacy department was analysed by an infectious diseases specialist in the presence of the prescriber and considering local guidelines and the patient's clinical conditions. main outcome measures: the indicators chosen to determine prescription pertinence were: treatment indication, prescribed dose and other antibiotics associated with the daptomycin prescription. results: 20 daptomycin prescriptions were analysed. observed indications were: sepsis (35%), infective endocarditis (25%), bone and joint infections (25%) and vascular prosthetic infections (10%). identified pathogens were: mrsa (35%), methicillin-resistant coagulase-negative staphylococci (25%), methicillin-sensitive staphylococcus aureus (10%), enterococci (10%) and methicillinsensitive coagulase-negative staphylococci (5%). daptomycin was prescribed as first-line treatment in 50% of cases. the mean dose was 7 mg/kg/day [3-10 mg/kg/day] for a mean duration of 17 days [2; 55 days] . local guidelines were followed in 20% of cases. daptomycin use was relevant for 70% of prescriptions. the irrelevant prescriptions triggered the modification or stoppage of antibiotic therapy in 50% of cases, respectively, generating an 18% decrease in consumption and an economy of over €6700 for our institution. conclusion: this study shows the efficiency of antimicrobial stewardship in adequately using antibiotics, limitating ecological impacts, improving patient care and decreasing healthcare costs. it also shows that guidelines alone are insufficient to ensure a proper use of antibiotics. without a close prescription follow-up, constant reminders and sustainable evaluations, guidelines only affect a few prescribers. within the context of an ''antimicrobial crisis'', further development of guidelines and antimicrobial stewardship is essential to fight increasing bacterial resistances and requires a close collaboration between all healthcare professionals including pharmacists. interviews were transcribed verbatim and data were analysed using systematic text condensation. results: three major themes were identified: benefits, unrealised potential and criteria and barriers for success. (1) benefits described by physicians included increased patient safety, increased awareness on drugs, and an ease of workload. drug interaction management was emphasized as one of the clinical pharmacists' most important work tasks, as well as being a resource for collaborating healthcare professions and to the patient himself. (2) the clinical pharmacists expressed that they had an unrealised potential and could contribute to a greater extent in the multidisciplinary team than they did already. they mentioned education towards physicians and nurses, contribution in treatment decision-making and patient counselling as examples for possible extended work tasks. (3) as criteria to succeed as a clinical pharmacist, physicians highlighted the importance of oral communication and physical presence on the wards. as barriers for integration in the team, the clinical pharmacists identified the physicians' lack of knowledge about the clinical pharmacists' skills as well as unclear expectations regarding their responsibilities. conclusion: physicians agreed that the clinical pharmacist represent a valuable contribution to the multidisciplinary team, where patient safety and drug interaction management are highlighted as main benefits. clinical pharmacists should to a greater extent educate healthcare professions in drug related topics and provide patient counselling. continuous effort on making the clinical pharmacist a natural part of the multidisciplinary team is crucial for the development of clinical pharmacy. by gathering perceptions from the collaborating professions as well as educating them on what clinical pharmacists can provide, we can develop a multidisciplinary team that enhances patient safety. hp-pc006: assessment of dual antiplatelet therapy following acute coronary syndrome using grace and crusade sadeer fhadil * , paul wright, sotiris antoniou please specify your abstract type: descriptive abstract (for projects) background and objective: mortality and morbidity benefits of dual antiplatelet therapy (dapt) following acute coronary syndrome (acs) have been unequivocally demonstrated in a large body of evidence. with the availability of more potent antiplatelet agents, balancing ischemic and bleeding risks to prevent adverse outcomes is an on-going challenge, in particular, recognising that patients with high bleeding risk were excluded from clinical trials. grace and crusade scores stratify risk of mortality and in-hospital major bleeding post acs respectively. these tools should be used to support antiplatelet choice in light of newer more potent agents that equally pose a greater risk of bleeding. design: grace and crusade scores were calculated for patients presenting with acs. clopidogrel was recommended for patients with a high or very high crusade score (greater bleeding risk). ticagrelor was recommended for patients presenting with st-elevation myocardial infarction (stemi) or those with nsteacs with a grace score of intermediate or above (greater ischemic risk) and a crusade score of moderate or less (low bleeding risk). in either case, treatment was at the discretion of the clinician and patients received concomitant aspirin. a registry was collated of risk scores, diagnosis and choice of antiplatelet therapy. results: 1030 patients were included in the registry, of which 587 (57%) presented with stemi and 443 (43%) presented with nsteacs. 558 of 752 (74%) patients with a greater ischemic risk received ticagrelor as part of their dapt regime. advanced age, concomitant anticoagulation and those awaiting surgery were the most common reasons for patients with a greater ischemic risk to receive clopidogrel. 145 (14%) had a high or very high crusade score. of these, 130 (90%) received clopidogrel as part of their dapt regime. conclusion: risk stratification was streamlined using the data collection tool and useful to support choice of dapt. european society of cardiology (esc) guidance recommends use of established risk scores for prognosis and bleeding; however evidence to correlate to choice of dapt is lacking. outcome data is currently being reviewed and will provide further evidence to correlate choice of dapt to grace and crusade scores. please specify your abstract type: descriptive abstract (for projects) background and objective: in europe, approximately 25% of the patients with the human immunodeficiency virus (hiv) infection are co-infected with the hepatitis c virus (hcv). treatment recommendations in hiv/hcv co-infected patients are identical to those in patients with hcv mono-infection. however, potential drug-drug interactions (ddis) between antiretroviral agents and new direct-antiviral agents (daas) imply the need of a careful selection of the hcv treatment regimen. the aim of the present study was to evaluate the need of a change in the antiretroviral therapy (art) due to potential ddis in patients with hiv/hcv co-infection who started treatment for hcv with new daas. we also assessed the effectiveness of hcv treatment 12 weeks after hcv treatment completion. design: we retrospectively registered clinical data about hcv and hiv management: hcv genotype, fibrosis metavir score, initial hcv viral load, hcv treatment and previous art regimen. we recorded the changes in art prior to starting hcv treatment and the reason of this switch (ddi, simplification or duplication of the therapy). results: between february 2015 and january 2016, 50 hiv/hcv coinfected patients started hcv treatment with a daas regimen. of them, 39 had advanced liver disease (fibrosis score: f3/f4) and 27 were infected with hcv genotype 1. prior to starting hcv treatment, 29 patients needed a switch in art regimen due to potential ddis with daas. simeprevir and the co-formulation ombitasvir/paritaprevir/ritonavir were the daas most frequently implicated in ddi with protease inhibitors or non-nucleoside reverse transcriptase inhibitors: 19/29 and 5/29, respectively. also, we observed some changes of art due to other causes. five switches occurred to adequate the regimen (discontinuation of ritonavir in candidates to take the co-formulation ombitasvir/paritaprevir/ ritonavir or art improvement to decrease pill burden). as for hcv treatment effectiveness, 42/50 (84%) patients achieved sustained viral response 12 weeks after therapy completion. conclusion: a large proportion of patients with hiv/hcv co-infection who initiate treatment with daas for hcv need to switch art due to potential interactions that may impact on effectiveness and safety of both treatments. additionally, some changes in art treatment are made to facilitate therapeutic adherence. these results highlight the need of a multidisciplinary approach in which interactions between art and hcv treatments should be carefully assessed. please specify your abstract type: descriptive abstract (for projects) background and objective: the potential impact of polymedication, iatrogenic events and medication error is a serious concern in hospitalized patients. clinical pharmacists can limit these risks by identify high risk. the aim of this study are to identify in six medical units high risk patients by using three predictive scores of rehospitalisation (8 ps) 1 , early mortality (charlson) 2 and drug related problems (drp) 3 . design: 49 clinical and therapeutic variables in 216 patients were collected through medical records and prescriptions by clinical pharmacists. scores were calculated during 2 months in six units (internal medicine, n = 30; nephrology, n = 35; geriatrics, n = 35; rheumatology, n = 45; cardiology, n = 54 and endocrinology, n = 29). the data were analysed by mann and whitney test for the continuous variables and chi square test for the qualitative variables. the coefficient of correlation between the three scores were calculated by a pearson test for normal distribution and by a spearman test for non normal distribution. patients were considered at a high risk for re-hospitalization (8ps [ 2) , early mortality (charlson [ 5) and iatrogenic events (drp c 8) . results: in the general population, the average age was 67.4 ± 18.1 years old and the sex ratio was 0.94. the average treatment used was 7.8 ± 4. charlson scores were higher in geriatric unit (6.3 ± 1.8) follow by medical interne unit (5.7 ± 2.7). the 8ps and drp scores were higher in nephrology unit respectively 2.5 ± 0.9 and 9.1 ± 2.6 follow by internal medecine unit 2.2 ± 1.3 and 7.6 ± 2.7. on contrary the rheumatology unit presented the lower level for the three scores. 51 patients were considered at high risk for three scores, 33% (n = 17) in nephrology unit (almost 49% of unit), 20% (n = 10) in geriatric unit, 18% (n = 9) in internal medicine unit, 18% (n = 9) in cardiology unit, 6% (n = 3) in endocrinology unit and 6% (n = 3) in rheumatology unit. conclusion: knowledge of the variables associated with these predictor scores could help clinical pharmacists to prioritise various medicine units and target those at risk. we identified especially three units at risk: nephrology, geriatric and internal medicine. thanks to these results, clinical pharmacists can rapidly and efficiently target patients who present iatrogenic and/or re-hospitalization risks. design: a retrospective observational analysis was conducted in our hospital, based on medical records of patients presenting atrial fibrillation (af) and treated by doacs from january 2011 to may 2016. to identify patients hospitalized due to severe bleeding, we analysed prothrombin complex concentrates (pccs) and activated pccs prescriptions, as well as pharmacovigilance declarations. results: 1328 patients were treated with doacs: 763 with rivaroxaban (57.5%), 286 with dabigatran (21.5%) and 279 with apixaban (21%). fifty-nine (4.4%) patients experienced at least one bleeding leading to hospitalization: 35 with rivaroxaban (4.6%), 16 with dagibatran (5.6%) and 8 with apixaban (2.9%). thirty-eight severe bleeding were identified (2.9%): 24 occurred with rivaroxaban (3.1%), 10 with dabigatran (3.5%) and 4 with apixaban (1.4%). they included 10 intracranial bleeding (26%) and 21 gastro-intestinal bleeding (55%). seven haemorrhages resulted in hypovolemic shock (dabigatran:4, rivaroxaban:2, apixaban:1) and 2 of them were fatal (dabigatran:2). rates of bleeding (p = 0.86, v 2 test) and of severe bleeding (p = 0.85, v 2 test) were not statistically different for the three molecules. in case of major haemorrhage, the recommended factor concentrate in our protocols differs between the anticoagulant. with dabigatran, the antidote idarucizumab (5 g, intravenously) should be administered, without waiting for plasma concentration results. with rivaroxaban, apixaban or unknown doacs, pcc (30-50 units/kg) is indicated. in case of pcc failure, activated pcc (30-50 units/kg) is suggested. pcc, activated pcc or idarucizumab (2) were used in 15/38 patients (40%). in rivaroxaban and apixaban-related haemorrhages, 10 patients received activated pcc: two had a 20 ui/kg dose and one had a 60 ui/kg dose. regarding dabigatran-related bleeding, one patient received pcc instead of idarucizumab. compliance with local recommendations was 92% (35, p [ 0.003, v 2 test) 0.9 pharmacovigilance reports were issued. conclusion: management of doacs-associated severe bleeding in our hospital respects local protocols. it should also be pointed out that patients with life threatening bleeding may benefit from pcc. however, the risk of thrombosis associated with pcc must be weighed against the risk of haemorrhage. since specific antidotes are emerging, like idarucizumab or andexanet alpha, new guidelines for doacs-related haemorrhage are expected. please specify your abstract type: descriptive abstract (for projects) background and objective: this project is part of a prospective quasi experimental proof-of-concept investigation of a clinical pharmacist intervention to reduce drug-related problems among people admitted to a ward in a rural hospital in northern sweden. the aim of this particular study is to explore doctors' and nurses' expectations of having a ward-based pharmacist providing clinical pharmacy services in a rural hospital. design: eighteen face to face semi-structured interviews were conducted with a purposive sample of doctors and nurses working on the ward were the clinical pharmacy service was going to be implemented. semi-structured interviews were digitally recorded, transcribed and analysed using thematic analysis. results: the majority of participants had limited experience or a vague idea of what pharmacists are able to do in a ward. most participants described traditional roles such as inventory, drug distribution and dispensing. most respondents were unaware of the pharmacists' knowledge, skills and competences. for some it was unclear how having a clinical pharmacist in the ward was going to impact on their workload this was particularly important for the nurses. some doctors (mainly experienced) were concerned that having a pharmacist may mean losing or not gaining competence on drugs. for others it was unclear how the pharmacists' will work with patients or what clinical skills they have. however most participants were positive about the implementation of the new service. conclusion: this study provided a rare opportunity to explore the doctors' and nurses expectations of the role of clinical pharmacists before a clinical pharmacy service was implemented. the results showed that the participants' expectations of the clinical pharmacist role were unclear. to successfully implement clinical pharmacy services in a clinical pharmacy ''naïve'' setting; roles, clinical competence and responsibilities should be clearly described. furthermore, it is important to focus on inter professional collaborations between doctors, nurses and pharmacists. practical for the local hospital setting. seven out of 9 experts agreed with pharmacist prescribing for the conditions identified. pharmacists (n = 31) were more willing to prescribe antihypertensive and antidiabetic medication (87.1%) when compared to oral anticoagulants (64.5%). these values are higher than those obtained by vella in 2014. the majority of pharmacists (87.1%) recommended that pharmacists should take up further studies to a master or doctorate level degree in a clinical aspect in order to be authorised to prescribe. conclusion: the developed framework for pharmacist prescribing and the guidelines developed for pharmacist prescribing of oral anticoagulants and pharmacotherapy of hypertension and diabetes mellitus were shown to be reliable and were accepted by pharmacists and physicians. please specify your abstract type: research abstract background and objective: valproic acid (vpa) and its derivates and mycophenolate mofetil (mmf) and mycophenolic acid used during pregnancy increase risk of congenital malformation and cognitive impairment. thus, the french national agency for medicines and health products safety (ansm) decided to establish new conditions of prescription and dispensation of drugs containing vpa (may 2015) and mmf (april 2016). a signed care agreement and a co-prescription of contraceptives are now mandatory in the drug dispensation for reproductive-age adolescent girls and adult women. this study will describe the impact of these new guidelines on our practice. our objective is to compare the vpa and mmf media coverage and the impact on the prescriptions. setting and method: we compared the mass communication between vpa and mmf on social media, webpages and journal article (public and professional journal) on google and googletrends in the first months around these new rules. we combined different keywords such as ''accord de soins'' and the drug name. in the same time, we collected and analysed vpa and mmf prescribing and dispensing data and compared it to the 2015 data for the first 6 months. main outcome measures: results: just before the vpa rule, the vpa was presented in the general press as the new health scandal after benfluorex mediator°w ith 100 google searches in march 2016 compared to 10 searches usually per month. simple research combining keywords reveal always more than twice more webpages concerning vpa than mmf. at the same time, a patients association (renaloo for renal failure) wrote to the ansm to contest the new rule with the double contraception and without any consultation of patients association. in our daily practice we also faced some physician reluctant to sign this prescription agreement with patient (too many agreements already asked, decision of ansm without any consultation of learned societies). the care agreements are kept in the patient records, a statement ''care agreement signed'' is reported in the electronic prescription of vpa and mmf. the overall consumption of mmf and vpa increase for respectively the first 2 and 3 months after rule implementation (from +122 to +326%) except for the micropakin 500 mg. the 6 months mmf data will be presented for the final communication. conclusion: the media pressure and the new regulation have an impact on prescription trends. these new prescription and dispensing rules concerned two different contexts: pathology, media coverage, possible drug alternatives. we were faced to some difficulty in implementing the new guidelines, which reveals a certain reluctance of the prescribers or the patients represented by associations. tdmp001: vancomycin trough serum concentrations are frequently subtherapeutic in a population of critically ill patients: a prospective observational study please specify your abstract type: descriptive abstract (for projects) background and objective: to design and characterise a framework of international pharmacy standards for pharmaceutical care application on oral anticoagulation for prevention of atrial fibrillation (af) related strokes. design: literature review (including existing international guidelines and quality measures) was conducted to characterise the standards and design an international framework for pharmaceutical practice application on oral anticoagulation for prevention of af-related strokes. expert opinions were sought through a delphi method to reach consensus on the framework domains and standards. results: the framework consisted of twelve overarching standards, which were defined and grouped into four domains as follows; ([personal care package]:-communication with patients, support decision making process, education and counselling, adherence. [medicines optimisation]:-clinical review and therapy optimisation, initiation and control, maintenance, supply and transfer between care settings. [workforce]:-workforce planning, training and development, analysing information; and [governance]:-assurance of service provision) specific to oral anticoagulation in prevention of af-related stroke. each standard was also categorised within dimensions and supporting statements to describe what a quality pharmacy service should deliver. a total of forty-five dimensions and twelve statements were incorporated into the framework. conclusion: a clearly defined framework of international standards was developed as a clinical tool and quality assurance to optimise the delivery of care for oral anticoagulation in prevention of af-related strokes. it will support pharmacists and their teams to develop their professional practice, improve services, and deliver safe and high quality patient care across all pharmacy settings. poster discussion forum i: community pharmacy and public health cp-pc004: nurses' and pharmacists' learning experiences from participating in inter professional medication reviews in primary health care: a qualitative study hege t. bell *,1 , anne gerd granås 2 , ragnhild omli 3 , ingela enmarker 4 , aslak steinsbekk 5 1 nord university/ntnu, trondheim, 2 hioa, oslo, 3 nord university, namsos, norway, 4 department of nursing, østersund, sweden, 5 ntnu, trondheim, norway please specify your abstract type: research abstract background and objective: traditionally, drug prescription and follow up have been the sole responsibility of physicians. however, interprofessional medication reviews (imrs) have been developed to prevent drug discrepancies and patient harm. what participating nurses and pharmacists learn from each other during imr is poorly studied. the aim of this study was to investigate nurses' and pharmacists' perceived learning experience after participating in imrs in primary health care for up to 2 years. setting and method: a qualitative study with semi-structured focus group interviews and telephone interviews with nurses and pharmacists with experience from imrs in nursing homes and home based services. the data was analysed thematically by using systematic text condensation. main outcome measures: a qualitative method is useful when looking at objects from the perspective of how they are experienced. results: sixteen nurses and four pharmacists were interviewed. the nurses' perception of the pharmacist changed from being a controller of drug management routines towards being a source of pharmacotherapy knowledge and a discussant partner of appropriate drug therapy in the elderly. the pharmacists became more aware of the nurses' crucial role of providing clinical information about the patient to enable individual advice. increasingly the nurses learned to link the patient's symptoms of effect and side effect to the drugs prescribed. with time both professions jointly spoke of an increased awareness of the benefit of working as a team and the perception of contributing to better and more individual care. conclusion: imrs in primary health care meet some challenges especially concerning how to ensure participation of all three professions and how to get thorough information about the patient. possible solutions might be to use shared communication tools like internet based communication programs and to introduce the patient as a participant at the imrs. please specify your abstract type: research abstract background and objective: international good pharmacy practice guidelines describe how pharmacists should counsel the patients about their medicines, offer additional services where needed, and intervene at drug related problems. daily practice often differs from theory. this study aimed at illustrating the whole process of prescribed medicines dispensing in daily community pharmacy practice. part b of the project focuses on pharmacists' opinions. setting and method: community pharmacies in basel, switzerland, were invited in random order for study participation. one master student in pharmacy performed non-participant observations during 1 day at each included community pharmacy. at dispensing of prescribed medicines, patient data, content of counselling, communication style, and provision of further services (e.g. follow-up offer) were documented on a checklist with predefined themes. interventions were documented systematically. a semi-structured interview on the pharmacists' opinions about the counselling, triggers, facilitators and barriers, and the documentation of interventions was conducted at each community pharmacy. main outcome measures: counselling content at prescription dispensing by numbers and by pharmacists' opinions; barriers, facilitators, and triggers for counselling at prescription dispensing. results: in march and april 2016, 18 of 49 invited community pharmacies participated in the study. out of 561 documented observation periods, 556 encounters were analysed (first prescription: 269/refill prescription: 287). counselling was provided to 367 (66.0%) clients with an average of 2.9 (±3.1) themes per encounter. a total of 148 clients refused counselling. themes most counselled at first and refill prescription dispensing were: drug intake (476/80), dosage (191/50) , and administration (163/38). for the pharmacists (n = 18), most important themes to be discussed at first prescription dispensing were indication (11), administration (9), and anamnesis (8); for refill prescription dispensing they were adherence (9), therapy benefits (9), and adverse effects (7). the majority of pharmacists (13) felt that it was their obligation to ask questions about patients' health during the dispensing of prescription medicines and named trigger (e.g. patient knowledge gap, patient motivation, interactions), but one-third reported difficulties with it. barriers were refusal by patients (13), communication problems (language, 7), lack of medical data (3) , and lack of time (3) . conclusion: a discrepancy in counselling content by observation compared to pharmacists' opinions was revealed. this might indicate that pharmacists are aware but hindered by barriers to practice according to good pharmacy practice guidelines. please specify your abstract type: research abstract background and objective: the 2020 workforce vision in scotland envisages 'making more and better use of technology …to increase access to services and improve efficiency' across the healthcare interface. services offered by community pharmacy remain limited by lack of shared access to patients' clinical information. in scotland, every patient has a unique identifier, their chi (community health index), which facilitates identification of/searching for patient records. the aim of this research was to explore the experiences of community pharmacists granted clinical portal access to patients' records. setting and method: from april 2015, community pharmacists across nhs tayside (n = 21) who had completed technical and information governance training were invited to maintain a portal log of their experiences of using the clinical portal to access patient records. each was asked to record when/why they considered accessing a patient's record and whether their information needs were met. portal logs were subject to independent summative content analysis by two researchers. this study gained ethical approval from robert gordon university. main outcome measures: not applicable. results: clinical portal logs were received from most participating pharmacists (n = 18/21). two were unavailable (moved to hospital setting; maternity leave). a third had not had occasion to access the clinical portal which he speculated was due to not working at weekends but also raised concerns about gaining patient consent. frequency of seven identified themes provided a partial indication of balance of reasons for usage. firstly (#1), to confirm a patient's prescription (n = 48), secondly (#2), for additional information (n = 46). less frequently (#3), portal access was to check repeat medications (n = 23). other reasons for access were (#4) to check hospital discharge (n = 21) followed by (#5) check on multi-compartment appliance aid status (n = 14) or (#6) check the emergency care summary (n = 11). there were also instances (#7) when portal access was not found to be helpful (n = 16) so traditional offline routes were followed. conclusion: preliminary findings indicate mainly positive experiences with no technical issues raised and community pharmacists' information needs largely met. although limited to a small number of pharmacists in only one health board, findings support scottish policy aims, including 'prescription for excellence.' further work is underway around patients' perspectives of community pharmacist access. please specify your abstract type: research abstract background and objective: multicompartment compliance aids (mcas) such as the multidrug punch cards pharmis ò are used to support patients in the daily management of their medication. solid oral medicines are unpacked from their original packaging and repacked in mcas although controversy exists about the stability of repackaged medicines. different countries published contradictory lists of medicines not recommended for repackaging. we aimed to define and apply criteria able to assess visual alteration of medicines repackaged in mcas. setting and method: eight criteria describing physical alteration of tablets/capsules were retrieved from the who international pharmacopoeia 2015: chipping, swelling, capping, rough surface, cracking, crushing under pressure, mottling, and discoloration. absence of one criteria gives 1 point. a maximum score of 8 points can be obtained. twenty-two critical medicines and three half tablets were repackaged in the multidrug punch cards pharmis ò and stored at accelerated conditions (40°c/75% rh) for 4 weeks. original blisters of medicines were stored at room temperature as control. each tablet/capsule was visually inspected after 7, 14, 21 and 28 days. main outcome measures: score according to eight criteria. results: after 4 weeks, 17 tablets/capsules including 2 of the half tablets showed no visual alteration and were identical to controls. a reduced score (3-7 points) was given to seven repackaged medicines and one half tablet within 4 weeks: madopar ò (3), pravastatin sandoz ò (4), carvedilol mepha ò (6), plavix ò (6), pantoprazol nycomed ò (7), adalat ò cr (7). swelling and rough surface were the most frequent. chipping and capping were not observed. conclusion: our eight visual criteria are able to detect physical alteration of repackaged solid oral medicines under stress conditions. in absence of reliable data we suggest to apply this simple quality control for repackaged medicines in pharmacy practice. because chemical stability testing is not feasible in practice, pragmatic solutions are sought. further studies are needed for storage at room temperature. cp-pc008: drug-related problems and symptom burden in nursing home residents kerstin bitter *,1 , ulrich jaehde 1 , christina pehe 2 , gabriela heuer 3 , manfred krü ger 3 1 clinical pharmacy, university of bonn, bonn, 2 aok rheinland/ hamburg, 3 pharmacists' association north rhine, düsseldorf, germany please specify your abstract type: research abstract background and objective: drug-related problems (drp) are common in the elderly due to polymedication. community pharmacies supplying drugs to nursing homes may play an important role in detecting and solving drp in nursing home residents. this project aims to evaluate whether community pharmacists can enhance the medication safety of nursing home residents by solving drp by means of a simple medication review (mr). furthermore, the applicability of a new tool to detect symptoms as potential adverse drug reactions in elderly patients should be tested. setting and method: nursing home residents at the minimum age of 65 years insured by aok rheinland/hamburg and regularly taking at least five drugs per day were invited to participate. pharmacists performed a mr based solely on the patients' medication data, including dosage regimens of the nursing home and self-medication data. the detected and solved drp were counted. additionally, a simple questionnaire (sympel) was distributed to the patients periodically in order to assess their symptom burden. main outcome measures: frequency and type of the patients' drp as well as their symptom burden before and after the mr. results: after testing the feasibility of this intervention in a pilot study, 54 patients were included in the main study so far. in average, the pharmacists identified two drp per patient and reported to the responsible general practitioner (gp) . as in the pilot study, most frequent drp documented by pharmacists were drugdrug-interactions (34%). 29% of the pharmacists' recommendations were accepted by the gp. 46% of the patients took at least one drug considered as potentially inadequate in the elderly. out of six different symptoms, patients reported dizziness and bruises most frequently. conclusion: pharmacists can detect many drp in nursing home residents by means of a simple mr. however, the full potential of this service to solve drp can only be exploited if the cooperation with the gps is improved. please specify your abstract type: research abstract background and objective: medicines for rare diseases (rd) are costly and have limited efficacy evidence but they represent around 20% of all innovative medicines. therefore, countries are facing challenges in providing patient access to them. the purpose of the study was to assess the patient access for slovenia and compare it with 23 other european countries in the last decade. setting and method: the medicines for rd that obtained marketing approval between 2005 and 2014 via centralised procedure were included in the study based on the orphanet list from january 2016. using the quarterly ims health database, sales data were analysed for slovenia and 21 other european union countries, norway and switzerland. patient access was assessed for each country and comparisons between the countries were made using the three main outcome measures. main outcome measures: the number of medicines for rd available; time to first continuous use after marketing approval; total pharmaceutical expenditure for medicines for rd in euros. results: altogether, 125 medicines for rd were approved between 2005 and 2014. complete sales data were available for 120 medicines which were included in the comparison. for germany and the united kingdom the continuous use of 102 (85%) and 94 (78%) was observed, respectively. the following italy, france, denmark and sweden use 60-70% of all the medicines. in slovenia, 66 (55%) medicines for rd were introduced. germany and the united kingdom times to first continuous use were the shortest (median time 1-3 months after marketing approval). median times below 12 months were observed for norway, sweden, austria, the netherlands, france and switzerland. other countries were slower in enabling first continuous use (median time from 12 to 34 months). germany, france, switzerland had the largest pharmaceutical expenditure per inhabitant in 2014 (29.2, 25.0 and 24.0 euros/inhabitant) while slovenia amounted to 18.5 euros/inhabitant. in slovenia more than a half of the medicines for rd approved in europe are used which ranks it in the middle of all the countries in comparison. comparing to the important european pharmaceutical markets like germany, united kingdom, france and italy, slovenia's median time to first continuous use is longer and pharmaceutical expenditure per inhabitant for these medicines is lower. pec002: mapping of the dlqi scores to eq-5d utility values using ordinal logistic regression and monte carlo simulations: is it plausible? please specify your abstract type: research abstract background and objective: converting dermatology life quality index (dlqi) scores to generic measure data would allow utility calculations and enable cost-effective analysis. this would meet the needs of health technology assessment agencies (htas) such as nice, who preferentially use the general health measure eq-5d. the dlqi is a specialty-specific measure unlike the eq-5d, a generic measure from which utility values can be derived. often several measures are implemented in studies with increased cost and patient burden. ordinal logistic regression (olr) was used to develop a model to convert dlqi scores to eq-5d based utility values for use in economic appraisal of medicines. setting and method: data from 4010 patients were randomly divided into estimation and validation sets to fit and test the model. a series of ordinal logistic regressions were fitted in spss v22 for the five eq-5d dimensions based on age, sex and all 10 individual items of the dlqi as predictors. the model produced three estimated probabilities per subject per eq-5d domain. using these estimated probabilities, a series of 10 monte carlo (mc) simulations were run for each subject resulting in predicted domain responses. from these, utility values were calculated and compared to actual patient values. main outcome measures: conversion of dlqi scores to eq-5d domain data results: there are conceptual overlaps between items of the dlqi and eq-5d. the validation data set (which was not included in the creation of the model), demonstrated that the models were highly predictive compared to actual responses, except for minor differences for the pain/discomfort domain. for example, for the eq-5d ' mobility' domain, 1389 patients answered 'no' (predicted 1392 and 440 patients answered 'some or extreme' (predicted 437) . we examined the model's latent variables, which also demonstrated high predictability at individual level. for example for the 'usual activities' domain the mean latent variable scores were -2.49, -1.62 and -0.86 for those responding 'no', 'some' and 'extreme' respectively, showing a clear increase in the scores with response. after excluding subjects with missing variable data there were 1769 patients in the estimation set and 1773 in the validation set. the model was shown to be highly predictive and repeated simulations demonstrated a stable model. the average predicted utility value for the entire validation set ranged from 0.742 to 0.753 across the 10 mc simulations compared to the actual average utility value of 0.754. conclusion: using olr, we have developed a method of mapping the disease-specific dlqi onto the eq-5d: utility values may then be derived for population data sets, and possibly for individuals. the olr technique could be used to convert data from other disease-specific quality-of-life measures to generic utility data for incorporation into cost-effective analyses, greatly enhancing the potential value of such information. tomi laptoš *,1 , tanja kersnik levart 2 1 hospital pharmacy, 2 the division of paediatrics, department of nephrology, university medical centre ljubljana, ljubljana, slovenia please specify your abstract type: descriptive abstract (for projects) background and objective: having to take medication during time in school may present certain discomfort for some children. suboptimal dosing regimens (i.e. dosing more frequent than determined by drug's trough:peak ratio) can be prevented by a clinical pharmacist's overview and therapy optimization. the aim of the study was to review and evaluate dosage regiments in paediatric patients on antihypertensive therapy. dosage regiments are defined as schedule of doses of a therapeutic agent per unit of time and the amount of a medicine to be given at specific time. design: electronic health records (ehr) review, evaluation of actual dosage regiments against regiments recommended in smpcs and clinical database (uptodate ò ), a consecutive case series study. results: ehrs of 254 patients, admitted to or discharged from the department of nephrology of the division of paediatrics, umcl in 2015 with suspected icd-10 diagnoses from i10 to i15 were reviewed. 107 patients were excluded (diagnosis not confirmed or lifestyle-change disease management only). the remaining 147 patients (average age 15.7 years (range 3-20)) received daily on average 1.59 medications (range 1-4) in 2.06 individual doses (range [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] . most frequently used drugs were perindopril (n = 57), ramipril (n = 47), amlodipine (n = 34), bisoprolol (n = 32) and doxazosin (n = 13). 10 patients received ex tempore oral suspensions. dosage regimen was not optimized in 17% (n = 25) of the patients, among those 4% (n = 6) receiving one medication only and 13% (n = 19) receiving more than one medication where at least one was not optimized. furthermore, 9% (n = 13) patients on stabledosage therapy (no dosage change of either medication in last 6 months with satisfactory clinical outcomes) were eligible for fixeddose combination medication. with optimized dosage regimens patients would receive daily on average 1.51 medication (range 1-4) (-5%) in 1.76 individual doses (range 1-9) (-15%). the difference was statistically significant (95% ci, p \ 0.05) in both cases. conclusion: our data show that the majority of the paediatric patients on antihypertensive therapy (83%) received their medication in optimal dosage regimens. however, with an estimated every fifth patient not being on optimal dosage regimen, a multidisciplinary approach is crucial to assure that the individual patient achieves the best clinical, humanistic and economic therapy outcomes. ph005: polypharmacy management programmes in the elderly: a case study in greece dimitra gennimata *,1 , christos kampolis 1 , aggelos vontetsianos 1 , jennifer mcintosh 2 , alpana mair 3 , on behalf of simpathy consortium please specify your abstract type: descriptive abstract (for projects) background and objective: polypharmacy management and medication adherence in the elderly are significant public health issues throughout the european union (eu). simpathy (stimulating innovation management of polypharmacy and adherence in the elderly) is a consortium of 10 organizations representing eight european countries, aiming at stimulating innovation around management of appropriate polypharmacy and adherence, ultimately providing tools for eu policy makers to develop and/or improve, implement and evaluate programs addressing these issues. design: a mixed-methods case study was carried out in greece, to identify policies on the management of polypharmacy and adherence issues in the elderly. a desk review of the polypharmacy and adherence policies at the government, regional and institutional level has been completed. key informant interviews were conducted with policymakers and health professionals responsible for developing and implementing strategies. focus groups consisting of policymakers, clinicians and patients validated the research findings. results: although e-prescription implementation is widespread (&98% coverage nationwide) and disease-specific guidelines have been developed, polypharmacy management is only associated with direct economic indicators. no formal policies or programmes are identified. significant contributions are coming from different health professional organizations that have chosen to provide expanded services to their patients, aiming at optimising drug therapy and thus polypharmacy management and medication adherence in the elderly. community pharmacists offer pharmaceutical care to patients, which includes management of prescribed medication, otc remedies, vitamins and supplements and food-drug interactions. hospital pharmacists in some state (public) hospitals review medication for inpatients and out-patients, communicate with prescribers and confirm the ''benefit-no harm'' principle in the prescribed medication (e.g. incompatibilities, side effects, 7-rights of medication). medical doctors, mostly general practitioners and some specialized ones, usually in primary healthcare settings, keep health records of their patients and have an overview of all administered medication. however, key barriers still remain the lack of coordination of institutions and authorities and overlap of their responsibilities, healthcare workforce and infrastructure shortages and several cultural issues. conclusion: all initiatives to medication management and medicines optimisation are provided without directive from national policies or guidelines. therefore, these activities rely on the goodwill of the health professionals to address pharmacotherapy and therefore polypharmacy management but they are not necessarily representative of what is happening nationwide. a national policy to implement the management of polypharmacy nationwide could mobilise the willingness of health professionals and ensure consistency of care. development and implementation of this policy should build on the grassroots efforts currently underway in this area. ph006: clinical profile and treatment discontinuation in a tuberculosis control state programme in brazil: preliminary results from sinan database simone s. bezerra 1 , mara guerreiro *,2,3 , nathany pessoa 4 , maria paula athayde 5 , rodrigo auad 6 , joão josé gomes 7 , josé lamartine soares sobrinho 1 1 post graduation program in therapeutic innovation, federal university of pernambuco, recife, pernambuco, brazil, 2 centro de investigação interdisciplinar (ciiem), instituto superior de ciências da saúde egas moniz, monte de caparica, 3 please specify your abstract type: research abstract background and objective: challenges remain in tuberculosis (tb) control. discontinuing treatment can leave patients infectious and contributes to the emergence of resistance. this study aimed to describe the clinical profile and cure and discontinuation rates of tb patients enrolled in the pernambuco tuberculosis control programme (pect). setting and method: the study was conducted in three sites in recife, brazil, designated a (one polyclinic plus eight general practice units), b (one hospital for medium-complexity patients) and c (one hospital for high-complexity patients). data were extracted from the notifiable diseases information system (sinan) for all pect outpatients, from 01/2012 to 12/2014 (n = 440). analysis was performed with the aid of action for excel; there is on-going analysis to further explore differences across sites. ethical approval was granted. main outcome measures: clinical form of the disease, hiv testing, new cases, cure and treatment discontinuation. results: sociodemographic data were available for sites a and b only. most patients were male (70%, n = 291), with age raging from 20 to 49 years old (60.5%, n = 252); most had a low education level (46%, n = 192) and low socioeconomic status (92%, n = 382). the most common clinical presentation was pulmonary tb. most cases were new (78.4%, n = 345); recurrence and enrolment after discontinuation were respectively 5.9 and 10.9% (n = 26 and n = 48). with respect to hiv, 37.27% of patients were seronegative (n = 164); about a third (35%; n = 155) had not performed hiv test. rates for cure were respectively 59.1% (n = 260), 28.95% (n = 128) and 16.6% (n = 73) in the sites a, b and c. correspondent rates for treatment discontinuation were 21.2%(n = 93), 24.9% (n = 110), 4.3% (n = 19), respectively. tb-related mortality ranged from 0 in site c to 5.4% in site b. conclusion: missed hiv tests may represent undetected tuberculosis/ hiv coinfection. site b presented the highest rates of intrapulmonary plus mixed tb forms, discontinuation of treatment and tb-related mortality; additionally, it had the lowest rate of enrolment after treatment discontinuation. patients co-infected with tb and hiv are firstly referred to this site, which may explain this finding. our findings may help managers allocating resources and assist clinical pharmacists in planning their interventions. findings also suggest the need of more intensive interventions in tb patients, such as pharmaceutical care programmes. please specify your abstract type: research abstract background and objective: pharmacists working in primary health clinics have various roles. pharmaceutical care is one of them. how to provide this service varies across countries and settings. the most optimal way to provide pharmaceutical care is important to define when developing clinical pharmacy services in a new setting such as primary care practices. general practitioners are key stakeholders in this endeavour. the aim of this study was to find the most optimal approach to providing pharmacist-led pharmaceutical care in primary health care clinics in iceland in collaboration with general practitioners. setting and method: action research provided the framework for this research. data was collected from pharmaceutical care interventions with patients, field observations, field notes, and interviews with general practitioners over the period of the study. the study ran from september 2012 to june 2015. three separate semi-structured in-depth interviews were conducted with five general practitioners from one primary health care clinic in iceland at different time points throughout the study. pharmacist-led pharmaceutical care was provided to patients (n = 125) before and between general practitioners' interviews. the study settings was a primary health care clinic in reykjavik area and the patients' homes. main outcome measures: how to provide pharmaceutical care in collaboration with general practitioners in the icelandic health care environment. results: direct contact between pharmacists and general practitioners over short distances are essential to providing optimal pharmaceutical care services. pharmacist's access to medical records is necessary even though face-to-face communication between pharmacist and patients are most effective in providing pharmaceutical care. pharmacist-led clinical service was deemed most needed in dose dispensing polypharmacy patients. patients require more information about drugs prescribed to them coupled with an accurate drug list with greater detail. conclusion: the most efficient collaboration when pharmacist and general practitioner is obtained when they work side by side at the primary health care clinic. when new services are developed it is vital to identify different requirements of the primary health care clinics to optimize the running of a clinical pharmacist service. ph008: accompaniment of patients treated with oral chemotherapy: a survey on patients' experience laure napoly *,1 , pascal paubel 2,3 , sylvie burnel 1 1 oncorif -regional cancer network, 2 health law and health economics deparment, 3 health law institute, inserm, umr s 1145, paris descartes university, sorbonne paris cité, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: antineoplastic agents taken orally are more and more used in cancer care. these medicines confer autonomy to patients. although, they may cause adverse effects that can lead to treatment adherence issue, unjustified hospitalizations, or premature treatment interruption. proper accompaniment of patient can prevent these issues. in order to define how to organize this accompaniment, we conducted a survey on patients' experience. the objective is to describe patients care pathway and identify their needs. design: a descriptive, qualitative, prospective, survey was conducted using self-administered questionnaires, in hospitals of ile-de-france region. inclusion criteria were: having being treated with oral neoplastic agents during minimum 2 months, age [18, solid tumor, no concomitant iv chemotherapy. collected data were: patients' sociodemographic and clinical profile, their insight about different steps of care pathway (information, treatment delivery, follow up), their behaviours and interactions with healthcare professionals, and their overall opinion. results: 44 patients were recruited in six hospitals. their sociodemographic and clinical characteristics were variable. 72% were treated with targeted therapy, 12% with cytotoxic agent, and 16% with endocrine therapy. patients showed high satisfaction for given information at the beginning of the treatment. principal source of information identified was the oncologist (100%). while the delivery of treatment, 40% of patients beneficiated of advices from the pharmacist. accompaniment of patients during treatment seemed unequal, with: a frequency of visits with the oncologist ranging from less than 1-3 months; 36% of patients not knowing any telephone number they can call in case of worries or questions about their condition or treatment; 39% not remembering any particular accompaniment treatment (visits or calls from nurses or doctors for example). for adverse effects management, three principals actors were identified: oncologist (95%), general practitioner (52%) and pharmacist (31%). regarding the use of oral chemotherapy, patient are satisfied with: it's comfort (93%); being more actively involved in their cancer care (90%); and state not having any anxiety taking chemotherapy home (95%) . asked openly about their concerned and needs three major concepts were identified: high concern about adverse effects, positive feedback about maintaining contact with health professionals between cures and difficulties of communication between health professionals. conclusion: there is a high satisfaction regarding oral chemotherapy and health professionals. the oncologist has a primordial place in patient pathway, whereas implication of pharmacist and general practitioner stays variable. adverse effects are a major concern that needs proactive accompaniment. the variability of our results suggests that accompaniment must be flexible and adapted to the needs of each patients. the key to flexibility could be good coordination and communication between healthcare professionals. ph009: general beliefs about medicines among independent elderly adults in sweden: data from an rct lina hellström *,1,2 , victoria throfast 2 1 the pharmaceutical department, kalmar county council, 2 ehealth institute, linnaeus university, kalmar, sweden please specify your abstract type: research abstract background and objective: there is a need to improve prescription and use of medications by the elderly. the objective of a recent rct was to investigate the effects of e-learning about medicines among elderly adults. a positive impact on the primary outcome measure, knowledge about medicines, is reported elsewhere. a secondary outcome measure, general beliefs about medicines, is reported below. setting and method: the study was a randomized controlled trial in elderly people (aged c65 years). participants were recruited from patient associations and pensionerś associations. participants were randomized to either an intervention group that participated in the e-learning, i.e. internet modules with video and audio, or a control group that did not take part in the e-learning. post-intervention data was collected using paper-based questionnaires, completed within two weeks after agreeing to participate in the study. the general beliefs about medicines questionnaire (bmqgeneral), comprising the subscales necessity, harm and overuse, was used to elicit beliefs. higher scores indicate stronger endorsement of scale constructs (range [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] . main outcome measures: bmq-general subscale scores. results: a total of 195 elderly people were included in the study, 96 in the intervention and 99 in the control group. the mean age in the total population was 74.5 years and 53% were women. eleven percent did not use any prescribed drugs while 27% used more than five prescribed drugs. the patients' scores were very similar in the two groups for all three bmq subscales. the median ''overuse'' score was 12 in the intervention group versus 13 in the control group, the median ''harm'' score was 10 (iqr 8-12) in both groups and the median ''necessity'' score was 18 in both groups. in the total population the most commonly expressed negative beliefs referred to overuse of drugs. 62.4% of respondents agreed with the statement ''if doctors had more time they would prescribe fewer medicines'', 43.4% stated ''doctors prescribe too many medicines'', and 37.9% stated ''doctors place too much trust in medicines''. a majority of the respondents agreed with the four items on the ''necessity'' scale. for example ''medicines help people to live a better life (96.9% agreed)''. conclusion: the studied e-learning intervention was not shown to have any impact on general beliefs about medicines. beliefs about medicines have been associated with a number of background variables which might explain why increased knowledge about medicines alone cannot change such beliefs. in general, respondents in the study had highly positive beliefs about the necessity of medicines. nevertheless, the results indicate that overuse of medicines is regarded as a problem. ph010: maf-plus: pharmacists' contributions to provision of financial assistance for medications ian wee * , charlene ong, niron naganathar 1 changi general hospital, singapore, singapore please specify your abstract type: descriptive abstract (for projects) background and objective: the medication assistance fund plus (maf-plus) is a government scheme introduced in singapore in 2011 to provide financial assistance to needy patients who meet pre-set criteria based on means testing. unlike previous schemes, maf-plus provides broader discretion to institutions when providing financial assistance. in our institution, pharmacists reviewed patients' case and medication histories, and filed recommendations to a multidisciplinary committee tasked with approving deserving maf-plus applications. the pharmacists' contributions to the committee, and the outcomes of the applications, are presented in this study. design: all maf-plus applications received between 1st october 2011 and 31st december 2015 were reviewed. pharmacists' comments for each application, where provided, were noted, as well as the range of medicines applied for, review approval rates, and cumulative percentage of available funds utilised. the effect of a recent widening of the scheme's scope to include notable high-cost items was also evaluated. results: between 2011 and 2015, 2001 maf-plus applications were reviewed, of which 1737 (86.8%) were approved. of the 264 rejected applications, 145 (54.9%) were channelled to alternative financial assistance schemes on the recommendation of the pharmacists. the medicines most commonly applied for were intended for the treatment of cardiac (24.3%), respiratory (14.7%), and psychiatric (13.5%) conditions. pharmacists' recommendations also led to a gradual expansion of our institution's list of pre-approved medicines-from 5 in 2011-2012 to 47 by end-2015. from 2014 onwards, pharmacists previewed increasing numbers of applications for high-cost medicines, particularly those for treatment of retroviral disease, hepatitis c, and rare diseases. cumulative utilisation of maf-plus funds (inclusive of annual replenishment) rose from 3.3% in 2011-2012 to 38.8% by end-2015, representing an average year-on-year growth of 151.1%. conclusion: using a process of judicious previewing of maf-plus applications, and recommendations to the maf-plus committee, pharmacists contributed to a high percentage of patients receiving financial assistance for medications. despite a steep growth in the number of applications received between 2011 and 2015, this approach helped to prevent over-extension in fund utilisation. pharmacists will likely be increasingly relied upon due to an anticipated rise in the number of applications for high-cost medicines. please specify your abstract type: research abstract background and objective: adolescents often treat themselves and take medications without parental supervision. lack of experience and knowledge of medicines in this age group frequently leads to inappropriate use of medicines and adverse drug reactions. data about the use of medicines among slovak adolescents and their knowledge of medicines have not been studied yet. setting and method: for our study we used the questionnaire method. the questionnaire contained 23 multidimensional items with closed-ended and open-ended questions, which focused on the characteristics of the adolescentś health status, use of medicines, also in relation to parents and adolescentś knowledge and perception of medicineś risk. we distributed 930 validated questionnaires for adolescents aged from 12 to 18 at secondary schools in all regions of slovakia. response rate was 70.6%. 657 questionnaires were finally analysed. the differences in the distribution of categorical variables between groups were evaluated using the chi square test. sas 9.4. was used as statistical software. main outcome measures: to determine adolescentś knowledge of medicines in terms of efficacy, self-medication, safety of therapy and analyse which medicines are the most frequently used by adolescents. to compare adolescents with chronic disease and healthy ones from the perception of pharmacotherapy point of view. results: in the analysed group 40.8% (n = 268) of adolescents are treated for chronic disease. mostly they suffer from allergy (25.0%, n = 67) and skin diseases (6.8%, n = 18). adolescents with chronic disease use regularly prescription medicines (36.9%, n = 99, p \ 0.001) and over the counter medicines (11.6%, n = 31, p \ 0.001). this group of adolescents better accept the pharmacotherapy with parental supervision (33.2%, n = 89, p = 0.0047 vs. healthy adolescents) and they believe in effectiveness of prescription medicines (71.3%, n = 191, p = 0.0226 vs. healthy adolescents). most frequently prescribed medicines were azithromycin, levocetirizine, ofloxacin and over the counter medicines were ibuprofen, paracetamol, ascorbic acid. we found out in all group of adolescents that 81.3% (n = 534) prefer self-medication without check-ups, 73.5% (n = 483) used drugs in the last 6 months without a prescription, 51.8% (n = 340) take over the counter medications independently without the supervision of parents, 14.9% (n = 154) buy medicines themselves in the pharmacy, 44.6% (n = 293) do not take medications as recommended, 56.6% (n = 372) believe that they have enough knowledge of medicines which they take, 51.4% (n = 338) resp. 49.6%, (n = 326) believe that prescription medicines resp. over the counter medicines are safe. conclusion: questionnaire analysis pointed out that slovak adolescents have not enough knowledge of medicines. the study provides new information in the field of risk perception and adolescentś knowledge of medicines in the slovak republic and highlights the areas that need to be studied in the future in terms of adolescentś education. federal university of pernambuco, 6 state technical school prof. agamenon magalhães, recife, pernambuco, brazil please specify your abstract type: research abstract background and objective: the effectiveness of tuberculosis (tb) control programmes depends critically on patients completing appropriate treatment. this study aimed to outline the cure and discontinuation rates of patients enrolled in the pernambuco tuberculosis control program (pect), based on dispensing data. setting and method: the study was carried out in three sites in recife public health system, brazil, designated a (one polyclinic plus eight general practice units), b (one hospital for medium-complexity patients) and c (one hospital for high-complexity patients). data were collected between 07-11/2014, through reports from the stock management software for public pharmacies (horus) for pect outpatients. reports corresponded to a total of 948 patients (232, 348 and 368 in sites a, b and c, respectively). horus defines ''cure'' as medicines collection for three, six or nine consecutive months without interruption, depending on the treatment scheme; discontinuation is defined as non-sequential collection of medicines or treatment interruption for two consecutive months or more. patients were assigned an ''undetermined'' status if treatment was ongoing. data were inputted onto an excel spreadsheet and checked for accuracy. quisquared test, fisher's exact test and bootstrap analysis were performed with r statistical computing. ethical approval was granted. main outcome measures: cure and discontinuation rates for pect outpatients. results: demographic data are not available for the sample. rates for cure were respectively 35.9% (83), 23.6% (82) and 31% (114) in the sites a, b and c, while rates for treatment discontinuation were 3.4% (8), 27.8% (97) and 9% (33), respectively. discontinuation rates were significantly different among the sites a, b and c (p \ 0.05). bootstrap analysis showed that overall the proportion of patients with an ''undetermined'' status in each site did not significantly change these differences. conclusion: only site a had an acceptable discontinuation rate, in light of the world health organization recommendations. this deserves attention as default treatment leaves patients infectious for longer, increases the risk of poor outcomes and fosters resistance to antibiotics. pharmacists could use dispensing data to signal tb patients at-risk of discontinuation, and subsequently tailor interventions addressing its causes. site b had the greater number of patients which discontinued treatment. patients co-infected with tb and hiv are firstly referred to this site, which may explain this finding. our findings suggest the need of more intensive interventions in patients co-infected with tb and hiv, such as pharmaceutical care programmes. please specify your abstract type: research abstract background and objective: many efforts are done to organise good quality and safe pharmaceutical care. in general, the involvement of a hospital pharmacist or hospital pharmacy personnel in the process of medication reconciliation results in a reduction of the number of medication discrepancies. however, in case of emergency admissions this topic is still insufficiently studied. the introduction of good medication reconciliation on the emergency department (er) requires firm logistical and organisational efforts. we investigated the effects of a drug reconciliation intervention by pharmacy personnel during emergency admissions in order to identify discrepancies between medication lists taken by er physicians and by pharmacy personnel. setting and method: this observational, comparative, non-randomised intervention study was performed in 2011. we calculated that a population size of 65 patients was sufficient to perform reliable measurements. inclusion criteria: all patients presented at the er and admitted to a hospital ward \24 after presentation with usage of one or more prescription drugs. exclusion criteria: age \18 years, residency outside the region delftland, inability to undergo an oral interview, absence of a medication list of the public pharmacy (ozislist), decease of the patient during er-stay and patients undergoing surgical procedures. discrepancies between both medication lists taken by an er physician or pharmacy technician were classified in four categories of increasing severity (1 = no discrepancy to 4 = clinical relevant discrepancy) using the index of the national coordinating council for medication error reporting and prevention (www.nccmerp.org). discrepancies were categorised by a panel consisting of a pharmacy technician, a (senior) hospital pharmacist and a 6th year pharmacy student. statistical analysis was carried out with a statistical software package (spss 18) using the mann-whitney u test and chi squares test. main outcome measures: during the intervention measurement we analysed the reconciliated medication by comparing the er's physician's list with the list of the pharmacy technician after a medication verification interview. the number of discrepancies were measured and judged by the panel. discrepancies were given a category 1, 2, 3 or 4 as defined. results: during the intervention measurement 768 patients were admitted to the er. sixty-five (65) patients (8.5%) met the in-and exclusion criteria. the number of medication discrepancies decreased significantly after intervention of the pharmacy technician by 52%, from 161 to 77 discrepancies. the average number of discrepancies per patient after intervention decreased by 68.0%, from average 2.5 to 0.8 discrepancies per patient. conclusion: medication verification by pharmacy personnel in the er reduces the number of medication discrepancies by half. medication lists generated with a standard interview by pharmacy technicians in combination with an ozis-list on admission of patients at the er is more complete and accurate than the current method. hp-pc015: discharged patients: a problem for community pharmacists? information transfer, as well as the role, needs, and objectives of pharmacists when they care for recently discharged patients. setting and method: a focus group was conducted with a sample of six community pharmacists from personal contacts to represent different characteristics. the focus group consisted of different questions and the recording was transcribed, fragmented and categorised. based on these results, a nationwide online-survey was created with the following questions: a) responder's characteristics, b) number and origin of prescriptions, c) role fulfilment of the joint-who/fip-guideline on good pharmacy practice, rated with a 5-point likertscale, d) 30 information items derived from the focus group discussion grouped into four categories and evaluated for their availability and for their usefulness by likert-scales, e) goals for discharge optimisation, f) additional comments. the questionnaire was piloted and translated forward and backward to french and italian by native speakers. it was sent to all managers of pharmacies belonging to the swiss pharmacist's association in summer 2015 (n = 1348). main outcome measures: conclusions from focus group discussion and responses to questions a-f from the nationwide questionnaire. results: the focus group participants (47.3 ± 13.7 years, 50% female, 50% employees) emphasised the importance of an expanded information transfer, especially for medication changes, unclear prescriptions, and information about a patient's medication acquisition. they were concerned about their extensive workload of discharge prescriptions, and mentioned treatment continuity as one of their goals. the questionnaire was answered by 194 pharmacists (response rate 14.4%, 49.7 ± 10.8 years, 50.5% female). there were 56.7% of responders who reported to fulfil their role (to manage a patient's therapy, function b) not satisfyingly. unavailable but essential information were allergies and the specification of off-label use prescription. unavailable although desired information were the reasons for therapy changes, indications, appointments, contact information, or compounding formulations. concerning design and transfer, information should be written in a structured way but no clear preference for a transfer method was found. goals of community pharmacists were: improved treatment continuity, patient safety, and pharmaceutical care. conclusion: swiss community pharmacists rarely receive sufficient information on discharge prescriptions. appropriate pharmaceutical care is therefore impeded. the knowledge and application of the findings enable directed optimisation of discharge. hp-pc016: patients attitude for using antipsychotic medication in the norwegian early intervention in psychosis, tips 2 study rafal yeisen *,1 , stein opjordsmoen 1,2,3 , inge joa 1,4 , jan olav johannessen 1,4 , jone bjørnestad 1 on behalf of centre for clinical research in psychosis, psychiatric division, stavanger university hospital, stavanger, norway background and objective: poor drug adherence in patients with psychosis leads to relapse, re-hospitalization, poor outcome and increased consumption of health services. pharmacoclinical studies have demonstrated that the treatment response decreases with each relapse. it is estimated that 50% of patients suffering from chronic illness are not taking medication as prescribed after 6 months. the purpose of this study is to investigate which experiential factors that potentially might affect adherence with medication in adults with psychotic disorders. setting and method: in a descriptive qualitative sub-study in the ongoing norwegian early intervention in psychosis, tips 2 study, where twenty-first episode patients (7 male, 13 female) participated in semi-structured interviews 2 years after inclusion. they were still using or had used antipsychotics during the last 2 years. data were analysed using interpretative phenomenological analysis. main outcome measures: adherence to antipsychotics. results: the data suggested four main themes, reflecting the patients' subjective experiences and their impact on the desire to adhere to antipsychotics: (1) admission experience as a psychotic's patient; (2) information from healthcare staff; (3) limited involvement in decision-making; (4) attitude to antipsychotics. conclusion: a number of factors had a positive influence on adherence to antipsychotics. pleasant admission/stay experiences, feeling that antipsychotics had therapeutic effects, mild or no side effects, and believing that antipsychotics are necessary and useful, were typical statements. please specify your abstract type: research abstract background and objective: the hospital-to-home transition is a vulnerable stage in a patient's care. patients can experience problems with medication supply, which possibly lead to therapy interruptions. the objectives of this study were to investigate medication supply after discharge, and patients' and physicians' opinions about the current discharge process and possible optimisations. setting and method: a telephone interview was conducted with 100 discharged patients from the surgical and internal medical wards from the cantonal hospital in baden (switzerland). inclusion criteria were: patients c50 years old, discharged home with a discharge prescription. patients were called between the 2nd and 6th day after discharge and a piloted, structured interview was performed, consisting of questions on experiences and optimisations. afterwards, semi-structured interviews were conducted with five physicians from the study hospital. results from patient interviews and the general discharge process were discussed. main outcome measures: proportion of filled prescription, frequency and type of supply problems including therapy interruptions. opinions of physicians and patients on current discharge process and possible optimisations. results: discharged patients were 65.6 ± 17.4 years old, 39% female, 53% from internal medicine, and 97% regularly visit the same pharmacy. of the 100 interviewed patients, 23 have not filled their prescriptions yet and 77 had their prescription filled when they were called. of these, 78% of them visited the pharmacy on the day of discharge, but it took up to the 6th day until all of them received their medication. supply problems were encountered by 14 patients (18%), mainly because of the medication not being in stock in the community pharmacy. only four patients experienced therapy interruptions, which took up to the 3rd day post-discharge. patients discharged from internal medical wards had more supply problems compared to surgical wards (relative risk = 5.56, p = 0.007). patients experiencing supply problems had statistically significant more medicines on a daily basis (8.0 ± 4.32 vs. 4.9 ± 3.04, p = 0.010). physicians were surprised about the late prescription filling and worried about the disease outcomes. however, interruptions were interpreted as unfrequent. when asked if, in future, hospitals should transfer prescription to the community pharmacy prior to discharge, 71% of patients refused and physicians were undecided, mainly because of a questionable benefit. but both groups indicated that giving some bridging supply would be welcome. conclusion: this study showed that patients discharged from a swiss hospital encounter supply problems, but therapy interruptions are seldom. giving some bridging supply was preferred over an early information transfer by patients and physicians. interventions should consider these opinions and focus on internal medicine patients with high number of medication. please specify your abstract type: research abstract background and objective: adherence to secondary prevention evidence-based medical (ebm) therapies for patients with st-segment elevation myocardial infarction (stemi) is essential to reduce long-term rates of major adverse cardiovascular events. current guidelines recommend the long-term use of low-dose aspirin, highintensity statins, angiotensin-converting enzyme inhibitors (acei)/ angiotensin receptor blockers (arb) and beta-blockers (bb), in addition to p2y 12 inhibitors for 1 year. we aimed to assess the adherence to secondary prevention ebm therapies from discharge to one-year follow-up among patients with stemi undergoing primary percutaneous coronary intervention (pci) in contemporary practice. setting and method: observational single-centre study including consecutive patients with stemi undergoing primary pci in a tertiary hospital in switzerland over a one-year period. secondary prevention ebm therapies were assessed at discharge and at one-year follow-up. main outcome measures: prescription of key secondary prevention ebm therapies (aspirin, p2y 12 inhibitors, statins, acei/arb and bb) from discharge to one-year follow-up after stemi. bb was recommended only for patients with heart failure or left ventricular ejection fraction (lvef) \40%. results: a total of 179 patients were included. ebm drug prescription at discharge was 99.4% for aspirin (n = 178), 97.8% for p2y 12 receptor inhibitor (n = 175), 97.2% for statin (n = 174), 93.9% for acei/arb (n = 168) and 87.5% for bb (n = 28, among 32 patients with lvef \ 40%). ticagrelor (84.6%) was the major p2y 12 inhibitor prescribed. overall, 25 ebm drugs were missing at discharge, with 13 of these missing drugs having no justification for no-prescription (contraindications, allergy or intolerance). at one-year follow-up (median 13.4 months, n = 156), aspirin, statins and acei/ arb prescription rates were 92.9% (n = 145), 92.3% (n = 144) and 82.1% (n = 128) respectively. 19 out of 23 patients (82.6%) with lvef \ 40% received a bb. among patients treated with ticagrelor at discharge, 31 (23.5%) were receiving ticagrelor at follow-up, whereas 21 (15.9%) were switched to another p2y 12 inhibitor. among patients who discontinued ticagrelor (n = 80, 60.6%), duration of dual antiplatelet therapy was 12 months for 80% (n = 64) and discontinued prematurely (\1 year) for 15% (n = 12) patients. reasons for ticagrelor early discontinuation or switch were not specified. conclusion: in a real-world cohort of patients with stemi undergoing primary pci, prescription of recommended secondary prevention medications at discharge is excellent. adherence to ebm therapies at 1 year remains high with more than 80% of patients receiving all ebm drugs. early discontinuation of dual antiplatelet therapy was observed in 15% of patients, whereas ticagrelor was switched for another p2y 12 inhibitor in 15.9% of patients. these observations highlight key opportunities to improve longitudinal use of secondary prevention therapies after stemi in routine clinical practice. although side effects are less common than traditional chemotherapies, certain ones such as pain, fatigue, nausea and vomiting can still be bothersome. in oncology outpatient clinics, side effects are monitored by oncology nurses; however due to high patient turnover and limited numbers of nurses, the assessment of side effects might not be performed adequately. therefore, aim of this study was to determine side effects of immunotherapy and targeted therapy and to compare the severity assessment of side effects by clinical pharmacist and nurses. setting and method: the study was conducted in the hacettepe university oncology hospital outpatient clinic. the patients who have been taking ipilimumab, nivolumab, pembrolizumab, bevacizumab, panitimumab or cetuximab during october 2015-march 2016 were included. the assessment of side effects were undertaken by a clinical pharmacist and nurses separately on each visit using the common terminology criteria for adverse events version-2 toxicity assessment scale. an independent clinical pharmacist compared the side effects' assessments by pharmacist and nurses for analysis. ethical approval was obtained from hacettepe university ethics committee. main outcome measures: to compare the severity of side effects of targeted drug therapies which were assessed by a clinical pharmacist and nurses. results: during the study period 204 visits of 43 patients were evaluated. a total of 5508 side effects assessments were recorded. among those assessments 909(16.5%) was assessed in different ranking by nurses and pharmacist. the differences in the number of assessments were mainly seen in criteria related to pain (n = 34; 51), sensory loss (n = 24; 59), fatigue (n = 114; 26), stress (n = 16; 28), insomnia (n = 18; 28) which was performed by nurses and pharmacist respectively. other side effects detected only by clinical pharmacist were oedema, cough, gastrointestinal complaints (heartburn, cramp) and sensitivity of odour which require close monitoring and in-depth counselling by clinical pharmacist. conclusion: this study explores the differences in assessment of side effects by pharmacist and nurses in targeted therapies. routine assessment of side effects between chemotherapy cycles might yield to misinterpretation or inadequate assessment due to workload of outpatient clinic. therefore, inter-professional interactions in outpatient clinics might close the communicational gaps and improve patient care. hp-pc021: implementation of clinical pharmacy in the acute psychiatric wards: improving quality of medical treatment across health care sectors amila zekovic *,1 , signe kristensen 1 , lisbeth lund pedersen 2 1 clinical pharmaceutical services, capital regional pharmacy, 2 head of clinic, mental health services, copenhagen, denmark please specify your abstract type: descriptive abstract (for projects) background and objective: a study from 2011 shows that people with a mental disorder had a two-to threefold mortality compared with the general population in denmark. life style diseases are the major reason for the excess mortality, partly due to undertreatment of physical disease and well known side effects from medicines such as obesity, diabetes, and heart disease. in may 2015, a clinical pharmacy service (cps) was implemented in all acute psychiatric wards (apw) in the capital region as a part of a three-year project funded by the danish health authorities. the objective is to illustrate how the implementation of clinical pharmacy in the apw in copenhagen increases the focus on drug related problems, rational pharmacotherapy and side effects, increasing the quality of medical treatment and patient safety across health care sectors. design: data was collected at the apw in copenhagen which consists of three wards and has a total capacity of 39 beds. inclusion criteria were patients to which two or more of the following apply: • c65 years of age • c6 drugs • high risk drugs (clozapine, sertindole and opioids) • combination of antipsychotics and benzodiazepines • diagnosed with liver/kidney disease the secondary inclusion criteria were all patients receiving c6 drugs as a single criterion. to obtain a valid medication history and secure medication reconciliation, the pharmacist interviewed included patients. the patients were also asked about side effects, compliance, and perceived effects of treatment. a medication review was conducted based on the patient interview, screening for interactions in an interaction database, and consideration of biomedical data in order to evaluate if treatments should be adjusted, initiated or discontinued. the pharmacist's input was discussed with the doctor, as inputs are more likely to be considered if they are communicated orally. finally, all inputs were documented in the patient's journal as a pharmacist note. the model for improvement was used as a tool for implementing the cps and is being used continuously for improving the service. results: between may 26th 2015 and june 24th 2016, 2285 patients were screened at admission to the apw, of which 30.7% met the inclusion criteria (702 patients). in this period the pharmacist conducted 475 notes, indicating that 67.7% of the included patients were seen by the pharmacist. in april 2016, 30 patients were in average admitted with 8.3 drugs and 1.5 inconsistencies between the hospital's medication orders and the medications that the patient had been taking. regarding patients who are discharged to community care shortly after admission, the pharmacist note is sent to their general practitioner for follow up. conclusion: overall, the implementation of a cps in the apw has been successful. medication reconciliation ensures that the patient is provided with correct medicine at admission, transfer or discharge. by performing a thorough medication review based on a consultation with the patient, the service contributes to an increase in quality of medical treatment. please specify your abstract type: descriptive abstract (for projects) background and objective: the importance of the role of a clinical pharmacist resident in the operating room during 6 months, in a private hospital belonging to a group devoted to healthcare for over 70 years. the hospital is recognized as a reference centre of excellence of hospital care in portugal. it has 145 inpatient beds, two surgical blocks with 9 rooms and 12 beds in the intensive care unit. the aim of the clinical pharmacist in the operating room is to ensure compliance with good clinical practice, safety and pharmacotherapeutic effectiveness, as well as optimization of drug costs. design: 1. logistics restructuring of pharmaceutical services and the need of the physical presence of the pharmacist in the operating room. 2. furthermore, the workstation of the pharmacist is moved to the operating room and the in-depth study of all medicines used in the operating room. 3. in compliance with the joint commission, definition, optimization and adjustment of drug stocks to the needs of the service itself. in close collaboration with the nursing staff, consumer kits were created for registration of drugs by type of surgery in order to facilitate registration and ensure billing efficiency. control of the analgesic drug's dispensation circuit in hospitalized surgical patients that stay less than 24 h in the hospital. ensure compliance with the project through which the health regulatory authority evaluates several hospitals in the country, creating a national ranking among hospital specialties. 4. clinical phase: creation of prescription protocols by type of surgical intervention based on national clinical guidelines. validate prescriptions in the intra-surgical block in compliance with antibiotic prophylaxis, antiemetic and thromboembolic, checking deviations in therapy according to good practice. identify pharmacologic hypersensitivities of patients by consulting the clinical process and anaesthesiology records. provide information on drugs, drug efficacy monitoring and adverse drug reactions in risk management platform. check off label use of drugs. results: of a total of 772 interventions, 360 relate to revenue optimization and 412 relate to clinical interventions. there was an increase of approximately 25% in billing. on what regards to clinical interventions, the majority of them showed deviations from good clinical practice. the physical presence of a clinical pharmacist in the surgical block is essential as the prescription and administration of drugs is carried out simultaneously, allowing immediate therapy validation, in order to increase the safety and efficacy. the pharmacist has the ability to interact with the multidisciplinary team, as well as monitoring the patient's clinical process, the pharmacotherapeutic profile and drug allergies, allowing the detection of any adverse drug reaction on-time. all these interventions are possible in the pre, intra and postoperative phases. results: counselling (av.(±sd) duration: 9 ± 4 min) was performed in 773 patients (57.9% female; av.(±sd) age: 51.7 (±21) years; av.(±sd) medicines at discharge: 5.4 (±3.9)). in 30% of patients mrps were intercepted. the five most common mrps (%) were: need for organisational support (30.5, e.g. proper prescriptions' writing), therapy-related discussions (14.6), untreated indications (12.8), errors in documentation (11.1), and medicines without an indication (9.7). 437 patients (56.5%) classified for study inclusion, of whom 157 (35.9%) consented to be followed-up and 113 (72%) provided data. roughly 80% of patients report having received information about medicines at discharge, of which three-fourths remember being informed by the pharmacist. more then every second patient (54.7%) reported having received valuable new information. changes in chronic-use medicines occurred in 40.6, 42.4, and 34.5% of patients at 1-, 3-, and 6-month, respectively. at 6-month, in 27.4% of patients chronic-use medicines were newly prescribed, in 23.9% discontinued. medical specialists initiated these changes in 72.8% of patients. one out of five patients couldn't recall the reasons for changes in medication. nearly 30% of patients showed moderate to little medication adherence at 6-month. it did not significantly change during the follow-up period. conclusion: clinical pharmacists' counselling prevents mrps at the transition from hospital to home. follow-up data show that changes occur in one out of three patients. medication adherence remains stable, but generally needs to be improved. please specify your abstract type: research abstract background and objective: until 2013, prescription analysis was based in our hospital pharmacy. clinical pharmacy has been deployed in care units since 2014. many clinical pharmacy services were developed: medication reconciliation, patient's therapeutic education and counselling, and prescription analysis unit based. the purpose of this study is to assess the impact of the clinical pharmacist as a direct patient-care team member on prescription analysis. setting and method: we collected pharmaceutical interventions (pis) of the first 6 months of 2013 and at the same period of the year 2015 in the neurology unit when the pharmacist was unit based. we studied and compared type of pis (medication, drug related problem-drp), rate of pis acceptance and clinical impact. focus was made on high alert risk medications and potentially inappropriate medications. 4.5% in 2015 versus none in 2013. when prescription analysis was based in the pharmacy unit, 31% of drp detected by the pharmacist had a potential clinical impact versus 59% when the pharmacist performed prescription analysis in the care unit (p \ 0.05). three drp detected in 2015 had serious potential harm. results: ward-based prescription analysis allowed detecting five more times drp with a significant more important clinical impact than pharmacy unit based prescription analysis. the clinical pharmacist as a direct patient-care team member is more efficient in detecting serious potential harm. indeed, the pharmacist has a greater knowledge of the patient's clinical condition. nevertheless the global rate of acceptance of pis was greater when the prescription analysis was based in the pharmacy unit even if the difference is not significant. but prescription analysis is more complex when performed in the care unit, taking account adherence of the patient, and potentially inappropriate medications resulting in much higher risk-taking by the ward-based pharmacist. conclusion: this study showed that unit based prescription analysis is the best way to detect drug related problem. it must be competed by medication reconciliation and medication review to improve medication safety process. hp-pc027: qt-prolongation in an acute psychiatric setting: fact or fiction? eva jacxsens *,1 , hans van den ameele 2 , jü rgen de fruyt 2 , yves vandekerckhove 3 , frank vancoillie 1 , veerle grootaert 1 1 pharmacy, 2 psychiatry, 3 cardiology, az sint-jan brugge-oostende av, bruges, belgium please specify your abstract type: research abstract background and objective: several psychotropic drugs can induce qt-prolongation, which is a well-known risk factor for developing torsade de pointes (tdp) and sudden death. the clinical relevance of this side effect of psychotropic medication remains unclear, especially in patients hospitalized in an acute hospital. to interpret the clinical importance of psychotropic drug induced qt-prolongation, we investigated the prevalence of these electrocardiographic changes. setting and method: a prospective study was conducted on four psychiatric wards in a general hospital: two acute, short-term psychiatric units (asp1 and asp2), one addiction service unit (asu) and one geriatric-psychiatric ward (gpw). all adult patients admitted between october 1st 2015 and march 15th 2016 on a psychiatric ward were eligible for inclusion. at admission, an ecg (ecg0) was performed and creatinine and potassium levels were measured. a second ecg (ecg1) was performed at least 7 days after the start of a psychotropic drug associated with a risk of qt-prolongation. qtcprolongation was defined as 470 ms for males and 480 ms for females. clinically relevant qtc-prolongation was defined as c500 ms. statistical analysis (r software) was done as appropriate. main outcome measures: prevalence of psychotropic drug induced qtc-changes and correlating factors. results: 268 patients (mean age 55 years, 59%female) were enrolled in the analysis. in 85 patients, an ecg1 was performed. qtc 0+1 were prolonged in 2.3%(5/220) of females and 3.7%(5/136) of males. no clinical relevant prolongation (c500 ms) was registered. higher qtc intervals were measured in the geriatric population. 28.5%(36/126) of all measured qtc were situated between [450 c qtc 0+1 b500 ms] in gpw versus 9.4%(22/233) in the other units. significant difference in qtc-changes was associated with sex (p = 0.02246). there was no correlation assessed between qtc-prolongation and age, number of psychotropic drugs or a specific single psychotropic drug (p [ 0.05). conclusion: in this study qtc-prolongation due to psychotropic drugs is less common than previously described. ecg monitoring may be unnecessary in the follow up of patients without risk factors and could reduce hospital and community costs. however, considering the potential harm associated with tdp, qt-prolongation should be avoided. we recommend recording an ecg before the start of a qt-prolonging psychotropic drug in risk patients: patients with a chronic alcohol or drug addiction, a cardiac history, on concomitant therapy with at least two qt-prolonging psychotropic drugs, or geriatric patients ([65 years). hp-pc028: implementation of medication reconciliation aase m. raddum *,1 , anne-lise sagen major 2 1 sykehusapotekene i midt-norge, sjukehusapoteket i å lesund, avd. volda sjukehus, volda, 2 sykehusapotekene i midt-norge, sjukehusapoteket i å lesund, å lesund, norway please specify your abstract type: descriptive abstract (for projects) background and objective: a correct and accurate medication list should accompany patients at transitions in care from one setting to another, including admission to hospital. complete information on drug use is a prerequisite for all hospital treatment, whereas incomplete information represents a potential patient safety risk. medication reconciliation is defined by the world health organization (who) as ''…the formal process in which health care professionals partner with patients to ensure accurate and complete medication information transfer at interfaces of care.'' the objective of this study was to investigate the quality of the medication history obtained for admitted patients. furthermore, measures to improve the quality of medication histories, i.e. implementation of medication reconciliation, were initiated. design: the study included patients admitted to the internal medicine ward. a comprehensive medication history was determined by performing a standardized patient interview and/or by using relevant sources of information. the primary endpoint was discrepancies between the medication history obtained on admission and the one determined prospectively by a clinical pharmacist. the clinical relevance of the discrepancies was not determined, but sorted according to six major categories, such as: medication not in chart, but patient reports using (omission) and medication in chart, but patient reports not using (commission). further on, in order to minimize the risk of discrepancies, it was focused on implementation of medication reconciliation. a campaign was initiated, where a clinical pharmacist held information meetings regarding the medication reconciliation procedure. for the next 9 weeks, the degree of medication reconciliation was recorded. to spur the degree of medication reconciliation, each ward's weekly numbers were published and the ward with the highest degree of medication reconciliation won a prize. results: among the 74 patients included, a total of 120 discrepancies were revealed. in summary, 50 patients had at least one discrepancy in their medication history, resulting in discrepancies in the medication lists of 68% of the included patients. at the start of the study, the level of medication reconciliation varied among the wards (23-54%), while at the end of the study the levels were increased (75-92%). conclusion: all the included wards improved their level of medication reconciliation during the study period. however, these new combinations have potential drug-drug and herb-drug interactions which can affect the safety and effectiveness of the treatment. in our clinical practice, the clinical pharmacist provides patient education about direct acting antiviral drugs (daa) based-regimens, promotes medication adherence and manages potential interactions with hcv treatment. the aim of the present study was to determine the prevalence of use of herbal products in the patients on hcv treatment, and to describe the potential hepatotoxicity of the herbal products and their interactions with hcv treatment. design: we included all adult patients on daa treatment for hcv who were dispensed drugs from 01/09/2014 to 31/12/2015. we retrospectively recorded demographic data (age and gender), clinical data related to hcv infection (hcv genotype, fibrosis stage, daa regimen and treatment outcomes) and type of herbal products consumed. we then assessed the presence of herb-drug interactions and the potential hepatotoxicity of herbal products. results: we obtained data from 359 patients on daa-based treatment for hcv. the prevalence of consumption of herbal products prior to starting the treatment was 20.61% (74/359). the most consumed herbal products were (prevalence [ 10% among herbal products users): milk thistle, green tea, chamomile, valerian, pennyroyal, boldo and artichoke. we detected four herbal products with potential hepatotoxic effects according to the literature: milk thistle, green tea, pennyroyal and aloe vera. the prevalence of consumption of these hepatotoxic plants among herbal products consumers were, respectively: 21.62, 17.57, 13.51 and 5.41%. we detected herb-drug interactions or potential for hepatotoxicity in 47 out of 74 patients who consumed herbal products. the management of these potential interactions consisted of stopping the herbal product before starting the hcv treatment. conclusion: the consumption of herbal products in our hcv patients was frequent. the management of potential interactions was conservative, recommending to stop herbal products. clinical pharmacists have an important role in the counselling, detection and management of potential herb-drug interactions and herbal products-related hepatotoxicity. poster discussion forum iii: hospital pharmacy and pharmaceutical care 2 please specify your abstract type: research abstract background and objective: anaemia is a common comorbidity of chronic kidney disease. intravenous (iv) iron is used when oral iron formulation became insufficient or to reduce the use of erythropoiesis-stimulating agents (esas) in haemodialysis (hd) patients. the lack of generic group for iv iron sucrose (is) preparations leads to a controversial issue about their clinical effectiveness. in this study, we evaluated the effectiveness of original is compared to is similar (iss) in hd patients. setting and method: a retrospective monocentric observational cohort study was conducted from 01/09/2014 to 31/08/2015, in a stable hd population to compare is and iss. the follow-up periods lasted 24 weeks and were separated by a one-month wash-out period. original is and iss were administered respectively during the first (p1) and the second (p2) periods. the comparisons were performed using the paired student's t test or the paired wilcoxon test for continuous data and the fisher's exact test for categorical data. main outcome measures: the main endpoint was the difference in haemoglobin (hb) levels between p1 and p2 per patient. anaemia parameters (serum iron, serum ferritin, transferrin saturation ratio), the number of transfused patients, the doses of iv is and the doses of erythropoiesis stimulating agents (esas) were compared before and after the switch from is to iss, as secondary endpoints. results: a total of 105 patients were included. there was no significant difference in mean hb value between p1 and p2 (6.78 ± 0.63 mmol/l versus 6.79 ± 0.59 mmol/l p = 0.97). anaemia parameters were significantly different between p1 and p2 (mean serum ferritin, serum transferrin and transferrin saturation ratio) with p \ 0.0001, except to the mean serum iron. the mean monthly dose of iv iron per patient and the mean dose of esas were respectively in p1 and in p2: 248.31 ± 159.18 mg versus 259.74 ± 158.92 mg (p = 0.39) and 0.46 ± 0.50ui/kg/week versus 0.59 ± 0.60ui/kg/ week (p = 0.005). transfusions occurred less frequently in p1 than in p2 (p = 0.02). conclusion: this study showed that iss was as effective as original is regarding hb levels. however anaemia parameters appeared to be in favour of is; the mean dose of esas seemed to be higher after switching from is to iss. these outcomes should be further explored using prospective comparative clinical studies. please specify your abstract type: research abstract background and objective: the pharmacy residents are sometimes up to deliver chemotherapy when they are on night or week-end duty at the hospital. a dispensation's error (delivery of metoject ò (methotrexate) for intrathecal (it) injection whereas it doesn't have the indication for this use), led us to test the pharmacy residents' knowledges about the it access in order to underscore the points to be improved. the final aim of this work is to secure the pharmaceutical care of the patient 24 h a day, 7 days a week. setting and method: an online and anonymous survey of 14 questions was sent to the 35 residents of our area. it was composed of three parts: specific general information, questions about the chemotherapy specifically (indication, maximum dose and volumes, molecules used), illustrated questions about real situation for the dispensation on duty. the answers were collected over a two weeks period. main outcome measures: we studied the rate of good answers in global and by respondent. results: twenty-five residents answered the survey, among them 60% never achieved any internship in a centralized unit of reconstitution of chemotherapy (urc). all the levels of internship are represented: 1st year (n = 4), 2nd year (n = 10), 3rd year (n = 7) and 4th year (n = 4). only 32% know where a medicine is injected intrathecally on the spinal column, 64% know on which level of the meninges. three residents think that a nurse can inject intrathecally. they also had to select the molecules which can be injected by this access: 20% answered vincristine, 8% vinblastine, 4% bortezomib; despite these three molecules are mortals if they are injected intrathecally. the majority know the indication of the it chemotherapy: prevention and treatment of cancers' meningeal localizations. sixty percent do not know that several molecules can be injected for the same patient in the same time. the maximum dose of methotrexate is known for half of the respondents, but only 28% for the cytarabine'one. only 3 residents out of 25 know that 10 ml is the maximum volume allowed to be injected for an adult. six residents would have delivered metoject ò 15 mg in pre syringe filled if a doctor had asked for an it during a night. lastly, there are only two people who know that aracytine ò (cytarabine) 100 mg must be reconstituted with sodium chloride for it use and not with the provided solvent containing benzylic alcohol. the score of the residents having already done an internship in an urc is 8.4/14 compared with 6.3/14 for those who never did. the respective scores per year of internship are 6.2 (1st year), 6.4 (2nd year), 7.4 (3rd year) and 7.9 (4th year). conclusion: results and answers have been presented in a meeting and sent to the residents. we initially note many gaps in knowledge. the residents who already worked in an urc and the elders got better results. all the residents could be on duty at the hospital and all must be formed. a second session will be organized in a month to evaluate the formation's impact. it also has been presented to the assistants during an interactive lesson. this formation is essential to guarantee the dispensation of the adequate product and a secured medical care of the patient. please specify your abstract type: descriptive abstract (for projects) background and objective: patient adherence to prescribed medications is crucial for reaching metabolic control goal. to better understand the impact of polypharmacy on medication adherence, we undertook a detailed survey of medication use among patients with endocrinologic diseases. the aim of this study was to determine medication adherence in a cohort of patients with endocrinologic diseases and to test the hypothesis that adherence decreases with increased number of medicines prescribed. design: we conducted structured interviews to determine self-reported adherence of patient on a scale of 0 (high) to 4 (low observance) (srap-4) and a measurement using morisky medication adherence scales . demographic and medication information were collected from medical record. for statistical analysis, mann-whiney u-test for continuous variables, with chi square for categorical variables and kendall test for correlation were used. results: our cohort included 149 patients, 52% were women and 76% were diabetic (65% suffering from type 2 diabetes). the mean age was 56 ± 14 years, the average number of medication was 7.3 ± 4.1. 53 (36%) patients were not able to estimate their adherence. patients reported srap-4 scale with an average of 1.1 ± 0.9, this estimation was significantly higher than mmas-4 with an average of 0.9 ± 0.9 (p \ 0.05). the proportion of adherence level were identical between srap-4 and mmas-4 with respectively 51 and 60% of high, 45 and 35% of medium and 4 and 5% of low adherence. a significand correlation between srap-4 and mmas-4 scales (r 2 = 0.58, p \ 0.0001) was found. however no correlation between adherence scale and number of treatment (r 2 = 0.0001 for mmas-4 and 0.01 for srap-4 scale) nor number of daily doses (r 2 = 0.0011 for mmas-4 and 0.016 for srap-4 scale). on the 1080 medications, 11% presented difficulties with observance. cardiovascular (34.5%), diabetes (25.9%) and psychiatric (13.8%) treatment are the three most involved drug classes in nonadherence. conclusion: in this cohort, patients reported high medication adherence. we highlighted a correlation between srap-4 and mmas-4 scales. surprisingly, we didn't find correlation between adherence scales and number of treatment or dose by day. the next step of this work will be the identification of risk factor of nonadherence using logistic regression analysis. hp-pc033: the office of access to healthcare: how to optimize secured access to treatments? claire chatron, adeline flatres, claudine hecquard, guillaume saint-lorant * , alexandra muzard pharmacy, chu caen, caen, france please specify your abstract type: research abstract background and objective: office of access to healthcare (oah) is an organization which offers a medical and social coverage to people who can't access to care and to medication because of the absence of social welfare, living conditions, or financial difficulties. medications are free dispensed thanks to retrocession activity in hospitals pharmacies. the aim of this study is to analyse this activity and to improve communication with patients and access to treatments by an adapted pharmaceutical interview. setting and method: this study includes all dispensations of year 2015. in order to get medications in our hospital, a social worker and the patient come at the hospital's pharmacy. one people of retrocession team (four assistants, two externs, two residents and two pharmacists) dispenses necessary drugs to the patient according to hospital drug formulary and operating protocol. a switch or a special order can be purposed if the drug is not available. then, we give the patient a medication management plan (mmp) to explain him how to take his treatment at home. retrocession team filled a quiz about this activity and ways to improve it. main outcome measures: the main topics included in the quiz and evaluated were: dispensation organization, english talking, feeling during the interview and evaluation of the mmp. results: three hundreds and ten patients were admitted in oah 2015. these patients come mainly from the eastern europe and do not speak french in most of cases. social workers, who can help for communication, are not always present because these patients can come during on-call duty. quiz results showed that weak points occurred during the interview: explanation of the mmp, languages barriers, mention '' if needed '' not understood by the patient. explanation of the order for a particular drug was difficult to operate too. mmp were only drafted in french which was not convenient for foreign people. however, modalities of dispensation were well understood by the retrocession team. following quiz results, mmp was translated into english by the retrocession team. mentions '' if needed '', '' number of maximum tablet a day: … '', ''your medication is in order, thank you for coming to look for this treatment back to the hospital on … '', '' … is the same as …, prescribed by your doctor on your medication list '' have been added and translated. results of the study and new mmp will be presented to the pharmaceutical team and to social workers in staff. an index card for ''communication in english with a patient'' has also been drafted. it contains sentences meadow drafted in english. conclusion: access quality health care service is important to achieve health equity and to increase the quality of everyone's life. these documents improve communication with patients and by the way their understanding about their treatment. the use and the impact of these documents on well understanding will be soon evaluated with social workers and patients. hp-pc034: improve the medication in an associated to general hospital nursing home luisa alonso * , marta vidal iglesias, lucia gómez carrasco, guillermo goda, laura garcia, laura marin, ana hernandez, alvaro moreno please specify your abstract type: descriptive abstract (for projects) background and objective: in order to improve the medication reconciliation and to implement training programs for the medical team in an associated to general hospital nursing (asnh) home we measured the discrepancies between pharmacy registered treatments (prt) and medical prescriptions (mp), and we analysed potentially inappropriate prescriptions according to ''american geriatrics society 2015 beers criteria'' and ''stopp-start 2014 criteria. design: retrospective observational study that included 143 patients admitted in the asnh. the ''consensus document on terminology and classification in medication reconciliation'' was considered for discrepancy classification. data collected: discrepancies between mp and prt. in 84 patients from the original group of 143, we reviewed potentially severe drug interactions, potentially inappropriate mp and drug classes to avoid in older adults and medications to be used with caution in older adults (according to stopp-start2014 and beers 2015) . all data were registered, measured and analysed in excel ò . results: 143 patients and a total of 1487 mp were reviewed. 367 discrepancies (24.7%) were found between the medical order and the prt, those discrepancies included errors of omission in prt (11.2%), absence of discontinuation of medication (8.3%), incorrect dosage (5.2%). potentially moderate to severe interactions: the most frequent drug groups were proton pump inhibitors (ppis) (12.9%), benzodiazepines (bzds) (9.7%), oral hypoglycemiants (9.7%), other groups with frequency over 5%, oral antihistaminic, statines, low molecular weight heparine (lmwh), laxatives, calcium salts and iron salts. 176 stopp criteria were identified that affected to 440 mp and the distribution was as follows: laxative combinations (40.5%), long term ppis (15.5%), cns depressants combinations (11.4%), long half life bzds combinations (10.9%), aspirin incorrect drug strength (9.1%) and other groups with lower frequencies, nsaids and prokinetics. start criteria: 12 being all of them by omission of the drug at the time of admission. beers 2015 criteria: 90 prescriptions in the ''avoid prescription in adults'' group of which corresponded largely to concomitantly cns depressants and long term use of ppis in no risk patients. conclusion: the difficult working conditions, the excessive workload and the high staff turnover, where doctors have a patient ratio over 100/1, make difficult to update treatments according to patient daily needs. a clear communication problem between the hospital pharmacy and the asnh prescribers exists due to lack of infrastructures, and it has been demonstrated with the high percentage of discrepancy, that implies an important logistic problem (not a safety problem) since the nurse team works directly with the original medical orders. the analysis of prescriptions showed the need for updating the medical knowledge. the high volume of stop and beers criteria and lack of doctors time made impossible the individual acting upon each patient, so short summaries of continuous training related to most frequent problems have been designed. please specify your abstract type: descriptive abstract (for projects) background and objective: our french university hospital is one of the most active centre for liver transplant (100 transplants annually). various professionals are involved in the graft patient care and education. much information and education sessions are exempted before and after the transplant. the objective of this work was to realize a short movie for patients (1) to get them ready for transplant (2) to give the key messages to support their transplant (3) to make family understanding the process and to promote the life behaviour changes. design: three members of the pharmaceutical team with nurses-led care coordination and a surgeon wrote the scenario. we requested two directors for 3 days of shooting. we defined the key points for the patient and places to film, and fixed the duration (7-12 min). the scenario was validated by the chief of the liver transplant unit and nurses-led care coordination. after the 3 days of film shooting, we selected sequences. results: the movie was a succession of six parts. (1) the movie has been burned onto cds, put on flash-drives and will be uploaded on the internet. because of the international origin of our patients, the video will be subtitled at least in english. the video will be broadcast to hospitals which do not transplant patients and refer them to our hospital. since the medical team was involved in a collaborative project, the making of the video has permitted to strengthen the cohesion. indeed, this work would not succeed if everybody did not express himself. patients understood the interest to testify about their lived experience with the liver transplant, because they wished to have such information when they were waiting for the graft. conclusion: this movie is very useful for patients and families who are looking for information before and after liver transplant. it is a tool to get them into condition patients. this video presents the advantage of being personalized (local and caregivers that the patient will encounter are filmed). furthermore, it maintains a dynamic involvement of the pharmacy (already well established with clinical pharmacy, patient education and medication reconciliation) in the liver transplant unit. the making of the film has been an opportunity to bind the members of the team together, by valuing the work of everyone. the film could be screened if this abstract is selected for an oral communication. please specify your abstract type: descriptive abstract (for projects) background and objective: numerous procedures on medication management at oslo university hospital aim to minimize the risk of medication-related errors. error reports and observations show great variation in the use of these procedures, primarily due to difficulties in their implementation and maintenance. our aim was to assess the effect of a novel teaching strategy, the impala project, on doctors and nurses compliance with the medication management procedures. design: the project was carried out at 12 general medicine wards at oslo university hospital for a period of 6 weeks at each ward. assessment of medication-related error reports yielded the following areas of focus: (i) correct medication prescription, (ii) specification of doses for medications given on an ''as required''-basis, (iii) double control of medication dosing, (iv) correct and documented generic substitution. weekly presentations by pharmacist(s), lasting for a maximum of 15 min, were given to doctors and nurses as part of daily ward routines. this was repeated over 4 weeks. data on medicationmanagement procedure compliance were recorded before the start of the intervention, during and after each intervention period. the results were presented and made available to both leaders and employees throughout the project period both as an incentive to improvement and as a motivation factor for continued effort. results: there was a marked increase in medication-management procedure compliance among the nurses, especially after the second week of intervention. the most marked increase was shown for double control. increase in medication-management procedure compliance was also present among the doctors, but was less prominent. the data presented gave an extra motivational kick according to the participants. the leaders and the employees stated that the impala strategy was easy to follow and gave results without much organizational effort. conclusion: fifteen minutes presentations given by a pharmacist(s) as part of daily ward routines, combined with presentation of results demonstrated considerable improvement in medication-management procedure compliance. please specify your abstract type: research abstract background and objective: high unexpected serum vancomycin concentrations (svcs) were observed in patients without impaired renal function during the therapeutic drug monitoring (tdm) in our pharmacokinetic service. the aim of this study was to analyse the evolution of the svcs and its relationship with the markers of renal function. setting and method: retrospective study conducted at a university hospital with a follow-up period of 3 months. only adult patients having at least two tdm were selected. trough svcs were measured by cmia (architect i-1000 analyser, abbott ò ) and fitted to a two-compartment model by using bayesian analysis (pks ò , abbott). clinical and demographic data and daily dose, as well as timings of vancomycin administration and of blood sample collection were accurately recorded. spss ò , version 22.0 was used to compare data from both tdm by student t-test (parametric data) and wilcoxon (nonparametric data). main outcome measures: concentration-to-dose ratio (cdr: trough concentration *1000/daily dose); glomerular filtration rates (gfr) estimated by cockroft-gault formula; measured and predicted svcs levels. results: 30 adult patients were included (females: 20%); median age 68 [35-93] years).the first and the second tdm were carried out after 1.5 [0.5-4 .0] and 3 [1.5-6.5 ] days from the beginning of the treatment, respectively. in the first tdm, no difference was found between the measured concentrations (11.93 (5.07) lg/ml) and those predicted (12.22 (5.58) mg/l. however, predictions were less accurate in the second tdm and predicted concentrations were significantly higher svcs (15.96 (4.32) mg/l vs. 12.88 (3.70) mg/ml, p \ 0.05). the median cdr in the second tdm was significantly higher than that calculated in the first one (6.2 [2.2-13 .6] l -1 vs. 9.6 [3.3-20.2] l-1; p \ 0.05), indicating a lower clearance and a drug accumulation. however, no statistically significant differences in the glomerular filtration rates were found (114 [30-230] ml/min vs. 107 ml/min) in the first and second tdm, respectively. conclusion: although the markers of renal function did not change during the treatment, a decrease in vancomycin clearance was observed. the pharmacokinetic model does not accurately predict evolution of the svcs over the treatment. the introduction of covariates such as the length of treatment or the cumulative dose in the pharmacokinetic model could improve its predictive performance. please specify your abstract type: descriptive abstract (for projects) background and objective: genetic polymorphism or major physiological changes have to be considered in patient therapeutic management. clinical pharmacists have a role to evaluate and optimize the appropriateness and effectiveness of patient's medications. we report here the impact of the clinical pharmacist and his collaboration with the clinical pharmacologist in the therapeutic management of a patient suffered from anorexia nervosa, a psychiatric disorder leading to body composition change that may influence drug pharmacokinetics and efficacy. design: case report. results: the patient was a 35-year old woman hospitalized for chronic pulmonary aspergillosis previously treated by voriconazole, posaconazole and itraconazole. her medical history included anorexia nervosa since 1997 with a body mass index of 9.8 kg m -2 , pulmonary tuberculosis in 2011 with relapse in 2013, and chronic pulmonary aspergillosis since 2014. at admission, a treatment by oral voriconazole at 100 mg/12 h was introduced. the trough concentration of voriconazole at steady state was .1 mg/l (therapeutic range 1-4 mg/l) despite taking drug on empty stomach. although the voriconazole dosage increased in 200 mg/12 h, the trough concentration did not increase significantly (0.2 mg/l). we hypothesized anorexia led to a significant mucosal atrophy and accordingly, a significant decrease in intestinal absorption surface which is a major determinant of the level of drug absorbed. thus, a switch from oral to intravenous route was performed (voriconazole 200 mg/12 h). according to subtherapeutic voriconazole concentrations (trough concentration: 0.2 mg/l) despite the use of intravenous route, we decided to perform genotyping to look for mutations of cytochromes p450 3a4*22, 2c19*2 and 2c19*17, particularly implicated in voriconazole metabolism. the presence of an ultrarapid metabolizer genotype (17* allelic variant of the 2c19 isoenzyme) in our patient should lead to increase drug dosage from 50 to 75%. finally, the patient was treated by intravenous voriconazole at 7 mg/kg/12 h (i.e., increase by 75%). the maximum concentration performed 24 h after iv route initiation was at 2.8 mg/l, suggesting a better efficacy. conclusion: this case report highlights the potential complexity of therapeutic management in some patients given anatomical and functional changes or genetic polymorphism, which can affect drug efficacy. clinical pharmacists in collaboration with clinical pharmacologists have to be able to help physicians in this type of situations. please specify your abstract type: research abstract background and objective: posaconazole (pcz) is widely used for invasive fungal infections as prophylactic, pre-emptive or curative therapy in lung transplantation. recently, a new formulation of pcz has been available in enteric-coated tablets. this new formulation improves pcz bioavailability, as compared to the oral suspension, which leads to increase pcz plasma trough concentrations (c min ) in haematological patients. no data related to pcz exposure and its effects on tacrolimus (tac), an immunosuppressant with narrow therapeutic index widely used, exists in lung transplantation. we aimed to assess the consequences of the treatment by pcz entericcoated tablets on pcz and tac exposure in lung transplant patients. setting and method: a single-centre retrospective study was conducted among lung transplant patients receiving tac and either enteric-coated pcz or both galenic forms. main outcome measures: pcz and tac exposure were estimated by the measurement of c min . to overcome the influence of dose (d), c min were adjusted on dose (c min /d) for both pcz and tac. a spearman test (nonparametric distribution) was performed to assess the correlation between pcz c min /d and tac c min /d. results: eighteen lung transplant patients (median age [q1; q3] = 48. 5 [34.7; 57.4] years; 50% female) were included between june 2015 and march 2016. eight patients received only pcz entericcoated tablets. pcz enteric-coated tablets were associated to an increase in pcz c min /d as compared to oral suspension (0.008 ± 0.006 l -1 vs. 0.001 ± 0.001 l -1 , p \ 0.0001). overall, pcz therapy initiation led to an increase in tac c min /d (0.002 ± 0.001 l -1 before initiation vs. 0.008 ± 0.007 l -1 after initiation, p = 0.02). tac c min /d was significantly higher with pcz enteric-coated tablets, as compared to pcz oral suspension (0.004 ± 0.004 l -1 vs. 0.009 ± 0.006 l -1 , p \ 0.0001). a weak correlation was observed between pcz c min /d and tac c min /d, independently to pcz galenic form (r = 0.37, p = 0.0001 with pcz enteric-coated tablets and r = 0.33, p = 0.02 with pcz oral suspension). conclusion: this pilot study in lung transplantation confirms the better bioavailability of pcz enteric-coated tablets as compared to oral suspension. our results show a more important increase in tac exposure with pcz enteric-coated tablets compared to pcz oral suspension, suggesting a concentration-dependent cyp450 3a4 inhibitor effect of pcz. these findings are of interest in clinical practice to monitor transplant patients treated by the new formulation of pcz. further analyses, including the consideration of confounders, will be conducted. please specify your abstract type: descriptive abstract (for projects) background and objective: within 8 months, two patients receiving apixaban developed agranulocytosis. based on temporal and clinical plausibility as well as published literature, the objective was to determine the causal relationship between agranulocytosis and apixaban. design: description of two agranulocytosis cases reported in our hospital. results: first case is an 89 years old male, admitted to the neurology unit (d0) for ischemic stroke. at admission, blood count showed no abnormalities. four days after admission, treatment administered consisted in: dextrose 5% infusion iv, sodic heparin iv, acetaminophen, atorvastatin, metoprolol. neutrophils count was normal (5.6 g/l). heparin was stopped at d9 and replaced with apixaban according to following dose regimen 2.5 mg twice a day. at d15, patient presented with hyperleukocytosis (neutrophils count 15 g/l) and high crp (109 mg/l). thus, a cytobacteriological urine test was performed. at d17, patient presented with hypothermia followed by hyperthermia related to acute sepsis. blood count showed agranulocytosis (neutrophils count 0.45 g/l). broad spectrum antibiotherapy was started (ceftriaxone and gentamycin). despite treatment, death of patient occurred at d17. the suspected cause of death was septic shock added to severe febrile neutropenia. following haemocultures confirmed sepsis (e. coli) possibly originating from urinary tract infection. second patient is a 76 years old male, admitted to the cardiology unit (d0) for bronchopneumopathy associated with tachycardia and atrial fibrillation. a treatment with heparin was immediately started in association with patient usual treatment (bisoprolol, valsartan, rosuvastatin, hydrochlorothiazide and manidipine). in addition, broad spectrum iv antibiotherapy was started with ceftriaxone and spiramycine followed at d7 by an oral treatment with cefixime and spiramycine until d12. heparin was replaced by apixaban at d1 (2.5 mg twice daily). antihypertensive treatment was adapted throughout patient's stay. patient presented neutropenia at d15 (neutrophils count 0.8 g/l), followed by agranulocytosis at d19 (neutrophils count 0.42 g/l) when it was decided to replace treatment with apixaban by fluindione. the following day, neutrophils count was about 0.28 g/l and patient received filgrastim. a myelogram showed a possible peripheral neutropenia. in the absence of other confounding factors (hiv, hbv, hcv, cmv), an iatrogenic agranulocytosis related to apixaban was suspected. conclusion: causal association with heparin is unlikely as neutropenia is not an adverse drug reaction known included in the smpc of this drug having a well-established safety profile. since the two patients were taking their usual treatment for a significant period of time, a causal relationship is deemed unlikely. temporal and clinical plausibility seem to indicate a possible relationship between agranulocytosis and apixaban. as this medicine has been recently approved, this might explain why no case has been reported in the literature and the absence of agranulocytosis as an adverse drug reaction of apixaban. please specify your abstract type: research abstract background and objective: taste is tightly connected to children's acceptability of medicines. two ways to overcome lack of acceptability are to administer solid formulations which are easier to taste mask and change to better tasting medicines. dicloxacillin is an antibiotic known for its unpalatability, and taste studies suggest that this might jeopardize its adherence. the aim of this study was to explore if prescription data can be used to estimate acceptability of antibiotics among children on a population level using dicloxacillin as an example drug. the research questions were: when comparing dicloxacillin with other antibiotics commonly used in children, (1) is there a difference in the age of conversion from liquid to solid formulation and (2) is there a difference in re-prescription rates on day 1 and 2 after the initial prescription? setting and method: we included all initial prescriptions of oral dicloxacillin, phenoxymethylpenicillin, amoxicillin and erythromycin for children 0-12 years registered in the norwegian prescription database (norpd) 2005-2007 due to dicloxacillin mixture being discontinued from the norwegian market in 2007. the age of conversion was defined as the age where half of the children were prescribed liquids and the other half prescribed solid formulations. re-prescription rates were defined as re-prescriptions of a different antibiotic or formulation on day 1 and 2 after the initial prescription, divided by the total number of prescriptions. main outcome measures: age of conversion and re-prescription rates of dicloxacillin compared with other common antibiotics. results: the age of conversion for dicloxacillin was 4.5 years, compared to 7 years for other common antibiotics. the average represcription rate for dicloxacillin was 8.2% for children 0-6 years and 1.8% % for children 7-12 years. the highest re-prescription rate of 13.3% was found in 2-year olds. corresponding numbers were 2.1, 1.8 and 2.3% for common antibiotics. conclusion: the lower age of conversion from liquid to solid formulation and higher re-prescription rate of dicloxacillin mixture compared to common antibiotics indicates that prescription data can be used to identify antibiotics with low acceptability for children 0-12 years. further studies are needed to investigate if this also holds true for other antibiotics. please specify your abstract type: research abstract background and objective: attention deficit/hyperactivity disorder (adhd) or hyperkinetic disorders (hkf) is among the most common mental disorders in children, and may persist through adolescence into adulthood. pharmacotherapy used for treating the disorders also has potential for misuse/abuse. the aim was to describe the prevalence and magnitude of use of stimulant drugs and atomoxetine, and compare consumption in the nordic countries. setting and method: a descriptive pharmacoepidemiological study from the * 26 million inhabitants of the five nordic countries in the period 2004-2014. data were collected from national prescription registers, public drug reports and by correspondence with public health institutions. population data were obtained from official statistical databases or by correspondence with public health institutions. main outcome measures: trend over time, comparison between countries, type of pharmaceutical, gender, age, comparability of data. results: the annual consumption has been increasing from 2004 to 2014, both in volume and prevalence of use. denmark had the largest increase in volume, from 0.6 to 8.2 ddd/1000 inhabitants/day. sweden had the highest increase in prevalence of use over the period, from 1.6 to 8.6 users/1000 inhabitants. iceland had the largest consumption of adhd medications in 2014, 21.9 ddd/1000 inhabitants/day. prevalence data was not available for iceland but sweden was highest in prevalence of use among the other countries in 2014: 8.6 users/1000 inhabitants. males aged 10-14 years had the largest volume and prevalence of use in 2014, but females' consumption had been increasing faster both in terms of numbers of users (* 1.5 9 faster) and in volume (*29 faster) than men's consumption. conclusion: variation in consumption is considerable and cannot be explained by diagnostic and prescription guidelines, as these are similar in the five countries. consumption has been increasing fast in the period in all the countries, and faster for women than for men, although men still consume larger volumes than women, and are more frequent users. please specify your abstract type: research abstract background and objective: in 2009 and 2013, regulatory bodies in usa (fda) and europe (ema), issued warnings on use of metoclopramide due to an increased risk for serious adverse drug reactions (adr), especially neurological adrs. ema recommended that metoclopramide only should be prescribed for up to 5 days while fda concluded that treatment longer than 12 weeks should be avoided. metoclopramide is commonly used to treat nausea and vomiting in pregnancy (nvp) and deficient breast milk production (10 days course). ema did not make any recommendations concerning use during pregnancy and lactation. the objective of this study is to assess the disproportionality of reporting of adr from metoclopramide, with special emphasis on neurological adrs and women in reproductive age. setting and method: data from whos global adr database vigibase ò for the time period november 1967 to may 2016 was used. the measure of disproportionality of reporting calculated was the proportional reporting ratio (prr), and 95% confidence intervals (ci). analyses were performed according to gender and age. time-toonset of adr was calculated. main outcome measures: proportional reporting ratio (prr) results: vigibase contains over 13 million adr reports. metoclopramide is a suspected/interacting drug in 47 407 of the reports, most common (72%) are neurological adrs. the majority (84%) of the metoclopramide adrs occurred within the first 3 days of use. a total of 65% of the reports was received the last 5 years (2011) (2012) (2013) (2014) (2015) . the reporting of neurological adrs was higher for metoclopramide than other medications in vigibase. women in reproductive age (18-44 years) reported higher proportion of neurological adrs (prr = 3.0, 95% ci 2.9-3.0, n = 4533) than women 45 + years (prr = 2.5, 95% ci 2.4-2.5, n = 3057) but a similar proportion as men 18-44 years (prr = 3.1, 95% ci 3.0-3.2, n = 1823). conclusion: there is a 2.5 to three fold higher proportion of all reports regarding neurological adrs for metoclopramide than for other drugs. patients initiating treatment with metoclopramide should be informed about risks of adrs and that most adrs occur within 3 days, and instructed to contact health care personnel and stop treatment if adrs occur. please specify your abstract type: descriptive abstract (for projects) background and objective: self-induced drug intoxications (sidi) are one of the most frequent reasons of hospitalization in emergency service (1%) with around 4-5/1000 inhabitants and represent around 6% of admissions in intensive care unit (icu). it is the most frequently used method of suicide attempts (sa) and the leading cause of hospitalization for young people under 30. the main objective of our study was to analyse, stratify and pharmaceutically map the different sidi identified in our icu. design: this is a prospective study over 20 months, including all icu patients following sidi from june 2014 to january 2016. we have collected psychiatric history and previous sa by sidi, usual treatment, state of consciousness, incriminating drugs, drug classes stratified according to the clinical severity score igsii, evolution, transfer in a specialized centre and average cost of stay. results: ninety-two cases were reported, representing 6% of icu admissions. the average hospital stay was 3 days for an average cost of 3396.5€. this amount is low compared with the average cost of all stays gone through the icu for the period (14,957€). ninety percent of patients had a psychiatric history and 48% a previous sa. the usual treatment was involved in 77% of sidi. half of the patients arrived conscious with an average of severity score igsii of 35/163, 88 being the highest found for a patient who had swallowed simultaneously pregabalin and nitrazepam. clinical severity of these patients is less than that found on average for all patients in the icu in this period (59/163). eighty-seven percent had a favorable evolution. only one death was observed after ingestion of propranolol. fifty-six and a half percent of patients were then hospitalized in a specialized centre. the great family of psychotropic is the most frequent with benzodiazepines 70%, neuroleptics 36%, antidepressants 31.5% and antiepileptic 17.5%. the main drugs involved are oxazepam 16%, alprazolam 15%, cyamemazine 14%, bromazepam 13% and quetiapine 8%. antihypertensives then arrive and represent 14% of sidi. the stratification of severity scores does not appear to show significant differences between drug classes, nor between mono or polydrug ingestions. conclusion: sa by drug ingestion are very common and are often linked to risky behaviours. for these epidemiological and economic findings, it is necessary to continue and develop prevention strategies avoiding the appearance of intoxication (primary), limiting the consequences (secondary), and reducing the risk of recurrence (tertiary). please specify your abstract type: research abstract background and objective: interpretation of quality of life scores to render them meaningful to aid clinical decision-making is an ongoing challenge. interventions often result in statistically significant quality of life (qol) improvement, but may not reach the threshold of clinical importance. the minimal clinically important difference (mcid) is the minimal score change of relevance clinically. the aim of this systematic review was to assess the impact on quality of life of topical, systemic and biologic treatments for psoriasis in randomised controlled trials (rcts). setting and method: prisma guidelines were followed. all available articles describing rcts of therapies for psoriasis that included qol measurements published up to november 2014 were identified. six databases were examined with 388 search terms. abstracts of articles were reviewed independently by two assessors: a third adjudicator resolved any opinion differences. risk of bias was assessed using the jadad scale. main outcome measures: reporting of the use of qol endpoints and impact of interventions in psoriasis. results: of 3597 screened article abstracts, 329 articles were selected for detailed review: 100 trials met the eligibility criteria, describing research on a total of 33,215 patients. reports of psoriasis interventions that fulfilled inclusion criteria have gradually increased over time : 1998-2004 = 12, 2005-2009 = 33, and 2010-2014 = 55 (1) to evaluate the relationship between the use of different therapeutic agents and the severity of osa, and (2) to determine the effects of commonly used medications on continuous positive airway pressure (cpap). setting and method: patient medical records (n = 2688) of 183 patients, that underwent sleep studies between the years 2009 and 2013 were collected over an eight-month period from the sleep laboratory department at mater dei hospital using a random sampling technique. data collected included body mass index, gender, age, epworth sleepiness score (ess), drug history, apnoea hypopnoea index (ahi) and cpap therapy prescription. likelihood ratio chi square test, paired samples t-test and multinomial logistic regression were the statistical tests used for data analysis. main outcome measures: assessment of the drug history in response to osa control using the ess and ahi scores. results: one hundred and seventy (92.9%) patients of the 183 patients (131 males, 52 females) were diagnosed with osa. forty-five (24.6%), 43 (23.5%) and 82 (44.8%) patients suffered from mild, moderate and severe osa respectively. patients had a mean age of 54 years. angiotensin ii receptor antagonists (arbs) (p-value = 0.022), sulphonylureas (p-value = 0.050), insulin therapy (p-value = 0.040) and non-benzodiazepine sedating agents (p-value = 0.037) were found to be associated with the presence of osa. a decline in the use of the arbs (p-value = 0.000), angiotensin converting enzyme inhibitors (p-value = 0.000) and non-benzodiazepine hypnotics (pvalue = 0.001) was observed over the study year period. reduction in the cpap therapy benefit was detected with the use of histamine (h 1 ) antagonists (p-value = 0.015), b-adrenergic blocking agents (pvalue = 0.001) and antiplatelets (p-value = 0.003). conclusion: it is confirmed that hypertension and diabetes mellitus type ii are the main co-morbidities associated with the presence of osa. reduction in the use of certain therapeutic agents is observed secondary to cpap therapy use. patients using specific drugs have been identified as being at risk of a reduced cpap therapy benefit. please specify your abstract type: research abstract background and objective: people are using increasingly more common of social networks such as facebook, twitter and youtube for different purposes. many people are using these networks with the aim of getting information and knowledge sharing. there are many groups that pharmacist is a member in social networks at turkey. the largest of these groups has 14,000 members. pharmacists are shared common problems, information and experiences in these groups. but the accuracy of the information shared on social networks are not always conclusive. the study aim to evaluate the impact of social network information sharing in the knowledge and attitude of pharmacists. setting and method: clinical pharmacy group has been created to share information on facebook. 2400 pharmacist joined this clinical pharmacy group. the group was fed by information which include new drugs, fda alerts, adverse event and case report and also drug related problems during the 6 months. pharmacists were assigned in two major groups, group a active pharmacist who becomes a member of our clinical pharmacy group, share and discuss information through the network and group b who is not a member. a knowledge measurement survey (ams) was given to both of them. main outcome measures: acknowledge measurement survey (ams) was developed and the difference in the score was used to evaluate the difference between the two study groups. results: 142 pharmacists participated in the study, 34.50% of the participants were a member of our facebook group and 65.49% of participants were not. 4.9% of the participants have doctoral degree or student, 15.4% have master degree or student, 32% have bachelor degree from 4 year-pharmacy faculty, 47.1% have bachelor degree from 5 year-pharmacy faculty. the education level distribution between the two groups was not statistically significant. while 63.64% of the ams questions were answered correctly in the member group only 44.09% were answered correctly in the non-member group. conclusion: the study emphasizes the importance of social network in providing the accurate and fastest information for the daily use of the pharmacists, there is a significant difference in knowledge between the pharmacist who join, share and discuss information on the social network and the one who do not join. cp-ce004: impacts of a community pharmacy practice experiences on student professionalism yunn-fang ho 1,2 , hung-wei lin *,1 , fang-ju lin 1,2 , sheng-ping chang 2 , yen-ming huang 1 1 graduate institute of clinical pharmacy, 2 school of pharmacy, college of medicine, national taiwan university, taipei, taiwan, r.o.c please specify your abstract type: research abstract background and objective: professionalism is valued globally and pharmacy schools are expected to nurture competent practitioners to better serve the public with humanity attitudes and behaviours. the study aims: (1) to understand possible differences in professionalism between pharmacy students and potential community pharmacist preceptors, and (2) to evaluate student changes in professionalism upon completing the community pharmacy practice experiences (cppe) at the end of the third (p3) year. setting and method: a modified chisholm's pharmacy professionalism instrument (18-item, 10-point likert scale) was administered to p3 students, pre-cppe and hopefully post-cppe in september, and community pharmacist practitioners who participated in a two-day preceptor training workshop. participants also provided their significance ratings toward ten traits, namely altruism, accountability, excellence, duty, honor and integrity, respect for others, communication, ethics, humanism, and teamwork. main outcome measures: differences or changes in chisholm professionalism scores. results: thirty-two students and fifty pharmacists participated in the survey. honor and integrity (8.9 ± 1.5) and communication (9.2 ± 1.1) were recognized by students (31.3%) and pharmacists (23.5%), respectively, as the most significant trait. humanism was rated the lowest in both groups (students, 8.2 ± 1.9; pharmacists, 8.1 ± 1.9). the 18-item professionalism scores ranged from 6.6 ± 1.6 (''i do not expect anything in return when i help someone.'') to 9.3 ± 0.9 (''i am respectful to individuals who have different backgrounds than mine.'') in the student group; whereas 8.1 ± 1.9 (''i do not expect anything in return when i help someone.'') to 9.5 ± 1.1 (''it is wrong to cheat to achieve higher rewards (i.e., grades, money).'') in the pharmacist group. in general, pharmacists' professionalism scores were higher and, in certain items, statistically significant differences were achieved. conclusion: professionalism might grow with professional competency and practice experiences as demonstrated by potential pharmacist preceptors. upon completion of cppe, students could probably exhibit gains in professionalism. more investigations are still underway. please specify your abstract type: descriptive abstract (for projects) background and objective: in france, a significant consumption of benzodiazepines (bzd) is observed in prisons. they are widely used during incarceration to treat or prevent anxiety and insomnia. furthermore, it is known that, an important traffic exists with these drugs because of the releasing properties of bzd in case of misuse. based on these observations, the pharmacist has set up a plan to improve the use of bzd in prison. the purpose of the study was to evaluate the impact of these measures after 1 year of implementation. design: in january 2015, we shared with physicians in a meeting to explain our plan for a better use of bzd and to set up new rules of prescription in prison: • regularly reducing the dose to limit drug tolerance • promoting the use of long half-life molecules which allow reducing addiction and misuse • advising sedatives anti-histaminics to treat insomnia • providing information to patients about addictives risks of bzd on the tv channel please specify your abstract type: descriptive abstract (for projects) background and objective: some drug combinations (described in thesaurus of national agency of drug) are contraindicated because they appear to increase the risk of torsade de pointes. the aim of this work is to standardize our pharmacists' intervention and to propose guidelines for doctors and pharmacists, depending on the situation and drugs, to limit these combinations and to reduce this risk at our hospital centre (1105 beds). design: a prospective survey was realized over a period of 5 months to identify the drug combinations prescribed in medical prescription software, from the national drug agency thesaurus, that might be inducing torsade de pointes. a multidisciplinary staff was then constituted composed of a cardiologist, a geriatrician, a paediatrician, an anaesthesiologist, a psychiatrist and pharmacists to identify the different situations and to establish guidelines. results: from the survey 18 drug combinations were found to be contraindicated due to increased risk of inducing torsade de pointes on a list 415 interventions realized by pharmacists. the work group identified three drugs with a therapeutic alternative: hydroxyzine, domperidone, escitalopram, the other drugs can't be switched because they are vital or have no alternative. the work group decided to maintain hydroxyzine but only on premedication and child anxiety, to eject domperidone from our therapeutic index and substitute it with metoclopramide or metopimazine, to not initialize escitalopram but to keep it if the patient has no have others risk factors associated or no contraindication. if the patient has a contraindication with a risk factor the doctor could prescribe other ssri. in addition, pharmacists alert doctors about the risk of torsade de pointes on medical prescription software if some contraindications are identified. conclusion: the contraindications identified must not be underestimated. this work allows identification of torsadogenic drugs commonly prescribed and provides guidance for doctors and pharmacists regarding drug combinations. the collective decision will be disseminated to sensitize all the doctors in the establishment. some treatments could not be substituted despite the contraindication; these must be retained but with clinical monitoring. conclusion: a substantial proportion of medication waste in the community pharmacy could have been prevented. unused medicines in the community pharmacy are generally of low economic value, making it unlikely that the costs that pharmacies will make with the redispensing of unused medicines will be covered. therefore, other actions to decrease medication waste in the community pharmacy, such as preventing that too much medicines are dispensed, should be considered. please specify your abstract type: research abstract background and objective: flaws in usage technique for inhalationmedicines is common, as much as half of the users may need some correction measures, to get the active substances down to the lungs and provide the intended effect. inadequate compliance, especially for regular-use preventive medications, is common. good guidance in pharmacies enhances correct use of medicines. the new norwegian pharmaceuticals policy (legemiddelmeldingen) from 2015 opened up for paid cognitive services, leading to the first such service being implemented in march 2016. the service can contribute to a more correct use of the medicines and, as a consequence, lead to better control of the symptoms for patients with asthma or copd. our objective was to map the variation in pharmacies' handling of an inquiry regarding lack of effect of an inhalation-medicine. the study was done prior to the implementation of the standardized service ''inhalation-guidance'' in norwegian pharmacies. setting and method: simulated patient (mystery shopper) visits in 100 pharmacies in oslo, akershus and buskerud in november/december 2015. the mystery shopper expressed just having started to use an inhaler because of her asthma, but not experiencing effect. structured data collection sheets were used to register the handling immediately after the visit. main outcome measures: scoring of the quality and contents of the information based on the products' patient information leaflets. results: the issue of inhalation-technique was mentioned in 74 of the pharmacies, whereof 18 asked the ''patient'' to show their inhalationtechnique, in order to correct and advice and 32 used an inhaler or demo-inhaler as an aid in the guidance. going through the instructions or watching a video-demonstration with the simulated patient also occurred, or referring the patient to read the instructions and/or watch the video-demonstration on his own. half of the pharmacies discussed the difference between use for preventive treatment of asthma and inhaler that is being used for treatment of attacks. sixty-five pharmacies gave no information about the importance of regular use of the preventive treatment. conclusion: there was considerable variation in how the pharmacies guided, which indicates a potential for improvement. the new guidance-service, implemented in norwegian pharmacies in march 2016, will contribute to better guidance. please specify your abstract type: research abstract background and objective: in portugal, tobacco addiction was responsible for over 12,000 deaths in 2013 (11% of the total deaths). the community pharmacist's contribution to control this public health problem is insufficiently documented. the aim of this study is to assess the contribution of the community pharmacist for smoking cessation. setting and method: a retrospective and longitudinal study of a convenience sample of patients integrating quit tobacco consultations, as part of a pharmaceutical care programme implemented by an outsourced pharmacist was performed at several community pharmacies. the smokers, aged 18 or over, were invited to join the programme. patients signed an informed consent and were submitted to a comprehensive approach by face-to-face consultations and telephone contacts. richmond and fagerström tests were used to evaluate motivation and nicotine dependence, respectively. the therapeutic plan (pharmacotherapy and behavioural counselling) was personalised to each smoker. the quit rates were evaluated by patient selfreport and confirmed by carbon monoxide measurements. the continuous variables are expressed as mean ± standard error of the mean. main outcome measures: quit rates at 1, 3, 6 and 12 months. results: between january 2009 and june 2016, 87 smokers joined the programme, 22 dropouts (25.3%). the remaining 65 smokers, 40 (61.5%) were male, with mean age of 48.4 ± 1.91 years. on average, each smoker consumed 21.0 ± 1.53 cigarettes per day. the mean age of initial tobacco use was 15.8 ± 0.51 years with 31.4 ± 1.98 years of consumption. about 70% reported moderate or high motivation and 60% medium or high dependence. a total of 315 consultations were held and, on average, each patient received 7.3 ± 0.82 interventions. all smokers received non-pharmacological interventions (e.g. motivational approach) and 61 (93.8%) also accepted pharmacological interventions, usually nicotine replacement products. the quit day was achieved by 50 patients (57.5%). a month after quit date, 41 patients were abstinent (41.7%). the number reduced to 32 after 3 months (36.8%), to 27 after 6 months (31.0%) and to 19 after 1 year (21.8%). these data upgrade and are consistent with our previously published results (2014). the smoking cessation consultation in the scope of a pharmaceutical care programme in community pharmacy seems to effectively contribute to the reduction of tobacco addiction in portugal. cp-pc013: patient counselling at dispensing of oral anticancer drugs in european countries from the pharmacists' perspective andreja eberl * , on behalf of epic working group pharmacy, institute of oncology ljubljana, ljubljana, slovenia please specify your abstract type: research abstract background and objective: the number of oral anticancer drugs (oads) available on the market grows constantly. consequently the number of patients, which have to manage the complex treatment with oads at home is increasing. the pharmacists present an important member of healthcare team, since they are dispensing oads to the patients, which need a high quality information at that crucial moment. therefore, our aim was to evaluate pharmacists perceived confidence and needs for specific continuing education in connection to oads dispensing in european countries. setting and method: we used an electronic mailing approach and a standardized online survey to ask practicing pharmacists in european countries about their experience with dispensing of oads. main outcome measures: frequency of patient counselling and fields of counselling, assessment of knowledge and skills. results: the frequency of patient counselling varied widely in participating countries between ''never'' and ''more than 80%'' at initial fill of an oad. at following refills the frequency of counselling was generally even lower. counselling mostly encompassed directions of use, the proper use of antiemetics and side effects. however many pharmacists stated, that they do not feel comfortable counselling patients of oads (25%) and even more acknowledged that they were uncomfortable with managing patients' side effects (20%). on the other hand only 45% of pharmacists believed, that they have received adequate knowledge of oads through undergraduate program, continuing education (ce) events and professional practice. many of pharmacists (70%) have not attended any of ce events related to oncology in last 2 years. pharmacists' responses differed little between the countries. conclusion: the proportion of pharmacists who regularly counsel their patients on oads is insufficient in view of importance of the patients' needs to manage their therapy at home. however the pharmacists seems to be aware of their knowledge deficits and educational needs. the field of oads needs better coverage in under-and postgraduate education. the number of ces has to be increased in order to improve the knowledge and skills in the areas of oads counselling. please specify your abstract type: research abstract background and objective: treatment guidelines for diabetes recommend that patients are well-informed about their disease, treatments and treatment goals, e.g. glycosylated haemoglobin (hba1c). the objective was to describe diabetes patients' self-monitoring of blood glucose (smbg) and potential need of guidance. please specify your abstract type: descriptive abstract (for projects) background and objective: in 2015, the international pharmaceutical federation collected data of remuneration models for community and hospital pharmacy and identified large variations between remuneration models and highlighted that the focus is largely on products and not on cognitive services. the aim of the study is to map the remuneration models of different pharmacist-led cognitive services in primary care across europe, with a special interest on medication reviews and to update a prior survey by bulajeva (bulajeva a et al. medication review practices in european countries. res social adm pharm 2014;10:731-40.). the definition of terms is pivotal for such a european survey to avoid results based on pseudoconceptions. hereafter we present the development of the survey and we will present first results from pilot tests. design: pharmacist-led cognitive services were selected based on a previous study by our group and by searching the literature, official government websites, the pcne wiki and arising links. the definitions of the terms of these services were based on searches in the mesh browser, medline and google scholar. additionally, a search in grey literature and in the internet was conducted to find appropriate foundation for the formulation of the definitions. the questionnaire will consist, of a first part about the remuneration of the pharmacist-led cognitive services. the focus is on country-specific differences in remuneration and the different levels of supply across europe. the second part of the survey is about the different types of medication review services with a focus on e.g. the implementation level, addressed issues, eligibility criteria. this survey will have a cross-sectional study design with an online questionnaire specific for invited participants across europe. to achieve the best quality of answers we will send this survey to at least two researchers with references in pharmacy practice, in each european country (purposive sample). the answers from each country will be checked for discrepancies and these potential discrepancies will be solved by a discussion with the responders. results: by the end of the pre-pilot phase, 22 different pharmacist-led cognitive services were identified and the correlating definitions of the terms were developed. conclusion: at the time of submission the pre-pilot phase has been finished and the pilot will start july 2016. please specify your abstract type: research abstract background and objective: medication adherence is one of the key aspects in assuring optimal health outcomes in majority of chronic diseases. the aim of the study was to evaluate copd patients' medication adherence in slovenia and its association with health outcomes. setting and method: patients were recruited by community pharmacists at the time of dispensing medication for copd. medication adherence was evaluated by using morisky medication adherence scale (mmas-8). patients who scored b6 points, 6.25-7.75 points and 8 points were regarded to have poor, moderate and good adherence, respectively. quality of life was evaluated by saint george's respiratory questionnaire (sgrq) and the impact of disease by copd assessment test (cat). the study was conducted in september 2014 and february 2015. the association between potential predictors and copd impact or quality of life was estimated using multiple linear regression in ibm spss statistics version 23. main outcome measures: medication adherence rate (mmas-8), quality of life (sgrq total score) and impact of disease (cat score). results: of 65 patients, majority were men (68%) with mean age 70 years. in average, patients were prescribed 2.5 medicines for copd and 3.8 medicines for other diseases. good, moderate and low adherence to copd medication regimens was found in 53.4, 32.8 and 13.8% of patients, respectively. mean cat scores and sgrq scores were 17.3 (range 3-34) and 41.3 (range 2-79), respectively. thirtyeight percent of patients experienced an exacerbation in the past year. linear regression showed no statistically significant association between medication adherence and quality of life or copd impact on patient. factors that statistically significantly predicted patients' quality of life were exacerbation in the past year, education level and number of concomitant medicines for other diseases. the latter was found to be the only factor associated with copd impact. conclusion: the study showed half of the copd patients to be optimally adherent to their treatment and only a small proportion of patients not taking their medicines regularly. due to the nature of the disease medication adherence does not seem to play the most important role in assuring optimal health outcomes in copd patients. please specify your abstract type: descriptive abstract (for projects) background and objective: intermediate care units (imcu) are designed to serve patients in need of more advanced medical care than the ordinary nursing home units can provide. the aim of this study was to see; (1) how medication information follows patients in and out of icmu and nursing home short-termcare units (stcu) (2) the type and amount of drug related problems (drp), focusing inappropriate drugs, and (3) if there are differences between the icmu and stcu in drug use and drps. design: patients c65 years old admitted and submitted at the imcu or stcu in the study period (10 weeks) were included. transfer of medication information were evaluated and given a score. the clinical pharmacist provided medication reconciliation upon admission, medication review and monitoring, and presented identified drps and a suggestion for solving the problem, to the multidisciplinary team. inappropriate drugs, identified by screening tools (stopp/norgep), and systematic medication reviews, were recorded. results: 14 patients from imcu and five from stcu were included. a hospital discharge summary including medical history followed mostly all patients. the score of the medication history was 7.5 points out of 16. by submission from either imcu or stcu, the score was 8.6. systematic drug review identified 3.9 drp in the imcu and 2.0 in the stcu. imcu patients used 9.5 drugs, stcu patients 10. in the icu, 14% of the identified drps was inappropriate drugs, none in the stcu. the clinical pharmacist in the multidisciplinary team presented 92% of the identified drps. the doctors agreed in 80% of the suggestions for solution, and started immediate changes in 43%. conclusion: a hospital discharge summary followed the patients, but the medical history part needs improvement. although few patients, the results suggest that imcu patients had more complicated medication and more inappropriate drugs than stcu patients did. clinical pharmacist in a multidisciplinary team provides useful contribution to identify, solve and prevent clinical relevant drps, including inappropriate drugs. please specify your abstract type: research abstract background and objective: lack of clinical effects of medication review on health-related quality of life of older people may be due to insufficient focus on health-related complaints. goal attainment scales (gas) are an instrument to formulate specific health-related goals. the objective of this early process-evaluation of the dreamer-study (drug use reconsidered in the elderly using goal attainment scales during medication review) is to investigate if pharmacists are able to formulate gas during a medication review of older people with polypharmacy. setting and method: older patients aged 70 years or older using 7 or more medicines are included in this study. half of the patients were randomized into the intervention group, where they received a medication review. during the patient interview, the pharmacist formulated gas in concordance with the patient. recommendations were made to reach these goals in collaboration with the gp. main outcome measures: number of performed medication reviews, total number of formulated gas and the three most frequent types of gas. results: until now 453 patients have been included in the drea-mer study (60% of the target). half of them (220) were randomized into the intervention group. by now 179 (81%) of these patients have received a patient interview. 143 goal attainment scales were formulated yet. the number of gas ranged from 0 to 3 per patient. the four most frequent gas were: polypharmacy-reducing the number of medicines (28), reducing pain (23), increasing mobility (16), reducing fatigue (15). conclusion: gas seem to be a feasible approach during medication review that increased focus on patient's needs and health-related complaints. cp-pc019: oral transmucosal fentanyl citrate: a regional survey of dispensing practices in community pharmacy please specify your abstract type: descriptive abstract (for projects) background and objective: oral transmucosal fentanyl citrate (otfc) is an opioid analgesic indicated for management of breakthrough cancer pain in patients with malignancies who are already receiving and who are tolerant to opioid therapy for their underlying persistent cancer pain. otfc are usually use off-label prescription, especially in noncancer patients or patients without opioid maintenance treatment. this practice can expose to iatrogenic risks, lack of efficacy, abuse and addiction. the observatory of drugs, medical devices and therapeutic innovation of upper normandy, conducted a study to assess the knowledge of pharmacists on these medications and assess dispensing practices (pharmaceutical analysis and advice to patients). design: between june and september 2015, two quizzes were sent to the 1344 pharmacists and 512 pharmacies in upper normandy: one included questions of knowledge and general practice, the other assess dispensing practices of otfc prescriptions received at the counter, regarding indication, dosage and associated opioid medication. results: of the 93 pharmacists who participate in the survey, 21% know the all of the 7 oftc specialties, 46% of them confuse transdermal and transmucosal fentanyl specialties. indication, dosage, titration methods and the main interest of oftc are known by 52, 43, 18 and 71% of them. only 30% have dispensed oftc more than 10 times over the past 12 months, 28% never have. they already have dispensed oftc in noncancer patients (45%) or without opioid maintenance treatment (36%). they consider not know enough about these drugs to be able to provide the necessary advice to patient (57%) and would like specific training on oftc (89%). of the 21 analyzed prescriptions, only 24% are consistent with the marketing authorization: otfc medicines are prescribing in noncancer patient (52%) and/or dosage is higher than four units per day (24%) and/or there is no prescribed opioid maintenance treatment (24%). only two prescriptions have been discussed with the prescriber, and all were approved and dispensed. conclusion: otfc specialties are occasionally dispensed and often misunderstanding by pharmacists. a good knowledge of otfc is necessary to achieve the pharmaceutical analysis and provided appropriate advice to patients, in order to guarantee the good use of these medicines. support tools for dispensation, recalling indication, . the most frequent interventions were drug substitution (n = 132), dose adjustment (n = 57), and clarification of information (n = 48). common services were reconstitution of suspension (n = 7), provision in advance for continuing supply (n = 26), and follow up offers (n = 3). conclusion: the observation of the dispensing process in community pharmacies revealed a broad range of tasks performed by the pharmacy and identified several variables likely to influence the counselling. in addition, pharmacy activities could be pictured by the documentation of pharmaceutical interventions. please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) is a multidisciplinary process to correct medication errors resulting from miscommunicated information at transitions of care. development of this activity is essential but it is hindered by the time required for its implementation. we must carefully choose which services can develop this activity. as it was recently introduced in cardiac surgery unit, this study aims to evaluate impact of this process to hospital admission (severity of potential harm of medication error intercepted) and to determine the relevance of this activity in this unit. design: prospective study conducted from january 2016 to april 2016. the data is recorded in an excel table, filled after each mr. there are five items: patient's age, best possible medication histories (bpmh), implementation period of the mr, inadvertent discrepancies (ids) and clinical impact. to assess the severity of ids, a scoring method was used (doerper et al. 2015) with the cooperation of surgeon and pharmacist. results: eighty-two patients (mean age 68 ± 8 years old) were included in the study, which represents 52% of the patients hospitalized in this service. the mean number of drugs per patient was 6 ± 3. the bpmh were obtained within 24 h to 72 h of admission to hospital. a total of 34 ids were detected, with a mean of 0.41 ids per patient. the most frequent type of ids was omission (52%, n = 16), error of dose (39%, n = 12). the three most common classes involved in ids were hypolipaemic drug (n = 9), antidiabetic drugs (n = 6) and the drugs for acid related disorders (n = 4). the mean of ids per patient (0.41) as well as the percentage of patients affected by a ids (32%) are less important in cardiac surgery than those observed in other services of the institution and in the literature. about clinical impact, 31% of patients presented with ids considered as minor, 44% significant and 25% major. among the major ids, none was evaluated as critical or catastrophic. in our study, this process remains retroactive. conclusion: one of challenge experienced when implementing mr process in hospitals is demonstrating its clinical impact. in order to address this concern, we found that the little ids with a serious clinical impact in this unit. mr is an interesting process to detect drug errors. to optimize our study we will improve our organization in order to be closer to the patient and to strengthen the doctor-pharmacist collaboration. please specify your abstract type: research abstract background and objective: special packaging like multidose drug dispensing (mdd) may optimize medication use in patients with a decreased ability to manage their own medication. however, it remains unclear how a 'decreased ability to manage medication' is defined. the objective of this study is to assess potential medication problems that contribute to a decreased ability to manage medication in patients starting with mdd compared to patients who use manually-dispensed drugs. setting and method: patients starting with mdd (cases) and patients using manually-dispensed drugs (controls) were interviewed in 45 community pharmacies. questions to assess potential medication problems covered three domains; medication adherence (12), practical management issues (12) and medication knowledge (2) . every potential medication problem was scored with one point. cognition was assessed with the mini-cog and frailty with the groningen frailty index (gfi). main outcome measures: mean scores of potential medication problems on the domains medication adherence, practical management issues and medication knowledge. results: 188 patients starting with mdd and 230 patients using manually-dispensed drugs were interviewed. patients starting with mdd scored more potential medication problems on all domains: adherence 5.5 versus 1.7, practical management issues 3.7 versus 2.1, medication knowledge 1.1 versus 0.3. on the three domains together, patients starting with mdd scored 10.2 [9.6-10.9] potential medication problems compared to 4.1 [3.7-4.6 ] for patients with manuallydispensed drugs. forty-two percent of the patients starting with mdd might be cognitive impaired and 63% was classified as frail compared to 20 and 27% respectively of the patients using manually-dispensed drugs. conclusion: patients starting with mdd reported significantly more potential problems on three domains that may contribute to a decreased ability to manage their medication. cp-pc024: fifteen key questions to assess patient knowledge on new oral anticoagulants corina metaxas * , valerie wentzky, sonja luginbü hl, kurt e. hersberger, isabelle arnet please specify your abstract type: research abstract background and objective: knowledge on new oral anticoagulants (noacs) is crucial for their safe and effective use. validated tools that assess patient knowledge exist for vitamin k antagonists, but not for noacs. we aimed to identify which questions are relevant for patient knowledge on noacs. setting and method: based on a systematic literature search, 45 questions were compiled for the assessment of noacs knowledge. key questions were selected through three rounds of ranking by an expert panel (four physicians, four pharmacists, four nurses). round 1 (online survey; importance): the 45 questions grouped into the nine educational topics of wofford,adapted for noac (disease, mode of action, risk-benefit, adherence, accessing healthcare professionals, diet/life-style, lab-monitoring, medication interactions, self-care) were to be rated as important/not important and educational topics were to be ranked according to decreasing importance. round 2 (online survey; relevance): the questions were to be ranked according to decreasing relevance. round 3 (focus group): number of questions was reduced by voting. main outcome measures: ranking of educational topics and questions (1 = most important/relevant) in march/april 2016. results: experts ranked adherence (2.2 ± 0.9) as the most important topic, followed by risk-benefit (3.0 ± 1.6), disease (3.7 ± 2.7), accessing healthcare professionals (4.1 ± 2.0), self-care (5.3 ± 2.6), lab-monitoring (5.6 ± 1.6), medication interactions (6.5 ± 1.8), diet/life-style (7.3 ± 0.9) and mode of action (7.8 ± 1.5). one question was judged as unimportant by all experts. out of the remaining 44 questions, 10 (22.7%) were selected as relevant for basic knowledge, 7 (15.9%) were combined into four questions and one new question was generated. a total of 15 key questions remained after the focus group discussion. conclusion: a multiprofessional expert panel was able to select key questions retrieved from literature and ensured content validity. the selected questions will be compiled into a tool to assess patient knowledge on noacs. background and objective: medicines use review (mur) was defined by the slovene chamber of pharmacies in december 2014 and an education program was set to assure pharmacists competencies. in june 2015 the first pharmacists were certified and implemented the service in the community pharmacies. additionally, an online database was established to collect mur reports and provide feedback on pharmacists' performance. the aim of the study was to evaluate identified drug related problems (drp) as well as pharmacists' interventions from mur documentation. setting and method: a preliminary retrospective analysis of documentation for mur services provided in the first year after implementation was performed. drps were classified using a slovenian drp classification system, which is based on the pcne classification v 6.2 [1] . data were analysed with descriptive statistics measures. main outcome measures: number and type of identified drp and pharmacists' intervention. results: a preliminary analysis was performed on 129 mur cases, performed by 11 certified pharmacists. in total 258 drps were identified: 116 (44.96%) manifested and 142 (55.04%) potential. patient had on average two drps, however 11 patients had none. main risk factor for potential drps was inappropriate use of medicines. adverse drug events (ades) presented 50.86% of manifested drps; the main risk factor was again inappropriate use. in two cases ades happened due to an allergic reaction. 29 different medicines were the cause of ades; mainly statins resulting in muscles pain and sleeplessness. another frequently manifested drp was insufficient effectiveness of treatment. drug interactions were risk factors in 12 cases of manifested drps, mainly in connection with antidepressants: serotonin syndrome due to escitalopram, bleedings in concurrent use of escitalopram and ginkgo, sleepiness, etc. pharmacist intervened independently in 74.4% of cases; 57 times recommendations were given to physicians. however, in 92.6% of cases the outcome of intervention is unknown. the preliminary results of the first mur cases points to a high number of identified manifested drps. however, the knowledge of intervention outcomes is lacking and therefore more attention has to be put on establishing adequate follow up on this issue. official definition represented harmonisation of several similar activities that have already been performed in slovenian pharmacies and also provided an educational program to assure pharmacists competencies. in may 2015 the first 18 pharmacists were certified and implemented the service in the community pharmacies. therefore, the aim of the research was to get an insight into the implementation of mur in slovenia from the perspective of the first community pharmacists that provide the service in practice. setting and method: a focus group with seven community pharmacists, that provide mur in practice, was run in february 2016. guided discussion included three main themes: the development and assurance of competencies, experience with the provision of service in practice and the future of the service. the discussion was voice recorded and analysed with the nvivo 11. written consent from included participants was obtained. main outcome measures: views, challenges and opportunities for the medicines use review service in slovenia. results: in total 364 themes were identified and organized in three main categories: competencies for quality provision of mur, mur's recognisability and organizational aspects of mur provision. participants emphasized broad knowledge in pharmacotherapy is pharmacists' key competence and advantage in performing mur when compared with other healthcare professions. recognisability of mur among other health care professions as well as participants' work environments is low. hence a comprehensive approach in marketing of the service is needed. positive patient's feedbacks were reported, however persuading patients to attend mur presented a challenge. another barrier was the time to perform mur, which could be overcome by suitable work organization and special time intended for mur. conclusion: participants of the focus panel had positive experience with the development of competencies and implementation of the service in the practice. several challenges were presented connected with the recognition of the service by patients, physicians and health care payer. they strongly believe that continuing professional development forms the base for quality of the service in the future. cp-pc027: evaluation of rational antibiotic dispensing in the community pharmacy setting: a simulated patient study betul okuyan * , mehmet ali savan, fikret vehbi izzettin, mesut sancar please specify your abstract type: research abstract background and objective: in the present study, it is aimed to evaluate rationale antibiotic dispensing without prescription in the community pharmacy setting; this will be done by using a simulated patient methods. setting and method: this study was conducted in malatya, located in the east part of turkey. the simulated patient visited the community pharmacies to meet the pharmacist, posing as the husband of a patient with acute uncomplicated rhinosinusitis. the simulated patient was trained regarding the standard information to be provided by the researchers and informed about the privacy of all information that would be gathered during the present study. the sample size was sixty-seven pharmacies, with a confidence interval of 95% and error of margin of 10%. the study was conducted over a total of 70 pharmacies. all the pharmacies were listed alphabetically and were randomly selected and allocated random numbers by a computerbased program. main outcome measures: after each community pharmacy was visited, the simulated patient filled the check list which had been drawn up for the purpose of the present study. due to ethical concerns, no audio or video records were used during the study. any suggested medications were not purchased from the community pharmacy. results: of the total community pharmacies that were visited 55.7% of them had female pharmacists and 44.3% were run by male pharmacists. the mean number of questions asked by pharmacists to the simulated patient was 3.17 ± 1.65. only eleven pharmacists did not suggest any medication for the simulated patient. however, thirty-two (45.7%) pharmacists recommended various medication regimens, including antibiotics. of them, 67.1% referred the simulated patient to a physician. conclusion: in conclusion, it was observed that dispensing antibiotics without prescription was still high, pharmacists did not take comprehensive medical or medication history from patients, and pharmacists provided insufficient medication information to the patient regarding suggested medications at community pharmacy setting. to avoid irrational antibiotic dispensing, it is essential to educate both health care providers and the general population. although dispensing antibiotics without prescription is illegal in some countries, it is necessary to actualize new regulations to avoid antibiotic dispensing without prescription. please specify your abstract type: research abstract background and objective: the medication adherence is an important part of active (as well as passive) attitude of a patient to the disease treatment. it represents the level of keeping the treating procedure as well as the recommendations of doctors, pharmacists and other healthcare professionals. this study deals with the adherence in patients with hypertension. the hypertensive patients are a substantial part of patients, daily visiting the community pharmacy to pick their prescriptions. these patients represent group of patients with typical asymptomatic disease. this means that they do not take the medicines or use them according to their own will. the result of their non-adherence could lead to later complications. the aim of the study was to evaluate the level of adherence and its relation to the clinical outcome-the blood pressure in hypertensive patients. setting and method: the methodology was based on a single anonymous questionnaire survey combined with the blood pressure measuring in a community pharmacy in slovakia. the modified morisky 4-item medication adherence tool was used in this study. main outcome measures: the results of medication adherence were evaluated as follows: 3-4 points = full adherence, 2 points = partial adherence and 0-1 = non-adherence. each participant should use at least one antihypertensive agent and fulfil the anonymous questionnaire in the community pharmacy. the pharmacist measured the blood pressure in each participant twice, within the interval of 10 min and used the average value in data sheet. results: the research included 150 hypertensive patients (55.33% females and 44.67% males). the results showed that almost 46% of the respondents were non-adherent to the prescribed pharmacotherapy (57.98% of those were males and 42.02% were females). the group of partially adherent patients consisted of 35.33% of the respondents (66.04% of those were female). only 18.67% respondents were fully adherent according to modified morisky score (67.86% of those were women). fully adherent patients reached an average blood pressure 117.393/76.464 mmhg; partially adherent hypertensive patients recorded an average blood pressure 124.162/80.623 mmhg; and in the non-adherent patients has been observed the average blood pressure 154.116/95.319 mmhg. the results showed an alarming situation, and confirm the published data. non-adherent patients could not goal the good clinical outcomes. this leads to adding of another medications, raising the risk of interactions and adverse drug reactions, complications of undertreated disease, and finally, to pharmacotherapy costs increasing. please specify your abstract type: research abstract background and objective: in psychology, depression is a mental state characterized by feelings of sadness, dejection, inner tension and indecision. in psychiatry, the depression is defined as a severe mental affective disorder which paralyzes clarity of thought, psychomotorics, sleep cycle and raises pessimistic and depressing emotions often lead to pathological changes of personality. during treatment of depression is often needed psychotherapy and pharmacotherapy as well. using of antidepressants requires the sufficient level of medication adherence in patients. non-adherence to antidepressant medication significantly contributes to the undertreatment of depression in primary care populations. the aim of this study was to evaluate the level of medication adherence to antidepressants to better understand the socio-behavioural factors associated with non-adherence. setting and method: the anonymous, face-to-face questionnaire survey was set in the community pharmacy in slovakia. questionnaire obtained questions on socio-behavioural factors and adherence tool-modified 8-item morisky score (mmmas-8). main outcome measures: respondents were 150 patients (39 males, 111 females) using at least one antidepressant. the results were evaluated as follows: 8 points = full adherence, 6-7 points = partial adherence and 0-5 = non-adherence. results were evaluated in relation to socio-behavioural factors. results: average level of the medication adherence in our group was 5113, which means the line between partial and full adherence. the results showed non-significant higher medication adherence level in males (5179) compared to females (5090). the highest level of medication adherence (5367) has been shown in patients 45-64 years old, the lowest average adherence level (non-adherence) was observed in patients up to 24 years old (4656). patient living in the city were more adherent to their medication (5127) compared to patients living in countryside (5083). the highest level of the partial medication adherence has been shown in secondary educated patients (5344). partial adherence level was higher in patients with monthly income over 1000 € (5750) compared to non-adherent patients with monthly income up to 300€ (4878). in patients using no other medications, only antidepressant, we have observed the highest partial adherence (5219). conclusion: our survey showed the partial antidepressant medication adherence levels in our study group. poor adherence results in low stabilization of clinical state in patient, in using more types of therapy and in increasing costs. there might be very important role of the community pharmacists and other health care professionals to improve the medication adherence and persistence through counselling and education patients on importance and need of antidepressant medication. (1) and medication regimen complexity was assessed by using the medication regimen complexity index (mrci) (2) . five and more medication usage has been defined as polypharmacy. results: a hundred and two elderly subjects (74.5 ± 6.0; 65 male) were included in this study. of them, 89.2% had two and more chronic diseases. the most common chronic diseases determined in study population were cardiovascular diseases (especially hypertension), diabetes and hyperlipidaemia. the polypharmacy has been defined in 77.5% of them. the mean of mrci per elderly patient was 12.5 ± 7.0. one or more pims use was observed in seventy-four elderly subjects (72.5%). of all elderly subjects, 59.8% were dispensed one and more medicines with a potential for drug-disease/ syndrome interaction. pims use was more frequently determined in patients with polypharmacy (78.5 vs. 52.2%, p \ 0.05). the total score of mrci was significantly increased with elevated number of pims (r = 0.304, p \ 0.01). conclusion: this study highlights a significant association between utilization of pims and both polypharmacy and higher total score of mrci in elderly patients. pharmacists could be evaluated utilization of pims in especially elderly patients with used five or more medications and/or higher total score of mrci. please specify your abstract type: research abstract background and objective: nursing home patients with multimorbidity often use multiple drugs simultaneously, which makes these patients more susceptible to adverse drug events. several studies have pointed to a need to increase the quality of prescribing to this population. to achieve this there is a need for reliable information about patients' diagnosis, and what is recorded as the drug's indication in different electronical and handwritten health records. the aim of this study was to examine the registered diagnoses, and indications for drug use in nursing home patients. we also wanted to study the extent to which diagnoses are untreated with drugs, as well as the extent to which drugs have a registered indication for use and a suitable recorded diagnosis. setting and method: data was collected for 70 long-term patients, on average 83 years old, and 66% females from four nursing homes in tromsø municipality, norway. we retrieved information about patients' diagnoses and indication for drug use from the electronic health record and written drug charts. two pharmacists conducted the linkage between the reported diagnoses and drug use. main outcome measures: percentage of untreated diagnoses and the percentage of drugs with a registered indication for use. results: as considered by the pharmacists, 70% of the registered diagnoses was untreated with drugs. dementia, gout and osteoporosis were the most commonly untreated diagnoses with, 97, 60 and 57%, respectively. in comparison, the indication for use listed on the patients' drug charts was reported for 82% of the drugs. the drugs with the highest percentage of recorded indications were acetylcysteine (n = 15), oxycodone (n = 14) and zopiclone (n = 11), where 100, 93 and 90% had a listed indication, respectively. conclusion: a high percentage of nursing home patients' diagnoses seem to be untreated. however, most drugs that patients received were listed with indication for use in the drug charts. to increase quality of drug prescribing, one should put emphasis on improving the recorded information in electronical health records. cp-pc033: personal changes in drug regimen: dangerous for health system? inga urtane, raivis pastars, dace bandere please specify your abstract type: research abstract background and objective: patient compliance is a key factor for a successful treatment and lack of it is the main reason for predicting treatment failure. in multiple researches patient adherence is determined to be as low as 50%. therefore it is important to identify the reasons of patients not following their drug regimen. objective. to analyse the patient comprehension of their drug regimen depending on the duration of hypertension and received treatment. setting and method: during the period from december 2015 to march 2016 a quantitative survey was conducted to include respondents who have been diagnosed with arterial hypertension and whose regimen includes at least one fixed dose combination drug. main outcome measures: in an anonymous survey data was collected about their demographic information, co-morbidity, other prescribed medication, intake regime, the average blood pressure during treatment, and patient's assessment of the prescribed therapy. collected data was analysed with spss. results: the study included 103 participants, most of whom (64.1%) were women. participants average age was 62.5 ± 12.5 years and the median arterial hypertension duration was 8 (5; 16) years. the study participants, who sometimes consciously adjusted dosing regimen, observed arterial hypertension for a longer period of time compared to the group, which follows the prescribed regimen according to their doctor's recommendation, respectively, 10 (6; 28) vs. 8 (4; 15); p = 0.110. group of respondents (n = 16) receiving c3 prescription drugs, more often deliberately adjusted treatment regimen compared to respondents (n = 8) treated with b2 prescription drugs, respectively 26.7 versus 18.6%; p = 0.310. respondents who deliberately adjusted drug were more often not satisfied with the number of longterm daily use of tablets (n = 13) compared to the group (n = 11), which had to intake fewer tablets every day, respectively, 54.2 versus 45.8%; p = 0.005. conclusion: arterial hypertension duration was associated with more frequent conscious adjustment of therapy without consulting a doctor. more individual prescriptions (c3) and an increase in the number of tablets per day at the same time also increases the risk of patients deliberately changing their dosing regimen. long-term drug users should receive additional attention during pharmaceutical care process to their respective treatment schedule in order to promote proper use of medication. please specify your abstract type: research abstract background and objective: diabetes is a health issue and real burden for 1 in 6 belgians. better adherence to the treatment could potentially reduce complications, decrease morbidity and mortality, and have a beneficial economic impact due to fewer consultations and hospitalizations. setting and method: a one-year program was started in 370 belgian pharmacies to accompany diabetes patients taking dpp-4 inhibitors and encourage them to be compliant with their treatment. this study concerns 270 of these pharmacies, all part of the same cooperative group. all pharmacists received prior training in motivational techniques and reviewed the bases of diabetes therapy with an e-learning program. materials developed for the patients included brochures on diabetes and its treatment, nutritional advice, physical exercise, foot care and tips and tricks for diabetics. main outcome measures: the impact on pharmacological adherence was measured using mmpr and pdc. two control groups were included: a historical control group and a group of patients that were not included in the project. non-pharmacological adherence was assessed using questionnaires. results: in the subgroup of 270 pharmacies, 495 patients were included in the program. by the end of april 2016, only 44 of them had completed the program; 78 patients came only once to the pharmacy. they either stopped their treatment after one prescription, or were occasional clients. adherence rates were found to be high in all groups (5.7-9.1% of patients with mmpr b 80%). only for the pdc, a statistically significant difference was measured between the intervention and control group (135.37 vs. 129.22%; p = 0.015). no other statistically significant impact was measured (neither pharmacological, nor non-pharmacological). conclusion: adherence was very high in all groups. the underlying reasons still need to be investigated (choice of adherence measure, healthy user effect, etc.). however, both patients and pharmacists were very pleased with this type of program. this new role of the pharmacist will definitely be more developed in the future. please specify your abstract type: research abstract background and objective: oral anticoagulants (oac) have a beneficial effect on the long term survival of patients with atrial fibrillation and venous thromboembolism. however oacs have also side effects such as bleeding, especially when used inappropriately. pharmaceutical care interventions aim to optimize medicines use and improve patient health outcomes. the literature lacks a review on the impact of pharmaceutical care interventions in patients using oac. therefore, we systematically assessed the impact of pharmaceutical care interventions on the effective and safe use of oac compared to usual care. setting and method: a systematic review was performed in pubmed and embase with synonyms/detailed specifications of the terms oral int j clin pharm (2017) . it was motivate for the need to sort the instruments for urm, including professional participation, and on the basis of the clinical management unit, and reduce variability in decisions. the p&t or ''multidisciplinary commission rational use of medicines'' is constituted by 13 people: one hospital medical director (president), head of pharmacy (secretary), and three directors of healthcare centre, three directors of department of specialities, one epidemiology, one hospital pharmacy, one primary care pharmacy and one paediatric. because some of these members are far between them, and normally dose not have too much time, we create an online platform to work, discuss and download all the necessary documents. setting and method: we used the facilities of the andalusian agency for healthcare quality (www.acsa.junta-andalucia.es), and as a base the law of the administrative decision. we have organized a session to discuss methodology with the participation of all members. main outcome measures: number of meeting and number of internal discussion emails. drug or protocol decisions. design of the platform. results: the design platform consists of five tabs: (1) has the member information, position, telephone and address, (2) email forum, following a subject line, (3) a place for meeting requests and then hang up the meeting minutes. (4) a tool allows you to upload documents to the portal (5) a search engine. two sessions are schedules and total of 28 mails. we have 4 of 13 members who have never participated online. at this moment we have adopted two decisions. conclusion: it is an online experience of one andalusian p&t committees, the low turnout makes go slower than expected, therefore physical meetings are necessary in this moment. we are working how to get more participation and involve in the project the committee members. please specify your abstract type: research abstract background and objective: liver cirrhosis can have a major impact on drug metabolism, requiring evaluation of drug safety and dosage in individual patients. currently, there are no guidelines on safe prescribing for medications in patients with liver cirrhosis, and these patients have many questions about safety and side effects of medication. the objective of this study is to explore the patient's needs on information about medication. setting and method: qualitative, semi-structured interviews were performed in 28 patients with a (history of) liver cirrhosis. the patients were approached through an item in the newsletter of de dutch association of liver patients. topics in the interview guide were preferences about information about medication, side effects, safety, drug dosage, and how patients preferred to receive this information. interviews were audiotaped and transcribed verbatim. interviews were analysed using thematic content analysis. main outcome measures: the experiences and needs of patients with liver cirrhosis concerning information about medication. results: patients indicated they had received sufficient information about the indication, possible drug-drug interactions and the duration of treatment. they preferred (more) information about how medications work, what adverse drug reactions could be expected and practical aspects concerning intake of medication. informational needs were related to questions 'how to act': patients with more informational needs took a more active role in responsibility for their own medication management. patients needed information to know what to do, e.g. in case of adverse drug reactions or when a dosage was forgotten. the doctor and internet were the preferred sources of information: doctors because of the personal contact and internet because of the accessibility. facilitating factors were 'taking time' in healthcare provider-patient contact and 'everyday language' for texts on the internet and in package leaflets. a combination of verbal information by the healthcare professional and written information was preferred. conclusion: patients with liver cirrhosis need information about medication to take an active role in their drug management. comission for medicines and medical devices, chu de toulouse, toulouse, france please specify your abstract type: descriptive abstract (for projects) background and objective: due to its common use, insulin is often considered as a harmless medication by lots of health professionals while an overdose can lead to dramatic consequences and death. between january 2014 and june 2016, in our university hospital, 6% (7 out of 121) of the declared adverse drug events have involved insulin: 2 were caused by prescription errors and 5 by administration errors. all were discovered after the medicines have been administered but thankfully none had serious consequences. the british national health service (nhs) and the french medication safety national agency (ansm) made a list of ''never events'': avoidable events which should never happen and misadministration of insulin is among them. the objective was to increase patient safety in the hospital by setting different actions to promote and improve the appropriate use of insulin and warn health professionals about the real dangers of this medicine. design: different actors participated in the implementation of these actions: the commission for medicines and medical devices (which is composed by doctors and pharmacists) directed a group made by physicians and clinical pharmacists from the department of cardiological and metabolic diseases'. results: in addition of the usual analysis of any adverse event linked to medication declared in the hospital, several actions were set up: • a didactic document summarizing all the ''sensitive'' steps during the prescription, stocking, dispensation and administration of insulin has made the front page of the hospital's intranet and was also diffused throughout the establishment. • a chart resuming all the different insulins commercialized in france has also been diffused. it contains their types, durations and onsets of action, conditions of storage and pictures of their packaging. • the 49 computerized protocols involving insulin are going to be reviewed in order to lower their numbers and harmonize their content. • a revision of the list of insulins available at the hospital is in progress to reduce their number and avoid any confusion between the different products. • an evaluation of insulin's computerized prescription practices will be made via a data request. : this topic about insulin shows a greater willingness to secure the medication circuit in the hospital. other action plans such as this one will be set up involving other medications among the never-events list. meanwhile, the commission for medicines and medical devices pursues its actions of promoting the appropriate use of medication. please specify your abstract type: descriptive abstract (for projects) background and objective: one of the hospital pharmacist tasks is to suggest substitutions to ensure conformity of medical prescription with the hospital formulary. indeed, when an eye drop isn't available at the hospital, there is a specific supply circuit which has to remain exceptional: it's ordered directly to the pharmaceutical wholesaler. in this context, ophthalmologists and clinical pharmacists created a table proposing therapeutic equivalencies with eye drops available at the hospital. after approval by the commission for medicines and medical devices, this tool has been diffused within the establishment via the intranet website since the beginning of 2013 to the medical and paramedical staff. the purpose of the study is to evaluate professional practices concerning the use of the eye drops' equivalence chart. design: in the study, we compared eye drops' orders made to the pharmaceutical wholesaler before and after the table's diffusion, thus between january 2012 and december 2015. for each order, we used the table available at this time to determine if equivalencies could have been proposed or not. if so, we identified the hospital ward and the pharmaceutical specialty. market changes have also been considered. results: we noticed a decreased frequency of eye-drops ordered despite available equivalencies: 52% in 2012 (before the table's diffusion), 25% in 2013 (after its diffusion), 33% in 2014 and 33% in 2015. prisons units are responsible of 95% of these orders: they have the lowest rates of substitutions. their most ordered pharmaceutical specialties are ophthalmic glaucoma agents: 46% ganfort ò (bimatoprost 0.3 mg/ml/timolol 0.5%), 20% xalacom ò (latanoprost + timolol 0.5%), 23% azopt ò (brinzolamide) for which the authorized substitutions are for the first two specialties: monoprost ò (latanoprost) + ophtim ò (timolol 0.5%) and for the third: dorzolamide ò . conclusion: equivalence table diffusion throughout the hospital has facilitated and improved the prescription and substitution of eyedrops. orders of pharmaceutical specialties despite authorized equivalencies available have declined by half. probably for practical reasons regarding long-term treatments, prison units make less substitutions but an awareness campaign will be carried out to reduce these rates. please specify your abstract type: research abstract background and objective: the patient's education and information is a mean to reduce medicine misuse and it can be performed with support of a leaflet or informative material about medicines. in brazil, there is a lack in regulation about this type of informative material to compounded medicines. the aim of this study was to evaluate the quality and effectiveness of leaflets developed to compounded medicines' users through knowledge's level and medicine treatment adherence. setting and method: analytical and quantitative study; 3 month prospective study through interviews, at time zero (t0) and after 30 days (t1) in a university pharmacy in goiás, brasil; fisher's exact test to measure effectiveness; ethics committee number 008/12. main outcome measures: categorization into high adherence and low adherence by morisky test; categorization into sufficient, regular or insufficient knowledge about medicine prescription; perceptions and suggestions about delivered leaflet in medicine dispensing process. results: of 52 patients (82.7% female, mean = 48.7 years), 93.5% considered as relevant the leaflet's content, as well 88.5% of them kept it and 67.4% of them read it. suggestions of 16.1% included a desire in increase font size, more emphasis on drug interactions and images. there was a predominance of regular knowledge in both analysed times (48.4% e 38.7%), however there was a decrease in high adherence to medicine treatment (19.2-7.7%). among patients who read the leaflet, no statistically significant association was found on these two variables at t0 and t1 (p = 0.24 and p = 0.84, respectively). knowledge about ''administration schedules'' showed a significant improvement after intervention (p = 0.02). 61.3% of patients considered that there was no need to obtain more information. conclusion: this study demonstrates the evaluated leaflets had relevance to patients and demonstrate clinical relevance. however was not observed statistically significance. this highlights the need of using different ways to measure the effectiveness of an informative material to promote rational use of medicines and depth studies and stimulation of greater attention from the health professionals to the topic. di006: chlormethine gel: effectiveness and tolerance to treat mycosis fungoides françois dugre *,1 , anne lefebure 1 , sonia martelli 1 , marion pin 1 , eve maubec 2 , philippe arnaud 1 1 pharmacy, 2 dermatology, bichat-claude bernard hospital, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: to determine the effectiveness and tolerance of chlormethine gel in treating mycosis fungoides. design: mycosis fungoides is the most common form of cutaneous t-cell lymphoma (mf-ctcl). early stages (ia and ib) can be controlled by skin-directed therapies such as chlormethine and carmustine. these drugs which are solutions for injection are usually used for skin application. chlormethine or mechlorethamine gel is an alkylating agent representing an alternative for previously treated patients diagnosed with mf-ctcl, in case of therapeutic failure and intolerance, or in case of chlormethine and carmustine solutions supply disruption. a retrospective observational analysis was conducted based on medical records of all patients treated by chlormethine gel in our hospital from the first of july to the first of september 2015. the following data were collected with an excel table: body surface area or bsa affected by disease, location of the lesions, therapeutic management, effectiveness and treatment tolerance. results: fourteen patients (7 women, 7 men, mean age 55 [min 33; max 84]) were treated with chlormethine gel in our hospital. twelve (86%) were treated three times per week, 2 (14%) once a day. before treatment by chlormethine gel, 4 (29%) patients were treated by dermocorticoids, 4 (29%) by dermocorticoids and phototherapy, and 1 (7%) by bexarotene, all of them stopped their treatment on account of inefficacity. one (7%) patient was treated by carmustine and dermocorticoid, and 3 (21%) by only carmustin, all of them stopped it because of supply disruption. one (7%) patient received it in first line therapy. ten (71%) patients showed a response (partial or complete), one (7%) experienced a stabilization of his disease. before treatment with topical chlormethine, seven patients (50%) had an involved bsa [ 10% and four of them (57.1%) experienced adverse effects. seven patients (50%) had an involved bsa \10% and three of them had (42.9%) side effects. a total of seven patients (50%) presented at least one adverse effect. five patients (36%) stopped the treatment on account of adverse effects; two of them (14%) interrupted it temporarily. reported side effects were: irritant dermatitis and erosive toxicity (5), rash (2) and telangiectasia (2) . conclusion: our results indicate that chlormethine gel can be effective to treat mycosis fungoides. however, it involves side effects that seems to be more frequent than those observed with chlormethine solution (used for skin application). indeed, the french national authority for health reports 28% of adverse effects for chlormethine solution versus 50% in our study for chlormethine gel. moreover, telangiectasia was never documented with chlormethine. this significant number of side effects of chlormethine gel can be explained by the gel formulation which induces patients to apply more product, especially in patients with plaques affecting more than 10% of the bsa. it is important to explain to patients to apply a thin film of chlormethine gel to involved skin areas and allow the skin to dry completely. sophie dumas *,1 , capucine devaux 1 , nathalie le guyader 2 1 diaconesses croix saint-simon hospital, 2 diaconesses croix saint-simon hospital, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: aprepitant, a neurokinin-1 receptor antagonist, prevents nausea and vomiting due to high and moderate emetogenic chemotherapy in combination with other antiemetic agents. it induces cytochrome p450 (cyp) 2c9 and moderately inhibits cyp3a4. drug-drug interaction could occur with intravenous anticancer or antiemetic drugs metabolised by these isoenzymes. it may lead to adverse effects or loss in efficacy. regarding recent international antiemetic guidelines, emergence of new intravenous chemotherapy and lack of bibliographic data, a report on aprepitant interactions is performed in oncology. the aim of this study is to review pharmacokinetic interactions with aprepitant in order to prevent potential toxic effects of intravenous anticancer or antiemetic agents and provide the best patient care. design: anticancer and antiemetic agents metabolised by cyp3a4 and 2c9 were identified. pharmacokinetic literature review was performed using medline ò database and laboratory data. clinical assessment and non-aprepitant pharmacokinetic studies were excluded. a table was established to summarize data. results: ten intravenous anticancer agents used in oncology are identified as cyp3a4 substrates. pharmacokinetic assessments are achieved for docetaxel, cyclophosphamide, vinorelbine, irinotecan and trabectedin. studies dealing with the five other drugs are strictly clinical assessments. among the different pharmacokinetic studies, only trabectedin showed relevant interaction with aprepitant. in this association, aprepitant dose needs to be adjusted. cyp2c9 catalyses the cyclophosphamide activation pathway with minor contribution. however, it would have few repercussions on cyclophosphamide pharmacokinetic. corticosteroids and 5 hydroxytryptamine type 3 (5ht-3) receptor antagonists are also metabolised by cyp3a4. aprepitant significantly increases corticosteroid plasma concentrations. in this case, corticosteroid dose adjustment should be applied. furthermore, no interaction has been found with 5ht-3 receptor antagonist. conclusion: regardless of the emetogenic level of anticancer agents, all drugs have been studied because of theirs potential combinations. two relevant pharmacokinetic interactions have been demonstrated leading to dose adjustment recommendation. corticosteroids doses, in association with aprepitant, should be reduced one-fourth for intravenous form and one half for oral form. aprepitant first dose should be decreased to 80 mg when it is co-administrated with trabectedin. these two results lead us to re-evaluate our prescription practices. please specify your abstract type: research abstract background and objective: nsaids are associated with serious adverse reactions which in turn are responsible for significant risks of morbidity and mortality. the aims of this project is to identify risks involved in nsaid administration including over-usage and significant drug interactions, and to analyse occurrence of side-effects. the trends of nsaid prescribing by physicians and pharmacists are also determined. setting and method: a pharmacy from each electoral district was chosen by stratified sampling. a sample population (n = 100) was obtained from 13 pharmacies in malta. data was collected through the completion of questionnaires carried out by the patients. the trends of nsaid prescribing were determined by another questionnaire directed to 49 pharmacists and physicians that was available online. main outcome measures: use of nsaids by patients and prescribing trends. results: back pain (n = 19), muscular pain (n = 13), headache (n = 12) and arthritic pain (n = 10) accounted for the most frequent use of nsaids. diclofenac accounted for the most commonly administered nsaid, taken by 58 of the patients, of which 48 use the 50 mg dose. chronic disorders of symptoms experienced by the patients included hypertension (n = 24), heartburn (n = 22), dyspepsia (n = 21), asthma (n = 4) and a history of helicobacter pylori infection (n = 2). other disorders suffered by single individuals include epilepsy, crohn's disease and renal dysfunction. more than half of the respondents (n = 55) admitted to self-prescribing regardless the fact that the majority of nsaids are prescription-only medications. epigastric pain (64.6%), stomach ulcers or gi bleeding (30.6%) and elevated blood pressure (29.8%) were the most common sideeffects that pharmacists and physicians come across. nsaids were frequently found to be co-administered with antihypertensives (68.1%) and ssris (37%) regardless of their significant risks of interacting with nsaids. 75.5% of the pharmacists and doctors believe that nsaids are being over-used and 95.9% state that closer monitoring of nsaid adverse effects is necessary. conclusion: the risk involved with nsaid administration due to over-usage and drug interactions is identified, and healthcare professionals are aware of this risk. pierre leduc, antoine lanneluc, christophe gellis * , sylvie poux, dominique plats, regine larnaudie corrèze, ch brive la gaillarde, brive la gaillarde, france please specify your abstract type: research abstract background and objective: proton pump inhibitors (ppi) are widely prescribed in hospital while their long-term use may be responsible of many potentially serious long-term side effects (hypomagnesemia, neutropenia, gastric cancer) and drug interactions (ppi are inhibitors of cyp2c19). the objective of this study was to assess the appropriateness of ppi prescriptions in a geriatric department in order to optimize their conditions of prescriptions. setting and method: this prospective study involved patients hospitalized between january 2016 and april 2016 in a geriatric department. the accordance of the prescriptions with the marketing authorization indications and the french guidelines 1 was analysed. data collection was done using a table excel. main outcome measures: collected information were related to patients (age, sex) and ppi prescriptions (active substance, administration route, dosage, duration of therapy, therapy indication and reassessment of ppi therapy). results: ninety-one patients were included: sr: 0.3, mean age: 87.3 years [78; 102]. ppi therapy prevalence over the period was 38%. the ppi were prescribed in the geriatric department in 33 patients (mostly esomeprazole) whereas 58 patients had ppi therapy (mostly esomeprazole) at the admission, for more than 2 years in 42 patients. oral route was the most frequent one (n = 86). 89 ppi were administered once a day and only three ppi were administered in the morning. 40% of ppi prescriptions were considered unjustified; the indications were prevention of haemorrhage with antiplatelet therapy (n = 19), prevention of haemorrhage with corticoid (n = 4), prevention of haemorrhage with anti-vitamin k (n = 3), dyspeptic disorders (n = 2), gastralgy (n = 4) and others reasons (n = 4). 60% of ppi prescriptions were considered relevant. the reassessment of ipp therapy (n = 25) lead to prescribe another dosage (n = 9), to stop therapy (n = 11) or no change (n = 5). conclusion: the study showed that the majority of ipp prescriptions were not in accordance with french guidelines. limiting the prescription to the indications, reassessing the therapy or respecting the therapy duration should reduce the risk of long term side effects and the economic burden of ppi in a long term use. please specify your abstract type: descriptive abstract (for projects) background and objective: to evaluate the effectiveness and safety of the use of high dose of tigecycline (200 mg followed by 100 mg every 12 h) a tertiary care hospital. design: retrospective observational study. period: january to december 2015. inclusion criteria: episodes use of tigecycline (200 mg followed by 100 mg every 12 h. exclusion criteria: time less than 4 days treatment. data source: corporate program stories electronic health. results: we identified 24 episodes in 23 patients (15 men, mean age: 71 years (23-88)). treatment was directed to multidrug-resistant organism infection in 11 cases (seven klebsiella pneumoniae oxa-48, two enterobacter cloacae, two enterococcus faecium and one methicillin resistant staphylococcus aureus. in one episode they coincided e. cloacae and e. faecium). in 14 cases had severe sepsis or septic shock (seven abdominal focus, six respiratory focus and one unknown focus). the median number of days of treatment was 12 (4-119). tigecycline was administered as monotherapy in three cases, bitherapy 13 and triple combination therapy in 13. the antibiotics were associated were: beta-lactam (11), aminoglycosides (10), quinolones (3) colistin (three, two inhaled cases), cotrimoxazole (1) and vancomycin (1) . in 13 episodes produced clinical and/or microbiological resolution and 7 antibiotics are rotated by progression picture or lack of improvement, death occurred in three cases and 1 was suspended on suspicion of hepatotoxicity. among the seven episodes of klebsiella pneumoniae oxa-48 infection there were four pneumonias, three with favourable evolution and one patient died, two bacteraemia, both with resolution clinical and microbiological, and one urinary tract infection resolved. among the 14 episodes in severe/ septic shock were five cures, six cases of antibiotic rotation progression or lack of improvement and three deaths while patients receiving therapy tigecycline. 2 patients showed an adverse effect possibly related to therapy tigecycline: 1 diarrhoea after 15 days of treatment and 1case of liver toxicity after 4 days of tigecycline and piperacillin-tazobactam which led to their withdrawal. int j clin pharm (2017) 39:208-341 253 conclusion: tigecycline has been used in double dose defined in data sheet especially in situations of severe sepsis or septic shock and infection multiresistant microorganisms. the effectiveness is conditioned by the clinical situation patient, being worse in severe/septic shock sepsis. tigecycline high dose was well tolerated and there was only a case of stopping the medication for suspected damage hepatic. di012: wikipedia and medicines: who edits medicine articles on the english wikipedia? kristian husvik skancke 1 , kristian svendsen *,2 1 department of history, uit -the arctic university of norway, 2 hospital pharmacy of tromsø, tromsø, norway please specify your abstract type: research abstract background and objective: the medical profession and pharmacists are divided on the usability of wikipedia for looking up health information. nevertheless wikipedia is widely used, more than half of us physicians and 94 percent of all medical students use wikipedia as a source of health-related information. there is a potential for incorrect and biased information being added by the pharmaceutical industry. the aim of this project was to examine who edits wikipedia articles on medicines and to investigate whether the pharmaceutical industry edits these articles. setting and method: two different groups of articles has been examined; the top ten bestselling medicines (substances) in the world in 2014 and the ten most recently approved medicines on the european market (until december 2014). the top ten medicines were selected from a consultancy report by evaluatepharma/ep vantage. the ten most recently approved medicines (new substances) were found on the european medicines agency webpage. we queried the english wikipedia on 11 january 2015 and information from the edit history and the editors' user information were extracted. unregistered editors were checked using a whois service. for the new medicines all editors were checked, while for the bestselling medicines large edits and initial edits was checked. main outcome measures: edits suspected of being made by the pharmaceutical industry. results: ten bestselling medicines: there are many users editing these articles and/or watching them, limiting the risk of misinformation from the industry. there was no indication that the pharmaceutical industry had edited any of the articles. ten most recent medicines: no article existed for dasabuvir. for the nine other substances there were relatively few editors and watchers. in four out of the nine articles we found evidence of edits from the pharmaceutical industry. these edits, were done by registered editors with very few edits except for the medicine in question and they had made large additions to the articles sometimes even before the medicine was marketed. conclusion: the pharmaceutical industry seems to edit articles about medicines on english wikipedia however we found no evidence of harmful edits and bestselling medicines have many editors monitoring the quality of articles. please specify your abstract type: research abstract background and objective: the pharmaceutical professional service of the monitored dosage systems (mds) tries to improve the adherence of the patients to the treatment. the aim was to analyse the relevance of the repackaging of the most sold medicines in our country being used by patients included in the mds professional service and to determine the information discrepancies according to the source used by the pharmacist. setting and method: cross-sectional descriptive study. community pharmacy and healthcare institutions. all the patients included in the pharmaceutical professional service of mds on june 1, 2016. data source: patients' records in the professional service, database of medicines ranked by sales in units in our country to december 2015 (400 medicines), information sources on medicines: (1) vademecum of medicines and (2) the centre of drug information of our agency of medicines. main outcome measures: number of institutionalized and ambulatory patients included in the professional service of the mds and demographic characteristics, sum of different repackaged medicines belonging to the studied patients, analysis of the repackaged medicines of major use, number of discrepancies on the repackaging of the medicines according to the information source. results: 88 patients were included in the professional service of the mds. 67 of them were institutionalized (average age: 39.9 years, 65.7% men, 76.1% polymedicated defined as using c4 prescribed chronic medicines) and the remaining 21 were ambulatory (average age: 76.8 years, 57.1% women, 23.7% polymedicated). 130 different medicines prescribed in the institutionalized patients were taken into account, 29 of them included in the sales ranking in our country. according to the first source, 18 of 29 medicines were eligible for repackaging, 6 medicines could be repackaged according to the laboratory manufacturer and the 5 remaining ones could not be repackaged. according to the second source, 21 of 29 medicines could be repackaged, and the 8 remaining ones could not. 128 different medicines prescribed in the ambulatory patients were taken into account, 37 of them included in the sales ranking in our country. according to the first source, 27 of 37 medicines could be repackaged, 8 medicines would depend on the laboratory manufacturer and the 2 remaining ones could not be repackaged. according to the second source, 27 of 37 medicines could be repackaged, and the 10 remaining ones must remain in the original package. discrepancies were observed in the information for 8 (27.6%) and 14 (37.8%) medicines in institutionalized and ambulatory patients, respectively, based on the sources used. conclusion: a considerable number of discrepancies in the information on the relevance of the repackaging of medications in the mds were found between two analysed sources. these findings have already improved the quality of this professional service. it would be necessary to alert the pharmacist of the existence of the above mentioned discrepancies to be able to prevent errors from occurring at the time of repackaging the medicines in the mds and, thus, increasing patient safety. please specify your abstract type: research abstract background and objective: despite the global advances of pharmacy practice and subsequently pharmacy education, students experience insufficient opportunities to practice the activities, tasks and processes essential to deliver pharmaceutical care. objective: to describe the development, implementation, and assessment of a clinical pharmacy practice (cpp) experience course in internal medicine, cardiovascular, respiratory clinics and drug information centre that is newly integrated into pharmacy curriculum at a university in north cyprus. setting and method: a 8 weeks structured pharmacy practice experience was designed for fifth year students. student competence was assessed using formative osces and summative written exams before and after the course, and mapped in eight main cpp competences. the course utilized a wide variety of learning and practical activities including rounds participation, morning case reports, interdisciplinary activities, carrying interventions, role-play, direct patient care, formal case presentations, journal clubs and answering drug queries. competencies tested and strengthened include: taking medication history, response to the symptoms, pharmacotherapy knowledge application, comprehensive patient assessment, data interpretation using evidence-based approach, public health counselling, drug related problems management, patient counselling and communication skills. student perceptions and experience was assessed using semi-structured group interview and a questionnaire. main outcome measures: student scores in osce; student's perceptions. results: student reported that the course met pre-set objectives with substantial learning in different areas of cpp. students scored best in communication skills (83.4 ± 1.74%), public health promotion (76.6 ± 2.32%) and patient counselling (68.0 ± 2.74%) than in resolution of drps (49.0 ± 4.33%) and pharmacotherapy application (49.0 ± 3.37%), while they significantly enhanced in di manipulation (88.1 ± 2.6%) compared to baseline assessment (33.1 ± 2.41%)(p = 0.0038). conclusion: the course provided a rich experiential learning environment rather than just theoretical knowledge of clinical pharmacy. students well perceived the course structure assessment and knowledge attained. this could be implemented in other faculties of pharmacy through turkey. please specify your abstract type: descriptive abstract (for projects) background and objective: clinical pharmacy and clinical pharmacology have many similar aspects. both areas present professionals who have groundings in drug therapy principles and who aim to optimize the efficacy and safety of therapies for patient's benefits. however, there are clear distinctions. clinical pharmacologists are in general doctors with an additional education in clinical pharmacology. many of these are prescribers of drugs in practice but are in usual connected to academic parts responsible for education and research. they belong to a well-recognized but small sub-specialty of medicine. in contrast, clinical pharmacists are part of a much greater group of professionals working in most hospitals in developed countries. while the former one is restricted and subordinate to distributing the drugs requested by the medical prescribers, the role of the pharmacist has increasingly developed to encircle monitoring outcomes of medicine treatment and report management, patient safety and budgetary responsibilities. pharmacists are currently capable to take on prescribing responsibilities in developed countries and have been actively involved in collaboration in practice of prescribing with doctors. they also take on a great part in education related to rational prescribing that was once thought the area of the clinical pharmacologist. given the difference in size of the two areas there is understandably increasing confusion in the minds of managers in health services as to the continuing role and identity of clinical pharmacology. this may illuminate, in part, the diminishing in numbers and visibility of clinical pharmacologists in certain countries. in fact, some might see the continuous development of clinical pharmacy as a direct danger to the viability and future existence of the specialty of clinical pharmacology. however, clinical pharmacy and clinical pharmacology working synergistically would serve for the well-being of the public. design: . results: . conclusion: . maxime apparuit *,1 , lea boissinot 1 , ngauv melodie 1 , stephanie charles weber 2 , isabelle lopez 1 , françois chast 1 1 pharmacy, hopital cochin, 2 pharmacy, hopital hotel-dieu, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: hereditary angioedema (hae) is a rare disease characterized by episodic attacks of swelling which can be life-threatening. treatment for hae involves prophylaxis and management of acute attacks. the objective of this study was to evaluate patients' knowledge of their disease and their treatment. design: a questionnaire about the disease and drug treatment has been implemented. it was distributed to patients through either a pharmacist during patients stay at the hospital, or the french association des malades souffrant d'angioedèmes (amsao). answers were collected by electronic or conventional mail. results: 39 patients completed the questionnaire. the average patients age is 25.8 ± 27.2 years. all of those interviewed could name their disease. for 23% of patients, the crisis happened unpredictably but in most cases a triggering factor was described, such as stress (21%), fatigue (18%) or an emotional shock (17%). oedema were located mainly in extremities (31%), abdomen (19%), ent sphere (12%) or face (11%). 17 patients (43%) reported having more than 12 crisis each year (eligible to prophylaxis), among them, 5 patients (13%) said they had no preventive treatment. all patients knew the difference between prophylactic and curative treatment of crisis. among the 38 patients receiving treatment for crisis, 16 were able to define which treatment to be used depending on the intensity and location of the crisis. the majority of patients used icatibant during a crisis, but the most frequently cited prophylaxis treatments were tranexamic acid (38%) and danazol (35%). for injectable drugs to treat acute episodes, icatibant (subcutaneous) and c1 esterase inhibitor (intravenous) were self-administrated respectively in 79 and 8% of patients. conclusion: this study showed that patients generally knew their disease and its treatment. however, they are insufficiently informed on drugs to be used according to the clinical situation and especially intravenous self-administration. therefore, it seems necessary to increase pharmacist involvement in patient's information about therapeutic strategy and drugs routes of administration. this for a major objective: an optimal self-care in a skilled patient. please specify your abstract type: descriptive abstract (for projects) background and objective: hospital pharmaceutical educations (hpe) on patients with oral anticoagulant (oa) can improve their overall management by providing skills on proper use. an ambulatory monitoring is necessary to ensure good compliance and understanding of the treatment. our study aimed at the establishment of hpe for patients with oa, the establishment of a hospital-city link in burgundy, and an evaluation of the expectations of ambulatory health professionals (ahp). design: the development of hpe has been performed in our centre for patients with oa and assessed between may and september 2015. in order to ensure continuity in their support, patients then received a binding document to the attending physician, pharmacist and nursing home stating the treatment and acquired skills. a satisfaction survey, with anonymous electronic questionnaire circulated by the representative boards evaluating the expectations of ahp, took place in order to improve and make the programme more attractive. results: two hundred and ninety-one patients could benefit from hpe and 252 came out with an oa. one hundred and forty-three answers were collected: 38 officinal pharmacists and 105 nurses. ninety-seven percent of ahp have judged relevant the following stated security goals: the name of the drug, its use, its risks and to be able to inform all ahp. ''associated pathologies and treatments,'' ''the last coagulation test'' and ''potential factors for non-adherence'' seem necessary for the binding document. more than 90% of participants found that this action will facilitate the establishment of pharmaceutical anticoagulant educations in cities, the dialogue around the oa with the doctor, patient's compliance and will secure the treatment. conclusion: hpe certainly help patients. its implementation for patients with oa in our hospital has generated a real interest. the addition of an ambulatory link allows continuing at best their support. the questionnaire has also allowed us to know the opinions of ahp involved and some improvements to the binding document may have been done. participants were asked to associate the task to the profession by determining whether each profession had the main responsibility for undertaking the task, a supportive responsibility, or whether they should not be involved at all. data was analysed using spss ò, version 22. the chi squared test was used to assess any significant association between categorical variables. main outcome measures: perception of the oncology pharmacist's role by healthcare professionals. results: from a total of 84 completed questionnaires, it was found that for tasks listed as ''patient education and counselling'', 18% were considered as the pharmacists' main responsibility, whereas 42% were believed to be supportive roles. main tasks included educating the patient regarding which medication to avoid during their treatment. for tasks listed as ''drug related problems'', 20 and 45% of tasks were found to include pharmacists as having main and supportive roles respectively. supportive tasks included dose calculation of anti-tumour therapy required per patient. in the ''authorisation of medication'' category pharmacists' main roles carried a total of 13% and supportive that of 50% of the total number of tasks. this included ordering anti-tumour medication. further analysis of data revealed that years of experience did not have a significant association with results obtained (p-value = 0.074); however physicians, pharmacists and allied healthcare professionals were found to involve the pharmacist most extensively (pvalue = 0.000). conclusion: tasks associated with the pharmacist were representative of the current role they possess within the oncology setting; however this association was limited to professionals having a close working relationship with pharmacists. this may be due to the lack of an established multidisciplinary team approach within this scenario thus limiting the perception of the oncology pharmacist's contribution. an implemented multidisciplinary team may improve communication between the professionals involved and optimises patient care. the aim of the study is to analyse from a qualitative and quantitative point of view the pharmacy resident's activity in pneumology service. setting and method: the study included all the daily prescriptions of three units of pneumology from january to april 2016. pi and data were extracted from the software pharma ò and collected in a summary excel ò table: nature of potential errors, nature of the proposals offered by residents, way of transmitting pi, and rate of pis' acceptance. main outcome measures: potential errors are collected by following the validated and standardized criterions of french society of clinical pharmacy. results: over 4 months, 7968 lines of prescriptions from 412 patients aged 67 years old (median [28-85]) were evaluated. sex ratio (m/f) was 1.46. one hundred and two medication problems have been found: overdose (21.6%), contraindication (ic) (20.7%), under dosage (7.8%), wrong rhythm of administration (7.8%), forgotten treatment (7.8%), dose unit error (5.9%), antibiotic indication missing (5.9%), drug not listed in the hospital formulary (4.9%), potassemie unchecked (4.9%), dose unadapted to renal function (4.9%) or to inr (2.9%), treatment not indicated (1.9%), wrong administration route (0.98%), antibiotic unreevaluated (0.98%), redundancy (0.98%). the proposals made to the doctors were: stopping treatment (25.5%), posology adaptation (19.6%), substitution (19.6%), dose unit modification (7.8%), adding information about the indication (6.7%), treatment renewal (6.7%), administration modalities changing (4.9%), biological monitoring (3.9%), therapeutical monitoring (2.9%), antibiotic treatment reevaluation (2.94%). all pi were made by informatical way. all medicinal classes were found in this study. hydroxyzine, cyamemazine and escitalopram were often found in contraindication errors. they are involved in cardiac disorders with qt extension. pis' acceptance rate was 82%. conclusion: this study shows the importance of pharmaceutical analysis on the quality of access to healthcare. the statement of pi allows us to identify the most frequent errors, warn and prevent doctors from these potentials errors by proposing solutions. the rate of acceptance is high which means that doctors agree with our proposals. pharmacists' implication in clinical pharmacy activities and their participation to medical rounds will improve this activity and by the way optimization of the management of the patient. please specify your abstract type: descriptive abstract (for projects) background and objective: ppis consumption is largely practiced in europe, because of their excellent tolerance in short time, and their misuse with regard to indications, dosage and treatment duration (in 2007, france was the 2nd,ppi consumer in eu). the result is drug iatrogenic disease and unjustified expenses in health insurance. objectives: assess the ppis consumption and appreciate conformity according to the latest recommendations for relevant prescriptions of ppis. design: prospective study via an audit (model created internally), every hospitalized patients with a ppis prescription, in two hospitals, on a given day. data collected through the patient's medical record. prescriptions conformity defined, by taking account of indication level (1: approved by the ma (marketing authorization), 2: non-valid but certified by international publications or learned society, 3: nonvalid without scientific proofs, 4: non-indicated), dosage and treatment duration. analysed situations with no conformity (inappropriate dosage despite conform indication, treatment duration unjustified and ppis prescribed in wrong indications (3 and 4) . results: 172 patients have ppis prescriptions (78 male, 25 £ 99 years] among 325 patients (53%). 45% ppis prescriptions began during the hospitalization. 53 (30%) of the ppis prescriptions are in accordance with the experiment (indication + dosage +treatment duration), as well in community than in hospitals. details: indication level 1 (92.5%), indication level 2-gi bleedings-(7.5%). 119 of the ppis prescription aren't in accordance. details: treatment duration (6%), dosage (3%), indication level 3-prevention of iatrogenic bleeding risk without nsaids prescription-(75%), indication level 4 (16%). regarding level 3 indications, ppis are always taken with anticoagulant and/or platelet aggregation inhibitors and/or corticoid. conclusion: the part of ppis prescriptions in this study is high. the majority of non-conformity is caused by ppis prescribed with an indication level 3. the improvement program will involve feeding back ppis' good use, to educate physicians (junior and senior) about the relevant ppis prescription and give advice in complex situations (indication 3 and 4). in collaboration with prescribers, shutdown protocol of ppis, prescribed in long term, could be implemented in order to avoid the acid rebound effect after brutal treatment discontinuation. hp-ce014: impact of a self-management program on inflammatory bowel disease patient in a university hospital caroline egon * , xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: inflammatory bowel disease (ibd) is a group of chronic inflammatory diseases that affects the colon and the small intestine. crohn's disease and ulcerative colitis are the principal types of ibd and involve severe diarrhoea, pain, fatigue and weight loss. ibd affects young adult with an increasing annual incidence (2.5 million concerned people in europe). patients with ibd are affected by somatic or psychosocial problems and patient education may contribute to their well-being. since september 2010, individual educational sessions have been set up and since september 2015, collective educational sessions. these sessions have been developed to improve patient's understanding of treatment options and medical adherence. the aim of this study was to demonstrate that a therapeutic education program (tep) could have a significant effect on ibd patient's skills with regards to their disease. design: after individual education sessions with a nurse, a group education session was introduced for outpatients with ibd. the collective session include approximately six to ten patients and is organized in a half day workshops (about disease and treatment) conducted by a multidisciplinary team. the workshops were performed by an education nurse, two hospital gastroenterologists, two hospital pharmacists and a community pharmacist. these sessions were wrapped up by a short satisfaction and knowledge questionnaires. results: in total, 141 ibd outpatients participated to the educational program, 112 patients with crohn's disease and 29 patients with ulcerative colitis (52.5% male; median age: 39). for the individual educational sessions, two competence questionnaires were performed about anti-tumour necrosis factor alpha (tnfa) therapy: one about general knowledge, another one about self-administration subcutaneous injection. 43 patients completed these questionnaires. for the collective educational session, the competence questionnaire developed consisting of six questions covering few items: disease, symptoms, treatment and complications. 14 patients completed this questionnaire. after the questionnaire, each participant received a summary document about drugs, side effects, therapeutic and medical advice. conclusion: the patient education program contributes to the improvement of self-management skills when it comes to ibd. pharmacists joining medical specialists and nurses provided pharmaceutical care with a positive impact on compliance, which is a determining factor for the success of the treatment and the quality of life in patients living with an ibd. this program will be continued and a new program for teenagers is to be established as well. hp-ce015: desensitization study of paclitaxel and carboplatin drug in the ovary tumor protocol in cuf descobertas hospital miguel â . freitas * , daniela brites, ana bota pharmacy, hospital cuf descobertas, lisbon, portugal please specify your abstract type: descriptive abstract (for projects) background and objective: the hospital pharmacy should be an integral part of the multidisciplinary team and implement strategies that meet the patient's needs. pharmacy, in oncological area, is in constant renewal. josé de mello saúde uses paclitaxel/carboplatin protocol as first line in ovarian tumor. although the antineoplastic agents are essential for the treatment of cancer, they can also cause hypersensitivity reactions, which may carry serious consequences. both immunoallergologist and oncologist create a desensitization protocol, which allows the reintroduction of the drug with greater security. the desensitization protocols involves the gradual administration of small quantities of the drug, resulting in a refractory period of the white blood cells (mastocytes) and a lower production of cytokines until the dose has been totally administrated. objective:to evaluate the efficacy of methods used to prevent and treat hypersensitivity reactions of carboplatin and paclitaxel, in order to carry on the treatment. design: a retrospective review of the patient files was performed in the day hospital between 2014 and 2016. we included only patients with moderate to severe immediate hypersensitivity reactions (b24 h) receiving carboplatin and paclitaxel. the desensitization protocol brigham and women's hospital was applied using three solutions with increasing concentrations (dilution 1: 100, 1:10 and 1:1) in twelve successive steps for about 6 h. results: in the period 2014-2016 were desensitized five patients with platinum group drugs, carboplatin (n = 4) and paclitaxel (n = 2) and the total elapsed six desensitization. almost all patients reached the scheduled daily dose, except a patient, which suspended the desensitization program for disease progression. conclusion: the desensitization protocol allowed the successful reintroduction of antineoplastic drugs in patients with a history of hypersensitivity reactions, in order to treat the disease. please specify your abstract type: research abstract background and objective: in the context of harmonization of clinical pharmacy activities within our region, a common medication reconciliation project was developed between two general hospitals. the objectives of this study were to initiate, a common medication reconciliation activity in the two hospitals, to analyse the results, and to communicate to all professionals in the area. setting and method: a working group composed of pharmacists of each hospital was formed to develop analytical documents. a 3-month prospective study was conducted in two general hospitals: in the first one, in an emergency department, and the other one, in a medicine department. patients included in the study were either elderly and/or had polypharmacy and/or were hospitalized for iatrogenic reason. at int j clin pharm (2017) 39:208-341 259 the point of admission and discharge for each patient, the pharmacist has completed a conciliation record, and has detected potential discrepancy. unintentional discrepancies were reviewed and corrected by doctors. at the discharge, medication changes were sent to general practitioner and community pharmacies. a satisfaction survey about this process was sent to 39 healthcare professionals (gp, pharmacist and nurses). a medication reconciliation's workshop was organized for a hundred healthcare professionals in the area. main outcome measures: at the point of admission, the conciliation record included the list of patient's home medication, admission medical orders, and the types of discrepancies. at the discharge, drugs prescribed were compared to admission medical orders. the satisfaction survey included seven questions to assess the process. results: during the study period, 35 patients were included corresponding to 351 prescription lines. reconciliation process required about 47 min per patient. we identified at admission 33 unintentional discrepancies. the most common unintentional discrepancy was the omission of medication (61%). 25% concerned alimentary tract and metabolism group. at the discharge, no discrepancies were found; the process required 35 min per patient.41% of healthcare professionals answered to our satisfaction survey to date. 100% are satisfied and believe that the process of medication reconciliation secures the patient medicinal treatment.56 healthcare professionals were present at the medication reconciliation's workshop, indicating an interest in the process. conclusion: in this experience of medication reconciliation, due to unintentional discrepancies observed, we had better implement this activity in the two general hospitals. a pharmacist devoted to this activity will be hire in each hospital. this relevant practice is well accepted by clinician. thus, we will improve communication with gp and community pharmacies. please specify your abstract type: descriptive abstract (for projects) background and objective: the sickle cell disease (scd) is a genetic, chronic disease, paroxystic in its unpredictable and polymorphic acute events. this most frequent genetic illness in the world is a major public health concern in french overseas territories. haute autorité de santé (has) recommendations for the care of scd advocate the development of therapeutic patient education (tpe). in martinique (french west indies), we consider the population of patients with scd in 1500 among which 1000 are followed in the adults sickle cell centre (ascc). one of the actions carried out by the ascc of our hospital is the tpe. the objective is to set up an original (because specific in the scd) tpe method, which enables the patient to live better with his disease on a daily basis, by teaching him and his family to recognize prematurely certain complications. design: we analysed needs from the outcomes of a national french survey has which one participated martinique and retained the following themes: the red blood cell, the genetic transmission, the main symptoms, the role of the water, the medicinal treatments and the questions of everyday life. we chose the innovative educational tools called the ''malles des savoirs ò **'', a set of unusual experiments, accessories and models, which, by using a method of active pedagogy ''omca*: observer, manipuler, comprendre, agir ***'', value the learner by offering to him to manipulate and to experiment by himself. results: in 2016, 24 healthcare professionals (doctors, pharmacists, nurses) and a president of patients with scd association followed one week of formation in the omca* method for the animation of six workshops for 10-15 teenagers and adults. every ''malle des savoirs ò **'' contains the necessary material for the animation and a guide of the organizer, including, for every tackled issue, a generic introduction, a presentation of the themes, the index cards of educational animations proposing the activities and one time of synthesis grouping the approaches concepts. the interactive manipulation allows the appropriation of the discoveries become then long-lasting experiences. a final evaluation allows to spot the problems met by learners to understand, to analyse the difficulties and to proceed to the useful adaptations during the next activity. conclusion: this tool, playful and perfectly adapted to the scd, engages, accompanies and helps patients in the construction of their own knowledges to return them actors of their disease. in 2017, we shall estimate the impact of the development of this specific tpe programme of the patient with scd. please specify your abstract type: research abstract background and objective: to investigate the frequencies and clinical relevance of unintentional medication discrepancies, between preadmission medication lists and discharge medication lists, at discharge from hospital. a discrepancy is considered unintentional if there is no documentation explaining the intent of the medication change or if it is unintentional according to the prescribing physician. setting and method: systematic literature review. main outcome measures: frequency of unintentional medication discrepancies per patient and per medication; frequency of clinically relevant medication discrepancies. results: of the patients included 14-88% experienced at least one unintentional medication discrepancy. of the medications used by the patients, 3-50% were involved in unintentional medication discrepancies. of unintentional medication discrepancies found in five studies, 15-58% were clinically relevant. conclusion: the review documented a high frequency of medication discrepancies, of which many were clinically relevant. ensuring sufficient communication of correct and complete medication information in transitions of care is a process which should be better implemented, to enhance patient safety. please specify your abstract type: research abstract background and objective: to investigate the frequency of medication changes not documented in the discharge letter, at discharge from hospital, for both regular, as needed and over-the-counter medications, supplements and herbal remedies (otc). secondary, differences between variables and patients with undocumented medication changes were investigated. setting and method: the patients included were all part of the intervention groups from an intervention study, conducted by one of the authors (tg), from april 2013 to december 2014. the best possible discharge medication list was compared against the medication list in the discharge letter and any discrepancy between the two lists was noted, taking into account the text in the discharge summary. main outcome measures: the proportion of patients affected by at least one undocumented medication change at discharge and proportion of medications with undocumented changes. the proportion of patients was compared using a test according to gender, age, number of preadmission/discharge medications and length of hospital stay. results: two hundred patients were included in the study. the proportion of patients experiencing at least one undocumented medication change for the three subgroups: regular medications; as needed; otc, were 78, 65 and 55% respectively. the proportion of medications involved in undocumented changes for the three subgroups were 34, 71 and 77% respectively. the proportion of patients experiencing undocumented medication changes was significantly higher in patients with more than five regular medications at admission, (p \ 0.001) and at discharge (p \ 0.001). in both regular and as needed medications, the proportion of patients experiencing undocumented medication changes was higher in patients hospitalized longer than 2 days (p \ 0.001 and p: \ 0.05 respectively). for otc, the rate of patients experiencing undocumented medication changes, was higher in females (p: \ 0.05). conclusion: a high proportion of patients are affected by at least one undocumented medication change and many medications are involved in undocumented changes. correct and complete medication information at admission and discharge may resolve many of these errors, ensuring patent safety at transitions of care. hp-ce020: participation in courses at learning and mastery centre and the impact on patients' beliefs about medicines merethe nilsen *,1 , erik oie 2 , kirsten k viktil 1 1 diakonhjemmet hospital pharmacy, 2 department of internal medicine, diakonhjemmet hospital, oslo, norway please specify your abstract type: descriptive abstract (for projects) background and objective: patients with chronic diseases are referred to learning and mastery centre (lmc) where the main objective is to support patients to cope with chronic diseases. education about the disease(s) (by a physician) and the medication treatment (by a clinical pharmacist) are important elements of these courses. little is known about how the participation at lmc influences the patients' beliefs about medicines. design: patients c18 years participating at a 2 days course at lmc regarding acute coronary disease or atrial fibrillation were included in the period september 2014-december 2015. the patients filled out 'beliefs about medicines questionnaire'(bmq) before and immediately after the course, and also 3 months after the course to evaluate their concern (bmq-concern) and necessity (bmq-necessity) of their cardiovascular medications. the bmq scores were dichotomized at scale midpoint (scale 1-5) to evaluate high and low concern and necessity, and these scores were combined to calculate the 'ambivalence'and 'acceptance', 'sceptical', and 'indifferent'rate to medications, and also the mean scores of the bmq were calculated. results: fifty patients were included, mean age 65 years, 14% were women, using a mean of 3.5 cardiovascular drugs taken regularly. fifty-eight percent of the patients had high concern prior to the course, whereas 37 and 60% had high concern immediately after and 3 months after the course, respectively. ninety-nine percent of the patients assessed their medication as highly necessary before the course, 100% immediately after, and 97% 3 months after the course. the mean score for bmq-necessity was 3.82 (sd 0.64) prior to course and 3.88 (0.56) and 3.78 (0.69) immediately after and 3 months after the course, respectively. the corresponding scores for bmq-concern were 2.58 (0.78), 2.39 (0.72), and 2.57 (0.77), respectively. the proportions of patients classified to be 'accepting'were 40, 63, and 43% at the three time points, respectively, and the corresponding numbers for patients classified as 'ambivalent'were 56, 38, and 60%, respectively. conclusion: the lmc course had an immediate positive influence on the patients' concern about their medicines and on 'acceptance'. however, the effect seems not to persist over time. a closer follow-up could be discussed. please specify your abstract type: research abstract background and objective: the narrative-based medicine was intended primarily for health care professionals, and the use of narratives can be applied in any settings to better understand the meaning of own profession, to rediscover/strengthen the motivation to work as a team. the italian society of hospital pharmacist (sifo) promotes a qualitative study aimed at getting the real picture of pharmacist's role within the national health system (nhs), the interaction with other health professionals and patients through the narratives of under specialization pharmacists (ui) and pharmacists already working in the nhs (hp). these data can be further investigated to increase the perceived value/role of the pharmacist. setting and method: sifo hps and uis joining the national pharmacy school specialization network were invited to participate. all pharmacists participating to the study were given a semi-structure interview. the methodology was developed within the conceptual framework of the grounded theory (gt) a research methodology that arises in the context of qualitative research. gt is a systematic methodology involving the construction of theory grounded in data systematically gathered and analysed. main outcome measures: analysis of narratives. narratives were analysed according to the classifications of kleinman, frank and launer and robinson together with transitional analysis (ta). results: a total number of 31 narratives were collected (16 ups and 15 hps). narratives from both group of participants show the need of strengthening the professional identity already in the early years of the pharmacy curriculum and more effectively during the years of specialization as well as the need of being educated to deliver patientcentred care as members of an interdisciplinary team. conclusion: this is the first step of a study that also includes patient's contribution to the definition of pharmacist's professional identity. hp-ce023: impact of pharmaceutical counselling on cancer patients' information desire and treatment satisfaction stephanie wuyts *,1 , jacques de grève 2 , veerle foulon 3 , hilde collier 1 , pieter-jan cortoos 1 1 pharmacy, 2 medical oncology, university hospital brussels, brussels, 3 faculty of pharmaceutical sciences, catholic university of leuven, leuven, belgium please specify your abstract type: research abstract background and objective: appropriately educating onco-/haematological patients is a prerequisite to improve patient empowerment, satisfaction and outcomes. objective: to quantify patients' information need and satisfaction on cancer drug therapy and how this can be improved by clinical pharmacist's counselling. additionally, the pharmacist's impact on therapy quality and costs is assessed. setting and method: setting: prospective, randomised study in the ambulatory (26 beds) and in-hospital onco-/haematology unit (34 beds) in a tertiary hospital. inclusion criteria: adult patients on intravenous or oral cancer therapy, with informed consent. methods: all patients were asked to complete standardised surveys (extent of information desired, eid; patient satisfaction with cancer treatment education, ps-cate and cancer satisfaction of treatment questionnaire, ctsq) on three occasions (at the start of a new therapy, during the second cycle and after 3 months). patients in the intervention group received additional counselling by a clinical pharmacist including medication reconciliation and review. control patients received standard of care (information on drug therapy was provided by the onco-/haematologist, followed by limited administration instructions by nursing staff). main outcome measures: patient information desire and satisfaction on cancer treatment results: 83 patients were included over a period of 6 months (control (n = 43); intervention (n = 40)). no significant differences were found between contact moments or patient groups for eid, ps-cate and ctsq-scores. however, scores for ps-cate on medication side effects were positively correlated with contact moment (r s = 0.198; p = 0.022). multiple linear regression analysis showed a similar trend (b = 0.207; p = 0.101). patients receiving first-line therapy (b = 0.270; p \ 0.001) and ambulatory patients (b = 0.027; p = 0.018) were more satisfied on treatment education. the clinical pharmacist documented more drugs than were recorded in the patient file (8 vs. 4.9 drugs/patient; p \ 0.001). on average, each patient required two pharmacist's interventions per occasion. intervention acceptance rate on drug related problems was high (72%). during the study, interventions shifted from therapy adjustments towards advice on supportive measures (1st contact: 12%; 3rd contact: 41%). improved medication stock control on the ward led to a savings of €36,890. conclusion: the clinical pharmacist can play an important role on the onco-/haematological ward, leading to improved drug reconciliation, patient counselling and cost savings. hospitalised patients and patients receiving salvage therapy appear to have higher educational needs, making them possibly overlooked target groups. finally, pharmaceutical counselling should be repeated and primarily focused on side-effect management to have a meaningful impact on patient satisfaction. please specify your abstract type: research abstract background and objective: europe is ahead of the usa and canada on approval, regulatory and marketing aspects of biosimilars. however, there is still uncertainty about interchangeability and substitution of biosimilars. the aim of the study is to assess pharmacists' perceptions about biosimilar interchangeability. setting and method: a cross-sectional study was carried out in june-july 2016. hospital pharmacists from quebec and france were invited to respond to an online survey of nine questions (surveymonkey ò , palo alto, ca, usa). the survey focuses on pharmacist's exposition to biosimilars (general knowledge, dispensing) and their perceptions about biosimilar interchangeability. a 5-item likert scale was used to answer to 15 statements based on key issues about biosimilar interchangeability. main outcome measures: levels of agreement on biosimilar interchangeability key issues. results: a total of 229 pharmacists responded (62% in quebec vs. 38% in france). the global response rate is: 27% (23% quebec vs. 34% france) (n = 229/880). 64% attended at least to one conference on biosimilars (57 vs. 74%). 36% had already dispensed biosimilars (7 vs. 81%). more than 95% of the pharmacists knew that: biosimilars can cause immunogenicity, clinical studies are requested for their approval, automatic substitution is not permitted. 43% considered that post-marketing surveillance for biosimilars should be reinforced. pharmacists considered that biosimilars are cheaper than the reference product (89 vs. 75%). there was no difference between the level of agreement of french and quebec pharmacists for the 15 statements. pharmacists agree that a list of biosimilar and interchangeable biologic products is necessary (85 vs. 77%), using the international nonproprietary name to prescribe a biological product can create confusion between the reference product and its biosimilar (60 vs. 55%), pharmacists should check if patients already experienced an immunogenic reaction before dispensing a biological product (82 vs. 70%). pharmacists disagree that a biosimilar can be used for all the indications of the reference product (53 vs. 46%). conclusion: perceptions of quebec and french hospital pharmacists about biosimilar interchangeability issues are very similar. this study highlights the need to deal with the lack of clarity of national guidances. clinical studies on biosimilar interchangeability must be conducted in the future to help pharmacists and physicians to take clear-headed decisions. please specify your abstract type: research abstract background and objective: analgesics are essential drugs in hospitals and especially in emergency units. medical and nurse staffs are used to the narcotic status of opioids. for some drugs, a regulatory change to narcotic status can discourage their use. for others, it could limit their access particularly in developing countries; that's why who did not recommend ketamine to be placed under international control (http://www.who.int/medicines/access/controlled-substances/ recommends_against_ick/en/). yet, the french drug agency has recently considered to register drugs containing ketamine as narcotics. the aim of this study was to assess the impact of this possible regulatory change on the pharmaceutical and medical practices in some paediatric french hospitals. setting and method: the survey was conducted in january-february 2016 in four parisian paediatric hospitals: four pharmacies, paediatric neurology and anaesthesia departments, intensive care units and pain management services. main outcome measures: pharmacists, clinicians, health managers and nurses were interviewed, using a standardized questionnaire with closed and opened questions, on the drug circuit including ordering, storage, distribution, prescription, administration and destruction. results: all the 20 health professionals (five pharmacists, ten clinicians, five nurses) indicate that the change to narcotic status would not preclude the use of an analgesic drug. they consider that the pharmaceutical aspects (dispensation, storage and transport, etc.) are not limiting, provided that clinical usefulness is demonstrated: short action onset allowing rapid efficacy, short duration of action allowing the replacement by another drugs if needed, and moderate clinical monitoring. change to narcotic status was rather seen as advantageous since allowing better traceability, use and prescription. half of the pharmacies (n = 2/4) had a computerized register of narcotics and 80% of care units (n = 4/5) had a drug staffing in addition to nominative prescriptions, which was used in all care services. the drugs were kept into secured rooms. none of the emergency units (n = 0/5) had a computerized secured cabinet. conclusion: according to this survey, narcotic status is not a limiting factor for a drug use in paediatric hospitals, when its clinical usefulness is clearly demonstrated. to promote its use, it is important to inform medical and nurse staffs and include it into care protocols. beyond the nominative prescription, implementation staffing is a key step. please specify your abstract type: research abstract background and objective: port-a-cath is an implanted venous access device most commonly used for frequent or continuous chemotherapy administration. however, the procedure and its subsequent maintenance are not free of complications and requires additional intervention by the clinical pharmacist who can provide further patient care to make a positive impact on. to assess the effective provision of appropriate patient counselling offered by a clinical pharmacist on reducing port-a-cath relatedcomplications in cancer patients. setting and method: a controlled prospective observational study carried out on 110 patients newly diagnosed with cancer eligible for chemotherapy administration at the oncology unit. assessment of port-a-cath related-complications were assessed at regular schedule of chemotherapeutic protocols administration. main outcome measures: to assess, reduce and solve port-a-cath related-complications. results: the most significant port-a-cath related complications were skin rash 55.5% (p \ 0.05) with occurrence in males (n = 40) and females (n = 21), skin erythema 5.5% with equal occurrence in both genders, followed by skin discharge 1.8% with also equal occurrence in both genders. a high occurrence of skin rash 88.2% occurred among diabetic cancer patients. a significant improvement in port-a-cath related complications after the provision of patient counselling by the clinical pharmacist was observed as skin rash (3.6%), skin discharge (0.9%), and skin erythema (0.9%). conclusion: results of this study pointed out the essential role of clinical pharmacist in argumenting patient care and improving port-a-cath related-complications in cancer patients. please specify your abstract type: research abstract background and objective: polytherapy, frequently used in the elderly, is associated to an increased risk of potential drug-drug interactions (pddis) and adverse drug reactions (adrs). literature demonstrated that medication reconciliation and medication review performed by hospital pharmacists are correlated to drug related problems (drps). aim: to define a structured and feasible model where hospital pharmacists support clinicians identifying drps and promote the safe use of medicines. setting and method: prospective, feasibility study conducted in four internal medicine wards of a hospital in northern italy. inpatients (c65 years old, treated with c5 drugs) were consecutively included; the recognition/reconciliation process was performed by pharmacists in order to identify changes between prescription profile at home and during the admission (active principles, dose, administration route). these changes were classified as intentional documented discrepancies (id), not documented (ind), not intentional (ni). prescriptions during the first 24-hours of hospitalisation were analysed to retrieve drps (ddis, inappropriate medications for elderly, off-label, over/ under dosage, duplications, adrs) then discussed with clinicians. based on literature, referring almost 1 drp in 70% of patients, a sample size of 50 patients should allow an estimate of drp rate over 50% (need of intervention) with a 80% power and a confidence interval of 95% (software stata version 12.0). main outcome measures: rate and type of: discrepancies, drps at admission and discharge, pharmacists consultations accepted by clinicians. results: ad interim results are presented. between october/2015-february/2016, 30 inpatients (16 male, 85.4 mean age) were included. overall, patients were admitted with 257 drugs used at home and 240 prescribed during the first 24-hours; pharmacists retrieved 99 discrepancies (45%id, 52%ind, 3%ni) and 118 drps, of which 57% ddis, 1% off-label, 3% overdoses, 3% duplications, 30% inappropriate drugs, 6% not notified adrs. the 70% of drps was known to clinicians and 52% considered clinically relevant for the patients. please specify your abstract type: research abstract background and objective: hypertension is a major risk factor for cardiovascular morbidity and mortality worldwide, for which management is based on two principal, complementary approacheslifestyle modification and lifelong treatment with antihypertensive medication. adherence to hypertension therapy is a major public health challenge, despite the availability of multiple classes of antihypertensive agents. factors contributing to non-adherence are multifactorial and include intolerances to drugs at standard doses that result in therapy discontinuation. medication intolerance (mi-htn) refers to patients who experience adverse drug reactions (adrs) to at least one antihypertensive medication, without a known immunological mechanism and the need to discontinue them. we sought to determine factors associated with mi-htn and to identify patients' beliefs and concerns about their antihypertensive treatment and medication in general. setting and method: a cross sectional survey consisting of selfreported questionnaires including beliefs about medicines questionnaire (bmq), perceived sensitivity to medication (psm) and quality of life was undertaken in an unselected patients attending a hypertension centre of excellence out-patient clinic based in london. main outcome measures: to determine factors associated with mi-htn and the impact of health beliefs and self-reported perceived sensitivity to medications on mi-htn and bp control. chi squared tests for comparisons between cases/controls and multiple logistic regression analysis were used for statistical analysis. results: 102 participants were included, of which 46 (45%) participants had mi-htn. two-thirds were female (p = 0.002) with a mean age of 70 ± 10 years (p 0.001), of whom 67.4% had uncontrolled hypertension (p = 0.063). calcium channel blockers were the most commonly reported intolerance by drug class followed by diuretics. being female and age [60 were statistically associated with a greater likelihood of reporting medicines intolerance (p \ 0.05). patients who believed that medicines are harmful were [5-times more likely to report mi-htn (p = 0.009) and 4-times more likely to have uncontrolled bp ([140/90 mmhg) (p = 0.024). patients with high self-perceived sensitivity to medication was 4-times more prone to mi-htn (p = 0.007). conclusion: our findings suggests the need for greater focus on behavioural change interventions to both improve patients' perception of the necessity to persist with lifelong antihypertensive medication and allay concerns regarding harmful effects of drugs may help with long term control of hypertension. please specify your abstract type: research abstract background and objective: today, the number of medical problems in heart transplant recipients has increased due to aging and complications common to immunosuppressive drugs. the co-existence or emergence of other disease states such as renal dysfunction, infection, diabetes, obesity, hypertension, hyperlipidaemia, malignancies, and osteoporosis necessitates the use of other medications. the use of these medications in combination with immunosuppressive agents increases the risk of drug-drug interactions. the aim of this study is to identify the frequency and significance of drug-drug interactions for the patients who received cardiac transplantation. setting and method: this retrospective study was conducted at a cardiovascular specialty hospital. all patients who received cardiac transplantation from the same surgery team between 2009 and 2014 (6 years) were included in the study. all data were collected from the medical records of the patients. only the most recent prescription before discharge was analysed for the presence and significance of drug-drug interactions. drug-drug interactions were checked using micromedex(r) interaction checker. main outcome measures: main outcome measures were the frequency and significance of drug-drug interactions. results: a total of 58 patients met the inclusion criteria and 58 prescriptions were analysed. each prescription contained an average of 11 drugs. a total of 529 drug-drug interactions were identified: 51.8% was classified as moderate; 43.4% as major and 3.7% as contraindicated. almost half of all interactions (n = 271) included immunosuppressive agents (59.4% was classified as moderate; 35.4% as major and 4.8% as contraindicated). conclusion: cardiac transplant recipients were found to have a high number of drug-drug interactions. in order to advise on these interactions which increase with poly-pharmacy, drugs with narrow therapeutic index or drugs that require intensive monitoring, it is recommended to include a transplantation pharmacist in the transplantation team. please specify your abstract type: research abstract background and objective: the aim of our study was to assess the impact of patient education provided by the pharmacist on gylcemic control, medication knowledge level and medication adherence of patients with type 2 diabetes. patients who were diagnosed with type 2 diabetes for at least one-year time and were receiving at least one antidiabetic medication, attending to the outpatient diabetes clinic for the control visit were informed about the study and invited to participate in the study. patients who gave their informed consent were included in the study. setting and method: the setting is a diabetes outpatient clinic of a state hospital. the medication knowledge levels, medication adherence scores, fasting blood glucose levels, hba1c levels and blood pressure of the patients were measured before pharmacist's education. after provision of standard information and individualized patient education all these parameters were measured again after 3 monthstime and the impact of the education was assessed. main outcome measures: main outcome measures are change in the clinical parameters (hba1c; fasting blood glucose; blood pressure), as well as improvements in medication knowledge and adherence levels. results: the study was conducted on 54 patients who met the inclusion criteria; none of the patients were lost to follow-up. majority (83%) of the patients was female and the mean age was 53.7 years. pharmacist intervention resulted in positive outcomes at all clinical parameters. systolic blood pressure decreased by 6 mmhg, while diastolic blood pressure decreased by 1.76 mmhg (p \ 0.05). hba1c level decreased by 0.39% (from 6.94 to 6.55%; p \ 0.05) and fasting blood glucose level by 7.1 mg/dl (p [ 0.05). on the other hand, the number of patients reaching the blood pressure goal increased from 36 to 46; and those reaching to hba1c goal increased from 23 to 32 (p \ 0.05 for all). similarly, the medication knowledge level [usual range 0-8] increased from 4.43 to 5.82 (p \ 0.001); and the medication adherence score [usual range 0-4] increased from 3.4 to 3.09 (p \ 0.001). conclusion: it can be concluded that pharmacist's contribution results in positive outcomes in glycaemic control and management of co-morbid conditions of type 2 diabetic patients by improving medication knowledge and adherence levels of the patients. pharmacists should take active role in management of chronic diseases. hp-pc043: impact of a pharmaceutical care program on glycemic control, medication knowledge and medication adherence levels of type 2 diabetic patients residing at a nursing home nimet saglam *,1 , sule apikoglu-rabus 1 , betul okuyan 1 , fikret v. izzettin 1 , nuran yildirim 2 1 clinical pharmacy department, marmara university faculty of pharmacy, 2 darulaceze nursing home, istanbul, turkey please specify your abstract type: research abstract background and objective: the aim of our study was to assess the impact of pharmaceutical care provided by the pharmacist on glycaemic control, medication knowledge level and medication adherence of patients with type 2 diabetes residing at a nursing home. setting and method: this prospective cohort study was conducted in a state nursing home (darülacaze nursing home) in istanbul, turkey on 39 patients who completed the whole study. all the patients received pharmaceutical care provided by the pharmacist. this pharmaceutical care program was held for 3 months. it consisted of an initial visit, followed by 5 ''care and control'' visits and a final control visit; each visit was held at two-week time intervals. at the initial visit, demographic and general clinical data were collected and medication knowledge and medication adherence levels of the patients were also assessed. pharmaceutical care needs were identified for each patient and recommendations addressing these issues were structured. education regarding the medications of the patients was provided in both verbal and written forms using the standard patient education leaflets prepared by the pharmacist. at each visit pharmaceutical care needs are assessed and pharmaceutical care is tailored accordingly. main outcome measures: main outcome measures are change in the clinical parameters (hba1c; fasting blood glucose), as well as improvements in medication knowledge and adherence levels. results: majority (74%) of the patients was male and the mean age was 68.8 years. pharmacist intervention resulted in positive outcomes regarding hba1c levels. hba1c level decreased by 0.35% (from 7.02 to 6.67%; p \ 0.05) and fasting blood glucose level by 11 mg/dl (p [ 0.05). similarly, the medication knowledge level [usual range 0-8] increased from 2.67 to 5.44 (p \ 0.001); and the medication adherence score [usual range 0-4] increased from 2.9 to 3.28 (p \ 0.01). conclusion: it can be concluded that pharmacist's contribution results in positive outcomes in glycaemic control of type 2 diabetic patients by improving medication knowledge and adherence levels of the patients. pharmacists should take active role in management of type 2 diabetes at the nursing home setting. please specify your abstract type: research abstract background and objective: haemoglobin variability is related to mortality and morbidity in haemodialysis, renal transplantation and pre-dialysis patients. some demographic, haematological and pharmacological variables may affect hb variability. but there are some controversies about the influences of different erythropoiesis stimulating agents (esa).the objective of this study is to determine the influence of different esa on haemoglobin variability in pre-dialysis patients. setting and method: we conducted a prospective observational study with chronic kidney disease patients recruited from outpatients of nephrology department of a tertiary university hospital (from january 2011 to june 2012). exclusion criteria were: stage i and ii, not treated with esa, haemodialysis, peritoneal dialysis, renal transplantation, thalassemia, and deficit of glucose-6-phosphate dehydrogenase . main outcome measures: patients included were treated with esa in maintenance phase (stable 6 months prior).hb variability was calculated by standard deviation (sd) and residual standard deviation (residual sd) of hb levels. statistical analysis was performed with spss 15.0 (spss inc, chicago). observation period was 18 months and data were recorded from the clinical records. (2) 5.7%, sofosbuvir/daclatasvir/ribavirin (2) 5.7%, sofosbuvir/simeprevir (4) 11.4%, sofosbuvir/ledipasvir (6) 17.1%, sofosbuvir/ledipasvir/ribavirin (3) 8.5%, dasabuvir/ombitasvir/paritaprevir/ritonavir (2) 5.7%, dasabuvir/ombitasvir/pari taprevir/ritonavir/ribavirin (14) 40% ombitasvir/paritaprevir/ritonavir/ ribavirin (1) 2.8%, sofosbuvir/ribavirin (1) 2.8%. viral load at week 4 was \15 iu/ml in 32 patients and at the end of treatment 33. conclusion: the results of rapid viral response at end of treatment were similar to those obtained in studies published to date. due to its recent access to these treatments it is necessary to continue monitoring these patients to assess virologic sustained response at 24 weeks after end of treatment. please specify your abstract type: research abstract background and objective: fragile patients are considered those vulnerable patients with a certain degree of complexity in their care (polypharmacy, multi-pathological, palliative and/or residents in social and healthcare institutions). to ensure their continuity of care and safety in the use of drugs we applied a medication reconciliation process at admission, transition of care and/or hospital discharge. objective: to analyse the results of the medication reconciliation process of a fragile patient. setting and method: we developed a list of current medication with the following sources of information: medical history, clinical databases and information provided by the patient (interview). clinical case: 95-year-old woman admitted through emergency department due to severe dyspnoea. no known drug allergy. background: heart failure, chronic hypertension, hypercholesterolemia, hyperthyroidism, hyperuricemia, gouty arthritis, chronic kidney disease and cognitive impairment by alzheimer disease. exploration and complementary tests: echocardiogram and analytical control. clinical judgment: acute decompensated heart failure. acute myocardial infarction. prerenal acute kidney injury. main outcome measures: medication reconciliation made at admission with the detection of discrepancies and deprescribing criteria at hospital discharge. results: fragile patient (high-risk) with 13 medicines as home treatment. patient was hemodynamically stable during the hospital stay. 9 discrepancies were detected between the prescribed medication and the home treatment. discrepancies justified (7): five by omission of medication (two new clinical situation, two therapeutic exchanges to adapt to the pharmacotherapy guide and one wrong drug) and two beginning of medication. discrepancies unjustified (2): by omission of medication. to discharge: one antiplatelet therapy was. after the comprehensive review, we made the following recommendations of deprescription: suspend one non-steroidal anti-inflammatory drug-nsaid (by risk of bleeding in association with concomitant antiplatelet and antidepressant therapy) and one benzodiazepine (central nervous system-cns side effects); modify treatment: reduce doses of diuretics (blood pressure lowering effect). pharmacotherapeutic recommendations were accepted. conclusion: detection of discrepancies in the medication reconciliation and deprescription process are effective and safe strategies that allow optimization of pharmacotherapy in fragile patients. the use of drugs such as nsaids (gastrolesive effect), the combination of drugs with cns side effects and hypotensive action (associated with falls) in elderly patients constitute situations of risk that should be reviewed in fragile patients, as an essential part of the clinical evaluation. please specify your abstract type: descriptive abstract (for projects) background and objective: there are no positions for clinical pharmacists at the hospital, so we are dependent on projects to be able to show how pharmacists can contribute in the clinical team. our aim in this project was to introduce pharmaceutical knowledge by implementing medication reconciliation and medication review in different hospital wards. we wanted to show that many patients have discrepancies in their medication lists during hospital stay and that some of the drugs or doses given can cause drug related problems for the patient. our final goal was to get the physicians to be more aware of these issues when treating their patients. design: the method used was based on the two first parts of the integrated medicines management. the pharmacist conducted a standardized drug interview with patients who prior to admission were responsible for their own drugs. for patients who could not be interviewed or were not responsible for administering their own drugs, a current medication list from relevant care level was obtained. the medication lists obtained were compared to the documentation in the patient's drug chart and discrepancies communicated to the physician. during the hospital stay, a medication review and monitoring was also conducted by the pharmacist. results were presented to the patients physician and discussed. results: a total of 129 patients were included and of these 63% had c1 discrepancy identified by the process. the most frequent type of discrepancy was the use of a drug that was not registered on admission (omission discrepancies). other discrepancies were wrong dose, dosage or formulation and registration of a drug the patient didn't use. drug-related problems were discovered in 61% of the patients and the most frequent were use of anticholinergic drugs in elderly, interactions, lack of treatment and monitoring and too high doses regarding kidney function. many of the detected drug related problems results in change in medication, other times the physician addresses the problem to the gp. the physicians were surprised of the high numbers of discrepancies in medication lists and drug related problems discovered. almost all the physicians considered that the pharmacist could be an important part of the treatment team and they wanted the participation of the pharmacist to be permanent. conclusion: the project led to increased awareness of the importance of medication reconciliation and medication review and showed the importance of pharmaceutical knowledge in the treatment team. unfortunately this was not sufficient to create positions for pharmacists in our hospital. new projects will focus on pharmacists teaching interns to improve the reconciliation at admission. please specify your abstract type: descriptive abstract (for projects) background and objective: we aimed to assess the quality of fluoroquinolones (fq) prescriptions at the toulouse university hospital emergency department as part of significant increase in consumption. design: retrospective mono-centric study of fq prescriptions written to adult patients managed at the emergency department (february 29th, 2016 -march 6th, 2016 . a pair consisting of a biologist pharmacist and a clinical pharmacist has analysed them using tools provided by the centre de coordination de lutte contre les infections nosocomiales (cclin). various criteria (pertinence of prescription, choice of antibiotic, dosage, duration of treatment, method of administration…) were faced with the guidelines issued by the société de pathologie infectieuse de langue française (spilf). results: about 1229 files were examined, 17 contained fq prescriptions for systemic use. the most frequently prescribed antibiotic was ofloxacin (59%) and the most frequent indications were urinary tract infections (47%). among the 17 prescriptions of fq, the establishment of fq was justified in 71% of cases and the antibiotic chosen was always the most suitable. nonconformities of dosage and/ or treatment time were found in a quarter of cases. overall, 47% did comply with guidelines. the prescriptions, due to the particularity of emergency were still permormed probabilistic. however, a reassessment of them was scheduled for two-third of outpatients. conclusion: this study highlights the conformity of less than half of the prescriptions. this demonstrates that there are still actions to ensure the accuracy of fq prescriptions. and it is in this sense that this audit should be registered under the impetus of the committee on anti-infectives. it will raise awareness among doctors in the proper use of this family of antibiotics. please specify your abstract type: descriptive abstract (for projects) background and objective: the number of persons suffering from end-stage renal disease (esrd) is growing worldwide, mainly due to the aging of the population. esrd incidence has been increasing by 3-7% per year for 10 years. it is estimated that worldwide, more than 1.5 million patients with established renal failure are being treated with haemodialysis (hd). water for haemodialysis must meet the physicochemical and bacteriological compliance standards defined by the european pharmacopoeia. as a medicine, this water is placed under the responsibility of hospital pharmacists. addressed to hospital pharmacists, this methodology guide will enable them not only to validate controls of haemodialysis water as well as drug prescriptions for dialysis patients, but also to familiarize themselves with the best currently existing dialysis techniques and medical devices. we have tried to simplify and synthesize existing circulars and guidelines so as to render them more readily understandable for the pharmacist in charge of a haemodialysis service, and thereby help to ensure optimally safe treatment of haemodialysis patients. design: the themes developed in this guide are: • a review of the different existing dialysis techniques, • a review of the different sampling points for controls of hd water, • a review of the physicochemical and bacteriological standards of these controls according to the latest recommendations of the european pharmacopeia, and of appropriate conduct for exceeding established thresholds, • a review of the main international recommendations with regard to clinical signs of chronic kidney disease: anaemia, mineral and bone disorders (ckd-mbd), high blood pressure. • a review of the various medical devices used in haemodialysis and haemodiafiltration. results: the recommendations of good practices summarized in this guide are integrated perfectly adapted to the concept of quality assurance and its role in the accreditation process. they are focused on improving patient safety by harmonizing pharmaceutical haemodialysis practices in different dialysis centres. conclusion: these types of recommendations may be transposable to other pharmaceutical fields and/or be used as a training tool for pharmacy students or young pharmacy school graduates. the format of this guide makes it convenient, easy to use every day. it will be revised regularly to ensure the sustainability of quality plans. please specify your abstract type: descriptive abstract (for projects) background and objective: combination antiretroviral therapy (cart) has strongly improved disease control in hiv-infected patients. however, aging and comorbidities are becoming a major problem in this group of patients. most hiv-infected patients are treated with five or more medications, and harms by polypharmacy increase proportionally with number of medications. possible risks include: poor medication adherence and consequently inefficient care, increased risk of drug interactions and adverse events, with prolonged hospitalization. the problem is worsened when patients are of nonnative language and so their comprehension and adherence to drug therapy can be very poor, compromising efficacy. the hivig study is designed to evaluate the impact of the interventions promoted by the clinical pharmacist in the optimization and comprehension to personal drug therapy, favouring compliance, in a cohort of patients, hiv infected with comorbidities like cancer; the cohort includes a high number of non-native italian language individuals. design: hivig is a randomised, parallel groups clinical trial. in april 2016 the study protocol was approved by the local ethical committee, aviano. the project is scheduled to start in autumn 2016. main objective: evaluation of the impact of a series of tools-''drug therapy setting interventions'' (dtsis) applied by the clinical pharmacist on a cohort pf hiv-infected patients with comorbidities, afferent for care at cro aviano. the treatment arm will be submitted to dtsis. dtsis interventions (treatment group) consist in: motivational interview, sharing and delivery of printed, explanatory material in the patient's native language, reconciliation of patients medications at hospital admission and at discharge; identification of potential risks due to drug-drug interactions; monitoring of compliance to drug therapy, and finally detection of adverse drug reactions (adrs) occurring in the course of care. the control group will undergo only to scheduled standard medical visits at cro. results: we expect to recruit a total 350 patients for a 24-months period of follow-up. statistical analysis will be performed by intention-to-treat and by protocol. at cro aviano, the italian cooperative group on aids and tumors (gicat) has studied malignancies in hiv-positive patients since 1986 and has a leading role for studies conducted in italy (vaccher, 2014) conclusion: previous collected data from the previous trial performed at cro aviano (target-vig), showed a positive impact in the optimization of individual drug therapy and in the reporting of adrs. hiv has an enormous impact on life of infected patients and represents a priority issue for the entire community. we consider the method of dtsi, combined with a close monitoring of patients by means of telephonic motivational interviews, the best added value performed by the profile of the clinical pharmacist in optimizing drug therapy and personal awareness about medicines. please specify your abstract type: research abstract background and objective: the world health organization reports that ''one in four people in the world will be affected by mental or neurological disorders at some point in their lives. around 450 million people currently suffer from such conditions, placing mental disorders among the leading causes of ill-health and disability worldwide». to review the evidences published about the roles and the impact of pharmacists in psychiatry. setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, mental illness and psychiatry from january 1st 1990 until june 14th 2016. manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions and descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in psychiatry. results: a total of 62 articles were included. described pharmaceutical interventions included patient-pharmacist relationship (7), medication reconciliation (26), patient care needs assessment (25), drug therapy assessment (74), patient follow-up (61), interdisciplinary work (26), knowledge transfer (104), competencies maintenance (2). the impact of pharmacists interventions was studied using a total of 369 indicators from which 146 (40%) had outcome measures. of these 146 outcome indicators, 68 (47%) were positive, 77 neutral and 1 negative (knowledge transfer strategy). positive impacts of pharmaceutical interventions were identified in the following areas: morbidity (24), patient adherence (11), patients or clinicians satisfaction (7), side effects management (2), medication errors prevention (2), mortality (2) please specify your abstract type: research abstract background and objective: the world health organization reports that 8.2 million people die each year from cancer, an estimated 13% of all deaths worldwide and that there is a 70% increase in new cases of cancer expected over the next two decades. to review the evidences published about the roles and the impact of pharmacists in cancer. setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, neoplasms from january 1st 1990 until june 20th 2016. manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions as well as descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in cancer. results: a total of 42 articles were included. described pharmaceutical interventions included patient-pharmacist relationship (6), patient care needs assessment (76), drug therapy assessment (84), drug compounding/dispensing (1), patient follow-up (93), interdisciplinary work (15), knowledge transfer (39). the impact of pharmacists interventions was studied using a total of 274 indicators from which 112 (41%) had outcome measures. of these 112 outcomes indicators, 98 (88%) were positive, 13 (12%) neutral and 1 (1%) negative. positive impacts of pharmaceutical interventions were identified in the following areas: morbidity (59), patient adherence (2), patients or clinicians' satisfaction (3), side effects management (8), medication errors prevention (7), mortality (0), costs (2) setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, myocardial infarction, acute coronary syndrome from january 1st 1990 until june 14th 2016. manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions and descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in myocardial infarction. results: a total of 35 articles were included. described pharmaceutical interventions included patient-pharmacist relationship (11), medication reconciliation (39), patient care needs assessment (2), drug therapy assessment (102), drug compounding/dispensing (8), patient follow-up (51), interdisciplinary work (60), knowledge transfer (52). the impact of pharmacists interventions was studied using a total of 177 indicators from which 107 (61%) had outcome int j clin pharm (2017) 39:208-341 269 measures. of these 107 outcome indicators, 49 (46%) were positive, 56 (52%) neutral and 2 (2%) negative. positive impacts of pharmaceutical interventions were identified in the following areas: morbidity (8), patient adherence (10), side effects management (1), mortality (5) and others (21). conclusion: the role and the impact of pharmacists have been studied in myocardial infarction and 46% of outcome indicators used in these studies show a positive impact of pharmaceutical interventions. pharmacists should pay attention to these evidences to improve their practice, contribute to prevention or insure treatment of patients with potential or found myocardial infarction. hp-pc055: impact of pharmaceutical care in vaccination: a review of literature please specify your abstract type: research abstract background and objective: the world health organization reports that ''immunization is the process whereby a person is made immune or resistant to an infectious disease, typically by the administration of a vaccine and a proven tool for controlling and eliminating lifethreatening infectious diseases and is estimated to avert between 2 and 3 million deaths each year. it is one of the most cost-effective health investments, with proven strategies that make it accessible to even the most hard-to-reach and vulnerable populations». to review the evidences published about the roles and the impact of pharmacists in vaccination. setting and method: literature review. a literature search was conducted using pubmed and the following terms: pharmacists, clinical pharmacy, pharmaceutical services, pharmaceutical care, pharmacy, vaccination and immunization from january 1st 1990 until july 5th 2016. manual search was also conducted using selected articles. the selection of articles was based on abstracts. selected articles were reviewed, analysed and entered in impactpharmacie.org website according a standard operating procedure. relevant key data were extracted for each article including the type and the description of pharmaceutical interventions and descriptive and outcomes indicators with their results. no statistical analysis was conducted. main outcome measures: proportion of outcome indicators associated to pharmaceutical interventions with a positive impact in vaccination. results: a total of 43 articles were included. described pharmaceutical interventions included patient-pharmacist relationship (37), medication reconciliation (19), patient care needs assessment (37), drug therapy assessment (26), patient follow-up (39), interdisciplinary work (11), knowledge transfer (47), competencies maintenance (1). the impact of pharmacists interventions was studied using a total of 212 indicators from which 81 (38%) had outcome measures. of these 81 outcome indicators, 65 (80%) were positive, 15 (19%) neutral and 1 negative. positive impacts of pharmaceutical interventions were identified in the following areas: cost (3), errors (2), morbidity (21), patient adherence (14), patients or clinicians satisfaction (3) please specify your abstract type: descriptive abstract (for projects) background and objective: evaluating the appropriateness and effectiveness of the patient's medications by analysing prescriptions is pharmacist side work. bedside drug administration and computerised drug administration traceability (cdat) in nursing care plan (ncp) are nurse's one. however, in order to check adherence, efficiency and tolerance of a drug, pharmacist has to ensure that the patient takes the medication appropriately. therefor ncp could be a useful tool. the aim of this study is to evaluate the effectiveness of cdat, and if not, define causes of divergences with real life situation. design: • comparison between unused drugs remained in individual patients' seven daily pill dispensers (considered as not taken) which come back from the evaluated service to the pharmacy, and their cdat status completed by nurses (taken, not taken or no status) • two recorded data, each collecting a three-week period, separated by a period of discussion with nurses: first results presentation, analysis of divergences by taking into account their feedbacks, and actions to raise their awareness about the importance of cdat. • pill dispensers' cdat is correct only if all returned drugs' status in ncp is ''not taken''. results: during the first period (n = 112 pill dispensers), 29.5% of pill dispensers had an incorrect cdat status. on average, 1.4 drug per pill dispenser didn't have an appropriate status in ncp (taken or no status). major causes of divergences were the lack of time and insufficient human resources, the fact that they often are interrupted in the middle of this task, a software which isn't ''user-friendly'' and a deficit of information about the issue. corrective actions were implemented, prior to the second recorded data period, targeting human factor of divergences (oral and written reminders about cdat with didactic memorandum on computers). after awareness actions, results (n = 110) were 23.6 and 1.5 respectively. conclusion: efforts about cdat have been done but not enough to observe a significantly improvement in short terms. ncp's level of reliability is not optimal yet and still dependent on nurses' practices. this study allowed us to strengthen the relationship between clinical service and pharmacy, and opens the way for further works particularly through corrective actions targeting material and organizational causes of divergences. please specify your abstract type: descriptive abstract (for projects) background and objective: in 2015, our teaching hospital has participated to a worldwide survey (global point prevalence survey (global-pps)) aimed to explore antimicrobial consumption and resistance in hospitals. because broad spectrum antibiotics have to be followed with the attention of resistance prevention, we focused our analysis on these antibiotics in our hospital (carbapenems, piperacillin/tazobactam and amoxicillin/clavulanic acid). design: the survey was performed by pharmaceutical team (senior and resident) with help of microbiologists and referring physicians. all wards of the hospital were included. hospitalized patients treated with antimicrobial agent (j01, j02, j04a, p01ab, a07, j05ah, p01b from the atc classification) prescribed at 8 a.m. on the day of the survey, were involved. from those who were treated by carbapenems, pip/taz or amx ac, following data were collected: age, gender, weight, doses, indications (probabilistic? documented? and if documented microbiological data), and mention of stop/review date of prescription. results: the survey was carried out from april to june 2015 in 51 wards. among the 1435 patients included, 369 patients (25.7%) were treated with antimicrobial agents.114 patients (30.9%) were treated with broad spectrum antibiotics: 53 (14.1%) with amx-ac, 47 with pip-tz, 6 with imipenem and 8 with meropenem. the mean age of patients was 60.5 ± 17.7 and the weight was 67.9 ± 13.9 kg. their prescriptions were concentrated in three types of wards: 24 (21.1%) in icu, 47 (41.2%) in medicine, 43 (37.7%) in surgery. moreover, we observe that bsa were used to treat 33 (28.9%) community acquired infections, 54 (47.4%) nosocomial infections, 6 (5.2%) used as medical prophylaxis, or surgical prophylaxis (n = 19, 16.7%). in relation to the type of treatment: 66 were empirical treatment (including 25 prophylaxes) and 48 were targeted treatments (3 bacteraemia, 5 joint and bones infections, 1 cardiovascular system infection, 12 urinary tract infections, 10 lower respiratory tract infections, 10 skin and soft tissues infections and 7 others infections). finally, 23 extended spectrum beta-lactamase (esbl) producing enterobacteriaceae and 1 third generation cephalosporin resistant enterobacteriaceae non-esbl producing were targeted by bsa regimen. conclusion: in this survey, use of bsa is globally compliant to french guidelines and we identified no improper prescription: multidrug resistant bacteria infections, several diseases and empirical treatments with limited duration of regimen. this shows that control of the proper use of antibiotics especially those with a broad spectrum is efficient in our hospital and has to be continued. this has been made possible due to a multidisciplinary approach including physicians, bacteriologists and pharmacists. please specify your abstract type: descriptive abstract (for projects) background and objective: in 2015, our teaching hospital has participated to a worldwide survey (global point prevalence survey (global-pps)) aimed to explore antimicrobial consumption and resistance in hospitals. from these results, we observed that sulfamethoxazole/trimethoprim (tmp/smx) was largely prescribed in our hospital. we focused then our analysis on these results with the attention of check of its proper use. design: the survey was performed by pharmaceutical team (senior and resident) with help of microbiologists and referring physicians. all wards of the hospital were included. hospitalized patients treated with antimicrobial agent (j01, j02, j04a, p01ab, a07, j05ah, p01b from the atc classification) prescribed at 8 a.m. on the day of the survey, were involved. from those who were treated by tmp/smx, following data were collected: age, gender, weight, doses, and indications (probabilistic? documented? and if documented microbiological data), and mention of stop/review date of prescription. please specify your abstract type: research abstract background and objective: in france, benzodiazepine (bzd) is frequently prescribed in elderly people (ep). long-term efficacy is often questioned, and treatment has to be regularly re-examined, especially in ep. in our geriatric day-hospital for assessment of frailty, a multidisciplinary team evaluates the patients and gives them preventative measures against the loss of autonomy. medication evaluation is part of these measures. the aim of our study was to evaluate the impact of a standardized intervention on the optimization of bzd treatment. setting and method: after a short interview and the delivery of an information booklet about bzd, patients were proposed an optimization of their bzd treatment (dosage reduction, occasional medication, switch to a short half-life bzd, or total discontinuation). patients were followed up monthly by a phone-interview over a 6-months period. main outcome measures: the main outcome measure was the prevalence of bzd optimized treatments after a 6 months follow-up. results: 18 patients were included. among them, 50% have been taking a bzd for more than 10 years, and 29% were prescribed a long half-life bzd, which can be qualified as inappropriate in ep. 50% of the subjects were frail and 44% pre-frail according to the fried criteria. at the end of the study, 33% of the patients had their bzd treatments optimized, including 17% of total discontinuation. conclusion: in frail or pre-frail elderly population, a standardized intervention can be useful to improve bzd treatment. an extension to this intervention would be the creation of an organisation tasked with routinely monitoring the patients withdrawal over a 6 month period. hba1c and weight were significantly reduced by 1.36 ± 1.79%, p \ 0.000 and 3.21 ± 3.52 kg, p \ 0.000, respectively; systolic bp (12.91 ± 10.57 mmhg, p \ 0.000), diastolic bp (6.39 ± 7.34 mmhg p \ 0.000) and triglycerides (45.58 ± 115.65 mg/dl, p .011).genital-and urinary tract infections were reported by 6.7% patients. any diabetic ketoacidosis case was reported. conclusion: sglt-2 inhibitors added to other oral antidiabetic drugs or insulin in patients with uncontrolled t2dm significantly improved glycaemic control, reduced weight, blood pressure and triglycerides, and was generally well tolerated. in conclusion, sglt-2 inhibitors, appears to be an important addition to the therapeutic options for the management of type 2 diabetes, particularly when used as add-on therapy. (1). treatment safety takes part of the decision to undergo bariatric surgery. during multidisciplinary team meetings, the clinical pharmacist must rely on guidelines to limit drug-induced iatrogenesis. this review aims at assessing influence of bariatric surgery on the clinical impact and pk of cardiotropic drugs so as to document pharmacists' notifications. setting and method: literature review on medline-1946 to may 2016-with terms: cardiovascular drugs and bariatric surgery or malabsorption syndrome. related articles were reviewed. main outcome measures: pharmacokinetic or pharmacodynamic data and clinical impact of cardiotropic drugs. results: a total of 924 titles, and abstracts when necessary, were screened for eligibility. after reviewing process, 15 studies were included: nine concerning digoxin, five beta-blockers (bb) and one amiodarone. published studies varied in methodology: five case report, seven case control and three cohort studies. studies reported variations of digoxin plasmatic concentrations among 22 patients versus 66, suggesting liquid oral form are preferred. no clinical event was notified. more the bb is liposoluble (propranolol), the higher the toxicity is, such as heart rate and blood pressure decreasing, with potential fatal outcomes. a case of amiodarone-induced hyperthyroidism is described after bariatric procedure showing an increase plasma concentration adjusted to weight. conclusion: while the impact on narrow therapeutic range drugs is documented, others cardiotropic drugs may cause serious patient injury justifying their monitoring. therefore, risk must be identified for all patients undergoing bariatric surgery to setting up closely therapeutic monitoring. further studies are still expected to lead to recommendations about posology and treatment withdrawal to improve patient safety. please specify your abstract type: research abstract background and objective: the issue of non-compliance to prescribed medical treatment has been reported to be a crucial problem in psychiatric outpatients. the aims of this study were to assess the extent of non-compliance in a cohort of psychiatric outpatients in malta and to investigate the applicability of using a 7-day multi-dose pill box in terms of practicality, ease of use and impact on compliance within this patient group. setting and method: the study was conducted at mount carmel hospital, a psychiatric hospital in malta. twenty outpatients were recruited by convenience sampling. the study was divided into two phases. during phase 1, patient compliance was assessed using the medication adherence rating scale (mars) survey and patients were administered part a of a questionnaire entitled 'assessment of the 7-day multi dose pill box'. this questionnaire evaluated the patients' opinion regarding the 7-day multi dose pill box before and after its use. in phase 2, the chosen patients were given a demonstration on how to use the 7-day multi dose pill box and the device was given to them to use at home for one week. after one week, part b of the questionnaire was completed and compliance was re-assessed using mars . main outcome measures: evaluation of adherence before and after use of the compliance aid device. results: of the 20 patients recruited, 9 were male and 11 were female. the mean age was 46 years (range 33-70) and the mean number of daily medications 6 (range 3-16). upon initial scoring using mars, 15 patients were adherent and 5 patients were nonadherent. a higher adherence was observed in patients taking 5 or more medications daily. ten patients accepted to move on to phase 2 of the study and took the device home to use for one week. out of these 10 patients, 4 felt that the way they take their medication improved following use of the device and 7 out of 10 patients would consider buying the device since they found it practical and easy to use. statistical analysis of mars score before and after use of the device showed no significant improvement in compliance (p [ 0.05). there was no significant association between level of adherence and type of psychiatric condition (p [ 0.05). furthermore, results did not indicate increased adherence in patients who have a carer in-charge of their medication administration or in patients using a compliance aid device (p [ 0.05). conclusion: the use of a compliance aid device in psychiatric patients is challenging due to difficulty in establishing patient communication and motivation. the pharmacist is in a position to identify patients who would benefit from the compliance aid device. adrien borowik * , anne fratta, fabien hernandez pharmacy, ap-hp, armand trousseau paediatric hospital, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: enoxaparin, a low molecular weight heparin, is the most prescribed anticoagulation treatment in paediatric indications. however, the marketing authorization mentions that due to the lack of data, the use of enoxaparin is not recommended to children nor anyone weighing less than 40 kg. thus, expert recommendations described specific dosage for the paediatric use: we aimed to compare these with our hospital practices. (3), sofosbuvir/ledipasvir (20), ombitasvir/ paritaprevir/ritonavir (4), ombitasvir/paritaprevir/ritonavir + dasabuvir (12), simeprevir + ifn (1) . twenty-six patients (44%) were treated for 24 weeks (12 week pay-back policy). twenty pharmacists' interventions were carried out with an acceptance rate of 80%. the interventions included treatment adjustments due to drug interactions (4), inappropriate treatment according to genotype (2), duration of treatment (5) and switch to a more cost-effective therapy (9). seven pharmacists' interventions concerning treatment switch were applied (78%) resulting in a cost saving of €102,102.7. all assessable patients (28) have a negative serum hcv rna 12 weeks after the end of treatment (svr = 100%) while 1 patient died during follow-up (due to the disease). conclusion: the hospital pharmacist, as an active member of the multidisciplinary team, has an essential role in guaranteeing optimal care for hcv patients at the best cost. monitoring has also shown to be fundamental to evaluate the real world effectiveness of these drugs approved with surrogate endpoints. hp-pc068: are hospital pharmaceutical staff educated on the criticality of thermosensitive drugs? camille castel, guillaume saint-lorant * please specify your abstract type: research abstract background and objective: in the use of thermosensitive drugs, the safety of patient care involves compliance with allowed temperatures. having the right information at time of care is essential. the aim of this study is to assess, within a french university hospital, pharmaceutical staff knowledge on the criticality of thermosensitive drugs and to educate them accordingly, including associated patient risks. setting and method: an assessment of knowledge using a questionnaire was led in january 2016 among pharmaceutical staff in a 1500-bed hospital (11 pharmacists, 14 pharmacy residents, 28 pharmacy technicians). evaluation criteria were: storage temperature of refrigerated drugs and frozen drugs, thermosensitive drug retention period after removal from the refrigerator, highest risk situation for a thermosensitive drug (t [ 8°c or t \ 2°c) and action to be taken during a temperature excursion. main outcome measures: to determine shortcomings in the management of thermosensitive drugs in order to adapt appropriate tools. results: 43 completed questionnaires were collected. collected questionnaires included 12% from pharmacists (n = 5), 23% from pharmacy residents (n = 10) and 65% from pharmacy technicians (n = 28). regulatory variations in storage temperatures of refrigerated and frozen drugs are known in respectively 79 and 32% of cases. 3% of pharmaceutical staff are aware of thermosensitive drug retention periods after removal from the refrigerator and 51% of the highest risk situation for a thermosensitive drug (t \ 2°c). the measures to adopt during a temperature excursion are understood in 84% of cases. conclusion: this study highlights the lack of knowledge on the management and criticality of thermosensitive drugs and the lack of information available to pharmaceutical staff. dissemination of data and questionnaire reponses have been beneficial for the pharmacy department and have reduced inequalities in available information among pharmaceutical staff. subsequent to the study, thermosensitive drug management procedures have been revised. the deployment of this questionnaire is continuing via the university hospital intranet in order to train all health professionals in good patient care. please specify your abstract type: research abstract background and objective: temocillin is a beta-lactam antibiotic exclusively active against gram-negative pathogens. its use can avoid that of broad spectrum antibiotics, such as carbapenems, for the treatment of infections due to extended-spectrum beta-lactamase producing enterobacteriaceae. however, the absence of recommendations by learned societies on temocillin use could lead to misuse and the emergence of resistance. the aim of this study is to identify the role of temocillin in a french university hospital arsenal in order to limit ecological risks. setting and method: a retrospective study was conducted in a 1500-bed university hospital. all adult patients having received at least 2 days of treatment between june 2015 and april 2016 were included. data collected for the study were: age, sex, treatment indication (type of infection, identified pathogen, dosage and treatment duration), previous antibiotics and therapeutic outcomes. main outcome measures: the indicators chosen were: treatment indication, prescribed dose and treatment duration. results: two patients were included. in july 2015, temocillin was used in a 47 year old female as first-line treatment of intraperitoneal haematoma infection due to multiresistant klebsiella pneumoniae. prescribed at a dose of 2 g twice daily by an infectious diseases specialist, treatment was continued at the same dose for up 3 weeks with therapeutic success. in august 2015, temocillin was used in a 59 year old male for the treatment of bacteraemia due to multiresistant enterobacter aerogenes. previously treated by imipenem/cilastatin, temocillin was prescribed as second-line treatment at a dose of 2 g twice daily by an infectious diseases specialist. treatment was continued at the same dose for up 6 weeks with therapeutic success. conclusion: the dissemination of antibiotic resistance among gramnegative enterobacteriaceae continues to be an increasing threat for healthcare worldwide. within this context, temocillin could be an interesting alternative. determining the role of temocillin in a therapeutic arsenal is essential. our hospital considers temocillin as a ''critical antibiotic'' although its use is not exclusively limited to the new drug application. therefore, temocillin prescriptions are monitored permanently by infectious diseases specialists, microbiologists and pharmacists in order to improve the good use of this antibiotic and to optimise patient safety. please specify your abstract type: research abstract background and objective: drinkable solutions are more susceptible to deterioration and can lead to a potential risk for patient care. having the right information at time of care is essential. the aim of this study is to assess nursing staff knowledge in a french university hospital on the management of drinkable solutions to elaborate tools to help health professionals and to enhance equality of information in order to optimise patient care. setting and method: an assessment of practice using a questionnaire was conducted in may 2016 among a share of the nursing staff in a int j clin pharm (2017) results: 133 completed questionnaires were collected. 20% of nursing staff replied that the period-after-opening is the same for all of drinkable solutions. this period is estimated at 1 month in 21% of cases, 2 weeks in 10% of cases and 7 days in 8% of cases. 58% of nursing staff do not know how to store drinkable solutions after opening. the date of opening or the date of expiry after opening are specified on the medicine bottle in respectively 77 and 3% of cases. only 11% of nursing staff have tools pertaining to the management of drinkable solutions. these observations led the pharmacy to create and distribute appropriate tools. storage methods for the drinkable solutions available in our hospital were collected directly from pharmaceutical laboratories. this information has been made available to nursing staff via drug control software (pharma ò , computer engineering, paris). conclusion: this study highlights the lack of knowledge on the management of drinkable solutions and the lack of information available to nursing staff. in our hospital, the dissemination of appropriate data reduced inequalities in available information between care units. data will soon be integrated within the drug prescription software (mc kesson usv2 ò , crossway, san francisco) in order to homogeneously train all health professionals in good patient care. please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) is a process which allows prevention of iatrogenic injuries during patient's hospitalisation and transfers. since 2013, a clinical pharmacist has been integrated into the orthopaedic surgery care. he has performed mr at patients' admission. the aim of this study was to evaluate the impact of medication reconciliation performed by a clinical pharmacist. design: a prospective monocentric study was conducted on patients admitted in an orthopaedic surgery care (elective or unplanned surgery), during 3 months. the clinical pharmacist established the best possible medication history (bpmh) from at least three sources of information (including patient interview when possible). then, it was compared to the admission medication order (amo) (from anaesthetists when elective or orthopaedists when unplanned). unintended medication discrepancies (umd) detected were discussed with prescribers in order to be corrected. epidemiological data, number and type of umd, therapeutic classes involved and the percentage of corrected umd were collected and their potential clinical impact was assessed. results: in this study, 325 patients were included during 3 months. elective surgeries were concerned in 72% of the cases. at least one umd was identified in 158 patients (49%) (median age: 77.1 years old; male/female ratio: 0.65). of these, 133 (84%) were older than 65 years old. finally, 406 umd were detected, being 2.6 by patient. main therapeutic classes concerned cardiovascular system (31%), nervous system (20%) and digestive system (18%). of the 406 umd detected by mr, there were 55% of omissions, 27% of inappropriate dosing and 13% of renewal prescriptions stopped by the patient. finally, 87% of umd were corrected. of these 406 umd, 2% were major errors (i.e. causing potential harm), 39% were significant errors (i.e. monitoring or intervention potentially required to preclude harm) and 59% were minor errors (i.e. without potential harm to the patient). conclusion: medication reconciliation process performed by a clinical pharmacist allows detection and correction of umd on half of patients in surgery care particularly on elderly patients. the high proportion of umd can be explained by the multiplicity of actors involved in medication management. health information technology could help to focus mr on patients at high-risk of adverse drug events. please specify your abstract type: research abstract background and objective: darunavir plus ritonavir (drv/r) have shown optimized results in simplification strategies (monotherapy (mt) or dual therapy (dt)) for selected hiv + in randomized clinical trials and real life experience. recent introduction of one pill drv plus cobicistat co-formulation (drv/c) may be particularly suited for both mt/dt allowing once daily administration optimizing dosage and adherence. the objective of our study is to evaluate efficacy and security of drv/c in mt and dt. setting and method: all hiv + adults with antiretroviral change to drv/c in mt/dt at a reference hospital in the northwest of spain were included in this retrospective study. a statistical analysis was performed using the spss v.19.software. main outcome measures: epidemiological, clinical, antiretroviral regimen, serum creatinine, lipids and inmunovirological data (rna-hiv and lymphocytes cd4) were compared previous and after change to drv/c. results: 71 hiv treatment-experienced patients have received drv/c in dt (27) or mt (44). 76.1% were men with a mean age of 48 years. main risk factors were: 45.1% heterosexual, 28.2% msm, 18.3% injection drug users, 2.8% mother-to-child transmission, 1.4% transfusion in haemophiliac patient and 4.2% unknown. cdc category distribution was 64.8% a, 4.2% b, 28.2% c and 2.8% unknown. overall mean nadir cd4 counts were 196.7 ± 115.1cells/mcl. mean time since drv/c prescription to discontinuation or until analysis was 182.5 days [range 61-296]. 86.4% drv/c mt were prescribed to patients with prior drv/r mt in order to simplify treatment and the mean time of the duration of these prior therapies were 3.1 years. in case of dt, 66.7% were prescribed on patients with prior drv/ r + 3tc with a mean duration of 1.3 years. serum creatinine increases (1.03 vs. 1.08; p \ 0.001) and cd4 decrease (714.1 vs. 663.3; p = 0.031) when patients move to drv/c. no significant change in the other analytical parameters and all patients maintained undetectable. 2 patients discontinue drv/c due to intolerance and inability to swallow in each case. conclusion: this preliminary study concludes that drv/c in mt or dt is efficacy (no viral rebound) and safety. although an increase in creatinine was observed, it would not be considered clinically significant. of note, lymphocytes decreased significantly and it will be important closely monitored to check that maintain effectiveness during the follow up. hp-pc073: developing clinical pharmacy in emergency department setting up a medication reconciliation process marion collignon *,1 , antoine gantier 1 , florent lapacherie 1 , hélène dewaele 1 , laura foucault 1 , anne-laure raso 1 , emmanuel cirot 1 , said laribi 2 , xavier pourrat 1 1 pharmacy, 2 emergency department, chru tours, tours, france please specify your abstract type: descriptive abstract (for projects) background and objective: in emergency department (ed), if a drug related problem (drp) happens at the patient admission, the risk is the error remains until discharge. one part of drp may be avoided with using medication reconciliation (mr). the objective of this study was to evaluate the feasibility of setting up a medication history (mh) of patients in ed in an acceptable lap of time before they were transferred in another unit or discharged. design: a 6 months prospective study was conducted in ed in a university hospital in france. two junior pharmacists coached by a senior pharmacist, after a 2 months training for mr, were in charge of the data and mh collection. for all patients, we collected age, mh according to number of sources, discrepancies identified, adherence to treatment (according to the social security questionnaire), type of sources. mh were established according to community pharmacies, patients, previous electronic patient files, prescription sheets, patient's family, packs of pills and to the general practitioner (gp). for patients from long term care facilities (ltcf), the mh was established only by communication with the ltcf. then, the current prescription was compared with the home medication regimen. mh and discrepancies (omitting medication, incorrect dose, ambiguous name) were recorded in the electronic patient files to be available during hospitalization. because ed does not have a pharmaceutical review of prescriptions, only major discrepancies were transmitted to physicians. results: we collected 1426 mh (187 from ltcf), with a sex ratio of 1.0 and a medium age of 74.5 years old. it represented an average of 9.5 mh per day or 19 min per mh. among patients who did not come from ltcf, sources used by pharmacy students were patient's community pharmacy (967, 78% of cases), patient (890, 72%), previous electronic patient file (769, 62%), prescription sheets (634, 51%), call to gp (80, 6.5%), gp mail (78, 6.3%), patient's family (47, 3.8%), packs of pills (29, 2.3%), community nurse (26, 2.1%). finally, 683 patients (48%) had been hospitalized, others were discharged. we analysed mh for 1099 patients: at least one drp occurred for 599 patients (55%). among 386 patients, 150 (39%) had an immediate pharmaceutical intervention because of the risk due to discrepancy. among 203 patients who did not come from ltcf and who could communicate, 162 were good adherent to treatment (80%). conclusion: this study highlights the great interest of the mh by pharmacists at ed, which avoids many drp. the presence of pharmacists in ed contributes to maintain a safe environment for medication and to assist prescribers in the continuity of treatment between home and hospital. spending 20 min by mh, we identify one drp every 11 min. nevertheless, it could be benefit to develop this activity because of the satisfaction of the emergency physicians. currently, mr is the first step to develop clinical pharmacy in the ed. please specify your abstract type: research abstract background and objective: emerging evidence in the literature suggests a high prevalence of suboptimal vitamin d (vitd) and an association between lower serum levels and higher mortality in cancer. the objective of this study was to quantify vitd deficiency in patients after surgery for head and neck cancer, and to determine the effect of one cholecalciferol intramuscular dose. setting and method: intervention study with a follow-up period of 5 months (november 2015-february 2016) performed on patients followed by the nutrition support unit after surgery for head and neck cancer. demographic and physiopatological data, including admission diagnosis, age, gender, calcium, magnesium and phosphate were collected. nutrition screening by conut index was carried out. a single intramuscular dose of 200.000 ui cholecalciferol (vitamine d3 bon ò ) was administered to vitd-deficient patients and serum 25-hidroxy-vitamin d (s25ohd) records after the administration, including primary carés records after discharge, were evaluated (reference range 30-70 ng/ml). main outcome measures: s25ohd (\20 ng/ml: deficiency; 20-31 ng/ml: insufficiency; c32 ng/ml: sufficiency). results: data from 25 patients with a mean (sd) age of 63.8 (14.8) years were collected (males: 92%). the admission diagnosis was laryngeal squamosis cell carcinoma (n = 14), glottis carcinoma (n = 6) and nasopharynx, tongue and skull base cancer (n = 5). at baseline, 1, 17 and 7 patients were considered have high, medium and low risk of malnutrition, respectively. the mean (sd) serum 25ohd was 8.46 (5.68) ng/ml (deficiency: 24 patients; insufficiency: 1 patient). despite the role of vitd in mineral balance, calcium, magnesium and phosphate mean (sd) serum levels were between the normal range 9.15 (0.36) mg/dl, 2.08 (0.22) mg/dl, and 2.49 (0.89) mg/dl, respectively. 17 s25ohd records were available 1 week after the administration (mean (sd) = 21.46 (13.79) ng/ml). 7 and 4 patients still showed deficiency and insufficiency, respectively. primary care's records from 3 patients were available after discharge (30.2, 36.5 and 52.5 ng/ml). conclusion: poor nutritional status and high prevalence of suboptimal vitd in patients with head and neck cancer were found. a single dose of intramuscular cholecalciferol slowly raises s25ohd. follow-up after discharge is essential to evaluate the achievement of the therapeutic objective. setting and method: this is a descriptive retrospective study. it took place in a teaching hospital. antifungal broad spectrum therapies (liposomal amphotericin b, caspofungin, micafungin, posaconazole, voriconazole) used between 1st january 2013 and 31st december 2015 were included. main outcome measures: indications, type of combination and patients specifications were analysed. results: only 19 patients (1.9% over all patients receiving antifungal therapy; n = 19/977) received an antifungal combination therapy during the study period. majority of patients presented risk factors: 31% of patients had an organ transplant (n = 6), 53% suffered from malignant blood disorders (four acute myeloid leukaemia, two chronic lymphoid leukemia, one non-hodgkin's lymphoma, one hodgkin's lymphoma and two refractory anaemia with excessive blast), 11% suffered from solid cancer (one lung cancer and one breast cancer) and 5% suffered from chronic obstructive bronchopneumopathy (n = 1). antifungal combination therapy was used against invasive aspergillosis in 68% of cases (n = 13) among which complications such as brain and cardiac impairment were found in 32% of patients (n = 6). the six remaining patients (32%) were co-infected with candidiasis for three patients and mucomycosis for three patients. voriconazole was logically the most used in combination, and just one patient received oral form. it was in majority prescribed with caspofungin (38%, n = 8) and intravenous liposomal amphotericin b (33%; n = 7). combination including liposomal amphotericin b and caspofungin (n = 3, 14%) or posaconazole with liposomal amphotericin b (n = 1) were found in our study. five patients deceased during the hospitalization of the fungal infection (26%) which shows the gravity of these cases. majority of patients ([50%) was treated less than 10 days with these combinations. conclusion: this retrospective study shows that patients who received antifungal combination therapy were mostly immunocompromised, co-infected or experienced a severe infection with severity factors. the antifungal combination was in majority initiated because monotherapy failed to cure the patient. all prescriptions were discussed with a mycologist who tried to shorter the combination treatment duration. this multidisciplinary approach is a major key in the process of these type of treatments. please specify your abstract type: research abstract background and objective: because of its broad spectrum and the risk of resistance mutation, delivery of posaconazole is nominative and controlled by hospital pharmacists. the aim of this work was to describe the use and pharmaceutical follow-up of posaconazole tablets over a 7-months period. setting and method: this is a descriptive retrospective study over a 7-months period from november 2015 to may 2016 in a teaching hospital. all patients who received posaconazole tablets were included. main outcome measures: indications and dosage were reported. results: 23 patients were included in the study. posaconazole tablets were used for: fungal invasive infection prophylaxis in case of stem cell transplantation (52%; n = 12), fungal invasive infection prophylaxis if a chemotherapy was started to treat a chronic myeloid leukaemia or a myelodysplasic syndrome (26%; n = 6); treatment of invasive aspergillosis (13%; n = 3); mycetoma (5%; n = 1); zygomycosis or mucormycosis while patient had renal impairment (5%; n = 1). all of these indications were approved for posaconazole (marketing authorization and local guidelines). only 10 patients (43%) received a loading dose (300 milligrams twice a day) as recommended in approval authorization. posaconazole blood levels were monitored by pharmacologists: 70% of patients (n = 16) did not need dosage modulation which shows that variability is not so important. but three patients did not have any assay to monitor posaconazole blood concentration. 1 patient received a loading dose and was switched to intravenous voriconazole after icu transfer. 3 patients needed increase and/or reduction dose to obtain optimal posaconazole blood levels. conclusion: this study describes the use and the follow-up of posaconazole tablets during the first months after its approval in europe. all indications are approved for posaconazole but this analysis shows that pharmacist have to remind the necessity of a loading dose. dosage can be adjusted according to assays results. please specify your abstract type: research abstract background and objective: due to the acute, hectic environment in a fast-paced work-flow emergency department (ed) it is a challenge to verify the correct and updated medication list for the admitted patients. when performing medication reconciliation (mr) in this environment, these challenge has to be taken into account and prioritizing patients for mr could be necessary. the objective of this study was to identify risk factors correlated to clinical relevant medication discrepancies (crmds) among patients admitted to ed, and based on these revealed risk factors, develop a model for prioritizing patients for mr in the fast-paced work-flow at the ed. setting and method: 276 patients continuously included at the ed, diakonhjemmet hospital (dh), oslo, norway. trained pharmacists and emergency nurse conducted mr. patient specific factors and revealed crmds, between hospital admission records and information about prehospital medication use, were recorded. binary linear regression was used to identify risk factors correlated to crmds. the prioritizing model was built using statics and clinical experiences. main outcome measures: what risk factors is correlated to crmds and how precisely do the prioritizing model classify the patients as high-and low-risk patients. results: 62% of the patients had c1 crmd. the following were identified as risk factors correlated to crmd and were suitable for inclusion in the prioritizing model; gender (woman), age (c60), c1 admission to hospital last 12 months, admission causes; surgical, malfunction, cancer. the model correctly classified 76.1% of the patients with crmds as high risk. further, 23.9% of the patients with crmds were classified by the model as low-risk patients (false negatives). the model classified 27.1% of the patients who did not have a crmd as high-risk patients (false positives). conclusion: the prioritizing model developed can be helpful in identifying what patients are at increased risk of having crmds in the fast-paced work-flow at the ed. identifying these patients will result in using the resources available in the ed in the most efficient manner and utilizing the full potential of the mr method. as a consequence of this, patient safety would be increased. hp-pc078: intravenous potassium chloride: quick audit of prescribers knowledge and recommendations regarding safe practice and proper usage asmaa damou * , vincent zaugg, martine postaire please specify your abstract type: descriptive abstract (for projects) background and objective: our hospital has established methods that try to ensure the safe use of high alert medications. intravenous potassium chloride (kcl) was the subject of preventive measures: separation of different dosages (kcl 7.46% vials reserved for paediatric services and kcl 10% vials reserved for adult services); creation of an advice record for doctors and nurses; specific labelling of storage areas; double-check the prescription and administration. the objective of this study was to evaluate the knowledge of the safe use of intravenous kcl by prescribers. design: multiple-choice questions were developed for prescribing recommendations established by our hospital with the collaboration of the doctor who is chairman of the central committee of vigilance and risk associated with care (cvris). a link to the online survey was sent by email to 85 physicians practicing in 14 departments (eight paediatric services and six adult services). the results were extracted and interpreted in excel ò . results: 57% of physicians responded to the survey (17 medicine residents, 32 hospital doctors). in paediatric services, 93% of doctors know that only the kcl 7.46% should be used. 87% know the unit of prescription to be used (mmol/kg or meq/kg), and 90% know that the maximum recommended infusion rate is 0.5 mmol/kg/hour (or 1 mmol/kg/h in recovery unit). in adult services, the recommended maximum rate of infusion (1 g/h) is known to all prescribers, but only 56% know that the concentration of kcl must be less than 4 g/l. 74% of paediatric doctors say that their kcl prescriptions are checked by a second doctor, but the answers in the same service area are sometimes contradictory. in adult services, only 6% of physicians say that the prescriptions are double-checked. the information brochure available on the intranet of the hospital is known by 16% of prescribers. the response rate of physicians to the survey was satisfactory. therefore, the recommendations are rather well known by prescribers, except the value of the maximum concentration of infusion for adults. the results of this audit were returned to the doctors, accompanied by a reminder stating the need to double-check the prescription and the existence of advice records on the website of the hospital. conclusion: this audit is an approach to increase the safety of the use of high alert medications. it will be completed a second time, by an evaluation of prescriptions collected and the storage conditions of potassium chloride in the care units. please specify your abstract type: research abstract background and objective: data listed behind each unit dose of a primary packaging of a pharmaceutical product are essential for a safe identification for the patient. however, the last medical services of the lausanne university hospital where nurses remove the solid form drugs (sfd) from their blisters when they prepare in advance the week container were in the vaud's prisons. the aims of the study were: (194), quetiapine (173) and ibuprofen (124) and 978 were psychotropics (39.8%). part 2. the four data identified as essential: brand name, dosage [mg], batch number, expiration date. the sfd unit doses were classified as green when the blister included four data, yellow with two or three and red with less than two. of the 273 sfd in cupboards, 90 were green (33%), 57 yellow (21%) and 126 red (46%); an infovigilance was sent to each manufacturers. part 3. potential barriers identified: trays' sizes and space in drug's cupboards; preparation time to cut versus to remove the blisters; risks of self/hetero-aggression with pre-cut blisters; drugs packaged in bulk; multidose liquid medications. using containers larger than is usual was rarely necessary; space in cupboards was sufficient. the preparation time gradually decreased during the study. ingestion or aggression with pre-cut blisters was considered as limited, based on literature and experiences of two others prisons (geneva; lyon). for bulk sfd and multidose liquid drugs: proposals to the pharmacy to store some alternatives blistered sfd; blistering expensive bulked drugs; availability of the entire package delivered to inmates. the pilot phase was initiated in may 2015. conclusion: a majority of inmates takes a drug treatment. half of sfd unit dose is identifiable (trade name and dosage) but an effort from manufacturers would better secure the drug supply chain. the study of the barriers helped to further implement the pilot phase. since early 2016, none of the five prisons medical wards are removing the blisters and no incident was reported. please specify your abstract type: research abstract background and objective: nefopam is a widely used antalgic in hospital. its use is contraindicated in the epileptic patient as it results in lowering the epileptogen threshold and is likely to trigger epileptic seizures. the clinical pharmacist should systematically warn the prescriber against this contraindication when analysing prescriptions. following the onset in our establishment of an epileptic condition in a patient treated with nefopam, who had not been subject to any pharmaceutical intervention (pi), we set about analysing the validation practices regarding this contraindication and possibly implementing actions designed to improve those practices. setting and method: retrospective collection over a period of 17 months of prescriptions for patients hospitalized in 210 hospital beds with clinical pharmacy service (associating med-reconciliation, checking prescription according to medical file and participation to medical rounds): orthopaedic surgery, hepatic-gastro-enterology, general surgery, liver transplant and chest surgery. records of patients with nefopam prescription associated to medication belonging to the therapeutic class of antiepileptics were consulted with a view to finding cases of epilepsy. the pharmaceutical alerts were extracted from the pharmaceutical software. main outcome measures: number of epileptic patients treated with nefopam, number of pharmaceutical interventions issued when prescribing nefopam in epileptic patients. the study focused on 11,252 patients. 3980 (35.4%) of them were prescribed nefopam, and 143 (1.3%) of them were prescribed nefopam associated to medication belonging to the therapeutic class of antiepileptics. after analysis of the patients' records has shown that 55 of them were really epileptic. only 29 pi's were effected (52.3% of problematic prescriptions), and 25 (86%) of them had an immediate prescription change. 77.8% (14/18) of the patients have a pi in medicine services compared to 40.5 (15/37) in surgery services (p \ 0.01). the results of this study show that 47% of the contraindications related to the use of nefopam in epileptic patients are not reported to the prescriber. these results will be presented to our pharmacists so they can take them into account. subsequently a new study will be conducted to measure the relevance and efficiency of this program. hélène dewaele * , anne-laure raso, emmanuel cirot, marion collignon, laura foucault, xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) has been demonstrated to reduce drug-related problems in inpatients. in our university hospital, mr has been performed for 200 beds for 10 years at the same time as prescriptions review. the aim of this study was to assess the impact of mr on pharmaceutical interventions (pi) during prescriptions review. design: a 6-month prospective study in orthopaedic surgery, hepato-gastro-enterology, general surgery, liver transplant and chest surgery was conducted. during medication review all pis were collected and those related to mr (rpi) were identified. thereafter for each patient we collected age, type of hospitalization unit (med or surgery) and for pis the drug associated and its acceptance by the medical team. results: during the study 4756 patients had a daily prescription review. 1576 patients (33%) had at least one drug-related problem. 928 lines of prescriptions were mentioned to have at least one rpi. rpi represent 33% of drug-related problems. 697 (75%) discrepancies were corrected by prescribers. the age of the patient was significantly different between patients with rpi (mean age: 70 years old) and with pi (mean age: 65 years old; p \ 0.05). the type of unit did impact the percentage of prescriptions with drug-related problems (medicine: 46.8; surgery: 66.8; p \ 0.01), the rate of corrected pi (medicine:75%, surgery: 61%, p \ 0.01), but did not impact the rate of corrected rpi (p = 0.49). in surgery units the rate of corrected rpi (967/1571) is significantly higher than corrected pi (601/804; p \ 0.001). medicines belonging to the four classes of: digestive and metabolism system, blood and blood flow, cardiovascular system, neurological system represent more than 75% of all the medication concerned by a resolved pi or rpi. the proportion of medicines from the digestive and metabolism class is the only class among those four that is not significantly different between resolved pi and rpi. conclusion: mr highlights a large number of discrepancies in inpatients. a modification of prescriptions due to mr occurs in 10% of the patients. in surgery units, these rpi are more frequently taken into account than drug-related problem warned by pis. indentifying patients for whom mr has the bigger impact could help us to reinforce our actions. please specify your abstract type: research abstract background and objective: diabetes is very frequently causing cardiovascular complications, thus impairing various systems and organs. therapy for these multiple conditions has to be revised and improved constantly. the aim of this closed retrospective study lead in bucharest emergency clinical hospital was the assessment of some of the diabetes mellitus (dm) complications and the related medication. setting and method: data was collected from cardiology, neurology, gastroenterology, internal medicine wards from bucharest emergency clinical hospital. only patients diagnosed with type 2 dm were included in the study. there were analysed 105 records from patients aged 36-89 of whom 65 were men, following the presence, signalling and monitoring of diabetic nephropathy and arteriopathy. main outcome measures: we investigated the relationship between diagnosis and/or biochemical signs of kidney disease (serum urea, serum creatinine levels), diagnosis of arteriopathy, and the drug therapy administered in the respective cases. we also assessed the sex and age distribution of the patients diagnosed with diabetes mellitus and facing at least one of its complications. results: kidney disease, as a dm complication, was present in 30% of cases, patients aged 55-89, of whom 57% were men. 53 patients received diuretic treatment, 5 of them being given hydrochlorothiazide, contraindicated in dm because of its hyperglycaemia-inducing effect. of the 105 patients, 36 had high serum urea levels ([50 mg/dl), 39 had high levels of serum creatinine ([1.2 mg/dl), and 26 presented risen levels for both, but only 16 were also diagnosed with kidney disease. 9 patients with kidney disease were given furosemide, known for altering the renal function. circulatory failure was found in 10% of the patients, aged 61-80 and 6% of subjects, aged 62-79, had both diabetic complications. conclusion: the present study emphasizes the role of the clinical pharmacist in adapting the medication of the diabetic patient, an inappropriate pharmacotherapy worsening dm complications. this is essential especially for elders, where polypathology and polymedication lead to a significant increase of dm complications risk. hp-pc084: epileptic seizure after treatment with thiocolchicoside: discussion about a case report valérie dobremez *,1 , adeline martin-dupray 2 , jacqueline berlioz 1 , pierric giraud 2 1 pharmacy, 2 neurology, centre hospitalier annecy-genevois, metz-tessy, france please specify your abstract type: descriptive abstract (for projects) background and objective: thiocolchicoside is a semisynthetic derivate of naturally occurring colchicoside, which is largely used in humans as a centrally acting muscle relaxant. this compound also has anti-inflammatory and analgesic effects. the objective of this work is to report a recent case of serious adverse effect of thiocolchicoside occurring in context post traumatic brain damage without sequalae. design: a 28-year-old woman suffered from headaches and neck pain since 5 days, she was treated with thiocolchicoside. she took 8 mg in the evening and 8 mg the next morning. five generalized tonic-clonic seizures, without recovery of normal consciousness between seizures, have occurred suddenly 15-30 min after the second administration. the patient was admitted to intensive care unit in order to control the epileptic seizures. a status epilepticus was diagnosed requiring intravenous drugs with clonazepam, phenobarbital and propofol. the patient was controlled and transferred in neurologic unit in order to complete paraclinical investigations. its main antecedent was a severe head injury at the age of 7 years following a public road accident. the brain scan revealed an old frontal hypodensity. rest of etiological assessment was negative (lumbar puncture, no infectious disease), numbers were normal. the definitive diagnosis was a status epilepticus on post-traumatic sequelae, sensitized by taking a proconvulsant drug. a treatment with levitiracetam was initiated at 750 mg twice a day. outcome was favourable with no recurrence 10 months later, a recommendation was requested to pharmacovigilance. results: the muscle relaxant activity of thiocolchicoside results of an agonist action on glycinergic receptors located primarily in the brain stem and spinal cord. however, thiocolchicoside also acts as an antagonist of the gaba-a receptor (mainly located in the cerebral cortex), this pharmacological action can cause a proconvulsant effect. epilepsy is a very rare adverse effect, only few cases have been reported in literature. the epileptogenic activity of thiocolchicoside occur mainly in patients with a history of epilepsy, acute brain injury or possible blood-brain barrier disruption. the chronology is consistent with the responsibility of the drug as a promoting factor. pharmacovigilance retains after analysing drug causality. conclusion: the case history indicates that thiocolchicoside has a powerful epileptogenic activity. thiocolchicoside can precipitate seizures in predisposed patients, and that its use should be avoided in patients with brain diseases (and therefore lower seizure thresholds) or blood-brain barrier disruption. pharmacists could warn physicians and should verify the absence of notable history before dispensing thiocolchicoside. hp-pc085: acute exacerbation generalized myasthenia after red yeast rice use: a case report valérie dobremez *,1 , amélie serra 2 , déborah grosset-janin 2 , jacqueline berlioz 1 , aymeric dopter 3 , jean-henri ruel 2 1 pharmacy, 2 neurology, centre hospitalier annecy-genevois, metz-tessy, 3 nutrivigilance, french agency for food, environmental and occupational health and safety, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: many drugs can induce acute exacerbations or reveal myasthenia gravis. self-medication or complementary and alternatives medicines expose patients. the objective of this work is to report a recent case of acute exacerbation of myasthenia gravis because of a dietary supplement use. design: intermittent vertical diplopia and ptosis of the left eye settled in a 69-year-old man. its main antecedent is hypertension treated with perindopril. the neurovascular origin was ruled out. the electromyogram (emg) found a significant decrement (11%) of a postsynaptic block in the tongue and right orbicularis muscle. acetylcholine receptor-antibodies were positive. myasthenia gravis was diagnosed (osserman score 90/100) and the patient was treated with pyridostigmine. the identification of carotid atheroma required a treatment with a statin that the patient refused. he preferred a cholesterol lowering dietary supplement, containing red yeast rice. six days later, he was hospitalized for an acute decompensation of myasthenia with bilateral ptosis, oculomotor paresis, drooping head, int j clin pharm (2017) 39:208-341 281 chewing trouble and dysphagia (osserman score 42/100). the patient is treated with high-dose intravenous immunoglobulins then corticosteroids. the dietary supplement is stopped. an opinion was requested to the clinical pharmacist of neurology. the osserman score gradually increases to 78/100. results: red yeast rice contains a range of compounds known as monacolins, of which monacolin k-renamed lovastatin, which was found to be an inhibitor of cholesterol synthesis and the progenitor of the statin family. a literature review has highlighted the responsibility of statins in acute exacerbations or reveal myasthenia gravis occurrences. in this case, the chronology is consistent with the responsibility of red yeast rice. the case was reported to the french system of nutrivigilance, which retained after analysing a probable intrinsic imputability score. conclusion: dietary supplement with red rice yeast are not recommended in case of myasthenia gravis. this is the first case of acute decompensation of myasthenia recorded with red yeast rice in the french system of nutrivigilance. multidisciplinary collaboration (neurologists, clinical pharmacist) has optimized the patient management. fanny durand * , camille lambert, antoine dupuis please specify your abstract type: descriptive abstract (for projects) background and objective: development of computerized prescription highlights the need to harmonize pharmaceutical analysis practices. the aim of this study is to analyse the antibiotics prescriptions in the treatment of urinary tract infections, to develop a pharmaceutical validation tool. design: a prospective observational study was conducted for one week, in 20 care units. pharmacists, interns, and pharmacy students were trained on spilf (french society of infectious pathology) recommendations, on pharmacist's role in the management of urinary tract infections, and on the data collection. all patients with antibiotic prescription for urinary tract infection were included. some data were collected: reason for hospitalization, clinical signs, results of susceptibility testing, risk factors for complications (organic or functional abnormality of urinary tract, male, pregnancy, elderly, severe immunodeficiency, severe renal impairment) and signs of severity (severe sepsis, septic shock, interventional surgical drainage). then, the treatments prescribed to the patient, probabilistic on the one hand and documented on the other hand, were compared to spilf recommendations. finally, during a multidisciplinary meeting (pharmacist, expert in infectious diseases), we selected the relevant pharmacist interventions. results: twenty-three patients were included (14 women, 9 men), 42% had a urinary catheter. 52.7% of prescriptions were concordant with spilf recommendations: probabilistic and documented treatment, and duration. among the non-conforming prescriptions, nine pharmacist interventions have been formulated: four prescriptions did not specify the duration of treatment, one antibiotic was prescribed on an insufficient period, two cases of severe acute pyelonephritis without prescription of aminoglycoside, one prescription was not reassessed according to results of susceptibility testing, one pregnant woman with urinary colonization without clinical signs, was treated before obtaining results of susceptibility testing. three cases of poor management are identified: two cases which treatment began only after results of susceptibility testing (a urinary tract infection linked to care, an acute pyelonephritis with complication risk), and a cystitis treated with nitrofurantoin while the germ was resistant. conclusion: a synthetic tool was created. there are three elements for helping pharmaceutical analysis: the questions to ask oneself facing a prescription of antibiotic for urinary tract infection, a flowchart to identify the recommendation adapted to the case, and finally a summary table showing spilf recommendations. this tool will be distributed and evaluated. hp-pc088: off-label use of rituximab in refractory antisynthetase syndrome (as) through a long-time experience in a neuromuscular diesases center lise durand * , carole metz, patrick tilleul, helga junot pharmacy, gh pitié salpêtrière, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: as is an idiopathic autoimmune inflammatory myopathy, characterized by presence of antisynthetase antibodies: anti-jo1, anti-pl7, anti-pl12. patients are usually first treated by corticosteroids (cs) or immunomodulating drugs. rituximab (rtx) has become another option for refractory as, supported by few uncontrolled studies 1 . because of its off-label use, our hospital pharmacy has implemented a controlled drug delivery. this work assesses a 2-years follow-up of patients treated by rtx and the resulted drug costs. design: patients registered in our database since december 2014 who received c1 injections of rtx to treat as, were analysed to describe their eligibility criteria, conditions of management and the clinical and biological effects of the treatment (creatine kinase (cpk) used as biomarker). patient files were consulted to collect all individual data and pharmaceutical software was used to review deliveries. drug costs were also reckoned based on prices from french health insurance. results: for 18 months, 14 patients (median age (min-max): 52 (20-76), 64% women) have been treated with rtx for refractory as, the majority with anti-jo1 antibodies (8). all patients suffer from muscular and lung affections, particularly interstitial pneumonia. many are also living with arthropathies (10) or cutaneous disorders (9). cardiac involvement is seldom (4 symptomatic patients). the mean age of diagnostic is 7.3 years and the mean treatment period is 2.6 years. the common treatment is 1 g at day1 (d1) and d15, then 1 g all 6 months. before rtx treatment, seven patients received c5 other drugs such as cs (93%), azathioprine (71%), methotrexate or mycophenolate mofetil (57%). prednisone and azathioprine are also prescribed with rtx respectively for 79 and 23%. treatment is associated with cures of intravenous immunoglobulins for four patients. to date, median number of administrations per patient is 4 (1-8), d1 and d15 included. all patients have presented positive effects on both clinical and biological markers, mainly during the first 6 months after treatment induction. wilcoxon tests show a significant difference in cpk level between d1 and m6, also between d1 and the last known result. today, three complete remissions are specified in patient file; only one hepatitis b virus reactivation is reported. since 2014, budget impact due to drug cost amounts to 119 000€. conclusion: whereas the use of rtx is controverted for treatment of all types of myopathy, as could have one of the best response 1 . our cohort shows real clinical results and positive effect on usual biomarker. our experience demonstrates the safe and successful use of repeated administrations in refractory as. however, there is a need for further controlled studies to assess the efficacy/safety of rtx and to define its place in the strategy in view of its cost-effectiveness ratio. the pharmaceutical controlled drug delivery has to be continued to supervise, support and document its proper off-label use. please specify your abstract type: descriptive abstract (for projects) background and objective: as a part of the national patient safety program, the northern norway regional health authority are implementing new procedures for medication reconciliation (mr) in hospitals in the region. the procedure defines that mr is the doctor's responsibility and describes how it should be performed. the aim of this study was to investigate whether the implementation of the procedure reduces medication discrepancies (mds) in the charts at bodø hospital. and 53.9% (7/13) of the patients died before discharge. parenteral nutrition was administered an average of 21.5 days (95% ci 2.5-40.5), of which 7.7 (95% ci 3.0-12.4) were with ipn. previous spn had been administered in 84.6% (11/13) of the patients. before beginning ipn, the average triglycerides level was 608.1 mg/ dl (95% ci 388.1-828.0) but at the end of the ipn it was 324.9 mg/ dl (95% ci 245.4-404.5), which lead to a mean reduction of 283.2 mg/dl (95% ci 45.3-520.0; p = 0.02). regarding to the total amount of lipids provided with parenteral nutrition, with ipn there was a mean reduction of 30.4 g (95% ci 12.4-48.5; p = 0.002) comparing to those administered with spn. conclusion: usage of ipn in critically ill patients with htg permits to adjust parenteral nutrition formulations to meet specific nutrition needs, enables to reduce the total amount of lipids administered and, therefore, it allows to significantly decrease triglycerides levels. jennifer a. esteban gonzález * , elisabet nogué pujadas, angels andreu crespo, xavier bonafont pujol, nuria romero pascual please specify your abstract type: descriptive abstract (for projects) background and objective: the incidents involving patient misidentification (pm), or wrong patient medical errors (wpme), are medication errors (me), near-miss or close-call situations which can pose a considerable threat to patient health. pm may be under-reported due to the unawareness of the error or the difficulty of identifying them. the aim of this study is to describe the incidence and categories of wpme in a university hospital. design: observational, retrospective analysis of the voluntary reported wpme in the pharmacy database since march 2010 until june 2016. these were classified in prescription, transcription, dispensing, administration and drug system errors. in addition, the national coordinating council for medication error reporting and prevention (nccmerp) taxonomy was used for classifying me according to the severity of the outcome. results: of 1767 me registered, 50 of them were wpme (2.8%). 40.0% of them were due to prescription errors, which consist on wrong labelled medical orders, intermingled patient prescriptions or patient misidentification in computerized physician order entry (cpoe). the administration errors supposed a 30.0% of the total amount of wpme and dispensing errors were 18.0%. 6% of wpme were transcription errors, which occurred previously to the implementation of cpoe, and the remaining 6.0% were system errors after cpoe. the wpme reported took place in the hospitalization wards (44.0%), pharmacy (20.0%), outpatient services (16.0%), intensive care unit (16.0%) and day-care hospital unit (4.0%). 88.0% occurred at working days and 12.0% at the weekends. wpme were notified by pharmacists (62.0%), nurses (34.0%) and physicians (4.0%). referring to the classification according to nccmerp, 48.0% of wpme didn't reach the patient (category b) whereas 40.0% reached the patient but didn't cause harm (category c) and 8.0% required patient monitoring (category d). the remaining wpme (4.0%) caused harm to patients and required medical intervention (category e). finally, in int j clin pharm (2017) 39:208-341 283 more than half of wpme (62.0%), reporters suggested measures to prevent these errors. conclusion: wpme represents near 3% of total me reported in our hospital. given that more than 50% reached the patient, safety measures must be implemented to reduce the risk of hazardous events. additionally, further encouragement in notification is necessary in order to improve patient safety. results: two men diagnosed with rrms aggressive evolution were included in the study. age: 23 and 31. both of them without any treatment by the time they started being treated with alemtuzumab (previously one of the patients had been treated with fingolimod, suspended by inefficiency). the protocol design for the elaboration and control of alemtuzumab in the pharmacy service ensures greater safety and represents a saving strategy. in addition, the development of the protocol in the electronic prescription system (silicon ò ) facilitates the prescription, proper administration and standardization of treatment among patients. the protocol includes daily alemtuzumab infusion for 5 days and other necessary medications including premedication (metylprednisolone, omeprazole, paracetamol and metoclopramide) and anti-infective prophylaxis (aciclovir). developed adverse effects during infusion were skin erythema, pruritus and fever. it was not necessary to stop the alemtuzumab infusion in any patient. during treatment, one patient developed a severe lymphopenia and upper respiratory tract infection (influenza a). conclusion: the role of the pharmacist is critical at various stages, from the preparation and the administration guidelines, to detection, monitoring and reporting of adverse effects. alemtuzumab is presented as an alternative for those patients who do not respond to standard therapies or who have rapidly evolving severe rrms. because of its mechanism of action it is important to closely monitor patients, with particular emphasis on prophylaxis of possible infections. hp-pc093: descriptive analysis of patients receiving oral anticoagulation following acute coronary syndromes sadeer fhadil * , paul wright, sotiris antoniou please specify your abstract type: descriptive abstract (for projects) background and objective: triple therapy with concomitant anticoagulant and dual antiplatelet therapy (dapt) following acute coronary syndrome (acs) increases bleeding risk by 50% compared to patients on dapt. bleeding post acs increases mortality and reinfarction risk; balancing ischemic and bleeding risks is particularly challenging in this population. european society of cardiology (esc) produced a consensus document, providing guidance for patients presenting with acs requiring concomitant anticoagulation; however optimal duration of triple therapy and safety and efficacy of novel oral anticoagulants (noacs) and more potent antiplatelet agents requires further evidence. design: a registry was collated of patients presenting with acs requiring concomitant anticoagulation. baseline characteristics, bleeding and ischemic risk scores, periprocedural treatment and antiplatelet/anticoagulant choice and duration was recorded and analysed for trends in prescribing. results: 71 patients have been included in the registry between oct 2015 and june 2016, of which 40 (56%) were naïve to anticoagulation prior to admission, 24 (34%) were taking warfarin and 7 (10%) were on noacs. atrial fibrillation (af) accounted for 51 (73%) cases, (average chadsvasc score of 5, hasbled score of 2), and 15 (21%) were for lv thrombus. of those naïve to anticoagulation, 25 (63%) were initiated on warfarin and 15 (37%) on a noac (last 10 patients all received noacs). of those on a noac for af, 17 (81%) were dose reduced on triple therapy; apixaban being the most commonly prescribed (59% apixaban, 35% rivaroxaban, 6% dabigatran). background and objective: solid oral formulations are more convenient than liquids to manufacture, store and administer for most adults. given this superiority, one would think that children were prompted to use solid formulations when available in an eligible dose. there are indications, however, that the conversion from liquid to solid formulation in children is influenced by characteristics of the liquid medication, rather than the child's ability to swallow solid medications. the aim of this study was therefore to explore if the proportion of oral liquid formulations differed between antibiotics commonly used for upper respiratory tract infections (urti) in hospitalized children. setting and method: we collected the sales data for 2015 for the children's department of the five university hospitals in norway. the three most common oral antibiotics used for urti in children were included: penicillin v, amoxicillin and erythromycin. the proportion of oral liquids was calculated by dividing the number of defined daily doses (ddd) of liquids by the total oral ddds for each substance. main outcome measures: the proportion of ddds of oral liquid antibiotics. results: a total of 2575 ddds of common oral urti antibiotics were sold in 2015, distributed as 30% erythromycin 31% amoxicillin and 39% penicillin v. amoxicillin had the highest proportion of liquid with 97%, followed closely by erythromycin at 94%. in contrast, only 70% of the ddds sold of oral penicillin v were liquids. conclusion: higher proportions of liquid amoxicillin and erythromycin compared to penicillin v were sold to children's departments in hospitals. there are several limitations regarding the quality of sales data, as we lack information of the administered doses as well as the child's age, gender, infection and specific needs. infections in hospitals often require initial intravenous treatment, and oral switch will often be based on the initial treatment. despite these limitations, the results fit well with earlier findings which indicate that children prefer liquid amoxicillin and erythromycin to penicillin v. hp-pc095: proactive medication reconciliation: a preliminary study to identify barriers before its implementation in surgery departments laura foucault * , marion collignon, hélène dewaele, anne laure raso, emmanuel cirot, xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: it's well known that medication reconciliation (mr) decreases drug-related problems at patient admission (pa). in surgery departments, for planned hospitalizations, mr is performed 24-48 h after the pa (pourrat x and al, 2013). during this period, some chronic treatments are unintentionally not prescribed to patients. the aim of proactive mr (pmr) is to anticipate the pa by collecting their medication history before their hospitalization. the objective of this study was to identify the barriers preventing pmr implementation in our hospital. design: one week prospective study in digestive and orthopaedic surgery units in a 600 beds' university hospital. the main outcome is to identify which barriers prevent the collection of mr before pa including the evaluation of time required to collect the relevant information, reconcile any discrepancies after the pa and identify the right sources from which to perform the mr. results: eighteen patients with a median age of 59 years old (14-84) were contacted by phone one week before their scheduled surgery. these calls were conducted by pharmacy residents mainly between 6 and 8 p.m. (a more practical time for patients and at the end of pharmacist's routine tasks). an average of 1.7 (1-3) calls per patient were conducted. one patient was unreachable by phone. the average duration of the calls was 7 min (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) . twelve community pharmacy (cp) were contacted. in all cases, cp have accepted to share information about the patient's prescriptions by phone and sending it by fax during the day. five pharmacists were not contacted because patients had no chronic treatment and consequently no regular cp. on 53 lines of prescriptions, 12 discrepancies between the patient's information and prescriptions were identified and 7 between prescriptions and the anaesthesia records. drug history was reported in the patient's records by pharmacy students on the day of pa in order to be used immediately by prescribers. surgery was cancelled for one patient. conclusion: the first step of an mr is made by a hospital anaesthetist some weeks before hospitalization but we have demonstrated that this step is not able to avert all potential errors. our study highlights that the time necessary to perform an mpr appears to be shorter than for an mr. in fact, it's sometimes difficult to properly interview patients during hospitalization (patient in operating room, drug-induced drowsiness). additionally, a key hurdle is to obtain any necessary modification of the prescriptions by surgeons. pmr can be expected to produce time saving efficiencies given that at pa, prescribers will have their full medication history. this study also allowed us to highlight the good cooperation between patients, cp and the hospital. it is worth noting that efforts were made to accommodate the schedules of a majority of working patients. however, as we would expect pharmacy student to perform the pmr, they will most likely attempt to contact patients during standard working hours which may impact the number of patients they are able to reach. laura foucault * , hélène dewaele, marion collignon, emmanuel cirot, anne laure raso, xavier pourrat please specify your abstract type: descriptive abstract (for projects) background and objective: the french legislation has clearly defined and integrated the therapeutic education of patient (tep) for healthcare professionals. the pharmacist is invited to get involved in tep as a caregiver around the patient. in our study, we are investigating how the pharmacist's role is viewed by patients with chronic diseases that are included in a tep program. design: prospective study on 17 patients included in a tep program (chronic inflammatory bowel diseases, rheumatoid arthritis, ankylosing spondylitis) between september 2015 and april 2016. in july 2016, the participants of group sessions (gs) conducted with health professionals, including a pharmacist, were interviewed on the phone. the principal outcome of the interviews was to evaluate how their view of the involved health professional's roles evolved before and after gs; to evaluate if they would consider being followed by their pharmacist for individual sessions (is) in a community pharmacy (cp); and if the information supplied by the pharmacist during gs was understandable. to health care. however, discussions between patients appear to be essential to facilitate their acceptance of a chronic condition. some patients also questioned the cp's skills and knowledge when it comes to their particular disease. nevertheless, 88.2% of patients have found that the vocabulary and documents used by pharmacist during gs was adapted and that the information supplied was very useful. conclusion: this study highlights that although the pharmacist is the drug's specialist, a majority of patients will more likely ask their physician about medication. their participation to the gs hasn't changed their habits even if the pharmacist intervention was relevant and understandable. the fact that the pharmacists took into account the level of health literacy of each participant was an appreciated aspect. cp should be more proactive in their relationship with the patients in order to highlight their skills and the assistance they can provide in a chronic disease. however, it's important to take in consideration that in some cases, patients have lived with their disease since childhood. the role of is is likely to be much more limited than in other situations given their key need is to interact with patients afflicted with the same condition. hp-pc097: use and safety of trastuzumab emtansin in her2 + metastatic breast cancer in a tertiary hospital c. chaguaceda galisteo * , alba manzaneque gordon, héctor josé del río torres, natália creus baró please specify your abstract type: descriptive abstract (for projects) background and objective: novel anti her2 drugs have changed the management of her2 + metastatic breast cancer patients. the aim of this study is to describe the use of trastuzumab emtansin (tdm-1) in clinical practice in a tertiary hospital and to evaluate its safety profile. design: we performed a retrospective study of patients who started tdm-1 between january 2013 and december 2015. we recorded demographic data, clinical and treatment variables, number of doses received, reasons for discontinuation, progression-free survival (pfs) and adverse effects (aes). data were obtained from the chemotherapy prescription program and medical records. aes were classified according to the common terminology criteria for adverse events version 4.0 of the national cancer institute. results: eleven female patients with a median age of 55.6 years [40.7-80.1] and an ecog 1 (9/11) were included. tdm-1 was prescribed as a third or further line treatment in 8/11 patients and as firstline in one patient who develop disease recurrence within 6 months of completing adjuvant therapy. median number of tdm-1 cycles was 8.5 . all treatments discontinuations were due to disease progression (6/11). pfs was 6.0 [1.9-20.7 months] (patients that received less than three cycles were excluded (n = 2)). most frequent aes were plaquetopenia, neutropenia and transaminitis but only grade 3 in three patients (two transaminitis and one neutropenia). conclusion: the lower pfs obtained comparing to the pivotal study (6.0 vs. 9.6 months) could be explained by the later use of tdm-1 in clinical practice (8/11 patients received tdm-1 as third or further line while 61% in the pivotal study were first or second line). tdm-1 safety profile was according to the summary product characteristics. few data are currently available regarding the use of tdm-1 in clinical practice. further data are required to position this drug in clinical practice. please specify your abstract type: descriptive abstract (for projects) background and objective: the hospital pharmacist for their specialized training in the area of medicines, possess a greater responsibility in the detection and reporting of adverse drug reactions (adrs), as well as other problems related to treatment, which may be subject to monitoring and reporting to the regulatory authorities and the respective laboratories. thus, the pharmaceutical services of the cuf infante santo hospital has implemented a pharmacovigilance program, with two main objectives: 1. optimization of the detection and reporting of problems related to therapy; 2. implementation of corrective and/or risk minimization measures. the pharmacovigilance program is based on the following methodology: 1. detection of adrs/problems related to therapy/medical device: the detection can be performed by the pharmacist or other health professional that guides the process to the pharmaceutical services. 2. information processing by the pharmaceutical services and realization of spontaneous reporting: the notification is performed both for the portuguese regulator (infarmed) as to the appropriate laboratory (if applicable). after evaluation by both entity, the conclusions are communicated to the pharmaceutical services, which has the responsibility to share it with all the other hospital services. 3. report of the event in the internal risk management platform: when applicable, the pharmaceutical services internally report the adverse event to the hospital's risk management department, leading to an internal evaluation of the current process. 4. completion of the process and implementation of corrective measures: when the regulatory authority and/or the laboratory sends the report/technical advice about the notification, the pharmaceutical service in partnership with the risk management team perform a reassessment of the whole process. if needed, corrective and/or monitoring measures are implemented. 5. monitoring of implemented measures: after the implementation of corrective and/or monitoring measures there is a period of evaluation. results: the implementation of this program for the period of 1 year, has led to a total of fourteen spontaneous reports. from all of these notifications, seven were related to quality defect of medicines, four were of adr, one was due to suspected lack of therapeutic efficacy, and lastly, one of the notifications was medication error derived. conclusion: the obtained results, over a 1 year period, by the pharmacovigilance program were satisfactory but the aim of the pharmaceutical services is to consolidate and optimize the same program with a view to achieving better results. the pharmaceutical services will continue to take responsibility for the pharmacovigilance circuit management in this hospital, by promoting a proactive approach to monitoring the safety, quality and efficacy of medicines, which possess the primary objective to patient safety assurance. please specify your abstract type: descriptive abstract (for projects) background and objective: for prematures, parenteral nutrition (pn) is essential for medical care but is complex (specific needs, daily change of intakes…). now, the software logipren ò , developed by the french society of neonatology, allows the prescription of pn as well as all the childish therapeutics. it is also in link with our production robot (baxa pomp) for individual pn bags. our objective was to integrate this software while optimizing our pharmaceutical validation process. design: the software implementation was lead by a physician/ pharmacist collaboration with several preliminary steps: • identification of pharmaceutical validation settings (pertinence of individual pn vs. industrial bags, parenteral approach, elements…). before the life-sized use of logipren ò , a base test has been experimented to identify possible difficulties and to realize some correctives actions of the software or our process. results: logipren ò leads us to a change in our pharmaceutical validation process, by introducing new elements: • the pharmaceutical validation of pn bags is done in collaboration with the physician, during the prescription step. • all the therapeutics are known, which allow the pharmacist to take into consideration all the intakes (micro-nutrients, vitamins…). • remove the transcription step of pn bags in our production software (abacus ò ) thanks to an interface with our production robot. • less production problems because of the coverage of those pharmaceutical aspects during the prescription. since 2 months, this reorganization helped us to propose 22 pharmaceutical notices for 234 prescriptions: • omissions (remove lipids, levocarnyl ò , micro-nutrients, electrolytes, remove industrial bags…) • modification (reduce proteins according to urea level, micronutrients and electrolytes posology, duration of lipids infusion…) conclusion: the implementation of logipren ò enabled us to reorganize of the pharmaceutical validation process with a consolidation of the role of the pharmacist during the prescription step, in the paediatric ward. it had a beneficial aspect by the reduction of the validation and production time, a decreased risk of error (suppression of job interrupts and better communication) and an improved production by the end of transcription step to abacus ò . furthermore, during our experimentation, we could bring to the software editor new ways to improve it and make it more efficient. 57% (52.9% in 2015) , difficulties in swallowing/psycho-behavioural distress in 60. 71% (41.2% in 2015) , and rejection of oral drug in 10. 71% (5.9% in 2015) . physicians and nurses indicate the reason in the medical record in 77.78% of case versus 50% last year. this year, 287 drug were crushed versus 134 drugs in 2015: 22% concerned nervous system group (vs. 25% in 2015), 18% concerned cardiovascular system group (vs. 19% in 2015) , and 15% concerned alimentary tract and metabolism group (vs. 13% in 2015) . nurses use guideline in 50% of cases versus 2.9% last year. as the previous year, in 100% of cases, washing hands before preparation and after administration are met. last year, none of them was wearing mask and gloves during this operation while this year, 17% was wearing mask and gloves. finally, in the two assessment, for each patient, drugs are systematically crushed together and then mixed with the patient's meal. conclusion: this study shows that crushing drugs is still problematic in our units. however, best practices were observed, such as the indication of the reason of crushing in the medical record, or the consultation of guideline. a new training for nurses will be conducted to create awareness about risks of crushing drug. please specify your abstract type: research abstract background and objective: in invasive candidemia, three echinocandins are indicated: caspofungin, mycafungin and anidulafungin. the aim of this work is to establish which echinocandin to prescribe in a french university hospital, given the scarcity of available clinical data in the literature regarding obese patients. setting and method: in a french uhc with 1500 beds, a multidisciplinary working group composed of a microbiologist, an infectious disease specialist and a pharmacist has been set up to analyse the various therapeutic options. main outcome measures: analysis of the literature, pharmacoeconomic study. results: four medications have been identified as possible therapeutic options. their adverse effects are similar and their administration rhythm is the same. according to recommendations by the esmid (2012) and the idsa (2016), the level of evidence for these three echinocandins in initial treatment of candidemia is equivalent. concerning obese patients, no weight limit is mentioned, int j clin pharm (2017) 39:208-341 287 despite recommended dosage adjustment. caspofungin must be prescribed at a dose of 70 mg/day for patients weighing over 80 kg. micafungin must be administered at a dose of 100 mg/day regardless of patient weight. in the case of persistence of cultures or if clinical condition does not improve, the dose may be increased to 200 mg/day. anidulafungin, which is not referenced in our establishment, must be prescribed at the same dose regardless of patient weight. from an economic point of view, in our hospital, micafungin at a dose 100 mg/day remains the least costly therapy. however, if its posology is doubled as indicated, caspofungin then becomes the most economic therapy. amphothericin b, an optional treatment, is never the most economically advantageous therapy. conclusion: as a result of this study, the chosen prescribed therapy for obese patients is caspofungin at a dose of 70 mg/day. this work has improved access to healthcare for obese patients. pharmacokinetics and survival data must be collected on the basis of various patient weights in order to predict clinical efficacy. kristin f. heier * , liv czynski please specify your abstract type: descriptive abstract (for projects) background and objective: the aim of this study was to develop a system to prioritize patients for medication reconciliation by pharmacists in the emergency department. it also proved a useful setting for evaluating how other health care professionals perceived the role of the pharmacist performing medical reconciliations within the emergency department. design: the study was located in the østfold municipal hospital, located in kalnes, norway. pharmacists used a prioritization model to identify ''high-risk patients'' having clinically relevant prehospital medication discrepancies between hospital admission records and the information obtained via medication histories, general physician referrals and nursing homes. pharmacists registered patient information such as age, gender and drug-related problems (drps). seventeen physicians and thirty nurses in the emergency department answered structured questionnaires anonymously. main outcome measures: • number of patients with medication reconciliation performed by a pharmacist. • number of drug-related problems denoted in the electronical journal and presented to the physician. • the overall experience physicians and the nurses had with pharmacists when located in the emergency department. results: pharmacists performed medication reconciliation for 262 patients, identifying 443 drps and 178 potential drps in total. fourteen of the physicians had read the journal notes from pharmacist and found them helpful (n = 4, 29%) or greatly beneficial (n = 10, 71%). most physicians (n = 14, 82%) and nurses (n = 19, 63%) reported a good cooperation with the pharmacist in the care of the patients. some of the physicians (n = 4, 29%) and most nurses (n = 21, 70%) wanted more information about the pharmacists work in the emergency department. the majority of ed staff (100% of physicians and 63% of nurses) found pharmacist as a good academic resource in the emergency department. conclusion: the physicians reported an improvement regarding the quality in the medication reconciliation made by pharmacists in the emergency department and both physicians and nurses expressed a need that pharmacists work in the emergency department on a more permanent basis. more information in general and especially better communication with nurses regarding the care of the patients are important actions need to optimise collaboration with pharmacist in the emergency department. results: a total of 105 patients were included in the study, median age was 53 years and 63% were males. they used in average four drugs regularly (range 1-15). almost three-quarters (70%) of the patients reported high or moderate adherence to all their regularly used drugs (mmas-8 c 6 (max 8)). of the 39 patients using oral spasmolytics, 74% reported high or moderate adherence to these drugs. the majority (97% of the patients) had high perceptions of necessity to their treatment (bmq [ 2.5 (max 5)), and 54% had a high level of concern (bmq [ 2.5 (max 5)). logistic regression analysis showed that there was no association between adherence and pain, nor between adherence and spasticity. younger age was found to be associated with higher risk of nonadherence. conclusion: even though overall adherence was high, the patients were more concerned to take their medicines compared to other patients with other chronic conditions. further studies are required for understanding adherence and attitudes toward medication in this population, and to help the patients feel safe about their medication regime. please specify your abstract type: descriptive abstract (for projects) background and objective: errors in medication lists often emerge in transition between health care levels, and there is need for strategies to communicate medication information. therefor we aimed to describe reasons why medication discrepancies (md) occurs in the transfer of patients between hospital and primary care service. design: in conjunction to a study based on use of structured medication report at transition from hospital to primary care service, we observed different reasons to why mds occurs. our observations and experiences linked to communication between health care levels is outlined. results: we observed that many md's disclosed at discharge could most likely be attributed to lack of medicines reconciliation at admission to hospital. for instance, several medicines were prescribed in primary care service prior to admission, but not at admission to the hospital. in addition, at admission, some medicines were listed as prescribed medications although not found in the medication lists in primary care service. we also observed that newly started and discontinued medicines were documented in the hospital discharge letter, but not implemented in primary care service. according to health care personnel in primary care service, insufficient communication about the patients' medications at discharge from hospital, led to corrections in the medication lists based on their previous knowledge about the patients. in addition, justified medication changes at discharge from hospital were not always implemented in primary care service due to professional disagreement. some stated that lack of trust was one reason for not always taking changes into account, often based on earlier experience. conclusion: these observations indicated that mds occurred both with and without intent when patients from primary care service were admitted to hospital and returned back due to poor communication. medication errors during hospitalisation and unproven intentional changes may be the consequences. due to this, it is important to improve the communication and confidence between professionals in the hospital and primary care service in order to reduce the number of mds and to enhance patient safety. please specify your abstract type: descriptive abstract (for projects) background and objective: intravenous human immunoglobulins (iv igs), plasma protein products, may cause in patient to a range of adverse side effects (headache, skin rash, kidney failure, thromboembolic event). in the framework of securing medicinal care, an assessment of professional practices has been conducted within our university hospital. the overall goal of this study is to evaluate the process of intravenous administration of human immunoglobulins done by the nurse staff. design: this prospective study has been carried out in three departments of neurology. an observation grid was established on the basis of guidelines on good practices. all in all, 53 criterions have been examined resuming: prerequisites before administration, patient setup, iv igs administration, monitoring, traceability of drug delivery and management of adverse side effects. results: during the course of this investigation, 51 administrations were observed. only 26% of nurses deliver information about the treatment to their patients before administration and 46% question patients about previous hypersensitivity reaction. the presence of spontaneous diuresis is verified in 14% of cases. emergency cart is not reachable in 33% of all cases. 78% of nurses ask patients to decline their identity. the use-by date on the bottles is checked in 51% of cases. at the time of preparation of perfusion, labelling does not mention either patient's name (48%) or date and hour of perfusion (93%). int j clin pharm (2017) 39:208-341 289 during perfusion, only 11% of nurses follow diuresis and 70% watch rate of administration. hydration is not always kept 20 min after the end of perfusion (80%). patient monitoring varies between 5 min and 1 h after perfusion's end. in 14% of cases, diuresis is monitored after the end of administration. 85% of nurses explain to patients side effects that may occur remotely. finally, administration traceability is was conform in 100% of all cases and in the event of adverse side effects, statement was made in 96% of cases. conclusion: best compliance scores have been achieved in myology department where patients are fewer than in the two others departments (6 vs. 20 and 25). a presentation of those results will be given in theses three departments in order to improve patient management and securitization of iv igs administration. this audit will be carried out soon in other departments. please specify your abstract type: descriptive abstract (for projects) background and objective: a new human polyvalent immunoglobulins dose (40 g) for intravenous administration is available on our establishment since 2014. in order to secure the administration, this new dosage was initially reserved for the healthcares using administration pumps (being four health-care). the aim of this survey was to evaluate the satisfaction of the nursing staff already user of the new 40 g dose and to estimate the motivation of the nonuser nursing staff by the audit date. design: this satisfaction survey was carried out with the most igiv consumer services (being internal medicine, neurology, cardiology and haematology). the questionnaire was structured in two sections: the first section regarding igiv in general, the second section concerning the new 40 g dose. the survey included multiple choice questions or questions with answers based on a four levels evaluation scale (not satisfied, mildly satisfied, satisfied, and very satisfied). results: the audit was realized on eight health-care, involving 41 nurses. among the 41 interviewed, 17 (42%) have already used the 40 g dosage. in 80% of cases, users were very satisfied and 20% were satisfied. the most positive points noted were: gain of time provided (89.5% of satisfaction), less manipulation needed (99.9% of satisfaction), and reducing of infectious risk (94.7%). moreover, the influence of the injection technique on users' satisfaction was further reported. indeed, according to nurses interviewed, the use of an injection pump is safer and improves the job comfort of nursing staff, unlike the injection by gravity (used in 14% of cases), which seems to slow down the use of this new dosage. in two cases, a positive opinion given by patient was also reported. finally, negatives points noted were related to administration instruments (use of pump or not) and to less flexibility in daily dose regulation. among the 58% not-user of this new dose, the 89% showed a strong interest for the product apart from services making the igiv administration by gravity. conclusion: in light of these results, the use of 40 g dose will be spread to other services. the general diffusion of this dosage will provide a gain of time also at the pharmacy, during the unitary delivery and the computer-based administration of every units. a second survey will be soon effected within patients involved in the switch 20 g/40 g. the capital region pharmacy, 2 clinic of neurology, rigshospitalet, blegdamsvej, copenhagen, denmark please specify your abstract type: research abstract background and objective: the clinic of neurology, rigshospitalet, copenhagen, denmark experience continuous medicine-related patient safety incidents (psi) related to newly admitted patients and patient transfers between wards. in order to prevent drug related problems (drp), the pharmacists increased their focus on these patients and provided systematic medication reconciliation. thus, the objective of this pilot study was to investigate if the intervention would help identify drug discrepancies (dd) and prevent drp. four wards were included in this study; two neurological, one neuro-anaesthetic (icu), and one neurosurgical ward(s). three wards use electronic medication module (epm), whereas the icu uses critical information system (cis). furthermore, all patients' prescriptions are registered on shared medication record (smr), which provides an overview of prescribed medicine. prescriptions cannot be transferred from smr and epm to cis and vice versa. we suspected that psi resulted from these system incompatibilities. setting and method: patients admitted or transferred from may 2nd 2016 to june 3rd 2016 were included. medication reconciliations using smr, epm and cis were conducted by a pharmacist on weekdays. dd were presented to a physician orally and documented. only dd accepted by physicians led to drug prescribing change. main outcome measures: number of identified dd. results: the study included 186 patients, of which 147 (79%) were newly-admitted. 39 patients (21%) were transferred between wards. of the transferred patients, 37 (95%) were transferred from the icu to other wards and 2 (5%) were transferred from other wards to the icu. of the newly-admitted patients, 44 (30%) were admitted to the icu and 103 (70%) were admitted to other wards. the pharmacists identified 16 dd; 3 dd (19%) in the transferred and 13 dd (81%) in the newly-admitted patients. in the transferred, 3 dd were all related to the icu. in the newly-admitted, 11 dd (85%) was related to the icu and 2 dd (15%) to other wards. of the 16 dds, 11 (69%) were accepted by the physician. an example of a severe dd identified was an omission of prednisolone to a patient admitted to the icu. conclusion: most dd were identified in patients admitted to or transferred from icu, which uses the incompatible system cis. pharmacist systematic medication reconciliation helps identify these dd and prevent drp. please specify your abstract type: research abstract background and objective: antibiotic related drug interactions are more likely in intensive care unit patients due to common polypharmacy and antibiotic usage. the aim of this study is to determine the antibiotic related drug interactions with three different online databases (micromedex-paid, medscape-free and drugs.com-free) and to evaluate these interaction information by clinical pharmacist. setting and method: a retrospective, descriptive study was set up in hacettepe university hospital's intensive care units, between november 10 and december 31, 2015. 62 patients who use at least one antibiotic were involved in this study. all drugs were assessed by each three databases and only antibiotic drug interactions were evaluated. clinical significance of identified drug interactions were evaluated by clinical pharmacist. main outcome measures: clinical pharmacist's assessment in significance of drug interactions indicated by three online databases. please specify your abstract type: research abstract background and objective: an implementation of clinical pharmacy practice by postgraduate students in intensive care units is a new way of learning in postgraduate education which creates opportunities in multidisciplinary collaboration in clinical pharmacy research, and also has influence on clinicians' routine patient care process. this system in educational program was ongoing in the department of clinical pharmacy since 2014. as a part of this educational program, drug related problems in intensive care units were described and analysed, an influence of clinical pharmacy postgraduate students on patient treatment process was sought. setting and method: a prospective, cross-sectional study was performed between the march-june 2016 in hacettepe university hospitals, department of internal diseases intensive care units which consists of 17 beds. three postgraduate pharmacy students from the department of clinical pharmacy, faculty of pharmacy conducted medication reconciliation in order to identify any problems in patients' medical orders. drug related problems (drps) were identified by the students and recommendations for management were approved by a supervisor of clinical pharmacy department before they were directed to physicians for approval. the students were not authorized to undertake any action in patient care process, therefore all required interventions for drp were undertaken by physicians and the acceptance ratio of the interventions were recorded. the pharmaceutical care network europe foundation classification system (v.6.2) was used to asses drps. main outcome measures: determination of drps by pharmacists and evaluation of their interventions' acceptance by physicians in intensive care units. results: during the study period, 106 patients were admitted to the intensive care units. each patient's medication orders were evaluated and 80 interventions were recommended by postgraduate students. the number of interventions per patient was 0.75. the acceptability rate of interventions by physicians was 96.3%. in addition, physicians were provided drug information on seven different occasions. recommendations regarding drug therapy were mainly related with treatment effectiveness and adverse reactions. the common causes of drps were requiring dose adjustment due to pharmacokinetic problems (42.5%), no therapeutic drug monitoring (18.8%), inappropriate timing of administration and/or dosing intervals (11.3%), requiring dose adjustment due to deterioration/improvement of diseases (6.3%), inappropriate drug selection (5%) and new indication for drug treatment presented (5%). the most common drugs responsible for drps were ranitidin, levothyroxine, allopurinol, pantoprazol, piperacillintazobactam and vancomycin. the study showed that the most common drps was dose-related, therefore close monitorisation of the intensive care unit patients by students in clinical pharmacy postgraduate program can help physicians in terms of detecting, preventing and minimizing drps in order to improve patients' health outcomes. please specify your abstract type: research abstract background and objective: antibiotic stewardship is the process of salvaging important antibiotic agents from becoming ineffective due to bacterial resistance. this is important because throughout the world antibiotics continue to be one of the most important classes of therapeutic agents due to their vital role in saving patient lives. key goals of antimicrobial stewardship are to improve clinical outcomes, prevent antibiotic resistance, promote patient safety, and reduce health care cost. pharmacist are in the frontlines because they perform antibiotic stewardship activities, such as selecting the most optimal antibiotic agent, adjusting drug-dosage, and stopping use of unnecessary antibiotics. as a result of the continuous rise in antibiotic resistance and decline in development of new antibiotics, antibiotic stewardship programs are proving to be indispensable in a health care settings. setting and method: 100 adult and paediatric inpatients receiving antibiotic therapy in the hospital medipol university has been evaluated. patients were selected randomly in the hospital system. patients were evaluated for antibiotic susceptibility results and compliance with antibiotic management guidelines. main outcome measures: to evaluate the antibiotic therapy in patients with culture results and to determine according the treatment guidelines. results: it was observed 10 different pathogens in blood culture results of 51 inpatients out of 100 patients who were treated with antibiotics in hospital. antibiotic susceptibility results for acinetobacter spp, staphylococcus spp, enterococcus spp, pseudomonas aeruginosa, klebsiella spp, e. coli spp, streptococcus spp, corynebacterium spp, streptococcus pneumonia and enterobacter spp are evaluated in the study. klebsiella spp was the most isolated pathogen at total of 85 culture results. most frequently resistance were int j clin pharm (2017) results: a total of 289 (28%) questionnaires were completed. of these, approximately 80% were answered by hospital nurses, the remaining mainly by physicians (18%) and 2% ''other''. on the question ''what is your general perception of the benefit of the clinical pharmacy service; for collaborating health professionals? for the patient?'' the total benefit was ranked 5.45 and 5.54 respectively (scale from 0 (''no benefit'') to 6 (''beneficial to a very large extent''). the open questions: ''what disadvantages/advantages have you experienced by the introduction of clinical pharmacist into multidisciplinary teams?'' received 153/185 comments respectively. physical obstacles regarding office space, interference with the decision making process, more time consuming processes and the issue of relying too much upon the advices given was reported as possible disadvantages. 120 respondents answered ''none'' to this question. the comments regarding advantages dealt mainly with general increased patient safety and quality assurance. in addition, advantages as work-load relieve, time saved, collegial support, practical help, and learning interchange between professions, were highlighted. conclusion: health-professionals assessed the clinical pharmacy service as highly beneficial. the advantages outlined were higher patient safety and quality regarding medication, in addition to collegial support, practical help and learning interchange. please specify your abstract type: descriptive abstract (for projects) background and objective: in june 2015, the french health authority, the «has», published an index resuming the recommendations of benzodiazépines (bzd) prescriptions and proposing an approach to stop using it. indeed, it has been established that there is a too high and too long consumption of bzd in france. a study of prescriptions' prevalence has been done in our hospital centre. the aim of this study was to know our situation regarding the use of bzd in order to set up some improvements and take part in their proper use. design: a prospective study has been done on a 5 months period in different services: geriatric, post-op and rehabilitation facilities, endocrinology, internal medicine, pneumology and cardiology services. the data were raised on a given day in each services and recovered thanks to the prescriptions software but also through interviews with the patients and their doctors. it was examined whether there was a bzd prescription (hypnotic or anxiolytic), whether the duration was superior or not to the duration of the amm and whether the prescription was done in our hospital centre. if the prescription was already part of the patient treatment, we looked if it was possible for the patient to stop using it, according to the has criteria. on their discharge, the letters and bzd prescriptions were also analysed and some patients' general practitioner were contacted after their discharge. results: 185 patients (median age 83 years old) were included from november 2015 to march 2016. 59.5% (110/185) of the patients had at least one bzd prescription the day we collected the data. we found only one bzd in 81 prescriptions (73.6%) and among them 77.7% (63/81) were anxiolytic bzd. among those prescriptions, 62.7% (69/ 110) already existed before the hospitalization and 37.3% (41/110) were given during the hospitalization (24 were prescribed automatically). 59.4% (60/110) of the prescriptions did not respect the legal duration of the amm (9 pieces of data were not found). 12.2% (5/41) already exceeded this duration limit. among the patients who already had a bzd treatment before going to hospital, 24.6% (17 out of 69) could consider stopping their use of bzd. by the end of this study, 143 patients were discharged from hospital, among them 48.3% (69/ 143) with a prescription of bzd. 55.2% (16/29) of the prescriptions established during the hospitalization had been renewed when the patient came out of the hospital, we managed to contact ten general practitioners (approximately 53.4 days after their discharge), nine patients carried on their bzd treatment, among them one patient had reduced his consumption. conclusion: this study is an example of the high proportion of bzd prescriptions in france which the majority doesn't respect the legal length of the amm. the prescriptions of bzd in the hospital are generally systematically renewed by the general practitioners. the patients must be informed about the risks of using those molecules. in order to ameliorate this practice in the hospital, a proper use leaflet, reminding the prescriptions of bzd, has been created and distributed in each services to make people aware. main causes of admission were infections (34%) (respiratory disease (23%) and other (11%)), hepatic disease (20%) and neoplasias complications (13.5%). 11 patients died during their admission; 5 due to hepatic disorder, 3 due to neoplasia, and 3 due to infections. conclusion: last diagnosis of hiv or no art treatment are causes of admission. immunovirological situation is related with their adherence but isńt with admissions. coinfection with hcv or hbv or others infections are risk factors for admission. center for psychopharmacology, diakonhjemmet hospital, oslo, norway please specify your abstract type: research abstract background and objective: complex medical history and treatment can potentially cause problems. the objective of this study was to investigate the prevalence of drug-related problems (drps) and medication discrepancies in internal medical patients with complex treatment at hospital admission. further, to investigate to which extent drps were identified as a result of medication reconciliation, and to which extent drps could be associated to the hospitalization. setting and method: patients with at least four regular medicines from two different therapeutic groups were consecutively included at admission to an internal medicine ward at a university hospital in norway in the period 01.09.14-15.02.15. pharmacists used the integrated medicines management (imm) model for medication reconciliation and medication reviews at admission. a medication discrepancy was defined as any discrepancy between the recorded medication list at admission and the patient's actual use of medications, as revealed by medication reconciliation. the patients' actual use of medications, medical journal and laboratory results, were used to perform a medication review at admission time and identify drps. the proportion of drps revealed due to medication reconciliation was calculated. moreover, the project group retrospectively assessed possible drp-induced hospitalizations based on clinical history, cause(s) of admission and identified drps. main outcome measures: the main outcome was the median number of drps per patient at admission. the proportion of drps revealed due to medication reconciliation, the proportion of patients with drps possibly associated to the hospitalization, and the median number of medication discrepancies, were included as secondary outcomes. results: 120 patients were included, 50.0% women. median patient age was 79 (range 27-96) and most of the patients were home-living before admittance (89.2%). in total 1359 drps were identified at admission, with a median number of 11 (range 2-27) per patient. 99 drps (7.3%) were identified due to medication reconciliation. for 25 patients (20.8%) a causal relationship between the hospitalization and the drps was assessed as ''possible''. medication discrepancies were revealed in 113 of the 120 included patients (94.2%), with a median number of 4 (range 0-14) per patient. conclusion: internal medical patients with complex drug regime are frequently exposed to drps and medication discrepancies at hospitalization. medication reconciliation could be essential to identify drps, which is likely a common cause of hospitalization in the studied patient population. hp-pc117: assessment of oral anticoagulant prescriptions and pharmaceutical analysis at the hospital by regional audit damien fuss *,1 , clélia monchablon 1 , anaïs breteau 1 , marie lefebvre-caussin 1 , rémi varin 2 , jean doucet 1 , mikael daouphars 3 , doreya monzat 1 1 omedit normandie -chu rouen, 2 chu rouen, 3 please specify your abstract type: descriptive abstract (for projects) background and objective: oral anticoagulants (oa) are the most common drug class associated with preventable adverse drug events in hospitalized patients that require optimizing the pharmaceutical analysis (pa) process. in this context, a regional audit was conducted on pa of prescriptions oral of oa. the aim of this study is to provide an overview of the treatment by oa in the hospital by evaluating the consistency of the oa prescriptions compared with national and european guidelines and evaluate the pharmaceutical interventions. design: this study is based on the collection of pa data (demographics, indication, posology, drug interactions, monitoring) as well as the collection of pharmaceutical interventions and discordance int j clin pharm (2017) 39:208-341 293 between guidelines recommendations and clinical practice. the inclusion criteria were any patient treated with oa (vitamin k antagonists (vka), non-vitamin k antagonist oral anticoagulants (noacs)). included patients were followed minimum 2 months. the primary outcomes include description of baseline characteristics of patients, the number of inappropriate prescriptions compared to the different clinical recommendations, the number of pharmaceutical interventions, the number of adverse drug reactions (adrs) related to oa use and the assessment of patient monitoring. results: during the 6-months study period, 588 patients were included in six health institutions. the average age was 78 years (70% of patients over 75 years old) and 59% of the patients were women. 32% of patients had renal impairment. 73% of patients were treated with vka, and 27% with noacs. it was the first prescription of oa for 27% of patients (56% with vka; 44% with noacs). the most common indication was the non-valvular atrial fibrillation (60%). in this indication, 99% of patients had cha2ds2-vasc score c2, and nearly 30% had a high risk of bleeding (has-bled score c3). 8 drug interactions were observed, and 35 adrs occurred related to oa. 42% of patients with an adrs had a has-bled score c3. 12.5% of prescriptions were considered inappropriate, including 45% noacs (no monitoring renal function in 13% of patients over 75 years initiating treatment, inappropriate posology in 14%, and 3% of contraindications). the rate of pharmaceutical interventions was 4%. nearly 60% of the prescriptions were already adapted when the pharmacist was starting analysis. conclusion: prescribers are sensitized of the risks on the oa prescriptions, which explained the delay upon pa and low rate of pharmaceutical interventions. however, the high number of inappropriate prescriptions shows the necessity to improve the pa process on these drugs, particularly by actions on therapy initiation and patient monitoring, especially for noacs. for this class, the impossibility of assess the level of anticoagulation by laboratory monitoring requires appropriate initiation and monitoring, especially an assessment of baseline renal function. please specify your abstract type: descriptive abstract (for projects) background and objective: the development of bacterial resistance these last 10 years is a public health major problem in the world and needs to implement actions. in france, the national drug safety agency has defined a list of ''critical antibiotics''. this list includes antibiotics particularly generator of bacterial resistance (amoxicillinclavulanate, cephalosporine, fluroquinolone) and antibiotics called ''last resort'' (antibiotics against gram-positive cocci, car-bapenem…). at our regional level, an evaluation of prescription of these critical antibiotics was proposed to all medical centers. the aim was to evaluate the quality of prescription of these critical antibiotics. design: the regional working group (pharmacists, infectious diseases physicians and biologists) had developed a collection grid including data on patients, antibiotics and four criteria: adequate molecule, compliance with medical prescriptions, duration of antibiotic therapy and reassessment at 72 h. this is a prospective study proposed to all health institutions (public and private), which had to be completed on a given day in all care units and had to be conducted by a team of multi-professional evaluators. the study included a quantitative part (number of patients hospitalized in the audited units, number of patients receiving antibiotics and number of critical antibiotic prescriptions) and a qualitative part (adequate to the four criteria). results: response rate was of 84%. the study investigated on 7026 patients hospitalized in the audited units, including 1391 patients (20%) receiving antibiotics. among the 1391 patients, 89% were hospitalized in medical, surgery or obstetrics units we recorded 865 prescriptions of ''critical antibiotics particularly generator of bacterial resistance'' (53% amoxicillin-clavulanate, 30% ceftriaxone, 14% fluoroquinolone and 3% other third-generation cephalosporine) and 42 prescriptions of antibiotics called ''last resort'' (74% carbapenem). the average age of the population was 69.9 years (±20 years). sex ratio was 1.1. 91% corresponded to curative use and 9% to prophylactic use. the expertise of infections diseases physician was requested in only 13% of the cases. the antibiotics were prescribed in majority to treat bronchopulmonary infections (38%), urinary tract infections (16%) and intraabdominal infections (16%). ninety-two percent of the prescriptions had a proper indication. 66% of the prescriptions complied to the guidelines. the duration of antibiotic therapy was adequate in 82% of the cases. only 45% of the prescriptions were correct according to these three criteria. forty-four percent of the prescriptions were reassessed and adapted by the physician. conclusion: this study is original because of its regional dimension and antibiotic analysis. the number of analysed prescriptions was significant with an overall proper prescription in adequate with the guidelines. however, actions must be implemented on duration and reassessment and adjustment of treatment. these results were presented to the participating hospitals. these three points will be reevaluated during a new regional audit. the criterion «no more 2 psychotropic drugs» has been met in 88.95% of assessment. otherwise, 2 or more psychotropic drugs are prescribed in 88.89% of assessment from the point of admission. the criterion «no more a benzodiazepine drug» has been met in 91.72% of assessment. otherwise, more than one benzodiazepine drug is prescribed in 59.26% of assessment from the point of admission. no contra-indication is detected in 93.25% otherwise, a contra-indication between two drugs causing torsade de pointes is detected from the point of admission in this department. no more 1 anticholinergic drug is prescribed in 84.05% of assessment. according to the french criteria, one or more inappropriate drug is prescribe in 46.93% of assessment. the most common inappropriate drug group prescribed was alimentary tract and metabolism drug (60.85%) (the hospital at home team needs these class of drug) followed by nervous system (25.95%) (prescribed at the point of admission) and by cardiovascular drugs (12.34%) (prescribed at the point of admission). finally, the criteria «no more one non-steroidal anti-inflammatory drug» and «no illogical association» have been met in all cases. conclusion: this analysis shows that most of criteria for «assessment of prescription among elderly in a «hospital at home» department have been met. when one has not been met, either the hospital at home team needs the drug prescribed, or this drug have been yet prescribed from the point of admission in this department. this study could be used for the next certification. hp-pc120: access to health care: case of autologous serum eye drops batiste martel, fabien lindenberg, camille castel, guillaume saint-lorant * please specify your abstract type: research abstract background and objective: autologous serum eye drops (ase), prepared from patient's serum, are indicated in the treatment of severe dry eye syndrome and defective epithelial healing. its in-hospital preparation within a controlled-atmosphere zone unable it to be dispensed by non-equipped hospital pharmacies. the aim of this study was to implement security measures to allow transport towards distant hospital pharmacies and all patients even those residing far from a regional university hospital (uh). setting and method: this study was conducted in a 1495-bed french university hospital. patient blood samples were taken within the university hospital every 12 weeks. serum was then biologically controlled (negative tests for hiv, hbv, hcv, tpha, vdrl). preparation was conducted 3 days after blood sampling. sterile preparations were then stored at a temperature of -18°c. studies showed that eye drops were stable 14 days after being thawed. transport of eye drops to distant hospital pharmacies requires to be conducted under controlled temperature i.e. below 8°c, to ensure the stability of eye drops. these pharmacies are located close to patient's homes. the entire process was examined by a pharmacy team in order to study and secure each step, transport in particular. main outcome measures: validation of each step of the autologous serum eye drop dispensing process, from sampling to receipt by different hospital pharmacies, transport in particular. results: 4 patients benefitted from the preparation. all patients resided more than 100 kilometres from a uh. a follow-up form was completed to qualify dispatching and to trace each step during transport. a temperature sensor was placed inside the box. the receiving agent was required to stop and control the sensor. a double retrospective control was performed by a pharmaceutical team via the recording of temperature sensors. a second follow-up form was drafted in order to track dispensation reviews, ongoing dispensation and future planning. a patient information booklet was distributed to hospital pharmacies to inform patients about good practice concerning eye drops. conclusion: technological necessities concerning autologous serum eye drop preparation and transport limit access to health care. in this study, the role of the pharmacist consisted in reducing inequalities among patients residing at a distance from the only regional uh. the role of the pharmacist is to ensure absolute quality of preparation between the uh and the patient. hp-pc121: computerized medication reconciliation: overview of pharmaceutical software used and support for development of integrated modules julie mocquard, anaïs berthe, elise rochais * , nicolas prévost, jean-claude maupetit, on behalf of centre de ressources régional en conciliation médicamenteuse omedit pays de la loire, nantes, france please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation aims to improve continuity of care for patients. in 2015, a national survey identified barriers for implementation of this activity in france, among which computerized systems were judged unsuitable for hospital practices. in the absence of appropriate hospital information systems (his), medication reconciliation remains a time consuming process implying manual transcriptions, potentially leading to a lack of traceability and medication errors. the objective of the study was to assess the current his used in a french region including the integration of medication reconciliation into the software and to define courses of action to assist this integration. design: an online survey conducted in may 2016 was addressed to head pharmacists of the 134 health facilities in the region, giving a total of 100 head pharmacists concerned. it included questions on the software used by the health facility, the development of medication reconciliation and its traceability, formulation of operational requirements to the editors of software and availability of a module integrating medication reconciliation provided by the software. results: seventy-eight pharmacists (78%) participated in the study, with all types of health facilities represented: public hospitals, clinics, home health agencies, haemodialysis structures and after care and rehabilitation facilities. thirty different software were identified in the region. 27 (35%) pharmacists planned to develop medication reconciliation in their health facility and 20 (26%) were already carrying out this activity. within these 26%, medication reconciliation was conducted on paper only for 9 (45%) of them, while 11 (55%) were using a computerized system (patient file, pharmaceutical software, other) for traceability. the most widely used software in the region contains a module enable for computerized medication reconciliation, and three other editors are currently developing one. no development is scheduled for another three editors nonetheless commonly used in the region. 15 (19%) pharmacists had contact with the editor of the software, and 10 had given thought to the preparation of requirement specifications to the editor to develop an integrated module of medication reconciliation. conclusion: despite the interest attributed to medication reconciliation and despite the need of a fully integrated module of medication reconciliation to his, only a few health facilities of the region possess an appropriate computerized system to develop this activity. this study underlines the approaches already made by pharmacists to editors in order to integrate medication reconciliation to the his. subsequently, retrieving these approaches and writing specifications common to all health facilities is scheduled, in order to assist them in providing a strong incentive for the editors to integrate medication reconciliation to existing his. please specify your abstract type: descriptive abstract (for projects) background and objective: medication reconciliation (mr) is an interactive and multiprofessional process that ensures the continuity of care by integrating the ongoing treatment to the new hospital prescription. this helps securing the patient's care pathway particularly at transition points. the objective is to initiate the mr process in our medical institution with a pilot study in the department of internal medicineemergency downstream to validate a methodology and adapted tools. design: the mr takes place in three steps performed by a pharmacy student: (1) realization of best possible medication histories (bpmh), combining at least three sources of information and using sources' collection form. this research begins with a patient interview done in pairs with a medical student using an interview guide. (2) comparison bpmh with the initial hospital prescription in the department (after passing through the emergency department) on the treatment reconciliation form. a status is assigned to each line of drugs and then the differences are identified (stopped, changed or added). these two steps are validated by a pharmacist. (3) discussion and characterization of observed differences (intentional/unintentional and documented/undocumented) with the senior physician. results: twenty-six mr were performed over 3 weeks in 2015. the mr is performed within 2 days after admission. on average, 2.3 information sources per patient were used for the bpmh: mainly drug prescription (dispensed in pharmacies community); analysis of emergency medical records and patient interview. for the 26 patients included, 268 drugs were listed. 148 discrepancies were observed and 62 were studied (status stopped or changed only): one documented intentional discrepancy, 43 undocumented intentional discrepancies and 18 unintentional discrepancies (ud). these uds affected 12 patients (1-3 medication errors per patient) and corresponded to a non-prescribed drug in 90% of the cases. vitamins, antihistamines, anti-reflux and proton-pump inhibitors were involved in 59% of cases; cardiovascular drugs in 17% and antiinfectious in 12%. through this pilot study, the methodology was validated: (a) need to have a minimum of three sources to achieve a relevant bpmh and to confirm each information with two sources; (b) need for a dedicated time with trained staffs; (c) development of tools to improve the traceability of information obtained from each source and traceability of medication reconciliation activity. conclusion: the mr establishment in the internal medicine department was helpful in identifying 18 medication errors that have been corrected. it is proposed to archive the treatment reconciliation form in the patient file to contribute to the traceability of information on treatment. this study strengthens the deployment of this method and mr tools to other services of the hospital. alma mulac * please specify your abstract type: research abstract background and objective: clinical pharmacists have an important role in improving healthcare services. there is lack of knowledge of clinical pharmacists' experiences in interprofessional collaboration. our objective was to explore the challenges and barriers experienced by clinical pharmacists in interdisciplinary teams in norway and incorporation of expanded pharmacist roles in hospital settings. setting and method: this qualitative study was conducted using semi-structured interviews. a total of 13 clinical pharmacists from four (government) hospitals were included in the study. the interviews were audio recorded using a digital recorder. the recordings were transcribed verbatim. main outcome measures: challenges and barriers clinical pharmacists experience in interdisciplinary teams in hospital setting. results: the main findings are that the pharmacists' role is little known to other health care professionals, particularly at hospitals with short tradition for clinical pharmacy services. clinical pharmacists have great motivation from being able to influence drug treatment for patients. from the perspective of the participating pharmacists they succeed in interdisciplinary cooperation when their professional knowledge solves the patients' drug-related problems. communicating recommendations to physicians with professional credibility has great importance for the intervention to be implemented. using the theoretical framework of communicating tensions, we argue that the pharmacists in our study use indirect communication to prevent physicians defensiveness to recommendations. lack of education in interprofessional cooperation and communication is apparent in this study. the participants also stated that there should be some form of quality assurance or education requirements before one can work as a clinical pharmacist. conclusion: training in communication for graduates and interprofessional collaboration during the undergraduate pharmacy education, can possibly help pharmacists with integration in interdisciplinary teams. increased attention to teamwork from the hospital leadership is essential for the implementation of interprofessional collaboration in a larger context. please specify your abstract type: descriptive abstract (for projects) background and objective: antifungal therapy in the icu, particularly therapy targeting resistant aspergillosis, mucormycosis and systemic candida, is often of lifesaving importance. posaconazole and voriconazole are the antifungal agents of choice. our aim was to compile a tool that can be used at the icu to address aspergillosis, mucormycosis and systemic candida in an optimal manner. design: female patient, age 50 + , liver transplant, crp [ 300 mg/ l, creatinine [ 150 lmol/l. abdominal x-ray imaging revealed four large abscesses and laboratory analyses confirmed mucormycosis. posaconazole intravenous (300 mg one times daily) and liposomal amphotericin b (1 mg/kg/day) were initiated. the inflammatory markers remained unchanged 5 days following initiation of therapy with no change in size or number of abscesses and the patient developed sepsis. amphotericin b dose was increased to 3 mg/ kg/day. after 1 week the inflammatory parameters and size of abscesses began to fall. the dosage form of posaconazole was switched from intravenous to mixture. the dose remained the same and within 24 h the crp rose to 600 mg/l. results: pharmacist intervention revealed a missing loading dose of intravenous posaconazole as well as incorrect dosage of the per oral form due to bioavailability variation. posaconazole mixture dose was increased to 400 mg two times daily. through serum concentration analysis of posaconazole was suggested prior to the dose increase. the serum concentration was 0.6 mg/l (range [1.0-1.25) . through serum concentration 4 days later was 1.2 mg/l. both crp and abscess size were on the decline. a dosage and tdm pocket card for posaconazole therapy of mucormycosis, aspergillosis and candida was compiled. conclusion: optimal systemic fungal infection therapy is essential, especially in the critically ill. of special importance is tdm and correct dose adjustment when dosage-form changes occur. please specify your abstract type: research abstract background and objective: potentially inappropriate prescriptions and omission of prescription, respectively ip and op, are common issues in the pharmacotherapy, especially in vulnerable population, such as elderly and children. there are many available tools detecting ip and op for geriatrics, however, similar tools are less common in paediatrics. therefore, a first target tool for paediatric population: popi «paediatrics: omission of prescriptions and inappropriate prescriptions» was created and was validated by delphi method in 2014. we aim to evaluate inter-rater reliability between health care professionals, who apply popi. our study also assessed their satisfaction and the accessibility of this tool. setting and method: twenty cases with or without ip or op were selected. these cases were identified in a previous retrospective ip-op prevalence study on 15.973 patients. these patients were admitted to the emergency department of a university mother and child hospital, between october 2014 and march 2015. one doctor and one pharmacist, who participated in the creation of popi tool, identified ip and op in 20 cases and composed ''standard answers''. these cases were then reviewed independently by eleven clinicians (including generalists, paediatricians, pharmacists, residents, general practitioners), who did not experience this tool before. inter-evaluator agreement was calculated by using the agreement kappa test. the satisfaction of users was also evaluated. main outcome measures: inter-evaluator agreement, the median time of use and the satisfaction of users. results: a high level of agreement of ip and op detection was recorded (ip: k median = 0.80; op: k median = 0.71). the easy use of popi was approved by 91% evaluators. the median time of use was 2 min 45 s per case (quartiles : 2.4-3.4) . as a result, there were 82% of clinicians satisfied with the provided popi and they would like to apply this tool in their daily practice. conclusion: popi demonstrated a good interrater reliability and is easy to use. this strong validation by many specialists prove popi is a reliable tool. it can be applied daily at work in paediatric section by doctors and pharmacists. other multicentre and prospective study should be conducted to evaluate economical and clinical impacts of popi. please specify your abstract type: descriptive abstract (for projects) background and objective: drug dosing during cvvh is challenging due to changes in pharmacokinetic parameters brought about by the patients' deterioration in health and factors associated with the physical process of filtration. this is of particular significance in the icu. in addition, there is the issue of the patients' diuresis or lack of such. this will affect the total clearance (cl total ) of the drug. the dose of antibiotics must therefore be calculated individually taking into account all of the above as well as changes of filtration parameters. our aim was to illustrate how such dosage calculations can be undertaken. design: a 50-year-old male patient, weight 75 kg, diagnosed with stenotrophomonas maltophilia infection. the trimethoprim/sulfamethoxazole dose was 7.5 mg trimethoprim/kg/day every 8 h as specified for anuric patients on cvvh. patient was initially anuric for 3 days after which diuresis was started. the dose was recalculated. results: creatinine clearance (crcl) related to cvvh during the anuric period was calculated accounting for ultrafiltration rate, sieving coefficient, blood-flow, haematocrit concentration and pre-dilution. the value was 22 ml/min. following diuresis on day 4, remaining kidney function was assessed by measuring urine and serum creatinine. the value for crcl renal (18 ml/min) was added to the extracorporeal clearance, and gave a total clearance of40 ml/min. this warranted dose adjustment of trimethoprim/sulfamethoxazole since this drug requires normal dosage at crcl [ 30 ml/min. conclusion: during cvvh, the presence or absence of diuresis must be taken into consideration when dosing antibiotics. in anuric patients, the cvvh-machine set up constitutes crcl total , but in patients with diuresis, the remaining crcl renal should be added. please specify your abstract type: descriptive abstract (for projects) background and objective: the aim of the study is; to evaluate patients' home (prescribed and non-prescribed) and hospital medication during hospital admission by computing medication regimen complexity index and investigating possible drug-drug interactions. design: patients (aged 18 and older) who applied internal service during 6 months (2 days/a week) were included to the study. patients' medical profile were obtained from patients' file. their home medication and hospital medication were calculated with medication regimen complexity index (1) and checked drug interactions with micromedex drug interaction program. results: a total of 151 from 360 of patients who applied to the internal service (male 46.4%, female 53.6; the mean age of patients was 69.01 ± 16.28.) were included to this study during 6 months. of them, 75.5% had low education level (\8 education years), 53.6% had 2 and more chronic diseases of them, 45% hospitalized last 6 months before this hospital admission. the most prevalent diagnoses documented at admission were kidney disease (19.8%), cardiovascular disease (15.3%) and cancer (13.2%). the mean of patients' home medication number was 5.64 ± 3.50 and the mean of their mrci scores was 16.02 ± 10.89. 45% in patients hospitalized in the last 6 months. at least one possible drug-drug interactions were found in 66.6% of patients at home medication and in 78.8% of patients at hospital medication, respectively. the mean number of possible drug-drug interactions at patients' home medications was 2.88 ± 3.62, while the mean number of possible drug-drug interactions at patients' hospital medications was 4.07 ± 4.06. of them, 53.6% had polypharmacy at home medication. the frequency of possible drug-drug interactions and the score of medication complexity index was found high among patients' hospital medications when compared with their home medications. conclusion: the potential role of pharmacist including medication reconciliation and medication review could improve rationale drug use during hospital admission. coronavirus. experts' local committee has approved to use oral ribavirin for the treatment of these respiratory viral infections. we aimed to assess the effectiveness and safety of oral ribavirin as main treatment in respiratory viral infections. setting and method: from may 2013 to october 2015, we performed a retrospective monocentric study including patients who received oral ribavirin for non-hcv infections. main outcome measures: viremia negativation was used to determine the response rate to oral ribavirin. specific toxicities (anaemia, cytopenia, liver dysfunction) and renal function were assessed biologically. results: thirty-five immunocompromised patients (f/m: 3/4, age: 57) were included. underlying conditions were lung transplant (n = 32), heart transplant (n = 1), pulmonary fibrosis (n = 1) and acute myeloblastic leukaemia (n = 1). the median duration between transplantation and infection was 1.8 years (0.1-10.8). nine patients were exclusively infected by rsv, 19 by hpiv (2 hpiv-1; 2 hpiv-2; 10 hpiv-3; 4 hpiv-4; 1 non-identified hpiv), 4 by hmpv and 1 by coronavirus. there were six co-infections: rsv/ hpiv-1, rsv/coronavirus, hpiv-2/hpiv-4 and hpiv-3 or 4/coronavirus (3 patients). all the patients were admitted in pulmonary division, except for the patient with heart transplant who was in cardiac intensive care unit. the administered dose was 400 mg tid or 200 mg tid if there was renal insufficiency (9 patients). the median duration of the treatment was 8 days . four patients prematurely discontinued the treatment due to severe toxicity or therapeutic change; three didn't respond to the treatment (no data for the last one). four patients were re-treated despite having a virological response to the first cure. one patient treated for a hpiv-3/coronavirus coinfection had an hpiv-3 relapse 64 days after ribavirin discontinuation. concerning the three other patients, they received a second cure to treat a new infection (coronavirus, hpiv-4 and hmpv, in opposition to hpiv-3 twice and hpiv-2 respectively). virological response rate was 82% (7/11 for rsv, 22/25 for hpiv, 4/5 for coronavirus and 4/4 for hmpv). two non-negative viremia patients (rsv and hpiv-4/coronavirus) received intravenous ribavirin after oral ribavirin therapy. no patient died from viral infection. twelve patients presented specific toxicity: one hepatic cytolysis and cholestasis, eight haemoglobin decrease, two pancytopenia and one mucositis. conclusion: despite the poor number of patient, our study shows that oral ribavirin seems to be efficient to treat hpiv, hmpv and coronavirus in immunocompromised adults. we observed known side effects that could generally be managed. oral ribavirin may thus represent a therapeutic strategy in several respiratory viral infections. please specify your abstract type: descriptive abstract (for projects) background and objective: reconciliation of medicine lists is important to ensure correct medical treatment of patients both in hospital and other healthcare levels. while reconciliation upon admission is part of the normal routine at surgical ward b, molde hospital, there has been less focus on reconciliation at discharge. as such, this study aimed to ensure reconciliation and correct transfer of medical information at discharge. design: medicine lists of all patients discharged from surgical ward b, molde hospital between week 39 and 51 in 2015 (n = 240) were investigated. the forms were gathered and counted based on the tasks signed for to ensure completed reconciliation and sufficient information given to the patient. the count was performed every 2-3 weeks, and the forms in each count was pooled together as one point of measure. the quality of medicine lists in discharge lists was evaluated based on the norwegian patient safety program criteria. medicine lists in discharge lists from week 39 to 51 (n = 102) were pooled together and compared to medicine lists in weeks 36-39 (n = 46). results: the results of reconciliation was divided into the subsections of surgical ward b, and represent the number of completed tasks as signed for in the reconciliation form. the surgical subsection showed a significant increase in patients with pre-checked medicine lists and reconciled medicine lists over the measured time period. similar results were not found in the orthopaedic subsection. as for the quality of medicine lists in the discharge lists, significant improvement was seen in all set criteria, with the exception of ''source'' in the surgical subsection. in the orthopaedic subsection however, no significant improvement was seen in any of the criteria other than ''indication for use''. conclusion: the implementation of reconciling medicine lists at discharge was successful. however, both subsections need to work further to ensure continuation and improvement of the process. furthermore we found varying results in the writing of medicine lists depending on subsection. still, regardless of the individual results of the two subsections there is big room for improvement to ensure that sufficient medical information is included in the discharge papers. please specify your abstract type: descriptive abstract (for projects) background and objective: from july 2015 clinical pharmacists began conducting medication histories and reviews (pharmacist notes) at the emergency surgical ward (esw), north zealand hospital (nzh). inclusion criteria are acute patients using c5 drugs or c1 risk drug (antidiabetics, anticoagulants, antipsychotics, benzodiazepines, opioids and digoxin). the aim of the service is to identify drugrelated problems and secure correct medication reconciliation between the medicine the patient is admitted with and the medicine in the electronic medication system (ems) in the hospital. the service ensures that the patients' medication follows across healthcare sectors. the objective is to determine if the discrepancies between the medicine the patient is admitted with and the medicine in ems (documented in the pharmacist notes) are used by the physicians. in addition to determine if the pharmacist interventions increase the physicians' acceptance rate of the discrepancies. design: data were collected at the esw at nzh (capacity of 27 beds). data consist of pharmacist notes conducted from august 2015 to may 2016. pharmacist notes were compared to the patient record and ems to identify if the pharmacist notes were considered by the physicians. in order to increase physicians' acceptance rate of the discrepancies suggested in the pharmacist notes, interventions were made according to the model for improvement. throughout the period, the focus was on oral delivery of the pharmacist notes. in december 2015 the pharmacist optimized the clinical relevance of the discrepancies, by creating and testing a list of products (including vitamins, herbal drugs, glucosamine etc.) which the pharmacist should not intervene on. in december 2015 the pharmacist also started to follow up on the pharmacist notes not considered by a physician the previous day to ensure that the physician considered the discrepancies. results: there were identified 599 discrepancies between the patients' actual medication at admission and ems at the hospital in 306 patient records (1.96 discrepancies per patient). in total 424 discrepancies were accepted by the physicians (1.39 discrepancies per patient). the physicians' acceptance rate was based on the acceptance of one or more of the discrepancies in the pharmacist note. baseline data were collected from august to november 2015, where 54 out of 85 pharmacist notes were accepted by the physicians resulting in an acceptance rate of 63.5%. from december 2015 to may 2016 the interventions made by the pharmacist contributed to an increase in acceptance rate to 81.8% (108 out of 132 notes accepted). if the pharmacist notes were not delivered orally to the treating physician the acceptance rate was 9% (8 out of 89 notes accepted). conclusion: the pharmacist interventions contributed to an increase in the physicians' acceptance rate of discrepancies from 56.5 to 81.7%. a result indicating that the pharmacist notes contributes to an increase the quality of the medication process across sectors. hp-pc134: how the centralization of medicines manufacturing enable to generalize the pharmaceutical validation? samantha oses * , soizic vandierdonck, vincent servant, dominique breilh please specify your abstract type: research abstract background and objective: the centralization of the reconstitution of injectable anti-infective drugs enhance to decrease costs and several risks. this minimization of the risks operates at several levels such as i) reduction of the staff exposure and external contamination of preparations during the reconstitution phase (with controlled atmosphere areas, isolators, etc.), ii) improvement in the quality of the management of infective diseases thanks to a pharmaceutical validation systematically performed after the prescription and before the reconstitution phase. the main objective of the study was to describe and quantify pharmaceutical validation on injectable anti-infective drugs prescriptions restored in a pharmaceutical reconstitution unit. setting and method: an observational descriptive study was carried out on each prescription with at least one injectable anti-infective drug that has to be reconstituted before administration. the process was as follows: 1-prescription by the physician on an electronic prescription software, 2-pharmaceutical validation and if necessary pharmaceutical intervention (pi) made by phone call, 3-reconstitution at the pharmacy, 4-administration to the patient. the pharmaceutical validation methodology followed the french society of clinical pharmacy (sfpc) guidelines ''prescriptions screening and analyses level'' published in the good practices of clinical pharmacy and one resident and one pharmacist were devoted to the activity every day. main outcome measures: the pharmaceutical validation was quantified by the number of pi by patient, which were categorized according to the sfpc guidelines. results: during 4 months, a total of 222 pi were collected. they concerned 93 patients with an average of 2.4 pi per patient. among them, 11.8% (11) concerned paediatric population. antibiotics were involved in 53.2% (118) then followed by 36.9% (82) cases (59.5% (69) biological assessment issues, 37.1% (43) absence of therapeutic drug monitoring (tdm) and 3.4% (4) the drug hasn't been adapted to the weight), dosage adjustments in 25.2% (56), information missing concerning the treatment indication in 15.8% (35) and miscellaneous pi in 6.8% (15) such as wrong clinical service on the prescription, etc. approval rate of physicians was 79.3% (176). conclusion: this study has shown that even if prescriptions were secured by electronic prescription software, the pharmaceutical validation remains essential. in that case, the centralization of the reconstitution of injectable anti-infective drugs enabled to generalize this activity on all prescriptions of the hospital. however, the pharmaceutical validation was focused only on anti-infective drugs, that was not fully efficient and must be extended to the whole prescription. it is a priority to develop a comprehensive and exhaustive validation on every medical prescription; however, this activity is highly time consuming and needs larger and more trained staff. hp-pc135: the start/stopp criteria as a helping tool to the pharmacists' medication review in the acute admissions unit of the regional hospital in horsens hans pedersen * please specify your abstract type: research abstract background and objective: polypharmacy occurs often increasing the need for patients' medications to be reviewed. the start/ stopp criteria help detects potentially inappropriate prescriptions in older people. in this study we aimed to measure and categorize the different start/stopp criteria found in medication reviews in the acute admissions unit of horsens and the acceptance rate. setting and method: patients admitted to the acute admissions unit were selected based on their age and the number of prescriptions in a period of 4 months. patients 65 years or more which received six or more drugs were included in the study. only patients who later were transferred to another medicine ward were included in the study. the pharmaceutical medicine review was performed by a clinical pharmacist using minimum two different sources; the electronic medical record and medication-lists. the guideline of pharmaceutical medicine review in the hospital pharmacy central denmark region was used as the standard-guideline. in addition, thestart/stopp criteria version 2 was used. main outcome measures: the number of start/stopp criteria found in medication reviews. the different start/stopp criteria were scored equally with one point each. results: 33 patients, 17 males and 16 females, out of 55, were included. the mean age was 79 years and the patients received in average 14 prescribed drugs. at admission the average number of stopp criteria were 1.1 ± 0.9 and 0.4 ± 0.6 for the start criteria. in average, 27% of the purposed stopp criteria were accepted by the physicians. the most frequently accepted stopp criteria were in the category of drugs that predictably increases the risk of falls in older people. the benzodiazepines where the most common drugs to be discontinued. in the start category, 25% of the suggested start criteria were accepted, which included: calcium and vitamin d3 supplement, beta-2 agonist and bisphosphonate. conclusion: the present study demonstrates that it was possible to integrate the start/stopp criteria as a helping tool in the medication reviews in the acute admissions unit of horsens. the start/stopp criteria were found within the different categories, however only a minor part of the registered start/stopp criteria were accepted by the physician. please specify your abstract type: research abstract background and objective: the objective of this work is to assess prescribing practices of somatostatin analogues in a surgery department, and to analyse the conformity of switching from immediateacting octreotide to the long-acting release (lar) form, in accordance to laboratories' guidelines. setting and method: retrospective observational study. a focus was realized on patients admitted in a digestive surgery unit between january 1 and december 31, 2015. the patients' medical records were reviewed for clinical features, diagnosis workup and treatment strategies. main outcome measures: medical records for patients with diagnosis of gastro-entero-pancreatic or endocrine tumors who had received injections of lar octreotide during hospitalization were reviewed and the economic impact of prescriptions errors has been evaluated. results: of the evaluated 234 patients, 73 (31%) were hospitalized in surgery digestive unit; mean age at first administration of octreotide was 66 years and 58% were male. the male and female ratio was 1.35:1. reasons for hospitalization were: digestive system neoplasms (75%), fistula (7%), intestinal obstructions (4%) and other pathologies (14%). of the 73 patients treated with octreotide, 41 (56%) received a lar form. only four patients received doses in accordance with guidelines: one at 20 mg/month lar form and three at 30 mg/month lar form, after having respectively been treated by intravenous octreotide at 300 and 600 mcg/day during 7-10 days. medical prescriptions of the 37 remaining patients did not comply: all patients received 30 mg/month after an intravenous treatment of 300 mcg/day, instead of 20 mg/month. from a financial perspective, these misuses have led to an additional cost of 6659.7 euros for the hospital, excluding tax (30 mg: 1389.29€/unit and 20 mg: 1212€/unit). conclusion: despite the publication of octreotide release form proper use recommendation in our hospital, 90% of patients of digestive unit are not right treated. a new guideline will be written added by doses of long-acting release and economic data. this work will be transmitted to specialists by clinical pharmacists. hp-pc137: pharmaceutical process for intrathecal analgesia in clinical oncology practice vivien pigeon * , guillaume binson, claire grignon, antoine dupuis please specify your abstract type: descriptive abstract (for projects) background and objective: in some cases, patients with cancer pain remain painful despite the use of high dose of intravenous opioids and intrathecal analgesia becomes the ultima recourse to manage acute pain. until 2015, intrathecal syringes were prepared by nurses in the unit care which involve a risk for patients. therefore, the aim of this work is to describe the set-up of the prescription and preparation process with the potential benefits for the safety. design: multidisciplinary concertation took place between pharmacists, physicians and surgical teams and several points were discussed to secure the process: • identification of patients with high level of infection risk; • identification of critical points of the pharmaceutical process; • validation of quality control and drug stability studies regarding drug compounding involving morphine, ropivacaine, baclofen and clonidine, alone or in admixture. results: multidisciplinary concertation lead us to define the most important points to set up the pharmaceutical process for intrathecal analgesia: • chosen patients are cancer patients; • implementation of a prescription software to secure the prescription step; • production of syringes by the pharmacy department implying several criteria: • preparation in controlled atmosphere area; • training of pharmacy technicians; • implementation of quality control and drug stability studies at 4°c in syringe over 48 h and at 37°c in pumps over 1 month; • microbiological control and bacterial endotoxin level. the implementation of a pharmaceutical process for intrathecal analgesia gave us the opportunity to reorganize the care of cancer patients tolerant to high dose of opioids. in this process, the pharmacy department plays a major role leading to decrease the risk of infections and errors of dosing. ingrid plessala *,1 , xavier deviot 1 , thomas sidibe 1 , zohra mostefaï 2 , michèle minvielle 2 , marta wyrtwal 2 , roselyne gervais 1 1 pharmacy, 2 geriatrics, saint-denis hospital centre, saint-denis, france please specify your abstract type: descriptive abstract (for projects) background and objective: proton pump inhibitors (ppis) are indicated in gastro-oesophageal reflux and peptic ulcer disease. they are widely prescribed, often in off-label indications. the objective of this work was to reassess ppis prescriptions in collaboration with geriatricians. proton pump inhibitors (ppis) are indicated in gastro-oesophageal reflux and peptic ulcer disease. they are widely prescribed, often in off-label indications. the objective of this work was to reassess ppis prescriptions in collaboration with geriatricians. design: prospective study in three geriatric wards. the study included ppis treated patients from these three geriatric wards. dose, indication of the ppi, age, gender and duration of treatment have been recorded for each patient. the relevance of each ppi treatment has been reassessed by a geriatrician, a pharmacist and a junior pharmacist, regarding the indication and the patient's clinical condition. following this re-evaluation, three situations arose: • to maintain ppi at the same dose (30 mg or 15 mg) • to maintain ppi but half dose (from 30 mg to 15 mg) • to stop ppi corrective actions have been recorded in patients' files to allow their traceability. results: 109 patients were included in the study. 61% of ppis prescriptions were off-label, 24% had no indication mentioned in patient's file and 11% were conform to the marketing authorization. 98% of patients have been on ppis medication longer than 2 months, which is the recommended treatment' duration in france, 55% longer than a year and 29% longer than 4 years. in collaboration with the geriatricians, ppi prescriptions were maintained for 52% of patients. we reduced the dose in 14% of cases. finally, we decided to stop a third of the ppis prescriptions. conclusion: ppis prescriptions are often longer than recommended. this can lead to side effects for patients. in france, lack of new recommendations since 2009 may explain this frequent misuse of ppis. there is also a reserve from doctors to stop these treatments, especially with fragile patients. in our case, the relevance of each ppi treatment was re-evaluated in three geriatric wards and we succeeded in shortening and stopping ppis medications in half of the situations. to assess the impact of this action on our geriatricians, a new review of ppis prescriptions relevance is programmed in 2017. ppis prescriptions are often longer than recommended. this can lead to side effects for patients. in france, lack of new recommendations since 2009 may explain this frequent misuse of ppis. there is also a reserve from doctors to stop these treatments, especially with fragile patients. in our case, the relevance of each ppi treatment was re-evaluated in three geriatric wards and we succeeded in shortening and stopping ppis medications in half of the situations. to assess the impact of this action on our geriatricians, a new review of ppis prescriptions relevance is programmed in 2017. hp-pc139: oral anticoagulants and heparin for children: standardized protocols for prescription, dispensation and administration alexandra liauzu 1 , marie-françoise hurtaud-roux 2 , ronan bonnefoy 3 , caroline farnoux 4 , philippe sachs 5 , theresa kwon 6 , olivier bourdon 7 , sophie ajzenfisz 8 , sonia prot-labarthe *,7 1 pharmacy, 2 hématologie clinique, ap-hp hôpital robert-debré, 3 cardiologie, 4 néonatologie, ap-hp hôpital robert debré, 5 réanimation pédiatrique, ap-hp hôpital robert-debré, 6 néphrologie, 7 pharmacy, ap-hp hôpital robert debré, 8 coordonnateur de la gestion des risques associés aux soins/ responsable du système de management de la qualité de la prise en charge médicamenteuse, ap-hp hôpital robert-debré, paris, france please specify your abstract type: research abstract background and objective: high-alert medications (ham) are medications that are associated with a high risk of serious harm if used improperly. we already identified paediatric ham used in our institution to identify safety measures for their use. anticoagulants and heparin were part of these high-alert medications. we aim to write standard protocol of use for low weight heparin and oral anticoagulant used in our mother-child teaching hospital. our secondary objectives were to decrease medication errors, anti-xa and inr unexplained variability and to help nurses to administer the drugs (standard dilution, oral solution available) setting and method: we carried out a literature search on pubmed ò , on websites of several learned or professional societies and agencies. the results of the literature search were compiled on written protocol and presented to our institute drug safety-steering committee composed of four doctors, two head nurses, two pharmacists, and one risk manager. main outcome measures: not applicable. results: the protocols concerned enoxaparin, tinzaparin, warfarin but we chose to also include protamine. the most difficult issue was to have standardized dilution and protocol for all ages and weight: from premature to adolescents and all units of care (from cardiology to intensive care unit, nephrology and neonatology). we took into account the administration errors we had in our hospital and the preexisting protocol to avoid any drastic error-prone change. the final version of these protocols will be presented on the final communication with web link to upload them. conclusion: for now we did note evaluate the impact of these protocols but a before/after analysis of error reports and users evaluation will be done. however, these protocols can help all health professionals working in paediatric units for benchmarking. hp-pc140: does a hospital formulary system impact timely medication administration and quality of inpatient care? anne-valérie putallaz *,1 , vera jordan-von gunten 1 , pierre-auguste petignat 2 , pierre turini 3 , johnny beney 1 1 division of pharmacy, institut central des hôpitaux, 2 division of internal medicine, 3 medical coordinator for quality of care and patient safety, hôpital du valais, sion, switzerland please specify your abstract type: research abstract background and objective: the prevalence of drug omissions is often underestimated but their impact can be clinically relevant. we hypothesized that delays in the administration of non-formulary/nonstored drugs could impair the quality of care. the aims of this study were: 1°to determine the time between the prescription and the administration of the first prescribed dose and, if applicable, to calculate how many doses were omitted. 2°to analyse the clinical relevance of the identified delays. setting and method: three months retrospective study of electronic records of patients hospitalized on the internal medicine wards of a network of hospitals supplied by a centralized pharmacy. this pharmacy is located in one of the sites; other sites are 15-45 km apart. main outcome measures: 1. for the main hospital site and the three distant sites: • median time between the prescription and the administration of the first prescribed dose • mean number of omitted doses for formulary and non-formulary/ non-stored drugs. 2. categorization of patient's harm caused by the delays of timecritical drugs, according to the ncc-merp taxonomy of medication errors. results: 16'954 prescriptions were analysed. calculated delays for non-stored/non-formulary drugs were longer than for formulary drugs. however, the median time to administration is less than 1 h for both formulary and non-stored/non-formulary drugs; and more than 95% of formulary drugs and around 90% of non-stored/non-formulary drugs were administered within 24 h following their prescription. there was no significant difference in the mean number of omitted doses or in the delays between the site where the centralized pharmacy is located and the other sites, except for one of them. a delay representing 1.5 or more omitted doses was found for 332 (1.96%) prescriptions. among them, only 17 were considered potentially clinically relevant. none of them caused severe harm to the patients involved. conclusion: in our setting, non-stored/non-formulary drugs take more time to be delivered than formulary drugs, but more than 95% of formulary drugs and around 90% of non-stored/non-formulary drugs are administered within 24 h following their prescription. none of the 17 patients who experienced delays underwent severe harm. our study showed that delays also occur for formulary drugs but no systematic cause of omission was identified; further studies should focus on all dose omissions during hospitalization. penelope randuineau *,1 , roger jeremy 1 , lauriane cornuault 1 , anne lecoeur 1 , franck lemercier 1 , isabelle javerliat 2 , thomas tritz 1 1 service de pharmacie à usage intérieur, 2 service de chirurgie vasculaire, hôpital ambroise paré, boulogne-billancourt, france please specify your abstract type: descriptive abstract (for projects) background and objective: a french national survey of inpatient adverse events reveals that nearly half of adverse drug events (ade) are preventable. medication errors behind these ade occur mainly during the transition steps of care pathway. in this context, medication reconciliation process has been implemented in our vascular surgery department. the objective of this study is to identify unintentional discrepancies (uid) and assess their potential clinical impact design: a pharmacy resident or a pharmacy student reconciliated patients: aged older than 65 or with at least five chronic treatments at admission or suffering from chronic diseases. patients were considered reconcilable if at least two reliable sources on usual patient's treatment were available. these many sources of data (patient interview, prescription or interview of general practitioner, reference dispensary, drug box …) were compared to the admission prescription during the first 48 h of hospitalization to detect and correct uid. based on gravity scale promoted by the french high authority of health, two pharmacists (a resident and a senior) and a vascular surgeon reviewed every uid in order to define their potential clinical impact. the uids were considered minor if it leads to no consequence for the patient, clinically significant if it leads to essential monitoring, major if it could cause temporary clinical consequences, and critical if it could result in permanent clinical consequences or the involvement of the prognosis. results: between february 15th and may 31st 2016, a total of 102 patients have been reconciled. 10 patients were excluded due to a lack of reliable sources. mean age was 73.9 years old (±11.4) and sex ratio m/f was 0.7. 85% of the reconciliated patients' admissions were scheduled. the mean number of medication was 10.8 (±2.9). 38 patients (41%) had at least one uid and the mean uids per patient was 2.0 (±1.6). the most common types of uids were omission (73%), incorrect dose (15%) and incorrect administration frequency (11%). more than 60% of these uid presented a potential clinical impact: an adverse effect (high blood pressure, hyperglycaemia) was observed for nine patients and lead to therapeutic optimization and monitoring; 37 uid were considered to have potential clinically significant impact (49%), 11 a potential major impact (15%) and 1 a potential critical impact. conclusion: these results appear consistent with those reported in literature. vascular surgeons have appreciated the approach and would like systematic medication reconciliation before surgery. as a major part of admissions were scheduled, we would like to establish the reconciliation before the patient's hospitalization every time it's possible. this new organization should facilitate the care pathway before surgery and decrease preventable postoperative adverse events. hp-pc142: delirium in elderly patients: successful use of melatonin gaëlle jouin 1 , aurélie reiter-schatz 1 , pierre bentzinger 2 , fatem-zohra laalou 2 , bénédicte gourieux *,1 1 pharmacy-sterilization, 2 orthopedic's intensive care unit, university hospital of strasbourg, strasbourg, france please specify your abstract type: descriptive abstract (for projects) background and objective: postoperative delirium happens to about one-third of elderly patients and is a major cause of morbidity and mortality. it is reported that haloperidol, an antipsychotic, has been the agent of choice for managing delirium. however, it induces cerebrovascular adverse effects and greater mortality. the hyperactive type of delirium is known to be associated with a low melatonin level and the loss of a normal melatonin secretion rhythm. the postoperative administration of melatonin to elderly could decrease the symptoms of delirium. the purpose of this study was to evaluate melatonin effectiveness in a cohort of patients suffering from postoperative delirium. design: a retrospective study of melatonin prescriptions has been conducted over a 12 months period. medical background, type of surgery, symptoms of delirium, use of antipsychotics and benzodiazepines have been studied in all patients who received melatonin in an orthopaedic surgery unit. length of hospital stay, time between delirium and melatonin administration and the effect of melatonin had been evaluated. results: a total of 14 patients were included: average age was 77.6 years (64-87), sex ratio m/f = 1. twelve patients (86%) were hospitalized because of an infection (prosthesis or osteoarticular). in 64% of cases (n = 9), the prescription of melatonin was started when the patients were hospitalized in our intensive care unit. nine patients (64%) were under chronic treatments like benzodiazepines or antipsychotics. the average length of hospital stay was 76 days (11-186). melatonin was started on an average of 14 days after surgery , and administered at the dose of 2 mg xr in the evening, during an average of 35 days (7-113). cognitive impairments requiring a prescription of melatonin were: confusion (86%, n = 12), agitation (64%, n = 9), daytime sleepiness (64%, n = 9), temporal-spatial disorientation (57%, n = 8), nocturnal awakening (14%, n = 2), hallucination (14%, n = 2), difficult falling asleep (7%, n = 1). the average time to recover from confusion was 8 days, agitation 4 days, daytime sleepiness 10 days, temporal-spatial disorientation 7 days, nocturnal awakening 16 days, hallucination 5 days and falling asleep 24 days. melatonin treatment helped stopping benzodiazepines treatment in six patients (66%). conclusion: after administration of melatonin, delirium symptoms were improved for all patients and benzodiazepines treatment stopped for six patients. earlier prescription of melatonin could regulate sleep-wake cycle and reduce the duration and incidence of delirium. please specify your abstract type: research abstract background and objective: denosumab (xgeva ò ), a fully human monoclonal antibody targeting rankl, which inhibits bone resorption, is indicated to prevent skeletal complications in patients with solid tumors and bone metastases. about 10% of patients develop hypocalcaemia, a common adverse event that may induce spasms, muscle cramps, paraesthesia, prolonged qt interval, tetany, convulsions… we report the management of ionic supplementation and physicochemical incompatibilities in a case of hypocalcaemia due to denosumab. setting and method: the clinical case was analysed with the pharmacovigilance regional center. main outcome measures: a 61 year old patient, with nodal and bone metastasis in prostate cancer, was treated with denosumab (stopped with the last injection 2 months before, on the 29th of march). he went to emergency on the 30th of may with asthenia, anorexia, nausea, diarrhoea, qt prolongation. biological results showed hypocalcaemia (corrected calcaemic = 1.94 mmol/l) and hypophosphatemia (phosphorus \ 0.21 mmol/l). concomitant calcium and phosphorus intravenous supplementation started with loading doses (10 g of calcium and 1.8 g of phosphorus) and then a week of following daily intakes: phosphorus (1 g iv and 1.2 g oral); calcium (1 g iv and 4.6 g oral). however, low-serum corrected calcium and phosphorus levels persist at 1.89 mmol/l and 0.24 mmol/l. results: incompatibility between phosphorus and calcium by formation of soluble or not-soluble complexes is described in literature. in our case, calcium and phosphorus were mixed in a same infusion. after a week of supplementation, calcium infusion is continued with increased dose (4 g/day) and phosphorus infusion is stopped. phosphorus oral supplementation remains stable (1.2 g per day); calcium oral supplementation is increased (9.3 g per day). 2 h between intakes is applied to avoid digestive complexation. 48 h later, corrected calcium levels are normalized at 2.19 mmol/l and phosphorus levels are still low. therefore, as hypocalcaemia due to denosumab induced a secondary hyperparathyroidism and thus hypophosphatemia; phosphorus levels are expected to increase subsequently. conclusion: this case report shows that recurrent hypocalcaemia with denosumab is possible few months after administration. supplementation with large amount of calcium is needed and administration methods may impact the effectiveness of supplementation. indeed, it seems that the incompatibility between phosphorus and calcium did not allow an effective supplementation. gunnhild langdal *,1,2 , ida rudberg 1 , lone holst 2 , anne-lise sagen major 1,3 1 central norway hospital pharmacy trust, å lesund, 2 centre for pharmacy, university of bergen, bergen, 3 møre og romsdal health trust, å lesund, norway please specify your abstract type: descriptive abstract (for projects) background and objective: drug interactions (dis) can cause side effects and lack of therapeutic effect. the objective of this study was to describe the prevalence of dis at the medical department of å lesund hospital, and to investigate how dis were managed by clinical pharmacists and physicians. design: at the medical department, å lesund hospital, clinical pharmacists serve seven out of ten wards, from which patients were included during a five weeks period. the clinical pharmacists selected patients for screening for potential dis (www.interaksjoner.no) as int j clin pharm (2017) 39:208-341 303 usual (= pharmacist group). detected dis were classified according to a predetermined classification system, and it was registered whether the physician implemented suggested changes in prescription. for patients not selected by clinical pharmacists (= non-pharmacist group), a pharmacy student performed the search for dis. results: in total 373 patients were admitted. on average, each patient had 1.6 dis, and 56.6% of the admitted patients had at least one di. the prevalence of dis was significantly higher among the 194 patients in the pharmacist group compared to the 179 patients in the non-pharmacist group (median@@@ 1 vs. 0, respectively, p \ 0.001). the groups differed significantly regarding number of drugs used, age, duration of hospital stay and number of warfarin users. 10.5% of the dis detected in the pharmacist group were discussed with the physician. the remaining 89.5% were considered not necessary to discuss for various reasons e.g. because they were considered not clinically relevant (30%) or already adjusted for in clinical practice (20%). for 24 dis the clinical pharmacist suggested a change in prescription, and 20 of these suggestions (83%) were implemented by the physician. conclusion: just over half of the patients were selected by the clinical pharmacist for screening of dis, and the pharmacist seemingly made a reasonable priority of patients with many drugs, old age, a long hospital stay and users of warfarin. only 1 of 10 dis was discussed with physicians. this indicated that pharmacists do a considerable work in assessing the relevance of dis before discussing with the physicians. it also seemed that changes in prescription suggested by the clinical pharmacist were reasonable. hp-pc145: securing the paediatric use of oral chemotherapy: a proactive risk assessment samia mouffak *,1 , linda an 1 , anne fratta 1 , anne auvrignon 2,3 , nadia marquis 3 , karine morand 1 1 pharmacy, 2 risk management committee, 3 hematology, armand trousseau hospital -aphp, paris, france please specify your abstract type: descriptive abstract (for projects) background and objective: oral chemotherapy is an important part of the therapeutic strategy in childhood cancer or haematological malignancy. it also represents an emerging risk area in oncology practice. several medications errors involving oral chemotherapy were reported in children of our onco-haematology department, fortunately without clinical consequences. nevertheless, the potential severity of such errors led us to implement a failure analysis of the paediatric oncology care pathway in order to identify and prevent potential risks, and secure the paediatric use of oral chemotherapy. design: we conducted a failure modes, effects and criticality analysis (fmeca) which is a proactive risk assessment approach. first, process maps were detailed for each step of the oncology care pathway. it was performed by a multi-disciplinary group composed of 2 physicians, 1 coordinating nurse, 2 hospital pharmacists and 1 pharmacy resident. then, for each step of the medication-use process, the team identified the failure modes, their main causes and effects. finally, participants rated the expected severity, frequency and detectability for each failure mode, assigning a score on a five-point scale. a risk priority number (rpn) was then calculated by multiplying those three indexes. the risks getting a high rpn were categorized as critical risks and have been the object of safety improvements. results: 69 failure modes were identified, including 15 critical risk failure modes. 9 critical failures were related to hospital discharge prescriptions and 6 were about the dispensation of oral chemotherapy by pharmacy assistants. most failures were due to prescriptions heterogeneity, lack of clinical information reported on prescriptions, and lack of training of pharmacy assistants in reading oral chemotherapy prescriptions and in mistake detection. two improvement strategies were implemented. first, physicians' awareness led to the harmonisation of practices and to the standardisation of discharge prescriptions. then, to enhance pharmacy assistants' abilities, an educational program on oral chemotherapy dispensation was planned. conclusion: the implementation of a fmeca has highlighted the most critical risks of oral chemotherapy medication-use process. the awareness of all caregivers and the targeted changes in our practices allowed us to improve the safety of the paediatric oncology care pathway. please specify your abstract type: descriptive abstract (for projects) background and objective: the purpose of this study was to investigate if medication reconciliation and medication review, by using the integrated medicines management (imm) model, were suitable to assure the quality of patients' medical treatment at a gastrointestinal surgical ward. furthermore, to analyse frequency, type, handling and clinical relevance of medication discrepancies (mds) and other medication related problems (mrps). design: patients, above 18 years of age, from two departments at a gastrointestinal surgical ward at a norwegian university hospital were included consecutively. medication reconciliation was performed at admission by a clinical pharmacist. the resulting medication histories were compared with the medications documented in the medical records. mds were detected and categorized. thereafter the clinical pharmacist identified mrps by reviewing the medical records systematically and categorized the revealed mrps. mds and mrps were presented for the physician with proposed solutions. the physician's actions to manage the mrps were registered. later a multidisciplinary team assessed the clinical significance of mds and mrps in a subset of patients. results: a total of 48 patients were included. overall, 144 mds and 153 mrps were identified. at least one md was revealed in 90% of the included patients, whereas at least one mrp was identified in 88% of the patients. the most frequent type of mds was omission, whereas mrps most often were related to medications that were considered unnecessary. totally, 76% of the mds and mrps were discussed with the treating physician. the physicians followed the pharmacist's input in 85% of the discussed md-cases and 62% of the mrp-issues. longterm consequences of mds and mrps were considered more serious than short-term consequences for the patients. conclusion: medication reconciliation and medication review revealed, solved and prevented a large number of mds and mrps in this study. the results emphasize that pharmacist involvement, by using the multidisciplinary imm-model, contributed to more correct medical records and furthermore to quality assurance of the patients' medical treatment at a gastrointestinal ward. hp-pc147: prevention and management of drug interactions in oncology day-hospital: results from a 6 months study involving drug assessment and pharmaceutical report to oncologist pauline-saraï zeller *,1 , chloé hugard 2 , céline mongaret 1,3 , juliette vella-boucaud 2 , antonin maréchal 1 , olivier bouché 2 , dominique hettler 1 , florian slimano 1,3 1 pharmacy, 2 oncology day hospital, university hospital reims, 3 clinical pharmacy, faculty of pharmacy, reims, france please specify your abstract type: research abstract background and objective: quality during transitions of care is a major concern in drug safety for patients. traditional hospitalization allows to reconciliation medication but there is not possible for dayhospitalization (patient's hospitalization short time and no outpatient medication prescribe by oncologists). however, lack of communication between health professionals may expose patients to drug-drug interactions (ddi). while ddi between oral antineoplastic and other drugs are well known, there is a lack of knowledge about ddi between parenteral antineoplastic (ak) and other drugs. in this pilot study, we aim to investigate prevalence and characteristics of ddi between ak and other drugs in real life and to propose a pharmaceutical report model to enhance patient's drugs safety. setting and method: during 6 months, all new oncologic patients (thoracic and digestive) receiving chemotherapy in day-hospital have been recruited by clinical pharmacist. first it was conducted a patient-clinical pharmacist interview and carried out the best possible medication history (bpmh) by contacting at least three different sources of drug information. then, the bpmh has been confronted with oncologic treatment (including concomitant medications such as like antiemetic) with support at least with two different database of ddi analysis. finally pharmaceutical recommendations in order to manage potential relevant ddi were reviewed with oncologists then reported and inserted in personal health record (phr). main outcome measures: prevalence and description of potential clinically relevant ddi in an ambulatory oncology population. results: from november, 2015 to april, 2016 n = 90 oncologic patients were included with following characteristics: mean age of 63.2, sex ratio 2:1, majority of oncologic thoracic localization (56%). number of oncologic concomitant medications per patient was 3.97 ± 0.94 (mean ± standard deviation). patients present an average of 2.2 ± 1.93 comorbidities (excluding cancer) and 5.97 ± 3.76 linked medications per patient. pharmaceutical analysis revealed 33 potential clinically relevant ddi (0.37 ± 0.97 per patient): 72% of them concern antiemetics (ondansetron and aprepitant): pharmaceutical interventions were formulated (including recommendations to adapt chronic treatment) and 39% of them involved biological monitoring (for renal function, inr, potassemie or magnesemie). conclusion: our pilot study confirms high prevalence of ddi between oncologic and non-oncologic drugs. clinical pharmacy services with bpmh performing and pharmaceutical recommendation appears to be useful to enhance patient' drug safety in oncology dayhospital. we currently are deploying our study in order to convey a pharmaceutical letter to general practitioner and community pharmacist. hp-pc148: loading dose of anti-infectives: elaboration of a tool helping pharmaceutical analysis julie soyer *,1 , cécile sanchez 1 , guillaume beraud 2 , nicolas venisse 3 , pauline lazaro 1 , antoine dupuis 1 1 pharmacy, 2 infectiology, 3 pharmacokinetics, university of poitiers, poitiers, france please specify your abstract type: descriptive abstract (for projects) background and objective: the recent data on vancomycin and ceftazidime confirm that continuous infusion is the best way of administration of these antibiotics. moreover a loading dose before the administration is required for the antibiotics to prevent from the infratherapeutic period at the start of infusion and limiting the risk of resistance emergence. long half-life antibiotics and antifungals also require a loading dose to be effective. the aim of this study is to analyse the prescriptions of anti-infective requiring a loading dose in order to develop a tool to help pharmaceutical analysis. design: a prospective observational study was carried out during 15 days in 16 units. initially, pharmacists, residents and students were trained (role of the loading dose, drugs concerned). then, all patients with anti-infective requiring loading dose were included. some data were collected: weight patient, creatinine clearance, loading dose or not, dose, administration mode, monitoring of steady state concentrations (vancomycin and ceftazidime) and dose adjustment. the results were analysed and compared to bibliographic research before discussion during a multi-disciplinary meeting (pharmacists, infection control specialist and pharmacokinetic specialist). finally, a list of relevant pharmacist interventions was selected. results: out of the 393 patients, 44 were enrolled for prescription of anti-infective requiring loading dose. twenty-six prescriptions including vancomycin, 8 ceftazidime, the others fluconazole, caspofungine, voriconazole and posaconazole. concerning vancomycin, the loading dose was prescribed in 85% of case, monitoring of steady state concentrations was performed in 90% of case and dose adjustment after first dosage was required in 56% of case. selected pharmacist interventions were: • to favour continuous infusion (excepted paediatric) • to keep loading dose at full dose even in patient with renal failure • to monitor steady state concentrations after the first 24 h in patient with renal failure or obesity • to adapt dosage when the target concentration is not reached concerning ceftazidime, the interventions were: • to recommend continuous infusion: 6 g/24 h after loading dose of 25 mg/kg • to monitor steady state concentrations in patient with renal failure a total of 27 interventions (dosage, adaption of posology at the monitoring, patients with renal failure, obese, paediatric patient, administration…) were identified by the group of experts. conclusion: this study allowed creating a recap data sheet for students and hospital pharmacists. the selected interventions will allow the harmonization of practices. these recommendations have been validated by the commission of the anti-infective. finally, this study shows that the pharmacist has a key role in the management of antiinfective requiring loading dose. hp-pc149: assessment of potentially inappropriate medications in orthogeriatric patients using the rasp list the detection of inappropriate prescribing. the objective of this study was to investigate if the rasp list (rationalization of home medication by an adjusted stopp list in older patients), an explicit screening method adapted to the belgian context, can be used to reduce the number of potentially inappropriate medications (pims) in orthogeriatric patients. setting and method: single-centre, interventional study conducted at the orthogeriatric department of the uz brussel, a 721-bed university hospital. the rasp list was first applied by a last year pharmacy student to the admission medication of orthogeriatric patients hospitalised in october 2015. after potential adaptations to the medication by a liaising geriatrician, the rasp list was additionally applied by the same pharmacy student to the discharge medication of these patients. main outcome measures: detection and reduction of the number of pims. results: in total, 59 orthogeriatric patients, from whom an informed consent was obtained, participated in this study. on admission, a total of 136 pims were detected in this population. at discharge, the number of pims decreased to 101. the median number of pims per patient decreased from 2 (on admission) to 1 (at discharge). this difference was statistically significant (p \ 0.001; wilcoxon signed rank test). drugs of atc class n (nervous system) were responsible for the highest number of pims. conclusion: pims can be detected and reduced in the hospital using the rasp list. a structured and collaborative medication review between (student) pharmacists and physicians appears a good approach to reduce the number of potentially inadequate drugs. nevertheless, more research is necessary to substantiate this further as well as to assess the clinical impact of the findings. hp-pc150: impact of implementing ward based dispensaries across a hospital site on both service delivery and patient care michelle sullivan, paul wright, christopher watson, malcolm smith, sotiris antoniou * please specify your abstract type: descriptive abstract (for projects) background and objective: waiting for medication at discharge is often quoted as a key factor for delaying patients leaving hospital. feedback from service users (patients and healthcare professionals) was for a more patient facing pharmacy service. this led to a phased installation of remote dispensaries on wards within the hospital to supply medicines. this new and innovative service enabled the supply function to be fully co-ordinated on the ward. this model was initially implemented on 8 wards, which coupled with one-stop dispensing meant 91% of discharges require nothing to be supplied at the point of validation, 100% of discharge prescriptions meeting key performance indicator of being dispensed and ready within 1 h with average turnaround time of 18 min for a discharge prescription and a reduction in missed doses-3.1% in september 2015 to 2.1% in march 2016. this success prompted further installation of remote dispensaries in all clinical areas on site. design: implementation included; purchasing hardware, pharmacy labellers, locating appropriate computer terminals and stock cupboards. the main pharmacy labelling and stock control system was fully integrated at ward level, enabling the automatic reordering of replacement stock. identification of items and quantities to stock for remote dispensaries was also needed prior to role out. there was a need to scope staffing requirements including the redeploying of roles from a main inpatient pharmacy to patient facing areas. results: over 6000 items are supplied at ward level each month via satellite pharmacies for all wards, equating to more than 80% of the total dispensing workload for the site allowing for pharmacy staff to be redistributed from dispensary to the ward. this offered the benefit of being more patient facing and supporting other initiatives such as patient counselling and medicines reconciliation. the project has impacted the pharmacists as it has enabled them to focus on clinical aspects of service delivery, including attendance of ward rounds as well as supporting a ward team approach with the pharmacy technician. results of missed dose audit from june 2016 shows across the site 41% (7) wards scored below the national 1.4% target and (29%) 5 wards had no unintentional missed doses. conclusion: ward based dispensing has led to pharmacists and pharmacy technicians being 100% ward based. as a constant presence on the ward, the team offer consistency within the pharmacy service for patients, nursing and medical staff. impact of pre-discharge planning has been beneficial to nurses, patients and work flow of the pharmacy teams. ward based dispensing has improved supply at discharge as well as promoting a more patient facing pharmacy service that has seen the pharmacy team instilled as integral to service delivery at ward level. kutay demirkan * , nursel surmelioglu, aygin bayraktar-ekincioglu clinical pharmacy, hacettepe university, ankara, turkey please specify your abstract type: research abstract background and objective: hacettepe university hospitals clinical pharmacy unit was established in april 2014. this unit runs its services by clinical pharmacy postgraduate students under the supervision of two qualified clinical pharmacists as part-time and oncall basis, in adults, paediatrics and oncology hospitals. the aim of this study was to identify drug related problems and describe its management strategies in inpatient and outpatient settings by pharmacists in clinical pharmacy postgraduate education program. setting and method: during a total of 9 months study period (period i: february-july 2015, and period ii: november-february 2016), clinical pharmacy postgraduate students followed patients for 2-3 times in a week in different services in hospitals (internal medicine, internal medicine intensive care, infectious diseases, neurology intensive care, paediatric bone marrow transplant/haematology unit, paediatric intensive care, geriatrics and nutrition units) and drug related problems were identified and pharmacists' recommendations were listed. main outcome measures: determination and evaluation of drug related problems by pharmacist in hospital. results: a total of 114 recommendations was provided for 93 patients. those recommendations were classified as alteration or discontinuation of drug treatment (33.3%), dose adjustment (31.6%), change in drug administration time (14.9%), inadequate treatment (7.9%), healthcare staff training/consulting (6.1%), patient education (5.3%) and error/deficit in therapeutic drug monitoring (1.7%). a majority of recommendations (n = 38) were related with alteration or discontinuation of drug treatment provided mainly in departments of internal medicine (n = 9, geriatrics (n = 7), neurology intensive care (n = 5) and infectious diseases service (n = 5). the following main reason for pharmacist's recommendation was related with dose adjustment (n = 36) which were provided in departments of internal intensive care (n = 16), infectious diseases service (n = 6), neurology (n = 5) and internal medicine (n = 5). conclusion: clinical pharmacy practices are being carried out effectively in many services, particularly in internal medicine services, internal medicine intensive care unit and infectious diseases services. a collaborative and bed-side education in postgraduate programs in clinical pharmacy help to increase the knowledge and skills of students in real life circumstances and also maintain safe and effective drug therapy by an involvement of clinical pharmacists in hospital services. hp-pc152: development of a tool to help pharmaceutical analysis in patients with hepatic failure barbara troussier *,1 , eric gautier 1 , astrid bacle 1 , florian charier 2 , christine silvain 3 , pauline lazaro 1 1 pharmacy, 2 gastroenterology, 3 hepatology and gastroenterology, university hospital of poitiers, france, poitiers, france please specify your abstract type: descriptive abstract (for projects) background and objective: hepatic impairment can cause significant changes in the pharmacokinetics of many medicines. however hospital pharmacists can be helpless in performing pharmaceutical analysis behind the lack of precise guidelines. we need a strategy to first detect accurately patients with hepatic impairment, then lead us in dose adjustments. the objectives of this project were to develop a helping tool for hospital pharmacists in the pharmaceutical analysis of patients with hepatic failure's prescription and to select relevant pharmacist interventions. design: we first planned an investigation of patients with hepatic failure's management, with multidisciplinary experts groups. the study was conducted during one week in post-surgical, gastro-enterology, endocrinology, cardiology, pulmonology, geriatric departments and reanimation care units. a flowchart based on hepatic's biomarkers helped us including patients. criteria used to assess hepatic impairment could be: a stage c child-pugh score, prothrombin score inferior to 70%, bilirubin superior to 50 micrograms per millilitres of blood without haemolysis, aspartate and alanin aminotransferases superior to three times the high normal value, and presence of a vitamin k antagonist interfering with those results. after a review of each included patient's prescription, we checked the major pharmacokinetic elimination pathway of each prescribed molecule (biliary or renal) and if hepatic biotransformation was expected. we also checked if the molecule could cause hepatic side effects. results: out of 474 patients, 15 patients were included for liver failure (3.2%) and 4 for a cholestasis (0.8%) mainly in reanimation care units (17.5%) and gastro-enterology (10%). among the 232 lines of prescribed medicines, the main pharmacological classes encountered were cardiology, (5%) pain (5%), psychiatry (4%), haemostasis (2%) and antibiotics (1%). at the end of the investigation, the expert group decided on the relevant pharmacist interventions. these were based on dose adjustment of anti-infectious, psychotropic drugs, painkillers, oral anti-diabetics, anti-coagulants and corticosteroids. alternatives are proposed for each class. conclusion: to conduct a better pharmaceutical analysis, 3 steps are necessary. first, any liver failure or cirrhosis must be detected thanks to the patient's biological results and medical record. then the patient's prescription can be analysed in order to highlight drugs that need a dose adjustment in a context of hepatic impairment. finally, the physicist and the pharmacist discuss about dose adjustments or alternatives if presence of contraindication with the drugs prescribed. soon the designed tool will be available to all pharmacists to harmonize clinical pharmacy practices. please specify your abstract type: research abstract background and objective: data regarding adherence rates to oral chemotherapy in lymphoma patients is limited. the aim was to assess pharmacist intervention on adherence to oral chemotherapy in patients suffering from hodgkin's (hl) and non-hodgkin's lymphoma (nhl). setting and method: following ethics approval, 5 hl and 41 nhl patients attending chemotherapy sessions at the medical investigations and treatment (mitu) at mater dei hospital accepted to participate. a questionnaire was compiled to evaluate adherence to oral chemotherapy and to assess pharmacist intervention. the questionnaire was divided into 3 sections (a-c). the same questionnaire was used for both the first interview (t = 0) and after 6 weeks (t = 1). an additional section (d) was incorporated at t = 1 to evaluate pharmacist intervention. section a consisted of questions regarding patient management of lymphoma. section b incorporated the morisky 8-item medication adherence scale (mmas-8) 1 to evaluate adherence to oral chemotherapy. a total mmas-8 score of zero indicates high adherence, a score between 1 and 2 indicates medium adherence and a score between 3 and 8 indicates low adherence. section c consisted of additional questions regarding medication adherence. between t = 0 and t = 1, pharmacist intervention involved providing each patient with an information leaflet which was developed in this study, an individualised treatment chart and verbal advice. ibm ò spss version 22 and the wilcoxon signed-rank test were used to assess changes in medication adherence between t = 0 and t = 1. main outcome measures: evaluation of pharmacist intervention on adherence to oral chemotherapy in patients suffering from hl and nhl. results: out of the 5 patients with hl at t = 0, 3 'never' missed a dose, 1 missed a dose 'once in a while' and 1 'sometimes' missed a dose. for the 41 patients with nhl at t = 0, 38 'never' missed a dose, 2 missed a dose 'once in a while' and 1 'sometimes' missed a dose. the reason for missing a dose was forgetfulness. all 41 nhl and 5 hl patients indicated the haematologist as their source of information about the management of lymphoma. of the 41 nhl patients, 3 scored low adherence and 38 scored medium adherence at t = 0 and after 6 weeks (t = 1) all 41 nhl patients who participated scored medium adherence. of the 5 hl patients, 2 scored low adherence and 3 scored medium adherence in the first interview (t = 0) and after 6 weeks (t = 1) all 5 hl patients who participated scored medium adherence. there was a statistically significant increase (p \ 0.05) in the number of patients who scored medium medication adherence between t = 0 and t = 1 for both nhl and hl patients. conclusion: this study shows how pharmacist intervention and extended professional services could be implemented in the clinical setting to impact on the management of hl and nhl patients. please specify your abstract type: descriptive abstract (for projects) background and objective: in may 2015, an activity of medication reconciliation was implemented in the gastroenterology service to carry on the optimization of the medication care of patients due to the recent computerization of their prescriptions. design: this project, worked in collaboration with the gastroenterology service has been introduced in two medical committees. this activity gathers pharmacy students, the pharmacist, senior and junior doctors. reconciled patients are selected according to several criteria (advanced age, poly pathological, poly-medicated and those for whom a drug background is difficult to retrieve for the medical team). a minimum of 3 information sources is used for the collection of the drug background. all information are synthetized on a paper, validated by the pharmacist and discussed again with the prescriber. results: on a 10-month period, 61 patients were reconciled with on average age of 72. the reconciliation is executed on average 2.4 days after the entry in the service. 96.7% of reconciliations are retroactive. the main sources of information used for the collection of the drug background are: in 85.2% of the cases an oral interview with the patient and/or the family; in 82% of the cases the prescriptions, the hometown pharmacist (78.7%) and a medical letter (67.2%). 6.7 drugs are on average on the hospital prescription, and 47.5% (29/61) of the patients are concerned with at least one non intentional divergence (nid). on average there are 1.2 nid/patient and 3.9 intentional divergences (id)/patient. the main types of nid are omissions (44.7%), drug dose errors (19.7%) and errors in administration frequency (11.8%). after the detection of nid, the proposed modifications to the prescribers are accepted in more than 50% of the cases (31/61). the average time of a reconciliation is 49 min. exchanges on the id and nid are made with the junior doctors in 85.2% of the cases. conclusion: some nid are occurring for 47.5% of the reconciled patients. it is therefore necessary to extend this new activity to reconciliation in other services in order to increase the interception of eventual medication mistakes and allow their correction. please specify your abstract type: research abstract background and objective: diuretic therapy is routinely used in the management of congestive heart failure (chf).,compliance with clinical practice guidelines is reported to result in improved outcomes for patients with chf such as reduced exacerbations. the aim was to assess the effect of pharmacist intervention on adherence to diuretic treatment in a hospital and community pharmacy scenario. setting and method: the study was undertaken at karin grech hospital (kgh), a geriatric and rehabilitation hospital, and in one community pharmacy. inclusion criteria for patients recruited from kgh were age over 60 years, suffering from chf and on bumetanide therapy. the validated 8-item morisky medication adherence scale (mmas-8) 1 was administered to patients on admission (t = 0), repeated after two weeks hospital stay (t = 1) and again one-month post-discharge (t = 2). a total mmas-8 score of zero indicates high adherence, a score between 1 and 2 indicates medium adherence and a score between 3 and 8 indicates low adherence. in the community setting patients on diuretic therapy were chosen by convenience sampling. the same adherence scale was administered prior to pharmacist intervention (t = 0) and one-month after pharmacist intervention (t = 1). pharmacist intervention in the community setting involved dissemination of an informative leaflet regarding chf and diuretic therapy developed for the purpose of this study. main outcome measures: impact of pharmacist intervention on adherence to diuretic therapy in chf patients. results: a total of 37 patients were recruited from the hospital setting, of whom 19 were female and 18 were male with a mean age of 80 years (range 67-97 years). on admission (t = 0), 16 patients scored high adherence, 11 scored medium adherence and 10 scored low adherence to bumetanide therapy. following 2 weeks at the hospital (t = 1), the number of patients scoring high adherence increased from 16 to 31 and the number of patients scoring low adherence decreased from 10 to 1. one-month post-discharge (t = 2), patients scoring high adherence decreased from 31 to 19 and patients scoring low adherence increased from 1 to 3 (p \ 0.05). a total of 38 patients were recruited from the community pharmacy, of whom 21 were female and 17 were male, with a mean age of 79 years (range 68-97 years). after pharmacist intervention (t = 1), the number of patients scoring high adherence increased from 21 to 23, while the patients scoring low adherence decreased from 9 to 5 (p [ 0.05). conclusion: pharmacist intervention in the hospital setting improved adherence to bumetanide therapy. in the community pharmacy setting, there was a slight improvement in the compliance. pharmacist monitoring and patient support is important post-discharge to ensure patient compliance to therapy. conclusion: surveillance of aeds may be followed by combination of data from adverse drug reaction databases and drug utilisation data from prescription databases. focus on reporting adverse reactions is important for pharmacists and clinicians, especially for newly approved drugs. awareness of increased exposure of aeds to new groups of patients followed by data regarding safety aspects is important and contributes to improved pharmacovigilance. please specify your abstract type: research abstract background and objective: the medication review of polymedicated patients is a priority shared among all healthcare professionals. a multidisciplinary approach of these patients is necessary to achieve the best results for their treatment (1) . the objective was to analyse the rate of acceptance of the recommendations made by the primary care pharmacist (pcp) to the general practitioner (gp) regarding the treatment of polymedicated patients. setting and method: setting: a primary health care centre (27,521 population). method: a review of the medical records of polymedicated patients (c5 chronic drugs for c6 months). the patients' data were collected from january to june 2015 from their clinical records. statistical descriptive analysis of data was performed. main outcome measures: drug related problems (drp) for each patient: interactions, contraindications, inadequate dosages, nonindicated drugs, omission of a necessary drug, duplications, medication with low therapeutic effect, and inappropriate medication for patients c75 years old. treatment alternatives proposed to gp's by pcp were also measured. results: 34 patients were included in the study (average age: 68.6 ± 11.7, 74% women). out of the 34 patients, 88 interventions were laid out to reduce the risks of drp's and to improve the efficiency of treatments. 97% of patients presented some drp or some intervention to improve the efficiency of their treatment, this mean an average 2.5 interventions for patient. the prevalence of intervention proposals were: non-indicated drugs (28%), interventions for improve the efficiency of treatments (20%), interactions (16%), inappropriate medication for patients c75 years old (10%), contraindicated drugs (9%), duplications (6%), medication with low therapeutic effect (5%), inadequate dosages (5%) and omission of a necessary drug (1%). 97% of these intervention proposals were accepted by the gp: 38% of the accepted proposals were carried out and from the remaining 62, 43.6% led to a prescription from a specialist physician. in 51% of the cases, the patient did not accept the changes. 5.4% were not carried out due to other issues. the main drug related problem was the prescription of non-indicated drugs and the most involved drug was omeprazole. conclusion: acceptance by gp's to changes proposed by primary care pharmacists was high. a significant number of changes was not accomplished due to the negative response by some patients and led prescriptions from a specialist physician. the gp greatly values the multidisciplinary aid in approaching the complexity of polymedicated patients. background and objective: case-reports provided evidence that influenza infections, particularly severe episodes, may exert neuronal damage in the cns and thereby increase the risk of depression. it was the aim of this study to analyse the association between influenza infections and the risk of developing incident depression. setting and method: we conducted a case-control analysis using the large uk-based primary care database clinical practice research datalink (cprd). this database contains anonymous longitudinal data from primary care. at present, it contains over 100 million person-years of data from some 10million active patients. the study encompassed 103,307 patients below the age of 80 years with an incident major depression diagnosis between 2000 and 2013, and we matched each case to one control patient on age, sex, general practice, number of medical encounters, and years of history in the cprd prior to the index date. main outcome measures: major depression diagnosis was identified by read-codes based on icd-10 codes (f32), with a minimum of three prescriptions for antidepressant drugs recorded after the diagnosis. we calculated relative risk estimates of developing depression in association with previous influenza infections, stratified by the number, timing and severity of such events, and we adjusted for a variety of comorbidities, smoking status, alcohol intake, body mass index, use of oral corticosteroids, and benzodiazepines. results: patients with a previous influenza infection had an increased risk of developing depression (or 1.30, 95% ci 1.25-1.34) compared to patients with no history of influenza infections. a recent influenza infection recorded within 30-180 days prior to the index date yielded an adjusted or of 1.57 (95% ci 1.36-1.81), and an increasing number of previous influenza infections was associated with increasing odds ratios (c3 recorded influenza infections, adjusted or 1.48, 95% ci 1.22-1.81). we did not see any differences in the relative depression risk associated with influenza with regard to a previous influenza vaccination. conclusion: this study suggests that influenza infections are associated with a moderately increased risk of developing depression. please specify your abstract type: research abstract background and objective: warfarin is known for its interactions with many drugs. elderly patients are particularly sensitive to warfarin interactions. to evaluate the incidence of potential drug interactions when prescribing new drugs to elderly patients on warfarin, a prospective observational study was conducted. setting and method: patients on warfarin older than 65 years were included and monitored for 6 months in 4 community pharmacies in croatia. data regarding new prescribed drugs was obtained from pharmacy records at the moment of dispensing or by patient selfreporting. the potential interacting drugs were identified using the lexicomp ò lexi-interact online software. only the clinically significant (levels c, d, x of clinical significance as classified by lexicomp ò lexi-interact online) interactions were included in this analysis. main outcome measures: number of new proscribed drugs, level of interaction with warfarin, mechanism of interactions. results: we included 157 elderly patients with an average age of 73 years. in the follow-up period, new drugs were prescribed to 54 patients (34.4%). there were 79 prescriptions of new drugs and 57 (72.2%) of those were drugs with a clinically significant interaction with warfarin. there were 39 prescriptions of drugs with level c of interaction (68.4%), and 18 (31.6%) with level d. there were no drug interactions of level x. in the group with level c the most prescribed drugs were antibiotics with 26 prescriptions: amoxicillin/clavulanate 28%, clindamycin 8%, ciprofloxacin 8%, norfloxacin 8%, azithromycin 5%, cefuroxime 5%, clarithromycin 3%, doxycycline 3%. the remaining 13 prescriptions included tramadol with paracetamol 18%, rosuvastatin 5%, simvastatin 3%, fluvastatin 3%, levothyroxine 3% and torasemide 3%. the dominant mechanism of the potential interactions was pharmacokinetic. in the group with level d the most prescribed drugs were nonsteroidal anti-inflammatory drugs with 12 prescriptions-diclofenac 35%, ibuprofen 23%, indomethacin 12%. among other drugs, 6 prescriptions were antibiotic sulfamethoxazole with trimethoprim 12%, fenofibrate 6%, miconazole 6%, and fluconazole 6%. the dominant mechanism of the potential interactions was pharmacodynamic. conclusion: pharmacists should actively monitor prescribing of new drugs to elderly patients on warfarin in order to reduce the risk of clinically significant drug interactions. please specify your abstract type: research abstract background and objective: explicit criteria of potentially inappropriate medications in the elderly (pims) have been published in the usa, canada, australia and many eu countries. there is a lack of studies describing prevalence of pim use in central and eastern europe. the aim of the eu cost action 1402 initiative wg1b (2015 wg1b ( -2018 is to evaluate the registration rates and use of pims in central and eastern europe compared to other eu countries participating in this initiative. this abstract describes preliminary findings on different registration rates of pims in different eu countries. setting and method: researchers/members of the eu cost action 1402 initiative from the czech republic, serbia, hungary, spain, turkey and portugal were asked to fill in evaluation tables for the list of 484 pims in the period 01-06/2016. items available in these evaluation tables related to: registration of individual pims on the pharmaceutical market, registered doses, drug forms, availability of pims on prescription or as otc drugs, prescription limits and the most frequently used brand names. data were evaluated using comparative descriptive statistics. main outcome measures: overall prevalence of registered pims in different countries, cross-country differences in availability of individual pims. results: of 484 pims 81.8% were registered in at least 1 participating country. for the czech republic (45.2%), turkey (48.6%), spain (52.1%) and hungary (54.1%) overall prevalence rates of registered pims were found to be similar. however, these prevalence rates substantially differed in serbia (low prevalence-33.9%) and portugal (high prevalence-68.5%). substantial differences were found also in the lists of individual pims registered in different countries. these lists were similar in spain and portugal compared to the czech republic, hungary, serbia and to turkey. conclusion: although overall prevalence rates of registered pims were similar in the majority of evaluated countries (except serbia and portugal), availability of individual pims was substantially different. our pilot results confirmed that there are substantial geographical/ regional differences in europe in the lists of pims available (in spain and portugal compared to central and eastern europe and compared to turkey). please specify your abstract type: research abstract background and objective: inappropriate prescribing is a common circumstance found in polymedicated patients. screening tools for identifying potentially inappropriate prescription (pip) and pharmacist interventions for evaluating them have been developed to decrease this (1) . the aim of this study was to evaluate the effectiveness of a pharmacist provided intervention to reduce pips in polymedicated patients. setting and method: the design was a quasi-experimental study focusing on a single group before and after intervention. the study took place from july to december of 2015 at three primary care centres (52,992 population). polymedicated patients were those using c10 chronic drugs for c6 months. main outcome measures: reduction in the rate of pip per polymedicated patient (number of pips found divided by the total number of polymedicated patients) before and after intervention, and the influence of the following variables: type of pip (inappropriate medication for patients c75 years old, medication with low therapeutic effect, duplication of benzodiazepines (bzd) or angiotensinconverting enzyme (ace) inhibitors, combination of anticoagulant and antiplatelet, combination of non-steroidal anti-inflammatory drug (nsaid) with a diuretic and ace inhibitor, nsaid in cardiovascular disease, chronic antipsychotic in dementia, chronic bzd, or chronic nsaid), gender and age of patients with at least one pip, and the main prescribed drugs involved in the pips based on atc classification system of world health organization. results: there were 1093 and 959 polymedicated patients before and after intervention, respectively. 71.36% (n = 780, before) and 68.30% (n = 655, after) of the total patients had at least one pip. the number of pips was reduced from 1373 to 1108, while the rate of pip per polymedicated patient decreased from 1.26 to 1.15, achieving the limit established by the regional health authority. 50.90% (before) and 48.70% (after) of patients had more than one pip at the same time, up to 5 pips per patient. before and after intervention, more than half of patients with at least one pip were c75 years old, and approximately 9 out of 10 were c65 years old. also before and after intervention, 8 out of 10 patients with chronic nsaid and with bzd duplication were women. 6 out of 10 patients with combination of anticoagulant and antiplatelet were men. the main pips before and after intervention were, respectively: chronic prescription of bzd (39.77 vs. 37.99% of the total pip), medications with low therapeutic effect (19.81 vs. 21.30%) and inappropriate medication for patients c75 years old (16.82 vs. 17.42%). the main atc group involved in the total of pips was drugs for the nervous system, and the five most prescribed drugs were all bzd (lorazepam being the first). conclusion: pharmacist provided intervention was able to reduce pip in polymedicated patients. gender, age and atc classification of drugs involved were factors in the pips. please specify your abstract type: research abstract background and objective: up to 10% of women are exposed to selective serotonin reuptake inhibitors (ssris) during pregnancy. information on their effect on birthweight and gestational age remains conflicting. the aim of this sibling-controlled prospective cohort study is to address shared genetic and family-level confounding to investigate the effects of prenatal ssri exposure and maternal depression on birthweight and gestational age. setting and method: we used the norwegian mother and child cohort study (moba) and the medical birth registry of norway (mbrn). our study population consisted of 27 756 siblings; 194 were prenatally exposed to ssris and 27 500 were unexposed to any antidepressant medication. random and fixed effects analysis with propensity score adjustment was used to evaluate the effects on birthweight and gestational age. main outcome measures: birth weight. gestational age. results: ssri exposure during two or more trimesters was associated with a decrease in birthweight of 205 g [95% confidence interval (ci) 372 to38] and a decrease in gestational length of 4.9 days (95% ci9.1 to1.4). neither maternal ssri use in one trimester, lifetime history of major depression nor depressive symptoms during pregnancy were associated with these pregnancy outcomes. conclusion: prenatal exposure to ssris during two or more trimesters may decrease birthweight and gestational length. our results indicate that neither maternal depression nor shared genetics and family environment fully explain this association. please specify your abstract type: research abstract background and objective: the drugs burden index (dbi) is a tool to evaluate the burden of medications with anticholinergic and sedative effects and this exposure has been associated with poorer physical and cognitive function in older people. objectives were; to determine the cumulative burden of anticholinergic and sedative medicines in older adults with intellectual disability (id) using the dbi, to examine the relationship between dbi score with demographics and comorbidity. setting and method: data from wave 2 of the intellectual disability supplement to the irish longitudinal study on ageing (ids-tilda), a nationally representative study of ageing people with id in ireland. dbi scores were calculated for all participants with available medication data (n = 677). bivariate associations between dbi and demographic and clinical characteristics were examined with a significance level of 0.05 main outcome measures: dbi scores of participants categorised into low (0), medium (0-1) and high (c1). dbi score categories were related to demographics, cognitive effects and to a modified functional comorbidity index (fci), which is associated with physical function in older adults. results: of 677 participants, 95.1% (644) had dbi exposure; 51.3% were exposed to any anticholinergic medication, 32.1% to any sedative medication; mean number of dbi medications 2.91 (±1.68), mean dbi score: 1.30 (±1.24). 145 (21.4%) participants had dbi score 0, 165 (24.4%) 0-1, and 367 (54.2%) c1. antiepileptics accounted for the greatest contribution to cumulative score (27.6%), antipsychotics (25%) and antidepressants (14%). there was no significant association between higher dbi score and sleep difficulties (p = 0.135). there was a significant age gradient associated with higher dbi score (p = 0.016) and significant association between higher scores and increased comorbidity scores; mean fci of 3.28 in those with dbi c 1, 2.73 in dbi 0-1 and 2.35 in those with dbi 0. conclusion: cumulative exposure to sedative and anticholinergic medicines was high in older adults with id. higher dbi scores were associated with higher comorbidity and associated poorer physical function. optimising use of medications with anticholinergic and sedative effects through medicines review by pharmacists as part of multidisciplinary teams using a tool such as the drug burden index may reduce functional decline and improve quality of life among older adults with id. please specify your abstract type: research abstract background and objective: poor adherence to pharmacotherapy may have considerable consequences for the patients' health and for healthcare costs to society. there was observed that diabetes patients have higher risk of later health complications development. it is necessary to be adherent to non-and pharmacological recommendations as well, to improve the clinical outcomes and decrease the cardiovascular risk (cvr). the aim of this study was to evaluate the medication adherence and cvr in group of patients with diabetes, and to find an association between them. setting and method: the methods were based on a questionnaire survey using a modified 8-item morisky score and score charts (2012). medication adherence and cvr were evaluated in the whole group (n = 107, 51 males and 56 females, range 22-86 years) as well as in subgroups according to age, gender, (no-/ex-) smoking, level of education, residence, number of used medicines, exercises, compliance to the diabetic diet, and total cholesterol levels. the survey was realized in three ambulatory diabetic centres in slovakia. the study has been approved by ethics committee of university hospital bratislava -ruzinov. all participants signed an informed consent. main outcome measures: the results of medication adherence were evaluated as follows: 8 points = full adherence, 6-7 points = partial adherence and 0-5 = non-adherence. the cvr (estimating 10-year cardiovascular attack risk) was evaluated according to score charts using data from questionnaire and medical records-gender, age, smoking, total cholesterol levels and blood pressure. the results showed a partial medication adherence in the study group in average (6.84 ± 0.28). the average value of cvr in the study group was 3.7%. the highest average medication adherence has been observed in males b65 years (7.03), with elementary education (7.0), in ex-smokers (7.1), in patients with regular physical activity-at least 3 times a week (7.29), in patients non-adherent to the diabetic diet (7.05), in patients using 2 medications (7.11), and in patients with satisfactory (4.5-5.0 mmol/l) total cholesterol levels (6.97). the lowest cvr has been observed in females b65 years (1.8%), in no-smokers (3.2%), with elementary education (3.0%), in patients with irregular physical activity (2.9%), in patients adherent to the diabetic diet (3.14) , in patients using 4 medications (2.9%) and in patients with satisfactory (4.5-5.0 mmol/l) total cholesterol levels (2.97) . on the other hand, the highest cvr has been observed in males [65 years (7.3%), smokers (5.9%), secondary educated patients (3.8%), without any physical activity (4.7%), in patients partially adherent to diabetic diet (4.7%), using 6 medications (4.1%) and, surprisingly, in patients with satisfactory (\4.5 mmol/l) total cholesterol levels (4.76%). conclusion: our survey has showed that medication adherence in our study group has been decreased and cvr has been increased. cvr and adherence to pharmacotherapy in the study group did not correlate with each other. the medication adherence, cvr and their relationships are specific in every patient. please specify your abstract type: research abstract background and objective: studies show that quality of life (qol) of patients with diabetes mellitus can influence medication adherence, satisfactorily improving clinical outcomes and reducing the morbidity and mortality rates and disease progression. this applies even upside down-medication adherence could significant contribute to improving patient qol. the aim of this study was to evaluate the medication adherence in group of patients with diabetes, to evaluate their qol and find a correlation between them. setting and method: the methodology was based on a questionnaire survey using a modified 8-item morisky score and questionnaire eq-5d-5l, including visual analogue scale (vas). medication adherence and qol were evaluated in the whole group (n = 107) as well as in subgroups according to age, gender, level of education, monthly income, number of used medicines and type antidiabetic treatment. the survey was realized in three ambulatory diabetic centres in slovakia. the study has been approved by ethics committee of university hospital bratislava-ruzinov. main outcome measures: the results of medication adherence were evaluated as follows: 8 points = full adherence, 6-7 points = partial adherence and 0-5 = non-adherence. the qol in 5 levels of 5 dimensions results were evaluated as follows: the lowest qol in every dimension = 1 point, the highest = 5 points. the highest vas evaluation has been 100 points and every patient should mark number on the scale 0-100 to indicate his/her health on current day. results: the results showed a partial medication adherence in the whole group in average (6.84 ± 0.28). the average value of the qol in the study group was 21.21 and vas 69.29. the highest medication adherence has been observed in males (7.04 ± 1.29), patients \40 years old (7.0 ± 1.05), with primary education (7.07 ± 1.04), with monthly income over 600€ (7.38 ± 0.99) and in patients using 2 medications (7.11 ± 1.6). the highest qol and vas (qol; vas) has been observed in males (22.0; 74.24), patients \40 years old (23.22; 77.22), university educated (23.11; 75.55) , with monthly income over 600€ (22.75; 75.63) . qol has been highest in patients using 3 medications (23.92), vas has been highest in patients using 1 medication (83.33). we have observed the highest level of medication adherence in patients treated with combined therapy-with oral antidiabetic agents and insulin (7.06), the lowest in patients treated with only insulin therapy (6.95). highest qol was recorded in patients treated with oral antidiabetic agents (22.04), and the lowest qol in patients with insulin therapy (19.97). the highest vas has been observed in patients using only oral antidiabetic agents (72.45), the lowest in patients using combined therapy (62.06). conclusion: survey has showed that medication adherence and qol in our study group has been decreased. qol and adherence to pharmacotherapy in the study group did not correlate with each other. the medication adherence, qol and their relationships are specific in every patient. the role of health care professionals should be in education and counselling with patients to improve qol and medication adherence as well. please specify your abstract type: research abstract background and objective: to assess the appropriateness of antibiotic prescriptions used for urinary tract infections (uti) in the elderly. setting and method: we included patients aged 70 years and older, hospitalized in the geriatric department and for whom a urine culture was performed between march and may 2016. a prescription was qualified as inappropriate: when the antibiotic prescribed was not the narrowest compared to the culture result, or when there was a contra-indication, or when the treatment duration was shorter or longer than recommended. prescriptions were consistent with the guidelines when they were identical to those adopted by the french society for infectious diseases in december 2015. main outcome measures: appropriateness of antibiotic prescription (type and duration) results: 47 elderly patients were included (women: 74.5% (n = 35), mean age: 85.9 years). 68% of antibiotic choices were appropriate and 64% of treatment durations were consistent to the guidelines. urinary clinical signs were mentioned in the medical files for 29.8% of the cases (n = 14). 28 patients received an empirical antibiotherapy (59.6%). 70.2% (n = 33) of urine cultures were positive with bacteria, escherichia coli being the most prevalent (n = 18). the urine culture results led to a change in antibiotics for 66.7% of the cases. for cystitis, 53.8% of the antibiotics chosen were appropriate (n = 7). the main reasons of non-conformity were the lack of deescalation (to amoxicillin or pivmecillinam), and the prescription of ciprofloxacin when the bacteria was in vitro resistant to other fluoroquinolones. the average duration of effective antibiotherapy for cystitis was 9.3 days (appropriateness: 53.8% (n = 7)). for pyelonephritis, 88.9% of the antibiotics chosen were appropriate (n = 8). the average duration of effective antibiotic treatment was 10.1 days (appropriateness: 77.8% (n = 7)). 40.4% of the patients had a transurethral catheterization (n = 19). another infection was diagnosed for 48.9% of the patients (n = 23). conclusion: according to these results, it appears important to reemphasize to the prescribers the guidelines around the uti diagnosis and treatment in order to improve the prescriptions appropriateness in elderly patients. it is particularly necessary to promote the de-escalation of antibiotherapy (with pivmecillinam for example which has recently become available in our hospital) and to insist about the recommended durations of treatment. please specify your abstract type: research abstract background and objective: to measure the use of potentially inappropriate medications (pim) in the general elderly population several criteria lists exist, e.g., beers criteria. last year, a set of explicit criteria for assessing pharmacologically inappropriate medication use in nursing homes was developed; the norwegian general practice-nursing home criteria (norgep-nh). the aim of this study was to investigate the prevalence of pims in nursing home patients using this new assessment tool. furthermore, we studied possible associations between the use of pims and factors like gender, age, geographical area and the number of drugs used. setting and method: cross-sectional study comprising 103 nursing home patients from two geographical different regions in norway; tromsø city (n = 70) and lofoten islands (n = 33). data was collected from november 2015 to january 2016. pims were identified by norgep-nh. we used logistic and poisson regression to examine possible associations between the use of pims and factors like gender, age, geographical area and the number of drugs used. main outcome measures: number of pims per patient, and odds ratios (or) and marginal effects for associations. results: nursing home patient used a mean (sd) of 10.9 (4.3) drugs; 7.2 (3.6) regularly and 3.7 (1.9) as needed. at least 69% of patients used one pim. concomitant use of three or more psychotropic drugs was the criterion most commonly identified (33%), followed by the use of antidepressant (26%) and hypnotics (23%). an increasing number of regularly used drugs increased the odds of having pims (or: 1.74), as well as it lead to 0.18 more pims per extra drug used. on average, patients c80 years had 0.46 fewer pims than patients \80 years. no statistical significant associations were seen between having pims and gender, nor geographical area and the use of as-needed medication. yet, statistical significant differences were identified in some criteria. conclusion: this is the first study that explicit uses norgep-nh. our results confirm that nursing home patients often use potentially inappropriate medications. this is an area where further work is necessary, not to measure the prevalence of pim, but to develop interventions in order to prevent pims from being used. pe020: use of pharmacy dispensing data to measure adherence and identify nonadherence with oral hypoglycaemic agents please specify your abstract type: research abstract background and objective: a framework for calculation of adherence for oral hypoglycaemic agents (ohas) based on data from health-insurance claims is available. pharmacy dispensing data aid identification of nonadherent patients in pharmacy practices. however, use of these data for calculation of oha adherence requires additional methodological categories. we examined the impact of different methodological choices on estimation of oha adherence using pharmacy dispensing data. setting and method: a framework for adherence calculation for pharmacy dispensing data was developed from health-insurance claims. a basic scenario was developed from 16 methodological categories. consequences of choices for different parameters within these categories on the scores of the three adherence measures were calculated from dispensing data. main outcome measures: for oha use between july 2013 and july 2014, three adherence measures were calculated: (1) average medication availability (ama); (2) mean rate of adherent patients with an ama c80% (mrap80); (3) please specify your abstract type: research abstract background and objective: ulcerative colitis (uc) is a chronic inflammatory disease usually affecting young adults and impacting on patient's quality of life. although many biological agents (bas) have been approved for the treatment of moderate-to-severe uc in patients who have responded inadequately to conventional therapy, the selection of bas is controversial due to the lack of head-to-head trials. indirect economic comparisons of these costly drugs are available from national healthcare perspectives that are not the italian ones. therefore, the objective is to evaluate cost-utility of bas for the treatment of refractory moderate-to-severe uc both in italy and in the lombardy region. setting and method: a markov model (considering 3 transition states: remission, clinical response, relapse) was constructed using the software r 3.3.1 markovchain-package to evaluate incremental cost-utility ratios (icur) of adalimumab, infliximab, infliximab biosimilar, golimumab and vedolizumab treatments of patients over a ten-year time horizon from the perspective of the italian (n) and lombardy region (r) healthcare system. clinical parameters were derived from clinical trials. costs (which have been actualised-1.5%) were obtained from the national database and regional public tender. utility was expressed as qaly (quality adjusted life years). main outcome measures: icur. results: costs per treatment were different from a n and r perspective (adalimumab -55%; infliximab -16.7%; infliximab biosimilar -29.6%; golimumab -9.6%; vedolizumab -10%). direct healthcare costs (treatment cost, visits, lab tests, hospital admissions) were calculated over 10 years of treatment per patient: adalimumab (n: €114,226.70, r: €68,314.12, -40.2%), infliximab (n: €130,594.90, r: €103,081.00, -21%), infliximab biosimilar (n: €110,437.80, r: €78,852.03, -28.6%), golimumab (n: €118,602.10, r: €96,922.20, -18.3%), vedolizumab (n: €113,851.80, r: €102,932.20, -9 .6%) with associated qaly respectively of 6.68, 6.66, 6.66, 6.70, 7.02. from a n perspective, infliximab biosimilar was dominating compared to all other treatments. the icur of vedolizumab/infliximab biosimilar was €9483.33 for 10 years (willingness to pay (wtp) €948.33/qaly). from a r perspective, adalimumab was dominating compared to all other treatments. the icur of vedolizumab/adalimumab was €101,817.88 for 10 years (wtp €10,181.78/qaly). conclusion: national and regional cua produced different results. as regional price discounts can occur, local analyses are needed to estimate the economic impact of therapies to ensure optimal choice. please specify your abstract type: research abstract background and objective: automated dispensing systems (ads) have been implemented to reduce overall medication errors related to picking, preparation and administration of drugs. costs of drug storage between ads and classic dispensing system (cds) had not been yet performed in france. our objective was to assess economic impact of ads compared to cds. setting and method: retrospective quasi experimental study was conducted in 2 university hospitals in 2015, one with ads (800 beds, 43 ads) and one with cds (600 beds, 31 cds (17) for ads and 53 (15) for cds (p \ 0.001). mean number of costly drug per system was 3 for ads and 1 for cds. the global stock value in the wards was 205,915€ in ads and 54,908€ in cds representing respectively 14.5 and 6.1% of total pharmacy stock value. conclusion: our data demonstrate that despite the same storage capacity, ads allow the storage of more expensive drugs such as innovative drugs fully reimbursed up to national reimbursement prices, due to the lower risk of pilferage. this preliminary study was focused mainly on stock value. subsequently, another study is conducted to evaluate cost of these two drug storage systems, satisfaction of pharmaceutical technicians and nurses and time allowed for systems reloading. please specify your abstract type: descriptive abstract (for projects) background and objective: in france, pharmacists are not entitled to substitute an original biological drug with its biosimilar, due to specific issues of efficiency, safety, and patient monitoring. our hospital referenced a biosimilar of infliximab on 6 january 2015. according to the french medication safety national agency's recommendations, it has been decided that naïve patients would be treated with biosimilars, and changes between specialties would be proscribed. the objective is to compare prescribing practices between infliximab and its biosimilar, 1 year after its introduction. design: a database tracking patients treated with infliximab was set up. data comparing prescribing practices of biosimilar and reference treatment were analysed between june 2015 and may 2016. regional and national infliximab consumption between january 2015 and february 2016 were used to compare the practices of our hospital with other hospitals. the past and future savings were estimated from repayments data of the regional health agency. results: infliximab was administered to 633 patients, of which 201 (32%) were naive. 111 patients were treated with biosimilar (i.e. 17.5% of all patients), of which 97 were naive. in the end, nearly 48% of naive patients actually received the biosimilar and 2.5% of patients treated with infliximab switched specialties during treatment. in 80% of cases, biosimilar prescriptions were consistent with the recommendations (vs. 94% for infliximab). in 79% of cases the off-label prescriptions of the biosimilar were explained in the patient record (vs. 75% for infliximab). in february 2016, the share of biosimilars was 14% in france, 12% at regional level and 15% locally. in 1 year, infliximab and its biosimilar's consumption in our hospital have increased by 12% in quantity and only 2% in expenditure (+€ 6 m expenditure). negotiating a lower purchase price and costs has enabled the hospital to save € 137,629 (vs. € 182,961 during the previous year). because of the decline of refund rates, the gains would have been zero without using the biosimilar but € 377,172 if it had been prescribed to every naive patient. conclusion: current data from the literature on security and effectiveness of infliximab biosimilars are very reassuring and the french medication safety national agency doesn't exclude the possibility of changing specialties during treatment. in our hospital, there is room to improve the efficiency of treatment with infliximab. feedback on prescribing practices will be given to prescribers and a campaign to widespread prescriptions of biosimilars will be made. the arrival of biosimilars on the market is a real economic opportunity for hospitals, which are increasingly financially constrained in particular by the arrival of therapeutic innovations which are more and more expensive. setting and method: the study used health claims data on prescription ppis from 1st january 2011 to 31st july 2014 obtained from the health insurance institute of slovenia. to assess medicine use and costs before and after trp implementation data were aggregated into four periods: jan-dec 2011, pre-baseline period; jan-dec 2012, baseline period; jan-sept 2013, transition period between announcement and introduction of trp; oct 2013 to jul 2014, period after trp enforcement. main outcome measures: medicine costs; defined daily doses (ddds) dispensed per 1000 inhabitants per day; market share; herfindahl-hirschaman index (hhi); number of active substance switches; number of exceptions when medicine is fully reimbursed since physicians may choose option ''not to switch medicine'' when adverse consequences are predicted. results: average monthly cost of ppis declined from € 1,350,289 in pre-baseline period to € 800,125 in period after trp introduction although the consumption increased from 52.4 to 55.2 ddds/1000 inhabitants/day. cost of ppis decreased the most in baseline period (26%), however trp induced 9.5% cost reduction compared to the transition period. the reference pantoprazole was market leader already in the transition period, but its use increased significantly after trp introduction and represented 51% of total ppis consumption. manufacturers' market shares were constant before trp, whereas trp caused decrease of the largest market share for 5%. still, this resulted in the minor market concentration change; hhi was on average 0.351 before and 0.307 after trp introduction. further, at least one active substance switch was detected in approx. 15 and 21% of patients before and after trp introduction, respectively. similarly, the proportion of exceptions when medicine was fully reimbursed increased from 6.7% in transition period to 23.7% in period after trp introduction. conclusion: enforcement of trp for ppi contributed to approx. € 1 m annual cost savings. from the payer's perspective the new policy was proven to be effective in reducing pharmaceutical expenditure; however trp also affected physician prescribing pattern and use of ppis. pec007: blood coagulation factor: improvements of the supply chain samantha oses * , serri traore, sonia caroline sorli, lea damery, philippe cestac, sylvie pomies, julien tourel please specify your abstract type: descriptive abstract (for projects) background and objective: most of the antihemophilic factor (ahf) must be held by a teaching hospital to face serious bleeding events. to ensure better availability, offsite-stocks at critical points are required (emergency unit, intensive care unit, etc.). however, this management system increases the risk of economic loss and alteration of the quality due to expired products. in this context, we carried out an optimization of the supply and management system of the ahf. to identify critical points of the supply and management system and to implement improvement solutions. design: a multidisciplinary working group belonging to a regional management centre of haemophilia was set up. two lines of improvement were discussed: i) optimization of stocks ii) optimization of the supply system. results: the optimization of stocks has led to the modification of the threshold of the lowest stock (ls) for 19 ahf out of 38. in 70% of cases, this stock modification has exceeded 15%. the overall cost of ls has been reduced by 15.0% (83,000 €) for the general stock at the central hospital pharmacy (hp) and by 8.5% for offsite-stocks (20,000 €). the ahf mainly involved in this reduction was fvii 5 mg (27,000 €), then followed by the strengths of 2 mg and 1 mg (13,000 € for each). in order to improve the ahf management, several propositions have been implemented: (1) developing an online, easily accessible and monthly updated spreadsheet that displayed several accurate data such as the shortest expiry date and the storage location. this operative tool is shared between all pharmacists involved in ahf management in order to facilitate a stock rotation and decrease economic losses, (2) regular reminders to physicians and health care staff concerning the guidelines for inventory management and the importance of checking the drug expiry date, (3) presentation of the financial results and raising awareness on ahf costs to the medical consultant[ppip1] and (4) optimizing stock distribution based on consumption on the different hospital sites for better patient care management (pcm). conclusion: this optimization of stocks and improvement of the supply chain have led to a direct cost saving of 83,000 €. however, a more accurate assessment has to be performed to quantify the direct and indirect impact on pcm and cost saving. this work has been done in a context of a sharing operative network at a regional level. the aim of such project is to share, to optimize and to improve practices, knowledge, human and medical health resources at a widespread level to enhance the security and quality of health services and to promote cost and time saving. please specify your abstract type: descriptive abstract (for projects) background and objective: the overall pharmaceuticals consumption in hospitals is rising, which has led to an increasing expenditure, challenging health care professionals and threatening patients safety. clinical trials in hospitals have increased over the past few years and currently play an important role, giving access to new investigational medicinal products and also avoiding costs with standard treatments. the objective of this study is to evaluate the savings of centro hospitalar do porto, a central university hospital with 800 beds and currently 80 clinical trials, with patients included in clinical trials between january 2013 and may 2016. design: retrospective observational study over 41 months. all the clinical trials ongoing between january 2013 and may 2016 were analysed and the data was collected based on: pathology and doses established; number of treatments per patient and the medium prices of standard treatments that patients would be receiving if they were not in the clinical trial. results: there were 112 clinical trials ongoing between january 2013 and may 2016, but only 30 were selected to be included in this study. the total number of patients included was 652. the clinical trials selected for this study were conducted in 6 medical specialties: 4 in dermatology, 6 in immunology clinical unit, 11 in hemato oncology, 1 in gastroenterology, 5 in ophtalmology and 3 in neurology. during these 41 months, with all ongoing clinical trials, centro hospitalar do porto was able to save, in medical products, more than 2 million euros. conclusion: during the period of time established, 82 of the clinical trials ongoing, were not selected due to: not including patients or not having an alternative treatment. hospitals and patients can benefit from clinical trials not only financially but also by preserving resources and medication. on centro hospitalar do porto, the pharmacists specialized in clinical trials, as members of the study team, are more and more required to perform specific tasks, their contribution has been increasing over the years and also have become more aware of all the advantages from participating in clinical trials. these savings can be used to provide a better assistance and contribute, in general, to a higher quality health care. please specify your abstract type: descriptive abstract (for projects) background and objective: several studies show a misuse of opioid maintenance treatment (omt) in detention. in fact, buprenorphine (bup) when it's misused, could present the same effects as heroine. in order to reduce misuses, the pharmacist decided to switch all the patients under bup to buprenorphine/naloxone (bup/nlx). bup/ nlx prevents patients from misusing by a withdrawal syndrome when it's issued by another route of administration than sublingual route. in france, bup/nlx is more expensive than bup which may explain why this therapeutic strategy is not often observed. the purpose of this study is to evaluate the extra cost after switching patients from bup to bup/nlx in order to decide if this choice could be maintained. design: to identify our population, we used the administration reports drugs written by nurses. please specify your abstract type: research abstract background and objective: haemophilia b is an x linked genetic disorder characterized by spontaneous or prolonged haemorrhages due to factor ix (fix) deficiency 1 . within the next few years, new treatments are willing to hit the market. among them are recombinant extended half-life products that will reduce by half the number of injections and will potentially improve the patient quality of life. the aim of the study is to describe the development of haemophilia treatments market between 2011 and 2014 and to forecast the potential impact of these new therapies on the haemophilia market. setting and method: national and french hospitals of paris (aphp) consumption data of 4 fix between 2011 and 2014 have been studied. new therapies in development or soon to be marketed have been identified. potential benefits and interest in the therapeutic care of these new products were discussed with haemophilia's medical experts. main outcome measures: quantity (ui) and value (euros) of fix aphp and national consumption. results: in 2014, 1 recombinant (rfix) and 3 plasma-derived factors (pfix) were on the french market. the ap-hp's purchases of these 4 factors represent almost 15 million ui and 10 million euros, which comprise 24% of national fix expenditures. in france and aphp, ambulatory care is a major part of the use of these treatments with nearly 90% of the fix purchases in 2014. french rfix consumptions are higher than pfix consumptions (64% against 36%). in the ap-hp hospitals, rfix even account for 89% of consumptions against 11% for pfix. both national and ap-hp rfix purchases have steadily increased between 2011 and 2014. the added competition arising from new treatments may lead to more competitive market procedures in hospitals and may reduce costs of haemophilia treatments. according to haemophilia doctor, long-acting (la) fix would offer obvious benefits like fewer infusions and presumably fewer bleeds. these treatments will mainly be used in a prophylactic wayin ambulatory care-than in a curative way (such as surgical use). conclusion: the therapeutic extent of these new treatments is still hard to define. the choice of treatment must remain consensual between physicians and patients. please specify your abstract type: descriptive abstract (for projects) background and objective: good practice about medicines imposes to health institutions a close monitoring of prescriptions, especially off-label prescriptions. patient care should take into account clinical profile, respect of guidelines and health expense control. we report here a case highlighting the significant role of the clinical pharmacist in care units to ensure medication good use in a castleman syndrome, a rare disease due to human herpesvirus 8 (hhv-8) and associated with human immunodeficiency virus (hiv) infection. design: case report. results: our patient, a 49 years old man (creatinine clearance rate (crcl): 95 ml/min), was diagnosed with hiv infection in february 2016 (cd4 at 160ui/l), leading to introduce a therapy by emtricitabine-tenofovir, darunavir, and ritonavir. the evolution was hampered by repeated episodes of acute renal failure (arf; crcl: 21 ml/min) and pancytopenia (hemoglobinemia at 8.6 g/dl, leucopoenia at 3.3g/l, and thrombopenia at 55g/l). because of hhv8 blood pcr at 30 000copies/ml, transient crises with pancytopenia, arf, and hiv infection, a diagnostic of kaposi sarcoma herpesvirus (kics), an atypical castleman syndrome, was retained. given the lake of data in literature for this rare disease, a multidisciplinary team (medical specialists and clinical pharmacists) was gathered to choose an appropriate therapeutic strategy. treatment regimen consisted of: day 1, intravenous etoposide at 250 mg; day 4, rituximab at 375 mg/ m 2 ; following one week later by rituximab 1 day and oral etoposide at 250 mg the day after. good communication between medical specialists and pharmacists enables the patient to get an optimal and personal treatment. relaying the information by clinical pharmacists in care units to pharmacists in charge of good practice facilitate the reimbursement. conclusion: clinical pharmacists in care unit help to optimize therapeutic strategies according to their experiences and scientific works. cooperation with physicians is improved, as well as prescriptions follow-up of off-label drugs, and health patients fully respected. quality and relevance of prescriptions are strengthened, with a better control of economic expenses. please specify your abstract type: research abstract background and objective: the maltese government launched the hpv vaccination scheme in 2013 and the national healthcare system (nhs) has since provided the cervarix ò vaccine free of charge to girls aged 12. the aim of this study was to assess the cost of the administration of hpv vaccines in the healthcare system of malta. this study was based on the scheme provided by the nhs. the number of girls born per year was used to estimate the annual cost for vaccinating 12 year old girls, based on the wholesale price and tender price respectively. the estimated yearly cost using the wholesale price was approximately €547,000 while the average estimated cost based on the tender price was approximately €157,000. this signifies that cost savings based on the tender price compared to wholesale costs were of approximately €390,000. the cost for the cohort who completed the three dose schedule using the tender price on average was of €171,000 per year. this result proved to be more than the anticipated cost. a reason for this could be that the number of girls aged 12 increased possibly due to an influx of immigrants. including boys in the vaccination scheme would increase costs by an average of €165,000 per year. conclusion: this study shows that procuring branded vaccines using the tendering process reduces expenditure for the government and the tax payer. wholesale prices were found to be more expensive than tender prices. this proves that the tendering system in malta is a potent system with many advantages for the tax paying public. the impact of the tendering process must therefore, be safeguarded. please specify your abstract type: research abstract background and objective: with the old age, presence of comorbidities, and overcrowding in mass gatherings such as the annual hajj pilgrimage in saudi arabia, there is a high risk of spreading infectious diseases among pilgrims and then within their country of origin. knowledge and application of hygiene principles in such an environment is therefore important to reduce the transmission of infectious diseases. up to date, there have been no studies to evaluate pilgrims' knowledge, attitude and practices toward mers-cov during the annual hajj pilgrimage in order to see whether there is a need for these aspects to be improved. setting and method: a cross-sectional survey study was conducted with a convenience sample of 257 participants. participants were pilgrims, aged over 18, and able to speak arabic or english. a selfadministered structured questionnaire was distributed during hajj season in mecca. descriptive and multiple linear regression analysis were used in data analysis. main outcome measures: assessing pilgrims' knowledge, attitude and practices regarding mers-cov. results: two hundred and fifty-seven participants completed the study, 80% of whom were female, and the median (iqr) age was 35 (24.5-43.5) years. pilgrims had moderately correct knowledge and accurate attitudes towards mers-cov with median scores of 5 (iqr 4-7) and 6 (iqr: 5-7) respectively. they were less educated about management (80%), hallmark symptoms (77%), high-risk individuals (45%) and source of coronavirus (38%). almost 40% of participants showed a negative attitude towards the use of protective measures such as avoiding food prepared under unsanitary conditions and contact with live animals. some participants (30%) were unable to comply with hygiene practices, particularly washing hands with soap and water or disinfectant after sneezing/coughing and wearing a face mask in crowded areas. educational level and employment status were significantly associated with knowledge whereas gender and age were significantly associated with attitude and practices respectively (p \ 0.05). the correlation between knowledge, attitude and practices was significant (correlation coefficient: 0.207; p \ 0.05). better knowledge was found to be a predictor for positive practice. conclusion: these findings aided in the assessment of the adequacy of current pilgrims' educational measures. they will also provide insight when designing future interventions to promote specific messages to improve knowledge, change attitude and improve practice regarding mers-cov. please specify your abstract type: research abstract background and objective: the prevalence of type 2 diabetes significantly increased in the paediatric population, which is affected by obesity worldwide. today, type 2 diabetes accounts for 45% of all cases of new-onset diabetes in adolescents. preventive health care particularly taking place at community pharmacies may involve risk assessment for the children and the adolescents, early referral for seeking relevant medical care and patient education on healthy lifestyle choices. the aim of the study is to conduct a type 2 diabetes risk assessment program for the kids b18 years of age of whose parents visited the community pharmacies involved in the study and also to identify the behavioural parameters that might be associated with this risk. setting and method: the study was conducted in 4 community pharmacies. all patients with kids aged b18 years who visited the study pharmacies during one-week period were informed about the study and invited to participate in the study. patients who gave their informed consent were included in the study. all data were provided by the parents. demographic data, height and weight of the kid, as well as data regarding the behavioural features (eating habits, exercising, time spent in front of a screen, etc.) of both the children and the parents were collected using standardized forms. type 2 diabetes risk test consisted of 8 questions and identified subjects at risk. the parent of the kid who was identified to have risk for type 2 diabetes was referred to a physician for further examination. also, information regarding type 2 diabetes and the importance of preventive measures such as converting to a healthy life-style was provided. main outcome measures: main outcome measures were the percentage of kids identified to be at risk of developing type 2 diabetes and the behavioural parameters associated with type 2 diabetes risk. results: the study involved 212 subjects. of the subjects 26% were identified to be at risk of type 2 diabetes. more girls than the boys had the risk (36 vs. 9.3%). those with type 2 diabetes risk were older, taller, heavier and had higher body mass index. they were spending more time in front of a screen (tv, pc, tablet, smart phone); 22.6% were spending more than 6 h a day. although the kids' eating habits were similar for those with and without risk, the parents' of the kids with risk ate out more frequently, consumed rice, pasta and pastry more frequently. both the kids with risk and their parents exercised more regularly and frequently. conclusion: this study shows that pharmacist have a vital role in identifying children and adolescents at risk for type 2 diabetes; thus at early management of this condition. identifying and addressing the behavioural parameters associated with the risk will be helpful in lifestyle modification interventions. please specify your abstract type: descriptive abstract (for projects) background and objective: analyse and promote the reporting of adverse drug events (ade), to improve the quality and safety of care to be able to control the risks. design: a software is available on the intranet website of the institution, to enable health professionals to report ade. the drug and medical devices commission (comedims) of the hospital, centralizes these statements and always makes a multidisciplinary and overall analysis of the event, using a collection sheet which is based on the pdca model (plan, do, check, act). it proposes the nursing and medical teams axes of improvement. results: in 2015, only 48 ade were reported and analysed by the comedims, including 20 from the paediatric centre (44%), particularly sensitized to this issue. health professionals are divided as follows: healthcare executives (60%), nurses (23%), pharmacists (11%), residential students (2%), doctors (2%) and others (2%). the main impacted steps of the drug circuit are: administration (62%), prescription (27%) and the use or implementation of a sterile medical device (4%). identified causes include related following factors: operational tasks and procedures (37%), health professionals (31%), work environment (13%), organization and management (7%), drugs or associated medical devices (5%). the number of ade reports, taking into account the size of the institution, remains very low. in january 2016, the comedims decided to broadcast a communication campaign to promote ade reporting, on the hospital website via the intranet. three months after the release, this document was viewed 1059 times, and the number of reports increased by 229% compared to the same period in 2015. conclusion: in front of the low number of returns of adverse drug events, and relying on the charter of non-punishment, the come-dims wants to increase health professionals' awareness. in our hospital, where e-learning about drug-related iatrogenesis is already available, the communication campaign with poster and analysis of adverse events seems to be a useful complementary tool to enhance awareness of medication safety concerns. please specify your abstract type: research abstract background and objective: the migration of modern social networks to the internet has facilitated the transition of traditional pharmacy networks online. the ubiquitous nature of social media (some) combined with merging of personal and professional personas have led to organisations publishing guidance on online behaviour and responsible use of social media. the research to date on the use of social media as a support for professional practice in general is limited. as the pharmacy profession evolves to embrace the technologies which underpin core services and mainstream online daily social activities, it is important that research tracks and evaluates its use and impact within the profession. the objective of this research was to explore and describe how and why pharmacists interact with hosted networks on social media. setting and method: two one-hour online hosted micro-blogging twitter chats were held in december 2015 via the #weph network. topic guides were developed around 'exploring the use of twitter and wepharmacists' in line with the wenetwork guidelines (#wecommunities), informed by existing literature, discussion with the #weph moderator after review by an expert panel. all research was carried out in accordance with university governance processes and association of internet researchers guidelines. themes were inducted from analysing the textual content of the chats using the topic guide as a framework. the research was approved by the school of pharmacy and life sciences ethics committee. main outcome measures: tweets per chat results: each of the chats had over 2 million impressions with participants representing international pharmacy practice. themes of e-professionalism and online privacy emerged as concerns; however, the benefits included using social media for education, networking, support mechanisms and career development. tweets highlighted personal experiences of 'trolling' (angry, offensive behaviour) and the effect on user interaction with social media. twitter was also recognised as a career development tool and, in particular, collaborative outcomes around mentorship networking early career pharmacists with more experienced colleagues. conclusion: results support the responsible use of social media as a force for inclusion, breaking down geographical barriers in support of pharmacy practice. further research is underway including a systematic review of guidance on the use of social media by registered healthcare professionals. please specify your abstract type: research abstract background and objective: it is estimated that half of the 350,000 persons with diabetes in norway have not been diagnosed. with early treatment, life expectancy can be increased and the incidence of longterm complications and health costs reduced. community pharmacies may be able to help uncover undiagnosed diabetes, but being diagnosed with diabetes can lead to strong emotional reactions, and how the diagnosis is given may influence the experience. the aim of this study was to explore how norwegian people living with type 2 diabetes (t2d) experienced being diagnosed, and what led up to the diagnosis. in addition, their attitudes towards a planned community pharmacy service to identify undiagnosed t2d was investigated. setting and method: three focus group interviews with people with t2d were conducted using a semi-structured interview guide. eleven participants were recruited through a course about type 2 diabetes. the interviews were audio-taped and transcribed in modified verbatim form and analysed in accordance with malteruds principles of systematic text condensation. the study was approved by the norwegian data protection authority, and did not require approval from the regional committee for medical and health research ethics. main outcome measures: how people with t2d describe their experiences of being diagnosed with t2d, how the disease was revealed and reactions towards using community pharmacies to perform risk assessment for t2d. results: none of the participants were diagnosed due to their own suspicion of having diabetes. some saw their doctor because of unspecific symptoms such as fatigue and thirst, and were thereafter diagnosed with t2d. others were diagnosed through a routine checkup. negative reactions like shock, discontent and denial were commonly used to describe the experience of being diagnosed with t2d, but some participants also expressed a more relaxed attitude, especially if they were familiar with the disease through family members. participants expressed a strong wish for more and better information following the diagnosis. ''it's a jungle out there'' was used to describe how difficult they felt it was to find trustworthy and understandable information. they described change of lifestyle, side effects from drug use, and stigma as challenges following the diagnosis. while in general the participants were positive to using community pharmacies to uncover undiagnosed diabetes as this could help reduce the number of people who were undiagnosed, some were sceptical. they questioned whether the pharmacy staff had the necessary competence of the for this type of service, and saw it as the doctor's responsibility. conclusion: more information and support when people are diagnosed with diabetes may lead to that the experience being diagnosed will be more adaptable and that the challenges living with diabetes are reduced. community pharmacies are important healthcare providers, and risk assessment of t2d at the pharmacy can be valuable. however, the pharmacies may also be helpful to reduce the information gap. please specify your abstract type: research abstract background and objective: chemotherapy-induced nausea and vomiting (cinv) is a disruptive and unpleasant side effect in chemotherapy patients and is associated with decline in patients' quality of life and decrement in the adherence to effective chemotherapy regimens. setting and method: 100 chemotherapy naive patients were included in this study. consistency with guidelines were assessed according to mascc/esmo 2014. flie questionnaire was administered to patients before chemotherapy, and 5 days after receiving chemotherapy to assess the difference in the quality of life due to chemotherapy administration. main outcome measures: patients were categorized into two groups as consistent with guidelines group (acute (gcga) and delayed (gcgd)) and inconsistent with guidelines group (acute (giga) and delayed (gigd)). flie score differences between the two groups were assessed. results: the median flie score for patients prior to chemotherapy was 126 and a dramatic decline was noticed post chemotherapy (flie score 108; p \ 0.001). the post-chemotherapy score were for nausea and for vomiting (49.5, 63 respectively). although the flie score differed significantly between gcgd and gigd (p \ 0.01), these differences were not significant in gcga and giga. conclusion: the significant drop in flie scores in the study (126 pre-to 108 post-chemotherapy) reflected substantial declination in patients' quality of life. the lower postchemotherapy flie score of nausea emphasized the negative impact of nausea, and to a lesser extent vomiting on the patients ability to complete normal daily activities such as enjoying meals and maintaining social activities. although there were no significant differences in flie scores between giga and gcga groups for acute cinv prevention, significant differences were noted between gigd and gcgd (p \ 0.001). the flie score was lower for gigd patients. this result implied guideline inconsistency associated with high incidence of nausea which negatively affect patient quality of life. as for the degree of compliance with gp, the results are expressed as percentage of compliance compared to the ideal of 100%. prescription criterion was fulfilled to 100%: all requirements of pntb were performed using standardized procedure. in what concerns validation, 94% of pntb prescriptions were validated by a pharmacist. the invalidated prescriptions were made outside opening hours of the pharmacy service, which is open monday to friday from 08:00 to 20:00 and on weekends and holidays from 08:00 to 15:00. 100% of the dispensations were individualized and not pntb stocks were found in hospital wards. as for preparation, 36% were supplemented with micronutrients. pntb of kabiven peripheral administration 1920 ml are not supplemented in our centre. of the remaining 325 prescriptions central administration, 81% were supplemented. in all cases, the addition of micronutrients was performed in laminar flow hood in pharmacy service and the corresponding galenic validation was performed. finally, in the process of administration, 94% of pntb identified with a complete label: name of the patient, medical record number, type of pntb, qualitative and quantitative composition, date of administration and infusion rate. conclusion: use practices of pntb of our centre are far from those recommended by the sefh standards. this initial evaluation will serve for improvement measures that increase the quality of prescribing and safe use of pntb, in order to minimize errors that can occur with the use of this therapeutic modality. please specify your abstract type: research abstract background and objective: methadone maintenance treatment was developed in malta in 1987 and is provided to patients by sedqa, the national agency against drug and alcohol abuse. methadone is the most frequently prescribed opioid in opioid substitution treatment and is dispensed through a centralised service through the substance misuse outpatients unit. in 2013, 1078 patients were in opioid substitution treatment, 976 of who were on methadone. in 2005, the government introduced a take-home methadone program. the prescribing, purchasing and dispensing of methadone are regulated by subsidiary legislation 101.06. the objectives were to determine whether community pharmacists in malta would be willing to dispense and supervise the consumption of methadone and to investigate the involvement of community pharmacies in the development of a regionalised methadone dispensing service. setting and method: the study was set in community pharmacies. a cross-sectional study, through the use of a questionnaire, was performed to quantitatively analyse whether pharmacists in malta would be willing to dispense methadone. the questionnaire consisted of 19 questions divided into 3 sections, with each section assessing a particular aspect of community pharmacists' attitudes towards methadone dispensing. community pharmacies were then chosen via a systematic sampling procedure. a hard copy of the questionnaire, addressed to the managing pharmacist, along with a cover letter, instructions on how the questionnaire was to be returned, and a prepaid self-addressed envelope was distributed via postage to 103 community pharmacies. an online format of the questionnaire was also circulated to 311 community pharmacists through the pharmacy council. data was analysed using spss version 21. main outcome measures: community pharmacist's attitudes towards methadone dispensing. results: a total of 109 responses were obtained and a response rate of 35.04% was achieved. eighteen percent of the pharmacists (n = 109) who responded to the questionnaire worked in a community pharmacy located in the north of malta, 24% in the centre, 17% in the south, 8% in the southeast and 4% in gozo. thirty-two percent of community pharmacists were willing to dispense methadone to drug misusers. the number of community pharmacists who are willing to dispense methadone increased to 41% if they were provided with appropriate education and support. twenty-nine percent of community pharmacists were prepared to handle the duty of supervising the consumption of methadone while 86% had never learnt about methadone and its clinical application within opioid substitution treatment. conclusion: community pharmacists should be provided with education and training regarding methadone substitution treatment before embarking on a new regionalised methadone dispensing service within community pharmacies. this would allow more community pharmacists to become involved in a new dispensing methadone service. pt009: evaluation of regorafenib in patients with colorectal cancer please specify your abstract type: research abstract background and objective: the colorectal cancer is the second more frequent cancer in europe and the third in the world. regorafenib is only approved in adult patients with metastatic colorectal cancer who are previously been treated with available therapies or are not considered suitable candidates to these treatments. regorafenib is an oral anti-tumor drug that blocks the kinases involved in the tumor angiogenesis (vegfr1, -2, -3, tie2), the oncogenesis (kit, ret, raf-1, braf, brafv600e) and the tumor microenvironment (pdgfr, fgfr).in this study, we are reviewed the reports of the patients with colorectal cancer who are been treated with regorafenib in our hospital and analysed the information in order to evaluate the efficacy and safety of regorafenib. setting and method: descriptive and observational study about the use of regorafenib from april 2015 to the present day. the variables studied, obtained from the software applications archinet and diraya, were: sex, age, pathology, location of metastasis, posology and adverse effects of regorafenib, tumor markers (cea y ca 19.9) before and after the treatment with this drug and the mutational state of kras. main outcome measures: the tumor markers cea and ca 19.9 only decreased in the 22.22% of the patients after the regorafenib treatment. results: regorafenib was taken by 9 patients (78%men).the average age of these patients was 64.78 ± 8.48 years old. the patients took regorafenib to treat: metastatic and non-intervened gastrointestinal stromal tumors (gist) e-iv that progressed with the previous treatment of imatinib and sunitinib (11.11% patients), intervened colon adenocarcinoma e-iv (33.33% patients), sigma adenocarcinoma e-iv (33.33% patients) and unresectable and non-intervened rectal adenocarcinoma e-iv (22.22% patients).all patients presented metastasis in different locations on the body: liver (55.55% patients), diaphragm (11.11% patients), intestine (11.11% patients) and lung (44.44% patients).the 77% of the patients started the treatment with 160 mg of regorafenib, administrated once a day for 3 weeks followed by one week without this drug; while the 22.22% of the patients started the treatment with 120 mg. however, the 33.33% had to decrease the initial dose and the 55.56% of the total patients had to get off the treatment because of the development of side effects. the most frequent adverse effects were: hypertension associated with headache, hyperbilirubinemia, elevation of ast and alt, intense asthenia. the 66.67% of the patients presents native kras. the native kras was presented in the 100% of the patients treated with regorafenib who had an appropriate development of the illness (decrease of cea and ca 19.9) conclusion: the decrease of cea in the 22.22% of the patients and the high development of side effects reveal that regorafenib has low effectiveness and security in the control of the progression of colorectal cancer. in addition, it is supposed that this drug has better results in native kras patients. however, more studies are necessaries in order to demonstrate the effectiveness of regorafenib in this pathology. pt010: evaluation of nintedanib in patients with non-small-cell lung carcinoma (nsclc) please specify your abstract type: research abstract background and objective: the nsclc means a high rate of mortality in developed countries. patients diagnosed with nsclc who debut with advanced or metastatic disease have a median survival of 13 months. one of the innovative drugs approved to improve survival in nsclc is nintedanib: an inhibitor of multiple tyrosine kinases, which can be found in some receptors on the surface of cells involves in the growth and spread of cancer cells (''pdgfr'', ''fgfr'' and ''vegfr''). nintedanib is not yet marketed in spain. hospital pharmacists are responsible for applying this treatment as ''expanded drug'', only after the elaboration of an exhaustive report. in this study, we have reviewed all the reports and classified the information in order to present our clinical practice. the objective of this study is to evaluate the effectiveness and safety of nintedanib in patients with nsclc treated in a tertiary hospital. setting and method: descriptive observational study of the use of nintedanib from november 2014 to september 2015. sex, age, body mass index (bmi), pathology, smoking habits, line of treatment, posology and adverse reactions of the treatment with nintedanib and tumor markers (cea an ca 19.9) before and later the treatment with nintedanib were collected from medical history through archinet informatic application. main outcome measures: the tumor marker cea decreased in 57% of the patients and ca 19.9 no decreased in any patient after nintedanib treatment. results: nintedanib was used in 7 patients (57% men and 43% smoker).the average age of these patients was 58 years old. the average bmi was 28 kg/m 2 (18-50).all patients received nintedanib together with docetaxel for metastatic nsclc with adenocarcinoma histology and with non-mutated egfr and alk in third line treatments. posology: all patients started the treatment with nintedanib 200 mg/12 h from day 2 to day 21 every 3 weeks; but 2 patients had to reduce the initial dose to 300 mg/24 h (1 patient) and 150 mg/12 h (1 patient) because of some adverse reactions. the side effects were: asthenia, diarrhoea, alteration of transaminases, muscle pain and cramps, weight loss and mucositis. conclusion: the decrease of cea in 57% of the patients reveals that nintedanib is effective in controlling nsclc progression which involves an increase of the survival and the quality of life of these patients. however, more studies are required to demonstrate the efficacy of nintedanib in this illness. please specify your abstract type: research abstract background and objective: patients with sore throat symptoms often seek fast, meaningful relief when presenting to their local pharmacy. flurbiprofen is a non-steroidal anti-inflammatory drug, which has been developed as a spray and lozenge to provide targeted relief for the main underlying process responsible for the symptoms of sore throats, inflammation. to study the relief provided by flurbiprofen 8.75 mg delivered as a spray or lozenge, we conducted a multicentre, randomised, double-blind, double-dummy, parallel group, activecontrolled, single-dose, non-inferiority study. setting and method: adult patients with acute sore throat were randomly assigned to take one dose of either flurbiprofen 8.75 mg spray plus a placebo lozenge, or flurbiprofen 8.75 mg lozenge plus placebo spray at 16 sites across russia. main outcome measures: patients rated sore throat relief using the sore throat relief rating scale (strrs; a 7-point scale, 0 = no relief, 1 = slight relief, 2 = mild relief, 3 = moderate relief, 4 = considerable relief, 5 = almost complete relief, 6 = complete relief) at timed intervals throughout 2 h starting from 1 min post completion of first dosing (1 min after administration of the spray, and 1 min after the lozenge had fully dissolved). adverse events (aes) were recorded over 2 h post-dose. results: 417 patients were assessed (n = 205 for spray, n = 212 for lozenge). [90% of patients in either treatment group experienced some relief (a score of [1 on the strrs) at 1 min post-dose, which increased to 98% of patients by 2 h. 55-60% of patients reported 'at least moderate relief', which is a well-recognised measure of a clinically meaningful effect at 1 min post-dose, which increased to 74-78% of patients by 2 h. over the 2 h post-dose, a total of 17 drugrelated aes were reported by 13 patients across both treatments and no severe adverse events were reported. conclusion: flurbiprofen 8.75 mg delivered as a lozenge or spray provides fast, clinically meaningful relief from sore throat. pt012: analising antiangiogenics prescription in an ophtalmology service after a protocol implementation silvia cornejo-uixeda * , ivan de la vega-zamorano, celia aparicio-rubio, olga carrascosa-piquer, manuel prieto-castello, agustin sanchez-alcaraz pharmacy, hospital universitario de la ribera, alzira, spain please specify your abstract type: descriptive abstract (for projects) background and objective: after some years using antiangiogenics in our hospital, we observed a large variety of use. considering the high cost of these treatments, we proposed ophthalmology service to develop a protocol of use, attending efficiency criteria. in this paper, we analyse the protocol implementation repercussion. design: a protocol of use was designed with the main of unify criteria and to use the most efficient treatment depending on the specific situation on each patient. once it was implemented, we compared two periods, the period after the implementation (january-may2016) and the period before of it (january-may2015). the protocol designed is the following: the cost for each injection and patient was the following: aflibercept 207€, bevacizumab 10€, ranibizumab 857€. results: in the 2015 period, 303 patients were treated with antiangiogenics.181(60%) with aflibercept, 110(36%) with bevacizumab and 12(4%) with ranibizumab. in the 2016 period, 297 patients were treated, 147(49%) with aflibercept, 134(46%) with bevacizumab and 16(5%) with ranibizumab. the consumption of aflibercept decreased a 19%, bevacizumab consumption increased 22% an ranibizumab increased a 33%.we also observed, some patients had more than one diagnostic at the same time. once the protocol was implemented, the percentage of use was the following: 38% 1. please specify your abstract type: research abstract background and objective: drug prescribing is the most common medical intervention in the elderly. however, elderly patients are more sensitive to the drug's effects due to pharmacokinetic and pharmacodynamic changes associated with aging. chronic diseases and co-morbidities often require the use of a large number of medications. therefore, when prescribing drugs for the elderly, the choice of suitable drugs, dosage and duration of treatment should be carefully considered as well as clinically significant drug interactions. inappropriate prescribing is often associated with an increased risk of adverse drug reactions, increased morbidity and mortality, and health care costs. the aim of this study was to determine the incidence of potentially inappropriate medications (pim) prescriptions in the elderly (c65 years) using the original protocol developed by mimica matanovic and vlahovic-palcevski. setting and method: we enrolled 240 patients hospitalized in clinic of internal medicine. data about patients' medications was collected during patient interview taken by the pharmacists on hospital admission. pharmacotherapy was analysed using the original protocol developed by mimica matanovic and vlahovic-palcevski in order to detect pims. main outcome measures: number and type of potentially inappropriate medications, potential clinically significant interactions. results: the average age of patients was 74 years (range 65-92), and the average number of drugs per respondent was 6.7 (range 1-15). a total of 109 patients (45.4%) were taking at least one pim. the most common pim were long-acting benzodiazepines, central antihypertensive moxonidine and non-steroidal anti-inflammatory drugs (nsaids) in patients with hypertension. in the study population, 110 patients (45.8%) have taken at least one combination of drugs that could result in a clinically significant interaction. the most common combinations included application of nsaids and antihypertensive drugs or diuretics, concomitant use of multiple medications with effects on the central nervous system and drug combinations that can cause hyperkalaemia. conclusion: this study revealed the high prevalence of inappropriate prescribing. clinical application of this protocol could be an effective method for improving and optimizing drug prescription with the aim to reduce the number of side effects and the morbidity and mortality associated with the drug use in the elderly. please specify your abstract type: research abstract background and objective: to reduce adverse effects of conventional amphotericin b formulation (deoxycholate or d-amb) it can be infused in intralipid ò (a fat parenteral nutrition), or lipid-based formulations can be used (i.e. amphotericin b lipid complex (ablc), amphotericin b colloidal dispersion (adcd) and liposomal amphotericin b (l-amb)). studies evaluating safety profiles present conflicting results. the aim of our study was to gather evidence on nephrotoxicity rates of d-amb versus lipid-based formulations in immunosuppressed patients susceptible to invasive fungal infection. setting and method: a systematic review, including randomized controlled trials (rcts) that compared the use of d-amb and amphotericin b lipid-based was performed. a search was conducted in pubmed, scopus, web of science and scielo. results were synthetized and meta-analysis was performed using software review manager 5.3. main outcome measures: nephrotoxicity rates. results: eighteen rcts were identified (n = 2525 participants). the result from the meta-analysis favours the treatment with the lipidbased amphotericin b formulations (or: 0.32 (0.25, 0.41) and presents a low heterogeneity (i 2 = 18%). about 22% of patients from lipid-based treatment group presented an increase in serum creatinine of one to two times, which corresponds to stage one or two of acute renal failure (arf). and 2% presented an increase of tree times in serum creatinine achieving a stage three in arf (severe) which will require dialysis. while in group treated with conventional formulation int j clin pharm (2017) all of these 23 patients, except one whose treatment adherence was inadequate, were cirrhotic (15/23), liver transplanted (5/23) and/ or presented hepatocellular carcinoma (3/23). 6/23 patients were coinfected with hiv. 8/23 patients (35%) were genotype 3. the total genotype 3 patients treated with daas (svr12/relapsed) were 79, which means that 10.1% (8/79) of all genotype 3 patients has had a relapse. 10/23 patients (43%) were treated with ledispavir/sofosbuvir (2.4% of a total of 411 patients (svr12/relapsed) treated with this option). 39% of patients who suffered a relapse were treated with daas sofosbuvir, simeprevir, daclatasvir, previously to the introduction of the newest antivirals (dasabuvir + ombitasvir/ paritaprevir/ritonavir, ledispavir/sofosbuvir), which represents 6.3% of the total of 142 patients treated with the older option. conclusion: relapses rate was 3.1%, slightly lower than reported in other studies. according to the references, these results show that genotype 3 is the one presenting more relapses. all the patients presented a deteriorated performance status, except for one whose treatment adherence was inadequate. patients treated before april 2015, when the newest daas where introduced, showed more relapses. more studies have to be developed in the near future since other daas will appear, the treatment options will be amplified and the number of relapses is expected to decrease. please specify your abstract type: research abstract background and objective: the inappropriate use of antibiotics remains a major issue since it causes bacterial resistance, longer hospital stay and increased mortality. antibiotic prescriptions must be monitored: the clinical pharmacist has a key role in ensuring patient safety and quality of pharmaceutical care. therefore, an antimicrobial stewardship program has been implemented as part of a national project of the italian society of hospital pharmacy (sifo). the objective is to describe the results obtained at the hospital. setting and method: a multidisciplinary antimicrobial management team has been implemented including clinical pharmacists, microbiologists and infectious disease specialists. the pharmacist examines drug charts on a daily basis in the department of medicine and supports clinicians to improve the appropriate use of antibiotics. data from 2 time-points were extracted from medical records and collected in an excel database: t0 (november 2015-january 2016) and t1 (february 2016-april 2016). main outcome measures: type of infection, antibiotic consumption data, type of isolated pathogens, patient allergies, clostridium difficile infection assessment and adverse drug reactions (adr). results: 465 records were analysed (t0-t1), 277 of which contained at least one antibiotic prescription. the most frequent infections were urinary tract (27%), respiratory (20%) and gastro-intestinal (14%). antibiotic therapy was started in 15.9% of cases due to aspecific increase of c-reactive protein (crp). ddds were calculated for each treatment and were grouped by type of infection and setting (empiric vs targeted): ceftriaxone, meropenem and metronidazole were the most widely used antibiotics for empiric therapy. at t1, an increase in the use of piperacillin-tazobactam instead of meropenem was observed. the ddd of ceftriaxone for targeted therapies decreased significantly, while an increase was observed for carbapenems, levofloxacin, glycopeptides and, in case of mdr bacteria, tigecycline. three allergies to antibiotics were reported in medical history. there were 20 clostridium difficile infections (5 relapses), confirmed by antibiogram. a total of 22 adrs were identified: 3 of these were related to antibiotics. conclusion: antimicrobial stewardship is a fundamental step to optimise antibiotic management, ensure patient safety and improve quality of care. the results obtained so far demonstrate the added value of a multidisciplinary team in controlling bacteria resistance and in the improving the use of antibiotics. please specify your abstract type: descriptive abstract (for projects) background and objective: the aim of this study was to analyse effectiveness and safety of pirfenidone, an anti-inflammatory and antifibrotic agent used for treatment of idiopathic pulmonary fibrosis. design: a retrospective, descriptive, observational study including all patients treated with pirfenidone at the hospital between march 2015 and june 2016 (15 month) was carried out. to identify patients and collect data the outpatient medication dispensation software farhos ò and the electronic medical record software hcis ò were used. statistical analysis was carried out using microsoft excel ò . demographic (age and sex), clinical (forced vital capacity (fvc), diffusing co capacity (dlco) and six-minute walk test (wt6 m)) and therapeutic (dosage and adverse reactions) variables were collected. results: throughout the study period, a total of 22 patients (16 males) started treatment with pirfenidone, with a median age of 74.5 years (46-81). during this period 5 patients were excluded for lack of monitoring. the median fvc, dlco, wt6 m values prior to pirfenidone therapy, were 59% (50 [ 81%), 38.5% (17 [ 65%) and 357 m (200-620 m) respectively. all patients met the inclusion criteria of capacity trial according to fvc and wt6 m; however 8 of them didn't meet the dlco criteria (at least 35%).'' all patients were monitored every 3 months. the median in fvc percentage change at the end of the study was -1% (-13% to +9%). 8 patients (50%) showed an improvement on fvc during treatment with a median change of 7%. in the other eight patients fvc value decreased with a median of -6%. only one patient would be candidate to discontinue treatment due to a lack of efficacy, according to discontinuation criteria established at the hospital (absolute decrease of c10% in fvc during first year of treatment). dlco percentage was measured in 14 patients, with a median change of 2% (-17% to +10%). dlco decreased in 6 patients. wt6 m was monitored in 12 patients, with a median change of -44.5 m (-222 m to +35 m). adverse effects related to pirfenidone were gastrointestinal disorders (9/17), increase of hepatic ggt (5/17), and dermatologic toxicity (2/17). six patients (35%) required a dose reduction because of gastrointestinal adverse effects. five patients (29%) discontinued treatment with pirfenidone due to hepatotoxicity (2), gastrointestinal (1) and dermatologic effects (1). one patient died. conclusion: half of the patients improved fvc during the period of the study. the other half, showed a decrease in fvc value which was similar to the median obtained in capacity trial. gastrointestinal disorders were the most frequent adverse effects and cause of discontinuing treatment. treatment monitoring is important to achieve therapeutic benefit and control the adverse effects. the national centre for epilepsy, oslo university hospital, oslo, norway please specify your abstract type: research abstract background and objective: systematic medication reviews in interdisciplinary teams can help to identify potential and actual drugrelated problems (drp). the centre for development of institutional and home care services in oslo, norway, conducted medication reviews for polypharmacy patients with mental disabilities in 2015-2016, based on a lack of knowledge about drug-related problems in this patient group. the objective was to examine prescribing patterns, frequencies and types of drp in patients with mental disabilities. setting and method: the forms for medication reviews were developed by the national patient safety campaign in norway. the nurse/social educator recruited eligible patients, observed them, and ordered test if needed. the clinical pharmacist (jwa) reviewed the medications to identify drps. the interdisciplinary case conference took place at the different general practitioners' offices being responsible for the individual patients. the general practitioner, the nurse/social educator and the pharmacist were present, and in some cases, also patients took part. main outcome measures: an independent researcher (aqm) collected and analysed the data based on the drp-forms containing information on the prescribed medicines, strength, dose, indication, a description of drp and suggested interventions to resolve them. results: overall, 40 patients with mental disabilities, aged 34-77 years, consented to have a medication review. they used on int j clin pharm (2017) 39:208-341 327 average 12 medicines (range 5-23). the team identified 191 drp in 39 of the 40 patients (average 4.9, range 0-13). overall, 79% of all drp were resolved. for one-third of the medicines, an action was taken to improve the prescribing. the most commonly medicines were analgesics (62%), antiepileptics (58%) and anxiolytics (52%). the most frequent drps were unnecessary drug choice (24%), side effects (11%) and too low dose (11%). drps were most common in antipsychotics (10%), antidepressants (9%) and anxiolytics (7%). conclusion: patients with intellectual disabilities take more medicines and have many drps compared to other patient groups. they are also more prone to taking combinations of cns-active medicines and therefore more at risk of side effects and drug interactions. pt020: protocol feasibility and patient findings when using a dry extract of zingiber officinale roscoe (ginger extract gr10) during pregnancy please specify your abstract type: research abstract background and objective: there is limited information about the use of dry extracts of ginger root. the objectives of this study are (1) to evaluate the feasibility of a pilot study with a food supplement among pregnant women (2) to learn what the patient findings are when using the dry extract of ginger during pregnancy. this abstract deals with the intermediate evaluation of a study conceived to investigate the safety of the ginger extract gr10 during pregnancy. setting and method: a prospective, interventional and real life pilot study with pregnant women between 4 and 14 weeks of gestation and having symptoms of nausea and vomiting or digestive complaints. the included patients can use the ginger extract gr10 for digestive comfort during pregnancy when needed. during the use, the score of digestive discomfort is noted and the researcher reports adverse events. main outcome measures: (1) number of included patients as an indicator of feasibility: including a number of 50 patients was taken as a target (2) analysis (qualitative and quantitative) of the patient diaries, more particularly patient behaviour, wellbeing and impressions. results: within twelve weeks, 51 patients were included with an average age of 29.9 years and a median age of 29 (19-42) years. 45 patients used gr10: 3 patients were dissatisfied, 15 patients had a neutral opinion and 19 patients were satisfied to very satisfied. one miscarriage occurred at a gestational age of almost 17 weeks (only 2 tablets of gr10 were used, with no relevant medical history in preceding pregnancies). two patients were hospitalized, of which 1 with hyperemesis gravidarum. one patient complained about heartburn and one patient experienced a bad taste and heartburn. three patients have indicated that they experienced more nausea after taking the tablets. 29 patients experienced no adverse events. the remaining 8 patients were not yet evaluated. of the 51 included patients, six patients decided not to use the product: 3 because their gastrointestinal complaints were not serious enough, 1 because problems of swallowing (using ginger gums instead). one patient was afraid for the negative consequences for her unborn child. the last of the nonusers indicated that she had no confidence in the product. conclusion: conducting a pilot study with the ginger extract gr10 in case of pregnancy is feasible. the majority of the evaluated patients were satisfied. signing the consent form does not guarantee the intake of the product. pregnant women remain very cautious in the use of unknown products during their pregnancy, even though it concerns a food supplement and not a drug. the severity of symptoms does not give a good indication whether or not and how often the product will be used. please specify your abstract type: descriptive abstract (for projects) background and objective: to analyse effectiveness and safety of ibrutinib, an oral inhibitor of bruton tyrosine kinase, in patients with mantle cell lymphoma (mcl) who have received at least one prior therapy. design: a descriptive observational study was carried out. all patients with relapsed or refractory mcl who started treatment with 560 mg of daily ibrutinib between september 2014 and june 2016 were included. patients were identified and followed through electronic medical record. demographic and baseline clinical characteristics of patients were collected: age, sex, ecog (eastern cooperative oncology group scale), number and type of prior regimens, simplified mipi status (mantle-cell lymphoma international prognostic index), and disease stage (relapsed or refractory). progression free survival (pfs) and response to treatment were recorded to evaluate effectiveness. adverse effects related to ibrutinib and possible interactions with concomitant medication were documented to measure safety. statistical analysis of the data was carried out using microsoft excel 2013 ò and spss ò 18. results: throughout the period of study a total of 5 patients (4 males and 1 female) with a mean age of 62.5 ± 8.2 years started treatment with ibrutinib. the median of previous treatments were 2 (1) (2) (3) (4) (5) including first-line treatment with high dose chemotherapy (100%), steam-cell transplantation (80%), rituximab (100%), bortezomib (60%) and lenalidomide (20%). the median ecog value prior to ibrutinib therapy was 0 (range 0-1). the mipi status was intermediate risk in 4 patients and high risk in 1, the disease stage was relapsed in 80% of the patients. partial response was reported in 3 patients. the mean pfs estimated at the end of the study period was 13 months (95% 4.4-21.5). adverse effects related to ibrutinib were: fatigue (10%), diarrhoea (10%) leucocytosis (30%) and infections (50%), including upper respiratory and urinary tract infections, sinusitis and pneumonia. one possible interaction between ibrutinib and everolimus was found in a liver transplant patient. close monitoring of everolimus plasmatic levels was recommended. conclusion: the mean pfs estimated in our study was similar to the median obtained in the pivotal phase ii trial. infections were the most frequent adverse effects. concomitant medication to ibrutinib should be checked, as ibrutibib is metabolised by cyp3a4 and interactions may be frequently present. 1 pharmacy, 2 hiv unit, germans trias i pujol hospital, badalona, spain please specify your abstract type: descriptive abstract (for projects) background and objective: dolutegravir (dtg) is one of the preferred options for initial antiretroviral therapy (art) due to its high efficacy, good tolerability and low potential for drug-drug interactions. nevertheless, an unexpectedly high rate of dtg discontinuation (up to 16%) due to adverse events in the clinical practice has been recently reported. therefore, we aimed at assessing the dtg discontinuation rate and reasons for discontinuation in our hospital. design: single-centre, retrospective study from september 2014 to june 2016 of 2709 patients cohort with art both naive and pretreated. patients who had started dtg-based art containing regimen were identified and the reasons for the discontinuations were analysed. data were collected using the primary care service program and the electronic prescription program. results: out of 2700 patients attended by pharmacy department in our hospital, 563 patients (494 males, mean age 47 years (range 16-84)) had started a dtg-based art. out of them, 61 patients were art naive and 502 art-experienced. at the moment of starting dtg, mean cd4 cells were 654cell/mm 3 (range 7-2147) and hiv-1 rna load in plasma was detectable in 69 patients. treatment discontinuation was reported in 52/563 patients (9.2%) with a median treatment time of 241 days (range 7-842). 8/52 patients (15.4%) were naïve and 44/52 patients (84.6%) pre-treated. most of the patients (404) were in single tablet regimens (str) containing dtg in combination with abacavir and lamivudine, whereas the rest were in combination with other antiretroviral drugs. the main reason for treatment discontinuation was toxicity in 38/52 patients (73.1%). the rest of the patients discontinued due to other motives (clinical trial inclusion (3/52), treated in another hospital (4/52), exitus (1/52) and others (6/52). reasons for the discontinuation were classified in different side effects: 17/38 (44.7%) related to central nervous system (cns) (insomnia, psychiatric disorders such as anxiety, nightmares and depression), 14/38 (36.8%) gastrointestinal effects, 4/38 (10.5%) headaches, 6/38 (15.8%) musculoskeletal effects, 4/38 (10.5%) fatigue, 1/38 (2.7%) allergy and 6/38 (15.8%) for other reasons. some patients reported various toxicities at once. conclusion: more than 6% of patients treated with dtg discontinued by toxicity reasons. it is important to note that half of these patients had cns adverse effects. please specify your abstract type: research abstract background and objective: hcv therapy has been revolutionised recently by the approval of antiviral agents direct-acting (daa) facilitating the treatment of patients coinfected with hiv/hcv. however, potential drug interactions and overlapping toxicities of both treatments represent the major challenges in adapting therapy. to analyse the prescription profile of direct acting antivirals (aad) in patients coinfected with hiv/hcv. setting and method: retrospective observational study from january 2015 to january 2016 in a specialty hospital. the data were collected from the hospital program of clinical stories, archinet ò , and the outpatient program farmatools ò . the results were analysed using the statistical program r-commander. main outcome measures: inclusion criteria: adult patients coinfected with hiv/hcv with undetectable viral load. the following variables were collected: age, gender, hcv genotype, degree of fibrosis, patient type (naïve or pre-treated), baseline cd4 count, cd4 levels end of treatment, sustained viral response (svr) and hcv treatment. results: 20 patients, of whom 16 were men, mean age 52 years were included. 9 patients received daclatasvir and sofosbuvir for hcv, 3 patients had genotype 1a and 1b respectively, 2 patients genotype 3 and 1 patient genotype 4. 8 patients had fibrosis f3 f4, 1. of the 9 patients 3 they had not received previous treatment (naïve) and 6 had failed to treatment. hiv treatment was modified in 8 patients, 6 patients achieved svr. the cv was undetectable to hiv treatment change for all patients. cd4 levels increased in all patients at the end of treatment for hcv with a median of 304 cells/ul and 398 at the beginning and end respectively. 2 patients received ombitasvir/paritaprevir/ritonavir and dasabuvir, who had a genotype 1a. these two patients had received previous treatment and had a f2 and f4 fibrosis. none of them was modified hiv treatment and only one got svr. cv remained undetectable and cd4 slightly increased after the treatment. 9 patients received ledipasvir and sofosbuvir, 6 patients had genotype 1a, 2 patients genotype 1b and 1 patient genotype 4. 4 patients had f4 fibrosis and 5 had f3. 9 patients had received previous treatment (naïve). the hiv treatment was modified only in one of the patients, 8 patients achieved svr. cv increase in 2 patients after the treatment while cd4 followed the trend of increasing. conclusion: the aad that caused fewer changes in the hiv treatment were ombitasvir/paritaprevir/ritonavir and dasabuvir followed by ledipasvir/sofosbuvir. sofosbuvir and daclatasvir present a greater number of interactions with hiv drugs so they behaved to a major change. more patients are needed to assess more accurately the aad leading to a minor modification. please specify your abstract type: research abstract background and objective: the simplification strategies reduce the amount of tablets and the toxicity in order to facilitate adherence in patients with virological suppression. the strategy more studied is monotherapy with a ritonavir-boosted protease inhibitors (pi/r). to analyse the effectiveness of monotherapy with pi/r in pre-treated patients infected with hiv. setting and method: retrospective observational study. selected hiv patients treated with pi/r monotherapy at any time of pharmacotherapeutic history to 30/12/2015, with at least one clinical and analytical control 6 months before the beginning. data were collected from the medical record archinet ò and outpatient farmatools ò program. variables included were age, sex, duration of monotherapy, virological failure, treatment failure, cd4% during monotherapy. main outcome measures: inclusion criteria: virological suppression for 1 year prior to the start of monotherapy, no previous ip virological failure, high cd4 count ([300 cell/ml) and a high level of drug adherence. the effectiveness is defined as the percentage of patients without virological failure (2 consecutive plasma viral load (vl) [200 copies/ml) and without treatment failure (any event causing retirement monotherapy). results: 141 patients with monotherapy, which represent 22% of patients with antiretroviral therapy (art) at our institution were identified. 29 were excluded (8 co-infected with hepatitis virus, 3 with insufficient data and 18 no had more than 6 months included), including 112 patients in the analysis, with a mean age of 45 years and 60% were men. the median of time monotherapy treatment was 1.75 years (639.5 days), 89(79.4%) patients received darunavir/r and 23 (20.53%) lopinavir/r. the effectiveness of monotherapy treatment during the follow up period was 100% with undetectable pvl at follow-up. the median of cd4% over the treatment time was 794 cell/ml (34%). conclusion: the effectiveness of treatment with ip/r monotherapy in our hospital obtained good results. according with our results treatment adherence plays a very important role. this is a current and valid strategy that brings benefits to the patient and to the healthcare system. please specify your abstract type: research abstract background and objective: the access to investigational drugs for patients who are not included in a clinical trial and without authorized therapeutic alternatives is known as compassionate use. the incorporation of the evidence-based medicine in the area of oncohaematology has implied that an important part of clinic therapy validated by evidence that could not be controlled from an administrative point of view. this is due to the continuous and progressive development of investigation and information on cancer treatment and the delay of the administration regulation. the use of drugs in this way is regulated by royal decree 1015/2009 (19/6). the objective of the study is to describe the use of cancer drugs through compassionate use in the last 5 years in a specialty hospital. setting and method: descriptive retrospective study on a specialty hospital. all the applications for a compassionate use drugs were analysed from january 2011 until october 2015. the data were obtained from medical records programme diraya ò and from an excel database of medicines in compassionate use of the pharmacy service. main outcome measures: the following variables were registered: • number of patient clinic history • authorized medicine • authorization date • applicant service results: we recorded 80 requests of cancer drugs in compassionate use during the 5 years of study. oncology was the service that recorded more authorizations with 95%, followed with gynaecology with 2.5% and finally endocrinology and haematology with 1.25%. 64 drugs of the 80 requests were approved (80%) and 16 unauthorized (20%) in the 5 years of study. the year in which more applications were received was 2013 (31.25%) and the least requests were received in 2012 (6.25%), being the year where all requests were authorized. in 2015 fewer applications were authorized, 75%. in the years 2011, 2013 and 2014 were authorized 88.3, 76 and 88.3%, respectively. a total of 34 different active drugs were received during the study, the most requested bevacizumab (24%) for grade iii oligoastrocytoma, ovarian cancer (monotherapy), metastatic gall bladder cancer and metastatic platinum-resistant ovarian cancer, everolimus (18%) for indications of neuroendocrine carcinoid tumour and metastatic breast cancer, nab-paclitaxel (18%) for invasive lobular carcinoma indications of high-grade and metastatic pancreatic cancer, ipilimumab (12%) for the indication of metastatic melanoma, and regorafenib for indications of colorectal cancer and metastatic gist i pre-treat with imatinib (12%). the solicitude of drugs through compassionate use needs effective commissions of pharmacy and therapeutics, along with the medical management to establish an agile and faster requesting circuit and the consequent use monitoring. please specify your abstract type: research abstract background and objective: to describe the standard procedure for the elaboration and control of a magistral formula (mf) to assess their effectiveness in two patients with cutaneous metastases of malignant melanoma refractory to other treatment. setting and method: medication for compassionate use was requested for two patients of 78 and 49 years with histopathologic diagnosis of cutaneous metastases of malignant melanoma in the left thigh and left heel in which the lack of response to first-line treatments made to be valued to start with adesleukina intralesional therapy. the first week was infiltrated 3 mu (1 ml) in 5 lesions less than 1 cm, 9mu (3 ml) in the larger lesions and repeating each week until complete remission of the lesions. in the 2nd patient we proceed in the same way but the second week was infiltrated 5mu (8 ml). the following week, infiltrated 9 mml, in 15 metastases and we turn to 2 weekly infiltrations. the response was assessed by clinical disappearance of the lesions treated. complete response (cr) is defined as a clinical disappearance of lesions and partial response (pr) greater than 50% reduction of the lesion diameter. main outcome measures: we performed a literature search (pubmed, trissel, spc) for all studies published to determine the standard procedure for preparing and monitoring the mf (processing, preservation, stability, dose and indication). results: the standard procedure of preparation and quality control was carried out following the rules established in rd 175/2001. it was made in a vertical laminar flow cabinet. the aldesleukin vial was reconstituted with 1.2 ml api (18 mu/ml) and then diluted with 4.8 ml of a solution of 0.1% albumin, 5% glucose as stabilizer, to avoid aggregate formation, preparing 1 ml syringes (3 mu/ml). it was obtained a homogeneous and clear solution without precipitate or opalescence appearance. stable 6 days in a refrigerator (2-8°c), protected from light. initially patients had approximately a total of 60 injuries. after 2 months of treatment it was obtained a cr of most lesions in the first patient and rp of the second patient injuries. treatment was well tolerated. the side effects presented were only a flu-like syndrome in the second patient. conclusion: intralesional administration aldeslukina has been effective in treating malignant melanoma skin metastases in our patients, allowing the extension of its use in patients with the same involvement refractory to other primary treatments. the results are similar to those of the publications consulted. please specify your abstract type: research abstract background and objective: chronic infection with hepatitis virus c (hcv) affects about 170 million people worldwide and is a leading cause of liver cirrhosis and hepatocellular carcinoma. the new direct acting antivirals against hcv have revolutionized the treatment of this disease. due to the high cost of these drugs it is necessary to assess their use in clinical practice. to evaluate the effectiveness of daclatasvir in combination with sofosbuvir in patients with hcv monoinfected in a specialty hospital. setting and method: retrospective observational study of patients who began treatment with the combination of daclatasvir and sofosbuvir from january 2015 to january 2016 in a specialty hospital. the data were collected from the hospital program of clinical stories archinet ò and the outpatient program farmatools ò . the results were analysed using the statistical program r-commander. main outcome measures: the sustained virologic response (svr) was considered the primary endpoint of the study. as secondary variables were analysed: sex, duration of treatment, naïve patients or pre-treated, degree of fibrosis, hcv genotype, concomitant use with ribavirin, viral load (vl) before treatment and medical service. results: there were included 28 patients of whom 23 were men. baseline characteristics were: 17 patients with genotype 3, 8 genotype 1b, 2 with genotype 1a and 1 genotype 4. the degree of fibrosis in the study was 15 patients with f4, f3 9 and 3 to f2. among the 17 patients infected with hcv genotype 3, 9 had not received prior treatment (naïve) and 8 had failed therapy. the duration of the treatment was 12 weeks to 16 patients and 24 weeks for 12 patients. only 7 patients receiving ribavirin of these 5 had genotype 3 and 2 genotype 1b. from ribavirin patients it was greater the number of patients in whom the treatment duration was 24 weeks (6 patients versus 1 with p-value = 0.008151). the digestive service attended to 17 patients while 11 patients were followed by infectious. the median cv was 3,067,940 iu/ml. svr was achieved in 81.2% of patients with hcv genotype 3 in 87.5% with genotype 1b and 100% with genotype 4 and 1a. after 12 weeks of treatment 61% of patients achieved svr and 39% after 24 weeks. only one patient died during treatment. the results are similar to those obtained in clinical trials. svr has not been influenced by hcv subtype, duration of treatment, degree of fibrosis, pre-treatment or by concomitant use of ribavirin. further studies are needed to evaluate the efficacy of this treatment. please specify your abstract type: research abstract background and objective: the safety and efficacy of medications can vary significantly between patients as a result of genetic variability. as genomic screening technologies become more widely available, pharmacists are ideally suited to utilize this tool to optimize medication management. the objective of this study is to evaluate the feasibility of implementing personalized medication services into community pharmacy practice and to assess the number of drug therapy problems identified as a result of pharmacogenomic screening. setting and method: the study was designed as open-label, nonrandomized, and observational. two community pharmacies in toronto, ontario offered pharmacogenomic screening as part of their professional services program. prior to initiation, participating pharmacists received structured, comprehensive training in pharmacogenetics. pharmacists then facilitated voluntary subject enrolment among patients who they believed would benefit from screening and met inclusion criteria. eligible patients received a simple buccal swab followed by dna analysis using pillcheck ò . pillcheck ò is a genotyping assay that translates genomic data and generates a personalized, evidence-based, report that provides insight into patients' inherited drug metabolic profile. upon receiving the report, pharmacists invited patients back to the clinic for interpretation of the results. clinically significant drug therapy problems were identified and recommendations for medication optimization were forwarded to the primary care physician. main outcome measures: number of clinically significant drug therapy problems identified by pharmacists as a result of pharmacogenomic testing. results: 100 patients were enrolled in the study. average age was 57.4 years and patients were taking a mean of 5.6 chronic medications. pharmacists cited the most common reasons for testing as ineffective therapy (44.6%), to address an adverse reaction (35.5%), and to guide initiation of therapy (11.8%). an average of 1.3 drug therapy problems were identified per patient. pharmacist recommendations included change in therapy (57.1%), dose adjustment (14.3%), discontinuation of a drug (7.1%), and increased monitoring (19.6%). generally, physician feedback was positive but did reveal an opportunity for a broader understanding of the technology. conclusion: these results highlight the readiness of community pharmacists to adopt pharmacogenetic screening into practice and their ability to leverage this novel technology to positively impact medication management. community pharmacists are ideally suited to both offer personalized medication services and interpret genomic results. please specify your abstract type: descriptive abstract (for projects) background and objective: visual impairment is a common geriatric syndrome and glaucoma/miotic eye drops treatment is a frequent therapeutic option. pharmacist's role in medication reconciliation is an effective process for reducing medication errors and supporting safe medication use. we observed that mentioned medication reconciliation was occasionally not performed during hospital stay and could be cause of delirium because of visual impairment. the aim of this study was to evaluate the influence of omission errors of eye drops treatment on incidence of acute confusional state. design: we conducted an observational, descriptive and retrospective study in an orthogeriatric unit with an average of 600 patients with hip fractures per year (95% surgically treated). data collection was performed from june 2015 to march 2016. reconciling medications at admission was performed by implementing the tools and resources of the canadian patient safety institute (cpsi). we extracted from our electronic database (filemaker pro ò ): • demographic patient data (age and gender). • name and posology of the glaucoma/miotic eye drops treatment. • medication reconciliation performed and identification of professional in charge (pharmacist, geriatrician or orthopaedic surgeon) registration during hospital stay. • protocolar management of delirium with tiapride occasional intramuscular administration performed if necessary was also registered to establish the incidence of acute confusional state. results: thirty-two patients (26 women and 6 men) were included, median age 86 year-old . in 21 patients, eye drops reconciliation treatment was performed by the pharmacist in 17 of the 21 patients, the geriatrician in 3 cases and the orthopaedic surgeon in 1. in 11 patients, the mentioned medication reconciliation was not performed (pharmacist absentism). considering the 21 patients on eye drops treatment during hospital stay, 4 (19.0%) of them suffer from acute confusional state. on the other hand, among the 11 patients without medication reconciliation, delirium was registered in 7 cases (63.6%). concerning ocular topic treatment, 2.4 ± 1.1 active principles per patient were observed, being the most frequent timolol (68.8%), brinzolamide (40.6%) and latanoprost (37.5%). conclusion: we consider of paramount importance the pharmacist evaluation availability at an orthogeriatric unit, minimizing the impact of acute confusional state during hospital stay by medication reconciliation. please specify your abstract type: descriptive abstract (for projects) background and objective: to report the therapeutic management of haemorrhagic rectocolitis onset in a lung-transplanted patient with mycophenolate-induced diarrhoea. design: case report. results: a 54-year-old-man lung transplant patient for alpha 1-antitrypsin deficiency in 2003 receiving mycophenolate mofetil, tacrolimus and corticosteroid developed chronic diarrhoea worsened by sigmoid and cecal necrosis in 2011, and treated successfully by sigmoidectomy. severe diarrhoea attributed to mycophenolate mofetil reappeared in april 2015, which motivated a switch to mycophenolate sodium. the absence of clinical improvement in june 2015 led to stop mycophenolate sodium and introduce azathioprine at 100 mg/day (absence of mutation for the thiopurine methyl transferase gene). one month later, the patient presented melena, diarrhoea, bloating, nausea, and knee pain, attributed to azathioprine. this latter was stopped and mycophenolate mofetil was rechallenged associated with symptomatic treatment (i.e., diosmectite and loperamide). in january 2016, a colonoscopy, performed in a context of profuse chronic diarrhoea with mucus during 3 months, highlighted haemorrhagic rectocolitis. therefore, the patient initiated sulfazalasine therapy with no clinical improvement, and then high doses of oral corticosteroids. because high-dose of oral corticosteroids was not recommended as a long-term treatment, mercaptopurine was proposed as a new therapeutic option. mercaptopurine has no indication as an immunosuppressive treatment in solid organ post-transplant supportive care. however, as the active metabolite of azathioprin, an immunosuppressive drug widely used in transplantation, mercaptopurine has immunosuppressive functions towards t-lymphocytes. after multiprofessional collaboration between gastroenterology, pneumology and pharmacy specialists, it was decided to stop mycophenolate mofetil and introduce mecaptopurine at 1.5 mg/kg/day, as immunosuppressant for haemorrhagic rectocolitis as well as lung transplantation. this unusual lung transplant immunosuppressive therapy, associated with tacrolimus, improved digestive disorders and patient's quality of life. currently, mercaptopurine is biologically and clinically well tolerated. the dosage of blood residual concentrations of purinethol metabolites (6-thioguanine and 6-methylmercaptopurine) is going to be performed. conclusion: immunosuppressive therapy in solid organ transplantation is a real challenge for patients who have comorbidity onset. despite a lack of data in the literature, a multidisciplinary collaboration based on comprehensive pharmacology skills is essential to choose the best therapeutic option in this type of patients. please specify your abstract type: descriptive abstract (for projects) background and objective: the use of complementary medicines (cm) in oncology is the subject of broad but still controversial interest. a large part of patients with cancer uses cm, including complementary drugs, during their treatment period. indeed, according to different studies, this proportion ranges from 18 to 83%. importantly, the risk of interaction between cm and anti-cancer drugs is not negligible; hence we need to identify these cm to ensure the security of our patients and the success of their treatment. design: to achieve this purpose, a monocentric retrospective analysis was conducted with collection of data by pharmacy students during medication reconciliation of hospitalized patients from january to june 2016. collected data are patients' characteristics, prevalence of cm use and potential cm-anticancer drug interactions. results: 161 patients were included in the study (91 men-70 women); median age was 65 [34-88 years]. a total of 24.2% (n = 39) were using a least one cm, most frequently homeopathy (62%, n = 24) or phytotherapy (36%, n = 14); some patients were using a combination of two cm (41%, n = 16). cm are mainly used by women in comparison to men (32.9% versus 17.6% and p = 0.025, chi square test). for phytotherapy, at least 36 different herbs were described by patients and among them the most frequently used were mistletoe (viscum album), propolis and fireweed (epilobium angustifolium). data analysis showed that 23% (n = 9) of patients were at risk of potential cm-anticancer drug interaction. moreover this risk was increased to 50% if we considered only patients taking phytotherapy. interactions included pharmacokinetic (15%, n = 3), such as altered hepatic metabolism, and pharmacodynamics ones (85%, n = 17). conclusion: in conclusion, our work clearly demonstrates that the use of cm by patients is associated with high risk of relevant drug interaction with their anti-cancer treatment. even if further investigations are necessary to clarify the clinical impact of these interactions, the use of cm must be considered during prescribing process. please specify your abstract type: research abstract background and objective: since their reimbursement, the direct oral anticoagulants (doacs) are increasingly used for stroke prevention in atrial fibrillation (af). the objective of this study was to identify the proportion of real life patients with af eligible for doac therapy, based on the inclusion and exclusion criteria used in the clinical studies and based on the officially approved indications as mentioned in the summary of product characteristics (smpc). setting and method: data for this retrospective cross-sectional study was extracted from the uz brussel stroke registry, containing anonymized data of 2205 patients with a suspected stroke. characteristics of patients with documented af were compared with the patient characteristics in clinical trials and the approved indications in the smpc. main outcome measures: proportion of real life patients with af eligible for doac therapy. results: data of 468 patients with af was analysed. based on the selection criteria of the clinical trials, significantly less patients were eligible for treatment with rivaroxaban compared to dabigatran etexilate (39.3% versus 47.6%; p = 0.010), but not compared to apixaban (45.5%; p = 0.055). based on the indications and contraindications in the smpc, significantly fewer patients were eligible for apixaban compared to dabigatran etexilate and rivaroxaban (62.0% for apixaban, 72.9% for dabigatran etexilate and 75.6% for rivaroxaban; p \ 0.001 and p \ 0.001, respectively). significantly more patients were eligible for doac therapy based on the indications and contraindications in the smpc compared to the inclusion and exclusion criteria of the clinical trials (72.9% versus 47.6%; p \ 0.001 for dabigatran; 75.6% versus 39.3%; p \ 0.001 for rivaroxaban and 62.0% versus 45.5%; p \ 0.001 for apixaban). conclusion: when taking into account the selection criteria from the pivotal clinical trials with doacs for stroke prevention in af, less than half of real life patients are eligible for therapy with one of the doacs. however, the indications mentioned in the smpcs of these drugs are less strict. please specify your abstract type: research abstract background and objective: idiopathic pulmonary fibrosis (ipf) is a disease in which tissue deep in the lungs becomes thick and stiff, or scarred, over time. the formation of scar tissue is called fibrosis. pirfenidone is an anti-fibrotic and anti-inflammatory agent, thus offers a new hope for treating progressive fibrotic diseases. int j clin pharm (2017) 39:208-341 333 our objective is to set a description of idiopathic pulmonary fibrosis patients treated with pirfenidone, as well as the adverse reactions observed. setting and method: descriptive study in which all patients have received pirfenidone. the data were obtained through the dispensing program of outpatient (farmatools) and review of medical records of the hospital database (archinet) and clinical station (diraya). main outcome measures: we have extracted from each patient baseline data, comorbidities, dose received, reported adverse reactions and data about haematology and biochemistry. results: we have a total amount of 5 patients treated with pirfenidone, all diagnosed with idiopathic pulmonary fibrosis, including 2 women and 3 men. the age of patients is between 66 and 81 years, with an average of 70.8 years. all patients are ex-smokers and one of them is also ex-alcoholic. concerning concomitant pathologies, 3 patients have diabetes mellitus, 2 have arterial hypertension, and one of them has ischemic heart disease. another has upper gastrointestinal bleeding prior, among others chronic pathologies. pirfenidone dose received was the usual dose in 4 of the 5 patients: days 1-7 267 mg every 8 h, days 8-15 534 mg every 8 h and a maintenance dose of 801 mg every 8 h. in one patient due to its low imc the dose received was smaller (1-7 days 267 mg every 12 h, days 8-15 267 mg every 8 h and maintenance dose of 534 mg every 8 h). in relation with the adverse effects, digestive discomfort were observed in 2 of the 5 patients, causing the interruption of the treatment in one of them (with prior gastrointestinal bleeding). in the other patient it was relieved by lowering the dose received. also, one patient has experienced photosensitivity. alterations in transaminase levels were observed in 2 patients but that didn't force to discontinue the treatment. no alterations were observed in the blood count. conclusion: treatment with pirfenidone is being generally well tolerated by patients. it has improved their life-quality and reached the objective data of a slowdown in disease progression. currently, the number of patients is no enough to give conclusive information in relation to the drug effectiveness. please specify your abstract type: research abstract background and objective: to describe the total amount of patients treated with a magistral formula of sodium cromoglycate 200 mg without excipients: indications, concomitant therapy and the response to therapy. setting and method: we run a descriptive study in which we included the totality of patients in treatment with a magistral formula of sodium cromoglycate 200 mg without excipients in a tertiary hospital. the data were obtained through paracelso (development of magistral formulas program), as well as with farmatools (dispensation program of outpatient) and the review of medical records from the hospital database (archinet), and diraya clinical station. main outcome measures: from each patient we extracted data relative to sex, age, diagnosis, time in treatment with the formula, dose received, response to therapy, concomitant antihistamines treatments and adverse effects. results: a total of 9 patients in treatment with a magistral formula of sodium cromoglycate 200 mg without excipients were reviewed: 2 women and 6 men with a mean age of 45.3 years old (range 38-59 years). regarding the indication of the prescription, 3 patients have been diagnosed of indolent systemic mastocytosis and the remaining 5 were diagnosed of mast cell activation syndrome. in all cases, the diagnosis was established by examination of the bone marrow in the mastocytosis studies institute of castilla la mancha (spain). on average, patients took the treatment 12.75 months, with a range between 3 months and 24 months. the dose received was 200 mg every 8 h in 7 patients, having to be increased to 400 mg 3 times daily in a case with poor response to the therapy. in the remaining patients, the treatment response has been optimal. in relation to the concomitant anti-allergic treatment received, 6 patients took fexofenadine daily during the study. no cases of adverse effects related to the therapy received have been reported. conclusion: both indolent systemic mastocytosis and mast cell activation syndrome are considered rare diseases, and we should indicate that in spain there are no commercial medicines available of sodium cromoglycate without excipients for its treatment. the treatment with this magistral formula of sodium cromoglycate 200 mg without excipients has been effective and well tolerated in all patients, improving the symptoms associated with their condition as well as their quality of life, and also, assuming a solution to the lack of marketing of the drug currently in spain. please specify your abstract type: research abstract background and objective: to analyse the prescription profile, safety and effectiveness of new therapies available for the treatment of hcv genotype 1b in a tertiary hospital. setting and method: we run a retrospective observational study in which we included a total amount of 59 patients infected with hcv genotype 1b treated with the new therapies against hcv from february 2015 to december 2015 in a tertiary hospital. the data were obtained through the outpatient dispensing program farmatools and the review of the medical records from the hospital database, archinet and prescription hepatitis c portal of the andalusian health service. main outcome measures: from each patient the following information was collected: sex, age, viral genotype (gen.), naive/nonnaive, hiv coinfection, presence of cirrhosis, degree of hepatic fibrosis measured by fibroscan, treatment prescribed and duration, adverse effects, sustained viral response (svr) and the service that made the prescription. results: a totality of 59 patients with hcv gen. 1b were reviewed which 64.4% of them were men with a mean age of 58.76 years (range 38-78 years). 21 of the patients were naive and only 2 of them were hiv co-infected, there were a 57.63% of cirrhotic patients. regarding the degree of hepatic fibrosis, 36 patients had grade f4, f3 grade 13 patients, 8 patients grade f2 and f1 grade 2 patients. the most commonly therapy prescribed was lepidasvir + sofosbuvir in 28 patients (14 without ribavirin and with ribavirin 14) using a treatment schedule of 12 weeks in 23 of them. the treatment was discontinued in one case because of the adverse effects, achieving svr in the remaining patients. the combo treatment with paritaprevir/ombitasvir/r + dasabuvir was prescribed in 16 times (10 without ribavirin and 6 with ribavirin) choosing only in one of them for a treatment period of 24 weeks. there were no treatment discontinuations and svr was achieved in all patients treated in this way. 8 patients received simeprevir + sofosbuvir for 12 weeks (3 without ribavirin and 5 with ribavirin), one patient of the left the treatment due to adverse effects. svr was found in the remaining patients who completed treatment. sofosbuvir + daclatasvir was prescribed to 5 patients, associating ribavirin in only one case. a treatment duration of 12 weeks was used in 3 patients and 24 weeks in the remaining two. one patient failed rvs without any incidences of adverse effects in any case. interferon + ribavirin sofosbuvir + was prescribed to 2 patients in 12-week regimen which was well tolerated achieving svr. digestivo service treated the 83% of the total amount of patients. conclusion: new therapies for hcv have been used in all the treated patients and the older drugs have been relegated. about the effectiveness, svr was achieved in 98.30% of patients. regarding the safety, only 2 patients have discontinued the treatment due to adverse effects representing less than 5% dropout rate of the therapy. please specify your abstract type: descriptive abstract (for projects) background and objective: thanks to pharmacogenetics we can identify and predict different responses to the same drug among different individuals. during these last years we have noted a big increase of dosing guidelines and advices about the use of several drugs due to the influence of different polymorphisms. the aim of this study is to describe and evaluate the use of pharmacogenetics in our hospital from april 2012, when we started our first research about pharmacogenetics, to the actual time, using these information in our daily clinical practice; and indeed quantify the number of different tests and the number of different clinical advices done because of pharmacogenetic information, by different healthcare specialty areas and drugs. design: we reviewed all the pharmacogenetic test requests in our hospital from april 2012 to april 2016, noting which health specialty and for which drug was asked the test. polymorphisms were genotyped using taqman ò genotyping assays technology by 2 independent laboratories to confirm the results. results: from april 2012 we were asked for 2208 pharmacogenetic tests from 7 different healthcare specialty areas: rheumatology (9.78%), infectious diseases (1.49%), oncology (3.53%), cardiology (71.51%), vascular surgery (5.11%), neurology (4.53%), ophthalmology (4.03%); this information was asked about 5 different drugs: clopidogrel (81.16%), trastuzumab (3.53%), ranibizumab (4.03%), azathioprine (2.99%) and tocilizumab (8.29%). from all the genotypes, 713 (32.29%) were done after using the drug (study phase) and 1495 (67.71%) were done previous to the use of the drug in daily clinical practice to make a ''clinical recommendation''; from these recommendations 1429 affected to the prescription of clopidogrel. conclusion: during the last 4 years we could implement the use of pharmacogenetics in the daily clinical practice in our hospital in 5 different healthcare areas affecting 2 drugs and we started research studies previous to its use on the clinical practice for other three different drugs. please specify your abstract type: descriptive abstract (for projects) background and objective: the drug burden index (dbi) is a tool used to quantify the anticholinergic and sedative burden of medication on an individual. it has been independently associated with poor physical and cognitive performance in community-dwelling older people. objectives were: to create an inventory of medications used in ireland with clinically significant anticholinergic and/or sedative activity and to decide upon the minimum daily dose (mdd) for each medication. design: medications with potential anticholinergic and/or sedative burden were identified by literature review and examination of the summary of product characteristics (smpc) for all medications registered in ireland. each medicine was classified as anticholinergic or sedative. drugs with both anticholinergic and sedative properties were classified as primarily anticholinergic. the mdd, a key component of the dbi score calculation, was selected by reference to the irish smpc. other options which were also considered for this value include the defined daily dose (ddd) of a medication, as available from the world health organisation (who), and the mdd as outlined in the british national formulary (bnf). mdds were decided upon regardless of indication as the lowest effective therapeutic dose as specified in the smpc for the medication. the final list of medicines and mdds to be included in the inventory was then defined by consensus of three pharmacists. results: in total, 383 medicines with potential anticholinergic and/or sedative activity were considered for inclusion. a final list of 258 medications was identified by consensus (117 anticholinergic, 141 sedative). of these, 128 (50%) were agents which act primarily on the nervous system. the three main therapeutic groups contributing to the inventory of dbi medications were antipsychotics (25 medications), antidepressants (21 medications) and antiepileptics (20 medications). conclusion: creation of an inventory of medications with anticholinergic and/or sedative properties, in combination with the individual mdds, was achieved. this is a useful resource for use in analysis of drug burden in an older population. it could help in both identifying patients who would benefit from medication review as well as analysing population medication data. please specify your abstract type: research abstract background and objective: vancomycin is an antibiotic widely used to treat infections such as bacteraemia, infective endocarditis, osteomyelitis, meningitis and pneumonia. nowadays, optimal trough concentration is stablished between 10 and 15 mg/l to avoid development of resistance or 15-20 mg/l to improve penetration in complicated infections. some articles 1 have been published explaining the methodology to calculate an expected trough level in steady state. our aim was to compare the trough serum value estimated by the mathematical method with a two-compartimental bayesian forecasting model. setting and method: observational retrospective study carried out in a tertiary hospital from january to december 2015. non obese adult patients with creatinine clearance (crcl) \ 120 ml/min and who have achieved steady state level were included. vancomycin serum values were measured using a chemiluminescence's immunoassay (cmia) and bayesian analysis was performed with abbottbase pksystem ò (pks ò ). the statistical analysis was made with medcalc software ò . bland-altman plot and passing-bablok regression were used to compare both methods. main outcome measures: sex, age, weight, dose, creatinine, and size were collected from clinical history. serum trough values (cminr) were collected from cmia. trough values were estimated using two methods: mathematical method (cminf) and bayesian calculations (cminb). results: 50 patients were included, with a mean age of 61 (±16.17) years. 52% were male and 48% female. they received a median dose per 24 h of 2000 (1000-3000) mg. the mean of cminr was 17.21 mg/l (95% ci 13.86-20.58), cminb 17.28 mg/l (95% ci 13.87-20.69), cminf 18.21 (95% ci 14. 2399-22.1856) . correlation coefficients (r) comparing both methods were significantly different: r between cminf and cminr was 0.75 (95% ci 0.5866-0.8467), while r between cminb and cminr was higher: 0.99 (95% 0.9900-0.9968). bland-alman plot analysis showed both methods cannot be used interchangeably. the regression equations estimated by passing-bablok regression were y = -3.873368 + 1.309775x and y = -0.110207 + 1.003266x. conclusion: bayesian method has demonstrated better correlation with real measures than mathematical method. most part of our patients could be underestimated or overestimated using mathematical methods which could cause toxicity or lack of efficacy, so this method is unsuitable for clinical use. bayesian estimation remains the best option for optimal dosing of vancomycin. please specify your abstract type: research abstract background and objective: combination therapy with digoxin and acenocoumarol is common in patients with atrial fibrillation (af). getting optimal concentrations of digoxin leads an appropriate response; taking into account its narrow therapeutic range and all the factors which can affect to its pharmacokinetics. interaction between them has been studied, even though its mechanism is not clear yet. patients who are taking both drugs need higher doses of digoxin; because they get lower concentrations by using the same dosage. the objective of this study was to analyse digoxin concentrations in patients treated with this combination compared to expected concentrations according to population parameters. setting and method: retrospective observational study from december 2015 to march 2016 performed by pharmacokinetic unit. patients included had chronic treatment with acenocoumarol and digoxin, which determination were realized in the steady state before the next dosage. patients with toxics concentrations of digoxin, or who were suspected nonadherence, were excluded. the plasma digoxin concentrations were determined through the autoanalyzer architect c-4000 ò (petinia). dosage adjustment was realized by the program abbot pharmacokinetics system (pks). a comparative between the real measured concentrations in patients and estimated concentrations were realized based on population parameters. finally, in order to get optimal concentrations, some dosage changes were proposed based on pharmacokinetic monitoring. data collected: population characteristics (gender, age, weight, and height), analytical data (potassium, urea, creatinine and clearance). main outcome measures: digoxin serum concentrations (optimal range 0.8-1 ng/ml). results: data from 73 patients, 65.8% women with a mean (sd) age of 77.84 (9.07) years were included in the study. at baseline, potassium, urea, creatinine and clearance mean (sd) was 4.43 (0.52) mmol/l; 55.99 (34.05) mg/dl; 0.96 (0.39) mg/dl; 48.76 (22.14) ml/min. 69.86% of the patients had lower concentrations than expected according to population parameters. finally, digoxin dosage was increased in 41.07% of patients, it was maintained in 47.96%, and it was decreased in 10.97%. conclusion: digoxin concentrations in patients with af in combination therapy of digoxin and acenocoumarol are lower than would be expected in most cases. it is important monitoring digoxinaemia to achieve optimal concentrations and a good clinical response. further studies are needed to determine the relevance of this interaction in clinical practice. please specify your abstract type: research abstract background and objective: tocilizumab (tcz) is a humanized monoclonal antibody inhibitor of il-6 receptor, indicated in combination with methotrexate in the treatment of rheumatoid arthritis (ra) in patients with inadequate response or intolerance to prior therapy. interleukin 6 is involved in the pathogenesis of rheumatoid arthritis via its broad effects on immune and inflammatory responses. previous studies have shown that c-allele at the -174g[c (rs1800795) polymorphism is related with a bad response to tocilizumab (according to eular criteria). the aim of our study was to explore the potential role of il-6 genetic polymorphisms as a predictor of tocilizumab efficacy in rheumatoid arthritis (ra) patients and check this association depending on the genotype. setting and method: the il-6 (g[c) (rs1800795) genetic variant was genotyped using predesigned taqman ò genotyping assays technology and analysed on a viia7 ò real-time pcr system. main outcome measures: clinical response was evaluated at 3, 6, 9 and 12 months according to the eular criteria. patients were classified as ''responders'' (good and moderate response according to eular criteria) and ''non-responders''. the statistical analysis was performed using spss v.20. results: we recruited 163 patients with ra treated with tocilizumab, these were aged 54.02 ± 11.11 (mean ± sd), 132 (81%) were women. the mean das28 at baseline was 5.66 ± 1.14. of these 163 patients, the il-6 g[c genetic polymorphism was significantly associated with ''responders'' at 3 months after the baseline (cc vs non-cc p = 0.039, or 0.270, 95% ci 0.072-1.005) but not at 6 (p = 0.666), 9 (p = 0.233) and 12 (p = 0.244) months. conclusion: the il-6 g[c may be useful as a genetic marker of tocilizumab efficacy at 3 months. other polymorphisms, clinical parameters and other pharmacological treatment during the follow-up may be checked about their influence on the response to tocilizumab. tdmp014: daptomycin pk/pd profile in neutropenic cancer patients with beta-lactam-resistant gram-positive infection nancy perrottet *,1 , frederic tissot 2 , laurent decosterd 3 , thierry buclin 3 , guy prod'hom 4 , christina orasch 2 , oscar marchetti 2 , farshid sadeghipour 1,5 , thierry calandra 2 , véronique erard 2 1 pharmacy service, 2 infectious diseases service, 3 laboratory and division of clinical pharmacology, service of biomedicine, 4 institute of microbiology, lausanne university hospital, lausanne, 5 school of pharmaceutical sciences, university of geneva, university of lausanne, geneva, switzerland please specify your abstract type: research abstract background and objective: the pharmacokinetics (pk) and pharmacodynamics (pd) of many antibiotics are modified in neutropenic patients and few data are available on daptomycin in this population. this prospective study aimed to assess the pk/pd profile of daptomycin in the treatment of neutropenic patients with beta-lactamresistant gram-positive cocci infections. setting and method: this substudy was performed in the context of a prospective pilot study on daptomycin versus vancomycin in adult hemato-oncological patients with febrile neutropenia and proven or suspected infection with methicillin-resistant staphylococci or betalactam-resistant enterococci. patients received daptomycin 6 mg/ kg/day (8 mg/kg/day for enterococci) for c7 days as a 2-min infusion. main outcome measures: pk analysis using a published non-linear mixed effect model with nonmem ò , followed by comparison of parameters with values published for healthy subjects. pd analysis based on auc/mic (area under the concentration-time curve/minimal inhibitory concentration). according to eucast, an auc/mic ratio [438 is required for bacteriostatic effect against staphylococci and [800 for a two-log reduction in bacterial count. for e. faecium, an auc/mic ratio of 0.94 has been suggested for bacteriostasis and 4.14 for a 1-log bacterial count reduction. results: model-derived mean auc observed in 13 patients was 539.3 ± 340.1 mg h/l, maximum concentration (cmax) 88 ± 28 mg/ l, minimal concentration (cmin) 7.2 ± 6.7 mg/l. clearance was 0.98 ± 0.36 l/h and volume of distribution at steady sate 11.3 ± 3.3 l, both values found higher than those reported in healthy subjects. all patients (7/7) with a staphylococcal infection achieved auc/mic values predictive of bacteriostatic effect on staphylococci, and 6 out of 7 values associated with two-log bacterial killing. of note, infection relapse occurred in the only patient with suboptimal daptomycin exposure (auc/mic of 580). the pd targets were also reached in the two patients with e. faecium infection. an asymptomatic elevation of creatine phosphokinase was reported in two patients (568 u/l and 218 u/l) with cmin of 25.7 and 13.7 mg/l, respectively. conclusion: daptomycin pk profile in 13 neutropenic cancer patients indicated higher total clearance and volume of distribution, along with lower total exposure, compared to healthy subjects. despite this, standard dosages allowed attainment of pd targets in 6/7 patients with a staphylococcal infection (two-log drop) and 2/2 with e. faecium infection (1-log drop) . please specify your abstract type: research abstract background and objective: individual clinical response to infliximab can be influenced by their pharmacokinetics and immunogenicity, so therapeutic monitoring of drug levels (tdm) can guide these biologic treatments. the objective was to analyse the suitability of serum infliximab trough levels (sitls) in patients with inflammatory bowel diseases (ibd) receiving dose schemes based only on clinical response. setting and method: prospective and descriptive study of patients with ibd treated with infliximab and under tdm. medical records were reviewed. dose schemes were established according to clinical guidelines (5 mg/kg every 8 weeks) and optimized based on an index of clinical response (mayo, pcr…). sitls (therapeutic range 3-9 mcg/ml) and anti-drug antibodies (ada) were measured in all of patients by elisa (promonitor ò ). ada presence was considered as a therapeutic failure indicator. informed voluntary consent was obtained from all patients. main outcome measures: sitls and ada. results: a total of 61 patients, with a median age of 48 years (range ), were included in the analysis. infliximab standard dose according to clinical guidelines were administered to 39 patients: 46.1% showed sitls under the therapeutic range (11.1% with ada). in eight patients with maintained good clinical response, dose decrease or interval elongation had been implemented: 25% of these patients showed sitls below the therapeutic range (100% with ada). it had been necessary to increase the dose or shorten the interval in 14 patients due to inadequate clinical response: 28.6% of these patients with sitls below the therapeutic range (50% with ada). conclusion: optimization based on clinical response of infliximab treatments in patients with ibd is not always an effective strategy, since it leads to a high percentage of patients with sitls below the therapeutic range and adas. tdm together with clinical response should guide the optimization of infliximab treatments. please specify your abstract type: research abstract background and objective: in addition to its anticonvulsive properties, valproate is also used as a mood stabiliser in bipolar disorder and as augmentation treatment of other psychiatric disorders. the unpredictable relationship between dose-plasma valproate concentrations and correlation between concentrations-efficacy suggest therapeutic drug monitoring (tdm) of plasma valproate concentrations might be useful. the aim of our study was to evaluate the rationale of a new protocol for measuring valproate concentrations and the incorporation of a clinical pharmacist in the process of valproate tdm service, compared to pre-existing standard measuring. setting and method: in the retrospective study we analysed the process of measuring plasma valproate concentrations at the department of psychiatry and at the unit for forensic psychiatry of a large teaching hospital in slovenia before the enrolment of a clinical pharmacist. for the prospective study we created a protocol for tdm of valproate in adults based on literature research. the protocol included reference range, sampling time, indications for sampling and schedule of other laboratory tests that have to be monitored during valproate therapy. main outcome measures: percentage of plasma valproate concentrations in reference range (c trough = 50-125 mg/l) before/after the enrolment of a clinical pharmacist, percentage of measured valproate c trough . results: in the retrospective study 30 randomly chosen patients with measured plasma valproate concentrations were included (56% male, age 49 ± 15 years, length of hospital stay 56 ± 40 days). plasma valproate concentrations were measured 5.8 ± 4.4 times per patient, 22% were in the reference range (other 78% subtherapeutic), 3% were drawn at c though , 15.5% were drawn for assessing compliance (nontrough). in the prospective study 19 patients were included (37% male, age 46 ± 16 years, length of hospital stay 36 ± 22 days). plasma valproate concentrations were measured 2.95 ± 1.5 times per patient, 43% were in the reference range (other subtherapeutic), 71% were drawn at c trough , 14.3% were drawn for assessing compliance. conclusion: the inclusion of a clinical pharmacist in valproate tdm service increased the number of valproate plasma concentrations in the reference range by almost 100% and increased the number of concentrations drawn at c trough , when indicated. including a clinical pharmacist in valproate tdm is beneficial and the new protocol is useful for optimising valproate therapy. concurrent and predictive validity of a self-reported measure of medication adherence the effect of pharmacist-led interventions in optimising prescribing in older adults in primary care: a systematic review aflibercept: 1. neovascular membranes with visual acuity higher than 0.1 2. one eye affection severe cardiovascular pathology (severe episodes in the last 6 months) non-responders to other anti-vegf bevacizumab: 1. diabetic macular edema macular edema secondary to vascular pathology setting and method: a longitudinal study was carried out in primary care centres. participants: patients aged c65, under treatment with 5 or more drugs and belonging to 7 primary care areas in 5 different towns. patients should have at least one of the following potential safety problems: (a) concomitant use of a non-steroidal anti-inflammatory drug (nsaid) with an antihypertensive drug, anticoagulant or antithrombotic drug; (b) use of two or more benzodiazepines. two clinical management units (cmu) were randomized per area to be included in the study. thirty patients per cmu were randomized to be enrolled and monitored during 30 months number of adverse effects (0.40; p \ 0.001) and number of clinical problems (0.19; p \ 0.001).with each year increase in age 026) and a significant rise in physician (0.08; p \ 0.001) and nurse (0.06; p \ 0.001) home visits. women compared to men resulted in a significant decrease 043) but a significant increase in visits to nurses (0.43; p \ 0.001), hospital admissions (0.39; p \ 0.053) and hospital visits (0.35; p \ 0.030). age, sex and npsp had no significant effect on falls, fractures or cardiovascular events. conclusion: the npsp in elderly patients contributes to an increase in the use of health services and comorbidity. effective interventions should be addressed to general practitioners to reduce inappropriate prescriptions bpa was found in the dialysate (39 ng/l) and ls (1033 ng/l) wherein the concentration of bpa decreases over time to reach 265 ng/l at the end of a session. finally, bpa was present in all tested dialysis at concentrations of up to 149.0 ng/dialyzer in the compartment mimicking the blood and to 174.0 ng/dialyzer in the dialysate despite prior rinsing with 2l of 0.9% nacl. conclusion: our study is the first one to show the risk of exposure to bpa and bpa-clx hdf-ol. while assessment of the impact of this exposure in a patient under treatment remains to be done, it is now possible to better master contamination by bpa and its four chlorinated derivatives through better practices (choice of medical devices) and improvement of the overall water treatment process san cecilio university hospital, 2 genomic unit san cecilio university hospital, 2 genomic unit, genyo, centre for genomics and oncological research the aim of this study is to compare the apparition of stroke, acs, cardio-vascular death and the need of surgery in patients after percutaneous transluminal angioplasty (pta) or stroke depending on the presence of cyp2c19*2*3 polymorphisms. setting and method: retrospective cohort study. we recruited patients treated with clopidogrel after a pta of the lower limb or stroke (without surgery) from 2010 to 2013 in our hospital. data collected: age, sex, cyp2c19*2 (rs4244285) and cyp2c19*3 (rs4986893) genotypes and the primary end-point: stroke, acs, cv death and surgery of the affected vessel during 12 months after discharge. polymorphisms were genotyped using taqman ò genotyping assays technology. main outcome measures: we recruited 58 patients with stroke (62.07% men; mean age 68.30) and 72 patients after pta (77.7% men; mean age 67.44) treated with clopidogrel after discharge 8%) suffered the primary end-point during 12 months after discharge; 1 of these patients had the cyp2c19*2 allele. among patients with pta of the lower limb: 25% of them had the cyp2c19*2 allele and no one a cyp2c19*3 allele; 25 (34.72%) of these 72 patients suffered the primary end-point during 12 months after the discharge and 11 of these had the *2 allele of the cyp2c19 isoenzyme *2 allele and treated with clopidogrel have a higher risk of the primary end-point than those patients not carrying it spain please specify your abstract type: research abstract background and objective: the engagement of fcgrs by tnf antagonists could affect to macrophage-mediated clearance of immune-complexes. the aim of our study was to evaluate the potential role of fcgr3a (a[c) (rs366911) single nucleotide polymorphism (snp) as a predictor of tocilizumab efficacy in rheumatoid arthritis (ra) patients. setting and method: the fcgr3a (a[c) (rs366911) snp was genotyped using predesigned taqman ò genotyping assays technology and analysed on a viia7 ò real-time pcr system. the statistical analysis was performed using spss v the mean age of the patients was 53.25 ± 12.42 years and 79% were women. the mean das28 at baseline was 5.71 ± 1.13. we found no statistically significant association between our end-point and the genetic polymorphisms studied tdmp011: therapeutic drug monitoring of infliximab biosimilar and anti-infliximab antibodies in inflammatory diseases patients with dermatological conditions and inflammatory bowel disease being treated with ifx-b (5 mg/kg/8 weeks after the induction dose) were included. the concentrations of ifx-b and ati-b were quantified by two sandwich-type elisa immunoassays (triturus ò analyser). main outcome measures: plasma levels of ifx-b and ati-b, clinical response and infusion reactions. the clinical response was assessed according to pathology of each patient (based on specific clinical variables for the pathology into the electronic history) pharmacokinetic results (% assessments): (a) 30.0% no ifx-b detection (c \ 0.035 mcg/ml) and positive ati-b (c [ 2 ua/ml) (3 assessments/1 patient). atis = 114, 282 y 309 ua/ml. no clinical response (nr) in 66.6% assessments. (b) 10.0% ifx-b and ati-b (c b 2 ua/ml) no detection (1 assessments/1 patient). nr 0%. (c) 60.0% ifx-b detection (c [ 0.035 mcg/ml) and negative ati-b (6 1 assessments/4 patients) weight: 63 (21-90) kg. twenty assessments, 2.5 (1-5) assessments per patient, 4 (4-8) ifx-b doses, 80% concomitant treatment (16/16-azathioprine, 8/16-corticosteroid) the incidence of ati-b was low. a correlation was observed between the presence of ati-b and loss of clinical response, as infliximab original. tdmp012: serum concentration of non-vitamin k antagonist oral anticoagulants (noacs) in older hip fracture patients ina linnerud 1 , mette i martinsen 2 estimation of t of noacs by t1/2 = ln2/kel [kel; elimination constant] using two s-concentration measurements. results: we included 167 patients (median age 84 years, 73.1% women). noac use was detected be serum analysis in 11 patients (6.6%; 100% coherent with mr), while 15 patients (9.0%) used warfarin. 7 of the 11 noac users (63.6%) had s-concentrations of noacs above the reference range at admission, and five patients (45.5%) had s-concentrations within the reference range before surgery. patients using noac had significantly longer median waitingtime for surgery than warfarin-users (50 vs 36 h, p = 0.004). blood transfusions were given to 36.4% of noac-users vs 21.4% of warfarin-users (p = 0.651). mean estimated t of noacs were 33, 16.5 and 14.5 h for dabigatran (n = 2), apixaban (n = 4) and rivaroxaban (n = 2), respectively. conclusion: mr is effective in detecting noac use in older hip fracture patients, but importantly s-concentrations are higher than expected in this population. this might reflect the significantly longer waiting-time for surgery this column is supplied with packing material made of totally porous spherical silica coated with a silicone polymer monolayer containing octadecyl (c18) groups. the mobile phase was composed of 0.5% na 2 po 4 h 2 o (ph 2.5), acetonitrile, and methanol (55:25:20, v/v/v), which was degassed in an ultrasonic bath prior to use. the flow rate was 1.0 ml/min at ambient temperature and sample detection was carried out at 250 nm. plasma samples were obtained from 11 patients with cml receiving nilotinib treatment. sampling was performed at the steady state. blood samples were collected by venipuncture 24 h after oral administration of nilotinib. plasma was separated by centrifugation at 1900 9 g for 15 min and stored at -40°c until analysis. plasma samples (100 ll) were then extracted as described above. the same samples were also sent to a commercial laboratory (bml, inc.) for assaying nilotinib concentration by liquid chromatography-tandem mass spectrometry (lc-ms/ms). in addition, we applied this method to tdm of cml patients receiving nilotinib at our hospital. main outcome measures: the calibration curve exhibited linearity over the nilotinib concentration range of 50-2500 ng/ml at 250 nm, with relative standard deviations (n = 5) of 7.1, 2.5, and 2.9% for 250, 1500, and 2500 ng/ml, respectively. the detection limit for nilotinib was 5 ng/ml due to three blank determinations (q = 3). in addition, we compared the results with those measured by lc-ms/ ms at bml, inc. (a commercial laboratory). as a result, a strong correlation was observed between the nilotinib concentrations measured by our hplc method and those obtained by lc/ms-ms (r 2 = 0.988, p \ 0.01). in addition, tdm of nilotinib was performed to six cml patients. there was the case which participated in dosage adjustment of nilotinib in hepatic dysfunction and poor glycaemic control. results: we have developed a simple ultraviolet detection method for the determination of nilotinib, which has high sensitivity and large dynamic range please specify your abstract type: research abstract key: cord-282202-q2q4vies authors: banerjee, amitava; katsoulis, michail; lai, alvina g.; pasea, laura; treibel, thomas a.; manisty, charlotte; denaxas, spiros; quarta, giovanni; hemingway, harry; cavalcante, joão l.; noursadeghi, mahdad; moon, james c. title: clinical academic research in the time of corona: a simulation study in england and a call for action date: 2020-08-13 journal: plos one doi: 10.1371/journal.pone.0237298 sha: doc_id: 282202 cord_uid: q2q4vies objectives: we aimed to model the impact of coronavirus (covid-19) on the clinical academic response in england, and to provide recommendations for covid-related research. design: a stochastic model to determine clinical academic capacity in england, incorporating the following key factors which affect the ability to conduct research in the covid-19 climate: (i) infection growth rate and population infection rate (from uk covid-19 statistics and who); (ii) strain on the healthcare system (from published model); and (iii) availability of clinical academic staff with appropriate skillsets affected by frontline clinical activity and sickness (from uk statistics). setting: clinical academics in primary and secondary care in england. participants: equivalent of 3200 full-time clinical academics in england. interventions: four policy approaches to covid-19 with differing population infection rates: “italy model” (6%), “mitigation” (10%), “relaxed mitigation” (40%) and “do-nothing” (80%) scenarios. low and high strain on the health system (no clinical academics able to do research at 10% and 5% infection rate, respectively. main outcome measures: number of full-time clinical academics available to conduct clinical research during the pandemic in england. results: in the “italy model”, “mitigation”, “relaxed mitigation” and “do-nothing” scenarios, from 5 march 2020 the duration (days) and peak infection rates (%) are 95(2.4%), 115(2.5%), 240(5.3%) and 240(16.7%) respectively. near complete attrition of academia (87% reduction, <400 clinical academics) occurs 35 days after pandemic start for 11, 34, 62, 76 days respectively—with no clinical academics at all for 37 days in the “do-nothing” scenario. restoration of normal academic workforce (80% of normal capacity) takes 11, 12, 30 and 26 weeks respectively. conclusions: pandemic covid-19 crushes the science needed at system level. national policies mitigate, but the academic community needs to adapt. we highlight six key strategies: radical prioritisation (eg 3–4 research ideas per institution), deep resourcing, non-standard leadership (repurposing of key non-frontline teams), rationalisation (profoundly simple approaches), careful site selection (eg protected sites with large academic backup) and complete suspension of academic competition with collaborative approaches. number of full-time clinical academics available to conduct clinical research during the pandemic in england. in the "italy model", "mitigation", "relaxed mitigation" and "do-nothing" scenarios, from 5 march 2020 the duration (days) and peak infection rates (%) are 95(2.4%), 115(2.5%), 240 (5.3%) and 240(16.7%) respectively. near complete attrition of academia (87% reduction, <400 clinical academics) occurs 35 days after pandemic start for 11, 34, 62, 76 days respectively-with no clinical academics at all for 37 days in the "do-nothing" scenario. restoration of normal academic workforce (80% of normal capacity) takes 11, 12, 30 and 26 weeks respectively. the pandemic sars-cov-2 virus (causing the disease, is unprecedented in its impact on individuals, populations and health systems [1] . since the first cases in wuhan, china in november 2019, every country has been affected [2, 3] but with wide variations in the ability and capacity to respond, with only half estimated to have operational readiness [4] . countries hit later can benefit and learn from acquired knowledge and experience of preceding countries. as part of this response, the research effort is crucial for development, testing and adoption of effective preventative and treatment [5, 6] . a pubmed search (november 2019 to april 2020), using terms "coronavirus" and "covid-19" showed 2206 and 1604 articles respectively, suggesting swift global research mobilisation. however, the publication mix shows the vast majority are reviews, opinions and commentary rather than formal research. many publications on covid-19 are not clinically led, and many are not directly clinically informed. "learning is difficult in the midst of an emergency" [7] , but our ability to deliver timely, high-impact clinical research, relevant to patients and populations, is critical across the academic spectrum [8] , from "bench to bedside to big data", whether basic biology, repurposed and novel therapeutic approaches, vaccines or modelling. obstacles to and strategies for delivering research during a pandemic are poorly characterised. anecdotally, many countries have a baseline shortage of clinical academics in translational science [9] and many leading pathfinder health institutions are within major international transport hubs (london, madrid, new york), which are affected early in the pandemic. lockdowns close university departments and funding bodies, with alternative funding sources (charities, philanthropy) hit by stockmarket falls and competing demand. frontline remoteness impedes communication of urgency to decision makers, themselves usually selected for process delivery rather than dynamic adaptability. critical researchers with relevant virology/immunological/intensive care knowledge are drawn in to local or national clinical responses. other academic staff most likely to redeploy to covid-19 research self-select for immediate response roles [10] with universities prioritising repurposing to frontline care [11] . high disease rates, required self-isolation periods [12, 13] and distractions of remote working degrade the focus needed to create new or repurposed research delivery structures. we therefore wanted to understand the pandemic research process and describe early lessons. our aims were to: (i) model potential impact of the pandemic on clinical academic capacity in england relating to covid-19; and (ii) develop evidence-based recommendations to inform the optimal scientific response to covid-19. based on our previous analysis of covid-19 cases and excess deaths in england [14] , we considered four scenarios of government interventions associated with different levels of population infection rates: 80% ("do-nothing"), 40% ("relaxed mitigation"), 10% ("mitigation") and 6% ("italy model"), since "partial suppression"(1%) and "full suppression"(0.001%) were no longer feasible. the analyses of excess deaths used data in a cohort design with prospective recording and follow-up from the clinical research using linked bespoke studies and electronic health records (caliber) open research platform with validated, reusable definitions of several hundred underlying conditions [15, 16] , linking electronic health records(ehr) from different data sources (via uk unique individual identification data, nhs numbers): primary care (clinical practice research datalink-gold), hospital care (hospital episodes statistics), and death registry (office of national statistics). approval was via the independent scientific advisory committee (16_022r) of the medicines and healthcare products regulatory agency in the uk in accordance with the declaration of helsinki. key variables were population infection rate, background mortality risk based on underlying conditions, and relative risk (rr) of mortality associated with covid-19. we used real-time data until 7 april 2020 for the number of confirmed cases and deaths [17] . we designed and implemented a simple stochastic model to predict number of new cases in the population. since the number of new cases are proportional to the active cases of the previous date (see web appendix), we used official data from 10 april and calculated the ratio new confirmed cases of day n active confirmed cases of day ðnà 1þ from 5 march onwards. we explored four different scenarios of growth of the infection curve, reflecting different government policies (do-nothing, relaxed mitigation, mitigation and the italy model), from april 10 (day 36 in our study which coincides with the date of the analysis) until day 250, see web s1 table in s1 file. we assumed that an individual remains infected for 2 weeks, followed by death or immunity, and that actual cases were~20 times more than confirmed cases, as people with mild or no symptoms are not routinely tested(based on prior estimates of 5-to 100-fold) [18] . further details are specified in the web appendix. we used nhs digital data (december 2019) to quantify number of doctors in england (n = 125,119) [19] . baseline number of clinical academics was estimated as 5% of doctors [20]: 6255 in england. based on uk clinical academic funding [21] , we assumed 50% fte (full time equivalent) overall, equivalent to~3000 100% fte academics, and 25% of doctors off sick and/or socially isolating at any time [22] . there are 1953 intensive care, 7678 emergency medicine, 395 infectious diseases and 2748 respiratory doctors in england [19] . we assumed doctors of any specialty could contribute to the covid-19 academic response, and necessary research skills and training were homogeneously available throughout the medical workforce. clinical academics are not available for research if: (i) they are delivering frontline care due to health system strain, or (ii) they are off sick. we modelled two scenarios with no medical academic capacity at 10% (low strain on the health system) and 5% (high strain on the health system) infection rates respectively. our outcome was the available number of medical academics during the pandemic in england. we assumed that the number of potentially available 100% fte clinical academics in research is 3200, but it is obvious that this number has decreased from the early days of the covid-19 pandemic. we present in detail the assumptions of modelling of available clinical academics in the web appendix. 1. northern italy: gq provided first-hand experience of the pandemic as a physician in bergamo, italy. 2. health care worker (hcw) cohort study: our team recently set up and started recruitment for the "healthcare worker bioresource: immune protection and pathogenesis in sars-cov-2" study (covid-hcw; nct04318314) [23] . 3. nightingale hospital: a new nhs field hospital has been established, providing extra medical and intensive care capacity for provision of care to covid-19 patients with a maximum theoretical capacity of 4000 beds, mainly intensive care [24] . we describe the scenario, staff involved and clinical and research priorities, and constraints. based on our model and our case studies, we have developed pragmatic recommendations for clinical research priorities relating to covid-19. study approval was granted by the independent scientific advisory committee (16_022r) of the medicines and healthcare products regulatory agency in the uk in accordance with the declaration of helsinki. assuming the "low strain on the health system" model (where there is no academic capacity at population infection rate of 10%), fig 2 shows that less than 400 100%fte clinical academics (~13%) will available after april 10 for 11, 34, 62, 76 days for the scenarios of "italy model", "mitigation", "relaxed mitigation" and "do-nothing" respectively. in the "do nothing scenario", no clinical academics are available to do research for 37 days (3/5/2020 to 8/6/2020). the predicted dates to reach 2560 clinical academics (80% normal capacity) are 23/6/2020, 1/7/2020, 3/11/2020 and 10/10/2020 for the scenarios of "italy model", "mitigation", "relaxed mitigation", and "do-nothing", respectively. in the "high strain on the health system" model (where there is no academic capacity at population infection rate of 5%), in the "relaxed mitigation" scenario, no clinical academics can do research for 18 days (13/5/2020 to 30/5/2020) and in the "do-nothing" scenario, from 23/4/2020 to 28/6/2020. the predicted dates to reach 2560 clinical academics (80% normal capacity) is 23/6/2020, 2/7/2020, 7/11/2020 and 11/10/2020 for the scenarios of "italy model", "mitigation", "relaxed mitigation", and "do-nothing" respectively. northern italy. as the first western region to be affected (lombardy, bergamo) there was effectively no warning. almost overnight a huge surge of severely ill patients hit us. it was the beginning of a nightmare. with no approved treatments, we had to re-organize the hospital wards, itu beds, transform simple general into sub-intensive units, commit all doctors from all specialities and research to covid-19 in a matter of hours-days. it was "catastrophe medicine", research was impossible and approaches were empiric based on analogy to other diseases. autopsy was our only science. "mors ubi gaudet succurrere vitae-where the dead are happy to help the living" and we started to appreciate the high rate of thrombotic complications and pulmonary pathology, initiating empiric anticoagulation and corticosteroids. only weeks later with external partnerships were formal randomized trials initiated. the covid-hcw study. italy informed our strategy. the team nucleus was 5 senior lecturers and 1 professor, all of whom had all their clinical work stopped as irrelevant in the pandemic (cardiac mri) and who had a track record of monthly large grant writing and detailed systems knowledge. the hospital had no emergency department, so it was protected with a large institution behind it. "exponential teams" were created to deliver national and local components of research permissions-permissions took 100 documents and~40 staff working at least part-time to deliver in 7 days (covid-consortium.com). following scoping, we rejected all but the most basic of aspirations: to capture (questionnaire, bloods and nasal swab) 400 hcw and track changes over 16 weeks-no clinical trial of an investigational medicinal product (ctimp) and no direct work with covid-19 patients. by day 16 from concept, 400 hcws had been recruited and the study was in follow-up. at this stage, funding, aliquoting, and detailed basic science plans were embarked on [23] . nightingale hospital. the nightingale hospital was the largest field hospital in europe with the largest number of intensive care and step-down facilities for covid-19. it was set up in 14 days from initial concept to first patient admitted nightingale is a learning system, underpinned by research. for patients, staff and wider nhs benefit, the design incorporates a commitment to learning fast and acting fast across all dimensions: clinical, operational, and staff wellbeing. our research approach is: (i) embedded within the quality and learning team, (ii) simple; and (iii) high-quality and high-volume recruitment. the onsite team is backed up by qmul, ucl and uclp, with multidisciplinary expertise, including virology, immunology and therapeutics. from an initial two clinical academic staff (ab and jm), a research governance structure has been set up rapidly and a simple strategy has been established. covid-19 consented studies can be observational or interventional (drugs), in patients or staff. we plan just one initial study in each domain, choosing the simplest possible approaches: patient observational(isaric), patient therapeutic(recovery), staff observational (covid-hcw with expansion to n = 1000) and staff therapy (pre-and/or post-exposure prophylaxis studies-to be confirmed]). the first patient therapeutic trial patient will be recruited on day 8 after first patient admitted. other studies (data, staff surveys) can be conducted at other sites (table 1) or after the initial exponential wave peaks. in addition, there are opportunities for non-consented research, such as epidemiologic and advanced data analytics; e.g. initiatives such as decovid [25] to mobilise data, computer scientists, analysts and analytic infrastructure, including and clinical expertise. there is potential to link effective learning directly to and from clinical questions. after discussion among co-authors, and consensus among a stakeholder group at the nightingale hospital, we produced recommendations for a covid-19 clinical research strategy ( table 2 ). in the first study of clinical academic capacity in the covid-19 era, we show the existential threat to research responses facing the uk and other countries. urgent recognition and mobilisation are required to ensure prioritisation of the most appropriate and clinically imperative science. we have developed recommendations relevant to all health systems. the healthcare and public health emergency caused by covid-19 is not in question, fuelling global discussion, modelling and multidisciplinary research at a pace rarely seen [26, 27] . however, strain on clinical academic workforce and infrastructure in different countries are notable omissions. despite programmes to promote research preparedness in epidemics, covid-19 poses particular challenges [28] to our responses which rest ultimately on research, whether vaccines, drugs, ventilation strategies, risk prediction or machine learning. our experiences are echoed in china, italy and other countries facing the pandemic. a. data analysis using existing systems b. simple delivery of samples 4. resourcing: profound project resourcing to deliver-essentially exponentially more staff than usual (e.g. estimate of up to 50 people per project immediately). a. clinical research: in the community or in large academic health centres b. basic science: using teams without clinical or basic science transferable skills for covid-19 work, and protecting research workers from clinical service duties. 6. dissemination: across uk and internationally to those considering covid-19 clinical research. data sharing and collaboration both nationally and internationally. https://doi.org/10.1371/journal.pone.0237298.t002 there have been quick efforts and advances in fields as diverse as genomics [29] and data science [30] , with rapid-response calls from major funders [5, [31] [32] [33] . however, our data signal a need for a far broader paradigm shift in research design and implementation. at every stage in the traditional research pipeline, there are roadblocks hampering swift reactions necessary to tackle covid-19 within and across countries. even on a "war footing", research processes are unnecessarily time-and resource-consuming, particularly when involving randomized controlled studies. specific hurdles are: (i) staff -doctors and research nurses, but also access to labs; (ii) stuff-consumables difficult to obtain due to challenging supply chains especially if they are competing with clinical service delivery, e.g. personal protective equipment; (iii) siteideally research space near to clinical areas; and systems-approvals in a timely fashion, e.g. research ethics committee, health research authority, local research and development team and standard operating procedures ins relevant institutions. emergencies as far-reaching as the current scenario require total rethinking of research delivery, and aspects that work better when some of the processes are accelerated and the permissions expedited, may well yield long-term benefits outside of covid-19 research. here we have modelled clinical academic time in terms of numbers of staff and time in the pandemic. however, a far deeper examination of the role of clinical academics beyond "hours at the desk" is warranted in times of public health emergency to include the "what" and "how" of their work. for example, certain tasks such as research permissions and data analysis may be diverted away from clinical academics, who may be better placed to act as conduits between the clinical and public health spheres and teams of non-clinical researchers. the needs of the hour are patient-centred, data-driven and time-responsive, and it may be time to usefully change the role and function of the clinical academic. it is worth noting that this is occurring against a backdrop of declining clinical academic numbers [21] . our simulations suggest the pandemic will create health system strain for many critical months. depending on a range of covid-related factors, we show that the clinical academic workforce may be depleted when it is needed most to lead and conduct clinical research, even in a relatively well-resourced context such as the uk, whether by funding, number of universities and staff, infrastructure or policy. therefore, other countries are likely to be worse affected. covid-19 research is least likely to occur where it is most needed, magnifying the well-documented "10-90 research gap", where only 10% of resources for global healthcare research are devoted to low-income settings where 90% of preventable deaths occur [34] . although covid-19 is a unique threat, there are lessons to be learned from prior health research strategies to address structural inequities, such as the global fund for malaria, tb and hiv/aids [29] . without coordinated international responses, including urgent funding and infrastructure, research will be retrospective, patchy and unlikely to have an effect. we provide six clear recommendations for science in the uk and globally in relation to covid-19 (radical prioritisation, leadership, rationalisation, resourcing, careful site selection and dissemination). radical prioritisation is important where field hospitals are being established in rapid timescales in different countries with delivery constraints. high-quality evidence can be obtained, but studies need to be lean with minimal complexity for key operational steps: consenting, randomisation, drug delivery, monitoring, outcomes and follow-up. the number of patients recruited to deliver definitive answers needs to be large, with fast recruitment across multiple sites. furthermore, adaptive trial designs are preferred as new arms (e.g. multi-drug) can be generated swiftly and other arms dropped (e.g. supportive care if one arm has a signal of efficacy) without restarting permissions, via substantial amendments [35, 36] . leadership and rationalisation are the next key steps. balance needs to be struck between clinical researchers in contact with the "frontline" so that research questions are clinically relevant and timely, and having research active leaders who will not be protected from frontline work. rationalisation involves a study selection strategy that is deeply resourced for a limited number (1 or 2) studies per covid cohort. in selecting these studies, a single study of one investigational medical product versus standard of care (supportive care) with 50:50 randomisation is inefficient compared to studies with multiple therapeutic arms. most single agent approaches to covid-19 are likely to have, at most, a modest effect. we used a stochastic model accounting for infection rate, infection growth rate and clinical academic capacity using up-to-date official statistics. there are limitations to our model and its assumptions. our model was simple and was based only on observational patterns of the number of new cases and actual cases from publicly available data [17] . we conducted analyses on 10 april, and on 11 april, some extra~3000 cases were added retrospectively and distributed over the past 10 days-we did not include these data. it did not take into account infectious disease epidemiology parameters, such as the basic reproductive number (r0), and we did not consider differing levels of risk of infection [37] [38] [39] . our model on the availability of clinical academics makes several assumptions (web appendix), including the total number of 100% fte academics as~3200, with a uniform skillset across the workforce. in the first study to model and estimate the impact of covid-19 on the coordinated clinical academic response at system level, we show that all countries face depletion of their clinical academic workforce for several months, which will greatly hamper research in prevention and treatment. the number of studies needs to be rationalised urgently and background problems in clinical academia need to be overcome quickly. to quote sir jeremy farrar, "the only exit from this pandemic is through science" [40] and that requires staffing. novel coronavirus and old lessons-preparing the health system for the pandemic early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study health security capacities in the context of covid-19 outbreak: an analysis of international health regulations annual report data from 182 countries wellcome statements on novel coronavirus (covid-19 covid-19: real-time dissemination of scientific information to fight a public health emergency of international concern thinking globally, acting locally-the u.s. response to covid-19 a call for action to establish a research agenda for building a future health workforce in europe academic factors in medical recruitment: evidence to support improvements in medical recruitment and retention by improving the academic content in medical posts royal college of physicians. covid-19 and its impact on nhs workforce clinical academics freed up to support nhs during covid-19 pandemic protecting healthcare personnel from 2019-ncov infection risks: lessons and suggestions. front med covid-19: protecting health-care workers estimating excess 1-year mortality from covid-19 according to underlying conditions and age in england: a population based cohort using nhs health records in 3.8 million adults uk phenomics platform for developing and validating electronic health record phenotypes: caliber a chronological map of 308 physical and mental health conditions from 4 million individuals in the english national health service. lancet digit health covid-19 coronavirus pandemic country estimates: uk. 5 a fiasco in the making? as the coronavirus pandemic takes hold, we are making decisions without reliable data. statnews nhs digital workforce statistics one in four nhs doctors 'sick or in isolation covid-19: healthcare worker bioresource: immune protection and pathogenesis in sars-cov-2 (covid19-hcw coronavirus: nightingale hospital opens at london's excel centre call for covid-19 rapid response data science taskforce locally informed simulation to predict hospital capacity needs during the covid-19 pandemic projecting demand for critical care beds during covid-19 outbreaks in canada international severe acute respiratory and emerging infection consortium genomic diversity of sars-cov-2 in coronavirus disease 2019 patients modified seir and ai prediction of the epidemics trend of covid-19 in china under public health interventions operational and implementation research within global fund to fight aids, tuberculosis and malaria grants: a situation analysis in six countries. global health announcing the covid-19 therapeutics accelerator coronavirus news, funding and resources for global health researchers the developing world in the randomised evaluation of covid-19 therapy adaptive platform trial for community-acquired pneumonia the effect of control strategies to reduce social mixing on outcomes of the covid-19 epidemic in wuhan, china: a modelling study early dynamics of transmission and control of covid-19: a mathematical modelling study estimates of the severity of coronavirus disease 2019: a model-based analysis opinion: the only exit from this pandemic is through science. we must fund it. globe and mail key: cord-026031-hnf5vayd authors: ford, richard b.; mazzaferro, elisa m. title: emergency care date: 2009-05-21 journal: kirk and bistner's handbook of veterinary procedures and emergency treatment doi: 10.1016/b0-72-160138-3/50002-3 sha: doc_id: 26031 cord_uid: hnf5vayd nan in the event that you suspect peritonitis and have a negative tap with abdominal paracentesis, a diagnostic peritoneal lavage can be performed. to perform abdominal paracentesis, follow this procedure: 1. place the patient in left lateral recumbency and clip a 4-to 6-inch square with the umbilicus in the center. 2. aseptically scrub the clipped area with antimicrobial scrub solution. 3. wearing gloves, insert a 22-or 20-gauge needle or over-the-needle catheter in four quadrants: cranial and to the right, cranial and to the left, caudal and to the right, and caudal and to the left of the umbilicus. as you insert the needle or catheter, gently twist the needle to push any abdominal organs away from the tip of the needle. local anesthesia typically is not required for this procedure, although a light sedative or analgesic may be necessary if severe abdominal pain is present. in some cases, fluid will flow freely from one or more of the needles. if not, gently aspirate with a 3-to 6-ml syringe or aspirate with the patient in a standing position. avoid changing positions with needles in place because iatrogenic puncture of intraabdominal organs may occur. 4. save any fluid collected in sterile red-and lavender-topped tubes for cytologic and biochemical analyses and bacterial culture. monitor hemorrhagic fluid carefully for the presence of clots. normally, hemorrhagic effusions rapidly become defibrinated and do not clot. clot formation can occur in the presence of ongoing active hemorrhage or may be due to the iatrogenic puncture of organs such as the spleen or liver. if abdominal paracentesis is negative, a diagnostic peritoneal lavage can be performed. peritoneal dialysis kits are commercially available but are fairly expensive and often impractical. to perform a diagnostic peritoneal lavage, follow this procedure: 1. clip and aseptically scrub the ventral abdomen as described previously. 2. wearing sterile gloves, cut multiple side ports in a 16-or 18-gauge over-the needle catheter. use care to not cut more than 50% of the circumference of the catheter, or else the catheter will become weakened and potentially can break off in the patient's abdomen. 3. insert the catheter into the peritoneal cavity caudal and to the right of the umbilicus, directing the catheter dorsally and caudally. 4. infuse 10 to 20 ml of sterile lactated ringer's solution or 0.9% saline solution that has been warmed to the patient's body temperature. during the instillation of fluid into the peritoneal cavity, watch closely for signs of respiratory distress because an increase in intraabdominal pressure can impair diaphragmatic excursions and respiratory function. 5. remove the catheter. 6. in ambulatory patients, walk the patient around while massaging the abdomen to distribute the fluid throughout the abdominal cavity. in nonambulatory patients, gently roll the patient from side to side. 7. next, aseptically scrub the patient's ventral abdomen again, and perform an abdominal paracentesis as described previously. save collected fluid for culture and cytologic analyses; however, biochemical analyses may be artifactually decreased because of dilution. remember that you likely will retrieve only a small portion of the fluid that you instilled. during the early stage of repair, granulation tissue, some exudate, and minor epithelialization is observed. place a nonadherent bandage with some antibacterial properties (petroleum or nitrofurazone-impregnated gauze) or absorbent material (foam sponge, hydrogel, or hydrocolloid dressing) in direct contact with the wound to minimize disruption of the granulation tissue bed. next, place an absorbent intermediate layer, followed by a porous outer layer, as previously described. granulation tissue can grow through gauze mesh or adhere to foam sponges and can be ripped away at the time of bandage removal. hemorrhage and disruption of the granulation tissue bed can occur. later in the repair process, granulation tissue can exude sanguineous drainage and have some epithelialization. a late nonadherent bandage is required. the contact layer should be some form of nonadherent dressing, foam sponge, hydrogel, or hydrocolloid substance. the intermediate layer and outer layers should be absorbent material and porous tape, respectively. with nonadherent dressings, wounds with viscous exudates may not be absorbed well. this may be advantageous and enhance epithelialization, provided that complications do not occur. infection, exuberant granulation tissue, or adherence of absorbent materials to the wound may occur and delay the healing process. moist healing is a newer concept of wound management in which wound exudates are allowed to stay in contact with the wound. in the absence of infection a moist wound heals faster and has enzymatic activity as a result of macrophage and polymorphonuclear cell breakdown. enzymatic degradation or "autolytic debridement" of the wound occurs. moist wounds tend to promote neutrophil and macrophage chemotaxis and bacterial phagocytosis better than use of wet-to-dry bandages. a potential complication and disadvantage of moist healing, however, is the development of bacterial colonization, folliculitis, and trauma to wound edges that can occur because of the continuously moist environment. use surfactant-type solutions (constant clens; kendall, mansfield, massachusetts) for initial wound cleansing and debridement. use occlusive dressings for rapid enzymatic debridement with bactericidal properties to aid in wound healing. bandage wet necrotic wounds with a dressing premoistened with hypertonic saline (curasalt [kendall] , 20% saline) to clean and debride the wounds. hypertonic saline functions to desiccate necrotic tissue and bacteria to debride the infected wound. remove and replace the hypertonic saline bandage every 24 to 48 hours. next, place gauze impregnated with antibacterial agents (kerlix amd [kendall] ) over the wound in the bandage layer to act as a barrier to bacterial colonization. if the wound is initially dry or has minimal exudate and is not obviously contaminated or infected, place amorphous gels of water, glycerin, and a polymer (curafil [kendall] ) over the wound to promote moisture and proteolytic healing. discontinue moisture gels such as curafil once the dry wound has become moist. finally, the final stage of moist healing helps to promote the development of a healthy granulation tissue bed. use calcium alginate dressings (curasorb or curasorb zn with zinc [kendall] ) in noninfected wounds with a moderate amount of drainage. alginate gels promote rapid development of a granulation tissue bed and epithelialization. foam dressings also can be applied to exudative wounds after a healthy granulation bed has formed. change foam dressings at least once every 4 to 7 days. for closed wounds without any drainage, such as a laceration that has been repaired surgically, a simple bandage with a nonadherent contact layer (telfa pad [kendall] , for example), intermediate layer of absorbent material, and an outer porous layer (elastikon, vetrap) can 1 be placed to prevent wound contamination during healing. the nonadherent pad will not stick to the wound and cause patient discomfort. because there usually is minimal drainage from the wound, the function of the intermediate layer is more protective than absorptive. any small amount will be absorbed into the intermediate layer of the bandage. it is important in any bandage to place the tape strips or "stirrups" on the patient's limb and then overlap in the bandage, to prevent the bandage from slipping. place the intermediate and tertiary layers loosely around the limb, starting distally and working proximally, with some overlap with each consecutive layer. this method prevents excessive pressure and potential to impair venous drainage. leave the toenails of the third and fourth digits exposed, whenever possible, to allow daily examination of the bandage to determine whether the bandage is impairing venous drainage. if the bandage is too tight and constricting or impeding vascular flow, the toes will become swollen and spread apart. when placed and maintained properly (e.g., the bandage does not get wet), there usually are relatively few complications observed with this type of bandage. in some cases, it is necessary to cover a wound in which a penrose drain has been placed to allow drainage. in many cases, there is a considerable amount of drainage from the drain and underlying soft tissues. the function of the bandage is to help obliterate dead space created by the wound itself, absorb the fluid that drains from the wound and that will contaminate the environment, and prevent external wicking of material from the external environment into the wound. when the bandage is removed, the clinician can examine the amount and type of material that has drained from the wound in order to determine when the drain should be removed. when placing a bandage over a draining wound, the contact layer should be a commercially available nonadherent dressing and several layers of absorbent wide-mesh gauze placed directly over the drain at the distal end of the incision. overlay the layers of gauze with a thick layer of absorbent intermediate dressing to absorb fluid that drains from the wound. if the gauze and intermediate layers are not thick or absorbent enough, there is a potential for the drainage fluid to reach the outer layer of the bandage and provide a source of wicking of bacteria from the external environment into the wound, leading to infection. some wounds such as lacerations have minor bleeding or hemorrhage that require an immediate bandage until definitive care can be provided. to create a pressure bandage, place a nonadherent dressing immediately in contact with the wound, followed by a thick layer of absorbent material, topped by a layer of elastic bandage material such as elastikon or vetrap. unlike the bandage for a closed wound, the top tertiary outer layer should be wrapped with some tension and even pressure around the limb, starting from the distal extremity (toes) and working proximally. the pressure bandage serves to control hemorrhage but should not be left on for long periods. pressure bandages that have been left on for too long can impair nerve function and lead to tissue necrosis and slough. therefore, pressure bandages should be used in the hospital only, so that the patient can be observed closely. if hemorrhage through the bandage occurs, place another bandage over the first until the wound can be repaired definitively. removal of the first bandage will only disrupt any clot that has formed and cause additional hemorrhage to occur. fractures require immediate immobilization to prevent additional patient discomfort and further trauma to the soft tissues of the affected limb. as with all bandages, a contact layer, intermediate layer, and outer layer should be used. place the contact layer in accordance 1 with any type of wound present. the intermediate layer should be thick absorbent material, followed by a top layer of elastic bandage material. an example is to place a telfa pad over a wound in an open distal radius-ulna fracture, followed by a thick layer of cotton gauze cast padding, followed by an elastic layer of kling (johnson & johnson medical, arlington, texas) , pulling each layer tightly over the previous layer with some overlap until the resultant bandage can be "thumped" with the clinician's thumb and forefinger and sound like a ripe watermelon. the bandage should be smooth with consecutive layers of even pressure on the limb, starting distally and working proximally. leave the toenails of the third and fourth digits exposed to monitor for impaired venous drainage that would suggest that the bandage is too tight and needs to be replaced. finally, place a top layer of vetrap or elastikon over the intermediary layer to protect it from becoming contaminated. if the bandage is used with a compound or open fracture, drainage may be impaired and actually lead to enhanced risk of wound infection. bandages placed for initial fracture immobilization are temporary until definitive fracture repair can be performed once the patient's cardiovascular and respiratory status are stable. wounds with exuberant granulation tissue must be handled carefully so as to not disrupt the healing process but to keep an overabundance of tissue from forming that will impair epithelialization. to bandage a wound with exuberant granulation tissue, place a corticosteroid-containing ointment on the wound, followed by a nonadherent contact layer. the corticosteroid will help control the exuberant growth of granulation tissue. next, carefully wrap an absorbent material over the contact layer, followed by careful placement of and overlay of elastic bandage material to place some pressure on the wound. leave the toenails of the third and fourth digits exposed so that circulation can be monitored several times daily. bandages that are too tight must be removed immediately to prevent damage to neuronal tissue and impaired vascularization, tissue necrosis, and slough. because wound drainage may be impaired, there is a risk of infection. gaping wounds or those that have undermined in between layers of subcutaneous tissue and fascia should be bandaged with a pressure bandage to help obliterate dead space and prevent seroma formation. an example of a wound that may require this type of bandage is removal of an infiltrative lipoma on the lateral or ventral thorax. use caution when placing pressure bandages around the thorax or cervical region because bandages placed too tightly may impair adequate ventilation. to place a pressure bandage and obliterate dead space, place a nonadherent contact layer over the wound. usually, a drain is placed in the wound, so place a large amount of wide-mesh gauze at the distal end of the drain to absorb any wound exudate or drainage. place several layers of absorbent material over the site to further absorb any drainage. place a layer of elastic cotton such as kling carefully but firmly over the dead space to cause enough pressure to control drainage. place at least two fingers in between the animal's thorax and the bandage to ensure that the bandage is not too tight. in many cases, the bandage should be placed once the animal has recovered from surgery and is able to stand. if the bandage is placed while the animal is still anesthetized and recumbent, there is a tendency for the bandage to be too tight. finally, the tertiary layer should be an elastic material such as elastikon or vetrap. many wounds require a pressure relief bandage to prevent contact with the external environment. wounds that may require pressure relief for healing include decubitus ulcers, pressure bandage or cast ulcers, impending ulcer areas (such as the ileum or ischium of recumbent or cachexic patients), and surgical repair sites of ulcerated areas. pressure relief bandages can be of two basic varieties: modified doughnut bandage and doughnut-shaped bandage. to create a cup or clamshell splint, follow this procedure (figures 1-7 to 1-11): 1. place a nonadherent contact layer directly over the wound. 2. place stirrups of tape in contact with the skin of the dog, to be placed over the intermediate layer and prevent the bandage from slipping. 3. place a fairly thick layer of absorbent intermediate bandage material over the contact layer such that the bandage is well-padded. pull the tape stirrups and secure them to the intermediate layer. 4. place a length of cast material that has been rolled to the appropriate length, such that the cast material is cupped around the patient's paw, and lies adjacent to the caudal aspect of the limb to the level of the carpus or tarsus. in the case of a clamshell splint, place a layer of cast material on the cranial and caudal aspect of the paw and conform it in place. 5. take the length of cast padding and soak it in warm water after it has been rolled to the appropriate length. wring out the pad, and secure/conform it to the caudal (or cranial and caudal, in the case of a clamshell splint) aspect of the distal limb and paw. 6. secure the cast material in place with a layer of elastic cotton gauze (kling). 7. secure the bandage in place with a snug layer of elastikon or vetrap. short or long splints made of cast material can be incorporated into a soft padded bandage to provide extra support of a limb above and below a fracture site. for a caudal or lateral splint to be effective, it must be incorporated for at least one joint above any fracture site to prevent a fulcrum effect and further disruption or damage to underlying soft tissue structures. a short lateral or caudal splint is used for fractures and luxations of the distal metacarpus, metatarsus, carpus, and tarsus. to place a short lateral or caudal splint, follow this procedure: 1. secure a contact layer as determined by the presence or absence of any wound in the area. 2. place tape stirrups on the distal extremity to be secured later to the intermediate bandage layer and to prevent slipping of the bandage distally. 3. place layers of roll cotton from the toes to the level of the mid tibia/fibula or mid radius/ulna. place the layers with even tension, with some overlap of each consecutive layer, moving distally to proximally on the limb. 4. secure the short caudal or lateral splint and conform it to the distal extremity to the level of the toes and proximally to the level of the mid tibia/fibula or mid radius/ulna. 5. secure the lateral or caudal splint to the limb with another outer layer of elastic cotton (kling). 6. cover the entire bandage and splint with an outer tertiary layer of vetrap or elastikon. make sure that the toenails of the third and fourth digits remain visible to allow daily evaluation of circulation. long lateral or caudal splints are used to immobilize fractures of the tibia/fibula and radius/ulna. the splints are fashioned as directed for short splints but extend proximally to the level of the axilla and inguinal regions to immobilize above the fracture site. â�¢ packed cell volume drops rapidly to less than 20% in the dog and less than 12% to 15% in the cat â�¢ acute loss of more than 30% of blood volume (30 ml/kg in dog, 20 ml/kg in cat) â�¢ clinical signs of lethargy, collapse, hypotension, tachycardia, tachypnea (acute or chronic blood loss) â�¢ ongoing hemorrhage is present â�¢ poor response to crystalloid and colloid infusion â�¢ life-threatening hemorrhage caused by thrombocytopenia or thrombocytopathia â�¢ surgical intervention is necessary in a patient with severe thrombocytopenia or thrombocytopathia plasma support â�¢ life-threatening hemorrhage with decreased coagulation factor activity â�¢ severe inflammation (pancreatitis, systemic inflammatory response syndrome) â�¢ replenish antithrombin (disseminated intravascular coagulation, protein-losing enteropathy or nephropathy) â�¢ surgery is necessary in a patient with decreased coagulation factor activity â�¢ severe hypoproteinemia is present; to partially replenish albumin, globulin, and clotting factors type a cats typically possess weak anti-b antibodies of igg and igm subtypes. transfusion of type b blood into a type a cat will result in milder clinical signs of reaction and a markedly decreased survival half-life of the infused rbcs to just 2 days. because type ab cats possess both moieties on their cell surface, they lack naturally occurring alloantibodies; transfusion of type a blood into a type ab cat can be performed safely if a type ab donor is not available. the life span of an rbc from a type-specific transfusion into a cat is approximately 33 days. . indications for fresh whole blood transfusion include disorders of hemostasis and coagulopathies including disseminated intravascular coagulation, von willebrand's disease, and hemophilia. fresh whole blood and platelet-rich plasma also can be administered in cases of severe thrombocytopenia and thrombocytopathia. stored whole blood and packed rbcs can be administered in patients with anemia. if pcv drops to below 10% or if rapid hemorrhage causes the pcv to drop below 20% in the dog or less than 12% to 1 *indicates that this must be done for each donor being tested. minor crossmatch* 2. obtain a crossmatch segment from blood bank refrigerator for each donor to be crossmatched, or use an edta tube of donor's blood. make sure tubes are labeled prop-erly. 3. collect 2 ml of blood from recipient and place in an edta tube. centrifuge blood for 5 minutes. 4. extract blood from donor tubing. centrifuge blood for 5 minutes. use a separate pipette for each transfer because cross-contamination can occur. 5. pipette plasma off of donor and recipient cells and place in tubes labeled dp and rp, respectively. 6. place 125 âµl of donor and recipient cells in tubes labeled dr and rr, respectively. 7. add 2.5 ml 0.9% sodium chloride solution from wash bottle to each red blood cell (rbc) tube, using some force to cause cells to mix. 8. centrifuge rbc suspension for 2 minutes. 9. discard supernatant and resuspend rbcs with 0.9% sodium chloride from wash bottle. 10 . repeat steps 8 and 9 for a total of three washes. 11. place 2 drops of donor rbc suspension and 2 drops of recipient plasma in tube labeled ma (this is the major crossmatch). 12. place 2 drops of donor plasma and 2 drops recipient rbc suspension in tube labeled mi (this is the minor crossmatch). 13. prepare control tubes by placing 2 drops donor plasma with 2 drops donor rbc suspension (this is the donor control); and place 2 drops recipient plasma with 2 drops recipient rbc suspension (this is the recipient control). 14. incubate major and minor crossmatches and control tubes at room temperature for 15 minutes. 15. centrifuge all tubes for 1 minute. 16. read tubes using an agglutination viewer. 17. check for agglutination and/or hemolysis. 18. score agglutination with the following scoring scale: 4+ one solid clump of cells 3+ several large clumps of cells 2+ medium-sized clumps of cells with a clear background 1+ hemolysis, no clumping of cells neg = negative for hemolysis; negative for clumping of red blood cells fresh whole blood coagulopathy with active hemorrhage (disseminated intravascular coagulation, thrombocytopenia; massive acute hemorrhage; no stored blood available) stored whole blood massive acute or ongoing hemorrhage; hypovolemic shock caused by hemorrhage that is unresponsive to conventional crystalloid and colloid fluid therapy; unavailability of equipment required to prepare blood components packed red blood cells nonregenerative anemia, immune-mediated hemolytic anemia, correction of anemia before surgery, acute or chronic blood loss fresh frozen plasma factor depletion associated with active hemorrhage (congenital: von willebrand's factor, hemophilia a, hemophilia b; acquired: vitamin k antagonist, rodenticide intoxication, dic); acute or chronic hypoproteinemia (burns, wound exudates, body cavity effusion; hepatic, renal, or gastrointestinal loss); colostrum replacement in neonates frozen plasma acute plasma or protein loss; chronic hypoproteinemia; (contains stable colostrum replacement in neonates; hemophilia b and clotting factors) selected clotting factor deficiencies platelet-rich plasma* thrombocytopenia with active hemorrhage (immune-mediated thrombocytopenia, dic); platelet function abnormality (congenital: thrombasthenia in bassett hounds; acquired: nsaids, other drugs) cryoprecipitate congenital factor deficiencies (routine or before surgery): (concentration of factor hemophilia a, hemophilia b, von willebrand's disease, viii, von willebrand's hypofibrinogenemia; acquired factor deficiencies factor, and fibrinogen) *must be purchased because logistically one cannot obtain enough blood simultaneously to provide a significant amount of platelets; platelets infused have a very short (<2 hours) half-life. dic, disseminated intravascular coagulation; nsaids, nonsteroidal antiinflammatory drugs. universal donor (e.g., should be administered whenever possible. because there is no universal donor in the cat and because cats possess naturally occurring alloantibodies, all cat blood should be typed and crossmatched before any transfusion. if fresh whole blood is not available, a hemoglobin-based oxygen carrier (oxyglobin, 2 to 7 ml/kg iv) can be administered until blood products become available. table 1 -4 indicates blood component dose and administration rates. blood products should be warmed slowly to 37â°c before administering them to the patient. blood warmer units are available for use in veterinary medicine to facilitate rapid transfusion without decreasing patient body temperature (thermal angel; enstill medical technologies, inc., dallas, texas). red blood cell and plasma products should be administered in a blood administration set containing a 170-âµm in-line filter. smaller in-line filters (20 âµm) also can be used in cases in which extremely small volumes are to be administered. blood products should be administered over a period of 4 hours, whenever possible, according to guidelines set by the american association of blood banks. the volume of blood components required to achieve a specific increment in the patient's pcv depends largely on whether whole blood or packed rbcs are transfused and whole blood 20 ml/kg will increase max rate: 22 ml/kg/ max: 22 ml/kg/ volume by 10% 24 hours hour packed red 10 ml/kg will increase critically ill blood cells volume by 10% patients (e.g., cardiac failure or renal failure): 3-4 ml/kg/hour fresh frozen 10 ml/kg body mass (repeat 4-10 ml/minute or use rates as for plasma in 2-3 days or in 3-5 days whole blood (infuse within 4-6 hours) or until bleeding stops); monitor act, aptt, and pt before and 1 hour after transfusion cryoprecipitate general: 1 unit/10 kg/12 hours 4-10 ml/minute or use rates as for whole or until bleeding stops blood (infuse within 4-6 hours) hemophilia a: 12-20 units factor viii/kg; 1 unit of cryoprecipitate contains approximately 125 units of factor viii platelet-rich 1 unit/10 kg (1 unit of 2 ml/minute plasma platelet-rich plasma will check platelet count before and 1 hour increase platelet count after transfusion 1 hour after transfusion by 10,000/âµl) whether there is ongoing hemorrhage or rbc destruction. because the pcv of packed rbcs is unusually high (80% for greyhound blood), a smaller total volume is required than whole blood to achieve a comparable increase in the patient's pcv. in general, 10 ml/kg of packed rbcs or 20 ml/kg whole blood will raise the recipient's pcv by 10%. the "rule of ones" states that 1 ml per 1 lb of whole blood will raise the pcv by 1%. if the patient's pcv does not raise by the amount anticipated by the foregoing calculation(s), causes of ongoing hemorrhage or destruction should be considered. the goal of red blood component therapy is to raise the pcv to 25% to 30% in dogs and 15% to 20% in cats. if an animal is hypovolemic and whole blood is administered, the fluid is redistributed into the extravascular compartment within 24 hours of transfusion. this will result in a secondary rise in the pcv 24 hours after the transfusion in addition to the initial rise 1 to 2 hours after the rbc transfusion is complete. the volume of plasma transfused depends largely on the patient's need. in general, plasma transfusion should not exceed more than 22 ml/kg during a 24-hour period for normovolemic animals. thaw plasma at room temperature, or place it in a ziplock freezer bag and run under cool (not warm) water until thawed. then administer the plasma through a blood administration set that contains an in-line blood filter or through a standard driptype administration set with a detachable in-line blood administration filter. the average rate of plasma infusion in a normovolemic patient should not exceed 22 ml/kg/hour. in acute need situations, plasma can be delivered at rates up to 5 to 6 ml/kg/minute. for patients with cardiac insufficiency or other circulatory problems, plasma infusion rates should not exceed 5 ml/kg/hour. plasma or other blood products should not be mixed with or used in the same infusion line as calcium-containing fluids, including lactated ringer's solution, calcium chloride, or calcium gluconate. the safest fluid to mix with any blood product is 0.9% sodium chloride. administer fresh frozen plasma, frozen plasma, and cryoprecipitate at a volume of 10 ml/kg until bleeding is controlled or source of ongoing albumin loss ceases. the goal of plasma transfusion therapy is to raise the albumin to a minimum of 2.0 g/dl or until bleeding stops as in the case of coagulopathies. monitor the patient to ensure that bleeding has stopped, coagulation profiles (act, aptt, and pt) have normalized, hypovolemia has stabilized, and/or total protein is normalizing, which are indications for discontinuing ongoing transfusion therapy. plasma cryoprecipitate can be purchased or manufactured through the partial thawing and then centrifugation of fresh frozen plasma. cryoprecipitate contains concentrated quantities of vwf, factor viii, and fibrinogen and is indicated in severe forms of von willebrand's disease and hemophilia a (factor viii deficiency). platelet-rich plasma must be purchased from a commercial source. one unit of fresh whole blood contains 2000 to 5000 platelets. the viability of the platelets contained in the fresh whole blood is short-lived, just 1 to 2 hours after transfusion into the recipient. because platelet-rich plasma is difficult to obtain, animals with severe thrombocytopenia or thrombocytopathia should be treated with immunomodulating therapies and the administration of fresh frozen plasma. in dogs, blood and plasma transfusions can be administered intravenously or intraosseously. the cephalic, lateral saphenous, medial saphenous, and jugular veins are used most commonly. fill the recipient set so that the blood in the drip chamber covers the filter (normal 170-âµm filter). with small amounts of blood (50 ml) or critically ill patients, use a 40-âµm filter. avoid latex filters for plasma and cryoprecipitate administration. blood can 30 1 emergency care be administered at variable rates, but the routine figure of 4 to 5 ml/minute often is used. normovolemic animals can receive blood at 22 ml/kg/day. dogs in heart failure should receive infusions at no more than 4 ml/kg/hour. volume is given as needed. to calculate the approximate volume of blood needed to raise hematocrit levels, use the following formula for the dog: anticoagulated blood volume (ml) = body mass (kg) ã� 90 ã� pcv desired â�� pcv of recipient pcv of donor in anticoagulant an alternative formula is the following: 2.2 ã� recipient body mass (kg) ã� 30 (dog) ã� pcv desired â�� pcv of recipient pcv of donor in anticoagulant surgical emergencies and shock may require several times this volume within a short period. if greater than 25% of the patient's blood volume is lost, supplementation with colloids, crystalloids, and blood products is indicated for fluid replacement. one volume of whole blood achieves the same increase in plasma as two to three volumes of plasma. if the patient's blood type is unknown and type a-negative whole blood is not available, any dog blood can be administered to a dog in acute need if the dog has never had a transfusion before. if mismatched blood is given, the patient will become sensitized, and after 5 days, destruction of the donor rbcs will begin. in addition, any subsequent mismatched transfusions may cause an immediate reaction (usually mild) and rapid destruction of the transfused rbcs. the clinical signs of a transfusion reaction typically only are seen when type a blood is administered to a type a-negative recipient that has been sensitized previously. incompatible blood transfusions to breeding females can result in isoimmunization and in hemolytic disease in the puppies. the a-negative bitch that receives a transfusion with a-positive and that produces a litter from an a-positive stud can have puppies with neonatal isoerythrolysis. cats with severe anemia in need of a blood transfusion are typically extremely depressed, lethargic, and anorexic. the stress of restraint and handling can push these critically ill patients over the edge and cause them to die. extreme gentleness and care are mandatory in restraint and handling. the critically ill cat should be cradled in a towel or blanket. supplemental flow-by or mask oxygen should be administered, whenever possible, although it may not be clinically helpful until oxygen-carrying capacity is replenished with infusion of rbcs or hemoglobin. blood can be administered by way of cephalic, medial saphenous, or the jugular vein. intramedullary infusion is also possible, if vascular access cannot be accomplished. the average 2-to 4-kg cat can accept 40 to 60 ml of whole blood injected intravenously over a period of 30 to 60 minutes. administer filtered blood at a rate of 5 to 10 ml/kg/hour. the following formula can be used to estimate the volume of blood required for transfusion in a cat: anticoagulated blood volume (ml) = body mass (kg) ã� 70 ã� pcv desired â�� pcv of recipient pcv of donor in anticoagulant the exact overall incidence and clinical significance of transfusion reactions in veterinary medicine are unknown. several studies have been performed that document the incidence of transfusion reactions in dogs and cats. overall, the incidence of transfusion reactions in dogs and cats is 2.5% and 2%, respectively. transfusion reactions can be immune-mediated and non-immune-mediated and can happen immediately or can be delayed until after a transfusion. acute reactions usually occur within minutes to hours of the onset of transfusion but may occur up to 48 hours after the transfusion has been stopped. acute immunologic reactions include hemolysis and acute hypersensitivity including rbcs, platelets, and leukocytes. signs of a delayed immunologic reaction include hemolysis, purpura, immunosuppression, and neonatal isoerythrolysis. acute nonimmunologic reactions include donor cell hemolysis before onset of transfusion, circulatory volume overload, bacterial contamination, citrate toxicity with clinical signs of hypocalcemia, coagulopathies, hyperammonemia, hypothermia, air embolism, acidosis, and pulmonary microembolism. delayed nonimmunologic reactions include the transmission and development of infectious diseases and hemosiderosis. clinical signs of a transfusion reaction typically depend on the amount of blood transfused, the type and amount of antibody involved in the reaction, and whether the recipient has had previous sensitization. monitoring the patient carefully during the transfusion period is essential in recognizing early signs of a transfusion reaction, including those that may become life threatening. a general guideline for patient monitoring is first to start the transfusion slowly during the first 15 minutes. monitor temperature, pulse, and respiration every 15 minutes for the first hour, 1 hour after the end of the transfusion, and every 12 hours minimally thereafter. also obtain a pcv immediately before the transfusion, 1 hour after the transfusion has been stopped, and every 12 hours thereafter. monitor coagulation parameters such as an act and platelet count at least daily in patients requiring transfusion therapy. the most common documented clinical signs of a transfusion reaction include pyrexia, urticaria, salivation/ptyalism, nausea, chills, and vomiting. other clinical signs of a transfusion reaction may include tachycardia, tremors, collapse, dyspnea, weakness, hypotension, collapse, and seizures. severe intravascular hemolytic reactions may occur within minutes of the start of the transfusion, causing hemoglobinemia, hemoglobinuria, disseminated intravascular coagulation, and clinical signs of shock. extravascular hemolytic reactions typically occur later and will result in hyperbilirubinemia and bilirubinuria. pretreatment of patients to help decrease the risk of a transfusion reaction remains controversial, and in most cases, pretreatment with glucocorticoids and antihistamines is ineffective at preventing intravascular hemolysis and other reactions should they occur. the most important component of preventing a transfusion reaction is to screen each recipient carefully and process the donor component therapy carefully before the administration of any blood products. treatment of a transfusion reaction depends on its severity. in all cases, stop the transfusion immediately when clinical signs of a reaction occur. in most cases, discontinuation of the transfusion and administration of drugs to stop the hypersensitivity reaction will be sufficient. once the medications have taken effect, restart the transfusion slowly and monitor the patient carefully for further signs of reaction. in more severe cases in which a patient's cardiovascular or respiratory system become compromised and hypotension, tachycardia, or tachypnea occurs, immediately discontinue the transfusion and administer diphenhydramine (1 mg/kg im), dexamethasone-sodium phosphate (0.25 to 0.5 mg/kg iv), and epinephrine to the patient. the patient should have a urinary catheter and central venous catheter placed for measurement of urine output and central venous pressures. aggressive fluid therapy may be necessary to avoid renal insufficiency or renal damage associated with severe intravascular hemolysis. overhydration with subsequent pulmonary edema generally can be managed with supplemental oxygen administration and intravenous or intramuscular administration of furosemide (2 to 4 mg/kg). plasma products with or without heparin can be administered for disseminated intravascular coagulation. the hbocs can be stored at room temperature and have a relatively long shelf life compared with red blood component products. the hbocs function to carry oxygen through the blood and can diffuse oxygen past areas of poor tissue perfusion. an additional characteristic of hbocs is as a potent colloid, serving to maintain fluid within the vascular space. for this reason, hbocs must be used with caution in euvolemic patients and patients with cardiovascular insufficiency. central venous pressure (cvp) measures the hydrostatic pressure in the anterior vena cava and is influenced by vascular fluid volume, vascular tone, function of the right side of the heart, and changes in intrathoracic pressure during the respiratory cycle. the cvp is not a true measure of blood volume but is used to gauge fluid therapy as a method of determining how effectively the heart can pump the fluid that is being delivered to it. thus the cvp reflects the interaction of the vascular fluid volume, vascular tone, and cardiac function. measure cvp in any patient with acute circulatory failure, large volume fluid diuresis (i.e., toxin or oliguric or anuric renal failure), fluid in-and-out monitoring, and cardiac dysfunction. the placement of central venous catheters and thus cvp measurements is contraindicated in patients with known coagulopathies including hypercoagulable states. to perform cvp monitoring, place a central venous catheter in the right or left jugular vein. in cats and small dogs, however, a long catheter placed in the lateral or medial saphenous vein can be used for trends in cvp monitoring. first, assemble the equipment necessary for jugular catheter (see vascular access techniques for how to place a jugular or saphenous long catheter) and cvp monitoring (box 1-7). after placing the jugular catheter, take a lateral thoracic radiograph to ensure that the tip of the catheter sits just outside of the right atrium for proper cvp measurements (see to establish an intravenous catheter for cvp, follow this procedure: 1. assemble the cvp setup such that the male end of a length of sterile intravenous catheter extension tubing is inserted into the t port of the jugular or medial/lateral saphenous catheter. make sure to flush the length of tubing with sterile saline before connecting it to the patient to avoid iatrogenic air embolism. 2. next, insert the male end of a three-way stopcock into the female end of the extension tubing. 3. attach a 20-ml syringe filled with heparinized sterile 0.9% saline to one of the female ports of the three-way stopcock and either a manometer or a second length of intravenous extension tubing attached to a metric ruler. 4. lay the patient in lateral or sternal recumbancy. 5. turn the stopcock off to the manometer/ruler and on to the patient. infuse a small amount of heparinized saline through the catheter to flush the catheter. 6. next, turn the stopcock off to the patient and on to the manometer. gently flush the manometer or length of extension tubing with heparinized saline from the syringe. use care not to agitate the fluid and create air bubbles within the line or manometer that will artifactually change the cvp measured. 7. next, lower the 0 cm point on the manometer or ruler to the level of the patient's manubrium (if the patient is in lateral recumbancy) or the point of the elbow (if the patient is in sternal recumbancy). 8. turn the stopcock off to the syringe, and allow the fluid column to equilibrate with the patient's intravascular volume. once the fluid column stops falling and the level rises and falls with the patient's heartbeat, measure the number adjacent to the bottom of the meniscus of the fluid column. this is the cvp in centimeters of water (see figure 1 -4). 9. repeat the measurement several times with the patient in the same position to make sure that none of the values has been increased or decreased artifactually in error. alternately, attach the central catheter to a pressure transducer and perform electronic monitoring of cvp. there is no absolute value for normal cvp. the normal cvp for small animal patients is 0 to 5 cm h 2 o. values less than zero are associated with absolute or relative hypovolemia. values of 5 to 10 cm h 2 o are borderline hypervolemia, and values greater than 10 cm h 2 o suggest intravascular volume overload. values greater than 15 cm h 2 o may be correlated with congestive heart failure and the development of pulmonary edema. in individual patients, the trend in change in cvp is more important than absolute values. as a rule of thumb, when using cvp measurements to gauge fluid therapy and avoid vascular and pulmonary overload, the cvp should not increase by more than 5 cm h 2 o in any 24-hour period. if an abrupt increase in cvp is found, repeat the measurement to make sure that the elevated value was not obtained in error. if the value truly has increased dramatically, temporarily discontinue fluid therapy and consider administration of a diuretic. delaforcade am, rozanski ea: central venous pressure and arterial blood pressure measurements, vet clin north am small anim pract 31 (6) the diagnosis of intracellular fluid deficit is difficult and is based more on the presence of hypernatremia or hyperosmolality than on clinical signs. an intracellular fluid deficit is expected when free water loss by insensible losses and vomiting, diarrhea, or urine is not matched by free water intake. consideration of the location of the patient's fluid deficit, history of vomiting and diarrhea, no visible clinical signs of deficit 4% dry mucous membranes, mild skin tenting 5% increased skin tenting, dry mucous membranes, mild tachycardia, normal pulse* 7% increased skin tenting, dry mucous membranes, tachycardia, weak pulse pressure 10% increased skin tenting, dry corneas, dry mucous membranes, 12% elevated or decreased heart rate, poor pulse quality, altered level of consciousness* the respiratory system further contributes to acid-base status by changes in the elimination of carbon dioxide. hyperventilation decreases the blood pco 2 and causes a respiratory alkalosis. hypoventilation increases the blood pco 2 and causes a respiratory acidosis. depending on the altitude, the pco 2 in dogs can range from 32 to 44 mm hg. in cats, normal is 28 to 32 mm hg. venous pco 2 values are 33 to 50 mm hg in dogs and 33 to 45 mm hg in cats. use a systematic approach whenever attempting to interpret a patient's acid-base status. ideally, obtain an arterial blood sample so that you can monitor the patient's oxygenation and ventilation. once an arterial blood sample has been obtained, follow these steps: 1. determine whether the blood sample is arterial or venous by looking at the oxygen saturation (sao 2 ). the sao 2 should be greater than 90% if the sample is truly arterial, although it can be as low as 80% if a patient has severe hypoxemia. 2. consider the patient's ph. if the ph is outside of the normal range, an acid-base disturbance is present. if the ph is within the normal range, an acid-base disturbance may or may not be present. if the ph is low, the patient is acidotic. if the ph is high, the patient is alkalotic. 3. next, look at the base excess or deficit. if the base excess is increased, the patient has higher than normal bicarbonate. if there is a base deficit, the patient may have a low bicarbonate or increase in unmeasured anions (e.g., lactic acid or ketoacids). 4. next, look at the bicarbonate. if the ph is low and the bicarbonate is low, the patient has a metabolic acidosis. if the ph is high and the bicarbonate is elevated, the patient has a metabolic alkalosis. 5. next, look at the paco 2 . if the patient's ph is low and the paco 2 is elevated, the patient has a respiratory acidosis. if the patient's ph is high and the paco 2 is low, the patient has a respiratory alkalosis. 6. finally, if you are interested in the patient's oxygenation, look at the pao 2 . normal pao 2 is greater than 80 mm hg. the metabolic acidosis early in renal failure may be hyperchloremic and later may convert to typical increased anion gap acidosis. 7. next, you must determine whether the disorders present are primary disorders or an expected compensation for disorders in the opposing system. for example, is the patient retaining bicarbonate (metabolic alkalosis) because of carbon dioxide retention (respiratory acidosis)? use the chart in table 1 -6 to evaluate whether the appropriate degree of compensation is occurring. if the adaptive response falls within the expected range, a simple acid-base disorder is present. if the response falls outside of the expected range, a mixed acid-base disorder is likely present. 8. finally, you must determine whether the patient's acid-base disturbance is compatible with the history and physical examination findings. if the acid-base disturbance does not fit with the patient's history and physical examination abnormalities, question the results of the blood gas analyses and possibly repeat them. the most desirable method of assessing the acid-base status of an animal is with a blood gas analyzer. arterial samples are preferred over venous samples, with heparin used as an anticoagulant (table 1-7) . potassium primarily is located in the intracellular fluid compartment. serum potassium is regulated by the actions of the sodium-potassium-adenosinetriphosphatase pump on cellular membranes, including those of the renal tubular epithelium. inorganic metabolic acidosis artifactually can raise serum potassium levels because of redistribution of extracellular potassium in exchange for intracellular hydrogen ion movement in an attempt to correct serum ph. metabolic acidosis potassium is one of the major players in the maintenance of resting membrane potentials of excitable tissue, including neurons and cardiac myocytes. changes in serum potassium can affect cardiac conduction adversely. hyperkalemia lowers the resting membrane potential and makes cardiac cells, particularly those of the atria, more susceptible to depolarization. characteristic signs of severe hyperkalemia that can be observed on an ecg rhythm strip include an absence of p waves, widened qrs complexes, and tall tented or spiked t waves. further increases in serum potassium can be associated with bradycardia, ventricular fibrillation, and cardiac asystole (death). treatment of hyperkalemia consists of administration of insulin (0.25 to 0.5 units/kg, iv regular insulin) and dextrose (1 g dextrose per unit of insulin administered, followed by 2.5% dextrose iv cri to prevent hypoglycemia), calcium (2 to 10 ml of 10% calcium gluconate administered iv slowly to effect), or sodium bicarbonate (1 meq/kg, iv slowly). insulin plus dextrose and bicarbonate therapy help drive the potassium intracellularly, whereas calcium antagonizes the effect of hyperkalemia on the myocardial cells. all of the treatments work within minutes, although the effects are relatively short-lived (20 minutes to 1 hour) unless the cause of the hyperkalemia is identified and treated appropriately (box 1-10). dilution of serum potassium also results from restoring intravascular fluid volume and correcting metabolic acidosis, in most cases. treatment with a fluid that does not contain potassium (preferably 0.9% sodium chloride) is recommended. hypokalemia elevates the resting membrane potential and results in cellular hyperpolarization. hypokalemia may be associated with ventricular dysrhythmias, but the ecg changes are not as characteristic as those observed with hyperkalemia. causes of hypokalemia include renal losses, anorexia, gastrointestinal loss (vomiting, diarrhea), intravenous fluid diuresis, loop diuretics, and postobstructive diuresis (box 1-11). if the serum potassium concentration is known, potassium supplementation in the form of potassium chloride or potassium phosphate can be added to the patient's intravenous fluids. correct serum potassium levels less than 3.0 meq/l or greater than 6.0 meq/l. potassium rates should not exceed 0.5 meq/kg/hour (table 1 -8) . metabolic acidosis from bicarbonate depletion often corrects itself with volume restoration in most small animal patients. patients with moderate to severe metabolic acidosis may benefit from bicarbonate supplementation therapy. the metabolic contribution to acid-base balance is identified by measuring the total carbon dioxide concentration or calculating the bicarbonate concentration. if these measurements are not available, the degree of expected metabolic acidosis can be estimated subjectively by the severity of underlying disease that often contributes to metabolic acidosis: hypovolemic or traumatic shock, septic shock, diabetic ketoacidosis, or oliguric/anuric renal failure. if the metabolic acidosis is estimated to be mild, moderate, or severe, add sodium bicarbonate at 1, 3, and 5 meq/kg body mass, respectively. patients with diabetic ketoacidosis may not require bicarbonate administration once volume replacement and perfusion is restored, and the ketoacids are metabolized to bicarbonate. if the bicarbonate measurement of base deficit is known, the following formula can be used as a gauge for bicarbonate supplementation: base deficit ã� 0.3 = body mass (kg) = meq bicarbonate to administer osmolality osmolality is measured by freezing point depression or a vapor pressure osmometer, or it may be calculated by the following formula: mosm/kg = 2[(na + ) + (k + )] + bun/2.8 + glucose/18 where sodium and potassium are measured in milliequivalents, and bun and glucose are measured in milligrams per deciliter. osmolalities less than 260 mosm/kg or greater 38 1 emergency care than 360 mosm/kg are serious enough to warrant therapy. the difference between the measured osmolality and the calculated osmolality (the osmolal gap) should be less than 10 mosm/kg. if the osmolal gap is greater than 20 mosm/kg, consider the presence of unmeasured anions such as ethylene glycol metabolites. the volume of extracellular fluid is determined by the total body sodium content, whereas the osmolality and sodium concentration are determined by water balance. serum sodium concentration is an indication of the amount of sodium relative to water in the extracellular fluid and provides no direct information about the total body sodium content. unlikely to cause hyperkalemia in presence of normal renal function unless iatrogenic (e.g., continuous infusion of potassium-containing fluids at an excessively rapid rate) acute mineral acidosis (e.g., hydrochloric acid or ammonium chloride) insulin deficiency (e.g., diabetic ketoacidosis) acute tumor lysis syndrome reperfusion of extremities after aortic thromboembolism in cats with cardiomyopathy hyperkalemic periodic paralysis (one case report in a pit bull) mild hyperkalemia after exercise in dogs with induced hypothyroidism infusion of lysine or arginine in total parenteral nutrition solutions nonspecific î²-blockers (e.g., propranolol)* cardiac glycosides (e.g., digoxin)* urethral obstruction ruptured bladder anuric or oliguric renal failure hypoadrenocorticism selected gastrointestinal disease (e.g., trichuriasis, salmonellosis, or perforated duodenal ulcer) late pregnancy in greyhound dogs (mechanism unknown but affected dogs had gastrointestinal fluid loss) chylothorax with repeated pleural fluid drainage hyporeninemic hypoaldosteronism â�  angiotensin-converting enzyme inhibitors (e.g., enalapril)* angiotensin receptor blockers (e.g., losartan)* cyclosporine and tacrolimus* potassium-sparing diuretics (e.g., spironolactone, amiloride, and triamterene)* nonsteroidal antiinflammatory drugs* heparin* trimethoprim* from dibartola sp: fluid, electrolyte and acid-base disorders in small animal practice, st louis, 2005, saunders. *likely to cause hyperkalemia only in conjunction with other contributing factors (e.g., other drugs, decreased renal function, or concurrent administration of potassium supplements). â�  not well documented in veterinary medicine. if refractory hypokalemia is present, supplement magnesium at 0.75 meq/kg/day for 24 hours. alone unlikely to cause hypokalemia unless diet is aberrant administration of potassium-free (e.g., 0.9% sodium chloride or 5% dextrose in water) or potassium-deficient fluids (e.g., lactated ringer's solution over several days) bentonite clay ingestion (e.g., cat litter) alkalemia insulin/glucose-containing fluids catecholamines hypothermia hypokalemic periodic paralysis (burmese cats) albuterol overdosage patients with hyponatremia or hypernatremia may have decreased, normal, or increased total body sodium content (boxes 1-12 and [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] ). an increased serum sodium concentration implies hyperosmolality, whereas a decrease in serum sodium concentration usually, but not always, implies hypoosmolality. the severity of clinical signs of hypernatremia and hyponatremia is related primarily to the rapidity of the onset of the change rather than to the magnitude of the associated plasma hyperosmolality or hypoosmolality. clinical signs of neurologic disturbances include disorientation, ataxia, and seizures, and coma may occur at serum sodium concentrations less than 120 meq/l or greater than 170 meq/l in dogs. therapy of hypernatremia or hyponatremia with fluid containing low or higher concentrations of sodium should proceed with caution, for rapid changes (decreases or increases) of serum sodium and osmolality can cause rapid changes in the intracellular and extracellular fluid flux, leading to intracellular dehydration or edema, even though the serum sodium has not been returned to normal. a rule of thumb is to not raise or lower the serum sodium by more than 15 meq/l during any one 24-hour period. restoration of the serum sodium concentration over a period of 48 to 72 hours is better. in almost all circumstances, an animal will correct its sodium balance with simple fluid restoration. if severe hypernatremia exists that suggests a free water deficit, however, the free water deficit should be calculated from the following formula: hypernatremia can be corrected slowly with 0.45% sodium chloride plus 2.5% dextrose, 5% dextrose in water, or lactated ringer's solution (sodium content: 130 meq/l). correct hyponatremia initially with 0.9% sodium chloride. sodium is balanced predominantly by chloride and bicarbonate. the difference between these concentrations, (na , has been called the anion gap. the normal anion gap is between 12 and 25 meq/l. when the anion gap exceeds 25, consider the possibility of an accumulation of unmeasured anions (e.g., lactate, ketoacids, phosphate, sulfate, ethylene glycol metabolites, and salicylate). abnormalities in the anion gap may be helpful in determining the cause of metabolic acidosis (boxes 1-14 and 1-15). the colloid oncotic pressure of blood is associated primarily with large-molecular-weight colloidal substances in circulation. the major player in maintaining intravascular and interstitial oncotic pressure, the water-retaining property of each fluid compartment, is albumin. albumin contributes roughly 80% to the colloidal oncotic pressure of blood. the majority of albumin is located within the interstitial space. hypoalbuminemia can result from increased loss in the form of protein-losing enteropathy or nephropathy and wound exudates, or it may be due to lack of hepatic albumin synthesis. serum albumin pools are in a constant flux with interstitial albumin. once interstitial albumin pools become depleted from replenishing serum albumin, serum albumin levels can continue to decrease, which can lead to a decrease in colloidal oncotic pressure. serum albumin less than 2.0 g/dl has been associated with inadequate intravascular fluid retention and the development of peripheral edema and third spacing of fluid. oncotic pressure can be restored with the use of artificial or synthetic colloids or natural colloids (see colloids). maintenance fluid requirements have been extrapolated from the formulas used to calculate a patient's daily metabolic energy requirements because it takes 1 ml of water to metabolize 1 kcal of energy (table 1 -9) . the patient's daily metabolic water (fluid) requirements can be calculated by the following formula: administration of an isotonic crystalloid fluid for maintenance requirements often can produce iatrogenic hypokalemia. in most cases, supplemental potassium must be added to prevent hypokalemia resulting from inappetance, kalliuresis, and supplementation with isotonic crystalloid fluids. the most reliable method of determining the degree of fluid deficit is by weighing the animal and calculating acute weight loss. acute weight loss in a patient with volume loss in the form of vomiting, feces, wound exudates, and urine is due to fluid loss and not loss of muscle or fat. lean body mass normally is not gained or lost rapidly enough to cause major changes in body weight. one milliliter of water weighs approximately 1 g. this fact allows calculation of the patient's fluid deficit, if ongoing losses can be measured. when a patient first presents, however, the body weight before a fluid deficit has occurred rarely is known. instead, one must rely on subjective measures of dehydration to estimate the patient's percent dehydration and to calculate the volume of fluid required to rehydrate the patient over the next 24 hours. to calculate the volume deficit, use the following formula: body mass (kg) ã� (% dehydration) ã� 1000 = fluid deficit (ml) the patient's fluid deficit must be added to the daily maintenance fluid requirements and administered over a 24-hour period. ongoing losses can be determined by measuring urine output, weighing the patient at least 2 to 3 times a day, and measuring the volume or weight of vomitus or diarrhea. a crystalloid fluid contains crystals of salts with a composition similar to that of the extracellular fluid space and can be used to maintain daily fluid requirements and replace fluid deficits or ongoing fluid losses (table 110) . metabolic, acid-base, and electrolyte imbalances also can be treated with isotonic fluids with or without supplemental electrolytes and buffers. depending on the patient's clinical condition, choose the specific isotonic crystalloid fluid to replace and maintain the patient's acid-base and electrolyte status ( table 1-11) . crystalloid fluids are readily available, are relatively inexpensive, and can be administered safely in large volumes to patients with no preexisting cardiac or renal disease or cerebral edema. following infusion, approximately 80% of the volume of a crystalloid fluid infused will redistribute to the interstitial fluid compartment. as such, crystalloid fluids alone are ineffective for ongoing intravascular volume depletion when given as a bolus. the crystalloid fluid bolus must be followed by a constant rate infusion, taking into consideration the patient's daily maintenance fluid requirements and ongoing fluid losses. administration of a large volume of crystalloid fluids can cause dilutional anemia and coagulopathies. *30 ã� bw kg + 70 = kcal/day = ml/day. note: this formula will slightly underestimate the requirements for patients that are less than 2 kg and will slightly overestimate the requirements for patients greater than 70 kg. retain fluid in the vascular space, the volume of crystalloid fluid infused (maintenance + deficit + ongoing losses) should be decreased by 25% to 50% to avoid vascular volume overload. two major classes of colloids exist: natural and synthetic. natural colloids (whole blood, packed rbcs, plasma) are discussed elsewhere in this text. concentrated human albumin is a natural purified colloid that recently has become more popular in the treatment of advanced hypoalbuminemia and hypoproteinemia and will be discussed here. synthetic colloids are starch polymers and include dextrans and hetastarch. concentrated human albumin is available as a 5% or 25% solution. the 5% solution has an osmolality similar to that of serum (308 mosm/l), whereas the 25% solution is hyperoncotic (1500 mosm/l). a 25% albumin solution draws fluid from the interstitial space into the intravascular space. concentrated albumin solutions often are used to restore circulating volume when synthetic colloids are not available. albumin not only is important at maintaining the colloidal oncotic pressure of blood but also serves as a valuable free-radical scavenger and carrier of drugs and hormones necessary for normal tissue function and healing. albumin levels less than 2.0 g/dl have been associated with increased morbidity and mortality. concentrated human albumin solutions can be administered as an effective method of restoring interstitial and serum albumin concentrations in situations of acute and chronic hypoalbuminemia. albumin (25%) is available in 50-and 100-ml vials and is more cost-efficient as an albumin replacement than procurement and administration of fresh frozen plasma. recommended albumin infusion rates are 2 to 5 ml/kg over 4 hours, after pretreatment with diphenhydramine. although concentrated human albumin is structurally similar to canine albumin, closely monitor the patient for signs of allergic reaction during and after the infusion. dextran-70 is a synthetic high-molecular-weight polysaccharide (sucrose polymer) with a molecular weight of 70,000 d. particles less than 50,000 d, are cleared rapidly by the kidneys, whereas larger particles are cleared more slowly by the hepatic reticuloendothelial system. dextran-70 can coat platelets and inhibit platelet function and so must be used with caution in patients with known coagulopathies. the total daily dosage should not exceed 40 ml/kg/day. hetastarch (hydroxyethyl starch) is a large-molecular-weight amylopectin polymer, has molecules with a molecular weight that exceeds 100,000 d, and has an average half-life of 24 to 36 hours in circulation. hetastarch can bind with vwf and cause prolongation of the act and aptt; however, it does not cause a coagulopathy. recommended rates of hetastarch infusion are 5-to 10-ml incremental boluses for the treatment of hypotension and 20 to 30 ml/kg/day as a constant rate infusion for maintenance of colloidal oncotic pressure. many are the acceptable ways to administer the fluids prescribed for each patient based on the degree of dehydration, estimation of ongoing losses, ability to tolerate oral fluid, and metabolic, acid-base, and electrolyte derangements. administer the fluids in a manner that is best for the patient and most appropriate for the practice. to determine the rate of intravenous fluid infusion, take the total volume of fluids that have been prescribed and divide the total volume by the total number of hours in a day that intravenous fluids can be delivered safely and monitored. the safest and most accurate way to deliver intravenous fluids, particularly in extremely small animals or those with congestive heart failure, is through an intravenous fluid pump. fluid should not be administered intravenously if the patient cannot be monitored to make sure that the fluids are being delivered at a safe rate and that the fluid line has not become disconnected. supplement fluids over as many hours as possible to allow the patient as much time as possible to redistribute and fully utilize the fluids administered. fluids administered too quickly can cause a diuresis to occur, such that the majority of the fluids administered will be excreted in the urine. if time is limited or if extra time is needed for safe administration of fluids, consider using a combination of intravenously and subcutaneously 46 1 emergency care administered fluids. intravenous is the preferred route of administration of fluids in any patient with dehydration and hypovolemia. as intravascular volume depletion occurs, reflex peripheral vasoconstriction occurs to restore core perfusion. the subcutaneous tissue are not perfused well and therefore fluids administered subcutaneously will not be absorbed well into the interstitial and intravascular spaces. subcutaneously administered fluids can be absorbed slowly and delivered effectively in the management of mild interstitial dehydration and in the treatment of renal insufficiency. subcutaneously administered fluids should never take the place of intravenously administered fluids in a hypovolemic patient or one with severe interstitial dehydration. intramedullary (intraosseous) infusion works well in small patients in which vascular access cannot be established. shock doses of fluids and other substances, including blood products, can be administered under pressure through an intraosseous cannula. because of the inherent discomfort and risk of osteomyelitis with intraosseous infusion, establish vascular access as soon as possible. the safest and most efficient method of intravenous fluid infusion is through a fluid pump. in cases in which a fluid pump is unavailable, infusion by gravity feed is the next option. infusion sets from various manufacturers have calibrated drip chambers such that a specific number of drops will equal 1 ml of fluid. fluid rates can be calculated based on the number of drops that fall into the drip chamber per minute: fluid volume to be infused (ml) = ml/hour number of hours available many pediatric drip sets deliver 60 drops/ml, such that milliliters/hour equals drops/ minute. carefully record fluid orders so that the volume to be administered is recorded as milliliters/hour, milliliters/day, and drops/minute. this will allow personnel to detect major discrepancies and calculation errors more readily. the volume actually delivered should be recorded in the record by nursing personnel. all additives should be listed clearly on the bottle on a piece of adhesive tape or a special label manufactured for this purpose. a strip of adhesive tape also can be attached to the bottle and marked appropriately to provide a quick visualization of the estimate of volume delivered. includes a large-bore flexible orogastric lavage tube, permanent marker or white tape, lubricating jelly, warm water, two large buckets, a roll of 2-inch white tape, and a manual lavage pump. to perform the orogastric lavage, follow this procedure: 1. place all animals under general anesthesia with a cuffed endotracheal tube in place to protect the airway and prevent aspiration of gastric contents into the lungs. 2. place a roll of 2-inch white tape into the animal's mouth, and secure the tape around the muzzle. you will insert the tube through the hole in the center of the roll of tape. 3. next, place the distal end of the tube at the level of the last rib, directly adjacent to the animal's thorax and abdomen. measure the length of the tube from the most distal end to the point where it comes out of the mouth, and label this location on the tube with a permanent marker or piece of white tape. 4. lubricate the distal portion of the tube, and gently insert it through the roll of tape in the animal's mouth. 5. gently push the tube down the esophagus. palpate the tube within the esophagus. two tubes should be palpable, the orogastric tube, and the patient's trachea. push the tube down into the stomach. you can verify location by blowing into the proximal end of the tube and simultaneously auscultating the stomach for borborygmi. 6. insert the manual pump to the proximal end of the tube, and instill the warm water. alternate instilling water with removal of fluid and gastric debris by gravity. repeat the process until the efflux fluid is clear of any debris. 7. save fluid from the gastric efflux fluid for toxicologic analyses. hackett tb: emergency approach to intoxications, clin tech small anim pract 15 (2):82-87, 2000. hypoxia, or inadequate tissue oxygenation, is the primary reason for supplemental oxygen therapy. major causes of hypoxia include hypoventilation, ventilation-perfusion mismatch, physiologic or right-to-left cardiac shunt, diffusion impairment, and decreased fraction of inspired oxygen (table 1-12) . inadequate tissue perfusion caused by low cardiac output or vascular obstruction also can result in circulatory hypoxia. finally, histiocytic hypoxia results from inability of cells to use oxygen that is delivered to them. this form of hypoxia can be observed with various toxin ingestions (bromethalin, cyanide) and in septic shock. a patient's oxygenation status can be monitored invasively by drawing of arterial blood gas samples or noninvasively through pulse oximetry, in most cases (see acid-base physiology and pulse oximetry). inspired air at sea level has a po 2 of 150 mm hg. as the air travels through the upper respiratory system to the level of the alveolus, the po 2 drops to 100 mm hg. tissue oxygen saturation in a normal healthy animal is 95 mm hg. after oxygen has been delivered to the tissues, the oxygen left in the venous system (pvo 2 ) is approximately 40 mm hg. normally, oxygen diffuses across the alveolar capillary membrane and binds reversibly with hemoglobin in rbcs. a small amount of oxygen is carried in an unbound diffusible form in the plasma. when an animal has an adequate amount of hemoglobin and hemoglobin becomes fully saturated while breathing room air, supplemental oxygen administration will only increase the sao 2 a small amount. the unbound form of oxygen dissolved in plasma will increase. if, however, inadequate hemoglobin saturation is obtained by breathing room air, as in a case of pneumonia or pulmonary edema, for example, breathing a higher fraction of inspired oxygen (fio 2 ) will improve bound and unbound hemoglobin levels. the formula for calculating oxygen content of arterial blood is as follows: where cao 2 is the arterial oxygen content, 1.34 is the amount of oxygen that can be carried by hemoglobin (hb), sao 2 is the hemoglobin saturation, and 0.003 ã� pao 2 is the amount of oxygen dissolved (unbound) in plasma. dissolved oxygen actually contributes little to the total amount of oxygen carried in the arterial blood, and the majority depends on the amount or availability of hemoglobin and the ability of the body (ph and respiratory status) to saturate the hemoglobin at the level of the alveoli. oxygen therapy is indicated whenever hypoxia is present. the underlying cause of the hypoxia also must be identified and treated, for chronic, lifelong oxygen therapy is rarely feasible in veterinary patients. if hemoglobin levels are low due to anemia, oxygen supplementation must occur along with rbc transfusions to increase hemoglobin mass. whenever possible, use arterial blood gas analyses or pulse oximetry to gauge a patient's response to oxygen therapy and to determine when an animal can be weaned from supplemental oxygen. the goal of oxygen therapy is to increase the amount of oxygen bound to hemoglobin in arterial blood. oxygen supplementation can be by hood, oxygen cage or tent, nasal or nasopharyngeal catheter, or tracheal tube. in rare cases, administration of oxygen with mechanical ventilation may be indicated. administration of supplemental oxygen to patients with chronic hypoxia is sometimes necessary but also dangerous. with chronic hypoxia the patient develops a chronic respiratory acidosis (elevated paco 2 ) and depends almost entirely on the hypoxic ventilatory drive to breathe. administration of supplemental oxygen increases pao 2 and may inhibit the central respiratory drive, leading to hypoventilation and possibly respiratory arrest. therefore, closely monitor animals with chronic hypoxia that are treated with supplemental oxygen. oxygen hoods can be purchased from commercial sources or can be manufactured in the hospital using a rigid elizabethan collar, tape, and plastic wrap. to make an oxygen hood, place several lengths of plastic wrap over the front of the elizabethan collar and tape them in place. leave the ventral third of the collar open to allow moisture and heat to dissipate and carbon dioxide to be eliminated. place a length of flexible oxygen tubing under the patient's collar into the front of the hood, and run humidified oxygen at a rate of 50 to 100 ml/kg/minute. animals may become overheated with an oxygen hood in place. carefully monitor the patient's temperature so that iatrogenic hyperthermia does not occur. commercially available plexiglass oxygen cages can be purchased from a variety of manufacturers. the best units include a mechanical thermostatically controlled compressor cooling unit, a circulatory fan, nebulizers or humidifiers to moisten the air, and a carbon dioxide absorber. alternately, a pediatric (infant) incubator can be purchased from hospital supply sources, and humidified oxygen can be run into the cage at 2 to 10 l/minute (depending on the size of the cage). high flow rates may be required to eliminate nitrogen and carbon dioxide from the cage. in most cases, the fio 2 inside the cage reaches 40% to 50% using this technique. disadvantages of using an oxygen cage are high consumption/ use of oxygen, rapid decrease in the fio 2 within the cage whenever the cage must be opened for patient treatments, lack of immediate access to the patient, and potential for iatrogenic hyperthermia. one of the most common methods for oxygen supplementation in dogs is nasal or nasopharyngeal oxygen catheters: 1. to place a nasal or nasopharyngeal catheter, obtain a red rubber catheter (8f to 12f, depending on the size of the patient). a. for nasal oxygen supplementation, measure the distal tip of the catheter from the medial canthus of the eye to the tip of the nose. b. for nasopharyngeal oxygen supplementation, measure the catheter from the ramus of the mandible to the tip of the nose. 2. mark the tube length at the tip of the nose with a permanent marker. 3. instill topical anesthetic such as proparacaine (0.5%) or lidocaine (2%) into the nostril before placement. 4. place a stay suture adjacent to (lateral aspect) the nostril while the topical anesthetic is taking effect. 5. lubricate the tip of the tube with sterile lubricant. 6. gently insert the tube into the ventral medial aspect of the nostril to the level made with the permanent marker. if you are inserting the tube into the nasopharynx, push the nasal meatus dorsally while simultaneously pushing the lateral aspect of the nostril medially to direct the tube into the ventral nasal meatus and avoid the cribriform plate. 7. once the tube has been inserted to the appropriate length, hold the tube in place with your fingers adjacent to the nostril, and suture the tube to the stay suture. if the tube is removed, you can cut the suture around the tube and leave the stay suture in place for later use, if necessary. 8. suture or staple the rest of the tube dorsally over the nose and in between the eyes to the top of the head, or laterally along the zygomatic arch. 9. attach the tube to a length of flexible oxygen tubing, and provide humidified oxygen at 50 to 100 ml/kg/minute. 10. secure an elizabethan collar around the patient's head to prevent the patient from scratching at the tube and removing it. the rule of 60s states that if a patient's pao 2 is less than 60 mm hg, or if the paco 2 is 60 mm hg, mechanical ventilation should be considered. for mechanical ventilation, anesthetize the patient and intubate the patient with an endotracheal tube. alternately, a temporary tracheostomy can be performed and the patient can be maintained on a plane of light to heavy sedation and ventilated through the tracheostomy site. this method, a noninvasive means of determining oxygenation is through the use of pulse oximetry. a pulse oximeter uses different wavelengths of light to distinguish characteristic differences in the properties of the different molecules in a fluid or gas mixture, in this case, oxygenated (oxyhemoglobin) and deoxygenated hemoglobin (deoxyhemoglobin) in pulsatile blood. the process is termed pulse oximetry. oxyhemoglobin and deoxyhemoglobin are different molecules that absorb and reflect different wavelengths of light. oxyhemoglobin absorbs light in the infrared spectrum, allowing wavelengths of light in the red spectrum to transmit through it. conversely, deoxyhemoglobin absorbs wavelengths of the red spectrum and allows wavelengths in the infrared spectrum to transmit through the molecule. the spectrophotometer in the pulse oximeter transmits light in the red (660 nanometers) and infrared (920 nanometers) spectra. the different wavelengths of light are transmitted across a pulsatile vascular bed and are detected by a photodetector on the other side. the photodetector processes the amount of light of varying wavelengths that reaches it, then transmits an electrical current to a processor that calculates the difference in the amount of light originally transmitted and the amount of light of similar wavelength that actually reaches the photodetector. the difference in each reflects the amount of light absorbed in the pulsatile blood and can be used to calculate the amount or ratio of oxyhemoglobin to deoxyhemoglobin in circulation, or the functional hemoglobin saturation by the formula: where hbo 2 is oxygenated hemoglobin, and hb is deoxygenated hemoglobin. four molecules of oxygen reversibly bind to hemoglobin for transport to the tissues. carbon monoxide similarly binds to hemoglobin and forms carboxyhemoglobin, a molecule that is detected similarly as oxygenated hemoglobin. thus sao 2 as detected by a pulse oximeter is not reliable if carboxyhemoglobin is present. in most cases, pulse oximetry or sao 2 corresponds reliably to the oxyhemoglobin dissociation curve. oxygen saturation greater than 90% corresponds to a pao 2 greater than 60 mm hg. above this value, large changes in pao 2 are reflected in relatively small changes in sao 2 , making pulse oximetry a relatively insensitive method of determining oxygenation status when pao 2 is normal. because pulse oximetry measures oxygenated versus nonoxygenated hemoglobin in pulsatile blood flow, it is fairly unreliable when severe vasoconstriction, hypothermia, shivering or trembling, or excessive patient movement are present. additionally, increased ambient lighting and the presence of methemoglobin or carboxyhemoglobin also can cause artifactual changes in the sao 2 , and thus the measurement is not reliable or accurate. most pulse oximeters also display a waveform and the patient's heart rate. if the photodetector does not detect a good quality signal, the waveform will not be normal, and the heart rate displayed on the monitor will not correlate with the patient's actual heart rate. the efficiency of ventilation is evaluated using the paco 2 value on an arterial blood gas sample. alternatively, a noninvasive method to determine end-tidal carbon dioxide is through use of a capnograph. the science of capnometry uses a spectrophotometer to measure carbon dioxide levels in exhaled gas. the capnometer is placed in the expiratory limb of an anesthetic circuit. a sample of exhaled gas is aliquoted from the breath, and an infrared light source is passed across the sample. a photodetector on the other side of the sample flow measures the amount or concentration of carbon dioxide in the sample of expired gas. the calculated value is displayed as end-tidal carbon dioxide. this value also can be displayed as a waveform. when placed in graphic form, a waveform known as a capnograph is displayed throughout the ventilatory cycle. normally, at the onset of exhalation, the gas exhaled into the expiratory limb of the tubing comes from the upper airway or physiologic dead space and contains relatively little carbon dioxide. as exhalation continues, a steep uphill slope occurs as more carbon dioxide is exhaled from the bronchial tree. near the end of exhalation, the capnogram reaches a plateau, which most accurately reflects the carbon dioxide level at the level of the alveolus. because carbon dioxide diffuses across the alveolar basement membrane so rapidly, this reflects arterial carbon dioxide levels. if a plateau is not reached and notching of the waveform occurs, check the system for leaks. if the baseline waveform does not reach zero, the patient may be rebreathing carbon dioxide or may be tachypneic, causing physiologic positive end-expiratory pressure. the soda-sorb in the system should be replaced if it has expired. conversely, low end-tidal carbon dioxide may be associated with a decrease in perfusion or blood flow. decreased perfusion can be associated with low end-tidal carbon dioxide values, particularly during cardiopulmonary cerebral resuscitation. end-tidal carbon dioxide levels are one of the most accurate predictors of the efficacy of cardiopulmonary cerebral resuscitation and patient outcome. additionally, the difference between arterial carbon dioxide levels (paco 2 ) and end-tidal carbon dioxide can be used to calculate dead-space ventilation. increases in the difference also occur with poor lung perfusion and pulmonary diffusion impairment. thoracocentesis refers to the aspiration of fluid or air from within the pleural space. thoracocentesis may be diagnostic to determine whether air or fluid is present and to characterize the nature of the fluid obtained. thoracocentesis also can be therapeutic when removing large volumes of air or fluid to allow pulmonary reexpansion and correction of hypoxemia and orthopnea. to perform thoracocentesis, follow this procedure: 1. first, assemble the equipment necessary (box 1-16). 2. next, clip a 10-cm square in the center of the patient's thorax on both sides. 3. aseptically scrub the clipped area. 4. ideally, thoracocentesis should be performed within the seventh to ninth intercostal space. rather than count rib spaces in an emergent situation, visualize the thoracic cage as a box, and the clipped area as a box within the box. you will insert your needle or catheter in the center of the box and then direct the bevel of the needle dorsally or ventrally to penetrate pockets of fluid or air present. 5. attach the needle or catheter hub to the length of intravenous extension tubing. attach the female port of the intravenous extension tubing to the male port of the three-way stopcock. attach the male port of the 60-ml syringe to one of the female ports of the three-way stopcock. the apparatus is now assembled for use. 6. insert the needle through the intercostal space such that the bevel of the needle initially is directed downward. 7. next, push down on the hub of the needle such that the needle becomes parallel with the thoracic wall. by moving the hub of the needle in a clockwise or counterclockwise manner, the bevel of the needle will move within the thoracic cavity to penetrate pockets of air or fluid. in general, air is located dorsally and fluid is located more ventrally, although this does not always occur. 8. aspirate air or fluid. save any fluid obtained for cytologic and biochemical analyses and bacterial culture and susceptibility testing. in cases of pneumothorax, if the thoracocentesis needs to be repeated more than 3 times, consider using a thoracostomy tube. place a thoracostomy tube in cases of pneumothorax whenever negative suction cannot be obtained or repeated accumulation of air requires multiple thoracocentesis procedures. thoracostomy tubes also can be placed to drain rapidly accumulating pleural effusion and for the medical management of pyothorax. before attempting thoracostomy tube placement, make sure that all necessary supplies are assembled (box 1-17; table 1-13) . to place a thoracostomy tube, follow this procedure: 1. lay the patient in lateral recumbency. 2. clip the patient's entire lateral thorax. 3. aseptically scrub the lateral thorax. 4. palpate the tenth intercostal space. 5. have an assistant pull the patient's skin cranially and ventrally toward the point of the elbow. this will facilitate creating a subcutaneous tunnel around the thoracostomy tube. 6. draw up 2 mg/kg 2% lidocaine (1 mg/kg for cats) along with a small amount of sodium bicarbonate to take away some of the sting. 7. insert the needle at the dorsal aspect of the tenth intercostal space and to the seventh intercostal space. inject the lidocaine into the seventh intercostal space at the point where the trocarized thoracic drainage catheter will penetrate into the thoracic cavity. slowly infuse the lidocaine as you withdraw the needle to create an anesthetized tunnel through which to insert the catheter. 8. while the local anesthetic is taking effect, remove the trocar from the catheter and cut the proximal end of the catheter with a mayo scissors to facilitate adaptation with the christmas tree adapter. 9. attach the christmas tree adapter to the three-way stopcock and the three-way stopcock to a length of intravenous extension tubing and the 60-ml syringe so that the apparatus can be attached immediately to the thoracostomy tube after placement. 10. aseptically scrub the lateral thorax a second time and then drape it with sterile huck towels secured with towel clamps. 11. wearing sterile gloves, make a small stab incision at the dorsal aspect of the tenth intercostal space. 12. insert the trocar back into the thoracostomy drainage tube. insert the trocar and tube into the incision. tunnel the tube cranially for approximately 3 intercostal spaces while an assistant simultaneously pulls the skin cranially and ventrally toward the point of the elbow. 13. at the seventh intercostal space, direct the trocar and catheter perpendicular to the thorax. grasp the catheter apparatus at the base adjacent to the thorax to prevent the trocar from going too far into the thorax. 14. place the palm of your dominant hand over the end of the trocar, and push the trocar and catheter into the thoracic cavity, throwing your weight into the placement in a swift motion, not by banging the butt of your hand on the end of the stylette. for small individuals, standing on a stool, or kneeling over the patient on the triage table can create leverage and make this process easier. the tube will enter the thorax with a pop. 15. gently push the catheter off of the stylette, and remove the stylette. 16. immediately attach the christmas tree adapter and have an assistant start to withdraw air or fluid while you secure the tube in place. 17. first, place a horizontal mattress suture around the tube to cinch the skin securely to the tube. use care to not penetrate the tube with your needle and suture. 18. next, place a purse-string suture around the tube at the tube entrance site. leave the ends of the suture long, so that you can create a finger-trap suture to the tube, holding the tube in place. 19. place a large square of antimicrobial-impregnated adhesive tape over the tube for further security and sterility. 20. if antimicrobial adhesive is not available, place a gauze pad 4 ã� 4 inches square over the tube, and then wrap the tube to the thorax with cotton roll gauze and elastikon adhesive tape. 21. draw the location of the tube on the bandage to prevent cutting it with subsequent bandage changes. an alternate technique to use if a trocar thoracic drainage catheter is not available is the following: 1. prepare the lateral thorax and infuse local lidocaine anesthetic as listed before. 2. make a small stab incision with a no. 10 scalpel blade, as listed before. 3. obtain the appropriately sized red rubber catheter and cut multiple side ports in the distal end of the catheter, taking care to not cut more than 50% of the circumference of the diameter of the tube. 4. insert a rigid, long urinary catheter into the red rubber catheter to make the catheter more rigid during insertion into the pleural space. 5. grasp the distal end of the catheter(s) in the teeth of a large carmalt. tunnel a metzenbaum scissors under the skin to the seventh intercostal space and make a puncture through the intercostal space. 6. remove the metzenbaum scissors, and then tunnel the carmalt and red rubber tube under the skin to the hole created in the seventh intercostal space with the metzenbaum scissors. 7. insert the tips of the carmalt and the red rubber catheter through the hole, and then open the teeth of the carmalt. 8. push the red rubber catheter cranially into the pleural cavity. 9. remove the carmalt and the rigid urinary catheter, and immediately attach the suction apparatus. secure the red rubber catheter in place as listed before. placement of a temporary tracheostomy can be lifesaving to relieve upper respiratory tract obstruction, to facilitate removal of airway secretions, to decrease dead space ventilation, to provide a route of inhalant anesthesia during maxillofacial surgery, and to facilitate mechanical ventilation. in an emergent situation in which asphyxiation is imminent and endotracheal intubation is not possible, any cutting instrument placed into the trachea distal to the point of obstruction can be used. to perform a slash tracheostomy, quickly clip the fur and scrub the skin over the third tracheal ring. make a small cut in the trachea with a no. 11 scalpel blade, and insert a firm tube, such as a syringe casing. alternately, insertion of a 22-gauge needle attached to intravenous extension tubing and adapted with a 1-ml syringe case to attach to a humidified oxygen source also temporarily can relieve obstruction until a temporary tracheostomy can be performed. in less emergent situations, place the patient under general anesthesia and intubate the patient. assemble all the equipment necessary before starting the temporary tracheostomy procedure (box 1-18). to perform a tracheostomy, follow this procedure: 1. place the patient in dorsal recumbency. 2. clip the ventral cervical region from the level of the ramus of the mandible caudally to the thoracic inlet and dorsally to midline. 3. aseptically scrub the clipped area, and then drape with sterile huck towels secured with towel clamps. 4. make a 3-cm ventral midline skin incision over the third to sixth tracheal rings, perpendicular to the trachea. 5. bluntly dissect through the sternohyoid muscles to the level of the trachea. 6. carefully pick up the fascia overlying the trachea and cut it away with a metzenbaum scissors. 7. place two stay sutures through/around adjacent tracheal rings. 8. incise in between trachea rings with a no. 11 scalpel blade. take care to not cut more than 50% of the circumference of the trachea. 9. using the stay sutures, pull the edges of the tracheal incision apart, and insert the tracheostomy tube. the shiley tube contains an internal obturator to facilitate placement into the tracheal lumen. remove the obturator, and then insert the inner cannula, which can be removed for cleaning as needed. 10. once the tube is in place, secure the tube around the neck with a length of sterile umbilical tape. postoperative care of the tracheostomy tube is as important as the procedure itself. because the tracheostomy tube essentially bypasses the protective effects of the upper respiratory system, one of the most important aspects of tracheostomy tube care and maintenance is to maintain sterility at all times. any oxygen source should be humidified with sterile water or saline to prevent drying of the respiratory mucosa. if supplemental oxygen is not required, instill 2 to 3 ml of sterile saline every 1 to 2 hours to moisten the mucosa. wearing sterile gloves, remove the internal tube and place it in a sterile bowl filled with sterile hydrogen peroxide and to be cleaned every 4 hours (or more frequently as necessary). if a shiley tube is not available, apply suction to the internal lumen of the tracheostomy tube every 1 to 2 hours (or more frequently as needed) with a sterile 12f red rubber catheter attached to a vacuum pump to remove any mucus or other debris that potentially could plug the tube. unless the patient demonstrates clinical signs of fever or infection, the prophylactic use of antibiotics is discouraged because of the risk of causing a resistant infection. after the temporary tracheostomy is no longer necessary, remove the tube and sutures, and leave the wound to heal by second intention. primary closure of the wounds could predispose the patient to subcutaneous emphysema and infection. baker gd: trans-tracheal oxygen therapy in dogs with severe respiratory compromise due to tick (i. holocyclus) toxicity, aust vet pract 34 (2) urohydropulsion is a therapeutic procedure for removal of uroliths from the urethra of the male dog. the technique works best if the animal is heavily sedated or is placed under general anesthesia (figure 1-12) . to perform urohydropulsion, follow this procedure: 1. place the animal in lateral recumbency. 2. clip the fur from the distal portion of the prepuce. 3. aseptically scrub the prepuce and flush the prepuce with 12 to 20 ml of antimicrobial flush solution. 4. have an assistant who is wearing gloves retract the penis from the prepuce. 5. while wearing sterile gloves, lubricate the tip of a rigid urinary catheter as for urethral catheterization. 6. gently insert the tip of the catheter into the urethra until you meet the resistance of the obstruction. 7. pinch the tip of the penis around the catheter. 8. have an assistant insert a gloved lubricated finger into the patient's rectum and press ventrally on the floor of the rectum to obstruct the pelvic urethra. 9. attach a 60-ml syringe filled with sterile saline into proximal tip of the catheter. 10. quickly inject fluid into the catheter and alternate compression and relaxation on the pelvic urethra such that the urethra dilates and suddenly releases the pressure, causing dislodgement of the stone. small stones may be ejected from the tip of the urethra, whereas larger stones may be retropulsed back into the urinary bladder to be removed surgically at a later time. the type of catheter that you choose for vascular access depends largely on the size and species of the patient, the fragility of the vessels to be catheterized, the proposed length of time that the catheter will be in place, the type and viscosity of the fluid or drug to be administered, the rate of fluid flow desired, and whether multiple repeated blood samples will be required (table 1-14) . a variety of over-the-needle, through-the-needle, and over-the-wire catheters are available for placement in a variety of vessels, including the jugular, cephalic, accessory cephalic, medial saphenous, lateral saphenous, dorsal pedal artery, and femoral artery. one of the most important aspects of proper catheter placement and maintenance is to maintain cleanliness at all times. the patient's urine, feces, saliva, and vomit are common sources of contamination of the catheter site. before placing a peripheral or central catheter in any patient, consider the patient's physical status including whether vomiting, diarrhea, excessive urination, or seizures. in a patient with an oral mass that is drooling excessively or a patient that is vomiting, peripheral cephalic catheterization may not be the most appropriate, to prevent contamination. conversely, in a patient with excessive urination or diarrhea, a lateral or medial saphenous catheter is likely to become contaminated quickly. whenever one places or handles a catheter or intravenous infusion line, the person should wash the hands carefully and wear gloves to prevent contamination of the intravenous catheter and fluid lines. one of the most common sources of catheter contamination in veterinary hospitals is through caretakers' hands. in emergent situations, placement of a catheter may be necessary under less than ideal circumstances. remove those catheters as soon as the patient is more stable, and place a second catheter using aseptic techniques. in general, once the location of the catheter has been decided, set up all equipment necessary for catheter placement before starting to handle and restrain the patient. lists the equipment needed for most types of catheter placement. after setting up all of the supplies needed, clip the fur over the site of catheter placement. make sure to clip all excess fur and long feathers away from the catheter site, to prevent contamination. for catheter placement in limbs, clip the fur circumferentially around the site of catheter placement to facilitate adherence of the tape to the limb and to facilitate catheter removal with minimal discomfort at a later date. next, aseptically scrub the catheter site with an antimicrobial scrub solution such as hibiclens. the site is now ready for catheter insertion. consider using a central venous catheter whenever multiple repeated blood samples will need to be collected from a patient during the hospital stay. central venous catheters also can be used for cvp measurement, administration of hyperoncotic solutions such as parenteral nutrition, and administration of crystalloid and colloid fluids, anesthesia, and other injectable drugs (figures 1-13 and 1-14) . to place a jugular central venous catheter, place the patient in lateral recumbancy and extend the head and neck such that the jugular furrow is straight. clip the fur from the ramus of the mandible caudally to the thoracic inlet and dorsally and ventrally to midline. wipe the clipped area with gauze 4 ã� 4-inch squares to remove any loose fur and other debris. aseptically scrub the clipped area with an antimicrobial cleanser. venocaths (abbott laboratories) are a through-the-needle catheter that is contained within a sterile sleeve for placement. alternately, other over-the-wire central venous catheters can be placed by the seldinger technique. sterility must be maintained at all times, regardless of the type of catheter placed. wearing sterile gloves, drape the site of catheter placement with sterile drapes, and occlude the jugular vein at the level of the thoracic inlet. pull the clear ring and wings of emergency diagnostic and therapeutic procedures 59 1 figure 1 -13: lateral thoracic radiograph of a central venous catheter. note that the tip of the catheter is inserted in its proper location, just outside of the right atrium. the catheter cover down toward the catheter itself to expose the needle. remove the guard off of the needle. lift the skin over the proposed site of catheter insertion and insert the needle under the skin, with the bevel of the needle facing up. next, reocclude the vessel and pull the skin tight over the vessel to prevent movement of the vessel as you attempt to insert the needle. in some cases, it may be difficult actually to see the vessel in obese patients. if you cannot visualize or palpate the needle, gently bounce the needle over the vessel with the bevel up. the vessel will bounce in place slightly, allowing a brief moment of visualization to facilitate catheter placement. once the vessel has been isolated and visualized, insert the needle into the vessel at a 15-to 30-degree angle. watch closely for a flash of blood in the catheter. when blood is observed, insert the needle a small distance farther, and then push the catheter and stylette into the vessel for the entire length, until the catheter and stylette can be secured in the catheter hub. if the catheter cannot be inserted fully into the vessel for its entire length, the tip of the needle may not be within the entire lumen, the catheter may be directed perivascularly, and the catheter may be caught at the thoracic flexure and may be moving into one of the tributaries that feeds the forelimb. extend the patient's head and neck, and lift the forelimb up to help facilitate placement. do not force the catheter in because the catheter potentially can form a knot and will need to be removed surgically. remove the needle from the vessel, and have an assistant place several 4 ã� 4-inch gauze squares over the site of catheter placement with some pressure to control hemorrhage. secure the catheter hub into the needle guard, and remove the stylette from the catheter. immediately insert a 3-to 6-ml syringe of heparinized saline and flush the catheter and draw back. if you are in the correct place, you will be able to draw blood from the catheter. to secure the catheter in place, tear a length of 1-inch white tape that will wrap around the patient's neck. pull a small length of the catheter out of the jugular vein to make a semicircle. the semicircle should be approximately 1 /2 inch in diameter. let the length of catheter lie on the skin, and then place 4 ã� 4-inch gauze squares impregnated with antimicrobial ointment over the site of catheter insertion. secure the proximal end of white tape around the white and blue pieces of the catheter, and wrap the tape around the patient's neck so that the tape adheres to the skin and fur. repeat the process by securing the gauze to the skin with two additional lengths of white tape, starting to secure the gauze in place by first wrapping the tape dorsally over the patient's neck, rather than under the patient's neck. in between each piece of tape and bandage layer, make sure that the catheter flushes and draws back freely, or else occlusion can occur. gently wrap layers of cotton roll gauze, kling, and elastikon or vetrap over the catheter. secure a male adapter or t port that has been flushed with heparinized saline, and then label the catheter with the size and length of catheter, date of catheter placement, and initials of the person who placed the catheter. the catheter is ready for use. monitor the catheter site daily for erythema, drainage, vessel thickening, or pain upon infusion. if any of these signs occur, or if the patient develops a fever of unknown origin, remove the catheter, culture the catheter tip aseptically, and replace the catheter in a different location. as long as the catheter is functional without complications, the catheter can remain in place. central catheters also can be placed via the seldinger or over-the-wire technique. a number of companies manufacture kits that contain the supplies necessary for over-the-wire catheter placement. each kit minimally should contain an over-the-needle catheter to place into the vessel, a long wire to insert through the original catheter placed, a vascular dilator to dilate the hole in the vessel created by the first catheter, and a long catheter to place into the vessel over the wire. additional accessories can include a paper drape, sterile gauze, a scalpel blade, local anesthetic, 22-gauge needles, and 3-or 6-ml syringes. restrain the patient and prepare the jugular furrow aseptically as for the percutaneous through-the-needle catheter placement. the person placing the catheter should wear sterile gloves throughout the process to maintain sterility. pick up the skin over the site of catheter placement, and insert a small bleb of local anesthetic through the skin. the local anesthetic should not be injected into the underlying vessel (figure 1-15) . make a small nick into the skin through the local anesthetic with a no. 10 or no. 11 scalpel blade. use care to avoid lacerating the underlying vessel. next, occlude the jugular vein as previously described, and insert the over-the-needle catheter into the vessel. watch for a flash of blood in the catheter hub. remove the stylette from the catheter. next, insert the long wire into the catheter and into the vessel (figures 1-16 and 1-17) . never let go of the wire. remove the catheter, and place the vascular dilator over the wire and into the vessel (figure 1-18) . gently twist to place the dilator into the vessel a short distance, creating a larger hole in the vessel. the vessel will bleed more after creating a larger hole. remove the vascular dilator, and leave the wire in place within the vessel. insert the long catheter over the wire into the vessel (figure 1-19) . push the catheter into the vessel to the catheter hub (figure 1-20) . slowly thread the wire through a proximal port in the catheter. once the catheter is in place, remove the wire, and suture the catheter in place to the skin with nonabsorbable suture. cover the catheter site with sterile gauze and antimicrobial ointment, cotton roll bandaging material, gauze, and kling or vetrap. flush the catheter with heparinized saline solution, and then use the catheter for infusion of parenteral nutrition, blood products, crystalloid and colloid fluids, medications, and frequent blood sample collection. examine the catheter site daily for evidence of infection or thrombophlebitis. the catheter can remain in place as long as it functions and no complications occur. place the patient in sternal recumbency as for cephalic venipuncture. clip the antebrachium circumferentially, and wipe the area clean of any loose fur and debris (figure 1-21) . aseptically scrub the clipped area, and have an assistant occlude the cephalic vein at the crook of the elbow. the person placing the catheter should grasp the distal carpus with the nondominant hand and insert the over-the-needle catheter into the vessel at a 15-to 30-degree angle ( figure 1-22) . watch for a flash of blood in the catheter hub, and then gently push the catheter off of the stylette (figure 1-23) . have the assistant occlude the vessel over the catheter to prevent backflow. flush the catheter with heparinized saline solution. make sure that the skin and catheter hub are clean and dry to ensure that the tape adheres to the catheter hub and skin. secure a length of 1 /2-inch white tape tightly around the catheter and then around the limb. make sure that the catheter hub does not "spin" in the tape, or else the catheter will fall out. next, secure a second length of 1-inch adhesive tape under the catheter and around the limb and catheter hub (figure 1-24 ). this piece of tape helps to stabilize the catheter in place. finally, place a flushed t port or male adapter in the catheter hub and secure to the limb with white tape. make sure that the tape is adhered to the skin securely, but not so tightly as to impede venous outflow (figure 1-25) . the catheter site can be covered with a cotton ball impregnated with antimicrobial ointment and layers of bandage material. label all catheters with the date of placement, the type and gauge of catheter inserted, and the initials of the person who placed the catheter. the femoral artery can be catheterized for placement of an indwelling arterial catheter. indwelling arterial catheters can be used for continuous invasive arterial blood pressure monitoring and for procurement of arterial blood samples. place the patient in lateral recumbancy, and tape the down leg in an extended position. clip the fur over the femoral artery and aseptically scrub the clipped area. palpate the femoral artery as it courses distally on the medial surface of the femur and anterior to the pectineus muscle. make a small nick incision over the proposed site of catheter placement using the bevel of an 18-gauge needle. place a long over-the-needle catheter through the nick in the skin and direct it toward the palpable pulse. place the tip of the catheter so that the needle tip rests in the subcutaneous tissue between the artery and the palpating index finger. advance the needle steeply at a 30-degree angle to secure the superficial wall of the vessel and then the deep wall of the vessel. the spontaneous flow of blood in the catheter hub ensures that the catheter is 1 figure 1 -25: catheter is taped in place with a t-port. situated in the lumen of the artery. feed the catheter off of the stylette, and cover the hub with a catheter cap. flush the catheter with sterile heparinized saline solution, and then secure it in place. some persons simply tape the catheter in place with pieces of 1 /2-and 1-inch adhesive tape. others use a "butterfly" piece of tape around the catheter hub and suture or glue the tape to the adjacent skin for added security. the dorsal pedal artery commonly is used for catheter placement. to place a dorsal pedal arterial catheter, place the patient in lateral recumbency. clip the fur over the dorsal pedal artery, and then aseptically scrub the clipped area. tape the distal limb so that the leg is twisted slightly medially for better exposure of the vessel, or the person placing the arterial catheter can manipulate the limb into the appropriate position. palpate the dorsal pedal pulse as it courses dorsally over the tarsus. place an over-the-needle catheter percutaneously at a 15-to 30-degree angle, threading the tip of the needle carefully toward the pulse. advance the needle in short, blunt movements, and watch the catheter hub closely for a flash of pulsating blood that signifies penetration into the lumen of the artery. then thread the catheter off of the stylette, and cover the catheter hub with a catheter cap. secure the catheter in place with lengths of 1 /2-and 1-inch adhesive tape as with any other intravenous catheter, and then flush it with heparinized saline solution every 2 to 4 hours. any vessel that can be catheterized percutaneously also can be catheterized with surgical cutdown. restrain the patient and clip and aseptically scrub the limb or jugular vein as for a percutaneous catheterization procedure. block the area for catheter placement with a local anesthetic before cutting the skin over the vessel with a no. 11 scalpel blade. while wearing sterile gloves, pick up the skin and incise the skin over the vessel. direct the sharp edge of the blade upward to avoid lacerating the underlying vessel. using blunt dissection, push the underlying subcutaneous fat and perivascular fascia away from the vessel with a mosquito hemostat. make sure that all tissue is removed from the vessel. using the mosquito hemostat, place two stay sutures of absorbable suture under the vessel. elevate the vessel until it is parallel with the incision, and gently insert the catheter and stylette into the vessel. secure the stay sutures loosely around the catheter. suture the skin over the catheter site with nonabsorbable suture, and then tape and bandage the catheter in place as for percutaneous placement. remove catheters placed surgically as soon as possible and exchange them for a percutaneously placed catheter to avoid infection and thrombophlebitis. the most important aspect of catheter maintenance is to maintain cleanliness and sterility at all times. an indwelling catheter can remain in place for as long as it is functional and no complications occur. change the bandage whenever it becomes wet or soiled to prevent wicking of bacteria and debris from the environment into the vessel. check the bandages and catheter sites at least once a day for signs of thrombophlebitis: erythema, vessel hardening or ropiness, pain upon injection or infusion, and discharge. also closely examine the tissue around and proximal and distal to the catheter. swelling of the paw can signify that the catheter tape and bandage are too tight and are occluding venous outflow. swelling above the catheter site is characteristic of perivascular leakage of fluid and may signify that the catheter is no longer within the lumen of the vessel. remove the catheter if it is no longer functional, if there is pain or resistance upon infusion, if there is unexplained fever or leukocytosis, or if there is evidence of cellulitis, thrombophlebitis, or catheter-related bacteremia or septicemia. aseptically culture the tip of the indwelling catheter for bacteria. animals should wear elizabethan collars or other forms of restraint if they lick or chew at the catheter or bandage. catheter patency may be maintained with constant fluid infusion or by intermittent flushing with heparinized saline (1000 units of unfractionated heparin per 250 to 500 ml of saline) every 6 hours. flush arterial catheters more frequently (every 2 hours). disconnect intravenous connections only when absolutely necessary. wear gloves whenever handling the catheter or connections. label all fluid lines and elevate them off of the floor to prevent contamination. date each fluid line and replace it once every 24 to 36 hours. if an intravenous catheter cannot be placed because of small patient size, hypovolemia, hypothermia, or severe hypotension, needles can be placed into the marrow cavity of the femur, humerus, and tibia for intraosseous infusion of fluids, drugs, and blood products. this technique is particularly useful in small kittens and puppies and in exotic species. contraindications to intraosseous infusion is in avian species (which have air in their bones), fractures, and sepsis, because osteomyelitis can develop. an intraosseous catheter is relatively easy to place and maintain but can cause patient discomfort and so should be changed to an intravenous catheter as soon as vascular access becomes possible. to place an intraosseous catheter, clip and aseptically scrub the fur over the proposed site of catheter placement. the easiest place for intraosseous placement is in the intertrochanteric fossa of the femur. inject a small amount of a local anesthetic through the skin and into the periosteum where the trocar or needle will be inserted. place the patient in lateral recumbency, and grasp the leg in between your fingers, with the stifle braced against the palm of your hand. push the stifle toward the abdomen (medially) to abduct the proximal femur away from the body. this will shift the sciatic nerve out of the way of catheter placement. insert the tip of the needle through the skin and into the intertrochanteric fossa. gently push with a simultaneous twisting motion, pushing the needle parallel with the shaft of the femur, toward your palm. you may feel a pop or decreased resistance as the needle enters the marrow cavity. gently flush the needle with heparinized saline. if the needle is plugged with bone debris, remove the needle and replace it with a fresh needle of the same type and size in the hole that you have created. a spinal needle with an internal stylette also can be placed. the stylette will prevent the needle from becoming clogged with bone debris during insertion. secure the hub of the needle with a butterfly length of white adhesive tape and then suture it to the skin to keep the catheter in place. the catheter is now ready for use. the patient should wear an elizabethan collar to prevent disruption or removal of the catheter. the intraosseous catheter can be maintained as any peripheral catheter, with frequent flushing and daily evaluation of the catheter site. the definition of pain has been debated philosophically over the ages and has changed as knowledge has increased. pain is defined as an unpleasant sensory or emotional experience associated with actual or perceived tissue damage. until recognition of a noxious stimulus occurs in the cerebral cortex, no response or adaptation results. rational management of pain requires an understanding of the underlying mechanisms involved in pain and an appreciation of how analgesic agents interact to disrupt pain mechanisms. multiple factors and causes produce pain in human beings and domestic animal species. the causes of pain, psychological and physical, may derive from many different mechanisms within emergency medicine, among them trauma, infectious disease, neglect, environmental stress, surgery, and acute decompensation of chronic medical conditions. the two major classes of pain are acute and chronic pain. box 1-20 gives specific categories and causes of pain. the pain sensing and response system can be divided into the following categories: nociceptors, which detect and filter the intensity of the noxious stimuli; primary afferent nerves, which transmit impulses to the central nervous system (cns); ascending tracts, which are part of the dorsal horn and the spinal cord that conveys stimuli to higher centers in the brain; higher centers, which are involved in pain discrimination, some memory, and motor control; and modulating or descending systems, which are a means of processing, memorizing, and modifying incoming impulses. current analgesic therapies may inhibit afferent nociceptive transmission within the brain and spinal cord; directly interrupt neural impulse conduction through the dorsal horn, primary afferent nerves, or dorsal root ganglion; or prevent the nociceptor sensitization that accompanies initial pain and inflammation. the physiologic aspects of pain are believed to be produced by the transmission, transduction, and integration of initial nerve endings, peripheral neuronal input, and ascending afferent nerves via the thalamus to the cerebral cortex. ascending afferent nerves to the limbic system are believed to be responsible for the emotional aspects of pain. there are several classification schemes for different types of pain. acute pain, such as that which results from trauma, surgery, or infectious agents, is abrupt in onset, relatively short in duration, and may be alleviated easily by analgesics. in contrast, chronic pain is a long-standing physical disorder or emotional distress that is slow in onset and difficult to treat. both types of pain can be classified further based on site of origin. somatic pain arises from superficial skin, subcutaneous tissue, body wall, or appendages. visceral pain arises from abdominal or thoracic viscera and primarily is associated with serosal irritation. analgesia, then, is the loss of pain without the loss of consciousness. this is in contrast to anesthesia, which is the loss of sensation in the whole body or a part of the body with the loss of consciousness or at least depression of the cns. untreated pain causes immediate changes in the neurohormonal axis, which in turn causes restlessness, agitation, increased heart and respiratory rates, fever, and blood pressure fluctuations, all of which are detrimental to the healing of the animal. a catabolic state is created as a result of increased secretion of catabolic hormones and decreased secretion of anabolic hormones. the net effect the majority of neurohormonal changes produce is an increase in the secretion of catabolic hormones. hyperglycemia is produced and may persist because of production of glucagon and relative lack of insulin. lipolytic activity is stimulated by cortisol, catecholamines, and growth hormone. cardiorespiratory effects of pain include increased cardiac output, vasoconstriction, hypoxemia, and hyperventilation. protein catabolism is a common occurrence and major concern regarding healing. pain associated with inflammation causes increase in tissue and blood levels of prostaglandins and cytokines, both of which promote protein catabolism indirectly by increasing the energy expenditure of the body. powerful evidence indicates that local anesthetic, sympathetic agonist, and opioid neural blockade may produce a modification of the responses to these physiologic changes. variable reduction in plasma cortisol, growth hormone, antidiuretic hormone, î²-endorphin, aldosterone, epinephrine, norepinephrine, and renin is based on the anesthetic technique and the drugs selected. prophylactic administration of analgesics blunts the response before it occurs; analgesics administered following perception or pain are not as effective, and higher doses are generally necessary to achieve an equivalent level of analgesia. effective pain control can be achieved only when the signs of pain can be assessed effectively, reliably, and regularly. the experience of pain is unique to each individual, which makes pain assessment difficult, especially in traumatized and critical patients. most attempts to assess clinical pain use behavioral observations and interactive variables in addition to assessment of physiologic responses such as heart rate and respiratory rate, blood pressure, and temperature. but many factors can influence the processing and outward projection of pain, including altered environments, species differences, withinspecies variations (age, breed, sex), and the type, severity, and chronicity of pain. within-species differences (age, breed, and sex) further complicate the pain assessment. most notable is that different breeds of dogs act differently when confronted with pain or fear. labrador retrievers tend to be stoic, whereas greyhounds and teacup breeds tend to react with a heightened state of arousal around even the simplest of procedures (e.g., subcutaneous injections and nail trims). the individual character and temperament of the animal further influences its response. pediatric and neonatal animals seem to have a lower threshold for pain and anxiety than older animals. in any species, the duration and type of pain make it more (acute) or less (chronic) likely to be expressed or exhibited outwardly. unfamiliarity with normal behaviors typical of a particular species or breed makes recognition of their painful behaviors and responses impossible. the definition and recognition of pain in an individual animal is challenging. because of all the differences discussed, there is no straight line from insult, albeit actual or perceived, to degree of pain experienced. nor is there a formula for treating "x" type of pain with "y" type of analgesic. a goal of analgesia is to treat all animals with analgesic drugs and modalities as preemptively as possible and using a multimodal approach. use analgesic treatment as a tool for diagnosis of pain in the event that recognition of these phenomena is difficult for the patient. in other words, with countless drugs and treatment modalities available, analgesic administration should never be withheld in an animal, even if pain is questionable. it is important to remember that no behavior or physiologic variable in and of itself is pathognomonic for pain. interactive and unprovoked (noninteractive) behavior assessments and trending of physiologic data are useful to determine the pain in an individual animal. this is known as pain scoring. baseline observations, especially those observations from someone who has known the animal well, can be helpful to serial behavior and pain assessments. pain scoring systems have been developed and are reviewed elsewhere; the purposes of these systems are to evaluate and to help guide diagnostic and analgesic treatments (table 1 -15) . regardless of the scale or method used to assess pain, the caregiver must recognize the limitations of the scale. if in doubt of whether pain is present or not, analgesic therapy should be used as a diagnostic tool. classic behaviors associated with pain in dogs and cats include abnormal postures, gaits, movements, and behaviors (boxes 1-21 and . stoicism is the apparent apathy and pain: assessment, prevention, and management 71 indifference in the presence of pain and is perhaps the no. 1 sign of ineffective pain relief or persistent pain in many animals, because so many display apathy and classically normal physiologic parameters even in the face of severe distress, overt suffering, or blatant trauma and illness. the absence of normal behaviors is also a clinical sign of pain, even when abnormal behaviors are not observed. acute pain results in many of the aforementioned behavioral and physiologic signs, but chronic pain in small animals is an entirely different and distinct entity. chronic pain is often present in the absence of obvious tissue pathology and changes in physical demeanor. again, the severity of the pain may not correlate with the severity of any pathologic condition that may or may not be present. chronic pain, especially if insidious in onset (cancer, dental, or degenerative pain), may well go unnoticed in dogs and cats, even by family members or intermittent caregivers. inappetance, lack of activity, panting in a species classically designed to be nose breathers, decreased interest in surroundings, different activity patterns, and abnormal postures are just a few signs of chronic pain in cats and dogs. cats are a species that in particular are exemplary in their abilities to hide chronic pain. they will exhibit marked familial withdrawal, finding secluded areas where they may remain for days to weeks when they experience acute and chronic pain. when deciding on a pain management protocol for a patient, always perform a thorough physical examination and include a pain score assessment before injury and pain has occurred, whenever possible. form a problem list to guide your choice of anesthesia and analgesia. for example, using a nonsteroidal antiinflammatory drug (nsaid) in an animal with renal failure would not be wise. remember to account for current medications that the patient may be taking that may augment or interfere with the analgesic or anesthetic drugs. use multimodal techniques and regional therapy and drugs to target pain at different sites before it occurs. once a strategy is decided upon, frequently reassess the patient and tailor the protocol to meet each patient's response and needs. drug therapy (in particular, opioids with or without î± 2 -agonists) is a cornerstone for acute pain treatment and surgical preemptive pain prevention. however, local anesthetics delivered epidurally, via perineural or plexus injection, intraarticular or trigger point injection, are also effective analgesics for acute and chronic forms of pain and inflammation. the nsaids that classically have been reserved for treatment of more chronic or persistent pain states now are being used regularly for treatment of acute and perioperative pain once blood pressure, coagulation, and gastrointestinal parameters have been normalized. an opioid is any natural or synthetic drug that is derived from the poppy, which interacts with opiate receptors identified on cell membranes. the drugs from this class constitute the most effective means of controlling acute, perioperative, and chronic pain in human and veterinary medicine (table 1 -16) . their physiologic effects result from the interaction with one or more of at least five endogenous opioid receptors (âµ, ï�, î´, îµ, and îº). âµ-receptor agonists are noted for their ability to produce profound analgesia with mild sedation. these drugs diminish "wind-up," the hyperexcitable state resulting from an afferent volley of nociceptive impulses. they elevate the pain threshold and are used preemptively to prevent acute pain. as a class, opioids cause cns depression with their intense analgesia. dose-related respiratory depression reflects diminished response to carbon dioxide levels. cardiac depression is secondary only to bradycardia and is more likely with certain opioids such as morphine and oxymorphone. narcotics produce few if any clinically significant cardiovascular effects in dogs and cats; they are considered cardiac soothing or sparing. because opioids increase intracranial and intraocular pressure, use them more cautiously in patients with severe cranial trauma and or ocular lesions. opioids directly stimulate the chemoreceptor trigger zone and may cause nausea and vomiting. most opioids depress the cough reflex via a central mechanism; this may be helpful in patients recovering from endotracheal intubation irritation. a key characteristic of opioids that makes them desirable for use in emergency and critical care situations is their reversibility. antagonists block or reverse the effect of agonists by combining with receptors and producing minimal or no effects. administer all reversal agents, such as naloxone and naltrexone, slowly if given intravenously and to effect. î± î± 2 -agonists as a class of drugs, î± 2 -agonists warrant special attention because most members of the group possess potent analgesic power at doses that are capable of causing sedation, cns depression, cardiovascular depression, and even general anesthetic states. originally developed for antihypertensive use, î± 2 -agonists quickly have attained sedative analgesic status in veterinary medicine (table 1 -17) . like the opioids, î± 2 -agonists produce their effects by aggravating î±-adrenergic receptors in the cns and periphery. 1 emergency care among them cyclooxygenase-1 (cox-1), the major constitutive enzyme primarily involved in normal physiologic functions, and cox-2, the enzyme responsible for most of the hyperalgesia and pain responses experienced after tissue injury or trauma. some nsaids inhibit cyclooxygenase and lipoxygenase activity. most of the currently available oral and parenteral nsaids for small animal medicine and surgery target the cyclooxygenase pathways predominantly, although one (tepoxalin) is thought to inhibit both pathways. inhibition of cox-1 and cox-2 can inhibit the protective effects and impair platelet aggregation and lead to gastrointestinal ulceration. there are definite contraindications and relative contraindications for the use of nsaids. nonsteroidal antiinflammatory drugs should not be administered to patients with renal or hepatic insufficiency, dehydration, hypotension or conditions that are associated with low circulating volume (congestive heart failure, unregulated anesthesia, shock), or evidence of ulcerative gastrointestinal disease. trauma patients should be stabilized completely regarding vascular volume, tone, and pressure before the use of nsaids. patients receiving concurrent administration of other nsaids or corticosteroids, or those considered to be cushingoid, should be evaluated carefully for an adequate "washout" period (time of clearance of drug from the system) before use of an nsaid or before switching nsaids. patients with coagulopathies, particularly those that are caused by platelet number or function defects or those caused by factor deficiencies, and patients with severe, uncontrolled asthma or other bronchial disease are probably not the patients in which to use nsaids. other advice is that nsaids not be administered to pregnant patients or to females attempting to become pregnant because cox-2 induction is necessary for ovulation and subsequent implantation of the embryo. the administration of nsaids should be considered only in the well-hydrated, normotensive dog or cat with normal renal or hepatic function, with no hemostatic abnormalities, and no concurrent steroid administration. nonsteroidal antiinflammatory drugs can be used in many settings of acute and chronic pain and inflammation. among these are the use in well-stabilized musculoskeletal trauma and surgical pain, osteoarthritis management, meningitis, mastitis, animal bite and other wound healing, mammary or transitional cell carcinoma, epithelial (dental, oral, urethral) inflammation, ophthalmologic procedures, and dermatologic or otic disease. whereas opioids seem to have an immediate analgesic effect when administered, most nsaids will take up to 30 minutes for their effect to be recognized. as such, most perioperative or acute nsaids use is part of a balanced pain management scheme, one that uses narcotics and local anesthetic techniques. nonsteroidal antiinflammatory drugs are devoid of many of the side effects of narcotic administration; namely, decreased gastrointestinal motility, altered sensorium, nausea/vomition, and sedation. nonsteroidal antiinflammatory drugs are also devoid of many of the side effects of steroid administration; namely, suppression of the pituitary adrenal axis. the toxic effects of salicylates in cats are well documented. cats are susceptible because of slow clearance and dose-dependent elimination because of deficient glucuronidation in this species. because of this, the dose and the dosing interval of most commonly used nsaids need to be altered in order for these drugs to be used. cats that have been given canine doses of nsaids (twice daily or even once daily repetitively) may show hyperthermia, hemorrhagic or ulcerative gastritis, kidney and liver injury, hyperthermia, respiratory alkalosis, and metabolic acidosis. acute and chronic toxicities of nsaids have been reported in cats, especially after repeat once daily dosing. ketoprofen, flunixin, aspirin, carprofen, and meloxicam have been administered safely to cats, although like most antibiotics and other medications, they are not approved and licensed for use in cats. an important note, though, is that dosing intervals ranging from 48 to 96 hours have been used, and antithrombotic effects often can be achieved at much lower doses than those required to treat fevers and inflammation. i recommend the use of no loading doses, minimum 48-hour dosing intervals, and assurance of adequate circulating blood volume, blood pressure, and renal function. because many of the nsaids are used off-label in cats, it is imperative that the clinician carefully calculate the dose, modify the dosing interval, and communicate this information to the client before dispensing the drug. even drugs that come in liquid form (meloxicam), if administered to cats via box-labeled directions used for dogs, will be given in near toxic doses. to worsen the misunderstanding about dosages for cats, drops from manufacturer's bottles often are calibrated drops; when these same liquids are transferred into pharmacy syringes for drop administration, the calibration of course is lost, and the animal potentially is overdosed. a more accurate method of dispensing and administering oral nsaids in cats is to calculate the dose in milligrams and determine the exact number of milliliters to administer, rather than use the drop method. ketamine classically was considered a dissociative anesthetic, but it also has potent activity as an n-methyl-d-aspartate (nmda) receptor antagonist. this receptor located in the cns mediates windup and central sensitization (a pathway from acute to chronic pain). blockade of this receptor with microdoses of ketamine results in the ability to provide body surface, somatic, and skin analgesia with potentially lower doses of opioids and î±-agonists. loading doses of 0.5 to 2 mg/kg are used intravenously with continuous rate infusions of 2 to 20 âµg/kg/minute. in and of itself, this drug possesses little to no analgesic ability and indeed in high doses alone often can aggravate, sensitize, or excite the animal in subacute or acute pain. amantadine is another nmda blocker that has been used for its antiviral and parkinson's stabilizing effects. amantadine has been used for neuropathic pain in human beings but is only available in an oral form. suggested starting doses for cats and dogs range from 3 to 10 mg/kg po daily. when the drug is given orally and intravenously, patients are unlikely to develop behavioral or cardiorespiratory effects with ketamine or amantadine. tramadol is an analgesic that possesses weak opioid âµ-agonist activity and norepinephrine and serotonin reuptake inhibition. tramadol is useful for mild to moderate pain in small animals. although the parent compound has very weak opioid activity, the metabolites have excellent binding affinity for the âµ-receptor. tramadol has been used for perisurgical pain control when given orally in cats and dogs at a dose of 1 to 10 mg/kg po sid to bid. cats appear to require only once daily dosing. regardless of its affinity for the opioid receptors, the true mechanism of action of tramadol in companion animals remains largely unknown. gabapentin is a synthetic analog of î³-aminobutyric acid (gaba). originally introduced as an antiepileptic drug, the mechanism of action of gabapentin remains somewhat unclear in veterinary medicine. the drug is among a number of commonly used antiepileptic medications used to treat central pain in human beings. the rationale for use is the ability of the drugs to suppress discharge in pathologically altered neurons. gabapentin does this through calcium channel modulation without binding to glutamate receptors. chronic, burning, neuropathic, and lancinating pain in small animals responds well to 1 to 10 mg/kg po daily. local anesthetic agents are the major class used as a peripheral-acting analgesic ( table 1 -19) . local anesthetics block the transmission of pain impulses at the peripheral nerve nociceptor regions. local anesthetics may be used to block peripheral nerves or inhibit nerve "zones" using regional techniques. although all local anesthetics are capable of providing pain relief, agents with a longer duration of action are preferred for pain management purposes. bupivacaine is an example of a long-acting local anesthetic drug that is used along with lidocaine for long-acting pain relief. a single dose of bupivacaine injected at a local site will provide local anesthesia and analgesia for 6 to 10 hours. when lidocaine is administered as an intravenous constant rate infusion (50 to 75 âµg/kg/minute in dogs, 1 to 10 âµg/kg/minute in cats) is effective in the treatment of chronic neuropathic pain and periosteal and peritoneal pain (e.g., pancreatitis). mexiletine, an oral sodium channel blocker, can be used as an alternative to injectable lidocaine for provision of background analgesia. many drugs (table 1 -20) are used in combination with opioids, î± 2 -agonists, and ketamine to provide anxiolysis and sedation. injection of local anesthetic solution into the connective tissue surrounding a particular nerve produces loss of sensation (sensory blockade) and/or paralysis (motor nerve blockade) in the region supplied by the nerve. local anesthetics also may be administered epidurally, intrathoracically, intraperitoneally, and intraarticularly. lidocaine and bupivacaine are the most commonly administered local anesthetics. lidocaine provides for quick, short-acting sensory and motor impairment. bupivacaine provides for later-onset, longerlasting desensitization without motor impairment. combinations of the two agents diluted with saline are used frequently to provide for quick-onset analgesia that lasts between 4 and 6 hours in most patients. adding narcotic and/or î± 2 agent often maximizes the analgesia and increases the pain-free interval to 8 to 18 hours. epinephrine and preservative-free solutions are recommended. precision placement of anesthetic close to nerves, roots, or plexuses is improved with the use of a stimulating nerve locator. cats seem to be more sensitive to the effects of local anesthetics; as such the lower ends of most dosing ranges are used for blockades in this species. unlike most instances of general anesthesia, during which the animal is rendered unconscious and nerve transmission is decreased by virtue of cns depression, local and regional techniques block the initiation of noxious signals, thereby effectively preventing pain from entering the cns. this is an effective means of not only preventing initial pain but also reducing the changes that take place in the dorsal horn of the spinal cord, spinothalamic tracts, limbic and reticular activating centers, and cortex. frequently, the neurohormonal response that is stimulated in pain and stress is blunted as well. overall, the patient has fewer local and systemic adverse effects of pain, disease processes are minimized, chronic pain states are unlikely, and outcome is improved. regional techniques are best used as part of an analgesic regimen that consists of their continuous administration, narcotics, î±-agonists, anxiolytics, and good nursing. lidocaine can be added to sterile lubricant in a one-to-one concentration to provide decreased sensation for urinary catheterization, nasal catheter insertion, minor road burn analgesia, and pyotraumatic dermatitis analgesia. proparacaine is a topical anesthetic useful for corneal or scleral injuries. local anesthetics can be used to infiltrate areas of damage or surgery by using long-term continuous drainage catheters and small, portable infusion pumps. this is an effective means of providing days of analgesia for massive surgical or traumatic soft tissue injury. even without the catheter, incisional or regional soft tissue blocking using a combination of 1 to 2 mg/kg lidocaine and 0.5 to 2 mg/kg bupivacaine diluted with equal volume of saline and 1:9 with sodium bicarbonate is effective for infiltrating large areas of injury. administration of local anesthetic drugs around the infraorbital, maxillary, ophthalmic mental, and alveolar nerves can provide excellent analgesia for dental, orofacial, and ophthalmic trauma and surgical procedures. each nerve may be desensitized by injecting 0.1 to 0.3 ml of a 2% lidocaine hydrochloride solution and 0.1 to 0.3 ml of 0.5% bupivacaine solution using a 1.2-to 2.5-cm, 22-to 25-gauge needle. precise placement perineurally versus intraneurally (neuroma formation common) is enhanced by using catheters in the foramen versus needle administration. always perform aspiration before administration to rule out intravascular injection of agents. this block is used to provide analgesia for thoracic, lower cervical, cranial abdominal, and diaphragmatic pain. following aseptic preparation, place a small through-the-needle (20-to 22-gauge) catheter in the thoracic cavity between the seventh and ninth intercostal space on the midlateral aspect of the thorax. aseptically mix a 0.5 to 1 mg/kg lidocaine and a 0.2 to 0.5 mg/kg bupivacaine dose with volume of saline equal to the volume of bupivacaine, and slowly inject it over a period of 2 to 5 minutes following aspiration to ensure that no intravascular injection occurs. depending on where the lesion is, position the patient to allow the intrapleural infusion to "coat" the area. most effective is positioning the patient in dorsal recumbency for several minutes following the block to make sure local anesthetic occupies the paravertebral gutters and hence the spinal nerve roots. the block should be repeated every 3 hours in dogs and every 8 to 12 hours in cats. secure the catheter to the skin surface for repetitive administration. administration of local anesthetic around the brachial plexus provides excellent analgesia for forelimb surgery, particularly that distal to the shoulder, and amputations. nerve locator-guided techniques are much more accurate and successful than blind placement of local anesthetic; however, even the latter is useful. to administer a brachial plexus blockade, follow this procedure: 1. aseptically prepare a small area of skin over the point of the shoulder. 2. insert a 22-gauge, 1 1 /2-to 3-inch spinal needle medial to the shoulder joint, axial to the lesser tubercle, and advance it caudally, medial to the body of the scapula, and toward the costochondral junction of the first rib. aspirate first before injection to make sure that intravenous injection does not occur. 3. inject one third of the volume of local anesthetic mix, and then slowly withdraw the needle and fan dorsally and ventrally while infusing the remaining fluid. 4. local anesthetic doses are similar to those for intrapleural blockade. epidural analgesia refers to the injection of an opioid, a phencyclidine, an î±-agonist, or an nsaid into the epidural space. epidural anesthesia refers to the injection of a local anesthetic. in most patients a combination of the two is used. epidural analgesia and anesthesia are used for a variety of acute and chronic surgical pain or traumatically induced pain in the pelvis, tail, perineum, hind limbs, abdomen, and thorax (table 1 -21) . procedures in which epidural analgesia and anesthesia are useful include forelimb and hind limb amputation, tail or perineal procedures, cesarean sections, diaphragmatic hernia repair, pancreatitis, peritonitis, and intervertebral disk disease. epidural blocks performed using opioids or bupivacaine will not result in hind limb paresis or decreased urinary or anal tone (incontinence), unlike lidocaine or mepivicaine epidural blocks. morphine is one of the most useful opioids for administration in the epidural space because of its slow systemic absorption. epidural catheters used for the instillation of drugs through constant rate infusion or intermittent injection can be placed in dogs and cats. routinely placed at the lumbosacral junction, these catheters are used with cocktails including preservative-free morphine, bupivacaine, medetomidine, and ketamine. extremely effective for preventing windup pain in the peritoneal cavity or caudal half of the body, the catheters may be maintained if placed aseptically for 7 to 14 days. to provide epidural analgesia or anesthesia, follow this procedure: 1. position the animal in lateral or sternal recumbency. 2. clip and aseptically scrub over the lumbosacral site. 3. palpate the craniodorsal-most extent of the wings of the ileum bilaterally and draw an imaginary line through them to envision the spine of l7 located immediately behind the imaginary line. 4. advance a 20-to 22-gauge, 1 1 /2-to 3-inch spinal or epidural needle through the skin just caudal to the spine of l7. 5. the needle will lose resistance as it is introduced into the epidural space. drop saline into the hub of the needle, and the saline will be pulled into the epidural space as the needle enters. discrete intercostal nerve blocks can provide effective analgesia for traumatic or postsurgical pain. identify the area of the injury, and infiltrate three segments on either side of the injury with analgesic. to perform an intercostal nerve block, follow this procedure: 1. clip and aseptically scrub the dorsal and ventral third of the chest wall. 2. palpate the intercostal space as far dorsally as possible. 3. use a 25-gauge, 0.625-inch needle at the caudolateral aspect of the affected rib segments and those cranial and caudal. 4. direct the tip of the needle caudally such that the tip of the needle "drops" off of the caudal rib. (this places the needle tip in proximity to the neuromuscular bundle that contains the intercostal nerve that runs in a groove on the caudomedial surface of the rib.) 5. aspirate to confirm that the drug will not go intravenously. 6. inject while slowly withdrawing the needle. inject 0.5 to 1.0 ml at each site, depending on the size of the animal. gaynor js, an acute condition in the abdomen is defined as the sudden onset of abdominal discomfort or pain caused by a variety of conditions involving intraabdominal organs. many animals have the primary complaint of lethargy, anorexia, ptyalism, vomiting, retching, diarrhea, hematochezia, crying out, moaning, or abnormal postures. abnormal postures can include generalized rigidity, walking tenderly or as if "on eggshells," or a prayer position in which the front limbs are lowered to the ground while the hind end remains standing. in some cases, it may be difficult initially to distinguish between true abdominal pain or referred pain from intervertebral disk disease. rapid progression and decompensation of the patient's cardiovascular status can lead to stupor, coma, and death in the most extreme cases, making rapid assessment, treatment, and definitive care extremely challenging. often the patient's signalment and history can increase the index of suspicion for a particular disease process. a thorough history often is overlooked or postponed in the initial stages of resuscitation of the patient with acute abdominal pain. often, asking the same question in a variety of methods can elicit an answer from the client that may lead to the source of the problem and the reason for acute abdominal pain. important questions to ask the client include the following: â�¢ what is your chief complaint or reason that you brought your animal in on emergency? â�¢ when did the signs first start, or when was your animal last normal? â�¢ do you think that the signs have been the same, better, or getting worse? â�¢ does your animal have any ongoing or past medical problems? â�¢ have similar signs occurred in the past? â�¢ does your animal have access to any known toxins, or does he or she run loose unattended? as with any other emergency, the clinician must follow the abcs of therapy, treating the most life-threatening problems first. first, perform a perfunctory physical examination. examination of the abdomen ideally should be performed last, in case inciting a painful stimulus precludes you from evaluating other organ systems more thoroughly. briefly observe the patient from a distance. are there any abnormal postures? is there respiratory distress? is the animal ambulatory, and if so, do you observe any gait abnormalities? do you observe any ptyalism or attempts to vomit? auscultate the patient's thorax for crackles that may signify aspiration pneumonia resulting from vomiting. examine the patient's mucous membrane color and capillary refill time, heart rate, heart rhythm, and pulse quality. many patients in pain have tachycardia that may or may not be accompanied by dysrhythmias. if a patient's heart rate is inappropriately bradycardic, consider hypoadrenocorticism, whipworm infestation, or urinary obstruction or trauma as a cause of hyperkalemia. assess the patient's hydration status by evaluating skin turgor, mucous membrane dryness, and whether the eyes appear sunken in their orbits. a brief neurologic examination should consist of whether the patient is actively having a seizure, or whether mental dullness, stupor, coma, or nystagmus are present. posture and spinal reflexes can assist in making a diagnosis of intervertebral disk disease versus abdominal pain. perform a rectal examination to evaluate for the presence of hematochezia or melena. finally, examination of the abdomen should proceed first with superficial and then deeper palpation. visually inspect the abdomen for the presence of external masses, bruising, or penetrating injuries. reddish discoloration of the periumbilical area often is associated with the presence of intraabdominal hemorrhage. it may be necessary to shave the fur to inspect the skin and underlying structures visually for bruising and ecchymoses. auscultate the abdomen for the presence or absence of borborygmi to characterize gut sounds. next, perform percussion and ballottement to evaluate for the presence of a gas-distended viscus or peritoneal effusion. finally, perform first superficial and then deep palpation of all quadrants of the abdomen, noting abnormal enlargement, masses, or whether focal pain is elicited in any one area. once the physical examination has been performed, implement initial therapy in the form of analgesia, fluid resuscitation, and antibiotics. treatment for any patient with an acute condition in the abdomen and shock is to treat the underlying cause, maintain tissue oxygen delivery, and prevent end-organ damage and failure. a more complete description of shock and oxygen delivery is given in the section on shock. 1 emergency care the administration of analgesic agents to any patient with acute abdominal pain is one of the most important therapies in the initial stages of case management. many patients with acute abdominal pain are clinically dehydrated or are in hypovolemic shock because of hemorrhage. careful titration of intravenous crystalloid and colloid fluids including blood products is necessary based on the patient's perfusion parameters including heart rate, capillary refill time, blood pressure, urine output, and pcv. fluid therapy also should be based on the most likely differential diagnoses, with specific fluid types administered according to the primary disease process. in dogs, a shock volume of fluids is calculated based on the total blood volume of 90 ml/kg/hour. in cats, shock fluid rate is based on plasma volume of 44 ml/kg/hour. in most cases, any crystalloid fluid can be administered at an initial volume of one fourth of a calculated shock dose and then titrated according to whether the patient's cardiovascular status responds favorably or not. in cases of an acute condition in the abdomen from known or suspected hypoadrenocorticism, severe whipworm infestation, or urinary tract obstruction or rupture, 0.9% sodium chloride fluid without added potassium is the fluid of choice. when hemorrhage is present, the administration of whole blood or packed rbcs may be indicated if the patient has clinical signs of anemia and shows clinical signs of lethargy, tachypnea, and weakness. fresh frozen plasma is indicated in cases of hemorrhage resulting from vitamin k antagonist rodenticide intoxication or hepatic failure or in cases of suspected disseminated intravascular coagulation (dic). a more thorough description of fluid therapy is given under the sections on shock and fluid therapy. the empiric use of broad-spectrum antibiotics is warranted in cases of suspected sepsis or peritonitis as a cause of acute abdominal pain. ampicillin sulbactam (22 mg/kg iv q6-8h) and enrofloxacin (10 mg/kg once daily) are the combination treatment of choice to cover gram-negative, gram-positive, aerobic, and anaerobic infections. alternative therapies include a second-generation cephalosporin such as cefotetan (30 mg/kg iv tid) or cefoxitin (22 mg/kg iv tid) or added anaerobic coverage with metronidazole (10 to 20 mg/kg iv tid). tissue oxygen delivery depends on a number of factors, including arterial oxygen content and cardiac output. if an animal has had vomiting and subsequent aspiration pneumonitis, treatment of hypoxemia with supplemental oxygen in the form of nasal, nasopharyngeal, hood, or transtracheal oxygen administration is important (see oxygen supplementation under emergency diagnostic and therapeutic procedures). perform a complete blood count in all cases of acute abdominal pain to determine if lifethreatening infection or coagulopathy including dic is present. in cases of sepsis, infection, or severe nonseptic inflammation, the white blood cell count may be normal, elevated, or low. examine a peripheral blood smear for the presence of toxic neutrophils, eosinophils, atypical lymphocytes, nucleated rbcs, platelet estimate, anisocytosis, and blood parasites. a falling pcv in the face of rbc transfusion suggests ongoing hemorrhage. perform a biochemistry panel to evaluate organ system function. azotemia with elevated bun and creatinine may be associated with prerenal dehydration, impaired renal function, or postrenal obstruction or leakage. the bun also can be elevated when gastrointestinal hemorrhage is present. serum amylase may be elevated with decreased renal function or in cases of pancreatitis. a normal serum amylase, however, does not rule out pancreatitis as a source of abdominal pain. serum lipase may be elevated with gastrointestinal inflammation or pancreatitis. like amylase, a normal serum lipase does not rule out pancreatitis. total bilirubin, alkaline phosphatase, and alanine transaminase may be elevated with primary cholestatic or hepatocellular diseases or may be due to extrahepatic causes including sepsis. obtain a urinalysis via cystocentesis whenever possible, except in cases of suspected pyometra or transitional cell carcinoma. azotemia in the presence of a nonconcentrated (isosthenuric or hyposthenuric) urine suggests primary renal disease. secondary causes of apparent renal azotemia and lack of concentrating ability also occur in cases of hypoadrenocorticism and gram-negative sepsis. renal tubular casts may be present in cases of acute renal ischemia or toxic insult to the kidneys. bacteriuria and pyuria may be present with infection and inflammation. when a urinalysis is obtained via free catch or urethral catheterization, the presence of bacteriuria or pyuria also may be associated with pyometra, vaginitis, or prostatitis/prostatic abscess. serum lactate is a biochemical indicator of decreased organ perfusion, decreased oxygen delivery or extraction, and end-organ anaerobic glycolysis. elevated serum lactate greater than 6 mmol/l has been associated with increased morbidity and need for gastric resection in cases of gdv and increased patient morbidity and mortality in other disease processes. rising serum lactate in the face of adequate fluid resuscitation is a negative prognostic sign. obtain abdominal radiographs as one of the first diagnostic tests when deciding whether to pursue medical or surgical management. the presence of gdv, linear foreign body, pneumoperitoneum, pyometra, or splenic torsion warrants immediate surgical intervention. if a loss of abdominal detail occurs because of peritoneal effusion, perform additional diagnostic tests including abdominal paracentesis (abdominocentesis) and abdominal ultrasound to determine the cause of the peritoneal effusion. abdominal ultrasonography is often useful in place of or in addition to abdominal radiographs. the sensitivity of abdominal ultrasonography is largely operator dependent. indications for immediate surgical intervention include loss of blood flow to an organ, linear bunching or placation of the intestinal tract, intussusception, pancreatic phlegmon or abscess, a fluid-filled uterus suggestive of pyometra, gastrointestinal obstruction, intraluminal gastrointestinal foreign body, dilated bile duct, or gallbladder mucocele, or gas within the wall of the stomach or gallbladder (emphysematous cholecystitis). the presence of peritoneal fluid alone does not warrant immediate surgical intervention without cytologic and biochemical evaluation of the fluid present. see also abdominal paracentesis and diagnostic peritoneal lavage. abdominal paracentesis (abdominocentesis) often is the deciding factor in whether to perform immediate surgery. abdominocentesis is a sensitive technique for detecting peritoneal effusion when more than 6 ml/kg of fluid is present within the abdominal cavity. abdominal effusion collected should be saved for bacterial culture and evaluated biochemically and cytologically based on your index of suspicion of the primary disease process. if creatinine, urea nitrogen (bun) or potassium is elevated compared with that of serum, uroabdomen is present. elevated abdominal fluid lipase or amylase compared with serum supports a diagnosis of pancreatitis. elevated lactate compared with serum lactate or an abdominal fluid glucose less than 50 mg/dl is highly sensitive and specific for bacterial/ septic peritonitis. the presence of bile pigment or bacteria is supportive of bile and septic peritonitis, respectively. free fibers in abdominal fluid along with clinical signs of abdominal pain strongly support gastrointestinal perforation, and immediate surgical exploration is required. text continued on p. 93 the following are clinical conditions, patient signalment, common history, physical examination, and characteristic findings of various diagnostic tests. a blank column next to a condition indicates no specific signalment, history, physical examination, or diagnostic test characteristic for a particular disease process. lack of contiguity of body wall surgical ( medical unless perforation present present c-shaped abnormal gas pattern with plication on radiographs surgical (immediate) dilation of bowel cranial to foreign object, radiopaque object in surgical (immediate) stomach or intestines, hypochloremic metabolic acidosis on bloodwork if pyloric outflow obstruction is present elevated or decreased wbc; foreign material, wbcs and medical unless perforation bacteria on abdominal fluid, elevated lactate and decreased present glucose on abdominal fluid target shaped soft tissue density on abdominal u/s, soft tissue surgical (immediate): density with gas dilation cranially on abdominal radiographs medical management of primary cause colonic distension with hard feces on radiographs medical increased or decreased wbc, septic abdominal effusion surgical (immediate) elevated t bili, alt, alk phos, and wbc hypoechoic hepatic medical after biopsy parenchyma on ultasound hepatomegaly elevated t bili, alt, alk phos, and wbc hyperechoic foci in surgical (immediate) gallbladder or sludge on u/s, free gas in wall of gall bladder abdominal effusion, bile pigment in effusion surgical (immediate) elevated t bili, alk phos, alt surgical (immediate) elevated or decreased wbc, elevated t bili, alk phos and surgical (immediate) alt, free gas in hepatic parenchyma on rads, hypoechoic mass with hyperechoic material in hepatic parenchyma on u/s heteroechoic liver with hyperechoic center on ultrasound surgical (immediate) mixed echogenic mass on ultrasound, soft tissue mass surgical (immediate or density on radiographs, elevated alk phos, alt, delayed) t bili, hypoglycemia pain-cont'd elevated t bili, alk phos, alt, amylase and/or lipase, elevated medical in most cases or decreased wbc, hypocalcemia, focal loss of detail in right unless abscess or cranial quadrant on radiographs hypo-to hyperechoic phlegmon is present pancreas with hyperechoic peri-pancreatic fat on ultrasound, abdominal and/or pleural effusion on radiographs and ultrasound pancreatic soft tissue mass effect on radiographs and surgical if mass identified, ultrasound, elevated amylase and lipase, hypoglycemia, otherwise medical elevated serum insulin management of hypoglycemia splenomegaly on radiographs, hyperechoic spleen with no surgical (immediate) blood flow on ultrasound soft tissue mass effect and loss of abdominal detail on surgical (immediate) radiographs, cavitated mass with abdominal effusion on u/s hyperechoic spleen with no blood flow on abdominal u/s, surgical (immediate) abdominal effusion, thrombocytopenia loss of abdominal detail on radiographs, peritoneal effusion medical unless refractory on u/s, hemoabdomen on abdominocentesis hypotension diagnosis based primarily on clinical signs medical fracture of the os penis on radiographs largely medical unless urethral tear diagnosis based primarily on clinical signs medical, although prepuce may need to be incised to allow replacement of penis into sheath prostatomegaly on radiographs and ultrasound hypoechoic medical prostate on u/s, pyuria and bacteriuria and u/a prostatomegaly on radiographs and ultrasound hypo-to surgical (delayed) hyperechoic prostate on u/s, bacteriuria and pyuria on u/a prostatomegaly on radiographs and ultrasound, prostatic medical/surgical mineralization on radiographs and ultrasound hypoechoic kidneys on u/s, pyuria on u/a, elevated wbc, medical azotemia pyuria, bacteriuria on u/a medical pyelectasia in abdominal u/s, azotemia surgical (immediate) renomegaly on radiographs, azotemia renal mass on u/s, renomegaly on radiographs surgical (immediate) renal mass on u/s, azotemia, lack of renal blood flow surgical (delayed) on u/s calculi in renal pelvis on radiographs and ultrasound, azotemia medical unless both kidneys affected ureteral calculi on radiographs and ultrasound, hydronephrosis, medical unless both azotemia kidneys affected ureteral calculi on radiographs and ultrasound, hydronephrosis, surgical (delayed until fluid or soft tissue density on u/s, azotemia electrolyte stabilization) diagnosis largely based on physical examination medical unless cannot pass findings urethral catheter azotemia, no peritoneal effusion, lack of urine output or surgical (delayed until outflow with ureteral catheterization, double contrast electrolyte stabilization) cystourethrogram indicated transitional cellular casts on u/a, hematuria, mass effect or surgical and medical thickened irregular urethra on ultrasound or management cystourethrogram hypoechoic swollen testicle on testicular ultrasound surgical (immediate) fluid or gas-filled tubular structure on abdominal ultrasound or surgical (immediate) abdominal radiographs soft tissue tubular structure on radiographs, fluid-filled uterus surgical ( in the event of a negative abdominocentesis, but peritoneal effusion or bile or gastrointestinal perforation are suspected, perform a diagnostic peritoneal lavage. peritoneal dialysis kits are commercially available but are often expensive and impractical (see p. 6). animals that have acute abdominal pain can be divided into three broad categories, depending on the primary cause of pain and the initial definitive treatment (table 1-24) . some diseases warrant a nonsurgical, medical approach to case management. other conditions require immediate surgery following rapid stabilization. other conditions initially can be managed medically until the patient is hemodynamically more stable and then may or may not require surgical intervention at a later time. specific management of each disease entity is listed under its own subheading. box 1-23 lists specific indications for exploratory laparotomy. the best means to explore the abdominal cavity accurately and thoroughly is to open the abdomen on midline from the level of the xyphoid process caudally to the pubis for full exposure and then to evaluate all organs in every quadrant in a systematic manner. address specific problems such as gastric or splenic torsion, enteroplication, and foreign body removal, and then copiously lavage the abdomen with warmed sterile saline solution. suction the saline solution thoroughly from the peritoneal cavity so as to not impair macrophage function. in cases of septic peritonitis, the abdomen may be left open, or a drain may be placed for further suction and lavage. the routine use of antibiotics in irrigation solutions is contraindicated because the antibiotics can irritate the peritoneum and delay healing. when the abdominal cavity is left open, secure sterile laparotomy towels and water-impermeable dressings over the abdominal wound with umbilical tape, and then change these daily or as strike-through occurs. open abdomen cases are often effusive and require meticulous evaluation and management of electrolyte imbalances and hypoalbuminemia. the abdomen can be closed and/or the abdominal drain removed when the volume of the effusion decreases, when bacteria are no longer present, and when the neutrophils become more healthy in appearance. bischoff mg: radiographic techniques and interpretation of the acute abdomen, clin tech small anim pract 18 (1) anaphylactic shock occurs as an immediate hypersensitivity reaction to a variety of inciting stimuli (box 1-24). in animals, the most naturally occurring anaphylactic reaction results from wasp or bee stings. most other reactions occur as a result of an abnormal sensitivity to items used in making medical diagnoses or treatment. during an anaphylactic reaction, activation of c5a and the complement system results in vascular smooth muscle dilation and the release of a cascade of inflammatory mediators, including histamine, slow-reacting substance of anaphylaxis, serotonin, heparin, acetylcholine, and bradykinin. clinical signs associated with anaphylaxis differ between dogs and cats. in dogs, clinical signs may include restlessness, vomiting, diarrhea, hematochezia, circulatory collapse, coma, and death. in cats, clinical signs often are associated with respiratory system abnormalities. clinical signs may include ptyalism, pruritus, vomiting, incoordination, bronchoconstriction, pulmonary edema and hemorrhage, laryngeal edema, collapse, and death. the most important steps to remember in any emergency is to follow the abcs of airway, breathing, and circulation. first, establish an airway through endotracheal intubation or emergency tracheostomy, if necessary. concurrently, an assistant should establish vascular or intraosseous access to administer drugs and fluids (box 1-25). the patient should be hospitalized until complete resolution of clinical signs. after initial stabilization and treatment, it is important to maintain vascular access and continue intravenous fluid therapy until the patient is no longer hypotensive, and vomiting and diarrhea have resolved. in cases of fulminant pulmonary hemorrhage and edema, administer supplemental oxygen until the patient is no longer hypoxemic or orthopneic on room air. normalize and maintain blood pressure using positive inotropes (dobutamine, 3-10 âµg/kg/ minute cri) or pressors (dopamine, 3 to 10 âµg/kg/minute iv cri; see shock). if bloodtinged vomitus or diarrhea has been observed, administer antibiotics to decrease the risk of bacterial translocation and sepsis (cefoxitin, 22 mg/kg iv tid; metronidazole, 10 mg/kg iv tid). also consider using gastroprotectant drugs (famotidine, 0.5 to 1.0 mg/kg iv; ranitidine, 0.5 to 2.0 mg/kg po, iv, im bid; sucralfate, 0.25 to 1.0 g po tid; omeprazole, 0.7 to 1.0 mg/kg po sid). a second and less serious form of allergic reaction is manifested as angioneurotic edema and urticaria. in most cases, clinical signs develop within 20 minutes of an inciting allergen. although this type of reaction causes patient discomfort, it rarely poses a life-threatening problem. most animals have mild to severe swelling of the maxilla and periorbital regions. the facial edema also may be accompanied by mild to severe generalized urticaria. some animals may paw at their face, rub at their eyes, or have vomiting or diarrhea. the treatment for angioneurotic edema involves suppressing the immune response by administration of short-acting glucocorticoid drugs and blocking the actions of histamine by the synergistic use of histamine 1 and histamine 2 receptor blockers (box 1-26). in some cases, the inciting cause is a known recent vaccination or insect sting. many times, however, the inciting cause is not known and is likely an exposure to a stinging insect or arachnid. differential diagnoses for acute facial swelling and/or urticaria include acetaminophen toxicity (cats), anterior caval syndrome, lymphadenitis, vasculitis, hypoalbuminemia, and contact dermatitis. observe animals that have presented for angioneurotic edema for a minimum of 20 to 30 minutes after injection of the short-acting glucocorticoids and antihistamines. monitor blood pressure to make sure that the patient does not have concurrent anaphylaxis and hypotension. after partial or complete resolution of clinical signs, the animal can be discharged to its owner for observation. in dogs, mild vomiting or diarrhea may occur within 1 to 2 days after this type of reaction. wherever possible, exposure to the inciting allergen should be avoided. â�¢ administer short-acting glucocorticoid: complications observed while a patient is under anesthesia can be divided into two broad categories: (1) those related to equipment malfunction or human error and (2) the patient's physiologic response to the cardiorespiratory effects of the anesthetic drugs. careful observation of the patient and familiarity with anesthetic equipment, drug protocols, and monitoring equipment is necessary for the safest anesthesia to occur. despite this, however, anesthetic-related complications are frequent and need to be recognized and treated appropriately. many anesthetic drugs have a dose-dependent depressive effect on the respiratory system and cause a decrease in respiratory rate and tidal volume, leading to hypoventilation. respiratory rate alone is not a reliable indicator of the patient's oxygenation and ventilatory status. the respiratory tidal volume can be measured with a wright's respirometer. perform pulse oximetry and capnography as noninvasive measures of the patient's oxygenation and ventilation. ventilation can be impaired as a result of anesthetic drugs, patient position, pneumothorax, pleural effusion (chylothorax, hemothorax, pyothorax), equipment malfunction, rebreathing of carbon dioxide, thoracic wall injury, or alveolar fluid (pulmonary edema, hemorrhage, or pneumonia). problems such as a diaphragmatic hernia, gdv, or gravid uterus can impede diaphragmatic excursions once the patient is placed on its back and can lead to impaired ventilation. the work of breathing also may be increased because of increased resistance of the anesthesia circuit and increased dead space ventilation. this is particularly important in small toy breeds. clinical signs of inadequate ventilation and respiratory complications include abnormal respiratory pattern, sudden changes in heart rate, cardiac dysrhythmias, cyanosis, and cardiopulmonary arrest. end-tidal carbon dioxide, or capnography, gives a graphic display of adequacy of ventilation. rapid decreases in end-tidal carbon dioxide can be caused by disconnection or obstruction of the patient's endotracheal tube or poor perfusion, namely, cardiopulmonary arrest (see capnometry [end-tidal carbon dioxide monitoring]). postoperatively, hypoventilation can occur because of the residual effects of the anesthetic drugs, hypothermia, overventilation during intraoperative support, surgical techniques that compromise ventilation (thoracotomy, cervical disk surgery, atlantooccipital stabilization), postoperative bandaging of the abdomen or thorax, ventilatory muscle fatigue, or injury to the cns. cardiac output is a function of heart rate and stroke volume. factors that influence stroke volume include vascular and cardiac preload, cardiac afterload, and cardiac contractility. the patient's cardiac output can be affected adversely by the negative inotropic and chronotropic and vasodilatory effects of anesthetic drugs, all leading to hypotension. 96 1 emergency care bradycardia, tachycardia, cardiac dysrhythmias, and vascular dilation can lead to hypotension and inadequate organ perfusion. table 1 -25 lists the normal heart rate and blood pressure in dogs and cats. bradycardia is defined as a heart rate below normal values. many anesthetic drugs can cause bradycardia. causes of bradycardia include the use of narcotics or î± 2 -agonist drugs, deep plane of anesthesia, increased vagal tone, hypothermia, and hypoxia. table 1 -26 lists the causes of bradycardia and the necessary immediate action or treatment. tachycardia is defined as a heart rate above normal values. common causes of tachycardia include vasodilation, drugs, inadequate anesthetic depth and perceived pain, hypercapnia, hypoxemia, hypotension, shock, or hyperthermia. table 1 -27 lists the causes and immediate action or treatment for tachycardia. hypotension is defined as physiologically low blood pressure (mean arterial pressure less than 65 mm hg). a mean arterial blood pressure less than 60 mm hg can result in inadequate tissue perfusion and oxygen delivery. the coronary arteries are perfused during diastole. inadequate diastolic blood pressure, less than 40 mm hg, can cause decreased coronary artery perfusion and myocardial hypoxemia that can predispose the heart to dysrhythmias. causes of perianesthetic hypotension include peripheral vasodilation by anesthetic drugs, bradycardia or tachyarrhythmias, hypothermia, inadequate cardiac preload from vasodilation or hemorrhage, decreased venous return from patient position or surgical manipulation of viscera, and decreased cardiac contractility. electrocardiogram monitoring is useful for the early detection of cardiac dysrhythmias during the perianesthetic period. clinical signs of cardiac dysrhythmias include irregular pulse rate or pressure, abnormal or irregular heart sounds, pallor, cyanosis, hypotension, and an abnormal ecg tracing. remember that the single best method of detecting cardiac 98 1 emergency care vagolytic drugs atropine allow time for the drug to wear off. glycopyrrolate allow time for the drug to wear off. sympathomimetic drugs epinephrine allow time for the drug to wear off; administer a î²-blocker; turn off infusion. isoproterenol administer a î²-blocker. turn off infusion; administer a î²-blocker. allow time for drug to wear off. inadequate anesthetic depth increase anesthetic depth. hypercapnia increase ventilation (assisted ventilation). hypoxemia increase gas flow and oxygenation. hypotension decrease anesthetic depth; administer an intravenous crystalloid or colloid bolus, positive inotrope drug, positive chronotrope drug, or pressor. hyperthermia apply ambient or active cooling measures; administer dantrolene sodium if malignant hyperthermia is suspected. hypothermia provide ambient rewarming. hypocalcemia * administer calcium chloride (10 mg/kg iv) or calcium gluconate (23 mg/kg). decrease vaporizer setting/anesthetic depth. reverse with opioids or a 2 -agonists. vasodilation administer an intravenous crystalloid bolus (10 ml/kg). administer an intravenous colloid bolus (5 ml/kg). administer a pressor (epinephrine, phenylephrine dysrhythmias is with your fingertips (palpate a pulse or apex heartbeat) and ears (auscultate the heart). confirm the dysrhythmia by auscultating the heart rate and rhythm, identify the p waves and the qrs complexes, and evaluate the relationship between the p waves and qrs complexes. is there a p wave for every qrs, and a qrs for every p wave? during anesthesia, fluid, acid-base, and electrolyte imbalances can predispose the patient to dysrhythmias. sympathetic and parasympathetic stimulation, including the time of intubation, can predispose the patient to dysrhythmias. if the patient's plane of anesthesia is too light, perception of pain can cause catecholamine release, sensitizing the myocardium to ectopic beats. atrioventricular blockade can be induced with the administration of î± 2 -agonist medications, including xylazine and medetomidine. thiobarbiturates (thiopental) can induce ventricular ectopy and bigeminy. although these dysrhythmias may not be harmful in the awake patient, anesthetized patients are at a particular risk of dysrhythmia-induced hypotension. carefully monitor and treat all dysrhythmias (see cardiac dysrhythmias). box 1-27 lists steps to take to prevent perianesthetic dysrhythmias. awakening during anesthesia can occur and can be caused by equipment failure and simply, although no one likes to admit it, human error. table 1 -29 lists causes of arousal during anesthesia and appropriate immediate actions. awaken patient, and administer dantrolene arousal (e.g., malignant hyperthermia) sodium. â�¢ stabilize acid-base and electrolyte balance before anesthetic induction, whenever possible. â�¢ rehydrate patient before anesthetic induction. â�¢ select anesthetic agents appropriate for the particular patient. â�¢ be aware of the effects of the drugs on the myocardium. â�¢ ensure adequate anesthetic depth and oxygenation before anesthetic induction. â�¢ ensure ventilatory support during anesthesia. â�¢ monitor heart rate, rhythm, blood pressure, pulse oximetry, and capnometry during anesthesia. â�¢ ensure adequate anesthetic depth before surgical stimulation. â�¢ avoid surgical manipulation to the heart or great vessels, whenever possible. â�¢ avoid changes in perianesthetic depth. â�¢ avoid hypothermia. delayed recovery can be caused by a number of factors, including excessive anesthetic depth, hypothermia, residual action of narcotics or tranquilizers, delayed metabolism of anesthetic drugs, hypoglycemia, hypocalcemia, hemorrhage, and breed or animal predisposition. careful monitoring of the patient's blood pressure, acid-base and electrolyte status, anesthetic depth, pcv, and vascular volume intraoperatively and taking care with supportive measures to prevent abnormalities can hasten anesthetic recovery and avoid postoperative complications. gaynor the presentation of a patient with a bleeding disorder often is a diagnostic challenge for the veterinary practitioner (boxes 1-28 and 1-29). in general, abnormal bleeding can be caused by five major categories: (1) vascular trauma, (2) circulating inhibitors of coagulation heparin fibrin degradation products development of spontaneous deep hematomas, unusually prolonged bleeding after traumatic injury, bleeding at multiple sites throughout the body involving multiple organ systems, delayed onset of severe hemorrhage after bleeding, and an inability on the practitioner's part to find an organic cause of bleeding. the signalment, history, clinical signs, and results of coagulation often can aid in making a rapid diagnosis of the primary cause of the disorder and in the selection of appropriate case management. when taking a history, ask the following important questions: â�¢ what is the nature of the bleeding? â�¢ what sites are affected? â�¢ how long has the bleeding been going on? â�¢ has your animal had any previous or similar episodes? â�¢ is there any possibility of any toxin exposure? â�¢ if so, when and how much did your animal consume? â�¢ is there any possibility of trauma? â�¢ does your animal run loose outdoors unattended? â�¢ have you ever traveled, and if so, where? â�¢ has your animal been on any medications recently or currently? â�¢ has your animal been vaccinated recently? â�¢ have any known relatives of your animal had any bleeding disorders? â�¢ are there any other abnormal signs that you have seen? abnormalities found on physical examination may aid in determining whether the hemorrhage is localized or generalized (i.e., bleeding from a venipuncture site versus bleeding diathesis). note whether the clinical signs are associated with a platelet problem and superficial hemorrhage or whether deep bleeding can be associated with abnormalities of the coagulation cascade. also, make an attempt to identify any concurrent illness that can predispose the patient to a bleeding disorder (i.e., pancreatitis, snakebite, sepsis, immunemediated hemolytic anemia, or severe trauma and crush or burn injury). abnormalities associated with coagulopathies include petechiae and ecchymoses, epistaxis, gingival bleeding, hematuria, hemarthrosis, melena, and hemorrhagic cavity (pleural and peritoneal or retroperitoneal) effusions. disseminated intravascular coagulation is a complex syndrome that results from the inappropriate activation of the clotting cascade, leading to disruption of the normal balance between thrombosis and fibrinolysis. the formation of diffuse microthrombi with concurrent consumption of platelets and activated clotting factors leads to end-organ thrombosis with various degrees of clinical hemorrhage. in animals, dic always results from some other pathologic process, including various forms of neoplasia, crush and heat-induced injury, sepsis, inflammation, and immune-mediated disorders (box 1-30). the pathophysiologic mechanisms involved in dic include vascular endothelial damage, activation and consumption of platelets, release of tissue procoagulants, and consumption of endogenous anticoagulants. because dic always results from some other disease process, diagnosis of dic is based on a number of criteria when evaluating various coagulation tests, peripheral blood smears, platelet count, and end products of thrombosis and fibrinolysis. there is no one definitive criterion for the diagnosis of dic (box 1-31). thrombocytopenia occurs as platelets are consumed during thrombosis. it is important to remember that trends in decline in platelet numbers are just as important as thrombocytopenia when making the diagnosis. in some cases the platelet count still may be within the normal reference range but has significantly decreased in the last 24 hours. early in dic the procoagulant cascade dominates, with hypercoagulability. activated clotting time, aptt, and pt may be rapid and shorter than normal. in most cases, we do not recognize the hypercoagulable state in our critically ill patients. later in dic, as platelets and activated clotting factors become consumed, the act, aptt, and pt become prolonged. antithrombin, a natural anticoagulant, also becomes consumed, and antithrombin levels decline. antithrombin levels can be measured at commercial laboratories and in some large veterinary institutions. the end products of thrombosis and subsequent fibrinolysis also can be measured. fibrinogen levels may decline, although this test is not sensitive or specific for dic. fibrin degradation (split) products also become elevated. fibrin degradation products are normally cleared by the liver, and these also become elevated in cases of hepatic failure because of lack of clearance. more recently, cageside d-dimer tests have become available to measure the breakdown product of cross-linked fibrin as a more sensitive and specific monitor of dic. management of dic first involves treating the primary underlying cause. by the time dic becomes evident, rapid and aggressive treatment is necessary. if you are suspicious of dic in any patient with a disease known to incite dic, then ideally, you should begin treatment before the hemostatic abnormalities start to occur for the best possible prognosis. treatment involves replacement of clotting factors and antithrombin and prevention of further clot formation. to replenish clotting factors and antithrombin, administer fresh whole blood or fresh frozen plasma. heparin requires antithrombin as a cofactor to inactivate thrombin and other activated coagulation factors. administer heparin (50 to 100 units/kg sq q6-8h of unfractionated heparin; or fractionated enoxaparin [lovenox], 1 mg/kg sq bid). aspirin (5 mg/kg po bid in dogs; every third day in cats) also can be administered to prevent platelet adhesion. management of dic also involves the rule of twenty monitoring and case management to maintain end-organ perfusion and oxygen delivery (see the rule of 20). hemophilia a is a sex-liked recessive trait that is carried by females and manifested in males. female hemophiliacs can occur when a hemophiliac male is bred with a carrier female. hemophilia a has been reported in cats and a number of dog breeds, including miniature schnauzer, saint bernard, miniature poodle, shetland sheepdog, english and irish setters, labrador retriever, german shepherd, collie, weimaraner, greyhound, chihuahua, english bulldog, samoyed, and vizsla. mild to moderate internal or external bleeding can occur. clinical signs of umbilical cord bleeding can become apparent in some animals shortly after weaning. gingival hemorrhage, hemarthrosis, gastrointestinal hemorrhage, and hematomas may occur. clotting profiles in animals with factor viii deficiency include prolonged aptt and act. the pt and buccal mucosa bleeding time are normal. affected animals have low factor viii activity but normal to high levels of factor viii-related antigen. carrier females can be detected by low (30% to 60% of normal) factor viii activity and normal to elevated levels of factor vii-related antigen. von willebrand's disease is a deficiency or defect in von willebrand's protein. a number of variants of the disease have been described: von willebrand's disease type i is associated with a defect in factor viir/protein concentration, and von willebrand's disease type ii is associated with a defect in viiir:vwf. type i von willebrand's disease is most common in veterinary medicine. von willebrand's disease has been identified in more than 29 breeds of dogs, with an incidence that varies from 10% to 60% depending on the breed of origin. affected breeds include doberman pinchers, german shepherd dogs, scottish terriers and standard manchester terriers, golden retrievers, chesapeake bay retrievers, miniature schnauzers, and pembroke welsh corgis. two forms of genetic expression occur: (1) autosomal recessive disease in which homozygous von willebrand's disease individuals have a bleeding disorder, whereas heterozygous individuals carry the trait but are clinically normal. the second variant of genetic expression involves an autosomal dominant disease with incomplete expression such that heterozygous individuals are affected carriers and homozygous individuals are severely affected. von willebrand's disease has high morbidity, but fortunately a low mortality. dogs with 30% or less than normal vwf tend to hemorrhage. platelet counts are normal, but bleeding times can be prolonged. the aptt can be slightly prolonged when factor viii is less than 50% of normal. routine screening tests are nondiagnostic for this disease, although in a predisposed breed with a normal platelet count, a prolonged buccal mucosa bleeding time strongly supports a diagnosis of von willebrand's disease. documentation of clinical bleeding with low or undetectable levels of factor viii antigen or platelet-related activities of vwf support a diagnosis of von willebrand's disease. recessive animals have zero vwf:antigen (a subunit of factor iii); heterozygotes have 15% to 60% of normal. in the incompletely dominant form, levels of vwf antigen are reduced (less than 7% to 60%). clinical signs in affected animals include epistaxis, hematuria, diarrhea with melena, penile bleeding, lameness, hemarthrosis, hematoma formation, and excessive bleeding with routine procedures such as nail trimming, ear cropping, tail docking, surgical procedures (spay, neuter), and lacerations. estrous and postpartum bleeding may be prolonged. a dna test to detect carriers of the vwf gene is available through vetgen (ann arbor, michigan) and michigan state university. patients with von willebrand's disease should avoid drugs known to affect platelet function adversely (sulfonamide, ampicillin, chloramphenicol, antihistamines, theophylline, phenothiazine tranquilizers, heparin, and estrogen). hemophilia b is an x-linked recessive trait that occurs with less frequency that hemophilia a. the disease has been reported in scottish terriers, shetland and old english sheepdogs, saint bernards, cocker spaniels, alaskan malamutes, labrador retrievers, bichon frises, airdale terriers, and british shorthair cats. carrier females have low (40% to 60% of normal) factor ix activity. clinical signs are more severe than for hemophilia a. congenital deficiencies of factor vii have been reported as an autosomal, incompletely dominant characteristic in beagles. heterozygotes have 50% factor vii deficiency. bleeding tends to be mild. the pt is prolonged in affected individuals. factor x deficiency has been documented in cocker spaniels and resembles fading-puppy syndrome in newborn dogs. internal or umbilical bleeding can occur, and affected dogs typically die. bleeding may be mild in adult dogs. in severe cases, factor x levels are reduced to 20% of normal; in mild cases, factor x levels are 20% to 70% of normal. factor xii deficiency has been documented as an inherited autosomal recessive trait in domestic cats. heterozygotes can be detected because they have a partial deficiency (50% of normal) of factor xii. homozygote cats have less than 2% factor xii activity. deficiency of hageman factor usually does not result in bleeding or other disorders. factor xi deficiency is an autosomal disease that has been documented in kerry blue terriers, great pyrenees, and english springer spaniels. in affected individuals, protracted bleeding may be observed. homozygotes have low factor xi activity (< 20% of normal), and heterozygotes have 40% to 60% of normal. the management of congenital defects of hemostasis typically involves replenishing the clotting factor that is present. usually, this can be accomplished in the form of fresh frozen plasma transfusion (20 ml/kg). if anemia is present because of severe hemorrhage, fresh whole blood or packed rbcs also can be administered. recent research has investigated the use of recombinant gene therapy in the treatment of specific factor deficiencies in dogs; however, the therapy is not yet available for use in clinical practice. in cases of von willebrand's disease, administration of fresh frozen plasma (10 to 20 ml/kg) or cryoprecipitate (1 unit/10 kg body mass) provides vwf, factor viii, and fibrinogen. doses can be repeated until hemorrhage ceases. 1-desamino-8-d-arginine vasopressin (ddavp) also can be administered (1 âµg/kg sc or iv diluted in 0.9% saline given over 10 to 20 minutes) to the donor and patient to increase the release of stored vwf from endothelial cells. a fresh whole blood transfusion can be obtained from the donor and immediately administered to the patient, or spun down and the fresh plasma administered if rbcs are not needed. administer a dose of ddavp to any affected dog before initiating any elective surgical procedures. a supply of fresh frozen plasma and rbcs should be on hand, should uncontrolled hemorrhage occur. platelets are essential to normal blood coagulation. after a vessel is damaged, release of vasoactive amines causes vasoconstriction and sluggish flow of blood in an attempt to squelch hemorrhage. platelets become activated by platelet activating factor, and attach to the damaged vascular endothelium. normal platelet adhesion depends on mediators such as calcium, fibrinogen, vwf:antigen, and a portion of factor viii. after adhesion, the platelets undergo primary aggregation and release a variety of chemical mediators including adenosine diphosphate, prostaglandins, serotonin, epinephrine, thromboplastin, and thromboxane a that promote secondary aggregation and contraction. platelet abnormalities can include decreased platelet production (thrombocytopenia), decreased platelet function (thrombocytopathia), increased platelet destruction, increased platelet consumption, and platelet sequestration. thrombocytopathia refers to platelet function abnormalities. alterations in platelet function can affect platelet adhesion, aggregation, or release of vasoactive substances that help form a stable clot (box 1-32). in von willebrand's disease there is a deficiency in vwf:antigen that results in altered platelet adhesion. vascular purpuras are reported and have been seen in collagen abnormalities such as ehlers-danlos syndrome, which can be inherited as an autosomal dominant trait with complete penetrance and has been recognized in german shepherd dogs, dachshunds, saint bernards, and labrador retrievers. thrombasthenic thrombopathia is a hereditary autosomal dominant abnormality that has been described in otterhounds, foxhounds and scottish terriers. in this condition, platelets do not aggregate normally in response to adenosine diphosphate and thrombin stimulation. evaluation of platelet function is based on a total platelet count, buccal mucosa bleeding time, and thromboelastography. platelet function defects (thrombocytopenia and thrombocytopathia) can affect both sexes. clinical signs can resemble von willebrand's disease. in most cases, buccal mucosa bleeding time will be prolonged, but platelet count and clotting tests will be normal. platelet count can be decreased because of problems with production, increased consumption, sequestration, or destruction. causes of accelerated platelet destruction are typically immune-mediated autoantibodies, drug antibodies, infection, and isoimmune destruction. consumption and sequestration usually are caused by dic, vasculitis, microangiopathic hemolytic anemia, severe vascular injury, hemolytic uremic syndrome, and gram-negative septicemia. primary thrombocytopenia with no known cause has been called idiopathic thrombocytic purpura. in approximately 80% of the cases, thrombocytopenia is associated with immune-mediated destruction caused by immune-mediated hemolytic anemia, systemic lupus erythematosus, rheumatoid arthritis, dic, and diseases that affect the bone marrow. in systemic lupus erythematosus, 20% to 30% of the affected dogs have concurrent idiopathic thrombocytic purpura. when immune-mediated hemolytic anemia and idiopathic thrombocytic purpura are present in the same patient, the disease is called evans syndrome. pf-3 is a non-complement-fixing antibody that is produced in the spleen and affects peripheral and bone marrow platelets and megakaryocytes. antibodies directed against platelets are usually of the igg subtype in animals. antiplatelet antibodies can be measured by a pf-3 release test. platelet counts with immune-mediated destruction typically are less than 50,000 platelets/âµl. infectious causes of thrombocytopenia include ehrlichia canis, anaplasma phagocytophilum (formerly, ehrlichia equi), and rickettsia rickettsii (rocky mountain spotted fever). primary immune-mediated thrombocytopenia has an unknown cause and most frequently is seen in middle-to older-aged female dogs. breed predispositions include cocker spaniels, german shepherd dogs, poodles (toy, miniature, standard), and old english sheepdogs. thrombocytopenia usually is manifested as petechiae, ecchymoses of skin and mucous membranes, hyphema, gingival and conjunctival bleeding, hematuria, melena, and epistaxis. to make a diagnosis of idiopathic thrombocytic purpura, measure the severity of thrombocytopenia (< 50,000 platelets/âµl), analyze the peripheral blood smear for evidence of platelet fragmentation or microthrombocytosis, normal to increased numbers of megakaryocytes in the bone marrow, detection of antiplatelet antibody, increased platelet counts after starting glucocorticoid therapy, and elimination of other causes of thrombocytopenia. if tick-borne illnesses are suspected, antibody titers for e. canis, a. phagocytophilum (formerly e. equi), and r. rickettsii should be performed. treatment of immune-mediated thrombocytopenia involves suppression of the immune system to stop the immune-mediated destruction and to stimulate platelet release from the bone marrow. traditionally, the gold standard to suppress the immune system is to use glucocorticoids (prednisone or prednisolone, 2 to 4 mg/kg po bid divided, or dexamethasone, 0.1 to 0.3 mg/kg iv or po q12h). more recently human serum immunoglobulin (igg) also has been used (0.2 to 0.5 g/kg iv in saline over 8 hours; pretreat with 1 mg/kg diphenhydramine 15 minutes before starting infusion). vincristine (0.5 mg/m 2 iv once) can stimulate the release of platelets from the bone marrow if megakaryocytic precursors are present; however, the platelets released may be immature and potentially nonfunctional. treatment with fresh whole blood or packed rbcs is appropriate if anemia is present; however, unless specific platelet-rich plasma has been purchased from a blood bank, fresh whole blood contains relatively few platelets, which are shortlived (2 hours) and will not effectively raise the platelet count at all. finally, long-term therapy is usually in the form of azathioprine (2 mg/kg po once daily, tapered to 1 mg/kg daily to every other day after 1 week) and cyclosporine (10 to 25 mg/kg po divided). if a tickborne illness is suspected, administer doxycycline (5 to 10 mg/kg po bid) for 4 weeks or if titers come back negative. thrombocytopenia also can occur in the cat. causes for thrombocytopenia in cats include infections (29%), neoplasia (20%), cardiac disease (7%), primary immune-mediated disease (2%), and unknown causes (20%). in one study of cats with feline leukemia and myeloproliferative disease, 44% of cases had thrombocytopenia. warfarin and coumarin derivatives are the major class of rodenticides used in the united states. vitamin k antagonist rodenticides inhibit the epoxidase reaction and deplete active vitamin k, causing a depletion of vitamin k-dependent coagulation factors (ii, vii, ix, x) within 24 hours to 1 week of ingestion, depending on the ingested dose. affected animals can spontaneously hemorrhage anywhere in the body. clinical signs can include hemoptysis, respiratory difficulty, cough, gingival bleeding, epistaxis, hematuria, hyphema, conjunctival bleeding, petechiae and ecchymoses, cavity hemorrhage (pleural, peritoneal, retroperitoneal) with acute weakness, lethargy or collapse, hemarthrosis with lameness, deep muscle bleeds, and intracranial or spinal cord hemorrhage. diagnosis of vitamin k antagonism includes prolonged pt. a pivka (protein induced by vitamin k absence or antagonism) test also can be performed, if possible. treatment of vitamin k antagonist rodenticide intoxication and other causes of vitamin k deficiency involves supplementation with vitamin k 1 (phytonadione, 5 mg/kg sq once with 25-gauge needle in multiple sites, and then 2.5 mg/kg po bid to tid for 30 days). never administer injections of vitamin k intramuscularly, because of the risk of causing deep muscle hematomas, or intravenously, because of the risk of anaphylaxis. the pt should be rechecked 2 days after the last vitamin k capsule is administered, for some of the secondgeneration warfarin derivates are fat-soluble, and treatment may be required for an additional 2 weeks. act, activated clotting time; aptt, activated partial thromboplastin time; bmbt, buccal mucosa bleeding time; fdp, fibrin degradation products; n, normal; pt, prothrombin time. thermal burns are fortunately a relatively infrequent occurrence in veterinary patients. box 1-33 lists various causes of malicious and accidental burns. the location of the burn is also important in assessing its severity and potential to lose function. burns on the perineum, feet, face, and ears are considered to be the most severe because of loss of function and severe pain. often the severity of thermal injury is difficult to assess in animals because hair coat potentially can mask clinical signs and because the thermal injury can continue after the animal has been removed from the heat source. the skin cools slowly and warms slowly, considerations that become important when initiating therapy for burns. the severity of thermal injury is associated with the temperature to which the animal is exposed, the duration of contact, and the ability of the tissue to dissipate heat. the tissue closest to the heat source undergoes necrosis and has decreased blood flow. the severity of thermal burn injury is associated directly with the temperature to which the animal is exposed, the percentage of total body surface area affected, the thickness of injured tissue, and whether underlying complications with other body systems occur. prognosis largely depends on the total body surface area affected (table 1-31) . superficial partial thickness, or first-degree, burns offer the most favorable prognosis. the affected epidermis initially appears erythematous and then quickly desquamates within 3 to 6 days. in most cases, fur grows back without leaving a scar. deep partial thickness, or second-degree, burns involve the epidermis and dermis and are associated with subcutaneous edema, inflammation, and pain. deep partial thickness burns heal from deeper adnexal tissues and from the wound edges and are associated with an increased chance of scarring and depigmentation. the most severe type is known as full thickness, or third-degree, burns, in which thermal injury destroys the entire thickness of the skin and forms an eschar. thrombosis of superficial and deeper skin vasculature and gangrene occurs. treatment involves sequential wound debridement. healing occurs by second intention and reepithelialization or by wound reconstruction. in most cases, scarring is extensive in affected areas. burns greater than 20% of total body surface area will have systemic effects, including impaired cardiovascular function, pulmonary dysfunction, and impaired immune function. burned tissue, with capillary damage, has increased permeability. the release of inflammatory cytokines, oxygen-derived free radical species, prostaglandins, leukotrienes, 108 1 emergency care histamine, serotonin, and kinins results in increased vascular permeability and leakage of plasma proteins into the interstitium and extravascular space. at the time of presentation, first examine the patient and ascertain whether airway obstruction, impaired ventilatory function, circulatory shock, or pain are present. if necessary, establish an airway with endotracheal intubation or emergency tracheostomy. next, cool the burned area(s) with topical cool water. use care to avoid overcooling and iatrogenic hypothermia. the best approach is to cool only one portion of the patient's body at a time, then dry, and repeat the process for all affected areas to avoid overcooling and iatrogenic hypothermia. establish vascular access and administer appropriate and judicious analgesic drugs and intravenous fluid therapy. whenever possible, avoid placing a catheter through an area of burned or damaged skin. in the early stages of burn injury, shock doses of intravenous crystalloid fluids usually are not required. later, however, as severe tissue exudation occurs, protein and fluid losses can become extensive, requiring aggressive crystalloid and colloid support to treat hypovolemia and hypoproteinemia. flush the eyes with sterile saline and examine behind the third eyelids for any particulate matter. stain the corneas to make sure that superficial corneal burns are not present. treat superficial corneal burns with triple antibiotic ophthalmic ointment. next, assess the total body surface area affected, as this will gauge prognosis. depending on the extent of the damage, decide whether the burn is superficial and local therapy is indicated or whether more severe injuries exist that may involve systemic therapy or possibly euthanasia. in most cases the diagnoses of thermal burns are based on a clinical history of being in a house fire, clothes dryer, or under a heating lamp. too frequently, however, thermal burns become apparent days after an elective surgical procedure in which the patient was placed on a faulty heating pad rather than a circulating warm water or warm air blanket. superficial burns appear as singed fur with desquamating, easily epilated hair. this condition also can resemble a superficial or deeper dermatophytosis if history is unknown. other differential diagnoses include immune-mediated vasculitis or erythema multiforme. unless the superficial dermis is blistered, it may be difficult to distinguish between a thermal burn, chemical burn, or electrical burn if the trauma went unnoticed. management of burn injury largely depends on the depth of injury and the total body surface area affected. partial thickness burns and those affecting less than 15% of the total body surface area will require support in the form of antibiotic ointment and systemic analgesic drugs. burns affecting greater than 15% of total body surface area or deep thickness burns require more aggressive therapy. central venous catheters can be placed to administer crystalloid and colloid fluids, parenteral nutrition if necessary, antibiotics, and analgesic drugs. monitor perfusion parameters closely, including heart rate, blood pressure, capillary refill time, and urine output. respiratory function can be impaired because of concurrent smoke inhalation, thermal damage to the upper airways and alveoli, and carboxyhemoglobin or methemoglobin intoxication. respiratory function also can be impaired because of burn injury to the skin around the thoracic cage. thoracic radiographs may reveal patchy interstitial to alveolar infiltrates associated with pulmonary edema, pneumonia, and atelectasis. bronchoscopy often reveals edema, inflammation, particulate matter, and ulceration of the tracheobronchial tree. in some cases, upper airway inflammation is so severe that an emergency tracheostomy must be performed to treat airway obstruction. administer supplemental humidified oxygen at 50 to 100 ml/kg/minute via endotracheal tube, tracheostomy, nasal or intratracheal tube, or hood oxygen if respiratory function and hypoxemia are present. perform blood work including a hematocrit, albumin, bun, creatinine, and glucose at the time of presentation. monitor serum electrolytes, albumin, and colloid oncotic pressure closely because derangements can be severe as burns become exudative. the goal of fluid therapy in the burn patient is to establish and maintain intravascular and interstitial fluid volume, normalize electrolyte and acid-base status, and maintain serum albumin and oncotic pressure. in the first 24 hours following burn injury, direct fluid therapy to maintaining the patient's metabolic fluid requirements. crystalloid fluids in the form of normosol-r, plasmalyte-m, or lactated ringer's solution can be administered according to the patient's electrolyte and acid-base status (see fluid therapy). monitor urine output, and keep it at 1 to 2 ml/kg/hour. avoid overhydration in the early stages of burn injury. in affected burn patients, calculate the amount of fluid that should be administered over a 24-hour period from the formula 1 â�� 4 ml/kg ã� percent total body surface area. administer half of this calculated dose over the first 8 hours and then the remaining half over the next 16 hours. in cats, administer only 50% to 75% of this calculated volume. to administer this volume and also avoid fluid overload is often difficult in critically ill patients with pulmonary involvement associated with smoke inhalation injury. avoid colloids in the first 6 hours after burn injury. monitor the patient closely for serous nasal discharge, chemosis, and rales that may signify pulmonary edema. as burns become exudative, weigh the patient at least twice daily. infused fluid should equal fluid output in the form of urine and wound exudates. acute weight loss signifies acute fluid loss and that crystalloid fluid infusion should be more aggressive. ideally, keep the patient's serum albumin equal to or greater than 2.0 g/dl and total protein between 4.0 and 6.5 g/dl using a combination of fresh frozen plasma or concentrated human albumin. adjunct colloidal support can be provided with synthetic colloids including hetastarch or hbocs. keep serum potassium within 3.5 to 4.5 meq/l using potassium chloride or potassium phosphate supplementation. if potassium supplementation exceeds 80 to 100 meq/l and the patient continues to have severe refractory hypokalemia, administer magnesium chloride (0.75 meq/kg/day) to enhance potassium retention. if anemia occurs, administer packed rbcs or whole blood (see blood component therapy). lavage wounds daily with lactated ringer's solution or 0.9% sodium chloride solution. place wet-to-dry bandages or bandages soaked in silver sulfadiazine or nitrofurazone ointment over the wounds. depending on the thickness of the burn, epilation and eschar formation and separation may take 2 to 10 days. at each bandage change, debride devitalized tissue to normal tissue. perform staged partial or total escharectomy, and leave the wound to heal by second intention or by reconstruction using skin advancement flaps or grafts. maintain meticulous sterility at all times, given that burn patients are at high risk for infection. administer broad-spectrum antibiotics including cefazolin and enrofloxacin. perform wound culture if a resistant bacterial infection is suspected. the most common cause of electrical injury is associated with an animal chewing on low-voltage alternating current electrical cords in the household. damage is caused by the current flowing through the path of least resistance, causing heat and thrombosis of vessels and neurons. in some cases, the owner witnesses the event. in other cases, the owner presents the patient because of vague nonspecific signs, and characteristic abnormalities on physical examination support a diagnosis of electrocution. burns on the face, paws, commissures of the mouth, tongue, and soft palate may be present. electrocution causes a massive release of catecholamines and can predispose the patient to noncardiogenic pulmonary edema within 36 hours of the incident. clinical signs may be isolated to the pulmonary system, including orthopnea, pulmonary crackles, and cyanosis. assess the patient's lips, tongue, soft palate, gingivae, and commissures of the mouth. early after electrocution, the wound may appear small and white, black, or yellow. later, the wound may become larger as tissue sloughs because of damaged vascular supply. assess the patient's respiratory status. auscultate the lungs to determine whether pulmonary crackles 110 1 emergency care are present. if the patient is stable, thoracic radiographs may demonstrate an interstitial to alveolar lung pattern in the dorsocaudal lung fields. measure the patient's heart rate, blood pressure, oxygenation as determined by pulse oximetry or arterial blood gas and urine output. immediate treatment consists of judicious use of analgesics for the burn injury, antibiotics (cefazolin, 22 mg/kg q8h; cephalexin, 22 mg/kg q8h), and humidified supplemental oxygen (50 to 100 ml/kg/minute). direct fluid therapy at providing the patient's metabolic fluid requirements. because of the risk of development of noncardiogenic pulmonary edema, avoid overzealous administration of crystalloid fluids. differential diagnoses for the patient with electrical burn injury and electrocution include chemical or thermal burn, immune-mediated glossitis, cardiogenic pulmonary edema, and pneumonia. management of the patient with electrical burn injury and electrocution primarily involves the administration of analgesic agents, supplemental humidified oxygen, and topical treatment of electrical burns. the noncardiogenic pulmonary edema is typically unresponsive to diuretics (i.e., furosemide), bronchodilators (i.e., aminophylline), and splanchnic vascular dilators (i.e., low-dose morphine). the use of glucocorticoids has no proven benefit and may impair respiratory immune function and is therefore contraindicated. oral burns may require debridement and advancement flaps if large defects or oronasal fistulas develop. if oral injury is severe, place an esophagostomy or percutaneous gastrostomy tube to ensure adequate nutrition during the healing process. if an animal survives the initial electrocution, prognosis is generally favorable with aggressive supportive care. chemical burns are associated with a number of inciting causes, including oxidizing agents, reducing agents, corrosive chemicals, protoplasmic poisons, desiccants, and vesicants. the treatment for chemical burns differs slightly from that for thermal burns, so it remains important to investigate the cause of the burn when providing initial treatment, whenever possible. at the scene, advise the owner to wrap the patient in a clean towel for transport. chilling can be avoided by then wrapping the patient in a second or third blanket. placement of ointments by well-doers should be avoided. encourage immediate transport to the nearest triage facility. the first and foremost consideration when treating a patient with chemical burn is to remove the animal from the inciting cause or offending agent. make no attempt to neutralize alkaline or acid substances because the procedure potentially could cause an exothermic reaction, leading to thermal injury in addition to the chemical injury. remove collars or leashes that may act as tourniquets or constricting devices. flush affected areas with copious amounts of cool water for several minutes, not cooling more than 10% to 20% of the body at any one time to prevent iatrogenic hypothermia. support breathing by extending the patient's head and neck. carefully clip the fur over affected areas for further evaluation of the extent of the injury. lavage exposed eyes with sterile saline, and stain the cornea to evaluate for any corneal burns. debride any wounds carefully, knowing that the full extent of the wound may not manifest itself for several days. then cover the wounds with antibiotic burn ointment such as silver sulfadiazine and an occlusive dressing. without a history of exposure, the differential diagnosis for any chemical burn includes thermal burn, necrotizing vasculitis, erythema multiforme, or superficial or deep pyoderma. contact local or national animal poison control regarding whether to attempt neutralization. perform daily bandage changes with staged debridement as the full extent of the wound manifests itself. place antimicrobial ointment and silver sulfadiazine ointment over the wound to prevent infection. the routine use of antibiotics may promote the development of a resistant bacterial infection. first-generation cephalosporin can be administered. if a more serious infection develops, perform culture and susceptibility testing to direct appropriate antibiotic therapy. the wound can heal by second intention or may require reconstructive repair for definitive closure. the primary cause of radiation injury in small animal patients is radiation therapy for neoplastic conditions. the goal of radiation therapy is to kill neoplastic cells. an unfortunate side effect is damage to adjacent normal tissue that results in necrosis, fibrosis, and impaired circulation to the affected area. radiation burns result in dermatitis, mucositis, impaired surgical wound healing, and chronic nonhealing wounds. in many cases, the degree of secondary radiation injury to normal tissue can be prevented or decreased with careful radiation planning and mapping of the radiation field, such that radiation exposure to normal tissue is limited to the smallest extent possible. with the advent of three-dimensional imaging modalities such as computed tomography (ct) and magnetic resonance imaging (mri), this has become more routine in veterinary oncology to date. radiation injury can be early and appear at the later stage of the course of radiation therapy. late effects can be delayed and occur 6 months to years after treatment. the degree of radiation injury is categorized based on the depth of tissue affected. first-degree changes cause cutaneous erythema. second-degree changes cause superficial desquamation. thirddegree changes cause deeper moist desquamation, and fourth-degree changes are associated with complete dermal destruction and ulceration. during the early stages of radiation injury, affected tissues may appear erythematous and edematous. wound exudates may be moist, or the skin may appear dry and scaly with desquamation or ulceration. later, the area may scar and depigment or may have induration, atrophy, telangiectasia, keratosis, and decreased adnexal structures. treatment for radiation dermatitis is to irrigate the area with warmed saline and to protect the area from self-mutilation. no-bite, or elizabethan, collars or loose clothing can be used to protect the area for patient-induced injury. mucositis can be treated with topical green tea baths and the administration of an oral solution of l-glutamine powder (4 g/m 2 ). local irrigation of xylocaine or lidocaine viscous jelly can be used in dogs but should be avoided in cats because of the risk of inducing hemolytic anemia and neurotoxicity. topical and systemic antibiotics (cephalexin, 22 mg/kg po tid) also can be administered. avoid antibiotics that can be sensitized by radiation (i.e., metronidazole). because most radiation burns are associated with a known exposure to radiation therapy, the cause of the patient's injury usually is known. if an animal presents to you with a scar, however, differential diagnoses may include nasal planum solar dermatitis, pemphigus foliaceus, discoid lupus, superficial necrolytic dermatitis, superficial or deep pyoderma, chemical burn, or thermal burn. treatment of radiation injury involves making the patient as comfortable as possible with analgesic drugs, prevention of self-mutilation, and staged debridement techniques. wounds can heal by second intention or may require reconstructive surgery. distress syndrome (ards), and anesthetic agents. the acute onset of bradycardia, change in mucous membrane color and capillary refill time, change in respiratory pattern, and change in mentation are signs of possible deterioration and impending cardiopulmonary arrest. the diagnosis of cardiopulmonary arrest is based on the absence of effective ventilation, severe cyanosis, absence of a palpable pulse or apex heartbeat, absence of heart sounds, and ecg evidence of asystole or other nonperfusing rhythm such as electricalmechanical dissociation (aka pulseless electrical activity) or ventricular fibrillation. the goals of cpcr are to obtain airway access, provide artificial ventilation and supplemental oxygen, implement cardiac compressions and cardiovascular support, recognize and treat dysrhythmias and arrhythmias, and provide stabilization and treatment for cardiovascular, pulmonary, and cerebral function in the event of a successful resuscitation. even with aggressive treatment and management, the overall success of cpcr is less than 5% in critically ill or traumatized patients and 20% to 30% in anesthetized patients. basic life support involves rapid intubation to gain airway access, artificial ventilation, and cardiac compressions to promote blood flow and delivery of oxygen to the brain and other important tissues (figure 1-26 ). perform the abcs or cabs of cpcr, where a is airway, b is breathing, and c is compression and circulation. recently, the paradigm has shifted to cabs. while a team member is grabbing an endotracheal tube, clearing the airway of foreign debris, and establishing airway access through endotracheal intubation, a second person starts external cardiac compressions to deliver oxygen that is in the bloodstream to the vital organs. the patient should be positioned in dorsal (> 7 kg) or lateral (< 7 kg) recumbency for external cardiac compressions. approximately 80 to 120 external compressions should be performed over the patient's sternum. a team member should palpate for a peripheral pulse to determine whether cardiac compressions are actually effective. if a peripheral pulse cannot be palpated for every chest compression, change the patient's position and have a larger individual perform compressions, or initiate open-chest cardiac resuscitation. once the patient is intubated, tie in the endotracheal tube and attach it to an oxygen source (anesthetic machine or mechanical ventilator or ambu bag) for artificial ventilation. the oxygen flow rate should be 150 ml/kg/minute. give two long breaths, and then 12 to 16 breaths per minute. simultaneous ventilation with thoracic compression increases the pressure difference in the thorax and allows more forward flow of oxygenated blood through the great vessels into the periphery. if possible, a third team member can initiate interposed abdominal compressions, compressing the abdomen when the thoracic cage is relaxed, to improve forward flow. if only one person is available to perform the thoracic compressions and ventilation, give two breaths for every 15 compressions (i.e., 15 thoracic compressions followed by two long breaths, and then start thoracic compressions again). the jen chung maneuver can be performed by placing a 25-to 22-gauge hypodermic needle through the skin of the nasal philtrum and twisting the needle into the periosteum to stimulate respirations. this maneuver appears to work better in cats than dogs at return to spontaneous respiration. advanced life support during cpcr involves ecg, pulse oximetry and capnometry monitoring, administration of drugs, and the administration of intravenous fluids (in select cases). most of the drugs used during cpcr can be administered directly into the lungs from the endotracheal tube (intratracheal tube). therefore, only in select instances is it necessary to establish vascular or intraosseous access during cpcr (figure 1-27) . if an animal experiences cardiopulmonary arrest because of extreme hemorrhage or hypovolemia, inappropriate vasodilation caused by sepsis or systemic inflammation, or vasodilation resulting from anesthesia, the administration of shock volumes (90 ml/kg/hour in dogs and 44 ml/kg/hour in cats) is appropriate. if a patient is euvolemic and experiences cardiopulmonary arrest, however, an increase in circulating fluid volume actually can impair coronary artery perfusion by increasing diastolic arterial blood pressure and is asystole is one of the most common rhythm disturbances that causes cardiac arrest in small animal patients. one of the most important things to do when the ecg looks like asystole is to make sure that the ecg monitor is working properly and that all ecg leads are attached properly to the patient. if asystole is truly present, reverse any opiate, î± 2 -agonist, or benzodiazepine drugs with their appropriate reversal agents. lowdose epinephrine (0.02 to 0.04 mg/kg diluted with 5 ml sterile saline) can be administered directly into the endotracheal tube via a rigid or red rubber catheter. if vascular access is available, epinephrine (0.02 to 0.04 mg/kg) can be administered intravenously. no drug should ever be administered directly into the heart by intracardiac injection. unless the heart is in the veterinarian's hand during open-chest cpcr, intracardiac injection is risky and potentially could lacerate a coronary artery or cause the myocardium to become more irritable and refractory to other therapies, if a drug is delivered into the myocardium and not into the ventricle. for these reasons, intracardiac injections are contraindicated. administer atropine (0.4 mg/kg iv, io, or 0.4 mg/kg it) immediately after the epinephrine. atropine, a vagolytic drug, serves to decrease tonic vagal inhibition of the sinoatrial and atrioventricular node and increase heart rate. administer atropine and epinephrine every 2 to 5 minutes during asystole while cardiac compressions, interposed abdominal compressions, and artificial ventilation are continued. although discontinuation of thoracic compressions can decrease the chance of success during cpcr, you must intermittently evaluate the ecg monitor for any rhythm change that may require different drug therapies. if the cardiac arrest was not witnessed or more than 2 to 5 minutes have passed without successful return to a perfusing rhythm, perform open-chest cpcr, if the client wishes. administer sodium bicarbonate (1 to 2 meq/kg iv) every 10 to 15 minutes during cpcr. sodium bicarbonate is the only drug used in cpcr that should not be administered intratracheally because of inactivation of pulmonary surfactant. electrical-mechanical dissociation also is known as pulseless electrical activity and is an electrical rhythm that may look wide and bizarre and irregular with no associated mechanical contraction of the ventricles. the rhythm can appear different from patient to patient. electrical-mechanical dissociation is one of the more common nonperfusing rhythms observed during cardiopulmonary arrest in small animal patients (figure 1-28) . when electrical-mechanical dissociation is identified, first confirm the rhythm and proceed with cpcr as previously described. electrical-mechanical dissociation is thought to be associated with high doses of endogenous endorphins and high vagal tone. the treatment of choice for electrical-mechanical dissociation is high-dose atropine (4 mg/kg iv, it [10 times the normal dose]) and naloxone hydrochloride (0.03 mg/kg iv, io, it). administer epinephrine (0.02 to 0.04 mg/kg diluted in 5 ml sterile 0.9% saline it). if the rhythm does not change within 2 minutes, consider open-chest cardiac massage. ventricular fibrillation can be coarse (figure 1-29) . patients with coarse ventricular fibrillation are easier to defibrillate than those with fine defibrillation. if ventricular fibrillation is identified, initiate cpcr as described previously (figure 1-30) . if an electrical defibrillator is available, administer 5 j/kg of direct current externally. when a patient in cardiopulmonary arrest is attached to ecg leads, it is important to use contact electrode paste, water-soluble gel such as ky jelly, or water, rather than any form of alcohol. electrical defibrillation of a patient who has alcohol on the ecg leads can lead to fire and thermal burns. reverse any opioid, î± 2 -agonist, and phenothiazine drugs that have been administered to the patient. if fine ventricular fibrillation is identified, administer epinephrine 1 figure 1 -28: electrical-mechanical dissociation (emd), also known as pulseless electrical activity (pea). the complexes often appear wide and bizarre without a palpable apex beat or functional contraction of the heart. this is just one example of emd, as many shapes and complexes may be observed. organized according to whether an electrical defibrillator is available. after each intervention step, the ecg should be reevaluated and the next step initiated if v-fib is still seen. if a new arrhythmia develops, the appropriate therapy for that rhythm should be inititated. if a sinus rhythm is seen with a palpable apex beat, postresuscitation measures should be implemented. perform open-chest cpcr immediately if a pathologic condition exists that prevents enough of a change in intrathoracic pressure that closed-chest cpcr will not be effective in promoting forward blood flow (box . to perform open-chest cpcr, place the patient in right lateral recumbency. clip a wide strip of fur over the left fifth to seventh intercostal space and quickly aseptically scrub over the clipped area. using a no. 10 scalpel blade, incise over the fifth intercostal space through the skin and subcutaneous tissue to the level of the intercostal muscles. with a mayo scissors, make a blunt stab incision through the intercostal muscles in the left sixth intercostal space. make sure that the person who is breathing for the patient deflates the lungs as you make the stab incision to avoid iatrogenic lung puncture. after the stab incision, open the tips of the mayo scissors and quickly open the muscle dorsally and ventrally to the sternum with a sliding motion. avoid the internal thoracic artery at the sternum and the intercostal arteries at the caudal aspect of each rib. cut the rib adjacent to the sternum and push it behind the rib in front of and at the caudal aspect of the incision to allow more room and better visualization if a rib spreading retractor is not available. visualize the heart in the pericardial sac. visualize the phrenic nerve, and incise the pericardium just ventral to the phrenic nerve. make sure to not cut the phrenic nerve. grasp the heart in your hand(s) and gently squeeze it from apex to base, allowing time for the ventricle to fill before the next "contraction." if the heart does not seem to be filling, administer fluids intravenously or directly into the right atrium. the descending aorta can be cross-clamped with a rummel tourniquet or red rubber catheter to improve perfusion to the brain and heart. postresuscitation care and monitoring (prolonged life support) postresuscitation care involves careful monitoring and management of the adverse effects of hypoxia and reperfusion injury on the brain and other vital organs. the first 4 hours after an arrest are most critical, because this is the time period in which an animal is most likely to rearrest unless the underlying cause of the initial arrest has been determine and treated (table 1 -32) . until an animal is adequately ventilating on its own, artificial ventilation by manual bagging or attaching the patient to a mechanical ventilator with supplemental oxygen must continue. the efficacy of oxygenation and ventilation can be monitored using a wright's respirometer, pulse oximetry, capnometry, and arterial blood . once an animal is extubated, administer supplemental oxygen (50 to 100 ml/ kg/minute) (see oxygen supplementation). the brain is sensitive to ischemia and reperfusion injury. the effects of cellular hypoxia and reperfusion include the development of oxygen-derived free radical species that contribute to cerebral edema. administer mannitol (0.5 to 1 g/kg iv over 5 to 10 minutes), followed by furosemide (1 mg/kg iv) 20 minutes later, to all patients that have experienced cardiopulmonary arrest and have had successful resuscitation. mannitol and furosemide work synergistically to decrease cerebral edema formation and scavenge oxygen-derived free radical species. the combination of cardiac arrest, myocardial ischemia and acidosis, and external or internal cardiac compressions often make the myocardium irritable and predisposed to dysrhythmias following successful cpcr. start lidocaine (1 to 2 mg/kg iv, followed by 50 to 100 âµg/kg/minute iv cri) in all patients following successful resuscitative efforts. monitor the ecg continuously for the presence of cardiac dysrhythmias and recurrence of nonperfusing rhythms. perform direct or indirect blood pressure monitoring. if a patient's systolic blood pressure is less than 80 mm hg, diastolic pressure is less than 40 mm hg, or mean arterial blood pressure is less than 60 mm hg, administer positive inotropic drugs (dobutamine, 1 to 20 âµg/kg/minute) and pressor agents (epinephrine, 0.02 to 0.04 mg/kg iv, io, it) to improve cardiac contractility, cardiac output, and core organ perfusion. the kidneys are sensitive to decreased perfusion and cellular hypoxia. place a urinary catheter and monitor urine output. in a euvolemic patient, normal urine output should be no less than 1 to 2 ml/kg/hour. if urine output is low, administer low-dose dopamine (3 to 5 âµg/kg/minute iv cri) in an attempt to dilate afferent renal vessels and improve renal perfusion. maintain acid-base and electrolyte status within normal reference ranges. monitor serum lactate as a rough indicator of organ perfusion and cellular oxygen extraction. the presence of elevated or rising serum lactate in the face of aggressive cardiorespiratory and cerebral support makes prognosis less favorable. cole sg, otto cm, hughes d: cardiopulmonary cerebral resuscitation: a clinical practice review part i, j vet emerg crit care 12 (4) immediate action depends largely on recognition of the primary or secondary cause of the dysrhythmia and treating the dysrhythmia and underlying cause. diagnosis of cardiac dysrhythmias is based on physical examination findings of abnormal thoracic/cardiac auscultation, the presence of abnormal pulse rhythm and quality, and recognition of ecg abnormalities. the ecg is critical to the accurate diagnosis of dysrhythmias. ventricular dysrhythmias arise from ectopic foci in the ventricles that cause the wave of depolarization to spread from cell to cell rather than spread through fast-conducting tissue. this causes the qrs complex to appear wide and bizarre, unless the ectopic focus originates close to the atrioventricular node high in the ventricle. other ecg features of ventricular dysrhythmias include a t wave polarity that is opposite to the qrs complex and nonrelated p waves. ventricular dysrhythmias may manifest as isolated ventricular premature complexes, couplets, or triplets; bigeminy; or ventricular tachycardia. relatively slow ventricular tachycardia is known as an idioventricular rhythm and is not as hemodynamically significant as faster ventricular tachycardia. idioventricular rhythm usually is less than 130 beats per minute and may alternate spontaneously with sinus arrhythmias (figures 1-31 to . supraventricular dysrhythmias arise from ectopic foci in the atria and are commonly associated with atrial dilatation and structural heart disease such as advanced acquired or congenital heart disease, cardiomyopathies, cardiac neoplasia, or advanced heartworm disease. occasionally, supraventricular dysrhythmias may be associated with respiratory or other systemic illness. sustained supraventricular tachycardia in the absence of underlying structural heart or systemic disease is disturbing and should alert the clinician that an accessory pathway conduction disturbance may be present, particularly in labrador retrievers. supraventricular dysrhythmias can manifest as isolated premature complexes (atrial premature complexes or contractions), sustained or paroxysmal supraventricular tachycardia (atrial tachycardia), or atrial fibrillation or flutter. in the dog, atrial fibrillation most commonly is associated with dilative cardiomyopathy. rarely and primarily in giant breed dogs, lone atrial fibrillation can occur with no underlying heart disease. atrial fibrillation and the resultant sustained elevation in ventricular rate are presumed to progress to dilative cardiomyopathy in such breeds. by comparison, atrial fibrillation is relatively uncommon in cats because of the small size of their atria but is associated most commonly with hypertrophic and restrictive cardiomyopathy. the ecg is critical to the diagnosis of a supraventricular dysrhythmia. the ecg usually demonstrates a normal appearance to the qrs complex unless aberrant conduction occurs in the ventricles, in which case the qrs can be wide but still originate from above the atrioventricular node. in most cases of a supraventricular dysrhythmia, some evidence of atrial activity including p waves, atrial flutter, or atrial fibrillation is apparent. in some cases, it may be difficult to diagnose the exact rhythm without slowing the rate down mechanically or through pharmacologic intervention. once a rhythm diagnosis is made, appropriate treatment strategies can be implemented (figures 1-35 and 1-36 ). treatment of ventricular dysrhythmias largely depends on the number of ectopic foci discharging, the rate and character of the dysrhythmia, and whether the presence of the abnormal beats is of adverse hemodynamic consequence, including risk of sudden death. many ventricular dysrhythmias, including slow idioventricular rhythms, ventricular bigeminy, or intermittent ventricular premature complexes, do not warrant antiarrhythmic therapy unless the patient is hypotensive and the dysrhythmia is thought to be contributing to the hypotension. in such cases, correction of the underlying disease process including hypoxia, pain, or anxiety often alleviates or decreases the incidence of the dysrhythmia. more serious ventricular dysrhythmias that warrant antiarrhythmic therapy (table 1 -33) include sustained ventricular tachycardia (>160 beats/minute in dogs; >220 beats/minute in cats), multifocal ventricular premature complexes originating from more than one place in the ventricles, and the presence of r-on-t phenomena where the t wave of the preceding complex is superimposed on the qrs of the next complex with no return to isoelectric shelf in between complexes. treat these ventricular dysrhythmias immediately and aggressively. in dogs, the mainstay of emergency treatment for ventricular dysrhythmias is lidocaine therapy. administer lidocaine (1 to 2 mg/kg iv bolus) over a period of 5 minutes to prevent the adverse side effects of seizures or vomiting. the bolus can be repeated an additional 3 times (total dose 8 mg/kg) over 15 minutes, or the patient can be placed on a constant rate infusion (50 to 100 âµg/kg/minute) if control of ventricular tachycardia is accomplished. also correct the patient's magnesium and potassium deficiencies to maximize the success of lidocaine therapy in the treatment of ventricular tachycardia. procainamide (4 mg/kg iv slowly over 3 to 5 minutes) also can be used to control ventricular tachycardia. if procainamide is successful at controlling ventricular tachycardia, administer it as a constant rate infusion (25 to 40 âµg/kg/minute). side effects of procainamide include vomiting, diarrhea, and hypotension. chronic oral therapy may or may not be necessary in the treatment of acute ventricular tachycardia. the decision to continue antiarrhythmic therapy depends on the underlying disease process and the expectation of persistent arrhythmogenesis of the underlying disease process. oral antiarrhythmic therapy is warranted in cases in which a serious ventricular dysrhythmia is recognized but the animal does not require hospitalization, such as the syncopal boxer with intermittent ventricular dysrhythmias and no evidence of structural heart disease. it deserves emphasis that asymptomatic, low-grade ventricular dysrhythmias probably do not require treatment. if maintenance therapy for ventricular dysrhythmias is needed, use an oral drug based on the underlying disease process, clinical familiarity, class of drug, dosing frequency, owner compliance, concurrent medications, cost, and potential adverse side effects. in the cat the mainstay of antiarrhythmic therapy is the use of a î²-adrenergic antagonist. in the acute management of ventricular dysrhythmias in cases of hypertrophic, restrictive, or unclassified cardiomyopathies, consider using injectable esmolol (0.05 to 1.0 mg/kg iv slowly to effect) or propranolol (0.02 to 0.06 mg/kg iv slowly to effect), particularly if the dysrhythmia results from hyperthyroidism. for chronic oral ventricular antiarrhythmic therapy in cats, propranolol (2.5 to 5.0 mg po per cat q8h) or atenolol (6.25 to 12.5 mg po per cat q12-24h) can be used. the decision to treat supraventricular dysrhythmias depends on the ventricular rate and the hemodynamic consequences of the dysrhythmia. for intermittent isolated atrial 124 1 emergency care procainamide 10-20 mg/kg po q6-8h tocainide* 10-20 mg/kg po q8h sotalol 40-120 mg per dog q12h (start low, then titrate up to effect) mexiletine 5-8 mg/kg po q8h atenolol 0.25-1.0 mg/kg po q12-24h (start low, titrate upward to effect) *do not use for longer than 2 weeks because of idiosyncratic blindness. premature contractions, couplets, and triplets, usually no treatment is required. when the ventricular rate exceeds 180 beats/minute, diastolic filling time is shortened, causing the heart to not fill adequately. the consequence is decreased cardiac output and decreased coronary artery perfusion. the goal of therapy is rhythm control or, in most cases, rate control. in cases of atrial fibrillation and congestive heart failure, conversion to a normal sinus rhythm rarely can be achieved, although electrocardioversion or pharmacoconversion can be attempted. in the dog a vagal maneuver can be attempted by pressing on the eyeballs or massaging the carotid body. for sustained supraventricular tachycardia, diltiazem (0.25 mg/kg iv), esmolol (0.05 to 0.1, titrated upward to a cumulative dose of 0.5 mg/kg iv), or propranolol (0.04 to 0.1 mg/kg iv slowly to effect) can be administered in an attempt to slow the ventricular rate in emergent situations. administer oral diltiazem (0.5 mg/kg po q8h), diltiazem (dilacor-xr) (1.5 to 6 mg/kg po q12-24h), propranolol (0.1 to 0.2 mg/kg tid, titrated up to a maximum of 0.5 mg/kg po q8h), atenolol (0.25 to 1 mg/kg q12-24h), or digoxin (0.005 to 0.01 mg/kg bid or 0.22 mg/m 2 for dogs greater than 15 kg). in the cat a vagal maneuver can be attempted by ocular or carotid massage. (diltiazem [dilacor] 30 to 60 po q12-24h), propranolol (2.5 to 10 mg/kg q12-24h), or atenolol (6.25 mg q12-24h) also can be administered. if structural heart disease is present, treat pulmonary edema and start angiotensin-converting enzyme inhibitor therapy. table 1 -34 summarizes the drugs used in the management of supraventricular dysrhythmias. severe bradycardia often results from systemic disease, drug therapy, anesthetic agents, or hypothermia and thus rarely requires specific therapy except to treat or reverse the underlying mechanisms promoting bradycardia. hemodynamically significant bradyarrhythmias that must be treated include atrial standstill, atrioventricular block, and sick sinus syndrome. atrial standstill most commonly is associated with hyperkalemia and is seen most often in urinary obstruction, renal failure, urinary trauma with uroabdomen, and hypoadrenocorticism. characteristic ecg abnormalities observed in atrial standstill are an absence of p waves, widened qrs complexes, and tall spiked t waves (figure 1-37 ). the treatment for hyperkalemia-induced atrial standstill is to correct the underlying cause and to drive potassium intracellularly and protect the myocardium from the adverse effects of hyperkalemia. regular insulin (0.25 to 0.5 units/kg iv) followed by dextrose (1 g/unit insulin iv, followed by 2.5% dextrose cri to prevent hypoglycemia) or sodium bicarbonate (1 meq/kg iv) can be administered to drive potassium intracellularly. calcium gluconate (0.5 ml/kg of 20% solution iv over 5 minutes) also can be administered as a cardioprotective drug until the cause of hyperkalemia has been identified and resolved. also administer sodium chloride fluids (0.9% sodium chloride iv) to promote kaliuresis. less commonly, atrial standstill is associated with atrial cardiomyopathy or silent atrium syndrome. persistent atrial standstill has been recognized without electrolyte abnormalities in the english springer spaniel and the siamese cat. short-term therapy for persistent atrial standstill includes atropine (0.04 mg/kg sq) until definitive treatment by implantation of a cardiac pacemaker can be performed. complete or third-degree atrioventricular block or high-grade symptomatic seconddegree atrioventricular block can be hemodynamically significant when ventricular rates are less than 60 beats/minute in the dog. classic clinical signs include weakness, exercise intolerance, lethargy, anorexia, syncope, and occasionally seizures. advanced atrioventricular block usually is caused by advanced idiopathic degeneration of the atrioventricular node. less commonly, atrioventricular block has been associated with digoxin toxicity, magnesium oversupplementation, cardiomyopathy, endocarditis, or infectious myocarditis (lyme disease). an accurate diagnosis is made based on the ecg findings of nonconducted p waves with ventricular escape beats. first-and second-degree atrioventricular block may not be hemodynamically significant and therefore may not require therapy. initially treat third-degree (complete) or symptomatic high-grade second-degree atrioventricular block (<60 beats/minute) with atropine (0.04 mg/kg sq or im). perform a follow-up ecg in 15 to 20 minutes. atropine is rarely successful in treating complete atrioventricular block. also attempt treatment with isoproterenol (0.04 to 0.08 âµg/kg/minute iv cri or 0.4 mg in 250 ml 5% dextrose in water iv slowly), a pure î²-agonist. definitive treatment requires permanent pacemaker implantation. consultation with a veterinary cardiologist who implants pacemakers is suggested. never attempt to convert or treat the observed ventricular escape beats with lidocaine ( figure 1-38) . sick sinus syndrome most commonly is recognized in the miniature schnauzer, although any dog can be affected. sick sinus syndrome usually results from idiopathic degeneration of the sinus node in the dog. in the cat, sinus node degeneration usually is associated with cardiomyopathy. dysfunction of the sinus node may manifest as marked bradycardia with periods of sinus arrest followed by junctional or ventricular escape complexes. a variant of sick sinus syndrome is the presence of severe bradycardia followed by periods of supraventricular tachycardia, often termed bradycardia-tachycardia syndrome. the most common clinical signs are syncope, exercise intolerance, and lethargy. in cats, hypertrophic cardiomyopathy is the most common form of acquired cardiac disease observed. congestive heart failure resulting from hypertrophic cardiomyopathy can occur in animals as young as 6 to 10 months of age. hypertrophic cardiomyopathy is characterized by stiff, noncompliant ventricles that do not relax during diastole, causing an increase in left atrial pressures and left atrial enlargement. other cardiomyopathies, including unclassified, restrictive, and dilated, are less common but also can occur in the cat. cats often develop acute exacerbation of clinical signs because of stress or arterial embolization. the rapid diagnosis of chf often is made on owner history, signalment, and physical examination findings (box 1-36). typical physical examination findings include a cardiac murmur or gallop dysrhythmia, abnormal breath sounds, respiratory difficulty and orthopnea, tachycardia, weak pulse quality, cool peripheral extremities, and pale or cyanotic mucous membrane. initiate immediate treatment based on physical examination findings and index of suspicion. in some cases, it is difficult to distinguish between chf and feline lower airway disease (asthma) without performing thoracic radiographs. let the animal rest and become stabilized before attempting any stressful procedures, including thoracic radiographs. immediate treatment consists of administering supplemental oxygen, decreasing circulating fluid volume with furosemide, dilating pulmonary and splanchnic capacitance vessels with topical nitroglycerine and morphine, and alleviating patient anxiety and stress (box 1-37). primary differential diagnoses are made based primarily on the patient's breed, age, clinical signs, history, and physical examination abnormalities. the most common differential diagnoses in a patient with chf are cardiac abnormalities and respiratory disease (chronic bronchitis [asthma], pulmonary hypertension, cor pulmonale, neoplasia). postpone diagnostic tests in any patient with suspected chf until the immediate treatments have taken effect and the patient is cardiovascularly more stable. in most cases, lateral and dorsoventral thoracic radiographs are one of the most important diagnostic tools in helping make a diagnosis of chf. increased perihilar interstitial to alveolar infiltrates are characteristic of pulmonary edema. left atrial enlargement may be observed as a "backpack" sign at the caudal cardiac waist. cardiomegaly of the right or left side also may 128 be present in cases of valvular insufficiency. in cats, increased sternal contact and a classic valentine-shaped heart may be observed in cases of hypertrophic cardiomyopathy. perform a vertebral heart score (sum) to measure cardiac size and determine whether cardiomegaly is present (box 1-38). also obtain arterial blood pressure and ecg readings to determine whether hypotension and dysrhythmias are present. atrial fibrillation, ventricular premature contractions, and supraventricular tachycardia are common rhythm disturbances that can affect cardiac output adversely and influence treatment choices. the echocardiogram is a useful noninvasive and nonstressful method to determine the degree of cardiac disease present. the echocardiogram is largely user-dependent. the quality of the study is based on the experience of the operator and the quality of the ultrasound machine. echocardiography can be a useful tool in making a diagnosis of pericardial effusion, dilated or hypertrophic cardiomyopathy, cardiac neoplasia, and endocarditis. the medical management of chf is designed to improve cardiac output and relieve clinical signs. the immediate goal of therapy is to reduce abnormal fluid accumulation and provide adequate cardiac output by increasing contractility, decreasing preload and ventricular afterload, and/or normalizing cardiac dysrhythmias. strict cage rest is of utmost importance when managing a patient with chf. after initial administration of furosemide, morphine, oxygen, and nitroglycerine paste, clinical signs of respiratory distress should show improvement within 30 minutes. if no improvement is observed, administer repeated doses of furosemide. reevaluate severe cases that are refractory to this standard treatment protocol. vasodilation should be the next step in the management of refractory cases, provided that a normal blood pressure is present. sodium nitroprusside is a potent balanced vasodilator that should be administered (1 to 10 âµg/kg/minute iv cri), taking care to monitor blood pressure continuously because severe vasodilation and hypotension can occur. the goal of nitroprusside therapy is to maintain a mean arterial blood pressure of 60 mm hg. sodium nitroprusside should not be considered in cases of refractory chf with severe hypotension. for more long-term management of chf, the use of angiotensin-converting enzyme (ace) inhibitors including enalapril (0.5 mg/kg po q12-24h), benazepril (0.5 mg/kg po q24h), and lisinopril (0.5 mg/kg po q24h) have become the mainstay of therapy to reduce sodium and fluid retention and decrease afterload. start angiotensin-converting enzyme inhibition as soon as a patient is able to tolerate oral medications. dobutamine (2.5 to 10 âµg/kg/minute cri diluted in 5% dextrose in water) can be administered to improve cardiac contractility, particularly in cases of dilated cardiomyopathy. at low doses, dobutamine, primarily a î²-adrenergic agonist, will improve cardiac output with minimal effects on heart rate. dobutamine must be given as a constant rate infusion with careful, continuous ecg monitoring. despite minimal effects on heart rate, emergency management of specific conditions 129 the vertebral heart sum can be calculated by performing the following steps: 1. measure the long axis of the heart from the apex to the carina on the lateral view and mark the distance on a sheet of paper. 2. measure the length of the long axis of the heart in terms of vertebral bodies, starting by counting caudally from the fourth thoracic vertebra; count the number of vertebrae that are covered by the length of the long axis of the heart. 3. measure the short axis of the heart at the caudal vena cava, perpendicular to the long axis of the heart. 4. count the number of thoracic vertebrae covered by the short axis of the heart, starting at t4. 5. add the two numbers together to yield the vertebral heart sum; a vertebral heart sum greater than 10.5 is consistent with cardiomegaly. sinus tachycardia or ventricular dysrhythmias may develop during infusion. cats are more sensitive to the effects of dobutamine than dogs. monitor carefully for seizures and facial twitching. digoxin is a cardiac glycoside that acts as a positive inotrope and negative chronotrope in the long-term management of chf. digoxin has a long (24 hours in dogs, and 60 hours in cats) half-life and so has minimal use in the emergency management of chf. in chronic management of chf resulting from dilated cardiomyopathy or advanced mitral disease, however, digoxin is extremely useful. oral digitalization protocols have been developed but are risky in that dysrhythmias and severe gastrointestinal side effects can occur. cats with chf often have fulminant pulmonary edema, pleural effusion, arterial thromboembolism, or some combination of all three. if the pleural effusion is significant, perform therapeutic thoracocentesis to relieve pulmonary atelectasis and improve oxygenation. once the diagnosis and initial management of chf has been made, formulate a plan for continued management and monitoring. tailor the therapeutic plan to the patient based on the cause of the chf, the presence of concurrent diseases, and response to therapy. an important and often overlooked part of the successful emergency management of chf is the open communication with the owner regarding the owner's emotional and financial commitment for immediate and long-term management to ensure appropriate quality of life for each patient. pathophysiology and treatment, vet j 162 (3) caval syndrome resulting from severe heartworm disease is caused by the rapid maturation of a large quantity of adult worms in the right atrium and cranial and caudal venae cavae. most cases of caval syndrome occur in regions of the world where heartworm disease is highly endemic and dogs spend a large portion of time living outdoors. caval syndrome is recognized by the following clinical signs and results of biochemical analyses: acute renal and hepatic failure, enlarged right atrium and posterior vena cava, ascites, hemoglobinuria, anemia, acute collapse, respiratory distress, dic, jugular pulses, circulating microfilariae, and sometimes tricuspid insufficiency. immediate action in cases of caval syndrome in dogs involves immediate stabilization of the cardiovascular and respiratory systems with supplemental oxygen, furosemide (4 mg/kg iv), and careful crystalloid fluid infusion. diagnosis of caval syndrome is based on clinical signs of cardiogenic shock with right ventricular heart failure, intravascular hemolysis, and renal and hepatic failure. thoracic radiographs reveal cardiomegaly of the right side and enlarged tortuous pulmonary arteries. a right axis deviation may be seen on ecg tracings. clinicopathologic changes observed include azotemia, inflammatory leukogram, regenerative anemia, eosinophilia, elevated hepatocellular enzyme activities, hemoglobinuria, and proteinuria. circulating microfilariae may be observed on peripheral blood smears or in the buffy coat of microhematocrit tubes. heart worm antigen tests will be strongly positive. echocardiographic changes include visualization of a large number of heartworms in the right atrium, pulmonary arteries, and vena cava, tricuspid insufficiency, and right atrial and ventricular enlargement. treatment involves surgical removal of as many of the adult heartworms as possible from the right jugular vein and right atrium. glucocorticosteroids are recommended to decrease inflammation and microangiopathic disease associated with heartworm infection. for more long-term management, administer adulticide therapy several weeks following surgery, followed by routine microfilaricide therapy and then prophylaxis. calvert pericardial effusion often develops as a consequence of neoplasia in the older dog and cat. the most common types of neoplasia that affect the heart and pericardium include hemangiosarcoma, chemodectoma, mesothelioma, and metastatic neoplasia. more rarely, other causes of pericardial effusion include benign idiopathic pericardial effusion, coagulopathy, left atrial rupture in dogs with chronic mitral valvular insufficiency, infection, or pericardial cysts. regardless of the cause of the effusion, the development of pericardial tamponade adversely affects cardiac output. cardiac output is a function of heart rate and stroke volume. stroke volume depends on cardiac preload. the presence of pericardial effusion can impede venous return to the heart and thus adversely affect preload. in addition, as preload decreases, heart rate reflexively increases in an attempt to maintain normal cardiac output. as heart rate increases more than 160 beats/minute, diastolic filling is impaired further, and cardiac output further declines. animals with pericardial effusion often demonstrate the classic signs of hypovolemic or cardiogenic shock: anorexia, weakness, lethargy, cyanosis, cool peripheral extremities, tachycardia, weak thready pulses, hypotension, and collapse. physical examination abnormalities may include muffled heart sounds, thready femoral pulses, pulsus paradoxus, jugular venous distention, weakness, tachycardia, cyanosis, and tachypnea. electrocardiogram findings may include low amplitude qrs complexes (<0.5 mv), sinus tachycardia, ventricular dysrhythmias, or electrical alternans (figure 1-39) . thoracic radiographs often demonstrate a globoid cardiac silhouette, although the cardiac silhouette rarely may appear normal with concurrent clinical signs of cardiogenic shock in cases of acute hemorrhage. in such cases the removal of even small amounts of pericardial effusion by pericardiocentesis can increase cardiac output exponentially and alleviate clinical signs (table 1-35) . unless an animal is dying before your eyes, ideally perform an echocardiogram to attempt to determine whether a right atrial, right auricular, or heart base mass is present before pericardiocentesis. before attempting pericardiocentesis, assemble all of the required supplies (box 1-39) . to perform pericardiocentesis, follow this procedure: 1. place the patient in sternal or lateral recumbency. 2. attach ecg leads to monitor the patient for dysrhythmias during the procedure. 3. clip a 6-cm square caudal to the right elbow over the fifth to seventh intercostal space. 4. aseptically scrub the clipped area, and infuse 1 to 2 mg/kg of 2% lidocaine mixed with a small amount of sodium bicarbonate just dorsal to the sternum at the sixth intercostal space. bury the needle to the hub, and inject the lidocaine as you withdraw the needle. 5. while the local anesthetic is taking effect, assemble the intravenous extension tubing, three-way stopcock, and 60-ml syringe. 6. wearing sterile gloves, make a small nick incision in the skin to decrease drag on the needle and catheter during insertion. 7. slowly insert the needle and catheter, watching for a flash of blood in the hub of the needle, and simultaneously watching for cardiac dysrhythmias on the ecg monitor. 8. once a flash of blood is observed in the hub of the needle, advance the catheter off of the stylette further into the pericardial sac, and remove the stylette. 9. attach the length of intravenous extension tubing to the catheter, and have an assistant withdraw the fluid slowly. 10. place a small amount of fluid in a red-topped tube, and watch for clots. clot formation could signify that you have penetrated the right ventricle inadvertently or that active hemorrhage is occurring. withdraw as much of the fluid as possible, and then remove the catheter. monitor the patient closely for fluid reaccumulation and recurrence of clinical signs of cardiogenic shock. less rd, bright jm, orton ec: intrapericardial cyst causing cardiac tamponade in a cat, j am anim hosp assoc 36 (2) foreign bodies within the ear canal (e.g., foxtails) can present as emergencies because of acute inflammation and pressure necrosis of the tissue of the external auditory meatus causing pain and discomfort. clinical signs may be limited to incessant head shaking or scratching of the ear canal. complete examination of the ear canal and removal of any foreign body often requires administration of a short-acting anesthetic agent. once the animal has been restrained sufficiently and placed under anesthesia, carefully examine the ear canal and remove any foreign material with an alligator forceps. stimulation of the ear canal can cause awakening after removal of all debris and detritus, gently wipe the internal and external ear canal with a sterile gauze. place a topical antimicrobial-antifungal-steroid ointment such as otomax in the ear every 8 to 12 hours. if pain and discomfort is severe, systemically effective opioids or nsaids may be required. otitis externa is a common emergency that causes excessive head shaking, scratching, and purulent malodorous aural discharge. clean the ear canal with an irrigating solution such as epiotic and wipe it clean of debris. perform a complete aural examination to determine whether a foreign body or tumor is present and whether the tympanic membrane is intact. heat-fix any discharge and examine it cytologically for bacteria and fungal organisms. following careful cleansing, instill a topical antibiotic-antifungal-steroid ointment. in severe cases in which the ear canal has scarred and closed down with chronicity, consider administering systemically effective antibiotics (cephalexin, 22 mg/kg po tid) and antifungal agents (ketoconazole, 10 mg/kg po q12h) instead of topical therapy. systemically effective steroids (prednisone or prednisolone, 0.5 mg/kg po q12h) may be indicated in cases of severe inflammation to decrease pruritus and patient discomfort. presentation of a patient with otitis interna often is characterized by torticollis, head tilt, nystagmus, circling to the affected side, or rolling. fever, pain, vomiting, and severe depression may accompany clinical signs. most cases of severe otitis interna are accompanied by severe otitis media. both conditions must be treated simultaneously. the most common causes of otitis interna are staphylococcus aureus, pseudomonas, escherichia coli, or proteus spp. otitis interna can develop by infection spreading across the tympanic membrane, through the eustachian tubes, or by hematogenous spread from the blood supply to the middle ear. in most cases of otitis media, the tympanic membrane is ruptured. perform a culture and susceptibility test of the debris behind the tympanic membrane and within the aural canal. carefully clean the external ear canal. medicate with a topical combination antibiotic, antifungal, and antibiotic ointment. administer high-dose antibiotics (cephalexin, 22 mg/kg po q8h, or enrofloxacin, 10 to 20 mg/kg po q24h). if the tympanic membrane is not ruptured but appears swollen and erythematous, a myringotomy may need to be performed. if clinical signs of otitis media persist despite topical and systemic therapy, radiographic or ct/mri examination of the tympanic bullae may be required. chronic shaking of the head and ears or aural trauma (bite wounds) causes disruption of the blood vessels and leads to the development of unilateral or bilateral aural hematomas. aural hematomas are clinically significant because they cause patient discomfort and are often due to the presence of some other underlying problem such as otitis externa, atopy, or aural foreign bodies. acute swelling of the external ear pinna with fluid is characteristic of an aural hematoma. in some cases, swelling can be so severe that the hematoma breaks open, bathing the patient and external living environment in blood. when a patient has an aural hematoma, investigate the underlying cause. perform a complete aural examination to determine whether an aural foreign body, otitis externa, or atopy are present. carefully examine and gently clean the inner ear canal. treat underlying causes. management of an aural hematoma involves draining the hemorrhagic fluid from the aural tissue and tacking the skin down in multiple places to prevent reaccumulation of fluid until the secondary cause is resolved. many techniques have been described to surgically tack down the skin overlying the hematoma. after the animal has been placed under general anesthesia, lance the hematoma down the middle with a scalpel blade and remove the fluid and blood clot. tack down the skin with multiple through-and-through interrupted or mattress sutures through the ear. some clinicians prefer to suture through and attach a sponge or length of x-ray film to the front and back of the ear for stabilization and support. more recently, a laser can be used to drill holes in the hematoma and tack the skin down in multiple areas. compress the ear against the head with a compression bandage, whenever possible, for 5 to 7 days after the initial surgery, and then recheck the ear. the patient must wear an elizabethan collar until the surgical wound and hematoma heal to prevent selfmutilation. also systemically treat underlying causative factors such as otitis externa with antibiotics, antifungals, and steroids as indicated. investigate and treat other underlying causes such as hypothyroidism or allergies. bass electrocution usually is observed in young animals after they have chewed on an electric cord. other causes of electrocution include use of defective electrical equipment or being struck by lightning. electric current passing through the body can produce severe dysrhythmias, including supraventricular or ventricular tachycardia and first-and thirddegree atrioventricular block. the electric current also can produce tissue destruction from heat and electrothermal burns. electrocution also commonly results in noncardiogenic pulmonary edema caused by massive catecholamine release and increase in pulmonary vascular pressures during the event. ventricular fibrillation can occur, although that depends on the intensity and path of the electrical current and duration of contact. clinical signs of electrocution include acute onset of respiratory distress with moist rales, and localized necrosis or thermal burns of the lips and tongue. often the skin at the commissures of the mouth appears white or yellow and firm to the touch. muscle fasciculations, loss of consciousness, and ventricular fibrillation may occur. thoracic radiographs often reveal an increased interstitial to alveolar lung pattern in the dorsocaudal lung fields. noncardiogenic pulmonary edema can develop up to 24 to 36 hours after the initial incident. the first 24 hours are most critical for the patient, and then prognosis improves. the most important aspect in the treatment of the patient with noncardiogenic pulmonary edema is to minimize stress and to provide supplemental oxygen, with positive pressure ventilation, when necessary. although treatment with vasodilators (low-dose morphine) and diuretics (furosemide) can be attempted, noncardiogenic pulmonary edema is typically resistant to vasodilator and diuretic therapy. positive inotropes and pressor drugs may be necessary to treat shock and hypotension. opioid drugs (morphine, hydromorphone, oxymorphone) may be useful in controlling anxiety until the pulmonary edema resolves. administer broad-spectrum antibiotics (cefazolin; amoxicillin and clavulanic acid [clavamox]) to treat thermal burns. use analgesic drugs to control patient discomfort. if thermal burns are extensive and prohibit adequate food intake, place a feeding tube as soon as the patient's cardiovascular and respiratory function are stable and the patient can tolerate anesthesia. prolapse of the uterus occurs in the immediate postparturient period in the bitch and queen. excessive straining during or after parturition causes the uterus to prolapse caudally through the vagina and vulva. immediate intervention is necessary. examine the bitch or queen for a retained fetus. treatment consists of general anesthesia to replace the prolapsed tissue. if the uterus is edematous, physical replacement may be difficult or impossible. application of a hypertonic solution such as hypertonic (7%) saline or dextrose (50%) to the exposed endometrium can help shrink the tissue. that, combined with gentle massage to stimulate uterine contraction and involution and lubrication with sterile lubricating jelly, can aid in replacement of the organ into its proper place. to ensure proper placement in the abdominal cavity and to prevent recurrence, perform an exploratory laparotomy and hysteropexy. postoperatively, administer oxytocin (5 to 20 units im) to cause uterine contraction. if the uterus contracts, it is usually not necessary to suture the vulva. administer antibiotics postoperatively. recurrence is uncommon, even with subsequent pregnancies. if the tissue is damaged or too edematous to replace or if the tissue is devitalized, traumatized or necrotic, perform an ovariohysterectomy. in some instances, replacement of the damaged tissue is not necessary before removal. pyometra occurs in dogs and cats. the disease process occurs as a result of infection overlying cystic endometrial hyperplasia under the constant influence of progesterone. during the 2-month luteal phase after estrus or following copulation, artificial insemination, or administration of hormones (particularly estradiol or progesterone), the myometrium becomes relaxed and favors a quiescent environment for bacterial proliferation. clinical signs of pyometra are associated with the presence of bacterial endotoxin and sepsis. early, affected animals become lethargic and anorectic. polyuria with secondary polydipsia is often present because of the influence of bacterial endotoxin on renal tubular concentration. if the cervix is open, purulent or mucoid vaginal discharge may be observed. later in the course of pyometra, vomiting, diarrhea, and progressive debilitation resulting from sepsis occur. diagnosis is based on clinical signs in an intact queen or bitch and radiographic or ultrasonographic evidence of a fluid-filled tubular density in the ventrocaudal abdomen, adjacent to the urinary bladder (figures 1-40 and 1-41) . treatment of open and closed pyometra is correction of fluid and electrolyte abnormalities, administration of broad-spectrum antibiotics, and ovariohysterectomy. close pyometra is a life-threatening septic condition. open pyometra also can become life-threatening and so should be treated aggressively. in closed pyometra, conservative medical therapy is not advised. administration of prostaglandins and oxytocin do not reliably cause the cervix 136 1 to open and can result in ascending infection from the uterus into the abdomen or uterine rupture, both of which can result in severe peritonitis. for animals with an open pyometra, ovariohysterectomy is the most reliable treatment for chronic cystic endometrial hyperplasia. although less successful than ovariohysterectomy, medical therapy may be attempted in breeding bitches as an alternative to surgery. the most widely used medical therapy in the breeding queen and bitch is administration of prostaglandin f 2î± . this drug has not been approved for use in the queen or bitch in the united states. to proceed with medical management of pyometra, first determine the size of the uterus. start the patient on antibiotic therapy (ampicillin, 22 mg/kg iv q6h, or enrofloxacin, 10 mg/kg po q24h). administer the prostaglandin f 2î± (250 âµg/kg sq q24h) for 2 to 7 days until the size of the uterus approaches normal. measure serum progesterone concentrations if the bitch is in diestrus. as the corpus luteum degrades under the influence of prostaglandin f 2î± , serum progesterone levels will decline. prostaglandin f 2î± is an abortifacient and thus should not be administered to the pregnant bitch or queen. clinical signs of a reaction to prostaglandin f 2î± can occur within 5 to 60 minutes in the bitch and can last for as long as 20 minutes. clinical signs of a reaction include restlessness, hypersalivation, panting, vomiting, defecation, abdominal pain, fever, and vocalization. in a very ill animal, death can occur. the efficacy of prostaglandin f 2î± is limited and may require more than one treatment. the bitch should be bred on the next heat cycle and then spayed because progressive cystic endometrial hyperplasia will continue to occur. acute metritis is an acute bacterial infection of the uterus that typically occurs within 1 to 2 weeks after parturition. the most common organism observed in metritis is e. coli ascending from the vulva and vaginal vault. sepsis can progress rapidly. clinical signs of acute metritis include inability to nurse puppies, anorexia, lethargy, foul-smelling purulentsanguineous vaginal discharge, vomiting, or acute collapse. physical examination may reveal fever, dehydration, and a turgid distended uterus. septic inflammation will be observed on vaginal cytologic examination. an enlarged uterus can be observed with abdominal radiographs and ultrasonography. treatment of acute metritis is directed at restoring hydration status with intravenous fluids and treating the infection with antibiotics. because the primary cause of metritis is e. coli infection, start enrofloxacin (10 mg/kg iv or po once daily) therapy. as soon as the patient's cardiovascular status is stable enough for anesthesia, perform an ovariohysterectomy. if the patient is not critical and is a valuable breeding bitch, medical therapy can be attempted. medical management of acute bacterial metritis includes administration of oxytocin (5 to 10 units q3h for three treatments) or administration of prostaglandin f 2î± (250 âµg/kg/day for 2 to 5 days) to evacuate the uterine exudate and increase uterine blood flow. either drug should be used concurrently with antibiotics. rupture of the gravid uterus is rare in cats and dogs but has been reported. uterine rupture may occur as a consequence of parturition or result from blunt abdominal trauma. feti expelled into the abdominal cavity may be resorbed but more commonly cause the development of peritonitis. if fetal circulation is not disrupted, the fetus actually may live to term. uterine rupture is an acute surgical emergency. an ovariohysterectomy with removal of the extrauterine puppies and membranes is recommended. if only one horn of the uterus is affected, a unilateral ovariohysterectomy can be performed to salvage the remaining unaffected puppies and preserve the breeding potential for the valuable bitch. if uterine rupture occurs because of pyometra, peritonitis is likely, and copious peritoneal lavage should be performed at the time of surgery. the patient should be placed on 7 to 14 days of antibiotic therapy (amoxicillin or amoxicillin and clavulanic acid [clavamox] with enrofloxacin). vaginal prolapse occurs from excessive proliferation and hyperplasia of vaginal tissue while under the influence of estrogen during proestrus (figure 1-42) . the hyperplastic tissue usually recedes during diestrus but reappears with subsequent heat cycles. vaginal prolapse can be confused with vaginal neoplasia. the former condition occurs primarily in younger animals, whereas the latter condition occurs primarily in older animals. treatment for vaginal hyperplasia or prolapse generally is not required if the tissue remains within the vagina. the proliferation can lead to dysuria or anuria, however. in some cases, the tissue becomes 138 1 emergency care dried out and devitalized or becomes traumatized by the animal. such extreme cases warrant immediate surgical intervention. the treatment for vaginal prolapse consists of ovariohysterectomy to remove the influence of estrogen, placement of an indwelling urinary catheter if the patient is dysuric, and protection of the hyperplastic tissue until it recedes on its own. although surgical resection of the hyperplastic tissue has been recommended, excessive hemorrhage after removal can occur, and so the procedure should not be attempted. the patient should wear an elizabethan collar at all times to prevent selfmutilation. administer broad-spectrum antibiotics for a minimum of 7 to 14 days or until the hyperplastic tissue recedes. keep the tissue clean with saline solution. dystocia, or difficult birth, can occur in the dog and cat but is more common in the dog. a diagnosis of dystocia is made based on the time of onset of visible labor and the time in which the last puppy or no puppy has been born, the intensity and timing of contractions, the timing of when the amniotic membranes first appear, the condition of the bitch, and the timing of gestation. causes of dystocia can be maternal or fetal and include primary or secondary uterine inertia, narrowing of the pelvic canal, hypocalcemia, psychological disturbances, or uterine torsion. maternal-fetal disproportion, or large fetus size in relation to the bitch or queen, also can result in dystocia (box 1-40). obtain an abdominal radiograph for all cases of suspected dystocia at the time of presentation to determine the size of the fetus, presentation of the fetus (both anterior or posterior presentation can be normal in the bitch or queen, but fetal malpositioning can cause dystocia), and whether there is radiographic evidence of a uterine rupture or torsion. if maternal-fetal disproportion, uterine torsion, or uterine rupture is observed, take the patient immediately to surgery. if the puppies or kittens are in a normal position for birth, medical management can be attempted. clip the perineum and aseptically scrub it. wearing sterile gloves, insert a lubricated finger into the vagina and palpate the cervix. massage (or "feather") the dorsal wall of the vagina to stimulate contractions. place an intravenous catheter, and administer oxytocin (2 to 20 units im), repeating up to 3 times at 30-minute intervals. in some cases, hypoglycemia or hypocalcemia can contribute to uterine inertia. administration of a calciumcontaining solution (lactated ringer's solution) with 2.5% dextrose is advised. alternately, administer 10% calcium gluconate (100 mg/5 kg iv slowly). if labor has not progressed after 1 hour, immediately perform a cesarean section. uterine torsion is an uncommon emergency seen in the gravid and nongravid uterus and has been reported in dogs and cats. the onset of clinical signs of abdominal pain and straining as if to whelp/queen or defecate is usually acute and constitutes a surgical emergency. in some cases, there may have been a history of delivery of a live or dead fetus. vaginal discharge may or may not be present. radiographs or ultrasound examination reveal a fluid-filled or air-filled tubular density in the ventral abdomen. treatment consists of placing an intravenous catheter, stabilizing the patient's cardiovascular status with intravenous fluids and sometimes blood products, and performing an immediate ovariohysterectomy. if there are viable feti, the uterus should be delivered en mass and the puppies or kittens delivered. the expulsion of one or more fetus before term is known as spontaneous abortion. in dogs and cats, it is possible to expel or abort one or more fetuses and still carry viable fetuses to term and deliver normally. clinical signs of spontaneous abortion include vaginal discharge and abdominal contractions. in some cases, the fetus is found, or there may be evidence of fetal membranes or remnants. causes of spontaneous abortion in dogs include brucella canis, herpesvirus, coronavirus, and toxoplasmosis. in cats, herpesvirus, coronavirus, and feline leukemia virus can cause spontaneous abortion. in both species, trauma, hormonal factors, environmental pathogens, drugs, and fetal factors also can result in spontaneous abortion. the safest method of pregnancy termination in the bitch or queen is by performing an ovariohysterectomy. oral diethylstilbesterol is not an effective mechanism of pregnancy termination in the bitch. a so-called mismating shot, an injection of estradiol cypionate (0.02 mg/lb im) is effective at causing termination of an early pregnancy but can be associated with severe side effects, including bone marrow suppression and pyometra. estradiol cypionate is not approved for use in the bitch or queen and is not recommended. prostaglandin f 2î± is a natural abortifacient in the bitch if treatment is started within 5 days of cytologic evidence of diestrus (noncornified epithelium on a vaginal smear). the prostaglandin f 2î± causes lysis of the corpora lutea and a rapid decline in progesterone concentration. the prostaglandin f 2î± is administered for a total of eight injections (250 âµg/kg q12h for 4 days), along with atropine (100 to 500 âµg/kg sq). side effects can occur within 5 to 40 minutes of injection and include restlessness, panting, salivation, abdominal pain, urination, vomiting, and diarrhea. walking the patient for 20 to 30 minutes after each treatment sometimes decreases the intensity of the reactions. bitches in the first half of the pregnancy often resorb the embryos. if prostaglandin f 2î± is administered in the second half of the pregnancy, the fetuses are aborted within 5 to 7 days of treatment. measure serum progesterone concentrations at the end of treatment to ensure complete lysis of the corpus luteum. prostaglandin f 2î± is not approved for pregnancy termination in the bitch. in cats, prostaglandin f 2î± can terminate pregnancy after day 4 of gestation. prostaglandin f 2î± should be used only in healthy queens (100 to 250 âµg/kg sq q24h for 2 days). side effects in the queen are similar to those observed in the bitch but typically have a shorter duration (2 to 20 minutes). prostaglandin f 2î± is not approved for use in cats in the united states. the use of prostaglandin f 2î± does not preclude breeding and pregnancy at a later date. biddle d, macintire dk: obstetrical emergencies, clin tech small anim pract 15 (2) in the dog and cat the majority of injuries to the scrotum are associated with animal fights or shearing and abrasive injuries sustained in accidents involving automobiles. scrotal injuries should be categorized as superficial or penetrating. treatment of superficial injuries to the scrotum includes cleaning the wound with dilute antimicrobial cleanser and drying it. administer antiinflammatory doses of steroids (prednisolone, 0.5 to 1.0 mg/kg po q12-24h) or nsaids (carprofen, 2.2 mg/kg po q12h in dogs) for the first several days after scrotal injury to prevent or treat edema. administer topical antibiotic ointment until the wound heals. in most cases, place an elizabethan collar to prevent self-mutilation. prognosis is generally favorable; however, semen quality may be affected for months after injury because of scrotal swelling and increased scrotal temperature. penetrating injuries to the scrotum are more serious and are associated with severe swelling and infection. surgically explore and debride penetrating scrotal wounds. administer systemically effective antibiotics and analgesics. in extreme cases, particularly those that involve the testicle, consider castration and scrotal ablation. scrotal dermatitis is common in intact male dogs and can be associated with direct physical injury, self-infliction from licking, chemical irritation, burns, or contact dermatitis. in affected animals, the scrotum can become extremely inflamed, swollen, and painful. if left untreated, pyogranulomatous dermatitis can develop. make an attempt to determine whether an underlying systemic illness is present that could predispose the animal to scrotal dermatitis. widespread vasculitis with scrotal edema, pain, fever, and dermatitis has been associated with rickettsia rickettsii (rocky mountain spotted fever) infection. brucella canis also has been associated with scrotal irritation and dermatitis. if scrotal dermatitis follows from an infectious cause, empiric use of glucocorticosteroids potentially can make the condition worse by suppressing immune function. empiric treatment with antibiotics also potentially can confound making an accurate diagnosis. treatment of scrotal dermatitis is to eliminate predisposing causes, if possible. place an elizabethan collar at all times to prevent self-mutilation. bathe the scrotum with a mild antimicrobial soap and dry it to remove any offending chemical irritants. topical medications including tar shampoo, tetracaine, neomycin, and petroleum can cause further irritation and are contraindicated. use oral or parenteral administration of glucocorticosteroids or nsaids to control discomfort and inflammation. scrotal hernias occur when the contents of the abdomen (intestines, fat, mesentery, omentum) protrude through the inguinal ring into the scrotal sac. like inguinal hernias, scrotal definitive therapy for a scrotal hernia involves exploratory laparotomy and surgical reduction of the contents of the hernia, surgical correction of the rent in the inguinal ring, and castration. trauma to the epididymis or testicle can cause testicular pain and swelling of one or both testes. treat penetrating trauma to the testicle by castration to prevent infection and selfmutilation. administer oral antibiotics (amoxicillin or amoxicillin-clavulanate) for 7 to 10 days after the injury. nonpenetrating injuries to the scrotum and testicle rarely may cause acute testicular hemorrhage or hydrocele formation. palpation of the affected area often reveals a peritesticular, soft, compliant area. treatment consists of cool compresses on the scrotum and testicle and administration of antiinflammatory doses of glucocorticosteroids or nsaids. if the swelling does not resolve spontaneously in 5 to 7 days, consider surgical exploration and drainage. increased scrotal temperature and testicular inflammation can affect semen quality for months after the initial incident. testicular torsion, or torsion of the spermatic cord, causes rotation of the testicle, ultimately causing obstruction to venous drainage. testicular torsion often is associated with a neoplastic mass of a retained testicle within the abdomen but also can be observed with nonneoplastic testes located within the scrotum. the predominant clinical signs are pain, stiff stilted gait, and the presence of an abnormally swollen testicle (if located within the scrotum). if an intraabdominal testicular torsion is present, pain, lethargy, anorexia, and vomiting can occur (see acute condition in the abdomen). an intraabdominal mass may be palpable. perform an abdominal or testicular ultrasound, preferably with color flow doppler to evaluate perfusion to the testicle. treatment involves surgical removal of the involved testes. bacterial infections of the testicle or epididymis most commonly are caused by ascending infections of the normal bacterial flora of the prepuce or urethra. common inhabitants include escherichia coli, staphylococcus aureus, streptococcus spp., and mycobacterium canis. brucella canis and r. rickettsii are also capable of causing orchitis and epididymitis in the dog. clinical signs of orchitis or epididymitis include testicular enlargement, stiff stilted gait, and reluctance to walk. physical examination often reveals a fever and self-induced trauma to the scrotum from licking or chewing at the inflamed area. collect a semen sample by ejaculation, and culture it to identify the causative organism. alternately, collect samples by needle aspiration of the affected organ(s) and test serologically for b. canis. treatment of infectious orchitis involves a minimum of 3 to 4 weeks of specific antimicrobial therapy, based on culture and susceptibility testing, whenever possible. if a bacterial culture cannot be obtained, initiate fluoroquinolone therapy (enrofloxacin, 10 mg/kg po q24h). doxycycline (5 mg/kg po bid for 7 days) has been shown to suppress but not eradicate b. canis infection. testicular inflammation and increased temperature can affect sperm quality for months after infection. the most common causes of acute prostatitis are associated with acute bacterial infection (e. coli, proteus spp., pseudomonas spp., and mycoplasma spp.). less common causes include fungal infection (blastomyces dermatitidis) or anaerobic bacterial infection. acute prostatitis is characterized by fever, caudal abdominal pain, lethargy, anorexia, blood in the ejaculate, hematuria, dyschezia, and occasionally stranguria or dysuria. the patient often appears painful and depressed and may be dehydrated on physical examination. symmetric or asymmetric prostatomegaly and prostate pain may be evident on rectal palpation. in severely affected dogs, clinical signs of tachycardia, hyperemic or injected mucous membranes, bounding pulses, lethargy, dehydration, and fever may be present because of sepsis. death can occur within 2 days if a prostatic abscess ruptures. diagnosis of acute prostatitis is confirmed based on the presenting clinical signs, neutrophilic leukocytosis (with or without a left shift), and positive urine culture results. prostatic samples may be obtained from the prostatic portion of the ejaculate, prostatic massage, urethral discharge, urine, or (less commonly) prostatic aspirate. although semen samples can yield positive bacterial cultures, dogs with acute prostatitis are often unwilling to ejaculate. radiography may reveal an enlarged prostate, but this alone does not confirm the diagnosis of prostatitis. an abdominal ultrasound often reveals prostatic abscessation and allows for the collection of samples from the affected area(s) via prostatic aspirate. aspiration of the affected tissue potentially can wick infection into periprostatic tracks. cytologic examination of the patient's ejaculate or prostatic wash from a dog with acute prostatitis reveals numerous inflammatory cells and may contain bacterial organisms. the treatment of a patient with acute prostatitis is directed at correcting dysuria and constipation associated with prostatic enlargement. enrofloxaxin (10 mg/kg po sid) can penetrate the inflamed prostatic tissue and is effective in treating gram-negative and mycoplasma spp. infections. ciprofloxacin does not appear to penetrate prostatic tissue as readily. alternatives to enrofloxacin therapy are trimethoprim-sulfamethoxazole (30 mg/kg po q12h) or chloramphenicol (25-50 mg/kg po q8h) for a minimum of 2 to 3 weeks. castration is recommended because benign prostatic hyperplasia may be a predisposing factor in the development of acute prostatitis. do not perform castration until the patient has been on antibiotic therapy for a minimum of 7 days, to prevent the surgical complication of schirrous cords. finasteride (proscar, 1 mg/kg po q24h), an antiandrogen 5î±-reductase inhibitor, may help reduce the size of prostatic tissue until the effects of castration are observed. if a prostatic abscess is present, perform marsupialization, surgical drainage, or ultrasonographic drainage. surgical therapy is associated with a large incidence of complications, including incontinence, chronic drainage from fistulas and stomas, septic shock, and death. fracture of the os penis is an uncommon condition encountered in male dogs. os penis fractures can occur with minimal soft tissue damage but cause hematuria and dysuria. on physical examination, urethral obstruction and crepitus in the penis are found. a lateral abdominal radiograph is usually sufficient to document the fracture. treatment consists of conservative therapy, in most cases, and consists primarily of analgesia administration. if the urethra also is damaged, place a urethral catheter for 5 to 7 days to allow the urethral mucosa to heal. fractures of the os penis that are comminuted or severe enough to cause urethral obstruction require open reduction and fixation, partial penile amputation, or antescrotal (prescrotal) urethrostomy. lacerations of the penis cause significant bleeding because of the extensive vascular supply to the penis. dogs and cats tend to lick penile lacerations and prevent adequate clot formation. sedation or general anesthesia often is required to evaluate and treat the laceration. after sedation or general anesthesia, place a urinary catheter and examine the penis under a stream of cold water. small lacerations can be managed with cold compresses and one to several absorbable sutures. extensive suturing usually is not required. prevent erection by isolating the patient from females in estrus or allowing excitement or excessive activity. place an elizabethan collar to prevent self-mutilation. initiate systemic antibiotic therapy to prevent infection. the inability to withdraw the penis into the prepuce in male dogs or cats is known as paraphimosis. paraphimosis usually develops following an erection in young male dogs and in 144 1 emergency care older dogs after coitus. mucosal edema, hemorrhage, self-mutilation, and necrosis requiring penile amputation can occur if left untreated. treatment consists of applying cold water to the penis and reducing edema with application of an osmotic substance such as sugar. examine the base of the penis for hair rings that can prevent retraction of the penis into the prepuce. rinse the penis carefully with cold water and lubricate it with sterile lubricant and replace it into the prepuce. if the penis cannot be reduced easily into the prepuce, anesthetize the patient and make a small incision at the lateral aspect of the preputial opening. replace the penis and close the incision with absorbable suture. place a purse-string suture and leave it in place for several days to prevent recurrence. instill topical antimicrobial ointment with steroids into the prepuce several times a day. in severe cases, a urinary catheter may need to be placed to prevent urethral obstruction, until penile swelling and edema resolve. place an elizabethan collar to prevent excessive licking during the healing process. prolapse of the distal urethra is a condition usually confined to intact male english bulldogs, although isolated incidences also have been reported in yorkshire and boston terriers. the exact cause of this condition is unknown but usually is associated with a condition that causes increased intraabdominal pressure or urethral straining, including sexual excitement, coughing, vomiting, obstructed airway or brachycephalic airway syndrome, urethral calculi, genitourinary tract infection, and masturbation. the urethral prolapse usually appears as a mushroom-tip congested, irritated mass at the end of the penis that may or may not bleed (figure 1-44) . in some cases, bleeding occurs or worsens with sexual excitement. clinical signs associated with the prolapsed urethra include excessive licking of the prepuce, stranguria, and preputial bleeding. once the mass is observed, other differential diagnoses include transmissible venereal tumor, urethral polyp, trauma, urethritis, and neoplasia. in most cases, however, the prolapse occurs in intact young dogs, making neoplastic conditions less likely. treatment for urethral prolapse should occur at the time of diagnosis to prevent selfinduced trauma and infection. immediate therapy includes manual reduction of the prolapsed tissue and placement of a purse-string suture around an indwelling urinary catheter. the purse-string suture can remain in place for up to 5 days until definitive repair. until the time of surgery, place an elizabethan collar on the patient to prevent self-mutilation. several forms of surgical correction have been described. in some cases, surgical resection of the prolapsed tissue with apposition of the urethral and penile mucosa can be attempted. more recently, a technique involving placement of several mattress sutures to reduce and secure the prolapsed tissue has been described. recurrence of prolapse can occur with either technique, particularly if the inciting event recurs. because there may be a genetic predisposition in this breed and because the prolapse can recur with sexual excitement, neutering should strongly be recommended. local freezing or frostbite most commonly affects the peripheral tissues of the ears, tail, paws, and genitalia that are sparsely covered with fur, are poorly vascularized, and may have been traumatized previously by cold. clinical signs of frostbite are paleness and appearance of a blanched pink to white discoloration to the skin. the skin also may appear black and necrotic. immediate treatment consists of slowly rewarming the affected area with moist heat at 29.5â° c (85â°f) or by immersion in warm water baths. analgesics may be required to alleviate patient discomfort. carefully dry the injured areas and protect them from further trauma. the use of prophylactic antibiotics is controversial because it can promote resistant bacterial infection. use of antibiotics should be based on the presence of infection. treatments that are ineffective and may be harmful include rubbing the affected areas, pressure bandages, and ointments. corticosteroids can decrease cellular immunity and promote infection and are therefore contraindicated. many frostbitten areas that appear nonviable can regain function gradually. use care when removing areas of necrotic tissue. affected areas may take several days to a week before fully manifesting areas of demarcation between healthy viable and necrotic nonviable tissue. chilling of the entire body from exposure or immersion in extremely cold water results in a decrease in core body temperature and physiologic processes that become irreversible when the body temperature falls below 24â°c (75â°f). mild hypothermia can be 32â°to 37â°c, moderate hypothermia from 28â°to 32â°c, and severe hypothermia below 28â°c. the duration of exposure and the general condition of the animal influences its ability to survive. clinical signs and consequences associated with hypothermia include shivering, vasoconstriction, mental depression, hypotension, sinus bradycardia, hypoventilation with decreased respiratory rate, increased blood viscosity, muscle stiffness, atrial and ventricular irritability, decreased level of consciousness, decreased oxygen consumption, metabolic (lactic) acidosis, respiratory acidosis, and coagulopathies including dic. if the animal is breathing, administer warm, humidified oxygen at 4 to 10 breaths per minute. if the animal is not breathing or is severely hypoventilating, endotracheal intubation with mechanical ventilation may be necessary. place an intravenous catheter and infuse warmed crystalloid fluids. if the blood glucose is less than 60 mg/dl, add supplemental dextrose (2.5%) to the crystalloid fluids. monitor the core body temperature and ecg closely. rewarming should occur in the form of external circulating warm water blankets, radiant heat, and circulating warm air blankets (bair hugger). never use a heating pad, to avoid iatrogenic thermal burn injury. severe hypothermia may require core rewarming in the form of intraperitoneal fluids (10 to 20 ml/kg of lactated ringer's solution warmed to 39.4â°c [103â°f]). place a temporary peritoneal dialysis catheter, and repeat the dialysis every 30 minutes until the patient's body temperature reaches 36.6â°to 37.7â°c (98â°to 100â°f). the body temperature should rise slowly, ideally no more than 1â°f per hour. because the response of the body to drugs is unpredictable, avoid administering drugs whenever possible, until the body temperature returns to normal. complications observed during rewarming include dic, cardiac dysrhythmias including cardiac arrest, pneumonia, pulmonary edema, cns edema, ards, and renal failure. heat stroke and heat-induced illness in dogs can be associated with excessive exertion, exposure to high environmental temperatures, stress, and other factors that cause an inability to dissipate heat. brachycephalic breeds, obesity, laryngeal paralysis, and older animals with cardiovascular disease can be particularly affected. hyperthermia is defined as a rectal temperature of 41â°to 43â°c (105â°to 110â°f). clinical signs of hyperthermia include congested hyperemic mucous membranes, tachycardia, and panting. more severe clinical signs include collapse (heat prostration), ataxia, vomiting, diarrhea, hypersalivation, muscle tremors, loss of consciousness, and seizures. heat-induced illness can affect all major organ systems in the body because of denaturation of cellular proteins and enzyme activities, inappropriate shunting of blood, hypotension, decreased oxygen delivery, and lactic acidosis. cardiac dysrhythmias, interstitial and intracellular dehydration, intravascular hypovolemia, central nervous dysfunction, slough of gastrointestinal mucosa, oliguria, and coagulopathies can be seen as organ function declines. excessive panting can result in respiratory alkalosis. poor tissue perfusion results in a metabolic acidosis. loss of water in excess of solutes such as sodium and chloride can lead to a free water deficit and severe hypernatremia. a marked increase in pcv occurs because of the free water loss. severe abnormalities in electrolytes and ph can lead to cerebral edema and death. treatment goals for the patient with heat-induced illness are to lower the core body temperature and support cardiovascular, respiratory, renal, gastrointestinal, neurologic, and hepatic functions. at the scene the veterinarian or caretaker can spray the animal with tepid (not cold) water. immersion in cold water or ice baths is absolutely contraindicated. cold water and ice will cause extreme peripheral vasoconstriction, inhibiting the patient's ability to dissipate heat through conductive and convective cooling mechanisms. as a result, core body temperature will continue to rise despite the good intentions of well-doers at the scene. animals that present to the veterinarian that have been cooled to the point of hypothermia have a worse prognosis. once the animal has presented to the veterinarian, the goal is to cool the animal's body temperature with towels soaked in tepid water, cool intravenous fluids, and fans until the temperature has decreased to 103â°f. organ system monitoring and support is based on the severity and duration of the heat stroke and the ability of the body to compensate and respond to treatment. management of the patient with heat-induced illness involves prompt aggressive cooling without being overzealous and creating iatrogenic hypothermia. administer cool intravenous crystalloid fluids to replenish volume and interstitial hydration and correct the patient's acid-base and electrolyte abnormalities. management consists of rule of twenty monitoring (see rule of 20), taking care to evaluate, restore, and maintain a normal cardiac rhythm, blood pressure, urine output, and mentation. administer antibiotics if there are any signs of gastrointestinal bleeding that will predispose the patient to bacterial translocation. monitor baseline chemistry tests including a complete blood count, biochemical panel, platelet count, coagulation tests, and urinalysis. treat coagulopathies including dic aggressively and promptly (see also disseminated intravascular coagulation). severe changes in mentation including stupor or coma worsen a patient's prognosis. following initial therapy, monitor the patient for a minimum of 24 to 48 hours for secondary organ damage, including renal failure, myoglobinuria, cerebral edema, and dic. dogs that are going to die of heat-induced illness usually die within the first 24 hours. animals that survive longer than 24 hours have a more favorable prognosis. immediate treatment consists of cooling the patient with cooling measures as for hyperthermia and heat-induced illness (see the previous discussion), and eliminating the cause (i.e., exertion, anesthesia, or neuromuscular blockers such as succinylcholine). if the patient is under general anesthesia, hyperventilate the patient to help eliminate carbon dioxide and respiratory acidosis. administer dantrolene sodium (1 to 2 mg/kg iv) to stabilize the sarcoplasmic reticulum and decrease its permeability to calcium. animals with malignant hyperthermia should avoid any predisposing factors, including exertion, hyperthermia, and anesthesia. after an episode of malignant hyperthermia, administer crystalloid fluids intravenously to aid in the elimination of myoglobin. monitor renal function closely for myoglobinuria and pigment damage to the renal tubular epithelium. monitor and correct acid-base and electrolyte changes. walters jm: hyperthermia. in wingfield we, editor: the veterinary icu book, jackson, wyo, 2001, teton newmedia. sometimes it is difficult to assess whether an animal has been bitten by a poisonous or nonpoisonous snake. in colorado, the bull snake closely resembles the prairie rattlesnake. both snakes make similar noise and can be alarming if noticed on a hike or in the backyard. whenever possible, identify the offending reptile but never risk being bitten. know what types of venomous creatures are in the geographic area of the practice. if an animal has been bitten by a nonpoisonous snake, usually the bite marks are small with multiple small tooth punctures, and the bite is relatively nonpainful. usually local reaction is negligible. however, large boas or pythons also can inflict large crushing injuries that can cause severe trauma, including bony fractures. treatment for a nonpoisonous snakebite involves clipping the bite wound and carefully cleaning the area with antimicrobial scrub solution. broad-spectrum antibiotics (e.g., amoxicillin-clavulanate, 16.25 mg/kg po q12h) are indicated because of the extensive bacterial flora in the mouths of snakes. monitor all snakebite victims for a minimum of 8 hours after the incident, particularly when the species of the offending reptile is in question. if clinical signs of envenomation occur, modify the patient's treatment appropriately and aggressively. the two major groups of venomous snakes in north america are the pit viper and the coral snake. all venomous snakes are dangerous. the severity of any given bite depends on the toxicity of the venom, the amount of venom injected, the site of envenomation, the size of the animal bitten, and the time from bite/envenomation to seeking appropriate medical intervention. the majority of reptile envenomations in the united states are inflicted by pit vipers, including the water moccasin (cottonmouth), copperhead, and numerous species of rattlesnakes. pit vipers are characterized by a deep pit located between the eye and nostril, elliptic pupils, and retractable front fangs (figure 1-45) . localized clinical signs of pit viper envenomation may include the presence of bleeding puncture wounds, local edema close to puncture wounds, immediate severe pain or collapse, edema, petechiae, and ecchymosis with subsequent tissue necrosis. systemic signs of pit viper envenomation may include hypotension, shock, coagulopathies, lethargy, weakness, muscle fasciculations, lymphangitis, rhabdomyolysis, and neurologic signs including respiratory depression and seizures. neurologic signs largely are associated with envenomation emergency management of specific conditions 149 by the mojave and canebrake rattlesnakes, although a potent neurotoxin, mojave toxin a, also has been identified in other subspecies of rattlesnake. clinical signs of envenomation may take several hours to appear. hospitalize all suspected victims and monitor them for a minimum of 24 hours. the severity of envenomation cannot be judged solely on the basis of local tissue reaction. first aid measures by animal caretakers do little to prevent further envenomation. the most important aspect of initiating therapy is to transport the animal to the nearest veterinary emergency facility. to determine whether an animal has been envenomated by a pit viper, examine a peripheral blood smear for the presence of echinocytes. echinocytes will appear within 15 minutes of envenomation and may disappear within 48 hours. other treatment should be initiated as rapidly and aggressively as possible, although controversy exists whether some therapies are warranted. the mainstay of therapy is to improve tissue perfusion with intravenous crystalloid fluids, prevent pain with judicious use of analgesic drugs, and when necessary, reverse or negate the effects of the venom with antivenin. because pit viper venom consists of multiple fractions, treat each envenomation as a complex poisoning. obtain vascular access and administer intravenous crystalloid fluids (one fourth of a calculated shock dose) according to the patient's perfusion parameters of heart rate, blood pressure, and capillary refill time (see also shock and fluid therapy). opioid analgesics are potent and should be administered at the time of presentation. (see also pharmacologic means to analgesia: major analgesics). diphenhydramine (0.5 to 1 mg/kg im or iv) also can be administered to decrease the effects of histamine. famotidine, a histamine 1 receptor antagonist, also can be administered (0.5 to 1 mg/kg iv) to work synergistically with diphenhydramine. although antihistamines have no effect on the venom per se, they may have an effect on the tissue reaction to the venom and may prevent an adverse reaction to antivenin. the use of glucocorticosteroids is controversial. glucocorticosteroids (dexamethasone sodium phosphate [dex-sp], 0.25 to 0.5 mg/kg iv) may stabilize cellular membranes and inhibit phospholipase, an active component of some pit viper toxins. polyvalent antivenin is necessary in many cases of pit viper envenomation, except in most cases of prairie rattlesnake (crotalus viridis viridis) envenomation in colorado. a recent study demonstrated no difference in outcome with or without the use of antivenin in cases of prairie rattlesnake envenomation. clinically, however, patients that receive antivenin are more comfortable and leave the hospital sooner than those that do not receive antivenin. the exact dose of antivenin is unknown in small animal patients. administer a dose of at least 1 vial of antivenin to neutralize circulating venom. mix antivenin with a swirling, rather than a shaking motion, to prevent foaming. mix the antivenin with a 250-ml bag of 0.9% saline, and then administer it slowly over a period of 4 hours. pretreat animals with diphenhydramine (0.5 to 1 mg/kg im) before the administration of antivenin, and then monitor the animal closely for clinical signs of angioneurotic edema, urticaria, tachyarrhythmias, vomiting, diarrhea, and weakness during the infusion. administration of antivenin into the bite site is relatively contraindicated and ineffective because uptake is delayed, and systemic effects are the more life-threatening. management of pit viper envenomation largely involves maintenance of normal tissue perfusion with intravenous fluids, decreasing patient discomfort with analgesia, and negating circulating venom with antivenin. hydrotherapy to the affected bite site with tepid water is often soothing to the patient. the empiric use of antibiotics is controversial but is recommended because of the favorable environment created by a snakebite (i.e., impregnation of superficial gram-positive bacteria and gram-negative bacteria from the mouth of the snake into a site of edematous necrotic tissue). administer amoxicillin-clavulanate (16.25 mg/kg po q12h, or cephalexin, 22 mg/kg po q8h). also consider administration of nsaids (carprofen, 2.2 mg/kg po q12h). monitor the patient closely for signs of local tissue necrosis and the development of thrombocytopenia and coagulopathies including dic (see management of disseminated intravascular coagulation). treat coagulopathies aggressively to prevent end-organ damage. coral snakes are characterized by brightly colored bands encircling the body, with red and black separated by yellow. "red on black, friend of jack; red on yellow, kill a fellow." types of coral snakes include the eastern coral, texas coral, and sonoran coral snakes. clinical signs of coral snake envenomation may include small puncture wounds, transient initial pain, muscle fasciculations, weakness, difficulty swallowing/dysphagia, ascending lower motor neuron paralysis, miotic pinpoint pupils, bulbar paralysis, respiratory collapse, and severe hemolysis. clinical signs may be delayed for as long as 18 hours after the initial bite. immediate treatment with antivenin is necessary in cases of coral snake envenomation before the clinical signs become apparent, whenever possible. support respiration during paralysis with mechanical ventilation. secure the patient's airway with a cuffed endotracheal tube to prevent aspiration pneumonia. clinical signs will progress rapidly once they develop. rapid administration with antivenin is the mainstay of therapy in suspected coral snake envenomation. respiratory and cardiovascular support should occur with mechanical ventilation and intravenous crystalloid fluids. keep the patient warm and dry in a quiet place. turn the patient every 4 to 6 hours to prevent atelectasis and decubitus ulcer formation. maintain cleanliness using a urinary catheter and closed urinary collection system. perform passive range of motion and deep muscle massage to prevent disuse atrophy of limb muscles and function. treat aspiration pneumonia aggressively with broad-spectrum antibiotics (ampicillin, 22 mg/kg iv q6h, with enrofloxacin, 10 mg/kg iv q24h, and then change to oral once tolerated and the patient is able to swallow) for 2 weeks past the resolution of radiographic signs of pneumonia, intravenous fluids, and nebulization with sterile saline and coupage chest physiotherapy. several weeks may elapse before a complete recovery. the adult black widow spider (latrodectus spp.) can be recognized by a red to orange hourglass-shaped marking on the underside of a globous, shiny, black abdomen. the immature female can be recognized by a colorful pattern of red, brown, and beige on the dorsal surface of the abdomen. adult and immature females are equally capable of envenomation. the male is unable to penetrate the skin because of its small size. black widow spiders are found throughout the united states and canada. black widow spider venom is neurotoxic and acts presynaptically, releasing large amounts of acetylcholine and norepinephrine. there appears to be a seasonal variation in the potency of the venom, lowest in the spring and highest in the fall. in dogs, envenomation results in hyperesthesia, muscle fasciculations, and hypertension. muscle rigidity without tenderness is characteristic. affected animals may demonstrate clinical signs of acute abdominal pain. tonic-clonic convulsions may occur but are rare. in cats, paralytic signs predominate and appear early as a ascending lower motor neuron paralysis. increased salivation, vomiting, and diarrhea may occur. serum biochemistry profiles often reveal significant elevations in creatine kinase and hypocalcemia. myoglobinemia and myoglobinuria can occur because of extreme muscle damage. management of black widow spider envenomation should be aggressive in the cat and dog, particularly when the exposure is known. in many cases, however, the diagnosis is made based on clinical signs, biochemical abnormalities, and lack of other apparent cause. antivenin (one vial) is available and should be administered after pretreatment with diphenhydramine. if antivenin is unavailable, administer a slow infusion of calcium-containing fluid such as lactated ringer's solution with calcium gluconate while carefully monitoring the patient's ecg. the small brown nonaggressive spider is characterized by a violin-shaped marking on the cephalothorax. the neck of the violin points toward the abdomen. brown spiders are found primarily in the southern half of the united states but have been documented as far north as michigan. the venom of the brown spider has a potent dermatonecrolytic effect and starts with a classic bull's-eye lesion. the lesion then develops into an indolent ulcer into dependent tissues promoted by complement fixation and influx of neutrophils into the affected area. the ulcer can take months to heal and often leaves a disfiguring scar. systemic reactions are rare but can include hemolysis, fever, thrombocytopenia, weakness, and joint pain. fatalities are possible. immediate management of an animal with brown spider envenomation is difficult because there is no specific antidote and because clinical signs may be delayed until necrosis of the skin and underlying tissues becomes apparent through the patient's fur 7 to 14 days after the initial bite. dapsone has been recommended at a dose of 1 mg/kg for 14 days. surgical excision of the ulcer may be helpful if performed in the early stages of wound appearance. glucocorticosteroids may be of some benefit if used within 48 hours of the bite. the ulcer should be left to heal by second intention. deep ulcers should be treated with antibiotics. bufo toad species (b. marinus, aka cane toad, marine toad, giant toad; and the colorado river toad or sonoran desert toad b. alvarius) can be associated with severe cardiac and neurotoxicity if an animal licks its skin. the severity of toxicity depends largely on the size of the dog. toxins in the cane toad, b. marinus, include catecholamines and vasoactive substances (epinephrine, norepinephrine, serotonin, dopamine) and bufo toxins (bufagins, bufotoxin, and bufotenine), the mechanism of which is similar to cardiac glycosides. clinical signs can range from ptyalism, weakness, ataxia, extensor rigidity, opisthotonus, and collapse to seizures. clinical signs associated with b. alvarius toxicity are limited largely to cardiac dysrhythmias, ataxia, and salivation. the animal should have its mouth rinsed out thoroughly with tap water even before presentation to the veterinarian. if the animal is unconscious or actively seizing and cannot protect its airway, flushing the mouth is contraindicated. once an animal presents to the veterinarian, the veterinarian should place an intravenous catheter and monitor the patient's ecg and blood pressure. attempt seizure control with diazepam (0.5 mg/kg iv) or pentobarbital (2 to 8 mg/kg iv to effect). ventricular dysrhythmias can be controlled first with esmolol (0.1 mg/kg). if esmolol is ineffective, administer a longer-acting parenteral î²-antagonist such as propranolol (0.05 mg/kg iv). ventricular tachycardia also can be treated with lidocaine (1 to 2 mg/kg iv, followed by 50 to 100 âµg/kg/minute iv cri). case management largely depends on supportive care and treating clinical signs as they occur. monitor baseline acid-base and electrolyte balance because severe metabolic acidosis may occur that should be treated with intravenous fluids and sodium bicarbonate (0.25 to 1 meq/kg iv). monitor ecg, blood pressure, and mentation changes closely. control seizures and cardiac dysrhythmias. eubig pa: bufo species intoxication: big toad, big problem, vet med 96 (8) lizards of the family hemodermatidae are the only two poisonous lizards in the world. they are found in the southwestern united states and mexico. the venom glands are located on either side of the lower jaw. because these lizards are typically lethargic and nonaggressive, bite wounds are rare. the lizards have grooved teeth that introduce the venom with a chewing motion as the lizard holds tenaciously to the victim. the majority of affected dogs are bitten on the upper lip, which is very painful. there are no proven first aid measures for bites from gila monsters or mexican bearded lizards. the lizard can be disengaged by inserting a prying instrument in between the jaws 1 and pushing at the back of the mouth. the teeth of the lizard are brittle and break off in the wound. topical irrigation with lidocaine and probing with a needle will aid in finding and removing the teeth from the victim. bite wounds will bleed excessively. irrigate wounds with sterile saline or lactated ringer's solution, and place compression on the affected area until bleeding ceases. monitor the patient for hypotension. establish intravenous access, and administer intravenous fluids according to the patient's perfusion parameters. antibiotic therapy is indicated because of the bacteria in the lizard's mouth. because no antidote is available, treatment is supportive according to patient signs. the majority of musculoskeletal emergencies are the result of external trauma, most commonly from motor vehicle accidents. blunt trauma invokes injury to multiple organ systems as a rule, rather than an exception. because of this, massive musculoskeletal injuries are assigned a relatively low priority during the initial triage and treatment of a traumatized animal. perform a rapid primary survey and institute any lifesaving emergency therapies. adhere to a crash plan or the abcs of resuscitation (see initial emergency examination, management, and triage). although musculoskeletal injuries are assigned a relatively lower priority, the degree of recovery from these injuries and financial obligation for fracture repair sometimes becomes a critical factor in a client's decision whether to pursue further therapy. one of the most important deciding factors is the long-term prognosis for the patient to have a good quality of life following fracture repair. the initial management of musculoskeletal injuries is important in ensuring the best chance for maximal recovery with minimal complications after definitive surgical fracture repair. this is particularly important for open fractures, spinal cord compromise, multiple fractures, open joints, articular fractures, physeal fractures, and concomitant ligamentous or neurologic compromise (box 1-41). immediately after the initial primary survey of a patient, perform a more thorough examination, including an orthopedic examination. multiple injuries often are observed in the patient that falls from height (e.g., "high-rise syndrome"), motor vehicle accidents, gunshot wounds, and encounters with other animals (e.g., "big-dog-little-dog"). address the most life threatening injuries, and palliate musculoskeletal injuries until more definitive repair can be attempted when the patient is more stable. in animals with the history of potential for multiple injuries, search thoroughly and meticulously for areas of injury to the spinal column, extremities, and for small puncture wounds. helpful signs that can provide a clue as to an underlying injury include swelling, bruising, abnormal motion, and crepitus (caused by subcutaneous emphysema or bony fracture). if the patient is alert, look for areas of tenderness or pain. in unconscious or depressed patients, reexamine the patient after the patient becomes more mentally alert. injuries often are missed during the initial examination in obtunded patients because of the early response and attenuation of pain. unconscious or immobile patients must have radiographic examination of the spinal column following stabilization and support. palpate the skull carefully for obvious depressions or crepitus that may be associated with a skull fracture. localization of the injury can be determined by motion in abnormal locations, swelling caused by hemorrhage or edema, pain during gentle movement or palpation, deformity, angular change, or a significant increase or decrease in normal range of motion of bones and joints. perform a rectal examination in all cases to palpate for pelvic fractures and displacement. once the diagnosis of a fracture or luxation has been confirmed, look for any evidence of skin lacerations or punctures near the fracture site. in long-haired breeds, clipping the fur near the fracture site often is necessary to perform a thorough examination of the area. if any wounds are found, the fracture is classified as an open fracture until proven otherwise. in some cases, the open fracture is obvious, with a large section of bone fragment protruding through the skin. in other cases, the puncture wound may be subtle, with only a small amount of blood or pinpoint hole in the skin surface. characteristics observed with open fractures include bone penetration, fat droplets or marrow elements in blood coming from the wound, subcutaneous emphysema on radiographs, and lacerations in the area of a fracture. protect the patient from further injury or contamination of wounds. excessive palpation to intentionally produce crepitus is inappropriate because it causes severe patient discomfort and has the potential to cause severe soft tissue and neurologic injury at the fracture site. sedation and analgesia aids in making the examination more comfortable for the patient and allows localization of the injury and comparison with the opposite extremity. higher-quality radiographs can be performed to determine the extent of the injury when the animal is sedated adequately and pain is controlled. sedate the patient judiciously with analgesic drugs. opioid drugs work well for orthopedic pain, produce minimal cardiorespiratory depression, and can be reversed with naloxone if necessary. handle the fracture site gently to avoid causing further pain and soft tissue injury at the fracture site. rough or careless handling of a fracture site can cause a closed fracture to penetrate through the skin and become an open fracture. cover open fractures immediately to prevent contamination of the fracture with nosocomial infection from the hospital. administer a first-generation cephalosporin (cephalexin, 22 mg/kg po q8h, or cefazolin, 22 mg/kg iv q8h). the bandage also serves to control hemorrhage and prevent desiccation of the bones and surrounding soft tissue structures. leave the initial bandages in place until the patient's cardiorespiratory status has been determined to be stable and more definitive wound management can occur in a clean, preferably sterile location. examine the neurologic status and cardiovascular status of the limb before and after treatment. determine the vascular status of the limb by checking the color and temperature of the limb, the state of distal pulses, and the degree of bleeding from a cut nail bed. in patients with severe cardiovascular compromise and hypotension caused by hemorrhagic shock, the viability of the limb may be in question until the cardiovascular status and blood pressure are normalized. reduction of the fracture or straightening of gross deformities may return normal vascularity to the limb. when checking neurologic status, examine for motor and sensory function to the limb. swelling may increase pressure on the nerves as they run through osteofascial compartments, resulting in decreased sensory or motor function, or neurapraxia. diminished function often returns to normal once the swelling subsides. serial physical examinations in the patient and response to initial stabilization therapy can lead to a higher index of suspicion that more occult injuries are present, such as a diaphragmatic hernia, perforated bowel, lacerated liver or spleen, or uroabdomen. to prevent ongoing trauma, reduce any fracture and then stabilize the site above and below the fracture. a modified robert jones splint or bandage often works well for fractures emergency management of specific conditions 155 involving the distal extremities. fractures of the humerus or femur are difficult to immobilize without the use of spica or over-the-hip coaptation splints to prevent mobility. inappropriate bandaging of humerus or femur fractures can result in a fulcrum effect and worsen the soft tissue and neurologic injuries. further displacement of vertebral bodies or luxations can cause cord compression or laceration such that return to function becomes impossible. immediately place any patient with a suspected spinal injury on a flat surface, and tape down the animal to prevent further movement until the spine has been cleared by a minimum or two orthogonal radiographic views (lateral and ventrodorsal views performed as a cross-table x-ray technique). wounds associated with musculoskeletal trauma are common and include injury to the bones, joints, tendons, and surrounding musculature (box 1-42). major problems associated with these cases are the presence of soft tissue trauma that makes wound closure hazardous or impossible, because of the risk of infection. chronic deep infection of traumatized wounds can cause delayed healing and sequestrum to develop, particularly if there is avascular bone or cartilage within the wound. in the early management of an open fracture, the areas should be splinted without pulling any exposed bone back into the soft tissue. the wound should not be probed or soaked, as nosocomial bacteria and other external contaminants can be introduced into the wound, leading to severe infection. because of the risk of actually causing infection, probing, flushing, or replacing tissues back into the wound should be performed at the time of formal debridement when the patient is physiologically stable. immediate bactericidal antibiotic therapy with a first-generation cephalosporin should be started immediately to obtain adequate concentrations of antibiotics at the fracture site. the duration of antibiotic therapy should ideally be limited to 2-3 days to prevent the risk of superinfection. treatment of open musculoskeletal injury involves three considerations: initial inspection and wound debridement, stabilization and repair, and wound bandaging. 156 1 emergency care when associated with a fracture, wound is created from the inside out by penetration of bone fragments through the skin or from a low-energy gunshot. simple or comminuted fracture pattern good stability of the two main bone segments treatment and prognosis are good and similar to those of a closed injury if wound is debrided and stabilized within 6 to 8 hours. when associated with a fracture, wound is created from the outside in. major deep injury with considerable soft tissue stripping from bone and muscle damage simple or comminuted fracture pattern prognosis is good if wound is debrided within 6 hours of injury and provided rigid stabilization with a bone plate or external fixator. results from major external force severe damage and necrosis of skin, subcutaneous tissue, muscle, nerve, bone, tendon, and arteries soft tissue damage may vary from crush injury to shearing injury associated with bite wounds or low-speed automobile accidents. requires immediate and delayed sequential debridement and rigid external fixation can require prolonged healing times guarded prognosis initial inspection and wound debridement include the following steps: 1. after the patient's cardiovascular status has been stabilized and it has been determined that it can withstand anesthesia, place the animal under general anesthesia and remove the temporary splint. 2. keeping the wound covered, shave the surrounding fur. 3. remove the covering and then place sterile lubricant jelly over the wound. shave the fur to the edges of the wound margin. 4. wash away any entrapped fur and the lubricant jelly. 5. complete an antiseptic scrub of the surrounding skin. 6. if the wound is a small puncture (e.g., gunshot pellets or bites), probe the wound with a sterile hemostat. do a thorough debridement if tissues deep to the hole are cavitated. if not deep, create a hole for drainage. 7. flush the wound with a physiologic solution (lactated ringer's solution is preferred). 8. debride the wound from outward to inward. cut away damaged areas of skin and deeper tissues to open up underlying cavitations and tissue injury. 9. continuously irrigate with warm physiologic solution (lactated ringer's solution is preferred). the stream must be strong enough to flush debris out of the bottom of the wound. to accomplish this, attach a 20-gauge needle to a 35-ml syringe (will deliver 7 psi). excise any obviously devitalized tissue. 10. do not remove any bone fragments that are firmly attached to soft tissue. do not cut into healthy soft tissue to find bullet or bone fragments, unless the bullet can cause injury to joints or nerve tissue. 11. do a primary repair of tendons and nerves if the wound is type i and recent (within 8 hours of the initial injury). if the wound is too severe or if there is obvious infection, tag the ends of the tendons and nerves for later repair. it is best to stabilize and repair open fractures as soon as the patient's cardiovascular and respiratory status can tolerate general anesthesia, provided that adequate stabilization is possible. if this is not possible because of the level of experience of the surgeon or the lack of necessary equipment, it is best to perform wound management and place a temporary splint until definitive repair can be performed. wound bandaging is discussed in the section on bandaging techniques. structural injuries to the joints are common and can involve both ligaments and articular cartilage injuries. cartilage does not heal well; therefore, injuries involving articular cartilage can lead to a significant loss of function and degenerative joint disease (osteoarthritis). cartilage injuries that are superficial evoke a short-lived enzymatic and metabolic response that does not stimulate enough cellular growth to repair the defect. superficial lesions remain as defects but do not progress to chondromalacia or osteoarthritis. deep cartilage lacerations that extend to subchondral bone produce an exuberant healing response from the cells of the underlying cartilage. in many cases, this material undergoes degeneration and leads to osteoarthritis. impact injuries to surface cartilage can cause chondrocyte and underlying bone injury. these lesions rapidly progress to osteoarthritis; however, they may be totally or partially reversible. treatment of grade i injuries requires short-term coaptation splints and has a good prognosis. grade ii injuries require surgical treatment with a suture stent and consistent postoperative coaptation splints to heal and maintain good function. healing of grade iii injuries often is a problem, and suture stents or surgical reapproximation may be indicated. failure to immobilize joints that are frequently flexed (elbow and stifle) can result in late complications of ligament repair. ligamentous injuries of joints, particularly the collateral ligaments of the stifle, elbow, and hock, and carpal hyperextension injuries are commonly missed and may require surgical fixation, including arthrodesis (box 1-43). fractures in immature animals differ from those in adults in that young puppies and kittens have a great ability to remodel bone. remodeling is dependent on the age of the patient and the location of the fracture. the younger the puppy or kitten and the closer the fracture to the epiphysis or growth plate, the greater the potential for remodeling and the development of angular limb deformities. remodeling occurs more effectively in longlimbed breeds of dogs than in short-limbed breeds. fractures through the growth plate of immature animals may potentially cause angular limb deformities, joint dislocations or incongruity, and osteoarthritis. this form of injury is commonly observed in the distal ulnar growth plate and the proximal and distal radial growth plates. high-rise syndrome in cats is seen in cats that fall from a height usually greater than 30 feet. it occurs most frequently in high-rise buildings in urban areas where cats lie on window ledges and suddenly fall out the window. the most common lesions observed in cats that fall from heights are thoracic injuries (rib and sternal fractures, pneumothorax, and pulmonary contusions) and facial and oral trauma (lip avulsions, mandibular symphyseal fractures, fractures of the hard palate, and maxillary fractures). limb and spinal cord fractures and luxations, radius and ulna fractures, abdominal trauma, urinary tract trauma, and diaphragmatic hernias are also common. the injuries sustained are often found in combination, rather than as an isolated injury of one area of the body. follow the mnemonic a crash plan when managing a cat suffering from high-rise syndrome, treating the animal immediately for shock. following cardiovascular and respiratory stabilization, evaluate thoracic and abdominal radiographs, including those of the spine. evaluate the bladder closely, making sure that the cat is able to urinate effectively. examine the hard palate, maxilla, and mandibular symphysis for fractures. palpate the pelvis and carefully manipulate all limbs to examine for fractures or ligamentous injuries. finally, perform a complete neurologic examination. patients that fall less than five stories often have a more guarded prognosis than patients that fall from higher levels. sometimes the owner witnesses the ingestion of a foreign body during play, such as throwing a stick or fetching a ball. cats tend to play with string or thread that becomes caught around the base of the tongue. in many cases, however, ingestion of the foreign object is not witnessed, and diagnosis is made based on clinical signs and physical examination. foreign bodies lodged in the oral cavity often cause irritation and discomfort, including difficulty breathing and difficulty swallowing. often, an animal paws at its mouth in an attempt to dislodge a stick or bones wedged across the roof of the mouth. irritation, inability to close the mouth, and blockage of the orpharynx can result in excessive drooling. the saliva may appear blood-tinged due to concurrent soft tissue trauma (figs 1-46 and 1-47) . obstruction of the glottis by a foreign body (e.g., tennis ball or toy) can result in cyanosis secondary to an obstructed airway and hypoxemia. in many cases, the object is small enough to enter the larynx but too large to be expelled. if a foreign object is lodged in the mouth for more than several days, halitosis and purulent discharge may be present. many animals are anxious at the time of presentation and may require sedation or a light plane of anesthesia to remove the foreign object. the animal may bite personnel and may have bitten the owner during his or her attempt to remove the object from the mouth en route to the hospital. propofol (47 mg/kg iv) or a combination of propofol with diazepam (0.5-1 mg/kg iv) is an excellent combination for a light plane of anesthesia. exercise caution when anesthetizing a patient with a ball lodged in the airway, as further compromise of respiratory function may occur and cause worsening of the hypoxemia. before inducing anesthesia, assemble all supplies necessary to remove the object. make sure that rigid towel clamps, sponge forceps, and bone forceps are on hand, because the foreign object is often very slippery with saliva. hemostats and carmalts may slip and not be useful in the removal of the foreign object. place a peripheral intravenous catheter to secure vascular access prior to anesthetic induction. have available the supplies necessary for an emergency tracheostomy, if the foreign object cannot be removed by usual methods. induce a light plane of anesthesia and then grasp the object with the sponge forceps or towel clamps, and extract. monitor the cardiorespiratory status of the animal at all times during the extraction process. if you are unable to remove the object, and if severe respiratory distress, including cyanosis, bradycardia, or ventricular dysrhythmias, develop, perform a tracheostomy distal to the site of obstruction. once the foreign body has been removed, administer supplemental flow-by oxygen until the animal awakens. if laryngeal edema or stridor on inspiration is present, administer a dose of dexamethasone sodium phosphate (0.25 mg/kg iv, im, sq) to decrease inflammation. the patient should be carefully monitored for 24 hours, because noncardiogenic pulmonary edema can develop secondary to airway obstruction. esophageal foreign bodies pose a serious medical emergency. it is helpful if the owner witnessed ingestion of the object and noted rapid onset of clinical signs. in many cases, however, ingestion is not witnessed, and the diagnosis must be made based on clinical signs, thoracic radiographs, and results of a barium swallow. the most common clinical signs are excessive salivation with drooling, gulping, and regurgitation after eating. many animals will make repeated swallowing motions. some animals exhibit a rigid "sawhorse" stance, with reluctance to move immediately after foreign body ingestion and esophageal entrapment. after completing a physical examination, evaluate cervical and thoracic radiographs to determine the location of the esophageal obstruction. esophageal foreign objects are lodged most commonly at the base of the heart, the carina, or just orad to the lower esophageal sphincter. if the object has been lodged for several days, pleural effusion and pneumomediastinum may be present secondary to esophageal perforation. endoscopy is useful for both diagnosis and removal of the foreign object; however, it is invasive and requires general anesthesia ( fig. 1-48) . remove foreign objects lodged in the esophagus with a rigid or flexible endoscope after the patient has been placed under general anesthesia. evaluate the integrity of the esophagus both before and after removal of the material because focal perforation or pressure necrosis can be present. necrosis of the mucosa and submucosa of the esophagus often leads to stricture formation or perforation. attempt to retrieve the object with a flexible fiberoptic endoscope if available. rigid tube endoscopy can also be performed. in many cases, smooth objects that cannot be easily grasped can be pushed into the stomach and allowed to dissolve or may be removed by gastrotomy. if the foreign body is firmly lodged in the esophagus and cannot be pulled or pushed into the stomach, or if perforation has already occurred, the prognosis for return to function without strictures is not favorable. in such cases, referral to a surgical specialist is recommended for esophagostomy or esophageal resection. after removal of the object, carefully examine the esophagus and then administer gastroprotectant agents (famotidine, 0.5 mg/kg po bid; sucralfate slurry, 0.5-1.0 g/dog) for a minimum of 5 to 7 days. to rest the esophagus, the patient should receive nothing per os (npo) for 24 to 48 hours. if esophageal irritation or erosion is moderate to severe, a percutaneous gastrotomy tube should be placed for feeding until the esophagus heals. perform repeat endoscopy every 7 days to evaluate the healing process and to determine whether stricture formation is occurring. persistent vomiting immediately or soon after eating is often associated with a gastric foreign body. in some cases, the owner knows that the patient has ingested a foreign body of some kind. in other cases, continued vomiting despite lack of response to conservative treatment (npo, antiemetics, gastroprotectant drugs) prompts further diagnostic procedures, including abdominal radiographs and bloodwork. obstruction to gastric outflow and vomiting of hydrochloric acid often cause a hypochloremic metabolic acidosis. radiopaque gastric foreign bodies may be observed on plain films. radiolucent cloth material may require a barium series to delineate the shape and location of the foreign body ( fig. 1-49) . treatment consists of removal with flexible endoscopy or a simple gastrotomy. most animals with uncomplicated gastric foreign bodies are relatively healthy, but any metabolic and electrolyte abnormalities should be corrected prior to anesthesia and surgery. small intestinal obstruction can be caused by foreign bodies, tumors, intussusception, volvulus, or strangulation within hernias. regardless of the cause, clinical signs of small intestinal obstruction depend on the location and degree of obstruction, and whether the bowel has perforated. clinical signs associated with a high small intestinal obstruction are usually more severe and more rapid in onset compared with partial or complete obstruction of the jejunum or ileum. complete obstructions that allow no fluid or chyme to pass are worse than partial obstructions, which can cause intermittent clinical signs interspersed with periods of normality (table 1 -36). the most common clinical signs associated with a complete small intestinal obstruction are anorexia, vomiting, lethargy, depression, dehydration, and sometimes abdominal pain. early clinical signs may be limited to anorexia and depression, making a diagnosis challenging unless the owner has a suspicion that the animal ingested some kind of foreign object. obstructions cranial to the common bile duct and pancreatic papillae lead to vomiting of gastric contents, namely hydrochloric acid, and a hypochloremic metabolic alkalosis. obstructions caudal to the common bile duct and pancreatic papillae result in loss of other electrolytes and sometimes mixed acid-base disorders. eventually, all animals with small intestinal obstruction vomit and have fluid loss into dilated segments of bowel, leading to dehydration and electrolyte abnormalities. increased luminal pressure causes decreased lymphatic drainage and bowel edema. the bowel wall eventually becomes ischemic and may rupture. linear foreign bodies should be suspected in any vomiting patient, particularly cats. string or thread often is looped around the base of the tongue and can be visualized in many cases by a thorough oral examination. to look properly under the tongue, grasp the top of the animal's head with one hand, and pull the lower jaw open with the index finger of the opposite hand while pushing up the thumb simultaneously on the tongue in between the intermandibular space. thread and string can be observed lying along the ventral aspect of the tongue. in some cases, if a linear foreign body is lodged very caudally, it cannot be visualized without heavy sedation or anesthesia. linear foreign bodies eventually cause bowel obstruction and perforation of the intestines along the mesenteric border. the foreign material (e.g., string, thread, cloth, pantyhose) becomes lodged proximally, and the intestines become plicated as the body attempts to push the material caudally through the intestines ( fig. 1-50) . continued peristalsis eventually causes a sawing motion of the material and perforation of the mesenteric border of the intestines. once peritonitis occurs, the prognosis is less favorable unless prompt and aggressive treatment is initiated. reevaluate any patient that does not respond to conservative symptomatic therapy, performing a complete blood count, serum biochemical panel (including electrolytes), and abdominal radiographs. intestinal masses may be palpable on physical examination and are often associated with signs of discomfort or pain when palpating over the mass. radiography and abdominal ultrasound are the most useful diagnostic aids. plain radiographs may be diagnostic when the foreign object is radiodense or there is characteristic dilation or plication of bowel loops. as a rule of thumb, the width of a loop of small bowel should be no larger than twice the width of a rib. diagnosis of small intestinal obstruction or ileus can be based on the appearance of stacking loops of dilated bowel. comparison of the width of the bowel with the width of a rib is often performed. with mild dilation, the bowel width is three to four times the rib width; with extensive dilation, five to six times the rib width ( fig.1-51) . in cases of linear foreign bodies, c-areas (comma-shaped areas) of gas trapped in the plicated bowel will appear stacked on one another. blunt, wedge-shaped areas of gas or square linear areas of gas adjacent to a distended bowel loop are characteristic of a foreign body lodged in the intestine. contrast radiography is indicated when confirmation of the suspected diagnosis is necessary and ultrasonography is not available. contrast material may outline the object or abruptly stop orad to the obstruction. the definitive treatment of any type of small intestinal foreign body is surgical removal. linear foreign bodies sometimes pass, but they should never be left untreated in a patient that is demonstrating clinical signs of inappetence, vomiting, lethargy, and dehydration. the timing of surgery is critical because the risk of intestinal perforation increases with time. prior to surgery, correct any acid-base and electrolyte abnormalities with intravenous fluid therapy. administer broad-spectrum antibiotics. perform an enterotomy or intestinal resection and anastomosis as soon as possible once the patient's acid-base and electrolyte status have been corrected. clinical signs of a foreign body in the large bowel are usually nonexistent. in most cases, if a foreign object has passed successfully through the small bowel, it will pass through the large bowel without incident unless bowel perforation and peritonitis occur. penetrating foreign bodies such as needles often cause localized or generalized peritonitis, abdominal pain, and fever. hematochezia may be present if the foreign object causes abrasion of the rectal mucosa. symptomatic patients should have abdominal radiographs performed. colonoscopy or exploratory laparotomy should be performed if survey radiographs are suggestive of a large intestinal obstruction or perforation. in most cases, large intestinal foreign bodies will pass without incident. surgery is required to treat perforations, peritonitis, or abscesses. 164 1 emergency care 1 figure 1 -51: after 60 minutes, the barium has stopped moving and has reached a blunt, intraluminal intestinal foreign body. note that barium appears wedge-shaped or square at the site of the foreign body. foreign bodies in the rectum and anus often are the result of ingestion of bones, wood material, needles, and thread, or malicious external insertion. often the material can pass through the entire gastrointestinal tract and then get stuck in the anal ring. clinical signs include hematochezia and dyschezia with straining to defecate. diagnosis is made by visual examination of the item in the anus, or by careful digital palpation after heavy sedation or short-acting general anesthesia. radiography is helpful in locating needles that have penetrated the rectum and lodged in the perirectal or perinatal tissues. treatment consists of careful removal of the needle digitally or surgically. intussusception is the acute invagination of one segment of bowel (the intussusceptum) into another (the intussuscipiens). the proximal segment always invaginates into the distal segment of bowel. intussusception most commonly occurs in puppies and kittens less than 1 year of age but can occur in an animal of any age with hypermotility of the small bowel, gastrointestinal parasites, and severe viral or bacterial enteritis. intussusception occurs primarily in the small bowel in the jejunum, ileum, and ileocolic junction. clinical signs include vomiting, abdominal discomfort, and hemorrhagic diarrhea. usually, hemorrhagic diarrhea is the first noticeable sign, and in puppies, may be due to parvoviral enteritis, with secondary intussusception. usually, the obstruction is partial with mild clinical signs. more serious clinical signs develop as the obstruction becomes more complete. differential diagnoses include hemorrhagic gastroenteritis, parvoviral enteritis, gastrointestinal parasites, intestinal foreign body, bacterial enteritis, and other causes of vomiting and diarrhea. the diagnosis of intussusception is often made based on palpation of a sausage-shaped firm, tubular structure in the abdomen accompanied by clinical signs and abdominal pain. plain radiographs may demonstrate segmental or generalized dilated segments of bowel, depending on the duration of the problem. ultrasonographs of the palpable mass resemble the layers of an onion, with hyperechoic intestinal walls separated by less echogenic edema. treatment consists of correction of the patient's acid-base and electrolyte abnormalities with intravenous fluids and surgical reduction or removal of the intussusception with resection and anastomosis. although enteroplication has been suggested, the technique has fallen out of favor because of the increased risk of later obstruction. the primary cause of intestinal inflammation and hypermotility must be identified and corrected. gastric dilatation can occur with or without volvulus in the dog. gastric dilatationvolvulus (gdv) occurs primarily in large-and giant-breed dogs with deep chests, such as the great dane, labrador retriever, saint bernard, german shepherd dog, gordon and irish setters, standard poodle, bernese mountain dog, and bassett hound. the risk of gdv increases with age; however, it can be seen in dogs as young as 4 months. deep, narrow-chested breeds are more likely to develop gdv than dogs with broader chests. the overall mortality for surgically treated gastric dilatation-volvulus ranges from 10% to 18%, with most deaths occurring in patients that required splenectomy and partial gastrectomy. clinical signs of gdv include abdominal distention, unproductive vomiting or retching, lethargy, weakness, sometimes straining to defecate, and collapse. the owner may think that the animal is vomiting productively because of the white foamy froth (saliva) that is not able to pass into the twisted stomach. in some cases, there is a history of the dog's being fed a large meal or consuming a large quantity of water prior to the onset of clinical signs. instruct the owner of any patient with a predisposition for and clinical signs of gdv to transport the animal to the nearest veterinary facility immediately. physical examination often reveals a distended abdomen with a tympanic area on auscultation. in dogs with very deep chests, it may be difficult to appreciate abdominal distention if the stomach is tucked up under the rib cage. depending on the stage of shock, the patient may have sinus tachycardia with bounding pulses, cardiac dysrhythmias with pulse deficits, or bradycardia. the mucous membranes may appear red and injected or pale with a prolonged capillary refill time. the patient may appear anxious and attempt to retch unproductively. if the patient is nonambulatory at the time of presentation, the prognosis is more guarded. the definitive diagnosis of gdv is based on clinical signs, physical examination findings, and radiographic appearance of gas distention of the gastric fundus with dorsocranial displacement of the pylorus and duodenum (the so-called "double-bubble" or "popeye arm" sign) ( fig.1-52) . in simple gastric dilatation without volvulus, there is gas distention of the stomach with anatomy appearing normal on radiography. with "food bloat," or gastric distention from overconsumption of food, ingesta is visible in the distended stomach ( fig. 1-53) . as soon as a patient presents with a possible gdv, place a large-bore intravenous catheter in the cephalic vein(s) and assess the patient's ecg, blood pressure, heart rate, capillary refill time, and respiratory function. obtain blood samples for a complete blood count, serum biochemistry profile, immediate lactate measurement, and coagulation tests before taking any radiographs. rapidly infuse a colloid (hetastarch or oxyglobin, 5 ml/kg iv bolus) along with shock volumes of a crystalloid fluid (up to 90 ml/kg/hour) (see section on shock). monitor perfusion parameters (heart rate, blood pressure, capillary refill time, and ecg) and titrate fluid therapy according to the patient's response. the use of short-acting glucocorticosteroids is controversial. glucocorticosteroids may help stabilize cellular membranes and decrease the mechanisms of ischemia-reperfusion injury, but no detailed studies have proved them to be beneficial versus not using glucocorticosteroids in the patient with gdv. attempt gastric decompression, either with placement of an orogastric tube or by trocharization. to place an orogastric tube, position the distal end of the tube at the level of the patient's last rib ( fig. 1-54 ) and place it adjacent to the animal's thorax; then put a piece of tape around the tube where it comes out of the mouth, once it is in place. put a roll of 2-inch tape in the patient's mouth behind the canine teeth and then secure the roll in place by taping the mouth closed around the roll of tape. lubricate the tube with lubricating jelly and slowly insert the tube through the center of the roll of tape into the stomach. the passing of the tube does not rule out volvulus. in some cases, the front legs of the patient need to be elevated, and the caudal aspect of the patient lowered (front legs standing on a table with back legs on the ground) to allow gravity to pull the stomach down to allow the tube to pass. once the tube has been passed, air within the stomach is relieved, and the stomach can be lavaged. the presence of gastric mucosa or blood in the efflux from the tube makes the prognosis more guarded. if an orogastric tube cannot be passed, clip and aseptically scrub the patient's lateral abdomen and then insert 16-gauge over-the-needle catheter. "pinging" the animal's side with simultaneous auscultation allows determination of the location that is most tympanic-that is, the proper location for catheter insertion. once intravenous fluids have been started in the animal, take a right lateral abdominal radiograph to document gdv. if no volvulus is present, the owner may elect for more conservative care, and the animal should be monitored in the hospital for a minimum of 24 hours. because some cases of gdv intermittently twist and untwist, the owner should be cautioned that although the stomach is not twisted at that moment, a volvulus can occur at any time. if radiographs demonstrate food bloat, induce emesis (apomorphine, 0.04 mg/kg iv) or perform orogastric lavage under general anesthesia. documentation of gastric dilatation-volvulus constitutes a surgical emergency. 1 figure 1 -53: example of "food bloat" with severe gastric distention caused by overconsump-following diagnosis of gdv, continue administration of intravenous fluids. serum lactate measurements greater than 6.0 mmol/l are associated with an increased risk of gastric necrosis, requirement for partial gastrectomy, and increased mortality. administer fresh frozen plasma (20 ml/kg) to patients with thrombocytopenia or prolonged pt, activated partial thromboplastin time (aptt), or activated clotting time (act). cardiac dysrhythmias, particularly ventricular dysrhythmias, are common in cases of gdv and are thought to occur secondary to ischemia and proinflammatory cytokines released during volvulus and reperfusion. lidocaine (1-2 mg/kg followed by 50 mcg/kg/minute iv cri) can be used to treat cardiac dysrhythmias preemptively that are associated with ischemia-reperfusion injury, or administration can be started when ventricular dysrhythmias are present. correct any electrolyte abnormalities, including hypokalemia and hypomagnesemia. the use of nonsteroidal antiinflammatory drugs (flunixin meglumine, carprofen, ketoprofen) that can potentially decrease renal perfusion and predispose to gastric ulcers is absolutely contraindicated. administer analgesic drugs (fentanyl, 2 âµ/kg iv bolus, followed by 3-20 âµ/kg/hour iv cri; or hydromorphone, 0.1 mg/kg iv) before anesthetic induction. after carrying out a balanced anesthesia protocol, the patient should be taken immediately to surgery for gastric derotation and gastropexy. postoperatively, assess the patient's ecg, blood pressure, platelet count, coagulation parameters, and gastric function (see section on rule of twenty). if no resection is required, the animal can be given small amounts of water beginning 12 hours after surgery. depending on the severity of the patient's condition, small amounts of a bland diet can be offered 12 to 24 hours postoperatively. continute supportive care with analgesia and crystalloid fluids until the patient is able to tolerate oral analgesic drugs (tramadol, 1-3 mg/kg po q8-12h). once the patient is ambulatory and able to eat and drink on its own, it can be released from the hospital; instruct the owner to feed the animal multiple small meals throughout the day for the first week. when the intestines twist around the root of the mesentery, a small intestinal or mesenteric volvulus occurs. the problem is most common in the young german shepherd dog, although it has been observed in other large and giant breeds. predisposing factors include pancreatic atrophy, gastrointestinal disease, trauma, and splenectomy. clinical signs of mesenteric volvulus include vomiting, hemorrhagic diarrhea, bowel distention, acute onset of clinical signs of shock, abdominal pain, brick-red mucous membranes (septicemia), and sudden death. diagnosis is based on an index of suspicion and the presence of clinical signs in a predisposed breed. plain radiographs often reveal grossly distended loops of bowel in a palisade gas pattern. in some dogs, multiple, tear-drop-shaped, gas-filled loops appear to rise from a focal point in the abdomen. usually, massive distention of the entire small bowel is observed ( fig. 1-55) . the presence of pneumoperitoneum or lack of abdominal detail secondary to the presence of abdominal fluid is characteristic of bowel perforation and peritonitis. in a patient with mesenteric volvulus, immediate aggressive action is necessary for the animal to have any chance of survival. treatment consists of massive volumes of iv crystalloid and colloid fluids (see section on iv therapy), broad-spectrum antibiotics (ampicillin, 22 mg/kg iv qid, with enrofloxacin, 10 mg/kg iv once daily), and surgical correction of the bowel. because of the massive release of proinflammatory cytokines, bacterial translocation, and ischemia, treatment for shock is of paramount importance (see sections on rule of twenty and shock). prognosis for any patient with mesenteric volvulus is poor. obstipation (obstructive constipation) is most common in the older cat. in cases of simple constipation, rehydrating the animal with intravenous fluids and stool softeners is often volvulus. this consistutes an immediate surgical emergency, and the prognosis is often poor. this condition is most common in young german shepherd dogs, but can be observed in any breed. sufficient for it to regain the ability to have a bowel movement. obstipation, however, is caused by adynamic ileus of the large bowel that eventually leads to megacolon. affected cats usually are anorectic, lethargic, and extremely dehydrated. treatment consists of rehydration with intravenous crystalloid fluids, correction of electrolyte abnormalities, enemas, and promotility agents such as cisapride (0.5 mg/kg po q8-24h). the use of phosphate enemas in cats is absolutely contraindicated because of the risk of causing acute, fatal hyperphosphatemia. in many cases, the patient should be placed under general anesthesia and manual deobstipation is performed with warm water soapy enemas and a gloved finger to relieve and disimpact the rectum. stool softeners such as lactulose and docusate stool sofener (dss) may also be used. predisposing causes of obstipation such as narrowing of the pelvic canal, perineal hernia, and tumors should be ruled out. adenocarcinoma is the most common neoplasm of the gastrointestinal tract that causes partial to complete obstruction. adenocarcinomas tend to be annular and constricting, and they may cause progressive obstruction of the lumen of the small or large bowel. siamese cats tend to have adenocarcinomas in the small intestine, whereas in dogs, the tumor tends to occur in the large intestine. clinical signs of adenocarcinoma are both acute and chronic and consist of anorexia, weight loss, and progressive vomiting that occur over weeks to months. effusion may be present if metastasis to peritoneal surfaces has occurred. diagnosis is based on clinical signs and physical examination findings of a palpable abdominal mass, radiographic evidence of an abdominal mass and small or large intestinal obstruction, or ultrasonographic evidence of an intestinal mass. treatment consists of surgical resection of the affected bowel segment. the prognosis for long-term survival (10-12 months) is good if the mass is completely resected and if other clinical signs of cachexia or metastasis are observed at the time of diagnosis. median survival is 15 to 30 weeks if metastasis to lymph nodes, liver, or the peritoneum are absent at the time of diagnosis. in dogs, the prognosis is more guarded. leiomyoma and leiomyosarcoma are tumors that can cause partial or complete obstruction of the bowel. clinical signs are often referred to progressive anemia, including weakness, lethargy, inappetence, and melena. hypoglycemia can be observed as a paraneoplastic syndrome, or due to sepsis and peritonitis secondary to bowel perforation. leiomyomas are most commonly observed at the ceco-colic junction or in the cecum. surgical resection and anastomosis is usually curative, and has a favorable prognosis. incarceration of a loop of bowel into congenital or acquired defects in the body wall can cause small bowel obstruction. pregnant females and young animals with congenital hernias are most at risk. rarely, older animals with perineal hernias and animals of any age with traumatic hernias can be affected. clinical signs are consistent with a small intestinal obstruction: anorexia, vomiting, lethargy, abdominal pain, and weakness. diagnosis is often made based on physical examination of a reducible or nonreducible mass in the body wall. hernias whose contents are reducible are usually asymptomatic. treatment consists of supportive care and rehydration, administration of broad-spectrum antibiotics, and surgical correction of the body wall hernia. in some cases, intestinal resection and anastomosis of the affected area is necessary when bowel ischemia occurs. the potential for bowel perforation should be suspected whenever there is any penetrating injury (knife, gunshot wound, bite wound, stick impalement) of the abdomen. injuries that result in bowel ischemia and rupture can also occur secondary to nonpenetrating blunt 170 1 emergency care trauma or shear forces (e.g., big dog-little dog/cat). perforation of the stomach and small and large intestines can occur with use of nonsteroidal antiinflammatory drugs. diagnosis of bowel perforation first depends on the alertness to the possibility that the bowel may have been perforated or penetrated. as a general rule, all penetrating injuries of the abdomen should be investigated by exploratory laparotomy. diagnostic peritoneal lavage (dpl) can be performed; however, early after penetrating injury of the bowel, dpl may be negative or nondiagnostic until peritonitis develops. whenever any patient with blunt or penetrating abdominal trauma does not respond to initial fluid therapy, or responds and then deteriorates, the index of suspicion for bowel injury should be raised. the findings of pneumoperitoneum on abdominal radiographs or of intracellular bacteria, extracellular bacteria, bile pigment, bowel contents, and cloudy appearance of fluid obtained by abdominocentesis or diagnostic peritoneal lavage fluid (see sections on abdominocentesis and diagnostic peritoneal lavage) warrant immediate surgical exploration. treatment largely consists of stabilizing the patient's cardiovascular and electrolyte status with intravenous fluids, administration of broad-spectrum antibiotics, and definitive surgical exploration and repair of injured structures. prolapse of the rectum is observed most frequently secondary to parasitism and gastrointestinal viral infections in young puppies and kittens with chronic diarrhea. older animals with rectal prolapse often have an underlying problem such as a tumor or mucosal lesion that causes straining and dyschezia. the diagnosis of a rectal prolapse is made based on physical examination findings. the diagnosis of rectal prolapse is sometimes difficult to distinguish from small intestinal intussusception. in rare cases, the intussusception can invaginate through the large bowel, rectum, and anus. the two entities are distinguished from one another by inserting a lubricated thermometer or blunt probe into the cul-de-sac formed by the junction of the prolapsed mucosa and mucocutaneous junction at the anal ring. inability to insert the probe or thermometer indicates that the rectal mucosa is prolapsed. passage of the probe signifies that the prolapsed segment is actually the intussusceptum. treatment can be performed easily if the prolapse is acute and the rectal mucosa is not too irritated or edematous. the presence of severely necrotic tissue warrants surgical intervention. to reduce an acute rectal prolapse, after placing the patient under general anesthesia, lubricate the prolapsed tissue and gently push it back into the rectum, using a lubricated syringe or syringe casing. apply a loose purse-string suture, leaving it in place for a minimum of 48 hours. de-worm the patient and administer stool softeners. if a rectal prolapse cannot be reduced, or if the tissue is nonviable, surgical intervention is warranted. in patients in which viable tissue does not stay reduced with a purse-string suture, a colopexy can be performed during a laparotomy. first, place tension on the colon to reduce the prolapse, and then suture the colon to the peritoneum of the lateral abdominal wall with two to three rows of 2-0 or 3-0 monofilament suture material. if the prolapsed tissue is nonviable, it must be amputated. place four stay sutures at 90-degree intervals through the wall of the prolapse at the mucocutaneous junction. resect the prolapse distal to the stay sutures and then reestablish the rectal continuity by suturing the seromuscular layers together in one circumferential line and the mucosal layers together in the other. replace the suture incision into the anal canal. following surgery, de-worm the patient and administer a stool softener and analgesic drugs. avoid using thermometers or other probes in the immediate postoperative period because they may disrupt suture lines. acute gastritis may be associated with a variety of clinical conditions, including oral hemorrhage, ingestion of highly fermentable nondigestable foods or garbage, toxins, foreign bodies, renal or hepatic failure, inflammatory bowel disease, and bacterial and viral infections. diarrhea often accompanies or follows acute gastritis. hemorrhagic gastroenteritis often occurs as a shock-like syndrome with a rapidly rising hematocrit level. clinical signs of gastritis include depression, lethargy, anterior abdominal pain, excessive water consumption, vomiting, and dehydration. differential diagnosis of acute gastritis includes pancreatitis, hepatic or renal failure, gastrointestinal obstruction, and toxicities (box 1-44). the diagnosis is often a diagnosis of exclusion of other causes (see preceding text). a careful and thorough examination of the vomitus may be helpful in arriving at a diagnosis. a complete blood count, serum biochemistry profile including amylase and lipase, parvovirus test (in young puppies), fecal flotation and cytology, abdominal radiographs (plain and/or contrast studies), and abdominal ultrasound may be warranted to rule out other causes of acute vomiting. while diagnostic tests are being performed, treatment consists of withholding all food and water for a minimum of 24 hours. after calculating the patient's degree of dehydration, administer a balanced crystalloid fluid to normalize acid-base and electrolyte status. control vomiting with antiemetics such as metoclopramide, prochlorperazine, chlorpromazine, dolasetron, and ondansetron (table 1-37). if vomiting is accompanied by diarrhea, administer broad-spectrum antibiotics (cefazolin, 22 mg/kg iv q8h, with metronidazole, 10 mg/kg iv q8h; or ampicillin, 22 mg/kg iv q6h, with enrofloxacin, 10 mg/kg iv q24h) to decrease the risk of bacterial translocation and bacteremia/septicemia. although antacids (famotidine, ranitidine, cimetidine) do not have a direct antiemetic effect, their use can decrease gastric acidity and esophageal irritation during vomiting. if gastritis is secondary to uremia or nonsteroidal antiinflammatory drug use, administer gastroprotectant and antiemetic drugs (ranitidine, 1 mg/kg po q12h; sucralfate, 0.25-1 g/dog po q8h; or omeprazole (0.5-1 mg/kg po q24h) to decrease acid secretion and coat areas of gastric ulceration (table 1 -37) . once food and water can be tolerated, the patient can be placed on an oral diet and medications, and intravenous fluids can be discontinued. do not use until a gastrointestinal obstruction has been ruled out. hemorrhagic gastroenteritis (hge) is an acute onset of severe hemorrhagic vomiting and diarrhea most commonly observed in young small-breed dogs (e.g., poodles, miniature dachshunds, miniature schnauzers) 2 to 4 years of age. clinical signs develop rapidly and include vomiting and fetid diarrhea with hemorrhage, often strawberry jam-like in appearance. the hematocrit can rise from 55% to 75%. often, the animal is extremely hypovolemic but has no apparent signs of abdominal pain. there is no known cause of hge, although clostridium perfringens, escherichia coli, campylobacter, and viral infections have been suggested but not consistently confirmed. other differential diagnoses of of hematemesis and hemorrhagic diarrhea include coronavirus, parvovirus, vascular stasis, sepsis, hepatic cirrhosis with portal hypertension, and other causes of severe shock. immediate treatment consists of placement of a large-bore intravenous catheter and replenishment of intravascular fluid volume with crystalloid fluids (up to 90 ml/kg/hour), while carefully monitoring the patient's hematocrit and total protein. administer broad-spectrum antibiotics (ampicillin, 22 mg/kg iv q6h, and enrofloxacin 10 mg/kg iv q24h) because of the high risk of bacterial translocation and sepsis. control vomiting with antiemetic drugs. monitor the patient's platelet count and coagulation tests for impending disseminated intravascular coagulation (dic), and administer fresh frozen plasma and heparin, as needed (see section on disseminated intravascular coagulation). when vomiting has ceased for 24 hours, offer the animal small amounts of water, and then a bland diet (e.g., boiled chicken and rice or boiled ground beef and rice mixed with low-fat cottage cheese). pancreatitis occurs most frequently in dogs but can occur in cats as well. in dogs, the onset of pancreatitis is sometimes preceded by ingestion of a fatty meal or the administration of drugs (e.g., potassium bromide or glucocorticoids). glucocorticoids can increase the viscosity of pancreatic secretions and induce ductal proliferation, resulting in narrowing and obstruction of the lumen of the pancreatic duct. pancreatitis can also occur following blunt or penetrating abdominal trauma, high duodenal obstruction causing outflow obstruction of the pancreatic papilla, pancreatic ischemia, duodenal reflux, biliary disease, and hyperadrenocorticism. in cats, acute necrotizing pancreatitis is associated with anorexia, lethargy, hyperglycemia, icterus, and sometimes acute death. chronic pancreatitis is more common in cats and results in intermittent vomiting, anorexia, weight loss, and lethargy. predisposing causes of chronic pancreatitis in cats include pancreatic flukes, viral infection, hepatic lipidosis, drugs, organophosphate toxicity, and toxoplasmosis. clinical signs of acute pancreatitis include sudden severe vomiting, abdominal pain, and lethargy. depending on the severity of pancreatic inflammation, depression, hypotension, and systemic inflammatory response syndrome (sirs) may be present. subacute cases may have minimal clinical signs. severe pancreatic edema can result in vascular changes and ischemia that perpetuates severe inflammation. hypovolemic shock and dic can also decrease pancreatic perfusion. severe pancreatic edema, autolysis, and ischemia lead to pancreatic necrosis. duodenal irritation is manifested as both vomiting and diarrhea. pain may be localized to the right upper abdominal quadrant or may be generalized if peripancreatic saponification occurs. differential diagnosis of pancreatitis is the same as for any other cause of vomiting. complications that occur in patients with severe pancreatitis include dehydration, acidbase and electrolyte abnormalities, hyperlipemia, hypotension, and localized peritonitis. hepatic necrosis, lipidosis, congestion, and abnormal architecture can develop. inflammatory mediators (bradykinin, phospholipase a, elastase, myocardial depressant factor, and bacterial endotoxins) stimulate the inflammatory cascade and can lead to sirs, with severe hypotension, clotting system activation, and dic. electrolyte imbalances and hypovolemia secondary to vomiting all can lead to multiple organ dysfunction syndrome (mods), and ultimately, death. if a patient survives an episode of acute pancreatitis, long-term sequelae can include diabetes mellitus. monitor patients with recurrent pancreatitis for clinical signs of polyuria, polydipsia, polyphagia, hyperglycemia, and glucosuria. the diagnosis of pancreatitis is based on the presence of clinical signs (which may be absent in cats), laboratory findings, and ultrasonographic evidence of pancreatic edema and increased peripancreatic echogenicity. serum biochemistry analyses can sometimes support a diagnosis of pancreatitis; however, serum amylase and lipase are often unreliable indicators of pancreatitis, depending on the chronicity of the process in the individual patient. both serum amylase and lipase are excreted in the urine. impaired renal clearance/ function can cause artifactual elevations of serum amylase and lipase in the absence of pancreatic inflammation. furthermore, serum lipase levels can be elevated as a result of gastrointestinal obstruction (e.g., foreign body). early in the course of the disease, levels can be two to six times normal, but they may decrease to within normal ranges at the time of presentation to the veterinarian. the transient nature of amylase elevation makes this test difficult to interpret, and it is not highly sensitive if a normal value is found. lipase levels also increase later in the course of the disease. amylase and lipase should be tested concurrently with the rest of the biochemistry profile. other changes often observed are elevations in bun and creatinine levels secondary to dehydration and prerenal azotemia, hyperglycemia, and hyperlipemia. hypocalcemia can occur secondary to peripancreatic fat saponification, and its presence warrants a more negative prognosis. a more specific measure is pancreatic lipase immunoreactivity, which becomes elevated in dogs and cats with pancreatitis. this test, combined with ultrasonographic or computed tomography evidence of pancreatitis, is the most sensitive and specific test available for making an accurate diagnosis. however, because the results of this test take time to obtain, animals must be treated in the meantime. abdominal effusion or fluid from diagnostic peritoneal lavage can be compared with serum amylase and lipase activity. abdominal lipase and amylase concentrations in the fluid greater than that in the peripheral blood are characteristic of chemical peritonitis associated with pancreatitis. wbc counts greater than 1000 cells/mm 3 , the presence of bacteria, toxic neutrophils, glucose levels less than 50 mg/dl, or lactate levels greater than that of serum are characteristic of septic peritonitis, and immediate exploratory laparotomy is warranted. if a biopsy sample obtained during laparotomy does not demonstrate inflammation, but this does not rule out pancreatitis, because disease can be focal in nature and yet cause severe clinical signs. abdominal radiographs may sometimes reveal a loss of abdominal detail or a ground glass appearance in the right upper quadrant. pancreatic edema and duodenal irritation can displace the gastric axis toward the left, toward the left with dorsomedial displacement of the proximal duodenum (the so-called "backwards 7" or "shepherd's crook" sign). ultrasonography and ct are more sensitive in making a diagnosis of pancreatitis. treatment of pancreatitis is largely supportive in nature and is designed to correct hypovolemia and electrolyte imbalances, prevent or reverse shock, maintain vital organ perfusion, alleviate discomfort and pain, and prevent vomiting (see section on rule of twenty). when treating pancreatitis in dogs, all food and water should be restricted. however, food should not be withheld from cats with chronic pancreatitis. give fresh frozen plasma to replenish alpha-2-macroglobulins. administer antiemetics such as chlorpromazine (use with caution in a hypovolemic or hypotensive patient), dolasetron, ondansetron, or metoclopramide to prevent or control vomiting. analgesic drugs can be provided in the form of constant rate infusion (fentanyl, 3-7 âµ/kg/hour iv cri, and lidocaine, 30-50 âµ/kg/minute iv cri), intrapleural injection (lidocaine, 1-2 mg/kg q8h), or intermittent parenteral injections (morphine, 0.25-1 mg/kg sq, im; hydromorphone, 0.1 mg/kg im or sq). because the pancreas must be rested, consider using parenteral nutrition. acute hepatic failure may be associated with toxins, adverse reaction to prescription medication, and bacterial or viral infections. the most frequent clinical signs observed in a patient with acute hepatic failure are anorexia, lethargy, vomiting, icterus, bleeding, and cns depression or seizures (associated with hepatic encephalopathy). differential diagnosis and causes of acute hepatic failure are listed in box 1-45. diagnosis of acute hepatic failure is based on clinical signs and biochemical evidence of hepatocellular (ast, alt) and cholestatic (alk phos, t bili, ggt) enzyme elevations. ultrasonography may be helpful in distinguishing the architecture of the liver, but unless a mass or abscess is present, cannot provide a specific diagnosis of the cause of the hepatic damage. management of the patient with acute hepatic failure includes correction of dehydration and acid-base and electrolyte abnormalities, as shown in the following list: â�¢ hypoalbuminemia: plasma or concentrated albumin. plasma also is an excellent source of clotting factors that can become depleted. â�¢ clotting abnormalities: vitamin k 1 (2.5 mg/kg sq or po q8-12h) to â�¢ severe anemia: fresh or stored blood â�¢ gastric hemorrhage: gastroprotectant drugs (omeprazole, ranitidine, famotidine, cimetidine, sucralfate) â�¢ hypoglycemia: dextrose supplementation (2.5%-5%) â�¢ hepatic failure, particularly when hypoglycemia is present: broad-spectrum antibiotics (ampicillin 22 mg/kg iv q6h; with enrofloxacin, 5 mg/kg iv q24h) â�¢ hepatic encephalopathy: lactulose or betadine enemas â�¢ cerebral edema: mannitol (0.5-1.0 g/kg iv over 10 to 15 minutes) followed by furosemide (1 mg/kg iv 20 minutes later). deterioration of clinical signs may signify the development of cerebral edema. applewhite aa, cornell kk, selcer ba: diagnosis and treatment of intussusception in dogs. comp cont educ pract vet 24 (2) often, systemic hypertension is diagnosed when the animal is seen by the veterinarian because of some other clinical sign, such as acute blindness, retinal detachment, hyphema, epistaxis, and cns signs following intracranial hemorrhage. diagnosis of systemic hypertension is often difficult in the absence of clinical signs and without performing invasive or noninvasive blood pressure monitoring. normal blood pressure (bp) measurements in dogs and cats are listed in table 1-38. hypertension is defined as a consistent elevation in systolic bp >200 mm hg, consistent diastolic bp >110 mm hg, and consistent mean arterial blood pressure >130 mm hg. the effects of systemic hypertension include left ventricular hypertrophy, cerebrovascular accident, renal vascular injury, optic nerve edema, hyphema, retinal vascular tortuosity, retinal hemorrhage, retinal detachment, vomiting, neurologic defects, coma, and excessive bleeding from cut surfaces. 176 1 emergency care dog 100-160 80-120 90-120 cat 120-150 70-130 100-150 patients with systemic hypertension should have a thorough diagnostic work-up to determine the underlying cause. although uncommon, hypertensive emergencies can occur with pheochromocytoma, acute renal failure, and acute glomerulonephritis. sodium nitroprusside (1-10 âµ/kg/minute iv cri) or diltiazem (0.3-0.5 mg/kg iv given slowly over 10 minutes, followed by 15 âµ/kg/minute) can be used to treat systemic hypertension. with the use of sodium nitroprusside or diltiazem, monitor carefully for hypotension. diagnosis is based on consistent elevations in systolic, diastolic, and/or mean arterial bp. because many of the clinical signs associated with systemic hypertension involve hemorrhage into some closed cavity, other causes of hemorrhage, such as vasculitis, thrombocytopenia, thrombocytopathia, and hepatic or renal failure, should be investigated (see section on coagulation disorders). diagnostic testing is based on clinical signs and index of suspicion for an underlying disease and may include a complete blood count; urinalysis; urine protein:creatinine ratio; acth stimulation test; thoracic and abdominal radiographs; thoracic and abdominal ultrasound; tick serology; brain ct or mri; and assays of serum electrolytes, aldosterone concentration, t4, endogenous tsh, plasma catecholamine, and growth hormone. management of systemic hypertension involves treatment of the primary underlying disorder, whenever possible. long-term adjunctive management includes sodium restriction in the form of cooked or prescription diets to decrease fluid retention. obese animals should be placed on dietary restrictions and undergo a weight reduction program. thiazide and loop diuretics may be used to decrease sodium retention and circulating blood volume. alpha-and beta-adrenergic blockers may be used, but they are largely ineffective as monotherapeutic agents for treating hypertension. calcium channel blockers and angiotensin-converting enzyme (ace) inhibitors are the mainstay of therapy in the treatment of hypertension in dogs and cats ( diabetic ketoacidosis (dka) is a potentially fatal and terminal consequence of unregulated insulin deficiency and possible glucagon excess. in the absence of insulin, unregulated lipolysis results in the beta-hydroxylation of fatty acids by abnormal hepatic metabolism. as a result, ketoacids-namely, acetoacetic acid, beta-hydroxybutyric acid, and acetoneare produced. early in the course of the disease, patients exhibit clinical signs associated with diabetes mellitus: weight loss, polyuria, polyphagia, and polydipsia. later, as ketoacids stimulate the chemoreceptor trigger zone, vomiting and dehydration occur, with resulting hypovolemia, hypotension, severe depression, abdominal pain, oliguria, and coma. at the time of presentation, often a strong odor of ketones (acetone) is present on the patient's breath. physical examination often reveals dehydration, severe depression or coma, and hypovolemic shock. in extreme cases, the patient exhibits a slow, deep kussmaul respiratory pattern in an attempt to blow off excess co 2 to compensate for the metabolic acidosis. a serum biochemistry profile and complete blood count often reveal prerenal azotemia, severe hyperglycemia (blood glucose >400 mg/dl), hyperosmolarity (>330 mosm/kg), lipemia, hypernatremia (sodium >145 meq/l), elevated hepatocellular and cholestatic enzyme activities, high anion gap, and metabolic acidosis. although a whole body potassium deficit is usually present, the serum potassium may appear artifactually elevated in response to metabolic acidosis. with severe metabolic acidosis, potassium moves extracellularly in exchange for a hydrogen ion. phosphorus too moves intracellularly in response to acidosis, and serum phosphorus is usually decreased. hypophosphatemia >2 mg/dl can result in intravascular hemolysis. urinalysis often reveals 4+ glucosuria, ketonuria, and a specific gravity of 1.030 or greater. the urine of all diabetic animals should be cultured to rule out a urinary tract infection or pyelonephritis. treatment of a patient with dka presents a therapeutic challenge. treatment is aimed at providing adequate insulin to normalize cellular glucose metabolism, correcting acidbase and electrolyte imbalances, rehydration and restoration of perfusion, correcting acidosis, providing carbohydrate sources for utilization during insulin administration, and identifying any precipitating cause of the dka. obtain blood samples for a complete blood count, and serum biochemistry electrolyte profiles. whenever possible, insert a central venous catheter for fluid infusion and procurement of repeat blood samples. calculate the patient's dehydration deficit and maintenance fluid requirements and give appropriate fluid and electrolytes over a period of 24 hours. it is advisable to rehydrate patients with severe hyperosmolarity for a minimum of 6 hours before starting insulin administration. use a balanced electrolyte solution (e.g., plasmalyte-m, normosol-r, lactated ringer's solution) or 0.9% saline solution for maintenance and rehydration. balanced electrolyte solutions contain small amounts of potassium and bicarbonate precursors that aid in the treatment of metabolic acidosis. treat animals with severe metabolic acidosis with an hco 3 â�� >11 meq/l or a ph <7.1 with supplemental bicarbonate (0.25-0.5 meq/kg). add supplemental dextrose to the patient's fluids as a carbohydrate source during insulin infusion. both insulin and carbohydrates are necessary for the proper metabolism of ketone bodies in patients with dka. the rate and type of fluid and amount of dextrose supplementation will change according to the patient's blood glucose concentration. serum potassium will drop rapidly as the metabolic acidosis is corrected with fluid and insulin administration. measure serum potassium every 8 hours, if possible, and supplement accordingly (see section on fluid therapy for chart of potassium supplementation). if the patient's potassium requirement exceeds 100 meq/l, or if the rate of potassium infusion approaches 0.5 meq/ kg/hour in the face of continued hypokalemia, magnesium should be supplemented. magnesium is required as a cofactor for many enzymatic processes and for normal function of the na,k-atpase pump. hypomagnesemia is a common electrolyte disturbance in many forms of critical illness. replenishing magnesium (mgcl 2 , 0.75 meq/kg/day iv cri) often helps to correct the refractory hypokalemia observed in patients with dka. patients with hypophosphatemia that approaches 2.0 mmol/l should receive potassium phosphate (0.01-0.03 mmol/kg/hour iv cri). when providing potassium phosphate supplementation, be aware of the additional potassium added to the patient's fluids, so as to not exceed recommended rates of potassium infusion. to determine the amount of potassium chloride (kcl) to add along with potassium phosphate (kpo 4 ), use the following formula: meq k + derived from kcl = total meq of k + to be administered over 24 hours â�� meq in which k + is derived from kpo 4 clinical signs of severe hypophosphatemia include muscle weakness, rhabdomyolysis, intravascular hemolysis, and decreased cerebral function that can lead to depression, stupor, seizures, or coma. regular insulin can be administered either im or as a constant rate infusion in the treatment of patients with dka. subcutaneous insulin should not be administered. because of the severe dehydration present in most patients with dka, subcutaneous insulin is poorly absorbed and is not effective until hydration has been restored. in the low-dose intravenous method, place regular insulin (1.1 units/kg for a cat, and 2.2 units/kg for a dog) in 250 ml of 0.9% saline solution. run 50 ml of this mixture through the intravenous line to allow the insulin to adsorb to the plastic tubing. administer the patient's insulin fluid rate according to blood glucose levels ( table 1 -40) . adjust the patient's total fluid volume according to changes in the insulin fluid rate as necessary. in many cases, multiple bags of fluids are necessary because they must be changed when fluctuations in blood glucose concentrations occur in response to therapy. infusion of the insulin mixture should be in a separate intravenous catheter. to replenish hydration, use a second intravenous line for the more rapid infusion of non-insulin-containing fluids. to administer the regular insulin im, first give 0.22 unit/kg im and then re-check the patient's blood glucose every hour. additional injections of regular insulin (0.11 unit/kg other fluid type (ml/hour) >250 10 0.9% nacl 200-250 7 0.45% nacl + 2.5% dextrose 150-200 5 0.45% nacl + 2.5% dextrose 100-150 5 0.45% nacl + 2.5% dextrose <100 0 0.45% nacl + 5% dextrose im) should be administered based on the patient's response to subsequent injections. once the patient's blood glucose falls to 200 to 250 mg/dl, add 2.5% to 5% dextrose to the fluids to maintain the blood glucose concentration at 200 to 300 mg/dl. continue intramuscular injection of regular insulin (0.1-0.4 unit/kg q4-6h) until the patient is rehydrated, no longer vomiting, and able to tolerate oral fluids and food without vomiting. even in patients with intramuscular regular insulin therapy, a central venous catheter should be placed for frequent blood sample collection. as the patient begins to respond to therapy, monitor electrolytes, glucose, and acid-base status carefully. hypokalemia, hypophosphatemia, and hypomagnesemia can occur. when the patient's hydration and acid-base status has normalized and the patient is able to tolerate oral food and water, a longer-acting insulin can be administered as for treatment of a patient with uncomplicated diabetes. extreme hyperosmolarity can result in a coma, if uncorrected. in patients with diabetes mellitus, hyperglycemia and hypernatremia secondary to osmotic diuresis and free water loss can lead to severe hyperosmolarity. in dogs, normal serum osmolality is <300 mosm/l of serum. hyperosmolarity is expected when serum osmolality is >340 mosm/l. if equipment for determining serum osmolarity is not available, osmolarity can be calculated by the following formula: osm/l = 2(na + k) + (glucose/18) + (bun/2.8) patients with severe dehydration, hyperglycemia, hypernatremia, and azotemia may experience cerebral edema without ketonemia. treatment is directed solely at rehydrating the patient and slowly reducing blood glucose levels using a hypotonic solution such as 0.45% nacl + 2.5% dextrose or 5% dextrose in water (d 5 w). after the initial rehydration period, administer potassium supplementation conservatively. red blood cells and the brain absolutely depend on the oxidation of glucose for energy. hypoglycemia can be caused by various systemic abnormalities that can be related to intestinal malabsorption of nutrients, impaired hepatic glycogenolysis or gluconeogenesis, and inadequate peripheral utilization of glucose. clinical signs of hypoglycemia are extremely variable and can include weakness, tremors, nervousness, polyphagia, ataxia, tachycardia, muscle twitching, incoordination, visual disturbances, and generalized seizures. clinical signs typically occur when serum glucose levels are <60 mg/dl. the combination of the clinical signs listed previously, documentation of low serum glucose, and alleviation of clinical signs upon glucose administration is known as whipple's triad. whenever a patient presents with hypoglycemia, consider the following important factors: the age of onset, the nature of the hypoglycemic episode (transient, persisent, or recurrent) , and the pattern based on the patient's history . treatment of hypoglycemia is directed at providing glucose supplementation and determining any underlying cause. administer supplemental dextrose (25%-50% dextrose, 2-5 ml/kg iv; or 10% dextrose, 20 ml/kg po) as quickly as possible. do not attempt oral glucose supplementation in any patient having a seizure or if the airway cannot be protected. administer intravenous fluids (e.g., normosol-r, lactated ringer's solution, 0.9% saline solution) with 2.5%-5% supplemental dextrose until the patient is eating and able to maintain euglycemia without supplementation. in some cases (e.g., insulinoma), eating or administration of supplemental dextrose can promote insulin secretion and exacerbate clinical signs and hypoglycemia. in cases of refractory hypoglycemia secondary to iatrogenic insulin overdose, glucagon (50 mg/kg iv bolus, then 10-40 ng/kg/minute iv cri) can also be administered along with supplemental dextrose. to make a glucagon infusion of 1000 ng/ml, reconstitute 1 ml (1 mg/ml) of glucagon according to the manufacturer's instructions and add this amount to 1000 ml of 0.9% saline solution. 1 emergency care the diagnosis of eclampsia (puerperal tetany) is often made on the basis of history and clinical signs. clinical signs can become evident when total calcium decreases to <8.0 mg/dl in dogs and <7.0 mg/dl in cats. the disease is often observed in small, excitable dogs, and stress may play a complicating role in the etiology. in most bitches, the disease manifests itself 1 to 3 weeks after parturition. in some cases, however, clinical signs can develop before parturition occurs. hypophosphatemia may accompany hypocalcemia. clinical signs of hypocalcemia include muscle tremors or fasciculations, panting, restlessness, aggression, hypersensitivity, disorientation, muscle cramping, hyperthermia, stiff gait, seizures, tachycardia, a prolonged qt interval on ecg, polydipsia, polyuria, and respiratory arrest. treatment of eclampsia consists of slow, cautious calcium supplementation (10% calcium gluconate, 0.15 mg/kg iv over 30 minutes). severe refractory tetanus can be controlled with intravenous diazepam. supportive care includes intravenous fluid administration and cooling (see section on hyperthermia and heat-induced illness). instruct the owner to give the patient oral calcium supplements (e.g., 1 to 2 tablets of tums bid-tid) after discharge from the hospital. also instruct the owner about how to wean the puppies, allowing the bitch to dry up, in order to prevent recurrence. recurrence with subsequent pregnancies is common, particularly in patients that receive calcium supplementation during gestation (table 1-41) . hypercalcemia can occur from a variety of causes. the gosh darn it mnemonic can be used to remember the various causes of hypercalcemia in small animal patients (box 1-47) . the gastrointestinal, renal, and nervous systems are most commonly affected, particularly when serum total calcium rises above 16.0 mg/dl. clinical signs of severe hypercalcemia include muscle weakness, vomiting, seizures, and coma. ecg abnormalities include prolonged pr interval, rapid qt interval, and ventricular fibrillation. the most serious clinical signs are often seen when hypercalcemia is observed in combination with hyperphosphatemia or hypokalemia. pay special attention to the "calcium ã� phosphorus product." if this product exceeds 70, dystrophic calcification can occur, leading to renal failure. renal complications include polyuria, polydipsia, dehydration, and loss of renal tubular concentrating ability. renal blood flow and the glomerular filtration rate (gfr) are impaired when serum total calcium exceeds 20 mg/dl. the extent, location, and number of renal tubular injuries are the main factors in determining whether renal damage secondary to hypercalcemia is reversible or irreversible. emergency therapy of hypercalcemia is warranted when severe renal compromise, cardiac dysfunction, or neurologic abnormalities are present, or if no clinical signs occur but the calcium ã� phosphorus product exceeds 70. the treatment of choice is correction of the underlying cause of hypercalcemia, whenever possible. in some cases, the results of diagnostic tests take time, and emergency therapy should be initiated immediately, before a definitive cause of the hypercalcemia is found. emergency management of hypercalcemia consists of reduction of serum calcium levels. administer intravenous fluids (0.9% saline solution) to expand extracellular fluid volume and promote calciuresis. to promote diuresis, initial intravenous fluid rates should approach two to three times maintenance levels (120-180 ml/kg/day). potassium supplementation may be required to prevent iatrogenic hypokalemia. administration of a loop diuretic such as furosemide (2-5 mg/kg iv) will promote calcium excretion. calcitonin (4 iu/kg im q12h for cats and 8 iu/kg im q24h for dogs) can be administered to decrease serum calcium levels. in severe refractory hypercalcemia secondary to cholecalciferol toxicity, more aggressive calcitonin therapy (4-7 iu/kg sq q6-8h) can be attempted. side effects of calcitonin treatment include vomiting and diarrhea. alternatively, bisphosphonates (pamidronate, 1.02-2.0 mg/kg iv) are useful in rapidly reducing serum calcium concentrations. glucocorticosteroids reduce calcium release from the bone, decrease intestinal absorption of calcium, and promote renal calcium excretion. administer glucocorticosteroids only after the underlying cause of hypercalcemia has been determined and appropriate therapy started. because many forms of neoplasia can result in hypercalcemia as a paraneoplastic syndrome, empiric use of glucocorticosteroids can induce multiple drug resistance, making the tumor refractory to the effects of chemotherapeutic agents. hypoadrenocorticism is most commonly observed in young to middle-aged female dogs, but it can occur in animals of any age, gender, and breed. clinical signs, which are referable to deficiency in glucocorticoid (cortisol) and mineralocorticoid (aldosterone) hormones, may develop slowly over time, leading to a waxing and waning course; acute clinical signs occur when >90% of the adrenal functional reserve has been destroyed. in such cases, complete adrenocortical collapse can result in an addisonian crisis. lack of aldosterone causes a lack of renal sodium and water retention, and impaired potassium excretion. the most significant clinical signs associated with hypoadrenocorticism are depression, lethargy, weakness, anorexia, shaking, shivering, vomiting, diarrhea, weight loss, abdominal pain, weakness, hypotension, dehydration, and inappropriate bradycardia (box 1-48) . the diagnosis of hypoadrenocorticism is made based on the patient's clinical signs in combination with electrolyte abnormalities that include hyperkalemia, hyponatremia, and hypochloremia. serum sodium concentration (115-130 meq/l) is often greatly reduced, and serum potassium is elevated (>6.0 meq/l). a sodium:potassium ratio of <27 is characteristic of hypoadrenocorticism, although not exactly pathognomonic. electrocardiographic changes associated with hyperkalemia include inappropriate bradycardia, absence of p waves, elevated spiked t waves, and widened qrs complexes. other more variable bloodwork abnormalities include a lack of a stress leukogram, eosinophilia, hypoglycemia, hyperphosphatemia, hypercalcemia, azotemia, and hypocholesterolemia. a definitive diagnosis of hypoadrenocorticism is based on an adrenocorticotropic hormone (acth) stimulation test. in patients with hypoadrenocorticism, baseline cortisol levels are usually low, with a lack of appropriate cortisol release after administration of acth analogue. rarely, animals with "atypical" hypoadrenocorticism lose glucocorticoid secreting ability from the zona fasciculata, but retain mineralocorticoid secretory ability from the zona glomerulosa. atypical addisonian patients have normal serum electrolytes but still have clinical signs of vomiting, diarrhea, weakness, lethargy, inappetence, muscle wasting, and weight loss. the diagnosis is more difficult in such cases because of the presence of normal electrolytes. an acth stimulation test should be considered, particularly in predisposed breeds. treatment of hypoadrenocorticism includes placement of a large-bore intravenous catheter, infusion of intravenous crystalloid fluids (0.9% saline solution), and replenishment of glucocorticoid and mineralocorticoid hormones. administer dexamethasone or dexamethasone-sodium phosphate (0.5-1.0 mg/kg iv). dexamethasone will not interfere with the acth stimulation test, unlike other longer-acting steroids (e.g., prednisolone, methylprednisolone sodium succinate, triamcinolone). depending on the severity of the patient's condition, consider monitoring using the rule of twenty. administer antiemetics and gastroprotectant drugs to treat nausea, vomiting, and hematemesis. give the patient broad-spectrum antibiotics (ampicillin, 22 mg/kg iv q6h) if hematochezia or hemorrhagic diarrhea is present. if severe gastrointestinal blood loss occurs, whole blood, packed red blood cells, or fresh frozen plasma may be required. control hypoglycemia with 2.5%-5.0% dextrose. use sodium bicarbonate, regular insulin with dextrose, or calcium gluconate to correct severe hyperkalemia with atrial standstill (see section on atrial standstill). chronic therapy for hypoadrenocorticism consists of mineralocorticoid and glucocorticosteroids supplementation for the rest of the animal's life. mineralocorticoid supplementation can be in the form of desoxycorticosterone pivalate (docp) (2.2 mg/kg im) or fludrocortisone acetate (0.1 mg/2.5-5 kg body weight daily). fludrocortisone acetate possesses both mineralocorticoid and glucocorticoid activities and can be used as the sole daily treatment of hypoadrenocorticism. (because fludrocortisone is poorly absorbed in some dogs, it may not completely normalize electrolyte abnormalities in these animals.) docp is primarily a mineralocorticoid. give supplemental glucocorticosteroids in the form of prednis(ol)one (1-0.25 mg/kg/day). in dogs, iatrogenic hypoadrenocorticism can be caused by abrupt discontinuation of glucocorticosteroid treatment. long-term glucocorticosteroid supplementation can downregulate the pituitary gland's excretion of endogenous acth and the zona fasciculata's ability to excrete cortisol. however, the zona glomerulosa's ability to secrete aldosterone does not appear to be affected. clinical signs of iatrogenic hypoadrenocorticism include inability to compensate for stress, weakness, lethargy, vomiting, diarrhea, and collapse. treatment of iatrogenic hypoadrenocorticism is the same as for naturally occurring disease. following immediate emergency treatment, the patient should be weaned slowly from exogenous glucocorticosteroid supplementation. severe hyperthyroidism can manifest as a medical emergency as a result of hypermetabolism. clinical signs in affected cats with severe thyrotoxicosis include fever, severe tachycardia (heart rate >240 bpm), vomiting, hypertension, congestive heart failure with pulmonary edema, and fulminant collapse. clinical signs typically are manifested as an end-stage of chronic debilitation associated with hyperthyroidism and are often preceded by polyphagia, weight loss, cardiac murmur, polyuria/polydipsia (pu/pd), vomiting, and diarrhea. treatment of thyrotoxicosis includes antagonizing the adrenergic activity by administration of a beta-adrenergic blocker (esmolol, (25-50 âµ/kg/minute, or propranolol, 0.02 mg/ kg/hour). administration of glucocorticosteroids (dexamethasone, 1 mg/kg) may inhibit the conversion of thyroxine (t 4 ) to the active form triiodothyronine (t 3 ) and decrease peripheral tissue responsiveness to t 3 , effectively blocking its effects. correct hypoglycemia with supplemental dextrose (2.5%). use care to avoid overhydration in a patient with cardiac failure or insufficiency. start the patient on methimazole as quickly as possible and consider the use of radioactive iodine therapy. to maintain cerebral perfusion pressure, blood pressure must be normalized. if other concurrent injuries are suspected (e.g., pulmonary contusions), administer synthetic colloid fluids (dextran-70, 5-10 ml/kg iv, or hetastarch, 5-10 ml/kg iv) to normalize blood pressure. although the use of colloids is controversial because of their potential to leak into the calvarium, the benefits of reestablishing cerebral perfusion far outweigh the risks of their use. hypertonic saline (7.5% nacl, 3-5 ml/kg iv) can also be administered over 10 to 15 minutes to expand intravascular volume. maintain blood glucose within normal reference ranges whenever possible, because hyperglycemia is a negative prognostic indicator in cases of head trauma. if tremors or seizures cause hyperthermia or increased metabolism, active cooling of the patient is warranted (see sections on hyperthermia and heat-induced injury). all patients with head trauma should receive care and monitoring based on the rule of twenty (see section on rule of twenty). examine the patient's level of consciousness, response to various stimuli, pupil size and reactivity to light, physiologic nystagmus, and cranial nerve deficits. in dogs, damage to the midbrain often produces coma and decerebrate rigidity. initial consciousness followed by a unconsciousness or stupor usually involves an injury to the brainstem. brainstem lesions can be caused by compressive skull fractures, extradural or subdural hematomas, or herniation through the foramen magnum from cerebral edema (box 1-49) . the patient's pupil size and response to light can be used to localize a diagnosis and give a rough prognosis for severity of disease and possibility for return to function. pupils can be normal in size, mydriatic, or miotic. whenever a pupil appears miotic, direct ocular 186 1 emergency care unconscious with no response to noxious stimuli injury with uveitis or secondary miosis due to brachial plexus injury should be ruled out. the eyes should always be examined to rule out ocular trauma. in a patient with head trauma, a change from dilated to constricted to normal pupil size is suggestive of improvement in clinical function. bilateral mydriatic pupils that are unresponsive to light in an unconscious animal are a grave prognostic sign and usually indicate an irreversible severe midbrain contusion. bilateral miotic pupils with normal nystagmus and ocular movements are associated with diffuse cerebral or diencephalic lesions. miotic pupils that become mydriatic indicate a progressive midbrain lesion with a poor prognosis. unilateral, slowly progressive pupillary abnormalities in the absence of direct ocular injury are characteristic of brainstem compression or herniation caused by progressive brain swelling. asymmetric pupils are seen in patients with rostral brainstem lesions and can change rapidly. unresponsive pupils that are seen in the midposition occur with brainstem lesions that extend into the medulla and are a grave sign. visual deficits are common with intracranial injury. lesions that are less severe and limited to the cerebrum produce contralateral menace deficits with normal pupillary light response. bilateral cerebral edema can cause blindness with a normal response to light if the midbrain is not disturbed. a patient that is severely depressed and recumbent may not respond to menacing gestures, even when visual pathways are intact. ocular, optic tract, optic nerve, or optic chiasm lesions can interfere with vision and the pupillary light response. brainstem contusion and cerebral edema may produce blindness and dilated unresponsive pupils due to disturbance of the oculomotor area. examine all cranial nerves carefully. cranial nerve abnormalities can indicate direct contusion or laceration of the neurons in the brainstem or where they exit the skull. cranial nerves that are initially normal then later lose function indicate a progressively expanding lesion. when specific cranial nerve deficits are present, the prognosis is considered guarded. clinical signs such as rolling to one side, torticollis, head tilt, and abnormal nystagmus are usually associated with petrosal bone or cerebellomedullary lesions that produce vestibular neuron dysfunction. fractures of the petrosal temporal bone often cause hemorrhage and cerebrospinal fluid (csf) leak from the external ear canal. if the lesion is limited to the membranous labyrinth, the loss of balance will be toward the injured side and the quick phase of the nystagmus will be toward the injured side. normal physiologic nystagmus requires that the pathway is between the peripheral vestibular neurons and the pontomedullary vestibular nuclei to the nuclei of the cranial nerves that innervate the extraocular muscles (iii, iv, vi). severe brainstem lesions disrupt this pathway. disruption of the pathway is manifested as an inability to produce normal physiologic nystagmus by moving the patient's head from side to side. in patients with severe central nervous system depression, this reflex may not be observed. next, assess postural changes and motor function abilities. a loss of the normal oculocephalic ("dolls-eye") reflex is an early sign of brainstem hemorrhage and a late sign of brainstem compression and herniation. any intracranial injury may be accompanied by a concurrent cervical spinal cord injury. handle animals with such injuries with extreme care to avoid causing further damage. whenever there is uncertainty whether a spinal cord lesion exists, strap the patient down to a flat surface and obtain radiographs of the spine. at least two orthogonal views may be required to see fractures; however, do not manipulate the patient until radiography has been completed. crosstable views, in which the bucky is turned perpendicular to the patient's spine, with a radiograph plate secured behind the patient, may be required to minimize patient motion. in patients with cerebral lesions, hemiparesis usually resolves within 1 to 3 days. evaluation of cranial nerve function at frequent intervals may reveal an initial injury or a progressively expanding lesion in the brain. signs of vestibular disorientation, marked head tilt, and abnormal nystagmus occur with contusions of the membranous labyrinth and fracture of the petrous temporal bone. hemorrhage and cerebrospinal fluid otorrhea may be visible from the external ear canal. rolling movements indicate an injury to the cerebellar-medullary vestibular system. respiratory dysfunction and abnormal respiratory patterns are sometimes observed with severe head injury. lesions of the diencephalon produce cheyne-stokes respirations, in which the patient takes progressively larger and larger breaths, pauses, then takes progressively smaller and smaller breaths. mesencephalic lesions cause hyperventilation and can result in respiratory alkalosis. medullary lesions result in a choppy, irregular respiratory pattern. clinical signs of respiratory dysfunction in the absence of primary respiratory damage indicate a guarded prognosis. after injury, seizures may be associated with intracranial hemorrhage, trauma, or an expanding intracranial mass lesion. immediately begin medical therapy to control the seizure. administer diazepam (0.5 mg/kg iv or 0.1-0.5 mg/kg/hour iv cri) to treat seizures. if diazepam is not effective in combination with other treatments to control intracranial edema, consider giving pentobarbital . loading doses of phenobarbital (16-20 mg/kg iv divided into 4 or 5 doses, given every 20 to 30 minutes) may be beneficial in preventing further seizures. severe refractory seizures or decreased mentation may be associated with cerebral edema and increased intracranial pressure. mannitol, an osmotic diuretic, is effective at reducing cerebral edema (0.5-1.0 g/kg iv over 10 to 15 minutes). mannitol also acts as a free radical scavenger that can inhibit the effects of cerebral ischemia-reperfusion injury. mannitol works synergistically with furosemide (1 mg/kg iv given 20 minutes after the mannitol infusion). corticosteroids have not been demonstrated to be beneficial in the treatment of head trauma and may induce hyperglycemia. hyperglycemia has been shown to be a negative prognostic indicator in cases of head trauma. also, glucocorticoids can suppress immune system function and impair wound healing. because of the known risks and lack of known benefits of glucocorticosteroids, their use in treatment of head trauma is contraindicated. the prognosis for any patient with severe head trauma is guarded. management of head trauma patients may include intense nursing care for a period of weeks to months, depending on the presence and extent of concurrent injuries. if progressive loss of consciousness occurs, surgery for decompression of compressive skull injuries should be considered. the most common injury associated with head trauma in small animals is a contusion with hemorrhage in the midbrain and pons. subdural or extradural hemorrhage with space-occupying blood clots is uncommon. diagnostic tests of head trauma may include skull radiographs, ct, and mri of the brain. special studies can help detect edema and hemorrhage in the brain and brainstem, and aid in making an accurate diagnosis and prognosis. a cerebrospinal fluid tap is contraindicated in patients with head trauma because of the risk of causing a rapid decrease in intracranial pressure and brainstem herniation. if a compressive skull fracture is present, the patient should be stabilized for surgery to remove the compression. surgery to alleviate increased intracranial pressure is rarely performed in veterinary medicine because of the poor prognosis and results. in some cases, when a lesion can be localized to one area, 1-to 2-cm burr holes can be placed through the skull over the affected area of the cerebrum, exposing the underlying brain tissue. blood clots can be removed through the holes. the bone flap may or may not be replaced, depending on the surgeon's preference and the degree of brain swelling. spinal cord injuries may be associated with trauma, disk rupture, fractures, and dislocation of the spinal column. proceed with caution when moving a patient with suspected spinal cord injury. avoid flexion, extension, and torsion of the vertebral column. all animals that are unconscious following a traumatic event should be considered to have cervical or thoracolumbar spinal injury until proved otherwise by radiography, ct, or mri. the animal should be moved onto a flat surface (e.g., board, door, window, picture frame) and taped down to prevent motion and further displacement of vertebrae. sedation with analgesics or tranquilizers may be necessary to keep the animal immobile and to minimize patient motion. whenever possible, avoid the use of narcotics in patients with head trauma because of the risk of increasing intracranial pressure. as in other emergencies, the abcs 188 1 emergency care should be evaluated, and the patient treated for shock, hemorrhage, and respiratory compromise. once the cardiovascular and respiratory systems have been evaluated and stabilized, a more thorough neurologic examination can be performed. protrusion of an intervertebral disk indicates that the disk is bulging into the vertebral canal as a result of dorsal shifting of the nuclear pulposus disk material. disk extrusion refers to the rupture of the outer disk membrane and extrusion of the nuclear material into the vertebral column. in dogs and cats, there are 36 intervertebral disks that potentially can cause a problem. chondrodystrophic breeds of dogs are predisposed to endochondral ossification and include the dachshund, shih tzu, french bulldog, bassett hound, welsh corgis, american spaniel, beagle, lhasa apso, and pekingese. initial examination of the patient with suspected intervertebral disk disease includes identifying the neuroanatomic location of the lesion based on clinical signs and neurologic deficits and then establishing a prognosis. the neurologic examination should be carried out without excessive manipulation of the animal. the presence of pain, edema, hemorrhage, or a visible deformity may localize an area of vertebral injury. once an area of suspected lesion is localized based on physical examination findings, take radiographs to establish a diagnosis and to institute therapy. in most cases, the animal must receive a short-acting anesthestic for proper radiographic technique and to prevent further injury. lateral and crosstable ventrodorsal (vd) or dorsoventral (dv) radiographs require less manipulation of the animal compared with traditional vd and dv projections. myelography is often required to delineate the location of the herniated disk material. prognosis in spinal cord injury depends on the extent of the injury and the reversibility of the damage. perception of noxious stimuli, or the presence of "deep pain," by the animal when the stimulus is applied caudal to the level of the lesion is a good sign. to apply a noxious stimulus, apply firm pressure to a toe on one of the rear limbs using a thick hemostat or a pair of pliers. flexion or withdrawl of the limb is simply a local spinal reflex, and should not be perceived as a positive response to or patient perception of the noxious stimulus. turning of the head, vocalization, dilation of the pupils, change in respiratory rate or character, or attempts to bite are behaviors that are more consistent with perception of the noxious stimulus. absence of perception of the noxious stimulus ("loss of deep pain") is a very poor prognosis for return to function. focal lesions are usually associated with vertebral fractures and displacement of the vertebral canal. focal lesions in one or more of the spinal cord segments from t 3 to t 4 can cause complete dysfunction of the injured tissue as a result of concussion, contusion, or laceration. the degree of structural damage cannot be determined from the neurologic signs alone. transverse focal lesions result in paraplegia, with intact pelvic limb spinal reflexes and analgesia of the limbs and body caudal to the lesion. clinical signs in patients with spinal injury are summarized in table 1 -43. carefully evaluate the cardiovascular and respiratory status of patients with spinal injuries. immediately address specific injuries such as pneumothorax, pulmonary contusions, hypovolemic shock, and open wounds. if there is palpable or radiographic evidence of a vertebral lesion causing compressive injury, surgery is the treatment of choice unless the displacement has compromised most or all of the vertebral canal. displacements through 50% to 100% of the vertebral canal are associated with a poor prognosis, particularly if deep pain is absent caudal to the lesion. in the absence of a radiographic lesion and in the presence of continued neurologic deficits, an mri or ct scan or myelography is warranted to localize a potentially correctable lesion. surgical exploration can be considered: with the objectives of providing spinal cord decompression by hemilaminectomy or laminectomy with removal of disk material or blood clots, realign and stabilize the vertebral column, and perform a meningotomy, if necessary. place the patient on a backboard or other rigid surface, taped down for transport and sedated, to be transported to a surgical specialist. the presence of worsening or ascending clinical signs may signify ascending-descending myelomalacia and is characteristic of a very poor prognosis.in acute spinal trauma, the use of glucocorticoids has been the mainstay of therapy; however, controversy exists about whether they actually offer any benefit. traditional glucocorticosteroid therapy is listed in box 1-50. more recently, the use of propylene glycol has proved to be beneficial in the treatment of acute traumatic herniated disk. high-dose glucocorticoids should only be used for the first 48 hours after initial injury. side effects of glucocorticosteroid therapy include gastric and intestinal ulceration. the prophylactic use of gastroprotectant drugs will not prevent gastrointestinal ulcer formation; however, if signs of gastrointestinal ulcer are present, institute gastroprotectant therapy. management of the patient with spinal cord injury includes aggressive nursing care and physical therapy. many patients with spinal cord injury have little to no control over bladder function, which results in chronic dribbling or retention of urine and overdistention of the urinary bladder with overflow incontinence. urinary bladder retention can lead to urinary tract infection, bladder atony, and overflow incontinence. manual expression of the bladder several times a day may be enough to keep the bladder empty. alternatively, place a urinary catheter to maintain patient cleanliness and to keep the bladder decompressed. (see section 5 on urinary catheterization). paralytic ileus and fecal retention are frequent complications of spinal cord injury. to help prevent constipation, provide highly digestable foods and maintain the patient's hydration with oral and intravenous fluids. mild enemas or stool softeners can also be used to treat fecal retention. to prevent decubital ulcer formation, turn the patient every 4 to 6 hours, and use clean, dry, soft padded bedding. apply deep muscle massage and passive range of motion exercises to prevent disuse atrophy of the muscles and dependent edema. the radial nerve innervates the extensor muscles of the elbow, carpus, and digits. the radial nerve also supplies sensory innervation to the distal craniolateral surface of the forearm and the dorsal surface of the forepaw. injuries to the radial nerve at the level of the elbow 190 1 emergency care cranial to c6 spastic tetraplegia or tetraparesis hyperreflexive all four limbs severe injury can result in death from respiratory failure. c6-t2 tetraparesis or tetraplegia depressed thoracic limb spinal reflexes (lower motor neuron) hyperreflexive pelvic limbs (upper motor neuron) t1-t3 horner' syndrome (prolapsed nictitans, enophthalmos, and miosis) t3-l3 schiff-sherrington syndrome (extensor rigidity of thoracic limbs, flaccid paralysis with atonia, areflexia, and analgesia of pelvic limbs) result in an inability to extend the carpus and digits. as a result, the animal walks and bears weight on the dorsal surface of the paw. there is also loss of cutaneous sensation, which leads to paw injury. injuries to the radial nerve above the elbow (in the shoulder area) results in an inability to extend the elbow and bear weight on the affected limb. it can take weeks before the full extent of the injury and any return to function are manifested. the animal may need to be placed in a carpal flexion sling or have eventual amputation if distal limb injury or self-mutilation occurs. the sciatic nerve primarily innervates the caudal thigh muscles that flex the stifle and extend the hip. the tibial branch of the sciatic nerve innervates the caudal leg muscles that extend the tarsus and flex the digits. the tibial nerve provides the sole cutaneous sensory innervation to the plantar aspect of the paw and digits. the peroneal branch of the sciatic nerve provides the sole sensory cutaneous innervation to the dorsal surface of the paw ( table 1 -44) . sciatic nerve injury may occur with pelvic fractures, particularly those that involve the body of the ileum at the greater ischiatic notch, or with sacroiliac luxations that contuse the l6 and l7 spinal nerves that pass ventral to the sacrum to contribute to the sciatic nerve. with sciatic nerve injury, there is decreased stifle flexion and overflexion of the hock (tibial nerve), and the animal walks on the dorsal surface of the paw (peroneal nerve). clinical signs of tibial or peroneal damage are seen with femur fractures or with inadvertent injection of drugs into the caudal thigh muscles. the femoral nerve innervates the extensor muscles of the stifle. the saphenous branch of the femoral nerve provides the sole cutaneous innervation to an area on the medial distal thigh, the leg, and the paw. the femoral nerve is protected by muscles and is rarely injured in pelvic fractures. clinical signs of femoral nerve injury are inability to support weight on the pelvic limb, absence of a patellar reflex, and analgesia in the area of cutaneous innervation. coma is complete loss of consciousness, with no response to noxious stimuli. in some animals that present in a coma or stuporous state, the immediate cause will be apparent. in other cases, however, a careful and thorough diagnostic work-up must be performed. a coma scale devised to assist in the clinical evaluation of the comatose patient is shown in table 1 -45. whenever an animal presents in a comatose state, immediately secure the emergency management of specific conditions 191 c6-t2 nerve roots radial nerve paralysis musculocutaneous nerve inability to flex the elbow axillary or thoracodorsal dropped elbow nerve median and ulnar nerves loss of cutaneous sensation on the caudal surface of the forearm and palmar and lateral surfaces of the paw; inability to flex the carpus and digits c8-t1 nerve roots radial, median, or ulnar nerve injury c6-c7 nerve roots musculocutaneous, suprascapular, and axillary injury c7-t3 horner's syndrome (miosis, enophthalmos, and prolapsed nictitans) airway by placing an endotracheal tube (see section on endotracheal intubation). if necessary, provide respiratory assistance, or at a minimum, supplemental oxygen. control existing hemorrhage and treat shock, if present. take a careful and thorough history from the owner. make careful note of any seizure, trauma, or toxin exposure, and whether prior episodes of coma have ever occurred. perform a careful physical examination, taking note of the patient's temperature, pulse, and respiration. an elevated temperature may suggest the presence of systemic infection, such as pneumonia or hepatitis, or a brain lesion with loss of hypothalamic thermoregulatory control. very high temperatures associated with shock and coma are often observed in animals with heat stroke (see section on heat stroke and heat-induced illness). circulatory collapse or barbiturate overdose can produce coma and hypothermia. abnormal respiratory patterns also may be observed in a comatose patient. hypoventilation may occur with elevated intracranial pressure or barbiturate overdose. rapid respiratory rate may be associated with pneumonia, metabolic acidosis (dka, uremia), or brainstem injury. examine the skin for any bruises or external trauma. examine the mucous membranes and make note of color and capillary refill time. icterus with petechiae or ecchymotic hemorrhage in a comatose patient may be associated with end-stage hepatic failure and hepatic encephalopathy. smell the patient's breath for the odor of ketones that may signify dka or end-stage hepatic failure. motor activity 6 normal gait, normal spinal reflexes hemiparesis, tetraparesis, or decerebrate activity 5 recumbent, intermittent extensor rigidity 4 recumbent, constant extensor rigidity 3 recumbent, constant extensor rigidity with opisthotonus 2 recumbent, hypotonia of muscles, depressed or absent spinal reflexes 1 normal papillary reflexes and oculocephalic reflexes 6 slow pupillary light reflexes and normal to reduced oculocephalic reflexes 5 bilateral unresponsive miosis with normal to reduced oculocephalic reflexes 4 pinpoint pupils with reduced to absent oculocephalic reflexes 3 unilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes 2 bilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes 1 occasional periods of alertness and responsive to environment 6 depression of delirium, capable of responding to environment but response 5 may be inappropriate semicomatose, responsive to visual stimuli 4 semicomatose, responsive to auditory stimuli 3 semicomatose, responsive only to repeated noxious stimuli 2 comatose, unresponsive to repeated noxious stimuli 1 *neurologic function is assessed for each of the three categories and a grade of 1 to 6 is assigned according to the descriptions for each grade. the total score is the sum of the three category scores. this scale is designed to assist the clinician in evaluating the neurologic status of the craniocerebral trauma patient. as a guideline and according to clinical impressions, a consistent total score of 3 to 8 represents a grave prognosis, 9 to 14 a poor to guarded prognosis, and 15 to 18 a good prognosis. (modified from the glasgow coma scale used in humans.) from shores a: craniocerebral trauma. in kirk rw, ed: current veterinary therapy x. small animal practice. philadelphia, wb saunders, 1989, p 849. finally, conduct a complete neurologic evaluation. the presence of asymmetric neurologic signs may suggest an intracranial mass lesion (e.g., hemorrhage, neoplasia, injury). usually, toxicities or metabolic disturbances (e.g., dka, hepatic encephalopathy) cause symmetric clinical signs of neurologic dysfunction, with cerebral signs predominating. in hepatic encephalopathy, pupils are usually normal in size and responsive to light. in toxicities, the pupils are abnormal in size and may be unresponsive to light. obtain a complete blood count, serum biochemistry profile, urinalysis, and specific tests for glucosuria and ketonuria. findings of a drastically elevated blood glucose with glucosuria, ketonuria, and high specific gravity are characteristic of dka. fever and uremic encephalopathy are characterized by severe azotemia with a low urine specific gravity. if barbiturate intoxication is suspected, save urine for later toxin analysis. evaluate urine sediment for calcium oxalate crystalluria that may indicate ethylene glycol toxicity. calculate plasma osmolality (see following section) to check for nonketotic hyperosmolar diabetes mellitus. elevated blood ammonia levels may be associated with hepatic encephalopathy. in uncontrolled diabetes mellitus, hyperosmolarity can result in clinical signs of disorientation, prostration, and coma. plasma osmolarity can be calculated from the formula: mosm/l = 2(na + k) + (glucose/18) + (bun/2.8) clinical signs of hyperosmolarity can occur when the plasma osmolarity exceeds 340 mosm/l. treatment of dka or nonketotic hyperosmolar syndrome is aimed at reducing ketoacid production, stimulating carbohydrate utilization, and impeding peripheral release of fatty acids. the treatment of choice is rehydration and provision of supplemental regular insulin and a carbohydrate source (see section on diabetic ketoacidosis). during ketosis, insulin resistance may be present. slow rehydration with 0.9% saline solution or other balanced crystalloid fluids (e.g., normosol-r, plasmalyte-m, lactated ringer's solution), should occur, with the goal of rehydration over 24 to 48 hours. too rapid rehydration can result in cerebral edema and exacerbation of clinical signs. hepatic encephalopathy (he) is characterized by an abnormal mental state associated with severe hepatic insufficiency. the most common cause of he is congenital or acquired c o m a portosystemic shunts. acute hepatic destruction can also be caused by toxins, drugs, or infectious causes. the treatment of he is considered a medical emergency (table 1 -46) . absorption of ammonia and other nitrogenous substances from the gastrointestinal tract is thought to be one of the complicating factors in he. prevent absorption of ammonia and other nitrogenous substances from the gastrointestinal tract by restricting dietary protein to 15% to 20% for dogs, and to 30% to 35% (on a dry matter basis) for cats. dietary protein should be from a nonanimal plant source (e.g., soybean) whenever possible. caloric requirements are met with lipids and carbohydrates. also prescribe cleansing enemas to rid the colon of residual material, and antibiotic therapy to reduce gastrointestinal tract bacteria. neomycin (15 mg/kg q6h) can be administered as a retention enema. metronidazole (7.5 mg/kg po, q8-12h) or amoxicillin-clavulanate (16.25 mg po q12h) can also be administered. administer lactulose (2.5-5.0 ml q8h for cats; 2.5-15 ml q8h for dogs) to trap ammonia in the colon to prevent absorption (table 1 -46) . administer lactulose orally to an alert animal, or as a retention enema to a comatose animal. if lactulose is not available, betadine retention enemas will change colonic ph and prevent ammonia absorption. a side effect of lactulose administration (po) is soft to diarrheic stool. a seizure is a transient disturbance of brain function that is sudden in onset, ceases spontaneously, and has a tendency to recur, depending on the cause. most seizures are generalized and result in a loss of consciousness and severe involuntary contraction of the skeletal muscles, resulting in tonic-clonic limb activity and opisthotonus. mastication, salivation, urination, and defecation are common. partial (petit mal) seizures range from limited limb activity, facial muscle twitching, and episodic behavioral abnormalities to brief loss of consciousness. similar clinical signs also can occur with syncopal episodes. conduct a careful cardiac examination in any patient with a history of petit mal seizures. seizures of any form constitute a medical emergency, particularly when they occur in clusters, or as status epilepticus. most seizures are of short duration and may have subsided by the time the animal is presented for treatment. whenever a seizure occurs, however, it is important that the animal does not inadvertently injure itself or a bystander. it is important to evaluate whether the patient has a coexisting disease that can predispose it to seizures, such as hepatic failure, uremia, diabetes mellitus, hypoglycemia, toxin exposure, insulin-secreting tumors, and thiamine deficiency. many toxins are responsible for clinical signs of tremors or seizures (see section on poisons and toxins). treatment of a primary disease entity can help control seizures, in some cases, provided that the underlying cause is investigated and treated. status epilepticus, a state of continuous uncontrolled seizure activity, is a medical emergency. when an animal is in a state of status epilepticus, immediately place a lateral or medial saphenous intravenous catheter and administer diazepam (0.5 mg/kg iv) to help control the seizure. in most cases, the seizure must be controlled before a diagnostic workup is attempted. whenever possible, however, blood samples should be collected before administration of any anticonvulsant agent because of the risk of incorrect test results. for example, the propylene glycol carrier in diazepam can cause a false-positive ethylene glycol test using an in-house testing kit. whenever possible, check blood glucose levels, particularly in young puppies or kittens, to evaluate and treat hypoglycemia as a cause of seizures. if hypoglycemia exists, administer 25% dextrose (1 g/kg iv). if diazepam partially controls the status epilepticus, administer a constant rate infusion (0.1 mg/kg/hour in 5% dextrose in water). diazepam is sensitive to light, and the bag and infusion line must be covered to prevent degradation of the drug. if diazepam fails to control status epilepticus, give pentobarbital (3-25 mg/kg iv to effect). the animal's airway should be intubated and protected while the patient is kept in the drug-induced coma. protracted cases of seizures may require mannitol and furosemide therapy to treat cerebral edema. administer intravenous fluids (balanced crystalloid at maintenance doses [see section on intravenous fluid therapy]). the patient should be turned every 4 to 6 hours to 194 1 emergency care prevent atelectasis. insert a urinary catheter for cleanliness, and place the animal on soft dry padded bedding to prevent decubital ulcer formation. depending on the length of time that the patient is rendered unconscious, apply passive range of motion exercises and deep muscle massage to prevent disuse atrophy of the muscles and dependent or disuse edema. monitor the patient's oxygenation and ventilation status by arterial blood gas measurement or pulse oximetry and capnometry (see section 5 on blood gas, pulse oximetry, and capnometry). administer supplemental oxygen to any patient that is hypoxemic secondary to hypoventilation or other causes. severe refractory seizures can result in the development of neurogenic pulmonary edema. lubricate the animal's eyes every 4 hours to prevent drying out and corneal abrasions. depending on the cause of the seizure, administer phenobarbital at a loading dose of 16 to 20 mg/kg iv given in four to five injections, every 20 to 30 minutes; make sure that the patient is rousable in between injections). seizures in cats often are associated with structural brain disease. the occurrence of partial focal seizures is unequivocally associated with a focal cerebral lesion and acquired structural brain disease. an initial high frequency of seizures is also a strong indication that structural brain disease is present. seizure activity in cats may occur as mild generalized seizures or complex partial seizures and may be associated with systemic disorders such as feline infectious peritonitis virus, toxoplasmosis, cryptococcus infection, lymphosarcoma, meningiomas, ischemic encephalopathy, and thiamine deficiency. thiamine deficiency in the cat can be a medical emergency characterized by dilated pupils, ataxic gait, cerebellar tremor, abnormal oculocephalic reflex, and seizures. treatment consists of administration of thiamine (50 mg/day) for three days. steffen f, grasmueck s: propofol for treatment of refractory seizures in dogs and a cat with intracranial disorders. j small anim pract 41 (11) (1997) (1998) (1999) . j am vet med assoc 218 (7): [1124] [1125] [1126] [1127] [1128] [1129] 2001 . an ocular emergency is any serious condition that causes or threatens to cause severe pain, deformity, or loss of vision. treat ocular emergencies immediately, within 1 to several hours after the emergency, whenever possible (box 1-51, 1-52). to assess the location and degree of ocular injury, perform a complete ocular examination. in some cases, short-acting sedation or general anesthesia in conjunction with topical local anesthetic may be necessary to perform the examination, because of patient discomfort and blepharospasm. the equipment listed in box 1-53 may be necessary and may be invaluable in making an accurate diagnosis. to perform a systematic and thorough ocular examination, first obtain a history from the owner. has there been any prior incident of ocular disease? is there any history of trauma or known chemical irritant or exposure? did the owner attempt any irrigation or medical techniques prior to presentation? when was the problem first noticed? has it changed at all since the owner noticed the problem? after a history has been obtained, examine the patient's eyes for discharge, blepharospasm, or photophobia. if any discharge is present, note its color and consistency. do not attempt to force the eyelids open if the patient is in extreme discomfort. administer a short-acting sedative and topical local anesthetic such as 0.5% proparacaine. note the position of the globe within its orbit. if the eye is exophthalmic, strabismus and protrusion of the third eyelid are often visible. exposure keratitis may be present. in cases of retrobulbar or zygomatic salivary gland inflammation, the patient will resist opening the mouth and exhibit signs of discomfort or pain. note any swelling, contusions, abrasions, or lacerations of the eyelids. note whether the lids are able to close completely and cover the cornea. if a laceration of the lid is present, determine the depth of the laceration. palpate the orbit for fractures, swelling, pain, crepitus, and cellulitis. examine the cornea and sclera for penetrating injury or foreign material. the use of lid retractors or small forceps can be very helpful in these cases. if a wound appears to penetrate completely into the globe, look for loss of uveal tissue, lens, or vitreous. do not put any pressure on the globe, because intraocular herniation may result. examine the conjunctiva for hemorrhage, chemosis, lacerations, and foreign bodies. examine the superior and inferior conjunctival cul-de-sacs for foreign material. in such cases, placement of a topical anesthetic and use of a moistened cotton swab is invaluable to sweep the conjunctival fornix to pick up foreign bodies. use a small, fine-tipped forceps to retract the third eyelid away from the globe and examine behind the third eyelid for foreign bodies. next, examine the cornea for opacities, ulcers, foreign bodies, abrasions, or lacerations. place a small amount of fluroescein stain mixed with sterile water or saline on the dorsal sclera. close the eye to disperse the stain over the surface of the cornea, then flush gently with sterile saline irrigation. examine the cornea again for any defects. a linear defect perpendicular to the long axis of the eye should alert the clinician to investigate the conjunctiva for dystechia. record the pupil size, shape, and response to light (both direct and consensual). examine the anterior chamber and note its depth and whether hyphema or aqueous flare are present. is the lens clear and is it in the normal position? lens luxation can cause the lens tissue to touch the cornea and cause acute corneal edema. measure intraocular pressure with a schiotz tonometer or tonopen. finally, dilate the pupil and examine the posterior chamber using a direct or indirect ophthalmoscope to look for intraocular hemorrhage, retinal hemorrhage, retinal detachment, tortuous retinal vessels, optic neuritis, and inflammation. the basic surgical instruments listed in box 1-54 may be useful in the treatment of ocular lacerations and other ophthalmic injuries: bite wounds and automobile trauma commonly cause lacerations and abrasions of the lid margins. the lids can be considered to be two-layer structures, with the anterior composed of the skin and orbicularis muscle and the posterior layer composed of the tarsus and conjunctiva. the openings of the meibomian glands in the lid margin form the approximate line separating the lids into anterior and posterior segments. splitting the lid into these two segments facilitates the use of sliding skin flaps to close wound defects, if necessary. clean and thoroughly but gently irrigate the wound with sterile saline solution before attempting any lid laceration repair. use sterile saline solution to irrigate the wound and conjunctiva. a 1% povidone-iodine scrub can be used on the skin, taking care to avoid getting any scrub material in the soft tissues of the eye. drape the eye with an adhesive ocular drape, if possible, to prevent further wound contamination. trim the ragged wound edges, but be very conservative with tissue debridement. leave as much tissue as possible to insure proper wound contracture with minimal lid deformity. close a small lid wound with a figure-of-eight or two-layered simple interrupted suture of absorbable suture material or nylon in the skin. the lid margins must be absolutely apposed to prevent postoperative lid notching. direct blunt trauma to the eye can cause severe ecchymosis because of the excellent vascular supply of the eyelids. other associated ocular injuries such as orbital hemorrhage, proptosis, and corneal laceration may also occur. trauma, allergic reactions, inflammation of the sebaceous glands (hordeolum), thrombocytopenia, and vitamin k antagonist rodenticide intoxication can all cause ecchymoses of the lids. treat eyelid ecchymoses initially with cool compresses, followed by warm compresses. resorption of blood can occur from 3 to 10 days after the initial insult. ocular allergies respond well to topical application (dexamethasone ophthalmic ointment q6-8h) and systemic administration of glucocorticosteroids, along with cool compresses. in order to fully assess the conjunctiva for abnormalities, it may be necessary to carefully dissect it away from the underlying sclera. when performing this dissection, do not place undue pressure on the globe because of the risk of herniation of the intraocular contents through a scleral wound. repair large conjunctival lacerations with 6-0 absorbable sutures, using an interrupted or continuous pattern. carefully approximate the margins of the conjunctiva to prevent formation of inclusion cysts. when large areas of the conjunctiva have been damaged, advancement flaps may be required to close the defect. subconjunctival hemorrhage is a common sequela of head trauma, and it may also be observed in various coagulopathies. by itself, it is not a serious problem but may signify severe underlying intraocular damage. a complete ocular examination is indicated. other causes of subconjunctival hemorrhage include thrombocytopenia, autoimmune hemolytic anemia, hemophilia, leptospirosis, vitamin k antagonist rodenticide intoxication, severe systemic infection or inflammation, and prolonged labor (dystocia). uncomplicated subconjunctival hemorrhage usually clears on its own within 14 days. if the conjunctiva is exposed because of swelling and hemorrhage, administer a topical protective triple antibiotic ophthalmic ointment every 6 to 8 hours until the conjunctival hemorrhage resolves. toxic, acid, and alkaline chemical injuries to the eye can sometimes occur. the severity of the injury caused by ocular burns depends on the concentration, type, and ph of the chemical and on the duration of exposure. weak acids do not penetrate biologic tissue very well. the hydrogen ion precipitates the protein upon contact and therefore provides some protection to the corneal stroma and intraocular contents. precipitation of corneal proteins produces a ground-glass appearance in the cornea. alkaline solutions and very strong acids penetrate tissues rapidly, causing saponification of the plasma membrane, denaturation of collagen, and vascular thrombosis within the conjunctiva, episclera, and anterior uvea. severe pain, blepharospasm, and photophobia are produced by exposure of free nerve endings in the corneal epithelium and conjunctiva. severe alkaline burns cause an increase in intraocular pressure. intraocular prostaglandins are released, and the intraocular aqueous ph increases, producing changes in the blood-aqueous barrier and secondary uveitis. uveitis with anterior synechia formation, eventual chronic glaucoma, phthisis, secondary cataract, and corneal perforation can occur. healing of the corneal epithelium is usually accomplished by neovascularization and sliding and increased mitosis of the corneal epithelium. severe stromal burns within the cornea heal by degradation and removal of necrotic debris, followed by replacement of the collagen matrix and corneal epithelial cells. the release of collagenase, endopeptidase, and cathepsins from polymorphonuclear cells serves to cause further corneal breakdown. in severe cases, only pmns may be present, and fibroblasts may never invade the corneal stroma. all chemical burns should be washed copiously with any clean aqueous solution available. if any sticky paste or powder is adherent to the conjunctival sac, remove it with moist cotton swabs and irrigation. begin mydriasis and cycloplegia by topical application of 1% atropine ophthalmic drops or ointment. start antibiotic therapy with triple antibiotic ophthalmic ointment or gentocin ointment every 6 to 8 hours. treat secondary glaucomas with topical carbonic anhydrase inhibitors. to avoid fibrinous adhesions and symblepharon formation, keep the conjunctival cul-de-sacs free of proteinaceous exudate that can form adhesions. analgesics are required for pain. oral nonsteroidal antiinflammatory agents such as carprofen, ketoprofen, meloxicam, or aspirin are recommended. persistent epithelial erosions may require a conjunctival flap left in place for 3 to 4 weeks or placement of a topical collagen shield (contact lens). topical antibiotics, mydriatics, and lubricants (lacrilube or puralube ointment) should also be used. strong acid or alkali burns can result in severe corneal stromal loss. in the past, topical n-acetylcysteine (10% mucomyst) has been recommended. this treatment is very painful. other treatments are also available, such as ethylenediaminetetraacetic acid (edta) (0.2 m solution) and patient serum to inhibit mammalian collagenase activity. to prepare patient serum, obtain 10 to 12 ml of whole blood from the patient. spin it down in a serum separator tube after a clot forms and then place the serum in a red-topped tube on the patient's cage. (the contents of the tube are viable for 4 days without refrigeration.) apply the serum topically to the affected eye every 1 to 2 hours. avoid using topical steroids because they inhibit fibroblast formation and corneal healing. in severe cases, if conjunctival swelling and chemosis also are present, antiinflammatory doses of oral steroids can be administered short-term. oral steroids and nonsteroidal antiinflammatory drugs should never be administered to the patient concurrently, because of the risk of gastrointestinal ulcer and perforation. corneal abrasions are associated with severe pain, blepharospasm, lacrimation, and photophobia. animals with such intense pain are often difficult to examine until analgesia has been administered. topical use of proparacaine (0.5% proparacaine hydrochloride) is usually sufficient to permit relaxation of the eyelids so that the eye can be examined. using a focal source of illumination and an eye loupe, examine the cornea, inferior and superior conjunctival fornixes, and medial aspect of the nictitans for foreign bodies. place a sterile drop of saline on a fluorescein-impregnated strip and touch the superior conjunctiva once to allow the stain to spread onto the surface of the eye. irrigate the eye to remove excess stain and then examine the corneal surface for any areas of stain uptake. if an area of the cornea persistently remains green, there is damage to the corneal epithelium in that area. initial treatment consists of application of a topical mydriatic (1 drop of 1% atropine in affected eye q12h) to prevent anterior synechiae and improve cycloplegia. triple antibiotic ointment is the treatment of choice (a 1 /4-inch strip in the affected eye q8h) until the ulcer heals. in some cases, nonhealing ulcers (e.g., boxer ulcer, indolent ulcer) form in which the epithelial growth does not adhere to the underlying cornea. gently debride the loose edges 1 of the ulcer/erosion with a cotton swab and topical anesthesia. more severe cases in which only minimal healing has occurred after 7 days of treatment require grid keratectomy, in which a 25-gauge needle is used to gently scratch the surface of the abrasion or ulcer in the form of a grid to promote neovascularization. apply a topical anesthetic before performing the procedure. a collagen contact lens also may be required to promote wound healing. all corneal abrasions should be reevaluated in 48 hours, and then every 4 to 7 days thereafter until they have healed. acute infectious keratitis secondary to bacterial infection is characterized by mucopurulent ocular discharge, rapidly progressing epithelial and corneal stromal loss, inflammatory cellular infiltrates into the corneal stroma, and secondary uveitis, often with hypopyon formation. confirmation of infectious keratitis is based on corneal scrapings and a positive gram stain. initial treatment for bacterial keratitis consists of systemic antibiotics and topical ciprofloxacin (0.3% eyedrops or ointment). penetrating injuries through the cornea may result in prolapse of intraocular contents. frequently, pieces of uveal tissue or fibrin effectively but temporarily seal the defect and permit the anterior chamber to re-form. avoid manipulation of these wounds until the animal has been anesthetized, as struggling or excitement can promote loss or dislodgement of the temporary seal and cause the intraocular contents to be extruded. superficial corneal lacerations need not be sutured and can be treated the same as a superficial corneal ulcer or abrasion. if the laceration penetrates more than 50% the thickness of the cornea, or extends more than 3 to 4 mm, it should be sutured. when placing sutures in the cornea, it is helpful to use magnification. referral to a veterinary ophthalmologist is advised. if a veterinary ophthalmologist is not available, use 7-0 or 8-0 silk, collagen, or nylon sutures on a micropoint spatula-type needle. use a simple interrupted suture pattern and leave the sutures in place for a minimum of 3 weeks. because many corneal lacerations are jagged and corneal edema forms, most of the wound edges cannot be tightly juxtaposed. in such cases, pull a conjunctival flap across the wound to prevent leakage of aqueous fluid. never suture through the full thickness of the cornea; rather, the suture should pass through the mid-third of the cornea. following closure of the corneal wound, the anterior chamber must be re-formed to prevent anterior synechia formation with secondary glaucoma. taking care to avoid iris injury, use a 25-or 26-gauge needle to insert sterile saline at the limbus. any defect in the suture line will be apparent because of leakage of the fluid from the site and should be repaired. incarceration of uveal tissue in corneal wounds is a difficult surgical problem. persistent incarceration of uveal tissue can result in development of a chronic wick in the cornea, a shallow anterior chamber, chronic irritation, edema, vascularization of the cornea, and intraocular infection that can lead to panophthalmitis. referral to a veterinary ophthalmologist is strongly recommended. the most common foreign bodies associated with ocular injuries in small animals are birdshot, bb pellets, and glass. the site of intraocular penetration of the foreign bodies may be obscured by the eyelids. a foreign body entering the eye may penetrate the cornea and fall into the anterior chamber or become lodged in the iris. foreign bodies may occasionally penetrate the lens capsule, producing cataracts. some metallic high-speed foreign bodies may penetrate the cornea, iris, and lens to lodge in the posterior wall of the eye or vitreous chamber. direct visualization of a foreign body is the best means of localization. examination of the eye with an indirect ophthalmoscope or biomicroscope (if available) is invaluable for locating foreign bodies. indirect visualization of the ocular foreign body can also be achieved through radiographic techniques. three separate views should be obtained to determine the plane of location of the foreign object. ct or mri may prove useful, although scatter from the foreign body may make it difficult to directly visualize with these techniques. ocular ultrasound is perhaps the most useful and refined radiographic technique for locating intraocular foreign bodies. before removing any foreign body from the eye, the risk and surgical danger of removing it must be weighed against the risks of leaving it in place. metallic foreign bodies in the anterior chamber are much easier to remove than nonmagnetic ones. attempted removal of foreign objects from the vitreous chamber of the eye has consistently produced poor results. for the best chance of recovery, ocular foreign bodies should be removed by a veterinary ophthalmologist whenever possible. blunt trauma to the globe can result in luxation or subluxation of the lens. the subluxated lens may move anteriorly and make the anterior chamber more shallow. trembling of the iris (iridodonesis) may be noticed when the lens is subluxated. in complete luxation, the lens may fall totally into the anterior chamber and obstruct aqueous outflow, causing secondary glaucoma. alternatively, the lens may be lost into the vitreous cavity. luxation of the lens is almost always associated with rupture of the hyaloid membrane and herniation of the vitreous through the pupillary space. emergency surgery for lens luxation is required if the lens is entirely within the anterior chamber or incarcerated within the pupil, causing a secondary pupillary block glaucoma. acute elevation in intraocular pressure can cause vision loss within 48 hours; thus, lens removal should be accomplished as quickly as possible. referral to a veterinary ophthalmologist is recommended. severe trauma to the globe or a direct blow to the head can result in retinal or vitreous hemorrhage. there may be large areas of subretinal or intraretinal hemorrhage. subretinal hemorrhage assumes a discrete globular form, and the blood appears reddish-blue in color. the retina is detached at the site of hemorrhage. superficial retinal hemorrhage may assume a flame-shaped appearance, and preretinal or vitreous hemorrhage assumes a bright-red amorphous appearance, obliterating the underlying retinal architecture. retinal and vitreous hemorrhage secondary to trauma usually resorbs spontaneously over a 2-to 3-week period. unfortunately, vitreous hemorrhage, as it organizes, can produce vitreous traction bands that eventually produce retinal detachment. expulsive choroid hemorrhage can occur at the time of injury and usually leads to retinal detachment, severe visual impairment, and total loss of vision. treatment of vitreal and retinal hemorrhage includes rest and correction of factors that may predispose to intraocular hemorrhage. more complicated cases may require vitrectomy performed by a veterinary ophthalmologist. hyphema refers to blood in the anterior chamber of the eye. the most common traumatic cause of hyphema is an automobile accident. hyphema may also present because of penetrating ocular wounds and coagulopathies. blood within the eye may come from the anterior or posterior uveal tract. trauma to the eye may result in iridodialysis or a tearing of the iris at its root, permitting excessive bleeding from the iris and ciliary body. usually, simple hyphema resolves spontaneously in 7 to 10 days and does not cause vision loss. loss of vision following bleeding into the anterior chamber is associated with secondary ocular injuries such as glaucoma, traumatic iritis, cataract, retinal detachment, endophthalmitis, and corneal scarring. treatment of hyphema must be individualized, but there are severe general principles of treatment. first, stop ongoing hemorrhage and prevent further bleeding whenever possible. this may involve correction of the underlying cause, if a coagulopathy is present. next, aid in the elimination of blood from the anterior chamber, control secondary glaucoma, and treat associated injuries, including traumatic iritis. finally, detect and treat any late complications of glaucoma. in most cases of traumatic hyphema, little can be done to arrest or prevent ongoing hemorrhage. it is best to restrict the animal's activity and prohibit exertion. rebleeding can occur within 5 days, and intraocular pressure must be monitored closely. after 5 to 7 days, the blood in the anterior chamber will change color from a bright red to bluish-black ("eight-ball hemorrhage"). if total hyphema persists and intraocular pressure rises despite therapy, surgical intervention by a veterinary ophthalmologist may be necessary. the primary route of escape of rbcs from the anterior chamber is via the anterior drainage angle. iris absorption and phagocytosis play a minor role in the removal of blood from the anterior chamber. because of the associated traumatic iritis in hyphema, topical administration of a glucocorticoid (1% dexamethasone drops or 1% prednisolone drops) is advised to control anterior chamber inflammation. a cycloplegic agent (1% atropine) should also be used. the formation of fibrin in the anterior chamber of the eye secondary to hemorrhage can produce adhesions of the iris and secondary glaucoma (see section on glaucoma secondary to hyphema) by blocking the trabecular network. hyphema secondary to retinal detachment (collie ectasia syndrome) and end-stage glaucoma are extremely difficult to treat medically and have a poor prognosis. proptosis of the globe is common secondary to trauma, particularly in brachycephalic breeds. proptosis of the globe in dolichocephalic breeds requires a greater degree of initiating contusion than the brachycephalic breeds because the orbits are so much deeper. therefore, secondary damage to the eye and cns associated with proptosis of the globe may be greater in the collie or greyhound than in the pug. when proptosis occurs, carefully evaluate the cardiovascular system for evidence of hypovolemic or hemorrhagic shock. examine the respiratory and neurologic systems. be sure to establish an airway and treat shock, if present. control hemorrhage and stabilize the cardiovascular system before attempting to replace the globe within its orbit or perform enucleation. during the initial management of the cardiovascular and respiratory systems, the eye should be covered with an ophthalmic grade ointment or sponges soaked in sterile saline to prevent the globe from drying out. proptosis of the globe can be associated with serious intraocular problems including iritis, chorioretinitis, retinal detachment, lens luxation, and avulsion of the optic nerve. stain the surface of the eye with fluorescein to look for topical abrasions or ulcers. carefully examine the sclera, cornea, and conjunctiva for penetrating injuries that may allow aqueous leakage. evaluate the size, location, and response to light of the pupil. a reactive pupil is better than a mydriatic fixed pupil. topical administration of a mydriatic (atropine 1%) to prevent persistent miosis and synechia formation is indicated, along with topical and oral antibiotics and oral analgesic therapy. reposition the proptosed globe with the patient under general anesthesia. make a lateral canthotomy incision to widen the palpebral fissure. lavage the globe with sterile saline irrigation to remove any external debris. place a copious amount of triple antibiotic ophthalmic ointment on the surface of the eye and then gently press the globe into the orbit using the flat side of a scalpel handle or a moistened sterile surgical sponge. do not probe the retro-orbital space with a needle or attempt to reduce intraocular pressure by paracentesis. when the globe is replaced in the orbit, close the lateral canthotomy incision with simple interrupted sutures. place three non-penetrating mattress sutures in the lid margins but do not draw them together. tighten the lid sutures through small pieces of a red rubber catheter or length of intravenous extension tubing to prevent the sutures from causing lid necrosis. leave the medial canthus of the eye open in order to allow topical treatment. postoperative treatment is directed at preventing further iritis and preventing infection. administer systemic broad-spectrum antibiotics (clavamox, 16.25 mg/kg po bid) and analgesic drugs. apply topical triple antibiotic ophthalmic ointment ( 1 /4 inch in affected eye q6-8h) and atropine (1% in affected eye q12h) to prevent infection, cycloplegia, and anterior synechiae. antiinflammatory doses of systemic steroids can also be added to the treatment 202 if severe periorbital inflammation is present. systemic steroids should never be used in conjunction with nonsteroidal antiinflammatory drugs, because of the risk of gastrointestinal ulceration and perforation. the sutures should remain in place for a minimum of 3 weeks. after this time, remove the sutures and inspect the globe. if proptosis recurs, repeat the treatment. following proptosis, strabismus is common secondary to periorbital muscle injury. even after extensive treatment, vision in the eye may still be lost. nonvisual eyes can remain in place, but phthisis may develop. carbonic anhydrase inhibitors such as acetazolamide and dichlorphenamide decrease aqueous secretion and may effectively reduce intraocular pressure if the trabecular outflow is still functioning at 40% of its capacity. an eye with a poorly functional trabecular outflow system will respond poorly to therapy with carbonic anhydrase inhibitors. osmotic agents such as mannitol or glycerol may be helpful in controlling glaucoma secondary to hyphema. reduction in vitreous chamber size can make the anterior chamber deeper and may allow increased aqueous outflow. evacuation of blood or blood clots from the anterior chamber is not advisable unless the glaucoma cannot be controlled medically or there is no indication after a prolonged period of time that blood is being resorbed. tissue plasminogen activator (t-pa) has proved to be useful in may be helpful in lysing blood clots and preventing excessive fibrin formation. the t-pa is reconstituted to make a solution of 250 âµ/ml, which is then frozen at â��70â°c in 0.5-ml aliquots. the thawed, warmed reconstituted t-pa is injected into the anterior chamber. blind probing of the anterior chamber of the eye and surgical intervention in an attempt to remove blood clots can cause serious complications such as rebleeding, lens luxation, iris damage, and damage to the corneal epithelium, and therefore is not advised. acute glaucoma is a rise in intraocular pressure that is not compatible with normal vision. glaucoma may present as early acute congestive or noncongestive glaucoma, or as end-stage disease. cardinal signs of glaucoma are a sudden onset of pain, photophobia, lacrimation, deep episcleral vascular engorgement, edematous insensitive cornea, shallow anterior chamber depth, dilated unresponsive pupil, loss of visual acuity, and buphthalmia. intraocular pressure usually exceeds 40 mm hg but may be normal or only slightly increased if glaucoma is secondary to anterior uveitis. most forms of clinical glaucoma in dogs are secondary to some other intraocular problem. primary glaucoma is recognized in some breeds, including the bassett hound, cocker spaniel, samoyed, bouvier des flandres, and some terrier breeds either from goniodysgenesis or a predisposition to lens luxation. other common causes of acute glaucoma are anterior uveitis and intumescent lens secondary to rapid cataract development, particularly in dogs with diabetes mellitus. treatment involves investigation of the underlying cause of the sudden rise in intraocular pressure and rapid reduction in intraocular pressure. permanent visual impairment is often associated with chronically buphthalmic globes or the presence of rippling or striae formation on the cornea. referral to a veterinary ophthalmologist is recommended. if the eye is still visual and not buphthalmic, the prognosis is favorable, depending on the cause of the acute glaucoma. treatment to reduce intraocular pressure consists of improving aqueous outflow, reducing intraocular volume with osmotic agents, and reducing aqueous formation (table 1 -47). the use of topical mydriatic agents in acute glaucoma is contraindicated because of the risk of making lens luxation or anterior uveitis worse. referral to a veterinary ophthalmologist for emergency surgery is indicated in cases of iris bombe, intumescent lens, or lens subluxation. administer osmotic agents to reduce the size of the vitreous body and the amount of aqueous. osmotic agents create an osmotic gradient between the intraocular fluids and the emergency management of specific conditions 203 vascular bed, thus allowing osmotic removal of fluid independent of the aqueous inflow and outflow systems. if no other treatments are available, oral glycerol (50%, 0.6 ml/kg or 1.4 g/kg) can be used to effectively reduce intraocular pressure. an adverse side effect of oral glycerol treatment is protracted vomiting. do not use glycerol in a diabetic patient. mannitol (1-2 g/kg iv over 1 hour) also effectively reduces intraocular pressure but does not cause vomiting. carbonic anhydrase inhibitors can be used to reduce intraocular volume by reducing aqueous production. oral administration of dichlorphenamide, methazolamide, and acetazolamide (2-4 mg/kg) is usually not very effective alone in reducing aqueous volume and intraocular pressure and also can cause metabolic acidosis. topical carbonic anhydrase inhibitors appear to be more effective (dorzolamide, trusopt) when used in conjunction with topical beta-blockers (timolol, 0.25% or 0.5% solution q8h). the most effective treatment for acute pressure reduction is use of a topical prostaglandin inhibitor (latanaprost). usually just one or two drops effectively reduces intraocular pressure in the emergency stages, until the patient can be referred to a veterinary ophthalmologist the following day. many clinical conditions that are presented as emergencies may be due in part or wholly to the presence of a neoplasm. paraneoplastic signs are summarized in table 1 -48. prompt identification of the neoplasia combined with knowledge of treatment, expected response to therapy, and long-term prognosis can aid owners and practitioners in making appropriate treatment decisions. hemorrhage or effusion can occur in any body cavity as a result of the presence of benign or malignant tumors. tumors secrete anticoagulants to allow angiogenesis to grow unchecked. hemorrhage often occurs as a result of rupture of a neoplasm or invasion of a neoplasm into a major vascular structure. effusion may be the result of direct fluid production by the mass or may be due to obstruction of lymphatic or venous flow. hemorrhagic effusions in the abdominal cavity occur most commonly with neoplastic masses of the spleen or liver. the most common causes are hemangiosarcoma and hepatocellular carcinoma. clinical signs associated with acute abdominal hemorrhage, regardless of the cause, are related to hypovolemic shock and decreased perfusion and include pale mucous membranes, tachycardia, anemia, lethargy, and acute collapse. treatment for abdominal hemorrhage includes placement of a large-bore peripheral cephalic catheter and starting one fourth of a shock dose (90 ml/kg/hour for dogs, and 44 ml/kg/hour for cats) of intravenous crystalloid fluids, taking care to carefully monitor perfusion parameters of heart rate, capillary refill time, mucous membrane color, and blood pressure. administer intravenous colloids such as dextran-70, hetastarch, and oxyglobin (5-10 ml/kg iv bolus) to restore intravascular volume and normotension. treat severe anemia with whole blood or packed rbcs to improve oxygen-carrying capacity and oxygen delivery (see sections on transfusion medicine and treatment of shock). confirm the presence of hemoabdomen abdominocentesis (see section on abdominocentesis). the presence of nonclotting hemorrhagic effusion is consistent with free blood. packed cell volume of the fluid is usually the same or higher than that of the peripheral blood. an abdominal compression bandage can be placed while further diagnostics are being performed. in cases of acute hemoabdomen, obtain right lateral, left lateral, and ventrodorsal or dorsoventral thoracic radiographs to help rule out obvious metastasis. monitor the patient's ecg and correct dysrhythmias as necessary (see section on cardiac dysrhythmias). surgery is indicated once the patient is stabilized. in some cases, hemorrhage is so severe that the patient should be taken immediately to surgery. when recommending surgery for a hemorrhaging intraabdominal mass, it is important to discuss likely diagnoses and long-term prognosis with the owner. hemangiosarcoma usually involves the spleen or liver or both. the presence of free abdominal hemorrhage is associated with a malignant tumor in 80% of cases. even when free abdominal hemorrhage is not present, the tumor is malignant in 50% of cases. approximately 66% (two thirds) of masses in the spleen are malignant (hemangiosarcoma, lymphoma, mast cell tumor, malignant fibrous histiocytoma, leiomyosarcoma, fibrosarcoma), and approximately one third are benign (hematoma, hemangioma). hepatocellular carcinoma usually affects one liver lobe (usually the left), and surgery is the treatment of choice. with complete surgical excision, median survival in dogs is longer than 300 days. if diffuse disease is observed at the time of surgery, the prognosis is poor. nonhemorrhagic effusions are associated with mesothelioma, lymphoma, carcinomatosis, or any mass that causes vascular or lymphatic obstruction. clinical signs of respiratory distress and abdominal distention with nonhemorrhagic effusions are usually slowly progressive in onset and not as severe as those observed with hemorrhage. treatment is usually aimed at identification of the underlying cause. obtain a fluid sample via thoracocentesis or abdominocentesis. to obtain further cells for cytologic evaluation, aspirate fluid from the thoracic or abdominal mass with ultrasound guidance. cytologic evaluation of the fluid will often elucidate the causative tumor type. an abdominal ultrasound can determine the degree of metastasis. perform therapeutic abdominocentesis or thoracocentesis if the effusion is causing respiratory difficulty. rapid re-accumulation of the fluid potentially can cause hypoproteinemia and hypovolemic shock. mesothelioma is a rare tumor most commonly observed in urban environments. in humans, mesothelioma has been associated with exposure to asbestos. it is sometimes difficult to differentiate between reactive mesothelial cells and malignant mesothelial cells. treatment is aimed at controlling the neoplastic effusion. intracavitary cisplatin has been demonstrated to slow rates of fluid re-accumulation, but is largely a palliative therapy. lymphoma is another tumor type that can cause thoracic or abdominal effusion. cytologic evaluation of the fluid usually reveals abundant lymphoblasts. treatment with multiagent chemotherapy protocols, with or without adjunctive radiation therapy, can prevent tumor remission and stop fluid accumulation. carcinomatosis occurs as a result of diffuse seeding of the abdominal cavity with malignant carcinomas and has a poor prognosis. carcinomatosis may occur de novo or from 1 metastasis of a primary tumor. treatment consists of fluid removal when respiratory difficulty occurs, with or without intracavitary cisplatin as a palliative measure. cisplatin should never be used in cats due to fatal acute pulmonary edema. clinical signs of hemorrhagic thoracic effusion include acute respiratory distress, anemia, hypovolemic or cardiogenic shock, and collapse. hemorrhagic thoracic effusions are rare in association with neoplastic effusions. a notable exception is intrathoracic hemorrhage in young dogs with osteosarcoma of the rib. hemorrhage can result when a primary lung tumor erodes through a vessel. hemangiosarcoma of the lungs or right auricular area can also result in hemorrhagic thoracic effusion. in many cases, hemorrhage may be confined to the pericardial sac with a right auricular mass, causing a globoid cardiac silhouette on thoracic radiographs. treatment consists of pericardiocentesis (see section on pericardial effusion and pericardiocentesis) and placement of a pericardial window, or the mass may be removed if it is in the right auricular appendage and resectable. although surgery can resolve clinical signs of right-sided heart failure, metastatic disease often develops soon afterward. nonhemorrhagic thoracic effusion is more common than hemorrhagic thoracic effusion, and is caused most commonly by mesothelioma, lymphoma, carcinomatosis, and thymoma. clinical signs develop gradually and include respiratory difficulty, cyanosis, and cough. supplemental oxygen should be administered. in many cases, thoracocentesis can be therapeutic and diagnostic. obtain thoracic radiographs both before and after thoracocentesis to determine whether a mass effect is present. following identification of a cause, definitive therapy can be instituted. mesotheliomas are rare and are associated with diffuse serosal disease. they are more common in dogs than in cats. effusions caused by mesotheliomas can affect the pleural or pericardial cavities. treatment is directed at removing effusion fluid and controlling reaccumulation with use of intracavitary platinum compounds, carboplatin, and cisplatin can be used in dogs. (cisplatin and carboplatin should never be used in cats.) chemical or physical pleurodesis may be helpful in controlling reaccumulation of fluid, but it is very painful in small animal patients. thoracic effusion secondary to lymphoma often is associated with an anterior mediastinal mass. t-cell lymphoma is the most common type of mediastinal mass observed in dogs. b-cell lymphoma is associated with a decreased response to chemotherapy and shorter survival times. treatment consists of combination chemotherapy with or without radiation therapy to decrease mass size. carcinomatosis is a diffuse disease of the pleural cavity that often is a result of metastasis from a primary pulmonary carcinoma or mammary adenocarcinoma. treatment is similar to that for mesothelioma and is aimed at controlling the effusion and delaying its recurrence. thymomas have been documented in both dogs and cats. dogs most commonly present with a cough, while cats present with clinical signs of respiratory distress and a restrictive respiratory pattern associated with the presence of pleural effusion. an anterior mediastinal mass is often observed on thoracic radiographs. in some cases, the pleural effusion must be drained via thoracocentesis before a mass is visible. ultrasound-guided aspiration and cytologic evaluation of the mass reveal a malignant epithelial tumor with small lymphocytes and mast cells. prognosis is good if the tumor can be completely excised. treatment consists of surgical removal with or without presurgical radiation therapy to shrink the mass. paraneoplastic syndromes of myasthenia gravis have been documented in dogs with thymomas. if megaesophagus or aspiration pneumonia is present, the prognosis is more guarded because of the high rate of complications. obstructive lesions affecting the urinary tract can be extramural (intra-abdominal, pelvic, or retroperitoneal) or intramural (urethral, bladder, or urethral wall) . transitional cell 1 carcinoma is the most common type of bladder tumor observed in dogs. prostatic adenocarcinoma, or neoplasia of the sublumbar lymph nodes (lymphoma, adenocarcinoma from apocrine gland adenocarcinoma), also can cause urethral obstruction. treatment is aimed at relieving the obstruction and then attempting to identify the cause of the disease. to alleviate the obstruction, pass a urinary catheter whenever possible. perform cystocentesis only as a last resort because of the risk of seeding the peritoneal cavity with tumor cells if transitional cell carcinoma is the cause of the obstruction. institute supportive therapy including intravenous fluids and correction of electrolyte abnormalities. plain radiographs may reveal a mass lesion or may not be helpful without double contrast cystography. abdominal ultrasound is more sensitive in identifying a mass lesion in the urinary bladder. masses in the pelvic urethra are difficult to visualize with ultrasonography. double contrast cystourethrography is preferred. once the patient is stabilized, biopsy or surgery is indicated to identify the cause of the mass and attempt resection. urine tests for transitional cell carcinoma are available for identification of transitional cell carcinoma in the dog. complete surgical excision of transitional cell carcinoma or removal of benign tumors of the urinary bladder yields a favorable prognosis. poorer prognosis is seen with incomplete excision. many transitional cell carcinomas are located in the trigone region of the bladder and cannot be completely excised. the nonsteroidal antiinflammatory drug piroxicam is helpful in alleviating clinical signs for a reported 7-month median survival. in some dogs, cisplatin and carboplatin may delay recurrence of transitional cell carcinoma. tumors of the prostate gland are always malignant and occur with equal frequency in castrated and uncastrated male dogs. diagnosis of prostatic tumors is based on ultrasonographic evidence of a mass effect or prostatomegaly and on transrectal or transabdominal aspiration or biopsy. surgery, chemotherapy, and radiation therapy generally are unrewarding over the long term, although palliative radiation therapy may relieve clinical signs for 2 to 6 months. luminal tumors of the gastrointestinal tract typically cause obstruction, with slowly progressive clinical signs including vomiting, inappetence, and weight loss, or with acute severe protracted vomiting. extraluminal obstructive lesions usually arise from adhesions, or strangulation may occur, resulting in obstruction. perforation of the mass through the gastric or intestinal wall can cause peritonitis. treatment consists of initial stabilization and rehydration, evaluation for evidence of metastasis, and surgical resection of the affected area in cases of adenocarcinoma, leiomyoma, leiomyosarcoma, and obstructive or perforated lymphoma. gastric and intestinal adenocarcinoma are the most common gastrointestinal tumors observed in dogs. affected animals typically have a history of anorexia, weight loss, and vomiting. obtain an abdominal ultrasound before performing any surgery. fine needle aspirates of the mass and adjacent lymph nodes are usually diagnostic and can determine whether there is local metastasis. many tumors are not resectable, and metastasis occurs in approximately 70% of cases. dogs with smaller tumors that can be resected typically have longer survival times. leiomyosarcomas occur in the intestines of dogs, and carry a more favorable prognosis than adenocarcinoma if the mass can be completely resected. with complete resection, the average survival time is longer than 1 year. the paraneoplastic syndrome of hypoglycemia has been observed with this tumor type. gastrointestinal lymphoma is the most common tumor of the gastrointestinal tract observed in cats. in comparison, it is relatively rare in dogs. unless there is complete obstruction or perforation of the gastrointestinal tract, surgical treatment for gastrointestinal lymphoma is not indicated. rather, multiple chemotherapy drugs are used in combination to achieve remission and resolution of the clinical signs of anorexia, weight loss, and vomiting. treatment responses unfortunately are poor. mast cell tumors of the gastrointestinal tract typically are manifested as gastrointestinal ulceration and hemorrhage in up to 83% of patients. the gastrointestinal hemorrhage that occurs with mast cell tumors results from increased acid secretion as a result of histamine receptor stimulation. treatment consists of histamine or proton pump inhibition (ranitidine, famotidine, cimetidine, or omeprazole). bowel perforation is a rare complication. many chemotherapy agents exert their effects on rapidly dividing normal and neoplastic cells. normal tissues that are commonly affected include the bone marrow, gastrointestinal tract, skin and hair follicles, and reproductive organs. some drugs have unique organspecific toxicities that must be monitored. knowledge and recognition of the expected type and onset of complications can alleviate their severity by rapid treatment, when complications occur (see table 1 -48) . neutropenia is the most common bone marrow toxicity observed secondary to chemotherapy in small animal patients (table 1 -49) . in most cases, the neutropenia is dose-dependent. the nadir, or lowest neutrophil count, is typically observed 5 to 10 days after chemotherapy treatment. once the nadir occurs, bone marrow recovery is observed, with an increase in circulating neutrophils within 36 to 72 hours (table 1 -49) . treatment of myelosuppression is largely supportive to treat or prevent sepsis. prophylactic antibiotics are recommended in the afebrile patient with a neutrophil count <2000/âµl. acceptable antibiotics include trimethoprim-sulfa and amoxicillin-clavulanate. granulocyte-colony stimulating factor (g-csf) (e.g., neupogen) is a recombinant human product that stimulates the release of neutrophils from the bone marrow, and its use shortens the recovery time following myelosuppressive drug therapy. disadvantages of g-csf include antibody production in response to the drug within 4 weeks of use and its high cost. to prevent ongoing neutropenia, subsequent chemotherapy dosages should be decreased by 25%, and the interval in between treatments increased. whenever possible, overlap of myelosuppressive drugs should be avoided. acute gastrointestinal toxicity can occur within 6 to 12 hours after administration of cisplatin and actinomycin d. in many cases, pretreatment with the antiemetics metoclopramide, butorphanol, chlorpromazine, dolasetron or ondansetron can prevent chemotherapyinduced nausea and vomiting. vomiting can also occur as a delayed side effect 3 to 5 days after treatment with doxorubicin (adriamycin), actinomycin d, methotrexate, and cytoxan. in delayed reactions, vomiting and diarrhea are caused by damage to intestinal crypt cells. treatment consists of administration of antiemetics, intravenous fluids, and a bland highly digestible diet. doxorubicin also can cause hemorrhagic colitis within 5 to 7 days of administration. treatment includes a bland diet, metronidazole, and tylosin tartrate (tylan powder). 1 emergency care mild to none not observed vincristine (low-dose), l-asparaginase, glucocorticosteroids moderate 7-10 days melphalan, cisplatin, mitoxantrone, actinomycin d severe 7-10 days doxorubicin, cyclophosphamide, vinblastine 1 paralytic ileus can be observed 2 to 5 days after administration of vincristine. this side effect is more common in humans than animals and can be treated with metoclopramide once a gastrointestinal obstruction has been ruled out. cardiotoxicity doxorubicin (adriamycin) causes a dose-dependent dilative cardiomyopathy when the cumulative dose reaches 100 to 150 mg/m 2 . in many cases, however, clinical signs do not occur until the cumulative dose is 240 mg/m 2 . the myocardial lesions are irreversible. treatment of cardiac dysrhythmias is dependent on the type of dysrhythmia (see section on treatment of dysrhythmias). discontinue doxorubicin and administer diuretics and positive inotropic therapy for dilative cardiomyopathy in order to delay the progression of congestive heart failure (see sections on treatment of congestive heart failure). if abnormalities are shown on electrocardiography performed before beginning therapy, substitute liposome-encapsulated doxorubicin or mitoxantrone substituted in the chemotherapy protocol. cardioprotectant drugs such as vitamin e, selenium, and n-acetyl cysteine have shown some promise in the prevention of doxorubicin-induced cardiotoxicity. cyclophosphamide can cause a sterile hemorrhagic cystitis. damage to the urinary bladder mucosa and vessels is caused by the toxic metabolite acrolein. clinical signs of sterile hemorrhagic cystitis include a history of cyclophosphamide administration, stranguria, hematuria, and pollakiuria. treatment for sterile hemorrhagic cystitis is discontinuation of the drug, treatment of any underlying urinary tract infection with antibiotic therapy based on susceptibility testing, and intravesicle drug administration. in extremely refractory cases, surgical debridement and cauterization of the bladder mucosa may be necessary. prevention of sterile hemorrhagic cystitis includes emptying the bladder frequently and administering the drug in the morning. concurrent administration of prednisone can induce polyuria and polydipsia. if sterile hemorrhagic cystitis occurs, chlorambucil can be substituted as a chemotherapeutic agent. anaphylactic reactions have been observed with the administration of l-asparaginase, adriamycin, etoposide, and paclitaxel. the risk of anaphylaxis increases with repeated administration, although in some animals anaphylaxis will occur on the first exposure to the drug. treatment consists of administration of epinephrine, diphenhydramine, famotidine, and glucocorticosteroids, as with any other life-threatening allergic reaction (see section on treatment of allergic reactions). to decrease the risk of an adverse reaction, give diphenhydramine (2.2 mg/kg im) 15 to 30 minutes before drug administration. slowing the rate of intravenous infusion also can decrease the chance of an anaphylactic reaction. cisplatin can cause a fatal irreversible pulmonary edema in cats, even at low dosages. 5-fluorouracil (5-fu) can cause a severe neurotoxicity in cats that results in ataxia and seizures. never use cisplatin or 5-fu in cats. poisoning cases benefit from a rapid, organized approach. key points in this approach are giving appropriate advice over the telephone, being able to access information sources, and providing appropriate treatment. there are only a few classes of poisons that account for the majority of toxicities reported in dogs and cats. every veterinarian should develop a familiarity with the clinical management of rodenticide and insecticide toxicity and be prepared with antidotes on hand. beyond the most common toxins, the spectrum of possibilities is endless, and the veterinarian must rely on appropriate information resources. it is important to have available a comprehensive source of pharmaceutical and plant identification resources. remarkably, considering the myriad of potentially toxic substances to which an animal can be exposed, relatively few specific antidotes are commonly used in veterinary medicine. because of the lack of specific antidotes, the veterinarian must treat each toxicity with general methods of poison management, applying basic critical care in the treatment of specific clinical signs associated with the poison exposure or toxicity. the adage "treat the patient, not the poison" often comes into play when the exact toxic substance is unknown, or has no specific antidote. before an animal arrives, the staff should be prepared to ask specific questions over the phone, and provide initial advice for clients, particularly if the animal lives some distance from the hospital (box 1-55.) it is important to have access to a database of information on toxic substances. thousands of potentially toxic substances are available on the market today. the american society for the prevention of cruelty to animals (aspca) animal poison control center provides direct access to veterinary toxicologists 24 hours a day, 365 days a year. for additional information, call the nearest veterinary school or emergency center (box 1-56). also, see section 6 for a table of emergency hotlines. check your local telephone book for a poison control center listing under emergency numbers, usually found on the front cover. although these numbers are for human poisonings, they have access to extensive poison and toxin databases and can potentially provide useful information for veterinarians, particularly regarding antidotal substances suitable for out of the ordinary toxins and human medications. information on the toxic ingredients in thousands of medications, insecticides, pesticides, and other registered commercial products has been confidentially placed by the government in these poison control centers. as new products are marketed, information regarding toxin ingredients is forwarded to the centers. various e-mail discussion lists can serve as an informative resource for practitioners, but access generally requires an initial subscription and may have the disadvantage of delayed 1 *do not keep the client on the telephone for too long. lengthy histories can be performed once the animal is at your hospital and you have started to initiate treatment. â�  hair dressing products sometimes have hydrogen peroxide as a 30% w/v; this concentration is not suitable for induction of emesis. is your animal breathing or does it have respiratory difficulty? what is the color of the gums or tongue? is your animal able to walk? is there any vomiting, diarrhea, trembling, or seizures? does it appear lethargic or hyperactive? what is the substance that your animal ingested (was exposed to)? did you witness the ingestion or exposure? how much did the animal consume? how long ago was the exposure? was the substance swallowed, or is it on the animal's skin or eyes? how is the patient acting? how long has the animal been acting that way? or when was the last time you saw your animal act normally? 2. first aid instructions for the client: induce vomiting at home and save the vomitus. never induce vomiting if the patient is depressed, appears comatose, or is actively seizing. if the animal has ingested a caustic substance (strong alkali or acids) or a petroleum-based product (kerosene or turpentine), never recommend induction of emesis. hydrogen peroxide (3% w/v â�  ) 5 ml = 1 tsp/10 lb of body weight can repeat once if no vomiting occurs after 10 minutes 3. remind the owner to bring a sample of the toxin and the vomitus in with the patient. 4. advise the owner to transport the patient as rapidly as possible to the nearest veterinary hospital. 1 response times. they are useful for ideas on standard and long-term therapy, but not emergency stabilization. an exception to this is the veterinary interactive network (vin), which posts message board communications. previous communications from veterinarians who treated a case with the same poison/toxin can be accessed with a subscription. many manufacturers operate an information service about their products. if the product label or name is available, check for a telephone number that may route you to a specialist. there are six essential steps in treating toxicities: 1. performing a physical examination 2. stabilizing the patient's vital signs 3. taking a thorough history 4. preventing continued absorption of the toxin 5. administering specific antidotes when available 6. facilitating clearance or metabolism of the absorbed toxin it is most important to provide symptomatic and supportive care both during and following emergency treatment. immediately on presentation, perform a brief but thorough physical examination. obtain a minimum database as well as serum, urine, or orogastric lavage samples for later toxicologic analyses. it is important at this time to systematically evaluate the patient's physical status, focusing particularly on the toxins most common to a particular geographic location and the organ systems most commonly affected by toxins in veterinary medicinenamely, the neurologic and gastrointestinal tracts. a checklist is useful when performing a complete physical examination (box 1-57). the minimium database includes a urine sample, packed cell volume, total protein, serum urea, and serum glucose. the information obtained from these simple cage-side tests is useful for determining dehydration, hemoconcentration, azotemia (renal or prerenal), and hypo-or hyperglycemia. when appropriate, obtain samples for serum biochemistry profiles, serum electrolytes, blood gases, serum osmolality, a complete hemogram, and coagulation profiles. samples of serum, urine, and any vomitus or orogastric lavage contents should be collected and saved for later toxicologic analyses as required later. stabilization of vital signs includes four major goals of treatment: maintain respiration, maintain cardiovascular function, control cns excitation, and control body temperature. in any patient with clinical signs of respiratory distress or respiratory dysfunction, supplemental oxygen should be administered via flow-by, oxygen hood, oxygen cage, nasal, nasopharyngeal, or transtracheal oxygen sources. ventilatory assistance may be necessary. irritant or corrosive substances can cause damage to the oropharyngeal mucosa to such an extent that airway obstruction occurs. when necessary, a temporary tracheostomy should be performed. arterial blood gases, pulse oximetry, and capnometry may be required to monitor oxygenation and ventilation. at the time of presentation, immediately place an intravenous catheter for administration of intravenous fluids, inotropes, antiarrhythmics, and antidotes, if necessary. the initial fluid of choice is a balanced crystalloid solution such as normosol-r, plasmalyte-m, or lactated ringer's solution. fluid therapy can later be changed based on the patient's acidbase and electrolyte status. some toxins can cause severe dysrhythmias and hyper-or hypotension. monitor blood pressure and perform ecg and correct any abnormalities according to standard therapy (see sections on hypotension and cardiac dysrhythmias). what is the pupil size? what is the pupil reactivity to light? is the ocular examination normal? what is the sensitivity to light or sound? nose: is it moist, dry, bubbling, or frothy, or caked with dirt? throat: are there any characteristic odors on the breath? are there any traces of foreign material on the tongue or in the crevices of the teeth or gums? are there petechiae or ecchymosis on the gums or bleeding from the gumline? what is the mucous membrane color? is it normal and pink, or dark red (injected), pale, or icteric? what is the capillary refill time? is it fast, normal, or slow? what is the patient's heart rate? are there any pulse deficits or dysrhythmias auscultated? what is the patient's blood pressure? what is the quality of the femoral pulse? is it synchronous with the heart rate, or are there dropped pulses? is the pulse bounding, normal, thready, or not palpable? what is the patient's electrocardiogram? what is the patient's respiratory rate? what is the patient's respiratory character? is it normal, fast, shallow, or labored? what do you hear on thoracic auscultation? do you hear harsh airway sounds or pulmonary crackles? what is the patient's rectal temperature? is there excessive salivation? is there evidence of vomiting or diarrhea? is abdominal palpation painful? do the intestinal loops feel normal, or are they fluid-filled or gas-filled? what is the color and consistency of the feces? is there a palpable urinary bladder? is there urine production? what is the color of the urine? peripheral lymph nodes should be normal in poisonings. some toxins cause hemolysis, methemoglobinemia, heinz body anemia, and coagulopathies. whole blood, fresh frozen plasma, packed rbcs, or hemoglobin-based oxygen carriers should be available and used if necessary. treat methemoglobinemia with a combination of ascorbic acid and n-acetylcysteine. many toxins affect the cns, producing clinical signs of excitation and/or seizures. diazepam is the drug of choice for most but not all seizures and tremors. if an animal has cns excitation secondary to the ingestion of selective norepinephrine reuptake inhibitors, avoid using diazepam, as it can potentially exacerbate clinical signs. muscle relaxants such as guaifenesin or methocarbamol may be required to control muscle spasm and tremors associated with some toxicities. consider animals that are in status epilepticus because of toxin exposure at high risk. such patients may not require the full dose of anesthetics or sedatives for seizure control. give phenobarbital (16-20 mg/kg iv) or pentobarbital (3-25 mg/kg iv to effect) for longer-term management of seizures. core body temperature can easily increase or decrease secondary to increased muscle activity or coma. animals may present as hypo-or hyperthermic, depending on the toxin ingested and the stage of toxicity. manage hypothermia with circulating hot water or hot air blankets, or place bubble wrap or saran wrap around the animal's peripheral extremities. manage hyperthermia by placing lukewarm wet towels on the patient until the rectal temperature has decreased to 39.5â°c (103â°f). (see section on of hyperthermia and heat-induced illness). if sedatives or anesthetics have been used, initial hyperthermia may initially resolve due to hypothalamic loss of thermoregulatory control, cool water bathing should not be performed. when the patient is first presented to the veterinarian, have the owner complete a toxicologic history form (figure 1-56) while the animal is being initially assessed and vital signs are being stabilized. when initial stabilization of vital signs has been accomplished, the veterinarian can discuss the patient's history with the owner. in urgent situations, the veterinarian should obtain a brief history as an initial procedure (box 1-58). knowing when the animal was last seen as normal provides a time frame in which the toxic substance was most likely accessed, allowing differential diagnoses to be ranked in some order of probability by rate of onset. in eliciting a history from the owner about the animal's access to poisons, it is important not to take anything for granted. many owners do not realize how poisonous some substances can be, such as insecticide products, garbage, cleaning chemicals, and over-the-counter drugs commonly used by humans. many owners will deny that an animal could have ingested anything that might be toxic, not wanting to believe that the source of the toxin is within their household or property, particularly if recreational drug exposure is suspected. it is useful to phrase questions in a neutral fashion-for example, "is such-and-such present on the premises?" rather than "could the dog have eaten such-and-such?" if recreational drug exposure is suspected, another way to question the owners is to ask whether they have had any guests in their house recently that may have had such-and-such (e.g., marijuana, cocaine, methamphetamine). this approach serves to minimize the suggestion of any bias or preconceptions. when questioning an owner about recent events, it is useful to realize and acknowledge that disruption in the household routine is a distinct factor in the occurrence accidents, including poisonings. examples of such disruptive events include moving from the house, family member is ill or in the hospital, and renovations or recent construction. while these events are occurring, the safeguards followed by a normally careful owner may be disrupted. often, doors or gates may be left open, animals may be outside instead of inside (or vice versa), and inexperienced people may be pet-sitters. once owners are made aware of the importance of assessing such risks, they are often able to provide insight into otherwise baffling circumstances. various methods can be used to remove toxins from the gastrointestinal tract, including emesis, orogastric lavage, cathartics, and enemas. adsorbents, ion exchange resins, or 1 precipitating or chelating agents may be used. removal of a toxic substance from the body surface may be necessary, depending on the toxin.the use of both emesis and orogastric lavage is less and less frequent in human medicine because of the risk of aspiration pneumonia and doubts about their efficacy. currently, management of poisonings in human medicine relies heavily on the use of activated charcoal combined with sorbitol as a cathartic, when appropriate, and supportive critical care. it should be emphasized, however, that the majority of poisonings in humans are due to drug overdoses (illicit or otherwise) (which have a relatively small volume and rapid absorption), for which this treatment is appropriate. furthermore, adoption of the approach rests on the availability of a hospital intensive care infrastructure, which is not always available in veterinary practice. induce emesis if the animal's physiology and neurologic status are stable (i.e., does not have respiratory depression or is not actively seizing, obtunded, unable to swallow or protect its airway). do not administer the same emetic more than twice. if the emetic doesn't work after two doses, give a different emetic or perform orogastric lavage under general anesthesia. emetics are strictly contraindicated for toxicity from petroleum-based products and corrosives because of the risk of aspiration pneumonia and further esophageal damage. emetics may also be of little value if poisons with antiemetic properties have been ingested, such as benzodiazepines, tricyclic antidepressants, and marijuana (table 1-50) . various emetics traditionally have been recommended for use in veterinary medicine. many have fallen out of favor because of the risk of causing adverse consequences and side effects. apomorphine (0.04 mg/kg iv or in the conjunctival sac) remains the standard but is less useful in certain situations in which the poison causes cns excitation or stimulation. it is ineffective in cats. other emetics include xylazine and hydrogen peroxide. do not use table salt because of the risk of severe oropharyngeal irritation and hypernatremia. do not use mustard powder or dishwashing liquid detergent because of the risk of severe oropharyngeal, esophageal, and gastric irritation. orogastric lavage is described in detail in the section on emergency procedures gastric lavage is contraindicated in treatment of toxicity from petroleum-based compounds and acid/alkali ingestion. the procedure can be messy but is very effective if performed within 1 to 2 hours of ingestion of the poison. to prevent aspiration, the patient should be placed under general anesthesia. keep the animal's head lowered during the procedure to prevent aspiration of stomach contents into the trachea. it is sometimes helpful to put the animal in both right and left lateral recumbency to allow complete emptying of gastric contents. repeat the procedure until the fluid runs clear from the stomach. in some cases in which solid material has been ingested, this process can take a long time, so be prepared with a large volume of warm water. following successful evacuation and lavage, administer a slurry of activated charcoal through the orogastric tube before removing it. keep the endotracheal tube cuffed and in place until the animal is semi-conscious, is starting the fight the tube, and is visibly able to swallow and protect its airway. â�¢ when was the animal last seen as normal? â�¢ what clinical signs developed? â�¢ how fast did the clinical signs develop? â�¢ when was the onset of clinical signs? â�¢ what is the animal's activity level? â�¢ does the animal have access to any poisonous substances? â�¢ this includes known toxins or chemicals, over-the-counter or prescription medications (including the owner's), and recreational drugs. enemas are useful to facilitate the action of cathartics and in cases in which the poison is a solid material (e.g., compost, snail bait, garbage) (box 1-59). it is best to use just lukewarm water. commercially available phosphate enema solutions can cause severe electrolyte disturbances (hyperphosphatemia, hyponatremia, hypocalcemia, and hypomagnesemia) and acid-base abnormalities (metabolic acidosis); therefore, they are absolutely contraindicated in small animal patients. use nonsterile nonspermicidal water-soluble lubricants (k-y jelly) old intravenous fluid bag enema bag 60-to 120-ml syringe fluid warm water, with or without hand or liquid dish soap the fluid volume required depends on the size of the animal and the state of its lower gastrointestinal tract. as with orogastric lavage, continue the procedure until the water runs clear. if difficulty is encountered emptying the lower gastrointestinal tract, repeat the enema in 1 or 2 hours, rather than be overzealous on the first attempt. cathartics are useful for hastening gastrointestinal elimination of toxins, and they are particularly useful for elimination of most solid toxicants (e.g., compost, garbage, snail baits). cathartics can be used in conjunction with activated charcoal. do not use magnesium-based cathartics in patients with cns depression, because hypermagnesemia can worsen this disorder and also cause cardiac rhythm disturbances (table 1-51) . activated charcoal (1-4 ml/kg) is the safest and to date the most effective adsorbent for the treatment of ingested toxins. activated charcoal can be administered after emesis or orogastric lavage or can be administered as the sole treatment. various preparations are available on the market, including dry powder, compressed tablets, granules, liquid suspensions, and concentrated paste preparations. commercially available products are relatively inexpensive and should be used whenever possible for ease of administration. vegetableorigin activated charcoal is the most efficient adsorbent and binds compounds with weak, nonionic bonds. some preparations are combined with sorbitol to provide simultaneous administration of an adsorbent and a cathartic; this combination has been shown to be most efficacious. repeated administration of activated charcoal every 4 to 6 hours has been shown to be beneficial in the management of a toxin that undergoes enterohepatic recirculation. administration of an oily cathartic or mixing the activated charcoal with food only serves to reduce the absorptive surface of the activated charcoal and therefore is not recommended. in general, substances that are very soluble and are rapidly absorbed are not well adsorbed by activated charcoal, including alkalis, nitrates, mineral acids, ethanol, methanol, ferrous sulfate, ammonia, and cyanide. kaolin and bentonite are clays that have been used as adsorbents. both are usually less effective than activated charcoal. however, they are reported to be better adsorbents than activated charcoal for the herbicide paraquat. ion exchange resins can ionically bind certain drugs or toxins. cholestyramine is one such resin, commonly used in human medicine to bind intestinal bile acids and thereby decrease cholesterol absorption. its application in toxicology extends to the absorption of fat-soluble toxins such as organochlorine and certain acidic compounds such as digitalis. ion exchange resins also have been used to delay or reduce the absorption of phenylbutazone, warfarin, chlorothiazide, tetracycline, phenobarbital, and thyroid preparations. precipitating, chelating, and diluting agents precipitating, chelating, and diluting agents are used primarily in the management of heavy metal intoxications, such as alkaloids or oxalates. they work by binding preferentially to the metal ion and creating a more soluble complex that is amenable to renal excretion. those chelating agents in common usage are calcium edta, deferoxamine, and d-penicillamine. calcium edta and deferoxamine should both be on hand in the veterinary hospital because they are necessary to treat zinc and iron toxicity, respectively, both of which have a short window of opportunity for therapeutic intervention. d-penicillamine has a wide application for a number of metal toxicities but tends to be used for long-term chronic therapy because it can be administered orally. various agents used for nonspecific dilution of toxins, including milk of magnesia and egg whites, although old-fashioned, still have wide application in many cases in which low-grade irritants have been ingested. bathing the animal is an important aspect of treatment for topical exposures to toxins such as insecticidal products, petroleum-based products, and aromatic oils. bathing an animal is not an innocuous procedure. to avoid hypothermia and shock, use warm water at all times. actively dry the animal to further minimize the risk of hypothermia. when bathing the animal, use rubber gloves and a plastic apron to avoid exposure to noxious agents. in most cases, a mild dishwashing soap is appropriate. medicated or antibacterial shampoos are less appropriate in this situation. for petroleum-based products in particular, dawn dishwashing liquid that "cuts the grease" works well to remove the oils. if dawn is not available, mechanics' hand cleaners or coconut oil-based soaps can be used instead. as a general principle, best results are obtained by barely wetting the patient's fur until the detergent is worked well into the fur, keeping the amount of water to a minimum until ready for the rinse. oil-based paint is best removed by clipping rather than by attempting removal with solvents, because solvents are also toxic. to remove powder products, brush and vacuum the animal before bathing it to eliminate further toxic exposure. with caustic alkaline or acidic products, the primary treatment is to dilute and flush the skin with warm water; do not attempt neutralization. neutralization can cause an exothermic reaction that causes further damage to the underlying tissues. eliminating poison from the eyes for ocular exposures, irrigate the eyes for a minimum of 20 to 30 minutes with warm (body temperature) tap water or warmed 0.9% sterile saline solution. the use of neutralizing substances is not recommended because of the risk of causing further ocular damage. following adequate irrigation, treat chemical burns of the eyes with lubricating ointments and possibly a temporary tarsorrhaphy. atropine may be indicated as a cycloplegic agent. systemic nonsteroidal antiinflammatory drugs can be used to control patient discomfort. daily follow-up examinations are required because epithelial damage may be delayed, especially with alkali burns, and it is difficult to predict the final extent of ocular damage. topical glucocorticosteroids are contraindicated if the corneal epithelium is not intact. if severe conjunctival swelling is present with a corneal ulcer, parenteral glucocorticosteroids can be administered to help alleviate inflammation, but nonsteroidal antiinflammatory drugs should not be used simultaneously due to the risk of gastrointestinal ulceration or perforation. whenever possible, administer specific antidotes to negate the effects of the toxin and prevent conversion of the substance to the toxic metabolite. three categories of agents are used in the management of poisonings. the first category is specific antidotes. unfortunately, few specific antidotes are available for use in veterinary medicine. some "classic" toxins and antidotes are now considered to be rare, such as curare and physostigmine, thallium and prussian blue, and fluoride and calcium borogluconate. these and a few others have been omitted from the table. the second, broader category of antidotes includes those drugs used in the symptomatic management of clinical signs, which are part of our routine veterinary stock. drugs such as atropine, sedatives, steroids, antiarrhythmics, and beta-blockers fall into this category. the third category comprises nonspecific decontaminants such as activated charcoal, cathartics, and emetics. these were discussed previously. many patients benefit from efforts to enhance clearance or metabolism of the absorbed toxins. some specific therapies have been developed for this purpose, including 4-methylpyrazole for ethylene glycol toxicity and specific antibodies such as digibind (digoxin immune fab [ovine]) for digitalis toxicity. other strategies are aimed at promoting renal excretion. renal excretion strategies include diuresis, ion trapping, and peritoneal dialysis or hemodialysis (see section on peritoneal dialysis). diuresis and ion trapping are applicable to a large number of toxins and are discussed here in more detail. other toxins respond to urine acidification and urine alkalinization. enhancing renal excretion of substances is most useful for those organic substances that are present in significant concentrations in the plasma. substances that are non-ionic and lipid-soluble, such as certain herbicides, are likely to be less affected by attempts to promote rapid renal elimination. before starting diuresis or ion trapping, intravenous fluid therapy should be adequate as determined by normal central venous pressure, urine output, and mean arterial blood pressure. if any of these values are less than normal, use other measures to ensure adequate renal perfusion, including but not limited to a constant rate infusion of dopamine. simple fluid diuresis can influence the excretion of certain substances. the use of mannitol as an osmotic diuretic may reduce the passive reabsorption of some toxic substances in the proximal renal convoluted tubule by reducing water reabsorption. dextrose (50%) can be used as an osmotic diuretic. furosemide can be used to promote diuresis, but again, there is no substitute for intravenous fluid therapy. the use of mannitol, dextrose, and furosemide is contraindicated in hypotensive or hypovolemic patients. take care to avoid causing dehydration with any diuretic; central venous pressure monitoring is strongly recommended. ion trapping is based on the principle that ionized substances do not cross renal tubular membranes easily, and are not well reabsorbed. if the urinary ph can be changed so that the toxin's chemical equilibrium shifts to its ionized form, then that toxin can be "trapped" in the urine and excreted. alkaline urine favors the ionization of acidic compounds, and acidic urine favors the ionization of alkaline compounds. those toxins that are amenable to ion trapping are mostly weak acids and weak bases. ammonium chloride can be used to promote urinary acidification. contraindications to the use of ammonium chloride include a preexisting metabolic acidosis, hepatic or renal insufficiency, and hemolysis or rhabdomyolysis leading to hemoglobinuria or myoglobinuria. signs of ammonia intoxication include cns depression and coma. when performing urine acidification, frequently check the serum potassium concentration and urine ph. urine alkalinization can be performed with use of sodium bicarbonate. contraindications to the use of sodium bicarbonate include metabolic alkalosis (particularly with concurrent use of furosemide), hypocalcemia, and hypokalemia. as with urine acidification, monitor the serum potassium concentration and urine ph frequently. the major steps in management of poisonings discussed here must be accompanied by application of the fundamentals of critical care. respiratory and cardiovascular support have been discussed previously. renal and gastrointestinal function and analgesia are particularly important in the management of the poisoning patient. maintenance of renal perfusion is a priority in the poisoning patient. fluid, electrolyte, and acid-base balance must be controlled and be accurate. poisoning patients are at particularly high risk for renal damage and acute renal failure, whether by primary toxic insult to the renal parenchyma or by acute or prolonged renal hypoperfusion. for this reason, a protocol that aims at preventing oliguria and ensuing renal failure is one of the therapeutic strategies that should be routinely employed. this protocol is described in box 1-60. gastrointestinal protectant drugs may be indicated for the management of those poisons that are gastrointestinal irritants or ulcerogenic. commonly used gastroprotectant drugs include cimetidine, ranitidine, famotidine, omeprazole, sucralfate, and misoprostol. antiemetics may be used to suppress intractable vomiting. metoclopramide is commonly used, and it is the drug of choice for centrally mediated nausea. antiemetics that work by different mechanisms can be used in combination as necessary. examples are dopamine 2-receptor antagonists such as prochlorperazine, 5-hydroxytryptamine antagonists such as ondansetron and dolasetron, and h-1 receptor antagonists such as diphenhydramine and meclizine. analgesics are more appropriate to treat poisonings than once thought. common effects of poisons including severe gastroenteritis and topical burns or ulcerations may warrant the use of analgesics. longer-acting analgesics such as morphine, hydromorphone, and buprenorphine are particularly useful. nutritional support may be necessary in the form of enteral or parenteral feeding in patients that have esophageal or gastric damage or that need to be sedated for long periods of time. endoscopy may be useful in assessing the degree of esophageal and gastric damage, particularly after ingestion of caustic substances. introduction: acetaminophen (paracetamol) is the active ingredient in tylenol and many over-thecounter cold products. acetaminophen is converted to n-acetyl-p-benzoquinonimine in the liver, a toxic substance that can cause oxidative injury of red blood cells and hepatocytes. clinical signs of acetaminophen toxicity include respiratory distress from lack of oxygen-carrying capacity, cyanosis, methemoglobinemia (chocolate-brown appearance of the blood and mucous membranes), lethargy, vomiting, and facial and paw swelling (cats). the toxic dose of acetaminophen is >100 mg/kg for dogs, and 50 mg/kg for cats. treatment of acetaminophen toxicity includes induction of emesis or orogastric lavage if the substance has been ingested within 30 minutes. activated charcoal should also be administered. in cases of severe anemia, give supplemental oxygen along with a packed rbc transfusion. administer intravenous fluids to maintain renal and hepatic perfusion. n-acetylcysteine, vitamin c, and cimetidine are the treatments of choice for methemoglobinemia in patients with acetaminophen toxicity. introduction: hydrochloric, nitric, and phosphoric acids cause chemical burns through contact with the skin and/or eyes. localized superficial coagulative necrosis occurs upon contact. usually, the patient's skin is painful to the touch or the animal may lick or chew at an irritated area that is not visible under the haircoat. if the chemical is swallowed, do not induce emesis or perform orogastric lavage, because of the risk of worsening esophageal irritation. rinse the patient's skin and eyes with warm water or warm saline for a minimum of 1 /2 hour. use analgesics and treat corneal ulcers (see section on corneal ulcers) as required. do not attempt chemical neutralization, because of the risk of causing an exothermic reaction and worsening tissue injury. aflatoxin (aspergillus flavus) is found in moldy feed grains. clinical signs of toxicity occur after ingestion and include vomiting, diarrhea, and acute hepatitis; abortion may occur in pregnant bitches. treatment of suspected aflatoxin ingestion consists of gastric decontamination, administration of activated charcoal, intravenous fluids, and hepatic supportive care (s-adenosyl methionine [same], milk thistle). drinking (ethanol), rubbing (isopropyl), and methyl (methanol) alcohols can be harmful if ingested (4.1 to 8.0 g/kg po). all cause disruption of neuronal membrane structure, impaired motor coordination, cns excitation followed by depression, and stupor that can lead to cardiac and respiratory arrest, depending on the amount ingested. affected animals may appear excited and then ataxic and lethargic. contact or inhalant injury can occur, causing dermal irritation and cutaneous hyperemia. methanol also can cause hepatotoxicity. 1 and diarrhea result from muscarinic overload. nicotinic overload produces muscle tremors. toxicity can result in seizures, coma, and death. 1 and cause severe irritation and corrosion of the mucous membranes and skin. some compounds also can cause clinical signs similar to those observed with anticholinesterase compounds, including muscle tremors, seizures, paralysis, and coma. methemoglobinemia can occur. 1 signs of ethylene glycol intoxication and renal impairment or failure, a negative test for the presence of calcium oxalate crystalluria means that there is no more ethylene glycol in the patient's serum because it has all been metabolized. cats are very sensitive to the toxic effects of ethylene glycol. in many cases, cat may have ingested a toxic dose, but because the sensitivity of the assay is low, test results will be negative. lack of treatment can result in death. there are three phases of ethylene glycol intoxication. in the first 1 to12 hours after ingestion (stage i), the patient may appear lethargic, disoriented, and ataxic. in stage ii (12 to 24 hours following ingestion), the patient improves and appears clinically normal. in stage iii (24 to 72 hours following ingestion), the patient demonstrates clinical signs of renal failure (polyuria and polydipsia) that progress to uremic renal failure (vomiting, lethargy, oral ulceration). finally, seizures, coma, and death occur. crosses, old english sheepdogs, and some terriers. clinical signs of ivermectin toxicity include vomiting, ataxia, hypersalivation, agitation, tremors, hyperactivity, hyperthermia, hypoventilation, coma, seizures, signs of circulatory shock, bradycardia, and death. clinical signs often occur within 2 to 24 hours after ingestion or iatrogenic overdose. blood ivermectin levels can be measured, but diagnosis is often made based on clinical signs and knowledge of exposure in predisposed breeds. there is no known antidote. the clinical course can be prolonged for weeks to months before recovery occurs. to treat known exposure, induce emesis or perform orogastric lavage if the substance was ingested was within 1 hour of presentation and the patient is not symptomatic. administer activated charcoal. control seizures with phenobarbital, pentobarbital, or propofol administered as intermittent boluses or as a constant rate infusion. diazepam, which potentially can worsen central nervous stimulation, is contraindicated. administer intravenous fluids to maintain perfusion and hydration, and treat hyperthermia. supportive care may be necessary, including supplemental oxygen (or mechanical ventilation, if necessary), frequent turning of the patient and passive range-of-motion exercises, placement of a urinary catheter to maintain patient cleanliness and monitor urine output, lubrication of the eyes, and parenteral nutrition (see section on rule of twenty). specific antidotes used to treat ivermectin toxicity include physostigmine and picrotoxin. physostigmine therapy was beneficial in some patients for a short period; picrotoxin caused severe violent seizures and therefore should be avoided. introduction d-limonene and linalool are components of citrus oil extracts used in some flea control products. the toxic dose is unknown, but cats appear to be very sensitive to exposure. clinical signs of toxicity include hypersalivation, muscle tremors, ataxia, and hypothermia. treatment of d-limonene and linalool exposure includes treatment of hypothermia, administration of activated charcoal to prevent further absorption, and careful, thorough bathing to prevent further dermal exposure. lead is ubiquitous, and is found in some paints, car batteries, fishing equipment/ sinkers, and plumbing materials. lead can be toxic at doses of 3 mg/kg. if more than than 10-25 mg/kg of lead is ingested, death can occur. lead causes toxicity by inhibiting sulfur-containing enzymes, leading to increased rbc fragility, and cns damage. clinical signs of hyperexcitability, dementia, vocalization, seizures, and lower motor neuron polyneuropathy can occur. affected animals may appear blind, or vomiting, anorexia, and constipation or diarrhea may occur. if lead toxicity is suspected, blood and urine lead levels can be measured. treatment of lead toxicity is supportive and is directed at treatment of clinical signs. control seizures with diazepam or phenobarbital. if cerebral edema is present, administer mannitol (0.5-1.0 g/kg iv), followed by furosemide (1 mg/kg iv 20 minutes after mannitol). sodium or magnesium sulfate should be administered as a cathartic. initiate chelation therapy with dimercaprol, penicillamine, or calcium edta. if a lead object is identified in the gastrointestinal tract on radiographs, remove the object using endoscopy or exploratory laparotomy. 1 hyperthermia, that occurs within 15 -30 minutes of ingestion. diarrhea and convulsions can develop. if hyperthermia is severe, renal failure secondary to myoglobinuria and disseminated intravascular coagulation can result. delayed hepatic failure has been described days after initial recovery. if metaldehyde toxicosis is suspected, analysis of urine, serum, and stomach contents is warranted. to treat metaldehyde toxicity, procure and maintain a patent airway and control cns excitation and muscle tremors. if an animal has just ingested the metaldehyde and is not symptomatic, induce emesis. if clinical signs are present, perform orogastric lavage. both emesis and orogastric lavage should be followed by administration of one dose of activated charcoal. administer intravenous fluids to control hyperthermia, prevent dehydration, and correct acid-base and electrolyte abnormalities. methocarbamol is the treatment of choice to control muscle tremors. diazepam can be used to control seizures if they occur. introduction mushroom ingestion most commonly causes activation of the autonomic nervous system, resulting in tremors, agitation, restlessness, hyperexcitability, and seizures. in some cases slud (salivation, lacrimation, urination, and defecation) is seen. some mushrooms (amanita spp.) also can cause hepatocellular toxicity. clinical signs include vomiting, anorexia, lethargy, and progressive icterus. 1 hemoglobinuria and pigment damage of the renal tubular epithelium. heinz bodies may be observed on cytologic evaluation of the peripheral blood smear. 1 paint in a sorbitol or glycerol carrier. when large quantities of these osmotically active sugars are ingested, osmotic shifts of fluid cause a sudden onset of neurologic or gastrointestinal signs, including ataxia, seizures, and osmotic diarrhea caused by massive fluid shifts into the gastrointestinal tract. the loss of water in excess of solute can result in hypernatremia, a free water deficit, and increased serum osmolality. following orogastric lavage, treatment of ingestion includes administering warm water enemas to help speed the movement of the paintballs through the gastrointestinal tract. do not administer activated charcoal (usually in a propylene glycol carrier), because the compound's cathartic action will pull more fluid into the gastrointestinal tract. baseline electrolytes should be obtained and then carefully monitored. if severe hypernatremia develops, administer hypotonic solutions such as 0.45% nacl + 2.5% dextrose or 5% dextrose in water after calculating the patient's free water deficit. because of the large volume of fluid loss, intravenous fluid rates may seem excessive but are necessary to normalize acid-base, electrolyte, and hydration status. in most cases, these patients can survive if the problem is recognized promptly and corrected with careful electrolyte monitoring, aggressive decontamination strategies, and intravenous fluid support. introduction paraquat, a dipyridyl compound, is the active ingredient in some herbicides. the ld 50 of paraquat is 25-50 mg/kg. paraquat initially causes cns excitation. it also causes production of oxygen-derived free radical species in the lungs, that can lead to the development of acute respiratory distress syndrome. initial clinical signs include vomiting, diarrhea, and seizures. within 2 to 3 days, clinical signs associated with severe respiratory distress and acute respiratory distress syndrome (ards) can develop, leading to death. chronic effects include pulmonary fibrosis, if the patient survives the initial toxicity period. the prognosis for paraquat toxicity is generally unfavorable. to treat paraquat ingestion, remove the toxin from the gastrointestinal tract as rapidly as possible after ingestion. there are no known antidotes. if the compound was ingested within the past hour and the animal is able to protect its airway, induce emesis. otherwise, perform orogastric lavage. activated charcoal is not as effective as clay or bentonite adsorbents for removing this particular toxin. early in the course of paraquat toxicity, oxygen therapy is contraindicated because of the risk of producing oxygen-derived free radical species. later, oxygen therapy, including mechanical ventilation, is necessary if ards develops. experimentally, free radical scavengers (n-acetyl cysteine, vitamin c, vitamin e, same) have been shown to be useful in preventing damage caused by oxygen-derived free radical species. hemoperfusion may be useful in eliminating the toxin, if it is performed early in the course of toxicity. pennyroyal oil is an herbal flea control compound that contains menthofuran as its toxic compound. menthofuran is hepatotoxic and may cause gastrointestinal hemorrhage and coagulopathies. to treat toxicity, administer a cathartic and activated charcoal and antiemetic and gastroprotectant drugs, and thoroughly bathe the animal to prevent further dermal exposure. petroleum distillates: see fuels phenobarbital: see barbiturates phenylcyclidine (angel dust) introduction phenylcyclidine (angel dust) is an illicit recreational drug that causes both cns depression and excitation, decreased cardiac output, and hypotension. to treat phenylcyclidine toxicity, place an intravenous catheter, and administer intravenous fluids and antiarrhythmic drugs to maintain organ perfusion. administer supplemental oxygen, and administer diazepam to control seizures. urine alkalinization can help eliminate the compound. phenylephrine is an î±-adrenergic agonist in many over-the-counter decongestant preparations. clinical signs of intoxication include mydriasis, tachypnea, agitation, hyperactivity, and abnormal flybiting and staring behavior. tachycardia, bradycardia, hypertension, hyperthermia, and seizures can occur. to treat phenylephrine toxicity, place an intravenous catheter and give intravenous fluids to maintain hydration, promote diuresis, and treat hyperthermia. administer prazosin or sodium nitroprusside to treat hypertension, antiarrhythmic drugs as necessary, and diazepam to control seizures. phenylpropanolamine has both î±and î²-adrenergic agonist effects, and is used primarily in the treatment of urinary incontinence in dogs. the drug was taken off of the market for use in humans because of the risk of stroke. clinical signs of phenylpropanolamine intoxication include hyperactivity, hyperthermia, mydriasis, tachyarrhythmias or bradycardia, hypertension, agitation, and seizures. to treat toxicity, administer prazosin or nitroprusside to control hypertension, a betablocker (esmolol, propranolol, atenolol) to control tachyarrhythmias, diazepam to control seizures, and intravenous fluids to maintain hydration and promote diuresis. urine acidification may aid in facilitating excretion. if bradycardia occurs, do not use atropine. pseudoephedrine is an î±and î²-adrenergic agonist that is a component of many over-thecounter decongestants and is used in the manufacture of crystal methamphetamine. clinical signs of toxicity include severe restlessness, tremors, mydriasis, agitation, hyperthermia, tachyarrhythmias or bradycardia, hypertension, and seizures. to treat toxicity, administer activated charcoal, intravenous fluids to promote diuresis and treat hyperthermia, chlorpromazine to combat î±-adrenergic effects, a beta-blocker (propranolol, esmolol, atenolol) to treat î²-adrenergic effects, and cyproheptadine (per rectum) to combat serotoninergic effects. piperazine is a gaba agonist, and causes cervical and truncal ataxia, tremors, seizures, coma, and death. salt used for thawing ice commonly contains calcium chloride, a compound that has a moderate toxic potential. calcium chloride produces strong local irritation and can cause gastroenteritis and gastrointestinal ulcers if ingested. respiratory emergencies consist of any problem that impairs delivery of oxygen to the level of the alveoli or diffusion of oxygen across the alveolar capillary membrane into the pulmonary capillary network. decreased respiratory rate or tidal volume can result in hypoxia and buildup of carbon dioxide, or hypercarbia, leading to respiratory acidosis. conditions most frequently encountered result in airflow obstruction, prevention of normal lung expansion, interference with pulmonary gas exchange (ventilation-perfusion mismatch), and alterations of pulmonary circulation. evaluation of the patient with respiratory distress is often challenging, because the most minimal stress can cause rapid deterioration, or even death in critical cases. careful observation of the patient from a distance often allows the clinician to determine the severity of respiratory distress and localize the lesion based on the patient's respiratory pattern and effort. animals in respiratory distress often have a rapid respiratory rate (>30 breaths per minute). as respiratory distress progresses, the patient may appear anxious and start openmouth breathing. the animal often develops an orthopneic posture, characterized by neck extension, open-mouthed breathing, and elbows abducted or pulled away from the body. cyanosis of the mucous membranes often indicates extreme decompensation. clinical signs of respiratory distress can develop acutely, or from decompensation of a more chronic problem that was preceded by a cough, noisy respirations, or exercise intolerance. localization of the cause of respiratory distress is essential to successful case management. in any patient with clinical signs of respiratory distress, the differential diagnosis should include primary pulmonary parenchymal disease, airway disease, thoracic cage disorders, congestive heart failure, dyshemoglobinemias (carbon monoxide, methemoglobin), and anemia. careful observation of the patient's respiratory pattern can aid in making a diagnosis of upper airway disease/obstruction, primary pulmonary parenchymal disease, pleural space disease, and abnormalities of the thoracic cage. it is often helpful to rest a hand on the patient and breathe along with the patient's effort, to confirm the periods of inhalation and exhalation. the pharynx, larynx, and extrathoracic trachea comprise the upper airway. obstructive lesions are associated with a marked inspiratory wheeze or stridor and slow deep inspiratory effort. auscultation of the larynx and trachea may reveal more subtle obstructions of normal air flow. stridor can usually be auscultated without the use of a stethoscope. lung sounds are usually normal. the neck should be carefully palpated for a mass lesion, tracheal collapse, and subcutaneous emphysema. subcutaneous emphysema suggests tracheal damage or collapse secondary to severe trauma. in some cases, there is a history of voice, or bark, change secondary to laryngeal dysfunction. differential diagnosis is usually based on the patient's signalment, history, and index of suspicion of a particular disease process. differential diagnoses of upper airway obstruction are listed in box 1-61. diseases of the pleural space often are associated with a restrictive respiratory pattern. inspiratory efforts are short, rapid, and shallow, and there is often a marked abdominal push. the pattern has been referred to as a choppy "dysynchronous" respiratory pattern. depending on the disease present, lung sounds may be muffled ventrally and enhanced dorsally. percussion of the thorax reveals decreased resonance if fluid is present. increased resonance is present with pneumothorax. decreased compressibility of the anterior thorax may be present with an anterior mediastinal mass lesion, particularly in cats and ferrets. a pneumothorax or diaphragmatic hernia is commonly associated with evidence of trauma, with or without rib fractures. respiratory distress due to hemothorax may be exacerbated by anemia. differential diagnoses for patients with evidence of pleural cavity disease include pneumothorax, diaphragmatic hernia, neoplasia, and various types of pleural effusion. primary pulmonary parenchymal disease can involve the intrathoracic airways, alveoli, interstitial space, and pulmonary vasculature. a rapid, shallow, restrictive respiratory pattern may be observed with a marked push on exhalation, particularly with obstructive airway disease such as chronic bronchitis (asthma) in cats. crackles or wheezes are heard on thoracic auscultation. differential diagnoses for pulmonary parenchymal disease include cardiogenic and noncardiogenic pulmonary edema, pneumonia, feline bronchitis (asthma), pulmonary contusion, aspiration pneumonitis, pulmonary thromboembolism, neoplasia, infection (bacterial, fungal, protozoal, viral) , and/or chronic bronchitis. other abnormal respiratory patterns may be evident, and warrant further consideration. tachypnea present in the absence of other signs of respiratory distress can be a normal response to nonrespiratory problems, including pain, hyperthermia, and stress. a restrictive respiratory pattern with minimal thoracic excursions can be associated with diseases of neuromuscular function, including ascending polyradiculoneuritis, botulism, and tick paralysis. if adequate ventilation cannot be maintained by the patient, mechanical ventilation may be indicated. kussmaul respiration manifests as very slow, very deep respirations when a metabolic acidosis is present. this type of respiratory pattern typically is observed in patients with severe diabetic ketoacidosis and renal failure in a compensatory attempt to blow off carbon dioxide. cheyne-stokes respiration is usually observed with a defect in the central respiratory control center. the classic pattern of cheyne-stokes respiration is normal or hyperventilation followed by a period of apnea or hypoventilation. in cases of lower cervical cord damage or damage to the central respiratory control center in the cns, the diaphragm alone may assume most of the ventilatory movement. with diaphragmatic fatigue, severe hypoventilation and resultant hypoxemia may require mechanical ventilation. immediate management of any patient in respiratory distress is to minimize stress at all costs. relatively benign procedures such as radiography or intravenous catheter placement can be fatal in patients with severe respiratory compromise. stabilization should always precede further diagnostic evaluation. in some cases, sedation may be required before performing any diagnostics, to prevent further stress. all patients should receive some form of supplemental oxygen, either by mask, cage, or flow-by techniques. in cases in which a severe pneumothorax or pleural effusion is suspected, perform therapeutic and diagnostic thoracocentesis bilaterally to allow lung re-expansion and alleviate respiratory distress, whenever possible. if thoracocentesis alone is not effective at maintaining lung re-expansion, place a thoracostomy tube (particularly in cases of tension pneumothorax). if hypovolemic/ hemorrhagic shock is present, initiate treatment while stabilizing the respiratory system (see section on shock). if an animal is suspected of having an upper airway obstruction, reestablish airflow. in cases of laryngeal paralysis, tracheal collapse, and brachycephalic airway syndrome, sedation is often very useful in alleviating the distress of airway obstruction. in cases of laryngeal collapse, however, sedation may make the condition worse. if laryngeal edema is severe, administer a dose of short-acting glucocorticosteroids (dexamethasone sodium phosphate) to decrease laryngeal inflammation and edema. if a foreign body is lodged in the pharynx, perform the heimlich maneuver by thrusting bluntly several times on the patient's sternum. objects such as balls or bones may be small enough to enter the larynx but too large to be expelled, and will require rapid-acting general anesthesia to facilitate dislodgement and removal. if the obstruction cannot be removed, bypassing the obstruction with an endotracheal tube or temporary tracheostomy should be considered. in an emergency, a temporary transtracheal oxygen catheter can quickly be placed in the following manner. connect a 20-or 22-gauge needle to a length of intravenous extension tubing and a 3-ml syringe. place the male connector of the syringe into the female portion of the extension tubing. cut off the syringe plunger and connect the resulting blunt end to a length of flexible tubing attached to a humidified oxygen source. run the oxygen at 10 l/minute to provide adequate oxygenation until a tracheostomy can be performed. (see sections on oxygen supplementation and tracheostomy). once the animal's condition has been stabilized, specific diagnostic tests, including arterial blood gas analyses, thoracic radiographs, and/or transtracheal wash, can be performed, depending on the patient's condition and needs. specific therapies for management of upper airway obstruction, pleural space disease, and pulmonary disease are discussed next. upper airway obstruction can occur as a result of intraluminal or extraluminal mass lesions or foreign bodies in the oropharynx (abscess, neoplasia), laryngeal paralysis, trauma, and anatomic abnormalities. clinical signs of an upper airway obstruction are associated with an animal's extreme efforts to inhale air past the obstruction. marked negative pressure occurs in the extrathoracic airways and can cause worsening of clinical signs. mucosal edema and inflammation further worsen the obstruction. therapy for upper airway obstruction is aimed at breaking the cycle of anxiety and respiratory distress. administer the anxiolytic tranquilizer acepromazine (0.02-0.05 mg/kg iv, im, sq) to decrease patient anxiety. many animals develop hyperthermia from increased respiratory effort and extreme anxiety. implement cooling measures in the form of cool intravenous fluids and wet towels soaked in tepid water placed over the animal (see section on hyperthermia). administer supplemental oxygen in a manner that is least stressful for the animal. short-acting glucocorticosteroids can also be administered (dexamethasone sodium phosphate, 0.25 mg/kg iv, sq, im) to decrease edema and inflammation. if the airway obstruction is severe and there is no response to initial measures to alleviate anxiety and decrease inflammation, establish control of ventilation by placement of an endotracheal tube (see section on endotracheal intubation), tracheal oxygen catheter, or temporary tracheostomy. to obtain airway control, administer a rapid-acting anesthetic (propofol, 4-7 mg/kg iv to effect), and intubate with a temporary tracheostomy. an intratracheal oxygen catheter can be placed with sedation and/or a local anesthetic (see technique for transtracheal wash). laryngeal paralysis is a congenital or acquired condition that occurs primarily in largebreed dogs secondary to denervation of the arytenoid cartilages by the recurrent laryngeal nerve. congenital laryngeal paralysis occurs in the bouvier des flandres, siberian husky, and bull terrier. acquired laryngeal paralysis occurs in labrador retrievers, saint bernards, and irish setters. acquired laryngeal paralysis can be idiopathic, acquired secondary to trauma to the recurrent laryngeal nerve, or can be a component of systemic neuromuscular disease. although rare, this condition also occurs in cats. with dysfunction of the recurrent laryngeal nerve, the intrinsic laryngeal muscles atrophy and degenerate. as a result, the vocal folds and arytenoid cartilage move in a paramedian position within the airway and fail to abduct during inhalation, causing airway obstruction. laryngeal paralysis can be partial or complete, unilateral or bilateral. in many cases, a change in bark is noted prior to the development of clinical signs of respiratory distress or exercise intolerance. when a patient presents with severe inspiratory stridor (with or without hyperthermia) initiate stabilization with anxiolytic tranquilizers, supplemental oxygen, and cooling measures. once the patient's condition has been stabilized, definitive measures to accurately document and assess the patient's airway should be considered. place the patient under very heavy sedation with short-acting barbiturates or propofol (4-7 mg/kg iv) and observe the arytenoid cartilages closely in all phases of respiration. administer just enough drug to allow careful examination without getting bitten. if the arytenoid cartilages do not abduct during inhalation, administer dopram (doxapram hydrochloride, 1-5 mg/kg iv) to stimulate respiration. absent or paradoxical laryngeal motion (closed during inspiration and open during exhalation) is characteristic of laryngeal paralysis. correction of the defect involves documentation and treatment of any underlying disorder and surgical repair of the area to open the airway. partial laryngectomy, arytenoid lateralization ("tie-back" surgery), or removal of the vocal folds has been used with some success. aspiration pneumonitis is common following these procedures. brachycephalic airway syndrome is associated with a series of anatomic abnormalities that collectively increase resistance to airflow. affected animals typically have stenotic nares, an elongated soft palate, and a hypoplastic trachea. components of the syndrome can occur alone or in combination. in severe cases, laryngeal saccular edema and eversion, and eventual pharyngeal collapse, can occur secondary to the severe increase in intrathoracic airway pressure required to overcome the resistance of the upper airways. specific airway anomalies can be identified with general anesthesia and laryngoscopy. severe respiratory distress should be treated as discussed previously. treatment requires surgical correction of the anatomic abnormalities. in animals with laryngeal collapse, surgical correction may not be possible, and a permanent tracheostomy may be required. because an elongated soft palate and stenotic nares can be identified before the onset of clinical signs, surgical correction to improve airflow when the animal is young may decrease the negative intra-thoracic pressure necessary to move air past these obstructions. the chronic consequences of everted laryngeal saccules and laryngeal collapse potentially can be prevented. tracheal collapse is common in middle-aged and older toy and small-breed dogs. the owner typically reports a chronic cough that is readily induced by excitement or palpation of the trachea. the cough often sounds like a "goose honk." diagnostic confirmation is obtained by lateral radiography or fluoroscopy of the cervical and thoracic trachea during all phases of respiration. acute decompensation is uncommon but does occur, particularly with excitement, exercise, and increased environmental temperatures or ambient humidity. therapy of the patient with acute respiratory distress secondary to tracheal collapse includes sedation, administration of supplemental oxygen, and provision of cooling measures to treat hyperthermia. cough suppressants (hydrocodone bitartrate-homatropine methylbromide, 0.25 mg/kg po q8-12h, or butorphanol, 0.5 mg/kg po q6-12h) are useful. tracheal collapse is a dynamic process that usually involves both the upper and lower airways. because of this, bypassing the obstruction is often difficult. tracheal stents have been 256 1 emergency care 1 used with limited success in combination with treatment of chronic lower airway disease. crush or bite injuries to the neck can result in fractures or avulsion of the laryngeal or tracheal cartilages. bypassing the obstructed area may be necessary until the patient is stable and can undergo surgical correction of the injury. if there is avulsion of the cranial trachea, it may be difficult to intubate the patient. a long, rigid urinary catheter can be inserted past the area of avulsion into the distal segment, and an endotracheal tube passed over the rigid catheter, to establish a secure airway. neck injury can also result in damage to the recurrent laryngeal nerve and laryngeal paralysis. foreign bodies can lodge in the nasal cavity, pharynx, larynx, and distal trachea. signs of foreign bodies in the nares include acute sneezing and pawing at or rubbing the muzzle on the ground. if the object is not removed, sneezing continues and a chronic nasal discharge develops. respiratory distress is uncommon, but the foreign body is severely irritating. pharyngeal and tracheal foreign bodies can cause severe obstruction to airflow and respiratory distress. diagnosis of a foreign body is based on the patient history, physical examination findings, and thoracic or cervical radiographs. smaller foreign bodies lodged in the distal airways may not be apparent radiographically but can cause pulmonary atelectasis. foreign bodies of the nose or pharynx can often be removed with an alligator forceps with the patient under anesthesia. if removal is not possible with a forceps, flushing the nasal cavity from cranial to caudal (pack the back of the mouth with gauze to prevent aspiration) can sometimes dislodge the foreign material into the gauze packing. rhinoscopy may be necessary. if an endoscope is not available, an otoscope can be used. foreign objects lodged in the trachea can be small and function like a ball valve during inhalation and exhalation, causing episodic hypoxia and collapse. when attempting to remove these objects, suspend the patient with its head down. remove the object with an alligator forceps, using a laryngoscope to aid in visualization. foreign bodies lodged in the trachea or bronchi require removal with endoscopic assistance. nasopharyngeal polyps (in cats, tumors, obstructive laryngitis, granulomas, abscesses, and cysts) can cause upper airway obstruction. clinical signs are usually gradual in onset. the lesions can be identified through careful laryngoscopic examination performed with the patient under general anesthesia. the nasopharynx above the soft palpate should always be included in the examination. pedunculated masses and cysts are excised at the time of evaluation. biopsy of diffusely infiltrative masses is indicated for histologic examination and prognosis. it is impossible to distinguish obstructive laryngitis from neoplasia based on gross appearance alone. whenever possible, material should be collected from abscesses and granulomas for cytologic evaluation and bacterial culture. extraluminal masses impinge on and slowly compress the upper airways, resulting in slow progression of clinical signs. masses are usually identified by palpation of the neck. enlarged mandibular lymph nodes, thyroid tumors, and other neoplasms may be present. diagnosis is usually based on a combination of radiography and ultrasonography. ct and/or mri are helpful in identifying the full extent and invasiveness of the lesion. definitive diagnosis is made with a fine-needle aspirate or biopsy. many thyroid tumors bleed excessively. the inside of each side of the hemithorax is covered in parietal pleura. the lung lobes are covered in visceral pleura. the two surfaces are in close contact with each other, and are contiguous at the hilum under normal circumstances. pneumothorax refers to free air within the pleural space, accumulating in between the parietal and visceral pleura. the term pleural effusion refers to fluid accumulation in that area but does not reflect the amount or type of fluid present. the mediastinal reflections of the pleura typically are thin in dogs and cats, and usually, but not always, connect. bilateral involvement of pneumothorax or pleural effusion is common. both pneumothorax and pleural effusion compromise the lungs' ability to expand and result in hypoxia and respiratory distress. pneumothorax can be classified as open versus closed, simple versus complicated, and tension. an open pneumothorax communicates with the external environment through a rent in the thoracic wall. a closed pneumothorax results from tears in the visceral pleura but does not communicate with the outside. a tension pneumothorax occurs as a result of a tear in the lung or chest wall that creates a flap valve, such that air is allowed to leave the lung and accumulate in the pleural space during inhalation, and closes to seal off exit of air from the pleural space during exhalation. tension pneumothorax can cause rapid decline in cardiopulmonary status and death if not recognized and treated immediately. a simple pneumothorax is one that can be controlled with a simple thoracocentesis. complicated pneumothorax involves repeated accumulation of air, requiring placement of a thoracic drainage catheter. in many cases, pneumothorax develops as a result of trauma. spontaneous pneumothorax occurs with rupture of cavitary lesions of the lung that may be congenital or acquired as a result of prior trauma, heartworm disease, airway disease (emphysema), paragonimiasis, neoplasia, or lung abscess. pneumothorax also rarely occurs as a result of esophageal tears or esophageal foreign bodies. rapid circulatory and respiratory compromise following traumatic pneumothorax can develop as a result of open or tension pneumothorax, rib fractures, airway obstruction, pulmonary contusions, hemothorax, cardiac dysrhythmias, cardiac tamponade, and hypovolemic shock. any patient that is rapidly decompensating after a traumatic episode must be quickly assessed, and emergency therapy initiated (see section on immediate management of trauma, a crash plan). diagnosis of pneumothorax is usually made based on a history of trauma, a rapid, shallow, restrictive respiratory pattern, and muffled heart and lung sounds on thoracic auscultation. the clinical signs and history alone should prompt the clinician to perform a bilateral diagnostic and therapeutic thoracocentesis before taking thoracic radiographs (see section on thoracocentesis). the stress of handling the patient for radiography can be deadly in severe cases of pneumothorax. although the mediastinum on both sides of the thorax connects, it is necessary to perform thoracocentesis on both sides to ensure maximal removal of free air in the pleural space and allow maximal lung expansion. if negative pressure cannot be obtained, or if the patient rapidly reaccumulates air, place a thoracostomy tube connected to continuous suction. (see section on thoracostomy tube placement). treat all penetrating wounds to the thorax as open sucking chest wounds unless proved otherwise. to "close" an open sucking chest wound, clip the fur around the wound as quickly as possible, and place sterile lubricant jelly or antimicrobial ointment circumferentially around the wound. cut a sterile glove to provide a covering. place the covering over the wound, making sure to cover all of the sterile lubricant, thus creating a seal to close the wound temporarily from the external environment. evaluate the patient's thorax via thoracocentesis while placing a thoracostomy tube. once the patient is stable, the open chest wound can be surgically explored, lavaged, and definitively corrected. all animals with open chest wounds should receive antibiotics (first-generation cephalosporin) to prevent infection. following stabilization, radiographs can be taken and evaluated. pneumothorax is confirmed by evidence of elevation of the cardiac silhouette above the sternum, increased density of the pulmonary parenchymal tissue, free air in between the parietal and visceral 1 pleura (making the outline of the lungs visible), and absence of pulmonary vascular structures in the periphery. parenchymal lesions within the lungs are best identified after as much air as possible has been removed from the thorax. obtain left and right lateral and ventrodorsal or dorsoventral views. a standing lateral view may reveal air-or fluid-filled cavitary masses. if underlying pulmonary disease is suspected as a cause of spontaneous pneumothorax, a transtracheal wash, fecal flotation, and heartworm test may be indicated. treatment of pneumothorax includes immediate bilateral thoracocentesis, covering of any open chest wounds, administration of supplemental oxygen, and placement of a thoracostomy tube if negative pressure cannot be obtained or if air rapidly reaccumulates. serial radiography, ct, or mri should be performed in dogs with spontaneous pneumothorax, because the condition can be associated with generalized pulmonary parenchymal disease. strict cage rest is required until air stops accumulating and the thoracostomy tube can be removed. the patient's chest tube should be aspirated every 4 hours after discontinuing continuous suction. if no air reaccumulates after 24 hours, the chest tube can be removed. exercise restriction is indicated for a minimum of 1 week. if bullae or mass lesions are present, exploratory thoracotomy should be considered as a diagnostic and potentially therapeutic option for long-term management in prevention of recurrence. pleural fluid cytologic analysis is indicated for all patients with pleural effusion before administration of antibiotics. the general term pleural effusion means a collection of fluid in the space between the parietal and visceral pleura but does not indicate what kind or how much fluid is present. clinical signs associated with pleural effusion depend on how much fluid is present, and how rapidly the fluid has accumulated. clinical signs associated with pleural effusion include respiratory distress, reluctance to lie down, labored breathing with an abdominal component on exhalation, cough, and lethargy. auscultation of the thorax may reveal muffled heart and lung sounds ventrally and increased lung sounds dorsally, although pockets of fluid may be present, depending on the chronicity of the effusion. percussion of the thorax may reveal decreased resonance. in stable patients, the presence of pleural effusion can be confirmed radiographically. radiographic confirmation of the pleural effusion should include right and left lateral and dorsoventral or ventrodorsal views. a handling or standing lateral view should be obtained if an anterior mediastinal mass is suspected. the standing lateral view will allow the fluid to collect in the costophrenic recess. in patients with respiratory distress, muffled heart and lung sounds, and suspicion of pleural effusion, thoracocentesis should be performed immediately. thoracocentesis can be both therapeutic and diagnostic. radiography is contraindicated because the procedure can cause undue stress and exacerbation of clinical signs in an unstable patient. pleural effusion can cause severe respiratory distress, and can be the result of a number of factors that must be considered when implementing an appropriate treatment plan. pathology of the pleura is almost always a secondary process except for primary bacterial pleuritis and pleural mesotheliomas. causes of pleural effusion in the cat and dog include pyothorax, feline infectious peritonitis, congestive heart failure, chylothorax, heartworm disease, hemothorax, hypoalbuminemia, lung lobe torsions, neoplasia, diaphragmatic hernia, and pancreatitis (box 1-62). in stable animals, diagnosis of pleural effusion can be made based â�¢ imbalance of transpleural or hydrostatic or protein osmotic forces â�¢ change in membrane permeability â�¢ decrease in rate of fluid reabsorption â�¢ combination of foregoing mechanisms on thoracic radiography or ultrasound. thoracic radiographs can show whether the pleural effusion is unilateral or bilateral. effusions in dogs and cats are usually bilateral. the lung parenchyma and the cardiac silhouette cannot be fully evaluated until most of the fluid has been evacuated from the pleural cavity. following thoracocentesis, radiography should be performed with left and right lateral and ventrodorsal or dorsoventral views. in cases of suspected heart failure, echocardiography also is necessary. pleural fluid cytologic analysis is indicated for all patients with pleural effusion. collect specimens before administering antibiotics, whenever possible, because treatment with antibiotics can make a septic condition (pyothorax) appear nonseptic. the remainder of the diagnostic workup and treatment is based on the type of fluid present (table 1 -52). the fluid may be a transudate, nonseptic exudate, septic exudate, chylous, hemorrhagic, or neoplastic. ultrasonographic evaluation of the thorax can be helpful in identifying intrathoracic masses, diaphragmatic hernias, lung lobe torsions, and cardiac abnormalities. unlike radiography, ultrasonography is facilitated by the presence of fluid in the pleural space. pyothorax refers to a septic effusion of the pleural cavity. the infection is generally the result of a combination of aerobic and anaerobic bacteria. rarely, fungal organisms are present. the source of the underlying organisms is rarely identified, particularly in cats, but can be caused by penetrating wounds through the chest wall, esophagus, migrating foreign bodies (especially grass awns), or primary lung infections. the most common organisms associated with pyothorax in the cat are pasteurella, bacteroides, and fusobacterium. fever is often present in addition to clinical signs of pleural effusion. septic shock is ununcommon. diagnosis of pyothorax is made based on cytologic analysis and the demonstration of intracellular and extracellular bacteria, toxin neutrophils and macrophages, and sometimes the presence of sulfur granules. gram stains of the fluid can assist in the initial identification of some organisms. bacterial cultures are indicated for bacteria identification and antibiotic susceptibility testing. administration of antibiotics before cytologic evaluation can cause a septic effusion to appear nonseptic. emergency treatment for pyothorax involves placement of an intravenous catheter, intravenous fluids to treat hypovolemic shock, and broad-spectrum antibiotics (ampicillin, 22 mg/kg iv q6h, and enrofloxacin, 10 mg/kg iv q24h). chloramphenicol also is an appropriate antibiotic to use for penetration into pockets of fluid. administration of a beta-lactam antibiotic (ampicillin or amoxicillin) with a beta-lactamase inhibitor (amoxicillin clavulanate or ampicillin sulbactam) is helpful in achieving better coverage of bacteroides spp. treatment of pyothorax differs in the cat and dog. in the cat, placement of one or two thoracic drainage catheters is recommended to allow continuous drainage of the intrathoracic abscess. inadequate drainage can result in treatment failure. fluid should be evaluated and the pleural cavity lavaged with 10 ml/kg of warmed 0.9% saline or lactated ringer's solution every 8 hours. approximately 75% of the infused volume should be recovered after each lavage. in dogs, or in cats with refractory pyothorax, perform an exploratory thoracotomy to remove any nidus of infection. rarely a foreign body is visible that can be removed at the time of surgery, but this finding is rare. antibiotics are indicated for a minimum of 6 to 8 weeks after removal of the thoracostomy tube. early diagnosis and aggressive treatment result in a good prognosis in the majority of patients with pyothorax. in cats, clinical signs of ptyalism and hypothermia at the time of presentation worsen the prognosis. chylothorax refers to the abnormal accumulation of chyle (lymphatic fluid) in the pleural cavity. the cisterna chili is the dilated collection pool of lymphatic ducts in the abdomen that accumulate chyle prior to entry into the thoracic duct located within the thoracic cavity. the thoracic duct enters the thorax at the aortic hiatus. numerous tributaries or collateral ducts exist. the functions of the lymphatic vessels collectively serve to deliver triglycerides and fat-soluble vitamins into the peripheral vascular circulation. damage of the thoracic duct or lymphatic system or obstruction to lymphatic flow can result in the development of chylous effusion in the pleural or peritoneal space. it is difficult to identify chylous effusions based on their milky appearance alone. to identify a chylous effusion versus a pseudochylous effusion, the triglyceride and cholesterol levels of the fluid must be compared with those of peripheral blood. chylous effusions have a higher triglyceride and lower cholesterol levels than peripheral blood. pseudochylous effusions have a higher cholesterol and lower triglyceride levels than peripheral blood. disease processes that can result in chylous effusions are listed in the box 1-63. clinical signs associated with chylous effusion are typical of any pleural effusion and of the disease process that caused the effusion. weight loss may be evident, depending on the chronicity of the process. the diagnosis is made based on thoracocentesis, cytology, and biochemical evaluation of the fluid (i.e., triglyceride and cholesterol levels). the fluid often appears milky or bloodtinged but can be clear if the patient has significant anorexia. typical cytologic characteristics are listed in table 1 -52. lymphangiography can be used to confirm trauma to the thoracic duct, but this is usually not necessary unless surgical ligation is going to be attempted. the diagnostic evaluation must also attempt to identify an underlying cause. therapy for chylothorax is difficult and primarily involves documentation and treatment of the underlying cause. if an underlying cause is not found, treatment is largely supportive and consists of intermittent thoracocentesis to drain the fluid as it accumulates and causes respiratory dysfunction, nutritional support, and maintenance of fluid balance. a variety of surgical techniques, including ligation of the thoracic duct, pleural-peritoneal shunts, and pleurodesis, have been attempted but have had limited success. most recently, the combination of thoracic duct ligation with subtotal pericardectomy has been shown to improve surgical success rates in the treatment of chylothorax. rutin, a bioflavinoid, has been used with limited success in the treatment of idiopathic chylothorax in cats. prognosis in many cases of chylothorax is guarded. extensive hemorrhage into the pleural cavity can cause fulminant respiratory distress due to sudden hypovolemia and anemia and interference with lung expansion. hemothorax typically is associated with trauma, systemic coagulopathy, lung lobe torsions, and erosive lesions within the thorax (usually neoplasia). diagnosis of hemothorax involves obtaining a fluid sample via thoracocentesis. hemorrhagic effusion must be differentiated from systemic blood inadvertently collected during the thoracocentesis procedure. unless the hemorrhage is peracute, fluid in cases of hemothorax is rapidly defibrinated and will not clot, has a packed cell volume less than that of venous blood, contains rbcs and macrophages. hemorrhagic effusions also usually contain a disproportionately higher number of white blood cells compared with peripheral blood. hemothorax commonly is the sole clinical sign observed in animals with vitamin k antagonist rodenticide intoxication and systemic coagulopathy. whenever an animal presents with signs of a hemorrhagic pleural effusion, perform coagulation testing immediately to determine whether a coagulopathy exists. the prothrombin time test is fast and can be performed as a cage-side test (see section on coagulopathy). therapy for hemorrhagic pleural effusions should address the blood and fluid loss. administer intravenous crystalloid fluids and rbc products (see section on transfusion therapy). when necessary, administer coagulation factors in the form of fresh whole blood or fresh frozen plasma, along with vitamin k 1 (5 mg/kg sq in multiple sites with a 25-gauge needle). if severe respiratory distress is present, evacuate the blood within the pleural space via thoracocentesis until clinical signs of respiratory distress resolve. fluid that remains aids in the recovery of the patient, because rbcs and proteins eventually will be reabsorbed. autotransfusion can be performed to salvage blood and reinfuse it into the anemic patient. in cases of neoplastic or traumatic uncontrollable hemorrhagic effusions, surgical exploration of the thorax is warranted. diaphragmatic hernia, or a rent in the diaphragm, can result in the protrusion of abdominal organs into the thoracic cavity and impair pulmonary expansion. organs that are commonly herniated into the thorax include the liver, stomach, and small intestines. diaphragmatic hernia usually is secondary to trauma but can occur as a congenital anomaly. in cases of trauma, rib fractures, pulmonary contusions, traumatic myocarditis, hemothorax, and shock are also often present concurrently with diaphragmatic hernia. respiratory distress can be caused by any one or a combination of the above lesions. animals with prior or chronic diaphragmatic hernias may have minimal clinical signs despite the presence of abdominal organs within the thorax. clinical signs of acute or severe diaphragmatic hernia include respiratory distress, cyanosis, and shock. a diagnosis of diaphragmatic hernia is made based on the patient's history (traumatic event), clinical signs, and radiographs. in some cases, ultrasonography or contrast peritoneography is necessary to confirm the diagnosis. contrast radiographs may show the presence of the stomach or intestines within the thorax following oral administration of barium. never administer barium directly into the peritoneal cavity or in cases of suspected gastrointestinal rupture. treatment of a patient with a diaphragmatic hernia includes cardiovascular and respiratory system stabilization before attempting surgical repair of the diaphragm. if the stomach is within the thorax, or if the patient's respiratory distress cannot be alleviated with medical management alone, immediate surgery is necessary. if the respiratory distress is minimal and the stomach is not located within the thorax, surgery can be postponed until the patient is a more stable anesthetic candidate. at the time of surgery, the abdominal organs are replaced into the abdominal cavity, and the rent in the diaphragm is closed. air must be evacuated from the thorax following closure of the diaphragm. if chronic diaphragmatic hernia is repaired, the complication of reexpansion pulmonary edema can occur. cardiac injury is a common complication secondary to blunt thoracic trauma. in most cases, cardiac injury is manifested as arrhythmias, including multiple premature ventricular contractions, ventricular tachycardia, st segment depression or elevation secondary to myocardial hypoxemia, and atrial fibrillation (see section on cardiac emergencies). myocardial infarction and cardiac failure can occur. careful and repeated assessments of the patient's blood pressure and ecg tracing should be a part of any diagnostic work-up for a patient that has sustained blunt thoracic trauma. rib fractures are associated with localized pain and painful respiratory movements. radiographs are helpful to confirm the diagnosis. careful palpation may reveal crepitus and instability of the fractured ribs. common problems associated with rib fractures 264 1 emergency care include pulmonary contusions, pericardial laceration, traumatic myocarditis, diaphragmatic hernia, and splenic laceration or rupture. a flail segment results from rib fractures of more than three adjacent ribs that produce a "floating segment" of the chest wall. the flail segment moves paradoxically with respiration-that is, it moves inward during inhalation and outward during exhalation. respiratory distress is associated with the pain caused by the fractures and the presence of traumatic underlying pulmonary pathology. therapy for rib fractures and flail chest includes administration of supplemental oxygen, treatment of pneumothorax or diaphragmatic hernia, and administration of systemic and local anesthesia to alleviate the discomfort associated with the fractures. although controversial, positioning the patient with the flail segment up may reduce pain and improve ventilation. avoid the use of chest wraps, which do nothing to stabilize the flail segment and can further impair respiratory excursions. following administration of a systemic analgesic, administer a local anesthetic at the dorsocaudal and ventrocaudal segment of each fractured rib, and in one rib in front of and behind the flail segment. often, pulmonary function will improve once the pain associated with rib fractures has been adequately treated. in rare cases in which the flail segment involves five or more ribs, surgical stabilization may be necessary. single rib fractures or smaller flail segments are allowed to heal on their own. feline bronchitis has a variety of names (bronchial asthma, asthma, acute bronchitis, allergic bronchitis, chronic asthmatic bronchitis, feline lower airway disease) and refers to the acute onset of respiratory distress secondary to narrowing of the bronchi. cats may present with an acute onset of severe restrictive respiratory pattern associated with lower airway obstruction. acute bronchitis in cats typically has an inflammatory component in the lower airways, resulting in acute bronchoconstriction, excessive mucus production, and inflammatory exudates. in cats with chronic bronchitis, there may be damage of the bronchial epithelium and fibrosis of the airways. these patients often have a history if intermittent exacerbation of clinical signs, intermittent cough, and periods of normality throughout the year. because there appears to be an allergic or inflammatory component in feline bronchitis, clinical signs can be acutely exacerbated by stress and the presence of aerosolized particles such as perfume, smoke, and carpet powders. causes of feline bronchitis include heartworm disease, parasitic infestation (lungworms), and (rarely) bacterial infection. on presentation, the patient should be placed in an oxygen cage and allowed to rest while being observed from a distance. postpone performing stressful diagnostic procedures until the patient's respiratory status has been stabilized. after careful thoracic auscultation, administer a short-acting bronchodilator (terbutaline, 0.01 mg/kg sq or im) along with a glucocorticosteroid (dexamethasone sodium phosphate 1 mg/kg im, sq, iv) to alleviate immediate bronchospasm and airway inflammation. clinical signs of feline bronchitis are characterized by a short, rapid respiratory pattern with prolonged expiration with an abdominal push. wheezes may be heard on thoracic auscultation. in some cases, no abnormalities are found on auscultation, but become acutely worse when the patient is stimulated to cough by tracheal palpation. radiographs may reveal a hyperinflated lung field with bronchial markings and caudal displacement of the diaphragm. in some cases, consolidation of the right middle lung lobe is present. a complete blood count and serum biochemistry profile can be performed, but results usually are unrewarding. in endemic areas, a heartworm test is warranted. fecal examination 1 by flotation and the baermann technique is helpful in ruling out lungworms and other parasites. bronchoalveolar lavage or transtracheal wash is useful for cytologic and bacterial examination. long-term management of feline bronchitis includes isolation from environmental exposure to potential allergens (litter dust, perfumes, smoke, incense, carpet powders) and treatment of bronchoconstriction and inflammation with a combination of oral and inhaled glucocorticosteroids and bronchodilators (table 1 -53). antibiotic therapy is contraindicated unless a pure culture of a pathogen is documented. oral therapy with steroids and bronchodilators should be used for a minimum of 4 weeks after an acute exacerbation and then gradually decreased to the lowest dose possible to alleviate clinical signs. metered dose inhalers are now available (aerokat.com) for administration of inhaled bronchodilators and steroids. fluticasone (flovent, 100 mcg/puff ) can be administered initially every 12 hours for 1 week and then decreased to once daily, in most cases. inhaled glucocorticosteroids are not absorbed systemically, and therefore patients do not develop the adverse side effects sometimes documented with oral glucocorticosteroid administration. because it takes time for glucocorticosteroids to reach peak effects in the lungs, administration of inhaled glucocorticosteroids should overlap with oral prednisolone administration for 5 to 7 days. treatment of pulmonary contusions is supportive. administer supplemental oxygen in a manner that is least stressful for the animal. arterial blood gas analysis or pulse oximetry can determine the degree of hypoxemia and monitor the response to therapy. intravenous fluids should be administered with caution to avoid exacerbating pulmonary hemorrhage or fluid accumulation in the alveoli. treat other conditions associated with the traumatic event. possible complications of pulmonary contusions are rare but include bacterial infection, abscessation, lung lobe consolidation, and the development of cavitary lesions. the routine use of antibiotics or steroids in cases of pulmonary contusions is contraindicated unless external wounds are present. empiric antibiotic use without evidence of external injury or known infection can potentially increase the risk of a resistant bacterial infection. steroids have been shown to decrease pulmonary alveolar macrophage function and impair wound healing and are contraindicated. aspiration pneumonia can occur in animals as a result of abnormal laryngeal or pharyngeal protective mechanisms or can be secondary to vomiting during states of altered mentation, including anesthesia, recovery from anesthesia, and sleep. megaesophagus, systemic polyneuropathy, myasthenia gravis, and localized oropharyngeal defects such as cleft palate can increase the risk of developing aspiration pneumonitis. iatrogenic causes of aspiration pneumonia include improper placement of nasogastric feeding tubes, overly aggressive force-feeding, and oral administration of drugs. aspiration of contents into the airways can cause mechanical airway obstruction, bronchoconstriction, chemical damage to the alveoli, and infection. severe inflammation and airway edema are common. pulmonary hemorrhage and necrosis can occur. diagnosis of aspiration pneumonia is based on clinical signs of pulmonary parenchymal disease, a history consistent with vomiting or other predisposing causes, and thoracic radiographs demonstrating a bronchointerstitial to alveolar pulmonary infiltrate. the most common site is the right middle lung lobe, although the pneumonia can occur anywhere, depending on the position of the patient at the time of aspiration. a transtracheal wash or bronchoalveolar lavage is useful for bacterial culture and susceptibility testing. treatment of aspiration pneumonia includes antibiotic therapy for the infection, administration of supplemental oxygen, and loosening the debris in the airways. administer intravenous fluids to maintain hydration. nebulization with sterile saline and chest physiotherapy (coupage) should be performed at least every 8 hours. antibiotics to consider in the treatment of aspiration pneumonia include ampicillin/enrofloxacin, amoxicillinclavulanate, ampicillin-sulbactam, trimethoprim sulfa, and chloramphenicol. the use of glucocorticosteroids is absolutely contraindicated. continue antibiotic therapy for a minimum of 2 weeks after the resolution of radiographic signs of pneumonia. pulmonary edema arises from the accumulation of fluid in the pulmonary interstitial alveolar spaces, and airways. ventilation-perfusion abnormalities result in hypoxia. pulmonary edema can be caused by increased pulmonary vasculature hydrostatic pressure, decreased pulmonary oncotic pressure, obstruction of lymphatic drainage, or increased capillary permeability. multiple factors can occur simultaneously. the most common cause of edema is increased pulmonary hydrostatic pressure resulting from left-sided congestive heart failure. decreased plasma oncotic pressure with albumin <1.5 g/dl can also result in accumulation of fluid in the pulmonary parenchyma. overzealous intravenous crystalloid fluid administration can result in dilution of serum oncotic pressure and vascular overload. obstruction of lymphatic drainage is usually caused by neoplasia. other causes of pulmonary edema include pulmonary thromboembolic disease, severe upper airway obstruction (noncardiogenic pulmonary edema), seizures, and head trauma. increased capillary permeability is associated with a variety of diseases that cause severe inflammation (systemic inflammatory response syndrome). the resultant pulmonary edema contains a high amount of protein and is known as acute respiratory 1 distress syndrome (ards). ards can be associated with pulmonary or extrapulmonary causes, including direct lung injury from trauma, aspiration pneumonia, sepsis, pancreatitis, smoke inhalation, oxygen toxicity, electrocution, and immune-mediated hemolytic anemia with disseminated intravascular coagulation. diagnosis of pulmonary edema is made based on clinical signs of respiratory distress and the presence of crackles on thoracic auscultation. in severe cases, cyanosis and fulminant blood-tinged frothy edema fluid may be present in the mouth and nostrils. immediate management includes administration of furosemide (4-8 mg/kg iv, im) and supplemental oxygen. sedation with low-dose morphine sulfate (0.025-0.1 mg/kg iv) is helpful in dilating the splanchnic capacitance vasculature and relieving anxiety for the patient. if fluid overload is suspected secondary to intravenous fluid administration, fluids should be discontinued. severely hypoalbuminemic patients should receive concentrated human albumin (2 ml/kg of a 25% solution) or fresh frozen plasma. furosemide as a constant rate infusion (0.66-0.1 mg/kg/hour) also can dilate the pulmonary vasculature and decrease fluid accumulation in cases of ards. following initial stabilization of the patient, thoracic radiographs and an echocardiogram should be assessed to determine cardiac side, pulmonary vascular size, and cardiac contractility. further diagnostic testing may be required to determine other underlying causes of pulmonary edema. heart failure is managed with vasodilators, diuretics, oxygen, and sometimes positive inotropes. treatment ultimately consists of administration of supplemental oxygen, minimal stress and patient handling, and judicious use of diuretics. in cases of cardiogenic pulmonary edema, administer furosemide (4-8 mg/kg iv, im) every 30 to 60 minutes until the patient loses 7% of its body weight. positive inotropic and antiarrhythmic therapy may be necessary to improve cardiac contractility and control dysrhythmias. the clinician should determine whether the cause of the pulmonary edema is secondary to congestive heart failure with pulmonary vascular overload, volume overload, hypoalbuminemia, or increased permeability (ards). pulmonary edema secondary to ards typically is refractory to supplemental oxygen and diuretic therapy. in many cases, mechanical ventilation should be considered. a diagnosis of pulmonary thromboembolism (pte) is difficult to make and is based on clinical signs of respiratory distress consistent with pte, lack of other causes of hypoxemia, a high index of suspicion in susceptible animals, the presence of a condition associated with pte, and radiographic findings. virchow's triad consists of vascular endothelial injury, sluggish blood flow with increased vascular stasis, and a hypercoagulable state as predisposing factors for thromboembolic disease. clinical conditions that predispose an animal to pte include hyperadrenocorticism, disseminated intravascular coagulation (dic), catheterization of blood vessels, bacterial endocarditis, protein-losing nephropathy or enteropathy, hyperviscosity syndromes, heat-induced illness, pancreatitis, diabetes mellitus, inflammatory bowel disease, and immune-mediated hemolytic anemia. definitive diagnosis requires angiography or a lung perfusion scan. clinical signs associated with pte include an acute onset of tachypnea, tachycardia, orthopnea, and cyanosis. if the embolism is large, the patient may respond poorly to supplemental oxygen administration. pulmonary hypertension can cause a split second heart sound on cardiac auscultation. in some cases, a normal thoracic radiograph is present in the face of severe respiratory distress. this is a classic finding in cases of pte. potential radiographic abnormalities include dilated, tortuous, or blunted pulmonary arteries; wedge-shaped opacities in the lungs distal to an obstructed artery; and interstitial to alveolar infiltrates. the right heart may be enlarged. echocardiography can show right heart enlargement, tricuspid regurgitation, pulmonary hypertension, and evidence of underlying cardiac disease, possibly with clots in the atria. measurement of antithrombin (at) and d-dimer levels can be useful in the identification of hypercoagulable states, including dic. treatment of any patient with at deficiency or dic includes replenishment of at and clotting factors in the form of fresh frozen plasma. treatment of pte includes therapy for cardiovascular shock, oxygen supplementation, and thrombolytic therapy (see section on thromboembolic therapy). for short-term treatment, administer heparin (heparin sodium, 200-300 units/kg sq once, followed by 100 units/kg q8h of unfractionated heparin; or fractionated heparin). thrombolytic therapy may include tissue plasminogen activator, streptokinase, or urokinase. long-term therapy with low molecular weight heparin or warfarin may be required to prevent further thromboembolic events. ideally, management should include treatment and elimination of the underlying disease. smoke inhalation commonly occurs when an animal is trapped in a burning building. the most severe respiratory complications of smoke inhalation are seen in animals that are close enough to the flames to also sustain burn injuries (see section on burn injury). at the scene, many animals are unconscious from the effects of hypoxia, hypercapnia, carbon monoxide intoxication, and hydrogen cyanide gases that accumulate in a fire. carbon monoxide produces hypoxia by avidly binding to and displacing oxygen binding to hemoglobin, resulting in severe impairment of oxygen-carrying capacity. the percentage of carboxyhemoglobin in peripheral blood depends on the amount or carbon monoxide in inhaled gases and the length of time of exposure. clinical signs of carbon monoxide intoxication include cyanosis, nausea, vomiting, collapse, respiratory failure, loss of consciousness, and death. smoke inhalation of superheated particles also causes damage to the upper airways and respiratory tree. the larynx can become severely edematous and obstruct inspiration. emergency endotracheal intubation, tracheal oxygen, or tracheostomy tube may be required in the initial resuscitation of the patient, depending on the extent of airway edema. inhalation of noxious gases and particles can cause damage to the terminal respiratory bronchioles. specific noxious gases that can cause alveolar damage include combustible particles from plastic, rubber, and other synthetic products. pulmonary edema, bacterial infection, and ards can result. in any case of smoke inhalation, the first and foremost treatment is to get the animal away from the source of the flames and smoke and administer supplemental oxygen at the scene. at the time of presentation, carefully examine the animal's eyes, mouth, and oropharynx suction soot and debris from the mouth and upper airways. evaluate the patient's respiratory rate, rhythm, and pulmonary sounds. arterial blood gases should be analyzed with co-oximetry to evaluate the pao 2 and carboxyhemoglobin concentrations. evaluation of sao 2 by pulse oximetry is not accurate in cases of smoke inhalation, as the pao 2 may appear normal, even when large quantities of carboxyhemoglobin are present. radiographs are helpful in determining the extent of pulmonary involvement, although radiographic signs may lag behind the appearance of clinical respiratory abnormalities by 16 to 24 hours. bronchoscopy and bronchoalveolar lavage provide a more thorough and accurate evaluation of the respiratory tree; however, these procedures should be performed only in patients whose cardiovascular and respiratory status is stable. management of the patient with smoke inhalation includes maintaining a patent airway, administration of supplemental oxygen, correction of hypoxemia and acid-base abnormalities, preventing infection, and treating thermal burns (see section on burn injury). if severe laryngeal edema is present, a temporary tracheostomy may be necessary to allow adequate oxygenation and ventilation. glucocorticosteroids should not be empirically used in the treatment of smoke inhalation, because of the risk of decreasing pulmonary alveolar macrophage function and increasing the potential for infection. in cases of severe laryngeal edema, however, glucocorticosteroids may be necessary to decrease edema and inflammation. the use of empiric antibiotics is contraindicated unless clinical signs of deterioration and bacterial pneumonia develop. epistaxis can be caused by facial trauma, a foreign body, bacterial or fungal rhinitis, neoplasia, coagulopathies, and systemic hypertension. acute, severe bilateral hemorrhage without wounds have been classified in several ways according their degree of tissue integrity, etiologic force, degree of contamination and duration, and degree of contamination and infection (table 1 -54) . there are also unique causes of wounds such as burns, psychogenic dermatoses, frostbite, decubital ulcers, and snake bite. the animal should be transported to the nearest veterinary facility for definitive care. the wound should be covered or packed with dry gauze or clean linen to protect the wound, and to prevent further hemorrhage and contamination. if an open fracture is present, the limb should be splinted without placing the exposed bone back into the wound. replacing the exposed bone fragment back through the skin wound can cause further damage to underlying soft tissue structures and increase the degree of contamination of deeper tissues. if a spinal fracture is suspected, the patient should be transported on a stable flat surface to prevent further spinal mobilization and neurologic injury. at the time of presentation, first refer to the abcs of trauma, taking care to evaluate and stabilize the patient's cardiovascular and respiratory status. after a complete physical examination and history, ancillary diagnostic techniques can be performed if the patient is hemodynamically stable (see section on triage, assessment, and treatment of emergencies). initially, every patient with superficial wound should receive some degree of analgesia and an injection of a first-generation cephalosporin, preferably within 3 hours of the injury. evaluate the wound after the patient's cardiovascular and respiratory status have been stabilized. always cover an open wound before taking an animal to the hospital to prevent a nosocomial infection. evaluate limb wounds for neural, vascular, and orthopedic abnormalities. carefully examine the structures deep to the superficial wounds. when there has been a delay in assessment of the wound, obtain samples for culture and antimicrobial susceptibility testing. if the wound is older and obviously infected, a gram stain can help guide appropriate antimicrobial therapy pending results of culture 1 and susceptibility testing. place a support bandage saturated with a water-soluble antibiotic ointment or nonirritating antimicrobial solution (e.g., 0.05% chlorhexidine, if bone or joint tissue is not exposed) around the wound. in addition to a first-generation cephalosporin, other appropriate antibiotic choices include amoxicillin-clavulanate, trimethoprim-sulfadiazine, amoxicillin, and ampicillin. if gram-negative flora are present, administer enrofloxacin. administer the antibiotics of choice for a minimum of 7 days unless a change of antibiotic therapy is indicated. at the time of wound cleansing or definitive wound repair, the patient should be placed under general anesthesia with endotracheal intubation, unless the procedure will be brief (i.e., less than 10 minutes). in such cases, a short-acting anesthetic combination open lacerations or skin loss closed crushing injuries and contusions etiologic force abrasion loss of epidermis and portions of dermis, usually caused by shearing between two compressive surfaces avulsion tearing of tissue from its attachment because of forces similar to those causing abrasion but of a greater magnitude incision wound created by a sharp object; wound edges are smooth and there is minimal trauma in the surrounding tissues laceration irregular wound caused by tearing of tissue with variable damage to the superficial and underlying tissue puncture penetrating wound caused by a missile or sharp object; superficial damage may be minimal; damage to deeper structures may be considerable; contamination by fur and bacteria with subsequent infection is common class i 0-6 hours with minimal contamination class ii 6-12 hours with significant contamination class iii >12 hours with gross contamination (analgesia + propofol, analgesia + ketamine/diazepam) can be administered to effect. heavy sedation with infiltration of a local anesthetic may also be appropriate for very small wounds, depending on the location of the wound and temperament of the patient. protect the wound by packing it with sterile gauze sponges soaked in sterile saline, or with watersoluble lubricating gel such as k-y jelly. clip the fur surrounding the wound, moving from the inner edge of the wound outward, to help prevent wound contamination with fur or other debris. scrub the wound and surrounding skin with an antimicrobial soap and solution such as dilute chlorhexidine until the area is free of all gross debris. gross debris within the wound itself can be flushed using a 30-ml syringe filled with sterile saline or lactated ringer's solution and an 18-gauge needle. pressure-lavage systems are also available for use, if desired. grossly contaminated wounds can be rinsed first with warm tap water to eliminate gross contamination, and then prepared as just described. debride the wound, removing skin and other soft tissue that is not obviously viable. obviously viable and questionable tissue should remain, and the wound left open for frequent reassessment on a daily basis. remove any dark or white segments of skin. questionable skin edges may or not regain viability and should be left in place for 48 hours, so the wound can fully reveal itself. excise grossly contaminated areas of fat and underlying fascia. blood vessels that are actively bleeding should be ligated to control hemorrhage, if collateral circulation is present. if nerve bundles are ligated cleanly in a clean wound, the nerve edges should be reapposed and anastomosed. if gross contamination is present, however, definitive neurologic repair should be delayed until healthy tissue is present. excise contaminated muscle until healthy bleeding tissue is present. anastamoe tendon lacerations if the wound is clean and not grossly contaminated. if gross contamination is present, the tendon can be temporarily anastomosed and a splint placed on the limb until definitive repair of healthy tissue is possible. thoroughly lavage open wounds to a joint with sterile saline or lactated ringer's solution. infusion of chlorhexidine or povidone-iodine solution into the joint can cause a decrease in cartilage repair and is contraindicated. smooth sharp edges and remove any obvious fragments. whenever possible, the joint capsule and ligaments should be partially or completely closed. after removing bullets and metal fragments, the subcutaneous tissue and skin should be left open to heal by second intention, or should be partially closed with a drain. the joint should then be immobilized. injuries and exposed bone should be carefully lavaged, taking care to remove any gross debris without pushing the debris further into the bone and wound. the bone should be covered with a moist dressing and stabilized until definitive fracture repair can be made. this type of injury typically is seen with shearing injuries of the distal extremities caused by interaction with slow-moving vehicles. perform wet-to-dry or enzymatic debridement until a healthy granulation bed is present. if large areas of contamination are present (e.g., necrotizing fasciitis), en bloc debridement may be necessary. en bloc debridement consists of complete excision of badly infected wounds without entering the wound cavity, to prevent systemic infection. this technique should be used only if there is sufficient skin and soft tissue to allow later closure and it can be performed without damaging any major nerves, tendons, or blood vessels. open wounds often are managed by second intention healing, delayed primary closure, or secondary closure. see section on wound management and bandaging for a more complete discussion on the use of various bandaging materials in the treatment of open wounds. if an animal is presented very shortly after a wound has occurred and there is minimal contamination and trauma, the wound can be closed after induction of anesthesia and 1 careful preparation of the wound and surrounding tissues. close any dead space under the skin with absorbable suture material in an interrupted suture pattern. avoid incising major blood vessels or nerves. close the subcutaneous tissues with absorbable suture material in an interrupted or continuous suture pattern. take care that there is not too much tension on the wound, or else surgical dehiscence will occur with patient movement. close the skin with nonabsorbable suture or surgical staples (2-0 to 4-0) . if there is any doubt at the time of repair about tissue status or inability to close all dead space, place a passive drain (penrose drain) so that the proximal end of the drain is anchored in the proximal aspect of the wound with a suture(s). leave the ends long so that the suture can be accurately identified at the time of drain removal. pass the suture through the skin, through the drain, and out the other side of the skin. place the rest of the drain into the wound and then secure it at the most ventral portion of the wound or exit hole in the most dependent area of the body, to allow drainage and prevent seroma formation. close the subcutaneous tissue over the drain before skin closure. during wound closure, be sure to not incorporate the subcutaneous or skin sutures into the drain, or it will not be possible to remove the drain without reopening the wound. bandage the area to prevent contamination. the drain can be removed once drainage is minimal (usually 3 to 5 days). active drains can be constructed or purchased; their use is indicated in wounds that are free of material that can plug the drain. to construct a small suction drain, remove the female portion or catheter hub at the end of a butterfly catheter. fenestrate the tubing so that there are multiple side holes, taking care to avoid making the holes larger than 50% of the circumference of the tubing. place the tubing into the wound via a small stab incision distal to the wound. use a purse-string suture around the tubing to facilitate a tight seal and prevent the tubing from exiting the wound. following wound closure, insert the butterfly needle into a 5-to 10-ml evacuated blood collection tube to allow fluid to drain into the tube. incorporate the tube into the bandage, and replace it when it becomes full. alternatively, the butterfly portion of the system can be removed and the tube fenestrated as described previously. place the tube into the wound and suture it in place to create a tight seal. secure the catheter hub to a syringe in which the plunger has been drawn back slightly to create suction. insert a metal pin or 16-to 18-gauge needle through the plunger at the top of the barrel to hold it at the desired level. incorporate the suction apparatus into the bandage and replace it when it becomes full. delayed primary closure should be considered when there is heavy contamination, purulent exudate, residual necrotic debris, skin tension, edema and erythema, and lymphangitis. delayed primary closure usually is made 3 to 5 days after the initial wound infliction and open wound management has been performed. once healthy tissue is observed, the skin edges should be debrided and the wound closed as with primary closure. secondary wound closure should be considered when infection and tissue trauma necessitate open wound management for more than 5 days. secondary wound closure is performed after the development of a healthy granulation bed. this technique also is useful when a wound has dehisced and has formed granulation tissue. if the wound edges can be manipulated into apposition and if epithelialization has not begun, the wound can be cleansed and the wound edges apposed and sutured. this is known as early secondary closure. late secondary closure should be performed whenever there is a considerable amount of granulation tissue, the edges of the wound cannot be manipulated into position, and epithelialization has already started. in such cases, the wound should be cleaned, and the skin edges debrided to remove the epithelium. the remaining wound edges are then sutured over the granulation tissue ( shock is defined as a state of inadequate circulating volume and inability to meet cellular oxygen demands. there are three types of shock: hypovolemic, cardiogenic, and septic. early recognition of the type of shock present is crucial in the successful clinical management of shock syndrome. tissue oxygen delivery is based on cardiac output and arterial oxygen concentration. knowledge of the components of normal oxygen delivery is essential to the treatment of shock in the critical patient. improper handling of animal during further tissue and neurologic damage may occur transport (e.g., improper limb or spine immobilization). inadequate assessment of animal's animal's condition may worsen or animal may general condition or wounded tissues succumb; tissue injuries may be overlooked. inadequate wound protection during further wound contamination may occur at assessment, resuscitation, or veterinary facility. stabilization procedures inadequate wound protection while further wound contamination with fur and preparing the surrounding area debris may occur. insufficient wound lavage wound infection may occur. hydrogen peroxide wound lavage lavage offers little bactericidal activity and contributes to irritation of tissues and delayed healing. lavage has short residual activity and absorption with large wound. overly aggressive initial layered debridement may result in the removal of viable debridement tissue. en bloc debridement debridement results in removal of large amounts of tissue and a large defect for closure. use of drains potential exists for bacteria to ascend along the drain, for drain removal by the animal or breakage of the drain, and for possible tissue emphysema with air being sucked under the skin with patient movement. tube-type drains drains may cause postoperative discomfort; fenestrations may become occluded to stop intraluminal drainage. deeply placed sutures in the presence drain may be incorporated into the repair and of a drain prevent drain removal. active drains high negative pressure may cause tissue injury; highly productive wounds may necessitate changing the evacuated blood tubes several times a day with constructed drains. oxygen delivery (do 2 ) = cardiac output (q) ã� arterial oxygen content (cao 2 ) where q = heart rate ã� stroke volume. stroke volume is affected by preload, afterload, and cardiac contractility. where hb = hemoglobin concentration, sao 2 = oxygen saturation, and pao 2 = arterial partial pressure of oxygen in mm hg. thus, factors that can adversely affect oxygen delivery include inadequate preload or loss of circulating volume, severe peripheral vasoconstriction and increased afterload, depressed cardiac contractility, tachycardia and decreased diastolic filling, cardiac dysrhythmias, inadequate circulating hemoglobin, and inadequate oxygen saturation of hemoglobin. during septic shock, enzymatic dysfunction and decreased cellular uptake and utilization of oxygen also contribute to anaerobic glycolysis. an inadequate circulating volume may develop secondary to maldistribution of available blood volume (traumatic, septic, and cardiogenic origin) or as a result of absolute hypovolemia (whole blood or loss of extracellular fluid). normally, the animal compensates by (1) splenic and vascular constriction to translocated blood from venous capacitance vessels to central arterial circulation, (2) arteriolar constriction to help maintain diastolic blood pressure and tissue perfusion, and (3) an increase in heart rate to help maintain cardiac output. arteriolar vasoconstrictions support perfusion to the brain and heart at the expense of other visceral organs. if vasoconstriction is severe enough to interfere with delivery of adequate tissue oxygen for a sufficient period of time, the animal may die. hypovolemic shock can result from acute hemorrhage or from severe fluid loss from vomiting, diarrhea, or third spacing of fluids. early in shock, baroreceptors in the carotid body and aortic arch sense a decrease in wall stretch from a decrease in circulating fluid volume. tonic inhibition of sympathetic tone via vagal stimulation is diminished, and heart rate and contractility increase and peripheral vessels constrict to compensate for the decrease in cardiac output. the compensatory mechanisms protect and support blood supply to the brain and heart at the expense of peripheral organ perfusion. this is called early compensatory shock. early compensatory shock is characterized by tachycardia, normal to fast capillary refill time, tachypnea, and normothermia. as shock progresses, the body loses its ability to compensate for ongoing fluid losses. early decompensatory shock is characterized by tachycardia, tachypnea, delayed capillary refill time, normotension to hypotension, and a fall in body temperature. end-stage decompensatory shock is characterized by bradycardia, markedly prolonged capillary refill time, hypothermia, and hypotension. aggressive treatment is necessary for any hope of a favorable outcome. septic shock should be considered in any patient with a known infection, recent instrumentation that could potentially introduce infection (indwelling intravenous or urinary catheter, surgery or penetrating injury), disorders or medical therapy that can compromise immune function (diabetes mellitus, immunodeficiency virus, parvovirus or feline panleukopenia virus infection, stress, malnutrition, glucocorticoids, chemotherapy). the presence of bacteria, viruses or rickettsiae, protozoa, or fungal organisms in the blood constitutes septicemia. septic shock is characterized by the presence of sepsis and refractory hypotension that is unresponsive to standard aggressive fluid therapy and inotropic or pressor support. septic shock and other causes of inflammation can lead to systemic inflammatory response syndrome (sirs). in animals, the presence of two or more of the criteria in table 1 -56 in the presence of suspected inflammation or sepsis constitutes sirs (table 1 -56). clinical signs associated with sepsis may be vague and nonspecific, including weakness, lethargy, vomiting, and diarrhea. cough and pulmonary crackles may be associated with pneumonia. decreased lung sounds may be associated with pyothorax. abdominal pain and fluid may be associated with septic peritonitis. vaginal discharge may or may not be present in patients with pyometra. diagnostic tests should include a white blood cell count, serum biochemical profile, coagulation tests, thoracic and abdominal radiographs, and urinalysis. the white blood cell count in a septic patient that is appropriately responding to the infection will be elevated with a left-shifted neutrophilia and leukocytosis. a degenerative left shift, in which leukopenia with elevated band neutrophils suggests an overwhelming infection. biochemical analyses may demonstrate hypoglycemia and nonspecific hepatocellular and cholestatic enzyme elevations. in the most severe cases, metabolic (lactic) acidosis, coagulopathies, and end-organ failure, including anuria and ards, may be present. cardiogenic shock occurs as a result of cardiac output inadequate to meet cellular oxygen demands. cardiogenic shock is associated with primary cardiomyopathies, cardiac dysrhythmias, pericardial fluid, and pericardial fibrosis. abnormalities seen on physical examination often are similar to those seen in other categories of shock, but they can also include cardiac murmurs, dysrhythmias, pulmonary rales, bloody frothy pulmonary edema fluid from the nares or mouth, orthopnea, and cyanosis. it is important to distinguish the primary cause of shock before implementing treatment (table 1-57) , whenever possible, because treatment for a suspected ruptured hemangiosarcoma differs markedly from the treatment for end-stage dilatative cardiomyopathy. the patient's clinical signs may be similar and include a peritoneal fluid wave, but the treatment for hypovolemia can dramatically worsen the congestive heart failure secondary to dilatative cardiomyopathy. when a patient presents with some form of shock, immediate vascular access is of paramount importance. place a large-bore peripheral or central venous catheter for the infusion of crystalloid or colloid fluids, blood component therapy, and drugs. monitor the patient's cardiopulmonary status (by ecg), blood pressure, oxygen saturation (as determined by pulse oximetry or arterial blood gas analyses), hematocrit, bun, and glucose. ancillary diagnostics, including thoracic and abdominal radiography, urinalysis, serum biochemistry profile, coagulation tests, complete blood count, abdominal ultrasound, and echocardiography, should be performed as determined by the individual patient's needs and the type of shock. the following list, called the "rule of twenty," is a guideline for case management of the shock patient. consideration of each aspect of the rule of twenty on a daily basis ensures temperature <100â°f or >103.5â°f <100â°f or >103.5â°f heart rate >120 beats/minute in dogs <140 or >250 beats/minute in cats respiratory rate >20 breaths/minute or paco 2 >40 breaths/minute or paco 2 <32 mm hg <32 mm hg white blood cell >18,000 cells/âµl 19,000 cells/âµl count or <4000 cells/âµl o r <5000 cells/ml or >10% bands or >10% bands 1 that major organ systems are not overlooked. the list also provides a means to integrate and relate changes in different organ systems functions with one another.* the treatment of hypovolemic and septic shock requires the placement of large-bore intravenous catheters in peripheral and central veins. if vascular access cannot be obtained percutaneously or by cutdown methods, intraosseous catheterization should be considered. once vascular access is achieved, rapidly administer large volumes of crystalloid or colloid fluids. as a rule of thumb, administer 1 /4 of a calculated shock dose of fluids-that is, 1 /4 ã� (90 ml/kg/hour) in dogs and 1 /4 ã� (44 ml/kg/hour) in cats) of a balanced crystalloid fluid ( normosol-r, plasmalyte-m, lactated ringer's solution, or 0.9% sterile saline). reassess the patient's perfusion parameters (heart rate, capillary refill time, blood pressure, urine output) on a continual basis to direct further fluid therapy. synthetic colloid fluids (hetastarch, dextran 70, or oxyglobin) can also be administered in the initial resuscitation from shock. a guideline is to administer 5 to 10 ml/kg of hetastarch or dextran as a bolus over 10 to 15 minutes and then reassess perfusion parameters. hypertonic saline (0.7% nacl, 4 ml/kg) can be used in cases of hemorrhagic shock to temporarily restore intravascular fluid volume by drawing fluid from the interstitial space. because this type of fluid resuscitation is short-lived, hypertonic saline should always be used with another crystalloid or colloid fluid, and it should not be used in patients with interstitial dehydration. if hemorrhagic shock is present, the goal should be to return a patient's blood pressure to normal (not supraphysiologic) levels (i.e., systolic pressure 90-100 mm hg, diastolic pressure >40 mm hg, and mean arterial pressure â�¥60 mm hg) to avoid iatrogenically causing clots to fall off and hemorrhage to re-start. in critically ill patients, fluid loss can be measured in the form of urine, vomit, diarrhea, body cavity effusions, and wound exudates. additionally, insensible losses (those that cannot be readily measured from sweat, panting, and cellular metabolism) constitute 20 ml/kg/ day. measurement of fluid "ins and outs" in conjunction with the patient's central venous pressure, hematocrit, albumin, and colloid oncotic pressure can help guide fluid therapy (see also section on fluid therapy). maintenance of normotension is necessary for adequate oxygen delivery to meet cellular energy demands. blood pressure can be measured using direct arterial catheterization, or through indirect means such as doppler plesthymography or oscillometric methods. the systolic pressure should remain at or greater than 90-100 mm hg at all times. the diastolic pressure is very important, too, as it constitutes two thirds of the mean arterial pressure; it must be greater than 40 mm hg for coronary artery perfusion. the mean arterial pressure should be greater than 60 mm hg for adequate tissue perfusion. if fluid resuscitation and pain management are not adequate in restoring blood pressure to normal, vasoactive drugs including positive inotropes and pressors should be considered (table 1 -58). in cases of cardiogenic shock, vasodilator drugs (table 1 -59) can be used to decrease vascular resistance and afterload. low-dose morphine (0.05 mg/kg, iv, im) dilates splanchnic vessels and helps reduce pulmonary edema. furosemide (1 mg/kg/hour) also can dilate pulmonary vasculature and potentially reduce edema fluid formation in cases of ards. cardiac output is a function of both heart rate and stroke volume. stroke volume or (the amount of blood that the ventricle pumps in 1 minute) is affected by preload, afterload, and contractility. during hypovolemic shock, there is a fall in cardiac preload due to a decrease in circulating blood volume. during septic and cardiogenic shock, there is a decrease in contractility secondary to inherent defects of the myocardium or due to the negative inotropic effects of inflammatory cytokines such as tnf-alpha, myocardial depressant factor, il-1, and il-10 released during sepsis and systemic inflammation. afterload also may be increased because of the compensatory mechanisms and neurohumoral activation of the renin-angiotensin-aldosterone axis in hypovolemic or cardiogenic shock. as heart rate increases to compensate for a decline in cardiac output, myocardial oxygen demand increases and diastolic filling time becomes shorter. because the coronary arteries are perfused during diastole, coronary perfusion can be impaired, and myocardial lactic acidosis can develop, causing a further decline in contractility. in addition to lactic acidosis, acid-base and electrolyte abnormalities, inflammatory cytokines, direct bruising of the myocardium from trauma, and areas of ischemia can further predispose the patient to ventricular or atrial dysrhythmias. cardiac dysrhythmias should be controlled whenever possible. treatment of bradycardia should be directed at treating the underlying cause. administer anticholinergic drugs such as atropine (0.04 mg/kg im) or glycopyrrolate (0.02 mg/kg im) as necessary. in cases of third-degree or complete atrioventricular (av) block, administer a pure betaagonist such as isoproterenol (0.04-0.08 âµg/kg/minute iv cri, or 0.4 mg in 250 ml of 5% dextrose in water iv slowly). perform passive rewarming if the patient is hypothermic. receptor activity dosage (iv) dopamine da 1 , da 2 , î± +++ , 5-25 âµg/kg/minute (blood pressure support)* î² +++ 1-5 âµg/kg/minute (renal afferent diuresis) dobutamine î± + , î² +++ 3-20 âµg/kg/minute* (blood pressure support, positive inotrope) norepinephrine î± +++ , î² + 0.05-0.3 mg/kg/minute; 0.01-0.02 mg/kg phenylephrine î± +++ , î² 0 0.05-0.2 mg/kg epinephrine î± +++ , î² +++ 0.02-0.5 mg/kg, 0.05-0.2 mg/kg/minute +++, strong receptor activity; 0, no receptor activity; +, weak receptor activity. *monitor for tachyarrhythmias at higher doses. correct any underlying electrolyte abnormalities such as hyperkalemia and hypo-and hypermagnesemia. treat ventricular dysrhythmias such as multifocal premature ventricular contractions (pvcs), sustained ventricular tachycardia >160 beats per minute, and r on t phenomenon (the t wave of the preceding beat occurs superimposed on the qrs complex of the next beat, and there is no return to isoelectric shelf), or if runs of ventricular tachycardia cause a drop in blood pressure. intravenous lidocaine and procainamide are the first drugs of choice for ventricular dysrhythmias. supraventricular tachycardia can impair cardiac output by impairing diastolic filling time. control supraventricular dysrhythmias with calcium channel blockers, beta-adrenergic blockers, or quinidine (table 1-60) . (disorientation); is 1 minute; 2 minutes) light sensitive and must be covered in foil and not kept for longer than 4 hours 1 albumin can decrease as a result of loss from the gastrointestinal tract, urinary system, and wound exudates, or into body cavity effusions. albumin synthesis can decrease during various forms of shock due to a preferential increase in hepatic acute phase protein synthesis. serum albumin contributes 80% of the colloid oncotic pressure of blood, in addition to its important roles as a free radical scavenger at sites of inflammation and as a drug and hormone carrier. albumin levels <2.0 g/dl have been associated with an increase in morbidity and mortality in human and veterinary patients. administer fresh frozen plasma (20 ml/kg) or concentrated human albumin (2 ml/kg of 25% solution) to maintain serum albumin â�¥2.0 g/dl. additional oncotic support can be in the form of synthetic colloids, as indicated. colloid oncotic pressure within the intravascular and interstitial spaces contributes to fluid flux. oncotic pressure can be measured with a colloid osmometer. normal oncotic pressure is 15 mm hg. in cases of sepsis and sirs, increased vascular permeability increases the tendency for leakage of fluids into the interstitial spaces. colloids that can be administered until the source of albumin loss resolves include the synthetic colloids hetastarch and dextran 70 (20-30 ml/kg/day), synthetic hemoglobin-based oxygen carriers (oxyglobin, 3-7 ml/kg/day), concentrated human albumin (25% albumin, 2 ml/kg), and plasma (20 ml/kg). oxygenation and ventilation can be evaluated by arterial blood gas analysis or by the noninvasive means of pulse oximetry and capnometry (see sections on pulse oximetry and capnometry). oxygen delivery can be impaired in cases of hypovolemic shock because of hemorrhage and anemia, and thus a decrease in functional capacity to carry oxygen, and is not to be used for more than 2 weeks due to idiosyncratic blindness. in cases of cardiogenic shock as a result of impaired ability to saturate hemoglobin due to pulmonary edema in the lungs, or decrease in cardiac output. in septic shock, decreases in cardiac output due to inflammatory cytokines and a decrease in cellular oxygen extraction can lead to lactic acidosis. increased cellular metabolism and decreases in respiratory function can lead to respiratory acidosis as co 2 increases. administer supplemental oxygen as flow-by, nasal or nasopharyngeal catheter, oxygen hood, or oxygen cage. supplemental oxygen should be humidified, and delivered at 50-100 ml/kg/minute. if oxygenation and ventilation are so impaired that the pao 2 remains <60 mm hg with the patient on supplemental oxygen, a paco 2 >60 mm hg, or severe respiratory fatigue, develops, and mechanical ventilation should be considered. glucose is a necessary fuel source for red blood cells and neuronal tissues, and serum glucose should be maintained within normal reference ranges. glucose supplementation can be administered as 2.5-5% solutions in crystalloid fluids, or in parenteral and enteral nutrition products. arterial and venous ph can be measured by performing blood gas analyses. decrease in tissue perfusion, impaired oxygen delivery, and decreased oxygen extraction in the various forms of shock can lead to anaerobic metabolism and metabolic acidosis. in most cases, improving tissue perfusion and oxygen delivery with crystalloid and colloid fluids, supplemental oxygen, and inotropic drugs will help normalize metabolic acidosis. serial measurements of serum lactate (normal, <2.5 mmol/l) can be used as a guide to evaluate the tissue response to fluid resuscitative efforts. serum electrolytes often become severely deranged in shock states. serum potassium, magnesium, sodium, chloride, and total and ionized calcium should be maintained within normal reference ranges. if metabolic acidosis is severe, sodium bicarbonate can be administered by calculating the formula base deficit ã� 0.3 ã� body weight in kg = meq bicarbonate to administer because iatrogenic metabolic alkalosis can occur, a conservative approach is to administer 1 /4 of the calculated dose and then recheck the patient's ph and bicarbonate levels. if the base excess is unknown, sodium bicarbonate can be administered in incremental doses of 1 meq/kg until the ph is above 7.2. complications associated with bicarbonate therapy include iatrogenic hypocalcemia, metabolic alkalosis, paradoxical cerebrospinal fluid acidosis, hypotension, restlessness, and death. massive trauma, neoplasia, sepsis, and systemic inflammation can all lead to coagulation abnormalities, including disseminated intravascular coagulation (dic). cage-side coagulation monitors are available for daily measurement of prothrombin time (pt), activated partial thromboplastin time (aptt), and platelet counts. fibrin degradation products (fibrin split products) become elevated in dic, trauma, hepatic disease, and surgery. coagulation proteins (clotting factors) and antithrombin often are lost with other proteins in hypoproteinemia or are consumed when microclots are formed and then dissolved. antithrombin levels can be measured by commercial laboratories. antithrombin and clotting factors can be replenished in the form of fresh frozen plasma transfusions. a more sensitive and specific test for dic is the detection of d-dimers, which can be measured by commercial laboratories. treatment for dic involves treatment and resolution of the underlying disease and administration of antithrombin and clotting factors in the form of fresh frozen plasma (20 ml/kg) and heparin (unfractionated, 50-100 units/kg sq tid; fractionated [lovenox], 1 mg/kg sq bid). monitor the patient for changes in mental status, including stupor, coma, decreased ability to swallow and protect the airway, and seizures. elevation of the patient's head can help to protect the airway and decrease the risk of increased intracranial pressure. serum glucose should be maintained within normal levels to prevent hypoglycemia-induced seizures. one of the major components of oxygen delivery is the binding to hemoglobin. packed cell volume must be kept above 20-30% for adequate cellular oxygen delivery. acid-base status can adversely affect oxygen offloading at the tissue level if metabolic or respiratory alkalosis is present. oxygen-carrying capacity and hemoglobin levels can be increased with administration of rbc component therapy or with hemoglobin-based oxygen carriers. monitoring of renal function includes daily measurement of bun, creatinine, and urine output. normal urine output in a hydrated euvolemic patient is 1-2 ml/kg/hour. fluid ins and outs should be measured in cases of suspected oliguria or anuria. in patients with oliguria or anuria, furosemide can be administered as a bolus (4-8 mg/kg) or by constant rate infusion (cri)(0.66-1 mg/kg/hour). mannitol should also be administered (0.5-1 g/kg over 10 to 15 minutes). dopamine (1-5 âµg/kg/minute cri) can be administered to dilate renal afferent vessels and improve urine output. the patient's white blood cell count may be elevated, normal, or decreased, depending on the type of shock. the decision to administer antibiotics should be made on a daily basis. superficial or deep staphylococcus or streptococcus infection usually can be treated with a first-generation cephalosporin (cefazolin, 22 mg/kg iv tid). if a known source of infection is present, administer a broad-spectrum antibiotic (cefoxitin, 22 mg/kg iv tid; ampicillin, 22 mg/kg qid, or enrofloxacin, 5-10 mg/kg once daily) pending results of culture and susceptibility testing. if broader anaerobic coverage is required, metronidazole (10 mg/kg iv tid) should be considered. gentamicin (3-5 mg/kg iv once daily) is a good choice for gram-negative sepsis, provided that the patient is well hydrated and has normal renal function. ideally, patients receiving any aminoglycoside antibiotic should have a daily urinalysis to check for renal tubular casts that signify renal damage. in dogs, the gut is the shock organ. impaired gastrointestinal motility and vomiting should aggressively be treated with antiemetics and promotility drugs (dolasetron, 0.6 mg/kg iv once daily, and metoclopramide, 1-2 mg/kg/day iv cri). metoclopramide is contraindicated in cases of suspected gastrointestinal obstruction. histamine-receptor blockers such as famotidine (0.5 mg/kg bid iv) and ranitidine (0.5 to 2 mg/kg iv bid, tid) or proton-pump inhibitors (omeprazole, 0.5-1 mg/kg po once daily) can be administered for esophagitis. administer sucralfate (0.25-1 g po tid) to treat gastric ulceration. if the gastrointestinal barrier function is diminished due to poor perfusion, infection, or inflammation, administer broad-spectrum antibiotics such as ampicillin (22 mg/kg iv qid) to prevent gastrointestinal bacterial translocation. the course of drug therapy should be reviewd daily and the patient should be monitored for potential drug interactions. for example, metoclopramide and dopamine, working at the same receptor, can effectively negate the effects of each other. cimetidine, a cytochrome p450 enzyme inhibitor, can decrease the metabolism of some drugs. drugs that are avidly protein-bound may have an increase in unbound fraction with concurrent hypoalbuminemia or when hypoalbuminemia is present. decreased renal function may impair the renal clearance of some drugs, requiring increased dosing interval or decreased dose. nutrition is of utmost importance in any critically ill patient. patients with septic shock may become hypermetabolic and require supraphysiologic nutrient caloric requirements, while others may actually become hypometabolic. enteral nutrition is preferred, whenever possible, because enterocytes undergo atrophy without luminal nutrient stimulation. a variety of enteral feeding tubes can be placed, depending on what portion of the gut is functional, to provide enteral nutrition in an inappetent patient. loss of gastrointestinal mucosal barrier function may predispose the patients to the development of bacterial translocation and may contribute to sepsis. if enteral nutrition is impossible because of protracted vomiting or gastrointestinal resection, glucose, lipid, and amino acid products are available that can be administered parenterally to meet nutrient needs until the gastrointestinal tract is functioning and the patient can be transitioned to enteral nutrition. assessment of pain in animals in shock can be challenging. pain can result in the release of catecholamines and glucocounterregulatory hormones that can impair nutrient assimilation and lead to negative nitrogen balance, impaired wound healing, and immunocompromise. in any animal determined to be in pain, analgesic drugs should be administered to control pain and discomfort at all times. opioids are cardiovascularly friendly, and their effects can easily be reversed with naloxone if adverse effects such as hypotension and hypoventilation occur. if the patient is nonambulatory, rotate the animal from side to side every 4 to 6 hours to prevent lung atelectasis. passive range-of-motion exercises and deep muscle massage should be performed to increase tissue perfusion, decrease dependent edema, and prevent disuse atrophy. animals should be kept completely dry on soft, padded bedding to prevent the development of decubital ulcers. all bandages, wound sites, and catheter sites should be checked daily for the presence of swelling, erythema, and pain. soiled bandages should be changed to prevent strike-through and contamination of the underlying catheter or wound. hospitalization can be a stressful experience for patient and client alike. allowing brief visits and walks outside in the fresh air can improve a patient's temperament and decrease stress. the preemptive use of analgesic drugs on a regular schedule (not prn) should be used to prevent pain before it occurs. pain decreases the patient's ability to sleep. lack of sleep can promote further stress and impaired wound healing. the use of glucocorticosteroids and antiprostaglandins in shock therapy remains a topic of wide controversy. although the use of these agents potentially may stabilize membranes, decrease the absorption of endotoxin, and decrease prostaglandin release, the routine use of glucocorticosteroids and antiprostaglandins can decrease renal perfusion and gastrointestinal blood flow, promoting gastrointestinal ulceration and impaired renal function. the administration of supraphysiologic levels of glucocorticosteroids in patients in any type of shock can increase sodium and water retention, depress cellular immune function, and impair wound healing. in clinical studies of small animal patients, the routine use of glucocorticosteroids and antiprostaglandins has not demonstrated definite improved survival. the risks of therapy do outweigh the anecdotal reported benefits, and therefore the empiric use of glucocorticosteroids and antiprostaglandins in any shock patient is urinary tract emergencies azotemia azotemia occurs when 75% or more of the nephrons are nonfunctional. the magnitude of the azotemia alone cannot be used to determine whether the azotemia is prerenal, renal, or postrenal in origin, or whether the disease process is acute or chronic, reversible or irreversible, progressive or nonprogressive. before beginning treatment for azotemia, the location or cause of the azotemia must be identified. take a thorough history and then perform a physical examination. obtain blood and urine samples before initiating fluid therapy, for accurate assessment of the location of the azotemia. for example, an azotemic animal with a history of vomiting and diarrhea that appears clinically dehydrated on physical examination, normally should have a concentrated urine specific gravity (>1.045) reflecting the attempt to conserve fluid. if this level is found, the azotemia is much less likely to be renal in origin, and the azotemia will likely resolve after rehydration. if, however, the urine specific gravity is isosthenuric or hyposthenuric (1.007-1.015) in the presence of azotemia and dehydration, primary intrinsic renal insufficiency is likely present. if the azotemia resolves with fluid therapy, the patient has prerenal and primary renal disease. if the azotemia does not resolve after rehydration, the patient has prerenal and primary renal failure. dogs with hypoadrenocorticism can have both prerenal and primary renal disease secondary to the lack of mineralocorticoid (aldosterone) influence on the renal collecting duct and renal interstitial medullary gradient. medullary washout can occur, causing isosthenuric urine in the presence of dehydration from vomiting and diarrhea. the patient often has azotemia due to fluid loss (dehydration and urinary loss) and gastric or intestinal hemorrhage (elevated bun). the prerenal component will resolve with treatment with glucocorticoids and crystalloid fluids, but the renal component may take several weeks to resolve, until the medullary concentration gradient is reestablished with the treatment and influence of mineralocorticoids. drugs such as corticosteroids and diuretics can influence renal tubular uptake and excretion of fluid, and cause a prerenal azotemia and isosthenuric urine in the absence of primary renal disease. treatment of azotemia includes calculation of the patient's dehydration estimate and maintenance fluid volumes, and administering that volume over the course of 24 hours. identify and treat underlying causes of prerenal azotemia (shock, vomiting, diarrhea). monitor urine output closely. once a patient is euvolemic, oliguria is defined as urine output <1-2 ml/kg/hour. urine output should return to normal in patients with prerenal azotemia as rehydration occurs. if a patient remains oliguric after rehydration, consider the possibility of oliguric acute intrinsic renal failure, and administer additional fluid therapy based on the patient's urine output, body weight, central venous pressure, and response to other medical therapies. prerenal azotemia is caused by conditions that decrease renal perfusion, including hypovolemic shock, severe dehydration, hypoadrenocorticism, congestive heart failure, cardiac tamponade, cardiac dysrhythmias, and hypotension. once renal perfusion is restored, the kidneys can resume normal function. glomerular filtration rate decreases when the mean arterial blood pressure falls to less than 80 mm hg in a patient with normal renal autoregulation. renal autoregulation can be impaired in some diseases. passive reabsorption of urea from the renal tubules can occur during states of low tubular flow (dehydration, hypotension) even if glomerular filtration is not decreased. if renal hypoperfusion is not quickly restored, the condition can progress from prerenal disease to acute intrinsic renal failure. prerenal and renal azotemia can coexist in animals with primary renal disease, as a result of vomiting and ongoing polyuria in the absence of any oral fluid intake. the treatment of prerenal azotemia consists of rehydration, antiemetic therapy, and treatment of the underlying cause of vomiting, diarrhea, or third spacing of fluids. acute intrinsic renal failure is characterized by an abrupt decline in renal function to the extent that azotemia and an inability to regulate solute and fluid balance. patients with acute intrinsic renal failure may be oliguric or polyuric, depending on the cause and state of renal failure. in small animals, the most common causes of acute intrinsic renal failure are renal ischemia and toxins. there are three phases of acute intrinsic renal failure: induction, maintenance, and recovery. during the induction phase, some insult (ischemia or toxin) to the kidneys occurs, leading to a defective concentrating mechanism, decreased renal clearance of nitrogenous waste (azotemia), and polyuria or oliguria. if treatment is initiated during the induction phase, progression to the maintenance phase potentially can be stopped. as the induction phase progresses, there is worsening of the urine-concentrating ability and azotemia. renal tubular epithelial cells and renal tubular casts can be seen on examination of the urine sediment. glucosuria may be present. the maintenance phase of acute intrinsic renal failure occurs after a critical amount of irreversible nephron injury. correction of the azotemia and removal of the cause of the problem do not result in return to normal function. in patients with oliguria, the extent of nephron damage is greater than that observed in patients with polyuria. the maintenance phase may last for several weeks to months. recovery of renal function may or may not occur, depending on the extent of injury. the most serious complications (overhydration and hyperkalemia) are observed in patients with oliguria. the recovery phase occurs with sufficient healing of damaged nephrons. azotemia may resolve, but concentrating defects may remain. if the patient was oliguric in the maintenance phase, a marked diuresis develops during the recovery phase that may be accompanied by fluid and electrolyte losses. this phase may last for weeks to months. treatment of acute intrinsic renal failure consists of determining the cause and ruling out obstruction or uroabdomen whenever possible. a careful history can sometimes determine whether there has been exposure to nephrotoxic drugs, chemicals, or food items. if ingestion or exposure to a toxic drug, chemical, or food occurred recently (within 2 to 4 hours), induce emesis with apomorphine (0.04 mg/kg iv). next, administer activated charcoal either orally or via stomach tube, to prevent further absorption of the toxin. obtain blood and urine samples for toxicologic analysis (e.g., ethylene glycol) and to determine whether azotemia or abnormalities in the urine sediment exist. (see section on ethylene glycol, grapes and raisins, and nonsteroidal antiinflammatory drugs). obtain a complete blood count, biochemical profile, and urinalysis to determine the presence of signs of chronic renal failure, including polyuria, polydipsia, and nonregenerative anemia. radiographs and abdominal ultrasound can help in determining the chronicity of renal failure. normal renal size is 2.5-3.5 times the length of l2 in dogs and 2.4-3.0 times the length of l2 in cats. monitor the patient's body weight at least twice a day to avoid overhydration. also monitor urine output; normal output is 1-2 ml/kg/hour. in cases of polyuric renal failure, massive fluid and electrolyte losses can occur. place a urinary catheter for patient cleanliness and to facilitate urine quantitation. measure fluid ins and outs (see section on fluid therapy). after the patient has been rehydrated, the amount of fluids administered should equal maintenance and insensible needs plus the volume of urine produced each day. if a urinary catheter cannot be placed or maintained, serial body weight measurements and central venous pressure should be used to monitor the patient's fluid balance and prevent overhydration. if the patient is oliguric (urine output <1-2 ml/kg/hour), pharmacologic intervention is necessary to increase urine output. first, administer furosemide (2-4 mg/kg or 0.66 mg/kg/hour iv cri). repeat bolus doses of furosemide if there is no response to initial treatment. if necessary, administer low-dose dopamine (3-5 âµg/kg/minute iv cri) to increase renal afferent dilatation and renal perfusion. dopamine and furosemide may be synergistic if administered together. if dopamine and furosemide therapy is ineffective, administer mannitol (0.25-0.5 g/kg iv) once only. if polyuria is present, management is 1 simplified because of the decreased risk of overhydration. if oliguria cannot be reversed, monitor the central venous pessure, body weight, and respiratory rate and effort, auscultate for crackles, and examine the patient carefully for signs of chemosis and the presence of serous nasal discharge. correct hyperkalemia with sodium bicarbonate (0.25-1.0 meq/kg iv) or with insulin (0.25 units/kg) plus dextrose (1 g/unit of insulin iv, followed by 2.5% dextrose iv cri). treat severe metabolic acidosis (ph <7.2 or hco 3 â�� <12 meq/l) with sodium bicarbonate. if anuria develops or oliguria is irreversible despite this therapy, begin peritoneal dialysis. obtain a renal biopsy to establish a diagnosis and prognosis (see section on renal biopsy). administer gastroprotectant drugs and antiemetics to control nausea and vomiting. if possible, avoid the use of nephrotoxic drugs and general anesthesia. initiate nutritional support in the form of an enteral feeding tube or parenteral nutrition as early as possible. once the patient enters the recovery phase, diuresis may occur that can lead to dehydration and electrolyte imbalances (hyponatremia, hypokalemia). dehydration and electrolyte imbalances can be treated with parenteral fluid and electrolyte supplementation. postrenal azotemia is primarily caused by urethral obstruction or leakage from the urinary tract into the abdomen (uroabdomen). complete urinary tract obstruction and uroabdomen are both ultimately fatal within 3 to 5 days if left untreated. in dogs, the most common causes of urethral obstruction are urinary (urethral) calculi or tumors of the urinary bladder or urethra. in male cats, feline urologic syndrome (fus) is the most common cause of urethral obstruction, although there has been an increased incidence of urethral calculi observed in recent years. a ruptured urinary bladder is the most common cause of uroabdomen and is usually secondary to blunt trauma. clinical signs of urinary tract obstruction include dysuria, hematuria, inability to urinate or initiate an adequate stream of urine, and a distended painful urinary bladder. late in the course of obstructive disease, clinical signs referable to uremia and azotemia (vomiting, oral ulcers, hematemesis, dehydration, lethargy, and anorexia) occur. the initial goal of treatment of urinary tract obstruction is to relieve the obstruction. in male dogs, a lubricated catheter can be inserted past the area of obstruction with the animal under heavy sedation or general anesthesia (see section on urohydropulsion). depending on the chronicity of the obstruction, serum electrolytes should be measured;an ecg should be obtained before administering any anesthetic drugs, because of the cardiotoxic effects of hyperkalemia (see section on atrial standstill). correct fluid, electrolyte, and acid-base abnormalities. if a urinary catheter cannot be placed, perform cystocentesis only as a last resort, because of the risk of urinary bladder rupture. definitive treatment includes identification and treatment of the underlying cause (tumor versus urinary calculi). in most cases, surgical intervention is necessary. if an unresectable tumor is present, a low-profile permanent cystostomy tube can be placed, if the owner desires. administration of piroxicam (feldene, 0.3 mg/kg po q24-48h) with or without chemotherapy may shrink the tumor mass and delay the progression of clinical signs. a complete discussion of this disorder is beyond the scope of this text (see additional reading for other sources of information). feline lower urinary tract disease can cause urethral obstruction, particularly in male cats. clinical signs include stranguria, dribbling of small amounts of urine, lethargy, inappetence, and vomiting. often, owners call with the primary complaint of constipation, because the cat is making frequent trips to the litterbox and straining. cases with a duration of obstruction <36 hours are considered uncomplicated; those with a duration >36 hours are complicated. treatment of urethral obstruction includes stabilizing and normalizing the patient's electrolyte status, induction of sedation or general anesthesia, and relieving the obstruction. obtain blood samples for analysis of electrolyte abnormalities. treat hyperkalemia (k + > 6.0 meq/l) with sodium bicarbonate (0.25-1.0 meq/kg iv), regular insulin (0.25 unit/ kg iv) plus dextrose (1 g//unit of insulin iv), followed by 2.5% dextrose iv cri to prevent hypoglycemia; or calcium gluconate (0.2 ml/kg 10% iv slowly). administer non-potassiumcontaining intravenous fluids in 0.9% saline solution. obtain an ecg to detect atrial standstill (see section on atrial standstill). in some cases, a urethral plug is visible at the tip of the penis. the urethral plug can sometimes be manually extracted or massaged from the penis, and the obstruction temporarily relieved. in such cases, it is still necessary to pass a urethral catheter to flush sediment from the urethra and urinary bladder. unless a patient is obtunded, administer an anesthetic such as ketamine, atropine, or propofol (4-7 mg/kg iv) with diazepam iv for patient comfort and muscle relaxation. once the patient is under anesthesia or heavily sedated, urinary catheterization should be performed. in some cases, it will be difficult to advance the catheter. lubricate a closedended tomcat catheter and pass the tip into the distal urethra. fill a 12-ml syringe with sterile saline and sterile lubricant and connect the syringe to the hub of the catheter. pulse the fluid into the catheter as you gently move the catheter tip back and forth against the urethral obstruction. when the catheter has been passed into the urinary bladder, obtain a urine sample for urinalysis. drain the bladder and flush with sterile saline solution until the urine efflux appears clear. remove the tomcat catheter and insert a 3-5 fr red rubber tube or argyle infant feeding catheter into the urethra for urine collection and quantitation. secure the urinary catheter to prepuce with a butterfly strip of 1-inch adhesive tape secured around the catheter and then sutured to either side of the prepuce. the catheter should be connected to a closed urinary collection system for cleanliness and to reduce the risk of ascending bacterial infection. an elizabethan collar should be placed at all times to prevent the patient from damaging or removing the catheter. when the urethral obstruction has been relieved and the catheter placed, continue intravenous fluid diuresis to alleviate postrenal azotemia. monitor the urine for bacteria and other sediment. in some cases, postobstructive diuresis can be severe. carefully monitor fluid ins and outs, along with body weight, to maintain adequate hydration and perfusion. remove the urinary catheter can be removed after 24 to 48 hours. palpate the bladder frequently to make sure that the patient is voiding normally and to detect the recurrence of obstruction. in patients with severe penile or urethral trauma or edema, administer a short-acting steroid (dexamethasone sodium phosphate, 0.25 mg/kg iv, im, sq). at the time of initial diagnosis and again at the time of discharge, the clients need to be instructed about the long-term management of feline lower urinary tract disease at home, and informed of the risks and consequences of recurrence. uroabdomen can occur from trauma or leakage from the kidneys, ureter, or urinary bladder. clinical signs of uroabdomen (azotemia, uremia, hyperkalemia) can also occur secondary to third spacing of urine and leakage into muscular tissue from a ruptured urethra. in most cases, urinary bladder trauma and rupture are secondary to blunt trauma. abdominocentesis should be performed in any animal with suspected blunt abdominal trauma, and any fluid obtained should be analyzed for creatinine or potassium and compared with the patient's serum levels. an abdominal effusion that has a low packed cell volume and a potassium or creatinine level greater than that of the patient's serum is consistent with the diagnosis of uroabdomen. uroabdomen is not a surgical emergency. however, medical management consists of placement of a temporary abdominal drainage catheter into the abdomen, to facilitate removal of urine from the peritoneal cavity. to place the catheter, position the patient in dorsal or lateral recumbency, shave the ventral abdomen, as for any exploratory laparotomy. aseptically scrub the clipped area, and instill a local anesthestic (lidocaine, 1-2 mg/kg) caudal and to the right of the umbilicus, through the skin, subcutaneous tissues, and rectus 290 1 emergency care clinical differentiation of acute necrotizing from chronic nonsuppurative pancreatitis in cats: 63 cases acute pancreatitis in dogs mesenteric volvulus in the dog: a retrospective study of 12 cases incidence and prognostic value of low plasma ionized calcium concentration in cats with pancreatitis: 46 cases (1996-1998) review of feline pancreatitis. part 2: clinical signs, diagnosis and treatment gastric dilatation-volvulus syndrome in dogs diagnostic approach to acute pancreatitis pathophysiology of organ failure in severe acute pancreatitis in dogs washabau rj: gastrointestinal motility disorders and gastrointestinal prokinetic therapy watson pt: exocrine pancreatic insufficiency as an end-stage of pancreatitis in 4 dogs clinical signs, underlying cause, and outcome in cats with seizures: 17 cases fibrocartilaginous embolism in 75 dogs: clinical findings and factors influencing the recovery rate kirk's current veterinary therapy xiii intervertebral disc extrusion in six cats medical management of acute spinal cord disease risk factors for recurrence of clinical signs associated with thoracolumbar intervertebral disk herniation in dogs: 229 cases intervertebral disk disease in 10 cats long-term functional outcome of dogs with severe injuries of the thoracolumbar spinal cord: 87 cases canine status epilepticus: a retrospective study of 50 cases risk factors for development of status epilepticus in dogs with idiopathic epilepsy and effects of status epilepticus on outcome and survival time: 32 cases (1990-1996) skills laboratory part i: performing a neurologic examination skills laboratory part ii: interpreting the results of the neurologic examination accuracy of localization of cervical intervertebral disk extrusion or protrusion using survey radiography in dogs medical and surgical management of the glaucoma patient the feline glaucomas: 82 cases (1995-1999) the canine glaucomas traumatic ocular protrusion in dogs and cats: 84 cases traumatic glaucoma in a dog ocular and orbital porcupine quills in the dog: a review and case series hyphema: pathophysiologic considerations. comp cont educ pract vet van der woerdt a: the treatment of acute glaucoma in dogs and cats administer crystalloid intravenous fluids at maintenance rates using a balanced electrolyte solution perform urinary catheterization and collection to monitor urine output monitor serum urea nitrogen and creatinine every 12 hours treat oliguria, defined as a drop in urine output to less than 1 ml/kg/hour ml/kg) bolus start dopamine at 3 to 5 âµg/kg/minute if no response to crystalloid/colloid bolus occurs within 30 minutes consider mannitol (0.5 to 1 g/kg iv) administration if no response to dopamine occurs within 30 minutes consider furosemide (4 to 8 mg/kg iv, or 0.66 to 1 mg/kg/hour iv cri) if no response to dopamine or mannitol occurs in 30 to 60 minutes if no response to furosemide, peritoneal dialysis or hemodialysis is indicated immediately, particularly if anuria is present administered with caution, because of the risk of exacerbating increased capillary permeability and causing pulmonary edema. animal patients. chlorphenoxy derivatives exert their toxic effects by an unknown mechanism, and cause clinical signs of gastroenteritis and muscle rigidity severe anemia should be treated with packed rbcs or hemoglobin-based oxygen carriers handbook of small animal toxicology and poisonings macadamia nut toxicosis in dogs the recognition and treatment of the intermediate syndrome of organophosphate poisoning in a dog acute renal failure in four dogs after raisin or grape ingestion pleural effusion in cats pulmonary function, ventilator management, and outcome of dogs with thoracic trauma and pulmonary contusions: 10 cases (1994-1998) acute lung injury and acute respiratory distress syndrome smoke exposure in cats: 22 cases (1986-1997) smoke exposure in dogs: 27 cases (1988-1997) thoracic duct ligation and pericardectomy for treatment of idiopathic chylothorax use of intraluminal nitinol stents in the treatment of tracheal collapse in a dog clinical approach to epistaxis the veterinary icu book. teton newmedia radiographic diagnosis of diaphragmatic hernia: review of 60 cases in dogs and cats tracheal collapse: diagnosis and medical and surgical management acute respiratory distress syndrome brachycephalic syndrome in dogs outcome and postoperative complications in dogs undergoing surgical treatment of laryngeal paralysis: 140 cases (1985-1998) full recovery following delayed neurologic signs after smoke inhalation in a dog aspiration pneumonitis the veterinary icu book. teton newmedia allergic airway disease canine pleural and mediastinal effusion, a retrospective study of 81 cases suggested strategies for ventilatory management in veterinary patients with acute respiratory distress syndrome laryngeal and tracheal disorders the veterinary icu book. teton newmedia medical and surgical treatment of pyothorax in dogs: 26 cases traumatic diaphragmatic hernia in cats: 34 cases canine pyothorax: clinical presentation, diagnosis, and treatment canine pyothorax: pleural anatomy and pathophysiology treatment of chronic pleural effusion with pleuroperitoneal shunt in dogs: 14 cases (1985-1999) effects of doxapram hydrochloride on laryngeal function of normal dogs and dogs with naturally occurring laryngeal paralysis an overview of positive pressure ventilation risk factors, prognostic indicators, and outcome of pyothorax in cats: 80 cases (1986-1999) use of percutaneous arterial embolization for the treatment of intractable epistaxis in 3 dogs systemic inflammatory response syndrome, sepsis, and multiple organ dysfunction cardiogenic shock and cardiac arrest hemostatic changes in dogs with naturally occurring sepsis multiple organ dysfunction syndrome in humans and dogs increased lactate concentrations in ill and injured dogs the role of albumin in health and disease pathophysiologic characteristics of hypovolemic shock usefulness of systemic inflammatory response syndrome criteria as an index for prognosis judgement current principles and application of d-dimer analysis in small animal practice choosing fluids in traumatic hypovolemic shock: the role of crystalloids, colloids and hypertonic saline colloid and crystalloid resuscitation thromboembolic disease: predispositions and management marks sl: systemic arterial thromboembolism retrospective study of streptokinase administration in 46 cats with arterial thromboembolism feline arterial thromboembolism: an update arterial thromboembolism in cats: acute crises in 127 cases (1992-2001) and long-term management with low-dose aspirin in 24 cases cut multiple holes in the side of a 14-16 fr red rubber tube or thoracic drainage catheter, using care not to make the cut wider than 50% of the circumference of the tube. insert the catheter into the abdominal cavity in a dorsal caudal direction. make sure that all incisions within the abdomen. secure the tube by placing a pursestring suture around the tube entrance site in the abdominal musculature with absorbable suture material. close the dead space in the subcutaneous tissues with absorbable suture. close the skin around the tube with another purse-string suture secured using a finger-trap technique. connect the tube to a closed urinary collection system and bandage the catheter to the abdomen. the tube can remain in place until the patient retrospective evaluation of acute renal failure in dogs uroabdomen in dogs and cats drug-induced nephrotoxicity: recognition and prevention peritoneal dialysis in emergency and critical care acute renal failure caused by lily ingestion in six cats early diagnosis of renal disease and renal failure acute renal failure in four dogs after raisin or grape ingestion disorders of the feline lower urinary tract the use of a low-profile cystostomy tube to relieve urethral obstruction in a dog renal biopsy: methods and interpretation feline idiopathic cystitis: current understanding of pathophysiology and management today's problem when did you first notice that something was wrong with your pet? when was the last time you noticed your pet act normally? what was the first abnormal sign noticed? what other conditions have developed and what are they? how soon did other signs develop? have the signs become better or worse since you first saw them? what is the name of the product? do you have the container with you today? is it a liquid concentrate, dilute spray, or solid? how long ago do you think that your pet was exposed to the poison? where do you think it happened? do you have any over-the-counter or prescription medications that your animal may have had access to? did you give any medications to your animal? is there any possibility of recreational drug exposure?your pet's recent activity did your pet eat this morning or last night? what is he/she normally fed? is there a chance that your pet may have gotten into the garbage? have you fed table scraps or anything new recently? if so, what? has your pet been off your property in the last 24-48 hours? does your pet run loose unattended? has your pet had any antiflea/tick medication within the last week?your pet's environment is your animal kept inside or outside of the house? is your pet kept in a fenced-in yard or allowed to run loose unattended? does your pet have access to neighboring properties (even for a short time)? where has your pet been in the last 24 hours? has your pet traveled outside of your immediate geographic location? if so, when? has your pet been to rural areas in the last week? has there been any gardening work recently? does your pet have access to a compost pile? any fertilizers or weed killer used in the last week? any construction work or renovation recently? any mouse or rat poison in your house, yard, or garage? any cleaning products used inside or outside the house within the last 48 hours? if so, which? have you changed your radiator fluid or does a car leak antifreeze? induce and maintain a patent airway and stabilize the patient's cardiovascular and respiratory status. control cns excitation with diazepam, if necessary, and control the patient's body temperature (both hypo-and hyperthermia) . induce vomiting if the patient is alert and can protect its airway; otherwise, perform orogastric lavage with the patient under general anesthesia with a cuffed endotracheal tube in place. alcohols do not bind well with activated charcoal. treat dermal exposure by bathing the area with warm water. introduction: if ingested, sodium or potassium hydroxide can cause severe contact dermatitis or irritation of the gastrointestinal tract. esophageal burns and full-thickness coagulative necrosis can occur. if an animal ingests a caustic alkali substance, feed the animal four egg whites mixed with 1 quart of warmed water. perform endoscopy within 24 hours to evaluate the extent of injury and to place a feeding tube, in severe cases. do not induce emesis , and do not perform orogastric lavage, because of the risk of worsening esophageal irritation. in cases of contact exposure to the skin or eyes, rinse the exposed area with warm water baths for at least 30 minutes. administer gastroprotectant, antiemetic, and analgesic drugs as necessary. avoid neutralization, which can cause a hyperthermic reaction and worsen injury to the skin and gastrointestinal tract. amitraz is the active ingredient in ascaricides and anti-tick and anti-mite products such as mitaban and taktic. the toxic dose is 10 to20 mg/kg. amitraz exerts its toxic effects by causing î±-adrenergic stimulation, and causes clinical signs similar to those observed with administration of xylazine: bradycardia, cns depression, ataxia, hypotension, hyperglycemia, hypothermia, cyanotic mucous membranes, polyuria, mydriasis, and emesis. a coma can develop. treatment of amitraz intoxication includes cardiovascular support with intravenous crystalloid fluids and induction of emesis in asymptomatic animals. if clinical signs are present, orogastric lavage may be required. many toxic compounds are impregnated in a collar form. if the patient has ingested a collar and does not vomit it, it should be removed using endoscopy or gastrotomy. administer activated charcoal to prevent or delay absorption of the toxic compound. yohimbine or atepamizole, both î±-adrenergic antagonists, are the treatment(s) of choice to reverse the clinical signs of toxicity. avoid the use of atropine, because it can potentially increase the viscosity of respiratory secretions and cause gastrointestinal ileus, thus promoting increased absorption of the toxic compound. ammonium hydroxide, or cleaning ammonia, can be caustic at high concentrations (see alkalis/caustics) and cause severe injury to the respiratory system if inhaled. pulmonary edema or pneumonia can occur, resulting in respiratory distress. ingestion of ammonia can cause severe irritation to the gastrointestinal tract and cause vomiting and esophageal injury. if ammonia is ingested, administer a dilute solution of egg white.administer gastroprotectant, antiemetic, and analgesic drugs as necessary. if pneumonia or pulmonary edema occurs secondary to aspiration of ammonia into the airways and alveolar spaces, treatment is largely supportive with supplemental oxygen administration, antibiotics, fluid therapy, and mechanical ventilation as necessary. diuretics may or may not be useful in the treatment of pulmonary edema secondary to ammonia inhalation. amphetamines cause cns excitation due to neurosynaptic stimulation, resulting in hypersensitivity to noise and motion, agitation, tremors, vomiting, diarrhea, and seizures. clinical signs of amphetamine toxicity include muscle tremors, tachyarrhythmias, mydriasis, ptyalism, and hyperthermia. amphetamines are rapidly absorbed from the gastrointestinal tract. treatment includes administration of intravenous fluids to maintain hydration and renal perfusion and correction of hyperthermia. administer sedative drugs such as chlorpromazine to control agitation and tremors, and diazepam to control seizures. urinary acidification can promote excretion and prevent reabsorption from the urinary bladder. in severe cases, treat cerebral edema with a combination of mannitol followed by furosemide to control increased intracranial pressure.antifreeze: see ethylene glycol antihistamines introduction antihistamines (loratadine, diphenhydramine, doxylamine, clemastine, meclizine, dimenhydrinate, chlorpheniramine, cyclizine, terfenadine, hydroxyzine) are available as over-thecounter and prescription allergy and anti-motion sickness products. clinical signs of antihistamine toxicity include restlessness, nausea, vomiting, agitation, seizures, hyperthermia, and tachyarrhythmias. treatment of antihistamine intoxication is largely symptomatic and supportive, as there is no known antidote. if ingestion is recent (within 1 to 2 hours) and the patient is not actively seizing and can protect its airway, induce emesis or perform orogastric lavage, followed by administration of activated charcoal and a cathartic. monitor the patient's heart rate, rhythm, and blood pressure. treat cardiac arrhythmias, if present, with appropriate therapies (see section on cardiac dysrhythmias). administer cooling measures and intravenous fluids to treat hyperthermia. a constant rate infusion of guaifenasin can be used to control muscle tremors. introduction î±-naphthylthiourea (antu) is manufactured as a white or blue-gray powder. the toxic dose in dogs is 10-40 mg/kg, and in cats is 75-100 mg/kg. younger dogs appear to be more resistant to its toxic effects. antu usually causes profound emesis and increased capillary permeability that eventually leads to pulmonary edema. treatment of antu toxicity includes respiratory support. mechanical ventilation may be required in severe cases of pulmonary edema. if an animal does not vomit, orogastric lavage should be performed. administer gastrointestinal protectant, antiemetic, and analgesic drugs. cardiovascular support in the form of intravenous crystalloids should be arsenic introduction inorganic arsenic (arsenic trioxide, sodium arsenite, sodium arsenate) is the active ingredient in many herbicides, defoliants, and insecticides, including ant killers. the toxic dose of sodium arsenate is 100-150 mg/kg; that of sodium arsenite is 1-25 mg/kg. sodium arsenite is less toxic, although cats are very susceptible. arsenic compounds interfere with cellular respiration by combining with sulfhydryl enzymes. clinical signs of toxicity include severe gastroenteritis, muscle weakness, capillary damage, hypotension, renal failure, seizures, and death. in many cases, clinical signs are acute in onset. treatment of arsenic toxicity involves procuring and maintaining a patent airway. administer intravenous crystalloid fluids to correct hypotension and hypovolemia, and normalize acidbase and electrolyte balance. if no clinical signs are present and if the compound was ingested within 2 hours, induce emesis. if clinical signs are present, perform orogastric lavage followed by administration of activated charcoal. if dermal exposure has occurred, throughly bathe the animal to prevent further absorption. dimercaprol (bal, 3-4 mg/kg im q8h) can be administered as a chelating agent. n-acetylcysteine (mucomyst) (for cats, 140-240 mg/kg po iv, then 70 mg/kg po iv q6h for 3 days; for dogs, 280 mg/kg po or iv, then 140 mg/kg po iv q4h for 3 days) has been shown to decrease arsenic toxicity in rats. aspirin causes inhibition of the production of prostaglandins, a high anion gap metabolic acidosis, gastrointestinal ulceration, hypophosphatemia, and decreased platelet aggregation when ingested in high quantities (>50 mg/kg/24 hours in dogs; >25 mg/kg/24 hours in cats). clinical signs of aspirin toxicity include tachypnea, vomiting, anorexia, lethargy, hematemesis, and melena. treatment of aspirin toxicity is largely supportive. if the ingestion was recent (within the last hour), induce emesis or perform orogastric lavage followed by administration of activated charcoal. administer intravenous crystalloid fluids to maintain hydration and correct acid-base abnormalities. administer synthetic prostaglandin analogues (misoprostol), gastroprotectant drugs, and antiemetics. alkalinization of the urine can enhance excretion. introduction baclofen is a gaba agonist centrally acting muscle relaxant. clinical signs of toxicity include vomiting, ataxia, vocalization, disorientation, seizures, hypoventilation, coma, and apnea. clinical signs can occur at doses as low as 1.3 mg/kg. treatment of baclofen ingestion includes induction of emesis if the animal is asymptomatic. otherwise, perform orogastric lavage. emesis or orogastric lavage should be followed by administration of activated charcoal. perform intravenous crystalloid fluid diuresis to promote elimination of the toxin, maintain renal perfusion, and normalize body temperature. supplemental oxygen or mechanical ventilation may be required for hypoventilation or apnea. if seizures occur, avoid the use of diazepam, which is a gaba agonist and can potentially worsen clinical signs. control seizures with intravenous introduction î²-adrenergic agonists, including terbutaline, albuterol (salbutamol), and metaproterenol, are commonly used in inhaled form for the treatment of asthma. animals commonly are exposed to the compounds after chewing on their owners' inhalers. clinical signs of î²-adrenergic stimulation include tachycardia, muscle tremors, and agitation. severe hypokalemia can occur. treatment of î²-adrenergic agonist intoxication includes treatment with beta-blockers (propranolol, esmolol, atenolol), intravenous fluids, and intravenous potassium supplementation. diazepam or acepromazine may be administered for sedation and muscle relaxation. introduction barbiturates such as phenobarbital are gaba agonists and induce cns depression. clinical signs of barbiturate overdose or toxicity include weakness, lethargy, hypotension, hypoventilation, stupor, coma, and death. treatment of barbiturate toxicity includes maintenance and support of the cardiovascular and respiratory systems. if clinical signs are absent and the patient can protect its airway, induce emesis followed by repeated doses of activated charcoal. perform orogastric lavage if emesis is contraindicated. administer supplemental oxygen if hypoventilation occurs. some animals may require mechanical ventilation. administer intravenous fluids to control perfusion and blood pressure. positive inotropic drugs may be required if dosedependent decrease in cardiac output and blood pressure occurs. alkalinization of the urine and peritoneal dialysis can be performed to enhance excretion and elimination. hemodialysis should be considered in severe cases, if available. automotive and dry cell batteries contain sulfuric acid that can be irritating on contact with the eyes, skin, and gastrointestinal tract. button batteries, which contain sodium or potassium hydroxide, cause contact irritation if chewed. to treat exposure, rinse the eyes and skin with copious amounts of warm tap water or sterile saline solution for a minimum of 30 minutes. if ingestion occurred, administer gastroprotectant and antiemetic drugs. induction of emesis and orogastric lavage is absolutely contraindicated because of the risk of aspiration pneumonia and worsening esophageal irritation. no attempt should be made at performing neutralization because of the risk of causing an exothermic reaction and worsening tissue damage. administer analgesics to control discomfort. benzoyl peroxide is the active ingredient in many over-the-counter acne preparations. ingestion can result in production of hydrogen peroxide, gastroenteritis, and gastric dilatation. topical exposure can cause dermal irritation and blistering. if an animal has ingested benzoyl peroxide, do not induce emesis, because of the risk of worsening esophageal irritation. instead, perform orogastric lavage. administer gastroprotectant and antiemetic medications and closely observe the patient observed for signs of gastric dilatation.bismuth subsalicylate (pepto-bismol): see aspirin bleach, chlorine (sodium hypochlorite) introduction sodium hypochlorite is available in dilute (3%-6%) or concentrated (50% industrial strength or swimming pool) solutions for a variety of purposes. sodium hypochlorite can cause severe contact irritation and tissue destruction, depending on the concentration. affected animals may have a bleached haircoat. treatment of exposure includes dilution with copious amounts of warm water or saline baths and ocular lavage. induction of emesis and orogastric lavage is absolutely contraindicated because of the risk of causing further esophageal irritation. to treat ingestion, give the animal milk or large amounts of water, in combination with gastroprotectant and antiemetic drugs, to dilute the contents in the stomach. administration of sodium bicarbonate or milk of magnesia is no longer recommended. nonchlorine bleaches (sodium peroxide or sodium perborate) have a moderate toxic potential if ingested. sodium peroxide can cause gastric distention. sodium perborate can cause severe gastric irritation, with vomiting and diarrhea; renal damage and cns excitation followed by depression can occur, depending on the amount ingested. to treat dermal or ocular exposure, rinse the skin or eyes with copious amounts of warm tap water or sterile saline for a minimum of 30 minutes; treat ocular injuries as necessary, if corneal burns have occurred. if the bleach has been ingested, do induce emesis and perform orogastric lavage. administer milk of magnesia (2-3 ml/kg). boric acid is the active ingredient in many ant and roach killers. the toxic ingredient (in amounts of 1-3 g/kg) can cause clinical signs in dogs by an unknown mechanism. clinical signs include vomiting (blue-green vomitus), blue-green stools, renal damage, and cns excitation and depression. treatment of boric acid or borate ingestion includes gastric decontamination with induction of emesis or orogastric lavage, followed by administration of a cathartic to hasten elimination. activated charcoal is not useful to treat ingestion of this toxin. administer intravenous fluid therapy to maintain renal perfusion. administer gastroprotectant and antiemetic drugs, as necessary. clostridium botulinum endospores can be found in carrion, food, garbage, and the environment. ingestion of endospores and c. botulinum endotoxin rarely can cause generalized neuromuscular blockade of spinal and cranial nerves, resulting in miosis, anisocoria, lower motor neuron weakness, and paralysis. respiratory paralysis, megaesophagus, and aspiration pneumonia can occur. clinical signs usually develop within 6 days of ingestion. differential diagnosis includes acute polyradiculoneuritis (coonhound paralysis), bromethalin intoxication, and tick paralysis. treatment of botulism is largely supportive; although an antitoxin exists, it often is of no benefit. treatment may include administration of intravenous fluids, frequent turning of the patient and passive range-of-motion exercises to prevent disuse muscle atrophy, and supplemental oxygen administration or mechanical ventilation. administer amoxicillin, ampicillin, or metronidazole. recovery may be prolonged, up to 3 to 4 weeks in some cases. bromethalin is the active ingredient in some brands of mouse and rat poisons. it usually is packaged as 0.01% bromethalin in green or tan pellets, and packaged in 16 -42.5 g place packs. the toxic dose for dogs is 116.7 g/kg, and for cats 3 g/kg. bromethalin causes toxicity by uncoupling of oxidative phosphorylation. an acute syndrome of vomiting, tremors, extensor rigidity, and seizures occurs within 24 hours of ingestion of high doses. delayed clinical signs occur within 3 to 7 days of ingestion of a lower dose and include posterior paresis progressing to ascending paralysis, cns depression, and coma. treatment of known bromethalin ingestion includes induction of emesis or orogastric lavage, and repeated doses of activated charcoal every 4 to 6 hours for 3 days, because bromethalin undergoes enterohepatic recirculation. supportive care includes intravenous fluids, anticonvulsants, muscle relaxants (methocarbamol up to 220 mg/kg/day iv to effect), frequent turning of the patient, and passive range-of-motion exercises. supplemental oxygen and /or mechanical ventilation may be required in patients with coma and severe hypoventilation. administer mannitol (0.5-1 g/kg) in conjunction with furosemide (1 mg/kg iv) if cerebral edema is suspected. the majority of caffeine toxicities occur in dogs that ingest coffee beans. caffeine causes phosphodiesterase inhibition, and can cause cardiac tachyarrhythmias, cns stimulation (hyperexcitability and seizures), diuresis, gastric ulcers, vomiting, and diarrhea. muscle tremors and seizures can occur, resulting in severe hyperthermia. treatment of caffeine toxicity is largely symptomatic and supportive, as there is no known antidote. if clinical signs are not apparent and the patient is able to protect its airway, induce emesis. alternatively, orogastric lavage can be performed, followed by administration of activated charcoal. administer diazepam to control seizures. administer betaadrenergic blockers (e.g., esmolol, propranolol, atenolol) to control tachyarrhythmias. give intravenous fluids to maintain hydration and correct hyperthermia. the patient should be walked frequently or have a urinary catheter placed to prevent reabsorption of the toxin from the urinary bladder. carbamate compounds are found in agricultural and home insecticide products. examples of carbamates include carbofuran, aldicarb, propoxur, carbaryl, and methiocarb. the toxic dose of each compound varies. carbamate compounds function by causing acetylcholinesterase inhibition. toxic amounts cause cns excitation, muscarinic acetylcholine overload, and slud (salivation, lacrimation, urination, and defecation). miosis, vomiting, treatment of carbamate intoxication includes maintaining an airway and, if necessary, artificial ventilation. administer intravenous crystalloid fluids to control the patient's hydration, blood pressure, and temperature. cooling measures may be warranted. induce emesis if the substance was ingested within 60 minutes and the animal is asymptomatic. give repeated doses of activated charcoal if the animal can swallow and protect its airway. control seizures with diazepam (0.5 mg/kg iv). bathe the patient thoroughly. atropine (0.2 mg/kg iv) is useful in controlling some of the muscarinic signs associated with the toxicity. pralidoxime hydrochloride (2-pam) is not useful in cases of carbamate intoxication. control muscle tremors with methocarbamol (up to 220 mg/kg iv) or guaifenesin. in humans, ingestion or inhalation of 3-5 ml of carbon tetrachloride can be fatal. clinical signs of carbon tetrachloride toxicity include vomiting and diarrhea, then progressive respiratory and central nervous system depression. ventricular dysrhythmias and hepatorenal damage ensue. the prognosis is grave. treatment of carbon tetrachloride inhalation includes procurement and maintenance of a patent airway with supplemental oxygen, and cardiovascular support. to treat ingestion, administer activated charcoal, and give intravenous fluids to maintain hydration and support renal function. chlorinated hydrocarbons include ddt, methoxychlor, lindane, dieldrin, aldrin, chlordane, chlordecone, perthane, toxaphene, heptachlor, mirex, and endosulfan. the toxic dose of each compound varies. chlorinated hydrocarbons exert their toxic effects by an unknown mechanism, and can be absorbed through the skin and the gastrointestinal tract. clinical signs are similar to those observed in organophosphate toxicity: cns excitation, seizures, slud, (salivation, lacrimation, urination, defecation), excessive bronchial secretions, vomiting, diarrhea, muscle tremors, and respiratory paralysis. secondary toxicity from toxic metabolites can cause renal and hepatic failure. chronic exposure may cause anorexia, vomiting, weight loss, tremors, seizures, and hepatic failure. the clinical course can be prolonged in small animal patients. treatment of chlorinated hydrocarbon toxicity is largely supportive in nature, as there is no known antidote. procure and maintain the patient's airway. normalize the body temperature to prevent hyperthermia. if the substance was just ingested and the patient is not demonstrating any clinical signs, induce emesis. if the patient is symptomatic, perform orogastric lavage followed by activated charcoal administration. bathe the patient thoroughly in cases of topical exposure. administer intravenous crystalloid fluids to maintain hydration. these compounds do not appear to be amenable to fluid diuresis. introduction: chlorphenoxy derivatives are found in 2,4-d, 2,4,5-t, mcpa, mcpp, and silvex. the ld 50 of 2,4-d is 100 mg/kg; however, the toxic dose appears to be much lower in small treatment treatment of chlorphenoxy derivative toxicity is largely supportive in nature, as there is no known antidote. secure the patient's airway and administer supplemental oxygen, as necessary. control cns excitation with diazepam (0.5 mg/kg iv). intravenous crystalloid fluid diuresis and urinary alkalinization can promote elimination. administer gastroprotectant and antiemetic drugs, as needed. the toxic effects of chocolate are related to theobromine. various types of chocolate have different concentrations of theobromine and thus can cause clinical signs of toxicity with ingestion of varying amounts of chocolate, depending on the type. the toxic dose of theobromine is 100-150 mg/kg in dogs. milk chocolate contains 44 mg/oz (154 mg/100 g) of chocolate, and has a low toxic potential. semisweet chocolate contains 150 mg/oz (528 mg/100 g), and baking chocolate contains 390 mg/oz (1365 mg/100 g). semisweet and baking chocolate, being the most concentrated, have a moderate to severe toxic potential, even in large dogs.clinical signs of theobromine intoxication are associated with phosphodiesterase inhibition and include cns stimulation (tremors, anxiety, seizures), myocardial stimulation (tachycardia and tachyarrhythmias), diuresis, and (at very high doses) gastrointestinal ulceration. with treatment, the condition of most dogs returns to normal within 12 to 24 hours (t1 /2 = 17.5 hours in dogs). potential side effects include gastroenteritis and pancreatitis due to the fat content of the chocolate. treatment of chocolate toxicity includes obtaining and maintaining a protected airway (if necessary), intravenous fluid diuresis, induction of emesis or orogastric lavage followed by administration of repeated doses of activated charcoal, and placement of a urinary catheter to prevent reabsorption of the toxin from the urinary bladder. cholecalciferol rodenticide ingestion can lead to increased intestinal and renal reabsorption of calcium, causing an increase in serum calcium and dystrophic mineralization of the kidneys and liver at 2-3 mg/kg. clinical signs include lethargy, anorexia, vomiting, constipation, and renal pain within 2 to 3 days of ingestion. seizures, muscle twitching, and central nervous system depression may be observed at very high doses. as renal failure progresses, polyuria, polydipsia, vomiting/hematemesis, uremic oral ulcers, and melena may be observed. if the compound was ingested recently (within 2 to 4 hours) induce emesis or perform orogastric lavage, followed by administration of activated charcoal. check the patient's serum calcium once daily for three days following ingestion. if clinical signs of toxicity or hypercalcemia are present, decrease serum calcium with loop diuretics (furosemide, 2-5 mg/kg po or iv q12h) and glucocorticosteroids (prednisone or prednisolone, 2-3 mg/kg po bid) to promote renal calcium excretion. in severe cases, salmon calcitonin (4-6 iu/kg sc q2-12h in dogs) or bisphosphonate compounds may be required. correct acid-base abnormalities with intravenous crystalloid fluid diuresis and sodium bicarbonate, if necessary. (see section on hypercalcemia.) denture cleaners contain sodium perborate as the active compound. sodium perborate can cause severe direct irritation of the mucous membranes and may also act as a cns depressant. clinical signs are similar to those seen if bleach or boric acid compound is ingested, namely vomiting, diarrhea, cns excitation then depression, and renal failure. treatment for ingestion of denture cleaner includes gastric decontamination along with induction of emesis or orogastric lavage and administration of a cathartic to hasten elimination. activated charcoal is not useful for treatment of ingestion of this toxin. administer intravenous fluid therapy to maintain renal perfusion. administer gastroprotectant and antiemetic drugs, as necessary. deodorants are usually composed of aluminum chloride and aluminum chlorohydrate. both have a moderate potential for toxicity. ingestion of deodorant compounds can cause oral irritation or necrosis, gastroenteritis, and nephrosis. treatment of deodorant ingestion includes orogastric lavage, and administration of antiemetic and gastroprotectant drugs. introduction anionic detergents include sulfonated or phosphorylated forms of benzene. dishwashing liquid is an example of an anionic detergent that can be toxic at doses of 1 -5 g/kg. anionic detergents cause significant mucosal damage and edema, gastrointestinal irritation, cns depression, seizures, and possible hemolysis. ocular exposure can cause corneal ulcers and edema. treatment of anionic detergent exposure is largely symptomatic, as there is no known antidote. to treat topical toxicity, flush the patient's eyes and skin with warmed tap water or 0.9% saline solution for a minimum of 30 minutes, taking care to avoid hypothermia. to treat ingestion, feed the patient milk and large amounts of water to dilute the toxin. do not induce emesis, because of the risk of worsening esophageal irritation. to dilute the toxin, perform orogastric lavage, followed by administration of activated charcoal. closely monitor the patient's respiratory status, because oropharyngeal edema can be severe. if necessary, perform endotracheal intubation in cases of airway obstruction. monitor the patient for signs of intravascular hemolysis. administer intravenous crystalloid fluids to maintain hydration until the patient is able to tolerate oral fluids. cationic detergents and disinfectants include quaternary ammonia compounds, isopropyl alcohol, and isopropanol. quaternary ammonia compounds have a serious toxic potential treatment treatment of cationic detergent exposure includes careful bathing and ocular rinsing of the patient for a minimum of 30 minutes, taking care to avoid hypotension. secure the patient's airway and monitor the patient's respiratory status. administer supplemental oxygen, if necessary. place an intravenous catheter and administer intravenous crystalloid fluids to maintain hydration. do not induce emesis, because of the risk of causing further esophageal irritation. give milk or large amounts of water orally, as tolerated by the patient, to dilute the toxin. nonionic detergents include alkyl and aryl polyether sulfates, alcohols, and sulfonates; alkyl phenol; polyethylene glycol; and phenol compounds. phenols are particularly toxic in cats and puppies. clinical signs of exposure include severe gastroenteritis and topical irritation. some compounds can be metabolized to glycolic and oxalic acid, causing renal damage similar to that observed with ethylene glycol toxicity. topical and ocular exposure should be treated with careful bathing or ocular irrigation for at least 30 minutes. administer activated charcoal to prevent absorption of the compound. as tolerated, give dilute milk or straight tap water orally to dilute the compound. administer antiemetic and gastroprotectant drugs to control vomiting and decrease gastrointestinal irritation. administer intravenous crystalloid fluids to maintain hydration and decrease the potential for renal tubular damage. monitor the patient's acid-base and electrolyte status and correct any abnormalities with appropriate intravenous fluid therapy. introduction diclone (phigone) is a dipyridyl compound that is a cns depressant. the ld 50 in rats is 25-50 mg/kg. dichlone reacts with thiol enzymes to cause methemoglobinemia and hepatorenal damage. to treat dichlone ingestion, induce emesis or perform orogastric lavage, followed by administration of activated charcoal and a cathartic. procure and maintain a patent airway. perform intravenous fluid diuresis to maintain renal perfusion. n-acetylcysteine may be useful in the treatment of methemoglobinemia. diethyltoluamide (deet) is the active ingredient in many insect repellants (e.g., off, cutters, hartz blockade). the mechanism of action of deet is not fully understood, but it acts as a lipophilic neurotoxin within 5 to 10 minutes of exposure. cats appear to be particularly sensitive to deet. a lethal dermal dose is 1.8 g/kg; if ingested, the lethal dose is much less. the toxic dose of dermal exposure in dogs is 7 g/kg. clinical signs of toxicity include aimless gazing, hypersalivation, chewing motions, and muscle tremors that progress to seizures. recumbency and death can occur within 30 minutes of exposure at high doses. treatment of deet toxicity is largely supportive, as there are no known antidotes. procure and maintain a patent airway and perform mechanical ventilation, if necessary. place an intravenous catheter and administer intravenous crystalloid fluids to control hydration and treat hypotension, as necessary. treat seizures with diazepam (0.5 mg/kg iv) or phenobarbital. because of the rapid onset of clinical signs, induction of emesis is contraindicated. perform orogastric lavage if the compound was ingested within the last 2 hours. administer multiple repeated doses of activated charcoal. cooling measures should be implemented to control hyperthermia. if dermal exposure has occurred, bathe the patient thoroughly to avoid further exposure and absorption. diquat is a dipyridyl compound that is the active ingredient in some herbicide compounds. the ld 50 of diquat is 25-50 mg/kg. like paraquat, diquat induces its toxic effects by causing the production of oxygen-derived free radical species. clinical signs of diquat intoxication include anorexia, vomiting, diarrhea, and acute renal failure. massive dehydration and electrolyte imbalances can occur as a result of fluid loss into the gastrointestinal tract. treatment of diquat intoxication is similar to that for paraquat ingestion. if the animal had ingested diquat within 1 hour of presentation, induce emesis. in clinical cases, orogastric lavage may be required. both emesis and orogastric lavage should be followed by administration of kaolin or bentonite as an adsorbent, rather than activated charcoal. place an intravenous catheter and administer crystalloid fluids to restore volume status and maintain renal perfusion. monitor urine output. if oliguria or anuria occurs, treatment with mannitol, furosemide, and dopamine may be considered. ecstasy (3,4-methylenedioxymethylamphetamine; mdma) is a recreational drug used by humans. ecstasy causes release of serotonin. clinical signs of intoxication are related to the serotonin syndrome (excitation, hyperthermia, tremors, and hypertension), and seizures may be observed. a urine drug screening test can be used to detect the presence of mdma. treatment of ecstasy intoxication is largely supportive, as there is no known antidote. administer intravenous fluids to maintain hydration, correct acid-base status, and treat hyperthermia. serotonin antagonist drugs (cyproheptadine) can be dissolved and administered per rectum to alleviate clinical signs. intravenous propranolol has additional antiserotonin effects. administer diazepam (0.5-2 mg/kg iv) to control seizures. if cerebral edema is suspected, administer mannitol, followed by furosemide. ethylene glycol is most commonly found in antifreeze solutions but is also in some paints, photography developer solutions, and windshield wiper fluid. ethylene glycol in itself is only minimally toxic. however, when it is metabolized to glycolate, glyoxal, glyoxylate, and oxalate, the metabolites cause an increased anion gap metabolic acidosis and precipitation of calcium oxalate crystals in the renal tubules, renal failure, and (ultimately) death.the toxic dose in dogs is 6.6 ml/kg, and in cats is 1.5 ml/kg. the toxin is absorbed quite readily from the gastrointestinal tract and can be detected in the patient's serum within an hour of ingestion. colorimetric tests that can be performed in most veterinary hospitals can detect larger quantities of ethylene glycol in the patient's serum. in a dog with clinical treatment begin treatment of known ethylene glycol ingestion immediately. induce emesis or perform orogastric lavage and adminiser repeated doses of activated charcoal. place an intravenous catheter and perform crystalloid fluid diuresis with a known antidote. the treatment of choice for dogs is administration of 4-methylpyrrazole (4-mp), which directly inhibits alcohol dehydrogenase, thus preventing the conversion of ethylene glycol to its toxic metabolites. the dose for dogs is 20 mg/kg initially, followed by 15 mg/kg at 12 and 24 hours and 5 mg/kg at 36 hours. 4-mp has been used experimentally at 6.25 times the recommended dose for dogs. in cats, treatment with 4-mp is effective if it is administered within the first 3 hours of ingestion.cats will demonstrate signs of sedation and hypothermia with this treatment. if 4-mp is not available, administer ethanol (600 mg/kg iv loading dose, followed by 100 mg/ kg/hour), or as a 20% solution (for dogs, 5.5 ml/kg iv q4h for five treatments, then q 6h for five more treatments; for cats, 5 ml/kg q8h for four treatments). grain alcohol (190 proof) contains approximately 715 mg/ml of ethanol. antiemetics and gastroprotective agents should be considered. urinary alkalinization and peritoneal dialysis may enhance the elimination of ethylene glycol and its metabolites. many fertilizers are on the market, and may be composed of urea or ammonium salts, phosphates, nitrates, potash, and metal salts. fertilizers have a moderate toxic potential, depending on the type and amount ingested. clinical signs of fertilizer ingestion include vomiting, diarrhea, metabolic acidosis, and diuresis. nitrates or nitrites can cause formation of methemoglobin and chocolate-brown blood. electrolyte disturbances include hyperkalemia, hyperphosphatemia, hyperammonemia, and hyperosmolality. treatment of fertilizer ingestion includes cardiovascular support, and administration of milk or a mixture of egg whites and water, followed by induction of emesis or orogastric lavage. correct electrolyte abnormalities as they occur (see section on hyperkalemia). administer antiemetic and gastroprotectant drugs, as necessary. administer intravenous fluids to control hydration and maintain blood pressure. n-acetylcysteine may be useful if methemoglobinemia is present. fipronil is the active ingredient in frontline, a flea control product. fipronil exerts its effects by gaba antagonism and can cause cns excitation. treatment of fiprinol toxicity includes treatment of cns excitation, treatment of hyperthermia by cooling measures, and administration of activated charcoal. fire extinguisher fluid contains chlorobromomethane or methyl bromide, both of which have a serious toxic potential. dermal or ocular irritation can occur. if ingested, the compounds can be converted to methanol, and cause high anion gap metabolic acidosis, cns excitation and depression, aspiration pneumonitis, and hepatorenal damage. to treat ocular or dermal exposure to fire extinguisher fluids, flush the eyes or skin with warmed tap water or 0.9% saline solution for a minimum of 30 minutes. do not induce emesis or perform orogastric lavage to treat ingestion, because of the risk of causing severe aspiration pneumonitis. gastroprotectant and antiemetic drugs may be used, if indicated. administer intravenous fluids to maintain hydration and renal perfusion. supplemental oxygen or mechanical ventilation may be required in severe cases of aspiration pneumonitis. fireplace colors contain salts of heavy metals-namely, copper rubidium, cesium, lead, arsenic, antimony, barium, selenium, and zinc, all of which have moderate toxic potential, depending on the amount ingested and the size of the patient. clinical signs are largely associated with gastrointestinal irritation (vomiting, diarrhea, anorexia). zinc toxicity can cause intravascular hemolysis and hepatorenal damage. to treat ingestion of fireplace colors, administer cathartics and activated charcoal and gastroprotectant and antiemetic drugs. place an intravenous catheter for intravenous crystalloid fluid administration to maintain hydration and renal perfusion. specific chelating agents may be useful in hastening elimination of the heavy metals. fireworks contain oxidizing agents (nitrates and chlorates) and metals (mercury, copper, strontium, barium, and phosphorus). ingestion of fireworks can cause hemorrhagic gastroenteritis and methemoglobinemia. to treat firework ingestion, induce emesis or perform orogastric lavage and administer activated charcoal. administer specific chelating drugs if the amount and type of metal are known, and administer gastroprotectant and antiemetic drugs. if methemoglobinemia occurs, administer n-acetylcysteine; a blood transfusion may be necessary. introduction fuels such as barbecue lighter fluid, gasoline, kerosene, and oils (mineral, fuel, lubricating) are petroleum distillate products that have a low toxic potential if ingested but can cause severe aspiration pneumonitis if as little as 1 ml is inhaled into the tracheobronchial tree. cns depression, mucosal damage, hepatorenal insufficiency, seizures, and corneal irritation can occur. if fuels are ingested, administer gastroprotectant and antiemetics drugs. do not induce emesis or perform orogastric lavage, because of the risk of aspiration pneumonia. to treat topical exposure, rinse the skin and eyes copiously with warm tap water or 0.9% saline solution. administer antiemetic and gastroprotectant drugs, as necessary. administer intravenous fluids to maintain hydration and treat acid-base and electrolyte abnormalities. children's glue contains polyvinyl acetate, which has a very low toxic potential. if inhaled, the compound can cause pneumonitis. treatment of polyvinyl acetate should be performed as clinical signs of pneumonitis (increased respiratory effort, cough, lethargy, respiratory distress) occur. introduction superglue contains methyl-2-cyanoacrylate, a compound that can cause severe dermal irritation on contact. do not induce emesis. do not bathe the animal, and do not apply other compounds (acetone, turpentine) in an attempt to remove the glue from the skin. the fur can be shaved, using care to avoid damaging the underlying skin. the affected area should be allowed to exfoliate naturally. glyophosate is a herbicide found in roundup and kleenup. if applied properly, the product has a very low toxic potential. clinical signs of toxicity include dermal and gastric irritation, including dermal erythema, anorexia, and vomiting. cns depression can occur. treatment includes thorough bathing in cases of dermal exposure, and induction of emesis or orogastric lavage followed by administration of activated charcoal. administer antiemetic and gastroprotectant drugs as necessary. administer intravenous crystalloid fluids to prevent dehydration secondary to vomiting. even small amounts of grapes and raisins can be toxic to dogs. the mechanism of toxicity remains unknown. clinical signs occur within 24 hours of ingestion of raisins or grapes, and include vomiting, anorexia, lethargy, and diarrhea (often with visible raisins or grapes in the fecal matter). within 48 hours, dogs demonstrate signs of acute renal failure (polyuria, polydipsia, vomiting) that can progress to anuria. to treat known ingestion of raisins or grapes, induce emesis or perform orogastric lavage, followed by repeated doses of activated charcoal. if clinical signs of vomiting and diarrhea are present, administer intravenous fluids and monitor urine output. aggressive intravenous fluid therapy, in conjunction with maintenance of renal perfusion, is necessary. in cases of anuric renal failure, dopamine, furosemide, and mannitol can be useful in increasing urine output. peritoneal or hemodialysis may be necessary in cases of severe oliguric or anuric renal failure. calcium channel blockers such as amlodipine and diltiazem can be used to treat systemic hypertension. supportive care includes treatment of hyperkalemia, and administration of gastroprotectant and antiemetic drugs and (if the animal is eating) phosphate binders. aromatic hydrocarbons include phenols, cresols, toluene, and naphthalene. all have a moderate toxic potential if ingested. toxicities associated with ingestion of aromatic hydrocarbons include cns depression, hepatorenal damage, muscle tremors, pneumonia, methemoglobinemia, and intravascular hemolysis. if an aromatic hydrocarbon is ingested, do not induce emesis, because of the risk of aspiration pneumonia. a dilute milk solution or water can be administered to dilute the compound. perform orogastric lavage. carefully monitor the patient's respiratory and cardiovascular status. administer supplemental oxygen if aspiration pneumonia is present. to treat topical exposure, thoroughly rinse the eyes and skin with copious amounts of warm tap water or 0.9% saline solution. imidacloprid is the compound used in the flea product advantage. clinical signs of toxicity are related to nicotinic cholinergic stimulation, causing neuromuscular excitation followed by collapse. the compound may induce respiratory paralysis. to treat imidacloprid toxicity, procure and maintain a patent airway with supplemental oxygen administration. control cns excitation with diazepam, phenobarbital, or propofol. administer enemas to hasten gastrointestinal elimination, and administer activated charcoal. bathe the animal thoroughly to prevent further dermal absorption. closely monitor the patient's oxygenation and ventilation status. if severe hypoventilation or respiratory paralysis occurs, initiate mechanical ventilation. iron and iron salts can cause severe gastroenteritis, myocardial toxicity, and hepatic damage if high enough doses are ingested. lawn fertilizers are a common source of iron salts. treatment of ingestion of iron and iron salts includes cardiovascular support in the form of intravenous fluids and antiarrhythmic drugs, as needed. induce emesis or perform orogastric lavage for gastric decontamination. a cathartic can be administered to promote elimination from the gastrointestinal tract. antiemetic and gastroprotectant drugs should be administered to prevent nausea and vomiting. in some cases, radiographs can aid in making a diagnosis of whether the compound was actually ingested. iron toxicity can be treated with the chelating agent deferoxamine. ivermectin is a gaba agonist that is used in commercial heartworm prevention and antihelminthic compounds and can be toxic in predisposed breeds, including collies, collie loperamide is an opioid derivative that is used to treat diarrhea. clinical signs of loperamide intoxication include constipation, ataxia, nausea, and sedation. induce emesis or perform orogastric lavage, followed by administration of activated charcoal and a cathartic. naloxone may be beneficial in the temporary reversal of ataxia and sedation. ingestion of macadamia nuts can cause clinical signs of vomiting, ataxia, and ascending paralysis in dogs. the toxic principle in macadamia nuts is unknown. there is no known antidote. treatment consists of supportive care, including administration of intravenous fluids and antiemetics and placement of a urinary catheter for patient cleanliness. clinical signs resolve in most cases within 72 hours. marijuana is a hallucinogen that can cause cns depression, ataxia, mydriasis, increased sensitivity to motion or sound, salivation, and tremors. along with these findings, a classic clinical sign is the sudden onset of dribbling urine. urine can be tested with drug test kits for tetrahydrocannabinoid (thc), the toxic compound in marijuana. there is no known antidote for marijuana toxicity; therefore, treatment is largely symptomatic. place an intravenous catheter and administer intravenous fluids to support hydration. administer atropine if severe bradycardia exists. induction of emesis can be attempted but because of the antiemetic effects of thc, is usually unsuccessful. orogastric lavage can be performed, followed by repeated doses of activated charcoal. clinical signs usually resolve within 12 to 16 hours. introduction "strike anywhere" matches, safety matches, and the striking surface of matchbook covers contain iron phosphorus or potassium chlorate. both compounds have a low toxic potential but can cause clinical signs of gastroenteritis and methemoglobinemia if large quantities are ingested. treatment of match and matchbook ingestion includes gastric decontamination with induction of emesis or orogastric lavage and administration of activated charcoal and a cathartic. if methemoglobinemia occurs, administer n-acetylcysteine, intravenous fluids, and supplemental oxygen. metaldehyde is the active ingredient in most brands of snail bait. the exact mechanism of toxicity is unknown but may involve inhibition of gaba channels. clinical signs associated with metaldehyde toxicity include severe muscle tremors, cns excitation, and treatment treatment of mushroom toxicity is largely supportive. if the mushroom was ingested within the last 2 hours, induce emesis or perform orogastric lavage and then administer activated charcoal. symptomatic treatment includes intravenous fluids to promote diuresis and treat hyperthermia and skeletal muscle relaxants to control tremors and seizures (methocarbamol, diazepam). if amanita ingestion is suspected, administer hepatoprotectant agents including milk thistle. mycotoxins from penicillium spp. are found in moldy foods, cream cheese, and nuts. clinical signs of intoxication include tremors, agitation, hyperesthesia, and seizures. if tremorigenic mycotoxin toxicity is suspected, a sample of the patient's serum and gastric contents or vomitus can be submitted to the michigan state university veterinary toxicology laboratory for tremorigen assay. there is no known antidote. perform orogastric lavage, followed by administration of activated charcoal. control tremors and seizures with methocarbamol, diazepam, phenobarbital, or pentobarbital. administer intravenous fluids to control hyperthermia and maintain hydration. in cases in which cerebral edema is suspected secondary to severe refractory seizures, administer intravenous mannitol and furosemide. naphthalene is the active ingredient in mothballs and has a high toxic potential. clinical signs associated with naphthalene toxicity include vomiting, methemoglobinemia, cns stimulation, seizures, and hepatic toxicity. a complete blood count often reveals heinz bodies and anemia. do not induce emesis if naphthalene ingestion is suspected. if the ingestion was within 1 hour of presentation, perform orogastric lavage. control seizures with diazepam or phenobarbital. administer intravenous fluids to control hyperthermia and maintain hydration. n-acetylcysteine can play a role in the treatment of methemoglobinemia. a packed rbc transfusion may be necessary if anemia is severe. observe the patient for clinical signs associated with hepatitis. nicotine toxicity occurs in animals as the result of ingestion of cigarettes, nicotine-containing gum, and some insecticides. nicotine stimulates autonomic ganglia at low doses, and blocks autonomic ganglia and the neuromuscular junction at high doses. absorption after ingestion is rapid. clinical signs include hyperexcitability and slud (salivation, lacrimation, urination, and defecation). muscle tremors, respiratory muscle fatigue or hypoventilation, tachyarrhythmias, seizures, coma, and death can occur. if the patient presents within 1 hour of ingestion and has no clinical signs, induce emesis, followed by administration of repeated doses of activated charcoal. in patients with clinical signs of toxicity, perform orogastric lavage. administer intravenous fluids to maintain hydration and promote diuresis, and treat hyperthermia. administer atropine to treat cholinergic symptoms. urinary acidification can promote nicotine excretion. nonsteroidal antiinflammatory drugs (nsaids) include ibuprofen, ketoprofen, carprofen, diclofenac, naproxen, celecoxib, valdecoxib, rofecoxib, and deracoxib. nsaids cause inhibition of prostaglandin synthesis, leading to gastrointestinal ulceration, renal failure and hepatotoxicity. ibuprofen toxicity has been associated with seizures in dogs, cats, and ferrets. the toxic dose varies with the specific compound ingested. to treat nsaid toxicity, induce emesis or perform orogastric lavage, followed by administration of multiple repeated doses of activated charcoal. place an intravenous catheter for crystalloid fluid diuresis to maintain renal perfusion. administer the synthetic prostaglandin analogue misoprostol to help maintain gastric and renal perfusion. control seizures, if present, with intravenous diazepam. administer gastroprotectant and antiemetic drugs to control vomiting and gastrointestinal hemorrhage. continue intravenous fluid diuresis for a minimum of 48 hours, with frequent monitoring of the patient's bun and creatinine. when the bun and creatinine levels are normal or have plateaued for 24 hours, slowly decrease fluid diuresis 25% per day until maintenance levels are restored. onions, garlic, and chives contain sulfoxide compounds that can cause oxidative damage of rbcs, leading to heinz body anemia, methemoglobinemia, and intravascular hemolysis. clinical signs of toxicity include weakness, lethargy, tachypnea, tachycardia, and pale mucous membranes. vomiting and diarrhea can occur. intravascular hemolysis can cause treatment treatment of onion, chive, and garlic toxicity includes administration of intravenous fluid diuresis, and induction of emesis or orogastric lavage, followed by administration of activated charcoal and a cathartic. in cases of severe anemia, packed rbc transfusion or administration of a hemoglobin-based oxygen carrier should be considered. opiate drugs include heroin, morphine, oxymorphone, fentanyl, meperidine, and codeine. opiate compounds bind to specific opioid receptors throughout the body and produce clinical signs of miosis or mydriasis (cats), and cns excitation, followed by ataxia and cns depression, leading to stupor and coma. hypoventilation, bradycardia, hypoxia, and cyanosis can occur. to treat known overdose or ingestion of an opiate compound, induce emesis (in asymptomatic animals) or perform orogastric lavage, followed by administration of activated charcoal. administer intravenous fluids and supplemental oxygen to support the cardiovascular and respiratory systems. mechanical ventilation may be necessary until hypoventilation resolves. administer repeated doses of naloxone as a specific antidote to reverse clinical signs of narcosis and hypoventilation. if seizures are present (meperidine toxicity), administer diazepam. organophosphate compounds traditionally are used in flea control products and insecticides. common examples of organophosphates include chlorpyrifos, coumaphos, diazinon, dichlorvos, and malathion. the toxic dose varies, depending on the particular compound and individual animal sensitivity. organophosphate toxicity causes acetylcholinesterase inhibition, resulting in clinical signs of cns stimulation, including tremors and seizures. muscarinic acetylcholine overload causes the classic slud signs of salivation, lacrimation, urination, and defecation. miosis, excessive bronchial secretions, muscle tremors, and respiratory paralysis can occur. an intermediate syndrome of generalized weakness, hypoventilation, and eventual paralysis with ventral cervical ventroflexion that may require mechanical ventilation has been described. if organophosphate toxicity is suspected, whole-blood acetylcholinesterase activity can be measured and will be low. treatment of toxicity includes careful and thorough bathing in cases of dermal exposure and, if the substance was ingested, gastric decontamination with induction of emesis or orogastric lavage, followed by administration of activated charcoal, and administration of the antidote pralidoxime hydrochloride . atropine can help control the muscarinic clinical signs. supportive care in the form of cooling measures, intravenous crystalloid fluids, and supplemental oxygen or mechanical ventilation may be required, depending on the severity of clinical signs. introduction ingestion of large amounts of paintballs can cause neurologic signs, electrolyte abnormalities, and occasionally death. paintballs are gelatin capsules that contain multiple colors of if ingestion was recent and if no clinical signs of toxicity are present, induce emesis or perform orogastric lavage, followed by administration of a cathartic and activated charcoal. there is no known antidote. treatment includes supportive care in the form of intravenous fluids and administration of phenobarbital or methocarbamol to control seizures and tremors. diazepam, a gaba agonist, is contraindicated, because it can potentially worsen clinical signs. urine acidification may hasten elimination. clinical signs can last from 3 to 5 days. pyrethrin and pyrethroid compounds are extracted from chrysanthemums, and include allethrin, decamethrin, tralomethrin, fenpropanthrin, pallethrin, sumethrin, permethrin, tetramethrin, cyfluthrin, and resemethrin. the oral toxicity is fairly low; however, the compounds can be significantly harmful if inhaled or applied to the skin. pyrethrin and pyrethroid compounds cause depolarization and blockade of nerve membrane potentials, causing clinical signs of tremors, seizures, respiratory distress, and paralysis. contact dermatitis can occur. to distinguish between pyrethrin/pyrethroid toxicity and organophosphate toxicity, acetylcholinesterase levels should be obtained; they will be normal if pyrethrins are the cause of the animal's clinical signs. treatment of toxicity is supportive, as there is no known antidote. carefully bathe the animal in lukewarm water to prevent further oral and dermal exposure. both hyperthermia and hypothermia can worsen clinical signs. administer activated charcoal to decrease enterohepatic recirculation. atropine may control clinical signs of excessive salivation. to control muscle tremors, administer methocarbamol to effect. administer diazepam or phenobarbital to control seizures, as necessary. rotenone is used as a common garden and delousing insecticide. fish and birds are very susceptible to rotenone toxicity. rotenone inhibits mitochondrial electron transport. clinical signs of tissue irritation and hypoglycemia can occur after topical or oral exposure. if the compound is inhaled, cns depression and seizures can occur. to treat toxicity, perform orogastric lavage, followed by administration of a cathartic and activated charcoal. bathe the animal carefully to prevent further dermal exposure and further ingestion. administer diazepam or phenobarbital to control seizures. the prognosis generally is guarded. treatment of ingestion includes dilution with milk, water, or egg whites. perform orogastric lavage, followed by administration of activated charcoal. administer intravenous crystalloid fluids to maintain hydration. administer antiemetic and gastroprotectant drugs to treat gastroenteritis and vomiting.shampoos, nonmedicated: see detergents, nonionic shampoos, selenium sulfide introduction selenium sulfide shampoos (e.g., selsun blue) have a low toxic potential, and primarily cause gastroenteritis. treatment of ingestion includes dilution with water, milk, or egg whites and administration of activated charcoal. carefully and thoroughly rinse the skin and eyes to prevent further exposure. administer antiemetic and gastroprotectant drugs in cases of severe gastroenteritis. zinc-based (zinc pyridinethione) anti-dandruff shampoos have a serious toxic potential if ingested or if ocular exposure occurs. gastrointestinal irritation, retinal detachment, progressive blindness, and exudative chorioretinitis can occur. treatment of ingestion includes gastric decontamination. induce emesis or perform orogastric lavage, followed by administration of a cathartic and activated charcoal.to treat ocular exposure, thoroughly rinse the patient's eyes for a minimum of 30 minutes. carefully monitor the animal for clinical signs of blindness. implement intravenous fluid to maintain hydration and renal perfusion in cases of severe gastroenteritis. silver polish contains the alkali substance sodium carbonate and cyanide salts, and has a serious toxic potential. ingestion results in rapid onset of vomiting and possibly cyanide toxicity. to treat ingestion, monitor and maintain the patient's respiration and cardiovascular status and administer intravenous crystalloid fluids. induce emesis, followed by administration of activated charcoal. administer sodium nitrite or sodium thiosulfate iv for cyanide toxicity. bath soap (bar soap) usually has low toxic potential and causes mild gastroenteritis with vomiting if ingested. to treat ingestion, include dilution with water, administration of intravenous fluids to maintain hydration, and administration of antiemetic and gastroprotectant drugs to treat gastroenteritis. sodium fluoroacetate is a colorless, odorless, tasteless compound that causes uncoupling of oxidative phosphorylation. the toxic dose in dogs and cats is 0.05-1.0 mg/kg. clinical signs of toxicity include cns excitation, seizures, and coma secondary to cerebral edema. the prognosis is guarded. to treat toxicity, procure and maintain a patent airway, monitor and stabilize the cardiovascular status, and control hyperthermia. perform orogastric lavage, followed by administration of activated charcoal. if clinical signs are not present at the time of presentation, induce emesis. administer intravenous fluids and supplemental oxygen, as necessary. strattera (atomoxetine hydrochloride) is a selective norepinephrine reuptake inhibitor used in the treatment of attention deficit hyperactivity disorder (adhd) in humans. peak serum concentrations occur in dogs within 3 to 4 hours of ingestion, with a peak half-life at 4 to 5 hours following ingestion. clinical signs of toxicity include cardiac tachyarrhythmias, hypertension, disorientation, agitation, trembling, tremors, and hyperthermia. treatment of intoxication is largely symptomatic and supportive in nature. first, induce emesis if the patient is conscious and has an intact gag reflex. orogastric lavage can also be performed. administer one dose of activated charcoal to prevent further absorption of the compound from the gastrointestinal tract. identify cardiac dysrhythmias and treat accordingly. control hypertension with sodium nitroprusside or diltiazem as a constant rate infusion. administer acepromazine or chlorpromazine to control agitation. do not use diazepam, because it can potentially worsen clinical signs. administer intravenous fluids to maintain hydration and promote diuresis. strychnine is the active ingredient in pesticides used to control rodents and other vermin. the toxic dose in dogs is 0.75 mg/kg, and in cats is 2 mg/kg. strychnine antagonizes spinal inhibitory neurotransmitters and causes severe muscle tremors, muscle rigidity, and seizures. clinical signs are stimulated or exacerbated by noise, touch, light, and sound. mydriasis, hyperthermia, and respiratory paralysis can occur. if strychnine toxicity is suspected, gastric contents should be collected and saved for analysis. if the animal is asymptomatic at the time of presentation, induce emesis. if clinical signs are present, perform orogastric lavage. both emesis and orogastric lavage should be followed by the administration of activated charcoal. administer intravenous crystalloid fluids to support the cardiovascular system, aid in cooling measures, and improve renal diuresis. treat cns stimulation with methocarbamol, diazepam, or phenobarbital. the animal should have cotton packed in its ears to prevent noise stimulation, and should be placed in a quiet, dark room. treatment of ingestion includes dilution with milk of magnesia or water, administration of antiemetic and gastroprotectant drugs, and administration of intravenous crystalloid fluids to maintain hydration. do not induce emesis, because of the risk of causing further esophageal irritation.sunscreen: see zinc and zinc oxide suntan lotion: see shampoos, zinc-based, and alcohols tar: see fuels tea tree oil (melaleuca oil) introduction tea tree (melaleuca) oil is an herbal-origin flea-control product. the toxic principles in tea tree oil are monoterpenes, which produce clinical signs of neuromuscular weakness, and ataxia. treatment of tea tree oil toxicity includes administration of cathartics and activated charcoal to prevent further absorption. carefully bathe the animal to prevent further dermal exposure. tetanus spores from clostridium tetani organisms are ubiquitous in the soil and feces, particularly in barnyards. cases have been reported in dogs after tooth eruption and after abdominal surgeries performed with cold sterilization packs. anaerobic wound infections can contain tetanus spores. the neurotoxin from c. tetani inhibits spinal inhibitory neurons, causing motor neuron excitation. extensor muscle rigidity ("sawhorse stance"), erect ears, and risus sardonicus (a sardonic grin) are characteristic features of tetanus. administer tetanus antitoxin if toxin has not already been bound in the cns. to eliminate the source of the toxin (e.g., abscess), open and debride all wounds. intravenous administration of ampicillin or penicillin g is the treatment of choice for tetanus. supportive care in the form of skeletal muscle relaxants, intravenous fluids and parenteral nutrition, and nursing care to prevent decubitus ulcer formation is required. in extreme cases, mechanical ventilation may be necessary. triazene compounds include atrazine, prometone, and monuron (telvar). the toxic mechanism of triazene compounds is unknown. clinical signs of toxicity include salivation, ataxia, hyporeflexia, contact dermatitis, hepatorenal damage, muscle spasms, respiratory difficulty, and death. treatment of triazene exposure includes cardiovascular and renal support in the form of intravenous crystalloid fluids, inotropic drugs, and antiarrhythmic agents, as necessary. if the exposure is recent, induce emesis. perform orogastric lavage in animals that cannot protect the airway. emesis and orogastric lavage should be followed by the administration of activated charcoal and a cathartic. carefully bathe the patient to prevent further dermal absorption. a variety of tricyclic antidepressants are available for use in both humans and animals, including amitriptyline, amoxapine, desipramine, doxepine, fluoxetine (prozac), fluvoxamine (luvox), imipramine, nortriptyline, paroxetine (paxil), protriptyline, sertraline (zoloft), and trimipramine. selective serotonin reuptake inhibitors (ssris) are rapidly absorbed from the digestive tract, with peak serum concentrations occurring 2 to 8 hours after ingestion. the elimination half-life for each drug differs in dogs, but typically last 16 to 24 hours. ssris inhibit the reuptake of serotonin, causing serotonin to accumulate in the brain. this can cause "serotonin syndrome," characterized by trembling, seizures, hyperthermia, ptyalism or hypersalivation, cramping or abdominal pain, vomiting, and diarrhea. other clinical signs of ssri intoxication include depression, tremors, bradycardia, tachyarrhythmias, and anorexia. any animal that has ingested an ssri should be promptly treated and carefully observed for at least 72 hours for side effects. the treatment of suspected ssri intoxication involves gastric decontamination if the patient is not depressed and has an intact gag reflex. perform orogastric lavage and administer activated charcoal to prevent further toxin absorption and hasten elimination from the gastrointestinal tract. treat other clinical signs symptomatically. administer intravenous diazepam to control seizures. treat tachyarrhythmias according to type. administer methocarbamol to control muscle tremors. cyproheptadine (1 mg/kg), a serotonin antagonist, can be dissolved in water and administered per rectum. vitamin k antagonist rodenticides, which are commonly found in pelleted or block form, inhibit the activation of the vitamin k-dependent coagulation factors ii, vii, ix, and x. clinical signs of hemorrhage occur within 2 to 7 days of exposure. hemorrhage can occur anywhere in the body, and can be manifested as petechiation of the skin or mucous membranes, hemorrhagic sclera, epistaxis, pulmonary parenchymal or pleural hemorrhage, gastrointestinal hemorrhage, pericardial hemorrhage, hematuria, retroperitoneal hemorrhage, hemarthrosis, and central nervous system hemorrhage. clinical signs include respiratory distress, cough, bleeding from the gums or into the eyes, ataxia, paresis, paralysis, seizures, hematuria, joint swelling, lameness, lethargy, weakness, inappetence, and collapse.diagnosis is made based on clinical signs and a prolonged activated clotting time, or prothrombin time. the pivka (proteins induced by vitamin k antagonism) test may be helpful but usually cannot be performed in-house. slight thrombocytopenia may be present secondary to hemorrhage; however, blood levels usually do not reach the critical level of <50,000 platelets/âµl to cause clinical signs of hemorrhage. in some cases, severe stressinduced hyperglycemia and glucosuria may be present but resolves within 24 hours. if the rodenticide was ingested within the last 2 hours, induce emesis. alternatively, orogastric lavage can be performed in an uncooperative patient. both emesis and orogastric lavage should be followed by administration of activated charcoal. the stomach contents can be submitted for analysis. following successful treatment, administer oral vitamin k for 30 days after the exposure; or a check prothrombin time 2 days after gastric decontamination. if the prothrombin time is prolonged, administer fresh frozen plasma and vitamin k.if the prothrombin time is normal, gastric decontamination was successful, and no further treatment is necessary.if an animal presents with clinical signs of intoxication, administer activated clotting factors in the form of fresh frozen plasma (20 ml/kg), and vitamin k 1 (5 mg/kg sq in multiple sites with a 24-gauge needle). packed rbcs or fresh whole blood may be required if the patient is also anemic. supportive care in the form of supplemental oxygen may be necessary in cases of pulmonary or pleural hemorrhage. following initial therapy and discharge, the patient should receive vitamin k 1 (2.5 mg/kg po q8-2h for 30 days), and prothrombin time should be checked 2 days after the last vitamin k capsule is administered. in some cases, depending on the type of anticoagulant ingested, an additional 2 weeks of vitamin k1 therapy may be required. xylitol is a sugar alcohol that, when ingested by humans, does not cause a significant increase in blood glucose, and therefore does not stimulate insulin release from the human pancreas. in dogs, however, xylitol causes a massive rapid and dose-dependent release of insulin from pancreatic beta-cells. following insulin release, clinically significant hypoglycemia can develop, followed by signs of vomiting, weakness, ataxia, mental depression, hypokalemia, hypoglycemic seizures, and coma. clinical signs associated with xylitol ingestion can be seen within 30 minutes of ingestion and can last for more than 12 hours, even with aggressive treatment. known xylitol ingestion should be treated as for other toxin ingestion. if no neurologic abnormalities exist at the time the patient is seen, induce emesis, followed by administration of activated charcoal. it remains unknown at this time whether activated charcoal actually delays or prevents the absorption of xylitol from the canine gastrointestinal tract. if clinical signs have already developed, perform orogastric lavage and gastric decontamination. blood glucose concentrations should be analyzed and maintained with supplemental dextrose as a constant rate infusion (2.5%-5%) until normoglycemia can be maintained with multiple frequent small meals. hypokalemia may develop because it is driven intracellularly by the actions of insulin. treat hypokalemia with supplemental potassium chloride by infusion, not to exceed 0.5 meq/kg/hour. pennies minted in the u.s. after 1982 contain large amounts of zinc rather than copper. other sources of zinc include zinc oxide ointment and hardware such as that found in metal bird cages. zinc toxicity causes intravascular hemolysis, anemia, gastroenteritis, and renal failure. if zinc toxicity is suspected, take an abdominal radiograph to document the presence of the metal in the stomach or intestines. (if zinc-containing ointment was ingested, this will not be visible on radiographs.) induce emesis or perform orogastric lavage, depending on the size of the object ingested. often, small objects such as pennies can be retrieved using endoscopy or surgical gastrotomy/enterotomy. always take an additional radiograph after the removal procedure to ensure that all objects have been successfully removed. administer intravenous fluids to maintain renal perfusion and promote fluid diuresis. administer gastroprotectant and antiemetic drugs. chelation therapy with succimer, calcium edta, dimercaprol, or penicillamine may be necessary. do not administer pulmonary contusions are a common sequela of blunt traumatic injury. a contusion basically is a bruise characterized by edema, hemorrhage, and vascular injury. contusions may be present at the time of presentation or can develop over the first 24 hours after injury. a diagnosis of pulmonary contusion can be made based on auscultation of pulmonary crackles, presence of respiratory distress, and the presence of patchy interstitial to alveolar infiltrates on thoracic radiographs. radiographic signs can lag behind the development of clinical signs of respiratory distress and hypoxemia by 24 hours. in most cases, cage rest is sufficient to temporarily diminish blood loss. sedation (acepromazine, 0.02-0.05 mg/kg iv, im, sq) may be helpful in alleviating anxiety and decreasing blood pressure. the hypotensive effects of acepromazine are potentially harmful if severe blood loss has occurred. if evidence of hypovolemia is present (see section on hypovolemic shock), intravenous fluid resuscitation should be administered. rapid assessment of clotting ability, with a platelet count estimate and clotting profile (act or aptt and pt), should be performed. if epistaxis secondary to vitamin k antagonist rodenticide intoxication is suspected, administer vitamin k 1 and fresh frozen plasma or fresh whole blood.persistent hemorrhage from a nasal disorder can be treated with dilute epinephrine (1:100,000) into the nasal cavity with the nose pointed toward the ceiling to promote vasoconstriction. if this fails, the animal can be anesthetized, and the nasal cavity packed with gauze, and the caudal oropharynx and external nares covered with umbilical tape to control hemorrhage. a rhinoscopy should be performed to determine the cause of ongoing hemorrhage. continued excessive hemorrhage can be controlled with ligation of the carotid artery on the side of the hemorrhage, or with percutaneous arterial embolization. systemic thromboembolism is most commonly recognized in cats with cardiomyopathies (hypertrophic, restrictive, unclassified, and dilatative) but can also occur in dogs with hyperadrenocorticism, disseminated intravascular coagulation (dic), systemic inflammatory response syndrome (sirs), protein-losing enteropathy and nephropathy, and tumors affecting the aorta and vena cava. thrombosis occurs through a complex series of mechanisms when the components of virchow's triad (hypercoaguable state, sluggish blood flow, and vascular endothelial injury or damage) are present. in cats, blood flow through a severely stretched left atrium is a predisposing factor to the development of clots and thromboembolism.the most common site of embolism is the aortic bifurcation, or "saddle thrombus." other, less common locations of thromboembolism include the forelimbs, kidneys, gastrointestinal tract, and cerebrum. diagnosis usually is made based on clinical signs of cool extremities, the presence of a cardiac murmur or gallop rhythm, auscultation of pulmonary crackles resulting from pulmonary edema, acute pain or paralysis of one or more peripheral extremities, respiratory distress, and pain and lack of a palpable pulse in affected limbs. the affected nailbeds and paw pads are cyanotic, and nails do not bleed when cut with a nail clipper.client education is one of the most important aspects of emergency management of the patient with thromboembolic disease. concurrent congestive heart failure (chf) occurs in 40% to 60% of cats with arterial thromboembolism. more than 70% of cats are euthanized during the initial thromboembolic event because of the poor long-term prognosis and the high risk of recurrence within days to months after the initial event, even with aggressive therapy. although the long-term prognosis varies from 2 months to 2 years after initial diagnosis and treatment, in the majority of cats thromboembolic disease recurs within 9 months. rectal temperature hypothermia and bradycardia on presentation are negative prognostic indicators.immediate treatment of a patient with chf and thromboembolic disease involves management of the chf with furosemide, oxygen, and vasodilators (nitroglycerine paste, morphine, nitroprusside). additional management includes analgesia (butorphanol, 0.1-0.4 mg/kg iv, im) and prevention of further clot formation. aspirin (10 mg/kg po q48h) is beneficial bcause of its antiplatelet effects. heparin works in conjunction with antithrombin to prevent further clot formation (100-200 units/kg iv, followed by 250-300 units/kg sq q8h in cats, and 100-200 units/kg sq q8h in dogs). acepromazine can cause peripheral vasodilation and decreased afterload but also can promote hypotension in a patient with concurrent chf. acepromazine (0.01-00.02 mg/kg sq) should be used with extreme caution, if at all.thrombolytic therapy can also be attempted, but in most cases is not without risk, and may be cost-prohibitive for many clients. streptokinase (90,000 units iv over 30 minutes and then 45,000 units/hour iv cri for 3 hours) was administered with some success in cats; however, many died of hyperkalemia or other complications during the infusion. tissue plasminogen activator (0.25-1 mg /kg/hour iv cri, up to 10 mg/kg total dose, to effect) has been used with some success but is cost-prohibitive for most clients. side effects of thrombolytic therapy include hyperkalemia with reperfusion and hemorrhage.in cats, the primary cause of arterial thromboembolism is cardiomyopathy. once an animal is determined to be stable enough for diagnostic procedures, lateral and dv thoracic radiographs and an echocardiogram should be performed. ultrasound of the distal aorta and renal arteries should also be performed to determine the location of the clot and help establish the prognosis.other diagnostic procedures to evaluate the presence and cause of thromboembolism include a complete blood count, serum biochemistry profile, urinalysis (to rule out proteinlosing nephropathy), urine protein:creatinine ratio, antithrombin levels, acth stimulation test (to rule out hyperadrenocorticism), heartworm antigen test (in dogs), thyroid profile (to rule out hyperthyroidism in cats, and hypothyroidism in dogs), thoracic radiographs, arterial blood gas analyses, coagulation tests, and coombs' test. selective and nonselective angiography can also be performed to determine the exact location of the thrombus.long-term management of thromboembolism involves management of the underlying disease process and preventing further clot formation. begin therapy with heparin until the aptt becomes prolonged 1.5 times; then administer warfarin (0.06-0.09 mg/kg/day). monitoring therapy based on prothrombin time and the international normalized ratio (inr, 2.0-4.0) is recommended. low-dose aspirin (5-10 mg/kg q48h) also has been recommended. physical therapy with warm water bathing, deep muscle massage, and passive range-of-motion exercises should be performed until the patient regains motor function. future therapy may involve the use of platelet receptor antagonists to prevent platelet activation and adhesion. key: cord-021555-rrverrsj authors: delano, margaret l.; mischler, scott a.; underwood, wendy j. title: biology and diseases of ruminants: sheep, goats, and cattle date: 2007-09-02 journal: laboratory animal medicine doi: 10.1016/b978-012263951-7/50017-x sha: doc_id: 21555 cord_uid: rrverrsj nan since the first edition of this book, the use of ruminants as research subjects has changed dramatically. formerly, large animals were primarily used for agricultural research or as models of human diseases. over the past decade, ruminants have continued in their traditional agricultural research role but are now extensively used for studies in molecular biology, genetic engi-british stock with egyptian and indian goats. this breed is relatively heat tolerant and produces milk with the highest butterfat (about 4-5%). fiber breeds include the angora and the cashmere. the angora, the source of mohair, originated in turkey. the cashmere breed is found primarily in mountainous areas of central asia. the la mancha, a newer breed of dairy goat first registered in the united states in 1958, has rudimentary ears that are a genetically dominant distinguishing characteristic of the breed. the meat breeds include the boer, sapel, ma tou, kambling, and pygmy. the pygmy goat is small and is sometimes used for both meat and milk. the mubend of uganda and the red sokoto of west africa produce quality skins for fine leather (smith and sherman, 1994) . most breeds of cattle are classified as "dairy" or "beef"; a few breeds are considered "dual-purpose." common dairy breeds in the united states include holstein-friesian, brown swiss, jersey, ayrshire, guernsey, and milking shorthorn. holsteins have the largest body size, whereas jerseys have the smallest. of breeds in temperate regions, jerseys have been considered to be the most heat tolerant, but holsteins have been found to adapt to warmer climates. there are many beef breeds. the more common in the united states include angus (also called aberdeen-angus), hereford (both polled and horned), and simmental (briggs and briggs, 1980; schmidt et al., 1988) . breeds indigenous to other continents, such as the cape buffalo, have been found to have unique innate immune characteristics that protect them from endemic trypanosomiasis (muranjan et al., 1997) . more detailed information regarding these and other ruminant breeds is available in briggs and briggs (1980) . "rare" or "minor" breeds of sheep, goats, and cattle are studied for their genetic and production characteristics. discussions of these and efforts at conservation are described in detail elsewhere (national research council, 1993) . several terms are unique to ruminants. in relation to sheep, a ewe is the female, and a ram is the adult intact male. a lamb is the young animal, and ram lamb and ewe lamb are commonly used terms. a wether is a castrated male. the birthing process is referred to as lambing. with respect to goats, a doe or nanny is the female. a buck or billy is the adult intact male. a kid or goatling is a young goat. a young male may be referred to as a buckling, and a young female may be referred to as a doeling. a castrated male in this species is also called a wether. the birthing process is called kidding. with respect to cattle, an adult female is a cow, and an adult male is a bull. a calf is a young animal. a heifer is a female who has not had her first calf. a steer is a castrated male. calving refers to the act of giving birth. ruminants have been used as research models since the inception of the land grant college system, first in production agriculture and now also in basic and applied studies for the anatomic and physiologic sciences and in biomedical research for a variety of purposes. healthy, normal young ruminants serve as models of cardiac transplantation and as preclinical models for evaluation of cardiac assist or prosthetic devices, such as vascular stents and cardiac valves (salerno et al., 1998) . for many years, ruminants have been useful research subjects for reproductive research, such as research on embryo transfer, artificial insemination, and control of the reproductive cycle (wall et al., 1997) . several important milestones in gene transfer, cloning, nuclear transfer, and genetic engineering techniques have been developed or demonstrated using these species (ebert et al., 1994; schnieke, 1997; cibelli et al., 1998a,b) (see fig. 1 ). one of many proposed uses of genetically engineered ruminants is the production of proteins that will be secreted in the milk and later isolated (ebert et al, 1994; memon and ebert, 1992) . healthy sheep and goats are also often used for antibody production (hanly et al., 1995) . genome mapping developed rapidly during the 1990s; extensive information is available and is increasing for sheep and cattle (broad et al., 1998; womack, 1998) . sheep are often selected for studying areas such as ruminant physiology and nutrition. these animals provide obvious bene-fits over the use of cattle in research from the standpoint of size, ease of handling, cost of maintenance, and docile behavior. sheep are also widely used models for basic and applied fetal and reproductive research (buttar, 1997; rees et al., 1998; ross and nijland, 1998) . the species is used for investigating circadian rhythms related to day length (lehman et al., 1997) , and the interaction between olfactory cues and behavior (kendrick et al., 1997) . the number and diversity of natural-and induceddisease research models in sheep are great and increasing. natural models include congenital hyperbilirubinemia/hepatic organic anion excretory defect (dubin-johnson syndrome) in the corriedale breed, congenital hyperbilirubinemia/hepatic organic anion uptake defect (gilbert syndrome) in the southdown breed, glucose-6-phosphate dehydrogenase deficiency in the dorset breed, gm~ gangliosidosis in the suffolk breed, and pulmonary adenomatosis (jaagsiekte) in many breeds (hegreberg, 198 l a) . induced models include arteriosclerosis, hemorrhagic shock, copper poisoning (wilson's disease), and metabolic toxocosis (hegreberg, 198 lb) . goats are used in a wide variety of agricultural and biomedical disciplines such as immunology, mastitis, nutrition, and parasitology research. vascular researchers select the goat because of the large, readily accessible jugular veins. goats with inherited caprine myotonia congenita ("fainting goats") have been used as a model for human myotonia congenita (thomsen's disease) (kuhn, 1993) . a line of inbred nubians serves as models for the genetic disease [3-mannosidosis and prenatal therapeutic cell transplantation strategies (lovell et al., 1997) . (these disorders are discussed in more detail in section iii,b,1.) goats are used as a model for osteoporosis research (welch et al., 1996) . cattle are often used as a source of ruminal fluid for research, teaching, or treatment of other cattle, by placing a permanent fistula in the left abdominal wall to allow sampling of ruminal fluid (dougherty, 1981) . cattle also serve as models of many infectious diseases, including zoonoses, and several inherited metabolic diseases. this species is useful for the basic and comparative research on the pathogenesis and immunology of inherited and infectious diseases. bovine trichomoniasis, caused by tritrichomonas (trichomonas)fetus, has been identified as a useful model for the human infection by trichomonas vaginalis (corbeil, 1995) . inherited cardiomyopathies have been found in the holstein-friesian, simmental-red holstein, black spotted friesian, and polled hereford with woolly coat (weil et al., 1997) . lipofuscinosis has been identified in ayrshires and friesians, and glycogenesis in shorthorns and brahmans. metabolic diseases such as hereditary orotic aciduria and hereditary zinc deficiency have been characterized in holstein-friesian or friesian cattle. holstein cattle also serve as a model for leukocyte adhesion deficiency syndrome (afip, 1995) . common breeds of normal, healthy ruminants are usually readily available, although seasonality may play a role, as noted below. agricultural sources and reputable farms may be located through land-grant universities or agricultural schools, cooperative extension and 4-h networks, regional ruminant breeders' associations, and farm bureaus. commercial sources of purposebred animals are found in technical publications and annual listings of research animal vendors. breeds carrying genetic traits of interest, either as animal models or as valuable production characteristics, may be located through literature or internet searches, animal science societies, breed or livestock conservation associations, and information resources such as the armed forces institute of pathology. organizations such as the institute for laboratory animal research (ilar), national center for research resources (ncrr), or the animal welfare information center (awic) may also serve as information sources about the animals needed. purpose-bred research sheep and goats are available from commercial vendors and are usually maintained in registered facilities under federal standards that are also acceptable to research animal accrediting agencies. these commercial animals are frequently described as specific pathogen-free (spf) and housed as biosecure or closed flocks. animal health programs are in place, and health reports or other quality assurance reports are usually available on request. agricultural sources of either small ruminant may be acceptable, but specific research needs may not have been addressed or may not be understood. lambs, kids, and milking goats may be difficult to locate in fall and winter months because most breeds of sheep and goats are seasonal breeders. management practices exist, however, to extend the breeding and milking seasons. most cattle used as animal models in research in the united states are from one of the dairy breeds, usually holstein, because this breed is now the most common. purpose-bred, specific pathogen-free research cattle are not typically available. because of selection and the management of dairy production units, calves and young stock are available year-round. availability of young beef cattle is more seasonal, according to production cycles typically followed by that industry. auction barns or sales are not appropriate sources for research ruminants. many of these animals are culls and will be poor-quality research subjects. they may be in poor body condition and stressed, may be sources of disease, and may contaminate other healthy animals, as well as the research facility. selection of the suppliers should be made only after research needs have been carefully considered. consistently working with and buying directly from as few sources as possible are best. certain types of research (i.e., agricultural nutrition studies) may better be served by selecting animals from local agricultural suppliers rather than commercial vendors located in a different geographical area. the selection of sources for research ruminants includes scrutiny of flock or herd record keeping; health monitoring, vaccination, and preventive medicine programs (including hoof care); production standards and management practices consistent with the industry; management of the breeding flock or herd; sanitation and waste handling programs; vermin and insect control measures (especially for flies and other flying insects); rearing programs for and condition of young stock; the location, health, and condition of the other animals on the premises; intensity of housing; and animal housing facilities. preliminary and periodic visits to the source farms should be conducted. it is important to establish a good relationship with the local attending large-animal veterinarians, who will be valuable resources for current approved therapies and practices. they may need to be oriented on the specific requirements of animal research. creative ways can be used to initiate and foster a good working relationship between the agricultural supplier and the research facility. supplying the vaccines or dewormers required for flock health programs, providing services such as quarterly serological testing or fecal examinations for the herd or flock, and paying a premium (rather than market price) for animals that meet the quality criteria established for the research animals are often helpful. a set of testing standards can be developed based on one high-quality supplier, and then flocks or herds can be "qualified" based on those standards. qualifying entails evaluations utilizing the facility and management aspects mentioned above and testing either a percentage of the herd or flock or the entire herd or flock for a number of infectious agents. the testing regimen itself should be carefully developed and evaluated. once qualified, each source farm should be reevaluated periodically to maintain its status. slaughter checks may be appropriate; otherwise necropsy of sentinel animals may be required. selected animals undergoing screening tests should be quarantined from the rest of flock or herd while awaiting test results. vaccination and deworming regimens can be instituted during these quarantine periods. a second quarantine should occur when animals arrive at the research facility. the animal screening process also depends on the origin of the animal (state, country) and the scientific program. federal and state regulations must be followed. socialization of the animals at the source facility should also be considered in terms of ease of handling and safety for personnel in the confinement of the research lab, barn, or farm. for example, frequently handled calves will be easier to manage, and adult dairy goats that have been acclimated to human contact are preferable. several texts provide information on industry standards for flock and herd management and preventive medicine strategies that can provide helpful orientation to those unfamiliar with these aspects. these references also provide information regarding vaccination products licensed for use in ruminants and typical herd and flock vaccination parasite control schedules ("current veterinary therapy," 1986 , 1999 "council report," 1994; "large animal internal medicine," 1996; smith and sherman, 1994) when designing a vaccination program during qualification of a source or at the research facility, it is important to evaluate the local disease incidence and the potential for exposure. vaccination programs should be conducted with an awareness of duration of passive immunity and stresses in ruminants' lives (e.g., weaning, grouping, management changes, and shipping) that may impair immunity or increase susceptibility to infectious diseases. it is also prudent to evaluate the cost-effectiveness of vaccination; labor and vaccine expenses may be much higher than the potential animal morbidity or mortality for diseases in a particular locality. not all of the vaccines mentioned subsequently will be necessary in all herds or flocks. vaccination needs for research animals will also depend on the local disease history, intent of the research, the age of the animals needed for research, and the length of time the animals will be housed. typical health screening programs for sheep include q fever (coxiella burnetii); contagious ecthyma; caseous lymphadenitis (corynebacterium pseudotuberculosis); johne's disease (mycobacterium paratuberculosis); ovine progressive pneumonia; internal parasitism such as nasal bots, lungworms, and intes-tinal worms; and external parasitism such as sheep keds. each supplier should be queried about vaccination programs for bluetongue, brucella ovis, campylobacter spp., chlamydia (enzootic abortion of ewes), clostridial diseases, pneumonia complex (parainfluenza 3, pasteurella haemolytica, and p. multocida), ovine ecthyma, rabies, dichelobacter (bacteroides) nodosus, arcanobacterium pseudotuberculosis, bacillus anthracis, and fusobacterium necrophorum. because of the limited number of biologics approved for small ruminants, products licensed for cattle have been used with success in sheep, and some licensed for sheep are used in goats ("council report," javma, 1994) . in some cases, approved feed additives, such as coccidiostats, are fed to sheep. the basic screening profile for goats should include q fever (coxiella burnettii), caprine arthritis encephalitis (cae), brucellosis, tuberculosis, and johne's disease (mycobacterium paratuberculosis) . goats may also be tested for caseous lymphadenitis, contagious ecthyma, or mycoplasma as needed. herd vaccination programs may include immunizations against tetanus and other clostridial diseases, chlamydia, campylobacter, contagious ecthyma, caseous lymphadenitis, corynebacterium pseudotuberculosis, and escherichia coli. cattle herds should be screened for johne's disease, brucellosis, tuberculosis, respiratory diseases, internal and external parasitism, and foot conditions such as hairy heel warts and foot rot. determination of the status of the herd with respect to bovine leukemia virus (blv) may be worthwhile. herd programs may include essential or highly recommended vaccines against bovine viral diarrhea virus (bvdv), infectious bovine rhinotracheitis virus (ibrv), bovine respiratory syncytial virus (brsv), parainfluenza 3 (pi-3), leptospira pomona, tritrichomonas fetus, rotavirus, coronavirus, campylobacter (vibrio) , pasteurella haemolytica and p. multocida, and brucella abortus. other vaccination programs, dependent on herd status, endemic diseases, or geographic location, may include immunizations against the clostridial diseases, moraxella bovis (pinkeye), fusobacterium necrophorum (foot rot), staphylococcus aureus (mastitis), haemophilus somnus, rabies, tetanus, bacillus anthracis, enterotoxigenic e. coll anaplasma, and other leptospira species. some products considered to have limited efficacy include vaccines against salmonella dublin and s. typhimurium. some autogenous vaccines may be more effective than the commercially available products--for example, the bovine papillomavirus (warts) vaccines. rearing programs for dairy calves differ from those for the smaller ruminants, including the withdrawal of calves from their dams immediately or by 24 hours after birth. in the cattle industry, antibiotics, ionophores (antibiotics that control selected populations of ruminal organisms), coccidiostats, probiotics, and other approved additives may be part of the milk replacers, grain and concentrate formulations, and/or creep feeding regimens. use varies by the segment of the industry, and regulations vary by country. subcutaneous hormonal implants (such as estradiol benzoate and progesterone combined, zeranol, or 17[~-estradiol) are administered, especially to beef calves destined for market rather than breeding, to promote growth. transportation of the animals from the source to the research facility must be carefully planned, and all applicable livestock travel regulations followed. it is best to have the animals transported in vehicles regularly utilized by the source farm. if commercial haulers are used, then disinfecting trucks, trailers, and associated equipment, such as ramps and chutes, beforehand is particularly important. the loading, footing, and distribution of the animals in the trailers and trucks, as well as environmental conditions during shipping, are important to consider to minimize stress and injury to the animals. sufficient time for acclimation to the facility, pens, handlers, feed, and water must be allowed once at the destination ("livestock handling and transport," 1998). recent publications address many general considerations as well as specifics about the facilities, husbandry, space requirements, and standard practices for research and production ruminants. institutions, private entities, researchers, and facility staff must also be aware of the recent adoption by the u.s. department of agriculture (usda) of specific guidelines for regulation of farm animals, such as ruminants, that are used in biomedical and other nonagricultural research. the usda animal care policy 29 notes that the "guide for the care and use of agricultural animals in agricultural research and teaching" and the "guide for the care and use of laboratory animals" provide additional information to supplement the existing animal welfare act regulations (cfr, 1985; fass, 1999; hays et al., 1998; nrc, 1996a; usda, 2000) . in all cases, stress should be considered and minimized in the husbandry and handling of ruminants. animals need to be provided adequate time to adapt to new surroundings. stress decreases feed intake, and the resulting energy, vitamin, and mineral deficiencies will affect the growth and development in younger animals. reproductive soundness and rumen function are affected by transport and similar stresses. standard practices such as weaning, castration, dehorning, vaccinations, deworming and treatments for external parasites, shipping and the associated feed and water deprivation, introduction to a new housing environment and new personnel, and intercurrent disease are all stressors (houpt, 1998) . animals should be acclimated to the use of halters and leads, temporary restraint devices, and other handling equipment associated with the research program. personnel in the research facility who are unfamiliar with ruminants should be trained in appropriate handling techniques. ap-preciation for ruminant behaviors has grown in recent years, and refined ruminant handling techniques have been published (houpt, 1998; grandin, 1998) . when ruminants are confinement-housed, care should be taken to provide adequate but draft-free ventilation. ammonia buildup and other waste gases may induce respiratory problems. in cold weather, if the ceiling, walls, or water pipes condense water, then the ventilation should be increased even at the expense of lower temperatures. even adult goats and younger cattle are quite comfortable in cold, even subfreezing temperatures, if provided with adequate amounts of dry dust-free bedding and draft protection. sheep, because of their wool, are remarkably tolerant to both hot and cold extremes. newborn lambs and recently shorn adults are susceptible to hypothermia, hyperthermia, and sunburn. therefore, in outside housing areas, sheep should be provided with shelters to minimize exposure to sun and inclement weather. animals housed under intensive confinement should be kept clean, and excreta should be removed from the pens or enclosures daily. feed and water equipment should be maintained in sound, clean condition and should be constructed to prevent fecal contamination. waterers should not create a muddy environment in paddocks or pens. there should be sufficient continuous-access waterers placed around the area to prevent competition or fighting. feeders should be constructed to conform to species size and feeding characteristics and to prevent entrapment of head and limbs. pens, other enclosures, passageways, chutes, and floors must be very sturdy to withstand such factors as the frequent cleaning; the strength, weight, and curiosity of all ages of animals; and the investigative and climbing behaviors of goats. chain-link fences are dangerous because goats (as well as some breeds and ages of sheep) are curious and tend to stand on their hind legs against fencing or walls. forelimbs may be caught easily in the mesh. floors in any areas where animals will be housed, led, or herded must ensure secure footing at all times to prevent slipping injuries. all ruminants are social and herding animals. therefore, they should be housed in groups or at least within eyesight and hearing of other animals. singly housed animals should have regular human contact. environmental enrichment should be governed by the experimental protocol or standard operating procedures, and durable play objects should be supplied to those animals that are housed in confinement. calves, in particular, that must be singly housed or that have been recently weaned, need play objects (morrow-tesch, 1997) . because sheep and goats are sensitive to changes in light cycle (especially reproductive parameters), photoperiod must be taken into account. normally, sheep and goats should be maintained on a cycle comparable to natural conditions. light intensity should be maintained at about 220 lux (ilar, 1996; fass, 1999) . light cycles can be manipulated for experimental reasons. the development of the digestive system and the unique function of the rumen are among the most notable comparative anatomic and physiologic characteristics of ruminants. there is a three-compartment forestomach (rumen, reticulum, and omasum) and a true stomach (abomasum). the mature rumen functions as an anaerobic fermentation chamber in which the enzymes, such as cellulase, of the resident bacteria allow the animals to prosper as herbivores. digestion is also aided by other microorganisms, such as protozoa (105-106/ml) and bacteria (109-101~ that contribute to rumen fermentation. the result is the production of volatile fatty acids (acetic, propionic, and butyric) . unlike in the monogastrics, fermentative digestion and volatile fatty acid absorption also occur in the large intestines. the main sources of energy for ruminants are volatile fatty acids (vfas) rather than glucose. glucose is formed from propionic acid (or from amino acids) for metabolism in the central nervous system (cns), uterus, and mammary glands. plasma glucose in ruminants is much lower than and is regulated differently from that in nonruminants. the rumen microorganisms also synthesize vitamins, such as b and k, and provide protein that is used by the animals' systems. large amounts of fermentation gases such as co2 and methane, and small amounts of nitrogen, are naturally eructed (hecker, 1983; schimdt et al., 1988) . intestinal immunoglobulin absorption by pinocytosis in the neonates is crucial to the success of passive transfer. this transfer mechanism is functional for approximately the first 36 hr after birth. neonatal ruminants are immunocompetent, however, and this condition is used to advantage for vaccinations against some common diseases of the neonatal and later juvenile periods, such as infectious bovine rhinotracheitis (ibr) vaccine (using modified live virus vaccines) to calves when their dams' colostrum is lacking antibody against this virus. unlike hepatic lipogenesis in humans, lipogenesis in sheep primarily occurs in adipose tissue and the mamrnary gland (hecker, 1983) . in addition to normal lymph node chains, and as in other ruminants, sheep have small red "nodes" associated with blood vessels. inadvertently named hemal "lymph nodes," they contain numerous red blood cells. sheep have a relatively large pituitary gland, and accessory adrenal medullary tissue may be interspersed throughout the abdominal cavity. three major ovine histocompatability classes have been identified and designated as ovar (ovis aries) classes i, ii, and iii (franz-werner et al., 1996) . bovines are recognized as having several unique aspects involving their immune systems. the bovine lymphocyte antigen (bola) system ranks after the hu-man (hla) and murine (h-2) systems in terms of depth of knowledge (lewin, 1996) . cattle are considered free of autoimmune diseases (schook and lamont, 1996) . the complexity of the immunobiology of the bovine mammary gland is being studied extensively because mastitis is the most prevalent disease in the dairy industry. several innate immune mechanisms and cellular defenses, and their variation throughout lactation, have been described (sordillo et al., 1997) . hematology and clinical reference texts are available for the ruminant species and include overviews of normal values for age, sex, and breed-specific ranges, as well as discussions regarding the influences on the hemogram of many management, nutritional, geographic, metabolic, physiologic (including lactation), medication, and iatrogenic variables (duncan and prasse, 1986; jain, 1986; kaneko et al., 1997) . these references should be consulted when preparing to include blood collection data in research protocols and when reviewing hematologic findings. in addition, most veterinary diagnostic laboratories have also developed databases for normal ranges for hematologic and clinical chemistry values based on subjects from their service areas, and these may be useful as local and breed references. appropriate control groups must be incorporated into each research plan, however, to establish the normal values (see table i ) for the particular locale, diagnostic facilities, breed, age, sex, and research circumstances. normal hematologic and clinical biochemistry data are presented in tables ii and iii. some general statements apply to most ruminants. most ruminants have fewer neutrophils than lymphocytes. the blood urea nitrogen (bun) values cannot be used as an indicator of renal function because of the metabolism of urea nitrogen by rumen microflora. because of the large volume of rumen water, ruminants can generally go several days without drinking before significant dehydration occurs. erythrocytes may become more fragile during rehydration, resulting in some degree of hemolysis and hemoglobinuria. severe dehydration can occur quickly, however, in animals that are ill. urine ph is generally alkaline in adult ruminants. ruminant erythrocytes are smaller than those in other mammals, and hematocrits tend to be overestimated unless blood samples are centrifuged for longer amounts of time for packing of the cell pellet. increased red-cell fragility is also associated with the smaller erythrocyte. rouleau formation does not occur in cattle but does to a limited extent in sheep and goats. in addition to fetal hemoglobin, sheep are reported to have at least six different hemoglobins (hecker, 1983) . blood coagulation in sheep is similar to that in humans. 2(di 0/3, dc 0/1, dp 3/3) = 20 2(di 0/3, dc 0/1, dp 3/3) = 20 2(di 0/3, dc 0/1, dp 3/3) = 20 permanent dental formula 2(10/3, c 0/1, m 3/3) = 32 2(10/3, c 0/1, m 3/3) = 32 2(10/3, c 0/1, m 3/3) = 32 avital sign data for goats are from "large animal internal medicine" (1996) . sheep weight data represent weights of feeder lamb and adult dry ewe (federation of animal science societies [fass], 1998) . goat weight data are for a large-breed male goat. cattle weight data represent weights of female holstein or guernsey dairy cattle (fass, 1998) . life span data for sheep and cattle are from brooks et al. (1984) . erythrocytes in pygmy and toggenburg goats tend to be more fragile than erythrocytes from other goat breeds. normal caprine erythrocytes lack central pallor because they are fiat and lack biconcavity. normal caprine erythrocytes may exhibit poikilocytosis. at least five blood groups have been reported in goats: b, c, m, r-o, and x. because transfusion reaction rates may be as high as 2-3%, cross-matching is advisable although not always practical (smith and sherman, 1994) . blood loss of up to 25% of the red cell mass at a single time point can be tolerated by healthy goats. blood may safely be obtained in volumes of 10 ml/kg body weight and given in volumes of 10-20 ml/kg. in general, aspartate aminotransferase (ast) and lactate dehydrogenase (ldh) are not liverspecific in goats, and alanine aminotransferase (alt; formally serum glutamic-pyruvic transaminase, or sgpt) cannot be used to evaluate hepatic disease in goats. ~,-glutamyltransferase (ggt) and alkaline phosphatase (ap) are associated with biliary stasis, and elevations in ggt are generally associated with hepatic damage. the nutritional needs of ruminants vary considerably according to the species, breed type, different phases of development, the use of the animals, location, and different stresses in their lives. for example, mineral requirements and other nutritional requirements vary even among breeds of cattle. several references are available that describe the varying requirements and are useful for determining the requirements of ruminants consistent with the parameters noted above and the type of feeds available (jurgens, 1988; "large animal clinical nutrition," 1991; nrc, 1981 nrc, , 1989 nrc, , 1993 nrc, , 1996b "large animal internal medicine," 1996) . preformulated commercial feeds, concentrates, and supplements are available specifically for the different species of ruminants. some of these provide complete energy and protein requirements or may be used as supplements for what cannot be provided entirely by pasture, forage, hay, or silage. concentrate mixtures contain salt, minerals, and other elements. concentrates should contain a protein source such as soybean meal, cottonseed meal, or linseed meal. computer programs are also readily available for those who may need to formulate and balance rations. the palatability of feeds should be taken into account. mineral deficiencies and supplementation have been shown to influence several physiologic parameters such as immune function. introduction of young stock should include continuation of the feeding program of the source or gradual transition to appropriate feed for the animals available in the region of the research facility (nrc, 1996) . good-quality pasture can support ruminants under certain circumstances. lush spring pastures, especially pastures containing alfalfa, can induce bloat, diarrhea, grass tetany, or nitrate poisoning. ruminants not acclimated to lush pasture should be fed good-quality hay and slowly introduced to pasture environments. when ruminants have access to pasture, it is important to be aware of different eating habits. sheep and cattle are grazers. goats are browsers and will readily eat grasses, as well as seeds, nuts, fruit, and woody-stemmed plants. goats, however, can also be selective eaters and will only eat the leafy, more nutritious parts of the plant. therefore, goats have a tendency to "waste" hay. other eating habits should also be considered. finely ground concentrates are not tolerated well by goats; pelleted concentrates are preferred because the goat will pick out large particles in mixes. generally, goats do not prefer "sweet" feeds that contain molasses and do not need supplemental concentrates if a good-quality pasture or hay is fed. when given access to a salt block, goats generally are self-regulating. grass-fed goats and lactating goats may need supplementation with calcium and phosphorus, whereas alfalfa-fed goats do not (bretzlaff et al., 1991) . horse and sheep feeds may be fed to goats provided that the feed does not contain much molasses (bretzlaff et al., 1991) . the copper content of horse feed is not excessive for goats, as it is for sheep. pelleted horse feeds with 25-28% fiber and 12-14% protein are good goat rations. goats will consume 5-8% of body weight in dry-matter intake (whereas cattle will usually consume only 4% of body weight). goats enjoy human contact, and small alfalfa cubes make tasty treats for the goat. rations that have excessive calcium-phosphorus ratios or elevated magnesium levels may induce urinary calculi in male ruminants. these may also occur when forage grasses are high in silicates and oxalates. to increase ovulation rate in does, some producers "flush" females by feeding 0.5-1 lb concentrate per head per day for several weeks before and after the initiation of the breeding season. thin pregnant dairy goats should be fed 1 lb concentrate per 2) 4.2-9.1 (6.5) 5.6-6.5 potassium (k; mmol/l) hp 3.9-5.4 (4.8) 3.5-6.7 (4.3 ___ 0.5) 3.9-5.8 (4. adata presented as ranges with mean and standard deviation in parentheses, s, serum; p, plasma; hp, heparinized plasma. clinical biochemistry data from kaneko et al. (1997) . day, with the amount increasing to 1.5 lb per head per day during the last 6 weeks of gestation. forage should be fed ad libitum during this time. all newborn ruminants must receive passive immunity from colostrum, the first postpartum milk of a dam that contains concentrated protective maternal antibodies (most as igg1), functional leukocytes, cytokines, vitamins, minerals, and protein. colostrum also has laxative properties. trypsin inhibitors in the colostrum allow the passage of intact antibody molecules, by pinocytosis, through the neonate's gut wall and into the bloodstream during the first few days after birth. the quality of the colostrum is directly related to herd or flock management, vaccination programs, and the dam's overall condition and nutrition throughout gestation and at the time of parturition. ensuring effective colostrum transfer is also dependent on the timing and amount taken by the neonate. most neonatal ruminants can suckle well within 3 hr of birth. those that do so have been shown to have significantly less diarrhea (naylor, 1996) . neonates weakened by dystocia or hypothermia, for example, should be hand-fed or tube-fed colostrum. if necessary, the dam should be hand-milked and the newborn fed colostrum (for example, 20-40 ml for kids) every 2-4 hr for the first 1-2 days. in typical management situations, dairy calves either are separated from their dams immediately after birth and bottle-fed colostrum, or they remain with their dams for only about 24 hr and suckle fresh colostrum during this time. dairy producers then refrigerate and/or freeze the colostrum that cannot be consumed by the calf during that time and then feed this diluted 50:50 with warm water 3 times a day to the calves during the next 2-3 days. extra frozen colostrum for emergencies may be obtained from dairy farmers; it is advantageous to obtain colostrum from well-managed herds and from the multiparous cows in the herd (not heifers) in the same geographic locale. holstein calves, for example, should receive a minimum of 3-5 liters within 12 hr of birth and then be fed about 10-15% of body weight in colostrum by 24 hr of age. after 3 days, calves are then placed on milk replacers. although young ruminants generally do well receiving their dams' milk, commercially available milk replacers are available and should generally be prepared and fed according to the manufacturer's recommendations. containers used to prepare and feed these replacers should be sanitized daily. the fat content of both calf and lamb milk replacers is excessive; however, calf milk replacers can be used for kids if care is taken not to overfeed. young ruminants can be offered good-quality hay (such as second cutting) to nibble on by 1 week of age. calves may be provided with calf starter, a commercially available concentrate with appropriate levels of energy and protein, fed according to the manufacturer's recommendations at 2-3 weeks of age. they can be weaned off milk replacer by 4-7 weeks of age. young ruminants (4-12 months of age) need good-quality forage as well as grain and concentrate supplementation to promote development of the rumen. in farm management situations, forage can be silage, pasture, and hay. in a confinement situation like a research unit, good-quality hay, such as second cutting, is desirable. animals should not be overfed and should be offered a mineral mix free-choice. in contrast to dairy calves, beef calves remain with their mother cows until weaning at 7 months of age. calves tend to suckle many times per day. as they mature, calves are creepfed, with the energy and protein content of the ration determined by the milk production of the dams and by the available forage, such as pasture. several useful references addressing ruminant reproduction in detail are available ("current veterinary therapy: food animal practice," 1986 practice," , 1993 practice," , 1999 "large animal internal medicine," 1996; "current therapy in large animal theriogenology," 1997; hafez, 1987) . sheep are seasonally polyestrous; most breeds will express estrus in the fall (northern hemisphere) and subsequently lamb in the spring. some breeds of sheep may cycle in both the fall and the spring. between seasonal periods of receptivity, the females undergo a long period of sexual quiescence called anestrus. in a research environment, ewes can be artificially stimulated to progress from anestrous to estrous cyclicity by maintaining the females in 8 hr of light and 16 hr of dark for 8-10 weeks. puberty is reached at about 7-8 months (or earlier) in both rams and ewes; rams will typically reach puberty before their female counterparts. ewes will display signs of estrus for about 24-30 hr and will ovulate spontaneously at the end of estrus. the estrous cycle length is 14-19 days, with an average of about 17 days. following breeding, the average length of gestation is 147-150 days. slightly longer gestations are observed in animals carrying single lambs (singlets), in animals carrying rams, and in certain breeds such as those derived from merinos. prolificacy, or the number of lambs produced per gestation, tends to be dependent on the maturity of the dam (older dams tend to have multiple lambs) and on breed characteristics (some fine-wool breeds have fewer multiple births). the finn and dorset breeds are especially prolific. lambs vary in size at birth from about 3-4 lb up to 25 lb. factors that affect birthweight include parental size, number of lambs in the litter (fewer lambs or singlets tend to be larger), age of the ewe (younger ewes have smaller lambs), lamb gender (males tend to be heavier), nutrition, and season or temperature (spring lambs tend to be larger than fall lambs). goats are seasonally polyestrous in temperate regions, so that young are born in favorable times of the year. they are shortday breeders, in that estrus (heat) is brought about by the decreasing light of shorter days. in temperate climates of the northern hemisphere, goats are normally anestrous during the summer and begin cycling in the fall. the actual length of the sexual cycle depends on day length, breed, and nutrition. most dairy goats cycle between august and february or march. nubians often have extended breeding cycles, and the sexual season of some breeds, including the alpine, can be extended by artificial means. the caprine gestation length averages 150 days with a variation of 145-155 days. does bear singletons, twins, and triplets, with slightly shorter gestation when the doe is carrying triplets. cows are polyestrous. domestication of cattle has included selection against seasonality of the breeding season, particularly in dairy breeds but to some extent also in the beef breeds. in spite of this, cattle have been found to be still sensitive, in varying manifestations, to photoperiodicity. reproductive physiology in cattle is influenced by many factors. the reproductive programs in source herds and at well-managed facilities will be production-related. extensive coverage of both physiologic basics and specific industry-related criteriamfor retention of a cow as a breeder, for examplenare addressed in detail in texts and references oriented toward herd and production management ("current veterinary therapy," 1986). gestation in cattle is approximately 280 days, with a range of 270-292 days. the length of gestation in cattle is influenced by fetal sex; fetal numbers; age and parity of the cow; breed; genotype of cow, bull, or fetus; nutrition; and local environmental factors. as noted, these factors are also important in sheep and goats. cows usually bear single calves, although twin births do occur. when twins are combinations of male and female calves, the female should be evaluated for freemartinism. ovine estrus detection is usually accomplished by the ram. nonetheless, because artificial insemination is achievable in ewes, clinical signs of estrus are important. typically, ewes in heat will show a mild enlargement of the vulva, with slight increases of mucus secretion. ewes may isolate from the flock and appear anxious. it is often better and clearly more reliable to employ the help of a sterile ram to mark females when they are in standing heat. two mating systems commonly employed include hand mating and group mating. with hand mating, ewes are placed either singly or in small groups with the ram of choice. ewes are removed as serviced. group mating involves placement of a mature ram with approximately 50-60 ewes for the entire 6-week breeding season. in either mating system, it is best to attach a marking harness to the male so that individual ewes can be identified as serviced. this is important so that parturition dates can be calculated. an easy, natural way to estimate pregnancy is by placing sterile teaser rams with the ewes at the end of the breeding season. any animal marked by the ram probably has not conceived. ultrasound scanners are also used for pregnancy detection. the ultrasound transducer is placed against the right abdomen; presence of a fetus is indicated on the machine. claims of 98% accuracy at 6 weeks postbreeding have been made, although accuracy is generally best beyond 60 days of gestation. interrectal doppler ultrasound probes detect fetal pulses. fetal heart rate is in the range of 130-160 beats per minute, whereas maternal heart rates tend to be 90-110 beats per minute. accuracy is best beyond 60 days of pregnancy. rectal-abdominal palpation is an inexpensive alternative. a plastic probe is introduced intrarectally into the ewe, which is restrained on her back in a cradle. the plastic probe is then manipulated toward the abdomen while palpating for the fetus with the opposite hand. the age of the doe when she first expresses heat varies with breed. some does will express signs of heat between 3 and 4 months old. however, does should be 7-10 months old or at least 80-90 lb in weight before being bred. the caprine estrous cycle lasts 18-24 days. the duration of estrus is 24-96 hr but averages about 40 hr. the estrous cycle can be more erratic in the beginning than in the end of the breeding season (smith, season (with winter delaying), and the level of nutrition (with higher levels hastening puberty). in some cases, the presence of mature cycling cows influences heifer puberty. with adequate nutrition, dairy breeds will reach puberty at 10-12 months and beef breeds at 11-15 months, and estrous cycles will occur regularly after the pubertal (first) estrus, maturing heifers will often have one or more ovulations before showing overt signs of estrus. only one follicle usually ovulates per estrous cycle (hafez, 1987) estrus, or standing heat, in cattle averages 12-16 hr in length, with a range of 6-24 hr ("large animal internal medicine," 1996) . detection of standing heat is important because it is closely related to the time of ovulation. ovulation occurs approximately 25-32 hr after estrus. detection of estrus is usually accomplished by visual observation of vaginal mucous discharge, mounting behavior by other females (i.e., the cow standing to be mounted is the individual in estrus), and receptivity to a bull (willingness to stand). successful visual detection of standing heat is dependent on observation skills of handlers, knowledge of the herd, stresses (e.g., detection decreased in bos taurus during heat stress), barn and yard surfaces (estrus detected better on dirt than on concrete), and maintaining a consistent observation schedule. teaser animals outfitted with marking devices are also used. other methods of detecting estrus include monitoring progesterone levels; glass slide and other evaluations of cervical mucus; change in vaginal ph; and body temperature changes (hafez, 1987) . estrous cycles are usually 21 days in length, with a range of 17-25 days. it is recommended that a heifer deliver her first calf by 2 years of age. after successful conception, progesterone levels in the cow remain elevated for most of the pregnancy, as the result of the 1997). "standing heat" is usually 12-24 hr but can be as short 9 corpus luteum of pregnancy, and they decline only during the as a few hours. signs of estrus in goats include uneasiness, tail switching or "flagging," redness and swelling of the vulva, clear vaginal discharge that becomes white by the end of estrus, vocalization such as continuous bleating, and occasionally riding and standing with other does. a doe that is not in heat will not stand to back pressure or for attempts to hold her tail. does can be induced to show signs of heat by buck exposure and will ovulate within 7-10 days after introduction of the buck. goats ovulate during the later part of the estrous cycle, most between 24-36 hr after the onset of estrus. nevertheless, goats should be mated once signs of estrus are recognized and every 12 hr until the end of estrus. most goats kid only once a year, although some goats near the equator may kid twice. once bred successfully, a goat will only rarely show signs of heat again. in fact, the first sign of pregnancy is usually a failure to return to heat, so animals should be carefully watched. pregnancy can be affirmed by a variety of means. goats will generally decrease milk production with pregnancy and should have at least a 6-to 8-week dry period for the udder to fully involute and prepare for the next milking period. in cattle, age of first estrus is dependent on the breed, the final month. conceptus implantation occurs beginning at about day 17. if the pregnancy fails before this time, the cow will begin to cycle again between days 18-24, but if the pregnancy ends after day 17, there may be a delayed return to estrus. realtime ultrasonography can be used to determine pregnancy as early as 9 days after insemination, with embyros seen by days 26-29. fetal gender can also be determined by experienced personnel by this method by about day 55. detection of pregnancy can be successful by 25-40 days after conception by observation of failure to return to estrus or by palpation per rectum (detecting fetal membrane slip by days 30-35 and/or amniotic vesicle by days 28-35). palpation of the fetus is possible by day 65 and placentomes by approximately days 100-110. palpation later in presumed pregnancy will provide information based on differences in size of the two uterine horns, changes in the uterine wall, and fremitus in the miduterine artery. pregnancy can also be determined with reasonable success rates by determining if progesterone levels are elevated at days 20-24 after insemination. levels of bovine pregnancy-specific protein b may also be measured; this is produced by trophoblastic cells and is detectable by days 15-24 and elevated throughout pregnancy. placentation in sheep, goats, and cattle is epitheliochorial and 10 ft. evaluation of a cow's udder prior to breeding and especotyledonary, in contrast to the diffuse or microcotyledonary cially as parturition approaches is important in order to assure placentas of horses and pigs. the placentomes, the infolded adequate nutrition and success of passive transfer by the functional units of the placenta, are formed as the result of fu-neonate. if the udder is edematous or if mastitis is present, for sion of the villi of the fetal cotyledons projecting into the crypts example, an alternate source of colostrum (such as frozen reof the maternal caruncles (specialized projections of uterine " serves) must made be available. poor udder conformation may mucosa). caruncles of sheep and goats are concave in shape, whereas those of cows are convex. the placentomes are distributed between the pregnant and nonpregant horns of the uterus in sheep, and there are 90-100. in cattle, although the placentomes initially develop around the fetus, they will eventually be distributed to the limit of the chorioallantoic membrane even in the nongravid horn. the placentomes in the nongravid horn will be smaller than in the gravid horn. the total number will be 70-120. the best birthing preparation for all dams is to ensure a proper plane of nutrition (not overnutrition) and adequate exercise. if possible, the dam should be confined to a birthing pasture or sanitized maternity pen a few days prior to parturition. the birthing environment will be very important in the overall health of the dam and offspring; stress minimization and a clean environment will benefit the immune health of both in the short and long term. outdoor parturition in a small birthing pasture has advantages. there is less stress and less intensity of pathogens. indoor maternity pens should be clean, dry, warm, well bedded, well ventilated but draft-free, and well lighted. adequate space per pen minimizes losses of neonates from being stepped and sat on by the dam. management of these pens, especially if concentrated in an area, is important to minimize pathogens to which dam and young are exposed. water troughs or buckets should be elevated or placed outside the pen, because lambs and kids have a tendency to fall or be pushed into them. soiled bedding should be removed from the birthing pen between dams, the area sanitized and allowed to dry, and fresh bedding installed for the next occupant. moving the female immediately before or during parturition may delay the birthing process. in goats, furthermore, in utero death may occur if parturition is unduly delayed. dams should be monitored closely during parturition for dystocias; these may result in loss of young or in young severely weakened from the prolonged birthing process. prior to parturition, ewes should be sheared or crutched. crutching refers to removing wool around the perineal and mammary areas; this minimizes fetal contamination during the birth process. foot trimming can be done at this time as well. the tail and perineal area of the doe should be clipped and cleaned to improve postbirth sanitation. in general, the pregnant doe needs a 14 ft 2 (1.2 m x 1.2 m) area for the birthing process, and area needs to be increased after birthing to allow spacing for kids. each cow should have a minimum pen area of 10 ft x also be problematic; contingency plans should be made to ensure adequate support for the young if they cannot suckle from those udders. inexperienced heifers may react indifferently or aggressively to their offspring and should be monitored more closely than older, multiparous cows with uneventful calving histories. ewes approaching parturition generally isolate themselves from the flock, become restless, stamp their feet, blat, and periodically turn and look at their abdomen. the pelvic region will appear relaxed, and milk will be present in the udder. once hard labor contractions begin, lambs will usually be born quickly. animals that do not appear to be progressing correctly should be examined for dystocia. most cases of fetal malpresentation or malpositioning can be corrected via vagino-uterine manipulation. occasionally cesarean sections will be necessary. sanitation, cleanliness, and adequate lubrication are of utmost importance when performing obstetrical procedures. for about a week before parturition, rectal temperature of the doe will be above normal, or about 103~ depending on environmental temperatures. approximately 24 hr prior to birth, rectal temperature will fall to slightly below normal. many large dairy-goat facilities attempt to control the onset of parturition in order to assist birthing. the drug of choice to induce parturition in the goat is prostaglandin f2~ (pgf2~) (ott, 1982) . on day 144 of gestation, goats given pgf2~ (2.5-5 mg) will deliver kids within 28-57 hr. most goats prefer to kid alone and do so unaided. human interaction can actually interfere with normal birthing, especially in young or nervous does. some does may reject kids if extensive human interference occurs. does nearing parturition have an obviously swollen udder and a red, swollen vulva. pelvic ligaments at the base of tail relax. the doe may circle to make a bed, get up and down, look at her tail or sides, push other goats away, and bleat softly. signs of impending parturition include restlessness; vocalization (bleating softly); uneasiness, including getting up and down, pawing, and bedding; and a mucous discharge, leading to a moist tail. eight to 12 hr prior to parturition, the cervix will dilate and the cervical mucous plug will be evident as a tan, smeared substance on the tail and perineum of the dam. kids should present within 1-6 hr in either anterior or posterior position. a posterior presentation can be recognized by the presence of upward-pointing feet. most does will rest between fetuses and are best left alone. however, if labor is prolonged more than 1 hr, a vaginal exam is indicated. if the pregnant goat is housed with other goats, then herdmates will express great interest in the dam. unless moved prior to parturition, it is best to leave the dam with the group until after parturition, because removal may delay parturition. goats are not prone to retained placenta. normal kids will be quite active and will quickly attempt to stand and nurse. weak kids should be towel-dried, warmed (via heat lamp, heat pad, or warm water bottle), and assisted to nurse or fed colostrum. the goat is one of the few ungulate species that will exhibit "false pregnancy," or pseudopregnancy. this is a fairly common condition. does may have characteristically distended abdomens and may develop hydrometra and "deliver" large volumes of cloudy fluid at expected due dates. subsequent pregnancies can be normal. goats should be tested for pregnancy by 40 days of age. veterinary use of prostaglandins has been successful in treating this condition. as in other species, parturition in cattle results from a combination of hormonal changes associated with the maturity of the fetus, notably acth (adrenocorticotropic hormone) and subsequent increases in fetal corticosteriods within 2 days of birth. administration of acth to a fetus, or administration to the dam, results in premature birth. pregnancy is extended if fetal pituitary or adrenal glands are removed surgically. the fetal cortisol probably affects placental steroid production, accounting for sharp increases in the estrogens and estrogen precursors. coincident with this, maternal progesterone levels fall. the rising levels of estrogen cause release of maternal pgf2~ and induction of oxytocin receptors. most cows will separate themselves from the rest of the herd. a cow will lift her tail and arch her back when she is within a few hours of delivering the calf, and most cows are recumbent when delivering the calf. typically, the whole birthing process takes about 100 min. the length of labor of cows carrying larger calves also will be longer. nervous heifers will take longer to deliver, and if they are disturbed, their labor may cease. all postparturient animals should be monitored for successful passage of these fetal membranes within 12 hr of birth. veterinary intervention is required if not. cows occasionally eat placentas, which may subsequently obstruct rumen outflow and require surgical correction. for cattle, it is now recommended practice to remove membranes that have passed, in order to prevent ingestion. following lambing, it is critical that the newborns be "processed" so that they will have greatest survival chances. in a well-managed flock, many lambs and ewes will not need much assistance. when assistance is given, the newborn lamb's nose and mouth should be wiped free of secretions; gently swinging the lambs, head down, aids in removal of these fluids. the lamb should be dried off and stimulated through rubbing to aid its breathing. the lamb's navel should be dipped in an iodine solution to prevent subsequent navel infections. and the lamb should be identified by the application of an ear tag or ear notch. it is extremely important that the lamb be supplied with highquality colostrum within the first 12 hr of birth. lambs that are not nursing on their own should be tube-fed with colostrum that has been collected and saved previously (i.e., frozen in ice cube trays) or collected from the mother after parturition. passive transfer can be assessed by measuring serum y-glutamyltransferase (ggt) levels (tessman et al., 1997) . after the first few days, colostrum changes over to milk. nursing lambs will ingest increasing amounts of milk as they grow. if the ewe cannot produce sufficient milk, the lamb should be "grafted" onto another ewe or fed artificially with a baby bottle. powdered milk replacers are commercially available; the content of ewe milk is much different from that of cow's milk; thus lamb milk replacer should specifically be used. one report notes that 50-70% of lamb deaths occur during the first week of life and up to 90% occur within the first month. good management of ewes during gestation, care of the lamb at parturition, application of an appropriate vaccination program, and observation and intervention within the first several weeks of a lamb's life will minimize losses (ross, 1989) . immediately after birth, the placenta and any birthing materials should be removed from the doe's pen. kids do not usually need assistance. if kids are to be raised by the dam, they can be left alone; otherwise, kids should be towel-dried and removed from the dam. kids are cold-sensitive and may require a heat lamp or other source of added warmth in cold weather. navel cords should be dipped in tincture of iodine, and kids should be dehorned and castrated within the first several days of life. to control caprine arthritis encephalitis (cae), kids should be immediately removed from the dam and hand-fed heattreated colostrum. colostrum should be heat-treated for 1 hr at 131 ~ e the first feeding can be up to 125 ml of colostrum. kids should receive a total of 250 ml colostrum within the first 36-48 hr of birth. after day 3, kids can be placed on milk replacer. milk replacers should contain 16-24% fat and 20-28% milkbased protein. by 14 days of age, kids should be consuming approximately 1.1-1.4 liters of milk per day. kids should be introduced to forages as soon as possible and may be weaned by 6-10 weeks or 18-25 lb body weight. milk that is fed can be reduced by 4 weeks of age by decreasing either the volume fed or the number of feedings. as with other dams, a cow is usually very attentive to her newborn calf, cleaning and softly vocalizing to the neonate. calves typically are standing by 1 hr after birth and are suckling within 3 hr. as noted previously, dairy calves may be removed from the cow even before suckling, and the colostrum milked from the dam and given to the calf. assistance may be required for nervous heifers, after dystocias and in extreme circumstances such as severe cold. cleaning the newborn's nose and mouth, rubbing down the neonate, assuring that the calf does not get chilled, and assuring that it receives adequate colostrum are all important under any of these circumstances. a stressed calf's umbilical may be treated with an iodine or chlorhexidine solution, although some authors note no benefit of navel treatment, specifying that successful transfer of passive immunity and sound sanitary management of birthing area are the most crucial factors in preventing omphalitis (navel ill) (house, 1996; kersting, 1997; kasari and roussel, 1999) . because newborn calves can be deficient in vitamin a and iron, these may be injected to improve disease resistance (wikse and baker, 1996) . in cases in which the dams' colostrum is known to be deficient in antibodies against common diseases, vaccinations may be administered at 1 day old and followed with boosters at regular intervals. dehorning is performed when horn buds appear. castration is performed between 2 and 9 weeks of age or later. sexing the young in any of the ruminant species is straightforward. the vulva of the female young is located just ventral to the anus. the genitalia of the male include a penis, located along the ventral midline, and a scrotum, located in the inguinal region. the phenomenon of the freemartin, a genetic female born as a twin to a male, is the result of anastomoses between placental circulations of the twin fetuses; the mixing of bloodforming cells and germ cells results in the xx/xy chimeras. this occurs in 85-90% of phenotypic bovine females born as co-twins with males. the female will often have abnormal vulva and clitoris, and the vagina will be a blind end because of the lack of a cervix. sometimes singleton freemartins are born if the male fetus is lost after 30 days' gestation. multiple births are selected for and are common in sheep; the freemartin phenomenon is regarded as rare. twinning is common in goats, and freemartinism occurs in about 6% of male-female pairs of twins. intersexes are seen in some goat breeds and when polled goats are mated. proof is usually based on evidence of abnormal genital development and reports of abnormal sexual behavior. prior to weaning, it must be established that lambs can nutritionally survive without mother's milk. thus, grain, and later roughage, should be offered to lambs well in advance of the day of weaning so that they can adjust to the feedstuff. to prevent the ewes from ingesting the lamb ration, a "creep" should be set up by building an area adjacent to the ewe-lamb pen and devising a slatted entry for the lambs to enter but not the ewes. therefore, the lambs will be accustomed to the new ration through this creep-feeding process. if lambs and ewes will be pastured later in the spring, it is still beneficial to creep-feed lambs until pasture growth is adequate enough to fulfill the requirements of the growing lambs. lambs that are consuming 1.5-2 lb of creep feed per day may be weaned. depending on the individual program, lambs may be weaned as early as 4 weeks of age, although 6-8 weeks of age is more common. if ewes are of a breed that will cycle twice a year, and if it is expected that they will be rebred, then the lambs must be weaned as early as possible so that lactational anestrus will resolve and ewes will recycle. another factor is the cost of lactation rations for the ewes; if lamb grain is more economical than ewe grain, then lambs should be weaned. about 4-5 days prior to weaning, feeding of the lactation ration to the ewes should be discontinued, and only roughage fed. at weaning, the lambs should be removed in the creep, and the ewes removed to an area that is not within sight (and preferably sound) of the lambs. the ewes should be monitored for postweaning mastitis and treated as necessary. ewes that have physical or disease problems or that have not been productive at lambing or feeding their lambs should be culled. the lambs should be monitored to assure that they continue to gain weight and are eating the new ration. kids should be introduced to forages within the first week of life because the natural curiosity of these animals will cause them to investigate sources of feed. kids can be weaned by 6-10 weeks or 18-25 lb. hand-fed milk should be reduced by 4 weeks of age by reducing the volume fed or by decreasing the number of feedings. dairy calves are now usually removed from their dams immediately after birth. it is less common now to allow the calves to remain with their dams for about 24 hr and suckle fresh colostrum during this time, because their intake will be inadequate. dairy producers refrigerate and/or freeze the colostrum produced during the first 24 hr and feed this, diluted 50:50 with warm water, twice a day to the calves during the next 2-3 days. holstein calves, for example, should receive a minimum of 3-5 liters within 12 hr of birth and then be fed about 10-15% of body weight in colostrum by 24 hr of age. after 3 days, calves are then placed on milk replacers, preformulated powders reconstituted with water that provide complete nutrition. milk replacers are commercially available and should be fed according to manufacturer's recommendations vaccination programs for calves vary with the preventive medicine program for the overall herd. passive immunity provided by colostrum from cows on sound management programs will last until a calf is about 6-7 months old; normally vaccinations are not necessary and are contraindicated during those first 6 months. the duration of passive immunity varies considerably among calves, however; some producers choose to begin vaccinating calves at 1-2 months of age and continue with monthly booster immunizations until the animals are 7 months old, when passive immunity is no longer a possibility. artificial insemination (ai) in sheep is more difficult than in cattle because sheep are smaller and cannot be reproductively manipulated via the rectum and because the cervix of sheep is more difficult to traverse with the insemination pipette. breeding animals artificially with fresh semen produces pregnancy rates averaging 50% (not unlike that of cattle); artificial insemination with frozen semen is less successful. several artificial insemination techniques have been used. laparoscopic ai involves the surgical instillation of semen into the uterus through a small abdominal opening. the procedure is successful but is technically involved and costly. cervical ai involves the transvaginal introduction of semen into the cervix. a modification of this technique (transcervical ai) allows for penetration through the cervix into the uterus. this method (called the guelph system for transcervical ai) leads to successful penetration into the uterus in up to 75% of ewes when performed by an experienced inseminator. artificial insemination is now an integral part of dairy herding; natural insemination as a management practice is relatively rare. technicians performing the ai technique are available through commercial enterprises. dairy production employees are also trained. information regarding the management of the donors and recipients, the storage and handling of the semen, and the skills and record keeping required is covered extensively elsewhere (nebel, 1997) . because sheep are hormonally similar to other ruminants, estrous synchronization techniques are comparable. progesterone suppresses follicle-stimulating hormone (fsh) secretion, preventing animals from developing follicles and exhibiting estrus. artificial or natural progesterone can be administered in the feed, through parenteral injection, subcuticular implants, and vaginal pessaries. the progesterone is withdrawn in about 12-14 days, after which the fsh secretion will initiate the process of follicle development (trower, 1993) . estrus usually will occur in 36-60 hr (average is 48 hr). a natural method of synchronization, often applied to promote flock breeding within a short period of time (and thus parturition will be within a narrow window as well), is the introduction of sterile rams with the ewes before the beginning of the normal fall mating period. pheromones released from males naturally stimulate the females to cycle and to synchronize their heats. it should be noted that introduction of a male during late anestrus will often stimulate ovulation in about 6 days; however, this cycle will generally be without clinical signs of estrus (silent heat). vasectomy of rams is one method of producing sterile "teaser rams." introduction of the buck to a group of does will induce ovulation and may even synchronize does. does that are kept separate from the buck will show signs of estrus, will ovulate within 6-10 days, and will have normal pregnancies when introduced to a buck. bucks with horns and intact scent glands are better able to induce ovulation than dehorned bucks, whose scent glands often been removed. control of breeding in the goat has been studied mostly in dairy breeds in order to produce milk throughout the year and to reduce kidding labor. goats in the luteal phase of the estrous cycle, days 4-16, are sensitive to pgf2~ (2.5-5 mg im) and will show estrus in 36-60 hr postinjection (bretzlaff, 1997) . dosing cycling animals twice 11 days apart will synchronize goats, and artificial insemination using this method has resulted in 40-60% conception rates (bretzlaff, 1997; greyling and van niekerk, 1986) . programs for timed breeding have been described and involve administering progestogens (bretzlaff, 1997) . vaginal pessaries of fluorogestone acetate left in place for 21 days in the doe followed by an injection of pregnant mare serum gonadotropin (pmsg) at the time of pessary removal have proven successful. also, when primed by pgf2~, an 11day regimen of fluorogestone acetate with pmsg given on day 9 has been successful. synchronization of cattle estrous cycles and superovulation are used as management techniques in certain commercial cattle and dairy production settings where estrus synchronization or embryo transfer is advantageous to production and management. the methodology is also used in the research setting for coordinating donors and recipients of embryos or other genetically manipulated tissues for implantation. the options and dosing regimens are described in detail in veterinary clinical texts (wenzel, 1997; vanderboom et al., 1997) . in synchronization, the principle is lysis of the existing corpus luteum. the more common practices involve the use of products approved for use in cattle such as pgf2~, one of its analogs, or products containing estradiol valerate. progestogens are also used in conjunction with estradiol valerate. other approaches, involving management techniques combined with pharmacologic interventions, are considered less successful. superovulation regimens involve injections of fsh either alone or with pgf2~ at timed internals. estrus is expected 48 hr after the final injection, and two inseminations are performed at 12 hr intervals after estrus detection. preparation of recipients involves injection of pgf2~ or progestogens with gonadotropins such as pmsg. for greatest success as management tools, these must be combined with a consistent program that provides appropriate nutrition for all cattle involved. synchronization of animals is also influenced by several other factors, however, such as time in the cycle when hormones are administered, response by each individual animal, whether the cow is a dairy or beef animal, parity and maturity of the cows, success of heat detection after the luteolysis, and accurate record keeping. embryo transfer involves the removal of multiple embryos from a superovulated embryo donor and transferring them to synchronized recipients. this method maximizes the genetic potential of the donor animal. the donor animal is hormonally superovulated and inseminated. in sheep, about 1 week after breeding, the embryos are surgically removed from the donor's uterus. in cattle, the procedure is nonsurgical. about 75% of expected embryos (determined by counting corpora lutea) can be recovered; successful recovery is affected by factors such as age of the donor, reproductive health, and experience of the surgeon or technician. furthermore, not all collected embryos are of transferable quality. recipients are hormonally synchronized with the donor animals. on the day of embryo collection, transferable embryos are implanted into the uterus of the recipient; laparoscopy has been used in the past and is now being replaced by nonsurgical methods. pregnancy rates average about 70%. if recipients are not available, embryos, like sperm, can be frozen and kept for later transfer. embryo transfer is commonly practiced in cattle as a herd improvement technique and as a research technique for engineered embyros. disease screening programs for all animals involved are important because several pathogens can be transmitted directly or indirectly, such as bovine viral diarrhea virus, bluetongue virus, infectious bovine rhinotracheitis virus, and mycoplasmal species. in sheep flocks and goat herds, as noted, male young are usually castrated by 1 month of age. the elastrator method is the more popular for animals less than 1 week of age. other methods include the emasculatome (crushing) and surgical removal ("knife method"). the distress associated with castration and tail docking in lambs is the subject of debate and has been researched recently (kent et al., 1995) . as noted, male calves are usually castrated as early as possible and no later than 3 month of age. in some production situations, however, where maximum hormone responsive muscle development and grouping animals together for procedures dictate scheduling, the procedure may be performed on older males. open and closed techniques are used, depending on the age of animals and on veterinary or farm practice. breeding and vasectomized rams and bucks are usually maintained by medium to large production farms. smaller farms often borrow breeding males. breeding males are typically selected by production record, pedigree, and/or breed. vasectomized males are often retired breeders and should be tattooed or identified clearly to avoid any wasted breeding time. the vasectomy technique for both species is comparable (smith and sherman, 1994) . rams may be housed together for most of the year, whereas bucks are penned separately. because ewes will exhibit only a limited number of estrous cycles before becoming reproductively quiescent, it is critical that the male be capable of successfully breeding the female in an expeditious manner. any defects in the external genitalia, reproductive diseases, or musculoskeletal abnormalities may prevent successful copulatory behaviors. furthermore, it is impor-tant to know the semen quality of the ram as one indicator of fertility. semen can be collected via electroejaculation or by use of a teaser mount. once semen is collected, it should be handled carefully and kept warm to prevent sperm death, leading to improper conclusions about the male. typically, the characteristics usually evaluated as a determinate of sperm quality are volume (normal between 0.7 and 2.0 ml); motility (% of sperm moving in a forward wave; high quality is associated with motility of approximately 90%); concentration (sperm count per unit of volume as measured by a hemocytometer; high-quality semen should contain 1.8 x 109 sperm per ml); morphology (live versus dead cells, as determined by special stains and the percentage of abnormal-appearing sperm; neither the abnormalities nor the dead sperm should exceed 10% in high-quality semen). the extensive use of artificial insemination in the dairy cattle industry has minimized the use of bulls on many farms, although a farm may maintain a few bulls for heat detection and for "cleanup" breeding. breeding bulls are maintained in beef production establishments. breeding bulls must be part of the herd vaccination program, with special attention to appropriate timing of immunizations for the commonly transmitted venereal diseases campylobacteriosis and trichomoniasis. tail docking is a relatively recent development in dairy herd management and is practiced in the belief that it will minimize bacterial contamination of the udder and therefore the milk. tails are typically docked to about 10 inches in length. the practice is more popular in certain regions in the united states. to date, there is no published study indicating that this technique provides any distinctive advantage over keeping the tail switch hair clipped short. healthy ruminants have good appetites, chew cud, are alert and curious, have healthy intact coats, move without hindrance, and have clear, bright, clean eyes and cool dry noses. even adult animals, when provided sufficient space, will play. sheep and goats have tidy "pelleted" dark green feces. cattle have pasty, moist, dark green-brown feces. ruminants normally vocalize, and handlers will learn to recognize normal communication among the group or directed at caregivers in contrast to that when animals are stressed. excessive, strained vocalizations are often a sign of stress in cattle. "bruxism," or grinding of the teeth by a ruminant, is usually associated with discomfort or pain. other signs of discomfort, stress, or illness include decreased time spent eating and cud chewing, restlessness, prolonged recumbency with outstretched neck and head, and hunched back when standing. unhealthy ruminants may be thin, may arch their backs or favor a limb, or may have external lumps or swollen joints, an unusual abdominal profile, or rough or dull coats. all ruminants are herd animals to some extent and social individuals; therefore, every effort should be made to allow contact among animals, in terms either of direct contact or of sound, smell, or sight. human contact and handling should be initiated promptly and maintained regularly and consistently throughout the animal's stay in the research facilities. animals should be provided sufficient time to acclimate to handlers and research staff. cattle and sheep can hear at higher frequencies than humans can and may react to sounds not perceived by handlers. knowledge of the peculiarities of sheep behavior will increase the ease of handling and decrease stress-related effects in research. generally, fine-wooled breeds, such as rambouillet, are the most gregarious and are best handled in groups. the meat, or "downs," breeds tend to be less gregarious, and the long-wooled breeds tend to be solitary (ross, 1989; asia, 1996) . nonetheless, movement of animals is simplified by proper facility design. sheep have a wide-angle visual field and are easily scared by activities that are taking place behind them. sheep should be moved slowly and gently. to capture individuals within a flock, it is best to confine the flock to a smaller space and use a shepherd's crook or to gently catch the animal in front of the neck/thorax. grabbing the wool can injure the animals, as well as damage the wool and the underlying tissues. sheep move best in chutes that have solid walls, and individual animals will generally follow a lead animal. any escape route will be challenged and, if successfully breached, will disrupt the entire flock movement. sheep movement is also disrupted by contrasts such as light and shadows that impinge on a chute or corral. finally, like most animals, sheep have a flight zone (minimum zone of comfort), the penetration of which will result in sheep scattering. this minimal flight distance can be modified by increasing handling of the animals and working at the edge of the zone, but it should always be considered when working with animals in chutes, pens, or other confined areas. goats exhibit behavioral characteristics that make them quite distinct from other ruminants. their browsing activity makes them quite orally investigative. goats will readily nibble or chew just about anything they come in contact with, so researchers should keep all paperwork and equipment out of reach. a herd of goats will readily chew through wood gates and fencing, especially when confined in areas without alternatives for chewing behavior. goats are also inquisitive, restless, agile jumpers and climbers, and quite mischievous. if maintained in paddocks, strong high fences are essential, as are adequate spaces for exercise or boulders or rock piles for hoof maintenance and recreational climbing. goats are more tolerant of isolation and are more easily acclimated to human contact than sheep are, but goats will confront unfamiliar intruders and make sneezing noises. goats with horns will use them to advantage, and horns may also become entangled in fencing. although less strongly affected by flock behavior, goats are social animals. most goats raised in close human contact are personable and cooperative and can easily be taught to stand for various procedures, including blood collection. an understanding of breed behaviors, sources of stress in cattle, play behaviors, calf behaviors, and dominance determinants will contribute to prevention of injuries to handlers and better health and welfare of the animals. ruminants of all ages, especially cattle of all ages, should be handled with an appreciation of the serious injury to human handlers that may result (houpt, 1998) . cattle have a wide visual field, as sheep do, and a flight zone that varies in size, according to previous handling experiences (gentle handling and animal tameness make the flight zone smaller) and the circumstances of the moment (grandin, 1993) . groups of cattle are moved effectively around a facility by utilizing chute systems, with sequences of gates, that minimize chances of animals turning around. dairy cattle have been bred and selected over centuries for their docile, tractable characters and production characteristics. in contrast, beef breeds have not been selected for docility and are generally more difficult to handle and restrain. beef breeds, such as angus, are known for their independent natures and protective maternal instincts. all cattle respond well to feed as a reward for desired behavior. healthy cattle typically are very curious and watchful and are alert to sounds and smells. when not grazing or eating, they hold their heads up. when sleeping, the head and neck may be tucked back. because of ruminant digestive and metabolic needs, much of the day is spent eating or cud chewing. occasionally, adult cows sit upright like dogs. cattle maintained inside tend to be more docile. in addition to forced isolation from other cattle, sources of stress include rough attitudes of handlers and unfamiliar visual patterns, routines, or environments. these stressors may exacerbate signs of systemic illnesses. calves are known for non-nutritive suckling, bar licking, and tongue rolling. non-nutritive suckling behavior is greater in hungry calves and also right after a milk meal. it is best to provide nipples and other clean noninjurious materials for the animals to suck. non-nutritive suckling can be detrimental in group-housed calves because it can result in disease transmission and hair ball formation. environmental enrichment devices have been developed to cope with this behavior. the behavior diminishes as the animals are weaned onto solid food (morrow-tesch, 1997) . play activity and vocalizations of calves mimic adult dominance behaviors. play activity by young adult cattle is more common in males, can be quite rough, and is often triggered by a change in the environment. dominance behaviors are dependent on direct physical contact among the cattle, and dominance hierarchies are established within a herd. horns, age, and weight have been reported to be the most important determi-nants. aggressive behaviors in cattle may be triggered by newly introduced animals or unfamiliar visual patterns and by feeding when animals are very hungry. aggression is more common among intact adult males. this section focuses primarily on the more common diseases affecting sheep, goats, and cattle in the united states and elsewhere in north america and those that are reportable. for detailed information not included in this limited overview and for diseases of importance internationally, the authors recommend several excellent comprehensive and focused veterinary clinical texts and periodicals that address ruminant diseases, preventive medicine, and individual and flock or herd management. these are listed under "major references" in the reference list at the end of this chapter. recommendations for current drug therapies, both approved and off-label use in ruminants, including withholding prior to slaughter, formularies, and related information can be found in the references noted above and in formularies (hawk and leary, 1995; plumb, 1999) . in addition, the food animal residue avoidance databank (farad), accessible on the internet <http://www.farad.org>, should be used as a resource. farad is a food safety project of the u.s. department of agriculture and is an information resource to prevent drug and pesticide residues in food animals and animal products. food; may be anorexic, weak, unthrifty and depressed; and may salivate excessively. diagnosis is made based on clinical signs and is confirmed by culture. epizootiology and transmission. the organism penetrates wounds of the skin, mouth, nose, gastrointestinal tract, testicles, and mammary gland. rough feed material and foreign bodies may play a role in causing abrasions. actino bacillus lignieresii then enters into deeper tissues, where it causes chronic inflammation and abscess formation. lymphatic spread may occur, leading to abscessation of lymph nodes or infection of other organs. necropsy findings. purulent discharges of white-green exudate drain from the tracts that often extend from the area of colonization to the skin surface. exudates will also contain characteristic small white-gray (sulfurlike) granules. the pus is usually nonodorous. differential diagnosis. contagious ecthyma and caseous lymphadenitis are the primary differentials. diseases or injuries causing oral pain and discomfort, such as dental infections, foreign bodies, and trauma, should be considered. treatment. animals should be fed softer feeds. antibiotics such as sulfonamides, tetracyclines, and ampicillin are effective, although high doses and long durations of therapy are required. penicillin is not effective. weekly systemic administration of sodium iodide for several weeks is not as effective as antibiotic therapy. surgical excision and drainage are not recommended. etiology. actinobacillus lignieresii is an aerobic, nonmotile, non-spore-forming, gram-negative rod that is widespread in soil and manure and is found as normal flora of the respiratory, gastrointestinal, and reproductive tracts of ruminants. in sheep and cattle, a. lignieresii causes sporadic, noncontagious, and potentially chronic disease characterized by diffuse abscess and granuloma formation in tissues of the head and occasionally other body organs. this disease, called wooden tongue, has not been documented in goats. clinical signs. skin lesions are common. tongue lesions are more common in cattle than in sheep. lip lesions are more common in sheep. soft-tissue or lymph node swelling accompanied by draining tracts is observed in the head and neck regions, as well as other areas. animals may have difficulty prehending prevention and control. because the organism enters through tissue wounds, especially those associated with oral trauma, feedstuffs should be closely monitored for coarse material and foreign bodies. b. arcanobacterium infection (formerly actinomycosis, or "lumpy jaw") etiology. arcanobacterium (formerly known as actinomyces or corynebacterium) pyogenes and a. bovis are anaerobic, nonmotile, non-spore-forming, gram-positive, pleomorphic rods to coccobacilli. arcanobacterium bovis is a normal part of the ruminant oral microflora and is the organism associated with "lumpy jaw" in cattle; this syndrome is rarely seen in sheep and goats. this organism has also been associated with pharyngitis and mastitis in cattle. clinical signs and diagnosis. arcanobacterium bovis causes mandibular lesions primarily. the mass will be firm, nonpainful, and immovable. draining tracts may develop over time. if teeth roots become involved, painful eating and weight loss are evident. radiographic studies are helpful for determining fistulas. diagnosis is based on clinical signs, and culture is required to confirm arcanobacterium. the prognosis is poor for lumpy jaw. epizootiology and transmission. these organisms are normal flora of the gastrointestinal tracts of ruminants and gain entrance into the tissues through abrasions and penetrating wounds. necropsy. draining lesions with sulfurlike granules (as with actinobacillosis) are frequently observed. ious degrees of depression and anorexia, and purulent discharges may be seen draining from the umbilicus. involvement of the urachus is usually followed by cystitis and associated signs of dysuria, stranguria, hematuria, and so on. severe sequelae may include septicemia, peritonitis, septic arthritis (joint ill), meningitis, osteomyelitis, and endocarditis. research complications. young stock affected by omphalophlebitis may be inappropriate subjects because of growth setbacks and physiologic stresses from the infection. affected adult animals will not thrive and, even with therapy, may not be appropriate research subjects. pathogenesis. arcanobacterium pyogenes is known to produce an exotoxin, which may be involved in the pathogenesis. differential diagnosis. actinobacillus lignieresii and caseous lymphadenitis are important differentials for draining tracts. a major differential for omphalophlebitis is an umbilical hernia, which will typically not be painful or infected. there are many differentials for septic joints and polyarthritis: chlamydia spp., mycoplasma spp., streptococci, coliforms, erysipelothrix rhusiopathiae, fusobacterium necrophorum, and salmonella spp. tumors, trauma to the affected area, such as the mandible, and dental disease or oral foreign body should also be considered. prevention and control. arcanobacterium bovis lesions can be prevented or minimized by feeds without coarse or sharp materials. treatment. penicillin or derivatives such as ampicillin or amoxicillin are treatments of choice. sodium iodides (intravenous) and potassium iodides (orally) have been utilized also. extended antibiotic therapy may be necessary. surgical excision is an option. in addition to medications noted above, isoniazid is somewhat effective for a. bovis infections in nonpregnant cattle. research complications. the possibility of long-term infection and long therapy are factors that will diminish the value of affected research animals. omphalophlebitis, omphaloarteritis, omphalitis, and navel ill are terms referring to infection of the umbilicus in young animals. arcanobacterium pyogenes is the most common organism causing omphalophlebitis, an acute localized inflammation and infection of the external umbilicus. most cases occur within the first 3 months of age, and animals are presented with a painful enlargement of the umbilicus. animals may exhibit varetiology. bacillus anthracis is a nonmotile, capsulated, sporeforming, aerobic, gram-positive bacillus that is found in alkaline soil, contaminated feeds (such as bonemeal), and water. common names for the disease anthrax include woolsorters' disease, splenic fever, charbon, and milzbrand. clinical signs and diagnosis. anthrax is a sporadic but very serious infectious disease of cattle, sheep, and goats characterized by septicemia, hyperthermia, anorexia, depression, listlessness, depression, and tremors. subacute and chronic cases may occur also and are characterized by swelling around the shoulders, ventral neck, and thorax. the incubation period is 1 day to 2 weeks. bloody secretions such as hematuria and bloody diarrhea often occur. abortion and blood-tinged milk may also be noted. the disease is usually fatal, especially in sheep and goats, after 1-3 days. death is the result of shock, renal failure, and anoxia. diagnosis is based on the clinical signs of peracute deaths and hemorrhage. stained blood smears may show short, single to chained bacilli. blood may be collected from a superficial vein and submitted for culture. epizootiology and transmission. cattle and sheep tend to be affected more commonly than goats, because of grazing habits. older animals are more vulnerable than younger, and bulls are more vulnerable than cows. although the disease occurs worldwide, and even in cold climates, most cases in the united states occur in the central and western states, and outbreaks usually occur as the result of spore release after abrupt climatic changes such as heavy rainfall after droughts or during warmer, dryer months. spores survive very well in the environment. the anthrax organisms (primarily spores) are generally ingested, sporulate, and replicate in the local tissues. abrasive forages may play a role in infection. transmission via insect bites or through skin abrasions rarely occurs. necropsy. necropsies should not be done around animal pens or pastures, and definitive diagnoses may be made without opening the animals. incomplete rigor mortis, rapid putrefaction, and dark, uncoagulated blood exuding from all body orifices are common findings. blood collected carefully and promptly from peripheral veins of freshly dead animals can be used diagnostically. splenomegaly, cyanosis, epicardial and subcutaneous hemorrhages, and lymphadenopathy are characterisitic of the disease. pathogenesis. the rapidly multiplying organisms enter the lymphatics and bloodstream and result in a severe septicemia and neurotoxicosis. encapsulation protects the organisms from phagocytosis. liberated toxins cause local edema. differential diagnosis. although anthrax should always be considered when an animal healthy the previous day dies acutely, other causes of acute death in ruminants should be considered, e.g., bloat, poisoning, enterotoxemia, malignant edema, blackleg, and black disease. prevention and control. outbreaks must bereported to state officials. anthrax is of particular concern as a bioterrorism agent. any vaccination programs should also be reviewed with regulatory personnel. herds in endemic areas and along waterways are usually vaccinated routinely with the sterne-strain spore vaccine (virulent, nonencapsulated, live). careful hygiene and quarantine practices are crucial during outbreaks. dead animals and contaminated materials should be incinerated or buried deeply. biting insects should be controlled. the disease is zoonotic and a serious public health risk. treatment. treatment of animals in early stages with penicillin and anthrax antitoxin (hyperimmune serum, if available) may be helpful. amoxicillin, erythromycin, oxytetracycline, gentamicin, and fluoroquinolones are also good therapeutic agents. during epidemics, animals should be vaccinated with the sterne vaccine. research complications. natural and experimental anthrax infections are a risk to research personnel; the pathogen may be present in many body fluids and can penetrate intact skin. the organism sporulates when exposed to air, and spores may be inhaled during postmortem examinations. etiology. brucella is a nonmotile, non-spore-forming, nonencapsulated, gram-negative coccobacillus. brucella abortus is one of several brucella species that infects domestic animals but cross-species infections occur rarely. brucella abortus or b. melitensis may cause brucellosis in sheep, cattle, and goats. brucella melitensis (biovar 1, 2, or 3) is the primary cause of sheep disease (garin-bastuji et al., 1998) . brucella ovis is more commonly associated with ovine epididymitis or orchitis than abortion. in the united states, clusters of brucellosis are still found in western areas contiguous to yellowstone national park. bang's disease is the common name given to the disease in ruminants. clinical signs and diagnosis. brucella melitensis in the adult ewe is generally asymptomatic and self-limiting within about 3 months. however, because the organism may enter and cause necrosis of the chorionic villi and fetal organs, abortion or stillbirths may occur. abortion usually occurs in the third trimester, after which the ewe will appear to recover. it has been reported that up to 20% of infected ewes may abort more than once. rams will also be infected and may develop orchitis or pneumonia. the disease caused by b. ovis is manifested by clinical or subclinical infection of the epididymis, leading to epididymal enlargement and testicular atrophy. brucella ovis causes decreased fertility. brucella melitensis is the more common cause of brucellosis in goats. brucella abortus has been shown to infect goats in natural and experimental infections, and b. ovis has also been shown to infect goats experimentally. does infected with b. melitensis will also abort during the third trimester. infections with b. abortus in cattle produce few clinical signs. there may be a brief septicemia during which organisms are phagocytosed by neutrophils and fixed macrophages in lymph nodes. in cows, the organism localizes in supramammary lymph nodes and udders and in the endometrium and placenta of pregnant cows. infection may cause abortions after the fifth month, with resulting retained placentas. permanent infection of the udder is common and results in shedding of organisms in milk. in bulls, the organism may cause unilateral orchitis and epidydimitis and involvement of the secondary sex organs. organisms may be in the semen. in infected herds, lameness may also be a clinical sign. diagnosis of brucellosis can be made by bacterial isolation of the brucella organism from necropsy samples (especially the fetal stomach contents), as well as by supportive serological evidence. many serological tests are available, such as the tube and plate agglutination tests, the card or rose bengal test, the rivanol precipitation test, complement fixation, enzyme-linked immunosorbent assay (elisa), polymerase chain reaction (pcr), and others. test selection is often dependent on state requirements in the united states. epizootiology and transmission. the primary route of transmission of b. abortus is ingestion of the organism from infected tissues and fluids (milk, vaginal and uterine discharges) during and for a few weeks after abortion or parturition; contaminated semen is considered to be a minor source of infection. exposure to the organism may occur via the gastrointestinal tract (contaminated feed or water), the respiratory tract (droplet infection), or the reproductive tract (contaminated semen) and through other mucous membranes such as the conjunctiva. brucella ovis is transmitted in the semen, as well as orally or nasally through contaminated feed and bedding. necropsy findings. a sheep fetus aborted due to brucella will exhibit generalized edema. the liver and spleen will be swollen, and serosal surfaces will be covered with petecchial hemorrhages. peritoneal and pleural cavities often contain serofibrinous exudates. the placenta will be leathery. pathogenesis. ruminants are considered especially susceptible to brucella infection, because of higher levels of erythritol (a sugar alcohol), which is a growth stimulant for the organism. brucella utilizes erythritol preferentially over glucose as an energy source. placentas and male genitalia also contain high levels of erythritol. brucella organisms also evade lysis when phagocytosed by macrophages and neutrophils and survive intracellularly in phagosomes. abortion is the result of placentitis, typically during the third trimester of gestation. brucella ovis enters the host through the mucous membranes, then passes into the lymphatics, causes hyperplasia of reticuloendothelial cells, and is spread to various organs via the blood. the organism localizes in the epididymides, the seminal vesicles, the bulbourethral glands, and the ampullae. orchitis may be a sequelae of the disease. epididymitis can be diagnosed by identifying gross lesions by palpation of the epididymides, by serological evidence of antibodies to b. ovis, and by semen cultures. differential diagnosis. differential diagnoses include all other abortion-causing diseases. many other agents, such as actinobacillus spp., arcanobacterium (actinomyces) pyogenes, eschericia coli, pseudomonas spp., proteus mirabilis, chlamydia, mycoplasma, and others may be associated with ovine epididymitis and orchitis. a clinically and pathologically similar agent, actinobacillus seminis, has been isolated from virgin rams. this organism has morphological and staining characteristics similar to those of b. ovis and complicates the diagnosis (genetzky, 1995) . prevention and control. the rev 1 vaccine has been recommended for vaccination of ewe lambs in endemic areas, but this vaccine is not used in the united states. separating young rams from potentially infected older males, sanitizing facilities, and vaccinating them with b. ovis bacterin can prevent the disease. over the past 20 years, aggressive federal and state regulatory and cattle herd health programs in the united states have provided control and prevention mechanisms for this pathogen through a combination of serological monitoring of herds, slaughter of diseased animals, herd management, vaccination programs, and monitoring of transported animals. most states are considered brucellosis-free in the cattle populations; thus, procurement of ruminants that have been exposed to this infectious agent will be unlikely. cattle vaccination programs can be very successful when conducted on a herd basis to reduce likelihood of exposure. strain 19 and the recently validated attentuated strain rb51 are live vaccines and can be used in healthy heifer calves 4-12 months old. vaccination for older animals may be done under certain circumstances. vaccination of bull calves is not recommended, because of low likelihood of spread through semen and possibility of vaccination-induced orchitis. the strain 19 vaccine induces long-term cell-mediated immunity, protects a herd from abortions, and protects the majority of a herd from reactors during a screening and culling program. the vaccine will not, however, protect the animals from becoming infected with b. abortus. strain 19 vaccine induces an antibody response in cattle. the rb51 vaccine does not result in antibody titers and therefore is advantageous because infection with brucella can be determined serologically. the rb51 vaccine has been designated as the official calfhood bovine brucellosis vaccine in the united states by the u.s. department of agriculture's animal and plant health inspection service (aphis) (stevens et al., 1997) . brucella vaccine should be administered to unstressed, healthy cattle, with attention to particular side effects of the vaccination material and to prevention of compounding stresses associated with weaning, regrouping, other management changes, and shipping. the rb51 is regarded as less pathogenic and abortigenic in cattle. clinical signs and diagnosis. ovine vibriosis is a contagious disease that causes abortion, stillbirths, and weak lambs. the organism inhabits the intestines and gallbladder in subclinical carriers. abortion generally occurs in the last trimester, and abortion storms may occur as more susceptible animals, such as maiden ewes, become exposed to the infectious tissues. it is reported that 20-25% of the flock may become infected and up to 5% of the ewes will die (jensen and swift, 1982) . some lambs may be born alive but will be weak, and dams will not be able to produce milk. diagnosis is achieved by microscopic identification or isolation of the organism from placenta, fetal abomasal contents, and maternal vaginal discharges. tentative identification of the organism can be made by observing curved ("gull-wing") rods in giemsa-stained or ziehl-neelsen-stained smears from fetal stomach contents, placentomes, or maternal uterine fluids. epizootiology and transmission. campylobacteriosis occurs worldwide. campylobacter spp., such as c. jejuni, normally inhabit ovine gastrointestinal tracts. transmission of the disease occurs through the gastrointestinal tract, followed by shedding, especially associated with aborted tissues and fluids. in abortion storms, considerable contamination of the environment will occur due to placenta, fetuses, and uterine fluids. ewes may have active campylobacter organisms in uterine discharges for several months after abortion. the bacteria will also be shed in feces, and feed and water contamination serve as another source. there is no venereal transmission in the ovine. necropsy. aborted fetuses will be edematous, with accumulation of serosanguinous fluids within the subcutis and muscle tissue fascia. the liver may contain 2-3 cm pale foci. placental tissues will be thickened and edematous and will contain serous fluids similar to those of the fetus. the placental cotyledons may appear gray. pathogenesis. the organism enters the bloodstream and causes a short-term bacteremia (1-2 weeks) prior to the localizing of the bacteria in the chorionic epithelial cells and finally passing into the fetus. should be considered in late gestation ovine abortions. a bacterin is available to prevent the disease. carrier states have been cleared by treating with a combination of antibiotics, including penicillin and oral chlortetra-cycline. aborting ewes should be isolated immediately from the rest of the flock. after an outbreak, ewes will develop immunity lasting 2-3 years. treatment. infected animals should be isolated and provided with supportive therapy. prompt decontamination of the area and disposal of the aborted tissues and discharges are important. research complications. losses from abortion may be considerable. campylobacter ssp. are zoonotic agents, and c. fetus subsp, intestinalis may be the cause of "shepherd's scours." ii. clinical signs and diagnosis. preliminary signs of a problem in the herd will be a high percentage of cows returning to estrus after breeding and temporary infertility. this will be particularly apparent in virgin heifers that may return to estrus by 40 days after breeding. long interestrous intervals also serve an indication of a problem. spontaneous abortions will occur in some cases, typically during the fourth to eighth months of gestation. severe endometritis may lead to salpingitis and permanent infertility. demonstration or isolation of the organism, a curved rod with corkscrew motility, is the basis for diagnosis. the vaginal mucous agglutination test is used to survey herds for campylobacteriosis. serology will not be worthwhile, because the infection does not trigger a sufficient antibody response. culture from breeding animals may be difficult because campylobacter will be overgrown by faster-growing species also present in the specimens. epizootiology and transmission. the bacteria is an obligate, ubiquitous organism of the genital tract. transmission is from infected bulls to heifers. older cows develop effective immunity. necropsy findings. necrotizing placentitis, dehydration, and fibrinous serositis will be found grossly. in addition, bronchopneumonia and hepatitis will be seen histologically. pathogenesis. campylobacter organisms grow readily in the genital tract, and infection is established within days of exposure. the resulting endometritis prevents conception or causes embyronic death. differential diagnosis. the primary differential diagnosis for campylobacteriosis is trichomoniasis. other venereal diseases should be considered when infertility problems are noted in a herd. these include brucellosis, mycoplasmosis, ureaplasmosis, infectious bovine rhinotracheitis-infectious pustular vulvovaginitis (ibr-ipv), and bovine virus diarrhea (bvd). leptospirosis should also be considered. in addition, management factors such as nutrition and age of heifers at introduction to the herd should be considered. prevention and control. killed bacterin vaccines are available, either as oil adjuvant or as aluminum hydroxide adsorbed. the former is preferred because of duration of immunity but causes granulomas. that vaccine also has specific recommendations regarding administration several months before the breeding season. the latter product is administered closer to the breeding season, and the duration of immunity is not as prolonged. in both cases, boosters should be given after the initial immunization and as part of the regular prebreeding regimen. only one bacterin product is approved for use in bulls. many combination vaccine products contain only the aluminum hydroxide adsorbed product. artificial insemination (ai) is particularly useful at controlling the disease, but bulls used for ai must be part of a screening program for this and other venereal diseases such as trichomoniasis. treatment. cows will usually recover from the infection, and treatment with antibiotics such as penicillin, administered as an intrauterine infusion, improve the chances of returning to breeding condition. etiology. the most common caprine bacterial skin infection is caused by staphylococcus intermedius or s. aureus and is known as staphylococcal dermatitis (smith and sherman, 1994) . the staphylococcus organisms are cocci and are categorized as primary pathogens or ubiquitous skin commensals of humans and animals. staphylococcus aureus and s. intermedius are classified as primary pathogens and produce coagulase, a virulence factor. clinical signs and diagnosis. small pustular lesions, caused by bacterial infection and inflammation of the hair follicle, occur around the teats and perineum. occasionally, the infection may involve the flanks, underbelly, axilla, inner thigh, and neck. staphylococcal dermatitis may occur secondary to other skin lesions. diagnosis is based on lesions. culture will distinguish s. aureus. pathogenesis. simple boredom may cause rubbing, followed by staphylococcal infection of damaged epidermis. differential diagnosis. the presence of scabs makes contagious ecthyma a differential diagnosis, along with fungal skin infections and nutritional causes of skin disease. treatment. severe infections should be treated with antibiotics based on culture and sensitivity. severe lesions and lesions localized to the underbelly, thighs, and udder benefit by periodic cleaning with an iodophor shampoo and spraying with an antibiotic and an astringent (smith and sherman, 1994) . h. clostridial diseases i. clostridium perfringens type c infection (enterotoxemia and struck) etiology. clostridium perfringens is an anaerobic, grampositive, nonmotile, spore-forming bacterium that lives in the soil, in contaminated feed, and in gastrointestinal tracts of ruminants. the bacteria is categorized by toxin production. toxins include alpha (hemolytic), beta (necrotizing), delta (cytotoxic and hemoltyic), epsilon, and iota. types of c. perfingens are a, b, c, d, and e. this is a common and economically significant disease of sheep, goats, and cattle. clinical signs and diagnosis. the beta toxin associated with overgrowth of this bacterium results in a fatal hemorrhagic enterocolitis within the first 72 hr of a young ruminant's life. many animals may be found dead, with no clinical presentation. affected animals are acutely anemic, dehydrated, anorexic, restless, and depressed and may display tremors or convulsions as well as abdominal pain. feces may range from loose gray-brown to dark red and malodorous. morbidity and mortality may be nearly 100%. a similar noncontagious but acutely fatal form of enterotoxemia in adult sheep, called struck, occurs in yearlings and adults. struck is rare in the united states. the disease is also caused by the beta toxin of c. perfringens type c and is often associated with rapid dietary changes or shearing stresses in sheep. although affected animals are usually found dead, clinical signs include uneasiness, depression, and convulsions. mortality is usually less than 15%. diagnosis is usually based on necropsy findings, although confirmation can be made by culture of the organism. identification of the beta toxin in intestinal contents may be difficult because of instability of the toxin. necropsy findings. necropsy findings include a milk-filled abomasum, and hemorrhage in the distal small intestine and throughout the large intestine. petechial hemorrhages of the serosal surfaces of many organs, especially the thymus, heart, and gastrointestinal tract, will be visible. hydropericardium, hydroperitoneum, and hemorrhagic mesenteric lymph nodes will also be present. pulmonary and brain edema may also be seen. histologically, the gram-positive c. perfringens organisms may be visible in excess numbers along the mucosal surface of the swollen, congested, necrotic intestines. in cases of struck, necropsy findings include congestion and erosions of the mucosa of the gastrointestinal tract, serosal hemorrhages, and serous peritoneal and pericardial fluids. in late stages of the disease and especially if prompt necropsy is not performed, the organism will infiltrate the muscle fascial layers and produce serohemorrhagic and gaseous infiltration of perimysial and epimysial spaces. pathogenesis. hemorrhagic enterotoxemia is an acute, sporadic disease caused by the beta toxin of clostridium perfringens type c. neonates ingest the organism, which then proliferates and attaches to the gastrointestinal microvilli and elaborates primarily the beta toxins. the trypsin inhibitors present in colostrum prevent inactivation of the beta toxin. the toxins injure intestinal epithelial cells and then enter the blood, leading to acute toxemia. the intestinal injury may result in diarrhea, with small amounts of hemorrhage. associated electrolyte and water loss result in dehydration, acidosis, and shock. differential diagnosis. differential diagnoses include other clostridial diseases such as blackleg and black disease, as well as coccidiosis, salmonellosis, anthrax, and acute poisoning. clinical signs in chronic cases in older animals, such as adult goats, include soft stools, weight loss, anorexia, depression, and severe diarrhea, sometimes with mucus and blood. mature affected sheep may be blind and anorectic and may head-press. necropsyfindings. necropsy findings are similar to those seen with c. perfringens type c. additionally, extremely necrotic, soft kidneys ("pulpy kidneys") are usually observed immediately following death. (this phenomenon is in contrast to what is normally associated with later stages of postmortem autolysis.) focal encephalomalacia, and petechial hemorrhages on serosal surfaces of the brain, diaphragm, gastrointestinal tract, and heart are common findings. diagnosis can be made from the typical clinical signs and necropsy findings as well as the observation of glucose in the urine at necropsy. shock, probably through vascular damage. the noncontagious, peracute form of enterotoxemia occurs in suckling, fast-growing animals, either nursing from their dams or on high-protein, high-energy concentrates. the largest, fastest-growing animals generally are predisposed to this condition; for example, lambs, fat ewe lambs, and usually singleton lambs tend to be most susceptible. the hyperglycemia and glucosuria seen in acute cases are due to epsilon toxin effects on liver glycogen metabolism. should be administered to the pregnant animals prior to parturition. an alternative includes administration of an antitoxin to the newborn lambs. the disease may become endemic once it is on the premises. treatment. treatment is difficult and usually unsuccessful. antitoxin may be useful in milder cases, and the antitoxin and toxoid can also be administered during an outbreak. differential diagnosis. tetanus, enterotoxigenic e. coli, botulism, polioencephalomalacia, grain overload, and listeriosis are differentials. prevention and control. vaccination prevents the disease. maternal antibodies last approximately 5 weeks postpartum; thus young animals should be vaccinated at about this time. feeding regimens to young, fast-growing animals and feeding of concentrates to adults should be evaluated carefully. research complications. this disease can be costly in losses of neonates and younger animals. treatment. treatment consists of support (fluids, warmth), antitoxin administration, oral antibiotics, and diet adjustment. toxin that is proteolytically activated by trypsin. this disease caused by c. perfringens tends to be associated with sheep and is of less importance in goats and cattle. clinical signs. the peracute condition in younger animals is characterized by sudden deaths, which are occasionally preceded by neurological signs such as incoordination, opisthotonus, and convulsions. because the disease progresses so rapidly to death (within 1-2 hr), clinical signs are rarely observed. hypersalivation, rapid respirations, hyperthermia, convulsions, and opisthotonus have been noted. in acute cases, hyperglycemia and glucosuria are considered almost pathognomonic. etiology. clostridium tetani is a strictly anaerobic, motile, spore-forming, gram-positive rod that persists in soils and manure and within the gastrointestinal tract. at least 10 serotypes of c. tetani exist. clinical signs. infection by c. tetani is characterized by a sporadic, acute, and fatal neuropathy. after an incubation period of 4 days to 3 weeks, the animal exhibits bloat; muscular spasticity; prolapse of the third eyelid; rigidity and extension of the limbs, leading to a stiff gate; an inability to chew; and hyperthermia. erect or drooped ears, retracted lips, drooling, hypersensitivity to external stimuli, and a "sawhorse" stance are frequent signs. the animal may convulse. death occurs within 3-10 days, and mortality is nearly 100%, primarily from respiratory failure. diagnosis is based on clinical signs. musclerelated serum enzymes such as aspartate aminotransferase (ast), creatinine kinase (ck), and lactate dehydrogenase (ldh) might be elevated. (jensen and swift, 1982) . serum cortisol may also be elevated, and stress hyperglycemia may be evident. permanent lameness may result in survivors. contaminant and is often found as part of the gut microflora of herbivores. the organisms sporulate and persist in the environment. all species of livestock are susceptible, but sheep and goats are more susceptible than cattle. individual cases may occur, or herd outbreaks may follow castration, tail docking, ear tagging, or dehorning. mouth wounds may also be sites of entry. pathogenesis. tetanus, or lockjaw, is caused by the toxins of c. tetani. all serovars produce the same exotoxin, which is a multiunit protein composed of tetanospasmin, which is neurotoxic, and tetanolysin, which is hemolytic. a nonspasmogenic toxin is also produced. contamination of wounds results in anaerobic proliferation of the bacterium and liberation of the tetanospasmin, which diffuses through motor neurons in a retrograde direction to the spinal cord. the toxin inhibits the release of glycine and y-aminobutyric acid from renshaw cells; this resuits in hypertonia and muscular spasms. proliferation of c. tetani in the gut of affected animals may also serve as a source and may produce clinical signs. the uterus is the most common site of infection in postparturient dairy cattle with retained placentas. differential diagnoses. early in the course of the infection, differential diagnoses include bloat, rabies, hypomagnesemic tetany, polioencephalomalacia, white muscle disease, enterotoxemia in lambs, and lead poisoning. polyarthritis of cattle is a differential for the gait changes in that species. necropsy findings. findings are nonspecific except for the inflammatory reaction associated with the wound. because of the low number of organisms necessary to cause neurotoxicosis, isolation of c. tetani from the wound may be difficult. administering tetanus antitoxin (e.g., at least 500 iu in an adult sheep or goat); vaccinating with tetanus toxoid; administering of antibiotics (penicillin, both parenterally [potassium penicillin intravenously and procaine penicillin intramuscularly] and flushed into the cleaned wound), a sedative or tranquilizer (e.g., acepromazine or chlorpromazine) and a muscle relaxant; and keeping the animal in a dark, quiet environment. supportive fluids and glucose must be administered until the animal is capable of feeding. if the animal survives, revaccination should be done 14 days after the previous dose. prevention and control like other ubiquitous clostridial diseases, tetanus is impossible to eradicate. the disease can be controlled and prevented by following good sanitation measures, aseptic surgical procedures, and vaccination programs. tetanus toxoid vaccine is available and very effective for stimulating long-term immunity. tetanus antitoxin can be administered (200 iu in lambs) as a preventive or in the face of disease as an adjunct to therapy. both the toxoid and the antitoxin can be administered to an animal at the same time, but they should not be mixed in the syringe, and each should be administered at different sites, with a second toxoid dose administered 4 weeks later. animals should be vaccinated 2 or 3 times during the first year of life. does and ewes should receive booster vaccinations within 2 months of parturition to ensure colostral antibodies. research complications. unprotected, younger ruminants may be affected following routine flock or herd management procedures. contaminated or inadequately managed open wounds or lesions in older animals may provide anaerobic incubation sites. etiology. clostridium novyi, an anaerobic, motile, sporeforming, gram-positive bacteria, is the agent of bighead and black disease. clostridium novyi type d (c. hemolyticum) is the cause of bacillary hemoglobinuria, or "red water." clostridium chauvoei is the causative agent of blackleg. clinical signs. bighead is a disease of rams characterized by edema of the head and neck. the edema may migrate to ventral regions such as the throat. additional clinical signs include swelling of the eyelids and nostrils. most animals will die within 48-72 hours. black disease, or infectious necrotic hepatitis, is a peracute, fatal disease associated with c. novyi. it is more common in cattle and sheep but may be seen in goats. the clinical course is 1-2 days in cattle and slightly shorter in sheep. otherwise healthy-appearing adult animals are often affected. clinical signs are rarely seen, because of the peracute nature of the disease. occasionally, hyperthermia, tachypnea, inability to keep up with other animals, and recumbency are observed prior to death. bacillary hemoglobinuria is an acute disease seen primarily in cattle and characterized by fever and anorexia, in addition to the hemoglobinemia and hemoglobinuria indicated by the name. animals that survive a few days will develop icterus. mortality may be high. blackleg, a disease similar to bighead, causes necrosis and emphysema of muscle masses, serohemorrhagic fluid accumulation around the infected area, and edema (jackson et al., 1995) . blackleg is more common in cattle than in sheep. the incubation period is 2-5 days and is followed by hyperthermia, muscular stiffness and pain, anorexia, and gangrenous myositis. the clinical course is short, 24-48 hr, and untreated animals invariably die. blackleg in cattle can be associated with subcutaneous edema or crepitation; these do not usually occur in sheep. most lesions are associated with muscles of the face, neck, perineum, thigh, and back. epizootiology and transmission. bighead is caused by the toxins of c. novyi, which enters through wounds often associated with horn injuries during fighting. the c. novyi type b organisms produce alpha and beta toxins, and the alpha toxins are mostly responsible for toxemia, tissue necrosis, and subsequent death. clostridium novyi type d is endemic in the western united states. it is hypothesized that the c. chauvoei organisms enter through the gastrointestinal tract. black disease and bacillary hemoglobinuria are associated with concurrent liver disease, often associated with fasciola infections (liver flukes); it is sometimes seen as a sequela to liver biopsies. the diseases are more common in summer months, and fecal contamination of pastures, flooding, and infected carcasses are sources of the organism. birds and wild animals may be vectors of the pathogen. ingested spores are believed to develop in hepatic tissue damaged and anoxic from the fluke migrations. necropsy. diagnosis of black disease is usually based on postmortem lesions. subcutaneous vessels will be engorged with blood, resulting in dried skin with a dark appearance. carcasses putrefy quickly. in addition, hepatomegaly and endocardial hemorrhages are common, and hepatic damage from flukes may be so severe that diagnosis is difficult. blood coagulates slowly in affected animals. pathogenesis. the propagation of the clostridial organisms is self-promoted by the damage caused by the toxins and the increased local anaerobic environment created. clostridium novyi proliferates in the soft tissues of the head and neck, and the resultant clostridial toxin causes increased capillary permeability and the liberation of serous fluids into the tissues. mixed infections with related clostridial organisms may lead to increasing hemorrhage and necrosis in the affected tissues. diagnosis is based on clinical signs. in black disease and bacillary hemoglobinuria disease, the ingested clostridial spores are absorbed, enter the liver, and cause hepatic necrosis. associated toxemia causes subcutaneous vascular dilatation; increased pericardial, pleural, and peritoneal fluid; and endocardial hemorrhages. the toxins produced by c. novyi, identified as beta, eta, and theta, and each having enzymatic or lytic properties or both, also contribute to the hemolytic disease. clostridium chauvoei spores proliferate in traumatized muscle areas damaged by transportation, rough handling, or injury. differential diagnosis. differential diagnoses include other clostridial diseases as well as photosensitization. hemolytic diseases such as babesiosis, leptospirosis, and hemobartonellosis should be included as differentials. treatment. for c. chauvoei infection (blackleg), early treatment with penicillin or tetracycline may be helpful. treatment for black disease is not rewarding even if the animal is found before death. carcasses from bacillary hemoglobinuria losses should be burned, buried deeply, or removed from the premises. prevention and control. vaccinating animals with multivalent clostridial vaccines can prevent these diseases. subcutaneous administration of vaccine material is recommended over intramuscular. vaccinations may be useful in an outbreak. careful handling of ruminants during shipping and transfers will contribute to fewer muscular injuries. for bighead, mature rams penned together should be monitored for lesions, especially during breeding season. control of fascioliasis is very important in prevention and control of black disease and in the optimal timing of vaccinations. etiology. clostridium septicum is the species usually associated with malignant edema, but mixed infections involving other clostridial species such as c. chauvoei, c. novyi, c. sordellii, and c. perfringens may occur. clostridium spp. are motile (c. chauvoei, c. septicum) or nonmotile, anaerobic, spore-forming, gram-positive rods. clinicial signs. malignant edema, or gas gangrene, is an acute and often fatal bacterial disease caused by clostridium spp. the incubation period is approximately 2-4 days. the affected area will be warm and will contain gaseous accumulations that can be palpated as crepitation of the subcutaneous tissue around the infected area. regional lymphadenopathy and fever may occur. the animal becomes anorexic, severely depressed, and possibly hyperthermic. edema and crepitation may be noted around the wound; death occurs within 12 hr to 2 days. epizootiology and transmission. the organisms are ubiquitous in the environment and may survive in the soil for years. the disease is especially prevalent in animals that have had recent wounds such as those that have undergone castration, docking, ear notching, shearing, or dystocia. necropsy findings. the tissue necrosis and hemorrhagic serous fluid accumulations resemble those of other clostridial diseases. pathogenesis. in most cases, the clostridial organisms cause a spreading infection through the fascial planes around the area of the injury; vegetative organisms then produce potent exotoxins, which result in necrosis (alpha toxin) and/or hemolysis (beta toxin). furthermore, the toxins enter the bloodstream and central nervous system, resulting in systemic collapse and high mortality. necropsy. spreading, crepitant lesions around wounds are suggestive of malignant edema. affected tissues are inflamed and necrotic. gas and serosanguineous fluids with foul odors infiltrate the tissue planes. large rod-shaped bacteria may be observed on histopathology; confirmation is made through culture and identification. intramuscular inoculation of guinea pigs causes a necrotizing myositis and death. organisms can be cultured from guinea pig tissues. treatment. infected animals can be treated with large doses of penicillin and fenestration of the wound is recommended. prevention and control. proper preparation of surgical sites, correct sanitation of instruments and the housing environment, and attention to postoperative wounds will help prevent this disease. multivalent clostridial vaccines are available. research complications. morbidity or loss of animals from lack of or unsuccessful vaccination and from contaminated surgical sites or wounds may be consequences of this disease. etiology. escherichia coli is a motile, aerobic, gram-negative, non-spore-forming coccobacillus commonly found in the environment and gastrointestinal tracts of ruminants. escherichia coli organisms have three areas of surface antigenic complexes (o, somatic; k, envelope or pili; and h, flagellar), which are used to "group" or classify the serotypes. colibacillosis is the common term for infections in younger animals caused by this bacteria. clinical signs. presentation of e. coli infections vary with the animal's age and the type of e. coli involved. enterotoxigenic e. coli infection causes gastroenteritis and/or septicemia in lambs and calves. colibacillosis generally develops within the first 72 hr of life when newborn animals are exposed to the organism. the enteric infection causes a semifluid, yellow to gray diarrhea. occasionally blood streaking of the feces may be observed. the animal may demonstrate abdominal pain, evidenced by arching of the back and extension of the tail, classically described as "tucked up." hyperthermia is rare. severe acidosis, depression, and recumbancy ensue, and mortality may be as high as 75%. the septicemic form generally occurs between 2 and 6 weeks of age. animals display an elevated body temperature and show signs suggestive of nervous system involvement such as incoordination, head pressing, circling, and the appearance of blindness. opisthotonos, depression, and death follow. occasionally, swollen, painful joints may be observed with septicemic colibacillosis. blood cultures may be helpful in identifying the septicemic form. in ruminants, e. coli is is a less common cause of cystitis and pyelonephritis. the cystitis is characterized by dysuria and pollakiuria; gross hematuria and pyuria may be present. the infection may or may not be restricted to the bladder; in the later presentation, and in cases of pyelonephritis, a cow will be acutely depressed, have a fever and ruminal stasis, and be anorexic. in chronic cases, animals will be polyuric and undergo weight loss. escherichia coli may also cause in utero disease in cattle, resulting in abortion or weakened offspring. epizootiology and transmission. escherichia coli is one of the most common gram-negative pathogens isolated from ruminant neonates. zeman et al. (1989) classify e. coli infections into four groups: enterotoxigenic, enterohemorrhagic, enteropathogenic, and enteroinvasive. enterotoxigenic e. coli (etec) attach to the enterocytes via pili, produce enterotoxins, and are the primary cause of colibacillosis in animals and humans. fimbrial (pili) antigens associated with ovine disease include k99 and f41. enterohemorrhagic e. coli (ehec) attach and efface the microviuus, produce verotoxins, and occasionally cause disease in humans and animals. enteropathogenic e. coli (epec) colonize and efface the microvillus but do not produce verotoxins. epec are associated with disease in humans and rabbits and cause a secretory diarrhea. enteroinvasive e. coli (eiec) invade the enterocytes of humans and cause a shigella-like disease. overcrowding and poor sanitation contribute significantly to the development of this disease in young animals. the organism will be endemic in a contaminated environment and present on dams' udders. the bacteria rapidly proliferate in the neonates' small intestines. the bacteria and associated toxins cause a secretory diarrhea, resulting in the loss of water and electrolytes. if the bacteria infiltrate the intestinal barrier and enter the blood, septicemia results. diagnosis of the enteric form can be made by observation of clinical signs, including diarrhea and staining of the tail and wool. necropsy findings. swollen, yellow to gray, fluid-filled small and large intestines, swollen and hemorrhagic mesenteric lymph nodes, and generalized tissue dehydration are common. septicemic lambs may have serofibrinous fluid in the peritoneal, thoracic, and pericardial cavities; enlarged joints containing fibrinopurulent exudates; and congested and inflamed meninges. isolation and serotyping of e. coli confirm the diagnosis. elisa and latex agglutination tests are available diagnostic tools. differential diagnosis. differential diagnoses include the enterotoxemias caused by c. perfringens type a, b, or c; campylobacter jejuni; coccidia, rotavirus, coronavirus, salmonella, and cryptosporidia. other contributing causes of abomasal tympany in young ruminants, such as dietary changes, copper deficiency, excessive intervals between feedings of milk replacer, or feeding large volumes should be considered. prevention and control. the best preventive measures are maintenance of proper housing conditions, limiting overcrowding, and frequently sanitizing lambing areas. attention to colostrum feeding techniques and colostral quality are important means of preventing disease. treatment must include intravenous fluid hydration and reestablishment of acid-base and electrolyte abnormalities. treatment. antibiotics such as trimethoprim-sulfadiazine, enrofloxacin, cephalothin, amikacin, and apramycin may be helpful; oral antibiotics are not recommended. vaccines are available for prevention of colibacillosis in cattle. etiology. corynebacterium pseudotuberculosis (previously c. ovis) are nonmotile, non-spore-forming, aerobic, short and curved, gram-positive coccobacilli. caseous lymphadenitis (cla) is such a common, chronic contagious disease of sheep and goats that any presentation of abscessing and draining lymph nodes should be presumed to be this disease until proven otherwise. the disease has been reported occasionally in cattle. clinical signs and diagnosis. abscessation of superficial lymph nodes, such as the superficial cervical, retropharyngeal, subiliacs (prefemoral), mammary, superficial inguinals, and popliteal nodes, and of deep nodes, such as mediastinal and mesenteric lymph nodes, is typical. radiographs may be helpful in identifying affected central nodes. peripheral lymph nodes may erode and drain caseous, "cheesy," yellow-green-tan secretions. the incubation period may be weeks to months. over time, an infected animal may become exercise-intolerant, anorexic, and debilitated. fever, increased respiratory rates, and pneumonia may also be common signs. exotoxin-induced hemolytic crises may occur occasionally. morbidity up to 15% is common, and morbid animals will often eventually succumb to the disease. diagnosis is based on clinical lesions; elisa serological testing is also available. smears of the exudate or lymph nodes aspirates can be gram-stained. lymph node aspirates may also be sent for culturing. epizootiology and transmission. the organism can survive for 6 months or more in the environment and enters via skin wounds, shearing, fighting, castration, and docking. ingestion and aerosolization (leading to pulmonary abscesses) have been reported as alternative routes of entry. necropsy findings. disseminated superficial abscesses as well as lesions of the mediastinal and mesenteric lymph nodes will be identified. cut surfaces of the affected lymph nodes may appear lamellated. lungs, liver, spleen, and kidneys may also be affected. cranioventral lung consolidation with hemorrhage, fibrin, and edema are seen histologically. pathogenesis. corynebacterium pseudotuberculosis produces an exotoxin (phospholipase d) that damages endothelial and blood cell membranes. this process enhances the organisms' ability to withstand phagocytosis. the infection spreads through the lymphatics to local lymph nodes. the necrotic lymph nodes seed local capillaries and hematogenously and lymphatically spread the organisms to other areas, especially the lungs. differential diagnosis. differentials include pathogens causing lymphadenopathy and abscessation. treatment. antibiotic therapy is not usually helpful. abscesses can be surgically lanced and flushed with iodinecontaining and/or hydrogen peroxide solutions. abscessing lymph nodes can be removed entirely from valuable animals. during warmer months, an insect repellent should be applied to and around healing lesions. all materials used to treat animals should be disposed of properly. because of the contagious nature of the disease, animals with draining and lanced lesions should be isolated from cla-negative animals at least until healed. commercial vaccines are available (piontkowski and shivvers, 1998) . minimizing contamination of the environment, using proper sanitation methods for facilities and instruments, segregating affected animals, and taking precautions to prevent injuries are all important. research complications. this pathogen is a risk for animals undergoing routine management procedures or invasive research procedures, because of its persistence in the environment, its long clinical incubation period, and its poor response to antibiotics. etiology. corynebacterium renale, c. cystitidis, and c. pilosum are sometimes referred to as the c. renale group. these are piliated and nonmotile gram-positive rods and are distinguished biochemically. corynebacterium renale causes pyelonephritis in cattle, and c. pilosum and c. cystitidis cause posthitis, also known as pizzle rot or sheath rot, in sheep and goats. in many references, all these clinical presentations are attributed to c. renale. clinical signs and diagnosis. acute pyelonephritis is characterized by fever, anorexia, polyuria, hematuria, pyuria, and arched back posture. untreated infections usually become chronic, with weight loss, anorexia, and loss of production in dairy animals. relapses are common, and some infections are severe and fatal. diagnosis of pyelonephritis is based on urinalysis (proteinuria and hematuria) and rectal or vaginal palpation (assessing ureteral enlargement). urine culturing may not be productive. in chronic cases, e. coli and other gram-negatives may be present. posthitis and vulvovaginitis are characteriazed by ulcers, crusting, swelling and pain. the area may have a distinct malodor. necrosis and scarring may be sequelae of more severe infections. fly-strike may also be a complication. diagnosis is based on clinical signs and on investigation of feeding regimens. epizootiology and transmission. ascending urinary tract infections with cystitis, ureteritis, and pyelonephritis are widespread problems, but incidence is relatively low. the vaginitis and posthitis contribute to the venereal transmission, but indirect transmission is possible because the organisms are stable in the environment and present on the wool or scabs shed from affected animals. posthitis occurs in intact and castrated sheep and goats. necropsy findings. pyelonephritis, multifocal kidney abscessation, dilated and thickened ureters, cystitis, and purulent exudate in many sections of the urinary tract are common finding at gross necropsy. of bovine genitourinary tracts. the pilus mediates colonization. conditions such as trauma, urinary tract obstruction, and anatomic anomalies may predispose to infection. in addition, more basic ph urine levels may block some immune defenses. infections ascend through the urinary tract. the bacteria are urease-positive when tested in vitro, and the ammonia produced in vivo during an infection damages mucosal linings, with subsequent inflammation. corynebacterium cystitidis and c. pilosum are normally found around the prepuce of sheep and goats. high-protein diets, resulting in higher urea excretion and more basic urine, are contributing factors. posthitis and vulvovaginitis may develop within a week of change to the more concentrated or richer diet, such as pasture or the addition of high-protein forage. the ammonia produced irritates the preputial and vulvar skin, increasing the vulnerability to infection. differential diagnosis. urolithiasis is a primary consideration for these diseases. contagious ecthyma should be considered for the crusting that is seen with posthitis and vulvovaginitis, although the lesions of contagious ecthyma are more likely to develop around the mouth. ovine viral ulcerative dermatosis is also a differential for the lesions of posthitis and vulvovaginitis. prevention and treatment. because high-protein feed is often associated with posthitis and vulvovaginitis, feeding prac-tices must be reconsidered. clipping long wool and hair also is helpful. treatment. long-term (3 weeks) penicillin treatment is effective for pyelonephritis. reduction of dietary protein, clipping and cleaning skin lesions, treating for or preventing fly-strike, and topical antibacterial treatments are effective for posthitis and vulvovaginitis; systemic therapy may be necessary for severe cases. surgical debridement or correction of scarring may also be indicated in severe cases. etiology. erysipelothrix rhusiopathiae is a nonmotile, nonspore-forming, gram-positive rod that resides in alkaline soils. clinical signs. erysipelothrix causes sporadic but chronic polyarthritis in lambs less than 3 months of age. in older goats, erysipelas has been associated with joint infections. epizootiology and transmission. the disease may follow wound inoculation associated with castration, docking, or improper disinfection of the umbilicus. following wound contamination and a 1-to 5-day incubation period, the lamb exhibits a fever and stiffness and lameness in one or more limbs. joints, especially the stifle, hock, elbow, and carpus, are tender but not greatly enlarged. necropsy findings. thickened articular capsules, mild increases in normal-appearing joint fluid and erosions of the articular cartilage are usually found. the joint capsule is infiltrated with mononuclear cells, but bacteria are difficult to find. diagnosis is based on clinical signs of polyarthritis, and confirmation is made by culturing the organism from the joints. differential diagnosis. differential diagnoses include polyarthritis caused by chlamydia or other bacteria and stiffness caused by white muscle disease. other bacteria causing septic joints include areanobacterium pyogenes and fusobacterium necrophorum. caprine arthritis encephalitis (cae) should also be considered. prevention and control. proper sanitation and prevention of wound contamination are important in preventing the infection in lambs. screening of goat herds for cae is recommended. therapy. erysipelas is sensitive to penicillin antibiotic m. etiology. dermatophilus congolensis is an aerobic, grampositive, filamentous bacterium with branching hyphae. dermatophilosis is a chronic bacterial skin disease characterized by crustiness and exudates accumulating at the base of the hair or wool fibers (scanlan et al., 1984) . clinical signs. animals will be painful but will not be pruritic. two forms of the disease exist in sheep: mycotic dermatitis (also known as lumpy wool) and strawberry foot rot. mycotic dermatitis is characterized by crusts and wool matting, with exudates over the back and sides of adult animals and about the face of lambs. strawberry foot rot is rare in the united states but is characterized by crusts and inflammation between the carpi and/or tarsi and the coronary bands. animals will be lame. in goats and cattle, similar clinical signs of crusty, suppurative dermatitis are seen; the disease is often referred to as cutaneous streptothricosis in these species. lesions in younger goats are seen along the tips of the ears and under the tail. diagnosis is based on clinical signs as well as the typical microscopic appearance on stained skin scrapings, cultures, and serology. epizootiology and transmission. the disease occurs worldwide, and the dermatophilus organism is believed to be a saprophyte. transmission occurs by direct or indirect contact and is aggravated by prolonged wet wool or hair associated with inclement weather. biting insects may aid in transmission. necropsy findings. lymphadenopathy as well as liver and splenic changes may be observed. histopathologically, superficial epidermal layers are necrotic and crusted with serum, white blood cells, and wool or hair. dermal layers are hyperemic and edematous and may be infiltrated with mononuclear cells. pathogenesis. lesions typically begin around the muzzle and hooves and the dorsal midline. prevention and control. potash alum and aluminum sulfate have been used as wool dusts in sheep to prevent dermatophilosis. minimizing moist conditions is helpful in controlling and preventing the disease. in addition, controlling external parasites or other factors that cause skin lesions is important. lesions will resolve during dry periods. treatment. animals can be treated with antibiotics such as penicillin and oxytetracycline. treating the animals with povidone-iodine shampoos or chlorhexidine solutions is also useful in clearing the disease. n. etiology. two bacteria, dichelobacter (bacteroides) nodosus and fusobacterium necrophorum, work synergistically in caus-ing contagious foot rot in sheep and goats. other organisms may be involved as secondary invaders. both dichelobacter and fusobacterium are nonmotile, non-spore-forming, anaerobic, gram-negative bacilli. foot rot is a contagious, acute or chronic dermatitis involving the hoof and underlying tissues (bulgin, 1986) . it is the leading cause of lameness in sheep. at least 20 serotypes of dichelobacter are known. arcanobacterium pyogenes may also contribute to the pathogenicity or to foot abscesses in goats. foot scald, an interdigital dermatitis, is caused primarily by d. nodosus alone. clinical signs. varying degrees of lameness are observed in all ages of animals within 2-3 weeks of exposure to the organisms. severely infected animals will show generalized signs of weight loss, decreased productivity, and anorexia associated with an inability to move. the interdigital skin and hooves will be moist, with a distinct necrotic odor. morbidity may reach 70% in susceptible animals. diagnosis is based on clinical signs. smears and cultures confirm the definitive agents. clinical signs of the milder disease, foot scald, include mild lameness, redness and swelling, and little to no odor. epizootiology and transmission. fusobacterium necrophorum is ubiquitous in soil and manure, in the gastrointestinal tract, and on the skin and hooves of domestic animals. in contrast, dichelobacter contaminates the soil and manure but rarely remains in the environment for more than about 2 weeks. some animals may be chronic carriers. overcrowded, warm, and moist environments are key elements in transmission. outbreaks are likely in the spring season. shipping trailers and contaminated pens or yards should be considered also as likely sources of the bacteria. pathogenesis. both organisms are transmitted to the susceptible animal by direct or indirect contact. the organisms enter the hoof through injuries or through sites where strongyloides papillosus larvae have penetrated. fusobacterium necrophorum initiates the colonization and is followed by d. nodosus. the latter attaches and releases proteases; these cause necrosis of the epidermal layers and separation of the hoof from the underlying dermis. the pathogenicity of the serotypes of d. nodosus is correlated with the production of these proteases and numbers of pili. additionally, f. necrophorum causes a severe, damaging inflammatory reaction. differential diagnosis. foot abscesses, tetanus, selenium/ vitamin e deficiencies, copper deficiency, strawberry foot rot, bluetongue virus infection (manifested with myopathy and coronitis), and trauma are among the many differentials that must be considered. treatment. affected animals are best treated by manually trimming the necrotic debris from the hooves, followed by application of local antibiotics and foot wraps. systemic antibiotics such as penicillin, oxytetracycline, and erythromycin may be used. goats have improved dramatically when given a single dose of penicillin (40,000 u/kg) (smith and sherman, 1994) . footbaths containing 10% zinc sulfate, 20% copper sulfate, or 10% formalin (not legal in all states) can be used for treatment as well as for prevention of the disease. affected animals should be separated from the flock. vaccination has been shown to be effective as part of the treatment regimen. some breeds of sheep and some breeds and lines of goats are resistant to infection. individual sheep may recover without treatment or are resistant to infection. epizootiology and transmission. cases may be sporadic, or epizootics may occur. bos taurus dairy breeds and animals with wide interdigital spaces are more commonly affected. the factors here are comparable to those present in foot rot of smaller ruminants. necropsy findings. findings at necropsy include dermatitis and necrosis of the skin and subcutaneous tissues. although necropsy would rarely be performed, secondary osteomyelitis may be noted in severe cases by sectioning limbs. prevention and control. prevention and control programs involve scrutiny of herd and flock management; quarantine of incoming animals; vaccination; segregation of affected animals; careful and regular hoof trimming; discarding trimmings from known or suspected infected hooves; maintaining animals in good body condition; avoiding muddy pens and holding areas; and culling individuals with chronic and nonresponsive infections. dichelobacter nodosus bacterins are commercially available; cross protection between serotypes varies. biannual vaccinination in wet areas may be essential. some breeds may develop vaccination site lumps. footbaths of 10% zinc sulfate, 10% formalin (where allowed by state regulations), or 10% copper sulfate are also considered very effective preventive measures. goats are less sensitive than sheep to the copper in the footbaths. treating and controlling foot rot is costly in terms of time, initial handling and treatments and their follow-up, housing space, and medications. etiology. interdigital necrobacillosis of cattle is caused by the synergistic infection of traumatized interdigital tissues by fusobacterium necrophorum and bacteroides melaninogenicus. like f. necrophorum, b. melaninogenicus is a nonmotile, anaerobic, gram-negative bacterium. dichelobacter nodosus, the agent of interdigital dermatitis, may be present in some cases. this is a common cause of lameness in cattle. clinical signs. clinical signs include mild to moderate lameness of sudden onset. hindlimbs are more commonly affected, and cattle will often flex the pastern and bear weight only on the toe. the interdigital space will be swollen, as will be the coronet and bulb areas. characteristic malodors will be noted, but there will be little purulent discharge. in more severe cases, animals will have elevated body temperature and loss of appetite. the les~ons progress to fissures with necrosis until healing occurs. the diagnosis is by the odor and appearance. anaerobic culturing confirms the organisms involved. pathogenesis. the bacteria enter through the skin of the interdigital area after trauma to the interdigital skin, from hardened mud, or from softening of the skin due to, for example, constant wet conditions in pens. colonization leads to cellulitis. in addition, f. necrophorum releases a leukocidal exotoxin that reduces phagocytosis and causes the necrosis, whereas the tissues and tendons are damaged by the proteases and collagenases produced by b. melaninogenicus. zinc deficiency may play a role in the pathogenesis in some situations. differential diagnoses. the most common differentials for sudden lameness include hairy heel warts and subsolar abcesses. bluetongue virus should also be considered. grain engorgement and secondary infection from cracks caused by selenium toxicosis should also be considered. the exotic footand-mouth disease virus would be considered in areas where that pathogen is found. prevention and control. as with foot rot in smaller ruminants, management of the area and herd are important. paddocks and pens should be kept dry, well drained, and free of material that will damage feet. footbaths and chlortetracycline in the feed have been shown to control incidence. affected animals should be segregated during treatment. chronically affected or severely lame animals should be culled. new cattle should be quarantined and evaluated. ing within a week include cleaning the feet and trimming necrotic tissue; parenteral antimicrobials, such as oxytetracycline or procaine penicillin, or sulfonomethazine in the drinking water or tetracyclines in feed; and footbaths (such as 10% zinc sulfate, 2.5% formalin, or 5% copper sulfate) twice a day. in severe cases, more aggressive therapy such as bandaging the feet or wiring the digits together may be needed. animals can recover without treatment but will be lame for several weeks. acquired immunity is reported to be poor. research complications are comparable to those noted for foot rot in smaller ruminants. fusobacterium necrophorum is also associated with foot abscesses, the infection of the deeper structures of the foot, in sheep and goats. only one claw of the affected hoof may be involved. the animals will be three-legged lame, and the affected hoof will be hot. pockets of purulent material may be in the heel or toe. etiology. bacteria such as fusobacterium spp., bacteroides spp., and dichelobacter nodosus have been isolated from bovine heel lesions. spirochete-like organisms have also been shown in the lesions of cows with papillomatous digital dermatitis (pdd), in the united states and europe; these have culturing requirements similar to those of treponema species. treatment. antibiotic and antiseptic regimens have been used successfully for this problem. antibiotics include parenteral cephalosporins and pencillins, as well as topical tetracyclines with bandaging. antiseptic or antibiotic solutions in footbaths include tetracyclines, zinc sulfate, lincomycin, spectinomycin, copper sulfate, and formalin. the footbaths must be well maintained, minimizing contamination by feces and other materials. tandem arrangements, such as the cleaning footbaths and then the medicated footbaths, and preventing dilution from precipitation are useful. other treatments such as surgical debridement, cryotherapy, and caustic topical solutions have been successful. research complications. infectious, contagious ppd is one of the major causes of lameness among heifers and dairy cattle and is a costly problem to treat. the outbreaks are generally worse in younger animals in chronically infected herds. the immune response is not well understood, and it may be temporary in older animals. clinical signs. all lesions occur on the haired, digital skin. one or all feet may be affected. most lesions occur on the plantar surface of the hindfoot (near the heel bulbs and/or extending from the interdigital space), but the palmar and dorsal aspect of the interdigital spaces may also be involved. progression of lesions, typically over 2-3 weeks, includes erect hairs, loss of hair, and thickening skin. moist plaques begin as red and remain red or turn gray or black. exudate or blood may be present on the plaque. plaques enlarge and "hairs" protrude from the roughened surface. lesioned areas are painful when touched. the lesions may or may not be malodorous. epizootiology and transmission. facility conditions and herd management are considered contributing factors. the following have been examined as contributing factors: nutrition, particularly zinc deficiency; poorly drained, low-oxygen, organic material underfoot; poor ventilation; rough flooring; damp and dirty bedding areas; and overcrowding. these interdigital lesions occur commonly in young stock and in dairy facilities throughout the world. the disease is seen only in cattle. pathogenesis. the organisms noted above, combined with poor facility and herd management, are critical in the pathogenesis. differential diagnosis. differentials for lameness will include sole abscesses, laminitis, and trauma. prevention and control. each facility and management condition noted above should be addressed in conjunction with appropriate antibiotic and/or antiseptic treatment regimens. all equipment used for hoof trimming must be cleaned and disinfected after every use. trucks and trailers should also be sanitized between groups of animals. etiology. haemophilus somnus is a pleomorphic, nonencapsulated, gram-negative bacterium. diseases caused by this organism include thromboembolic meningoencephalitis (teme), septicemia, arthritis, and reproductive failures due to genital tract infections in males and females. haemophilus somnus is a also major contributor to the bovine respiratory disease complex. haemophilus spp. have been associated with respiratory disease in sheep and goats. clinical signs. the neurologic presentation may be preceded by 1-2 weeks of dry, harsh coughing. neurologic signs include depression, ataxia, falling, conscious proprioceptive deficits; signs such as head tilt from otitis interna or otitis media, opisthotonus, and convulsions may be seen as the brain stem is affected. high fever, extreme morbidity, and death within 36 hr may occur. respiratory tract infections are usually part of the complex with infectious bovine rhinotracheitis virus, bovine respiratory syncytial virus, bovine viral diarrhea virus, parainfluenza 3, mycoplasma, and pasteurella, and the synergism among these contributes to the signs of bovine respiratory disease complex (brdc). in acute neurologic as well as chronic pneumonic infections, polyarthritis may develop. abortion, vulvitis, vaginitis, endometritis, placentitis, and failure to conceive are manifestations of reproductive tract disease. in all cases, asymptomatic infections may also occur. diagnosis based on culture findings is difficult because h. somnus is part of the normal nasopharyngeal flora. paired serum samples are recommended; single titers in some animals seem to be high because of passive immunity, previous vaccination, or previous exposure. in cases of abortion, other causes should be eliminated from consideration. because the organism is considered part of the normal flora of cattle and can be isolated from numerous tissues, the distinction between the normal flora and the status of chronic carrier is not clear. outbreaks are associated with younger cattle in feedlots in western united states, but stresses of travel and coinfection with other respiratory pathogens are involved in some cases. adult cattle have also been affected. vaccination for viral respiratory pathogens may increase susceptibility. transmission is by respiratory and genital tract secretions. the organism does not persist in the environment. times of stress to the cattle is worthwhile. killed whole-cell bacterins are commercially available; these have been shown to be effective in controlling the respiratory disease presentation. control of other clinical aspects of the h. somnus disease by these bacterins has not been well described. treatment. rapid treatment at the first signs of neurologic disease is important in an outbreak. haemophilus somnus is susceptible to several antibiotics, such as oxytetracycline and penicillin, and these are often used in sequence until the cattle are recovered. necropsy findings. pathognomonic central nervous system lesions include multifocal red-brown foci of necrosis and inflammation on and within the brain and the meninges. many thrombi with bacterial colonies will be seen in these affected areas. ocular lesions may also be seen, including conjunctivitis, retinal hemorrhages, and edema. usually animals with neurological disease will not have respiratory tract lesions. the respiratory tract lesions include bronchopneumonia and suppurative pleuritis. when combined with pasteurella infection, the pathology becomes more severe. aborted fetuses will not show lesions, but necrotizing placentitis will be evident histologically. pathogenesis. inhalation of contaminated respiratory secretions from carrier animals is the primary means of transmission. the anatomical location of bacterial residence within the carriers has not been identified. after gaining access by way of the respiratory tract, the bacteria proliferate, and a bacteremia develops. the bacteria are phagocytosed by neutrophils but are not killed. the thrombosis formation is due to the adherence by the nonphagocytosed organisms to vascular endothelial cells, degeneration and desquamation of these cells, and exposure of subendothelial collagen, with subsequent initiation of the intrinsic coagulation pathway. antigen-antibody complex formation, resulting in vasculitis, is also correlated with high levels of agglutinating antibodies. other pathogens associated with neurological disease and respiratory disease such as pasteurella hemolytica, p. multocida, and p. aeruginosa. in smaller ruminants, corynebacterium pseudotuberculosis should be considered. prevention and control. stressed animals or those exposed to known carriers can be treated prophylactically with tetracycline administered parenterally or orally (in the feed or water). the late-stage polyarthritis is resistant to antibiotic therapy, because of failure of the antibiotic to reach the site of infection. planning vaccination programs carefully will decrease chances of outbreaks. for example, avoiding vaccinating animals for infectious bovine rhinotrachetitis and bovine viral diarrhea during clinical signs. leptospirosis is a contagious but uncommon disease in sheep and goats. the disease may cause abortion, anemia, hemoglobinuria, and icterus and is often associated with a concurrent fever. after a 4-to 10-day incubation period, the organism enters the bloodstream and causes bacteremia, fever, and red-cell hemolysis. leptospiremia may last up to 7 days. immune stimulation is apparently rapid, and antibodies are detectable at the end of the first week of infection; crossserovar protection does not occur. during active bacteremia, hemolysis may result in hemoglobin levels of 50% below normal. hyperthermia, hemoglobinuria, icterus, and anemia may be observed during this phase, and ewes in late gestation may abort. abortion usually occurs only once. mortality rates of above 50% have been reported in infected ewes and lambs (jensen and swift, 1982) . subclinical infection is more common in nonpregnant and nonlactating animals. sheep infected with leptospirosis may display a hemolytic crisis associated with igm acting as a cold-reacting hemagglutinin. acute and chronic infections in cattle are more common than infections in sheep and goats. acute forms in cattle display signs similar to those in sheep. acute infection in calves may progress to meningitis and death. lactating cows will have severe drops in production. chronic cases may lead to abortion, with retained placenta, and weakened calves or animals that carry the infection. infertility may also be a sequela. epizootiology and transmission. leptospires are a large genus, and leptospirosis is a complicated disease to prevent, treat, and control. the organism survives well in the environment, especially in moist, warm, stagnant water. cattle, swine, and other domestic and wild animals are potential carriers of serovars common to particular regions. wild animals often serve as maintenance hosts, but domestic livestock may be reservoirs also. organisms are shed in urine, in uterine discharges, and through milk. animals become carriers when they are infected with a host-adapted serovar; sporadic clinical disease is more commonly associated with exposure to a non-hostadapted serovar (heath and johnson, 1994) . infection may occur via oral ingestion of contaminated feed and water, via placental fluids, or through the mucous membranes of the susceptible animal. placental or venereal transmission may occur. as the organisms are cleared from the bloodstream, they chronically infect the renal convoluted tubules and the reproductive tract (and occasionally the cerebrospinal fluid or vitreous humor). chronically infected animals may shed the organism in the urine for 60 days or longer. necropsy. diagnosis is confirmed by identification of leptospires in fetal tissues. the leptospires are visible in silver-or fluorescent antibody-stained sections of liver or kidney. leptospires may also be seen under dark-field or phase-contrast microscopy of fetal stomach contents. fetal and maternal serology, and diagnostic tests such as the microscopic agglutination test, are useful; interpretation is complicated because of cross reaction of antibodies to many serovars. differential diagnosis. more than one serovar may cause infection in one animal, and each serovar should be considered as a separate pathogen. because of the associated anemia, differential diagnoses should include copper toxicity and parasites, in addition to other abortifacient diseases. prevention and control. polyvalent vaccines, tailored to common serovars regionally, are available and effective for preventing leptospirosis in cattle. immunity is serovar specific. because serological titers tend to diminish rapidly (40-50 days in sheep [jensen and swift, 1982] ), frequent vaccination may be necessary. other prevention measures such as species-specific housing, control of wild rodents, and proper sanitation should be instituted. treatment. antibiotic treatment is aimed at treating ill animals and trying to clear the carrier state. treatment methods for acute leptospirosis include oxytetracycline for 3-6 days. addition of oxytetracycline or chlortetracycline to the feed for 1 week may be helpful. these antibiotics are considered best for removal of the carrier state of some serovars. vaccination and antibiotic therapy can be combined in an outbreak. research complications. leptospirosis is zoonotic and may be associated with flulike symptoms, meningitis, or hepatorenal failure in humans. etiology. listeria monocytogenes is a pleomorphic, motile, non-spore-forming, [3-hemolytic, gram-positive bacillus that inhabits the soil for long periods of time and has been often found in fermented feedstuffs such as spoiled silage. of the 16 known serovars, several produce clinical signs in ruminants. listeria ivanovii (associated with abortions in sheep) is serovar 5. clinical signs. listeriosis is an acute, sporadic, noncontagious disease associated with neurological signs or abortions in sheep and other ruminants. the overall case rate is low. the disease may present as an isolated case or with multiple animals affected. three forms of disease are described: encephalitis, placentitis with abortion, and septicemia with hepatitis and pneumonia. the encephalitic form is most common in sheep; septicemic forms may occur in neonatal lambs (scarratt, 1987) . clinically, the encephalitic form begins with depression, anorexia, and mild hyperthermia after an incubation period of 2-3 weeks. as the disease progresses, animals exhibit nasal discharges and conjunctivitis and begin to walk in circles, as if disoriented. facial paralytic lesions, including drooping of an ear or eyelid, dilation of a nostril, or strabismus occur unilaterally on the affected side as the result of dysfunction of some or all the cranial nerves v-xii. the neck will by flexed away from the affected side. facial muscle twitching, protrusion of the tongue, dysphagia, hypersalivation, and nasal discharges may be noted. the hypersalivation may lead to metabolic acidosis in advanced cases in cattle. anorexia, prostration, coma, and death follow. the placental form usually results in last-trimester abortions in ewes and does, which typically survive this form of the disease. the affected females may be asymptomatic or may show severe clinical signs such as fever and depression, with subsequent retained placenta or endometritis. abortion usually occurs within 2 weeks of listeria infection. in cattle, abortion occurs during the last 2 months of gestation and has been induced experimentally 6-8 days after exposure. cows present with the range of clinical signs seen in smaller-ruminant dams. there is no long-term effect on the fertility of affected dams. epizootiology and transmission. the organism is transmitted by oral ingestion of contaminated feeds and water or possibly by inhalation. by the oral route, the organism enters through breaks in the oral cavity and ascends to the brain stem by way of nerves. when severe outbreaks occur, feedstuffs should be assessed for spoilage. listeria organisms can be shed by asymptomatic carriers, especially at the end of pregnancy and at lambing. diagnosis and necropsy findings. diagnosis is usually made from clinical signs. culture confirms the diagnosis (cold enrichment at 20~ is preferable but not essential for isolation). impression smears will show the pleomorphic gram-positive characterisitics of the pathogen. tissue fluorescent antibody techniques may also be utilized. gross lesions are not observed with the encephalitic form. microscopic lesions include thrombosis, neutrophilic or mononuclear foci in areas of inflammation, and neuritis. the pons, medulla, and anterior spinal cord are primarily affected in the encephalitic form. microabscesses of the midbrain are characteristic of listeria encephalitis in sheep. aborted fetuses that are intact may show fibrinous polyserositis, with excessive serous fluids; small, necrotic foci of the liver; and small abomasal erosions. necrotic lesions of the fetal spleen and lungs may also be seen. in goats, listeria-induced neurological lesions occur only in the brain stem. placentitis, focal bronchopneumonia, hepatitis, splenitis, and nephritis may be seen with other forms. pathogenesis. with the encephalitic form, the organism penetrates mucosal abrasions and enters the trigeminal or hypoglossal nerves. the listeria organisms then migrate along the nerves and associated lymphatics to the brain stem (medulla and pons). in the septicemic form, the organism penetrates tissues of the gastrointestinal tract and enters the bloodstream, to be distributed to the liver, spleen, lungs, kidneys, and placenta. after infection, organisms are shed in all body secretions (infected milk is an important risk factor for zoonosis). a toxin produced by listeria monocytogenes is correlated with pathogenicity, but the mechanism of the pathogenesis of this molecule has not been elucidated. differential diagnoses. rabies, bacterial meningitis, brain abscess, lead toxicity, and otitis media must be considered as differentials. in sheep, the differentials include organisms that cause abortion, and neurological signs, such as enterotoxemia due to clostridium perfringens type d. in goats, the major differentials include caprine arthritis encephalitis viral infection and chlamydial and mycoplasmal infections. in both species, scrapie is a differential. in cattle, aberrant parasite migration or hemophilus somnus infection must also be considered. prevention and control. affected dams should be segregated and treated. other animals in the group may be treated with oxytetracycline as needed. aborted tissues should be removed immediately. proper storage of fermented feeds minimizes this source of contamination. when silage spoils, the ph increases, producing a suitable growth environment for the organism. commercial vaccines are not available in the united states. treatment. affected animals can be treated aggressively with penicillin, ampicillin, oxytetracycline, or erythromycin. exceptionally high levels of penicillin are required for treating affected cattle. severely affected animals should receive appropriate fluid support and other nursing care. treatment is less successful, and mortality is especially high in sheep. recovered animals tend to resist reinfection. research complications. in addition to the loss of fetal animals, stress to the dams, and risks to other animals, any aborted tissue by a ruminant should be regarded as a potential zoonotic risk. listeria can cause mild to severe flulike symptoms in humans and may be a particular risk for pregnant women and for older or immune-compromised individuals. listeriosis in humans is a reportable disease. etiology. lyme disease is caused by the spirochete borrelia burgdorferi. clinical signs and diagnosis. reports in ruminants indicate seroconversion to b. burgdorferi, but there are few definitive correlations to the arthritis that is present. diagnosis requires culturing from the affected joints and diagnostic elimination of other causes of lameness and arthritis. epizootiology and transmission. the organism is present throughout much of the northern hemisphere and has been reported in many mammals and also in birds. ticks of the ixodes ricinus complex are the major vectors of the spirochete and must be attached for 24 hr for successful transmission. pathogenesis. the ixodes ticks have three life stages: larval, nymphal, and adult. feeding occurs once during each stage, and wild animals are the source of blood meals. the larval stages feed from rodents, such as the white-footed deer mouse, peromyscus leucopus, from which they acquire the spirochete. the nymphal stage is that which usually infects other animals. the adult ticks are usually found on deer. differential diagnosis. seroconversion to b. burgdorferi does not necessarily confirm the cause of arthritis. other causes of arthritis and lameness in ruminants include trauma, caprine arthritis encephalitis virus, mycoplasma spp., chlamydia psittaci, erysipelothrix spp., arcanobacterium pyogenes, brucella spp., and rickets. prevention and control. control of the tick vector is the most important factor in preventing the possibility of exposure or disease. treatment. antibiotic therapy, with tetracycline, penicillin, amoxicillin, and cephalosporins, is used for diagnosed or suspected lyme arthritis. research complications. lyme disease is zoonotic, and the lxodes ticks transmit the disease to humans. v. mastitis i. ovine mastitis mastitis in ewes may be acute, subclinical, or chronic. acute mastitis often results in anorexia, fever, abnormal milk, and swelling of the mammary gland. pasteurella haemolytica is the most common cause of acute mastitis. additional isolates may include, in order of prevalence, staphylococcus aureus, actinomyces (corynebacterium) spp., and histophilus ovis. escherichia coli and pseudomonas aeruginosa have also been found to cause acute mastitis. as many as six serotypes of pasteurella haemolytica have been isolated from the mammary glands of mastitic ewes. furthermore, intramammary inoculation of these organisms isolated from ovine and bovine pulmonary lesions has resulted in clinical mastitis in ewes (watkins.and jones, 1992) . subclinical mastitis is detected only indirectly, by counting somatic cells. the most common isolate from ewes with subclinical mastitis is coagulase-negative staphylococci. other isolates include actinomyces bovis, streptococcus uberis, s. dysgalactiae, micrococcus spp., bacillus spp., and fecal streptococci. most of these organisms are commonly found in the environment. diffuse chronic mastitis, or hardbag, results from interstitial accumulations of lymphocytes in the udder. both glands are usually affected, but no inflammation is present. serological evidence suggests that diffuse chronic mastitis is caused by the retrovirus that causes ovine progressive pneumonia (opp or maedi/visna virus). other bacterial agents or mycoplasma have not usually been isolated from udders with this type of mastitis. acute mastitis occurs in approximately 5% of lactating ewes annually, and it usually occurs either soon after lambing or when lambs are 3-4 months old (lasgard and vaabenoe, 1993) . subclinical mastitis occurs in 4-50% of lactating ewes (kirk and glenn, 1996) . subclinical mastitis is more common in ewes from high-milk-producing breeds. skin or teat lesions and dermatitis increase the prevalence of disease. acute mastitis can be diagnosed in ewes with associated systemic signs of disease by physical examination of the udder and inspection of the milk. subclinical mastitis is often suggested by somatic cell counts elevated above 1 x 106 cells/ml. when high somatic cell counts are identified, subclinical mastitis can be diagnosed by milk culture. the california mastitis test may also be helpful as an indicator of mastitis. manual palpation of a hard, indurated udder as well as serological testing for the maedi/visna virus is helpful in confirming the diagnosis of diffuse chronic mastitis. treatment for acute bacterial mastitis should include aggressive application of broad-spectrum antibiotics (intramammary and systemic) and supportive therapy such as fluids and anti-inflammatory drugs. it is may be helpful to milk out the infected ud-der frequently; oxytocin injections preceding milking will improve gland evacuation. because somatic cell counting is often not routinely performed, treatment of subclinical mastitis is seldom done. there is currently no treatment available for diffuse chronic mastitis. ii. caprine mastitis lactating goats are subject to inflammation of mammary gland, or mastitis. the primary causative organisms are staphylococcus epidermidis and other coagulasenegative staphylococcus spp. clinical signs of mastitis include abnormal coloration or composition of milk, mammary gland redness, heat and pain, enlargement of the mammary gland, discoloration of the mammary gland, and systemic signs of septicemia. large abscesses may be present in the affected gland. staphylococcus aureus is also associated with caprine mastitis, and toxemia may be part of the clinical picture. this organism produces a necrotizing alpha toxin that can result in gangrenous mastitis. caprine mastitis may be clinical or subclinical, and the first indication of mastitis may be weak, depressed, or thin kids. diagnosis is based on careful culture of mastitic milk. treatment includes frequent stripping, intramammary antibiotics, and nonsteroidal anti-inflammatory drugs. oxytocin (5-10 u) may help milk letdown for frequent strippings. bovine mastitis products can be used in the goat; however, care should be taken not to insert the mastitis tube tip fully, because damage to the protective keratin layer lining the teat canal may occur. in severe acute systemic cases, steroids, fluids, and systemic antibiotics may be necessary. other less common causes of mastitis in goats include streptococcus spp. (s. agalactiae, s. dysgalactiae, s. uberis, and zooepidemicus). gram-negative causes of caprine mastitis include escherichia coli, klebsiella pneumoniae, pasteurella spp., pseudomonas, and proteus mirabilis. corynebacterium pseudotuberculosis can cause mammary gland abscessation, whereas mycoplasma mycoides may cause agalactia and systemic disease. "hard udder" can be caused by caprine arthritis encephalitis virus (caev). brucellosis and listeriosis can cause a subclinical interstitial mastitis (smith and sherman, 1994) . iii. bovine mastitis mastitis is the disease of greatest economic importance for the dairy cattle industry. the majority of the impact will be on the production and overall health of the cows, but low-incidence herds also diminish the risk of calves' ingesting or being exposed to pathogens. the most common bovine mastitis pathogens include staphylococcus aureus and streptococcus agalactiae, s. dysgalactiae, and s. uberis; coliform agents such as escherichia coli, enterobacter aerogenes, serratia marcescens, and klebsiella pneumoniae; mycoplasmal species such as mycoplasma bovis, m. bovigenitalium, m. californicum, m. canadensis, and m. alkalescens; and salmonella spp. such as s. typhimurium, s. newport, s. enteritidis, s. dublin, and s. muenster. many of these agents such as staphylococcus spp., salmonella spp., and the coliforms can cause both acute and chronic mastitis, as well as severe systemic disease, including fever and anorexia. these must be regarded as herd and environmental pathogens in terms of treatment and prevention. the pathogenesis of staphylococcal infections is comparable to that in goats. staphylococcus agalactiae can be cleared from udders because it does not invade other tissues, is an obligate resident of the glands, and is susceptible to penicillin. in contrast, s. uberis and s. dysgalactiae are environmental organisms and can be highly resistant to pencillin. mycoplasma bovis is the more common of the mycoplasmal pathogens and can cause severe infections. transmission of the mycoplasmas is not well defined but may be related to their presence in other organ systems. treatments for mycoplasmal mastitis are not successful; culling is recommended. there are many interrelated factors associated with prevention and control of mastitis in a herd, including herd health and dry cow management, order of animals milked, milking procedures, milking equipment, condition of the teats, and the condition of the environment. management of the overall herd includes aspects such as vaccination programs, nutrition, isolation of incoming animals, and quarantine and treatment of or culling diseased individuals. culturing or testing newly freshened cows and monitoring the bulk milk tank serve as indicators of subclinical mastitis. herd management will diminish teat lesions. bacterin vaccines are available for preventing and controlling coliform mastitis and s. aureus mastitis. at the time of dry-off, all cows must be treated by intramammary route. some infections can be successfully cleared during this time. younger, disease-free animals should be milked first; any animals with diagnosed problems should be milked after the rest of the herd and/or segregated during treatment. milkers' hands easily serve as a means of pathogen transmission, and wearing rubber gloves is recommended. teat and udder cleaning practices include washing and drying with single-service paper or cloth towels or pre-and postmilking dipping. milking equipment must be maintained to provide proper vacuum levels and pumping rates, and liners should be the appropriate size. facilities that provide clean and dry areas for the animals to rest, feed, and move will diminish teat injuries and reduce exposures to mastitis pathogens. in that regard, inorganic bedding such as clean sand harbors few pathogens in contrast to shavings and sawdust. w. etiology. moraxella bovis, a gram-negative coccobacillus, is the most common cause of infectious bovine keratoconjunctivitis (ibk) in cattle. this organism is not a cause of keratoconjunctivitis in sheep and goats. the disease includes conjunctivitis and ulcerative keratitis. the pathogenic m. bovis strain is piliated, and at least seven serotypes exist. clinical signs. lacrimation, photophobia, and blepharospasm are seen initially. conjunctival injection and chemosis develop within a day of exposure, and then keratitis with corneal edema and ulcers. anterior uveitis may be a sequela within a few days, and thicker mucopurulent ocular discharge may be seen. corneal vascularization begins by 10 days after onset. reepithelialization of the corneal ulcers occurs by 2-3 weeks after onset. diagnosis is usually based on clinical signs, but culturing is helpful and fluoroscein staining is useful for demonstrating corneal ulceration. epizootiology and transmission. the disease is more severe in younger cattle. the clinical signs of ibk tend to be more severe in cattle that are also infected with infectious bovine rhinotracheitis (ibr) virus or those that have been vaccinated recently with modified live ibr vaccine. the bacteria are shed in nasal secretions and cattle with no clinical symptoms may be carriers. transmission is by fomites, flies, aerosols, and direct contact. incidence in winter months is very low. nonhemolytic strains are associated with the winter epidemics, and hemolytic strains are associated with summer epidemics. necropsy findings. necropsy is not typically performed on these cases. corneal edema, ulceration, hypopyon, and uveitis would be noted, depending on the stage of infection. pathogenesis. the pili ofm. bovis bind to receptors of corneal epithelium. the virulent strains of the bacteria then release the enzymes that damage the corneal epithelial cells. other factors contributing to infection include ultraviolet light and trauma from dust and plant materials. differential diagnoses. infectious bovine rhinotrachetitis virus causes conjunctivitis, but the central corneal ulceration that is characteristic of ibk is not seen with m. bovis infections. mycoplasma, listeria, branhamella (neisseria) , and adenovirus may be cultured from affected bovine eyes but none has been shown to produce the corneal lesions when inoculated into susceptible animals. prevention and control. cattle should not be immunized intranasally with modified live infectious bovine rhinotracheitis vaccine during ibk outbreaks; this will likely exacerbate the infection. new animals should be quarantined and treated prophylactically before introduction to herds. the available vaccines, containing. m. bovis pili or killed m. bovis, help decrease incidence and severity of disease; these preparations are not completely effective, because the m. bovis strain may not be homologous to that used for the vaccine preparation. other preventive measures include 10% permethrin-impregnated bilateral ear tags, pour-on avermectins, or dust bags or face rubbers containing insecticide (such as 5% coumaphos) to control flies throughout the season and premises; mowing of high pasture grass to minimize ocular trauma; provision of shade; control of dust and sources of other mechanical trauma; and segregation of animals by age. treatment. cattle can recover without treatment, but younger animals should be treated as soon as the infection is detected. antibiotic treatments include topical, subconjunctival administration and intramuscular dosing. several standard topical antibiotics have been shown to be effective, including oxytetracycline, gentamicin, and triple antibiotic combinations. these should be administered twice per day. subconjunctival injections of antibiotics, such as penicillin g, provide higher corneal levels of drug; these are typically administered only once or twice in severe cases. intramuscular doses of long-acting oxytetracycline, given on alternate days, are effective in larger herds, and 2 doses 72 hr apart eliminate carriers. third-eyelid flaps, temporary tarsorrhaphy, or eye patches may be useful in certain cases. epizootiology and transmission. although m. bovis can be killed by sunlight, it otherwise survives a long time in the environment and in cattle feces. animals acquire the infection from the environment or from other animals via aerosols, from contaminated feed and water, and from secretions such as milk, semen, genital discharges, urine, and feces. clinically normal animals may serve as carriers. the bacilli stimulate an initial neutrophilic tissue response. neutrophils become necrotic and are phagocytosed by macrophages, forming giant epithelioid cells called langhans' giant cells. an outer lymphocytic zone is formed, and fibrotic encapsulation creates the classical caseous nodules. vascular erosion and hematogenous migration of the organisms may lead to lesions throughout the body. necropsy findings. yellow primary tubercles (granulomas) with central areas of caseous necrosis and calcification are present in the lungs. caseous nodules are also associated with gastrointestinal organs and mesenteric lymph nodes. research complications. this pathogen does present a complication due to the carrier status of some animals, the likelihood of herd outbreaks, the severity of disease in younger animals, and the morbidity, possible progression to uveitis, and time and treatment costs associated with infections. the overall condition of the cattle will be affected for several weeks, and permanent visual impairment or loss, as well as ocular disfigurement, may occur. mycobacterium bovis infection (tuberculosis) etiology. mycobacteria are aerobic, nonmotile, non-sporeforming, acid-fast pleomorphic bacteria. most cases of tuberculosis in sheep are related to mycobacterium bovis or m. avium. cases in goats have been attributed to m. bovis, m. avium, or m. tuberculosis. mycobacterium bovis, or the bovine tubercle bacillus, is the cause in cattle but has been isolated from many domestic and wild mammals. other agents of mammalian tuberculosis include m. microti and m. africanum. clinical signs. tuberculosis is a sporadic, chronic, contagious disease of ruminants and is zoonotic. the infection is often asymptomatic later in the illness, and it may be diagnosed only at necropsy. the respiratory system (m. bovis) or the digestive system (m. avium) is the primary site of infection; other tissues such as mammary tissue and reproductive tract may be infrequently involved. locations of the characteristic tubercles will determine whether clinical signs are seen. respiratory signs may include dyspnea, coughing, and pneumonia. digestive tract signs include diarrhea, bloat, or constipation; diarrhea is most common. lymphadenopathy occurs in advanced cases. fever and generalized disease may be seen after calving. infected goats lose weight and develop a persistent cough. prevention and control. significant progress has been made in eradication programs in the united states during the past several decades, but during the 1990s, infected animals continued to be found in domestic cattle herds and particularly in captive deer herds in hunting preserves. the intradermal tuberculin test, using purified protein derivative (ppd), is usually used as a diagnostic indicator in live animals. this test should be performed annually on bovine and caprine dairy herds (and bison herds); the official tests are the caudal fold, comparative cervical, and single cervical tests. notification to state officials is required following identification of intradermal-positive animals. great care must be exercised in any handling of tissue or necropsies of reactors, and state animal health officials should be consulted regarding disposal of materials and cleaning of premises following depopulation of positive animals. no treatment is recommended, and treatment is usually not allowed, because of the zoonotic potential, chronicity of the disease, and the treatment costs. slaughter is preferred, to prevent potential transmission to humans. paratuberculosis, or johne 's disease (mycobacterium paratube rculo sis) etiology. mycobacterium paratuberculosis, the causative agent of johne's disease, is a fastidious, non-spore-forming, acid-fast, gram-positive rod. the organism is actually a subspecies of m. avium, but m. paratuberculosis does not produce the siderophore mycobactin (an iron-binding molecule) of m. avium. clinical signs and diagnosis. johne's disease is a chronic, contagious, granulomatous disease of adult ruminants and is characterized by unthriftiness, weight loss, and intermittent diarrhea. in sheep and goats, chronic wasting is usually seen, occasionally with pasty feces or diarrhea. in cattle, chronic diarrhea and rapid weight loss are the most common clinical signs of the disease. usually older adult animals are infected, but over time in an infected herd, younger animals will become infected when sufficient doses of organisms are ingested. although clinical signs are nonspecific, johne's disease should be considered if the affected diarrheic animals have a good appetite and are on a good anthelmintic program. the disease is diagnosed based on clinical signs and laboratory analyses, although none of the tests is more than 50% sensitive. in addition, the sensitivity of the serological tests differs between species. the standard is the fecal culture that takes 8-12 weeks. theenzyme-linked immunosorbent assay (elisa) is now considered the most reliable serological test, but false negatives do occur. other serological tests such as agar gel immunodiffusion (agid) and complement fixation are useful. herd screening may be done using the agid or elisa serological tests. identification of the organism on culture, or the presence of acid-fast organisms on mucosal or mesenteric lymph node smears or from rectal biopsies, helps confirm the diagnosis. some animals serologically negative for johne's disease, however, have been found to be positive on fecal culture. commercial agid tests approved for use in cattle may be useful in diagnosing johne's disease in sheep (dubash et al., 1996) . serological tests cross-react with other species of mycobacterium, especially m. avium. epizootiology and transmission. the organism is prevalent in the environment and is transmitted to young animals by direct or indirect contact. although vertical transmission has been reported, the organism more commonly enters the gastrointestinal tract and penetrates the mucosa of the distal small intestine, primarily the ileum. chronic carriers may intermittently shed the organisms. parasite that grows only in macrophages of infected animals. nursing infected dams are a primary source of infection of neonates. if the organism is not cleared, it proliferates slowly in the tissue, leading to inflammatory reactions that progress through neutrophilic to mononuclear stages. the organism may penetrate the lymphatics and proliferate in mesenteric lymph nodes. after an incubation period of a year or more, some of the carriers will progress to clinical disease manifested by fibrotic and hyperplastic changes in the ileum, leading to the classic thickening in the region. gut changes result in intermittent diarrhea, with subsequent dehydration, electrolyte imbalances, and malnutrition, although this clinical sign is more common in cattle than in sheep or goats. necropsy and diagnosis. the ileum from infected cattle is grossly thickened; this is not seen in sheep and goats. ileal and ileocecal lymph nodes provide the best samples for histology and acid-fast staining. differential diagnosis. diseases causing chronic wasting and poor coat and body condition of all ruminants should be considered. these include chronic salmonellosis, peritonitis, severe parasitism, winter dysentery, and pyelonephritis. deer can be infected, and the lesions can be confused with those of tuberculosis. prevention and control. prevention is the most effective method to manage this pathogen. efforts should be focused on eliminating the disease through test and slaughter. neonates should not be reared by infected dams. some states have johne's disease eradication programs. facilities and pastures where animals testing positive for johne' disease were maintained should be thoroughly cleaned and kept vacant for a year after culling. other considerations. mycobacterium paratuberculosis is being investigated as a factor in the development of crohn's disease in humans. etiology. the most common organism causing infection of the umbilicus is arcanobacterium (formerly actinomyces, corynebacterium) pyogenes; other bacteria may be present. arcanobacterium spp. are anaerobic, nonmotile, non-sporeforming, gram-positive, pleomorphic rods to coccobacilli. other environmental contaminants are also associated with this disease, such as escherichia coli, enterococcus spp., proteus, streptococcus spp., and staplylococcus spp. clinical signs and diagnosis. navel ill is an acute localized inflammation and infection of the external umbilicus. animals present with fever and painful enlargement of the umbilicus. animals may exhibit various degrees of depression and anorexia, and purulent discharges may be seen draining from the umbilicus. involvement of the urachus is usually followed by cystitis and associated signs of dysuria, stranguria, and hematuria. other common severe sequelae include septicemia, pneumonia, peritonitis, septic arthritis (joint ill), meningitis, osteomyelitis, uveitis, endocarditis, and diarrhea. neonates, and most cases occur within the first 3 months of age. cleanliness of the birthing and housing environment and successful transfer of passive immunity are important factors in the occurrence of the disease. dystocia resulting in weak neonates can be a factor predisposing to the development of the disease. navel ill is diagnosed by typical clinical signs. the presence of microabscesses and palpation of the umbilical area for firm intra-abdominal structures extending from the umbilicus are abnormal. assessment of colostral immunoglobulin transfer may contribute to determination of the prognosis. navel ill should always be considered for young ruminants with fever of unknown origin during the first week of life and for slightly older lambs, kids, or calves that are not thriving. arthrocentesis of affected joints and culture of the fluid for identification of the pathogen are also diagnostic options and essential for effective antimicrobial selection. differential diagnosis. the major differential is an umbilical hernia, which will typically not be painful or infected and can often be reduced. mycoplasmal arthritis is a differential in kids. in the past, erysipelothrix rhusopathiae was a common navel ill pathogen in sheep. treatment. omphalitis can be treated with a 10 to 14 day course of broad-spectrum antibiotics such as ampicillin, amoxicillin, penicillin, ceftiofur, florfenicol, and erythromycin. if an isolated abscess is palpable, it should be surgically opened and repeatedly flushed with iodine solutions. surgical reduction of the infected umbilicus is indicated if intra-abdominal structures are involved. the prognosis for recovery is good if systemic involvement has not occurred. prevention and control. the disease is best prevented and controlled by providing clean birthing environments, ensuring adequate colostral immunity, thoroughly dipping the umbilicus of newborns in tincture of iodine or strong iodine solution (lugol's), monitoring for dystocias, and maintaining young growing animals in noncontaminated environments. may invade the bloodstream, causing disseminated septicemia. clinically, the lambs may exhibit nasal discharge of mucopurulent to hemorrhagic exudate, hyperthermia, coughing, dyspnea, anorexia, and depression. with the respiratory form, auscultation of the thorax suggests dullness and consolidation of anteroventral lobes; this will be confirmed by radiographs. the disease is diagnosed by clinical signs, blood cultures from septicemic animals, blood smears showing bipolar organisms, and history of predisposing stressors. in cultures, p. hemolytica is distinguished from p. multocida by hemolysis on blood agar; only p. multocida produces indole. epizootiology and transmission. the organism is ubiquitous in the environment and in the respiratory tracts of these animals. younger ruminants, between 2 and 12 months of age, are especially prone to infection during times of stress, such as weaning, transportation, dietary changes, weather changes, and overcrowding. the pneumonic form appears as a complex associated with concurrent infections such as parainfluenza 3, adenovirus type 6, respiratory syncytial virus, mycoplasmas, chlamydia, pasteurella multocida and bordetella parapertussis (martin, 1996; brogden et al., 1998) . the organism is transmitted between animals by direct and indirect contact, through inhalation or ingestion. necropsy findings. necropsy lesions include areas of necrosis and hemorrhage in the small intestines and multifocal 1 mm lesions distributed on the surfaces of the lungs and liver. with the pneumonic form, serofibrinous exudates fill the alveoli; ventral lung lobes are consolidated and are congested and purple-gray in color. fibrinous pleuritis, pericarditis, and hematogenously induced arthritis also may be evident.. the disease can be costly to treat, and the toll taken on young animals due to the consequences of systemic infection may detract from their research value. etiology. pasteurella hemolytica and p. multocida are aerobic, nonmotile, non-spore-forming, bipolar, gram-negative rods. biotype a serotypes are associated with pneumonia and septicemia in all ruminants (ellis, 1984) . serotype 1 of p. hemolytica is considered a major cause of pulmonary lesions of bovine bronchopneumonia and fibrinous bronchopneumonia. clinical signs. pasteurellosis is an acute bacterial disease characterized by bronchopneumonia, septicemia, and sudden death. the organism invades the mucosa of the gastrointestinal tract or respiratory tract and causes localized areas of necrosis, hemorrhage, and thrombosis. the lungs and liver are frequent areas of formation of microabscesses. acute rhinitis or pharyngitis often precedes the respiratory form. the organism also pathogenesis. a leukotoxin is considered to be a key factor in the pathogenesis of the p. hemolytica infection. macrophages and neutrophils are lysed by the toxin as they arrive at the lung, and the enzymes released by the neutrophils cause additional damage to the tissue. treatment. treatment may include the use of antibiotics such as penicillin, ampicillin, tylosin, sulfonamides, or oxytetracycline. newer antibiotics, such as ceftiofur, tilmicosin, spectinomycin, and florfenicol, are very effective and approved for use in cattle. in outbreaks, cultures from fresh necropsies are helpful for determining sensitivities useful for the remaining group. prevention and control. the incidence of disease can be decreased by minimizing the degree of stress; by improving management, such as nutrition and control of parasitism; and, in cattle and sheep, by vaccinating for viral respiratory infections such as parainfluenza. early pasteurella hemolytica bacterin vaccines for use in cattle are not considered effective, but newer products based on immunizing against the leukotoxin and some bacterial capsule surface antigens are effective. pasteurella multocida bacterins and live streptomycin-dependent mutant vaccines are available. in young animals, passive immunity is protective. preventive measures also include maintaining good ventilation in enclosures and barns. new animals to the flock or herds should be quarantined for at least 2 weeks before introduction. etiology. salmonella typhimurium is a motile, aerobic to facultatively anaerobic, non-spore-forming, gram-negative bacillus and is the organism associated with enteric disease and some abortions in ruminants. it is a common inhabitant of the gastrointestinal tract of ruminants. current nomenclature categorizes s. typhimurium as a serovar within the species s. enteritidis (the other two species are s. typhi and s. choleraesuis). salmonella typhimurium, s. dublin, and s. newport are the common species seen in bovine cases. salmonella typhimurium, s. dublin, s. anatum, and s. montevideo are seen in ovine and caprine cases, although a host-adapted species has not been identified in the goat. ovine abortions due to various salmonella species are not reported in the united states but are enzootic in other countries. salmonella serotypes have been associated with aborted fetuses in all ruminant species. clinical signs and diagnosis. salmonellosis causes acute gastroenteritis, dysentery, and septicemia (anderson and blanchard, 1989) . clinically, the animals become anorexic and hyperthermic. diarrhea or dysentery develops; feces may contain mucus and/or blood and have a putrid odor. animals become severely depressed and weak, losing a high percentage of their body weight. animals may die in 1-5 days because of dehydration associated with dysenteric fluid loss, septicemia, shock, and acidosis. morbidity may be 25%, and mortality may be high. septicemia may result in subsequent meningitis, polyarthritis, and pneumonia. chronically infected animals may have intermittent diarrhea. in goats, salmonellosis may be recognized as diarrhea and septicemia in neonates, as enteritis in preweaned kids and mature goats, and, rarely, as abortion. adult cases may be sporadic, with intermittent bouts of diarrhea, subacute or even chronic. morbidity and mortality will be highest in neonates, and some may simply be found dead. the older animals generally tend to fare better during the disease. abdominal distension with profuse yellow feces is common. kids become severely depressed, anorexic, febrile (with temperatures as high as 106~176 dehydrated, acidotic, recumbent, and comatose. salmonella abortions may occur throughout gestation. there may not be any other clinical signs, or abortion may be seen with diarrhea, fever, and vulvar discharges. hemorrhage, placental necrosis, and edema will be present. metritis and placental retention may occur. some mortality of dams may occur. diagnosis is based on clinical signs and can be confirmed by culturing fresh feces or at necropsy. because of intermittent shedding of organisms, culture may be difficult; repeated cultures are recommended. leukopenia and a degenerative shift to the left are not uncommon hematological findings. epizootiology and transmission. stresses associated with recent shipping, overcrowding, and inclement weather may predispose the animal to enteric infection. birds and rodents may be natural reservoirs of salmonella in external housing environments. transmission is fecal-oral. after ingestion, the organisms may proliferate throughout the gastrointestinal tract and may penetrate the mucosa of the intestines, invade the peyer's patches and lymphatics, and migrate to the spleen, liver, and other organs. animals that survive may become chronic carriers and shedders of the organisms, and this has been demonstrated experimentally (arora, 1983) . fecal-oral transmission is also associated with salmonella abortion; veneral transmission has not been reported. necropsy findings and diagnosis. animals will have noticeable perineal staining. intestines (particularly the ileum, cecum, and colon) may contain mucoid feces with or without hemorrhages. petechial hemorrhages and areas of necrosis may be noticed on the surface of the liver, heart, and mesenteric lymph nodes. the wall of the intestines, gallbladder, and mesenteric lymph nodes will be edematous, and a pseudodiphtheritic membrane lining the distal small intestines and colon may be observed. this membrane is not normally seen in the goat (smith and sherman, 1994) . splenomegaly may be present. aborted fetuses will often be autolysed. placentitis, placental necrosis, and hemorrhage are commonly seen. serologic evidence of recent infection can be demonstrated in the dam. salmonella can be isolated from the aborted tissues. pathogenesis. after ingestion, the organism proliferates in the intestine. damage to the intestines and the resulting diarrhea are due to the bacterial production of cytoxin and endotoxin. although the salmonella organisms will be taken up by phagocytic cells involved in the inflammatory response, they survive and multiply further. septicemia is a common sequela, with the bacteria localizing throughout the body. in latently infected animals, it is often shed from the gallbladder and mesenteric lymph nodes. younger animals may be susceptible because of immature immunity and intestinal flora and higher intestinal ph. carriers may develop clinical disease when stressed. differential diagnoses. in young animals, differentials include other enteropathogens: escherichia coli, rotavirus and coronavirus, clostridia, cryptosporidia, and other coccidial forms. these pathogens may also be present in the affected animals. differentials in adults include bovine viral diarrheas and winter dysentery in cattle and parasitemia and enterotoxemia in all ruminants. prevention and control. affected animals should be isolated during herd outbreaks. samples for culture should include herdmates, water and feed sources, recently arrived livestock (other species), and area wildlife, including birds and rodents. repeated cultures, culling of animals, intensive cleaning, and disinfection of facilities are all important during outbreaks. the bacteria survive for about a week in moist cow manure. vaccination using the commercially available killed bacterin or autologous bacterins may be useful in outbreaks involving pregnant cattle, although the j-5 bacterin is now considered better. treatment. nursing care includes rehydration and correction of acid-base abnormalities. antibiotic therapy may be useful in cases with septicemia, but it is controversial because it may induce carrier animals. gentamicin, trimethoprim-sulfadiazine, ampicillin, enrofloxacin, and amikacin antibiotics may be successful. negative, rod-shaped bacterium. type a is more virulent than type b. clinical signs. although tularemia is a disease of livestock, pets, and wild animals, sheep are most commonly affected. the disease is characterized by hyperthermia, muscular stiffness, and lymphadenopathy. infected animals move stiffly, are depressed, and are hyperthermic. anemia and diarrhea may develop, and infected lymph nodes enlarge and may ulcerate. mortality may reach 40%. animals that recover will have immunity of long duration. epizootiology and transmission. the disease is most commonly transmitted by ticks or biting flies. the wood tick, dermacentor andersoni, is an important vector in transmitting the disease in the western united states, and, as natural hosts, wild rodents and rabbits tend to be reservoirs of the pathogen. research complications. salmonellosis is zoonotic, and some serotypes of the organism have caused fatalities even in immunocompetent humans. attempts should be made to identify and cull carrier animals. pathogenesis. the organisms, entering the tick bite wound, move via lymphatics to lymph nodes and subsequently to the bloodstream, where they cause septicemia. the organisms can also be transmitted orally through contaminated water. etiology. spirochete-like organisms are associated with this disease; it is now recognized that the agent is not a chlamydial organism. the disease has been reported only in the foothills bordering the central valley of california. necropsy findings. ticks may also be present on the carcasses. suppurative, necrotic lymph nodes are typical. lungs will be congested and edematous. diagnosis is confirmed by prompt culturing of the organism from lymph nodes, spleen, or liver where granulomatous lesions form; p. tularensis does not survive for long periods in carcasses. serological findings may also be helpful. clinical signs. cows that become infected with the causative agent before 6 months of gestation abort or give birth to weak calves without any clinical sign of infection. cows infected after 6 months of gestation give birth to normal calves. affected cows rarely abort in subsequent pregnancies. the tick vector is ornithonecropsy. fetuses show several pathological changes, including enlargement of the cervical lymph nodes, spleen, and liver. the calf's thymus will be small, and histologically there will be losses of thymic cortical lymphocytes. histologic changes in lymph nodes and spleen include vasculitis, necrosis, and histiocytosis. treatment. chlortetracycline treatment has been effective in controlling this disease. etiology. tularemia is caused by pasteurella (francisella) tularensis a nonmotile, non-spore-forming, aerobic, gram-control and prevention. eliminating the tick vectors can prevent tularemia. animals should be provided with fresh water frequently. the organism can survive in freezing conditions and in water and mud for long periods of time. caretakers, veterinarians, and researchers should take special precautions before handling the tissues of infected sheep, because this is a method of zoonotic spread. research complications. the disease is zoonotic, and transmission to people may result from tick bites or from handling contaminated tissues. although not a major disease of concern in sheep, researchers using potentially infected animals from western range states of the united states should be aware of it. the organism is antigenically related to brucella spp. etiology. yersiniosis is caused by infections with yersinia enterocolitica, a gram-negative, aerobic, and facultative anaerobe of the family enterobacteriaceae. there are 50 serotypes reported for y. enterocolitica. yersinia pseudotuberculosis infections have also been seen in ruminants. enteric infections predominate in the diseases caused by these bacteria. clinical signs and diagnosis. clinical disease may be seen rarely in many groups of ruminants. goats of 1-6 months old suffer from the enteric form of the disease, which is characterized by sudden death or the acute onset of watery diarrhea lasting 1 or more days. spontaneous abortions and weak neonates are also clinical manifestations of infection. lactating does may have mastitis that becomes chronically hemorrhagic. bacteremia results in internal abscesses, abortion, and acute deaths. yersinia pseudotuberculosis has been associated with laboratory goat epizootics (obwolo, 1976) . diarrhea in pastured sheep, stressed by other factors, has also been reported. diagnosis is based on culture and serology. epizootiology and transmission. the bacteria are carried by wild birds and rodents, and transmission is by ingestion of contaminated feed and water. research complications. yersinia is zoonotic. prevention and control. control measure are not well defined, because the epidemiology of the disease is poorly understood (smith and sherman, 1994) . tissues from affected goats must be handled and disposed of properly. areas housing affected goats must be thoroughly sanitized. treatment. in case of an abortion storm, treatment of goats with tetracycline has been useful. other broad-spectrum antibiotics may also be useful. clinical signs. contagious caprine pleuropneumonia is characterized by severe dyspnea, nasal discharge, cough, and fever (mcmartin et al., 1980) . infections with other mycoplasma species also have similar clinical signs. septicemia without respiratory involvement may also be a presentation. epizootiology and transmission. this disease is highly contagious, with high morbidity and mortality. transmission is by aerosols. mycoplasma mycoides subsp, mycoides has become a serious cause of morbidity and mortality of goat kids in the united states. necropsy. large amounts of pale straw-colored fluid and fibrinous pneumonia and pleurisy are typical. some lung consolidation may be present. meningitis, fibrinous pericarditis, and fibrinopurulent arthritis may also be found. diagnosis is usually made at necropsy by culture of the organism from lungs and other internal organs. differential dagnosis. in the united states, the principal differential for m. mycoides subsp, mycoides is caprine arthritis encephalitis. treatment. tylosin and oxytetracycline are effective. some infections are slow to resolve. prevention and control. vaccines are available in some areas. infected herds are quarantined. new goats should be quarantined before introduction to the herd. research complications. the worldwide distribution of the f38 biotype, as well as the aerosol transmission and high mor-bidity and mortality characteristics of mycoplasmal infectious, make these infections economically important diseases. considerable attention is presently given to this genus as a source of morbidity and mortality in goats. iv. mycoplasma conjunctivae (mycoplasmal keratoconjunctivitis) etiology. mycoplasma conjunctivae causes infectious conjunctivitis, or pinkeye, in sheep and goats with associated hyperemia, edema, lacrimation, and corneal lesions. mycoplasma mycoides subsp, mycoides, m. agalactiae, m. arginini, and acholeplasma oculusi have also been associated with keratoconjunctivitis in these species. respiratory disease and other infections, such as mastitis, may also be observed. clinical signs and diagnosis. all ages of animals may be affected. initially, lacrimation, conjunctival vessel injection, and then keratitis and neovascularization are seen. sometimes uveitis is evident. although the presentation is usually unilateral, bilateral involvement is possible. recurring infections are common. culturing provides the better diagnostic information, and cultures will be positive even after clinical signs have diminished. ily between animals by direct contact. animals can become reinfected, and carrier animals may be a factor in outbreaks. necropsy. it is unlikely that animals would die or be euthanized and undergo necropsy for this problem. conjunctival scrapings would include neutrophils during earlier stages and lymphocytes during later stages. epithelial cell cytoplasm should be examined for organisms. differential diagnosis. the primary differential in sheep and goats is chlamydia, as well as branhamella, rickettsia (colesiota) conjunctivae, and infectious bovine rhinotracheitis in goats only. it is important to consider these differentials if arthritis, pneumonia, or mastitis is present in the group or the individual. treatment. animals do recover spontaneously within about 10 weeks. tetracycline ointments and powders are also used. third-eyelid flaps may be necessary if corneal ulceration develops. prevention and control. new animals should be quarantined and, if necessary treated, before introduction to the flock or herd. etiology. eperythrozoonosis is a rare, sporadic, noncontagious, blood-borne disease in ruminants worldwide caused by the rickettsial agent eperythrozoon. host-specific species of importance are e. ovis, the causative species in sheep and goats, and e. wenyoni, e. tegnodes, and e. tuomii, the causative agents in cattle. although the disease is of minor importance, it can cause severe anemia and debilitation in affected animals. haemobartonella bovis is also rare, and is usually found only in association with other rickettsial diseases. clinical signs and diagnosis. the disease is more severe in sheep. following an incubation period of 1-3 weeks, infected animals exhibit episodic hyperthermia, weakness, and anemia. losses may be greater in younger lambs. cattle are usually latently infected but may have swollen and tender teats and legs. fever, anemia, and depression will be present if the cattle are stressed by another systemic disease. diagnosis is based on clinical evidence of anemia and is confirmed by observing the rickettsiae on the surface of red blood cells in a blood smear. epizootiology and transmission. the rickettsial organisms are transmitted typically to young sheep by biting insects, ticks, contaminated needles or blood-contaminated surgical instruments. necropsyfindings. necropsy findings include splenic enlargement and tissue icterus. has resulted in transient hyperthermia, mild respiratory disease, and mastitis. abortions, stillbirths, and births of weak lambs are also seen. epizootiology and transmission. coxiella burnetii is extremely resistant to environmental changes as well as to disinfectants; persistence in the environment for a year or longer is possible. the organism is associated with either a free-living or an arthropod-borne cycle. coxiella burnetii is found in a variety of tick species, such as ixodid or argasid, where it replicates and is excreted in the feces. once introduced into a mammal, coxiella may be maintained without a tick intermediate. the organism is especially concentrated in placental tissues, replicates in trophoblasts, and will be in reproductive fluids. additionally, the organism is shed in milk, urine, feces, and oronasal secretions. necropsy findings. no specific lesion will be seen in aborted or stillborn fetuses, but necrotizing placentitis will be a finding in cases of abortion. the placenta will contain white chalky plaques and a red-brown exudate. the disease can be diagnosed by identifying the rickettsial organisms in smears of placental secretions. the organism has been found in the placentas of clinically normal animals. the organism stains red with modified ziehl-neelsen and macchiavello stains and purple with giemsa stain. pathogenesis. the organism invades and destroys red blood cells. it is believed that intravascular hemolysis and erythrophagocytosis contribute to the macrocytic anemia. as with other red blood cell parasites, splenectomy aggravates the disease. differential diagnosis. because of the organisms' similarity to chlamydia, confirmation must be made by culture techniques, immunofluorescent procedures, elisa, and complement fixation tests. differential diagnosis. clontridium novyi type d, babesiosis, and leptospirosis are the primary differentials. prevention and control. following strict sanitation practices for surgical procedures and controlling external parasites prevent the disease. treatment. treatment is not usually recommended, but oxytetracycline has been used. sheep will develop immunity if supported nutritionally during the disease. research complications. splenectomized animals are the experimental models used to study these diseases. ii. q fever, or query fever (coxiella burnetii) etiology. coxiella burnetii is a small, gram-negative, obligate intracellular rickettsial organism that causes query fever and is regarded as a major cause of late abortion in sheep. clinical signs. infection of ruminants with c. burnetii is usually asymptomatic. experimental inoculation in other mammals treatment. coxiella can be treated with oxytetracyclines. a vaccine is not commercially available. prevention and control. any aborting animals should be segregated from other animals, and other pregnant animals should be treated prophylactically with tetracycline. serologic screening of ruminant sources should be performed routinely. barrier housing, a review of ventilation exhaust, and defined handling procedures are often required. all placentas and all aborted tissues should be handled and disposed of carefully. q fever has been reported in many mammalian species, including cats. research complications. coxiella burnetii-free animals are particularly important in studies involving fetuses and placentation. because of its zoonotic potential, c. burnetii presents a unique problem in the animal research facility environment. a single organism has been shown to cause disease. some of the greatest concerns are the risk to immunocompromised individuals, pregnant women, and other animals, and the presence of carrier animals or those that may shed the organism in placentas, for example. etiology. the ruminant adenoviruses are dna viruses that cause respiratory and reproductive tract diseases. nine antigenic types of the bovine adenovirus have been identified, with type 3 associated with respiratory disease. two of the ovine and two of the caprine antigenic types have been identified. clinical signs. signs of infection range from subclinical to severe, including pneumonia, enteritis, conjunctivitis, keratoconjunctivitis, weak calf syndrome, and abortion. respiratory tract and intestinal tract diseases may be concurrent. infections caused by this virus are often found associated with other viral and bacterial infections. epizootiology and transmission. the virus is believed to be widespread, but prevalence and characteristics of infection have not been characterized. transmission of adenoviruses in other species (e.g., canine) is by aerosols or fecal-oral routes. necropsy findings. lesions found after experimental infections include atelectasis, edema, and consolidation of the lungs. etiology. the bluetongue virus is an rna virus in the orbivirus genus and reoviridae family. five serotypes (2, 10, 11, 13, and 17) have been identified in the united states, where it is seen mostly in western states. bluetongue is an acute arthropodborne viral disease of ruminants, characterized by stomatitis, depression, coronary band lesions, and congenital abnormalities (bulgin, 1986) . clinical signs and diagnosis. sheep are the most likely to show clinical signs. clinical disease is less common in goats and cattle. early in the infection, animals will spike a fever and will develop hyperemia and congestion of tissues of the mouth, lips, and ears. the virus name, bluetongue, is associated with the typical cyanotic membranes. the fever may subside, but tissue lesions erode, causing ulcers. increased salivary discharges and anorexia are often related to ulcers of the dental pad, lips, gums, and tongue, although salivation and lacrimation may precede apparent ulceration. chorioretinitis and conjunctivitis are also common signs in cattle and sheep. lameness may be observed associated with coronitis and is evident in the rear legs. skin lesions such as drying and cracking of the nose, alopecia, and mammary glands are also observed. secondary bacterial pneumonia may also occur. animals may also develop severe diarrhea and become recumbent. sudden deaths due to cardiomyopathy may occur at any time during the disease. hematologically, animals will be leukopenic. the course of the disease is about 2 weeks, and mortality may reach 80%. if animals are pregnant, the virus crosses the placenta and causes central nervous system lesions. abortions may occur at any stage of gestation in cattle. prolonged gestation may result from cerebellar hypoplasia and lack of normal sequence to induce parturition. cerebellar hypoplasia will also be present in young born of the infected dams, as well as hydrocephalus, cataracts, gingival hyperplasia, or arthrogryposis. diagnosis is suspected with the characteristic clinical signs and exposure to viral vectors. virus isolation is the best diagnostic approach if blood is collected during the febrile stage of the disease or brains from aborted fetuses. fluorescent antibody tests, elisa, virus neutralization tests, pcr, and agar gel immunodiffusion (agid) tests are also used to confirm the diagnosis. necropsy findings. at necropsy, erosive lesions may be observed around the mouth, tongue, palate, esophagus, and pillars of the rumen. ulceration or hyperemia of the coronary bands may also be seen. many of the internal organs will contain petechial and ecchymotic hemorrhages of the surfaces, and hemorrhage may be seen at the base of the pulmonary artery. pathogenesis. the virus multiplies in the hemocoel and salivary glands of the fly and is excreted in transmissible form in the insect's saliva. after entering the host, the virus causes prolonged viremia. the incubation period is 6-14 days. the virus migrates to and attacks the vascular endothelium. the resulting vasculitis accounts for the lesions of the skin, mouth, tongue, esophagus, and rumen and the edema often found in many tissues. ballooning degeneration of affected tissues, followed by necrosis and ulceration, occurs. the effects on fetuses appear to be due to generalized infections of developing organs. differential diagnosis. differentials include other infectious vesicular diseases such as foot-and-mouth disease, contagious ecthyma, bovine viral diarrhea virus-mucosal disease, infectious bovine rhinotracheitis, bovine papular stomatitis, and malignant catarrhal fever. rinderpest is a differential in countries where it is endemic. photosensitization should be considered. foot rot is a differential for the lameness and coronitis. differentials for the manifestations such as arthrogryposis include border disease virus and genetic predispositions of some breeds such as charolais cattle and merino sheep. prevention and control. cellular and humoral immunity are necessary for protection from infection. the bluetongue virus is insidious because the genome is capable of reassortment, and some vaccines will not have the antigenic components represented in the local infection. in addition, there is little to no cross protection between strains. modified live vaccines are available in some parts of the united states but should not be used in pregnant animals. vaccinating lambs and rams in an outbreak is worthwhile, for example, but vaccinating lategestation ewes may cause birth defects or abortions. congenital defects are more common from vaccine use than from naturally occurring infection. minimizing exposure to the vector in endemic areas will decrease the incidence of the disease. treatment. supportive care and nursing care are helpful, including gruels or softer feeds, easily accessed water, and shaded resting places. nonsteroidal anti-inflammatory drugs are often administered. for the cases of secondary bacterial pneumonia and some cases of bluetongue conjunctivitis, antibiotics may be administered. research complications. this is a reportable disease because clinical signs resemble foot-and-mouth disease and other exotic vesicular diseases. etiology. bovine lymphosarcoma refers to lymphoproliferative diseases in young cattle that are not associated with bovine leukemia virus (blv) infection, and those in older cattle that are associated with b lv. b lv is a b lymphocyte-associated retrovirus (johnson and kaneene, 1993a,b,c) . clinical signs. forms of bovine lymphosarcoma that are not associated with blv infection are calf, or juvenile; thymic, or adolescent (animals 6 months to 2 years old); and cutaneous (any age). the calf form is rare and characterized by generalized lymphadenopathy. onset may be sudden, and the disease is usually fatal within a few weeks. signs include lymphadenopathy, anemia, weight loss, and weakness. some animals may be paralyzed because of spinal cord compression from subperiosteal infiltration of neoplastic cells. the adolescent form is also rare, the course rapid, and the prognosis poor. the disease is seen most often in beef breeds such as hereford cattle and is characterized by space-occupying masses in the neck or thorax. these masses are also often present in the brisket. secondary effects of the masses are loss of condition, dysphagia, rumen tympany, and fatal bloat. the cutaneous presentation has a longer course and may wax and wane. the masses are found at the anus, vulva, escutcheon, shoulder, and flank; they are painful when palpated, raised, and often ulcerated. the animals are anemic, and neoplastic involvement may affect cardiac function. generalized or limited lymphadenopathy may be apparent. only the adult, or enzootic, form of bovine lymphosarcoma is associated with blv infection. many animals do not develop any malignancies or clinical signs of infection and simply remain permanently infected. some cows manifest disease only during the periparturient period. malignant lymphoma is the more common, whereas leukosis, due to b-lymphocyte proliferation, is rare. clinical signs are loss of condition and a drop in production of dairy cattle, anorexia, diarrhea, ataxia, paresis, and other signs dependent on the location of the neoplastic tissue. tumors are associated with lymphoid tissues. common sites also include the abomasum, spinal canal, and uterus. cardiac tumors develop at the right atrial or left ventricular myocardium, and associated beat and rate abnormalities may be auscultated. the common ocular manifestation of the disease is exophthalmos due to retrobulbar masses. many internal organs may be involved, and tumors may be palpable per rectum. secondary infections will be due to immunosuppression and the weakened state of the animal. sheep have acquired blv infection naturally and have been used as experimental models; in both situations, this species is susceptible to tumor and leukemia development. goats seroconvert but do not develop the clinical syndromes. diagnosis is based on the animal's age, clinical signs, serology, hematology findings according to the form, aspirates or biopsies of masses, and necropsy findings. kits are available for running agid, for which the blv antigens gp-51 and gp-24 are used; antibodies may be detected within weeks after exposure and may also help in predicting disease in clinically normal cattle. elisa and pcr diagnostic aids will also be helpful. worldwide. it is estimated that at least 50% of the cattle in the united states are infected with blv. as few as 1% of these animals develop lymphosarcoma, but the adult form of the disease described here is the most common bovine neoplastic disease in the united states. larger herds tend to have higher rates. genetic predisposition may be involved; in addition to the presence of blv, the type of bovine lymphocyte antigen (bola) may be correlated to resistance or susceptibility and to the course of the disease. transmission is believed to be by inhalation of blv in secretions; in colostrum; horizontally by contaminated equipment not sanitized between cattle; and by rectum (e.g., mucosal irritation during per-rectum exams or procedures). natural-service bulls may transmit the infection to cows. cows infected with blv may transmit the infection to their calves in utero. tabanid and other flies also serve as vectors, but these represent a minor means of transmission. necropsy findings. neoplastic infiltration of many organs and tissues are found in the calf form and the cutaneous forms. tumors may be local or widely distributed in the enzootic form. definitive diagnosis of neoplastic tissue specimens is by histology. pathogenesis. as with other retroviruses, the blv integrates viral dna into host target cell dna by means of the reverse transcriptase enzyme, creating a provirus. epizootiology and transmission. the virus is reported to be widespread. occurrence is often seasonal, and biting insects may be vectors. transmission with successful infection requires deep penetration of the skin. transmission may be by contaminated milkers' hands, contaminated equipment, and other fomites. differential diagnosis. differential diagnoses include other diseases that cause lesions on teats such as pseudocowpox, papillomatosis, and vesicular stomatitis. other vesicular diseases may be considered, but other more severe clinical signs might be associated with those. there is no vaccine for this disease. development and maintenance of a blv-free herd, or controlling infection within a herd, requires financial and programmatic commitments: blv-positive and blv-negative animals maintained separately; serologic testing (such as at least every 6 months) and separating positive animals; and washing and then disinfecting instruments, needles (or using sterile singleuse products), and equipment for ear tagging and dehorning and other such equipment between animals. a fresh rectal exam sleeve and lubricant should be used for each animal examined. otherwise serologically positive cows may have undetectable antibodies during the periparturient period. embryo transfer recipients should be negative, and the virus will not be transferred by the embryonic stage. calves should be fed colostrum from serologically negative cows. treatment. treatment regimens of corticosteroids and cancer chemotherapeutic agents provide only short-term improvement. in cases where ova, embryos, or semen need to be collected, supportive care for the affected animals is essential. research complications. the united states and several countries, some in europe, have official programs for eradication of enzootic bovine leukosis. prevention and control. established milking hygiene practices are important control measures: having milkers wash their hands with germicidal solutions or wear gloves, cleaning equipment between animals, and separating affected animals. treatment. there is no treatment, and affected animals should be separated from the herd and milked last. lesions can be cleaned and treated with topical antibacterials. etiology. the bovine viral diarrhea virus (bvdv) is a pestivirus of the flaviviridae family. the flaviviridae include hog cholera virus and border disease virus of sheep. the virus contains a single strand of positive-sense rna. a broad range of disease and immune effects is produced by b vdv only in cattle. in addition, this virus is important in the etiology of bovine pneumonias. bovine viral diarrhea/mucosal disease (bvd/md) is one of the most important viral diseases and one of the most complex diseases of cattle. strains of bvdv are characterized as cytopathic (cp) and noncytopathic (ncp), based on cell-culture growth characteristics. the virus has also been categorized as type 1 and type 2 isolates. heterologous strains exist that may confound even sound vaccination programs. etiology. bovine herpesvirus 2 causes bovine herpes mammillitis, a widespread disease characterized by teat and udder lesions, as well as oral and skin lesions. clinical signs and diagnosis. lesions begin suddenly with teat swelling; the tissue will be edematous and tender when touched. the udder lesions may extend to the perineum. the lesions progress to vesicles, then to ulcers; these may take 10 weeks to heal. lesions rarely may also develop focally around the mouth and generally on the skin of the udder. secondary mastitis may occur, because of bacteria associated with the scabs. diagnosis is by clinical signs and serologically. clinical signs and diagnosis. signs of bvdv infections may be subclinical but also include abortions, congenital abnormalities, reduced fertility, persistent infection (pi) with gradual debilitation, and acute and fatal disease. the presence of antibodies, whether from passive transfer or immunizations, does not necessarily guarantee protection from the various forms of the disease. an acute form of the disease, caused by type 2 bvdv, occurs in cattle without sufficient immunity. after an incubation period of 5-7 days, clinical signs include fever, anorexia, oculonasal discharge, oral erosions (including on the hard palate), diarrhea, and decreased milk production. the disease course may be shorter with hemorrhagic syndrome and death within 2 days. clinical signs of b vdv in calves also include severe enteritis and pneumonia. when susceptible cows are infected in utero from gestational be found extending throughout the gastrointestinal tract to the days 50-100, or gestational cows are vaccinated with a modi-cecum. the respiratory tract lesions will often be complicated fled live vaccine, abortion or stillbirth result. congenital defects caused by bvdv during gestational days 90-170 include impaired immunity (thymic atrophy), cerebellar hypoplasia, ocular defects, alopecia or hypotrichosis, dysmyelinogenesis, hydranencephaly, hydrocephalus, and intrauterine growth retardation. typical signs of cerebellar dysfunction will be evident in calves, such as wide-based stance, weakness, opisthotonus, hyperflexion, hypermetria, nystagmus, or strabismus. some severely affected calves will not be able to stand. ophthalmic effects include retinal degeneration and microphthalmia. fetuses can also be infected in utero, normal at birth, immunotolerant to the virus, and persistently infected (pi). the term mucosal disease is commonly associated with this form of the infection. many pi animals do not survive to maturity, however, and many have weakened immune systems. the pi animals are important because they shed virus and will probably show the clinical signs of mucosal disease (md) caused by a cp b vdv strain derived from an ncp b vdv strain. these md clinical signs include fever, anorexia, and profuse diarrhea that may include blood and fibrin casts, and oral and pharyngeal erosions, as well as erosion at the interdigital spaces and on the teats and vulva. many other associated clinical signs include anemia, bloat, lameness, or corneal opacities and discharges. secondary effects of hemorrhage and dehydration also contribute to the morbidity and mortality. animals that do not succumb to the disease will be chronically unthrifty, debilitated, and infection-prone. diagnosis in affected calves is based on herd health history, clinical signs, and antibodies to b vdv in precolostral serum. viral culturing from blood may be useful. in older animals, oral lesions, serology, detection of viral antigen, and virus isolation contribute to the diagnosis. leukopenia, and especially lymphopenia, are seen. serology must be interpreted with the awareness of the possibility of pi immunotolerant animals. vaccination against the disease carries its own set of side effects and potential problems, especially when using modified live vaccines, whether against cp or ncp strains. the condition of the animals is also a variable. epizootiology and transmission. bvdv is present throughout the world. transmission occurs easily by direct contact between cattle, from feed contaminated with secretions or feces, and by aborted fetuses and placentas. pi females transmit the virus to their fetuses. semen also is a source of virus. necropsy findings. in affected calves, histopathologic findings include necrosis of external germinal cells, focal hemorrhages, and folial edema. later in the disease, large cavities develop in the cerebellum, and atrophy of the cerebellar folia and thin neuropil are evident. older calves may have areas of intestinal necrosis. in cases where oral erosions occur, erosions will by secondary bacterial pneumonia. when the hemorrhagic syndrome develops, petechiation and mucosal bleeding will be present. pathogenesis. the cp and ncp strains are thought to be related mutations of the bvdv; the cp short-lived isolates are believed to arise from the ncp strains. the ncp strains are those present in the pi animals, and the strains are maintained in cattle populations. cp and ncp isolates vary in virulence, and classification of these types is based on viral surface proteins. considerable antigenic variation also exists between strains and types. other viral infections, such as bovine respiratory syncytial virus and infectious bovine rhinotracheitis, may also be present in the same animals. the pathology caused by b vdv is due to its ability to infect epithelial cells and impair the functioning of immune cell populations through out the bovine system. in type 2 bvdv hemorrhagic syndrome, death results from viral-induced thrombocytopenia. in fetuses, the virus infects developing germinal cells of the cerebellum. the purkinje's cells in the granular layer are killed, and necrosis and inflammation follow. the immune effects are the result of the virus's interfering with neutrophil and macrophage functions and of lymphocyte blastogenesis. all of these predispose the affected animals to bacterial infections with pasteurella haemolytica. b vdv damages dividing cells in fetal organ systems, resulting in abortions and congenital effects. differential diagnosis. many differentials must be considered for the clinical manifestations of b vdv infections. differentials for enteritis of calves include viral infections, cryptosporidia, escherichia coli, salmonella, and coccidia. salmonella, winter dysentery, johne's disease, intestinal parasites, malignant catarrhal fever (mcf), and copper deficiency are differentials for the diarrhea seen in the disease in adult animals. respiratory tract pathogens such as bovine respiratory syncytial virus, pasteurella, haemophilus, and mycoplasma must be considered for the respiratory tract manifestations. oral lesions are also produced by mcf, vesicular stomatitis, bluetongue, and papular stomatitis. infectious bovine herpesvirus 1, leptospirosis, brucellosis, trichomoniasis, and mycosis should be considered in cases of abortion. prevention and control. combined with sound management in a typical cattle herd, vaccination is the best way to prevent b vdv and should be integrated into the herd health program, timed appropriately preceding breeding, gestation, or stressful events. vaccine preparations for b vdv are modified live virus (mlv) or killed virus. each has advantages and disadvantages. the former induces rapid immunity (within 1 week) after a single dose, provides longer duration of immunity against sev-eral strains, and induces serum neutralizing antibodies. mlv vaccines are not recommended for use in pregnant cattle, may induce mucosal disease, and may be immunosuppressive at the time of vaccination. the immunosuppression is detrimental if cattle are concurrently exposed to field-strain virus because it will facilitate infection and possible clinical disease. the mlv strains may cross the placenta, resulting in fetal infections. the killed vaccines are safer in pregnant animals but require booster doses after the initial immunization, may need to be given 2-3 times per year, and do not induce cell-mediated immunity. passive immunity may protect most calves for up to 6-8 months of age. subsequent vaccination with mlv may provide lifelong immunity, but this is not guaranteed. annual boosters are recommended to protect against vaccine breaks. the virus persists in the environment for 2 weeks and is susceptible to the disfectants chlorhexidine, hypochlorite, iodophors, and aldehydes. maintenance of a closed herd to prevent any possibility of the introduction of the virus is difficult. isolation of new animals, avoidance of the purchase of pregnant cows, scrutiny of records from source farms, use of semen tested bulls, minimization of stress, testing of embryo-recipient cows, and maintainenance of populations of ruminants (smaller or wild species) separately on the premises will minimize viral exposure. other management strategies may require a program for testing and culling pi cattle. this can be expensive but may be a worthwhile investment to remove the virus shedders from a herd. no specific treatment is available. supportive care and treatment with antibiotics to prevent secondary infection are recommended. animals that survive the infection should be evaluated a month after recovery to determine their status as pi or virus-free. etiology. cache valley virus (cvv), of the arbovirus genus of the bunyaviridae family, is a cause of congenital defects in lambs. cvv infection in fetal and newborn lambs include arthrogryposis, microencephaly, hydranencephaly, porencephaly, cerebellar hypoplasia, and micromyelia. stillbirths and mummified fetuses are seen. lambs will be born weak and will act abnormally. diagnosis is by evidence of seroconversion in precolostral blood samples or fetal fluids, as the result of in utero infection. western united states, although it has been isolated in a few midwestern states. although considered a disease of sheep, virus has been isolated from cattle and from wild ruminants and antibodies found in white-tailed deer. transmission is by arthropods during the first trimester of pregnancy. etiology. caprine arthritis encephalitis virus (caev) occurs worldwide, with a high prevalence in the united states. caprine arthritis encephalitis (cae) is considered the most important viral disease of goats. the caev is in the lentivirus genus of the retroviridae family. it causes chronic arthritis in adults and encephalitis in young. caev is in the same viral genus as the ovine progressive pneumonia virus (oppv). clinical signs and diagnosis. the most common presentation in goats is an insidious, progressive arthritis in animals 6 months of age and older. animals become stiff, have difficulty getting up, and may be clinically lame in one or both forelimbs. carpal joints are so swollen and painful that the animal prefers to eat, drink, and walk on its "knees." in dairy goats, milk production decreases, and udders may become firmer. this retrovirus also causes neurological clinical signs in young kids 2-6 months old. kids may be bright and alert, afebrile, and able to eat normally even when recumbent. some kids may initially show unilateral weakness in a rear limb, which progresses to hemiplegia or tetraplegia. mild to severe lower motor neuron deficits may be noted, but spinal reflexes are intact. clinical signs may also include head tilt, blindness, ataxia, and facial nerve paralysis. older animals in the group may experience interstitial pneumonia or chronic arthritis. the pneumonia is similar to the pneumonia in sheep caused by oppv; the course is gradual but progressive, and animals will eventually lose weight and have respiratory distress. some animals in a herd may not develop any clinical signs. diagnosis is based on clinical signs, postmortem lesions, and positive serology for viral antibodies to caev. an agar gel immunodiffusion (agid) test identifies antibodies to the virus and is used for diagnosis. kids acquire an anti-caev antibody in colostrum, and this passive immunity may be interpreted as indicative of infection with the virus. the antibody does not prevent viral transmission. ep&ootiology and transmission. the virus is prevalent in most industrialized countries. the common means of transmission, from adults to kids, is in the colostrum and milk in spite of the presence of anti-caev antibody in the colostrum. transmission may occur among adult goats by contact. intrauterine transmission is believed to be rare. transmission to sheep has occurred only experimentally; there is no documented case of natural transmission. necropsy findings. necropsy and histopathology reveal a striking synovial hyperplasia of the joints with infiltrates of lymphocytes, macrophages, and plasma cells. other histologic lesions include demyelination in the brain and spinal cord, with multifocal invasion of lymphocytes, macrophages, and plasma cells. in severe cases of mastitis, the udder may appear to be composed of lymphoid tissue. tem, resulting in the formation of non-neutralizing antibody to viral core proteins and envelope proteins. immune complex formation in synovial, mammary gland, and neurological tissue is thought to result in the clinical changes observed. most commonly, the carpal joint is affected, followed by the stifle, hock, and hip. the infection is lifelong. differential diagnosis. the differential diagnosis for the neurologic form of caev should include copper deficiency, enzootic pneumonia, white muscle disease, listeriosis, and spinal cord disease or injury. the differential diagnosis for caev arthritis should include chlamydia and mycoplasma. prevention and control. herds can be screened for cae by testing serologically, using an agid or an enzyme-linked immunosorbent assay (elisa) test. the elisa is purported to be more sensitive, whereas the agid is more specific. individual animals show great variation in development of antibody. because cae is highly prevalent in the united states, and because seronegative animals can shed organisms in the milk, retesting herds at least annually may be necessary. recently, an immunoprecipitation test for cae has been developed that has high sensitivity and specificity. control measures include management practices such as test and cull, prevention of milk transmission, and isolation of affected animals. parturition must be monitored, and kids must be removed immediately and fed heat-treated colostrum (56~ for 1 hr). caev-negative goats should be separated from caevpositive goats. treatment. there is no treatment for caev. is also referred to as bovine herpesvirus 1 (bhv-1) and is an alphaherpesvirus. ibrv causes or contributes to several bovine syndromes, including respiratory and reproductive tract diseases. it is one of the primary pathogens in the bovine respiratory disease complex. strains include bhv-i.1 (associated with respiratory disease), bhv 1.2 (associated with respiratory and genital diseases), and bhv 1.4 (associated with neurological diseases), which has been reclassified as bovine herpesvirus 5. clude conjunctivitis, rhinotracheitis, pustular vulvovaginitis, balanoposthitis, abortion, encephalomyelitis, and mastitis. the respiratory form is known as infectious bovine rhinotracheitis, and clinical signs may range from mild to severe, the latter particularly when there are additional respiratory viral infections or secondary bacterial infections. the mortality rate in more mature cattle is low, however, unless there is secondary bacterial pneumonia. fever, anorexia, restlessness, hyperemia of the muzzle, gray pustules on the muzzle (that later form plaques), nasal discharge (that may progress from serous to mucopurulent), hyperpnea, coughing, salivation, conjunctivitis with excessive epiphora, and decreased production in dairy animals are typical signs. open-mouth breathing may be seen if the larynx or nasopharygneal areas are blocked by mucopurulent discharges. neonatal calves may develop respiratory as well as general systemic disease. in these cases, in addition to the symptoms already noted, the soft palate may become necrotic, and gastrointestinal tract ulceration occurs. young calves are most susceptible to the encephalitic form; signs include dull attitude, head pressing, vocalizations, nystagmus, head tilt, blindness, convulsions, and coma, as well as some signs, such as discharges, seen with respiratory tract presentations. this form is usually fatal within 5 days. abortion may occur simultaneously with the conjunctival or respiratory tract diseases, when the respiratory infection appears to be mild, or may be delayed by as much as 3 months after the respiratory tract disease signs. infectious pustular vulvovaginitis is most commonly seen in dairy cows, and clinical signs may be mild and not noticed. otherwise, signs are fever, depression, anorexia, swelling of the vulvar labia, vulvar discharge, and vestibular mucosa reddened by pustules. the cow will often carry her tail elevated away from these lesions. these soon coalesce, and a fibrous membrane covers the ulcerated area. if uncomplicated, the infection lasts about 4-5 days, and lesions heal in 2 weeks. younger infected bulls may develop balanoposthitis with edema, swelling, and pain such that the animals will not service cows. epizootiology and transmission. ibrv is widely distributed throughout the world, and adult animals are the reservoirs of infection. the disease is more common in intensive calf-rearing situations and in grouped or stressed cattle. transmission is primarily by secretions, such as nasal, during and after clinical signs of disease. modified live vaccines are capable of causing latent infections. necropsy findings. fibrinonecrotic rhinotracheitis is considered pathognomic for ibrv respiratory tract infections. there will be adherent necrotic lesions in the respiratory, ocular, and reproductive mucosa. when there are secondary bacterial infections, such as pasteurella bronchopneumonia, findings will include congested tracheal mucosa and petechial and ecchymotic hemorrhages in that tissue. lesions from the encephalitic form include lymphocytic meningoencephalitis and will be found throughout the gray matter (neuronal degeneration, perivascular cuffing) and white matter (myelitis, demyelination). intranuclear inclusion bodies are not a common finding with this herpesvirus. pathogenesis. in the encephalitic form, the virus first grows in nasal mucosa and produces plaques. these resolve within 11 days, and the encephalitis develops after the virus spreads centripetally to the brain stem by the trigeminal nerve dendrites. latent infections are also established in neural tissue. differential diagnosis. the severe oral erosions seen with bvdv infections are rare with infectious bovine rhinotracheitis-infectious pustular vulvovaginitis (ibr-ipv). the conjunctivitis of ibr may initially be mistaken for that of a moraxella bovis (pinkeye) infection; the ibr will be peripheral, and there will not be corneal ulceration. bovine viral diarrhea virus and ibrv are the most common viral causes of bovine abortion. differentials for balanoposthitis include trauma from service. vated, attenuated, modified live, and genetically altered preparations. some are in combination with parainfluenza 3 (pi-3) virus. the mlv preparations are administered intranasally; these are advantageous in calves for inducing mucosal immunity even when serologic passive immunity is already present and adequate. some newer vaccines, with gene deletion, allow for serologic differentiation between antibody responses from infection or immunization. bulls with the venereal form of the infection will transmit the virus in semen; intranasal vaccine may be used to provide some immunity. treatment. uncomplicated mild infections will resolve over a few weeks; palliative treatments, such as cleaning ocular discharges and supplying softened food, are helpful in recovery. antibiotics are usually administered because of the high likelihood of secondary bacterial pneumonia. the encephalitic animals may need to be treated with anticonvulsants. etiology. parainfluenza 3, an rna virus of the family paramyxoviridae, causes mild respiratory disease of ruminants when it is the sole pathogen. the viral infection often predisposes the respiratory system to severe disease associated with concurrent viral or bacterial pathogens. viral strains are reported to vary in virulence. serotypes seen in the smaller ruminants are distinct from those isolated from cattle. clinical signs and diagnosis. infections ranging from asymptomatic to mild signs of upper respiratory tract disease are associated with this virus by itself; infections are almost never fatal. clinical signs include ocular and nasal discharges, cough, fever, and increased respiratory rate and breath sounds. in pregnant animals, exposure to pi-3 can result in abortions. clinical signs become apparent or more severe when additional viral pathogens are present, such as bovine viral diarrhea virus, or a secondary bacterial infection, such as pasteurella haemolytica infection, is involved. greater morbidity and mortality will be sequelae of the bacterial infections. viral isolation or direct immunofluorescence antibody (ifa) from nasal swabs can be used for definitive diagnosis. presently it is assumed that the virus is widespread in goats, but firm evidence is lacking. for an infection of pi-3 only, findings will be negligible. some congestion of respiratory mucosa, swelling of respiratory tract-associated lymph nodes, and mild pneumonitis may be noted grossly and histologically. intranuclear and intracytoplasmic inclusion bodies may be present in the mucosal epithelial cells. findings will be similar but not as severe as those caused by bovine respiratory syncytial virus. immunohistochemistry may also be used. pathogenesis. pi-3 infects the epithelial mucosa of the respiratory tract; however, the disease is often asymptomatic when uncomplicated. differential diagnosis. differentials, particularly in cattle, include infections with other respiratory tract viruses of ruminants: ibrv, bvdv, bovine respiratory syncytial virus, and type 3 bovine adenovirus. prevention and control. immunization, management, and nutrition are important for this respiratory pathogen, as for others. in cattle, modified live vaccines for intramuscular (im), subcutaneous (sc), or intranasal (in) administration are available. the im and sc routes provide immune protection within 1 week after administration but will not provide protection in the presence of passively acquired antibodies. it is contraindicated for pregnant animals because it will cause abortion. the in route immunizes in the presence of passively acquired antibodies, provides immunity within 3 days of administration, and stimulates the production of interferon. other vaccine formulations, about which less information is reported, include inactivated or chemically altered live-virus preparations; both are administered im, and followup immunizations are needed within 4 weeks. booster vaccinations are recommended for all preparations within 2-6 months after the initial immunization. all presently marketed vaccine products come in combination with other bovine respiratory viruses as multivaccine products. the humoral immunity protects against pi-3 abortions. there is no approved pi-3 vaccine for sheep and goats. the use of the cattle formulation in these smaller ruminants is not recommended. sound management of housing, sanitation, nutrition, and preventive medicine programs are all equally important components in prevention and control. treatment. uncomplicated disease is not treated. etiology. the respiratory syncytial viruses are pneumoviruses of the paramyxoviridae family and are common causes of severe disease in ruminants, especially calves and yearling cattle. two serotypes of the bovine respiratory syncytial virus (brsv) have been described for cattle; these may be similar or identical to the virus seen in sheep and goats. clinicalfindings and diagnosis. infections may be subclinical or develop into severe illness. clinical signs include fever, hyperpnea, spontaneous or easily induced cough, nasal discharge, and conjunctivitis. interstitial pneumonia usually develops, and harsh respiratory sounds are evident on auscultation. development of emphysema indicates a poor prognosis, and death may occur in the severe cases of the viral infection. secondary bacterial pneumonia, especially with pasteurella haemolytica, with morbidity and mortality, is also a common sequela. abortions have been assciated with brsv outbreaks. diagnosis is based on virus isolation and serology (acute and convalescent). nasal swabs for virus isolation should be taken when animals have fever and before onset of respiratory disease. prevention and control. vaccination should be part of the standard health program, and all animals should be vaccinated regularly. vaccinations should be administered within 1-2 months of stressful events, such as weaning, shipping, and introduction to new surroundings. currently available vaccines include an inactivated preparation and a modified live virus preparation administered intramuscularly or subcutaneously; immunity develops well in yearling animals, and colostral antibodies develop when cows are vaccinated during late gestation. passive immunity from colostrum provides at least partial protection to calves in herds where disease is prevalent. but this immunity suppresses the mucosal iga response and serum antibody responses. the basis for successful immune protection is the mucosal memory iga, but this is difficult to achieve with present vaccine formulations. the virus is easily inactivated in the environment. preventive measures in preweaning animals should include preconditioning to minimize weaning stress. treatment. recovery can be spontaneous; however, antibiotics and supportive therapy are useful to prevent or control secondary bacterial pneumonia. in severe cases, antihistamines and corticosteriods may also be necessary. use of vaccine during natural infection is not productive and may result in severe disease. etiology. ulcerative dermatosis is a contagious disease of sheep only. it is caused by a poxvirus similar to but distinct from the causative agent of contagious ecthyma ("current veterinary therapy," 1993). epizootiology and transmission. these viruses are considered ubiquitous in domestic cattle and are transmitted by aerosols. teroventral lung lobes. edema and emphysema are present. as the name indicates, syncytia, which may have inclusions, form in areas of the lungs infected with the virus. necrotizing bronchiolitis, bronchiolitis obliterans, and hyaline membrane formation will be evident microscopically. crusts associated with the skin and mucous membranes of the genitalia, face, and feet (bulgin, 1986) . genital lesions are much more common than the facial or coronal lesions. discomfort may be associated with the lesions. paraphimosis occasionally occurs. these lesions are painful; during breeding season, animals will avoid coitus. morbidity is low to moderate, and mortality negligible if the flock is otherwise healthy. diagnosis is based on clinical signs. pathogenesis. the severe form of the disease, which often follows a mild preliminary infection, is thought to be caused by immune-mediated factors during the process of infection in the lung. virulence may vary greatly among viral strains. united states, ulcerative dermatosis is transmitted through direct contact with abraded skin of the prepuce, vulva, face, and feet. necropsy findings. necropsy would rarely be necessary to diagnose an outbreak in a healthy flock. findings will be similar to those described for contagious ecthyma. when no contact with cattle has occurred. persistently infected animals, such as lambs, are shedding reservoirs of the virus in urine, feces, and saliva throughout their lives. pathogenesis. following an incubation period of 2-5 days, the virus replicates in the epidermal cells and leads to necrosis and pustule formation. pustules rapidly break, forming weeping ulcers. the ulcers scab over and eventually form a fibrotic scar. the disease usually resolves in 2-6 weeks. rarely, the disease will persist for many months to more than a year. differential diagnosis. the main differential is contagious ecthyma, which is grossly and histopathologically associated with epithelial hyperplasia. this is also a feature of ulcerative dermatosis. imals, especially males, should not be used for breeding. treatment. affected animals should be separated from the rest of the flock. treatment is supportive, including antiseptic ointments and astringents. research complications. breeding and maintenance of the flocks' condition, because of the pain associated with eating, will be compromised during an outbreak. etiology. border disease, also known as hairy shaker disease (or "fuzzies" in the southwestern united states), is a disease of sheep caused by a virus closely related to the bovine viral diarrhea virus (bvdv), a pestivirus of the togaviridae family. goats are also affected. the virus causes few pathogenic effects in cattle. clinical signs and diagnosis. border disease in ewes causes early embryonic death, abortion of macerated or mummified fetuses, or birth of lambs with developmental abnormalities. lambs infected in utero that survive until parturition may be born weak and often exhibit a number of congenital defects such as tremor, hirsutism (sometimes darkly pigmented over the shoulders and head), hypothyroidism, central nervous system defects, and joint abnormalities, including arthrogryposis. later, survivors may be more susceptible to diseases and may develop persistent, sometimes fatal, diarrhea. the virus infection produces similar clinical manifestations in goats, except that the hair changes are not seen. diagnosis includes the typical signs described above, as well as serological evidence of viral infection. virus isolation confirms the diagnosis. wide, and reports of disease are sporadic. disease has occurred necropsy findings. lesions include placentitis, and characteristic joint and hair-coat changes in the fetus. histologically, axonal swelling, neuronal vacuolation, dysmyelination, and focal microgliosis are observed in central nervous system structures. pathogenesis. the virus entering the ewe via the gastrointestinal or respiratory tracts penetrates the mucous membranes and causes maternal and fetal viremia. infection during the first 45 days of gestation causes embryonic death. in lambs infected between 45 and 80 days, the virus activates follicular development, diminishes the myelination of neurons, and causes dysfunction of the thyroid gland. infection after 80 days of gestation results in lambs that are born persistently infected. infected lambs have high perinatal mortality; survivors have diminished signs over time but, as noted, continue to shed the virus. prevention and control. border disease can be prevented by vaccinating breeding ewes with killed-bvdv vaccine. congenitally affected lambs should be maintained separately and disposed of as soon as humanely possible. new animals to the flock should be screened serologically. if cattle are housed nearby, vaccination programs for bvdv should be maintained. treatment. there is no treatment other than supportive care for affected animals. etiology. contagious ecthyma, also known as contagious pustular dermatitis, sore mouth, or off, is an acute dermatitis of sheep and goats caused by a parapoxvirus. this disease occurs worldwide and is zoonotic. naturally occurring disease has also been reported in other species such as musk ox and reindeer. other parapoxviruses infect the mucous membranes and skin of cattle, causing the diseases bovine pustular dermatitis and pseudocowpox. clinical signs and diagnosis. the disease is characterized by the presence of papules, vesicles, or pustules and subsequently scabs of the skin of the face, genitals of both sexes, and coronary bands of the feet. lesions develop most frequently at mucocutaneous junctions and are found most commonly at the commissures of the mouth. off is usually found in young animals less than 1 year of age. younger lambs and kids will have difficulty nursing and become weak. lesions may also develop on udders of nursing dams, which may resist suckling by offspring to nurse, leading to secondary mastitis. the scabs may appear nodular and raised above the surface of the surrounding skin. morbidity in a susceptible group of animals may exceed 90%. mortality is low, but the course of the disease may last up to 6 weeks. diagnosis is based on characteristic lesions. biopsies may reveal eosinophilic cytoplasmic inclusions and proliferative lesions under the skin. electron microscopy will reveal the virus itself. disease is confirmed by virus isolation. epizootiology and transmission. all ages of sheep and goats are susceptible. seasonal occurrences immediately after lambing and after entry into a feedlot are common; stress likely plays a role in susceptibility to this viral disease. older animals develop immunity that usually prevents reinfection for at least 1 or more years. resistant animals may be present in some flocks or herds. the virus is very resistant to environmental conditions and may contaminate small-ruminant facilities, pens, feedlots, and the like for many years as the result of scabs that have been shed from infected animals. transmission occurs through superficial lesions such as punctures from grass awns, scrapes, shearing, and other common injuries. necropsy findings. necropsy findings include ballooning degeneration of epidermal and dermal layers, edema, granulomatous inflammation, vesiculation, and cellular hyperplasia. secondary bacterial infection may also be evident. pathogenesis. the virus is typical of the poxviridae, resembling sheep poxvirus (not found in the united states) and vaccinia virus and replicating in the cytoplasm of epithelial cells. following an incubation period of 2-14 days, papules and vesicles develop around the margins of the lips, nostrils, eyelids, gums, tongue, or teats; skin of the genitalia; or coronary band of the feet. the vesicles form pustules that rupture and finally scab over. virus should be considered in both sheep and goats. an important differential in goats is staphylococcal dermatitis. prevention and control. individuals handling infected animals should be advised of precautions beforehand, should wear gloves, and should separate work clothing and other personal protective equipment. clippers, ear tagging devices, and other similar equipment should always be cleaned and disinfected after each use. colostral antibodies may not be protective. vaccinating lambs and kids with commercial vaccine best prevents the disease. dried scabs from previous outbreaks may also be used by rubbing the material into scarified skin on the inner thigh or axilla. animals newly introduced to infected premises should be vaccinated upon arrival. precautions must be taken when vaccinating animals, because the vaccine may induce orf in the animal handlers; it is not recommended to vaccinate animals in flocks already free of the disease. affected dairy goats should be milked last, using disposable towels for cleaning teat ends. treatment. affected animals should be isolated and provided supportive care, especially tube feeding for young animals whose mouths are too sore to nurse. treatment should also address secondary bacterial infections of the orf lesions, including systemic antibiotics for more severe infections. treatment for myiasis may also be necessary. the viral infection is self-limiting, with recovery in about 4 weeks. research complications. carrier animals may be a factor in flock or herd outbreaks. contagious ecthyma is a zoonotic disease, and human-to-human transmission can also occur. the virus typically enters through abrasions on the hands and results in a large (several centimeters) nodule that is described as being extremely painful and lasting for as many as 6 weeks. lesions heal without scarring. etiology. foot-and-mouth disease (fmd) is caused by the foot-and-mouth disease virus, a picornavirus in the aphthovirus genus. the disease is also referred to as aftosa or aphthous fever. seven immunologically distinct types of the virus have been identified, with 60 subtypes within those 7. epidemics of the disease have occurred worldwide. north and central america have been free of the virus since the mid-1950s. this is a reportable disease in the united states; clinical signs are very similar to other vesicular diseases. cattle (and swine) are primarily affected, but disease can occur in sheep and is usually subclinical in goats. clinical signs and diagnosis. in addition to vesicle formation around and in the mouth, hooves, and teats, fever, anorexia, weakness, and salivation occur. vesicles may be as large as 10 cm, rupture after 2 days, and subsequently erode. secondary bacterial infections often occur at the erosions. anorexia is likely due to the pain associated with the oral lesions. high morbidity and low mortality, except for the high mortality in young cattle, are typical. diagnosis must be based on elisa, virus neutralization, fluorescent antibody tests, and complement fixation. epizootiology and transmission. domestic and wild ruminants and several other species, such as swine, rats, bears, and llamas are hosts. asymptomatic goats can serve as virus reservoirs for more susceptible cohoused species such as cattle. greater mortality occurs in younger animals. the united states, great britain, canada, japan, new zealand, and australia are fmd-free, whereas the disease is endemic in most of south america, parts of europe, and throughout asia and africa. the virus is very contagious and is spread primarily by the inhalation of aerosols, which can be carried over long distances. transmission may also occur by fomites, such as shoes, clothing, and equipment. human hands, soiled bedding, and animal products such as frozen or partially cooked meat and meat products, hides, semen, and pasteurized milk also serve as sources of virus. necropsy findings. vesicles, erosions, and ulcers are present in the oral cavity as well as on the rumen pillars and mammary alveolar epithelium. myocardial and skeletal muscle degeneration (zenker's) is most common (and accounts for the greater mortality) in younger animals. histological findings include lack of inclusion bodies. vesicular lesions include intracellular and extracellular edema, cellular degeneration, and separation of the basal epithelium. replicates in the pharynx and digestive tract in the cells of the stratum spinosum, and viremia and spread of virus to many tissues occur before clinical signs develop. virus shedding begins about 24 hr before clinical signs are apparent. vesicles result from the separation of the superficial epithelium from the basal epithelium. fluid fills the basal epithelium, and erosions develop when the epithelium sloughs. persistent infection also occurs, and virus can be found for months or years in the pharnyx; the mechanisms for the persistence are not known. differential diagnosis. vesicular stomatitis is the principal differential. other differentials include contagious ecthyma (orf), rinderpest, bluetongue, malignant catarrhal fever, bovine papular stomatitis, bovine herpes mammillitis, and infectious bovine rhinotracheitis virus infection. products from endemic areas is regulated. quarantine and slaughter are practiced in outbreaks in endemic areas. quarantine and vaccination are also used in endemic areas, but vaccines must be type-specific and repeated 2 or 3 times per year to be effective and will provide only partial protection. autogenous vaccines are best in an outbreak. passive immunity protects calves for up to 5 months after birth. the virus is inactivated by extremes of ph, sunlight, high temperatures, sodium hydroxide, sodium carbonate, and acetic acid. treatment. nursing care and antibiotic therapy to minimize secondary reactions help with recovery. humoral immunity is considered the more important immune mechanism, with cellmediated immunity of less importance. research complications. rare cases in humans have been reported. importation into the united states of animal products from endemic areas is prohibited. etiology. malignant catarrhal fever (mcf) is a severe disease primarily of cattle. the agents of mcf are viruses of the gammaherpesvirinae subfamily. alcelaphine herpesvirus 1 and 2 and ovine herpesvirus 2 are known strains. the alcelaphine strains are seen in africa. the ovine strain is seen in north america. the alcelaphine and ovine strains differ in incubation times and duration of illness. disease may occur sporadically or as outbreaks. clinical signs and diagnosis. signs range from subclinical to recrudescing latent infections to the lethal disease seen in susceptible species, such as cattle. sudden death may also occur in cattle. presentations of the disease may be categorized as alimentary, encephalitis, or skin forms; all three may occur in an animal. corneal edema starting at the limbus and progressing centripetally is a nearly pathognomonic sign; photophobia, severe keratoconjunctivitis, and ocular involvement may follow. other signs include prolonged fever, oral mucosal erosions, salivation, lacrimation, purulent nasal discharge, encephalitis, and pronounced lymphadenopathy. as the disease progresses, cattle may shed horns and hooves. in north america, cattle will also have severe diarrhea. the course of the disease may extend to 1 week. recovery is usually prolonged, and some permanent debilitation may occur. the disease is fatal in severely affected individuals. history of exposure, as well as the clinical signs and lesions, contributes to the diagnosis. serology, pcr-based assays, viral isolation, and cell-culture assays, such as cytopathic effects on thyroid cell cultures, are also used. because of the susceptibility of rabbits, inoculation of this species may be used. in less severe outbreaks or individual animal disease, definitive diagnosis may never be made. necropsy. gross findings at necropsy include necrotic and ulcerated nasal and oral mucosa; thickened, edematous, ulcerated, and hemorrhagic areas of the intestinal tract; swollen, friable, and hemorrhagic lymph nodes and other lymphatic tissues; and erosion of affected mucosal surfaces. lymph nodes should be submitted for histological examination. histological findings include nonsuppurative vasculitis and encephalitis; large numbers of lymphocytes and lymphoblasts will be present without evidence of virus. pathogenesis. the incubation period may be up to 3 months. vascular endothelium and all epithelial surfaces will be affected. the virus is believed to cause proliferation of cytotoxic t lymphocytes with natural killer cell activities, and the resulting lesions are due to an autoimmune type of phenomenon. differential diagnoses. the differentials for this disease are bovine viral diarrhea/mucosal disease, bovine respiratory disease complex, infectious bovine rhinotracheitis, bluetongue, vesicular stomatitis, and foot-and-mouth disease. causes of encephalitis, such as bovine spongiform encephalopathy and rabies, should be considered. in africa, rinderpest is also a differential. other differentials are arsenic toxicity and chlorinated naphthalene toxicity. in north america, sheep, as well as cattle that have been either exposed or that have survived the disease, are reservoirs for outbreaks in other cattle. if there is concern regarding presence of the virus, animals should be screened serologically; once an animal has been infected, it remains infected indefinitely. lambs can be free of the infection if removed from the flock at weaning. the virus is very fragile outside of host's cells and will not survive in the environment for more than a few hours. lobes; and hematological findings indicate anemia and leukocytosis. the rare neurological signs include flexion of fetlock and pastern joints, tremors of facial muscles, progressive paresis and paralysis, depression, and prostration. death occurs in weeks to months. the disease can be serologically diagnosed with agar gel immunodiffusion (agid) tests, virus isolation, serum neutralization, complement fixation, and enzyme-linked immunosorbent assay (elisa) tests. sixty-eight percent of sheep in some states have been infected with the virus (radostits et al., 1994) . it is transmitted horizontally via inhalation of aerosolized virus particles and vertically between the infected dam and fetus. in addition, transmission through the milk or colostrum is considered common (knowles, 1997) . necropsy findings. lesions are observed in lungs, mammary glands, joints, and the brain. pulmonary adhesions, ventral lung lobe consolidation, bronchial lymph node enlargement, mastitis, and degenerative arthritis are visualized grossly. meningeal edema, thickening of the choroid plexus, and foci of leukoencephalomalacia are seen in the central nervous system (cns). histologically, interalveolar septal thickening, lymphoid hyperplasia, histiocyte and fibrocyte proliferation, and squamous epithelial changes are seen in the lungs. meningitis, lymphoid hyperplasia, demyelination, and glial fibrosis are seen in the cns. affected and any exposed animals should be isolated from healthy animals. there is no specific treatment for mcf; supportive treatment may improve recovery rates. corticosteroids may be useful. etiology. an rna virus in the lentivirus group of the retroviridae family causes ovine progressive pneumonia (opp), or maedi/visna. maedi refers to the progressive pneumonia presentation of the disease; visna refers to the central nervous system disease, which is reported predominantly in iceland. visna has been reported in goats but may have been due to caprine arthritis encephalitis infection. clinical signs and diagnosis. opp is a viral disease of adult sheep characterized by weakness, unthriftiness, weight loss, and pneumonia (pepin et al., 1998; de la concha bermejillo, 1997) . clinically, animals exhibit signs of progressive pulmonary disease after an extremely long incubation period of up to 2 years. respiratory rate and dyspnea gradually increase as the disease progresses. the animal continues to eat throughout the disease; however, animals progressively lose weight and become weak. additionally, mastitis is a common clinical feature. thoracic auscultation reveals consolidation of ventral lung pathogenesis. the virus has a predilection for the lungs, mediastinal lymph nodes, udder, spleen, joints, and rarely the brain. after initial infection, the virus integrates into the dna of mature monocytes and persists as a provirus. later in the animal's life, infected monocytes mature as lung (and other tissue) macrophages and establish active infection. the virus induces lymphoproliferative disease, histiocyte and fibrocyte proliferation in the alveolar septa, and squamous metaplasia. pulmonary alveolar and vascular changes impinge on oxygen and carbon dioxide exchange and lead to serious hypoxia and pulmonary hypertension. secondary bacterial pneumonia may contribute to the animal's death. pulmonary adenomatosis is the differ-prevention and control. isolating or removing infected animals can prevent the disease. facilities and equipment should also be disinfected. ii. proliferative stomatitis (bovine papular stomatitis) etiology. a parapoxvirus is the causative agent of bovine papular stomatitis. this virus is considered to be closely related to the parapoxvirus that causes contagious ecthyma and pseudocowpox. it is also a zoonotic disease. the disease is not considered of major consequence, but high morbidity and mortality may be seen in severe outbreaks. in addition, lesions are comparable in appearance to those seen with vesicular stomatitis, bovine viral diarrhea virus, and foot-and-mouth disease. the disease occurs worldwide. clinical signs and diagnosis. raised red papules or erosions or shallow ulcers on the muzzle, nose, oral mucosa (including the hard palate), esophagus, and rumen of younger cattle are the most common findings. in some outbreaks, the papules will be associated with ulcerative esophagitis, salivation, diarrhea, and subsequent weight loss. lesions persist or may come and go over a span of several months. morbidity among herds may be 100%. mortalities are rare. bovine papular stomatitis is associated with "rat tail" in feedlot cattle. animals continue to eat and usually do not show a fever. no lesion is seen on the feet. the infection may also be asymptomatic. diagnosis is based on clinical signs, histological findings, and viral isolation. epizootiology and transmission. cattle less than 1 year of age are most commonly affected, and disease is rare in older cattle. transmission is by animal-to-animal contact. necropsy findings. raised papules may be found around the muzzle and mouth and involve the mucosa of the esophagus and rumen. histologically, epithelial cells will show hydropic degeneration and hyperplasia of the lamina propria. eosinophilic inclusions will be in the cytoplasm of infected epithelial cells. pathogenesis. following exposure to the virus, erythematous macules most commonly appear on the nares, followed by the mouth. these become raised papules within a day, regressing after days to weeks; the lesions that remain will be persistent yellow, red, or brown spots. some infections may recur or persist, with animals showing lesions intermittently or continuously over several months. differential diagnosis. pseudocowpox, vesicular stomatitis, foot-and-mouth disease, and bovine viral diarrhea virus infection are the differentials for this disease. the differential for the "rat tail" clinical sign is sarcocystis infection. there is no vaccine available for bovine papular stomatitis. because of the similarity of this virus to the parapoxvirus of contagious ecthyma, it is important to be aware of the persistence in the environment and susceptibility of younger cattle. vaccination using the local strain, and the skin scarification technique for off, have been protective. handlers should wear gloves and protective clothing. treatment. cattle usually will not require extensive nursing care, but lesions with secondary bacterial infections should be treated with antibiotics. their hands at sites of contact with lesions of cattle. iii. pseudocowpox etiology. pseudocowpox is a worldwide cattle disease caused by a parapoxvirus related to the causative agents of contagious ecthyma and bovine papular stomatitis (see sections iii,a,2,m and iii,a,2,q,ii). lesions are confined to the teats. this is also a zoonotic disease. clinical signs and diagnosis. minor lesions are usually confined to the teats. these are distinctive because of the ring-or horseshoe-shaped scab that develops after 10 days. additional lesions sometimes develop on the udder, the medial aspect of the thighs, and the scrotum. the teat lesions may predispose to mastitis. etiology. pulmonary adenomatosis is a rare but progressive wasting disease of sheep, with worldwide distribution. pulmonary adenomatosis is caused by a type d retrovirus antigenically related to the mason-pfizer monkey virus. jaagsiekte was the designation when the disease was described originally in south africa. progressive respiratory signs such as dyspnea, rapid respiration, and wasting. the disease is diagnosed by these chronic clinical signs and histology. epizootiology and transmission. the disease is transmitted by aerosols. body fluids of viremic animals, such as milk, blood, saliva, tears, semen, and bronchial secretions, will contain the virus or cells carrying the virus. necropsy. the adenomas and adenocarcinomas will be small firm lesions distributed throughout the lungs. the adenocarcinomas metastasize to regional lymph nodes. pathogenesis. as with ovine progressive pneumonia (opp), the incubation period is up to 2 years long. adenocarcinomatous lesions arising from type ii alveolar epithelial cells may be discrete or confluent and involve all lung lobes. with or is a differential diagnosis for opp. etiology. cutaneous papillomatosis is a very common disease in cattle and is much less common among sheep and goats. the disease is a viral-induced proliferation of the epithelium of the neck, face, back, and legs. these tumors are caused by a papillomavirus (dna virus) of the papovaviridae family, and the viruses are host-specific and often body site-specific. most are benign, although some forms in cattle and one form in goats can become malignant. in cattle, the site specificity of the papillomavirus strains are particularly well recognized. designations of the currently recognized bovine papillomavirus (bpv) types are bpv-1 through bpv-5. clinical signs and diagnosis. the papillomas may last up to 12 months and are seen more frequently in younger animals. lesions have typical wart appearances and may be single or multiple, small (1 mm) or very large (500 mm). the infections will generally be benign, but pain will be evident when warts develop on occlusal surfaces or within the gastrointestinal tract. in addition, when infections are severe, weight loss may occur. when warts occur on teats, secondary mastitis may develop. in cattle, bpv-1 and bpv-2 cause fibropapillomas on teats and penises or on head, neck, and dewlap, respectively. bpv-3 causes flat warts that occur in all body locations, b pv-4 causes warts in the gastrointestinal tract, and b pv-5 causes small white warts (called rice-grain warts) on teats. warts caused by bpv-3 and bpv-5 do not regress spontaneously. prognosis in cattle is poor only when papillomatosis involves more than 20% of the body surface. in sheep, warts are the verrucous type. the disease is of little consequence unless the warts develop in an area that causes dis-comfort or incapacitation such as between the digits, on the lips, or over the joints. in adult sheep, warts may transform to squamous cell carcinoma. in goats, the disease is rare, and the warts are also of the verrucous type and occasionally may develop into squamous cell carcinoma. warts on goat udders tend to be persistent. diagnosis is made by observing the typical proliferative lesions. epizootiology and transmission. older animals are less sensitive to papillomatosis than young animals, although immunosupressed animals of any age may develop warts as the result of harbored latent infections. the virus is transmitted by direct and indirect (fomite) contact, entering through surface wounds and sites such as tattoos. pathogenesis. the incubation period ranges from 1 to 6 months. the virus induces epidermal and fibrous tissue proliferation, often described as cauliflower-like skin tumors. the disease is generally self-limiting. differential diagnosis. in sheep and goats, differentials include contagious ecthyma, ulcerative dermatosis, strawberry foot rot, and sheep and goat pox. for cattle) or autogenous vaccines must be used with a recognition that papovavirus strains are host-specific and that immunity from infection or vaccination is viral-type-specific. autogenous vaccines are generally considered more effective. some vaccine preparations are effective at prevention but not treatment of outbreaks. viricidal products are recommended for disinfection of contaminated environments. minimizing cutaneous injuries and sanitizing equipment (tattoo devices, dehorners, ear taggers, etc.) in a virucidal solution between uses are also recommended preventive and control measures. halters, brushes, and other items may also be sources of virus. treatment. warts will often spontaneously resolve as immunity develops. in severe cases or with flockwide or herdwide problems, affected animals should be isolated from nonaffected animals, and premises disinfected. warts can be surgically excised and autogenous vaccines can be made and administered to help prevent disease spread. cryosurgery with liquid nitrogen or dry ice has also proven to be successful for wart removal. topical agents such as podophyllin (various formulations) and dimethyl sulfoxide may be applied to individual lesions once daily until regression. etiology. pseudorabies is an acute encephalitic disease caused by a neurotropic alphaherpesvirus, the porcine herpesvirus 1. one serotype is recognized, but strain differences exist. the disease has worldwide distribution. it is a primarily a clinical dis-ease of cattle, with less frequent reports (but no less severe clinical manifestations) in sheep and goats. during the rapid course of this usually fatal disease. at the site of virus inoculation or in other locations, abrasions, swelling, intense pruritus, and alopecia are seen. pruritus will not be asymmetric. animals will also become hyperthermic and will vocalize frantically. other neurological signs range from hoof stamping, kicking at the pruritic area, salivation, tongue chewing, head pressing and circling, to paresthesia or hyperesthesia, ataxia, and conscious proprioceptive deficits. nystagmus and strabismus are also seen. animals will be fearful or depressed, and aggression is sometimes seen. recumbency and coma precede death. diagnostic evidence includes clinical findings; virus isolation from nasal or pharyngeal secretions or postmortem tissues; and histological findings at necropsy. serology of affected animals is not productive, because of the rapid course. if swine are housed nearby, or if swine were transported in the same vehicles as affected animals, serological evaluations are worthwhile from those animals. epizootiology and transmission. swine are the primary hosts for pseudorabies virus, but they are usually asymptomatic and serve as reservoirs for the virus. the infection can remain latent in the trigeminal ganglion of pigs and recrudesce during stressful conditions. other animals are dead-end hosts. the unprotected virus will survive only a few weeks in the environment but may remain viable in meat (including carcasses) or saliva and will survive outside the host, in favorable conditions, in the summer for several weeks and the winter for several months. transmission is by oral, intranasal, intradermal, or subcutaneous introduction of the virus. when the virus is inhaled, the clinical signs of pruritus are less likely to be seen. transmission can also be by inadvertent exposure (e.g., contaminated syringes) of ruminants to the modified live vaccines developed for use in swine. spread between infected ruminants is a less likely means of transmission, because of the relatively short period of virus shedding. transport vehicles used for swine may also be sources of the virus. raccoons are believed to be vectors of the virus. horses are resistant to infection. there is no pathognomonic gross lesion. definitive histologic findings include severe, focal, nonsuppurative encephalitis and myelitis. eosinophilic intranuclear inclusion bodies (cowdry type a) may be present in some affected neurons. methods such as immunofluorescence and immunoperoxidase staining can be used to show presence of the porcine herpesvirus 1. pathogenesis. the incubation period is 90-156 hr and duration of the illness is 8-72 hr. the longest duration is seen in animals with pruritus around the head. differential diagnoses. differentials for the neurologic signs of pseudorabies infection include rabies, polioencephalomalacia, salt poisoning, meningitis, lead poisoning, hypomagnesemia, and enterotoxemia. those for the intense pruritus include psoroptic mange and scrapie in sheep, sarcoptic mange, and pediculosis. prevention and control. pseudorabies is a reportable disease in the united states, where a nationwide eradication program exists; states are rated regarding status. effective disinfectants include sodium hypochlorite (10% solution), formalin, peracetic acid, tamed iodines, and quaternary ammonium compounds. five minutes of contact time is required, and then surfaces must be rinsed. other disinfectant methods for viral killing include 6 hr of formaldehyde fumigation, or 360 min of ultraviolet light. transport vehicles should be cleaned and disinfected between species. serological screening for pseudorabies of swine housed near ruminants is essential. there is no treatment, and most affected ani-research complications. swine housed close to research ruminants should be serologically screened prior to purchase, and all transport vehicles should be cleaned and disinfected between loads of large animals. humans have been reported to seroconvert. the porcine herpesvirus 1 shares antigens with the infectious bovine rhinotracheitis virus. etiology. rabies is a sporadic but fatal, acute viral disease affecting the central nervous system. the rabies virus is a neurotropic rna virus of the lyssavirus genus and the rhabdoviridae family. sheep, goats, and cattle are susceptible. the zoonotic potential of this virus must be kept in mind at all times when handling moribund animals with neurological signs characteristic of the disease. rabies is endemic in many areas of the world and within areas of the unites states. this is a reportable disease in north america. clinical findings and diagnosis. animals generally progress through three phases: prodromal, excitatory, and paralytic. many signs in the different species during these stages are nonspecific, and forms of the disease are also referred to as dumb or furious. during the short prodromal phase, animals are hyperthermic and apprehensive. animals progress to the excitatory phase, during which they refuse to eat or drink and are active and aggressive. repeated vocalizations, tenesmus, sexual excitement, and salivation occur during this phase. the final paralytic stage, with recumbency and death, occurs over several hours to days. this paralytic stage is common in cattle, and animals may simply be found dead. the clinical course is usually 1-4 days. diagnosis is based on clinical signs, with a progressive and fatal course. confirmation presently is made with the fluorescent antibody technique on brain tissue. epizootiology and transmission. the rabies virus is transmitted via a bite wound inflicted by a rabid animal. cats, dogs, raccoons, skunks, foxes, wild canids, and bats are the common disease vectors in north america. virus is also transmitted in milk and aerosols. necropsy findings. few lesions are seen at necropsy. many secondary lesions from manic behaviors during the course of disease may be evident. histological findings will include nonsuppurative encephalitis. negri bodies in the cytoplasm of neurons of the hippocampus and in purkinje's cells are pathognomonic histologic findings. pathogenesis. after exposure, the incubation period is variable, from 2 weeks to several months, depending on the distance that the virus has to travel to reach the central nervous system. the rabies virus proliferates locally, gains access to neurons by attaching to acetylcholine receptors, via a viral surface glycoprotein, migrates along sensory nerves to the spinal cord and brain, and then descends via cranial nerves (trigeminal, facial, olfactory, glossopharyngeal) to oral and nasal cavity structures (i.e., salivary glands). the fatal outcome is currently believed to be multifactorial, related to anorexia, respiratory paralysis, and effects on the pituitary. differential diagnosis. rabies should be included on the differential list when clinical signs of neurologic disease are evident. other differentials for ruminants include herpesvirus encephalitis, thromboemobolic meningoencephalitis, nervous ketosis, grass tetany, and nervous cocciodiosis. prevention and control. vaccines approved for use cattle and sheep are commercially available and contain inactivated virus; there is not one available in the united states for goats. ruminants in endemic areas, such as the east coast of the united states, should be routinely vaccinated. any animals housed outside that may be exposed to rabid animals should be vaccinated. vaccination programs generally begin at 3 months of age, with a booster at 1 year of age and then annual or triennial boosters. awareness of the current rabies case reports for the region and wildlife reservoirs, however, is important. monitoring for and exclusion of wildlife from large-animal facilities are worthwhile preventive measures. the virus is fragile and unstable outside of a host animal. research complications. aerosolized virus is infective. personal protective equipment, including gloves, face mask, and eye shields, must be worn by individuals handling animals that are manifesting neurological disease signs. bovine spongiform encephalopathy, a transmissible spongiform encephalopathy (tse), is not known to occur in the united states, where since 1989 it has been listed as a reportable disease. the profound impact of this disease on the cattle industry in great britain during the past two decades is well known. the disease may be caused by a scrapielike (prion) agent. it is believed that the source of infection for cattle was feedstuff derived from sheep meat and bonemeal that had been inadequately treated during processing. the incubation period of years, the lack of detectable host immune response, the debilitating and progressive neurological illness, and the pathology localized to the central nervous system are characteristics of the disease, and are is comparable to the characteristics of other tse diseases such as scrapie, which affects sheep and goats. in addition, the infectious agent is extremely resistant to dessication and disinfectants. confirmation of disease is by histological examination of brain tissue collected at necropsy; the vacuolation that occurs during the disease will be symmetrical and in the gray matter of the brain stem. molecular biology techniques, such as western blots and immunohistochemistry, may also be used to identify the presence of the prion protein. differentials include many infectious or toxic agents that affect the bovine nervous and musculoskeletal systems, such as rabies, listeriosis, and lead poisoning. metabolic disorders such as ketosis, milk fever, and grass tetany are also differentials. there is no vaccine or treatment. prevention focuses on import regulations and not feeding ruminant protein to ruminants; recent usda regulations prohibit feeding any mammalian proteins to ruminants. etiology. scrapie is a sporadic, slow, neurodegenerative disease caused by a prion. scrapie is a reportable disease. it is much more common in sheep than in goats. the disease is similar to transmissible mink encephalopathy, kuru, creutzfeldt-jakob disease, and bovine spongiform encephalopathy (mad cow disease). prions are nonantigenic, replicating protein agents. clinical signs and diagnosis. during early clinical stages, animals are excitable and hard to control. tremors of head and neck muscles, as well as uncoordinated movements and unusual "bunny-hopping" gaits are observed. in advanced stages of the disease, animals experience severe pruritus and will self-mutilate while rubbing on fences, trees, and other objects. blindness and abortion may also be seen. morbidity may reach 50% within a flock. most animals invariably die within 4-6 weeks; some animals may survive 6 months. in goats, the disease is also fatal. pruritus is generally less severe but may be localized. a wide range of clinical signs have also been noted in goats, including listlessness, stiffness or restlessness, or behavioral changes such as irritability, hunched posture, twitching, and erect tail and ears. as with sheep, the disease gradually progresses to anorexia and debilitation. diagnosis can be made by clinical signs and histopathological lesions. a newer diagnostic test in live animals is based on sampling from the third eyelid. tests for genetic resistance or susceptibility require a tube of edta blood and are reasonably priced. epizootiology and transmission. the suffolk breed of sheep tends to be especially susceptible. scrapie has also been reported in several other breeds, including cheviot, dorset, hampshire, corriedale, shropshire, merino, and rambouillet. it is believed that there is hereditary susceptibility in these breeds. targhees tend to be resistant. genomic research indicates there are two chromosomsal sites governing this trait; these sites are referred to codons 171 (q, r, or h genes can be present) and 136 (a or v genes can be present). of the five genes, r genes appear to confer immunity to clinical scrapie in suffolks in the united states. affected suffolks in the united states that have been tested have been aa qq. the disease is also enzootic is many other countries. the disease tends to affect newborns and young animals; however, because the incubation period tends to range from 2 to 5 years, adult animals display signs of the disease. scrapie is transmitted horizontally by direct or indirect contact; nasal secretions or placentas serve as sources of the infectious agent. vertical transmission is questioned, and transplacental transmission is considered unlikely. necropsy findings. at necropsy, no gross lesion is observed. histopathologically, neuronal vacuolization, astrogliosis, and spongiform degeneration are visualized in the brain stem, the spinal cord, and especially the thalamus. inflammatory lesions are not seen. pathogenesis. replication of the prions probably occurs first in lymphoid tissues throughout the host's body and then progresses to neural tissue. differential diagnosis. in sheep and goats, depending on the speed of onset, differentials for the pruritus include ectoparasites, pseudorabies, and photosensitization. prevention and control. if the disease diagnosed in a flock, quarantine and slaughter, followed by strict sanitation, are usually required. the u.s. department of agriculture has approved the use of 2% sodium hydroxide as the only disinfectant for sanitation of scrapie-infected premises. prions are highly resistant to physicochemical means of disinfection. artificial insemination or embryo transfer has been shown to decrease the spread of scrapie (linnabary et al., 1991) . research complications. as noted, this is a reportable disease. stringent regulations exist in the united states regarding importation of small ruminants from scrapie-infected countries. etiology. vesicular stomatitis (vs) is caused by the vesicular stomatitis virus (vsv), a member of the rhabdoviridae. three serotypes are recognized: new jersey, indiana, and isfahan. the new jersey and indiana strains cause sporadic disease in cattle in the united states. the disease is rare in sheep. clinical signs and diagnosis. adult cattle are most likely to develop vs. fever and development of vesicles on the oral mucous membranes are the initial clinical signs. lesions on the teats and interdigital spaces also develop. the vesicles progress quickly to ulcers and erosions. the animal's tongue may be severely involved. anorexia and salivation are common. weight loss and decreased milk production are noticeable. morbidity will be high in an outbreak, but mortality will be low to nonexistent. diagnostic work should be initiated as soon as possible to distinguish this from foot-and-mouth disease. diagnosis is based on analysis of fluid, serum, or membranes associated with the vesicles. virus isolation, enzyme-linked immunosorbent assay (elisa), competitive elisa (celisa), complement fixation, and serum neutralization are used for diagnosis. epizootiology and transmission. this disease occurs in several other mammalian species, including swine, horses, and wild ruminants. vsv is an enveloped virus and survives well in different environmental conditions, including in soil, extremes of ph, and low temperatures. outbreaks of vs occur sporadically in the united states, but it is not understood how or in what species the virus survives between these outbreaks. incidence of disease decreases during colder seasons. equipment, such as milking machines, contaminated by secretions is a mechanical vector, as are human hands. transmission may also be from contaminated water and feed. transmission is also believed to occur by insects (blackflies, sand flies, and culicoides) that may simply be mechanical vectors. it is believed that carrier animals do not occur in this disease. necropsy. it is rare for animals to be necropsied as the result of this disease. typical vesicular lesion histology is seen, with ballooning degeneration and edema. there is no inclusion body formation. pathogenesis. lesions often begin within 24 hr after exposure. the virus invades oral epithelium. injuries or trauma in any area typically affected, such as mouth, teats, or interdigital areas, will increase the likelihood of lesions developing there. animals will develop a long-term immunity; this immunity can be overwhelmed, however, by a large dose of the virus. differential diagnosis. foot-and-mouth disease lesions are identical to vs lesions. other differentials in cattle include bovine viral diarrhea, malignant catarrhal fever, contagious ecthyma, photosensitization, trauma, and caustic agents. prevention and control. quarantine and restrictions on shipping infected animals or animals from the premises housing affected animals are required in an outbreak. vaccines are available for use in outbreaks and have decreased the severity of lesions. phenolics, quaternaries, and halogens are effective for inactivating and disinfecting equipment and facilities. treatment. affected animals should be segregated from the rest of the herd and provided with separate water and softened feed. these animals should be cared for after unaffected animals. any feed or water contaminated by these animals should not be used for other animals; contaminated equipment should be disinfected. topical or systemic antibiotics control secondary bacterial infections. cases of mastitis secondary to teat lesions must be treated as necessary. any abrasive materials that could cause further trauma to the animals should be removed. research complications. animals developing vesicular lesions must be reported promptly to eliminate the possibility of an outbreak of foot-and-mouth disease. personal protective equipment, especially gloves, should be worn when handling any animals with vesicular lesions. vsv causes a flulike illness in humans. x. viral diarrhea diseases i. ovine. rotavirus, of the family reoviridae, induces an acute, transient diarrhea in lambs within the first few weeks of life. four antigenic groups (a-d) have been identified by differences in capsid antigens vp3 and vp7. primarily group a, but also groups b and c, have been isolated from sheep. the disease is characterized by yellow, semifluid to watery diarrhea occurring 1-4 days after infection. the disease can progress to dehydration, anorexia and weight loss, acidosis, depression, and occasionally death. the virus is ingested with contaminated feed and water and selectively infects and destroys the enterocytes at the tips of the small intestinal villi. the villi are replaced with immature cells that lack sufficient digestive enzymes; osmotic diarrhea results. virus may remain in the environment for several months. the disease is diagnosed by virus isolation, electron microscopy of feces, fecal fluorescent antibody, fecal elisa tests (marketed tests generally detect group a rotavirus), and fecal latex agglutination tests. rotavirus diarrhea is treated by supportive therapy, including maintaining hydration, electrolyte, and acid-base balance. a rotavirus vaccine is available for cattle; because of cross-species immunity, oral administration of high-quality bovine colostrum from vaccinated cows to infected sheep may be helpful ("current veterinary therapy," 1993). coronavirus, of the family coronaviridae, produces a more severe, long-lasting disease when compared with rotavirus. clinical signs are similar to above, although the incubation period tends to be shorter (20-36 hr), and animals exhibit less anorexia than those with rotavirus. additionally, mild respiratory disease may be noted (janke, 1989) . like rotavirus, coronavirus also destroys enterocytes of the villus tips. the virus can be visualized with electron microscopy. treatment is supportive; close consideration of hydration and acid-base status is essential. bovine vaccines are available. ii. caprine. rotavirus, coronavirus, and adenoviruses affect neonatal goats; however, little has been documented on the pathology and significance of these agents in this age group. it appears that bacteria play a more important role in neonatal kid diarrheal diseases then in neonatal calf diarrheas. iii. bovine. rotaviruses, coronaviruses, parvoviruses, and bovine viral diarrhea virus (bvdv) are associated with diarrheal disease in calves. each pathogen multiplies within and destroys the intestinal epithelial cells, resulting in villous atrophy and clinical signs of diarrhea (soft to watery feces), dehydration, and abdominal pain. these viral infections may be complicated by parasitic infections (e.g., cryptosporidium, eimeria) or bacterial infections (e.g., escherichia coli, salmonella, campylobacter). treatment is aimed at correcting dehydration, electrolyte imbalances, and acidosis; cessation of milk replacers and administration of fluid therapy intravenously and by stomach tube may be necessary, depending on the presence of suckle reflex and the condition of the animals. diagnosis is by immunoassays available for some viruses, viral culture, exclusion or identification of presence of other pathogens (by culture or fecal exams), and microscopic examination of necropsy specimens. prevention focuses on calves suckling good-quality colostrum; other recommendations for calf care are in section ii,b,5. combination vaccine products are available for immunizing dams against rotavirus, coronavirus, and enterotoxigenic e. coli. additional supportive care for calves includes providing calves with sufficient energy and vitamins until milk intake can resume. rotaviruses of serogroup a are the most common type in neonatal calves; 4-to 14-day old calves are typically affected, but younger and older animals may also be affected. the small intestine is the site of infection. antirotavirus antibody is present in colostrum, and onset of rotavirus diarrhea coincides with the decline of this local protection. transmission is likely from other affected calves and asymptomatic adult carriers. the diarrhea is typically a distinctive yellow. colitis with tenesmus, mucus, and blood may be seen. this virus may be zoonotic. coronaviruses are commonly associated with disease in calves during the first month of life, and they infect small-and large-intestinal epithelial cells. the virus infection may extend to mild pneumonia. transmission is by infected calves and also by asymptomatic adult cattle, including dams excreting virus at the time of parturition. calves that appear to have recovered continue to shed virus for several weeks. parvovirus infections are usually associated with neonatal calves. b vdv infections also are seen in neonates and also affect many systems and produce other clinical signs and syndromes that are described in section iii,a,2,e. iv. winter dysentery. winter dysentery is an acute, winterseasonal, epizootic diarrheal disease of adult cattle, although it has been reported in 4-month-old calves. the etiology has not yet been defined, but a viral pathogen is suspected. coronavirus-like viral particles have been isolated from cattle feces, either the same as or similar to the coronavirus of calf diarrhea. outbreaks typically last a few weeks, and first-lactation or younger cattle are affected first, with waves of illness moving through a herd. individual cows are ill for only a few days. the incubation period is estimated at 2-8 days. the outbreaks of disease are often seen in herds throughout the local area. clinical signs include explosive diarrhea, anorexia, depression, and decreased production. the diarrhea has a distinctive musty, sweet odor and is light brown and bubbly, but some blood streaks or clots may be mixed in with the feces. animals will become dehydrated quickly but are thirsty. respiratory symptoms such as nasolacrimal discharges and coughing may develop. recovery is generally spontaneous. mortalities are rare. diagnosis is based on characteristic patterns of clinical signs, and elimination of diarrheas caused by parasites such as coccidia, bacterial organisms such as salmonella or mycobacterium paratuberculosis, and viruses such as b vdv. pathology is present in the colonic mucosa, and necrosis is present in the crypts. etiology. chlamydia psittaci is a nonmotile, obligate, intracytoplasmic, gram-negative bacterium. clinical signs. enzootic abortion in sheep and goats is a contagious disease characterized by hyperthermia and late abortion or by birth of stillborn or weak lambs or kids (rodolakis et al., 1998) . the only presenting clinical sign may be serosanguineous vulvar discharges. other animals may present with arthritis or pneumonia. infection of animals prior to about 120 days of gestation results in abortion, stillbirths, or birth of weak lambs. infection after 120 days results in potentially normal births, but the dams or offspring may be latently infected. latently infected animals that were infected during their dry period may abort during the next pregnancy. ewes or does generally only abort once, and thus recovered animals will be immune to future infections. and specific antigens associated with the cell surface. the group antigen is common among all chlamydia; the specific antigen is common to related subgroups. two subgroups are recognized, one that causes eae and one that causes polyarthritis and conjunctivitis. the disease is transmitted by direct contact with infectious secretions such as placental, fetal, and uterine fluids or by indirect contact with contaminated feed and water. necropsy. placental lesions include intercotyledonary plaques and necrosis and cotyledonary hemorrhages. histopathological evidence of leukocytic infiltration, edema, and necrosis is found throughout the placentome. fetal lesions include giant-cell accumulation in mesenteric lymph nodes and lymphohistiocytic proliferations around the blood vessels within the liver. diagnosis is based on clinical signs and laboratory (serological or histopathological) identification of the organism. impression smears in placental tissues stained with giemsa, gimenez, or modified ziehl-neelsen can provide preliminary indications of the causative agent. immunofluorescence, enzyme-linked immunosorbent assay (elisa), and polymerase chain reaction (pcr) methods also aid in diagnosis. differential diagnosis. q fever will be the major differential for late-term abortion and necrotizing placentitis. campylobacter and toxoplasma should also be considered for late-term abortion. treatment. animals may respond to treatment with oxytetracycline. abortions are prevented through administration of a commercial vaccine, but the vaccine will not eliminate infections. this is a sheep vaccine and should be administered before breeding and annually to at least the young females entering the breeding herd or flock. research complications. in addition to losses or compromise of research animals, pregnant women should not handle aborted tissues. etiology. chlamydia psittaci is a nonmotile, obligate intracellular, gram-negative bacterium. chlamydial polyarthritis is an acute, contagious disease characterized by fever, lameness (bulgin, 1986) , and conjunctivitis (see section iii,a,3,c) in growing and nursing lambs. clinical signs. clinically, animals will appear lame on one or all legs and in major joints, including the scapulohumeral, humeroradioulnar, coxofemoral, femorotibial, and tibiotarsal joints. lambs may be anorexic and febrile. animals frequently also exhibit concurrent conjunctivitis. the disease usually resolves in approximately 4 weeks. joint inflammation usually resolves without causing chronic articular changes. epizootiology and transmission. the disease is transmitted to susceptible animals by direct contact as well as by contaminated feed and water. the organism penetrates the gastrointestinal tract and migrates to joints and synovial membranes as well as to the conjunctiva. the organism causes acute inflammation and associated fibrinopurulent exudates. necropsy findings. lesions are found in joints, tendon sheaths, conjunctiva, and lungs. pathological sites will be edematous and hyperemic, with fibrinous exudates but without articular changes. lesions will be infiltrated with mononuclear cells. lung lesions include atelectasis and alveolar inspissation. diagnosis is based on clinical signs. synovial taps and subsequent smears may allow the identification of chlamydial inclusion bodies. treatment. animals respond to treatment with parenteral oxytetracycline. etiology. chlamydia psittaci, a nonmotile, obligate intracellular, gram-negative bacterium, is the most common cause of infectious keratoconjunctivitis in sheep. chlamydia and mycoplasma are considered to be the most common causes of this disease in goats. chlamydial conjunctivitis is not a disease of cattle. clinical signs. infectious keratoconjunctivitis is an acute, contagious disease characterized in earlier stages by conjunctival hyperemia, epiphora, and edema and in later stages by, corneal edema, ulceration, and opacity. perforation may result from the ulceration. animals will be photophobic. in less severe cases, corneal healing associated with fibrosis and neovascularization occurs in 3-4 days. lymphoid tissues associated with the conjunctiva and nictitating membrane may enlarge and prolapse the eyelids. morbidity may reach 80-90%. bilateral and symmetrical infections characterize most outbreaks. relapses may occur. other concurrent systemic infections may be seen, such as polyarthritis or abortion in sheep and polyarthritis, mastitis, and uterine infections in goats. epizootiology and transmission. direct contact, and mechanical vectors such as flies easily spread the organism. necropsy. if the chlamydial or mycoplasmal agents are suspected, diagnostic laboratories should be contacted for recommendations regarding sampling. conjunctival smears are also useful. pathogenesis. the pathogen penetrates the conjunctival epithelium and replicates in the cytoplasm by forming initial and elementary bodies. the infection moves from cell to cell and causes an acute inflammation and resultant purulent exudate. the chlamydial organism may penetrate the bloodstream and migrate to the opposite eye or joints, leading to arthritis. diagnosis is suggested by the clinical signs. cytoplasmic inclusions observed on conjunctival scrapings and immunofluorescent techniques help confirm the diagnosis. differential diagnosis. nonchlamydial keratoconjunctivitis also occurs in sheep and goats. the primary agents involved include mycoplasma conjunctiva, m. agalactiae in goats, and branhamella (neisseria) ovis. a less common differential for sheep and cattle is listeria monocytogenes. other differentials include eye worms, trauma, and foreign bodies such as windblown materials (pollen, dust) and poor-quality hay; these latter irritants and stress may predispose the animals' eyes to the infectious agents. should be minimized whenever possible. quarantine of new animals and treatment, if necessary, before introduction into the flock or herd are important measures. shade should be provided for all animals. treatment. the infections can be self-limiting in 2-3 weeks without treatment. treatment consists of topical application of tetracycline ophthalmic ointments. systemic or oral oxytetracycline treatments have been used with the topical treatment. atropine may be added to the treatment regimen when uveitis is present. shade should be provided. a. protozoa i. anaplasmosis etiology. anaplasmosis is an infectious, hemolytic, noncontagious, transmissible disease of cattle caused by the protozoan anaplasma marginale. anaplasma is a member of the anaplasmatacae family within the order rickettsiales. in sheep and goats, the disease is caused by a. ovis and is an uncommon cause of hemolytic disease. anaplasmosis has not been reported in goats in the united states. some controversy exists regarding the classification. most recently it is classified as a protozoal disease because of similarities to babesiosis. it has also been classified as a rickettsial pathogen. this summary addresses the disease in cattle with limited reference to a. ovis infections, but there are many similarities to the disease in cattle. clinical signs and diagnosis. acute anemia is the predominant sign in anaplasmosis, and fever coincides with parasitemia. weakness, pallor, lethargy, dehydration, and anorexia are the result of the anemia. four disease stagesnincubation, developmental, convalescent, and carriermare recognized. the incubation stage may be long, 3-8 weeks, and is characterized by a rise in body temperature as the infection moves to the next stage. most clinical signs occur during the 4-to 9-day developmental stage, with hemolytic anemia being common. death is most likely to occur at this stage or at the beginning of the convalescent stage. death may also occur from anoxia, because of the animal's inability to handle any exertion or stress, especially if treatment is initiated when severe anemia exists. reticulocytosis characterizes the convalescent stage, which may continue for many weeks. morbidity is high, and mortality is low. the carrier stage is defined as the time in the convalescent stage when the animal host becomes a reservoir of the disease, and anaplasma organisms and any parasitemia are not discernible. common serologic tests are the complement fixation test and the rapid card test. these become positive after the incubation phase and do not distinguish between the later three stages of disease. definitive diagnosis is made by clinical and necropsy findings. staining of thin blood smears with wright's or giemsa stain allows detection of basophilic, spherical a. marginale bodies near the red blood cell peripheries. evidence will most likely be found before a hemolytic episode. a negative finding should not eliminate the pathogen from consideration. epizootiology and transmission. the disease is common in cattle in the southern and western united states. anaplasma organisms are spread biologically or mechanically. mechanical transmission occurs when infected red blood cells are passed from one host to another on the mouthparts of seasonal biting flies. sometimes mosquitoes or instruments such as dehorners or hypodermic needles may facilitate transfer of infected red cells from one animal to another. biological transmission occurs when the tick stage of the organism is passed by dermacentor andersoni and d. occidentalis ticks. the carrier stage covers the time when discernible anaplasma organisms can be found on host blood smears. recovered animals serve as immune carriers and disease reservoirs. necropsy. pale tissues and watery, thin blood are typical findings. splenomegaly, hepatomegaly, and gallbladder distension are common findings. pathogenesis. the parasites infect the host's red blood cells, and acute hemolysis occurs during the parasites' developmental stage. the four stages of the parasite's life cycle are described above because these are closely linked to the clinical stages. differential diagnosis. the clinical disease closely resembles the protozoal disease babesiosis. whole organism) programs are not entirely effective, and vaccine should not be administered to pregnant cows. neonatal isoerythrolysis may occur because of the antierythrocyte antibodies stimulated by one vaccine product. vaccinated animals can still become infected and become carriers. the cattle vaccine has shown no efficacy in smaller ruminants, and there is no a. ovis vaccine. identifying carriers serologically and treating with tetracycline during and/or after vector seasons may be an option. removing carriers to a separate herd is also an approach. interstate movement of infected animals is regulated. treatment. oxytetracycline, administered once, helps reduce the severity of the infection during the developmental stage. other tetracycline treatment programs have been described to help control carriers. ii. babesiosis (red water, texas cattle fever, cattle tick fever) etiology. babesia bovis and ba. bigemina are protozoa that cause subclinical infections or disease in cattle. these are intraerythrocytic parasites. babesia bovis is regarded as the more virulent of the two organisms. this disease is not seen in the smaller ruminants in the united states. clinical signs and diagnosis. the more common presentation is liver and kidney failure due to hemolysis with icterus, hemoglobinuria, and fever. hemoglobinuria indicates a poor prognosis. acute encephalitis is a less common presentation and begins acutely with fever, ataxia, depression, deficits in conscious proprioception, mania, convulsions, and coma. the encephalitic form generally also has a poor prognosis. sudden death may occur. thin blood smears stained with giemsa will show babesia trophozoites at some stages of the disease, but lack of these cannot be interpreted as a negative. the trophozoites occur in a variety of shapes, such as piriform, round, or rod. complement fixation, immunofluorescent antibody, and enzyme immunoassay are the most favored of the available serologic tests. babesiosis is present on several continents, including the americas. in addition to domestic cattle, some wild ruminants, such as white-tailed deer and american buffalo, are also susceptible. bos indicus breeds have resistance to the disease and the tick vectors. innate resistance factors have been found in all calves. if infected, these animals will not show many signs of disease during the first year of life and will become carriers. stress can cause disease development. prevention and control. offspring of immune carriers resist infection up to 6 months of age because of passive immunity. vector control and attention to hygiene are essential, such as between-animal rinsing in disinfectant of mechanical vectors such as dehorners. there is no entirely effective means, however, to prevent and control the disease. vaccination (killed necropsy findings. signs of acute hemolytic crisis are the most common findings, including hepatomegaly, splenomegaly, dark and distended gallbladder, pale tissues, thin blood, scattered hemorrhages, and petechiation. animals dying after a longer course of disease will be emaciated and icteric, with thin blood, pale kidneys, and enlarged liver. pathogenesis. the protozoon is transmitted by the cattle fever ticks boophilus annulatus, b. microplus, and b. decoloratus; these one-host ticks acquire the protozoon from infected animals. it is passed transovarially, and both nymph and adult ticks may transmit to other cattle. only b. ovis is transmitted by the larval stage. clinical signs develop about 2 weeks after tick infestations or mechanical transmission but may develop sooner with the mechanical transmission. hemolysis is due to intracellular reproduction of the parasites and occurs intra-and extravascularly. in addition to the release of merozoites, proteolytic enzymes are also released, and these contribute to the clinical metabolic acidosis and anoxia. the development of the encephalitis form is believed to be the result of direct invasion of the central nervous system, disseminated intravascular coagulation, capillary thrombosis by the parasites and infarction, and/or tissue anoxia. differential diagnosis. in addition to anaplasmosis, other differentials for the hemolytic form of the disease are leptospirosis, chronic copper toxicity, and bacillary hemoglobinuria. several differentials in the united states for the encephalitic presentation include rabies, nervous system coccidiosis, polioencephalomalacia, lead poisoning, infectious bovine rhinotracheitis, salt poisoning, and chlorinated hydrocarbon toxicity. prevention and control. control or eradication of ticks and cleaning of equipment to prevent mechanical transmission, as noted in section iii,a,3,a,i, are important preventive measures. some vaccination approaches have been effective, but a commercial product is not available. treatment. supportive care is indicated, including blood transfusions, fluids, and antibiotics. medications such as diminazene diaceturate, phenamidine diisethionate, imidocarb diprionate, or amicarbalide diisethionate are most commonly used. treatment outcomes will be either elimination of the parasite or development of a chronic carrier state immune to further disease. research complications. this is a reportable disease in the united states. iii. coccidiosis etiology. coccidiosis is an important acute and chronic protozoal disease of ruminants. in young ruminants, it is characterized primarily by hemorrhagic diarrhea. adult ruminants may carry and shed the protozoa, but they rarely display clinical signs. intensive rearing and housing conditions and stress increase the severity of the disease in all age groups. coccidia are protozoal organisms of the phylum apicomplexa, members of which are obligatory intracellular parasites. there are at least 11 reported species of coccidia in sheep, of which several are considered pathogenic: eimeria ashata, e. crandallis, and e. ovinoidalis (schillhorn van veen, 1986). at least 9 species of eimeria have been recognized in the goat (foreyt, 1990) . eimeria ninakohlyakimovae, e. arloingi, and e. christenseni are regarded as the most pathogenic. eimeria bovis and e. zuernii (highly pathogenic), and e. auburnensis and e. alabamensis (moderately pathogenic), are among the 13 species known to infect cattle. eimeria zuernii is more commonly seen in older cattle and is the agent of "winter coccidiosis." clinical signs and diagnosis. hemorrhagic diarrhea develops 10 days to 3 weeks after infection. fecal staining of the tail and perineum will be present. animals will frequently display tenesmus; rectal prolapses may also develop. anorexia, weight loss, dehydration, anemia, fever (infrequently), depression, and weakness may also be seen in all ruminants. the diarrhea is watery and malodorous and will contain variable amounts of blood and fibrinous, necrotic tissues. the intestinal hemorrhage may subsequently lead to anemia and hypoproteinemia. depending on the predilection of the coccidial species for small and/or large intestines, malabsorption of nutrients or water may occur, and electrolyte imbalances may be severe. concurrent disease with other enteropathogens may also be part of the clinical picture. in sheep, secondary bacterial infection with organisms such as fusobacterium necrophorum may ensue. young goats may die peracutely or suffer severe anemia from blood loss into the bowel. older goats may lose the pelleted form of feces. cattle may have explosive diarrhea and develop anal paralysis. the disease is usually diagnosed by history and clinical signs. numerous oocysts will frequently be observed in fresh fecal flotation (salt or sugar solution) samples as the diarrhea begins. laboratory results are usually reported as number of oocysts per gram of feces. coccidia seen on routine fecal evaluations reflect shedding, possibly of nonpathogenic species, without necessarily being indicative of impending or resolving mild disease. epkzootiology and transmission. as noted, coccidiosis is a common disease in young ruminants. in goats, young animals aged 3 weeks to 5 months are primarily affected, but isolated outbreaks in adults may occur after stressful conditions such as transportation or diet changes. coccidia are host-specific and also host cell-specific. the disease is transmitted via ingestion of sporulated oocysts. coccidial oocysts remain viable for long periods of time when in moist, shady conditions. necropsy. necropsies provide information on specific locations and severity of lesions that correlate with the species involved. ileitis, typhlitis, and colitis with associated necrosis and hemorrhage will be observed. mucosal scrapings will frequently yield oocysts. various coccidial stages associated with schizogony or gametogony may be observed in histopathological sections of the intestines. fibrin and cellular infiltrates will be found in the lamina propria. pathogenesis. this parasite has a complex life cycle in which sexual and asexual reproduction occurs in gastrointestinal enterocytes (speer, 1996) . the severity of the disease is correlated primarily with the number of ingested oocysts. specifics of life cycles vary with the species, and those characteristics contribute to the pathogenicity. in most cases, the disease is well established by the time clinical signs are seen. oocysts must undergo sporulation over a 3-to 10-day period in the environment. after ingestion of the sporulated oocysts, sporozoites are released and penetrate the intestinal mucosa and form schizonts. schizonts initially undergo replication by fission to form merozoites and eventually undergo sexual reproduction, forming new oocysts. the organisms cause edema and hyperemia; penetration into the lamina propria may lead to necrosis of capillaries and hemorrhage. differential diagnosis. differential diagnoses include the many enteropathogens associated with acute diarrhea in young ruminants: cryptosporidia, colibacilli, salmonella, enterotoxins, yersinia, viruses, and other intestinal parasites such as helminths. in cattle, for example, bovine viral diarrhea virus and helminthiasis caused by ostergia must be considered. management factors, such as dietary-induced diarrheas, are also differentials. in older animals, differentials in addition to stress are malnutrition, grain engorgement, and other intestinal parasitisms. prevention and control. good management practices will help prevent the disease. oocysts are resistant to disinfectants but are susceptible to dry or freezing conditions. proper sanitation of animal housing and minimizing overcrowding are essential. coccidiostats added to the feed and water are helpful in preventing the disease in areas of high exposure. treatment. affected animals should be isolated. on an individual basis, treatment should also include provision of a dry, warm environment, fluids, electrolytes (orally or intravenously), antibiotics (to prevent bacterial invasion and septicemia), and administration of coccidiostats. coccidiostats are preferred to coccidiocidals because the former allow immunity to develop. although many coccidial infections tend to be self-limiting, sulfonamides and amprolium may be used to aid in the treatment of disease. other anticoccidial drugs include decoquinate, lasalocid, and monensin; labels should be checked for specific approval in a species or specific indications. animals treated with amprolium should be monitored for development of secondary polioencephalomalacia. pen mates of affected animals should be considered exposed and should be treated to control early stages of infection. mechanisms of immunity have not been well defined but appear to be correlated with the particular coccidial species and their characteristics (for example, the extent of intracellular penetration). immunity may result when low numbers are ingested and there is only mild disease. immunity also may develop after more severe infections. iv. cryptosporidiosis etiology. cryptosporidium organisms are a very common cause of diarrhea in young ruminants. four cryptosporidium species have been described in vertebrates: c. baileyi and c. meleagridis in birds and c. parvum and c. muris in mammals. cryptosporidium parvum is the species affecting sheep (rings and rings, 1996) . debate continues regarding whether there are definite host-specific variants. clinical signs and diagnosis. cryptosporidiosis is characterized by protracted, watery diarrhea and debilitation. the diarrhea may last only 6-10 days or may be persistent and fatal. the diarrhea is watery and yellow, and blood, mucus, bile, and undigested milk may also be present. infected animals will display tenesmus, anorexia and weight loss, dehydration, and depression. in relapsing cases, animals become cachectic. overall, morbidity will be high, and mortality variable. mucosal scrapings or fixed stained tissue sections may be useful in diagnosis. the disease is also diagnosed by detecting the oocysts in iodine-stained feces or in tissues stained with periodic acid-schiff stain or methenamine silver. cryptosporidium also stains red on acid-fast stains such as kinyoun or ziehl-neelsen. fecal flotations should be performed without sugar solutions or with sugar solutions at specific gravity of 1.27 (foryet, 1990) . fecal immunofluorescent antibody (ifa) techniques have also been described. epizootiology and transmission. younger ruminants are commonly affected: lambs, kids (especially kids between the ages of 5 and 10 days old), and calves less than 30 days old. like other coccidians, cryptosporidium is transmitted via the fecal-oral route. in addition to local contamination, water supplies have also been sources of the infecting oocysts. the oocysts are extremely resistant to desiccation in the environment and may survive in the soil and manure for many months. necropsy findings. the lesions caused by cryptosporidium are nonspecific. animals will be emaciated. moderate enteritis and hyperplasia of the crypt epithelial cells with villous atrophy as well as villous fusion, primarily in the lower small intestines, will be present. cecal and colonic mucosae may sometimes be involved. gastrointestinal smears may be made at necropsy and stained as described above. pathogenesis. although cryptosporidium infections are clinically similar to eimeria infections (moore, 1989) , cryptosporidium, in contrast to eimeria, invades just under the surface but does not invade the cytoplasm of enterocytes. there is no intermediate host. the oocysts are half the size of eimeria oocysts and are shed sporulated; they are, therefore, immediately infective. within 2-7 days of exposure, diarrhea and oocyst shedding occur. the diarrhea is the result of malabsorption and, in younger animals, intraluminal milk fermentation. autoinfection within the lumen of the intestines may also occur and result in persistent infections. in addition, several other pathogens may be involved, such as concurrent coronavirus and rotavirus infections in calves. environmental stressors such as cold weather increase mortality. intensive housing arrangements increase morbidity and mortality. differential diagnosis. other causes of diarrhea in younger ruminants include rotavirus, coronavirus, and other enteric viral infections; enterotoxigenic escherichia coli; clostridium; other coccidial pathogens; and dietary causes (inappropriate use of milk replacers). in addition, these other agents may also be causing illness in the affected animals and may complicate the diagnosis and the treatment picture. eimeria is more likely to cause diarrhea in calves and lambs at 3-4 weeks of age. giardia organisms may be seen in fecal preparations from young ruminants but are not considered to play a significant role in enteric disease. blood. animals exhibit fever, dehydration, and depression. chronic cases may result in a "poor doer" syndrome with weight loss and unthriftiness. giardia can be diagnosed by identifying the motile piriform trophozoites in fresh fecal mounts. oval cysts can be floated with zinc sulfate solution (33%). standard solutions tend to be too hyperosmotic and to distort the cysts. newer enzyme-linked immunosorbent assay (elisa) and ifa tests are sensitive and specific. epizootiology and transmission. giardia infection may occur at any age, but young animals are predisposed. chronic oocyst shedding is common. transmission of the cyst stage is fecaloral. wild animals may serve as reservoirs. necropsy findings. gross lesions may not be evident. villous atrophy and cuboidal enterocytes may be evident histologically. prevention and control. precautions should be taken when handling infected animals. affected animals must be removed and isolated as soon as possible. animal housing areas should be disinfected with undiluted commercial bleach or 5% ammonia. formalin (10%) fumigation has proven successful (foryet, 1990) . after being cleaned, areas should be allowed to dry thoroughly and should remain unpopulated for a period of time. because enteric disease often is multifactorial, other pathogens should also be considered, and management and husbandry should be examined. no known drug treatment is available. the disease is generally self-limiting, so symptomatic, supportive therapy aimed at rehydrating, correcting electrolyte and acid-base balance, and providing energy is often effective. supplementation with vitamin a may be helpful. age resistance begins to develop when the animals are about 1 month old. research complications. cryptosporidiosis is a zoonotic disease. it is easily spread from calves to humans, for example, even as the result of simply handling clothing soiled by calf diarrhea. adult immunocompetent humans are reported to experience watery diarrhea, cramping, flatulence, and headache. the disease can be life-threatening in immunocompromised individuals. v. giardiasis etiology. giardia lamblia (also called g. intestinalis and g. duodenalis) is a flagellate protozoon. giardiasis is a worldwide protozoal-induced diarrheal disease of mammals and some birds (kirkpatrick, 1989 ), but it not considered to be a significant pathogen in ruminants. clinical signs and diagnosis. diarrhea may be continuous or intermittent, is pasty to watery, is yellow, and may contain pathogenesis. following ingestion, each giardia cyst releases four trophozoites, which attach to the enterocytes of the duodenum and proximal jejunum and subsequently divide by binary fission or encyst. the organism causes little intestinal pathology, and the cause of diarrhea is unknown but is thought to be related to disruption of digestive enzyme function, leading to malabsorption. disturbances in intestinal motility may also occur (rings and rings, 1996) . prevention and control. intensive housing and warm environments should be minimized. cysts can survive in the environment for long periods of time but are susceptible to desiccation. effective disinfectants include quaternary ammonium compounds, bleach-water solution (1:16 or 1:32), steam, or boiling water. after cleaning, areas should be left empty and allowed to dry completely. treatment. giardia has been successfully treated with oral metronidazole. benzimidazole anthelmintics are also effective, but these are not approved for use in animals for this purpose. should be taken when handling infected animals. etiology. neosporosis is a common, worldwide cause of bovine abortion caused by the protozoal species neospora caninum. abortions have also been reported in sheep and goats. neonatal disease is seen in lambs, kids, and calves. until 1988, these infections were misdiagnosed as caused by toxoplasma gondii. some similarities exist between the life cycles and pathogeneses of both organisms. clinical signs and diagnosis. abortion is the only clinical sign seen in adult cattle and occurs sporadically, endemically, or as abortion storms. bovine abortions occur between the third and seventh month of gestation; fetal age at abortion correlates with the parity of the dam as well as with pattern of abortion in the herd. although cows that abort tend to be culled after the first or second abortion, repeated n. caninum-caused abortions will occur progressively later in gestation (up to about 6 months) and within a shorter time frame in the same cow (thurmond and hietala, 1997) . although infections in adults are asymptomatic other than the abortions, decreased milk production has been noted in congenitally infected cows. many neospora-infected calves will be born asymptomatic. weakness will be evident in some infected calves, but this resolves. rare clinical signs include exophthalmos or asymmetric eyes, weight loss, ataxia, hyperflexion or hyperextension of all limbs, decreased patellar reflexes, and loss of conscious proprioception. some fetal deaths will occur, and resorption, mummification, autolysis, or stillbirth will follow. immunohistochemistry and histopathology of fetal tissue are the most efficient and reliable means of establishing a postmortem diagnosis. serology (ifa and elisa) is useful, including precolostral levels in weak neonates, but this indicates only exposure. titers of dams will not be elevated at the time of abortion; fetal serology is influenced by the stage of gestation and course of infection. earlier and rapid infections are less likely to yield antibodies against neospora. none of the currently available tests is predictive of disease. epizootiology and transmission. the parasite is now acknowledged to be widespread in dairy and cattle herds. the life cycle of n. caninum is complex, and many aspects remain to be clarified. the definitive host is the dog (mcallister et al., 1998) . placental or aborted tissues are the most likely sources of infection for the definitive host and play a minor role in transmission to the intermediate hosts. the many intermediate hosts include ruminants, deer, and horses. transplacental transmission is the major mode of transmission in dairy cattle and is the means by which a herd's infection is perpetuated. a less significant mode of transmission is by ingestion of oocysts, which sporulate in the environment or in the intermediate host's body. reactivation in a chronically infected animal's body is the result of rupture of tissue cysts in neural tissue. seropositive immunity does not protect a cow from future abortions. many seropositive cows and calves will never abort or show clinical signs, respectively. some immunological cross-reactivity may exist among neospora, cryptosporidia, and coccidium. necropsy findings. aborted fetuses will usually be autolysed. in those from which tissue can be recovered, tissue cysts are most commonly found in the brain. spinal cord is also useful. histological lesions include mild to moderate gliosis, nonsuppurative encephalitis, and perivascular infiltration by mixed mononuclear cells. pathogenesis. as with toxoplasma, cell death is the result of intracellular multiplication of neospora tachyzoites. neospora undergoes sexual replication in the dog's intestinal tract, and oocysts are shed in the feces. the intermediate hosts develop nonclinical systemic infections, with tachyzoites in several organs, and parasites then localize and become encysted in particular tissues, especially the brain. infections of this type are latent and lifelong. except when immunocompromised, most cattle do not usually develop clinical signs and do not have fetal loss. fetuses become infected, leading to fetal death, mid-gestation abortions, or live calves with latent infections or congenital brain disease. it usually takes 2-4 weeks for a fetus to die and to be expelled. many aspects of the role of the maternal immune response and pregnancy-associated immunodeficiency in the patterns of neospora abortions remain to be elucidated. differential diagnosis. even when there is a herd history of confirmed neospora abortions, leptospirosis, bovine viral diarrhea virus (bvdv), infectious bovine rhinotracheitis virus (ibrv), salmonellosis, and campylobacteriosis should be considered. bvdv in particular should be considered for abortion storms. differentials for weak calves are b vdv, perinatal hypoxia following dystocia (immediate postpartum time), bluetongue virus, toxoplasma, exposure to teratogens, or congenital defects. prevention and control. the primary preventive measure is preventing contact with contaminated feces. oocysts will not survive dry environments or extremes of temperature. dog populations should be controlled, and dogs and other canids should not have access to placentas or aborted fetuses. dogs should also be restricted from feed bunks and other feed storage areas. preventive culling is not economically practical for most producers. a vaccine recently became available. if embryo transfer is practiced, recipients should be screened serologically before use. laxis. there is no known treatment or immunoprophyclinical signs and diagnosis. clinical signs of sarcocystosis infection are seen in cattle during the stage when the parasite encysts in soft tissues. often the infections are asymptomatic. fever, anemia, ataxia, symmetric lameness, tremors, tail-switch hair loss, excessive salivation, diarrhea, and weight loss are clinical signs. abortions in cattle occur during the second trimester and in smaller ruminants 28 days after ingestion of the sporulated oocysts. definitive diagnosis is based on finding merozoites and meronts in neural tissue lesions. clinical hematology results include decreased hematocrit, decreased serum protein, and prolonged prothrombin times. sarcocystis-specific igg will increase dramatically by 5-6 weeks after infection. there is no cross-reaction between sarcocystis and toxoplasma. epizootiology and transmission. infection rates among cattle in the united states are estimated to be very high. transmission is by ingestion of feed and water contaminated by feces of the definitive hosts. dogs are the definitive hosts for the species that infect the smaller ruminants. cats, dogs, and primates (including humans when s. hominis is involved) are the definitive hosts for the species that infect cattle. necropsy. aborted fetuses may be autolysed. lesions in neural tissues, including meningoencephalomyelitis, focal malacia, perivascular cuffing, neuronal degeneration, and gliosis, are most marked in the cerebellum and midbrain. lesions may be found in other tissues, such as lymphadenopathy, and hemorrhages may be found in muscles and on serous surfaces. cysts in cardiac and skeletal muscles are common incidental findings during necropsies. pathogenesis. ingestion of muscle flesh from an infected ruminant results in sarcocystis cysts' being broken down in the carnivore's digestive system, release of bradyzoites, infection of intestinal mucosal cells by the bradyzoites, differentiation into sexual stages, fusion of the male and female gametes to form oocysts, and shedding as sporocysts by the definitive hosts. the sporocysts are eaten by the ruminant and penetrate the bowel walls; several stages of development occur in endothelial cells of arteries. merozoites are the form that enters soft tissues, such as muscle, and subsequently encysts. prevention and control. feed supplies of ruminants must be protected from fecal contamination by domestic and wild carnivores. these animals should be controlled and must also not have access to carcasses. in larger production situations, monensin may be fed as a prophylactic measure. treatment. monensin fed during incubation is prophylactic, but the efficacy in clinically affected cattle is not known. etiology. toxoplasmosis is caused by the obligate intracellular protozoon toxoplasma gondii, a coccidial parasite of the family eimeridae. cats are the only definitive hosts, and several warm-blooded animals, including ruminants, have been shown to be intermediate hosts. the disease is a major cause of abortion in sheep and goats and less common in cattle. clinical signs and diagnosis. clinical signs depend on the organ or tissue parasitized. toxoplasmosis is typically associated with placentitis, abortion, stillbirths, or birth of weak young (underwood and rook, 1992; buxton, 1998) . it has also been shown to cause pneumonia and nonsuppurative encephalitis. the enteritis at the early stage of infection may be fatal in some hosts. hydrocephalus does not occur in animals as it does in human fetal toxoplasma infections. rare clinical presentations in ruminants include retinitis and chorioretinitis; these are usually asymptomatic. infection of the ewe during the first trimester usually leads to fetal resorption, during the second trimester leads to abortion, and during the third trimester leads to birth of weak to normal lambs with subsequent high perinatal mortality. congenitally infected lambs may display encephalitic signs of circling, incoordination, muscular paresis, and prostration. in sheep, weak young will develop normally if they survive the first week after birth. infected adult sheep show no systemic illness. infected adult goats, however, may die. diagnosis may be difficult, and biological, serological, and histological methods are helpful. serological tests are the most readily available. complement fixation and the sabin-feldman antibody test may assist in diagnosis. antibodies found in fetuses are indicative of congenital infection and are typically detectable 35 days after infection; fetal thoracic fluid is especially useful in demonstrating serological evidence of exposure. biological methods, such as tissue culture or inoculation of mice with maternal body fluids, or with postmortem or necropsy tissues, are more time-consuming and expensive. epizootiology and transmission. this protozoon is considered ubiquitous. fifty percent (50%) of adult western sheep and 20% of feedlot lambs have positive hemagglutination titers (1:64 or higher) (jensen and swift, 1982) . transmission among the definitive host is by ingestion of tissue cysts. necropsy findings. at necropsy, placental cotyledons contain multiple small white areas that are sites of necrosis, edema, and calcification. fetal brains may show nonspecific lesions such as coagulative necrosis, nonsuppurative encephalomyelitis, pneumonia, myocarditis, and hepatitis. histologically, granulomas with toxoplasma organisms may be seen in the retina, myocardium, liver, kidney, brain, and other tissues. impression smears of these tissues, stained appropriately (e.g., with giemsa), provide a rapid means of diagnosis. identification of the organism in tissue sections (especially of the heart and the brain) also confirms the findings. toxoplasma gondii is crescent-shaped, with a clearly visible nuclei, and will be found within macrophages. pathogenesis. the protozoon has three infectious stages: the tachyzoite, the bradyzoite, and the sporozoite within the oocyst. the definitive hosts, felids, become infected by ingesting cyst stages in mammalian tissues, by ingesting oocysts in feces, and by transplacental transfer. ingested zoites invade epithelial cells and eventually undergo sexual reproduction, resulting in new oocysts, which the cats will shed in the feces. cats rarely show clinical signs of infection. one cat can shed millions of oocysts in 1 gm of feces, but the asymptomatic shedding takes place for only a few weeks in its life. oocysts sporulate in cat feces after 1 day. ruminants are intermediate hosts of toxoplasmosis and become infected by ingesting sporulated oocyst-contaminated water or feed. as in the definitive host, the ingested sporozoite invades epithelial cells within the intestine but also further invades the bloodstream and is transported throughout the host. the organism migrates to tissues such as the brain, liver, muscles, and placenta. placental infection develops about 14 days after ingestion of the oocysts. the damage caused by an infection is due to multiplication within cells. toxoplasma does not produce any toxin. campylobacter, chlamydia, and q fever. prevention and control. feline populations on source farms should be controlled. eliminating contamination of feed and water with cat feces is the best preventive measure. sporulated oocysts can survive in soil and other places for long periods of time and are resistant to desiccation and freezing. vaccines for abortion prevention in sheep are available in new zealand and europe. treatment. toxoplasmosis treatment is ineffective, although feeding monensin during pregnancy may be helpful (underwood and rook, 1992) . (monensin is not approved for this use in the unites states.) weak lambs that survive the first week after birth will mature normally and will not deliver toxoplasmainfected young. research complications. because toxoplasmosis is zoonotic, precautions must be taken when handling tissues from any abortions or neurological cases. infections in immunocompromised humans have been fatal. etiology. trichomoniasis is an insidious venereal disease of cattle caused by tritrichomonas (also referred to as trichomonas) fetus, a large, pear-shaped, flagellated protozoon. the organism is an obligate parasite of the reproductive tract, and it requires a microaerophilic environment to establish chronic infections. in the united states, it is now primarily a disease seen in western beef herds. there are many similarities between trichomoniasis and campylobacteriosis; both diseases cause herd infertility problems. clinical signs and diagnosis. clinical signs include infertility manifested by high nonpregnancy rates as well as periodic py-ometras and abortions during the first half of gestation. often the problem is not recognized until herd pregnancy checks indicate many "open," delayed-estrus, late-bred cows, or cows with postcoital pyometras. the abortion rate varies from 5% to 30%, and placentas will be expelled or retained. tritrichomonas fetus also causes mild salpingitis but this does not result in permanent damage. other than these manifestations, infection with t. fetus causes no systemic signs. diagnosis is based on patterns of infertility and pyometras. for example, pyometras in postcoital heifers or cows are suggestive of this pathogen. diagnostic methods include identifying or culturing the trichomonads from preputial smegma, cervicovaginal mucus, uterine exudates, placental fluids, or abomasal contents of aborted fetuses. other nonpathogenic protozoa from fecal contamination may be present in the sample. the trichomonad has three anterior flagellae, one posterior flagella, and an undulating membrane; it travels in fluids with a characteristic jerky movement. culturing must be done on specific media, such as diamond's or modified pastridge. real exposure from breeding bulls or cows or, in some cases, contaminated breeding equipment. necropsy findings. nonspecific lesions, such as pyogranulomatous bronchopneumonia of fetuses and placentitis, may be seen in aborted material; some cases will have no gross lesions. histologically, trichomonads may be visible in the fetal lung lesions and the placenta; those tissues are also the most useful for culturing. pathogenesis. tritrichomonas fetus colonizes the female reproductive tract, and subsequent clinical manifestations may be related to the size of the initial infecting dose. tritrichomonas fetus does not interfere with conception. embryonic death occurs within the first 2 months of infection. affected cows will clear the infection over a span of months and maintain immunity for about 6 months. infections in younger bulls are transient; apparently organisms are cleared by the bulls' immune systems and are dependent on exposure to infected females. older bulls become chronic carriers, probably because of the ability of t. fetus to colonize deeper epithelial crypts of the prepuce and penis. differential diagnosis. campylobacteriosis is the other primary differential for reduced reproductive efficiency of a herd. other venereal diseases should be considered when infertility problems are noted in a herd: brucellosis, mycoplasmosis, ureaplasmosis, and infectious pustular vulvovaginitis. in addition, management factors such as nutrition and age of heifers at introduction to the herd should be considered. heifers, cows, and breeding bulls are vaccinated subcutaneously twice at 2 to 4 week intervals, with the booster dose administered 4 weeks before breeding season starts. similar timing is recommended for administration of the annual booster; a long, anamnestic response does not occur. bulls used for artificial insemination (ai) are screened routinely for t. fetus (and campylobacter) . ai reduces but does not eliminate the disease. the use of younger, vaccinated bulls is recommcmded in all circumstances. new animals should be tested before introduction to the herd. control measures also include culling affected cows or else removing them from the breeding herd for 3 months to rest and clear the infection. culling chronically infected bulls is strongly recommended. treatment. imidazole compounds have been effective, but the use of these is not permitted in food animals in the united states. therapeutic immunizations are worthwhile when a positive diagnosis has been made. these will not curtail fetal losses but will shorten the convalescence of the affected cows and improve immunity of breeding bulls. research complications. trichomoniasis should be considered whenever natural service is used and fertility problems are encountered. nematodes are important ruminant pathogens that cause acute, chronic, subclinical, and clinical disease in adults and adolescents. the major helminths may cause gastroenteritis associated with intestinal hemorrhage and malnutrition. nematodiasis is associated with grazing exposure to infective larvae; animals procured for research may have had exposure to these helminths. mixed infections of these parasites are common. generally, older animals develop resistance to some of the species; thus, animals between about 2 months and 2 years of age are most susceptible to infection. because of the parasites' effects on the animals' physiology, infection in these younger animals is a major contributor to a cycle of poor nutrition and digestion, compromised immune responses, and impaired growth and development. diagnosis is primarily based on fecal flotation techniques; however, because many of these nematodes have similar-appearing ova, hatching the ova and identifying the larvae are often required (baermann technique). a number of anthelmintics can be used to interrupt nematode life cycles. see zajac and moore (1993) and pugh et al. (1998) for comprehensive reviews of treatment and control of nematodiasis. i. haemonchus contortus, h. placei (barber's pole worm, large stomach worm) . haemonchus contortus is the most important internal parasite of sheep and goats, and the brief description here focuses on the disease in the smaller ruminants. haemonchus contortus and h. placei infections do occur in younger cattle and are similar to the disease in sheep. haemonchus is extremely pathogenic, and the adults feed by sucking blood from the mucosa of the abomasum. severe anemia may lead to death. weight loss, decreased milk production, poor wool growth, and intermandibular and cervical edema due to hypoproteinemia ("bottle jaw") are also common clinical signs. diarrhea is not seen in all cases but may sometimes be severe or chronic. the life cycle is direct. under optimal conditions, a complete life cycle, from ingestion of larvae to eggs passed in the feces, occurs in 3 weeks. embryonated eggs may develop into infective larvae within a week. hypobiotic (arrested) larvae may exist for several months in animal tissues, serving as a reservoir for future pasture contamination. periparturient increases in egg shedding by ewes contribute to large numbers of eggs spread on spring pastures ("spring rise"). resistance to common anthelmintics has developed; currently ivermectin or benzimidazole products are used, with a minimum of 2 dosings given 2-3 weeks apart. levamisole is also used. in severe cases, animals may benefit from blood transfusions and iron supplementation. because animals may easily acquire infective larvae from ingestion of contaminated feed and from contaminated pastures, general facility sanitation and pasture management and rotation are important preventive and control measures. haemonchus contortus is susceptible to destruction by freezing temperatures and dry conditions. ii. ostertagia (teladorsagia) circumcincta (medium stomach worm). ostertagia circumcincta is also highly pathogenic for sheep and goats and, like haemonchus, attaches to the abomasal mucosa and ingests blood. the life cycle is comparable to that of haemonchus, including the phenomenon of hypobiosis. larvae are especially resistant to cool temperatures, however, and will overwinter on pastures. larvae-induced hyperplasia of abomasal epithelial glands results in a change of gastric ph from about 2.0 to near 7.0, leading to decreased digestive enzyme activity and malnutrition. clinical syndromes are categorized as type 1 or type 2. the former type is associated with infections acquired in fall or spring and is seen in younger animals. the latter type is associated with emergence of the arrested larvae during spring or fall. clinical signs include anemia, weight loss, decreased milk production, and unthriftiness. diarrhea is usually seen in type 1 only; the symptoms of type 2 are comparable to those of haemonchus infections. anthelmintic drug therapy is comparable to that for haemonchus, and drug resistance is also a problem with ostertagia. iii. ostertagia ostertagi (cattle stomach worm). ostertagia ostertagi is the most pathogenic and most costly of the cattle nematodes. ostertagia leptospicularis and o. bisonis also cause disease. the life cycle is direct, and egg shedding by the cattle may occur within 3-4 weeks of ingestion of infective larvae. hypobiosis is also a characteristic of o. ostertagi. in the initial steps of infection, the normal processes of the abomasum are profoundly disrupted and cells are destroyed as the larvae develop within and emerge from the glands. moroccan leather appearance is the term to describe the result of cellular hyperplasia and loss of cell differentiation. cycles of infection and morbidity depend on geographic location, climate, and production cycles. type 1 cattle ostertagiasis is associated with ingestion of large numbers of infective larvae, occurs in animals less than 2 years old, and causes diarrhea and anorexia. type 2 ostertagiasis occurs in cattle 2-4 years old and older adults, is the result of the emergence and development of hypobiotic larvae, and in addition to signs seen with type 1, hypoproteinemia with development of submandibular edema, fever, and anemia is a clinical sign. treatment options include ivermectin, fenbendazole, and levamisole; all are effective against the arrested larvae. ostertagia is susceptible to desiccation but is resistant to freezing. iv. trichostrongylus vitrinus, t. axei, t. colubriformis (hair worms) . trichostrongylus species favor cooler conditions, and some larvae may overwinter. although the different species may affect different segments of the gastrointestinal tract, the nematode attaches to the mucosa and affects secretion and/or absorption. trichostrongylus vitrinus and t. colubriformis infect the small intestine of sheep and goats. trichostrongylus axei infects the abomasum of cattle, sheep, and goats and causes increases in abomasal ph similar to those seen with ostertagia. mucosal hyperplasia is not seen. the prepatent period is about 3 weeks. affected animals display unthriftiness, anorexia, decreased milk production, weight loss, diarrhea, and dehydration. these worms show intermediate resistance to freezing temperatures and dry conditions. v. nematodirus spathiger, n. battus (thread-necked worms vii. strongyloides papillosus. strongyloides papillosus is a small-intestinal parasite of sheep and cattle. strongyloides has a different life cycle from that of many nematodes. the eggs, expelled in the feces, are larvated, and when they hatch, they form both free-living males and females or parasitic females only. the parasitic females may enter the gastrointestinal tract through oral ingestion, such as in milk during nursing, or through direct penetration of the skin. penetrating larvae enter the bloodstream and are transported to the lungs, where they penetrate the alveoli, are coughed up, and then swallowed to ultimately enter the gastrointestinal tract. adult females may reproduce in the small intestines by parthenogenesis. clinical signs associated with strongyloides include weight loss, diarrhea, unthriftiness, and dermatitis in cases where large numbers migrate through the skin. the current broad-spectrum anthelmintics are effective against strongyloides. strongyloides, bunostomum infection may involve oral ingestion or direct penetration of the skin (followed by tracheal migration and swallowing). the larvae mature in the small intestines and suck blood. larvae are susceptible to desiccation and freezing. heavy infection with bunostomum may result in anemia, diarrhea, intestinal hemorrhage, edema, and weight loss. ix. oesophagostomum columbianum, o. venulosum (nodule worms) . oesophagostomum spp. primarily infect the large intestine and occasionally the distal small intestine, causing nodule worm disease, or simply gut. oesophagostomum columbianum and o. venulosum infect sheep and cattle. these nematodes may affect sheep from 3 months to 2 years of age, and the prepatent period is about 6 weeks. larvae are highly sensitive to freezing and desiccation and rarely overwinter. larvae penetrate the large-intestinal mucosa but occasionally move into the deeper areas of the intestinal wall near the serosa. the resultant inflammatory reaction may lead to the formation of a caseous nodule that may mineralize over time. intestinal lesions may accelerate peristalsis, leading to diarrhea, or may inhibit peristalsis (later stages), resulting in constipation. clinical signs include weakness, unthriftiness, alternating episodes of diarrhea and constipation, and severe weight loss. nodular lesions are typical at necropsy. x. chabertia ovis (large-mouth bowel worm). chabertia ovis is a minor colon parasite of sheep, goats, and cattle and is seen primarily in sheep. signs of infection are not usually seen in cattle. prepatent periods are up to 50 days. heavy infection, which may result from as few as 100 worms located at the proximal end of the colon, may lead to hemorrhagic mucoid diarrhea, weight loss, weakness, colitis, and mild anemia. xi. trichuris (whipworms). trichuris spp. are mildly pathogenic nematodes and are usually attached to the cecal mucosa. trichuris has a rather long prepatent period, extending from 1 to 3 months. the oval eggs are double-operculated and survive well in pasture environmental extremes. the adult worms also have a characterisitic morphology, with one thicker end appearing as a whip handle. the nematodes cause a minor cecitis and will feed on blood. clinical infection is rare and results in diarrhea with mucus and blood. treatment and prevention methods are similar to those for other nematodes. xii. dictyocaulus (lungworms). dictyocaulus spp., or lungworms, are nematodes that cause varying clinical signs in ruminants. in sheep, dictyocaulus filaria, protostrongylus rufescens, and muellerius capillaris cause disease; dictyocaulus is the most pathogenic. goats are infected by the same species as sheep, but infections are uncommon. dictyocaulus viviparus is the only lungworm found in cattle, causing "fog fever." infections with these parasites in the united states tend to be associated with cooler, moister climates. lungworms induce a severe parasitic bronchitis (known as husk, or verminous pneumonia) in sheep between approximately 2 and 18 months of age. sheep infected with any of the lungworm species may display coughing, dyspnea, nasal discharge, weight loss, unthriftiness, and occasionally fever. coughing and dyspnea are symptoms in goats. diagnosis is suggested by persistent coughing and nasal discharge and is confirmed by identifying larvae in the feces or adults in pathological samples. the baermann technique, involving prompt examination of room-temperature feces, is usually used; zinc sulfate flotation is also used. dictyocaulus has a direct life cycle. the adult worms reside in the large bronchi. dictyocaulus produces embryonated eggs that are coughed up and swallowed; the eggs then hatch in the intestines, and larvae are expelled in the feces. the expelled larvae are infectious in about 7-10 days and, after ingestion, penetrate the intestinal mucosa and move through the lymphatics and blood into the lungs, where they develop into adults in about 5 weeks. dictyocaulus filaria causes an especially severe bronchitis in sheep. protostrongylus inhabits smaller bronchioles. muellerius is of minor pathogenicity. protostrongylus and muellerius require the snail or slug as an intermediate host. infection occurs through ingestion of infected snails; infections are less likely than those caused by the direct ingestion of dictyocaulus larvae. immunity wanes over a year. viral and bacterial respiratory tract infections may be associated with the parasitic infection. more severe illness is seen after infections with cooperia and ostertagia, because of a synergism between the nematodes even if the cattle are not currently infected with those parasites. hypobiosis (arrested development of immature worms in lung tissue) is associated with dictyocaulus infections; cattle will be silent carriers, showing no clinical signs and serving as a means for the infection to survive over winter or a dry season. pastures can be heavily contaminated during the next grazing season. necropsy lesions include bronchiolitis and bronchitis, atelectasis, and hyperplasia of peribronchiolar lymphoid tissue. nematodes frequently reside in the bronchi of the diaphragmatic lung lobes and are frequently enmeshed with frothy exudate. prevention and control of the disease involve appropriate pasture management. elimination of intermediate hosts is important in sheep and goat pastures. in a laboratory setting, animals may be procured that are already harboring the disease. infected animals can be treated with anthelmintics such as ivermectin or levamisole. muellerius tends to be resistant to levamisole. there is no anthelmintic currently approved for goats, but fenbendazole, administered 2 weeks apart, has been effective for all three tapeworms are rarely of clinical or economic importance. in younger animals, heavy infections result in potbellies, constipation or mild diarrhea, poor growth, rough coat, and anemia. moniezia expansa, and less commonly moniezia benedini, inhabit the small intestines of grazing ruminants. moniezia expansa has the widest distribution of the tapeworm species in north america. soil mites (galumna spp. and oribatula spp.) contribute to the life cycle as intermediate hosts, a period that lasts up to 16 weeks. cysticercoids released from the mites are grazed, pass into the small intestines, and mature. no clinical or pathological sign is usually observed with moniezia infection; diagnosis is made by observing the characteristic triangularshaped eggs in fecal flotation examinations. infection is treated with cestocides. thysanosoma actinoides, or the fringed tapeworm, is a cestode that resides in the duodenum, bile duct, and pancreatic duct of sheep and cattle raised primarily west of the mississippi river in the united states. thysanosoma is of the family anoplocephalidae. the life cycle is indirect, and the intermediate host is the psocid louse. larval forms, or cysticercoids, are ingested by grazing animals, and the prepatent period is several months. typically, no clinical signs are observed with thysanosoma infection; nonetheless, liver damage, resulting in liver condemnation at slaughter, occurs. necropsy lesions include bile and/or ductal hyperplasia and fibrosis. thysanosoma is diagnosed premortem by identifying the gravid segments in the feces. ii. abdominal or visceral cysticercosis. abdominal or visceral cysticercosis is an occasional finding at slaughter. the socalled bladder worms typically affect the liver or peritoneal cavity and are the larval form of taenia hydatigena, the common tapeworm of the dog family. taenia hydatigena resides in the small intestines of canids, and its gravid segments, oncospheres, contaminate feed and water sources. after ingestion, the larvae penetrate the intestinal mucosa, are transported via the bloodstream to the liver, and cause migration tracts throughout the liver parenchyma. the larvae may leave the liver and migrate into the peritoneal cavity, where they attach and develop over the next 1-9 months into small fluid-filled bladders. the life cycle is completed only after these bladders are ingested by a carnivore, thus completing the maturation of the adult tapeworms. although larval migration may cause nonspecific signs such as anorexia, hyperthermia, and weight loss, affected animals are usually asymptomatic. at necropsy, the bladder worms will be observed attached to the peritoneal or organ surfaces. migration tracts may result in fibrosis and inflammation. diagnosis is usually made at necropsy. because of the migration through the liver, fasciola hepatica is a differential diagnosis. minimizing exposure to canine feces-contaminated feeds and water effectively interrupts the life cycle. research animals may have been exposed prior to purchase. echinococcosis, like cysticercosis, is an occasional finding at slaughter or necropsy. the hydatid cyst is the larval intermediate of the adult tapeworm echinococcus granulosus, which resides in the small intestines of dogs and wild canids. embryonated ova are expelled in the feces of the primary host and are ingested by herbivores, swine, and potentially humans. the eggs hatch in the gastrointestinal tract, and the oncospheres penetrate the mucosal lining, enter the bloodstream, and are transported to various organs such as the liver and lungs. the cystic structure develops and potentially ruptures, forming new cystic structures. clinically, echinococcosis presents minimal clinical signs; unthriftiness or pneumonic lesions may be associated with infected organs. cysts are typically observed at necropsy. prevention should be aimed at decreasing fecal contamination of feed and water by canids. additionally, tapeworm-infected dogs can be treated with standard tapeworm therapies. treatment of infected ruminants is uncommon. iv. gid. coenuris cerebralis, the larval form of the canid tapeworm taenia (multiceps) multiceps, is the causative agent of the rare condition called gid. the disease occurs in ruminants as well as many other mammalian species. the larval parasite, ingested from fecal-contaminated food and water, invades the brain and spinal cord and develops as a bladder worm that causes pressure necrosis of the nervous tissues. the resultant signs of hyperesthesia, meningitis, paresis, paralysis, ataxia, and convulsions are observed. diagnosis is usually made at necropsy. eliminating transfer from the canid hosts prevents the disease. the cercariae leave the intermediate host, swim to grassy vegetation, lose their tail, and become a cystlike metacercaria. the metacercariae may remain in a dormant stage on the grass for 6 months or longer until ingested by a ruminant. the ingested metacercariae penetrate the small-intestinal wall and migrate through the abdominal cavity to the liver. there they locate in a bile duct, mature, and remain for up to 4 years. acute liver fluke disease is related to the damage caused by the migration of immature flukes. migratory flukes may lead to liver inflammation, hemorrhage, necrosis, and fibrosis. fascioloides magna infections in sheep and goats can be fatal as the result of just one fluke tunneling through hepatic tissue. in cattle, infections are often asymptomatic because of the host's encapsulation of the parasite. liver fluke damage may predispose to invasion by anaerobic clostridium species such as c. novyi that could lead to fatal black disease or bacillary hemoglobinuria. chronic disease may result from fluke-induced physical damage to the bile ducts and cholangiohepatitis. blood loss into the bile may lead to anemia and hypoproteinemia. liver damage also is evidenced by increases in liver enzymes such as y-glutamyl transpeptidase (ggt). persistent eosinophilia is also seen with liver fluke disease. other clinical signs of liver fluke disease include anorexia, weight loss, unthriftiness, edema, and ascites. at necropsy, livers will be pale and friable and may have distinct migration tunnels along the serosal surfaces. bile ducts will be enlarged, and areas of fibrosis will be evident. diagnosis can be made from clinical signs and postmortem mites cause a chronic dermatitis. the principal symptom of these infections is intense pruritus. in addition, papules, crusts, alopecia, and secondary dermatitis are seen. anemia, disruption of reproductive cycles, and increased susceptibility to other diseases may also occur. mites are rare in ruminants in the united states, but infections of sarcoptes and psorergates mange must be reported to animal health officials. ruminants in poorly managed facilities are generally the most susceptible to infection, and infections are more frequent during winter months. diagnosis is based on signs, examination of skin scrapings, and response to therapy. no effective treatment for demodectic mange in large animals has been found. the differential for mite infestations is pediculosis. several genera of mites may affect sheep. these have been eradicated from flocks in the united states or are very rare and include psoroptes ovis (common scabies), sarcoptes scabiei (head scabies, barn itch), psorergates ovis (sheep itch mite), chorioptes ovis (foot scabies, tail mange), and demodex ovis (follicular mange). goats can also be infected by sarcoptic, chorioptic, and psoroptic mange. the scabies mite sarcoptes rupicaprae invades epidermal tissue and causes focal pruritic areas around the head and neck. the chorioptic mite, either chorioptes bovis or c. caprae, does not invade epidermal tissue but rather feeds on dead skin tissue. the chorioptic mite prefers distal limbs, the udder, and the scrotum and can be a significant cause of pruri-tus. the psoroptic mite psoroptes cuniculi commonly occurs in the ear canal and causes head shaking and scratching. repeated treatments of lime sulfur, amitraz, or ivermectin may be effective (smith and sherman, 1994) . goats are also susceptible to demodectic mange caused by demodex caprae. adult mites invade hair follicles and sebaceous glands. pustules may develop with secondary bacterial infection. psoroptes bovis continues to be present in cattle in the united states, although it has been eradicated from sheep. chorioptes bovis typically infects lower hindlimbs, perineum, tail, and scrotum but can become generalized. the sarcoptic mange mite s. scabei can survive off the host, so fomite transmission is a factor. the mange usually begins around the head but then spreads. this parasite can be transmitted to humans. demodex bovis infects cattle; nodules on the face and neck are typical. demodex bovis infections may resolve without treatment. lindane, coumaphos, malathion, and lime sulfur are used to treat psoroptes and psorergates. ivermectin is effective against sarcoptes and is approved for use in cattle. lice that infect ruminants are of the orders mallophaga, biting or chewing lice, and anoplura, sucking lice. these are wingless insects. members of the mallophaga are colored yellow to red; members of the anoplura are blue gray. lice produce a seasonal (winter-to-spring), chronic dermatitis. in sheep, biting lice include damalinia (bovicola) ovis (sheep body louse). sucking lice that infect sheep include linognathus ovillus (blue body louse) and l. pedalis (sheep foot louse). in goats, biting lice infection are caused by d. caprae (goat biting louse), d. limbatus (angora goat biting louse), and d. crassipes. suckir/g louse infections in goats are caused by l. stenopis and l. africanus. damalinia bovis is the cattle biting louse. sucking lice include l. vituli, solenopotes capillatus, haematopinus eurysternus, and h. quadripertusus. pruritus is the most common sign and often results in alopecia and excoriation. the host's rubbing and grooming may not correlate with the extent of infestation. hairballs can result from overgrooming in cattle. in severe cases, the organisms can lead to anemia, weight loss, and damaged wool in sheep and damaged pelts in other ruminants. young animals with severe infestations of sucking lice may become anemic or even die. pregnant animals with heavy infestations may abort. in sheep infected with the foot louse, lameness may result. lice are generally species-specific. those infecting ruminants are usually smaller than 5 mm. goats may serve as a source of infection for sheep by harboring damalinia ovis. transmission is primarily by direct contact between animals. transmission can also occur by attachment to flies or by fomites. some animals are identified as carriers and seem to be particularly susceptible to infestations. biting or chewing lice inhabit the host's face, lower legs, and flanks and feed on epidermal debris and sebaceous secretions. sucking lice inhabit the host's neck, back, and body region and feed on blood. lice eggs or nits are attached to hairs near the skin. three nymphal stages, or instars, occur between egg and adult, and the growth cycle takes about 1 month for all species. lice cannot survive for more than a few days off the host. all ruminant mite infestations are differentials for the clinical signs seen with pediculosis. animals that are carriers should be culled, because these individuals may perpetuate the infection in the group. lice are effectively treated with a variety of insecticides, including coumaphos, dichlorvos, crotoxyphos, avermectin, and pyrethroids. label directions should be read and adhered to, including withdrawal times. products should not be used on female dairy animals. treatments must be repeated at least twice at intervals appropriate for nit hatches (about every 16 days) because nits will not be killed. fall treatments are useful in managing the infections. systemic treatments in cattle are contraindicated when there may be concurrent larvae of cattle grubs (hypoderma lineatum and h. bovis). back rubbers with insecticides, capitalizing on self-treatment, are useful for cattle. sustained-release insecticide-containing ear tags are approved for use in cattle. etiology. ruminants are susceptible to many species of ixodidae (hard-shell ticks) and argasidae (softshell ticks). many diseases, including anaplasmosis, babesiosis, and q fever are transmitted by ticks. clinical signs and diagnosis. tick infestations are associated with decreased productivity, loss of blood and blood proteins, transmission of diseases, debilitation, and even death. feeding sites on the host vary with the tick species. ticks are associated with an acute paralytic syndrome called tick paralysis. this disease is characterized by ascending paralysis and may lead to death if the tick is not removed before the paralysis reaches the respiratory muscles. diagnosis is based on identification of the species. epizootiology and transmission. ticks are not as host-specific as lice. ticks are classified as one-host, two-host, or three-host; this refers to whether they drop off the host between larval and nymphal stages to molt. pathogenesis of tick infestations. patterns of feeding on the host differ between argasidae and ixodidae. the former feed repeatedly, whereas the latter feed once during each life stage. pathogenesis of tick paralysis. following a tick-feeding period of 4-6 days, the tick salivary toxin travels hematogenously to the myoneural junctions and spinal cord and inhibits nerve transmission. removal of the ticks reverses the syndrome unless paralysis has migrated anteriorly to the respiratory centers of the medulla. in these cases, death due to respiratory failure occurs. insecticides. ticks can be treated using systemic or topical h. other parasites i. nasal bots (nasal myiasis, head grubs). nasal myiasis causes a chronic rhinitis and sinusitis. the disease is caused by the larval forms of the botfly oestrus ovis. the botfly deposits eggs around the nostrils of sheep. the ova hatch, and the larvae migrate throughout the nasal cavity and sinuses, feeding on mucus and debris. in 2-10 months, the larvae complete their growing phase, migrate back to the nasal cavity, and are sneezed out. the mature larvae penetrate the soil and pupate for 1-1.5 months and emerge as botflies. clinically, early in the disease course, animals display unique behaviors such as stamping, snorting, sneezing, and rubbing their noses against each other or objects. hypersensitivity to the larvae occurs (dorchies et al., 1998) . later, mucopurulent nasal discharges associated with the larval-induced inflammation of mucosal linings will be observed. at necropsy, larvae will be observed in the nasal cavity or sinuses. mild inflammatory reactions, mucosal thickening, and exudates will accompany the larvae. the disease is diagnosed by observing the behaviors or identifying organisms at necropsy. up to 80% of a flock will potentially be infected; treatment should be employed on the rest of the flock. ivermectins and other insecticides will eliminate the larvae; but treatment should be done in the early fall, when larvae are small. fly repellents may be helpful at preventing additional infections. ii. screwworm flies. cochliomyia hominivorax (callitroga americana) is the the screwworm that causes occasional disease in the southwestern united states along the mexico border. eradication programs have been pursued, and the disease is reportable. large greenish flies lay large numbers of white eggs as shinglelike layers at the edges of open wounds (including docking and castration sites), soiled skin, or abrasions. eggs hatch within 24 hr. larvae are obligate parasites of living tissue, and the cycle is perpetuated because the increasingly large wound continues to be attractive to the next generation of flies. larvae eventually drop off, pupate best in hot climates, and hatch in 3 weeks. large cavities in parasitized tissue are formed, and lesions are characterized by malodor, large volumes of brown exudate, and necrosis. single animals or entire herds may be affected. treatment is intensive, with dressings and larvicidal applications. if there is no intervention, the host succumbs to secondary infections and fluid loss. effective current control regimens include subcutaneous injection of ivermectin and programs that release sterile male flies. iii. sheep keds ("sheep ticks"). in sheep and goats, sheep keds produce a chronic irritation and dermatitis with associated pruritus. the disease is caused by melophagus ovinus, which is a fiat, brown, blood-sucking, wingless fly; the term sheep tick is incorrectly used. the adult fly lives entirely on the skin of sheep. females mate and produce 10-15 larvae following a gestation of about 10-12 days. the larvae attach to the wool or hair and then pupate for about 3 weeks. the adult female feeds on blood and lives for 4-5 months; the life cycle is completed in about 5-6 weeks. infection is highest in fall and winter. pruritus develops around the neck, sides, abdomen, and rump. in severe cases, anemia may occur. keds can transmit bluetongue virus. keds are diagnosed by gross or microscopic identification. ivermectin or other insecticides are useful treatment agents. portant, other immune mechanisms are not well understood. immunity may not be of long duration. recovery is enhanced by correcting nutritional deficiencies and improving housing and ventilation problems. a number of topical treatments, such as 2-5% lime-sulfur solution, 3% captan, iodophors, thiabendazole, and 0.5% sodium hypochlorite, can be used. in severe cases, systemic therapy with griseofulvin may be successful. prevention and control. the animals' environment and overall physical condition should be reassessed with particular attention to ventilation, crowding, sanitation, and nutrition. pens should be thoroughly cleaned and disinfected. research complications. ringworm is a zoonotic disease. etiology. dermatophytosis, or infection of the keratinized layers of skin, is caused mostly by species of the genera trichophyton and microsporum. the primary causes in sheep are t. mentagrophytes and t. verrucosum. in goats, the agents are t. mentagrophytes, m. canis, m. gypseum, t. verrucosum, t. schoenleinii, and epidermophyton floccosum. in cattle, t. verrucosum is the primary causative agent. dermatophytosis is a common fungal infection of the epidermis of cattle and is less common in sheep and goats. clinical signs and diagnosis. multiple, gray, crusty, circumscribed, hyperkeratotic lesions are characteristic of infection. lesions will vary in size. in all ruminants, lesions will be around the head, neck, and ears. in goats and cattle, lesions will extend down the neck, and in cattle, lesions develop particularly around the eyes and on the thorax. cattle lesions are unique in the marked crustiness, which progressively appears wartlike. hair shafts become brittle and break off. intense pruritus is often associated with the alopecic lesions. the disease can be diagnosed by microscopic identification of hyphae and conidia on the hairs following skin scraping and 20% potassium hydroxide digestion. dermatophyte test media (dtm) cultures are the most reliable means to diagnose the fungus. broken hairs from the periphery of the lesion are the best sources of the fungus. epizootiology and transmission. younger animals are more susceptible, and factors such as crowding, indoor housing, warm and humid conditions, and poor nutrition are also important. transmission is by direct contact or by contact with contaminated fomites, such as equipment, fencing, or feed bunks. pathogenesis. incubation can be as long as 6 weeks. the organisms invade and multiply in hair shafts. treatment. spontaneous recovery occurs in all species in 1-4 months. although cell-mediated immunity is considered iminverted eyelids are a common inherited disorder of lambs and kids of most breeds. generally, the lower eyelid is affected and turns inward, causing various degrees of trauma to the conjunctiva and cornea. young animals will display tearing, blepharospasm, and photophobia initially. if the disorder is left uncorrected, corneal ulcers, perforating ulcers, uveitis, and blindness may occur. placing a suture or a surgical staple in the lower eyelid and the cheek, effectively anchoring the lid in an everted position, successfully treats the condition. the procedure likely results in the formation of some degree of scar tissue within the lower lid, because when the suture eventually is removed, the condition rarely returns. other treatments include the injection of a "bleb" of penicillin in the lid, regular manual correction over a 2-day period early in the animal's life, and application of ophthalmic ointments, powders, and solutions. boric acid or 10% argyrol solutions have been used as treatments. because of the genetic predisposition, prevention of the condition requires removal of maternal or paternal carriers. [3-mannosidosis is an autosomal recessive lysosomal storage disease of goats. the disease affects kids of the nubian breed and is identified by intention tremors and difficulty or inability of newborns to stand. cells of affected animals are vacuolated because of a lack of lysosomal hydroxylase, which results in accumulation of oligosaccharides. newborn kids are unable to rise, and they have characteristic flexion of the carpal joint and hyperextension of the pastern joint. kids are born deaf and with musculoskeletal deformities such as domed skull, small narrow muzzle, small palpebral fissures, enophthalmos, and depressed nasal bridge (smith and sherman, 1994) . carrier adults can be identified by plasma measurements of [3-mannosidase activity. caprine congenital myotonia is an inherited autosomal dominant disease that affects voluntary striated skeletal muscles. goats with this disease are commonly known as fainting goats. "fainting" is actually transient spasms of skeletal musculature brought about by visual, tactile, or auditory stimuli (smith and sherman, 1994) . muscle fiber membranes appear to have fewer chloride channels than normal, resulting in decreased chloride conduction across the membrane, with subsequent increased membrane excitability and repetitive firing (smith and sherman, 1994) . contractions of skeletal muscle are sustained for up to 1 min. kids exhibit the condition by 6 weeks of age, and males appear to exhibit more severe clinical signs than females (smith and sherman, 1994) . electromyographic studies produce an audible "dive-bomber" sound characteristic of hyperexcitable cell membranes (smith and sherman, 1994) . i. congenital erythropoietic porphyria. congenital erythropoietic porphyria (cep) is an autosomal recessive disease of cattle seen primarily in holsteins, herefords, and shorthorns. the disease also occurs in limousin cattle, humans, and some other species. in the homozygous recessive animal, symptoms of the disease may vary from mild to severe and occur at different times of the year and in different ages of animals. a reddish brown discoloration of teeth and bones is a characteristic of the disease, as is discolored urine, general weakness and failure to thrive, photosensitization, and photophobia. bones are more fragile compared with bones of normal animals. a regenerative anemia occurs as the result of the shortened life span of erythrocytes, due to accumulations of porphyrins. the genetic defect is associated with low activity of an essential enzyme, uroporphyrinogen iii synthase, in the porphyrin-heme synthesis pathway in erythrocytic tissue. the ranges in the presentation of the disease are believed to be related to varying cycles of porphyrin synthesis. porphyrins are excreted in varying amounts in the urine and the discoloration fluoresces under a wood's lamp. diagnosis is based on these clinical and visible signs of porphyria; skin biopsy provides definitive diagnosis. heterozygotes may have milder symptoms. many other genetic defects, in all major organ systems, have been described in numerous breeds of cattle and are described in detail elsewhere ("large animal internal medicine," 1996) . in many cases, the genetic basis has been clarified, and associated defects also noted. many defects are reported in particular breeds, but as crossbreeding increases and new breeds are developed, these traits are appearing in these animals. the bovine genome continues to be further characterized, and more linkage maps and gene locations are forthcoming (womack, 1998) . some bovine genetic defects are also regarded as models of genetic disease, such as leukocyte adhesion deficiency of holstein cattle. some of the more commonly reported defects include syndactyly in holsteins and other breeds and polydactyly in simmentals; lysosomal storage diseases such as a-mannosidosis in some beef breeds; enzyme deficiencies such as citrullinemia in holsteins; and progressive degenerative myeloencephalopathy ("weaver") in brown swiss. ii. goiter of sheep. a defect in the synthesis of thyroid hormone has been identified in merino sheep (radostits et al., 1994) . lambs born with the defect have enlargement of the thyroid gland, a silky appearance to the wool, and a high degree of mortality. edema, bowing of the legs, and facial abnormalities have also been noted in animals with this disorder. immaturity of the lungs at birth causes neonatal respiratory distress and resuits in dyspnea and respiratory failure. spider lamb syndrome is an inherited, often lethal, musculoskeletal disorder primarily occurring in suffolk and hampshire breeds. severely affected lambs die shortly after birth. animals that survive the perinatal period develop angular limb deformities, scoliosis, and facial deformities. with time, affected animals become debilitated, exhibit joint pain, and develop neurological problems associated with the spinal abnormalities. radiologically, secondary ossification centers--especially the physis, subchondral areas, and cuboidal bonesmare affected. abnormal endochondral ossification leads to excess cartilage formation, notably apparent in the elbows. lambs will typically display abnormally long limbs, medial deviation of the carpus and tarsus, flattening of the sternum, scoliosis/kyphosis of the vertebrae, and a rounded nose. muscle atrophy is common. diagnosis can be based on typical clinical signs, which are similar to those seen with marfan syndrome in humans (rook et al., 1986) . long-term survival is rare; treatment is unsuccessful. i. abomasal and duodenal ulcers. abomasal and duodenal ulcers occur more frequently in calves and adult cattle than in sheep and goats. like rumenitis, abomasal and duodenal ulcers may be associated with lactic acidosis. concurrent disease, such as salmonellosis, bluetongue, or overuse of anti-inflammatory drugs, or recent shipping or environmental stresses may also lead to ulcer formation. copper deficiency, dietary changes, mycotic infections, clostridium perfringens abomasitis, and abomasal bezoars are associated with this disease in calves. in older adult cattle, abomasal lymphosarcoma may be the underlying condition. gastric acid hypersecretion in conjunction with insufficient gastric mucous secretion will physically destroy the gastric epithelium. deep ulceration may cause serious hemorrhage and/or perforation with peritonitis. chronic hemorrhage may lead to anemia. although ulcers are often asymptomatic in calves, perforation with peritonitis is more common than hemorrhage. dark feces or melena and abdominal pain may be observed. arched back, restlessness, kicking at the abdomen, bruxism, and anorexia are common signs of abdominal pain. fecal occult blood is as an easy diagnostic test. treatment includes gastrointestinal protectants and histamine antagonists. anemia may be symptomatically treated with parenteral iron injections and anabolic steroids. preventive measures in cattle herds include ensuring optimal passive immunity for calves, minimizing stress to calves, and striving for a herd free of bovine leukosis virus. ii. abomasal emptying defect. abomasal emptying defect of sheep is a sporadic syndrome associated with abomasal distension and weight loss. suffolks tend to be especially predisposed, although the disease has been diagnosed in hampshires, columbias, and corriedales. the mechanism of the disease is unknown. affected animals will exhibit a gradual weight loss with a history of normal appetites. feces will continue to be normal. ventral abdominal distension associated with abomasal accumulation of feedstuffs will be apparent in many of the animals. diagnosis is primarily based on history and clinical signs. elevations in rumen chloride concentrations (> 15 meq/liter) are commonly found. radiography or ultrasonography may be helpful at identifying the distended abomasum. abomasal emptying defect is usually eventually fatal. medical treatment with metoclopramide and mineral oil may be helpful in early disease. iii. abomasal displacement. displaced abomasum (da) is a sporadic disorder usually associated with multiparous 4-to 7year-old dairy cows in early lactation, but the condition can occur even in young calves. displacement to the right (rda) may be further complicated by torsion (rta), a surgical emergency. left displacement (lda) is more common than rda. clinical signs include anorexia, lack of cud chewing, decreased frequency of ruminal contractions, shallow respirations, increased heart rate, treading, and decreased milk production. diagnosis is based on characteristic areas of tympanic resonance during auscultation-percussion of the lateral to lateral-ventral abdomen ("pings"), ruminal displacement palpated per rectum, and clinical signs. cow-side clinical chemistry findings include hypoglycemia and ketonuria; more extensive evaluations will often indicate moderate to severe electrolyte and acid-base abnormalities. da occurs because of gas accumulation within the viscus, and the abomasum "floats" up from its normal ventral location to the lateral abdominal wall. no exact cause of da has been identified, but it is commonly associated with stress; high levels of concentrate in the diet, leading to forestomach atony; and many disorders, including lack of regular exercise, mastitis, hypocalcemia, retained placenta, metritis, or twins. factors such as body size and conformation indicate the possibility of genetic predisposition. treatments include surgical and nonsurgical techniques for lda; the former has a better chance of per-manent correction. emergency surgery is necessary for rta; the disorder is fatal within 72 hr. recurrence is rare after surgical correction. electrolyte and acid-base imbalances are likely in severe cases and especially with rta. prevention includes reducing stress, taking greater care in the introduction and feeding of concentrates, and reducing incidence of predisposing diseases noted above (rohrbach et al., 1999) . fat cow syndrome is seen in peri-or postparturient overconditioned or obese multiparous dairy cows. factors in the development of the condition include negative energy balance related to the normal decreased dry matter intake as parturition approaches; hormonal changes associated with parturition; and concurrent diseases of parturition that decrease feed intake and increase energy needs. the possible concurrent diseases include metritis, retained fetal membranes, mastitis, parturient paresis, and displaced abomasum. signs are nonspecific and include depression, anorexia, and weakness. prognosis is usually guarded. diagnosis is based on herd management, the animal's condition, ketonuria, and clinical signs. in prepartum cattle and in lactating cows, blood levels of nonesterified fatty acids (nefa) greater than 1000 ~teq/liter and 325-400 ~teq/liter, respectively, are abnormal (gerloff and herdt, 1999) . triglyceride analysis of liver biposy specimens are useful. in affected cows, body fat is mobilized, in the form of nefa in response to the energy demands. hepatic lipidosis occurs rapidly as the nefa are converted into hepatic triglycerides. the ability of the liver to extract the albumin-bound nefa from the blood is better than that of other tissues that need and can also use nefa as an energy source. treatment for any concurrent diseases must be pursued aggressively, as well as measures to increase and stabilize blood glucose, decrease nefa production, and increase forestomach digestion to improve production of normally metabolized volatile fatty acids. therapeutic measures include intravenous glucose drips, insulin (nph or lente) injections every 12 hr, and transfaunation of ruminal fluid from a normal cow. prevention includes minimizing stress to lategestation cows. dry and lactating cows should be maintained separately; their energy, protein, and dry matter requirements are very different. cows with prolonged lactation or delayed breeding should be managed to prevent weight gain. i. bloat. bloat or tympanites refers to an excessive accumulation of gas in the rumen. the condition most frequently occurs in animals that have been recently fed abundant quantities of succulent forages or grains. bloat is classified into two broad categories: frothy bloat and free-gas bloat. frothy bloat is associated with ingestion of feeds that produce a stable froth that is not easily expelled from the rumen. fermentation gases such as co2, ch4, and minor gases such as n2, 02, h2, and h2s incorporate into the froth, overdistend the rumen, and eventu-ally compromise respiration by limiting diaphragm movement. the froth is often derived from a combination of salivary mucoproteins, protozoal or bacterial proteins, and proteins, pectins, saponins, or hemicellulose associated with ingested leaves or grain. typical foodstuffs that cause frothy bloat include green legumes, leguminous hay (alfalfa, clover), or grain (especially barley, corn, and soybean meal). free-gas bloat is less related to feeds ingested; rather, it is caused by rumen atony or by physical or pathological problems that prevent normal gas eructation. some examples of causes of free-gas bloat are esophageal obstructions (foreign bodies, tumors, abscesses, and enlarged cervical or thoracic lymph nodes), vagal nerve paralysis or injury, and central nervous system conditions that affect eructation reflexes. clinically, the animal will exhibit rumen distension, and tympany will be observed in the left paralumbar fossa. additional signs may include colic-like pain of the abdomen and dyspnea. passage of a stomach tube helps to differentiate between free-gas bloat and frothy bloat; and with free-gas bloat, expulsion of gas through the stomach tube aids in treatment of the disorder. once rumen distension is alleviated with free-gas bloat, the underlying cause must be investigated to prevent recurrence. frothy bloat is more difficult to treat, because the foam blocks the stomach tube. addition of mineral oil, household detergents, or antifermentative compounds via the tube may help break down the surface tension, allowing the gas to be expelled. in acute, life-threatening cases of bloat, treatment should be aimed at alleviating rumen distension by placing a trocar or surgical rumenotomy into the rumen via the paralumbar fossa. limiting the consumption of feedstuffs prone to induce bloat can prevent the disease. additionally, poloxalene or monensin will decrease the incidence of frothy bloat. ii. lactic acidosis. lactic acidosis, or rumen acidosis, is an acute metabolic disease caused by engorgement of grains or other highly fermentable carbohydrate sources. the disease is most frequently related to a rapid change in diet from one containing high roughage to one containing excessive carbohydrates. diet components that predispose to acidosis include common feed grains; feedstuffs such as sugar beets, molasses, and potatoes; by-products such as brewer's grains; and bakery products. biochemically, ingestion of large amounts of the carbohydrate-rich diet causes the normally gram-negative rumen bacterial populations to shift to gram-positive streptococcus and lactobacillus species. the gram-positive organisms efficiently convert the starches to lactic acid. the lactic acid acidifies the rumen contents, leading to rumen mucosal inflammation, and increases the osmolality of rumen fluids, leading to sequestration of fluids and osmotic attraction of plasma and tissue fluid to the rumen. lactic acid-induced rumenitis predisposes the animal to ulcers, to liver abscesses from "absorbed" bacterial pathogens, to laminitis from absorbed toxins, and to polioencephalomalacia from the inability of the new rumen bacterial populations to produce sufficient thiamine needed to maintain normal nervous system function. clinically, animals will become anorexic, depressed, and weak within 1-3 days after the initial insult. incoordination, ataxia, dehydration, hemoconcentration, rapid pulse and respiration, diarrhea, abdominal pain, and lameness will also be noted 9 rumen distension and an acetone-like odor to the breath, milk, or urine may also be observed. diagnosis is based on history and clinical signs. blood, urine, or milk ketones can be detected (moore and ishler, 1997) . additionally, rumen ph, which is normally above 6.0, will drop to less than 5.0 and in severe cases may achieve levels as low as 3.8. similarly, urine ph will become acidic, blood ph will drop below 7.4, and hematocrit will appear to increase due to the relative hemoconcentration. necropsy findings will be determined by secondary conditions. the primary lactic acidosis will cause swelling and necrosis of rumen papillae and abomasal hemorrhages and ulcers. treatment must be applied early in the syndrome. in early hours of severe carbohydrate engorgement, rumenotomy and evacuation of the contents are appropriate. the 9 t 9 patient should be given mineral oil and antlfermentatlves to prevent the continued conversion of starches to acids and the absorption of metabolic products. bicarbonate or other antacids like magnesium carbonate or magnesium hydroxide introduced into the rumen will aid in adjusting rumen ph. furthermore, animals can be given oral tetracycline or penicillin, which will decrease the gram-positive bacterial population. iii. rumen parakeratosis. parakeratosis is a degenerative condition of the rumen mucosa that leads to keratinization of the papillary epithelium 9 excessive and continuous feeding of diets low in roughage causes the mucosal changes 9 generally, this condition is seen in feedlot lambs and steers that are fed an all-grain diet. clinically, animals may exhibit only poor rates of gain, due to changes in the absorptive capacity of the injured mucosa. at necropsy, papillae will be thickened and rough. they will frequently be dark in color, and multiple papillae will clump together. abscessation may be observed. histopathologically, papilla surfaces will have hyperkeratinization of the squamous epithelium. chronic laminitis may be observed. however, diagnosis of parakeratosis is generally made at necropsy. feeding adequate roughage, such as stemmy hay, will prevent the disease. antibiotics may be administered to prevent secondary liver abscess formation. iv. rumenitis. rumenitis is an acute or chronic inflammation of the rumen, which occurs most commonly as a sequela to lactic acidosis 9 in addition to concentrate feeding, inadequate roughage in the diet is also associated with this disorder 9 rumenitis may occur with contagious ecthyma infection or following ingestion of poisons or other irritants. because rumenitis is often associated with lactic acidosis, it tends to occur in feedlot animals. the inflamed ruminal epithelium becomes necrotic and sloughs, creating ulcers. endogenous rumen bacteria such as fusobacterium necrophorum may invade the ulcers, penetrate the circulatory system, and induce abscesses of the liver. clinically, the animals will appear depressed and anorexic. rumen motility will be decreased, and animals will lose weight. the disease may resolve in a week to 10 days; mortality may reach 20%. necropsy lesions include rumen inflammation and ulcers in the anteroventral sac. granulation tissue and scarring may be observed following healing. rumenitis is not typically diagnosed clinically; thus, specific treatment is not commonly done. the disease can be prevented by minimizing the incidence of lactic acidosis. etiology. traumatic reticulitis-reticuloperitonitis is a disease of cattle related to their exploratory tendencies and ingestion of many different, nonvegetative materials. the disease is rarely seen in smaller ruminants. clinical signs. clinical signs range from asymptomatic to severe, depending on the penetration and damage by the foreign object after settling in the animal's forestomach. many signs during the early, acute stages will be nonspecific, ranging from arched back, listlessness, anorexia, fever, decrease in production, ketosis, regurgitation, decrease or cessation of ruminal contractions, bloat, tachypnea, tachycardia, and grunts when urinating, defecating, or being forced to move. the prognosis is poor when peritonitis becomes diffuse. sudden death can occur if the heart, coronary vessels, or other large vessels are punctured by the migrating object. epizootiology and transmission. this is a noncontagious disease. the occurrence is directly related to sharp or metallic indigestible items in the feed or environment that the cattle mouth and swallow. necropsy findings. in severe cases, necropsy findings include extensive inflammation throughout the cranial abdomen, malodorous peritoneal fluid accumulations, and lesions at the reticular sites of migration of the foreign objects. cardiac puncture will be present in those animals succumbing to sudden death. pathogenesis. consumed objects initially settle in the rumen but are dumped into the reticulum during the digestive process, and normal contraction may eventually lead to puncture of the reticular wall. this sets off a localized inflammation or a localized or more generalized peritonitis. the inflammation may also temporarily or permanently affect innervation of local tissues and organs. further damage may result from migration and penetration of the diaphragm, pericardium, and heart. diagnosis is based on clinical signs, knowledge of herd management techniques in terms of placement of forestomach magnets, and reflection of acute or chronic infection on the hemogram. radiographs and abdominocentesis may be useful. differential diagnosis. differentials include abomasal ulcers, hepatic ulcers, neoplasia (such as lymphosarcoma, usually in older animals, or intestinal carcinoma), laminitis, and cor pulmonale. infectious diseases that are differentials include systemic leptospirosis and internal parasitism. diseases causing sudden death may need to be considered. prevention and control. this problem can be prevented entirely by elimination of sharp objects in cattle feed and in the housing and pasture environments. adequately sized magnets placed in feed handling equipment and forestomach magnets (placed per os with a bailing gun in young stock at 6-8 months of age) are also significant prevention measures. treatment. provision of a forestomach magnet, confinement, and nursing care, including antibiotics, are the initial treatments. in severe cases, rumenotomy may be considered. etiology. pregnancy toxemia is a primary metabolic disease of ewes and does in advanced pregnancy. beef heifers are susceptible to protein energy malnutrition (pem) syndrome, which is also referred to as pregnancy toxemia. clinical signs. in sheep, this disease is characterized by hypoglycemia, ketonemia, ketonuria, weakness, and blindness. hypoglycemic and ketotic ewes begin to wander aimlessly and to move away from the flock. they become anorexic and act uncoordinated, frequently leaning against objects. advanced signs may include blindness, muscle tremors, teeth grinding, convulsions, and coma. body temperature, heart rate, respiratory rate, and rumen motility continue normally. up to 80% of infected ewes may die from the disease. the course of the disease may last up to a week. in goats, the disease usually occurs in the last 6 weeks of gestation, especially in does carrying triplets. pregnancy toxemia should be considered with any goat showing signs of illness in late gestation. the doe may separate herself from the herd, stagger, or circle and may appear blind. appetite is poor, and tremors may be evident. a rapid metabolic acidosis results in subsequent recumbency. urinalysis will readily reveal ketonuria. if fetal death occurs, acute toxemia and death of the doe may result. in beef heifers, weight loss and thin body condition, weakness and inability to stand, and depression are clinical signs. some cows develop diarrhea. because the catabolic state is often so advanced, most affected heifers die even if treated. pregnancy toxemia is diagnosed by evidence of typical clinical signs. sodium nitroprusside tablets or ketosis dipsticks may be used to identify ketones in the urine or plasma of ewes and does. blood glucose levels found to be below 25 mg/dl and ketonuria are good diagnostic indicators. in cattle, ketonuria is not a typical finding; hypocalcemia and anemia may be present. that are obese or bearing twins or triplets. the disease develops during the last 6 weeks of pregnancy. pem most frequently occurs in heifers during the final trimester of pregnancy. necropsy findings. at necropsy, affected ewes will often have multiple fetuses, which may have died and decomposed. the liver will be enlarged, yellow, and friable, with fatty degeneration. the adrenal gland may also be enlarged. in cattle, heifers will be very thin, and in addition to a fatty liver, signs of concurrent diseases may be present. pathogenesis. rapid fetal growth, a decline in maternal nutrition, and a voluntary decrease in food intake in overfat ewes result in an inadequate supply of glucose needed for both maternal and fetal tissues. the ewe develops a severe hypoglycemia in early stages of the disease. the ruminant absorbs little dietary glucose; rather, it produces and absorbs volatile fatty acids (acetic, propionic, and butyric acids) from consumed feedstuffs. propionic acid is absorbed and selectively converted to glucose through gluconeogenesis. when the animal is in a state of negative energy balance, it hydrolyzes fats to glycerol and fatty acids. glycerol is converted to glucose while the fatty acids are metabolized for energy. the oxidation of fatty acids in the face of declining oxaloacetate levels (required for normal krebs cycle function) results in the formation of ketone bodies (acetone, acetoacetic acid, and [3-hydroxybutyric acid), thus causing the condition ketoacidosis. heifer cattle have high energy requirements for completing normal body growth and supporting a pregnancy. additional energy requirements are needed during pregnancy for winter conditions and during concurrent diseases. marginal diets and poor-quality forage will place the cows in a negative energy balance. differential diagnosis. hypocalcemia is a common differential diagnosis. in cattle, differentials include chronic or untreated diseases such as johne's disease, lymphosarcoma, parasitism, and chronic respiratory diseases. prevention and control. pregnancy toxemia can be prevented by providing adequate nutrition during late gestation and by maintaining animals in appropriate nonfat condition during pregnancy. in late pregnancy, the dietary energy and protein should be increased 1.5-2 times the maintenance level. pem can be prevented by maintaining appropriate body condition earlier in pregnancy and supplying good-quality forage for the last trimester. treatment. in sheep, because the morbidity may be as high as 20%, treatment should be directed at the flock rather than the in-dividual. treating the individual is usually unsuccessful. oral administration of 200 ml of propylene glycol or 50% glucose twice a day, anabolic steroids, and high doses of adrenocorticosteroids may be helpful. if ewes are still responsive and not severely acidotic or in renal failure, cesarean section may be successful by rapidly removing the fetus, which is the dietary drain for the ewe. in goats, pregnancy toxemia is best treated by removal of the fetuses either by cesarean section or induction of parturition. parturition can be induced in does by either dexamethasone (10 mg) or pgf2a (10 ~tg). in addition, goats may be treated with 10% dextrose (100 to 200 ml iv) or propylene glycol (60 ml per os 2 or 3 times a day). adjunctive therapy includes normalizing acid base and hydration status, administration of vitamin b 12 and transfaunation. heifers may be force-fed alfalfa gruels, given propylene glycol per os, placed on iv 50% glucose drips, and treated for concurrent disease. research complications. in research requiring pregnant ewes in late stages of gestation, for example, this disease should be considered if the animals are likely to bear twins and will be transported or stressed in other ways during that time. f hypocalcemia (parturient paresis, milk fever) etiology. hypocalcemia is an acute metabolic disease of ruminants that requires emergency treatment; the presentation is slightly different in ewes, does, and cows. clinical signs and diagnosis. in sheep, the disease is seen in ewes during the last 6 weeks of pregnancy and is characterized by muscle tetany, incoordination, paralysis, and finally coma. as calcium levels drop, ewes begin to show early signs such as stiffness and incoordination of movements, especially in the hindlimbs. later, muscular tremors, muscular weakness, and recumbency will ensue. animals will frequently be found breathing rapidly despite a normal body temperature. morbidity may approach 30%, and mortality may reach as high as 90% in untreated animals. affected does become bloated, weak, unsteady, and eventually recumbent. cows are affected within 24-48 hr before or after parturition. cows initially are weak and show evidence of muscle tremors, then deteriorate to sternal recumbency, with the head usually tucked to the abdomen, and an inability to stand. tachycardia, dilated pupils, anorexia, hypothermia, depression, ruminal stasis, bloat, uterine inertia, and loss of anal tone are also seen at this stage. the terminal stage of disease is a rapid progression from coma to death. heart rates will be high, but pulse may not be detectable. hypocalcemia is diagnosed based on the pregnancy stage of the female and on clinical signs. it is later confirmed by laboratory findings of low serum calcium. with hypocalcemia in ewes, the plasma concentrations of calcium drop from normal values of 8-12 mg/dl to values of 3-6 mg/dl. in cattle, plasma levels below 7.5 mg/dl are hypocalcemic; at the terminal stages levels may be 2 mg/dl. ewes during the last 6 weeks of pregnancy or during the first few weeks of lactation. the disease is not as common in the dairy goat as in the dairy cow. high-producing, older, multiparous dairy cows are the most susceptible, and the jersey breed is considered susceptible. cows that have survived one episode are prone to recurrence. in addition, dry cows must be managed carefully regarding limiting dietary calcium. the disease is not common in beef cattle unless there is an overall poor nutrition program. ing at necropsy. there is no pathognomonic or typical find-pathogenesis. during the periparturient period, calcium requirements for fetal skeletal growth exceed calcium absorbed from the diet and from bone metabolism. additionally, dietary calcium intake is thought to be compromised because, in advanced pregnancy, animals may not be able to eat enough to sustain adequate nutrient levels, and intestinal absorption capabilities do not respond as quickly as needed. after parturition, calcium needs increase dramatically because of calcium levels in colostrum and milk. recent information suggests that legume and grass forages, high in potassium and low in magnesium, create a slight physiological alkalosis (at least in cattle), which antagonizes normal calcium regulation (rings et al., 1997) . thus, bone resorption, renal resorption, and gastrointestinal absorption of calcium are less than maximal. prevention and control. maintaining appropriate nutrition during the last trimester is helpful in preventing the disease. in cows and does, for example, limiting calcium intake by removing alfalfa from the diet is helpful. treatment. hypocalcemia must be treated quickly based on clinical signs; pretreatment blood samples can be saved for later confirmation. twenty percent calcium borogluconate solution should be administered by slow intravenous infusion. response will often be rapid, with the resolution of the animal's dull mentation. less severely affected animals will often try to stand in a short time. relapses are common, however, in sheep and cattle. hypermagnesemia and hypophosphatemia often coincide with hypocalcemia. these imbalances should be considered when animals appear to be unresponsive to treatment. hypocalcemia in the goat can be treated with 50-100 ml of calcium borogluconate. heart rate should be monitored closely throughout calcium administration. if an irregular or rapid heart rate is detected, then calcium treatment should be slowed or discontinued. calcium gels and boluses are also available for treatment (rings et al, 1997) . prognosis is generally good if the animal is treated early in the disease, but the prognosis will often be poor when treatment is initiated in later stages of the disease. etiology. urolithiasis is a metabolic disease of intact and castrated male sheep, goats, and cattle that is characterized by the formation of bladder and urethral crystals, urethral blockage, and anuria (murray, 1985) . the disease occurs rarely in female ruminants. clinical signs and diagnosis. affected animals will vocalize and begin to show signs of uneasiness, such as treading, straining postures, arched backs, raised tails, and squatting while attempting to urinate. these postures may be mistaken for tenesmus. male cattle may develop swelling along the ventral perineal area. affected animals will not stay with the herd or flock. small amounts of urine may be discharged, and crystal deposits may be visible attached to the preputial hairs. additionally, in smaller ruminants, the filiform urethral appendage (pizzle) often becomes dark purple to black in color. the pulsing pelvic urethra may be detected by manual or digital rectal palpation, and bladder distention may be noticeable in cattle by the same means. as the disease progresses to complete urethral blockage, the animal will become anorexic and show signs of abdominal pain, such as kicking at the belly. the abdomen will swell as the bladder enlarges, and rupture can occur within 36 hr after development of clinical signs. bladder or urethral rupture may cause a short-lived period of apparent pain relief; subsequent development of uremia will eventually lead to death. the disease may progress over a period of 1-2 weeks, and the mortality is high unless the blockages are reversed. diagnosis is made by the typical clinical signs. abdominal taps may yield urine. calculi are usually composed of calcium phosphate or ammonium phosphate matrices. clinical disease is usually seen in growing intact or castrated males. the disease may be sporadic or there may be clusters of cases in the flock or herd. necropsy findings. necropsy findings include urine in the abdomen with or without bladder or urethral rupture. renal hydronephrosis may be evident. calculi or struvite crystal sediment will be observed in the bladder and urethra. histologically, trauma to the urethra and ureters will be present. etary, anatomical, hormonal, and environmental factors. male sheep and goats have a urethral process that predisposes them to entrapment of calculi. in cattle, the urethra narrows at the sigmoid flexure, and calculi lodge there most frequently. additionally, the removal of testosterone by early castration is thought to result in hypoplasia of the urethra and penis. this physical reduction in the size of the excretory tube may predispose to the precipitation of and blockage by the struvite minerals. grains fed to growing animals tend to be high in phosphorus and magnesium content. these calculogenic diets lead to the formation of struvite (magnesium ammonium phosphate) crystals. other minerals associated with urolithiasis include silica (range grasses), carbonates (some grasses and clover pastures), calcium (exclusively alfalfa hay), and oxalates (fescue grasses). differential diagnosis. grain engorgement colic, gastrointestinal blockage, and causes of tenemus, such as enteritis or trauma, are differentials. trauma to the urethral process should be considered. urinary tract infections are uncommon in ruminants. prevention and control. one case often is indicative of a potential problem in the group. urolithiasis can be minimized by monitoring the calcium:phosphorus ratio in the diet. the normal ratio should be 2:1. additionally, increasing the amount of dietary roughage will help balance the mineral intake. increasing the amount of salt (sodium chloride, 2-4%) in the diet to increase water consumption, or adding ammonium chloride to the diet, at 10 gm/head/day or 2% of the ration, to acidify the urine, will aid in the prevention of this disease. palatability of and accessibility to water should be assessed as well as functioning of automatic watering equipment. treatment. treatment is primarily surgical (van metre et al. 1996) . initially, amputation of the filiform urethral appendage may alleviate the disease since urethral blockage often begins here. as the disease progresses, urethral blockage in the sigmoid flexure as well as throughout the urethra may occur. in more advanced stages, perineal urethrostomy may yield good results. the prognosis is poor when the condition becomes chronic, reoccurs, or surgery is required. research complications. young castrated and intact male ruminants used in the laboratory setting will be the susceptible age group for this disorder. rickets is a disease of young, growing animals but rarely occurs in goats. it is a metabolic disease characterized by a failure of bone matrix mineralization at the epiphysis of long bones due to lack of phosphorus. the condition can occur as an absolute deficiency in vitamin d2, an inadequate dietary supply of phosphorus, or a long-term dietary imbalance of calcium and phosphorus. the syndrome must be differentiated from epiphisitis (unequal growth of the epiphyses of long bones in young, rapidly growing kids fed diets with excess calcium). clinical signs include poor growth, enlarged costochondral junctions, narrow chests, painful joints, and reluctance to move. spontaneous fractures of long bones may occur. animals will recover when dietary phosphorus is provided and if joint damage is not severe. a. copper deficiency (enzootic ataxia, swayback) etiology. chronic copper deficiency in pregnant ewes and does may produce a metabolic disorder in their lambs and kids called enzootic ataxia. in goats, this deficiency also causes swayback in the fetuses. clinical signs and diagnosis. this disease results in a progressive hindlimb ataxia and apparent blindness in lambs up to about 3 months of age. additionally, because copper is essential for osteogenesis, hematopoiesis, myelination, and pigmentation of wool and hair, ewes may appear unthrifty, may be anemic, and may have poor, depigmented wool with a decrease in wool crimp. affected kids are born weak, tremble, and have a characteristic concavity to the spinal cord, leading to the name swayback. when the deficiency occurs later during gestation, demyelination is limited to the spinal cord and brain stem. kids are born normally but develop a progressive ataxia, leading to paralysis, muscle atrophy, and depressed spinal reflexes with lower motor neuron signs. diagnosis is based on low copper levels found in feedstuffs and tissues at necropsy. diagnosis is based on clinical signs, feed analysis, and pathological findings. epizootiology and transmission. enzootic ataxia is rarely seen in western states; most north american diets have sufficient copper levels to prevent this disease. copper antagonists in the feed or forage at sufficient levels, such as molybdenum, sulfate, and cadmium, however, may predispose to copper deficiencies. pathogenesis. the maternal copper deficiency leads to a disturbance early in the embryonic development of myelination in the central nervous system and the spinal cord. copper is part of the cytochrome oxidase system and other enzyme complexes and is important in myelination, osteogenesis, hematopoiesis (iron absorption and hemoglobin formation), immune system development, and maintenance and normal growth (smith and sherman, 1994) . differential diagnosis. the differential diagnosis for newborns includes [3-mannosidosis, hypoglycemia, and hypothermia. for older animals the differential should include caprine arthritis encephalitis (goats), enzootic muscular dystrophy, listeriosis, spinal trauma or abscessation, and cerebrospinal nematodiasis. prevention and control. copper deficiency can be prevented by providing balanced nutrition for pregnant animals. necropsy findings. gross encephalomalacia has been noted. histopathologically, white matter of the brain and spinal cord displays gelatinization and cavitation. extensive nerve demyelination and necrosis are evident. postmortem lesions include extensive demyelination and neuronal degeneration. treatment. because the condition is developmental, supplemental copper may improve clinical signs but not eliminate them. necropsy findings. common findings at necropsy include icterus; a soft, dark, friable, enlarged spleen; an enlarged, yellow-brown friable liver; and "gun-barrel" black kidneys. hemoglobin-stained urine will be visible in the bladder. copper accumulations in the liver reaching 1000-3000 ppm are toxic. pathogenesis. hemolysis occurs when sufficient amounts of copper are ingested or released suddenly from the liver and is believed to be due direct interaction of the copper with red-cell surface molecules. stresses such as transportation, lactation, and poor nutrition or exercise may precipitate the hemolysis. etiology: acute or chronic copper ingestion or liver injury often causes a severe, acute hemolytic anemia in weanling to adult sheep and in calves and adult dairy cattle. growing lambs may be the most susceptible. copper toxicosis is rare in goats. differential diagnosis. other causes of hemolytic disease include babesiosis, trypanosomiasis, and plant poisonings such as kale. arsenic ingestion, organophosphate toxicity, and cyanide or nitrate poisoning should also be considered as the source of poisoning. urethral obstruction and gastrointestinal emergencies should be considered for the abdominal pain. clinical signs and diagnosis. the clinical course in sheep can be as short as 1-4 days, and mortality may reach 75%. hemolysis, anemia, hemoglobinuria, and icterus characterize the acute hemolytic crisis, associated with copper released from the overloaded liver. some clinical signs are related to direct irritation to the gastrointestinal tract mucosa. weakness, vomiting, abdominal pain, bruxism, diarrhea, respiratory difficulty, and circulatory collapse are followed by recumbency and death. hepatic biopsy is currently considered the best diagnostic approach; serum or plasma levels of copper and hepatic enzymes such as aspartate aminotransferase (ast) and y-glutamyltransferase (ggt) may provide some information, but it is generally believed that these will not accurately reflect total copper load or hepatic damage. and goats is the range of 20-100 mg/kg, and for cattle it is 220-880 mg/kg. chronic poisoning in sheep may occur when 3.5 mg/kg is ingested. copper-containing pesticides, soil additives, therapeutics, and improperly formulated feeds may potentially lead to copper toxicity. phytogenous sources include certain pastures such as subterranean clover. feed low in molybdenum, zinc, or calcium may lead to increased uptake of copper from properly balanced rations. a common cause of the disease in sheep is feeding concentrates balanced for cattle; cattle feeds and mineral blocks contain much higher quantities of copper than are required for sheep. chronic ingestion of these feedstuffs leads to copper accumulation and toxicity. copper toxicosis has been reported in calves given regular oral or parenteral copper supplements, and in adult dairy cattle given copper supplements to compensate for copper-deficient pasture. pregnant dairy cattle may be more susceptible to copper toxicity. rare sources of copper ingestion may include copper sulfate footbaths. control and prevention. the disease is prevented by carefully monitoring copper access in sheep and copper supplementation in cattle. sheep and goats should not be fed feedstuffs formulated for cattle, and dairy calf milk replacer should not be used for lambs and kids. molybdenum may be administered to animals considered at high risk. molybdenum-deficient pastures may be treated with molybdenum superphosphate. herd copper supplementation should be undertaken with the knowledge of existing hepatic copper levels, and existing copper and molybdenum levels, in the feedstuffs. treatment. oral treatment for sheep consists of ammonium or sodium molybdenate (50-100 mg/day), and sodium thiosulfate (0.5-1.0 mg/day) for 3 weeks aids in excretion of copper. oral d-penicillamine daily for 6 days (50 mg/kg) has also been shown to increase copper excretion in sheep. ammonium molybdenate has been administered intravenously to goats at 1.7 mg/kg for 3 treatments on alternate days. cattle have been treated orally with sodium molybdenate (3 gm/day) or sodium thiosulfate (5 gm/day). treatment for anemia and nephrosis may be necessary in severe cases. merino crosses and the british breeds, may be more susceptible to copper toxicosis caused by phytogenous sources. (nutritional muscular dystrophy, nutritional myodegeneration, white muscle disease, stiff lamb disease) etiology. white muscle disease, also known as stiff lamb disease, is a nutritional muscular dystrophy caused by a deficiency of selenium or vitamin e. clinical signs and diagnosis. clinically two forms of the disease have been identified: cardiac and skeletal. the cardiac form occurs most commonly in neonates. in these, respiratory difficulty will be a manifestation of damage to cardiac, diaphragmatic, and intercostal muscles. young will be able to nurse when assisted. in slightly older animals, the disease is characterized by locomotor disturbances and/or circulatory failure. clinically, animals may display paresis, stiffness or inability to stand, rapid but weak pulse, and acute death. mortality may reach 70% (jensen and swift, 1982) . paresis and sudden death in neonates with associated pathological signs are frequently diagnostic. with the skeletal form, affected animals are stiff and reluctant to move, and muscles of affected animals are painful. young will be reluctant to get up but will readily nurse when assisted. peracute to acute myocardial degeneration may occur in the cardiac form, and animals may simply be found dead. serum selenium levels are usually below 50 ppb (normal is 158-160 ppb) (nelson, 1983) . diagnosis may also include determination of antemortem whole blood levels of selenium and plasma levels of vitamin e. glutathione peroxidase levels in red blood cells can be measured as an indirect test. clinical biochemistry findings of significant elevations of aspartate aminotransferase (ast) in creatinine kinase (ck) are also supportive of the diagnosis. epizootiology and transmission. selenium deficiency has been associated with formulated diets deficient in selenium, forages grown on selenium-deficient soils in certain geographic regions, and forages such as alfalfa and clover that have an inability to efficiently extract available selenium from the soils. rumen bacterial reduction of selenium compounds to unavailable elemental selenium may also contribute to the disease. necropsy findings. necropsy lesions include petechial hemorrhages and muscle edema. hallmarks are pale white streaking of affected skeletal and cardiac muscle. these are due to coagulation necrosis. pale striated muscles of the limb, diaphragm, and tongue are also seen. antioxidants that protect lipid membranes from oxidative destruction. selenium is a cofactor for glutathione peroxidase, which converts hydrogen peroxide to water and other nontoxic compounds. lack of one or both results in loss of membrane integrity. differential diagnosis. in neonatal ruminants presenting with respiratory and cardiac dysfunction, differentials include congenital cardiac anomalies. differentials generally for weak neonates or sudden or peracute neonatal deaths should include septicemia, pneumonia, toxicity, diarrhea, and dehydration. prevention and control. awareness of regional selenium deficiencies is important. control involves providing good-quality roughage, vitamin e and selenium supplementation, and parenteral injections prior to parturition and weaning. treatment. affected animals may be treated by administering vitamin e or selenium injections. administering vitamin e or selenium to ewes in late pregnancy can prevent white muscle disease (kott et al., 1998) . the label dose for selenium is 2.5-3 mg/45 kg of body weight. combination products are available and can be used in goats at the sheep dose (smith and sherman, 1994) . proper mineral balance in the diet is critical. selenium toxicity occurs most frequently as the result of excessive dosing to prevent or correct selenium deficiency or as the result of ingestion of selenium-converting plants. the main preventive measure for the former is the use of the appropriate product for the species. secondarily, the concentration of the available product should be double-checked. in the united states, ruminants in the midwest and western areas may be subject to selenium toxicity when pastured in areas containing selenium-converting plants. signs of overdosing include weakness, dyspnea, bloating, and diarrhea. shock, paresis, and death may occur. initial clinical signs of excessive selenium intake from plants are observed in the distal limb, with cracked hoof walls and subsequent infection and irregular hoof growth. etiology. polioencephalomalacia (pem) is a noninfectious, noncontagious disease characterized by neurological signs. growing and adult ruminants on high-concentrate diets are typically affected. animals exposed to toxic plants or moldy feed containing thiaminases, feed high in sulfates, or unusually high doses of some medications are also at risk. clinical signs and diagnosis. an early sign may be mild diarrhea. acute clinical signs include bruxism, hyperesthesia, involuntary muscle contractions, depression, partial or complete opisthotonus, nystagmus, dorsomedial strabismus, seizures, and death. in subacute cases of the disease, animals may appear to walk aimlessly as if blind or may display head-pressing postures. hypersalivation may be present, but body temperatures and ocular reflexes are normal. morbidity and mortality may be high, especially in younger animals. diagnosis is suggestive from clinical signs and from response to intensive parental thiamine hydrochloride. epizootiology and transmission. pem is caused by a thiamin deficiency. the disease tends to be seen more frequently in cattle and sheep feedlots where the concentrates fed are high in fermentable carbohydrates. pastured animals are also vulnerable if grain is feed. thiaminase-containing plants, such as bracken fern, are often unpalatable so will less likely be a contributing factor. recent studies have also indicated that high levels of sulfate in the diet, such as in the fermentable, low-fiber concentrates, may play an important role. medications such as as amprolium, levamisole, and thiabendazole have thiaminantagonizing activity when given in excessive doses. sherman, 1994) . vitamin a deficiencies associated with hyperkeratosis have been reported, as well as vitamin e-responsive and selenium-responsive dermatitis. necropsy signs. cerebral lesions characterized by softening and discoloration are grossly observed in the gray matter. microscopically, neurons will exhibit edema, chromatolysis, and shrinkage. gliosis and cerebral capillary proliferation may be observed. a lack of thiamin results in inappropriate carbohydrate metabolism and accumulation of pyruvate and other intermediaries that lead to cerebral edema and neuronal degeneration. differential diagnosis. several important differentials include acute lead poisoning, nitrofuran toxicity, hypomagnesemia, vitamin a deficiency, listeriosis, pregnancy toxemia, infectious thromboembolic meningoencephalitis, and type d clostridial enterotoxemia. prevention and control. the disease can be prevented by monitoring the diet and by providing adequate roughage necessary to prevent overgrowth of thiaminase-producing ruminal flora and to maximize ruminal production of b vitamins. if excess sulfur is the primary factor, immediate removal of the source is critical. neonatal ruminants are born without immunoglobulins and must receive colostrum by 24 hr after birth. the morbidity and mortality associated with failure of or inadequate passive transfer, such as enteric and respiratory illnesses, can be severe. measures to assure passive immunity for neonatal ruminants are covered in section ii,b,5, and clinical signs of illness associated with lack of immunity are addressed in the discussions of bacterial diseases (e.g., escherichia coli infections) and, of viral diseases (e.g., diarrheas) in section iii,a,1 and iii,a,2. generally, transfer of less than 600 mg/dl of immunoglobulins in the serum is classified as failure of transfer, 600-1600 mg/dl is partial, and above 1600 mg/dl is complete transfer. methods to determine success of transfer should be performed within a week of birth and include single radial immunodiffusion (quantitates immunogloblin classes); zinc sulfate turbidity (semiquantitative); sodium sulfite precipitation (semiquantitative); glutaraldehyde coagulation (coagulates above specific level); and, y-glutamyltransferase (assays enzyme in high concentration in colostrum and absorbed simultaneously with colostrum). treatment. early aggressive treatment is essential to save animals. the disease is treated by frequent parenteral administration of thiamine hydrochloride, the first dose being administered intravenously. dexamethasone, b vitamins, and diazepam may also be required. treatment is less successful when sulfur plays a prominent role in the etiology. research complications. this disease is preventable. although the disease is less likely to occur in smaller groups of confined ruminants, the risks of feeding concentrates or moldy feed, for example, with minimal good-quality roughage, should be kept in mind. vitamin d toxicity can result either from iatrogenic overadministration or ingestion of the plant trisetum flavescens. serum calcium levels may be high enough that blood in edta tubes will clot. laminitis is common in ruminants and can be caused by sudden changes in diet, excess dietary energy, and grain overload (or overeating). laminitis is also associated with mastitis and metritis. facility conditions, such as concrete flooring, poor manure management, and inadequate resting areas may also contribute to the pathogenesis of the disease. the complete pathogenesis of laminitis is poorly understood; however, it is thought that changes in the diet cause changes in rumen microbial populations, resulting in acidosis and endotoxemia. dramatic changes in the vascular endothelium result in chronic inflammation of the sensitive laminae of the hoof, separation of corium and hoof wall, and rotation of the third phalanx. affected animals may be reluctant to get up or walk, will shift their weight frequently, and will grind teeth or walk on carpi. chronically, the hoof wall takes on a "slipper" appearance. treatment consists of identifying the underlying cause, administering antiinflammatories (phenylbutazone, flunixin meglumin), feeding good-quality forages only, and regular foot trimming. in goats, nutritional deficiencies often manifest as a generalized poor coat that is dry, scaly, thin, and erectile. zincresponsive dermatitis has been reported in goats (smith and otherwise normal, well-managed lambs, kids, and calves can develop loose, pasty feces due to a nutritional imbalance caused by overfeeding and/or improper mixing of milk replacers. only milk replacer formulated for the particular species should be used. once nutritional imbalances are corrected, the feces readily return to normal. sudden changes in diet can also result in loose feces. photosensitization is an acute dermatitis associated with an interaction between photosensitive chemicals and sunlight. the photosensitive chemicals are usually ingested, but in some cases exposure may be by contact. animals with a lack of pigment are more susceptible to the disease. three types of photosensitization occur: primary; secondary, or hepatogenous; and aberrant. primary photosensitization is related to uncommon plant pigments or to drugs such as phenothiazine, sulfonamides, or tetracyclines. secondary photosensitization is more common in large animals and is specifically related to the plant pigment phylloerythrin. phylloerythrin, a porphyrin compound, is a degradation product of chlorophyll released by rumen microbial digestion. liver disease or injury, which prevents normal conjugation of phylloerythrin and excretion through the biliary system, predisposes to photosensitization. the only example of aberrant photosensitization is congenital porphyria of cattle (see section iii,b,1). pathologically, the photosensitive chemical is deposited in the skin and is activated by absorbed sunlight. the activated pigments transfer their energy to local proteins and amino acids, which, in the presence of oxygen, are converted to vasoactive substances. the vasoactive substances increase the permeability of capillaries, leading to fluid and plasma protein losses and eventually to local tissue necrosis. photosensitization can occur within hours to days after sun exposure and produces lesions of the face, vulva, and coronary bands; lesions are most likely to occur on white-haired areas. initially, edema of the lips, corneas, eyelids, nasal planum, face, vulva, or coronary bands occurs. the facial edema, nostril constriction, and swollen lips potentially lead to difficulty in breathing. with secondary photosensitization, icterus is also common. necrosis and gangrene may occur. diagnosis is based on clinical lesions and exposure to the photosensitive chemi-cals and sunlight. treatment is symptomatic. the prognosis for hepatogenous type may be guarded if hepatic disease is severe. from excessive straining associated with dysuria from the pressure of the fetuses and/or abdominal contents on the bladder. if the prolapse obstructs subsequent urination, rupture of the bladder may occur. the vaginal prolapse can be reduced and repaired if discovered early, and techniques in small and large ruminants are comparable. the animal should be restrained, and the prolapsed tissue should be cleansed with disinfectants. best done under epidural anesthesia, the vagina is replaced into the pelvic canal and the vulvar or vestibular opening is sutured closed (buhner suture). alternatively, a commercial device called a bearing retainer (or truss) can be placed into the reduced vagina and tied to the wool, thereby holding the vagina in proper orientation without interfering with subsequent lambing. vaginal prolapses may have a hereditary basis in ewes and cows and may prolapse the following year. these animals should be culled. vaginal prolapses may occur in nonpregnant animals that graze estrogenic plants or as a sequela to docking the tail too close to the body (ross, 1989) . uterine prolapses occur sporadically in postpartum ewes and cattle. the gravid horn invaginates after delivery and protrudes from the vulva. the cause is unknown, but excessive traction utilized to correct dystocia or retained placenta, uterine atony, hypocalcemia, and overconditioning or lack of exercise have been implicated. in cattle, the uterine prolapses usually develop within 1 week of calving, are more common in dairy cows than in beef cows, and are often associated with dystocia or hypocalcemia. cows may also have concurrent parturient paresis. initially, the tissue will appear normal, but edema and environmental contamination or injuries of the tissue develop quickly. clinical signs will include increased pulse and respiratory rates, straining, restlessness, and anorexia. if identified early, the uterus can be replaced as for vaginal prolapses. electrolyte imbalances should be corrected if present. additional supportive therapy, including the use of antibiotics should always be considered. tetanus prophylaxis should be included. oxytocin should be administered to induce uterine reduction. vaginal closures are less successful at retaining uterine prolapses. preventive and control measures include regular exercise for breeding animals, and management of prepartum nutrition and body condition. vaginal and uterine prolapses occur in ewes, does, and cows. the conditions are not common in does. vaginal prolapses usually occur during late gestation and may be related to relaxation of the pelvic ligaments in response to hormone levels. in sheep, these are most common in overconditioned ewes that are also carrying twins or triplets. overconsumption of roughages, which distends the rumen, and lack of exercise leading to intraabdominal fat may predispose an animal to vaginal prolapse by increasing intra-abdominal pressure. the condition may result f rectal prolapse rectal prolapse is common in growing, weaned lambs and in cattle from 6 months to 2 years old. the physical eversion of the rectum through the anal sphincter is usually secondary to other diseases or management-related circumstances. rectal prolapses may occur secondary to gastrointestinal infection or inflammation, especially when the colon is involved. diseases that cause tenesmus, such as coccidiosis, salmonellosis, and intestinal worms, may result in prolapse. urolithiasis may result in prolapses as the animal strains to urinate. any form of cystitis or urethritis, vaginal irritation, or vaginal prolapse and some forms of hepatic disease may lead to rectal prolapse. abdominal enlargement related to advanced stages of pregnancy, excessive rumen filling or bloat, and overconditioning may cause prolapse. finally, excessive coughing during respiratory tract infections, improper tail docking (too short), growth implants, prolonged recumbency, or overcrowded housing with animal piling may lead to prolapses. diagnosis is based on clinical signs. early prolapses may be corrected by holding the animal with the head down, while a colleague places a pursestring suture around the anus. the mucosa and underlying tissue of prolapses that have been present for longer periods of time will often become necrotic, dry, friable, and devitalized and will require surgical amputation or the placement of prolapse rings to remove the tissue. rectal prolapse may also be accompanied by intestinal intussusceptions that will further complicate the treatment and increase mortality. occasionally, acute rectal prolapse with evisceration will result in shock and prompt death of the animal. prognosis depends on the cause and extent of the prolapse as well as the timeliness of intervention. in all cases of treatment, determination and elimination of the underlying cause are essential. gastrointestinal accumulations or obstructions of hair (and/ or sometimes very coarse roughage, forming bezoars) occur in cattle and sheep. cattle that are maintained on a low-roughage diet, that lick their coats frequently, that have long hair coats from outdoor housing, or that have heavy lice or mite infestations and associated pruritus will often develop bezoars. in addition, younger calves with abomasal ulcers have been found to be more likely to have abomasal tric. hobezoars as well. clinical signs may be mild or severe according to size, number, and location. ruminal trichobezoars rarely result in clinical signs. obstruction will be accompanied by signs of pain, development of bloat, and decreased fecal production. serum profiles will show hypochloridemia; other imbalances depend on the duration of the problem. diagnosis is also based on abdominal auscultation, rectal palpation, and ultrasound (useful in calves and smaller ruminants). treatment is surgical, such as paracostal laparotomy (for abomasal), paralumbar celiotomy with manual breakdown, or enterotomy. supportive care should be administered as necessary to correct electrolyte imbalances and to prevent inflammation and sepsis. prognosis is generally good if the condition is diagnosed and treated before dehydration and imbalances become severe and peritonitis develops. prevention includes providing good-quality roughage and treating lice and mange infestations. wounds may be sustained from poorly constructed pens or fences, or from skirmishes among animals. predators will usu-ally be sources of bite wounds. standard veterinary wound assessment and care are essential for wounds or bites. tetanus antitoxin may be indicated. use of approved antibiotics may be appropriate. the lesion should be cleaned with disinfectants and repaired with primary closure if it is clean and uncontaminated. thorough cleaning, regular monitoring, and healing by second intention are recommended for older wounds. abscesses may also occur in the soft tissues of the hooves (sole abscesses; see section iii,c,3) because of entrapped foreign bodies or hoof cracks that fill with dirt. preventive measures include improvement of housing facilities, pens, and pastures; monitoring hierarchies among animals penned together; and implementing predator control measures, such as sound fencing, flock guard dogs, or donkeys, in pasture situations. acute anaphylatic reactions in sheep, goats, and cattle are often clinically referable to the respiratory system. anaphylactic vaccine reactions cause acute lung edema; lungs are the primary site of lesions if collapse and death are sequelae. the animals will also be anxious and shivering and will become hyperthermic. salivation, diarrhea, and bloat also occur. immediate therapy must include epinephrine by intravenous infusion at (1 ml of 1:1000 per 50 kg of body weight for goats and 1:10,000 (0.1 mg/ml) or 0.01 mg/kg (about 5 ml) for adult cows.) furosemide (5 mg/kg) may be beneficial to reduce edema. prognosis is usually guarded. recovery can occur within 2 hr. in a research environment, catheter sites or experimental surgeries may be sources of iatrogenic infection. traumatic injuries to peripheral nerves can cause acute lameness. improper administration of therapeutics can easily cause this type of lameness. injections given in gluteals or between the semimembranosus and semitendinosus can cause irritation to the sciatic nerve and subsequent lameness. contraction of the quadriceps results in the limb being pulled forward. injections in the caudal thigh can damage the peroneal nerve and cause knuckling at the fetlock. traumatic injury to the radial nerve can result in a "dropped elbow" (nelson, 1983) . husbandry procedures such as tail docking, castration, dehorning, dosing with a bailing gun, and shearing may result in superficial lesions, dermal infections, or cases of tetanus. bailing-gun injuries to the pharynx may lead to cellulitis with coughing, decreased appetite, and sensitivity to palpation. standard veterinary assessment and care are essential for these cases. local and systemic antibiotics with supportive care may be indicated. swelling around peripheral nerves caused by inoculations may be reduced by diuretics and anti-inflammato-ries. mild cases of peripheral nerve damage may recover in 7-14 days. personnel training, including review of relevant anatomy, preprocedure preparation, appropriate technique, careful surgical site preparation, rigorous instrument sanitation, and sterile technique will minimize the incidence of potential complications from surgical procedures. albumin values and foaming urine. the proteinuria also distinguishes amyloidosis (and glomerulonephritis) from other causes of weight loss and diarrhea in cattle such as johne's disease, parasitism, copper deficiency, salmonellosis, and bovine viral diarrhea virus infection. prognosis is poor, and no treatment is reported. neoplasia and tumors are relatively rare in ruminants. lymphosarcoma/leukemia in sheep has been shown to result from infection by a virus related (or identical) to the bovine leukemia virus. pulmonary carcinoma (pulmonary adenomatosis) and hepatic tumors are found in sheep. virus-induced papillomatosis (warts), discussed in section iii,a,2,s, and squamous cell carcinomas have also been reported in sheep. in goats, thymoma is one of the two most common neoplasias reported, although no distinct clinical syndrome has been described. cutaneous papillomas are the most common skin and udder tumor of goats, and although outbreaks involve multiple animals, no wart virus has been identified. persistent udder papillomas may progress to squamous cell carcinoma. lymphosarcoma is reported rarely in goats. although adrenocortical adenomas have been reported frequently and almost exclusively in older wethers, no clinical condition has been described. lymphosarcoma of various organ systems and "cancer eye" (bovine ocular squamous cell carcinoma, or oscc) are the most commonly reported cancers in cattle. lymphosarcoma is described in section iii,a,2,c. lack of periocular pigmentation and the amount and intensity of exposure to solar ultraviolet light are considered important factors in oscc. genetic factors may also play a role. many cases occur in herefords. this is a disease of older cattle; no case has been reported in animals less than 4 years of age. the cancer metastasizes through the lymph system to major organs. treatment in either lymphosarcoma or oscc is recommended only as a palliative measure. the extent of ocular neoplastic involvement is a significant criterion for carcass condemnation. papillomatosis (warts) are common in cattle (see section iii,a,2,s). dental wear is seen most commonly in sheep. as sheep age, excessive dental wear may lead to an inability to properly masticate feed, manifesting as weight loss and unthriftiness. several factors predisposing to dental wear should be considered. the diet should be properly balanced for minerals, especially calcium and phosphorus, because primary or secondary calcium deficiency during teeth development results in softening of the enamel and dentin. dietary contamination with silica (i.e., hays and grains harvested in sandy regions) will lead to mechanical wear on the teeth. likewise, animals grazing or being fed in sandy environments will have excessive tooth wear. sheep older than about 5 years of age are especially prone to tooth wear and should be checked frequently, especially if signs of weight loss or malnutrition are evident. managing the content and consistency of the diets can best prevent the disease. of the ruminants, cows are the most frequently affected by subsolar absesses. dirt becomes packed into cracks in the horny layer of the sole of the hoof, and contamination eventually extends into the sensitive areas of the hoof, with lameness and infection resulting. animals maintained in very soiled or muddy conditions, combined with poor hoof care, are more likely affected. fusobacterium necrophorum is often the pathogen involved. separation of the animal, supportive care, surgical drainage, and antibiotic treatment are indicated. amyloidosis amyloidosis in adult cattle is due to accumulations of amyloid protein in the kidney, liver, adrenal glands, and gastrointestinal tract. the disease has been classified as aa type, or associated with chronic inflammatory disease, although other unknown factors are believed to be involved in some cases. clinical signs include chronic diarrhea, weight loss, decreased production, nonpainful renomegaly, and generalized edema. the loss of protein in the urine contributes to abnormal plasma advances in sheep and goat medicine animals and animal products, subchapter a, animal welfare formulary for laboratory animals domestic animal behavior for veterinarians and animal scientists schlam's veterinary hematology diseases of sheep animal feeding and nutrition guide for the care and use of laboratory animals veterinary drug handbook veterinary medicine: a textbook of the diseases of cattle, sheep, pigs, goats, and horses sheep production and management animal and plant health inspection service (aphis), policy #29, farm animals used for nonagricultural purposes goats the clinical syndromes caused by salmonella infection armed forces institute of pathology (afip) (1995) the effect of stress on the carrier state of salmonella typhimurium in goats bibliography of naturally occurring models of human disease clinical signs, treatment, and postmortem lesions in dairy goats with enterotoxemia: 13 cases control of the estrous cycle the goat industry: feeding for optimal production neurologic disease in sheep and goats modern breeds of livestock the sheep gene map pasteurella haemolytica complicated respiratory infections in sheep and goats ungulates as laboratory animals diagnosis of lameness in sheep an overview of the influence of ace inhibitors on fetalplacental circulation and perinatal development protozoan infections (toxoplasma gondii, neospora caninum, and sarcocystis spp.) in sheep and goats: recent advances cloned transgenic calves produced from nonquiescent fibroblasts transgenic bovine chimeric offspring produced from somatic cell-derived stem-like cells use of an animal model of trichomoniasis as a basis for understanding this disease in women council report: vaccination guidelines for small ruminants (sheep, goats, llamas, domestic deer, and wapiti) (1994) maedi-visna and ovine progressive pneumonia pathophysiology of oestrus ovis infection in sheep and goats: a review experimental surgery in farm animals evaluation of an agar gel immunodiffusion test kit for detection of antibodies to mycobacterium paratuberculosis in sheep veterinary laboratory medicine induction of human tissue plasminogen activator in the mammary gland of transgenic goats pasteurella haemolytica infections in sheep coccidiosis and cryptosporidiosis in sheep and goats the major histocompatibility complex region of domestic animal species brucella melitensis infection in sheep: present and future hemoglobin switching epididymitis in rams current veterinary therapy: food animal practice livestock handling guide: management practices that reduce livestock bruises and injuries, and improve handling efficiency. livestock conservation institute synchronization of oestrus in the boer goat doe: dose effect of prostaglandin in the double injection scheme. south afr guide to the dissection of domestic ruminants reproduction in farm animals review of polyclonal antibody production procedures in mammal and poultry considerations in the design and construction of facilities for farm species clinical update: leptospirosis the sheep as an experimental animal bibliography oflnduced animal models of human disease bibliography of naturally occurring models of human disease postpartum assessment and care of the newborn ruminant animal genetics guide for the care and use of laboratory animals blackleg: a new perspective on an old disease protecting calves from viral diarrhea bovine leukemia virus. part 1: descriptive epidemiology, clinical manifestations, and diagnostic tests bovine leukemia virus. part 2: risk factors of transmission bovine leukemia virus. part 3: zoonotic potential, molecular epidemiology, and an animal model. in "infectious disease in food animal practice bovine leukemia virus. part 4: economic impact and control measures brucella abortus strain rb51 vaccine: its advantages and risks current veterinary therapy: food animal practice neural control of maternal behavior and olfactory recognition of offspring comparison of the burdizzo and rubber ring methods for castrating and tail docking lambs postpartum care of the cow and calf advances in the control of foot rot in sheep mastitis in ewes giardiasis in large animals laboratory diagnostic tests for retrovirus infections of small ruminants effects of dietary vitamin e supplementation during late pregnancy on lamb mortality and ewe productivity myotonia congenita (thomsen) and recessive myotonia genetic and environmental causes of variation in mastitis in sheep the gnrh system of seasonal breeders: anatomy and plasticity genetic organization, polymorphism, and function of the bovine major histocampaticulity complex scrapie in sheep biochemical and morphological expression of early prenatal caprine beta-mannosidosis respiratory infections of sheep dogs are the definitive hosts of neospora caninum a century of classical contagious caprine pleuropneumonia from original description to aetiology sheep and goat practice 2 gene manipulation in goats through biotechnology minimizing morbidity and mortality from cryptosporidiosis managing dairy cows during the transition period: focus on ketosis environmental enrichment for dairy calves and pigs the trypanocidal cape buffalo serum protein is xanthine oxidase oral rehydration therapy for diarrheic calves neonatal ruminant diarrhea techniques for artificial insemination of cattle with frozenthawed semen noninfectious causes of lameness neosporosis: its prevalence and economic impact a review of yersinosis (yersinia pseudotuberculosis infection) dairy goat reproduction maedivisna virus in sheep: a review evaluation of a commercially available vaccine against corynebacterium pseudotuberculosis for use in sheep ruminant production management: control programs for gastrointestinal nematodes in sheep and goats fetal brain injury following prolonged hypoxemia and placental insufficiency: a review managing cryptosporidium and giardia infections in domestic ruminants milk fever: seeking new solutions to an old problem recent advances on ovine chlamydial abortion risk factors for abomasal displacement in dairy cows the spider syndrome: a report on one purebred flock development of ingestive behavior current state of in vivo preclinical heart valve evaluation dermatophilus congolensis infections in cattle and sheep ovine listeric encephalitis coccidiosis in ruminants principles of dairy science human factor ix transgenic sheep produced by transfer of nuclei from transfected fetal fibroblasts the major histocompatibility complex region of domestic animal species clinical reproductive anatomy and physiology of the doe immunobiology of the mammary gland coccidiosis brucella abortus strain rb51: a new brucellosis vaccine for cattle use of age and serum gamma-glutamyltransferase activity to assess passive transfer status in lambs effect of congenitally acquired neospora caninum infection on risk of abortion and subsequent abortions in dairy cattle artificial control of breeding in ewes toxoplasmosis infection in sheep bovine reproductive biotechnology transgenic dairy cattle. genetic engineering on a large scale the effect of intra-mammary inoculation of lactating ewes with pasteurella haemolytica isolates from different sources bovine surgery and lameness reduction of myocardial myoglobin in bovine dilated cardiomyopathy intraosseous infusion of prostaglandin e2 prevents disuse-induced bone loss in the tibia estrous cycle synchronization the bronchopneumonias (respiratory disease complex of cattle, sheep, and goats) the cattle gene map treatment and control of gastrointestinal nematodes in sheep diagnosis, treatment, and management of enteric colibacillosis key: cord-010980-sizuef1v authors: nan title: ectes abstracts 2020 date: 2020-05-11 journal: eur j trauma emerg surg doi: 10.1007/s00068-020-01343-y sha: doc_id: 10980 cord_uid: sizuef1v nan the gertality-score: a feasible and adequate tool to predict mortality in geriatric trauma patients introduction: a large number of prediction models and subsequent outcome scores for trauma mortality have been developed over the last decades. however, feasible scoring systems for the severely injured geriatric patient are lacking. the aim of this study was to develop a new mortality prediction model for severily injured geriatric patients. materials and methods: the german trauma registry was utilized and all geriatric individuals (c 65 years) admitted between 2008 and 2017 with an iss [1] c 9 were included. patient and trauma characteristics, diagnostics, therapy and outcome data were gathered. the specific odds of all variables for mortality were calculated. relevant variables were added to the novel gertality-scoring system. subsequently, this score as a sole predictor for mortality was compared with the geriatric trauma outcome score 2 , iss, patient's age and max ais. results: a total of 58.055 trauma patients with a mean age of 77 years were included. based on the univariable analysis, the following five variables were included in the gertality-score: age c 80 years, pbrc-transfusion requirements from admission to ward, asa-score c 3, gcs b 13, ais c 4. the values of a given parameter are added to reach the total gertality-score (range 0-5 points). the auc found in the novel gertality-score was 0.803, whereas the geriatric trauma outcome score had an auc of 0.784. conclusions: the novel gertality-score is a simple and feasible scoring system that enables an adequate prediction of the probability of mortality in severely injured geriatric patients by using only five specific parameters. references: 1. champion hr, et al. the major trauma outcome study: establishing national norms for trauma care. j trauma. 1990; 30:1356-65. 2. zhao fz, et al. estimating geriatric mortality after injury using age, injury severity, and performance of a transfusion: the geriatric trauma outcome score. j palliat med. 2015; 18(8) :677-81. the longer the better! 'extending thawed plasma shelf life to 14 days' introduction: major bleeding is one of the most common causes of death after severe polytrauma. one of the most recent interventions that aims for bleeding control is resuscitative balloon occlusion of the aorta (reboa). this study aims to compare macro-and microcirculatory changes of intraabdominal organs and the lower extremity during the use of reboa. materials and methods: six pigs were anesthesized and received a median laparotomy. the reboa catheter (reliant balloon, medtronic) was inserted via the inguinal artery and occluded in zones 3, 2 and 1. the occlusion of the reboa was vizualized with fluoroscopy. the balloon was inflated for 10 min per zone. during this time the local microcirculation was measured with oxygen to see (o2c, lea). between each zone the balloon was deflated for 10 min. blood pressure was measured at the carotis artery and the femoral artery. results: baseline values of microcirculation differ significantly among organs. the flow rate is significantly higher in intraabdominal organs (colon 205.7 a.u., stomach 170.2 a.u.) compared to the extremity (67.0 a.u., p \ 0.001). blood pressure measured at the carotic artery increased significantly after inflation of the balloon (p \ 0.001). this increase depends on the zone of inflation (increase of ? 60 mmhg in zone 1 compared to baseline). the increase of blood pressure after inflation in zone 3 is comparable to the baseline value. the colon is most sensitive to changes of microcirculation whereas the stomach and the extremity are most robust. conclusions: reboa is a new device to control for massive bleeding. different organ systems react differently to the same occlusion of the aorta. the systemic blood pressure does not mirror the local microcirculation of the abdominal organs. during emergency resuscitation with reboa these changes should be kept in mind. none of the authors have any conflicts of interests to declare. investigation of coagulopathies and its relevance with mortality and transfusion rates using thromboelastography in trauma patients introduction: fibrinolysis shutdown after injury is a common and lethal coagulopathic phenotype. patients with polytrauma, especially those with brain hemorrhage, require delayed initiation of prophylactic or therapeutic anticoagulation despite a measurable hypercoagulable state. to understand and modulate the post-trauma coagulation milieu, we assess patients with daily thromboelastography(teg). we hypothesized that persistently high clot strength and low dissolution is associated with thrombotic adverse outcomes in severely injured patients. materials and methods: adult patients with blunt or penetrating injuries admitted to the icu of a level i urban trauma center from jan-jul 2019 were included. adverse outcomes were defined as death, ventilator-free-days (vfd) = 0, acute lung injury (ali), acute kidney injury (aki), and venous thromboembolic events (vte). we assessed trends of clot dissolution (fibrinolysis, ly30%) and strength (maximum amplitude, ma) in the first 5 icu days using linear mixed models to account for repeated measures and missing observations. ly30% was box-cox power-transformed to approximate normality. significance for pairwise comparisons at each time was adjusted by false-discovery-rate. results: 175 patients: median age 48-years, 23% female, iss 15 (iqr 9-24), 89% blunt mechanism, median 4 icu days . overall, 16% developed one or more of the following; 9%vfd = 0, 8%ali, 14%aki, 5%vte, 7%death. ly30 was persistently lower in patients with adverse outcomes compared to those without (interaction time*adverse_outcomes p = 0.046), with fdr-adjusted significant differences at icu days 1 and 2 (fig 1) . conversely, ma did not differ significantly by adverse outcome status(interaction time*complications p = 0.44, fig 2) . conclusions: low clot dissolution, not clot strength, is associated with adverse outcomes in severely injured trauma patients. additional work is underway for earlier identification of sd phenotypes and strategies to mitigate impaired fibrinolysis. introduction: angioembolization (ae) is can be both diagnostic and therapeutic in management of a hemodynamically unstable trauma patient. however, patients who would benefit from ae typically require emergent surgery for their injuries. the critical decision of transferring a patient to the operating room versus the interventional radiology suite can be bypassed with the advent of intra-operative angioembolization (ioae) . while the ability to perform such an intervention was previously limited by the availability of costly rooms termed raptor (resuscitation with angiography, percutaneous techniques and open repair) suites, it has been suggested that using c-arm digital subtraction angiography (dsa) is a comparable alternative. this case series aims to establish the feasibility and safety of ioae. materials and methods: we conducted a retrospective anlaysis of all trauma patients at our level 1 trauma centre who underwent ioae with a concomitant surgical intervention from january 2011 to april 2019. results: a total of 49 patients (79.6% male, 43.9 ± 17.3 years, 91.8% blunt) underwent ioae using the c-arm dsa. all but one patient underwent exploratory laparotomy, 20.4% of which underwent an additional surgical procedure (ex. exploratory thoracotomy, orthopaedic). either gelfoam (89.8%), coils (2.0%), or a combination of both (8.2%) were used for embolization. internal iliac embolization was performed in 85.7% of cases (57.1% bilateral) and five patients (10.2%) required hepatic embolization. ae was successful in all but one case, inferior vena cava filters were placed in 71.4% of cases, and 12.2% of patients required a second ae. the 30-day mortality was 30.6%. conclusions: our results suggest ioae is a feasible and safe management option in severe trauma patients with the advantage of concurrent operative intervention and ongoing active resuscitation with good success in hemorrhage control. introduction: partial resuscitative endovascular balloon occlusion of the aorta (reboa) is a new concept of aortic occlusion to reduce the ischemic injuries below the occlusion level. it is, however, difficult to determine when the occlusion is partial in a clinical setting. end-tidal carbon dioxide (etco2) is a product of aerobic metabolism and its production is reduced during ischemia and anaerobic metabolism. the aim of this study was to investigate if etco2 is a good predictor of the degree of aortic occlusion during normovolemia and hemorrhagic shock in a porcine model. methods: nine pigs, 25-32 kg, were anesthetized and surgically prepared. then, gradual zone 1 aortic occlusion by 33%, 66% and 100% was induced, during first normovolemia and then controlled hemorrhagic grade iv shock. hemodynamic/respiratory variables, blood gases, aortic/mesenteric blood flow, blood pressure of common femoral artery and etco2 were measured continuously. oxygen consumption and carbon dioxide production were calculated for each timepoint for correlation measurement to different methods for partial occlusion determination. background: acute appendicitis is one of the most common surgical emergencies worldwide. the aim of this meta-analysis of randomized controlled trials was to compare the safety and efficacy of antibiotic treatment versus appendicectomy as the primary treatment for patients diagnosed to have acute appendicitis. methods: a systematic online search was conducted using the following databases: pubmed, scopus, cochrane database, the virtual health library, clinical trials.gov and science direct. only randomized controlled trials (rcts) that compared antibiotics treatment (a) versus surgical treatment (s) as primary treatment of appendicitis were included. results: eight rcts with 1.849 patients were included: 897 in the antibiotics group and 952 in appendicectomy group. higher rate of treatment success was noted in appendicectomy group 96.5% versus only 67.8% in the antibiotics group (p \ 0.00001) (fig. 1 ). follow up period for recurrence was one year in all studies and the recurrence at 1 year was reported in 15.2% (136/897) of patients treated with antibiotics and 69.9% (95/136) of them underwent appendicectomy. moreover, rate of overall were 8.3% in a group and 16.2% in s group (odd ratio 0.44 [0.21-0.94], ci 95%, p-value: 0.0002) (fig. 2) . a longer length of hospital stay was reported among antibiotics group (2.96 ± 0.52 in a group versus 2.51 ± 0.56 in s group, p 0.02). conclusions: appendicectomy has significantly higher efficacy rate but higher complications rate when compared to antibiotics treatment. most of the studies included in this meta-analysis conveyed a high risk of bias, hence more well-designed rcts are recommended. introduction: post-operative adhesions are associated with increased risk of morbidity and mortality. up to date no effective measures has been introduced to decrease intra-abdominal adhesions following laparotomy. oxiplex-ap gel has been used in extra-abdominal surgical procedures to prevent adhesions. in the current study oxiplex-ap was tested in a mural animal model to investigate its efficacy in reducing post-surgical intra-abdominal adhesions. materials and methods: forty rats subjected to laparotomy were randomly divided into 4 groups of 10. a serosa injury was made on the small intestine and three different treatments were applied: simple suture, simple suture ? oxiplexap, and oxiplex-ap only; the last group received no treatment of the injury before closure of the abdomen. all animals were kept alive for 14 days, and a second laparotomy was done to measure the intra-abdominal adhesion by the nair classification. results: at second look laparotomy a significant difference in adhesion was noticed between the simple sutures and simple suture ? oxiplex-ap were the latter had developed less adhesions. there was also a trend towards less adhesion development between the simple sutures and oxiplex-ap only group, with less adhesions in the latter. conclusions: the use of oxiplex-ap was associated with decrease adhesion formation in the current animal model particularly without suturing. further investigations into these findings are needed. introduction: emergency abdominal surgery is known to result in high morbidity and mortality. furthermore, evidence suggests that unplanned admissions to the intensive care unit (icu) are associated with higher in-hospital mortality than those patients with planned icu admissions 1 . the aim of the study was to describe the patient population who required an unplanned admission to icu following emergency laparotomy at the royal melbourne hospital. materials and methods: a single-centre retrospective observational study was performed using prospectively collected data between 2012 and 2017. patients who underwent an emergency laparotomy and experienced an unplanned icu admission were included. patients who underwent a trauma laparotomy were excluded from the study. results: 764 emergency laparotomies were performed. of these, 94 (12.3%) required an unplanned admission to icu. fourty-two patients (45%) were female, and 60 patients (64%) were aged 60 years and above. sixty-three (67%) were admitted due to single organ dysfunction (clavien-dindo iva). the median time to icu admission was 5 days in patients classified to have experienced clavien-dindo iva, while it was 6 days in patients who experience multi-organ dysfunction (clavien-dindo ivb). thirty-seven patients (39%) were admitted to icu due to complications classified as cardiopulmonary. conclusions: recognising that emergency laparotomy is a high risk procedure, with the elderly patients accounting for the majority of unplanned icu admissions, it is imperative to utilise risk stratification methods to guide optimal peri-operative management. this should result in improved utilisation of critical care resources and overall patient outcomes. introduction: the way of reconstruction following intestinal resection in the emergency settings is still controversial. the question which is better between hand-sewn and stapled anastomosis in trauma and emergency surgery occasionally arises; however, there have been few reports comparing these methods. materials and methods: a record-based retrospective study was performed to compare hand-sewn with functional end-to-end anastomoses in trauma and emergency operations from october 2014 to october 2019 in one of the largest trauma and emergency centers in japan. the patients who had intestinal resection with functional endto-end or hand-sewn anastomosis in an emergency surgery were included. the patients who had covering ileostomy or colostomy, or who underwent surgery as an elective operation were excluded. the primary outcome is the rate of complication associated with anastomosis. the statistical analyses were performed using a chi introduction: injuries are the fourth leading cause of death in europe. laparotomy is the standard treatment for penetrating abdominal wounds. because of the morbidity and the high rate of negative laparotomies, the nonoperative treatment is effectively developing. the aim of this study is to analyze the complications and the quality of life of the patients after laparotomy for this kind of wounds. materials and methods: a retrospective cohort of patients was studied between 2007 and 2016 at the laveran military teaching hospital in marseille. one hundred and eighty-six trunk gunshot or stab wound were recorded, including 74 abdominal wounds. thirtyfour patients were managed by laparotomy and included in this study. the patients and their referring general practitioners were contacted to complete missing data and the sf-12 quality of life score. results: among the 34 patients included, the average age was 39 years and most of them were men. the indication for laparotomy was mainly based on the hemodynamic instability, then according to the results of the computed tomography in case of suspicion of specific lesions: bowel injuries, major vascular injury, mesenteric or mesocolic vascular injury, diaphragmatic injury and intraperitoneal bladder rupture. only 5 laparotomies were negatives. eleven complications after laparotomy were found (32,4%), including 7 early (within the 30 days) and 4 late. no complication was found after negative or non-therapeutic laparotomies. the quality of life of the patients after one year is similar to those of the general population. conclusions: the most common indication for laparotomy for abdominal penetrating trauma is hemodynamic instability. the rate of laparotomy complications for penetrating abdominal trauma is similar to those of scheduled surgeries. the quality of life after this care remains unchanged. these results may insist on the fact that the ''gold standard'' treatment for penetrating abdominal injury remains the laparotomy objectives: splenic artery embolization (sae), a routinely used adjunct in the non-operative management (nom) of splenic injuries(si), was widely adopted in trauma about two decades ago. we examined complications that occurred with this modality at a level 1 trauma center over a recent 8-year period and compared this to the prior 11 years. methods: patients who had sae for si between 2011-2018 were identified. sae complications were noted. splenic abscess, splenic infarction and contrast-induced renal insufficiency were considered major complications. coil migration, fever and pleural effusions were regarded ''minor'' complications. the results were compared with data from a prior study examining similar indices at the same trauma center between 2000 and 2010. fishers exact test was used for comparison. results: there were 716 patients admitted with si in the recent period, of which 159 (22%) underwent immediate splenectomy. sae was performed in 74 (13.3%) of the 557 patients who underwent nom. of these sae patients, 50% had a contrast blush and 41.9% were either aast grade 4 or 5. five sae patients (6.8%) had splenectomy for continued bleeding. the overall complication rate was 28.4%. major complications occurred in 11 patients (14.9%) and minor in 13 patients (17.6%). embolization location in the splenic artery was proximal in 54.1%, distal in 20.3% and in both in 25.7%. there was no association between complications and coil location by logistic regression. differences between the two periods shown in table 1 . conclusion: sae continues to be a useful adjunct in nom of si and has seen increased utilization. complications continue to occur,although fewer minor complications were noted in the second period. no association between embolization location and complications was noted in the recent period. judicious utilization of sae is imperative given the complications that continue to be noted from this procedure. the effect of the time spent in the emergency department on the mortality rates and cause of death in patients who underwent emergent laparotomy introduction: the purpose of this study was to a) examine the effect of the time spent in the emergency department (ed) on hypotensive patients in need of emergent laparotomy and b) to determine the mortality rates and cause of death in these patients. materials and methods: between 2007-2017, 184 patients were included (99 men and 85 women, mean age 45.2 years) who underwent laparotomy less or equal to 90 min from ed admission. of the 184 patients, 107 (group 1) had a systolic blood pressure (sbp) greater than 90 mmhg and 77 had a sbp less or equal to 90 mmhg. all patients had abdominal injuries with an injury scale score (iss) between 3 and 6. the in-hospital mortality represented the primary outcome, while secondary outcomes included cause of death and time to death. results: in this study both groups spent a median of 51 min in the ed, but the time from the ed to the operating theatre was shorter in the group 1 (40 min versus 76 min). in total, the mortality rate was 27%, but in the group 1 the mortality was 49%. the sbp on arrival in the ed was strongly associated with the risk of death. furthermore, we observed significant positive correlation between the probability of death and the time spent in the ed, with an increase of probability of death equal to 0.40% per minute spent in the ed. in both groups the hemorrhage was the commonest cause of death (62%). the results of this study indicate that, in patients with abdominal injuries requiring emergent laparotomy, the probability of death is proportional to both extent of hypotension and the length of time spent in the ed. especially, in patients who were presented with a sbp inferior of equal of 90 mmhg, this probability increased as much as 2% for each 5 min. despite many advances in trauma surgery, half of hypotensive patients are going to die in the first 24 h. introduction: injury to the pancreas may lead to significant morbidity and mortality. we studied the prevalence of pancreatic endocrine and exocrine functions and evaluated the morphological regenerations in pancreas following partial pancreatectomy. materials and methods: patients with pancreatic trauma were recruited ambispectively from january 2010 to december 2017. endocrine functions were assessed at the time of admission and at 6 months follow up with 75 g oral glucose tolerance test (ogtt), serum insulin and c-peptide levels, hba1c estimation and exocrine functions were assessed with faecal elastase test. pancreatic volumetry was done with imaging studies at 1-and 6-months post discharge. results: twenty patients were studied with a median age of 30 years at the time of injury. all the patients were normoglycemic on admission; only one patient who underwent pancreatic resection developed diabetes mellitus requiring insulin on follow up. 7 patients (35%) were found to have prediabetes by american diabetes association (ada) criteria. 11 patients (55%) had pancreatic exocrine insufficiency. pancreatic volume increment, from mean pancreatic volume of 48.65 cm3 to 54.29 cm 3 , was noted in partial pancreatectomy patients. conclusions: overt endocrine and exocrine insufficiency is rare in pancreatic trauma patients. but subsets of patients are biochemically predicted to have higher risks of endocrine dysfunction and exocrine insufficiency. hence, while dealing with pancreatic trauma patients, one should remember the possible metabolic disorders associated and the need for specific investigations. pancreatic volume increment is a new finding which opens up more opportunities for further research. hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal, 2 hospital de santo espírito da ilha terceira, orthopedics and traumatology, angra do heroísmo, portugal introduction: rope bullfights are traditional events in the azores islands, where a bull is set on the streets, arrested by a rope on its neck. around 220 events happen every year and it is already part of the island's touristic attractions. inevitably, every year, people get injured either from direct trauma with the bull or from falls when trying to escape from the animal. the aim of this study was to characterize the type of injuries that occur in these bullfighting events, as to their incidence, mechanism of injury, anatomical affected area and severity. materials and methods: we prospectively registered all cases of injured people who suffered any type of trauma during rope bullfights and received emergency therapy in the local hospital, between 2018 and 2019. results: 56 patients recured to the emergency department, 16.1% female, with mean age of 44.2 years. regarding the mechanism of injury, 66.1% occured due to direct trauma to the animal while in the remaining 33.9% resulted from falls during escape or handling of the rope. the most commonly affected anatomical areas were the limbs (39.3%) followed by the head and neck (23.2%) and thorax (7.1%). in 26,8% of the cases, patients suffered from multiple traumas. in 76.8% of the cases the treatments performed were wound care, wound closure and/or symptomatic therapy. in total, 10 patiens were hospitalized, 5 patients required interventions in the operating room (4 closed fracture reductions and 1 exploratory laparotomy with splenectomy) and 2 patients were hemodynamically unstable upon admission (hypovolemic shock due to splenic fracture and cet). conclusions: the rare articles published describe the mechanisms of injury associated with bullfights in spanish centers and injuries resulting from wild cow accidents in indian cities. this is the first local descriptive study on the prevalence of traumatic injuries associated to this specific type of rope bullfights. introduction: the two-stage splenic rupture is seldom, its risk is unpredictable and a precise diagnosis of a ct and/or mri imaging unexpectable or unexcludable. generally, and due to our experience and current literature a two-stage rupture occurs within one week after trauma. though dramatic courses after two or three weeks are known. therefore, it is suggested to perform a prophylactic angioembolization in (still) hemodynamically stable patients. materials and methods: a retrospective study in a level-one trauma centre of switzerland did analyse all patients that underwent a prophylactic angioembolisation after an explicit diagnose by ct and/or mri of a splenic parenchymal lesion after trauma between 2010 and 2016. further inclusion criteria were hemodynamical stability (sys rr [ 90 mmhg) and missing indication for immediate laparotomy. results: 11 patients (4 f, 7 m) with an average age of 44 ± 15 years underwent preemptive angioembolisation after traumatic lesions of the spleen. the ais abdomen was 3 in 9 and 4 in 2 patients. besides a splenic injury 3 patients did also have a kidney injury. the overall iss was 22 ± 5 points. 8 patients suffered additional thoracic or head trauma. in 5 patients the angioembolisation was performed on admission, in 1 on the 1st, in 3 at the 2nd and respectively 1 in the 3rd and 4th day of. in 1 case an uncomplicated selective embolization of a main duct of the splenic artery was performed. in 10 patients the trouble-free proximal embolization of the splenic artery was done. the average stay was 11 ± 6.0 days. no deaths or complications seen due to angioembolisation or splenic rupture. there were no complications or operative introduction: traumatic abdominal wall hernias (tawhs) are uncommon, and the optimal management is debated. tawhs most often result from blunt trauma and are associated with severe intraabdominal injuries. our institutional protocol mandates primary repair only if the patient undergoes laparotomy for other reasons and is without mesh. since 2011, primary repair of lumbar hernias included bone anchors when indicated. we wanted to describe the tawh patients treated operatively during initial hospitalization focusing on injury mechanism, diagnosis, associated injuries, operative techniques, early complications and outcomes. materials and methods: we performed a retrospective, descriptive cohort-analysis of data from the institutional trauma registry from 2007-2018. all operatively managed tawhs were identified based on ais codes, ncsp codes and relevant key words. results: of the 30 identified patients, 14 (47%) were women. median age was 37 years (range 10-73). median iss was 20 and 21 patients had iss [ 15. injury mechanism was blunt except for one explosion. 25 patients (84%) had been in a mvc, and 23 of these (92%) had seat belt injuries. 22 of these patients had a disruption of the muscle from the iliac crest, and one had a hernia through a fractured iliac wing. 3 bicycle falls and 1 fall from height had hernias in the anterior abdominal wall. two meshes were placed, with no known complications. bone anchors (twinfix ò 3,5 mm) were used in 7 patients. no recurring hernias were identified in the 18 patients with routine follow-up (1-21 months) . conclusions: surgery for tawh is uncommon in our institution. tawh is often associated with severe torso injuries and primary repair is only done when laparotomy for other reasons is indicated. primary suture of the muscle, including use of bone anchors seems to be adequate treatment, as we have identified no recurrences. a longterm follow-up study is warranted for operated and non-operated patients with tawh. a comparison of sub-specialty operative adolescent patient outcomes in adult and pediatric trauma centers introduction: adolescent trauma victims may be treated at either an adult (atc) or pediatric trauma center (ptc). these centers have different resources, surgeon training and overnight in-house coverage. it is not known how outcomes compare with regards to the very small subset of patients that actually undergo a surgical trauma intervention. we hypothesized that presentation to a ptc would yield increased mortality when subspecialty intervention was required and that this would be most pronounced at night when in-house attending coverage is absent at all state ptcs. materials and methods: a review of the pennsylvania trauma outcome study (ptos) database was performed to capture patients aged 12-18 who underwent any non-orthopedic trauma surgery. cohorts were created for cranial, thoracic, abdominal or vascular surgery from 2007-2017. trauma centers were divided as adult level 1 (atc1), adult level 2 (atc2) or pediatric (ptc). groups were created based on time of arrival with 7am-7pm being dayshift and 7:01pm-659am being night shift. age, race, mechanism of injury, vital signs, gcs, iss, los and mortality were evaluated. ancova was utilized to control for iss variation. spss was used for all analyses. results: 1851 patients met initial criteria. atc1s saw more minority patients and more males than other center types. atc1s saw an overall older cohort (16.9 years vs 16.6 years in atc2 and 14.6 years in ptc, p \ 0.001). despite this age difference, presenting systolic blood pressure was lowest at the atc1s (117.8 mmhg vs 125.7 mmhg at atc2 and 125.34 mmhg at ptc, p \ 0.001). iss and triss and overall mortality were not different and this included when grouped by day or night shift. of note, trauma thoracotomy was more likely to be performed at night in adult centers. hospital length of stay was significantly lower for atc2 (8.33 days vs 10.41 in atc1 vs and 11.38 in ptc). conclusions: adult and pediatric trauma centers see different patients. operative trauma cases are surprisingly low at our state's ptcs and trauma thoracotomy was more likely to be performed at night in atcs than ptcs. broader study is needed to uncover differences in operative care and outcomes. treatment of dislocation of the patella as a result of sports injuries in children. forecast and consequences in adulthood k. furmanova 1 , o. loskutov 1 , a. naumenko 1 1 medinua clinic and lab, ortopedics, dnepr, ukraine introduction: dislocations of the patella with a rupture of the medial patellofemoral ligament (mpfl) account for 8-10% of acute injuries of the knee joint [1, 2] . inadequate therapeutic tactics of these injuries in childhood and youth, as a result of sports injuries, are fraught with complications in the form of the instability of the knee joint, residual deformities and contractures in patients in adulthood [2, 3] . materials and methods: in the period from 2014 to 2018 349 cases of rupture of mpfl among children aged 7-18 years who were involved in sports were observed. the examination included conducting a clinical examination, axial radiography with flexion of the joint at angles of 45°and 90°, mri of the knee joint. results: in 87.9% (307 cases) the integrity of the mpfl(with a reduced number of sutures) was restored using a yamamoto suture, and in 42 cases (12.1%), the autoplasty of the mpfl was performed. excellent medium-term (5 years) clinical and functional results according to the ikdc scale were noted in 80.2% of cases, good in 14.9%, satisfactory in 4.9%. in 12 patients (3.4%) there was a relapse of dislocation after performing an mpfl suture during the first year after surgery mainly due to noncompliance with the recommendations. conclusions: injury to the knee joint with the patella dislocation in childhood and adolescence, associated with a sports injury is an indication for surgical treatment in order to adequately restore the integrity of the mpfl and prevent disabling complications. our yamamoto suture technique is more optimal for treating young patients with instability of the patella and is recommended for widespread use in pediatric orthopedists due to its undeniable clinical advantages. osteotomy with a defect 1 cm placed 8 cm below tibial plateau. 4 types of fixation have been simulated: plate fixation of only a medial pillar, plate fixation of only a lateral pillar, plate fixation of both pillars, and locking intramedullary nailing. results: in case of plate fixation of only a medial pillar, the injury to an interosseal membrane causes an expressed valgus deformation at axial loading, leading to a reasonable (1095.2 mpa) overload of the fixator in the osteotomy area. the use of a lateral plate leads to excessive loading on an external pillar, while the medial pillar remains unsupported. this causes overloads of the fixator in the osteotomy area (880.6 mpa). the double plate fixation is typical of the lowest extent of bone fragments displacements (1.25 mm) . this is a super-rigid type of osteosynthesis, able to cause a stress-shielding syndrome in the adjacent bone. it has been estimated that the method of im nailing is an optimal fixation method, with minimum loading of the fixator (250.4 mpa) and the best distribution of changed elastic strains in the bone-implant system. conclusions: the mathematical simulation demonstrates that fixation by a medial plate is possible only if support functions of the ligament system and interosseal membrane remained intact. if an injury is a high-energy one, nailing is preferable. introduction: treatment of large bone defects is one of the great challenges in contemporary orthopedic and traumatic surgery. grafts are necessary to support bone healing. a well-established allograft is demineralized bone matrix (dbm) prepared from donated human bone. a recent development is a new fibrous demineralized bone matrix (f-dbm) with a high surface-to-volume ratio. in this study we examine toxicity of an innovative dbm fibers preparation. materials and methods: f-dbm was transplanted to a 5 mm, platestabilized, femoral critical-size-bone-defect of 5 mm in sprague-dawley (sd)-rats (n = 6). healthy animals were used as control. after 3 months histology, hematological analyses as well as serum biochemistry was performed. were measured as indicators of free radical exposure. there were no significant differences between the control group and animals receiving f-dbm. hematology as well as biochemistry did not differ between operated animals and control. histologically no evidence of damage to liver and kidney and a good bone healing could be observed in most cases. conclusions: taken together, these results provide evidence for no systemic toxicity of the bone allograft. i have received no significant financial interest, consultancy or other relationship with products, manufacturer(s) of products or providers of services or financial support related to this abstract. • i hereby confirm that my abstract is based on previously unpublished data and that i own the rights to the written summaries of research or observations presented in the abstract, or that i have obtained permission for the acknowledged sources for other excerpts taken from copyrighted works. • in submitting an abstract i hereby agree that the copyright of my abstract is transferred to the european society of trauma and emergency surgery. • i hereby confirm that i will present my abstract at the congress in case it is accepted. sponsor: german institute for cell and tissue replacement (dizg, gemeinnützige gmbh), berlin, germany. intramedullary nailing through suprapatellar approach in distal tibia fractures: a retrospective study evaluating clinical and radiographic results d. bustamante recuenco 1 , a. gómez 1 , j. m. pardo garcía 1 , e. garcía 1 , p. castillón 2 , p. caba doussoux 1 1 hospital 12 de octubre, madrid, spain, madrid, spain, 2 hospital mutua terrasa, orthopaedics, barcelona, spain introduction: distal tibia fractures (dtf) can be operated either by intramedullary nailing (imn) or by orif with plates. the current literature shows a higher rate of malalignment and consolidation delay with imn when compared to plates. in these studies, an infrapatellar approach for the imn is performed. recent studies show a better alignment in dtf treated with imn by suprapatellar approach, though functional and biological outcomes have not been analyzed yet. our goal is to assess the clinical and radiographic results of the treatment of dtf with imn using a suprapatellar approach. materials and methods: a two-center retrospective study was performed, collecting the cases with dtf treated with suprapatellar imn from 05/2011 to 08/2018. results: a total of 82 patients were obtained, with a mean age of 45.5 years. the average follow-up was 13 months. 82% of the fractures were ao type 43a, presenting the remaining 18% intra-articular involvement. 6 patients presented complications, corresponding in 4 of them to superficial infections. as for clinical results, complete mobility in the knee and ankle was obtained in almost all cases. at the radiographic level, a total of 15% (12) of distal malalignment cases were detected, defined as more than 5°deviation from normal axis in the coronal and sagittal planes. most of the fractures consolidated in a period of 3-4 months. there were 13 cases of delayed consolidation, from which 2 developed pseudoarthrosis. conclusions: intramedullary nailing through a suprapatellar approach for dtf offers good clinical and radiographic results, with low rates of malalignment and lack of consolidation. more studies are required to compare the results obtained with other fixation methods for these fractures. reference: avilucea fr, triantafillou k, whiting ps, perez ea, mir hr. suprapatellar intramedullary nail technique lowers rate of malalignment of distal tibia fractures. j orthop trauma. 2016;30(10) :557-60. the clinical consequences of follow-up radiographs in ankle fractures are unclear and indications for these radiographs are seldom well-defined. routine radiographic imaging in the follow up of patients with an ankle fracture adds to treatment costs, although retrospective studies dispute its usefulness. the aim of this study was to assess if a protocol with a reduced number of routine radiographs would lead to cost savings, without compromising clinical outcomes. materials and methods: a multicentre randomized controlled trial was conducted. patients were randomly assigned in a 1:1 ratio to usual-care (consisting of routine radiography at one, two, six and twelve weeks) or reduced-imaging (radiographs only obtained for a clinical indication at six and twelve weeks). functional outcome was assessed using the omas and aaos ankle questionnaires, quality of life was measured with eq-5d-3l and sf-36 questionnaires. other outcome measures included complications, pain, the number of radiographs, health perception and self-perceived recovery. costs were measured with self-reported questionnaires results: the study group consisted of 247 participants, of which 154 (63%) received operative treatment. patients in the reduced-imaging group received median 4 radiographs, whilst patients in the usual care group received median 5 radiographs (p \ 0.005). omas, aaos scores, quality of life, pain, health perception and self-perceived recovery did not differ between groups. we observed 32 complications in the reduced imaging group. this did not differ significantly from the usual care group (29 complications p = 0.51). a significant reduction in radiographic imaging costs was observed (-€48 per patient, 95% ci -72 to -25). overall costs per patient were comparable (130 [95% ci -2975 to 3723]). conclusions: implementation of a reduced imaging protocol in the follow up of ankle fractures leads to cost savings and more importantly does not lead to worse functional outcomes. results after percutaneous and arthroscopically assisted osteosynthesis of calcaneal fractures w. grün 1 , m. molund 2 , f. nilsen 2 , a. stødle 1 1 oslo university hospital, orthopaedic department, ullevål, oslo, norway, 2 østfold hospital, orthopaedic department, grålum, norway introduction: operative treatment of calcaneal fractures using the extensile lateral approach is associated with high rates of soft tissue complications. during the last years there has been a trend towards less invasive fixation methods. percutaneous and arthroscopically assisted calcaneal osteosynthesis (paco) combines the advantages of good visualization of the posterior facet of the subtalar joint with a minimally invasive approach. materials and methods: we conducted a clinical and radiographic follow-up of 24 patients with 25 calcaneal fractures treated by paco with a minimum follow-up of 1 year. there were 16 sanders ii and 9 sanders iii fractures. the mean follow-up period was 17.6 months (sd 6.7). our primary outcome was the american orthopaedic foot and ankle society (aofas) ankle-hindfoot score. secondary outcomes were the calcaneus fracture scoring system (cfss), the manchester-oxford foot questionaire (moxfq), the visual analog scale (vas) for pain and the incidence of complications. radiographs were obtained to evaluate the reduction of the fractures as well as the presence of subtalar osteoarthritis. results: the median aofas score was 85 (range, 50-100), the cfss score 85 (26-100), the moxfq score 26.6 (0-76.6). the vas pain score was 0 (0-5.7) at rest and 4.05 (0-8.2) during activity. the böhler angle improved from mean 3.5 degrees (sd 12.6) preoperatively to 27.8 degrees (10.7) postoperatively. however, the follow-up radiographs showed subsidence of the fractures and a böhler angle of 20.4 degrees (13.2). 96% of the operated feet showed signs of posttraumatic subtalar osteoarthritis. there were no wound healing complications. two patients were reoperated with screw removal due to prominent screws. conclusions: our results suggest that paco gives good clinical results and a reduced risk of complications in selected calcaneal fractures. prospective longterm studies will be necessary to better evaluate the potential advantages and limitations of paco. with the nascent state of microsurgical services in the region the application of negative pressure wound therapy (npwt) has proven to be very helpful. an improvised npwt has made it locally available to patients. this report aims to show how this has improved the management of open fractures of the lower limb in a resource restricted setting. materials and methods: a 30-month review of cases of lower limb open fractures managed at a regional trauma centre in nigeria was done. the type of wounds were classified based on region and need for soft tissue coverage. results: a total of 256 cases were reviewed approximately 53% of these case were gustilo and anderson type iii. of these 87 had npwt as part of their management. some of the benefits of observed were; reduced frequency of wound dressings, and shorter time to optimize wound for closure. conclusions: the locally improvised npwt has proven to be an affordable and cost-effective tool in the management of open lower limb fractures. it remains an invaluable alternative of care in the absence of microsurgical skills and patented device with are far from reach owing to financial constraints. references: 1. hussain a, singh k, singh m. cost effectiveness of vacuum assisted closure and its modifications: a review. isrn plast surg. 2013; 2013:1-5. 2. isiguzo c, ogbonnaya i, uduezue a. modification of negative pressure wound therapy in the economically constrained region: a preliminary report. vol. 8, nigerian j plast surg. joytal printing press; 2012. p. 39-43. 3 . mba u, nevo a. challenges of limb salvage in a resource limited environment: case report and review of literature. niger j plast surg. 2018;14(1): 5. 4 . novak a, wasim sk, palmer j. the evidence-based principles of negative pressure wound therapy in trauma and orthopedics. open orthop j. 2014; 8:168-77 . introduction: lower extremity vascular trauma may result in limb loss or mortality. this study examined outcomes of lower extremity vascular trauma (levt) and potential associations to amputation/mortality. materials and methods: a retrospective cohort study of patients (n = 79; 82 limbs) with levt between 2000 and 2018 in a single trauma center. only patients requiring a vascular procedure were included. data were extracted from the swedish vascular registry (swedvasc) and the swedish trauma registry (swetrau). results: mean age 35 ± 17 years; men 85% (67/79); trauma mechanism 49% (39/79) blunt and 51% (40/79) penetrating. 71% of patients underwent preoperative cta; 30% of patients (23/76) were transferred to hybrid operating room. arterial injury was present in 73/82 limbs (89%) and venous injury in 43/81 limbs (53%). the most frequently injured artery was popliteal artery (25/73; 34%) followed by superficial femoral artery (23/73; 32%). most common vascular operative procedure was arterial bypass/interposition graft (45/82; 55%). a vascular shunt was used in 32% of cases (25/78). fasciotomy was performed in 49% (40/81) of limbs. four patients were lost to follow-up after less than five days. there were eleven limbs (11/75; 15%) amputated within 30-day postoperative follow-up. all amputations were caused by blunt trauma. 28% (7/25) of arterial injuries below-the-knee led to amputation. thirty-day mortality rate was 5.3% (4/75) . univariate analysis showed that fractures (p \ 0.001), soft tissue injury (p \ 0.001), multiple injuries (p = 0.011), and blunt mechanism (p \ 0.001) were associated with amputation and mortality after levt. conclusions: this study showed that amputations after levt are caused by blunt trauma. also levt combined with fractures, soft tissue injury, or multiple injuries increased the risk of amputation and mortality. multi-center study enabling multivariate analysis to adjust for potential confounding factors is imperative to confirm these findings. incidence, treatment and financial burden of tibial plateau fractures in belgium between 2006 and 2018 describe the incidence, evolution in management and financial burden of tpf in belgium between 2006 and 2018. we compare national data with data from uz leuven (uzl), the largest university hospital in belgium. materials and methods: this study includes all tpf treated in belgium between 2006 and 2018. we identified 35.226 tpf, of which 861 fractures were treated in uzl. despcriptive statistics were used to analyze the data. results: the annual incidence increased from 20.6 to 29.1/100,000/y. an increase in number was true for both operatively treated patients (otp) and non-operatively treated patients (notp), but was more pronounced in the latter (31% vs. 68% increase). the rate of surgery (ros) decreased from 41.4% to 35.5%. the mean ros for uzl was 49.0%. the total financial burden in belgium increased with 36%, mainly driven by increasing costs in otp. hospitalisation rates for notp decreased from 34% to 16%, as day hospital admission occured more commonly. the mean hospitalisation cost was €8,754 for otp and €9,103 for notp. costs for uzl inpatients were €10,358 and € 9,163. nursing days accounted for 64% of the cost in otp and 75% in notp. the mean los was 15.8 days for otp and 18.7 days for notp. uzl patients had a mean los of 16.3 and 11.7 days. conclusions: tpf are associated with increasing hospital related healthcare costs. as nursing days determine the majority of the financial burden, measures should be taken to avoid prolonged los. introduction: rotational malalignment (rm) is a common postoperative complication after intramedullary (im) nailing of tibial shaft fractures. computed tomography (ct) is commonly used for detection of malrotation, however reliability is frequently questioned. the purpose of this study is to evaluate the intra-and inter-observer reliability of low-dose protocolled bilateral postoperative ct-assessment of rotational malalignment after im nailing of tibial shaft fractures. materials and methods: a total of 155 patients were prospectively included with tibial shaft fractures that were treated with imn in a level-i trauma center. all patients underwent postoperative bilateral low-dose ct-assessment (effective dose of 0.03784-0.05768 mgy) as per hospital protocol. four observers performed the validated reproducible measurements of tibial torsion in degrees, based on standardized techniques. the intra-class coefficient (icc) was calculated to evaluate intra-and inter-observer reliability. the intra-and inter-observer reliability was categorized according to landis and koch. results: intra-observer reliability for quantification of rotational malalignment on postoperative ct after imn of tibial shaft fractures was excellent with 0.95 (95% ci = 0.92-0.97). the overall inter-observer reliability was 0.90 (95% ci = 0.87-0.92), also excellent according landis and koch. discussion and conclusion: first, bilateral postoperative low-dosesimilar radiation exposure as plain chest radiographs-ct assessment of tibial rotational alignment is a reliable diagnostic imaging modality to assess rotational malalignment in patients following imn of tibial shaft fractures and it allows for early revision surgery. second, it may contribute to our understanding of the incidence, predictors, and clinical relevance of postoperative tibial rotational malalignment in patients treated with imn for a tibial shaft fracture, and facilitates future studies on this topic. the trauma emergency laparotomy audit (tela) t. collaborators 1 , m. marsden 2 , p. vulliamy 2 , r. carden 2 , o. najiuba 2 , n. tai 2 , r. davenport 2 1 tela collaboration, natric, n/a, united kingdom, 2 queen mary university of london, centre for trauma science, london, united kingdom introduction: mortality for shocked trauma patients undergoing emergency laparotomy remains unchanged for 20 years. the tela study aimed to describe the contemporary peri-operative management and patient outcome following abdominal injury. materials and methods: a prospective multicentre observational study of all patients undergoing emergency abdominal surgery within 24 h of injury was performed in the uk and ireland for six months from the 1st january 2019. shock was defined as the receipt of blood transfusion, with clinical or biochemical evidence of hypoperfusion. results: the study included 363 patients from 35 hospitals, of whom 159 (44%) were shocked and received a median of 6 units red blood cells. shocked patients were more likely to have a blunt mechanism of injury (56% vs 32%, p \ 0.01) and had a 20% mortality (32/159). half of these deaths occurred in the operating room (or). patients that died were more severely injured (injury severity score 35 (iqr 24-50) vs 25 (iqr 16-36), p = 0.01) and had a greater degree of shock at hospital arrival (base deficit 13.0 (iqr 7.7-18.1) vs 6.3 (3.2-11.1) , p \ 0.01). processes of care were equivalent or better among non-survivors, with a higher proportion of patients that died undergoing laparotomy within 90 min of arrival in the emergency department (54% vs 26%, p = 0.01) and a lower proportion receiving crystalloid in the or (29% vs 75%, p \ 0.01). however, delays to achieving definitive haemorrhage control and delivering balanced blood transfusion ratios were observed among both survivors and non-survivors. conclusions: damage control resuscitation principles are followed most closely in patients that die. despite better processes of care, 1 in 5 shocked patients died in this study justifying the continued search for novel therapeutic approaches. pre-operative temporary haemorrhage control and pharmacological mitigation of the effects of shock may be productive avenues of research to improve patient outcomes. introduction: tranexamic acid (txa) has been shown to reduce mortality in bleeding trauma patients, with greater effect if administered early. normally administered intravenously, txa can also be administered intramuscularly, which could be advantageous in low resource and military settings. intramuscular use has only been tested in healthy patients, and it is likely that shock will reduce intramuscular uptake. materials and methods: in a prospective experimental study norwegian landrace pigs (40-50 kg) utilised in a surgical course in haemostatic emergency surgery were subjected to various abdominal and thoracic trauma. after 1 h of surgery the pigs were injected with 15 mg/kg txa either intravenously or intramuscularly. blood samples were drawn at 0, 5, 15, 25, 35, 45, 60 and 80 min. the samples were centrifuged and analysed with liquid chromatography-mass spectrometry (lc-ms/ms). results: preliminary results from 3 animals in the intramuscular and 2 animals in the intravenous group. mean plasma concentration with sd of txa as a function of time is shown in figure 1. plasma concentration in the intramuscular group was near 10 ug/ml 15 min after administration, and rose above 14 ug/ml after 60 min. conclusions: plasma concentrations reported to inhibit fibrinolysis in vitro is 10 -17.5 ug/ml (1, 2) . if this extrapolates to the clinical situation intramuscular administration would yield plasma levels within the lower end of therapeutic range after 15 min. in ongoing haemorrhagic shock plasma concentrations of txa after intramuscular administration were considerably lower than after intravenous administration, but within therapeutic range . introduction: fallowing laparoscopic cholecystectomy(lc), patients suffer from postoperative pain, especially in the abdomen. intraperitoneal local anesthesia (ipla) reduces pain after laparoscopic cholecystectomy(lc). acute cholecystitis(ac)-associated inflammation, increased gallbladder wall thickness, dissection difficulties, and a longer operative time are several reasons for assuming a benefit in pain scores in urgent lc with ipla application. the aim was to determine the postoperative analgesic efficacy of high-volume lowdose intraperitoneal bupivacaine in urgent lc. materials and methods: fifty-seven patients, american society of anesthesiologists(asa) physical status i or ii were randomly assigned to receive either normal saline(group a) or intraperitoneal bupivacaine(group b) at the beginning or at the end of the surgery in urgent lc. the primary outcome was the scores of postoperative pain by visual analogue scale score (vas) after surgery. results: postoperative vas scores at 1st and 4th hours were significantly lower in group b than group a (p \ 0.001). postoperative vrs scores at 1st, 4th and 8th hours were significantly lower in group b than group a (p \ 0.001, p:0.002, p:0.004). anelgesic use was significantly higher in group a at 1st postoperative hour than group b (p \ 0.001). shoulder pain was significantly lower in group b than in group a (p \ 0.001). patient satisfaction was significantly higher in group b than in group a (p \ 0.001). conclusions: high-volume low-concentration intraperitoneal bupivacaine instillation resulted in better postoperative pain control along with reduced incidence of shoulder pain and analgesic consumption in comparison to control group in urgent lc. introduction: in-hospital resuscitative thoracotomy is an established procedure for patients with penetrating cardiac injuries. the survival rate is dismal in patients with cardiac arrest prior to admission. prehospital resuscitative thoracotomy (prt) was introduced by the london hems with the highest published survival rate of 18%. we aimed to identify the number of patients who could potentially benefit from prt in our major trauma center catchment area. materials and methods: data from 2010 to 2017 were collected from the institutional trauma registry and electronic records. we included patients [ 17 years, with penetrating cardiac injury, or penetrating chest trauma and cardiac arrest, or penetrating chest trauma and sbp \ 70 mmhg. commonly used criteria for prt are tamponade with cardiac arrest lasting \ 10 min at the time of ambulance arrival and with [ 10 min remaining transportation time to hospital. results: cardiac injury was found in 25 of 54 included patients. of these 25, 14 arrived at the hospital with signs of life and survived. 8 of the 11 patients who died had tamponade. criteria for prt were not met in 6 of 8 patients with tamponade. two patients could have been eligible for prt. one patient was found in oslo with cardiac arrest lasting 10 min. the patient had multiple stab wounds to the chest and had several perforations of the right atrium, not technically manageable in a prehospital setting. the second patient was injured outside our primary catchment area and arrested with prehospital personnel present. prt was performed and the tamponade relieved, but compression of the aorta was necessary. the patient was declared dead shortly after hospital admission. conclusions: in 8 years in a population of 1.6 million, two patients met london hems criteria for prt. prt was performed in one patient who was declared dead shortly after hospital admission while one patient suffered from injuries which are unmanageable in a prehospital setting. isolated tissue injury leads to fibrinolytic shutdown, tpa resistance and alterations in clot structure in a porcine model introduction: trauma-induced coagulopathy includes a spectrum of hypo-to hypercoagulable phenotypes with differing levels of fibrinolysis and tpa sensitivity. fibrinolysis shutdown is associated with increased late mortality and shown in small animal studies to be driven by tissue injury. utilizing a novel method of clot structure analysis, we hypothesize that isolated tissue injury provokes fibrinolysis shutdown, tpa resistance and is associated with altered clot structure resulting in enhanced clot stability. materials and methods: all male pigs (n = 13) underwent anesthesia, intubation, femoral artery cannulation and mini-laparotomy. tissue injury (n = 9), was inflicted with bilateral chest wall muscular cutdowns and bilateral femoral fractures using a captive bolt pistol. mean arterial pressure was maintained at [ 50mmhg. timed blood samples analyzed using tpa challenged and citrated native teg to evaluate tpa resistance and fibrinolytic shutdown respectively. after 3 mm punch biopsy induced splenic injury, clot was collected, washed, and chemically fractioned by strong cation exchange chromatography. tandem mass spectrometry and bioinformatic analysis were used to evaluate clot structure and factor xiiia cross-linking patterns and covalently associated proteins. results: tissue injury pigs showed increased tpa resistance (change tpa-teg ly30: -39.1% vs -10.1% p = 0.0028) and a trend of fibrinolytic shutdown evidenced by teg compared to control (fig. 1) . splenic clot structure analysis demonstrated altered clot structure (fig. 2) and identified elevated levels of protease inhibitors such as alpha 2 macroglobulin and alpha 2 antiplasmin at 6 h post tissue injury compared to baseline. conclusions: in a porcine model, isolated tissue injury provokes fibrinolysis shutdown and tpa resistance resulting in altered clot structure with an increased incorporation of anti-protease proteins resulting in enhanced clot stability. there is a high incidence of rotational malalignment after intramedullary nailing of tibial shaft fractures: a prospective cohort series of 155 patients n. j. bleeker 1 1 amsterdam medical centre, flinders university, department of orthopedics and trauma surgery, amserdam, netherlands introduction: intramedullary nailing (imn) is the treatment of choice for most tibial shaft fractures due to its minimalistic surgical approach, superior fracture healing, and rapid recovery. however, an iatrogenic pitfall is rotational malalignment (rm). the aim of this prospective cohort study was to determine the incidence of rm and to evaluate the efficacy of protocolled bilateral postoperative computed tomography (ct) assessment of rotational tibial alignment. materials and methods: between 2009 and 2016 we prospectively included 155 patients (111 male (72%)), with a mean age of 41 years, with a unilateral tibial shaft fracture. as per hospital protocol, patients underwent a routine low-dose bilateral postoperative ct to assess rm. forty-two patients (27%) suffered open injuries; 29 (19%) were involved in a multi-trauma sustaining more than one injury. according to the ao/ota classification, there were 95 simple (61%), 35 wedge (23%), and 25 complex fractures (16%). fracture location within the tibial shaft varied with six patients (4%) being within the proximal third, 47 (30%) middle third, and 90 (58%) distal third. there were 11 segmental (7%) fractures that involved more than one third of the tibia. results: fifty-five patients (35%) had post-reduction rm including 46 patients (30%) between 10°-19°, seven patients (5%) with a rm between 20°-29°, and two patients (1%) with a rm greater than 30°w hen compared to the uninjured side. of the patients with rm, the tibia was externally malrotated in 29 patients (53%). three patients (2% of cohort or 5% of those with rm) underwent revision surgery to correct the rm as detected on ct scan. conclusions: this study reveals a high incidence of rm following tibial nails (35%) with a surprisingly low revision rate (5% of those with rm). a subsequent study should aim to assess clinical relevance of rm in terms of functional outcome and gait analysis. for now ctrotational-profiling provides a platform for early recognition and correction of rm secondary to tibial imn. level of evidence: therapeutic level ii -prospective cohort study. materials and methods: the tarn database was analysed retrospectively to quantify the number of trauma team activations, patients with major trauma (mt), causes of injury, and subspecialty-specific trauma procedures. crude and risk-adjusted mortality rates, observed to expected (o/e) mortality ratio, and risk-adjusted rates of survival from mt were also calculated. results: the number of trauma team activations has risen by a factor of 5. the predominant injury mechanism that resulted in mt was a fall from less than 2 m. there has been a fivefold increase in the overall number of trauma surgical procedures. orthopaedic surgeons have performed 84% of trauma procedures, followed by neurosurgeons, oral and maxillofacial surgeons, and visceral trauma surgeons. the rate of trauma laparotomies per consultant fluctuated between 0.4 and 0.8 per month. a fall from less than 2 m, road traffic accident and a fall from more than 2 m were the three leading causes of death from mt. the overall o/e mortality ratio was 1.1. conclusions: aintree trauma profile has significantly changed since 2011. this change highlights the potential need for a review of how mt services are offered at aintree to reduce the o/e mortality ratio. this may be achieved through more co-ordinated provision of trauma care, prevention, audit and research programmes. the role of visceral trauma surgery should be reconsidered within the context of the surgical patients' needs and demands, and fundamental requirements of the profession. inter-hospital variation in surgical intensity for trauma admissions: a multicenter cohort study l. moore 1 , m. p. patton 2 , i. farhat 2 , p. a. tardif 2 , c. gonthier 3 , a. belcaid 3 , f. lauzier 2 , a. turgeon 2 , j. clément 2 1 université laval, social and preventive medicine, québec, canada, 2 chu de québec-université-laval, québec, canada, 3 introduction: guidelines for trauma patients are increasingly moving away from surgical management towards less invasive procedures but there is a knowledge gap on how these recommendations are influencing practice. we aimed to assess inter-hospital variation in surgical intensity for trauma patients and identify determinants of surgical intensity. materials and methods: we conducted a retrospective multicenter cohort study based on the 57 trauma centers of an inclusive canadian provincial trauma system. we included adults admitted for major trauma between 2007 and 2016. analyses were stratified for orthopedic (n = 17,001), neurological (n = 12,888) and thoracoabdominal surgery (n = 9816). surgical intensity was quantified with the number of surgical procedures during the first 72 h. inter-hospital variation was assessed with the intra-class correlation coefficient (icc) from multilevel poisson regression models. relative risks (rr) were generated to identify determinants. results: moderate inter-hospital variation was observed for orthopedic surgery (icc = 14.4%, 95% confidence interval [ci]: 12. 1-20.4) whereas variation was low for thoracoabdominal surgery (icc = 2.7%, 95% ci: 1.7-3.1) and neurosurgery (icc = 0.8%, 95% ci: 0.8-1.2). level iv centers had similar surgical intensity for thoracoabdominal injuries (rr: 1.20, 95% ci: 0.65-2.25) but lower intensity for orthopedic injuries (rr = 0.31, 95% ci: 0.17-0.57) than level i/ii centers. during the study period, we observed a decrease in intensity for neurosurgery (rr for 2015 (rr for -16 versus 2007 .76, 95% ci: 0.68-0.84) and thoracoabdominal surgery (rr = 0.74, 95% ci: 0.63-0.87). conclusions: the observed inter-hospital variation in risk-adjusted surgical intensity suggests that there may be opportunities for quality improvement in surgical care for injury admissions. a better understanding of how surgical intensity influences clinical outcomes is needed to inform quality improvement activities. pre-hospital injury diagnosis a. easthope 1 , m. marsden 2 , g. grier 2 1 barts and the london medical school, london, united kingdom, 2 royal london hospital, centre for trauma science, london, united kingdom introduction: accurate pre-hospital diagnosis of a patient's injuries may improve care by facilitating effective intervention at the scene and reducing time to definitive treatment in hospital 1 . we sought to assess the diagnostic accuracy of injuries by london's air ambulance (laa) clinicians and identify conditions in which clinical accuracy may deteriorate. materials and methods: a retrospective review was undertaken of all patients conveyed to the royal london hospital by laa from october 2017 for six-months. pre-hospital injury scores, coded using the abbreviated injury score (ais) were compared to hospital discharge ais. patient outcomes were evaluated in the case of underscored injuries. results: during the study period 688 patients were seen and 177 met eligibility. mean clinical sensitivity and specificity was 62% and 93% respectively. chest injury identification was most sensitive (77%) and pelvic injury least sensitive (41%). the relative risk (rr) of underscored injuries to the chest, abdomen and pelvis increased with decreasing glasgow coma scale (gcs) peaking at 1.7 (iqr 1.3-2.0). the average accuracy of injury identification was 88% with a negative predictive value of 90%. no overt patient morbidity resulted from a missed, or under-scored injury. all missed injuries were subsequently identified in the emergency department. conclusions: the pre-hospital diagnosis of injuries has reasonable sensitivity and excellent specificity. accurate pelvic injury diagnosis is more challenging than chest or abdomen. with decreasing gcs, the risk of missing injuries increases. clinicians should be aware of the potential for error when treating trauma patients with impaired conscious levels. comorbidities, injury severity and complications predict mortality in severe thoracic trauma: a retrospective analysis from the norwegian national trauma registry of epidemiology, clinical factors and risk factors for mortality of patients with thoracic injuries. materials and methods: adult patients treated for severe thoracic trauma (injury severity ais c 3), between 2009 and 2016 at haukeland university hospital were included. data were extracted from (1) the haukeland university hospital local trauma registry, and (2) the norwegian trauma registry. additional data on comorbidities and complications was collected from patient records. the factors age, gender, comorbidities [charlson comorbidity index (cci)], anticoagulant use, injury severity [revised trauma score (rts)], [injury severity score (iss)] and complications [clavien-dindo scale (cds)] were analyzed for being predictive of in-hospital mortality. multivariate logistic regression analyses with backward selection methods were used. results: data of 399 patients were analyzed, of which 55 (14%) patients died. median iss was 34 in the non-survivors (iqr 22, 43) and 17 (iqr 13, 25) in survivors (p = .001). data of 282 patients were used in the risk factor for mortality analysis. two or more comorbidities measured by cci (or: 7.02, p = 0.006), injury severity measured with the rts (or: 0.41, p = \ 0.001), and grade c 3 complications on the cds (or: 7.66, p = 0.001) were significant predictors for mortality. conclusions: severe comorbidities significantly decreased the chances of survival after thoracic trauma. injury severity was also found to be a significant predictor of mortality. physiological injury severity, measured by rts, appeared to be a stronger predictor of mortality than iss after thoracic trauma. finally, severe complications led to considerably higher risk of mortality following thoracic trauma. the psychosocial impact of e-bike accidents and changing values of older patients in the netherlands, a qualitative study s. berben 1 , l. vloet 1 , e. c. t. tan 2 , m. edwards 2,3 , a. brants 2,3,4 , g. olthuis 2, 3, 4, 5 , a. oerlemans 2, 3, 4, 5 , f. haverkamp 2, 3, 5 introduction: the mechanical impact of e-bike accidents, increasingly used by older persons, has shown to be higher compared to regular bike accidents. however, the psychological impact of e-bike accidents in older trauma patients, their experiences in emergency and follow-up care, and the possible change in values and beliefs in response to the accident is still unknown. materials and methods: we used a qualitative design and included older patients (65 ? years) with a variety of (severe) injuries, who were admitted to the emergency department after an e-bike accident (n = 12) and their relatives (n = 11). they were interviewed within one month (t1) and after three months (t3) of the date of accident. interviews were transcribed verbatim and analyzed via a thematic analysis approach using an ethical perspective. results: many patients required (in)formal care after hospital discharge. in general patients were satisfied with the provided emergency surgical care, although some patients reported limited and insufficient information on rehabilitation and homecare support. the analysis yielded impaired physical condition, anxiety, increased vulnerability and dependency of care givers as psychosocial impact. freedom impairment, shifting relational autonomy, and confrontation with vulnerability and mortality were reported changes in values. central values as mobility and freedom, vitality and health, social participation and recreation were put under pressure and needed to be negotiated again after the accident in order to decide whether to use the e-bike again. conclusions: follow-up information of surgeons and emergency physicians after initial hospital care for older trauma patients with an e-bike accident shows room for improvement, with more specific consideration for the psychological impact of trauma and changes in values after e-bike accidents. eur j trauma emerg surg. 2018. https://doi.org/10.1007/s00068-018-1033-5. traumatic subaxial cervical fractures: functional prognostic factors and survival analysis introduction: the main goal of this study is to identify the risk factors for poor functional outcomes and to analyze the overall survival (os) and complications rate in patients with traumatic cervical spinal cord injury (sci) and subaxial cervical fracture (sacf) treated with open surgical fixation. materials and methods: the authors retrospectively reviewed sixtyfive consecutive patients from one single center with traumatic unstable sacf and associated sci treated surgically between 2010 and 2017. we exclude cervical fractures with concomitant severe head injury, brachial plexus injury, lumbar plexus injury, superior or inferior limb fractures and patients who were lost during the followup period. statistical analysis using a chi square test, student's t-test and logist regression were used to identify factors associated with poor functional outcomes after surgical treatment. os analyses were performed using kaplan-meier curves. results: the 5-year survival rate was 81.8%. four patients died in the first 30 days after surgery and 6,7% need a reoperation. the median time from injury to surgery was 3.6 days. the complication rate was 62%, being respiratory failure the most common one. preoperatively, 64% had an asia \ c. about 57% of the patients with asia between a-d had improve one or more asia grades. logistic regression analysis show that older age, sacf above c5, asia \ c pre-surgery and long time from injury to surgery were related with poor prognosis. the os rate was higher in patients with neurological improvement, without signs of neurogenic shock at presentation and in sacf bellow c4. conclusions: our results suggest that sacf should be treated as soon as possible in order to improve the os rates and functional outcomes. older patients, lower asia at presentation and sacf above c5 are related with worst functional outcomes. introduction: compression fractures of multilevel vertebral bodies are common in children. due to segmental plasticity, several adjacent vertebral bodies are compressed to a lesser degree at each body. plain ap and lateral x-ray is the first diagnostic examination in the emergency department (ed), but a proper diagnosis is often delayed or missed. materials and methods: this is a retrospective, monocentric study in children falling on their back who showed up at the orthopedic ed, between december 2017 and september 2019. nine children (4f, 5 m) with an average age of 11.1 years were included. trauma occurred playing games and doing sports in all cases. all children were subjected to x-ray, followed by mri scans for doubtful findings on the plain x-ray or persistent mild pain (t1, t2, t2-stir sequences). results: cuneiform vertebral fracture or vertebral body height reduction was diagnosed with x-ray in five vertebrae while mri showed fractures in 32 vertebrae including compression and edema of adjacent vertebrae in the t2-stir sequence. therefore only 15.6% vertebral fractures have been detected by plain x-ray. the injured vertebral bodies were so distributed: t3 n = 1, t4 n = 2, t5 n = 3, t6 n = 4, t7 n = 3, t8 n = 3, t9 n = 4, t10 n = 3, t11 n = 2, t12 n = 2, l1 n = 2, l3 n = 1, s4 n = 1, s5 n = 1. the most involved spine section was between t3 and t10 with 20 fractures. conclusions: vertebral fractures are not always related to hyperflexion or forward hinging mechanism. mri showed vertebral compression fractures and the t2-stir sequence showed edema as post-traumatic evidence that had not been detected by x-ray. in absence of a radiologically visible lesion, the persistence of pain should be investigated by performing mri scans. the middle thoracic spine level appeared to be the most involved one in pediatric vertebral fractures. introduction: occipitocervical fixation (ocf) is an effective surgical method to treat various craniovertebral junction (cvj) pathologies. a rigid fixation achieved from ocf displaces other techniques of cvj stabilization unfortunately during procedure deep and wide wound is performed. aim of this study is to share our experience in ocf and lately performed percutaneous ocfs with intraoperative ct guided navigation system. materials and methods: of 34 patients who underwent ocf 6 were performed percutaneously. o-arm ct scans were used to illustrate and measure radiologic parameters. screws were implanted in c1 lateral masses (2) , isthmus of c2 (68) and c3 pedicles (68) and assessed according gertzbein robbins (gr) in modification of bredow classification from a to e. results: a total 138 screws were implanted, 114 of them was performed in open surgery and 24 percutaneously. outcome in gr classification for screws implanted in open surgery was: a 58 (50,88%), b 22 (19,3%), c 16 (14,04%), d 9 (8,77%) and e 9 (7,02%) while in percutaneous: a 21 (87,5%) and b 1 (12,5%) . in open surgery one screw was revised. conclusions: percutaneous occipitocervical fusion seems to be a good option to achieve desirable effect in cervical pedicle screws implantation. during procedure whole nuchal muscles are preserved. ct guided surgery and microscope view are necessary to perform percutaneous ocf. introduction: studies have found higher risk of traumatic deaths in rural areas in norway combined with a paradoxically decreased prevalence of severe, non-fatal injuries (1) . this study investigates the risk of fatal and non-fatal injuries among all adults in norway in the period 2002-2016. materials and methods: all traumatic injuries and deaths among persons with residential address in norway from 2002-2016 were included. data was collected from the norwegian patient registry and the norwegian national cause of death registry. all cases were stratified according to six groups of centrality based on statistics norway's classification of centrality 2017. mortality-and injury rates was calculated per 100,000 inhabitants per year. results: the mortality rate differed significantly according to the levels of centrality (p \ 0.05). the mortality rate in the most urban group (1) was 64.2 and in the most rural group (6) 78.6. the lowest mortality rate was found in centrality group 2 (57.9). there was an increased risk of death between centrality group 1 and group 6 with a relative risk of 1.23 (ci: 1.0-1.5, p \ 0.05). the most common cause of death was transport injuries, self harm, fall injury and other external causes. the highest urban-rural gradient was seen in transport injuries with a relative risk of 3.0 (ci 1.7-5.3, p \ 0.001) comparing group 6 to group 1. group 2 had the lowest risk of nonfatal injuries (1531) and group 6 the highest (1803). the risk of nonfatal injuries increased with higher grade of rurality, comparing group 1 and 6 revealed a relative risk 1.07 (ki 1.02-1.11, p \ 0.001). conclusions: the more rural the higher risk of traumatic deaths and non-fatal injuries. transport injuries had the highest urban-rural gradient. references: 1. bakke hk, hansen is, bendixen ab, morild i, lilleng pk, wisborg t. fatal injury as a function of rurality-a tale of introduction: virtual fracture clinics (vfcs) are an alternative to conventional fracture clinics for management of musculoskeletal injuries. they have been shown to be a safe and effective model for upper and lower limb injuries. there is limited data to support their use for specialist thoracolumbar fracture follow-up. materials and methods: lean methodology including process mapping was applied to identify a safe virtual alternative for the pathway. first cycle analysis of 100 consecutive referrals to a traditional specialist thoracolumbar fracture clinic. second cycle analysis of 100 consecutive referrals six months after introduction of a vfc. results: mean time to first outpatient review in first cycle was 84 days. referrals led to 240 booked outpatient appointments and 66 were missed (28% non-attendance). 54% of referrals had 3 or more scheduled appointments. 82/100 were ao type a1-3 and all of these received non-operative treatment. 9/100 were ao type a4 or b and 8 of these received non-operative treatment. 1 patient received operative stabilisation (ao type b). process mapping identified two pathways-virtual review with advice letter and physiotherapy referral (outcome a-ao type a1-3) or face to face review (outcome b-ao type a4 or b). mean time to outpatient review in second cycle was 10 days. 79/100 received outcome a. 8/79 (10%) made a telephone call for advice and only 2/79 (3%) asked for a face to face appointment. 19/100 received outcome b and all were discharged after one visit. 0 patients in cycle 2 required operative stabilisation. statistically significant reduction in number of scheduled face-to-face reviews (240 versus 19; p \ 0.001) and mean time to first review (84 days versus 10 days; p \ 0.001). conclusion: virtual thoracolumbar fracture clinics are a safe and clinically effective alternative to traditional fracture clinic models. lean methodology can be uses to extend virtual clinic pathways to specialist trauma clinics. treatment prognosis of 340 cases of fragility fracture of pelvis m. yoshida 1 1 fujita health universityhospital, emergency, aichi, japan introduction: the number of cases of fragility fracture of pelvis in the elderly has been increasing in recent years, but there are still not enough reports of surgical treatment as a treatment method, but there is still no certainty how to treat. so we investigated prognosis of 340 cases of fragility fracture of pelvis. materials and methods: subjects were 340 fragility fracture of pelvis treated at a single center from april 2012 to april 2019, 40 males, 300 females, average age 82 ± 9.5 years. only cases that had ct scan were included. we examined rommens classification, the presence of injury, presence of hip implants, functional prognosis, and 1-year mortality. results: the breakdown of rommens classification is type ia 78 cases, ib 2 cases, iia 14 cases, iib 74 cases, iic 51 cases there were 32 cases of iiia, 3 cases of iiic, 1 case of iva, 50 cases of ivb, and 4 cases of ivc. surgical treatment was indicated in 16 cases (4.7%) (iic 1 case, iiia 7 cases, ivb 5 cases, ivc 3 cases) there were 28 cases (8.2%) with no injury mechanism and 61 cases (18%) with hip implants. 109 cases (32%) were able to follow up for more than 1 year including telephone surveys, and 42.3% of them did not recover to functional level before injury. the one-year mortality rate was 10.2%. conclusions: in the 340 cases studied here, 16 cases (4.7%) were indicated for surgery. the prognosis and mortality rate are almost the same as those reported overseas, and as with proximal femoral fractures, there is a possibility that it may be greatly involved in adl decline in the elderly. we think that further study is needed in the future. conclusions: patients with a femoral neck fracture who received a hip hemiarthroplasty and used anticoagulation had no significant longer delay to surgery and had a higher mean loss of hemoglobin points. as a clinical consequence of this, more packed cells were supplemented. also more postoperative hematomas were found in the population with anticoagulation. no differences were found in mortality rates at 30-days and one year. results: on all eight patients the easy-approach was applied without adverse events. in four cases the plate osteosynthesis was done completely endoscopically with excellent results for the patients regarding pain relief and scar development. in the remaining four cases the endoscopic stabilization was not performed for the following reasons: in the first overall case primarily only the endoscopic approach was planned. in the fourth overall case, ventilation showed high end-expiratory co2-levels after endoscopic situs preparation, so we converted to the open plating. in the fifth overall case, the easyapproach was applied to evacuate a retrosymphyseal hematoma in a patient with a stable pubic rami fracture. in the eighth overall case, the anterior pelvic ring injury was a bilateral multifragmentary pubic rami fracture in combination with a disruption of the symphysis. after endoscopic situs preparation with clipping of the corona mortis vessel, reduction of the displaced symphysis could not be done endoscopically. conclusions: we demonstrated that the endoscopic plate osteosynthesis of the anterior pelvic ring is feasible with existing standard laparoscopic instruments. the evaluation of the easy-approach in the clinical setting is going on, while the development of suitable reduction tools is one major goal of future studies. introduction: retrograde intramedullary pubic ramus screw fixation is less invasive method and biomechanically stable compared to the plate fixation. the purpose of this study is to examine the feasibility of screw insertion using computed tomography (ct). materials and methods: we analyzed sixty ct data (30cases in male and female each). by using ct analyzing software, the virtual column with 6.5 mm diameter was inserted so that we analyzed the feasibility of the screw insertion. and the intramedullary diameter of the pubic ramus at the parasymphyseal area, base, and acetabulum were measured. results: the virtual 6.5 mm diameter screws could be inserted in 100% (30/30) in male and 23.3% (7/30) in female. the cause that screws insertion was impossible was penetration to the hip joint in all cases. the screw inserting point was 19.2 mm and 21.5 mm from the medial border of the pubic symphysis and 11.5 mm and 9.8 mm from the upper border of the pubic symphysis in male and female respectively (p [ 0.05). the intramedullary diameter of pubic ramus was 15.7 mm, 13.8 mm and 12.5 mm at parasymphyseal area, 13.2 mm, 11.4 mm and 9.4 mm at the base of pubis, and 14.5 mm. 13.5 mm and 11.7 mm at the acetabulum in male, female who had the screw corridor and female who didn't have the screw corridor respectively. the diameter of the pubic ramus of the female who didn't have the screw corridor was significantly small compared to male and pubic ramus in three measuring points (p \ 0.05). , 5% of the screws were revised. there were no neurovascular or urologic complications. radiographic nonunion was observed in 10% with a minimum follow-up of 6 months, this correlated with a peri-implant infection (p 0.001), operation [ 6 months after trauma (p 0.02) and non-significantly with implant loosening (p 0.076). there was no correlation of nonunion with patient's age, the fracture mechanism or a non-excellent reduction. in total, 12.5% of the patients were re-operated, in 5.1% a re-osteosynthesis was conducted. conclusions: retrograde trans-pubic screws show good clinical results with lower or similar complication rates compared to alternative methods as plate fixation or external fixator. fracture union did not depend on fracture mechanism or age. hence, this minimal-invasive method is especially attractive in elderly patients with an ffp. because it is an internal fixation of the superior pubic ramus with relative stability, an anatomic open reduction is not necessary to achieve fracture union. the need for extraperitonal pelvic packing -finally confirmed to be vanishing? introduction: the presence of cerebral venous thrombosis (cvt) is increasingly recognized in traumatic brain injury (tbi), but its complication rate and effect on outcome remains undetermined. in this study, we characterize the complications and outcome-effect of cvt in tbi patients. materials and methods: in a retrospective, case-control study of patients included in the oslo university hospital trauma registry and radiology registry from 2008-2014, we identified patients with cvt (cases) and without cvt (controls). groups were matched regarding abbreviated injury severity (ais) head region score 3-6. cases were identified by ais or icd-code for cvt and a ct/mr venography confirmed to be positive for cvt, whereas controls had no ais or icd-code for cvt and a ct/mr venography confirmed to be negative for cvt. risk of mortality was assessed using multivariate logistic regression adjusting for initial gcs, iss and rotterdam score. results are also reported for subgroups according to cvt location ( fig. 1 introduction: the aims of this prospective cohort study were (i) to identify trajectories of recovery in patients with mild traumatic brain injury (mtbi) during the first two years after trauma and (ii) assess patients and injury characteristics for these trajectories. materials and methods: all adult trauma patients with mtbi (aisseverity 1 or 2 and an injury severity score \ 9) who were admitted to a hospital in a region of the netherlands from august 2015 to november 2016 were asked to complete questionnaires. the questionnaires could be completed at 1 week, and 1, 3, 6, 12 and 24 months and included the euroqol-5-d for health status, including a cognition dimension, the hospital anxiety depression scale (hads-d and hads-a for symptoms of depression and anxiety respectively) and the impact of event scale (ies) (for post-traumatic stress symptoms). latent class trajectory analysis was used to determine trajectories of recovery in latentgold 5.1, patient and injury characteristics of the classes were assessed in ibm spss 24.0. results: a total of 1027 patients (47% of total) completed at least one follow-up questionnaire. the number of classes (trajectories) ranged from 3 for cognition to 11 for depression. poor recovery classes of cognition and health status consisted of mostly females, patients with low education, higher age, longer length of stay at the hospital and frail patients. the class with full recovery consisted of young patients, with most recovery occurring during the first six months after injury. patients who reported poor health status before injury scored significantly lower health status after injury and showed no recovery over time. conclusions: different recovery patterns were present in patients with mild traumatic brain injury. especially frail elderly patients who reported poor health status before injury have poor outcome up to 24 months after injury. post-concussive symptoms in children and adolescents with traumatic brain injury: a center-tbi study introduction: acute respiratory is associated with high morbidity and mortality. in addition, its etiologies are heterogeneous and the outcome depends on the underlying cause. the aim of the present study is to analyze, whether the mortality of posttraumatic ards is affected (1) over time, (2) attributable to geographic distribution, (3) related to the used definition and (4) introduction: many factors of trauma care have changed in the last decades. this review investigated the effect of these changes on overall and cause-specific mortality in polytrauma patients admitted to the intensive care unit (icu). moreover, changes in trauma mechanism over time and differences between continents were analyzed. materials and methods: a systematic review of literature on overall mortality in polytrauma patients admitted to the icu was conducted. overall and cause-specific mortality rates were extracted as well as the trauma mechanism of each patient. linear regression on changes in overall and cause-specific mortality rates was performed. results: thirty studies, which reported mortality rates for 83,502observed patients, were included and showed a decrease of 0.4% in overall mortality per year ( fig. 1 ). brain-related death has become more common over the years, whereas multiple organ dysfunction syndrome (mods), acute respiratory distress syndrome and sepsis became less prevalent (fig. 2) . mods was the most common cause of death in north america and brain-related death was the most common in asia, south america and europe (fig. 3a) . penetrating trauma was most often reported in north and south america and asia (fig. 3b) . conclusions: overall mortality in polytrauma patients admitted to the icu has been decreasing as a result of the improvements in trauma care. a shift from mods to brain-related death could be observed. more research on preventative measures for the latter is required to ensure a further decline in mortality. moreover, we have shown geographical differences in cause-specific mortality, which may provide learning possibilities between similar trauma centers resulting in improvement of trauma care introduction: aim of the current study was to assess an association between trauma patient volume of the intensive care unit and inhospital mortality. materials and methods: from data of the japan trauma databank, this retrospective cohort study selected adult (c 16 y) trauma patients hospitalized in the intensive care unit with the injury severity score of c 9. after applying a multiple imputation on all the study variables, a logistic regression generalized estimating equation after adjustment for age, sex, mechanism of trauma, and the injury severity score as covariates and hospitals as a cluster assessed an association between quartile of patient volume in intensive care unit and hospital mortality. introduction: quality and content of early fracture hematoma (fh) dictate the healing process in long bone fractures. different reaming protocols for intramedullary nailing (imn) are available. however, the impact of reaming strategies on immune cell characteristics of early fracture hematoma is unclear. we hypothesized that the application of reaming irrigation and aspiration (ria) techniques optimizes cellular content of fracture hematoma. materials and methods: twenty-four pigs underwent standardized femur fracturing. then, animals were exposed to different protocols of imn. group a underwent no reaming prior to imn. group b was treated with conventional reaming plus imn and group c composed of animals treated with ria and subsequent nailing. fracture hematoma was collected 6 h after reaming. fh-immune cells were isolated and studied by flowcytometry. cell viability was tested by annexin-v-labelling. neutrophil activation was determined by mac-1/cd11bcell surface expression levels, whereas fcyriii/cd16-receptor expression was utilized to investigate neutrophil maturation. results: all animals survived the observation period. propertions of white blood cell subtypes in fh did not differ between conditions. however, the percentage of viable fracture hematoma immune cells was significantly higher in the ria-group, compared with conventional reaming (respectively mean 86.7% vs. 96.5%, p = 0.04). additionally, both neutrophil cd16-expression (-35%) and cd11bexpression (-61%) were significantly lower in those animals treated with ria compared with the conventional reaming condition. conclusions: this experimental study reveals that reamed irrigationaspiration (ria) prior to imn is associated with increased immune cell viability and less neutrophil senescence/activation in early fracture hematoma. this underlines the important role of imn in optimizing local cellular immune homeostasis during the formationphase of early fracture hematoma. introduction: the study and determination of the traumatic pattern in bicyclists-delivery employees. the recording of personal protective equipment and evaluation of the selection criteria of their self protection. materials and methods: a total of 22 patients (21 men and 1 woman) with mean age of 33.8 years (18 -52 years) were included over a study period from january 2017 to march 2019. twenty-one patients admitted to the hospital with a total of 26 injuries treated operatively, whereas 15 injuries were treated conservatively. we recorded and evaluated the use of adequate personal protective equipment of these delivery employees. results: the mean hospitalization time was 7.6 days (2-12 days) . a total of 2 thoracic injuries, 3 traumatic brain injuries, 6 spine injuries, 25 lower extremity injuries and 5 upper extremity injuries were recorded. surgical treatment concerned 3 patients with upper extremities and 18 patients with lower extremities injuries and the anatomic regions involved were the distal radius (3), pelvic ring injury (1), femoral fractures (6), tibial plateau fractures (4), patella fractures (2), diaphyseal tibial fractures (6), and ankle fractures (4) . conclusions: the lack of an adequate personal protective equipment due to their low financial status in combination with the absence of driving professional education among workers in this category of delivery employees results in lower extremity injuries with the majority requiring hospitalization and surgery. further investigation is needed, as well as constant training and setting right criteria for the pursuit of such employment. results: a total of nine rct's (462 patients) and the sixteen observational studies (4245 patients) were included. the pooled nonunion rate did not differ significantly between both treatment groups (risk difference: 0%; or 0.98, 95% ci 0.68-1.42). more patients treated with nailing required re-intervention (risk difference: 2%; or 2.11, 95% ci 1.09-4.08) with shoulder impingement being the most predominant indication. more patients treated with pate fixation developed radial nerve palsy compared to nailing (or 0.43, 95% ci 0.31-0.61). notably the absolute risk difference is small (2%) and during follow-up the palsy resolved spontaneously in the majority of patients. nailing lead to a faster time to union (mean difference: 2.5 week, 95% ci 3.1-1.8), lower infection rate (risk difference: 2%, or 0.48, 95% ci 0.31-0.75) and shorter operation duration (mean difference: 20 min, 95% ci 32.0-9.4). functional scores were comparable in both groups (standardised mean difference: -0.13, 95% ci -0.46 to 0.19). there was no difference between effect estimates form observational studies and rct's. conclusion: there appears to be no difference between plate fixation and nailing for humeral shaft fractures with regard to non-union rate and functional outcome. patients treated with plate fixation have a higher risk for infection and radial nerve palsy, but lower risk for reintervention. the absolute differences, however, are small. nailing does differ significantly from plate fixation in terms of shorter operation duration and time to union. the pooled estimates from randomised clinical trials did not differ significantly from estimates obtained from observational studies. post-traumatic complications are more often after medial clavicle injuries compared to lateral clavicle injuries introduction: medial clavicle injuries (mci) are widely unexplored, especially in contrast to lateral clavicle injuries (lci). current research concerning mci assumes a higher severity of mci, e.g. concerning concomitant injuries. our aim is to evaluate by big data analysis if these rare injuries would also lead to a higher number of post-traumatic complications. materials and methods: we focused on the mci subgroup consisting of medial clavicle fracture and sternoclavicular joint dislocation. the lateral clavicle fracture and the acromioclavicular joint dislocation were summarized to the subgroup of lci. the midshaft clavicle fracture was analyzed for comparison. the data are based on icd-10 codes of all german hospitals as provided by the german federal statistical office. anonymized patient data from 2012 to 2014 were evaluated. the retrospective analysis addresses the fracture healing in dislocation, delayed union and non-union. results: the proportion of all patients suffering from complications was 3.1%, which were attributed to one of the three post-traumatic complications. each complication rate for the single injury and the single complication was rather low with a maximum of 1%. mci were more likely to be affected by post-traumatic complications than lci with a ratio of 2.7 to 3.3 times (p \ 0.005). the midshaft clavicle fracture was similarly frequently affected by complications with 41.6% of all complications as the mci (44.2%). the lci accounted for the smallest proportion at 14.2%. conclusions: we proved that mci are more often associated with post-traumatic complications than injuries of the other parts of the clavicle. this is another hint that mci appear to be more complex than lci. this could be due to a missing standard procedure and the higher number of concomitant injuries in mci. further representative clinical studies are required since miscoding is a frequent issue in research concerning clavicle injuries, especially in a big data analysis. quantification of trauma center accessibility using gis-based technology introduction: there is no generally accepted methodology to asses trauma system access and optimal geographical trauma center distribution. the goal of this study is to determine the influence of trauma center(tc) distribution during high and low traffic density using geographical-information-system(gis)-technology. methods: using arcgis-pro, we calculated differences in transport time (tt) and population coverage in seven scenarios with 1, 2, or 3 tcs during rush [r]-and low traffic [l] hours in a densely-populated region with 3tcs in the netherlands (fig. 1) . results: in the seven scenarios, the population that could reach the nearest tc within (\) 45 min, varied between 96-99% ( fig. 2) in the three-tc-scenario, roughly 55% of the population could reach the nearest tc \ 15 min in [r] and [l] . the hypothetical scenarios with two geographically well-spread tcs showed similar results as the current three-tc-scenario. in the one-tc-scenarios, the population reaching the nearest tc \ 15 min decreased by 23-36% in both [r] and [l] compared to the three-tc-scenario. in the three-tcscenario the average tt increased with about 1.5 min to almost 21 min in [r] , in comparison to 19 min during [l] (fig. 3) . similar results were seen in the scenarios with two geographically well-spread tcs. in the one-tc-scenarios and the geographically close two-tcscenario the average tt increased by 5-8 min [l] and 7-9 min [r] in comparison to the three-tc-scenario. conclusion: this study shows that a gis-model for trauma center access offers a quantifiable and objective method to evaluate trauma system configuration in areas with different geography and demography. applying this technology to one of the most densely populated areas in the netherlands shows that the transport time from accident to trauma center would remain acceptable if the current situation with three trauma centers would be changed to a scenario with two geographically well-spread centers. classifying posttraumatic stress disorder courses in physical trauma patients: an observational prospective cohort study introduction: the aim was to identify different courses of posttraumatic stress disorder (ptsd) in physical trauma patients. then, to examine whether these classes could be characterized by sociodemographic, clinical, psychological, and personality outcomes. methods: patients completed the impact of event scale-revised (ies-r), m.i.n.i.-plus after inclusion, 3, 6, 9, and 12 months after injury to examine different courses. the hospital anxiety and depression scale, neo-five factor inventory, state-trait anxiety inventory-trait, and the whoqol-bref were completed after inclusion only. latent class analysis, chi square tests, and anova were performed to analyze the aims. results: in total, 267 patients were included. the mean age was 54.1 (sd = 16.1) and 62% were male patients. the ies-r (see figure 1 ) and the m.i.n.i-plus had five classes (1: moderately, 2: little bit, 3: worse, 4: none, 5: quite a bit of ptsd symptoms). patients in class 3 are diagnosed with ptsd (cut-off score c 33). on both questionnaires, patients (proportion & 11%) in class 3 or 5, scored higher on anxiety, depressive symptoms, neuroticism, and trait anxiety compared to the other classes over 12 months after trauma. lower scores on all domains, except for social domain on the ies-r, were found compared to the other classes (ies-r; physical domain: class 3 vs. 4 (mean ± sd): 10.4 ± 3.3 vs. 14.8 ± 2.4, p-value = \ 0.001). psychological and personality outcomes were significantly different on all courses. also, patients in class 3 or 5 were younger compared to the other classes (ies-r; class 3 vs. 4: 43.5 ± 15.4 vs. 59.1 ± 14.8, p-value = \ 0.001). no medical outcomes for ptsd were found. conclusions: about 11% suffer from ptsd symptoms 12 months after trauma. different courses were defined by sociodemographic, psychological, and personality characteristics. professionals can, short after trauma, recognize patients at risk for ptsd when they focus on these characteristics. then, an intervention can be offered. six meter, the criterion for severe adult trauma to falls from heights in cdc field triage needs to be lowered introduction: trauma is one of major public health care issue which is costly to society. differences vary from region to region, but blunt trauma accounts for a large part of the total trauma, and the rates of the falls from heights among the blunt trauma is getting higher. it is serious that falls from heights is often accompanied by severe multiple trauma. therefore, authors studied the relationship between the height of the fall/other related factors and outcomes including hospital stay/mortality. materials and methods: retrospective cohort study of the 670 adult falls-from-heights patients visited a regional trauma center for 4 years (from 2014.01.01 to 2017.12.31). results: of total 670 patients, the number of d.o.a patients were 69. the height from falls of the deceased patients was statistically significantly higher than that of the survived patients. (19.4 ± 15.3 m vs. 4.3 ± 4.2, p \ 0.001) the auc of the roc curve of the height from fall to mortality was 0.879. (figure) the sensitivity of 3.75 m was 90.7% and 6.5 m was 81.4%, respectively. the traumatic brain injury, pelvis fracture, visceral organ injury, age, and the height from fall were statistically significant risk factors in multivariate analysis for mortality (p = \ 0.001, 0.11, 0,001, 0.004, and 0.03 respectively). conclusions: the height from the fall is closely related with mortality. we think the current height for the severe fall injury in cdc field triage for trauma is high and needs to be lower to 3.5 introduction: operative management of severe trauma is a team effort, requiring excellent communication skills. surgeons, anesthesiologists and nurses need to coordinate effectively in order to ensure an excellent clinical outcome. the definitive surgical trauma care (dstc), definitive anesthesia trauma care (datc) and definitive perioperative nurses trauma care (dpntc) courses provide an excellent opportunity to train efficient teamwork. we aimed to study the impact of the joint dstc-datc-dpntc courses in candidates' perceptions and skills in perioperative communication. materials and methods: study population of 39 candidates (18 surgeons, 10 anesthesiologists and 11 nurses) participating in a joint dstc-datc-dpntc course in coimbra, portugal. median age of 32 years (range 27 -52). female gender in 26 (67%) of cases. all participants attended joint lectures, case discussions and surgical skills session, emphasizing intraoperative communication. postcourse survey on several aspects of peri-operative communication, with responses on a likert scale. participants were also asked which aspects of intraoperative communication they valued the most. statistical analysis with spps, 25.0 (wilcoxon signed rank test, significance with p-value \ 0.05). results: all participants responded to the survey. results displayed an increase in the self-assessed importance of team briefing and intraoperative communication, particularly routine periodic communication, rather than only at critical moments (p \ 0.05). postoperative team debriefing was also valued as highly relevant. closed-loop and direct, by-name communication were highly rated (p \ 0.001). self-reported communication skills improved significantly during the course (p \ 0.001). conclusions: joint training in the dstc-datc-dpntc courses provides a unique opportunity to improve candidates' self-awareness and skills in intraoperative communication. a public health approach to knife related trauma in liverpool: a geospatial study r. shellien 1 , n. misra 1,2 , j. germain 2 , m. whitfield 2 1 aintree university hospital, emergency general surgery and trauma unit, liverpool, united kingdom, 2 liverpool john moores university, public health institute, liverpool, united kingdom introduction: liverpool is a city that has undergone recent rapic socioeconomic change. despite reductions in overall deprivation, incidents of stabbings have increased by 64% in the last 7 years. this study will describe the trend in knife crime, drawing on governmental data and policies to conclude the reasons behind the trend. materials and methods: a retrospective cohort study of patients presenting to north-west ambulance service (nwas) with a penetrating injury in liverpool between 2012 and 2018. data collected included patient demographics, geography and timing of incidents and correlation to datasets of multiple indices of deprivation and knife crime prevention outreach education programmes. results: incidents of stabbings have increased by 64% between 2012 and 2018. victims were more likely to be males (82%) between the ages of 20 and 24 (13%). the peak rate was between 20:00-21:00 (7.9%) and trough between 08:00-09:00 (1.3%). there is a spike in incidents of stabbings of 15-19 year olds from 15:00 to 21:00, correlating with school closure. there appears to be statistically poor correlation between deprivation of lower super output areas and stabbings (r 2 = 0.11, 0.29 and 0.18 for 2010, 2015 and 2019 respectively). however, when the data is split into larger areas, middle super output areas (msoas), deprivation appears to be a further risk factor. this study has identified certain geographical areas as high risk. conclusions: this study allows for targeted public health interventions at populations most at risk of knife trauma, including geographical mapping of high-risk areas, so that interventions can be distributed appropriately. references: ministry of housing, communities and local government (2019 government ( , 2015 government ( , 2010 introduction: trauma teams treat complex patients with injuries posing significant resuscitative and management challenges. effective teamwork is essential to optimise patient outcomes and improve survival, with failure contributing to adverse events [1] . the role of multidisciplinary (mdt) trauma training has been demonstrated by the military operational surgical training course (most) [2] . it is imperative that civilian trauma training adopts similar methodology to optimise team work. materials and methods: the three-day multidisciplinary trauma course comprised cadaveric-based skills teaching supplemented by lectures and real-life scenario discussion. delegates were senior surgical and anaesthetic registrars and consultants, alongside trauma team leaders (ttl), scrub staff and operating department practitioners (odp). pre-and post-course questionnaires assessed perceptions of multidisciplinary trauma simulation and confidence in specialty specific skills. results: all delegates reported mdt simulation clarified each role, including their own, in the trauma team. post-course, scrub staff and odps felt confident gaining intraosseous access (p \ 0.0002), surgical delegates had improved confidence performing all skills (p \ 0.01), with anaesthetists and ttls more confident in haemorrhage control and performing resuscitative thoracotomy (p \ 0.02). conclusions: mdt trauma training improves team understanding of role and effectively teaches skills. mdt courses with experienced faculty are one way of improving mdt trauma team function. further careful evaluation is required to assess performance of trauma teams in real scenarios. introduction: despite a dramatic rise in youth knife crime, the factors associated with it remain underexplored, especially in the critical pre-college years, which hinders effective counter-knife carrying interventions. the current research is the first to addresses this deficit. materials and methods: 161 british male school students (mean age = 13.48, sd = 1.061) coming from four different schools completed a short 15-min survey. they indicated their standing on a number of dimensions (school-adapted and shortened-scale-based predictors) derived from theories of violence, developmental psychology and related research (i.e. violence acceptance, need for respect, belief in self-defence, belief in a just world, narcissism, psychopathy, impulsivity, sensation seeking, and need for closure). results: for perceived knife harmfulness (i.e., the knife's assumed value in inflicting injury and death)-the total variance explained by the model was 8.7%, r2 = 0.087; f(10, 167) = 2.585. the only statistically significant predictors were: right-wing authoritariamism (b = 0.242, p = 0.005) and need for respect (b = 0.192, p = 0.026). the other factors were not statistically significant. for the perceived value of knife defence (i.e., its assumed defensive worth in violent confrontations) -the total variance explained by the model was 26.5%, r2 = 0.265; f(10, 167) = 7.032, pviolence acceptance (b = 0.208, p = 0.007), followed by need for closure (b = 0.202, p = 0.005), narcissism (b = 0.194, p = 0.011) and psychopathy (b = 0.177, p = 0.034). conclusions: this study provides evidence for future knife-carrying prevention interventions, such as talks in schools or social media videos, to focus more on how to increase self-esteem, stimulate empathy for and better understanding of other people, and approach problems from multiple (rather than just two) perspectives, emphasizing the ultimate superiority of the human intellect over brute force. introduction: the physician's response unit (pru) is a novel service that operates from the royal gwent hospital's emergency department (ed), in newport, south wales. it involves an emergency medicine consultant and a paramedic responding to 999 calls in a rapid response vehicle. their aim is to treat and, hopefully, discharge patients at the scene, reducing ed admissions. the pru can also refer patients on to other departments, e.g. the medical assessment unit, allowing patients to bypass the ed. methods: the author spent six weeks out in the pru and in the ed to observe and speak to patients. to assess whether ed admissions were reduced, the dispositions of patients seen by the pru were recorded on a daily log sheet. the service users' satisfaction with the pru was evaluated using simple questionnaires. this included both patients and paramedics, who can request the pru for support with a patient. results: the pru saw 245 patients during the project's timeframe. 64% (n = 156) of these patients were discharged at scene, while 16% (n = 38) were sent to the ed. 100% (n = 32) of patients asked described the care they received from the pru as equal to or better than care they have received previously. 94% (n = 30) of patients rated their overall satisfaction with the pru as 10/10. conclusions: the pru is very well received by both patients and paramedics and has been shown to reduce the number of patients attending the ed. this system excellently implements the principles of prudent healthcare introduction: in germany reducing alcohol related harms in youth is still a priority, because adolescents and young adults still have the highest accident risk in road traffic. therefore, the p.a.r.t.y.-project aim to increase awareness of alcohol and risk-related issues. the purpose of this study was to analyse the risk behaviour of adolescents before and after a prevention project in two different hospitals in germany. materials and methods: during a one-day prevention project, young people within the age of 13 to 17 years got an overview of the route an accident victim go through from the ambulance until the rehabilitation. before and after the prevention day, a structured written survey was completed by the adolescents. results: 799 students participated in the p.a.r.t.y. program between 2013 and 2018. the gender distribution of the participating students were balanced. the average age of the adolescent was 15 years. according to the program, the risk assessment and risk behaviour improved through the project significantly (\ 0.05). the evaluation of the students' satisfaction was rated as good. the majority of students prefer to repeat the project day after 2 years. conclusions: the prevention program shows that the program increase for short-term the awareness for risk related trauma in youth. nevertheless, long-term studies are necessary to receive data regarding the long-lasting effect. references: the present study is funded by the ministry for energy, infrastructure and digitization of the country mecklenburg-vorpommern, germany. development of a claims-based risk adjustment model for trauma introduction: duodenal injury is rare. the diagnosis requires a high index of suspicion which might result in delayed treatment. there is limited data on the delayed diagnosis group, especially high grade duodenal injuries. the purpose of this study is to determine the characteristics and outcomes of delayed high grade duodenal injuries. materials and methods: charts of all patients from 2008-2018 who had history of small bowel injuries are reviewed. the inclusion criteria were age between 15-80 years old, diagnosis with duodenal injuries at least grade 3 with delayed operation at least 6 h after injuries. baseline characteristics and postoperative outcomes were recorded. results: of the 212 small bowel injuries, 32 (15%) were duodenal injuries. the overall mortality was 6%. delayed diagnosis more than 6 h with at least grade 3 of duodenal injuries were 9 cases. the overall in-hospital mortality rate of the delayed group was 22.2% (2/ 9) who had concomittent hemorrhagic shock and low initial systolic blood pressure. 4 cases (44.4%) were diagnosed within 72 h and had better outcomes without leakage. they could step diet within 14 days and had shorter length of hospital stay (mean = 18 days). 3 patients (33.3%) presented with delayed diagnosis more than 72 h (the maximum was 408 h after injuries). all these 3 patients had anastomosis leakage and need reoperation. they had initial low level of serum albumin (mean 2.5 mg/dl), high white blood cell count, low serum bicarbonate and presented with preoperative acute kidney injury. conclusions: delayed diagnosis and surgical treatment of high grade duodenal injuries lead to poor outcome. low initial blood pressure associated with mortality and delayed treatment more than 72 h had higher morbidity. references: gary sa, frederick am, charles sc, et al. delayed diagnosis of blunt duodenal injury: an avoidable complication. acs meeting. 1998; 187(4) :393-9. routine follow-up imaging has no advantage in the non-operative management of blunt splenic injury in adult patients modality. the aim of this study was to investigate the incidence and time to failure of nom as well as to evaluate the relevance of follow-up imaging. materials and methods: all adult patients with bsi admitted to our level i trauma center, including two associated hospitals, between 01/01/ 2010 and 31/12/2017 were retrospectively analyzed. demographic data, injury severity score, splenic injury grade, modality, results and consequences of follow-up imaging were retrospectively analyzed. results: a total of 122 patients with a mean age of 43.8 ± 20.7 years (16-84 years) met inclusion criteria. 20 patients (16.4%) underwent immediate intervention. 102 patients (83.6%) were treated by nom. failure of nom occurred in 4 patients (3.9%). failure was significantly associated with active bleeding (or 33.75, 95% ci 3.1, 363.2, p = 0.004) , and liver cirrhosis (or 197, 95% ci 7.4, 5265.1, p = 0.001) . 80 patients (78.4%) in the nom-group received followup imaging by ultrasound (us, n = 51) or computed tomography (ct, n = 29). in 57 cases, routine imaging examinations were conducted (43 us and 14 ct scans) without prior clinical deterioration. 55 (96.4%) of these imaging results revealed no new significant findings. every failure of nom was detected following clinical deterioration. conclusions: to our knowledge this study includes the largest monocentric patient cohort undergoing ultrasound as first-line followup imaging modality in the nom setting of bsi in adult patients. the results indicate that a routine follow-up imaging, regardless of the modality, has no therapeutic advantage. indication for radiological follow-up should be based on clinical findings. if indicated, a ct scan should be used as preferred imaging modality. the association between bmi and mortality of renal injuries in adult trauma patients introduction: the role of body mass index (bmi) on solid organ injuries remains debatable. while some studies have shown no association between bmi and hepatic or splenic injuries, others have reported that severe hepatic injuries were more common in pediatric patients with bmi [ 30. the aim of this study is to examine the association of bmi and mortality, as well as any significant differences between operative vs. non-operative management. materials and methods: this was a retrospective study using the 2016 american college of surgeons-trauma quality improvement program database to identify all adult patients (ages 18 to \ 65) with traumatic renal injuries. the primary analysis showed a different pattern of mortality between patients with bmi \ 29 and those with bmi c 29 kg/m 2 . then, the study population was divided into patients with bmi \ 29 and those with bmi c 29 kg/m 2 . multivariable logistic regression was conducted to assess any association of mortality with age, gender, bmi, and injury severity score (iss). results: 3782 adult trauma patients were identified. a greater proportion of males (75.2%) and females (24.8%) had bmi \ 29 kg/m 2 (p = 0.5). the average age of patients with bmi \ 29 kg/m 2 was 32.3 (sd = 12.7) years which was significantly younger than that in patients with bmi c 29 kg/m 2 , 37.8 (sd = 13.6) years (p = 0.001). patients with bmi \ 29 kg/m 2 were found to have a significantly higher mortality rate of 6.5% vs. 4.4% in patients with bmi c 29 kg/m 2 (p = 0.02). however, there was no significant difference in type of operative or nonoperative management between patients with bmi \ 29 vs. bmi c 29 kg/m 2 . after multivariable logistic regression, mortality was associated with age, bmi and iss. no effect modification of sex was observed in the relationship of mortality and bmi. conclusions: adult patients with renal injuries and bmi \ 29 kg/m 2 have significantly higher rates of mortality compared with adult patients with renal injuries and bmi c 29 kg/m 2 . introduction: trauma is an ever-evolving surgical discipline. trauma remains a major source of global mortality. the operative and non-operative options for trauma patients has steadily increased. the development of trauma protocols, advancement in transport to trauma centres and radiological techniques has seen a shift in trauma surgery caseload. observing and understanding this shift from operative management to an increasing non-operative management of trauma cases will better prepare the acute medical team in this setting. materials and methods: prospective trauma registry data was collected and analysed retrospectively. patients presenting to a tertiary referral hospital between jan 2011 to dec 2015 with an injury severity score of [ 15 were reviewed. patients who were transferred to another facility for management were excluded. the demographic data and surgical outcome data were collected and analysed. trend analysis of the operative cases performed for each specialty. results: 2162 major trauma patients presented to the john hunter hospital between january 2011 to dec 2015. there was a non-statistically significant increase in the number of presentations (389 pt in 2011 vs 494 in 2015, p = 0.1625). there was a decreasing rate of operations performed for trauma patients (60% in 2011 vs 43% in 2015, p \ 0.0001). there was an increasing rate of orthopaedic surgery cases and operative time compared to other specialties (178 in 2011 vs 246 in 2015, p \ 0.001). general surgical major trauma operating cases noted a significant decline over the study time (82 in 2011 vs 33 in 2015, p \ 0.001). conclusions: there is a sizeable shift in the caseload of different surgical specialties in regard to major trauma patients over the course of 5 years from 2011 to 2015. orthopaedics has seen a significant increase in operative caseload and surgical time required to adequately manage major trauma presentations. the workload and experience of general surgical teams will likely be affected by these changes. the distribution of resources needs to be reflected in the changing work demands of each surgical subspecialty. traumatic internal hernia with delayed small bowel strangulation after pelvic ring injury hospitalization, follow up abdomen ct checked. there was no other specific change than increased thigh hematoma. eight days after hospitalization, ct was re-examined due to abdominal pain with abdominal distraction. an ct showed peritonitis with pneumoperitoneum and small amount of ascites. small bowel herniation through right pubic bone fracture site with ischemic change also noted. diagnosis: diagnosis was traumatic pelvic hernia with delayed small bowel strangulation. therapy and progressions: an emergency operation was performed. ileal loop was hernitated and perforation was found. emphysematouns change and fluid collection was exsited at perineal area and left high. after small bowel loop segmental resection, wound vac was applied at thigh area. comments: traumatic pelvic hernia is rare. diagnosis is challenging in the acute setting and often delayed due to lack of awareness. when diagnosed, efforts should be made to look for other serious injuries as traumatic pelvic hernia usually associated with concomitant intraabdominal injuries. the optimal management of traumatic hernia should be individualised based on the mechanism and severity of injury, presence of concomitant injuries, size of defect, and presence of incarceration. delayed treatment may read to fatal outcomes. careful inspection of the patient is important. references: vincent k, cheah sd. traumatic abdominal wall hernia-a case of handlebar hernia. med j malaysia. 2018;73(6):425-6. angio-embolization in pediatric trauma patients with blunt splenic injury: a systematicreview t. nijdam 1 , r. spijkerman 1 , l. hesselink 1 , t. hardcastle 2 , l. leenen 1 , f. hietbrink 1 1 umc utrecht, traumasurgery, utrecht, netherlands, 2 inkosi albert luthuli central hospital, trauma, durban, south africa introduction: non-operative management (nom) for children with blunt splenic injury (bsi) is nowadays a commonly used treatment in pediatric trauma departments. in adult trauma departments the addition of splenic angio-embolization (sae) is suggested to decrease the failure rate of nom in high grade splenic injuries. however, the use of sae in pediatric trauma departments is very uncommon and it is unknown if sae is of additional value in pediatric trauma patients. therefore, the aim was to analyze the available literature on sae in pediatric trauma patients with bsi. materials and methods: a literature search was performed to find eligible studies that analyzed sae in pediatric patients with bsi. the primary outcome was failure of treatment in these patients. secondary outcomes were the success rate of sae, length of stay and mortality. the relative risk (rr) was calculated to compare primary outcome between study groups. results: in total 219 studies were identified through the search, a total of 6 studies matched our inclusion criteria and were selected for this review. studies included a total of 12.310 pediatric patients, of whom 539 underwent sae. patient age ranged from &lt;1 year to 18 years, mean age was 12.1 years. both injury severity score and spleen injury grade were higher in the sae group compared to the nom group. failure rate of sae was 8%. no spleen related morality was observed in the sae group. conclusions: the literature suggests that sae might be of added value in a very selective group of pediatric trauma patients with high grade splenic injures. however, since limited evidence is available concerning the use of sae in pediatric trauma patients with bsi, no firm conclusions can be drawn about safety and effectiveness. introduction: the management algorithms for trauma have changed with the development of specialised trauma centres. the aim of this study was to review the management and outcomes of patients with traumatic small bowel (sb) and colonic injuries. material and methods: patients treated for sb and colonic injuries between 2008-2018 at aintree university hospital (liverpool) were identified using the prospective trauma audit and research network database. the management and outcomes of the patients included were analysed. results: 44 patients sustained sb and colonic injuries. there were 29 (65.91%) sb injuries and 21 (47.73%) colonic injuries (6 patients had a sb and colonic injury). 17 patients (38.64%) of injuries were due to knife stabbing wounds, 14 (31.82%) patients were due to gunshot wounds, and 13 (29.55%) patients were due to road traffic accidents/ blunt blows. damage control surgery was performed in 7 (15.91%) patients. colonic injuries included 6 (28.57%) haematomas and 15 (71.43%) perforations. a resection and stoma (rs) procedure was performed in 9 patients (42.86%), primary repair (pr) in 8 patients (38.10%) and resection with anastomosis (ra) in 4 patients (19.05%). sb injuries included 6 (20.69%) haematomas and 23 (79.31%) perforations. pr was performed in 19 (65.52%) cases and ra in 10 (34.48%) cases. the overall complication rate after sb and colonic injury was 50% (22 patients) with a significant complication rate (7 patients, p value = 0.017) for patients undergoing rs in colonic trauma. the 30-day mortality rate was 2.27% (1 patient). conclusions: pr in sb and colonic injuries appears safe. in our dataset, rs appeared to have a higher complication rate. our study highlights that such injuries are uncommon with a high complication rate. surgeons need to provide individualised treatment. introduction: nowadays, patients with high grade bsi are preferably treated using spleen preserving treatments (spt). it is assumed that patients with low grade bsi treated with spt have a good splenic function after recovery. however, there is no consensus on splenic function after high grade bsi. in several institutions, asplenic/hyposplenic infection prevention protocol will be executed in all patients who had spt after high grade bsi, where other institutions evaluate splenic function first. scintigraphy is believed to be the best flow/activity test to approximate splenic functionality. the aim of the study was to analyze whether spleen injury grade is associated with diminished splenic function. secondarily, we aimed to evaluate whether splenic function testing is necessary in pediatric patients after bsi. material and methods: a retrospective study was performed from january 1998 to january 2018. in our institution patients with bsi grade iv of v are assumed hyposplenic and will receive a splenic function test. we included all patients with a minimum follow-up test period of 5 days. all tests were analyzed by the radiology specialist. for each patient we furthermore collected clinical data, including the date of trauma, gender, age, mechanism of injury, ais of splenic injury and iss. results: 33 patients consisted of 23 male and 10 female, with a median (iqr) age of 11.8 (7. 3-13.5) . median iss was 16.0 (13-30.5) and the median spleen ais was 4 (3) (4) . nom was used in 26 patients, sae in five patients and two patients were treated with surgical mesh technique. the median follow-up time of all performed tests was 59 (22-75) days. a total of 20 patients (61%) had a grade iv or v splenic injury. scintigraphy was utilized to test most patients. a total of 32 out of 33 patients had an adequate splenic function, including all sae patients. conclusions: even high grade splenic injuries show adequate splenic function in the follow-up of pediatric trauma patients after bsi. therefore routine diagnostic follow-up by scintigraphy is not necessary in this specific patient group. evaluation of abdominal injuries treated at stavanger university hospital: occurrence, severity and mortality j. w. larsen 1 , k. søreide 1,2 , j. a. søreide 1,2 , k. tjosevik 1 , k. material and methods: retrospective evaluation of data recorded prospectively in the hospital's trauma registry between january 2004 and december 2018. patients with abbreviated injury scale (ais) code for abdominal injury were included. descriptive analyzes are presented for demographic data, injury type, mechanism, and severity, as well as 30-days mortality. results: a total of 449 patients with abdominal injuries were included (6.2% of all trauma patients). 70% where men. median age was 31. the injury mechanism was blunt in 91%. transport accidents were the most frequent cause of injury (57%). median iss was 21, and median niss 25. overall 30-days mortality was 12.5%, with a median trauma injury severity score (triss) of 0,07. multiple abdominal injuries were recorded in 44% of the patients. 86% had associated injuries in other body regions, most frequently in the thoracic region (65.5%). solid organ injury occurred in 83% of the patients, with liver injury (38%), splenic injury (33%), and kidney injury (23%) encountered most frequently. an ais score c 3 was found in 56% of liver injuries, 65% of splenic injuries, and in 43% of patients with kidney injuries. hollow viscus injuries were found in 20% of the patients. injuries to the small intestine (8%) and colon (6%) were most frequent. abdominal vessel injuries were encountered in 15%, and 94% of these had an ais score c 3. conclusions: abdominal injuries are dominated by solid organ injuries following blunt injury mechanism and are often associated with concomitant thoracic injury. patients who dies within 30 days from admission are characterized by a low probability of survival shown by triss. pancreatic trauma management in a third level centre a. gonzález-costa 1 , r. gracia-roman 1 , s. montmany-vioque 2 , a. campos-serra 1 , r. lobato-gil 1 , c. zerpa-martin 1 , f. j. garcía-borobia 3 , p. rebasa-cladera 2 , s. navarro-soto 2 management. the aim of the study is to review the management and describe the most frequent complications of pancreatic trauma in our centre. material and methods: observational study with prospective collection of data, from march 2006 to march 2019. inclusion criteria: trauma patients older than 16 admitted to the emergency department who were admitted to icu or died before admission. demographic data has been collected, also vital signs, iss, mechanism of action, mortality, complications, and lesions. results: between 2006 and 2019, 1798 polytraumatic patients were registered. only 17 had pancreatic trauma (0.95%). the male: female ratio was 11:6; with an average age of 47.7 years (sd 13.4) . mean iss of 24.5 (sd 15.1), mean ais of 2.1 (sd 0.97) and mortality of 23.5% (4 patients). the most frequent pancreatic lesion was at the head of the pancreas (9 patients; 52.9%), followed by body-tail (6 patients; 35.3%) and two patients with full section (11.7%). 64.7% of patients were treated with non-operative management. five patients required urgent surgery (29%), requiring corporocaudal pancreatectomy in 2 cases and drainage in 3 patients. an embolization of a gastroduodenal artery aneurysm was performed in 1 patient. respiratory complications were the most frequent. 4 patients developed a pancreatic fistula (23.5%), although in surgical patients this complication was much higher (60% in our series). one of them required puestow pancreaticojejunostomy and 1 patient developed necrotizing pancreatitis (5.8%). conclusions: pancreatic trauma is very uncommon. its management can be difficult, depending on the degree of injury (aast), with a high rate of complications. therefore, combined management and monitoring by the surgery and intensive care team will be very important. introduction: the aim of this retrospective study was to evaluate and compare the clinical outcomes of conservative versus surgical treatment in a series of patients with liver injury. material and methods: between 2005-2017, there were included 128 patients. according the treatment chosen, the patients were subdivided in two groups. non-operative management was considered in hemodynamically stable patients. the failure of conservative treatment was defined as need to resort to operative management after a period of strict monitoring when the reason was related to the liver or associated injuries or need for late angioembolization. all hemodynamically unstable patients were subjected surgical treatment. results: conservative treatment was selected for 101 patients and only in 8 of them was failed due to associated delayed bleeding and small bowel injury. 27 patients underwent emergent surgery which included packing, lobectomy and splenectomy. operative findings revealed grade iii liver injuries in 71% and grade iv in 28%. pneumonia, sepsis and ards were the most frequently associated complications. the overall mortality rate was 8.6%. in 19 patients of conservative group, non-surgical treatment failed with surgery being required. the mortality in the group of patients who underwent emergent laparotomy on admission was of 6 patients. conclusions: conservative treatment of blunt traumatic hepatic injuries is applicable in patients presenting hemodynamic stability with mild hepatic injuries and it could be successful even in high graded injuries with low morbidity and mortality. surgical treatment is indicated in grade v injuries. nevertheless, failure of conservative treatment does not necessarily lead to an increase in the incidence of complications or mortality. with the trend towards more conservative management strategies, surgeons' exposure to laparotomies for blunt injuries in rtas has decreased. the aim of this study was to examine surgeons' exposure to laparotomies following blunt trauma which remains important to maintain low patient morbidity and mortality rates. material and methods: data was collected for adult patients admitted to mater dei hospital (malta) following rtas with ctproven intrabdominal injuries between january 2008 and january 2018. results: 114 patients (74 (64.91%) males vs. 40 (35.09%) female (p value \ 0.05), mean age = 36.66 years) were included in the study. 88 patients (77.19%) were car occupants whilst 26 patients (22.81%) were pedestrians. 94 (82.46%) patients had single intraabdominal organ injury, whilst 20 (17.54%) had multiple intraabdominal organ injuries. the 30-day mortality rate was 11.40% (13 patients). liver injuries occurred in 57 (42.54%) patients, splenic injuries occurred in 50 (37.31%) patients, kidney injuries in 18 (13.41%) patients and other organs were injured in 9 (6.72%) patients. conservative management was followed in 81 (71.05%) patients, angioembolisation was utilised in 12 (10.53%) patients and operative management was performed in 19 (16.67%) patients during the 10-year period. this resulted in 2 trauma laparotomies following rtas per year. conclusions: only a minority of patients require operative management after rtas. surgeons in small countries have limited exposure to complex rta's. in view of the low exposure to emergency laparotomies following rtas, changes to our local training programme was done. trauma courses, lectures and fellowships in eu have been implemented to maintain surgical skills to an optimal level. references: european commission, annual accident report. european commission, directorate general for transport june 2017. case history: a 61 year old female presented to the accident and emergency department 10 h post colonoscopy with complaints of left sided abdominal pain. this colonoscopy was requested under a 2-week wait for a history of chronic diarrhoea. this was a complete and uneventful examination ath the time, with random colonic and ileal biopsies taken. she attended a ? e with left sided abdominal pain increasing in severity. clinical findings: she was found to have an exquisitely tender abdomen, experienced more in the left upper quadrant. she was clinically shocked with a marked hypotension and tachycardia. investigation/results: a ct of her abdomen and pelvis showed free fluid within the abdomen and pelvis, with active bleeding and large haematoma adjacent to the spleen. the grade of splenic injury however was not commented upon by the reporting radiologist. interventional radiological embolism was considered but unfeasible as patient not stable haemodynamically. diagnosis: she was diagnosed with a splenic injury post-colonoscopy, with internal bleeding and haemodynamic instability. therapy and progressions: she underwent an emergency splenectomy overnight and was transferred to the intensive care unit for postoperative care. she recovered well, was stepped down to ward level care and was discharged with post splenectomy protocols, including all necessary vaccinations. comments: splenic rupture post-colonoscopy is a very rare event, with less than 115 cases reported worldwide since 1974. however, it still should be considered as a cause of a ? e presentation in patients with upper abdominal pain and haemodynamic instability after recent colonoscopy. we wanted to present this rare case to the international audience of estes congress to raise awareness of this rare complication. clinical findings: hemorrhagic shock and consciousness disorder were observed. her abdomen was distended, and she was intubated in the emergency room. investigation/results: ct revealed massive intra-abdominal bleeding. diagnosis: massive intra-abdominal bleeding due to hepatic laceration. therapy and progression: damage control surgery (dcs) and transcatheter arterial embolization (tae) were performed. she was transported to a hybrid operating room. she experienced cardiac arrest before operation. cardiopulmonary resuscitation was immediately initiated, resulting in the return of spontaneous circulation. laparotomy with perihepatic packing (php) was performed, but she experienced two more episodes of cardiac arrest during operation. then, tae was performed for right hepatic artery extravasation. after physiological function restoration, including rewarming, coagulopathy correction and hemodynamic stabilization in the intensive care unit. she gradually became hemodynamically stable. however, incomplete hemostasis was obtained at second-look laparotomy 18 h later. because of bleeding, we repeated php. we performed cholecystectomy and abdominal closure after confirming complete hemostasis (46 h post-accident). she was discharged ambulatory without neurological deficit (day 82). comments: prognosis of traumatic cardiac arrest is generally poor, and survival without considerable neurological deficit is very rare. we reported a surviving patient with severe hepatic laceration. sharing of strategies and tactics, such as blood transfusion, tae, trauma team approach to surgery, early decision of dcs improves outcome of patients with severe abdominal trauma. references: resuscitation. 2010;10:1400-33. introduction: the spleen is the most commonly injured organ after blunt trauma. non operative treatment (nom) of splenic injuries has gained wide acceptance. transcatheter embolization of the splenic artery is considered a useful adjunct in aast lesions c 3 without active bleeding. we report a retrospective review of all patients admitted to a level 1 trauma center with blunt splenic injury from 2012 to 2019 and compare their treatment and outcome with a previous series from 2007 to 2011, when angioembolization was performed only in case of contrast blush at ct scan. patients and results: from 2012 to june 2019, 59 patients with blunt splenic injuries were admitted to the ed of a level 1 university hospital in milan, italy. men to female ratio was 5:1,the mean age 44.9 ± 20 years (range 16-90), and the iss 22 ± 11.5(range 2-57). eight patients (13.6%) underwent emergent splenectomy due to hemodynamic instability. of the 51 stable patients treated with nom, those with aast lesions c 3 (n = 25) were submitted also to angiography and 23 to embolization of the spleen (45%), either proximally (12) or distally (11). two nom failed, and the patients were submitted to splenectomy or distal embolization. the median hospital stay was 13.1 ± 11.5 days. the total spleen salvage rate was 96%. no associated abdominal injuries were missed in the nom group. in the previous series of 31 patients (mean age 34.7 ± 15.4 years, range 17-88, #:$ = 7:1, iss 18 ± 7, range 4-38), 4 underwent emergency splenectomy (13%), and 27 (87%) were treated conservatively, with only 7 embolization (25,9%) in case of aast c 3 at ct scan. failure of nom were 2, and the spleen salvage rate 80.6%. liver injury following multiple cardiopulmonary resuscitations case history: this is a case of a 44 year old woman who presented to the emergency department (ed) due to worsening dyspnea complicated by two lengthy cardiac arrests. after the first resuscitation and return to spontaneous circulation (rosc), echocardiography was done and showed severely dilated right ventricle with strain, suggestive of massive pulmonary embolism, for which rtpa was given. arrest occurred again, and post rosc, heparin was started and the patient was transferred to the icu. extracorporeal membrane oxygenation (ecmo) was initiated but complicated by severe hemodynamic instability and a third cardiac arrest, so cardiopulmonary resuscitation (cpr) was performed till rosc and massive transfusion protocol was started for suspected intraperitoneal bleeding. clinical findings: after ecmo cannulation, abdominal distention was noted with a severe drop in hemoglobin and an increased intraabdominal pressure (25 mmhg). abdominal bedside ultrasound showed significant amount of dense free fluid. the decision for an urgent exploratory laparotomy was made and the patient was taken to the operating room. therapy and progressions: deep liver laceration over the right hepatic dome with rupture of the capsule and an estimated hemoperitoneum of 3 l were found intra-op. controlling the bleeding was difficult due to the laceration site and the patients coagulopathic status, so packing was done and the patient was transferred to icu for correction of the coagulopathy and re-evaluation in 48 h. the liver was unpacked after 48 h, bleeding sites were cauterized and sutured and the liver was wrapped with a mesh with an attempt for a tamponade effect. the patient's stay in icu was complicated with kidney injury requiring chronic dialysis but otherwise recovered well. comments: liver injury is a rare but serious complication after cpr that should be considered in case of persistent hemodynamic instability along with bedside findings. this case is intriguing due to the right sided liver injury with no overlying rib fractures. blunt renal trauma after electrical injury: a series of curious events. a. nixon 1 , e. falidas 1 , d. davris 1 , a. botou 1 , g. sofos 1 1 chalkida general hospital, department of surgery, chalkida, greece case history: a 25 yr old patient was referred to the emergency department (ed) of our hospital from a primary health center after sustaining an electrical injury (220 v ac). the patient experienced loss of consciousness (loc) and promptly fell to the ground in a supine position. the patient arrived approximately 3 h after the incident. clinical findings: vital signs: bp: 90/45 mmhg, hr: 110 bpm. the patient's major complaint was left flank and abdominal pain. no obvious thermal injuries were observed or any other signs of external trauma. a left abdominal mass developed which was evident on physical examination. in addition, examination of urine revealed gross hematuria. investigation/results: ekg monitoring documented sinus tachycardia without evidence of cardiac arrhythmias. fast indicated the presence of a massive retroperitoneal hematoma. the fast exam indicated the left kidney as the probable source of hemorrhage. the initial hematocrit (hct) from the primary health facility was 44% while results from the ed recorded a hct of 22%. diagnosis: grade v renal trauma. therapy and progressions: a massive transfusion protocol was initiated. the patient underwent an emergency laparotomy and a left nephrectomy was performed. subsequent imaging did not reveal other injures. comments: the history of electrical injury could have misdirected investigation efforts towards cardiogenic shock. this case suggests that even in the absence of a high energy impact, sustained hemodynamic instability should always be attributed to hemorrhagic shock until disproven. in addition, the management of grade v renal trauma in blunt injury remains a controversial topic, however we believe that in cases of class iv shock, surgical management is imperative. case history: 56 y.o. female with a history of chagas' disease of 30 years duration and esophageal involvement in the last few months. she's admitted for a first endoscopic balloon dilatation due to dysphagia, which is performed according to protocol, and a tear of the mucosa layer is observed during it. clinical findings: she's stable for the first 36 h but with continuous thoracic pain of moderate intensity according to the gi specialist. on the second day there's a general worsening of the patient's condition, with dyspnea, fever, desaturation and tachycardia. results and diagnosis: she develops leukopenia and elevations of acute phase reactants, and a ct scan reports a distal esophageal perforation with free extravasation of contrast in the mediastinum and bilateral pleural effusions. therapy and progressions: emergency surgery is performed through a midline supraumbilical laparotomy which shows peritonitis around the epigastric area. after opening the hiatus, a very long transmural esophageal tear with devitalized tissues and severe contamination are observed. a trans-hiatal esophagectomy was decided and, given the hemodynamic stability, a gastroplasty is performed and brought up to the neck without anastomosis, along with a terminal cervical esophagostomy and feeding jejunostomy. the patient did well in the postop period. we were able to do the esophagogastric anastomosis in the neck 14 days later, during the same admission. comments: the surgical technique in esophageal perforation depends mainly on the time elapsed since the perforation, and on the condition of the patient. esophagectomy is sometimes unavoidable, and a gastroplasty can be brought up to the neck at the same time in selected cases, with reconstruction of the upper gi tract during the same admission. introduction: the spleen is one of the most frequently injured abdominal organ. the anatomy of the lesion defines the degree according to aast, ranging from grade i to v in increasing complexity. the diagnosis of splenic trauma may be difficult, as 40% of patients may show no signs or symptoms at primary survey. the approach involves two main strategies: conservative or surgical. the strategy should take into account four aspects: hemodynamic status, anatomy of the lesion, associated injuries and organizational structures of the evaluation site. this study aims to evaluate the type of approach performed on different degrees of splenic trauma during 7 years in a portuguese trauma center. material and methods: we conducted a retrospective study including all patients diagnosed with splenic trauma during a period of seven years. by consulting the patient's clinical files we evaluated and compared: demographic data, trauma kinetics, degree of splenic injury and the approach taken as well as morbidity and mortality. results: of the 119 patients studied, most were male with blunt trauma. in 58 patients the inicial approach was surgery and in 61 the option was conservative treatment. in grade iii or iv lesions conservative treatment failed in 16% of patients. patients in whom the surgical approach was first chosen had predominantly grade iv lesions, with total splenectomy being the preferred approach. in grade iii lesions, the option was mainly conservative surgery of the spleen. conclusions: the initial approach of splenic trauma results essentially of the experience of emergency teams and support structures for surveillance and intervention (intervention radiology and 24-h operating room availability). the attempt to try conservative strategy is increasing over time. introduction: for decades, helicopter emergency medical services (hems) contribute greatly to prehospital trauma patient's care by performing advanced medical interventions on scene. unnecessary dispatches, resulting in cancellations, cause these vital resources to be temporarily unavailable. these cancellations contribute to overtriage and provide additional costs to society. an earlier study showed a cancellation rate of 44% in our trauma region. however, little empirical knowledge exists about reasons for cancellations for different mechanisms of injury (moi) and type of dispatch. this study aims to examine the current cancellation rate in our trauma region over a 6-year period. additionally, insights in cancellation reasons for different moi and type of dispatch are evaluated. methods: a retrospective study was performed, using data derived from the hems database of trauma region north west netherlands, between april 1st 2013 and april 1st 2019. information regarding patient's characteristics, date and time of day, moi, type of dispatch, and cancellation reason were compared. results: in total, 18,639 patients were included. hems was cancelled in 54.5% of dispatches. the majority of dispatches (76.1%) were cancelled because the patient was physiologic-and neurologically stable. dispatches simultaneously activated with ems were cancelled 58.3% of times, compared to 15.1% when hems assistance was additionally requested by ems on scene. no differences were found between dayand night-time dispatches. trauma related dispatches were cancelled more frequently compared to non-trauma related dispatches. conclusions: this study found a considerable-and increased cancellation rate compared to previous research. an explanation for this finding could be better adherence to dispatch protocols. furthermore, a great variety in cancellation rates was found among different moi's. therefore, continuous critical evaluation of hems triage is important and dispatch criteria should be adjusted if necessary. case history: two separate cases of high speed road traffic collision. the first is 31 years old female without significant past medical history. the second is 28 years old male who had short extremitis due to history of spastic quadriplegic cerebral palsy alongside congenital kyphosis and postural scoliosis. clinical findings: on examination the first patient was hemodynamically stable with soft abdomen and bruising over the left pelvic area. the second patient had left side neck and right side chest bruises; furthermore, he was tachycardic with normal blood pressure, but he was generally pale, getting clammy and significantly sweaty. investigation/results: fast scan for both patients showed free fluid in the abdomen and ct scan was uncertain of the source in the first patient. in the second, a large mesenteric haematoma was evident on ct with contrast extravasation with corresponding significant drop in hemoglobin and raised lactate levels. diagnosis: case 1: hemodynamically stable blunt abdominal trauma. case 2: hemodynamically unstable blunt abdominal trauma. therapy and progressions: the first patient was managed conservatively initially but worsened overnight with a drop in haemoglobin and increase in lactate mandating emergency laparotomy. hemoperitoneum and 60 cm of ischaemic bowel with tear in the mesentery was found. she had an uneventful recovery after resection and primary anastomosis. the second patient underwent immediate emergency laparotomy. there was evidence of hemoperitoneum (3 l) and similar mesenteric tear with ischemia involving 50 cm of the terminal ileum. resection with end to end anastomosis was done. patient was then transferred to itu; however, he developed chest infection which prolonged hospital stay. comments: hemodynamic instability is a major factor in mandating urgent exploratory laparotomy in bat and bucket-handle injury is not uncommon following road traffic accidents. introduction: incisional hernias are one of the most common complications post-abdominal surgery, affecting between 10-25% of patients undergoing a laparotomy. a number of risk factors are associated with their development such as age, bmi, type of surgery and co-morbidities. these risk factors also affect their levels of recurrence which is why the technique undertaken to repair these is of such interest. the primary purpose of this meta-analysis was to examine which repair technique is associated with the lowest level of recurrence whilst a secondary aim was to examine whether the frequency of common complications was dependent on the type of repair utilised. material and methods: this systematic review and meta-analysis was conducted by both co-authors. the following information sources were utilised; cochrane/embase/google scholar/pubmed/scopus. in relation to the eligibility criteria-papers that were published from 1990 onwards and in the english language were included with any length of follow-up. study selection was as per the inclusion/exclusion criteria below and only cohort studies/rcts/systematic reviews/ meta-analyses and case control studies were included. inclusion criteria: abdominal incisional hernias, all types of repairmesh/open/laparoscopic/sutured repair/primary repair etc. in terms of the exclusion criteria-any hernia repair that was not incisional was excluded. results and conclusions: in terms of the primary question posed by this repair, meta-analysis shows that there is a significant difference between open vs laparoscopic technique and recurrence rates in relation to the primary question posed by this paper whilst the use of mesh impacts negatively on post-operative wound infection rates. this invites an interesting debate on the merits of each technique whilst demonstrating the need for a multicentre randomised controlled trial. laparoscopic approach in penetrating abdominal trauma: case study and review of the literature b. vieira 1 , v. taranu 1 , a. silva 1 , d. galvão 1 , a. soares 1 1 hospital de santo espírito da ilha terceira, general surgery, angra do heroísmo, portugal introduction: laparoscopy(ls) has greatly improved surgical outcomes in many elective abdominal procedures. the use of ls in acute care is becoming widely accepted. however, a number of safety issues have limited its application in abdominal trauma. notwithstanding with the reports and studies of the past decade proving its safety and accuracy, ls is slowly replacing the need for exploratory laparotomies. case report: a 34 yo male sustained with penetrating stab wound on the left flank. he was hemodynamically stable. ct confirmed intraperitoneal positioning of the knife, without free fluid or air nor any evidence of organ injury. an exploratory ls was performed and confirmed the intraperitoneal positioning of the knife. abdominal exploration revealed a jejunal transfixating lesion about 1 m from treiz's angle that was manually closed. the patient maintained a favorable po evolution and was discharged on the 4thpo day. discussion/conclusion: a number of concerns have limited the use of ls in abdominal penetrating trauma. initially, it resulted in high rates of missed injury, mainly of the small bowel, generating considerable criticism. the development of systematic abdominal explorations in ls, as described by choi and kawahara, resulted in a rate of missed injuries close to zero. moreover, direct visualization using ls has shown superior specificity and sensitivity in identifying peritoneal penetration, hollow viscus injuries and diaphragmatic lesions when compared to ct. in the case reported here, ct didn't show any image suspected of perfuration such as free air or fluid, and yet ls showed a small bowell injury. besides its advantages as a diagnostic tool avoiding negative laparotomies in more than 50% of the cases, thanks to evolving techniques and improved practice, it may also be therapeutic and allow safe definitive treatment for many types of injuries as described here. method: this is a monocentric retrospective study from a database entered prospectively. all patients admitted to the university hospital in nice with splenic trauma between 01/01/2006 and 01/06/2018 were included. the primary endpoint was performing splenectomy as a failure of a nom. results: 290 patients were included in our study. the majority of splenic lesions were severe grades, that is to say greater than 3. in total, 83 splenectomies were performed urgently, i.e. 29% of patients; 88 angio-embolizations were performed, i.e. 31% of patients with a success rate greater than 80%; 14.7% of 136 patients who had not anterior angio-embolization required secondary splenectomy; 19.7% of the 61 patients who had anterior angio-embolization required secondary splenectomy. in the patient group with successful angio-embolization, the mean age was 44 years vs 37.5 years in the nom failure group (p = 0.15). a decrease in hemoglobin between admission and 6 h after admission was found in the nom failure group compared with the successful embolization group (p = 0.064). conclusion: hemoglobin monitoring in the hours following admission of a patient with splenic trauma may be an important factor in the surveillance of hemodynamically stable patients. prospective studies could confirm these results. missed ureteric injuries in gunshot injuries of the abdomen: how to avoid? introduction: traumatic ureteral injuries are uncommon. penetrating rather than blunt trauma is the most common cause of ureteral injuries. the aim of this study is to make a strategy to avoid missing ureteric injuries in gunshot injuries of the abdomen. material and methods: 765 patients were operated in our hospital in 3 years period. all patients were managed according to atls guidelines. for stable patients, full radiological work up was done, while hemodynamically unstable patients were shifted to or immediately for laparotomy and exploration. all patients demographic and clinical data were recorded these include :patient age, sex, mechanism of injury, hemodynamic state on arrival to the rr, anatomical site of gunshot injury, associated injuries, ureteric injuries detected early or late, early repair, delayed presentation and morbidly associated with delayed discovery. results: ureteric injuries were found in 12 patients out of 765 patients who underwent laparotomy for gunshot injuries had ureteric injury in an incidence of 1.5%. ureteric injuries were missed in the first laparotomy in 3 patients. associated injuries of other abdominal viscera include; colon injuries affecting ascending and descending colon in all the patients. conclusions: ct and pyelogram are the modalities of choice in stable patient but in unstable patients the early recognition of ureteric injuries depends on high index of suspicion leading to surgical exploration of the ureter along its course. case history: we present a case of a 72 year old man, who was injured by his agricultural machine in the abdomen. clinical findings: he was transferred in the emergency department and he was hemodynamically stable. he had several traumas in his abdominal wall. from the largest one, in the left iliac fossa, omentum, transverse colon and loops of the small intestine were protruded out of the abdominal wall. the small bowel was ischemic and ruptured. investigation/results: computed tomography investigation, revealed small amounts of liquid and air in the abdominal cavity. diagnosis: the patient was immediately operated. the destroyed loop of the small bowel was resected with the use of a stapler and the field was washout. then with a midline incision the abdomen was opened. there were no other injuries inside the abdomen cavity. there was an extensive injury with a creation of a large gap in the anterolateral abdominal wall. it was impossible to identify the left rectus abdominis muscle as also the lateral muscles (external and internal oblique and transversus abdominis). therapy and progressions: a side to side entero-enteric anastomosis was created and a meticulous observation and washout of the abdomen were performed. for the closure of the abdominal wall a double-sided mesh from polypropylene coated with silicone on one side (20 9 25 cm) was placed and the operation was completed. all the other wounds of the abdominal wall were closed with loop nylon stitches no 1. a closed suction drain was placed above the mesh. the patient had a very good postoperative course. he was dismissed from the hospital after 15 days in a very good condition. comments: the usage of mesh was very useful for the reconstruction of the abdominal wall. there is no conflict of interest. strategy shift from damage control surgery to primary radical surgery improve the outcome of blunt hepatic injury involving inferior vena cava introduction: the diagnosis of abdominal trauma is a real challenge even for surgeons experienced in trauma. clinical findings are usually unreliable, and abdominal examination is made up of various factors. diagnostic tools that help the attending physician make critical decisions, such as the need for laparotomy or conservative treatment, are mandatory if we propose a favorable outcome. material and methods: the study was performed in the clinic i surgery, the county clinical emergency hospital craiova, between 2014-2018 and analyzed a number of 70 abdominal traumas hospitalized, investigated and treated in the clinic. the methods of paraclinical diagnosis are evaluated comparatively, the study analyzing the evolution and the tendencies during the studied period, from 2014, to 2018. results: the study allowed an evaluation of the diagnosis and treatment methods compared to the data in the literature. conclusions: thus ct scan remains the standard criterion for detecting solid organic lesions. in addition, a ct scan of the abdomen may reveal other associated lesions. fast ultrasound is an important and valuable alternative for diagnosing abdominal trauma, especially for patients who are hemodynamically unstable and cannot be mobilized. there is a tendency in the treatment of abdominal trauma, as evidenced by the literature data on the use of conservative versus surgical treatment for a larger number of cases introduction: antiplatelet agents and anticoagulant drugs are widely used in prevention of cardiovascular incidents, which poses a challenge in surgical emergencies. the drafting of a multidisciplinary protocol for the treatment of pharmacological induced coagulopathy in patients who require urgent surgery standardizes management and increases patients' perioperative safety. material and methods: aims of the study were to describe the results from the protocol implementation. a retrospective study was conducted by examining reports of every patient presenting pharmacological induced coagulopathy and undergoing emergent surgery, recorded in our center from 2012 to 2017 inclusive. different algorithms used were explained and data such as need of transfusion, reintervention rate and perioperative complications were analyzed. results: data from 169 patients were analyzed, median age of 79, 100 (59%) men. 107 patients (63%) used anticoagulant drugs. fresh frozen plasma transfusion and/or prothrombin complex concentrates were used according to the guideline. 73 (43%) patients used antiplatelet agents. 77% of them underwent a delayed 48 h surgery directly. tirofiban therapy was established in 7 patients on dual therapy due to medium-high risk of cardiovascular event. regarding surgical approach, 59 (35%) were laparoscopic, 96 (57%) open and conversion occurred in 14 (8%) cases, but only 1 of them due to intraoperative hemorrhagic complication. only 2 cases of postoperative hemorrhagic complications led up to reintervention and only one isolated case of thrombotic complication was reported. finally, 7 (4%) mortality cases were reported, but none was caused by hemorrhagic nor thrombotic complications. conclusions: establishment of a guideline on management of pharmacological induced coagulopathy in emergent surgery is crucial in all surgical emergency units and has proven to be effective and safe. introduction: digestive haemorrhage is a frequent pathology. most of the episodes are self-limited, but in some cases massive haemorrhage occurs, leading to a 10% mortality rate. severe problems occurs when endoscopic treatment is not effective, requiring emergent surgery with poor prognosis. the aim of this study is to evaluate the implementation of interventional radiology techniques on short-term results. methods: a retrospective descriptive study was performed reviewing patients who underwent radiological embolization after failure of endoscopic conventional treatment between 2015-2019 in our hospital. a total of 41 patients were included. results: 22 patients were male. 24 cases were from lower gi track and 17 were from the upper gi with a similar death rate between them, with a higher rebleeding rate in upper gi (35.2% vs 12.5%). 29% of the arteriographies did not show any bleeding site, 4 of them developed a new bleeding episode. overall patients who undergo embolization, urgent surgery was avoided in 8 of the 11 patients diagnosed as upper gi haemorrhage and in 15 of the 19 patients diagnosed as lower gi haemorrhage. 5 patients died, those death occurred later on the recovery of the acute bleeding episode and embolization, all of them related to patients comorbidities. conclusions: arterial embolization has become an important tool in order to treat massive haemorrhages of the gastrointestinal tract. it seems to decrease the mortality and morbidity rate, but some complications can be associated such as rebleeding or bowel ischaemia. massive transfusion protocol with early administration of platelet and fresh-frozen plasma along with packed red cells in the initial phase of resuscitation is associated with improved outcomes introduction: massive transfusion (mt) in a ratio of 1:1:1 (prbc:platelet:ffp) is the standard of care in hemorrhaging trauma patients. the aim of our study was to compare the outcomes of patients who receive near balanced resuscitation (nbr) compared to unbalanced resuscitation (ubr) during the initial phase of resuscitation. material and methods: we performed a 4-year analysis of the acs-tqip. all adult patients (age [ 18) who received mt (defined as transfusion of prbc c 10 units in 24-h) were included. patients were stratified into two groups: nbr defined as prbc:platelets:ffp in 1: [ 0.5: [ 0.5 and ubr (1: \ 0.5: \ 0.5) in the first 4 h of resuscitation. primary outcome measure was mortality. secondary outcome measures were complications, and hospital length of stay. propensity matching was performed to match the two groups. results: a total of 10,321 patients received mt. mean age was 40 ± 12 years, median iss was 29 [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] . overall 24 h mortality was 27.9%. only 36% patients received nbr while 74% received ubr in the first 4-h. using propensity score matching, patients were matched for demographics, ed vitals, iss, ais and injury parameters. patients who received nbr in the early resuscitation phase had lower mortality (23% vs. 31%, p = 0.01), lower overall complications (38% vs. 55%, p = 0.01), with no difference in hospital length of stay (17 days vs. 16 days, p = 0.53) compared to the ubr group. conclusions: only one-third of patient receiving massive transfusion receive prbc, ffp and platelet in a ratio closer to 1:1:1 in the initial 4-h and they have lower mortality and complications compared to patients with unbalanced resuscitation. material and methods: the goal is to assess mtp strategies in level-1 trauma centres in the netherlands and compare these with each other and (inter) national guidelines. a trauma surgeon or anaesthesiologist involved in compiling the mtp in each level-1 trauma centre in the netherlands and dutch ministry of defence was approached to share their mtp and comment on their protocol in a survey or oral follow-up interview. results: all eleven level-1 trauma centres responded. content of the packages and transfusion ratio (red blood cells/plasma/platelets) was 3:3:1, 5:5:1, 5:3:1, 2:3:1, 4:4:1, 5:2:1, 2:2:1 and 4:3:1. tranexamic acid was used in all centres and an additional dose was administered in eight centres. fibrinogen was given directly (n = 4), with persistent bleeding (n = 3), based on clauss fibrinogen (n = 3) or rotem ò (n = 1). standard coagulation monitoring are used in all centres, but most hospitals use also rotational thromboelastometry (rotem ò ) (n = 6), thromboelastography (teg ò ) (n = 1) or both (n = 1). all centres used additional medication for patients using anticoagulants, but its use was ambiguous. conclusions: mtps in dutch level 1 trauma centres differs from (inter) national guidelines in transfusion ratio and additional medication, which could be explained by misinterpretation of the 1:1:1 ratio, changes in components and following an outdated dutch national guideline. whether these differences in mtps actually leads to different patient outcomes will follow from data that is currently being collected. this study is sponsored by the dutch ministry of defence. anastomotic bleeding after colorectal surgery: incidence, management and complications introduction: postoperative anastomotic bleeding (pab) is a frequent minor complication (1-9%) that usually resolves by a conservative approach. hemodynamic instability and anemization may develop requiring urgent management. the aim of our study is to describe pab and its treatment. material and methods: observational retrospective cohort study of patients with pab collected between july 2014 and september 2019. pab was defined as an episode of lower gi bleeding after colorectal surgery with at least one anastomosis. characteristics of patients, surgery, length of hospital stay, morbidity and mortality, and management of pab were reviewed. results: a total of 38 (5.5%) patients with pab was collected. median age was of 75 years (iqr 64-80), with a median estimated asa grade of 3. the most common procedure was a right hemicolectomy (50%), followed by sigmoidectomy (24%). 95% of surgeries were laparoscopic. only 2 cases were converted to an open approach. 37% of patients had the first episode of pab during the first 24 h after surgery, while 32% after the third postoperative day. pab was treated conservatively in 84% of the cases. the remaining 16% required urgent endoscopic management identifying the bleeding through the anastomosis line, using clips in 5 patients and hemospray in 1 patient to control it. no complications were recorded after endoscopic treatment. just 1 case required surgical reintervention. a total of 12 (32%) patients required blood transfusion with a median of 2 (iqr 2-3.75) units. length of hospital stay was 6.5 days. no mortality related to pab was registered. conclusions: pab is a mild complication after colorectal surgery. most of the patients respond to conservative management. urgent endoscopic treatment seems to be effective and safe to control pab even during the first postoperative day. introduction: hemorrhagic shock and associated reperfusion injuries are davastating situations during the treatment of polytrauma patients. the aim of this study was to analyze and compare alterations of the local circulatory changes of various body regions during hemorrhagic shock and after fluid resuscitation. material and methods: this study was conducted on male pigs. they suffered a standardized polytrauma including femoral fracture, blunt thoracic trauma and liver laceration. further, the suffered a hemorrhagic shock for 1 h (aimed map 25 mmhg). fluid resuscitation with three times drawn blood volume after hemorrhagic shock. retrograde nailing for femoral fracture and chest tube in case of pneumothorax liver packing. measuring circulation at liver, colon, stomach, and extremity. results: inclusion of 27 animals. local circulation at the extremity decreased significantly compared to baseline values during hemorrhagic shock (82.3 a.u. versus 31.7 a.u., p \ 0.001). after resuscitation the flow rate at the extremity was comparable to baseline values. the stomach was least sensitive to hemorrhagic shock, whereas the oxygen delivery rate at the colon decreased during shock phase and remained decreased during fluid resuscitation (p \ 0.001). conclusions: different body regions react differently to hemorrhagic shock. the colon appears to be most vulnerable to changes based on hemorrhage. the delayed improvement of circulation in liver, colon, and extremities may represent a trigger for systemic hyperinflammation and subsequent sirs and sepsis. none of the authors have any conflicts of interest to declare. massive transfusion in penetrating trauma: the search for a specific prediction system introduction: prediction systems of massive transfusion (mt) were developed from cohorts with a small proportion of penetrating trauma. some of them required laboratory tests. we aimed to evaluate abc score and to identify independent predictors of mt in a cohort of torso penetrating trauma (tpt) material and methods: adults with tpt, managed in a level-i trauma center, who received one or more packed red blood cells (prbc), were included. variables obtained during the evaluation in the trauma bay were registered prospectively. the ability to predict mt was evaluated with simple, multiple logistic regressions and roc curves. results: we included 162 patients; 88.9% were male, and 84.6% received fire-arm wounds. twenty-one (13%) received mt. mt patients were intubated more frequently in the pre-hospital, had lower sbp, higher hr, lower gcs, and received more frequently vasopressors (p \ 0.05) when compared with the no-mt patients. trauma mechanism, number or localization of the wounds, and positive fast could not discriminate mt (p [ 0.05). hypotension, tachycardia, and alteration of the glasgow coma scale or its motor response behaved as independent predictors of mt. models created with these variables showed better discriminative ability than abc score, with adequate goodness to fit. conclusions: prediction models of mt, based on heart rate, systolic blood pressure, and neurologic alteration outperformed abc score in a tpt cohort. introduction: rectus sheath hematoma presents with abdominal pain and anterior abdominal wall mass. it can be followed conservatively and rarely causes mortality (1) . in this study we aimed to review rectus sheath hematoma cases consulted to our department and to present our management. material and methods: the data of 35 patients admitted with rectus sheath hematoma between 2009 and 2018 was collected using hospital database. treatment modalities, demographic data and complications were reviewed retrospectively. results: all the cases presented with abdominal pain and/or with a palpable abdominal mass. 82.8% of the patients (n = 29) were receiving anticoagulant therapy at the time of admission. the mean inr value was 2.34. 28 patients were followed up with es&ffp transfusion and conservative treatment. 3 patients not eligible for conservative care underwent inferior epigastric artery embolization and hematomas in 2 patients were evacuated via a percutaneous drainage catheter. 1 patient went through laparotomy for an infected hematoma and one patient underwent laparotomy plus packing. the patient who had laparotomy plus packing died due to intraabdominal hematoma and sepsis. conclusions: rectus sheath heamatoma is a rare cause of acute abdominal pain. the patients diagnosed early and have suitable indications can be treated conservatively (2) . rectus sheath hematoma should be considered in the differential when a patient with a history of anticoagulant drug use presents with acute abdominal pain in order to prevent unnecessary surgery and complications. introduction: an early delivery of blood products when massive transfusion protocols (mtp) are triggered is mandatory to improve trauma patients survival. scores predicting massive transfusion (mt) have already been described (1) . the aim of our study is to compare scores for predicting mt and identify the best trigger for mtp. material and methods: multicentric retrospective study from the trauma registry of the spanish surgeons' association. severe trauma patients (injury severity score [iss] c 15), admitted to 18 different level 1 trauma centers, from january 2017 to september 2019 were included. demographic and clinical information was recorded, and predictive scores for mt were assessed. results: 1113 patients were included. medium age was 47.1 ± 19.6 years, 861 (77.4%) were male. median iss was 22 (iqr 13). in 4% of the patients a mt (defined as c 10 units of packed rbc) was necessary, while a mtp was triggered in 13.6%. surgery was performed in 55.8%. the overall mortality was of 9.9%. predictive scores for mt were compared: gap (glasgow coma scale, age, systolic blood pressure), shock index (si), assessment of blood consumption (abc) and mabc (modified abc). auroc for gap was 0.735 ± 0.037, si 0.907 ± 0.016, abc 0.881 ± 0.034 and mabc 0.882 ± 0.036, showing differences between gap (the worst score) and the others, p \ 0.01. no differences were found between si, ab and mabc. best cut-off points were calculated. si c 0.8 better predicts mt with a sensitivity 100%, specificity 63.4%, positive and negative predictive values 10.3% and 100%. conclusions: si, abc and mabc are all good scores for predicting mt in our population. appealing by its simplicity, we recommend si as the best trigger for mtp. protocols should be standardized to improve the accuracy of mtp activation for trauma patients. introduction: the prevalence of knife-related offences is rising in the uk. successful management of trauma patients requires the co-ordinated response of specialist services, including transfusion. we aimed to assess the impact of knife-crime on transfusion support within a uk adult major trauma centre (mtc). material and methods: retrospective review of patients admitted to a uk mtc following knife injuries resulting from interpersonal violence during a three-year period (may 2015-april 2018). source material included electronic patient records, tarn database and massive transfusion protocol (mtp) logbook. patient characteristics, resource utilisation including transfusion, mtp activation and outcome were collated. results: 540 patients were identified, 502 (93%) were male. median age was 27 years. 237 (44%) were under the age of 25. 245 patients (45%) presented with circulatory compromise (sbp \ 110). 97 patients (18%) had attended our hospital previously for violencerelated trauma. 71% arrived at hospital between 1900 h to 0700 h. 346 (64%) required one or more surgical procedures. median length of stay was 3 days. 95 patients (18%) received blood transfusion. median units transfused were 4 prbc, 2ffp, 1 platelets (atd). mean component use was 6 pbrc (range 1-61), 3.8 ffp (0-36), platelets 0.6 (0-12), cryoprecipitate 0.6 (0-14). annual mtp activations increased from 99 to 157 during the study period (total 360). stabbings accounted for 25.4% of these (99 patients), of which 70 (78%) were transfused. conclusions: knife crime presents a burden to blood transfusion, accounting for a quarter of mtp activations. patients typically present out of hours with implications for service planning and delivery. patient profile together with repeat healthcare attendance and surgery requiring transfusion has implications for red cell allo-immunisation. we recommend timely baseline blood grouping and triage to optimise the safe use of rhd positive cellular components. introduction: spontaneous intramural small bowel hematoma is a very rare complication of anticoagulant therapy. nowadays, the prevalence is increasing due to the widespread use of computerized tomography and the increasing number of patients receiving anticoagulant therapy. material and methods: 15 patients admitted to our center between january 2010 and june 2019 and treated with the diagnosis of intramural hematoma were retrospectively evaluated. results: the median age of the patients was 69 years (44-84) and 9 (60%) were male. at the time of appeal, warfarin intoxication was present in 14 cases (93%) and the median inr was 7.25 (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) . one patient had known factor 7 deficiency. diagnosis was made by computerized tomography in all cases. one intramural hematoma was localized in the duodenum (6.7%), nine in the jejunum (60%), and five in the ileum (33.3%) six patients (40%) had ileus findings. all patients underwent fresh frozen plasma replacement due to high inr levels and bleeding. median tdp transfusion was 3 units (2-7). only 3 patients (20%) required erythrocyte suspension replacement. all cases were followed up conservatively and there was no need for intensive care. the median hospital stay was 4 (3-10) days. conclusions: due to the limited number of studies in the literature with a large number of cases, retrospective evaluation of 15 singlecenter cases may be helpful. spontaneous intramural small bowel hematoma should be considered in the elderly population under warfarin therapy who present with abdominal pain, especially if inr values are above therapeutic limits spontaneous regression is seen in the majority of cases. non operative management and correction of coagulopathy with fresh frozen plasma replacement is the preferred approach. references: abbas ma, et al. spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome. arch surg. 2002; 137(3) :306-10. pre-hospital decision-making: identifying the challenges assessing and managing traumatic haemorrhage and coagulopathy m. marsden 1 , r. bagga 2 , k. gillies 3 , r. lyon 4 , s. kellett 5 , r. davenport 1 , n. tai 1 expert pre-hospital clinicians in making decisions about the diagnosis and treatment of patients with major haemorrhage and suspected tic. methods: semi-structured interviews were conducted with 10 senior pre-hospital consultants from london's air ambulance and air ambulance kent, surrey and sussex. interviews probed clinicians on how they make decisions relating to the pre-hospital assessment of major haemorrhage and tic and subsequent blood product transfusion. the interviews were analysed using descriptive thematic analysis. results: all clinicians agreed that identifying and treating major haemorrhage was vital. half of the clinicians reported making no conscious assessment for tic and six reported tic should be managed in a hospital setting. four broad themes were identified: collation of information, weighing utility of different approaches, influence of experience and evaluation of unknowns. collating information from multiple sources drove clinical decision-making. decisions on blood product transfusion were made after weighing potential benefits (e.g. improve microvascular perfusion) against harms. clinical experience was reported as key to nuance clinical assessment, detect subtle signs and identify patterns. uncertainty complicated clinical decision-making in two domains; incomplete knowledge of a patient's injury and uncertainty of best clinical practice. conclusion: the pre-hospital identification and treatment of major haemorrhage was recognised as challenging and fundamental. necessity of pre-hospital tic diagnosis and treatment divided opinion. identifying these four themes allows for a greater understanding of the factors involved in making these decisions and will guide the creation of more accurate decision support tools to aid pre-hospital clinicians. nothing to declare. introduction: massive transfusion (mt) is defined as the administration of c 10 packed red blood cells (prbc) in 24 h. alternative definitions have been proposed; however, there is little understanding about the discriminative ability of different mt definitions with regards to mortality and multiorgan failure (mof). we aim to assess and compare the discriminative ability of different definitions of mt concerning mortality and mof. material and methods: we included patients who arrived to the emergency department and required trauma team activation at a level i trauma center in the city of cali, colombia between 2014-2018. demographics and trauma characteristics were evaluated. the following mt definitions were measured: 50 units of blood products in 24 h (t50), 10 u prbc in 24 (t10-24), 6 u prbc in 6 h (t6-6), 10 prbc in 6 h (t10-6), the combination of t10-24 and t6 (t-combi), 5 prbc in 4 h (t5-4), 4 prbc in 1 h (t4-1) and 3 units of prbcs in 60 min. the operative characteristics were calculated for each definition. mof was defined as a sofa score of c 6 points. results: we included 394 subjects, 88.6% male. trauma mechanism was penetrating in 87.3%. the median and interquartile range (iqr) of age was 28 years iqr (22-37) and of iss 25 (16-26). lesions were located in the torso in 42.4% of patients, and 47.2% had a positive abc score. a total of 264 (67%) received at least 1 unit of prbc. tables 1 and 2 presents the operative characteristics of 10 definitions of mt with respect to mortality and mof, respectively. conclusions: although all definitions showed an association with higher odds with the outcomes of interest, none of them showed an accurate diagnostic capacity regarding mof and mortality. thus, we advise caution when relying on the classical definition of mt ([ 10 rbc units in 24 h) to guide the flow of care of severely injured patients. trauma and coagulation: trends in coagulation factors in the severely injured trauma patient introduction: trauma-induced coagulopathy (tic), affects about 25-30% of the major trauma patients. in the past, tic was considered as a consequence of the coagulation factors' dilution after a highvolume colloid administration. today tic is seen as a phenomenon that can arise after trauma; the first event is the c-protein activation by the tissue damage and hypoperfusion, resulting in the subversion of the hemostatic process. material and methods: the 40 patients of the 2018 pilot study ''trauma and coagulation'' run in irccs san raffaele scientific institute have been reviewed and analyzed using a suite of experimental coagulation factors including rotem parameters, activated protein c (apc), thrombomodulin, endothelial protein c receptor, thrombin-antithrombin complex (tat), plasminogen activator inhibitor 1 (pai-1), seselectin, interleukin-8 (il-8), interleukin-10 (il-10), d-dimer (xdp), antithrombin iii (atiii), and prothrombin fragment f1 ? 2 (f1 ? 2). new 15 patients have been enrolled to validate the results of the pilot study. results: there is a statistically significative correlation between clinical scores of severity of trauma and risk of massive transfusion (iss, abc and tash) and some of the experimental coagulation factors analyzed. case history: to evaluate the role of negative pressure wound-care systems applied to the pleural cavity in case of severe acute empyemas and frail patients not amenable to conventional surgery. clinical findings: we report the case of a 67 yrs old male critically ill patient suffering from complications of cardiac surgeries who developed a severe right empyema with broncho-pleural fistula through the site of a previous pulmonary hernia. investigation/results: we review the actual indications of negative pressure therapy in thoracic surgical emergencies especially in septic patients unfit for surgery. in our case the repeated application of negative pressure with dedicated dressings through the initial thoracotomy was the chosen damage control approach because of the sepsis and poor conditions. diagnosis, therapy and progressions: air leaks were later found to originate from a subsegmentary branch of middle lobe bronchus. subsequent video-assisted debridement procedures followed by negative pressure therapy managed to (1) control the infection, (2) reduce the thoracotomy incision into a thoracoscopic access and (3) heal the pleural cavity, restoring eventually better general conditions of the patient. the closure of the bronchial fistula required further procedures after the acute phase when sepsis was overcome. comments: negative pressure systems can be applied to the pleural cavity with many advantages in selected critically ill patients. they allow to contain, treat and resolve infections both of chest wall and pleural cavity in case of severe empyemas reducing also wound pain and eliminating the need of chest drains. air leaks may also be managed by negative pressure therapy with adequate indications and particular attention to its settings. references: sziklavari z. mini-open vacuum-assisted closure therapy with instillation for debilitated and septic patients with pleural empyema. eur j cardiothorac surg. 2015. flail chest: the renaissance of rib osteosynthesis c. leite 1 , a. oliveira 1 , a. lemos 1 , b. barbosa 1 , c. casimiro 1 1 centro hospitalar tondela-viseu, general surgery, viseu, portugal case history: we present the clinical case of a male patient of 79 years old. injury mechanism: fall from his own height over the right hemithorax. clinical findings: 5 rib fractures with flail chest and significant displacement of bone edges. symptoms: intense thoracic pain. diagnosis: rib fractures with flail chest. therapy and progressions: multimodal analgesia. on the 4th day, he presented a tension pneumothorax. after adequate intercostal drainage, the pneumothorax relapsed. on the 8th day, he underwent a right posterolateral thoracotomy, open reduction and internal fixation of 3 ribs with plates and screws and intercostal drainage. evolution: he received respiratory kinesiotherapy and was discharged on the 8th pos op day. follow-up at 1st and 5th months, without functional impairment and with preservation of quality of life. comments: rib fracture is the most common injury in the setting of thoracic trauma and is associated with a higher morbimortality. in the last 60 years, positive pressure mechanical ventilation was the first line treatment of respiratory insufficiency caused by rib fractures. however, severe complications associated with prolonged mechanical ventilation, have elicited the rising implementation of open rib reduction and internal fixation techniques. the most consensual indications are: flail chest with fracture of at least 3 ribs, significant displacement of bone edges or uncontrolled pain. rib osteosynthesis is a simple method but requires clinical experience in thoracic approaches and handling of specific instruments and material. its implementation in non-ventilated patients reduces the need for mechanical ventilation, pain, length of stay and allows preservation of quality of life. yokohama city university medical center, advanced critical care and emergency center, yokohama, japan, 2 saiseikai yokohama-shi nanbu hospital, department of surgery, yokohama, japan, 3 yokohama city university, department of general surgery, yokohama, japan, 4 yokohama city university, department of emergency medicine, yokohama, japan introduction: although americans and europeans report emergency room thoracotomy (ert) is of value in penetrating trauma patients, most of ert is performed for blunt trauma in japan. after the establishment of the local government-directed major trauma center in the city of yokohama, the unexpected trauma survivor rate increased in the single center study. we report our experience in ert and surveyed the effect of the establishment. material and methods: patient characteristics (backgrounds, mechanism of injury, indication for ert, anatomic injuries, interventions and survival) of those who underwent emergency thoracotomy compliant with the guideline of western trauma association, between october 2012 and september 2019 were analyzed. results: fifty-eight patients (42 males) underwent emergency thoracotomy. median age was 39.8 (5-85) years. fifty-seven were performed for blunt trauma (98%) and only 1 for penetrating injuries. twenty-three patients presented with cardiac arrest on arrival, while thirty-five had deep and refractory hypotension. overall, survival rate improved from 0 (0/14) to 14% (6/44) (p = 0.18) after the establishment of the trauma center. of patients presenting with cardiac arrest, only one survived. conclusions: the establishment of major trauma center seemed to affect the survival rate of the patient edt was performed. introduction: more than 45% of polytrauma events involve chest injuries. one third of these patients sustain thoracic instability due to serial rib fractures. thanks to numerous innovations in implant development several approaches currently exist for surgical rib stabilization (srs). however, no consensus exists regarding patient selection for srs to date. material and methods: retrospective single center cohort analysis in trauma patients. serial rib fracture was defined as three consecutive ribs confirmed by chest ct. cohort includes 243 patients that were treated conservatively and 34 patients that underwent srs by plate osteosynthesis. demographic patient data, trauma mechanism, injury pattern, injury severity score (iss), glasgow coma scale (gcs) and hospital course were analyzed. two matched pair analyses stratified for iss (32 pairs) and gcs (25 pairs) were performed to minimize selection bias. results: the majority of patients was male (74%) and aged 55 ± 20 years. serial rib fractures were located left/right/bilateral in 46%/ 36%/19% of cases. other thoracic bone injury included sternum (18%), scapula (16%) and clavicula (13%). visceral injury consisted of pneumothorax (51%), lung contusion (33%) and diaphragmatic rupture (2%). average iss was 22 ± 7.3. overall hospital stay was 15.9 and icu stay 7.4 days. in hospital mortality was 13%. srs did not improve hospital course or postoperative complications in the complete study cohort. however, patients undergoing srs had significantly reduced gcs (7.6 ± 5.3 vs 11.22 ± 4,8; p = 0.006). matched pair analysis stratified for gcs showed a reduced need for blood substitution and shorter icu stays (9 vs 15 days; p = 0.005) including shorter respirator time (143 vs 305 h; p = 0.003) and reduced in hospital mortality (4 vs 12%). conclusions: patients with serial rib fractures and simultaneous severe cerebral injury benefit from surgical rib stabilization. tracheal and bilateral recurrent laryngeal nerve disruption injury secondary to accidental strangulation by dupatta case history: 18 year old female brought to trauma emergency with a/h/o accidental strangulation injury with dhupatta at farm field while working with thresher machine after 6 h of injury. patient had severe dyspnoea, dysphagia, paining neck clinical findings: primary survey revealed threatened airway with extensive surgical emphysema, rr-29/min, spo2-80% on high flow oxygen mask, hemodynamically stable, and had no neurological deficits. patient was immediately intubated, however ventilation could not be maintained and surgical emphysema worsened hence immediate tracheostomy was established. investigation/results: computed tomography (ct) head and ct angiography of neck with venous phase study of neck and chest with ct esophagogram revealed complete disruption of cricotracheal junction with extensive cervical and upper thoracic surgical emphysema and no other injuries. diagnosis: disruption of trachea from cricoid cartilage with crushed trachea with loss of approximately 4 cm, cricoid and thyroid cartilage fracture, complete avulsion of bilateral recurrent laryngeal nerves and serosal tear of esophagus. therapy and progressions: neck exploration with debridement of tracheal margins and anastomosis between trachea and cricoid cartilage with repair of cricoid, laryngeal cartilage and esophageal serosal repair was performed. comments: post-operatively patient underwent fibreoptic bronchoscopy and revealed paramedian location of vocal cords. at present patient is with tracheostomy tube in situ undergoing speech therapy and is able to generate comprehensible sounds. further laryngeal framework surgery is being planned. introduction: emergency resuscitative thoracotomy (ert) is a lifesaving procedure in selected patients and it is often considered a controversial ''last chance'' method of resuscitation. objectives of ert are to resolve pericardial tamponade, to repair heart injuries, to perform an open cardiac massage, to cross-clamp the aorta to redistribute blood flow to the myocardium and brain, to control intrathoracic bleeding and air embolism in the bronchial venous system. outcome mostly in blunt trauma is believed to be poor. material and methods: we retrospective reviewed 32 patients c 18 years who underwent ert at san camillo-forlanini hospital (rome, italy) between january 2009 and september 2019 with traumatic arrest for blunt or penetrating injuries. results: of 32 ert, 7 (21.9%) were for blunt trauma, 25 (78.1%) were for penetrating trauma. 65.6% of patients were male. the collectively reported overall survival was 59% (n = 19). when including erts designated as done in the emergency department for blunt mechanism, only 1 patient survived (14.3%). survival after erts for penetrating trauma was 72% (18 of 25). conclusions: our experience suggests that ert is a technique that should be utilized for patients with critical penetrating injuries. the reported outcome after ert in european civilian trauma populations is favorable with an overall survival of 43%. multicenter, prospective, observational data are needed to validate the modern role of ert in blunt or penetrating trauma. references: narvestad jk, et al. emergency resuscitative thoracotomy performed in european civilian trauma patients with blunt or penetrating injuries: a systematic review. eur j trauma emerg surg. 2016;42 (6) case history: an 81-year-old male driving a car collided with a wall at a speed of 40 km/h and was brought to a hospital near the scene. he was diagnosed with right multiple rib fractures and hemopneumothorax, and transferred to our emergency center for definitive care. clinical findings: the patient's consciousness was clear and his heart rate, blood pressure, respiratory rate, and o 2 saturation (room air) on arrival were 60/min, 120/74 mmhg, 23/min, and 90%, respectively. subcutaneous emphysema was identified on the right side of his chest and his right breathing sound decreased on auscultation. there was no tenderness and rebound on abdominal examination. investigation/results: an enhanced whole-body computed tomography scan revealed a small disruption on the right diaphragm behind the sternum and free air in the abdomen. diagnosis: the diagnosis was right traumatic diaphragmatic injury, sternum fracture, and right multiple rib fractures with pneumohemothorax. there was free air in the abdomen but without evidence of perforation of the digestive tract as there was no finding of peritonitis on physical examination. thus, pneumoperitoneum from the thorax was strongly suspected. therapy and progressions: laparoscopic observation revealed a 1.5 cm-length of disruption on the diaphragm in the right sternocostal triangle. this was covered with falciform ligament using extracorporeal knot tying method because there was little seam allowance in front of the disruption on the sternum side, and direct suture was not possible. prognosis was good following surgery, and the chest drain was removed on postoperative day 3 and the patient was discharged on postoperative day 4. comments: laparoscopic repair of the diaphragm using extracorporeal knot tying method is often used for retrosternal (morgagni) hernias. however, the method was also useful in this case because the diaphragmatic injury occurred in the sternocostal triangle. rib fractures associated with pneumo-and/or hemothorax; does everyone need a chest tube? v. snartland 1 , p. a. naess 2 , c. gaarder 2 , m. hestnes 3 , p. majak 2,1,4 1 faculty of medicine, university of oslo, oslo, norway, 2 oslo university hospital, department of traumatology, oslo, norway, 3 oslo university hospital, trauma registry, oslo, norway, 4 oslo university hospital, department of cardiothoracic surgery, oslo, norway introduction: pneumo-and/or hemothorax are often seen in trauma patients with rib fractures (rfs). standard treatment for pneumothorax (ptx), hemothorax (htx) and hemopneumothorax (hptx) is tube thoracostomy (tt). however, a non-operative approach can be applied in selected patients. we wanted to assess our practice in patients with rib fractures and associated ptx, htx or hptx. material and methods: all adult patients (c 18 years) with rf, admitted by a trauma team at oslo university hospital in 2017 were identified retrospectively and those with associated ptx, htx or hptx were then included in the study. patients who underwent tt prior to arrival and those who died were excluded. spss v25 was used for statistical analysis. results: of the 241 patients with rfs, a total of 90 patients had ptx, htx or hptx. fifty-one percent (46/90) of these patients were treated with tt and 85% (39/46) of the patients underwent tt within 6 h after arrival. the presence of opacification (p \ 0.01), chest wall deformity (p \ 0.01) and pneumothorax size (p \ 0.01) were significantly higher on chest x-ray in the tt group compared to the nonoperative group. intubation at arrival was also significantly more common in patients treated with tt (p \ 0.01). there was no difference in the presence of subcutaneous emphysema between the groups. the tt group was sicker than the non-operative group (had a significantly lower systolic blood pressure, a lower gcs and a higher lactate on arrival). oxygen saturation, heart rate, respiratory rate, ph and hemoglobin did not differ significantly between the groups. conclusions: in trauma patients with rf concurrent ptx, htx or hptx should be suspected. in our study only half of these patients were treated with tt, and 85% of tubes were inserted within 6 h after admission. size of the ptx, radiological presence of opacification and deformity of the chest wall should be addressed when choosing treatment strategy. introduction: emergency department thoracotomy (edt) is a potentially life-saving surgical procedure performed in the emergency department (ed) in patients presenting with cardiac arrest following penetrating thoracic trauma. however, it is not clear if all surgeons are prepared or motivated to perform this procedure. furthermore, not all institutions are equipped, either in terms of logistics or team training, to perform edt. our purpose was to perform a pilot study in a cohort of polish surgeons of various specializations, in order to ascertain who would and who would not (and why) perform edt in their departments. material and methods: study population of 69 surgeons (27 specialists, 42 residents) from various hospitals in poland, mean age: 31-40 years, 55.1% men, 43.5% women. study respondents were asked to fill in a questionnaire on the indications and motivation to perform edt in their clinical practice. results: most respondents (n = 54, 78%) correctly recognized the indications to perform edt. however, only 35 (51%) declared they would perform it. the reasons for not performing edt were: lack of team training (63.7%); lack of equipment (58%); lack of motivation among ed personnel (40.6%); the ed is not prepared (27.5%); the respondent is not prepared (26%). only 6 participants (8.7%) declared that their institutions had the edt protocol. conclusions: this survey demonstrates that, although most surgeons agree on the indications for edt, the level of preparedness in its execution is lacking. the main reasons are the lack of team training, the lack of equipment and the lack of motivation among ed personnel. other relevant reasons were the lack of preparation of either a surgeon or a department. these results demonstrate that improvements in institutional logistics as well as in team and individual training can translate into improved care. we strongly advise the performance of a pan-european survey on edt to address other unrecognized issues. mediastinum widening: how to manage it? a. gonzález-costa 1 , r. gracia-roman 1 , s. montmany-vioque 2 , m. s. santos-espi 3 , r. lobato-gil 1 , m. pascua-solé 1 , a. campos-serra 1 , a. luna-aufroy 2 , p. rebasa-cladera 2 , s. navarro-soto 2 1 parc tauli hospital universitari, trauma and emergency general surgery department, sabadell, spain, 2 parc tauli hospital universitari, esofagogastric general surgery department, sabadell, spain, 3 parc tauli hospital universitari, angiology and vascular surgery, sabadell, spain case history: a 23-year old male was admitted to our emergency department as a polytrauma code, because of a gunshot wound in the neck. clinical findings: his airway was compromised with expansive cervical hematoma. intubation was difficult. he was hemodynamically unstable with cervical bleeding, in which manual compression was applied. results: chest x-ray showed mediastinal widening without pneumo or hemothorax. diagnosis: urgent sternotomy while maintaining manual compression on the cervical bleeding, followed by left antero-lateral cervicotomy. injuries: section of left jugular vein and left carotid artery, lesions of unnamed vein. free cervical chylous fluid. left pleura and pericardium were opened without identifying major injuries. therapy and progressions: jugular vein was repaired with continuous suture and carotid artery with patch sutured. unnamed vein was sectioned between ligatures. thoracic duct was ligated. after surgery, ct scan showed cervical and mediastinal hematomas without signs of active bleeding, and correct permeability of the vessels, with no cranial lesions. the patient was admitted to the intensive care unit. tracheostomy was performed. fibrobronchoscopy, fibrogastroscopy and esophagogastricoduodenal discarded airway and esophageal lesions. he presented the following complications: • small mediastinal collection • right diaphragmatic paralysis. • paralysis of vi left cranial nerve (mononeuritis of vascular origin). the patient was discharged on the 30th postoperative day. comments: in this kind of trauma is essential the airway management with intubation when necessary. it is important that mediastinal widening visualized in the chest x-ray in a traumatic patient, should be an indication of surgery. in our case, it was essential to start it with sternotomy while maintaining manual neck compression, and in a second time, perform the cervical approach since that prevented the patient from suffering a greater blood loss. background: clavicular fracture is very common in childhood. otherwise, the medial third of the clavicle is the less affected. the current report describes a new pattern of clavicular injury, in which a medial third clavicular fracture and posterior sternoclavicular joint (scj) dislocation occur together in a skeletally immature patient. clinical findings: an 8-year-old boy sustained a direct impact to his left shoulder resulting from the fall of a sofa. at admission, he complained of severe pain in the clavicular and shoulder associated with functional limb impotence. physical examination revealed deformity of the proximal third clavicle, with swelling and tenderness to palpation along the medial left clavicle. no signs of skin pression or neurovascular impairment were found. the anteroposterior radiograph of the left clavicle showed a fracture of the proximal third shaft and an asymmetry of the scj. computed tomography confirmed the association of a greenstick fracture of the proximal third clavicular shaft, accompanied by a mild posterior scj dislocation. therapy and progressions: the left limb was immobilized with a sling during 3 weeks, after which physical therapy was initiated to improve range of motion using active and gentle active-assisted exercises. at the 2 months medical consultation, he presented asymptomatic, with good bone healing, full range of motion of the shoulder and absence of relevant aesthetic deformity. comments: in the immature skeleton, scj dislocation and epiphyseal fracture of the proximal clavicle are very rare entities due to the multiple strong ligaments that stabilize the scj. trauma in the proximal third of the clavicle typically results in fractures in the region of the physis and only more rarely culminate in dislocations of the scj. these injuries warrant a high index of suspicion, and early ct scanning is recommended. although treatment may be conservative, in situations of major displacement, surgery should be considered. use of rib fracture scoring systems in a uk major trauma unit: a retrospective audit and lessons learnt introduction: rib fractures are detected in 10% of trauma patients [1] . significant morbidity and admission to intensive care units (itu) is common [1] . rib fracture scores do not have strong validity as a predictor, but are a useful screening tool to identify patients at higher risk, of morbidity. the aim of this study was to audit the use of rib fixation scores in a single major trauma centre. material and methods: a retrospective audit of trauma patients with rib fractures presenting to a single major trauma centre over a 1-year period subsequently admitted to itu was performed. demographics, length of itu stay, rib fracture score (rfs) and ribscore were recorded and comparisons made between patients who had surgical rib fixation and those who did not. results: 86 patients with traumatic rib fractures were admitted to itu over 1-year, 19 of whom had rib fixation. mean age of patients undergoing surgery was 74 compared to 52 in the non-surgical cohort. average rfs was higher in the surgical cohort (14 vs 6; p = \ 0.001), as was average ribscore (3 vs 1; p = \ 0.002). incidence of flail segment was higher in surgical cohort (37% vs 10%; p = \ 0.001), as was number of rib fractures (9 vs 5; p = \ 0.001) and incidence of 1st rib fracture (20% vs 8%, p = \ 0.289). rib fractures treated surgically had a longer itu stay (12.3 days vs 5.31; p = \ 0.001). conclusions: surgical rib fixation patients were older and had longer itu stay. higher rib fracture scores correlated with need for surgical intervention. this highlights the need for careful patient selection for rib fixation, as they appear to fall in a more vulnerable patient demographic. there is a need for a score combining ribscore and rfs, ensuring the nature of fractures and presence of flail segments are interpreted in the context of patient age, to ensure this vulnerable patient group undergoes surgical fixation only when necessary. jichi medical university, shimotsuke tochigi, japan case history: an 82-year-old female individual hurt her back while walking during a hospital rehabilitation program after experiencing a brain stroke. her hemoglobin level gradually decreased to 6.0 g/dl on the 5th day after injury. a non-enhanced abdominal ct scan revealed a burst fracture of the lumbar spine. the patient was brought to our emergency center for a thorough examination. clinical findings: her vital signs on arrival were gcs: e4v4m6, hr: 79, bp: 135/75, rr: 19, and bt: 36.3. her back presented a severe kyphotic spine. the palpebral conjunctiva was anemic and there were no injuries on her surface. no abnormalities were detected upon auscultation of the thorax and no tenderness and rebound was detected upon physical examination of the patient's abdomen. investigation/results: hemoglobin level was 5.9 g/dl and lactate 2.8 mmol/l on arrival. an enhanced chest and abdominal ct scan revealed a burst fracture of the 5th lumbar spine, a large hematoma around it, and a pseudoaneurysm of the lumbar artery. diagnosis: a pseudoaneurysm of the lumbar artery and a burst fracture of the 5th lumbar spine was diagnosed. therapy and progressions: the angioembolization of the lumbar artery was abandoned because the distance between the abdominal aorta and the aneurysm was \ 5 mm. endovascular aneurysm repair (evar) was finally performed. after the successful completion of the surgery, the patient was discharged on the 11th day after evar. comments: slight injury caused the fracture of the lumbar spine, possibly yielding pseudoaneurysm of the lumbar artery. such pseudoaneurysms are rare and employing evar for its treatment is equally rare. blunt lumbar artery injury may be a differential diagnosis for the elderly patients who present burst spine fractures with extreme anemia or shock, even if it results from a minimal injury. case history: a 23 year old co-driver was hit by another car on her side. air rescue found the patient with gcs 3 and right tension pneumothorax. oral intubation, decompression with chest tube and transportation to the nearest level one trauma center was undertaken. clinical findings/investigation/results: on presentation in the emergency room the patient was hemodynamically instable with free fluid in efast-sonography and a haemoglobin of 2.2 g/dl. she was immediately taken to the operation room where laparotomy was performed. liver rupture and right diaphragm rupture was found. diagnosis: right hilar bronchial disruption. therapy and progressions: despite packing of the liver the patient remained instable. due to continuous bleeding from diaphragm rupture side right anterolateral thoracotomy was performed. bronchial disruption close to the hilus was detected leading to total pneumonectomy. after surgery the patient recovered under intensive care. six weeks after initial trauma the patient presented with ileus. a gastric tube was placed without complications. chest x-ray was performed showing intrathoracal displacement of the gastric tube. in an emergency operation the insufficient bronchus trunk was covered with an intercostal muscle flap. comments: this case shows the rare necessity of total pneumonectomy after blunt chest trauma and its typical complication with insufficiency of the bronchial trunk. after total pneumonectomy surgery covering the bronchial trunk should be performed as soon as possible to prevent insufficiency. in these patients gastric tubes should only be placed under endoscopic vision. because of the high complication rate total pneumonectomy should only be performed as a last resort procedure in the context of damage-control surgery. introduction: multiple rib fractures continue to be a challenging problem as the associated pain leads to a compromise in respiration. proper analgesia is required for physiotherapy, and to prevent development of respiratory failure. ultrasound-guided serratus plane block (spb) has recently been described as a regional anesthetic technique to provide analgesia to a hemithorax by blocking the lateral branches of the intercostal nerves. material and methods: from sept 2018 we applied the serratus plane block for pain control in 12 patients with multiple rib fractures. we administered 0.25-0.125% bupivacaine solution with easypump for 5-8 days, the infusion rate was 5 ml/h. after admission we measured pulmonary function of patients and recorded the forced vital capacity (fvc). we repeated the test after the catheter insertion on the 2-5-10 days. in our control group (14 patients introduction: rib fractures are the most frequent injury after blunt thoracic trauma. it is very important to choose the most appropriate interventions to minimize or prevent complications. but who will benefit most of those interventions remains a challenge. material and methods: a retrospective study with a prospective data collection from march 2006 to december 2018. there have been included all traumatic patients older than 16 years old, that were admitted to the icu or who were died before the admission and had a plain chest radiograph (cxr) and thoracic or thoraco-abdominal scan (ct scan) in the first 72 h. demographic data has been collected, vital signs, iss, mechanism of action, need of ventilation or intubation, lesions, complications, cause of death. a total of 553 cxr were reevaluated by one general surgeon (one of the authors) and one radiologist, who were blinded to the results of the subsequent chest ct scan, the written radiology report and the patient's outcome. rib fractures, pneumothorax, hemothorax, pulmonary contusion, laceration and atelectasis were described. results: attending to the number of fractures, the kappa between the radiologist, the surgeon and the ct report is very low: surgeon-ct k = 0.18, radiologist-ct k = 0.2, and radiologist-surgeon k = 0.46. both radiologist and surgeon under-diagnosed rib fractures. we tried to predict respiratory failure and pneumonia using the number of fractures, and scores (chest trauma score, ribscore and rib fracture score). results are shown on the table. conclusions: plain radiography seems not to be a good diagnostic method for rib fractures. both radiologists and surgeons under-diagnosed rib fractures. scores based on radiography seem un-useful given that this under-diagnoses rib fractures; but with a precision of 71% by the surgeon evaluating cxr and using a score like rfs perhaps it is enough to decide which patients require a ct scan or more specific treatment in the icu. surgical experience of traumatic diaphragm injury in a single regional trauma center for 5 years introduction: this study is a retrospective review of the experience with the management of traumatic diaphragm injury in our trauma center from 2014 to 2018. material and methods: we identified a total of 31 patients with the traumatic diaphragm injury coded from the institutional trauma registry. we reviewed the radiographic finding of radiologists and the electronic medical record (emr). results: the mean of injury severity score (iss) was 30.3 ± 13.7. except for 1 case, the plain chest x-ray was evaluated in the patients before surgery, only 3 patients were revealed positive finding for diaphragm injury (n = 3/30, 10%). the computed tomography (ct) was performed for 22 patients, the positive finding was 31.8% (n = 7/ 22). according to the clinician impression before surgery, the diagnosis for diaphragm injury was showed 48.4% (n = 14/31). approaches were laparotomy in 14 patients (45.2%), thoracotomy in 9 (29.0%), thoracoscopy in 3 (6.5%), laparoscopy in 1 (3.2%), open conversion after thoracoscopic or laparoscopic exploration in 2 (6.5%), median sternotomy in 2 (6.5%). the occurrence of herniation was 10 (32.3%). the mean of the calculated rupture size in the operation field was 5.8 ± 3.8 cm. in our study, the herniated peritoneal organ was observed in more than 3 cm size rupture of the diaphragm. 6 patients were performed surgical management of diaphragm rupture after 24 h. conclusions: without herniation of organs, the radiologic evaluation was difficult to detect diaphragm injury. and, detect of diaphragm injury with herniation of organ, the injury of the diaphragm was predicted a larger than 3 cm. case history and clinical findings: a 44-year-old man presented to the emergency room with a single self-inflicted left chest gunshot wound at the level of 2nd rib. on arrival patient was conscious, with systolic blood pressure 100 mmhg and heart rate 120 bpm. extremities were pale, cold. jugular veins distended. investigation/results: fast scan was negative. chest radiograph revealed a metal foreign body with the size of 4 9 5 mm at the projection of heart. a ct scan of chest and abdomen demonstrated bullet inside the dorsal wall of the left ventricle and blood in pericardium and left pleural cavity (figs. 1, 2) . therapy and progression: patient was taken to the operation room for median sternotomy. due to severe deterioration of patient's condition, 30 ml of blood was aspirated from the pericardium prior to sternotomy. during subsequent pericardiotomy 500 ml of blood was evacuated. main pulmonary artery wall gunshot injury was detected above the pulmonary valve. the wound was sutured, after which the hemodynamics stabilized. cardiac surgeon was consulted about the air gun bullet inside the myocardium. it was decided that removal of the bullet is not indicated. the patient was observed in the icu for the next 36 h, later transferred to the thoracic surgery ward. the postoperative course was uneventful. an echocardiogram demonstrated a perforation of the anterior leaflet of mitral valve with a mild to moderate regurgitation, otherwise no abnormalities. patient was discharged on day 10. patient has been followed up on an annual basis for the last 2 years. patient's exercise tolerance and cardiac function according to repeated echocardiography remains unchanged with no evidence of dyskinesia or other abnormalities. bullet is retained in the same location (fig. 3) . comments: this case illustrates a successful management of usually lethal injury of main pulmonary artery and reflects that retained myocardial foreign body does not necessarily cause any complications. profile of penetrating chest injuries in hostile environment: a three year study introduction: penetrating chest injuries are one of the leading causes of death and major morbidity in operations involving high energy weapon systems. this study aimed at assess the profile of penetrating chest injuries suffered during armed combat operations in a hostile environment over a three year period. material and methods: a retrospective and prospective, non-randomized study designed to assess the profile of chest injuries in armed combat operations over 3 years. all patients with penetrating chest injuries were included in the study. results: there were 967 trauma cases out of which 111 patients suffered penetrating chest injuries. the age range of patients was 20-46 years and all were male. a total of 15 casualties were brought dead (14.73%). there were 11 lung injuries and two diaphragmatic injuries. thoracotomy was required in 7 patients (7.27%) and intercostal chest drainage (icd) in 29 patients (23.64%). average blood loss was 440 ml and duration of hospital stay ranged from 4 to 62 days. conclusions: ballistic injuries to the chest are frequently fatal due to injuries to the heart, major vessels and tracheobronchial tree. prompt and efficient pre hospital treatment, expedient evacuation to a surgical facility and swift management by critical care specialists and surgeons can be instrumental in reducing mortality and morbidity. the cornerstone of management is bedside intercostal chest drain insertion as a formal thoracotomy is seldom needed. penetrating chest injuries can be managed by general surgeons with training in thoracotomy and repair of intra-thoracic structures does the number of a-or low symptomatic but intervention requiring complications justify regularly chest x-ray controls after less than 3 rib fractures? c. deininger 1,2 , f. wichlas 1,2 , s. deininger 3 , v. hofmann 1,2 1 university hospital of salzburg, orthopedics and traumatology, salzburg, austria, 2 universitätsklinikum salzburg, klinik für orthopädie und traumatologie, salzburg, austria, 3 universitätsklinikum salzburg, universitätsklinik für urologie und andrologie, salzburg, austria introduction: fractures of less than 3 ribs may still cause delayed complications (1) . the aim of this retrospective study is to determine whether standardized control imaging in a-or low symptomatic patients reveals a significant number of intervention requiring complications and therefor should be recommended. material and methods: all patients with less than 3 rib fractures presenting in our emergency department after any trauma mechanism in the study period of 3 years (2015-2017) and available for follow up were included retrospectively in the study. results: we included 249 patients in this study, 137 (55.0%) of which were male, 112 female (45.0%), with a median age of 64.2 ± 24.8 years. in 150 patients (60.2%) 1 rib was affected, in 99 patients (39.8%) 2, the fractured ribs being true ribs (1-7) in 72 cases (28.9%), false ribs (8-12) in 151 cases (60.6%) and both in 26 cases (10.4%). the affected thorax half was the left side in 124 cases (49.8%), the right side in 121 cases (48.6%) and both thorax halves in 4 cases (1.6%). the trauma mechanisms were falls at home, traffic accidents, sporting accidents, work accidents, fighting related and minor trauma in 172 (69.1%), 30 (12.0%), 19 (7.6%), 18 (7.2%), 6 (2.4%) and 4 (1.6%) cases, respectively. the median follow up time was 9 ± 4 days. 4 patients (1.6%) required delayed intervention: 1 case of hemopneumothorax and 3 cases of pneumothorax all treated with chest tube. conclusions: planned chest x-ray controls seem not to be necessary. symptom triggered reappearance for patients after rib fractures in hospitals seems to be sufficient and more economical compared to regularly re-imaging (2) is computed tomography a first line modality in stable blunt chest trauma elderly patients? a. becker 1,2 , y. berlin 1,2 , d. hershko 3,2 1 emek medical center, department of surgery a, afula, israel, 2 technion-israel institute of technology, haifa, israel, 3 emek medical center, surgery, afula, israel introduction: adult older, patients aged [ 65 years, represent up to 20-25% of all trauma patients admitted to the trauma centers. chest trauma in older patients have been recognized to strongly influence mortality. the estimated of 20% mortality and pneumonia rate for these patients was observed (1, 2) . based on low diagnostic accuracy of cxr, interpretation difficulties due to aging chest wall deformities, we hypothesized that ct chest should be the first imaging modality in stable elderly blunt chest trauma patients. patients and methods a retrospective analysis of all blunt trauma admissions at emek medical center between 2014-2018 years was performed in order to identify patients with blunt chest trauma. only stable trauma patients with abbreviated injury score (ais). results: among 473 patients that met inclusion criteria, there were 289(61%) patients aged 18-64 years old and 184 (39%) patients aged c 65. in the first group of patients (18-64), 240 had ct chest on arrival. in the second group of patients (aged c 65), there were 18 (9.7%) patients with missed injuries. in this group, patients who had ct chest on arrival, 7 of 130 (5.4%) patients had missed injuries. eleven of 54 (20%) patients who had no ct chest on arrival, diagnosed with missed injuries (p-0.014). readmission rate in the first group of patients (18-64) was 5 of 240 (2%) who had ct chest on arrival, and 2 of 49 (4%) who had cxr on arrival only (p-0.3). in the second group (c 65), readmission rate was 5 of 130 (3.8%) patients with ct chest on arrival, and 7 of 54 who had cxr on arrival only (13%) (p-0.051). conclusions: based on our study result we conclude that ct chest should be a first imaging tool in stable elderly patients with blunt chest trauma. no disclosures. efficacy and safety of small-bored tube thoracotomy for chest trauma: large-bored chest tubes will no longer be needed introduction: tube thoracostomy drainage is an important treatment for traumatic pneumothorax and hemothorax. traditionally, largebored chest tubes have been recommended for successful drainage and prevention for clogging by clots. however, there is little evidence that large-bored tubes are more effective than smaller ones. in consideration of invasiveness, in our emergency room (er), we use 20 fr chest tube for all trauma patients when chest thoracotomy is indicated. the aim of our study is to investigate the efficacy and safety of small-bored tubes for chest trauma patients. material and methods: we conducted a retrospective observational study. we included the adult patients ([ 18 years old) who had undergone tube thoracostomy with 20 fr chest tubes for chest trauma during the 5 years from october 2013 to september 2018 in our er. the patients with cardiopulmonary arrest on contact or on arrival were excluded. we evaluated tube-size related complications defined as obstruction and worsening of pneumothorax/hemothorax due to ineffective drainage. results: there were 102 eligible patients, 77% were male, mean age was 59.6 and the average injury severity score was 17.8 (± 9.6). sixty-six tube thoracostomies were performed by emergency physicians and 38 were performed by thoracic surgeons. the average duration of tube placement was 3.86 days (± 1.8). there were not any tube-size related complications nor any patients who required additional tube insertion. case history, clinical findings: 4 different stable hemodynamic cases with thoracoabdominal penetrating trauma and negative fast evaluation were enrolled in study. subsequent hemo/pneumothorax was managed initially by tube thoracostomy. investigation/results: hence laparoscopic investigation is an effective method for evaluation of diaphragmatic injuries in thoracoabdominal penetrating trauma, patients underwent diagnostic laparoscopy. in case 1, classic approach was done by open technique 10 mm port insertion in sub umbilical. two 5 mm ports inserted in lower abdomen at the level of midclavicular line. then 10 mm port was added in subxiphoid area and by introducing zero-degree camera through it a better exposure was obtained. in case 2, 10 mm sub umbilical port, 5 mm port in subxiphoid and another 5 mm working port at the level of umbilicus and right midclavicular line were applied. a 30-degree camera used. exposure, working space and exploration maneuvers were much easier to perform in compare with case 1. in case 3, port placement was identical to case 2 but zerodegree camera was used. due to poor exposure, subxiphoid port was replaced by a 10 mm one and used for camera insertion, then an acceptable exposure was obtained. in case 4, port placement of case 3 was used by using 30-degree camera which resulted in a great exposure. diagnosis, therapy, progressions: patients tolerated the operation well and underwent appropriate management according to their intra operation findings; post-op courses passed without any complications. comments: in patients with suspicious diaphragmatic injury and according to available facilities in our centers, in unilateral injuries we suggest that a 5 mm port in subxiphoid area can be used instead of contralateral midclavicular 5 mm port. in bilateral injuries, if enough exposure doesn't achieve, a 5 mm port in subxiphoid can be added. in absence of 30 degree cameras, 10 mm port use in subxiphoid can give surgeons better exposure. hemodynamic instability in patients with extremity injuries: motor vehicle accidents and shot wounds vs. explosions a. mahamid 1 , i. ashkenazi 1 1 hillel yaffe medical center, hadera, israel introduction: we previously reported that hemorrhagic instability (hs) was a complication of extremity injuries in as many as 1 of 7 of patients treated in one medical center following explosions. the objective of this study was to evaluate whether the prevalence of hs in patients with other high energetic injuries such as motor vehicle accidents and shot wounds (mva/sw) is different or not. material and methods: victims following mva/sw with extremity injuries and hs treated in one medical center during 2017 were identified with the aid of the national trauma registry and the center's blood bank. hs was defined as tachycardia (pulse [ 100/min) and/or hypotension (systolic pressure \ 100 mmhg) in need of blood transfusions to reverse instability. patients in whom hs could be attributed to injuries other than the extremity injury were excluded. these were compared to patients treated following bomb explosions (1994) (1995) (1996) (1997) (1998) (1999) (2000) (2001) (2002) (2003) (2004) (2005) conclusions: the proportion of patients in need of blood transfusion is much higher in patients whose extremity injury was caused by an explosion. the relative risk for hs is almost 5 times higher in these patients. new technologies in soft tissue wound management limit reconstruction complexity and enhance recovery introduction: large soft tissue losses are associated with infection, increased morbidity and mortality, increased costs and poor outcome functionality. the purpose of this study was to evaluate the efficacy of a combination treatment of combined topclosure ò tension relief system (trs) and administration of regulated oxygen and antibiotic irrigation negative pressure-assisted wound therapy (roi-npt) in the treatment of patients suffering from significant soft tissue loss. patients with open abdomen, large infected wounds, and extensive soft tissue loss treated with trs and roi-npt. results: full wound closure was achieved in [ 100 patients treated without skin grafts or flaps. primary failure was successfully followed with secondary closure with the same system. the trs system allowed early postoperative physiotherapy with good to excellent functional results. limitations and complications will be discussed. 1. trs is a novel device for stretching, and securing wound closure, applying stress relaxation and mechanical creep for primary closure of large skin defects that otherwise would have required closure by skin grafts, flaps or tissue expanders. 2. irrigation may accelerate the evacuation of infectious material from the wound and may provide a novel method for antibiotic administration. 3. supplemental oxygen to the wound reverses reduced o2 levels in the wound's atmosphere inherent to the conventional negative pressure-assisted wound therapy restricting vacuum use in anaerobic contamination. moris topaz is the inventor and patent holder of the topclosure ò and vcarea ò . attendees' perceptions about tourniquet safety use aboard, easiness of application, and preference among four devices tested assessed. material and methods: the descriptive study design assessed employing a post-seminar survey, participants' perceptions of tourniquet safety use, application easiness, and preference among the four devices tested (cat, sam-xt, swat-t, and rats). the first two variables measured on a one-to-ten scale (being ten the easiest or safest, and one the least easy or least safe), while preference was measured by frequency count, with only one device to select as the preferred. frequencies and percentages for categorical variables and averages calculated and compared using the anova test (p \ 0.01). results: a total of 51 sailors, 12 (24%) females, and 39 (76%) males, aged between 20 and 21, participated in the workshop and completed the survey. the mean for the perception of safety regarding onboard usage was 7.5. as for application easiness, cat and sam-xt ranked equally high (8.5), followed by swat (7.9) and rats (6.9), and the only statistical difference found was for rats (p \ 0.01). cat was reported as preferred by 38 participants (74%), followed by sam-xt 10 (20%), swat-t 2 (4%), and rats 1 (2%). conclusions: jse crewmembers (non-medical personnel) considered safe the use of tourniquets on board. of the four devices assessed, cat and sam-xt were regarded as equally easy to use and rats the least of all. cat was reported as preferred by almost three out of every four respondents. introduction: surge capacity is the ability to manage the increased influx of critically ill or injured patients during suddenly onset crisis, like a mass-casualty incident (mci) or disaster. during such an event all ordinary resources are activated and used in a systematic, structured and planned way. there are, however, situations where conventional healthcare means are insufficient and additional resources must be summoned. this study investigates the possibility of using community resources such as primary health care centers, nonmedical professionals and non-standardized facilities together with educational initiatives to increase surge capacity in a flexible manner. purpose: to investigate the possibility of an increased and flexible surge capacity during a crisis, disaster or mass casualty incident (mci) by examining the main components of surge capacity (sc) (staff, stuff, structure, and system) in the västragötaland region of sweden. method: this thesis uses a mixed methods research approach with an explanatory sequential design. a literature search was performed by using standard search engines utilizing relevant keywords, questionnaires and semistructured interviews were used for data collection from primary health care centers, dental and veterinary clinics, schools, hotels and sports facilities to determine capabilities, barriers, limitations and interest to be included in a flexible surge capacity system. results: preliminary findings indicate that there is interest, capacity and capability in the investigated municipalities to partake in a fscplan: primary healthcare centers can be toned up with drills and exercises, civilians can be educated in advanced first aid procedures (immediate responders) and focused leadership (scene management), schools, hotels and sports facilities can be prepared with advanced first aids kits and be used as alternative care facilities. these alternatives together represent the concept of flexible surge capacity. conclusion: flexible surge capacity can be a possible approach to create extra resources in disaster situations, mci's, or whenever supporting infrastructure is not intact. new educational initiatives, drills and exercises, laymen empowerment and organizational and legal changes might be needed to realize a flexible surge capacity. introduction: a hospital may need partial or total evacuation because of internal or external incidents, such as in natural disasters and or armed conflicts. an evacuation aims either to transport a large number of patients to other medical facilities or to prepare enough space to receive a large number of victims. despite many publications and reports on successful and unsuccessful evacuations, and lessons learned, there is still no standardized guide for such an evacuation, and many hospitals lack the proper preparedness. we aimed to analyze the preparedness of hospitals for a total evacuation by looking into some key parameters necessary for a successful performance. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. eleven questions were sent to representatives from 15 euand non-eu countries. results: our findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the eu or other non-eu countries included in this study. some countries did not respond to our questions due to the lack of relevant guidelines, instructions, or time. conclusions: hospitals are exposed to internal and external incidents and require an adequate evacuation plan. there is a need for a multinational collaboration, specifically within the eu, to establish a standardized evacuation plan. references: nero c, ö rtenwall p, khorram-manesh a. hospital evacuation; planning, assessment, performance and evaluation. j acute dis. 2012;1(1):58-64. introduction: the importance of and the need for medical management during any armed conflict is a fact. many medical achievements have been accomplished due to wars and armed conflicts. the world is, however, divided into countries with and without related military healthcare services. there is a need for joint structure with the civilian in the former, while in the latter the civilian healthcare is responsible for offering services to the military. this study aims to identify the needs of military healthcare system and military medicine as an independent specialty. material and methods: a literature search was performed by using the standard search motors in the related fields, and by using relevant keywords. relevant professionals were asked about the pros and cons of having established military healthcare. the data was collected and analyzed. results: although our findings indicate a need for military medicine/ healthcare as a professional specialty, the organizational divisions between military and civilian healthcare systems seems to be changing. the current security issues worldwide, the pattern of injuries and resource scarcity indicates a need for improved collaboration and maybe a fusion between these entities. conclusions: new security threats, modern technology, the pattern of medical injuries, and the lack of adequate surge capacity may indicate a very close collaboration between military and civilian healthcare systems. such a close collaboration may develop to fusion and a total defense healthcare system that can act both in peace and during conflicts. references: ringel js. the elasticity of demand for health care. a review of the literature and its application to the military health system. https://apps.dtic.mil/docs/citations/ada403148 khorram-manesh, a. facilitators and constrainers of civilian-military collaboration: the swedish perspectives. eur j trauma emerg surg. 2018. https://doi.org/10.1007/s00068-018-1058-9. alternative methods of mandibular comminuted fracture fixation in severe maxillofacial injured patients introduction: severe maxillofacial injuries refer to significant facial trauma with communitive bony fractures and soft tissue loss. they result in violent trauma as firearm injuries (wartimes injuries, terrorist attack, suicide attempt) and high velocity motor vehicle accidents. the initial management consist of fighting hemorrhage, fighting asphyxia, wounds debridement and suture, and fractures stabilization, especially mandibular fracture stabilization. our study aims to share thoughts on the alternative methods of comminuted mandibular fracture fixation within the context: kind of injury, multitrauma patients, mass-casualty situation, precarious situation or hostile environment. material and methods: based on our experience (clinical cases), on senior surgeons questioning and on medical literature data, we sought to identify, to evaluate and to compare the different available methods to stabilize comminuted mandibular fractures in severe facial injured patients. results: open reduction and stable internal fixation (using macro plate), external pin fixation and closed reduction with maxillomandibular fixation are the methods of treatment which are the most classically used and described. however, some methods using kirschner wires are reported: in cross extrafocal pinning ( fig. 1) , external fixation and handmade splints. all these methods differ in their complexity of use, in their availability, and in their possibilities to treat one kind of mandibular fracture or another. conclusions: the stabilization method of comminuted mandibular fracture will be choose depending on material availability, on surgeon's abilities, on the time available (mass-casualty situation) and on the patient's overall condition. even if stabilization methods using wires are less commonly used, they appear to us to be useful in the initial management of the severe maxillofacial injured patient with comminuted mandibular fracture, especially in austere conditions. causes of combat casualties' death at medical treatment facilities (mtf) in modern conflicts: russian experience i. samokhvalov 1 , v. badalov 1 , k. golovko 1 , t. suprun 1 , v. chupriaev 1 material and methods: data including mechanism of injury, physiologic and laboratory variables, staged surgical treatment and cause of death were obtained from the combat trauma registry of the kirov military medical academy war surgery department. the combat trauma registry includes 5581 russian wounded in military conflicts over the past decades, 451 of them (8.1%) dead of wounds (dow) at the mtf. results: 50.3% of the total dow number died at the role ii field medical units, 17.3% died at the forward military role iii hospitals, and 32.4% died at the role iv hospitals. the causes of dow patients delivered to the mtf were nonsurvivable traumatic brain wound (19.7%), life-threatening consequences of injuries-mainly massive blood loss due to external and internal bleeding and acute respiratory failure (34.8%), as well as the late septic complications (45.5%). terms of death depended on the cause of dow. so for nonsurvivable traumatic brain injuries, they amounted to 0.5 ± 0.1 days, for lifethreatening consequences of wounds-2.1 ± 0.2 days, and in the development of complications-15.7 ± 0.3 days. conclusions: there is a high mortality rate among the combat casualties delivered to mtf in modern asymmetric warfare (8.1%). moreover, half of these patients (50.3%) die at role ii field medical units mostly from nonsurvivable injuries and from acute irreversible blood loss that occurred at the prehospital stage. the main cause of hospital combat mortality is severe septic complications of combat trauma. in consideration of the present counterterrorism practices, prevention and initial treatment for primary blast injury by shock waves constitute a particularly urgent subject because blast injuries and gunshot wounds account for the majority of terrorism deaths. in japan, due to strict ethical standards in animal experiments, there is no appropriate animal model of blast injury. we established an original small animal model of blast injury using a laser-induced shock wave at the national defense medical college (ndmc). however, since the experiments were conducted using only small animals, such as mice and rats, it was necessary to establish a medium-sized animal model aimed to test the applicability in human patients in the long term. correspondingly, we established a blast tube, which was authorized globally as a shock wave-generating device that causes blast injury based on air pressure differences, in the ndmc research institute using the budget of advanced research on military medicine of japan in 2017. this allowed us to conduct scientific studies on blast injury using mediumsized animals. in this presentation, we will introduce the structure and function of the blast tube installed in the ndmc and present some of the results of our research thus far. this research is financially unfortunately, even if hospital and their staff are an essential key for successful response to mcis, the plan are seldom well-known and, above all, exercises are quite neglected at local and national levels. due to mci rarity, simulation exercises are the only way to achieve proficiency in mci response. therefore, we tested an original mci training system (macsim ò ) adapted to the pemaf of a large university hospital in milan (italy). material and methods: the original mci training format called macsim-pemaf (emergency plan for massive influx of casualties)was developed for the italian society for trauma and emergency surgery (sicut) in 2016. it uses macsim ò , a simulation tool scientifically validated for training and assessment of healthcare professionals in mci management. between 2016 and 2018 the course was held for the emergency department staff of a single university hospital of milan (italy) (foundation cà granda-ospedale maggiore policlinico). macsim ò was used to reproduce the hospital resources, with different mci scenarios. during the simulation the participants had the opportunity to test the local pemaf, in adjunct to their knowledge and skills. course effectiveness was evaluated by a pre-and post-course self-assessment questionnaire. results: macsim-pemaf was tested in seven courses, for a total of 258 participants. pre-and post-test questionnaires showed a significant improvement in hospital staff self-perception of knowledge and skills in mci management. on a 1-10 scale, the improvement value was from 4.4 ± 2.5 to 7.5 ± 1.9 (p \ 0.001). conclusions: macsim-pemaf is a useful tool to test single hospital pemaf. it is versatile enough to adapt to specific realties, mimicking different traumatic scenarios. participants, acting in their usual professional roles, can increase their self-perception to be able to respond to a mci with in-hospital resources. introduction: emt are field health facilities, specifically structured to operate in case of disaster, where local healthcare resources are insufficient. there are 3 types of emt. ''emt2 regione piemonte'' is the first italian emt to be certificated by who. it's a type 2, meaning that more than triage and stabilization of emergency cases it's provided with an icu, a 24/7 working operation room, a test lab, radiological and ultrasound devices. it can admit up to 20 inpatients. cyclone idai made landfall on 3/15/19 in the district of dondo in mozambique. it brought torrential rains and strong winds and had heavy impacts on the city of beira and surrounding areas resulting in loss of communication and access. in addition important damage and destruction to shelter, settlements, health and wash facilities occurred. on 3/20 italian government approved the aid mission, from march 21st to 26th three italian military aircraft transported the medical staff and the boxes containing the hospital to maputo and then in beira. on 3/30, the hospital began working, treating an average of 80 patients and performing 4-5 surgeries per day, involving mozambican staff who immediately well integrated with the italian colleagues. results: 25 days of activities. 62 surgeries (28 orthopaedic, 10 general surgery, 18 gynaecology, 6 plastic surgery). 35.4% of the cases related to cyclone. mean tiss: 10 (8-13). mean age 33 (1-73) 34 females, 28 males. types of anaesthesia: 73% locoregional, 10% general, 17% analgosedation. conclusions: our first experience in a mass casualties' scenario showed how important is to refresh team skills through periodic drills. the leadership is of paramount importance to keep the team united and to support collaboration with other nations' teams and with the local population. adaptability and open-mindedness are fundamental. emts do not arrive in loco immediately so that longer periods of mission and integration with local medical staffs should be programmed. introduction: in utrecht, the netherlands, a worldwide unique major incident hospital is continuously standby to receive multiple victims during mass casualty events. each year, different types of mass casualty events are simulated with a varying number of victims, to train command and control under extreme circumstances. in utrecht, on march 18th 2019, a terrorist opened gunshot fire in crowded public transport. the aim of the study is to compare our experiences in simulation versus reality. material and methods: an internal evaluation was performed by questionnaires completed by participants and an external evaluation was performed by interviews. results: all five victims were brought to the major incident hospital, of whom two were dead on arrival, one died seven days after due to multiple organ failure and two survived after multiple surgical procedures. all victims arrived within 36 min after the major incident hospital was activated. a sufficient number of medical staff was alarmed for these five victims, however, since the event occurred during office hours, at least a double amount of staff showed up. among some medical staff on commanding key positions fear arose about their own safety and of relatives outside the hospital. this was exaggerated by incomplete and incorrect provided information from the scene. although medical care of the victims was not affected at all, occasionally the anxiety negatively influenced the command and control structure. conclusions: the combination of anxiety and a surplus of awaiting and benevolent curious medical staff resulted in occasional insufficient performance of the existing command and control structure, despite proper training. however, simulation of fear in a training is very difficult. nowadays, with the increasing threat of terror attacks, one should be aware of the influence of fear and anxiety on personnel, even with low numbers of victims. ethic and law issues during mass casualties management operations in foreign countries introduction: mass casualties incidents occur even more frequently during the last years globally. international help in order to manage them, when needed and asked, has to take into consideration special aspects of ethics and local law status in order to successfully fulfill its expectation. purpose: to demonstrate the ethic and law issues that arise during mass casualties management operations in foreign countries. material and method: literature review from recent management operations in syria, iran and sub saharan africa. results: during such operations a lot of ethical and law issues arise. the knowledge of ethics and laws in the country that these take place is essential and critical for the successful result of them. special care must be taken for the management of women, children and dead people. traditions and religion status of the local populations also must be taken into consideration and actions must take place in accordance to respect of the local authorities and social conditions. conclusions: mass casualties management operations in foreign countries is a challenging mission. ethic and law issues arise and must be taken into consideration for the success of the mission. western surgical experience is one thing, but surgical practice in countries in conflict zones is another. the pathologies are different, the thermal conditions are often difficult and the follow-up of the patients is fundamentally modified. humanitarian surgery is becoming more professional and most organizations are setting up a training program for new surgeons embarking on the humanitarian adventure. international committee of the red cross (icrc) has implemented an onboarding-surgeon experience, before to become a fully icrc surgeon. i hereby present my personal onboarding experience in south sudan: how to learn a new type of surgery, how to come with an helicopter to collect patients in the bush and then, how much you learn about yourself. conflict of interest: i only represent my own experience and i do not represent icrc. surgical clinical reasoning during the war in the period between 1992 and 1996, i was the head of operating rooms and icu at the clinic for orthopedic surgery and traumatology, in sarajevo. working in the operating room whose walls are shaking because of the sniping and shelling was not remembered by any other generation of surgeons. there were around 55000 traumatized citizens of sarajevo. thousands of injured, dying patients were seeking for help from a small number of surgeons. the duty of a surgeon working in the war conditions, without water, electricity, medicines, or heat, is not easy at all, and there were a lot of difficult situations. for example, one day, operated children were again wounded by direct shelling on the walls of pediatric department of our clinic. after we re-operated the children, we also operated the injured nurses. 27th may, 1992 , 5th february, 1994 , and 28th august, 1995 were the most painful experiences in the surgical treatment of disaster in the center of sarajevo, with a large number of massively traumatized patients. while you were helping one casualty, others were pulling our arms or legs. while you were helping one patient, others were dying in the cramp of pain. during the war, a series of traumatic events happened. above many thousands of them, i admitted a 13-year-old girl, severely injured, with traumatic lower leg amputation of the leg, and severe injuries of the thigh, pelvis, and neck. we operated on her through the night. during the surgery, she received 51 whole blood transfusions. following the surgery, she was stabilized on pediatric department of our clinic. one day, i saw her mother brought her a gift, immensely valuable in those days, a small canister of pure water. in the 2008, one girl approached me, and asked me if i remembered her. i remembered the canister of pure water. she was happy to show me how she can walk now, and told me she lives in canada and works as a university assistant. i was more than happy to see her walk proudly, as she was leaving. she injury pattern of 2019 earthquake in athens, greece: the panic-effect introduction: earthquakes are devastating events. greece is known to be in the first place of seismicity in europe and sixth worldwide. lately, a 5.1 richter earthquake shook the greek capital, and fortunately no substantial construction damage was sustained. the aim of the study is to evaluate the classification and severity of all injuries, as well as the type of orthopedic surgical procedures performed, in addition to the role that panic plays on the occurrence of these kind of trauma material and methods: prospective case-series study, conducted in the emergency department of our hospital after the july 19th, 2019 earthquake. the study included 18 patients treated by our department, who sustained injuries in their attempt to run away from the scene. age range was from 20 to 84 years old (mean 54.9 y.o), 11 were female and 7 were male. results: a total of 23 injuries reviewed. upper extremities were involved in 9 of all cases, lower extremities in 13 and one patient suffered minor head trauma. four patients required hospitalization and all of them underwent surgical treatment. open reduction and internal fixation performed in 2 patients (1 calcaneus fracture and 1 olecranon fracture), 1 patient underwent intramedullary nail fixation (tibial shaft fracture) and external fixation was applied to another (distal tibia fracture). six patients were conclusions: panic is an independent contributing factor in natural disaster associated trauma. prior education, preparedness and combined team effort are clearly needed, in order to reduce the incidence of these injuries. regardless of age, panic may result in various types of fractures, even in cases there are no substantial construction damages after an earthquake. digital and analogue record system for mass casualty incidences at sea: results, reliability and validity introduction: mistriage may have serious consequences for patients in mass causality incidences (mci) at sea. therefore, an exercise was conducted to compare the reliability and validity of an analogue and tablet based recording system for triage of sample patients. material and methods: 50 volunteers were asked to triage with the start-algorithm (black, red, yellow and green) 50 patients in a given time using an analogue and tablet based system. triage score distribution and agreement between the two triage methods and a predefined standard were reported. the present study assessed the triage results as well as the reliability through cronbachs alpha and kappa. for testing of validity and internal consistency, the sensitivity, specificity and predictive value was measured. results: forty-eight participants completed a total of 3545 triages. while the number of triaged patients in the given time was significantly higher with the analogue system compared to the digital system (p-value 0.001, t-test), the validity measured with the cronbachs alpha and unweighted cohens kappa was higher with the digital system. for each triage category, higher values were gained with the digital system. the sensitivity, specificity and predictive value for the digital system was higher than for the analogue system. conclusions: this study gives reliable and valid results comparing a digital versus an analogue triage system for a mci at sea. significant differences could be found for the number of triages and the number of under triage. the results of the study show that the used digital system has a slightly higher reliability and validity than the analogue triage system. references: the present work is part of the project improved emergency treatment and organization in the event of a mass casualty of casualties at sea (venomas), planned within the framework of the research network ''kompetenz und organisation für den massenanfall von patienten in der seeschifffahrt'' (kompass) and funded by the federal ministry of education and research (grant number: 13n13256). predicting outcome for extremity wounds in pediatric casualties of war introduction: during the early 90s, the international committee of the red cross (icrc) implemented the red cross wound classification (rcwc) for penetrating wounds. wound grades of 1, 2 and 3 describe the amount of kinetic energy transferred to the tissue (low, high and massive, respectively). currently, this classification system mostly serves as a descriptive tool, but it is hypothesized it could also support clinical decision making. the aim of this study is to assess whether the wound grade of a pediatric patient's extremity wound correlates with patient outcomes. material and methods: this study included pediatric patients (age \ 15 years), who have been treated by the icrc for conflictrelated extremity injuries between 1988 and 2012. the correlation of the following variables with the wound grade were analyzed: number of surgeries required, length of stay, and in-hospital mortality. results: the study cohort consisted of 2459 pediatric patients. the higher the wound grade, the more surgeries were performed per patient (p \ 0.05), with a mean of 4 surgeries per patient if they had a wound grading of 3. there were no significant differences in mortality rates between any of the wound grades, which were 1.0% (20/1953), 0.0% (0/342) and 1.9% (3/161) for wound grade 1, 2 and 3 respectively. pediatric patients with wound grade 3 were hospitalized for the longest period (mean 49.6 days), followed by wound grade 2 (mean 40.0 days) and wound grade 1 (mean 25.9 days; all with p \ 0.05). conclusions: the wound grade of pediatric patients' extremity wounds appears to correlate with some patient outcomes, but not with mortality. grading of extremity wounds according to the rcws could support clinical decision making in pediatric patients. introduction: during the last few decades, french armed forces have regularly deployed in asymmetric conflicts. surgical support for casualties of these conflicts occurs in nato role 2 and 3 medical treatment facilities (mtf); definitive surgical care occurs in france following a strategic medical evacuation. the aim of this study was to describe the combat injury profile of these soldiers who presented with either non-exclusively orthopedic and/or non-exclusively brain injuries. material and methods: this descriptive study is a retrospective analysis of the surgical management of french casualties performed in role 2 or 3 mtf in afghanistan, mali, niger, djibouti and the central african republic between january 2004 and december 2014. results: one hundred patients were included. forty had fragment wounds. the most severe lesions were of the head, neck or thorax. the average injury severity score (iss) was 34.9 (ic 95% 29.8-40). 17 damage control procedures were performed. thirty patients died with a mean iss of 61 (ic 95% 56-67); 5 deaths were considered as preventable deaths. the most frequent surgical procedures in the mtf were digestive (n = 31) and thoracic surgery (n = 19). thirty patients needed second-look surgery in france; eleven had severe complications. no patient died following medical evacuation to france. conclusions: results from this study indicate that the mortality following non-exclusively brain or orthopedic injuries remains high in modern asymmetric conflicts. introduction: telemedicine has been applied to disasters and extreme environments for more than 20 years, however, despite the many lessons learned so far, telemedicine is still not a common part of the immediate disaster response. for this reason, a review of the literature was conducted to investigate whether telemedicine technology can be used to address medical and non-medical needs in extreme environments. material and methods: this systematic review included 9 studies published in the period 2000-2019, originating from literature search bases medline, scopus, cinahl and pubmed. the case of neemo project were studied so to evaluate the diagnostical and surgical care of the patients regarding the emergency response in a remote and constricted area, with limited human medical resources and using the telecommunications and telerobotic technologies. results: the majority of the included studies have highlighted the importance of telemedicine interventions in extreme environments, stressing that it is a viable solution to health care provision. in addition, it has been found that telemedicinal technology provides the possibility of virtual collaboration between healthcare professionals with various specializations. projects neemo 7,9,12 engaged to eliminate the challenges of telesurgery. conclusions: future studies such as large multicentre randomized trials will have to be conducted that will lead to safe conclusions on the usefulness and efficiency of telemedicine applications in extreme environments. introduction: tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage. the optimal tourniquet type and effectiveness of non-commercial devices is unclear, and the aim of this study. material and methods: this prospective observational cadaverbased study was performed using a perfused cadaver model with a standardized superficial femoral artery injury bleeding at 700 ml/ min. five devices were tested: cat (combat application tourniquet), rats (rapid application tourniquet system), swat-t (stretch, wrap, and tuck tourniquet), a triangle bandage and a stick and a leather belt. 48 volunteer medical students with no prior clinical tourniquet experience participated. each student underwent a practical hands-on demonstration of each of the 5 tourniquets, prior to the test. using a random number generator, they then placed all 5 tourniquets in random order. outcomes measures included time to hemostasis, total time to secure devices, estimated blood loss (ebl) and difficulty rating. a one-way anova repeated measures was used to compare efficacy between the tourniquets in achieving the outcomes. results: participants' mean age was 25 ± 2.6 years and 29 (60%) were male. all participants were able to stop the bleeding with 4 of the 5 tourniquets. with the rats there was a 4% failure rate. among the five types of tourniquets, time to hemostasis and ebl were not statistically significantly different (p [ 0.05). the swat-t required the longest time to be secured (47.8 ± 17.0), while the belt was the fastest (15.2 ± 6.5; p \ 0.001). conclusions: all five tourniquets, including the non-commercial devices, were effective in achieving hemostasis. a standard leather belt was the fastest to place and able to stop the bleeding. however, it required continuous pressure to maintain hemostasis. nevertheless, in an emergency setting where commercial devices are not available, improvised tourniquets may be an affective lifesaving bridge to definitive care. hospital preparedness for mass gathering events and mass casualty incidents in matera, european capital of culture for 2019 introduction: mass casualty incidents (mci) may occur during mass gathering events (mge). lack of preparedness of health system increases mortality. education and training are crucial. hospital mci plans are mandatory in italy, but they are poorly known. on 2014, matera was declared italian host of european capital of culture for 2019: the local hospital decided to revise the hospital plan for massive influx of injured (pemaf) and to start a program to train the staff. material and methods: the pemaf was reviewed through simulations that involved all the staff. a partnership with mrmi-italia (italian chapter of the international association medical response to major incident and disaster-mrmi&d) leaded to the support of experts and to the organization of residential courses based on the macsim ò (mass casualty simulation) simulation tool. educational capacity of the residential events was tested through a self-assessment tool. results: alert, coordination and command sequences were defined. all the available resources were recorded and the functional areas identified. the communication network was improved. documentation and registration system was prepared. standard operational procedures (action cards) were created for the key positions. 7 residential educational events of macsim-pemaf were organized. the educational capacity was tested through self-evaluation: knowledge of participants resulted improved. conclusions: mge are a great opportunity for the hosting community but they also represent an increased risk of mci. preparedness is mandatory for health system. the format macsim-pemaf seems to be adequate to review the existing plans and transfer skills to attendants. introduction: the cruise industry is facing a constantly growth of infectious diseases. some of them are reaching the extent of mass casualty incidences (mci), which are overwhelming the capacity of the local rescue system. our aim was to improve the ability to act in a mci due to an infectious emergency regarding the situation at sea/in the port. hamburg, as one of the largest ports in europe, was chosen for analysis. material and methods: the collaborative project ''adaptive resilience management in the port'' (armihn) is funded by the german federal ministry of education and research. scenarios due to an infectiological emergency were developed together with the university central department of occupational medicine and maritime medicine and the hamburg port health center in hamburg, germany. these scenarios were specified with all key stakeholders in the port. the organizational structure of the current emergency management was analyzed and a new concept was developed. results: for the ship and the port, emergency strategies dealing with mass casualties of injured persons are available. nevertheless, current concepts regarding this special situation of an infectiological mci were missing. we developed a new concept, which based on the models concerning mass casualties of injured persons. for this purpose, emergency surgeons can be recommended as experts regarding coping with a major emergency and for developing adaptive training concepts. conclusions: new operational concepts coping with mci of infectious patients were developed. in a second step, an emergency plan and a training concept for relevant stakeholders in the port will be developed. these will be evaluated in a full exercise in the port of hamburg and tested for their suitability. the results will be transferred to comparable infrastructures to cope with a major case incident with infected people in the port area. emergency surgeons should be involved in these steps due to their expertise. the work was funded by the german federal ministry of education and research (13n14925). no further significant relationships. war surgery training, the use of swine model in military simulation center introduction: due to the international instability, our forces are deployed in many place and our military surgeons have to deal with ballistics trauma and improvised explosive devices related trauma. in order to be well prepared and effective in these isolated situation, the val de grace school (our military health service academy) provide a 2 years course to train the young surgeon. this 2 year surgical courses ended with war trauma surgery simulation on a swine model. material and methods: this use of the swine alive model is incorporated in the cesimco (military surgical simulation center) and also use for the training of our fully registered surgical team. this laboratory responds to all civilian authorizations and ethical considerations as enacted by european rules (felasa). results: the aim of this presentation is to show the different procedures and the teaching provided in this structure to improve surgical skills in war condition. all procedures are approved by the ministry in charge of the animal experimentation and respond to the animal welfare regulation. the number of swine used in these teaching is reduced to the minimum. we think that this animal model and its use in military forward surgical facilities, is the end point of the 2 years military surgical course provided by the val de grace school. conclusions: this model is actually the most reliable and ethically acceptable teaching procedure we've found. during these teaching the students have to deal with open trauma and hemorrhagic lesions in damage control situation. we try to follow the different type of war related lesions observed in french military in order to stick to the reality of the field. this teaching is now mandatory before being deployed as a military surgeon on field. case history: 29-year-old male, previously healthy, admitted to the er due to shotgun injury to the right hip. during transport, the bleeding open wound was covered, two iv catheters were introduced, and saline and painkillers were administered. on admission, the patient was conscious, eupneic and normotensive, with a gcs score of 15. clinical findings: after the primary survey and exclusion of cranial, thoracic and abdominal lesions, the limb injury was addressed, showing a 3 9 4 cm oval-shaped wound. the right leg was shortened and externally rotated. pulses were present but the patient referred calf and foot hypoesthesia. investigation/results: x-rays showed a comminuted pertrochanteric fracture and the presence of metallic foreign bodies. diagnosis: open right pertrochanteric fracture. therapy and progressions: initially, the wound was covered, and iv antibiotics and supportive therapy were given. in the or, irrigation, surgical debridement, and foreign body removal were performed, followed by orif with one dall-miles cable and a cephalomedullary femoral long nail. after surgery, the patient maintained lower limb hypoesthesia and had plantar flexion and foot dorsiflexion grade 0 motor deficit. during follow-up, soft tissues recovered uneventfully and bone healing successfully occurred. full weight-bearing was tolerated at 6 weeks post-op but the neurological deficits persisted despite physiatric treatment. electromyography confirmed severe partial lesion of the sciatic nerve. comments: generally, clean wound, fracture stability, restoration of circulation and skin closure of neurovascular structures are a priority and should be a reason for delayed nerve repair. introduction: despite mass casualty incidents (mci) are becoming a common concern, particularly regarding the care of paediatric victims, pure paediatric trauma centres (ptc) are still rare in europe. the purpose of this study is to assess the capacity of the hospitals in the metropolitan area of milan in case of mci involving the paediatric population, with focus on the pre-impact planning phase. material and methods: relevant literature and existing guidelines were reviewed by the representatives of four referral centres for the management of either trauma or paediatric patients. minimum standard requirements of care of paediatric trauma and consequently the maximal surge capacities for each hospital were defined based on the severity of injuries and personnel/equipment availability. results: overall, the four hospitals are able to treat 8 patients with the highest priority (t1), 8 to 12 patients with intermediate priority (t2), and 24 patients with deferrable priority (t3). severely injured patients \ 3 years old should be preferentially transported to the hospitals with paediatric expertise, whereas patients between 3 to 12 years of age can be managed in multi-speciality structures. conclusions: in case of mci it is not always possible to rely on the availability of a ptc. hospitals with paediatric trauma care expertise can work in synergy with ptcs, or offer an alternative if there is no ptc, and should therefore be included in disaster plans for mci involving paediatric victims. case history: we present a case of a 46-year-old male with a proximal radius and ulna gunshot fracture associated with a complete lesion of the brachial artery, which was urgently repaired by grafting in his native country. a partial proximal radius excision was also performed. three months later, after soft tissue recovery, the ulna fracture was fixed with a dcp plate plus iliac crest bone graft. at 2 months follow up x-rays showed hardware loosening, so the plate was removed and an external fixator was implanted. in this situation the patient attended to our clinic 18 months after the initial injury. clinical findings: findings included proximal pin purulence, an elbow varus deformity and a limited joint motion: flexion 45°, extension 40°, supination/pronation 20°. investigation/results: x-rays and ct scan showed proximal ulna pseudoarthrosis. diagnosis: proximal ulna pseudoarthrosis after a gunshot fracture. therapy and progressions: a two-stage procedure was performed. initially we performed a wide debridement and external fixator removal. an ulna nail combined with gentamicin and vancomycin pmma spacer was implanted. s. aureus was identified in intraoperative cultures. in a second stage, 1 year after, the nail and spacer were removed and a vascularized fibula graft with saphenous loop was implanted and fixed with a va-lcp plate. the central band of the interosseous membrane was repaired with a prosthetic device. currently, the patient presents full flexion range, hyperextension of 20°, active pronation of 50°and supination of 20°. x-rays show graft consolidation. comments: gunshot fractures are complicated lesions with significant soft tissue damage and high risk of vascular and nervous injury. a thorough study and initial systematic approach is mandatory in order to avoid later complications. introduction: the purpose of our study was to independently analyze pediatric trauma data, especially that of preschool-aged children, including demographics, injury patterns, the associated mechanism of injury, and outcomes, at a single institution in korea to gain a better understanding of current trends in non-regional trauma centers. material and methods: we conducted a retrospective review of preschool-aged children with trauma, who presented to the emergency department a single center between march 2010 and december 2018. results: overall, there were 303 pediatric patients who experienced trauma admitted during this study period. the frequency of admissions was similarly high in all seasons except winter. falls were the most common mechanism of injury at all ages, except 1, 2, and 4 years of age, according to comparative analysis by age and mechanism. the most common place of trauma at 1-3 years of age was at home, and outside the home at the age of 4 years or older. the most common injury region was to an extremity (65.7%). mean injury severity score was 5 ± 4.3, and the mean hospital stay was 5.9 ± 10.4 days. conclusions: although mortality from trauma is low in pediatric patients, we must continue to improve treatment outcomes for children. it is unlikely for a hospital to have a pediatric trauma specialist, such as a pediatric orthopedic surgeon or plastic surgeon, due to manpower constraints. in order to further improve the outcome of treatment with insufficient resources, it is necessary to recognize agespecific characteristics. question: the new safety situation in europe and the lessons learnt civilian events of damage show that hospitals have to be prepared for mass casualties. the shift of the operational mode to ''emergency medicine'' have to be planed and practiced. the reporting tool for this is the hospital action plan (hap) that every hospital should have. the efficiency of the existing plan is already proven in different largescale exercises. in germany the legislator obligates the hospitals to enable there staff to properly perform the different tasks of the hap. in addition, the have to develop and evaluate proper training and exercises. goal of this study was to establish along the hap of a level one trauma center an modular mass casualty training (manv 100) that would help to analyze the tasks to face and to deepen the existing structures of communication. method: we set a scenario with 100 casualties and evolved the different shifting phases of the trauma center (alarming-, mobilization-, constitution phase). setting the concept of training outside the regular service period we took in account that there will be a lack of resources and material. we did not exercise in a large-scale but trained in small groups modular. we also did a screen adaption of the hap of the trauma center to have a mind set for the staff and a starting point to the scenario. to teach our operative procedure we simulated our ''3 columns concept'' (medical, personal and infrastructure) to the staff. specific to the different task groups (medical doctors, technicians, nurses) we exercised and the different sectors (er, triage, or, command etc.) and the necessary shifts of the different hospital sectors when a mass casualty occurs. before and after we did a query of the staff to see how much impact the modular exercise would have on the hap-knowledge of our staff. results: we were able to simulate realistically an identical mass casualty scenario to different staff groups of our hospital. knowledge about the hap increased significant from 76 to 92% after the trainings. 97% of the staff see a clear improvement of information about the hap. also, the specific shifting-phases and the enrolment of the plan to move in an ''emergency medicine mode'' understand 85% better. 95% of the staff fell now a much better preparedness than before. 89% think that through modular exercises and small group training the communication in between working groups improved. conclusion: we could manage to improve a significant increase of knowledge about the hap in our staff. all the small group modular training in the different sector can be easily but together in large-scale exercise and other teams like police, military or fire-department can easily be added. introduction: dstc course focusses on surgical skills for trauma care. it is designed to teach surgical techniques for the definitive treatment of severe trauma. currently, it has evolved into an international trauma team course. our objective was to assess faculty members' opinion regarding course content, educational methods, and incorporation of non-technical skills. material and methods: a descriptive study was designed using an anonymous online survey issued from may 1 to august 31, 2019. senior international faculties' opinion from 19 countries assessed. the survey inquired views of courses content, duration, adequacy of hands-on practice, need for updates, and usefulness of incorporating non-technical skills to the course. results: from the 102 surveys issued, 36 were (35%) answered. the course content was valued as very satisfactory by 58%; 97% were very satisfied or satisfied with courses educational method. 80% considered the time devoted to lectures, case discussions, and skills lab very adequate or adequate. course duration (2 days) was valued suitably by 80% of responders. the inclusion of non-technical skills was considered as very important by 19%, important 31%, of some importance 11%, of little importance by 31%, and unimportant by 8%. this result reflects the insufficient sense of significance, among some, of the importance of trauma team dynamics. course content updates were seen as convenient by 97% of the surveyed population, suggesting them at least every 2-4 years. conclusions: dstc international faculty response to the online survey tool was inadequate, receiving 35% of the targeted study population. of the assessed faculty, most were satisfied with course content, duration, and educational methods. the surveyed population lacked a uniform perception of the importance of incorporating nontechnical skills. introduction: dstc is an iatsic course emphasizing on teaching surgical skills for trauma care. in many countries, it is an essential course focused on the ''second hour'' beyond atls and teamwork. initially centered on the surgeon, it currently seems to be adopting a trauma team training (ttt) model, incorporating the anesthetist to the program (ds-datc). our objective was to review this changing trend in three countries: spain, portugal, and brazil. material and methods: a descriptive study was designed by faculty from the three countries examining course records and analyzing its evolution during the last five years. number and types of courses delivered in each country from 2015 to 2019 reported, and the proportion of dstc to ds-datc scrutinized. frequencies and percentages calculated for categorical variables and the proportion of course types also determined. results: during the 5-year studied period, 70 dstc courses were issued: 34 (48%) in spain, 30 (43%) in brazil, and 6 (9%) in portugal. a total of 15 (21%) ds-datc courses in the three countries, and the percentage of total delivered in each country was as follows; spain 7 (21%), portugal 5 (83%) and brazil 3 (10%). overall ds-datc to dstc ratio was 1:5, detailed as follows: portugal 5:6, spain 7:34, and introduction: thailand is a disaster-prone country with a high dependency on tourism. it has been affected by both natural and manmade emergencies. the thai emergency healthcare system consists of emergency physicians working at hospitals and prehospital levels, emphasizing their essential role in emergency management of any incident. we aimed to investigate the thai emergency physicians' level of preparedness by using tabletop simulation exercises and three different scenarios. material and methods: using the 3lc (three level collaboration) method, two training sessions were arranged for over 50 thai emergency physicians, who were divided into three groups of prehospital, hospital, and incident command staff. three scenarios of a terror attack and explosion, riot and shooting, and high building fire were discussed in the groups. results: our findings indicate that the initial shortcomings in command and control, communication, coordination, and the ability of situation assessment increased in all groups step by step and after each scenario. new perspectives and innovative measures were presented by participants, which improved the whole management on the final day. conclusions: tabletop simulation exercises increase the ability, knowledge, and attitude of thai emergency physicians in managing major incidents in strategic, tactical, and operative managerial levels, and should be included in their professional curriculum. introduction: non-operative management of traumatic injuries has led to decreased surgical exposure for trauma trainees [1] . while simulation using cadavers may improve exposure to damage control techniques, tissue handling realism is variable depending on embalmment and perfusion techniques [2] . objective: to evaluate the feasibility of perfused thiel cadaver use for trauma surgery simulation. material and methods: thiel cadavers were cannulated in the ascending aorta and right atrium to create a left-to-right perfusion system. a magnetic pump was used to achieve a pulsatile flow with a gelatin-based solution, aiming for a flow of 4 l/min. peripheral circulation was improved with arteriovenous fistulas (carotid-jugular, femoro-femoral and brachio-brachial). a left common iliac vein injury was performed laparoscopically through the sigmoid mesentery. the surgical trainee was blinded to the initial injury and assisted by a staff surgeon. results: a trauma laparotomy was performed. the small bowel was eviscerated and all four quadrants were packed with gauze. a left, expanding zone iii hematoma was detected. the left sigmoid colon was mobilized to achieve proximal control of the left iliac vessels. the left common iliac vein was actively bleeding and ligated according to damage control principles. the left ureter was uninjured. the sigmoid mesentery was closed, without active bleeding. the remaining of the abdominal cavity was explored without other injuries. time from laparotomy to closure was 43 min. tissue handling and circulation dynamics were highly realistic due to thiel embalmment and pulsatile perfusion. conclusions: pulse-perfused thiel cadavers represent a realistic simulation option for surgical trainees. widespread implementation may provide accurate simulation for lifesaving procedures rarely performed in an era of non-operative management of traumatic injury. a new concept of intra-operative performance monitoring and self-assessment in hepato-pancreato-biliary surgery and other surgical specialties s. kharchenko 1,2 , m. yanovsky 3 1 colmar civil hospital, university of strasbourg, department of general surgery, colmar, france, 2 hepato-biliary institute henri bismuth, paris, france, 3 interceg, kharkiv, ukraine introduction: currently, the majority of learning curve studies for surgical interventions associated with simple chronometric estimation in a whole: from incision to closure. a selective approach for step-bystep time fixation of all hpb interventions (hepatectomy, others) or other surgical specialties can bring a new vision of correlation between intra-operative timing and the clinical outcome. material and methods: every operation can be divided into step items so standardized worldwide, for example, planned or urgent laparoscopic cholecystectomy e.g. incision to port placement, exposure, dissection to cholangiography, cholangiography, extraction, closure. results: the prototype named chronoi of infrastructure for automated monitoring (simulator of time tracking activities, web-service for request processing, database and knowledge base collection subsystems, learning curve representative and analytics software) is designed and to be implemented. individual self-assessment is available in a real-time fashion. the learning curve changes are shown per procedure. up to our knowledge, we can firstly in the world describe the surgeons, incl. in hpb, as speedy, standard or nonstandard depending on the surgeon's ''individual speed'' in operative performance. it's to be documented in their e-logbooks according to the current fellowship standards or practice re-certification. conclusion: the intra-operative monitoring and worldwide standardization give a new vision of the surgical practice in hpb surgery meaning an introduction of monitoring-based clinical outcomes (timing with morbi-mortality or other). only new trials will approve the role of the presented concept in hpb surgery as well as in general, emergency and trauma. introduction: the management of patients victims of war weapons and collective emergencies represents a major public health issue in france, but also abroad. terrorist events in recent years on the national territory have highlighted the need for training the population and caregivers in the management of these injuries. because of his experiment in the domain, the french military medical service (fmms) was requested to cooperate with the french prehospital teams in order to improve knowledge and teaching in this area. today, a continuing medical education, easily available and free access is needed in this area. material and methods: development of video podcasts (infographics) of a few minutes on the theme of management of patients victims of war weapons and collective emergencies. the working group ensures the production and quality of educational messages. production is provided by the communication establishment of defense. the broadcast is displayed on the channel you tube of the fmms. results: the title of the traum'cast podcast is the contraction of trauma and podcast. twelve episodes are scheduled on a 2-weeks rhythm. the podcast program is as follows: conclusion: fmms knowledge and experiment in managing patients victims of war weapons is unique. teaching can take various forms, theoretical, practical, academic, or through publications. traum'cast is a major innovation in the dissemination of this knowledge and each episode focuses on a specific skill. traum'cast will highlight the applicability of military medicine concepts in a civilian environment. traum'cast will be translated in an english version. project was supported by grants of french ministry of defense (innovation department). splenectomy in current surgical practice: a tricky and elusive procedure for the surgical resident? introduction: splenic rupture and oncologic resections are the most common indications for splenectomy, but technical expertise is progressively being taken over by non-operative and more conservative approaches. material and methods: retrospective review of all total splenectomies performed between february 2012 and january 2019 at an italian academic hospital, assessing demographics, diagnosis, operating surgeon, surgical approach, complication rate, postoperative critical care admission, and 30-day mortality. results: over 7 years, 163 consecutive splenectomies were performed by 25 different surgeons, 4 of whom surgical trainees, with 83 unplanned (i.e. emergency/iatrogenic injury) and 80 planned (i.e. benign/malignant disorders) procedures and an average of 11.9 and 11.4 procedures per year respectively. over the study period, only 9 surgeons performed at least 6 procedures and only 5 performed at least 12 procedures. laparoscopy was performed in 9.8% of cases, predominantly during planned procedures, with an overall 37.5% conversion rate mostly related to technical difficulties (i.e. spleen dimension, difficult vascular visualization). overall major postoperative complication rate (clavien-dindo c 3) was 19.6%, slightly higher in emergency procedures although not significantly different (13.7% vs. 25.3%, p = 0.08). reintervention rate was 12.3%, due to hemorrhage in more than half of cases. overall 30-day mortality rate was 5.5%, with elective 30-day mortality rate of 3.7% (p = 0.49). conclusions: splenectomy may be required ever more rarely but potential risks are not irrelevant. competence for surgical trainees should be achieved elsewhere (e.g. simulated/cadaveric training case history: an 84 year old femal patient underwent changing of the components of the tha because of aseptic loosening. due to circumstances the surgeon decided to implant a cemented femoral component. the procedure was without any significant abnormalities. the first postoperative radiograph was planned after recovery-as usual. the x-ray imaging showed a misplaced femoral component. therefore a ct-scan was performed additionally and the malposition of the cemented femoral component was confirmed. the patient had to undergo another surgery-removing of the cemented femoral component and implantation of a new well placed one. therapy and progressions: after prompt resuscitation, an emergency laparotomy was performed and an anastomotic leak was found, requiring re-do ileo-ileal anastomosis. postoperative course was complicated by intra-abdominal collection treated by antibiotics alone (clavien-dindo grade 2). the patient was discharged on 20th pod. at pathological report, segmental absence of intestinal musculature (saim) was diagnosed. the revision of past specimens confirmed the same finding. comments: usually recognized in neonates/premature infants, saim is generally an incidental finding in adults [1] , often undiagnosed and more frequently described in the colon [2] . in such scenario, main differential diagnosis is ischemia. etiology is unclear and can be classified as either primary/congenital or secondary. the former is characterized by acute onset of symptoms, whereas in the latter a longer history of intestinal symptoms is usually present [1, 3] . most authors agree upon a congenital pathogenesis. generally, saim is associated with hollow viscus perforation and treated with surgical resection. contrary to our experience, no recurrence of intestinal perforation has been reported [2] virgen del rocío university hospital, general surgery, seville, spain, 2 hospital regional de málaga, general surgery, málaga, spain, 3 hospital de estella, general surgery, navarra, spain, 4 hospital gregorio marañón, general surgery, madrid, spain, 5 complejo hospitalario de jaen, general surgery, jaen, spain introduction: specific training in the management of trauma patients is essential for surgeons. training through courses in this area (atls, dstc, musec) directly impacts the care of these patients. the aim of this study is to know the specific training in trauma care of spanish surgeons. materials and methods: a national survey has been sent to all member surgeons of the spanish surgeons association. it has evaluated their degree of participation in emergency surgery acute care, and therefore the possibility of attending trauma patients, their participation in the initial care at their hospital, as well as their specific training in this area. results: the survey has been completed by 510 surgeons from 47 spanish regions, and most surgeons who responded were from catalonia and andalusia. 456 (89.41%) of those surveyed take calls for the ed. only 171 (33.53%) report having a hospital registry of trauma patients. 72.15% of surgeons answer that in their hospital the general surgeon is not involved in the initial care of trauma patients. 66.47% have taken the atls course, 40.78% the dstc course, and 11.57% the musec course (or another course on e-fast). despite this, 85.69% consider the atls course should be mandatory during residency, and 43.33% of those surveyed consider trauma care in their hospital as very bad or deficient. conclusions: according to this survey, specific training in trauma care is still deficient in spain and with many aspects that can be improved. only 40% of those surveyed have received specific training in definitive surgical management of severe trauma. despite this, a large percentage of surgeons take calls for the ed routinely, and face the challenge of managing these patients. exploring team leaders' decision-making challenges in civilian and military complex trauma introduction: in the nordic countries professionals may work in both civilian and military trauma care. timely and effective decisionmaking in complex trauma is essential in improving survival benefits. the mindset and management priorities differ among medical professionals, and correlate with different experience levels. trauma leaders are usually senior surgeons with extensive experience and well-developed decision-making skills. simulation training has been shown to be effective in practicing decision-making. the aim of this study is to explore the team leaders' decision-making challenges in complex trauma care and structure them with the activity theory framework (at). material and methods: video recordings at a trauma center in johannesburg and live observations of complex trauma training in gothenburg focusing on team leaders' decision-making challenges were analyzed and systemized using the at. results: the team leaders' activities were mapped onto the main elements of at ( fig. 1) whereby the decision making challenges were classified into six categories (table 1) . conclusions: the at framework may benefit and inform the design of educational interventions by structuring key issues of complex activities. introduction: trauma is one of the main causes of mortality worldwide and prevention stands out as one of the main ways to modify its incidence. a prime example of such initiatives is the prevent alcohol and risk-related trauma in youth program (p.a.r.t.y.). it aims to raise awareness of the population most at risk for trauma, young people from 14 to 18 years. the study objective was to evaluate the program impact on students' knowledge and behavior. material and methods: a quantitative, uncontrolled intervention cohort study was conducted through the responses of the p.a.r.t.y. in 2017 and 2018. data collection occurred through the application of a questionnaire to participating and non-participating students of public schools in the city of campinas, after a few months of participation in the program. results: among 697 answers, 53.9% were male, 87.2% between 15 and 17 years, and 22.7% program participants. time between participation and answers was 10.4 (± 3.7) months. regarding the first conducts when facing traffic trauma, 48.7% of those who participated chose the correct answer, against 14.8% of those who did not. about the first care while the service does not arrive, 85.5% of the first group answered correctly, compared to 35.1% of the second. concerning about the service that should be called in the event of a trauma, 66.4% of participants would call correctly against 28.0% of non-participants. in questions related to traffic laws, 74.3% of participants opted for the correct answer as to what should be done in the face of a running over, against 23.20% of non-participants. conclusions: students who had participated in the program had a higher rate of correct answers, a few months after the event, compared with students who did not attend. thus, it is concluded that there is a impact over the time caused by it. introduction: currently, intraosseous (io) devices are necessary for the resuscitation of severe trauma patients. however, opportunities to learn io device insertion are limited for residents. the aim of this study was to conduct a simulation of io device insertion for residents and to evaluate its effectiveness. material and methods: in this simulation, residents inserted io needles into the sternum of pigs under general anesthesia with the instructor's guidance. comprehension tests and questionnaires about satisfaction level and self-efficacy were conducted before and after the simulation. the objective evaluation was the io access success rate, and the subjective evaluation was obtained from points on comprehension tests and questionnaires. results: thirty-six residents participated in this study. just one resident had successfully obtained io access clinically. success rate of establishing io access in the simulation was 100%. the rate of test completion was 100% and that of questionnaire with survey response was 61%. the comprehension test results improved from 9.2 ± 0.94 to 9.6 ± 0.79 (mean ± standard deviation, p = 0.01739) out of 10 points. the questionnaires concerning satisfaction level changed from 7.4 ± 2.9 to 14 ± 1.3 (p \ 0.0001) out of 15 points. the questions specifically concerning self-efficacy dramatically increased from 1.8 ± 0.91 to 4.1 ± 0.64 (p \ 0.0001) out of 5 points after the simulation. conclusions: the simulation in this study improved the knowledge, satisfaction level, and self-efficacy of the residents for io access. the success rate of confirmation of io access in this study was 100%. this experience may positively affect their clinical performance in trauma care. case history: case 1. a 37-year-old white man presented to the ed complaining of intense abdominal pain and vomiting. he referred at least two previous episodes with associated fever which resolved spontaneously. case 2. a 35 years old white man consulted at the ed for intense abdominal pain, nausea, anorexia and constipation for the last 48 h. none history of abdominal surgery were registered. clinical findings: in both cases, the abdomen was distended without bowel sounds. investigation/results: case 1. abdomen xr: distended small bowel loops localized at the right side. ct scan: an encapsulated cluster of dilated small bowel loops into the ascending mesocolon. case 2. ct scan: an encapsulated nonrotated small bowel in the right side of transverse mesocolon and mesenteric vascular pedicle displaced. diagnosis: intestinal obstruction secondary right paraduodenal hernia therapy and progressions: emergency midline laparotomy that evidenced a rpdh which was reduced before closing the mesentery defect. the postoperative was uneventful. comments: paraduodenal hernias are a type of internal hernia and a rare cause of intestinal obstruction accounting for about 0.5% of all hernias. right paraduodenal hernias are far less common than left ones. symptoms of paraduodenal hernias are nonspecific. preoperative diagnosis of pdh by imaging techniques is difficult. contrastenhanced ct scan is highly recommended as the most specific method of diagnosis for pdh. with the increased use and improved enhancement of ct scans, paraduodenal hernias currently can be diagnosed preoperatively. this advancement in diagnostics coupled with increasing experience and facility of general surgeons in using laparoscopic techniques has led to the initiation of laparoscopic repair of internal hernias. case history: a 52-year-old female patient who goes to the emergency department due to vomiting and abdominal pain. since the accident, the patient reported post-prandial discomfort and gastroesophageal reflux, as well as self-limited abdominal cramps. clinical findings: soft, depressible abdomen. bowel sounds on left hemithorax. investigation/results: cxr: right hemidiaphragm elevation. lab test: leukocytosis. thorax and abdomen ct: right anterior diaphragmatic hernia and passive atelectasis secondary to ascent of dilated small intestine and colon. diagnosis: intestinal obstruction secondary post trauma diaphragmatic hernia. therapy and progressions: emergency laparotomy due to symptoms compatible with intestinal obstruction secondary to incarcerated diaphragmatic hernia. it is right diaphragmatic chronic rupture chronic with omental incarceration, antrum, small bowel and ascending colon with reversible signs of suffering. chelotomy and content reduction, herniorrhaphy with loose spots with non-absorbable material are performed. endothoracic drainage is left removed at 48 h. the postoperative course is uncomplicated. comments: trauma events should be considered in the diagnostic process to avoid delayed treatment. case history/clinical findings: we present a 61-year-old male patient with a history of large pelvic mass in the rectum-prostate space under study, since 4 months. he were admitted into the emergency unit, 3 days after the mass biopsy, with fever up to 40°c and rectorrhagia. the patient rapidly developed septic shock with hemodynamic instability and elevation of acute phase reactants. abdominal ct was performed: pelvic mass of 11 9 9.3 9 12.5 cm, of heterogeneous content, with areas of blood density. we decided doing an emergency surgical exploration of this mass as the only suspected origin of infection. investigation/results: in the surgical exploration the mass was protruding on the anterior rectum wall. the mass was drainaged with an output of 400 ml of purulent material mixed with clots and necrotic tissue. foley no. 22 probe was placed inside the cavity. in the postoperative period, the patient showed significant hematochezia, so he was reoperated performing hemostasis and rectal tamponade. it was effective and a new foley catheter was replaced at 24 h. when the purulent drain gave way, the catheter was removed and the patient evolved favorably. diagnosis: cytology analysis: mesenchymal type lesion, morphologically and immunophenotypically compatible with gist (gastrointestinal stromal tumor). ihq profile: cd34, dog1, c-kit positive. therapy and progressions/comments: the complications of gist are usually acute abdomen due to peritonitis secondary to perforation or hemorrhage. however, the formation of intratumoral abscesses is very inusual, although is described in the literature. emergency surgery is often necessary due to the significant affectation of the general condition of the patient and the difficulty of the diagnosis. fournier's gangrene (fg) is a surgical emergency defined by an obliterating endarteritis of the subcutaneous tissue arteries of infectious etiology, with progressive necrotizing fasciitis of the perineal, abdominal, thoracic or lower limbs, which can lead to multiorgan failure. a 75 years old woman was admitted in our er presenting with a 1 week worsening vulvar pain. clinical exam showed vulvar and mons venus erythema, without lesions, bp was 111/47 mmhg and she had a fever of 38.2°c. blood work showed leukocytosis (27.68 9 10 3 /ll), neutrophilia (25.8 9 10 3 /ll) and crp of 387 mg/ l. past medical history of obesity, right thp and total thyroidectomy. vulvar cellulitis was the initial diagnosis and empirical atb was implemented. on d2, due to an evolution into septic shock and spread of an emphysematous inflammatory process to the right thigh and buttock, the diagnosis of fg was made. during emergent surgery we observed extensive fascial and tissue necrosis from the asis and suprapubic region to the proximal third of the right thigh and perineum. extensive necrosectomy, drainage of purulent exudate and transversostomy were performed. empirical second-line broad-spectrum atb was started. she underwent new necrosectomies and surgical debridements on po days 2 and 4 and needed icu stay for 5 days. daily dressing changes were performed with povidone iodine and later with octenidine. microbiology sample showed polymicrobial infection with gram positive and negative organisms as well as anaerobes, thus confirming the diagnosis of fg type i of vulvar origin. after surgical and hd stabilization, the patient underwent plastic reconstructive surgery, with local flaps and partial skin graft. the postoperative period was uneventful and the outcome was great. introduction: appendicitis is not uncommon in the elderly but may often be mis-diagnosed [1] . the aim of this study was to explore the specific traits and treatments of this group in a swedish context to better understand where to optimize the management. material and methods: all acute appendectomies registered in the southern general hospital registry between january 2015 and june 2019 constituted the cohort (n = 2687). patients were stratified into two groups; c 65 and \ 65 years of age. significances were computed with pearsons chi2 and anova. results: the older group made up 8% of the study population (n = 214). the elderly population was female to a larger extent (or 1.57, p \ 0.05), triaged higher in the emergency department (p \ 0.05) and had higher asa classifications (p \ 0.05). the elderly were also perceived as sicker at the time of decision for surgery, expressed as having higher priorities for surgery (p \ 0.05). no significant difference between the groups in time from arrival to decision for surgery was found, nor for the time from arrival to surgery. there was a higher rate of perforations in the elderly group (53.8% vs 25.0%, p \ 0.05), twice the length of hospital stay (p \ 0.05) but no significant differences in complication rates (9.2 vs 5.8%, p = 0.71). twenty-eight day mortality rate was 0% in the younger group and 1.9% in the older group (p \ 0.05). conclusions: this study shows that an elderly group of appendicitis patients are more frail and more acutely sick when presenting to the hospital. in spite of higher priority for surgery, the elderly experience longer hospitalization and higher mortality rate, but not more complications. the findings are consistent with antecedent research. introduction: existing evidence points towards the notion that patients undergoing emergency surgery receive a poorer consenting quality when compared to their elective counterparts. with 70,000 cholecystectomies in england a year, cholecystectomy is one of the most frequently performed procedures both in the emergency and elective settings. however, to date, no studies have explored the relationship between consenting quality and the setting of cholecystectomy. we aimed to measure the quality of informed consent (ic) for patients who underwent emergency vs elective cholecystectomy. material and methods: the final review included the analysis of 174 ic forms completed between 2011-2017. percentage proportions were calculated to demonstrate the degree of completeness of consenting against a total of 57 components of information. binary regression was utilised for subgroup analysis. results: patients undergoing emergency surgery were more likely than elective patients to be warned of severe perioperative complications such as cardiac disorders (46.6% vs 25.9%, p = 0.038), fluid collection (46.6% vs 25.9%, p = 0.010), and infected bile spillage (8.6% vs 1.7%, p = 0.049). elective patients were more likely to be counselled about the risk of less serious side effects of cholecystectomy such as diarrhoea (19.8% vs 3.4%, p = 0.027). patients in asa 2-3 group were more likely to be counselled about the occurrence of pulmonary embolism. interestingly, patients were more likely to receive a patient information leaflet if they were females and under 60. conclusions: the results of this study demonstrate multiple inconsistencies in the level of disclosed information to patients undergoing cholecystectomy. the results suggest that the consenting physicians make assumptions regarding the information that the patient would like to receive based on patient demographics and clinical factors, highlighting the need for more consistent consenting procedures. acute calculous cholecystitis and the timing of cholecystectomy: advocating early surgery i. moutsos 1 , r. lunevicius 1 1 liverpool university hospitals nhs foundation trust, general surgery, liverpool, united kingdom introduction: cholecystectomy cures acute calculous cholecystitis (acc) in nearly all patients and, according to nice, augis, tokyo and wses guidelines, should be conducted at the earliest opportunity, within 7 days of the diagnosis. the present audit aimed to measure whether the care of patients with acc meets the standards of best practice and to assess whether early cholecystectomy was a more beneficial and safer intervention as compared to delayed cholecystectomy. material and methods: a ''snapshot'' sample of 50 patients operated on between 12/2018 and 06/2019 with an index admission diagnosis of acc was reviewed. the selected patients were divided into three subgroups according to the timing of their surgery: 1-7 (early), 8-28, and[ 28 days. the other measures used in this audit were the rates of conversion to open surgery, subtotal cholecystectomy (stc), perioperative complication-specific morbidity, secondary interventions, and admission to intensive therapy unit (itu). results: nine patients (18%) underwent early cholecystectomy-laparoscopic (n = 8) or primary open (n = 1); 40 of the other 41 patients-delayed laparoscopic cholecystectomy. the rates of stc were similar in both subgroups-11.11% (1/9) vs 9.76% (4/41). delayed cholecystectomy was related to five side effects: higher rates of postoperative collections (three patients, 7.32%), external bile leak (one patient, 2.44%), ercp (2.44%), emergency re-operations (two patients, 5.56%), and admission to itu (5.56%). they all occurred in the delayed [ 4 weeks surgery subgroup of 36 patients. conclusions: although no significant associations were found when comparing early to delayed cholecystectomy, this analysis shows that postoperative morbidity, the rates of secondary interventions and admissions to itu were higher when surgery was delayed. this audit advocates that early cholecystectomy should become a standard of practice as per national and international guidelines. esophagopericardial fistula following primary repair for chronic esophageal ulceration presenting with pericardial tamponade: a case report and outline of management and treatment case history: a 54-year-old man with chronic esophageal ulcerations presented with substernal pain, fever, and shortness of breath. a radiograph revealed a right pleural effusion and pneumomediastinum consistent with an esophageal perforation (fig. 1 ). he underwent a right thoracotomy, primary esophageal repair with intercostal muscle flap buttress, and gastrojejunostomy feeding access. a post-procedural gastrograffin study demonstrated an anastomotic leak (fig. 2) . a right thoracostomy drain was placed for diversion. the patient was discharged home and returned 10 days later. clinical findings: he presented with substernal pain, hypotension, and fatigue. thoracic computed-tomography (ct) revealed a pneumopericardium and an esophagopericardial fistula (epf) manifesting as pericardial tamponade (fig. 3) . diagnosis: epf. therapy and progressions: the patient underwent a subxiphoid pericardial window and mediastinal drain placement for decompression. an esophagogastroduodenoscopy revealed an exposed right atrium, thus precluding esophageal stenting. sepsis and antibioticassociated clostridium difficile colitis complicated his post-operative course. once resolved, the patient underwent a partial esophageal resection, epf ligation, and esophagogastrostomy. the postoperative gastrograffin study did not demonstrate an anastomotic stricture or leak. the patient tolerated a regular diet and was discharged home. comments: esophagopericardial fistula is a rare clinical entity most often caused by benign disease. prompt diagnosis and treatmentpericardial decompression and fistula ligation-is critical. due to wide use of proton pump inhibitors and development of interventional radiology (ir), causative reasons are changing. introduction: secondary peritonitis yields high morbidity and mortality rates. besides rapid source control, adequate antimicrobial therapy is essential to improve outcomes. thus initial empiric therapy has to take suspected germ spectrum as well as possible resistance rates into account. microbial selection and resistances may pose problems during prolonged administration of antibiotics. however, a possible negative effect of multi-resistant germs on mortality has not yet been clarified. the choice of a suitable antibiotic and the relevance of its efficacy on isolated germs as well as the relationship between germ spectrum and clinical condition of the patients need to be clarified. material and methods: intraabdominal swabs from consecutive patients from 2010 to 2018 requiring intensive care due to secondary peritonitis were evaluated retrospectively. patient characteristics and outcomes, germ spectrum and resistance rates were collected. changes over the course of therapy and development of resistance as well as influences on the clinical course were analyzed. introduction: complicated intra-abdominal infections (c-iai) represent challenging diseases with high mortality rates. depending on different selection criteria and therapy strategies the reported mortality rates vary between 7.6 and 36%. usually a distinction between community (cap) and hospital acquired peritonitis (hap) is made. hap can further be classified as postoperative peritonitis (pop) or non-postoperative peritonitis (hap-non-pop). we conducted a retrospective analysis of patients with c-iai requiring intensive care therapy. material and methods: all patients with c-iai requiring surgery and intensive care treated at the danube hospital in vienna from 2010 to 2018 were retrospectively analyzed. a total of 195 patients where included into the study and grouped as cap, hap-non-pop or pop. for each group comorbidity and patient characteristics, source and cause of infection, hospital and icu stay, apache ii, saps ii and sofa-scores, mortality and outcome were calculated and compared to each other, using fisher exact test or mann-whitney-u-test. results: a total of 195 c-iai were treated, consisting of 37.3% cap, 12.7% hap-non-pop and 50% pop. concerning the patient characteristics and comorbidities no significant differences were seen between the groups, except for malignant diseases which were significantly higher in pop. the postoperative (source control) apache ii and saps ii values did not differ between cap and pop (apache ii mean: cap 13.5, pop 13.29) whereas both were significantly higher in hap-non-pop (apache ii mean: 16.32). mortality rates were not significantly different in cap and pop (34.2% vs. 36.26%): however, hap-non-pop was complicated by a nearly doubled death rate (57.14%). conclusions: although patients with pop are described to have a higher mortality in the literature, this could not be shown in our study. postoperative survival was comparable between cap and pop patients. hap-non-pop demonstrated a significantly higher mortality. acute appendicitis and acute diverticulitis presenting concurrently treated surgically and conservatively clinical findings: on examination the abdomen was soft but there was tenderness and guarding in the right iliac fossa and suprapubic region. her observations were stable on admission and she was afebrile. investigation/results: laboratory tests demonstrated a wcc 24.79 (9 10 9 /l) and crp of 57.5 (mg/l). urinalysis was normal. a ct of the abdomen and pelvis with intravenous contrast demonstrated acute appendicitis with non-perforated sigmoid diverticulitis (fig. 1, fig. 2 ). diagnosis: concurrent acute appendicitis and non-perforated sigmoid diverticulitis. therapy and progressions: the patient underwent a laparoscopic appendicectomy. intraoperative findings included a retrocaecal inflamed appendix and diverticulitis in the pelvis which was not disturbed. there was no pus in the pelvis. she recovered well postoperatively and was discharged home to complete one week of oral antibiotics the following day. the histology demonstrated acute appendicitis. comments: there are very few reports in the literature of concurrent appendicitis and sigmoid diverticulitis despite these two pathologies being amongst the most common presentations of abdominal pain. this case demonstrates the value of cross sectional imaging, ct imaging is a helpful diagnostic tool and is highly sensitive and specific for both diverticulitis and appendicitis.the challenge in this case is balancing the two differing managements of these two conditions. most cases of diverticulitis are managed conservatively with dietary modification and antibiotics. operative management is only usually considered if there are associated complications such as intraabdominal perforation. this is in contrast to appendicitis where the standard treatment is to undergo surgery. references millions of people die from major trauma annually. 30-40% of these deaths are due to exsanguination, with nearly half dying prior to hospital arrival. when properly managed, these deaths are preventable. this paper summarizes data relating to the extent of hemorrhage as a cause of mortality in the traumatic arena. an overview of the pathophysiological steps occurring during massive bleeding and their clinical implication is presented. a variety of treatment options, both historical and current, is then discussed, including vascular occlusion methods and hemostatic dressings, along with their limitations and complications. finally, woundclot, a new hemostatic gauze, is introduced, which not only requires no compression when it is applied, but allows the first responder to rapidly and effectively treat more than one casualty within seconds. additionally, it is adaptable to a wide array of clinical applications, both traumatic and surgical, including situations where vascular occlusion methods are not practical or are contraindicated. i am the clinical research administrator for core scientific creations treating acute colonic diverticulitis with extraluminal pericolic air; a multi-centre retrospective cohort study background: since the emergence of acute care surgery as an entity encompassing trauma and emergency general surgery there have been several studies evaluating patient outcomes noting a higher unexpected survivorship and expedited operative times, shorter hospital stays, and fewer complications for patients undergoing procedures such as appendectomy; however, these superior outcomes have not been demonstrated across the array of emergency surgical cases. the aim of this investigation is to determine whether patients operated on by acute care surgeons in a trauma center benefit from the trauma model of in-house availability, earlier availability of surgical care, and care dictated by evidence-based protocol. we examined our health care system's data to determine if trauma centers were to able to provide more timely care with improved outcomes, by focusing on truly emergent general surgery cases. this was examined by identifying and quantitatively comparing time to operative intervention, need for re-operation, hospital length of stay, duration of stay spent in intensive care unit, and patient disposition at time of discharge. methods: this is a retrospective cohort study. patients presenting with emergency general surgery conditions (incarcerated hernia, perforated viscus, sbo, necrotizing soft tissue infection) who underwent surgery within 24 h of presentation were selected. outcomes were compared between patients presenting to our two trauma centers versus our two non-trauma centers. n = 1600 results: at this time we are nearing the finalization of our data interpretation. we are examining mean time to operation, los, icu los, need for re-operation, and disposition at discharge. discussion: although our data analysis is not complete we feel that the results of our data will shed valuable and needed light onto the care delivered to emergency general surgery patients by surgeons in this increasingly complex population. anastomosis leakage after hartmann removal, with conservative treatment at the beginning but after, bad evolution, a surgery was performed with colostomy and vac system. 3 patient. after 24 h, he develop a compartmental syndrome and a vac system was applied. investigation/results: 1 patient. after the first change the distance between the two layers was 18 cm and botulinum toxin was applied. 2 pat. the distance between the two layers of abdomen was 20 cm and botulinum toxin was applied. 3 patient. the distance between the two layers was 18 cms and toxin was applied. unfortunately, he suffered from a hepatorenal syndrome and died. diagnosis: open abdomen with distance between the two layers: 18 cm, 20 and 18 cm. therapy and progressions: we have added botulism toxin with doses of 20 units in each side of abdominal wall. 1 patient. three changes after, the abdomen wall was closed. 11 months later, the abdominal wall is ok. 2 patient. a reduction of 50% was got. comments: the use of open abdomen in patients suffer from septic shock or after an abdominal compartment syndrome often poses a challenge in the abdomen closure. we have developed a protocol, dividing our patients according to the distance between the two layers in two group: more than 10 cm or 10 cm or less. in the first group ([ 10), we present our first 3 cases in our protocol. conclusions: botulinum toxin can make easier abdomen closure when the distance between the two layers is more than 10 cms incidentally discovered splenic peliosis in a patient with no comorbidity clinical findings: a 51-year-old man with no comorbidities visited our emergency medical center based on a complaint of chest pain. the chest and abdomen radiographs, electrocardiogram, and cardiac markers showed no abnormalities; therefore, he was discharged from the hospital. two months later, he returned to our hospital with abdominal pain and distension. he was hemodynamically stable, and there were little tenderness and rebound tenderness on his abdomen, although he complained a slight abdomen discomfort investigation/results: no abnormalities were found on the laboratory examinations, including complete blood cell count, cardiac markers, and coagulation profile. an abdomen computed tomography revealed multiple hemorrhagic cysts on spleen with moderate amount of hemoperitoneum. diagnosis: ruptured splenic peliosis with hemoperitoneum. therapy and progressions: laparoscopic splenectomy was done because recurrent rupture of hemorrhagic cysts was strongly anticipated. on histologic examination, the blood-filled cysts were welldemarcated, distributed in red pulp congestion. no vascular-endothelial cells were observed, and normal lining cells were disappeared in the wall. comments: a peliosis is a rare disorder characterized by widespread, blood-filled cystic cavities within the parenchymatous organs. the liver is the most commonly involved organ, and an isolated splenic peliosis is extremely uncommon. patients are often asymptomatic; therefore, early recognition and withdrawal of offending agents is crucial. in cases with the rupture of surface lesions, which can occur spontaneously or by the minor trauma, prompt surgical management is necessarily required. splenectomy offers the advantage of a definite histological diagnosis with the complete elimination of the risk of recurrent hemorrhage. introduction: despite an evident success and advantages of endoscopic surgery, the discussion on reasonability of endoscopic surgeries in children with acute appendicitis is still going on. purpose: to assess the effectiveness of laparoscopic techniques for treating appendicular peritonitis in children. material and methods: 149 children with appendicular peritonitis were operated in our hospital (2016) (2017) (2018) . they aged 1-17 years (11 ± 3.5); 65.2% of boys, 34.8% of girls. appendicular peritonitis was registered in 7.7% cases of acute appendicitis. three ports were used for the approach: appendectomy was performed by the ligature technique with roder loop. results: laparoscopic surgery is indicated in all forms of appendicular peritonitis, except appendicular abscess stage 3, and total abscessing peritonitis. in appendicular abscess stage 3, we perform a puncture and drainage under ultrasound control. 3-6 months later appendectomy is made. total abscessing peritonitis is an indication for laparotomy. laparoscopic surgery in patients with peritonitis has the following stages: diagnostic laparoscopy; sanation of the abdominal cavity by the aspiration of purulent exudate; ligature appendectomy; in diffuse and combined peritonitis a pelvic aspiration drainage is made. in appendicular abscess stage 2, we additionally put the aspiration drainage in the cavity of destructed abscess. conclusions: laparoscopic technique applied for surgeries in children with acute appendicitis has considerably improved outcomes introduction: nighttime emergency surgery is associated with increased postoperative morbidity and mortality [1] , and delayed appendectomy due to acute appendicitis is not linked to a higher rate of postoperative complications (pc) [2] . the aim of this study was to determine whether appendectomy on-call (oc) was associated with higher risk of pc. (1) (2) (3) (4) (5) (6) (7) (8) . two patients underwent major thigh amputation. negative pressure wound therapy and hyperbaric oxygen therapy were used in 15 and 7 patients, respectively. three patients died (mortality rate = 12%). conclusions: the mortality and major amputation rates (12% and 8%, respectively) were lower than those reported previously. in this study, even when patients had multiple organ failure or septic shock, major amputation was not always needed because of effective communication between the infection control team and intensive care specialists, resulting in radical debridement without amputation. material and methods: a systematic search in pubmed/medline, embase, cinahl and central was performed. the primary outcomes were mortality and amputation. these outcomes were related to the following time related variables (1) time from onset symptoms to presentation; (2) time from onset symptoms to surgery; (3) time from presentation to surgery; (4) duration of the initial surgical procedure. for the meta-analysis, effects were estimated using random-effects meta-analysis models. results: a total of 109 studies (6051 patients) were included for qualitative analysis, of which 1277 patients died (21.1%). a total of 33 studies (2123 nsti patients) were included for the different quantitative analyses performed. mortality was significantly lower for patients with surgery within 6 h after presentation compared to when treatment was delayed more than 6 h (or 0.43; 95% ci 0.26-0.70). surgical treatment within 6 h resulted in a 19% mortality rate compared to 32% when surgical treatment was delayed more than 6 h. also, surgery within 12 h reduced the mortality compared to surgery after 12 h from presentation (or 0.41; 95% ci 0.27-0.61). patient delay (time from onset of symptoms to presentation or surgery) did not significantly affect the mortality in this study. none of the time related variables assessed reduced the amputation rate. conclusions: average mortality rates reported remained constant (around 20%) over the past 20 years (fig. 1) . surgical debridement as soon as possible lowers the mortality rate for nsti with almost 50%. thus, a sense of urgency is essential in the treatment of nsti. altemeiers procedure in an emergency setting case history: three patients with irreducible incarcerated rectal prolapsed were referred to our department for treatment. all patients were female and their age was 57, 82 and 85 years old. all patients suffered from severe co-morbidities. clinical findings: all patients presented with incarcerated rectal prolapse. in one patient there was macroscopic evidence of mucosal necrosis, whereas the other two patients had evidence of ischemia. the former patient was febrile whereas the latter did not exhibit signs or symptoms indicative of sepsis. investigation/results: blood panels demonstrated leukocytosis and elevated levels of c-reactive protein (crp) in all patients. apart from routine imaging upon admission (e.g. chest radiography), no other imaging modalities were performed. diagnosis: irreducible incarcerated rectal prolapse. therapy and progressions: initially manual reduction of the prolapsed was attempted without success. all patients were evaluated as high risk surgical candidates. altemeier's procedure was selected as a safer alternative to an abdominal approach. all patients were successfully discharged after resumption of bowel function. comments: incarcerated rectal prolapse is a rare clinical condition. initial management involves manual reduction of the prolapse. when this is not feasible, urgent surgical management is mandatory. in patients with severe co-morbidities, altemeir's procedure is a safe and effective treatment when performed by an experienced practitioner. introduction: treatment options for sigmoid volvulus are decided by its severity. uncomplicated cases are usually treated by endoscopic detorsion followed by elective surgery and complicated cases or cases can't be detorsioned are treated with emergency surgery. in this study we aim to review a single center experience in long term management of sigmoid volvulus cases. material and methods: data of the sigmoid volvulus cases between 2009-2018 were collected using hospital database. files of 57 patients were reviewed for treatment modalities, demographic info and complications. 4 patients were dropped from the study due to inadequate long term follow-up. results: 37 were men and 16 were women. mean age was 54,9. endoscopic detorsion was attempted in 30 cases. success rate was 90% (n = 27). 10 of these patients were followed up with elective surgery. 23 patients with complicated cases and 3 unsuccessful detorsion patients were managed by emergency surgery. 16 hartman procedures, 10 anterior resections, 2 left hemicolectomies, 1 subtotal colectomy and 2 transverse loop colostomies were done. a stoma was created in 28 cases. 22 patients had their stoma created in the primary surgery and an additional of 6 stomas were created due to anastomosis leakage. mortality rate in the first 7 days was 25% (n = 7) in patients with a stoma (n = 28). asa and charlson co-morbidity scores were exceptionally high in the mortality group. in the remaining patient group, stoma closure rate was 57.1%. conclusions: endoscopic detorsion is a powerful and highly successful management option in uncomplicated cases when done by an experienced staff. emergency surgery shouldn't be delayed in complicated cases or after unsuccessful detorsion attempts. introduction: esophageal perforation has high mortality rates when not treated aggressively. treatment options are conservative approach, endoscopic intervention and surgery. purpose of this study is to review cases of esophageal perforation in a single center and to evaluate types of diagnosis and treatment options. material and methods: using hospital database we collected data of 26 patients diagnosed with esophageal perforation between 2009-2018. we reviewed treatment modalities, demographic data and complications. 1 patient was removed from the study due to insufficient long term data. results: 13 were female and 12 were male. average age was 59.9. average time between the onset of symptoms and admission was 2.2 days. the most common etiology was iatrogenic (n = 16) followed by consumption of corrosive substances in 2 patients, spontaneous perforation in 2 patients, esophageal tumour in 3 patients and foreign body ingestion in 2 patients. 11 patients were treated surgically, 8 patients were treated with endoscopic stenting and 1 patient was treated with surgery following stenting. 5 patients were managed conservatively with antibiotherapy. average time in intensive care was 8.4 days and average hospital stay was 26.6 days. mortality was seen in 3 patients treated with surgery and 2 patients treated with stents. conclusions: esophageal perforations are mainly iatrogenic but also can be caused by multiple reasons. especially in cases developed after endoscopy, rapid intervention can be a significant factor that can decrease both mortality and morbidity rates. introduction: spontaneous rupture of liver tumors (rlt) is a rare but potentially life-threatening condition. damage control techniques, namely perihepatic packing (php), is a resource for the most physiologically compromised patients, with more stable patients undergoing transarterial embolization (tae) or immediate resection. decision algorithm depends on patient status, available resources and liver function. the authors present their center experience in managing rlt and propose a management algorithm. material and methods: eighteen consecutive patients who underwent surgery for rlt in our department (january 1988-october 2019). inclusion criteria: spontaneous rupture and evidence of intraperitoneal bleeding. fourteen patients were male. mean age of 62.6 years (35-86). thirteen patients (72%) presented in hemorrhagic shock. mean tumor size was 6.72 cm (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) . most frequent pathological diagnosis were: hepatocellular carcinoma in 12 cases (67%); adenoma in three cases (17%); metastases in two cases (11%); liver sarcoma in one case (5.6%). median of seven units transfused by patient (0-25). statistical analyses with spss tm version 23.0 results: six patients (33%) needed immediate surgery (php in three and resection in three). five (28%) underwent urgent ([ 2 h and \ 24 h) and seven (39%) delayed ([ 24 h) resection. hepatectomy was performed on all (fifteen minor and two major) but one patient php only. eight patients (44%) underwent tae prior to resection, two of them (11%) between php and hepatectomy. median length of stay 10 days . major morbidity in three patients (17%); mortality in three patients (17%). number of transfused units associated with increased risk of complications (p = 0.009). conclusions: rupture of liver tumors is a severe complication. although hepatic resection, with or without preoperative tae, should be considered gold standard, damage control techniques such as php are the only option for physiologically compromised patients (fig. 1) . seasonal variability of cellulitis: a five year retrospective cohort study introduction: it is commonly purported that the incidence of cellulitis is highly seasonal but there is little empirical evidence supporting this assertion. this 5 year retrospective cohort study set out to identify whether there is a statistically significant relationship between an increase in temperature and incidences of cellulitis. as a corollary to this proposition, length of hospital stay for cellulitis was examined in relation to the level of inflammatory markers upon admission and micro-organism identified on culture. material and methods: this is a 5 year retrospective single centre cohort study of all patients admitted with cellulitis to tallaght university hospital from 2014 to 2018 inclusive. the patient cohort was identified via the use of a prospectively managed database of all surgical admissions and corroborated via examination of clinical chart records. dates of admission were correlated with the average temperature of dublin as provided by the meteorological office of ireland. site of infection, inflammatory markers and the prevalent micro-organism were also identified whilst the length of admission was extrapolated from hipe (hospital inpatient enquiry) records. results: there were 710 admissions for cellulitis with 3 cases of necrotising fasciitis. there was a statistically significant (p \ 0.05) relationship between temperature and cellulitis with admission peaking in late summer/autumn. age correlated significantly with readmission. furthermore, the level of crp had a statistically significant prognostic value as an independent predictor for the length of hospital stay with a high level resulting in a prolonged admission. conclusions: there is a statistically significant relationship between a rise in temperature and the incidence of cellulitis. furthermore age is an independent risk factor for re-admission with same whilst inflammatory markers at time of admission can be used as a prognostic marker for length of stay. case history | clinical findings: a 88-year-old female patient, with history of type ii diabetes, high blood pressure and major depressive syndrome, was admitted in the emergency room department complaining of abdominal pain. based on the patient's history and physical examination, a presumptive diagnosis of renal colic was initially made. however, after 2 days, the patient showed signs of fever, aggravated abdominal pain and vomiting. investigation/results | diagnosis | therapy and progressions: a ct scan showed the presence of a radiopaque foreign body near the duodenum, the presence of air bubbles outside the intestinal lumen and an hepatic abscess. we agreed to perform a laparoscopy, drainage of hepatic abscess and fish bone removal after successfully identification. after 4 days, the laboratory findings showed persistent leukocytosis and raised cpr, which led to a second ct scan with maintenance of the hepatic abscess. the decision was to perform a percutaneous drainage. after the second drainage, the patient had an uneventful recovery. comments: foreign body ingestion into the gastrointestinal (gi) tract is rare and typically accidental in adults. most ingested foreign bodies pass through the gastrointestinal tract without the need for any intervention. gi perforation is rare and can occur at any site. surgical intervention is required in less than 1% of the cases. fish bones are the most commonly ingested objects. preoperative diagnosis, when possible, is made with ct scan, identifying a linear high-density structure. high level of suspicion is of paramount importance. in cases of delayed diagnosis, perforation may lead to intraperitoneal abscess formation. reports of hepatic abscess secondary to fish bone perforation has been limited to isolated case reports in the literature. case history: description of two cases of appendicular goblet cell carcinoid tumors, which debuted as acute appendicitis. patient a was a 54-year-old woman with a 24-h evolution of classic symptoms of acute appendicitis. patient b was a 70-year-old female that consulted for chronic abdominal pain in rlq that recently increased pain intensity and fever. clinical findings: patient a had pain and defense in rlq without a fever. patient b had a chronic painful fluctuating mass in rlq, with fever over 38°c. investigation/results: patient's a lab test showed leukocytosis and us findings of acute appendicitis. the patient's b ctscan showed an intra-abdominal abscess fistulized to the abdominal wall, along with formation of a phlegmonous mass related to appendicular plastron. diagnosis: the anatomopathological reports for both patients were informed as appendicular goblet cell carcinoid tumor. therapy and progressions: both underwent laparoscopic exploration. after appendicectomy in patient a, when the diagnosis of gcct was made, the case was discussed at our mdt meeting and a right hemicolectomy was indicated and performed shortly after. in the patient b a right hemicolectomy was performed in the initial surgery due to the magnitude of tissue involvement. currently, both are receiving chemotherapy with xelox without signs of recurrence or tumor spread on follow up. comments: the gcc is a rare entity of appendicular tumors with a less favorable prognosis than the appendicular pure neuroendocrine tumors. it behaves like a low-grade adenocarcinoma and often presents as disseminated disease. therefore, sometimes surgical treatment with appendicectomy is not enough, needing the right hemicolectomy to avoid recurrence. this is recommended for tumors [ 2 cm, pt3 or t4 and higher grade histology. introduction: among the post-pancreatoduodenectomy complications post pancreatoduodenectomy hemorrhage (pph) is the least common complication, but severe form may be life-threatening without an urgent treatment. late pph are more likely due to a complex physio-pathological pathway secondary to different etiologies. the understanding of the etiology and such a pathway could therefore be of great interest to guide the treatment of potential lifethreatening late severe pph. results: during the aforementioned period 347 patients underwent pd, of whom 18 (5.18%) developed pph. early pph was reported in one patient (5.6%) with severe bleeding from the gastric stapler line. late pph were reported in 17 of these patients (94.4%). the most common causes were bleeding from a vascular pseudoaneurysm reported in 6 patients of which, one had mild and 5 had severe hemorrhage and bleeding from gastro-enteric anastomosis marginal ulcer in 6 patients, all with mild hemorrhage. no etiology was fond in 5 patients with mild hemorrhage. a significant association was found between the severity of late hemorrhage and the vascular pseudoaneurysm as a cause of bleeding (p \ 0.001). all pseudoaneurysm bleeding occurred in cases complicated by a postoperative pancreatic fistula (popf) with a significant statistical association (p \ 0.001). conclusions: the most common cause of pph was bleeding from a vascular pseudoaneurysm, most of them were severe bleeding with late presentation and all were associated with a popf. in these cases, early detection by cta is mandatory, allowing an urgent treatment by angiography of such a bleeding vascular complication following pd. ventral hernia in hostile situation introduction: there is no consensus about the benefit or harm derived from adding a mesh hernioplasty at the same time as an urgent intraperitoneal surgery for another cause. the use of a prosthesis in contaminated fields is controversial, but suture repair has a high risk of recurrence. the main objective has been to analyze the impact of the simultaneous repair of uncomplicated midline hernias at the same time as emergency surgery for another cause, in relation to the presentation of complications, the surgical site infection rate (isq) and recurrences. material and methods: retrospective, observational study of all urgently operated patients (surgery open and laparoscopic) in the period between 2015-2018 who underwent a simultaneous midline primary ventral hernioplasty. the background, circumstances of the surgery and postoperative complications during the first month and long term through the basis of prospective data of emergency surgery and complications of our surgery department. results: a total of 94 patients (50 female) met the inclusion criteria with a mean age of 57.2 years (sd = 17.5), average bmi of 28.7 kg/ m 2 (sd = 5.1). the most frequently performed interventions were: appendectomy (38.3%); cholecystectomy (48.9%); and lysis of adhesions (4.3%). the 89.4% of all interventions were performed by laparoscopic approach. they presented associated peritonitis in 12.8% of the cases. the 41.5% of patients presented some complication, in 13.8% surgical site infection (3.2% organ space). during the followup three recurrences were detected (3.2%), no patient has presented chronic infection related to the use of prostheses. conclusions: in our series the simultaneous performance of hernia repair of the midline in the context of emergency surgery for another cause has been safe and not associated with long-term complications and low recurrence rate. the open abdomen: our experience introduction: ''open abdomen'' refers to a solution in which the abdominal content is left deliberately exposed under a temporary cover for a variable amount of time. since 1970 this method has been used more and more for the treatment of severe intra-abdominal infections. starting from the 80s the concept has been also applied in trauma surgery. material and methods: between 2002/2019 we have treated 200 patients with this technique. in 45 cases the etiology was traumatic, in the remaining cases the abdominal pathology was inflammatory. in the last years we also started to use it in some cases of treatment of surgical complications. the techniques we used were different and changed during the time. at the beginning of the experience we've completed 4 drainages of the abdominal cavity according to mickulizt, 5 laparostomies with mesh, 18 bogota bags. these techniques have been abandoned since the negative pressure therapy came out. we started with the barker vacuum pack (36 cases), followed by the vac (vacuum assisted closure) and ab thera kci ò (33 patients) systems and in the last three years we used the cnp suprasorb ò of lohmann and raucher (104 patients case history: 79 year old lady presented at the a&e with few days history of constipation, faeculent vomiting, abdominal distension and pain in the lower abdomen. she had hysterectomy many years ago through a lower midline incision. her urgent ct scan of the abdomen and pelvis confirmed an incarcerated right obturator hernia containing a small bowel loop causing bowel obstruction. clinical findings: elderly, frail patient with mild tachycardia, distended abdomen and lower abdominal tenderness with guarding in the left iliac fossa. per rectal examination was unremarkable. investigation/results: inflammatory markers were raised, lactate, liver and kidney function was in normal limits with only mild hypokalaemia and hyponatraemia. ct abdomen and pelvis confirmed small bowel obstruction at the mid ileal level due to right obturator hernia. diagnosis: incarcerated right obturator hernia causing small bowel obstruction. therapy and progressions: patient was taken to the operating theatre for urgent laparotomy. dilated small bowel loops and incarcerated right obturator hernia was found with proximal ileal loop in it. after blunt stretching and dilatation of the obturator foramen, the involved ileal loop was reduced. it was deemed viable, therefore no bowel resection was required. the defect at the right obturator foramen was closed with suture. post-operatively the patient was transferred to the intensive care unit for further management. comments: obturator hernias are a rare type of pelvic hernias. their real incidence is unknown but it is thought to be less than 1% of all hernias worldwide and due to its non-specific symptoms and late diagnosis, they require bowel resectional surgery in nearly 50% of the cases. howship-romberg sign is helpful in diagnosing such a hernia, but the ultimate diagnostic choice is ct scanning which is the only way to find this condition early and avoid bowel ischaemia. case history: a 21-year-old woman without previous medical history presented to the emergency department with abdominal pain and dysphagia associated with nausea, vomiting and absolute constipation. during previous months, she reported having ingested hair. clinical findings: abdominal examination revealed a distended abdomen with rebound tenderness and tinkly bowel sounds. investigation/results: ct-scan showed a distended stomach with a mussel-shaped, heterogeneous and non-enhancing mass. an esophagogastroduodenoscopy revealed hair inside the lower esophagus and the stomach. diagnosis: high intestinal obstruction due to a gastric trichobezoar. therapy and progressions: the patient underwent laparotomy, gastrotomy and trichobezoar removal (fig. 3) . the postoperative period was uneventful and she was discharged home on the 8th pod with a psychiatric evaluation scheduled. comments: bezoars are rare conditions consisting of compacted material that is unable to pass through the gastrointestinal tract. 1 this condition usually involves the stomach; rarely, it can extend into the small bowel and even the colon, giving the so-called rapunzel syndrome. 2 bezoars could be composed by vegetable material (phytobezoars), hair (trichobezoars), drugs (pharmacobezoars), or other materials. 1, 3 a trichobezoar is the result of trichotillomania, trichophagia or other psychiatric disorders. 3 always consider bezoars in differential diagnosis. introduction: the effectiveness of different step-up approaches is increasingly evaluated but results are controversial. we assessed the results of a standardized step-up approach protocol in the treatment of acute severe necrotizing pancreatitis, with a special focus on patient stratification to obtain an early identification of those deserving a more aggressive strategy. matherials and methods: this is a retrospective analysis of patients with acute severe pancreatitis over a period of 10 years. the variables taken into account were: etiology and severity of the disease, sepsis, organ failure, hemodynamic stability, treatment, los, morbidity, mortality. since 2016, patients with infected necrosis underwent a standardized step-up approach: percutaneous drainage only; percutaneous and endoscopic procedure; surgery. the results were compared with the standard care delivered from 2009 to 2015. results: among 142 patients, 51 (35.9%) were identified as affected by severe necrotizing disease. overall mortality was 29.4%. the initial management was non operativein all patients. mortality in the step-up group was 20% (3/15) vs 25% (9/36) in the standard care group. conclusion: a standardized step-up approach protocol offers better results than standard care in the management of acute severe necrotizing pancreatitis. however, a better stratification of patients. introduction:the appendix stump closure in complicated appendicitis has been widely practiced in different ways such as metal clip, hem-o-lok clip, endoloop and endostapler. the treatment of complicated appendicitis with necrosis and perforation of the appendix base is controversial. we aimed evaluate the efficacy of laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and base perforation. material and methods:from january 2015 to october 2019, we evaluated 28 consecutive patients who underwent a laparoscopic partial caecum resection in complicated appendicitis with necrosis and perforation of the appendix base. partial caecum resection was performed with the endostapler to close the appendix base at ileocaecal junction. results:the laparoscopic partial caecum resection with endostapler was used in %92.8 of the cases. the mean operative time was 100.07 ± 34.12 min. there were necrosis of appendix base in 12, perforation of appendix base and diffuse peritonitis in 9, perforation of the appendix base and localized peritonitis in 7 of the patients. the wound and intra-abdominal infection rates were 9.8% and 7.2%, respectively. there were no operative complications and the conversion rate was 7.2%. the average length of hospital stay was 4.46 ± 3.10 days. there was no leakage on the stapler line. conclusions:the laparoscopic partial caecum resection with endostapler in complicated appendicitis with necrosis and perforation of the appendix base, is a safe and effective technique. introduction: the term ''''volvulus'''' comes from the latin ''''volvere''''meaning twist. if left unattended, sigmoid volvulus can compromise the blood supply of the involved segment,leading to ischemia,gangrene,perforation and death. the mainstay of sigmoid volvulus management has been through proctoscopic or colonoscopic decompression when feasible, followed by surgery either during the same admission or electively. the aim of our study is to identify patients which can benefit of immediate surgical approach and prognostic factors associated with failure of conservative/endoscopic treatment. materials and methods: charts of 27 patients admitted for sigmoid volvulus to our institute were retrospectively analysed. we revised ct scan images and laboratory tests of all the patients to identify risk factors for conservative treatment failure. results: 18 patients underwent surgical procedures; in 9 cases after a failure of an initial conservative approach; 9 patients were managed with endoscopic approach only. elective surgery was performed in 2 patients. case history: we report a 32-year-old male case presenting left hand middle finger pain after pressured paint gun shot in volar proximal phalanx clinical findings: on physical examination swelling and tenderness on the volar side of the hand was observed (fig. 1 ) investigation/results: pain was remarkably more intense with passive finger extension. distal nerurovascular status was unscathed. there was no fracture reported on radiography. leukocytosis and acute phase reactants rise was observed on laboratory examination diagnosis: after physical, radiological and laboratory examination the diagnosis of acute flexor tenosynovitis was made. therapy and progressions: open debridement and irrigation following bruner incisions on middle finger was undertaken within 4 h of injury. paint impregned in tissues could be observed in subcutaneous tissue, palmar fascia and flexor tendon sheath. paint affected tissues samples were analysed in microbiology laboratory (fig 2, 3) after checking nerurovascular indemnity, 14g drainage was left in deep tissues and skin suture was performed with 4-0 monofilament non absorbable suture. the patient followed 3 days intravenous antibiotical therapy followed by 4 weeks oral treatment. he attended physiotherapy program postoperatively, reporting no functional disability or wound complications after 3 weeks. comments: chemical flexor tenosynovitis is an important emergency which must be correctly diagnosed and treated due to quick progression and potential morbidity if not treated effectively (1) in our experience, case was managed by open debridement and irrigation but different treatments can be followed depending of patientsclinical situation, such as iv antibiotics with serial examinations or percutaneous drainage. it should also be noted that australia does not have a specific subspecialty in emergency surgery. the acute surgical unit at the tch was set up in 2010 in order to provide a dedicated acute unit to service the ever increasing demand acute surgery. previous model was that the acute surgical service was integrated into the elective work. 16 additional beds were provided to the unit including the positions of a dedicated director and chief nurse. the achievement of the unit has been the decreased time to theatre, less after-hours operating, standardised treatment approaches, and dedicated emergency surgery medical staff. the difficulties have included clinician engagement, competing resources with elective surgery, emergency surgical presentations increasing by 3-6% each year, and the unit''s beds being used for non-acute patients as the hospital approaches regular 100%. the acute surgical unit has evolved into a specialised acute care that enables rapid assessment and treatment of patients with staff dedicated with skills in this area. treating pyogenic liver abscesses secondary to diverticulitis in a patient using immunosuppressants for crohns disease by performing a sigmoid colectomy introduction: pyogenic liver abscess (pla) formation due to microbial contamination of the liver parenchyma is often seen secondary to intra-abdominal infections. pla formation due to crohn''s disease (cd) is a rare complication and not well-documented in current literature. as symptoms often mimic a cd exacerbation, diagnosis is often delayed and severe disease may develop. optimal treatment for this group of patients remains debatable. case presentation: a 54-year-old man was admitted to the hospital with a 2-week history of overall malaise, fever and night sweats. patient''s history solely stated a 6-year treatment of cd that was stable over the past period with infliximab and azathioprine. investigations and treatment: biochemical analysis revealed a c-reactive protein of 314 mg/l and a white blood cell count of 15.3 9 109/l. an abdominal ct scan showed multiple abscesses in the right lobe of the liver and a thickening of the wall in the transition of the descendent colon to sigmoid. the patient''s immunosuppressants were paused, intravenous antibiotics were administered and a percutaneous drainage of the biggest pla was performed. however, the clinical condition of the patient did not improve. colonoscopy and pet-ct scan did not reveal any other sites of infections. as patient remained septic and previous imaging revealed mild diverticulitis rather than active cd, an emergency hartmann''s procedure was performed. hereafter, the patient recovered rapidly and the plas resolved completely. conclusion: diverticulitis of the sigmoid colon should be considered as causative pathology in patients presenting with multiple pyogenic liver abscesses and a history of crohn''s disease that is in full remission with immunosuppression. when the abscesses exceed 3 cm in size and are multilocular, resection of the inflamed colon can be a treatment option of value. clinical findings: epigastric pain and recent episode of hematemesis. pain at deep palpation of the epigastrium, no signs of peritoneal irritation investigation/results: abdominal x-ray and ct showing a large right sided strangulated paraesophageal peh, with pneumatosis of the gastric wall diagnosis: right sided strangulated peh therapy and progressions: emergent laparotomy. peh reduced, ischemic portion of the stomach recovering viability. closure of diaphragmatic defect with non-absorbable suture, reinforcement of lower esophageal sphincter with round ligament (ligamentum teres hepatis) and anterior partial fundoplication (dor). postoperative course uneventful, patient discharged on 10th pod. comments: peh are mediastinal displacements of abdominal organs, most often the stomach, associated with laxity or a hole in the phrenoesophageal membrane, large enough to allow the gastric fundus to herniate. because the stomach is attached to the gastroesophageal junction, it tends to rotate around its axis leading to organoaxial volvulus. occurrence and size increases with age. peh account for 5-15% of all diaphragmatic hernias. in patients without prohibitive operative risk, they should be surgically corrected, avoiding the risk of acute and potentially life-threatening complications when emergent surgical repair is required. the risk of developing these complications is less than 2%/yr and associated mortality rate is approximately 5%. case history: patient was a previously healthy 40-year-old female with an unremarkable past medical history, non-smoker with a high body mass index (bmi [ 30). she first presented to a level 2 medical facility with acute left upper leg pain and swelling. one week prior to this she had a progressive cough, swinging fever, and malaise. clinical findings: patient was transferred to our hospital haemodynamically unstable, acidotic, hypoxemic and delusional. tachypnea and oliguria were present. she continued to deteriorate clinically with pyrexia (t 39,3 oc), resistant shock, and toxaemia. on examination her left leg was found to be paresthetic below the femoral-inguinal fold. investigation/results: abg samples showed lactic acidosis with a ph of 7.32 and lactate of 3.2 mmol/l. hypoxia and hypocapnea were present.her biochemical profile showed acute kidney injury (aki) with raised creatinine kinase (cpk) 850 and serum creatinine (cr) 2.08. chest x-ray illustrated bilateral lung infiltrations (ards image). diagnosis: patient was urgently referred to a ct scan of the left femur with i.v. contrast for suspected necrotising fasciitis. ct findings highlighted a deep muscular femoral abscess with multiple regional fluid collections and necrotizing inflammation from the femur diaphysis to the patella. therapy and progressions: the patient was immediately transferred to or for emergency surgical exploration and debridement. almost the entire anterior compartment of the femur was necrotic and hence an extensive excision of the dead tissues and packing with npwt was performed. comments: severe snm can cause marked systemic toxic effects, namely, the streptococcal toxic shock syndrome (stss). stss secondary to snm is a life-threatening host response to gas superantigens with a mortality rate as high as 80%. clinical findings: patient had a diffusedlty tender abdomen and had not passed flatus proceeding his admission to the a ? e department and was vomiting. investigation/results: ct abdomen showed small bowel dilatation with abrupt cut-off point proximal to the icv diagnosis: a diagnosis of small bowel obstruction was made based on the clinical and ct findings. therapy and progressions: patient was taken to theatre for laparoscopy ? -proceed and a 'slipped' bowel lopp was noted within the peritoneal flap that had been created a week prior during the original hernia repair. the 'v lock'' suture line was found to be loose which is thought to have led to this complication. the bowel loop was reduced, deemed viable and an internal hernia repair was performed. post-operative period was unremarkable and the patient was discharged day 3 posy-operatively. comments: during lap tapp hernia repair, there are currently at least 3 options avaiable for peritoneal flap closure; (sutures, tackers and glue.) suregons prefernce prevails over the chosen approach. when sutures are chosen, most surgeons prefer the self-locking v-lock stitch. by adopting this technique, meticulous periotneal closure is impoartan, as loose suturing of the peritoneum can lead to post operative complications of internal herniation and small bowel obstruction, as described in this case. a multi-centre prospective study would be welcomed, to compare efficacy and safety of all types of peritoneal closure devices. introduction: peer review assessment of medical treatment has been shown to be a robust way of improving quality of care in trauma in our institution and globally. in 2016 we introduced regular morbidity and mortality meetings at the department of gastrointestinal surgery. severe complications (revised accordion classification [ 3) after surgery were identified on a weekly basis, evaluated and data included in a local quality registry with the aim of revealing suboptimal surgical quality and continuously improving our results. material and methods: retrospective analysis of collected data from the described quality registry. all adult patients who had undergone gastrointestinal surgery in 2018 were assessed. results: of 2091 surgical procedures performed, 70% were emergency procedures. a total of 11% (239/2091) experienced a severe complication after surgery and 6% (125/2091) required reoperation. in the group of upper gastrointestinal surgery [n = 570 (27%)] 59% were emergency procedures. anastomotic leak (al) was identified in 15% (9/59) undergoing thoraco-laparoscopic esophagectomy and in 8% (3/36 patients) after gastrectomy. of 190 laparoscopic cholecystectomies, 79% were emergency procedures with 1% (1/151) reoperation. of 106 hernia repairs, 5% required reoperation. in the group of lower gastrointestinal surgery [n = 1521 (73%)] 74% were emergency procedures. al was diagnosed in 5% of 257 colonic resections and 11% of 87 patients after rectal resection. in emergency colorectal resections(n = 30) there were no al. of 497 appendectomies, 5 patients (1%) required reoperation. the most frequent cause of reoperation was revision of stoma (26), followed by reoperation for al (25), abscess (19), and wound dehiscence (13). 17 patients died after surgery of which 15 were emergency surgical patients. conclusions: systematic assessment of all severe complications helps reveal surgical procedures which can be improved but also to identify surgical procedures with low complications rates. plans are being developed to improve the quality of the identified procedures. all surgical departments should have regular and thorough assessment of their activity. acute surgical patients operated by emergency surgeons has less risk of post-operative complications and mortality d. gumaa 1 1 east kent hospitals university nhs foundation trust, general surgery, ashford, united kingdom introduction: in england and wales, we perform over 300,000 emergency laparotomy every year. 30 days mortality rate is around 10-11%. in our study we are trying to demonstrate if have dedicated emergency surgery service will make a difference in the outcome of emergency laparotomy. material and methods: retrospective study on prospectively collected data from nela database done in a large district general hospital. all patients over 18 years old who underwent emergency laparotomy for acute surgical condition between november 2017 and january 2019 were included in the study. mortality and post-operative complications were the primary outcomes. results: total of 191 patients were included in the study, 114 operations were performed by emergency surgeons (es). 30 days mortality rate was 9%, while it was 12.8% for the none emergency surgeons group (nes) post-operative complications were 13.1% compared to 15% for patients operated by nes. there was shorter itu stay with average of 2.8 days, while the itu stay for the other group was 3.3 days, but the es group had higher chance of unplanned return to theatre. 7.6% of the patients went back to theatre compared to 6% of the other group. reasons of unplanned return to theatre was mainly post-operative collection or wound dehiscence. conclusions: emergency surgeons has better outcomes when they perform emergency laparotomy, may be because they perform higher number of laparotomy compared to their peers. emergency surgery has been a growing subspeciality recently, and with no doubts having surgical emergency units has improved the patient's care around uk. the advantage of 2 g over 1 g of prophylactic cefazolin in surgical site infections in trauma surgery below the knee introduction: the rate of surgical site infections(ssi) after foot/ankle surgery remains high, despite the implementation of antibiotic prophylaxis (1) . recently guidelines suggest a single dose of 2 g instead of 1 g of cefazolin for implant surgery, this decision is largely based on pharmacokinetic studies (2) . however, the clinical effect of this higher dose has never been investigated in this region. this retrospective cohort study therefore investigated the effect of 2 g compared to 1 g of prophylactic cefazolin on the incidence of ssis in foot/ankle surgery. material and methods: all patients undergoing trauma-related surgery of the foot, ankle or lower leg between september 2015 and march 2019 were included. primary outcome was the incidence of a ssi. ssis were compared between patients receiving 1 g and 2 g of cefazolin as surgical prophylaxis. results: a total of 293 patients received 1 g and 126 patients received 2 g of cefazolin. the groups did not differ in gender, age, weight, co-morbidities or intoxications. the overall number of ssis was 19 (6.5%) in the 1 g group and 6 (4.8%) in the 2 g group. corrected for the confounders ''age'', ''smoking'' and ''blood loss'' this was not statistically significant (p = .705). conclusions: even though the decrease in ssi rate from 6.5 to 4.8% was found not to be statistically significant, it might be clinically relevant considering the reduction in morbidity, mortality and healthcare costs. research linking pharmacokinetic and clinical results of prophylactic cefazolin is needed to establish whether or not the current recommendations and guidelines are sufficient for preventing ssis in foot/ankle surgery. introduction:right-sided colonic diverticulitis (rd) is much rarer than left-sided (ld) and subsequently, controversies concerning the most appropriate treatment remain unsolved. our experience let us believe that mild rd can benefit from an outpatient management. material and methods: we performed a single center retrospective comparative study in which we included all our diverticulitis patients that were treated as inpatient in our unit. we divided in two groups:rd and ld group. the ld group was created by randomization from a prospective ld patients database. results: we included 24 rd and 94 ld patients treated in our unit from july 2016 to july 2019. median age was 53.9 in rd and 57.2 in ld, with a 52.2% of females in rd vs 45.2% in ld. asa classification was significantly lower in rd (asai:58.3% vs 33%, asaii:41.7% vs 46,8, asaiii:0 vs 18.1%, asaiv:0 vs 2.1% p = 0.005). the presence of neumoperitoneum in ct scan was significantly higher in ld 16.7% vs 59.6% p = 0.001) surgery was performed in 26.5% of the left-sided diverticulitis compared to 0 of the rd group (p = 0.0019). antibiotics of third line (imipenem and meropenem) were only required for ld (0 vs 26.1% p = 0.003). length of hospital stay was significantly shorter (p = 0.001) in rd (3.58 ± 1.35) than in ld group (6.11 ± 3,47) conclusions: in our series, patients with right diverticulitis had fewer perforations in the ct scan, they required lower spectrum antibiotics and did not required any surgical treatment with a shorter length of hospital stay. we consider that mild right diverticulitis could benefit from an outpatient treatment with oral antibiotic following similar recommendations to those followed for mild ld patients. when surgery should not be immediate, a night of hospitalization in a specialized environment is performed and surgery deferred overnight. in some selected patients, a return home is possible with a scheduled emergency surgery the next day. the pa.r.c.o.ur protocol is set up in the surgical emergencies of the university hospital of lille after a suitable medical treatment and enlightened information. this retrospective study assesses whether this deferred surgical management allows a return home on the day of the operation. methods: between 1/01/2015 and 1/09/2018, 3468 records of patients operated for an abscess, appendicitis, cholecystitis or symptomatic inguinal hernia were reviewed. 321 patients who did not have criteria for immediate surgical management (peritonitis, occlusion, sepsis, cellulitis, intravenous treatment need) agreed to return to their home for an os the next day. results: 286/89% interventions were performed in os and allowed a return home at day 0, within a median time of 7 h [iqr 6-9]. conclusions: the pa.r.c.o.ur protocol makes it possible to reserve the availability of the entire technical platform (operating rooms and beds) to the most serious pathologies with a failure rate of 11%. the medico-economic benefits, the efficiency in the management of the beds and the satisfaction of the patient and medical staff of this protocol must be evaluated prospectively. a 69 years old woman was admitted in our er presenting with a 12 h sharp epigastric and ruq pain, fever, nausea and vomiting, hd stable. the patient had a past medical history of tachyarrhythmia, open-angle glaucoma and lower limb venous insufficiency. her past surgical history included an hysterectomy and bilateral salpingooophorectomy, appendectomy and left inguinal hernioplasty. during clinical examination, signs of peritoneal irritation were present. ct scan revealed a small pneumoperitoneum in the luq and multiple small and large bowel diverticula, without free peritoneal fluid. blood work showed mild leukocytosis and neutrophilia. we performed an urgent exploratory laparoscopy in which dozens of small intestine diverticula were found, increasing proximally in number. one of them, 20 cm distally from the treitzs angle, showed signs of perforation, with a small abscess and surrounding fibrin. the affected bowel was externalized through a 4 cm laparotomy for segmental resection and a manual double-layer terminoterminal jejunojejunostomy was performed. in the perforated jejunal diverticulum, a 25 mm cod fishbone was identified as the cause of the perforation. the histopathological examination of the extracted 6 cm tissue sample, found several diverticular structures of the muscular wall, one of which with a 2 mm perforation and a granulocytic infiltrate with serosa involvement. complicated cases of small bowel diverticulosis are best managed by segmental resection surgery. despite being quite rare, every surgeon should be aware of such acute abdomen presentation. asymptomatic cases benefit from a watch-and-wait approach. case history: a 47-year-old female consulted to the emergency department for a 24 h epigastric pain. it was accompanied by nausea without vomiting. clinical findings: the patient was hemodynamically normal and the abdomen was soft with minimal distention. investigation/results: x-rays showed large gastric dilation. the abdominal ct scan showed mesenteric axial gastric volvulus with minimal free fluid. suddenly, the patient presented diffuse abdominal pain with diaphoresis, mucocutaneous pallor, hypotension and tachycardia. diagnosis: a gastric volvulus with gastric ischemia was suspected. broad-spectrum antibiotic therapy and resuscitation measures were started. emergency surgery was indicated. therapy and progressions: a decompressive gastrostomy, gastric reduction and devolvulation, transverse colon resection due to ischemia and splenectomy were performed. after 12 h, she required total gastrectomy and right hemicolectomy due to ischemia secondary to severe septic shock associated with disseminated intravascular coagulation. comments: the gastric volvulus is an uncommon entity, being the mesenteric-axial type so rare. there are very few cases described whose manifestation is accompanied by hypovolemic shock secondary to splenic laceration, which occurred due to the great gastric distention. early diagnosis is the key to start treatment as quickly as possible, due to high mortality the main mechanism of death is usually vascular involvement, perforation and multiorgan failure. results: we analyzed 13,621 pediatric ogis, and 23.3% of pediatric cases occurred in the 0-5 age group, 20.1% in 6-10, 19.9% in 11-15, and 36.7% in 16-20. the average age of the cohort was 11.5 years and 76.5% of cases occurred in boys. racial distribution revealed 35.8% of cases in caucasians, 17.0% in african americans, and 17.3% in hispanics. most (39.9%) cases were documented in the southern united states. of our 13,621 cases, 12.6% underwent vitrectomy, 4.2% underwent enucleation, and 1.8% developed endophthalmitis. the rate of endophthalmitis development after ogi was highest (4.6%) in the asian/pacific islander group. the average length of stay for the entire cohort was 3.51 days, and the average cost per day was $11,724.01. table 1 contains a breakdown of our statistics. conclusions: as documented in the nis, ogi occurs more commonly in boys than in girls at a ratio of approximately 3:1. the rates of vitrectomy and enucleation are higher in boys. we noted a higher of rate of enucleation in asian/pacific islanders and african americans. the plurality of ogis occur in the 16-20 age group; this age group also has the highest relative rate of enucleation. with respect to location, ogis occurring in the western united states had the highest average cost per day of inpatient stay. autologous tissue from intramedullary channel parietes for femur nonunions management introduction: a reamer-irrigator-aspirator (ria) method is deeply reliable for getting high volumes of bone graft/mscs. high rates of successful outcomes have been reported after the use of ria bone fragments to cure non-unions. material and methods: being supported by histomorphological examination of the material acquired while drilling intramedullary channels of 41 patients with femur nonunions (20-hypertrophic, 21oligotrophic), we have discovered that nevertheless, expressions of the dystrophy and necrosis in bone tissue and marrow in pseudoarthrosis areas depend on time since fracture occurrence, the microscopic study of the material 5 cm above and below a fracture line has demonstrated ordinary structures of bone tissue and marrow in all cases. introduction: this study aimed to evaluate the outcomes of ankle fractures with posterior malleolus fragments (pmfs) involving \ 25% of the articular surface treated with or without screw fixation. material and methods: among patients with ankle fractures and pmfs who underwent surgery between march 2014 and february 2017, 62 with type 1 pmfs involving \ 25% of the articular surface were included. of these 62 patients, 32 underwent screw fixation for pmfs and lateral and/or medial malleolar fracture fixation (group a) and 30 underwent internal fixation for malleolar fractures without screw fixation for pmfs (group b). ankle joint alignment and fracture healing were measured using plain radiography and computed tomography (ct). clinical outcomes were determined using the american academy of orthopaedic surgeons foot and ankle questionnaire, short form-36, and american orthopaedic foot & ankle society scale. results: nonunion was not noted in either group. however, we detected union with a step-off of 2 mm or more in 2 cases from group b. with regard to ankle joint alignment, 1 case in group a and 3 cases in group b showed mild asymmetry of the medial and lateral clear spaces on ct at 12 months. clinical outcomes at 6 and 12 months after surgery were better in group a than in group b. conclusions: screw fixation of pmfs was effective for fracture healing and maintaining ankle alignment. additionally, it improved short-term clinical outcomes, which we believe was due to stabilization of ankle fractures with pmfs involving\ 25% of the articular surface. references: level ii, prospective comparative study. how accurate can gaps and step-offs be determined in acetabular fracture treatment? introduction: the assessment of gaps and steps in acetabular fractures is challenging. studies evaluating the value of various imaging techniques to enable accurate quantification of acetabular fracture displacement are limited. this study aimed to assess the inter-and intraobserver variability of gap and step-off measurements using pelvic radiographs, intraoperative fluoroscopy and computed tomography (ct). material and methods: sixty patients, surgically treated for acetabular fractures, were included. five observers measured the gap and step-off on all the pre-and postoperative pelvic radiographs and ct scans. intraoperative fluoroscopy images were reassessed to determine the presence of gaps and/or step-offs. the inter-and intraobserver variability were calculated for the measurements using pelvic radiographs or ct scans. kappa was calculated for the intraoperative fluoroscopy assessment. results: for the preoperative displacement, the intraclass correlation coefficient (icc) was 0.4 (gap and step-off) using pelvic radiographs, and 0.4 (gap) and 0.0 (step-off) using ct scans. for the postoperative displacement the icc was 0.4 (gap) and 0.2 (step-off) using pelvic radiographs and 0.3 (gap) and 0.4 (step-off) using ct scans. the average kappa for the intraoperative gap and/or step-off assessment using fluoroscopy was 0.2 (-0.36 to 1) both for the inter-and intraobserver assessment. conclusions: there is little agreement between the observers regarding the measurements of the preoperative displacement, the presence of gaps and step-offs intraoperatively and the measurements of the postoperative displacement. a possible explanation for this is that the acetabulum has a three-dimensional spherical shape with multiple fracture lines and fragments going in different directions. single radiographic or ct-based gap or step-off measurements do not seem to be representative for the fracture characteristics, therefore the use of 3d measurements should be considered. introduction: long-term intake of glucocorticoids leads to pathologic changes in bone and cartilage tissues. material and methods: to understand how to prevent the occurrence of the pathology, we studied the use of vitamin d, vitamin e and a combination thereof on the background of the intake of prednisolone, 0.5 mg/ 100 g of body weight. the experiment involved 68 male rats of wistar linear breed. the animals were 2 months old and weighted 100.0 ± 5.0 g. the experiment included 4 series of animals, 17 rats in each, namely: the first group-intact animals; the rest of the animals received prednisolone, 0.5 mg/100 g of body weight. the rats of the third series received additionally 100 iu of vitamin d3. the animals from the fourth group also received 0.726 iu (0.6 mg) of vitamin e. results: long-term administration of prednisolone to the experimental animals has caused significant structural and functional disorders in their bone and cartilage tissues. they can be construed as simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d3 and e has demonstrated its ability to promote restoration of histomorphologic features of bone and articular cartilage in proximal femur epiphysis and epiphyseal cartilage of proximal femur epimetaphysis in animals with simulated glucocorticoid-induced osteochondropathy. the combination of the vitamins d3 and e has demonstrated a better effect on the background of the glucocorticoid-induced osteochondropathy, compared to the vitamin d3 alone. conclusions: preventive administration of the vitamins d3 and e while treatment with prednisolone leads to avoidance of the majority of pathologic changes, resulting otherwise from glucocorticoid-induced osteochondropathy. konyang university hospital, orthopaedic, deajeon, south korea introduction: the purpose of this study was to evaluate clinical, radiological and functional outcomes of patients had osteochondral autograft harvested from the ipsilateral femoral head for a femoral head defect after posterior hip fracture dislocation material and methods: this study was approved by irb at our institution. a retrospective chart review of a prospectively performed operation was performed at two university hospital between march 1, 2014, and june 30, 2018 . all fracture was classified by the ao/ota classification. we included the patients had minimum 6 months of follow up periods. ten displaced head fractures were addressed through posterior surgical dislocation and two patients had no posterior dislocation was operated using smith-peterson approach. an osteochondral graft was harvested from inferior non-weight bearing articular surface and grafted to osteochondral defect. all patients were full weight bearing by 3 months results: we had 86 femoral head fracture dislocation. 5 patients were excluded due to lost to follow up. twelve of 81 with type i/ii pipkin fracture dislocation with the articular defect and reduced within 12 h of injury was identified for review. the patients were followed up for a mean of 13.2 months. there was no osteonecrosis. decreased joint space was identified in two patients. all fractures achieved union. the mean harris hip score of last follow up was 89.1 (56-98) one patient who operated using the smith-peterson approach had femoral nerve palsy. conclusions: the clinical and radiological results after treatment of femoral head fracture dislocation with articular defect by osteochondral autograft harvested from its own non-weight bearing articular surface show good outcomes. hospital universitario fundacion jimenez diaz, madrid, spain, 2 hospital universitario 12 de octubre, madrid, spain, 3 hospital universitario la paz, madrid, spain introduction: preoperative computerized tomography scan provides important information about ankle fractures associating posterior malleolus, helping us distinguishing fractures affecting distal tibiofibular joint. the aim of our paper is to describe our series of patients suffering an ankle fracture with posterior malleolus involvement. methods: fifty-two consecutive patients, with ankle fracture involving posterior malleolus were evaluated prospectively. all of them were assed with a preoperative ct scan, demographic data, fracture mechanism, surgical approaches, posterior malleolus size measured classification and treatments were analyzed. results: most frequent posterior malleolus pattern according to bartonicek classification was type ii, twenty-two patients (42.3%). an alternative surgical approach was performed in thirty-three patients (63%) as a consequence of information provided by ct scan. no statistical differences were observed when measuring posterior malleolus in conventional x-rays or ct scan. analysis of variance showed a p value less than 0.05 when comparing pm size and haraguchi and bartonicek classifications. discussion and conclusion: ct scan is required to perform an adequate preoperative study of ankle fractures involving posterior malleolus, using this information to provide a better outcome to our patients. effect of atorvastatin and losartan on gene expression and cell count in a rat model of posttraumatic joint contracture of the knee-a blinded and randomized animal study introduction: myofibroblasts have been associated with increased posttraumatic joint contracture, which has a massive impact on articular function. atorvastatin and losartan have shown to reduce the proliferation of cardiac, hepatic and pulmonary myofibroblasts. the aim of this study was to evaluate the effect of atorvastatin and losartan on gene expression, cell count and collagen deposition in the posterior joint capsule 2, 4 and 8 weeks after trauma in a rat model of posttraumatic joint contracture of the knee. material and methods: posterior capsular injury and kirschner-wire immobilization of the knee were performed in 72 sprague-dawley rats. atorvastatin, losartan, or placebo was administered daily orally. the rats were sacrificed at either 2 (n = 24), 4 (n = 24) or 8 (n = 24) weeks after initial surgery. rats euthanized at week 8 had their k-wire removed at week 4, followed by a remobilization period of another 4 weeks. the results were evaluated via qpcr and immunohistochemistry. results: losartan reduced the number of myofibroblasts in comparison to the control at week 2 and 4, whereas atorvastatin lowered myofibroblasts only at week 2 (p \ 0.05). atorvastatin reduced the collagen deposition at week 2, whereas losartan had no effect on collagen deposition. losartan decreased gene expression of connective tissue growth factor (ctgf) at week 4 and of tgf-b at week 8. clinical findings: positive anterior drawer test, grade iii valgus instability, and a palpable gap below the patella were assessed. no neurovascular alterations were found and ankle-brachial index scored [ 0.9. investigation/results: initial immobilization with a splint was performed. radiographs showed a high patella with no other lesions. mri revealed a complete rupture of the patellar tendon and a complex multiligamentous injury with complete anterior cruciate ligament (acl) tear, avulsion of distal medial colateral ligament (mcl), and a complex rupture of both meniscus. diagnosis: knee dislocation with patellar tendon rupture. therapy and progressions: definitive treatment was performed 7 days after the initial lesion, with arthroscopic resection of the posterior horn of the external meniscus and reconstruction of the acl with posterior tibial tendon allograft, as well as open repair of the patellar tendon and the internal meniscus, with subsequent mcl distal reinsertion. immediate partial weight-bearing with an extension orthosis was allowed. the patient is currently progressing with rehabilitation. comments: knee dislocation is a rare injury, and most cases are due to highenergy trauma. concomitant rupture of the patellar tendon is very unusual, and most cases are described in the context of open injuries. surgery is mandatory in order to restore full stability of the knee, with either one intervention or a staged surgery, including repair of the collateral ligaments and the patellar tendon followed by arthroscopic reconstruction of the cruciate ligaments. postoperative management consists on early rom restoration and weight-bearing as tolerated. introduction: apophyseal anterior inferior iliac spine (aiis) fractures are rare injuries. they most commonly occur in athletes in adolescence period. because the ossification of pelvis is not completed, apophyses are the weakest part of musculo-tendinous unit during this period, thus avulsion fractures are more frequent than muscle ruptures. aiis avulsions are the result of sudden and forceful contraction of rectus femoris muscle concentrically or eccentrically. material and methods: we report a clinical case of a aiis avulsion fracture in a young male football player, after being misdiagnosed as muscle strain. results: our patient was treated with conservative treatment including bed rest, analgesia, using crutches and toe-touch weight bearing, progressing to full weight bearing as tolerated and nonsteroidal anti-inflammatory drugs. at follow-up, he showed relief from his pain and mechanical symptoms and regained full range of motion and returned to his previous levels of activity. conclusions: diagnosis requires careful attention to the physical examination and imaging. in this case, the fracture was managed successfully with a conservative approach. good results and return to previous levels of activity can be achieved with conservative treatment. when misdiagnosed as a simple strain, the late diagnosis may cause chronic pain with decreased sportive performance in the future. therefore, a carefully taken anamnesis and physical examination with comparative anterior-posterior pelvic x-rays are needed not to miss avulsions in adolescents; also in some instances, more advanced scanning methods must be considered. introduction: the problem of meniscus damage in children is due to unsatisfactory treatment results, which is associated with the frequent execution of meniscectomies. amount of unjustified meniscectomies and the incidence of osteoarthritis can be reduced if menisci are repaired. material and methods: during the period january 2018-august 2019 66 children with injuries of the meniscus were treated in morozov children's clinical hospital. 59 children underwent meniscus repair by suturing using three techniques: ''all inside'', ''inside out'' and ''outside to inside''. meniscus suture decision was made taking into account the assessment of the severity of the damage. the period from the moment of injury wasn't taken into account. the technique of meniscus suture was determined depending on the location and type of damage. we met 4 children with damage to the discoid meniscus who underwent partial resection and meniscus suture. 7 children underwent a meniscectomy due to severe traumatic and degenerative changes. children had mri of the knee after 6 months and x-ray after 12 months. results: 30 children achieved a satisfactory functional result; 28 operated children are at the rehabilitation stage. we faced a complication-limitation of flexion in the knee joint in 1 child. in all children on the control mri, the absence of synovitis, the safety of the reconstructed meniscus contour and the decrease in the intensity of the hyperechoic signal in the gap zone in dynamics are determined. conclusions: the introduction of a technique for repair meniscus integrity in the daily practice of an arthroscopist makes it possible to reduce the number of meniscectomies, which will reduce the number of unsatisfactory treatment results for this pathology and prevent the development of early osteoarthritis of these, 97 children revealed a fracture-dislocation of the patella. in 64 children, a tangential fracture of the lateral condyle of the femur was noted. in 110 children, the dislocation was repeated. we met 89 children with bilateral damage. all children with complete damage to the medial patellofemoral ligament, fracture-dislocation of the patella and dysplastic dislocation were performed tendon plastic using the quadriceps femoris tendon. the technique includes: transplanting a graft quadriceps tendon graft without cutting off the patella. next, the transplant is subfascial carried out in the medial direction and is fixed with a bio-integrated screw in the femur. results: the rehabilitation period was 4 months. 10% of children have a satisfactory result (there is a limitation of flexion in the knee joint to 90°). 90% have an excellent clinical result: the full range of motion in the knee joint, the absence of pain and a return to sports. none of the operated children had relapses of dislocation. conclusions: it is recommended to consider the technique of tendon plasty of the medial patellofemoral ligament using the quadriceps femoris tendon as a method of choosing the treatment for patellar dislocation in children. case history: a 13-year-old boy who was injured while playing baseball. he was playing as a catcher and was bumped into the runner, therefore his ankle got twisted. he was immediately taken to the hospital. clinical findings: x-ray the distal tibial epiphyseal growth plate was irregular. although the ankle joint was not dislocated. in the ct, the proximal fibular fragment was caught behind the posterior edge of epiphysis of the distal tibia and was trapped there. investigation/results: the patient must be operated in order to repair the ankle. but the reduction of the entrapped distal tibia epiphysis was not easy without open. diagnosis: we diagnosed with bosworth like fracture. therapy and progressions: reduction was not easy, however we performed it by the pulling the fibula towards to outside, pulling out the curled anterior tibiofibular ligament, and then pushing into the tibia. we performed screw fixation after reduction of distal tibial epiphysis. furthermore, we fixed the fibula with plate. we made him to do range of motion exercise and toe touch gait from next day, and full weight bearing from 6 weeks. we removed the implant 5 months after the surgery. he did well subsequently, and at 3 years after injury, he had normal function of the ankle, and normal x-ray. and he has returned to sports without pain. introduction: judo is the most popular martial art in the world and the first martial art recognized since 1964 as an olympic sport. worldwide, the international judo federation has registered 200 countries with about 40 million judo practitioners. like martial arts, judo mainly involves grip and throwing techniques. the competition rules in judo have been subject to constant adjustment and optimization in recent years. injuries prevalence is an important factor in the contact martial arts. material and methods: a prospective cohort study of all registered international athletes (1023) at three different european judo contests in germany were accomplished with the aim to investigate the injury rate as well as the pattern of injury. the age of the athletes ranged between 15 and 20 years. injury incidence rates were calculated per 1000 athlete-exposures (iirae) and per 1000 min of exposure (iirme). independent variables were sex and weight division. subgroups were compared by calculating the injury incidence rate ratio. results: severe injuries by judo tournaments are rare. the most frequently injured regions were the hand and head. the fights of the main block are riskier than the finals. the incidence of injury in heavyweight division differed with lightweight competitors. the risk of injury for female and male competitors differed slightly. conclusions: further studies are needed to determine a judo specific injury patterns and factors especially in the pre-competitional phase. investigation of prevention-strategies like the adaptation of competition rules etc. makes sense. does garden''s classification of femoral neck fracture match between orthopedic specialist and clinical resident? t. inoue 1 , s. inoue 1 , t. muraoka 1 1 prefectural miyazaki hospital, orthopedics, miyazaki, japan introduction: garden''s classification is the most popular classification of femoral neck fractures. femoral neck fracture should be operated^24 h; however poor agreement make waiting time longer because it takes more time to prepare implants and biological clean room. we investigate the agreement of the garden''s classification (non-displacement type or displacement type) between clinical resident and orthopedic specialist. material and methods: the examiner are a clinical resident (2nd year) and an orthopedic specialist (19th year). the subjects were 55 cases of femoral neck fractures treated at our hospital between january and december 2018. first, the examiners classified them into a non-displacement type and a displacement type (test 1). second, the examiners studied the literature about unclassifiable type. third, the examiners classified 55 cases 1 month later once more (test 2). finally, we compared the first test with the second test using the agreement (the number of matched patients/total) and kappa coefficient. results: the test 1 showed that the agreement and kappa coefficient were 81.8% and 0.337. the test 2 showed agreement was 90.9%, 0.614. the intra-observer agreement of clinical resident was 90.90% and kappa coefficient was 0.6520. the orthopedic specialist was 98.18%, and kappa coefficient was 0.930. at test 1, 10 cases did not match. 4 cases of those were unclassifiable type, which were valgus type with medial fracture line. with slight displacement, agreement will get lower; some doctors consider it displacement type. conclusions: unclassifiable type makes us confused. it makes agreement better to discuss about unclassifiable type. introduction: the aim of this retrospective study was to describe the profile of missed hand and foot fractures in multitrauma patients and to elucidate risk factors for the delayed diagnosis. material and methods: from 2005 to 2017, there were included 279 patients. missed fractures were defined as fractures, which were not diagnosed during primary and secondary survey. patients were assessed for age, sex, glasgow coma scale, injury severity score, and length of stay in hospital (los). timing of hand or foot diagnosis related to admission date (measured in days) was noted. results: overall, 5.9% of patients had a delayed diagnosis of hand fracture, 7.3% ha a delayed diagnosis of foot fracture. the mean gcs for patients with delayed diagnosis was 11, whereas patients with diagnosis the day of admission had and mean gcs of 14 (p \ 0.001). patients with delayed diagnosis had a mean iss of 13.4 versus 9.1 for those diagnosed the day of admission (p \ 0.001). furthermore, patients with delayed diagnosis had a mean los of 9.8 days, whereas those diagnosed at the time of admission had a mean los of 5 days (p \ 0.001). concerning delayed diagnosis hand fractures, metacarpal and phalangeal fractures were the most common injuries overall (46.9% and 25.8%, respectively). concerning delayed diagnosis foot fractures, metatarsal fractures (52 cases) and calcaneus fractures were the most common injuries overall, followed by talus fractures and toe fractures. conclusions: this study revealed that with a decreased gcs and increase in iss, polytrauma patients are increasingly at risk for delayed diagnosis of hand and foot fractures with a concomitantly increased los. as a delayed diagnosis has significant impact on the final functional outcome, correct and careful primary, secondary and tertiary survey is essential. introduction: the aim of this study was a) to determine the methods of hemorrhage control currently being used in clinical practice and b) to analyze pelvic fracture mortality rates before and after initiation of a multidisciplinary pelvic fracture protocol. material and method: between 2005 and 2017, we included 98 trauma patients with pelvic fractures (group 1). a similar retrospective examination was performed on a number of 85 trauma patients without pelvic fractures (control group). there were collected injury severity score (iss), the highest abbreviated injury scale (ais) score in each anatomic region and methods of pelvic hemorrhage control. there were also recorded hospital lengths of stay (los) and in-hospital mortality. results: the average follow-up was 24-months. the average iss in group 1 and group 2 was respectively 13.8 and 9.7. in both groups the commonest mechanism of injury was motor vehicle crash (40.5%). in group 1, angioembolization and external fixator placement were the commonest used method of hemorrhage control. 8 patients underwent diagnostic angiography with contrast extravasation noted in 4 patients. patients with pelvic fracture had a mean hospital los of 17.3 days. the overall in-hospital mortality rate of patients with pelvic fractures was 11.7%, while in group 2 the overall in-hospital mortality was 6.5%. age, shock, severe head injury and increasing iss, are all significantly associated with mortality in the pelvic fracture group. conclusions: the findings from this study demonstrate no clear relationship between the choice of hemorrhage control intervention used and the patient's clinical status. in healthier patients with unstable pelvic fractures, the mortality rate was similar to that of patients with stable fracture patterns. introduction: various percutaneous screw placement for pelvic and acetabulum fractures is often difficult because of complex anatomical morphology, however, it becomes very beneficial to set enough fixation stability if we can insert the long screws. 3d-ct navigation system for the screw placement is beneficial for precise screw insertion. we investigated the accuracy of screws with 3d-ct navigation. material and methods: our retrospective case series were assessed by the accuracy of screws with 3d-ct navigation for pelvic and acetabulum fractures. twenty-six patients who sustained pelvic fractures and thirteen patients who sustained acetabular fractures were included in this study and 3.5 mm cortical screws or 6.5 mm cannulated screws were inserted with 3d-ct navigation. we investigated the number of screws and screw positions which is measured by postoperative ct scan and classified by smith criteria. results: we inserted 13 tits (transiliac-transsacral) screws and 31 is (iliosacral) screws for pelvic fractures. 43 of 44 screws (97.7%) were placed in correct position (grade0 or 1). 1 screw for s1 lesion was placed in incorrect position. meanwhile we inserted 1 antegrade pubic screw, 5 anterior column screws, 27 posterior column screws and 6 infra-acetabular screws. 35 of 39 screws (89.7%) were placed in correct position (grade0 or 1). 4 screws were in incorrect position and they were all cortical screws. and there was no complication related to screw insertion. conclusions: our study highlights that 3d-ct navigation system reduced the malposition rate of screw insertion for pelvic and acetabular fractures. however, we sometimes had difficulty in inserting tits screw for s1 lesion and cortical screw for acetabular fractures. we assumed that this was caused by narrowness of s1 corridor and flexibility of drill or inserting cortical screws in wrong position manually. we should pay much more attention even using 3d-ct navigation. is operative therapy still warranted for dislocated acetabular fractures in elderly patients? introduction: the incidence of acetabular fractures in elderly patients is increasing. there is no consensus about the right treatment for the impaired elderly patient with an acetabular fracture. the aim of study was to investigate acetabular fractures in the elderly patient and the risk of a secondary tha. material and methods: a retrospective study was performed from 2004 till 2014 in the radboudumc nijmegen. all patients with an acetabular fracture were reviewed. they were divided into two groups, younger than 65 and 65 or older. ct scans were used for classification according to letournel and for the quality of the reduction according to matta. there was a follow-up of minimal 2 years. results: in total, 267 patients attended at the radboudumc with an acetabular fracture, of which 68 were 65 years or older. in the younger group, 156 patients received surgery and 40 elderly patients. according to matta, an anatomical reduction was achieved in 15% of the young patients and 8% of the elderly patients. imperfect reduction was achieved in 46% of the younger patients and 49% of the elderly patients. thirteen percent of younger group and 30% of the older group needed a tha based due to the posttraumatic arthritis, the younger group after 32 months and the older group after 22 months on average. one younger patient with anatomical reduction needed a tha, none of the elderly patients. twenty-three percent of the younger patients and 50% of the elderly patients, all with a poor reduction, needed a tha. age, the complexity of the fracture and the quality of the reduction were important factors leading to a secondary total hip arthroplasty. conclusions: elderly patients are two times more likely to need a secondary total hip arthroplasty. after an anatomical reduction, the risk is very low, even in the elderly. surgery for dislocated acetabular fractures is a good option when there is a possibility for a good reduction. references: letournel e. matta jm. introduction: in japan, as a definition of basicervical fractures of the proximal femur, a fracture line is placed into and out of the joint capsule of the hip joint. however, in fact there are various fracture types.we classified these fracture types based on treatment methods and reported on these results. material and methods: 958 cases of proximal femoral fractures treated in our hospital from january 2011 to december 2017. basicervical fractures occurred in 25 cases (2.61%). all cases diagnosed with x-ray and 3d-ct, and observed for 3 months or more after surgery. results: there are two types of basicervical fractures: the fracture line exists around the just inside of the intertrochanteric part: normal type(n type); 5 cases (0.52%), and fracture line exists subcapital at ventral side, the coronal plane in the center of the neck and the trochanteric fossa at the dorsal part: coronal shear type(c type); 20 cases (2.09%).c type was further classified by treatment method depending on existence of posterolateral fragment and anterior wall fracture. c type without comminution (2 part:c-2 type) was 12 cases (1.25%). with posterolateral fragment (3 part:c-3 type) was 5 cases (0.52%), with posterolateral fragment and anterior wall fragment (4 part:c-4 type) was 3 cases (0.31%).n type and c-2 type were treated by sliding hip screw (shs) with anti-rotation screw. c-3 type: shs with trochanteric stabilizing plate, c-4 type because of the bony contact area is very small: hemi-arthroplasty with calcar replacement was performed. cut out occurred in 3 cases of c-2 type and 1 case of c-3 type, but others obtained union.. one case of c-4 type occurred peri-prosthetic fracture intraoperatively. conclusions: we classified 25 cases of basicervical fractures, and according to its classification, treatment method was decided and good clinical results were obtained. strategies aimed at preventing chronic opioid use after trauma: a scoping review c. cô té 1 , m. berube 2 1 université laval, faculty of nursing, québec city, canada, 2 chu de quebec research center, université laval, trauma, emergency, critical care medicine, québec city, canada introduction: a high incidence of chronic opioid use (up to 58%) has been documented after trauma. 1 solutions are urgently needed considering the importance of this public health issue. we aim to identify strategies to prevent chronic opioid use in the trauma population and to assess their level of evidence. material and methods: we initiated a scoping review of literature to identify research articles and guidelines on preventive strategies. several databases and websites of trauma were searched. strategies were classified according to their types and targeted trauma populations. the level of evidence was summarized according to an adaptation of oxford center for evidence-based medicine classifications and strategies effectiveness. results: close to 10 000 items have been screened until now from which 3 studies 2-4 and one guideline were found eligible. 5 two studies 2-3 combined education with mandatory limit of opioid prescriptions (level iii) in the orthopaedic trauma population and the other study used tailored physical training after whiplash injury 4 (level i). findings showed reduction of opioid use or complete weaning at 6 and 12 weeks after trauma, however the effect was not maintained beyond 12 weeks. guidelines on orthopaedic trauma 5 made the following recommendations: prescribe the lowest effective dose for the shortest period (strong, high-quality evidence), avoid long-acting opioids in the acute setting (strong, moderate-quality evidence), and prescribe precisely (avoiding ranges of dose and duration) (strong, low-quality evidence). conclusions: chronic opioid use is an important issue in trauma patients. findings highlighted the need for more research to reduce the burden associated with chronic opioid use in this population. references material and methods: we analyzed 85 clinical cases: men-32 and women-53, mean age 53 years. trauma circumstances: habitual trauma-60 cases, traffic accident-15, precipitation-6, sport-3, aggression-1. for cohort analize schatzker classification was used: especially type i was meet in 9 cases, ii-22, iii-11, iv-3, v-26, vi-14; 81 close, 4 open. for paraclinic examination were used x-ray and ct. surgical management consisted of: close reduction, internal fixation-10 cases (8-percutaneus canulated screws arthroscopic assisted, 2-external fixator), open reduction, internal fixation-75 cases. bone graft was done in 15 cases. results: postoperative follow up was performed at 6, 12, 18, 24 weeks. patients were evaluated according to the lysholm knee scoring scale, obtaining an average score of 88 points. bone healing was achieved in a period of between 12 to 18 weeks. postoperative complication developed in 11 cases. results were depending on the stability of osteosynthesis, precocity, rightness of functional reeducation and patient compliance. conclusions: favorable functional results and less complication were met in cases of individual approach of surgical management, a good choice of implants and minimally invasive surgical techniques. fractures of the shoulder processes-a case report case history, clinical findings and diagnosis: 17-year-old male, low-speed motorcycle crash with subsequent polytrauma. he presented with right shoulder pain, swelling and pain to the touch. articular ct revealed a type i fracture of the coracoid base, type iii acromion fracture and scapular body fracture without displacement. results, therapy and progressions: he was submitted to surgical treatment 7 days later. a superior ''sabercut'' approach with open reduction and osteosynthesis of the coracoid process was performed with a cancellous screw and washer and fixation of the acromion with 2 k-wires and tension band wire. fracture of the scapular body followed a conservative treatment. immediate postoperative period was uneventful and he presented with favourable evolution in the subsequent 6-week, 12-week and 6-month follow-up. at present time, at 14-month follow-up, maintained anatomical reduction in radiological control, complete arm abduction and no limitation with efforts. comments: conservative treatment is generally indicated for all shoulder body fractures without displacement. fractures of the coracoid or acromion with [ 1 cm displacement are described as an indication for surgical treatment. fractures of the acromium without displacement may follow conservative treatment with sling immobilization. surgical fixation can be achieved with screws, plate and screws or tension band wire. although controversial, surgical treatment for coracoid fractures is preferred, especially in active young patients with open reduction and fixation with screws or, if necessary, with plate and screws. the treatment applied in the present case, all approaches described in the literature as being effective and with good results, is in agreement with the options described in the literature and constitutes a corroborative example of its efficient results. case history: a 49-year-old male, hand worker, attended to our emergency department after a traffic accident complaining about pain and swelling in his left wrist. initial radiographs revealed an isolated dorsal dislocation of the lunate that went unnoticed. two and a half months later he was referred to our clinic. clinical findings: findings included dorsal wrist deformity and pain. he presented a decreased passive wrist flexion and extension range of motion, with normal finger tendinous function. investigation/results: plain x-rays showed persistence of the lunate dorsal dislocation without any associated injuries. diagnosis: chronic isolated dorsal dislocation of the lunate therapy and progressions: open reduction was performed using a dorsal approach. the scapholunate, lunotriquetal and scaphocapitate spaces were stabilized with a compression screw and kirschner wires respectively. the patient persisted with pain and functional limitation after the surgery, showing an insufficient reduction of the scapholunate space on the x-ray. nine months after the initial surgery, he developed a purulent fistula on the ulnar edge of the carpus. after it was resolved, a total wrist arthrodesis was performed using the mannerfelt technique. at the 3 months follow up, he was clinically stable, consolidation of the arthrodesis was documented and he had returned to his previous normal activities. comments: isolated dorsal dislocation of the lunate is a rare lesion. the delay in the diagnosis of carpal dislocations is frequent. this compromises the final outcome of reconstructive techniques and the risk of residual instability, hence increasing the risk of chronic pain associated with posttraumatic osteoarthritis. in the case of chronic lesions, treatment with palliative techniques such as proximal carpectomy or joint arthrodesis should be taken into consideration. references: siddiqui n., sarkar s. isolated dorsal dislocation of the lunate. open orthop j. 2012;6:531-4 is ultrasound-guided regional anesthesia safer than landmark technique? one-hospital experience introduction: according to the literature the application of ultrasound (us) in performing regional anesthesia had a significant impact on patient safety by increasing the success rate [1] . in 2006 a donated ultrasound device became available in the institute of emergency medicine, chisinau, republic of moldova. due to lack of equipment both us guided and landmark techniques have been performed. the aim of this study was to analyze the two methods of performing regional anesthesia, in order to estimate the potentials benefits of of us guided techniques (succes rate and doses). results: the bivariate analysis showed that, out of 100 anesthetics in lmg, a number of 13 were reported as unsuccessful, compared with a number of 20 in usg. the v 2 test with corrections for continuity did not determine significance (test value 1.306, df = 1, p = .253, effect size = .007), rr being 1.67 (95% ci 0.78-3.58). linear regression for dose (lidocaine) modeling, in patients included in the research, showed a decrease of the dose by 57 mg in lmg, the confidence interval being quite wide (95% ci -.938, -.192). that is, the actual decrease is within the limits of 19 and 94 mg. conclusions: the tendency towards higher failure rate in successfully performing an us guided regional anesthesia and relative ''uncertain'' decreasing of dosage are in contradiction with the international statistical data. this in turn evidenced probable deficiencies in the training of the practitioners in field of ultrasound guided techniques in our country. the prospective research to confirme/infirme these results and estimate the complication rate follows. references: 1. barrington mj, uda y. did ultrasound fulfill the promise of safety in regional anesthesia? current opinion in anaesthesiology 2018; 31 (5) results: average age 41 years old (34-62).all were active labour patient. the most frequent mechanism was high energy trauma (traffic accident), 2 of who presented gustilo grade iiib open fractures operated in the country of origin. most frequent pattern of fracture was 23-c.2 (2 cases) and 23-c.3 (2 cases). initial conservative treatment was performed in 2 of the cases. one persistent pseudoartrhosis with osteosynthesis material failure. in every case, preoperative ct and early surgical intervention were carried. in 3 cases, an additional procedure was associated at the radioulnar distal joint. in all cases consolidation occurred. one patient required reintervention for persistent pseudoarthrosis. average consolidation time 6 months (3) (4) (5) (6) (7) (8) (9) .average follow-up of 61 months (22-116). average active joint balance: flexion 49°(15°-70°), extension 38°(10°-65°), pronation 68°(40°-70°), supination 82°(70°-85°). average dash 21.56 (0-50.8).force reduction greater than 50% compared to contralateral in 2 of the cases. radiological parameters:radial height 8.7 mm (7-12),radial inclination 15°(9-19°),volar angulation 11.8°( 0.2°-21°), ulnar variance 2.85 mm (1) (2) (3) (4) (5) . conclusions: malunion of the distal radius is an uncommon and severe complication with increasing incidence that requires early and personalized surgical treatment to achieve the correction of the deformity, preserving mobility acquiring consolidation with acceptable functional results case history: isolated ulnar translocation of the carpus is unusual. when the translation occurs without injury of the radius, ulna or carpal bones are often misdiagnosed. early diagnosis is key, to avoid further complications such as redislocation of the carpus (1). clinical findings: in our case a young male patient suffered a high energy motorcycle accident. he had no a b c d problem investigation/results: the ulnar translation of the left carpus was evident but comparison x-rays were taken on both wrist for further evaluation. the distance between the line, drawn through the axis of the radius and the center of the capitate bone was measured bilaterally. the results were 14.3 mm vs 4.7 mm. diagnosis: isolated, open ulnar translocation of the radiocarpal joint, dumontier type i, was diagnosed. treatment: the primary treatment was debridement, reposition and fixation with ex fix. after the wound healing on 18th days we made reconstruction. volar approach was used, we re-reponate the carpus and fixated the position with two 2 mm smooth kirschner wires. the radioscaphocapitate and long radiolunate and radioscaphoid ligaments were reattached to the volar margins of radius using mitek mini anchors. we put the ex fix and left the bended wires percutaneously. after 10 weeks the ex fix and the k wires were remove. wrist motion exercises were initiated under supervision of physiotherapist. comments: after 16 weeks the wrist was in good alignment, the flexion-extension were 20-20, the deviations were 15-20°. the radiographic signs of this injury are unusual and often misdiagnosed. it can be useful to compare with contralateral x-rays. the radiolunate and radioscaphocapitate ligaments is considered crucial in prevention of ulnar translation. in our opinion the radiolunate arthrodesis can be reserved for failed ligament repairs. introduction: within the orthopaedic paediatric population, there is a distinct paucity of literature in regard to post-operative paediatric analgesic regimes. supracondylar humeral fractures account for 33% of all paediatric limb fractures and there has been a marked divergence in recent literature concerning the most appropriate choice of analgesia for this cohort with recent studies recommending the routine inclusion of an opioid agent post-operatively on prescription. opioids have deleterious side effects pertinent to paediatrics. in our institution, patients'' only receive a prescription for acetaminophen and nsaids upon discharge. our study assessed postoperative analgesic satisfaction rates in all paediatric patients who underwent crpp for supracondylar humeral fractures in our institution from january 2018 to december 2018. material and methods: this is a retrospective multi-surgeon case series of all paediatric patients who underwent crpp from january 2018 to december 2018. patient data was extrapolated from theatre records and clinical charts. for each patient, all analgesic agents given were identified, the dosage, route and frequency of administration in addition to the length of their hospital stay and time from injury to operation. following discharge, patients'' guardians were contacted retrospectively and a questionnaire was administered which ascertained the efficacy and duration of analgesia used by the patient postoperatively. results: fifty patients were identified for inclusion within the study who met the inclusion and exclusion criteria. there was a 92% satisfaction rating amongst the responders with the analgesic regime recommended-acetaminophen & nsaids. conclusions: in stark contrast to papers which we discuss throughout our paper, our study conclusively demonstrates that opioid prescriptions are not required upon discharge for supracondylar fractures within a paediatric population case history: a 57-year old man suffered an isolated injury of his right hand in a motorcycle accident. clinical findings: the patient presented with a swollen hand, a subtotal amputation of the middle finger at the level of the middle phalanx and lacerations to the other fingers (fig. 1) . investigation/results: after excluding injuries to other body regions, radiographs and a ct of the hand were performed (fig. 2) . diagnosis: closed fracture dislocation of cmc joints from ii. to v. finger, comminuted fracture of the middle phalanx of the middle finger, closed fracture of the proximal phalanx of the middle finger, other lacerations to the iv. and the v. finger. therapy and progressions: urgent open reduction and internal fixation (orif) with k wires of the cmc joints. exploration of the middle finger reviled heavy contamination and comminution of the phalanx, with injury to one neurovascular bundle. a phalangectomy with acute finger shortening was performed with creation of a new ip articulation (distal to proximal phalanx) (fig. 3, 4) . progression after the surgery was uneventful. there was no sign of infection. the shortened finger was sufficiently perfused and the patient reported a sense of touch. k wires were removed after 6 weeks and physical therapy was started. the patient has limited rom in his neo ip joint with minimal pain (vas 2-3) (fig. 5) . comments: middle phalangectomy of the hand was described in the literature only in two papers which report treatment of chronical or congenital diseases. the authors propose this method as an alternative to amputation in selected trauma cases. results: 29 patients (15 m, 14 f, mean age 43 y) with 40 fractures were included. 13 kidney-tpl, 6 lung-tpl, 5 liver-tpl, 3 heart-tpl, 2 kidney/pancreas-tpl. all patients got treated with at least two immunosuppressive drugs. cause of accident: 37.5% sports/leisure, 35% work/household, 12.5% traffic accidents, 5% without trauma. the operation was performed under perioperative long-term antibiosis, often with a combination of two or three drugs. patients were hospitalized for an average duration of 11.3 days and were also examined by the particular organ specialists. osteosynthesis: in 90% primary operative fracture treatment, in 10% two-step procedure. 11 plates distal radius and ulna [healing period (h) conclusions: the fracture healing was possible but significantly delayed. the wound healing took longer. the immunosuppressive therapy may be responsible for these problems. the rehabilitation of movement and weight bearing has to be adapted to the slowed fracture healing. introduction: the prevalence of fragility fractures of the pelvis (ffp) increases, including in up to 90% a lesion of the posterior pelvic ring. an operative therapy is indicated in cases of prolonged or immobilizing pain or in a displaced dorsal fracture. methods: patients suffering an ffp treated with a minimal-invasive trans-sacral bar through s1 from 2009 to 2017 were included. the patients or their relatives were contacted to ask about mortality, the present mobility and place of residence. 96% of all patients still alive could be included in follow-up. results: 73 females and 6 males with a mean age of 76.7 ± 9.5 years (50-95) were included. concomitant stabilization of the anterior pelvic ring was performed in 53%. 16.5% underwent an operative revision (5% evacuation of hematoma, 5% peri-implant infection, 10% hardware removal-combinations possible). the trans-sacral bar was removed in one case due to malpositioning. the length of stay was 20 ± 12 days. at discharge, 46% were mobile on the ward, 14% in their room, 35% for transfer to sitting position and 5% were bedridden. 24% were discharged to their home, 49% in geriatric rehabilitation unit, the remaining to other rehabilitation or to a nursing home. during follow-up, mortality was 27%, one patient died during hospital stay. the patients died in average 158 ± 109 weeks after discharge. after a follow-up of 206 ± 151 weeks, 52% lived at their home, thereof one-third with assistance. 63% needed a walking aid, 16% were mobile without walking aid, 21% were bedridden or only mobile to sitting position. conclusion: the trans-sacral bar in s1 is a valuable minimal-invasive stabilization method to recover mobility in elderly with an ffp. a relatively long in-hospital stay could be explained by the initial trial of conservative treatment and due to intra-and inter-departmental cogeriatric services. the high mortality and need for assistance reflects this geriatric, multi-morbid patient collective. case history: a 58-years-old woman was admitted in the emergency room after being run over by a bus. clinical findings: at the emergency room, she was conscient and hemodynamic stable. head, thoracic or abdominal trauma were excluded. the patient presented with an open wound in left popliteal area with massive bleeding with exposure of gastrocnemius and soleus muscles and achilles tendon investigation: radiologic images didn't show any fracture. a limb angiography showed complete perfusion of the leg, without any lesion on major arteries. diagnosis: open aquilles tendon avulsion through the popliteal fossa therapy and progressions: the patient was taken to the operating room. we approach the popliteal area and found a small laceration of popliteal vein, which was sutured with prolene 6/0. then, we reference the achilles tendon, and tunneled the posterior face of the leg, and passed the tendon through the tunnel. a distal approach, above the insertion of achilles tendon was done, and two suture anchors preloaded with 2 sutures were inserted in the medial and lateral sides of the calcaneal tuberosity, then we did an krackow suture. we also did a fasciectomy on the lateral side of the leg, to prevent compartmental syndrome. the patient was put in a posterior cast with 208 of flexion for 4 weeks. the immediate post-operative time was in an intermedia unit care, to control possible multiorgan failure. in 2 days, she was discharged to orthopedics nursery. due to the degloving of subcutaneous tissue, she evolved with some blisters which made her stay inpatient about 4 weeks. after some time, she developed some areas of skin necrosis, which needed some intervention by plastic surgery with skin graft. now, she has skin completely healed, some loss of strength in the leg, with loss of plantarflexion, and is under prolonged rehabilitation program. therapy and progressions: she was rushed into the or and submitted to external fixation of the humerus and bones of the forearm, debridement, and primary closure of the forearm and hand. successive dressings and debridement was maintained and, at 19th postoperatory day(po) the external fixator of the left humerus was removed and a nailing was performed as well as an osteosynthesis of the clavicle fracture with anatomical plate. at 40thpo the external fixator of the forearm bones was removed and an open reduction and internal fixation of the radius with lcp plate and closed reduction and internal fixation of the ulna with an anterograde ten nail was performed. at 49thpo, she underwent an autologous skin graft of the forearm and hand wounds. good clinical evolution of the wounds and fractures, all of which evolved to consolidation, although m3 fracture malunion was verified as well as deficit of thumb abduction and extension of 3rd-5th fingers. uefi of 65/80. comments: the approach of polytrauma patients should be sequential, according to the atls protocol, preserving life, limb and function. treatment of these lesions is complex and, if poorly managed, can be associated with high morbidity, as most patients combine severe and contaminated lesions, extensive skin loss, open fractures, postoperative infection. a sequential approach is required, which involves injury assessment, infection prevention, soft tissue treatment and fracture stabilization. introduction: pelvic fractures, though rare (3-8%), are often associated with high mortality (5-20%). the factual outcomes in polytrauma patients with the additional burden of pelvic fractures are unknown. the purpose of this study is to provide an in-depth analysis of pelvic fractures in seriously injured patients. material and methods: this is a retrospective analysis of prospectively maintained trauma registry from 2012 to 2018. we included all trauma patients with iss c 16. group i, which had an additional burden of pelvic fractures, was compared with group ii, consisted of patients without pelvic fractures. a double-adjustment propensity score match (psm) analysis was utilized to minimize confounding and unbiased estimation of the impact of pelvic fractures. 24.68 ± 10.86, asmd = 0.15).patients in group i had higher number of genitourinary surgery (p = 0.04), exploratory laparotomy (p = 0.03). therequirement of angio-embolization was similar in between two groups (p = 1.00). while there were no difference in mortality (or 0.69, 95% ci 0.31-2.15, p = 0.82), group i had higher odds of severe sepsis (or 1.42 95% ci 1.19-2.92, p = 0.03) and ventilator-associated pneumonia (or 3.64, 95% ci 1.74-9.72, p = 0.01) conclusions: pelvic fractures in polytrauma patients did not translate into higher mortality. however, there was an increased risk of sepsis and vap. evidence-based management at tertiary care specialized centers can further enhance the outcomes. investigation/results: ap pelvis x-ray reveals a complex left proximal femur fracture with neck and trochanteric extension. a ct-scan was obtained and showed a complex fracture pattern with subcapital and trochanteric extension. blood analysis showed a hemoglobin of 8.6 g/dl. diagnosis: therapy and progressions: at admission, patient refused erythrocytes'' concentrate transfusion and was hospitalized for pain control and hemodynamic stabilization. despite alternative measures such as intravenous iron supplementation and erythropoietin, hemoglobin values remained lower than 7.8 g/dl, thus preventing any surgical procedure. at day 12, patient finally decided to accept packed red blood cells and was then transfused. at day 14 and with a hemoglobin of 11.8 g/dl, the patient was finally submitted to a total hip arthroplasty with an uncemented revision femoral stem. at day 15, the patient initiated the rehabilitation protocol with hospital discharge at day 21 with a hemoglobin of 10.2 g/dl. comments: proximal femur fractures arise as one of the major problems of present traumatology. comorbidities frequently prevent surgical treatment within the golden hour (first 48 h) and thus limiting the postoperative results. in this particular case, a timely surgical approach would have made it possible to try a more conservative procedure with femoral osteosynthesis. the surgical delayed due to low hemoglobin values limited the surgical options and forced a more aggressive procedure. routine versus on demand removal of the syndesmotic screw; a multicenter randomized controlled trial on functional outcome introduction: syndesmotic injuries are common, being present in approximately 15-20% of surgically treated ankle fractures 1 . one of the most commonly used ways of fixation is the syndesmotic screw (ss). traditionally, this screw is removed after 8-12 weeks as it is thought to hamper ankle function and cause pain. however, a recent study showed that implant removal does not always result in improvement of functional outcome 2 . with the relatively high complication rate of implant removal in mind, retaining sss could be beneficial. we therefore aimed to investigate the effect of retaining the ss on functional outcome. material and methods: in this multicenter rct, patients were randomized between routine and on demand removal (upon patients request). the primary outcome was functional outcome at 12 months after ss placement, measured by the olerud-molander score (omas) with a non-inferiority limit of 10 points (90% power, a = 0.025). secondary outcomes include quality of life, range of motion, complications and costs of ss removal. results: a total of 197 patients were randomized, of which 93 for routine removal and 104 for on demand removal. the mean age was 45 years old and 63% was male. follow up of all participants will be completed in march 2020. results of the primary outcome analysis are therefore not yet available, but will be at the conference. conclusions: if on demand removal of the ss is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. this means that patients will not have to undergo a secondary procedure, resulting in fewer complications and subsequent lower costs. introduction: treatment options for pertrochanteric fractures of the hip are extra-or intramedullary fixation. the aim of this study is to identify risk factors for the development of complications: varus deformity, neck shortening, revision and cut-out. material and methods: retrospective cohort study in which radiographs of patients with pertrochanteric fractures, treated at the uz brussel between 2008 and 2016, were reviewed. fracture type, type of the device, cut-out and revision where noted. measurements for the centrum-collum-diaphyseal angle (ccd) of the two hips, impaction, tip apex distance (tad), parker''s ratio were realized. statistical analyzes were made with logistic and multiple linear regression analyzes. results: 248 patients were included. bmi (p = 0,043), type of osteosynthesis (p = 0,024), dhs ? plate (p = 0,006), short nail (p = 0,011) and the tad (p = 0,000) are independent risk factors for the development of varus deformity after consolidation. for impaction are bmi (p = 0,005), short nail (p = 0,000), long nail (p = 0,000) and fracture type a1 (p = 0,001) independent risk factors. we identified a marginal statistical significant risk factor for cut-out: tad (p = 0,051). conclusions: 31,4% of the patients had varus deformity after consolidation. the risk of varus deformity rises with a higher bmi and a higher tad. the risk for this complication was higher when using a nail. neck impaction was shown more together with a high bmi and less in fracture type a1 and with the use of a short or long nail. in the prevention of cut-out, it is important to keep the tad low. case history: 85-year old female with previous distal femoral plating (17 years ago) and ipsilateral proximal femoral nailing (2 months ago) presented with a diaphyseal femur fracture. clinical findings: extremity was swollen, painful, neurocirculatory intact, no shortening or external rotation was seen. she was unable to lift her leg. scars showed no sign of infection. investigation: x-ray revealed a spiral fracture including distal pfna locking screw, unhealed proximal femur fracture without loss of reduction, protruding pfna blade and a healed distal femoral fracture. diagnosis: peri-implant fracture classification proposed by the singapore group presented a discrepancy between nail type 1 subtype b and plate type 2 subtype. by simplification, we disregarded the distal (healed) fracture to choose the first option. therapy: firstly, the distal femoral plate was removed as the preoperative simplification dictated. secondly, pfna distal locking screw was removed and the pfna blade shortened. after open reduction 2 cerclage wires were applied. a long lcp plate was initially fixed through the plate and pfna locking hole, adjusted in line, fixed proximally with 8 screws through a locking attachment plate and 1 cerclage, distally 5 locking screws were used. comments: distal femoral callus prevented the use of a long nail. as the proximal fracture was not yet healed, we avoided full implant removal. as the pfna was unstable, fixation through the plate and pfna distal locking hole enabled implant coupling to strengthen the construct. the plate covered the entire bone to bridge the possible loci minori left by the plate removal and minimize stress risers. background: we have been reported the usefulness of intra-medullary antibiotics perfusion (imap) and intra-soft tissue antibiotics perfusion (isap) for suppressing open fracture and bone infection. imap and isap was a method of antibiotics delivery with the continuous administration of high-dose aminoglycosides. however, the best dose was not obviously. the purpose of this study was to evaluate translation of aminoglycosides from imap or isap. as follows: 11 males and 8 females, average age was 54.9 years old, 10 intramedullary nails and 9 plates. one dialysis patient was including. we measured concentration of gentamicin from imap, isap and in blood, outflow. results: average administration concentration of all cases was 1236.67 lg/ml. average blood concentration of all cases was 1 lg/ml and outflow concentration were 1107.77 lg/ml. average blood and outflow concentration of each dosage were shown as follows: 600 lg/ ml: 0.6 lg/ml, 868 lg/ml, 1200 lg/ml: 0.83 lg/ml, 1135.1 lg/ml, 1600 lg/ml: 1.9 lg/ml, 4800 lg/ml, 2400 lg/ml: 1.03 lg/ml, 547.5 lg/ml. in dialysis patient case, 1200 lg/ml administration lead concentration of blood as 2.46 lg/ml, outflow as 822 lg/ml. side effect were not observed. discussion: local antibiotic administration using imap and isap showed increasing blood concentration depend on administration dose. under 2400 lg/ml administration dose showed safe blood concentration(\ 2 lg/ml). on the other hand, 2400 lg/ml administration dose achieve trough concentrations over 100-1000 times of minimum inhibitory concentration. furthermore, we need to pay attention for administration dose in dialysis patient case. conclusion: 2400 lg/ml administration dose achieved safe and effective local concentration. introduction: distal radius fractures and supracondylar humerus fractures are two of the most common fractures seen in children. most can be treated with non-operative treatment but a small number require operative reduction and surgical stabilisation, often with percutaneous kirschner wires. this study aims to identify whether an early review is required before planned removal of the wires. materials and methods: retrospective review of paediatric patients undergoing surgical reduction and stabilisation with percutaneous kirschner wires for upper limb injuries. data collected over threemonth period (june-august 2019). number and type of outpatient reviews, imaging episodes and clinical interventions recorded. results: 45 consecutive patients with mean age 9 years (range 4-15). 35 distal radius fractures and 10 supracondylar humerus fractures. 3 patients transferred to another unit. 41/42 patients received a 2 week check and then a second review where the wires were removed. mean time to first outpatient review 10.5 days (sd 7.6). at initial appointment all patients had a change of cast and a satisfactory radiograph. mean time to second outpatient review was 26.9 days (sd 7.9). at the second appointment 33/41 patients had the wires and cast removed and subsequent satisfactory radiograph. 8/41 required a further period of casting. 19/41 had a third appointment. 4/41 required formal physiotherapy after cast removal. there was one transient anterior interosseous nerve palsy after supracondylar fracture stabilisation. clinical union of the fracture and good functional outcome was seen in all cases. conclusion: the initial outpatient review at 1-2 weeks allows a lighter weight cast to be applied but in this series the radiograph taken after the cast was changed did not alter management. our findings support a cast change alone at 2 weeks and then clinician review with radiographs at the time of wire removal. introduction: the aim of this study was to describe surgical technique, report on patient-based functional outcomes and complications following open reduction and internal fixation in patients with scapular fractures. methods: the study comprised 14 patients who were treated with open reduction and internal fixation (orif) of a scapular fractures between september 2010 and july 2018. surgical indications were as follows: medial/lateral displacement greater than 20 mm; shortening greater than 25 mm; angular deformity greater than 40°; intraarticular step-off greater than 4 mm and double shoulder suspensory injuries (including fracture of clavicle, coracoid or acromion with displacement greater than 10 mm). all patients underwent x-ray examination (true ap, y scapular view) and computed tomography (ct) scans. fractures were classified according to the revised (ao/ota) classification system. functional outcome were measured using the constant-murley score. results: seven patients had glenoid fossa fracture, six patients had scapular body fracture and one patient had acromion process fracture. all glenoid fossa and scapular body fractures were exposed via the judet approach. eleven of 14 patients were reviewed with constant-murley score at the final follow-up examination, three patients were lost for follow-up. the mean follow-up after injury was 44 months (6-92 months). we found in four patients infraspinatus muscle hypotrophy. mean constant-murley score was 93.45 (± 8.93) for injured arm and 98.36 (± 2.91) for uninjured arm. mean score between injured and uninjured arm was 4.91(± 6.49) which is excellent functional outcome according to grading the constant-murley score. conclusions: open reduction and internal fixation of displaced scapular fractures is a safe and effective treatment option that results in reliable union rate and good to excellent functional outcome. introduction: the aim of this study was to evaluate clinical and radiological results of intramedullary radius and ulna nails in treatment of adult forearm fractures. methods: the retrospective study included 21 patients who were treated with intramedullary nailing of forearm fractures between january 2010 and september 2017. the medical records and radiographic images of all patients, taken preoperatively and postoperatively, were reviewed. fractures were classified according to the ao/ota classification system by reviewing the radiographs. we analayzed time to union, union rate, clinical outcome and complications. results: primary intramedullary osteosynthesis were performed in 17 patients with forearm diaphyseal fractures. the average time to union was 2 months (range, 2-4 months) in primary osteosynthesis cohort. secondary intramedullary osteosynthesis were performed in four patients following removal of plates and screws due to pseudoarthrosis. the average time to union was 4 months (range, 2-6 months) in secondary osteosynthesis cohort. overall union rate was 95,24% in 21 forearms with fractures or pseudoarthrosis of the radius, ulna, or both bones, which were treated with intramedullary nail with compression screw. overall complications were one nonunion, one postoperative rupture of the extensor pollicis longus tendon and one postoperative transitory radial nerve palsy. conclusions: intramedullary nailing of adult forearm fractures is a safe and effective treatment option that results in reliable union rate and good to excellent clinical outcome. key words: forearm fractures, intramedullary nailing, biological fixation, union rate results: transverse or short oblique fractures of the middle third of the humeral shaft were treated using a retrograde approach. spiral fractures of the middle third of the humeral shaft were treated through the antegrade approach. comminuted fractures of the proximal third of the humeral shaft were treated mostly through the antegrade approach. comminuted fractures of the distal third of the humeral shaft were usually treated using the retrograde approach. whenever possible, we prefer retrograde insertion because the approach through the shoulder joint is avoided. reduction with retrograde nailingnis easier because upper arm was placed on the radiolucent operating table extension. interlocking screw insertion by freehand techique is also easier to perform because there is no danger of radial nerve injury. nonunion was found in eight patients (1,8%). there were five patients (1,1%) with postoperative transitory radial nerve palsy that fully recovered within 6 months. conclusions: the choice of approach to the medullary canal depends on the fracture type and the fracture site. therefore, antegrade nailing should be performed for proximal third humeral shaft fractures and complex middle third humeral shaft fractures, while retrograde nailing should be perforemd for distal third humeral shaft fractures and simple transvese or short oblique middle third humeral shaft fractures. keywords: humeral shaft fractures, intramedullary nailing, radial nerve palsy, nonunion the diaphyseal aseptic tibial nonunions after failed previous treatment options managed with the reamed intramedullary locking nail i. kostic 1 , m. m. mitkovic 2 1 clinical center nis, university hospital, orthopaedics and traumatology, nis, serbia, 2 university of nis, serbia, orthopaedics and traumatology, nis, serbia introduction: in this article, we present our approach to the surgical treatment of noninfected tibial shaft nonunions. material and methods: between 2014 and 2016, 33 patients with aseptic diaphyseal tibial nonunion was treated by reamed intramedullary nailing and were retrospectively reviewed. all patients, preoperatively, were evaluated for the signs of the infection, by the same protocol. results: the time that elapsed from injury to intramedullary nailing ranged from 9 to 48 months (mean 17 months).open intramedullary nailing was unavoidable in 25 cases (75,75%), while closed nailing was performed in 8 patients (24,25%). all patients were followed up in average period of 2 years postoperative (range 1-4 years), and 31(93,9%) patients achieved a solid union within the first 8 months. conclusions: in conclusion, a reamed intramedullary nail provides optimal conditions for stable fixation, good rotational control, adequate alignment, early weight-bearing and a high union rate of tibial non-unions. percutaneous figure of 8 suture as a novel technique for treating closed tendinous mallet injuries following failed splinting therapy. t. eltantawy 1 , a. yousif 1 , k. maheshwari 1 , a. hartpinto 1 1 bedford hospital, plastic surgery, bedford, united kingdom introduction: mallet injuries are common injuries affecting the hand. majority of them are managed using conservative method, however a small percentage of patients that do not do well on conservative treatment need an operative intervention. we wish to evaluate the efficacy of percutaneous figure of 8 suture as a new technique for treating closed tendinous mallet injuries resistant to splinting therapy, as a minimally invasive treatment option. material and methods: we present a case series of 5 patients who had persistence of more than 30 degree extensor lag, despite splinting minimally for 9 weeks. all of these were treated with a percutaneous figure of 8 suture placed across the dorsum of dipj, which provided splinting for further 4 weeks. this technique provides fixation for the dipj in hyperextension position by going through the periosteum on both sides and was done under local anaesthesia. results: the mean age of our patients was 40 years, with a single digit involved in all patients. all the five cases had nearly fully straight dipj with less than 10°extensor lag following 4 weeks of percutaneous stitch placement. there was no further recurrence with mobilisation or overlying skin necrosis. conclusions: percutaneous figure of 8 suturing technique can be an effective, minimally invasive and safe technique to treat closed tendinous mallet injuries not responding well for conservative splinting. introduction: osteosynthesis of pertrochanteric fractures (pf) is a frequently performed procedure in orthopaedic trauma care. dynamization of the osteosynthesis during fracture healing can lead to dynamization of the lag screw. which can cause debilitating complaints. a spontaneous femoral neck fracture (sfnf) after implant removal was seen in 5 patients over a 6 month period. based on these 5 cases we evaluate the different aspects of the pathophysiological and mechanical mechanisms of lag screw dynamization, complaints and complications in pf healing. material and methods: pubmed search on incidence of chronic pain, gait impairment associated with dynamization of osteosynthesis, risk factors for dynamization and complications after implant removal. based on research data preventive recommendations are suggested. results: literature describes complaints as reduced mobility, gait impairment and chronic pain in association with lag screw dynamization. an important risk factor is the ao-classification of pf, a2 type fractures are significantly associated with more dynamization and the onset of trochanteric pain and gait disturbances. partial implant removal can reduce complaints in the majority of symptomatic patients, and induce symptoms in 20% of asymptomatic patients. literature study shows a sfnf after lag screw removal with an incidence of 15%, affecting mostly vulnerable elderly patient resulting in a high mortality rate. risk factors associated with an increased risk of this complication are pre-existing systemic osteoporosis, stress-shielding, pre-loading of the implant. most importantly the removal itself, a sfnf with the implant in situ is very uncommon. conclusions: the clinical indications for implant removal in healed pf are not well established, and should be restricted to specific cases. after removal, partial weight bearing and good patient counselling is extremely important. replacement with shorter lag screw should be considered. metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with a spray on their surface of hydroxyapatite and 1% silver v. protsenko 1 , a. abudayeh 2 , v. chornyi 2 , y. solonitsyn 1 1 institute of traumatology and orthopedics of nams of ukraine, onco-orthopedics, kiev, ukraine, 2 bogomolets national medical university, kiev, ukraine introduction: surgical intervention in the case of pathological bone fracture against the background of metastatic lesion involves performing osteosynthesis. for more effective integration of the metal plate with the bone, a material based on bioactive glass was sprayed on their surface. bioactive glass-based material is an osteoinductive and osteoconductive biomaterial that integrates quickly with bone, forms a bone-ceramic complex, and is transformed into bone over time. material and methods: metal osteosynthesis of pathological bone fractures with metastatic lesion of plates with spraying on their surface of hydroxyapatite and 1% silver was performed in 12 patients. the functional result of the operated limb was calculated on the msts scale. evaluation of pain was performed on the scale of r.g. watkins. the quality of life of patients was evaluated using the eortc qlq-c30 system. the evaluation of the integration of the plate with the bone was performed by radiological examination and by osteoscintigraphy. results: postoperative complications were found in 1 (8,3%) patient, recurrence of metastatic tumor was noted in 2 (16,7%) patients. the functional result of the operated limb after metal osteosynthesis was 76,8%. the degree of pain decreased from 92,2% to 24,6%. the quality of life of patients after metal osteosynthesis improved from 38 to 74 points. x-ray examination revealed the formation of callus within a shorter timeframe, as evidenced by the more intense accumulation of radioisotope during osteoscintigraphy. introduction:the aim of this study was to evaluate the results in patients who had heal intertrochanteric fracture but did not receive adequate mobilization and rehabilitation support. material and methods:sixty patients over 70 years old age were included in our study. the rehabilitation emphasized pain relief, muscle strength, range of motion, endurance, balance challenges, and proprioceptive enhancement for all patients. it started postoperative first day and was delivered twice a day by the physical therapist until discharge. patients were discharged on average 7.4 days (2-20 days) after surgery. the mobilization of patients was evaluated with the parker and palmer mobility scoring system, the clinical evaluation was performed with the haris hip scoring and daily living activities were evaluated with the barthel life index before and at the end of the fracture. results:34 female 26 male patients were included in our study. the mean age was 75,2 (70-84) years and the mean follow-up period was 25,5 (10-40) months. 35 patients had a1 type, 25 patients had a2 type intertrochanteric femur fracture. in the last follow-up, all patients had fracture union. patients' mobility, daily life activity and clinical evaluations were found to be statistically significantly worse in the last control than before surgery. conclusions:the success of the surgical treatment and the union of the fracture after fixation are not sufficient for the successful mobility,daily life activity,and clinical results.the success in the functional results are significantly related with the ambulatory ability.although early mobilization and rehabilitation support are important in intertrochanteric femur fractures after surgery,the continuity of mabilization and rehabilitation support after hospital discharge is more important.the rehabilitation which administered by the patient''s ralations after hospital discharge is not sufficient.therefore,the importance of home-based rehabilitation is increased. the prognostic value of the hip screw position in trochanteric fractures i. gárgyán 1 , î csonka 1 , t. ecseri 1 1 university of szeged, department of traumatology, szeged, hungary introduction: in our study, we analyzed one of the hungarian population's most frequent injuries, the hip fracture, focusing mainly on the lateral femoral neck and the pertrochanteric fractures. according to the classification of the swiss association for ostheosynthesis (ao), we focused on 31-a1 and 31-a2 fractures, the incidence of which increases by ageing. material and methods: between 2010 and 2016, we analyzed the data of 1179 patients. all of the fractures were stabilized with intramedullary nails. 992 patients received stryker gamma3 ò , whereas 187 patients' fractures were solved with synthesis pfna ò nail. in all cases, closed reduction method was used with fluoroscopy on an extension table. the surgeries were done in general or epidural anesthesia and performed by traumatology residents or specialists using standard lateral exploration. data were collected using gepacs software and statistical analysis was done with ms excel. results: cut-out occurred in 33 cases (2,79%): out of that 21 (1.78%) were left sided and 12 were (1,01%) right sided. 29 (87.87%) patients were treated with gamma3 nail, and in 4 (12,12%) cases pfna nail was used. the average tad-index was 18 mm. conclusions: according to recommendations of the tad-index value, when using dynamic hip screw, it should be 20 mm or lower. the average index value was 18 mm which was equal in the complicated and non-complicated groups. our study shows that the cutout is independent from the tad-index value, thus this recommendation cannot be applied for intramedullary nails. oita university hospital, acute trauma, emergency, and critical care center, yufu, japan, 2 oita university, orthopaedic surgery, yufu-city, oita, japan introduction: dome impaction fragments (difs) in acetabular fractures are typically accompanied with anterior column fragments and recognized as the gull sign on plain radiographs. meanwhile there are some difs which do not fit into typical difs. the aims of this study were to define atypical dif and describe tips for diagnosis and intraoperative visualization. material and methods: this study was a retrospective case review. we defined atypical difs as the fragments which were independent of anterior column fragments and did not show the gull sign on plain radiographs. from jan 2012 to july 2019, there were 68 patients of acetabular fractures, and 15 patients (22.1%) had difs. among them, 3 patients (4.4%) were identified as the cases with atypical difs. all of them were male. the ages were from 55 to 68. results: the atypical difs were not obvious on x-rays (fig. 1) . all three atypical difs were located at posteromedial weight bearing zones of the acetabulum. case 1 and 2 were displaced in accordance with posterior column fragments, and were visualized clearly on the sagittal view of ct images (fig. 2) . case 3 was impacted posteriorly into a posterior part of the ilium as a free fragment, and well visualized on ct sagittal and coronal views. anterior intrapelvic approach was chosen in all patients to treat atypical difs. the iliac oblique view was useful to visualize the atypical difs intraoperatively in case 1 and 2. in both cases, the reverse gull sign appeared after reduction of posterior column fragments (fig. 3) . in case 3, the inlet view was useful to visualized the atypical dif intraoperatively.the fragments were reduced and fixed with supra-acetabular screws (fig. 4) . results: we found prospective two to 10 years after acetabular osteosynthesis 64,04% complications. avn of the femoral head was present in 5,55% of the hips reduced within 24 h and 27,77% of the hips reduced more than 24 h after the injury [p = 0,013; 9 2=4,94; or = 25 (95% ci = 1,29-1121,5) ]. post-traumatic oa of the hip we found in 23,07% (fig. 1 ) infections we found in 5,1% (1 deep, 1 superficial), iatrogenic nerve palsy in 1 (2,56%), traumatic nerve palsy in 15,38% (6), dvt in 5,12% (2) , and ho in 10,25% (4) cases. in one case (2,56%) revision surgery was done. conclusions: acetabular fractures are followed with complications. some complications depend on surgery, meanwhile others cannot be affected on (type of fracture, impaction of acetabulum, injury of the femoral head, dislocation of femoral head). good knowledge of acetabular anatomy, surgical technique, experienced surgical team, early surgery, anatomical reduction and stable orif, early mobilization, can significantly influence excellent/good functional outcomes and reduce possibility for complications. introduction: reduction is one of the important factors in surgical treatment of femoral trochanteric fractures. in this study, postoperative reduction status was examined and the relationship between this reduction status and unsatisfactory cases was investigated. material and methods: 135 cases of femoral trochanteric fractures over 65 years treated with pfna-ii were investigated. postoperative reduction status was evaluated in ap and lateral view of x-ray and ct. anatomical reduction means medial or anterior cortex is reduced anatomically (abbreviation am and aa). intramedullary reduction means medial or anterior cortex of proximal fragment is inside the shaft (im, ia). extramedullary reduction is medial or anterior cortex of proximal fragment is overlapped to cortex of shaft (em, ea). unsatisfactory cases were ununited cases until 6 months and excessive sliding cases over 10 mm. reduction status of these cases was evaluated. results: postoperative status was classified with combination of medial and anterior reduction status. so there are nine groups and number of each group are as follows; im-ia:6 case, im-aa:5 cases, im-ea:0 case, am-ia:14 cases, am-aa: 46 case, am-ea:4 cases, em-ia:17 cases, em-aa:32 cases, em-ea:12 cases. non-united cases until 6 months were 29cases. reduction status of non-united cases were; im-ia:2 cases, im-ea:3 cases, am-ia:4 cases, am-aa:6 cases, em-ia:8 cases, em-aa:6 cases. there was no case in extramedullary reduction of anterior cortex. excessive sliding of blade over 10 mm was 11cases. there was also no case of extramedullary reduction of anterior cortex in these 11 cases (2 cases were cut out). conclusions: our results show there are no ununited cases and excessive sliding cases in extramedullary reduction of anterior cortex. this means extramedullary reduction of anterior cortex is important to reduce unsatisfactory results in surgical treatment of femoral trochanteric fractures. male injured open lateral condyle fracture of femur by to be bitten by a pig. after 5 months from initial debridement, i confirmed the size of bone defect was 3 cm(2) 9 3 cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after 7 months from bone transplantation, i confirmed bone union and two 6.5 mm diameter osteochondral grafts and 4.5 mm diameter osteochondral graft were transplanted for the chondral defect lesion. case 2; seventy year old male injured open lateral condyle fracture of femur by traffic accident. after 3 months from first debridement, i confirmed the bone defect (size 7 cm(2) 9 3 cm in depth) and the same size of bone was harvested from iliac crest and transplanted in the bone defect area. and simultaneously two 10 mm diameter osteochondral grafts were transplanted for the chondral defect lesion. case 3; 37 year old male injured open lateral condyle fracture of femur by traffic accident. i confirmed the size of bone defect was 6 cm(2) 9 3 cm in depth. the same size of bone was harvested from iliac crest and transplanted in the bone defect area of lateral condyle of the femur. after 1 month from bone transplantation, he had undergone autologous chondrocyte implantation. investigation/results: at last follow-up, average flexion angle of knee was 147 degrees. in all cases, lysholm knee scoring scale was good. diagnosis: large traumatic osteochondral defect of the weightbearing articular surface of the knee comments: treatment of large traumatic osteochondral defect of the weight-bearing articular surface of the knee is a difficult condition to treat. combination of bone transplantation and osteochondral autograft transfer or autologous chondrocyte implantation is useful strategy for the injury. references: tegner y., lysholm j., clin orthop relat res., 198, 43-108, 1985 pr 264 treatment of double tension band wiring method with ai wiring system for transcondylar distal humeral fractures m. uchino 1 1 hakujikai memorial general hospital, orthopaedic surgery, tokyo, japan introduction: as ai wiring system is united the pin with the cable due to compressed sleeve, the pin is never deviated. we review the treatment of transcondylar distal humeral fractures with ai wiring system in geriatric patients. patients and methods: 6 were identified as receiving this surgery. all patients were female and their mean age was 68 years. they were assessed union rate, range of motion for elbow joint, postoperative complication and functional outcome for japanese orthopedic score. results: union rate was 100%. the mean arch of motion was 95°at latest follow-up. the complications were detected 3 cases which were temporary ulnar palsy for 2 cases and hardware failure for 1 case. the average of functional outcome was 73 points (73/100). conclusion: tension band wiring of transcondylar distal humeral fractures with ai wiring system provides stable fixation for osteoporotic bone and tiny fragment. introduction: the purpose of this study was a comparative evaluation of the complications related to the treatment of trochanteric fractures using 2-screw proximal femoral nail (pfn) versus proximal femoral anti-rotational blade nail (pfna). material and methods: a retrospective review was conducted between march 2013 and march 2019. the study included 519 patients treated surgically for trochanteric fractures. the mean age was 79,8 ± 12,0 (24-100) years. patients were treated by pfn (393 patients, 75, 7%) or by pfna (126 patients, 24,3%). implant related complications were the primary objectives. infection and revision surgery were also recorded. results: complications were observed in 38 (9.7%) patients in pfn group and 7 (5,6%) patients in pfna group (p = 0.15). screw backout (n = 11) and cut-out (n = 11) occurred in 5,6% patients treated with pfn. in the pfna group, cut-out occurred in 1,6% (n = 2) of cases. infection (n = 3) represented 2,4% in pfna patients and 2,3% (n = 9) in pfn group. there were no statistically significant differences in both groups considering implant-related complications (p = 0,14) and infections (p = 1.0). revision surgery was performed in 7 (1,3%) patients. soft tissue problems are more likely in fractures due to high energy impact than low energy type fractures. high energy type present with horizontal fractures of tibia and fibula (i.e. on the same level), whereas in low energy type tibia fractures they present with spiral or oblique fracture patterns often associated with concomitant fractures of the posterior rim of the distal tibia (i.e. volkmann's triangle). posterior malleolus fractures occur regularly but are often missed and seen only on ct scans obtained either for preoperative planning or to verify postoperative rotation. in literature these mostly undisplaced fractures are treated with screw fixation mostly from anterior. but is this really necessary? material and methods: we retrospectively analysed 21 consecutive tibia shaft fractures operatively treated over the past 2 years at our regional hospital analysing the fracture pattern. results: out of 21 patients with tibia shaft fractures 9 patients presented with a posterior rim fracture of the tibia. no routine stabilisation of the volkmann fragment was performed, in all cases the posterior rim fragments healed uneventful. angles of 60°and above seem to present themselves with a concomitant fracture of the posterior malleolus. they are mostly undisplaced and the trauma mechanisms is low energy and torsion. none out of the 9 patients had known osteoporosis. conclusions: low energy and torsion-type tibia fractures with an angle of [ 60°seem to have an accompanying undisplaced fracture of the posterior malleolus. these fractures are usually undisplaced and do not need to be addressed. as a consequence there seems to be no need to actively rule them out with ct scans prior to surgery. concomitant ankle fractures including posterior rim fractures should be addressed like isolated ankle fractures. the dangers of bouncing: a prospecive cohort study of injuries associated with trampolines and bouncy castles over a 3 month period in a paediatric population. introduction: within the orthopaedic paediatric population, there is an increasing incidence of presentation of fractures associated with both trampolines & bouncy castles. whilst this phenomenon has been depicted frequently within the media in recent years given the dramatic upsurge in trampoline and bouncy castle usage, there have been few studies documenting either the incidence of fractures associated with either. materials and methods: this was a prospective cohort study conducted within our institution over a 3 month period june to august inclusive 2019. all paediatric patients who sustain a fracture and present to the national childrens'' hospital are referred to the orthopaedic department either whilst as an inpatient or as an outpatient depending on the assessment of the severity of injury. a standardised mixed questionnaire was given to all parents''/guardians which recorded the type of injury, type of trampoline/bouncy castle, inherent awareness of safety precautions governing the usage of either and application of same was recorded. the type of fracture was corroborated via examination of x-ray in addition to the recording of any complications via examination of clinical chart records. results: there were 88 patients who sustained a fracture directly related to the usage of either a trampoline or bouncy castle for which the majority required operative intervention. there was wide variability in the nature of injuries recorded; supracondylar/radial fractures were the most common whilst more complex injuries such as an open fracture of the femur was rarer. conclusions: awareness and application of necessary safety precautions was low (38%) amongst parents'' supervising parents''/guardians highlighting the need for greater public awareness of same. furthermore, the incidence of severe injury relating to usage of trampolines/bouncy castles is not uncommon highlighting the high risk activity that trampolining is. introduction: conventional plate fixation (pf) of distal fibular fractures in elderly patients is associated with a high risk of wound and implant related complications. intramedullary fixation (imf) using a fibular nail is a minimally invasive alternative to pf that provides superior biomechanical strength and allows immediate full weight-bearing postoperatively. aim: to compare the postoperative complications of minimally invasive intramedullary nail fixation to conventional pf for lauge-hansen supination external rotation type 4 fractures in patients aged 65 years or older treated in a single geriatric trauma unit in the netherlands. methods: a retrospective cohort study was performed including unstable ankle fractures in patients aged 65 years or older treated with either imf or pf between 1 january 2017 to 1 january 2019. the primary outcome measure was the total number of wound related complications. results: a total number of 58 patients were included with a mean age of 73.9 years (range 65 to 95). the imf-cohort (n = 13) had a significantly higher mean age (82.5 versus 71.4 years, p = 0.002) and charlson co-morbidity index (4.7 versus 3.6, p = 0.005) compared to the pf-cohort (n = 45). the total number of postoperative complications was lower after imf (31%) compared to pf (53%), although this relative difference was not statistically significant (p = 0.152). all 4 complications observed in the imf-cohort were wound related but demanded no debridement or implant removal. wound related complications did not differ significantly from pf (31% versus 44%, p = 0.378). no implant related complications, hospital-acquired complications or mortality were observed after imf. conclusion: despite the higher mean age and co-morbidity status of patients treated with a minimally invasive intramedullary nail, the total number of postoperative complications was lower after imf compared to pf. this technique might be a promising alternative in a selected group of patients. the authors declare that they have no commercial associations that might pose a conflict of interest. no funding or other compensation was received for the research, authorship or publication of this article. gustilo type ii and 4 gustilo type iii fractures. the treatment protocol was external fixation at admission and definitive osteosynthesis with plate at 15 ± 7 days. a single approach to the tibia was performed in 32 patients, and a combined anterior and posterior approach was used in 9. the incidence of complications was 50%: 15 cases of poor soft tissue evolution, of which 7 were infections. 9 patients evolved to nonunion. osteoarthritis appeared in 100% of patients (70.73% grade 3), and only one patient needed arthrodesis. 15.91% had a valgus ldta (\ 86°) and 38.64% a varus deformity ([ 92°). we found a significant relationship between the history of open fracture and the development of complications (p \ 0.05). we found no relationship between the incidence of complications and the approach. conclusions: tibia ao43c fractures have a high percentage of complications and evolve to well-tolerated osteoarthritis. open fracture seems to significantly influence the poor postoperative outcomes of these patients. clinical findings: a 24-year-old male, who suffers a closed chest trauma with pneumothorax, right pulmonary contusion and poor pneumoperitoneum. also a grade iiia open fracture of the right femur, with a 10 cm bone defect. investigation/results: upon arrival at the hospital, he needs orotracheal intubation, as well as blood transfusion with 9 red blood cell concentrates. external fixator is placed on the right femur. diagnosis: a iiia grade diaphyseal open fracture of the right femur with 10 cm bone defect, bearing external fixator with one broken proximal pin and positive culture for s maltophila in the distal pin. therapy and progressions: antibiotic treatment and medical optimization are performed, cemented intramedullary nailing (t2-stryker) with antibiotic (vancomycin-tobramycin), as well as cement spacer with antibiotic (masquelet's first stage) in the defect area. in second time, withdrawal of spacer and contribution of ria autograft of contralateral femur and allograft respecting membrane. the patient begins the protected weight bearing with two crutches immediately, without using them 3 months after the surgery. bone consolidation without pain or limitation after 1 year. comments: the induced membrane technique is a simple and effective technique for the reconstruction of segmental bone defects and can be used as a first time technique together with the initial stabilization, leaving the defect ready for graft delivery in the second time. introduction: carpal metacarpal dislocation is a rare entity that accounts for less than 1% of all carpal injuries. dorsal dislocations are the most common and occur most frequently after violent trauma in young individuals and are easily overlooked and may lead to longterm sequelae. material and methods: we present the case of a carpal metacarpal dislocation from d2 to d4. male, 40 years old, no relevant personal history. brought to the emergency service after a motorcycle accident with projection. he had a symphysis pubis diastasis, a distal radius fracture on the right wrist and a fracture of the left forearm bones. no other apparent injuries associated. at week 4, he presented edema and dorsal deformity of the left hand associated with limited finger movements. neurovascular assessment was normal. the radiological evaluation showed a carpal metacarpal dislocation from m2 to m4. it was an unstable reduction so open reduction was performed, with debridement of fibrous material, until exposure of the articular surfaces, and reduction and fixation with k wires of the three metacarpals (from d2 to d4). similarly, m5 was stabilized with a k-wire due to clinical instability observed intraoperatively. results: it is necessary to reduce and stabilize these lesions to avoid vasculonervous compression and skin distress. open reduction is indicated in irreducible cases allowing debridement and excision or os of small osteochondral fragments and fixation of associated fractures. conclusions: combined dislocation of multiple metacarpals is a rare lesion that compromises the functional prognosis of the hand in the absence of adequate treatment. instability and post traumatic arthrosis are among the sequelae of this lesion. identify the lesion to allow the appropriate treatment usually leads to good results. case history: 16-year-old suffered direct trauma to his right hand after falling off his bicycle. clinical findings: on physical examination showed edema and bruising from the base of the thumb and thenar eminence, tenderness over the cmc joint and functional disability speacialy in pincer grasp. no neurovascular injuries investigation/results: the x-ray revealed a comminuted fracture of the base of the thumb metacarpal. diagnosis: we identifed a rolando fracture. therapy and progressions: on the day after the trauma, he was submited to open reduction and osteosinthesis with lateral-palmar plate and screws, through radiopalmar aproach of the thumb base. intra operatively no dorsal fragments werefound to be left undisplaced. two months after surgery, the patient went back to the hospital for sudden pain and inability to extend the thumb. clinically with rupture of the long extensor of the thumb. on the x-ray, the fracture was aligned. the latero-lateral tenorrhaphy with kessler suture was preformed and intraoperatively a bony spicule was identified in the proximal stump of the tendon, which was removed. 6 months after the initial trauma, the patient has a consolidated neck and no limitation of the mobility of the thumb. comments: rollando fracture is relatively rare in adolescents. the aim of treatment should be exact reduction usually with open technics. the main complications are stifness and early arthrosis. there are also records of conflicts with the plates and even rupture of the extensor tendon, so the radiopalmar placement of the plate was chosen. nevertheless, the rupture occurred due to conflict with an unidentified bone fragment during surgery causing an unexpected complication in this case. the immobilization necessary after tenorrhaphy could have caused joint stiffness, but in this case the teenager fully recovered after physical therapy case history: periprosthetic and periimplant femoral fractures are an increasingly frequent pathology. in many cases they are a challenge with limited or too aggressive therapeutic options. it is important to investigate new approaches that increase the arsenal of the orthopedic surgeon. the recently described mipo (minimally invasive plate osteosynthesis) approach for the medial aspect of the femur may seem like a dangerous procedure because of the anatomical structures that run along the medial aspect of the thigh, but it is a viable and useful option in selected cases. clinical findings: we present the case of a 54-year-old patient with a total hip replacement who presented a first periprosthetic vancouver b1 fracture of the femur that was treated with a lateral blocked plate. subsequently the patient presented a second supracondylar femur fracture below the first plate (vancouver c). investigation/results: after thinking over the possible therapeutic options, we decided to treat our patient by means of the medial femoral mipo approach with a long medially placed blocked plate, managing to stabilize the fracture and superimpose the plate on the previous implants without the necessity of removing the previous lateral plate. diagnosis: periprosthetic and periimplant supracondylar left femoral fracture. therapy and progressions: we used the surgical technique of the medial femoral mipo approach as described by apivatthakakul 1 . comments: we consider that the medial femoral mipo approach is a useful therapeutic tool to consider. it seems a safe and low-invasive option for the resolution of cases in which the lateral mipo approach is not a feasible option. references: 1 c. jiamton y t. apivatthakakul, « the safety and feasibility of minimally invasive plate osteosynthesis (mipo) on the medial side of the femur: a cadaveric injection study » , injury, vol. 46, n.o 11, pp. 2170 » , injury, vol. 46, n.o 11, pp. -2176 » , injury, vol. 46, n.o 11, pp. , nov. 2015 . posterior knee dislocation with neurovascular injury associated-a case report case history, investigation and diagnosis: a 58-year-old male was brought in after 4 h following a heavy straw bale fall. he presented with a posterior knee dislocation that had already been reduced and an open wound in the popliteal fossa. the limb was flushed and pale on the extremity, with absence of the pedis and posterior tibial pulses. stability tests revealed unstable knee in all axes. an anterior shoulder dislocation was diagnosed and reduced. therapy and progressions: an emergent surgery was performed, involving a transarticular external knee fixation and a femoro-popliteal bypass above the knee (angiogram revealed a stop sign at the level of the interarticular popliteal artery). he developed circulatory shock and was admitted to the intensive care unit. on the 1stpostoperative day(po) was diagnosed a compartment syndrome that was treated with fasciotomies. these incisions showed a slow but progressive evolution, that required vacuum dressings and underwent autologous skin graft on the 34thpo day. the external fixator was removed on the 41stpo day and rehabilitation was started. on a 5-month follow-up, the patient had a good evolution of the wounds, but a knee with valgus and anteroposterior laxity and severe complete peroneal, tibial and sural neurological injury, confirmed with electromyography, and neuropathic pain. introduction: isolated iliac wing fractures represent only a small part of all pelvic fractures. these fractures are associated with severe injuries, but are considered benign. the literature lack information about the function and quality of life of these patients. our objective was to evaluate the long-term effects of isolated iliac wing fractures. material and methods: patients with pelvic fractures treated at oslo university hospital, ullevaal, in the time period 2006-2016, were extracted from the local fracture registry. 403 patients were registered in this period. a search was also made in the hospital''s administrative electronic database for patients registered with diagnose code s32.3 in icd-10 in the same period. 37 patients were identified. in total, 13 patients had an isolated iliac wing fracture, and these were invited to a follow-up examination, including proms (eq-5d-3l and majeed score), clinical examination, and pelvic x-ray. results: nine patients agreed to participate in the study, median 7 years after the fracture (range 4-13). all of them were injured from high energy trauma, with mean niss 18, 3 (range 5-66) . four of the fractures were open, and seven of the patients had associated injuries. five were treated with internal fixation. the mean eq-5d vas was 84 (range 75-99). five patients reported pain, one of them related to the pelvic fracture. the mean majeed score was 87 (range 64-100). seven patients had sensory deficit in the lateral thigh. one patient had difference in range of motion between the two hips. the x-rays showed healed fractures in all the patients. eight of them showed ectopic ossification. conclusions: our study confirms previous studies that isolated iliac wing fractures are results of high energy trauma with severe associated injuries. however, the majority of this group of patients seem to have a good general state of health, which is in accordance with the general assumption of the injury as a benign one. fenton's syndrome-a case report of a common underdiagnosed entity case history: a right handed 54-year-old male, construction worker, was admitted in our emergency department, after a 3 meters fall. the authors report a case of fenton's syndrome in a politrauma scenarium. clinical findings: both right elbow and left wrist were painful, swollen and with a remarkable restriction of the range of motion (rom). patient also reported lower back pain. no neurovascular injuries were detected. investigation/results: x-ray and ct scan confirmed a fracture of a lumbar vertebra, fracture of the right olecranon and, on is left wrist, a carpal fracture-luxation mayfield 4 of both scaphoid and capitate associated with rotation of the last one proximal pole-fenton''s syndrome. diagnosis: this syndrome is an atypical presentation of perilunate fracture dislocation and, therefore, difficult to diagnose. few reports were found in literature. after an open reduction of the fractures, a definitive fixation with headless herbert screws was achieved. percutaneous kw and immobilization of the wrist were performed to further stabilization of the lunotriquetral joint. 12 weeks later consolidation was noted. a decrease of 15°in extension and flexion were detected when compared with the contralateral wrist. grip strength test was similar on both hands. osteosynthesis of the right olecranon was also realized. comments: a careful neurovascular assessment is important. although it is rare, injuries of median nerve were already reported associated to this complex fractures. open reduction and osteosynthesis are necessary due to the great instability and the risk of nonunion and osteonecrosis of the rotated proximal segment. introduction: intramedullary nailing has been popularly applied for the femoral shaft fractures. the current study aimed to analyze the femur geometry for development of implant design with 3 dimensional skeletonization. material and methods: we acquired computed tomography (ct) images of both femur reviewed in a single center from 2015 to 2017. the total 1400 participants were enrolled and they were divided into subgroups according to age (decades) and gender. each subgroup included 100 persons, respectively. these images are used to produce 3d samplings. with the skeletonization, we obtained the geometry parameter; (1) femur shaft length from the tip of the greater trochanter to the bicondylar line, (2) the minimum diameter of the medullary canal and its location, (3) anteroposterior (ap) diameter and lateral diameter of the entire femur, (4) radius of curvature (roc) of the femur (bowing). we compared all parameters according to sex and age. results: the average age of the participants were 54.0 years (range 20-89 years) and the number of each gender was exactly same. the femur length was 425.5 ± 37.6 mm (range, 337.4-516.0 mm) and the femur shaft length was 383.0 ± 35.6 mm (range 301.3-466.5 mm), both of them were longer in male (p = 0.002, \ 0.001). the minimum diameter of the medullary canal was 9.4 ± 1.9 mm (range 5.0-18.1 mm). the roc was 810.7 ± 202.5 mm (range 338. 3-1491.8 mm) . the rate of the minimum diameter less than 8 mm and 7 mm was 26.0% and 9.4%, respectively. the rate of roc with less than 750 mm and 700 mm was 28.5% and 21.3%, respectively. conclusions: this geometry analysis showed that there are mismatch problem between the current nail and the medullary canal in 9.4% and the roc of the femur was smaller than that of the current nail systems (1000-1500 mm). the result indicates potential mismatch problem in clinical cases and the problem can be resolved with newly designed nail system. the study was funded by national reserach foundation of korea (nrf-2018r1d1a1b07050224). safe zone of the infracacetabular screw: virtual mapping of 362 three-dimensional hemipelvises for quantitative anatomic analysis introduction: an infra-acetabular screw can provide increased stability in fixating acetabular fracture. we conducted this study to define the incidence of the safe corridor for infra-acetabular screw and to determine the correlation between the safe corridor and other demographic factors such as age, sex and height. material & methods: pelvis computed tomography (ct) of 182 participants was extracted with evenly age-and sex-allotted. 362 virtual three-dimensional (3d) model was generated. a search was performed to find the maximum-with corridor connecting two points. the entry and exit point was displaced in the template. the maximum diameter of each corridor was measured in automatic procedure. a minimum 5 mm corridor diameter, sate corridor, was defined as a cutoff for placing a 3.5 mm cortical screw in clinical setting. all data were presented as mean and range or mean and standard deviation. two-sample t test and regression analysis were used to compare difference between groups based on sex, age, and height. results: among 354 hemipelvis, 250 hemipelves (70.6%) satisfied a minimum safe corridor diameter of 5 mm. when divided into a subgroup by the patient's gender, the incidence of the safe corridor of a male group was statistically higher than a female group (82.0% vs 59.1%), with the mean corridor diameter of 6.24 mm (95% ci, 0.2) and 5.44 mm (95% ci, 0.2), respectively (p \ 0.001). in correlation analysis, only the height showed a positive correlation with the diameter of the safe corridor of a total population (r = 0.25; p \ 0.001). conclusions: the study provided the safe corridor was found in 81% of male and 69% of female, and the taller had the higher incidence of the safe corridor. the patient''s height was correlated with the corridor diameter of the infra-acetabular screw, whereas the patient''s age did not correlate with the corridor diameter. introduction: femoral neck fractures in middle-aged and older patients represent one of the most common orthopedic conditions. osteosynthesis, as a primary treatment option for femoral neck fractures has shown to have successful outcomes. however, this is not the case for old fractures. the purpose of this study was to evaluate the outcomes of treatment of femoral neck fractures in which cementless total hip arthroplasty was indicated. the aim of our study was to analyze the prosthetic failure, i.e., the reasons for unsuccessful outcome, in order to suggest the indications for primary osteosynthesis which could guide the femoral neck fracture management. material and methods: a total of 120 patients were analyzed in this study, with femoral neck fracture treated with osteosynthesis. reviewing the radiological findings, as well as the course of the treatment, we set up the criteria, on the basis of which we could advice the immediate implantation of total hip prosthesis for the femoral neck fracture. results: old fractures, varus deformity of the femoral head and neck, dislocation, as well as the comminuted fractures, are all factors affecting the surgical outcomes of osteosynthesis. additionally, medical and technical equipment of medical institution, personnel competence, and minutious surgical technique affect the treatment outcomes. introduction:proximal ulnar fractures are usually osteosynthesized by means of angle stable plate osteosynthesis. despite good functional results of this procedure, complications such as high access morbidity and disruptive osteosynthesis material with a high rate of material removal are described. the aim of our study was the development of a new locking nail and test setup for comparison with a plate osteosynthesis on artificial bones. material and methods: in our biomechanical laboratory, a jupiter 2b fracture of the proximal ulna was standardized on 20 sawbones and stabilized by means of the newly developed nail or anglestable posterior plate osteosynthesis. a servopneumatic testing machine, the specimens were flexed under a cyclic load (30-300 n) in the physiological range of movement of the elbow from 0°to 90°.the maximum elastic deformation of the specimens and the loosening of the implants were evaluated after 608 test cycles. results: the primary stability of the constructs at the anterior cortical bone after nail osteosynthesis was significantly greater (0.29 ± 0.13 mm) than in the angle-stable plate osteosynthesis (0.97 ± 0.30 mm, p \ 0.001).after passing through the test cycles, both implants showed a low loosening rate. in the area of the anterior cortex, the locking nail showed a significantly lower rate of loosening (nail 0.08 ± 0.06 mm, plate 0.24 ± 0.13 mm, p \ 0.001). at the dorsal cortex, there were no differences between plate and nail in both series of measurements. conclusions: intramedullary implants provide biomechanical benefits in fracture stabilization. good biomechanical results have already been shown in the literature after nailing olecranon fractures2. nevertheless, due to the complex anatomy and the resulting difficult implantation technique, ulnar nails could not prevail in practice. the presented nail allows a safe stability with simple surgical technique. introduction: adequate treatment of tibial plateau fractures is crucial to minimize patient disability, development of posttraumatic arthritis and subsequent need for a total knee arthroplasty (tka). however, due to the complexity of the fracture, adequate reduction cannot always be achieved which could result in the early conversion to a tka. in this study we introduce a quantitative 3d fracture assessment method and investigate whether it could help to identify patients that are at risk of conversion to a tka. material and methods: we retrospectively included 135 patients, who were treated for a tibial plateau fracture between 2003 and 2017. 16 patients developed severe posttraumatic arthritis and underwent conversion to a tka. from all patients, 3d models were created using the pre-operative ct-scans. for each patient, the 3d gap area between the fracture lines, representing an innovative combined gap and step-off measurement in 3d, was determined in order to quantify the displacement (figure 1 ). roc curve analysis was performed to determine a critical cut-off value for the 3d gap area. kaplan-meier survival curves were created to assess the association between 3d fracture anatomy and risk on a tka at follow up. results: a critical cut-off value of 700 mm 2 was found to give highest combined sensitivity and specificity for 3d gap area and the risk of tka at follow-up. kaplan-meier survival curves showed 98.9% knee survival (no tka) at 2 year follow up in the group with a gap area of \ 700 mm 2 , whereas in the group with a gap area of c 700 mm 2 a knee survival of 82.5% was found. at 10 year follow up knee survival was 97.9% and 63.8%, respectively, for the two groups (\ 700 mm 2 and c 700 mm 2 ). conclusions: we developed an innovative method to quantify the amount of displacement in 3d. pre-operative 3d fracture assessment could be used as an addition to the current fracture classification methods to help identify patients who have a high risk on conversion to tka at follow-up. introduction: soft tissue sarcomas (sts) in the anterior compartment of the thigh are frequent. the extent of quadriceps resection is controversial. the aim of the present study is to communicate our results in complete quadricectomies due to high-grade sts. material and methods: we present 8 sts, in stage iiib of the ajcc, with a mean craniocaudal diameter of 15 cm (9-25). there were 4 women and 4 men, with a mean age of 58 years (35-79). six were undifferentiated pleomorphic sarcomas, 1 myxofibrosarcoma and 1 clear cell sarcoma. in every case, total quadricectomy was performed with wide margins. posterior reconstruction with local muscle transfers was performed, expect for the younger patient, who received a vascularized contralateral vastus lateralis transplant. in all cases, complementary radiotherapy was indicated, and in 4 patients adjuvant chemotherapy. results: three patients required friedrich due to necrosis of the edges of the surgical wound. one patient died 50 months after the intervention as a result of multiple metastasis, and two due to medical complications after 1 week and 4 months, respectively. the average follow-up time for the rest was 28 months , with no local recurrence. as for functional outcomes, mean msts score was 20 (14-30), with deficit of active knee extension in most of them. the functional result of the patient with the vascularized muscle transplantation was excellent. all of them were satisfied with the results of the treatment. conclusions: quadricectomy provides good functional and acceptable cancer results, although it is not exempt from complications in frail patients. vascularized muscle transplantation, though complex, can improve functional results, especially in younger patients. introduction: operative treatment is a valuable option in displaced proximal and/or middle one-third diaphyseal humeral fractures. although plate osteosynthesis is preferred to intramedullary nailing, surgery can be complicated by radial nerve palsy. a helical plate could avoid this high-impact complication. to date there is however a lack of published evidence in literature, although recent asian case reports show promising results. material and methods: we retrospectively reviewed 16 patients who were treated with open reduction and internal fixation with a helical plate consecutively from october 2016 until august 2018 at az groeninge, kortrijk. a deltopectoral approach was used in combination with a distal anterolateral incision, whether or not in continuity. a self-molded long philos plate was used in the first 9 patients, while in our last 7 patients the a.l.p.s plate (zimmer ò ) was used. standard radiographs were obtained pre-and postoperatively. we retrospectively searched for complications, e.g. radial nerve palsy, infection and/or loosening. in autumn 2019, 12 patients were reassessed. patient''s general health status was evaluated using the eq-5d-5l score. constant-murley scores and dash scores were used for evaluating shoulder function and disability measures consecutively. results: all humeral fractures consolidated at 3 months. there were no radial nerve palsies due to surgery. one plate was removed after 1 year due to a late infection. with a minimum follow up of 1 year, the mean dash score was 22 (0-93) and the mean constant-murley score was 68 (33-95). the dash score was inversely proportional with the constant-murley score and patient''s general health status. conclusion: a helical plate avoids neurological complications with similar healing rates and good to excellent shoulder function at 1 year follow up in the treatment for proximal and/or middle one-third diaphyseal humeral fractures. the use of antibiotic-impregnated cancellous bone grafts in onestage surgery for chronic orthopaedic infection: preliminary clinical results k. dendoncker 1 , g. putzeys 1,2 1 az groeninge, tissue bank, kortrijk, belgium, 2 az groeninge, orthopaedic center, kortrijk, belgium introduction: the use of cancellous bone allografts is an established technique in reconstructive orthopaedic surgery. unfortunately, its use is generally avoided in the presence of a local infection. antibiotic impregnated cancellous bone grafts has shown its effectiveness as an local antibiotic delivery system [1] [2] [3] . in this clinical study, we report our first personal experience with the use of vancomycin-impregnated cancellous bone grafts in one-stage surgery for periprosthetic joint infections (pji) and fracture-related infections (fri). material and methods: between december 2015 and march 2019 nine patients were treated during a one-stage surgery with vancomycinimpregnated cancellous bone grafts, containing 1 g vancomycin per 10 cc bone. regular clinical, laboratory and radiographic follow-ups were performed for at least 6 months after surgery. results: the procedures included revision of 5 pjis (hip and humerus) and 4 fris (tibia, femur and clavicula). one tibia required further revision because of recurrent infection and one hip has an uncertain infection state, however the remaining 7 patients stayed free from infection during a follow-up of at least 6 months. interestingly, in one patient the vancomycin concentration could be determined in the drainage fluid from the wound. radiographic examination revealed no signs of osteolysis or loosening, good incorporation of the bone graft and progressive consolidation. conclusions: within the limits of the study, the use of vancomycinimpregnated cancellous bone grafts in one-stage surgery to treat pji and fri yielded positive outcomes in terms of clinical, laboratory and radiographic follow-up. this technique might offer new treatment strategies in often devastating injuries. references: 1. putzeys g., et al. orthopaedic proceedings. 2015; 97-b:supp_16, 145-145. 2 with the modified arthroscopic approach (group b). the prospective follow-up included the lysholm score, the subjective questionnaire of the ikdc score and the specifically extended oak score for clinical evaluation. the rolimeter ò was used to test the translational mobility of the knee joint. the statistical significance level was set at 5%. results: the follow-up was 28.5 ± 19.60 months and 30.6 ± 26.26 months postoperatively in group a and b, respectively. the subjective scores were tested. group a and b achieved a mean lysholm score of 70.3 ± 5.32 and 69.6 ± 19.82 points respectively. in the subjective ikdc assessment, group a achieved 67.3 ± 7.76 points and group b 65.9 ± 12.35 points. the clinical oak score was 77.5 ± 6.10 points in group a and 75.3 ± 11.31 points in group b. the following values could be recorded for the stability of the posterior cruciate ligament: the side difference in the rear drawer test was 1.75 ± 1,192 mm in group a and 2.50 ± 2.160 mm in group b. in the reversed lachman test, a difference of 2.37 ± 2.175 mm and 3.22 ± 2.059 mm was measured in group a and b, respectively. all values mentioned were comparable between the two evaluated groups. conclusions: the results of the two surgical techniques were comparable. therefore the arthroscopic approach is the preferred method in our institute. simple correction technique of femoral malrotation after pfn-a osteosynthesis of trochanteric fracture k. pavotbawan 1 , p. stillhard 1 , c. sommer 1 1 kantonsspital graubünden, department of trauma surgery, chur, switzerland introduction: malrotation after intramedullary nailing in femoral shaft fractures are well known. but malrotation after nailing of trochanteric fractures is an underestimated problem. during surgery the axial alignment can easily be evaluated by fluoroscopy in both planes. but the torsional alignment is difficult to assess especially with the patient placed on the traction table. in literature a malrotation after pfna is described in up to 25% of the cases. a revision with replacement of the blade, especially in patients with poor bone quality, may result in a reduced stability. to our knowledge there is no publication till to date to give a treatment pathway for this problem. we developed a rather easy technique to derotate a malrotated femur after pfna fixation. material and methods: the basic idea is to leave the usually well placed blade insitu in the femoral head, just rotating the distal main fragment around the nail. therefore, a small u-shaped osteotomy with a chisel is performed in the femoral cortex just anterior of the entry site of the blade. the length (l) of this osteotomy can be calculated, following the formula: l = d x p x a/360 (d = diameter of femur, a = angle of malrotation). then the distal locking bolt is removed, the leg derotated and finally locked again. the procedure is controlled by two schanz''screws separately inserted in both main fragments angulated to each other in the angle ''a''. results: since 2014 3 patients were detected with a clinically relevant femoral malrotation. all patients had an internal malrotation from 30 to 40 degrees confirmed and measured by ct scan. all of them were successfully revised in the above described technique 5-9 days after initial fixation. conclusions: first, we believe that malrotation after trochanteric fracture fixation is an underestimated problem. and second our method is a simple salvage procedure for malrotated trochanteric fractures after pfna, leaving the blade in situ in the femoral head. optimal intramedullary nailing for trochanteric fractures: the importance of distal locking screw and reduction position t. waki 1 , t. yano 1 , k. ito 1 , s. matsushima 1 1 akashi medical center, orthopaedic surgery, akashi, japan introduction: distal locking issue for trochanteric fractures is still controversial. therefore, the purpose of this study was to investigate the complications between distal unlocked group and distal locked group. further, the relationships were evaluated between these complications rates and their reduction positions after operation. material and methods: 365 operations were performed for trochanteric fracture (ao 31a1 ?a2) from 2012 to 2018. of these, patients with f/u periods [ 3 month were 218. gamma3 im nailing system (stryker) was used for all patients. 146 patients (unlocked group) from 2012 to 2016 operated without distal locking screw. 72 patients (locked group) from 2016 to 2018 operated with distal locking screw. we retrospectively analyzed those patients who suffered complications such as delayed healing and postoperative periimplant fractures and cut-out of the lag screw. further, in lateral view of their radiographs, we evaluated the position of the proximal fragment compared with distal fragment. the reduction positions were divided into 3 groups: anterior (subtype-a), neutral (subtype-n), and posterior (subtype-p). results: in unlocked group, complication was shown in 94 patients (complication group). delayed healing was shown in 94/146 (64.4%) in unlocked group and 12/72 (16.7%) in locked group. peri-implant fracture was shown in 3/146 (2.1%) in unlocked group and 0/72 (0%) in locked group. cut-out of the lag screw was shown in 4/146 (2.7%) in unlocked group and 1/72 (1.3%) in locked group. in complication group, subtype-p was more than non-complication group. conclusion: in the current study, higher number of complications was seen in the distal unlocked group. and, our study showed the reduction position might be associated with post-operative complications. we concluded that nailing without distal locking screw might be dangerous and subtype-p should be avoided. introduction: heterotopic ossification (ho) after acetabular fracture surgery has been one of the common complications and often limits function with the range of motion severely. surgical resection is challenging and only effective treatment for established ho. we herein report four cases who underwent surgical resection and mobilization for ho after acetabular fractures surgery. material and methods: four cases with severe ho after acetabular fracture surgery were included in this study. the mean age at operation was 45 years old, and all patients were males. in judet-letournel classification, there were three cases classified as posterior wall fracture, and one case as transverse and posterior wall fracture. two of four cases were combined with posterior dislocation of the hip. in all cases, the first operation was performed using with the kocher-langenbeck (kl) approach. results: surgical resection of ho was performed using with the kl approach at 8.4 months (range 5-12 months) after the first operation. the median operating time and intraoperative bleeding were respectively 4.5 h and 3130 ml. intraoperative 3d navigation was used in one case. as postoperative complications, one case developed sciatic nerve palsy and another case sustained the iatrogenic femoral neck fracture. all cases have no recurrence with a follow-up of 4.9 years after the surgical resection. conclusions: surgical resection is the only treatment for symptomatic ho. but that requires preoperative planning and must be performed carefully because the extent of resection is still controversial and that may develop severe complications such as nerve palsy and iatrogenic fractures. by using navigation, we can determine the extent of resection easily and operated safely. case history: 18-year-old male, previously healthy, turned to the hospital after a motorbike crash, resulting in high energy direct trauma of the right wrist. clinical findings: upon admission, cranial, thoracic, abdominal and other traumatic injuries were excluded. the patient presented with pain, swelling and visible deformity of the right wrist and hand, hypoesthesia of the 5th finger, and no perfusion deficits. investigation/results: x-rays showed volar perilunate carpal dislocation with associated comminuted scaphoid fracture, radial styloid avulsion, and metacarpal phalangeal dislocation of the 5th digit. under sedation, closed reduction of the metacarpal phalangeal joint was accomplished, and reduction of the carpal dislocation was attempted unsuccessfully. the wrist was temporarily immobilized in a cast and taken to the or. diagnosis: transcaphoid-transradial-styloid-perilunate volar dislocation therapy and progressions: surgical treatment comprised loose bodies removal, reduction of the perilunate dislocation, orif of the scaphoid using a herbert screw, and stabilization of the carpal rows using two percutaneous kirschner wires. after surgery, a thumb spica cast was applied. post-operatively, neurovascular status was normal. at 6 weeks, x-rays showed signs of bone healing, the cast and k wires were removed, and physical therapy was initiated. at 6 months, scaphoid fracture consolidation was achieved. the patient remained with a mild deficit in wrist extension but reported no pain nor important limitation in daily living activities. comments: perilunate injuries with displacement or dislocation usually require surgery. persistent instability is a described complication, often progressing to secondary post-traumatic arthritis of the wrist and carpus, termed scapholunate advanced collapse. introduction: this study was conducted to study the patient characteristics, classification, treatment, complications and functional outcome of operatively treated displaced intra-articular calcaneal fractures (diacf) in a level 1 trauma center in the netherlands material and methods: patients with an diacf, classified as sanders c 2 and operatively treated with percutaneous screw fixation (psf) or open reduction and internal fixation (orif) between january 1998 and december 2017 were identified. pre-and postoperative radiological assessment was performed. functional outcome, range of motion and change in footwear were evaluated with the use of the american orthopaedic foot & ankle society (aofas) score and the maryland footscore. general health and patient satisfaction was assessed using the short form-36 (sf-36) and the visual analogue scale results: in total, 116 patients with an operatively treated diacf were identified. 67 patient with 76 diacf completed the questionnaires. there were 52 males and 15 females, mean age at trauma was 45 years. average follow up was 11 years. 17 were classified as sanders type 2, 31 and 19 as respectively type 3 and 4. 36 were joint depression and 38 were tongue-type fractures. there were no differences in sanders classification between the group treated with orif and psf. for orif and psf there were (25-25%), (52-42%) and (22-33%) for respectively sanders type 2, 3 and 4 fractures. mean aofas, mfs, sf-36 and vas was (75-74), (79-78), (59-66) and (7-9) for respectively orif and psf. mean pre-and post-bohler angle was (11-24) and (15-22) for respectively psf and orif. 7 underwent an ankle arthrodesis. surgical site infection and deep infection occurred in (12,5-25%) and (12,5-8%) in respectively psf and orif conclusions: long-term comparison shows no significant differences between orif and psf in treatment of sanders fracture type, bohler angle reduction, on functional outcome or complication rates introduction: the prevalence of hand injury in the pediatric population is attributed to their curiosity, limited fear of pain and diminuted motor coordination. the seymour fracture, which was first reported by seymour in 1966, represents a transverse extra-articular open fracture of the distal phalanges associated with nail bed injuries. the fracture includes salter-harris type i and ii fractures as well as juxta-epiphyseal injuries. material and methods: the aim of this report is to present a case of a seymour fracture in a young boy and describe the injury mechanism associated with misuse of the newly emerging vehicle, the hoverboard. results: our patient was treated promptly and provided with appropriate management following the standard of care in our hospital for such injuries: disimpaction and repair of the nail bed, reduction of the fracture, and k-wire fixation across the distal interphalangeal joint. the patient was discharged with a volar slab and was prescribed an oral antibiotic. the patient recovered well with no major deficits. conclusions: the timely recognition and management of seymour fractures is crucial. the surgical treatment has good results however, conservative management can be an option in some specific cases. antibiotics are always required. we report a case of a fracture pattern resulting from the improper use of an hoverboard. although improper use was a factor, design fault also plays a role in causing the injury. hoverboards are a new transport technology that has been introduced in recent years. because of the number of injuries that have resulted from hoverboards, they should be used in the most controlled way possible to prevent any unnecessary injuries. case history: we report the case of a 32 years old male from bangladesh, with 6 months of progressively increasing pain, limited range of motion and swelling on his left knee, with 6 kg of weight loss and inguinal lymph nodes. clinical findings: knee radiography and mri of the knee demonstrated a voluminous soft tissue mass surrounding the distal femur with intraarticular and posterior extension. a toracic-abdominal-pelvic ct showed supra and infradiaphragmatic lymph nodes. c-reactive protein level was 5,72 mg/dl. investigation/results: the clinical picture suggested a lymphoproliferative syndrome. a biopsy was performed, revealing 100 cm 3 of purulent material. synovial fluid had 548 leucocytes/ul, 70% of polymorphonuclear cells, 30% of mononuclear cells and undetectable glucose. acid-alcohol resistant bacilli test and pcr test for mycobacterium tuberculosis were positive. diagnosis: mycobacterium tuberculosis knee arthritis therapy and progressions: the patient was treated with polytherapy consisting on rifampin, isoniazid, pyrazinamide and ethambutol. 6 months later, the patient reports no pain, and tumor size has decreased. comments: mycobacterium tuberculosis infection is not a common disease in developed countries. however, the incidence in europe is increasing due to immigration. even though the lung is the most affected organ, osteoarticular tuberculosis represents around 10% of extra-pulmonary cases. tuberculosis simulates several diseases. because of non-specific symptoms and radiological signs, it can be difficult to diagnose. in a patient with chronic knee pain and limited range of motion, tuberculosis infection should be kept in mind, among other differential diagnoses, such as fibromatosis, pigmented villonodular synovitis or soft tissue sarcomas. clinical findings: the patient presented with a valgus deformity of the knee, the medial femoral condyle protuding on the medial side of the knee. neurovascular status was intact. investigation/results: xray revealed lateral dislocation of the knee. mri revealed mcl, pcl and acl rupture. diagnosis: knee dislocation (kd) grade iii (schenck). therapy and progressions: the patient underwent emergent closed reduction. neurovascular status was intact after resuction. due to important oedema and blisters, the lower limb was immobilized with a brace to allow for skin surveillance. after 3 weeks, the brace was replaced by a long leg cast for 2 more weeks. after 6 months, the patient maintained residual pain, rom -5/855 and minor instability. comments: kd are unusual injuries, associated with high energy trauma, therefore they often result in disruption of at least 3 major ligaments and associated injuries, from soft tissue to vascular structures. emergent reduction is mandatory, and definitive treatment can be conservative, or early/late surgical repair/reconstruction of the ruptured ligaments. there is a lack of large prospective clinical studies comparing the different types of treatment. even so, data tend to associate early surgical treatment with better functional outcomes, though there is no statistic evidence supporting its improvement of the range of motion or stability. long term complications most frequently include residual pain, instability or rigidity. rarely the knee returns to its pre-injured state, independently of the treatment used. references: dwyer, t., et al. (2012) . outcomes of treatment of multiple ligament knee injuries. the journal of knee surgery, 25(04), 317-326. advising a reduction after a fracture of the distal radius, reliability with and without use of expert based criteria introduction: distal radius fractures (drf) are common, however many aspects of its management remain subject of debate 1 . this study assessed the interobserver reliability of surgeons concerning the recommendation for a reduction and the improvement of expert based criteria for reduction. material and methods: we sent out 2 surveys to members of the science of variation group. the first survey divided participants in 4 groups, each rated 23-24 radiographs of drf. resulting in 95 rated fractures by 80 participants. each observer indicated whether they would advise a reduction or not. the second survey randomized participants (68 surgeons) to either receive or not receive criteria for reduction and participants indicated if they would recommend reduction. results: the reliability for advising a reduction was poor, kappa 0.31 (95% ci 0.23-0.39). multivariable linear regression analyses indicated that each additional degree of dorsal angulation increased the change of recommending a reduction by 3% (beta 0.03, 95% ci 0.02-0.03 p \ 0.001). criteria for reduction did not increase interobserver reliability for recommending reduction (no criteria kappa 0.43 95% ci 0.26-0.59 vs. criteria 0.47 95% ci 0.33-0.61). the likelihood of recommending a reduction was higher in the group using the criteria (0.61 vs 0.68, p = 0.009). conclusions: poor interobserver reliability is associated with greater practice variation. dorsal angulation is the main drive for recommending a reduction. the liberal use of the criteria in combination with a specific focus on dorsal angulation leads in our opinion to less variation in treatment recommendation for distal radius fractures. this is something future study could assess for distal radius fractures in actual practice introduction: the number of pertrochanteric hip fractures increases proportionally to the increase in life expectancy. currently, the most used treatment in these fractures is the antegrade nailing. suffering a second fracture in the same femur around an antegrade nail is an uncommon complication, but it has a great impact on the patient. the aim of this study is to describe the type of perinail femoral fractures observed in our center, the treatment performed and the medium-term results. material and methods: between 2013 and 2018, 14 patients presented a perinail femoral fracture. 13 were women and one was male, with an average age of 83. initial fractures were classified according to the ao classification: 6 were 31a1, 5 were 31a2 and 3 were 31a3. 8 of them were synthesized by short pfn-a (synthes), 3 with short pfn (synthes) and 3 with gamma3 (stryker). the average time since osteosynthesis of the proximal femur fracture and the perinail fracture was 3.5 years (1 month-12 years). results: 11 of the peri-implant fractures occurred at the level of the nail tip or the distal locking screw. the remaining 3 fractures occurred in the distal femur. these 3 supracondylar fractures and 2 of the fractures at the level of the nail tip were synthesized with a va condylar plate (synthes), overlapped with the nail. in the rest of the fractures around the tip of the nail, the short nail was removed and replaced by a long pfn-a nail. one of the patients died in the immediate postoperative period. two patients died during the first year. in the rest of the patients, a complete consolidation of the fracture was observed, and their previous baseline situation was recovered. conclusions: peri-implant femur fracture is a rare but very severe condition, which requires good surgical planning, and is not without complications. gamagori city hospital, department of orthopedics, gamagori, japan, 3 nagoya daini redcross hospital, department of orthopedics, nagoya, japan introduction: hip fracture is a leading worldwide health problem for the elderly. a missed diagnosis of hip fracture on radiography leads to a dismal prognosis. the application of a computer-aided diagnosis (cad) system using artificial intelligence (ai) to detect hip fracture can potentially improve the accuracy and efficiency of hip fracture diagnosis. material and methods: cad system using ai was trained using 4851 cases, 5242 plain frontal pelvic radiographs (pxrs) between 2009 and 2019 from each institution. the accuracy, sensitivity, falsenegative rate, and area under the receiver operating characteristic curve (auc) were evaluated on 500 independent pxrs. the authors mixed resnext as classification algorithm and ssd as object detection algorithm to train cad system. results: the algorithm achieved an accuracy of 94.1%, a sensitivity of 96.2%, a false-negative rate of 1%, and an auc of 0.94 for identifying hip fractures. the visualization algorithm showed an accuracy of 97.9% for lesion identification. conclusions: our cad system using ai not only detected hip fractures on pxrs with a low false-negative rate but also had high accuracy for localizing fracture lesions. the cad system using ai might be an efficient and economical model to help clinicians make a diagnosis without interrupting the current clinical pathway. medical faculty university of nis, orthopaedic surgery, nis, serbia, 2 clinical center nis, orthopaedic and traumatology clinic, nis, serbia, 3 orthopaedic word of medical center, cuprija, serbia introduction: bone reconstruction and limb lengthening usually refers to application of ilizarov or other ring external fixation devi-ces1. we present here series of posttraumatic reconstruction and limb lengthening, by the use of new concept of 3d unilateral external fixation device. material and methods: as a clinical material, we present series of 59 patients with different posttraumatic deformities (28) and limbs discrepancy (31) as a result of severe traffic accidents and wars. all patients have been treated by specially designed unilateral 3d external fixation system. that system is not bulky and it is more comfortable in comparison to ring fixators. procedure is relatively simple, so patients handle the device by themselves. during biomechanical testing, it was found that stability of this device is similar to ring systems. the last version of the device includes computer program and two sensors. results: all deformity corrections have been achieved successfully. sliding graft procedure has successfully been performed in all 9 patients with bone defect reconstruction from 5 to 11 cm. in one patient with complex deformity and shortening, correction couldn''t be achieved during one procedure, so additional operations, by the use of the same system have been performed and correction completed. superficial pin tract infection rate was 11.1% and we didn''t have deep infection. there were no other complications including dvt, joint stiffness, neurovascular injuries. conclusion: unilateral external fixation device with balanced 3d stability provides the same success of bone reconstruction and limb lengthening as ring fixators, but it is more comfortable and more easy for handling. references: treatment principles in bone reconstruction and limb lengthening of the lower extremity. olesen uk, nygaard t, kold sv, hede a. ugeskr laeger. 2017 nov 20; 179(47) at this moment author has licence agreement with the producer of external fixation devices. all patients were classified into the isolated hip fracture and the concomitant fracture. we analyzed these patients'' characteristics such as age, gender, bone mineral density (bmd), body mass index (bmi), korean version of mini-mental state examination (mmse-k), injury mechanism, and length of hospital stay. results: the most common site of upper extremity fracture was distal radius fracture of 15 patients (42.8%), followed by proximal humeral fracture of 8 (22.8%). concomitant fractures occurred on the same side in 30 patients (85.7%). the mean age of patients with a concomitant fracture was younger than that of patients with an isolated hip fracture (p \ 0.05). mean preinjury mmse-k was 22.7 in isolated hip fracture and 25.6 in concomitant fracture patients (p \ 0.05). mean length of hospital stay was statistically significant different between two groups (p \ 0.05). according to fracture site of hip, there was no statistically different prevalence of upper extremity fracture in femoral intertrochanteric fracture compared to the neck fracture. conclusions: we found a 3.4% prevalence of concomitant hip and upper extremity fractures. it was found that the younger the age with preserved cognitive ability in elderly patients with a hip fracture, the higher the prevalence of upper extremity fracture. in addition, it is important to keep in mind that patients with a concomitant fracture have a longer hospital stay and difficulty in rehabilitation. on the other hand, the amount of bleeding was 658 ml in group e and 792 ml in group l, and there was no significant difference between the two groups. poor cases on postoperative images were 30% in group e and 11% in group l, and the joa hip score was 68.4 (groupe) and 91.2(group l). in clinical results is significantly improved in group l. conclusions: the treatment results improved significantly in group l. as the number of experienced cases increased from these results, the reduction accuracy and treatment results improved, so experience was considered important for improving the treatment results of acetabular fractures. the additional value of the weight-bearing and gravity stress radiograph in determining stability of isolated type b ankle fractures introduction: the goal of the current study is to investigate whether the weight-bearing and gravity stress radiographs have additional value in determining stability in isolated type b fibular fractures. this in order to make the important distinction between fractures that need surgical treatment and fractures that can be safely treated conservatively. material and methods: 90 patients with an isolated type b ankle fracture, without medial or posterior fracture, and a medial clear space (mcs) \ 6 mm on the regular mortise radiograph were included. in the emergency room, a gravity radiograph was performed (in accordance with out protocol). within 1 week, an additional mri scan was made. at this moment, in 51 patients a weight-bearing radiograph was performed too. the mcs measurements of these regular mortise, gravity and weight-bearing radiograph were compared with the mri findings. the mri scan was set as reference standard to detect injury of the deltoid ligament in order to determine (in)stability. results: mean mcs on mortise radiograph was 3.3 mm (range 1.7-5.9); in 12 (13.3%) patients the mcs was [ 4 mm and in 15 patients (18.3%) the superior clear space (scs) was [ mcs ? 1 mm. in 2 (2.4%) patients, the scs [ mcs ? 2 mm. on the gravity stress radiograph, 14.4% of the patients had a mcs [ 6 mm. the weight-bearing radiograph showed a mcs [ 4 mm in 3 (5.9%) patients. in 4 (4.4%) patients, the mri showed a complete rupture of the deltoid ligament. in 21 (23.3%) patients a partial rupture was seen. 10 patients (11.1%) received surgical treatment. in all conservatively treated patients, no secondary dislocation occurred and there was no need for postponed surgical treatment. conclusions: the gravity stress view has a tendency to overestimate the mcs. thus, potentially too many stable fractures are incorrectly diagnosed instable and receive unnecessarily surgical treatment (with additional costs and risks). the weight-bearing radiograph, on the contrary, does not overrate the medial injury and can safely be used in the decision making process of treating conservatively and weightbearing (for example by using a brace) introduction: the purpose of this study was to identify the effect of the intravenous iron supplementation on demand of perioperative blood transfusion and post-operative hemoglobin recovery in geriatric hip fractures. material and methods: a retrospective cohort study was performed on patients who underwent surgery with proximal femoral nail for hip fracture and age 60 years old or older between jan 2018 and may 2019 in a single center. the participants were divided into 2 groups according to preoperative intravenous iron supplementation (iron isomaltoside, monofer ò , pharmacosmos, holbaek, denmark); group 1 (n = 25) with monofer 400 mg before surgery and group 2 (n = 33) without monofer. transfusion was preformed when the hgb was less than 8 mg/dl). primary endpoint was incidence of perioperative transfusion. secondary endpoints were various hemoglobin (hgb) levels. results: the average age of the participants were 77.4 years old, and average body mass index (bmi) was 22.8. demographic data including age, sex, bmi, comorbidity (charlson comorbidity index) of each group showed no difference. the complications from intravenous iron administration were not occurred. the preoperative hgb was 11.4 mg/dl (group 1 11.9 ± 2.1 vs, group 2 10.9 ± 1.9, p = 0.591). the hgb at the postoperative day 2 was 10.2 mg/dl (group 1 10.5 ± 2.1 vs group 2 9.9 ± 1.8, p = 0.273). the average hgb at the postoperative 1 month was 11.6 mg/dl (group 1 11.7 ± 1.7 vs group 2 11.5 ± 1.5, p = 0.431). transfusion rate was 51.7% (30/58) and the rate showed no difference between 2 groups (40.0% vs 60.6%, p = 0.120. the recovery of hgb between postoperative 1 month and preoperative state showed statistically difference (group 1 0.166 vs group 2 -.0579, p = 0.049), and iron supplementation group had more recovery. conclusions: intravenous iron supplement before the hip fracture surgery in elderly helped to recover hgb at postoperative 1 month. comminuted subtrochanteric femur fractures-our experiences introduction: subtrochanteric femoral fractures account for approximately 25% of all the hip fractures and their treatment represents a challenge because of the short proximal fragment and highenergy forces. material and methods: a total of 17 patients with subtrochanteric, highly comminuted fractures, were included in this study, with age range from 30 to 60 years. the mechanism of injury in all patients was high-energy trauma. in each case we applied a long gamma nail (limma lto) without focus opening. results: in all patients, good clinical and radiologic results were accomplished, in addition to early weight-bearing, without shortening of the legs, or consequences on the state of the hip and morbidity in general. conclusions: although the comminuted subtrochanteric femur fractures represent a challenge for the orthopedic surgeons, osteosynthesis using long gamma nail without the focus opening provides outstanding results. introduction: this study analyzed the association between the postoperative reduced position obtained on using short femoral nails (sfns) and the amount of sliding after fixation in unstable trochanteric fractures. material and methods: this retrospective study included 12 patients with unstable trochanteric fractures with posterolateral support deficiency who underwent osteosynthesis with sfns and were followedup for 3 months or longer. the study included 6 men and 6 women with a mean age of 76.3 years at the time of fracture. closed or open reduction was performed to achieve anatomical to medial type position on frontal view and anatomical to extramedullary type position on lateral view, followed by fixation with sfns. immediately and extramedullary type in 4 patients immediately after surgery. three months after surgery, the reduced position worsened from the anatomical to intramedullary type in 2 patients. according to the reduced positions at 3 months after surgery, the mean amount of sliding was 8.7 mm in patients with intramedullary type, 3.3 mm in those with anatomical type, and 3.7 mm in those with extramedullary type. the amount was larger in those with intramedullary type than in those with anatomical and extramedullary types. moreover, excessive sliding was observed in 1 patient with intramedullary type. conclusions:to prevent excessive sliding by ensuring anteromedial bony support in unstable trochanteric fractures with posterolateral support deficiency, open reduction should be aggressively performed to overcorrect to the extramedullary type when reduction performed on a traction table results in either anatomical or intramedullary type positioning. in this paper, we report 31 patient previously studied for osteomyelitis caused by high-energy missile trauma, in 1996. that study involved a total of 120 patients with osteomyelits, divided into two groups, according to the treatment protocol applied. the group 1 included patients treated using classic surgical methods, including debridement, curretage, forage, perfusion drainage and sequestration. the group 2 included patients treated using recommended surgical methods and used pmma antibiotic beads. 25 years after, we tried to contact all of the 120 patients, for the purpose of follow-up. however, only 31 patient was available for analysis. among 31 patients we followed-up, 11 were treated using recommended surgical protocol, while the remaining 20 patients were treated using classic surgical methods. we present the patients' general status, as well as the local surgical status and radiographic analysis, 25 years after. we obtained long-term results of both treatment protocols applied. from the group 1, 9 patients developed chronic recurrent osteomyelitis, while only one patient from the group 2 developed such condition. introduction: the aim of this study was to evaluate the treatment results using anterior subcutaneous internal fixation(infix) for the pelvic fractures and to consider an improvement strategy for the complications. material and methods: from 2013 to 2019, 31 pelvic fractures were enrolled. there were two males and 29 females. the average age was 80 years. there were 26 fragility fractures and five high energy fractures. our operative procedure was as below: the connection between screws and rod was just above the fascia of the sartorius muscle. the connection bar was pre-bended before the operation using the initial axial ct scan. we assessed bone union, additional fixation, the distance between the femoral artery and connection rod (dar), the distance of protruded bar lateral to the connection (dpb), and complications. results: bone union achieved in 27 out of 31 cases. there was one nonunion and three early deaths because of medical complications. seventeen out of 31 cases required additional posterior fixations. the average dar was 17.1 (3.2-49.2 mm) , and the dpb was 10.1 (0-24) mm. thirteen out of 31 cases (41.9%) had complications. there were seven lateral femoral cutaneous nerve (lfcn) symptoms (3 required implant removal (ir)), two infections (1 required ir), one hematoma (ir), one irritation (ir), one heterotopic ossification, one loosening (re-operation). there were no femoral vessels and nerve-related symptoms. to release lfcn and surrounding soft tissues decreased the nerve symptoms. conclusions: to connect the screws, and the rod just above the sartorius fascia could avoid major vessels and nerve complications, and also irritations. although this study found a high complication rate of infix, to release the lfcn and around soft tissue could decrease the complications. introduction: several studies have reported that posterior or anterior tilt increases the risk of reoperation in undisplaced femoral neck fractures (garden i/ii) after internal fixation performed using nonangular stable devices such as pins and multiple screws. however, to the best of our knowledge, there is limited research involving angular stable devices. the present study aimed to investigate the clinical outcomes in undisplaced femoral neck fractures after internal fixation using angular stable devices. material and methods: this retrospective study included 35 patients (mean age, 79.2 [range, 65-95] years) who underwent internal fixation using angular stable devices between january 2011 and january 2019. undisplaced femoral neck fractures with garden alignment index (gai) b 170°(posterior tilt angle c 10°) or gai b 190°( anterior tilt angle c 10°) were included (posterior: 34, anterior: 1) in this study. patients were followed up for at least 3 months (mean, 16.3 months). we analyzed the preoperative and last-followed gai on lateral radiographs, non-union, and late segmental collapse (lsc). results: among the 35 patients, non-union was identified in 2 (5.7%) and lsc was observed in 4 (11.4%). the mean preoperative gai was 159.8°(range, 125°-203°), and the mean last-followed gai was 164.5°(158°-182°). the overall complication (non-union and lsc) rate was 17.1% (6/35 patients). among 16 patients with gai c 20°, lsc occurred in 3 (18.8%). conclusions: in undisplaced femoral neck fractures, preoperative posterior c 10°is a risk factor for postoperative complications even when internal fixation is performed using angular stable devices; thus, primary arthroplasty may be considered. case history: the patient is a 77-year-old female who had undergone lumpectomy at the age of 53 when she was diagnosed with breast cancer. she had antiresorptive drug therapy for bone metastasis, since 10 years after the lumpectomy. she fell down from standing height and was diagnosed as right femoral subtrochanteric fracture. her femur was fixed with short femoral nail. she complained left hip pain at age 77.she complained left hip pain from july 2018. clinical findings: she could walk with crutch.rom of left hip was normal. investigation/results: breast surgeon took mri and there was metastasis in the proximal part of femur. he thought the cause of pain was this metastasis. however, there was fracture line at the height of lesser trochanter when she visited our department. diagnosis: atypical fracture was strongly suspected, however, fracture line was little higher as normal atypical fracture. therapy and progressions: osteosynthesis with long femoral nail was performed 4 months after first visit to our department because of increasing pain. pathological findings were metastasis and fracture. after surgery, radiation to femur was performed. she can walk without pain by crutch and fracture line is almost disappeared on 11 months after surgery. comments: atypical femoral fractures (affs) are recently observed as a complication of antiresorptive drugs for bone metastasis. however, there were metastasis and atypical fracture in this case. introduction: in the present study we aim to evaluate the articular surface reduction quality by means of postoperative computer tomography (ct), in complex tibial plateau fractures, treated with an illizarov frame. materials and methods: this retrospective case series covers the period from 03-2010 to 10-2018. forty-four patients with a mean age of 39 years (range 19-65 years), with a complex intrarticular proximal tibia fracture were included. fracture types iii to vi according to schatzker's classification were included. the majority were closed injuries, apart from 2 cases (a gustilo anderson type 3a and a type 2). all patients were placed on a fracture table. a mini-open reduction of the articular surface was followed by application of a knee spanning illizarov frame. post-operatively all patients were subject to ct of the injured knee. outcomes were measured using the american knee society score. results: mean outpatient follow up was of at least 12 months (range of 12-21 months). mean time for fracture consolidation 15.5 weeks (ranging from 13 to 19 weeks). according to the degree of postoperative articular surface depression patients were grouped as follows: 8 had under 2 mm, 19 had 2-4 mm and 17 over 4 mm of depression. those with less than 3.5 mm of collapse had 95% chances of an excellent result according to akss. on the contrary, those with more than 4.5 mm of articular surface collapse had 100% chances for low scores and functional results. the achievement of a mechanical axis within 5°of the contralateral limb was positively correlated with good functional results but did not have a correlation with the akss. conclusions: complex tibial plateau fractures may be treated successfully with mini open reduction and the application of an illizarov frame. post-operative ct denotes the exact degree of displacement of the articular surface, which is prognostic regarding outcome. postoperative x-rays may be misleading, since they can underestimate articular surface collapse. introduction: a new trauma center building was constructed in march 2016, and the process from the trauma bay to the operation room is faster. we hypothesized that this process improved the survival rate of trauma patients in need of trauma laparotomy. material and methods: the new trauma center separates the trauma bay from the emergency room, and the trauma team exam patients initially. it also has a separate operation room that is always available for emergency surgery. therefore, the decision to perform laparotomy and time to operation has been shortened. from january 2011 to december 2018, trauma patients who underwent emergency laparotomy were included. those younger than 18 years, who had delayed operation, underwent surgical observation, delayed admission by patient, or underwent angiography first were excluded. patients were dichotomized to the before-trauma-center (bc) and after-traumacenter (ac) groups, and their characteristics and clinical outcomes were compared. results: of 644 patients, 349 were included in the bc group and 295 were included in the ac group. the times from admission to operation introduction: acute care is a growing worldwide burden with increasing visits to the emergency department (ed). the acute care system in the netherlands is almost overloaded and costs are increasing. almost 50% of ed visits have surgical disease. there is no nationwide acute care surgery (acs) model implemented yet, and resources and infrastructure are organized differently in almost every hospital. this study provides an overview of the existing systems nationwide, and basis for a national uniform model. material and methods: an online survey was distributed through the dutch surgical society and sent to all dutch hospitals. after sending a reminder, the survey was closed and results were analyzed. results: thirty-two hospitals (41%) participated in the survey. in 78% a surgeon (trauma, vascular or gastro-intestinal) was assigned as consultant and responsible for ed admissions, emergencies in-house, and in some cases also emergency surgeries. 59% of hospitals have an ed observation unit (edou). a dedicated emergency surgery operating room (esor) is available in 69% (24/7 available in 73%), and used efficiently in 55% primarily due to the following challenges: elective surgery scheduled at esor (59%), necessary stop of esor when elective programs are delayed (64%). in hospitals without an esor, the emergency surgeries are scheduled in between elective surgeries resulting in extending programs into the evening. finally, 90% of respondents was familiar with acs, with 62% being positive about exploring options of implementing such a model in our country, and 77% of the respondents opts for more focus on acs in surgical residency. conclusions: in the netherlands the organization of acute care varies. the main common bottleneck is the logistics around the or. implementation of a dedicated esor and unconditional availability 24/7 of this or seem to be the most important factors for optimal efficiency. although there needs to be more focus on acs in general, implementing a uniform model nationwide seems challenging at this moment. trauma team activations (tta) at an european trauma center: 1029 cases analyzed s. saar 1,2 , e. lipping 1 , h. vospert 1 , r. volmer 2 , h. k. laas 2 , j. lepp 1 , k. g. isand 1 , p. talving 2,3 1 north estonia medical centre, division of acute care surgery, tallinn, estonia, 2 university of tartu, tartu, estonia, 3 north estonia medical centre, tallinn, estonia introduction: the north estonia medical centre (nemc) is the largest trauma center in estonia with evolving capabilities. however, studies scrutinizing trauma team activations (tta) are currently lacking. thus, we initiated an investigation to document tta profile and outcomes. material and methods: all tta patients admitted to the nemc between 1/2016 and 12/2018 were retrospectively identified. data collected included demographics, injury severity score (iss), management, hospital length of stay (hlos), and in-hospital outcomes. primary outcome was 30-day mortality. results: overall, 1029 patients were included. mean age was 39.3 ± 20.4 years and 74.2% were male. penetrating and blunt trauma accounted for 11.5% and 88.5% of the cases, respectively. non-ground level falls were the predominant mechanism of injury constituting 32.1% of the admissions. mean iss was 10.3 ± 11.5 and 24.7% of the patients were severely injured (iss [ 15). blood alcohol level (bal) was positive at 31.1%. a total of 21.1% of the patients had an emergent operation. mean hlos was 8.0 ± 15.2 days.overall 30-day mortality and mortality of severely injured patients was 5.1% and 19.3%, respectively. conclusions: the current investigation documents comparable outcomes with established european trauma facilities [1, 2] . blunt injury patterns predominate, however, high penetrating trauma incidence for european settings was noted. high rate of positive bal in tta patients warrants national preventive measures. introduction: the acute care surgery (acs) model was initially developed as a dedicated service for the provision of high quality 24/7 non-trauma emergency surgical care. after implementation in the united states (us), the model has been adopted in several variations around the world.in this systemic review we investigated which components are essential for a potential uniform acs model, by giving an overview of the current available acs models worldwide and their state of implementation. material and methods: a literature search (2000-2018) was conducted using pubmed, medline, embase, cochrane library and web of science databases following the prisma guidelines. all relevant data of acs models were extracted from included articles. results: sixty-five articles describing acs models in 12 different countries were included in this review. the majority consist of a dedicated surgical service, providing non-trauma emergency surgical coverage, with daytime on-site attending coverage by an attending surgeon who is cleared from elective duties, and 24/7 in-house resident coverage. emergency department coverage and access to an acute care operating room varied widely across countries. critical care is fully embedded in the original us model as part of the acute care chain (acc), while in most other countries it is still a separate unit. while in most european countries acs is not a recognised specialty yet, there is a tendency towards more structured acute care, with training and separation from elective practice. conclusions: acs is gradually implemented worldwide. however, large national and international heterogeneity exists in the structure and components of the model. critical care is still a separate unit and specialty in most systems while it is essential to be part of the acc in order to provide the best peri-operative care of the physiologically deranged patient. universal acceptance of one global acs model seems challenging, however a global consensus on essential components would benefit any healthcare system. introduction: the recent financial crisis in greece is coped mainly with reformations towards cost effectiveness and rationality in the management of public expenses. the goal of the study is to evaluate the cost and time effectiveness in the management of the surgical patients admitted in emergency department (ed). methods: for a period of 8 h/day in 8 consecutive days, surgical cases presented in the ed of a tertiary university hospital of athens were followed. inclusion criteria were need for laboratory tests or imaging examinations or an immediate resuscitative intervention. data recorded regarding demographics, vitals, critical time points, disease and management. physician related data and cost of examinations were also collected. case severity was calculated by early warning score [1] . results: she average waiting time for each patient was 51 min and the average total time until final decision was 3:02 h. blood tests costs reached an average of 17,59€ per case and imaging an average of 77,88€. the striking finding was that only one out of 60 patients was of medium clinical risk, while all the others were of low. thus, substantial symptoms and clinical findings were lacking and as the ''tertiary care'' character of the hospital was mandating conclusive diagnosis, exams were ordered. this approach absorbs time and funds putting at risk the very few severe cases which are the target population for the magnitude of the facility. the current study indicates that the use of a tertiary hospital as a primary health care center by the public, is disorganizing the system, and increase the cost in time, funds, and preventable morbidity and mortality. a pre-hospital triage and management of the low severity cases system is pending to be established in our environment and becomes top priority in an era of prolonged financial crash. for years, surgical emergencies in ecuador have been managed without significant standardization. scarce numbers of specialists, lack of a constant presence of full-time teaching faculty versed in emergency surgery and lack of continuity with surgical trainees led to variability in clinical and surgical decision-making. to address these issues, the regional hospital vicente corral moscoso (hvcm) adapted and implemented a model of ''trauma and acute care surgery'' (tacs) to the reality of cuenca, ecuador. a cohort study was carried out, comparing trauma and acute care surgery patients exposed to the ''traditional care model'' before the implementation of the tacs model. variables assessed included: surgical wait times, number of hospital visits, number of surgical interventions, number of surgeries performed per surgeon and inhospital mortality. higher mortality was found in the traditional care model (rr of 1.29, p b 0.05) compared to the tacs model. we observed a statistically significant decrease in surgical wait time (10.6-3.2 h for emergency general surgery, 6.3-1.6 h for trauma, p b 0.05). lengthof-stay decreased in trauma patients (9-6 days p b 0.05). the total number of surgical interventions increased (3,919.6-57,445.8, p b 0.05) ; by extension, the total number of surgeries performed per surgeon also increased (5.37-223.68, p b 0.05) . the implementation of tacs model in a typical resource-restrained, tertiary care hospital in latin america had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients, and length-of-stay in trauma patients. we also noted a statistically significant decrease in mortality. while cost could not be objectively evaluated with the available data, savings to the overall system and patients can be inferred by decreased mortality, length-ofstay and surgical wait times. to our knowledge, this is the first implementation of an tacs model that has been described in latin america. introduction: traumatic injuries constitute one of our major public health challenges. the most effective means to reduce the impact trauma has on individuals and society is primary injury prevention, reducing the incidence of traumatic events, which relies on detailed knowledge of risk factors. the aim of this study is to facilitate targeted injury prevention through improved data collection and analysis on impairing substances as risk factors for traumatic injuries. material and methods: idart is a national prospective observational study including analyses of the toxicological profile of all patients c 16 year of age admitted via trauma team activation to any norwegian trauma hospital (n38) during a 12 month study period. residual blood from routinely drawn blood samples at trauma admission is analyzed for alcohol, illegal and psychoactive drugs. toxicological data will be linked to clinical data from the national trauma registry. results: the study period started march 1st, 2019, and during the first 6 months 2689 patients were included from 34 trauma hospitals. more than 30% of the included patients tested positive for psychoactive substances according to preliminary data. data on the prevalence of different psychoactive substances disaggregated by mechanism of injury, demography and geography from the 12 month study period will be presented. conclusions: the idart study will provide a detailed descriptive analysis on the prevalence of alcohol, illicit and medicinal drug use among all patients admitted to a norwegian hospital with suspected severe injury. subgroup analyses will include prevalence of alcohol and other substances in subgroups analyses on patient and injury characteristics and geographical variations. analyses will aim to identify high risk groups according age, gender, circumstances of the injury, geographical location and type of psychoactive substance. the dutch nationwide trauma registry: the value of capturing all acute trauma admissions m. driessen 1 , l. sturms 1 , l. leenen 1 1 lnaz/umcu, trauma surgery, nijmegen, netherlands introduction: twenty years ago the dutch government decided to reform the trauma care system and designated 11 level 1 regional trauma centers (rtcs). these centers, in collaboration with ambulance services and regional hospitals, have managed to set up regionalized inclusive trauma systems. moreover, they set up the dutch national trauma registry (dntr) as a quality evaluation and epidemiology resource. in this resource all acute hospital admissions were included, in order to measure the hospital and prehospital processes and outcomes. in the current study we demonstrate its current status and compare it with national trauma registries from the uk and germany. material and methods: the dntr includes all injured patients treated at the ed of 98% of all hospitals in the netherlands within 48 h after the trauma followed by direct admission, transfer to another hospital or death at the ed. a representative descriptive analysis of extracted data from 2018 is demonstrated. results: between 2007 and 2018 a total of 865,460 trauma cases have been registered in the dntr. hospital participation has increased from 64% up to 98%. in 2018 alone, a total of 77.529 patient were included, 50% concerned males, the median age was 64 years. 6% of all admissions had an iss c 16, of which 70% was treated at a rtc. from this cohort, in comparison, only 5% and 32% of the dntr patients met tr-dgu or tarn inclusion criteria. particularly children, elderly and patients admitted at non rtcs are not captured in the tr-dgu or tarn. also, part of iss c 16 and fatal cases do not meet tr-dgu or tarn inclusion criteria. conclusions: the dntr has evolved into a comprehensive wellstructured nationwide population-based trauma register, with an annual number of 80,000 cases being entered in the database the dtr has grown to be one of the largest trauma databases in europe. the registry enables studies on the injury burden and quality and efficiency of the entire trauma care system encompassing all traumareceiving hospitals. introduction: trauma mortality is not distributed evenly. rural areas have higher incidence rates of trauma mortality than urban areas. the rural northern part of the nordic countries have common challenges with sparsely populated areas, long distances, and an arctic climate. the aim of this study was to compare the cause and rate of fatal injuries in the northernmost area of the nordic countries over a fiveyear period. material and methods: in this retrospective cohort we used the cause of death registries and collated all deaths from 2007 to 2011 with an external cause of death (icd-10, v01-y98, except y40-84 and t80-88). the study area was the three northernmost counties in norway, the four northernmost counties in finland and sweden and the whole of iceland. we used 95% confidence intervals (ci 95) to test for differences between the countries. results: there were 4308 deaths in the study area during the 5-year period. low energy (le) trauma constituted 24% and high energy (he) trauma 76% of deaths. northern finland had the highest incidence for both high energy trauma and low energy trauma. iceland had the lowest incidence for high-, and low energy trauma. iceland had the lowest prehospital share of deaths at 74% and the lowest incidence of injuries occurring in a rural location. the incidence rates for he trauma death was 36,1/100.000/year in northern finland, 15,6/100.000/year in iceland, 27,0/100.000/year in northern norway and 23,0/100.000/year in northern sweden. conclusions: there were significant and unexpected differences in the epidemiology of trauma death between the countries. the differences suggest that a comparison of the trauma care systems and preventive strategies in the countries is required. the diurnal and seasonal relationships of pedestrian injuries secondary to motor vehicles in young people introduction: there remains a significant morbidity and mortality in young pedestrians that are hit by motor vehicles, even in the era of pedestrian crossings and speed limits. the aim of this study was to compare incidence and injury severity of motor vehicle-related pedestrian trauma according to time of day and season in a young population. we hypothesised that injuries in young people would be more prevalent during dusk and dawn and during autumn and winter. material and methods: data was reviewed from patients in the 10-25 year old age group in the trauma audit and research network (tarn) national database, who had been involved as a pedestrian in a motor vehicle accident between 2015 and 2018. the incidence of injuries, their severity (using the injury severity score [iss]), hospital transfer time and mortality were analysed according to the hours of daylight, darkness and seasons. results: 64.5% of injuries occurred during time of darkness post sunset, while 35.5% occurred during daylight. the incidence of injuries in motor vehicle accidents, in absolute terms, was highest during 1630-2400, with a second peak at 1500-1630. the greatest injury rate (number of injuries/hour) occurred during 0730-0900 and 1500-1630 with respective rates of 5.3 and 8. injuries scoring an iss over 15 occurred 21.7% at 1500-16300 and a further 42.9% until 2400. mortality was greatest during 1500-1630 involving 4 out of the total 7 deaths. autumn was the predominant season and lead to 40.3% of injuries, with a further 22.6% in winter. this demonstrated a clear difference to 19.4% and 17.7% in spring and summer. conclusions: we have identified a relationship between reduced daylight and the frequency and severity of pedestrian trauma in young people suggesting that reduced visibility may play a significant role which could be addressed through a targeted public health approach to implement change. enhancing cost effectiveness in a system in crisis: a 7,581 patient study a. tsolakidis 1 , c. christou 1 , p. smyrnis 1 , a. prionas 1 , a. tooulias 1 , g. tsoulfas 1 , v. n. papadopoulos 1 1 aristotle university of thessaloniki, 1st department of surgery, papageorgiou general hospital, thessaloniki, thessaloniki, greece introduction: to date, there is no national trauma database in greece. the goal of our study is to record and evaluate trauma management at our university hospital as well as to measure the associated healthcare cost, while laying out the foundations for a national database. material and methods: retrospective study of trauma patients (n = 7,581) between 2014 and 2019. demographic information, injury patterns and severity, outcomes and cost were recorded. results: the proportion of patients that were transferred to the hospital by the national emergency medical services was 28,6%, whereas 3873 (51%) of our trauma patients did not meet the us trauma field triage algorithm criteria. over-triage of trauma patients to our facility ranged from 90.7 to 96.7%, depending on the criteria used. 299 (3.9%) of our patients received operative management and 22% (65) of them had postoperative complications. an iss [ 15 was seen in 228(3%) of our patients and their mortality was 19,3%. the overall non-salary cost for trauma management was 3.118.625 euros. the cost resulting from the observed over-triage ranged from 419.501 to 1.742.748 euros. furthermore 1108 (14.6%) of our patients underwent at least one ct scan that did not show any significant traumatic lesion. the cost of hospitalization of these patients was 592.508 euros. conclusions: the prehospital triage of trauma patients in the greek national health system is ineffective, with significant over triaging, leading to excessive costs. appropriate use of criteria for diagnostic procedures and algorithms may lead to a, much-needed, reduction of these costs. introduction: in japan, there are 290 emergency and critical care centers nationwide (one center for approximately every 500,000 people), and a system is in place to accept local critically ill patients 24 h a day, irrespective of whether their conditions are intrinsic or extrinsic. however, manpower and medical care systems differ depending on the emergency and critical care center, and the establishment of a system for consolidating severe trauma patients has been particularly problematic. material and methods: this study examined 518 cases where the patient had some sign of life when encountered by ambulance teams of the 1278 cases of traffic accident deaths that occurred in chiba prefecture between 2009 and 2015. thirteen emergency and critical care center representatives in chiba prefecture met to verify each case based on data from the police, fire department, and medical institutions. the cases were classified into (1) preventable trauma death (ptd) cases, (2) suspected ptd cases, and (3) non-life-saving cases; the problems (causes of ptd) in each case were examined. result: there were 115 cases (22%) of ptd and suspected ptd. sixty-eight of these cases were transported to emergency and critical care centers. the most common cause of death was bleeding, accounting for 78 cases and the locations where the problems that caused ptd occurred were outside of the hospital (n = 11) and in the hospital (n = 67). the problems that occurred in the hospital (including duplications) include circulatory management (n = 42, 54%), the treatment plan (n = 32, 41%), delay of lifesaving surgery (n = 28, 36%), and delay of diagnosis (n = 20, 26%). most of these occurred in the initial emergency care room. conclusion: this study clarified that ptd still occurs in relation to bleeding control in the current trauma care system in chiba prefecture. it is vital to establish a national ''trauma center'' and to thoroughly consolidate trauma cases to eradicate ptd. analysis of the impact of the implementation of a trauma team in a trauma center from an upper-middle-income country introduction: trauma teams (tt) improve the care process and the outcomes. a multidisciplinary tt was conformed in september 2015 to achieve a rapid response by specialists in emergency medicine, trauma surgery, diagnostic imaging services, and blood bank in a level i trauma university hospital in southwestern colombia. objective: to evaluate the impact of a tt implementation in terms of times of attention and mortality. material and methods: retrospective study. all the patients with the highest level of tt activation treated in the 15 months after the tt implementation were included. the subjects triaged to the trauma center in the 15 months pre tt were taken as controls. four hundred sixty-four patients were included, 220 before the implementation of the tt (btt) and 244 after (att). demographic data, trauma characteristics, times to tomography, and trauma surgery and mortality were recorded. the analysis was made on stata 15,1 ò . categorical variables were described as quantities and proportionscontinuous variables as mean and standard deviation or median and interquartile range (iqr). categorical variables were compared by chi2 or fisher's test. continuous variables with student's t or wilcoxon-mann-withney. a multiple logistic regression model was created to evaluate the impact on mortality if being treated att, adjusted by age, trauma severity, and physiologic response on admission. results: the time from admission to the ct scan was 56 min (iqr 39-100) in the btt group and 40 min (iqr 24-76) in the att group, p &lt; 0.001. the time to trauma surgery was 116 min (iqr 63-214) in the btt group and 52 min iqr 24-76) in the att group, p &lt; 0.001. mortality in the btt group was 18.1% and 13.1% in the att group. adjusted or was 0.406 (0.215-0.789) p = 0.006 conclusions: the implementation of a multidisciplinary trauma team associated with a reduction of the times to tomography and surgery and with a decrease in mortality risk. no prediction of an unfavourable outcome after surgical treatment of chronic subdural hematoma patients using machine-learning l. riemann 1 , a. younsi 1 , c. habel 1 , j. fischer 1 , a. unterberg 1 , k. zweckberger 1 1 university hospital heidelberg, neurosurgery, heidelberg, germany introduction: chronic subdural hematomas (csdh) are expected to become the most frequent neurosurgical disease by the year 2030.1 although often perceived as a ''benign'' condition, considerable rates of mortality and poor outcome have been reported. we therefore evaluated factors associated with an unfavorable outcome after surgical treatment of csdh patients by developing a predictive model using machine-learning. material and methods: consecutive patients treated for csdh with surgical evacuation between 2006 and 2018 at a single institution were retrospectively analyzed. potential demographical, clinical, imaging and laboratory predictors were assessed and a decision-tree predicting unfavorable outcome (gos 1-3) was subsequently developed using the classification and regression tree (cart) algorithm. out-of-sample model performance was evaluated using repeated cross-validation (fivefold with 200 repetitions). results: 755 eligible patients were analyzed. median age was 75 (iqr 68-81) years and 69% were males. mortality rate was 1.6% and rate of unfavorable outcome was 14.3%. the developed decision-tree to predict unfavorable outcome had 5 splits and included the following 4 clinical variables (in descending order of calculated importance): gcs, comorbidities, hb, and age. after cross-validation, the following model performance metrics were obtained: a model accuracy of 0.88 (0.85-0.90), sensitivity of 0.35 (0.19-0.51), and specificity of 0.96 (0.94-0.99). conclusions: gcs, comorbidities, hb, and age were identified as the most important clinical predictors for an unfavorable outcome in csdh patients after surgery. the developed model was simple and still displayed a high accuracy and very high specificity, the sensitivity was however rather low. our results might help clinicians to better assess the prognosis in patients with csdh. introduction: in most developing countries access to tertiary care neurosurgical setup is uncommon. majority trauma including neurotrauma & medical conditions requiring emergency neurosurgical interventions present to a general surgeon. this study is an attempt to highlight the importance of emergency neurosurgery as a skill amongst general surgeons & also focus on the challenges in managing such cases in austere environments material and methods: this study was a retrospective analysis of progressively collected data of trauma patients with a specific focus on head injuries & emergency neurosurgical interventions for both traumatic & non traumatic indications in a level 2 trauma centre in a semi urban area over a period of 2 years from august 2016 to september 2018 results: a total of 720 patients of trauma were analysed out of which 392 were head injuries. road traffic accidents accounted for nearly 77% of head injuries. atypical trauma especially in rural setup e.g. train collision, animal related causes were also seen. males accounted for majority (m:f = 2.6:1). mean age was 37 yrs. 104 patients had imaging findings suggestive of severe head injury. acute sdh was the commonest post traumatic finding and mca territory infarct in non traumatic group. 22 patients underwent emergency neurosurgical intervention with a survival of 61%. factors associated with poor outcome were delayed presentation (p \ 0.05), sdh with diffuse axonal injury. alcohol consumption was a significant factor. conclusions: emergency neurosurgery is an essential skill for general surgeons. performing such cases in a low resource environment in absence of modern day facilities for imaging, icp monitoring & powered equipment presents a significant challenge. general surgeons should be able to perform operative interventions with basic handheld instruments. operative management whenever indicated should be done & helps improve outcomes. head trauma in polytraumatized patient. analysis of risk factors and neurological prognosis b. castro 1,2,3 , m. morote gonzález 1,2,4 , l. cebolla 1,2,4 , a. sada 1,2,4 , l. seisdedos 1, 2, 4, 5, 6 , j. gil 6 , c. rey valcárcel 6,7 , f. j. turégano fuentes 6,7 , c. tristan 1 , c. ruiz moreno 1 1 hgugm, surgery, madrid, spain, 2 hospital, madrid, spain, 3 hospital, madrid, spain, 4 hospitall, madrid, spain, 5 hospital, madrid, spain, 6 hospital, madrid, spain, 7 hospital, madrid, sri lanka introduction: severe trauma is one of the most frequent causes of death and disability and traumatic brain injury (tbi) in polytrauma is the main cause of death and disability in survivors. the aim of this study is to analyze mortality associated to tbi in the last 25 years, prognostic factors associated with it and neurological outcomes in survivors with tbi. methods: retrospective observational study that includes risk factors and functional neurologic evaluation in polytrauma patients attended in gregorio marañon hospital between 1993-2018. inclusion criteria were severe trauma patients (iss c 15) with a tbi and abnormal ct of the head. we analyzed mortality trend in two periods : 1993-2005 and 2005-2018 , and neurological evolution and outcome at discharge with functional scores (ramkin scale and gos) in the second one. results: from 1993 to 2018, 2818 severe trauma patients were admitted, 788 (27,9%) with brain or central nervous system injuries visible on head ct. median age was 37'5; 71.4% were men. the global mortality of the cohort has been 34,1%, 27.6% of them for neurological causes. ischemic heart disease, anticoagulation, abnormal pupils or eye opening, the need for surgery, shock, gos, iss, niss, cranial ais are significant associated with higher mortality (p \ 0,05).the mortality rate due to neurological causes decreases in the second period from 19,5 to 14,8%, this descent being statistically significant (p = 0,017). between 2005 and 2018 27,9% patients died from cnsi, and 4,2% of tbi survivors had a vegetative status at discharge, 16,7% had major disability, and 33,9% had a good neurological recovery. conclusions: mortality due to tbi decreased in the last 12 years, but this improvement after tbi was at the expense of a high rate of vegetative status and great disability, showing the need for continuous research in this area. introduction: severe traumatic brain injury (tbi) constitutes one of the most frequent causes of intensive care unit admissions and is a major cause of death and disability among young people. decompressive craniectomy (dc) is a life-saving measure used to relieve intracranial pressure (icp). this procedure is related with low mortality rates and poor functional outcomes. the aim of this study is to analyze the survival rates and prognostic factors related with functional outcomes after dc for severe tbi. material and methods: retrospective, single center study of 60 patients with severe tbi in whom a dc was performed between the years 2006 and 2016. demographic features, clinical parameters, radiological findings and clinical outcomes were included in the study. for the statistical analysis we used anova, chi-square, kaplan meyer, cox regression and logistic regression. a p value of less than 0.05 was considered to indicate statistical significance. results: the mean initial glasgow coma scale was 5,65 ± 1,69 and the mean initial motor response (imr) was 3,20 ± 1,48. the mean icp after dc was 9,75 ± 3,35. the 30-day survival after dc was 65%. twenty percent of the patients improve ate least 1 point in the glasgow outcome scale (gos) between 6 and 24 months after surgery. twelve patients improve from unfavorable gos to favorable gos. at 24-month follow-up, 30% of the patients has gos [ 3. younger age, high irm a post-operative icp were the factors significantly associated with a higher chance of outcome improvement. conclusions: dc is useful for the management of refractory intracranial hypertension related to severe tbi, and in selected patients is associated with good functional outcomes. introduction: antiplatelets and anticoagulation, commonly referred to as antithrombotic therapy, are frequently used in patients c 65 years. the use of antiplatelets and anticoagulation are associated with increased incidence of intracranial bleeding (1, 2) . there are two research questions addressed in this study: (1) does preinjury antithrombotic therapy affect survival in elderly patients with tbi? (2) are direct oral anticoagulants (doacs) associated with better survival than vitamin k antagonists (vka) in tbi patients on anticoagulation? materials andmethods: retrospective cohort study based on data extracted from the oslo tbi registry. included in the study are tbi patients c 65 years admitted to ouh with cerebral-ct showing signs of acute trauma (hemorrhage, fracture, vascular injury) in the time period 2014-2019. the impact of age, comorbidity, antithrombotic medication and antithrombotic reversal protocol for survival will be explored. results: the patient inclusion is ongoing. preliminary data will be presented at the 21 st ectes in april 2020. the estimated number of tbi patients c 65 years with cerebral-ct showing signs of acute trauma in the study period is * 850. in this patients group, the expected preinjury use of antiplatelet and anticoagulation medication is * 33% and * 23%, respectively. conclusions: the knowledge regarding impact of preinjury antithrombotic therapy on survival in elderly tbi patients is clinically relevant, and may improve patient management in the acute phase of injury. references: introduction: traumatic acute subdural hematoma (asdh), especially the large ones in need of surgical evacuation, is associated with high mortality. contemporary population-based series of surgically treated asdh are sparse. the two main aims of this single-center study from oslo university hospital (ous) were to estimate incidence of surgery for asdh in the population of helse sør-øst, and estimate in-hospital and 1-month survival of these patients. treatment of tbi at ous adheres to the brain trauma foundation guidelines, with icp controlled therapy and evacuation of asdh when gcs \ 14 and hematoma volume c 30 cm 3 or midline shift c 5 mm or hematoma width [ 10 mm. the goals of tbi treatment for adults have been to maintain icp \ 22 mmhg and cerebral perfusion pressure (cpp) c 60 mmhg. methods: from 01.01.2015 all patients with traumatic brain injury (tbi) with positive head ct, admitted to ous, living in helse sør-øst (3.0 million inhabitants) and having a norwegian social security number, have been included in our approved tbi-quality register. included in the present study are all patients with asdh undergoing evacuation of the hematoma within 7 days of trauma. the following data were extracted from the register; demographic variables, date of injury and trauma mechanism, severity of head injury according to hiss grade, rotterdam ct score, surgical procedures, multitrauma, glasgow outcome scale at discharge and date of death. results: 116 asdh patients were operated in the 4-year period 2015-2018, 72% males, mean age was 58 years (10-92), the most frequent trauma mechanism was falls (60%), 29% were under influence of ethanol, 58% had severe tbi and 28% had multitrauma. the incidence of surgically treated asdh in helse sør-øst was 1/100.000/year. in-hospital and 1-month mortality was 9.5% and 15%, respectively. conclusion: the presented data for incidence and mortality will be compared with earlier reports. age-related difference in impacts of coagulopathy in patients with isolated traumatic brain injury: an observational cohort study w. takayama 1 , a. endo 1 , y. otomo 1 1 tokyo medical and dental university hospital of medicine, trauma and acute critical care, tokyo, japan background: age and trauma-induced coagulopathy (tic) have been reported to be the predictors of poor outcome following traumatic brain injury (tbi). whether the impact of brain injury induced coagulopathy on outcomes have age related differently is unknown. objectives: we evaluated the age-related difference in the impact of tic on outcomes in patients with isolated tbi. methods: a retrospective observational study was conducted in two tertiary emergency critical care medical centers in japan from 2013 to 2018. the patients with isolated tbi [head abbreviated injury scale (ais) c 3, and other ais \ 3] were included. we evaluated the impact of coagulopathy (international normalized ratio c 1.2, and/or platelet count \ 120 9 109/l, and/or fibrinogen b 150 mg/dl) on the outcomes [glasgow outcome scale-extended (gos-e) scores, inhospital mortality and ventilation free days (vfd)] in both group using univariate and multivariate models. furthermore, we visualized the impact of coagulopathy on gos-e according to age, by using a generalized additive model. results: of the 1036 patients studied, they were divided based on their age: non-elderly group (n = 501, 16-64 years) and elderly group (n = 535, age c 65 years). although, in the multivariate model, age and coagulopathy were significantly associated with lower gos-e, in-hospital mortality and shorter vfd in the non-elderly group, significant impact of coagulopathy was not observed for all the outcomes in the elderly group. the correlation between coagulopathy and lower gos-e decreased with age after round 70 years old. conclusions: in patients with isolated tbi, impact of coagulopathy on functional and survival outcomes was lower in geriatric patients. no difference in mortality between isolated tbi and polytrauma with tbi: it is all about the brain introduction: despite improvements in trauma and critical care mortality caused by traumatic brain injury (tbi) remains high. [1] as polytrauma is naturally associated with increased mortality, this study compared mortality rates in isolated tbi (itbi) patients and polytrauma patients with tbi admitted to icu. material and methods: a 3-year retrospective cohort study included both consecutive trauma patients with itbi with ais head c 3 (ais of other body regions b 2) and polytrauma patients with ais head c 3 admitted to a level-i trauma center icu. patients \ 15 years of age, injury caused by asphyxiation, drowning, burns and transfers from and to other hospitals were excluded. patient demographics, shock and resuscitation parameters, denver multiple organ failure scores and acute respiratory distress syndrome (ards) data were collected. [2] data is shown as medians with interquartile ranges. p-values \ 0.05 were statistically significant. results: a total of 259 patients were included. the median age was 54 (33-67) years, 177 (68%) patients were male, median iss was 26 (20-33). seventy-nine (31%) of all patients died. polytrauma patients developed more often ards (7% vs 1% p = 0.041) but had similar mods rates (18% vs 10% p = 0.066). polytrauma patients stayed longer on the ventilator (7 vs. 3 days p b 0.001), longer in icu (9 vs. 4 days p b 0.001) and longer in hospital (24 vs. 11 days p b 0.001). there was no distinction in in-hospital mortality of itbi and polytrauma patients (35% vs. 24% p = 0.06). tbi contributed to all deaths in itbi patients and all but three deaths (89%) in polytrauma patients. conclusions: tbi was the main cause of death in both groups. there was no difference in mortality rates between polytrauma patients with tbi and itbi patients, even though polytrauma patients were more severely injured. references: [1] dewan mc et al. estimating the global incidence of traumatic brain injury. j neurosurg. 2018;130(4):1080-97. no significant relationships or conflict of interests. how modeling the brain ventricles could help brain trauma understanding (1). in pathological cases as in hydrocephalus, or in brain trauma, it is likely that each patient's ventricle structure has an impact on the way they behave. for instance, a shock wave may turn out differently according to the ventricle's shape. this can explain why for a same shock, the clinical translation is not the same. the aim of the study is to implement a finite element model of the cranio-cerebral system and to analyse the impact of a trauma simulation. material and methods: this is amonocentricretrospective study from 2018. the database contains 33 ct scans of healthy patients. we used itk-snap software to segment the ventricles and matlab to implement the model. results: the mean volume of the 33 total ventricles is 43 ml (sd = 31). the median is 31 ml (table 1) .to identify the correlation between the parameters acquired we performed a pearson test. we found multiple significant correlations and one of the most relevant one is between the ventricular volume and the width of the third ventricle ( table 2 ). showing that the total ventricular volume is statistically correlated to the width of the third ventricle is clinically interesting. we could potentially simplify our analysis of the ventricular system in head trauma by measuring less coordinates and yet come up to an accurate prognosis. the ventricle volumes are used as neuroimaging marker of brain changes in health and brain trauma. to our knowledge, it is the first time they are studied in vivo on ct-scan. this study and the existing correlations are relevant for the configuration of the finite element model on going. it can surely help the comprehension of the interaction between the structural parts of the cranio-cerebral system during brain trauma. (excitatory-glutamate, and inhibitory-c-aminobutyric acid, gaba), is crucial for the normal cerebral functioning. gaba concentrations vary in different cerebral zones [1] responsible for different cerebral tasks. in this study, [gaba] is measured in the posterior cingulate cortex (pcc) of children with acute mtbi. material and methods: 8 acute mtbi patients (\ 70 h since injury, 15.7 ± 1.9 y.o) and 12 healthy controls (19.3 ± 0.7 y.o). mri scanner philips achieva 3t was used. standard mri protocol for tbi revealed no pathological lesions in brain of any subject. magnetic resonance spectroscopy (mega-press [2] ) was applied to obtain gaba signal without macromolecules. spectroscopy voxel is demonstrated on fig. 1 . intensities of gaba, glutamate ? glutamine, creatine and water signals were calculated in gannet program [3] . absolute concentrations were calculated. mann-whitney was used to reveal the statistical significance of between-group differences. results: typical gaba spectrum processing in gannet is demonstrated on fig. 2 . no changes in glx were found. the values of [gaba] in pcc are demonstrated on fig. 3 : the increase in gaba is not statistically significant. conclusions: this is the first study of [gaba] in pcc of children with acute mtbi. the result of current work disagrees with our previous study, where gaba was increased (p \ 0.005) in the anterior cingulate cortex of children with mtbi [4] . this indicates to a necessity of further data collecting in order to reveal any [gaba] alterations in various cerebral loci. this would help to identify the causes of an inhibition/excitation imbalance and to predict possible dysfunctions of cns following mtbi. results: tnaa and naag concentrations along with stable naa concentration were found to be reduced in patient group. reduced asp and elevated mi concentrations were also found. the main finding of the study is that tnaa signal reduction in wm after mild traumatic brain injury is associated with the drop of the naag concentration rather than of naa one, as it was thought previously. this highlights the importance of separation of these signals at least for wm studies to avoid misinterpretations of the results. naag plays an important role in its selective activation of the mglur3 receptors, thus providing neuroprotective and neuroreparative function immediately after mtbi. it might have potential for the development of new therapy strategy for patients with injuries of various severity. introduction: traumatic brain injury (tbi) is globally recognized as a major health and socioeconomic issue. however, reported numbers vary and often represent subgroups. the number of hospital-admitted tbi has an important impact on hospital resources. thus, the monitoring of hospitalized tbi patients is needed. in 2015, oslo neurosurgical tbi registry was established and includes patients admitted to oslo university hospital (ouh) with traumatic intracranial injury identified by neuroimaging. the aim is to introduce the registry; describe the patient group and volume. material and methods: descriptive study from oslo neurosurgical tbi registry. results: 1701 patients from south-east region were included in 2015-2018 (population 3 million). mean age was 52 years (sd 24), 69% were males. most frequent cause of injury was falls (55%), increasing with age. 27% was influenced by alcohol at time of injury. preinjury antithrombotic therapy was common (25%). most of the patients had multiple pathologies on ct caput, e.g. simultaneous cranial fracture, sdh, tsah and brain contusion (four most frequent). accompanying injuries were found in 48%. 37% was transported to ouh directly form accident scene. 27% was classified as severe tbi upon arrival ouh, 35% was intubated, and trauma team was activated in 77%. median annual and monthly numbers of cases were 419 (range 384-480) and 36 (range 17-49), respectively. no clear change in case load between years and months, except a slight decline in march. admission rate peaked during the weekend. patients were continuously admitted throughout day and night, [ 50% between 18:00 and 06:00. conclusions: patients included in the registry were older than those included in previous tbi studies. the numbers of cases admitted were stable across the months and years. however, the majority of patients were admitted during weekends and nights; thus handled by duty staff. relationship between brain-body temperature difference and neurologic outcomes in patients with severe head trauma introduction: brain is one of the most vulnerable organ to temperature. the association between core body temperature(ct) and neurologic outcomes in patients with post-cardiac arrest, severe head trauma and stroke has been reported. there were few reports comparing brain temperature(bt) with ct and peripheral temperature(pt). we investigated the association of differences among bt, ct and pt with neurologic outcomes in patients with severe head trauma. material and methods: we retrospectively reviewed data for patients with severe head trauma who underwent monitoring intracranial cerebral pressure(icp), bt, ct and pt simultaneously between january 2012 and december 2018. results: we evaluated 6 patients with a median age of 32 years (range 20-71 years). glasgow outcome scale(gos) at discharge were as follows: good recovery(gr) 2, severely disabled(sd) 1, vegetative state(vs) 2, death(d) 1. table 1 showed the average values of icp, cerebral perfusion pressure(cpp), bt, ct, pt, differences between each temperature (bt-ct, ct-pt, bt-pt) and gos in each patients. there was remarkable difference between bt and ct in the dead patient, whereas less differences were found in the other alive patients. we found greater difference between bt/ct and pt in the vs patients than gr patients. conclusions: greater differences between bt/ct and pt can be related to poorer neurologic outcomes introduction: minor head traumas are difficult to assess even with guidelines, hence head cts are often requested. as head cts are increasingly accessible, the demand on the radiology department often exceeds its capacity. there has been an increase in head cts at the oslo emergency department (oed), norway. the scandinavian guidelines for initial management of head injuries in adults (sg) is standard practice in the oed when assessing patients with head trauma.the aim of this study is to assess the number of patients with traumatic brain injury, evaluate guideline compliance and false negative initial reports by junior radiologists. material and methods: a consecutive cohort of 2000 patients from jan-june 2016 who received a head ct at oed due to minor head trauma was assessed. data was gathered from the ct request form, radiology report and ct images. the data points analyzed were: type of trauma, gcs, anticoagulants, loss of consciousness, nausea and vomiting, positive traumatic ct findings, and number of head cts within a 5 year period. results: intracranial bleeds were reported in 100 (5%) patients, 5 (0.25%) required neurosurgical intervention. skull fractures were reported in 10 (0.5%) patients, however no intracranial bleeds were present. it was impossible to assess guideline compliance because 40% of the referrals lacked adequate clinical information. ten bleeds were missed, however no further action was needed. 20% received more than 2 head cts in 5 years conclusions: head injury guidelines can improve clinical practice and reduce unnecessary ct scans; thus minimizing radiation exposure. based on the low number of positive findings, we hypothesize that sg compliance can be improved at oed. compliance was not assessable for nearly half of the patients, due to vital clinical factors missing. implementation of a standardized ct referral form based on the sg and educating junior ed doctors may decrease the number of unnecessary head cts. introduction: to date, there is no ideal allograft that provides local antibiotic release. along with this, existing fillers are expensive material, which complicates their application in practice. all this leads to the need to look for new ways to solve this problem. material and methods: gentamicin was used as an antibacterial drug because of its wide spectrum of action and thermal stability. for the study, staphylococcus aureus attc 1518 was used as a microbial strain. the antibiotic release from the studied materials was determined by equilibrium dialysis over the entire observation period. gentamicin antibiotic concentration was determined by hplc. results: an allograft impregnated with an antibiotic, prepared according to the marburg system in the area of the subcortical part of the bone, suppresses the staphylococcus aureus attc 1518 strain twice as much as perossal. when comparing bone allografts impregnated in various ways, the longest release time showed a perforated allograft.a bone graft impregnated with an antibiotic by incubation showed a 9% longer release time compared to perossal granules (p \ 0.05).when in vitro incubation of the antibiotic gentamicin with the drug ''perossal'', the dissociation rate is more than 97% in the first two days. when the antibiotic gentamicin with a bone allograft is incubated in vitro on the second day, dissociation into the extracellular space makes up more than 56% of the drug from the previously bound (p \ 0.05), which also indicates a longer release time from the bone allograft. conclusions: in vitro, a bone allograft impregnated with an antibiotic is able to reversibly bind the antibiotic gentamicin and gradually release it over a period of 7 days. the use of a bone allograft impregnated with an antibiotic suppresses the growth zones of staphylococcus aureus strains. references: rudenko a., impregnation of the bone allograft: comparison of heads coloring. european journal of trauma and emergency surgery 2019 (suppl) p.70 acute appendicitis and pregnancy: from incidence to modern management: literature review and proposal for consensus estes experts guidelines a. l. bubuianu 1 , a. mihailescu 1 , g. pokusevski 1 1 tameside general hospital, general/emergency surgery, ashtonunder-lyne, united kingdom introduction: acute abdominal pathology during pregnancy has historically been a challenging decision for the emergency surgeon, that had to deal with 2 patients at same time. acute appendicitis has probably the highest prevalence of all. early involvement of the gynaecological team was considered paramount and the ongoing debate laparoscopic versus open intervention, has been more recently challenged by case reports where antibiotics alone have been a successful strategy. material and methods: literature review has been conducted by the investigating team, using the following search algorithm: 2 reviewers screened pubmed portal to conduct a thorough search of the 3 most important medical databases, cochrane's library, medline and embase. case reports and low quality case series have been excluded from the literature review. results: there is currently no general consensus in regards to operative strategy in acute appendicitis during pregnancy, but most authors described safety of laparoscopic intervention in the first 2 trimesters and favoured open approach in a mother closer to term. the antibiotic treatment alone can only be considered in presumed early appendicitis, where there are no features of pending perforation, presence of phlebolith or established peritonitis and should be done under the close monitoring of experienced general surgeons. conclusions: an expert consensus is required in first instance, (set of questions submitted to audience at end of presentation for their expert opinion) regarding optimal treatment strategy in acute appendicitis during pregnancy, followed by a multicenter prospective randomised control trial, which we are hopeful to engage with help of numerous european hospitals where estes members activate. introduction: deep tissue pressure injuries (dtpi) are complex and difficult to treat. the higher prevalence is observed in paraplegic and elderly populations. primary closure of large, stage-4 dtpis is rarely feasible and flap closure is customarily applied. presented is a technique using tension relief system (trs; topclosureò tension relief system) and regulated oxygen and irrigation negative pressure wound therapy (roi-npt; vcareaò) to facilitate simple primary wound closure of dtpis. methods: large, stage-4 dtpis were closed by a limited surgical procedure entailing conservative debridement, en-bloc primary wound closure based on the application of trs and roi-npt. results: details of the closure of consecutive 10 large dtpis in 9 patients is presented. immediate primary closure was achieved in 7 cases, while three others were closed over 6-45 days. surgery time ranged between 1.5 and 3 h and hospitalization between 8 and 37 days. following a median follow-up of 19 months (range 1-42 months), all wounds healed with one late recurrence. post-operative wound infection observed in one patient was successfully treated with systemic antibiotics. minor skin damage inflicted by the tension sutures at the anchoring sites healed spontaneously. gradual return to partial loading of the operated area was enabled within 1-4 weeks and full weight-bearing was achieved within 4-6 weeks. introduction: chronic pain is a disabling condition affecting 50-85% of trauma patients. 1 considering the burden of chronic pain, interest in interventions to prevent this disorder after trauma has grown. a descriptive review of literature was undertaken to assess the evidence on these interventions. 1 material and methods: medline, cinahl and cochrane library databases were searched to identify interventional studies published up to august 2019. websites of injury, critical care and pain organizations were also consulted to retrieve relevant guidelines. the literature search used combinations of medical subject headings and keyword under the themes of pain, trauma, surgery and preventive interventions. results: many knowledge syntheses relevant to the population of trauma published between 2016 and 2019 were found. 1 low to moderate level of evidence was reported for pharmacological interventions such as the administration of ketamine, neuropathic pain medication and multimodal analgesia. local or regional nerve block in the presence of factures was associated with a high level of evidence. very low to low evidence was described for nonpharmacological interventions including cryotherapy and early mobilization. finally, psychological interventions were associated with a low to moderate level of evidence and multimodal pain management interventions (pharmacological and non-pharmacological) with a high level of evidence. conclusions: research is still needed to define the role of interventions to prevent chronic pain in trauma patients. thus far, multimodal pain management interventions involving multidisciplinary team management appear to be the most promising. implementing such interventions could reduce the negative consequences associated with chronic pain. introduction: chronic use of opioids has been documented 60% of trauma patients. 1 accordingly, the tapering opioids prescription program in trauma (topp-trauma) was developed. 2 the aim of this study was to assess the feasibility of topp-trauma and explore the efficacy of topp-trauma in reducing opioid use. material and methods: a 2-arm pilot rct was conducted in patients presenting a high risk for chronic opioid use. we aimed to recruit 50 participants to receive either topp-trauma or an educational pamphlet. topp-trauma comprised educational and counseling sessions. the feasibility assessment of topp-trauma was based on the ability to provide its components. the morphine equivalent dose (med) per day as well as pain intensity and pain interference with activities were measured at 6 and 12 weeks following discharge. results: preliminary findings based on data collected in 30 participants showed that 4 counseling sessions were most frequently needed to completely taper opioids. sessions attendance reached 70%. nearly 70% of eligible patients accepted to participate and an attrition rate of 23% was found. even though the experimental group consumed a higher med 24 h prior to hospital discharge compared to the control group (77.1 vs 54.8), its med/day intake was lower at 6 weeks (1.0 vs 9.20) and 12 weeks (0 vs 3.8). these self-reported data were validated by the total med delivered by participants'' pharmacy at both time points (500.6 vs 561.3 at 6 weeks; 500.6 vs 949.3 at 12 weeks). minimal mean score differences were observed in both groups with regard to pain intensity and interference with activities. conclusions: data collected until now provided evidence on the feasibility of topp-trauma and on the program potential efficacy. challenges that will require to be addressed in future rct include the acceptance to take part in the study and participants' drop out. introduction: head preserving surgical treatment for ao-type 31b fractures with little to no dislocation consists of three canullated screws or a dynamic hip screw (dhs). there is a new alternative: the femoral neck system (fns). the fns has some advantages over dhs. the anti-rotation screw provides extra rotational stability because of the diverging design. furthermore, the incision is smaller in fns and only one locking screw is necessary for plate fixation. we present the first results of this new surgical fixation of femoral neck fractures with fns. material and methods: during the period of november 2018 until october 2019, all patients with femoral neck fractures treated with fns, were included in this prospective single center cohort study. patient characteristics, fracture classification (ao, garden, pauwel), perioperative parameters and postoperative complications were registered. patients were allowed to mobilize based on the principle of permissive weightbearing. follow up was planned after 6 weeks and 12 weeks. primary outcome measure was cut-out rate within 3 months. results: twenty-four patients with a femoral neck fracture (ao-type 31b) were surgically treated with fns. median age was 58, (range 47-75). median operation time was 33 mins (range 16-49). mean duration of in hospital stay was 4 days (range 1-12 days). twentytwo (91,67%) patients completed the regular follow up of 12 weeks. one patient (4%) had a reoperation due to a cut-out. during follow up one patient developed a wound-infection (4%) which was treated with intravenous antibiotics conclusions: femoral neck system as surgical treatment for femoral neck fractures shows promising first results. low cut-out rate, limited operation time, low mortality and short duration of in-hospital stay make this device a possible alternative for dhs of canullated screws. definitive conclusions should be made after studying long term results in larger cohorts. references: none. new personalized approach to enteroatmospheric fistulas using 3d bioprinting device introduction: enteroatmospheric fistula is a challenge for surgeons. it presents a great clinical variability. this diversity means that, despite having tried multiple devices and techniques to achieve local control of the intestinal effluvium over the rest of the wound, there is currently no technique that can solve this problem in all patients. 3d printing is a novel therapy that allows the customization of the devices according to the needs of each patient. the aim of this study is to describe the technique of manufacturing a custom device designed by bioscanner imaging and manufactured using a 3d printer for use in the management of enteroatmospheric fistula. we describe our initial results. materials and methods: we present four patients with enteroatmospheric fistula. the intestinal segment involved, the dimensions of the wound, the intestinal debit and the size of the exposed intestinal surface are substantially. all require an average of 4-5 daily cures by the nurse. after obtaining images of each fistula with a bioscanner, a personalized device was designed and made by a 3d printer. the polycaprolactone device was placed including inside the fistulous orifices and surrounding it with npwt in order to accelerate the healing of the wound to ostomize the fistula or achieve its definitive closure. results: four devices with different designs have been manufactured. the wound remained isolated from the intestinal contents after placement, favouring the granulation of the surrounding tissue with npwt and thus avoiding contamination of the wound. the system remained without leaks for an average of 48 h, reducing the need for daily cures, improving patient comfort and avoiding complications. conclusions: the use of a manufacturing model using 3d bioprosthesis printing in order to create a personalized device that fits the characteristics of the patient's wound is feasible and offers promising results in the management of enteroatmospheric fistulas. new approaches in bone tissue engineering: innovative scaffold design for principle unlimited size bone substitutes introduction: in bone tissue engineering (bte), autologous boneregenerative cells are combined with a scaffold for large bone defect treatment. microporous, polylactic acid scaffolds showed good healing results in bone defects in small animals. transfer to large animal models, however, is challenging and not easily achieved simply by upscaling the design. increasing diffusion distances has a negative impact on cell survival and nutrition supply. this can lead to cell death and ultimately implant failure.this approach focuses on scaffold architectures, that meet all the requirements for a modern bone substitute. biological-functional, porous subunits in a loadbearing, compression-resistant frame structure characterise the innovative design. an open, macro-and microporous internal architecture provides optimal conditions for oxygen and nutrient supply in the inner areas of the implant by diffusion. material and methods: during the design process, 3 prototypes (temple (figure a) , grid (figure b) , onion (figure c)) were 3dprinted (fused filament fabrication) using polylactic acid (pla). -after incubation with saos-2 (sarcoma osteogenic) cells for 14 days (measurements on days 1, 7, 14 and 21), cell morphology, distribution and survival (fluorescence microscopy, ldh-based cytotoxicity assay), metabolic activity (mtt test) and osteogenic gene expression were determined. results: all designs not only showed cell colonization, but cells also sustained their ability to differentiate (already after 14 days) and to divide. the open, hierarchical-structured design, with its innovative porous structure, provides a good basis for cell settlement and proliferation. the modular design allows easy upscaling and offers potential solutions to previous limitations scaffold developement in bone tissue engineering. references: the value of 3d reconstructions in determining post-operative reduction in acetabular fractures: a pilot study introduction: in patients with acetabular fractures, the reconstructed three-dimensional (3d) model of the contralateral acetabulum could be used as a mirrored template for the anatomic configuration of the affected joint. this has not been validated. material and methods: computer tomography (ct)-scans of twenty patients with unaffected acetabula were used. the symmetry of the generated 3d models was evaluated through; (1) mirroring of the acetabulum; (2) initial rough matching; (3) automatic optimisation of the matching via surface-based matching; (4) calculation of distances between surfaces by evaluating the euclidean (straight-line) error distance between the closest points between left and right. the percentages of surface-points of the left and right acetabulum with a distance smaller than 0.5, 1.0, 1.5 and 2.0 mm were calculated and evaluated, in relation to matta's criteria, for acetabular fracture reductions. the analysis was performed using the mirrored left acetabulum matched onto the right original structure (left mirrored to right original; ''lm2ro'') and the right mirrored to left original (rm2lo). to determine the inter-observer agreement the procedure was repeated by a second assessor for the first ten patients. results: patients had a mean ± sd age of 39.6 ± 15.6 years, 56% was male. the mean distance deviation was less than 0.75 mm in all 40 comparisons. the calculated distances in 90.7% of the surface points of the left and right acetabulum were below the tolerance threshold of 1.0 mm, based on matta's anatomical reduction critera (table 2). absolute differences between assessors were\ 0.5 mm per patient with an overall moderate agreement of 70%. conclusions: 3d reconstructed models of healthy left and right acetabula are highly similar and could potentially be used as mirrored duplicates. the next step will be to investigate these results in patients with reduced acetabular fractures. : matta, j. (1996 ).j bone joint sur am. 1996 78:1632-45 pr 202 minimally invasive plate osteosynthesis technique for distal humeral fracture: a cadaveric study v. hofmann 1 , c. deininger 1 , t. freude 1 , f. wichlas 1 1 university hospital salzburg, orthopedics and traumatology, salzburg, austria introduction: in our study we want to evaluate the feasibility of minimally invasive plate osteosynthesis (mipo) technique for distal humeral fracture using anatomically precontoured double plate osteosynthesis. material and methods: eight elbows from four thiel fixed cadavers were included. on unfractued cadavers we tested the minimally invasive approach with two separate incisions, one at the lateral and one at the medial epicondylus. the preformed plates were inserted directly into the bone on sides and fixed with percutaneous screws. then we created an ao type a3 and c3 fracture. the reduction was performed under x-ray control and stabilized with k-wires. then we also inserted the plates in mipo technique. in the case of an intraarticular fracture, an olecranon osteotomy was additional performed in a minimal invasive way to control the distal humeral joint surface. after finishing reduction and fixation the approach were extended to control the fracture alignement, position of the plates and to expose the ulnar nerve. results: the plate position was satisfactory and we could not detect any major soft tissue damage or ulnar nerve injury by using the minimally invasive plate osteosynthesis technique. in the extraarticular fractures, reduction was achieved with k-wires and was acceptable in all cases. the intra-articular fractures were controlled by an additional olecranon osteotomy using the mipo technique with a good view on the joint surface of the distal humerus. conclusions: the findings of the present study show that mipo technique in distal humerus fracture is feasible and save especially for ao type a fractures. in ao type c fractures the olecranon osteotomy provided enough visibility to evaluate the distal humeral joint surface. the surgical technique is demanding, and care must be taken not to injure the ulnar nerve. never the less it is an effective surgical treatment method and an alternative option to open techniques. correlation between pelvic incidence and acetabular orientation in anteversion and inclination-an analysis based on a 3d statistical model of the pelvic ring introduction: the pelvic ring is a complex bony structure with a central role for the human''s mobility building the connecting part between the upper body and the lower extremities. pelvic incidence and acetabular orientation are two important parameters used in the description of pelvic anatomy and are of central importance for understanding the biomechanical interaction of spine, pelvis and hip joints. the objective of the study was the analysis of a potential correlation between pelvic incidence and acetabular orientation. material and methods: a 3d statistical model of the pelvic ring consisting of 100 individual ct scans of european adults without bony pathologies was used to analyse pelvic incidence and acetabular orientation in anteversion and inclination. an additional analysis on the correlation between those parameters was performed using the software spss. results: a slight positive correlation between pelvic incidence and acetabular anteversion could be shown (r = 0.223; p = 0.019) as well as a strong positive correlation between anteversion and inclination (r = 0.570; p \ 0.001). pelvic incidence and acetabular inclination showed none statistically significant correlation (r = 0.102; p = 0.311). conclusions: the results of the study might contribute to a better understanding of the biomechanical interaction between the axial skeleton and the lower extremities and deliver valuable information concerning preoperative planning in orthopaedic and trauma surgery of the lumbar spine, the pelvis and the hip joints like for example reconstructive surgery after trauma, operative treatment of congenital or acquired deformities or total joint arthroplasty. references: boulay et al., ''pelvic incidence: a predictive factor for three-dimensional acetabular orientation-a preliminarystudy. '' anat res int. 2014; :594650. doi: 10.1155 /594650. epub 2014 . introduction: the majority of distal clavicle fractures (dcfs) are displaced fractures and are prone to delayed-or non-union. 1 there are several options for surgical reconstruction, open reduction and fixation or hook plate, but in patients with a comminuted or small fracture they are known to have a high complication and failure rate, and secondary surgery for removal is often necessary. we hypothesize that resection of the distal fracture fragment and subsequent stabilization with the lockdown device, is an alternative for selected patients with dcfs. methods: eleven patients with a comminuted dcf were treated with a lockdown device. data on pain and range of motion were documented and the constant shoulder score (css), oxford shoulder score (oss) and nottingham clavicle score (ncs) were assessed at one year follow-up. results: eight patients underwent surgery within 2 weeks, compared to 3 patients where the surgery was delayed ([ 2 weeks) due to persisting pain and delayed-union. none of the patients had postoperative complications. in 3 months after treatment, 10 patients were complaint-free. one patient had hardware removal due to pain at the site of the screw head. four patients were assessed after one year follow-up. the mean pain score was 3.2. the mean flexion 142,5°, abduction 120,5°, exorotation 56°and extension 54°. the css had a mean of 21.75, oss 43.75 and the ncs a mean of 70. conclusions: all 11 patients had a good short-term clinical outcome and hardware complications did not occur. we are the first to describe the use of the lockdown device in dcfs. this device is not dependent on fracture healing and secondary surgery is not necessary, therefore it can be an alternative in the treatment of dcfs. a larger series and longer follow-up is necessary to confirm this conclusion. in this ongoing study, the remainder seven patients will be included and presented at the estes. moore type i tibial head fractures are one of the most challenging fractures to treat. material and methods: we performed the following approaches on eight thiel fixed cadavers: the anterolateral (with an osteotomy of the tuberculum gerdyi, a subcapital fibula-osteotomy and an osteotomy of the tuberositas tibia), the medial approach (with submeniscal arthrotomy and a dissection of the medial collateral ligament) and the posterior approach with a submeniscal athrotomy. the reachable borders of the articular joint surface have been marked by a k-wire. the visual joint surface has also been radiographically documented by inserting k-wires into the tibia head. finally the results have been photo documented on the exarticulated joints. results: the reachable areas of the articular surface have been defined and documented. the combination of the subcapital fibulaosteotomy and the submeniscal arthrotomy showed the most increase in accessibility to the articular surface in the dorsal part. an additional osteotomy of the tuberculum gerdyi increased the vision on the entire lateral and anterior articular surface. the submeniscal arthrotomy, at the medial approach, has not a good view on the surface. the posterior approach showed only a limited view on the lateral and medial articular surface at the dorsal part. none of the surgical approaches sufficiently visualizes the intercondylar region. conclusions: a fracture-specific approach strategy is critical for the preoperative planning of complex tibia-head fractures. subcapital fibula osteotomy is the most efficient surgical approach to reach the posterior and lateral articular surface. for the anterior articular surface, the best overview was achieved by an osteotomy of the tuberculum gerdyi. it was not possible to see and control the intercondylar region with any approach. introduction: osteosarcoma (os) is the most common bone carcinoma in humans. at the time of the first diagnosis are already in about 20% metastases present. the current treatment strategies include above all radical surgical resection and chemotherapy. in the search for alternative therapy methods. treatment with cold atmospheric plasma (cap) shows promising prospects. at the cellular level, this leads to various cellular mechanisms and finally to induction of anticancerogenic effects such as growth inhibition, apoptosis, and changes in the cell-cell interactions. the impact of cap on the integrity of the cell membrane of os cells, however, is unknown. material and methods: suspended cells from two human osteosarcoma cell lines (u2-os, mnng) were treated for 10 s, 30 s, and 60 s with cap. cell proliferation was determined after 4 h, 24, 48, 72, 96 and 120 h using casy cell counter. dye loss assay was performed by using fluorescein diacetate (fda). this was followed by indirect treatment with cap for 60 s. in the cell-free supernatant was determined by tecan multireader the dye emission. flow cytometry assay was used after cap treatments and incubation with fda. the mean fda fluorescence intensity of individual cells in the flow cytometer was measured. results: cell kinetics showed significant inhibition of cell proliferation in both cell lines after cap treatment. the assays for determination of the dye level showed a significantly increased membrane permeability of both cell lines after cap treatment. the significant effect on the membrane integrity correlated with treatment duration. conclusions: this confirms a modulating influence of cap on the functionality of the cell membrane and may support the anti-proliferative effect of the cap treatment. thus, cap is a promising therapy option, especially for chemotherapy-resistant entities introduction: osteosarcoma (os) is the most common bone cancer in humans. standard therapy includes radical surgical resection and chemotherapy, but due to strong toxic effects, new treatment options are urgently needed. currently, there is a discussion about expanding the oncological therapy spectrum and treat with cold atmospheric plasma (cap). it is a reactive ionized gas rich in radicals, photons, and electromagnetic rays. its biological effects are primarily mediated by reactive oxygen and nitrogen species (rons). due to its low temperature, cap is suited for medical applications. in vitro studies have shown the antitumoral effect of cap also for pancreatic cancer, melanoma, ovarian, breast, and colon cancer. material and methods: human os cell lines u2-os and mnng/ hos were used. proliferation assay. the growth of cap-treated cells was examined using a casy cell counter. caspase 3/7 assay. following cap treatment, the activities of caspase-3 and caspase-7 were measured using a specific substrate peptide coupled with a fluorescent dye (cellevent tm ). single-cell gel electrophoresis comet assay. dna damage after cap treatment was identified using alkaline microgel electrophoresis. dna migration was measured using comet score software. the percentage of tail dna was used to indicate the relative fluorescence intensity of the head and tail. tunel assay. after cap treatment tunel analysis was performed. results: the results revealed that the cap treatment of os cell lines leads to significant inhibition of cell growth. subsequently, the activation of caspases and the induction of apoptotic dna fragmentation was demonstrated. the treatment of os cells with cap leads to an induction of apoptosis and a reduction of cell growth. introduction: extra peritoneal packing (epp) is a quick and highly effective method to control pelvic hemorrhage. we hypothesized that this procedure may be as safely and efficiently performed in the emergency room (er) as in the operating room (or). methods: retrospective study of 29 patients who underwent epp in the er or or in two trauma centers in israel between 2008-2018. material and methods: retrospective study of 29 patients who underwent epp in the er or or in two trauma centers in israel between 2008-2018. results: 29 patients were included in our study, 13 in the er-epp group and 16 in the or-epp group. the mean injury severity score (iss) was 34.9 ± 11.8. following epp, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). a raise in the mean arterial pressure (map) with a median of 25 mmhg (mean 30.0 ± 27.5, p = 0.000009) was documented. all patients who did not achieve hemodynamic stability after epp had multiple sources of bleeding or fatal head injury and eventually succumbed. the overall mortality rate was 27.5% (8/29) with no difference between the or and er-epp groups. patients who underwent epp in the er showed higher change in map (p = 0.0458). no differences were found between er and or epp in the amount of transfused blood products, surgical site infections and length of stay in the hospital. however, patients who underwent er epp were more prone to develop deep vein thrombosis (dvt): 50% (5/10) vs 9% (1/11) in er and or-epp groups respectively (p = 0.038). conclusions: epp is equally effective when performed in the er or or with similar surgical site infection rates but higher incidence of dvt. level of evidence: retrospective cohort study, level iv. introduction: application of supraacetabular schanz screws is usually performed under image intensifier guidance. the aim of this study was to perform it without imaging, with the hypothesis that, respecting anatomical landmarks, pre-and intraoperative fluoroscopy can be avoided. material and methods: insertion of the supra-acetabular schanz screws was performed in 14 human adult cadavers. with cadavers placed in supine position, the anterior superior iliac spine (asis) was palpated. starting from this landmark, 2 cm were measured in a distal and 2 cm in the medial direction. at this point, a 2 cm long oblique skin incision was performed. through this approach, 150 mm schanz screws were drilled bilaterally into the supra-acetabular corridor with an angulation of 20°to distal as well as 20°to medial. combined obturator oblique-outlet views (cooo) were taken bilaterally to prove the screw position. six of the specimens underwent a 3d-ctscan. images were evaluated concerning correct screw positioning. skin and subcutaneous tissues were removed in the ilioinguinal region and possible lesions to the lateral femoral cutaneous nerve (lfcn) or to the joint capsule were evaluated. results: during radiographic evaluation of the cooo-scans (14 specimens) and the 3d-scans (6 specimens), the schanz screws were placed inside the supra-acetabular corridor in all specimens (14/14). during dissections, no intracapsular screw placements or lfcn lesions were found. conclusions: using our technique, all schanz screws could be sufficiently inserted without intraprocedural x-ray imaging. references: 1. karaharju, e. and p. slätis, external fixation of double vertical pelvic fractures with a trapezoid compression frame. inhury, 1978. 10: p. 142-145. 2. mears, d. and f. fu, external fixation in pelvic fractures. orthop clin north am, 1980. 11: p. 465-479. 3. mears, d. and f. fu, modern concepts of external skeletal fixation of the pelvis. clin orthop, 1980. 151: p. 65-72. pr 210 epidemiology of self-inflicted major trauma r. stoner 1 , n. misra 1 , l. mason 1 1 aintree university hospital, liverpool, united kingdom introduction: in the united kingdom, severely injured patients are taken directly to a major trauma centre (mtc). whilst deliberate self harm (dsh) is a known mechanism for this, there is limited prior research. 1-9% of major trauma is thought to be self inflicted 1,2 . our aim was to describe the epidemiology of presentation to our mtc resulting from dsh. material and methods: retrospective review of patient records in our mtc for adult trauma team activations between 01/07/2016 and 30/06/2018. data was collected on patient demographics, location type, injury severity score (iss), mechanism of injury and mortality. results: 194 episodes of dsh made up 6.4% of all trauma cases, involving 180 patients; 2.6% re-attended. z-scores show no change in incidence over time, but significant variability month by month, with 6/24 months [ 1sd from mean. mean patient age 37 years (range 16-78). 67.8% were male. 64.9% came from residential location and 8.2% from prison. most common mechanism was penetrating trauma (51.5%). in-hospital mortality was 10% (13.4% in males vs 3.4% in females, chi 2 p = 0.04). conclusions: this is the largest review of self inflicted trauma cases in a uk mtc, with a similar incidence to prior studies. there was no observed correlation with season or trend over time. mortality was higher in male patients, in keeping with national statistics on suicide, whilst dsh in females was linked to less severe injury; severity is related to mechanism of injury. injury from self stabbing/cutting was most common in patients from residential locations, whilst hanging was more common in prisoners. this study identifies preventable risk factors for major self inflicted injury. introduction: the distribution of trauma deaths was classically described following a trimodal pattern. during the last decade improvements in trauma care as damage control resuscitation (dcr) have minimized resuscitation injury. we hypothesized that the implementation of dcr in severely injured trauma patients is associated with less mortality and modifies mortality pattern. material and methods: we performed a 25-year (1993-2018) retrospective cohort analysis of all severely injured trauma patients (niss c 35) who underwent surgery at our level 1 trauma center. since 2005, dcr was implemented including damage control surgery, minimizing crystalloids and increasing the use of blood products. our patients were stratified into two phases: pre-dcr ( -2004 ( ) and post-dcr (2005 . results: a total of 308 patients were identified. there were 172 patients (55.84%) in the pre-dcr group and 136 patients (44.16%) in the post-dcr group. mean age (35.17 vs 39.49, non significant (ns)), mechanism of injury (blunt trauma: 89.53% vs 86.76%, ns) and shock on admission (35.46% vs 36.02%, ns) were similar between groups. there is a significant reduction in the rate of overall mortality (44.18% vs 33.82%, p \ 0.05). while early deaths from traumatic brain injury (47.36% vs 47.82%, ns) and hemorrhage (39.47% vs 41.62%, ns) are alike, mortality secondary to multisystem organ failure (msof) is lessened (13.15 vs 6.52%, p \ 0.05). conclusions: dcr has helped in reducing overall mortality and mortality due to msof in our severely injured trauma patients. introduction: the mangled extremity severity score (mess) was constructed as an objective quantification criterion for limb trauma. a mess of or greater than 7 was proposed as a cut-off point for primary limb amputation. opinions concerning the predictive value of the mess vary broadly in the literature. the aim of this study was to evaluate the applicability of the mess in a contemporary civilian central european cohort. material and methods: all patients treated for extremity injuries with arterial reconstruction at two centres between january 2005 and december 2014 were assessed. the mangled extremity severity score (mess) and the amputation rate were determined. results: seventy-one patients met the inclusion criteria and could be evaluated for trauma mechanism and injury patterns. the mean mess was ). seventy-three percent of all patients (52/71) had a mess b 7 and 27% (19/71) of c 7. eight patients (11%) underwent secondary amputation. patients with a mess c 7 showed a higher, but statistically not significant secondary amputation rate (21.1%; 4/19) than those with a mess b 7 (7.7%; 4/52; p = 0.20). the area under the roc curve was 0.57 (ci 0.41; 0.73). conclusions: based on these results, the mess seems to be an inappropriate predictor for amputation in civilian settings in central europe possibly due to therapeutic advances in the treatment of orthopaedic, vascular, neurologic and soft tissue traumas. introduction: in polytrauma victims the acute respiratory distress syndrome (ards) is a major cause of morbidity and mortality. it presents a complex pathophysiology that is characterized by pulmonary activated coagulation and reduced fibrinolysis. due to the fact that the pulmonary endothelium is considered a key modulator of ards and that tpa in plasma is predominantly synthesized and secreted by vascular endothelial cells, we hypothesized that the time courses of serum tissue-type plasminogen activator (tpa) and its main inhibitor, the plasminogen activator inhibitor type-1 (pai-1), might indicate a clinical approach to preventing ards in polytrauma victims. material and methods: twenty-eight consecutive polytraumatized patients with concomitant thoracic trauma, age c 18 years, iss c 16, who were directly admitted to our level i trauma center, were evaluated. blood samples were taken initially and on day 1, 3, 5, 7, 10, 14 , and 21 during hospitalization. luminex multi-analyte-technology was used for analysis of tpa and pai-1 antigen levels. results: both levels were particularly high at admission. although they significantly declined within three and seven days, respectively, they remained elevated throughout three weeks. throughout this observation period mean tpa antigen levels were higher in polytrauma victims suffering ards than in those without ards, whereas mean pai-1 levels were higher in polytrauma victims sustaining pneumonia than in those without pneumonia. noteworthy, in each patient, who developed ards, the tpa antigen level raised up to the onset of the syndrome and declined afterwards. conclusions: the development of ards has to be expected in a polytrauma victims if the tpa antigen level continues to rise after admission. potentially, in patients with a low risk of excessive bleeding the onset of the syndrome might be prevented by the timely administration of recombinant profibrinolytic proteins. motocross is a dangerous business: small bowell perforation case report case history: a 19 year-old male, previously healthy, was admitted to the ed after being involved in a motorcross accident. he suffered blunt abdominal trauma. clinical findings: at admission, patient presented pale but haemodinamically stable. physical examination was unremarkable except for an evident abdominal wall hematoma and abdominal guarding over the left quadrants. investigation/results: abdominal ultrasound showed an intestinal loop with decreased peristalsis with a small amount of liquid adjacent (fig 1) . due to the patient's haemodynamic stability, ct scan was performed (fig 2. ) which showed liquid in the left flank and iliac fossa, but without an identifiable intrabdominal lesion. diagnosis: the patient was admitted to the operating theatre with acute abdomen. therapy and progressions: intraoperatively fecal peritonitis was evident from a 3 cm-hole on the antimesenteric border of the jejunum, the enterotomy was closed and profuse lavage was done; the abdominal wall closed without drainage. the patient went through an empirical antibiotic cycle. liquids per os were started on the first postoperative day and the patient progressed without issues. he was discharged at the 5th postoperative day. the remaining follow-up was uneventful. comments: small bowel perforation after blunt abdominal trauma is rare. sbmi has a high morbidity and mortality that increase with delayed diagnosis; however, clinical and radiographic signs of perforation are often absent, like in the case presented. ct is considered the gold-standard. in our specific situation, the small bowel perforation did not produce any pneumoperitoneum in a young patient with very good physiologic status that kept him hemodynamically stable. the prognosis of pelvic injury is closely related to the severity of vascular injury rather than the complexity of bony fracture y. wu 1 , c. hsieh 1 , c. fu 1 1 chang gung memorial hospital, trauma and emergency surgery department, taoyuan city, taiwan introduction: pelvic injuries are among the most dangerous and deadly trauma. although complex pelvic fractures are often associated with vascular injuries, it is still unclear regarding the impact of the severity of vascular injury to the outcome of patients. we hypothesized that, in addition to the complexity of bony fracture, the severity of pelvic vascular injury plays a more decisive role to the patients'' outcome. material and methods:medical records of patients with pelvic fracture in a single trauma center between jan 2016 and dec 2017 were retrospectively reviewed. those who had an abbreviated injury scale (ais) c 3 other than pelvis were excluded. based on ct results, the type of pelvic fracture was classified according to young-burgess classification, and the severity of vascular injury were recorded as minor (fracture with or without hematoma) or severe (hematoma with contrast pooling or extravasation). the patient demographics, clinical parameters, and outcome measures were compared between the groups. results: among the 156 patients, severe vascular injury were noted in 26 patients. patients with severe vascular injuries had significantly increased amount of red blood cell transfusion (rbct) (11.8 vs. 3.8 units, p = 0.002), longer icu stay (is) (3.1 vs. 1.0 days, p = 0.011) and total hospital stay (hs) (15.8 vs. 11.0 days, p = 0.023) compared to minor vascular injuries. on the other hand, those with complicated pelvic fracture (lc type ii/iii, apc type ii/iii, vs and combined type) had similar amount of rbct and is compared to that of simple pelvic fracture (lc type i, apc type i) except a longer hs (13.4 vs. 10.1 days, p = 0.036). conclusions: our results indicated that the severity of vascular injury is more closely correlated to the outcome of patients with pelvic fractures than the type of bony fracture does. in addition to the type of bony fracture, the grade of vascular injury should be considered as an important part of pelvic injury classification. associated abdominal injuries do not influence reduction quality in operatively treated pelvic fractures-a multicenter cohort study from the german pelvic registry results: 16.359 patients with pelvic injuries were treated during this period. 21.6% had a concomitant abdominal trauma. the mean age was 61.5 ± 23.4 years. comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger (47.3 ± 22.0 vs. 70.3 ± 20.5 years; p \ 0.001). both, complication rates (21.9% vs. 10.0%; p \ 0.001) and mortality (8.1% vs. 1.9%;p \ 0.001) were significantly higher. in the subgroup of acetabular fractures, the time until definitive surgery of the pelvis was significantly longer in the group with the combined injury (5.7 ± 4.8 vs. 4.7 ± 4.0 days; p \ 0.001) . the grade of successful anatomic reduction did not differ between the two groups. conclusions: patients with a pelvic injury have a concomitant abdominal trauma in about 20% of the cases. the clinical course is significantly prolonged in patients with a combined injury, with increased rates of morbidity and mortality. however, the quality of the postoperative results is not influenced by a concomitant abdominal injury. a. martins rangel 1 , r. pozzi 1 , j. alfredo cavalcante padilha 1 , s. sardinha 1 , f. eduardo silva 1 , d. teixeira rangel 1 1 heat, trauma center, são gonçalo, brazil f.f.c., male, 27 years old, was admitted to the trauma center about 12 h after a stabbing wound in the neck. upon examination the patient was mechanically ventilated and hemodynamically stable, with an exposed sectioned trachea, which had a tracheostomy tube applied. the penetrating injury itself was mostly allocated in zone ii. he had a ct angiography and was referred to the or for surgical treatment. the cervicotomy found that both the external and internal right jugular veins had been injured alongside the sternocleidomastoid, sternohyoid and homohyoid muscles, the thyroid cartilage, just above the vocal cords, which had exposed the anterior larynx and the epiglottis the right anterior jugular vein and smaller tributaries of the right internal jugular vein, were ligated; a tracheostomy was performed and the thyroid cartilage and anterior laryngopharyngeal wall were reconstructed with the epiglottis implantation, sternoid, homohyoid and sternocleidomastoid muscle sutures, after which the platysma was closed but not the skin, left to secondary healing. patient was extubated within 48 h, discharged from icu on the fifth postoperative day. thickened oral diet was introduced on the 16th day, and by the 21th day he was discharged without the tracheostomy tube, with a normal diet. comments: the cervical region is an area susceptible to serious injury due to the presence of vital structures, with massive hemorrhage, airway obstruction, cervical spine injuries and cerebral ischemia as the leading causes of death. initial management of penetrating injuries follows the principles of trauma care with airway control initially. references: bhatt nr-penetrating neck injury from a screwdriver: can the no zone approach be applied to zone i injuries? bmj yan wang-penetrating neck trauma caused by a rebar-a case report. medicine (2018) introduction: annually, approximately 3,600 people decease as a result of a fall in the netherlands, according to the statistics netherlands. the aim of this study is to evaluate the demographic parameters, fall characteristics and resulting injury patterns of this group in the region of amsterdam. methods: all patients deceased as a result of injury due to a fall in the period july 1st 2013 until july 1st 2018 in the region of amsterdam were included. data were collected from the database (formatus) of the department of forensic medicine (public health service amsterdam). results: during the study period 1,258 patients deceased after a fall. the mean age was 83 years (0-103 years) and 41% was male. a psychiatric disease was diagnosed or suspected in 44% of the population of which cognitive impairment, including dementia, was encountered in most of the cases (82%). the majority of the falls happened at home (47%) or at nursing facilities. a minority (1.3%) was work related. over 81% of the falls was from standing position, 17.6% was not from standing position of which 80.1% regarded falls from stairs, the majority was male. multitrauma patients accounted for 17.1% of the population. from the remaining 1,040 patients, 61.7% sustained one or more injuries to the pelvis or extremities. central nervous system (cns) injuries were described in 31.3% of the patients. mortality was in 26.8% of the cases due to primary cns injury, 62.3% was due to complications of which clinical deterioration (58.7%) and infection (17.1%) were the most common. conclusions: in the region of amsterdam the majority of deaths due to a fall regards the geriatric population. fall from standing position and mortality due to complications, mainly clinical deterioration, accounted for the majority of deaths. intervention to prevent falls and thereby complications need more awareness to reduce mortality. results from a multidisciplinary blunt splenic injury protocol introduction: the majority of splenic injuries are currently managed non-operatively. failure of non-operative management includes grade iv or v splenic injury or vascular abnormalities that are suitable for embolization. the primary indication for operative management of blunt splenic injury is hemodynamic instability. in our center, the last twenty splenic injuries, admitted during two years, were not managed according to published guidelines. ten patients (50%) underwent splenectomy, being unstable only 2 of them (10% of the whole sample). material and methods: staff from anesthesiology, interventional radiology and trauma surgery came up with a joint protocol. grade iii splenic injury non-operatively management, including fluid responsiveness (achieving shock index (ht/bp) below 0.9 after a bolus of colloids) and, focus placed only on hemodynamic stability instead of on vascular abnormalities are our principal modifications regarding already published protocols. results: seventeen patients with blunt spleen trauma were admitted after starting up our protocol. six (2 grade iii, 2 grade ii and 2 grade i) splenic injuries were successfully managed non-operatively. prophylatic embolization was performed in five patients: 3 were grade iv spleen trauma and 2 were grade iii spleen trauma with vascular abnormalities. one grade iii splenic trauma was embolized due to a pseudoaneurysm detected in ct scan performed 72 h post injury. five grade v spleen trauma required urgent surgery. 4 of them presented with shock index [ 0.9. conclusions: our multidisciplinary protocol has helped in improving outcomes in blunt splenic injuries. we have achieved an almost full compliance to our protocol. case history: 82-year old male experienced severe blunt trauma after a bus accident. clinical findings: he is found alert (gcs = 15), hemodynamically stable and with a patent airway. he presented catastrophic lower left limb where tourniquet was applied. 1 gram of tranexamic acid (txa) and 500 ml of crystalloids were administered. he was intubated in the site of injury and transfered to our center, being always hemodynamically stable. on hospital admission he was normotensive (bp = 140/70 mmhg, sinus rithm 85 ppm), shock index \ 0.9. he suffered uneventfully amputation of the limb with no need for blood products transfusion. his past medical history was only pertinent for hypertension. investigation/results: following urgent damage control surgery, ct scan was performed where acute bilateral pulmonary embolism was diagnosed. diagnosis: asymptomatic acute bilateral pulmonary embolism therapy and progressions: during icu stay, the patient kept hemodynamically stable. endotracheal tube is removed one day later and he is successfully transfered to the ward three days later. comments: hypercoagulability can occur after severe tissue injury, that is likely related to tissue factor exposure and impaired endothelial release of tissue plasminogen activator (tpa). in contrast, when shock and hypoperfusion occur, activation of the protein c pathway and endothelial tpa release induce a shift from a procoagulant to a hypocoagulable and hyperfibrinolytic state with a high risk of bleeding. it can be inferred that a patient presenting with severe tissue injury without shock is at high risk of perioperative thrombosis and txa might not be administered. (1) . it signifies high energy force, representative of severe overall trauma. study reported mortality of blunt pelvic trauma to reach 4.8-50% (2) . injury severity score (iss), hypotension, head injury, posterior fracture & haemorrhage have been implicated (3) . however, there is a paucity of data in developing countries. this study identifies the problem burden, management outcomes and factors predicting mortality. material and methods: 568 patients had pelvic trauma, retrospectively from jan 2014 to dec 2017 and prospectively from may 2018 to april 2019. 501 patients was included after excluding less than 18 years and coagulation disorder results: majority were males (78.2%),with a mean age of 34.8. mechanism was rti (72.3%) followed by fall from height (18%), railway accidents (4.8%). mean iss & rts was 17.37 and 7.41 respectively. associated injury were long bone fractures (34.3%), chest injuries (33.53%).head injury (10.4%). lateral compression (63.9%), was the most common followed by anteroposterior compression (17%) & combined (11.17%).majority underwent operative intervention (56.5%) for pelvis or associated injury. the mortality rate was 15.7% secondary to haemorrhagic shock (49.4%) and sepsis (34.2%). the factors were male gender, age, iss, rts, head injury, unstable pelvis. however, no association with haemoglobin, long bone fracture, and massive transfusion protocol was found conclusions: our study showed a mortality of 15.7% which is comparing with previous study introduction: the number of patients admitted to oslo university hospital (ouh) due to bicycle trauma is increasing. we aimed to identify possible predictors of serious and fatal bicycle injury. material and methods: the ouh trauma registry was searched for patients treated for bicycle trauma between 2005 and 2016. data extraction included putative predictors of serious and fatal injuries, defined as iss c 9 and death within 30 days, respectively. univariate analyses were performed and reported as odds ratios (or). p \ 0.05 was regarded as statistically significant. results: 1543 bicyclists were admitted, 72% were males, median age was 40 years (range 3-91). injury mechanisms were single bicycle crash in 68%, collision with a motorized vehicle in 27%, bicycle vs. bicycle in 4% and others in 1%. serious injuries were seen in 63% and 2.3% died. predictors for serious and fatal bicycle trauma are presented in figure 1 . conclusions: we identified age c 50, high comorbidity and loss of consciousness (gcs b 12) as predictors for both serious and fatal injury after bicycle trauma. single bicycle crash was the most common cause of serious bicycle injury in our trauma center. diagnosis, investigation and results: all case reports represent polytrauma patients with clinical worsening and admission to the icu, with subsequent development of acute respiratory distress syndrome (ards) refractory to primary measures. therapy and progressions: different mechanisms led to the development of ards in the different cases. on a primary approach, standard measures such as curarization, recruitment maneuvers, prone positioning and peep increase were applied whenever possible. an absence of improvement led to an almost inevitable need of extracorporeal membrane oxygenation (ecmo) rescue therapy. all patients responded positively to this treatment without major complications and were eventually discharged from the icu. comments: ards is a major cause of respiratory failure in polytrauma patients. among the many therapeutic options, ecmo emerges as a powerful tool as rescue therapy in respiratory failure refractory to all other measures, being the present case reports corroborative examples of its efficiency. introduction: nowadays when cities are improving fast and significantly, including transportation system, even more we encounter with high energy trauma . still the most vulnerable on the roads are pedestrians. material and methods: the analysis of the data collected prospectively from january 2017 to october 2019 was performed including the mechanism and diagnosis of polytrauma, patient demographics and the main outcomes. results: in total, 903 patients were assessed according to the polytrauma protocol. the median age of the cohort was 43 years (iqr 30-55), male patients, 68.2% vs. 31.8% females, p = 0.045. the most frequent mechanism was a pedestrian struck by a vehicle in 33.9% cases, and falling from a height of over 2 m in 29.7%. of those patients who had musculoskeletal injuries, in 31.1% the trauma mechanism was a fall from a height and in 28.2% pedestrians were struck by a vehicle, 36.1% of patients who fell from a height and 29.5% of those struck by a vehicle suffered visceral injuries. the most common cause of neurotrauma was a fall from a height in 33.7%, and pedestrians involved in car accidents in 29.8%. from the whole cohort, 27 patients were not saved, resulting in a 2.9% mortality rate. most patients (25) who died had iss [ 50. the mortality reached 2.3% among pedestrians struck by a vehicle and 5.1% among patients who fell from a height of over 2 m. conclusions: the most common mechanism in the cohort was a pedestrian struck by a vehicle, followed by falling from a height, with a predominant involvement of male patients. similarly, the most frequent cause of musculoskeletal injuries and visceral injuries was falling from a height and pedestrians struck by a vehicle, demonstrating an important direction for polytrauma prevention. introduction: recent reviews of uk trauma data show altering demographics. patients are increasingly older and sustain lower energy injuries, with falls \ 2 m being the most common (1) . material and methods: data collected over 5 years in a major trauma centre was used to calculate injury specific admission rates, case fatality rates and injury specific mortality attribution. data on patient age, footwear, lighting, alcohol intoxication and previous admissions were collected in falls \ 2 m resulting in mortality. results: patients sustaining falls \ 2 m represented 36% of admissions and 37% of mortalities. all falls represented 58% of admissions and 69% of mortalities. case fatality of falls of \ 2 m and [ 2 m was 6.59% and 9.35%. all fall case fatality was 7.62%. this was significantly higher than the case fatality of stabbings (1.0%) and rtas (4.7%). in falls \ 2 m causing fatality, mean patient age was 71.7 years. 50% of patients aged 40-59 were under the influence of alcohol when falling, with 56% aged 60-79, but only 13% patients aged 80-99. 12% aged 40-59 who died when falling were wearing slippers. this increased to 31% in those aged 60-79, and 50% aged 80-99. 69% of falls occurred under daylight/full light. 13% of patients aged 40-59 who died after falling had been admitted to hospital within the last year, although this increased to 19% in those aged 60-79, and 27% aged 80-99. conclusions: falls were the most common cause for hospital admission, had the highest case fatality of injury mechanisms and caused the most patient mortality. alcohol intoxication was associated with falls in younger patients who died after falling, but this was less common in older patients. wearing slippers was less common in the young but significantly associated with fatal falls in older patients. these results offer a range of therapeutic targets when developing fall prevention strategies. introduction: the treatment of splenic lesions is determined by the hemodynamic situation, the degree of injury and the presence of bleeding. arterial embolization has expanded the indications of the conservative treatment. retrospective observational study on splenic traumatism and its therapeutic options. material and methods: a total of 60 patients with splenic injury have been treated at our centre between 2014 and 2018. 43 patients were hemodynamically stable: 11 were embolized and 32 received a conservative treatment. 17 patients were hemodynamically unstable: 6 had a good response to the resuscitation treatment so they were embolized, but there was one patient who deceased because of other causes. from these 17 patients, 10 patients received splenectomy. results: the main objective of this study is to review the management of the trauma patient with splenic injury. of the total of 60 patients with splenic trauma, average iss of 27, 17 underwent splenic embolization, 17 underwent urgent splenectomy and 26 were treated with conservative treatment. the 17 embolized, 6 were hemodynamic unstable at arrival but responded to the fluid therapy, 3 had a splenic lesion grade iv, 1 a grade iii, 1 grade ii and another a grade i. the success rate of embolization was 100% in the 17 embolized patients. 7 patient died, only one of them in the embolization group and was not related to the splenic trauma nor embolization, 4 were in the urgent splenectomy group due to severity of trauma, 1 died before receiving any treatment and 1 in the conservative treatment group due to other complications. conclusions: patients who respond to volume or are hemodinamically with high-grade lesions, arterial embolization would be less aggressive treatment options with excellent results. haukeland university hospital, surgical unit/ regional traumacenter, bergen, norway, 2 norwegian university of science and technology, trondheim, norway, 3 haukeland university hospital, physical and rehabilitation medicine, bergen, norway, 4 university of bergen, bergen, norway, 5 st olavs hospital, physical and rehabilitation medicine, trondheim, norway introduction: during the past decades acute trauma care has improved through the development of highly specialized trauma centres and teams. since patients are considerable young when being affected, trauma may lead to life-long physical, cognitive and emotional constraints interfering with an independent self-determined life (1, 2) . in 2016, a revised national plan for the treatment of trauma patients in norway was published (3) . the plan emphasizes the importance of rehabilitation and the need for early interdisciplinary rehabilitation. this study will examine in which extent patients receive rehabilitation in early phase after trauma as recommended in the norwegian national plan. in addition we will examine what follow-up patients receive after trauma, quality of life, functional level and use of health care and next-of kin resources. material and methods: patients admitted to regional trauma center in mid-or western norway in 2017 with niss c 12 are recruited to participate. data will be collected from national trauma register, the norwegian patient register, the municipal patient and user register, data from statistics norway, the electronic patient record (epj) and the patient/relatives questionnaire. discussion: the results will be useful in the preparation of patient courses that comply with strong recommendations in the national trauma plan, ensuring equal treatment and raising awarness about rehabilitation for trauma patients. introduction: diaphragmatic lesions involve wounds and rupture of the diaphragm, through penetrating wounds or thoraco-abdominal trauma. their incidence is 1-15%. the diagnosis may be late, despite the technical advances made by medical imaging. the choice of surgical approach and technique is still controversial. mortality is usually related to the associated injuries. the present paper analyzes the incidence of diaphragmatic lesions that occur in thoraco-abdominal trauma, their epidemiology, diagnosis and treatment. material and methods: we performed a retrospective study over a 5-year period (2014-2018) , in the surgical units of the emergency county hospital of braila, including all patients diagnosed with diaphragmatic lesions. results: during the study period, 73 patients had thoracic-abdominal trauma. there were 41 cases of blunt trauma and 32 thoracic-abdominal trauma. our study involved 9 cases of diaphragmatic injuries (12.3%), 7 by road accident and 2 by white weapon. the sex ratio was 4:1. the average age was 38 years. chest radiography was a contributory preoperative diagnosis in 4 cases. the diaphragmatic wound was on the left side in 8 cases, and its average size was 5 cm. the surgical procedure involved the reduction in the abdomen of the herniated viscera and the monoplane suture of the diaphragm by nonabsorbable ''x'' points in all cases. chest aspiration was the rule. there was only one death in a complex polytrauma case. case history: we report the one case which performed tae, angioplasty, thoracotomy, laparotomy and preperitoneal pelvic packing (ppp) in the hybrid emergency room (h-er). the patient was male in the 60 s, who was riding on his motorcycle and fell from a 5 m height. clinical findings: he was in shock state. diagnosis: we scanned cect and diagnosed subdural hematoma, traumatic subarachnoid hematoma, lt hemopneumothorax, lung contusion, multiple costal bone fracture, intercostal artery injury, splenic injury (gradeiii), pelvic bone fracture. therapy: we inserted the drainage tube to the hemopneumothorax and did the tae for the pelvic bone fracture and splenic injury. after tae, he was in still shock state. the bleeding volume from the lt drainage tube increased, so trauma surgeons did the emergency thoracotomy and thoracic endovascular aortic repair (tevar) for intercostal artery injury. we suspected he also had abdominal compartment syndrome due to recanalization of tae, and they performed the emergency laparotomy and did ppp for the pelvic bone fracture. comments: we install an ivr-ct system in our trauma resuscitation room in october 2017. we named it h-er, as it enables us to do all examinations (sonography, ct and fluoroscopy) and treatments (ir, operation) required for trauma in a single room. we have to perform prompt diagnosis and treatment, especially in cases of severe polytrauma cases. a retrospective study proved that the h-er had shortened the time of ct initiation and emergency procedure and that lead to improve mortality 1). h-er is a novel trauma resuscitation room to do all treatments required in the only one room for severe traumatic patients introduction: according to the previous advanced trauma life support (atls) guidance, the early assessment of trauma patients with haemorrhage were classified upon the vital signs. recently, national trauma registry analyses suggested to extend the assessment criteria with the base deficit (bd), referring to the metabolic status. our objective was to investigate the relevance of bd and to explore new prognostic factors in the early assessment of the severely injured. material and methods: our study included 162 patients registered between 01.01. 2016 and 11.09 .2019 on our emergency ward for whom the trauma team was activated. they were grouped into severity groups (i-iv) according to either the vital signs (classical) or the extended criteria with bd. the data were extracted from medical documentations of the early phase of treatment. as primary outcome, we compared the 24-h mortality rate of the patient groups. we studied the need for massive transfusion and intensive care unit care as secondary outcomes. results: according to the classical assessment, 50% of the patients were assigned to group i (lowest risk for haemorrhagic shock) and 23% to group ii. the remaining 27% were grouped into groups iii and iv (higher risk). with taking bd into consideration, 58% were reassigned to a higher risk group; however, this change affected only groups i and ii. the 24-h mortality changed only in group i (0.7% vs 7.7%; p = 0.002). bd did not affect the need for massive transfusion. in groups i and ii, 3.5% of the patients, in groups iii-iv 23% needed intensive care unit treatment. conclusions: bd is an effective prognostic factor in the early assessment of trauma patients. however, compared to the vital signbased evaluation, it provides extra informaton only in less severe cases. according to our findings, it may help to assess the need for the administration of blood products. grants: nkfi k120232; ginop-2.3.2-15-2016-00015; efop-3.6.2-16-2017-00006 . complejo hospitalario de jaén, servicio de cirugía general y del aparato digestivo, jaén, spain, 2 complejo hospitalario de jaén, servicio de anestesiología y reanimación, jaén, spain case history: 56 years old male, with history of hypertension and dyslipidemia, suffered a backhoe accident and was admitted in a regional hospital. on initial assesment he presented contusion and two laceration wounds in left chest and in lumbar region. body ct informed subcutaneous emphysema and left rib fractures from 6th to 11th, left hemidiaphragm edema, laminar left pneumothorax and contusive lung. posterior lumbar hematoma and no intra-abdominal free fluid. laceration wounds were partially sutured, with drainages through the wounds clinical findings: he was transferred to our emergency department, presenting dyspnea, tachycardia, sweating, painful luq and left hemithorax worsening with breathing investigation/results: reviewed by our radiologist, tc images showed herniation of abdominal organs into the chest diagnosis: traumatic hernia in left costophrenic recess. multiple rib fractures therapy and progressions: the hernia contents (left colonic flexure and omentum) were reduced and defect closed with primary repair in emergency surgery. rib fractures treated by osteosynthesis.on 4th pod left renal artery dissection and renal infarction were evidence in a new ct. comments: diaphragmatic injuries are caused by blunt or penetrating thoraco-abdominal trauma. potentially life-threatening due to the herniation of abdominal organs and severe associated lesions. clinical suspicion is important as prompt diagnosis and treatment are necessary for good outcomes. in our case, the initial clinical assessment was incorrect and the transfer put the patient in danger as an emergency surgery should have been performed before transfer. this enhances the importance of a correct initial management of polytrauma patients. introduction: the fractures of the calcaneus account for about 1-2% of all fractures of the human skeleton. the majority of these fractures (70%) are intra-articular and surgical intervention is a widely accepted way of treatment material and methods: the aim of this study was to evaluate the results of open reduction and internal fixation for di-afc.in a period of 24 years (1995-2019) 70 patients (9 patients with bilateral fractures) with age range from 19 to 79 years old, were treated surgically using the lateral extensile approach. follow-up was 1-24 years. the results were evaluated based on x-ray parameters (calcaneal morphology, bohler''s and gissane''s angles), active range of motion, footwear problems and time needed to return to work. the sf-36 health survey was used for outcome assessment. results: fracture mean healing time was 15,6 weeks. the outcome was excellent in 32 cases, good in 28 cases and poor in 12 cases. the complications were malposition of fixation in 11 patients, superficial wound slough in 8 patients, reflex sympathetic dystrophy in 6 patients, deep infection in 2 patients who were treated with antibiotics and metalwork removal following union of the fracture. one patient resulted in metal breakage with consequent pseudarthrosis. finally one patient developed chronic osteomyelitis and is under treatment. the treatment with open reduction and internal fixation for di-afc is indicated, provided that the restoration of calcaneal shape, alignment and height is achieved. long term functional results with mild pain, few alterations in activities of daily living or work, and essentially no footwear problems, can be expected from a properly performed open reduction and internal fixation. extraperitoneal rectal injury in emodinamically unstable patient treated after dcs with external traction applied in an endorectal balloon r. somigli 1 1 hospital, general and emergency surgery, pistoia, italy case history: a 46-year-old man was crushed between two vehicles while he was working. he arrived in er hemodynamically unstable, so he underwent to emergency surgery. clinical findings: at rectal examination there was evidence of almost complete antero-lateral anorectal laceration. at abdominal examination there was evidence of anorectal full-thickness laceration and urethra full laceration. investigation/results: no diagnostic was required in preop because of patient instabilty. diagnosis: pelvic fracture with hemodynamic instability, severe rectal injury and complete prostatic urethra transection. therapy and progressions: el, lateral colostomy, pelvic paking, cistostomy and hip external binder. damage control surgery was performed. on 3 pod second look was carried out and an almost complete extraperitoneal rectal injury was found during pelvic depaking. properitoneum was drained and a baloon probe was introduced in the rectum to allow the proximal rectal flap to advance to the distal rectum. stomal washes were performed with no rectal leak and rectal baloon traction mantained for 10 days. radiological and endoscopic check haven't shown any leak and a good mucosal reconstruction. mri no sphincteral anatonical defects. waiting for emg before stoma reversal. comments: the optimal managment for extraperitoneal rectal injuries remains controversial. an approach with lateral colostomy and conservative treatment of rectal lacerations with rectal trac-tion baloon, could represent a safe treatment alternative in those cases with sphincter preservation, with a lower risk of complication. exploring differences between iss and niss scores for 30-day mortality in adult and elderly trauma patients in a norwegian national trauma cohort m. introduction: injury severity score (iss) and new injury severity score (niss) with a threshold over 15 is commonly used to define severe injury and to define the study population in trauma registrybased studies for both adult and elderly trauma patients (1) . for elderly patients (c 65 years) this might be unreasonably high and might lead to exclusion of significantly injured elderly with increased risk of mortality. the aim of this study was to assess whether there were significant differences in 30-days mortality between adults and elderly trauma patients for different frequently used iss and niss thresholds material and methods: the norwegian trauma registry was interrogated to identify all adult (c 16 years) trauma patients included in the registry from january 2015 through december 2018. data were dichotomized to age groups ''adult'' and ''elderly'' (16-64 and c 65 respectively) with 30-days mortality as primary endpoint. mortality rates were assessed for iss and niss thresholds of [ 9, [ 12 and [ 15. we applied descriptive statistics and chi-squared test for comparisons. results: 23768 patients with available information about age, 30-days mortality and iss and niss scores were included in the analysis, of which 16224 patients were 16-64 years old and 4706 patients were c 65 years. 238 adult and 500 elderly patients died, giving overall mortality rates of 1.5% and 10.6% respectively. for iss and niss [ 9 there was a significantly higher 30-days mortality in elderly trauma patients (17.3% and 15.2% respectively) than adult patients (4.7 and 3.8% respectively) (p \ 0,001), as for all other iss and niss thresholds tested. conclusions: this study demonstrates that elderly trauma patients has a significantly higher mortality risk than adult trauma patients at all iss or niss-thresholds analysed. this group has a significant mortality even at iss and niss above 9. introduction: the trauma tertiary survey (tts) is a widely accepted tool in the prevention of missed injury. existing literature on its effectiveness focusses on multitrauma patients. this study investigates the yield of the tertiary survey in trauma who are admitted for tts, without having any significant injury. material and methods: a single center retrospective cohort study was performed in a level ii trauma center. trauma patients without any clinically significant injury at the primary and secondary survey were included. the primary outcome was missed injury found during tts (type 1). secondary outcomes were missed injury found after tts but during admission (type 2), mortality and hospital length of stay [ 2 days. results: from 355 included patients, 11 patients (3.1%) had a type 1 missed injury. alcohol consumption was associated with an increased risk for type 1 missed injuries (odds ratio = 5.49, 95% ci: 1.36-22.16) . a type 2 missed injury was only found once, it concerned the only case of trauma related mortility. out of 335 nonoperated patients, 65 (19.4%) were admitted for more than two days. these patients were significantly older (71 vs. 39 years, p \ 0.001) and had a higher asa classification, 3-4 vs. 1-2 (47.5% vs. 12.7%, p \ 0.001). conclusions: tts showed missed injuries in only 3.1% of trauma patients who had no clinical significant injury found during primary and secondary survey. high costs of admission, together with a low yield found for this study's population the cost benefit of hospitalizing these patients is for discussion. future research should therefore focus on the identification of predictors of a positive tertiary survey. references: 1. advanced trauma life supportò student course manual. 2. keijzers, et al., the effect of tertiary surveys on missed injuries in trauma: a systematic review. 3. enderson et al., the tertiary trauma survey: a prospective study of missed injury. the 4-h rule in the emergency department and its association with surgical mortality in one public hospital in israel: retrospective study i. ashkenazi 1 1 hillel yaffe medical center, hadera, israel introduction: in order to improve patient treatment the 4-h rule in the emergency department (ed) was introduced in many countries as well as in israel. within four h, patients attending the ed must be seen, treated, and a decision must be reached whether these patients are to be admitted or discharged. though a popular performancebased measure, whether the 4-h rule in ed is associated with a decrease in mortality is controversial. the primary objective of this study was to evaluate the association between time in the ed and surgical mortality in one public hospital in israel. material and methods: included in this retrospective study were patients admitted to the ed of hymc during 2017. patients dying on the first day were excluded. . results: included in this study were 106,766 patients. of these, 28,108 (26.3%) patients were hospitalized and the rest were discharged. overall, 825 patients died. general surgery accounted for 18,391 patients of which 73 died (8.8% of hospital deaths; 0.4% of all surgical patients; 1.9% of patients hospitalized in general surgery). internal medicine together with general surgery and orthopedic surgery accounted for 98.5%, 98.6% and 98.5% of the mortalities observed in patients with decisions made within 0-4 h, in patients with decisions made beyond 4 h and in all the patients respectively. forty-five patients with decisions made within 4 h died compared to 28 with decisions made beyond 4 h. these represent 0.3% and 0.6% of all surgical patients in the ed (whether hospitalized or discharged) and 1.9% and 1.9% of those hospitalized. conclusions: general surgery is the second largest contributor to hospital morality. in both absolute terms and relative terms, mortality was not increased by delays in decisions made beyond 4 h. the adoption of this performance-based measure should be questioned. introduction: trauma is an important cause of mortality [1, 2] . researchers are looking for optimal death/survival predictive models in trauma population. one way is to validate traumatic scores for different medical systems [1] . the aim of our study was to validate the new injury severy score (niss) in severe trauma ( introduction: the international classification of diseases-based injury severity score (iciss) has been proposed as a reliable tool to measure trauma system performance especially in countries where a trauma registry has not been yet established. the purpose of this study is to assess the predictive capability for in-hospital mortality of iciss with international and adjusted survival risk ratios (srrs) in greek trauma population. material and methods: this single center, retrospective cohort study was conducted in a greek tertiary care hospital between january 2015 to december 2018. the trauma population was defined as hospitalized patients with a principal hospital discharge diagnosis in the range icd-10 s00-t79. duplicated injury icd codes, readmissions, transfer to another hospital and missing data were excluded. the primary outcome was in-hospital mortality. adjusted srrs was calculated from patients with multiple injuries and the following two iciss scores were evaluated: multiplicative-injury (iciss) and singleworst-injury (swi). the models were assessed in terms of their discrimination, measured by receiver operating curve (roc) analysis and calibration measured using calibration curves. results: a total of 30195 patients were included in the study. median age was 60 ± 22 years and mortality rate was 2,1%. based on international srrs, the area under the curve was 0,839 (95% ci 0.826-0.852) for iciss-multiplicative and 0,839 (95% ci 0.826-0.852) for iciss-worst injury. both modes had statistically significant better performance with adjusted greek srrs (aur = 0,877 95% ci 0.867-0.887 and aur = 0,880 95% ci 0.870-0.890, respectively). conclusions: this analysis has demonstrated the validity iciss model for in-hospital mortality prediction in greek trauma population. further research is warranted to confirm the performance of iciss using a sufficiently sized sample to define national srrs. introduction: the occurrence of intra-abdominal abscesses is the most serious post-operative infective complication after appendectomy. a significant amount of research has been conducted in an attempt to identify those patients at greatest risk. pct is initially described as an early, sensitive and specific marker for sepsis associated with bacterial infection. we hypothesize that pct could serve as a predictor of the development of intraabdominal abscess and postoperative infective complication material and methods: the present study is a prospective, single centre, observational cohort study involving patients undergoing emergency appendectomy. all patients admitted to the acute care surgery ward for appendicitis were screened for study eligibility. pct poc samples will be obtained preoperatively (t0) and post procedure (t1) at 24 h (t2), 48 h (t3), and 5 days (t3) post procedure. the primary objective of this study was to assess the diagnostic accuracy of point-of-care testing for pct in identifying post appendectomy abscess. the secondary objective was to determine the diagnostic accuracy in identifying any infective complication conclusions: we expect the incidence of abscess and infective complication to be increased in the pct elevated group compared with the control group. previous investigations indicate the overall morbidity related to infective complication is approximately 1-10% of patient undergoing laparoscopic appendectomy. our pilot study revealed that the incidence could be as high as 15% in patients with prolonged elevated pct levels. introduction: hand trauma is a common cause for attendance to the accident and emergency (a&e), accounting for nearly 10-30% of all patients 1 . it is essential that accurate treatment and management is done as the implications of mismanagement are long term, which may lead to disability, loss of work and income, livelihood, and even psychological issues 1 . the presence of a specialised hand surgeon is essential for management of these injuries 2 , but in the a&e setting it is not always possible to have such specialised care and there is a need for an efficient triage system. materials and methods: we did an audit in our department and found a delay in the referral of patients from a&e to our trauma clinic, which was quite expected due to a high patient inflow. we devised a trauma pathway for the a&e, known as the d-system which outlines for them till what day from trauma is a particular hand patient safe to be sent to the hand clinic or who needs an urgent referral to a higher trauma centre, based on urgency of need of intervention. the pathway is in the form of a simple flowchart, which is easy to understand even for junior members of the team. we intend to do another audit after implementation of the pathway to assess change in practice. conclusion: it is essential to have simplified pathways for non-specialist areas in order to streamline treatment and offer the best care, in the limited availability of resources, especially at smaller hospitals. our aim is to develop one such system and assess it's effective in delivering better care. introduction: a quantitative method for measuring trauma severity has many potential applications. the intent of this study was to evaluate the accuracy of the mgap score and its components in prediction of in-hospital mortality versus the accuracy of the revised trauma score rts at a trauma center. material and methods: this study included 825 patients with trauma. data regarding age, mechanism of injury, systolic blood pressure, glasgow coma score and respiratory rate were collected at trauma center of alberto torres hospital. mgap and rts scores were calculated, and their accuracy to predict survival/death outcome. results the study included 825 patients, ranging in age from 2 to 89 years, 69% male. from the total sample, 159 patients who suffered from penetrating trauma and 666 patients who suffered from blunt trauma were observed. in the comparison of the scores, rts and mgap, there was no significant superiority in any of them for predicting the outcome -which in our study was hospital discharge or death -even when compared by trauma mechanism. the gcs proved to be a very sensitive criterion in both scores, especially in patients with traumatic brain injury, totaling 62 patients in our statistical analysis, of which 56,4% had a negative outcome. rts was slightly superior than mgap in patients classified by the score as high chance of mortality, with 75% versus 69% of assertiveness. conclusions: up to the moment, there is no evidence to support the superiority of one of the analyzed scores as a predictor of mortality in the patients evaluated. although the rts score is more widely used in trauma centers, the application of the mgap score is more feasible in pre or in-hospital care of polytrauma patients, since it does not use respiratory rate in its parameters. validation of d-dimer for screening for venous thromboembolism in pelvic and lower extremity trauma patients t. uehara 1,2 , t. noda 3 , t. yumoto 4 , n. kobayashi 5 , a. nakao 4 , t. ozaki 2 1 okayama university, emergency healthcare and disaster medicine, okayama, japan, 2 okayama university, orthopaedic surgery, okayama, japan, 3 okayama university, musculoskeletal traumatology, okayama, japan, 4 okayama university, emergency and critical care medicine, okayama, japan, 5 okayama saidaiji hospital, okayama, japan introduction: venous thromboembolism (vte) is a life-threatening complication after major trauma patients. we previously reported that the patients with higher injury severity score (iss) and lower extremity trauma had high risk for vte. additionally, high d-dimer levels (cut-off d-dimer value, 12.45 lg/ml) on day 10 were useful for screening for vte in major trauma patients. we validated d-dimer levels for vte screening for patients with pelvic and lower extremity trauma. material and methods: a retrospective study was undertaken between april and august 2019 at the okayama university hospital. 19 patients with pelvic or lower extremity trauma were included (median iss, 18). we collected following data; age, sex, iss, the number of operation times, value of d-dimer in screening, incidence of vte and use of anticoagulants. results: eleven patients showed high d-dimer levels in screening, furthermore, six patients were diagnosed vte using contrast-enhanced computed tomography. symptomatic pulmonary embolism was not occurred. patients with vte had undergone orthopaedic surgeries two or more times. fourteen patients received therapeutically or prophylactic anticoagulation therapies. conclusions: measurements of d-dimer levels after pelvic or lower extremity trauma patients were useful for screening of incidence of vte. direct oral anticoagulants were convenient for treatment to vte. trauma patients often needed several times of surgeries, heparin was also useful in perioperative period. introduction: early assessment of the clinical status of severely injured patients is crucial for guiding surgical treatment. several scales are available to differentiate between risk categories. we compared four established scoring systems in regard to their predictive abilities for early versus late in-hospital complications. methods: database from a level i trauma center. the following four scales were tested: the clinical grading scale (cgs; covers acidosis, shock, coagulation, and soft tissue injuries), the modified clinical grading scale (mcgs), the polytrauma grading score (ptgs), and the early appropriate care protocol (eac; covers acid-base changes). admission values were selected from each scale and the following endpoints were compared: mortality, pneumonia, sepsis, death from hemorrhagic shock, and multiple organ failure. results: in total, 3668 severely injured patients were included (mean age, 45.8 ± 20 years; mean iss, 28.2 ± 15.1 points; incidence of pneumonia, 19.0%; incidence of sepsis, 14.9%; death from hem. shock, 4.1%; death from multiple organ failure (mof), 1.9%; mortality rate, 26.8%). istinct differences in the prediction of complications, including mortality, for these scores (or ranging from 0.5 to 9.1). the ptgs demonstrated the highest predictive value for any late complication (or = 2.0), sepsis (or = 2.6, p = 0.05), or pneumonia (or = 2.0, p = 0.2). the eac demonstrated good prediction for hemorrhage-induced early mortality (or = 7.1, p \ 0.0001), but did not predict late complications (sepsis, or = 0.8 and p = 0.52; pneumonia, or = 1.1 and p = 0.7) cgs and mcgs are not comparable and should not be used interchangeably (krippendorff a = 0.045). conclusion: our data show that prediction of complications is more precise after using values that covers different physiological systems (coagulation, hemorrhage, acid-base changes, and soft tissue damage) when compared with using values of only one physiological system (e.g., acidosis). none of the authors have any conflicts of interest to declare. mortality rate related to trauma mechanisms in trauma center at alberto torres hospital from january 2014 to july 2019 r. p. pereira 1 , r. adriana martins 1 , j. a. c. padilha 1 , f. e. silva 1,2 , d. rangel 1 1 alberto torres hospital, trauma center, são gonçalo, brazil, 2 federal university of rio de janeiro, niterói, brazil introduction: to demonstrate the healthcare services of the trauma center of rio de janeiro based on epidemiological data and on the specificity of the type of initial care delivered to multiple trauma patients, comparing the mortality rate at the second peak of death with the worldwide literature. materials/methods: retrospective study extracted from ''ct heat'' database. polytraumatized patients of both sexes were included and the mortality rate was calculated taking into account the second peak of death from trauma, gender, age and primary mechanisms of injury. discussion: the data collected show 3% mortality in the second peak, with firearm projectiles (40%) followed by traffic accident and fall as the primary causes of death. conclusion: because of the structural and health care profile of this trauma center, it was possible to reach the desirable mortality rate according to the worldwide literature (less than 5%). introduction: trauma patients are sometimes in critical condition upon arrival and need aggressive treatments to survive. despite all efforts many end up dying. it seems necessary to try to identify those patients with a very high risk of death to avoid futile treatments. the aim of our study was to develop a simple clinical tool to predict mortality in trauma patients that can be easily calculated in the ed. material and methods: we analyzed data from all trauma patients arriving at a spanish trauma hospital from june 1993 to june 2018. patient demographics, physiologic trauma scores, vital signs, and glasgow coma scale (gcs) were recorded. our primary outcome was mortality. logistic regression analysis (lra) was performed using three variables (age, shock index (si), and gcs) to determine the appropriate weights for predicting mortality. using them, we constructed a simple score to calculate mortality. results: 2678 patients were studied. the mortality rate was 15.9%. our score was constructed using weights derived from lra for age [ 55y (2 points), si [ 1(3 points) , and gcs conclusions: our score is easy and quick to calculate and could be a useful tool to predict mortality using early available parameters upon arrival in the ed. acknowledging the ethics involved in this topic, this score could sort out patients with a very high risk of death and in whom aggressive therapeutic measures could be limited early or withdrawn in agreement with family members references: haider a, et al (2019) (2015) (2016) states the average cost for an a&e attendance and non-elective inpatient stay is £138 and £1,609 respectively highlighting the importance for schemes to reduce hospital admissions. assess impact of ambulatory care, surgical emergency assessment unit (seau) and ''emergency surgeon of the week'' (esw) on hospital admissions for surgical referrals (gp/ a&e). material and methods: retrospective analysis of prospectively collected data of hospital admissions from the patient centre database before and after implementation of seau (in november 2014) and esw (in november 2017), including the units'' activities. emergency general surgeon followed 1:5 (monday-thursday, 0800-1800) rota based at seau. results: since 2014 (50 months), seau has reviewed 12451 (new 7543; follow ups 4908) patients. surgical admissions (sa) pre and post implementation seau were 766* and 629*/month respectively, a drop by 18%. esw helped a further drop by another 14% to 520*/month. 58% of new referrals were admitted and overall 35% of all patients reviewed were admitted. juniors (st3/st4) and seniors (st5-8/staff grades/consultants) admitted 40% and 34% of the referrals respectively. 2950 uss and 1959 ct were performed in dedicated seau slots. 98% attending seau were likely to recommend the unit to friends or relatives. conclusions: in the face of unprecedented demand for hospital beds (more so in the winter), ''emergency surgeon of the week'' based at seau could be the answer to relieving the capacity, financial pressures and providing high quality safe patient care for our already strained nhs. surgical emergencies, an educational and medico-economic challenge introduction: surgical emergencies are a frequent reason for consultation in the emergency department and are responsible for significant morbidity and mortality. our study aims to present the number of patients admitted for a surgical emergency in a french level 1 trauma-center and the volume of patients operated in emergency depending on the different specialties. method: we conducted a retrospective, single-center study of the hospital emergency department (uas) of the university hospital center of nice between january 2017 and december 2018. we studied the volume represented by surgical emergencies according to the different specialties. results: the emergency department welcomed 192,004 patients, of which 38,351 surgical emergencies patients accounted for 20% of the total activity; 14397 patients were operated on urgently, which represents 35% of all surgical procedures in our hospital. conclusion: surgical emergencies are an important part of the activity of our hospitals. an academic definition is difficult to achieve. a regional organization is needed for the management and optimal care of these patients. the creation of regional centers, as for the trauma centers, seems indispensable, especially for the most serious patients, allowing both a better medico-economic and educational management of surgical emergencies. introduction: every new admission to the icu prompts a handover from the referring department to the icu staff. this step in the patient pathway provides an opportunity for information to be lost and for patient care to be compromised. mortality rates in intensive care have fallen over the last 20 years, however, 20% of patients admitted to an icu will die during their admission (1) . communication errors contribute to approximately two-thirds of notable clinical incidents; over half of these are related to a handover (2) . nice have concluded that structured handovers can result in reduced mortality, reduced length of hospital stay and improvements in senior clinical staff and nurse satisfaction (3) . material and methods: a checklist was created to review to score the handover. this was created with doctors and nurses and is relevant for handovers between all staff members. information was gathered prospectively by directly observing 17 handovers on the icu. results: there is a notable discrepancy in the quality of handovers of new patients. this is true of handovers between doctors, nurses and a combination of the two. 41% (n = 7) of patients weren't handed over to a doctor. the most commonly missed pieces of information were details of the patient's weight (96%, n = 16), their height (100%, n = 17), whether the patient has previously been admitted to an icu (78%, n = 15) and whether the patient has any allergies (71%, n = 12). conclusions: the handover of new patients to the icu is often unstructured and important information is missed. this can be said for all staff members and grades, and for handovers from all hospital departments. introduction: bowel resection for acute mesenteric ischaemia (ami) in elderly is associated with significant morbidity and mortality, and increasing age and frailty are associated with increased risk. this study aims to assess the short-term outcomes for elderly patients undergoing surgery for ami, and to assess the accuracy of surgical risk calculators in this population, to determine their utility in preoperative discussions. introduction: intertrochanteric femoral fracture of the super-elderly is often difficult to treat because good surgery does not always lead to good functional prognosis. we investigated the factors affecting the functional prognosis in patients with intertrochanteric fracture over 90 years old. material and methods: 94 cases of intertrochanteric fracture over 90 years old who had undergone surgical treatment at our hospital between december 2010 and september 2018 were examined. nine men and 85 women, age at injury ranged from 90 to 101 years, with a median of 93 years. the average postoperative follow-up period was 3.7 months. for these cases, the mobility was classified into independent walking, assisted walking (cane, walker), wheelchair, bedridden, and the transition of pre-and postoperative mobility was analyzed. the significance test was performed using the mann-whitney u test, and p \ 0.05 was considered significant. results: by fracture type, when jensen classifications i and ii were stable, iii, iv, and v were unstable, mobility of unstable type was significantly reduced (p = 0.024). when the waiting period for surgery is divided by the median of 4 days, there was no difference in mobility reduction between groups of less than 4 days and groups of more than 4 days (p = 0.925). although there was no significant difference in the presence or absence of preoperative rehabilitation intervention (p = 0.08), there was a tendency for less decline in mobility when preoperative rehabilitation intervention was performed. conclusions: in the treatment of this fracture, early surgical treatment after injury is recommended, but in the case of very elderly people, waiting is often required due to existing diseases and poor general condition . this study suggests the importance of preoperative rehabilitation intervention during the waiting period for surgery to prevent disuse disorders. references: 1. kelly-pettersson et al. waiting time to surgery is correlated with an increased risk of serious adverse events during hospital stay in patients with hip-fracture: a cohort study international journal of nursing studies 69 (2017) 91-97. older patients with traumatic shock exhibited lower pulse pressure compared with younger patients; an analysis of nationwide trauma data base in japan introduction: the study purpose was to assess the effect of age on the relationship between pulse pressure (pp) and systolic blood pressure (sbp) in patients with traumatic shock. material and methods: in this retrospective cohort study using nationwide trauma data base in japan from april 2004 to may 2019, trauma patients 18 years of age and older with sbp \ 90 mmhg were selected. patients with severe traumatic brain injury (the abbreviated injury scale on head [ 3) and cardiac arrest (hr = 0 and sbp \ 60 mmhg) were excluded. linear regression analysis assessed association between pp and sbp interacted by age group dichotomized as \ 60 or c 60 years old. results: during the study period, 12444 patients were included. the linear regression analysis indicated the significant association between pp and sbp in overall population (ec, estimated coefficient = 0.37 95%ci [0.33, 0.37], p \ 0.001). association between pp and sbp was significantly interacted by the age group (ec = 0.32 95%ci [0.29, 0.35] introduction: high rates of trauma in south africa (sa) predominantly affect the youth, yet the geriatric population is not exempt. 1 in addition to inherent challenges of age, elderly trauma patients are further compromised by resource constraints. 2 we aimed to assess injuries and outcomes in elderly patients admitted to a tertiary trauma unit in sa. material and methods: a retrospective record review was done of all patients 60 years and older, admitted to the trauma unit over an 8-month period. injury severity score (iss), mechanism of injury (moi), in-hospital complications and length of hospital stay were documented. results: 275 patients (mean age: 72 years; 57% female) were included with mean iss of 8. the most frequent mois included nontraumatic falls (54%), falls from height (10%), motor-vehicle collisions (9%), pedestrian vehicle collisions (7%), and blunt injuries (8%, 87% intentionally inflicted). eighty patients (30%) experienced at least one in-hospital complication. the mortality rate was 7%. the mean length of hospital stay was 7 days. conclusions: despite the known vulnerablities of the elderly, the mortality rate and isss of this cohort were relativley low. however, when compared to first world literature, intentionally inflicted injuries and certain preventable mois (e.g. fall from height and pedestrian vehicle collisions) were common, [3] [4] introduction: the majority of new colorectal cancer is diagnosed in people [ 65 years, yet the elderly are less likely to undergo curative surgery. chronological age is poorly correlated with post-operative outcomes and is not an acceptable measure of risk. conversely, frailty is a strong predictor of poor outcomes following surgery and presents an opportunity for patient optimisation. the aim of this systematic review is to assess the available evidence between frailty and outcomes in patients of all ages undergoing surgical resections for colorectal cancer. material and methods: pubmed was searched for articles reporting outcomes for patients deemed frail undergoing elective or emergency colorectal cancer resection up until august 2019. the primary outcome was mortality (30 and 90 day). secondary outcomes; length of stay, readmission, reoperation & post-operative complications. results: 143 studies identified, 17 studies were deemed eligible for inclusion. study types, frailty assessments & outcomes measured were variable. despite this heterogeneity, categorisation of ''frailty'' was associated with higher rates of post-operative mortality, complications, readmission, and length of stay. conclusions: based on current evidence, frailty is a strong predictor of poor clinical outcomes in patients undergoing surgery for colorectal cancer. standardisation of frailty assessment and measure of outcomes is needed for more robust analysis. accurate risk stratification of patients will allow us to make informed treatment decisions and identify patients who may benefit from prehabilitation and intensive tailored post-operative care. introduction: pneumatosis intestinalis (pi) and hepatic portal venous gas (hpvg) are two radiological findings associated with a broad range of medical conditions. pi can be primary (15% of cases),usually with a benign course, or secondary (85% of cases),which results from obstructive or ischemic gastrointestinal diseases. only a minority of pi is associated to free abdominal air. in literature there is no consensus on radiological and biochemical markers of favourable outcome nor on treatment options-medical or surgical. we tried to identify prognostic markers in a series admitted to a single university hospital. material and methods: the medical records of 36 patients with pi and/or hpvg admitted to ospedale maggiore policlinico (milan, italy) in the period 2012-2019 were collected the ct scan were reviewed by a single radiologist. results: mean age was 76.4 ± 14 years (43-94). pi was primary in 13,9% of the patients (n = 5), and secondary in 86,1% (n = 31). at ct, pi was associated to portal gas in 13 patients (36%) (8 dead, 6 alive) and to free air in 7 patients (20%) (4 dead, 3 alive). linear or rounded gas collections were equally distributed in primary and secondary pi. the colon was involved in 16 patients (44%), followed by the small intestine in 15 (41,6%),and the stomach (n = 2). in 7 patients serum lactate was [ 4, and 6 died. leucocytosis (wbc [ 11,000/mm 3 ) was present in 8 patients (1 alive).four patients had peritonitis and 2 abdominal tenderness. laparotomy was performed in 1 primary (alive) and 16 secondary pi (4 deaths).in two patients it was diagnostic; in 6 and 2 associated to right or left colectomy, in 3 to ileal resection and in 3 to other procedures.surgery was judged futile in 12 patients; all died a few hours after emergency department access. conclusions: we could not found any relationship between clinical, biochemical and radiological findings and outcome of pi. mesenteric and portal gas is a ominous finding, but did not reach significant value. successful transcatheter arterial embolization for a giant pseudoaneurysm of gluteal muscle due to ground level fall in elderly woman with direct oral anticoagulants t. kadoya 1 , r. nakama 1 , k. arakawa 2 , t. ogura 1 , k. kase 1 1 saiseikai utsunomiya hospital, department of emergency medicine and critical care medicine, utsunomiya, japan, 2 saiseikai utsunomiya hospital, department of radiology, utsunomiya, japan case history: a 90's year-old woman using apixaban fell on the ground and was transferred to previous hospital. magnetic resonance imaging was taken and she was diagnosed as gluteal hematoma. she was treated conservatively but hemoglobin (hb) level was gradually decreased. although she was administered red blood cell as needed, anemia progressed. contrast-enhanced ct showed expanding hematoma of gluteal muscle. she transferred our hospital for advanced treatment including surgery on 5th day on hospital. clinical findings: vital signs were stable on arrival at our hospital. extensive subcutaneous hematoma was found in the right thigh and gluteal lesion. investigation/results: laboratory test showed that hb 6.6 g/dl and normal coagulation status. contrast-enhanced ct showed a giant pseudoaneurysm inside the gluteal muscle. therapy and progressions: angiography showed a giant aneurysm of peripheral branch of internal iliac artery. we performed transcatheter arterial embolization (tae) for it by gelatin sponge. after tae, there was no complication and progressive anemia was stopped. she was transferred to another hospital for rehabilitation six days after tae. comments: increase use of direct oral anticoagulants in elderly people could induce severe hemorrhagic trauma by minimal mechanism. tae is minimal invasive and safety procedure for such trauma case. introduction: the number of elderly people will increase during the next few decades. more importantly, the number of people aged 80 or above are projected to increase 100% in developed countries. in spain, people over age 80 were 4.68% of the population in 2009, and this will increase to 6.19% in 2019. that has implications in the health services and in the management of trauma patients. material and methods: we did a retrospective cohort analysis of trauma patients c 80 y.o. admitted to our level i trauma center during the time-period of 2009-2019. demographic data, icu care, and mortality were assessed. results: 109 trauma patients c 80 y.o. were admitted during that period. this is a 200% increase compared with the number of patients admitted during the previous decade (1999) (2000) (2001) (2002) (2003) (2004) (2005) (2006) (2007) (2008) (2009) . mean age was 84.8 ± 2.4 years, and median new injury severity score (niss) was 17 (interquartile range 13 to 27). 46% were male. the mechanism of injury was 50% falls, and 47% pedestrian runovers. 48 patients were admitted to icu, with median niss of 25 and mortality rate of 38%. among severely injured trauma patients (niss c 35) the hospital mortality rate of those c 80 years was 90%, much higher than in the age group of 65-79 years (40%), with a significant difference (p \ 0.05). no differences mortality rates between 65-79 years and youngers with the same niss. conclusions: the geriatric trauma patient population is on the rise worldwide. this should be taken into account in our trauma centres in order to be able to adapt and try to improve trauma care in these patients. introduction: frailty is a geriatric syndrome which has been considered as a risk factor in the elderly, increasing adverse events in terms of global health, as hospitalization, increase of falls, need of institutionalization, and mortality. the aim of this study is to evaluate relationship between frailty, and the presence of major complications in the postoperative course of patients older than 70 years undergoing emergency surgery. material and methods: prospective, longitudinal, cohort study, using four different scales of frailty as a predictor of risk for short-term adverse events, for patients during the postoperative course of emergency surgery (may 2017-september 2018). the sample is categorized according to four frailty scales (clinical frailty scale, frail score, trst and share-fi) . we analyze the variables regarding diagnoses, clinical examination at admission, surgical procedures, and postoperative outcomes during the first 30 days. clavien-dindo classification was used in order to graduate the severity of complications. results: 92 patients were included with a mean age of 78,71 years (sd 6, 26) . 53,3% of the simple are women. frailty prevalence ranges, according to the frailty scales, from 14,13% to 46%. median hospital stay was 6 days ( iqr 3, 65) . all four frailty scales show statistical differences to predict major complication in our simple. trst and frail scales show the strongest measure of association (or 7,69 and 5,92, respectively). the frail phenotype, is also related to an increased of mortality, and frail scale is the frailty scale with largest or (or = 16,071).only frail show association with longer hospital stay ([ 12 days), and reoperation rate. conclusions: frailty represents a predictive marker of major complications and mortality, for patients older than 70 years undergoing emergency surgery. frail score, shows the strongest relationship with mortality and complications. introduction: age has been identified as a predictor of trauma mortality [1] and it is known that even low energy trauma may cause severe injuries in the elderly [2] . the aim of this study was to explore how the elderly trauma patients, and the care thereof, differ from the younger ones in a swedish context. material and methods: the swedish trauma registry (swetrau) was used. consecutive recorded trauma cases that presented at one level ii trauma hospital during december 2019-august 2019 were included (n = 676). patients were stratified into groups; those c 65 and those results: in the c 65 years group, sex distribution was more even (female 49.6 vs 34.9%, p \ 0.05), physical status according to pretrauma asa classification was higher (mean 2.62 vs 1.45, p \ 0.05) and the trauma mechanism was predominantly low-energy (falls from no height) as opposed to the conclusions: the trauma among elderly swedish patients are more often of low energy compared to the younger population. in spite of this, the elderly are more severely injured, require more surgical interventions, and their short term mortality is increased 20-fold. measures aimed at prevention of low energy trauma of the elderly are therefore much needed. introduction: there are intramedullary or extramedullary methods in internal fixation od trochanteric fractures. seldynamisalbe internal fixator with two sliding screws (sif), as an extramedullary method, and gamma nail (gn), as an intramedullary method, are in routine trochanteric fractures treatment at our institution for last two decades. material and methods: health related quality of life and hip function were assesed at least two years after surgery, in the series of 71 patients with a surgically treated ao 31a1 or 31a2 fracture type. there were two groups of patients: group treated by sif and group treated by gn. examination had been performed using sf-12 test, with its physical component score (pcs) and mental component score (mcs), and harris hip score (hhs) tests. results: in sif group, mean pcs was 59,7, mean mcs was 64,9 and mean hhs was 70,7. in gn group mean pcs was 68,2, mean mcs was 70,7 and mean hhs was 76,3. there was no significant difference regarding all these parameters between the groups of patients (p [ 0,05). there was correlation between all evaluated parameters, both in groups of patients particularly and in all patients (p \ 0,05 we identified undertriage in 31,6% (31/98). falls from own height (0-1 m) was found in 54 patients with iss [ 15, 25/54 (46%) of them was found to have been undertiaged (p 0.004). we found an association between gcs \ 15 and undertriage (p = 0.01). 60% (206/341) falls between 0-1 m and 30% (61/ 206) of these without trauma team. falls between 1-5 m 12,5% (15/ 120) without trauma team. all 10 with fall [ 5 m had trauma team. mortality was 12% (41/341), no association between height of fall and mortality (p 0.237). undertriage was not associated with increased mortality (p = 0,104). median age in mortality group was 87 years versus 73 years in surviving group (p \ 0.001). in univariate analysis there was association between prehospital bp \ 90 (p 0.043), gcs \ 15(p \ 0,001), iss 3 16 (p \ 0.001), prehospital rr [ 30, rts \ 12 (p \ 0.001) asa score [ 1 (p \ 0.001) and mortality. conclusions: we found significant undertriage in the geriatric trauma population with fall injuries. gcs \ 15 and low energy falls was associated with undertriage but not with mortality. laparoscopic direct repair of an incarcerated spigelian hernia c. bergamini 1 , v. iacopini 1 , r. de vincenti 1 , a. bottari 1 , g. alemanno 1 , p. prosperi 1 1 aou-careggi, emergency surgery, firenze, italy spigelian hernia occurs through a defect in the anterior abdominal wall adjacent to the semilunar line. it is in itself very rare and more over it is difficult to diagnose clinically. it has been estimated that it constitutes 0.12% of abdominal wall hernias. the majority of patients present with symptomatic incarceration of preperitoneal fat or intraabdominal viscera. radiographic studies are beneficial in confirming the diagnosis. the high rate of incarceration with or without strangulation mandates operative repair once the diagnosis is confirmed. the spigelian hernia has been repaired by both conventional and laparoscopic approach. laparoscopic management of spigelian hernia is well established. most of the authors have managed it by transperitoneal approach either by a direct repair or by placing the mesh in intraperitoneal position or raising the peritoneal flap and placing the mesh in extraperitoneal space. there have also been case reports of management of spigelian hernia by total extraperitoneal approach. we present the case of an obese eighty-four y.o patient. complaining for a sudden onset abdominal pain in the right low quadrant, mimicking an appendicitis. the ct scan demonstrated a typical picture of a spigelian hernia containing an intestinal loop. the loop showed classical signs of parietal wall ischemia. the video describes the surgical laparoscopic approach of this case which was able to confirm the diagnosis e to reduce the loop into the abdomen. the loop initially appeared diffusely ischemic, but after the intra-abdominal reduction some signs of vitality started to be noticed. however, they were incomplete; thus the loop was resected. the hernia defect was successively repaired in a direct way because of the small caliber (\ 4 cm of diameter) and the possible contamination coming from the intestinal resection. post-operative course was particularly benign and the patient was discharged on the seventh post-operative day in good health. introduction: trauma audit & research network (tarn) data shows older persons falling from standing height and sustaining significant injury has become the commonest trauma presentation in england and wales 1 . we aimed to assess whether frailty predicts poor outcomes in the elderly. material and methods: retrospective database review of tarn eligible patients [ 65 years old admitted in a 19 week period with documented rockwood clinical frailty score 2 . age, injury severity score (iss), length of stay (los) and mortality were noted. the inhospital mortality group was sub-analysed. logistic regression was performed (stata v15), odds ratios and 95% ci reported. results: older age was associated with higher cfs in the 263 patients studied. increasing cfs was associated with increased overall mortality (cfs6-9 vs cfs1-5 or 2.14; 95% ci 0.88-5.21), decreased likelihood of pre-hospital trauma alert and increased length of stay (cfs6-9 stayed 4 days more than cfs1-5). all 22 deaths had cfs [ 3 and head or chest injury. adjusting for age and cfs those with chest injury were 1.15 times more likely to die (or 1.15 95%ci 0.44-3.04). mortality in those with rib fracture was 5 times higher in cfs6-9 vs cfs1-5 (or 5.53 95%ci 1.21-25.28). conclusions: increasing age and cfs (especially 6-9) are associated with poor outcomes in elderly trauma, thus cfs is a useful prognostic tool in severely injured elderly patients. chest injuries are a major cause of mortality in this group, especially with increasing frailty. major trauma centres must develop practice management guidelines to appropriately manage these patients. introduction: major trauma causes activation of the complement system, which plays a key role in development of systemic inflammatory response syndrome and multiple organ failure. complement is known to be activated early after trauma 1, but the relationship between outcome and the extent of complement activation during the first critical hours after injury is unknown. we hypothesized that complement activation in the first hours after trauma displays a highly dynamic pattern which is associated with outcome. material and methods: complement activation was assessed by plasma terminal c5b-9 complement complex (tcc) using elisa in a prospective cohort of 136 trauma patients. samples were obtained at admission, after 2, 4, 6 and 8 h, and daily in the intensive care unit. the extent of complement activation was assessed as area under the concentration curves 3-6 h after injury (tcc-auc3-6). the relative contribution of complement activation, base excess (be) and new injury severity score (niss) to outcome was analyzed by multivariable analyses. results: niss and be were associated with tcc-auc3-6 in bivariate analyses (spearmans rho (p) was respectively 0,23 (p = 0.01) and -0.33 (p = 0.0003)). in multivariable analyses, niss and initial tcc alone predicted 50% of the variability in ventilatorfree days (vfds), whereas initial tcc and tcc-auc3-6 predicted 66%. tcc auc3-6 alone contributed with 16% to the model. tcc-auc3-6 was also significantly higher in patients deceased at day 30 (4.9; 2.1-17.9 (median; quartiles) vs. 2.4; 1.8-3.8, p = 0.048 introduction: massive transfusion protocols [mtp] have been widely adopted for the care of bleeding trauma patients but their actual effectiveness is unclear. this study aims to conduct an updated meta-analysis to evaluate the effect of implementing an mtp on the mortality of trauma patients. material and methods: medline, pubmed, google scholar and cochrane library databases were systematically searched for relevant articles published from 1 january 2008, to 31 july 2019, using a combination of key words and additional manual searching of reference lists. three reviewers independently screened the articles for potential inclusion. eligible articles were original articles in english, included trauma patients and compared mortality outcomes before and after institutional implementation of a mtp. primary outcomes were 24 h and overall mortality. results: nineteen studies met inclusion criteria, analyzing outcomes from 2,962 trauma patients. there was a wide range of outcome and process indicators utilized by the different authors. mtps significantly reduced over-all mortality, pre-mtp-40.4% and post-mtp 32.6% [or 0.7 (0.56-0.89)] for trauma patients. 24-h mortality was not significantly reduced [or 0.87 (0.60-1.25)]. conclusions: the institution of an mtp has a significant over-all mortality reduction for trauma patients. we encourage that researchers use standard nomenclature and indicators, provide more details regarding protocols and patient populations and incorporate advances in the management of bleeding trauma patients in all future mtp studies. introduction: when resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized with good outcomes for penetrating trauma patients. however, evidence that these concepts apply well to the management of blunt trauma is lacking. this study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock. material and methods: in this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival \ 0.6. patient's characteristics, examinations, severity and administrated therapies were compared between survivors and non-survivors. data are described with median (25-75% interquartile range) or number. results: thirty patients were included and median injury severity score in survivors vs non-survivors was 41 (36-51) vs 45 (34-53) (p = 0.49), with no significant difference in probability of survival. despite no significant difference in injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8310 [ conclusions: vasopressor administration and high-dose use for hemorrhagic shock following severe blunt trauma are significantly associated with increased mortality. although the transfused volume of blood products tends to be increased, early termination of vasopressor should be considered. all authors have no significant relationships with regard to this study. early amplitudes of citrated functional fibrinogen in thromboelastography to predict massive transfusion introduction: this study aims to evaluate the role of early amplitudes of the thromboelastography measure of citrated functional fibrinogen (cff) to predict massive transfusion (mtx) defined as transfusion of c 4 of any blood products within an hour of arrival to a major trauma centre. material and methods: trauma patients c 16 years requiring activation of the major haemorrhage protocol with teg performed on a tegò 6 s hemostasis analyser were eligible for inclusion. exclusion criteria were arrival [ 3 h after injury, pregnancy, bleeding disorder or anticoagulant use. patient demographics and transfusion requirements were obtained from medical notes. teg manager was accessed to extract amplitudes at 5 min (a5), 10 min (a10) introduction: hyperfibrinolysis, remains a significant characteristic of acute traumatic coagulopathy induced mortality. s100a10, a cell surface protein, when shed creats an occult hyperfibrinolytic subtype. annexin a2 (a2), a multicompartment protein that co-localizes with s100a10 and contains a tissue plasminogen activator (tpa) binding site has been shown to enhance tpa activity 100-fold and thus behaves as marker of hyperfibrinolysis. we hypothesize that increased concentrations of a2 in blood will enhance tpa fibrinolysis. material and methods: blood was collected from (12) healthy volunteers. recombinant a2 in concentrations 1, 25, 50, 75, 100, 125 lg/ ml was added blood and then combined with tpa 75 ng/ml. samples were assessed using thromboelastography (teg). blood samples were collected from trauma activations from 2014-current at a single, urban, level-1 trauma center. samples were assessed using a combination of rapid, citrated native and tpa challenge teg. a2 levels were established via proteomic analysis. results: a2 50-125 (lg/ml) significantly increased tpa mediated ly30% vs tpa alone (a2 ? tpa [50-125] median 21.5% vs tpa 12.0% p \ 0.01). a2 without tpa had no significant effect on ly30% and was similar to the lysis of control (a2 75 lg/ml 0.7% vs control 1.2% p = 0.36). a2 75-125 (lg/ml) significantly increased r time from control and tpa alone (control normalized to 1 vs a2 median 1.77-fold increase in minutes p \ 0.01 and tpa 0.68-fold decrease vs a2 median 1.77-fold increase p \ 0.001). rapid teg for patient 1 vs patient 2 in our ongoing study was 3.4% vs 4.2% and 1.7% and 51.8% respectively on tpa challenge teg. proteomic analysis of a2 relative activity found a 6.6-fold a2 activity in patient 2 compared to patient 1. conclusions: exogenous cell free a2 significantly increases tpa mediated fibrinolysis measured by teg. preliminary data from our ongoing trauma study evaluating a2 levels and hyperfibrinolysis coincide with our in vitro study. introduction: massive transfusion protocol can be activated to mobilize the blood products resource in a timely and effective manner. blood products, however, are still wasted or overused. we aimed to study what proportion of patients who met the abc criteria for massive transfusion received 4 or more units packed rbc (prbc). material and methods: a retrospective study all level i trauma patients admitted with arrival systolic blood pressure of 90 or less (july 2017 to may 2018) was recruited. transfusion was complied with stts. all clinical and laboratory findings, and management procedures were populated from the data registry. results: 214 of 1200 admitted trauma patients met the inclusion criteria. of 214 patients who where admitted with hypotension, 39 of 95 patients (41.05%), who met the abc criteria for receiving 4 or more prbc were stabilized with 2 or 3 units. in other words, stts enabled us to save 69 units of prbc. arrival data, i.e. blood pressure (cut of point: 83 mmhg and p value:0.01), shock index (cut of point: 0.79 and p value:0.0009) and pulse rate (cut of point:112 beat/min and p value:0.01) were significantly different in patients prescribed 4 or more units prbc. after initial resuscitation, blood pressure (cut of point:98 mmhg and p value:0.0001 shock index cut of point: 0.9 and p value:0.001), pulse rate(cut of poinan95 beat/min and p value:0.001) presence of pelvic fracture, positive fast,and base deficit [ 10 were significantly different in the group received 4 or more units prbc. conclusions: massive transfusion protocol with abc criteria may lead to wasted or overused blood products.consideration of dcr continuation strategy complied with stts along with the findings of this study has resulted in a refined protocol characterized by more effective and efficient blood product resource allocation. references: 1-chang r, holcomb jb. optimal fluid therapy for traumatic hemorrhagic shock. critical care clinics. 2017 jan 1;33 (1) case history: we present the clinical case of a female patient of 77 years old who had been taking aspirin. mechanism of injury: a fall from her own height, resulting in head trauma. clinical findings: dysphonia and stridor, having underwent an immediate orotracheal intubation. investigation/results: she had a head ct done that was normal; and a cervical column and neck ct that showed a large retropharyngeal hematoma, without an associated vertebrae fracture. diagnosis: large retropharyngeal hematoma. therapy and progressions: she was admitted to the intensive care unit for mechanical ventilation. on 2nd day, she underwent a surgical tracheostomy. on 4th day, underwent weaning from mechanical ventilation. on 6 h day, was transferred to the ent ward, had the tracheostomy tube removed and was discharged from hospital. comments: a hematoma in this potential space may constitute an immediately life threatening emergency due to airway compromise. in 1991, thomas et al found only 29 cases described in the literature since 1966. the most common cause is the blunt cervical trauma (in 38% of the cases). other causes are the cervical hyperextension injury, cervical vertebrae fracture, cough, sneeze, strain, blunt head trauma, swallow a foreign body, retropharyngeal infection, carotid artery aneurism, internal jugular vein puncture, metastatic disease, coagulopathy, anticoagulants, etc. in the setting of trauma, the mechanism of injury generally permits explaining the presenting injuries. in this case, the clinical severity expressed by the patient seemed to be disproportional to the resultant injury. however, the presence of haemorrhage contributing factors associated with the existence of fascial spaces in the neck, should warn us of the possibility of formation of deep cervical hematomas that may cause an occult airway obstruction. case history: a 27-year-old male with a personal history of consumption of alcohol, cannabis, smoked cocaine and heroin. he was found in decubitus position and in a situation of cardiac arrest. the last time he was seen in his baseline situation was 48 h before. after performing cpr and administration of naloxone and flumacenyl, sinus rhythm was achieved. clinical findings: 24 h after admission, increased tension was observed in left leg, thigh and gluteal region. absence dorsalis pedis, tibialis posterior and popliteal pulse was observed in a doppler examination. investigation/results: intracompartmental pressure measurement revealed a result of 28 mmhg in the deep posterior compartment and 20 mmhg in the superficial (diastolic bp 40 mmhg). at admission k levels were 10.50 meq/l, creatinine 2.24 mg/dl and ck 113438 u/l. diagnosis: opioid-related compartment syndrome. therapy and progressions: urgent fasciotomies of the leg and thigh were performed 3 h after diagnosis with a posteromedial and anterolateral approach in the first case and with a lateral approach in the latter. herniation and signs of poor viability in all the compartments were observed. after the surgery, he persisted with anuria and a ck peak of 288,000 u/ l, which was next normalized. 7 debridements were performedfor the next 25 days. subsequently, after the isolation of p. stutzeri and mucor in the wound and the absence of signs of vitality, a supracondylar amputation was performed. after, hemodynamic status improved. 2 weeks after the amputation it was possible to withdraw hemodialysis, which he had required since admission. comments: opioid misuse is a topic of growing interest. recent works have reported a worse prognosis in the case of opioid-related compartment syndrome. a high level of suspicion is necessary to make a prompt diagnose in these patients. introduction: the pelvic binder is a mechanical device designed to compress instable pelvic ring fractures and minimize dead space in order to limit blood loss. it is generally recommended to apply a pelvic binder if an unstable injury is suspected and the patient presents with a ''c-problem''. the effectiveness remains questionable though. material and methods: a total of 1207 trauma patients between 2014 and 2018 were retrospectively evaluated regarding instable pelvic injury. 108 patients were admitted with a pelvic binder applied. the correct application was evaluated using ct scout. four groups were generated: group 1 with correct pelvic binder application, group 2 with incorrect placement, group 3 with no pelvic binder at time of admission, group 4 with pelvic binder applied in er. total outcome was determined based upon iss, age, preclinical time, time to ct, shock index, hemoglobin at admission, survival rate, administration of blood products as well as total hospital and icu days. results: 43% of all pelvic binders were applied incorrectly. 30 patients (28%) suffered an instable pelvic fracture. patient survival was not influenced by the preclinical application of a pelvic binder (80% group 1 vs. 81,82% group 3, p = 0,719). no significant statistical difference was found for total icu days 9,08 vs. 11,56, p = 0,399; total hospital days 23,42 vs. 24,76, p = 0,630; rbc transfusion 5, 87 vs. 3, 63, p = 0, 791; iss 23, 8 vs. 24, 5, p = 0, 815. conclusions: the correct application of a pelvic binder seems to pose problems preclinically. while the need to minimize blood loss is crucial, our collective did not benefit from this device. additionally, survival rates of the patients that suffered an instable pelvic fracture were unaffected. the iss remains the strongest predictor of total patient survival in pelvic trauma. trauma resuscitation times in a level 1 trauma center in the netherlands: a prospective overview introduction: in trauma, time is considered to be an important factor influencing patient's outcome. in the first hour after injury, appropriate care has the greatest effect on trauma patient's survival. previous research showed that measuring in-hospital trauma resuscitation times, contributes to insights and improvement of the resuscitation process. however, despite developments of atls guidelines, no recent empirical knowledge regarding resuscitation times exists. the aim of this study is to examine in-hospital trauma resuscitation times in a level 1 trauma center in the netherlands. material and methods: a prospective study was performed in level 1 trauma center amsterdam umc location vumc, between may 2019 and august 2019. trauma patients, aged c 16, presented during daytime at the trauma resuscitation room were included. information regarding patient's characteristics, trauma-and injury type, handover duration, duration till start of diagnostics and intervention, total resuscitation time, patient's disposition and survival were compared. results: in total, 50 patients were analyzed. motorized traffic accident (42%) and blunt injury (92%) were the most common mechanism-and injury types. median prehospital to in-hospital handover time was 3.40 min (iqr 1.20) . median duration till start of diagnostics and intervention were 8.01 (iqr 2.42) and 9.59 min (iqr 9.55) respectively. median total resuscitation time showed to be 40.25 min (iqr 23.01 background: terrorist attacks and civilian mass casualty events are frequent, and some countries have implemented tourniquets for uncontrollable extremity bleeding in civilian settings. we summarized current knowledge on the use of pre-hospital tourniquets in civilian settings to assess whether their use increases the survival rate in civilian patients with life-threatening hemorrhages from the extremities. methods: using the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, we searched medline (ovid), embase (ovid), cochrane library, and epistemonikos in january 2019. all types of studies that examined the topic in a pre-hospital setting published after january 1, 2000, were included. the protocol was registered in prospero (crd42019123172). results: among 3460 screened records, 55 studies were identified as relevant. due to a lack of relevant civilian studies, military studies were also included. the studies were highly heterogeneous, with low quality of evidence. most studies reported increased survival in the tourniquet group, but few had relevant comparators, and the survival benefit was difficult to estimate. most studies reported a reduced need for blood transfusion, with few and mainly transient adverse effects from tourniquet use. conclusion: the data suggest that the use of commercial tourniquets in a civilian setting to control life-threatening extremity hemorrhage is probably associated with improved survival, reduced need for blood transfusion, and few and transient adverse effects. the effect of venous infusion by emergency medical service personnel on the prognosis of severe traffic accident patients: a nation-wide study in japan y. katayama 1 , t. kitamura 1,2 , t. hirose 1 , y. nakagawa 1 , t. shimazu 1 1 osaka university graduate school of medicine, department of traumatology and acute critical medicine, suita, japan, 2 osaka university graduate school of medicine, environmental and population science, suita, japan introduction: in japan, the law of paramedic was revised in 2014, and it became possible for paramedic in japan to secure an infusion route before cardiac arrest for severe patients. however, the effect of this treatment on the prognosis of severe trauma patients has not been assessed. we assessed this effect on the prognosis of severe traffic accident patients with using population-based ambulance record and nation-wide hospital-based trauma registry in japan. material and methods: this study was a retrospective observational study and the study periods was 2 years between january 2016 to december 2017. we linked the nation-wide hospital based trauma registry (jtdb) and the population-based ambulance record in japan in case. in this study, we included the traffic accident patients with iss score more than 16 and excluded cardiopulmonary arrest patients on the arrival of ems on the scene and missing data cases. the main outcome was cardiopulmonary arrest on hospital arrival. mcnemar's test and conditional logistic regression analysis were used to assess the association between the securing a infusion route by ems personnel and the primary outcome after one-to-one propensity score matching for securing a infusion route or not. results: 3502 traffic accident patients were eligible for analysis and 142 patients were dripped by ems personnel. after one-to-one propensity score matching, the proportion of cardiopulmonary arrest on hospital arrival were 5.6% (8/142) in patients dripped by ems personnel and 7.7% (11/142) in patients not dripped by ems personnel, respectively (p = 0.648). the adjusted odds ratio for securing a infusion route was 0.727 [95% confidence interval; 0.293-1.808, p = 0.493]. conclusions: in this study, there was no association between the securing a infusion route and outcome of traffic accident patients. the association between trauma patient characteristics and adverse laboratory values: which patient characteristics are most predictive? introduction: in more than 60 countries worldwide, laboratory testing is protocol driven since 1978 when it was included in the practice guideline of the advanced trauma life support course (atls). 1 however, it is not clear yet which patient characteristics are associated with unfortunate laboratory values. the aim was to create an overview of the characteristics that were associated with adverse laboratory values. material and methods: this cohort study was performed at amsterdam umc, location amc (level 1 trauma center), including patients during a period of 2 years. data concerning age, gender, asa scores, injury severity scores (iss), glasgow coma scores (gcs), mechanism of injury, type of injury (blunt or penetrating) and the presence of helicopter emergency medical services (hems) were obtained. the hematology panel included hemoglobin, hematocrit, mcv, leucocyte and thrombocyte values. the coagulation panel included inr, pt, aptt, fibrinogen and d-dimer values. other panels include arterial blood gas, kidney and liver panels. the association between trauma patient characteristics and laboratory values were determined by using binary and multinomial logistic regression. results: a total of 1287 patients were included, consisting of predominantly men (66%) with a mean age of 46 years old. an increase in age and iss was correlated with abnormal laboratory values (p = 0.00). additionally, male gender, iss [ 16, blunt trauma and the absence of hems was associated with a deviation in laboratory values (p \ 0.05). other patient characteristics did not show a significant correlation with adverse laboratory values. case history: a 47-year-old man presented with a classic case of pituitary apoplexy with a history of headache, nausea and vomiting. clinical findings: he was found to have a sellar and suprasellar mass with internal cystic and hemorrhagic component consistent with a pituitary macroadenoma. investigation/results: he underwent transsphenoidal sugery for a pituitary macroadenoma. because the tumor was invaded to left cavernous sinus, we left small portion of the tumor. eighth day after surgery, he underwent gamma-knife surgery (gks) for residual tumor. after two weeks, he complained of left ptosis. we considered the 3rd nerve palsy to be a post-radiation reaction at first. after 3 months, the symptoms had been continuous and mri showed increased size of cystic lesion involving left cavernous sinus. diagnosis: ct angiogram demonstrated a saccular aneurysm at left distal ica. endovascular coil embolization was performed. therapy and progressions: after 3 months of the intervention, the 3rd nerve palsy was partly improving. comments: our case report emphasizes the necessity of cerebrovascular imaging before surgery for pa. mr angiography/ct angiography is not currently obligatory in patients with pituitary adenoma, but in cases with the symptoms of displacement of the neuro-vascular structures it can be of great value. even in patients without such presentations, it may be helpful to evaluate the vascular involvement. case history: a 16-year-old boy during the preparation for a fishing session was pierced to the left orbitary region by a high-speed spearfishing steel. clinical findings: upon arrival the patient was conscious and responsive with a gcs of 15, he followed commands appropriately and there were no motor of sensory deficits. investigation/results: plain skull radiographs showed the spear crossing the skull from the left orbit to the posterior part of the parietal bone. diagnosis: the patient was immediately intubated to prevent involuntary movement of the foreign body. ct scan showed the fracture of the left orbitary roof where a 30 centimetres long metallic object crosses the cerebral parenchyma of the left hemisphere and perforates the left parietal skull. therapy and progressions: under direct visualization via transorbital approach the foreign body was removed together with bone fragments, hemostasis was done and orbitary roof repaired. serial cranial ct scan showed progressive reduction of frontal and parietal hematoma. the movement of the eye improved after a few days, normalizing with the regression of periorbital edema. upon discharge at 11 th postoperative day the patient had a gcs score of 15, no motor deficit and minimal visual loss. comments: penetrating injury of the skull and brain are relatively uncommon events, representing about 0,4% of all head injuries. orbital roof is relatively thinner part of the skull that can provide easy access to projectile objects, which can penetrate into cranial cavity and damaging the brain parenchyma. the principles of treatment are removal of bone fragments and foreign body, control of persistent bleeding and intracranial hypertension, prevention of infection though debridement of all contaminated and necrotic tissue and at the same time preservation of as much nervous tissue as possible. multitraumapatients whith severe head injury (ais ‡ 3) are more quickly carried out ct scan on than a patient without severe head injury v. giil-jensen 1 , k. andersen 1 , t. k. helle 2 1 haukeland univercity hospital, sugical department, bergen, norway, 2 haukeland univercity hospital, ambulance service, bergen, norway introduction: trauma patients who are prone to severe head injuries during trauma may profit from obtaining a rapid clarification of the injury magnitude when using ct examination. in the case of a delayed ct examination, the consequence of the head injury could be more extensive. in this study, we wanted to see if those with severe head injury (ais c 3) received a faster ct survey than those who had no severe head injury. material and methods: retrospective registry study of severely injured patients (iss [ 15) which had been hospitalized as a trauma patient at haukeland university hospital in the period 2015-2019. in the study, we have excluded all patients entered as multitrauma but who have iss \ 16 and all patients who have not defined ct time. it turns out that over half of the patients lacked the registration of accurate time for the ct survey in the national trauma register. the number is still considered large enough to find a result. results: 2542 patients were received as multitraumatic at haukeland university hospital during the period. of these, 493 was severely injured. of these, 265 patients had severe head injuries and they again had 52 head injuries as the only serious injury (ais c 3). median time from arrival receipt to start ct, for this group was 27 min. in the control group that was severely injured but without severe head injury is the same time 33 min. there was 102 patients in the control group. conclusions: for the patients in this study who had severe injuries (n:493), the median time from the arrival in the emergency department to the ct starts was 6 min shorter for severe head injuries than for the group without severe head injuries. introduction: the patients with severe traumatic brain injury (stbi) who needs surgical intervention often experience acute traumatic coagulopathy (atc). earlier transfusion with high blood product ratios (plasma, platelets, and red blood cells via 1:1:1 ratio) is recommended for severely injured patients. however, recommended blood product ratio for stbi is still controversial. material and methods: we retrospectively reviewed successive adult stbi who underwent surgical treatment in our hospital between january 2016 and december 2018. we have transfused plasma aggressively to maintain blood fibrinogen above 150-200 mg/dl. we evaluated the total amount of transfusion and mortality. we exclude cases administered fibrinogen concentrate. results: 53 patients were enrolled. the amount of transfusion for 24h is rbc 4.2units, ffp 7.8units, pc 3.8units . stbi with severe other trauma needs higher ratio of plasma. discussion: tissue injury of stbi causes severe coagulopathy and 1:1:1 transfusion was thought to be insufficient for stbi in order to maintain fibrinogen. we agressively transfused plasma but we achieved fibrinogen value above 150 only in 20% of stbi with severe other trauma. agressive plasma transfusion had limitation for hyperfibrinolysis so we expect other product, for example fibrinogen concentrate. introduction: traumatic brain injury (tbi) remains a leading cause of hospital admission and mortality amongst trauma patients. intracranial hemorrhage (ich) can occur with tbi and presents a severe complication. low complication tolerance in developed countries and uncertainty on actual risk cause excessive diagnostics and hospitalization, considered unnecessary and expensive. methods: tbi cases indicated for cranial computer tomography (ct) according to international guidelines, at our level i trauma center between 2008-2018 were retrospectively included. multivariate logistic regression was performed for ich, progression and mortality predictors. results: 2036 tbi patients (m: 57.5; age at trauma: 57.6 ± 22.6), were included. ct was performed in 96.5%, skull fracture diagnosed in 18.6%, ich in 51.9%, ich progression in 28.4%. in patients \ 35a, chronic alcohol consumption (p = 0.004) and neurocranial fracture (p \ 0.001) were significant ich risk factors in a multivariate analysis. in patients between 35-65a, chronic alcohol consumption (p \ 0.001) and skull fracture (p \ 0.001) revealed as significant ich predictors. in patients [ 65a, age (p = 0.009), anticoagulation (p = 0.007) and neurocranial fracture (p \ 0.001) were significant risk factors for ich, age (p = 0.01) was an independent risk factor for mortality. late onset ich only occurred in cases with at least 2 of 3 factors: age [ 65, anticoagulation, neurocranial fracture. overall hospitalization might have been reduced by 15.8% via low risk cases. conclusions: triggered by decreasing error tolerance, international guidelines for mild tbi focus on safety maximization. repeated ct in initially ich negative cases should only be considered in high risk patients. non-ich cases aged \ 65 years do not gain safety from observation or hospitalization. recommendations from our data might, without impact on patient safety, reduce costs by unnecessary hospitalization and diagnostics. references: to be added by the authors. evaluation of low-value clinical practices in acute trauma care: a multi-center retrospective study l. moore 1 , k. soltana 2 , j. clément 2 , a. turgeon 2 , î mercier 3 , r. krouchev 2 , p. a. tardif 2 , s. bouderba 3 , a. belcaid 4 1 université laval, social and preventive medicine, québec, canada, 2 chu de québec-université-laval, québec, canada, 3 université-laval, québec, canada, 4 introduction: low-value clinical practices have been identified as one of the most important areas of excess healthcare spending and are associated with adverse health outcomes. the objectives of this study were to estimate the frequency low-value practices in injury care and assess inter-hospital variations. material and methods: we identified low-value clinical practices from internationally recognized clinical guidelines. we conducted a population-based retrospective cohort study using data from an inclusive canadian trauma system (2010-2017) to calculate frequencies and assessed inter-hospital variations with intra-class correlation coefficients (icc). results: we identified 29 low-value practices of which 9 could be measured and validated using trauma registry data. the three lowvalue clinical practices with the highest absolute and relative frequencies were pelvic x-rays in hemodynamically stable patients with a negative physical exam for pelvic injury (42.9%), head ct in adults with minor head injury who were negative on a validated clinical decision rule (24.3%) and chest x-ray in hemodynamically stable patients with a normal physical exam (6.9%). we observed high inter-hospital variation for surgical management of penetrating zone ii neck injury without hard signs (icc = 27%), and moderate variation for head ct in adults with minor head injury who were negative on a validated clinical decision rule (icc = 6.3%). conclusions: we have developed and validated algorithms to evaluate nine potentially low-value clinical practices using trauma registry data. highest frequencies were observed for imaging in the emergency department and the highest inter-hospital variation was observed for inappropriate surgical management. these data can be used to advance the agenda on low-value care for injury admissions. dysfunction of functional connectivity between default mode network and cerebellar structures in patients with mtbi in acute stage. rsfmri and dti study introduction: mild traumatic brain injury (mtbi) occupies one of the first places in children injuries. among all brain networks at the resting state, the default mode network (dmn) is the most widely studied network. the aim of this study is to examine functional connectivity in normal-appearing cortex in acute period of mtbi using rsfmri. material and methods: 34 mr negative participants were studied in age from 12 to 17 years (mean age-14.5 years). group of patients consisted of 17 children with mild traumatic brain injury in acute stage. 17 age-matched healthy volunteers comprised control group. all studies were performed at phillips achieva 3.0t mri scanner using 32-channel head coil. fmri data were processed using functional connectivity toolbox conn. seed-based analysis was performed in order to reveal disturbances in functional connectivity. statistical processing was performed using statistica 12. results: dti analysis didn't show any changes in values of apparent diffusion coefficient (adc) and fractional anisotropy (fa) between two groups (see fig. 1 ). no statistically significant differences in correlation strength between dmn parts were observed in two groups (see fig. 2 ). intergroup seed-based analysis revealed statistically significant (p \ 0,05) difference in neural correlations between dmn parts and vermis (cerebellum structural part): positive link in control group and negative link in group of patients. conclusions: one of the most common symptoms of mtbi is dizziness as a result of impaired movements coordination. vermis as an essential cerebellum part plays an important role in the vestibuloocular system which is involved in the learning of basic motor skills in the brain. vermis aids in the synchronization of eye and motor functions in order for the visual field and the motor skills to function together.our results show that mtbi appears to be a possible reason of connectivity malfunction in normal-appearing vermis. references: predictors of developing post-traumatic endophthalmitis introduction: 1h magnetic resonance spectroscopy (1h mrs) allows to study structural and metabolic brain disorders in various pathological conditions in vivo. non-invasive method determines its advantage for use in children in serious condition with acute cerebral injuries. this determined the purpose of the study: to identify criteria of irreversible brain damage based on the 1h mr spectra analysis in comatose children with acute traumatic brain injury (tbi) or anoxia. material and methods: 8 patients (6 months-16 years) were examined in the acute period of severe cerebral injury (gcs score 3-4): six were in acute and subacute period of severe tbi, one patient was examined on the seventh day after drowning, and one-a day after acute cerebral blood flow (hemorrhage). all patients died in 10-20 days after the study. control group included 10 healthy children aged from 7 to 13 years. single voxel 1h mrs and 2d 1h mrs was performed on 3t scanner. 1h spectroscopic voxel (te/tr = 35/ 2000 ms, voi = 3 cm 3 , nsa = 32) was oriented on mri intact areas: cortex of frontal, parietal and occipital lobes (fig. 1) , thalamic nuclei (fig. 2) , cerebellum, brainstem (fig. 3) . for 2d 1h mrs a spin-echo point-resolved spectroscopy (press) sequence was used (te/tr = 144/2000 ms) with the spectroscopic voi of 150 cm 3 on frontal lobes. results: in all spectra lactate (lac) signal, dominating all other signals, was detected. n-acetylaspartate (naa) was reduced by 60% and creatine/phosphocreatine (cr)-by 35%. conclusions: 1h mrs is a non-invasive prognostic method in patients with acute cerebral brain damage in coma. the cause of patients' death is the shift of cerebral glucose metabolism to an anaerobic type, as evidenced by the accumulation of lac. disturbance of energy metabolism causes a decrease of cr and a decrease in the neuronal marker naa. the combination of these patterns in acute cerebral injury, regardless of etiology indicates irreversible brain tissue damage. introduction: scalds and contact burns are the most common burn injuries both in children and adults. data are conflicting regarding which type of burns are more severe. we compared scalds, contact, and flame/fire burns at our burn center to determine which type were more likely to result in full thickness injuries and prolonged length of stay (los). material and methods: we conducted a structured retrospective medical record review of all patient admissions to a regional burn unit over a 10-year period between 2000 and 2010. data included demographic, clinical, and specific burn characteristics. the association between patient predictor variables and outcomes (full thickness burns, los) was explored using chi-square and stepwise logistic regression. results: there were 1,038 patients with either scald (n = 537, 52%), fire/flame (n = 434, 42%) or contact burns (n = 67, 6%). burn depth was not available for 216 cases (21%). mean (sd) age was 29 (25), 64% were male. mean (sd) total body surface area (tbsa) was 10 (11)%. 24% of burns contained areas of full thickness injury. patients with scalds were younger than those with contact or fire burns (22 ± 24 vs. 32 ± 28 vs. 38 ± 22 years respectively, p \ 0.001). the percentage of burns that were full thickness by etiology were contacts (45%), fire/flame (34%) and scalds (13%); p \ 0.001. after adjusting for age, location, and tbsa, scalds were less likely to result in full thickness injuries than contact burns (odds ratio 0.23, 9%%ci, 0.11-0.48). adjusting for multiple testing, univariate analysis (as well as the multivariate analysis) showed no difference in % 3rd degree burns between fire and contact burns, but scalds were significantly lower than each of those. los for scalds (8 ± 10) and contact burns (8 ± 11) was significantly shorter than for fire/flame (14 ± 25 days, p \ 0.001). conclusions: while less common, contact and flame burns were more likely to result in full thickness injuries than scalds. references: epidemiology, treatment, costs, and long-term outcomes of patients with fireworks-related injuries (rocket); a multicenter prospective observational case series introduction: the aim of this study is to provide detailed information about the patient and injury characteristics, medical and societal costs, and clinical and functional outcome in patients with injuries resulting from fireworks. material and methods: a multicenter, prospective, observational case series performed in the southwest netherlands trauma region, which reflects 15% of the netherlands and includes a level i trauma center, a burn center, and an eye hospital. all patients with any injury from consumer fireworks, treated at a dutch hospital between december 1, 2017 and january 31, 2018, were eligible for inclusion. exclusion criteria were unknown contact information or insufficient understanding of dutch or english language. the primary outcome measure was injury characteristics. secondary outcome measures included treatment, direct medical and indirect societal costs, and clinical and functional outcome until one year after trauma. results: 54 out of 63 patients agreed to participate in this study. the majority was male (n = 50; 93%), 50% were children \ 16 years, and 46% were bystanders. injuries were located to the upper extremity or eyes and were mostly burns (n = 38; 48%) of partial thickness (n = 32; 84%). fifteen (28%) patients were admitted and 11 (20%) patients needed surgery. the mean total costs per patient were €6,320 (95% ci €3,400 to €9,245). patient-reported quality of life and functional outcome was not significantly different during follow-up compared with pre-trauma. conclusion: the most common injuries afflicted by consumer fireworks were burns, mostly located to the upper extremity, and eye injuries. fireworks can result in severe injuries, for which 15 (28%) patients needed hospital admission and 11 (20%) patients needed surgical treatment. although some injuries resulted in permanent disability, 1 year after trauma it in general did not have major or longlasting impact on patients'' self-reported quality of life or functional abilities. persistent inflammation, immunosuppression and catabolism syndrome after polytrauma: a rare syndrome with major consequences. l. hesselink 1 , r. spijkerman 1 , r. hoepelman 1 , l. koenderman 2 , l. leenen 1 , f. hietbrink 1 1 umc utrecht, trauma surgery, utrecht, netherlands, 2 wilhelmina children's hospital, center for translational immunology, utrecht, netherlands introduction: more severely injured patients survive the critical first phase after trauma nowadays. a substantial portion of these patients require long-term critical care support and suffer from recurrent infections. this clinical condition fits in a syndrome referred to as ''persistent inflammation, immunosuppression and catabolism syndrome'' (pics). the aim of this study was to investigate the incidence of pics and clinical outcomes of trauma patients with pics in a level one trauma center. material and methods: all trauma patients c 16 years admitted to the intensive care unit (icu) for c 14 days between 2007 and 2017, were included. patients with isolated neurological injuries were excluded. pics patients were identified by icu stay c 14 days, c 3 infectious complications and increased catabolism. infectious complications included infections during hospitalization and readmissions due to an infection. increased catabolism was defined as weight loss [ 10%, a body mass index. results: of the 3,859 polytrauma patients, 194 patients had an icu stay c 14 days. after exclusion of patients with isolated neurological injuries, 78 patients were included. of these patients, 18 developed pics. pics patients sustained 5 infectious complications on average (compared to 1 in the non-pics group, p \ 0.001) and 72.2% of the pics patients developed sepsis. also, pics patients had a longer hospital stay (mean of 90 days versus 50 days, p \ 0.001) and sustained more surgical procedures (mean of 13 versus 4 per patient, p \ 0.001). infectious readmissions occurred until 5 years after the initial trauma. conclusions: patients who develop pics experience long-term inflammatory complications that lead to frequent readmissions and surgical procedures. therefore, despite its low incidence, this clinical condition forms a burden on patients and a substantial financial burden on society. hyperbilirubinemia as a risk factor of the trauma icu patient introduction: hyperbilirubinemia is common in the intensive care unit (icu). hyperbilirubinemia has been considered as a risk factor of the icu patient. hyperbilirubinemia can have various causes. the hyperbilirubinemia has never been studied for the trauma icu patient. the aim of this study is to elucidate the incidence and effects of the hyperbilirubinemia for the trauma icu patient. material and methods: retrospective review of the trauma icu patients from 2017.01.01 to 2017.06.30. initial bilirubin serum level, 48 h bilirubin level, 7 day bilirubin level, highest bilirubin level, overall morbidity and mortality and other clinical variables were identified and evaluated. the patients who have highest bilirubin level c 3.0 mg/dl were defined as hyperbilirubinemia group. results: a total 78 patients were enrolled in this study. hyperbilirubinemia above serum bilirubin c 3.0 mg/dl were appeared in 26 patients. the mortality of the hyperbilirubinemia group was higher than the other group (71.4% vs 29.6%, p = 0.03). the icu stay of the hyperbilirubinemia group was longer than the other group (12.4 day vs 7.1 day, p = 0.04). the hyperbilirubinemia group had more incidences of pneumonia, acute kidney injury, and sepsis than the other group (42.9% vs 57%, p = 0.01/ 33.3% vs 66.7%, p = 0.001/0% vs 100%, p \ 0.001). conclusions: the hyperbilirubinemia is a risk factor of the trauma icu. if the hyperbilirubinemia is appeared, the cause of the hyperbilirubinemia should be evaluated and make an effort to correct hyperbilirubinemia for the each cause of the hyperbilirubinemia. case history: we present the clinical case of a male patient of 37 years old. injury mechanism: a firework burst on his right forearm. clinical findings: injury: a large area of carbonization of the muscles of the flexor compartment. signs and symptoms: intense pain in the hand and forearm with local oedema and tension. diagnosis: deep burn of the forearm. therapy and progressions: surgical debridement and fasciotomy of this compartment; followed by deferred and progressive primary closure by means of rubber bands that were tightened as the oedema diminuished-shoelace technique. evolution: discharged from hospital on the 8th pos op day; follow-up at 3rd and 6th month without functional impairment, with a good healing evolution. comments: deep burns that reach the subfascial planes of the limbs, increase the pressure in the muscular compartments, and may progress to a compartment syndrome. there is no specific cutoff value of pressure for this diagnosis; consequently, the final decision to proceed with a fasciotomy relies on the clinical experience. surgical debridement and fasciotomy may result in large wounds, sometimes difficult to close. grafts and flaps result in another wounds and carry a risk of pain, infection, scar shrinking and necrosis. the diagnosis of a limb compartment syndrome is almost always a clinical one and requires a high index of suspicion so as to the fasciotomy is done in time. the shoelace technique is a simple, reproducible and cost-effective method of deferred closure of a large wound, preserving functionality and resulting in a good final cosmesis. references: johnson ls et al, management of extremity fasciotomy sites prospective randomized evaluation of two techniques, am j surg. 2018. the use of propranolol in the management of acute thermal burn injury: evaluation of the effect of fixed dosages in african patients c. jac-okereke 1 , i. onah 1,2 1 esut teaching hospital, surgery, enugu, nigeria, 2 national orthopaedic hospital, enugu, nigeria introduction: propranolol has been shown to improve outcomes in burn patients. its effects are achieved at doses that reduce the heart rate by 10-25%. africans have a different propranolol pharmacogenetic profile as compared to other races. there is paucity of literary works on the use of propranolol in africans with burns. in our study, we explored the effectiveness of fixed dosages of propranolol in nigerian patients. material and methods: this was a prospective comparative study of adult burn patients; two test groups received propranolol 40 mg/day and 240 mg/day respectively. the average daily pulse rate prior to and after the administration of propranolol were compared. results: patients in the control group had no effective reduction in their pulse rate. patients who received propranolol at a dose of 240 mg/day had a reduction c 10%. no adverse events were observed. conclusion: it is important to establish the effective dosage of propranolol in burn patients of african-descent and explore its potential benefits in their treatment. although we cannot draw strong case history: the authors present in their paper three cases of blunt abdominal injury caused by seat belt in car accident. in the first two cases there was no diagnostic problem thanks to clear clinical finding. in the third case there was no clinical correlation and even repeated auxiliary examinations did not indicate the need for surgical intervention of the abdominal cavity. clinical findings: case no. 1-male 37 y. old, haemodynamic stability, thoracic an abdominal pain, fast positivity, on ct free fluid in abdominal cavity, small spleen laceration, positivity of peritoneal symptomatology. case no. 2-male 42 y. old, haemodynamic stability, bilateral hypogastric pain without peritoneal symptomatology, fast with small perihepatic fluid, on ct fluido-pneumoperitoneum. case no. 3-female 42 y. old, haemodynamic stability, thoracic pain, massive oedema on the right side of the neck and supraclavicular area, without abdominal symptomatology. fast with small subhepatal fluid collection-4 mm, ct scan with large neck haematoma and fracture of 1st rib, apical pneumothorax-12 mm. intraabdominal only subhepatal fluid stripe-18 mm, suspected of small hepatic laceration. after 3 days the clinical status rapidly changed, during 2 h peritoneal symptomatology occured. on control ct scan fluido-pneumoperitoneum was detected. investigation/results: all patients underwent surgical procedure diagnosis: bowel mesenteric injury therapy and progressions: the first patient underwent ileo-caecal and hartmann resection, by the second patient was small intestine and col. sigmoideum resection needed, and the last one underwent ileal resection and npwt. comments: despite the current diagnostic methods blunt abdominal injuries, unlike the penetrating ones, can present a certain diagnostic problem especially when they are accompanied by other serious conditions such as manifest chest injuries. introduction: patients with hypertension and peritonitis must undergo a laparotomy. in isolated parenchymal lesions of the liver, the spleen or kidneys interventional or conservative approaches are more frequently used. to miss a hollow viscus organ lesion, that would need an operative procedure, is a constant fear. it is the aim of this study to identify significant predictors of the simultaneous presence of a hollow viscus lesion in patients with parenchymal organ lesions. material and methods: data of over 20'000 inpatients of a levelone-trauma centre between 2008 and 2016 were analysed. only hemodynamically stable patients with a splenic-, liver-, or kidney injury (independent of grade) after blunt abdominal trauma were included. significant predictors were detected in bi-and multivariant analysis. results: of the 341 patients with an average age of 42 ± 20 years 43% (n = 148) had a splenic-, 49% (n = 168) a liver-and 23% (n = 79) a kidney rupture. the total iss was 30 ± 16 points. in 52 patients (15%) a hollow viscus injury could be found (stomach n = 5, small bowl n = 29, colon n = 22, rectum n = 4). injuries of the thorax (76%), the extremities (70%), the head (70%), the vertebra column (43%) and the pelvis (30%) were diagnosed as concomitant injuries. due to multivariant analysis neither age, gender, heart frequency at admission, gcs, base excess, the coagulation parameters, the hemoglobin value nor the separate injury regions could be identified to be predictive factors for the presence of a hollow viscus lesion. conclusions: clinical parameters taken at admission are not useful to predict hollow viscus injuries. the ct-scan is currently seen to be the best possible imaging modality, but it can be false negative, especially within the first 60 min after trauma. repetitive clinical examination is necessary. in doubt a diagnostic laparoscopy or even laparotomy has to be performed. introduction: a heavy abdominal trauma is associated with a high morbidity and mortality. it is the aim of this study to show injury patterns in the abdomen and concomitant injuries in polytraumatized patients as well as to identify risk factors of the decease. material and methods: data of over 20'000 inpatients of a level-one trauma centre between 2008 and 2016 were retrospectively analysed. only patients with a relevant abdominal trauma (ais abdomen c 3) were included. the ais score was determined either with a contrast enhanced computed tomography or intraoperatively. significant risk factors were detected in bi-and multivariate analysis. results: 315 patients with an averaga age of 43 ± 18 years were included. 48% (n = 155) had an ais abdomen of 3, 40% (n = 127) of 4 and 10% (n = 33) of 5. the overall iss was 31 ± 16 points. the mechanism of injury was mainly blunt (87%). a splenic rupture was present in 40% (n = 128), a liver rupture in 35% (n = 112) and a kidney rupture in 26% (n = 68). hollow viscus injuries were present in 13% (small bowl n = 44, colon n = 33, stomach n = 13, rectum n = 7, bladder n = 14). concomitant injuries were determined in 88% of the patients. of these 70% were diagnosed a thoracic injury, 66% injuries at the extremities, 55% head injuries. 47% spinal injuries and 31% pelvic injuries. the mortality was 16% (n = 51). a liver rupture (p = 0.031, or 4.0), pelvic injuries (p = 0.02, or 4.4), age (p = 0.043, or 1.032), hypotension (systolic blood pressure \ 90 mmhg) (p = 0.003, or 8.2) and a low gcs at admission (p \ 0.001, or 0.67) were determined to be significant risk factors. conclusions: in our trauma department life threatening abdominal traumata are treated about every 10 days. lethal abdominal injuries were mostly associated with serious liver ruptures or pelvic injuries. due to our experience we recommend the use of an early ct-scan as thereby the injury severity can be fast and precisely assessed. case history: a 44 yo female was tranferred to our icu on day 2 of a severe acute necrotizing alchoolic pancreatitis with mof. crrt with cytosorb was immediately started. on day 7 after onset (dao7) an acs with a new organ failure (lung) showed up. open abdomen (oa) and tac with mesh-mediated/npwt got a temporary improvement. clinical findings: on dao10 (oa3), reopening of the mesh entailed a sudden fascial retraction of 6 cm. a new larger mesh was positioned. on dao14 (oa7) the fascial defect measured both on ct slices and in or was 26 cm. provision of a longterm oa was done. therapy and progressions: a new fascial traction device (fas-ciotensò, germany)1 was positioned on dao14 (oa7), with a continuous traction weight of 6-8 kg. revision was scheduled any 2-4 days, according to clinical needs, including combined anterior and retroperitoneal necrosectomy. progressive traction allowed to get a 5 cm fascial gap under traction on dao38 (oa31). anterior cst was thus performed and fascia primarily closed. completion of necrosectomy was done through the bilateral lumbar incisions and npwt. comments: early fascial closure is a goal in oa. mesh-mediated traction/npwt is the most effective strategy, but primary fascial closure is sometimes impossible. 2 the duration of oa is a key point. fasciotensò allowed to overcome the failure of mesh-mediated option and avoided fascia retraction in a longterm oa. it was quickly managed by the nurse staff, allowed a easier access to the abdomen and a proper positioning of the protective film. its effectiveness in this demanding case makes it an interesting option for shortening fascial closure in septic oa too. background: small bowel obstruction (sbo) caused by intra-abdominal adhesions is one of the main surgical emergencies. in most of the time, adhesions are created by previous abdominal surgeries. without any severity signs, the medical treatment is first proposed to avoid superfluous surgery. we noticed that the failure of medical treatment is frequently seen in patients previously operated of appendicectomy. the purpose of this study is to determine the eventual relation between a previous appendicectomy and failure of medical treatment in sbo. methods: we conducted a retrospective data collection using a diagnostic code for bowel obstruction in patients who have consulted in emergency from 01.01.2011 to 01.01.2019 at the salengro university hospital in lille. using the administrative database, 1194 patients were identified. we excluded all children, patients with wrong diagnosis and those whose outcome was not known. finally, 324 patients with sbo on intra-abdominal adhesions confirmed on ct-scan were reviewed. the patients were separated in two groups. the group 1 (g1) included patients who required surgical management during hospitalization (107 patients) and group 2 (g2) patients with successful medical treatment (217 patients). we compared the rate of previous appendectomy in these two groups using a pearson's chi-squared test. in a second step, we tried to find out if there were others factor associated with failure of medical management. results: there was significant difference between the two groups with a higher rate of appendectomy in the surgical management group g1 (p = 0.00773). this difference was even more pronounced if appendectomy was the only surgical history. in the subgroup analysis of patients with previous appendicectomy, the laparoscopic approach or laparotomy didn't influence the outcome of the management of the sbo. conclusion: this study shows the difference between the two groups of sbo, with more surgery sanction in the group of patients previously operated of appendicectomy. perhaps because this surgery involves the very distal part of the small bowel and decrease the efficiency of a proximal nasogastric aspiration. these results should not change the initial management of sbo by medical treatment in absence of severity signs. however, knowing this data, we have to consider that a history of appendicectomy is a risk factor of failure of medical treatment in this situation. introduction: diaphragmatic injuries are a rare consequence of closed thoraco-abdominal trauma that could be difficult to detect due to paucity of clinical signs and frequent erroneous interpretation of radiological images. the overall incidence of diaphragmatic injury is 0,8-5,8% in blunt trauma. if the injury is not recognized it could lead to considerable risk of late morbidity and mortality. this study reviews our 10 years experience in the management of this patients. material and methods: a retrospective review of trauma registry of our tertiary referral centre was performed. preoperative, intraoperative and postoperative data were analysed to assess determinants of mortality, morbidity and effect of therapeutic delay by univariate analysis models. penetrating injuries were excluded from the study. results: over 10 years 31 patients with diaphragmatic injury due to blunt trauma were identified: 4 had a simple laceration of the diaphragm without hernia, 21 had acute and 6 chronic diaphragmatic hernia. the mean patient age was 40 years (range 17--78 years). overall mortality was 15%. the site of injury was the left diaphragm in 18 cases, the right diaphragm in 8 cases and bilateral in 1 case.the hernia content was stomach (9), colon (4), spleen (3), liver (3), omentum (2) and multiorgan (6). all acute patients were managed with primary suture repair via laparotomy except for two patients that required additional thoracotomy; chronic patients were treated laparoscopically in 4 cases (66,6%), in which a synthetic or a biosynthetic mesh was used to reinforce the suture. higher morbidity and mortality was seen in multiple associated injuries, head injuries associated, right diaprhagm injury, age [ 65 years and treatment delay [ 24 h. conclusions: delayed treatment of diaphragmatic injuries could be dramatic: it is importnat not to misinterpreter the radiological findings and to reassess the patient mantaining a high level of suspicion of these injuries. trauma opposing vector forces resulting in distal avulsion of internal oblique muscle: a case report p. spada 1 , p. fransvea 1 , g. altieri 1 , m. di grezia 1 , v. cozza 1 , g. pepe 1 , a. la greca 1 , g. sganga 1 1 fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy case history: abdominal muscle injuries after blunt trauma are rare but increasingly recognized. here we report a case of blunt trauma resulting in a complete disinsertion of the distal part of the internal oblique muscle. case report: 46 y.o. male, was involved in a roll over motor vehicle accident. primary survey was carried out according to atlsò approach with good response. he had a seatbelt sign. according to the dynamic of the trauma he underwent a ct. diagnosis: a ce-mdct revealed complete disinsertion of the oblique muscles of the left abdomen from their iliac insertion, with herniation of adipose tissue and hematoma of the soft tissues without active blushing. no other traumatic injuries were identified. therapy progressions: a conservative treatment of the hematoma of the left abdominal wall was adopted. the patients was then ischarged from hospital after 4 days. no late complications were observed. comments: the overall incidence in all traumatic admission is 0.2-0.9%. a deep knowledge of vector force involved in trauma and their influence in the specific anatomical changes of the abdominal wall muscle can lead to suspicious of this rare injuries even if no other lesion are detected. in our opinion this trauma case is useful in reminding us to look for it because the radiologist or a no well experienced trauma surgeon may miss it 1 fondazione policlinico universitario agostino gemelli irccs, catholic university of rome, division of emergency surgery, roma, italy introduction: the best and correct management of patients with open abdomen (oa) is nowadays still unclear. our algorithm consists of using an intra abdominal negative pressure wound therapy device plus an early medial mesh mediated fascia traction (''step by step'' procedure). the aim of this study was to asses outcomes of this algorithm technique based on patient conditions and open abdomen technique performed. materials and methods: we performed a retrospective analysis of 50 patients treated with open abdomen technique from 01/06/2016 to the 01/06/2019. variables taken into account were: initial diagnosis, open abdomen technique used, number of surgical interventions, abdominal wall closure technique, length of stay in the icu, inhospital morbidity and mortality rates. we collected also data on the post-operative development of incisional hernias and entero-atmospheric fistula. results: 4/50 of open abdomen were done after trauma. in the remaining cases open abdomen was done for non-traumatic disease. 36 patients have been treated following our algorithm (with negative pressure wound therapy abthera device and step by step approach with medial mesh mediated fascia traction). in this group fascial retraction was significant lower and definitive direct abdominal wall closure rate was statistically higher. conclusion: an early fascia traction mediated with a mesh lead to an earlier fascia closure with a lower need of mesh positioning for definitive closure; the rate of post incisional hernia is similar among the two groups references: case history: a 59 year old male presented in the er with malaise, fatigue and loss of appetite. he was recently hospitalised due to a peritonsillar abscess and during investigations he was first-diagnosed with non-hodgkin lymphoma. his medical and surgical history were otherwise unremarkable. clinical findings: on admission the patient was febrile and tachycardic (hr 120 bpm) but remained hemodynamically stable (bp:157/ 99 mmhg). clinical examination revealed abdominal distention and rebound tenderness in the right abdomen. investigation/results: blood tests were significant for leukocytosis (wbc: 48.300/ll-neut:75%), acute kidney injury (urea: 240 mg/dl, cr: 3.0 mg/dl), elevated crp (313 mg/l) and ldh (520 iu/l), hyponatremia (na:126 mmol/l) and hypoalbuminemia. chest and abdominal x-rays were non-diagnostic, while abdominal ultrasound showed increased air presence along the medial line. investigations concluded with an abdominal ct scan that revealed pneumoperitoneum, small bowel distention and multiple enlarged mesenteric lymph nodes. diagnosis: the patient was transferred to the or for an explorative laparotomy. he was diagnosed with ileo-cecal intussusception causing bowel ischemia and perforation at the ileocecal valve. enlarged lymph nodes were observed along the mesentery. therapy and progressions: the affected ileus and colon were removed and a subtotal colectomy with end ileostomy was performed. the pathology report confirmed infiltration of the dissected bowel and lymph nodes by lymphoma cells. the patient continued treatment in the icu. he was discharged on the 14th postoperative day. comments: intussusception is rare in adults and, contrary to children, is highly associated with malignancies. resection without reduction has been advocated-wherever possible-in order to ensure better oncological outcomes. introduction: emergency surgeries are oftenly related to contaminated/infected fields, where the implantation of non reabsorbable meshes for reconstruction of the abdominal wall may not be recomendable. we aim to evaluate the results of polyvinylidenfluoride (pvdf) meshes used for complicated ventral hernia in the acute setting material and methods: retrospective analysis of patients with vh undergoing emergency surgery on which a pvdf mesh was required, in a third level hospital (november 2013-september 2019). we analyzed early and late postoperative complications and 1-year recurrence rates. association between grade of contamination, mesh placement and infectious complications and recurrences was investigated using binary and multiple regression. results: we collected 123 patients with a mean age of 62''3 years, mean bmi of 31''1 kg/m 2 and mean cedar index of 51''6. 96''4% of patients had a grade 2-3 ventral hernia according to rosen''s index. concomitant procedures included al least one organ resection in 48''7% of surgeries and previous contamined mesh explantation in 11''5%. a pvdf mesh was placed using an intraperitoneal onlay mesh (ipom) technique in 56''3% of cases and an interposition location in 39''9%. readmission rate was 15''7%, one-month recurrence 5''7% and recurrence after a year 19''1%. overall mortality rate was 27.6%. risk of recurrence was related with patients with a rosen score over 2 (p \ 0.001) and also with postoperative ssi (p = 0.045). higher recurrence rates were not found regarding the pdvf meshes placement. postoperative seroma and hematoma rates were 21''1% and 10''6%. enteroatmospheric fistula rate was 7''8%. conclusions: pvdf prosthesis seems to be an useful material for complicated ventral hernia repair, specially in the acute setting, showing similar recurrence and infectious complication (fistula, chronic mesh infection, surgical site infection) rates with regard to different prosthesis used in the literature. operative vs non-operative management in liver trauma patients in a uk major trauma centre conclusions: the airs can predict the histologic severity and the intra operative findings in patients with a high clinical suspicion of aa. airs could be useful to reduce negative appendectomy and predict the postoperative stay to evaluate the deformity progression in spine injuries (dorsal, dorsolumbar, lumbar) managed by internal fixation. introduction: there continues to be controversy surrounding the management of thoracolumbar burst fractures. numerous methods of fixation have been described for this injury, but to our knowledge, spinal fusion has always been part of the stabilising procedure, whether this involves an anterior or a posterior approach. material and methods: 64 patients with spinal injury (dorsal, dorsolumbar, lumbar) were included. all patients had dorsal, dorsolumbar, lumbar spine injuries managed with posterior short segment pedicle screw fixation and were followed up for at least one year after surgery. preoperative, post operative and follow up lateral radiographs were examined for cobb''s angle, anterior wedge compression angle and upper and lower adjacent intervertebral disc heights anteriorly, middle and posteriorly. results: at final follow up, the mean improvement in cobb''s angle post operatively was 10.8°. the mean loss of correction of cobb''s angle was 7.1°with sd of 5.7°compared to post operative. the mean improvement in anterior wedge compression angle was 7.1°post operatively. the mean loss of reduction in anterior wedge compression angle was 2.05°with sd of 2.3°. the increase in cobb''s angle was statically significant (r = 0.684, p = 0.001) with the loss of reduction of anterior wedge compression angle at follow up and loss in intervetebral disc height at upper intervetebral disc anteriorly only(r = 0.545, p = 0.013). the mean period at which sitting and standing was initiated was 1.5 months and 3.12 months respectively and mean periods for which brace was used was 8.6 months. conclusions: pedicle screw fixation is good but related to loss in reduction of anterior wedge compression angle and decrease in upper intervertebral disc height anteriorly. references: p. l. sanderson:short segment fixation of thoracolumbar burst fractures without fusion. introduction: with the newly implemented ao upper cervical spine classification system a modern, pragmatic system has been established. to what extent the simplification is helpful or whether an adjustment of the new ao classification may be discussed, forms the question of this work. material and methods: retrospective analysis of 60 upper cervical spine injuries with ct/mri diagnostics presented to 4 trauma surgeons with several years' experience to do classification and suggest treatment. results: the classification according to the known systems showed a relatively good agreement in the exact classification and therapy. the classification according to the new ao upper cervical spine was simple and consistent but revealed different treatment recommendations for two subtypes (iii type a and iii type b). conclusions: the new ao upper cervical spine classification system leads to a simplification. uncertainties remain with the most frequent fractures on the upper cervical spine, the c2 fractures. these will be managed under iii type a. however, just these injuries require completely different treatment concepts. further adaptation is required for type iii b because there uncertainties regarding the therapy also remain. case history: a 83-year-old woman, on treatment with acenocoumarol due to atrial fibrillation, and interatrial communication, suffered a compression fracture of the vertebrae l2 to l4 after a lowenergy trauma. due to poor pain control, she underwent a percutaneous transpedicular kyphoplasty, with no intraoperative complications. clinical findings: during the immediate postoperative period, she developed dysarthria and claudication of barré in her right upper limb. investigation/results: an angio-ct scan was performed, showing endovascular material in the left middle cerebral artery (mca) and within the lungs, compatible with cement emboli. mri showed cortico-subcortical ischemic areas in mca territory. cement-embolism stroke after percutaneous kyphoplasty therapy and progressions: conservative treatment was chosen due to the high number of emboli and the favorable evolution of the patient, with resolution of the neurologic symptoms in 48 h without sequelae. 15 days later, she suffered a transient ischemic attack, with no changes in the ct-scan compared to the previous images, which also solved with no residual deficits. one month after this episode, the patient died due to a spontaneous cerebellar hemorrhage related to acenocoumarol overdose. comments: kyphoplasty is a safe technique performed to treat vertebral compression fractures in elderly patients, with good clinical results and a low complication rate. its main complications are related to the leakage of cement from the vertebral body, usually well tolerated. other complications are exceptional, such as cerebral strokes, cardiac perforation, or death. the present case, although infrequent, shows us the need to assess the risk-benefit balance when operating fragile patients, as life-threatening complications may happen in these procedures. references: 1. marden fa, putman cm. cement-embolic stroke associated with vertebroplasty. ajnr am j neuroradiol. 2008 nov;29(10):1986-8. survival rate and application number of total hip arthroplasty in patients with femoral neck fracture: an analysis of clinical studies and national arthroplasty registers g. hauer 1 , a. heri 1 , s. klim 1 , p. puchwein 1 , a. leithner 1 , p. sadoghi 1 1 medical university of graz, department of orthopaedics and trauma, graz, austria introduction: total hip arthroplasty (tha) is an increasingly popular treatment option for fractured neck of femur (nof) [1, 2] . the aim of this study was to systematically review all literature on primary tha after fractured nof to calculate an overall revision rate. furthermore, we wanted to compare primary tha implantations after fractured nof between different countries in terms of tha number per inhabitant. material and methods: all clinical studies on tha for femoral neck fractures between 1999 and 2019 were reviewed and evaluated with a special interest on revision rate. revision rate was calculated as ''revision per 100 component years'' [3] . tha registers were compared between different countries with respect to the number of primary implantations per inhabitant. results: twenty-two studies showed a mean revision rate of 11.8% after ten years. we identified eight arthroplasty registers that revealed an annual average incidence of tha for fractured nof of 9.7 per 100,000 inhabitants (table 1) . conclusions: we found similar annual numbers of thas for fractured nof per inhabitant across countries. revision rates in clinical studies are higher compared to registry data [1, 2, 4] . the results of this analysis can be used to rank present and future national tha numbers within an international context. early clinical predictors of pneumonia in patients with acute spinal cord injury without bone injury: a retrospective study t. sakamoto 1 , s. kanezaki 1 , n. notani 1 1 oita university, oita, japan introduction: pneumonia is still significant complication that associates with mortality and duration of hospitalization in patient with acute spinal cord injury without bone injury (sciwobi). the purpose of this retrospective study is to clarify early clinical predictors of pneumonia in patients with sciwobi. material and methods: we reviewed the medical records of patients with sciwobi who admitted between january 2012 and november 2019. spearman's rank-correlation coefficient was used to test the relationship between each parameter. multiple logistic regression analysis was performed to determine the factors that influenced pneumonic morbidity. results: a total of 44 patients with acute sciwobi, who were evaluated for neurological impairment within 24 h after injury, were reviewed. pneumonia occurred in 11 patients (25%), seven patients injured at c4 and four at c5. according to spearman's rank method, asia motor score, beginning period of nutrition, ventilator use, neurological level of injury (nli) ] c5, low prognostic nutritional index (pni) were correlated with onset of pneumonia. logistic regression found ventilator use to be most predictive of pneumonia (odds ratio [or] = 12.7, 95% confidence interval [ci] 1.24-131), followed by nli ] c5 (or 2.3, 95% ci 0.36-14.4), beginning period of nutrition (or 2.1, 95% ci 0.95-4.8), pni (or 1.3, 95% ci 0.94-2.5). conclusions: in addition nli, low pni increases the risk of pneumonia. we consider that improving nutritional status, especially early initiation of enteral nutrition, decrease the incidence of pneumonia. bicycle-related cervical spine fractures e. helseth 1 , j. ramm-pettersen 1 , s. f. eng 1 , i. naess 1 , m. mejlaender-evjensvold 1 , h. linnerud 1 1 oslo university hospital, neurosurgery, oslo, norway introduction: the incidence of traumatic cervical spine fractures (cs-fx) in the norwegian population is 15/100,000/year, and 12% of these injuries are bicycle-related (1, 2) . materials and methods: prospective cohort study of all bicyclerelated cs-fx in the south-east norwegian population (3.0 million) in the time period 2015-2018. the data were retrieved from our quality control database for traumatic cs-fx in south-east norway. in the database all cs-fx patients (c0 (occipital condyle) to c7/th1) are prospectively registered. results: during the four-year study period 209 patients with bicyclerelated cs-fx were registered, 175 (84%) were males, and mean age was 52 years (range 16-87). the cs-fx was located in the upper cervical segment (c0-c2) in 68 (33%) patients, lower cervical segment (c3-th1) in 117 (56%), and at both segments in 24 (11%). the most common fx subtype was c0-fx. spinal cord injury secondary to cs-fx was registered in 26 patients (12%). fracture stabilization was achieved with open surgery in 41 (20%), external immobilization with a stiff collar alone in 147 (70%,) and without treatment in 21 (10%). conclusions: severe bicycle-related cervical spine injuries are not uncommon. the increasing political desire to move commuting from motorized vehicles to bicycles warrants a heightened focus on road safety. introduction: the need for cervical immobilization is predicted by the atls, the standard of care in trauma since 1980, because cervical trauma is a important cause of disability. however, its discontinuation was linked to x-rays, a fact that has been changed thanks to the development of two algorithms that assess the severity of cervical trauma: the canadian c-spine rule (ccr) and the national emergency x-radigraphy utilization study (nexus). material and methods: this study aims to compare the reduction values in the number of ct scans required after the application of both algorithms in a level-1 trauma center and to verify the degree of adherence of residents in the use of each. cohort study with randomized application by residents of the algorithms in all patients suffering from blunt trauma with cervical collars who were admitted from august to october 2019. the conducts had their frequencies analyzed to obtain an inference about the efficacy of each method in the abstention of x-rays and case resolution, in addition to verifying if the indicated conduct was followed by the resident, inferring on the confidence in the algorithm. results: 158 cases were evaluated during this period, of which 76 were by the ccr algorithm and 82 by the nexus. the indication rate for ccr imaging was 39.4% and nexus was 42.6%, showing no statistical difference between them (p = 0,682; ci = 95%). in the evaluation of the effective conduct, which evaluated the reliability of the algorithm, there was no disagreement between them (p [ 0,05; ci = 95%). conclusions: neither method demonstrated superiority to the other in reducing the indication of imaging exams and its uses had equal adherence by resident physicians. panacek case history: a 65 year old lady presented with severe neck pain following a fall and cervical hyper-extension injury. she had previously undergone anterior cervical discectomy and fusion at c6/7 with placement of artificial interbody bone graft. postoperatively, the patient reported an excellent clinical outcome and later imaging confirmed interbody fusion. clinical findings: on examination, the patient was neurologically intact but reported severe mid-cervical neck pain with reduced range of movement. investigation/results: imaging included ct and mri of the whole spine diagnosis: imaging revealed an unstable hyper-extension injury of the cervical spine. a fracture extended through the caudal end of the fused graft-vertebral interface at c6/7 with disruption of the posterior elements. therapy and progressions: given the severity of the injury surgery was recommended. the patient underwent uneventful c6-t1 posterior instrumentation and fusion with excellent outcome (follow up two years). comments: this is the first report of a cervical spine fracture through the site of an anterior cervical discectomy and fusion. it is hypothesised that the fused cervical segment resulted in increased stress at the fused caudal graft-vertebral interface during hyper-extension, this combined with reduced tensile strength at the graft-vertebral interface resulted in this unusual transverse fracture pattern. the clinician should be aware that patients presenting with cervical spine trauma in the context of previous cervical spine surgery are prone to greater mechanical forces. there should be a high index of suspicion for serious injury prompting thorough assessment and investigation. pr 445 s1-screw-fixation: computer aided study prevent unguided missile r. krassnig 1 , w. pichler 2 , e. viertler 3 , a. schwarz 4 , r. wildburger 1 , g. hohenberger 5 1 auva rehabilitation clinic tobelbad, tobelbad, austria, 2 boldin und pichler og, graz, austria, 3 medical university graz, graz, austria, 4 auva unfallkrankenhaus, graz, austria, 5 medical university graz, orthopaedics and trauma, graz, austria introduction: transiliosacral screw fixation of unstable dorsal pelvic ring fractures is not much present neither in literature nor in practice. in cause of the complex anatomy and the varying narrow safe bony corridors its a demanding procedure. limited information is available on optimal placement and the geometry of safe zones for screw insertion in the pelvis. material and methods: 3d-reconstructions of 50 consecutive ct scans of polytraumatic injured patients (15 female, 35 male) were the basis to insert two virtual cad bolts (representing screws) into the first two sacral segments as performing during screw fixation. results: in s1 the narrowest point was reached after a mean of 62.75 mm respectively 63.31 mm, depending on the selected way of measurement. for s2 the mean distance to the tricky constriction area amounted to 50.61 mm, respectively 51.54 mm. the average height in s1 measured 25.88 mm and the average width 25.49 mm. according, the average height for s2 was 17.54 mm and the average width 17.61 mm. the measurement results didn't show a significant difference between male and female pelvis bones for any distance of interest. conclusions: an optimal screw position is very important, because in the areas of bony narrowing are the exit points of the sacral nerves, which exit through the foramina anteriorly and posteriorly. damage to this nerve structures can cause severe long-term consequences such as numbness or paralysis. knowledge of predefined distances may aid in preoperative planning, decrease operative and radiation times and may prevent unguided missiles. clinical findings: there were absent breath sounds on the right side of the thorax, ultrasound showed an extensive pleural effusion. a chest tube was inserted and 2l of bloody-milky fluid was drained. investigation/results: ct scan showed fractured c1-c2 and th1-th3 vertebral bodies, fractured lateral osteophytes of th11-12 and probable injury of the thoracic duct at th11-12 level. pleural effusion analysis showed raised cholesterol and triglyceride levels. diagnosis: traumatic chylothorax; fractures th11-th12, th1-th3, c1-c2 therapy and progressions: patient was kept on ventilatory support for 3 days. primarily she was treated with total parenteral nutrition followed by no fat and hypolipidemic diet. the chest tube was removed after 8 days. she was discharged in stable condition the following day. at the 1 month check-up she was stable and eupnoic. comments: traumatic chylothorax caused by blunt chest trauma is extremely rare. there are hypotheses that injuries to the thoracic duct are caused by hyperextension of the spine or by increased thoracic/ abdominal pressure (seat-belt injuries). in our case, chylothorax probably resulted from fractured lateral osteophytes. patients are usually successfully treated with pleural drainage and total parenteral nutrition. if there is no improvement after 2 weeks or if drainage exceeds 1.5l/day or 1l/day for more than 5 days, thoracic duct ligation should be considered. conservative treatment resulting in t-l or lumbar kyphosis can worsen the quality of life of the patient whereas traditional open surgery may be an overtreatment in some cases, considering blood loss, possible complications, hospital stay and delayed functional recovery. in this setting, a good option can be a percutaneous minimally invasive surgery. the advantages of percutaneous pedicle screw fixation are: preservation of posterior musculature, less blood loss, shorter operative time, lower infection risk, less postoperative pain, shorter hospital stay and easier implant removal after bone union. limitations such as inability to achieve direct spinal canal decompression can be dealed by combination with open techniques. the objective of this study was to report the results of ppsf on these fractures and the technical problems we had to overcome. methods: 32 patients are included, treated with percutaneous transpedicular fixation and stabilization with minimally invasive technique from december 2015 to october 2019. 24 patients were males, 8 females; average age was 46,5 years (range from 18 to 82). in all cases, system pathfinder-nxt (zimmer) was used. results: most of the patients presented an early post-operative mobilization with amelioration concerning pain and a low complication rate. limitations in mobilization were mainly due to coexistent injuries, polytrauma or non-reversible neurological deficit. conclusion: ppsf is a reliable and safe procedure which does not replace the open technique but adds to treatment options by restoring a good sagittal alignment similar to those reported for open surgery. removal of hard material is advocated after fracture healing to preserve the lumbar spinal mobility and avoid zygapophyseal joint osteoarthritis. critical surgery within the first hour of presentation: is it a feasible intervention for better trauma care outcomes in low and middle income countries? introduction: in low and middle-income countries (lmic) golden hour care concept is almost nonexistence due to resource constraints. in this study, we analyzed one novel concept of critical surgery within the first hour of admission as a possible intervention which could be applied in the existing scenario in these countries without much resource requirement. material and methods: a retrospective analysis of a prospectively maintained data registry under a project named titco (towards improved trauma care outcome) was done. registry data from a level -1 trauma centre in india were analyzed from october 2013 to september 2015. all patients who admitted and underwent critical surgical interventions within the first hour of presentation were analyzed. these patients were divided into two groups depending upon primary presentation or referred from another facility. statistical analysis was done between these two groups to compare the outcome. results: sixty-one (57.6%) patients were directly admitted from the site of the incident whereas forty-five (42.4%) were transferred from other hospitals for surgical needs. the median time from injury to presentation for primary patients was 50 min with interquartile range (iqr) of 40. in the referred patient median time gap between the injury to our center (not referring center) was 230 min with iqr of 350. this difference was statistically significant. major outcome indicators in the form of median icu and total stay, as well as mortality, were not significantly different conclusions: proposed concept might be a useful hospital-based intervention in existing trauma system in lmic to improve the outcome of injured patients along with improving prehospital services. oslo university hospital, ullevål, orthopedic department, oslo, norway, 2 extrastiftelsen, oslo, norway introduction: it is well-known that physical activity is good for us. although the skeletal muscle is the main organ which is directly affected, exercise affects the whole body. the mechanisms responsible for these beneficial effects are gradually becoming known to us through extensive research. this might make it easier for physicians to prescribe exercise as a therapy equally and even more beneficial than drugs regarding effect and risk profile. the aim of this thesis was to review the current literature on the molecular mechanisms of exercise-induced health benefits. material and methods: a search in medline and embase resulted in 468 articles. they were sorted by title and abstract, then by reading the full text. relevant articles from the reference-lists were included. 18 sources were found outside of the search. results: when we exercise, the skeletal muscle is subjected to several mechanical and chemical stimuli, which in turn activate a set of kinases and phosphatases. these are molecules that regulate transcription-factors and co-activators, and this leads to adaption of the muscle-cells. i addition, the muscle secretes a number of proteins called myokines, which conduct the effect of exercise to other organs and tissues. some lead to increased cerebral neuroplasticity, hypertrophy and angiogenesis (bdnf, vegf and igf-1). several interleukins have also been identified as myokines, and they mediate an anti-inflammatory effect which is favorable in the prevention and management of conditions like atherosclerosis and type 2 diabetes. lastly, we found that exercise leads to epigenetic changes, altering the genetic expression in several types of tissues. some studies suggest that the epigenome is affected by exercise even before we are born, giving babies born to physically active mothers a favorable epigenetic expression. conclusions: we should use this knowledge to support the implementation of physical activity in treatment and preventive health care. impact on undertriage and mortality after changing from a twotiered to one-tiered trauma team activation protocol costs. prognostic factors may assist in identifying high cost groups with potentially modifiable factors for targeted preventive interventions, hence reducing costs and increase rtw rates. evaluation of long-term follow-up and consequences of gunshot and stab wounds in a french civilian population introduction: the data concerning long-temr follow-up of patients and consequences of gunshot wound (gsw) and stab wound (sw) are almost inexistent in the literature. in finland, a 2014 study showed that 12% of patients with trunk wounds died secondarily from alcohol-related or violent problems [1] , highlighting the secondary importance of long-term care for these patients. the main objective of our study was to analyze the hospital and posthospital follow-up of patients with gsw or sw and to evaluate late complications and the consequences of these traumas. material and methods: from january 2007 to january 2017, 165 patients were hospitalized for gsw or sw management in laveran military hospital. hospital data were collected via informatic patient file and post-hospital data via a telephone questionnaire with the general physician (gp). results: median hospital follow-up was 28 days . seventy-six patients had a follow-up visit with their gp (46%). median follow-up was 47 mois . twenty-four patients were totally lost to follow-up (14.5%). global follow-up identified 54 patients with longterm consequences (32.7%), 20 psychiatrics and 30 organics. seventeen cases of recurrence were found (10.3%). high iss, age, gsw and gp identified in patient medical file were significantly linked to long-term consequences occurrence. conclusion: this study showed a high number of long-term consequences occurrence among patients with gsw or sw. however, the extra-hospital follow-up seems insufficient. it is therefore imperative to strengthen the compliance and adherence to the care network of these patients. awareness and involvement of medical, paramedical teams and gp role seems essential to screening and management of these consequences. introduction: focused assessment with sonography for trauma(-fast) is an effective tool for assessments of severely injured patients, especially in the settings of helicopter emergency medical service(hems) because of limited devices and time. the objective of this study is to investigate accuracy of trauma ultrasound in helicopter emergency service compared with enhanced ct scan. material and methods: we investigated the trauma patients in 3 years which was demonstrated fast and delivered to the advanced critical care center in gifu university by hems. accuracy of the fast was determined by comparison to the presence of injury, primarily determined by computed tomography, and to required interventions. results: 108 patients were included in this criteria. there were 57 and 13 patients in which we found fluids in thoracic or abdominal cavity by enhanced ct scans and ultrasounds in hems, respectively. sensitivity and specificity, positive predictive value, negative predictive value, accuracy were 0.24, 0.963, 0.866, 0.559, 0.60. if we limited the data for abdominal fluids, each data were 0.409, 0.988, 0.9, 0.86, 0.87. in the patients of negative fast with positive ct, no patient died due to hemorrhage in thoracic or abdominal cavity. conclusions: it has been reported that sensitivity of fast in hems was lower compared with in er. in the settings of prehospital trauma care, advantages of portable ultrasound could be limited because of peculiar environments. and also, the thoracic or abdominal fluids could increase with time by organ injuries and it causes fast negative in acute phases.in this series, we could not find cases which has possibility of death because of negative fast and might influence the treatment. repeated fast or careful assessment of patients based on the other findings could be beneficial. references: the sensitivity of fast in hems was low and demonstrating fast for several times could be effective to detect the thoracic or abdominal hemorrhage. pre-hospital trauma care in switzerland and germany: do they speak the same language? 1 los angeles county ? usc medical center, department of surgery, divison of acute care surgery and surgical critical care, los angeles, united states introduction: field amputation can be life-saving for entrapped patients requiring surgical extrication. under these austere conditions, the procedure must be performed as rapidly as possible with limited equipment, often in a confined space, while minimizing provider risk. the aim of this study was to determine the optimal saw for a field amputation. material and methods: this was a prospective cadaver-based study. four saws (gigli, hand pruning, electric oscillating and reciprocating) were tested in human cadavers. each saw was used to transect four separate long bones (humerus, ulna/radius, femur and tibia/fibula). the time required for each saw to cut through the bone, the number of attempts, slippage, quality of proximal bone cut and extent of body fluid splatter as well as the physical space required by each device during the amputation were recorded. univariate analysis (fisher's exact and kruskal-wallis or mann-whitney u-test) was used to compare the outcomes between the different saws. results: the fastest saw was the reciprocating followed by oscillating (2.1 [1.4-3.7 ] sec vs 3.0 [1.6-4.9 ] sec, p = 0.007). the number of attempts required to amputate (5.8 [3.0-8.3] , p = 0.02) and the amount of slippage (3.0 [1.5-3.8 ], p = 0.03) were highest with the pruning saw. the reciprocating saw had the worst proximal bone cut quality (75% poor, p = 0.04) and the largest blood splatter (47.5 [41-63] , p = 0.044). the physical space required to perform an amputation ranged from 3500 cm 3 with the oscillating to 12000 cm 3 with the reciprocating saw. overall, the oscillating saw outperformed the others in number of attempts, slippage and quality of bone cut and physical space requirements, and was the second fastest ( table 1) . conclusions: the speed, precision, safety, space required, as well as the highly adjustable blade in the oscillating saw make it ideal for a field amputation. a gigli saw is an excellent backup for when electrical tools cannot be used or fail. impact of air medical transport on the survival of major trauma patients in thailand e. surakarn 1 , w. siriwanitchaphan 1 1 bangkok hospital headquarters, bangkok trauma center, bangkok, thailand introduction: air medical transport is an alternative mode of interfacility transfer for injured patients who required a higher level of trauma care in thailand. this study assessed the impact of air medical transport on the survival of major trauma patients transferred from local hospitals to a tertiary care hospital. material and methods: trauma registry of 2014-2018 was reviewed. major trauma patients transferred by air ambulance were identified. injury severity score (iss), predicted mortality and actual survival to hospital discharge were studied and compared between two subgroups, the seriously injured patients (iss 15-24) and the severely injured patients (iss [ 24) . the predicted mortality was calculated from the probability of survival (ps) of trauma and injury severity score (triss). results: there were 99 major trauma patients (iss [ 15) transferred by air ambulance in five years period. 62 patients were severely injured (median iss = 33), and 37 patients were seriously injured (median iss = 17). the range of flight time was 20-200 min. the overall survival rate was 88.88%. the predicted mortality in the severely injured group was 21 cases (33.87%), but the actual mortality was nine (14.51%), 19.36% lower than predicted mortality. the predicted mortality in the seriously injured group was one case (2.7%), while the actual number was two (5.4%). the eleven deaths in this study were eight cases of severe traumatic brain injury(tbi) patients, two cases of massive bleeding with subsequent multi-organ failure and one drowning. conclusions: air medical transport significantly improved the survival of severely injured patients who need higher level of trauma care. severe tbi and the presence of multi-organ failure associated with unfavorable outcomes. however, a detailed analysis of the trends and epidemiology of rtis affecting the most vulnerable children in qatar, under 5 years of age, has not been conducted. this study's primary objective of is to describe the epidemiology of rtis and deaths in young pediatric patients in qatar. material and methods: data, for all young pediatric [under 5 years] victims of rti''s and rti deaths from january 1, 2008 , through december 31, 2017 , from the trauma registry of the hamad trauma center [htc], the national level 1 trauma referral center of qatar, was analyzed. this data was correlated and compared with data from the hamad general hospital mortuary and vital statistics data from the qatar ministry of development planning and statistics, the vital statistics annual bulletin, for the years 2008-2017. results: the htc attended to 271 patients, under 5 years, with severe rtis and 15 in-hospital rti deaths were reported during the study period. males made up 83.7% of the injured and 60% of fatalities.the average age of the injured was 3 years and for fatalities was it was 2.8 years. the rti incidence rate per 100,000 for both sexes, under 5 years, has been unchanged (246 in 2007 and 225 in 2017) . the road mortality rate, per 100,000, has decreased significantly, from 46.3 in 2008 to 7.2 in 2017. since 2014, the proportion of pre-hospital deaths has been increasing, 25-100%, and the in-hospital death rates has been reduced to 0%. conclusions: rapid improvements in pre and in-hospital post-crash care in qatar have resulted in marked reductions in in-hospital deaths for young children with rtis. the emergence of pre-hospital road deaths of under 5''s must be made a priority for road safety in qatar. the implementation of proven prevention programsshould be fast tracked in order to directly address this issue. introduction: despite improving survival of patients in prehospital traumatic cardiac arrest (tca), initiation and/or discontinuation of resuscitation of tca patients remains a subject of debate among prehospital emergency medical service providers. the aim of this study was to identify factors that influence decision making by prehospital emergency medical service providers during resuscitation of patients with tca. methods: twenty-five semi-structured interviews were conducted with experienced ambulance nurses, hems nurses and hems physicians individually, followed by a focus group discussion. participants had to be currently active in prehospital medicine in the netherlands. interviews were encoded for analysis using atlas.ti. using qualitative analysis, different themes around decision making in tca were identified. results: the causes of bleeding were grouped into several categories.the most frequent cause with 7 cases in a row is attributed to diverticular bleeding,other causes of bleeding were angiodysplasia,post polypectomy bleeding,gist tumor,rectal ulcers and inflammatory disease.no case presented mortal or serious complications,secondary to the procedure. only 2 cases presented a mild complication: focal mucosal ischemia of the embolized intestinal segment that was resolved with conservative treatment.lesions in charge of bleeding in those 5 cases in which the angiographic treatment failed,were:ulcer in 2 cases,a case of bleeding after endoscopic polypectomy, a case of diverticular bleeding and bleeding secondary to a coagulation disorder.among these patients, the definitive treatment was the following: -a second angiographic treatment was effective in the case of bleeding due to coagulation disorder. -a case of self-limited bleeding. -surgical treatment was the definitive treatment in both cases of bleeding in the context of and patient with bleeding after polypectomy. we have not observed a significant relationship neither the type of lesion or its location with the probability of failure of the angiographic treatment. nor do we observe a significant relationship between the type of material used for embolization and the risk of treatment failure. comments: our data show that angioembolization is an effective and safe technique to treatment lgi bleeding. references: clin endosc 2019. endoscopic therapy for acute diverticular bleeding introduction: the use of resuscitative endovascular balloon occlusion of the aorta (reboa) as adjunct for temporary hemorrhage control in patients with major torso hemorrhage is increasing. specifications and characteristics of available aortic occlusion balloons (aob) are diverse. in order to minimize the risk of failure and complications it is important to choose a device that fits the requirements per medical situation. the aim of this study is to provide guidance in the choice of an aob in a specific situation. material and methods: 29 aob were assessed for characteristics and different properties of each are outlined. the bending stiffness was measured with a three-point bending device. results: although all aob tested are small caliber devices ranging from 6 (er-reboa tm ) to 10 french (codaò 46), some need large bore access sheaths up to 22 french (fogarty ò 45 and lemaitre tm 45) or even insertion via surgical cut-down (equalizer tm 40). the bending stiffness of the aob varied from 0.08 n/mm (± 0.008 sd) with the codaò 32 to 0.72 n/mm (± 0.024 sd) with the russian prototype. guidewire-free devices are generally stiffer than over-thewire catheters. the tokai rescue balloon tm showed kinking of the shaft at low bending pressures. the er-reboa tm , fogarty ò , lemaitre tm , reboa balloon ò , and rescue balloon tm are the only catheters with external length marks to assist blind positioning. the only aob using a non-compliant balloon is the reboa balloon ò . conclusions: specifications of available aob are diverse. in resource-limited settings, reboa should be performed with a rather stiff device that can be placed without wire and fluoroscopy, such as the er-reboa tm , fogarty ò , and lemaitre tm . of these aob, the er-reboa tm is the only catheter compatible with a small 7 french sheath. use of non-compliant balloons without real-time fluoroscopy is not advised given the potential risk of aortic rupture. when fluoroscopy is available, a guidewire can be considered. case history: 89 year old male patient presenting with an initially uncomplicated pertrochanteric fracture, treated by an intramedullary nailing system (figs. 1 and 2) . days after the operation and mobilization without any adverse events the patient was readmitted. clinical findings: massive swelling, hematoma and pain. investigation/results: sudden fall of hb values down to 4,4 g/dl, ct scans showed the lesser trochanter located directly to the deeper femoral artery after mobilization (fig. 3) . diagnosis: perforation of the deep femoral artery and several veins by the dislocated lesser trochanter therapy and progressions: blood transfusion, intraoperative cardiopulmonary resuscitation, several revision surgeries to stop the bleeding by oversewing the deep femoral artery and ligation of the veins, removal of the lesser trochanter fragment (fig. 4) . admission to intensive care unit. subsequent plastic coverage. comments: according to literature, bleeding complications and injuries of the deep femoral artery can occur even several days after an initially uncomplicated pertrochanteric hip fracture. besides acute life-threatening bleeding, false aneurysm can occur (1) (2) (3) . even if those late complications are very rare, the consequence for the patient can be devastating. these rare cases show the clear obligation to a thorough follow up treatment and regularly dressing changes. investigation/results: arterial colour doppler of the popliteal artery showed hypoechoeic contents and narrowed lumen. biphasic flow was seen in both popliteal and posterior tibial arteries. diagnosis: popliteal artery injury with delayed repair therapy and progressions: two incision and four compartment fasciotomy was done under regional block the next day which revealed a non contractile posterior compartment. superficial and deep muscles of the posterior compartment had doubtful viability. left distal sfa to infragenicular popliteal artery bypass graft was placed on day 4 post injury. blood flow was established upto the ankle and foot, confirmed on check angio. however, foot drop of the patient persisted. after appearance of a healthy granulation tissue at the wound site (7 days), a split thickness skin graft was placed to give coverage with 100% uptake of the graft. comments: blunt popliteal artery injury has been reported to result in amputation rates of nearly 30-60%.the importance of a detailed vascular examination of a blunt trauma patient is emphasized as a limb can be salvaged if timely intervention is done. in this case even with an unfavourable mess score. case history: a healthy 27-year-old male, with no history of interest, suffers a high-energy trauma as a water bottle rushes over his left knee. clinical findings: go to the emergency room with pain and functional impotence in the left knee, with its anatomical deformity. knee x-ray pa and l are performed and the distal pulses that are present are taken. ankle-brachial index [ 0.9. closed reduction is performed in emergencies under sedation and control x-ray is requested, aiming at correct reduction. it was decided to keep under observation for 24-48 h before discharge from hospital to schedule regulated ligament reconstruction surgery after studying with mri. therapy and progressions: at 12 h of evolution after the accident and after having reduced the dislocation, the patient who has the leg with a temperature equal to the contralateral is reassessed, however, there is no palpable dorsal pedis pulse or posterior tibial palpation in the affected leg. it is decided to urgently request an angiotc and it is objective thrombosis of popliteal artery. vascular surgeon is contacted and emergency surgery is decided. a by-pass is performed with vena safena. diagnosis: traumatic knee dislocation and popliteal artery injury comments: in the 21st century, complementary tests in diagnosis are becoming increasingly important. however, in this case we want to management of aseptic tibial nonunion anastasios g. c. reamed interlocking intramedullary nailing for the treatment of tibial diaphyseal fractures and aseptic nonunions. can we expect an optimum result? results of a systematic approach to exchange nailing for the treatment of aseptic tibial nonunion management of tibial non-union using reamed interlocking intramedullary nailing the radiographic union scale in tibial (rust) fractures: reliability of the outcome measure at an independent centre pelvic trauma: wses classification and guidelines damage control orthopaedics in unstable pelvic ring injuries references: beuran, m. trauma scores: a review of the literature glasgow coma scale, age, and arterial pressure (mgap): a new simple prehospital triage score to predict mortality in trauma patients. critical care medicine. champion hr. a revision of the trauma score proximal femoral nail antirotation versus gamma3 nail for intramedullary nailing of unstable trochanteric fractures. a randomised comparative study results of the femur fractures treated with the new selfdynamisable internal fixator (sif) dhs helical blade for elderly patients with osteoporotic femoral intertrochanteric fractures the hypermetabolic response to burn injury and interventions to modify this response racial differences in propranolol enantiomer kinetics following simultaneous i.v. and oral administration propranolol dosing practices in adult burn patients the hypermetabolic response to burn injury and modulation of this response: an overview. wound heal south africa management strategies and outcome of blunt traumatic abdominal wall defects: a single centre experience blunt traumatic abdominal wall hernias: a surgeon's dilemma blunt traumatic abdominal wall hernias: associated injuries and optimal timing and method of repair traumatic abdominal wall herniation: case series review and discussion trauma patients with open abdomen: do they differ from others? a single center experience h. fagertun 1 , a. seternes department of circulation and medical imaging, trondheim, norway introduction: treatment with open abdomen is demanding for patients, staff and hospital. a multidisciplinary approach is mandatory. the aim of this study was to compare trauma patients with open abdomen (oa) and patients treated with oa for other reasons, regarding outcome and resources spent. material and methods: retrospective study of patients treated with oa in a tertiary hospital in norway. ten were trauma patients vacuum-assisted wound closure and mesh-mediated fascial traction for open abdomen therapy-a systematic review prospective study examining clinical outcomes associated with a negative pressure wound therapy system and barker's vacuum packing technique thoracic-abdominal trauma with diaphragm lesions n. vlad 1 , i. streanga 1 , a. morar 1 , i st. spiridon'' hospital iasi. we have analyzed clinical data, trauma mechanism, pathology of the lesion, time trauma-diagnostic, associated lesions, treatment, and follow-up. results: there have been 18 patients (12 men, 6 women), mean age 42. location of diaphragmatic tears has been on the left hemidiaphragm (12 cases), on the right hemidiaphragm (3 cases), or bilateral (3 cases). the trauma mechanism has been blunt (10 cases) or penetrant (8 cases). all patients had associated visceral lesions and had been operated right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literaturereview traumatic diaphrag-matic ruptures: clinical presentation, diagnosis and surgicalapproach in adults traumatic rupture of the diaphragm: experiencewith 65 patients 9% (82/393) were aast grade 4 or 5. in the total group, median age was 32 years, 66.1% were male and 79.6% were blunt injuries. median iss in the nom group was 22 and 25 in the om group. median iss for those with grade 4 or 5 injury was 26. 64.6% (254/393) underwent nom, compared to 59.8% (49/82) of those with aast grade 4 or 5. for each 1 mmhg increase in systolic blood pressure, patients with grade 4 or 5 injury were 3% less likely to have an operation (or 0.97, p = 0.003) and for each 1 beat increase in heart rate intra-operative grade i was revealed in 57 patients (49,8%), grade ii in 24 (20,8%), grade iii in 8 (6,7%) grade iv in 21 (18,2%) and grade v in 5 (4,5%). histologic finding of catarral appendicitis was found in 32 (27,8%) patients, 39 (34%) had phlegmonous appendicitis and 44 (38,2%) had gangrenous appendicitis. the airs difference was statistically significant with histological findings quality of publications regarding the outcome of revision rate after arthroplasty swedish hip arthroplasty register annual report joon yung lee: risk factors for failure of nonoperative treatment for unilateral cervical facet fractures in 2018, 501patients were included in the trauma registry. median iss was 9 and 103 patients had an iss [ 15. of these patients 31/103 (30%) were undertriaged with a mortality of 5/31(16%). the total mortality in 2018 was 4,8% (24/501). i 2017, median age was 62 years for the patients with no tta vs 36 years for those patients who did receive a tta (p \ 0.001) prognostic factors for medical and productivity costs, and return to work after trauma: a prospective cohort study l results: a total of 3785 trauma patients (39% of total study population) responded to at least one follow-up questionnaire. mean medical costs per patient (€9,710) and mean productivity costs per patient (€9,000) varied widely. prognostic factors for high medical costs were higher age, female gender, spine injury, lower extremity injury, severe head injury, high injury severity, comorbidities, and pre-injury health status. productivity costs were highest in males, and in patients with spinal cord injury, high injury severity, longer length of stay at the hospital and patients admitted to the icu. prognostic factors for rtw were high educational level, male gender, low injury severity swiss and german (pre-)hospital systems, distribution and organisation of trauma centres differ from each other [1,2]. it is unclear if outcome in trauma patients differs as well. therefore, this study aims to determine differences in characteristics, therapy and outcome of trauma patients between both german-speaking countries. material and methods: the traumaregister dguò (tr-dgu) was between 01-2009 and 12-2017 were included if they required icu care or died. trauma pattern trauma care in germany trauma systems in europe practical assessment of different saw types for field amputation: a cadaver-based test study these themes were: factual information (e.g., electrocardiography rhythm)educational programs and future guidelines. references: rosemurgy as, prehospital traumatic cardiac arrest: the cost of futility blunt vertebral vascular injury in trauma patients: atlsò recommendations and review of current evidence treatment-relater outcomes fron blunt cerebrovascular injuries. importance of routine follow-up arteriography provided the catheters used for this study. no other support was provided diagnosis: the probe had perforated the ivc wall. therapy and progressions: open repair was performed through a xifopubic laparotomy and the cattel-braasch maneuver to expose the ivc (fig. 3). a retroperitoneal hematoma was observed anteriorly to the infrarenal ivc, without active bleeding. the ivc was dissected out sufficiently to permit proximal and distal vascular control (fig. 4), the probe was then removed and the laceration on the infrarenal ivc closed with a running suture. the postoperative course was uneventful. comments: to our knowledge this is the first reported case of symptomatic ivc laceration by an ice probe during ca. references: enriquez a. use of intracardiac echocardiography in interventional cardiology complications of catheter ablation for atrial fibrilla iatrogenic percutaneous vascular injuries: clinical, presentation, imaging, and management vascular complications during catheter ablation of cardiac arrhythmias: a comparison between vascular ultrasound guided access and conventional vascular access false aneurysm of the profunda artery resulting from intertrochanteric fracture. a case report profunda femoris arterial laceration secondary to intertrochanteric hip fracture fragments. a case report with major thoraco-abdominal vascular injuries (aorta, inferior vena cava and main branches). data on demographic, clinical status and imaging was recorded. descriptive and kaplan meir survival analysis was performed. results: 87 patients were included. median age was 33 years (iqr 45-25), 70 (80.5%) were male. aorta was the most frequently damaged vessel (40,2%) the median iss was 29 (iqr 38-25)interventional procedure. overall mortality was 46%, with 45% of deaths during the first hour, 37.5% in the first 24 h and 17.5% afterwards. median survival was 54 days (ic19-88). we compared survival curves in periods abdominal vascular trauma. trauma surg acute care open history: popliteal artery injuries are frequently seen with fractures, dislocations, or penetrating injuries. a thirty one year old pathologies. references: natsuhara, k.m. et al, what is the frequency of vascular injury after knee dislocation knee dislocation and vascular injury: 4-year experience at a uk major trauma centre and vascular hub can vascular injury be appropriately assessed with physical examination after knee dislocation? introduction: this retrospective cohort study investigated the prevalence of and risk factors for preoperative venous thromboembolism (vte) in patients with a hip fracture and a delay of [ 24 h from injury to surgery. material and methods: this observational study included 208 patients with a hip fracture surgically treated at 1 university hospital. patients underwent indirect multidetector computed tomographic (mdct) venography for preoperative vte detection after admission. overall vte risk and median time from injury to ct scan were calculated. age, sex, fracture type, time from injury to ct scan, body mass index, preinjury mobility score, previous anticoagulation treatment, previous hospitalization for vte, varicose veins, and medical comorbidities were considered potential risk factors. results: the prevalence of preoperative vte was 11.1% (23 of 208 patients). the mean time from injury to ct scan was 4.9 days. the delay from the time of injury to ct scan averaged 7.6 days for patients who developed preoperative vte, compared with 4.2 days for patients who had not developed vte. in the adjusted models, female sex, subtrochanteric fracture, pulmonary disease, cancer, previous hospitalization for vte, and varicose veins were risk factors for vte. the final multivariate logistic regression analysis introduction: vertebral compression fractures constitute a large percentage of traumatic injuries of spine. the initial management plays an important role in the final outcomes. the present study aims to study the profile of vertebral injuries in rural & semi urban population & to analyse the role of level two hospitals in initial management of vertebral injuries. material and methods: this study was a retrospective analysis of progressively collected data of patients presenting with vertebral injuries in a level two hospital catering to semi urban & rural population in india. the initial presentation along with the age & sex profile was noted. etiological factors leading to compression fractures were noted. any neurological deficit either at the time of admission or transfer to a tertiary care neurocentre was noted as per asia scale. initial management was carried out in accordance with the atls guidelines. results: a total of 44 out 3000 patients admitted with complaints of back pain were diagnosed to have compression fractures of the spine. the mean age was 49.4 years. male: female ratio was approx 5:1. the lumbo sacral spine region was the most comply affected region. two patients were incidentally detected to have vertebral fractures as a result of metastatic malignancy. a due note was made regarding patients who had deteriorated during the transfer in terms of neurological deficit & evidence of spinal shock. conclusions: road traffic accidents contribute a significant portion of vertebral trauma . smaller hospitals & general surgeons have an important role to play in terms of initial stabilisation of such patients particularly the ones presenting with neurogenic shock. a good initial management has sigificant bearing on outcomes. analysis of risk factors for tracheostomy in cervical spinal cord injury without bone injury n. notani 1 , s. kanezaki 1 , t. sakamoto 1 , h. tsumura 1 1 oita university, orthopaedic surgery, yuhu, oita, japan introduction: there are many cases that require tracheostomy in the acute phase of cervical spinal cord injury, and various risk factors have been reported so far. however, there has been no report on cervical spinal cord injury without bone injury. the aim of this study is to evaluate risk factors for tracheostomy in patients with cervical spinal cord injury without bone injury. material and methods: we conducted a retrospective observational study. patients who were treated for cervical spinal cord injury without bone injury in our hospital were divided into 2 groups: tracheostomy (tc) group and no tracheostomy (no tc) group. we compared variables, including age, sex, asia impairment scale (ais), neurological level of injury (nli), injury severity score (iss), vital signs, blood gas analysis, tracheal intubation, chest complication, smoking history between two groups. results: there were 8 patients in tc group, and 46 patients in no tc group. on univariate analysis, there were significant differences in age, ais a, tracheal intubation, nli ] c4. on multivariate analysis, nli ] c4 was an independent predictor of tracheostomy. conclusions: in this study, we demonstrated that nli ] tc4 could be useful to predict tracheostomy in patients with cervical spinal cord injury without bone injury. case history: many fractures of the articular processes of the cervical spine are associated with displacement and instability, approximately 5% of all traumatic cervical spine injuries involve isolated fracture of the articular processes non-displaced or minimally displaced. [1] this case demonstrates a isolated facet fracture of the cervical spine with c7 radiculapathy treated with minimally invasive spine surgery techniques clinical findings: a 47-year-old male was admitted to the neurosurgery department due to severe neck pain (vas 9/10). the pain radiating to the right upper extermity along dermatome c7. neck and trunk rotation worsened the pain. investigation/results: furthermore, physical examination revealed hyperaesthesia in the right index finger without muscle weakness. ailments suddenly appeared 4 weeks earlier after getting up in the morning. imaging demonstrated isolated, unilateral fracture of the right superior articular process of c7 diagnosis: imaging demonstrated isolated, unilateral fracture of the right superior articular process of c7 therapy and progressions: the patient was treated by microsurgical c7 decompression and fusion of c6-7 under navigation guidance. intraoperative ct scans were performed to evaluate sufficient bone removal.after the surgery, the neck and upper extremity pain subsided. the patient had returned to his usual job and sport activities. comments: this case illustrates the value of the navigation and intraoperative ct in the evaluation of bony decompression, anatomy and location of implants. navigation minimized iatrogenic injury resulting in reducing postoperative complications like chronic pain, kyphotic deformity and muscular atrophy.introduction: resuscitative endovascular balloon occlusion of aorta (reboa) is a technique initially developed in the military for trauma patients injured in combat 1 . recently, there has been much debate on its role in civilian trauma cases in controlling non-compressible torso haemorrhage (ncth) 2 . this review aims to provide an update on current literature on the outcomes and concerns of this procedure. material and methods: a systematic literature search according to prisma guidelines was performed over the period of january 2005 to august 2019 across embase, medline and cochrane databases. patient characteristics, mechanism and severity of injury, survival rates and post-reboa complications between survivors and non-survivors were compared. results: a total of 32 studies were included in this review. 8% and 92% of the 4042 reboa cases were penetrative and blunt cases respectively. the survival rates ranged from 6 to 100% across the studies. systolic blood pressure (sbp) was significantly elevated post-procedure, from 75.6 to 119.0 mmhg in the survivor group (p \ 0.001) and 61.4 to 96.8 mmhg in the non-survivor group (p = 0.001). the injury severity score (iss) was lower in the survivor group (31.9 vs 41.7; p \ 0.001) whereas their glasgow coma scale (gcs) was higher (12.3 vs 5.6; p = 0.008). the survivors also had a shorter duration of aortic occlusion (48.2 vs 93.3 min; p = 0.001). common complications noted following the procedure include renal injury, lower limb ischaemia and thrombosis. conclusions: pre-reboa sbp, iss, gcs and duration of aortic occlusion were found to be associated with survival. complications directly due to the procedure were difficult to ascertain. a prospective study in a multiple trauma centre is needed for further evaluation of the indications, feasibility and complications involved in reboa. references: introduction: traumatic vertebral artery injury (vai) is a wellknown complication of cervical spine injury and often causes posterior circulation stroke. we report preventive effect of acute phase endovascular intervention for traumatic vai. material and methods: all patients with cervical spine injury were surveyed with post-contrast computed tomography for vai. when vai was diagnosed, the affected vertebral artery (va) was occluded with endovascular intervention before spine reduction and fixation. brain ischemic lesion was evaluated before and after the treatment. results: forty-one patients with vai associated with cervical spine injury underwent endovascular intervention. the affected va was occluded with endovascular coils before cervical spine reduction and fixation in 38 patients, and after treatment in one patient. va stenting was done for another two. six presented new brain infarctions after spine surgery. of these, two had endovascular intervention after spine reduction. out of 38 patients who had endovascular embolization before spine reduction, four had newly developed infarctions after spine surgery, of which two were symptomatic. there were no complications related to the endovascular procedure. conclusions: in conclusion, endovascular embolization for traumatic vai before spine reduction and fixation was found to be effective to prevent symptomatic brain infarction. introduction: the use of drug coating balloons (dcb) in primary or secondary angioplasty for peripheral vascular disease is a new tendency. the use of paclitaxel decelerates the growth and hyperplasia of neo-intima tissue which can cause re-stenosis and total occlusion in the spot of pta is a very promising technique in long lasting results of balloon ptas. purpose: to demonstrate our experience and results of the technique of dcb pta with the use of drag coating balloons. material and method: in the period between march 2013 and september 2019, 65 patients with sfa lessions were treated with pta with dcb for acute limb ischemia. 41 were males and 24 females. mean age was 69,2 y.o (± 6.39). patients were examined pro operationally and immediate post operationally in abi difference and their post operational follow up included measurement of abi and u/s triplex scan on the 1st, 3rd, 6th and 12th month(where chronically available) after pta. results: the mean immediate post operative increase of abi was 0,32 (± 0,13). were chronically available the increase of abi remained to 0,26 in the 3 months follow up, 0,23 in the 6 months and 0,21 in the 12th month follow up while patency of the artery treated remained in all patients. 2 of the patients suffered from acute complications during or short after the pta (1 with peripheral embolization and 1 with retroperitoneal hematoma) which were treated immediately and left no consequences. conclusions: the use of dcb for pta in acute ischemia is a quite new, promising technique for maintaining patency of treated arteries for long time post operative period. the medium time results from its use in our clinic seem to be satisfactory. jichi medical university hospital, tochigi, japancase history: a 38-year-old male hit his neck hard against the fence. thereafter, he experienced difficulty in breathing and severe neck pain. he was brought to the emergency center by ambulance. clinical findings: his vital signs on arrival were gcs: e4v5m6, hr: 70, bp: 157/101, rr: 20, spo 2 : 100 (3lo 2 ). significant neck edema and tracheal deviation were noted. inspiratory stridor was not heard with no signs of retracted breathing or subcutaneous emphysema. investigation/results: an enhanced ct scan of the neck revealed tracheal deviation and compression with ruptures of the left thyroid lobe. a large hematoma and arterial extravasation from a branch of the inferior thyroid artery were noted. diagnosis: rupture of the left thyroid lobe and injury around the distal portion of the left inferior thyroid artery. therapy and progressions: after securing the airway by intubation, angiography of the neck was performed; extravasation from a branch of the left inferior thyroid artery was suspected. angioembolization was continued for hemostasis using gelatin sponge. neck edema improved in the intensive care unit. following extubation on the hospital day 6, the patient was discharged on the 8 th day with no complication. comments: thyroid injury due to blunt neck trauma is rare and surgical intervention such as hemithyroidectomy is generally prescribed. the patient''s condition, in this case, improved by angioembolization without any invasive surgical procedures. catheter procedure may, thus, be effective for hemostasis on thyroid injury after the confirmation of airway placement. introduction: the indication for resuscitative endovascular balloon occlusion of the aorta (reboa) is hemodynamically unstable patients in life-threatening hemorrhage below diaphragm. it was unclear that the difference of indications for reboa affects mortality in trauma.material and methods: this study used data from the japan trauma data bank (jtdb) (2004-2019), a nationwide trauma registry, to describe the epidemiology of reboa. adult trauma patients used reboa were included. patients were excluded if they had cardiac arrest at the scene or dead on arrival, or had an unsurvivable injury of any region of the body as defined by the abbreviated injury scale. patients were classified by whether patients had indications for reboa. the indications for reboa were defined by indications for hemostasis to intraabdominal, retroperitoneal, pelvic or extremity hemorrhage. the indications were decided by the delphi method with the cooperation of experts in trauma for this study. the contraindications were defined by brain injury needed intervention and hemorrhage above diaphragm. the logistic regression was used to assess the mortality after adjustment for injury severity score. as a sensitivity analysis, a generalized linear mixed model with random effects of a facility was performed. results: of 361,706 patients registered in the jtdb, 993 patients underwent reboa. 669 had indications for reboa and 294 underwent reboa without indications. the physiological variables were similar, but the consciousness was worse in the no-indications group. injury severity of brain and chest were higher in the no-indications group. the indications group had 6.7% and the no-indications group had 13.6% contraindications for reboa. the mortality was similar (43.6% versus 46.5%, or 0.80, 95%ci 0.58-1.10). a sensitivity analysis showed the same result as the primary analysis (or 0.82, 95%ci 0.60-1.12). introduction: most incident first responders have a primary nonmedical role, but are frequently the only professionals initially at the scene. early hemorrhage control via advanced techniques such as resuscitative endovascular balloon occlusion of the aorta (reboa) can save lives. training first responders these techniques has therefore the potential to improve outcomes. this study evaluates the ability to train quick response team fire fighters (qrt-ff) to gain percutaneous femoral artery access and place a reboa catheter, using a comprehensive theoretical and practical training program. material and methods: six qrt-ff participated in the training. sof medics from a previous training served as control group. a formalized training curriculum included basic anatomy and endovascular materials for percutaneous access and reboa catheter placement. key skills were: (1) preparation of an endovascular toolkit, (2) achieving vascular access in the model and (3) placement and positioning of the reboa catheter. results: qrt-ff had significantly better baseline knowledge of surgical anatomy (p = 0.048) compared to medics. they also scored significantly better on using endovascular materials (p = 0.003), performing the procedure without unnecessary attempts (p = 0.032) and overall technical skills (p = 0.030). the median time from start to reboa inflation was 3:23 min for qrt-ff and 5:05 min for medics. procedure times improved in all qrt-ff and 4 of the 5 medics in a second attempt of gaining vascular access and reboa placement. conclusions: our comprehensive theoretical and practical training program proves suitable for percutaneous femoral access and reboa placement training of qrt-ff without prior ultrasound or endovascular experience. repetition reduces procedure times. training in the use of advanced hemorrhage control techniques such as reboa, as a secondary occupational task, has the potential to improve outcomes for severely bleeding casualties in out-of-hospital settings. prytime medical tm devices, inc. provided the reboa access task trainer (ratt) and the catheters used for this study. no other support was provided.the authors declare that there are no conflicts of interest that could inappropriately influence (bias) their work. introduction: angioembolization (ae) has become an important component in the management of bleeding from severe pelvic fractures. timely availablity of ae is required for both, level 1 and 2 trauma centers. the aim of this study was to assess the utilization of this procedure in level 1 and 2 trauma centers and effect on oucomes. material and methods: retrospective, 3-year (2013-2016) study using the the american college of surgeons tqip database, including adult patients with isolated severe pelvic facture (ais [3] [4] [5] . patients who underwent laparotomy or preperitoneal packing within 4 h from admission were excluded, operative management for bleeding control between 4 and 24 h was considered as failure. univariate analysis was used to compare patients in level 1 vs 2 centers, multivariate regression analysis was performed to determine factors predictive for mortality and overall complications.results: 10102 patients (6960 in level 1; 3142 in level 2 centers) met the criteria for inclusion. overall, 610 (6.0%) underwent ae, with a trend toward higher ae rate in level 1 centers (6.3% vs 5.4%, p = 0.061). no significant differences were observed in timing and failure rate of ae between the 2 levels. particulary in the ae subgroup there was a significantly lower blood product utilization in the first 24 h in level i centers (prbc 5.6 vs 6.9 units, p = 0.015; plasma 3.8 vs 5.5 units, p = 0.003). mortality and overall complication rates were similar. table 1 the level of trauma center was not a predictive factor for mortality (or 1.306, p = 0.284) and overall complications (or 1.046, p = 0.591). conclusions: in isolated severe pelvic fractures, there was a trend toward higher ae rate and significantly lower utilization of blood products in level 1 centers. there were no significant differences in mortality or complications. the ae subgroup in level 2 centers had a higher blood products use without outcome benefit, suggesting more restrictive transfusion policy may be considered. portal vein thrombosis after distal splenopancreatectomy: successful recanalization using fogarty balloon catheter case history: intraoperative lesion of smv during distal splenopancreatectomy is repaired using peritoneal patch harvested from anterior abdominal wall clinical findings: postoperative increase in serum lactate and d-dimer without signs of peritonitis prompts bedside doppler us showing no blood flood within portal vein (pv) investigation/results: ct angiography is performed suspecting acute mesenteric ischemia, but no abnormal bowel enhancement/ thickness is seen despite complete pv thrombosis. anticoagulation with unfractioned heparin is started, but clinical conditions deteriorate diagnosis: at reintervention, bowel is viable, so the surgeon performs fogarty balloon catheter thrombectomy successfully reestablishing blood flow within pv. no intestinal resection is required therapy and progressions: pv patency is regularly evaluated with us. anticoagulation with low molecular weight heparin is prosecuted for 3 months and then suspended since no recurrence is recorded meanwhile comments: pv thrombosis is uncommon but can follow injury to portal venous axis during surgery. anticoagulation with heparin should be started as soon as the diagnosis is made and maintained for at least 3-6 months postoperatively to prevent recurrence. patients with persisting/worsening symptoms 48-72 h after initiation of anticoagulation, or those with peritonitis who are poor surgical candidates may be considered for interventional radiological treatment. otherwise, surgical intervention is required and may encompass resection of necrotic bowel. thrombectomy and/or balloon dilation/vascular stent placement may be helpful in recently developed pv thrombosis since risk of recurrence seems to be decreased references: acute mesenteric ischemia: guidelines of the world society of emergency surgery (world j emerg surg 2017); mesenteric venous thrombosis (j clin exp hepatol 2014); contemporary management of acute mesenteric ischemia in the endovascular era (vasc endovascular surg 2019)